Indian Journal of Critical Care Medicine
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   Table of Contents - Current issue
Coverpage
May 2016
Volume 20 | Issue 5
Page Nos. 261-314

Online since Tuesday, May 10, 2016

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RESEARCH ARTICLES  

Comparison of suction above cuff and standard endotracheal tubes in neurological patients for the incidence of ventilator-associated pneumonia and in-hospital outcome: A randomized controlled pilot study Highly accessed article p. 261
Sritam Jena, Sriganesh Kamath, Dheeraj Masapu, HB Veenakumari, Venkatapura J Ramesh, Varadarajan Bhadrinarayan, R Ravikumar
DOI:10.4103/0972-5229.182196  
Background: Ventilator-associated pneumonia (VAP) is a common complication with endotracheal intubation. The occurrence of VAP results in significant mortality and morbidity. Earlier studies have shown reduction in the incidence of VAP with subglottic secretion drainage. The incidence of VAP in neurologically injured patients is higher and can impact the neurological outcome. This study aimed to compare the incidence of VAP with standard endotracheal tube (SETT) and suction above cuff endotracheal tube (SACETT) in neurologically ill patients and its impact on clinical outcome. Methods: Fifty-four patients with neurological illnesses aged ≥18 years and requiring intubation and/or ventilation and anticipated to remain on ETT for ≥48 h were randomized to receive either SETT or SACETT. All the VAP preventive measures were similar between two groups except for the difference in type of tube. Results: The data of 50 patients were analyzed. The incidence of clinical VAP was 20% in SETT group and 12% in SACETT group; (P = 0.70). The incidence of microbiological VAP was higher in the SETT group (52%) as compared to SACETT group (44%) but not statistically significant; (P = 0.78). There was no difference between the two groups for measured outcomes such as duration of intubation, mechanical ventilation, and Intensive Care Unit stay. Conclusions: In this pilot study in neurological population, a there was no significant difference in incidence of clinical and microbiological VAP was seen between SETT and SACETT, when other strategies for VAP prevention were similar. Other outcomes were similar with use of either tube for intubation.
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Oral care practices for patients in Intensive Care Units: A pilot survey p. 267
Alexandre Franco Miranda, Renata Monteiro de Paula, Cinthia Goncalves Barbosa de Castro Piau, Priscila Paganini Costa, Ana Cristina Barreto Bezerra
DOI:10.4103/0972-5229.182203  
Objective: To assess the level of knowledge and difficulties concerning hospitalized patients regarding preventive oral health measures among professionals working in Intensive Care Units (ICUs). Study Population and Methods: A cross-sectional survey was conducted among 71 health professionals working in the ICU. A self-administered questionnaire was used to determine the methods used, frequency, and attitude toward oral care provided to patients in Brazilian ICUs. The variables were analyzed using descriptive statistics (percentages). A one-sample t-test between proportions was used to assess significant differences between percentages. t-statistics were considered statistically significant for P < 0.05. Bonferroni correction was applied to account for multiple testing. Results: Most participants were nursing professionals (80.3%) working 12-h shifts in the ICU (70.4%); about 87.3% and 66.2% reported having knowledge about coated tongue and nosocomial pneumonia, respectively (P < 0.05). Most reported using spatulas, gauze, and toothbrushes (49.3%) or only toothbrushes (28.2%) with 0.12% chlorhexidine (49.3%) to sanitize the oral cavity of ICU patients (P < 0.01). Most professionals felt that adequate time was available to provide oral care to ICU patients and that oral care was a priority for mechanically ventilated patients (80.3% and 83.1%, respectively, P < 0.05). However, most professionals (56.4%) reported feeling that the oral cavity was difficult to clean (P < 0.05). Conclusion: The survey results suggest that additional education is necessary to increase awareness among ICU professionals of the association between dental plaque and systemic conditions of patients, to standardize oral care protocols, and to promote the oral health of patients in ICUs.
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Antimicrobial agents' utilization and cost pattern in an Intensive Care Unit of a Teaching Hospital in South India p. 274
Nikhilesh Anand, IM Nagendra Nayak, MV Advaitha, Noble J Thaikattil, Kiran A Kantanavar, Sanjit Anand
DOI:10.4103/0972-5229.182200  
Background and Aims: High utilization and inappropriate usage of antimicrobial agents (AMAs) in an Intensive Care Unit (ICU) increases resistant organisms, morbidity, mortality, and treatment cost. Prescription audit and active feedback are a proven method to check the irrational prescription. Measuring drug utilization in DDD/100 bed-days is proposed by the WHO to analyze and compare the utilization of drugs. Data of AMAs utilization are required for planning an antibiotic policy and for follow-up of intervention strategies. Hence, in this study, we proposed to evaluate the utilization pattern and cost analysis of AMA used in the ICU. Methodology: A prospective observational study was conducted for 1 year from January 1, 2014, to December 31, 2014, and the data were obtained from the ICU of a tertiary care hospital. The demographic data, disease data, relevant investigation, the utilization of different classes of AMAs (WHO-ATC classification) as well as individual drugs and their costs were recorded. Results: One thousand eight hundred and sixty-two prescriptions of AMAs were recorded during the study period with an average of 1.73 ± 0.04 prescriptions/patient. About 80.4% patients were prescribed AMAs during admission. Ceftriaxone (22.77%) was the most commonly prescribed AMA followed by piperacillin/tazobactam (15.79%), metronidazole (12%), amoxicillin/clavulanic acid (6.44%), and azithromycin (4.34%). Ceftriaxone, piperacillin/tazobactam, metronidazole, and linezolid were the five maximally utilized AMAs with 38.52, 19.22, 14.34, 8.76, and 8.16 DDD/100 bed-days respectively. An average cost of AMAs used per patient was 2213 Indian rupees (INR). Conclusion: A high utilization of AMAs and a high cost of treatment were noticed which was comparable to other published data, though an increased use of newer AMAs such as linezolid, clindamycin, meropenem, colistin was noticed.
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REVIEW ARTICLE Top

Tracheostomy in special groups of critically ill patients: Who, when, and where? p. 280
Aisling Longworth, David Veitch, Sandeep Gudibande, Tony Whitehouse, Catherine Snelson, Tonny Veenith
DOI:10.4103/0972-5229.182202  
Tracheostomy is one of the most common procedures undertaken in critically ill patients. It offers many theoretical advantages over translaryngeal intubation. Recent evidence in a heterogeneous group of critically ill patients, however, has not demonstrated a benefit for tracheostomy, in terms of mortality, length of stay in Intensive Care Unit (ICU), or incidence of ventilator-associated pneumonia. It may be a beneficial intervention in articular subsets of ICU patients. In this article, we will focus on the evidence for the timing of tracheostomy and its effect on various subgroups of patients in critical care.
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BRIEF COMMUNICATIONS Top

Exploration of eosinopenia as a diagnostic parameter to differentiate sepsis from systemic inflammatory response syndrome: Results from an observational study p. 285
Dimple Anand, Sumit Ray, Seema Bhargava, Lalit M Srivastava, Ashish Garg, Imran Gafoor, Rahul Singh, Debashish Dhar
DOI:10.4103/0972-5229.182199  
Aim of the Study: Initial differentiation of sepsis from systemic inflammatory response syndrome (SIRS) is of prime importance for early institution of appropriate treatment. This study aimed to compare the differential diagnostic efficacy of absolute eosinophil count (AEC - a routinely available economic marker) with total leukocyte count (TLC) and procalcitonin (PCT - a costly marker available only in specialized settings). Materials and Methods: In this prospective observational study, 170 patients of sepsis (severe sepsis = 125; SIRS = 45) were enrolled. AEC, TLC, and PCT were measured in the blood of all patients at the time of admission and data analyzed statistically. Results: Median AEC was 0 cells/mm3 in both SIRS and sepsis. TLC and PCT levels were significantly higher (P < 0.001) in culture negative, culture positive, and overall sepsis groups in comparison to SIRS group. At a cutoff of < 50 cells/mm3, AEC demonstrated a sensitivity and specificity of 23% and 68%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of TLC were 57%, 71%, 85%, 37% and of PCT were 82.4%, 82.2%, 93%, and 63%, respectively with area under curve of 0.455 for AEC, 0.640 for TLC, 0.908 for PCT. Conclusions: This study suggests that eosinopenia is not a reliable diagnostic tool to differentiate sepsis from SIRS. PCT and TLC are better differential diagnostic biomarkers.
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Evaluation of antibiotic use in Pediatric Intensive Care Unit of a developing country p. 291
Qalab Abbas, Anwar Ul Haq, Raman Kumar, Syed Asad Ali, Kashif Hussain, Sadia Shakoor
DOI:10.4103/0972-5229.182197  
Background: Pediatric Intensive Care Unit (PICU) patients are often prescribed antibiotics with a low threshold in comparison to patients elsewhere. Irrational antibiotics use can lead to rapid emergence of drug resistance, so surveillance of their use is important. Objectives: To evaluate the use of antibiotics in relation to bacteriological findings in PICU of a Tertiary Hospital. Methods: Retrospective review of medical records of all children (age 1 month–16 years) admitted in our closed multidisciplinary-cardiothoracic PICU from January to June 2013 was performed, after approval from Ethical Review Committee. For each antibiotic, indication (prophylactic, empiric, therapeutic) and duration of use were recorded. All diagnoses of infections were recorded according to diagnostic criteria of IPSCC 2005. Results are presented as frequency and percentages and median with inter quartile range using SPSS version 19. Results: All of the total 240 patients admitted in PICU during the study period received antibiotics: 43% (n = 104) prophylactically, 42% (n = 102) empirically, and 15% (n = 15) therapeutically. Median number of antibiotic use per patient in PICU was 3, with range of 1–7. 25% received 1 antibiotic, 23% received 2 antibiotics, 29% received 3 antibiotics, and rest received ≥4 antibiotics. Most commonly used antibiotics were cefazolin, meropenem, vancomycin and ceftriaxone, and most frequently used combination was meropenem and vancomycin. In majority of the cases, (70%) empiric antibiotic combinations were stopped in 72 h. Conclusion: This is the first report of antibiotics use in PICU from our country, which shows that antibiotics are prescribed universally in our PICU. Strategies to assess the need for antibiotic use are needed.
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CASE REPORTS Top

Extracorporeal treatment with high-volume continuous venovenous hemodiafiltration and charcoal-based sorbent hemoperfusion for severe metformin-associated lactic acidosis p. 295
Suneel Kumar Garg, Omender Singh, Desh Deepak, Akhilesh Singh, Rohit Yadav, Kirti Vashist
DOI:10.4103/0972-5229.182205  
We present a case of a 49-year-old female with an alleged history of ingestion of approximately 100 tablets of metformin (850 mg each). Investigations revealed severe lactic acidosis with lactate levels of 13.5 mmol/L and pH of 7.17. This indicates severe toxicity and is associated with a high mortality. Charcoal-based sorbent hemoperfusion was done as a desperate effort, as patient continued to deteriorate despite supportive care and high-volume continuous venovenous hemodiafiltration. The patient survived despite metformin-associated lactic acidosis related to severe metformin toxicity.
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A rare complication of tracheal intubation p. 299
Wan Fadzlina Wan Muhd Shukeri, Wan Mohd Nazaruddin Wan Hassan, Chandran Nadarajan
DOI:10.4103/0972-5229.182209  
Accidental endobronchial intubation is a frequent complication in critically ill patients requiring tracheal intubation (TI). If such complication occurs, it is more often the right main bronchus that is intubated due to anatomical reasons. Left main bronchus (LMB) intubation is rare. Here, we report a case with auscultatory, bronchoscopic, and radiographic evidence of accidental LMB intubation in a pregnant woman with dengue shock syndrome. We highlight this case to increase awareness about this possible-but-rare complication of TI.
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Spontaneous arterial hemorrhage as a complication of dengue p. 302
Shoma Vinay Rao, Gijoe George Jacob, Nithin Abraham Raju, Sneha Ann Ancheri
DOI:10.4103/0972-5229.182201  
Bleeding complications of dengue hemorrhagic fever such as epistaxis, gum bleeding, gastrointestinal bleeding, hypermenorrhea, hematuria, and thrombocytopenia have been documented. A 49-year-old female presented with complaints of intermittent high-grade fever for the past 4 days, lower abdominal pain and altered sensorium for 1 day. Laboratory investigations revealed severe anemia, mild thrombocytopenia, hypofibrinogenemia, and positive dengue serology. Emergency ultrasound examination of the abdomen revealed a possible rapidly expanding hematoma from the inferior epigastric artery and suggested urgent computed tomography (CT) angiogram for confirmation of the same. CT angiogram was confirmatory, and patient underwent emergency embolization of the right inferior epigastric artery. We report the first case of inferior epigastric hemorrhage and rectus sheath hematoma as a consequence of dengue.
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Statin-induced rhabdomyolysis in patient with renal failure and underlying undiagnosed hypothyroidism p. 305
Sachinkumar N Ambapkar, Naresh Shetty, Arpita Dwivedy, Harshad Onkarrao Malve
DOI:10.4103/0972-5229.182210  
Rhabdomyolysis is a syndrome characterized by muscle necrosis which causes the release of myoglobin into the bloodstream. The manifestations of this syndrome range from asymptomatic elevation of serum muscle enzymes to life-threatening cases associated with extremely high enzyme levels, electrolyte imbalance, and acute renal failure. Symptoms of rhabdomyolysis include dark urine, muscle weakness, and fatigue. Statins are commonly used drugs for the prevention and management of dyslipidemia. We present an interesting and critical case on statin-induced rhabdomyolysis with renal failure and previously undiagnosed idiopathic hypothyroidism.
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LETTERS TO THE EDITOR Top

Dying within dying: Ethical dilemmas of treating terminally ill patients with acute life-threatening illnesses p. 308
Shahla Siddiqui
DOI:10.4103/0972-5229.182206  
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Scorpion bite, a sting to the heart! p. 309
Gajanan Yelme, Atul Jindal
DOI:10.4103/0972-5229.182198  
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An aberrantly positioned central venous catheter: A presage of an underlying anatomical anomaly p. 310
Vikas Saini, Aakriti Gupta, Tanvir Samra
DOI:10.4103/0972-5229.182208  
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Mid-term assessment of the decade of action for road safety: Progress made, yet at a slow rate p. 312
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava, Jegadeesh Ramasamy
DOI:10.4103/0972-5229.182204  
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Another cutaneous sign of acute pancreatitis p. 313
Jayabal Pandiaraja
DOI:10.4103/0972-5229.182207  
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