Indian Journal of Critical Care Medicine
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   Table of Contents - Current issue
Coverpage
September 2014
Volume 18 | Issue 9
Page Nos. 555-640

Online since Thursday, September 04, 2014

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EDITORIALS  

The lack of scientific evidence in clinical practice guideline in brain death determination: Implications for organ donation and transplantation p. 555
Joseph L Verheijde, Mohamed Y Rady
DOI:10.4103/0972-5229.140136  
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Let's change our behaviors: From bed rest and heavy sedation to awake, spontaneously breathing and early mobilized Intensive Care Unit patients p. 558
Daniel De Backer, Michelle Norrenberg
DOI:10.4103/0972-5229.140137  
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Coming together to care for the dying in India p. 560
Raj Kumar Mani
DOI:10.4103/0972-5229.140139  
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Challenges in the implementation of "end-of-life care" guidelines in India: How to open the "Gordian Knot"? p. 563
Shivakumar Iyer
DOI:10.4103/0972-5229.140140  
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RESEARCH ARTICLES Top

Hypoalbuminemia in critically sick children p. 565
Lokesh K Tiwari, Sunit Singhi, M Jayashree, Arun K Baranwal, Arun Bansal
DOI:10.4103/0972-5229.140143  
Context: There is a paucity of data evaluating serum albumin levels and outcome of critically ill-children admitted to intensive care unit (ICU). Aims: The aim was to study frequency of hypoalbuminemia and examine association between hypoalbuminemia and outcome in critically ill-children. Settings and Design: Retrospective review of medical records of 435 patients admitted to 12 bedded pediatric ICU (PICU). Materials and Methods: Patients with hypoalbuminemia on admission or any time during PICU stay were compared with normoalbuminemic patients for demographic and clinical profile. Effect of albumin infusion was also examined. Odds ratio and 95% confidence interval were calculated using SPSS 16. Results: Hypoalbuminemia was present on admission in 21% (92 of 435) patients that increased to 34% at the end of 1 st week and to 37% (164 of 435) during rest of the stay in PICU. Hypoalbuminemic patients had higher Pediatric Risk of Mortality scores (12.9 vs. 7.5, P < 0.001) and prolonged PICU stay (13.8 vs. 6.7 days, P < 0.001); higher likelihood of respiratory failure requiring mechanical ventilaton (84.8% vs. 28.8%, P < 0.001), prolonged ventilatory support, progression to multiorgan dysfunction syndrome (87.8% vs. 16.2%) and risk of mortality (25.6% vs. 17.7%). Though, the survivors among recipients of albumin infusion had significantly higher increase in serum albumin level (0.76 g/dL, standard deviation [SD] 0.54) compared with nonsurvivors (0.46 g/dL, SD 0.44; P = 0.016), albumin infusion did not reduce the risk of mortality. Conclusions: Hypoalbuminemia is a significant indicator of mortality and morbidity in critically sick children. More studies are needed to define role of albumin infusion in treatment of such patients.
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Association between electrocardiographic findings and cardiac dysfunction in adult isolated traumatic brain injury p. 570
Vijay Krishnamoorthy, Sumidtra Prathep, Deepak Sharma, Edward Gibbons, Monica S Vavilala
DOI:10.4103/0972-5229.140144  
Introduction: Abnormal electrocardiographic (ECG) findings can be seen in traumatic brain injury (TBI) patients. ECG may be an inexpensive tool to identify patients at high risk for developing cardiac dysfunction after TBI. The aim of this study was to examine abnormal ECG findings after isolated TBI and their association with true cardiac dysfunction, based on echocardiogram. Methods: Data from adult patients with isolated TBI between 2003 and 2010 was retrospectively examined. Inclusion criteria included the presence of a 12-lead ECG within 24 h of admission and a formal echocardiographic examination within 72 h of admission after TBI. Patients with preexisting cardiac disease were excluded. Baseline clinical characteristics, 12-lead ECG, and echocardiogram report were abstracted. Logistic regression was used to identify the relationship of specific ECG abnormalities with cardiac dysfunction. Results: We examined data from 59 patients with isolated TBI who underwent 12-lead ECG and echocardiographic evaluation. In this cohort, 13 (22%) patients had tachycardia (heart rate >100 bpm), 25 (42.4%) patients had a prolonged QTc, and 6 (10.2%) patients had morphologic end-repolarization abnormalities (MERA), with each having an association with abnormal echocardiographic findings: Odds ratios (and 95% confidence intervals) were 4.14 (1.02-17.05), 9.0 (1.74-46.65), and 5.63 (1.96-32.94), respectively. Ischemic-like ECG changes were not associated with echocardiographic abnormalities. Conclusions: Repolarization abnormalities (prolonged QTc and MERA), but not ischemic-like ECG changes, are associated with cardiac dysfunction after isolated TBI. 12-lead ECG may be an inexpensive screening tool to evaluate isolated TBI patients for cardiac dysfunction prior to more expensive or invasive studies.
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Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine p. 575
Rajesh Chawla, Sheila Nainan Myatra, Nagarajan Ramakrishnan, Subhash Todi, Sudha Kansal, Sananta Kumar Dash
DOI:10.4103/0972-5229.140146  
Background and Aim: Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU. Materials and Methods: A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods. Results: Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay's Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation. Conclusion: The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.
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Radiation exposure among medical professionals working in the Intensive Care Unit p. 591
Suhail S Siddiqui, Ashish Jha, Nambiraj Konar, Priya Ranganathan, Deepak D Deshpande, Jigeeshu V Divatia
DOI:10.4103/0972-5229.140150  
Background and Aims: With the expanding use of diagnostic and therapeutic radiological modalities in critically ill patients, doctors working in Intensive Care Units (ICUs) are increasingly exposed to ionizing radiation. This risk of radiation exposure occurs not only during bedside radiologic procedures, but also when ICU physicians accompany patients to radiology suites. The aim of this study was to quantify levels of radiation exposure among medical professionals working in the ICU. Materials and Methods: The study was carried out prospectively over 6 months in the ICU of a tertiary-referral cancer hospital. Two teams consisting of 4 ICU resident doctors each were instructed to wear thermoluminescent dosimeters (TLDs) during their duty shifts. Standard radiation protection precautions were used throughout the study period. TLDs were also placed in selected areas of the ICU to measure the amount of scattered radiation. TLDs were analyzed at the end of every 3 months. Results: The readings recorded on TLDs placed in the ICU were almost immeasurable. The mean value of residents' radiation exposure was 0.059 mSv, though the highest individual reading approached 0.1 mSv. The projected maximum yearly radiation exposure was 0.4 mSv. Conclusions: If standard radiation safety precautions are followed, the cumulative radiation exposure to ICU resident doctors is well within permissible limits and is not a cause of concern. However, with the increasing use of radiological procedures in the management of critically ill patients, there is a need to repeat such audits periodically to monitor radiation exposure.
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REVIEW ARTICLE Top

Brainstem death: A comprehensive review in Indian perspective p. 596
Anant Dattatray Dhanwate
DOI:10.4103/0972-5229.140151  
With the advent of cardiopulmonary resuscitation techniques, the cardiopulmonary definition of death lost its significance in favor of brain death. Brain death is a permanent cessation of all functions of the brain in which though individual organs may function but lack of integrating function of the brain, lack of respiratory drive, consciousness, and cognition confirms to the definition that death is an irreversible cessation of functioning of the organism as a whole. In spite of medical and legal acceptance globally, the concept of brain death and brain-stem death is still unclear to many. Brain death is not promptly declared due to lack of awareness and doubts about the legal procedure of certification. Many brain dead patients are kept on life supporting systems needlessly. In this comprehensive review, an attempt has been made to highlight the history and concept of brain death and brain-stem death; the anatomical and physiological basis of brain-stem death, and criteria to diagnose brain-stem death in India.
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CASE REPORTS Top

Sepsis associated with Lactobacillus bacteremia in a patient with ischemic colitis p. 606
Hrishikesh S Kulkarni, Charbel C Khoury
DOI:10.4103/0972-5229.140152  
Lactobacillus species is a known commensal of the mouth, gastrointestinal, and genitourinary tract. However, its isolation on blood cultures is often overlooked and attributed to bench contamination. We present a case of a 58-year-old immunocompetent male who initially presented with altered mental status, but developed sepsis from Lactobacillus bacteremia during his hospital course, while on mechanical ventilation. He was found to have ischemic colitis on colonoscopy. His condition improved with antibiotics and supportive management. Using this example of ischemic colitis, we stress that in the right clinical setting, Lactobacillus bacteremia is a harbinger for a serious underlying pathology and should not be ignored.
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Osmotic demyelination syndrome in a normonatremic patient of chronic kidney disease p. 609
Atul Abhishek Jha, Vineet Behera, Anantharam Jairam, Krishna Venkatesh Baliga
DOI:10.4103/0972-5229.140153  
Osmotic Demyelination Syndrome (ODS) is associated with rapid correction of hyponatremia or fluid shifts, and is characterized by neurological involvement related to pons, brainstem or other areas of the brain. All possible measures should be taken to prevent this serious disorder. Diagnosing this condition early is very important and requires a high index of suspicion. The treatment is purely supportive and most patients may show dramatic recovery. ODS occurring in normonatremic and hypernatremic patients is very rare. We report a case of an 18-year-old boy of end-stage renal disease who presented with an episode of acute gastroenteritis. He was managed with aggressive intravenous fluids, hemodialysis and other supportive therapy. But, he developed altered sensorium and seizures that progressed to features of spastic quadriparesis and lower cranial nerve palsy. Neuroimaging showed hyperintensities in pons and midbrain suggestive of ODS. The patient had normal sodium levels at all times and had no evidence of hyponatremia. The patient was managed with hemodialysis, physiotherapy and other conservative measures and had a gradual clinical and radiological recovery.
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Permissive hypercapnia: Is there any upper limit? p. 612
Sunil Kumar Garg
DOI:10.4103/0972-5229.140154  
A 19-year-old male presented with history of massive hemoptysis. The patient was kept on mechanical ventilation because of severe hypoxia. Lung protective ventilation with low tidal volume was given in view of very poor pulmonary compliance. During the course of treatment, the patient developed a very high CO 2 level of 373 mmHg. The patient was successfully weaned off on the 9 th day without any obvious adverse consequences.
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GUIDELINES Top

End-of-life care policy: An integrated care plan for the dying  Highly accessed article p. 615
Sheila Nainan Myatra, Naveen Salins, Shivakumar Iyer, Stanley C Macaden, Jigeeshu V Divatia, Maryann Muckaden, Priyadarshini Kulkarni, Srinagesh Simha, Raj Kumar Mani
DOI:10.4103/0972-5229.140155  
Purpose: The purpose was to develop an end-of-life care (EOLC) policy for patients who are dying with an advanced life limiting illness and to develop practical procedural guidelines for limiting inappropriate therapeutic medical interventions and improve the quality of care of the dying within an ethical framework and through a professional and family/patient consensus process. Evidence: The Indian Society of Critical Care Medicine (ISCCM) published its first guidelines on EOLC in 2005 [1] which was later revised in 2012. [2] Since these publications, there has been an exponential increase in empirical information and discussion on the subject. The literature reviewed observational studies, surveys, randomized controlled studies, as well as guidelines and recommendations, for education and quality improvement published across the world. The search terms were: EOLC; do not resuscitate directives; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care; EOLC in India; cultural variations. Indian Association of Palliative Care (IAPC) also recently published its consensus position statement on EOLC policy for the dying. [3] Method: An expert committee of members of the ISCCM and IAPC was formed to make a joint EOLC policy for the dying patients. Proposals from the chair were discussed, debated, and recommendations were formulated through a consensus process. The members extensively reviewed national and international established ethical principles and current procedural practices. This joint EOLC policy has incorporated the sociocultural, ethical, and legal perspectives, while taking into account the needs and situation unique to India.
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LETTERS TO THE EDITOR Top

Patient safety and prevention of unexpected events occurring during the intra-hospital transport of critically ill ICU patients p. 636
Kumari Shweta, Sachin Kumar
DOI:10.4103/0972-5229.140156  
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Subdural hematoma in Plasmodium vivax malaria: Another Nail hammered on the coffin p. 636
Subramanian Senthilkumaran, Chidambaram Ananth, Sandeep B Gore, Ponniah Thirumalaikolundusubramanian
DOI:10.4103/0972-5229.140157  
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Invasive pulmonary aspergillosis in an immunocompetent patient with severe dengue fever p. 637
Birendra Pradhan, Atul Jindal
DOI:10.4103/0972-5229.140158  
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Rhino-orbito-cerebral mucormycosis in a child with diabetic ketoacidosis p. 638
Snehamayee Nayak, Atul Jindal
DOI:10.4103/0972-5229.140160  
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Nosocomial candiduria in chronic liver disease patients at a hepatobilliary center p. 639
Armin Ahmed, Afzal Azim, Mohan Gurjar, Arvind Kumar Baronia
DOI:10.4103/0972-5229.140161  
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Comment on: "Transfusion associated circulatory overload" p. 640
James K.H. Ho, J. Henry G Antrum
DOI:10.4103/0972-5229.140163  
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