One of the greatest achievements of modern medicine is the development of antibiotics against life-threatening infections, but the emergence of multidrug-resistant (MDR) gram negative bacteria has drastically narrowed down the therapeutic options against them. This limitation has led clinicians to reappraise the clinical application of polymyxins, an old class of cationic, cyclic polypeptide antibiotics. Polymyxins are active against selected gram-negative bacteria, including the Acinetobacter species, Pseudomonas aeruginosa, Klebsiella species, and Enterobacter species. In this article, we summarise the chemistry, pharmacokinetics, and pharmacodynamics of polymyxins and the latest understanding of their action against MDR pathogens.

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Acute organic insecticide poisoning is a major health problem all over the world, particularly in the developing countries, where organophosphates (OPs) are the most common suicidal poisons with high morbidity and mortality and account for a large proportion of patients admitted to intensive care units. Other insecticides less commonly used are organocarbamates, organochlorides, and pyrethroids, which are less toxic and are associated with less morbidity and mortality. Patients with poisoning present with a wide spectrum of gastrointestinal, neurological, and cardiac manifestations. A strong clinical suspicion is necessary to make an early diagnosis and to start appropriate therapy. Treatment is primarily supportive and includes decontamination, anticholinergics, protection of the airway, and cardiac and respiratory support. The use of oximes has been controversial and may be associated with higher mortality owing to a higher incidence of type-II paralysis. They may have other toxic side effects. This paper reviews the literature on OP poisoning.

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Background and Aims : Severe pulmonary involvement in leptospirosis carries high mortality rates. It is the most common cause of death due to leptospirosis in many parts of India and the world. Exacerbated immune response of the host plays an important role in its pathogenesis. Hence, immunosuppressive drugs could be useful in its treatment. Glucocorticosteroids have been found to be useful in several studies. Cyclophosphamide, an immunosuppressive agent, has been found to be useful in a majority of pulmonary alveolar hemorrhages due to non leptospiral causes. This study was carried out to study the effects of cyclophosphamide in patients with leptospiral pulmonary alveolar hemorrhage. Method: A total of 65 patients with confirmed leptospirosis with severe pulmonary involvement admitted to a tertiary care center in south Gujarat were included in the study. All of the patients were treated with injection crystalline penicillin, methyl prednisolone pulse therapy, and non invasive mechanical ventilation. A total of 33 patients were given parenteral cyclophosphamide 60 mg/kg body weight stat on diagnosis. Their outcomes were compared with the remaining 32 patients who had not been given this drug. Survival was considered the main outcome indicator. Results: Out of the 33 patients treated with cyclophosphamide, 22 (66.7%) survived, while in the control group out of 32 patients, three (9.4%) survived. On statistical analysis, the odds ratio was 19.33 (4.22-102.13) and the P-value was < 0.001. Leucopenia (78.78%) and alopecia (18.75%) were the main side effects noted. No mortality was noted due to these side effects. Conclusion: Cyclophosphamide improves survival in cases of severe pulmonary alveolar hemorrhage due to leptospirosis. Statistically, the improvement is highly significant.

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Trauma-care systems in India are at a nascent stage of development. Industrialized cities, rural towns and villages coexist, with variety of health care facilities and almost complete lack of organized trauma care. There is gross disparity between trauma services available in various parts of the country. Rural India has inefficient services for trauma care, due to the varied topography, financial constraints and lack of appropriate health infrastructure. There is no national lead agency to coordinate various components of a trauma system. No mechanism for accreditation of trauma centres and professionals exists. Education in trauma life-support skills has only recently become available. A nationwide survey encompassing various facilities has demonstrated significant deficiencies in current trauma systems. Although injury is a major public-health problem, the government, medical fraternity and the society are yet to recognize it as a growing challenge.

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Fat embolism syndrome (FES) is a serious clinical disorder occurring after trauma, orthopedic procedures and rarely in non-traumatic patients. Fat emboli develop in nearly all patients with bone fractures, but they are usually asymptomatic. Small number of patients develop signs and symptoms of various organ system dysfunction due to either mechanical obstruction of capillaries by fat emboli or due to hydrolysis of fat to fatty acids. A triad of lung, brain and skin involvement develop after an asymptomatic period of 24 to 72 hours. This symptom complex is called FES. The incidence reported is up to 30%, but many mild cases may recover unnoticed. Diagnosis of fat embolism is clinical with nonspecific, insensitive diagnostic test results. Treatment of fat embolism syndrome remains supportive and in most cases can be prevented by early fixation of large bone factures. Here we report two cases of traumatic fat embolism, which were diagnosed initially by Gurd's criteria and subsequently confirmed by typical appearance on magnetic resonance imaging (MRI) of the brain in these patients. These patients were successfully treated with supportive management. In conclusion, diagnosis of FES needs high index of suspicion, exclusion of other conditions and use of clinical criteria in combination with imaging. Magnetic resonance imaging of the brain is of great importance in diagnosis and management of these patients.

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Ingestion of copper sulphate is an uncommon mode of poisoning in the Indian subcontinent. Cases are mainly suicidal in nature. The clinical course of the copper sulphate intoxicated patient is often complex involving intravascular hemolysis, jaundice and renal failure. The treatment is mainly supportive. In severe cases methemoglobinemia needs treatment. Mortality is quite high in severe cases. A comprehensive review of the clinical presentation and management of copper sulphate poisoning is done.

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Background: Despite remarkable progress that has been achieved in the recent years in the diagnosis, prevention, and therapy for ventilator-associated pneumonia (VAP), this disease continues to create complication during the course of treatment in a significant proportion of patients while receiving mechanical ventilation. Objective: This study was designed to evaluate the effect of multimodality chest physiotherapy in intubated and mechanically ventilated patients undergoing treatment in the intensive care units (ICUs) for prevention of VAP. Patients and Methods: A total of 101 adult intubated and mechanically ventilated patients were included in this study. Manual hyperinflation (MH) and suctioning were administered to patients in the control group (n = 51), and positioning and chest wall vibrations in addition to MH plus suctioning (multimodality chest physiotherapy) were administered to patients in the study group (n = 50) till they were extubated. Both the groups were subjected to treatment twice a day. Standard care in the form of routine nursing care, pharmacological therapy, inhalation therapy, as advised by the concerned physician/surgeon was strictly implemented throughout the intervention period. Results: Data were analyzed using SPSS window version 9.0. The Clinical Pulmonary infection Score (CPIS) Score showed significant decrease at the end of extubation/successful outcome or discharge in both the groups (P = 0.00). In addition, significant decrease in mortality rate was noted in the study group (24%) as compared to the control group (49%) (P = 0.007). Conclusions: It was observed in this study that twice-daily multimodality chest physiotherapy was associated with a significant decrease in the CPIS Scores in the study group as compared to the control group suggesting a decrease in the occurrence of VAP. There was also a significant reduction in the mortality rates with the use of multimodality chest physiotherapy in mechanically ventilated patients.

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Context and Aim: Ventilator-associated pneumonia (VAP) remains to be the commonest cause of hospital morbidity and mortality in spite of advances in diagnostic techniques and management. This project aims to study the various risk factors and the common microbial flora associated with VAP. It also evaluates the use of APACHEIII scores for prognostication. Study Design: A prospective cohort study was conducted over 1 year in medical critical care unit (CCU) of a tertiary-care teaching hospital. Methods and Material: VAP was diagnosed using the clinical pulmonary infection score (CPIS) of more than 6. The study cohort comprised 51 patients. All CCU patients requiring mechanical ventilation for more than 48 h formed the study group. Statistical Analysis Used: Univariate analysis, c2-test, and paired "t-test." Results: Twenty-four out of fifty-one cases developed VAP. These cases had an average APACHEIII score of more than 55 on admission to critical care unit (CCU). They needed prolonged mechanical ventilation and had lower PaO2/FiO2 ratio as compared with the remaining patients who did not develop VAP. Pseudomonas aeroginosa was the commonest and most lethal organism. The mortality in the VAP group was 37% and correlated very well with higher APACHEIII scores on admission. Conclusions: Longer duration of mechanical ventilation and the need of reintubation are associated with proportionate rise in the incidence of VAP. Deteriorating PaO2/FiO2 ratio correlated well with the onset of VAP. Higher APACHEIII scores on admission stratify the mortality risk.

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Context: Patients in intensive care units have impaired ocular protective mechanisms, resulting in a high risk of developing eye complications. Various eye care protocols are being used, but none is proven to be absolutely effective. Aims: To compare the efficacy of using a combination of ocular lubricants and securing tape over the eyelids (Open chamber method), with use of swimming goggles and regular moistening of eyelids with gauze soaked in sterile water (Closed chamber method), to prevent corneal epithelial breakdown in the sedated and semiconscious intensive care adult patient. Settings and Design: A randomized clinical study was performed. Patients with Glasgow coma scale score of £ 10/15, admitted into the Medical ICU of a large teaching hospital, over a four month duration, were studied. Materials and Methods: Patients were examined daily by an Ophthalmologist, using a portable slit lamp and the patient's corneas were tested daily using 1% Fluorescein drops. Standard grading scales were used to record eyelid position and corneal and conjunctival changes. Statistical analysis used: Quantitative variables were described in terms of their relative frequencies in proportions. Null hypothesis was applied to derive the statistical significance of the observed variations in both the treatment groups. Chi-square test for relationships was used to assess the effect of specific variables on the development of keratopathy. Results: Sixty one patients (122 eyes) in the open chamber group and 63 (126 eyes) in the closed chamber group, were analyzed. Incomplete lid closure was seen in 74 eyes (30%). Exposure keratopathy was noticed in 39 eyes (32%) in open chamber group and ten (8%) in closed chamber group and was more severe in the former group. There was no difference in the incidence of conjunctival oedema in both groups. Incomplete lid closure and use of muscle relaxants, were significant risk factors for developing keratopathy. Conclusions: Use of swimming goggles and regular moistening of eyelids with gauze soaked in sterile water providing a moisture chamber, is more effective than using a combination of ocular lubricants and securing tape over the eyelids, in preventing corneal epithelial breakdown in sedated and semiconscious intensive care unit patients.

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Postoperative pain is both distressing and detrimental for the patient. The management of postoperative pain involves assessment of the pain in terms of intensity at rest and activity associated pain, treatment by pharmacological and non pharmacological means as well as monitoring induced side-effects. Besides being physically and emotionally disabling, the pain is associated with various physiological effects involving the increased perioperative stress response. The pain causes the patient to remain immobile, thus becoming vulnerable to DVT, pulmonary atelectasis, muscle wasting and urinary retention. Poor control of postoperative pain could be due to various reasons which may include uniformed prescribing without taking into consideration the individual patient's physical status, the surgery that has been performed or the site and intensity of pain. Besides, the poor compliance of orders in administrating the analgesics prescribed and the fact that optimal pain relief is not aimed for may also contribute to the inadequate management of the pain occurring in the postoperative period. Thus, despite all efforts, there continues to be inadequate pain relief in a large majority of patients. The introduction of multimodal analgesia including opioids and non-opioids, delivered through various routes, neuraxial use of local anesthetics, either alone or in combination with other drugs, nerve blocks, antihyperalgesics and techniques such as patient controlled analgesia and pre-emptive analgesia have greatly improved the efficacy of pain-control while minimizing the side-effects of any one modality. The recent recommendation of planning the pain services in an organized manner and implementation of Acute Pain Services (APS) has proven to be beneficial and rewarding.

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Background and Aims: The emergence of multidrug resistant strains of Gram-negative bacteria, especially the lactose nonfermenters like Pseudomonas and Acinetobacter, in the intensive care units have prompted renewed worldwide interest in the polymyxins. However, perceived nephrotoxicity has been a major vexation limiting their early and regular use in severe sepsis. This study was conducted to assess the safety and efficacy of polymyxin B in patients with severe sepsis and septic shock. Materials and Methods: Forty-five patients with sepsis admitted in our medical-surgical intensive care units were identified from pharmacy records to have received polymyxin B. We retrospectively reviewed the clinical and microbiologic outcomes as well as occurrence of renal failure temporally related to the use of intravenous polymyxin B. Results: polymyxin B was used in severe sepsis and septic shock with the isolated organism being resistant to other available antimicrobials or clinical deterioration despite carbapenem use. Overall mortality was 52% and among patients who received at least eight days of intravenous polymyxin B, 67% patients with initial septic shock and 62% with severe sepsis survived. The target multidrug resistant organism was cleared in 88% of subjects evaluated by repeat microbiologic testing. Acute renal failure developed in only two patients (4%). Conclusions: Polymyxin B has acceptable effectiveness against nosocomial multidrug resistant Gram-negative sepsis. The associated nephrotoxicity has been found to be significantly lower than previously reported even in patients with background renal impairment and established risk factors of renal failure.

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Background and Aims: The 2009 pandemic influenza A (H1N1) has taken its toll across most parts of India. We aimed to study its epidemiology, clinical characteristics and outcomes from an Indian multidisciplinary intensive care unit (ICU). Materials and Methods: All patients admitted to our ICU with a flu-like illness and who tested positive for the 2009 H1N1 by reverse -transcriptase polymerase- chain -reaction assay during a 3 month period were prospectively studied. Results: Thirty one patients were admitted to the ICU during the study period. Patients were in the younger age group with a median age of 35 years (IQR: 28.2-42.8). Obesity was the commonest risk factor. Twenty six patients (83.9%) required ventilator support; the median duration of ventilator support was 10 days (IQR: 4-22). Severe hypoxemia was the predominant feature in all patients. Circulatory failure requiring vasopressors occurred in 18 (58.1%) patients and acute kidney injury in 6 (3.2%) patients. Twenty six patients were alive at the end of 28 days; subsequently all except one were discharged. The median duration of hospital stay was 15 (IQR: 8-22.5) days. Increasing APACHE II scores were associated with an increased risk of death (Hazard Ratio: 1.1; CI: 1.08 -1.2; P = 0.04). Mean tidal volumes in non-survivors were significantly lower; this was related to poor lung compliance in this group. Conclusions: 2009 H1N1 infection caused severe disease in relatively young patients without significant co-morbidities, characterized by severe hypoxemia and the requirement for prolonged mechanical ventilation. Extra-pulmonary organ failure included circulatory and renal failure.

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The absence of guidelines for withdrawal and withholding of life support in Indian law is perceived to be the most important obstacle to the practice of appropriate end of life care. In addition, physicians appear to be apprehensive about their civil or criminal liability when called upon to make decisions to limit life-supporting therapies. The following account explores the existing Constitutional and legal provisions that can reasonably be used by physicians in their defence. The article provides illustrative case histories that bring to focus the ethical dilemmas commonly faced by the physician .It also spells out the need for new legislation specifically addressing end-of-life issues.

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Central venous catheters are routinely placed in patients undergoing major surgeries where expected volume and hemodynamic disturbances are likely consequences. The incorrect positioning may give false central venous pressure (CVP) readings leading to incorrect volume replacement and other serious complications. 50 American Society of Anaesthesiologists grade II-IV patients aged 18-60 years were selected for right-sided internal jugular vein (IJV) catheterization using Seldinger's technique. In group A, central venous catheterization was done under electrocardiography (ECG) guidance. In group B, the catheter was inserted blindly using Peres' formula of "height (in cm)/10". The position of the tip of central venous catheter was confirmed radiologically by postoperative chest X-ray. 92% of patients in group A had radiologically correct positioning of catheter tip i.e. above the carina, while in group B 48% patients had over-insertion of the catheter in to the right atrium. Intra-atrial ECG technique to judge correct tip positioning is simple and economical. It can determine the exact position intraoperatively and can justify a delayed postoperative chest X-ray to confirm CVC line tip placement.

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Forty patients of aluminum phosphide poisoning who were admitted to the ICU of Sir Sunder Lal Hospital, Banaras Hindu University, were studied. Restlessness, excessive thirst, shock, arrhythmias, tachypnoea, and severe metabolic acidosis were the common clinical findings. Only repeated and full correction with intravenous sodium bicarbonate was able to cope up with the severity and rapidity of acidosis. There was no significant change in blood pressure, pulse rate, and respiratory rate after full correction but gradually pulse and systolic blood pressure settled after ionotropic support in the survivors. There was significant improvement from 30.36% in the case when only half correction was done, as has been the common practice, to 57.5%, when full correction of metabolic acidosis was done.

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Background: Acute respiratory distress syndrome (ARDS) owing to leptospirosis is associated with a high mortality. This is in spite of mechanical ventilation in a critical care setting. ARDS by its very nature, associated with economic constraints in our patients has made treating these patients a challenge. Objective: To study if combination of methylprednisolone and noninvasive ventilation is life-saving in ARDS owing to leptospirosis. Design: Interventional pilot study. Setting: Medical intensive care unit of a rural medical college hospital. Participants: Eight patients diagnosed to have ARDS owing to leptospirosis. Main outcome indicator: Survival. Results: Seven out of eight patients who were treated with methylprednisolone and noninvasive ventilation recovered fully to resume normal life. Conclusion: Methylprednisolone with noninvasive ventilation is life-saving in ARDS owing to leptospirosis.

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Mechanical ventilation is routinely delivered to patients admitted in intensive care units to reduce work of breathing, improve oxygenation, or correct respiratory acidosis. Although traditional modes of mechanical ventilation achieve many of these goals, they have important limitations. Alternative modes are supposed to handle some of these limitations and are now available on modern ventilators. This article reviews general aspects of functioning and limitations of traditional modes of mechanical ventilation, and the potential interest of some new promising modes.

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Aim: To study the prevalence of symptoms suggestive of post-traumatic stress disorder in relatives of severe trauma patients admitted to the ICU. Materials and Methods: 177 relatives of trauma patients admitted to the ICU were studied to evaluate the negative psychological impact resulting from this admission by using the impact of event scale-revised [IES-R]. About 76 of these relatives could be followed up again with questionnaire after 2 years. Result: Of the 177 relatives, 85 (48%) were males and 92 (52%) females with no statistically significant difference in their scores. About 7 days after admission, 34-54% of the 177 relatives had moderate and 19-41% had severe symptoms suggestive of PTSD. For the 76 relatives who participated in both 2002 and 2004, symptoms suggestive of PTSD were moderate in 39-61% and severe in 12-39% initially. After 2 years the scores were moderate in 12-14% and severe in 4-5%. Maximum scores amongst the three subscales were for hyperarrousal symptom with mean scores of 2.1±1. In the group-which could be followed up after 2 years, initially 79% of the respondents had sum of IES-R scores ?26 suggesting severe symptoms, which declined to 14% after 2 years. Conclusion: Findings of this study suggest that 79% of the relatives of severe trauma patients develop PTSD symptoms following ICU admission. In most, the scores reduced with time but 14% continued to have severe scores at the end of 2 years suggesting the presence of persisting psychological disturbance in them.

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There is a growing concern about the rapid rise in resistance of Staphylococcus aureus to antimicrobial agents. Our objective was to determine the prevalence and pattern of antibiotic sensitivity among Methicillin-resistant and Methicillin-sensitive Staphylococcus aureus in Surat, South Gujarat, India. Covering the period of three months from August-2004 to October 2004, we processed the samples of Pus, Urine, Blood, high vaginal swabs, Sputum, throat swabs, drains and ear swabs received from New Civil Hospital, Surat. Total 135 Staphylococci were isolated, out of which, 48 (35.55%) were coagulase positive. These coagulase positive Staphylococci isolates were screened for Methicillin-resistance by a slide latex agglutination kit for the rapid detection of PBP2' (Penicillin binding protein 2a). Sensitivity to amikacin, erythromycin, clindamycin and tetracycline were also carried out following Kirbey Bauer disc diffusion method. Methicillin resistance among the Staphylococcus aureus isolates was 39.5%. Resistance to all antibiotics tested among the Methicillin-resistance and Methicillin-sensitive, staphylococci was found to be 26.3% and 6.8% respectively, which is statistically significant. Methicillin-resistance is a useful marker in selecting appropriate antimicrobial agents for treatment of infections caused by S. aureus changing pattern of resistance of S. aureus makes its periodic surveillance mandatory.

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Rhabdomyolysis can be caused by a variety of physical,chemical, metabolic, infective and toxic causes. We present two patients who developed rhabdomyolysis after consumption of hairdye containing paraphenylene diamine. Both of them developed renal, liver and respiratory failure requiring renal replacement. We were able to save one patient whereas the other died. Intentional hair dye poisoning is an emerging threat. Early recognition of the complications and prompt treatment is necessary for a successful outcome.

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We describe the management of a case of methemoglobinemia secondary to ingestion of indoxacarb, an oxadiazine insecticide.

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Cerebral malaria is a diffuse encephalopathy associated with seizures and status epilepticus which can occur in up to one-third of patients with severe malaria, particularly that caused by Plasmodium falciparum. In this article, we report three cases of Plasmodium vivax malaria (all adult male patients) complicated by seizures and symptoms of diffuse meningoencephalitis. Two patients had predominantly meningeal signs, while in the third patient the features were purely of encephalitis All cases were treated with artesunate. Usually, cerebral malaria is caused by P. falciparum, and rarely, cerebral malaria is a presenting complication or occurs during the course of P. vivax infection.

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