Indian Journal of Critical Care Medicine

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2013 | June | Volume 17 | Issue 3

EDITORIAL

Abdul Ghafur

Superbugs and we intensivists: A time for introspection…

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:2] [Pages No:125 - 126]

PDF  |  DOI: 10.4103/0972-5229.117034  |  Open Access |  How to cite  | 

EDITORIAL

Sunit Singhi, Karthi Nallaswamy

Catheter related blood stream infection in Indian PICUs: Several unanswered issues!

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:2] [Pages No:127 - 128]

PDF  |  DOI: 10.4103/0972-5229.117035  |  Open Access |  How to cite  | 

RESEARCH ARTICLE

Arvind Kumar Baronia, Ratender Kumar Singh, Mohan Gurjar, Bhaskar P. Rao

Carbapenem-resistant Acinetobacter ventilator-associated pneumonia: Clinical characteristics and outcome

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:6] [Pages No:129 - 134]

Keywords: Acinetobacter, carbapenem, intensive care unit, ventilator-associated pneumonia

PDF  |  DOI: 10.4103/0972-5229.117036  |  Open Access |  How to cite  | 

Abstract

Objective: To study the clinical characteristics and 28-days mortality in patients with ventilator-associated pneumonia (VAP) due to carbapenem-resistant Acinetobacter (CRA). Design: Retrospective, observational, cohort study. Setting: Intensive care unit (ICU) of a university hospital. Materials and Methods: Microbiologically confirmed VAP due to CRA infection. Intervention: None. Results: Out of 87 patients with VAP due to CRA, 60 (69%) were male; whose median age was 51 years; 73 (84%) patients were medical; 26 (30%) had history of hospitalization in last 3 months; median acute physiology and chronic health evaluation (APACHE) II was 15 and median SOFA 9 at admission; primary reason for ICU admission was respiratory failure (34%); 46 (53%) patients had more than 2 organ failure at ICU admission; median length of ICU stay was 19 days; 66 (76%) patients need vasoactive agents during ICU stay, whereas 55 (63%) patients had renal failure; median duration of mechanical ventilation was 17 days; 22 (25%) patients had acute respiratory distress syndrome (ARDS) during ICU stay; 72 (83%) patients had exposure to carbapenem before inclusion in the study; 33 (38%) patients had same organism at other sites. In the follow-up, 47 (54%) patient survived at 28 days after having VAP; whereas only 40 (46%) patients were discharged from the hospital. Conclusions: CRA-VAP has high crude mortality. Advanced age; severity of illness and presence of pneumonia at ICU admission; and presence of shock, ARDS and renal failure have impact on outcome in these patients.

RESEARCH ARTICLE

Diana Thomas, Narayanan Parameswaran, B. N. Harish

Catheter related blood stream infections in the paediatric intensive care unit: A descriptive study

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:5] [Pages No:135 - 139]

Keywords: Catheter related blood stream infections, nosocomial infections, pediatric intensive care unit

PDF  |  DOI: 10.4103/0972-5229.117038  |  Open Access |  How to cite  | 

Abstract

Context: Catheter related blood stream infections (CRBSI) contributes significantly to morbidity, mortality and costs in intensive care unit (ICU). The patient profile, infrastructure and resources in ICU are different in the developing world as compared to western countries. Studies regarding CRBSI from pediatric intensive care unit (PICU) are scanty in the Indian literature. Aims: To determine the frequency and risk factors of CRBSI in children admitted to PICU. Settings and Design: Descriptive study done in the PICU of a tertiary care teaching hospital over a period of four months. Materials and Methods: Study children were followed up from the time of catheterization till discharge. Their clinical and treatment details were recorded and blood culture was done every 72 h, starting at 48 h after catheterization. The adherence of doctors to Centre for Disease Control (CDC) guidelines for catheter insertion was assessed using a checklist. Statistical Analysis: Clinical parameters were compared between colonized and non-colonized subjects and between patients with and without CRBSI. Unpaired t-test and Chi-square test were used to test the significance of observed differences. Results: Out of the 41 children, 21 developed colonization of their central venous catheter (66.24/1000 catheter days), and two developed CRBSI (6.3/1000 catheter days). Infants had a higher risk for developing colonization (P = 0.01). There was 85% adherence to CDC guidelines for catheter insertion. Conclusions: The incidence of CRBSI and catheter colonization is high in our in spite of good catheter insertion practices. Hence further studies to establish the role of adherence to catheter maintenance practices in reducing risk of CRBSI is required. The role of a composite package of interventions including insertion and maintenance bundles specifically targeting infants needs to be studied to bring down the catheter colonization as well as CRBSI rates.

RESEARCH ARTICLE

Upendra Kaul, Amit Varma, Anu Gupta, Ashish Gupta

Infective endocarditis in an Indian setup: Are we entering the ′modern′ era?

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:8] [Pages No:140 - 147]

Keywords: Demographics, echocardiography, infective endocarditis, microbiologic characteristics, rheumatic heart disease

PDF  |  DOI: 10.4103/0972-5229.117041  |  Open Access |  How to cite  | 

Abstract

Background: The clinical profile of infective endocarditis (IE) has been continuously evolving over last 3-4 decades as highlighted by many studies from developed world. Objectives: To evaluate the recent changes in the spectrum and clinical profile, and outcome of IE in an Indian setup. Materials and Methods: This was a descriptive, cross-sectional study. Demographic, clinical, characteristics, treatment, and outcome were examined in ′definite′ cases of IE admitted at our institute between July 2005 and December 2010. Results: 61 ′definite′ cases were identified. Mean patient age was 49.3 ± 13.7 years. Male to female ratio was 3.3:1. Rheumatic heart disease was the underlying heart disease in 23 (37.7%) patients. 33 (54.1%) patients had already received antibiotic therapy before presentation to us. Blood cultures were positive in 41 (67.2%) patients. Streptococci and staphylococci were the commonest microbial isolates, 9 (21.4%) patients each. Transesophageal echocardiography (TEE) was done for all the patients. Vegetations were detected in 54 (88%) patients. Surgery was done in 30 (49.2%) patients. In-hospital mortality happened in 4 (6.5%) patients. Conclusions: We recorded several new trends, like: 1) an increasing age, 2) an increasing proportion of patients with no previously known heart disease, 3) improving culture positivity rates, 4) rise in staphylococcal infections, 5) increased usage of TEE, 6) high elective surgical rate, and 7) apparent improved survival rates. These changes point to the fact that ′modern era′ changes in the profile of IE have started to appear in a selected population in India.

RESEARCH ARTICLE

Özgür Çiftçi, Murat Günday, Mustafa Çaliskan, Hakan Güllü, Rafi Dogan, Aytekin Güven, Haldun Müderrisoglu

Mild carbon monoxide poisoning impairs left ventricular diastolic function

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:6] [Pages No:148 - 153]

Keywords: Carbon monoxide, elasticity imaging techniques, left ventricular function, right ventricular function, tissue Doppler

PDF  |  DOI: 10.4103/0972-5229.117044  |  Open Access |  How to cite  | 

Abstract

Rationale: Carbon monoxide (CO) poisoning is associated with direct cardiovascular toxicity. In mild CO poisoning in which cardiovascular life support is not required, the effects of CO on left and right ventricular functions are unknown in patients without cardiac failure. Objectives: Echocardiography was used to determine whether or not mild CO poisoning impairs ventricular function. Twenty otherwise healthy patients with CO poisoning and 20 age- and gender-matched controls were studied. Echocardiographic examinations were performed at the time of admission and 1 week after poisoning. Results: The impairment observed in the left and right ventricular diastolic function at the time of admission was greater than the impairment 1 week after poisoning. Mild CO poisoning did not have a significant effect on systolic function. Carboxyhemoglobin levels were positively correlated with left ventricular diastolic dysfunction, whereas the levels were not correlated with right ventricular diastolic function. Conclusions: In CO intoxication, the development of left and right ventricular diastolic dysfunction precedes systolic abnormality. Patients with mild CO poisoning do not manifest cardiovascular symptoms; however, it should be borne in mind that most of these patients have myocardial involvement.

REVIEW ARTICLE

Amit Agrawal, Shweta Goyal

Ketamine in status asthmaticus: A review

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:8] [Pages No:154 - 161]

Keywords: Bronchodilator, emergency department, intensive care unit, ketamine, status asthmaticus

PDF  |  DOI: 10.4103/0972-5229.117048  |  Open Access |  How to cite  | 

Abstract

Background and Aims : Status asthmaticus is a common cause of morbidity and mortality. The addition of ketamine to the standard treatment regimen of severe asthma has shown to improve outcome and alleviate the need for mechanical ventilation. The purpose of this review is to determine the pulmonary effects of ketamine and to determine whether sufficient evidence exists to support its use for refractory status asthmaticus. Data Source: MEDLINE, EMBASE, Google Scholar, and Cochrane data bases (from their inception to Jan 2012) using key words \"ketamine,\" \"asthma,\" \"bronchospasm,\" \"bronchodilator,\" and \"mechanical ventilation\" were searched to identify the reports on the use of ketamine as a bronchodilator in acute severe asthma or status asthmaticus, and manual review of article bibliographies was done. Relevant databases were searched for the ongoing trials on use of ketamine as a bronchodilator. Outcome measures were analyzed using following clinical questions: Indication, dose and duration of ketamine use, main effects on respiratory mechanics, adverse effects, and mortality. Results: Twenty reports illustrating the use of ketamine as a bronchodilator were identified. In total, 244 patients aged 5 months to 70 years received ketamine for bronchospasm. Twelve case reports, 3 double-blind randomized placebo-controlled trials, 2 prospective observational studies, 2 clinical evaluation study, and 1 retrospective chart review were retrieved. Most of the studies showed improved outcome with use of ketamine in acute severe asthma unresponsive to conventional treatment. Patients who received ketamine improved clinically, had lower oxygen requirements, and obviated the need for invasive ventilation. Mechanically-ventilated patients for severe bronchospasm showed reduction in peak inspiratory pressures, improved gas exchange, dynamic compliance and minute ventilation, and could be weaned off successfully following introduction of ketamine. Conclusion: In various studies, ketamine has been found to be a potential bronchodilator in severe asthma. However, a large prospective clinical trial is warranted before laying down any definitive recommendations on its use in status asthmaticus.

REVIEW ARTICLE

Krishna M. Sundar, Mazen Sires

Sepsis induced immunosuppression: Implications for secondary infections and complications

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:8] [Pages No:162 - 169]

Keywords: Chronic critical care illness, sepsis, immune dysfunction, pneumonia, ventilator-associated

PDF  |  DOI: 10.4103/0972-5229.117054  |  Open Access |  How to cite  | 

Abstract

Sepsis is the commonest cause of admission to medical ICUs across the world. Mortality from sepsis continues to be high. Besides shock and multi-organ dysfunction occurring following the intense inflammatory reaction to sepsis, complications arising from sepsis-related immunoparalysis contribute to the morbidity and mortality from sepsis. This review explores the basis for sepsis related immune dysfunction and discusses its clinical implications for the treating intensivist. Recent trends indicate that a significant proportion of septic patients succumb to the complications of secondary infections and chronic critical care illness from the initial bout of sepsis. Therefore care-givers in the ICU need to be aware of the impediments posed by sepsis-related immune dysfunction that can impair recovery in patients with sepsis and contribute to sepsis-related mortality.

SHORT COMMUNICATION

Lawni Goswami, Chandrashish Chakravarty, Babita Hazarika

Prevalence of malnutrition in a tertiary care hospital in India

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:4] [Pages No:170 - 173]

Keywords: Indian intensive care unit, malnutrition, subjective global nutritional assessment

PDF  |  DOI: 10.4103/0972-5229.117058  |  Open Access |  How to cite  | 

Abstract

Introduction: Malnutrition adversely affects clinical outcome of hospitalized patients. This observational prospective study was done to assess the prevalence of malnutrition and its grade among patients admitted in a mixed intensive care unit (ICU) of a tertiary care hospital in order to help devise a comprehensive nutrition program for the malnourished. Materials and Methods: A total of 500 sequential patients admitted to the ICU were screened on admission over a year period for malnutrition using the Subjective Global Nutritional Assessment (SGNA) score. Distribution of the degree of malnutrition according to co-morbidities was also documented. Results: Of the total, 198 (39.6%) patients were malnourished, including one patient qualifying as severely malnourished; 68% patients were male, however, there was no statistically significant difference between nutrition status between sexes. Hypertension, diabetes, and cancer were the three most commonly encountered co-morbidities among the malnourished. A total of 86% of all cancer patients admitted were malnourished against only 12% of trauma patients. Conclusion: This study showed that almost two-fifth of the patients admitted were malnourished in this tertiary care hospital and that there is an urgent need to develop a comprehensive nutritional care program in many such Indian ICUs.

SHORT COMMUNICATION

Binila Chacko, John Victor Peter, Gunasekaran Karthik, Kartik Ramakrishna, Mathew F. Griffith, John Antony Jude Prakash, Victoria Job, Petra L. Graham

Elevated procalcitonin is associated with increased mortality in patients with scrub typhus infection needing intensive care admission

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:4] [Pages No:174 - 177]

Keywords: Biomarker, intensive care unit, outcome, procalcitonin, scrub typhus

PDF  |  DOI: 10.4103/0972-5229.117063  |  Open Access |  How to cite  | 

Abstract

Context: Procalcitonin is a biomarker of bacterial sepsis. It is unclear if scrub typhus, a rickettsial illness, is associated with elevated procalcitonin levels. Aim: To assess if scrub typhus infection is associated with high procalcitonin levels and whether high levels portend a poorer prognosis. Setting and Design: Retrospective study of patients with severe scrub typhus infection, admitted to the medical intensive care unit of a tertiary care university affiliated teaching hospital. Materials and Methods: Eighty-four patients with severe scrub typhus infection that also had procalcitonin levels were assessed. Statistical Analysis: Relationship between procalcitonin and mortality explored using univariate and multivariate analyses. Results: The mean (±standard deviation) age was 40.0 ± 15.5 years. Patients were symptomatic for 8.3 ± 4.3 days prior to presentation. The median admission procalcitonin level was 4.0 (interquartile range 1.8 to 8.5) ng/ml; 59 (70.2%) patients had levels >2 ng/ml. Invasive mechanical ventilation was required in 65 patients; 20 patients died. On univariate analysis, admission procalcitonin was associated with increased odds of death [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03 to 1.18]. On multivariate logistic regression analysis including procalcitonin and APACHE-II score, the APACHE-II score was significantly associated with mortality (OR 1.16, 95% CI 1.06 to 1.30, P = 0.004) while a trend was observed with procalcitonin (OR 1.05, 95%CI 1.01 to 1.13, P = 0.09). The area under the receiver operating characteristic (ROC) curve, AUC, for mortality was 0.77 for procalcitonin and 0.78 for APACHE-II. Conclusions: Procalcitonin is elevated in severe scrub typhus infection and may be associated with higher mortality.

Educational Forum

Death in the hospital: Breaking the bad news to the bereaved family

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:4] [Pages No:178 - 181]

Keywords: In hospital death, bereaved, grief reaction, breaking bad news

PDF  |  DOI: 10.4103/0972-5229.117067  |  Open Access |  How to cite  | 

Abstract

Informing the family members about the sudden death of their loved one is a highly stressful experience for the treating doctors. Breaking the bad news to the bereaved family needs special skill on the part of the clinicians. An elaborate, step-wise modified action plan for breaking the sad news and grief reduction based on the literature has been presented here. The guidelines mentioned in the article are simply the tips to the clinicians and not to be considered as any form of protocols. Inclusion of this subject into the undergraduate medical curriculum has to be considered. By doing so, we can look forward to produce junior doctors who are better at coping with this awkward but extremely important aspect of clinical medicine.

CASE REPORT

Kavitha Saravu, Sonal Sekhar, Ananth Pai, Ananthakrishna Shastry Barkur, V. Rajesh, Jagadeswara Rao Earla

Paraquat - A deadly poison: Report of a case and review

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:3] [Pages No:182 - 184]

Keywords: Acute respiratory distress syndrome, case study, clinical toxicology, herbicide, paraquat, pesticide poisoning

PDF  |  DOI: 10.4103/0972-5229.117074  |  Open Access |  How to cite  | 

Abstract

Paraquat is a bipyridilium herbicide used widely in our country and is a highly toxic compound. A 16-year-old female patient was admitted to the emergency department of our tertiary care hospital in South India with the history of alleged consumption of paraquat poison. Since there is dearth of high quality evidence- based treatment for this poisoning, different treatment modalities have been tried to manage patient′s condition. In this case, none of the strategies could work well. Most of the patients reported with paraquat intoxication are from agricultural background; usually such patients cannot afford the treatment expenses. This paper presents a fatal case of acute poisoning with paraquat who succumbed to acute respiratory distress syndrome (ARDS).

CASE REPORT

Vivek S. Guleria, Prabhat Chauhan, Subramanian Shankar

All that seems sepsis is not sepsis

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:3] [Pages No:185 - 187]

Keywords: Catastrophic antiphospholipid syndrome, sepsis, systemic lupus erythematosus

PDF  |  DOI: 10.4103/0972-5229.117077  |  Open Access |  How to cite  | 

Abstract

Catastrophic antiphospholipid antibody syndrome (CAPS) resembles severe sepsis in its acute presentation, with features of systemic inflammatory response syndrome (SIRS) leading to multiple organ dysfunction. Infections are the best known triggers of CAPS. This emphasizes the need for early diagnosis and aggressive treatment as the mortality is as high as 50%. We present a 42-year-old woman who developed SIRS postoperatively and was eventually diagnosed as CAPS.

CASE REPORT

Purnima Aggarwal, Chandrika Azad, Kana R. Jat

Bronchial asthma with ABPA presenting as PTE

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:2] [Pages No:188 - 189]

Keywords: Allergic bronchopulmonary aspergillosis, bronchial asthma, cor pulmonale, pulmonary thrombo-embolism

PDF  |  DOI: 10.4103/0972-5229.117078  |  Open Access |  How to cite  | 

Abstract

Allergic bronchopulmonary aspergillosis (ABPA), as a complication of asthma, is rare in children. The persistent and poorly-controlled asthma leading to cor pulmonale is not uncommon in adults but rarely described in the pediatric age group. Here, we report a case of asthma and ABPA complicated by pulmonary thrombo-embolism and cor pulmonale. To the best of our knowledge, such association has never been reported in the pediatric age group.

CASE REPORT

Veena R. Shah, Kalpana S. Vora, Geeta P. Parikh, Pranjal R. Modi

Successful resuscitation after suspected carbon dioxide embolism during laparoscopic ureteric reconstructive surgery

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:2] [Pages No:190 - 191]

Keywords: Carbon dioxide embolism, end-tidal carbon dioxide monitoring, laparoscopy

PDF  |  DOI: 10.4103/0972-5229.117081  |  Open Access |  How to cite  | 

Abstract

Carbon dioxide (CO2) embolism is a rare but potentially fatal complication of laparoscopic surgery. We report a case of presumed CO2 embolism in a 35-year-old female during laparoscopic ureteric reconstructive surgery. After 2 h of operating time, a sudden decrease in end-tidal carbon dioxide and deterioration of hemodynamic status followed by cardiac arrest with pulseless electrical activity suggested gas embolism. Immediate cardiopulmonary resuscitation and inotropic support resulted in successful outcome. Thus, early recognition of the complication and prompt treatment can avoid catastrophy.

LETTERS TO THE EDITOR

Selcuk Yaylaci, Altug Osken, Ibrahim Kocayigit, Ercan Aydin, Mehmet Akif Cakar, Ali Tamer, Hüseyin Gündüz

Electrocardiographic ST segment changes due to the mad honey intoxication

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:2] [Pages No:192 - 193]

PDF  |  DOI: 10.4103/0972-5229.117084  |  Open Access |  How to cite  | 

LETTER TO EDITOR

M Ravishankar, Sameer Mahamud Jahagirdar, Laxmimani Umeshkumar , Umeshkumar Athiraman

Migration of subclavian venous catheter tip: Patient positioning in ICU makes a difference

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:2] [Pages No:193 - 194]

PDF  |  DOI: 10.4103/0972-5229.117085  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Lithium toxicity and sepsis: Time for a rethink?

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:2] [Pages No:194 - 195]

PDF  |  DOI: 10.4103/0972-5229.117088  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Xavier Wittebole, Philippe Hantson

High-dose insulin therapy in a case of subarachnoid hemorrhage-related severe cardiodepression with ischemic-like electrocardiographic changes

[Year:2013] [Month:June] [Volume:17] [Number:3] [Pages:3] [Pages No:195 - 197]

PDF  |  DOI: 10.4103/0972-5229.117091  |  Open Access |  How to cite  | 

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