How to cite this article:
Bhagchandani R, Singhi S, Peter JV, Chugh TD, Varghese GM, Karthi N, Kalantri S, Munjal M, Rungta N. Tropical fevers: Management guidelines. Indian J Crit Care Med 2014; 18 (2):62-69.
Tropical fevers were defined as infections that are prevalent in, or are unique to tropical and subtropical regions. Some of these occur throughout the year and some especially in rainy and post-rainy season. Concerned about high prevalence and morbidity and mortality caused by these infections, and overlapping clinical presentations, difficulties in arriving at specific diagnoses and need for early empiric treatment, Indian Society of Critical Care Medicine (ISCCM) constituted an expert committee to develop a consensus statement and guidelines for management of these diseases in the emergency and critical care. The committee decided to focus on most common infections on the basis of available epidemiologic data from India and overall experience of the group. These included dengue hemorrhagic fever, rickettsial infections/scrub typhus, malaria (usually falciparum), typhoid, and leptospira bacterial sepsis and common viral infections like influenza. The committee recommends a ′syndromic approach′ to diagnosis and treatment of critical tropical infections and has identified five major clinical syndromes: undifferentiated fever, fever with rash / thrombocytopenia, fever with acute respiratory distress syndrome (ARDS), fever with encephalopathy and fever with multi organ dysfunction syndrome. Evidence based algorithms are presented to guide critical care specialists to choose reliable rapid diagnostic modalities and early empiric therapy based on clinical syndromes.
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Uppala R, Samransamruajkit R, Prapphal N, Sritippayawan S, Pongsanon K, Deelodejanawong J. Clinical outcomes after utilizing surviving sepsis campaign in children with septic shock and prognostic value of initial plasma NT-proBNP. Indian J Crit Care Med 2014; 18 (2):70-76.
Background and Objective: The surviving sepsis campaign treatment guideline (SSC) implementation is associated with improved outcome in adults with severe sepsis. The effect on outcome of pediatric sepsis is less clear. Purpose : To determine the clinical outcomes of SSC implementation and to investigate the prognostic value of initial plasma NT-proBNP and procalcitonin in children. Materials and Methods: Infants and children (aged 1month/0-15 years with severe sepsis or septic shock) were prospectively enrolled and treated according to the guidelines. Initial blood drawn was saved for NT-pro-BNP, procalcitonin measurements and clinical data were also recorded. Results: A total of 47 subjects were recruited. Since the application of the SSC, our mortality rate had significantly decreased from 42-19% (P = 0.003) as compared to the data in the previous 3 years. Clinical factors that significantly increased the mortality rate were: Initial central venous oxygen saturation < 7 0% after fluid resuscitation [odds ratio (OR) = 23.3; 95% confidence interval (CI) 3.7-143; P = 0.001], and initial albumin level (≤ 3 g/dl, OR = 6.7; 95% CI 1.2-37.5, P = 0.03). There was asignificant difference between the initial NT-proBNP levels between survivors and non survivors, (6280.3 ± 9597 ng/L, P < 0.001), but not for procalcitonin (12.7 ± 24.8, 29.3 ± 46 μg/L, P = 0.1), respectively. An initial NT-proBNP level of more than 11,200 pg/ml predicted Pediatric Intensive Care Unit (PICU) mortality with a sensitivity of 85.7% and a specificity of 90%. Conclusions: A modified SSC for severe sepsis and septic shock significantly reduced the mortality rate in our PICU. High initial NT-ProBNP level was associated with mortality.
Nibu Varghese John,
Manesh C. Misra
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Agrawal D, Gupta G, Punia P, Tak V, John NV, Misra MC. Outbreak of Streptococcus pyogenes emm type 58 in a high dependency unit of a level-1 trauma center of India. Indian J Crit Care Med 2014; 18 (2):77-82.
Background and Aims: Group A Streptococcus (GAS) can cause illnesses ranging from self-limited to severe, life-threatening, invasive infections. The objective of the following study was to investigate a suspected Streptococcus pyogenes outbreak in a high dependency unit (HDU) of our trauma center. Materials and Methods: All the isolates of beta hemolytic Streptococci were identified by standard microbiological methods, Vitek 2 system and latex agglutination tests. Antimicrobial susceptibility testing was performed as recommended by Clinical Laboratory Standards Institute. Exotoxin genes, including speA, speB, speC, speF, smeZ, ssa, speG, speH, speJ, speL, speM and speI were detected by polymerase chain reaction (PCR). The emm types of isolates of S. pyogenes were determined by sequencing the variable 5′ end of emm gene after amplification by PCR. Results: In a 28 bedded poly-trauma ward with a four bedded HDU three out of four patients developed S. pyogenes emm type 58 infection. The strain was macrolide and tetracycline resistant and produced the Streptococcal pyrogenic exotoxins speB, speC, speG, speF and smeZ. Surveillance sampling was done for investigation from patients, health-care workers and environmental samples. Conclusion: An outbreak of GAS infections was established caused by the uncommonly reported emm type 58. The outbreak was controlled by prompt treatment, intensive surveillance, feedback and training.
Context: Hyponatremia is a common electrolyte disturbance in critically ill hence understanding its implications is important. Aims: This study was carried out to ascertain frequency, predisposing conditions and outcome in critically ill patients with hyponatremia on intensive care unit (ICU) admission. Settings and Design: This was an observational, prospective study of a series of ICU patients during a 12-month period. Materials and Methods: The patients were divided into two groups: Hyponatremic (serum sodium < 135 mmol/L) and Eunatremic groups (135-145 mmol/L). Clinical examination included volume status and drug history, biochemistries, clinical diagnosis and cause of hyponatremia. Statistical Analysis Used: Fisher′s exact test, unpaired t-tests Wilcoxon ranksum tests, profile-likelihood method, log-rank test and Kaplan-Meier curves were used. P < 0.05 were considered to be statistically significant. Results: In the hyponatremic group, the frequency of hyponatremia on ICU admission was 34.3%, most were euvolumic, 58.96%. Females comprised of 36.5%. The mean age was 60.4 ± 17.2. The Syndrome of inappropriate Antidiuretic Hormone (SIADH) criteria was met in ninety-one patients (36.25%), peumonia being the leading cause of SIADH. Patients with severe sepsis, elective surgery patients, renal failure and heart failure, cirrhosis of liver and subarachnoid hemorrhage were other more likely etiologic causes (P < 0.05). The hyponatremic group spent a longer time in the ICU (P = 0.02), had longer mechanical ventilator days (P < 0.05) and had an increased mortality rate (P = 0.01). Conclusions: Hyponatremia present on admission to the ICU is independent risk factors for poor prognosis.
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Mouad H, Belayachi J, Madani N, Abouqal R. Preventability of death in a medical intensive care unit at a university hospital in a developing country. Indian J Crit Care Med 2014; 18 (2):88-94.
Objective: To determine the incidence and characteristics of preventable in-ICU deaths. Materials and Methods: A one-year observational study was conducted in a medical ICU of a teaching hospital. All patients who died in medical ICU beyond 24 h were analyzed and reviewed during daily medical meeting. A death was considered preventable when it would not have occurred if the patient had received ordinary standards of care appropriate for the time of study. Preventability of death was classified by using a 1-6 point preventability scale. The types of medical errors causing preventable in-ICU deaths and the contributory factors to deaths were identified. Results: 120 deaths (47 ± 19 years, 57 months-63 weeks) were analyzed (mortality: 23%; 95% confidence interval (CI):15-31%). At admission, Acute Physiology and Chronic Health Evaluation (APACHE) II score was 18 ± 7.6 and Charlson comorbidity index was 1.3 ± 1.6. The main diagnosis was infectious disease (57%) and respiratory disease (23%). The median period between the ICU admission and death was 5 days. The rate of preventable in-ICU deaths was 14.1% (17/120). The most common medical errors related to occurrence of preventable in-ICU deaths were therapeutic error (52.9%) and inappropriate technical procedure (23.5%). The preventable in-ICU deaths were associated with inadequate training or supervision of clinical staff (58.8%), no protocol (47.1%), inadequate functioning of hospital departments (29.4%), unavailable equipment (23.5%), and inadequate communication (17.6%). Conclusion: According to our study, one to two in-ICU deaths would be preventable per month. Our results suggest that the implementation of supervision and protocols could improve outcomes for critically ill patients.
Background and Aims: Intensive care unit acquired weakness (ICUAW) is a common occurrence in patients who are critically ill. It is most often due to critical illness polyneuropathy (CIP) or to critical illness myopathy (CIM). ICUAW is increasingly being recognized partly as a consequence of improved survival in patients with severe sepsis and multi-organ failure, partly related to commonly used agents such as steroids and muscle relaxants. There have been occasional reports of CIP and CIM in children, but little is known about their prevalence or clinical impact in the pediatric population. This review summarizes the current understanding of pathophysiology, clinical presentation, diagnosis and treatment of CIP and CIM in general with special reference to published literature in the pediatric age group. Subjects and Methods: Studies were identified through MedLine and Embase using relevant MeSH and Key words. Both adult and pediatric studies were included. Results: ICUAW in children is a poorly described entity with unknown incidence, etiology and unclear long-term prognosis. Conclusions: Critical illness polyneuropathy and myopathy is relatively rare, but clinically significant sequelae of multifactorial origin affecting morbidity, length of intensive care unit (ICU) stay and possibly mortality in critically ill children admitted to pediatric ICU.
Niteen D. Karnik,
Jaimala Vijay Shetye,
Swati M. Surkar,
Amita A. Mehta
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Karnik ND, Shetye JV, Surkar SM, Mehta AA. Delayed onset neuropathy along with recurrent laryngeal nerve palsy due to organophosphate poisoning and the role of physiotherapy rehabilitation. Indian J Crit Care Med 2014; 18 (2):102-104.
Organophosphorus poisoning is a major global cause of health problems and the leading cause of mortality and morbidity in the developing countries. In this, the inhibition of acetyl-choline esterase and neurotoxic esterase along with nicotinic receptor involvement produces three well-identified and documented clinical phases: The initial cholinergic phase, which is a medical emergency often requiring management in an intensive care unit; the intermediate syndrome, during which prolonged ventilator care is necessary; and finally delayed neurotoxicity. Vocal cord paralysis is rare and leads to aphonia. Role of physiotherapy rehabilitation is substantial in all three stages and aims at early weaning off from mechanical ventilator until the functional independence and community integration of the patient.
Invasive monitoring is the need of the hour in today′s scenario in intensive care units and perioperatively in hemodynamically unstable patients. Despite careful placement using proper landmarks and USG guided methods central venous canuulation (CVC) is associated sometimes with unforeseen complications. We report a rare complication of coiling of CVC in the left subclavian vein.
Mohammed Arshad Ali,
Jalal Syed Shafiuddin Shaheen,
Mohammed Ali Khan
Thrombotic thrombocytopenic purpura (TTP) is a rare syndrome of unknown cause with an estimated incidence of one case per million. The disease is characterized by a pentad of symptoms: Thrombocytopenia, microangiopathic hemolytic anemia, neurologic changes, renal dysfunction, and fever. It causes thrombosis in the microvasculature of several organs, producing diverse manifestations. Acute pancreatitis (AP) is a well-described consequence of TTP. Acute pancreatitis triggering TTP is uncommon.
Spontaneous rupture of the spleen with hemoperitoneum is a very rare, but serious manifestation of dengue fever (DF). We report a case of a young female who was presented with atraumatic abdominal pain, hypovolemic shock, anemia, ascites and hepatosplenomegaly with a recent history of a febrile illness. Subsequent investigations proved the presence of hemoperitoneum with spontaneous splenic rupture with seropositivity for DF. Early diagnosis and conservative management in this case resulted in a favorable outcome.
Methemoglobinemia is an altered state of hemoglobin resulting in impaired oxygen delivery to the tissues. Deliberate ingestion of certain insecticides and pesticides may result in this condition. We report a case of severe methemoglobinemia after deliberate ingestion of an insecticide marketed to be safe and containing only biological extracts and fillers. Methemoglobinemia should be suspected with low oxygen saturation on pulse oxymetry and the presence of chocolate colored blood. The methemoglobin level of 91% in our patient is the highest level reported among methemoglobinemia survivors.
Santoshi Balkrishna Malkarnekar,
B. G. Kiran
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Malkarnekar SB, Anjanappa R, Naveen L, Kiran BG. Acute methemoglobinemia with hemolytic anemia following bio-organic plant nutrient compound exposure: Two case reports. Indian J Crit Care Med 2014; 18 (2):115-117.
Two young women, were reffered to our hospital on two different occasions with history of breathlessness and mental confusion, following consumption of two different bio-organic plant nutrient compounds with a suicidal intent. On examination, they had cyanotic mucous membranes, and their blood samples showed the classic ′dark chocolate brown′ appearance. Work up revealed cyanosis unresponsive to oxygen supplementation and absence of cardiopulmonary abnormality. Pulse oximetry revealed saturation of 75% in case 1 and 80% in case 2, on 8 liters oxygen supplementation via face masks, although their arterial blood gas analysis was normal, suggestive of \"saturation gap\". Methemoglobinemia was suspected based on these findings and was confirmed by Carbon monoxide-oximetry (CO-oximetry). Methylene blue was administered and the patients showed dramatic improvement. Both the patients developed evidence of hemolysis approximately 72 hours following admission which improved with blood transfusion and supportive treatment. The patients were eventually discharged without any neurological sequalae.
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Jha A, Baronia AK, Samanta S. Angiographic catheter as airway exchange device through laryngeal airway mask in unanticipated difficult airway in emergency department. Indian J Crit Care Med 2014; 18 (2):120-121.