Indian Journal of Critical Care Medicine
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   Table of Contents - Current issue
Coverpage
May 2015
Volume 19 | Issue 5
Page Nos. 251-296

Online since Wednesday, May 06, 2015

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RESEARCH ARTICLES  

Urinary neutrophil gelatinase-associated lipocalin in critically ill surgical cancer patients p. 251
Pericles Almeida Delfino Duarte, Andreia Cristina Fumagalli, Vanessa Wandeur, Delmiro Becker
DOI:10.4103/0972-5229.156459  
Background and Aims: Neutrophil gelatinase-associated lipocalin (N-GAL) is an early biomarker of acute kidney injury (AKI) due to various etiologies. On the other hand, N-GAL is also elevated in patients with acute inflammatory conditions and in several solid neoplasms. The goal of this study was to assess the efficacy of N-GAL as a predictor of AKI and mortality in oncological surgical patients postoperatively in the intensive care unit (ICU). Methods: This was a prospective cohort observation study on adult cancer patients submitted to elective or emergency surgeries and admitted in the ICU. Urinary N-GAL was measured at the first 2 h after admission. AKI incidence and other complications were assessed, including hospital mortality. Results: A total of 22 patients were assessed (77% male, age 52.8 years, Acute Physiology and Chronic Health Evaluation II [APACHE II] 17.3) in whom the most frequent site of cancer was the gastrointestinal tract. AKI incidence was 13.6%. Urinary N-GAL was a predictor of AKI (22.0 ng/ml in patients without AKI vs. 239.1 ng/ml in patients with AKI, P < 0.001). Multivariate analysis showed that the main predictors of AKI were age, APACHE II, and N-GAL. N-GAL was also higher, although not statistically significant in patients who died in the hospital. Conclusions: In oncological postoperative patients admitted to the ICU, urinary N-GAL was an independent predictor of AKI; moreover, its level was higher in the deceased patients.
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Stress levels of critical care doctors in India: A national survey Highly accessed article p. 257
Rahul Amte, Kartik Munta, Palepu B Gopal
DOI:10.4103/0972-5229.156464  
Background: Doctors working in critical care units are prone to higher stress due to various factors such as higher mortality and morbidity, demanding service conditions and need for higher knowledge and technical skill. Aim: The aim was to evaluate the stress level and the causative stressors in doctors working in critical care units in India. Materials and Methods: A two modality questionnaire-based cross-sectional survey was conducted. In manual mode, randomly selected delegates attending the annual congress of Indian Society of Critical Care Medicine filled the questionnaire. In the electronic mode, the questionnaires were E-mailed to critical care doctors. These questionnaires were based on General Health Questionnaire-12 (GHQ-12). Completely filled 242 responses were utilized for comparative and correlation analysis. Results: Prevalence of moderate to severe stress level was 40% with a mean score of 2 on GHQ-12 scale. Too much responsibility at times and managing VIP patients ranked as the top two stressors studied, while the difficult relationship with colleagues and sexual harassment were the least. Intensivists were spending longest hours in the Intensive Care Unit (ICU) followed by pulmonologists and anesthetists. The mean number of ICU bed critical care doctors entrusted with was 13.2 ± 6.3. Substance abuse to relieve stress was reported as alcohol (21%), anxiolytic or antidepressants (18%) and smoking (14%). Conclusion: Despite the higher workload, stress levels measured in our survey in Indian critical care doctors were lower compared to International data. Substantiation of this data through a wider study and broad-based measures to improve the quality of critical care units and quality of the lives of these doctors is the need of the hour.
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Problems and limitations in thrombolysis of acute stroke patients at a tertiary care center p. 265
Sushma K Gurav, Kapil G Zirpe, RS Wadia, Manishprasad K Pathak, Abhijeet M Deshmukh, Rahul V Sonawane, Nikhil Goli
DOI:10.4103/0972-5229.156468  
Aim: (1) To evaluate the number of patients thrombolysed within 1 h of arrival to emergency room (ER) (2) To identify reasons for delay in thrombolysis of acute stroke patients. Materials and Methods: All patients admitted to ER with symptoms suggestive of stroke from January 2011 to November 2013 were studied. Retrospective data were collected to evaluate ER to needle (door to needle time [DTNt]) time and reasons for delay in thrombolysis. The parameters studied (1) onset of symptoms to ER time, (2) ER to imaging time (door to imaging time [DTIt]), (4) ER to needle time (door to needle) and (5) contraindications for thrombolysis. Results: A total of 695 patients with suspected stroke were admitted during study period. 547 (78%) patients were out of window period. 148 patients (21%, M = 104, F = 44) arrived within window period (<4.5 h.). 104 (70.27%) were contraindicated for thrombolysis. Majority were intracerebral bleeds. 44 (29.7%) were eligible for thrombolysis. 7 (15.9%) were thrombolysed within 1 h. The mean time for arrival of patients from onset of symptoms to hospital (symptom to door) 83 min (median - 47). The mean door to neuro-physician time (DTPt) was 32 min (median - 15 min).The mean DTIt was 58 min (median - 50 min). The mean DTNt 104 (median - 100 min). Conclusion: Reasons for delay in thrombolysis are: Absence of stroke education program for common people. Lack of priority for triage and imaging for stroke patients.
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REVIEW ARTICLE Top

Metabolic acidosis during parenteral nutrition: Pathophysiological mechanisms p. 270
Evangelia Dounousi, Xanthi Zikou, Vasilis Koulouras, Kostas Katopodis
DOI:10.4103/0972-5229.156473  
Total parenteral nutrition (TPN) is associated with metabolic complications including metabolic acidosis (MA), one of the main disorders of acid-base balance. The main causes involved in the appearance of MA during TPN administration are the metabolism of cationic amino acids and amino acids containing sulfuric acid (exogenous addition), the titratable acidity of the infused parenteral solution, the addition of acidificant agents (hydrochloric acid, acetic acid), thiamine deficiency, disruption of carbohydrate and lipid metabolic pathways and D-fructose administration. Moreover, hypophosphatemia that appears during TPN therapy contributes significantly to the maintenance of MA. This review describes in a comprehensive way the pathophysiological mechanisms involved in the appearance of MA induced by intravenous administration of TPN products most commonly used in critically ill-patients.
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BRIEF COMMUNICATION Top

Complications during the management of pediatric refractory status epilepticus with benzodiazepine and pentobarbital infusions p. 275
William Patten, Sayed Z Naqvi, Andre Raszynski, Balagangadhar R Totapally
DOI:10.4103/0972-5229.156476  
The objective of this retrospective study was to evaluate complications in the management of refractory status epilepticus (RSE) treated with benzodiazepine and pentobarbital infusions. Of 28 children with RSE, eleven (39%) were treated with a pentobarbital infusion after failure to control RSE with a benzodiazepine infusion; while17 children (61%) required only a benzodiazepine infusion. The mean maximum pentobarbital infusion dosage was 5.2 ± 1.8 mg/kg/h. Twenty-five patients received a continuous midazolam infusion with an average dosage of 0.41 ± 0.43 mg/kg/h. The median length of stay was longer for the pentobarbital group. Children requiring pentobarbital therapy were more likely to develop hypotension, require inotropic support, need intubation, mechanical ventilation, peripheral nutrition, and blood products; furthermore, they were more likely to develop hypertension and movement disorder after or during weaning. In conclusion, children with RSE who required pentobarbital therapy had a longer hospital stay with more complications.
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CASE REPORTS Top

How we managed a difficult to ventilate patient p. 278
Sunil Kumar Garg
DOI:10.4103/0972-5229.156478  
A 40-year-old female presented with respiratory difficulty, cough and sputum with blood streaking. Her right lung was destroyed, and trachea was shifted to the same side. On mechanical ventilation, she developed hypoxia and rise in blood pressure. Ventilator was not delivering set tidal volume. After looking into the cause, it was decided to reintubate the patient with new endotracheal tube after cutting bevel. Thereafter, there was successful ventilation.
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Acute concentrated phenol dermal burns: Complications and management p. 280
Tapan Jayantilal Parikh
DOI:10.4103/0972-5229.156481  
Phenol burns can result in multiple organ failure. This is a case report of acute severe phenol dermal burn after accidental splash of 94% phenol on 35-year-old patient's body who was brought to hospital after 90 min of exposure. Decontamination was done with high-density water and glycerol. Early complications in form of metabolic acidosis and acute renal failure required hemodialysis. Extensive protein denaturation was managed with IV albumin and high protein diet. Patient also developed pleural effusion and acute respiratory distress syndrome, but these were successfully managed by intercostal drain tube insertion and noninvasive ventilation. The patient survived after multiple organ failures and widespread burns despite the fact that it has been observed that outcome of phenol burns with >60 2 inches of skin affected or two or more organs failure involving renal system is nearly fatal.
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Intravenous ketamine for treatment of super-refractory convulsive status epilepticus with septic shock: A report of two cases p. 283
Gentle Sunder Shrestha, Pankaj Joshi, Santosh Chhetri, Ragesh Karn, Subhash Prasad Acharya
DOI:10.4103/0972-5229.156484  
Refractory and super-refractory status epilepticus is a life-threatening neurological emergency, associated with high morbidity and mortality. Treatment should be aimed to stop seizure and to avoid cerebral damage and another morbidity. Published data about effectiveness, safety and outcome of various therapies and treatment approaches are sparse and are mainly based on small case series and retrospective data. Here we report successful management of two cases of super-refractory status epilepticus refractory to anesthetic therapy with midazolam and complicated by septic shock, managed successfully with ketamine infusion.
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Extra corporeal carbon dioxide removal: A reliable modality in refractory hypercapnia to prevent invasive ventilation p. 286
Atiharsh Mohan Agarwal, Tapas Kumar Singh
DOI:10.4103/0972-5229.156487  
Extracorporeal carbon dioxide removal (ECCO2R) is a valid alternative to consider in hypercapnic respiratory failure in chronic obstructive pulmonary disease (COPD) patients to avoid invasive ventilation when noninvasive ventilation fails. Here we report a similar case, after obtaining informed consent, where a patient suffering from severe hypercapnic respiratory failure due to COPD, was selected for ECCO2R and improved remarkably.
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LETTERS TO THE EDITOR Top

Catastrophic antiphospholipid syndrome (CAPS): A rare and fatal encounter p. 289
Jayant K Mehta
DOI:10.4103/0972-5229.156489  
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Bilateral symmetrical digital gangrene of upper and lower limbs due to purpura fulminans caused by Streptococcus pyogenes: A rare entity p. 290
Goyal Kush Ashokkumar, Rao Madhu, Mathew Shaji, Budania Raghuveer Singh
DOI:10.4103/0972-5229.156493  
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Congenital lobar emphysema: Intubation and ventilation strategies p. 291
Shailesh Kumar, Prakash K Dubey
DOI:10.4103/0972-5229.156495  
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Methylmalonic acidemia and diabetic ketoacidosis: An unusual association p. 292
Suresh Kumar
DOI:10.4103/0972-5229.156496  
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Mortality patterns among critically ill children in a pediatric intensive care unit of a developing country p. 293
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/0972-5229.156499  
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Comments on "Candida glabrata candidemia; an emerging threat in critically ill patients" p. 294
Armin Ahmed, Afzal Azim, Arvind Kumar Baronia
DOI:10.4103/0972-5229.156501  
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Antimicrobial dosing in critically ill patients with sepsis-induced acute kidney injury p. 295
Shakti Bedanta Mishra, Afzal Azim
DOI:10.4103/0972-5229.156502  
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CytoSorb-friend or foe!! p. 296
Saroj Kumar Pattnaik, Bibekananda Panda
DOI:10.4103/0972-5229.156504  
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