Indian Journal of Critical Care Medicine
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   2011| January-March  | Volume 15 | Issue 1  
    Online since March 22, 2011

 
 
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RESEARCH ARTICLES
Significance of serum procalcitonin in sepsis
Uchil Sudhir, Ravi Kumar Venkatachalaiah, Thimmaiah Anil Kumar, Medha Yogesh Rao, Punith Kempegowda
January-March 2011, 15(1):1-5
DOI:10.4103/0972-5229.78214  PMID:21633539
Context: Rapid treatment of sepsis is of crucial importance for survival of patients. Specific and rapid markers of bacterial infection have been sought for early diagnosis of sepsis. One such measurement, Procalcitonin (PCT), has recently become of interest as a possible marker of the systemic inflammatory response to infection. Aims: This study was done to find out the common sources of sepsis and to evaluate the diagnostic value of PCT, its predictive value and its relation with Sepsis-related Organ Failure Assessment (SOFA) scores and mortality in various stages of sepsis. Settings and Design: The prospective study was conducted at our tertiary care center from October 2006 to December 2008. A total of 100 patients were included in the study. The study sample included all patients aged above 18 years presenting consecutively to our center during the study period with acute sepsis. They were divided into three groups: sepsis, severe sepsis and septic shock based on standardized criteria. Materials and Methods: PCT and various other relevant factors were measured in all study subjects. These parameters were compared among the three study groups. The statistical analyses were done using Student "t" test and two-way analysis of variance (ANOVA). Results: Respiratory tract infection was the most common source of sepsis. PCT proved to be an excellent indicator of sepsis with sensitivity of 94%. There was a significant association between serum PCT and SOFA scores (P < 0.05). Serum PCT levels did not predict mortality in the present study. Conclusions: PCT is among the most promising sepsis markers, capable of complementing clinical signs and routine lab parameters suggestive of severe infection.
  5,301 1,803 11
Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit
Ashu S Mathai, Smitha E George, John Abraham
January-March 2011, 15(1):6-15
DOI:10.4103/0972-5229.78215  PMID:21633540
Context: The role of hand hygiene in preventing health care associated infections (HCAIs) has been clearly established. However, compliance rates remain poor among health care personnel. Aims: a) To investigate the health care workers' hand hygiene compliance rates in the intensive care unit (ICU), b) to assess reasons for non-compliance and c) to study the efficacy of a multimodal intervention strategy at improving compliance. Settings: A mixed medical-surgical ICU of a tertiary level hospital. Design: A before-after prospective, observational, intervention study. Materials and Methods: All health care personnel who came in contact with patients in the ICU were observed for their hand hygiene compliance before and after a multimodal intervention strategy (education, posters, verbal reminders and easy availability of products). A self-report questionnaire was also circulated to assess perceptions regarding compliance. Statistical analysis was done using c2 test or Fisher exact test (Epi info software). Results: Hand hygiene compliance among medical personnel working in the ICU was 26% and the most common reason cited for non-compliance was lack of time (37%). The overall compliance improved significantly following the intervention to 57.36% (P<0.000). All health care worker groups showed significant improvements: staff nurses (21.48-61.59%, P<0.0000), nursing students (9.86-33.33%, P<0.0000), resident trainees (21.62-60.71%, P<0.0000), visiting consultants (22-57.14%, P=0.0001), physiotherapists (70-75.95%, P=0.413) and paramedical staff (10.71-55.45%, P< 0.0000). Conclusions: Hand hygiene compliance among health care workers in the ICU is poor; however, intervention strategies, such as the one used, can be useful in improving the compliance rates significantly.
  5,456 848 9
Comparison of bronchoscopic and non-bronchoscopic techniques for diagnosis of ventilator associated pneumonia
GC Khilnani, T.K Luqman Arafath, Vijay Hadda, Arti Kapil, Seema Sood, SK Sharma
January-March 2011, 15(1):16-23
DOI:10.4103/0972-5229.78218  PMID:21633541
Background: The diagnosis of ventilator associated pneumonia (VAP) remains a challenge because the clinical signs and symptoms lack both sensitivity and specificity and the selection of microbiologic diagnostic procedure is still a matter of debate. Aims and Objective: To study the role of various bronchoscopic and non-bronchoscopic diagnostic techniques for diagnosis of VAP. Settings and Design: This prospective comparative study was conducted in a medical ICU of a tertiary care center. Materials and Methods: Twenty-five patients, clinically diagnosed with VAP, were evaluated by bronchoscopic and non-bronchoscopic procedures for diagnosis. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various bronchoscopic and non-bronchoscopic techniques were calculated, taking clinical pulmonary infection score (CPIS) of ≥6 as reference standard. Results: Our study has shown that for the diagnosis of VAP, bronchoscopic brush had a sensitivity, specificity, PPV and NPV of 94.9% [confidence interval (CI): 70.6-99.7], 57.1% (CI: 13.4-86.1), 85% (CI: 61.1-96) and 80% (CI: 21.9-98.7), respectively. Bronchoscopic bronchoalveolar lavage (BAL) had a sensitivity, specificity, PPV and NPV of 77.8% (CI: 51.9-92.6), 71.8% (CI: 24.1-94), 87.3% (CI: 60.4-97.8) and 55.5% (CI: 17.4-82.6), respectively. Sensitivity, specificity, PPV and NPV for non-bronchoscopic BAL (NBAL) were 83.3% (CI: 57.7-95.6), 71.43% (CI: 24.1-94), 88.2% (CI: 62.3-97.4) and 62.5% (CI: 20.2-88.2), respectively. Endotracheal aspirate (ETA) yield was only 52% and showed poor concordance with BAL (k-0.351; P-0.064) and NBAL (k-0.272; P-0.161). There was a good microbiologic concordance among different bronchoscopic and non-bronchoscopic distal airway sampling techniques. Conclusion: NBAL is an inexpensive, easy, and useful technique for microbiologic diagnosis of VAP. Our findings, if verified, might simplify the approach for the diagnosis of VAP.
  3,846 646 7
An evaluation of the charlson co-morbidity score for predicting sepsis after elective major surgery
Peter A Hampshire, Arpan Guha, Ann Strong, Dawn Parsons, Patricia Rowan
January-March 2011, 15(1):30-36
DOI:10.4103/0972-5229.78221  PMID:21633543
Background and Aims: Severe sepsis is a significant cause of morbidity and mortality following major surgery. The Charlson co-morbidity score (CCS) has been shown to be associated with severe sepsis following major surgery for cancer. This prospective observational study investigated the effect of patient factors (CCS, gender, age and malignancy) and intraoperative factors (duration of surgery and allogeneic blood transfusion) on the incidence of sepsis after elective major surgery, and the impact of patient co-morbidities on length of stay in critical care. Materials and Methods: We prospectively identified a cohort of 101 patients undergoing elective major surgery in a university teaching hospital. The CCS was calculated before surgery, and the incidence of sepsis was documented following surgery. We investigated whether age, malignancy, intraoperative allogeneic blood transfusion, length of surgery or gender were associated with sepsis following surgery. Results: Twenty-seven (27%) patients developed sepsis. Using multivariate logistic regression, the duration of surgery was associated with the development of sepsis after surgery (P = 0.054, odds ratio 1.2). The CCS was not associated with sepsis in this population of cancer and non-cancer patients undergoing elective major surgery, but was associated with longer length of stay in the intensive care unit (P = 0.016). Conclusions: Duration of surgery, but not patient co-morbidity as assessed by the CCS, may predict the postoperative incidence of sepsis. CCS could be used as a guide to predict consumption of critical care resources by elective surgical patients. A higher CCS was associated with a longer ICU stay. Resources, such as postoperative goal directed therapy, may be useful in reducing length of stay, hospital costs and risks of infective complications in this subgroup of patients with higher CCS.
  4,120 360 1
Electrolytes assessed by point-of-care testing - Are the values comparable with results obtained from the central laboratory?
Binila Chacko, John Victor Peter, Shalom Patole, Jude Joseph Fleming, Ratnasamy Selvakumar
January-March 2011, 15(1):24-29
DOI:10.4103/0972-5229.78219  PMID:21633542
Background and Aims: When dealing with very sick patients, the speed and accuracy of tests to detect metabolic derangements is very important. We evaluated if there was agreement between whole blood electrolytes measured by a point-of-care device and serum electrolytes measured using indirect ion-selective electrodes. Materials and Methods: In this prospective study, electrolytes were analyzed in 44 paired samples drawn from critically ill patients. Whole blood electrolytes were analyzed using a point-of-care blood gas analyzer and serum electrolytes were analyzed in the central laboratory on samples transported through a rapid transit pneumatic system. Agreement was summarized by the mean difference with 95% limits of agreement (LOA) and Lin's concordance correlation (p c). Results: There was a significant difference in the mean (±standard deviation) sodium value between whole blood and serum samples (135.8 ± 5.7 mmol/L vs. 139.9 ± 5.4 mmol/L, P < 0.001), with the agreement being modest (p c = 0.71; mean difference -4.0; 95% LOA -8.78 to 0.65). Although the agreement between whole blood and serum potassium was good (p c = 0.96), and the average difference small (-0.3; 95% LOA -0.72 to 0.13), individual differences were clinically significant, particularly at lower potassium values. For potassium values <3.0 mmol/L, the concordance was low (p c = 0.53) and the LOA was wide (1.0 to -0.13). The concordance for potassium was good (p c = 0.96) for values ≥3.0 (mean difference -0.2; 95% LOA -0.48 to 0.06). Conclusions: Clinicians should be aware of the difference between whole blood and serum electrolytes, particularly when urgent samples are tested at point of care and routine follow-up electrolytes are sent to the central laboratory. A correction factor needs to be determined at each center.
  3,745 477 3
CASE REPORTS
Anaphylactic reaction to intravenous diclofenac
Ranju Singh, Deepak Bansal, Neha Baduni, Homay Vajifdar
January-March 2011, 15(1):37-39
DOI:10.4103/0972-5229.78222  PMID:21633544
Diclofenac sodium is a non-steroidal anti-inflammatory drug widely used as an opioid sparing agent for postoperative analgesia. Anaphylaxis due to intravenous diclofenac sodium is very rare. We report a case of anaphylactic reaction to IV diclofenac sodium, occurring postoperatively in a 25-year-old primigravida, the clinical features of which mimicked pulmonary embolism. The rarity, clinical importance and the diagnostic dilemma associated prompted us to report this case.
  3,034 434 2
LETTERS TO THE EDITOR
Right subclavian artery cannulation: Is chest roentgenogram sufficient to diagnose the complication?
Amit Jain
January-March 2011, 15(1):61-62
DOI:10.4103/0972-5229.78234  PMID:21633554
  2,798 222 1
CASE REPORTS
Hemodialysis through persistent left superior vena cava
VB Kute, AV Vanikar, MR Gumber, PR Shah, KR Goplani, HL Trivedi
January-March 2011, 15(1):40-42
DOI:10.4103/0972-5229.78223  PMID:21633545
We report a case of end stage renal disease patient who displayed a persistent left superior vena cava (PLSVC) after placement of hemodialysis (HD) catheter through left internal jugular vein, as revealed by routine post-procedure X-ray chest. The diagnosis of PLSVC was confirmed by arterial blood gas, two-dimensional echocardiography, computed tomography thorax and angiographic examination. This anomaly is rather rare; few studies on safety of PLSVC for HD have been reported. The catheter was uneventfully used for HD for 2 months with careful continuous monitoring and removed after arteriovenous fistula was successfully cannulated. Physicians who place HD catheters in the left jugular/subclavian vein should be aware of the existence of PLSVC.
  2,583 269 7
Nonchylous idiopathic pleural effusion in the newborn
Geeta Gathwala, Jagjit Singh, KN Rattan, Kapil Bhalla
January-March 2011, 15(1):46-48
DOI:10.4103/0972-5229.78226  PMID:21633547
Congenital isolated pleural effusion is a rare cause of respiratory distress in neonates. It is usually chylous. Herein, we report a rare case of nonchylous congenital idiopathic pleural effusion.
  2,326 239 1
Post-traumatic skin and soft tissue infection due to Aeromonas hydrophila
Bijayini Behera, Sandeep Bhoriwal, Purva Mathur, Sushma Sagar, Maneesh Singhal, MC Misra
January-March 2011, 15(1):49-51
DOI:10.4103/0972-5229.78228  PMID:21633548
We report a case of posttraumatic skin and soft tissue infection in a patient who sustained laceration after being hit by a water tanker. Aeromonas hydrophila was isolated from pus and was identified to the species level by Vitek 2 and a battery of biochemical tests. The patient responded to thorough drainage, debridement of wound and 2 weeks of intravenous antibiotics. The patient was taken up for split skin grafting of the raw area. She was discharged with satisfactory graft uptake after 1 week without any further antibiotics advice. Follow-up after 3 weeks was satisfactory with healthy cover on the raw area and normal weight bearing on the left leg.
  2,115 290 2
Contralateral hyperinflation: Computed tomography demonstration of an unusual complication of unrecognized endobronchial intubation
Jyotindu Debnath, Rajesh Kumar, R Bala Murali Krishna, Ankit Mathur
January-March 2011, 15(1):52-54
DOI:10.4103/0972-5229.78229  PMID:21633549
Endobronchial intubation (EBI) is an important complication of endotracheal intubation. In a case of unrecognized EBI, usually, the intubated lung gets hyperinflated while the contralateral lung collapses. We report a case of unrecognized right main stem EBI with ipsilateral normal aeration and contralateral hyperinflation detected during computed tomography scan of the chest for trauma work up in a case of severe head injury.
  2,087 226 2
Apical ballooning syndrome after attempted suicidal hanging
Jose Chacko, Gagan Brar, Ashok Elangovan, Ramanathan Moorthy
January-March 2011, 15(1):43-45
DOI:10.4103/0972-5229.78225  PMID:21633546
We report a case of "Apical Ballooning Syndrome" following attempted suicidal hanging. Our patient developed retrosternal chest pain and ischemic changes on electrocardiography (ECG), a day after the suicidal attempt. She underwent an angiogram considering the possibility of acute coronary syndrome. However, her coronary arteries were normal; the left ventricle showed the typical ballooning pattern characterized by hypokinesia of the distal septum and apex. On follow-up a week later, she remained asymptomatic; her ECG changes had reversed and the left ventricular contractility was normal on echocardiography.
  2,007 299 3
RAPID COMMUNICATION
Revisiting the eye opening response of the Glasgow Coma Scale
Taopheeq Bamidele Rabiu
January-March 2011, 15(1):58-59
DOI:10.4103/0972-5229.78231  PMID:21633551
The Glasgow Coma Scale (GCS), introduced by Teasdale and Jenneth in 1974, has received tremendous acclaim from clinicians and has been extensively used in clinical practice for the evaluation of the level of consciousness. The author notes that some traumatic brain injury patients close eyes in response to painful stimuli as opposed to the eye opening response to pain of the GCS. A revision of the eye opening response subsection of the GCS is suggested.
  1,766 371 -
CASE REPORTS
Drug interaction leading to prolonged sedation in a postoperative high risk coronary bypass surgery patient
Shrikant Bobade, Vinay Kulkarni, Sudhir Dhumne, Saurabh Barde, Jitesh Chauhan, Avinash Sharma
January-March 2011, 15(1):55-57
DOI:10.4103/0972-5229.78230  PMID:21633550
Use of midazolam infusion in mechanically ventilated patient is an established practice in critical care. In our case, the use of erythromycin as a prokinetic agent for better tolerance of enteral feeding and paralytic ileus led to an interaction between midazolam and erythromycin, which resulted in prolonged and deeply sedated patient. In a critically ill patient, there is always a possibility of multiple drug interactions. It is important to understand them and they should be considered before starting new medication.
  1,647 285 -
LETTERS TO THE EDITOR
Critically ill patients with 2009 H1N1 infection in an Indian intensive care unit
Vivek B Kute, Pankaj R Shah, Manoj R Gumber, Aruna V Vanikar, Hargovind L Trivedi
January-March 2011, 15(1):62-63
DOI:10.4103/0972-5229.78236  PMID:21633556
  1,239 212 -
Encephalopathy as a presenting feature of ascariasis in a child
Syed Ahmed Zaki, Vijay Lad
January-March 2011, 15(1):63-64
DOI:10.4103/0972-5229.78237  PMID:21633557
  1,171 215 -
Novel H1N1 influenza infection in intensive care unit
Viroj Wiwanitkit
January-March 2011, 15(1):60-60
DOI:10.4103/0972-5229.78232  PMID:21633552
  1,033 213 1
Authors' reply
J Chacko, B Gagan, E Ashok, M Radha, HV Hemanth
January-March 2011, 15(1):60-61
PMID:21633553
  960 191 -
Author's reply
Nataraj Madagondapalli Srinivasan, Akshay Kumar
January-March 2011, 15(1):62-62
PMID:21633555
  925 173 -
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