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January 2017
Volume 21 | Issue 1
Page Nos. 1-64

Online since Friday, January 13, 2017

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EDITORIAL  

Can less be more in intensive care? p. 1
Farhad N Kapadia, Ritoo Kapoor, Mayuri Trivedi
DOI:10.4103/0972-5229.198308  
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RESEARCH ARTICLES Top

The impact of early tracheostomy in neurotrauma patients: A retrospective study p. 6
Kapil G Zirpe, Deepali Vishnu Tambe, Abhijit M Deshmukh, Sushma K Gurav
DOI:10.4103/0972-5229.198309  
Background: Although majority of neurotrauma patients require long term ventilatory support but the timing of tracheostomy in such patients is controversial. Method: This retrospective study was conducted at a Tertiary Care Hospital, Pune, India. Patients >18 years of age, who underwent percutaneous tracheostomy (PCT) from June 2010 to November 2014 at neurotrauma unit (NTU) of hospital, were included. Patients were divided in two groups according to the timing of tracheostomy, early tracheostomy (ET) group (≤5 days; N=100) and late tracheostomy (LT) group (>5 days; N=64). The nonparametric Mann-Whitney test, and Chi-square tests were used to compare these groups. Result: There were no significant differences between the groups in terms of age, sex, APACHE II and GCS Score. Patients in the ET group had a significantly shorter stay in the NTU compared to patients in the LT group (mean, 18 vs. 21.2 days, p=0.005), fewer mechanical ventilation days (mean, 8.1 vs. 11.7 days, P=0.000) and shorter length of stay in hospital (mean, 28.8 vs. 34.37 days, P=0.019). There was no difference between ET and LT groups in post PCT ventilator free days (mean, 8.2 vs. 9.4 days; P=0.094). Mortality rates in ET vs. LT groups were also comparable (35% vs. 29.7%; P=0.480). Conclusion: Results suggest that ET in neurotrauma patients might be associated with shorter length of stay in NTU and hospital, and shorter duration of mechanical ventilation however there was no mortality difference.
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Experiences with continuous venovenous hemofiltration using 18mmol/l predilution citrate anticoagulation and a phosphate containing replacement solution p. 11
Yuen Henry Jeffrey, Shum Hoi-Ping, Anne Leung Kit Hung, Lam Chung-Ling, Yan Wing-Wa, Lai King-Yiu
DOI:10.4103/0972-5229.198311  
Context: Regional citrate anticoagulation for continuous renal replacement therapy is associated with a longer filter-life, less bleeding events and improved mortality. Problems associated with using Prismocitrate 10/2 solution in continuous renal replacement therapy, include hypomagnesemia, hypophosphatemia and the need for additional bicarbonate infusion. Aims: This study uses the new Prismocitrate 18/0 solution for improved buffer balance and Phoxilium solution for a more favourable electrolyte profile. Settings and Design: A retrospective analysis of patients who underwent continuous venovenous hemofiltration (CVVH) using Prismocitrate 18/0 and Phoxilium in our 21-bed ICU was conducted from March to July 2014. Methods and Material: Continuous venovenous hemofiltration (CVVH) was performed at fixed rate by using Prismocitrate 18/0 predilution at 1250 ml/hour, a blood flow rate of 110 ml/min and post-replacement with Phoxilium at 1250 ml/hr. CVVH was run for 72 h or until filter clotting, transportation, or achievement of the clinical target. Statistical Analysis Used: The results were displayed as the median with the interquartile range (IQR). The trend in pH, electrolytes, and base excess are shown using a standard box plot. All analyses were performed by the Statistical Package for Social Science for Windows, version 17 (SPSS, Chicago, IL, USA). Results: Forty-five CVVH episodes were analysed. The median circuit lifetime was 44 h (interquartile range, IQR 29-55). Metabolic alkalosis, hypophosphatemia and hypomagnesemia occurred in 8.3%, 3.5% and 40.2% of the blood samples, respectively. No patient developed hypokalemia or citrate toxicity. Conclusions: This new CVVH regime is safe and easy to administer for critically ill patients.
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Outcome of noncardiac surgical patients admitted to a multidisciplinary intensive care unit p. 17
Pradeep Kumar, MK Renuka, MS Kalaiselvan, AS Arunkumar
DOI:10.4103/0972-5229.198321  
Context: Surgical procedures carry significant morbidity and mortality depending on the type of surgery and patients. There is a dearth of evidence from India on the outcome of surgical patients admitted to an Intensive Care Unit (ICU). Aims: We aimed to describe the incidence and risk factors of postoperative complications and mortality in noncardiac surgical patients admitted to the ICU. Settings and Design: This was a prospective observational study on all perioperative patients admitted to a multidisciplinary ICU for 18 months. Subjects and Methods: Data on demography, admission Acute Physiology and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA) scores, perioperative course, type and duration of surgery, reason for ICU admission, ICU interventions, and perioperative complications were recorded. The primary outcomes analyzed were perioperative complications and mortality. Results: The study included 762 patients with a mean age of (mean ± standard deviation [SD]) 50.5 ± 18 years and a male (58.4%) preponderance. The mean (±SD) admission APACHE-II and SOFA scores were 15 (±5.0) and 4.26 (±2.6), respectively. The most common reason for ICU admission was elective mechanical ventilation 50%, followed by prolonged surgery 26.2% and hemodynamic instability 21.2%. Most (51.1%) patients belonged to American Society of Anaesthesiologists physical Status III or IV and Lee's surgical risk Category I and II (66.8%). The most common surgical procedures performed were gastro-intestinal (28.5%) followed by interventional Neuro-radiology (14.0%) and orthopedic (13.9%). Overall perioperative complications were observed in 51.4% (n = 392). Common complications observed were hemodynamic instability 24%, hypothermia 17.2%, sepsis 17.3%, poor glycemic control 11.2%, perioperative myocardial infarction 7.1%, cardiac arrest 0.13%, and acute kidney injury (AKI) 10.1%. The overall hospital mortality was 7.9%. Multivariate logistic regression analysis showed that admission APACHE-II score, sepsis, AKI, and ICU length of stay were independent predictors for mortality. Conclusions: High risk perioperative patients after noncardiac surgery have significant mortality and morbidity.
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Dynamic changes of plasma neutrophil gelatinase-associated lipocalin predicted mortality in critically ill patients with systemic inflammatory response syndrome p. 23
Azrina Md Ralib, Suhaila Nanyan, Mohd Basri Mat Nor
DOI:10.4103/0972-5229.198322  
Background and Aims: About 50% of patients admitted to the Intensive Care Unit have systemic inflammatory response syndrome (SIRS), and about 10%-20% of them died. Early risk stratification is important to reduce mortality. Plasma neutrophil gelatinase-associated lipocalin (NGAL) is increased by inflammation and infection. Its ability to predict mortality in SIRS patients is of interest. We evaluated the ability of serial measurement of NGAL for the prediction of mortality in critically ill patients with SIRS. Materials and Methods: This is a secondary analysis of a single-center, prospective, observational study. Patients who fulfill the SIRS criteria were recruited in the study. Delta NGAL at 24 and 48 h (ΔNGAL-24 and ΔNGAL-48) was defined as 24 and 48 h NGAL minus day 1 NGAL; NGAL clearance (NGALc) was defined as percentage of ΔNGAL over day 1 NGAL. The primary outcome of the study is in-hospital mortality. Results: A total of 151 patients were analyzed, of which 53 (35%) died. Nonsurvivors were older (51 vs. 45, P = 0.03) and had higher Sequential Organ Failure Assessment (9 ± 7 vs. 7 ± 4, P = 0.02) and Simplified Acute Physiology Score II (47 ± 15 vs. 40 ± 15, P = 0.01) scores as compared to survivors. NGAL concentrations over 3 days were higher in nonsurvivors compared to survivors (repeated measures analysis of variance, P = 0.02). Day 1 NGAL, ΔNGAL-24, and NGALc-24 were not independently predictive of mortality. However, day 3 NGAL, ΔNGAL-48, and NGALc-48 were predictive after adjusted for age and severity of illness (odds ratio 9.1 [1.97-41.7]). Conclusions: NGAL dynamics over 48 h independently predicted mortality in critically ill patients with SIRS. This could assist clinicians in risk stratification of this group of high-risk patients.
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CASE REPORTS Top

Hypernatremia in the neonate: Neonatal hypernatremia and hypernatremic dehydration in neonates receiving exclusive breastfeeding p. 30
Nilofer Salim Mujawar, Archana Nirmal Jaiswal
DOI:10.4103/0972-5229.198323  
Aims and Objectives: Evaluation of neonatal hypernatremia and hypernatremic dehydration in neonates receiving exclusive breastfeeding. Introduction: Neonatal hypernatremia is a serious condition in the newborn period. We present infants with hypernatremic dehydration due to breast milk (BM) hypernatremia. Hypernatremic dehydration in breast-fed newborns is usually secondary to insufficient lactation. We present the neonatal hypernatremia and hypernatremic dehydration encountered between January and December, 2012, its causes and treatment. Methodology: This was a retrospective study. We analyzed records of babies admitted to the Neonatal Intensive Care Unit who were investigated and found to have hypernatremia and whose mother's BM sodium (BM Na) was done. Inclusion Criteria: (1) Babies with serum Na >145 meq/l, (2) euglycemia, (3) normocalcemic, (4) no clinical and lab evidence of sepsis, (5) exclusive breast feeds. Exclusion Criteria: Neonates not satisfying any mentioned criterion. Results: BM Na correlated strongly with neonatal hypernatremia in exclusively breast-fed babies who did not otherwise have any risk factor. Conclusion: Elevated BM Na is an important etiological factor in neonatal hypernatremia.
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BRIEF COMMUNICATIONS Top

Zinc supplementation in adult mechanically ventilated trauma patients is associated with decreased occurrence of ventilator-associated pneumonia: A secondary analysis of a prospective, observational study p. 34
Farshad Hasanzadeh Kiabi, Abbas Alipour, Hadi Darvishi-Khezri, Aily Aliasgharian, Amir Emami Zeydi
DOI:10.4103/0972-5229.198324  
Background: Ventilator-associated pneumonia (VAP) is a type of lung infection that typically affects critically ill patients undergoing mechanical ventilation (MV) in the Intensive Care Unit (ICU). The aim of this analysis is to determine potential association between zinc supplementation with the occurrence of VAP in adult mechanically ventilated trauma patients. Subjects and Methods: This secondary analysis of a prospective observational study was carried out over a period of 1 year in ICUs of one teaching hospital in Iran. A total of 186 adults mechanically ventilated trauma patients, who required at least 48 h of MV and received zinc sulfate supplement (n = 82) or not (n = 104) during their ICU stay, were monitored for the occurrence of VAP until their discharge from the ICU or death. Results: Forty-one of 186 patients developed VAP, 29.09 days after admission (95% confidence interval [CI]: 26.27-31.9). The overall incidence of VAP was 18.82 cases per 1000 days of intubation (95% CI: 13.86-25.57). Patients who received zinc sulfate supplement have smaller hazard of progression to VAP than others (hazard ratio: 0.318 [95% CI: 0.138-0.732]; P < 0.0001). Conclusion: The findings show that zinc supplementation may be associated with a significant reduction in the occurrence of VAP in adult mechanically ventilated trauma patients. Further well-designed randomized clinical trials to confirm the efficacy of this potential preventive modality are warranted.
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Invasive candidiasis in severe acute pancreatitis: Experience from a tertiary care teaching hospital p. 40
Arvind Kumar Baronia, Afzal Azim, Armin Ahmed, Mohan Gurjar, Rungmei S. K. Marak, Reema Yadav, Preeti Sharma
DOI:10.4103/0972-5229.198325  
Background: Invasive candidiasis (IC) is associated with increased morbidity in severe acute pancreatitis (SAP). There is limited information regarding the predisposing factors, Candida species distribution and in vitro susceptibility. Methodology: Current data have been derived from a larger prospective nonintervention study conducted on 200 critically ill patients which was done to study the antifungal prescription practices, collect epidemiological data, and perform an external validation of risk prediction models for IC under senior research associateship program of Council of Scientific and Industrial Research New Delhi. Of these critically ill patients, thirty had SAP and were included for analysis. Results: There were 23 males and 7 females. Out of eight patients (27%) who developed IC, three had isolated candidemia, two had isolated deep-seated candidiasis while three had both candidemia and deep-seated candidiasis. SAP patients with IC had a longer duration of Intensive Care Unit stay, hospital stay, days on mechanical ventilation and duration of shock. Mortality was not different between SAP patients with or without IC. Conclusion: There is a high rate of Candida infection in SAP. More studies are needed to generate epidemiological data and develop antifungal stewardship in this subset of high-risk population.
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Benefits of and untoward events during intrahospital transport of pediatric intensive care unit patients p. 46
MM Harish, Suhail Sarwar Siddiqui, Natesh R Prabu, Harish K Chaudhari, Jigeeshu V Divatia, Atul Prabhakar Kulkarni
DOI:10.4103/0972-5229.198326  
Background and Aims: The transport of critically ill patients for procedures or imaging outside the Intensive Care Unit (ICU) is potentially hazardous; hence, the transport process must be organized and efficient. The literature about benefits of and untoward events (UEs) during intrahospital transport of pediatric critically ill patient is scarce. We, therefore, audited the UEs during and benefits of intrahospital transport of critically ill pediatric patients in our ICU. Subjects and Methods: Eighty critically ill pediatric (<18 years) cancer patients, transported from the ICU for either diagnostic or therapeutic procedure over a period of 6 months, were included in the study. The data collected included the destination (computed tomography scan, intervention radiology, magnetic resonance imaging scan, and operation theater), accompanying medical personnel, UEs, and benefits obtained during transport. Results: Among eighty pediatric patients, the median age was 8 years (range 2-17 years). During the transport, four (5%) patients required endotracheal intubation, three (3.75%) patients required intercostal drain placement, and six (7.5%) patients required cardiopulmonary resuscitation. Accidental removal of central venous catheter was reported in three (3.75%) patients, drain came out in four (5%) patients, and three (3.75%) patients had accidental extubation. Transport indirectly led to a change in antibiotic therapy in 24 (30%) patients and directly helped in change of therapy in the form of interventions in 20 (25%) patients. Conclusion: Critically ill children can be transported safely with adequate pretransport preparations, which may help in avoiding major UEs and benefit the patient by change in the therapy.
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CASE REPORTS Top

Chinese restaurant syndrome p. 49
Himmatrao Saluba Bawaskar, Pramodini Himmatrao Bawaskar, Parag Himmatrao Bawaskar
DOI:10.4103/0972-5229.198327  
In India, eating Chinese food has become very popular. We hereby report a case who presented with angioneurotic edema of the uvula and the surrounding structures, after eating Chinese food, which resulted in severe difficulty in swallowing saliva and inability to speak.
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Large in-transient left ventricular thrombus due to anabolic steroid-induced cardiomyopathy p. 51
Feridoun Sabzi, Reza Faraji
DOI:10.4103/0972-5229.198328  
The presence of small or moderate size thrombosis is not uncommon in left ventricle (LV) as results of basic co-moribund disease, but huge LV thrombosis that protrudes to aortic valve in the LV outflow tract (LVOT) tract is an exceptionally rare phenomenon. We report a 34-year-old bodybuilder athlete with cardiomyopathy and massive LV thrombosis. The thrombosis extended to LVOT and protruded through the aortic valve in systole and posed a high risk of systemic emboli. The patient underwent open heart surgery, and the clot was removed. The operation was complicated by low cardiac output syndrome that managed by intra-aortic balloon pump and high dose of inotropic drugs and hemodialysis. The patient died on the 15 th day after surgery with multiorgan failures.
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Hyperchloremic metabolic acidosis following total gut irrigation with normal saline in pediatric patients: A rare occurrence p. 55
Indu Bala, Deepak Dwivedi, Divya Jain, Jai Kumar Mahajan
DOI:10.4103/0972-5229.198329  
Use of 0.9% sodium chloride for total gut irrigation (TGI) through nasogastric route is an effective method of bowel preparation in children undergoing colorectal surgeries. TGI with normal saline (NS) can result in nausea, vomiting, abdominal distension, and mild electrolyte imbalance; however, hyperchloremic metabolic acidosis has not been documented. We report two cases of hyperchloremic metabolic acidosis in children posted for colorectal surgery following TGI with NS who were successfully managed.
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Pericardial effusion and cardiac tamponade following percutaneously inserted central line insertion in an extremely low-birth-weight baby: Case report and successful management p. 57
Avinash V Desai, Abnish Kumar, Praful Shanbhag, Forum Shah
DOI:10.4103/0972-5229.198330  
Pericardial effusion and cardiac tamponade are rare complications of percutaneously inserted central lines (PICLs), in extremely low-birth-weight babies. This particular complication carries a high degree of mortality, if not suspected and diagnosed. Bedside echocardiography proves not only diagnostic but also can be lifesaving in these conditions. Here, we wish to report such a baby who suddenly deteriorated and showed cardiovascular instability 2 days after the insertion of PICL. Immediate bedside echocardiography helped pick up the effusion which was drained using a subxiphoid percutaneous approach.
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LETTERS TO THE EDITOR Top

Armored endotracheal tube: Concerns in intensive care unit p. 60
Vinodhadevi Vijayakumar, Arimanickam Ganesamoorthi
DOI:10.4103/0972-5229.198331  
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Re: thoughts on the current management of acute aluminum phosphide toxicity and proposals for therapy: An evidence-based review p. 61
Hossein Hassanian-Moghaddam, Nasim Zamani
DOI:10.4103/0972-5229.198332  
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Brought dead cases in tertiary care hospital in central India p. 62
Saurabh Kumar Patel, Jyoti Singh, HP Singh, Kshama Visshwakarma
DOI:10.4103/0972-5229.198333  
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Pulmonary management in aluminum phosphide poisoning p. 63
Ashok Kumar Pannu
DOI:10.4103/0972-5229.198334  
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