Indian Journal of Critical Care Medicine

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2013 | August | Volume 17 | Issue 4

EDITORIAL

Praveen Khilnani

Bedside ultrasound and echocardiography by the pediatric intensivist: An evolving tool and a feasible option in a pediatric ICU

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:2] [Pages No:201 - 202]

PDF  |  DOI: 10.4103/0972-5229.118405  |  Open Access |  How to cite  | 

EDITORIAL

Bala Ramachandran

Acute kidney injury in critically ill children: More than just urine output

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:2] [Pages No:203 - 204]

PDF  |  DOI: 10.4103/0972-5229.118407  |  Open Access |  How to cite  | 

EDITORIAL

Pallab Ray, Rachna Singh

Methicillin-resistant Staphylococcus aureus carriage screening in intensive care

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:2] [Pages No:205 - 206]

PDF  |  DOI: 10.4103/0972-5229.118409  |  Open Access |  How to cite  | 

RESEARCH ARTICLE

Nivedita Mondal, Parameswaran Narayanan, Sivaprakasam Prabha, Subramanian Mahadevan, Niranjan Biswal, Sadagopan Srinivasan

Clinical profile of acute kidney injury in a pediatric intensive care unit from Southern India: A prospective observational study

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:7] [Pages No:207 - 213]

Keywords: Acute kidney injury, critically ill-children, pediatric intensive care unit

PDF  |  DOI: 10.4103/0972-5229.118412  |  Open Access |  How to cite  | 

Abstract

Background: Although the term acute renal failure was replaced by acute kidney injury (AKI) recently, there is a paucity of data on the incidence and profile of AKI in critically ill children from the developing world. Objectives: The objective of this study is to determine the incidence, etiology, short term outcome and predictors of fatality in critically ill children admitted to the pediatric intensive care unit (PICU) with AKI, aged 1 month to 13 years. Materials and Methods: In this prospective observational study, from June 2010 to March 2011, 215 children admitted to the PICU were screened for AKI, defined according to the AKI Network criteria. The patients with AKI were followed-up until discharge/death. Their clinical and biochemical data were recorded. Results: The incidence of AKI among 215 patients screened was 54 (25.1%). The common etiologies were infections, [34 (62.9%)], acute glomerulonephritis (7.6%), snake envenomation (5.7%), hemolytic uremic syndrome (3.8%) and congestive cardiac failures (3.8%). Among infections, pneumonia and septicemia constituted 26.5% each, meningoencephalitis accounted for 23.5%, and dengue, scrub typhus, tuberculosis and malaria constituted 9.3% of children with AKI. 27.8% of patients required dialysis. Overall mortality was 46.3%. On logistic regression analysis, requirement of mechanical ventilation was an independent predictor of fatality in AKI. Conclusions: Besides the high incidence of AKI in critically ill-children admitted to the PICU (25.1%), the condition was associated with adverse outcomes, including high mortality (46.3%) and need for dialysis (27.8%). Infections dominated the etiological profile. Requirement of mechanical ventilation predicted an adverse outcome in our patient population.

RESEARCH ARTICLE

Prithwis Bhattacharyya, Jeetendra Gurung, Annie Bakorlin Khyriem, Amit Banik, Wihiwot Valarie Lyngdoh, Basabdatta Choudhury

Association of biofilm production with multidrug resistance among clinical isolates of Acinetobacter baumannii and Pseudomonas aeruginosa from intensive care unit

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:5] [Pages No:214 - 218]

Keywords: Pseudomonas aeruginosa,Acinetobacter baumannii, biofilm, multidrug resistant

PDF  |  DOI: 10.4103/0972-5229.118416  |  Open Access |  How to cite  | 

Abstract

Background and Aims: Given choice, bacteria prefer a community-based, surface-bound colony to an individual existence. The inclination for bacteria to become surface bound is so ubiquitous in diverse ecosystems that it suggests a strong survival strategy and selective advantage for surface dwellers over their free-ranging counterparts. Virtually any surface, biotic or abiotic (animal, mineral, or vegetable) is suitable for bacterial colonization and biofilm formation. Thus, a biofilm is \"a functional consortium of microorganisms organized within an extensive exopolymeric matrix.\" Materials and Methods: The present study was undertaken to detect biofilm production from the repertoire stocks of Acinetobacter baumannii (A. baumannii) and Pseudomonas aeruginosa (P. aeruginosa) obtained from clinical specimens. The tube method was performed to qualitatively detect biofilm production. Results: A total of 109 isolates of both organisms were included in the study, out of which 42% (46/109) isolates showed biofilm detection. Among the biofilm producers, 57% of P. aeruginosa and 73% of A. baumannii showed multidrug resistance (MDR) pattern which was statistically significant in comparison to nonbiofilm producers (P < 0.001). Conclusion: To the best of our knowledge, this is the only study to have tested the biofilm production in both P. aeruginosa and A. baumannii in a single study. Biofilm production and MDR pattern were found to be significantly higher in A. baumannii than P. aeruginosa. Antibiotic resistance was significantly higher among biofilm producing P. aeruginosa than non producers. Similarly, antibiotic resistance was significantly higher among biofilm producing A. baumannii than non producers.

RESEARCH ARTICLE

Lukman Femi Owolabi, Alhassan Datti Mohammed, Mahmoud Muazu Dalhat, Aliyu Ibrahim, Salisu Aliyu, Desola Shakirat Owolabi

Factors associated with death and predictors of 1-month mortality in nontraumatic coma in a tertiary hospital in Northwestern Nigeria

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:5] [Pages No:219 - 223]

Keywords: Coma, mortality, predictors

PDF  |  DOI: 10.4103/0972-5229.118422  |  Open Access |  How to cite  | 

Abstract

Background: Coma occurring in the course of an illness ordinarily implies a poor prognosis and early prognostication is important for treatment decisions. The study was undertaken to study the factors associated with mortality in nontraumatic coma in a tertiary institution. Materials and Methods: In this prospective observational study, adults with clinically confirmed coma Glasgow coma scale (GCS) score of ≤8, admitted consecutively to the emergency unit of a tertiary hospital in Northwestern Nigeria over a period of 18 months were recruited. Vital parameters, severity of coma by GCS and neurological signs were recorded. The etiology of coma was determined on the basis of history, clinical examination, and laboratory investigations. Outcome was determined within 1 month of onset of coma by patients′ death or survival. Results: A total of 194 patients (140 males and 54 females) were recruited with mean age was 53.7 ± 1.4. The predominant etiological factors were central nervous system (CNS) infections (28.9%), toxic and metabolic (28.9%), and stroke (23.7%). Overall, 1-month mortality was 49%. On univariate analysis, the factors that showed significant association with outcome were gender, blood pressure, GCS, breathing pattern, pupillary size, pupillary reaction, papiloedema, and abnormal posturing. Abnormal pupillary size, severe hypertension, and GCS score ≤5 were independent predictors of in-hospital 1-month mortality in nontraumatic coma. Conclusion: The independent important predictors of nontraumatic 1-month coma mortality in a developing country setting were GCS ≤ 5, abnormal pupillary size, and severe hypertension.

RESEARCH ARTICLE

Niranjan Kissoon, Suchitra Ranjit

Bedside echocardiography is useful in assessing children with fluid and inotrope resistant septic shock

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:7] [Pages No:224 - 230]

Keywords: outcome, sepsis, septic shock, therapy,Children, diagnosis, echocardiography, myocardial dysfunction

PDF  |  DOI: 10.4103/0972-5229.118426  |  Open Access |  How to cite  | 

Abstract

Objective: To report changes in the cardiovascular management of fluid and inotropic resistant septic shock in children based on echocardiography. Design: Retrospective case series. Setting: Tertiary care Pediatric Intensive Care Unit (PICU), Chennai. Patients: Twenty-two patients with unresolved septic shock after 60 ml/kg fluid plus inotropic agents in the first hour. Interventions: Bedside echocardiography (echo) within 6 h of admission to the PICU. Results: Over a 28-month period, of 37 patients with septic shock, 22 children remained in shock despite 60 ml/kg fluid and dopamine and/or dobutamine infusions as per guidelines. On clinical exam, 12 patients had warm shock and ten had cold shock, however, six exhibited an unusual pattern of cold shock with wide pulse pressures on invasive arterial monitoring. The most common echocardiographic finding was uncorrected hypovolemia in 12/22 patient while ten patients had impaired left ± right ventricular function. Echocardiography permitted an appreciation of the underlying disordered pathophysiology and a rationale for adjustment of treatment. Shock resolved in 17 (77%) and 16 patients (73%) survived to discharge. Conclusions: Bedside echo provided crucial information that was not apparent on clinical assessment and affords a simple noninvasive tool to determine the cause of low cardiac output in patients who remain in shock despite 60 ml/kg fluid and inotropic support. Most patients in our series had vasodilatory shock with wide pulse pressures and most common finding on echo was uncorrected hypovolemia. The echo findings allowed adjustment of therapy which was not possible based on clinical examination alone.

CASE REPORT

Mohammed Ashraf, Parvaiz A. Koul, Umar Hafiz Khan, Rafi A. Jan, Sanaullah Shah, Abdul Baseer Qadri, Burhan Wani, Feroze Ahmad, Sajjad R. Bazaz

Osmotic demyelination syndrome following slow correction of hyponatremia: Possible role of hypokalemia

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:3] [Pages No:231 - 233]

Keywords: Electrolyte disturbances, hypokalemia, hyponatremia, locked-in state

PDF  |  DOI: 10.4103/0972-5229.118433  |  Open Access |  How to cite  | 

Abstract

A 47-year-old male presented with hyponatremia that was corrected slowly as per the recommended guidelines. The patient improved initially but went on to develop a quadriparesis with a locked-in state due to a central as well as extrapontine myelinolysis and subsequently succumbed to an intercurrent infective illness. The patient had associated hypokalemia. Hyponatremia can result in central pontine myelinolysis even when the electrolyte disorder is treated slowly, and the concomitant hypokalemia seems to play a contributory role in the pathogenesis of the neurological disorder.

REVIEW ARTICLE

Yalcin Solak, Nedim Yilmaz Selcuk, Abduzhappar Gaipov, Ramazan Ucar, Zeynep Biyik, Kadir Acar

Thrombotic thrombocytopenic purpura secondary to ABO group incompatible blood transfusion in a patient after cardiac surgery

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:3] [Pages No:234 - 236]

Keywords: ABO incompatible, blood transfusion, coronary artery bypass grafting surgery, thrombotic thrombocytopenic purpura

PDF  |  DOI: 10.4103/0972-5229.118440  |  Open Access |  How to cite  | 

Abstract

The triggers of secondary thrombotic thrombopcytopenic purpura (TTP) include drug toxicity, radiation and high-dose chemotherapy, angioinvasive infections, surgery and acute graft versus host disease. TTP secondary to surgery have been reported in a number of cases. Most of the cases have been occurred after open heart surgery. Extensive endothelial damage is held responsible as the initiating mechanism in postoperative TTP cases. However, there is no report of secondary TTP describing development owing to ABO incompatible blood transfusion. Here, we describe a patient who developed TTP after transfusion of ABO incompatible blood during hospitalization for bypass surgery. We also propose a hypothesis which may account for the possible underlying mechanism.

CASE REPORT

Surjya Prasad Upadhyay, Piyush N. Mallick, Manish Jagia, Raj Kumar A. Singh

Acute arterial thrombosis associated with inadvertent high dose of tranexamic acid

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:3] [Pages No:237 - 239]

Keywords: Arterial thrombosis, hemorrhage control, thrombo-embolism, tranexamic acid

PDF  |  DOI: 10.4103/0972-5229.118443  |  Open Access |  How to cite  | 

Abstract

Tranexamic acid (TA) act as anti-fibrinolytic agent and is widely used to limit bleeding in clinical practice. Tranexemic acid bind with plasminogen and prevent its conversion to plasmin, which limits the fibrinolytic pathway, so there is a theoretical risk of increasing thrombosis with high or prolonged therapy with TA. We encountered a case of acute arterial thrombosis following inadvertent administration of high dose of TA. A 27-years-old male with no other co-morbidity was ordered intravenous 1 gm TA to control excessive bleeding from previous bladder injury, but by mistake, he received 10 gm of TA. The patient developed signs and symptoms of acute ischemia in the right lower limb, which was diagnosed as acute iliac arterial thrombosis by computed tomography (CT) angiography. The patient was managed with systemic heparinization, fasciotomy for impending gangrene and other supportive care following which he recovered fully within a few days. Caution should be exercised for all prophylactic use, especially with high dosage or prolonged therapy with TA.

CASE REPORT

Tarik Purtuloglu, Sami Eksert, Fatih Simsek, Ali Sizlan, Ahmet Cosar

A new treatment modality for unilateral athelectasis: Recruitment maneuver with endobronchial blocker

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:3] [Pages No:240 - 242]

Keywords: Atelectasis, endobronchial blocker, treatment

PDF  |  DOI: 10.4103/0972-5229.118445  |  Open Access |  How to cite  | 

Abstract

Atelectasis is a commonly seen complication during the post-operative period in intensive care units. The treatment of atelectasis depends on the underlying cause. We aimed to share our experience on the treatment of right total atelectasis in our intensive care unit applied with the help of the endobronchial blocker.

SHORT COMMUNICATION

Jagdish Chander, Priya Datta, Hena Rani Vasdeva

Optimization of multiple muco-cutaneous site sampling method for screening MRSA colonization in ICU

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:3] [Pages No:243 - 245]

Keywords: Asymptomatic colonization, intensive care unit, methicillin resistant Staphylococcus aureus colonization

PDF  |  DOI: 10.4103/0972-5229.118421  |  Open Access |  How to cite  | 

Abstract

Aims: Active screening for methicillin resistant Staphylococcus aureus (MRSA) carriers remains a vital component of infection control policy in any health-care setting. The relative advantage of multiple anatomical site screening for detecting MRSA carriers is well recognized. However, this leads to increase in financial and logistical load in a developing world scenario. The objective of our study was to determine the sensitivity of MRSA screening of nose, throat, axilla, groin, perineum and the site of catheterization (central line catheter) individually among intensive care unit patients and to compare it with the sensitivity of multiple site screening. Materials and Methods: Active surveillance of 400 patients was done to detect MRSA colonization; 6 sites-nose, throat, axilla, perineum, groin and site of catheter were swabbed. Result and Discussion: The throat swab alone was able to detect maximum number of MRSA (76/90) carriers, with sensitivity of 84.4%. Next in order of sensitivity was nasal swab, which tested 77.7% of MRSA colonized patients. When multiple sites are screened, the sensitivity for MRSA detection increased to 95%. Conclusions: We found that though throat represent the most common site of MRSA colonization, nose or groin must also be sampled simultaneously to attain a higher sensitivity.

SHORT COMMUNICATION

Rupinder Singh Bhatia, Siddhartha Garg, Anupam Shrivastava

An observation of impact of neurological consultations in intensive care patients: Case series of 23 patients

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:7] [Pages No:246 - 252]

Keywords: neurological consults, outcome of intensive care unit patients,Delayed recovery, difficult weaning

PDF  |  DOI: 10.4103/0972-5229.118430  |  Open Access |  How to cite  | 

Abstract

Objective: The objective of the present study was to assess the impact of neurological consultation and intervention upon patient outcome in intensive care unit (ICU). Settings: A retrospective observational study was conducted in the 24-bedded multispecialty ICU of a 350 bedded tertiary care hospital over 8 months period, from January 2011 to August 2011. Critically, ill-patients with varied neurological symptomatology affecting the course of illness and ICU discharge were included. Neurological consult sought for, investigations ordered by the neurologist, interventions carried out, treatment started and the impact of such treatment on the outcome of patients were noted. The length of ICU stay was also noted. Results: Over a period of 8 months, there were 864 ICU admissions. On neurological consult, 23 patients had a positive finding affecting the outcome: 5 patients were diagnosed to have parkinson′s disease, 4 patients had neuromuscular disease, 9 patients had high creatinine phosphokinase levels, 2 patients had restless legs syndrome and 3 patients were diagnosed to have seizure disorder. Conclusions: On being examined and investigated by neurologist, a variety of co-existing neurological disorders could be diagnosed and if managed early, patients had a faster recovery, rapid weaning and early discharge from the ICU.

META ANALYSIS

John L. Moran

The role of non-invasive positive pressure ventilation in post-extubation respiratory failure: An evaluation using meta-analytic techniques

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:9] [Pages No:253 - 261]

Keywords: Bi-level positive airway pressure ventilation, continuous positive airway pressure ventilation, non-invasive ventilation, post-extubation, reintubation, respiratory failure

PDF  |  DOI: 10.4103/0972-5229.118477  |  Open Access |  How to cite  | 

Abstract

Background: The use of non-invasive positive pressure ventilation (NIPPV) in post-extubation respiratory failure is not well-established. Meta-analytic techniques were used to assess the effects of prophylactic application of NIPPV (prior to the development of respiratory failure) and therapeutic application of NIPPV (subsequent to the development of respiratory failure). Materials and Methods: Randomized controlled trials (RCTs) from 1966 to May 2010 were identified using electronic databases. RCTs, which reported the use of NIPPV in post-extubation respiratory failure with defined assessable endpoints: reintubation, mortality and length of stay, were included. Results: Reintubation was the primary outcome, mortality and lengths of stay were the secondary outcomes. Risk ratios (RR) were calculated for discrete outcomes and weighted mean differences (WMD) for continuous measures. There were 13 trials with 1420 patients; 9 prophylactic with 861 patients and 4 therapeutic with 559 patients. In the prophylactic group, NIPPV was associated with lower rates of reintubation: RR 0.53 (95% confidence interval [CI], 0.28-0.98), P = 0.04. In the therapeutic group, NIPPV showed a null effect on reintubation: RR 0.79 (95% CI, 0.50-1.25), P = 0.31. The analysis on the secondary outcomes suggested significant reduction of hospital mortality with prophylactic application of NIPPV: RR 0.62 (95% CI 0.4-0.97), P = 0.03, with no effect on the other outcomes. Therapeutic application of NIPPV reduced intensive care unit length of stay: WMD −1.17 (95% CI −2.82 to −0.33), P = 0.006, but no effect on the other secondary outcomes. Conclusions: The results of this review suggested prophylactic NIPPV was beneficial with respect to reintubation and the therapeutic use of NIPPV showed a null effect.

LETTERS TO THE EDITOR

Vinodhadevi Vijayakumar, Gunavathy Kandappan, Prabha Udayakumar, Ramashankari Padmanabhan

What is normal in an abnormality? Central venous cannulation in a patient with Situs inversus totalis with dextrocardia and poly Cystic kidney disease

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:2] [Pages No:262 - 263]

PDF  |  DOI: 10.4103/0972-5229.118406  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Pragyan Swagatika Panda, Surya Kumar Dube, Suman Sarkar, Dinesh Kumar Singh

Metabolic alkalosis: A less appreciated side effect of Imipenem-cilastatin use

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:2] [Pages No:263 - 264]

PDF  |  DOI: 10.4103/0972-5229.118411  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Surya Kumar Dube, Tumul Chowdhury

Intravenous lignocaine for treatment of refractory ileus following spinal cord injury

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:1] [Pages No:264 - 264]

PDF  |  DOI: 10.4103/0972-5229.118418  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Rajaram Burrah, Ravi Patel, Archana Sonig, Uma Devi

An unusual complication of internal jugular vein catheterization

[Year:2013] [Month:August] [Volume:17] [Number:4] [Pages:2] [Pages No:265 - 266]

PDF  |  DOI: 10.4103/0972-5229.118419  |  Open Access |  How to cite  | 

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