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Indian Journal of Critical Care Medicine
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  Most popular articles (Since April 07, 2004)

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Treatment of Organophosphate Poisoning
RS Wadia
April-June 2003, 7(2):85-87
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Acute ingestion of copper sulphate: A review on its clinical manifestations and management
Kavitha Saravu, Jimmy Jose, Mahadeva N Bhat, Beena Jimmy, BA Shastry
April-June 2007, 11(2):74-80
Ingestion of copper sulphate is an uncommon mode of poisoning in the Indian subcontinent. Cases are mainly suicidal in nature. The clinical course of the copper sulphate intoxicated patient is often complex involving intravascular hemolysis, jaundice and renal failure. The treatment is mainly supportive. In severe cases methemoglobinemia needs treatment. Mortality is quite high in severe cases. A comprehensive review of the clinical presentation and management of copper sulphate poisoning is done.
  69,540 1,804 16
Organophosphate poisoning: Diagnosis of intermediate syndrome
L Poojara, D Vasudevan, AS Arun Kumar, V Kamat
April-June 2003, 7(2):94-102
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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Colloid versus crystalloids in shock
Ken Hillman
January-March 2004, 8(1):14-21
This is a review of the use of colloid and crystalloid in shock. The article discusses the pathophysiological consequences of ischaemia and shock; reviews the underlying physiology of fluid compartments and how they may be affected by disease; examines the physiological determinants of intravenous (IV) fluid use; and finally reviews the literature on colloid and crystalloid use for the management of shock.
  58,460 2,393 2
Postoperative fever
A Rudra, S Pal, A Acharjee
October-December 2006, 10(4):264-271
Postoperative fever is one of the most common problems seen in the postoperative ward. Most cases of fever immediately following surgery are self-limiting. The appearance of postoperative fever is not limited to specific types of surgery. Fever can occur immediately after surgery and seen to be related directly to the operation or may occur sometime after the surgery as a result of an infection at the surgical site or infections that involve organs distant from the surgery. Therefore, during evaluating postoperative fever, it is important to recognize when a wait - and - see approach is appropriate, when further work-up is needed and when immediate action is indicated.
  52,214 1,982 7
Guidelines for noninvasive ventilation in acute respiratory failure
Rajesh Chawla, GC Khilnani, JC Suri, N Ramakrishnan, RK Mani, Shirish Prayag, Shruti Nagarkar, Sudha Kansal, US Sidhu, Vijay Kumar
April-June 2006, 10(2):117-147
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Limitation of life support in the ICU: Ethical issues relating to end of life care
RK Mani
April-June 2003, 7(2):112-117
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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Interpretation of arterial blood gas
Pramod Sood, Gunchan Paul, Sandeep Puri
April-June 2010, 14(2):57-64
DOI:10.4103/0972-5229.68215  PMID:20859488
Disorders of acid-base balance can lead to severe complications in many disease states, and occasionally the abnormality may be so severe as to become a life-threatening risk factor. The process of analysis and monitoring of arterial blood gas (ABG) is an essential part of diagnosing and managing the oxygenation status and acid-base balance of the high-risk patients, as well as in the care of critically ill patients in the Intensive Care Unit. Since both areas manifest sudden and life-threatening changes in all the systems concerned, a thorough understanding of acid-base balance is mandatory for any physician, and the anesthesiologist is no exception. However, the understanding of ABGs and their interpretation can sometimes be very confusing and also an arduous task. Many methods do exist in literature to guide the interpretation of the ABGs. The discussion in this article does not include all those methods, such as analysis of base excess or Stewart's strong ion difference, but a logical and systematic approach is presented to enable us to make a much easier interpretation through them. The proper application of the concepts of acid-base balance will help the healthcare provider not only to follow the progress of a patient, but also to evaluate the effectiveness of care being provided.
  34,293 5,748 5
Clinical management guidelines of pediatric septic shock
Praveen Khilnani
July-September 2005, 9(3):164-172
Septic shock in children is the prototype combination of hypovolemia,cardiogenic and distributive shock. Recently published American college of critical care medinie(ACCM )recommendations for hemodynamic support of neonatal and pediatric patients with sepsis,Surviving sepsis campaign and its pediatric considerations and subsequent revision of definitions for pediatric sepsis has led to compilation of this review article. Practical application of this information in Indian set up in a child with septic shock will be discussed based on available evidence.Though guidelines mainly apply to pediatric age group,however a reference has been made to neonatal age group wherever applicable.
  35,548 2,970 1
Critical illness neuropathy
J Vijayan, Mathew Alexander
January-March 2005, 9(1):32-34
The neuromuscular syndrome of acute limb and respiratory weakness that commonly accompanies patients with multi-organ failure and sepsis constitutes critical illness polyneuropathy. It is a major cause of difficulty in weaning off the patient from the ventilator after respiratory and cardiac causes have been excluded. It is usually an axonal motor-sensory polyneuropathy, and is usually associated with or accompanied with a coma producing septic encephalopathy. The neuropathy is usually not apparent until the patient's encephalopathy has peaked, and may be noted only when the brain dysfunction is resolving. Patients usually have a protracted hospital course complicated by multi-organ failure and the systemic inflammatory response syndrome. Elevated serum glucose levels and reduced albumin are risk factors for nerve dysfunction, as is prolonged intensive care unit stay. Polyneuropathy may develop after only one week of the systemic inflammatory response syndrome, but the frequency tends to correlate with the duration of the severe illness.
  33,863 1,996 1
Fighting cardiac arrest: Automated external defibrillator
V Kumar, KM Adhikari, YD Singh
October-December 2003, 7(4):242-249
Ventricular tachyarrhythmias – Ventricular fibrillation (VF) and Ventricular tachycardia (VT) account for most of out-of-hospital sudden cardiac arrests. Defibrillation is the specific therapy for VF/pulseless VT. Time to defibrillation is the most important determinant of survival from these cardiac arrests. Automated external defibrillator (AED) has largely replaced the conventional defibrillator in Basic life support (BLS) programmes for out-of-hospital cardiac arrests. AED use by trained laypersons in the community as part of Public Access Defibrillation (PAD) programmes has significantly reduced time to defibrillation and increased survival. AED is now being stipulated for home use in people at high risk of sudden cardiac death. AED placement is also recommended in all areas of hospital. Physicians and Intesivists should strive to familiarize the medical fraternity in our country with AED use so that PAD programmes can be launched in the near future.
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Transfusion practice in the ICU: When to transfuse?
JL Vincent, G Yalavatti
October-December 2003, 7(4):237-241
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Postoperative delirium
A Rudra, S Chatterjee, J Kirtania, S Sengupta, G Moitra, S Sirohia, R Wankhade, S Banerjee
October-December 2006, 10(4):235-240
Postoperative delirium (POD) is frequently under diagnosed and more often than not, under treated. It is the final common manifestation of multiple neurotransmitter abnormalities; with features of impaired cognition, fluctuating consciousness and a disturbed sleep-awake cycle. At least 15% of elderly patients undergoing major procedures have POD, with an associated increase in mortality. Various risk factors and batteries of clinical examination have been devised to diagnose delirium, followed by a multifaceted approach to treatment, using biopsychological along with pharmacological intervention.
  26,804 1,416 1
Pediatric Aids – Part 1
P Khilnani, SK Rajdev, R uttam
October-December 2003, 7(4):257-272
Much progress has been made in the therapy of pediatric HIV infection, which has been transformed from a usually fatal disease into that of a chronic disease model. Early, aggressive therapy with the goal of complete suppression of viral replication (undetectable plasma virus) should be the therapeutic goal, but this new, more hopeful environment has been created at the cost of complexity and compromises in quality of life. The rapid pace of new developments and therapeutic complexities argue strongly for care in specialized centers or, at least, frequent consultation. Principles of therapy in the pediatric intensive care unit remain unchanged. Efforts are ongoing to develop simpler, more effective therapeutic regimens that suppress and ultimately eradicate infection and that stimulate immune reconstitution and reduces need for frequent hospitalization.
  27,048 1,071 -
Fluid resuscitation in trauma
A Rudra, S Chatterjee, S Sengupta, R Wankhade, S Sirohia, T Das
October-December 2006, 10(4):241-249
Appropriate fluid replacement is an essential component of trauma fluid resuscitation. Once hemorrhage is controlled, restoration of normovolemia is a priority. In the presence of uncontrolled haemorrhage, aggressive fluid management may be harmful. The crystalloid-colloid debate continues but existing clinical practice is more likely to reflect local biases rather than evidence based medicine. Colloids vary substantially in their pharmacology and pharmacokinetics,and the experimental finding based on one colloid cannot be extrapolated reliably to another. In the initial stages of trauma resuscitation the precise fluid used is probably not important as long as an appropriate volume is given. Later, when the microcirculation is 'leaky', there may be some advantages to high or medium weight colloids such as hydroxyethyl starch. Hypertonic saline solutions may have some benefit in patients with head injuries. A number of hemoglobin solutions are under development, but one of the most promising of these has been withdrawn recently. It is highly likely that at least one of these solutions will eventually become routine therapy for trauma patient resuscitation. In the meantime, contrary to traditional teaching, recent data suggest that restrictive strategy of red cell transfusion may improve outcome in some critically ill patients.
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Pathophysiological aspects of clinical management following toxic trauma
DJ Baker
October-December 2003, 7(4):250-256
  26,473 579 -
Management of pediatric head injury
Praveen Khilnani
April-June 2004, 8(2):85-92
  24,954 1,452 1
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
Purpose: 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. Results: 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 of physiotherapists' 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. Conclusion: All physiotherapists in ICU are routinely involved in chest physiotherapy and mobilization
  24,247 1,309 4
The constitutional and legal provisions in Indian law for limiting life support
S Balakrishnan, RK Mani
April-June 2005, 9(2):108-114
The absence of guidelines for withdrawal and withholding of life support in Indian law is perceived to be the most important obstacle to the practice of appropriate end of life care. In addition, physicians appear to be apprehensive about their civil or criminal liability when called upon to make decisions to limit life-supporting therapies. The following account explores the existing Constitutional and legal provisions that can reasonably be used by physicians in their defence. The article provides illustrative case histories that bring to focus the ethical dilemmas commonly faced by the physician .It also spells out the need for new legislation specifically addressing end-of-life issues.
  24,518 1,019 9
Intracranial hypertension after traumatic brain injury
Ian Seppelt
April-June 2004, 8(2):120-126
Traumatic brain injury is a devastating problem with both high mortality and high subsequent morbidity. Injury to the brain occurs both at the time of the initial trauma (the primary injury) and subsequently due to ongoing cerebral ischaemia (the secondary injury). Hypotension and hypoxaemia are well recognized causes of this secondary injury. In the intensive care unit raised intracranial pressure (intracranial hypertension) is seen frequently after a severe diffuse brain injury and leads to cerebral ischaemia by compromising cerebral perfusion. This paper reviews the pathophysiology of intracranial hypertension and summarises current and experimental approaches to its management in the intensive care unit.
  23,876 1,187 2
Extubation failure in intensive care unit: Predictors and management
Atul P Kulkarni, Vandana Agarwal
January-March 2008, 12(1):1-9
DOI:10.4103/0972-5229.40942  PMID:19826583
Extubation failure-need for reintubation within 72 h of extubation, is common in intensive care unit (ICU). It can cause increased morbidity, higher costs, higher ICU and hospital length of stay (LOS) and mortality. Patients with advanced age, high severity of illness at ICU admission and extubation, preexisting chronic respiratory and cardiovascular disorders are at increased risk of extubation failure. Unresolved illness, development and progression of organ failure during the time from extubation to reintubation and reintubation itself have been proposed as reasons for increased morbidity and mortality. Parameters used to predict extubation failure can be categorized into parameters assessing respiratory mechanics, airway patency and protection and cardiovascular reserve. Adequate cough strength, minimal secretions and alertness are necessary for successful extubation. Evidence suggests that early institution of non-invasive ventilation and prophylactic administration of methylprednisolone may prevent reintubation in some patients. The intensivist needs to identify patients at high risk of extubation failure and be prepared to reinstitute ventilation early to prevent adverse outcomes.
  22,074 2,730 10
Glyphosate surfactant herbicide poisoning and management
Kranthi Mahendrakar, Pradeep M. Venkategowda, S. Manimala Rao, Dnyaneshwar P. Mutkule
May 2014, 18(5):328-330
DOI:10.4103/0972-5229.132508  PMID:24914265
Glyphosate is a widely used herbicide in agriculture, forestry, industrial weed control and aquatic environments. Glyphosate potential as herbicide was first reported in 1971. It is a non-selective herbicide. It can cause a wide range of clinical manifestations in human beings like skin and throat irritation to hypotension, oliguria and death. We are reporting a case of a 35-year-old male patient who was admitted to our tertiary care hospital following intentional ingestion of around 200 ml of herbicide containing glyphosate. Initially, gastric lavage done and the patient was managed with intubation and mechanical ventilation, noradrenaline and vasopressin infusion, continuous veno-venous hemodiafiltration and intravenous (IV) lipid emulsion (20% intralipid 100 ml), patient was successfully treated and discharged home. This case report emphasizes on timely systemic supportive measure as a sole method of treatment since this poison has no known specific antidote and the use of IV lipid emulsion for a successful outcome.
  23,168 630 -
Hyponatremia in neurological diseases in ICU
Rahul Lath
January-March 2005, 9(1):47-51
Hyponatremia is the commonest electrolyte disturbance encountered in the neurological and neurosurgical intensive care units. It can present with signs and symptoms mimicking a neurological disease and can worsen the existing neurological deficits. Hyponatremia in neurological disorders is usually of the hypo-osmolar type caused either due to the Syndrome of Inappropriate Secretion of Anti Diuretic Hormone (SIADH) or Cerebral Salt Wasting Syndrome (CSWS). It is important to distinguish between these two disorders, as the treatment of the two differ to a large extent. In SIADH, the fluid intake is restricted, whereas in CSWS the treatment involves fluid and salt replacement.
  22,053 1,541 2
Mechanical ventilation: changing concepts
Pablo Rodriguez, Michel Dojat, Laurent Brochard
October-December 2005, 9(4):235-243
Mechanical ventilation is routinely delivered to patients admitted in intensive care units to reduce work of breathing, improve oxygenation, or correct respiratory acidosis. Although traditional modes of mechanical ventilation achieve many of these goals, they have important limitations. Alternative modes are supposed to handle some of these limitations and are now available on modern ventilators. This article reviews general aspects of functioning and limitations of traditional modes of mechanical ventilation, and the potential interest of some new promising modes.
  20,822 1,993 6
Multiple organ dysfunction syndrome due to tropical infections
FE Udwadia
October-December 2003, 7(4):233-236
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Online since 7th April '04
Published by Wolters Kluwer - Medknow