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2003| January-March | Volume 7 | Issue 1
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Sedation and analgesia in pediatric intensive care unit
P Khilnani, J Kaur
January-March 2003, 7(1):42-49
Common indications of sedation in the PICU (Pediatric intensive care unit) include mechanical Ventilation and various procedures performed in the PICU and in radiology or endoscopy suites. Sedation potentiates the effect of narcotics, thereby ensuring better comfort and analgesia. Sedation is a mandatory prerequisite prior to and during administration of neuromuscular blockers. This review includes practical pharmacology and uses of commonly used agents in the PICU.
Intrahospital Transit Care of the Critically Ill
January-March 2003, 7(1):34-41
An ideal patient transport system should indeed be a mobile ICU. Optimal features to be desired are light weight, unhindered access for patient evaluation and management, uncluttered environment for cardiopulmonary resuscitation in transit, low cost and, where relevant, adaptability to surface and air transportation. In appropriate situations, suitability for inter-hospital and intra-hospital transport of the critically ill with the same transit-care equipment will be an added advantage. Such systems could also be adapted for pre-hospital evacuation of the critically ill. The investment of time, intellect and technological labour in devising and maintaining a good transit care team with affordable equipment and trained medical and nursing staff is an integral part of running an intensive care service.
January-March 2003, 7(1):26-33
Early warning of end organ hypoperfusion in the critically ill, will help the intensivist in initiating corrective measures to prevent multi organ failure. Common end points of tissue perfusion like cardiac output, serum lactate and mixed venous oxygen saturation indicates global oxygen delivery and do not reflect regional perfusion and oxygenation. In low cardiac output states, the gut mucosa is the first to be affected by poor perfusion due to the counter current blood flow pattern in the intestinal villi. Gastric tonometry, by indirectly measuring the gut mucosal PCO2, gives an indication of the gastric mucosal perfusion. It is assumed that the increased gastric mucosal CO2 leading to gastric mucosal acidosis is a result of anaerobic metabolism consequent to splanchnic hypo perfusion. An increase in gut wall CO2 occurs due to anaerobic metabolism as well as decreased CO2 wash out secondary to a poor perfusion state. Gastric tonometry measures the balance between gut metabolism (CO2 production) and gut perfusion (CO2 removal). Saline tonometry is useful in assessing the gastric intramucosal pH (pHi). This is calculated from the measured intramucosal CO2 and the calculated arterial bicarbonate using the Henderson Hasselbach equation. Air tonometry which is a more recent development assesses the difference between the gastric mucosal CO2 (PgCO2) and arterial / end tidal CO2. The normal gap is 7–10 mmHg. A gap of >23 mmHg indicates anaerobic metabolism. There are several practical limitations to the application of gastric tonometry to assess splanchnic perfusion. Despite these limitations it is an easy and relatively non invasive method in following trends. Further refinements in technique could make it a more reliable monitor in predicting outcome in the critically ill patient. However the complexities of gastrointestinal physiology are yet to be resolved and we await large randomised studies on air tonometry to provide scientific proof that it is a prognostic marker in critically ill patients
Guillain Barre syndrome mimicking cerebral death
SK Rajdev, D Sarma, R Singh, R Uttam, P Khilnani
January-March 2003, 7(1):50-52
Guillain Barre Syndrome, an acute diffuse demyelinating disorder, predominantly present with the motor manifestations with few variants. The present report describes an unusual presentation of GBS, which initially suggested brain death. A 14 years old male presented with sudden onset of rapidly progressive weakness of all four limbs which progressively evolved into clinical condition simulating brain death.
Readmissions in a surgical intensive care unit: patient characteristics and outcome
N Amin, JV Divatia, V Agarwal, AP Kulkarni
January-March 2003, 7(1):14-17
Aims: To determine the incidence, patient characteristics, reasons and outcome of readmissions in a surgical ICU. Patients and Methods: Analysis of 1316 admissions in 1190 patients. Patients were classified as those who never required readmission (NOREAD, n = 1086) and those who had > 1 ICU admission (READ, n =104 patients and 230 admissions) and those readmitted within 48 hours and those after 48 hrs. Results: 104 (8.7%) patients required ICU readmission. Of these 17 (1.4% of total and 16.3% of readmitted patients) were readmitted within 48 hrs. Readmission rates were maximum in patients with GI system involvement (n=66, 66.5%) followed by respiratory system involvement (n = 22, 21%). 22%patients were readmitted due to complications involving the same organ system, 58% (n = 60/104) patients were readmitted due to complications involving new organ system and 20% (n = 21/104) were readmitted following operative intervention. The readmission APACHE score was higher than in NOREAD GROUP (15.46+9.61Vs 12.01+8.66). The readmitted patients had a longer ICU stay (5.68+6.75 Vs 3.76+6.61 days) and higher mortality rate (34% Vs 17.4%) than the NOREAD GROUP. Conclusion: Patients with surgery of GI and RS are at greatest risk of ICU readmission. Respiratory complications are the major reason for ICU readmission due to new complication. Readmitted patients have a longer duration of ICU stay and higher mortality rate than those who are not readmitted. The readmission rate is affected by case-mix of the ICU.
January-March 2003, 7(1):56-56
A Randomized, Controlled Trial of the Use of Pulmonary-Artery Catheters in High-Risk Surgical Patients
JD Sandham, RD Hull, RF Brant
January-March 2003, 7(1):54-55
Application of the Australian Council on Healthcare Standards clinical markers of quality of care to the ICU of an Indian tertiary referral hospital
FN Kapadia, KS Bhojani
January-March 2003, 7(1):18-20
The Australian Council on Healthcare Standards (ACHS) used three clinical markers to evaluate quality of care in Intensive Care. They were, one, unplanned readmission to the Intensive Care Unit (ICU) within 48 hours of transfer, two, incidence of pneumothorax associated with central venous catheter (CVC) insertion or attempted insertion in ICU and three, incidence of unplanned extubation (UE) of endotracheal tube (ETT) per intubated day. We recorded the incidence of these clinical markers in our ICU, in 922 patients over a six month period and compared this with those recorded in Australia. We recorded a readmission rate of 1.04%, which was similar to that of 1.62% noted by the ACHS. We recorded a CVC associated pneumothorax of 2.73%, which was not statistically significantly higher than the 1.27% recorded by the ACHS. We did not have a single episode of UE in the 6 months study period while the ACHS reported a significantly higher rate of 0.37% per intubated day. These quality marker incidences were associated with an overall crude mortality of 17.8% and with Standardized Mortality Ratios (SMR) of 0.75 by SAPS II and 0.57 by APACHE II.
Report on Severe Acute Respiratory Distress Syndrome (“SARS”) - are we really dealing with a new syndrome?
January-March 2003, 7(1):10-13
Economic analysis: A basic primer
January-March 2003, 7(1):21-25
Medical knowledge is advancing at an incredible rate. This rapid increase in the fundamental understanding of disease states has led to some important breakthroughs in care over the past ten years and will undoubtedly lead to untold more. At the same time that we are being presented with more options for diagnosis and treatment, governments around the world are fighting to reduce deficit spending and inflation. As a direct result of this combination of reduced spending and increased options for care, medical professionals are being asked to provide more effective care more efficiently. The randomized control trial may be the best way to determine the effectiveness of different options, however, only a full economic analysis can help decide which option is more efficient. This paper is intended to provide the reader with a basic understanding of the methods used to perform a full economic analysis.
LETTER TO EDITOR
Letter to the Editor
January-March 2003, 7(1):57-61
One-Year Outcomes in Survivors of the Acute Respiratory Distress Syndrome
MS Herridge, AM Cheung, CM Tansey
January-March 2003, 7(1):53-54
From the Editors’ Desk
S Talekar, S Prayag
January-March 2003, 7(1):5-6
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