Indian Journal of Critical Care Medicine
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June 2016
Volume 20 | Issue 6
Page Nos. 319-381

Online since Monday, June 13, 2016

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RESEARCH ARTICLES  

Postoperative nutrition practices in abdominal surgery patients in a tertiary referral hospital Intensive Care Unit: A prospective analysis p. 319
Tejaswini Arunachala Murthy, Pradeep Rangappa, BJ Anil, Ipe Jacob, Karthik Rao
DOI:10.4103/0972-5229.183910  
Background: Benefit of early enteral feeds in surgical patients admitted to Intensive Care Units (ICUs) has been emphasized by several studies. Apprehensions about anastomotic leaks in gastrointestinal surgical patients prevent initiation of early enteral nutrition (EN). The impact of these practices on outcome in Indian scenario is less studied. Aims: This study compares the impact of early EN (within 48 h after surgery) with late EN (48 h postsurgery) on outcomes in abdominal surgical ICU patients. Settings and Design: Postabdominal surgery patients admitted to a tertiary referral hospital ICU over a 2-year period were analyzed. Methods: Only patients directly admitted to ICU after abdominal surgery were included in this study. ICU stay>3 days was considered as prolonged; with average ICU length of stay (LOS) for this ICU being 3 days. The primary outcome was in-patient mortality. ICU LOS, hospital LOS, infection rates, and ventilator days were secondary outcome measures. Acute Physiology and Chronic Health Evaluation II scores were calculated. SPSS and Microsoft Excel were used for analysis. Results: Of 91 ICU patients included, 58 received early EN and 33 late EN. Hospital LOS and infection rates were less in early EN group. Use of parenteral nutrition (odds ratio [OR] 5.25, 95% confidence interval (CI); P = 0.003) and number of nil-per-oral days (OR 8.25, 95% CI; P ≤ 0.001) were other predictors of prolonged LOS. Conclusions: Early EN in postabdominal surgery ICU patients was associated with reduced hospital LOS and infection rates. ICU LOS, duration of mechanical ventilation and mortality rates did not vary.
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Sleep after critical illness: Study of survivors of acute respiratory distress syndrome and systematic review of literature p. 323
Sahajal Dhooria, Inderpaul Singh Sehgal, Anshu Kumar Agrawal, Ritesh Agarwal, Ashutosh Nath Aggarwal, Digambar Behera
DOI:10.4103/0972-5229.183908  
Background and Aims: This study aims to evaluate the sleep quality, architecture, sleep-related quality of life, and sleep-disordered breathing (SDB) in acute respiratory distress syndrome (ARDS) survivors early after discharge. Materials and Methods: In this prospective, observational study, consecutive patients with ARDS discharged from the Intensive Care Unit (ICU) underwent evaluation with Epworth sleepiness scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Functional Outcomes of Sleep Questionnaire (FOSQ), and overnight polysomnography. Patients having one or more of the following characteristics were classified as having abnormal sleep: ESS>10, PSQI>5, FOSQ <17.9, apnea–hypopnea index (AHI) ≥5, or AHI during rapid eye movement (REM) sleep ≥5. Results: Twenty patients (median interquartile range [IQR] age of 24 [22–28] years, 11 [55%] females) were included in the study. Acute febrile illness of unknown etiology with multi-organ dysfunction syndrome was the most common underlying etiology for ARDS. The median (IQR) PaO2/FiO2ratio and APACHE II scores on admission were 176 (151–191.5) and 14 (14–16), respectively. The median (IQR) duration of stay in the ICU was 10 days (7.3–19.5). The overall sleep efficiency (median [IQR], 54% [32.3–65.4%]) was poor. None of the patients had ESS>10, seven (35%) had global PSQI>5 and one had FOSQ <17.9. Ten (50%) patients had at least one characteristic that suggested abnormal sleep (4 insomnia, 2 central sleep apnea, 1 obstructive sleep apnea, 1 REM-SDB, and 2 with a high PSQI, but no specific sleep abnormality). Conclusions: Sleep disturbances are common in ARDS survivors early after discharge from the ICU.
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Acute kidney injury-incidence, prognostic factors, and outcome of patients in an Intensive Care Unit in a tertiary center: A prospective observational study p. 332
Sara Korula, Sindhu Balakrishnan, Shyam Sundar, Vergis Paul, Anuroop Balagopal
DOI:10.4103/0972-5229.183904  
Background and Aims: The information regarding the incidence of acute kidney injury (AKI) in medical Intensive Care Units (ICUs) in South India is limited. The aim of the study was to find the incidence, prognostic factors, and outcome of patients with AKI. We also assessed whether only urine output criteria of risk, injury, failure, loss, end (RIFLE) classification can be used to look at the outcome of AKI. Patients and Methods: This was a prospective, cross-sectional study of 6 months duration in a 28 bedded medical ICU of a tertiary center. AKI was defined as an absolute creatinine value of>1.6 mg/dl or a 25% increase from baseline creatinine values. Results: The incidence of AKI was 16.1%, and mortality was 7.8% in our study population. Among patients with AKI 87 (75.7%) patients had sepsis. 71.3% patients had metabolic acidosis on admission, and 47.8% patients were in shock. 57.4% of patient's required mechanical ventilation (MV). 39.1% of AKI patients required renal replacement therapy (RRT). Requirement of RRT was significantly affected by increasing age, Acute Physiology and Chronic Health Evaluation II and sequential organ failure assessment scores on admission, serum creatinine, and use of vasopressors. 49.5% of patients with AKI died within 28 days. Increasing age, MV, hemodialysis (HD), hypertension, chronic kidney disease, and requirement of noradrenaline support were associated with increasing 28 days mortality. The maximum RIFLE score with urine output criteria showed association to the requirement of HD in univariate analysis but did not show relation to mortality. Conclusion: The incidence of AKI was 16.1% in critically ill patients. In patients with AKI, 39.1% patients required HD and 28 days mortality was 49.5%. The study also showed good univariate association of urine output criteria of RIFLE classification to the requirement of HD in AKI patients.
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Mobilization of patients in neurological Intensive Care Units of India: A survey p. 337
Anup Bhat, Kalyana Chakravarthy, Bhamini K Rao
DOI:10.4103/0972-5229.183911  
Context: The rehabilitation needs of the patients in neurological Intensive Care Units (ICUs) vary from that of a medical ICU patient. Early mobilization is known to improve the various neurological outcomes in patients admitted to neurological ICUs, although little is known about the practice pattern among physiotherapists. The mobilization practice pattern may vary significantly than that of developed countries due to the reasons of differences in training of professionals, availability of equipment, and financial assistance by health insurance. Aim of the Study: To study the current mobilization practices by the physiotherapists in neurological ICUs of India. Subjects and Methods: A cross-sectional survey was conducted with a content validated questionnaire about the mobilization practices. Online questionnaire was distributed to physiotherapists working in neurological ICUs of India. Descriptive statistics were used. Results: Out of 185 e-mails sent, 82 physiotherapists completed the survey (survey response rate = 44%). Eighty participants (97.6%) mentioned that the patients received some form of mobilization during the day. The majority of the physiotherapists (58.5%), “always” provided bed mobility exercises to their patients when it was found appropriate for the patients. Many physiotherapists (41.5%) used tilt table “sometimes” to introduce orthostatism for their patients. Conclusion: Mobilization in various forms is being practiced in the neurological ICUs of India. However, fewer mobilization sessions are conducted on weekends and night hours in Indian Neurological ICUs.
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REVIEW ARTICLES Top

High frequency oscillatory ventilation in leptospirosis pulmonary hemorrhage syndrome: A case series study p. 342
Mohd Basri Mat Nor, Azrina Md Ralib, Noor Airini Ibrahim, Mohd Rasydan Abdul-Ghani
DOI:10.4103/0972-5229.183906  
Hypoxemia in severe leptospirosis-associated pulmonary hemorrhage syndrome (LPHS) is a challenging clinical scenario not usually responsive to maximal support on mechanical ventilation. We described the efficacy and safety of high frequency oscillatory ventilation (HFOV) as rescue therapy in acute respiratory failure secondary to LPHS. This is a retrospective case study of five patients with diagnosis of severe LPHS, who were admitted to Intensive Care Unit from October 2014 to January 2015. They developed refractory hypoxemia on conventional mechanical ventilation and rescue therapy was indicated. All patients responded rapidly by showing improvements in oxygen index and PaO2/FiO2ratio within first 72 h of therapy. Despite severity of illness evidenced by high Simplified Acute Physiological II and Sequential Organ Failure Assessment scores, all patients were discharged from hospital alive. In view of the rapid onset and extent of hemorrhage which may culminate quickly into asphyxiation and death, HFOV may indeed be lifesaving in severe LPHS.
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Yakson touch as a part of early intervention in the Neonatal Intensive Care Unit: A systematic narrative review p. 349
Preeti Parashar, Asir John Samuel, Arpna Bansal, Vencita Priyanka Aranka
DOI:10.4103/0972-5229.183897  
Yakson is a Korean therapeutic touch given to neonates and infants by caressing their abdomen with one hand while the other hand is placed on the back of the neonate\infant either to relieve their pain or to calm them down. It was traditionally used by Koreans by caressing the aching body part of their children with a belief that it would relieve their pain. In spite of clinical evidence of its usefulness, there is limited literature available on Yakson touch. A systematic narrative review (SNR) was undertaken on studies that were carried out on the effectiveness of Yakson touch on infants and neonates. Only seven studies were detected from five major electronic databases, searched with the keywords: “Yakson,“ “Yakson touch,” and “Yakson in neonates”. One of the studies has been included in two Cochrane reviews by the same group of researchers published in 2011 and 2015, respectively, and also in a literature review. The evidence from these articles suggests that Yakson touch is able to increase the sleep scores of infants, affects their behavioral response, decreases the stress levels, increases maternal attachment, and has calming effects on them. However, the number of studies is limited, and thus the efficacy of this intervention has not been sufficiently established. Hence, there is a definite need for future studies to prove the efficacy of Yakson to include it in the early intervention programs. This SNR is aimed at compiling the studies which determined to prove the efficacy of the intervention of Yakson.
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SHORT COMMUNICATIONS Top

The risk factors of colistin methanesulfonate associated nephrotoxicity p. 353
Elif Tükenmez Tigen, E Nursen Koltka, Arzu Dogru, Melek Gura, Haluk Vahabaoglu
DOI:10.4103/0972-5229.183905  
Purpose: The risk factors of colistin methanesulfonate (CMS) associated nephrotoxicity are important. Our study attempts look into the prevalence of CMS-associated nephrotoxicity in Intensive Care Units (ICUs), and related risk factors. Materials and Methods: The study was conducted between September 2010 and April 2012 on 55 patients who underwent CMS treatment. Nephrotoxicity risk was defined based on the Risk Injury Failure Loss End-stage kidney disease criteria. Results: Fifty-five patients included in the study. A total of 22 (40%) patients developed nephrotoxicity. The correlation was detected between nephrotoxicity and patients over 65 with a high Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score. APACHE II score was revealed an independent risk factor for nephrotoxicity. Conclusion: Advanced age and a high APACHE II score are significant risk factors in the development of nephrotoxicity at ICUs following CMS use. Patient selection and close monitoring are critical when starting CMS treatment.
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Bedside placement of small-bowel feeding tube in Intensive Care Unit for enteral nutrition p. 357
Antara Gokhale, Sandeep Kantoor, Sadanandan Prakash, Yogesh Manhas, Juhi Chandwani, Ashraf Ezzat Mahmoud
DOI:10.4103/0972-5229.183909  
Enteral nutrition is the preferred mode of nutrition in critically ill patients whenever feasible as it has a number of advantages over parenteral feeding. Both gastric and small-bowel feeding can effectively deliver calories. In patients with gastroparesis, small-bowel feeding can help avoid parenteral feeding. We carried out a retrospective observational study to assess the ability to insert the Tiger 2 tube into the small bowel at the bedside in 25 patients who failed to tolerate gastric feeds. The time taken, rate of successful insertion, and ability to feed these patients using a standardized feeding protocol were noted. Success rate of insertion was 78% and feeding could be established. This method reduced the delays and risks associated with transportation and dependence on other specialties.
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CASE REPORTS Top

Panayiotopoulos syndrome in a child masquerading as septic shock p. 361
Syed Ahmed Zaki, Devendra Kumar Verma, Pavan Tayde
DOI:10.4103/0972-5229.183912  
Panayiotopoulos syndrome (PS) is a benign childhood epilepsy with predominant autonomic symptoms. The syndrome can have varied presentations resulting in diagnostic dilemma. We herein describe a 3-year-old boy with PS, who had manifestations similar to septic shock. His investigations were normal and had a complete recovery. Through this case, we wish to highlight the unusual presentation of PS as septic shock. Physicians should be aware of the different ways in which this syndrome can present to ensure its early diagnosis and treatment.
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Neurally adjusted ventilation assist in weaning difficulty: First case report from India p. 364
Milind Baldi, Inderpaul Singh Sehgal, Sahajal Dhooria, Digambar Behera, Ritesh Agarwal
DOI:10.4103/0972-5229.183896  
Invasive mechanical ventilation is an integral component in the management of critically ill patients. In certain situations, liberation from mechanical ventilation becomes difficult resulting in prolonged ventilation. Patient-ventilator dyssynchrony is a frequently encountered reason for difficult weaning. Neurally adjusted ventilatory assist (NAVA) is a novel mode of ventilation that utilizes the electrical activity of diaphragm to pick up respiratory signals and delivers assistance in proportion to the ventilatory requirement of a patient. It may, therefore, be associated with a better patient-ventilator synchrony thereby facilitating weaning. Herein, we report the first case from India describing the use of NAVA in successfully weaning a patient with difficult weaning.
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Successful management of zinc phosphide poisoning p. 368
Vahid Shakoori, Mahsa Agahi, Maryam Vasheghani-Farahani, Sayed Mahdi Marashi
DOI:10.4103/0972-5229.183907  
Zinc phosphide (Zn2P3) rodenticide, is generally misused intentionally for suicidal purpose in Iran. For many years, scientists believe that liberation of phosphine (PH3) on contact with acidic content of the stomach is responsible for clinical presentations. However, relatively long time interval between ingestion of Zn2P3and presentation of its systemic toxicity, and progression of acute liver failure could not be explained by the current opinion. Hence, an innovative theory intended that phosphonium, as an intermediate product will create and pass through the stomach, which then will reduce to produce PH3in the luminal tract. Here, we present a case of massive Zn2P3poisoning. In our case, we used repeated doses of castor oil to induce bowel movement with an aim of removing unabsorbed toxin, which was proved by radiography. Interestingly, the patient presents only mild symptoms of toxicity such as transient metabolic acidosis and hepatic dysfunction.
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Clinically HIV but negative serology: Think of idiopathic CD4+ lymphocytopenia p. 371
Vidya Sanjay Nagar, Rahul Kadu, Shamshersingh Gajendra Chauhan, Rudrarpan Chatterjee, Aniruddha Kaushik, Deniskumar Vashrambhai Patel, Ankita Sood
DOI:10.4103/0972-5229.183899  
idiopathic CD4+ lymphocytopenia (ICL) is a rare disorder characterized by the presence of depleted CD4 cell line without the presence of HIV infection. Slight male preponderance is noticed and is usually seen in the middle age group. Opportunistic infections are the reason for their discovery and here we describe a case where a man was diagnosed as having Pneumocystis jiroveci pneumonia and oral candidiasis.
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Thrombotic microangiopathy as an initial manifestation in HIV patients p. 374
Thanigachalam Dineshkumar, Jeyachandran Dhanapriya, Palanivel Jaganathan, Ramanathan Sakthirajan, Natarajan Gopalakrishnan, T Balasubramaniyan
DOI:10.4103/0972-5229.183903  
Thrombotic microangiopathy (TMA) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, microvascular thrombosis, and various organ dysfunctions. TMA usually occurs in a more advanced stage of HIV disease. TMA as an initial presenting feature is rare. We here report a male patient who presented with oliguric renal failure. Investigations revealed anemia, thrombocytopenia, schistocytes in peripheral smear, and HIV-positive. Renal biopsy revealed TMA. He was treated with hemodialysis and started on highly active antiretroviral therapy.
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LETTERS TO THE EDITOR Top

Esophageal pressure-guided positive end-expiratory pressure in acute respiratory distress syndrome: The jury is still out! p. 377
Animesh Ray, Ayush Gupta
DOI:10.4103/0972-5229.183900  
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Procedural improvisation to prevent guidewire kinking in Griggs percutaneous tracheostomy without bronchoscopic guidance p. 378
Saroj Kumar Pattnaik, Banambar Ray
DOI:10.4103/0972-5229.183901  
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Keep an eye on Murphy's eye during percutaneous dilatational tracheostomy p. 379
Prakash K Dubey, Om P Sanjeev
DOI:10.4103/0972-5229.183898  
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Hyperthermia and malfunction of transesophageal echocardiographic probe p. 380
Minati Choudhury, Sandeep Chauhan
DOI:10.4103/0972-5229.183902  
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