Indian Journal of Critical Care Medicine
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Coverpage
January 2015
Volume 19 | Issue 1
Page Nos. 1-58

Online since Tuesday, January 06, 2015

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EDITORIAL  

Reliable assessment of perfusion is the Holy Grail of intensive care p. 1
Balagangadhar R Totapally
DOI:10.4103/0972-5229.148626  
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RESEARCH ARTICLES Top

Comparison of monitoring performance of bioreactance versus esophageal Doppler in pediatric patients p. 3
Clément Dubost, Adrien Bouglé, Calliope Hallynck, Matthieu Le Dorze, Philippe Roulleau, Catherine Baujard, Dan Benhamou
DOI:10.4103/0972-5229.148630  
Background and Aims: Cardiac output (CO) monitoring and goal-directed therapy during major abdominal surgery is currently used to decrease postoperative complications. However, few monitors are currently available for pediatric patients. Nicom ® is a noninvasive CO monitoring technique based on the bioreactance principle (analysis of frequency variations of a delivered oscillating current traversing the thoracic cavity). Nicom ® may be a useful monitor for pediatric patients. Subjects and Methods: Pediatric patients undergoing major abdominal surgery under general anesthesia with cardiac monitoring by transesophageal Doppler (TED) were included. Continuously recorded hemodynamic variables obtained from both bioreactance and TED were compared. Data were analyzed using the Bland-Altman method. Results: A total of 113 pairs of cardiac index (CI) measurments from 16 patients were analyzed. Mean age was 59 months (95% CI: 42-75) and mean weight was 17 kg (95% CI: 15-20). In the overall population, Bland-Altman analysis revealed a bias of 0.4 L/min/m 2 , precision of 1.55 L/min/m 2 , limits of agreement of −1.1 to 1.9 L/min/m 2 and a percentage error of 47%. For children weighing >15 kg, results were: Bias 0.51 L/min/m 2 , precision 1.17 L/min/m 2 , limits of agreement −0.64 to 1.66 L/min/m 2 and percentage error 34%. Conclusion: Simultaneous CI estimations made by bioreactance and TED showed high percentage of errors that is not clinically acceptable. Bioreactance cannot be considered suitable for monitoring pediatric patients.
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Therapeutic plasma exchange in the treatment of myasthenia gravis p. 9
Rajesh Kumar, S Birinder Paul, Sonia Gupta, Gagandeep Singh, Amarjit Kaur
DOI:10.4103/0972-5229.148631  
Aim: The aim of this study was to analyze the retrospective experience related to the indication, complication and outcome of Therapeutic Plasma Exchange (TPE) in Myasthenia gravis (MG). It is a well known autoimmune disease characterized by antibodies against the acetylcholine receptor (anti-ACHR) on the post synaptic surface of the motor end plate. Plasma exchange is the therapeutic modality well established in MG with a positive recommendation based on strong consensus of class III evidence. Materials and Methods: A total of 35 patients of MG were submitted to a total of 41 cycles and 171 session of TPE. It was performed using a single volume plasma exchange with intermittent cell separator (Hemonetics) by Femoral or central line access and schedule preferably on alternate day interval. Immediate outcome was assessed shortly after each session and overall outcome at discharge. Results: Total of 110 patients of MG who were admitted to our hospital during the study period of two years. 35 (31.8%) patients had TPE performed with mean age of 32 years (M:F = 2:1). The mean number of TPE session was 4.2 (SD±1.2), volume exchange was 2215 ml (SD±435); overall incidence of adverse reaction was 21.7%. All patients had immediate benefits of each TPE cycle. Good acceptance of procedure was observed in 78.3% of patients. Conclusion: TPE may be considered as one of the treatment options especially in developing countries like ours as it is relatively less costly but as effective for myasthenic crisis as other modalities.
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Nosocomial infections in the intensive care unit: Incidence, risk factors, outcome and associated pathogens in a public tertiary teaching hospital of Eastern India p. 14
Sugata Dasgupta, Soumi Das, Neeraj S Chawan, Avijit Hazra
DOI:10.4103/0972-5229.148633  
Background: The increased morbidity and mortality associated with nosocomial infections in the intensive care unit (ICU) is a matter of serious concern today. Aims: To determine the incidence of nosocomial infections acquired in the ICU, their risk factors, the causative pathogens and the outcome in a tertiary care teaching hospital. Materials and Methods: This was a prospective observational study conducted in a 12 bedded combined medical and surgical ICU of a medical college hospital. The study group comprised 242 patients admitted for more than 48 h in the ICU. Data were collected regarding severity of the illness, primary reason for ICU admission, presence of risk factors, presence of infection, infecting agent, length of ICU and hospital stay, and survival status and logistic regression analysis was done. Results: The nosocomial infection rate was 11.98% (95% confidence interval 7.89-16.07%). Pneumonia was the most frequently detected infection (62.07%), followed by urinary tract infections and central venous catheter associated bloodstream infections. Prior antimicrobial therapy, urinary catheterization and length of ICU stay were found to be statistically significant risk factors associated with nosocomial infection. Nosocomial infection resulted in a statistically significant increase in length of ICU and hospital stay, but not in mortality. Conclusion: Nosocomial infections increase morbidity of hospitalized patients. These findings can be utilized for planning nosocomial infection surveillance program in our setting.
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The comparison of extemporaneous preparations of omeprazole, pantoprazole oral suspension and intravenous pantoprazole on the gastric pH of critically ill-patients p. 21
Yasamin Dabiri, Fanak Fahimi, Hamidreza Jamaati, Seyed Mohammad Reza Hashemian
DOI:10.4103/0972-5229.148635  
Background: Stress-related mucosal disease occurs in many critically ill-patients within 24 h of admission. Proton pump inhibitor therapy has been documented to produce more potent inhibition of gastric acid secretion than histamine 2 receptor antagonists. This study aimed to compare extemporaneous preparations of omeprazole, pantoprazole oral suspension and intravenous (IV) pantoprazole on the gastric pH in intensive care unit patients. Materials and Methods: This was a randomized single-blind-study. Patients of ≥ 16 years of age with a nasogastric tube, who required mechanical ventilation for ≥ 48 h, were eligible for inclusion. The excluded patients were those with active gastrointestinal bleeding, known allergy to omeprazole and pantoprazole and those intolerant to the nasogastric tube. Fifty-six patients were randomized to treatment with omeprazole suspension 2 mg/ml (40 mg every day), pantoprazole suspension 2 mg/ml (40 mg every day) and IV pantoprazole (40 mg every day) for up to 14 days. Gastric aspirates were sampled before and 1-2.5 h after the drug administration for the pH measurement using an external pH meter. Data were analyzed using SPSS (version 21.0). Results: In this study, 56 critically ill-patients (39 male, 17 female, mean age: 61.5 ± 15.65 years) were followed for the control of the gastric pH. On each of the 14 trial days the mean of the gastric pH alteration was significantly higher in omeprazole and pantoprazole suspension-treated patients than in IV pantoprazole-treated patients (P < 0.001). Conclusion: Omeprazole and pantoprazole oral suspension are more effective than IV pantoprazole in increasing the gastric pH.
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REVIEW ARTICLE Top

Recent advances in management of acute liver failure Highly accessed article p. 27
Charles Panackel, Rony Thomas, Benoy Sebastian, Sunil K Mathai
DOI:10.4103/0972-5229.148636  
Acute liver failure (ALF) is a life-threatening illness, where a previously normal liver fails within days to weeks. Sudden loss of synthetic and detoxification function of liver results in jaundice, encephalopathy, coagulopathy, and multiorgan failure. The etiology of ALF varies demographically. The mortality of ALF is as high as 40-50%. The initial care of patients with ALF depends on prompt recognition of the condition and early detection of etiology. Management includes intensive care support, treatment of specific etiology if present and early detection of candidates for liver transplantation. Liver transplantation remains the only therapeutic intervention with proven survival benefit in patients with irreversible ALF. Living related liver transplantation, auxiliary liver transplantation, and  ABO-incompatible liver transplantation are coming up in a big way. Liver assist devices and hepatocyte transplant remain experimental and further advances are required. Public health measures to control hepatitis A, B, E, and drug-induced liver injury will reduce the incidence and mortality of ALF.
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BRIEF COMMUNICATIONS Top

Paroxysmal sympathetic hyperactivity in neurological critical care p. 34
Rajesh Verma, Prithvi Giri, Imran Rizvi
DOI:10.4103/0972-5229.148638  
Introduction: Paroxysmal sympathetic hyperactivity (PSH) is a clinical disorder mainly caused by traumatic brain injury, stroke, encephalitis and other types of brain injury. The clinical features are episodes of hypertension, tachycardia, tachypnea, fever and dystonic postures. In this study, we described clinical profile and outcome of six patients of PSH admitted in neurocritical care unit. Materials and Methods: This was a prospective observational study conducted at neurology critical care unit of a tertiary care center. All patients admitted at neurology critical unit during 6-month period from August 2013 to January 2014 were screened for the occurrence of PSH. The clinical details and outcome was documented. Results: PSH was observed in 6 patients. Male to female ratio was 5:1. Mean age ± SD was 36.67 ± 15.19 years. The leading causes were traumatic brain injury (two patients), stroke (two patients) and Japanese encephalitis (JE) (one patient) and tuberculous meningitis (one patient). Conclusion: PSH is an unusual complication in neurocritical care. It prolonged the hospitalization and hampers recovery. The other life-threatening conditions that mimic PSH should be excluded. The association with JE and tuberculous meningitis was not previously described in literature.
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Confirmation of endovenous placement of central catheter using the ultrasonographic "bubble test" p. 38
Ajit S Baviskar, Khalid I Khatib, Sanjeev Bhoi, Sagar C Galwankar, Harshad C Dongare
DOI:10.4103/0972-5229.148642  
Insertion of central venous catheter (CVC) is the most common procedure to be performed in Intensive Care Units. Addition of ultrasonographic guidance to this procedure, which was initially performed blindly, has improved safety of this procedure. Confirmation of endovenous placement of CVC though, is tricky, as methods for confirmation are either operator dependent, time-consuming or not available at bedside. Prospective observational study was carried out to study feasibility of use of sonobubble test to confirm the presence of CVC within central vein. After insertion of CVC in the internal jugular, subclavian or axillary vein, a 10 ml bolus of shaken saline microbubble is injected through port of CVC, and opacification of right atrium is observed in xiphoid view on ultrasonography. The Sonobubble test was helpful for dynamic confirmation of endovenous placement of CVC and prevented complications such as arterial puncture and cannulation. We recommend its use following CVC insertion.
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Echocardiologic evaluation and follow-up of cardiovascular complications in children with scorpion sting in coastal South India p. 42
Chandra Mohan Kumar, SV Naveen Prasad
DOI:10.4103/0972-5229.148645  
Introduction and Objective : Scorpion stings are a common emergency in India and many other tropical countries. In India, the red scorpions are more prevalent, and their venom is more likely to cause myocardial dysfunctions. There are very few studies conducted on this problem. The following study was done in Andhra Pradesh and aimed to identify cardiovascular complications of scorpion stings in children with a follow-up of 6 months Study Design: Prospective observational study. Setting: Children admitted with scorpion sting in a tertiary care hospital between December 2009 and November 2010 and followed-up till May 2011. Results: Scorpion stings account for 1 in every 36 admissions. Maximum cases were in 0-3 years age group. Electrocardiogram changes were seen in 76% cases and myocarditis in 42% cases. Echocardiography revealed decreased ejection fraction (EF), transient mitral regurgitation and wall motion abnormalities were observed. Average EF improved from 16% on day 1 to 47.94% and 59% on day 5 and 14 respectively, which was highly statistically significant. By the end of 1 month, all the survivors had normal EF and no residual cardiac dysfunction was observed at 6 months. Conclusion: Scorpion stings, a common and fatal medical emergency in India, produce echocardiographic changes without any long term residual damage on myocardial activity.
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CASE REPORTS Top

Congenital lobar emphysema: A modified approach to anesthetic management p. 47
Malathi C Nandihalli, Srinivas H Thammaiah, Nalini Kotekar, Prashanth R Putran
DOI:10.4103/0972-5229.148648  
Congenital lobar emphysema (CLE) is a potentially reversible, though life-threatening cause of respiratory distress in neonates. It is a rare developmental anomaly of the lower respiratory tract. A 10-month-old child presented with fever, cough and difficulty in breathing. Respiratory system examination revealed tachypnea with intercostal retraction, decreased breath sounds over the left upper lobe and room air saturation of 95%. Chest radiograph and computed tomography showed hyperinflated left upper zones with mediastinal shift. Left thoracotomy, followed by left upper lobectomy was performed under general anesthesia with one lung ventilation. Oxygen saturation, blood pressure, electrocardiogram and capnogram were continuously monitored. During anesthesia, conventionally positive pressure ventilation is avoided until the diseased lobe is isolated, however we adopted gentle manual ventilation maintaining the airway pressure before thoracotomy as described by Cotι and Payne et al. Successful anesthetic management of CLE can be achieved by proper understanding of pathophysiology, good perioperative monitoring, and adopting novel management strategies.
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Severe Mycobacterium tuberculosis-related immune reconstitution syndrome in an immunocompetent patient p. 50
Srinivas Rajagopala, Sujatha Chandrasekharan
DOI:10.4103/0972-5229.148650  
We present a young immunocompetent male with diagnosed sputum culture-positive tuberculosis on intensive phase with observed daily four-drug antituberculosis therapy. He presented at 1-month of treatment with sequential bilateral pneumothoraces, increase in cavitation and consolidation and respiratory failure. Repeat smears for acid-fast bacilli had downgraded, and cultures were negative. Quantiferon-GOLD (initially negative) was now strongly positive. A diagnosis of possible immune reconstitution syndrome was considered and 0.25 mg/kg/day oral steroids administered. We also discuss an approach to differential diagnosis of a patient worsening on treatment for microbiologically confirmed tuberculosis in this manuscript.
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LETTERS TO THE EDITOR Top

Absent internal jugular vein: Another case for ultrasound guided vascular access p. 53
Vimi Rewari, Ravindran Chandran, Rashmi Ramachandran, Anjan Trikha
DOI:10.4103/0972-5229.148652  
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Management of central venous catheters in intensive care units: Comparative study of guidelines versus practice p. 54
Arushi Gupta, Tanvir Samra, Neerja Banerjee, Rajesh Sood
DOI:10.4103/0972-5229.148653  
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Permissive hypercapnia: Is there any upper limit? p. 56
Snehamayee Nayak, Atul Jindal
DOI:10.4103/0972-5229.148655  
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A rare survival after 2,4-D (ethyl ester) poisoning: Role of forced alkaline diuresis p. 57
Vaneet Jearth, Rajan Negi, Vivek Chauhan, Kailashnath Sharma
DOI:10.4103/0972-5229.148658  
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