Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series.

BACKGROUND: Surgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthesia. These complications are detrimental to the child and medical personnel and cause tremendous psychologic stress to parents. Our aim is to decrease these complications through dexmedetomidine, an alpha-2 receptor agonist with anxiolytic, sympatholytic, and analgetic properties. Devoid of respiratory depressant effect, it allows patients to maintain effective ventilation and reduce agitation, postoperatively. Its unique anesthetic property may shed light on providing safe anesthesia and gentle emergence to this young, vulnerable population. CASE PRESENTATION: A total of 21 patients of Sundanese ethnicity, aged 3 months to 8 years (9 males and 12 females), underwent cleft lip or cleft palate surgery using total intravenous dexmedetomidine. Anesthesia was induced using sevoflurane, fentanyl, and propofol, and airway was secured. Intravenous dexmedetomidine 1.5 µg/kg was administered within 10 minutes, and a maintenance dose of 1.5 µg/kg/hour was continued as the sole anesthetic maintenance agent thereafter. Hemodynamics and anesthetic depth using Patient State Index (SEDLine™ monitor, Masimo Corporation, Irvine, CA, USA) were monitored carefully throughout the surgical procedure. Dexmedetomidine did not cause any hemodynamic derangements or postoperative complications in any of our patients. We found agitation in 9.5% (2/21) of patients. CONCLUSION: Dexmedetomidine can be used as a total intravenous anesthetic agent to maintain anesthesia and provide gentle emergence to infants and young children undergoing cleft lip and palate repair.

ANTIMICROBIAL RESISTANCE AND MORTALITY.

Background: Antibiotic resistance has been a long-debated topic since decades ago. The development of stronger, newer antibiotics, implementation of antibiotic stewardship and revised guidelines remain the main focus of our society to prevent resistancy. But is it really resistancy that cause higher mortality to patients with multidrug resistance (MDR) infections? Methods: We conducted a cohort retrospective study from 2016 to 2019 in our Intensive care unit (ICU). Antimicrobial susceptibility test (AST) results were analyzed for their association with patient mortality outcomes. Results: Over the four-year period, 381 positive bacterial cultures were analyzed and 51% of them grew MDR pathogens upon their first culture. The overall mortality rate was 19% (38/195), and there was no significant association between MDR and mortality; p 0.387. A strong association was however found between patients with medical cases with an OR 1.76; CI 1.76-2.55; p 0.003 and those with APACHE scores ≥20 upon admittance to the ICU, OR 1.32; CI 1.68-8.29; p 0.001. Conclusion: Resistancy is not the true cause of mortality. Infection by resistant microbes does not necessarily mean the worst outcome since virulency is the actual cause of pathogenicity, and thus mortality.

Severe COVID-19 in the intensive care unit: a case series.

BACKGROUND: Coronavirus disease 2019 (COVID-19) was first identified in Indonesia in March 2020, and the number of infections has grown exponentially. The situation is at its worst, overwhelming intensive care unit (ICU) resources and capacity. CASE PRESENTATION: This is a single-center observational case study of 21 confirmed COVID-19 patients admitted to the ICU from March 20, 2020, to April 31, 2020. Demographics, baseline comorbidities, clinical symptoms, laboratory tests, electrocardiogram (ECG) and chest imaging were obtained consecutively during patient care. We identified 21 patients with confirmed COVID-19 severe infection in our ICU. The mean (± standard deviation) age of the patients was 54 ± 10 years; 95% were men, with shortness of breath (90.6%) the most common symptom. Hypertension was identified as a comorbidity in 28.6% of patients. The most common reason for admission to the ICU was hypoxemic respiratory failure, with 80% (17 patients) requiring mechanical ventilation. Half of the patients (10) died between day 1 and day 18, with septic shock as the primary cause of death. Of the 11 surviving patients, five were discharged home, while six were discharged from the ICU but remained in the hospital ward. Even then, the median length of ICU stay amongst survivors was 18 days. CONCLUSIONS: To date, there are no known effective antiviral agents or specific therapy to treat COVID-19. As severe systemic inflammatory response and multiple organ failure seems to be the primary cause of death, supportive care in maintaining oxygenation and hemodynamic stability remain the mainstay goals in treating critically ill COVID-19 patients.

Fluids and sepsis: changing the paradigm of fluid therapy: a case report.

BACKGROUND: Over the past 16 years, sepsis management has been guided by large-volume fluid administration to achieve certain hemodynamic optimization as advocated in the Rivers protocol. However, the safety of such practice has been questioned because large-volume fluid administration is associated with fluid overload and carries the worst outcome in patients with sepsis. Researchers in multiple studies have declared that using less fluid leads to increased survival, but they did not describe how to administer fluids in a timely and appropriate manner. CASE PRESENTATION: An 86-year-old previously healthy Sundanese man was admitted to the intensive care unit at our institution with septic shock, acute kidney injury, and respiratory distress. Standard care was implemented during his initial care in the high-care unit; nevertheless, his condition worsened, and he was transferred to the intensive care unit. We describe the timing of fluid administration and elaborate on the amount of fluids needed using a conservative fluid regimen in a continuum of resuscitated sepsis. CONCLUSIONS: Because fluid depletion in septic shock is caused by capillary leak and pathologic vasoplegia, continuation of fluid administration will drive intravascular fluid into the interstitial space, thereby producing marked tissue edema and disrupting vital oxygenation. Thus, fluids have the power to heal or kill. Therefore, management of patients with sepsis should entail early vasopressors with adequate fluid resuscitation followed by a conservative fluid regimen.

Management of severe dengue hemorrhagic fever and bleeding complications in a primigravida patient: a case report.

BACKGROUND: The incidence of dengue hemorrhagic fever is increasing among the adult population living in endemic areas. The disease carries a 0.73% fatality rate for the general population, but what happens when the disease strikes a special subpopulation group, the obstetrics? Perhaps the important question specific to this special subpopulation revolves around the right time and mode of delivery under severe coagulopathy and plasma leakage in conditions of imminent delivery. CASE PRESENTATION: A 24-year-old primigravid Sundanese woman presented to our intensive care unit due to acute pulmonary edema secondary to massive plasma leakage caused by severe dengue. She tested positive for both immunoglobulin G and immunoglobulin M dengue serology indicating she had secondary dengue infection, which placed her at risk for an exaggerated cytokine response as was evident clinically. She had to undergo an emergency cesarean section which was later complicated by rebleeding and hemodynamic instability due to an atypical defervescence period. She was successfully managed by multiple blood transfusions and was discharged from our intensive care unit on day 8 without any negative sequel. CONCLUSIONS: Fever, thrombocytopenia, and hemoconcentration are the classical symptoms of dengue hemorrhagic fever observed in adult, pediatric, and obstetric populations. However, a clinician must be particularly watchful in treating a pregnant dengue-infected patient as physiologic hematology changes provide greater volume compensation and the advent of shock marks significant volume loss. In conclusion, an important principle in the management of dengue hemorrhagic fever in pregnancy is to prioritize maternal well-being prior to addressing fetal issues.