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   Table of Contents - Current issue
June 2017
Volume 21 | Issue 6
Page Nos. 343-413

Online since Thursday, June 15, 2017

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A retrospective study of physiological observation-reporting practices and the recognition, response, and outcomes following cardiopulmonary arrest in a low-to-middle-income country p. 343
Ambepitiyawaduge Pubudu De Silva, Jayasingha Arachchilage Sujeewa, Nirodha De Silva, Rathnayake Mudiyanselage Danapala Rathnayake, Lakmal Vithanage, Ponsuge Chathurani Sigera, Sithum Munasinghe, Abi Beane, Tim Stephens, Priyantha Lakmini Athapattu, Kosala Saroj Amarasiri Jayasinghe, Arjen M Dondorp, Rashan Haniffa
Background and Aims: In Sri Lanka, as in most low-to-middle-income countries (LMICs), early warning systems (EWSs) are not in use. Understanding observation-reporting practices and response to deterioration is a necessary step in evaluating the feasibility of EWS implementation in a LMIC setting. This study describes the practices of observation reporting and the recognition and response to presumed cardiopulmonary arrest in a LMIC. Patients and Methods: This retrospective study was carried out at District General Hospital Monaragala, Sri Lanka. One hundred and fifty adult patients who had cardiac arrests and were reported to a nurse responder were included in the study. Results: Availability of six parameters (excluding mentation) was significantly higher at admission (P < 0.05) than at 24 and 48 h prior to cardiac arrest. Patients had a 49.3% immediate return of spontaneous circulation (ROSC) and 35.3% survival to hospital discharge. Nearly 48.6% of patients who had ROSC did not receive postarrest intensive care. Intubation was performed in 46 (62.2%) patients who went on to have ROSC compared with 28 (36.8%) with no ROSC (P < 0.05). Defibrillation, performed in eight (10.8%) patients who had ROSC and eight (10.5%) in whom did not, was statistically insignificant (P = 0.995). Conclusions: Observations commonly used to detect deterioration are poorly reported, and reporting practices would need to be improved prior to EWS implementation. These findings reinforce the need for training in acute care and resuscitation skills for health-care teams in LMIC settings as part of a program of improving recognition and response to acute deterioration.
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A study of continuous renal replacement therapy and acute peritoneal dialysis in hemodynamic unstable patients p. 346
Ajay Jaryal, Sanjay Vikrant
Objective: The objective of the following study was to assess the outcome of continuous renal replacement therapy (CRRT) and acute peritoneal dialysis (PD) in dialysis-requiring renal failure in patients with hemodynamic instability. Materials and Methods: A retrospective analysis of all the patients who received CRRT and acute PD over a period of 1 year at our institute, a tertiary care center, was done for diagnosis, type of renal replacement therapy (RRT), and survival outcome. The indications for administering either of the therapy were usual indications of doing hemodialysis with the presence of hemodynamic instability (systolic blood pressure <90 mm of Hg even with inotropes). Results: Forty patients, 22 in CRRT and 18 in acute PD group were studied. All these patients required inotropes to maintain desired blood pressure. Twenty-five (62.5%) patients had acute kidney injury (AKI), and 15 (37.5%) had chronic kidney disease (CKD) superimposed over other primary diagnosis. A total of 8 (20%) patients (4 in CRRT, 4 in acute PD) survived at the time of discharge from hospital. The mean age of survivors was approximately a decade less than nonsurvivors (P = 0.15). Overall, there were no survivors in CKD group and all the patients who survived at the time of discharge from hospital had underlying AKI (P = 0.016). Conclusion: This study showing comparable survival outcome in acute PD and CRRT gives evidence that either of the modalities can be adopted in hemodynamically unstable patients requiring RRT depending on the resources available.
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Colistin nephrotoxicity in adults: Single centre large series from India p. 350
Abdul Ghafur, Swati Gohel, Vidyalakshmi Devarajan, T Raja, Jose Easow, MA Raja, Sankar Sreenivas, Balasubramaniam Ramakrishnan, T Ramakrishnan, SG Raman, Dedeepiya Devaprasad, Balaji Venkatachalam, Ramesh Nimmagadda
Context: Limited Indian data are available on the rate of colistin nephrotoxicity and other risk factors contributing to the development of this important side effect. Aim: This study aims to generate data on colistin nephrotoxicity from a large cohort of Indian patients. Design: Retrospective cohort study. Materials and Methods: Case record analysis of patients who received colistin, in an oncology center in India, between January 2011 and December 2015. Nephrotoxicity was assessed using risk, injury, failure, loss, and end-stage (RIFLE) criteria. Statistical Analysis: P < 0.05 was considered as statistically significant. Results: Out of the 229 patients, 13.1% (30/229) developed abnormal RIFLE. Abnormal RIFLE group (n = 30), in comparison to the normal renal function group (n = 199), had higher number of patients in intensive care unit (ICU) (96% vs. 79%, P = 0.02), higher Acute Physiology and Chronic Health Evaluation (APACHE II) score (23 vs. 19 P = 0.0001), Charlson score (5.9 vs. 4.3, P = 0.001), mechanical ventilation (90% vs. 67%, P = 0.016), 28 days mortality (63% vs. 25%, P = 0.0001), and abnormal baseline creatinine (36% vs. 8%, P = 0.001). Coadministration of vancomycin had higher rates of nephrotoxicity (P = 0.039). There was no significant difference in nephrotoxicity between 6 and 9 MU/day dosing pattern (8.8% vs. 13.8%, P = 0.058). Conclusion: Nephrotoxicity rate in our retrospective single center large series of patients receiving colistin was 13.1%. Patients with abnormal baseline creatinine, ICU stay, and higher disease severity are at higher risk of nephrotoxicity while on colistin. A daily dose of 9 million does not significantly increase nephrotoxicity compared to the 6 million. Concomitant administration of vancomycin with colistin increases the risk of nephrotoxicity.
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Continuous renal replacement therapy applications on extracorporeal membrane oxygenation circuit p. 355
Ayse Filiz Yetimakman, Murat Tanyildiz, Selman Kesici, Esra Kockuzu, Benan Bayrakci
Background and Aims: Continuous venovenous hemofiltration or hemodiafiltration is used frequently in pediatric patients, but experience of continuous renal replacement therapy (CRRT) application on extracorporeal membrane oxygenation (ECMO) circuit is still limited. Among several methods used for applying CRRT on ECMO patients, we aim to share our experience on inclusion of a CRRT device in the ECMO circuit which we believe is easier and safer to apply. Materials and Methods: The data were collected on demographics, outcomes, and details of the treatment of ECMO patients who had CRRT. During the study period of 3 years, venous cannula of ECMO circuit before pump was used for CRRT access for both the filter inlet and outlet of CRRT machine to minimize the thromboembolic complications. The common indication for CRRT was fluid overload. Results: CRRT was used in 3.68% of a total number of patients admitted and 43% of patients on ECMO. The patients have undergone renal replacement therapy for periods of time ranging between 24 h and 25 days (260 h mean). The survival rate of this group of patients with multiorgan failure was 33%. Renal recovery occurred in all of the survivors. Complications such as electrolyte imbalance, hypothermia, and bradykinin syndrome were easily managed. Conclusions: Adding a CRRT device on ECMO circuit is a safe and effective technique. The major advantages of this technique are easy to access, applying CRRT without extra anticoagulation process, preventing potential hemodynamic disturbances, and increased clearance of solutes and fluid overload using larger hemofilter.
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Quality of dying in the medical intensive care unit: Comparison between thai buddhists and thai muslims p. 359
Veerapong Vattanavanit, Supattra Uppanisakorn, Rungsun Bhurayanontachai, Bodin Khwannimit
Background and Aims: Religious belief is an important aspect that influences the life of a patient, especially in Asia. We aim to compare the quality of death in an Intensive Care Unit (ICU) between Buddhists and Muslims from the perspectives of the relatives of the patients and the nurses and physicians. Subjects and Methods: This was a cohort study of critically ill patients who died after admission to a medical ICU in Songklanagarind Hospital in Thailand between 2015 and 2016. We interviewed by telephone the relatives of patients. The nurses and physicians who cared for the patients responded to a self-questionnaire. Results: A total of 112 patients were enrolled in the study. The quality of death and dying-1 scores in Thai Buddhists and Muslim patients rated by the relatives (8 vs. 8, P = 0.55), nurses (8 vs. 8, P = 0.28), and physicians (7 vs. 7, P = 0.74) were not different. The ratings by the nurses correlated with the relatives (rs = 0.41, P < 0.001) but did not correlate with the physicians (rs = 0.15, P = 0.12). Compared with Buddhist patients, Muslim patients were more likely to have documentation in place at the time of the death of do not resuscitate (100% vs. 80.2%, P = 0.02) and withholding and withdrawing life support (100% vs. 80.2%, P = 0.02). Conclusion: There was no difference in the quality of dying and death between Thai Buddhists and Muslims. However, some elements of palliative care were not similar.
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Incidence proportion of acute cor pulmonale in patients with acute respiratory distress syndrome subjected to lung protective ventilation: A systematic review and meta-analysis Highly accessed article p. 364
Saurabh Kumar Das, Nang Sujali Choupoo, Priyam Saikia, Amitabh Lahkar
Introduction: Reported incidence of acute cor pulmonale (ACP) in patients with acute respiratory distress syndrome (ARDS) varies from 10% to 84%, despite being subjected to lung protective ventilation according to the current guidelines. The objective of this review is to find pooled cumulative incidence of ACP in patients with ARDS undergoing lung protective ventilation. Materials and Methods: We searched MEDLINE, EMBASE, Cochrane Library, KoreaMed, LILACS, and WHO Clinical Trial Registry. Cross-sectional or cohort studies were included if they reported or provided data that could be used to calculate the incidence proportion of ACP. Inverse variance heterogeneity (IVhet) and random effect model were used for the main outcome and measures. Results: We included 16 studies encompassing 1661 patients. The cumulative incidence of ACP using IVhet analysis was 23% (95% confidence interval [CI] = 18%–28%) over 3 days of lung protective ventilation. Random effect analysis of 7 studies (1250 patients) revealed pooled odd ratio of mortality of 1.16 (95% CI = 0.80-1.67, P = 0.44) due to ACP. Conclusion: Patients with ARDS have a 23% risk of developing ACP with lung protective ventilation. Findings of this review indicate the need of updating existing guidelines for ventilating ARDS patients to incorporate right ventricle protective strategy. PROSPERO registration number: CRD42017054688.
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Effect of calories delivered on clinical outcomes in critically ill patients: Systemic review and meta-analysis p. 376
Legese Chelkeba, Mojtaba Mojtahedzadeh, Zeleke Mekonnen
Introduction: International guidelines are promoting early enteral nutrition (EN) as a means of feeding critically ill adult patients to improve clinical outcomes. The question of how much calorie intake is enough to improve the outcomes still remained inconclusive. Therefore, we carried out a meta-analysis to evaluate the effect of low calorie (LC) versus high calorie (HC) delivery on critically ill patients' outcomes. Methods: We included randomized clinical trials (RCTs) that compared LC EN with or without supplemental parenteral nutrition with HC delivery in this meta-analysis irrespective of the site of nutritional delivery in the gastrointestinal tract. We searched PubMed, EMBASE, and Cochrane central register of controlled trials electronic databases to identify RCTs that compared the effects of initially different calorie intake in critical illness. The primary outcome was overall mortality. Results: This meta-analysis included 17 RCTs with a total of 3,593 participants. The result of analysis showed that there was no significant difference between the LC group and HC group in overall mortality (risk ratio [RR], 0.98; 95% confidence interval [CI], 0.87–1.10; P = 0.74; I2 = 6%; P = 0.38), or new-onset pneumonia (RR, 0.92; 95% CI, 0.73–1.16, P = 0.46; I2 = 38%, P = 0. 11). Conclusion: The current meta-analysis showed that there was no significant difference in mortality of critically ill patients initially between the two groups.
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Fatal postoperative hemolysis due to severe falciparum malaria p. 391
Amol T Kothekar, Vijaya Patil, Nambiraj Konar, Jigeeshu Divatia
A 60-year-old apparently healthy female patient underwent mastectomy for breast cancer. She had sinus tachycardia and no other abnormal finding in the preoperative period. However, the immediate postoperative course was stormy with the development of anemia, thrombocytopenia, hemolysis, and renal failure with severe metabolic acidosis. Peripheral blood smear revealed the presence of ring forms of Plasmodium falciparum. Multiorgan failure and death occurred within 36 h of surgery in spite of initiation of antimalarial agents. Diagnosis of malaria should be kept in mind in the event of development of sudden unexplained deterioration or multiorgan dysfunction associated with thrombocytopenia, hemolysis, and severe metabolic acidosis, even in previously asymptomatic patients, especially in residents or recent travelers of the malaria-endemic area.
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Rare presentation of congenital diaphragmatic hernia in a sexagenarian p. 394
C Danny Darlington, G Fatima Shirly Anitha
Congenital diaphragmatic hernia (CDH) usually presents in the neonatal period, and about 10% of reported cases occur in adults. The most common type is Bochdalek's hernia, which occurs through a defect in the posterolateral portion of the diaphragm with an estimated prevalence of 1 in 2500 live births. CDH in adults presents with gastrointestinal or respiratory symptoms, which can be acute or intermittent. We report a case of CDH diagnosed in a 55-year-old man, who presented with acute onset of chest pain and dyspnea with insignificant past history. This patient was initially evaluated medically for myocardial infarction followed by intercostal chest drainage placement, before a definitive diagnosis of CDH was made. This case is reported for its rarity and to highlight the high index of suspicion needed to diagnose CDH in adulthood. This is specially important as CDH, masquerades as other acute conditions in older individuals thereby delaying the diagnosis.
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Melioidosis: An emerging infection with fatal outcomes p. 397
Isabella Princess, R Ebenezer, Nagarajan Ramakrishnan, Arun Kumar Daniel, S Nandini, MA Thirunarayan
According to the Centers for Disease Control and Prevention, from being nonendemic for melioidosis, India has now become endemic for the disease since 2012. Until then, melioidosis cases were being reported sporadically from India. There have been isolated case reports from few states across the country for the past few years. Most of the times, Burkholderia pseudomallei may be misreported as Pseudomonas species, especially in resource-poor laboratories. Due to its varied clinical presentation, the specific clinical diagnosis can be difficult, thereby making laboratory diagnosis mandatory. This could make a huge impact on patient care as this organism has a different treatment protocol as well as virulence determinants which influence the course of management. Although known for its endemicity in Australia, Thailand, and other Southeast Asian countries, B. pseudomallei has emerged in new areas such as India, Southern China, Brazil, and Malawi. We present a rare case of melioidosis with rapid disease progression to fatal outcome from Chennai, South India.
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Metatarsal fracture leading to massive pulmonary embolism p. 401
Vikas Rajpurohit, Prateek Tejvir, Neelam Meena, Kailash Mittal
Immobilization and bed rest after fracture and orthopedic surgery are routinely advised protocol. Period of bed rest usually depends on the type of injury and orthopedic procedure, ranging from few days to weeks. The trauma, surgery, and immobilization with other contributing factors can lead to deep vein thrombosis and pulmonary embolism (PE) in these patients. Although there is high incidence of PE in such patients, it is difficult to diagnose, primarily because of the variety of nonspecific signs and symptoms. Here, we discuss a case of a 30-year-old female, who had suffered a trivial roadside accident leading to metatarsal bone fracture and later on presented in emergency with seizures, pulmonary edema, and cardiac arrest, after immobilization of just 5 days which was diagnosed to be result of massive PE. Here, we will discuss the pathophysiology, risk factors, and management of massive PE.
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Blunt trauma neck with complete tracheal transection a diagnostic and therapeutic challenge to the trauma team p. 404
K. N. J Prakash Raju, D Anandhi, R Surendar, Ashwith Shetty, Vinay R Pandit
Survival following trachea-esophageal transection is uncommon. Establishing a secure airway has the highest priority in trauma management. Airway management is a unique and a defining element to the specialty of emergency medicine. There is no doubt regarding the significance of establishing a patent airway in the critically ill patient in the emergency department. Cannot intubate and cannot ventilate situation is a nightmare to all emergency physicians. The most important take-home message from this case report is that every Emergency physician should have the ability to predict “difficult airway” and recognize “failed airway” very early and be skilled in performing rescue techniques when routine oral-tracheal intubation fails. Any delay at any step in the “failed airway” management algorithm may not save the critically ill dying patient. Here, we report a case of blunt trauma following high-velocity road traffic accident, presenting in the peri-arrest state, in whom we noticed “failed airway” which turned out to be due to complete tracheal transection. In our patient, although we had secured the airway immediately, he had already sustained hypoxic brain damage. This scenario emphasizes the importance of prehospital care in developing countries.
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Invasive mediastinal Aspergillosis in immunocompetent male with invasion of left atrium and hilar structures p. 408
Munta Kartik, Arun Kanala, Sunilnadikuda , S Manimala Rao, P Swathi Prakasham
Aspergillus is described as mould characterised by septate hyphae about 2-4μ in diameter, it is ubiquitous in nature and spreads by inhalation of spores. It causes opportunistic infections in almost six forms namely Allergic bronchopulmonary aspergillosis, Aspergillus sinusitis, Cutaneous aspergillosis, Aspergilloma, Chronic pulmonary aspergillosis, Invasive aspergillosis. Invasive aspergillosis of mediastinum in an immunocompetent patient has rarely been reported. We present a case of a young male who had presented with chest pain, cough and breathleness was later diagnosed as fulminant mediastinal aspergillosis. Incisional biopsy with histology report and endotracheal cultures helped in diagnosing mediastinal aspergillosis. Despite initiation of the right antifungal therapy and best supportive measures, patient died of septic shock and multiorgan dysfunction. This case report highlights the need for higher suspicion in such cases of mediastinal masses and early tissue biopsy which can help in reducing mortality.
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Awareness of allergic angina syndrome p. 412
Monish S Raut, Sibashankar Kar, Arun Maheshwari
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