Crit Care Research Articles

Abstract Su1202: The utility of post cardiac arrest temperature control protocol according to the severity of hypoxic encephalopathy based on amplitude-integrated electroencephalography findings

Introduction: The TTM2 trial showed that active fever prevention below 37.5°C and hypothermia at 33°C had similar outcomes in out-of-hospital post cardiac arrest patients. However, the patients in the trial had mild hypoxic encephalopathy, and the effects of hypothermia may vary with its severity. We previously reported that amplitude-integrated electroencephalography (aEEG) findings after the return of spontaneous circulation can be used to categorize the severity of hypoxic encephalopathy (Crit Care. 2018;22:226). In September 2022, we adopted a new temperature control protocol wherein the target temperature was set based on aEEG findings. This study examined changes in outcomes before and after implementing this new protocol. Methods: We assessed out-of-hospital cardiac arrest patients who received post cardiac arrest care in our emergency intensive care unit between March 2021 and February 2024. We divided the patients into two groups: before (B) and after (A) the introduction of the new protocol. We classified the patients into categories 1 (C1) to 4 (C4) based on the severity of hypoxic encephalopathy (Figure 1). All patients in group B were treated with hypothermia at 34°C. In group A, patients in C1 were treated with active fever prevention, and those in C2–C4 received hypothermia at 34°C (Figure 2). Primary outcome was favorable neurological outcomes (cerebral performance categories of 1 or 2) at hospital discharge. Secondary outcome was the duration of mechanical ventilation. Results: A total of 160 patients were included. The median age was 62 years and 105 (66%) patients had cardiac etiology. Fifty-five (34%) patients underwent extracorporeal cardiopulmonary resuscitation. The median cardiac arrest time was 29 min. Groups B and A comprised 57 and 103 patients, respectively. C1 category comprised 20 and 28 patients in groups B and A, respectively. The rate of favorable neurological outcomes was 35% in both B and A groups (p=1.00). Regarding C1 patients, the rates were 90% and 86% in B and A groups (p=1.00). Median duration of mechanical ventilation was 5 and 3 days in group B and A, respectively (p=0.11). Conclusion: Neurological outcomes before and after introducing the new protocol were similar. Management of patients with mild hypoxic encephalopathy can be simplified with active fever prevention. A temperature control protocol based on the severity of hypoxic encephalopathy using aEEG findings is feasible for emergency physicians.

Opportunities and Challenges of Application of Cytosorb Therapy in Sepsis Management

Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection. In 2017, an estimated 48·9 million incident cases of sepsis were recorded worldwide, and 11·0 million sepsis-related deaths were reported, representing 19·7% of all global deaths.1 Though overall data related to sepsis is poor but it is also a major health care challenge for resource limited countries. Severe sepsis is a significant & common health problem in ICU patients of Bangladesh2. A continuum of severity from sepsis to septic shock and multi-organ dysfunction syndrome (MODS) exists. MODS is a clinical syndrome characterized by the development of progressive and potentially reversible physiologic dysfunction in 2 or more organs or organ systems that is induced by a variety of acute insults, including sepsis. Sepsis leads to malignant intravascular inflammation, coagulopathy, circulatory derangement, tissue hypoxia, cytotoxicity and apoptosis. As a result, dysfunction of vital organ systems occur. Host response and other factors influenc outcome. Patients with sepsis must be treated with-timely, appropriate antibiotics, intravenousfluids, vasopressor and inotropic support & oxygen therapy.3 Other additional treatments including extracorporeal blood purification techniques (BPT). These techniques include hemofiltration, hemoperfusion, intermittent or continuous high-volume hemofiltration (HVHF), plasmapheresis or adsorption.4 The rationale behind such an approach is to achieve “immune homeostasis” which theoretically reduces the potential damage caused by dysregulation of the host response to infection. Given the pivotal role of cytokine production in sepsis, it follows that removal of these substances, through such BPT, may attenuate the response particularly in the early phase of sepsis.5 Indications include 1) Rhabdomyolysis resulting from Reperfusion syndrome, Trauma, Malignant Hyperthermia. 2) External injuries including Sepsis/Septic shock, Hemorrhagic shock, Trauma, Ruptured aortic aneurysm, Post-Cardiac Arrest Syndrome, Cardio-pulmonary resuscitation, Extensive surgery, Organ transplantation, Cardiosurgical intervention, Severe skin and soft tissue damage, Burns, Necrotizing fasciitis, Post-Cardiotomy Syndrome, Acute Respiratory Distress Syndrome. 3) Diseases: Pancreatitis, Liver insufficiency, Renal insufficiency, Stroke, Myocardial infarction, Cardiogenic shock/Heart failure, Tumor Lysis Syndrome, Hemophagocytosis Syndrome. Liver failure/Hyperbilirubinemia bridging to transplant or to recovery, Life-threatening bleeding under Direct Oral Anticoagulants (DOAC)6. Bangladesh Crit Care J September 2024; 12 (2): 79-80

Outcome of Targeted Driving Pressure Mechanical Ventilation in ARDS patients

Background: Lung protective strategy in acute respiratory distress syndrome (ARDS) patients is based on low tidal volume (VT), lower end-inspiratory (plateau) pressure and higher positive end-expiratory pressure (PEEP). But to predict body weight adjusted tidal volume, heterogeneous pathology of the lung in ARDS with different respiratory system compliance (CRS) is not considered. In driving pressure (ΔP=VT / CRS) tidal volume (VT) is normalized to functional lung size. It is unclear whether mechanical ventilation targeting driving pressure (ΔP) is more effective than low tidal volume ventilation (LTVV) in patients with ARDS. Materials and Methods: An open labelled randomized controlled trial was conducted at Intensive Care Unit of Dhaka Medical College Hospital, a tertiary care referral hospital over 12 months from March 2021 to February 2022. Ninety two patients with ARDS, defined by the Berlin criteria, requiring mechanical ventilation were randomized to 1:1 ratio after enrollment in the study using simple random sampling, one group receiving targeted driving pressure (ΔP) that is </=14cm of H2O ventilation another group receiving low tidal volume ventilation (LTVV) that is 4-6ml/kg PBW. Results: The study found no significant differences between the two groups in terms of clinical variables and laboratory parameters (p > 0.05), except for the duration of mechanical ventilation (MV), which was significantly shorter in the Targeted ΔP group (p<0.05). Aspiration pneumonia was the most common cause of ARDS, occurring in 34.8% of the Targeted ΔP group and 39.1% of the LTVV group. The Targeted ΔP group demonstrated a significant increase in mean respiratory system compliance compared to the LTVV group (p<0.001), and a significantly shorter length of ICU stay (p <0.001). Additionally, the PaO2/FiO2 ratio was significantly higher in the Targeted ΔP group on Days 3, 5, and 7 (p<0.05). Mean exhaled tidal volume was also significantly higher in the Targeted ΔP group on these days (p<0.05). In the Targeted ΔP group, mean driving pressure significantly decreased on Days 3, 5, and 7 (p <0.001), along with a significant reduction in mean plateau pressure (PPlt) (p <0.001). Mean positive end-expiratory pressure (PEEP) significantly decreased on Days 3, 5, and 7 (p <0.001). Respiratory rate significantly decreased on Day 7 (p <0.05). Mean set tidal volume (VT) significantly increased on Days 3, 5, and 7 (p <0.001). Moreover, the 28-day mortality incidence was significantly lower in the Targeted ΔP group compared to the LTVV group (8.7% vs. 26.1%, p <0.05). Conclusion: Targeted Driving pressure (ΔP) guided ventilation offers significant clinical benefits over LTVV in managing ARDS patients in terms of increased respiratory system compliance (CRS), shorter lengths of hospital and ICU stays, and lower in-hospital mortality. Bangladesh Crit Care J September 2024; 12 (2): 81-88

Hypomagnesaemia among Diabetic Patients with Chronic Kidney Disease: A Cross-sectional Study

Background: The clinical role of magnesium, especially of hypomagnesaemia, in diabetic and chronic kidney disease patients has been underestimated for many years. Objective: To determine the frequency of hypomagnesaemia in diabetic patients with chronic kidney disease and to investigate the relationship of magnesium level with glycemic and renal status. Methodology: This was a cross-sectional observational study performed on 100 diabetic patients with chronic kidney disease, admitted to BIRDEM General Hospital, Dhaka, Bangladesh, excluding patients with history of chronic diarrhea, laxative abuse, diuretic use, alcoholism and those on dialysis. Several socio-demographic and biochemical parameters were analyzed and compared with magnesium level. Results: Frequency of hypomagnesaemia among the study population was 37% (p= 0.009) and the frequency was found to be increasing with increasing stage of chronic kidney disease. Frequency of hypomagnesaemia was more in patients with uncontrolled fasting blood glucose, post meal blood glucose and HbA1c level (p<0.05). Serum magnesium levels positively correlated with serum creatinine levels (Pearson’s correlation coefficient, r=0.428, p=0.001) and inversely correlated with GFR (Pearson’s correlation coefficient, r= -0.275, p= 0.006). Conclusion: The frequency of hypomagnesaemia among diabetic patients with chronic kidney disease is common. So it would be prudent to routinely monitor for hypomagnesaemia in diabetic patients with chronic kidney. Bangladesh Crit Care J September 2024; 12 (2): 132-137

A Case of Abdominal Discomfort for Long Duration

In our regular medical practice, we encounter a lot of patients with abdominal discomfort. Commonly every physician suspects this kind of symptoms as gaseous distension of gastro-intestinal tract or acidity. The most valuable thing is the proper physical examination to rule out any underlying pathology. Most common causes of epigastric pain are associated with gastritis, or hepatobiliary system and pancreas related disorders. Here we will describe a 47-year-old male patient who presented with abdominal discomfort for last 6 months. For last 2 months he developed an epigastric lump which was increasing in size and was associated with weight loss. After proper clinical evaluation and necessary relevant investigations, he was diagnosed having Non-Hodgkin’s Lymphoma (NHL). Non-Hodgkins Lymphoma represents monoclonal proliferation of lymphoid cells. The incidence of these tumors increases with age. Clinically the proliferation rate indicates whether it is a high- or low-grade tumor. The patient underwent some investigations like CT guided FNAC from the enlarged abdominal lymph node which confirmed high grade Non-Hodgkins Lymphoma and started with chemotherapy and responded well. As abdominal discomfort is one of the common complaints, we face during our regular medical practice so routine physical examination including abdominal examination is very crucial and informative for clinical diagnosis and Lymphoma is an important differential diagnosis in case of any abdominal lump. Bangladesh Crit Care J September 2024; 12 (2): 175-178

A Case of Fat Embolism Syndrome after Fracture of Tibia Fibula

Fat embolism syndrome is a fatal condition that affects several organs. It often occurs after trauma or orthopedic surgeries. Most are unnoticed, and treatment of it is primarily supportive, with early fracture repair as a preventative measure. This case report describes a patient who had a left tibia fibula fracture diagnosed using Gurd's criteria and verified by a CT pulmonary angiography and MRI, and was treated with supportive care. Bangladesh Crit Care J September 2024; 12 (2): 167-171

Evaluation of Bedside Lung Ultrasonography in Diagnosis of Acute Pulmonary Oedema

Background: Pulmonary oedema is one of the major causes of mortality and morbidity. Acute heart failure is the major cause of pulmonary oedema. NT-pro B-type natriuretic peptide has been found to be effective in distinguishing acute pulmonary oedema from other causes of dyspnea in the emergency care setting. But it is costly and time consuming. Bedside lung ultrasonography (LUS) is being considered as noninvasive, radiation-free and easy to perform tool to diagnosis pulmonary oedema. Objective: To determine the role of bedside LUS in diagnosis of patients with acute pulmonary oedema. Methods: This observational cross-sectional study was carried out in ICU, Department of Anaesthesia, Analgesia, Palliative & Intensive Care Medicine, Dhaka Medical College Hospital, Dhaka from August 2018 to October 2019. Ethical approval was sought before conduction of the study. One hundred critically-ill patients with pulmonary oedema, detected by clinical examination & chest X-ray, due to heart failure were included in the study. Routine labs including NT-pro B-type natriuretic peptide level were sent. Bedside LUS was done with a portable ultrasound machine. Data was collected by using a semi-structured data sheet. Observation and Results: The median age was 42 years (IQR 18-66). Among them, 67.71% were male. 90.0% of patients diagnosed as acute pulmonary oedema by NT-pro B-type natriuretic peptide levels findings and 88.5% of patients were diagnosed as acute pulmonary oedema by bedside lung ultrasonography. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of lung ultrasonography findings alone statistically significant as 94.2%, 66.7%, 96.4% & 54.5% and 91.66% respectively in detection of pulmonary oedema. Conclusions: Bed side lung ultrasonography can be an effective adjunct tool for rapid and high diagnostic accuracy for diagnosis of acute pulmonary oedema along with NT pro BNP level in ICU. Bangladesh Crit Care J September 2024; 12 (2): 113-117

Evaluation of the Safety and Effectiveness of Ultrasound-guided Internal Jugular Vein Catheterization in Critically Ill Patients

Background:Central venous catheterization is a frequently performed procedure in intensive care units (ICU) for diagnostic and therapeutic purpose. As an invasive procedure it carries some risk and should be performed with few attempts. Traditionally this procedure is performed blindly by considering body surface landmark, but this procedure can be done with the help of ultrasound machine as an alternative of landmark procedure. Objectives: Evaluation of the safety and effectiveness of USG-guided internal jugular vein(IJV) catheterization in critically ill patients. Methods: This prospective observational study was conducted in the ICU of Dhaka Medical College Hospital, from May 2017 to October 2018. Patients scheduled for central venous catheterization via the IJV were included based on selection criteria and randomly allocated into two groups of 50 patients each using card sampling. Group A received ultrasound-guided catheterization, while the landmark technique was used in Group B. Results: The analysis revealed that in the ultrasound group 49 out of 50 (98.0%) patients were successfully catheterized while the landmark method was successful in 45 out of 50 (90.0%) patients. Successful catheterization by first attempt was possible in 29 patients of group A, where as it was 5 in group B. The average number of attempts for successful catheterization in Group A was 1.7 (SD=0.2) and in the landmark group it was 2.8 (SD=0.1). On the average, 4.9 minutes (SD=1.3) were needed for catheterization in ultrasound group. The time was significantly increased in the landmark group 11.4 (SD=5.8). Total number of complication was 2 in Group A and it was 8 in Group B. After considered all the above parameter, by using four points safety and effectiveness rating scale, safety and effectiveness mean score was 10.3 for Group A and 8.2 for Group B. Conclusion: Two-dimensional ultrasound offers improved safety and quality when compared with an anatomical landmark technique for IJV catheterization. Bangladesh Crit Care J September 2024; 12 (2): 96-104

A case of Iatrogenic Pseudo Aneurysm of Femoral Artery

A 55-year-old woman was admitted hospital in-patient unit withfever and breathlessness for 5 days. Pertinent medical history included chronic kidney disease (CKD), poorly controlled Diabetes with retinopathy, Hypertension and Bronchial asthma. After admission patient was found to be severely anaemic and her stool was black and tarry. Blood transfusion was required for correction of anaemia. Endoscopy of upper GIT was planned after stabilization. RT PCR for COVID-19 was positive. After couple of days she became desaturated in spite of high level of oxygen delivery and was shifted to ICU. Bangladesh Crit Care J September 2024; 12 (2): 179-180

Spot Urine Sodium to Potassium Ratio as a Tool to Assess Severity and Mortality among Patients with Decompensated Cirrhosis having Ascites

Background: Decompensated cirrhosis of liver is considered as a systemic disease affecting the functions of several other organs. Renal function is an independent prognostic factor for patients with decompensated cirrhosis, but assessing renal function through glomerular filtration rate are not convenient, especially for routine use. Previous study found that spot urinary sodium to potassium ratio (UNa/K) was associated with renal dysfunction which influences the severity and outcome in decompensated cirrhosis of liver patients having ascites. Aims and objectives: The present study was aimed to determine the relation of the ratio of sodium to potassium in randomly collected urine samples with severity of disease and mortality in decompensated cirrhosis having ascites. Materials and Methods: This longitudinal study was conducted at the Department of Gastrointestinal, Hepatobiliary and Pancreatic Disorders, BIRDEM General Hospital, Shahbagh, Dhaka, Bangladesh, from July, 2019 to August, 202l. A total of 150 patients with a confirmed diagnosis of decompensated cirrhosis with ascites were enrolled in this study. A detailed history and thorough clinical examination were carried out in each patient, along with relevant investigations. Data collection was done through a structured questionnaire. Data were analyzed using the statistical software SPSS 23. Results: Age of the patients was 59.0±12.91 (mean±SD) years, male predominance was observed (52%). The UNa/K ratio was 4.24±3.25 (mean±SD) with a range of 0.42 to 18.46. Diagnostic accuracy of UNa/K ratio in the detection of severity and mortality was estimated by the receiver operating characteristic (ROC) curve. The AUC of UNa/K ratio was 0.608 and 0.640 for severity and mortality respectively. Sensitivity, specificity, PPV and NPV at cut-off 2.55 were 50.0, 66.0, 42.4 and 72.5; at 2.65 were 54.0, 66.0, 44.3, and 74.2; at 2.87 were 58.0, 62.0, 43.3, and 74.7; at 3.21 were 58.0, 58.0, 40.8, and 73.4 respectively for severity score (MELD). Patients with UNa+/K+ less than 2.87 or equal, had a significantly higher MELD score category (p= 0.02). At 3 months follow-up, 24.7% mortality was observed. Sensitivity, specificity, PPV and NPV at cut-off 1.62 were 51.4, 85.8, 54.3 and 84.3; at 1.79 were 54.1, 79.7, 46.5 and 84.1; at 1.83 were 59.5, 77.0, 45.8 and 85.3; at 2.87 were 58.0, 62.0, 43.3, and 74.7 respectively for mortality. The UNa/K ratio was statistically low among the patients who didn’t survive (p<.05). Conclusion: This study revealed that decreased ratio of spot urinary sodium to potassium was associated with the severity and mortality among decompensated cirrhosis of liver patients with ascites. Bangladesh Crit Care J September 2024; 12 (2): 118-124

A case of Peripartum Cardiomyopathy with associated Post-Cesarean section and Grand mal seizure

Peripartum cardiomyopathy (PPCM) is a rare but life-threatening disease in later stages of pregnancy. PPCM presents in the last month of pregnancy or within five months of puerperium in the absence of pre- existing heart disease. It remains a poorly understood entity and its management remains a topic of debate. Although majority recovers, long-term morbidity is quitecommon. Peripartum discomforts often mask and delay the diagnosis of PPCM. Unavailability of previous cardiac imaging is rather common and this makes the diagnosis even more complicated. Early and aggressive management towards reducing preload show evidence of better outcome. Here we report a case of PPCM presenting to us diagnosed after Caesarean Section followed by Grand mal seizure. Bangladesh Crit Care J September 2024; 12 (2): 163-166

Clinico-Epidemiological Profile and Outcome of Acute Poisoning Patients admitted to Intensive Care Unit in A Tertiary Level Private Hospital in Bangladesh

Background: Acute poisoning is a prevalent health issue necessitating Intensive Care Unit (ICU) admission in developing countries. This study evaluates the socio-demographic characteristics, clinical parameters, and outcomes of acute poisoning patients admitted to the ICU in a tertiary level private hospital in Bangladesh. Method: This retrospective cohort study was conducted at tertiary care private hospital in Narayanganj, Bangladesh. Data was collected from ICU medical records from January 2023 to April 2024, enrolling a total of 57 patients aged 18 years or more who presented with acute poisoning. Data analysis was performed using Stata (Statistical Software for Data Science) 17.0(p < 0.05) Results: Out of 57 patients, 52.63% were females, with mean age of 27.84 years. Suicidal intent accounted for 84.21% of cases, and the primary reasons for poisoning included marital (61.40%) and familial disharmony (15.79%). The predominant type of poisoning was due to sedatives (17.54%) followed by aluminium phosphide (14.04%), and stupefying agents (14.04%). Aluminium phosphide poisoning had a 100% fatality rate, while sedatives and several other agents had 100% recovery rate. Statistical analysis showed a significant association between the type of poison and the final outcome (χ2(15) = 38.7996, p = 0.001). Conclusion: The study highlights the prevalence of intentional poisoning among young adults, especially females, with sedatives, aluminium phosphide, and stupefying agents being the most common. The high mortality rate from aluminium phosphide underscores the need for strict regulations and public awareness to control access to these substances. Bangladesh Crit Care J September 2024; 12 (2): 89-95

Tissue Doppler Right Ventricle Myocardial Performance Index (TDI RV-MPI) Versus Tricuspid Annular Plane Systolic Excursion (TAPSE) in Evaluation of RV dysfunction in Patients with or without LV dysfunction

Introduction: Cardiovascular disease remains a leading cause of death. Right ventricular (RV) function is a strong predictor of outcome in many cardiovascular diseases, but its significance is often neglected. It has often been coined “the forgotten chamber. RV dysfunction may be secondary to left ventricle (LV) dysfunction as a consequence of “Ventricular Interdependence”. As RV dysfunction is associated with high in-hospital morbidity and mortality, early reorganization of RV dysfunction is warranted; but until today it remains a challenging task because of complex structure and asymmetric shape of RV. Objective: Our objective was to compare the efficacy of Tissue Doppler Right Ventricle Myocardial Performance Index (TDI RV-MPI) with Tricuspid Annular Plane Systolic Excursion (TAPSE), as a predictor of RV Systolic dysfunction. Methods: This was a cross-sectional study in patients undergoing comprehensive Transthoracic Echocardiography for any indication. Our aim was to compare Tissue Doppler Right ventricle Myocardial Performance Index (TDI RV-MPI) with TAPSE to predict RV function in patients with or without LV dysfunction .The current study recruited 100 patients who presented to the Cardiology Clinic of Lab Aid Cardiac Hospital. In addition to calculation of conventional, quantitative LVEF done in 2D guided M-mode in Para-sternal long-axis view, RV function was assessed in all subjects by measurement of Tricuspid Annular Plane Systolic Excursion (TAPSE) & Tissue Doppler RV Myocardial Performance Index (TDI RV-MPI). Both were compared in prediction of RV dysfunction in patients with or without LV systolic dysfunction Results: RV dysfunction was found in subjects with LV dysfunction by both TAPSE & TDI RV -MPI. RV dysfunction increased with reducing left ventricular ejection fraction. Normal TAPSE (~24 mm) was evidence of normal TDI RV-MPI (0.2594±0.03269, P<.001), consistent with normal RV function. Of note, reduced TAPSE (~12 mm) was at the same time was evidence of increased TDI RV-MPI (0.7550±0.06351, P<.001), suggestive of RV dysfunction. Simultaneously normal LVEF (~ 55%) was evidence of normal TAPSE (22±1.582 mm, P<.001) & normal TDI RV-MPI (0.25±.0509, P<.001). Reduced LVEF (~25%) was at the same time, evidence of reduced TAPSE (15.50±3.317 mm, P<.001) & increased TDI RV-MPI (0.66±.1150, P<.001). A statistically significant negative correlation of TDI RV-MPI (r=-0.927) was observed with TAPSE (p<0.001). Also statistically significant negative correlation of TDI RV-MPI (r=-0.798) and significant positive correlation of TAPSE (r=0.813) were observed with LVEF (p<0.001). In the analysis TDI RV-MPI maintained significant correlation with both LVEF & TAPSE. In linear regression analysis TAPSE & LVEF were significant independent predictor of TDI RV-MPI. Most important determinants of TDI RV-MPI was TAPSE (R=0.927, p<0.001) . Conclusion: This study demonstrated that in patients with LV dysfunction there was RV dysfunction due to ‘ventricular interdependence’ as detected by both TAPSE & TDI RV-MPI. TDI RV-MPI is a simple, sensitive, reproducible, noninvasive, non-geometirc echocadiographic parameter to provide global assessment of systolic and diastolic function of RV. It has the ability to detect RV dysfunction at an early stage, so as to reduce morbidity and mortality in these patients. It is evident that TDI RV-MPI can be a surrogate of TAPSE even with superior efficacy in RV functional assessment maintaining close relation with LVEF. These observations could guide decision making in daily clinical practice. Bangladesh Crit Care J September 2024; 12 (2): 105-112

Incidence Pattern and Outcome of Diseases in Patients Admitted in Coronary Care Unit in a Tertiary Care Hospital in Dhaka - A 3 Year Retrospective Study

Background: Cardiovascular disease (CVD) is the leading causes of death globally. Like other countries, CVD prevalence is also rising among the adults in Bangladesh. Most of the cardiac emergencies and acute ailments are preferably managed in a specially designed place of a hospital called Coronary Care Unit, which has better facilities of monitoring, care and support. In every day-to-day practice a proportion of diabetic patients need to admit in CCU for different life threatening crisis. For better understanding of such CVD prevalence scenario, we conducted this retrospective observational study. Aim of the Study: Our objective was to assess the pattern and incidence of CVD admitted in CCU with their outcomes among the population using the data from the record book. Methodology: This is a retrospective observational study carried out in the Coronary Care Unit (CCU) of BIRDEM Hospital Dhaka Bangladesh from 2017-2019. Total 1069 patients (861 were Diabetic and rest were non diabetic) who were admitted to the CCU of this Institute from 2017-2019 were studied and evaluated to see the pattern of cardiac emergencies in diabetic population. Results: Among 1069 patients, 57.2% were male and 42.8% were female. Majority (80.54%) of them were diabetic. Most of the patients belonged to age 50 years and above. Seven hundred and one (65.57%) patients were admitted due to Ischemic Heart Disease (IHD) in different forms. Among the Acute Coronary Syndrome, most prevalent one was NSTEMI (354). Among NSTEMI group, where 50.37% were male and 50.67% were female, 102 patients had Unstable Angina and 73 had STEMI. Eighty nine patients were admitted after intervention (PCI or CABG) and 61 patients had Ischemic Dilated Cardiomyopathy (IDCM) due to some complications. Four hundred and twenty patients admitted due to Heart Failure and 137 patients were admitted due to different forms of Shock. Cardiac function was assessed (by Teichholz method and Biplane Simpson's method) among the admitted patients and 57.31% of patients had moderate LV dysfunction, 29.26% had severe systolic dysfunction and remainder 13.43% found to have mild LV systolic dysfunction. Mean hospital stay was assessed and it was found to be gradually declining from 13.33 in 2017 to 9.23 in 2019 (p=0.041*). Outcome of the study population shows that ~ 66% were transfer to general ward or cabin of the department of cardiology after initial stabilization, 17.3% were discharged directly from CCU, and 5.42% patients were transferred to other department after recovery. About 5.5% were become critically ill for which they need to transfer under care of ICU, 2.5% were transfer for intervention (to other institutes according to patient’s economical ability and preference for CABG, Pace maker implantation, PTCI etc.) and 3.3% patients were expired. Conclusion: In this study, incidence of IHD found higher than other cardiac diseases. NSTEMI is about three times more than Unstable Angina and about five times more prevalent than STEMI for the reason of admission in CCU. Diabetes Mellitus was found in majority of the admitted patients in CCU and the number of diabetic population is increasing which may also responsible for leading more coronary heart disease in our country in future. 88.7% of study population was shifted to general ward after initial stabilization after acute crisis, 2.5% required further cardiac intervention and 5.5% become critical and required ICU support. Only 3.3% of total population expired after all possible support. Bangladesh Crit Care J September 2024; 12 (2): 125-131

Renal Replacement in the Critically ill with Acute Kidney Injury: When and How to Initiate Therapy

Although Acute Kidney Injury (AKI) is a common complication in the critically ill, there is still no specific therapy. Similarly the diagnosis of AKI, while regulated by specific criteria, is not free from pitfalls. Newer biomarkers are also being added in the diagnostic panel that helps in identifying the stage, severity and underlying cause of this condition. When preventive and supportive management fails, Renal Replacement Therapy (RRT) becomes necessary. RRT is one of the most invasive management procedures and it is associated with many complications. Hence the time of onset and the modality of choice are two of the most puzzling aspects of this procedure. Over the last decade and a half, a lot of RCTs, observational studies and meta analyses have been carried to find the exact answer to these questions. While all the answers are not yet simplified, we have specific guiding parameters now as to the choice of modality and onset of dialysis for AKI. There is still need for further research for more specific answers to these age old questions. Bangladesh Crit Care J September 2024; 12 (2): 153-159

Euglycemic Diabetic Ketoacidosis Presenting as Chest Pain and Vomiting in a Patient taking SGLT-2 inhibitor

Empagliflozin-induced Euglycemic Diabetic Ketoacidosis (EDKA) is a life-threatening metabolic emergency of Diabetes Mellitus. It is characterized by metabolic acidosis (i.e., pH <7.3 and Serum bicarbonate <15mEq/dl) with an increased anion gap, ketonemia and relatively normal serum glucose level. EDKA resembles Diabetic Keto Acidosis (DKA) but does not exhibit the typical high blood sugar levels. In EDKA, blood glucose is usually below 200 mg/dL. This condition is a diagnostic challenge as euglycemia masks the underlying diabetic ketoacidosis. Here we present a case of Empagliflozin-induced Euglycemic Diabetic Ketoacidosis presented with palpitation and several episodes of vomiting. The aim of this article is to create awareness among clinicians to consider this diagnosis in the differential, especially in the patients taking SGLT-2 inhibitors. Bangladesh Crit Care J September 2024; 12 (2): 172-174

Effect of Silodosin on bladder outlet during antegrade cystourethrogram in patients with pelvic fracture urethral distraction defect

Background: Pelvic fracture urethral distraction defect is a traumatic injury to the male urethra that affects the region between the bulbar urethra and the prostatic apex. Pelvic fracture causes urethral injury in about 10% of patients. Combined retrograde urethrogram and antegrade cystourethrogram is used to define the length of the urethral injury before planning the definitive surgery. But during antegrade cystourethrogram bladder outlet sometimes fails to open due to faulty technique, prolong suprapubic catheterization and increase sympathetic drive, leading to erroneous estimation of the length of urethral injury. To overcome this problem Silodosin used in this study, which is a highly uroselective and rapid-acting α-adrenoreceptor antagonist in comparison to other α-adrenoreceptor antagonists available in the market. The uroselectivity of Silodosin helps in maximizing the effect by opening the bladder outlet and limiting the adverse effect on the cardiovascular system.The objective of the study was to assess the effectiveness of Silodosin in opening bladder outlet in patients with pelvic fracture urethral distraction defect on antegrade cystourethrogram. Methods: This is a Quasi-experimental study that was conducted in the Department of Urology, Bangabandhu Sheikh Mujib Medical University. In this study, 35 Patients with pelvic fracture urethral distraction defect with suprapubic catheter in situ who failed to open the bladder outlet on initial antegrade cystourethrogram were included. Urine culture and sensitivity report is confirmed negative. All participants were received a single dose of Silodosin capsule 3 hours before the antegrade cystourethrogram. Retrograde urethrogram was performed. After 3 hours bladder was filled with diluted contrast through the indwelling suprapubic catheter under sterile conditions according to bladder capacity. When the participants were felt the normal desire to void, bladder filling was stopped and voiding command was given and x-ray films were taken. Then the x-ray films were reviewed and findings were noted about the opening of the bladder outlet and visualization of the posterior urethra. Any complications during the procedure were observed and noted. After confirming hemodynamic stability, patients were advised to go home and continue the prescribed antibiotic for 5 days. Results: Thirty-five men were evaluated during this study period. The mean ages of the patients were 39.9±10.4 years. All patients had a suprapubic catheter in situ and the mean duration of the suprapubic catheter was 3.8 ± 1.5 months. On average 363±87.3 ml of diluted contrast were introduced to initiate voiding reflex. Thirty-two patients out of the 35 patients (91.4%) were able to achieve the satisfactory opening of the bladder outlet (95% confidence interval 82.11- 100%), while 3 patients (8.6%) failed to open the bladder outlet. No patient developed postural hypotension after single dose of Silodosin. Two patients were reported post procedure (combined retrograde urethrogram and antegrade cystourethrogram) fever, which needed another 5 days antibiotic treatment. Conclusion: Single dose of Silodosin before antegrade cystourethrogram conferred a statistically significant increase in opening the bladder outlet inpelvic fracture urethral distraction defectpatients. Bangladesh Crit Care J September 2024; 12 (2): 138-144

An Elderly Lady with Tetany and Brain Calcification

We present the case of a 59-year-old Bangladeshi lady who presented in Intensive Care Unit with tetany and altered level of consciousness. Tetany resolved after giving IV calcium injection. Initial laboratory investigations showed hypocalcemia. Non-contrast CT brain showed irregular bilateral symmetrical calcifications in basal ganglia, thalami, cerebellum and corona radiata. Subsequent laboratory test revealed low parathyroid hormone level. So, she was diagnosed as Fahr’s syndrome due to secondary hypoparathyroidism. This is a rare neurological disorder characterized by metabolic, biochemical, neuroradiological and neuropsychiatric abnormalities due to symmetrical and bilateral intracranial calcifications. Bangladesh Crit Care J September 2024; 12 (2): 160-162

Hepatocellular Changes on Paracetamol Induced Liver Damage in Long Evans Male Rats upon Green Tea Administration

Background: The liver is a vital organ that serves a number of purposes in our body. It may be harmed by pollutants, substances with toxic effects, and long-term, unchecked drug use. Green tea is a well-liked beverage that has gained popularity recently and may have hepatoprotective properties. Objective: To observe the effect of green tea (Camellia sinensis) on paracetamol induced liver damage in Long Evans male rats. Methods: From July 1st, 2018, to June 30th, 2019, this study was conducted in the Department of Physiology at Sir Salimullah Medical College (SSMC), Dhaka. For the purpose of the study, thirty (30) male Long Evans rats, weighing between 150 and 200 grams and 90 to 120 days old, appeared to be in good health. They were split into two groups after 14 days of acclimatization: Group A, which served as the control group, and Group B, which served as the experimental group (green tea pretreatment and paracetamol treated). Group A1 (baseline control group) and group A2 (paracetamol treated control group) comprised the subdivided control group. There were ten rats in each of these groups. For 28 days, the rats were all fed a baseline diet. The baseline control group was given normal saline (20 ml/kg/day) orally every day for 28 days in addition to their basal diet. For the final three days of the study—the 26th and 28th—the paracetamol-treated control group was given oral paracetamol at a dose of 1.5 g/kg/day. During the final three days of the study period (the 26th and 28th days), the experimental group was given oral paracetamol (1.5g/kg/day) and an ethanolic extract of green tea (500 mg/kg/day) for a total of 28 days. On day 29, every rat was sacrificed. Following the sacrifice, liver samples were taken. Hepatic contents of malondialdehyde (MDA) were measured by using standard laboratory method. Histopathology of liver was also done by using standard laboratory procedure in the department of pathology, SSMC. Version 22 of the Statistical Package of Social Science (SPSS) for Windows was used to do the statistical analysis. The data were displayed as mean±SD. To compare the results, one-way ANOVA, post hoc Bonferroni, and Chi-square tests were used, where appropriate. A p value of less than 0.05 was regarded as significant. Result: When compared to the baseline control group, the mean malondialdehyde concentration in the liver was significantly (p) greater in the green tea pretreatment, paracetamol treated, and control groups who received paracetamol treatment. Once more, the groups treated with green tea and paracetamol had mean malondialdehyde concentrations in their livers that were significantly (p) lower than those of the paracetamol group. Additionally, 0% of the rats in the baseline control group, 100% of the rats in the paracetamol-treated group, and 30% of the rats in the green tea-pretreated and paracetamol-treated group had abnormal histological findings of the liver. Conclusion: This study revealed that green tea has hepatoprotective effect against paracetamol induced liver damage in Long Evans male rats. Bangladesh Crit Care J September 2024; 12 (2): 145-152

Respiratory Complications in the Immediate Postoperative Period after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Nowadays: An Observational Study.

Several respiratory complications have been described after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Patients admitted to intensive care unit (ICU) after CRS and HIPEC during 10 years. Demographic characteristics; severity of illness; complete blood sample; chest radiographs; type of cancer and extension; HIPEC drug and temperature; ICU and hospital stay; and mortality. Of the 124 patients included, 67 patients (54.0%) presented respiratory complications: 56 (83.6%) acute respiratory failure, 25 (37.3%) pleural effusion, 13 (19.4%) atelectasis, and 3 (4.5%) other; only 1 (3.0%) developed pneumonia. They had higher severity scores at ICU admission. 1 patient required initiation of invasive mechanical ventilation during ICU admission due to pneumonia, and 1 patient needed placement of a pleural chest tube due to symptomatic pleural effusion.Only the need for a high fluid balance during surgery was correlated to the development of respiratory complications on multivariate analysis.Median ICU stay was 5 (4.0-5.0) days. ICU mortality was 0.8.0%. In our study, 54% of patients treated with CRS and HIPEC developed respiratory complications during the postoperative period. However, the majority of these complications were not severe and did not significantly impact mortality rates or hospital stays. Pintado MC, Oñoro A, Beltran D, Nevado E. Respiratory Complications in the Immediate Postoperative Period after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Nowadays: An Observational Study. Indian J Crit Care Med 2024;28(10):952-957.