Background: Despite remarkable progress that has been achieved in the recent years in the diagnosis, prevention, and therapy for ventilator-associated pneumonia (VAP), this disease continues to create complication during the course of treatment in a significant proportion of patients while receiving mechanical ventilation. Objective: This study was designed to evaluate the effect of multimodality chest physiotherapy in intubated and mechanically ventilated patients undergoing treatment in the intensive care units (ICUs) for prevention of VAP. Patients and Methods: A total of 101 adult intubated and mechanically ventilated patients were included in this study. Manual hyperinflation (MH) and suctioning were administered to patients in the control group (n = 51), and positioning and chest wall vibrations in addition to MH plus suctioning (multimodality chest physiotherapy) were administered to patients in the study group (n = 50) till they were extubated. Both the groups were subjected to treatment twice a day. Standard care in the form of routine nursing care, pharmacological therapy, inhalation therapy, as advised by the concerned physician/surgeon was strictly implemented throughout the intervention period. Results: Data were analyzed using SPSS window version 9.0. The Clinical Pulmonary infection Score (CPIS) Score showed significant decrease at the end of extubation/successful outcome or discharge in both the groups (P = 0.00). In addition, significant decrease in mortality rate was noted in the study group (24%) as compared to the control group (49%) (P = 0.007). Conclusions: It was observed in this study that twice-daily multimodality chest physiotherapy was associated with a significant decrease in the CPIS Scores in the study group as compared to the control group suggesting a decrease in the occurrence of VAP. There was also a significant reduction in the mortality rates with the use of multimodality chest physiotherapy in mechanically ventilated patients.

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Background and Aims: The 2009 pandemic influenza A (H1N1) has taken its toll across most parts of India. We aimed to study its epidemiology, clinical characteristics and outcomes from an Indian multidisciplinary intensive care unit (ICU). Materials and Methods: All patients admitted to our ICU with a flu-like illness and who tested positive for the 2009 H1N1 by reverse -transcriptase polymerase- chain -reaction assay during a 3 month period were prospectively studied. Results: Thirty one patients were admitted to the ICU during the study period. Patients were in the younger age group with a median age of 35 years (IQR: 28.2-42.8). Obesity was the commonest risk factor. Twenty six patients (83.9%) required ventilator support; the median duration of ventilator support was 10 days (IQR: 4-22). Severe hypoxemia was the predominant feature in all patients. Circulatory failure requiring vasopressors occurred in 18 (58.1%) patients and acute kidney injury in 6 (3.2%) patients. Twenty six patients were alive at the end of 28 days; subsequently all except one were discharged. The median duration of hospital stay was 15 (IQR: 8-22.5) days. Increasing APACHE II scores were associated with an increased risk of death (Hazard Ratio: 1.1; CI: 1.08 -1.2; P = 0.04). Mean tidal volumes in non-survivors were significantly lower; this was related to poor lung compliance in this group. Conclusions: 2009 H1N1 infection caused severe disease in relatively young patients without significant co-morbidities, characterized by severe hypoxemia and the requirement for prolonged mechanical ventilation. Extra-pulmonary organ failure included circulatory and renal failure.

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Cannulation of the subclavian vein has its inherent risks. Post procedure chest radiograph is one of the investigations done to rule out immediate complications. Unless the clinician is aware as to what to look for in the radiograph, some of the dangerous complications can be overlooked. Accidental subclavian artery cannulation is identified immediately by color and jet of the blood. Also the position of the catheter tip has to be confirmed by obtaining the arterial pressure tracing using a pressure transducer. Non availability of Doppler ultrasound and pressure transducer are limiting factors for immediate confirmation of proper catheter placement. Also, in patients with severe hypotension and reduced oxygen content of blood, accidental arterial puncture may not show the characteristic bright red pulsatile back flow of arterial blood. In these situations radiography can be used as a diagnostic tool to rule out subclavian artery cannulation.

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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.

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Aims: To identify the relatives of the intensive care unit (ICU) patients at risk for developing symptoms of posttraumatic stress disorders. Setting: A multidisciplinary hospital ICU. Design: Prospective single center observational study. Material and Methods: Relatives of patients admitted in the ICU (May06-Nov06) who consented to answer the questionnaire participated in the study. Anxiety was assessed by using the Hospital Anxiety and Depression Scale (HAD) and vulnerability to posttraumatic disorder (PTSD) by using the Impact of Event Scale Revised (IES-R) which was administered on the fifth day of admission and at two months following discharge or death. Results: During admission, 48% of the relatives had a HAD score >11 and 72% showed IES-R score >26. There was no association of HAD with gender, patient outcome, working status, age of the patient, or mode of payment of the bills. There was significant association of IES-R >26 with trauma admission, HAD score >11 and mode of payment with the relatives of insured being more stressed as compared to those who settled their bills personally. A total of 35% relatives showed symptoms of posttraumatic stress reaction consistent with a high risk of PTSD after two months. Death in the hospital resulted in elevated HAD and IES-R score during admission and at the two month follow-up. Persistence of stress symptoms was more in school drop outs, working relatives, parents and those with initial anxiety score >11. Conclusions: HAD score greater than 11 was the only factor at admission which could statistically predict a higher PTSD score on follow-up. Adequate counseling of this group of relatives may prevent lasting psychological sequelae of an ICU admission in the relatives of critically ill.

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A 42-year-old Indian man received 450 mg rifampicin (RIF) and 150 mg isoniazid (INH) daily after being diagnosed of a latent tuberculosis infection. Baseline serum aminotransferase and total bilirubin levels were within normal limits. On day 31 of treatment, the patient experienced epigastric discomfort and general malaise and one week later he developed nausea and episodic vomiting. The patient missed his first scheduled clinic appointment and he continued taking RIF-INH despite his symptoms. He visited the tuberculosis clinic on day 47 of treatment where he was found to be jaundiced and his liver enzymes were elevated. RIF-INH was stopped and the patient was admitted to our hospital as a case of RIF-INH induced hepatitis. On the 7th day of hospitalization, the patient developed consciousness disturbance with flapping tremor and high ammonia level. The patient was diagnosed with fulminant hepatic failure and transferred immediately to the medical intensive care unit, where he died 4 days later.

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Objective: To study acid-base imbalance in common pediatric diseases (such as sepsis, bronchopneumonia, diarrhea, birth-asphyxia etc.) in neonates. Design and Setting: An observational study was conducted in an emergency room of a tertiary teaching care hospital in Haryana, India. Patients and Methods: Fifty neonates (from first hour to one month) attending pediatric emergency services with various ailments. Blood gas analysis, electrolytes, plasma lactate, and plasma albumin were estimated in neonates. Results: Metabolic acidosis was the most common acid-base disorder. Hyperlactatemia was observed in more than half of such cases. Birth asphyxia was another common disorder with the highest mortality in neonates followed by bronchopneumonia and sepsis. Significant correlation between mortality and critical values of lactate was observed. Conclusion: Birth asphyxia with high-lactate levels in neonates constituted major alterations in acid-base disorders seen in an emergency room of a tertiary teaching care hospital. Plasma lactate concentration measurement provides an invaluable tool to assess type of metabolic acidosis in addition to predicting mortality in these neonates.

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Acute disseminated encephalomyelitis (ADEM), seen mostly in children, is an acute demyelinating disease, affecting mainly the white matter of brain and spinal cord. We report an unusual case of ADEM in an 11-year old boy with end-stage renal disease, who underwent hemopoietic stem cell transplantation prior to renal transplantation. He needed admission to the intensive care unit and required mechanical ventilation. He responded to intravenous injection of steroids and upon recovery, underwent renal transplantation successfully.

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Acute intermittent porphyria (AIP), the most common and the most severe form of acute hepatic porphyria, is an autosomal dominant condition. It results from lower-than-normal levels (less than 50%) of porphobilinogen (PBG) deaminase. Patients may present commonly with gastrointestinal complaints and neuropsychiatric manifestations. Diagnosis may be confirmed with the presence of intermediary metabolites of haem synthesis, amino levulinic acid (ALA) and PBG in urine or with specific enzyme assays. Abdominal pain is the most common symptom (90%). Peripheral polyneuropathy, primarily motor with flaccid paresis of proximal musculature, with or without autonomic involvement, is characteristic. Respiratory failure necessitates ventilator and intensive care support. Avoidance of precipitating factors and the use of haem preparations and intravenous dextrose form the basis of management. Gabapentin and propofol, rather than the conventional antiepileptics appear to be the appropriate choice for seizure control. Here, we present intensive care management of four cases of AIP with varying clinical presentation.

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Spontaneous medastinal emphysema, as a complication of acute severe asthma, is an uncommon entity. It usually runs a benign course and resolves spontaneously without any surgical intervention. Recognition of this complication is critical, as it has to be differentiated from other life threatening ones including oesophageal rupture, Boerhave's syndrome, acute coronary syndrome and pulmonary embolism. This case is being presented to emphasize its recognition in the differential diagnosis of complications arising from acute severe asthma and to present its management strategy in detail.

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