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   Table of Contents - Current issue
July 2014
Volume 18 | Issue 7
Page Nos. 415-485

Online since Saturday, July 05, 2014

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Colistin pharmacokinetics/pharmacodynamics and acute kidney injury: A difficult but reasonable marriage p. 415
Patrick M Honore, Rita Jacobs, Elisabeth De Waele, Viola Van Gorp, Herbert D Spapen
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Pain and discomfort management during central venous catheter insertion p. 417
Abele Donati, Elisa Damiani, Erica Adrario, Rocco Romano, Paolo Pelaia
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Moving away from benzodiazepine as a primary sedative in the intensive care unit; is clonidine a viable alternative? p. 419
Paul M Szumita, David P Reardon
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Effects of fentanyl on procedural pain and discomfort associated with central venous catheter insertion: A prospective, randomized, double-blind, placebo controlled trial p. 421
Aloka Samantaray, Mangu Hanumantha Rao
Context: Central venous catheter (CVC) insertion induces pain and discomfort to a conscious patient despite application of a local anesthetic (LA) field block and this pain can be greatly lessened by using additional analgesics. Aim: The aim of this study is to evaluate the efficacy of fentanyl along with LA field infiltration in controlling pain and discomfort associated with CVC insertion. Settings and Design: A prospective, randomized, double-blind, placebo-controlled trial was conducted at tertiary referral center. Materials and Methods: Fifty-four patients scheduled for planned CVC were randomly assigned to receive either fentanyl (2 μg/kg) or 0.9% normal saline. Pain and discomfort using a verbal numeric rating pain scale at 5 times points during CVC insertion were assessed and analyzed. Results: The median interquartile range pain score is worst for placebo group after LAI (5 [3-6]) and in the immediate postprocedure period (5 [4-5]) which was significantly attenuated by addition of fentanyl (3.5 [2-5] and 3 [2-4]) (P = 0.009 and 0.001 respectively). Overall, fentanyl and placebo group were not statistically different with median discomfort score except at T10 (P = 0.047). Conclusions: Preprocedural bolus fentanyl infusion provides adequate analgesia and can be safely used for alleviating pain during CVC insertion in conscious patients.
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Evaluation of risk of nephrotoxicity with high dose, extended-interval colistin administration p. 427
Arun Dewan, Mujeeb Shoukat
Aim: The aim was to evaluate the risk of nephrotoxicity with high-dose, extended-interval regimen of colistin administration in critical ill patients. Materials and Methods: This prospective study was conducted on patients suffering from sepsis due to Gram-negative infection susceptible only to colistin. The dosing schedule for colistin was 9 million units stat followed by 4.5 million units at 12 hourly interval (adjusted as per body weight and renal functions). The serum creatinine and creatinine clearance were estimated at the start of therapy and daily during therapy. Results: Thirty-one patients suffering ventilator associated pneumonia (61.29%), blood stream infections (29.03%) and urinary tract infections (9.67%) due to Gram-negative multiple drug resistance organisms were assessed. Most commonly isolated organism were Acinetobacter baumannii (54.83%), Klebsiella pneumonia (16.12%) and Pseudomonas (29.03%). Five patients (16.12%) developed acute kidney injury within 4-5 days of start of therapy and returned to baseline after 6 days with no patient requiring renal replacement therapy or discontinuation of colistin. Conclusion: Our study showed that high-dose, extended-interval colistin can be given to critically ill patients without any significant risk of nephrotoxicity.
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Comparison of clonidine and dexmedetomidine for short-term sedation of intensive care unit patients p. 431
Uma Srivastava, Mita Eunice Sarkar, Aditya Kumar, Amrita Gupta, Archana Agarwal, Tapas Kumar Singh, Vivek Badada, Yogita Dwivedi
Background and Objectives: Patients on mechanical ventilation in intensive care unit (ICU) are often uncomfortable because of anxiety, pain, and endotracheal intubation; therefore, require sedation. Alpha-2 agonists are known to produce sedation. We compared clonidine and dexmedetomidine as sole agents for sedation. Study Design: Prospective, randomized, controlled open-label study. Materials and Methods: A total of 70 patients requiring a minimum of 12 h of mechanical ventilation with concomitant sedation, were randomly allocated into two groups. Group C (n = 35) received intravenous (IV) clonidine (1 μg/kg/h titrated up to 2 μg/kg/h to attain target sedation), and Group D (n = 35) received IV dexmedetomidine for sedation (loading 0.7 μg/kg and maintenance 0.2 μg/kg/h titrated up to 0.7 μg/kg/h to achieve target sedation). A Ramsay Sedation Score of 3-4 was considered as target sedation. Additional sedation with diazepam was given when required to achieve target sedation. The quality of sedation, hemodynamic changes and adverse effects were noted and compared between the two groups. Results: Target sedation was achieved in 86% observations in Group D and 62% in Group C (P = 0.04). Additional sedation was needed by more patients in Group C compared with Group D (14 and 8 in Groups C and D, respectively, P = 0.034), mainly due to concomitant hypotension on increasing the dose of clonidine. Hypotension was the most common side-effect in Group C, occurring in 11/35 patients of Group C and 3/35 patients of Group D (P = 0.02). Rebound hypertension was seen in four patients receiving clonidine, but none in receiving dexmedetomidine. Conclusion: Both clonidine and dexmedetomidine produced effective sedation; however, the hemodynamic stability provided by dexmedetomidine gives it an edge over clonidine for short-term sedation of ICU patients.
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Clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock from Rohtak, Haryana: A prospective observational study p. 437
Gurpreet Kaur, Nikhil Vinayak, Kundan Mittal, Jaya Shankar Kaushik, Mohammad Aamir
Background: Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries. Methods: A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated. Results: A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08). Conclusion: Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.
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A review of video laryngoscopes relevant to the intensive care unit Highly accessed article p. 442
Dharshi Karalapillai, Jai Darvall, Justin Mandeville, Louise Ellard, Jon Graham, Laurence Weinberg
The incidence of difficult direct intubation in the intensive care unit (ICU) is estimated to be as high as 20%. Recent advances in video-technology have led to the development of video laryngoscopes as new intubation devices to assist in difficult airway management. Clinical studies indicate superiority of video laryngoscopes relative to conventional direct laryngoscopy in selected patients. They are therefore an important addition to the armamentarium of any clinician performing endotracheal intubation. We present a practical review of commonly available video laryngoscopes with respect to design, clinical efficacy, and safety aspects relevant to their use in the ICU.
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Acute encephalitis syndrome following scrub typhus infection p. 453
Ayan Kar, M Dhanaraj, Devaprasad Dedeepiya, K Harikrishna
Objective: The aim was to find the incidence of acute encephalitis syndrome (AES) secondary to scrub infection and to observe the clinical, biochemical, radiological profile, and outcomes in these patients. Materials and Methods: A total of 20 consecutive patients of AES were evaluated for scrub infection using scrub typhus immunoglobulin M enzyme linked immuno-sorbant assay positivity along with the presence or absence of an eschar. Clinical profile, routine laboratory tests, cerebrospinal fluid (CSF) analysis, and neuroimaging were analyzed. Patients were treated with doxycycline and followed-up. Results: Among 20 consecutive patients with AES, 6 (30%) were due to scrub infection. They presented with acute onset fever, altered sensorium, seizures. "Eschar" was seen in 50% of patients. CSF done in two of them was similar to consistent with viral meningitis. Magnetic resonance imaging brain revealed cerebral edema, bright lesions in the putamen and the thalamus on T2-weighted and fluid-attenuated inversion recovery sequences. Renal involvement was seen in all patients. All patients responded well to oral doxycycline. Conclusion: AES is not an uncommon neurological presentation following scrub typhus infection. It should be suspected in all patients with fever, altered sensorium, and renal involvement. Oral doxycycline should be started as early as possible for better outcomes.
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Hypomagnesemia in the intensive care unit: Choosing your gastrointestinal prophylaxis, a case report and review of the literature p. 456
Aileen K Wang, Shweta Sharma, Paul Kim, Karen Mrejen-Shakin
We report a case of symptomatic hypomagnesaemia in medical intensive care unit that is strongly related to proton pump inhibitors (PPIs) and provide literature review. A 65-year-old male with severe gastroesophageal reflux on omeprazole 20 mg orally twice a day, who presented to the hospital with abdominal pain, nausea, diarrhea, and new onset seizures. On admission, his serum magnesium level was undetectable. Electrocardiogram showed a new right bundle branch block with a prolonged QT interval. The hypomagnesemia was corrected with aggressive magnesium supplementation and hypomagnesemia resolved only after the PPI was stopped. Neurologic and cardiac abnormalities were corrected. This is a life-threatening case of an undetectable magnesium level strongly associated with PPI use. In critically, ill patients with refractory hypomagnesemia, we advocate considering changing gastrointestinal prophylaxis from a PPI to a histamine-receptor blocker.
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Severe valproate induced hyperammonemic encephalopathy successfully managed with peritoneal dialysis p. 461
Amandeep Kumar, Ashish Suri, Bhawani S Sharma
Valproic acid (VPA) is a commonly used drug for epilepsy, psychiatric disorders and migraine and is frequently used in neurosurgical intensive care units. Though most of its side-effects are mild and transient, certain idiosyncratic side-effects have been attributed to VPA. Valproate induced hyperammonemia (VIH) is one such side-effect. VIH can produce symptoms of encephalopathy known as valproate induced hyperammonemic encephalopathy (VHE). VIH and VHE usually respond to withdrawal of VPA. However, in some cases VHE can be unresponsive to supportive measures and severe enough to be life-threatening. In such cases, dialysis can be used to rapidly reverse hyperammonemia and VHE and can prove to be a lifesaving measure. We report such a case of VIH and life-threatening VHE in a postoperative neurosurgical patient that was managed successfully with peritoneal dialysis.
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A rare cause of wheezing in an infant: Esophageal duplication cyst p. 464
Kapil Kapoor, Mamta Jajoo, Swati Dublish, Anup Mohta
Esophageal duplication cyst (EDC) is classified as a subgroup of foregut duplication cyst. They are very rare and predominantly detected in children. We present an unusual cause of wheezing in a 2-month-old infant. The diagnosis of EDC was suspected by bronchoscopy, provisionally confirmed by magnetic resonance imaging, and followed by successful surgical excision of the cyst. We conclude that foregut duplication cyst of the esophagus is very rare, and must be considered in the differential diagnosis of persistent wheezing in infants who do not respond to conventional treatment.
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Amlodipine poisoning revisited: Acidosis, acute kidney injury and acute respiratory distress syndrome p. 467
Kushal Naha, J Suryanarayana, Riffat Abdul Aziz, Barkur Ananthakrishna Shastry
We report the case of an 18-year-old girl presenting with shock following ingestion of 85 mg of amlodipine and 850 mg of atenolol with suicidal intent. Subsequently, the patient developed severe metabolic acidosis, acute kidney injury, and acute respiratory distress syndrome, which were managed conservatively. The patient ultimately made a full recovery. Given the popularity of amlodipine and atenolol as antihypertensive drugs in this part of the world, it is likely that more such cases will be encountered in the future. Physicians should be aware of the severe complications that can develop with amlodipine overdose.
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Acute kidney injury and rhabdomyolysis due to multiple wasp stings p. 470
Hemachandar Radhakrishnan
In most patients, wasp stings cause local reactions and rarely anaphylaxis. Acute kidney injury and rhabdomyolysis are unusual complications of wasp stings. We report a case of acute kidney injury and rhabdomyolysis secondary to multiple wasp stings. A 55-year-old farmer developed multi organ dysfunction with acute kidney injury and rhabdomyolysis 3 days after he had sustained multiple wasp stings. The etiology of acute kidney injury is probably both rhabdomyolysis and acute tubular necrosis. He improved completely after hemodialysis and intensive care.
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Hydatid cyst of the interventricular septum causing complete heart block and postoperative ventricular septal defect p. 473
Feridoun Sabzi, Reza Faraji
Cardiac involvement is seen in 0.5-2% of patients with hydatid disease, and involvement of the interventricular septum (IVS) is even rarer. We report surgical treatment of a large cardiac hydatid cyst in the IVS. A 55-year-old woman presented with dyspnea and bradycardia. Transthoracic echocardiography revealed a large cyst in the mid to apical part of the IVS. The patient was placed on cardiopulmonary bypass. Through an incision to bulging part of cyst into right atrium, and without opening adjacent cardiac chambers, we aspirated the entire contents of the cyst, removed its germinative membrane, and washed the cavity with 96% alcoholic solution. The patient recovered uneventfully. She had begun taking albendazole 5 days preoperatively, and this therapy was continued for 12 weeks postoperatively. A permanent pace maker was implanted because she was dependent on temporary pace maker and after 1 year follow-up, complete heart block had not recovered to normal conduction rhythm.
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Scrub typhus presenting as Purpura fulminans p. 476
Suhasini Tirumala, Bijayini Behera, Srikanth Jawalkar, Pradeep Kumar Mishra, Pavithra Vani Patalay, Sudha Ayyagari, Pavani Nimmala
Seriously ill patients presenting with purpura fulminans, sepsis and multi-organ failure often require extensive diagnostic workup for proper diagnosis and management. Host of common infections prevalent in the tropics, e.g. malaria, dengue; other septicemic infections e.g. meningococcemia, typhoid, leptospirosis, toxic shock syndrome, scarlet fever, viral exanthems like measles, infectious mononucleosis, collagen vascular diseases (Kawasaki disease, other vasculitis) diseases, and adverse drug reactions are often kept in mind, and the index of suspicion for rickettsial illness is quite low. We present a case of Indian tick typhus presenting with purpura fulminans (retiform purpura all over the body), sepsis and multiorgan failure without lymphadenopathy and eschar, successfully treated with doxycycline and discharged home. Hence, a high index clinical suspicion and prompt administration of a simple therapy has led to successful recovery of the patient.
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"Syndromic approach" to diagnosis and treatment of critical tropical infections p. 479
Hai Err, Viroj Wiwanitkit
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Reusable ultrasound probe covers p. 479
Richa Saroa, Sukanya Mitra, Shradha Sinha
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Bedside test for anisocoria: Not a small matter p. 480
Subramanian Senthilkumaran, Namasivayam Balamurugan, Ritesh G Menezes, Ponniah Thirumalaikolundusubramanian
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A lost guidewire p. 481
Pralay Kumar Sarkar, Kamal Mubarak
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Well-designed trials on TEE monitoring in the ICU: The time has arrived p. 482
Vijay Krishnamoorthy
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Methylene blue unresponsive methemoglobinemia p. 483
Seyed Mostafa Mirakbari
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Role of acidic pH of intravenous fluids in subsequent development of metabolic acidosis- may not be what it seems p. 484
Priyam Saikia, Dipika Choudhury, Bikash B Bora
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