Indian Journal of Critical Care Medicine
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  » Table of Contents - Current issue
April 2016
Volume 20 | Issue 4
Page Nos. 207-256

Online since Monday, April 11, 2016

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Cytokines, granulocyte-monocyte colony stimulating factor, interleukin-3 and erythropoietin: Can be a therapeutic option for the stimulation of hematopoietic progenitor cells in trauma-hemorrhagic shock? p. 207
Manoj Kumar, Sanjeev Bhoi
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Initial Sequential Organ Failure Assessment score versus Simplified Acute Physiology score to analyze multiple organ dysfunction in infectious diseases in Intensive Care Unit p. 210
Remyasri Nair, Nithish M Bhandary, Ashton D D'Souza
Aims: To investigate initial Sequential Organ Failure Assessment (SOFA) score of patients in Intensive Care Unit (ICU), who were diagnosed with infectious disease, as an indicator of multiple organ dysfunction and to examine if initial SOFA score is a better mortality predictor compared to Simplified Acute Physiology Score (SAPS). Materials and Methods: Hospital-based study done in medical ICU, from June to September 2014 with a sample size of 48. Patients aged 18 years and above, diagnosed with infectious disease were included. Patients with history of chronic illness (renal/hepatic/pulmonary/  cardiovascular), diabetes, hypertension, chronic obstructive pulmonary disease, heart disease, those on immunosuppressive therapy/chemoradiotherapy for malignancy and patients in immunocompromised state were excluded. Blood investigations were obtained. Six organ dysfunctions were assessed using initial SOFA score and graded from 0 to 4. SAPS was calculated as the sum of points assigned to each of the 17 variables (12 physiological, age, type of admission, and three underlying diseases). The outcome measure was survival status at ICU discharge. Results: We categorized infectious diseases into dengue fever, leptospirosis, malaria, respiratory tract infections, and others which included undiagnosed febrile illness, meningitis, urinary tract infection and gastroenteritis. Initial SOFA score was both sensitive and specific; SAPS lacked sensitivity. We found no significant association between age and survival status. Both SAPS and initial SOFA score were found to be statistically significant as mortality predictors. There is significant association of initial SOFA score in analyzing organ dysfunction in infectious diseases (P < 0.001). SAPS showed no statistical significance. There was statistically significant (P = 0.015) percentage of nonsurvivors with moderate and severe dysfunction, based on SOFA score. Nonsurvivors had higher SAPS but was not statistically significant (P = 0.094). Conclusions: Initial SOFA score is a superior mortality predictor. It easily measures degree of organ dysfunction in infectious diseases and complements other scoring systems.
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Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study Highly accessed article p. 216
Jigeeshu V Divatia, Pravin R Amin, Nagarajan Ramakrishnan, Farhad N Kapadia, Subhash Todi, Samir Sahu, Deepak Govil, Rajesh Chawla, Atul P Kulkarni, Srinivas Samavedam, Charu K Jani, Narendra Rungta, Devi Prasad Samaddar, Sujata Mehta, Ramesh Venkataraman, Ashit Hegde, BD Bande, Sanjay Dhanuka, Virendra Singh, Reshma Tewari, Kapil Zirpe, Prachee Sathe, INDICAPS Study Investigators
Aims: To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). Patients and Methods: An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. Results: On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. Conclusions: The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.
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Assessment of long-term impact of formal certified cardiopulmonary resuscitation training program among nurses p. 226
PP Saramma, L Suja Raj, PK Dash, PS Sarma
Context: Cardiopulmonary resuscitation (CPR) and emergency cardiovascular care guidelines are periodically renewed and published by the American Heart Association. Formal training programs are conducted based on these guidelines. Despite widespread training CPR is often poorly performed. Hospital educators spend a significant amount of time and money in training health professionals and maintaining basic life support (BLS) and advanced cardiac life support (ACLS) skills among them. However, very little data are available in the literature highlighting the long-term impact of these training. Aims: To evaluate the impact of formal certified CPR training program on the knowledge and skill of CPR among nurses, to identify self-reported outcomes of attempted CPR and training needs of nurses. Setting and Design : Tertiary care hospital, Prospective, repeated-measures design. Subjects and Methods: A series of certified BLS and ACLS training programs were conducted during 2010 and 2011. Written and practical performance tests were done. Final testing was undertaken 3-4 years after training. The sample included all available, willing CPR certified nurses and experience matched CPR noncertified nurses. Statistical Analysis Used: SPSS for Windows version 21.0. Results: The majority of the 206 nurses (93 CPR certified and 113 noncertified) were females. There was a statistically significant increase in mean knowledge level and overall performance before and after the formal certified CPR training program (P = 0.000). However, the mean knowledge scores were equivalent among the CPR certified and noncertified nurses, although the certified nurses scored a higher mean score (P = 0.140). Conclusions: Formal certified CPR training program increases CPR knowledge and skill. However, significant long-term effects could not be found. There is a need for regular and periodic recertification.
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Are sodium and potassium results on arterial blood gas analyzer equivalent to those on electrolyte analyzer? p. 233
Shalini Gupta, Ashwani K Gupta, Kamaljit Singh, Minni Verma
Objectives: The present study was conducted with the aim to compare the sodium (Na) and  potassium (K) results on arterial blood gas (ABG) and electrolyte analyzers both of which use direct ion selective electrode technology. Materials and Methods: This was a retrospective study in which data were collected for simultaneous ABG and serum electrolyte samples of a patient received in Biochemistry Laboratory during February to May 2015. The ABG samples received in heparinized syringes were processed on Radiometer ABL80 analyzer immediately. Electrolytes in serum sample were measured on ST-100 Sensa Core analyzer after centrifugation. Data were collected for 112 samples and analyzed with the help of Excel 2010 and  Statistical software for Microsoft excel XLSTAT 2015 software. Results: The mean Na level in serum sample was 139.4 ± 8.2 mmol/L compared to 137.8 ± 10.5 mmol/L in ABG (P < 0.05). The mean difference between the results was 1.6 mmol/L. Mean K level in serum sample was 3.8 ± 0.9 mmol/L as compared to 3.7 ± 0.9 mmol/L in ABG sample (P < 0.05). The mean difference between the results was 0.14 mmol/L. Statistically significant difference was observed in results of two instruments in low Na (<135 mmol/L) and normal K (3.5-5.2 mmol/L) ranges. The 95% limit of agreement for Na and K on both instruments was 9.9 to −13.2 mmol/L and 0.79 to −1.07 mmol/L respectively. Conclusions: The clinicians should be cautious in using the electrolyte results of electrolyte and ABG analyzer in inter exchangeable manner.
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The devil is in the detail: Acute Guillain-Barré syndrome camouflaged as neurosarcoidosis in a critically ill patient admitted to an Intensive Care Unit p. 238
Pooja Prathapan Sarada, Krishnaswamy Sundararajan
Guillain-Barré syndrome (GBS) is an acute demyelinating polyneuropathy, usually evoked by antecedent infection. Sarcoidosis is a multisystem chronic granulomatous disorder with neurological involvement occurring in a minority. We present a case of a 43-year-old Caucasian man who presented with acute ascending polyradiculoneuropathy with a recent diagnosis of pulmonary sarcoidosis. The absence of acute flaccid paralysis excluded a clinical diagnosis of GBS in the first instance. Subsequently, a rapid onset of proximal weakness with multi-organ failure led to the diagnosis of GBS, which necessitated intravenous immunoglobulin and plasmapheresis to which the patient responded adequately, and he was subsequently discharged home. Neurosarcoidosis often masquerades as other disorders, leading to a diagnostic dilemma; also, the occurrence of a GBS-like clinical phenotype secondary to neurosarcoidosis may make diagnosing coexisting GBS a therapeutic challenge. This article not only serves to exemplify the rare association of neurosarcoidosis with GBS but also highlights the need for a high index of clinical suspicion for GBS and accurate history taking in any patient who may present with rapidly progressing weakness to an Intensive Care Unit.
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Severe subcutaneous emphysema and pneumomediastinum secondary to noninvasive ventilation support in status asthmaticus p. 242
Lara González García, Corsino Rey, Alberto Medina, Juan Mayordomo-Colunga
A 12-year-old male with status asthmaticus developed subcutaneous emphysema and pneumomediastinum. He was transferred to our unit, where he received noninvasive ventilation (NIV). This respiratory support technique is not an absolute contraindication in these cases. After 2 h on NIV, he worsened sharply and the subcutaneous emphysema got bigger suddenly. He needed invasive ventilation for 5 days. Final outcome was satisfactory. This case illustrates that it is mandatory to keep a high level of vigilance when using NIV in patients with air leaks.
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Acute fibrinous and organizing pneumonia: A rare form of nonbacterial pneumonia p. 245
Prashant Saxena, Kuldeep Kumar, Sarita Mittal, Nidhi Goyal, Sahil Trikha, Arti Vashisth
Acute fibrinous and organizing pneumonia (AFOP) is a rare disease characterized by bilateral basilar infiltrates and histological findings of organizing pneumonia and intra-alveolar fibrin in the form of "fibrin balls." Here, we report a 43-year-old female with complaints of fever, dry cough, and shortness of breath with hypoxemia. High-resolution computed tomography thorax revealed diffuse confluent consolidation in bilateral lung zones. Bronchoscopy and transbronchial biopsy revealed features of AFOP. With prednisolone treatment, there was an improvement in her condition. AFOP is a rare disease and should be taken into consideration and differential diagnosis of severe acute pneumonias with no significant comorbidities.
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Chest trauma: A case for single lung ventilation p. 248
Nagaraj Pandharikar, Anil Sachdev, Neeraj Gupta, Suresh Gupta, Dhiren Gupta
Chest trauma is one of the important causes of mortality and morbidity in pediatric trauma patients. The complexity, magnitude, and type of lung injury make it extremely challenging to provide optimal oxygenation and ventilation while protecting the lung from further injury due to mechanical ventilation. Independent lung ventilation is used sporadically in these patients who do not respond to these conventional ventilatory strategies using double-lumen endotracheal tubes, bronchial blocker balloons, etc. However, this equipment may not be easily available in developing countries, especially for pediatric patients. Here, we present a case of severe chest trauma with pulmonary contusion, flail chest, and bronchopleural fistula, who did not respond to conventional lung protective strategies. She was successfully managed with bronchoscopy-guided unilateral placement of conventional endotracheal tube followed by single lung ventilation leading to resolution of a chest injury.
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Ischemic stroke due to occlusion of the artery of Percheron p. 251
Sulena , Paramdeep Singh, Rupinderjeet Kaur, Naveen Kumar
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A rare aspect of Crohn's disease: Pulmonary involvement in a child p. 252
Mahmood Dhahir Al-Mendalawi
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Can integrative weaning index be a routine predictor for weaning success? p. 253
Sachin Gupta, Deepak Govil
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Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with Intensive Care Unit mortality in critically ill p. 254
PV Sai Saran, Shakti Bedanta Mishra, Pralay Shankar Ghosh, Afzal Azim
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The ATAK complex (Adrenaline, Takotsubo, Anaphylaxis, and Kounis hypersensitivity -associated coronary syndrome) in neurological conditions p. 255
Nicholas G Kounis, Nicholas Grapsas, George D Soufras, Dimitrios Lianas, Nicholas Patsouras, George Hahalis
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