Indian Journal of Critical Care Medicine : 2013 - 17(1)

Reimbursement for critical care services in India

Raja Jayaram — Fri,17 May 2013

Raja Jayaram, Nagarajan Ramakrishnan

Indian Journal of Critical Care Medicine 2013 17(1):1-9

There are significant variations in critical care practices, costs, and reimbursements in various countries. Of note, there is a paucity of reliable information on remuneration and reimbursement models for intensivists in India. This review article aims to analyze the existing reimbursement models in United States and United Kingdom and propose a frame-work model that may be applicable in India.

Supraclavicular approach of central venous catheter insertion in critical patients in emergency settings: Re-visited

Gaurav Singh Tomar — Fri,17 May 2013

Gaurav Singh Tomar, Sonali Chawla, Suprio Ganguly, Grace Cherian, Akhilesh Tiwari

Indian Journal of Critical Care Medicine 2013 17(1):10-15

The supraclavicular approach was first put into clinical practice in 1965 by Yoffa and is an underused method for gaining central access. It offers several advantages over the conventional infraclavicular approach to the subclavian vein. At the insertion site, the subclavian vein is closer to the skin, and the right-sided approach offers a straighter path into the subclavian vein. Also, this site is often more accessible during CPR and surgical procedures. In patients who are obese, this anatomic area is less distorted and in patient with congestive heart failure and cervical spine instability repositioning is not required.

Adaptive support ventilation: State of the art review

Jaime Fernández — Fri,17 May 2013

Jaime Fernández, Dayra Miguelena, Hernando Mulett, Javier Godoy, Federico Martinón-Torres

Indian Journal of Critical Care Medicine 2013 17(1):16-22

Mechanical ventilation is one of the most commonly applied interventions in intensive care units. Despite its life-saving role, it can be a risky procedure for the patient if not applied appropriately. To decrease risks, new ventilator modes continue to be developed in an attempt to improve patient outcomes. Advances in ventilator modes include closed-loop systems that facilitate ventilator manipulation of variables based on measured respiratory parameters. Adaptive support ventilation (ASV) is a positive pressure mode of mechanical ventilation that is closed-loop controlled, and automatically adjust based on the patient's requirements. In order to deliver safe and appropriate patient care, clinicians need to achieve a thorough understanding of this mode, including its effects on underlying respiratory mechanics. This article will discuss ASV while emphasizing appropriate ventilator settings, their advantages and disadvantages, their particular effects on oxygenation and ventilation, and the monitoring priorities for clinicians.

Intensive care nurses' opinions and practice for oral care of mechanically ventilated patients

Mohsen Adib-Hajbaghery — Fri,17 May 2013

Mohsen Adib-Hajbaghery, Akram Ansari, Ismail Azizi-Fini

Indian Journal of Critical Care Medicine 2013 17(1):23-27

Context: Oral care is an essential aspect of critical care nursing. However, no study has been published on oral care practice of Iranian and Asian nurses. The majority of published studies were conducted in western and European countries. Aims: This study aimed to evaluate the nurses' opinions and practice about oral care in patients under mechanical ventilation. Settings and Design: A cross-sectional study was conducted on 130 intensive care nurses from 6 intensive care units in the university hospitals of Iran. Materials and Methods: A questionnaire was used to gather the data and charts of 45 patients were evaluated. Statistical analysis: Descriptive statistical analysis are presented. Results: Oral care obtained the 7 th rank in prority and a mean score of 5.7 on a scale of 1-10. More than 21% of subjects did not perform oral care in their usual duties. High load of writing tasks and personnel shortages were the major barriers to oral care. Only 20% of the patients' charts contained a report on oral care. Conclusions: Nurses did not consider oral care in intensive care patients as a high priority. This result highlights the need to continue education programs on oral care for improving the knowledge and attitude of intensive care nurses with respect to oral care.

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

Sundar Varun — Fri,17 May 2013

Sundar Varun, Emmanuel Bhaskar, Georgi Abraham, Anandabhavan Sukumaramenon Arunkumar, Muthiah Kothandaramanujam Renuka

Indian Journal of Critical Care Medicine 2013 17(1):28-33

Context: Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality. Aims: To study the risk factors for HAH in settings that practice a preventive protocol. Settings and Design: Two tertiary-care hospitals. Prospective observational study design. Materials and Methods: Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h. Statistical Analysis Used: Risk factors associated with HAH was analysed by multiple logistic regression. Results: Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years ( P = 0.02), acute kidney injury (AKI) on admission ( P = 0.01), mechanical ventilation ( P = 0.01), need for ionotropes ( P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission ( P < 0.001), enteral tube feeds ( P = 0.002), negative fluid balance ( P = 0.02) and mannitol use ( P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients. Conclusions: The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.

Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India

Poornima B Ramachandra Bhat — Fri,17 May 2013

Poornima B Ramachandra Bhat, Mahesha H Navada, Sujaya V Rao, G Nagarathna

Indian Journal of Critical Care Medicine 2013 17(1):34-37

Background and Aim: To evaluate the occurrence, indications, course, interventions, and outcome of obstetric patients admitted to the intensive care unit (ICU). Design: Retrospective study. Setting: ICU of a Medical College Hospital. Materials and Methods: The data collected were age, parity, obstetric status, primary diagnosis, interventions, and outcome of obstetric patients admitted to the ICU from Jan 2005 to June 2011. Results: Total deliveries were 16,804 in 6.5 years. Obstetric admissions to the ICU were (n = 65) which constitutes 0.39% of deliveries. Majority of the admissions were in the postpartum period (n = 46, 70.8%). The two common indications for admission were obstetric hemorrhage (n = 18, 27.7%) and pregnancy related hypertension with its complications (n = 17, 26.2%). The most common intervention was artificial ventilation (n = 41, 63%). The mortality among obstetric admissions in the ICU was (33.8% (22/65)). The patients appropriate for High Dependency Unit (HDU) care was (32.3% (21/65)). The statistical analysis was done by fractional percentage and Chi-square test. Conclusions: Hemorrhage and pregnancy-related hypertension with its complications are the two common indications for ICU admissions. The need for a HDU should be considered.

Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients

Nirmal Raj Gopinathan — Fri,17 May 2013

Nirmal Raj Gopinathan, Ramesh K Sen, Vibhu K Viswanathan, Amit Aggarwal, HC Mallikarjun, Sakthivel R Rajaram Manoharan, Radheshyam Sament, Avinash Kumar

Indian Journal of Critical Care Medicine 2013 17(1):38-42

Background: Fat embolism is one of the apocalyptic pulmonary complications following high energy trauma situations. Since delay in diagnosis may have devastating consequences, early, easily accessible and relatively inexpensive investigations for risk stratification may prove useful, especially in developing nations. Materials and Methods: This prospective trial included a total of 67 young polytrauma patients, in whom the role of nine easily available, rapidly performable clinical or laboratory investigations (or observations noted at admission) in predicting the later occurrence of fat embolism syndrome were assessed. All the patients also underwent continuous monitoring of oxygen saturation with pulsoximetry. Results: The correlation between initial serum lactate (within 12 hours of injury) and hypoxia was statistically significant. There was a trend towards correlation with FES(by Gurd's criteria) (P=0.07), Sensitivity of 24-hour monitoring of oxygen saturation in predicting later pulmonary deterioration approached 100%. Conclusions: The combination of three factors including polytrauma (with NISS >17), serum lactate >22 mmol/l at admission (within 12 hours of injury) fall in oxygen saturation (SaO 2 below 90% in the initial 24 hours) predict the development of post-traumatic pulmonary complications, especially the fat embolism syndrome.

Multivisceral organ failure related to leptospirosis in pregnant patient

Sbai Hicham — Fri,17 May 2013

Sbai Hicham, Mellouki ihsane, El Bouazzaoui Abderahim, Boukatta Brahim, Smail Labib, Harrandou Mustapha, Khatouf Mohamed, Ibrahimi Adil, Melhouf Abdelilah, Kanjaa Nabil

Indian Journal of Critical Care Medicine 2013 17(1):43-45

Leptospirosis is the most widespread zoonosis in the world. It is caused by pathogenic leptospira infection. This infection is also an uncommon cause of hepatorenal failure. Indeed, hemolysis, elevated liver enzyme levels and low platelet count syndrome, and acute fatty liver of pregnancy are specific to the pregnant state. Leptospirosis is rarely described in pregnancy; it might mimic puerperal sepsis or hepatorenal failure associated with pregnancy induced hypertension. We report a case of leptospirosis presenting as multiple organ failure during third trimester of pregnancy with a good outcome.

Clinically lesser known entity in India: A Report of two cases of Melioidosis

Purabi Barman — Fri,17 May 2013

Purabi Barman, Ravneet Kaur, Kamlesh Kumar

Indian Journal of Critical Care Medicine 2013 17(1):46-48

Melioidosis is endemic in the South Asian regions, like Thailand, Singapore Malaysia and Australia. The disease is more pronounced in the southern part of the country. It is caused by Burkholderia pseudomallei which causes systemic involvement, morbidity and mortality associated with the disease is high. Due to highly varied clinical presentation, and low general awareness this infection is largely underdiagnosed and under reported in our country. Most laboratories in the country still rely on conventional culturing methods with their low sensitivity, adding to the under reporting. To enhance physician awareness we describe here two cases who presented to our institute after months of misdiagnosis.

Septic acute kidney injury in critically ill Indian patients

Mohan Gurjar — Fri,17 May 2013

Mohan Gurjar, Arvind K Baronia, Afzal Azim, Narayan Prasad, Sunil Jain, Ratender K Singh, Banani Poddar, Dharmendra Bhadauria

Indian Journal of Critical Care Medicine 2013 17(1):49-52

Acute kidney injury (AKI) is an independent variable for poor outcome in critically ill patients. The pathophysiology of septic AKI is distinct from that of non-septic AKI. We studied the clinical profile and outcome of septic AKI since such data is sparse in Indian patients. In this single-center retrospective, observational, cohort study, septic AKI has been found with high incidence (31%) and overall mortality was 52%. Age, number of non-renal organ failure, and APACHE II score were found as significant predictors of outcome in this population.

Accidental guide-wire loss during central venous catheterization: A report of two life-threatening cases

Tanmoy Ghatak — Fri,17 May 2013

Tanmoy Ghatak, Afzal Azim, Arvind K Baronia, Neelima K Ghatak

Indian Journal of Critical Care Medicine 2013 17(1):53-54

Bed-side ultrasound of the optic nerve sheath in a patient with bilateral acutely dilated pupils

Mohan Gurjar — Fri,17 May 2013

Mohan Gurjar, Nabeel Muzaffar, Afzal Azim, Arvind K Baronia

Indian Journal of Critical Care Medicine 2013 17(1):54-55

Red man syndrome due to accidental overdose of rifampicin

Syed Ahmed Zaki — Fri,17 May 2013

Syed Ahmed Zaki, Swapnil Bhongade, Preeti Shanbag

Indian Journal of Critical Care Medicine 2013 17(1):55-56

Acute myocardial infarction in a young cocaine addict with normal coronaries: time to raise awareness among emergency physicians

Achyut Sarkar — Fri,17 May 2013

Achyut Sarkar, Arindam Pande, GS Naveen Chandra, Imran Ahmed

Indian Journal of Critical Care Medicine 2013 17(1):56-58