HOW CLOSELY IS PROTEIN CARBONYL (PCO) LEVEL CORRELATED WITH SEPSIS-RELATED ORGAN FUNCTION ASSESSMENT (SOFA) SCORE?

Objective: Sepsis remains an unsolved problem in hospitals since its mortality rate is not significantly reduced despite considerable therapy efforts. The most used prognostic tool is the Sepsis-related Organ Function (SOFA) score, which requires several clinical and laboratory examinations; our recent studies also showed that the protein carbonyl level (PCO) has prognostic value in predicting sepsis mortality. Methods: This prospective study was designed to assess the correlation between PCO values and the SOFA score following ethical approval. Adult patients aged>18 y who met the Sepsis-3 definition were included. Exclusion criteria were patients not admitted to the intensive care unit. Dropout criteria included mortality within the 1h bundle protocol. Baseline demographic data and blood collection were measured for all subjects. Subjects were treated with the 1h bundle protocol and observed for 28 d. Results: Fifty-nine subjects were included, with no significant differences in age, sex, diagnosis, microbiology or Charlson’s Comorbidity score between survivors and non-survivors. The SOFA score was higher in non-survivors (10.90±3.38 vs 8.11±3.07; p=0.003), as was the PCO value (24.5 [14.67-81] vs 18 [15-21.33]; p<0.001). However, the correlation between PCO and SOFA score is very weak (r=0.101; p=0.45). Conclusion: Both the PCO level and SOFA scores were higher in non-survivor septic patients. However, they have a very weak correlation and cannot be used interchangeably

Relationship between Neutrophil to Lymphocyte Ratio with Diaphragm Thickness in Critical Patients

Abstract   Background: The cause of weaning failure is multifactorial. One of the causes was Ventilator Induced Diaphragm Dysfunction (VIDD) due to thinning process of the diaphragm thickness. Decreased diaphragm muscle mass might occur due to inflammatory process. Methods: The study was an observational analytic study from September 2018 to January 2019 in Mohammad Hoesin Hospital, Palembang – Indonesia. Ethical appoval for the study was obtained from Ethics Committee and subjects were recruited after signing the informed consents. Only 30 subjects were involved in the end of the study. About 6 mL of blood sample from cubital vein was withdrawn from each subject to measure neutrophils and lymphocytes. Patients’ diaphragm thickness was measured by using ultrasonography on 0th, 3rd, 5th day. Collected data were then analyzed with STATA 15. Results: The chi-square test showed that the relationship of NLR (neutophil to lymphocyte ratio) of the 0th day to the decrease in diaphragm thickness on the 3rd day was not significant (p = 0.254), while the decrease in diaphragm thickness on the 5th day was significant (p = 0.015). Subjects with initial NLR values >7 had a significant higher risk of having decreased diaphragm thickness compared to subjects with initial NLR values ​​≤7 (RR = 1.62 (0.99-2.64); p-value = 0.003). Conclusion: Neutrophil to lymphocyte ratio affected the decrease of diaphragm thickness in patients using mechanical ventilation

Factors Associated with Mortality of Intensive Care Unit Patients with Acute Kidney Injury at Cipto Mangunkusumo National Central General Hospital

Background: the incidence of acute kidney injury (AKI) in intensive care units is associated with increased mortality, post AKI morbidity and high treatment costs. Research on factors related to mortality of AKI patients in intensive care units in Indonesia, especially Cipto Mangungkusumo General Hospital has never been done. This study aims to determine the prevalence of AKI, mortality rate of AKI patients, and the factors associated with increased mortality of AKI patients in intensive care units in ICU Cipto Mangunkusumo General Hospital. Methods: this is a retrospective cohort study of all patients diagnosed with AKI in the intensive care unit at Cipto Mangunkusumo General Hospital, January 2015 - December 2016. An analysis of bivariate relationships with multvariate with STATA Statistics 15.0 between age > 60 years, sepsis, use of ventilator, ventilator duration, dialysis, oligoanuria, and APACHE II scores at admission with mortality. Results: the prevalence of AKI patients in the intensive care unit was 12.25% (675 of 5511 subjects) and 220 subjects (32.59%) of the 675 analyzed subjects died in the intensive care unit. Factors related to increased mortality in multivariate analysis were sepsis (OR 6,174; IK95% 3,116-12,233), oligoanuria (OR 4,173; IK95% 2,104-8,274), use of ventilator (OR 3,085; IK95% 1,348-7,057), (scores APACHE II at admission) 1/2 [OR 1,597; IK95% 1.154-2.209], and the duration of the ventilator (OR 1.062; IK95% 1.012-1.114). Conclusion: the prevalence of AKI patients and their mortality rate in the intensive care unit of Cipto Mangunkusumo General Hospital obtained 12.25% and 32.59%. Sepsis, oligoanuria, ventilators (APACHE II score at admission) 1/2, and ventilator duration are factors that are significantly associated with increased mortality of AKI patients in intensive care units

Optimal Amikacin Levels for Patients with Sepsis in Intensive Care Unit of Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Background: Amikacin is one of the antibiotics of choice for sepsis and septic shock. Pharmacokinetic of amikacin can be influenced by septic condition with subsequent effect on its pharmacodynamic. At Cipto Mangunkusumo Hospital (RSCM), Jakarta, adult patients in the ICU were given standard amikacin dose of 1 g/day, however the achievement of optimal plasma level had never been evaluated. This study aimed to evaluate whether the optimal plasma level of amikacin was achieved with the use of standard dose in septic conditions. Methods: all septic patients admitted to the intensive care unit of a national tertiary hospital receiving standard dose of 1g/day IV amikacin during May-September 2015 were included in this study. Information of minimum inhibitory concentration MIC was obtained from microbial culture. Cmax of amikacin was measured 30 minutes after administration and optimal level was calculated. Optimal amikacin level was considered achieved when Cmax/MIC ratio >8. Results: average Cmax achieved for all patients was 86.4 (43.5-238) µg/mL with 87% patients had Cmax of >64 µg/mL.MIC data were available for 7 of 23 patients. MICs for identified pathogens were 0.75 - >256 µg/mL (K. pneumonia), 0.75 - >256 µg/mL(A. baumanii), 1.5 - >256 µg/mL (P. aeruginosa)and 0.75 – 16 µg/mL(E. coli). Four out of seven patients achieved optimal amikacin level. Conclusion: despite high Cmax, only half of the patients achieved optimal amikacin level with highly variable Cmax. This study suggests that measurement of Cmax and MIC are important to optimize septic patients management

Clinical impact of endemic NDM-producing Klebsiella pneumoniae in intensive care units of the national referral hospital in Jakarta, Indonesia

OBJECTIVE: A prospective observational study was performed to assess the epidemiology and clinical impact of carbapenem-non-susceptible Klebsiella pneumoniae (CNKP) in intensive care units (ICUs) of the national referral hospital in Jakarta, Indonesia. MATERIALS/METHODS: Adult patients consecutively hospitalized for > 48 h in two ICUs of the national referral hospital were included from April until October 2013 and from April until August 2014. K. pneumoniae from clinical cultures and standardized screening of rectum and throat on admission, discharge and weekly if hospitalized > 7 days were collected. Environmental niches and healthcare workers (HCWs) were also screened. Susceptibility was determined phenotypically and the presence of carbapenemase genes by PCR. Raman spectroscopy as well as multiple-locus variable number tandem repeat analysis (MLVA) were used for typing. RESULTS: Twenty-two out of 412 (5.3%) patients carried CNKP on admission and 37/390 (9.5%) acquired CNKP during ICU stay. The acquisition rate was 24.7/1000 patient-days at risk. One out of 31 (3.2%) environmental isolates was a CNKP. None of the HCWs carried CNKP. Acquisition of CNKP was associated with longer ICU stay (adjusted Hazard Ratio: 2.32 [CI99: 1.35-3.68]). ICU survival was lower among patients with CNKP compared to patients with carbapenem-susceptible K. pneumoniae (aHR 2.57, p = 0.005). Ninety-six of the 100 (96%) CNKP isolates carried a carbapenemase gene, predominantly blaNDM. Raman typing revealed three major clusters among 48 Raman types identified, whereas MLVA distinguished six major clusters among a total of 30 different genotypes. CONCLUSIONS: NDM-producing CNKP are introduced into these ICUs and some strains expand clonally among patients and the environment, resulting in endemic CNKP. CNKP acquisition was associated with prolonged ICU stay and may affect ICU survival. TRIAL REGISTRATION: The study was registered at Netherlands Trial Register http://www.trialregister.nl. Candidate number: 23527, NTR number: NTR5541, NL number: NL5425 (https://www.trialregister.nl/trial/5424), Retrospectively registered: NTR: 22 December 2015

Epidemiology and characterisation of carbapenem-non-susceptible Pseudomonas aeruginosa in a large intensive care unit in Jakarta, Indonesia

The aim of this study was to describe the epidemiology and clinical impact of carbapenem-non-susceptible Pseudomonas aeruginosa (CNPA) in intensive care units (ICUs) of the national refer

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 >2, and in a low-risk group if their score was <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

High-Risk International Clones of Carbapenem-Nonsusceptible Pseudomonas aeruginosa Endemic to Indonesian Intensive Care Units

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, ST375, 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

Efek perbedaan Volume Tidal Ventilasi Mekanik Selama Operasi terhadap Rasio PaO2/FiO2 Pascakraniotomi Elektif

Latar Belakang: Kraniotomi elektif memiliki insidens komplikasi paru pascaoperasi (25%) dan mortalitas (10%) yang tinggi; insiden ini lebih rendah pada pemakaian volume tidal rendah sebagai teknik proteksi paru. Penelitian ini meneliti efek volume tidal 6 mL/kg dan 10 mL/kg terhadap rasio PaO2/FiO2(sebagai parameter keparahan cedera paru) pascaoperasi pada kraniotomi elektif. Subjek dan Metode: Setelah mendapat izin Komite Etik FKUI/Rumah Sakit Cipto Mangukusumo dan konsen pasien, dilakukan uji klinis acak pada 52 pasien kraniotomi elektif yang dirandomisasi ke dalam 2 kelompok: ventilasi mekanik selama operasi dengan volume tidal 6 mL/kg (VT–6) atau 10 mL/kg (VT–10), lalu dilakukan analisis gas darah. Hasil: Rasio PaO2/FiO2 kelompok VT-6 dan VT–10 secara berurutan: pada 1 jam pascainduksi 413,7 ± 113,4 mmHg dan 401,5 ± 106,3 mmHg (p0.05); pada akhir operasi, 466,6 ± 94,6 mmHg dan 471,1 ± 89,0 mmHg (p0.05), pada 24 jam pascainduksi, 418,8 ± 108,8 mmHg dan 448,5 ± 119,6 mmHg (p0.05); pada 48 jam pascainduksi, 414,9 ± 88,1 mmHg dan 402,5 ± 100,7 mmHg (p0.05 ). Tidak ada perbedaan signifikan insiden mortalitas dan komplikasi paru dan ekstraparu diantara dua kelompok. Simpulan: Tidak ada perbedaan signifikan antara volume tidal 6 ml/kg dan 10 ml/kg terhadap ratio PaO2/FiO2 pada pasien kraniotomi elektif. The Effect of Different Tidal Volume against Postoperative PaO2/FiO2 Ratio in Elective Craniotomy Patients Background: Elective craniotomy is associated with a high incidence of postoperative pulmonary complications/PPC (25%) and mortality (10%); in which these incidence went down with the administration of low tidal volume. This study investigated the effect of low tidal volume in intraoperative PaO2/FiO2 ratio in elective craniotomy patients. Subject and Methods: After approval from Ethics Committee Faculty of Medicine Universitas Indonesia, Ciptomangunkusumo Hospital and consent from patients,a randomized controlled trialwas done to 52 elective craniotomy patients. Subjects were ventilated with tidal volume 6 mL/kg (VT–6) or 10 mL/kg (VT–10) intraoperatively, then blood gas analyses wereperformed. Results: PaO2/FiO2 ratio of VT–6 and VT–10 respectively: at 1 hour postinduction, 413.7 ± 113.4 mmHg and 401.5 ± 106.3 mmHg (p0.05); at end of surgery, 466.6 ± 94.6 mmHg and 471.1 ± 89.0 mmHg (p0.05); at 24 hours postinduction, 418.8 ± 108.8 and 448.5± 119.6 mmHg (p0.05); at 48 hours postinduction, 414.9 ± 88.1 mmHg and 402.5 ± 100.7 mmHg (p0.05). There were no significant differences on mortality, lung and extralung complications observed between both groups Conclusions: There were no significant difference between tidal volume 6 ml/kg and 10 ml/kg against intraoperative PaO2/FiO2 ratio in elective craniotomy patients