Background: Cockroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) formulae have not been validated in critically ill Indian patients. We sought to quantify the discrepancy, if any, in Glomerular Filteration Rate (GFR) estimated by CG and MDRD formulae with 24 hrs urine Creatinine Clearance (Cr Cl). Materials and Methods: Prospective cohort study in 50 adult patients in a mixed medical-surgical intensive care unit. Inclusion criteria: Intensive Therapy Unit (ITU) stay >48 hrs and indwelling urinary catheter. Exclusion criteria: Age <18 years, pregnancy, dialysis, urine output <400 ml/day and patients receiving ranitidine, cefoxitin, trimethoprim or diuretics. We estimated Creatinine Clearance by CG and MDRD formula and measured GFR by 24 hrs urine creatinine clearance. Bland Altman plot was used to find the difference between the paired observations. The association between the methods was measured by the product moment correlation coefficient. Result: The mean GFR as calculated by Creatinine Clearance was 79.76 ml/min/1.73 m 2 [95% Confidence Interval (CI) 65.79 to 93.72], that by CG formula was 90.05 ml/min/1.73 m 2 [95% CI: 74.50 to 105.60], by MDRD was 85.92 ml/min/1.73 m 2 [95% CI: 71.25 to 100.59]. The Bias and Precision between CG and Cr Cl were -4.5 and 140.24 respectively, between MDRD and Cr Cl was -6.1 and 122.52. The Correlation coefficient of CG formula as a measure of GFR was 0.65 ( P < 0.0001), that of MDRD was 0.70 ( P < 0.0001). Conclusion: We conclude that CG and MDRD formulae have a strong correlation with measured GFR but are not a reliable measure and overestimate GFR in critically ill Indian patients.
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Shweta K, Jindal S. Economic analysis of costs associated with a Respiratory Intensive Care Unit in a tertiary care teaching hospital in Northern India. Indian J Crit Care Med 2013; 17 (2):76-81.
Background: There is a paucity of cost analytical studies from resource constrained developing countries defining intensive care costs and their containment. Objective: Economic analysis of costs in a Respiratory Intensive Care Unit (RICU) of a tertiary care teaching hospital in northern India. Materials and Methods: A prospective study was conducted in 74 patients admitted in the RICU. Costs were segregated into fixed and variable costs. Total and categorized costs averaged per day and costs incurred on the first day of the RICU stay were calculated. Correlation of the costs was performed with the length of stay, length of mechanical ventilation, survival, and therapeutic intervention scoring system-28 (TISS-28). Results: The total cost per day was Indian rupees (INR) 10,364 (US $ 222). 46.4% of the total cost was borne by hospital and rest by patients. The mean cost represented 36.8% of the total cost and 69.8% of the variable cost. Expenditure on personnel salary constituted 37% of the total costs and 86% of the fixed cost. Length of stay in RICU was significantly higher in nonsurvivors (14.73 ± 13.6 days) vs. survivors (8.3 ± 7.8 days) ( P < 0.05). The TISS-28 score points in survivors was 30.6 vs. nonsurvivors 69.2 per nurse ( P < 0.05) correlating strongly with the total cost (r = 0.91). Conclusion: Although considerably less expensive than in economically developed countries, intensive care in India remains expensive relative to the cost of living. The cost block methodology provides a framework for cost estimation, aids resource allocation and allows international comparisons of economic models.
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Subramanian G, Anitha V. Comparison of central venous saturation by standard ABG machine versus co-oximeter: Is 18 carat as good as the 24 carat gold standard?. Indian J Crit Care Med 2013; 17 (2):82-86.
Aims: Aggressive therapy aimed at desired end-points of Early Goal Directed Therapy (EGDT) is the cornerstone of septic shock management. A key endpoint that improves outcomes is achieving central venous saturation (ScvO 2 ) >70%. The gold standard to measure ScvO 2 is by a co-oximeter (co-ox). Settings and Design: This prospective, observational study from a multidisciplinary pediatric intensive care unit (PICU) was conducted to assess the validity of ScvO 2 levels by standard ABG (stand ABG) machine in comparison with co-ox in conditions that shifted the oxygen dissociation curve (ODC) to the right or left in sick children and controls. Materials and Methods: Data from paired samples was tested for correlation coefficient for pH, paCO 2, paO 2, and ScvO 2. Tests for correlation (Pearson′s coefficient) and agreement (Bland-Altman analysis) were performed on ScvO 2 values obtained in various subgroups. Sensitivity and specificity for ScvO 2 values determined by standard ABG machine versus co-ox were calculated in reference to EGDT endpoints. Results: A total of 141 paired samples were collected from 82 children. Despite a statistically significant difference in the pH and ScvO 2, there was good linear correlation between these parameters. Limits of agreement between ScvO 2 measured by standard ABG machine and co-ox by Bland-Altman gave 2.3% bias with 95% CI of -24.2% to 19.5%. Sensitivity and specificity of standard ABG machine in detecting low ScvO 2 in shock was 84.21% and 93.18% respectively, while it was false positive in 4 samples. Conclusions: The less expensive standard ABG machine showed satisfactory correlation with gold standard co-ox over a range of patient conditions; however, the wide range for agreement was of concern and it performed particularly poorly in anemic patients.
Shefali K. Sharma,
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Gulati V, Sharma SK, Mathur P, Sahney C. Profile of micro-organisms in intensive care unit of a level-1 trauma centre: A retrospective study. Indian J Crit Care Med 2013; 17 (2):87-91.
Background: Patients with trauma usually require highly specialized care in ICU and many times their recovery is complicated by infections. Aim of this study was to determine the profile of pathogens and their impact on outcome among these patients. Materials and Methods: The clinical records of 101 consecutive patients who were admitted for more than 48-hrs in ICU during Jun-Dec 2007 were analyzed. Results: Total of 953 samples from blood, urine, BAL or pus/collection were subjected to cultures. From 276 samples, 299 organisms were isolated. Among pathogens Candida Spp. [89 (29%)] were the most common, followed by Acinetobacter Spp. [69 (23%)], Pseudomonas Spp. [63 (21%)], Klebsiella Spp. [31 (10%)], coagulase negative Staphylococcus aureus [16 (5%)], E coli [12 (4%)], Enterobacter Spp. [7 (2%)], S aureus [6 (2%)], Enterococcus Spp. [5 (2%)], Citrobacter Spp. [2 (0.6%)], S maltophila [1 (0.3%)] and Providentia Spp. [1 (0.3%)]. For gram negative pathogens drug-resistance rates were as follows: Fluoroquinolones, 76%; 3 rd generation cephalosporins, 74%; aminoglycosides, 66%; β-lactams/β-lactamase inhibitors combinations, 64%; and carbapenems, 50%. Among these 27% of pathogens were resistant to all 5 classes of drugs. 58% of Staphylococcus aureus were methicillin-resistant whereas 85% of coagulase negative Staphylococcus were methicillin resistant. The mortality was higher among patients in whom pathogens were isolated [Odd′s Ratio (OR) 0.185; 95% confidence interval (CI) 0.049-0.640; P = 0.002]. Conclusions: Isolation of multi-drug resistant pathogens is common among trauma patients admitted in ICU and is associated with increased mortality and could impact on the consumption of hospital resources. The importance of high rate of fungal isolation needs to be studied among these patients.
Hanan M. Hamed,
Seham Awad El-Sherbini,
Nahla A. Barakat,
Tarek M. Farid,
Enas Abdel Rasheed
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Hamed HM, El-Sherbini SA, Barakat NA, Farid TM, Rasheed EA. Serum cystatin C is a poor biomarker for diagnosing acute kidney injury in critically-ill children. Indian J Crit Care Med 2013; 17 (2):92-98.
Background: Accurate diagnosis of acute kidney injury (AKI) is problematic especially in critically-ill patients in whom renal function is in an unsteady state. Aim: Our aim was to evaluate the role of serum (S.) cystatin C as an early biomarker of AKI in critically-ill children. Subjects and Methods: S. creatinine and S. cystatin C were measured in 32 critically-ill children who were at risk for developing AKI. AKI was defined by both: Risk,-injury,-failure,-loss, and-endstage renal disease (RIFLE) classification and glomerular filtration rate (GFR) <80 ml/min/1.73 m 2. GFR was estimated by both Schwartz formula and S. cystatin C-based equation. Results: S. cystatin C was not statistically higher in AKI patients compared with non-AKI by RIFLE classification (median 1.48 mg/l vs. 1.16 mg/l, P = 0.1) while S. creatinine was significantly higher (median 0.8 mg/dl vs. 0.4 mg/dl, P = 0.001). On estimating GFR by the two equations we found, a lag between rise of S. cystatin C and creatinine denoted by lower GFR by Schwartz formula in four patients, on other hand, six patients had elevated S. cystatin C with low GFR despite normal creatinine and GFR, denoting poor concordance between the two equations and the two markers. The ability of S. creatinine in predicting AKI was superior to S. cystatin with area under the curve (AUC) 0.95 with sensitivity and specificity (100% and 84.6%, respectively) using the RIFLE classification. The same findings were found when using Schwartz formula. Conclusion: S. cystatin C is a poor biomarker for diagnosing AKI in critically-ill children.
Tracheal rupture is an infrequent, severe complication of endotracheal intubation, which can be difficult to diagnose. Post-intubation tracheal rupture (PiTR) is distinct from non-iatrogenic causes of tracheobronchial trauma and often requires different treatment. The increasing adoption of pre-hospital emergency services increases the likelihood of such complications from emergency intubations. Effective management strategies for PiTR outside specialist cardiothoracic units are possible. Two cases of severe PiTR, successfully managed non-operatively on a general medical-surgical intensive care unit, illustrate a modified approach to current standards. The evidence base for PiTR is reviewed and a pragmatic management algorithm presented.
Continuous positive airway pressure is required by patients of obstructive sleep apnea to prevent any obstruction of airways. This requires CPAP machines which are costly, have electrical dependence and are not readily available. The nasal CPAP assembly devised by us overcomes most of these limitations and can be made from easily available materials.
Urea cycle disorders (UCD) are common during neonatal period, and it is rarely reported in adults. We are reporting a patient presenting with post-partum neuropsychiatric symptoms rapidly progressing to coma. Markedly raised serum ammonia level on presentation with an initial normal magnetic resonance imaging (MRI) of brain and normal liver function tests led to the suspicion of UCD, which was confirmed on the basis of urine orotic acid and elevated serum amino acid levels. We had to resort to hemodialysis to correct the hyperammonemic coma, which was unresponsive to conventional anti-ammonia measures. She exhibited remarkable improvement with a progressive decline in serum ammonia with repeated hemodialysis and made a full recovery. Timely diagnosis and early institution of hemodialysis in the setting of a poor neurological status maybe considered a suitable treatment option.
Syed Moied Ahmed,
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Ahmed SM, Khan M, Zaka-ur-Rab Z, Nadeem A, Agarwal S. Hypertensive encephalopathy following snake bite in a child: A diagnostic dilemma. Indian J Crit Care Med 2013; 17 (2):111-112.
Children in rural India are a vulnerable group for snake bites. Improper elicitation of history and atypical presentations could lead to misdiagnosis and delay in treatment. We are reporting the case of an 8-year-old male child who presented with convulsions, unconsciousness and hypertension who was initially managed as a case of hypertensive encephalopathy showing no sign of improvement even after 20 hs. The history when reviewed suggested neurotoxic snake bite although the patient did not have any classical local findings. Anti-snake venom administration was followed by prompt recovery. We therefore suggest that snake bite should be considered in patients from rural background presenting with hypertension, convulsion and unconsciousness, even in the absence of classical features of snake bite.
Poor neurological outcome is a common sequel of prolonged cardiac arrest. Although Therapeutic Hypothermia (TH) for neuroprotection has been a subject for research for over Half a century, its use has been limited because of many controversies and lack of clear guidelines. However for over two decades there has been a revival of interest in mild therapeutic hypothermia (32-34°C) for neuroprotection. However its use after primary asystolic cardiac arrest has been questioned.
Herein presenting two cases of prolonged asystolic arrest (39 minutes and 25 minutes); where therapeutic hypothermia was successfully used in following prolonged cardio pulmonary resuscitation. On patients who were in deep coma after resuscitation, TH was applied for 24 hours as per institutional protocol with full neurological recovery in both the cases. Therapeutic hypothermia might have a potential role in even in non-shockable arrests and should be considered in every successful cardiopulmonary resuscitation with poor neurological status.
Neuroleptic malignant syndrome (NMS) is a rare but well described complication of the administration of antipsychotic agents. Compartment syndrome, with increased pressures within the confined space of fascial sheaths leading to compression damage of the contained tissue, similarly is well described. Brachial plexus injuries caused by patient malposition are also very rare but a few cases have been reported. We report a case where these three complications occurred together. This was attributable to the patient developing NMS whilst asleep in the prone position overnight.
This report describes a 35 year old male who presented with seizures after consuming 4-5 bottles of \"ALL-OUT\" a commercial composition of pyrethroid used as insecticides. Our case report supports authors reporting an association of pyrethroid poisoning with status epilepticus.