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2007| October-December | Volume 11 | Issue 4
December 31, 2007
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Postoperative pain and its management
Sona Chaturvedi, Amit Chaturvedi
October-December 2007, 11(4):204-211
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.
Rhabdomyolysis due to hair dye poisoning: An emerging threat
Krishnaswamy Sampathkumar, Yesudas Santhakumari Sooraj, Rajappannair Prabha Ajeshkumar, Amol Ramesh Mahaldar, Ramakrishnan Muthiah
October-December 2007, 11(4):212-214
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.
Role of physiotherapists in intensive care units of India: A multicenter survey
Jithendra A Kumar, Arun G Maiya, Daphne Pereira
October-December 2007, 11(4):198-203
The purpose of this study was to find what role physiotherapists play in the care of the critically ill in Indian Intensive Care Units (ICU).
Materials and Methods:
Study Design and Setting: Exploratory cross-sectional survey Questionaires were sent to 260 ICUs in India. A stamped self-addressed envelope was enclosed with the questionnaire and a period of six weeks for completion were given in an attempt to ensure good response rates. If response was not obtained within
six weeks, two subsequent reminders were sent to the hospitals with a further time gap of six weeks.
Eighty-nine completed questionnaires were received and analyzed, representing 35% of the questionnaires sent. The present study revealed that, 24% of ICUs had a resident physiotherapist available during the night and 79% of physiotherapists available on-call. In almost 90% of ICUs
physiotherapists performed chest manipulations, mobilization, incentive spirometry and postural drainage. Correlation
role between different states of India, were performed by Chi-square. Mann-Whitney U test was performed to compare, within each of the five states for two types of postings in relation to the years of experience in ICU.
All physiotherapists in ICU are routinely involved in chest physiotherapy and mobilization
Comparison of norepinephrine and dopamine in the management of septic shock using impedance cardiography
Sharad K Mathur, Rajiv Dhunna, Arpan Chakraborty
October-December 2007, 11(4):186-191
Vasoconstrictors are one of the therapeutic modalities in the treatment of septic shock. In the present study, we have compared the effects of dopamine and norepinephrine in the treatment of septic shock with pre-defined end-points and continuous non-invasive cardiac output monitoring using impedance cardiography.
Randomized controlled trial.
Sixteen-bedded mixed intensive care unit of a tertiary care teaching institution.
Materials and Methods:
The study included 50 consecutive patients presenting with septic shock and divided randomly into two groups with 25 patients in each group. Group I patients were treated with dopamine and those in Group II were treated with norepinephrine. They were optimized with fluid resuscitation upto CVP>10 cm of H
O, packed red cells transfusion upto hematocrit >30, oxygenation and ventilation upto PaO
>60 mmHg before the inotropes were started. The goal of therapy was to achieve and maintain for six hours, all of the following: (1) SBP >90 mm Hg, (2) SVRI >1100 dynes.s/cm
, (3) Cardiac Index >4.0L/min/m
, (4) IDO
and (5) IVO
The demographic data, baseline parameters and post-treatment parameters were statistically analyzed by using t-test.
The post-treatment parameters were statistically significant showing the superiority of norepinephrine over dopamine in optimization of hemodynamics and patient survival. Significant improvement in systolic blood pressure, heart rate, cardiac index, SVRI, IVO
and urine output were found in norepinephrine group than the dopamine group. Dopamine showed a response in 10 out of 25 patients up to a maximum dose of 25 mcg/kg/min while with norepinephrine, 19 patients responded up to a maximum dose of 2.5 mcg/kg/min The hemodynamic parameters were preserved in norepinephrine group with better preservation of organ perfusion and oxygen utilization with maintenance of splanchnic and renal blood flow as evidenced by significant increase in O2 uptake and urine flow.
Norepinephrine was more useful in reversing the hemodynamic and metabolic abnormalities of septic shock compared to dopamine at the doses tested.
A prospective cohort study on anemia and blood transfusion in critically ill patients
Naveen Manchal, S Jayaram
October-December 2007, 11(4):182-185
The management of anemia and blood transfusion practices in the ICU have been a subject of controversy.
The aims of this study were 1) To assess the prevalence of anemia and study the association of blood transfusion and mortality in critically ill patients. 2) To compare restrictive transfusion policy (Hb < 7 g/dl) and liberal transfusion policy. (Hb < 10 g/dl).
Settings and Design:
A matched cohort study was performed in a tertiary care teaching hospital.
Materials and Methods:
To study the association between blood transfusions and mortality, control patients were those who never received blood during ICU stay. They were selected according to the following matching criteria: Age (± 5 years), sex, APACHE II score (± 5 points), history of cardiac or renal disease and clinical diagnosis.
Statistical Analysis Used:
The Chi-square test.
The incidence of anemia is high in critically ill patients. Anemic patients had a longer duration of stay in the ICU. There is an association between blood transfusion and higher mortality in critically ill patients. A restrictive transfusion policy was associated with lesser mortality.
Anemia is associated with increased morbidity reflected by the increased duration of stay in the ICU. Blood transfusion is associated with increased mortality and a restrictive transfusion policy is associated with increased survival.
Severe hyperkalemia with normal electrocardiogram
Sanjay Sharma, Harish Gupta, Meena Ghosh, Anantanarayan Padmanabhan
October-December 2007, 11(4):215-217
We report a case of severe hyperkalemia and normal electrocardiogram in an ex-preterm infant with renal failure due to bilateral obstruction of pelvicalyceal system caused by renal fungal mycetoma. In spite of maximal serum potassium of 11.3 mmol/L the ECG did not show any changes associated with hyperkalemia.
Determination of intravascular volume status in critically ill patients using portable chest X-rays: Measurement of the vascular pedicle width
Nawal Salahuddin, M Aslam, Ishtiaq Chishti, Shehla Siddiqui
October-December 2007, 11(4):192-197
Background and Aims:
Traditionally, invasive hemodynamic pressure measurements have been used to assess the volume status in critically ill patients. The vascular pedicle, as seen on chest radiographs,
is the mediastinal silhouette of the great vessels. It is measured by drawing a perpendicular line from the point at which the left subclavian artery emerges from the aortic arch and measured across to the point at which the superior vena cava crosses the right main stem bronchus. We carried out this study to establish a correlation between the width of the vascular pedicle as seen on chest radiographs and daily fluid balance or pulmonary capillary occlusion pressure in mechanically ventilated, critically ill patients.
Materials and Methods:
In this prospective clinical study, 50 consecutive adult patients in a tertiary care, multidisciplinary intensive care unit underwent simultaneous measurements of the width of the vascular pedicle as seen on standardized, portable chest radiographs in the supine position and pulmonary capillary occlusion pressure measurements. Twenty-four hour fluid balance calculations were also recorded for each patient.
Vascular pedicle width measurements correlated closely with positive fluid balance, r = + 0.88,
0.000. A Receiver Operating Characteristic curve demonstrated that a vascular pedicle width of 86.5 mm had a 100% sensitivity and an 80% specificity (area under the curve 0.823, 95% confidence intervals 0.714-0.932) for predicting fluid overload equal to and greater than 1200 ml. The correlation between pulmonary capillary occlusion pressures and width of the vascular pedicle was poor, r = 0.41,
Our findings suggest that the vascular pedicle width on daily chest radiographs can be used to assess hypervolemia in the intensive care unit. Serial changes in the pedicle width could possibly be used to increase the accuracy of predictions.
It is not just the work - It is also the words
October-December 2007, 11(4):169-172
The ideal transfusion trigger in critically ill patients
October-December 2007, 11(4):173-175
An increase in weight worsens the respiratory state and leads to intensive care unit re-admission
Yoshinori Matsuoka, Akinori Zaitsu
October-December 2007, 11(4):176-181
We investigated the reasons for intensive care unit (ICU) readmission of patients with acute respiratory failure. Of 88 patients re-admitted to our ICU over a 15-month period, 16 were suffering from acute respiratory failure. Body weight, blood gases, time without food during the initial ICU stay and excess extracellular fluid (∆ECF) were determined. The interval until ICU readmission (D) was defined as the time between the last day of the first admission and the first day of the second admission. Significant correlations were found among the values for D, ∆ECF and P/F ratio; a patient with a P/F ratio below 200 on the day of release from ICU and a ∆ECF over 3 kg was likely to return to the ICU within four days. Hence, we conclude that fluid-management failure may be associated with ICU readmission in acute respiratory failure patients.
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