Indian Journal of Critical Care Medicine

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2014 | November | Volume 18 | Issue 11

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Optic nerve sheath diameter: An ultrasonographic window to view raised intracranial pressure?

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:2] [Pages No:707 - 708]

   DOI: 10.4103/0972-5229.144007  |  Open Access |  How to cite  | 



Chand Wattal, Jaswinder Oberoi

Mupirocin resistant staphylococcus aureus nasal colonization among healthcare workers

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:2] [Pages No:709 - 710]

   DOI: 10.4103/0972-5229.144009  |  Open Access |  How to cite  | 



Dardi Kaur, Pandey Narayan

Mupirocin resistance in nasal carriage of Staphylococcus aureus among healthcare workers of a tertiary care rural hospital

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:6] [Pages No:716 - 721]

Keywords: Antibiotic resistance, methicillin-resistant coagulase-negative Staphylococci, methicillin-resistant Staphylococcus aureus, mupirocin resistance

   DOI: 10.4103/0972-5229.144013  |  Open Access |  How to cite  | 


Introduction: Mupirocin (pseudomonic acid A) is a topical antimicrobial agent with excellent antistaphylococcal and antistreptococcal activity. A nasal formulation is approved by the United States Food and Drug Administration for eradicating nasal carriage in adult patients as well as in health care personnel. Resistance to mupirocin has already been reported worldwide. The increasing prevalence of mupirocin resistance among Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) species could be an important threat to the future use of mupirocin against methicillin-resistant S. aureus (MRSA). Thus, this study was carried out to find the prevalence of mupirocin resistance in S. aureus and CoNS by disc diffusion and to determine the rates of high-level and low-level mupirocin resistance in S. aureus and CoNS by disc diffusion. Materials and Methods: A total of 140 healthcare workers (HCWs) (doctor, nursing staff, housekeeping staff) were randomly selected. S. aureus and CoNS isolates were tested for mupirocin resistance by the disk diffusion method using 5 μg and 200 μg mupirocin discs. MRSA isolates were tested for antibiotics by Kirby-Bauer disc-diffusion method as per Clinical and Laboratory Standards Institute guidelines. Results: Out of 140 nasal swabs collected from HCWs, S. aureus was isolated in 38 (27.14%), and CoNS was isolated in 73 (52.14%). MRSA was isolated in 20 (14.28%) and methicillin-resistant coagulase-negative Staphylococci (MRCoNS) in 34 (24.29%. Methicillin-sensitive S. aureus (MSSA) and MSCoNS isolates were 100% sensitive to mupirocin, but two isolates from MRSA (1.43%) and five from MRCoNS (3.57%) were mupirocin resistant. Conclusion: The presence of mupirocin resistance in MRSA and MRCoNS is a cause for concern. It could be limited by regular surveillance and effective infection control initiatives so to inform health care facilities to guide therapeutic and prophylactic use of mupirocin.



Srikant Gadwalkar, N. Kumar, D. P. Kushal, G. Shyamala, M.Z. Mohammad, Huggi Vishwanatha

Judicious use of antisnake venom in the present period of scarcity

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:6] [Pages No:722 - 727]

Keywords: Acute kidney injury, low dose antisnake venom, snake bite

   DOI: 10.4103/0972-5229.144014  |  Open Access |  How to cite  | 


Context: Although antisnake venom (ASV) has been used for many years, selection of an optimal dose is a debated issue due to acute shortage of ASV in India. Despite evidence for smaller doses, most centers still use conventional doses. Aims: This study aimed to evaluate the effects of two different dosage regimens on the outcome of patients with snake envenomation, using a retrospective descriptive analysis of patient records admitted in our hospital. Settings and Design: A retrospective descriptive case series study was conducted from hospital records consisting 155 snakebite patients from June 2013 to January 2014. Materials and Methods: Patients were divided into two groups: Low dose ASV group (received <10 vials) and high dose ASV group (received ≥10 vials). Various complications were compared among these two groups. Results: The mean dose of ASV used in high dose, and low-dose group was 14.7 ± 5.3 and 4.2 ± 2.3, respectively. In low dose group, 20.5% of patients had acute kidney injury, whereas it was 10.9% in high dose group. In low dose group, 12.3% patients had neuroparalysis severe enough to require ventilator support and mortality rate was 5.5% which was comparable to the high-dose group (15.8% had neuroparalysis requiring ventilator support and a mortality rate of 8.5%). Conclusion: This study demonstrated that the low dose ASV regimen in poisonous snake bites along with supportive treatment as necessary is as efficacious as high dose regimen and has comparable complications.



Chetan Shirodkar, Dnyaneshwar Mutkule, Yogesh Harde, Pradeep Venkategowda, M. Mahesh

Optic nerve sheath diameter as a marker for evaluation and prognostication of intracranial pressure in Indian patients: An observational study

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:7] [Pages No:728 - 734]

Keywords: Computed tomography, intensive care unit, magnetic resonance imaging, mannitol, optic nerve sheath diameter, raised intracranial pressure, ultrasonography

   DOI: 10.4103/0972-5229.144015  |  Open Access |  How to cite  | 


Background and Aims: The aim was to evaluate efficacy of optic nerve sheath diameter (ONSD) by ultrasound as a noninvasive method for detecting raised intracranial pressure (ICP) in intensive care unit, to compare with computed tomography/magnetic resonance imaging (MRI) findings of raised ICP and to prognosticate ONSD value with treatment. Materials and Methods: We conducted a prospective, observational study on 101 adults by including 41 healthy individuals in group A as control and 60 patients in group B admitted with fever, headache, vomiting, and altered sensorium. We examined them in supine position using 10 MHz linear array probe on closed eyelid. ONSD was measured 3 mm behind the globe in each eye. A mean binocular ONSD > 4.6 mm in female and 4.8 mm in male was considered abnormal. Midline shift, edema, effacement or ONSD > 5.0 mm on T2 MRI suggestive of elevated ICP was used to evaluate ONSD accuracy. Results: Group A mean ONSD was 4.6 mm in females and 4.8 mm in males. Group B mean ONSD for 17 females was 5.103 ± 0.6221 mm (P = 0.002) and for 43 males 5.081 ± 0.5799 mm (P = 0.032). Radiological sign of raised ICP was confirmed in 35 patients (females = 11 and males = 24) with high ONSD value. Sensitivity of detecting raised ICP by ONSD was 84.6% in females and 75% in males while specificity was 100% in both genders. Out of 25 patients without radiological signs of raised ICP 10 patients showed high ONSD (females = 4.735 mm and males = 4.907 mm). ONSD was well prognosticated with treatment modalities. Conclusion: Bedside ocular ultrasonography for measuring ONSD can be used an early test for diagnosing raised ICP as it is a noninvasive, cost effective bedside test, which can be repeated for re-evaluation.



John Victor Peter, Thomas Sudarsan, John Moran

Clinical features of organophosphate poisoning: A review of different classification systems and approaches

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:11] [Pages No:735 - 745]

Keywords: Intermediate syndrome, manifestations, organophosphate, poisoning

   DOI: 10.4103/0972-5229.144017  |  Open Access |  How to cite  | 


Purpose: The typical toxidrome in organophosphate (OP) poisoning comprises of the Salivation, Lacrimation, Urination, Defecation, Gastric cramps, Emesis (SLUDGE) symptoms. However, several other manifestations are described. We review the spectrum of symptoms and signs in OP poisoning as well as the different approaches to clinical features in these patients. Materials and Methods: Articles were obtained by electronic search of PubMed® between 1966 and April 2014 using the search terms organophosphorus compounds or phosphoric acid esters AND poison or poisoning AND manifestations. Results: Of the 5026 articles on OP poisoning, 2584 articles pertained to human poisoning; 452 articles focusing on clinical manifestations in human OP poisoning were retrieved for detailed evaluation. In addition to the traditional approach of symptoms and signs of OP poisoning as peripheral (muscarinic, nicotinic) and central nervous system receptor stimulation, symptoms were alternatively approached using a time-based classification. In this, symptom onset was categorized as acute (within 24-h), delayed (24-h to 2-week) or late (beyond 2-week). Although most symptoms occur with minutes or hours following acute exposure, delayed onset symptoms occurring after a period of minimal or mild symptoms, may impact treatment and timing of the discharge following acute exposure. Symptoms and signs were also viewed as an organ specific as cardiovascular, respiratory or neurological manifestations. An organ specific approach enables focused management of individual organ dysfunction that may vary with different OP compounds. Conclusions: Different approaches to the symptoms and signs in OP poisoning may better our understanding of the underlying mechanism that in turn may assist with the management of acutely poisoned patients.



Emma Joynes, Satinder Dalay, Jaimin Patel, Samia Fayek

A complete audit cycle to assess adherence to a lung protective ventilation strategy

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:4] [Pages No:746 - 749]

Keywords: Intensive care, protective, respiratory, tidal volume, ventilation

   DOI: 10.4103/0972-5229.144020  |  Open Access |  How to cite  | 


There is clear evidence for the use of a protective ventilation protocol in patients with acute respiratory distress syndrome (ARDS). There is evidence to suggest that protective ventilation is beneficial in patients at risk of ARDS. A protective ventilation strategy was implemented on our intensive care unit in critical care patients who required mechanical ventilation for over 48 h, with and at risk for ARDS. A complete audit cycle was performed over 13 months to assess compliance with a safe ventilation protocol in intensive care. The ARDS network mechanical ventilation protocol was used as the standard for our protective ventilation strategy. This recommends ventilation with a tidal volume (Vt ) of 6 ml/kg of ideal body weight (IBW) and plateau airway pressure of ≤30 cm H 2 O. The initial audit failed to meet this standard with Vt ′s of 9.5 ml/kg of IBW. Following the implementation of a ventilation strategy and an educational program, we demonstrate a significant improvement in practice with Vt ′s of 6.6 ml/kg of IBW in the re-audit. This highlights the importance of simple interventions and continuous education in maintaining high standards of care.



V. Ramasubramanian, Ravikant Porwal, Naga Rajesh

Carbapenem resistant Gram-negative bacteremia in an Indian intensive care unit: A review of the clinical profile and treatment outcome of 50 patients

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:4] [Pages No:750 - 753]

Keywords: Bacteremia in Indian intensive care unit, carbapenem resistant Gram-negative bacteremia, carbapenem resistant Klebsiella pneumoniae, multidrug-resistant bacteremia

   DOI: 10.4103/0972-5229.144021  |  Open Access |  How to cite  | 


Background: Growing antimicrobial resistance and limited therapeutic options to treat carbapenem-resistant bacteremia prompted us to evaluate the clinical outcomes associated with healthcare-associated bacteremia. Methods: This was a retrospective observational study of carbapenem-resistant Gram-negative bacteremia performed at a tertiary care facility in Chennai, India between May 2011 and May 2012. Results: In our study, patients had mean 11.76 days of intensive care unit (ICU) care and mean time to onset of bacteremia was 6.4 days after admission. The commonest organism was Klebsiella pneumoniae (44%). Patients with combination treatment had lower mortality (44.8%) compared with colistin monotherapy (66.6%); (P = 0.35). Conclusion: Carbapenem resistant bacteremia is a late onset infection in patients with antibiotic exposure in the ICU and carries a 30 days mortality of 60%; K. pneumoniae is the most common organism at our center. Two drug combinations appear to carry a lower mortality compared with monotherapy.



Gentle Sunder Shrestha, B. Poudyal, A. S. Bhattarai, P. S. Shrestha, G. Sedain, N. Acharya

Perioperative management of two cases of hemophilia with spontaneous intracerebral hemorrhage undergoing emergency craniotomy in resource constrained setup of Nepal

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:3] [Pages No:754 - 756]

Keywords: craniotomy, hemophilia, intracerebral hemorrhage, perioperative care

   DOI: 10.4103/0972-5229.144023  |  Open Access |  How to cite  | 


Patients with hemophilia are prone to develop spontaneous intracranial hemorrhage. It carries a significant risk of morbidity and mortality. In this case series, we report two cases of hemophilia who suffered spontaneous intracerebral hemorrhage with features of raised intracranial pressure and were successfully managed perioperatively. The patients were managed with early intensive care unit management, measures to reduce intracranial pressure, perioperative clotting factor administration, airway management and surgery to decrease the raised intracranial pressure. Both patients improved following surgery and were discharged home. Perioperative multidisciplinary management of hemophilia is discussed in this series.



Menon Sunilkumar, Thekkuttuparambil Ajith, Vadakut Parvathy

Acute ammonium dichromate poisoning in a 2 year-old child

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:2] [Pages No:757 - 758]

Keywords: Ammonium dichromate, ascorbic acid, hepato-renal failure dimercaprol, N-acetylcysteine

   DOI: 10.4103/0972-5229.144024  |  Open Access |  How to cite  | 


Hexavalent chromium compounds are most commonly used in printing, dyeing, plastics and rayon manufacturing. Poisoning in children by ammonium dichromate, an odorless and bright orange-red crystal, are rarely reported. Acute poisoning will result in death due to multi-organ failure. The target organs that are affected by this poison are the respiratory system, kidneys, liver, eyes and skin. On ingestion, initially there is a relative lack of severe symptoms and signs. Hence, the delay in seeking medical attention could lead to the increased rate of mortality. In this case study, we report the ingestion of ammonium dichromate by a child. Despite appropriate management, such as hepatic supportive measures and plasma transfusion, the toxicity progressed to multi-organ failure and death.



Sujeet Raina

Syndrome based treatment guidelines for critical tropical infections

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:1] [Pages No:761 - 761]

   DOI: 10.4103/0972-5229.144026  |  Open Access |  How to cite  | 



Kieran Walsh

Funding sources for continuing medical education: A different perspective

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:1] [Pages No:762 - 762]

   DOI: 10.4103/0972-5229.144027  |  Open Access |  How to cite  | 



A letter in response to "noninvasive ventilation: Are we overdoing it?"

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:2] [Pages No:762 - 763]

   DOI: 10.4103/0972-5229.144028  |  Open Access |  How to cite  | 



Kapil Dev Soni, Deviprasad Dash, Biplab Mishra

Intensive care unit management of a posttraumatic pneumonectomy case

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:3] [Pages No:763 - 765]

   DOI: 10.4103/0972-5229.144029  |  Open Access |  How to cite  | 



Sim Tin

Symptomatic hypomagnesemia and proton pump inhibitors

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:1] [Pages No:765 - 765]

   DOI: 10.4103/0972-5229.144030  |  Open Access |  How to cite  | 



Himmatrao Bawaskar, Parag Bawaskar, Pramodini Bawaskar

Refractory hyperkalemia related to heparin abuse

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:2] [Pages No:765 - 766]

   DOI: 10.4103/0972-5229.144032  |  Open Access |  How to cite  | 



Ritesh G. Menezes, Srinivasan Jayaraman

Glibenclamide: A second wind for refractory hyperkalemia

[Year:2014] [Month:November] [Volume:18] [Number:11] [Pages:2] [Pages No:766 - 767]

   DOI: 10.4103/0972-5229.144033  |  Open Access |  How to cite  | 


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