Bangladesh Critical Care Journal <p>Official journal of the Bangladesh Society of Critical Care Medicine. Full text articles available.</p> en-US <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Upon acceptance for publication the copyright of the paper automatically transfers to the BCCJ and will not be published elsewhere either in part or whole without written permission of the copyright holder.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> (Prof. Dr. Mohammad Omar Faruq) (Md Fahmid Uddin Khondoker) Tue, 08 Oct 2019 09:22:32 +0000 OJS 60 Nurturing the Critical Care Concept <p>Abstract not available</p> <p>Bangladesh Crit Care J September 2019; 7(2): 63-65</p> Chulananda Goonasekera, Ross Freebairn ##submission.copyrightStatement## Sun, 06 Oct 2019 10:48:43 +0000 Withholding and Withdrawal of Life-Sustaining Treatments in critically ill ICU patients: A study on attitude of Physicians of Bangladesh <p><strong>Background : </strong>This study is a sub analysis of data submitted on behalf of Bangladesh in an International study ( ACME 2012) involving physicians working in Asian ICUs.</p> <p><strong>Objective : </strong>To describe attitude of physicians of ICUs of Bangladesh toward withholding and withdrawal of life sustaining treatments in end of life care, to assess factors associated with these observations and to compare the findings especially with those of physicians of low – middle income Asian ICUs.</p> <p><strong>Method : </strong>Self-administered pre-set structured and scenario based survey conducted among 101 physicians working in 38 ICUs of Bangladesh.</p> <p><strong>Results : </strong>For patients with no real chance of recovering a meaningful life, 20 of 101 respondents reported that they almost always or often withheld life-sustaining treatments and 18 of 101 respondents almost always or often withdrew life-sustaining treatments.44 respondents in our study reported that they almost always or often withheld life sustaining treatments whereas 10 respondents almost always or often withdrew life sustaining treatments. 72% of all our respondents would implement DNR orders. In Bangladesh, religion (Islam) does not influence decision of complying with DNR order requested by family. Our study showed 71% of physicians were more likely to “do everything” if a patient with hypoxic-ischaemic encephalopathy developed septic shock. In our study, physicians were more ready to withdraw vasopressors and hemo dialysis than enteral feeding and intravenous fluids. Physicians from Bangladesh generally perceived more legal risk with limitation of life sustaining treatments because of lack of legislation for such practices. When it comes to limit aggressive lifesaving treatments, Bangladeshi physicians were less likely accede to families request to withdraw them on financial ground.</p> <p><strong>Conclusion : </strong>Like physicians of low-middle income countries of Asia, Bangladeshi ICU physicians’ self-reported practice of limiting life sustaining treatments, role of families and surrogates and perception of legal rights were significantly different than physicians of high income countries of Asia. However unlike physicians from other low income Asian countries, physicians from Bangladesh were less likely to accede to families request to withdraw life sustaining treatments on financial ground.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 66-72</p> Mohammad Omar Faruq, ARM Nooruzzaman, Rownak Jahan Tamanna, Amina Sultana, Uzzwal Kumar Mallick, Mohammad Asaduzzaman, Mohammad Motiul Islam, Md Sirajul Islam, Rawshan Arra Khanam, Samira Humaira Habib, Ashiq Haider Choudhury ##submission.copyrightStatement## Tue, 08 Oct 2019 09:00:08 +0000 Ventilator-associated pneumonia in Coronary Care Unit of a tertiary level hospital in Bangladesh: causative organisms and pattern of antibiotic sensitivity <p><strong>Background: </strong>Ventilator-Associated Pneumonia (VAP) is a frequent nosocomial infection. The etiology of VAP varieswith different patient populations and types of critical care settings.</p> <p><strong>Materials &amp; methods: </strong>This prospective observational study was conducted at the Coronary Care Unit (CCU) ofIbrahim Cardiac Hospital &amp; Research Institute from April 2016 to November 2016. Demographic details andincidence of VAP was recorded and analysed by appropriate statistical tests.</p> <p><strong>Results: </strong>52 patients required mechanical ventilation, of whom 19 (36.5%) developed VAP. 15 (78.9%) had early VAP,while 4 (21.2%) had late VAP. CPIS, Modified CPIS and APACHE II Score- all were significantly higher among thosewho developed VAP (p&lt;0.01). The most frequent indication for intubation among those who developed VAP was type Irespiratory failure (57.9%), type II respiratory failure (15.8%) and post-cardiac arrest (26.3%). Acinetobacter (31.6%)was the commonest organism isolated on tracheal aspirate, followed by Pseudomonas (21.05%), Candida (21.05%)and Klebsiella (10.5%). Acinetobacter, Klebsiella and MRSA were the organisms isolated from tracheal aspirates ofthose with late onset VAP. Acinetobacter was mostly sensitive to Colistin, 80% of Pseudomonas is also sensitive tosame. A number of organisms were resistant to Amikacin and Imipenem.</p> <p><strong>Conclusion</strong>: The commonest organism responsible for VAP in our CCU was Acinetobacter, which was largely sensitiveto Colistin. The emergence of antibiotic resistance of microorganisms causing VAP is a matter of serious concern inthis study. Regular surveillance of antibiotic susceptibility pattern is very important to prevent multi-resistant bacterialinfections.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 73-76</p> Md Rezaul Karim, Rita Mayedah, Fathima Aaysha Cader ##submission.copyrightStatement## Tue, 08 Oct 2019 00:00:00 +0000 Etiology and Short term Outcome of Acute Kidney Injury (AKI) in Hospitalized Patients : A Single Center Study <p>Acute Kidney Injury (AKI) is a common cause of morbidity and mortality worldwide. However it is a treatablecondition. Any disease when associated with AKI, mortality and morbidity increase manifolds.1 Early diagnosis andtreatment is important to reduce morbidity, mortality and ICU admission. Causes of AKI may vary in country to countryeven within the country. International society of Nephrology has set a high ambitious goal “0 by 25” targeting zerodeath due to untreated AKI by 2025. Heading this challenge, it is important to know the causes of AKI worldwide.However, most of the AKI studies have been done in the developed countries and limited information is availableregarding Asia, Africa and south America. Inspired by this slogan, this study was directed to find out the causes of AKIin admitted patients in United Hospital Limited between July 2015 to February 2017. Total 98 patients were includedin the study. In our study, Infection and cardio-renal syndrome were the leading causes of AKI. Drug induced AKI alsocontributed a significant portion.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 77-80</p> Tania Mahbub, Chowdhury Rifat Niger, Rawshan Arra Khanam, Mohammad Omar Faruq ##submission.copyrightStatement## Tue, 08 Oct 2019 09:17:42 +0000 FNAC of Hepatic Malignancy and it’s Clinical Correlation. <p><strong>Background: </strong>Hepatic malignancy is an important clinical condition which is associated with poor outcome. Clinicalassessment of a patient with hepatic malignancy is crucial to sort out the primary and secondary, and so biochemicaland radiological investigations are needed. Hence fine needle aspiration cytology (FNAC) of the lesion is essentialwhich is a minimal invasive procedure to combat a deadly disease.</p> <p><strong>Objective: </strong>The aim of this prospective cross sectional observational study was clinical assessment of primary andsecondary hepatic malignancy and its co-relation with FNAC of hepatic malignancy.</p> <p><strong>Methods: </strong>Patients admitted in Medicine Department, Dhaka medical College, with hepatic malignancy from January2013 to June 2014 and then confirmed by FNAC (USG guided) of liver mass were included in the study. A total 100patients were enrolled in the study in a non-random convenient sampling method.</p> <p><strong>Result: </strong>In this study 42 patients were found having primary Hepatocellular Carcinoma (HCC) and 58 patients hadsecondary hepatic malignancy. FNAC confirmed secondary hepatic malignancy (n=58) as metastatic adenocarcinoma43(74.1%), metastatic small cell carcinoma 9(15.5%), Gastro Intestinal Stromal Tumour (GIST) 2(3.4%), squamouscell carcinoma 2(3.4%) &amp; Non Hodgkins lymphoma 2(3.4%). Most of the patients of primary hepatic malignancybetween 20-40 years 18(42.9%) and secondary hepatic malignancy between 40-60 years 35(60.3%). Incidence in maleis more in both primary 31(73.8%) and secondary 38(65.5%) hepatic malignancy. Both HCC and secondariespredominantly presents with abdominal pain, 39(92.9%) cases of HCC and 47(81.0%) of secondaries. Incidence ofmultiple lesion in ultrasonogram is more in both primary 30(71.4%) and secondary 47(81.0%) hepatic malignancy.Positive HBsAg, Positive Anti HBc (total), Positive Anti HCV were found in 15(35.7%), 11(26.2%) and 9(21.4%) casesof HCC respectively. Positive Alpha Feto Protein (AFP) was found insignificant in this study.</p> <p><strong>Conclusion: </strong>Fine Needle Aspiration (FNA) is a useful diagnostic test for evaluating patients with discrete hepaticmasses. Correlation with clinical, radiological and cytological findings is helpful in arriving at the correct diagnosisand therefore increases overall accuracy and cost-effectiveness of the procedure.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 81-85</p> Abul Hayat Manik, Rezaul Ekram, Pranab Kumar Mallik, Moushumi Mahzabeen, Md. Rafikul Islam, Md. Robed Amin ##submission.copyrightStatement## Tue, 08 Oct 2019 09:17:54 +0000 Clinical profile of patients with Idiopathic Dilated Cardiomyopathy in a Tertiary Care Hospital of Bangladesh <p><strong>Background: </strong>High prevalence of Chronic heart failure due to Idiopathic Dilated Cardiomyopathy (DCM) is animportant cause of heart failure in Bangladesh. This study was carried out to find the clinical characteristics of thepatients with Idiopathic DCM, so that the data can be used to treat symptoms and improve survival and treatment.</p> <p><strong>Methodology: </strong>This prospective observational study was carried out in the Department of Cardiology, BIRDEMGeneral Hospital, Dhaka, Bangladesh from January 2012 to December 2018. Total 50 consecutive admittedpatients fulfilling the criteria of Idiopathic DCM were studied. Clinical information, findings fromEchocardiography and other relevant investigations were collected for analysis.</p> <p><strong>Results: </strong>Among total 50 patients, 30(60.0%) were male and 20(40.0%) were female. Majority 20(40.0%) patientsbelonged to age 51-60 years and their mean age was found 55.34±13.24 years. Using NYHA (New York HeartAssociation) functional status classification of the patients, 18(36.0%) patients were found in NYHA class I,15(30.0%) in class II, 12(24.0%) in class III and 5(10.0%)in class IV. Almost all patients presented with three basicsymptoms i.e. exertional dyspnea, easy fatigability and pedal edema. Orthopnea, Paroxosmal Nocturnal Dyspnoea(PND), palpitation &amp; chest pain wewe also reported in almost half of the patients. Mean pulse was found88.78±15.75 beat/min, respiratory rate 20.79±6.48 breath/min, BMI 23.12±3.29 kg/m<sup>2</sup>, systolic BP 119.03±22.22mmHg and diastolic BP 75.00±12.54 mmHg. Bilateral basal crepitation 45(90.0%), Pedal edema 43(86.0%),Raised JVP 39(78.0%), Hepatomegaly 35(70.0%) were also found. Third heart sound in 34(68.0%), Pan systolicmurmur of Mitral regurgitation 40(80.0%), Pansystolic murmur of Tricuspid regurgitation was present in42(84.0%) among study patients. Mean left ventricular ejection fraction was found 30.44 ±4.91%, LVIDs 5.24±0.51cm and LVIDd 6.18 ±0.52 cm.</p> <p><strong>Conclusion: </strong>Majority of the Idiopathic DCM patients belonged to age 51-60 year age group with malepredominance and clinical presentation was variable.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 86-89</p> Shabnam Jahan Hoque, Aparna Rahman, Md. Zahid Alam, S M Rezaul Irfan ##submission.copyrightStatement## Tue, 08 Oct 2019 09:18:02 +0000 Incidence, Type and Anatomical Location of Gastric Polyp: Experience of a Tertiary Level Hospital in Bangladesh <p><strong>Background: </strong>Gastric polyps are small gastric mucosal lesions, usually asymptomatic in most cases and are generallydiscovered incidentally during upper Gastro Intestinal (GI) tract endoscopy. But some polyps have malignant potential.We observed the characteristics and frequency of gastric polyps, derived from the gastric mucosal epithelium in a seriesof endoscopies.</p> <p><strong>Method: </strong>Fifty three patients were studied in a series of 2890 consecutive upper GI endoscopies done over one yearperiod. Each patient had only one examination and were analyzed on the basis of their location, size, type and histopathological findings. All patients had at least one gastric polyp, as confirmed by histological examination.</p> <p><strong>Result: </strong>Among 2890 endoscopies we found gastric polyps in 53 cases. So the incidence was 1.83 %. Mean age of thestudy population was 50.25±11.75. Polyp was more prevalent among female (64%). Most of the patients were presentedwith anemia, heartburn and abdominal pain, 57%, 42% and 36% respectively. Other less common clinical features areanorexia (13%), melaena (9.4%) and hematemesis (1.9%). 64% patients were diabetic and 76% patients used PPI withduration of 19.00±9.78 months.Most of the polyps were located at the body of stomach (47.1%), less common sites were antrum (15.1%), cardia(7.6%), fundus (7.6%), Gastro Esophageal (GE) junction (3.8%) and duodenum (1.9%). Majority of the polyps weresmall and medium sized (37.7%, 35.8%) and large (11.3%). Sessile polyp was found in 49.1% cases, other common typewas pedunculated (39.5%). Only 28% patient had surface ulceration on polyp and commonest histological type washyperplastic 75.4%, 18.9% patient had adenomatous polyp. Brunner’s gland adenoma and carcinoid were rare, 3.8%and 1.9% respectively. Multiple polyps were found in 30% patient.</p> <p><strong>Conclusion: </strong>Gastric epithelial polyps are infrequent and most of them measure less than 1 cm. The upper GI tractendoscopy is the safest and efficient method for the diagnosis of the gastric polyps, as in most of the patients does notshow characteristic symptoms. The histopathological definition is necessary to classify the polyps as well as detectionof dysplastic changes. Biopsy from different part of the stomach is necessary to find out the gastritis and dysplasticchanges.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 90-94</p> Md. Nazmul Hoque, Shireen Ahmed ##submission.copyrightStatement## Tue, 08 Oct 2019 09:18:12 +0000 Immunohistochemical Study on Hormone Receptors and HER2 Status in Invasive Breast Carcinoma and its Therapeutic Implications <p><strong>Background: </strong>Immunohistochemistry (IHC) has become an integral part of histopathology in the diagnosis of biopsysample. Although haematoxylin and eosin (H &amp; E) stain remains the fundamental basis for diagnostic pathology of thebreast, IHC stains provide useful and sometimes vital information. Moreover, the role of hormonal therapy in hormonereceptor–positive breast tumours, as well as targeted chemotherapeutic agents for human epidermal growth factorreceptor-2 (HER2) positive cases, IHC studies represent a major part of workups.</p> <p><strong>Objective: </strong>The study was carried out to identify the common immunohistochemical markers in invasive breastcarcinoma and to find out the relationship between hormonal receptor status and HER2 over expression with the gradeof tumour and its therapeutic implications.</p> <p><strong>Method: </strong>In the present study, immunohistochemical assay of total seventy-two blocks of breast carcinoma patients wasperformed to know the hormone receptors and HER2 status as well as histological examination.</p> <p><strong>Result: </strong>72 samples were grouped to study hormonal status and their relation with clinicopathological factors. Outcomeof this study documented 58.33 %, 44.44% and 25 % expression rate of estrogen receptor (ER), progesterone receptor(PR) and human epidermal growth factor receptor-2 (HER2) respectively. The negative expression of HER2 receptorsfound higher (75%) than ER &amp; PR. The ER, PR negative and HER2 Positive cases found in high grade breast cancer(Grade-3). An inverse correlation of HER2 expression with ER and PR expression was observed (p=0.001).</p> <p><strong>Conclusion: </strong>The role of hormone receptors and HER2 repression as a prognostic and therapeutic tool in breast canceris widely accepted and effective for patients.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 95-98</p> Md Iqbal Karim, Md Tarikul Islam, Nazlima Nargis ##submission.copyrightStatement## Tue, 08 Oct 2019 09:18:22 +0000 Pyoderma Gangrenosum : An enigma without a cure? <p>Pyoderma Gangrenosum (PG) is a rare, chronic, recurrent distinctive cutaneous ulceration which is usually idiopathic,but may be associated with systemic diseases in at least 50% of patients who are affected. The diagnosis is made byexcluding other causes of similar-appearing cutaneous ulcerations, including infection, malignancy, vasculitis,collagen vascular diseases, diabetes and trauma. The etiopathogenesis of PG is still not well understood. Clinically, itis classified into ulcerative, pustular, bullous and vegetative types. A few atypical and rare variants have also beendescribed. The diagnosis mainly depends on the recognition of evolving clinical features as investigations only assistin the diagnosis. Therapy for pyoderma gangrenosum involves the use of anti-inflammatory agents, includingantibiotics, corticosteroids, immunosuppressive and biologic agents.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 99-101</p> Mohammad Kamrul Ahsan ##submission.copyrightStatement## Tue, 08 Oct 2019 09:18:31 +0000 Determination of Minimum Inhibitory Concentration (MIC) of Imipenem against Salmonella typhi <p><strong>Objective: </strong>To determine the MIC of Imipenem against Salmonella Typhi.</p> <p><strong>Study Design</strong>: An interventional study.</p> <p><strong>Place of Study: </strong>Department of Pharmacology &amp; Therapeutics in collaboration with Department of Microbiology atAd-din Sakina Women’s Medical College, Jashore.</p> <p><strong>Study Duration: </strong>January 2018 to May 2018.</p> <p><strong>Methodology: </strong>MIC of Imipenem was determined by Broth Dilution Technique against standard strain of Salmonellatyphi ATCC 24683.</p> <p><strong>Result: </strong>The MIC of Imipenem against Salmonella typhi was 0.75 μg/ml.</p> <p><strong>Conclusion: </strong>Imipenem is a potential therapeutic agent for Salmonella typhi infection.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 102-105</p> Sanjoy Saha, RR Gomes, Khan Shakil Ahmed, Serajul Islam, Shyamal Kumar Saha, MM Islam, Kishore Kumar Biswas, Shib Prasad Saha ##submission.copyrightStatement## Tue, 08 Oct 2019 09:18:49 +0000 Acquired Melanonychia and Mucocutaneous Hyper pigmentation with Hydroxyurea Therapy for the Treatment of Blast Crisis of Chronic Myeloid Leukaemia: A Case Report <p>Hydroxyurea is an antineoplastic agent used to treat chronic myeloid leukaemia (especially in accelerated phaseand blast crisis). We report this unique case of a 60 year old lady who was diagnosed case of chronic-phase ofchronic myeloid leukaemia was getting imatinib and well suited. As a consequence of imatinib noncompliance,she developed blast crisis and was subsequently hydroxyurea initiated. At her 3<sup>rd</sup>month follow-up she presentedwith blackening of her exposed parts of the body, all three mucocutaneous areas especially skin of her hands, feet,fingernails, toenails and oral mucosa in some extent.Hydroxyurea-induced melanonychia and mucocutaneous hyperpigmentation is rarely reported. To the best of ourknowledge, this is one of the few published reports of hydroxyurea induced mucocutaneous hyperpigmentationand melanonychia involving all 20 nails. The mainstays of treatment are withdrawal of the drug andsun-avoidance; laser therapy is a hope for cure in small percentage of permanent cases. A correct diagnosis isessential to prevent undue fears in the patient. Proper advice to the patient regarding adverse reactions ofparticular agent and close monitoring after prescribing should be ensured to prevent harm to patients. Alwaysshould remember, drugs not only save life, but can even take it.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 106-108</p> - Md Atiquzzaman, Md Abu Taher, PK Bhattacharyya, Momtaz Begum, Tayef Md Tahlil Islam, Shahidul Alam, Farzana Akhtar, - Md Ashikuzzaman Sohan ##submission.copyrightStatement## Tue, 08 Oct 2019 09:18:59 +0000 Severe Obstructive Sleep Apnea in an young Adult <p>Obstructive Sleep Apnea (OSA) is a serious common sleep disorder needs life long care. OSA is caused by recurrentupper airway obstruction due to increased upper airway collapsibility during sleep. It is highly associated with obesitywith several endocrine and metabolic diseases. Hypothyroidism may cause OSA, also linked with obesity. Obesity isalso a risk factor for hypertension.This paper is presenting a case of obstructive sleep apnea with obesity, hypertensionand hypothyroidism. A 35 years old male presented with the complaints of excessive day time sleepiness, loud snoring,fragmented sleep, apnea like attack, occasional morning headache. Whole night polysomnography was done anddiagnosed as severe obstructive sleep apnea. At therapeutic part of polysomnography, he was treated with BiPAP.</p> <p>BangladeshCrit Care J September 2019; 7(2): 109-110</p> Fatema Yasmin, Rawshan Arra Khanam ##submission.copyrightStatement## Tue, 08 Oct 2019 09:19:08 +0000 Rrefractory Metabolic Acidosis in a Diabetic Patient : A case of Unsuspected Methanol Intoxication <p>We present a case of a 45 years old male, diabetic and hypertensive who was admited into hospital with a history ofrestlessness, blurring of vision and breathlessness for one day. Inspite of conservative treatment for 10 hours, hisgeneral condition gradually detoriated and he was shifted to ICU. He was kept on mechanical ventilator. Hislaboratory results showed severe high anion gap metabolic acidosis not corrected by sodibicarb and adequate fluidresuscitation. MRI of brain showed bilateral putamenal lesion suspecting methanol intoxication. His acidosis persistedand after giving 3 sessions of Sustained Low Efficiency Dialysis (SLED), metabolic acidosis was corrected withnormalization of renal function. After six months in a follow-up, patient complained of total blindness and fundalphotography showed bilateral optic atrophy.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 111-112</p> Uzzwal Kumar Mallick, S M Hossain Shahid, Mohammad Omar Faruq, Mohammad Asaduzzaman, Amina Sultana, Aflatun Asha ##submission.copyrightStatement## Tue, 08 Oct 2019 09:19:20 +0000 Occupational inhalation injury by Hydrogen Sulfide causing multi organ failure –A case study <p>Hydrogen sulfide is a notorious agent known to cause serious injuries in the occupational field. We are going to discussa case of a 20 years old male working in a effluent treatment plant in Savar, Bangladesh who accidentally entered thefume room and was exposed to the toxic gas. He lost consciousness and was brought to our care from a local hospitalafter endotracheal intubation condition. He was found in state of unconsciousness grade III on admission to our ICU.His brain CT scan revealed diffuse cerebral edema. Chest X-ray revealed finding suggestive of diffuse pneumonitis.Cardiology evaluation suggested Toxic cardiomyopathy as his high sensitive Troponin I was very high on admission (2037ng/L). Supportive care was given in the form of mechanical ventilation, antibiotics, anticonvulsant andanti-ischemic medications. Patient regained consciousness on day 10 after admission and gradually improvedclinically. By the end of the month of stay in hospital he was significantly improved.</p> <p>Bangladesh Crit Care J September 2019; 7(2): 113-115</p> Karishma Shamarukh, - Mohammad Omar Faruq, Nasrin Jahan, Amina Sultana, Ridwan Naim Faruq ##submission.copyrightStatement## Tue, 08 Oct 2019 09:19:30 +0000 A case of Leaking Abdominal Aortic Aneurysm <p>Abstract not available</p> <p>Bangladesh Crit Care J September 2019; 7(2): 116-117</p> Rashedul Haque, Mohammad Omar Faruq, Amina Sultana, Mir Atiqur Rahman, Karishma Shamarukh, S M Razibul Hasan ##submission.copyrightStatement## Tue, 08 Oct 2019 09:19:38 +0000