Indian Journal of Critical Care Medicine
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Coverpage
April 2014
Volume 18 | Issue 4
Page Nos. 189-261

Online since Monday, April 14, 2014

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EDITORIALS  

Ultrasound in the critically ill: Look for lung water! Highly accessed article p. 189
Young-Jae Cho
DOI:10.4103/0972-5229.130566  
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Sleep quality in intensive care unit: Are we doing our best for our patients? p. 191
Francisco J Romero-Bermejo
DOI:10.4103/0972-5229.130567  
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Characterizing sepsis: Another small piece of the puzzle p. 193
Jean-Louis Vincent
DOI:10.4103/0972-5229.130568  
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RESEARCH ARTICLES Top

Transthoracic ultrasound assessment of B-lines for identifying the increment of extravascular lung water in shock patients requiring fluid resuscitation p. 195
Pongdhep Theerawit, Nutchanart Touman, Yuda Sutherasan, Sumalee Kiatboonsri
DOI:10.4103/0972-5229.130569  
Introduction: Several studies have shown that the number of B-lines was related to the amount of extravascular lung water (EVLW). In our study, we aimed to demonstrate the magnitude of the incremental B-lines in shock patients with positive net fluid balance and the association with gas exchange impairment. Materials and Methods: We performed trans-thoracic ultrasound at admission (T 0 ) and at follow-up period (T FL ) to demonstrate the change of B lines ( B-lines) after fluid therapy. We compared the total B-line score (TBS) at T 0 and T FL and calculated the Pearson's correlation coefficient between the B-lines and PaO 2 /FiO 2 ratio. Results: A total of 20 patients were analyzed. All patients had septic shock. Net fluid balance was + 2228.05 ± 1982.15 ml. The TBS at T 0 and T FL were 36.6 ± 23.73 and 63.80 ± 29.25 (P < 0.01). The B-lines along anterior axillary line (AAL) correlated to the TBS (r = 0.90, P < 0.01). The B-lines along AAL had inverse correlation to PaO 2 /FiO 2 ratio (r = −0.704, P < 0.05). The increase of B-lines ≥ 10 was related to the decrease of PaO 2 /FiO 2 ratio. The inter-observer reliability between two ultrasound readers was high (r = 0.92, P < 0.01). Discussion : The number of B-lines increased in shock patients with positive net fluid balance and correlated to impaired oxygenation. These data supported the benefit of ultrasound for assessing the EVLW.
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Ventilator-associated pneumonia in a tertiary care intensive care unit: Analysis of incidence, risk factors and mortality p. 200
Neelima Ranjan, Uma Chaudhary, Dhruva Chaudhry, KP Ranjan
DOI:10.4103/0972-5229.130570  
Background: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection diagnosed in the intensive care unit (ICU) and in spite of advances in diagnostic techniques and management it remains a common cause of hospital morbidity and mortality. Objective: The primary objective of the following study is to determine the incidence, various risk factors and attributable mortality associated with VAP and secondary objective is to identify the various bacterial pathogens causing VAP in the ICU. Materials and Methods: This prospective observational study was carried out over a period of 1 year. VAP was diagnosed using the clinical pulmonary infection score. Endotracheal aspirate (ETA) and bronchoalveolar lavage (BAL) samples of suspected cases of VAP were collected from ICU patients and processed as per standard protocols. Statistical Analysis: Fisher's exact test was applied when to compare two or more set of variables were compared. Results: The incidence of VAP in our study was 57.14% and the incidence density of VAP was 31.7/1000 ventilator days. Trauma was the commonest underlying condition associated with VAP. The incidence of VAP increased as the duration of mechanical ventilation increased and there was a total agreement in bacteriology between semi-quantitative ETAs and BALs in our study. The overall mortality associated with VAP was observed to be 48.33%. Conclusions: The incidence of VAP was 57.14%. Study showed that the incidence of VAP is directly proportional to the duration of mechanical ventilation. The most common pathogens causing VAP were Acinetobacter spp. and Pseudomonas aeruginosa and were associated with a high fatality rate.
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Association between heat shock protein 70 gene polymorphisms and clinical outcomes in intensive care unit patients with sepsis p. 205
Kartik Ramakrishna, Srinivasan Pugazhendhi, Jayakanthan Kabeerdoss, John Victor Peter
DOI:10.4103/0972-5229.130571  
Objective: The objective of the following study is to evaluate the associations between single nucleotide polymorphisms (SNPs) in the Heat Shock Protein 70 (HSP70) gene, gene expression of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF- ) and medical intensive care unit (MICU) stay and organ failure in sepsis. Materials and Methods: MICU patients with sepsis were genotyped for rs1061581, rs2227956, rs1008438 and rs1043618 polymorphisms in HSP70 gene using polymerase chain reaction (PCR)-restriction fragment length polymorphism analysis or allele-specific PCR. Messenger ribonucleic acid (mRNA) expression of IL-6 and TNF- were quantitated in peripheral blood lymphocytes. Outcomes were recorded. Results: 108 patients (48 male) aged 40.7 ± 16.0 (mean ± standard deviation) years included H1N1 infection (36), scrub typhus (29) and urosepsis (12). Seventy-one (65.7%) had dysfunction of three or more organ systems, 66 patients (61.1%) were treated by mechanical ventilation, 21 (19.4%) needed dialysis. ICU stay was 9.3 ± 7.3 days. Mortality was 38.9%. One or more SNPs were noted in 101/108 (93.5%) and organ failure was noted in only 1/7 patients without a single SNP. The A allelotypes of rs1061581 and rs1008438 were associated with hematological dysfunction (P = 0.03 and 0.07) and longer ICU stay (P = 0.05 and 0.04), whereas IL-6 and TNF- mRNA levels were associated with central nervous system dysfunction. Conclusions: HSP70 genotypes may determine some adverse outcomes in patients with sepsis.
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Propofol versus flunitrazepam for inducing and maintaining sleep in postoperative ICU patients p. 212
Cornelius Engelmann, Jan Wallenborn, Derk Olthoff, Udo X Kaisers, Henrik Rüffert
DOI:10.4103/0972-5229.130572  
Context: Sleep deprivation is a common problem on intensive care units (ICUs) influencing not only cognition, but also cellular functions. An appropriate sleep-wake cycle should therefore be maintained to improve patients' outcome. Multiple disruptive factors on ICUs necessitate the administration of sedating and sleep-promoting drugs for patients who are not analgo-sedated. Aims: The objective of the present study was to evaluate sleep quantity and sleep quality in ICU patients receiving either propofol or flunitrazepam. Settings and Design: Monocentric, randomized, double-blinded trial. Materials and Methods: A total of 66 ICU patients were enrolled in the study (flunitrazepam n = 32, propofol n = 34). Propofol was injected continuously (2 mg/kg/h), flunitrazepam as a bolus dose (0.015 mg/kg). Differences between groups were evaluated using a standardized sleep diary and the bispectral index (BIS). Statistical Analysis Used: Group comparisons were performed by Mann-Whitney U-Test. P < 0.05 was considered to be statistically significant. Results: Sleep quality and the frequency of awakenings were significantly better in the propofol group (Pg). In the same group lower BIS values were recorded (median BIS propofol 74.05, flunitrazepam 78.7 [P = 0.016]). BIS values had to be classified predominantly to slow-wave sleep under propofol and light sleep after administration of flunitrazepam. Sleep quality improved in the Pg with decreasing frequency of awakenings and in the flunitrazepam group with increasing sleep duration. Conclusions: Continuous low-dose injection of propofol for promoting and maintaining night sleep in ICU patients who are not analgo-sedated was superior to flunitrazepam regarding sleep quality and sleep structure.
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REVIEW ARTICLES Top

Scoring systems in the intensive care unit: A compendium p. 220
Amy Grace Rapsang, Devajit C Shyam
DOI:10.4103/0972-5229.130573  
Severity scales are important adjuncts of treatment in the intensive care unit (ICU) in order to predict patient outcome, comparing quality-of-care and stratification for clinical trials. Even though disease severity scores are not the key elements of treatment, they are however, an essential part of improvement in clinical decisions and in identifying patients with unexpected outcomes. Prediction models do face many challenges, but, proper application of these models helps in decision making at the right time and in decreasing hospital cost. In fact, they have become a necessary tool to describe ICU populations and to explain differences in mortality. However, it is also important to note that the choice of the severity score scale, index, or model should accurately match the event, setting or application; as mis-application, of such systems can lead to wastage of time, increased cost, unwarranted extrapolations and poor science. This article provides a brief overview of ICU severity scales (along with their predicted death/survival rate calculations) developed over the last 3 decades including several of them which has been revised accordingly.
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Glycemic control in critically ill: A moving target p. 229
Subhash Todi
DOI:10.4103/0972-5229.130574  
Glycemic control targets in intensive care units (ICUs) have three distinct domains. Firstly, excessive hyperglycemia needs to be avoided. The upper limit of this varies depending on the patient population studied and diabetic status of the patients. Surgical patients particularly cardiac surgery patients tend to benefit from a lower upper limit of glycemic control, which is not evident in medically ill patient. Patient with premorbid diabetic status tends to tolerate higher blood sugar level better than normoglycemics. Secondly, hypoglycemia is clearly detrimental in all groups of critically ill patient and all measures to avoid this catastrophe need to be a part of any glycemic control protocol. Thirdly, glycemic variability has increasingly been shown to be detrimental in this patient population. Glycemic control protocols need to take this into consideration and target to reduce any of the available metrics of glycemic variability. Newer technologies including continuous glucose monitoring techniques will help in titrating all these three domains within a desirable range.
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SHORT COMMUNICATION Top

Nosocomial candiduria in chronic liver disease patients at a hepatobilliary center p. 234
Neha Rathor, Vikas Khillan, SK Sarin
DOI:10.4103/0972-5229.130575  
Background: Nosocomial urinary tract infections (UTIs) are common in catheterized patients. Fungal UTI has become an important nosocomial problem over the past decade. The microbiology of candiduria is rapidly evolving and new trends are being reported. Aims: To study the microbiological trends and antifungal resistance profile of Candida in urine of catheterized chronic liver disease (CLD) patients at a super specialty hepatobiliary tertiary-care center. Materials and Methods: urine samples were collected by sterile technique, processed by semi-quantitative method as per the standard protocols. Direct microscopic examination of urine sample was also done to look for the presence of pus cells, red blood cells, casts, crystals or any bacterial or fungal element. Result: A total of 337 yeast isolates were obtained from catheterized patients, non-albicans Candida spp. emerged as the predominant pathogen and was responsible for 67.06% of nosocomial fungal UTI. Candida tropicalis accounted for 34.71% of the cases, whereas Candida albicans grew in 32.93%, Candida glabrata 16.32%, rare Candida spp. Nearly 11.5% (Candida hemolunii to be confirmed by molecular methods). Antifungal sensitivity varied non-albicans species except C. tropicalis, Candida parapsilosis were more often resistant to antifungal drugs. Conclusion: Nosocomial Candida UTIs in CLD patients is common, due to the cumulative pressure of contributing factors such as urinary instrumentation and prolonged use of broad-spectrum antibiotics. Non-albicans Candida were found to outnumber C. albicans in catherized CLD patients. Risk of strain persistence is also higher with non-albicans Candida. Thus, species identification and susceptibility testing is a must for appropriate management of such patients.
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CASE REPORTS Top

Spiked helmet sign: An under-recognized electrocardiogram finding in critically ill patients p. 238
Ajay Agarwal, Timothy G Janz, Naga V Garikipati
DOI:10.4103/0972-5229.130576  
A 77-year-old male patient presented with rhabdomyolysis. He developed progressive respiratory failure and acute respiratory distress syndrome during his hospital stay requiring mechanical ventilation. An electrocardiogram during mechanical ventilation showed findings suggestive of ST elevation myocardial infarction. Closer review showed dome and spike findings that have been likened to a "spiked helmet." This finding has been associated with significant mortality. We discuss this under-recognized finding and the potential contributing mechanisms.
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Guillain-Barre syndrome complicated by acute fatal rhabdomyolysis p. 241
Amrish Saxena, Vineeta Singh, Nitin Verma
DOI:10.4103/0972-5229.130577  
Guillain-Barre syndrome (GBS) is a heterogenous group of peripheral-nerve disorders with similar clinical presentation characterized by acute, self-limited, progressive, bilateral and relatively symmetric ascending flaccid paralysis, which peaks in 2-4 weeks and then subsides. The usual complications, which occur in a patient of GBS are pneumonia, sepsis, pulmonary embolism, respiratory insufficiency and cardiac arrest. The clinical course of GBS complicated by acute rhabdomyolysis is extremely rare. We present the case of GBS with marked elevation in serum creatine kinase, serum myoglobin levels and persistent hyperkalemia as a result of associated acute rhabdomyolysis.
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Atypical manifestations of organophosphorus poisoning following subcutaneous injection of Dichlorvos with suicidal intention p. 244
Supradip Ghosh
DOI:10.4103/0972-5229.130578  
Current case report describes a 37-year-old female patient who was admitted to the hospital following subcutaneous injection of Dichlorvos with an insulin syringe. The only peripheral cholinergic sign observed on admission was excessive salivation with bilateral pyramidal tract signs. Locally she had necrosis of skin and subcutaneous tissue with surrounding blisters. In the subsequent course of her illness, she developed respiratory arrest requiring ventilator support. She also had delayed extrapyramidal manifestations. Relevant literature is reviewed. Possibility of route-specific, delayed predominant central nervous system effect of Dichlorvos postulated.
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High dose intravenous immunoglobulin may be complicated by myocardial infarction p. 247
Kolar Vishwanath Vinod, Mritunjai Kumar, Kare Kadavath Nisar
DOI:10.4103/0972-5229.130579  
Intravenous immunoglobulin [IVIg] is useful for treating several clinical conditions and is largely considered safe, without major adverse events. Here we report a case of acute ST elevation myocardial infarction associated with high dose IVIg administration in a previously healthy 69-year-old male patient of Guillain Barre syndrome. The case is being reported to emphasize the need for treating physicians to be aware of thrombotic complications associated with IVIg. The thrombotic complications associated with IVIg are reviewed in brief , and the measures to reduce them are discussed.
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Posterior reversible encephalopathy syndrome in a patient of organophosphate poisoning p. 250
Rajesh Phatake, Sameer Desai, Manikanth Lodaya, Shrinivas Deshpande, Nagaraj Tankasali
DOI:10.4103/0972-5229.130580  
A 32-year-old male presented with a history of consuming some organophosphorous compound with suicidal intention.He was treated with atropine, pralidoxime, ventilator support. During stay patient had persistent irritability, tachycardiaand hypertension despite sedation and labetalol infusion. He developed headache, visual blurring hemiparesis and focal seizures. Magnetic resonance imaging of the brain revealed multifocal hyperintensities mainly in subcortical areas of parietal and occipital regions in T2-weighted images, with increased values of Apparent Diffusion Coefficient, suggesting posterior reversible encephalopathy syndrome (PRES). The possibilities of PRES caused by organophosphorous poisoning either due to hypertension caused by autonomic deregulation or direct neurological toxicity has been discussed.
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Methylene blue unresponsive methemoglobinemia p. 253
Sibabratta Patnaik, Manivachagan Muthappa Natarajan, Ebor Jacob James, Kala Ebenezer
DOI:10.4103/0972-5229.130582  
Acquired methemoglobinemia is an uncommon blood disorder induced by exposure to certain oxidizing agents and drugs. Although parents may not give any history of toxin ingestion; with the aid of pulse-oximetry and blood gas analysis, we can diagnose methemoglobinemia. Prompt recognition of this condition is required in emergency situations to institute early methylene blue therapy. We report an unusual case of severe toxic methemoglobinemia, which did not respond to methylene blue, but was successfully managed with exchange transfusion.
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LETTERS TO THE EDITOR Top

Difficult extubation after large tongue swelling in intensive care unit p. 256
Monish S Raut, Arun Maheshwari
DOI:10.4103/0972-5229.130583  
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Snake bite and stroke: Our experience of two cases p. 257
Gunchan Paul, Birinder S Paul, Sandeep Puri
DOI:10.4103/0972-5229.130585  
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The anticonvulsant of choice in pyrethroid induced convulsions p. 258
Subramanian Senthilkumaran, Namasivayam Balamurugan, Ritesh G Menezes, Ponniah Thirumalaikolundusubramanian
DOI:10.4103/0972-5229.130587  
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Is gastric residual volume monitoring in critically ill patients receiving mechanical ventilation an evidence-based practice? p. 259
Abbas Heydari, Amir Emami Zeydi
DOI:10.4103/0972-5229.130588  
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"DIRECT CPR"- Mnemonic to remember 2010 AHA BLS CPR guidelines p. 261
Indu M Sen, Mitali Sen
DOI:10.4103/0972-5229.130589  
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