Indian Journal of Critical Care Medicine
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Coverpage
March 2015
Volume 19 | Issue 3
Page Nos. 133-192

Online since Thursday, March 05, 2015

Accessed 253 times.

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EDITORIALS  

End-of-life care in the Pediatric Intensive Care Units: Challenges and ethical principles p. 133
Brenda M Morrow
DOI:10.4103/0972-5229.152749  
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Can we consider procalcitonin as a consolidated biomarker in sepsis management? p. 136
A Garcia-de-Lorenzo, SM Sanchez
DOI:10.4103/0972-5229.152751  
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Candida glabrata candidemia p. 138
Arunaloke Chakrabarti
DOI:10.4103/0972-5229.152753  
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RESEARCH ARTICLES Top

Procalcitonin kinetics as a prognostic marker in severe sepsis/septic shock Highly accessed article p. 140
Banani Poddar, Mohan Gurjar, Sushma Singh, Amita Aggarwal, Ratender Singh, Afzal Azim, Arvind Baronia
DOI:10.4103/0972-5229.152755  
Background and Aims: To evaluate the prognostic value of change (fall) in serum procalcitonin level (PCT) in critically ill adults with severe sepsis/septic shock. Methods: This was a prospective observational study in a general purpose Intensive Care Unit of a teaching Institute. PCT was measured at admission (D0) and after 72-96 h (D4) by electrochemi-luminescence immunoassay (BRAHMS PCT kit) in adults (>18 years) admitted with severe sepsis or septic shock. Change in procalcitonin values from D0 to D4 was correlated with the primary outcome, that is, 28 days mortality. All results are reported as median (interquartile range). Results: A total of 171 (100 males) of 181 patients were included. The median age was 46 years (range 19-79). 137 patients were in septic shock and 34 in severe sepsis. The sequential organ failure assessment (SOFA) score in all patients was 11 (9-14).91 (53.2%) patients survived at 28 days (survivors). The baseline procalcitonin was similar in two groups (3.48 [1.04-15.85] vs. 5.27 [1.81-23.57] ng/ml in survivors and nonsurvivors [NS] respectively). The procalcitonin change was 1.58 (0.20-8.52) in survivors and 0.28 (-1.38-6.17) in NS (P = 0.01). The C-statistic of percentage change in procalcitonin from D0 to D4 to predict survival was 0.73 (95% confidence interval [CI]: 0.65-0.82) when compared to 0.78 (95% CI: 0.71-0.86) for change of SOFA score. For an absolute fall in procalcitonin of >1 ng/ml, a 70% fall predicted survival with 75% sensitivity and 64% specificity. Conclusions: In critically ill-patients with severe sepsis/septic shock, change (fall) in procalcitonin is associated with good outcome.
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Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country p. 147
Naveed-ur-Rehman Siddiqui, Zohaib Ashraf, Humaira Jurair, Anwarul Haque
DOI:10.4103/0972-5229.152756  
Background and Aim: Advances in biomedical technology have made medical treatment to be continued beyond a point, at which it does not confer an advantage but may increase the suffering of patients. In such cases, continuation of care may not always be useful, and this has given rise to the concept of limitation of life-sustaining treatment. Our aim was to study mortality patterns over a 6-year period in a Pediatric Intensive Care Unit (PICU) in a developing country and to compare the results with published data from other countries. Materials a nd Methods: Retrospective cohort study was conducted in a PICU of a tertiary care hospital in Pakistan. Data were drawn from the medical records of children aged 1-month - 16 years of age who died in PICU, from January 2007 to December 2012. Results: A total of 248 (from an admitted number of 1919) patients died over a period of 6 years with a mortality rate 12.9%. The median age of children who died was 2.8 years, of which 60.5% (n = 150) were males. The most common source of admission was from the emergency room (57.5%, n = 143). The most common cause of death was limitation of life-sustaining treatment (63.7%, n = 158) followed by failed cardiopulmonary resuscitation (28.2%, n = 70) and brain death (8.1%, n = 20). We also found an increasing trend of limitation of life-sustaining treatment do-not-resuscitate (DNR) over the 6-year reporting period. Conclusion: We found limitation of life support treatment (DNR + Withdrawal of Life support Treatment) to be the most common cause of death, and parents were always involved in the end-of-life care decision-making.
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Candida glabrata candidemia: An emerging threat in critically ill patients p. 151
Ashish Gupta, Anu Gupta, Amit Varma
DOI:10.4103/0972-5229.152757  
Background: Candidemia is an important nosocomial blood stream infection in critically ill patients. Although several studies have addressed candidemia, very few have reviewed the impact of Candida glabrata candidemia in Intensive Care Unit (ICU) patients. Materials and Methods: The medical records of ICU patients between 2006 and 2010 were reviewed retrospectively. The epidemiology, clinical features and mortality related risk factors among our adult ICU patients were seen. Results: Among 144 episodes of candidemia, C. glabrata (n = 26; 18.05%) was the third most common species isolated. The incidence of C. glabrata candidemia was 0.21/1000 ICU admissions. The most common risk factors were prior exposure to broad spectrum antibiotics (100%), central venous catheter (100%), mechanical ventilation (76.9%), diabetes mellitus (50%), age >65 years (46.15%). Urine (23%) was the most common source of C. glabrata candidemia. Overall in hospital 30 days mortality rate due to C. glabrata fungemia was 53.8%. Patients who were treated with fluconazole showed better outcome than patients treated with amphotericin B. Renal failure requiring hemodialysis was the significantly associated with mortality in our study. Conclusion: Candida glabrata was the 3 rd most common Candida causing candidemia in our ICUs with a incidence of 0.21/1000 ICU admissions. The outcome of ICU acquired C. glabrata candidemia was poor with 30 days mortality rate of 53.8%. Renal failure requiring hemodialysis was the only risk factor associated with mortality. Further studies are required to identify the other risk factors associated with mortality in C. glabrata candidemia.
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Age influences the predictive value of Acute Physiology and Chronic Health Evaluation II and Intensive Care National Audit and Research Centre scoring models in patients admitted to Intensive Care Units after in-hospital cardiac arrest p. 155
D. N. S. Senaratne, T Veenith
DOI:10.4103/0972-5229.152758  
Introduction: Outcomes following in-hospital cardiac arrest (IHCA) are generally poor though different patient populations may benefit to different degrees from admission to Intensive Care Units (ICUs). Risk stratification algorithms may be useful in identifying patients who are most likely to benefit from ICU admission and so may aid allocation of this scarce resource. We aimed to compare the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Intensive Care National Audit and Research Centre (ICNARC) scoring systems in predicting outcome following ICU admission after IHCA in younger (≤69 years) and older (≥70 years) patients. Materials and Methods: We performed a retrospective observational study in two adult ICUs from January 2006 to February 2010 inclusive. Patients were divided into younger (≤69 years) and older (≥70 years) patients. The primary outcome measures were acute hospital mortality and area under the curve (AUC) calculation for receiver operating characteristic (ROC) analysis. Results: Two hundred and sixty-one adult consecutive adult patients admitted following IHCA. Hospital mortality was 58.6%. ROC analysis demonstrated that ICNARC was more accurate than APACHE II in predicting acute hospital outcomes in the adult population (AUC 0.734 vs. 0.706). Both scoring systems performed weaker when predicting outcomes in younger patients compared to older patients (ICNARC AUC 0.655 vs. 0.810; APACHE II AUC 0.660 vs. 0.759). Discussion : Both APACHE II and ICNARC predict outcome well in older patients. In younger patients, their value is less clear, and so they must be used with caution.
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Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting? p. 159
Iuri Christmann Wawrzeniak, Sergio Henrique Loss, Maria Cristina Martins Moraes, Fabiane Lopes De La Vega, Josue Almeida Victorino
DOI:10.4103/0972-5229.152759  
Context: Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended. Aims: The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting. Settings and Design: retrospective and observational cohort study at tertiary hospital. Subjects and Methods: All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT. Results: A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively). Conclusions: Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.
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BRIEF COMMUNICATIONS Top

Osmotic demyelination syndrome in Intensive Care Unit p. 166
Parnandi Bhaskar Rao, Afzal Azim, Neha Singh, Arvind Kumar Baronia, Anand Kumar, Banani Poddar
DOI:10.4103/0972-5229.152760  
Dyselectrolytemia, especially hyponatremia is a common occurrence in hospitalized patients, and a number of dreaded complications arise out of the disorder itself and its treatment. Osmotic demyelination syndrome develops secondary to rapid correction of hyponatremia. As the disease is rare and available literature from Intensive Care Units are limited, we report our retrospective observation over 5 years. Overall incidence was 2.5% with altered sensorium and hypokalemia as most common symptom and associated factor respectively. Isolated pontine involvement was in 41% and combined pontine, and extra-pontine lesions were found in 23% of cases. All patients received supportive therapy; out of which 2 died and complete neurological recovery was seen in 24% of patients. Our findings suggest that a well organized supportive therapy and multidisciplinary approach is of more concern than many available therapeutic modalities which are still to be proved.
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Laryngeal air column width ratio in predicting post extubation stridor p. 170
Pradeep M Venkategowda, Kranthi Mahendrakar, S Manimala Rao, Dnyaneshwar P Mutkule, Chetan G Shirodkar, H Yogesh
DOI:10.4103/0972-5229.152763  
Aim: Correlation of upper air column width ratio in postextubation stridor patients. Materials and Methods: A prospective observational study was conducted in a tertiary hospital between January and December 2013. Patients who were admitted in Intensive Care Unit and intubated for >24 h were included (72 patients). The upper airway air column width ratio (air column width before extubation/air column width after intubation) was calculated and compared in patient with or without postextubation stridor. Results: The incidence of stridor was 6.9% (5/72). The duration of mechanical ventilation was 5.60 ± 1.14 days and 3.91 ± 1.45 days in stridor and nonstridor group respectively. In all 5 patients who had stridor, the upper airway air column width ratio was 0.8 or less. Conclusion: Air column width ratio of 0.8 or less may be helpful in predicting postextubation stridor, which should be confirmed by large observational studies.
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CASE REPORTS Top

A rare case of leptospirosis with isolated lung involvement p. 174
Vijay Kumar Agrawal, Abhishek Bansal, Meenu Pujani
DOI:10.4103/0972-5229.152765  
Leptospirosis is a zoonosis caused by a pathogenic spirochete "leptospira interrogans." Severe form of leprospira infection is usually associated with jaundice and renal involvement, leading to major hemorrhagic complications. Lung involvement can vary from subtle clinical features to deadly pulmonary hemorrhage and acute respiratory distress syndrome (ARDS). We recently managed a case of leptospirosis with isolated lung involvement as alveolar hemorrhage and ARDS. Our patient had acute febrile illness with respiratory symptoms associated with radiological picture of pulmonary hemorrhage. Patient was managed with noninvasive ventilation with high flow oxygen, antibiotic and pulse steroids therapy. In conclusion, leptospirosis can present with predominant pulmonary involvement, instead of the classical triad of Weil disease. High index of suspicion should be kept in acute febrile illness patients with respiratory symptoms and alveolar hemorrhage. Early diagnosis and management with oxygenation, antibiotics and immunosuppresents can prevent complications and mortality.
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Fatal lactic acidosis possibly related to ganciclovir therapy in a renal transplant patient? p. 177
Xavier Wittebole, Johann Morelle, Marie-Françoise Vincent, Philippe Hantson
DOI:10.4103/0972-5229.152772  
Ganciclovir is widely prescribed in renal transplant patients for the prevention or treatment of herpes and cytomegalovirus (CMV) infections. Side-effects are usually represented by hematological disorders, and particularly leucopenia. We report a case of severe and fatal lactic acidosis developing in a 76-year-old renal transplant woman, a few days after ganciclovir has been introduced to treat CMV pneumonia. Usual etiologies of lactic acidosis were ruled out. A high lactate/pyruvate molecular ratio was suggestive of a respiratory chain dysfunction. With the analogy to nucleoside analogues-related lactic acidosis, we suggest that ganciclovir may exceptionally be responsible for respiratory chain dysfunction and subsequent lactic acidosis, and we discuss potential risk factors in our patient.
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Near fatal spontaneous intraperitoneal bleeding: A rare manifestation in a congenital factor X deficiency carrier p. 180
KV Vinod, B Hitha, R Kaaviya, TK Dutta
DOI:10.4103/0972-5229.152774  
Congenital factor X (FX) deficiency is a rare coagulation disorder of autosomal recessive inheritance, characterized by bleeding of variable severity. Bleeding severity generally correlates with the level of FX functional activity and severe bleeding usually occurs in moderate and severe deficiency, when FX coagulant activity is <5%. FX activity above 10% is infrequently associated with severe bleeding. Here we report the rare occurrence of life-threatening massive spontaneous intraperitoneal bleeding with hypovolemic shock, resulting from spontaneous rupture of an ovarian luteal cyst in a 25-year-old FX deficiency carrier woman, with a FX activity of 26%. She was managed successfully conservatively, with fresh frozen plasma and packed red blood cell transfusions and she showed gradual improvement. The case is being reported to discuss the diagnosis and management of this rare inherited coagulation disorder.
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Methylmalonic acidemia mimicking diabetic ketoacidosis and septic shock in infants p. 183
Navdeep Saini, Ashwini Malhotra, Sanjay Chhabra, Sunny Chhabra
DOI:10.4103/0972-5229.152776  
Methylmalonic acidemia (MMA) is most common inherited type of organic acidemia. It has diverse presentation in older infants without any initial apparent symptoms. MMA sometimes present with sudden metabolic decompensation, which may mimics common emergencies like septic shock and diabetic ketoacidosis (DKA) without early recognition can be fatal. In born error of metabolism especially organic acidemia should be suspected in any infant presented with severe high anion gap metabolic acidosis. We report two cases of MMA in infants presented acutely mimicking DKA and septic shock.
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LETTERS TO THE EDITOR Top

Pharmaceutical companies as the funding sources for continuing medical education Highly accessed article p. 186
Tanuj Kanchan
DOI:10.4103/0972-5229.152778  
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Methyl alcohol poisoning causing putamen necrosis p. 187
Seyed Mostafa Mirakbari
DOI:10.4103/0972-5229.152780  
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Mobilization in Indian intensive care units: Where do we stand? p. 188
Baskaran Chandrasekaran, Senthil S Kumar, Chandra S Sekar
DOI:10.4103/0972-5229.152782  
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Hyponatremia management in critically ill: Food (protein) for thought p. 189
Sunil Kumar Garg
DOI:10.4103/0972-5229.152784  
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Rhabdomyolysis in lumbar spinal surgery: Early detection is crucial p. 190
Raghvendra Nayak, Bijesh Ravindran Nair, Shalini Nair, Mathew Joseph
DOI:10.4103/0972-5229.152786  
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Geriatric Critical Care in India p. 191
Swagata Tripathy
DOI:10.4103/0972-5229.152788  
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