Indian Journal of Critical Care Medicine
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   Table of Contents - Current issue
August 2014
Volume 18 | Issue 8
Page Nos. 489-551

Online since Tuesday, August 05, 2014

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Scrub typhus: Emerging cause of multiorgan dysfunction p. 489
Narendra Rungta
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Noninvasive ventilation success: Combining knowledge and experience p. 492
P Saxena, RK Mani
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Optimum positive end-expiratory pressure 40 years later p. 494
Laurent Brochard, Lu Chen, Ewan Goligher
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Profile of organ dysfunction and predictors of mortality in severe scrub typhus infection requiring intensive care admission p. 497
Mathew Griffith, John Victor Peter, Gunasekaran Karthik, Kartik Ramakrishna, John Antony Jude Prakash, Rajamanickam C Kalki, George M Varghese, Anugragh Chrispal, Kishore Pichamuthu, Ramya Iyyadurai, Ooriapadickal Cherian Abraham
Background and Aims: Scrub typhus, a zoonotic rickettsial infection, is an important reason for intensive care unit (ICU) admission in the Indian subcontinent. We describe the clinical profile, organ dysfunction, and predictors of mortality of severe scrub typhus infection. Materials and Methods: Retrospective study of patients admitted with scrub typhus infection to a tertiary care university affiliated teaching hospital in India during a 21-month period. Results: The cohort (n = 116) aged 40.0 ± 15.2 years (mean ± SD), presented 8.5 ± 4.4 days after symptom onset. Common symptoms included fever (100%), breathlessness (68.5%), and altered mental status (25.5%). Forty-seven (41.6%) patients had an eschar. Admission APACHE-II score was 19.6 ± 8.2. Ninety-one (85.2%) patients had dysfunction of 3 or more organ systems. Respiratory (96.6%) and hematological (86.2%) dysfunction were frequent. Mechanical ventilation was required in 102 (87.9%) patients, of whom 14 (12.1%) were solely managed with non-invasive ventilation. Thirteen patients (11.2%) required dialysis. Duration of hospital stay was 10.7 ± 9.7 days. Actual hospital mortality (24.1%) was less than predicted APACHE-II mortality (36%; 95% Confidence interval 32-41). APACHE-II score and duration of fever were independently associated with mortality on logistic regression analysis. Conclusions: In this cohort of severe scrub typhus infection with multi-organ dysfunction, survival was good despite high severity of illness scores. APACHE-II score and duration of fever independently predicted mortality.
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Noninvasive ventilation: Are we overdoing it? p. 503
Sankalp Purwar, Ramesh Venkataraman, R Senthilkumar, Nagarajan Ramakrishnan, Babu K Abraham
Background: Use of noninvasive ventilation (NIV) outside guideline recommendations is common. We audited use of NIV in our tertiary care critical care unit (CCU) to evaluate appropriateness of use and patient outcomes when used outside level I recommendations. Materials and Methods: Prospective observational study of all patients requiring NIV. Clinical parameters and arterial blood gases were recorded at initiation of NIV and 2 h later (or earlier if clinically warranted). NIV titration and decision to intubate were left to the discretion of treating intensivist. Patients were categorized into two groups: Group 1: Those with level I indications for use of NIV and group 2: All other levels of indications. Patients were followed until hospital discharge. Results: From January 2010 to June 2010, 1120 patients were admitted to the CCU. Of these 106 patients required NIV support with 40.6% (n = 43/106) being in group 1 and 59.4% (n = 63/106) in group 2. Of these 35.8% patients (38/106) failed NIV and required endotracheal intubation. NIV failure rates (41.27% vs. 27.91%; P = 0.02) and mortality (30.6% vs. 18.6%; P = 0.03) were significantly higher in group 2 patients. In a logistic regression analysis Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.02), time on NIV before intubation (P = 0.001) and baseline PaCO 2 levels (P = 0.01) were strongly associated with mortality. Conclusion: Noninvasive ventilation failure and mortality rates were significantly higher when used outside level I recommendations. APACHE II score, baseline PaCO 2 and duration on NIV prior to intubation were predictors of increased mortality.
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Compliance versus dead space for optimum positive end expiratory pressure determination in acute respiratory distress syndrome p. 508
Ghada Fouad El-Baradey, Nagat Sayed El-Shamaa
Objective: To Compare compliance versus dead space (Vd) targeted positive end-expiratory pressure (PEEP) as regard its effect on lung mechanics and oxygenation. Materials and Methods: This study was carried out on 30 adult acute respiratory distress syndrome patients. The ventilator was initially set on volume controlled with tidal volume (Vt) 7 mL/kg predicted body weight (PBW), inspiratory plateau pressure (Ppl) <30 cm H 2 O. If the Ppl was >30 cm H 2 O with a TV of 6 mL/kg PBW, a step-wise Vt reduction of 1 mL/kg PBW to as low as 4 mL/kg/PBW was allowed. Respiratory rate adjusted to maintain pH 7.30-7.45. FiO 2 start at 100%. Best PEEP determined at 2 points, one by titrating PEEP until reaching the highest static compliance (Cst) (PEEP Cst) and the other one is at the lowest Vd/Vt (PEEP Vd/Vt). The following data measured before and 30 min after setting PEEP Cst and PEEP Vd/Vt. Cst, PaCO 2 - PetCO 2 , Vd/Vt, PaO 2 /FiO 2 , Ppl, heart rate, mean arterial pressure and oxygen saturation. Results: optimum PEEP determined by Vd/Vt was significantly (P < 0.05) lower than the optimum PEEP determined by Cst. Best PEEP Vd/Vt showed a significant decrease (P < 0.05) in Cst, PaCO 2 - PetCO 2, Vd/Vt and Ppl in comparison with best PEEP Cst. The PaO 2 /FiO 2 showed a significant increase (P < 0.05) with best PEEP Vd/Vt in comparison with best PEEP Cst. Conclusion: Vd guided PEEP improved compliance and oxygenation with less Ppl. Hence, its use as a guide for best PEEP determination may be useful.
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Funding sources for continuing medical education: An observational study p. 513
Ramesh Venkataraman, Lakshmi Ranganathan, Arun S Ponnish, Babu K Abraham, Nagarajan Ramakrishnan
Aims: Medical accreditation bodies and licensing authorities are increasingly mandating continuing medical education (CME) credits for maintenance of licensure of healthcare providers. However, the costs involved in participating in these CME activities are often substantial and may be a major deterrent in obtaining these mandatory credits. It is assumed that healthcare providers often obtain sponsorship from their institutions or third party payers (i.e. pharmaceutical-industry) to attend these educational activities. Data currently does not exist exploring the funding sources for CME activities in India. In this study, we examine the relative proportion of CME activities sponsored by self, institution and the pharmaceutical-industry. We also wanted to explore the characteristics of courses that have a high proportion of self-sponsorship. Materials and Methods: This is a retrospective audit of the data during the year 2009 conducted at an autonomous clinical training academy. The details of the sponsor of each CME activity were collected from an existing database. Participants were subsequently categorized as sponsored by self, sponsored by institution or sponsored by pharmaceutical-industry. Results: In the year 2009, a total of 2235 participants attended 40 different CME activities at the training academy. Of the total participants, 881 (39.4%) were sponsored by self, 898 (40.2%) were sponsored by institution and 456 (20.3%) by pharmaceutical-industry. About 47.8% participants attended courses that carried an international accreditation. For the courses that offer international accreditation, 63.3% were sponsored by self, 34.9% were sponsored by institution and 1.6% were sponsored by pharmaceutical-industry. There were 126 participants (5.6%) who returned to the academy for another CME activity during the study period. Self-sponsored (SS) candidates were more likely to sponsor themselves again for subsequent CME activity compared with the other two groups (P < 0.001). Conclusions: In our study, majority of healthcare professionals attending CME activities were either self or institution sponsored. There was a greater inclination for self-sponsoring for activities with international accreditation. SS candidates were more likely to sponsor themselves again for subsequent CME activities.
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Pediatric acute kidney injury: A syndrome under paradigm shift p. 518
Mohd Ashraf, Naveed Shahzad, Mohd Irshad, Sheikh Quyoom Hussain, Parvez Ahmed
The recent standardization and validation of definitions of pediatric acute kidney injury (pAKI) has ignited new dimensions of pAKI epidemiology and its risk factors. pAKI causes increased morbidity and mortality in critically ill-children. Among the hospitalized patients incidence of pAKI ranges from 1% to 31%, while mortality ranges from 28% to 82%, presenting a broad range due to lack of uniformly acceptable pAKI definition. In addition, cumulative data regarding the progression of pAKI to chronic kidney disease in children is rising. Despite these alarming figures, treatment modalities have failed to deliver significantly. In this review, we will summarize the latest developments of pAKI and highlight important aspects of pAKI management.
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Hyperkalemic paralysis in primary adrenal insufficiency p. 527
Ajay Mishra, Himanshu V Pandya, Nikhil Dave, Chinmaye M Sapre, Sneha Chaudhary
Hyperkalemic paralysis due to Addison's disease is rare, and potentially life-threatening entity presenting with flaccid motor weakness. This case under discussion highlights Hyperkalemic paralysis as initial symptomatic manifestation of primary adrenal insufficiency.
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Successful use of sustained low efficiency dialysis in a case of severe phenobarbital poisoning p. 530
Sayandeep Jana, Chandrashish Chakravarty, Abhijit Taraphder, Suresh Ramasubban
A 30-year-old female presented with coma and subsequent cardiac arrest caused by phenobarbital overdosage, requiring ventilatory and vasopressor support. She had also developed severe hypoxia following gastric aspiration. Initial therapy, including activated charcoal and forced alkaline diuresis, failed to significantly lower her drug levels and there was minimal neurological improvement. As she was hemodynamically unstable, and unsuitable for conventional dialysis, she was put on sustained low efficiency dialysis (SLED) to facilitate drug removal. SLED resulted in marked reduction in plasma level of phenobarbital, which eventually led to early extubation, improved cognition and aided full recovery. Thus, we concluded that SLED can be an effective alternative in cases of severe phenobarbital poisoning, where conventional hemodialysis or hemoperfusion cannot be initiated, to hasten drug elimination and facilitate early recovery.
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An unusual cause of gastrointestinal bleed p. 533
CK Adarsh, Ravi Kiran, Mallikarjun
Gastrointestinal (GI) bleed often brings the patient to the emergency medical service with great anxiety. Known common causes of GI bleed include ulcers, varices, Mallory-Weiss among others. All causes of GI bleed should be considered however unusual during the evaluation. Aortoenteric fistula (AEF) is one of the unusual causes of GI bleed, which has to be considered especially in patients with a history of abdominal surgery in general and aortic surgery in particular.
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Spontaneous cryptococcal peritonitis with fungemia in patients with decompensated cirrhosis: Report of two cases p. 536
Chinmaya Kumar Bal, Vikram Bhatia, Vikas Khillan, Neha Rathor, Deepak Saini, Ripu Daman, Shiv Kumar Sarin
Cryptococcus neoformans is encapsulated yeast that predominately infects immunocompromised individuals. Liver disease is an under-recognized predisposition for cryptococcal disease. We report two nonalcoholic, nondiabetic, and human immunodeficiency virus - negative cirrhotic patients, with spontaneous cryptococcal peritonitis. Cryptococcus infection was diagnosed by culture of ascitic fluid and peripheral blood in both. We treated the first patient with amphotericin-B, but he expired. The second patient with earlier diagnosis, survived to discharge with fluconazole treatment. We suggest a high clinical suspicion for Cryptococcus as a possible etiology of spontaneous peritonitis in cirrhotic patients.
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Deep vein thrombosis of upper extremities due to reactive thrombocytosis in septic patients p. 540
Shakti Bedanta Mishra, Jashwini Bhoyer, Mohan Gurjar, Nabeel Muzaffar, Anupam Verma
Deep venous thrombosis (DVT) is not an uncommon condition in the intensive care unit (ICU), and having high morbidity and mortality. Upper limb DVT also is increasingly being recognized as a clinical entity. The presence of the indwelling catheter in neck veins is a risk for developing venous thrombus, which may be further aggravated by presence of thrombocytosis. In ICU patients with sepsis, reactive thrombocytosis has been found during the recovery phase. Here, we are presenting two cases, having thrombocytosis and central venous catheter who developed upper limb DVT.
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Multinodular goiter with retrosternal extension causing airway obstruction: Management in intensive care unit and operating room p. 543
Ravi Madhusudhana, B.R. Krishna Kumar, N Suresh Kumar, RB Rakesh, KR Archana, BG Harish
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Management of snake bite victims in a Tertiary Care Intensive Care Unit in North India p. 544
Vikas Saini, Dinesh Sardana, Tanvir Samra
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Ofloxacin-induced toxic epidermal necrolysis p. 545
Gaurang Gupta
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Internal jugular vein thrombosis from rhino-cerebral mucormycosis: Be careful before cannulation p. 546
Rinoy Chandran, Pallavi Mishra, DK Pawar, Souvik Maitra, Jineesh Valakkada
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Vasovagal syncope during spirometric exercise p. 548
Monish S Raut, Arun Maheshwari
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Acute epiglottitis from corrosive ingestion p. 548
Vinod Vishwanath Kolar, Srikant Sadashivan, Siddarth Muralidharan
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Application of rapid ultrasound in shock protocol in the ICU for management of shock p. 550
Srishti S Jain, Kedar K Toraskar, Azizullah H Khan, Yunus S Loya
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Corrigentum p. 551
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