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2004| July-September | Volume 8 | Issue 3
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Role of lactate in critically ill children
Shruti Agrawal, Anil Sachdev, Dhiren Gupta, Krishan Chugh
July-September 2004, 8(3):173-181
Lactic acidosis is a common finding in critically ill patients. It has been used as a prognostic marker of the outcome in Pediatric Intensive Care Unit patients. Lactic acid is produced as a product of anaerobic glycolysis and is reversibly converted to pyruvate in the presence of favorable metabolic environment. All the body tissues can produce and consume lactate with few having predominant function of production and others of consumption. Liver is a major organ for lactate consumption and it is the liver, which metabolizes the increased lactic acid produced in regional tissue beds. The lactate levels can be done on arterial, venous, or mixed venous blood and can be measured by various methods. Serial lactate concentrations and the difference in arterial and mixed venous lactate levels or between the arterial and regional blood lactate levels like jugular venous lactate levels have been shown to have better correlation with the outcome. High initial blood lactate levels and persistently high lactate levels have been correlated with poor outcome. There are various causes of lactic acid overproduction, which may produce either hyperlactatemia or lactic acidosis. High blood lactate levels are found in critically ill patients with shock of any etiology and sepsis due to various reasons, which include increased catecholamine induced glucose flux apart from the tissue hypoperfusion and hypoxia. Various other illnesses can cause an increase in blood lactate levels like acute lung/liver injury, severe asthma, poisoning, post cardiac surgery etc. Treating the underlying disease leading to lactic acidosis is the best measure to control lactic acidosis. Some therapeutic choices are available to neutralize the effect of lactic acid on cell function, but none has stood the test of time and are tried only in desperate situations.
Subclinical hypocortisolemia in patients with sepsis in a medical intensive care unit in India (The SHIPS Study)
Sujith Thomas Chacko, George John, Nihal Thomas, Arun Jose Nellickal
July-September 2004, 8(3):162-167
OBJECTIVES: (1) To determine the prevalence of relative adrenal insufficiency in critically ill patients in shock requiring vasopressors for more than 24 hrs, to maintain a mean arterial pressure of 70 mm of Hg. (2) To identify possible risk factors (markers) of a poor cortisol response. METHODOLOGY: A prospective analysis of 49 critically ill vasopressor dependant patients was performed. A 1 mcg of Synacthen stimulation test was performed and the cortisol response was assessed at 30' and 60'. The criterion of minimum increment in the cortisol response of 9 mcg/dl was used to identify those with relative adrenal insufficiency. The patients were followed up until the time of discharge from hospital. Survival and morbidity indices were the final outcome measures assessed. RESULTS: The prevalence of relative adrenal insufficiency in this study was 81.6%. The mean basal cortisol value was 23.24 and the mean cortisol response was 6.22.The mean age (41.95 vs. 50.98), APACHE Score (16.63 vs. 16.44), pH (7.32 vs. 7.36) and sodium levels (135.55 vs. 134) were not significantly different between poor responders and good responders. CONCLUSIONS: (1) Relative adrenal insufficiency (hypocortisolemia) in vasopressor dependant critically ill patients is common (>80%). (2) In view of the high prevalence of hypocortisolemia in prolonged critical illness (as demonstrated by this study) and recent literature demonstrating benefit with replacement of glucocorticoids and mineralocorticoids in patients with relative adrenal insufficiency, it may be worthwhile considering steroid replacement in Indian patients in an ICU setting.
A proposed new scoring system for tetanus
SS Sidhartha, JV Peter, HS Subhash, M Cherian, L Jeyaseelan, AM Cherian
July-September 2004, 8(3):168-172
INTRODUCTION: Tetanus in adults continues to be a major public health problem in developing countries. Prognosis in tetanus is largely dependent on the various clinical characteristics. This study was carried out to develop a clinical prognostic scoring system according to the natural progression of the disease and to assess its ability to predict the need for specific therapeutic interventions and mortality. MATERIALS AND METHODS: Sixty-five patients were studied, 15 prospectively and 50 retrospectively with an age range between 12 to 70 years. RESULTS: The incubation period was > 7 days in 26 patients (40%), <24 hours in 25 patients (38%), 53 patients (81.5%) had generalized rigidity and 19 (29%) had autonomic dysfunction. Forty-eight (74%) patients needed tracheostomy and 29 (45%) needed mechanical ventilation. The overall mortality was 34%. There was a linear correlation between the grade of tetanus and mortality, (score <2 = 1%, <4 = 3%, >5 = 26%), need for Tracheostomy, (score <4 = 18%, 5 = 26%, >5 = 47%), need for ventilation (scores <4 = 6-8%, 5 = 12%, >5 = 34%), diazepam requirement (scores <4 mean 1500 mg, >5 mean 4000-5000 mg) and duration of ICU stay (score <4 mean of 1 week, > 5 mean 2 to 3 weeks. The overall sensitivity and specificity was 61% and 87% respectively for severe tetanus (score > 6). Multivariate logistic regression analysis showed patients above the age of 50 years (
= 0.003) and need for mechanical ventilation (
= 0.009) were significantly associated with high mortality. DISCUSSION: Prognostication of tetanus with this system was better in comparison with the existing scoring systems in predicting mortality and the need for specific therapeutic interventions. CONCLUSION: The proposed scoring system is a good indicator of the severity of tetanus and use of this system will help in identifying high-risk patients enabling early therapeuticintervention.
Serum markers of severe traumatic brain injury: Are they useful?
Linda E Pelinka
July-September 2004, 8(3):190-193
Video data for patient safety
Colin F Mackenzie
July-September 2004, 8(3):194-198
Current issues in the diagnosis of brain stem death
Anne J Sutcliffe
July-September 2004, 8(3):185-189
Return of corticosteroids for septic shock- new dose, new insights
July-September 2004, 8(3):145-147
Continuous veno-venous hemofiltration for ARF in critically Ill patients
Valentine Lobo, Aniket Joshi, Seema Joseph, Sudhir Wandre, Clares Norton, Sayali Joshi, FF Wadia
July-September 2004, 8(3):148-152
The mortality of critically ill patients who develop ARF in an ICU setting is extremely high (50-80%). Any mode of renal replacement therapy chosen should be able to achieve solute and water clearance while maintaining hemodynamic stability, have a positive effect on nutrition, and have low complication rates. AIM: To determine the efficacy and feasibility of Continuous Venovenous hemofiltration (CVVH) in critically ill patients with ARF. Inclusion criteria: Patients with ARF requiring 2 or more inotropes to maintain systolic blood pressure >100 mm of Hg. Failed or technically impossible hemodialysis or peritoneal dialysis. Time Period: July 2002 - June 2003. MATERIALS AND METHODS: Polysulfone hemofilter 0.7m2, [Aquamax (Edwards) or Multimat BL680 (Bellco).] Blood flow of 150-200 ml/minute (Travenol). Volumetrically controlled Ultrafiltration of > 2000 ml per hour (Watson Marlowe) and replacement fluid infusion [(Infusomat-P) post filter]. Anticoagulation: Heparin infusion or regional heparinisation. RESULTS: 22 patients included, 6 with recent abdominal surgery. 11 underwent hemodiafiltration and hemofiltration each. Severe sepsis was present in 21, and DIC in18. 5 patients were on immunosuppressive therapy. The time from ICU admission to the start of CVVH was 114 + 88.08 hours. The duration of CVVH was 35.93 + 20.91 hours, (range 11 to 84 hours). The mean hourly ultrafiltration of 93.72 + 65.57 ml and total ultrafiltration of 3955.55 + 4132 ml was tolerated by all patients without limiting hypotension. The APACHE II scores had significantly worsened between admission (22.5 + 6.71) to starting CVVH (36.05 + 4.08), [
<0.001]. The daily costs of CVVH were Rs. 5000 compared to Rs. 2150 for PD and Rs. 1500 for extended daily dialysis CONCLUSIONS: CVVH was effective in providing metabolic correction in ARF, in the setting of multi-organ failure. It is technically feasible even when conventional hemodialysis or peritoneal dialysis cannot be performed.
Does it matter how we treat phenobarbitone overdose of moderate severity?
S Srinivas, Sunil Karanth, V Nayyar
July-September 2004, 8(3):153-156
AIM: To study if the routine use of combined Forced Alkaline Diuresis (FAD) and Hemodialysis (HD), confers any advantage in terms of quicker drug elimination, reduced ICU stay or lower costs, among patients with moderate Phenobarbitone overdose. MATERIALS AND METHODS: A retrospective analysis of all available records of patients admitted with phenobarbitone overdose between March 1995 and September 2002, was carried out. RESULTS: 42 records could be analysed. Fourteen patients each had drug levels above 100 mg/L and between 60 -100 mg/L. Out of the fourteen with drug levels between 60-100 mg/L, 9 were treated with FAD alone and the rest with combined FAD + HD. The parameter, which influenced the modality of drug elimination, was the GCS, which correlated neither with the dose consumed, nor the drug levels at admission. Those treated with FAD alone stayed in the ICU a shorter while needed fewer cycles of FAD for detoxification and ultimately spent significantly less for their treatment. CONCLUSIONS: Routine use of combined FAD and HD confers no advantage when used among patients with moderate phenobarbitone overdose whose GCS is more than 8 and are hemodynamically stable.
A two years outcome analysis of patients on intra-aortic balloon pump in a tertiary care center
FN Kapadia, S Vadi, K Bajan, U Shukla
July-September 2004, 8(3):157-161
AIMS: To analyze data of patients with IABP insertion with respect to severity of illness, complications and outcome. MATERIALS AND METHODS: A retrospective study conducted on 70 patients over 2 years. Patients were divided into Group 1, emergent insertion and Group 2, elective insertion. They were further analyzed for degree of cardiac dysfunction [ventricular performance assessed by 2-D echocardiography and dose of inotropes required], location [Intensive Care Unit (ICU), Operating Room (OR) or Cath lab] and occurrence of complications [thrombocytopenia, worsening renal parameters, and thrombo-embolic phenomena]. RESULTS: 29 patients underwent emergent insertion and 41 patients had elective insertion. Indications were cardiogenic shock- 24 (34.28%) patients; pulmonary edema 7 (10%) patients; peri-operatively 29 (41.42%)patients; and for cath lab support 10 (14%)patients. Most of the patients were also on inotropes: dopamine=48(82.75%), epinephrine=40(68.96%), norepinephrine=7(12.06%) and dobutamine=6(10.34%). Common complications noted were thrombocytopenia in 41 patients and azotemia in 30 patients. Three patients (37.5%) required embolectomy and one later needed an amputation. Twenty three patients died . The mortality rate was highest in patients with an ejection fraction < 20% (71.42%). Mean duration of IABP was 60 hours. CONCLUSIONS: IABP was an effective tool for circulatory support for a range of indications.
LITERATURE REVIEW ARTICLE
Fluids, CPR, sedation, MET, pyrexia and mobile phones
Samir Suri, Michael Parr
July-September 2004, 8(3):182-184
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