Vasopressin or antidiuretic hormone is a potent endogenous hormone, which is responsible for regulating plasma osmolality and volume. In high concentrations, it also raises blood pressure by inducing moderate vasoconstriction. It acts as a neurotransmitter in the brain to control circadian rhythm, thermoregulation and adrenocorticotropic hormone release. The therapeutic use of vasopressin has become increasingly important in the critical care environment in the management of cranial diabetes insipidus, bleeding abnormalities, esophageal variceal hemorrhage, asystolic cardiac arrest and septic shock. After 10 years of ongoing research, vasopressin has grown to a potential component as a vasopressor agent of the anesthesiologist's armamentarium in the treatment of cardiac arrest and severe shock states.

The development of critical patient related generalized neuromuscular weakness, referred to as critical illness polyneuropathy (CIP) and critical illness myopathy (CIM), is a major complication in patients admitted to intensive care units (ICU). Both CIP and CIM cause muscle weakness and paresis in critically ill patients during their ICU stay. Early mobilization or kinesiotherapy have shown muscle weakness reversion in critically ill patients providing faster return to function, reducing weaning time, and length of hospitalization. Exercises in the form of passive, active, and resisted forms have proved to improve strength and psychological well being. Clinical trials using neuromuscular electrical stimulation to increase muscle mass, muscle strength and improve blood circulation to the surrounding tissue have proved beneficial. The role of electrical stimulation is unproven as yet. Recent evidence indicates no difference between treated and untreated muscles. Future research is recommended to conduct clinical trials using neuromuscular electrical stimulation, exercises, and early mobilization as a treatment protocol in larger populations of patients in ICU.

Context: Body mass index (BMI), serum albumin, and C-reactive protein (CRP) appear to be major determinants of hospitalization. Aim: To determine the predictive ability of BMI, Sequential Organ Failure Assessment (SOFA score), serum albumin, and CRP to assess the duration and outcome of mechanical ventilation (MV). Materials and Methods: Thirty patients aged >18 years who required mechanical ventilation (MV) were enrolled for the study. They were divided into two groups; patients who improved (Group 1), patients who expired (Group 2). Group 1 was further divided into two groups: patients on MV for <5 days (Group A), and patients on MV for >5days (Group B). BMI and SOFA score were calculated, and serum albumin and CRP were estimated. Results and Discussion: Out of the 30 patients, 18 patients successfully improved after MV (Group 1) and 12 patients expired (Group 2). Among the 18 patients in group 1, ten patients improved within 5 days (Group A) and 8 patients after 5 days (Group B). SOFA score and CRP were significantly increased (P value 0.0003 and 0.0001, respectively) in group 2 when compared to group 1. CRP >24.2 mg/L or SOFA score >7 at the start of MV increases the probability of mortality by factor 13.08 or 3.92, respectively The above parameters did not show any statistical difference when group A was compared to group B. Conclusion: Simple, economic and easily accessible markers like CRP and assessment tools of critically ill patients with SOFA score are important determinants of possible outcomes of a patient from MV.

Background: It is well known that heat wave is a major cause of weather related mortality in extreme of ages. While auditing our hospital mortality record, we found higher surgical mortality in the months of summer season which inspired us to look into the impact of hot climate in elderly surgical patients. Materials and Methods: An observational prospective cohort study was undertaken to study the impact of hot climate on elderly (age > 60 yrs) surgical patients over one year when outside temperature was more than 20 ^o C. 98 elderly patients requiring general anaesthesia for surgery were enrolled. Patients were grouped on the basis of peak outdoor temperature with a cut off value of 30 ^o C. Group I- when peak outdoor temperature ranged between 20-30 ^o C (comfortable zone) and Group II - when peak outdoor temperature ranged above 30 ^o C. To reduce the bias, inclusion and exclusion criterion were defined. Meteorological factors, patient characteristics, surgical risk factors and other related data were noted. Data was analyzed using student's't' and z-test for statistical significance. Results: There were statistically significant complications and prolonged hospital stay in group II as compared to I (13.21±6.44 Vs 9.81±3.54 days, P value =0.01) on univariate analysis. High risk patients had more complications in hot weather. Stepwise multivariate regression analysis showed higher adverse impact of poor physical and cardiac status than hot climate. Conclusion: Hot and humid weather adversely affect the perioperative outcome in elderly surgical patients. Patients with poor reserves are at greater perioperative risk during hot and humid climate.

Background: The initial empirical therapy of Ventilator Associated Pneumonia (VAP) modified based on the knowledge of local microbiological data is associated with decreased morbidity and mortality. The objective was to find the incidence and risk factors associated with VAP, the implicated pathogens and their susceptibility pattern as well as to assess the final clinical outcome in VAP. Materials and Methods: This was a prospective cohort study of 107 patients taken on ventilatory support for two or more days and those not suffering from pneumonia prior were to be taken on ventilator. The study was done over a period of one year. VAP was diagnosed using clinical pulmonary infection score of >6. The mortality, incidence of VAP, frequency of different pathogens isolated, their antibiotic sensitivity pattern, duration of mechanical ventilation and duration of hospital stay were assessed. Statistical Analysis: Univariate analysis, χ² test and paired t-test. Results: The incidence of VAP was 28.04%. Mortality in VAP group was 46.67%, while in the non-VAP group was 27.28%. High APACHE II score was associated with a high mortality rate as well as increased incidence of VAP. The most common organisms isolated from endotracheal aspirate of patients who developed VAP were Pseudomonas aeruginosa, Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae and Acinetobacter baumannii. Most strains of Pseudomonas (55.56%) were resistant to commonly used beta-lactam antibiotics known to be effective against Pseudomonas. All strains of Staphylococcus aureus were MRSA and most isolates of K. pneumoniae (85.71%) were extended-spectrum beta-lactamase producing. About 50% isolates of Acinetobacter were resistant to carbapenems. Mortality was highest for infections caused by A. baumannii (83.33%) and K. pneumoniae (71.42%). Conclusions: APACHE II score can be used to stratify the risk of development of VAP and overall risk of mortality. Drug-resistant strains of various organisms are an important cause of VAP in our setting.

Background and Aims: An association of high lactate levels with mortality has been found in adult patients with septic shock. However, there is controversial literature regarding the same in children. The aim of this study was to find the correlation of serum lactate levels in pediatric septic shock with survival. Settings and Design: This was a prospective observational study at PICU of a tertiary care center of North India. Materials and Methods: A total of 30 children admitted to PICU with diagnosis of septic shock were included in the study. PRISM III score and demographic characteristics of all children were recorded. Serum lactate levels were measured in arterial blood at 0-3, 12, and 24 h of PICU admission. The outcome (survival or death) was correlated with serum lactate levels. Results: Septic shock was the most common (79.3%) type of shock and had 50% mortality. Initial as well as subsequent lactate levels were significantly higher in nonsurvivors. A lactate value of more than 45 mg/dl (5 mmol/l) at 0-3, 12, and 24 h of PICU admission had an odds ratio for death of 6.7, 12.5, and 8.6 (95% CI: 1.044-42.431, 1.850-84.442, 1.241-61.683) with a positive predictive value (PPV) of 38%, 71%, 64% and a negative predictive value (NPV) of 80%, 83%, and 83%, respectively. Conclusions: Nonsurvivors had higher blood lactate levels at admission as well as at 12 and 24 h. A lactate value of more than 45 mg/dl (5 mmol/l) was a good predictor of death.

Objective : To determine the effects of parenteral omega 3 fatty acids (10% fatty acids) on respiratory parameters and outcome in ventilated patients with acute lung injury. Measurements and Main Results : Patients were randomized into two groups - one receiving standard isonitrogenous isocaloric enteral diet and the second receiving standard diet supplemented with parenteral omega 3 fatty acids (Omegaven, Fresenius Kabi) for 14 days. Patients demographics, APACHE IV, Nutritional assessment and admission category was noted at the time of admission. No significant difference was found in nutritional variables (BMI, Albumin). Compared with baseline PaO ² /FiO ² ratio (control vs. drug group: 199 ± 124 vs. 145 ± 100; P = 0.06), by days 4, 7, and 14, patients receiving the drug did not show a significant improvement in oxygenation (PaO ² /FiO ² : 151.83 ± 80.19 vs. 177.19 ± 94.05; P = 0.26, 145.20 ± 109.5 vs. 159.48 ± 109.89; P = 0.61 and 95.97 ± 141.72 vs. 128.97 ± 140.35; P = 0.36). However, the change in oxygenation from baseline to day 14 was significantly better in the intervention as compared to control group (145/129 vs. 199/95; P < 0.0004). There was no significant difference in the length of ventilation (LOV) and length of ICU stay (LOS). There was no difference in survival at 28 days. Also, there was no significant difference in the length of ventilation and ICU stay in the survivors group as compared to the non survivors group. Conclusions : In ventilated patients with acute respiratory distress syndrome, intravenous Omega 3 fatty acids alone do not improve ventilation, length of ICU stay, or survival.

Upper extremity deep vein thrombosis commonly refers to thrombosis of the axillary and/or subclavian veins. This condition may lead to some serious complications like pulmonary embolism if the diagnosis and treatment are delayed. We introduce here one such case where the diagnosis of this rare condition was difficult because of the atypical clinical manifestation but the chylous ascites provided a valuable clue which led to early diagnosis and treatment of this patient.

Methemoglobinemia and hemolysis are rare findings following phosphine poisoning. In this paper, a case of aluminum phosphide (AlP) poisoning complicated by methemoglobinemia and hemolysis with a successful treatment is reported. A 28-year-old male patient presented following intentional ingestion of an AlP tablet. In this case, hematuria, hemolysis and methemoglobinemia were significant events. A methemoglobin level of 46% was detected by CO-oximetry. The patient was treated with ascorbic acid and methylene blue and he also received supportive care. Two weeks after admission, the patient was discharged from the hospital. Hemolysis and methemoglobinemia may complicate the course of phosphine poisoning.

A case of severe sodium valproate overdose is presented in which medicinal management failed to reverse coma of the patient. High-flux hemodialysis was then used to eliminate sodium valproate. This case demonstrated the effectiveness of hemodialysis in not only decreasing valproate levels very rapidly but also as an effective anti-coma management.

Toxic epidermal necrolysis (TEN), also known as Lyell's syndrome, is a widespread life-threatening mucocutaneous disease where there is extensive detachment of the skin and mucous membrane. Many factors involved in the etiology of TEN including adverse drug reactions. Here we are reporting a case of toxic epidermal necrolysis in an adult male patient after receiving carbamazepine in a 38 year old male. On the18^th day of carbamazepine, patient developed blisters which first appeared on the trunk, chest and arms. The erythematous rash was covering almost all over the body with epidermal detachment of 70% body surface area. There was loss of eye lashes, congestion of conjunctiva with mucopurulent discharge and exposure keratitis. The clinical impression was TEN induced by carbamazepine. Carbamazepine was stopped immediately. He was treated with high dose intravenous betamethasone and systemic and topical antibiotics. After one month, the progression of the skin lesions halted and he was discharged.

The differential diagnosis of life-threatening microangiopathic disorders in a postpartum female includes severe preeclampsia-eclampsia, hemolysis, elevated liver functions tests, low platelets syndrome and thrombotic thrombocytopenic purpura. There is considerable overlapping in the clinical and laboratory findings between these conditions, and hence an exact diagnosis may not be always possible. However, there is considerable maternal mortality and morbidity associated with these disorders. This case underlines the complexity of pregnancy-related microangiopathies regarding their differential diagnosis, multiple organ dysfunction and role of therapeutic plasma exchange in their management.

Leptospirosis is an important emerging zoonosis with a worldwide distribution that is characterized by a broad spectrum of clinical manifestations ranging from inapparent infection to fulminant disease. Leptospirosis has protean clinical manifestations. The classical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Unusual clinical manifestations may result from involvement of pulmonary, cardiovascular, neural, gastrointestinal, ocular and other systems. Immunological phenomena secondary to antigenic mimicry may also be an important component of many clinical features and may be responsible for reactive arthritis. The presentation of paraparesis in combination with Weil's syndrome is rare. Few cases were reported with leptospirosis and paraparesis in India and abroad. It is important to bear in mind that leptospiral illness may be a significant component in cases of dual infections or in simultaneous infections with more than two pathogens. Here we are reporting a case of Weil's syndrome with paraparesis in 28-year-old male patient who was critically ill due to severe hepatorenal dysfunction and hyperkalemia.

Intramural hematoma of duodenum (IDH) is a relatively unusual complication associated with endoscopic treatment of bleeding peptic ulcer. This unusual condition is usually seen in children following blunt trauma to the abdomen. We describe here a case of IDH occurring following endoscopic therapy for bleeding duodenal ulcer in an adult patient with end-stage renal disease. The hematomas appeared on the second day of endoscopic intervention, caused transient duodenal obstruction and resolved spontaneously with conservative treatment in a week.

Neurological prognostication in cardiac arrest survivors is difficult, especially when the primary etiology is respiratory arrest. Prognostic factors designed to have zero false-positive rates to robustly confirm poor outcome are usually inadequate to rule out poor outcomes (i.e., high specificity and low sensitivity). One of the least understood prognosticators is generalised status myoclonus (GSM), with case reports confusing GSM, isolated myoclonic jerks and post-hypoxic intention myoclonus (Lance Adams syndrome [LAS]). With several prognostic indicators (including status myoclonus) having been validated in the pre-hypothermia era, their current relevance is debatable. New modalities such as brain magnetic resonance imaging (MRI) and continuous electroencephalography are being evaluated. We describe here a pregnant woman resuscitated from a cardiac arrest due to acute severe asthma, and an inability to reach a consensus based on published guidelines, with a brief overview of myoclonus, LAS and the role of MRI brain in assisting prognostication.