Characteristics and outcomes of patients with severe COVID-19 in Indonesia: Lessons from the first wave.

BACKGROUND: Indonesia's national response to COVID-19 evolved rapidly throughout 2020. Understanding pandemic response and outcomes is crucial for better mitigation strategies ahead. This study describes the characteristics and outcomes of patients admitted to ICU during the early stages of the pandemic. METHODS: This is a multi-centre prospective observational study including patients from twelve collaborating hospitals in Indonesia. All patients were clinically suspected or laboratory-confirmed COVID-19 cases admitted to ICU between January 2020 and March 2021. The primary outcome was monthly ICU mortality. Descriptive statistics of patient characteristics and treatment were generated as secondary outcomes. RESULTS: From 559 subjects, the overall mortality was 68% and decreased over the study period, while the mortality of patients that received mechanical ventilation was 92%, consistently high over the study period. Fatal cases showed 2- and 4-day delays from symptoms onset to hospital admissions and ICU admissions, respectively. Evidence-backed approaches which could influence patient outcome, such as extracorporeal membrane oxygenation, prone positioning, renal replacement therapy, and neuromuscular blockade were scarcely administered. CONCLUSIONS: The mortality rate of COVID-19 patients in Indonesia was extremely high during the first major outbreak of disease, particularly in those mechanically ventilated. Delayed admission and unavailability of evidence-based approaches due to high burden on health facility during COVID-19 crisis could be addressed by efficient public health measures and enhancing health infrastructure to improve the future pandemic response.

Indonesian Study: Triiodothyronine for Infants Less than 5 Months Undergoing Cardiopulmonary Bypass.

This study evaluates the efficacy and safety of oral triiodothyronine on time to extubation for infants less than 5 months undergoing heart surgery in Indonesia, and primarily relates to patients in emerging programs with high malnutrition and mortality. In this randomized, double-blind, placebo-controlled trial, oral triiodothyronine (T3, Tetronine®) 1 µg/kg-body weight/dose or placebo (saccharum lactis) was administered via nasogastric tube every 6 h for 60 h to treatment group. A total of 120 patients were randomized into T3 (61 patients) and placebo (59 patients) groups. The majority of the patients had moderate to severe malnutrition (55.83%) with a high post-operative mortality rate of 23.3%. The T3 group showed significantly higher serum FT3 levels from 1 until 48 h post cross-clamp removal (p < 0.0001), lower incidence of low cardiac output syndrome at both 6 h (28 [45.9%] vs. 39 [66.1%] patients, p = 0.03, OR 2.3, 95% CI: 1.10-4.81) and 12 h after cross-clamp removal (25 [41.7%] vs. 36 [63.2%], p = 0.02, OR 2.40, 95% CI: 1.14-5.05). Although not statistically significant, the treatment group had shorter median (IQR) intubation time (2.59 [1.25-5.24] vs. 3.77 [1.28-6.64] days, p = 0.16, HR 1.36, 95% CI: 0.88-2.09)] and lower mortality (10 [16.4%] vs. 18 [30.5%], p = 0.07]. Patients with Aristotle score < 10.0 (low risk) receiving T3 had faster extubation than placebo patients (p = 0.021, HR of 1.90, 95% CI: 1.10-3.28) and were significantly less likely to require CPR or experience infection (p = 0.027, OR 8.56, 95% CI:0.99-73.9 and p = 0.022, OR 4.09 95% CI: 1.16-14.4, respectively). Oral T3 supplementation reduced overall incidence of low cardiac output syndrome and significantly reduced the time to extubation in low-risk patients. Therefore, prophylactic oral T3 administration may be beneficial in these patients.Trial Registration: ClinicalTrials.gov NCT02222532.

Thiamine levels in Indonesian children with congenital heart diseases undergoing surgery using cardiopulmonary bypass machine.

BACKGROUND: This study evaluated thiamine levels in Indonesian children with congenital heart diseases before and after cardiopulmonary bypass and their relationship with clinical and surgical outcomes. METHOD: A prospective, single center cross-sectional study was conducted to evaluate thiamine levels in 25 children undergoing congenital heart diseases surgery with cardiopulmonary bypass procedure. Thiamine levels were quantified using a high-performance liquid chromatography method. RESULT: Preoperative thiamine deficiency was observed in one subject. Thiamine levels did not differ statistically between nutritional status and clinical outcomes categories. There were no significant changes in thiamine levels before and after cardiopulmonary bypass (median pre versus post (P25-75): 50 ng/mL (59.00-116.00) and 83.00 ng/mL (70.00-101.00), p = 0.84), although a significant reduction in thiamine levels were observed with longer cardiopulmonary bypass duration (p = 0.017, R = -0.472). CONCLUSION: Thiamine levels were not significantly impacted by cardiac surgery except in patients undergoing extremely long cardiopulmonary bypass duration. However, clinical outcome was not affected by thiamine levels.

Paediatric COVID-19 mortality: a database analysis of the impact of health resource disparity.

BACKGROUND: The impact of the COVID-19 pandemic on paediatric populations varied between high-income countries (HICs) versus low-income to middle-income countries (LMICs). We sought to investigate differences in paediatric clinical outcomes and identify factors contributing to disparity between countries. METHODS: The International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) COVID-19 database was queried to include children under 19 years of age admitted to hospital from January 2020 to April 2021 with suspected or confirmed COVID-19 diagnosis. Univariate and multivariable analysis of contributing factors for mortality were assessed by country group (HICs vs LMICs) as defined by the World Bank criteria. RESULTS: A total of 12 860 children (3819 from 21 HICs and 9041 from 15 LMICs) participated in this study. Of these, 8961 were laboratory-confirmed and 3899 suspected COVID-19 cases. About 52% of LMICs children were black, and more than 40% were infants and adolescent. Overall in-hospital mortality rate (95% CI) was 3.3% [=(3.0% to 3.6%), higher in LMICs than HICs (4.0% (3.6% to 4.4%) and 1.7% (1.3% to 2.1%), respectively). There were significant differences between country income groups in intervention profile, with higher use of antibiotics, antivirals, corticosteroids, prone positioning, high flow nasal cannula, non-invasive and invasive mechanical ventilation in HICs. Out of the 439 mechanically ventilated children, mortality occurred in 106 (24.1%) subjects, which was higher in LMICs than HICs (89 (43.6%) vs 17 (7.2%) respectively). Pre-existing infectious comorbidities (tuberculosis and HIV) and some complications (bacterial pneumonia, acute respiratory distress syndrome and myocarditis) were significantly higher in LMICs compared with HICs. On multivariable analysis, LMIC as country income group was associated with increased risk of mortality (adjusted HR 4.73 (3.16 to 7.10)). CONCLUSION: Mortality and morbidities were higher in LMICs than HICs, and it may be attributable to differences in patient demographics, complications and access to supportive and treatment modalities.

Acceptance and willingness to purchase a hypothetical COVID-19 vaccine in a region under Shariah law: A cross-sectional study in Aceh, Indonesia.

Vaccines are urgently needed to control the coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to determine the acceptance of and willingness to purchase a hypothetical COVID-19 vaccine in the general population of Aceh, a holistic Shariah law implementation province in Indonesia. An online cross-sectional study was conducted using a quota sampling technique between 1 to 24 September 2021. To determine hypothetical vaccine acceptance, respondents were asked if they were willing to accept vaccines with combinations of either 50% or 95% effectiveness and either 5% or 20% risk of adverse effects. Willingness to purchase was assessed by asking whether the participants would pay for such vaccines at certain price points. Logistic regression analysis was used to assess the associated determinants. Out of 377 respondents included in the final analysis, 86.5% were willing to accept a COVID-19 vaccine with 95% effectiveness and 5% adverse effects. The acceptance rate dropped to 45.1% if the risk of adverse effects was 20%. Vaccines with 50% effectiveness and 5% adverse effects were acceptable to 42.2% but the acceptance went down to 17.2% if the risk of adverse effects increased to 20%. Multivariate analysis found that men were twice as likely to accept a vaccine with 95% effectiveness and 5% adverse effects compared to females (aOR: 2.01; 95% CI 1.05-3.86). We found that 156/377 (41.3%) of respondents were willing to purchase a COVID-19 vaccine and of these participants 71.1% were willing to pay between Indonesian Rupiah (IDR) 50,000-150,000 (US$ 3.33-10.00). In conclusion, the acceptance rate of a hypothetical COVID-19 vaccine varied based on effectiveness and the risk of adverse effects.

Nitroglycerin inhalation for acute treatment of pulmonary arterial hypertension in children with congenital heart disease.

OBJECTIVES: Acute pulmonary hypertension and pulmonary hypertensive crisis may result in adverse clinical outcomes if unsuccessfully treated. Inhaled nitric oxide has long been considered as the standard pharmacotherapy for acute pulmonary hypertension, but lack of feasibility in some settings and evidences challenging its benefits lead to the use of alternative treatment, amongst which is nitroglycerin inhalation. The purpose of this review article is to discuss available data on the use of nitroglycerin inhalation for acute treatment of pulmonary hypertension in children with CHD and its potential benefit in post-operative setting. DATA SOURCES: Literatures included in this review were acquired by searching in PubMed online database. Keywords used were "Pulmonary Hypertension", "Congenital heart defects", "Pediatrics", "Inhaled nitroglycerin", and its synonyms. STUDY SELECTION: Title and abstract were screened to select relevant literatures including the three paediatric clinical trials on nitroglycerin inhalation. Critical appraisal of the clinical trials was then done using the University of Oxford Centre of Evidence-Based Medicine Critical Appraisal Tools. CONCLUSIONS: Paediatric studies showed the benefit of nitroglycerin inhalation in uncorrected cases of CHD during catheterisation procedures. Until recently, there have been no studies conducted in paediatric post-operative CHD cases. Further study is required to provide evidence for inhaled nitroglycerin use in this setting including the appropriate dosing and potential side effects with repeated administration.

The effect of oral triiodothyronine supplementation on lactate and pyruvate after paediatric cardiac surgery.

OBJECTIVE: To determine if triiodothyronine alters lactate, glucose, and pyruvate metabolism, and if serum pyruvate concentration could serve as a predictor of low cardiac output syndrome in children after cardiopulmonary bypass procedures. METHODS: This study was ancillary to the Oral Triiodothyronine for Infants and Children undergoing Cardiopulmonary bypass (OTICC) trial. Serum pyruvate was measured in the first 48 patients and lactate and glucose were measured in all 208 patients enrolled in the OTICC study on the induction of anaesthesia, 1 and 24 hours post-aortic cross-clamp removal. Patients were also defined as having low cardiac output syndrome according to the OTICC trial protocol. RESULT: Amongst the designated patient population for pyruvate analysis, 22 received placebo, and 26 received triiodothyronine (T3). Lactate concentrations were nearly 20 times greater than pyruvate. Lactate and pyruvate levels were not significantly different between T3 and placebo group. Glucose levels were significantly higher in the placebo group mainly at 24-hour post-cross-clamp removal. Additionally, lactate and glucose levels peaked at 1-hour post-cross-clamp removal in low cardiac output syndrome and non-low cardiac output syndrome patients, but subsequently decreased at a slower rate in low cardiac output syndrome. Lactate and pyruvate concentrations correlated with glucose only prior to surgery. CONCLUSION: Thyroid supplementation does not alter systemic lactate/pyruvate metabolism after cardiopulmonary bypass and reperfusion. Pyruvate levels are not useful for predicting low cardiac output syndrome. Increased blood glucose may be regarded as a response to hypermetabolic stress, seen mostly in patients with low cardiac output syndrome.