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   Table of Contents - Current issue
Coverpage
September 2018
Volume 22 | Issue 9
Page Nos. 629-686

Online since Monday, September 17, 2018

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RESEARCH ARTICLES  

The importance of serial time point quantitative assessment of cardiac Troponin I in the diagnosis of acute myocardial damage p. 629
Arindam Bose, Vidyut Jain, Girish Kawthekar, Chandrabala Chhabra, Nanda Hemvani, Dhananjay S Chitnis
DOI:10.4103/ijccm.IJCCM_8_16  
Objective: The present study was aimed to establish a threshold value for cardiac troponin I (cTnI) for nonacute coronary syndrome (ACS) participants from the local population and also to determine the importance of serial time point estimation of cTnI in acute myocardial infarction (AMI), non-ST-elevated MI (NSTEMI), and unstable angina cases. Methods: The present study included 194 cases, admitted in ICCU with the complaint of anginal pain; 31 were diagnosed with AMI with typical electrocardiography (ECG) changes; whereas, 48 cases were diagnosed with NSTEMI. The latter group of cases was selected for the time point study of cTnI release at 0–4 h, 6–12 h, 72 h, and 144 h of admission. cTnI levels were assessed using the Abbott ARCHITECT i1000SR system. Results: ACS was clinically ruled out in 98 cases, and cTnI level for them was used to decide cTnI threshold for the non-ACS group. cTnI level was checked in 17 cases of unstable angina. The threshold value of cTnI for non-ACS participants was 0.1 ng/ml and can be considered as cut-off value for the regional population. The data suggested that the peak of cTnI levels in most of the AMI cases reached during 6–12 h. The cTnI levels were lower than 0.1 ng/ml, and no significant change in ECG was noticed in 17 cases of unstable angina. Conclusion: The present study suggested that the repeat of cTnI assay after 4–6 h of admission is required if the initial value is <3 ng/ml.
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Non- neurological complications after traumatic brain injury: A prospective observational study p. 632
Keshav Goyal, Amarjyoti Hazarika, Ankur Khandelwal, Navdeep Sokhal, Ashish Bindra, Niraj Kumar, Shweta Kedia, Girija P Rath
DOI:10.4103/ijccm.IJCCM_156_18  
Introduction and Aims: Recognizing and treating nonneurological complications occurring in traumatic brain injury (TBI) patients during intensive care unit (ICU) stay are challenging. The aim is to estimate various nonneurological complications in TBI patients. The secondary aim is to see the effect of these complications on ICU stay, disability, and mortality. Materials and Methods: This was a prospective observational study at the neuro-ICU of a Level-I trauma center. A total of 154 TBI patients were enrolled. The period of the study was from admission to discharge from ICU or demise. Inclusion criteria were patients aged >16 years and patients with severe TBI (Glasgow coma score [GCS] ≤8). Nonneurological complications were frequent in TBI patients. Results: We observed respiratory complications to be the most common (61%). Other complications, in the decreasing order, included dyselectrolytemia (46.1%), cardiovascular (34.4%), coagulopathy (33.1%), sepsis (26%), abdominal complications (17.5%), and acute kidney injury (AKI, 3.9%). The presence of systemic complications except AKI was found to be significantly associated with increased ICU stay. Most of the patients of AKI died early in ICU. Respiratory dysfunction was found to be independently associated with 3.05 times higher risk of worsening clinical condition (disability) (P < 0.018). The presence of cardiovascular complications during ICU stay (4.2 times, P < 0.005), AKI (24.7 times, P < 0.02), coagulopathy (3.13 times, P < 0.047), and GCS <6 (4.2 times, P < 0.006) of TBI was independently associated with significantly increased risk of ICU mortality. Conclusion: TBI patients tend to have poor outcome due to concomitant nonneurological complications. These have significant bearing on ICU stay, disability, and mortality.
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Targeted-volume noninvasive ventilation reduces extubation failure in postextubated medical Intensive Care Unit patients: A randomized controlled trial p. 639
Vorawut Thanthitaweewat, Dittapol Muntham, Naricha Chirakalwasan
DOI:10.4103/ijccm.IJCCM_236_18  
Purpose: Till date, the benefit of using noninvasive ventilation (NIV) routinely after extubation to prevent reintubation has been conflicting. We aim to demonstrate the effect of targeted-volume NIV for the prevention of reintubation and extubation failure after planned extubation in medical intensive care unit (ICU) patients. Study Design: This was a prospective, randomized controlled study. Materials and Methods: Patients on invasive mechanical ventilation for more than 48 hrs for acute respiratory failure, who were ready for extubation, were randomized into targeted-volume NIV (intervention group) or oxygen mask (controlled group) immediately after extubation and continuously for 24 hrs. Results: A total of 58 patients were enrolled in this study. The targeted-volume NIV group was observed to have a trend toward lower reintubation rate within 48 hrs compared to oxygen mask group (0% vs. 17.2%; P = 0.052). Extubation failure rate within 48 hrs was significantly lower in targeted-volume NIV group compared to oxygen mask group (0% vs. 41.38%; P < 0.001). There was a trend toward lower ICU length of stay (6[5] days vs. 10[8] days (median interquartile range [IQR]); P = 0.053) as well as shorter hospital length of stay after extubation (10[19] days vs. 18[15] days (median [IQR]); P = 0.059). There were no differences in the incidence of ventilator-associated pneumonia (VAP)/hospital-acquired pneumonia (HAP) (6.90% vs. 20.69%;P = 0.253) and 28 day-mortality (13.79% vs. 20.69%; P = 0.487). Conclusions: Our study is the first study to demonstrate the benefit of application of targeted-volume NIV immediately after extubation in reducing extubation failure rate. There was a trend toward lowering reintubation rate and shorter ICU length of stay and hospital length of stay after extubation in mixed medical ICU patients.
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Sonographic measurement of optic nerve sheath diameter: How steep is the learning curve for a novice operator? p. 646
Gentle Sunder Shrestha, Binayak Upadhyay, Aanchal Shahi, KC Jaya Ram, Pankaj Joshi, Bishesh Sharma Poudyal
DOI:10.4103/ijccm.IJCCM_104_18  
Background: Transbulbar sonography for measuring optic nerve sheath diameter (ONSD) is noninvasive bedside technique for detection of raised intracranial pressure. This study aims to evaluate the number of sonographic evaluations required for a novice operator to learn proper measurement of ONSD after a formal training and supervised scanning session. Methods: Three novice operators and one expert operator measured ONSD of 27 healthy volunteers using linear array transducer HFL38x (frequency range of 6–13 MHz) (MicroMaxx®; SonoSite, USA). In each eye, ONSD was measured three times by each observer and mean value was determined. Correlation coefficient was calculated between the novice and the experienced operator and in between the novice operators. Number of scans, after which the significant correlation developed between novice and the experienced operator and between the novice operators, was analyzed. Results: Cronbach's alpha was tested to evaluate the reliability of the values obtained from intra- and interobservations. For all 27 cases, the value of Cronbach's alpha was high: 0.80–0.99 for the right eye and 0.69-0.97 for the left eye. The mean interobserver variations were plotted on a graph which fluctuated largely in the first 17 cases but oscillated around 0.5–0.30 in the last 10 cases. Conclusion: Learning curve for novice operators to measure ONSD is steep and they can be taught to measure ONSD in healthy volunteers by sonography in supervised clinical session with an acceptable clinical precision and accuracy comparable to an experienced operator.
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Evaluating extravascular lung water in sepsis: Three lung-ultrasound techniques compared against transpulmonary thermodilution p. 650
Pattarin Pirompanich, Dimitrios Karakitsos, Abdulrahman Alharthy, Lawrence Marshall Gillman, Michael Blaivas, Brian M Buchanan, Peter G Brindley, Anan Wattanathum
DOI:10.4103/ijccm.IJCCM_256_18  
Background: Excessive extravascular lung water (EVLW) is associated with increased morbidity and mortality. We compared three lung-ultrasound (L-US) techniques against the reference-standard transpulmonary thermodilution (TPTD) technique to access EVLW. Materials and Methods: This was a prospective, single-blind, cross-sectional study. Forty-four septic patients were enrolled. EVLW index was measured by the TPTD method, and an index of ≥10 mL/kg was considered diagnostic of pulmonary edema. EVLW index was then compared to three established bedside L-US protocols that evaluate sonographic B-lines: (1) a 28-zone protocol (total B-line score [TBS]) (2) a scanning 8-region examination, and (3) a 4-point examination. Results: Eighty-nine comparisons were obtained. A statistically significant positive correlation was found between L-US TBS and an EVLW index ≥10 mL/kg (r = 0.668,P < 0.001). The 28-zone protocol score ≥39 has a sensitivity of 81.6% and a specificity of 76.5% to define EVLW index ≥10 mL/kg. In contrast, the positive 4-point examination and scanning 8-regions showed low sensitivity (23.7% and 50.0%, respectively) but high specificity (96.1% and 88.2%, respectively). Ten patients with a total of 21 comparisons met criteria for acute respiratory distress syndrome (ARDS). In this subgroup, only the TBS had statistically significant positive correlation to EVLW (r = 0.488,P = 0.025). Conclusion: L-US is feasible in patients with severe sepsis. In addition, L-US 28-zone protocol demonstrated high specificity and better sensitivity than abbreviated 4- and 8-zone protocols. In ARDS, the L-US 28-zone protocol was more accurate than the 4- and 8-zone protocols in predicting EVLW. Consideration of limitations of the latter protocols may prevent clinicians from reaching premature conclusions regarding the prediction of EVLW. Trial Registration: ISRCTN11419081. Registered 4 February 2015 retrospectively.
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BRIEF COMMUNICATIONS Top

Survey on perceived impact of religion, culture, and social network information on surrogate decision-making in a South Asian developed country p. 656
Shahla Siddiqui, Sukhanya Sureish, Audris Chia
DOI:10.4103/ijccm.IJCCM_383_17  
Introduction: Relatives often have to assume responsibility for making end of life choices as surrogate decision-makers for patients with diminished or are lacking capacity. Our aim was to study the influence of religion, culture and social network information on surrogate decision making. Methods: This study was an exploratory, prospective, survey. Questions addressed the role of surrogates in decision making and the importance and influence of religion, culture and social media on such decisions. Results: 34 respondents filled out the anonymous survey. Surrogate decision making is a complex process and influenced by many factors. Conclusion: This survey points to a need for wider studies looking at the factors influencing people when making such important decisions and further social psychology interventions to evaluate whether such decisions can be made more consistent and patient centred.
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Diagnostic and prognostic role of neutrophil-to-lymphocyte ratio in early and late phase of sepsis p. 660
Rajnish Kaushik, Monika Gupta, Madhu Sharma, Debraj Jash, Neetu Jain, Nitin Sinha, Aditya Chaudhry, Dhruva Chaudhry
DOI:10.4103/ijccm.IJCCM_59_18  
Objective: Early diagnosis of sepsis is necessary to decrease morbidity and mortality. This study aims to evaluate neutrophil-to-lymphocyte ratio (NLR) as diagnostic and prognostic of early and late phase of sepsis. Methods: It was a prospective, observational study, conducted in Intensive Care and High Dependency Unit (Daycare) of the Department of Pulmonary and Critical Care Medicine (tertiary care center), Rohtak, from January 2017 to December 2017. A total of 56 cases of newly diagnosed cases of sepsis were included in the study and 20 healthy adults were taken as controls. Daily NLR was calculated in cases till the primary outcome. Results: The results suggested that NLR seems to have promising role as diagnostic and prognostic marker (with P = 0.001 and P = 0.045, respectively) in sepsis. Conclusion: The study suggests that NLR can be a useful diagnostic and prognostic marker in sepsis.
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EDUCATIONAL FORUM Top

Hypernatremia due to urea-induced osmotic diuresis: Physiology at the bedside p. 664
Sonali Vadi, Kenneth Yim
DOI:10.4103/ijccm.IJCCM_266_18  
Hypernatremia secondary to urea-induced solute diuresis is due to the renal excretion of electrolyte-free water. This concept is explained here step-wise physiologically with the help of a clinical vignette.
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CASE REPORTS Top

Hepatitis a virus-induced severe hemolysis complicated by severe Glucose-6-Phosphate Dehydrogenase deficiency p. 670
Dhruva Sharma, Omender Singh, Deven Juneja, Amit Goel, Suneel Kumar Garg, Shashank Shekhar
DOI:10.4103/ijccm.IJCCM_260_18  
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an x-linked recessive genetic disorder with mutation in the G6PD gene. Defect in the enzyme G6PD causes red blood cells (RBCs) to breakdown prematurely causing hemolytic anemia. Hemolytic anemia is also a known hematological complication associated with viral hepatitis. In such patients, hemolysis may be more severe if there is any secondary injury to RBC in the form of membrane defect, oxidative stress, or enzyme deficiency like in G6PD deficiency. Here, we present a case of an adult, not previously diagnosed with G6PD deficiency, who presented with viral hepatitis, severe hemolysis, and multiorgan failure.
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Severe hypokalemia mimicking brain death p. 674
Asif Ali Hitawala, Piyush Garg, Abhay Jain, Ashish Nahar
DOI:10.4103/ijccm.IJCCM_163_18  
We discuss a case of a 20-year-old female who presented with history of fever, vomiting, and decreased oral intake for 10 days followed by one episode of generalized tonic–clonic seizure and altered sensorium for 5–6 h. On arrival in the emergency room, she had Glasgow Coma Scale 3 (E1V1M1), both pupils fixed and dilated, low blood pressure, low oxygen saturation, and few gasping breaths. She appeared to be brain dead and was assumed to have a very poor prognosis. Investigations revealed severe hypokalemia. She had also suffered acute hypoxic-ischemic injury to the brain. However, she recovered and was discharged about 2 weeks later.
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A rare case of localized tetanus p. 678
Deepak S Sharma, Mit B Shah
DOI:10.4103/ijccm.IJCCM_182_18  
Tetanus is a severe and potentially fatal infection caused by the bacterium Clostridium tetani. Presentations of tetanus include generalized tetanus, neonatal tetanus, cephalic tetanus, and localized tetanus, the latter two being much rarer. We present case of a 55-year-old male farmer, presented with an injury to the left toe. A surgical wound exploration and washout with administration of human tetanus immunoglobulin and tetanus toxoid were given as treatment with antibiotic support. This case report points out the importance of the early recognition of a rare form of this fatal infectious disease, which may present with prodromal symptoms before the generalized form shows its clinical effects. Successful management includes prompt diagnosis, neutralization of circulating toxin and elimination of C. tetani infection, control of spasms, maintenance of the airway, and management of respiratory failure and autonomic dysfunction.
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Verapamil as an adjuvant treatment for drug-resistant epilepsy p. 680
S Lakshmikanthcharan, Mohamed Hisham, SK Chaitanya Juluri, Sivakumar Mundilipayalam Nandakumar
DOI:10.4103/ijccm.IJCCM_250_18  
Almost one-third of the people suffering from epilepsy continue to have seizures in spite of using appropriate antiepileptics. Pharmacoresistance is defined as the failure to achieve seizure control with two or more anticonvulsant medications at appropriate daily dosage. Here, we discuss one such gentleman whose seizures had been intractable despite multiple antiepileptic drugs in maximum tolerable doses. Verapamil, a calcium channel blocker, was used for its P-glycoprotein inhibition properties to overcome the pharmacoresistance in this patient with satisfactory seizure control. There are a few studies with limited patients on the successful usage of verapamil in a patient with pharmacoresistant status epilepticus (SE). We intend to publish this case report to draw interest among the critical care physicians on pharmacoresistant SE, the different hypotheses that prevail, its causes and the available management strategies.
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LETTERS TO THE EDITOR Top

Speech and swallowing function outcome following early tracheostomy in patients who underwent neurosurgical intervention p. 683
Pralay Shankar Ghosh, Sukanya Naskar, Afzal Azim
DOI:10.4103/ijccm.IJCCM_307_18  
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Echographic comparison of optic nerve sheath diameter between both eyes p. 684
Maddalena De Bernardo, Ilaria De Pascale
DOI:10.4103/ijccm.IJCCM_243_18  
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Organ donation rate in brain-dead patients in a tertiary referral center p. 685
Shivakumar Mutnal, Pradeep Rangappa, Ipe Jacob, Karthik Rao
DOI:10.4103/ijccm.IJCCM_526_17  
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