Bangladesh Critical Care Journal

Severe Acute Pancreatitis Complicated by Acute Pulmonary Embolism: a case report

Ehteshamul Hakim — 2024-04-04

Acute pancreatitis is a painful condition in which the pancreas becomes inflamed and edematous usually for a short period of time. Pulmonary embolism due to severe acute pancreatitis is a rare but serious condition. A 68-year-old patient got admitted in gastroenterology department of a tertiary care hospital of Dhaka, Bangladesh with chief complaints of severe abdominal pain for 5 hours and several episodes of vomiting for same duration. After admission relative investigation and examination were done. His USG revealed swollen oedematous pancreas with peripancreatic fluid collection, bilateral renal parenchyma changes with cortical cyst. Patient’s Glasgow Imrie score was 3, Numeric pain score (NRS) was 4, Urine output was normal. The patient was categorized into severe acute pancreatitis. The patient was treated with antimicrobials, proton pump inhibitors, analgesic, and fluid resuscitation. But patient’s medical condition deteriorated and oxygen demand increased. Due to susceptibility of pulmonary embolism and worsening of patient’s condition a thrombolysis was done. Severe acute pancreatitis complicating with pulmonary embolism is a fatal condition.1 Early diagnosis and treatment are fundamental for treating this dreadful condition. When Patient with acute pancreatitis exhibits dyspnoea, leg oedema and thromboembolic events, pulmonary embolism should be suspected. Following early diagnosis, thrombolysis is necessary to combat this situation.

Bangladesh Crit Care J March 2024; 12 (1): 50-54

Living tape worms in the duodenal lumen: A rare case report

Mohammad Shamsul Arfin — 2024-04-04

Fascioliasis is an infection caused by a trematode of the liver, Fasciola hepatica, which affects sheep, goats and cattle. Humans become accidental hosts through drinking contaminated water or ingesting raw green vegetables that has been contaminated with encysted metacercariae, which is the infective form. Fascioliasis has a hepatic phase and a biliary phase, each displaying different clinical signs and symptoms. Common signs and symptoms of the hepatic phase are abdominal pain, fever, eosinophilia, and abnormal liver function tests. The biliary phase of the disease usually presents with intermittent right upper quadrant pain with or without cholangitis or cholestasis. However, it is very rare to find a living flukes in the common bile duct (CBD) and duodenal lumen as it usually lives in gall-bladder and smaller biliary tracts. Here we report a case of human infestation of Fasciola hepatica, who presented with respiratory tract infection with abdominal pain & dyspeptic symptoms and eventually during evaluation, an upper gastro-intestinal endoscopy revealed several flat worms at the second part of the duodenum. The worms were sent to microbiology department for identification. The organisms were confirmed to be Fasciola hepatica. The patient was given tablet Nitazoxanide 500mg 12 hourly for 7 days. The symptoms reduced in intensity after two days of nitazoxanide. The patient was then discharged with an advice of a stool routine examination after one month of completion of nitazoxanide. As fasciolosis is non endemic in our country, a high degree of suspicion is required to ensure early detection and management of such cases. Patients with abdominal pain, altered liver function tests & eosinophilia should always be evaluated for a suspected Fasciola hepatica infection and should be kept as a differential in these cases.

Bangladesh Crit Care J March 2024; 12 (1): 54-57

Hypertriglyceridemia induced acute pancreatitis and efficacy of therapeutic plasma exchange

Ehteshamul Hakim — 2024-04-04

Acute pancreatitis is a condition in which the pancreas becomes inflamed suddenly within a short period of time. Typically, this condition lasts less than 6 weeks, with most cases resolving within 1-2 weeks. The major causes of acute pancreatitis are ethanol, gallstones, and hypertriglyceridemia. Acute pancreatitis that is caused by hypertriglyceridemia can be severe and life-threatening. Compared to other causes of pancreatitis, studies have shown that the acute pancreatitis induced by hypertriglyceridemia is more serious and can lead to recurrent episodes of pancreatitis, eventually leading to chronic pancreatitis. Here, we report a clinical experience with a patient of high triglyceride induced pancreatitis. He was treated with two sessions of Therapeutic Plasma exchange along with intravenous insulin, statins, and fibrates. In recent times, plasmapheresis has been used to treat severe cases of hypertriglyceridemia-induced acute pancreatitis with success. Early initiation, along with appropriate supportive measures, may lead to favourable outcomes and reduce the risk of complications. However, further research is needed to determine the exact role and timing of plasmapheresis in managing acute pancreatitis caused by hypertriglyceridemia.

Bangladesh Crit Care J March 2024; 12 (1): 58-61

A Case of Post Viral Acute Longitudinal Extensive Transverse Myelitis (LETM): MOGAD- A New Horizon

Richmond Ronald Gomes — 2024-04-04

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently identified autoimmune disorder that presents in both adults and children. It is a group of central nervous system demyelinating diseases caused by auto antibodies against myelin oligosaccharide protein, a myelin sheath component protein, and present with a variety of symptoms, including optic neuritis, longitudinal extensive transverse myelitis (LETM), acute disseminated encephalomyelitis (ADEM), brainstem encephalitis, and corticobasal encephalitis. Although there are clinical phenotypic overlaps between MOGAD, multiple sclerosis, and aquaporin-4 antibody-associated neuromyelitis optica spectrum disorder (NMOSD) cumulative biological, clinical, and pathological evidence discriminates between these conditions. Here, we present a case of a young male with acute onset of spastic paraplegia with sphincters involvement and patchy loss of pinprick sensation with positive Anti-MOG Antibody shortly after viral febrile illness.

Bangladesh Crit Care J March 2024; 12 (1): 62-67

Peri-partum Thrombotic thrombocytopenic purpura - A 29 years old pregnant lady presented with convulsion and thrombocytopenia

Farhana Huq Tushi — 2024-04-04

Thrombotic thrombocytopenic purpura associated with pregnancy is a rare antibody‐mediated thrombotic microangiopathy with high maternal and fetal mortality. We present a 29-year-old Bangladeshi pregnant lady of 32 weeks of gestation who presented to a tertiary care hospital with multiples episodes of generalized convulsion. She was immediately transferred to the operation theatre and after delivery of her baby, she was transferred to ICU. Her reports revealed features of hemolytic anemia, thrombocytopenia and renal failure. She was suspected as a case of Thrombotic thrombocytopenic purpura and received therapeutic plasma exchange. Her condition gradually improved and she was discharged to home in stable condition.

Bangladesh Crit Care J March 2024; 12 (1): 68-71

Clustered Carbon Monoxide Poisoning Cases: Accidental Poisoning In A Vehicle

Ejaj Uddin Ahmed — 2024-04-04

Carbon monoxide (CO) is a product of combustion of organic matter in the presence of inadequate supply of oxygen. Common sources are burning fuel, engine exhaust, burning of animal dung, heater emissions and gas geyser. It is a toxic, clear, colorless and tasteless gas. The clinical presentation runs a spectrum, ranging from headache and dizziness to coma and death. Here we report three cases that presented to us in the month of November 2023 with history, sign & symptoms suggestive of CO poisoning.

Bangladesh Crit Care J March 2024; 12 (1): 72-74

Procalcitonin and C-Reactive Protein in Critically Ill Patients with Sepsis and Septic Shock Admitted in an ICU of a Tertiary Care Hospital in Bangladesh

Susmita Hossain Natasha — 2024-04-04

Background: Early intervention and predicting outcome has become a cornerstone in the treatment of sepsis as this may ensure the difference between survival and mortality. Both C-reactive protein and Procalcitonin have long been identified as good diagnostic markers of sepsis but their prognostic value is still a matter of debate. This study aims to find this particular point out. Objectives: Objective of this current study is to see the relationship of Procalcitonin and C-reactive protein respectively with the outcome of the patients with sepsis and septic shock and to compare their usefulness as predictors of outcome. Methods: This study was carried out in Intensive Care Unit of BIRDEM General Hospital, Shahbag, Dhaka for a period of one year. All consecutive patients with sepsis and septic shock were enrolled as study subjects during this period according to selection criteria. At the time of diagnosis that is at zero hour of development of sepsis or septic shock both C-reactive protein and Procalcitonin were measured and it was repeated at 24 hours. Data were collected in preformed data collection sheet and analyzed by the SPSS. Results: In this study, total 170 patients were enrolled as a case of sepsis or septic shock. The mean age was 59.5 ± 15.8 with a range between 20-96 years. Fifty seven (34%) patients had septic shock either during admission or during the first 24 hour of ICU stay and 46 (27.1%) patients did not survive their illness. The mean SOFA score was 6.30±2.18, mean duration of ICU stay 5.5.±2.98 days and mean MAP was 83.73±24.49 mmHg and 98 patients (57.65%) patients were ventilated during their admission. Diabetes mellitus had majority among co-morbidities with 147 (86.4%) patients having diabetes mellitus. Finally after calculating the cut off values from Youden’s index C-reactive protein was found to be more sensitive and Procalcitonin more specific as predictors of outcome. Conclusion: This study concludes that both Procalcitonin and C-reactive protein can individually predict outcome in sepsis and septic shock and one is not inferiorto the other.The dynamic changes of both these biomarkers over first 24 hours were also strongly associated with outcome. It was noted that while C-reactive protein was more sensitive, Procalcitonin was more specific.

Bangladesh Crit Care J March 2024; 12 (1): 4-10

Correlation of Tricuspid Annular Plane Systolic Excursion (TAPSE), as a predictor of Right Ventricular Systolic Function with Left Ventricular Systolic Function

Rownak Jahan Tamanna — 2024-04-04

Introduction: Right Ventricular (RV) function is a strong predictor of outcome in many Cardiovascular Diseases, but its significance is often neglected. Right Ventricle (RV) dysfunction may be secondary to Left Ventricle (LV) dysfunction as a consequence of “Ventricular Interdependence. Tricuspid Annular Plane Systolic Excursion (TAPSE) is an Echocardiographic measure that allows us to assess Right Ventricular systolic function and it correlates well with reference techniques like Cardiac Magnetic Resonance Imaging. Echocardiographic recording of the Tricuspid Annular Plane Systolic Excursion (TAPSE) has been recommended for assessing Right Ventricular function in cardiac patients. As RV dysfunction is associated with high in-hospital morbidity and mortality, early reorganization of RV dysfunction is warranted in patients with or without LV dysfunction. Objective: Our objective was to demonstrate the relationship of TAPSE, as a predictor of RV Systolic Function with Left Ventricular Systolic Function. Method: This was a cross –sectional study in patients undergoing comprehensive Transthoracic Echocardiography for any indication. From April 2022 to March 2023 we prospectively enrolled 100 adult (from 30 to age 103years) of both sexes who presented to the Cardiology Clinic of LABAID Cardiac Hospital. We performed a complete Transthoracic Echocardiography study. Assessed LV systolic function by conventional method. We additionally measured TAPSE in 2-dimensional M-mode Echocardiograms from the apical 4- chamber view, positioning the cursor on the lateral Tricuspid Annulus near the free RV wall and aligning it as close as possible to the apex of the heart. The mean values were taken by at least 2 measurements for reducing inter-observer and intra-observer variability’s. Values of TAPSE as a predictor of RV Systolic Function were correlated with Left Ventricular Systolic Function. Patients with confirmed congenital & Valvular heart disease were excluded. Results: Mean TAPSE values were (19.15±3.87mm) irrespective of LVEF, with no significant differences between sexes, (18.45±3.801 mm) in male , (19.94±3.853 mm) in female (P=.056). TAPSE value was (22.00±1.581 mm) in person with normal LVEF & (16.77±2.455 mm) in person with reduced LVEF (P<.001). A statistically significant positive correlation of LVEF (r=.813) and significant negative correlation of EPSS (r=-.639) were observed with TAPSE (p<0.001). But no significant correlation of TAPSE was found between age (r=-.185), gender (r=.192) & RVIDd (r= -.063) (p >0.05). Multivariate analysis confirmed these correlations and the interactions between variables. Graph of estimated population-based TAPSE values adjusted by LV function was provided. Conclusion: We determined the values of TAPSE in patients with or without LV systolic dysfunction and assessed relationship of these values with LVEF. TAPSE is predictive of RV Systolic function & correlated significantly with LV systolic function. The TAPSE measurement is simple & reproducible. This observation could guide decision making in daily clinical practice.

Bangladesh Crit Care J March 2024; 12 (1): 11-17

Association Between Serum Uric Acid Level and the Severity of Parkinsons Disease: A cross sectional study

Muhammad Shamsul Islam — 2024-04-04

Background: Parkinson’s disease is a chronic, progressive, neurodegenerative disease. Various factors have been attributed to the development and progression of the diseaseover the years. Uric acid is the final oxidation product of purine metabolism with potent antioxidant properties, which could play an important role in reducing the risk of development of Parkinson’s disease (PD) as well as it could have a role in delaying the progression of Parkinson’s disease (PD). Aim: This study aims at evaluating the role of serum uric acid level in clinical progression of Parkinson’s disease. Methods: This cross-sectional study was conducted among 70 patients of Parkinson’s disease attending the outpatient department and meeting the inclusion criteria. All the clinical and biochemical data were collected and analyzed by SPSS. Mean serum uric acid levels were compared between different stages of Parkinson’s disease. A p value of less than 0.05 was considered as significant. Result: Mean age of the patients with Parkinson’s disease was 62.25 ± 8.56 years with a male to female ratio of 1.12:1. Regarding the clinical presentation of the patients, it was observed that 16 (22.9%) patients had combination of tremor, hypokinesia, rigidity and postural imbalance, 18 (25.7%) had tremor, hypokinesia & rigidity and 36 (51.4%) had tremor and rigidity. It was observed that 24.3% of the patients had sensory, sleep and cognitive disorder, 21.4% patients had sleep and cognitive disorder, 2.9% patient had disorder in sleep and anosmia, 8.6% patients had only sleep disturbance, 17.1% had only cognitive disturbance but 25.7% had no non-motor symptoms. Majority (61.4%) patient’s disease duration was 1-5 years. The mean duration of disease was found 6.34±5.53 years. Majority 34 (48.6%) patients were in stage II, 19 (27.1%) were in stage III, 5 (10.0%) were in stage IV and 12 (17.1%) were in stage V. Mean serum uric acid was found to be 3.45±1.26mg/dL (2.0-5.8) in male and 3.36±0.81mg/dL(2.1-5.8) in female patients.Serum uric acid level steadily reduced with the severity of PD which is statistically significant. Advanced stages of parkinson’s disease were associated with significantly lower levels of serum uric acid. The difference between the stages were statistically significant (p=0.007). Conclusion: This study shows a negative association between serum uric acid level and the severity of Parkinson’s disease. The level of serum uric acid decreased with the disease progression. This study added evidence consistent with an association between serum uric acid level and the severity of Parkinson’s disease. This finding pushes us to emphasize on the role of uric acid levels on the Parkinson’s disease.

Bangladesh Crit Care J March 2024; 12 (1): 18-24

A Clinicopathological study of Guillain-Barrḗ Syndrome in a Tertiary Level Hospital

A K M Ferdous Rahman — 2024-04-04

Background: Guillain-Barre syndrome (GBS) stands out as the most prevalent autoimmune neurological disorder. This investigation involves a comparative analysis of clinical observations, neurophysiological assessments, and cerebrospinal fluid examination, outcomes among patients with GBS. Method: A retrospective review of medical records constituted the methodology for this study, spanning from July 1, 2023, to December 31, 2023. Sociodemographic traits, antecedent illnesses, clinical progression, laboratory results, therapeutic interventions, and ultimate outcomes were assessed and compared among the study participants. Results: The study encompassed 8 patients, with an average age of 42.75 years. Respiratory complications were evident in 87.5% of the patients. In CSF analysis, 62.50% exhibited a normal cell count, while 37.50% displayed an elevated count. Elevated CSF protein levels were observed in 50% of patients, with a corresponding 50% revealing normal CSF protein levels. Increased CSF protein was associated with delayed lumbar puncture, demyelinating nerve conduction study subtype, and sensory motor variant. Regarding treatment modalities, 37.5% received intravenous immunoglobulin, and 25% underwent plasma exchange therapy. The acute phase of the disease resulted in a 25% mortality rate among patients. Conclusion: Guillain-Barre syndrome manifests diverse clinical presentations and laboratory findings. Notably, a high cerebrospinal fluid cell count challenges the widely accepted Brighton criteria for GBS diagnosis. Further investigations are warranted to elucidate the correlation between elevated CSF cell count and other factors influencing pathogenesis and outcomes in GBS patients.

Bangladesh Crit Care J March 2024; 12 (1): 25-28

Correlation of Caval Index and Central Venous Pressure in Non-ventilated Critically ill Patients

Mohammad Asrafuzzaman — 2024-04-04

Background: Determination of intravascular volume status can sometimes be challenging part of critically ill patient’s management in ICU. Invasive haemodynamic monitoring of central venous pressure is a useful guide in directing early resuscitative efforts and assist in reducing the morbidity and mortality of ICU patients with severe sepsis/septic shock. Obtaining invasive hemodynamic monitoring can lead to complications and time consuming. Sonographic measurement of the inferior vena cava (IVC) diameter and IVC collapsibility, termed the caval index is a non-invasive method of estimating the fluid status in critically ill patients. The study was designed to see the correlation between caval index and central venous pressure (CVP) in non-ventilated critically ill patients. Objectives: The aim of the study was to evaluate the correlation of caval index and central venous pressure in non-ventilated critically ill patients. Methods: It was a hospital based descriptive type of cross-sectional study, carried out in the ICU at the Department of Anaesthesia, Analgesia, Palliative & Intensive Care Medicine, Dhaka Medical College Hospital, Dhaka from the period of May 2017 to October 2018. A total number of 86 patients were enrolled in this study. Study subjects were patients (age >18 years) with critically-ill non-ventilated and whom central venous catheter inserted for CVP monitoring. Central venous pressure was measured first by CVP manometer. Then IVC diameter and caval index were measured with curvilinear probe of the Sonosite ultrasound device. The correlation of CVP and CI was calculated. Statistical analyses of the results were obtained by using window-based Microsoft Excel and Statistical Packages for Social Sciences (SPSS-24). Results: In this study, according to CVP 33.7% (29) of patients were hypovolemic with mean (±SD) CVP 5.3±1.2 cm H20, euvolemic were 38.3% (33) with mean (±SD) CVP 10.6±1.7 cm H20 and hypervolemic were 27.9% (24) with mean±SD CVP 16.1±1.5 cm H20. Mean caval index (CI) (%) mean (±SD) was found 57.1±7.23 in hypovolemic patients, 39.5±2.65 in euvolemic & hypervolemic patients. So, the result shows >50 % CI is associated with CVP < 8 mm of Hg and < 50% CI is associated with CVP > 8 mm of Hg. Pearsons correlation coefficient test used to assess the strength and nature of correlation between two variables. There was a statistically significant correlation between the mean CVP and the caval index (p < 0.001). So findings revealed that there is an inverse relationship between the caval index and CVP. Conclusion: The caval index had acceptable correlation with CVP at the level of IVC entry into the right atrium. It was concluded that there is an inverse relationship of CVP with the caval index.

Bangladesh Crit Care J March 2024; 12 (1): 29-34

Effect of High Dose Methylprednisolone in Near Hanging Patients: A Retrospective Observational Study in a Tertiary Level Private Hospital in Bangladesh

A K M Ferdous Rahman — 2024-04-04

Background: In the context of Bangladesh, hanging stands out as a notable method of suicide. This study focuses on patients who presented with near hanging, assessing their clinical profile, response to early management protocol and their outcome. Method: Spanning from January 1 to December 31, 2023, this retrospective study delves into the records of 10 Bangladeshi patients who engaged in near hanging. Demographic, clinical, and treatment particulars were collected along with initiation of early management protocol with an emphasis on the administration of high-dose methylprednisolone. The study evaluates the outcomes, including length of stay in the intensive care unit (ICU), and the need for intubation & mechanical ventilation, and in hospital mortality. Results: Within the specified sample size of 10 patients, comprising 30% men with a median age of 18 (range: 14–40), admission data revealed that 20% of patients had a Glasgow Coma Scale of ≤8, 10% exhibited hypotension, and no patient experienced hanging-induced cardiac arrest. All patients received high-dose methylprednisolone to reduce inflammation and oedema in injured spinal cord. Notably, a positive neurological outcome was observed in 90% of patients, with no reported mortality. The median length of stay in the ICU was 3 days, and only 10% of patients required intubation. Conclusion: The administration of high-dose methylprednisolone resulted in favourable outcomes. The study showed a zero-mortality rate, a median ICU stay of 3 days, and a 10% requirement for intubation. These findings emphasize the potential efficacy of high-dose methylprednisolone in managing near hanging cases in the Bangladeshi population, offering insights for future interventions and research.

Bangladesh Crit Care J March 2024; 12 (1): 35-40

Update on the Acute Management of Ischemic Stroke

Alim Akhtar Bhuiyan — 2024-04-04

Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.

Bangladesh Crit Care J March 2024; 12 (1): 41-49

Infection Control in ICU: What an intensivist can do to reduce ICU-acquired infections

Ridwan Naim Faruq — 2024-04-04

Bangladesh Crit Care J March 2024; 12 (1): 1-3

Abstract not available

A Case of Delayed Right Ventricle Perforation following Permanent Pacemaker Insertion complicated with Sepsis

Tamanna Yasmin Shena — 2024-04-04

Bangladesh Crit Care J March 2024; 12 (1): 75-78

Abstract not available