Indian Journal of Critical Care Medicine
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  » Table of Contents - Current issue
August 2015
Volume 19 | Issue 8
Page Nos. 443-501

Online since Friday, August 07, 2015

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Optic nerve sheath diameter measurement using bedside ultrasound: Is it accurate? p. 443
Deepak Govil, Shrikanth Srinivasan
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Acute physiology and chronic health evaluation II for critically ill children? p. 446
Jhuma Sankar
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Tracheostomy in the management of patients with thermal injuries p. 449
Mónica Mourelo, Rita Galeiras, Sonia Pértega, David Freire, Eugenia López, Javier Broullón, Eva Campos
Objective: To assess the use and clinical impact of tracheostomy in burn patients. Summary Background Data: The role of tracheostomy in the management of burn patients is controversial, with only a few recent studies conducted in this population. Methods: Retrospective study of all adult burn patients who underwent a tracheostomy in a Burns Unit between 1995 and 2013. These were compared with a control group (1:1) who underwent orotracheal intubation. Hospital records were reviewed to obtain demographic and clinical information, including those related to respiratory support and tracheostomy. The McNemar's Chi-square and Signed-Rank Tests were used to study differences in morbimortality between both groups. Results: A total of n = 20 patients underwent tracheostomy (0.9% of admissions, 56.0 ± 19.5 years, 60.0% women). The most common indication was long-term ventilation (75%), 24.6 ± 19.7 days after admission. Thirteen patients were successfully decannulated with a fatal complication observed in one case. Patients in the tracheostomy group were found to require longer-term mechanical ventilation (43.2 vs. 20.4 days; P = 0.004), with no differences in respiratory infection rates (30.0% vs. 31.6%; P = 0.687) or mortality (30.0% vs. 42.1%; P = 0.500). Ventilator weaning times (15.7 vs. 3.3 days; P = 0.001) and hospital stays (99.1 vs. 53.1 days; P = 0.030) were longer in the tracheostomy group, with no differences in duration of sedation. Conclusions: Tracheostomy may be a safe procedure in burn patients and is not associated with higher rates of mortality or respiratory infection. Tracheostomy patients showed longer mechanical ventilation times and higher morbidity, probably not attributable to tracheostomy.
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Prognostic significance of early platelet count decline in preterm newborns p. 456
Abeer Abd Elmoneim, Mohammed Zolaly, Ehab Abd El-Moneim, Eisa Sultan
Objectives: Decline of platelets with or without thrombocytopenia is observed in critically ill preterm newborns. Prognostic significance of platelets count in Neonatal Intensive Care Unit focused on outcome after thrombocytopenia. We aimed to estimate the changes in platelets count within the first 7 days of life in preterm newborns and its relation to final outcomes. Methods: Retrospectively, the platelets count during the first 7 days of life, and its association with mortality, length of stay among survivors (LOS), and later severe morbidities were determined. Appropriate regression analyses were used to examine possible relations between studied variables. Results and Discussion: Platelets drop that did not reach thrombocytopenia level in the first 7 days of life happened in 61.7%. Platelets count drop in the first 7 days of life was a predictor of mortality, LOS, and major morbidities such as intraventricular hemorrhage and necrotizing enterocolitis. Conclusions: Platelets count drop within the first 7 days of life independent of thrombocytopenia can be used to predict increased mortality, LOS, and the development of later severe morbidities in critically ill preterm neonates.
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Role of acute physiology and chronic health evaluation II scoring system in determining the severity and prognosis of critically ill patients in pediatric intensive care unit p. 462
NP Chhangani, Minhas Amandeep, Sandeep Choudhary, Vidit Gupta, Vishnu Goyal
Objective: This study was conducted to validate the use of Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system in pediatric population in predicting the risk of mortality and to compare the predicted death rate (using APACHE II) with the actual death rate of the patients. Design: Hospital-based prospective study. Setting: Tertiary care Pediatric Intensive Care Unit (PICU) in Western Rajasthan, India. Methods: A total of 100 critically ill children between 1 and 18 years of age admitted to PICU and fulfilling the inclusion criteria were enrolled. APACHE II score was calculated in each patient on the day of admission. The predicted mortality was calculated on the basis of this score. Results: The mean APACHE II score was 21.35 ± 5.76. Mean APACHE II score among the survivors was 16.60 ± 6.12, and mean APACHE II score among the nonsurvivors was 26.11 ± 5.41, and the difference was statistically significant (P = 0.00). The area under the receiver operating characteristic curve for APACHE II score was found to be 0.889 (P = 0.008) indicating good discrimination. Conclusion: APACHE II scoring system has a good discrimination and calibration when applied to a pediatric population.
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Correlation of measurement of optic nerve sheath diameter using ultrasound with magnetic resonance imaging p. 466
Chetan G Shirodkar, Kartik Munta, S Manimala Rao, M Uma Mahesh
Background and Aims: Analysis to correlate the measurements of optic nerve sheath diameter (ONSD) obtained by using ultrasound to magnetic resonance imaging (MRI) techniques in order to establish the accuracy of ocular sonography as a noninvasive modality for detecting raised intracranial pressure (ICP). Materials and Methods: A prospective, observational study was performed in 100 cases of adult meningoencephalitis patients admitted to Intensive Care Unit in whom MRI was performed for neurodiagnosis. ONSD was measured in such patients, 3 mm behind the globe in each eye. A mean binocular ONSD >4.6 mm in female and 4.8 mm in male was taken as cut-off values for diagnosing raised ICP. This was compared with ONSD measured on T2-weighted MRI image measured 3 mm behind the globe. The reading obtained from both the methods were compared with Bland-Altman analysis for correlation and the findings were tabulated. Results: The mean ONSD values measured with ultrasonography (USG) and MRI for female were 5.48 ± 0.43 mm and 5.68 ± 0.44 mm and for male were 5.40 ± 0.37 mm and 5.56 ± 0.38 mm, respectively. The mean age of the female and male was 53.90 ± 17.84 and 56.06 ± 15.67 years, respectively. On comparing ultrasound with MRI-derived ONSD values, we found acceptable agreement between both methods for measurements at a depth of 3 mm (r = 0.02, P < 0.001). Conclusion: In our study, we have found a good correlation between ocular USG and MRI of ONSD. The study has shown agreement with the fact that ocular sonography can be used as a noninvasive tool for detecting raised ICP with accuracy.
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Procalcitonin levels in salmonella infection p. 471
Vikas Mishra, Jehangir Sorabjee
Aim: Procalcitonin (PCT) as a diagnostic marker for bacteremia and sepsis has been extensively studied. We aimed to study PCT levels in Salmonella infections whether they would serve as marker for early diagnosis in endemic areas to start empiric treatment while awaiting blood culture report. Materials and Methods: BACTEC blood culture was used to isolate Salmonella in suspected enteric fever patients. Serum PCT levels were estimated before starting treatment. Results: In 60 proven enteric fever patients, median value of serum PCT levels was 0.22 ng/ml, values ranging between 0.05 and 4 ng/ml. 95% of patients had near normal or mild increase (<0.5 ng/ml), only 5% of patients showed elevated levels. Notably, high PCT levels were found only in severe sepsis. Conclusion: PCT levels in Salmonella infections are near normal or minimally increased which differentiates it from other systemic Gram-negative infections. PCT cannot be used as a specific diagnostic marker of typhoid.
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Prehospital transport practices prevalent among patients presenting to the pediatric emergency of a tertiary care hospital p. 474
Jhuma Sankar, Archana Singh, Praveen Narsaria, Nishanth Dev, Pradeep Singh, Nandkishore Dubey
Background and Objectives: Prehospital transport practices prevalent among children presenting to the emergency are under-reported. Our objectives were to evaluate the prehospital transport practices prevalent among children presenting to the pediatric emergency and their subsequent clinical course and outcome. Methods: In this prospective observational study we enrolled all children ≤17 years of age presenting to the pediatric emergency (from January to June 2013) and recorded their demographic data and variables pertaining to prehospital transport practices. Data was entered into Microsoft Excel and analyzed using Stata 11 (StataCorp, College Station, TX, USA). Results: A total of 319 patients presented to the emergency during the study period. Acute gastroenteritis, respiratory tract infection and fever were the most common reasons for presentation to the emergency. Seventy-three (23%) children required admission. Most commonly used public transport was auto-rickshaw (138, 43.5%) and median time taken to reach hospital was 22 min (interquartile range: 5, 720). Twenty-six patients were referred from another health facility. Of these, 25 were transported in ambulance unaccompanied. About 8% (25) of parents reported having difficulties in transporting their child to the hospital and 57% (181) of parents felt fellow passengers and drivers were unhelpful. On post-hoc analysis, only time taken to reach the hospital (30 vs. 20 min; relative risk [95% confidence interval]: 1.02 [1.007, 1.03], P = 0.003) and the illness nature were significant (45% vs. 2.6%; 0.58 [0.50, 0.67], P ≤ 0.0001) on multivariate analysis. Conclusions: In relation to prehospital transport among pediatric patients we observed that one-quarter of children presenting to the emergency required admission, the auto-rickshaw was the commonest mode of transport and that there is a lack of prior communication before referring patients for further management.
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The evaluation and management of heat injuries in an intensive care unit p. 479
Seema Mahant
In this summer season (May-June 2014) most of the days temperature was more than 40°C. Our hospital is surrounded by huge slums area. The population which is low in socioeconomic status used to work in such high temperature for more than 8 h daily. Hence, they are very prone to develop heat injuries in the form of heat edema, heat tetany, heat syncope, heat cramps, miliaria rubra, heat exhaustion, and heatstroke. Again it is compulsory to upgrade our knowledge on this life threatening condition.
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Propylthiouracil-induced autoimmune disease p. 484
Santosh Paiaulla, Pradeep Marur Venkategowda, S Manimala Rao, Banda Balaraju
Hyperthyroidism is a condition characterized by excessive production of thyroid hormones. Propylthiouracil (PTU) is commonly used as first line drug in the management of hyperthyroidism. This is a case report of 24-year-old female, a known case of hyperthyroidism since 4 years, who came with a history of fever and myalgia since 3 days and dyspnea with coughing out of blood since 1 day. Patient was taking PTU (100 mg per day) since 4 years for hyperthyroidism. Patient was immediately intubated for type-II respiratory failure. Diagnosed to be having PTU-induced autoimmune disease. PTU was stopped and treated with methylprednisolone and cyclophosphamide. Clinical features improved over a period of 8 days and discharged home successfully. Having a high suspicion for the onset of autoimmune disease in hyperthyroidism patients who are on PTU therapy and timely treatment with immunosuppressants and supportive care along with the withdrawal of the drug can make a difference in morbidity and mortality.
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Early plasmapheresis in patients with severe hypertriglyceridemia induced acute pancreatitis p. 487
Prashant Nasa, George Alexander, Amitabh Kulkarni, Deven Juneja, Sudhish Sehra, Rajesh Agarwal, Kandy Koul
Hypertriglyceridemia can cause severe diseases such as acute pancreatitis (AP) and coronary artery disease. The routine management of hypertriglyceridemia is dietary restriction of fat and lipid-lowering medications to manage the secondary or precipitating causes of hypertriglyceridemia. However, in cases of AP with severe hypertriglyceridemia (SHTG) (triglycerides [TG] >1000 mg/dl) rapid reduction of TG levels to well below 1000 mg/dl can improve outcome and prevent further episodes of pancreatitis. Plasmapheresis is a therapeutic option in such medical emergencies. We discussed 2 cases of severe AP with SHTG where we used early plsmapheresis along with other supportive management.
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A case of misplaced permacath dialysis catheter p. 490
Mohammed Arshad Ali, Kishore Raikar, Asha Kishore
Central venous placement using ultrasound has significantly reduced the complications associated with blind puncture. The central venous catheter can still get misplaced if it follows an anomalous route after appropriate puncture of desired vessel. We report a case of misplaced dialysis catheter into the accessory hemiazygos vein which resulted in a large hemothorax, and we recommend the routine use of a fluoroscope for placement of dialysis catheters so as to avoid serious complications.
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Status spasticus and psoas muscle edema due to anti-GAD antibody associated stiff-man syndrome p. 493
Boby Varkey Maramattom
Severe muscle rigidity and spasms are uncommon causes of Intensive Care Unit (ICU) admissions. Stiff-man syndrome (SMS) is a rare disorder characterized by continuous muscle spasms, axial muscle rigidity, "tin soldier gait," and continuous motor unit activity on electromyography. There are three clinical variants of SMS; stiff-limb syndrome, classical SMS, and paraneoplastic encephalomyelitis with rigidity and myoclonus. Three types of antibodies have been associated with SMS; however, anti-glutamic acid decarboxylase (GAD) antibodies are the most frequent and are seen in the idiopathic type of SMS. The spasms of SMS can be very disabling and severe enough to cause muscle ruptures and skeletal fractures. We present a case of anti-GAD positive SMS with "status spasticus" causing bilateral psoas myoedema and rhabdomyolysis due to repeated axial muscle jerking in a 64-year-old man and discuss the differential diagnosis of a "jerking patient in the ICU."
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An unusual toxicity with beta blocker and calcium channel blocker p. 496
Vijay Anand, Shalini Nair
The increasing use of beta and calcium channel blockers for management of cardiac comorbidities has led to more frequent complications in the postoperative period. Anesthetic interaction with these drugs can lead to delayed manifestations of features of toxicity, even when administered in therapeutic doses. We report a case with an uneventful intraoperative period but profound bradycardia and hypotension postoperatively, only relieved with high-dose insulin therapy.
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Intensive care unit mishap during nebulization p. 499
Monika Jindal, Atul Jindal, Subrata Kumar Singha
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Uncommon complication of bilevel positive airway pressure p. 500
Monish S Raut, Arun Maheshwari
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Hypokalemic paraparesis: Presenting feature of previously undiagnosed celiac disease in celiac crisis p. 501
Pankaj Kumar, Anupam Badhan
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