Decision for early tracheostomy in respiratory failure of a paralyzed myasthenia gravis patient with sepsis-induced pneumonia: A case report.

INTRODUCTION: The neuromuscular condition myasthenia gravis (MG) can make treating sepsis-induced pneumonia more challenging. Since these patients risk respiratory failure, decisions about airway treatment, including tracheostomy, can be difficult. We report a case of a patient with sepsis and concurrent MG who underwent an early tracheostomy due to acute respiratory failure. PRESENTATION OF CASE: A 44-year-old woman with a history of MG presented to the emergency department with a stiff tongue, hypersalivation, limb paralysis and a phlegmy cough causing severe respiratory distress, aggravated by community-acquired pneumonia. A chest X-ray showed extensive infiltration and consolidation in the lower lobes. The patient was transferred immediately to the intensive care unit on mechanical ventilation. Despite initial treatment with antibiotics and respiratory support, her mental and respiratory status deteriorated rapidly. Given the risk of myasthenic crisis, sepsis and impending respiratory failure, with anticipated lengthy ventilator utilization and hospitalization, a multidisciplinary team decided to perform an early tracheostomy. DISCUSSION: The early tracheostomy procedure was carried out securely on the third day of hospitalization. This allowed for better pulmonary hygiene, adequate ventilation, airway clearance and rehabilitation therapy. The family contributed to stoma care and breathing exercises. The patient's respiratory condition steadily improved over the following weeks. The cough reflex remained well, and mechanical ventilation was gradually weaned off. CONCLUSION: Early tracheostomy in a paralyzed MG patient with sepsis-induced pneumonia can improve clinical outcomes and optimize airway management.

Early continuous renal replacement therapy for postoperative patient with acute kidney injury following total pancreato-splenectomy: a case report.

BACKGROUND: Acute kidney injury is a devastating postoperative complication. Renal replacement therapy is a treatment modality for acute kidney injury. Continuous renal replacement therapy is the treatment of choice for patients with hemodynamic instability. The main question in the management of acute kidney injury is when to initiate the renal replacement therapy. Several studies have demonstrated improvement in patients with septic acute kidney injury, following early continuous renal replacement therapy. To date, no guidelines have been established on the perfect timing to initiate continuous renal replacement therapy. In this case report, we did an early continuous renal replacement therapy as an extracorporeal therapy for blood purification and renal support. CASE PRESENTATION: Our patient was a 46-year-old male of Malay ethnicity, undergoing total pancreatectomy due to a duodenal tumor. The preoperative assessment showed that the patient was high risk. Intraoperatively, massive surgical bleeding was sustained due to extensive tumor resection; thus, massive blood product transfusion was necessary. After the surgery, the patient suffered from postoperative acute kidney injury. We performed early continuous renal replacement therapy, within 24 hours after the diagnosis of acute kidney injury. Upon completion of continuous renal replacement therapy, the patient's condition improved, and he was discharged from the intensive care unit on the sixth postoperative day. CONCLUSION: The timing for the initiation of renal replacement therapy remains controversial. It is clear that the "conventional criteria" for initiating renal replacement therapy need correction. We found that early continuous renal replacement therapy initiated in less than 24 hour after the postoperative acute kidney injury diagnosis gave our patient survival benefit.

High-Risk International Clones of Carbapenem-Nonsusceptible Pseudomonas aeruginosa Endemic to Indonesian Intensive Care Units: Impact of a Multifaceted Infection Control Intervention Analyzed at the Genomic Level.

Infection control effectiveness evaluations require detailed epidemiological and microbiological data. We analyzed the genomic profiles of carbapenem-nonsusceptible Pseudomonas aeruginosa (CNPA) strains collected from two intensive care units (ICUs) in the national referral hospital in Jakarta, Indonesia, where a multifaceted infection control intervention was applied. We used clinical data combined with whole-genome sequencing (WGS) of systematically collected CNPA to infer the transmission dynamics of CNPA strains and to characterize their resistome. We found that the number of CNPA transmissions and acquisitions by patients was highly variable over time but that, overall, the rates were not significantly reduced by the intervention. Environmental sources were involved in these transmissions and acquisitions. Four high-risk international CNPA clones (ST235, ST823, ST357, and ST446) dominated, but the distribution of these clones changed significantly after the intervention was implemented. Using resistome analysis, carbapenem resistance was explained by the presence of various carbapenemase-encoding genes (blaGES-5, blaVIM-2-8, and blaIMP-1-7-43) and by mutations within the porin OprD. Our results reveal for the first time the dynamics of P. aeruginosa antimicrobial resistance (AMR) profiles in Indonesia and additionally show the utility of WGS in combination with clinical data to evaluate the impact of an infection control intervention. (This study has been registered at www.trialregister.nl under registration no. NTR5541).IMPORTANCE In low-to-middle-income countries such as Indonesia, work in intensive care units (ICUs) can be hampered by lack of resources. Conducting large epidemiological studies in such settings using genomic tools is rather challenging. Still, we were able to systematically study the transmissions of carbapenem-nonsusceptible strains of P. aeruginosa (CNPA) within and between ICUs, before and after an infection control intervention. Our data show the importance of the broad dissemination of the internationally recognized CNPA clones, the relevance of environmental reservoirs, and the mixed effects of the implemented intervention; it led to a profound change in the clonal make-up of CNPA, but it did not reduce the patients' risk of CNPA acquisitions. Thus, CNPA epidemiology in Indonesian ICUs is part of a global expansion of multiple CNPA clones that remains difficult to control by infection prevention measures.

A novel diagnosis scoring model to predict invasive pulmonary aspergillosis in the intensive care unit.

OBJECTIVES: To improve the quality of invasive pulmonary aspergillosis (IPA) management for intensive care unit (ICU) patients using a practical diagnostic scoring model. METHODS: This nested case-control study aimed to determine the incidence of IPA in 405 ICU patients, between July 2012 and June 2014, at 6 hospitals in Jakarta, Indonesia. Phenotypic identifications and galactomannan (GM) tests of sera and lung excreta were performed in mycology laboratory, Parasitology Department, Faculty of Medicine, Universitas Indonesia in Jakarta, Indonesia. RESULTS: The incidence of IPA in the ICUs was 7.7% (31 of 405 patients). A scoring model used for IPA diagnosis showed 4 variables as the most potential risk factors: lung excreta GM index (score 2), solid organ malignancy (score 2), pulmonary tuberculosis (score 2), and systemic corticosteroids (score 1). Patients were included in a high-risk group if their score was greater than 2, and in a low-risk group if their score was less than 2. CONCLUSION: This study provides a novel diagnosis scoring model to predict IPA in ICU patients. Using this model, a more rapid diagnosis and treatment of IPA may be possible. The application of the diagnosis scoring should be preceded by specified pre-requisites.