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   Table of Contents - Current issue
April-June 2022
Volume 6 | Issue 2
Page Nos. 73-126

Online since Monday, May 9, 2022

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Neutrophil–Lymphocyte Ratio and Dysbiosis: New Paradigm of Immunonutrition p. 73
Vera Irawany, Marilaeta Cindryani
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Intratracheal Lidocaine Reduces Incidence of Cough During Extubation and Sore Throat After Tonsillectomy Surgery: A Randomized, Single-blind Clinical Trial p. 75
I Made Artawan, Sidarta Sagita, Maria Agnes Etty Dedi
Background: The incidence of cough during extubation occurs in 40–76% of patients. One effort to reduce this incidence is the use of lidocaine. This study aims to further investigate the benefits of intratracheal lidocaine in reducing the incidence of cough during extubation and sore throat after tonsillectomy surgery. Materials and Methods: This study is a single-blind clinical trial. The research subjects were taken by consecutive sampling. A total of 51 subjects who met inclusion and exclusion criteria will be divided into three groups: lidocaine intubation group (Group LI); lidocaine extubation group (Group LE), and control group. Comparison of cough scores during extubation and sore throat scores on the 1st and 6th hours after tonsillectomy surgery in the three groups was analyzed. Results: In this study, the results showed the cough scores and sore throat scores on the 1st and 6th hours postoperatively between the LI and LE groups when compared with the control group were significantly lower (P < 0.001). The cough scores between the LI group and the LE group were not significantly different (P = 0.234). Likewise, comparison of sore throat scores on the 1st and 6th hours postoperatively between the LI group and the LE group was not significantly different (P = 0.728 and P = 0.537, respectively). Conclusion: Lidocaine intratracheal given just before intubation or just before extubation significantly reduced the incidence of cough during extubation and sore throat on the 1st and 6th hours postoperatively when compared with placebo in the post-tonsillectomy surgery.
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Basil (Ocimum basilicum) Leaves Essential Oil Ameliorates GluR1 Receptor Expression, TNF-α Level, and Pain-like Behaviors in Post-operative Pain Setting p. 80
Dewa Ayu Mas Shintya Dewi, Made Jawi, Nyoman Mantik Astawa, Christopher Ryalino
Background: Unrelieved post-operative pain is an emerging healthcare concern with ever increasing global volume of surgical procedures. GluR1 subunit coupled with tumor necrosis factor (TNF)-α expression plays a major role in the development of post-operative pain mediated by α-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) receptor. There was no existing evidence on the analgesic potential of basil essential oil (BEO) in post-operative settings, despite its well-established antinociceptive and anti-inflammatory activities. Materials and Methods: BEO was subjected to gas chromatography–mass spectrometry (GC–MS) analysis to identify the active ingredients. The antinociceptive and anti-inflammatory activities of orally administrated basil (Ocimum basilicum) essential oil were tested in a rat model of post-operative pain using hindpaw surgical incision as noxious stimuli. TNF-α and GluR1 subunit expressions were measured using enzyme-linked immunosorbent assay and immunohistochemistry methods. Spontaneous pain and mechanical hyperalgesia were measured using mouse grimace scale and Von Frey monofilament test, respectively. All outcomes were evaluated in acute post-operative pain timeframe. Results: Chemical analysis identified 14 terpenoids predominated with caryophyllene and citral. BEO administration caused a significant reduction of TNF-α (67.23 ± 2.46 vs. 70.45 ± 4.89; P = 0.019) and GluR1 (3.03 ± 0.56 vs. 3.90 ± 1.12; P = 0.005) levels at 24 h after surgical incision when compared with the control group. Significant spontaneous pain, pain threshold, and pain-like behaviors frequency reduction at 1-, 4-, and 24-h post-surgical incision were also noted. Conclusion: Effective antinociceptive activity of BEO through modulation of GluR1 and TNF-α levels was further confirmed in the behavioral outcome. Advancement into clinical translation necessitates BEO pharmacological profiling, especially given the diversity of chemotypes.
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Effects of Parenteral Protein Concentrations in Critically Ill Patients in ICU: A Comparative Study p. 85
Ibrahim Abbas Youssef, Karim Naser Hasan, Ahmed Hassanein Mohmed
Background: Parenteral protein supplements can prevent deterioration of acute critical illness during admission at intensive care unit (ICU). This study aimed to evaluate the effect of parenteral proteins on ICU outcome and to compare the effect of two different protein concentrations on handgrip strength in critically ill patients. Materials and Methods: This prospective comparative study included 60 acute critically ill patients who had parenteral nutrition during their ICU stay. The patients were divided into two groups: a standard protein group who received protein concentration of 1 g/kg/day (group A) and a high-protein group who received protein concentration of 2 g/kg/day (group B). The nutrition was delivered through a central line and the separate bottles technique. Results: Nitrogen balance was more negative in group B compared to group A within the first 3 days. The handgrip strength on day 7 was significantly higher in group B than group A. The forearm thickness, quadriceps muscle thickness, and overall muscle thickness were significantly higher in group B on day 7. The durations of mechanical ventilation, ICU stay, and total hospital stay were not significantly different between both groups. The protein dose was not significantly associated with the overall 2-month mortality. Conclusion: High parenteral protein intake (2 g/kg/day) associated with better handgrip strength and significant improvement of muscle thickness at the end of the 1st week of follow-up. Studies with larger sample size and longer durations of follow-up are recommended.
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The effect of body temperature changes on inflammation response and patients’ comfort in patients undergoing laparotomy with general anesthesia p. 91
Fransiskus Silvester Raymond Galag, Tjokorda Gde Agung Senapathi, Made Subagiartha, Ida Bagus Krisna Jaya Sutawan, Christopher Ryalino, Adinda Putra Pradhana
Background: Surgery and general anesthesia are responsible for disrupting the normal balance between heat production and loss. Inadvertent perioperative hypothermia is a common complication in patients undergoing surgery with general anesthesia. General anesthestic agents are known to cause suppression of thermoregulatory defense mechanisms during general anesthesia, which results in perioperative hypothermia. Hypothermia carries significant various adverse effects; patients’ discomfort and inflammatory stress response are the two variable which will be studied. Materials and Methods: This is a prospective observational analytic cohort study, conducted in the central operating theater of Sanglah Hospital, Bali over a period of 4 months. We included all eligible patients who underwent elective laparotomy and gave consent to the study. Body temperature was measured in three different locations: axilla, tympanic membrane, and nasopharynx, before, during, and after surgery. We measured C-reactive protein (CRP), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (PLR) before and after the surgery. Patients’ comfort level was obtained using the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) scoring system. Results: A total of 60 patients were included. There was a significant increase of inflammatory markers, CRP, PLR, and NLR, before and after the surgery (P < 0.001), as well as reduced body temperature during surgery (P < 0.01); however, there was no significant relationship between the two (P > 0.05). The changes of body temperature significantly affect patients’ comfort level (P < 0.001), whereas room temperature did not show significant impact on patients’ comfort level. On linear regression, there is no significant correlation between body temperature changes and inflammatory response escalation. The increase of CRP was significantly correlated with gender, women, and blood loss, whereas the increase of PLR was related significantly with blood loss and age. Conclusion: Surgery and general anesthesia are causing hypothermia and escalation of inflammatory response. This study result supports prior publication in which both surgery and general anesthesia are the cause of inadvertent perioperative hypothermia; yet, hypothermia does not induce significant rise in all of inflammatory responses measured in this study. It is believed that the major surgery stress response is the cause of significant increase in inflammatory responses.
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Custodiol-HTK Solution Vs. Conventional Cardioplegia for Myocardial Protection During Coronary Artery Bypass Grafting Following Recent ST-Elevation Myocardial Infarction p. 97
Walaa Ahmed Saber, Mohamed El-Ghannam, Yasser Shaban Mubarak, Hesham Hassan Mahdy, Ramy Mohamed Reda Khorshid
Background: Histidine-tryptophan-ketoglutarate (HTK), Bretschneider’s, or Custodiol is an intracellular crystalloid cardioplegic solution which is claimed to offer single shot cardioplegia for myocardial protection during complex cardiac procedures for up to 3 h. We aimed to compare the clinical outcome of early coronary artery bypass grafting (CABG) using blood cardioplegia vs. Custodiol solution for myocardial protection in patients with recent ST-elevation myocardial infarction (STEMI). Materials and Methods: This prospective comparative study included 100 patients with recent STEMI who underwent early CABG at our institution between January 2019 and December 2020. The patients were divided into two groups: group A (n = 50) received blood cardioplegia and group B (n = 50) received Custodiol-HTK crystalloid cardioplegia. Results: There were non-significant differences in postoperative mortality and complication rates between both the groups except for significantly higher proportion of post-operative arrythmias after Custodiol cardioplegia (26% vs. 8%, P = 0.01). Custodiol was associated with significantly lower levels of blood troponin and higher levels of blood lactate for 6 h after CABG. Custodiol results in significantly shorter durations of mechanical ventilation (11.98 ± 4.03 vs. 18.28 ± 8.84 h, P < 0.001) and intensive care unit (ICU) stay (70.04 ± 14.80 vs. 80.20 ± 19.91 h, P = 0.01), with non-significantly shorter duration of post-operative hospital stay (7.98 ± 2.76 vs. 9.24 ± 3.41 days, P = 0.06). Conclusion: Custodiol as a single shot without interruption of the operative technique offers shorter durations of mechanical ventilation and ICU stay than blood cardioplegia, with more acceptable levels of post-operative troponin in high-risk patients who underwent early CABG for recent STEMI.
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The Bacteriological and Clinical Outcomes of Ventilator-associated Pneumonia Post-cardiac Surgery in the Pediatric Surgical Intensive Care Unit: A Prospective, Observational Study p. 103
K S Bharathi, Gegal Pruthi, S Lathashree, Parimala Prasanna Simha
Background: Ventilator-associated pneumonia (VAP) is a serious nosocomial infection that threatens pediatric patients who have undergone cardiac surgery. The aim of this study is to analyze the bacteriological profile and antibiotic resistance pattern of the organisms grown from pediatric patients diagnosed as VAP after cardiac surgery and also to study the bacteriological and clinical outcomes of the patients. Patients and Methods: This prospective observational study was conducted in a tertiary care teaching institution in children aged younger than 14 years who had undergone cardiac surgery and were diagnosed to have VAP and on mechanical ventilation (MV). The clinical and the bacteriological profile of patients with VAP, the systemic antibiotics used, the resistance pattern to the antibiotics, and, finally, the bacteriological and clinical outcomes were analyzed. Results: Among the 98 patients with VAP, 55% were early onset (<4 days of MV) and 45% were late onset (>4 days of MV) VAP. Among the most common pathogens causing VAP, Klebsiella and Escherichia coli contributed to 18% each of the total VAP. Twenty percent of VAP were polymicrobial in origin. About 63% of organisms were resistant to Augmentin, and 11% of the organisms were multidrug resistant (MDR). Conclusion: This study not only showed the pattern of early and late onset VAP but also revealed the bacteriological profile and the resistance pattern of the local microbial flora causing VAP, guiding us in a more efficient management of VAP in children.
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Comparison of Macintosh, McCoy, Truview EVO2, and King Vision Laryngoscopes for Intubation in Patients with Immobilized Cervical Spine: A Randomized, Controlled Trial p. 108
Smita Gulati, Samarendra Nath Samui, Anisha De
Background: Immobilization of the neck in cervical spine injury patients can lead to misalignment of the oral, pharyngeal, and laryngeal axis, thereby making intubation more difficult. The principal aim of our study was to compare the efficacy of King Vision, Truview Evo2, and McCoy with Macintosh laryngoscope in patients getting intubated with cervical spine immobilized using manual inline stabilization. Materials and Methods: This was a randomized, controlled trial of 160 patients who were randomized to undergo surgery under general anesthesia with endotracheal intubation. We equally divided the subjects into using either Macintosh, McCoy, Truview Evo2, and King Vision laryngoscopes to facilitate intubation. We evaluated the intubation difficulty using the Intubation Difficulty Score (IDS) and Cormack–Lehane grading. Results: King Vision, Truview Evo2, and McCoy reduced the IDS as compared to Macintosh (P < 0.001). King Vision showed a first-attempt success rate of 100%. Cormack and Lehane’s glottic views were best with King Vision followed by Truview Evo2 and there was much less need for external manipulation as compared to McCoy and Macintosh. Time taken for intubation was least with McCoy blade (22.9 ± 7.2 s, P < 0.001). Conclusion: The use of both King Vision and Truview Evo2 significantly resulted in a decreased the IDS and improved Cormack–Lehane grading as compared to Macintosh and McCoy.
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Neutrophil and Platelet Count Upon Hospital Admission as Predictors of Severe COVID-19 Infection: An Observational Study p. 115
I Made Bagiada, I Gde Raka Widiana
Background: The severity of COVID-19 infection may depend on severe inflammation and hypercoagulability mechanisms. These processes may be rapidly identified in peripheral blood tests. This study aims to determine whether components of complete blood counts are able to predict the severity of COVID-19 infection. Materials and Methods: This is a prospective, observational analytical study carried out in the Indonesian population. We included all patients admitted to our hospital for COVID-19 during a 3-month period. We obtained blood samples for complete blood count examinations upon hospital admission. Confirmation of COVID-19 infection was based on a polymerase chain reaction test. Severe COVID-19 infection was determined if the patients had a Severe Community-Acquired Pneumonia (SCAP) score of >10. We collected blood samples upon hospital admission for leukocyte, neutrophil, lymphocyte, platelet, and monocyte counts. Results: We included 131 patients consisting of 77 (58.8%) males and 54 (41.2%) females. There were significant associations between neutrophil count and SCAP score (r = 0.28; P = 0.001) and platelet count (r = 0.023; P = 0.007). Upon regression analysis, we found that every 1,000 declines in platelet count was associated with increased risk (0.8%) of severe COVID-19, whereas every 1,000 declines in the neutrophil count was associated with decreased risk (18%) of severe COVID-19. Conclusion: There is a significant, weak positive correlation between neutrophil and platelet counts and the severity of COVID-19 infection as expressed by the SCAP score.
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Transfusion-related acute lung injury (TRALI) in post-partum bleeding patient: A case report p. 119
Maulydia Maulydia, Prananda Surya Airlangga, Mara Imam Taufiq Siregar, Dewi Rosita Hendriana
Transfusion-related acute lung injury (TRALI) is a rare but fatal complication of blood transfusion. However, it is frequently under-reported and not diagnosed. We reported a 32-year-old pregnant woman at 30/31 gestational weeks who developed acute respiratory distress and hemodynamic instability during transfusion in the post-operative period. Diagnosis of TRALI was made after excluding other possible causes of acute lung injury. We treated the patient with conservative treatment in the obstetrics emergency room based on the initial examination results and scheduled for an elective cesarean section (C-section). Transfusions of packed red blood cells were planned to increase the Hb level. The patient suddenly experienced shortness of breath during the transfusion with a relative risk of 30–36×/min. The patient was given 10 lpm oxygen via a non-rebreathing mask, and oxygen saturation was 86%. The patient’s blood pressure was 88/40 mmHg, and heart rate was 126×/min. The transfusion was immediately stopped. Fluid resuscitation with a crystalloid solution for hemodynamic improvement was given when the patient was intubated. After several treatments, the patient’s condition was getting better. On day 4, hemoglobin level increased to 9.1 mg/dL, hematocrit 27.6%, leukocytes 9.660/µL, and platelets 72,000/µL. Ventilator weaning was done gradually, and the patient was finally extubated on the 5th day of treatment.
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Technological Advances in Cardiac Anesthesia: We Live in Exciting Times Ensuring Better Patient Safety and Care p. 123
Kunal Sarin, Ajay Chandra, Anurag Garg
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The Future Role of Galectin-3 in COVID-19 Era p. 125
I Made Gede Widnyana, Marilaeta Cindryani, Ni Made Ayu Wulan Sari
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