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   Table of Contents - Current issue
Coverpage
November 2018
Volume 22 | Issue 11
Page Nos. 767-820

Online since Monday, November 19, 2018

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RESEARCH ARTICLES  

Cumulative fluid balance and outcome of extubation: A prospective observational study from a general intensive care unit p. 767
Supradip Ghosh, Aayush Chawla, Kirtee Mishra, Ranupriya Jhalani, Ripenmeet Salhotra, Amandeep Singh
DOI:10.4103/ijccm.IJCCM_216_18  
Introduction: This study was aimed to examine the impact of cumulative fluid balance on extubation failure following planned extubation. Methods: Consecutive adult patients (≥16 years) admitted in a general intensive care unit (ICU), between January 1, 2016, and December 31, 2017, mechanically ventilated for at least 24 h and extubated following successful spontaneous breathing trial, were prospectively evaluated. Results: The cumulative fluid balance at extubation was significantly higher in the extubation failure group (median 4336.5 ml vs. 2752 ml, P = 0.036). The area under the receiver operating characteristic curve for cumulative balance to predict extubation failure was 0.6 (95% confidence interval [CI]: 0.504–0.697) with optimal cutoff value of 3490 ml (sensitivity and specificity of 60% and 59.5%, respectively). Other risk factors for extubation failure identified by univariate analysis were the duration of mechanical ventilation at extubation, chronic kidney or neurological disease, heart rate, and respiratory rate. In multiple regression model, the cumulative fluid balance >3490 ml retained its predictive potential for extubation failure (odds ratio = 2.191, 95% CI = 1.015–4.730). Conclusions: Our result validates the association between higher cumulative fluid balance and extubation failure in an Indian ICU. A future randomized control trial may examine any role of therapeutic diuresis/ultrafiltration in preventing failed extubation in patients who fulfill the readiness to wean criteria with cumulative net fluid balance ≥3490 ml.
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Nutrition management of acute postliver transplant recipients p. 773
Neha Bakshi, Kalyani Singh
DOI:10.4103/ijccm.IJCCM_227_18  
Aim: Acute post liver transplant (LT) phase is characterized by hypermetabolism and increased nutrient requirements. This study aimed to provide the cardinal data on nutrition progression in the management of acute post-LT patients. Methods: This exploratory study recruited 54 adult acute post-LT recipients. The information regarding patient stay, weight status, biochemical parameters, and route of feeding was gathered. Recipients' dietary and nutrient intake was computed by 24-h dietary recall method. Results: The data exhibited a significant trend of lower hemoglobin, platelet, and albumin levels and increased bilirubin (T), alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase levels (P < 0.05). In acute post-LT patients, a significant decrease in weight status (P < 0.001**) was observed. The recipients' information on daily nutrition progression showed significantly lower intake of calorie, protein, fats, calcium (P < 0.05) and lower percentage adequacy of other nutrients as compared to the recommended guidelines. The energy and protein intake from the parenteral route of feeding significantly decreased and that of through oral route significantly increased (P < 0.05) from postoperative day (POD) 2 to POD 9 and POD 12. Conclusion: There are scant data on nutrition management in acute post-LT phase. The present study provides the framework for the formulation of continuous, patient-centric, aggressive nutrition management interventions for acute post-LT recipients.
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Point-of-care ultrasound to evaluate thickness of rectus femoris, vastus intermedius muscle, and fat as an indicator of muscle and fat wasting in critically ill patients in a multidisciplinary intensive care unit p. 781
Yeshaswini Katari, Rangalakshmi Srinivasan, Priyadarshini Arvind, Sahajananda Hiremathada
DOI:10.4103/ijccm.IJCCM_394_18  
Background: Muscular atrophy is the universal feature in patients with ICUAW. Muscles of the lower limb are more prone to early atrophy. Measurement of fat thickness is used to assess malnutrition. This study was designed to evaluate if, subcutaneous fat also reduces along with muscle thickness and if it can be reliably used as an indicator of nutritional assessment in critically ill patients using point of care ultrasound. Materials and Methods: An observational clinical study of 100 patients admitted to multidisciplinary intensive care units (ICUs). Total anterior thigh thickness, thickness of the rectus femoris muscle, fat thickness, and the combined thickness of vastus intermedius and rectus femoris were taken on day 1, 3, and 7 of ICU admission. Results: There was progressive loss of muscle mass from day 1 to day 7. Muscle loss was not only limited to rectus femoris, but vastus intermedius also showed a significant decrease as indicated by the bone to muscle measurement. Skin to bone measurement which includes both muscle and fat compartment showed a decline. Conclusions: There is potential utility of ultrasound for early detection and probable corrective measures to prevent ICUAW. The rectus femoris thickness, skin to bone, and bone to muscle thickness show statistically significant difference on day 3, day 7 compared to day 1. Fat layer did not show statistically significant decrease.
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Lung ultrasound and blood gas-based classification of critically ill patients with dyspnea: A pathophysiologic approach p. 789
Saurabh Saigal, Rajnish Joshi, Jai Prakash Sharma, Vandana Pandey, Abhijit Pakhare
DOI:10.4103/ijccm.IJCCM_338_18  
Introduction: The objective of this study was to classify dyspneic patients and to evaluate outcome variables on the basis of lung ultrasound (LUS) and arterial blood gas (ABG) findings. Methods: We performed a retrospective chart-based review in which we included patients with dyspnea admitted to our intensive care unit (ICU) between March 2015 and August 2016. On the basis of LUS (presence of A-lines/B-lines) and ABG (hypoxia/hypercarbia), patients were classified into six groups: (i) metabolic defect (dry lung, no hypoxia); (ii) perfusion defect (dry lung, hypoxia); (iii) ventilation defect (dry lung, hypoxia, and hypercarbia); (iv) ventilation and alveolar defect (wet lung, hypoxia, and hypercarbia); (v) alveolar defect-consolidation ([wet lung] hypoxia, no echocardiographic [ECG] abnormality); (vi) alveolar defect-pulmonary edema (wet lung [usually bilateral], hypoxia, ECG abnormality). The patient's demographic data, sequential organ failure assessment (SOFA) score, need for intubation, vasopressors, form of mechanical ventilation, ICU outcome, and length of stay were noted. Results: A total of 244 out of 435 patients were eligible for inclusion in the study. The median age was 56 years. 132 patients (54.1%) required mechanical ventilation, and median SOFA score was 7. Noninvasive ventilation was required in 87.5% of patients with ventilation defect as compared to 9.2% with alveolar defect-consolidation (P < 0.0001). We had 21.7% mortality in patients with alveolar defect-consolidation, 10.8% mortality in patients with metabolic defect, and 8.7% mortality in patients with alveolar defect-pulmonary edema (P < 0.0001). Conclusion: This classification gives an organized approach in managing patients with dyspnea. It predicts that patients with alveolar defect-consolidation are most sick of all the groups and need immediate intervention.
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Factors affecting early treatment goals of sepsis patients presenting to the emergency department p. 797
CK Kassyap, Siju V Abraham, S Vimal Krishnan, Babu Urumese Palatty, PC Rajeev
DOI:10.4103/ijccm.IJCCM_27_18  
Background and Objectives: Sepsis is a major cause of emergency medicine admission. It is associated with high mortality and morbidity. Even though sepsis is common in the Indian subcontinent, there is a paucity of data on the management of sepsis in India. The aim was to study the factors affecting early treatment goals. Methods: All clinically suspected sepsis patients consenting to be part of the study were included. The diagnosis of sepsis was made by the treating physician in the emergency department as per the Surviving Sepsis Guidelines criteria. All cases were managed as per institutional treatment protocol. The patients were prospectively followed up and the time taken to achieve the goal-directed sepsis bundle documented and analyzed. Results and Discussion: Of the 75 patients studied, the 3-hour(h) bundles were achieved in 70.7% of cases and 6-h bundles were achieved in 84% of cases. Meantime for obtaining blood culture was 107 min and administration of first dose antibiotics was 134 min. Thirty patients failed to achieve the early treatment goals, of which six were under-triaged, seven due to physicians delay in recognizing sepsis, 11 due to logistical delay, and six were due to financial constraints. Conclusion: The sepsis bundle goals were not achieved because of various factors such as under triaging, delay in diagnosis, logistical delay, and financial constraints. Further studies on whether sensitization of medical fraternity about sepsis, implementation of insurance policies for patient care or better point of care diagnostics would aid in achieving the bundles may be evaluated further.
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CASE REPORTS Top

Fatal iron toxicity in an adult: Clinical profile and review p. 801
Mandar Ramachandra Sane, Kamal Malukani, Rashmi Kulkarni, Abhishek Varun
DOI:10.4103/ijccm.IJCCM_188_18  
Acute iron toxicity is usually seen in children with accidental ingestion of iron-containing syrups. However, the literature on acute iron toxicity with suicidal intent in adults is scant. We report an instance wherein an adult committed suicide by ingestion of multiple iron tablets. Delay in treatment was there due to misdiagnosis of the intoxicating agent. She developed fulminant hepatic failure with rapid clinical deterioration. Despite aggressive supportive management, the patient succumbed to the toxic doses of iron. Clinical course and postmortem features are discussed with a review of the literature.
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A case of keraunoparalysis: A bolt from the blue p. 804
Sadananda B Naik, RV Murali Krishna
DOI:10.4103/ijccm.IJCCM_325_18  
Keraunoparalysis is a catastrophic but fortunately totally reversible neuroparalysis of the limbs occurring due to a lightning strike. One such case with transient right hemiparesis along with a brief account of the pathophysiology of this unique neurologic problem has been presented here.
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Papillary muscle dysfunction due to coronary slow-flow phenomenon presenting with acute mitral regurgitation and unilateral pulmonary edema p. 806
Jose Chacko, Gagan Brar, Bhargav Mundlapudi, Pradeep Kumar
DOI:10.4103/ijccm.IJCCM_343_18  
Cardiogenic pulmonary edema usually presents with characteristic clinical features and bilateral infiltrates on the chest radiograph. Rarely, pulmonary edema may manifest unilaterally, leading to a mistaken diagnosis of a primary lung pathology. We present a 30-year-old man who developed acute coronary syndrome following an overdose of alprazolam. He developed breathlessness with unilateral infiltrates on the chest radiograph. Echocardiography revealed regional wall motion abnormalities related to underlying ischemia and acute mitral regurgitation with an eccentric jet. Besides, he had significant impairment of left ventricular systolic function. His coronary angiogram revealed a slow-flow phenomenon in the right coronary and left anterior descending artery territories. Ischemia-related dysfunction of the posterolateral papillary muscle probably led to a floppy posterior mitral leaflet and an eccentrically directed regurgitant jet, leading to unilateral pulmonary edema. He was commenced on dual antiplatelet therapy, heparin infusion, atorvastatin, frusemide, and ramipril, following which he showed gradual clinical improvement along with resolution of the radiological infiltrates. His left ventricular function improved, and the mitral valve function normalized on echocardiography within a week.
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Bilateral parotid enlargement and trismus: An unexpected clinical finding in a patient with common krait (Bungarus caeruleus) bite p. 809
Sujeet Raina, Bhagwan Dass Negi, Sayan Malakar, Rajesh Sharma, Mahesh Kumar
DOI:10.4103/ijccm.IJCCM_402_18  
We report a case of bilateral parotid enlargement and trismus due to the bite of common krait (Bungarus caeruleus). These clinical findings have not been reported in literature after the bite with this species.
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Disseminated pyomyositis due to Burkholderia cepacia: A case report p. 811
Sai Saran, Vijay Sundar Singh, Sagarika Panda, Mohan Gurjar, Krushna Chandra Pani, Kalyani Borde, Afzal Azim
DOI:10.4103/ijccm.IJCCM_141_18  
Pyomyositis is a tropical infection affecting skeletal muscles manifesting as high-grade fever with pain in the affected limbs usually caused by Gram-positive microorganisms. Gram-negative organisms causing pyomyositis is uncommon but has been reported. Burkholderia cepacia is a Gram-negative nonfermenter causing opportunistic infections in immunocompromised patients, has been reported to cause pyomyositis only once before. We report a case of B. cepacia pyomyositis in a patient with no history of immunocompromised status, manifesting as disseminated infection with hemophagocytic syndrome presenting to our intensive care unit.
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Ventriculitis caused by multidrug-resistant bacteria in a medical intensive care unit with limited resources p. 814
Pedja Kovacevic, Sasa Dragic, Vlado Djajic
DOI:10.4103/ijccm.IJCCM_352_18  
The widespread use of various devices in the diagnosis or treatment of critically ill neurological patients has led to the more frequent appearance of a new group of meningitis and ventriculitis caused by resistant Gram-negative bacteria or staphylococci. In literature, it has been labeled as health care-associated meningitis and ventriculitis. In our clinical practice (in resource-limited countries), we still have any viable experience neither in the application of these diagnostic and therapeutic tools nor in the handling of complications resulting from their use. However, we have had positive results with the help of the existing guidelines and advice from colleagues in the region (through a video consultation model) while also respecting other factors that reflect our work environment.
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Severe sepsis due to chryseobacterium indologenes, a possible emergent multidrug-resistant organism in intensive care unit-acquired infections p. 817
Sonika Agarwal, Barnali Kakati, Sushant Khanduri
DOI:10.4103/ijccm.IJCCM_278_18  
Opportunistic infections in the intensive care unit are quite common which can cause devastating disease in many hospitalized and immunocompromised patients. Chryseobacterium indologenes is one such microorganism which is an emerging cause of nosocomial infections. Many cases had been reported from its infections, but the treatment protocol for its management is still not established. We present two cases of C. indologenes infections which were hospital acquired. The pandrug-resistant nature of the bacteria and the associated mortality were uncommon with these two cases.
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LETTER TO THE EDITOR Top

Author reply p. 820
Tuna Demirdal, Pinar Sen, Salih Atakan Nemli
DOI:10.4103/ijccm.IJCCM_308_18  
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