Indian Journal of Critical Care Medicine

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2008 | March | Volume 12 | Issue 1

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Extubation failure in intensive care unit: Predictors and management

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:9] [Pages No:1 - 9]

Keywords: Extubation, failure of, predictors of, reintubation, weaning

   DOI: 10.4103/0972-5229.40942  |  Open Access |  How to cite  | 


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.



Veena R. Shah, Geeta P. Parikh, Anish M. Joshi, Guruprasad P. Bhosale

Optimal positioning of right-sided internal jugular venous catheters: Comparison of intra-atrial electrocardiography versus Peres′ formula

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:5] [Pages No:10 - 14]

Keywords: Central venous catheterization, intra-atrial electrocardiography, Peres′ height formula

   DOI: 10.4103/0972-5229.40943  |  Open Access |  How to cite  | 


Central venous catheters are routinely placed in patients undergoing major surgeries where expected volume and hemodynamic disturbances are likely consequences. The incorrect positioning may give false central venous pressure (CVP) readings leading to incorrect volume replacement and other serious complications. 50 American Society of Anaesthesiologists grade II-IV patients aged 18-60 years were selected for right-sided internal jugular vein (IJV) catheterization using Seldinger′s technique. In group A, central venous catheterization was done under electrocardiography (ECG) guidance. In group B, the catheter was inserted blindly using Peres′ formula of “height (in cm)/10”. The position of the tip of central venous catheter was confirmed radiologically by postoperative chest X-ray. 92% of patients in group A had radiologically correct positioning of catheter tip i.e. above the carina, while in group B 48% patients had over-insertion of the catheter in to the right atrium. Intra-atrial ECG technique to judge correct tip positioning is simple and economical. It can determine the exact position intraoperatively and can justify a delayed postoperative chest X-ray to confirm CVC line tip placement.



Prithwis Bhattacharya, Suman Sarkar, Anil Paswan

Cerebrovascular manifestations and alteration of coagulation profile in scorpion sting: A case series

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:3] [Pages No:15 - 17]

Keywords: Disseminated intravascular coagulation, scorpion sting, stroke

   DOI: 10.4103/0972-5229.40944  |  Open Access |  How to cite  | 


Cerebrovascular manifestations are uncommon presentations of scorpion sting in the Indian subcontinent. A prospective study was carried out on 42 patients with scorpion sting in the intensive care unit (ICU) of the Institute of Medical Sciences, Banaras Hindu University, Varanasi-05, INDIA, during the period of May 2005 to October 2007. In all the patients detailed history, physical examination with a specific neurological examination and routine biochemical testing and fundus examination were done. Computerized tomography and magnetic resonance imaging were done in cases with neurological deficit. All these patients also underwent a complete hematological, rheumatologic and cardiovascular work-up for stroke. Cerebrovascular involvement was noted in three patients (7.15%). Hemorrhagic stroke was noted in two patients (4.77%) and thrombotic stroke was noted in one patient (2.39%). The mean time of presentation of neurological symptoms was 3 days. Contrary to world literature, there have been no reports of cranial nerve palsies or neuromuscular involvement in our series.



Hatem Kallel, Fouzia Mahjoubi, Hassen Dammak, Mabrouk Bahloul, Chokri Ben Hamida, Hedi Chelly, Noureddine Rekik, Adnene Hammami, Mounir Bouaziz

Correlation between antibiotic use and changes in susceptibility patterns of Pseudomonas aeruginosa in a medical-surgical intensive care unit

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:6] [Pages No:18 - 23]

Keywords: Ciprofloxacin, use, imipenem, P. aeruginosa, resistance

   DOI: 10.4103/0972-5229.40945  |  Open Access |  How to cite  | 


Context: Multiple surveillance programmes have reported a decline in antibiotic susceptibility of P. aeruginosa. Aim: Our study aimed to study the relationship between the use of antipseudomonal drugs and the development of resistance of P. aerogenosa to these drugs. Setting and Design: Our study is retrospective. It was conducted in a medical surgical intensive care unit during a five-year period (January 1 st, 1999 to December 31, 2003), which was divided into 20 quarters. We had monitored the use of antipseudomonal agents and the resistance rates of P. aeruginosa to these drugs. Statistical Methods: The associations between use and resistance were quantified using non-partial and partial correlation coefficients according to Pearson and Spearman. Results: Over the study period, the most frequently used antipseudomonal agent was Imipenem (152 ± 46 DDD/1000 patients-day) and the resistance rate of P. aeruginosa to Imipenem was 44.3 ± 9.5% (range, 30 and 60%). In addition, Imipenem use correlated significantly with development of resistance to Imipenem in the same (P < 0.05) and in the following quarter (P < 0.05); and Ciprofloxacin use correlated significantly with resistance to Ciprofloxacin in the following quarter (P < 0.05). However, use of Ceftazidime or Amikacine had no apparent association with development of resistance. Conclusion: We conclude that the extensive use of imipenem or ciprofloxacin in intensive care units may lead to the emergence of imipenem- and ciprofloxacin-resistant strains of P. aeruginosa and that antibiotic prescription policy has a significant impact on P. aeruginosa resistance rates in an intensive care unit.



Narendra Vaidya, L.V. Pillai, A. D. Khade, Saiffuddin Hussainy

Variability of serum phenytoin levels in critically ill head injured patients in intensive care unit

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:4] [Pages No:24 - 27]

Keywords: Head injured, phenytoin level, variability

   DOI: 10.4103/0972-5229.40946  |  Open Access |  How to cite  | 


Patients with large variations in phenytoin levels despite standard doses may prove to become difficult clinical problems. Our study of 34 head injury patients whose serum phenytoin levels were measured on day one and day five following intravenous loading and maintenance dose of phenytoin, showed 38.24% patients, to have therapeutic phenytoin levels on day one, while 20% were in toxic range. On day five, 23% patients were in toxic and 29.41% were in therapeutic range. Only 21% patients remained in the therapeutic range during the monitoring period. This study shows that there is a wide variability of phenytoin levels in the ICU patients with a difference of more than 100% between the highest and lowest phenytoin level in individual cases (in four patients the difference exceeded 500%) raising concern about the safety of the drug. Hence it is recommended that intensive care unit patients receiving phenytoin therapy should have periodic serum phenytoin obtained even in absence of seizures or classic signs phenytoin toxicity.



Mridula Pawar, Mohandeep Kaur, Jasvinder Kaur Kohli, Shailendra Mishra

Critical events in intensive care unit

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:4] [Pages No:28 - 31]

Keywords: Critical events, intensive care unit, outcome, reporting

   DOI: 10.4103/0972-5229.40947  |  Open Access |  How to cite  | 


This prospective study was designed to have an insight into critical events occurring in the 13-bedded multidisciplinary intensive care unit (ICU) of our hospital and to report the critical events to evaluate the avoidable/iatrogenic problems so as to improve patient outcome and keep a self-check in the ICU. The errors reported were due to wrong mechanical or human performance. Repeated performance errors of the same kind pointed to the problem area, to which was paid proper attention in the required manner. Some malfunctioning equipments were abandoned and the need for adequate availability of staff was emphasized. Reporting of critical events was done keeping the patients′ and doctor′s identities anonymous through a proforma designed to report the event.



Ashok Parchani, Nissar Shaikh, Venkatraman Bhat, Marie Anne Kattren

Fat embolism syndrome: Clinical and imaging considerations: Case report and review of literature

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:5] [Pages No:32 - 36]

Keywords: Fat embolism syndrome, imaging, magnetic resonance imaging

   DOI: 10.4103/0972-5229.40948  |  Open Access |  How to cite  | 


Fat embolism syndrome (FES) is a serious clinical disorder occurring after trauma, orthopedic procedures and rarely in non-traumatic patients. Fat emboli develop in nearly all patients with bone fractures, but they are usually asymptomatic. Small number of patients develop signs and symptoms of various organ system dysfunction due to either mechanical obstruction of capillaries by fat emboli or due to hydrolysis of fat to fatty acids. A triad of lung, brain and skin involvement develop after an asymptomatic period of 24 to 72 hours. This symptom complex is called FES. The incidence reported is up to 30%, but many mild cases may recover unnoticed. Diagnosis of fat embolism is clinical with nonspecific, insensitive diagnostic test results. Treatment of fat embolism syndrome remains supportive and in most cases can be prevented by early fixation of large bone factures. Here we report two cases of traumatic fat embolism, which were diagnosed initially by Gurd′s criteria and subsequently confirmed by typical appearance on magnetic resonance imaging (MRI) of the brain in these patients. These patients were successfully treated with supportive management. In conclusion, diagnosis of FES needs high index of suspicion, exclusion of other conditions and use of clinical criteria in combination with imaging. Magnetic resonance imaging of the brain is of great importance in diagnosis and management of these patients.



C. Shivaprasad

Fatal aluminium phosphide poisoning due to myocardial depression refractory to high dose inotropic support and intra-aortic balloon counterpulsation

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:2] [Pages No:37 - 38]

Keywords: Aluminium phospide, intraaortic balloon counterpulsation, myocardial depression

   DOI: 10.4103/0972-5229.40949  |  Open Access |  How to cite  | 


We report a case of aluminium phosphide poisioning that presented to us with refractory myocardial depression. This patient developed worsening circulatory failure that did not respond to inotropic or vasopressor support and intra-aortic balloon counterpulsation. She went on to develop progressive metabolic acidosis, renal failure and died within 48 hours of admission to the intensive care unit.



Govarthanan Rajendiran, Rajamahesh Jayabalan, Saravanan Chandrahasan, Ashwin Kumar Mani

A case of acute paraplegia that improved with dialysis

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:3] [Pages No:39 - 41]

Keywords: Acute paraplegia, hemodialysis, hyperkalemia

   DOI: 10.4103/0972-5229.40950  |  Open Access |  How to cite  | 


Acute severe hyperkalemia can present as acute paraplegia independent of cardiac effects, even though cardiac muscle is more sensitive to serum potassium changes. We managed a patient with acute hyperkalemic paralysis who did not have threatening cardiac/electrocardiographic manifestations. The limb weakness became normal after hemodialysis.



L.V. Pillai, Gopal Achari, Sanjay Desai, Vinayak Patil

Acute respiratory failure as a manifestation of an arachnoid cyst

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:4] [Pages No:42 - 45]

Keywords: Cystoperitoneal shunt, posterior fossa arachnoid cyst, respiratory arrest

   DOI: 10.4103/0972-5229.40951  |  Open Access |  How to cite  | 


Arachnoid cysts are the most common congenital cystic lesions in the brain occurring in the middle fossa, suprasellar region and occasionally in the posterior fossa. Conventionally all cysts are considered as benign and symptoms are attributed to expansion of cysts causing compression of adjacent neurological structures, bleeds within the cyst or due to the development of acute hydrocephalus. We are reporting this case of a 15-year-old female patient with non-progressive weakness in the limbs since the age of seven years who presented with acute onset syncopal attacks and respiratory failure. She was intubated and ventilated. An magnetic resonance imaging scan showed large posterior fossa cyst extending up to mid second cervical vertebra causing compression of the medulla and pons, with mild hydrocephalus. After a failed attempt to wean her from the ventilator a cysto peritoneal shunt surgery was performed following which she was weaned from the ventilator successfully. Weakness in the upper and lower limbs, which had increased in the preceding month, also improved following the surgery.



Radhika Dhamija, Susan Bannon

QT prolongation with methadone

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:2] [Pages No:46 - 47]

   DOI: 10.4103/0972-5229.40954  |  Open Access |  How to cite  | 



Farhad Kapadia


[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:1] [Pages No:46 - 46]

   DOI: 10.4103/0972-5229.40953  |  Open Access |  How to cite  | 



P.S.R.K Haranath

Norepinephrine infusion in septic shock

[Year:2008] [Month:March] [Volume:12] [Number:1] [Pages:1] [Pages No:46 - 46]

   DOI: 10.4103/0972-5229.40952  |  Open Access |  How to cite  | 


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