Indian Journal of Critical Care Medicine
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   Table of Contents - Current issue
December 2014
Volume 18 | Issue 12
Page Nos. 771-834

Online since Friday, December 05, 2014

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Critical care of elderly in India: Coming of age? p. 771
Palepu B Gopal
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Endotoxin hemadsorption in septic shock p. 773
Jamshed D Sunavala, Joanne M Mascarenhas
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Do we need a protocol for weaning patients from noninvasive ventilation? p. 775
Gopi C Khilnani, Neetu Jain
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Griggs percutaneous tracheostomy without bronchoscopic guidance is a safe method: A case series of 300 patients in a tertiary care Intensive Care Unit p. 778
Saroj Kumar Pattnaik, Banambar Ray, Sharmili Sinha
Introduction: Percutaneous tracheostomy (PCT) is being increasingly done by intensivists for critical care unit patients requiring either prolonged ventilation and/or for airway protection. [1] Bronchoscopic guidance considered a gold standard, [2],[3] is not always possible due to logistic reasons and ventilation issues. We share our experience of Griggs PCT technique without bronchoscopic guidance with simple modifications to ensure safe execution of the procedure. Objective: The purpose of this study was to evaluate the safety issues and complications of PCT without bronchoscopic guidance in a multi-disciplinary tertiary Intensive Care Unit (ICU). Materials and Methods: A retrospective review of consecutive PCTs performed in our ICU between August 2010 and December 2013 by Griggs guide wire dilating forceps technique without bronchoscopic guidance is being presented. It is done by withdrawing endotracheal tube with inflated cuff while monitoring expired tidal volume on ventilator and ensuring the free mobility of guide wire during each step of the procedure, thereby ensuring a safe placement of the tracheostomy tube (TT) in trachea. Results: Analysis of 300 PCTs showed 26 patients (8.6%) had complications including 2 (0.6%) patients deteriorated neurologically and 2 (0.6%) deaths observed within 24 h following procedure. The median operating time was 3.5 min (range, 2.5-8 min). There were no TT placement problems in any case. Conclusion: Percutaneous tracheostomy can be safely performed without bronchoscopic guidance by adhering to simple steps as described.
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Alteco endotoxin hemoadsorption in Gram-negative septic shock patients p. 783
Hoi Ping Shum, Yuk Wah Leung, Sin Man Lam, King Chung Chan, Wing Wa Yan
Background and Aims: Severe sepsis and septic shock are common causes of mortality and morbidity in an intensive care unit setting. Endotoxin, derived from the outer membranes of Gram-negative bacteria, is considered a major factor in the pathogenesis of sepsis. This study investigated the effect of Alteco endotoxin hemoadsorption device on Gram-negative septic shock patients. Materials and Methods: An open, controlled, prospective, randomized, single-center trial was conducted between February 2010 and June 2012. Patients with septic shock due to intra-abdominal sepsis were randomized to either conventional therapy (n = 8) or conventional therapy plus two 2-hourly sessions of Alteco endotoxin hemoadsorption (n = 7). Primary endpoint was the Sequential Organ Failure Assessment (SOFA) score changes from 0 to 72 h. Secondary end points included vasopressor requirement, PaO 2 /FiO 2 ratio (PFR), length of stay (LOS), and 28-day mortality. Results: This study was terminated early as interim analysis showed a low probability of significant findings. No significant difference was noted between the two groups with respect to change in SOFA score, vasopressor score, PFR, LOS, and 28-day mortality. Side-effect was minimal. Conclusions: We could not identify any clinical benefit on the addition of Alteco endotoxin hemoadsorption to conventional therapy in patients who suffered from intra-abdominal sepsis with shock. The side effect profile of this novel device was acceptable.
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Do Intensive Care Unit treatment modalities predict mortality in geriatric patients: An observational study from an Indian Intensive Care Unit p. 789
Kanwalpreet Sodhi, Manender Kumar Singla, Anupam Shrivastava, Namita Bansal
Background: Ageing being a global phenomenon, increasing number of elderly patients are admitted to Intensive Care Units (ICU). Hence, there is a need for continued research on outcomes of ICU treatment in the elderly. Objectives: Examine age-related difference in outcomes of geriatric ICU patients. Analyze ICU treatment modalities predicting mortality in patients >65 years of age. Materials and Methods: A retrospective observational study was conducted in 2317 patients admitted in a multi-specialty ICU of a tertiary care hospital over 2-year study period from January 1, 2011 to December 31, 2012. A clinical database was collected which included age, sex, specialty under which admitted, APACHE-II and SOFA scores, patient outcome, average length of ICU stay, and the treatment modalities used in ICU including mechanical ventilation, inotropes, hemodialysis, and tracheostomy. Patients were divided into two groups: <65 years (Control group) and >65 years (Geriatric age group). Results: The observed overall ICU mortality rate in the study population was 19.6%; no statistical difference was observed between the control and geriatric age group in overall mortality (P > 0.05). Mechanical ventilation (P = 0.003, odds ratio [OR] =0.573, 95% confidence interval [CI] =0.390-0.843) and use of inotropes (P = 0.018, OR = 0.661, 95% CI = 0.456-0.958) were found to be predictors of mortality in elderly population. On multivariate analysis, inotropic support was found to be an independent ICU treatment modality predicting mortality in the geriatric age group (β coefficient = 1.221, P = 0.000). Conclusion: Intensive Care Unit mortality rates increased in the geriatric population requiring mechanical ventilation and inotropes during ICU stay. Only inotropic support could be identified as independent risk factor for mortality.
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Drug-induced anaphylactic reactions in Indian population: A systematic review p. 796
Tejas K Patel, Parvati B Patel, Manish J Barvaliya, CB Tripathi
Background: Epidemiological data on drug-induced anaphylactic reactions are limited in India and are largely depending on studies from developed countries. Aim: The aim was to analyze the published studies of drug-induced anaphylaxis reported from India in relation with causative drugs and other clinical characteristics. Materials and Methods: The electronic databases were searched for Indian publications from 1998 to 2013 describing anaphylactic reactions. The information was collected for demographics, set up in which anaphylaxis occurred, causative drugs, incubation period, clinical features, associated allergic conditions, past reactions, co-morbid conditions, skin testing, IgE assays, therapeutic intervention and mortality. Reactions were analyzed for severity, causality, and preventability. Data were extracted and summarized by absolute numbers, mean (95% confidence interval [CI]), percentages and odds ratio (OR) (95% CI). Results: From 3839 retrieved references, 52 references describing 54 reactions were included. The mean age was 35.31 (95% CI: 30.52-40.10) years. Total female patients were 61.11%. Majority reactions were developed in perioperative conditions (53.70%), ward (20.37%) and home (11.11%). The major incriminated groups were antimicrobials (18.52%), nonsteroidal antiinflammatory drugs-(NSAIDs) (12.96%) and neuromuscular blockers (12.96%). Common causative drugs were diclofenac (11.11%), atracurium (7.41%) and β-lactams (5.96%). Cardiovascular (98.15%) and respiratory (81.48%) symptoms dominated the presentation. Skin tests and IgE assays were performed in 37.03% and 18.52% cases, respectively. The fatal cases were associated with complications (OR =5.04; 95% CI: 1.41-17.92), cerebral hypoxic damage (OR =6.80; 95% CI: 2.14-21.58) and preventable reactions (OR =14.33; 95% CI: 2.33-87.97). Conclusion: Antimicrobials, NSAIDs, and neuromuscular blockers are common causative groups. The most fatal cases can be prevented by avoiding allergen drugs.
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The benefits of tight glycemic control in critical illness: Sweeter than assumed? p. 807
Andrew John Gardner
Hyperglycemia has long been observed amongst critically ill patients and associated with increased mortality and morbidity. Tight glycemic control (TGC) is the clinical practice of controlling blood glucose (BG) down to the "normal" 4.4-6.1 mmol/L range of a healthy adult, aiming to avoid any potential deleterious effects of hyperglycemia. The ground-breaking Leuven trials reported a mortality benefit of approximately 10% when using this technique, which led many to endorse its benefits. In stark contrast, the multi-center normoglycemia in intensive care evaluation-survival using glucose algorithm regulation (NICE-SUGAR) trial, not only failed to replicate this outcome, but showed TGC appeared to be harmful. This review attempts to re-analyze the current literature and suggests that hope for a benefit from TGC should not be so hastily abandoned. Inconsistencies in study design make a like-for-like comparison of the Leuven and NICE-SUGAR trials challenging. Inadequate measures preventing hypoglycemic events are likely to have contributed to the increased mortality observed in the NICE-SUGAR treatment group. New technologies, including predictive models, are being developed to improve the safety of TGC, primarily by minimizing hypoglycemia. Intensive Care Units which are unequipped in trained staff and monitoring capacity would be unwise to attempt TGC, especially considering its yet undefined benefit and the deleterious nature of hypoglycemia. International recommendations now advise clinicians to ensure critically ill patients maintain a BG of <10 mmol/L. Despite encouraging evidence, currently we can only speculate and remain optimistic that the benefit of TGC in clinical practice is sweeter than assumed.
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Challenges in management of blast injuries in Intensive Care Unit: Case series and review p. 814
Tanvir Samra, Mridula Pawar, Jasvinder Kaur
Blast injuries are rare, but life-threatening medical emergencies. We report the clinical presentation and management of four bomb blast victims admitted in Intensive Care Unit of Trauma center of our hospital in 2011. Three of them had lung injury; hemothorax (2) and pneumothorax (1). Traumatic brain injury was present in only one. Long bone fractures were present in all the victims. Presence of multiple shrapnels was a universal finding. Two blast victims died (day 7 and day 9); cause of death was multi-organ failure and septic shock. Issues relating to complexity of injuries, complications, management, and outcome are discussed.
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Potassium permanganate toxicity: A rare case with difficult airway management and hepatic damage p. 819
Vijay Kumar Agrawal, Abhishek Bansal, Ranjeet Kumar, Bhanwar Lal Kumawat, Parul Mahajan
Potassium permanganate (KMnO 4 ) is rarely used for suicidal attempt. Its ingestion can lead to local as well as systemic toxicities due to coagulation necrosis and damage, caused by free radicals of permanganate. We recently managed a case of suicidal ingestion of KMnO 4 in a lethal dose. She had significant narrowing of upper airway leading to difficult intubation as well as hepatic dysfunction and coagulopathy as systemic manifestation. We suggest to keep ourselves ready to handle difficult airway with the aid of fiber optic bronchoscope or surgical airway management in such patients. Upper gastrointestinal (GI) endoscopy should be done at the earliest to determine the extent of upper GI injury and further nutrition planning.
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Use of a novel hemoadsorption device for cytokine removal as adjuvant therapy in a patient with septic shock with multi-organ dysfunction: A case study Highly accessed article p. 822
Reshma Basu, Sunjay Pathak, Jyoti Goyal, Rajeev Chaudhry, Rati B Goel, Anil Barwal
CytoSorb ® (CytoSorbents Corporation, USA) is a novel sorbent hemoadsorption device for cytokine removal. The aim of this study was to examine the clinical use of CytoSorb ® in the management of patient with septic shock. We used this device as an adjuvant to stabilize a young patient with multi-organ failure and severe sepsis with septic shock. A 36-year-old female patient was hospitalized with the complaints of malaise, general body ache, and breathing difficulty and had a medical history of diabetes mellitus type II, hypertension, obstructive sleep apnea, hypothyroidism and morbid obesity. She was diagnosed to have septic shock with multi-organ dysfunction (MODS) and a low perfusion state. CytoSorb ® hemoadsorption column was used as an attempt at blood purification. Acute physiology and chronic health evaluation score, MODS score, and sequential organ failure assessment score were measured before and after the device application. CytoSorb application as an adjuvant therapy could be considered in septic shock.
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Acute airway obstruction due to spontaneous intrathyroid hemorrhage precipitated by anticoagulation therapy p. 825
Laxmi Kokatnur, Mohan Rudrappa, Penchala Mittadodla
Acute airway compromise due to hemorrhage in of thyroid gland is a rare life-hreating condition. The increasing use of anticoagulants for various reasons is likely increased the occurrence of this this complication. We describe an elderly patient on anticoagulation for atrial fibrillation, which developed swelling on the right side of neck causing acute airway obstruction requiring emergency intubation for airway protection. Computed tomographic scan showed massive intrathyroid hemorrhage along with substernal extension. She had supratherapeutic INR which was appropriately corrected emergently. She underwent resection of the thyroid gland which showed multinodular goiter without any evidence of malignancy. Our case illustrates the rare but lethal bleeding complication of anticoagulants in critical anatomical area and we request physicians should be wary of similar conditions.
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Prospective cohort versus retrospective cohort studies to estimate incidence p. 828
Kanica Kaushal
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Evaluation of BACTEC™ blood culture system for culture of normally sterile body fluids p. 829
Uttam Udayan, Meena Dias
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N-acetylcystein in dengue hepatitis p. 830
Viroj Wiwanitkit
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Coiling of central venous catheter in right internal jugular vein p. 830
Tanvir Samra, Vikas Saini
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A case of guidewire embolism during central venous catheterization: Better safe than sorry! p. 831
Geeta P Parikh, Sumedha Shonde, Rajkiran Shah, Nirav Kharadi
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Correlation of end-tidal and arterial carbon-dioxide levels in critically Ill neonates and children p. 833
Hiren Mehta, Rahul Kashyap, Sangita Trivedi
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Successful management of acute kidney injury in severe acute pancreatitis with intra-abdominal hypertension using peritoneal dialysis p. 834
Jaya Prakash Nath, Jacob George, Mohan Das, Noble Gracious, Sajeev Kumar, NS Vineetha
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