Indian Journal of Critical Care Medicine

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2008 | September | Volume 12 | Issue 3

EDITORIAL

Suveer Singh

Arterialised blood gas sampling in the critically ill: Correct tools for the job?

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:2] [Pages No:89 - 90]

PDF  |  DOI: 10.4103/0972-5229.43675  |  Open Access |  How to cite  | 

RESEARCH ARTICLE

Mayank Vats, Naresh Trehan, Ajmer Singh

Incidence and management of diaphragmatic palsy in patients after cardiac surgery

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:5] [Pages No:91 - 95]

Keywords: Adult cardiac surgery, chest physiotherapy, diaphragmatic palsy

PDF  |  DOI: 10.4103/0972-5229.43676  |  Open Access |  How to cite  | 

Abstract

Background: Diaphragm is the most important part of the respiratory system. Diaphragmatic palsy following cardiac surgery is not uncommon and can cause deterioration of pulmonary functions and attendant pulmonary complications. Objectives: Aim of this study was to observe the incidence of diaphragmatic palsy after off pump coronary artery bypass grafting (OPCAB) as compared to conventional CABG and to assess the efficacy of chest physiotherapy on diaphragmatic palsy in post cardiac surgical patients. Design and Setting: An observational prospective interventional study done at a tertiary care cardiac centre. Patients: 2280 consecutive adult patients who underwent cardiac surgery from February 2005 to august 2005. Results: 30 patients out of 2280 (1.31%) developed diaphragmatic palsy. Patients were divided based on the presence or absence of symptoms viz. breathlessness at rest or exertion or with the change of posture along with hypoxemia and / or hypercapnia. Group I included 14 patients who were symptomatic (CABG n=13, post valve surgery n=1), While Group II included 16 asymptomatic patients (CABG n=12, post valve surgery n=4), 9 patients (64%) from Group I (n=14) and 4 patients (25%) from group II showed complete recovery from diaphragmatic palsy as demonstrated ultrasonographically. Conclusion: The incidence of diaphragmatic palsy was remarkably less in our adult cardiac surgical patients because most of the cardiac surgeries were performed off pump and intensive chest physiotherapy beginning shortly after extubation helped in complete or near complete recovery of diaphragmatic palsy. Chest Physiotherapy led to marked improvement in functional outcome following post cardiac surgery diaphragmatic palsy. We also conclude that ultrasonography is a simple valuable bed-side tool for rapid diagnosis of diaphragmatic palsy

RESEARCH ARTICLE

Mohammadreza Safavi, Azim Honarmand

Prediction of arterial blood gas values from arterialized earlobe blood gas values in patients treated with mechanical ventilation

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:6] [Pages No:96 - 101]

Keywords: Arterialized earlobe blood gas, critically illness, mechanical ventilation

PDF  |  DOI: 10.4103/0972-5229.43677  |  Open Access |  How to cite  | 

Abstract

Background/Objective: Arterial blood gas (ABG) analysis is useful in evaluation of the clinical condition of critically ill patients; however, arterial puncture or insertion of an arterial catheter may sometimes be difficult and cause many complications. Arterialized ear lobe blood samples have been described as adequate to gauge gas exchange in acute and chronically ill pediatric patients. Purpose: This study evaluates whether pH, partial pressure of oxygen (PO 2), partial pressure of carbon dioxide (PCO 2), base excess (BE), and bicarbonate (HCO 3) values of arterialized earlobe blood samples could accurately predict their arterial blood gas analogs for adult patients treated by mechanical ventilation in an intensive care unit (ICU). Setting: A prospective descriptive study Methods: Sixty-seven patients who were admitted to ICU and treated with mechanical ventilation were included in this study. Blood samples were drawn simultaneously from the radial artery and arterialized earlobe of each patient. Results: Regression equations and mean percentage-difference equations were derived to predict arterial pH, PCO 2, PO 2, BE, and HCO 3 -values from their earlobe analogs. pH, PCO 2, BE, and HCO 3 all significantly correlated in ABG and earlobe values. In spite of a highly significant correlation, the limits of agreement between the two methods were wide for PO 2. Regression equations for prediction of pH, PCO 2, BE, and HCO3- values were: arterial pH (pHa) = 1.81+ 0.76 x earlobe pH (pHe) [r = 0.791, P < 0.001]; PaCO 2 = 1.224+ 1.058 x earlobePCO 2 (PeCO 2) [r = 0.956, P < 0.001]; arterial BE (BEa) = 1.14+ 0.95 x earlobe BE (BEe) [r= 0.894, P < 0.001], and arterial HCO 3 - (HCO 3 -a) = 1.41+ earlobe HCO 3 (HCO 3 -e) [r = 0.874, P < 0.001]. The predicted ABG values from the mean percentage-difference equations were derived as follows: pHa = pHe x 1.001; PaCO 2 = PeCO 2 x 0.33; BEa = BEe x 0.57; and HCO 3 -a = HCO 3 -e x 1.06. Conclusions: Arterialized earlobe blood gas can accurately predict the ABG values of pH, PCO 2, BE, and HCO 3 - for patients who do not require regular continuous blood pressure measurements and close monitoring of arterial PO 2 measurements.

RESEARCH ARTICLE

Krishan Chugh, Shruti Agrawal, Anil Sachdev

Platelet counts and outcome in the pediatric intensive care unit

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:7] [Pages No:102 - 108]

Keywords: Coagulopathy, mortality, pediatric intensive care, platelets, prognosis, thrombocytopenia

PDF  |  DOI: 10.4103/0972-5229.43678  |  Open Access |  How to cite  | 

Abstract

Objectives: Thrombocytopenia is commonly observed in critically ill patients. This study was undertaken to evaluate the variation in platelet counts and the risk factors associated with thrombocytopenia and mortality in pediatric intensive care patients. In addition, prognostic value of platelet counts for outcome in pediatric intensive care unit was studied. Study Design: Prospective, observational cohort analysis. Setting: 8- bedded pediatric intensive care unit of a tertiary care teaching hospital. Patients: All consecutively admitted patients (n=138) staying in the pediatric intensive care unit (PICU) for at least 48h over a 7 months period were studied. Measurements and Main Results: Thrombocytopenia was defined as platelet counts < 150.0/nL. Median 1 st day Pediatric Risk of Mortality Score (PRISM) was 5 (range 0-30) and median ICU stay was 4 days (range 2-98 days). Twenty five percent patients had at least one episode of thrombocytopenia during the stay. Twenty percent of these patients had thrombocytopenia on admission and rest (80%) developed it during the PICU stay. Seventy one percent (19) of the patients developed thrombocytopenia by fourth day of admission. Patients with PICU acquired thrombocytopenia had statistically significant lower baseline, nadir and 4th day platelet counts and a significantly higher drop in platelet counts (56% vs. 6% P< 0.001) as compared to non thrombocytopenic patients. PRISM score, long PICU stay, sepsis, coagulopathy, and creatinine levels were significantly associated with occurrence of thrombocytopenia. Patients with thrombocytopenia had higher probability of bleeding (34% vs. 15%, P=0.01). Higher platelet counts on admission were associated with significantly reduced risk of thrombocytopenia (P=0.00) Baseline, nadir and day-4 platelet counts, presence of thrombocytopenia on admission, sepsis, coagulopathy and a higher mean PRISM score on univariate analysis were significantly associated with mortality. Leucopenia or leucocytosis, thrombocytopenia and coagulopathy were found to significantly affect outcome. Drop in platelet counts was found to have slightly higher discriminative value for mortality prediction than PRISM on the ROC curve. The survivors had higher platelet counts throughout the PICU stay and after an initial fall in platelet counts in the PICU showed a significantly higher rise in the platelet counts in the following days than the non-survivors. Conclusions: Thrombocytopenia is common in PICU. Patients requiring cardiopulmonary resuscitation or with circulatory shock, coagulopathy, sepsis and with more severe disease have higher risk of developing thrombocytopenia. Thrombocytopenic patients have a higher risk of bleeding. Drop in platelet counts >27% and thrombocytopenia were independently related to mortality. Serial measurements of platelet counts are better predictors of pediatric intensive care outcome than one-time values. Any drop in platelet counts even without thrombocytopenia needs an urgent and extensive evaluation.

RESEARCH ARTICLE

V. Theodore Barnett, V. K. Aurora

Physician beliefs and practice regarding end-of-life care in India

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:7] [Pages No:109 - 115]

Keywords: ICU, life-support, questionnaire

PDF  |  DOI: 10.4103/0972-5229.43679  |  Open Access |  How to cite  | 

Abstract

Background and Aims: Physician beliefs and practices largely determine the withdrawal of life support in intensive care units. No information exists regarding beliefs regarding the withdrawal of life support among physicians in India. Materials and Methods: We performed a questionnaire at the NAPCON conference in Jaipur. Results: One hundred and twenty-two questionnaires were completed and returned. The majority of respondents did not apply do not resuscitate orders. Most physicians stated withdrawal of life support was not allowed or practiced at their institution. Thirty-five percent of physicians stated they performed life-support withdrawal. Barriers to good end-of-life care were primarily legal but also included hospital policy and social constraints. Conclusions: Pulmonary and critical care physicians in India have a lower rate of withdrawal of life support than western physicians. The reasons seem to be primarily legal and policy related. Culture and religion were not identified as barriers. Clarification of the legal and policy status of withdrawal of life support is needed

REVIEW ARTICLE

P. Kumar, A. Rudra, S. Chatterjee, S. Sengupta, T. Das, G. Maitra

Obstructive sleep apnoea and anaesthesia

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:8] [Pages No:116 - 123]

Keywords: Anaesthesia, complications, obstructive sleep apnoea, perioperative care

PDF  |  DOI: 10.4103/0972-5229.43680  |  Open Access |  How to cite  | 

Abstract

Obstructive sleep apnoea (OSA) correlates positively with obesity and age, both of which are becoming increasingly prevalent. Obstructive sleep apnoea occurs much more frequently in clinical practice than formerly diagnosed, and that this condition represents complex challenges for difficulty in mask ventilation, laryngoscopic intubation, accelerated arterial desaturation, postoperative monitoring and discharge status. In this review article pathophysiology, diagnosis, and perioperative management of this group of patients have been discussed in detail.

CASE REPORT

M. N. Ramakrishna, Devi Prasad Hegde, Ratan Gupta, Girish T. Nagendra, Sharad Damodar

Transfusion associated graft versus host disease in an immunocompetent individual following coronary artery bypass grafting

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:4] [Pages No:124 - 127]

Keywords: Cardiopulmonary bypass, engraftment, immunocompetent, irradiation, transfusion

PDF  |  DOI: 10.4103/0972-5229.43681  |  Open Access |  How to cite  | 

Abstract

Transfusion associated graft versus host disease (TA-GVHD) is a rare but commonly fatal complication of transfusion of cellular blood products, which usually occurs in immunosuppressed individuals following transfusion and subsequent engraftment of viable T lymphocytes. Very rarely it may arise in apparently immunocompetent individuals. The clinical syndrome consists of fever, skin rash, diarrhoea, hepatic dysfunction, and bone marrow aplasia. The outcome is nearly always fatal. We present here a case report of fatal TA-GVHD in a “presumed” immunocompetent patient, post coronary artery bypass grafting surgery after transfusion of blood products. The patient died 24 days after transfusion. There is a perceived increased risk of TA-GVHD following bypass grafting and other surgical procedures where cardiopulmonary bypass is required. TA-GVHD is probably underreported and the incidence is felt to be too low to warrant routine irradiation of cellular products for this group of patients. Clinicians, pathologists, and transfusion centers should be aware of this rare but devastating complication of blood transfusion after cardiac surgery.

CASE REPORT

Pratish George, Jasmine Das, Basant Pawar, Naveen Kakkar

Thrombotic thrombocytopenic purpura and systemic lupus erythematosus: Successful management of a rare presentation

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:4] [Pages No:128 - 131]

Keywords: Plasma exchange, systemic lupus erythematosus, thrombotic thrombocytopenic purpura

PDF  |  DOI: 10.4103/0972-5229.43682  |  Open Access |  How to cite  | 

Abstract

Thrombotic thrombocytopenic purpura (TTP) and systemic lupus erythematosus (SLE) very rarely present simultaneously and pose a diagnostic and therapeutic dilemma to the critical care team. Prompt diagnosis and management with plasma exchange and immunosuppression is life-saving. A patient critically ill with TTP and SLE, successfully managed in the acute period of illness with plasma exchange, steroids and mycophenolate mofetil is described.

CASE REPORT

Swagata Tripathy, Padmini Mishra, S. C. Dash

Refeeding syndrome

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:4] [Pages No:132 - 135]

Keywords: Hypophosphatemia, malnutrition

PDF  |  DOI: 10.4103/0972-5229.43683  |  Open Access |  How to cite  | 

Abstract

We report a case of a fifty-year-old male who was admitted with a three month history of increasing weakness, prostration, decreasing appetite and inability to swallow. The patient was a chronic alcoholic, unemployed, and of very poor socioeconomic background. The patient was initially investigated for upper GI malignancy, Addisons disease, bulbar palsy and other endocrinopathies. Concurrent management was started for severe electrolyte abnormalities and enteral nutritional supplementation was begun. By the fourth day of feeding patient developed severe hypophosphatemia and other life-threatening features suggesting refeeding syndrome. The patient was managed for the manifestations of refeeding syndrome. A final diagnosis of chronic alcoholic malnutrition with refeeding syndrome was made. Refeeding of previously starving patients may lead to a variety of complications including sudden death.

CASE REPORT

Prithwis Bhattacharya, Suman Sarkar, Krutisundar Mandal

Successful management of massive intraoperative pulmonary fat embolism with percutaneous cardiopulmonary support

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:4] [Pages No:136 - 139]

Keywords: Fat embolism, orthopedic surgery, percutaneous cardiopulmonary support

PDF  |  DOI: 10.4103/0972-5229.43684  |  Open Access |  How to cite  | 

Abstract

We report a patient who sustained catastrophic pulmonary fat embolism, during open reduction, internal fixation (ORIF) of fracture femur′ In our opinion, the use of percutaneous cardiopulmonary support with (PCPS), saved the patient from certain death.

Educational Forum

Suman Sarkar

Artificial blood

[Year:2008] [Month:September] [Volume:12] [Number:3] [Pages:5] [Pages No:140 - 144]

Keywords: Blood, artificial blood, Perfluorocarbons

PDF  |  DOI: 10.4103/0972-5229.43685  |  Open Access |  How to cite  | 

Abstract

Artificial blood is a product made to act as a substitute for red blood cells. While true blood serves many different functions, artificial blood is designed for the sole purpose of transporting oxygen and carbon dioxide throughout the body. Depending on the type of artificial blood, it can be produced in different ways using synthetic production, chemical isolation, or recombinant biochemical technology. Development of the first blood substitutes dates back to the early 1600s, and the search for the ideal blood substitute continues. Various manufacturers have products in clinical trials; however, no truly safe and effective artificial blood product is currently marketed. It is anticipated that when an artificial blood product is available, it will have annual sales of over $7.6 billion in the United States alone.

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