Context: Patients in intensive care units have impaired ocular protective mechanisms, resulting in a high risk of developing eye complications. Various eye care protocols are being used, but none is proven to be absolutely effective. Aims: To compare the efficacy of using a combination of ocular lubricants and securing tape over the eyelids (Open chamber method), with use of swimming goggles and regular moistening of eyelids with gauze soaked in sterile water (Closed chamber method), to prevent corneal epithelial breakdown in the sedated and semiconscious intensive care adult patient. Settings and Design: A randomized clinical study was performed. Patients with Glasgow coma scale score of £ 10/15, admitted into the Medical ICU of a large teaching hospital, over a four month duration, were studied. Materials and Methods: Patients were examined daily by an Ophthalmologist, using a portable slit lamp and the patient′s corneas were tested daily using 1% Fluorescein drops. Standard grading scales were used to record eyelid position and corneal and conjunctival changes. Statistical analysis used: Quantitative variables were described in terms of their relative frequencies in proportions. Null hypothesis was applied to derive the statistical significance of the observed variations in both the treatment groups. Chi-square test for relationships was used to assess the effect of specific variables on the development of keratopathy. Results: Sixty one patients (122 eyes) in the open chamber group and 63 (126 eyes) in the closed chamber group, were analyzed. Incomplete lid closure was seen in 74 eyes (30%). Exposure keratopathy was noticed in 39 eyes (32%) in open chamber group and ten (8%) in closed chamber group and was more severe in the former group. There was no difference in the incidence of conjunctival oedema in both groups. Incomplete lid closure and use of muscle relaxants, were significant risk factors for developing keratopathy. Conclusions: Use of swimming goggles and regular moistening of eyelids with gauze soaked in sterile water providing a moisture chamber, is more effective than using a combination of ocular lubricants and securing tape over the eyelids, in preventing corneal epithelial breakdown in sedated and semiconscious intensive care unit patients.

Context: The total time spent in nursing care depends on the type of patient and the patient′s condition. We analysed factors that influenced the time spent in nursing a patient. Aims: To analyse the factors in a patient′s condition that influenced time spent in nursing a patient. Materials and Methods: This study was performed in the Surgical Intensive Care Unit of a tertiary referral centre, over a period of one month. The total time spent on a patient in nursing care for the first 24 hours of admission, was recorded. This time was divided into time for routine nursing care, time for interventions, time for monitoring and time for administering medications. Statistical analysis used: A backward stepwise linear regression analysis using the age, sex, diagnosis, type of admission and ventilatory status as variables, was done. Results: Patients admitted after elective surgery required less time (852.4 ± 234.1 minutes), than those admitted after either emergency surgery (1069.5 ± 187.3 minutes), or directly from the ward or the emergency room (1253.7 ± 42.1 minutes). Patients who were ventilated required more time (1111.5 ± 132.5 minutes), than those brought on a T-piece (732.2 ± 134.8 minutes or extubated (639.5 ± 155.6 minutes). The regression analysis showed that only the type of admission and the ventilatory status significantly affected the time. Conclusions: This study showed that the type of admission and ventilatory status significantly influenced the time spent in nursing care. This will help optimal utilization of nursing resources.

Background: The management of acute intracranial hypertension refractory to medical management remains a challenging endeavour. Mortality and morbidity rates remain high despite optimal medical management. Decompressive craniectomy has been proposed as an effective treatment for patients who have raised intracranial pressure (ICP) refractory to medical management. This study examined the outcome of patients who underwent this procedure. Aim: To assess the outcome of patients who underwent decompressive craniectomy. Materials and Methods: We conducted a prospective audit of consecutive patients of one neurosurgical unit, who underwent decompressive craniectomy at a tertiary care centre between 01/01/2004 to 31/03/2005. A complete neurological assessment, including Glasgow coma scale (GCS) and pupils was done and recorded at the time of admission, deterioration, post-op one wk and post-op three wks. End points were Glasgow outcome score (GOS) and Karnofsky score at 30 days, at discharge and at 6 months. Results: We studied 12 patients who were aged 30 to 69 yrs (Mean = 47 yrs). Unlike most interventions in critical care, survival is not an acceptable single end point. Good recovery (Karnofsky score ³80 / GOS³4) was seen in five patients. Three patients were alive with severe disability (Karnofsky score 1-70 / GOS 2-3), at follow up. Four patients died (Karnofsky score 0 / GOS 1). Conclusion: Eight patients who underwent decompressive craniectomy survived. Five of these patients had a good recovery. The other three survived with severe disability.

Background and Aims: Chest trauma is a major public health problem in India, but only few studies have been conducted to analyze its magnitude and management. The present study was carried out to determine the epidemiological profile of chest trauma cases and to analyze the management strategies with an aim to identify the scope of improvement in our set-up. Materials and Methods: It is a retrospective study of cases admitted with chest trauma, to a tertiary care hospital. Records of the patients admitted to the hospital with chest trauma over a period of one year were analyzed for the patients′ demographic profile; mechanism, nature and severity of injuries; associated injuries; management and outcome of cases. Results: Out of a total of 105 patients, most were males, belonged to age group of 21-40 years and suffered blunt trauma. Motor vehicle accident was the commonest mechanism of injury. The interval from injury to admission ranged from one hour, to more than 24 hours. Eight patients were admitted to the ICU, out of which 5 required ventilatory support. The most frequently used analgesics in the wards were non-steroidal anti-inflammatory drugs (NSAID). Ninety one patients improved, while seven patients died in the hospital. Conclusions: Chest trauma due to blunt injury is an important cause of morbidity and mortality in young males. Despite limitations of resources and manpower, attempts are being made to manage patients successfully. However, creation of dedicated trauma teams with well-designed management protocols in hospitals can further improve the outcome.

In recent years, transplantation has assumed an important role in the treatment of patients with end-stage organ failure. With the passage of Transplantation of Human Organ Act by the Indian parliament, transplantation of organs from brain dead donors has become a reality. Although there are many issues in success of cadaver programme, intensivists can play a crucial role by converting a potential donor into an actual donor. This article reviews the identification of potential organ donor and pathophysiological changes surrounding brain death, with particular emphasis on management of the organ donor in the intensive care unit. With an increased awareness of donor management issues and the application of a rational physiological approach, the number of functional organs for transplantation can be increased.

More than twenty-five years have elapsed since the first Do Not Resuscitate (DNR) policies were proposed. A historical review of the application of DNR policies is provided with its rationale and perceived effects. A viewpoint is presented, that acceptance of implied consent for cardiopulmonary resuscitation (CPR) in hospitalized patients was responsible for drawing up of DNR policies. Unfortunately, the principle of informed consent as related to CPR and DNR policies, has had unintended consequences. Practical results do not indicate that medical practices have become more humane. Abuses of the process go beyond matters of style and experience, in communicating with surrogate decision-makers. Instead of generating compassion and respect for the patient, policies may contribute to cynicism and lack of caring amongst physicians. Overly optimistic dependence on advance directives to reform medical practices, appears unjustified. The concept of futility to limit demands for non-beneficial care is examined. It is unlikely that physicians can routinely invoke futility, as an argument to limit treatments. A re-examination of DNR policies as a defense against technologic imperative is warranted.

Massive lower gastrointestinal (GI) hemorrhage is a rare manifestation of GI cytomegalovirus (CMV) infection, in a critically ill patient. We report a 69-year-old man, known to have chronic obstructive pulmonary disease on ventilator, who developed sudden onset abdominal pain and massive lower GI bleeding. Due to uncontrolled bleeding, the patient was explored surgically. Bleeding from ileum was evident. The affected segment of the ileum was resected. Histology confirmed the diagnosis of CMV enteritis and Gancyclovir was initiated. On the following days, his physical state had improved and bleeding was resolved.

Duodenal rupture following blunt abdominal trauma is rare and it usually seen with other abdominal organ injuries. It represents approximately 2% to 20% of patients with blunt abdominal injury and often occurs after blows to the upper abdomen, or abdominal compression from high-riding seat belts. Two cases of blunt duodenal rupture successfully treated surgically, are presented with their preoperative diagnosis and final out comes.

A 9 months old immunocompetent male baby was admitted with high grade fever, erythematous maculo-papular rash and frequent loose stools. He was unwell three weeks prior, with febrile illness and anemia, for which he was transfused 2 units of non irradiated whole blood from first-degree family donors (father and mother), in a private hospital. Seven days after transfusion, he became symptomatic. Investigations revealed elevated liver enzymes, elevated bilirubin levels and progressive pancytopenia. Clinical findings and results of skin biopsy and bone marrow examination were consistent with transfusion-associated graft-versus-host disease. He was treated with steroids, Cyclosporin, broad spectrum antibiotics and supported by irradiated blood components. He died on day 10, post admission and day 31, post transfusion, despite intensive medical care.

A 23 yrs old patient presented in unconscious state with subsequent development of extrapyramidal symptoms and hyperthermia. On investigations, he was found to have high CPK levels. He was treated with dopaminergic drugs and improved. Later history of intake of stemetil and antipsychotics was found.