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Background: Antimicrobial resistance is one of the most significant challenges to global public health and the risk factors in severe pneumonia are constantly growing. Therefore, this study aimed to identify factors associated with antimicrobial resistance and conduct survival analysis of severe pneumonia patients with single and multiple pathogens in the National Referral Hospital, Jakarta, Indonesia., Methods: A retrospective method was used, and secondary data were collected from severe pneumonia patients admitted to the intensive care unit at Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia, from January 2016 to December 2022. Respiratory specimens were collected through bronchial washing. Furthermore, univariate and multivariate analyses were performed to analyze factors associated with antimicrobial resistance. Kaplan‒Meier survival curves were generated with the log-rank test to compare 30-day mortality between patients infected with single, dual, and multiple pathogens., Results: The results showed that a total of 333 patients from 415 enrolled were analyzed. Klebsiella pneumoniae (35.4%), Acinetobacter baumannii (29.3 % ), and Pseudomonas aeruginosa (15.4%) were the most frequently isolated Gram-negative pathogens. Factors associated with resistance to aminoglycoside, carbapenem, and quinolone were sepsis, cerebrovascular disease, and ventilator-associated pneumonia, as indicated by p  < 0.05. In addition, the Kaplan-Meier curves showed that multiple pathogens influenced the survival rate of severe pneumonia patients ( p  < 0.05)., Conclusions: Sepsis, cerebrovascular disease, and ventilator-associated pneumonia were associated with antimicrobial resistance in severe pneumonia patients. The survival rate of patients infected with multiple pathogens was low. This suggests the importance of further awareness regarding empirical antibiotic stewardship and mortality assessment in severe pneumonia patients., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Multidrug-resistant Gram-negative bacteria (MDR-GNB) are prevalent in intensive care units (ICUs), leading to increased morbidity and mortality. Limited data on MDR-GNB in Indonesia prompted this study to determine the prevalence and risk factors associated with MDR-GNB colonization, enhancing screening strategies, and acquiring phenotypic and genotypic data on these bacteria., Methods: This analytical cross-sectional observational study included participants who met the criteria and were admitted to the ICU at Dr. Cipto Mangunkusumo Hospital from January to December 2022. We used multivariate analysis on the findings from rectal swab screening, sociodemographic, clinical, and microbiological examinations., Results: Out of 108 participants, 172 cultures comprised 165 Gram-negative isolates, four yeasts, and three with no growth. The prevalence of patients colonized with MDR-GNB was 51.85% (56/108), and the prevalence of MDR-GNB isolates was 39.53% (68/172), with the most common MDR-GNB being Escherichia coli (29.65%) and Klebsiella pneumoniae (19.44%). The most resistant gene found in ESBL was CTX-M (75%), and the carbapenemase producer gene was NDM (5.88%). Risk factors associated with MDR-GNB colonization were the length of stay before admission to the ICU (p = 0.003) and a history of previous antibiotic therapy (p = 0.036)., Conclusion: In this study, two risk factors were associated with the occurrence of MDR-GNB colonization, with the prevalence of MDR-GNB colonization in patients initially admitted to the ICU still quite high. Therefore, selecting screening patients based on risk factors at the time of initial admission to the ICU is crucial for infection control programs.

Invasive candidiasis (IC) ranks among the primary causes of deadly fungal infections. The frequency of IC rises alongside increasing number of patients with altered immune systems, critically ill, chronic diseases, and various medical procedures. The disease causes high morbidity and mortality, as well as prolonged stay and increases hospital costs. The diagnosis and management of IC in Indonesia is still a challenge. Laboratory facilities in identifying pathogenic fungi and susceptibility tests to antifungals are still limited. Clinical awareness and financial support from health policymakers are also insufficient. Early diagnosis is essential for proper treatment to reduce morbidity and mortality rates. Initiated by the Indonesian Pulmonary Mycoses Centre (IPMC), several expert representatives from six medical professional organizations in Indonesia have agreed to set up a meeting series to prepare a joint draft on the diagnosis and management of IC. The expert panel aimed to achieve a consensus on the clinical practice guidelines for diagnosing and treating IC in Indonesia.

Background: Coronavirus disease 2019 (COVID-19) is a global pandemic. Coagulopathy is one of the most common complications characterized by increased D-dimer level. We aimed to investigate the dose-response relationship between elevated D-dimer level and mortality in critically ill COVID-19 patients., Methods: This was a retrospective observational study in 259 critically ill COVID-19 patients requiring intensive care unit admission between March and December 2020. We compared the mortality rate between patients with and without elevated D-dimer. Receiver operating characteristic (ROC) curve analysis, Fagan's nomogram, and dose-response relationship were performed to determine the association between D-dimer level and mortality., Results: Overall mortality rate was 40.9% (106 patients). Median D-dimer level was higher in non-survivor group (10,170 ng/mL vs 4,050 ng/mL, p=0.028). The association remained significant after multivariate logistic regression analysis (p=0.046). The optimal cut-off for D-dimer level to predict mortality from ROC curve analysis was 9,020 ng/mL (OR (odds ratio) 3.73 [95% CI (confidence interval) 1.91 - 7.28], p<0.001). D-dimer level >9,020 ng/mL confers 67% posterior probability of mortality and D-dimer level <9,020 ng/mL had 35% probability of mortality., Conclusions: There was a non-linear dose-response relationship between D-dimer level and mortality with P nonlinearity of 0.004. D-dimer level was associated with mortality in critically ill COVID-19 patients in the non-linear dose-response relationship., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Aditianingsih D et al.)

Background: Bronchoscopy procedure in patients with COVID-19 poses significant challenges, especially in a developing country with limited resources., Objectives: We aim to describe the clinical characteristics of severe and critical COVID-19 patients treated in an intensive care unit (ICU) and their bronchoscopy findings., Methods: We performed a retrospective analysis of clinical data of ICU patients with COVID-19 treated and received bronchoscopy procedures. This study retrospectively included all consecutive patients who underwent bronchoscopy at a teaching hospital in Depok, Indonesia, from May, 2020, until May, 2021., Results: A total of 57 bronchoscopy procedures in 54 patients were performed in this study. Primary procedure indications were retained mucus (68.4%) and ventilatory support weaning failure (15.8%). Bronchoscopic findings were mostly hyperaemic mucosa (95.00%) and purulent secretion (50.90%). Microbiological findings from bronchoalveolar samples were Acinetobacter baumanii, Klebsiella pneumoniae , and Candida albicans (33.3%, 26.6%, and 10.5%, respectively). The most common fungal isolated were Candida albicans (28%), followed by Candida tropicalis (16%) and Aspergillus sp. (8%). The overall length of hospital stay was 24 days, and the in-ICU stay was 22.06 ± 10.99 days. The patients' survival of 28-days postprocedural outcome was 25.9% (14 subjects). Follow-up found that 20.4% of patients survived after sixty days of hospitalization., Conclusion: Diagnostic and therapeutic bronchoscopy in ICU patients with COVID-19 was safe and feasible to perform in developing countries with limited resources. It could help bronchial mucous clearance and confirm microbiological infection. The procedures should be strictly performed for patients with indications and comply with safety standards., Competing Interests: The authors declare no conflict of interest, financial or otherwise., (© 2022 Pratomo et al.)

Background: Ovarian cancer remains as one of the deadliest gynecologic problems globally. Often appears in advanced state, its surgery proves to be a challenge for clinicians. This study aim to present complications surrounding ovarian cancer surgery., Materials and Methods: This study was a cross-sectional study to analyze reports of intraoperative and postoperative complications in ovarian cancer patients undergoing laparotomy in Dr. Cipto Mangunkusumo National General Hospital, Jakarta from January 2018 to December 2019. Ovarian cancer patients undergoing laparotomy surgery were included in the study. Patients with a history of other cancers or having incomplete data were excluded from the study. Intraoperative complications included intestinal, ureter, bladder injury, and postoperative complications included paralytic ileus, surgical wound infection and sepsis were documented., Results: A total of 78 subjects were included in the study. The total proportion of complications was 19.2%. The most prevalent intraoperative complications were intestinal injury (12.8%), bladder injury (2.6%), and ureter injury (1.3%). Most prevalent postoperative complications reported were surgical wound infection (5.2%), sepsis (3.9%), while none of the patients had paralytic ileus., Conclusion: The proportion of intraoperative and postoperative complications in ovarian cancer surgery was still at alarming level (19.2%). Further steps are needed to ameliorate the rate of complications surrounding ovarian cancer surgery., Competing Interests: Author GP, Author BED, Author AK, Author DA, Author YM, Author IW, Author KJ declare that they have no conflict of interest., (© 2022 The Authors.)

Background: Cardiac index (CI; cardiac output indexed to body surface area) is routinely measured during kidney transplant surgery. Bioimpedance cardiometry is a transthoracic impedance as the non-invasive alternative for hemodynamic monitoring, using semi-invasive uncalibrated pulse wave or contour (UPC) analysis., Objectives: We performed a cross-sectional observational study on 50 kidney transplant patients to compare the CI measurement agreement, concordance rate, and trending ability between bioimpedance and UPC analysis., Methods: For each patient, CI was measured by bioimpedance analysis (ICON TM ) and UPC analysis (EV1000 TM ) devices at three time points: after induction, during incision, and at reperfusion. The device measurement accuracy was assessed by the bias value, limit of agreement (LoA), and percentage error (PE) using Bland-Altman analyses. Trending ability was assessed by angular bias and polar concordance through four-quadrant and polar plot analyses., Results: From each time point and pooled measurement, the correlation coefficients were 0.267, 0.327, 0.321, and 0.348. Bland-Altman analyses showed mean bias values of 1.18, 1.06, 1.48, and 1.30, LoA of -1.35 to 3.72, -1.39 to 3.51, -1.07 to 4.04, and -1.17 to 3.78, and PE of 82.21, 78.50, 68.74, and 74.58%, respectively. Polar plot analyses revealed angular bias values of -10.37º, -15.01º, -18.68º, and -12.62º, with radial LoA of 89.79º, 85.86º, 83.38º, and 87.82º, respectively. The four-quadrant plot concordance rates were 70.77, 67.35, 65.90, and 69.79%. These analyses showed poor agreement, weak concordance, and low trending ability of bioimpedance cardiometry to UPC analysis., Conclusions: Bioimpedance and UPC analysis for CI measurements were not interchangeable in patients undergoing kidney transplant surgery. Cardiac index monitoring using bioimpedance cardiometry during kidney transplantation should be interpreted cautiously because it showed poor reliability due to low accuracy, precision, and trending ability for CI measurement., Competing Interests: Conflict of Interests: The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript., (Copyright © 2021, Author(s).)

One of the main causes of acute respiratory distress syndrome in coronavirus disease 2019 (COVID-19) is cytokine storm, although the exact cause is still unknown. Umbilical cord mesenchymal stromal cells (UC-MSCs) influence proinflammatory T-helper 2 (Th 2 ) cells to shift to an anti-inflammatory agent. To investigate efficacy of UC-MSC administration as adjuvant therapy in critically ill patients with COVID-19, we conducted a double-blind, multicentered, randomized controlled trial at four COVID-19 referral hospitals in Jakarta, Indonesia. This study included 40 randomly allocated critically ill patients with COVID-19; 20 patients received an intravenous infusion of 1 × 10 6 /kg body weight UC-MSCs in 100 ml saline (0.9%) solution (SS) and 20 patients received 100 ml 0.9% SS as the control group. All patients received standard therapy. The primary outcome was measured by survival rate and/or length of ventilator usage. The secondary outcome was measured by clinical and laboratory improvement, with serious adverse events. Our study showed the survival rate in the UC-MSCs group was 2.5 times higher than that in the control group (P = .047), which is 10 patients and 4 patients in the UC-MSCs and control groups, respectively. In patients with comorbidities, UC-MSC administration increased the survival rate by 4.5 times compared with controls. The length of stay in the intensive care unit and ventilator usage were not statistically significant, and no adverse events were reported. The application of infusion UC-MSCs significantly decreased interleukin 6 in the recovered patients (P = .023). Therefore, application of intravenous UC-MSCs as adjuvant treatment for critically ill patients with COVID-19 increases the survival rate by modulating the immune system toward an anti-inflammatory state., (© 2021 The Authors. STEM CELLS TRANSLATIONAL MEDICINE published by Wiley Periodicals LLC on behalf of AlphaMed Press.)

Purpose: To evaluate a low-cost multimodal intervention on the acquisition of carbapenem-non-susceptible Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa by patients in low-resource intensive care units., Materials and Methods: We performed a quasi-experimental study in a referral hospital in Jakarta, Indonesia: pre-intervention phase 1 (2013-2014), intervention phase 2 (2014-2015) and post-intervention phase 3 (2015-2016). The intervention was hand hygiene promotion and environmental cleaning and disinfection combined with patient disinfection and cohorting. The primary outcome was acquisition of resistant bacteria per 100 patient-days at risk, which was assessed by active microbiological surveillance and analysed with a multilevel Poisson segmented regression model., Results: In phase 1 (387 patients), the acquisition rate was 4.3/100 days for carbapenem-non-susceptible A. baumannii versus 1.1/100 days for both K. pneumoniae and P. aeruginosa. There was a significant step change from phase 1 to phase 3 (361 patients) in the acquisition of carbapenem-non-susceptible strains, the incidence rate ratio (IRR) was 0.343 (99%CI: 0.164-0.717). This significant change was mainly due to reduced acquisitions of resistant A. baumannii (IRR 0.4, 99%CI: 0.181-1.061). Negative confounding was observed., Conclusion: A multimodal intervention to prevent acquisition of resistant pathogens is feasible and may be effective in ICUs in lower-middle income countries., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Coronavirus disease 19 (COVID-19) which is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has been a problem worldwide, particularly due to the high rate of transmission and wide range of clinical manifestations. Acute respiratory distress syndrome (ARDS) and multiorgan failure are the most common events observed in severe cases and can be fatal. Cytokine storm syndrome emerges as one of the possibilities for the development of ARDS and multiorgan failure in severe cases of COVID-19. This case report describes a case of a 53-year-old male patient who has been diagnosed with COVID-19. Further evaluation in this patient showed that there was a marked increase in IL-6 level in blood accompanied with hyperferritinemia, which was in accordance with the characteristic of cytokine storm syndrome. Patient was treated with tocilizumab, a monoclonal antibody and is an antagonist to IL-6 receptor. The binding between tocilizumab and IL-6 receptors effectively inhibit and manage cytokine storm syndrome. Although this case report reported the efficacy of tocilizumab in managing cytokine storm syndrome, tocilizumab has several adverse effects requiring close monitoring. Further clinical randomized control trial is required to evaluate the efficacy and safety of tocilizumab administration in participants with various clinical characteristics and greater number of subjects.

Objective: The aim of this study was to investigate the course of diaphragm changes in mechanically ventilated patients in ICU after four days of mechanical ventilation. In addition, to evaluate correlation of various demographic variables to baseline diaphragm muscle thickness and their effects on the course of diaphragm muscle thickness changes., Methods: This study was conducted from December 2018 to February 2019 at Cipto Mangunkusumo National Hospital. Thirty critically ill patients using mechanical ventilation in the ICU were included. Baseline demographic data were collected. Baseline end expiratory diaphragm thickness was measured within one hour after starting mechanical ventilation and repeated every 24 hours for four days. Mortality and duration of mechanical ventilation were recorded., Results: There were no differences in baseline diaphragm thickness according to gender, body mass index and modified Rankin Score. The subjects were divided into two categories: duration of mechanical ventilation less than seven days and duration of ventilation of seven days or more. The mean baseline diaphragm thickness was 2.11 + 0.15 mm. A rapid decrease of diaphragm muscle thickness was found within 24 hours. Diaphragm muscle thickness changed over subsequent measurements during observation. It was found that rapid diaphragm muscle thinning corresponded with longer duration of mechanical ventilation and worse outcomes., Conclusions: Diaphragm muscle thinning was seen early in the course of mechanical ventilation. Diaphragm muscle thickness changed over time, and there was no correlation with other measured variables.

Objective: This pilot study was performed to identify the differences between the effectiveness of HFNC and conventional oxygen therapy., Methods: This study was a part of a more extensive ongoing study in a tertiary care hospital from January to April 2019. Criteria for inclusion were adult patients scheduled for upper-abdominal surgery. Patients were randomised into two groups: conventional oxygen therapy (n=10) and HFNC therapy (n=10). The differences in (clinical parameters;Mean Arterial Pressure (MAP), heart rate, respiratory rate), diaphragm thickening on ultrasound, air lung distribution on Electrical Impedance Tomography (EIT), and blood gas analysis data between both groups were assessed at specific times. Adverse events were recorded and treated during the study. The data collected was analysed using SPSS software version 23.0., Results: During the recuritment of patients, no issues were indentified in this study. Therefore, no clinical or statistical differences in EIT and ultrasound diaphragm thickening between the two groups were observed; no clinical or statistical differences in patterns in clinical parameters were found. The mean arterial PO2 was particulary different at time 1: 137.10 mmHg for patients in the conventional therapy group and 93.95 mmHg in the HFNC group (p = 0.001). A patient in the HFNC group reported a feeling of discomfort., Conclusions: The aim of this study was to observe differences between HFNC and conventional oxygen therapy. Nonetheless, more data are needed in order to achieve a conclusive result.

Objective: A prospective observational study was performed to assess the epidemiology and clinical impact of carbapenem-non-susceptible Klebsiella pneumoniae (CNKP) in intensive care units (ICUs) of the national referral hospital in Jakarta, Indonesia., Materials/methods: Adult patients consecutively hospitalized for > 48 h in two ICUs of the national referral hospital were included from April until October 2013 and from April until August 2014. K. pneumoniae from clinical cultures and standardized screening of rectum and throat on admission, discharge and weekly if hospitalized > 7 days were collected. Environmental niches and healthcare workers (HCWs) were also screened. Susceptibility was determined phenotypically and the presence of carbapenemase genes by PCR. Raman spectroscopy as well as multiple-locus variable number tandem repeat analysis (MLVA) were used for typing., Results: Twenty-two out of 412 (5.3%) patients carried CNKP on admission and 37/390 (9.5%) acquired CNKP during ICU stay. The acquisition rate was 24.7/1000 patient-days at risk. One out of 31 (3.2%) environmental isolates was a CNKP. None of the HCWs carried CNKP. Acquisition of CNKP was associated with longer ICU stay (adjusted Hazard Ratio: 2.32 [CI 99 : 1.35-3.68]). ICU survival was lower among patients with CNKP compared to patients with carbapenem-susceptible K. pneumoniae (aHR 2.57, p = 0.005). Ninety-six of the 100 (96%) CNKP isolates carried a carbapenemase gene, predominantly bla NDM . Raman typing revealed three major clusters among 48 Raman types identified, whereas MLVA distinguished six major clusters among a total of 30 different genotypes., Conclusions: NDM-producing CNKP are introduced into these ICUs and some strains expand clonally among patients and the environment, resulting in endemic CNKP. CNKP acquisition was associated with prolonged ICU stay and may affect ICU survival., Trial Registration: The study was registered at Netherlands Trial Register http://www.trialregister.nl. Candidate number: 23527, NTR number: NTR5541, NL number: NL5425 (https://www.trialregister.nl/trial/5424), Retrospectively registered: NTR: 22 December 2015.

Importance: Infection is frequent among patients in the intensive care unit (ICU). Contemporary information about the types of infections, causative pathogens, and outcomes can aid the development of policies for prevention, diagnosis, treatment, and resource allocation and may assist in the design of interventional studies., Objective: To provide information about the prevalence and outcomes of infection and the available resources in ICUs worldwide., Design, Setting, and Participants: Observational 24-hour point prevalence study with longitudinal follow-up at 1150 centers in 88 countries. All adult patients (aged ≥18 years) treated at a participating ICU during a 24-hour period commencing at 08:00 on September 13, 2017, were included. The final follow-up date was November 13, 2017., Exposures: Infection diagnosis and receipt of antibiotics., Main Outcomes and Measures: Prevalence of infection and antibiotic exposure (cross-sectional design) and all-cause in-hospital mortality (longitudinal design)., Results: Among 15 202 included patients (mean age, 61.1 years [SD, 17.3 years]; 9181 were men [60.4%]), infection data were available for 15 165 (99.8%); 8135 (54%) had suspected or proven infection, including 1760 (22%) with ICU-acquired infection. A total of 10 640 patients (70%) received at least 1 antibiotic. The proportion of patients with suspected or proven infection ranged from 43% (141/328) in Australasia to 60% (1892/3150) in Asia and the Middle East. Among the 8135 patients with suspected or proven infection, 5259 (65%) had at least 1 positive microbiological culture; gram-negative microorganisms were identified in 67% of these patients (n = 3540), gram-positive microorganisms in 37% (n = 1946), and fungal microorganisms in 16% (n = 864). The in-hospital mortality rate was 30% (2404/7936) in patients with suspected or proven infection. In a multilevel analysis, ICU-acquired infection was independently associated with higher risk of mortality compared with community-acquired infection (odds ratio [OR], 1.32 [95% CI, 1.10-1.60]; P = .003). Among antibiotic-resistant microorganisms, infection with vancomycin-resistant Enterococcus (OR, 2.41 [95% CI, 1.43-4.06]; P = .001), Klebsiella resistant to β-lactam antibiotics, including third-generation cephalosporins and carbapenems (OR, 1.29 [95% CI, 1.02-1.63]; P = .03), or carbapenem-resistant Acinetobacter species (OR, 1.40 [95% CI, 1.08-1.81]; P = .01) was independently associated with a higher risk of death vs infection with another microorganism., Conclusions and Relevance: In a worldwide sample of patients admitted to ICUs in September 2017, the prevalence of suspected or proven infection was high, with a substantial risk of in-hospital mortality.

Background: Laparoscopic nephrectomy is a preferred technique for living kidney donation. However, positive-pressure pneumoperitoneum may have an unfavorable effect on the remaining kidney and other distant organs due to inflamed vascular endothelium and renal tubular cell injury in response to increased systemic inflammation. Early detection of vascular endothelial and renal tubular response is needed to prevent further kidney injury due to increased intraabdominal pressure induced by pneumoperitoneum. Transperitoneal laparoscopic living donor nephrectomy represented a human model of mild increasing intraabdominal pressure. This study aimed to assess the effect of increased intraabdominal pressure on vascular endothelium and renal tubular cells by comparing the effects of low and standard pressure pneumoperitoneum on vascular endothelial growth factor receptor-2 (VEGFR-2) expression and the shedding of syndecan-1 as the early markers to a systemic inflammation., Methods: We conducted a prospective randomized study on 44 patients undergoing laparoscopic donor nephrectomy. Subjects were assigned to standard (12 mmHg) or low pressure (8 mmHg) groups. Baseline, intraoperative, and postoperative plasma interleukin-6, syndecan-1, and sVEGFR-2 were quantified by ELISA. Syndecan-1 and VEGFR-2 expression were assessed immunohistochemically in renal cortex tissue. Renal tubule and peritubular capillary ultrastructures were examined using electron microscopy. Perioperative hemodynamic changes, end-tidal CO 2 , serum creatinine, blood urea nitrogen, and urinary KIM-1 were recorded., Results: The low pressure group showed lower intra- and postoperative heart rate, intraoperative plasma IL-6, sVEGFR-2 levels and plasma syndecan-1 than standard pressure group. Proximal tubule syndecan-1 expression was higher in the low pressure group. Proximal-distal tubules and peritubular capillary endothelium VEGFR-2 expression were lower in low pressure group. The low pressure group showed renal tubule and peritubular capillary ultrastructure with intact cell membranes, clear cell boundaries, and intact brush borders, while standard pressure group showed swollen nuclei, tenuous cell membrane, distant boundaries, vacuolizations, and detached brush borders., Conclusion: The low pressure pneumoperitoneum attenuated the inflammatory response and resulted in reduction of syndecan-1 shedding and VEGFR-2 expression as the renal tubular and vascular endothelial proinflammatory markers to injury due to a systemic inflammation in laparoscopic nephrectomy., Trial Registration: ClinicalTrials.gov NCT:03219398, prospectively registered on July 17th, 2017.

Background: Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy., Methods: Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB (n = 31) or continuous epidural (n = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed., Result: The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group (p = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter (p < 0.001) in the QLB group., Conclusion: The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia, and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy., Trial Registration: ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.

Background: Target-controlled infusion (TCI) propofol and sevoflurane are common agents for general anesthesia, including for kidney transplantation procedure. This study compared the effect of TCI propofol and sevoflurane on intraoperative hemodynamic profile in kidney transplant patients., Methods: A single-blinded prospective study was performed in 46 kidney transplant recipients who were randomized into receiving TCI propofol or sevoflurane as anesthetics maintenance. Hemodynamic parameters such as mean arterial pressure (MAP), cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI) were measured at baseline before induction, postintubation, first surgical incision, every 15 minutes after the first incision, reperfusion, and 15 minutes after reperfusion. Data were analyzed using unpaired t -test, paired t -test, and general linear model., Results: Intraoperative MAP, CI, SVI, and SVRI changes were similar in both groups ( p  = 0.480, 0.216, 0.086, and 0.054). In comparison to the baseline value, TCI propofol and sevoflurane groups showed significant reductions of MAP at postintubation ( p =0.010; p < 0.001) and during the first surgical incision ( p =0.009; p < 0.001); significant reduction of CI at postintubation ( p =0.003; p < 0.001) and during the first surgical incision ( p < 0.001; p < 0.001); significant reduction of SVI at postintubation ( p =0.013; p =0.008), during the first surgical incision ( p =0.008; p =0.003), and 15 minutes after reperfusion ( p =0.010; p =0.005); and significant increasing of SVRI during the first surgical incision ( p =0.007; p =0.005). The TCI propofol group showed significantly lower SVRI compared to the sevoflurane group postintubation ( p =0.029) and during the first surgical incision ( p =0.026)., Conclusion: Intraoperative hemodynamic profile was similar between the TCI propofol and sevoflurane group during kidney transplant surgery. The TCI propofol group had higher CI and SVI but showed significantly lower SVRI as compared to the sevoflurane group. The incidence of postanesthesia agitation, postoperative outcome, and complication were not significantly different between the two groups., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2019 Dita Aditianingsih et al.)

Infection control effectiveness evaluations require detailed epidemiological and microbiological data. We analyzed the genomic profiles of carbapenem-nonsusceptible Pseudomonas aeruginosa (CNPA) strains collected from two intensive care units (ICUs) in the national referral hospital in Jakarta, Indonesia, where a multifaceted infection control intervention was applied. We used clinical data combined with whole-genome sequencing (WGS) of systematically collected CNPA to infer the transmission dynamics of CNPA strains and to characterize their resistome. We found that the number of CNPA transmissions and acquisitions by patients was highly variable over time but that, overall, the rates were not significantly reduced by the intervention. Environmental sources were involved in these transmissions and acquisitions. Four high-risk international CNPA clones (ST235, ST823, ST357, and ST446) dominated, but the distribution of these clones changed significantly after the intervention was implemented. Using resistome analysis, carbapenem resistance was explained by the presence of various carbapenemase-encoding genes ( bla GES-5 , bla VIM-2-8 , and bla IMP-1-7-43 ) and by mutations within the porin OprD. Our results reveal for the first time the dynamics of P. aeruginosa antimicrobial resistance (AMR) profiles in Indonesia and additionally show the utility of WGS in combination with clinical data to evaluate the impact of an infection control intervention. (This study has been registered at www.trialregister.nl under registration no. NTR5541). IMPORTANCE In low-to-middle-income countries such as Indonesia, work in intensive care units (ICUs) can be hampered by lack of resources. Conducting large epidemiological studies in such settings using genomic tools is rather challenging. Still, we were able to systematically study the transmissions of carbapenem-nonsusceptible strains of P. aeruginosa (CNPA) within and between ICUs, before and after an infection control intervention. Our data show the importance of the broad dissemination of the internationally recognized CNPA clones, the relevance of environmental reservoirs, and the mixed effects of the implemented intervention; it led to a profound change in the clonal make-up of CNPA, but it did not reduce the patients' risk of CNPA acquisitions. Thus, CNPA epidemiology in Indonesian ICUs is part of a global expansion of multiple CNPA clones that remains difficult to control by infection prevention measures., (Copyright © 2019 Pelegrin et al.)

The aim of this study was to describe the epidemiology and clinical impact of carbapenem-non-susceptible Pseudomonas aeruginosa (CNPA) in intensive care units (ICUs) of the national referral hospital of Indonesia. Adult patients admitted to ICUs were prospectively included. Pseudomonas aeruginosa were from clinical cultures and systematic screening. Environmental niches and healthcare workers (HCWs) were also screened. Susceptibility was determined phenotypically and the presence of carbapenemase genes was determined by PCR. Multiple loci variable-number tandem repeat analysis (MLVA) and multilocus sequence typing (MLST) were used for genotyping. Of the patients included in the study, 17/412 (4.1%) carried CNPA on admission and 34/395 (8.6%) became positive during their ICU stay. The acquisition rate was 18/1000 patient-days at risk. Of 16 environmental isolates, 12 (75.0%) were CNPA. HCWs screened negative. Acquisition of CNPA was associated with longer ICU stay (adjusted hazard ratio = 1.89, 99% confidence interval 1.12-3.13). Mortality was >40% among patients with CNPA versus <30% among those without CNPA (P = 0.019). Moreover, 83/119 (69.7%) CNPA carried either bla VIM (n = 36), bla IMP (n = 23) or bla GES-5 (n = 24). Four sequence types (STs) dominated (ST235, ST823, ST446 and ST357). Five major MLVA clusters were distinguished, two belonging to ST235 and the other three to ST823, ST446 and ST357. CNPA are introduced into these ICUs and some strains expand clonally among patients and the environment, creating endemic CNPA. VIM-, IMP- and GES-5 genes are prevalent. CNPA acquisition was associated with prolonged ICU stay and may affect ICU survival., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Hand hygiene (HH) is considered to be the single most effective measure in preventing healthcare-associated infections. However, HH compliance rates among nurses and doctors in hospitals are often very low. Few studies have addressed HH compliance in Indonesia, performed interventions to increase HH compliance, and none have had long-term follow-up. We, therefore, addressed this issue by performing long-term follow-up after a multifaceted intervention in the intensive care unit (ICU) setting., Methods: This was an observational, prospective, before-and-after intervention study (May-September 2014, February-April 2017). We measured HH knowledge and HH compliance before (at baseline) and directly after a multifaceted improvement program (post-intervention) and performed a re-evaluation three years later. The multifaceted improvement program included education, feedback, reminders, interviews and the use of role models. The study involved nurses and physicians working in two ICUs of the Dr. Cipto Mangunkusumo Hospital in Jakarta., Results: A total of 97 at baseline, and 72 at post-intervention HH knowledge questionnaires were completed. There was a statistically significant improvement in the median overall HH knowledge score at post-intervention (from 15 to 22, p  < 0.001). There was no significant difference between the two ICUs. The overall HH compliance was 27% at baseline and significantly improved to 77% post-intervention ( p  < 0.001). For all five HH moments, the compliance of nurses and physicians separately improved significantly from the baseline phase to the post-intervention phase ( p  < 0.001), except for 'moment 3' (after body fluid exposure), for which baseline rates were already high. Most of the compliance rates were significantly lower in both groups of healthcare workers upon follow-up three years later. Overall, the HH compliance of the nurses was significantly better than the physicians' compliance ( p  = 0.005)., Conclusions: Our multifaceted improvement program, for nurses and physicians of the ICUs in the largest hospital of Indonesia, resulted in a significant improvement of the HH knowledge and HH compliance, but HH compliance levels waned over time after the intervention, indicating a need for continued monitoring and repeated interventions., Trial Registration: The study was registered at www.trialregister.nl (No: 5541). Candidate number: 23527, NTR number: NTR5541, Date registered NTR: 22-DECEMBER-2015., Competing Interests: Competing interestsYRS is an awardee of the DIKTI-NESO Scholarship by The Directorate General of Higher Education of Indonesia Ministry of Research, Technology and Higher Education of the Republic of Indonesia, and Department of Medical Microbiology and Infectious Diseases, Erasmus MC in Rotterdam, The Netherlands. All authors report no conflict of interest relevant to this article.

Background: An adequate anesthesia technique generates appropriate postoperative analgesic properties and decreases the patient's stress response. This will lead to decreased morbidity and mortality associated with immunology disturbances, such as infection, prolonged wound healing, and sepsis., Objectives: The aim of this study was to compare interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations, as the markers of the stress response, between continuous epidural and quadratus lumborum (QL) block as postoperative analgesia techniques among living kidney donors., Methods: Sixty-two patients were randomly divided into two equal groups: continuous epidural and QL block. A group received bilateral QL block with 20 mL of bupivacaine 0.25% and the other received 6 mL/hour of bupivacaine 0.25% continuously via an epidural catheter. Prior to extubation, the QL block group received bilateral QL block with the same dose and the continuous epidural group was administered with 6 mL/hour of bupivacaine 0.125%. Blood samples were drawn to compare IL-6 and CRP concentrations after intubation (preoperatively), directly after surgery, 24 hours postoperatively, and 48 hours postoperatively. Postoperative pain was measured with the numerical rating scale (NRS). Morphine requirement and duration of catheter usage were also measured postoperatively. Side effects within 24 hours postoperatively were noted. Data were analyzed with independent t -test or Mann-Whitney test., Results: No difference was observed between the groups in the plasma concentration of IL-6 either after surgery or 24 hours postoperatively (P = 0.785 and P = 0.361, respectively) although the mean IL-6 concentration 24 hours postoperatively was lower in the QL block group than in the continuous epidural group. CRP concentration was not significantly different between the groups either after surgery or 48 hours postoperatively (P = 0.805 and P = 0.636, respectively)., Conclusions: There was no significant difference in IL-6 and CRP concentrations between continuous epidural and QL block among living kidney donors. Both continuous epidural and QL block techniques showed comparable postoperative analgesic properties among living kidney donors undergoing laparoscopic nephrectomy.

Background: Postoperative pain management is important for the early recovery of the living donor patient. Patient-controlled opioid analgesia, epidural analgesia, or a combination of both is the preferred pain management after abdominal surgery although these approaches have serious side effects. The transversus abdominis plane (TAP) block has been increasingly used for postoperative pain management and the addition of dexamethasone to local anesthetic can prolong the duration of action., Objectives: This study evaluated the efficacy of ultrasound-guided three-quadrant TAP block analgesia with the addition of dexamethasone, compared to the continuous epidural analgesia in postoperative cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic living donor nephrectomy., Methods: A prospective randomized control study was conducted on 50 patients with ASA I-II, 18 - 65 years old, BMI 18 - 30, and undergoing transperitoneal laparoscopic donor nephrectomy under general anesthesia. The patients were randomly assigned into either a three-quadrant TAP block group (n = 25) with 20 mL of 0.25% bupivacaine plus dexamethasone 8 mg or a continuous epidural group (n = 25) using 0.125% bupivacaine postoperatively. The morphine consumption and the numerical rating scale (NRS) at rest and movement were evaluated at 2, 6, 12, and 24 hours postoperatively. The postoperative first-time mobilization and duration of urinary catheter usage were recorded., Results: Patients demographic characteristics were similar in the two groups. During 24 hours after the surgery, cumulative morphine consumption (P = 0.232), the NRS at rest and movement (P > 0.05), and the first-time mobilization (P = 0.075) were not significantly different between the groups, except that the NRS during movement at 12 hours was significantly lower in the TAP block group (P = 0.004). The duration of urinary catheterization was significantly longer as a side effect in the continuous epidural group (P < 0.001)., Conclusions: The three-quadrant TAP block with the addition of dexamethasone showed comparable analgesic effects as the continuous epidural analgesia in cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic donor nephrectomy., Competing Interests: Financial Disclosure:Dr Dita Aditianingsih as the author and main corresponding author represented all the authors in this manuscript, stated that we have no financial interests related to the material in the manuscript.

Background & Aims: Guidance on managing the nutritional requirements of critically ill patients in the intensive care unit (ICU) has been issued by several international bodies. While these guidelines are consulted in ICUs across the Asia-Pacific and Middle East regions, there is little guidance available that is tailored to the unique healthcare environments and demographics across these regions. Furthermore, the lack of consistent data from randomized controlled clinical trials, reliance on expert consensus, and differing recommendations in international guidelines necessitate further expert guidance on regional best practice when providing nutrition therapy for critically ill patients in ICUs in Asia-Pacific and the Middle East., Methods: The Asia-Pacific and Middle East Working Group on Nutrition in the ICU has identified major areas of uncertainty in clinical practice for healthcare professionals providing nutrition therapy in Asia-Pacific and the Middle East and developed a series of consensus statements to guide nutrition therapy in the ICU in these regions., Results: Accordingly, consensus statements have been provided on nutrition risk assessment and parenteral and enteral feeding strategies in the ICU, monitoring adequacy of, and tolerance to, nutrition in the ICU and institutional processes for nutrition therapy in the ICU. Furthermore, the Working Group has noted areas requiring additional research, including the most appropriate use of hypocaloric feeding in the ICU., Conclusions: The objective of the Working Group in formulating these statements is to guide healthcare professionals in practicing appropriate clinical nutrition in the ICU, with a focus on improving quality of care, which will translate into improved patient outcomes., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Carbapenem-nonsusceptible A. baumannii-calcoaceticus complex have emerged worldwide, but the epidemiology in Indonesian hospitals has not been studied., Methods: A prospective observational study was performed on the intensive care units (ICUs) of the national referral hospital in Jakarta-Indonesia, in 2013 and 2014. All consecutive adult patients admitted and hospitalized for >48 h in ICUs were included. Basic and clinical data at admission were recorded. Carbapenem-nonsusceptible A. baumannii-calcoaceticus complex from clinical cultures and standardized screening were included. Environmental niches and healthcare workers (HCWs) were also screened. PCR was used to detect carbapenemase genes, and Raman spectroscopy as well as multilocus sequence typing (MLST) for typing., Results: Of 412 included patients, 69 (16.7%) carried carbapenem-nonsusceptible A. baumannii-calcoaceticus complex on admission, and 89 (25.9%) became positive during ICU stay. The acquisition rate was 43 per 1000 patient-days at risk. Six isolates were cultured from environment and one from a HCW. Acquisition of carbapenem-nonsusceptible A. baumannii-calcoaceticus complex was associated with longer ICU stay (median interquartile range [IQR]: 11 days [5-18], adjusted hazard ratio [aHR]: 2.56 [99% confidence interval (CI):1.76-3.70]), but not with mortality (adjusted odds ratio: 1.59 [99%CI: 0.74-3.40] at the chosen level of significance). The bla OXA-23 -like gene was detected in 292/318 (91.8%) isolates, including isolates from the environment and HCW. Typing revealed five major clusters. Sequence types (ST)195, ST208, ST218, ST642 as well as new STs were found. The dominant clone consisted of isolates from patients and environment throughout the study period., Conclusions: Carbapenem-nonsusceptible A. baumannii-calcoaceticus complex are endemic in this setting. Prevention requires source control and limiting transmission of strains., Trial Registration: The study was retrospectively registered at www.trialregister.nl (No:5541). Candidate number: 23,527, NTR number: NTR5541, Date registered NTR: 22nd December 2015., Competing Interests: The Ethics Committee of the Faculty of Medicine, Universitas Indonesia, approved the research on 17th September 2012, No: 561/PT02.FK/ETIK/2012, (No: 757/UN2.F1/ETIK/X/2014). A Material Transfer Agreement (MTA) was reviewed and approved by the Director of National Institute Research and Development, Ministry of Health (No: LB.02.01/I.9.4/8500/2013). Written informed consent was obtained using a form that was approved by the Ethics Committee Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital. A signature and the date of signature was put on the form by the study subjects or their guardians and by the person who conducted the informed consent discussion and two witnesess. The signature confirmed that the consent was based on information that had been understood including publication.Yulia Rosa Saharman is an awardee of The DIKTI-NESO Scholarship by The Directorate General of Higher Education of Indonesia Ministry of Research, Technology and Higher Education of the Republic of Indonesia, and Department of Medical Microbiology and Infectious Diseases, Erasmus MC in Rotterdam, The Netherlands. Preliminary results of this study were presented at the 54th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) 2014 in Washington, DC (poster C-1477). All authors report no conflict of interest relevant to this article.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: The incidence of invasive fungal disease (IFD) is increasing worldwide in the past two to three decades. Critically ill patients in Intensive Care Units are more vulnerable to fungal infection. Early detection and treatment are important to decrease morbidity and mortality in critically ill patients., Objective: Our study aimed to assess factors associated with early IFD in critically ill patients., Materials and Methods: This prospective cohort study was conducted in critically ill patients, from March to September 2015. Total number of patients (74) in this study was drawn based on one of the risk factors (human immunodeficiency virus). Specimens were collected on day 5-7 of hospitalization. Multivariate analysis with logistic regression was performed for factors, with P < 0.25 in bivariate analysis., Results: Two hundred and six patients were enrolled in this study. Seventy-four patients were with IFD, majority were males (52.7%), mean age was 58 years (range 18-79), mean Leon's score was 3 (score range 2-5), majority group was nonsurgical/nontrauma (72.9%), and mean fungal isolation was positive on day 5. Candida sp. (92.2%) is the most frquently isolated fungal infection. Urine culture yielded the highest number of fungal isolates (70.1%). Mortality rate in this study was 50%. In multivariate analysis, diabetes mellitus (DM) ( P = 0.018, odds ratio 2.078, 95% confidence interval 1.135-3.803) was found as an independent factor associated with early IFD critically ill patients., Conclusion: DM is a significant factor for the incidence of early IFD in critically ill patients., Competing Interests: There are no conflicts of interest.

Fluid therapy is a core concept in the management of perioperative and critically ill patients for maintenance of intravascular volume and organ perfusion. Recent evidence regarding the vascular barrier and its role in terms of vascular leakage has led to a new concept for fluid administration. The choice of fluid used should be based on the fluid composition and the underlying pathophysiology of the patient. Avoidance of both hypo- and hypervolaemia is essential when treating circulatory failure. In daily practice, the assessment of individual thresholds in order to optimize cardiac preload and avoid hypovolaemia or deleterious fluid overload remains a challenge. Liberal versus restrictive fluid management has been challenged by recent evidence, and the ideal approach appears to be goal-directed fluid therapy., (Copyright © 2014 Elsevier Ltd. All rights reserved.)