Indian Journal of Critical Care Medicine

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2009 | June | Volume 13 | Issue 2

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Ashima Malhotra, Prem N. Kakar, Deep Arora, Shibani Das, Pradeep Govil

Colistin and polymyxin B: A re-emergence

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:5] [Pages No:49 - 53]

Keywords: Multidrug-resistant organisms, polymyxins

   DOI: 10.4103/0972-5229.56048  |  Open Access |  How to cite  | 


One of the greatest achievements of modern medicine is the development of antibiotics against life-threatening infections, but the emergence of multidrug-resistant (MDR) gram negative bacteria has drastically narrowed down the therapeutic options against them. This limitation has led clinicians to reappraise the clinical application of polymyxins, an old class of cationic, cyclic polypeptide antibiotics. Polymyxins are active against selected gram-negative bacteria, including the Acinetobacter species, Pseudomonas aeruginosa, Klebsiella species, and Enterobacter species. In this article, we summarise the chemistry, pharmacokinetics, and pharmacodynamics of polymyxins and the latest understanding of their action against MDR pathogens.



Niranjan Kissoon, Indumathy Santhanam, S. R. Kamath, Jayanthi Ramesh, Janani Shankar

GAP between knowledge and skills for the implementation of the ACCM/PALS septic shock guidelines in India: Is the bridge too far?

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:5] [Pages No:54 - 58]

Keywords: Septic shock, recognition, children, emergency department, ACCM guidelines, PALS, knowledge barriers, critical illness

   DOI: 10.4103/0972-5229.56049  |  Open Access |  How to cite  | 


Objective: To determine whether physicians were aware of and had the skills to implement the American College of Critical Care Medicine/Pediatric Advanced Life Support Course septic shock protocol. Design: A cross-sectional questionnaire survey. Setting: Four academic institutions in Chennai, Manipal, Mangalore, and Trivandrum - cities representing the three southern states of Tamil Nadu, Karnataka, and Kerala, respectively, between February and April 2006. Interventions: Pre and post lecture questions. They were evaluated using 11 questions testing knowledge and 10 questions testing their comfort level in performing interventions related to the initial resuscitation in septic shock. Measurement and Main Result: The ACCM/PALS sepsis guidelines were taught during the PALS course conducted in the four academic institutions. A total of 118 delegates participated, of whom 114 (97%) were pediatricians and four (3%) were anaesthetists. The overall mean number of correct responses for the 11 questions testing knowledge before and after the lecture was 2.1 and 4.07, respectively P=0.001(paired t test). Although, 42% of the respondents (n=50) were aware of the ACCM guidelines, 88% (n=104) did not adhere to it in their practice. A total of 86% (n=101) and 66% (n=78) did not feel comfortable titrating inotropes or intubating in the ED; 78% (n=92) and 67% (n=78), respectively felt that central venous access (CVA) and arterial pressure (AP) monitoring were unimportant in the management of fluid refractory shock. Of the physicians, 20% (n=24) had never intubated a patient, 78% (n=92) had not introduced a central venous catheter, and 76% (n=90) had never introduced an intra-arterial catheter. Conclusions: In view of the lack of skills and suboptimal knowledge, the ACCM/PALS sepsis guidelines may be inappropriate in its current format in the Indian setting. More emphasis needs to be placed on educating community pediatricians with a simpler clinical protocol, which has the potential to save many more children.



Amr S. Omar, Masood ur Rahman, Said Abuhasna

Left atrial function for outcome prediction in severe sepsis and septic shock: An echocardiographic study

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:7] [Pages No:59 - 65]

Keywords: Left atrial function, mortality, septic shock

   DOI: 10.4103/0972-5229.56050  |  Open Access |  How to cite  | 


Left ventricular function and B-type natriuretic peptide (BNP) assessments are used to predict mortality in septic patients. Left atrial function has never been used to prognosticate outcome in septic patients. Objectives: To assess if deterioration of left atrial function in patients with severe sepsis and septic shock could predict mortality. Methods: We studied 30 patients with severe sepsis or septic shock with a mean age of 49.8±16.17. Echocardiographic parameters were measured on admission, Day 4, and Day 7, which comprised left ventricular ejection fraction (EF), and atrial function that is expressed as atrial ejection force (AEF). All patients were subjected to BNP assay as well. Multivariate analyses adjusted for APACHE II score was used for mortality prediction. Results: The underlying source for sepsis was lung in 10 patients (33%), blood in 7 patients (23.3%), abdomen in 7 patients (23.7%), and 3 patients (10%) had UTI as a cause of sepsis. Only one patient had CNS infection. In-hospital mortality was 23.3% (7 patients). Admission EF showed a significant difference between survivors and non survivors, 49.01±6.51 vs.. 56.44±6.93% (P < 0.01). On the other hand, admission AEF showed insignificant changes between the same groups, 10.9±2.81 vs. 9.41±2.4 k/dynes P=0.21, while BNP was significantly higher in the non survivors, 1123±236.08 vs. 592.7±347.1 pg/ml (P< 0.001). The predicatable variables for mortality was Acute Physiology and Chronic Health Evaluation II score, BNP, then EF. Conclusion: In septic patients, left atrial function unlike the ventricular function and BNP levels can not be used as an independent predictor of mortality.



Uma Krishna, Suresh P. Joshi, Mukesh Modh

An evaluation of serial blood lactate measurement as an early predictor of shock and its outcome in patients of trauma or sepsis

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:8] [Pages No:66 - 73]

Keywords: Outcome, sepsis, serial lactate values, shock, trauma

   DOI: 10.4103/0972-5229.56051  |  Open Access |  How to cite  | 


Context: Attainment of hemodynamic parameters to within a normal range may leave patients in compensatory shock. In such patients, serial blood lactate evaluation can be useful in predicting shock. Aims: To ascertain the role of serum lactate as a predictor of shock and its outcome in patients of trauma and sepsis. Settings and Design: A prospective, non-interventional study. Materials and Methods: The study included 50 patients (5 to 60 years old) of trauma admitted within 12 hours of injury and patients of suspected or proven sepsis. Those with chronic medical illnesses, alcohol intoxication, or poisoning were excluded. Blood lactate levels were analyzed at admission and 12, 24, and 36 hours of inclusion with records of corresponding hemodynamic variables, investigations, and interventions. The outcome was recorded as survival or non-survival. Statistical Analysis Used: Statistical analysis was done with a student′s t test and repeated measure ANOVA (Analysis of Variance). Results: An analysis revealed higher mean lactate levels in non-survivors as compared with survivors. Mean lactate levels in non-survivors did not attain normal levels, while that of survivors reached normal levels by 24 hrs in trauma patients and 36 hrs in sepsis patients. The predicted mortality rates by a lactate level >40 mg/dl at admission, 12, 24, and 36 hours were 52.6%, 61.5%, 83.3%, and 100%, respectively for both the subgroups combined. Non-survivors had a higher incidence of MODS (Multi Organ Dysfunction Syndrome). Conclusions: Serial lactate values followed over a period of time can be used to predict impending complications or grave outcome in patients of trauma or sepsis. Interventions that decrease lactate values to normal early may improve chances of survival and can be considered effective therapy. Lactate values need to be followed for a longer period of time in critical patients.



Anil T. Kumar, U. Sudhir, K. Punith, V. N. Ravi Kumar, Medha Y. Rao

Cytokine profile in elderly patients with sepsis

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:5] [Pages No:74 - 78]

Keywords: Cytokine profile, IL-6, prognosis, sepsis, TNF-α

   DOI: 10.4103/0972-5229.56052  |  Open Access |  How to cite  | 


Context: Sepsis is a serious health problem in the elderly with a high degree of mortality. There is very limited data available in elderly subjects regarding the markers for sepsis. Development of good markers will help in overall management and prediction of sepsis. Objectives: Serial estimation of Interleukin-6 (IL-6) and Tumor Necrosis Factor-Alpha (TNF-α) and their correlation with mortality in sepsis in elderly patients and to determine the influence of gender on cytokine production and mortality in elderly patients with sepsis. Settings and Design: The prospective study was conducted at our tertiary care center from April 2007 to September 2008. Elderly Patients satisfying the Systemic Inflammatory Response Syndrome (SIRS) criteria were included. Methods and Material: TNF-α and IL-6 were estimated in 30 elderly patients admitted to our intensive care unit with SIRS and sepsis. The estimations were done on day 1, 3 and 7 of admission. Statistical Analysis Used: Student and paired ′t′ tests, and ANOVA, which were further followed up by post-hoc ′t′ tests with Bonferroni correction using SPSS. Results: Reducing levels of IL-6 levels from day 1 to 7 was found in the survivor group. TNF-α level was significantly low on day 1 in the nonsurvivor female group. Conclusions: Serial estimation of cytokines in elderly patients with sepsis will help in prediction of mortality. Female gender was an independent predictor of increased morality in critically ill patients with sepsis.



Samir V. Trivedi, Ashwin H. Vasava, Tinkal C. Patel, Lovleen C. Bhatia

Cyclophosphamide in pulmonary alveolar hemorrhage due to leptospirosis

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:6] [Pages No:79 - 84]

Keywords: Cyclophosphamide, leptospirosis, pulmonary alveolar hemorrhage

   DOI: 10.4103/0972-5229.56053  |  Open Access |  How to cite  | 


Background and Aims: Severe pulmonary involvement in leptospirosis carries high mortality rates. It is the most common cause of death due to leptospirosis in many parts of India and the world. Exacerbated immune response of the host plays an important role in its pathogenesis. Hence, immunosuppressive drugs could be useful in its treatment. Glucocorticosteroids have been found to be useful in several studies. Cyclophosphamide, an immunosuppressive agent, has been found to be useful in a majority of pulmonary alveolar hemorrhages due to non leptospiral causes. This study was carried out to study the effects of cyclophosphamide in patients with leptospiral pulmonary alveolar hemorrhage. Method: A total of 65 patients with confirmed leptospirosis with severe pulmonary involvement admitted to a tertiary care center in south Gujarat were included in the study. All of the patients were treated with injection crystalline penicillin, methyl prednisolone pulse therapy, and non invasive mechanical ventilation. A total of 33 patients were given parenteral cyclophosphamide 60 mg/kg body weight stat on diagnosis. Their outcomes were compared with the remaining 32 patients who had not been given this drug. Survival was considered the main outcome indicator. Results: Out of the 33 patients treated with cyclophosphamide, 22 (66.7%) survived, while in the control group out of 32 patients, three (9.4%) survived. On statistical analysis, the odds ratio was 19.33 (4.22-102.13) and the P-value was < 0.001. Leucopenia (78.78%) and alopecia (18.75%) were the main side effects noted. No mortality was noted due to these side effects. Conclusion: Cyclophosphamide improves survival in cases of severe pulmonary alveolar hemorrhage due to leptospirosis. Statistically, the improvement is highly significant.



Muzaffar Maqbool, Zafar Amin Shah, Fayaz Ahmad Wani, Abdul Wahid, Shaheena Parveen, Arjumand Nazir

Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:7] [Pages No:85 - 91]

Keywords: Adrenal insufficiency, cortisol, mortality, septic shock

   DOI: 10.4103/0972-5229.56054  |  Open Access |  How to cite  | 


Background: Corticosteroid insufficiency in acute illness can be difficult to discern clinically. Occult adrenal insufficiency (i.e., Δmax ≤9 μg/dL) after corticotropin may be associated with a high mortality rate. Objective: To assess the prevalence of occult adrenal insufficiency and the prognostic value of short corticotropin stimulation test in patients with septic shock. Materials and Methods: A total of 30 consecutive patients admitted in the adult intensive care unit of the Sheri Kashmir Institute of Medical Sciences who met the clinical criteria for septic shock were prospectively enrolled in the study. A low dose (1 μg) short corticotropin stimulation test was performed; blood samples were taken before the injection (T0) and 30 (T30) and 60 (T60) minutes afterward. Results: The prevalence of occult adrenal insufficiency was 57%. The 28-day mortality rate was 60% and the median time to death was 12 days. The following seven variables remained independently associated with death: organ system failure scores, simplified acute physiology score II score, mean arterial pressure, low platelet count, PaO 2: FIO 2, random baseline cortisol (T0) > 34 μg/dL, and maximum variation after test (Δmax) of ≤9 μg/dL. Three different mortality patterns were observed: (I) low (T0 ≤34 μg/dL and Δmax > 9 μg/dL; a 28-day mortality rate of 33%),(II) intermediate (T0 > 34 μg/dL and Δmax >9 μg/dL or T0 ≤34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 71%), and (III) high (T0 > 34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 82%). Conclusion: A short corticotropin test using low-dose corticotropin (1 μg) has a good prognostic value. High basal cortisol and a low increase in cortisol on corticotropin stimulation test are predictors of a poor outcome in patients with septic shock.



Harsimran Singh, Anurag Tewari, Balvinder Kaur, Suchita Garg

U turn to venous air embolism

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:2] [Pages No:92 - 93]

Keywords: Glass bottles, IV fluid therapy, venous air embolism

   DOI: 10.4103/0972-5229.56055  |  Open Access |  How to cite  | 


There is a definitive risk of venous air embolism when the fluid infusion is complete and the drip set is still open in a glass bottle. We have devised a novel way of preventing the chances of air embolism when the fluid in the glass bottle finishes. It really gives a “U” turn to the chances of venous air embolism.



Negar Motayagheni, Ramin Azhough, Ali Reza Barband, Mitra Niafar, Hojjat Pourfathi

Spontaneous rupture of adrenal pheochromocytoma in a patient with Von Recklinghausen′s disease

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:2] [Pages No:94 - 95]

Keywords: Adrenal tumor, pheochromocytoma, von Recklinghausen′s disease, retroperitoneal hematoma

   DOI: 10.4103/0972-5229.56056  |  Open Access |  How to cite  | 


Spontaneous rupture of an adrenal pheochromocytoma is extremely rare and can be lethal because of dramatic changes in the circulation. We describe a 35-year-old Iranian female with previously diagnosed von Recklinghausen s disease who suffered spontaneous rupture of an adrenal pheochromocytoma, misdiagnosed as renal colic followed by an extensive retroperitoneal hematoma, irreversible hemodynamic shock, and death.



Amit Singhal, C. S. Pramesh

Airway bleed after percutaneous tracheostomy is not always procedure-related

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:3] [Pages No:96 - 98]

Keywords: Bleeding, complications, percutaneous tracheostomy

   DOI: 10.4103/0972-5229.56057  |  Open Access |  How to cite  | 


Tracheotomies are the most frequent surgical procedures performed in the intensive care unit. We present a case of major hemorrhage that occurred in the intensive care unit during an elective percutaneous dilational tracheostomy in a 46-year-old female diagnosed with multiple myeloma. The patient was later taken to the operation theatre and procedure-related cause of bleeding was ruled out. It was subsequently realized that the cause of bleeding was intrapulmonary and occurred coincidently with the tracheostomy.



Vikas Kesarwani, Dhaval R. Ghelani, Graham Reece

Hepatic portal venous gas: A case report and review of literature

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:4] [Pages No:99 - 102]

Keywords: Ischemia, gas, mesentery, portal vein

   DOI: 10.4103/0972-5229.56058  |  Open Access |  How to cite  | 


Hepatic portal venous gas (HPVG) results from mesenteric ischemia and a wide variety of other causes. The primary factors that favour the development of this pathologic entity are intestinal wall alterations, bowel distension, and sepsis. Findings of HPVG during an ultrasound or computed tomography (CT) scan should be carefully evaluated in the context of the clinical picture. In the absence of features of bowel ischemia, the prognosis of patients with HPVG is usually good.



Prasad Kasliwal, Manimala S. Rao

Plasmodium vivax malaria: An unusual presentation

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:3] [Pages No:103 - 105]

Keywords: Acute respiratory distress syndrome, Plasmodium vivax, PfHRP-2, NIV

   DOI: 10.4103/0972-5229.56059  |  Open Access |  How to cite  | 


Acute renal failure, disseminated intravascular coagulation (DIC), acute respiratory distress syndrome (ARDS), hypoglycemia, coma, or epileptic seizures are manifestations of severe Plasmodium falciparum malaria. On the other hand, Plasmodium vivax malaria seldom results in pulmonary damage, and pulmonary complications are exceedingly rare. We report the case of a 42-year-old male living in a malaria-endemic area who presented with ARDS and was diagnosed as having Plasmodium vivax malaria. A diagnosis of Plasmodium vivax malaria was established by a positive Plasmodium LDH immunochromatographic assay while a negative PfHRP2 based assay ruled out P. falciparum malaria. After specific anti-plasmodial therapy and intensive supportive care, the patient recovered and was discharged from hospital. The use of NIPPV in vivax-malaria related ARDS was associated with a good outcome.



Supradip Ghosh, Alok Ahlawat, Krishna Rai, Ashu Arora

An unusual cause of status epilepticus

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:2] [Pages No:106 - 107]

Keywords: Deltamethrin, pyrethroid insecticide, status epilepticus

   DOI: 10.4103/0972-5229.56060  |  Open Access |  How to cite  | 


A 24-year-old female presented with status epilepticus following ingestion of a pyrethroid insecticide Deltamethrin. The pathophysiology, clinical features, and management of pyrethroid poisoning are discussed in this article.



Pradeep Rangappa, Britta Uhde, Roger W. Byard, Alex Wurm, Peter D. Thomas

Fatal cerebral arterial gas embolism after endoscopic retrograde cholangiopancreatography

[Year:2009] [Month:June] [Volume:13] [Number:2] [Pages:5] [Pages No:108 - 112]

Keywords: Cerebral arterial gas embolism, endoscopic retrograde cholangiopancreatography, hyperbaric oxygen (HBO 2)

   DOI: 10.4103/0972-5229.56061  |  Open Access |  How to cite  | 


We report the case of a 50-year-old woman undergoing elective endoscopic retrograde cholangiopancreatography, who developed coma and hemiparesis secondary to severe cerebral artery gas embolism. Despite prompt diagnosis and early hyperbaric oxygen therapy (HBO 2) she developed severe cerebral edema and died within 24 h.


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