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   Table of Contents - Current issue
Coverpage
August 2017
Volume 21 | Issue 8
Page Nos. 483-542

Online since Monday, August 14, 2017

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RESEARCH ARTICLES  

A methodological study to develop a standard operational protocol for nurses on central line catheter care of patients in selected intensive care units p. 483
Rashmita Devi, Sandhya Ghai, Neena Vir Singh, GD Puri
DOI:10.4103/ijccm.IJCCM_261_16  
Aim: This study aims to develop a standard operational protocol (SOP) for central line catheter care for nurses. Materials and Methods: A preliminary draft of protocol based on extensive review of the literature was developed. The current practices of the nurses regarding central line catheter care were observed. Focus group discussions (FGD) were conducted with the nurses to identify the problems encountered by them during care of central line. Four rounds of Delphi were conducted to validate the protocol. The protocol was found to be feasible in terms of understanding, clarity and easy implementation after conducting a pilot study. An observation checklist was developed from the final draft of the protocol. The nurses were taught regarding the central line catheter care as per the protocol. 30 nurses were observed during central line catheter care by the researcher. After implementation of the protocol, feedback of the nurses was taken by conducting FGDs. Results: Content validity index of each item in the protocol was acceptable. The overall Cronbach's alpha value of the checklist was 0.75. It was concluded that the checklist is reliable and each item has a contribution in the checklist. Conclusion: This protocol addresses interventions to enable staff to provide proper care of the central line catheter to prevent CLABSI.
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Studying the power of the integrative weaning index in predicting the success rate of the spontaneous breathing trial in patients under mechanical ventilation p. 488
Sahar Ebrahimabadi, Ahmad Bagheri Moghadam, Mohammadali Vakili, Mahnaz Modanloo, Homeira Khoddam
DOI:10.4103/ijccm.IJCCM_10_17  
Background and Aims: The use of weaning predictive indicators can avoid early extubation and wrongful prolonged mechanical ventilation. This study aimed to determine the power of the integrative weaning index (IWI) in predicting the success rate of the spontaneous breathing trial (SBT) in patients under mechanical ventilation. Materials and Methods: In this prospective study, 105 patients undergoing mechanical ventilation for over 48 h were enrolled. Before weaning initiation, the IWI was calculated and based on the defined cutoff point (≥25), the success rate of the SBT was predicted. In case of weaning from the device, 2-h SBT was performed and the physiologic and respiratory indices were continuously studied while being intubated. If they were in the normal range besides the patient's tolerance, the test was considered as a success. The result was then compared with the IWI and further analyzed. Results: The SBT was successful in 90 (85.7%) and unsuccessful in 15 (14.3%) cases. The difference between the true patient outcome after SBT, and the IWI prediction was 0.143 according to the Kappa agreement coefficient (P < 0.001). Moreover, regarding the predictive power, IWI had high sensitivity (95.6%), specificity (40%), positive and negative predictive values (90.5% and 60), positive and negative likelihood ratios (1.59 and 0.11), and accuracy (86.7%). Conclusion: The IWI as a more objective indicator has acceptable accuracy and power for predicting the 2-h SBT result. Therefore, in addition to the reliable prediction of the final weaning outcome, it has favorable power to predict if the patient is ready to breathe spontaneously as the first step to weaning.
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How useful is extravascular lung water measurement in managing lung injury in intensive care unit? p. 494
Anirban Bhattacharjee, Debasis Pradhan, Prithwis Bhattacharyya, Samarjit Dey, Daniala Chhunthang, Akash Handique, Angkita Barman, Mohd Yunus
DOI:10.4103/ijccm.IJCCM_40_17  
Context: The primary goal of septic shock management is optimization of organ perfusion, often at the risk of overloading the interstitium and causing pulmonary edema. The conventionally used end points of resuscitation do not generally include volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). Aims: This study aimed to assess the prognostic value of EVLWI and PVPI by calculating their correlation with the severity of lung injury. Settings and Design: This prospective observational study included twenty mechanically ventilated critically ill patients with Acute Physiology and Chronic Health Evaluation score (APACHE II) >20. Subjects and Methods: EVLWI and PVPI were measured using transpulmonary thermodilution, and simultaneously, PaO2:FiO2 ratio, alveolar-arterial gradient of oxygen (AaDO2), and chest radiograph scores from two radiologists were obtained. Statistical Analysis: The correlation of EVLWI and PVPI with chest radiograph scores, PaO2:FiO2 ratio, and AaDO2 were calculated. The inter-observer agreement between the two radiologists was tested using kappa test. Results: EVLWI and PVPI correlated modestly with PaO2:FiO2 (r = −0.32, P = 0.0004; r = −0.39, P = 0.0001). There was a better correlation of EVLWI and PVPI with PaO2:FiO2 ratio (r = −0.71, P < 0.0001; r = −0.58, P = 0.0001) in the acute respiratory distress syndrome (ARDS) subgroup. The EVLWI values correlated significantly with corresponding chest radiograph scores (r = 0.71, P < 0.0001 for observer 1 and r = 0.68, P < 0.0001 for observer 2). Conclusions: EVLWI and PVPI may have a prognostic significance in the assessment of lung injury in septic shock patients with ARDS. Further research is required to reveal the usefulness of EVLWI as an end point of fluid resuscitation in the management of septic shock with ARDS.
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Effect of fat-based versus carbohydrate-based enteral feeding on glycemic control in critically ill patients: A randomized clinical trial p. 500
Mahdieh Nourmohammadi, Omid Moradi Moghadam, Mohammad Niakan Lahiji, Sevak Hatamian, Zahra Vahdat Shariatpanahi
DOI:10.4103/ijccm.IJCCM_118_17  
Background and Aims: The aim of this study was to evaluate the preventive effects of high-fat enteral feeding on glycemic control and clinical outcomes in critically ill patients: a randomized clinical trial. Materials and Methods: This study was done on 42 normoglycemic patients admitted to Intensive Care Unit (ICU). Patients were randomly classified into three groups of 14 each. Control group (A) received carbohydrate-based diet (protein: 20%, fat: 30%, and carbohydrate: 50%), study groups received two types of high-fat diet; Group B (protein: 20%, fat: 45% including half of olive oil and half sunflower oil, and carbohydrate: 35%); and Group C (protein: 20%, fat: 45% including sunflower oil, and carbohydrate: 35%) in the first 48 h of admission. Results: Basal characteristics of participants were the same. After the feeding trial, there was no difference between the groups in mean plasma and capillary glucose levels and insulin requirements. Serum high density lipoprotein (HDL)-cholesterol level was increased significantly in Group B on day 10 compared to admission level (40.75 ± 5.58 vs. 43.56 ± 2.25, P = 0.05). We did not find any difference in organ failure involvement and mortality rate between groups. The number of ICU free days was significantly more in Group B compared to the control group (P = 0.04). Conclusion: High-fat diets have no preventive effect on stress hyperglycemia. High monounsaturated fat diet may increase serum HDL-cholesterol level and decrease the length of stay in ICU.
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Association of massive transfusion for resuscitation in gastrointestinal bleeding with transfusion-related acute lung injury p. 506
James J Case, Nasreen Khan, Michael Delrahim, Jasmina Dizdarevic, Dane J Nichols, Martin A Schreiber, Thomas G Deloughery, Akram Khan
DOI:10.4103/ijccm.IJCCM_380_16  
Background and Aims: This study aimed to understand the use of massive transfusion (MT) for gastrointestinal bleeding (GIB). Patients and Methods: We performed a retrospective analysis of patients admitted to our medical Intensive Care Unit (ICU) with GIB for the type of bleeding, quantity of blood products transfused, and risk of transfusion-related acute lung injury (TRALI) and death. MT was defined as transfusion of 10 or more units of red blood cell (RBC) within a 24-h period in a 1-unit RBC: 1-unit fresh frozen plasma: and 1-unit platelet ratio. TRALI was defined as development of acute lung injury (ALI), within 6 h of transfusion, with new bilateral pulmonary infiltrates, absence of circulatory overload, or other explanation for ALI. Results: In a 43-month interval, 169 patients were admitted to the ICU with GIB and received blood products, of whom 13 received MT. Ten patients developed TRALI, of whom 7 (70%) had received MT. MT was associated with an increased risk of TRALI (odds ratio [OR]: 17.9, 95% confidence interval [CI]: 2.9–111.2, P = 0.002) after adjusting for age, sex, body mass index, baseline vitals, and laboratory data. Death was predicted by MT (OR: 5.6, 95% CI: 1.6–19.7, P = 0.007), TRALI (OR: 2.3, 95% CI: 1.1–4.6, P = 0.02), and Acute Physiologic Chronic Health Evaluation II score (OR: 1.17 per unit increase, 95% CI: 1.09–1.26, P < 0.001) after adjusting for age and sex. Conclusions: MT for GIB is associated with an increased risk of TRALI and death. Prospective studies assessing the use of MT in this population are needed to understand and improve outcomes.
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External validation of risk prediction scores for invasive candidiasis in a medical/surgical intensive care unit: An observational study p. 514
Armin Ahmed, Arvind Kumar Baronia, Afzal Azim, Rungmei S. K Marak, Reema Yadav, Preeti Sharma, Mohan Gurjar, Banani Poddar, Ratender Kumar Singh
DOI:10.4103/ijccm.IJCCM_33_17  
Background: The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. Methods: We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostrosky's clinical prediction rule (CPR). Patients' characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. Results: Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%–47%, along with negative predictive values (NPVs) in the range of 84%–96% in the subgroup analysis. Conclusion: Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy.
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REVIEW ARTICLE Top

Mathematics of ventilator-induced lung injury Highly accessed article p. 521
Ubaidur Rahaman
DOI:10.4103/ijccm.IJCCM_411_16  
Ventilator-induced lung injury (VILI) results from mechanical disruption of blood-gas barrier and consequent edema and releases of inflammatory mediators. A transpulmonary pressure (PL) of 17 cmH2O increases baby lung volume to its anatomical limit, predisposing to VILI. Viscoelastic property of lung makes pulmonary mechanics time dependent so that stress (PL) increases with respiratory rate. Alveolar inhomogeneity in acute respiratory distress syndrome acts as a stress riser, multiplying global stress at regional level experienced by baby lung. Limitation of stress (PL) rather than strain (tidal volume [VT]) is the safe strategy of mechanical ventilation to prevent VILI. Driving pressure is the noninvasive surrogate of lung strain, but its relations to PL is dependent on the chest wall compliance. Determinants of lung stress (VT, driving pressure, positive end-expiratory pressure, and inspiratory flow) can be quantified in terms of mechanical power, and a safe threshold can be determined, which can be used in decision-making between safe mechanical ventilation and extracorporeal lung support.
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BRIEF COMMUNICATIONS Top

Fecal carriage of extended-spectrum beta-lactamase-producing enterobacteriaceae in intensive care unit patients p. 525
Shalini Shenoy Mulki, Kavya Ramamurthy, Sevitha Bhat
DOI:10.4103/ijccm.IJCCM_112_17  
Background and Aims: Increasing and indiscriminate use of antibiotics has led the bacteria to develop resistance to most of the antibiotics. Beta-lactamase production is the mechanism of resistance to beta-lactams. Extended-spectrum beta-lactamases (ESBLs) have been found in the members of Enterobacteriaceae such as Escherichia coli and Klebsiella spp. which are the common health-care-associated pathogens. The aim was to study the rate of fecal carriage of ESBL-producing Enterobacteriaceae in patients admitted to the Intensive Care Unit (ICU) of tertiary care hospital and follow them subsequently for the development of infections. Materials and Methods: A hospital-based descriptive study was conducted in the department of microbiology of a tertiary care hospital for a period of 2 months from June 2016 to August 2016. Rectal swabs were collected from the patients admitted to the ICU after a period of 48 h. The swab was inoculated onto a special selective media (ChromID ESBL media). The results were noted according to the color of the colony produced. These patients are followed for the development of infection and the ESBL-producing organisms. Results: A total of 60 rectal swabs were cultured, 39 (65%) showed a positive result. Out of which, 22 (56%) were ESBL-producing E. coli and 17 (43%) Klebsiella spp. Twenty-three (38%) of the total patients screened were infected with ESBL-producing organisms. Conclusion: The study revealed high rates of carriage of ESBL producers in patients admitted to the ICU.
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Effectiveness of humidification with heat and moisture exchanger-booster in tracheostomized patients p. 528
Isabel Gonzalez, Pilar Jimenez, Jorge Valdivia, Antonio Esquinas
DOI:10.4103/ijccm.IJCCM_117_17  
Background: The two most commonly used types of humidifiers are heated humidifiers and heat and moisture exchange humidifiers. Heated humidifiers provide adequate temperature and humidity without affecting the respiratory pattern, but overdose can cause high temperatures and humidity resulting in condensation, which increases the risk of bacteria in the circuit. These devices are expensive. Heat and moisture exchanger filter is a new concept of humidification, increasing the moisture content in inspired gases. Aims: This study aims to determine the effectiveness of the heat and moisture exchanger (HME)-Booster system to humidify inspired air in patients under mechanical ventilation. Materials and Methods: We evaluated the humidification provided by 10 HME-Booster for tracheostomized patients under mechanical ventilation using Servo I respirators, belonging to the Maquet company and Evita 4. Results: There was an increase in the inspired air humidity after 1 h with the humidifier. Conclusion: The HME-Booster combines the advantages of heat and moisture exchange minimizing the negatives. It increases the amount of moisture in inspired gas in mechanically ventilated tracheostomized patients. It is easy and safe to use. The type of ventilator used has no influence on the result.
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CASE REPORTS Top

Temporary left ventricular pacing: A desperate life-saving measure in emergency situation p. 531
Ajaz Ahamad Lone, Mohd Iqbal Dar, Fayaz Ahamad Rather, Mohd Sultan Alai, Imran Hafiz, Jahangir Rashid Beigh
DOI:10.4103/ijccm.IJCCM_358_16  
Transcutaneous or transvenous pacing of the right ventricle is performed as a routine practice for patients received with symptomatic bradycardia or complete heart block with relative ease in cath lab. However, more and more patients are received with multiple comorbidities, critical condition, and difficult vascular access. In this article, we describe a patient with difficult venous access with tricuspid regurgitation and displaced the right ventricular pacemaker temporary lead undergoing coronary angiography who was managed with emergent nonconventional left ventricular pacing.
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Hemolytic-uremic syndrome complicating acute pancreatitis p. 534
Narinder Pal Singh, Neeru P Aggarwal, Hardik R Shah, Laxmi Kant Jha, Anish Kumar
DOI:10.4103/ijccm.IJCCM_121_17  
Hemolytic-uremic syndrome (HUS) is characterized by acute kidney injury with hemolytic anemia and thrombocytopenia. It has diverse etiologies, clinical manifestations, and risk factors. Acute pancreatitis as a cause of HUS is rare in adults. We report a case of 32-year-old male who presented with ethanol-induced acute pancreatitis complicated with hemolytic-uremic syndrome managed with hemodialysis and plasmapheresis.
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Hemodialysis for lactic acidosis p. 537
N Karthiraj, Nagarajan Ramakrishnan, Ashwin K Mani
DOI:10.4103/ijccm.IJCCM_167_17  
Lactic acidosis (Type A) is common in critically ill patients and usually treated by correcting the underlying etiology. We present the case of a young female who presented with life-threatening lactic acidosis secondary to hematological malignancy. Timely initiation of hemodialysis was lifesaving. The case highlights the importance of considering Type B lactic acidosis (in this case secondary to a hematological malignancy) and also initiating renal replacement therapy when routine measures are ineffective.
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LETTERS TO THE EDITOR Top

Thrombotic thrombocytopenic purpura or disseminated intravascular coagulation? p. 539
Ashok Kumar Pannu, Atul Saroch
DOI:10.4103/ijccm.IJCCM_174_17  
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Does N-acetyl cysteine have protective effects in acute aluminum phosphide poisoning? p. 539
Samaneh Nakhaee, Omid Mehrpour, Mahdi Balali-Mood
DOI:10.4103/ijccm.IJCCM_223_17  
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Dengue and thrombotic thrombocytopenic purpura p. 540
Viroj Wiwanitkit
DOI:10.4103/ijccm.IJCCM_217_17  
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Vitamin D deficiency in critically ill p. 541
Suresh Kumar Angurana, Vishal Guglani
DOI:10.4103/ijccm.IJCCM_224_17  
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