Indian Journal of Critical Care Medicine

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2013 | December | Volume 17 | Issue 6

Paper Sessions

Paper Sessions: Oral Presentation

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:10] [Pages No:1 - 10]

PDF  |  DOI: 10.5005/ijccm-17-6-1  |  Open Access |  How to cite  | 

Paper Sessions

Paper Sessions: Poster Presentation

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:34] [Pages No:11 - 44]

PDF  |  DOI: 10.5005/ijccm-17-6-11  |  Open Access |  How to cite  | 

EDITORIAL

Pediatric Oral Sessions

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:5] [Pages No:45 - 49]

PDF  |  DOI: 10.5005/ijccm-17-6-45  |  Open Access |  How to cite  | 

EDITORIAL

Neetu Jain, Gopi C Khilnani

Ventilator-Associated pneumonia: Changing microbiology and implications

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:2] [Pages No:331 - 332]

PDF  |  DOI: 10.4103/0972-5229.123432  |  Open Access |  How to cite  | 

EDITORIAL

Pravin Amin

Does altering protein and energy change outcomes in the ICU?

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:2] [Pages No:333 - 334]

PDF  |  DOI: 10.4103/0972-5229.123433  |  Open Access |  How to cite  | 

EDITORIAL

Percutaneous dilatational tracheostomy: Guided well with real-time ultrasound

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:2] [Pages No:335 - 336]

PDF  |  DOI: 10.4103/0972-5229.123434  |  Open Access |  How to cite  | 

RESEARCH ARTICLE

V. Preethi, Rishikesh Kumar, Vasudev Guddattu, Ananthakrishna Shastry, Chiranjay Mukhopadhyay

Determinants of ventilator associated pneumonia and its impact on prognosis: A tertiary care experience

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:6] [Pages No:337 - 342]

Keywords: Hospital acquired pneumonia, India, multidrug resistant organism, ventilator associated pneumonia

PDF  |  DOI: 10.4103/0972-5229.123435  |  Open Access |  How to cite  | 

Abstract

Background: Ventilator associated pneumonia (VAP) is a major cause of poor outcome among patients in the intensive care units (ICU) world-wide. We sought to determine the factors associated with development of VAP and its prognosis among patients admitted to different ICUs of a Tertiary Care Hospital in India. Methodology: We did a matched case control study during October 2009 to May 2011 among patients, ≥18 years with mechanical ventilation. Patients who developed pneumonia after 48 h of ventilation were selected in the case group and those who did not develop pneumonia constituted the control group. Patients′ history, clinical and laboratory findings were recorded and analyzed. Results: There were 52 patients included in each group. Among cases, early onset ventilator associated pneumonia (EVAP) occurred in 27 (51.9%) and late onset ventilator associated pneumonia (LVAP) in 25 (48.1%). Drug resistant organisms contributed to 76.9% of VAP. Bacteremia (P = 0.002), prior use of steroid/immunosuppressant (P = 0.004) and re-intubations (P = 0.021) were associated with the occurrence of VAP. The association of Acinetobacter (P = 0.025) and Pseudomonas (P = 0.047) for LVAP was found to be statistically significant. Duration of mechanical ventilation (P = 0.001), ICU stay (P = 0.049) and requirement for tracheostomy (P = 0.043) were significantly higher in VAP. Among each case and control groups, 19 (36.5%) expired. Conclusion: We found a higher proportion of LVAP compared with EVAP and a higher proportion of drug resistant organisms among LVAP, especially Pseudomonas and Acinetobacter. Drug resistant Pseudomonas was associated with higher mortality.

RESEARCH ARTICLE

Saúl-Javier Rugeles, Juan-David Rueda, Carlos-Eduardo Díaz, Diego Rosselli

Hyperproteic hypocaloric enteral nutrition in the critically ill patient: A randomized controlled clinical trial

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:7] [Pages No:343 - 349]

Keywords: Colombia, critical care, hypocaloric enteral nutrition, permissive underfeeding, randomized controlled trial

PDF  |  DOI: 10.4103/0972-5229.123438  |  Open Access |  How to cite  | 

Abstract

Introduction: Our aim was to evaluate the impact of hyperproteic hypocaloric enteral feeding on clinical outcomes in critically ill patients, particularly on severity of organic failure measured with the Sequential Organ Failure Assessment (SOFA). Materials and Methods: In a double blind clinical trial, 80 critically ill adult patients were randomized to hyperproteic hypocaloric or to isocaloric enteral nutrition; all patients completed follow-up of at least 4 days. Prescribed caloric intake was: Hyperproteic hypocaloric enteral nutrition (15 kcal/kg with 1.7 g/kg of protein) or isocaloric enteral nutrition (25 kcal/kg with 20% of the calories as protein). The main outcome was the differences in delta SOFA at 48 h. Secondary outcomes were intensive care unit (ICU) length of stay, days on ventilator, hyperglycemic events, and insulin requirements. Results: There were no differences in SOFA score at baseline (7.5 (standard deviation (SD) 2.9) vs 6.7 (SD 2.5) P = 0.17). The total amount of calories delivered was similarly low in both groups (12 kcal/kg in intervention group vs 14 kcal/kg in controls), but proteic delivery was significantly different (1.4 vs 0.76 g/kg, respectively P ≤ 0.0001). The intervention group showed an improvement in SOFA score at 48 h (delta SOFA 1.7 (SD 1.9) vs 0.7 (SD 2.8) P = 0.04) and less hyperglycemic episodes per day (1.0 (SD 1.3) vs 1.7 (SD 2.5) P = 0.017). Discussion: Enteral hyperproteic hypocaloric nutrition therapy could be associated with a decrease in multiple organ failure measured with SOFA score. We also found decreased hyperglycemia and a trend towards less mechanical ventilation days and ICU length of stay.

RESEARCH ARTICLE

Rajni Sharma, Pallavi Goyal, Viswas Chhapola, Sandeep Kumar

Use of liquid heparin for blood gas sampling in pediatric intensive care unit: A comparative study of effects of varying volumes of heparin on blood gas parameters

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:5] [Pages No:350 - 354]

Keywords: Blood gas analysis, liquid heparin, pre-analytic error

PDF  |  DOI: 10.4103/0972-5229.123443  |  Open Access |  How to cite  | 

Abstract

Background and Aims: Pre-analytical errors in sample collection affect the reliability of blood gas (BG) analysis. Amount of liquid heparin as anticoagulant in samples for BG can affect results by its dilutional direct binding and compositional effects. The aim of this study was to examine the effect of varying amounts of heparin in blood samples on results. Materials and Methods : The prospective study was conducted on 15 children at a pediatric intensive care unit (PICU). Three different heparinized syringes were used containing minimal, 60 IU and 120 IU of heparin. A total volume of 1 ml blood in each syringe was taken and was analyzed by blood gas analyzer. Statistical analysis used related samples Friedman′s test and Wilcoxon signed ranks test for paired comparisons. The observed bias was also compared with the desirable bias according to specifications by Ricos et al. Results: There was a significant difference (P < 0.05) in values of pH, pCO 2, HCO3, Hb and Na + in the three syringes. The pCO 2, HCO3 and Na + levels decreased with the increasing amount of heparin. The observed percentage bias was more than desirable percentage bias specifications for pCO 2, HCO3, Hb, Na +, K + and Cl levels. Conclusions: Syringes with minimal liquid heparin are most appropriate for studying BG parameters as they have the least effect on these parameters. There is a need to standardize the procedure of syringe preparation for BG analysis. Further studies are needed to compare minimal amounts of heparin with commercially available dry balanced heparin syringes.

RESEARCH ARTICLE

Akila Prashant, Prashant Vishwanath, Nalini Kotekar, Parveen Doddamani, Suma M. Nataraj

Can soluble CD163 predict outcome of patients with acute respiratory distress from mechanical ventilation?: A pilot study

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:4] [Pages No:355 - 358]

Keywords: Acute respiratory distress, mechanical ventilation, soluble CD163

PDF  |  DOI: 10.4103/0972-5229.123445  |  Open Access |  How to cite  | 

Abstract

Purpose: CD163 is a monocyte/macrophage-associated antigen which has recently been identified as a hemoglobin scavenger receptor and has also anti-inflammatory properties and an immunoregulatory role. This surface receptor undergoes ectodomain shedding upon an inflammatory stimulus, leading to increased fraction of soluble CD163 (sCD163). Hence, we hypothesized that the mechanical ventilation (MV) which is known to elicit inflammatory response may cause increased serum levels of sCD163 which can predict the outcome of patients from MV. Subjects and Methods: Thirty patients with acute respiratory distress aged >18 years who required MV were enrolled for the study. Serum levels of sCD163 were estimated using quantitative immunometric sandwich enzyme immunoassay technique from 3 mL of the venous blood sample which was collected immediately and at 24 h after the patient was connected to MV. On the basis of the outcome of the patient from MV, they were divided into two groups; survivors and nonsurvivors. Results: Out of the 30 patients, 18 patients survived and 12 patients expired. Serum levels of sCD163 were significantly increased in nonsurvivors when compared with survivors (P < 0.01) at 24 h after connecting to MV. sCD163 > 1020 ng/mL at 24 h of MV increases the probability of mortality by factor 6. An increase of sCD163 by 1 ng/mL significantly increases the relative probability of mortality by a factor of 1.0017 (95% confidence interval, 1.0004-1.0030, P = 0.0005). Conclusions: Elevated levels of sCD163 at 24 h of MV help in predicting the outcome of patients with acute respiratory failure from MV.

RESEARCH ARTICLE

Shyam Krishnan, Tejas Chokshi, Gopala Krishna Alaparthi, K. Vaishali, C.P. Zulfeequer

Practice patterns of physiotherapists in neonatal intensive care units: A national survey

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:8] [Pages No:359 - 366]

Keywords: Chest physiotherapy, early intervention, neonatal intensive care unit, neuromuscular physiotherapy, survey

PDF  |  DOI: 10.4103/0972-5229.123448  |  Open Access |  How to cite  | 

Abstract

Objective: To determine practice pattern of physiotherapists in the neonatal intensive care units (ICUs) in India with regards to cardiopulmonary and neuromuscular physiotherapy. Materials and Methods: A cross-sectional survey was conducted across India, in which 285 questionnaires were sent via e-mail to physiotherapists working in neonatal intensive care units. Results: A total of 139 completed questionnaires were returned with a response rate of 48.7%, with a majority of responses from Karnataka, Maharashtra and Gujarat. More than 90% of physiotherapists performed chest physiotherapy in neonatal ICUs. Chest physiotherapy assessment predominantly focused on vital parameter assessment (86%) and in treatment predominantly focused on percussion (74.1%), vibration (75.5%), chest manipulation (73.3%), postural drainage (67.6%) and suction (65.4%). In neuromuscular physiotherapy more than 60% of physiotherapists used positioning, and parent education, whereas more than 45% focused on passive range of motion exercise and therapeutic handling. Conclusion: The practice pattern of physiotherapists for neonates in neonatal intensive care units involves both chest physiotherapy as well neuromuscular physiotherapy. Chest physiotherapy assessment focused mainly on vital parameter assessment (heart rate, respiratory rate and partial pressure of oxygen saturation SpO 2 ). Treatment focused on airway clearance techniques including percussion, vibration, postural drainage and airway suction. In neuromuscular physiotherapy most physiotherapists focused on parent education and passive range of motion exercise, therapeutic handling, as well as positioning.

Short Communication

Meghana Srivastava, Harpreet Sandhu

Real-time ultrasound guided percutaneous dilatational tracheostomy in critically ill patients: A step towards safety!

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:3] [Pages No:367 - 369]

Keywords: Bronchoscopes, percutaneous, real-time, tracheostomy, ultrasonography

PDF  |  DOI: 10.4103/0972-5229.123449  |  Open Access |  How to cite  | 

Abstract

There are few reports and observational data that support the safety and efficacy of real-time ultrasound guided (USG) percutaneous dilatational tracheostomy (PDT) when compared with unguided tracheostomy. We performed real-time USG PDT in our intensive care unit (ICU) patients with the aim of providing safe and cost effective point-of-care management. Real-time ultrasonography has the potential advantage of enabling the clinicians to define the needle path by showing displacement of tissues ahead of needle.

REVIEW ARTICLE

Satyen Parida, Sandeep Kumar Mishra

Urinary tract infections in the critical care unit: A brief review

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:5] [Pages No:370 - 374]

Keywords: Catheter-associated urinary tract infection, critical care unit, urinary tract infection

PDF  |  DOI: 10.4103/0972-5229.123451  |  Open Access |  How to cite  | 

Abstract

The use of indwelling catheters in the Critical Care Units (CCUs) has a major role in determining the incidence and the morbidity as well as mortality from hospital-acquired urinary tract infections (UTIs). Instituting evidence-based protocols can significantly reduce both the prevalence of indwelling catheterization as well as the incidence of hospital-acquired UTIs. The prevalence of catheter-associated urinary tract infections (CAUTIs) in the CCUs is directly linked to the widespread use of indwelling catheters in these settings. CAUTIs result in significant cost escalation for individual hospitals as well as the healthcare system as a whole. A UTI is an inflammatory response to colonization of the urinary tract, most commonly by bacteria or fungi. A UTI should be differentiated from the mere detection of bacteria in the urinary tract. This condition, referred to as asymptomatic bacteriuria, is common and does not require treatment, especially in the patient with an indwelling urinary catheter. A CAUTI occurs when a patient with an indwelling urinary catheter develops 2 or more signs or symptoms of a UTI such as hematuria, fever, suprapubic or flank pain, change in urine character, and altered mental status. CAUTI is classified as a complicated UTI. The current review highlights the important management issues in critical care patients having CAUTI. We performed a MEDLINE search using combinations of keywords such as urinary tract infection, critical care unit and indwelling urinary catheter. We reviewed the relevant publications with regard to CAUTI in patients in CCU.

CASE REPORT

Ajay Handa, Vimal Upreti, V. R. Ratheesh, Pawan Dhull

Shock due to amlodipine overdose

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:3] [Pages No:375 - 377]

Keywords: Amlodipine, calcium channel blocker, hypotension

PDF  |  DOI: 10.4103/0972-5229.123452  |  Open Access |  How to cite  | 

Abstract

Amlodipine is a commonly prescribed calcium channel blocker. Its toxicity is the leading cause of drug overdose seen in the practice of cardiovascular medicine. It can lead to profound hypotension and shock. Management involves early and aggressive supportive measures and calcium infusion in large doses to overcome competitive blockade. We report one such case that presented with amlodipine overdose and was successfully managed.

LETTER TO EDITOR

Sananta Kumar Dash, Rakesh Sharma, Devender Kumar Agrawal, Harsh Dua

Acquired hemophilia complicated by cardiorenal syndrome type 3

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:4] [Pages No:378 - 381]

Keywords: Acquired hemophilia, cardiorenal syndrome, factor VIII inhibitor, recombinant activated factor VII

PDF  |  DOI: 10.4103/0972-5229.123456  |  Open Access |  How to cite  | 

Abstract

Development of autoantibodies against coagulation factor VIII (FVIII) leads to a rare condition defined as acquired hemophilia (AH). If not diagnosed and treated early, AH may be associated with high mortality and morbidity. A 65-year-old woman presented with history of macrohematuria, acute renal failure, cardiogenic shock, and acute respiratory failure. Blood investigation revealed azotemia, prolonged activated partial thromboplastin time (aPTT), coagulation FVIII level of <1%, and presence of FVIII inhibitor. Echocardiography showed global hypokinesia and ultrasonography and computed tomography (CT) revealed bilateral hydroureteronephrosis. The final diagnosis was acquired hemophilia A, complicated by acute obstructive renal failure and cardiorenal syndrome (CRS) type 3. Patient was managed with mechanical ventilation, heparin-free hemodialysis, negative fluid balance, recombinant activated factor VII, and prednisolone. Hematuria was relieved, renal function improved, and cardiac function showed improvement on repeat echocardiography. Patient was discharged on prednisolone with subsequent follow ups.

CASE REPORT

Vinay Marulasiddappa, C. A. Tejesh

Lemierre′s syndrome presenting with septic shock

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:3] [Pages No:382 - 384]

Keywords: Internal jugular vein thrombosis, Lemierre′s syndrome, oropharyngeal infection

PDF  |  DOI: 10.4103/0972-5229.123460  |  Open Access |  How to cite  | 

Abstract

Lemierre′s syndrome is a rare condition characterized by septic thrombophlebitis of the internal jugular vein and metastatic abscesses following oropharyngeal infection. Though classically caused by Fusobacterium necrophorum, a number of other causative organisms have been reported in literature. We report a case of Lemierre′s syndrome following parapharyngeal abscess due to staphylococcus aureus which progressed to septic shock.

CASE REPORT

Neelam Marwaha, Ratti Ram Sharma, Rekha Hans

Dramatic response to plasma exchange in systemic lupus erythematosus with acute complications: Report of two cases

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:3] [Pages No:385 - 387]

Keywords: Diffuse alveolar hemorrhage, systemic lupus nephritis, therapeutic plasma exchange

PDF  |  DOI: 10.4103/0972-5229.123462  |  Open Access |  How to cite  | 

Abstract

Acute exacerbations and complications are common in patients of systemic lupus erythematosus (SLE) despite of adequate long-term therapy with immunosuppressive drugs. So other options like therapeutic plasma exchange (TPE) can be considered as part of management. Here, we share our experience of two patients of SLE with acute complications who were successfully managed with TPE.

CASE REPORT

Anupam Shrivastava, Sidhartha Garg, Bakhshish Singh, Manender Kumar Singla

Refractory hyperkalemia related to heparin abuse

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:4] [Pages No:388 - 391]

Keywords: Hemodialysis, heparin abuse, hyperkalemia

PDF  |  DOI: 10.4103/0972-5229.123463  |  Open Access |  How to cite  | 

Abstract

Hyperkalemia is a potentially life-threatening condition, which may occur in many clinical settings. Heparin-induced hyperkalemia is less well-recognized than other side effects of heparin therapy. Even lesser known is heparin abuse amongst drug addicts. We report a case of fatal hyperkalemia related to long-term heparin abuse, which was refractory to anti-hyperkalemia therapy including hemodialysis. The objective is to alert the clinicians to possible abuse of heparin in drug addicts, which can be a cause for refractory hyperkalemia. We also briefly review the available literature on heparin-induced hyperkalemia.

CASE REPORT

Meera Ramakrishnan

Salmonella typhimurium meningitis in infancy

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:2] [Pages No:392 - 393]

Keywords: Infant, meningitis, Salmonella typhimurium

PDF  |  DOI: 10.4103/0972-5229.123464  |  Open Access |  How to cite  | 

Abstract

We report a case of meningitis due to Salmonella typhimurium in a four-month-old female infant. The child was brought to the pediatric emergency department with complaints of fever, cold, and generalized convulsion. On examination, the child was febrile and was having seizures. The anterior fontanelle was not bulging. Lumbar puncture was done and Salmonella typhimurium was isolated from cerebrospinal fluid. Initially the infant improved clinically with appropriate management, but had a fatal outcome due to nosocomial pneumonia.

LETTERS TO THE EDITOR

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

Ceftriaxone induced immune hemolytic anemia with disseminated intravascular coagulation

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:2] [Pages No:394 - 395]

PDF  |  DOI: 10.4103/0972-5229.123465  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Satinder Gombar, Richa Saroa, Sanjeev Palta, Deepak Aggarwal

Worsening acute respiratory distress syndrome: Is it immune reconstitution inflammatory syndrome?

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:2] [Pages No:395 - 396]

PDF  |  DOI: 10.4103/0972-5229.123466  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Veena Shah, Geeta Parikh, Deepika Singh, Prachi Kadam, Nirav Kharadi

An unusual cause of anaphylaxis during surgery

[Year:2013] [Month:December] [Volume:17] [Number:6] [Pages:2] [Pages No:396 - 397]

PDF  |  DOI: 10.4103/0972-5229.123467  |  Open Access |  How to cite  | 

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