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Organophosphate compound (OPC) poisoning with suicidal intent is common in Indian ICUs. The effect of OPCs is to produce a persistent depolarization of the neuromuscular junction leading to muscle weakness. After initial recovery from cholinergic crisis, some patients have resurgence of respiratory muscle paralysis requiring continued ventilatory support. This is termed intermediate syndrome (IMS). This could be due to a change in the type of neuromuscular block to a non depolarisation block characterized by a fade on tetanic stimulation. However peripheral nerve stimulation using train-of-four ratio (TOF) and/tetanus have failed to consistently show such a change. We elected to study whether electro physiological monitoring using repetitive nerve stimulation might show a decremental response during IMS. Material & Methods: This was a prospective blinded study done from April 2002 to March 2003 in our ICU. 45 consecutive patients of OPC poisoning admitted during this period were included in this study. Repetitive nerve stimulation (RNS) using a train of ten at 3Hz 10Hz and 30Hz (slow , intermediate and fast speeds respectively) at the median nerve was done on all patients on day 1, 4, 7 and every 4th day thereafter until discharge. Patients were ventilated until ready to wean as per our usual protocol. The results of the RNS study were not revealed to the intensivist. Results: 9 out of 45 patients required ventilation for more than 6 days and showed overt signs of intermediate syndrome - proximal muscle weakness, twitching and respiratory weakness. Only 2 patients out of the 9 had a decremental response on RNS at 3Hz indicating a post-junctional dysfunction at the motor end-plate, Both patients had consumed a very large quantity of OPC and were deeply comatose for >4 days and required ventilation for >12 days. All other patients with IMS showed no changes on RNS. The exact type of poison consumed varied with each individual patient. Conclusion: RNS is a poorly sensitive marker in diagnosing intermediate syndrome after OPC poisoning. We need to develop more sensitive markers to diagnose IMS.

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In recent years, increasingly, intensivists have focused attention on the ethical aspects of end-of- life care. This has led to shifts in the approach from aggressive interventions to one of mitigating pain and taking into account the wishes and sensibilities of the patients' families with regard to continuing futile care. While the legal implications of this change in practice has led to the evolution of precise guidelines in the US and in Europe, in India this vital area of critical care remains largely unexplored. This review outlines the recent changes in clinical practice based on ethical principles and the legality of limiting life support in the context of futile or end-of-life care. An appraisal of the ethical issues in critical care urges us to apply intensive care with humanity and compassion. We need to respect the choices and the emotional needs of the patient and his family. Our duties must include providing information, balanced interpretation of results & counseling of the family to enable them to take rational decisions. Our strategy in end-of-life care should be unambiguous and we should ensure that there is consensus among all the physicians involved in the patient’s care. The medical community must work towards evolving legislation appropriate to Indian conditions.

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The risk of mortality or significant morbidity is high among critically ill patients who are treated in the intensive care unit (ICU) for more than 5 days. These patients are susceptible to sepsis, excessive inflammation, critical illness polyneuropathy and multiple organ failure, the latter often being the cause of death. Most intensive care patients, even those who did not previously suffer from diabetes, are hyperglycemic. This is presumed to reflect an adaptive development of insulin resistance. We hypothesized that hyperglycemia is not a beneficial adaptation to severe illness but rather predisposes patients to many of the typical intensive care complications, prolonged intensive care dependence and death. The effects of intensive insulin therapy to maintain normoglycemia during critical illness were studied in a large group (N=1548) of ventilated, surgical ICU patients. An algorithm was proposed for implementing this procedure. The randomly assigned intensive insulin therapy group received insulin infusion tailored to control blood glucose levels in the range 80–110 mg/dl, whereas the conventional-treatment group only received insulin when glucose levels exceeded 200 mg/dl and in that event were maintained in a target range of 180–200 mg/dl. Intensive insulin therapy induced a 43% reduction of intensive care mortality risk (p = 0.036 after correction for interim analyses) and a 34% reduction of hospital mortality (p = 0.005). A reduced risk of severe infections by 46% (p = 0.003) was associated with a 35% reduction in prolonged (> 10 d) requirement for antibiotic therapy (p < 0.001). In addition, excessive inflammation was prevented. Logistic regression analysis indicated that control of blood glucose levels, rather than insulin administration itself, likely explains the observed clinical benefits. In conclusion, use of insulin infusion to maintain normoglycemia using a titration algorithm, at least in populations similar to those in our study, improves outcome. Further data are needed to establish the applicability of this strategy to other patient groups, such as those in the medical ICU and in general hospital care.

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Rational & Objective: Early detection of hypoxemia and oxygen therapy improves the outcome of children with acute respiratory illnesses (ARI). However, facility to measure oxygen saturation (SpO2) is not available in many health facilities of resource poor countries. We have studied prevalence of hypoxemia in children with ARI and examined value of various clinical signs to predict hypoxemia. Subjects & Methods: Consecutive children, aged 2 months – 59 months, with respiratory symptom(s) attending the pediatric emergency service between Oct 2001 to December 2002 were studied. Presence or absence of cough, nasal flaring, ability to feed/drink, cyanosis, chestwall indrawing, wheeze, tachypnoea (respiratory rate >50/min in children up to 11 months and >40/min up to 59 months), crepitations on auscultation and oxygen saturation (SpO2, by Nellcore™pulse oximeter) and clinical diagnosis were recorded. Results: Of 2216 children studied 266 (11.9%) had hypoxemia (SpO2 £90%). It was seen in 73.8% of 126 patients with WHO defined very severe pneumonia, 25.8% of 331 patients with severe pneumonia, 11% of 146 patients with bronochiolitis and 6.5% of 338 patients with acute asthma. Most sensitive indicators of hypoxemia were chestwall indrawing (sensitivity-90%, negative predictive value –98%) and crepitations (sensitivity-75%, negative predictive value 95.7%) while the best positive predictive value was seen with cyanosis (71.4%) and inability to feed (47.6%). Nasal flaring had the good balance of sensitivity (64%), specificity (82%) and positive predictive value (33%) among the signs studied. Conclusion: None of the clinical signs of respiratory distress had all the attributes of a good predictors of hypoxemia. Chest wall indrawing was the most sensitive and “inability to feed/ drink” was the most specific indicator.

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Background: Pulmonary embolism is the most common preventable cause of death in hospitalised patient. It can readily be prevented by adequate prophylaxis. Inspite of multiple guidelines on risk factor assessment for venous thromboembolism (VTE), utilization of deep venous thrombosis (DVT) prophylaxis remains less than satisfactory. Critically ill patient are at increased risk of developing VTE which leads to significant morbidity and mortality in this population. In western intensive care units utilization of DVT prophylaxis varies from 40-90%. There has not been a systematic study to detect the incidence of DVT prophylaxis in India. Objective: To assess the utilization of Deep Venous Thrombosis (DVT) prophylaxis in Multidisciplinary critical care unit. Design: Prospective Cohort Multi-centre Study. Setting: Multidisciplinary critical care units in the Metropolitan city of Kolkata (India). Method: Prospective chart survey of one hundred consecutive itu admissions. Results: Of 100 consecutive admissions who were eligible for DVT prophylaxis, as per predefined criterias, DVT prophylaxis was administered to 44 of 100 study patients (44%). Fifty-six eligible study patients (56%) did not receive DVT prophylaxis. The study patients had an average of 2.9 risk factors for DVT. Thirty patients received subcutaneous heparin, twenty six of which were low molecular weight heparin (LMWH), thirteen patients received anti embolism stockings, one patient received both LMWH and antiembolism stockings. Conclusion: Forty four percent (44%) of the medical /surgical critically ill patient included in our study received DVT prophylaxis.

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Aim: To compare exchange transfusions done for severe malaria using the traditional whole blood exchange method with therapeutic red cell exchange (TREX) done using a Cobe spectra cell separator. Methods: 6 children with acute, severe malaria and parasitic infestation rates (IR) >50% with multi organ failure, were subjected to exchange transfusions. 3 had whole blood single volume exchanges and 3 had TREX using the Cobe-Spectra cell separator. The two groups were compared for difficulties encountered, time taken, complications, quantity of blood products used, metabolic and hematological derangements and fall in IR. Results: The TREX took less time per 100 ml of blood exchanged, resulted in a 24% more efficient decrease in the IR and required less donor plasma. 3/3 tolerated the TREX well whereas one child had complications of hypocalcemia and acidosis with the whole blood exchange. The rise in hemoglobin/hematocrit was comparable in both and the platelet count was not significantly altered in either group. There was no significant alteration in the DIC profile in either group. All 6 children recovered within comparable time frames. Conclusion: The TREX was safer, more efficacious and less time consuming. This procedure is recommended whenever available for red cell exchange in malaria.

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Background: This retrospective chart review assessed the characteristics and outcome of patients with hematological disorders who required admission to medical intensive care unit over a 4 year period (January 1998 to December 2001). Results: There were a total of 104 patients, 67 (64%) male, 37 (36%) female subjects, with a mean age of 36.3 ± 15.3 years (range 10 to 65 years). The mean duration from hospital admission to ICU transfer was 11 days. Sixty-nine (66%) had malignant and 35 (34%) had non-malignant conditions. Respiratory distress was the commonest reason for ICU admission 58 (56%). The other indications were hemodynamic instability 38 (36%), low sensorium 22 (21%), following cardio-pulmonary arrest 12 (11.5%) and generalized tonic-clonic seizures 5 (5%). Forty-three (42%) patients had absolute neutophil count (ANC) less than 500, 48 (47.5%) had platelet count < 20000. The mean duration of ICU stay was 4 days (range < 24 hours to 28 days). Sixty-nine (66%) patients required mechanical ventilation, 61 (59%) required hemodynamic support. Pneumonia or sepsis was diagnosed in 71 (68%). Twenty-five (24%) survived ICU stay and 20 (19%) survived to hospital discharge. ICU admission following cardio-pulmonary arrest, advanced malignancy, requirement of mechanical ventilation, vasopressor support, ANC count < 500 and platelet count < 20000 were the predictors of adverse outcome. Associated organ dysfunction further increases the mortality.

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Objective: To enhance the clinician’s awareness of Strongyloidiasis as a cause of critical illness. Design: A case report. Setting: A 600- bed, tertiary care hospital in New Delhi, India. Patient: A 53 years old diabetic male, presenting with acute respiratory failure, having received treatment for 2 weeks for acute bronchitis that included corticosteroids. He had a history of receiving several courses of treatment for Strongyloides stercoralis larvae detected in his stools. During this admission, he went on to develop neurological signs, cutaneous lesions and acute respiratory distress syndrome (ARDS). Negative stool examinations led to the diagnosis being delayed until the 7th day, when the larvae were demonstrated in the skin lesions and tracheal aspirate. Conclusion: Awareness of the varied presentations of Strongyloidiasis and a diligent search for the larvae at various sites are crucial for early diagnosis.

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There has been a recent resurgence in the use of corticosteroids for the treatment of haemodynamic insufficiency in septic patients. The low doses of steroids now recommended are believed to be effective either because of their anti-inflammatory properties or their benefit on the “relative adrenal insufficiency” that occurs in these patients. The value of such steroid therapy in burn wound sepsis is not described. We report on two patients with major burns and sepsis who responded with haemodynamic stabilization when low-dose hydrocortisone was administered.

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