Pada pasien COVID-19 dengan ARDS terjadi gangguan oksigenasi dan ventilasi. Menurut kriteria Berlin ARDS, oksigenasi diukur dengan PaO2/FiO2, namun tidak mengukur ventilasi alveolar yang diukur dengan dead space yang dapat terjadi akibat kondisi, seperti kerusakan endotel, mikrotrombus, dan penggunaan ventilator yang berlebih. Tujuan penelitian ini menganalisis penggunaan ventilatory ratio (VR) dan dead space fraction (Vd/Vt) sebagai prediktor mortalitas pasien COVID-19 ARDS. Penelitian ini adalah analitik kohort retrospektif. Data dikumpulkan dari rekam medik pasien COVID-19 yang dirawat di RIK RSUD Dr. Soetomo periode Juni–September 2020 dengan teknik total sampling terhadap subjek yang memenuhi kriteria inklusi dan tidak termasuk eksklusi. Data yang dikumpulkan adalah nilai VR dan Vd/Vt (diambil dari data laboratorium), kondisi klinis pasien dan pengaturan ventilator 24 jam pertama setelah terintubasi. Penelitian ini didapatkan 77 dari 80 subjek yang memenuhi kriteria. Nilai VR berhubungan dengan mortalitas secara signifikan dengan nilai p 0,001; cut off 1,84; sensitivitas 84,2%; spesifisitas 85%; RR 30,22; CI 95%: 7,31–124,89. Vd/Vt dan mortalitas menunjukkan hubungan yang signifikan terhadap mortalitas dengan nilai p 0.001. Uji analisis Spearman VR dengan Vd/Vt didapatkan hasil korelasi yang kuat dengan koefisien korelasi 0,704 dan p 0,001. Simpulan, nilai VR dan Vd/Vt dapat digunakan sebagai prediktor mortalitas pasien COVID-19 dengan ARDS dan keduanya mempunyai korelasi yang kuat. VR dapat menggantikan Vd/Vt.
<p>Rational empirical antimicrobial therapy is an important component of sepsis patient management. This study aimed to assess the rationality of empirical antimicrobial therapy in patients diagnosed with sepsis admitted in intermediate care ward of internal medicine department (RPI) of Dr. Soetomo General Hospital from January 2016 to July 2017. Medical records of 91 patients diagnosed with sepsis were collected and studied retrospectively in period from July 2017 to November 2017. 91 (85.05%) medical records from 107 sepsis patients were evaluated. Cultures and antimicrobial sensitivity tests were carried out in 21 (23.07%) patients. 14 patients yielded positive culture results, 9 of which were MDRO positive with ESBL as resistant marker. Empirical antibiotic therapies for these patients were reviewed according to Gyssens method.</p><p>73 (80.2%) of 91 patients were deemed receiving appropriate empirical antibiotic therapies. Ceftriaxone IV injection as monotherapy or combination therapy were the most common empirical antibiotic therapies (82 in 91 patients, 90.1%), despite local microbiologic flora and antibiogram show most pathogens were resistant to ceftriaxone. Mortality rate in this study was high, 92.3% (84 patients died) despite rational empirical antibiotic therapies were high.<strong> </strong>This study concluded that empirical antibiotic therapies in sepsis patients according to guidelines adopted in Soetomo General Hospital, albeit deemed rational, was no longer appropriate according to local antibiogram issued by microbiological department of Soetomo General Hospital.</p><p> </p><strong>Keywords: <em>Empirical Antibiotics Therapy, Gyssens criteria, Intermediate Care Ward, Sepsis, Septic Shock</em></strong>
Introduction: Myasthenia gravis (MG) is an acquired autoimmune disorder clinically characterized by skeletal muscle weakness & fatigability on exertion with prevalence as high as 2–7 in 10,000 and women are affected more frequently than men (~3:2). Over 12-16% of generalized MG patients experience crisis once in their lifetime. A serious complication of myasthenia gravis is respiratory failure. This may be secondary to an exacerbation of myasthenia (myasthenia crisis) or to treatment with excess doses of a cholinesterase inhibitor (cholinergic crisis). Case Report: Thirty-two years old woman refereed from a private hospital to ED for further treatment with myasthenia in crisis, after nine days of treatment in the previous ICU. Patient already in intubation with mechanical ventilation and history of the treatment of a high dose of multiple anticholinesterase drugs and steroids without plasmapheresis or immunoglobulin intravenous. During admission, diarrhea was present, with no sign of GI infection. On the third day of admission, the patient performed a Spontaneous Breathing Trial and was a success then extubated. Then two day after extubation, the patient falls to respiratory failure and need mechanical ventilation. Anticholinesterase test was performed, and it shows no improvement in clinical signs, and diagnose as Cholinergic Crisis. After re-adjustment of anticholinesterase drug with a lower dose, clinically, the respiratory condition improved, and on the 10th day of admission, the patient was succeed extubated. At 12nd days of ICU admission, patient discharge from ICU. Discussion: Myasthenia and Cholinergic Crisis is a severe and life-threatening condition characterized by generalized muscle weakness with a respiratory compromise that requires ventilatory support. Respiratory failure may be present in the cholinergic crisis without cholinergic symptoms (miosis, diarrhea, urinary incontinence, bradycardia, emesis, lacrimation, or salivation). The most important management aspect of Myasthenia patients in crisis is the recognition and treatment of myasthenia vs cholinergic crisis.
Sepsis is the most common cause of ICU mortality in USA. Mortality of sepsis in developing countries is still very high, about 50- 70% and has became a 80% incidence in septic shock. There was a decrease of CD4+ T lymphocyte count in patients with sepsis caused by apoptosis indicating septic patients suffered from immune functional impairment. CD4+ T lymphocyte count can reflect the severity of sepsis and predict the prognosis of the patients with sepsis effectively. Eighty eight (88) patients who met sepsis criteria were studied. The researchers collected clinical variables of all patients within 24 hours diagnosis of sepsis, and calculated APACHE II score. At the same time, blood sample were taken to measure the CD4+ T lymphocyte count. The data were analyzed using independent Student-T-test and ROC curve was used for prognosis. There is a significant difference in CD4+ T lymphocyte count between non survival and survival group (non survival group 203±178 cells/μL, survival group 442±303 cells/μL, p<0.001), and the percentage of CD4+ T lymphocyte (non survival group 25.05±11.55%, survival group 34.38±9.15%, p<0.001). There is an under ROC curve for CD4+ T lymphocyte count was 0.81, and for the percentage of CD4+ T lymphocyte was 0.748. Cut off value for CD4+ T lymphocyte count was 204 cells/μL, and the percentage of CD4+ T lymphocytes was 25.23%. Based on this study, the CD4+ T lymphocyte count can be used as a predictor of prognosis in sepsis patients.
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