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   Table of Contents - Current issue
Coverpage
January 2018
Volume 22 | Issue 1
Page Nos. 1-58

Online since Monday, January 15, 2018

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RESEARCH ARTICLES  

Effect of continuous versus intermittent subglottic suctioning on tracheal mucosa by the mallinckrodt taperguard evac oral tracheal tube in intensive care unit ventilated patients: A prospective randomized study p. 1
Philippe Seguin, Harmonie Perrichet, Estelle Le Pabic, Yoann Launey, Marie Tiercin, Romain Corre, Graziella Brinchault, Bruno Laviolle
DOI:10.4103/ijccm.IJCCM_350_17  
Background and Aims: A risk of tracheal mucosa injury induced by subglottic suctioning has been raised. Therefore, this prospective randomized study aims to compare the effect of continuous suctioning of subglottic secretions versus intermittent suctioning of subglottic secretions (CSSS vs. ISSS) secretions on tracheal mucosa in front of the suctioning port of the endotracheal tube. Patients and Methods: Patients requiring intubation or reintubation in Intensive Care Unit with an expected ventilation duration > 24 h were eligible. Participants received CSSS at −20 mmHg or ISSS at −100 mmHg during 15 s and no suction during 8 s. The effect on tracheal mucosa in front of the suction port was assessed after intubation (T0) and before extubation (T1) using bronchoscopy. Tracheal mucosa damages were graded into five categories (no injury, erythema, edema, ulceration, or necrosis). The occurrence (no injury observed at T0 but present at T1) or the worsening (injury observed at T0 exacerbating at T1) was studied. Results: Seventy-three patients were included and 53 patients (CSSS, n = 26 and ISSS, n = 27) were evaluable on the primary endpoint. The occurrence or worsening of tracheal mucosal damages did not differ between the two groups (CSSS, n = 7 [27%] vs. ISSS, n = 5 [17%], P = 0.465). Daily average volume of suctioned secretion was higher with ISSS (74 ± 100 ml vs. 20 ± 25 ml, P < 0.001). Impossibility to aspirate was higher with CSSS (0.14 ± 0.16 per day vs. 0.03 ± 0.07 per day, P < 0.001). Conclusions: Our results suggest that tracheal mucosal damages did not differ between CSSS and ISSS. The aspirated volume was higher and impossibility to aspirate was lower with ISSS. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01555229.
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Clinical profile, intensive care unit course, and outcome of patients admitted in intensive care unit with chikungunya p. 5
Anish Gupta, Deven Juneja, Omender Singh, Suneel Kumar Garg, Varun Arora, Desh Deepak
DOI:10.4103/ijccm.IJCCM_336_17  
Objective: Chikungunya is generally a mild disease, rarely requiring Intensive Care Unit (ICU) admission. However, certain populations may develop organ dysfunction necessitating ICU admission. The purpose of the study was to assess the clinical profile and course of chikungunya patients admitted to the ICU, and to ascertain factors linked with poor outcome. Methods: All patients with chikungunya admitted to ICU were included in the study. Admission Acute Physiology and Chronic Health Evaluation (APACHE) II score and sequential organ failure assessment (SOFA) score were calculated. Primary outcome measured was 28-day mortality and secondary outcomes measured were length of hospital and ICU stay and the need for vasopressor support, renal replacement therapy (RRT), and mechanical ventilation (MV). Logistic regression analysis was performed to identify factors predicting mortality. Results: The most common complaints were fever (96.67%) and altered sensorium (56.67%). Mean admission APACHE II and SOFA scores were 17.28 ± 7.9 and 7.15 ± 4.2, respectively. Fifty-one patients had underlying comorbidities. Vasopressors were required by 46.76%; RRT by 26.67%, and MV by 58.33%, respectively. The 28-day mortality was 36.67%. High APACHE II score (odds ratio: 1.535; 95% confidence interval: 1.053–2.237; P = 0.026) and need for dialysis (odds ratio: 833.221; 95% confidence interval: 1.853–374,664.825; P = 0.031) could independently predict mortality. Conclusions: Patients with chikungunya fever may require ICU admission for organ failure. They are generally elderly patients with underlying comorbidities. Despite aggressive resuscitation and organ support, these patients are at high risk of death. Admission APACHE II score and need for dialysis may predict patients at higher risk of death.
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Audit of postoperative surgical intensive care unit admissions p. 10
Shaili K Patel, Samir M Kacheriwala, Dipesh D Duttaroy
DOI:10.4103/ijccm.IJCCM_387_17  
Objective: The objective of this study was to conduct an audit of Surgical Intensive Care Unit (SICU) for identifying the admission risk factors and evaluating the outcomes of postoperative surgical patients. Design: This was a prospective, observational study. Setting: This study was conducted at SICU of a 1500-bedded tertiary care university hospital in Western India. Subject and Methods: Two hundred and forty patients admitted to the SICU postoperatively over a period of 15 months. Results: Planned and unplanned postoperative SICU admission rate was 4.45% and 0.09% of the 5284 patients operated. Indications for planned admissions included preoperative medical illnesses, anticipated blood loss, and anticipated mechanical ventilation while unpredicted intraoperative hypotension was the principal cause of unplanned admittance. Univariate analysis for two groups of the American Society of Anesthesiologists (ASA) physical status indicated that advanced age, high American College of Cardiology/American Heart Association (ACC/AHA) surgical risk, emergency surgery, planned admissions, and mortality were related to high ASA class. Analysis for ACC/AHA surgical risk showed association of high ACC/AHA surgical risk with advanced age, male gender, high ASA physical status, emergency surgery, planned admissions, and mortality. High mortality was observed in patients with SICU stay of >7 days (75.86%) and readmitted cases (72.73%). Conclusion: The need for postoperative critical care is significantly higher in males, elderly, patients with poor preoperative risk stratification scores, preexisting medical illness, major intraoperative hemorrhage, hypotension requiring inotropic support, perioperative respiratory problems and patients undergoing abdominal, trauma, and emergent surgeries. A larger study inclusive of other surgical subspecialties would aid in optimal decision-making for admissions to the SICU.
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Pattern and outcome of obstetric admissions into the intensive care unit of a Southeast Nigerian Hospital p. 16
Benjamin Chukwuma Ozumba, Leonard Ogbonna Ajah, Vitus Okwuchukwu Obi, Uche Anthony Umeh, Joseph Tochukwu Enebe, Kingsley Chukwu Obioha
DOI:10.4103/ijccm.IJCCM_297_17  
Background and Aims: Although pregnancy and labor are considered physiological processes, the potential for catastrophic complications is constant and may develop rapidly. There is growing evidence that admission of high-risk patients into the Intensive Care Unit (ICU) is associated with a reduction in maternal mortality. This study was aimed at reviewing all obstetric patients admitted into the ICU. Materials and Methods: This was a retrospective study of all obstetric patients who were admitted into the ICU between January 1, 2012, and December 31, 2013. Results: There were 89 obstetric patients admitted and managed at the ICU out of 5176 deliveries, thereby accounting for 1 admission in 58 deliveries. Majority of the patients were between 26 and 30 years, primiparous, and unbooked. The indications for ICU admission in this study were ruptured uterus (36.0%), eclampsia (22.5%), obstetric hemorrhage (19.1%), septicemia (10.1%), severe preeclampsia (6.7%), and obstructed labor (6.7%). The maternal and perinatal mortality was 13.5% and 47.2%, respectively. Maternal unbooked status was significantly associated with maternal mortality (P &*#60; 0.05). Conclusion: Ruptured uterus was the most common indication for ICU admission in the center. Maternal mortality was significantly associated with unbooked status. This underscores the importance of booking for antenatal care, prompt presentation at the hospital during emergencies, skilled birth attendance, and provision of adequate facilities for the management of critical obstetric cases in this environment.
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Multicenter observational study to evaluate epidemiology and resistance patterns of common intensive care unit-infections p. 20
Ramesh Venkataraman, Jigeeshu V Divatia, Nagarajan Ramakrishnan, Rajesh Chawla, Pravin Amin, Palepu Gopal, Dhruva Chaudhry, Kapil Zirpe, Babu Abraham
DOI:10.4103/ijccm.IJCCM_394_17  
Background: There is limited data regarding the microbiology of Intensive Care Unit (ICU)-acquired infections, such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), and catheter-related bloodstream infections (CRBSI) from India. Objectives: To explore the microbiology and resistance patterns of ICU-acquired infections and evaluate their outcomes. Materials and Methods: This was a multicenter observational study, conducted by Indian Society of Critical Care Medicine (MOSER study) between August 2011 and October 2012. Patients in the ICU ≥48 h with any ICU-acquired infection within 14 days of index ICU stay were included. Patient demographics, relevant clinical, and microbiological details were collected. Follow-up until hospital discharge or death was done, and 6-month survival data were collected. Results: Of the 381 patients included in the study, 346 patients had 1 ICU infection and 35 had more than one ICU infection. Among patients with single infections, 223 had VAP with Acinetobacter being the most common isolate. CAUTI was seen in 42 patients with Klebsiella as the most common organism. CRBSI was seen in 81 patients and Klebsiella was the most common causative organism. Multidrug resistance was noted in 87.5% of Acinetobacter, 75.5% of Klebsiella, 61.9% of Escherichia coli, and 58.9% of Pseudomonas isolates, respectively. Staphylococcus constituted only 2.4% of isolates. Mortality rates were 26%, 11.9%, and 34.6% in VAP, CAUTI, and CRBSI, respectively. Conclusion: VAP is the most common infection followed by CRBSI and CAUTI. Multidrug-resistant Gram-negative bacteria are the most common organisms. Staphylococcus aureus is uncommon in the Indian setting.
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BRIEF COMMUNICATIONS Top

Outcome of patients admitted to a tertiary referral intensive care unit with urosepsis needing source control p. 27
Chaitra C Rao, Pradeep Rangappa, Karthik Rao, Ipe Jacob
DOI:10.4103/ijccm.IJCCM_322_17  
Introduction: Urosepsis is one of the common causes of admission to the Intensive Care Unit (ICU). It has traditionally been treated with antibiotics, but surgical management with Double J [DJ] ureteral stents is gaining popularity. This study compares patients with complicated urosepsis who underwent surgical source control by ureteral stenting with those managed medically. Materials and Methods: The study enrolled patients admitted to a tertiary adult ICU with a diagnosis of urosepsis over a period of 2 years. The primary outcomes were renal replacement therapy (RRT) requirement and ICU mortality. The secondary outcomes were ICU and hospital length of stay, ventilator-free days, and inotrope free days. Patients were divided those with obstructive and nonobstructive urinary tract infection (UTI). Results: A total of 58 patients met the criteria, of who 32 had obstructive UTI and were included in Group A, with the remaining 26 with nonobstructive UTI comprised Group B. In Group A, 27 patients underwent source control with ureteral DJ stenting, three patients recovered with medical management, and two who were advised source control did not consent to the procedure. Seventeen patients in Group A and seven patients in Group B required RRT (P = 0.044). There was no significant difference in ICU mortality, hospital mortality, and 28 days survival between the two groups. Conclusion: With early source control, obstructive UTI outcomes were comparable to nonobstructive UTI. However, despite undergoing ureteric stenting, more patients with obstructive UTI required RRT than those with nonobstructive UTI.
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Acute renal failure adversely affects survival in pediatric dengue infection p. 30
Biswanath Basu, Birendranath Roy
DOI:10.4103/ijccm.IJCCM_94_17  
Aims: Dengue is currently one of the most important mosquito-borne viral infections. Acute renal failure (ARF) is a serious complication among children suffering from dengue infection. Subjects and Methods: A retrospective cohort review of baseline characteristics, disease outcomes, and risk factors of dengue-infected patients, with and without renal failure (RF), were compared. Results: Among 97 children with dengue, 13.4% had RF (estimated glomerular filtration rate <60 ml/min/1.73 m2) at presentation. In comparison to all children (100%) of RF cohort, only 32% children of non-RF cohort (P &*#60; 0.0001) were suffering either from dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS). The 7-day survival rate was 61.5% (8/13) among RF group as compared to 96.4% (81/84) in non-RF group (P &*#60; 0.001). When a fraction of patients who needed vasopressor support were significantly higher in RF cohort (70% vs. 14% for RF and non-RF, respectively, P < 0.001), requirement of mechanical ventilation (15% vs. 11%, P = 0.67) was comparable in both cohorts. Conclusions: DHF/DSS is an independent risk factor for the development of ARF in patients with dengue infection. Mortality rate is high once RF develops in these children.
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Role of correction factor in minimizing errors while calculating electrolyte values between Blood–gas analyzer and laboratory autoanalyzer: A comparative study p. 34
Abhinav Banerjee, Gesu Mehrotra
DOI:10.4103/ijccm.IJCCM_406_17  
Aims: Electrolytes are charged elements that play important functions in the body. They are measured by both arterial blood–gas (ABG) analyzers and autoanalyzers (AA). In this study, we tried to find out the correction factor for sodium and potassium to establish the concordance between ABG and AA values. Materials and Methods: We prospectively studied 100 samples of patients, and for validation of the result, we applied our result on 30 patients later. 1.5 ml of blood collected in the 2.0 ml syringe preflushed with heparin and analyzed using blood–gas analyzer (ABG). Another sample was sent, to central laboratory, where serum Na+ and K+ concentrations were analyzed. Means, standard deviations, and coefficients of variation with Karl Pearson's correlation coefficients were found out. Deming regression analysis was performed and Bland–Altman plots were also constructed. Results: The mean sodium and potassium were 130.27 ± 7.85 mmol/L and 3.542 ± 0.76 mmol/L using ABG and 139.28 ± 7.89 mmol/L and 4.196 ± 0.72 mmol/L using AA. Concordance between ABG and AA is done by adding the correction factor: for sodium, correction factor is 9.01, standard error = 1.113, class interval = 6.815–11.205; and for potassium (K+), correction factor is 0.654, standard error = 0.1047, class interval = 0.4475–0.8605. Conclusion: The instrument type and calibration methods differ in different hospitals, so it is important that each center conducts an in-hospital study to know the correction factor before installation of an ABG, and the factor should be used accordingly to minimize all errors.
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CASE REPORTS Top

An interesting presentation of pheochromocytoma p. 40
Sunil Kumar Garg, Pragya Garg, Mehmet Urumdas
DOI:10.4103/ijccm.IJCCM_407_17  
Pheochromocytoma is a rare cause of hypertension, but it could have severe consequences if not recognized and treated appropriately. Pheochromocytoma classically presents with paroxysms of hypertension and adrenergic symptoms including classic triad of episodic headache, sweating, and tachycardia. The clinical presentation of pheochromocytoma can mimic a number of other medical conditions including migraine, cardiac arrhythmias, myocardial infarction, and stroke, thus making the diagnosis of pheochromocytoma difficult, and treatment is directed toward presenting issue rather than underlying problem in such patients. We present a case of a 41-year-old male patient who presented with cerebellar infarct and found to have aortic thrombi and later developed acute myocardial infaction during same hospitalization. To the best of our knowledge, this is the first reported case of this kind.
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Quad fever: Treatment through lowering of ambient temperature p. 43
Shyam Sundar Krishnan, Pulak Nigam, Omar Bachh, Madabushi Chakravarthy Vasudevan
DOI:10.4103/ijccm.IJCCM_295_17  
Hyperpyrexia is a rare and at times fatal condition seen in an Intensive Care Unit setup. We encountered a case of a 65-year-old patient with road traffic accident presenting with dorsal spine fracture at D10level. He underwent decompression and fusion for the same. He developed hyperpyrexia of sudden onset on the 10th day of admission with no source of infection and adequate broad-spectrum antibiotic coverage with adequate thrombo-embolic prevention in place. The patient showed no response to antipyretic agents and other cooling methods. The origin of hyperthermia was idiopathic, and we speculate that the cause was secondary to hyperthermic thermoregulatory dysfunction often quoted as “quad fever,” seen in spinal cord injury. We present a brief review of literature and the importance of early identification and treatment of this potentially fatal condition.
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Cardiotoxic effects of raw opium p. 46
Piyush Garg, Asif Ali Hitawala, Manoj Agarwal
DOI:10.4103/ijccm.IJCCM_427_17  
While opioid drug toxicity and side effects of long-term opioid use during medical care are well studied, there is little information regarding effects of ingestion of raw opium. Characterization of the effects to a particular alkaloid is difficult since raw opium contains a number of alkaloids. Here, we present a case of poisoning due to ingestion of raw opium leading to severe myocardial suppression.
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Successful use of ketamine for burst suppression in super refractory status epilepticus following substance abuse p. 49
Dnyaneshwar P Mutkule, S Manimala Rao, Jaydip Ray Chaudhuri, Kunche Rajasri
DOI:10.4103/ijccm.IJCCM_370_17  
Status epilepticus is frequently encountered in neuro Intensive Care Units. It is a medical emergency and if not treated promptly can lead to severe brain damage and even death. Here, we present the case of a 18-year-old male with uncontrolled and unrelenting seizures with a rare etiology requiring ketamine infusion for burst suppression as it was resistant to thiopentone and midazolam infusions. The management of this case is presented in detail.
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Phlegmasia cerulea dolens following heparin-induced thrombocytopenia p. 51
Deepesh G Aggarwal, Shilpa S Bhojraj, Ali Asgar Behrainwalla, Charu K Jani, Simin S Mehta
DOI:10.4103/ijccm.IJCCM_183_16  
The authors present a case of a 49-year-old woman who underwent coronary artery bypass grafting after suffering from an acute coronary syndrome and later developed phlegmasia cerulea dolens with heparin-induced thrombocytopenia (HIT) and HIT thrombosis (HITT).
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CASE SERIES Top

Heart rate variability in children following drowning injury p. 53
Madhuradhar Chegondi, Jun Sasaki, Sayed Naqvi, Wei-Chiang Lin, Andre Raszynski, Balagangadhar R Totapally
DOI:10.4103/ijccm.IJCCM_120_16  
Heart rate variability (HRV) has been used as prognostic tool in various disorders in pediatric and adult patients. In our study we aimed to evaluate heart rate variability indices and their association with neurological outcome in three children with anoxic brain injury following drowning. Three children included in the study were admitted following drowning and required mechanical ventilation and targeted temperature management. All physiologic data, including electrocardiography (ECG) and EEG were collected for a period of 3–5 days after enrollment. ECG signals were analyzed in both time and frequency domains. The spectral power of the low-frequency (LF) band (0.04–0.15 Hz) and that of the high-frequency (HF) band (0.15–0.4 Hz), the standard deviation of the average R to R ECG intervals (SDANN) were calculated. Mean low-frequency/high-frequency power ratios (LF/HF) were compared using a two-tailed t-test and ANOVA with Tukey–Kramer multiple comparisons. The power in the LF band, the LF/HF power ratio, and the SDANN, were lower in children who had a poor outcome, and during periods of isoelectric or burst suppression EEG patterns.
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LETTER TO THE EDITOR Top

Epidemiology and antifungal susceptibility of Candida species isolated from urinary tract infections: A study from an intensive care unit of a tertiary care hospital p. 56
Priya Datta, Mandeep Kaur, Satinder Gombar, Jagdish Chander
DOI:10.4103/ijccm.IJCCM_130_17  
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QUIZ Top

Quiz p. 58
Yash Javeri
DOI:10.4103/ijccm.IJCCM_487_17  
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