Indian Journal of Critical Care Medicine

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2012 | October | Volume 16 | Issue 4

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Rishikesh Kumar, Vasanth Somavarapu, Ananthkrishna B. Shastry

Clinical profile, species-specific severity grading, and outcome determinants of snake envenomation: An Indian tertiary care hospital-based prospective study

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:6] [Pages No:187 - 192]

Keywords: Antivenins, envenomation, ophitoxaemia, severity grade, snakebite

   DOI: 10.4103/0972-5229.106499  |  Open Access |  How to cite  | 


Objective: We undertook this study to assess the clinical profile and outcome determinants of different snake envenomation as well as to assign species-specific severity grade to different cases based on clinico - laboratory evidence scale. Materials and Methods: A prospective clinico - epidemiologic evaluation for outcome determinants of snakebite envenomation was carried out based on a clinico - laboratory severity grading scale, among 76 patients over a period of 2 years, in a tertiary care hospital in southern India. Results: Majority of patients were male agricultural workers (53.9%) followed by housewives (19.7%), and students (9.2%). Occurrence of viper snake envenomation with hemotoxic syndrome (73.68%) was highest followed by cobra and krait envenomation with neurotoxic (19.73%) and hemo - neurotoxic (5.3%) syndrome, respectively. On the contrary, maximum mortality and severity was seen in krait (60%) followed by cobra (13.33%) and viper (8.9%) envenomation. The average dose of anti-snake venom (ASV) administered varied from 9.83 (±7.22) to 20.25 (±4.92) vials throughout grade I to IV in all snake species envenomation. An increase in severity grade, ASV dose, and mortality were observed with the corresponding delay in ′bite to needle time.′ Also, initial traditional treatments and krait species envenomation were significantly associated with higher grades of severity and mortality. Conclusion: There is an urgent need to spread awareness among the community for avoidance of traditional treatment and any delay in medical intervention in snakebite incidents.



Amit Varma, Naresh Agrawal, Jyotirmay Das

Point of care serum lactate levels as a prognostic marker of outcome in complex pediatric cardiac surgery patients: Can we utilize it?

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:5] [Pages No:193 - 197]

Keywords: Children, pediatric cardiac surgery, plasma lactate

   DOI: 10.4103/0972-5229.106500  |  Open Access |  How to cite  | 


Background: Post-operative course after complex pediatric cardiac surgery is unpredictable. Although, change in arterial lactate levels has been used as a surrogate marker for many years, scientific evidence correlating the early perioperative lactate levels with outcome is still lacking. Objective: To evaluate the trends in lactate levels from intraoperative period to an extended post-operative period in pediatric intensive care unit (PICU) and to assess its usefulness as a prognostic marker. Design: Prospective observational study. Setting: Tertiary pediatric cardiac surgical unit. Patients: Thirty-five non-consecutive children aged 1-140 months who underwent surgery for congenital heart diseases (CHD) on cardiopulmonary bypass (CPB). Intervention: None. Materials and Methods: Arterial blood lactate levels were obtained at the following time points: After induction of anesthesia, 15 and 45 min after institution of CPB, at the start of rewarming, after sternotomy closure, then at 1, 6, 24, and 48 h in PICU. Other hemodynamic and clinical variables, CPB variables, blood gas values, and laboratory variables were also recorded. Results: Four patients died out of 35 patients (11.4%). Non-survivors showed significant persistent elevation in lactates (>4.0 mmol/l). Peak lactates correlate significantly with longer aortic cross clamp time, CPB duration, ventilation hours and PICU stay. Conclusion: Early point of care lactate can be a useful prognostic marker in post-cardiac surgery patients in adjunct with other parameters measured in PICU. This reiterates the importance of measuring lactates and timely recognition of at-risk patients, which on early intervention can help in reducing post-operative morbidity and mortality.



Dheeraj Gupta, Navneet Singh, Reena Das

Severe hemophagocytic lymphohistiocytosis in adults-experience from an intensive care unit from North India

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:6] [Pages No:198 - 203]

Keywords: Hemophagocytic lymphohistiocytosis, hemophagocytic syndrome, multi-organ dysfunction, tropics

   DOI: 10.4103/0972-5229.106501  |  Open Access |  How to cite  | 


Background: Hemophagocytic lymphohistiocytosis (HLH) has been reported to complicate fulminant tropical infections but data on severe HLH with multi-organ dysfunction (MODS) are scant. Materials and Methods: Retrospective review of medical electronic records of our intensive care unit (ICU) over a 2-year period. Results: We describe 10 adult patients with HLH and MODS. Patients had short symptom duration prior to presentation and had rapid deterioration during their hospitalization course. Fever, organomegaly, neurologic abnormalities, hepatic abnormalities, and cutaneous signs were very common. No patient had diagnosed HLH at ICU admission (median 4 criteria [Inter Quartile Range 2-4.25]). All patients required mechanical ventilation and 80% required vasopressors. Infection-associated HLH (IAHS) was the most common etiology (80%). Seventy percent (7/10) of patients were treated with steroids and 20% received intravenous immunoglobulin. Etoposide and/or cyclosporine were administered in 20% (2/10). Nosocomial infections occurred in 40% and the ICU mortality was 70%. Conclusions: Severe HLH with MODS has a very high mortality. Data on adult cohorts with IAHS in the tropics with defined treatment protocols are urgently needed.



Lakshmi Raman, Elizabeth A. Persad, Marita T. Thompson, Paul W. Sheeran

The use of extracorporeal life support in adolescent amlodipine overdose

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:204 - 206]

Keywords: Amlodipine overdose, calcium channel blocker, extra corporeal life support.

   DOI: 10.4103/0972-5229.106502  |  Open Access |  How to cite  | 


Calcium channel blocker (CCB) toxicity is associated with refractory hypotension and can be fatal. A 13 year old young woman presented to the emergency department(ED) six hours after an intentional overdose of amlodipine, barbiturates, and alcohol. She remained extremely hypotensive despite the administration of normal saline and calcium chloride and despite infusions of norepinephrine, epinephrine, insulin, and dextrose. Due to increasing evidence of end organ dysfunction, Extracorporeal Life Support (ECLS) was initiated 9 hours after presentation to the ED. The patient′s blood pressure and end organ function immediately improved after cannulation. She was successfully decannulated after 57 hours of ECLS and was neurologically intact. Patients with calcium channel blocker overdose who are resistant to medical interventions may respond favorably to early ECLS.



Jose Alberto Garcia Noain, Amparo Cantin Golet, Jorge Navarro Calzada, Ascension Muñoz Mellado, Julian Mozota Duarte

Living after sudden death: A case report of Naxos disease

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:207 - 209]

Keywords: Arrhythmogenic right ventricular dysplasia, Naxos disease, palmoplantar keratoderma, sudden death, woolly hair.

   DOI: 10.4103/0972-5229.106503  |  Open Access |  How to cite  | 


Naxos disease is a recessive inherited condition with arrhythmogenic right ventricular dysplasia (ARVD) and a peculiar cutaneous phenotype (woolly hair and a palmoplantar keratoderma). Woolly hair appears from birth, palmoplantar keratoderma develops during childhood and cardiomyopathy is clinically manifested by adolescence. Patients present with syncope, sustained ventricular tachycardia or sudden death. We report a case of a 14 year old boy from Spain, who was admitted into our emergency room after being resuscitated from cardiac arrest, secondary to malignant ventricular tachycardia that developed while he was playing basketball.



K.N. Prasad, L. Priya, Sanjay Sasikumar

Overcoming the problem of pseudohypoxemia in myeloproliferative disorders: Another trick in the bag

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:210 - 212]

Keywords: Chronic myeloid leukaemia, precooling, pseudohypoxaemia

   DOI: 10.4103/0972-5229.106504  |  Open Access |  How to cite  | 


Pseudohypoxaemia or spurious hypoxaemia is a recurrent problem faced on arterial blood gas analysis in patients with hyperleucocytosis leading to management dilemmas and unnecessary respiratory interventions. Various methods have been suggested to reduce the magnitude of this problem. We report a case of pseudohypoxaemia due to blast crisis in a patient of chronic myeloid leukaemia where arterial blood gas analysed from precooled syringe helped us resolve the problem and hastened our weaning from oxygen therapy.



N. Byju, James Jose, K. Saifudheen, V. Abdul Gafoor, P. Jithendranath

Cerebral venous thrombosis presenting as multiple lower cranial nerve palsies

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:213 - 215]

Keywords: Cerebral venous thrombosis, lower cranial nerve palsies, magnetic resonance imaging

   DOI: 10.4103/0972-5229.106505  |  Open Access |  How to cite  | 


Cerebral venous thrombosis (CVT) is a well-recognized entity, but its clinical presentation is varied and often mimics many neurological disorders, making it a diagnostic challenge. Cerebral venous thrombosis has a wide spectrum of signs and symptoms, which may evolve suddenly or over weeks. It mimics many neurological conditions such as meningitis, encephalopathy, idiopathic intracranial hypertension, and stroke. Cerebral venous thrombosis presenting as multiple lower cranial nerve palsies, are rarely reported. We describe a pregnant lady who presented with sensorineural deafness of the right ear and paralysis of the 9 th, 10 th, and 12 th cranial nerves on the right side. She was diagnosed to have thrombosis of the right transverse sinus and sigmoid sinus with extension to the jugular vein and confluence of sinuses. She improved with anticoagulant treatment.



Sohil Pothiawala

Spontaneous subarachnoid hemorrhage as a differential diagnosis of pre-hospital cardiac arrest

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:216 - 218]

Keywords: Cardiac arrest, cardiopulmonary resuscitation, subarachnoid hemorrhage, survival

   DOI: 10.4103/0972-5229.106506  |  Open Access |  How to cite  | 


Spontaneous subarachnoid hemorrhage is the most common neurological disorder leading to pre-hospital cardiac arrest. ECG changes in SAH may mimic myocardial infarction or ischemia, and thus lead to delayed treatment of the primary problem. Early identification of SAH-induced cardiac arrest with the use of computed tomography scan of the brain obtained immediately after resuscitation will aid emergency physicians make further decisions. The overall prognosis of patients who are resuscitated is extremely poor. But, prompt neurosurgical referral and multidisciplinary intensive care management can improve the survival rate and the functional outcome. Thus, physicians should consider SAH as a differential diagnosis in patients presenting with pre-hospital cardiac arrest.



Suyash Kulkarni, Dilip Karnad

Unusual presentation of pericardial effusion

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:219 - 221]

Keywords: Cardiac tamponade, cough syncope, pericardial effusion

   DOI: 10.4103/0972-5229.106507  |  Open Access |  How to cite  | 


Cough syncope is classically described in patients with chronic obstructive pulmonary disease, and it is quite rare to find a treatable condition for the same. However, it is extremely rare to have cough syncope due to pericardial effusion. We present a case of pericardial effusion who presented to the intensive care with cough syncope.



Mehmet Basmaci, Askin E. Hasturk

Chronic subdural hematoma in a child with acute myeloid leukemia after leukocytosis

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:222 - 224]

Keywords: Acute myeloid leukemia, child, leukocytosis, subdural hematoma

   DOI: 10.4103/0972-5229.106508  |  Open Access |  How to cite  | 


Severe complications that develop in the early stages in patients with acute leukemia have a mortal course. Bleeding, leukostasis, and less frequently, infections are responsible for early mortality. Hemorrhage is most common in acute leukemia and usually leads to death. Hemorrhage may occur due to chemotherapy or bone marrow transplantation in patients with acute leukemia. Leukocytosis, thrombocytopenia, sepsis, and coagulopathy increase the risk of bleeding. There may be multiple etiologic factors. Subdural or subarachnoid hemorrhage is less common than an intra-axial hemorrhage. The incidence of spontaneous subdural hematoma is higher in patients with leukemia. Although advances in the treatment of platelet transfusion and disseminated intravascular coagulation have decreased the incidence of hemorrhagic complications in patients receiving chemotherapy for acute leukemia, intracranial hemorrhage-related deaths are a significant problem. We discussed the etiology and management of chronic subdural hematoma detected in a two-year-old male patient with Acute Myeloid Leukemia and hyperleukocytosis.



Ratender K. Singh, Saurabh Saigal

Acute methotrexate toxicity presenting as multiorgan failure and acute pneumonitis: A rare case report

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:225 - 227]

Keywords: Folinic acid, methotrexate, pneumonitis

   DOI: 10.4103/0972-5229.106509  |  Open Access |  How to cite  | 


Acute methotrexate toxicity rarely presents as medical emergency in form of multiorgan failure. Acute pneumonitis following low-dose methotrexate is rarely reported in literature. It is important to recognize this, as the drug must be discontinued immediately and rescue measures in form of folinic acid and hydration instituted promptly.



Neha Baduni, Sunil Kumar Sinha, Manoj K. Sanwal

Perioperative management of a patient with myxedema coma and septicemic shock

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:228 - 230]

Keywords: Inotropes, myxedema coma, parenteral elroxine, septicemia, shock, thyroxine

   DOI: 10.4103/0972-5229.106510  |  Open Access |  How to cite  | 


Myxedema coma is a life-threatening but uncommon complication of long-standing, neglected hypothyroidism. It was first reported by Ord in 1879. Till date only around 200 cases have been reported in literature. The incidence in European countries is 0.22 per million per year. No epidemiological data is available from the Indian subcontinent. We are reporting the case of an elderly lady who went into life-threatening myxedema coma along with septicemic shock, and was successfully treated with oral thyroxine.



Alka Bhasin, Archana Chaturvedi

Severe suicidal digoxin toxicity managed with resin hemoperfusion: A case report

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:231 - 233]

Keywords: Atrioventricular block, digoxin toxicity, resin hemoperfusion

   DOI: 10.4103/0972-5229.106511  |  Open Access |  How to cite  | 


Owing to its wide and easy availability, digoxin has got a significant abuse potential and may be used for suicidal purposes. Digoxin-specific antibody (Fab) fragments have become the mainstay of therapy for severe digoxin toxicity and have significantly helped in reducing mortality. However, due to its high cost and limited availability alternative measures may need to be used to manage severe intoxications especially in countries like India, where Fab fragments are unavailable. Here, we present a case of a young female who presented to our casualty with alleged history of consumption of 17.5 mg of digoxin tablets. After admission to ICU, she developed atrioventricular blocks with hemodynamic instability which had to be managed with temporary pacemaker. Her serum digoxin levels were high (12.63 ng/ml) and in the absence of Fab fragments, resin hemoperfusion was done which drastically reduced the serum digoxin levels and reverted the symptoms.



Evangelos Papadomichelakis, Georgia Vrioni, Georgios Pappas, Maria Pantelaki, Fanourios Kontos, Loukia Zerva, Apostolos Armaganidis

A life-threatening case of disseminated nocardiosis due to Nocardia brasiliensis

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:4] [Pages No:234 - 237]

Keywords: Nocardia, Nocardia brasiliensis, nocardiosis

   DOI: 10.4103/0972-5229.106512  |  Open Access |  How to cite  | 


Nocardiosis is a rare disease caused by infection with Nocardia species, aerobic actinomycetes with a worldwide distribution. A rare life-threatening disseminated Nocardia brasiliensis infection is described in an elderly, immunocompromised patient. Microorganism was recovered from bronchial secretions and dermal lesions, and was identified using molecular assays. Prompt, timely diagnosis and appropriate treatment ensured a favorable outcome.



Nandita Joshi, Chhavi Sarabpreert Sharma, Sai

Acute barium intoxication following ingestion of soap water solution

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:3] [Pages No:238 - 240]

Keywords: Barium, hypokalemia, poisoning

   DOI: 10.4103/0972-5229.106513  |  Open Access |  How to cite  | 


We present a rare case in which a young girl ingested a solution of a hair-removing soap. The ingestion resulted in profound hypokalemia and severe acidosis leading to flaccid paralysis, respiratory arrest and ventricular arrhythmias. Ultimately the patient made complete recovery. The soapwas found to contain barium sulfide. The degree of paralysis and acidosis appeared to be directly related to serum potassium levels.



Shinshu Katayama, Shin Nunomiya, Masahiko Wada, Kazuhide Misawa, Shinichiro Tanaka, Kansuke Koyama, Toshitaka Koinuma

Hyperlactatemia caused by intra-venous administration of glycerol: A case study

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:4] [Pages No:241 - 244]

Keywords: Glycerol, hyperlactatemia, pyruvic acid

   DOI: 10.4103/0972-5229.106514  |  Open Access |  How to cite  | 


Glyceol® is an intracranial pressure reducing agent composed of 5% fructose and concentrated glycerol. Although rapid administration of fructose is known to cause lactic acidosis, little is known about hyperlactatemia caused by Glyceol® administration itself in adults. We observed an adult case of hyperlactatemia occurred after administration of 200 mL of Glyceol® over a period of 30 minutes. Since there was no evidence of an underlying liver disease or metabolic abnormality, and no findings of sepsis or impaired tissue perfusion, the cause of this condition was deemed to be the rapid loading of fructose contained as a constituent of Glyceol®. We then performed a retrospective chart review and found other 9 cases admitted to Jichi Medical University Hospital ICU and administered Glyceol® during the past year. Their lactate levels increased in general, peaked approximately 45 minutes after Glyceol® administration and returned to pre-administration levels around 3 hours after. Although hyperlactatemia is an important indicator of sepsis and impaired tissue perfusion, caution is required when performing such an assessment in patients being administered Glyceol® .



Rita Galeiras, Beatriz Besteiro, Maria Madruga

Issues about diagnosis and treatment of toxic epidermal necrolysis

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:1] [Pages No:245 - 245]

   DOI: 10.4103/0972-5229.106515  |  Open Access |  How to cite  | 


Authors' reply

Kambiz Soltaninejad, Leiws S. Nelson, Nastaran Khodakarim, Zohreh Dadvar, Shahin Shadnia

Authors′ reply

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:1] [Pages No:246 - 246]

   DOI: 10.5005/ijccm-16-4-246  |  Open Access |  How to cite  | 



Hossein Sanaei-Zadeh

Use of naloxone in valproate overdose

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:2] [Pages No:246 - 247]

   DOI: 10.4103/0972-5229.106517  |  Open Access |  How to cite  | 



Manpreet Singh, Dheeraj Kapoor

Upside-down twist with angulation maneuver for guide wire insertion in ultrasound-guided supraclavicular approach for subclavian catheterization: Our experience

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:2] [Pages No:247 - 248]

   DOI: 10.4103/0972-5229.106518  |  Open Access |  How to cite  | 



Hossein Sanaei-Zadeh

Aluminum phosphide poisoning and development of hemolysis and methemoglobinemia

[Year:2012] [Month:October] [Volume:16] [Number:4] [Pages:2] [Pages No:248 - 249]

   DOI: 10.4103/0972-5229.106519  |  Open Access |  How to cite  | 


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