Indian Journal of Critical Care Medicine
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  ╗ Table of Contents - Current issue
July 2016
Volume 20 | Issue 7
Page Nos. 385-437

Online since Wednesday, July 13, 2016

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Impact of malnutrition on pediatric risk of mortality score and outcome in Pediatric Intensive Care Unit Highly accessed article p. 385
Romi Nangalu, Puneet Aulakh Pooni, Siddharth Bhargav, Harmesh Singh Bains
Objectives: This study was done to determine the effect of malnutrition on mortality in Pediatric Intensive Care Unit (PICU) and on the pediatric risk of mortality (PRISM) scoring. Subjects and Methods: This was a prospective study done over 1 year. There were total 400 patients (1 month 14 years), who were divided into cases with weight for age <3 rd centile and controls with ≥3 rd centile of WHO charts. Cases were subdivided into mild/moderate (61-80% of expected weight for age) and severe malnutrition (<60%). Results: Out of total, 38.5% patients were underweight, and malnutrition was more in infancy, 61/104, i.e. 58.5% (P - 0.003). There was no significant difference in vitals at admission. Cases needed prolonged mechanical ventilation (P - 0.0063) and hospital stay (P - 0.0332) compared to controls. Mean and median PRISM scores were comparable in both the groups, but mortality was significantly higher in severely malnourished (P value 0.027). Conclusion: Severe malnutrition is independently associated with higher mortality even with similar PRISM score. There is need to give an additional score to children with weight for age <60% of expected.
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Characteristics and mortality of elderly patients admitted to the Intensive Care Unit of a district hospital p. 391
JosÚ Carlos Llamas Reyes, Joaquín Valle Alonso, Javier Fonseca, Margarita Luque Santos, María de los Ángeles Ruiz-Cabello Jiménez, Jay Braniff
Aim: To study all the elderly patients (≥75 years) who were admitted in an Intensive Care Unit (ICU) of a Spanish hospital and identify factors associated with mortality. Patients and Methods: A retrospective, observational data collected prospectively in patients ≥75 years recruited from the ICU in the period of January 2004 to December 2010. Results: During the study period, 1661 patients were admitted to our unit, of whom 553 (33.3%) were older than 75 years. The mean age was 79.9 years, 317 (57.3%) were male, and the overall in-hospital mortality was 94 patients (17% confidence interval 14-20.3%). When comparing patients who survived to those who died, we found significant differences in mean age (P = 0.001), Acute Physiologic Assessment and Chronic Health Evaluation II and Simplified Acute Physiology Scoring II (SAPS II) on admission (P < 0.0001, postoperative patients (P = 0.001), and need for mechanical ventilation (P < 0.0001). Comparing age groups, we found statistically significant differences in SAPS II (P = 0.007), diagnosis of non-ST-segment elevation myocardial infarction (P = 0.014), complicated postoperative period (P = 0.001), and pacemaker (P = 0.034). Mortality between the groups was statistically significant (P = 0.004). The survival between the group of 65 and 74 years and patients >75 years was not significant (P = 0.1390). Conclusions: The percentage of elderly patients in our unit is high, with low mortality rates. The age itself is not the sole determinant for admission to the ICU and other factors should be taken into account.
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A comparative cost analysis of polytrauma and neurosurgery Intensive Care Units at an apex trauma care facility in India p. 398
Parmeshwar Kumar, V Jithesh, Shakti Kumar Gupta
Context: Although Intensive Care Units (ICUs) only account for 10% of the hospital beds, they consume nearly 22% of the hospital resources. Few definitive costing studies have been conducted in Indian settings that would help determine appropriate resource allocation. Aim: The aim of this study was to evaluate and compare the cost of intensive care delivery between multispecialty and neurosurgery ICUs at an apex trauma care facility in India. Materials and Methods: The study was conducted in a polytrauma and neurosurgery ICU at a 203-bedded Level IV trauma care facility in New Delhi, India, from May 1, 2012 to June 30, 2012. The study was cross-sectional, retrospective, and record-based. Traditional costing was used to arrive at the cost for both direct and indirect cost estimates. The cost centers included in the study were building cost, equipment cost, human resources, materials and supplies, clinical and nonclinical support services, engineering maintenance cost, and biomedical waste management. Statistical Analysis: Statistical analysis was performed by Fisher's two tailed t-test. Results: Total cost/bed/day for the multispecialty ICU was Rs. 14,976.9/- and for the neurosurgery ICU, it was Rs. 14,306.7/-, workforce constituting nearly half of the expenditure in both ICUs. The cost center wise and overall difference in the cost among the ICUs were statistically significant. Conclusions: Quantification of expenditure in running an ICU in a trauma center would assist health-care decision makers in better allocation of resources. Although multispecialty ICUs are more cost-effective, other factors will also play a role in defining the kind of ICU that needs to be designed.
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Early demographic and clinical predictors of developing acute kidney injury in snake bite patients: A retrospective controlled study from an Indian tertiary care hospital in North Eastern Uttar Pradesh India p. 404
RR Singh, Dharmendra Uraiya, Anoop Kumar, Neeraj Tripathi
Aims: This study was conducted retrospectively to define early demographic and clinical predictors for acute kidney injury (AKI) among snake bite patients at the time of hospital admission. Materials and Methods: We analyzed 138 cases with a poisonous snake bite. Patients were classified into two groups according to the presence and absence of AKI. The data regarding clinical features and demographic profile of these patients were collected from the hospital records in a prestructured pro forma and statistically compared. Results: Of the 138 patients of venomous snake bite, 62 developed AKI (44.92%). Patients who developed AKI were older in age. Moreover, prolonged bite to anti-snake venom (ASV) time had a significant relationship in developing AKI (P < 0.05). Among the clinical features, there was an independent positive association of AKI with abdomen pain, tenderness and vomiting, cellulitis, bleeding tendencies, myalgia, and black or brown urine (P < 0.05). Neurological features were inversely associated with renal involvement. Conclusion: We found that marked abdominal pain, tenderness and vomiting, myalgia, black or brown urine, bite site cellulitis, bleeding tendencies, and prolonged (>2 h) bite to ASV time were significantly associated with the development of AKI in snake bite patients.
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Complications of tracheal intubation in critically ill pediatric cancer patients p. 409
Suhail Sarwar Siddiqui, S Janarthanan, MM Harish, Harish Chaudhari, R Natesh Prabu, Jigeeshu V Divatia, Atul Prabhakar Kulkarni
Background and Aims: The oncologists are treating cancer more aggressively, leading to increase in number of pediatric admissions to the ICU. Due to anatomical and physiological differences, pediatric patients are at high risk of complications during intubation. We evaluated the incidence of complications during intubations in pediatric patients in our ICU. Subjects and Methods: We performed retrospective analysis of complications occurring during intubation in 42 pediatric patients. All intubations were orotracheal. We recorded number of attempts at intubation, need for use of intubation adjuncts and complications during laryngoscopy and intubation. The incidence of difficult intubation, hypoxia, and severe cardiovascular collapse was also noted. Results: Complications occurred during 13 (31%) intubations. Hypoxia and severe cardiovascular collapse occurred in during 7 (16.7%) intubations each, while 4 patients (9.5%) (n=4) had cardiac arrest during intubation. Thirty three (78.6%) intubations were successful in first attempt and difficult intubation was recorded in 4 patients. Conclusion: Critically ill pediatric cancer patients have a high rate of complications during intubation.
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The incidence of deep venous thrombosis in high-risk Indian neurosurgical patients: Need for early chemoprophylaxis? p. 412
Ajith John George, Shalini Nair, Jayanthi Chinnaiya Karthic, Mathew Joseph
Introduction: Deep venous thrombosis (DVT) is thought to be less common in Asians than in Caucasian population. The incidence of DVT in high-risk groups, especially the neurosurgical (NS) patients, has not been well studied. This leaves no firm basis for the start of early prophylactic anticoagulation within first 5 postoperative days in Indian NS patients. This is a prospective observational study to determine the early occurrence of DVT in the NS patients. Patients and Methods: We screened 137 consecutive high-risk NS patients based on inclusion and exclusion criteria. The femoral veins were screened using Doppler ultrasound on day 1, 3, and 5 of admission into the NS Intensive Care Unit (ICU) at tertiary center from South India. Results: Among 2887 admissions to NICU 147 patients met inclusion criteria. One hundred thirty seven were screened for DVT. There was a 4.3% (6/137) incidence of DVT with none of the six patients having signs or symptoms of pulmonary embolism. Among the risk factors studied, there was a significant association with femoral catheterization and a probable association with weakness/paraparesis/paraplegia. The mortality in the study group was 10.8% with none attributable to DVT or pulmonary embolism. Conclusion: There is a low incidence of DVT among the high risk neurosurgical population evaluated within the first 5 days of admission to NICU, limiting the need for early chemical thrombo-prophylaxis in these patients. With strict protocols for mechanical prophylaxis with passive leg exercise, early mobilization and serial femoral Doppler screening, heparin anticoagulation can be restricted within the first 5 days of ICU admission in high risk patients.
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The role of C-reactive protein as a diagnostic predictor of sepsis in a multidisciplinary Intensive Care Unit of a tertiary care center in Nepal p. 417
Saurabh Pradhan, Ashish Ghimire, Balkrishna Bhattarai, Bashudha Khanal, Krishna Pokharel, Madhab Lamsal, Sidhhartha Koirala
Aim: C-reactive protein (CRP) is a commonly used biomarker of sepsis, the leading cause of mortality in Intensive Care Units (ICUs). However, sufficient data are still lacking to strongly recommend it in clinical practice. The present study is aimed to find out its reliability in diagnosing sepsis. Materials and Methods: CRP was measured in ICU-admitted patients with systemic inflammatory response syndrome and compared using a cutoff of 50 mg/L with the gold standard for diagnosing sepsis, taken as isolation of organism from a suspected source of infection or the Centers for Disease Control criteria for clinical sepsis. Results: CRP had a sensitivity and specificity of 84.3% and 46.15%, respectively. Area under the receiver operating characteristics curve was calculated to be 0.683 (±0.153, P < 0.05). The cutoff value with the best diagnostic accuracy was found to be 61 mg/L. Conclusion: CRP is a sensitive marker of sepsis, but it is not specific.
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Tombs of Aspergillus: A missed cause of recurrent respiratory infections in allergic bronchopulmonary aspergillosis p. 421
Onkar Kumar Jha, Arjun Khanna, Charul Dabral, Deepak Talwar
Broncholithiasis is an often overlooked condition and has been associated with symptoms such as cough, hemoptysis, and recurrent respiratory infections. The most common mechanism of a broncholith formation is the enlargement and subsequent erosion of a lymph node into an adjacent airway. Here, we describe this entity in a patient with advanced allergic bronchopulmonary aspergillosis, with chronic hypercapnic respiratory failure, and with frequent infective exacerbations. These frequent exacerbations were initially attributed to the poor lung function of the patient and the inability to cough out the secretions. The diagnosis of broncholithiasis was eventually established on bronchoscopy, when the patient was intubated and mechanically ventilated. In this patient, the mixed broncholiths were not associated with mediastinal lymphadenopathy and with biopsy showing Aspergillus with no lymph node tissue indicating its bronchial origin. A high index of suspicion should be kept in patients with recurrent infective exacerbations of pulmonary diseases, especially when computed tomography images show calcifications in the vicinity of airways even in the absence of lymphadenopathy, as most of these can be treated with routine bronchoscopic interventions.
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Systemic thrombolysis with recombinant tissue plasminogen activator for acute life-threatening Blalock-Taussig shunt obstruction p. 425
Franco Diaz, William C Sasser, Mark A Law, Jeffrey A Alten
Modified Blalock-Taussig shunt (mBTS) obstruction can be life-threatening, especially when it represents the only source of pulmonary blood flow. Current therapeutic options to reverse obstruction include surgical shunt revision/replacement, interventional endovascular procedures including balloon angioplasty and/or stent placement, and a combination of local and systemic thrombolytic therapy. We report two cases of acute mBTS thrombosis successfully treated with systemic recombinant tissue plasminogen activator in infants convalescing after cardiac surgery when the clinical status and resources precluded traditionally described rescue therapies.
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Acute intermittent porphyria: A critical diagnosis for favorable outcome p. 428
Chhaya Divecha, Milind S Tullu, Akanksha Gandhi, Chandrahas T Deshmukh
Acute intermittent porphyria (AIP) is an inherited metabolic disorder characterized by the accumulation of toxic metabolites of the heme pathway. It rarely presents in the prepubertal age group. AIP often presents with nonspecific and nonlocalizing symptoms. Moreover, several commonly used medications and stress states are known to precipitate an attack. We present the case of a previously healthy 5 years female who was diagnosed as acute central nervous system infection/inflammation at admission. It was the presence of red flags that led to a correct diagnosis. Besides supportive management, a dedicated search for intravenous hemin (chemically heme arginate, aminolevulinic acid synthase inhibitor, and drug of choice) was attempted. Unexpected help was rendered by doctors from a medical college in Gujarat, and two ampoules could be obtained. The patient received three doses of intravenous hemin; however, she succumbed later. This case is presented for the diagnostic and therapeutic challenges faced in developing countries.
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Hospital curtains: An undermined source of nosocomial infections p. 432
Usman Ghani, Salman Assad, Touqeer Sulehria, Immad Arif
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Dealing with the neglected public health issue of drowning in low-resource settings p. 433
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava, Jegadeesh Ramasamy
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Calculating incidence and prognosis in a prospective study p. 434
Kanica Kaushal
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Odontogenic-related sepsis p. 435
Ryan Wereski
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Erratum: Yakson touch as a part of early intervention in the Neonatal Intensive Care Unit: A systematic narrative review p. 437

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