Bangladesh Critical Care Journal Official journal of the Bangladesh Society of Critical Care Medicine. Full text articles available. Bangladesh Society of Critical Care Medicine en-US Bangladesh Critical Care Journal 2304-0009 <p>Upon acceptance for publication the copyright of the paper automatically transfers to the BCCJ and will not be published elsewhere either in part or whole without written permission of the copyright holder.</p><p>Except for personal use, no part of the materials published in this journal may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, photocopying, recording or otherwise without the prior written permission of the publisher.</p> Cutting cost without compromising quality: Can we deliver ICU care to our poor? <p>Abstract not available</p><p>Bangladesh Crit Care J September 2018; 6(2): 62-64</p> Mohammad Omar Faruq Samira Humaira Habib ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 62 64 10.3329/bccj.v6i2.38578 Prognostic value of Amino Terminal Pro B-type Natriuretic Peptide (NT-proBNP) in patient with severe sepsis and septic shock in an ICU of tertiary care hospital of Bangladesh. <p><strong>Background: </strong>Severe sepsis and septic shock are the leading cause of ICU admission. Despite the adequate resuscitation, septic shock is frequently associated with multiple system organ failure (MSOF) and death. This study examined the clinical utility of the level of NT-proBNP as an indicator of outcome in severe sepsis and septic shock.</p><p><strong>Objectives: </strong>to find relationship between level of NT-Pro-BNP and the outcome of the patients of severe sepsis and septic shock.</p><p><strong>Design: </strong>This Prospective observational study done in ICU of BIRDEM General Hospital.</p><p><strong>Method: </strong>All consecutive patients who were diagnosed as severe sepsis and septic shock according to SSC (Surviving Sepsis Campaign) guidelines fulfilling the selection criteria were included in the study. Informed written consent was taken from patient’s first degree relatives. Just after admission of severe sepsis and septic shock patients into ICU and development of severe sepsis or septic shock of previously admitted ICU patients, blood sample for serum NT-proBNP level was sent to hospital laboratory. 28 days were taken as follow up period for all patients in this study. Outcome was measured by mortality. Those who were discharged or transferred were classified as survivors and those who were died, categorized as non survivors. Those who were neither discharged nor dead during the study period were classified as survivors. Patient’s resusci-tation and management were done according to the standard ICU protocol of BIRDEM General Hospital.</p><p><strong>Result: </strong>A total 127 of patients fulfilled the criteria of sepsis and septic shock and study inclusion criteria during the study period. The mean &amp; SD of age in this study was 63.69 ± 17.79 years. 52% (n = 66) were male &amp; 48% (n = 61) were female. Here DM was the most common (83.5%) comorbidity and predominant diagnoses were Pneumonia (58.3%) &amp; UTI (30.7%). Among 127 patients, 24.4% (n=31) were in septic shock and 75.6% (n= 96) patients present with severe sepsis. Level of NT-proBNP of severe sepsis patients were 4608.64 ± 7712.12 &amp; Level of NT-proBNP of septic shock patients were 19239.06 ± 13058.05 (P&lt;0.0001). Among 31 (24.4%) septic shock patients, 32.2% (n=10) patients were survivor and NT-proBNP level was 7333.50 ± 10624 pg/ml; 67.8% (n=21) patients were non survivor and NT-proBNP level was 24908.38 ± 10017.87 pg/ml (P &lt;0.001). In this study among 96 (75.6%) patients with severe sepsis, 88.7% (n=86) were survivor and NT-proBNP level was 2436.41 ± 3755.03 pg/ml; 11.3% (n=11) patients were non-survivors and NT-proBNP level was 21238.36 ± 10095.34 pg/ml (P&lt;0.0001).</p><p><strong>Conclusion: </strong>Severe sepsis and septic shock are the leading cause of ICU admission and also leading cause of death. Our study showed that, elderly with diabetes mellitus had developed more sepsis. Pneumonia and UTI are commonest cause of sepsis.Sepsis causes extreme inflammatory reactions involving all organs of whole body including heart, causing release of NT-proBNP. Raised level of this biomarker associated with increased rate of mortality.</p><p>Bangladesh Crit Care J September 2018; 6(2): 65-70</p> Tarikul Hamid Rozina Sultana ASM Areef Ahsan Kaniz Fatema Fatema Ahmed Debasish Kumar Registrar Madhurima Saha Suraiya Nazneen ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 65 70 10.3329/bccj.v6i2.38579 Laparoscopic Ventral Mesh Rectopexy (LVMR) - an Early Experience in Birdem Hospital <p><strong>Background : </strong>Full thickness rectal prolapse are treated by multiple procedures through perineal and abdominal approach. Consensus is lacking as to the best option. Each procedure is associated with significant recurrence rate.</p><p><strong>Objective : </strong>The aim of this study is to report the effectiveness, complications following laparoscopic ventral mesh rectopexy in patients with full thickness rectal prolapse.</p><p><strong>Methods : </strong>The study is a retrospective evaluation of 6 consecutive patients by a single attending surgeon in a general and laparoscopic surgery unit,between July 2014 to June 2016. Peritoneum was incised at the pouch of Douglas or rectovesical pouch, space created between the rectum and the vagina or urinary bladder, polypropylene mesh was fixed to the rectum with non-absorbable suture and to the promontory of the sacrum with same suture instead of staples. In females, the mesh was also fixed anteriorly with posterior fornix of vagina. The peritoneum was suture closed over the mesh. Patients were reviewed at 1 and 6 months, then annually to assess recurrence, morbidity and mortality.</p><p><strong>Result : </strong>There was no recurrence or mortality among four female and two male patients. Morbidity consistedof chronic deep perineal pain in one youngmale patient who was treated conservatively with oral analgesic.</p><p><strong>Conclusion : </strong>LVMR seems to emerge as a safe and effective procedure to treat full thickness rectal prolapse, but large series and long term results are needed and we are continuing the study for the same.</p><p>Bangladesh Crit Care J September 2018; 6(2): 71-73</p> Md Ezharul Haque Ratan Hasina Alam ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 71 73 10.3329/bccj.v6i2.38580 Association of Serum Low Density Lipoprotein Cholesterol and High Density Lipoprotein Cholesterol with Hypertension in Adult Female <p><strong>Background: </strong>Hypertension is a chronic and debilitating disease. Its complications are increasing all over the world, leading to life threatening medical problems like cardiovascular diseases, stroke and end stage renal diseases. An association between hyperlipidemia and hypertension has been identified.</p><p><strong>Objectives: </strong>The study was carried out to observe the association of serum low density lipoprotein cholesterol and high density lipoprotein cholesterol level with hypertension in adult female subjects.</p><p><strong>Method: </strong>This cross sectional study was conducted in the Department of Physiology, Dhaka Medical College, Dhaka, during the period of January 2011 to December 2011. A total number of sixty female subjects were selected with age ranging from30 to50 years. Among them 30 female subjects with hypertension were included from out-patient department of Medicine, Dhaka Medical College Hospital, Dhaka as study group(B) and 30 apparently healthy females were taken as control group(A) for comparison. Estimation of serum fasting serum low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) levels were done by enzymatic method in the Department of Physiology, Dhaka Medical College Dhaka in both groups. Systolic blood pressure and diastolic blood pressure of all participants were recorded by standard method. Data were analyzed by Unpaired Student’s- test and Pearson's correlation co-efficient (r) test as applicable.</p><p><strong>Result: </strong>The value of fasting serum LDL level was significantly higher in subjects with hypertension than those of control. Fasting serum HDL level was significantly lower in subjects with hypertension in comparison to control. In subjects with hypertension fasting serum LDL-C showed positive correlation with systolic and diastolic blood pressure and serum HDL-C showed negative correlation with systolic and diastolic blood pressure.</p><p><strong>Conclusion: </strong>Present study revealed that systolic and diastolic blood pressure has positive relationship with low density lipoprotein cholesterol (LDL-C) and negative relationship with high density lipoprotein cholesterol (HDL-C) levels.</p><p>Bangladesh Crit Care J September 2018; 6(2): 74-79</p> Sayeeda Mahmuda Nahid Yeasmin Mahmuda Abira Farhana Rahman Mahmudul Hasan Rukhshana Rabbani Shahanara Yeasmin Tamanna Binte Habib Konica Das ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 74 79 10.3329/bccj.v6i2.38581 Laparoscopic Appendicectomy in All Benign Pathologies of the Appendix: A retrospective study <p><strong>Background: </strong>Acute appendicitis is one of the most common surgical conditions and urgent appendicectomyis recommended and practiced for more than 100 years1,2. McBurney's appendicectomy by an open muscle splitting technique was the gold standard surgical procedure1. Laparoscopic appendicectomy (LA) is gaining popularity since 1987. But this new technique has a longer learning curve and requires expensive equipment (high capital investments).The aim of this study was to ascertain the generalizability of this novel procedure when appendicectomy is indicated.</p><p><strong>Method: </strong>This study was done over a period of six years in BIRDEM. Between March 2010 to February 2016, all consecutive cases of Laparoscopic appendicectomy was selected for the study. Operation was performed under general anaesthesia using standard three puncture technique. After the procedure all resected specimen was sent for histopathology.</p><p><strong>Result: </strong>Laparoscopicappendicectomy was attempted in 113 patients, 57(50.4%) female and 56(49.6%) males. Mean age of the patients were 35.2 years and ranged from 5 to 65 years. Laparoscopicappendicectomy was performed in emergency basis in 102(90%) due to acute appendicitis, gangrenous appendix, perforated appendix or appendicular abscess. Eleven patients (10%) underwent elective surgery due to interval appendicectomy, mucocole of appendix, incidental appendicectomy. The most common indication for laparoscopic appendicectomy in this series was acute appendicitis (62%). Only one patient (&lt;1%) had to be converted to an open appendicectomy due to injury to caecal wall. There was no peri-operative mortality in this series. Hundred and five patients (93%) weredischarged in lessthan 24 hours of surgery and seven (6%) within 48 hours of surgery after removal of intrabdominal drain. Follow-up period was one month to two years.</p><p><strong>Conclusion: </strong>All the advantages of laparoscopy are well applied in laparoscopic appendicectomy. Morbidity, mortality and conversion rate came down to a minimum with time and experience. Hence laparoscopic appendicectomy should be the procedure of choice when appendicectomy in indicated.</p><p>Bangladesh Crit Care J September 2018; 6(2): 80-83</p> Md Ezharul Haque Ratan Hasina Alam ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 80 83 10.3329/bccj.v6i2.38582 Therapeutic hypothermia in Post - cardiac arrest : It is time to revisit the guidelines. <p><strong>Background: </strong>Targeted Temperature Management (TTM), previously known as therapeutic hypothermia is an important tool for prevention and reversal of neurological injury and mortality reduction. Over the recent period, the use of induced hypothermia has raised many questions and recent large, randomized controlled trials (RCTs) have failed to demonstrate the benefit of TTM on clinical outcomes. The objective of this article was to compare different studies on neurological outcomes after use of TTM in different clinical situations, different temperatures and rates of cooling.</p><p><strong>Methods: </strong>We incorporated studies from 1950s to recent years using search engines like PubMed, Science Direct, Google Scholar.</p><p><strong>Results: </strong>Initial two small, unblinded trials have demonstrated improved neurological outcome in out of hospital shockable cardiac arrest. Recent studies showed that TTM was not associated with higher rates of survival or favorable neurological outcome in patients with IHCA and was rather associated with potential harm, lower likelihood of survival after discharge and long term neurological survival. TTM also didn’t show any favorable results in non-shockable cardiac arrests. Hypothermia of 36<sup>°</sup>C did not confer much benefit over 32<sup>°</sup>C -34<sup>°</sup>C.</p><p><strong>Conclusion: </strong>Recent large studies didn’t show no strong evidence that TTM is highly effective. Further methodologically robust studies are required in both shockable and non-shockable cardiac arrest for TTM to have any effect on neurological outcome.</p><p>Bangladesh Crit Care J September 2018; 6(2): 84-87</p> Afroz Shirin Tasbirul Islam ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 84 87 10.3329/bccj.v6i2.38583 Albumin Infusion Therapy in Critical Patients <p>Human albumin has been the area of interests and research for the last 65 years. A major advance in our understanding of albumin has been achieved as complete gene sequence and the location of mutations of albumin was unfolded. Clinical uses of albumin were first introduced during the Second World War when adequate plasma supply was not possible due to logistical complexities. In the 1950s, this protein was introduced for management of patients with liver cirrhosis however differing opinions exist amongst hepatologists. Critical illness causes changes in the rates of synthesis and degradation of albumin and this illness also alters the distribution of albumin protein between intravascular and extravascular spaces. The human albumin level which falls in early part of critical illness will not easily rise again until the recovery phase of that illness. Giving exogenous albumin to increase the intravascular albumin concentration during critical illness is beneficial, although the kinetics of albumin given intravenously will differ greatly between critically ill-patients and healthy individuals. This review aims to discuss current opinion, interest and clinical application of albumin infusion therapy and will inspect the role of albumin in health and critical illness.</p><p>Bangladesh Crit Care J September 2018; 6(2): 88-91</p> Sheikh Anisul Haque Fahmida Kabir Khawaja Haque ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 88 91 10.3329/bccj.v6i2.38584 Is cardiac arrest an inflammatory state? Adding steroid into ACLS guidelines will save more lives? <p>Cardiac arrest is a life-threatening condition with low survival rate. Over the years ACLS guidelines have been developed to reduce cardiac arrest specific mortality rate. In this review article, the authors researched steroid use during and after CPR for determining its effect on survival rate and post cardiac arrest disabilities. Scholarly articles from well-known reputed journals relevant to both cardiac arrest and steroid use since 1960 have been reviewed. This article first examines the question whether cardiac arrest can be considered an inflammatory state. Afterwards, evidence of the beneficial role of steroid use in cardiac arrest and in other cardiac conditions have been outlined. In conclusion, this review paper summarizes any benefits of steroid use in cardiac arrest.</p><p>Bangladesh Crit Care J September 2018; 6(2): 92-94</p> Tapati Chowdhury Arpona Dev Nath Tasbirul Islam ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 92 94 10.3329/bccj.v6i2.38585 Radio Opacity of Honey: A Unique Physical Property with The Potential of A Radio Contrast Media <p><strong>Background: </strong>Honey is known for its various physical properties, chemical contents and as a topical therapeutic agent. However its potential use in diagnostic radiology has not been reported.</p><p><strong>Aims: </strong>To establish radio opacity of honey as its unique physical property, to establish its relationship with other physical properties, chemical contents and to determine if honey has any potential as diagnostic contrast media.</p><p><strong>Material and Methods: </strong>CT scanner was used to calculate radio density in Hounsfield Unit (HU) on six honey samples, honey samples of different dilutions, Iopamidol, 25% glucose and agents containing Calcium, Iron, Magnesium and Potassium. Plain X-ray was obtained on honey samples, honey filled plastic tubes, and honey impregnated cotton gauze. Radio density of honey samples was compared with four selected physical properties of honey.</p><p><strong>Results: </strong>Radio density of six honey samples ranged between 287±3.4 HU and 329±5.3 HU. Radio density of 2% Iopamidol, a commonly used radio contrast agent was 341±8.2 HU. Compared to honey, 25% glucose had low radio density and 15% Potassium chloride had high radio density. Radio density of six honey samples were compared with corresponding density (p=0.0003), specific gravity (p=0.0002), refractive index (p=0.0001) and dynamic viscosity (p=0.10). Plain X-ray images of honey samples showed marked radio opacity.</p><p><strong>Conclusion: </strong>Radio opacity of honey is probably related to its high carbohydrate and potassium content. Honey’s anti-bacterial &amp; healing benefit will offer dual therapeutic and diagnostic advantage with concomitant use as a topical radio contrast agent.</p><p>Bangladesh Crit Care J September 2018; 6(2): 95-99</p> Mohammad Omar Faruq Abul Mokarim Rafael Mursalin Md Abu Bin Hasan Susan Saika Ahmed Ashiq Haider Choudhury Gulshan Ara Ridwan Naim Faruq Samira Humaira Habib Md Rezaul Karim Momana Afrose ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 95 99 10.3329/bccj.v6i2.38586 An elderly lady with dementia and myoclonus : Think of Sporadic Creutzfeldt Jakob Disease <p>Creutzfeldt Jakob disease (CJD) is an incurable, invariably fatal, rapidly progressive neurodegenerative disease caused by an abnormal isoform of a cellular glycoprotein known as the prion protein. CJD occurs worldwide, estimated annual incidence is about one case per million populations per year. Sporadic Creutzfeldt Jakob disease (sCJD) is a human prion disease; infection with this disease usually leads to death within one year of onset of illness. The characteristic clinical &amp; diagnostic features of rapidly progressive dementia, myoclonus, visual or cerebellar signs, pyramidal/extrapyramidal sign, Akinetic mutism and positive result on the presence of 14-3-3 protein in CSF assay, typical EEG features and MRI findings of brain are highly suggestive of diagnosis. Biopsy of brain for histopathological examination is more specific &amp; confirmatory for diagnosis. This article reports a case of sCJD who was diagnosed by characteristic findings of MRI of brain, Electroencephalography (EEG) &amp; cerebrospinal (CSF) assay at National University Hospital (NUH), Singapore and later on admitted at United Hospital Limited (UHL) Dhaka for palliative and supportive management.</p><p>Bangladesh Crit Care J September 2018; 6(2): 100-101</p> Noor E Jabeen Sanzida Akhter Mohd Mozibor Rahman ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 100 101 10.3329/bccj.v6i2.38587 A case of refractory hypertension in young age <p>Renal artery stenosis (RAS) is most common cause of secondary hypertension and accounts for approximately 1–3% of all causes of hypertension. Fibromuscular dysplasia (FMD) is important cause of RAS in young patients. Various therapeutic options are currently available for patients with renovascular hypertension: medical antihypertensive therapy, surgical revascularisation and transluminal angioplasty including stent implantation. We present in this report a female patient with left renal artery &amp; left renal atrophy and segmental marked stenosis of supra renal aorta who presented with hypertensive encephalopathy &amp; viral meningitis. Patient was successfully treated with antiviral agent.</p><p>Bangladesh Crit Care J September 2018; 6(2): 102-104</p> Uzzwal Kumar Mallick Mohammad Asaduzzaman Silfat Azam Md Shamsul Hoque Masud Kabir Farhana Mumtaz Rafat Raihan Sakhawat Hossain Kazi Ikramul Hoque ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 102 104 10.3329/bccj.v6i2.38588 Primary Pulmonary Hydatid Disease <p>Echinococcosis is a parasitic disease endemic in many parts of the world. Liver is the most common affected organ followed by lungs. However, the infestation of the latter is usually secondary to another infected organ system. Symptoms are not specific and can be produced by the mass effect or cyst complications. In the article we are reporting a case of pulmonary echinococcosis in a middle aged male, where the patient presented with symptoms of fever, cough with expectoration, weight loss and dysponea. An extensive work-up showed no other foci of infestation, hence final diagnosis was done based on chest radiography and tomography scan findings and was successfully treated with Albendazole.</p><p>Bangladesh Crit Care J September 2018; 6(2): 105-107</p> Md Tarek Alam Sadia Saber Rafa Faaria Alam Mohammad Monower Hossain ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 105 107 10.3329/bccj.v6i2.38589 Neuroleptic Malignant Syndrome – A medical emergency in a psychiatric patient <p>With an estimated incidence of 0.02 to 3.23%1, neuroleptic malignant syndrome (NMS) is a rare idiosyncratic reaction to antipsychotic drugs; having a relatively high fatality rate of about 10%2. Here, we are reporting, a 38 years old female schizoaffective patient, presented with fever, muscle rigidity and altered sensorium who had started tablet risperidone(an atypical antipsychotic drug) 11 days prior to hospital admission. After initial sepsis work up and neuroimaging, infective causes and acute cerebrovascular incidents were ruled out and a presumptive diagnosis of NMS was made. Immediate discontinuation of suspected causative agent, along with the provision of supportive care leads to complete resolution of all the symptoms in our patient.</p><p>Bangladesh Crit Care J September 2018; 6(2): 108-110</p> Rajib Ahsan Sumon Eshita Majumder ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 108 110 10.3329/bccj.v6i2.38590 A 46, XX / 46, XY mosaicism or chimerism diagnosed by Karyotyping <p>The presence of both 46, XX and 46, XY cell lines in a person is a very rare condition which is known as either chimerism or mosaicism. These conditions usually determined in early childhood during investigation of ambiguous genitalia. Our case is probably the first such report case in our country. Our case was ten months aged child, born to non-consanguinous couple referred to Cytogenetics unit of Immunology Department of BIRDEM General Hospital for chromosomal analysis and Karyotyping with the chief complaint of right sided undescended testis. He was normal looking and playful, presenting complaint was small penis with abnormal urethral opening and absence of one testis since birth. His developmental milestones were normal and intelligence was average. There was no history of congenital and genetic diseases in their family. On examination of the external genitalia the following features were noticed: stretched penile length (SPL) 3.5 cm with penoscrotal hypospadiasis. Right sided testis was not palpable as undescended and left sided testis was palpable in scrotum , volume of which was 2 to 3 ml.</p><p>Bangladesh Crit Care J September 2018; 6(2): 111-113</p> Mansura Khan Mohammad Moniruzzaman Fauzia Mohsin Ashesh K Chowdhury ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 111 113 10.3329/bccj.v6i2.38591 Large Cerebral Arachnoid Cyst <p>Abstract not available</p><p>Bangladesh Crit Care J September 2018; 6(2): 114-115</p> Md Atiquzzaman Mohammad Omar Faruq Mohammad Rabiul Halim Md Ashikuzzaman Sohan ##submission.copyrightStatement## 2018-10-15 2018-10-15 6 2 114 115 10.3329/bccj.v6i2.38592