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   Table of Contents - Current issue
July 2018
Volume 22 | Issue 7
Page Nos. 475-564

Online since Tuesday, July 17, 2018

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Deadly Nipah outbreak in Kerala: Lessons learned for the future Highly accessed article p. 475
AK Ajith Kumar, AS Anoop Kumar
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The association between arterial oxygen tension, hemoglobin concentration, and mortality in mechanically ventilated critically ill patients p. 477
Mahesh Ramanan, Nick Fisher
Background: Hypoxemia and anemia are common findings in critically ill patients admitted to Intensive Care Units. Both are independently associated with significant morbidity and mortality. However, the interaction between oxygenation and anemia and their impact on mortality in critically ill patients has not been clearly defined. We undertook this study to determine whether hemoglobin (Hb) level would modify the association between hypoxemia and mortality in mechanically ventilated critically ill patients. Methods: We performed a retrospective cohort study of all mechanically ventilated adult patients (aged >16 years) in the Australian and New Zealand Intensive Care Society Adult Patient Database (APD) admitted over a 10-year period. Multivariate hierarchical logistic regression was used to assess the relationship between hypoxemia and hospital mortality stratified by Hb. Results: Of 1,196,089 patients in the APD, 219,723 satisfied our inclusion and exclusion criteria. There was a linear negative relationship between hypoxemia and hospital mortality which was significantly modified when stratified by Hb. Hb independently increased the risk of mortality in patients with arterial oxygen tension <102. Conclusions: Hb is an effect modifier on the association between oxygenation and mortality.
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Comparison of mechanical insufflation–Exsufflation and endotracheal suctioning in mechanically ventilated patients: Effects on respiratory mechanics, hemodynamics, and volume of secretions p. 485
William M Coutinho, Paulo J. C. Vieira, Fernanda M Kutchak, Alexandre S Dias, Marcelo M Rieder, Luiz Alberto Forgiarini
Context: Cough assist (CA) is a device to improve bronchial hygiene of patients with secretion in the airways and ineffective cough. Aims: To compare the physiological effects and the volume of secretion of mechanical insufflation–exsufflation (CA device) with isolated endotracheal suctioning in mechanically ventilated patients. Settings and Design: Randomized crossover trial. Materials and Methods: The patients were randomly allocated to the first technique, then the following technique was performed in the next day. We collected the variables related to oxygen saturation, hemodynamics (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure [MAP]), and respiratory mechanics (tidal volume, minute volume, respiratory rate, and lung compliance and resistance), pre- and postimplementation (immediately and after 15 and 30 min), and the aspirated volume of secretion. Statistical Analysis Used: We used two-way analysis of variance followed by the Student–Newman–Keuls t-test to compare the variables at different time points. Student's t-test was used to compare secretion volumes. All data were stored and analyzed in SPSS for Windows Version 19.0. The significance level was set at 5%. Results: Forty-three patients were included in the study. When we compared the results before and after the application of the techniques, we observed no significant difference in lung compliance, pulmonary resistance, MAP, peripheral oxygen saturation, and secretion volume in both groups. Conclusions: The mechanical insufflation–exsufflation does not alter respiratory mechanics and hemodynamic stability, and it does not improve airway clearance in mechanically ventilated patients.
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A questionnaire-based survey of physician perceptions of the prevalence of antimicrobial resistance and their antibiotic prescribing patterns p. 491
Vaishali Gupte, Jaideep Gogtay, Raj Kumar Mani
Background: Antibiotic resistance is a serious problem being faced by physicians worldwide. This article was designed to study physician perceptions of antibiotic resistance and their prescribing patterns. Materials and Methods: A structured questionnaire was developed for reporting the prevalence of antibiotic resistance as perceived by physicians and recording their antibiotic preferences in specific contexts. A total of 539 intensivists across India participated in the study. Results: The prevalence of multidrug-resistant (MDR) Gram-negative pathogens was reported to be on the rise in Intensive Care Units. The prevalence rate of carbapenem-resistant Enterobacteriaceae was reported to be between 20% and 40% by 33% of the participants. Piperacillin-tazobactam was the preferred beta-lactam/beta-lactamase inhibitor antibiotic by the majority of intensivists (47%) in the treatment of infections caused by extended-spectrum beta-lactamase producers. Meropenem was recommended to be used at a higher dose (2 g t.i.d.) by 41% of intensivists for Pseudomonas/Acinetobacter infections with high minimum inhibitory concentration values for meropenem. De-escalation data revealed that 43% of intensivists “always” would like to de-escalate from carbapenems, based on the antibiotic susceptibility data. Minocycline was recommended by 33% for the treatment of ventilator-associated pneumonia (VAP) and by 21% for bloodstream infections caused by MDR Acinetobacter. Up to 83% of intensivists preferred the use of nebulized colistin for the management of VAP/hospital-acquired pneumonia. Conclusion: This study reveals that the prevalence of MDR Gram-negative pathogens is perceived to be on the rise. Prescription patterns indicate high levels of variability. Hence, antibiotic stewardship is essential to standardize antibiotic prescriptions not only for efficacy but also to reduce the burden of multiple drug resistance.
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Impact of additional short session of video training on performance of basic life support skills in 2nd-Year medical students p. 498
Vikramjeet Arora, Manju Bala, Sumit Chawla
Context: Basic life support (BLS) is a core life-saving skill which everyone should know, but knowledge of BLS is poor even among medical students. Aims: The aim of our study was to assess the knowledge regarding BLS among medical students and see impact of training and also to know whether a short session of video training made an impact on their cardiopulmonary resuscitation (CPR) skills. Settings and Design: Ninety-two 2nd-year medical students were included in the study. Materials and Methods: Their baseline knowledge regarding BLS was assessed before workshop with pretest 1. Following workshop posttest 1 and 1 month later, posttest 2 was conducted. A short duration video training on BLS was done after posttest 2 and its impact was assessed 2 months later with performance of CPR skills on a mannequin. Statistical Analysis Used: Data analysis was done using SPSS version 23.0. Pearson's Chi-square test was used to evaluate the differences between groups for categorized variables. Unpaired and paired t-test was used to calculate the difference of means for quantitative variables. Results: There was significant improvement in knowledge regarding BLS after the workshop. Even after 1 month, though there was decline in knowledge, still it was significantly higher than the baseline. Short duration video training session did not lead to any improvement in BLS skills. Conclusions: BLS training should start early in medical curriculum with reinforcement at regular intervals. Single short duration video training session did not have any impact on improvement of skills.
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Resurgence of global opportunistic multidrug-resistant Stenotrophomonas maltophilia p. 503
Pradheer Gupta, Pratibha Kale, Vikas Khillan
Context: Stenotrophomonas maltophilia is a known nosocomial pathogen which is intrinsically resistant to multiple antibiotics. In India, S. maltophilia infection has only few case reports. Aim: To determine the incidence of S. maltophilia infection from clinical isolates based on the specimen type, antibiotic susceptibility pattern, and impact on outcome. Settings and Design: One-year retrospective study was done at a tertiary liver care center. Methods: Patients with S. maltophilia isolation in clinical samples were selected. Serial levels of serum procalcitonin and total leukocyte count were recorded. Environmental surveillance was done from the wards of S. maltophilia isolation as part of routine practice. Statistical Analysis: Continuous data were compared using Kruskal–Wallis test/Mann–Whitney test. The categorical data were compared by Chi-square/Fisher's exact test, wherever necessary. Besides this, an appropriate analysis like survival was carried out at the time of data analysis. Results: One hundred isolates were obtained from eighty patients of six wards. The greatest number (44/100, 44%) were from the Liver Coma Intensive Care Unit and the lowest (3/100) from the day care. Isolation from the respiratory samples was 1.32% and bloodstream infection 0.6%. Of 100 isolates, 12 (12%) were resistant to both trimethoprim–sulfamethoxazole and levofloxacin. Conclusion: S. maltophilia was effectively isolated from the hospital environment, with two of hand impression and three of water samples' positive. Patients with respiratory infection had most S. maltophilia isolates. Antibiotic susceptibility revealed more resistance than reported in this region.
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Neurological prognostications for the therapeutic hypothermia among comatose survivors of cardiac arrest p. 509
Napplika Kongpolprom, Jiraphat Cholkraisuwat
Background: Currently, there are limited data of prognostic clues for neurological recovery in comatose survivors undergoing therapeutic hypothermia (TH). We aimed to evaluate clinical signs and findings that could predict neurological outcomes, and determine the optimal time for the prognostication. Materials and Methods: We retrospectively reviewed database of postarrest survivors treated with TH in our hospital from 2006 to 2014. Cerebral performance category (CPC), neurological signs and findings in electroencephalography (EEG) and brain computed tomography (CT) were evaluated. In addition, the optimal time to evaluate neurological status was analyzed. Results: TH was performed in 51 postarrest patients. Approximately 53% of TH patients survived at discharge and 33% of the hospital survivors had favorable outcome (CPC1-2). The prognostic clues for unfavorable outcome (CPC3-5) at discharge were lack of pupillary light response (PLR) and/or gag reflex after rewarming, and the absence of at least one of the brainstem reflexes, no eye-opening, or abnormal motor response on the 7th day. Myoclonus and seizure could not be used to indicate poor prognosis. In addition, prognostic values of EEG and CT findings were inconclusive. Conclusions: Our study showed the simple neurological signs helped predict short-term neurological prognosis. The most reliable sign determining unfavorable outcome was the lack of PLR. The optimal time to assess prognosis was either at 48–72 h or 7 days after return of spontaneous circulation.
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Acute leukoencephalopathy with restricted diffusion p. 519
Mahesh Kamate
Treatment and outcome of children with acute encephalopathy depend on the cause, prompt treatment of the underlying cause, and use of adequate supportive measures. Many novel causes of acute encephalopathy are emerging where lumbar puncture, computed tomography of the head, and routine biochemical testing can be normal such as acute disseminated encephalomyelitis and febrile infection-related refractory epilepsy syndrome. Magnetic resonance imaging (MRI) plays an important role in the workup of children with acute leukoencephalopathy. Despite this in few cases, a correct diagnosis is not possible and novel conditions have been described in the last decade. One such condition is acute encephalopathy with biphasic seizures and restricted diffusion also called as acute leukoencephalopathy with restricted diffusion. Here, the routine MRI sequences such as T1, T2, and fluid-attenuated inversion recovery sequences can be normal. Here, we have reviewed the etiology, types, clinicoradiological features, and treatment of this condition.
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Feasibility and accuracy of a nonmedical research person in assimilation and calculation of acute physiologic assessment and chronic health evaluation scores in an Indian intensive care unit p. 524
George Prashanth Kurian, Pritish John Korula, Mahasampath S Gowri
Background: The Physiologic Assessment and Chronic Health Evaluation (APACHE) score assimilation and calculation, as well as other demographic data collection, is inherent to research and nonresearch related needs of intensive care. There may be a role for well-trained nonmedical personnel to collect this vital material to enhance research and the standard of care in the Intensive Care Units (ICUs) in countries that are poorly funded and resourced in terms of medical personnel. Aims: The aim of this study is to verify the interrater reliability of a trained nonmedical personnel and ICU trainee in the collection and calculation APACHE scores. Materials and Methods: In a prospective study, two raters who were blinded, one a trained nonmedical ward clerk and another an ICU trainee, assimilated data and calculated APACHE scores for 60 consecutive patients admitted to two tertiary mixed ICUs (with a total of 19 beds). Primary outcomes were to assess interrater and interclass correlation as well as the agreement of scores between the two raters. Results: There was an excellent correlation of APACHE scores (Kappa coefficient of 0.92) and Bland–Altman plot depicted overall good agreement with low bias between raters. Conclusions: A well-trained and supervised nonmedical research person can assimilate and calculate APACHE II scores with good agreement with an ICU trainee. This may help in deriving data from medically understaffed ICUs in India, thus promoting much-needed research from such ICUs.
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CD14+ monocytic cytokines: Impact on outcome in severely injured patients p. 528
Nidhi Bhardwaj, Surbhi Khurana, Subodh Kumar, Sushma Sagar, Amit Gupta, Biplap Mishra, Kapil Dev Soni, Purva Mathur
Introduction: Trauma is one of the leading causes of mortality worldwide. Trauma patients, who presented to the hospital casualty department within 24 h of injury, further admitted to the Surgical Intensive Care Unit were enrolled in this study. Materials and Methods: The aim was to study the peripheral blood monocyte activity to produce tumor necrosis factor (TNF-α), interleukin-1 (IL-1) β, IL-6, and IL-8 in severely injured patients after trauma. Result: A total of 28 polytrauma patients were enrolled and observed that the levels of TNF-α, IL-1 β, IL-6, and IL-8 were signifi cantly decreased and levels of IL-8 were increased in the fatal patients compared to the healthy controls. Conclusion: After trauma, an immediate hyperactivation of circulating monocytes is rapidly followed by a substantial paralysis of cell function. Decreased activity of monocytes can be used to identify potential fatal immunological disruption. Since immunological disruption occurs before clinical symptoms; our study proposes an immunological prognostication score for trauma victims.
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In vitro activity of fosfomycin against multidrug-resistant urinary and nonurinary gram-negative isolates p. 533
Bijayini Behera, Srujana Mohanty, Subhrajyoti Sahu, Ashok Kumar Praharaj
Background: The era of multidrug-resistant (MDR) Gram-negative bacilli (GNB) has renewed interest in fosfomycin. Aim: The present study evaluated the in vitro activity of fosfomycin against MDR urinary and nonurinary GNB isolates. Materials and Methods: Fosfomycin susceptibility was carried out by agar dilution for a total of 279 (142 from urine and 137 from other samples) MDR-GNB. Disk diffusion was done for urinary isolates only. Results: Urinary tract isolates had a high degree of susceptibility to fosfomycin (overall susceptibility, 90.8%), whereas only 42.9% of nonurinary isolates retained susceptibility to the drug. Percentage susceptibility rates for urinary and nonurinary isolates of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter spp. were 99%, 91.3%, 66%, 0% and 62%, 44.4%, 32%, 11%, respectively. Conclusion: Fosfomycin showed excellent in vitro activity for uropathogens. Large-scale evaluation of fosfomycin against MDR systemic isolates is required to evaluate its therapeutic efficacy.
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The era of device colonizers: Chryseobacterium indologenes infections from a tertiary care center in North India p. 537
Vidhi Jain, Chinmoy Sahu, Nayani Amrin Fatema Afzal Hussain, Malay Ghar, Kashi Nath Prasad
Background: Chryseobacterium indologenes is a hospital environment contaminant and can cause healthcare-associated infections. Methods: Patients with C. indologenes infections in a tertiary care center in North India for 6 months were evaluated for susceptibility patterns, comorbidities, mechanical devices, risk factors, and treatment outcomes. The organism was provisionally identified phenotypically, and identification was confirmed by the BD Phoenix automated microbiology system. Minimum inhibitory concentration values of antibiotic susceptibility were determined. Results: A total of 12 isolates of C. indologenes were recovered from 11 patients. Five patients had C. indologenes bloodstream infection (BSI), one had ventilator-associated pneumonia (VAP), and one had both BSI and VAP. In four others, the organism was isolated from the catheterized urinary tract. All VAP and BSI patients were admitted to the Intensive Care Units and mechanically ventilated; all had central lines and history of colistin therapy during the past 15 days. The common underlying risk factors were diabetes, hypertension, and coronary artery disease. Conclusions: C. indologenes infections are increasing because of higher use of carbapenems and colistin, to which it is intrinsically resistant.
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Brain dead presentation of snake bite p. 541
Sonika Agarwal, Nidhi Kaeley, Sushant Khanduri, Nand Kishore
Snakebite is considered as a significant public health problem contributing considerably to morbidity and mortality. A neurotoxic snake bite can present from mild ptosis to complete paralysis with external and internal ophthalmoplegia. Three patients presented in emergency intubated outside with deeply comatose, fixed dilated pupil, and absent doll's eye reflex mimicking as brain dead.
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Cardiopulmonary arrest and extracorporeal membrane oxygenation: Case report and review p. 544
Alexander Robinson, Aniket S Rali, Zubair Shah, Travis Abicht, Eric Hockstad, Andrew Sauer
National trends suggest that less than one in four patients experiencing in-hospital cardiac arrest (IHCA) in the United States survive to discharge. This is especially relevant as the rates of IHCA are expected to rise in the years to come. Only a modest upward trend in survival to discharge among patients with IHCA over the past decade warrants evaluation of novel ideas to improve outcomes postcardiopulmonary resuscitation. One such idea is that the use of veno-arterial-extracorporeal membrane oxygenation (VA-ECMO) to augment standard advanced cardiac life support algorithm in patients with an identifiable and reversible cause of cardiac arrest would improve survival to discharge. Here, we present the case of a patient with refractory ventricular fibrillation arrest who was transitioned to VA-ECMO immediately following cardiac catheterization for an IHCA.
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A case of unusual occurrence of nasogastric tube feed coming through the chest tube in a 27-year-old polytrauma patient p. 547
Raunaq Chakraborty, Mohd Shoaib Budoo, Sukhyanti Kerai
The provision of early and adequate nutritional support is vital for the successful recovery from the trauma in any form. Nutritional support is enteral unless specified otherwise as dictated by various benefits of the former. Nasogastric tubes provide effective and common mode of enteral feed due to the ease of placement and maintenance. To our knowledge, the late presentation of diaphragmatic hernia with gastric perforation in a trauma patient leading to feed coming through chest tube is very rare of the complications.
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Chondrodysplasia punctata with severe airway stenosis p. 552
Bobbity Deepthi, Viswas Chhapola, Sandeep Kumar Kanwal, Ankita Goel Sharma, Virendra Kumar
Chondrodysplasia punctata (CDP) is a group of skeletal dysplasias characterized primarily by punctate calcifications in cartilage. It is a rare disease with an incidence of 1:100,000 live births. Extensive airway involvement with calcification of tracheal, bronchial, and thyroid cartilage in CDP is an infrequent finding. We aim to report a case of CDP with characteristic radiological features and severe airway involvement.
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Epidural hematoma: Vigilance beyond guidelines Highly accessed article p. 555
Nitin Madhukar Bhorkar, Tasneem Saleh Dhansura, Urmila Bhaktiprasad Tarawade, Sanket Sharad Mehta
Coagulopathy either from the use of anticoagulant, antiplatelet, or thrombolytic medications or from underlying medical conditions is considered one of the major risk factors for epidural hematoma formation related to epidural catheter placement or removal. The American Society of Regional Anesthesia and Pain Medicine (ASRA) has laid down guidelines regarding timing of neuraxial blockade or removal of neuraxial catheters in patients receiving either antithrombotic or thrombolytic therapy. We present a case of acute onset of paraplegia because of an epidural hematoma following removal of the epidural catheter in a patient who was given the first dose of antithrombotic therapy after the removal of the epidural catheter as per the ASRA guidelines. The epidural hematoma was diagnosed with an urgent magnetic resonance imaging, and the patient was urgently taken up for surgical evacuation of the hematoma. The patient made full recovery over 1 week period.
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Curious case of acute unilateral deep vein thrombosis: May-thurner syndrome p. 558
Manohar N. M. Bhat, Rohit Vadala, Ebenezer Rabindrarajan, Nagarajan Ramakrishnan
May-Thurner syndrome (MTS) or iliac vein compression syndrome is an uncommon cause of deep venous thrombosis (DVT) of the lower limb occurring, especially on the left side. It occurs due to compression of the left common iliac vein by the right common iliac artery and occurs predominantly in young females. The awareness of such a presentation is essential to guide therapy. We report one such unusual case of acute-onset DVT of the left lower limb due to MTS.
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Loss of guidewire p. 561
Wolfram Schummer
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Bloodless arterial cannulation technique p. 562
Amruta Shringarpure, Pushkar Desai
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Thromboelastographic analysis of hemostatic abnormalities in dengue patients admitted in a multidisciplinary intensive care unit: A cross-sectional study p. 563
Syed Nabeel Muzaffar, Suhail Sarwar Siddiqui, Afzal Azim
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