Thirteen patients with severe neuroparalytic snake envenomation admitted in intensive care unit with respiratory failure over a four months period. Initially ptosis and ophthalmoplegia, followed by bulbar palsy and respiratory muscle weakness was the common sequele. All of them received cardio-respiratory support with mechanical ventilation, anti-snake venom (median dose of 20 vials) and anticholinesterase therapy. Except one suffering from hypoxic brain injury due to delayed presentation, rest survived with complete neurological recovery. So good outcome in such cases is related with early cardio respiratory support and anti venom therapy

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Introduction: The study aimed to assess and compare the vulnerability and severity of outcomes in patients who suffered self-extubation and accidental extubation during their stay in the ICU. Design: Prospective observational study. Setting: Sixteen-bedded mixed intensive care unit in a tertiary care hospital. Materials and Methods: All adult patients admitted in ICU with either an endotracheal tube or a tracheostomy were included in the study. The time and description of the type of unplanned extubation, the cause and severity of the incident and its impact on the course of the patient's illness, the person who noted the incident first and how it was detected were noted. Results: The rate of unplanned extubation was 32 (1.42/100 tube days) in 552 intubated patients (2243 tube days). Of them, 26 patients suffered self-extubation while the rest six patients were accidentally extubated. Re-intubation was required in eight patients after self-extubation while it was needed in all the six patients of accidental extubation. Three patients of accidental extubation went on to develop respiratory arrest including one patient who developed cardiac arrest. Conclusion: The outcome of the patients who suffered self-extubation is better than those with accidental extubations.

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Over the last century, our understanding of selenium has progressed considerably and we have come to recognize it as an essential component or cofactor of enzymes throughout metabolism, such as glutathione peroxidase (GPx), thioredoxine reductase and iodine deiodinase. GPx acts against hydrogen peroxide and lipid peroxidation and is an important line of defense against free radicals; thioredoxine reductase is involved in nucleus redox status; and iodine deiodinase is involved in thyroid hormone metabolism, which is frequently impaired in critically ill patients. Selenium also has an anticarcinogenic effect that is thought to be induced by the production of methyselenol, a selenometabolite that affects gene expression and modifies cell cycling and immune function. We review current knowledge concerning clinically relevant selenoproteins, discuss the potential role of these compounds in health and disease, review the epidemiology of selenium deficiency and its clinical implications with a special emphasis on critically ill patients and discuss the role of selenium supplementation in critical care settings.

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Advances in the DNA hybrid technology led to the development of various biologicals that specifically target TNF-α. There are currently three anti- TNF- α drugs available- etanercept, infliximab and adalimumab. Etanercept is approved by FDA for rheumatoid arthritis (RA) in 2000 followed by its approval for ankylosing spondylitis, psoriasis and psoriatic arthritis. Infliximab and adalimumab are approved by FDA in 2002 for RA. Infliximab is also approved for ankylosing spondylitis, psoriasis, psoriatic arthritis, crohn's disease and ulcerative colitis and adalimumab for psoriatic arthritis and ankylosing spondylitis. Other conditions like bronchial asthma, diabetes mellitus, malignancies, septic shock, behcet's disease, bullous dermatitis, neutrophilic dermatitis, toxic epidermal necrolysis, systemic vasculitis, pyoderma gangrenosum, pustular dermatitis, alcoholic hepatitis, cerebral malaria, hemolytic uremic syndrome, pre-eclampsia, allograft rejection, uveitis, otitis media, snakebite, erythema nodosum, myelodysplastic syndromes, graft versus host disease, dermatomyositis and polymyositis are the potential targets for anti-TNF- α therapy. There are resent reports of serious infections like tuberculosis with the use of anti-TNF therapy. In developing country like India these agents should be used with strict pharmaco-vigilance and chemo-prophylaxis for tuberculosis.

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Objectives: To report a case of ovarian hyperstimulation syndrome (OHSS), to discuss the differential diagnosis and to give a review of current evidences in diagnosis and management of ovarian hyperstimulation syndrome. Design: A detailed description of a case of OHSS followed by a thorough review of case reports, randomized controlled trials and review articles to assess the current modalities of diagnosis and management of ovarian hyperstimulation syndrome. Results: A 29-year-old female was admitted with dyspnoea and features suggestive of polyserositis. Patient was evaluated for causes of polyserositis. She gave history of ovulation induction and invitro fertilization one week prior to the onset of dyspnoea. With the positive history of invitro fertilization and negative markers for other causes of capillary leak syndrome the patient was diagnosed to have OHSS. She was treated and improved within a week. Conclusion: Diagnosis and management of ovarian hyperstimulation syndrome requires high index of suspicion, prompt investigation and early initiation of effective therapy. With correct diagnosis and early treatment, most patients recover.

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Study Objectives: To compare the survival benefits and cost effectiveness of cefepime-levofloxacin (C-L) as an alternative empirical antibiotic therapy for ventilator associated pneumonia (VAP) with the most widely recommended combination of piperacillin-tazobactam and amikacin (P-T-A). Design: Prospective, observational, cohort study. Materials and Methods: A total number of 879 patients were admitted in the ICU during 1st April 2004 to 31 ^st March 2005 and were screened for the study. Ninety-three patients were clinically suspected to develop early onset VAP. The patients were randomly divided into two groups receiving Cefepime-Levofloxacin (C-L) or Piperacillin-Tazobactam-Amikacin (P-T-A) as empirical antibiotic therapy. Treatment outcome was compared between the groups, which included ICU mortality, duration of mechanical ventilation, duration of ICU stay and total cost incurred on antibiotics. Results: The epidemiological characteristics including mean age and APACHE II score were comparable between the two groups. The mortality rates in the two groups were similar. The duration of mechanical ventilation was shorter in C-L group (5-8 days) as compared to P-T-A group (6-11 days). Also, the mean duration of ICU stay was reduced in C-L group (16±2.1 days) as compared to P-T-A group (19±3.4 days). Further, the overall cost of antibiotics in C-L group was 1/3 ^rd of the cost in P-T-A group. Eleven patients were found to be receiving inappropriate antibiotics and seven patients developed ARF during the course of antibiotic therapy. These patients were excluded from the study. Conclusion: Cefepime-Levofloxacin combination is an effective alternative to piperacillin-tazobactam-amikacin for empirical treatment of VAP. It reduces the duration of mechanical ventilation, number of days of ICU stay and overall cost of antibiotics

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Background: Traumatic airway injuries are fortunately rare. Though injuries can be obvious and initial management straightforward, the diagnosis can be difficult. We present a case of penetrating cervical tracheal injury due to 'chain snatching' in a young female. Case Report: The young female patient presented in the Emergency Department with a bleeding neck wound. Orotracheal intubation was done after resuscitation, revealing a transected trachea. There was no injury to major vessels or nerves, so the wound was debrided and closed in layers and a tracheostomy tube was placed through the transected trachea. Postoperatively, the patient was ventilated for 72h, after which she completely recovered. Discussion: Initial management can be complicated by associated head, neck and thoracic injuries. Orotracheal intubation or tracheostomy through the tracheal wound is the ideal way to manage these cases. Surgical repair of the trachea is not always necessary. Mortality rates and the incidence of late complications remain high and have been related to delays in diagnosis and definitive treatment.

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Aim: To compare the safety and efficacy of low dose vs high dose of amphotericin B in cryptococcal meningitis associated with HIV infection. Materials and Methods: Retrospective data of patients admitted with clinical diagnosis with or without microbiological evidence of cryptococcal meningitis was collected from Jan 2000-Mar 2006. Patients' details were collected in a proforma which included patient's age, weight, signs and symptoms of disease and microbiological report (blood and CSF analysis). Data also included coexisting disease; concomitant medications taken along with amphotericin B. Adverse drug reactions which occurred during the period of treatment were recorded. Patients were grouped as low dose group and high dose group depending on the dose of amphotericin B given for the treatment of cryptococcal meningitis. Patients who received amphotericin B at doses of 0.33 to 0.64 mg/kg body weight per day were categorized under low dose group and patients who received amphotericin B at doses of 0.7 to 1.1 mg/kg/day were categorized under high dose group. All data were pooled and analyzed between the groups using chi square test. Result: Total number of patients included in the study were 38, 26 in the low dose group and 12 in the high dose group. In the low dose group, 20 were males and six were females, in the high dose group eight were males and four were females. The commonest underlying diseases were tuberculosis (17 in low dose group, nine in high dose group), Pneumocystis carinii (jeroveci) pneumonia (16 in low dose group, seven in high dose group) and oral candidiasis (eight in low dose group, seven in high dose group), Toxoplasmosis (three in low dose group, one in high dose group), hypertension (1 in group A) and diabetes mellitus (1 in group B). Concomitant medication received along with amphotericin B for coexisting diseases in both the groups were antitubercular therapy, cotrimoxazole, antiviral therapy and premedications such as Ondansetran, Domperidone, Diclofenac, Mannitol, Dexamethazone and Pheniramine. Comparison between the groups showed that the cure rate is similar in both the groups ( P =0.440, where as over all mortality was higher in low dose group than in high dose group which was statistically significant ( P =0.03). Adverse effects were higher in high dose group than in low dose group such as hypokalemia ( P =0.04), facial puffiness ( P =0.01). Other adverse effects were comparable in both the groups. Conclusion: High dose of amphotericin B therapy is more efficacious. However hypokalemia and clinical features of nephrotoxicity was higher with patients on high dose therapy, which can be managed by proper monitoring.

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Percutaneous subclavian vein catheterization is a widely used procedure for a variety of purposes. We describe here a previously unreported complication of this procedure.

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An audit of 27 ventilated patients who underwent percutaneous endoscopic gastrostomy (PEG) in ICU revealed that this procedure could be safely performed in the ICU under local anesthesia. None of the patients had any hemodynamic or respiratory complications. All of them could be started on enteral feeds on the following day. PEG done in the ICU avoids the complications of transportation to the operation theater and general anesthesia.

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Life-threatening hemoptysis is one the most challenging condition encountered in critical care. Bronchial artery embolization (BAE) has become an established procedure, in the management of massive and recurrent hemoptysis. Bronchial arteries have variable anatomy. The reported prevalence of bronchial arteries with an anomalous origin ranges from 8.5 -35%. We are describing two patients who presented with hemoptysis and were effectively managed with bronchial artery embolization. Both these patients had anomalous origin of bronchial artery from the internal mammary artery, one from the Right Internal Mammary Artery (RIMA) and one from the Left Internal Mammary Artery (LIMA). The procedures were performed under general anesthesia. In the first case a double lumen endobronchial tube was used while in the second case, the patient was managed without tracheal intubation. The first patient was dyspnoeic; saturation was poor and was unable to maintain her airway probably due to profuse blood in her airways. We used a double lumen tube in her to isolate the diseased lung from the healthier lung. We gave her muscle relaxants and mechanical ventilation so that a stable lung field could be provided during embolization. The second patient was quite stable and comfortable while breathing room air. We decided not to interfere with his airway. A back-up plan and preparation for urgent airway control and lung isolation was done inside the catheterization laboratory.From the management point of view, an unstable patient with life-threatening hemorrhage needs airway control and lung isolation. A stable patient with minimum to moderate bleeding may be managed safely under general anesthesia with the patient spontaneously breathing.

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Background: Tight glycemic control in the critically ill is known to reduce both the morbidity and the mortality. It is essential that intensivists and endocrinologists involved in the care of these patients have a good understanding of the concepts related to this condition. Objectives: To assess the knowledge, attitudes and practices about achieving tight glycemic control in the critically ill among the endocrinologists and intensivists practicing in the city of Chennai. Materials and Methods: Questionnaires containing ten questions pertaining to clinical outcomes, drawbacks, target levels of glycemic control and insulin regimen in achieving tight glycemia in the critically ill were sent to a total of six endocrinologists and 52 intensivists practicing in Chennai. Results: All those who were administered the questionnaires responded. Majority of the responders (88%) believed in tight glycemic control in the critically ill because of better outcomes from hospitalization. A minority did not for fear of hypoglycemia. Fifty percent agreed on the cut off value of 110 mg/dL as followed in the Van den Berghe study. Seventy percent used glucometer for monitoring sugar levels. Most preferred using regular insulin as infusion. Conclusions: There seems to be a good understanding and standard practices among the endocrinologists and intensivists in achieving strict glycemic control in the critically ill. Setting up of standard intensive care unit glycemic control protocols will settle all the methodological differences and make the practices more uniform.

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