Association between hyperglycemia and organ dysfunction in shock patients

Background Hyperglycemia is an important marker of both poor clinical outcomes and high mortality rate in critically ill patients. Glucose toxicity results in cell damage that leads to organ dysfunction. Objective To evaluate for an association between hyperglycemia and the incidence of organ dysfunction in shock patients. Methods This cross-sectional study was conducted in the pediatric intensive care unit (PICU) of Dr. Moh. Hoesin Hospital, Palembang from June to November 2011. Subjects were consecutively-enrolled, shock patients without a history of diabetes mellitus. Illness severity and organ dysfunction were determined by pediatric risk of mortality (PRISM) III score and pediatric logistic organ dysfunction (PELOD) scores, respectively. Hyperglycemia was defined as a blood glucose level 2: 110 mg/dL. Statistical analysis was performed with SPSS version 15. Results Mean age of subjects was 2.30 (SD 2.93) years. Mean PRISM III score was 15 .11 (SD 5 .63). Prevalence of hyperglycemia was 80.0%. Mean glucose level was 179.51 (SD 86.84) mgldL. Mean PELOD score was 16.02 (SD 13.87). Organ dysfunction was observed in 86.7% of subjects. The most common organ dysfunction observed in our subjects was liver dysfunction (73.3%). There was a significant association between hyperglycemia and organ dysfunction (OR43.750;95%CI 4.036 to474.252, P=0.001). The blood glucose level cutoff points indicative of organ dysfunction, PRISM III score 2: 8, and PELOD score 2: 20.5 were 114.5 mg/ dL, 129 mgldL, and 166 mg/dL, respectively. Conclusion There is an association between hyperglycemia and organ dysfunction. The upper limit blood glucose level indicative of organ dysfunction is 114.5 mg/dL. A glucose level of 129 mgldL may be considered to be a warning to start blood glucose monitoring. A level above 166 mgldL may be used to indicate the necessity of starting insulin therapy intervention

Pola Kuman dan Uji Kepekaan Antibiotik pada Pasien Unit Perawatan Intensif Anak RSMH Palembang

Latar belakang. Unit perawatan intensif anak atau Pediatric Intensive Care Unit (PICU) termasuk unit dengan banyak pemakaian antibiotik. Pemilihan awal antibiotik secara empiris, selanjutnya memerlukan data jenis kuman serta resistensinya terhadap antibiotik. Pemakaian antibiotik yang tidak tepat akan mengakibatkan resistensi kuman dan memperburuk kondisi pasien kritis. Tujuan. Mengetahui pola kuman dan uji kepekaan pasien baru yang dirawat di Unit Perawatan Intensif sebagai salah satu dasar untuk menentukan terapi empiris. Metode. Studi deskriptif pada serial kasus pasien yang dirawat di Unit Perawatan Intensif (PICU) Anak RSMH/FK UNSRI Palembang sejak April 2009 sampai dengan September 2009. Data dianalisis secara deskriptif dengan tampilan frekuensi dan persentase menggunakan program SPSS 15.0. Hasil. Subjek penelitian 69 orang berusia antara 1 bulan sampai 15 tahun, 58% laki-laki dan 42% perempuan. Ditemukan 75,4% pasien baru terdapat kuman dalam spesimen cairan tubuhnya. Infeksi terbanyak adalah bronkopneumonia (21%). Saluran napas merupakan lokasi terbanyak terdapat bakteri (93,9%), diikuti dengan darah (33,3%), terakhir adalah urin (29%). Bakteri terbanyak yang ditemukan dari pemeriksaan biakan adalah Staphylococcus spp. (22,97%), Acinetobacter calcoaceticus (21,62%), Pseudomonas aeruginosa (13,51%), Klebsiella pneumoniae (12,16%), Streptococcus spp. (9,45%), dan sisanya 20,56% mikroorganisme lain. Imipenem dan amikacin masih memiliki sensitifitas yang tinggi terhadap seluruh bakteri yang ditemukan. Antibiotik seperti ceftriaxon, ampicillin, dan gentamicin menunjukkan resistensi yang cukup tinggi. Vancomicin memiliki efektifitas yang sangat baik dan memiliki sensitifitas 100% untuk semua sampel yang diuji. Kesimpulan. Bakteri terbanyak yang ditemukan adalah Staphylococcus, sedangkan imipenem, amikacin, dan vancomicin memiliki sensitifitas yang tinggi terhadap seluruh bakteri yang ditemukan

Validation of the Pediatric Early Warning Score to determine patient deterioration from illness

Background Patients who enter the emergency room (ERER) present with a variety of conditions, ranging from mild to critical. As such, it may be hard to determine which patients are in need of intensive care unit treatment. The Pediatric Early Warning Score (PEWS) has been used to identify signs of critical illness in pediatric patients. Objective To validate the PEWS system for assessing signs of critical illness in pediatric patients at Dr. Mohammad Hoesin Hospital, Palembang. Methods Subjects were children aged 1 month to 18 years who received treatment in the ERER and Pediatrics Ward in Dr. Mohammad Hoesin Hospital in March to April 2015. Assessment with PEWS was based on vital sign examinations. Scores ranged from 0 to 9. The PEWS was generally taken twice, first in the ER , then after 6 hours in the ward. We obtained the cut-off point, sensitivity, and specificity of PEWS, in terms of need for pediatric intensive care unit (PICU) treatment. Results One hundred fifty patients were included in this study. Patients with PEW score of 5 or greater in the ER were relatively more likely to be transferred to the PICU, with a sensitivity of 94.4% and a specificity of 82.5%. The cut-off point obtained from the ROC curve was score 4.5 with AUC 96.7% (95%CI 93.4 to 99.9%; P<0.001). Conclusion A PEWS score of cut-off ≥5 may be used to determine which patients are in critically ill condition requiring treatment in PICU

Perubahan Strong Ion Difference Pasca Resusitasi Cairan antara Ringer Laktat dan Normal Salin pada Anak dengan Syok

Latar belakang. Pemberian cairan resusitasi pada syok akan memengaruhi status asam basa tubuh melalui pengaruhnya terhadap strong ion difference (SID) berdasarkan teori Stewart. Normal salin (NS) dan ringer laktat sering digunakan sebagai cairan resusitasi namun terdapat kekhawatiran bahwa penggunaan NS dapat menyebabkan asidosis hiperkloremik dan masalah ini belum banyak diteliti pada anak. Tujuan. Membandingkan perubahan SID dan pH plasma setelah pemberian cairan RL dan NS pada syok. Metode. Dilakukan uji klinik terbuka acak terkontrol di UPIA RSMH bulan Juli 2014 sampai Maret 2015. Randomisasi blok dilakukan pada 44 subjek penelitian rentang usia 2 bulan sampai 14 tahun. Hasil. Terdapat 23 subjek pada kelompok RL dan 21 pada kelompok NS. Pada kelompok RL, rerata SID dan pH setelah resusitasi tidak mengalami perubahan bermakna (SID 32,96±5,26 menjadi 32,32±6,34 mEq/L, p=0,089; pH 7,40 menjadi 7,42 dengan p=0,346). Pada kelompok NS (SID 34,44±8,1 menjadi 32,4±7,24 mEq/L, p=0,354; pH 7,290 menjadi 7,345 dengan p=0,434). Antara kelompok RL dan NS, tidak ditemukan perbedaan bermakna dalam rerata selisih SID (SID RL -1,22 mEq/L dan NS -1,97 mEq/L dengan p=0,177) dan pH (pH RL 0,013±0,088 dan NS 0,032±0,11 dengan p=0,534). Ditemukan penurunan bermakna kadar kalium pada kelompok NS setelah resusitasi (4,32±1,05 menjadi 3,73 ± 1,06 mEq/L, p=0,032). Kesimpulan. Resusitasi cairan dengan RL dan NS memberikan perubahan SID dan pH yang tidak berbeda pada kasus syok anak di unit perawatan intensif anak

Hubungan Acute Kidney Injury dan Skor Pelod pada Pasien Penyakit Kritis

Latar belakang. Insiden dan mortalitas acute kidney injury (AKI) pada pasien penyakit kritis cukup tinggi, diperlukan penilaian secara objektif menggunakan skor prognostik dalam menentukan prognosis pasien yang disertai AKI. Tujuan. Mengetahui hubungan antara AKI dan skor PELOD pada pasien penyakit kritis. Metode. Penelitian dilakukan di UPIA RS Moh. Hoesin Palembang selama bulan November 2011-Maret 2012, sampel dipilih secara konsekutif. Hubungan antara AKI dan skor PELOD dianalisis dengan uji Kai Kuadrat, Fisher, dan Mann-Whitney. Kesintasan dianalisis dengan uji Kaplan Meier. Hasil. Subjek penelitian terdiri dari 113 anak, prevalensi AKI sebesar 60,2%, AKI risk 41,2%, injury 25%, dan failure 33,8%. Prevalensi kematian pasien AKI 57,4%, risk 39,3%, injury 47,1%, failure 87%. Skor PELOD lebih tinggi pada pasien AKI (19,7±1,62 vs 6,8±1,31). Analisis korelasi dan regresi antara kadar kreatinin serum dan skor PELOD didapatkan r=0,518 dan r2=0,256. Kesimpulan. Acute kidney injury dan skor PELOD memiliki hubungan positif, dan kontribusi AKI terhadap variasi skor PELOD 25,6% menjelaskan bahwa pasien penyakit kritis dengan skor PELOD rendah akan tetap memiliki prognosis yang buruk jika pasien tersebut mengalami AKI

Insulin therapy for hyperglycemia in critically ill patients

Background Hyperglycemia in critically ill patients is associated with higher mortality. Insulin therapy may improve outcomes, not only by preventing deleterious effects of hyperglycemia, but by improving the molecular dynamics in organ dysfunction. Objectives To assess the effects of insulin therapy on critically ill patients in an intensive care unit (ICU) setting and the risk of hypoglycemia. Methods An open-label, clinical trial was conducted in the Pediatric Intensive Care Unit (PICU) of Dr. Moh. Hoesin Hospital, Palembang, from November 2011 to March 2012. Subjects were consecutively assigned to receive either regular insulin at a dose of 0.05 U/kg/h if the blood glucose level reached >200 mg%, or standard therapy (control group). Blood glucose levels were measured hourly until they reached 80-110 mg%. Dose adjustments were made when the blood glucose level reached 145 mg%, by reducing the insulin dose to 0.025 U/kg/h. Outcomes of therapy were measured by Pediatric Logistic Organ Dysfunction (PELOD) score improvement, mortality rate and the occurrence of hypoglycemia. Results Forty subjects were enrolled in this study, with 20 subjects assigned to the insulin therapy group and 20 subjects to the standard therapy group. Two subjects, one from each group, were not included in the final analysis due to their deaths within 24 hours. There was no significant difference in distribution of PELOD scores before intervention between the groups (OR=0.5; 95%CI 0.1 to 1.9, P=0.32). However, after intervention, the PELOD scores was significantly lower in insulin therapy group compared to control group (OR 0.2; 95% CI 0.05 to 0.8, P=0.02). In the insulin group after intervention, fewer subjects had scores >20.5 and more subjects had scores ≤20.5, indicated a lower risk of organ dysfunction. There was also a significantly lower mortality rate in the insulin group compared to the control group (OR 0.2; 95% CI 0.05 to 0.8, P=0.02). None of the subjects suffered hypoglycemia. Conclusion Insulin is beneficial in improving organ dysfunction and decreasing mortality for critically ill patients

Continuous sedation vs. daily sedation interruption in mechanically-ventilated children

Background A daily sedation interruption (DSI) protocol in ventilated patientsis an effective method of improving sedation management that decreases the duration of mechanical ventilation. In adult patients, it is a safe and effective approach, as well as common practice. For ventilated children,its effectiveness and feasibilityare unknown. Objective To compare continuous sedation and DSI in mechanically-ventilated children with respect todurationof mechanical ventilation, the time needed for patients to awaken, and the frequency of adverse events. Method This randomized, controlled, open-label trial, was performed in a pediatric intensive care unit (PICU). Forty children on mechanical ventilation were included. Patients were randomly assigned to receive either continuous sedation or DSI. The duration of mechanical ventilation was the primary outcome, while the time for patients to awaken on sedative infusion and the frequency of adverse events were secondary outcomes. Results Forty patients were randomized into the continuous sedation protocol (18 subjects) or into the DSI protocol (22 subjects). The median (interquartile range) duration of mechanical ventilation was significantly shorter in the DSI compared to the continuous sedation group [41.50 (30-96) hours vs. 61 (30-132) hours, respectively; (P=0.033)]. The time for patients to awaken was also significantly lower in the DSI than in the continuous sedation group [median (interquartile range): 28 (24-78) vs. 45.5 (25-12) hours, respectively; (P=0.003)]. The frequencies of adverse events were similar in both groups. The severity of illness contributed to outcome variables. Conclusion The duration of mechanical ventilation and the time for patients to awaken are significantly reduced in the DSI group compared to the continuous sedation group

Use of pediatric logistic organ dysfunction in determining prognostic among pediatric intensive care unIt patIents

Background Pediatric intensive care unit is the place for caring the children \\lith higher risk of mortality, usually with multiple organ dysfunction syndrome (MODS) that can increase difficulty in detennining prognostic. Th erefore, an objective severity of illness and organ dysfunction score is needed. Pediatric logistic organ dysfunction (PELOD) score can be considered as a representative for probability of death and predicting the prognostic. Objective To determine the prognostic of patients in PICU Mohammad Hoesin hospital (RSMH), Palembang, using PELOD score. Methods An observational study was conducted from April-September 2009 among PICU patients. PELOD score was assessed in the first 24 hour. S tatistical analysis was performed using Z-Mann Whitney test, Hosmer-Lemeshow goodness-of-fit, ROC curve and survival analysis Kaplan Meier (KM). Results There were 45 (55%) boys and 36 (44%) girls with mean age 51 (SD 6 ,4 7) months. Children with MODS were 75%. Death was 37 (45%) and survival was 44 (54%) with mean length of stay was 181,92 (SE 30,23) hours. PELOD score was from 0 to 51. The best PELOD score related to death in coordinate point was 20,5 with ROC 0,862. Length of stay in grup \\lith PELOD score 20.5 was 93 (SE 17.48) hours (log rank P=0.000). S urvival function KM showed that the higher PELOD score, the shorter length of stay in PICU.Henceforth, the higher probability prediction of mortality. Conclusion PELOD score can be used as a prognostic predictor of mortality among PICU patients in Mohammad Hoesin Hospital (RSMH), Palemhang

Ketorolac vs. tramadol for pain management after abdominal surgery in children

Background Tramadol is a pure analgesic widely used for postoperative treatment and well tolerated by children. Howevet; it has only a 50% efficacy. Ketorolac, a nonsteroid anri inflammation drug (NSAID), is widely used in adults and has up to 85% clinical efficacy. Data supporting the use of ketorolac in children has been limited. Objective To compare the clinical efficacies of intravenous ketorolac and tramadol for moderatetosevere pain management after abdominal surgery in children. Methods A doubleblind controlled trial was conducted in Moh. Hoesin Hospital, Palembang, from January to June 2012. Subjects were postoperative children aged 1 7 years who met the inclusion criteria. T hey were randomized into two groups who received either intravenous ketorolac or tramadol. Subjects assessed their pain level using the Face, Legs, Anns, Cry and Consolability (FLACC) pain scale. T he FLACC scores ::::;3 were considered to indicate clinical success of the intervention. Data were analyzed by Ttest, Chisquare test, and Fischer's exact test. Results Of the 60 subjects who underwent abdominal surgery with general anesthesia, 31 (52%) were boys and 29 (48%) were girls. Subjects' mean age and body weight were 3.7 (SD 1.82) years and 12.6 (SD 2.85) kg, respectively. Mean duration of surgery was 71.7 (SD 21.11) minutes and mean postoperative FLACC score was 6.6 (SD 0.5). Eight subjects dropped out of the study. Efficacies of ketorolac and tramadol were not significantly different at 21/26 and 17/26, respectively (P=OJ5). In addition, there was no significant difference in the number of patients experiencing a >3 FLACC score decline between ketorolac and tramadol groups (P=0.61). Conclusion T here is no significant difference in the efficacies of intravenous ketorolac and tramadol for moderatetosevere pain management after abdominal surgery in children. [Paediatr Indones.2014;54:118.21.]

The pediatric index of mortality 3 score to predict mortality in a pediatric intensive care unit in Palembang, South Sumatera, Indonesia

Background For critically ill patients in the pediatric intensive care unit (PICU), a scoring system is helpful for assessing the severity of morbidity and predicting the risk of mortality. The Pediatric Index of Mortality (PIM) 3 score consists of ten easy simple variables, so that the probability of death can be assessed prior to undergoing advanced therapies. The PIM 3 score in inexpensive and comprised of routine laboratory variables performed in PICU patients. In Indonesia, studies to validate the PIM 3 score have been limited. Objective To evaluate the PIM 3 score for predicting the probability of death in the PICU, Dr. Mohammad Hoesin Hospital (MHH), Palembang. Methods A prospective, cohort study was performed in the PICU, MHH, Palembang, from February to April 2016. The PIM 3 score was calculated within 2 hours of patients admission to the PICU by an  android calculator application. PIM3 score and mortality were analyzed by Mann-Whitney test; calibration was performed by Hosmer-Lameshow goodness of fit test, discrimination was done by receiver operating characteristic (ROC) curve analysis; and standardized mortality ratio (SMR) was calculated. Results During the study period there were 81 PICU patients, 69 children were included, ranging in age from 1,5 to 187 months. The overall mortality rate was 40,58%. The most common illnesses in our subjects were malignancy (17,4%), post non-thoracic surgery (14,5%), dengue shock syndrome (14,5%), respiratory disease (13%), and neurological disease (11,6%). Subjects’ PIM3 scores ranged from 1,02% to 58,84%, with means of 26,08% in non-survivors and 13,05% in survivors. The SMR was 2,24, indicating that death was underpredicted. The AUC of 0,771 (95% CI of 0,651 to 0,891) indicated that the PIM3 score had good discrimination. Conclusion In Mohammad Hoesin Hospital, Palembang, South Sumatera, the PIM 3 can be used to predict mortality in PICU patients, but the score should be multiplied by a factor of 2.24. This recalibration is needed due to the presumed lower standard of care at this hospital compared to that of the originating PIM 3 institutions in developed countries