Volume 12

November 2009, Volume 12, No. 4
August 2009, Volume 12, No. 4
• Critical Care Economics:

  Health care costs represent a large percentage of the gross domestic product all over the world. According to the National Health Statistics Group, health care expenditure in the United States accounted for as much as 14% of the gross national product in 1992 and it is projected to reach 30% by 2030.
  The intensive care unit (ICU) represents the hallmark of highly competent modern hospitals, offering highly trained staff and life-saving technology and it is also one of the most expensive units in the hospital.
  Expenses related to running the ICU have been estimated at approximately 20% of total hospital costs, despite only representing 10% of all hospital beds.
  Assisted mechanical ventilation particularly affects the high costs in the ICU. Actually, a mere of 1 million persons per year receive mechanical ventilation during their stay in the ICU. A variety of different approaches to stabilize or reduce costs in the ICU have been suggested. Reducing the length of ICU stay, improving the patient’s condition to prevent co-morbid events, and introducing specialized teams to round in the ICU are some of the recent actions taken in the search for cost-effective therapies.
  The aim of this article is to provide some of the basic principles of economic assessment in critically ill patients and present an overall review of the strategies followed to reduce costs and resource usage in the ICUs around the world.

• The Use of APRV and Open Lung Management for Improving the Outcome of Lung Procurement for Transplantation:

  One of the most difficult organs to procure for donation is the lung. A detailed understanding of the physiology of mechanical ventilation and its effect on donor lungs is needed to impact on the outcome of lung transplantation. An organized protocol for mechanical ventilation management of the organ donor using the Open Lung Model may positively affect the number of organs that can be procured, and the function of these organs post transplant.
  Based on physiologic principles, the use of new modes of ventilation may affect the modulation of cytokines, decrease the transmigration of organisms into the donor lung, and preserve surfactant function in that lung. Therefore, we have developed a protocol guided by physiologic-based parameters and airway pressure release ventilation (APRV), with ongoing feedback from an advanced respiratory care team to manage donor patients closely.
  Setting: 650 bed university hospital and transplant center.
  Conclusion: We have developed a physiologic-based protocol, using APRV to achieve lung procurement that can decrease peak pressures and recruit the lungs using less and simultaneously increasing the PaO2 while using lower FIO2. This protocol may preserve surfactant function and assist during postoperative management.
  Additionally, this management mode may protect the donor organs from physiologic decay and even improve the outcomes. Further studies to measure long-term outcome need to be developed to validate physiologically based mechanical ventilation.

• Haemodynamic Stability and Vasopressor Use During Low-dose Spinal Anaesthesia in the High Risk Elderly:

  Background: Surgical repair of fractured neck of femur in the elderly is frequently performed under spinal anaesthesia. Elderly patients are particularly susceptible to developing hypotension with this technique. The use of single shot, low-dose bupivacaine/
  fentanyl spinal anaesthesia has been shown to significantly reduce the incidence of hypotension. This clinical audit compares the haemodynamic stability and the adequacy of the sensory block duration in elderly patients receiving low-dose bupivacaine spinal anaesthesia with patients receiving standard dose spinal anaesthesia.
  Method: Data from 60 elderly patients who had undergone surgical repair of fractured neck of femur within the same time period was collected using theatre coding records and systematic review of clinical notes. Thirty patients received a low-dose (4mg) bupivacaine plus 20 ?g fentanyl spinal anaesthetic (LDSA), 30 received a standard dose (10-14 mg) bupivacaine plus fentanyl (10-20 ?g) spinal anaesthetic (SDSA). Significant hypotension was defined as a systolic pressure decrease equal to or more than 25% of base line value or absolute value ?90 mmHg.
  Results: 76% of the SDSA group compared to 10% of the LDSA group experienced significant hypotension. Decreases in mean systolic pressures from baseline over time were significantly greater in the SDSA group (p<0.001). The incidence of inadequate surgical blocks was higher in the LDSA group at 26% (n=8) compared to 3% (n=1) in the SDSA group. Six of the 8 LDSA patients with inadequate blocks reported pain/discomfort around wound closure.
  Conclusion: In our elderly patients low-dose bupivacaine/fentanyl spinal anaesthesia provides greater haemodynamic stability compared to standard dose spinal anaesthesia during surgical repair of hip fractures. In a small percentage of patients in the LDSA group the surgical time outlasted the sensory block duration however, local anaesthetic applied to the operation site allowed uneventful completion of surgery.

• Gastric Emptying of Oral Nutritional Supplements Assessed by Ultrasound:

  Fasting has been the standard of many medical procedures such as upper endoscopic procedure, surgery, bronchoscopy and abdominal ultrasound imaging. Generally, the fasting recommendations follow The Canadian Anesthetist’s Society (CAS) and American Society of Anesthesiologists (ASA) guidelines. In that recommendation, patients only received clear liquid which contains simple carbohydrate or water two to six hours prior to surgery. After three hours of meal body has to provide nutritions for itself by gluconeogenesis.
  In addition to nutritional issues, gastric irritation and dehydration occur as well. All these conditions can have adverse effects on the patients pre and post-surgical outcomes.
  Oral nutritional supplements (ONS) contain complete nutrient is a standard formula which could be given as an option to the patients undergoing surgery or endoscopic procedures. In a preoperative period, besides providing adequate nutrients, ONS also improves patient satisfaction.
  We present a case of gastric emptying of 200 ml ONS assessed by ultrasound. The ONS when tracked by the ultrasound resulted in passing through the stomach within two hours. We suggest that 200 ml ONS can be given to patients two hours prior to medical and surgical procedures.

• Comparison of Apache II, SOFA, and Modified SOFA Scores in Predicting Mortality of Surgical Patients in Intensive Care Unit:

  Introduction: Scoring systems were developed to assess the severity of organ failures and to predict mortality. The sequential organ failure assessment (SOFA) score and its modification (MSOFA) are gaining popularity through their proven simplicity, validity, and reliability in previous studies.
  Objective: To determine and compare the validity of the SOFA and MSOFA scores with the Acute Physiology and Chronic Health Evaluation II (APACHE II) score for predicting mortality in surgical patients treated in ICU in Dr. Hasan Sadikin General Hospital in Bandung, West Java, Indonesia.
  Patients and Methods: This was a prospective observational cohort study involving consecutively 144 surgical patients (from January 2008 to December 2008). APACHE II, SOFA, and MSOFA scores were determined on admission. SOFA and MSOFA scores were also repeated every 48-72 hours until ICU discharge or death for determining mean and maximum values of SOFA and MSOFA. Scores validation were determined using Hosmer-Lemeshow goodness-of-fit test and receiver operating characteristic (ROC) curve analyses to determine the area under the curve (AUC).
  Results: Mortality rate was 39.8%. The mean APACHE II score (11.63±5.55, 14.95±4.27; p?0.001), SOFA(3.7±2.23, 5.86±2.88, p?0.001), and MSOFA(3.98±1.95, 5.79±1.98, p?0.001) were all higher in non-survivors than in survivors. Discrimination was less satisfactory for APACHE II (AuROC=0.69; p?0.001) and acceptable for both initial SOFA (AuROC=0.73; p?0.001) and initial MSOFA (AuROC=0.75; p?0.001). Mean and maximum values of SOFA and MSOFA showed even better discrimination values with AuROC=0.92;
  p?0.001, and AuROC=0.91; p?0.001 for meanSOFA and maksSOFA respectively, and AuROC=0.90; p?0.001, AuROC=0.90; p?0.001 for meanMSOFA and maksMSOFA respectively.
  Conclusion: SOFA and MSOFA scoring systems are better than APACHE II system in predicting mortality in ICU surgical patients. Serial measurements of SOFA and MSOFA score significantly improve their predictive accuracy.

• Posterior Reversible Encephalopathy Syndrome: A Review:

  Posterior reversible encephalopathy syndrome (PRES) is a clinical-neuroradiological entity characterized by headache, vomiting, altered mental status, blurred vision and seizures as well as images suggesting whitegray matter edema involving in most cases posterior regions of the central nervous system, as demonstrated by magnetic resonance image. The development of PRES is most commonly associated with hypertensive encephalopathy, preeclampsia-eclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome, and immunosuppressive/cytotoxic drugs. While usually reversible, the early recognition and treatment of this syndrome is important to prevent permanent neurological sequelae. The treatment is based in the management or withdrawal of the triggering factor. In this manuscript we will briefly review the pathogenesis, clinical scenario, diagnostic studies and management of PRES.

• Young Man with a Right ‘White-out’ Lung
August 2009, Volume 12, No. 3

• Management of Hydrofluoric Acid Injury in the Emergency Department and Critical Care Units:

  Exposure to hydrogen fluoride, whether in its gaseous or liquid form, can cause severe metabolic disturbances and even death. We present a case of an adult gentleman who was successfully treated after exposure to a large vapor cloud of hydrogen fluoride while working at a refinery. The patient exhibited various symptoms and signs including dermal, ophthalmic, and pulmonary irritation. He was successfully treated using various forms and routes of calcium gluconate administration. The prompt reaction and attention of the patient and his co-workers to this life-threatening exposure, and the recognition and awareness of the emergency department personnel limited the systemic absorption and toxicity. A comprehensive review of the literature is presented.

• Severe Plesiomonas shigelloides Gastroenteritis in a Young Healthy Patient:

  Introduction: Plesiomonas shigelloides gastroenteritis is rare in humans and occurs following the consumption of raw seafood, contaminated water and oysters containing the microorganism.
  Clinical Picture: We describe a case of a young healthy lady, who had severe gastroenteritis after eating undercooked fish at Hawker Centre. The stool culture grew positive for Plesiomonas shigelloides.
  Treatment and Outcome: She was treated with intravenous ceftriaxone and later changed to oral ciprofloxacin. She was discharged well.
  Conclusion: Plesiomonas shigelloides should be diagnosed and treated early as can cause severe gastroenteritis even in young healthy individuals. Untreated infections can be severe and fatal especially in immunocompromised hosts. Prevention of infection is the key and can be done by avoiding the consumption of raw seafood, contaminated water and oysters containing the microorganism.

• Ventilator Bundle Compliance: Report from a Neurosurgical Intensive Care Unit:

  Objective and Setting: Ventilator associated pneumonia (VAP) is the leading cause of mortality of hospital-acquired infections. One strategy for addressing this issue has been the ventilator bundle. This intervention was implemented in the University District Hospital (UDH) as part of an initiative to improve health care in the neurosurgical intensive care unit (NSICU) of an academic centre.
  Design and Interventions: From July 2007 to December 2007 educational strategies consisting of monthly lectures, bed pamphlets and card reminders were used to educate the health care team. Ventilator bundle intervention compliance was evaluated daily in random shifts during a 14-day period during July-August 2007 and December 2007.
  Measurements and Results: Pre-educational compliance was recorded at 6%. Individual component compliance was (1) Head of bed (HOB)>30° - 14%, (2) Withdrawal of sedation - 67%, (3) Peptic ulcer (PUD) prophylaxis - 93%, (4) Deep venous thrombosis (DVT) prophylaxis - 87%. Post-educational compliance was 59% with individual compliances of 74%, 72%, 95%, 92% respectively. A statistically significant increase in compliance was observed in ventilator bundle compliance and HOB elevation (p<0.01).
  Conclusions: A simple educational strategy can improve compliance of the ventilator bundle. This in turn and although not demonstrated can subsequently effect the mortality of patients. Collaborative work between team members of the unit is the key to compliance.

• Exercise-Associated Hyponatremia and the Varon-Ayus Syndrome
• Acute Lobar Atelectasis During Mechanical Ventilation: To Beat, Suck, or Blow?:

  We describe a patient with lobar atelectasis who was successfully treated with airway pressure release venti-lation (APRV) after failed attempts at recruitment with endotracheal suctioning, chest therapy, and bronchoscopy. We review the literature on the effectiveness of the various methods to treat lobar atelectasis. Mechanically ventilated patients have an ineffective cough reflex and are unable to adequately deal with their respiratory sections. Atelectasis is therefore a common problem in these patients. The risk of atelectasis may be increased with the widespread use of a lung protective strategy utilizing low tidal volumes (6 ml/kg IBW). Atelectasis may worsen hypoxemia through shunting and may predispose to nosocomial pneumonia. Traditionally the treatment of atelectasis in mechanically ventilated patients has centered on chest therapy (slapping, beating and vibrating) and endotracheal suctioning. When this fails, bronchoscopy and/or recruitment maneuvers are attempted. We describe the successful use of airway pressure release ventilation (APRV) for the treatment of atelectasis in a patient who failed the traditional treatment modalities.

• RhAPC in Neurocritical Care: Case Series and Literature Review of Spinal Cord Injury, Severe Sepsis and RhAPC Therapy:

  Spinal cord injury (SCI) is a serious condition that produces lifelong disabilities, with only limited therapeutic measures currently available. The incidence of SCI in the United States is estimated to be 30-40 cases per one million inhabitants, with resultant in-hospital mortality of 20 to 52 percent. Traumatic SCI is followed by a progressive injury process that involves various pathophysiological events that lead to tissue destruction. Although the mechanisms are not fully understood, progressive vascular events, such as ischemia/reperfusion-induced endothelial damage, are involved in this process. As in sepsis, studies have demonstrated that activated neutrophils are important in inducing the damage to endothelial cells. A common complication in patients with SCI is sepsis, which is associated with acute organ dysfunction, and results in a generalized inflammatory and procoagulant state. Sepsis is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock, that if related to SCI may be aggravated with concomitant spinal shock. We describe our experience with recombinant human activated protein C (rhAPC) in patients with SCI and severe sepsis (SS).

• An Unusual Chest Pain
• Role of Enteral Nutrition in Pre-operative Patients:

  Preoperative fasting had been the standard of care for years. In the light of newest recommendations this practice has been changing. In 1999, The Canadian Anesthetist’s Society (CAS) and American Society of Anes-thesiologists (ASA) had published guidelines, which recommends that patients be allowed to drink clear fluid two hours prior to induction of anesthesia. However, still the traditional preoperative approach of fasting for several hours is being carried out in several institutions. We present a case of burn patient who had undergone skin-graft surgically on four occasions. The patient received two different nutritional regimens in the pre-operative period; enteral nutrition and fasting. The preoperative nutrition management of patient with enteral nutrition resulted in more satisfaction, less hunger, thirst and reduced postoperative nausea and vomiting (PONV) as compared to when the patient was receiving no enteral nutrition in preoperative period.

May 2009, Volume 12, No. 2

• Differential Effects of Ventricular Pacing Sites of Contraction Synchrony and Global Cardiac Performance:

  Background: Quantification of left ventricular (LV) dyssynchrony allows for objective measures of resynchronization therapy (CRT) effectiveness. We tested the hypothesis that site of LV pacing, fusion beats and baseline contractility alter contraction synchrony as quantified by regional and global measures of LV performance.
  Methods and Results: In 8 open-chested pentobarbital-anesthetized
  canine preparations we compared the effects of right atrial (RA), RA-high right ventricular (RV) free wall, as a model of left bundle branch block contraction pattern, RA-LV apex (LVa), RA-LV free wall (LVfw), and RA-RV-apical LV (CRTa) and RA-RV-free wall LV (CRTfw), as CRT. LV pressure-volume loops recorded using high-fidelity pressure and conductance catheters and echocardiographic angle-corrected color-coded strain imaging of mid-LV short axis views analyzed radial strain from six segments. To control for contractile state esmolol-induced beta blockage was studied, and in 5 dogs to control for RA and ventricular pacing fusion beat artifacts, repeat studies were done following AV node ablation. RA-RV pacing reduced stroke work (SW) (57±18 to 33±13* mmHg·mL,*p<0.05 vs RA pacing), decreased LV end-diastolic volume and induced marked radial dyssynchrony (maximal time difference between peak segmental strain) from 31±15 to 234±60* ms. Changes in radial dyssynchrony correlated significantly with changes in SW (r=-0.53, p<0.01). Dyssynchrony improved with both CRTa and CRTfw (69*±31 and 98*±63 ms, respectively) while SW only improved with CRTa (62±22* and 37±13 mmHg·mL, respectively * p<0.05 vs RV pacing). CRTa also tended to increased LV end-diastolic volume over RA-RV. Esmolol slowed HR from 118±10 to 108±10 beats/min* and tended to decrease contractility (end-systolic elastance (Ees) from 12.1±7.9 to 8.9±3.9 mmHg/ml, p=0.167) but did not alter the degree of RV-pacing induced dyssynchrony. AV ablation had no effect on the observed apical and free wall contraction differences seen during baseline conditions.
  Conclusion: Although both CRTa and CRTfw reduced contraction dyssynchrony, CRTa tended to improve global LV performance more by increasing end-diastolic volume. Thus, CRT may improve global LV performance differently, depending on the LV pacing site.

• Purpura Fulminans Due to Staphylococcus Aureus: An Emerging Disease:

  Background: Purpura fulminans is an acute illness commonly associated with meningococcemia or invasive streptococcal disease. It is characterized by disseminated intravascular coagulation and purpuric skin lesions. In this article we reported a case of purpura fulminans associated with Staphylococcus aureus.
  Methods: The case was identified in the General Hospital of Mazatlán, Sinaloa, México during 2007. Staphylococcus aureus infection was diagnosed on the basis of culture result. Susceptibility to methicillin was determined. The ability of the isolated organism to produce super antigens was not possible to determine.
  Results: The isolated strain of Staphylococcus aureus in the present case was isolated from secretion of an intact phlyctena; the organism was not obtained from blood cultures. The isolated strain was methicillin resistant. We used immunomodulator drugs as alfa-2a interferon and thalidomide, antibiotics and support measures. The patient survived with intact extremities.
  Conclusions: Purpura fulminans due to Staphylococcus aureus is a newly and emerging disease commonly associated with superantigen production. It is a very aggressive and even fatal illness that deserves special attention.

• Giant Right Atrium Secondary to Mitral Stenosis:

  A 59-year-old Hispanic lady with history of rheumatic fever and chronic atrial fi brillation presented to the emergency department with severe dyspnea. Seventeen years prior to this presentation, she had undergone re-do mitral valve replacement, and tricuspid annuloplasty. The patient’s chest radiograph revealed massively dilated right chambers of the heart (Figure 1). An electrocardiogram showed right axis deviation, atrial fi brillation with a controlled heart rate of 70 beats per minute. A chest computed tomography (CT) scan revealed a gigantic right atrium measuring approximately 12 cm in its largest diameter (Figure 2).
  These images are relevant because this reveals one of the few cases of massively dilated right atrium, despite previous mitral valve replacement and tricuspid annuloplasty. Other etiologies of a dilated right atrium in patient with dyspnea in the ED and intensive care unit (ICU) include: chronic obstructive pulmonary disease, tricuspid valvular stenosis, severe mitral valvular pathology with pulmonary hypertension, chronic pulmonary emboli, and untreated congenital heart disease.

• Portal and Splenic Vein Thrombosis Caused by Acute Pancreatitis:

  A 30-year-old Hispanic gentleman with past medical history of hypertension and dyslipidemia, presented to the emergency department with complaints of a blunt, constant, epigastric pain radiating to his back for 24 hours. Physical examination revealed a man in severe distress, tachypneic and tachycardic. Laboratory data, as well as the physical exam, were consistent with acute severe pancreatitis. The patient was admitted to the intensive care unit (ICU) and a computed tomography (CT) of his abdomen was obtained revealing a large thrombus in the portal vein (Figure 1).
  The patient’s condition deteriorated requiring assisted ventilation and vasopressor support. Two weeks following his admission to the ICU, a repeat CT of the abdomen revealed persistence of the portal vein thrombus and a new splenic vein thrombosis (Figure 2). The patient was managed conservatively with anticoagulation and eventually weaned off assisted ventilation. The patient was discharged home several weeks after his initial admission.

• Respiratory Distress in an Elderly - Delayed Presentation of an Odontoid Fracture:

  An 85-year-old man with history of severe dementia lay down for a nap and was witnessed by his family to immediately lose consciousness, with agonal breathing. He was ventilated by facemask by the paramedics when they attended. His vital signs were stable. On admission to hospital he grimaced to painful stimulus only (Glasgow Coma Score=6/15). His arterial blood gas revealed - pH 7.21, pCO2 70 mmHg and bicarbonate 27 mmol/L. He was intubated.
  The patient had a fall 1 week before. He had complained of intermittent headache and neck pain since then. He also developed new symptoms of breathlessness upon lying fl at. Computed tomography (CT) of cranium and neck was done. Figure 1 and 2 showed a fracture through the base of the odontoid (type II). Figure 3 showed prevertebral soft tissue swelling associated with the fracture. After discussion with the family, he was treated conservatively with a cervical collar in view of his advanced age and dementia.

• Venomous Snakebites in Two Children:

  Venomous snakebites, although uncommon, are potentially fatal. Venomous snakes can be grouped as having hemotoxic and neurotoxic venom. Children with venomous snakebites present with signs and symptoms ranging from fang bite marks, with or without swelling and local pain, to severe condition such as coagulopathy, renal failure and shock. We reported two pediatric cases of snakebites admitted at the same day to Pediatric Emergency Department Dr. Hasan Sadikin Hospital from two different areas in Bandung. Both patients had similar clinical signs and symptoms consisted of fang bite marks, local pain, tingling, swelling beyond the area adjacent to proximal lesion. Both patients were bitten by venomous snakes and thus were treated with antivenin sera immediately. Identifi cation of the snake from the first case could be done straight away because the victim could recognize the snake from the pictures that were shown to him that we assumed came from subfamily of Elapidae. Patient from the second case could not identify the type of snake. Hospitalization for at least 24-48 hours is required to monitor victims of venomous snakebites for signs and symptoms of neurologic or hematologic disorder. Both patients were discharged from the hospital in good condition after 48 hours of monitoring.

February 2009, Volume 12, No. 1
• Lupus Pneumonitis
• Effect of APRV with PS on Indices of Oxygenation and Ventilation in Patients with Severe ARDS: A Cohort Study:

  Background: Airway pressure release ventilation (APRV) is an alternative approach to the “open-lung” ventilation strategy and has recently emerged as an alternative ventilatory strategy in patients with severe ARDS.
  Aims: Our objective was to assess the effect of APRV+low level pressure support (PS) on indices of oxygenation and ventilation in patients with severe ARDS.
  Methods: During the study period we recorded oxygenation and ventilation data (for up to 96 hours) as well as the use of sedative and vasopressor agents in patients in our MICU with severe ARDS (PaO2/FiO2<150) who we switched to APRV+PS from low tidal volume assist-controlled (AC) ventilation. Vd/Vt was measured by volumetric capnography. Patients were followed until hospital discharge or death.
  Results: Twenty-two patients with severe ARDS secondary to sepsis were studied. The patients were on AC for 4±3.5 days prior to conversion to APRV. The PaO2/FiO2 increased (134±48 to 210±87 mmHg; p=0.03) while the Vd/Vt fell signifi cantly (66±10 to 54±10%; p=0.01) by 24 hours. These changes were maintained throughout the study period. The total daily dose of sedative and vasopressor agents decreased by 46% and 55% respectively by 24 hours. While these patients were critically ill with a high anticipated mortality, 12 (54%) survived to hospital discharge.
  Conclusions: APRV+PS improves oxygenation and V/Q mismatching in patients with severe ARDS allowing a decrease in the use of sedative agents. While the survival benefit of APRV could not be assessed in this study, APRV should be considered in the ventilatory strategy of patients with severe ARDS.

• Efficacy and Safety of Preoperative Administration of Half Molar Hypertonic Sodium Lactate during TURP:

  Background: Water irrigation during transurethral resection of prostate (TURP) often caused hyponatremia, hypoosmolality, and decreasing of pH called TURP syndrome. Current standard fluid therapy in TURP still could not prevent or correct TURP syndrome. This study was aimed to assess the efficacy and safety of preoperative hypertonic sodium lactate (HSL) infusion in maintaining plasma sodium level, osmolality, arterial pH and hemodynamic parameters during TURP compared to normal saline (NS).
  Methods: In this prospective randomized controlled double blind study, 22 patients underwent TURP surgery under spinal anesthesia were assigned into 2 groups with 11 patients in each group. HSL or NS were administered before spinal anesthesia with loading dose 4 mL/kgBW within 20 minutes. During procedure NS with 2-4 mL/kgBW/hr were infused as maintenance in both groups.
  Result: Postoperative mean of sodium level and osmolality in HSL group was significantly different compared to NS group (142.2±2.0 mEq/L vs 138.9±2.1 mEq/L, p<0.05, and 294.6±3.5 mOsm/kg vs 290.6±3.2 mOsm/kg, p<0.05) respectively. Postoperative pH in HSL group was 7.433±0.04, whereas in NS group was 7.356±0.05 (p<0.05). Evolution of hemodynamic parameters was better in HSL group. Five of 11 patients in NS group need ephedrine injection due to decreased of blood pressure >30% after spinal anesthesia, whereas none of patients in HSL group need ephedrine.
  Conclusion: Preoperative administration of hypertonic sodium lactate in TURP was better in maintaining plasma sodium level, osmolality, arterial pH and also hemodynamic parameters than normal saline.

• Compliance of Guidelines for Intensive Care Unit Admissions in San Juan City Hospital in a Three Months Period:

  Purpose: To measure the degree of compliance of national guidelines for admission to the Intensive Care Unit (ICU) at San Juan City Hospital (SJCH).
  Design: This was a prospective observational cohort study at an urban academic hospital. We revised prospectively for three consecutive months all the patients admitted to ICU and then compare the admission criteria used with the national guidelines for ICU admission.
  Patients and participants: We included all patients who were admitted to ICU from September 1st to November 30th, 2006, for a total of 125 patients.
  Interventions: Data collection from the medical record at the time of admission to ICU.
  Measurements and results: A total of 125 patients were admitted to ICU during the three months period of the study. Of these 58% were in compliance with national guidelines. The pulmonary system criteria was the most numerous admission criteria with 41.9% followed by the cardiac system criteria with 25.7% and gastrointestinal system criteria with 13.5%. Regarding the objective parameters model criteria the vital signs and laboratory values was the most frequent with 35.7% followed by electrocardiogram parameters criteria with 21.4% and physical findings criteria with 7.1%.
  Conclusions: Our findings revealed that, in general, admissions at SJCH are done accordingly to national guidelines. But a 42% of admissions without criteria is a very high number of admissions which signified a wrong utilization of expensive resources. This finding correlates with the deficiencies in admission criteria knowledge among medical admission officers.

• Heparin-Induced Thrombocytopenia (HIT) Syndrome:

  Heparin has been available as a clinical treatment and prevention for thromboembolic disease for half a century. Known complications of heparin therapy include bleeding, allergic reactions, osteoporosis, and thrombocytopenia. Heparin-induced thrombocytopenia (HIT) is a common and potentially grave adverse effect of heparin treatment. HIT is unusual among drug-induced thrombocytopenias in that it is more apt to cause thrombosis than bleeding. HIT-associated thrombosis can result in arterial and venous thrombosis leading to stroke, myocardial infarction, limb gangrene, amputation and even death. HIT pathogenesis is thought to involve antibody binding to an epitope on the platelet factor 4 (PF4)-heparin complex. The antibody bound complex then binds Fc?RII receptors on the platelet surface, which activates blood-coagulation pathways and concomitantly produces extensive platelet activation and aggregation. HIT diagnosis is based on the presence of thrombosis and diagnostic laboratory tests including immunoassays for HIT antibodies and functional tests, such as the 14C-serotonin release assay. Heparin treatment should be withdrawn immediately upon diagnosis of HIT, and the patient should be subjected to an alternative treatment for at least 5 days unless the HIT diagnosis is disproven. Once the patient has been stabilized, warfarin treatment should commence while the patient is still receiving the alternative anticoagulant therapy.

• Ventilator Associated Pneumonia: Incidence, Etiology, and Preventive Strategies:

  Objective: To determine the incidence of ventilator associated pneumonia (VAP) in the intensive care unit, and to characterize most common causative pathogens and resistance pattern. To evaluate compliance to VAP prevention strategies and their documentation in order to identify areas for quality improvement.
  Design: A retrospective single center study was performed in which medical records were reviewed from all patients on mechanical ventilator admitted to intensive care unit from January to December 2007. The Clinical Pulmonary Infection Score (CPIS) and problem list were used to identify VAP cases. Data on microbial isolates and antimicrobial resistance were collected as well as documentation of measures to prevent VAP.
  Setting: A multidisciplinary, eight-bed Intensive Care Unit (ICU) at a metropolitan municipal hospital in Puerto Rico.
  Patients and participants: A total of 60 patients that required mechanical ventilation for more than 48 hours.
  Measurements and results: The overall estimated VAP rate was 37.15. There was an extremely low compliance to head of bed elevation, daily sedation interruption and oral care. The most common pathogens identified in early and late onset VAP were Klebsiella species, Acinetobacter baumanii, and Pseudomonas aeruginosa, all being multidrug resistant pathogens.
  Conclusions: The lack of compliance to VAP preventive measures as part of the routine management of patients in mechanical ventilation may explain the high VAP rate. Multidisciplinary teams are needed to establish standardized protocols as well as periodic quality improvement reviews to prevent this complication.

• Persistent Fever in a Young Critically Ill Woman
• The 16th International Symposium on Critical Care & Emergency Medicine