Indian Journal of Critical Care Medicine

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2013 | October | Volume 17 | Issue 5

GUIDELINES

Praveen Khilnani

Guidelines for aute medical management of severe traumatic brain injury in infants and children

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:1 - 2]

PDF  |  DOI: 10.5005/ijccm-17-5-1  |  Open Access |  How to cite  | 

GUIDELINES

AM Bhagwati, S Singhi, B Ramachandran, N Ramakrishnan, R Gopalakrishnan, VN Kamat, P Nagaraja, S Prayag, S Todi

Guidelines for the Prevention of Infections Associated with the Use of Vascular Catheters in Indian Intensive Care Units

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:12] [Pages No:3 - 14]

PDF  |  DOI: 10.5005/ijccm-17-5-3  |  Open Access |  How to cite  | 

EDITORIAL

N. Ramakrishnan, A. K. Baronia, J. V. Divatia, A. Bhagwati, R. Chawla, S. Iyer, C. K. Jani, S. Joad, V. Kamat, F. Kapadia, Y. Mehta, S. N. Myatra, S. Nagarkar, V. Nayyar, S. Padhy, R. Rajagopalan, B. Ray, S. Sahu, S. Sampath, S. Todi

Critical care delivery in intensive care units in India: Defining the functions, roles and responsibilities of a consultant intensivist

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:11] [Pages No:15 - 25]

PDF  |  DOI: 10.5005/ijccm-17-5-15  |  Open Access |  How to cite  | 

GUIDELINES

J. V. Divatia, R. Chawla, F. Kapadia, S. N. Myatra, R. Rajagopalan, P. Amin, P. Khilnani, S. Prayag, S. K. Todi, R. Uttam

Guidelines for end-of-life and palliative care in Indian intensive care to units: ISCCM consensus Ethical Position Statement

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:16] [Pages No:26 - 41]

PDF  |  DOI: 10.5005/ijccm-17-5-26  |  Open Access |  How to cite  | 

GUIDELINES

Rakesh Sharma, J. C. Suri, N. Ramakrishnan, R. K. Mani, G. C. Khilnani, U. S. Sidhu

Guidelines for noninvasive ventilation in acute respiratory failure

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:29] [Pages No:42 - 70]

PDF  |  DOI: 10.5005/ijccm-17-5-42  |  Open Access |  How to cite  | 

EDITORIAL

Auditing costs of intensive care in cancer patients in India: A new area explored

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:269 - 270]

PDF  |  DOI: 10.4103/0972-5229.120315  |  Open Access |  How to cite  | 

EDITORIAL

Deelip Kadam

H1N1 influenza pandemic: What we did and what we learnt?

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:271 - 272]

PDF  |  DOI: 10.4103/0972-5229.120316  |  Open Access |  How to cite  | 

EDITORIAL

Savio G. Barreto, Adarsh Chaudhary

Predictors of septic shock following gastrointestinal anastomotic leaks: Only signposts, no destination

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:273 - 274]

PDF  |  DOI: 10.4103/0972-5229.120317  |  Open Access |  How to cite  | 

RESEARCH ARTICLE

Bipin Narayanrao Jibhkate

Predictors of mortality and length of stay in hospitalized cases of 2009 influenza A (H1N1): Experiences of a tertiary care center

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:8] [Pages No:275 - 282]

Keywords: 2009 influenza A, H1N1, hospitalized, length of stay, mortality, predictors

PDF  |  DOI: 10.4103/0972-5229.120318  |  Open Access |  How to cite  | 

Abstract

Aim: To study the clinical characteristics and outcome of admitted patients of H1N1 (hemagglutinin -H neuraminidase -N) influenza in a tertiary level hospital, from Oct 2009 to Dec 2010. Materials and Methods: A retrospective analysis of 77 confirmed patients admitted in this unit with H1N1 infection. Results: Of the 77 patients studied, 33 (42.8%) were female. Mean age was 40.88 ± 13.45 years, majority (70.13%) being less than 50 years. Thirty eight (49.3%) patients had at least one co-morbidity, diabetes mellitus being the most common (n = 15, 19.5%). The most common presenting symptom was fever in 75 (97.4%) patients, cough in 67 (87%) and dyspnoea in 59 (76.6%) patients. At admission, mean PaO2/FiO2 ratio was 213.16 ± 132.75 mmHg (n = 60) while mean PaCO 2 was 40.14 ± 14.86 mmHg. One or more organ failure was present in 45 (58.4%) patients. Nineteen (24.60%) patients required invasive mechanical ventilation. Circulatory failure was observed in 10 (13%) patients while 2 patients required hemodialysis. Overall, 13% mortality (n = 10) was observed. PaCO 2 level at admission (OR 1.093; 95% confidence interval: 1.002-1.193; P = 0.044) and number of organ failure (OR 8.089; 95% confidence interval: 1.133-57.778; P = 0.037) were identified as independent risk- factors for mortality. Conclusion: Increased duration of dyspnoea prior to admission, pneumonia, low PaO 2 /FiO 2 ratio at admission and 24 hours later, higher PaCO 2 values on admission, higher O 2 requirement, number of organ failures and use of corticosteroids and delay in specialized treatment were associated with a poorer outcome.

RESEARCH ARTICLE

Amit Kumar Mandal, Ruchika Nandha, Kavita Sekhri

To study the clinical efficacy and nephrotoxicity along with the risk factors for acute kidney injury associated with parenteral polymyxin B

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:5] [Pages No:283 - 287]

Keywords: Acinetobacter baumannii, acute kidney injury, multidrug resistance gram −ve septicemia, nephrotoxicity, polymyxin B

PDF  |  DOI: 10.4103/0972-5229.120319  |  Open Access |  How to cite  | 

Abstract

Aim : The aim of this study was to evaluate the clinical efficacy and nephrotoxicity along with the risk factors for acute kidney injury (AKI) associated with the parenteral polymyxin B in patients with the multidrug resistance (MDR) gram −ve infections in a tertiary Intensive care unit (ICU). Materials and Methods : A retrospective cohort study (March 2010-October 2011) was conducted in Medical ICU of a 23 bedded tertiary care hospital in Northern India. Results : Out of 71 ICU patients who were administered polymyxin B, only 32 (M:F = 1:0.8) met the inclusion criteria. Patients with concurrent administration of nephrotoxic drugs were excluded from the study. Mean age of patients was 48.53 ± 13.90 years ranging from 16 years to 68 years. 6 out of 32 (18.7%) patients progressed to AKI, whereas renal functions remained normal in 26 (81.2%) patients. No statistically significant difference was observed in mortality between AKI and non AKI patients at the end of therapy (33.3% vs. 26.9%, P value 0.756). Older age (62.33 ± 11.90 vs. 45.34 ± 2.45, P value 0.005) was found to be an independent risk factor for causing nephrotoxicity. Conclusion : In the present scenario of rising infections with MDR gram −ve micro-organisms, this pilot study suggests that polymyxin B can be used effectively and safely in patients not receiving other nephrotoxic drugs, with cautious administration in older patients as they are more vulnerable to nephrotoxicity caused by polymyxin B.

RESEARCH ARTICLE

Saradha Suresh, Poovazhagi Varadarajan, Shanthi Sangareddi, Jeyanthi Gandhi

Pediatric index of mortality 2 score as an outcome predictor in pediatric Intensive Care Unit in India

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:4] [Pages No:288 - 291]

Keywords: Mortality, pediatric index of mortality 2 score, shock, ventilation

PDF  |  DOI: 10.4103/0972-5229.120320  |  Open Access |  How to cite  | 

Abstract

Background and Aims: Pediatric index of mortality (PIM) 2 score is one of the severity scoring systems being used for predicting outcome of patients admitted to intensive care units (ICUs). The aim of the present study was to evaluate the usefulness of PIM2 score in predicting mortality in a tertiary care pediatric ICU (PICU) and to assess the associated factors in predicting mortality such as presence of shock, need for assisted ventilation and Glasgow coma scale <8. Materials and Methods: This was a prospective observation study done at tertiary care PICU from May 2011 to July 2011. Consecutive 119 patients admitted to PICU (aged 1 month to 12 years) were enrolled in the study. PIM2 scoring was done for all patients. The outcome was recorded as death or discharge. The associated factors for mortality were analyzed with SPSS 17. Results: PIM2 score discriminated between death and survival at a 99.8 cut-off, with area under receiver operating characteristic curve 0.843 with 95% confidence interval (CI) (0.765, 0.903). Most patients were referred late to this hospital, which explains higher death rate (46.2%), lesser length of hospital stay (mean 2.98 days) in the mortality group, and increased rate of mechanical ventilation (68.1%). Presence of shock was independently associated with mortality, as evidenced by binary logistic regression. Conclusion: PIM2 score discriminated well between survivors and death at PICU. Presence of shock was significantly associated with mortality.

RESEARCH ARTICLE

Jigeeshu V. Divatia

A prospective audit of costs of intensive care in cancer patients in India

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:6] [Pages No:292 - 297]

Keywords: Cost analysis, costs, effective cost per survivor, health economics, intensive care, length of stay

PDF  |  DOI: 10.4103/0972-5229.120321  |  Open Access |  How to cite  | 

Abstract

Background: The costs of healthcare are increasing. Intensive care poses largest burden on the hospital budget, even in developed countries. We attempted to find out the costs of intensive care in an Indian cancer hospital. Materials and Methods: Cost data was prospectively collected for patient-related and non-patient-related activities in a mixed surgical, medical cancer ICU. Demographic data, source, reason, and length of ICU stay were recorded. Total per day costs, costs for patients admitted from wards and operating rooms, and effective cost per survivor (ECPS) were calculated. Results: Data was collected for 101 consecutive ICU patients. Fifty-five patients were admitted after surgery (total patient hours 3485 i.e., 145.21 patient days). The mean (SD) intensive care unit length of stay (ICU LOS) was 64.84 (58.47) hrs. (8.25 to 552). Fifty-three patients survived to discharge. Forty-six patients were admitted from wards (hematooncology) or casualty and stayed 3980.25 patient hrs (165.84 patient days). The mean (SD, range) ICU LOS was 106.84 (64.05, 1-336) hrs. Of these, 26 patients survived to discharge. The effective cost per survivor (ECPS) was significantly higher for patients admitted from wards. [Rs. 83,558 = 00 (USD 1856.84) vs. Rs. 15,049 = 00 (USD 334.42)]. Conclusion: The costs of ICU place much higher burden on the patients as the Indian GDP and per capita income is much lower. Better selection process is needed for hemato-oncology patients for ICU admission for better utilization of scarce resources. Such data as ours can be used to inform families and physicians about anticipated costs.

RESEARCH ARTICLE

Predictors of septic shock following anastomotic leak after major gastrointestinal surgery: An audit from a tertiary care institute

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:6] [Pages No:298 - 303]

Keywords: Anastomotic leakage, post-leak sepsis, septic shock

PDF  |  DOI: 10.4103/0972-5229.120322  |  Open Access |  How to cite  | 

Abstract

Background: Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes. Objective: The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery. Design: Retrospective, audit. Materials and Methods: The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group). Results: The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks. Conclusion: Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage.

BRIEF COMMUNICATION

M. S. Ratnamani, Ratna Rao

Elizabethkingia meningoseptica : Emerging nosocomial pathogen in bedside hemodialysis patients

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:4] [Pages No:304 - 307]

Keywords: Colistin resistance, Elizabethkingia meningoseptica, hemodialysis

PDF  |  DOI: 10.4103/0972-5229.120323  |  Open Access |  How to cite  | 

Abstract

Elizabethkingia meningoseptica, a ubiquitous gram-negative aerobic bacillus, is an emerging hospital acquired pathogen in patients on dialysis. It has been isolated in the hospital environment in water supplies, disinfectants, and medical devices. We present here an analysis of eight healthcare-acquired infections with this organism in adults. To the best of our our knowledge, this is the first report of infections with this organism in patients on hemodialysis. Materials and Methods: Over a 6-month period, eight patients were infected with E. meningoseptica in our hospital. These patients had bacteremia and lower respiratory tract infection. All these patients were on on mechanical ventilation and undergoing bedside hemodialysis in the intensive care unit (ICU). Environmental surveillance was done to detect the possible source. Results: These patients had a common denominator of bedside hemodialysis, and use of broad-spectrum antibiotics. E. meningoseptica was isolated from the water and sink of the ICU. Conclusion: E. meningoseptica is emerging as a nosocomial pathogen among patients on hemodialysis. Its unusual resistance pattern coupled with inherent resistance to colistin makes this organism difficult to treat unless susceptibility patterns are available. Isolation of this organism in handwash sink and water is a significant finding as they have been reported to survive in chlorinated water. Disinfecting the sinks and using filtered water for hand washing in critical areas may help in preventing infections with this organism.

CASE REPORT

K. V. Vinod, Shailendra Prasad Verma, Balasubramanian Karthikeyan, Ariga Kishore, Tarun Kumar Dutta

Cerebral infarction leading to hemiplegia: A rare complication of acute pancreatitis

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:3] [Pages No:308 - 310]

Keywords: Complications, cerebral infarction, hemiplegia, pancreatitis, thrombosis

PDF  |  DOI: 10.4103/0972-5229.120325  |  Open Access |  How to cite  | 

Abstract

Peripancreatic vascular thrombosis is a known complication of acute pancreatitis (AP) and chronic pancreatitis. However, hemiplegia resulting from cerebral infarction due to cerebral arterial thrombosis is a rare complication of AP. Here, we report a case of alcohol related severe AP with multi-organ dysfunction, which was complicated by large left sided middle cerebral artery territory infarct - leading to right sided hemiplegia in a 48-year-old male patient. The neurological and vascular thrombotic complications of pancreatitis, their pathogenesis and management are discussed in brief.

CASE REPORT

J. Jonathan Arul, Divya Bala

Fatal overdose of iron tablets in adults

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:3] [Pages No:311 - 313]

Keywords: Adults, fatal, iron tablets, overdose

PDF  |  DOI: 10.4103/0972-5229.120326  |  Open Access |  How to cite  | 

Abstract

Acute iron toxicity is usually seen in children with accidental ingestion of iron-containing syrups. However, the literature on acute iron toxicity with suicidal intent in adults is scant. We report, the first instance of two adults with fatal ingestion of a single drug overdose with iron tablets from India. Two young adults developed severe gastro-intestinal bleeding and fulminant hepatic failure 48 h after deliberate consumption of large doses of iron tablets. Serum iron levels measured 36 h after ingestion were normal presumably due to the redistribution of iron to the intracellular compartment. Despite aggressive supportive management in medical intensive care unit of a tertiary care hospital, the patients succumbed to the toxic doses of iron.

CASE REPORT

Avdhesh Bansal, Vikas Sikri

A case of pulmonary alveolar proteinosis treated with whole lung lavage

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:4] [Pages No:314 - 317]

Keywords: Granulocyte macrophage colony stimulating factor, pulmonary alveolar proteinosis, Trans Bronchial Lung Biopsy, whole-lung lavage

PDF  |  DOI: 10.4103/0972-5229.120327  |  Open Access |  How to cite  | 

Abstract

Pulmonary alveolar proteinosis represents a rare syndrome characterized by the accumulation of proteinaceous phospholipid-laden material in the alveoli. This leads to impaired gas exchange and arterial hypoxemia of varying degrees. The diagnosis is confirmed by lung biopsy. Sequential whole-lung lavage (WLL) first described in 1963 is the standard of care. We report a case of a male diagnosed of having pulmonary alveolar proteinosis (PAP) on transbroncial lung biopsy (TBLB). He was treated with sequential WLL (Left followed by right, Left being more involved on chest X-ray) followed by recombinant GM-CSF, with good result.

CASE REPORT

Vivek B. Kute, Hargovind L. Trivedi, Pankaj R. Shah, Manoj R. Gumber, Himanshu V. Patel, Aruna Vanikar

Posterior reversible encephalopathy syndrome-an under recognized manifestation of Chronic Kidney Disease

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:3] [Pages No:318 - 320]

Keywords: Chronic kidney disease, hypertension, posterior reversible encephalopathy syndrome

PDF  |  DOI: 10.4103/0972-5229.120329  |  Open Access |  How to cite  | 

Abstract

First Report of the Indian Chronic Kidney Disease (CKD) Registry showed that patient with CKD in India more frequently presented in Stage V. Many patients have uncontrolled hypertension and uremia due to noncompliance or non affordability of renal replacement therapy which can lead to complications such as posterior reversible encephalopathy syndrome (PRES). A 17-year-old female had end stage renal disease (ESRD) due to malignant hypertension. She developed headaches, altered consciousness, visual disturbances and seizures. A non contrast brain computed tomography revealed bilateral symmetrical white matter hypodensity in parietal, temporal, and occipital region suggesting PRES. Intravenous lorazepam was given for acute control of seizure and she required phenytoin, valproic acid, levetiracetam to control seizures. She was started on more frequent hemodialysis. She required five types of antihypertensive drugs to control blood pressure. We report successful renal transplantation (RTx) in a CKD patient with PRES. Constraints in operating an effective maintenance dialysis program leave RTx as the only viable option for ESRD patients in our country to prevent complications like PRES associated with uremia and uncontrolled hypertension

CASE REPORT

Ajay Mishra, Nikhil Dave

Neem oil poisoning: Case report of an adult with toxic encephalopathy

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:321 - 322]

Keywords: Neem oil, poisoning, toxic encephalopathy

PDF  |  DOI: 10.4103/0972-5229.120330  |  Open Access |  How to cite  | 

Abstract

Neem oil has widespread use in Indian subcontinent due to its many bioactive properties. Azadirachtin, an active ingredient, is implicated in causing the effects seen in neem oil poisoning. Neem oil poisoning is rare in adults. This report highlights the toxicity associated with neem oil poisoning in an elderly male. The patient presented with vomiting, seizures, metabolic acidosis, and toxic encephalopathy. The patient recovered completely with symptomatic treatment.

LETTERS TO THE EDITOR

Arimanickam Ganesamoorthi, K. Gopalakrishna

A simple clinical method to detect mal-positioning during subclavian venous cannulation

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:1] [Pages No:323 - 323]

PDF  |  DOI: 10.4103/0972-5229.120331  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Prantar Chakrabarti, Utpal Chaudhuri, Lalit S. Raut, Uttam Kumar Nath

Comments on chronic subdural hematoma in a child with acute myeloid leukemia after leukocytosis

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:324 - 325]

PDF  |  DOI: 10.4103/0972-5229.120333  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Supradip Ghosh

Unrestricted prescription of dabigatran: Is it safe in a resource-limited setting

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:325 - 326]

PDF  |  DOI: 10.4103/0972-5229.120335  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Chandni Sinha, Chhavi Sawhney, Arati Rai, Anshuman Mishra

An unusual cause of decrease in GCS in a patient with craniofacial injury

[Year:2013] [Month:October] [Volume:17] [Number:5] [Pages:2] [Pages No:326 - 327]

PDF  |  DOI: 10.4103/0972-5229.120337  |  Open Access |  How to cite  | 

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