Indian Journal of Critical Care Medicine
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  » Table of Contents - Current issue
September 2015
Volume 19 | Issue 9
Page Nos. 505-567

Online since Tuesday, September 08, 2015

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Measuring family satisfaction in an Indian Intensive Care Unit p. 505
Naveen Salins
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Critical care: Are we customer friendly? p. 507
Ramesh Venkataraman, Lakshmi Ranganathan, V Rajnibala, Babu K Abraham, Senthilkumar Rajagopalan, Nagarajan Ramakrishnan
Objective: Assessing and enhancing family satisfaction are imperative for the provision of comprehensive intensive care. There is a paucity of Indian data exploring family's perception of Intensive Care Unit (ICU) patients. We wanted to explore family satisfaction and whether it differed in families of patients admitted under intensivists and nonintensivists in our semi-open ICU. Methodology: We surveyed family members of 200 consecutive patients, between March and September 2009 who were in ICU for >3 days. An internationally validated family satisfaction survey was adapted and was administered to a family member, on day 4 of the patient's stay. The survey consisted of 15 questions in five categories - patient care, medical counseling, staff interaction, visiting hours, and facilities and was set to a Likert scale of 1-4. Mean, median, and proportions were computed to describe answers for each question and category. Results: A total of 515 patients were admitted during the study period, of which 200 patients stayed in the ICU >3 days. One family member each of the 200 patients completed the survey with 100% response rate. Families reported the greatest satisfaction with patient care (94.5%) and least satisfaction with visiting hours (60.5%). Chi-square tests performed for each of the five categories revealed no significant difference between satisfaction scores of intensivists and nonintensivists' patients. Conclusion: Family members of ICU patients were satisfied with current care and communication, irrespective of whether they were admitted under intensivists or nonintensivists. Family members preferred open visiting hours policy than a time limited one.
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Calcium homeostasis disorder during and after neonatal extracorporeal membrane oxygenation p. 513
Jerome Rambaud, Isabelle Guellec, Julia Guilbert, Pierre-Louis Léger, Sylvain Renolleau
Background and Aims: Extracorporeal membrane oxygenation (ECMO) is used during pediatric resuscitation in case of refractory hypoxemia or septic shock under maximum therapy. Previous studies describe calcium homeostasis dysregulation. The aim of this study was to confirmed of calcium homeostasis dysregulation in neonates under ECMO and supposed news explanation. Subjects and Methods: From November 2012 to July 2013, we performed a prospective single center observational study. Eleven neonatal patients were included. Blood was obtained before and during ECMO (day 7, 14 and 21) for parathyroid hormone (PTH), protein adjusted serum calcium, ionized calcium, magnesium, and calcitriol levels. All surviving patients underwent a consultation up to 6 months after ECMO weaning. Results: During ECMO PTH was inadequately high with normal serum calcium on day 7 (PTH: 73.54 ± 40 ng/l; calcemia: 2.33 ± 0.21 mmol/l), day 14 (PTH: 57.63 ± 29.57 ng/l; calcemia: 2.44 ± 0.43 mmol/l) and day 21 (PTH: 54.93 ± 8.43 ng/l; calcemia: 2.13 ± 0.09 mmol/l). The absence of correlation between serum calcium and PTH levels seem to confirm the dysregulation of PTH - serum calcium metabolism during ECMO. Six months after ECMO weaning, we noticed hypercalcemia with normal PTH. Conclusions: We confirmed the existence of severe disturbances of calcium homeostasis in neonates on ECMO and supposed the possible damage of calcium regulation. We did not succeed in finding clear explanations of these disturbances.
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Assessing nutrition in the critically ill elderly patient: A comparison of two screening tools p. 518
Swagata Tripathy, JC Mishra
Context: Few malnutrition screening tests are validated in the elderly Intensive Care Unit (ICU) patient. Aim: Having previously established malnutrition as a cause of higher mortality in this population, we compared two screening tools in elderly patients. Subjects and Methods: For this prospective study, 111 consecutive patients admitted to the ICU and > 65 years underwent the Malnutrition Universal Screening Tool (MUST), and the Geriatric Nutrition Risk Index (GNRI) screening tests. Statistical Analysis: Standard definition of malnutrition risk was taken as the gold standard to evaluate the sensitivity, specificity and predictive values of the tools. The k statistic was calculated to measure the agreement between the tools. The Shrout classification was used to interpret its values. Results: The mean age of the patients screened was 74.7 ± 8.4 (65-97 years). The standard definition, MUST and GNRI identified 52.2%, 65.4%, and 64.9% to be malnourished, respectively. The sensitivity and specificity of the tests were 96.5% computed tomography (CI) (87.9-99.5%) and 72.3% CI (57.5-84.5%) for MUST and 89.5% CI (75.2-96.7%) and 55.0% CI (75.2-96.9%) for GNRI, respectively. Screening was not possible by GNRI and MUST tool in 31% versus 4% of patients, respectively. The agreement between the tools was moderate for Standard-MUST k = 0.65 and MUST-GNRI k = 0.60 and fair for Standard-GNRI k = 0.43. Conclusions: The risk of malnutrition is high among our patients as identified by all the tools. Both GNRI and MUST showed a high sensitivity with MUST showing a higher specificity and greater applicability.
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Neonatal mechanical ventilation: Indications and outcome p. 523
Qazi Iqbal, Mir M Younus, Asif Ahmed, Ikhlas Ahmad, Javed Iqbal, Bashir A Charoo, S Wajid Ali
Background and Aims: Decreasing mortality in sick and ventilated neonates is an endeavor of all neonatologists. To reduce the high mortality in this group of neonates, identification of risk factors is important. This study was undertaken to find out the indications of ventilation and complications in ventilated neonates and also study possible predictors of outcome. Subjects: Age <1-month; mechanically ventilated; not having suspected metabolic disorders or congenital anomalies; excluding postoperative patients. Methods: Neonates consecutively put on mechanical ventilation during the study period (October 2011 to November 2013) enrolled. Primary disease of the neonates along with complications present listed. Clinical and laboratory parameters analyzed to find the predictors of mortality. Results: Total 300 neonates were ventilated. 52% were male. Mean age, weight, and gestational age were 21 ± 62 h, 2320 ± 846.2 g, and 35.2 ± 4.9 weeks, respectively. 130 (43%) neonates died. Respiratory distress syndrome (RDS) (31.1%), sepsis (22.7%), and birth asphyxia (18%) were the most common indications for ventilation. Mortality in ventilated patients with sepsis, pneumonia, RDS or birth asphyxia was 64.7%, 60%, 44.6%, and 33.3%, respectively. Weight <2500 g, gestation <34 weeks, initial pH <7.1, presence of sepsis, apnea, shock, pulmonary hemorrhage, hypoglycemia, neutropenia, and thrombocytopenia were significantly associated with mortality (P < 0.05). Resuscitation at birth, seizures, intra ventricular hemorrhage, pneumothorax, ventilator-associated pneumonia, PO 2 , or PCO 2 did not have a significant association with mortality. On logistic regression, gestation <34 weeks, initial pH <7.1, pulmonary hemorrhage, or shock were independently significant predictors of mortality. Conclusions: Weight <2500 g, gestation <34 weeks, initial arterial pH <7.1, shock, pulmonary hemorrhage, apnea, hypoglycemia, neutropenia, and thrombocytopenia were significant predictors of mortality in ventilated neonates.
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Critical care medicine for emerging Middle East respiratory syndrome: Which point to be considered? p. 528
Viroj Wiwanitkit
The Middle East respiratory syndrome (MERS) is a new emerging respiratory tract infection. This coronavirus infection is firstly reported from the Middle East, and it becomes threat for the global public health at present due to its existence in a remote area such as USA and Korea. The concern on the management of the patients is very important. Since most of the patients can develop severe respiratory illness and critical care management is needed, the issue on critical care for MERS is the topic to be discussed in critical medicine.
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Use of metabolic monitors in a multidisciplinary Intensive Care Unit: A prospective pilot study of 20 patients p. 531
Tanvir Samra, Neerja Banerjee, Arushi Gupta
Introduction: Caloric intake of critically ill patients are usually calculated using predictive equations. Recent advances in gas exchange measurements have the potential to estimate energy expenditure at the bedside and at different time periods. Materials and Methods: Energy needs of critically ill patients were estimated over a period of 3 months using simplistic formula of 25 kcal/kg/day estimated energy expenditure (EEE), Harris-Benedict equation (HBE) (Basal energy expenditure [BEE]) and M-COVX metabolic monitor resting energy expenditure (REE) on day 4 of Intensive Care Unit (ICU) admission. Calculations based on HBE were taken as standard, and percentage errors (PE) were calculated for each patient for values derived from simplistic formula and metabolic monitor. Adequacy of nutritional intake in ICU was also assessed. Results: Metabolic monitor could be used in only 20/70 patients. The mean age of patients was 40 years, 65% were males, and average body mass index was 23.69 kg/m 2 . Intermittent intolerance to feeds was reported in 50%. Values of REE and EEE were greater than BEE in 70% of patients. A significant difference was reported in values of PE of ≤20% and ≥30%; P = 0.0003 and 0.0001, respectively estimated using REE and EEE. Conclusions: It is not feasible to use metabolic monitors in all patients. Variability in readings is large and further studies are needed to establish the validity of its measurements. Calculations using simplistic formulas are much closer to values obtained using HBE.
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Targeted temperature management: Current evidence and practices in critical care p. 537
Saurabh Saigal, Jai Prakash Sharma, Ritika Dhurwe, Sanjay Kumar, Mohan Gurjar
Targeted temperature management (TTM) in today's modern era, especially in intensive care units represents a promising multifaceted therapy for a variety of conditions. Though hypothermia is being used since Hippocratic era, the renewed interest of late has been since early 21 st century. There have been multiple advancements in this field and varieties of cooling devices are available at present. TTM requires careful titration of its depth, duration and rewarming as it is associated with side-effects. The purpose of this review is to find out the best evidence-based clinical practice criteria of therapeutic hypothermia in critical care settings. TTM is an unique therapeutic modality for salvaging neurological tissue viability in critically ill patients viz. Post-cardiac arrest, traumatic brain injury (TBI), meningitis, acute liver failure and stroke. TTM is standard of care in post-cardiac arrest situations; there has been a lot of controversy of late regarding temperature ranges to be used for the same. In patients with TBI, it reduces intracranial pressure, but has not shown any favorable neurologic outcome. Hypothermia is generally accepted treatment for hypoxic ischemic encephalopathy in newborns. The current available technology to induce and maintain hypothermia allows for precise temperature control. Future studies should focus on optimizing hypothermic treatment to full benefit of our patients and its application in other clinical scenarios.
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Anaphylaxis to scorpion antivenin and its management following envenomation by Indian red scorpion, Mesobuthus tamulus Highly accessed article p. 547
Rahul Ramesh Bhoite, Girija Ramesh Bhoite, Dayanand N Bagdure, Himmatrao S Bawaskar
Mesobuthus tamulus is an Indian red scorpion that is responsible for numerous cases of scorpion stings in the Indian subcontinent. Antivenin, vasodilators, and benzodiazepines are medications of choice in the treatment of scorpion bites. Adverse reactions such as anaphylaxis to antivenin have been infrequently described in the literature. We, herein, present a case of a 42-year-old man stung by Indian red scorpion while gardening at home in India, who presented with extreme pain at the sting site and signs of cardio-toxicity. He was treated with scorpion antivenin and vasodilators but developed anaphylaxis to antivenin. We discuss management strategies. Anaphylaxis to antivenin should be on the differential during management of scorpion bites because classical signs of anaphylaxis may be absent.
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An unusually dry story p. 550
Srinivas Rajagopala, Gurukiran Danigeti, Dharanipragada Subrahmanyan
We present a middle-aged woman with a prior history of central nervous system (CNS) demyelinating disorder who presented with an acute onset quadriparesis and respiratory failure. The evaluation revealed distal renal tubular acidosis with hypokalemia and medullary nephrocalcinosis. Weakness persisted despite potassium correction, and ongoing evaluation confirmed recurrent CNS and long-segment spinal cord demyelination with anti-aquaporin-4 antibodies. There was no history of dry eyes or dry mouth. Anti-Sjogren's syndrome A antigen antibodies were elevated, and there was reduced salivary flow on scintigraphy. Coexistent antiphospholipid antibody syndrome with inferior vena cava thrombosis was also found on evaluation. The index patient highlights several rare manifestations of primary Sjogren's syndrome (pSS) as the presenting features and highlights the differential diagnosis of the clinical syndromes in which pSS should be considered in the Intensive Care Unit.
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Crimean-Congo hemorrhagic fever: An emerging threat for the intensivist p. 554
Abhinav Bhanot, Arjun Khanna, Deepak Talwar
We present the case of a 55-year-old female, who presented with 15 days of fever with rash, pancytopenia, and altered behavior. She was investigated for routine causes of fever with rash and multi organ dysfunction and treated for the same. As she tested negative for all routine causes of such an illness and did not show improvement to therapy, she was investigated for Crimean-Congo hemorrhagic fever and tested positive for the same. She was started on ribavirin, but eventually succumbed to her illness. This disease has rarely been reported from the Northern India and we need to have high clinical suspicion for this deadly disease so that appropriate therapy can be started in time for the patient and prophylaxis given to all inadvertently exposed.
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Difficult airway management from Emergency Department till Intensive Care Unit p. 557
Debasis Pradhan, Prithwis Bhattacharyya
We report a case of "can ventilate but can't intubate" situation which was successfully managed in the Emergency Department and Intensive Care Unit by the use of ProSeal laryngeal mask airway and Frova Intubating Introducer as bridging rescue devices. Use of appropriate technique while strictly following the difficult airway algorithm is the mainstay of airway management in unanticipated difficult airway situations. Although the multiple airway devices were used but each step took not more than 2 min and "don't struggle, skip to the next step principle" was followed. With the availability of many advanced airway management tools, the intensivists should have a training and experience along with preparedness in order to perform such lifesaving airway managements.
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Should intensivist do routine abdominal ultrasound? p. 560
Sukhen Samanta, Sujay Samanta, Kapil Dev Soni, Richa Aggarwal
Roundworm infestation is common in tropical climate population with a low socioeconomic status. We describe a case of a young male with polytrauma accident who presented with small bowel dysfunction with a high gastric residual volume during enteral feeding. While searching the etiology, the intensivist performed bedside abdominal ultrasound (USG) as a part of whole body USG screening along with clinical examination using different frequency probes to examine bowel movement and ultimately found ascariasis to be the cause. This case report will boost up the wide use of bedside USG by critical care physicians in their patient workup.
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Severe masseter spasms in a Rett syndrome during rapid sequence intubation: A succinylcholine severe side effect p. 563
Rambaud Jerome, Renolleau Sylvain
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System of adverse drug reactions reporting: What, where, how, and whom to report? p. 564
Vivekanandan Kalaiselvan, Pranay Kumar, Prabhakar Mishra, Gyanendra Nath Singh
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Factors for early death in rabies- the bitter truth p. 566
Subramanian Senthilkumaran, Narendra Nath Jena, Sandeep B Gore, Rishya Manikam, Ponniah Thirumalaikolundusubramanian
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