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   Table of Contents - Current issue
Coverpage
May 2017
Volume 21 | Issue 5
Page Nos. 253-337

Online since Tuesday, May 16, 2017

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RESEARCH ARTICLES  

Use of nutrition risk in critically ill (NUTRIC) score to assess nutritional risk in mechanically ventilated patients: A prospective observational study p. 253
MS Kalaiselvan, MK Renuka, AS Arunkumar
DOI:10.4103/ijccm.IJCCM_24_17  
Context: Nutritional risk assessment must be done on all critically ill patients. Malnutrition in intensive care unit (ICU) patients is associated with adverse clinical outcomes. Traditional scoring systems cannot be used for screening in mechanically ventilated (MV) patients because these patients are unable to provide information on their history of food intake and weight loss. The Nutrition Risk in Critically ill (NUTRIC) score is the appropriate nutritional assessment tool in MV patients. Aims: This prospective observational study was conducted to identify the nutritional risk in MV patients using modified NUTRIC (mNUTRIC) score (with the exception of interleukin-6). Patients and Methods: All adult patients admitted to the ICU and required MV for more than 48 h were included in the study. Data were collected on variables required to calculate mNUTRIC score. Patients with mNUTRIC score ≥5 are considered at nutritional risk. Outcome data were collected on ICU length of stay, ventilator-free days, and mortality. Results: A total of 678 MV patients fit into the inclusion criteria. Majority of the patients were male (67%). Mean age of the patients was 55 years. About 288 (42.5%) patients were at high nutritional risk (mNUTRIC score ≥5). Patients with high mNUTRIC score ≥5 had longer mean ICU average length of stay of 9.0 (±4.2) versus 7.8 (±5.8) mean (± standard deviation) days (P < 0.01) and higher mortality 41.4% versus 26.1% (P < 0.0) compared to patients with low NUTRIC score (≤4). High mNUTRIC score (≥5) predicted mortality with area under the curve of 0.582 (95% confidence interval 0.535-0.628). Conclusions: Nearly 42.5% of MV patients admitted to ICU were at nutritional risk, and high mNUTRIC score was associated with increased ICU length of stay and higher mortality.
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Reliability of ultrasonography in confirming endotracheal tube placement in an emergency setting p. 257
Vimal Koshy Thomas, Cherish Paul, Punchalil Chathappan Rajeev, Babu Urumese Palatty
DOI:10.4103/ijccm.IJCCM_417_16  
Background and Objectives: Over the past few years, ultrasonography is increasingly being used to confirm the correct placement of endotracheal tube (ETT). In our study, we aimed to compare it with the traditional clinical methods and the gold standard quantitative waveform capnography. Two primary outcomes were measured in our study. First was the sensitivity and specificity of ultrasonography against the other two methods to confirm endotracheal intubation. The second primary outcome assessed was the time taken for each method to confirm tube placement in an emergency setting. Methods: This is a single-centered, prospective cohort study conducted in an emergency department of a tertiary care hospital. We included 100 patients with indication of emergency intubation by convenient sampling. The intubation was performed as per standard hospital protocol. As part of the study protocol, ultrasonography was used to identify ETT placement simultaneously with the intubation procedure along with quantitative waveform capnography (end-tidal carbon dioxide) and clinical methods. Confirmation of tube placement and time taken for the same were noted by three separate health-care staffs. Results and Discussion: Out of the 100 intubation attempts, five (5%) had esophageal intubations. The sensitivity and specificity of diagnosis using ultrasonography were 97.89% and 100%, respectively. This was statistically comparable with the other two modalities. The time taken to confirm tube placement with ultrasonography was 8.27 ± 1.54 s compared to waveform capnography and clinical methods which were 18.06 ± 2.58 and 20.72 ± 3.21 s, respectively. The time taken by ultrasonography was significantly less. Conclusions: Ultrasonography confirmed tube placement with comparable sensitivity and specificity to quantitative waveform capnography and clinical methods. But then, it yielded results considerably faster than the other two modalities.
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A pilot randomized controlled trial of comparison between extended daily hemodialysis and continuous veno-venous hemodialysis in patients of acute kidney injury with septic shock p. 262
Shakti Bedanta Mishra, Afzal Azim, Narayan Prasad, Ratendra Kumar Singh, Banani Poddar, Mohan Gurjar, Arvind Kumar Baronia
DOI:10.4103/ijccm.IJCCM_85_17  
Aim of Study: Acute kidney injury (AKI) is common in patients of septic shock. There is sparse data comparing sustained low-efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT) in patients with septic shock. Materials and Methods: This is a prospective randomized study in a 12-bedded medical intensive care unit. After clearance from institute's ethics committee and obtaining informed consent from the relatives, sixty adult patients with septic shock who were to undergo dialysis for AKI were included in the study. They were randomly assigned to SLED or CRRT group. Hemodynamic instability was defined as in terms of vasopressor dependency (VD). The worst value of VD during the dialysis session was taken into consideration. The primary objective was look at hemodynamic changes and secondarily into the efficacy. Results: The demographic data were comparable between the sixty patients randomized to thirty in each group. Delta VD and delta vasopressor index (DVI) were similar in SLED group compared to the CRRT group. CRRT group had better efficacy in terms of both equivalent renal urea clearance though fluid balance was not significantly better in CRRT group. Conclusion: SLED is a viable modality of renal replacement therapy in patients with septic shock as the hemodynamic effects are similar to CRRT.
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Thromboelastography for evaluation of coagulopathy in nonbleeding patients with sepsis at intensive care unit admission p. 268
Syed Nabeel Muzaffar, Arvind Kumar Baronia, Afzal Azim, Anupam Verma, Mohan Gurjar, Banani Poddar, Ratender Kumar Singh
DOI:10.4103/ijccm.IJCCM_72_17  
Background: Thromboelastography (TEG) is a global test of coagulation which analyzes the whole coagulation process. TEG is popular in trauma, liver transplant, and cardiac surgeries, but studies in sepsis are limited. We have assessed the utility of TEG for evaluating coagulopathy in nonbleeding patients with sepsis. Materials and Methods: A prospective, observational study was done in 12-bedded Intensive Care Unit (ICU) of a tertiary care hospital in North India, during May 2014-November 2014. After ethical clearance, all patients at ICU admission with sepsis were included in the study. Exclusion criteria were age <18 years, plasma/platelet transfusion before admission, patients on oral antiplatelets/anticoagulants, or with underlying hematological disorders. At admission, blood samples for TEG were analyzed by kaolin-based TEG analyzer within an hour of collecting 2.7 ml citrated blood from arterial line. TEG parameters included reaction time (R), K time (K), alpha angle (a), maximum amplitude (MA), coagulation index (CI), and lysis index (LY 30). Results: In TEG, mean values of R, K, a, MA, CI, and LY30 were 6.45 ± 2.59 (min), 1.67 ± 0.96 (min), 66.37 ± 10.44 ( 0 ), 67.08 ± 10.33 (mm), 0.63 ± 3.46, and 2.23 ± 4.08 (%), respectively. In conventional coagulation assay (CCA), mean values of international normalized ratio (INR), platelet, and fibrinogen were 1.63 ± 0.57, 153.96 ± 99.16 (×10 3 /mm 3 ), and 301.33 ± 112.82 (mg/dl), respectively. In those with deranged INR (INR ≥1.6), 60% were normocoagulable and 20% were hypercoagulable. Similarly, 81% patients with thrombocytopenia (platelet count <1,00,000/mL) were normocoagulable. Conclusion: TEG could differentiate among normocoagulant, hypocoagulant, hypercoagulant states (unlike CCAs). Patients with septic shock had trend toward hypocoagulant state while those without shock had trend toward hypercoagulant state.
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The benefit of benzodiazepine reduction: Improving sedation in surgical intensive care p. 274
Ralph Schneider, Andreas Puetz, Timon Vassiliou, Thomas Wiesmann, Ulrike Lewan, Hinnerk Wulf, Detlef K Bartsch, Caroline Rolfes
DOI:10.4103/ijccm.IJCCM_67_17  
Aims: Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation. Methods: In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed. Results: Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128). Conclusions: The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.
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Hospital-acquired infection: Prevalence and outcome in infants undergoing open heart surgery in the present era p. 281
Manoj Kumar Sahu, Bharat Siddharth, Velayudham Devagouru, Sachin Talwar, Sarvesh Pal Singh, Shiv Chaudhary, Balram Airan
DOI:10.4103/ijccm.IJCCM_62_17  
Background: The aim of this study is to evaluate the causal relation between hospital-acquired infection (HAI) and clinical outcomes following cardiac surgery in neonates and infants and to identify the risk factors for the development of HAI in this subset of patients. Materials and Methods: After Ethics committee approval, one hundred consecutive infants undergoing open heart surgery (OHS) between June 2015 and June 2016 were included in this prospective observational study. Data were prospectively collected. The incidence and distribution of HAI, the microorganisms, their antibiotic resistance and patients' outcome were determined. The Centers for Disease Control and Prevention criteria were used for defining HAIs. Univariate and multivariate risk factor analysis was done using Stata 14. Results: Sixteen infants developed microbiologically documented HAI after cardiac surgery. Neonatal age group was found to be most susceptible. Lower respiratory tract infections accounted for majority of the infections (47.4%) followed by bloodstream infection (31.6%), urinary tract infection (10.5%), and surgical site infection (10.5%). Klebsiella (36.8%) and Acinetobacter (26.3%) were the most frequently isolated pathogens. HAI was associated with prolonged ventilation duration (P = 0.005), Intensive Care Unit stay (P = 0.0004), and hospital stay (P = 0.002). Multivariate risk factor analysis revealed that preoperative hospital stay (odds ratio [OR] 1.22, 95% confidence interval (CI) 1.6-1.39, P = 0.004), and prolonged cardiopulmonary bypass (CPB) (OR 1.03, 95% CI 1.01-1.05, P = 0.001) were associated with the development of HAI. Conclusion: HAI still remains a dreaded complication in infants after OHS and contributing to morbidity and mortality. Strategies such as decreasing preoperative hospital stay, CPB time, and early extubation should be encouraged to prevent HAI.
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The effect of high-dose parenteral sodium selenite in critically ill patients following sepsis: A clinical and mechanistic study p. 287
Legese Chelkeba, Arezoo Ahmadi, Mohammad Abdollahi, Atabak Najafi, Mohammad Hosein Ghadimi, Reza Mosaed, Mojtaba Mojtahedzadeh
DOI:10.4103/ijccm.IJCCM_343_16  
Introduction: Severe sepsis and septic shock is characterized by inflammation and oxidative stress. Selenium levels have been reported to be low due to loss or increased requirements during severe sepsis and septic shock. We investigated the effect of high-dose parenteral selenium administration in septic patients. Methods: A prospective, randomized control clinical trial was performed in septic patients. After randomization, patients in selenium group received high-dose parenteral sodium selenite (2 mg intravenous [IV] bolus followed by 1.5 mg IV continuous infusion daily for 14 days) plus standard therapy and the control group received standard therapy. The primary endpoint was mortality at 28 days. Changes in the mean levels of high mobility group box-1 (HMGB-1) protein and superoxide dismutase (SOD), duration of vasopressor therapy, incidence of acute renal failure, and 60 days' mortality were secondary endpoints. Results: Fifty-four patients were randomized into selenium group (n = 29) and control group (n = 25). There was no significant difference in 28-day mortality. No significant difference between the two groups with respect to the average levels of HMGB-1 protein and SOD at any point in time over the course of 14 days had observed. Conclusion: In early administration within the first 6 h of sepsis diagnosis, our study demonstrated that high-dose parenteral selenium administration had no significant effect either on 28-day mortality or the mean levels of HMGB-1 and SOD (Trial Registration: IRCT201212082887N4 at WHO Clinical Trial Registry, August 29, 2014).
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Critically ill obstetric patients in a general critical care unit: A 5 years' retrospective study in a public teaching hospital of Eastern India p. 294
Sugata Dasgupta, Tulika Jha, Priyojit Bagchi, Shipti Sradha Singh, Ramprasad Gorai, Sourav Das Choudhury
DOI:10.4103/ijccm.IJCCM_445_16  
Background: Critical care services are essential for the subset of obstetric patients suffering from severe maternal morbidity. Studies on obstetric critical care are important for benchmarking the issues which need to be addressed while managing critically ill obstetric patients. Although there are several published studies on obstetric critical care from India and abroad, studies from Eastern India are limited. The present study was conducted to fill in this lacuna and to audit the obstetric critical care admissions over a 5 years' period. Settings and Design: Retrospective cohort study conducted in the general critical care unit (CCU) of a government teaching hospital. Materials and Methods: The records of all obstetric patients managed in the CCU over a span of 5 years (January 2011-December 2015) were analyzed. Results: During the study, 205 obstetric patients were admitted with a CCU admission rate of 2.1 per 1000 deliveries. Obstetric hemorrhage (34.64%) was the most common primary diagnosis among them followed by pregnancy-induced hypertension (26.83%). Severe hemorrhage leading to organ failure (40.48%) was the main direct indication of admission. Invasive ventilation was needed in 75.61% patients, and overall obstetric mortality rate was 33.66%. The median duration (in days) of invasive ventilation was 2 (interquartile range [IQR] 1-7), and the median length of CCU stay (in days) was 5 (IQR 3-9). Conclusions: Adequate number of critical care beds, a dedicated obstetric high dependency unit, and effective coordination between critical care and maternity services may prove helpful in high volume obstetric centers.
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GUIDELINES Top

Management of potential organ donor: Indian Society of Critical Care Medicine: Position statement p. 303
Rahul Anil Pandit, Kapil G Zirpe, Sushma Kirtikumar Gurav, Atul P Kulkarni, Sunil Karnath, Deepak Govil, Babu Abhram, Yatin Mehta, Abinav Gupta, Ashit Hegde, Vijaya Patil, Pradip Bhatacharya, Subhal Dixit, Srinivas Samavedan, Subhash Todi
DOI:10.4103/ijccm.IJCCM_160_17  
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BRIEF COMMUNICATION Top

A study of 24 patients with colistin-resistant Gram-negative isolates in a tertiary care hospital in South India p. 317
Rajalakshmi Arjun, Ram Gopalakrishnan, P Senthur Nambi, D Suresh Kumar, R Madhumitha, V Ramasubramanian
DOI:10.4103/ijccm.IJCCM_454_16  
Background: As the use of colistin to treat carbapenem-resistant Gram-negative infections increases, colistin resistance is being increasingly reported in Indian hospitals. Materials and Methods: Retrospective chart review of clinical data from patients with colistin-resistant isolates (minimum inhibitory concentration >2 mcg/ml). Clinical profile, outcome, and antibiotics that were used for treatment were analyzed. Results: Twenty-four colistin-resistant isolates were reported over 18 months (January 2014-June 2015). A history of previous hospitalization within 3 months was present in all the patients. An invasive device was used in 22 (91.67%) patients. Urine was the most common source of the isolate, followed by blood and respiratory samples. Klebsiella pneumoniae constituted 87.5% of all isolates. Sixteen (66.6%) were considered to have true infection, whereas eight (33.3%) were considered to represent colonization. Susceptibility of these isolates to other drugs tested was tigecycline in 75%, chloramphenicol 62.5%, amikacin 29.17%, co-trimoxazole 12.5%, and fosfomycin (sensitive in all 4 isolates tested). Antibiotics that were used for treatment were combinations among the following antimicrobials-tigecycline, chloramphenicol, fosfomycin, amikacin, ciprofloxacin, co-trimoxazole, and sulbactam. Among eight patients who were considered to have colonization, there were no deaths. Bacteremic patients had a significantly higher risk of death compared to all nonbacteremic patients (P = 0.014). Conclusions: Colistin resistance among Gram-negative bacteria, especially K. pneumoniae, is emerging in Indian hospitals. At least one-third of isolates represented colonization only rather than true infection and did not require treatment. Among patients with true infection, only 25% had a satisfactory outcome and survived to discharge. Fosfomycin, tigecycline, and chloramphenicol may be options for combination therapy.
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CASE REPORTS Top

Titration of ideal positive end-expiratory pressure in acute respiratory distress syndrome: Comparison between lower inflection point and esophageal pressure method using volumetric capnography p. 322
Nandakishore Baikunje, Inderpaul Singh Sehgal, Sahajal Dhooria, Kuruswamy Thurai Prasad, Ritesh Agarwal
DOI:10.4103/ijccm.IJCCM_11_17  
The tenets of mechanical ventilation in acute respiratory distress syndrome (ARDS) include the utilization of low tidal volume and optimal application of positive end-expiratory pressure (PEEP). Optimal PEEP in ARDS is characterized by reduction in alveolar dead space along with improvement in the lung compliance and resultant betterment in oxygenation. There are various methods of setting PEEP in ARDS. Herein, we report a patient of ARDS, wherein we employed measurement of dead space using volumetric capnography to compare two different PEEP strategies, namely, the lower inflection point and transpulmonary pressure monitoring.
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Severe pediatric acute respiratory distress syndrome due to scrub typhus: Successful ventilation with airway pressure release ventilation mode after becoming refractory to protective ventilation p. 326
Sudha Chandelia, Sarika Jain
DOI:10.4103/ijccm.IJCCM_38_17  
Scrub typhus can affect lungs from mild illness like pneumonitis to a severe illness like acute respiratory distress syndrome (ARDS). Such patients may be very challenging to treat when their hypoxemia becomes severe and refractory to treatment. Main treatment is supportive in terms of mechanical ventilation. In adult ARDS, low tidal volume (TV) ventilation has been recommended, but there is no consensus on most effective ventilation mode in children. We present a case of a 12-year-old girl who developed severe ARDS (PO 2 /FiO 2 ratio - 58), refractory to low TV ventilation. There was a rapid improvement in oxygenation on the application of airway pressure release ventilation (APRV) mode within ΍ h. She was successfully ventilated and weaned off the ventilator over 5 days. This case highlights the utility of APRV mode of ventilation as a rescue therapy for severe refractory ARDS in children.
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Neurogenic pulmonary edema in traumatic brain injury p. 329
Ramanan Rajagopal, Swaminathan Ganesh, Muralidharan Vetrivel
DOI:10.4103/ijccm.IJCCM_431_16  
A 29-year-old male admitted with severe traumatic brain injury following a road traffic accident was sedated and ventilated uneventfully for 72 h. On the fourth posttrauma day, after stopping sedation to assess readiness for extubation, he developed sudden onset desaturation; arterial blood gas showed severe diffusion defect with very low PaO 2 /FiO 2 ratio following an episode of generalized tonic-clonic seizure. The differential diagnoses and further management are discussed.
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LETTERS TO THE EDITOR Top

Intentional self-harm human poisoning with agricultural micronutrient foliar spray: From rural India of Southern Karnataka p. 332
Srujitha Marupuru, Girish Thunga, Muralidhar Varma, Sudha Vidyasagar, Pranav Chandak, Sai Mounika Cherukuri
DOI:10.4103/ijccm.IJCCM_345_16  
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Overestimation of cardiac output by bent pulmonary artery catheter p. 333
Monish S Raut, Sibashankar Kar, Arun Maheshwari, Moloy Rajkhowa, Sumir Dubey, Ganesh Shivnani, Himanshu Arora
DOI:10.4103/ijccm.IJCCM_59_17  
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Trouble shooting a small sized IJV p. 335
Vikas Saini, Dinesh Kumar Sardana, Tanvir Samra, Sameer Sethi
DOI:10.4103/ijccm.IJCCM_398_16  
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ERRATUM Top

Erratum: Changes in B-type natriuretic peptide and related hemodynamic parameters following a fluid challenge in critically ill patients with severe sepsis or septic shock p. 337

DOI:10.4103/0972-5229.206320  
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