Indian Journal of Critical Care Medicine

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2014 | March | Volume 18 | Issue 3

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Himmatrao Bawaskar

Snake bite poisoning: A neglected life-threatening occupational hazard

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:2] [Pages No:123 - 124]

   DOI: 10.4103/0972-5229.128698  |  Open Access |  How to cite  | 



Prashant Saxena

Preventing hospital acquired infections: A challenge we must accept

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:2] [Pages No:125 - 126]

   DOI: 10.4103/0972-5229.128699  |  Open Access |  How to cite  | 



Burnout in the ICU: Playing with fire?

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:2] [Pages No:127 - 128]

   DOI: 10.4103/0972-5229.128700  |  Open Access |  How to cite  | 



Shweta Naik, Rameshwor Yengkom, Vijay Kalrao, Atul Mulay

Acute kidney injury in critically ill children: Risk factors and outcomes

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:5] [Pages No:129 - 133]

Keywords: Acute kidney injury, pediatric intensive care unit, pRIFLE, PRISM III, sepsis

   DOI: 10.4103/0972-5229.128701  |  Open Access |  How to cite  | 


Background: Acute kidney injury (AKI) is common in patients in the pediatric intensive care unit (PICU) and is associated with poor outcome. We conducted the present study to determine the incidence, risk factors and outcomes of AKI in the PICU. Materials and Methods: We collected data retrospectively from case records of children admitted to the PICU during one year. We defined and classified AKI according to modified pRIFLE criteria. We used multivariate logistic regression to determine risk factors of AKI and association of AKI with mortality and morbidity. Results: Of the 252 children included in the study, 103 (40.9%) children developed AKI. Of these 103 patients with AKI, 39 (37.9%) patients reached pRIFLE max of Risk, 37 (35.9%) patients reached Injury, and 27 (26.2%) had Failure. Mean Pediatric Risk of Mortality (PRISM III) score at admission was higher in patients with AKI than in controls (P < 0.001).



Sujeet Raina, Ajay Jaryal, Sunil Raina, Rashmi Kaul, Vishav Chander

Snakebite profile from a medical college in rural setting in the hills of Himachal Pradesh, India

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:5] [Pages No:134 - 138]

Keywords: Envenomation, Himalayas, neglected tropical disease, reptiles

   DOI: 10.4103/0972-5229.128702  |  Open Access |  How to cite  | 


Objective: The objective of the following study is to assess the clinical profiles and manifestations of snakebite patients in the rural hilly setting of Shivalik and the Lesser Himalayan region of Himachal Pradesh. Materials and Methods: A hospital record-based retrospective descriptive study was carried out that included details on demography, clinical profile, treatment and outcome among 200 patients over a period of 2 years. The data was analyzed using Chi-square test for comparison. Results: 142 (71%) patients were young (age group of 16-45 years) and the number of male patients was 118 (59%) and female patients were 82 (41%). All the cases recorded presented in the months of April to November. Not a single case was recorded from December to March. The most frequently bitten sites were the lower limbs particularly the feet. 86 (43%) of the patients presented without any features of envenomation. Neuroparalysis was the commonest presentation in 53 (46%) patients followed by hemotoxicity in 36 (31%) among symptomatic patients. Early morning neuroparalysis syndrome was the presentation in 26.4% patients. Allergic reactions in the form of early anaphylaxis were noted in 7% patients. Conclusion: Snake bite is a neglected tropical disease affecting poor villagers in rural areas. Future research focusing on understanding epidemiological determinants of snake bite is desired.



Kalpalatha K. Guntupalli, Sherry Wachtel, Antara Mallampalli, Salim Surani

Burnout in the intensive care unit professionals

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:5] [Pages No:139 - 143]

Keywords: Burnout nurses, intensive care unit nurses, sleepy nurses, sleepy therapist

   DOI: 10.4103/0972-5229.128703  |  Open Access |  How to cite  | 


Background: Professional burnout has been widely explored in health care. We conducted this study in our hospital intensive care unit (ICU) in United States to explore the burnout among nurses and respiratory therapists (RT). Materials and Methods: A survey consisting of two parts was used to assess burnout. Part 1 addressed the demographic information and work hours. Part 2 addressed the Maslach Burnout Inventory-Human Service Survey. Results: The analysis included 213 total subjects; Nurses 151 (71%) and RT 62 (29%). On the emotional exhaustion (EE) scale, 54% scored \"Moderate\" to \"High\" and 40% scored \"Moderate\" to \"High\" on the depersonalization (DP) scale. Notably 40.6% scored \"Low\" on personal accomplishment (PA) scale. Conclusion: High level of EE, DP and lower PAs were seen among two groups of health care providers in the ICUs.



D. K. Daphnee, S. Bhuvaneshwari

Critical care 24 × 7: But, why is critical nutrition interrupted?

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:5] [Pages No:144 - 148]

Keywords: Critical care, enteral nutrition, interruption of feeds, malnutrition

   DOI: 10.4103/0972-5229.128704  |  Open Access |  How to cite  | 


Background and Aims: Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN. Materials and Methods: Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others. Results: Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to \"procedures inside CCU\". Conclusion: Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.



S. N. Myatra, D. P. Samaddar

Guidelines for prevention of hospital acquired infections

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:15] [Pages No:149 - 163]

Keywords: Hospital Acquired Infection prevention, Standard Precautions, Burns, Monitoring Surveillance, Antibiotic Stewardship

   DOI: 10.4103/0972-5229.128705  |  Open Access |  How to cite  | 


These guidelines, written for clinicians, contains evidence-based recommendations for the prevention of hospital acquired infections Hospital acquired infections are a major cause of mortality and morbidity and provide challenge to clinicians. Measures of infection control include identifying patients at risk of nosocomial infections, observing hand hygiene, following standard precautions to reduce transmission and strategies to reduce VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be emphasized upon. Infection prevention in special subsets of patients - burns patients, include identifying sources of organism, identification of organisms, isolation if required, antibiotic prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus, early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher risk of opportunistic infections. The post tranplant timetable is divided into three time periods for determining risk of infections. Room ventilation, cleaning and decontamination, protective clothing with care regarding food requires special consideration. Monitoring and Surveillance are prioritized depending upon the needs. Designated infection control teams should supervise the process and help in collection and compilation of data. Antibiotic Stewardship Recommendations include constituting a team, close coordination between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of information technology among other measure. The recommendations in these guidelines are intended to support, and not replace, good clinical judgment. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments.



Juhi Chandwani, Sandeep Kantor, Kalpana Sarma, Maher J. Albahrani

Wernicke′s encephalopathy following hyperemesis gravidarum

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:3] [Pages No:164 - 166]

Keywords: Central pontine myelinolysis, hyperemesis gravidarum, Wernicke′s encephalopathy

   DOI: 10.4103/0972-5229.128706  |  Open Access |  How to cite  | 


Wernicke′s encephalopathy (WE) is a potentially reversible yet serious neurological manifestation caused by vitamin B 1 (thiamine) deficiency. It is commonly associated with heavy alcohol consumption. Other clinical associations are with hyperemesis gravidarum (HG), starvation, and prolonged intravenous feeding. Most patients present with the triad of ocular signs, ataxia, and confusion. It can be associated with life-threatening complication like central pontine myelinolysis (CPM). We report two cases of WE following HG, with two different outcomes.



Latif Duran, Servet Kayhan, Celal Kati, Hizir Ufuk Akdemir, Kemal Balci, Yucel Yavuz

Cerebral fat embolism syndrome after long bone fracture due to gunshot injury

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:3] [Pages No:167 - 169]

Keywords: Cerebral fat embolism, diffusion weighted magnetic resonance imaging, starfield pattern

   DOI: 10.4103/0972-5229.128707  |  Open Access |  How to cite  | 


Cerebral fat embolism syndrome is a lethal complication of long-bone fractures and clinically manifasted with respiratory distress, altered mental status, and petechial rash. We presented a 20-year-old male admitted with gun-shot wounds to his left leg. Twenty-four hours after the event, he had generalized tonic clonic seizures, decorticate posture and a Glascow Coma Scale of seven with localization of painful stimuli. Subsequent magnetic resonance imaging of the brain showed a star-field pattern defining multiple lesions of restricted diffusion. On a 4-week follow-up, he had returned to normal neurological function. Despite the severity of the neurological condition upon initial presentation, the case cerebral fat embolism illustrates that, cerebral dysfunction associated with cerebral fat embolism illustrates reversible.



Narat Srivali, Patompong Ungprasert, Wonngarm Kittanamongkolchai, Nischala Ammannagari

Lemierre′s syndrome: An often missed life-threatening infection

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:3] [Pages No:170 - 172]

Keywords: Anaerobic infection, fusobacterium, Lemierre′s syndrome, postanginal sepsis

   DOI: 10.4103/0972-5229.128708  |  Open Access |  How to cite  | 


Lemierre′s syndrome is an uncommon, but fatal infection of the internal jugular vein (IJV) that is usually caused by Fusobacteirum necrophorum although a wide range of bacteria has been reported as causative agents. Typical symptoms include fever, sore throat, neck swelling, pulmonary symptoms and arthralgia; however, the diagnosis of this infection is frequently overlooked as initial manifestation might be subtle and non-specific. Definite diagnosis requires positive blood culture and radiological evidence of thrombus in the IJV. We describe a case of a patient with Lemierre′s syndrome who was initially misdiagnosed with viral upper respiratory tract infection. High index of suspicion is pivotal to the diagnosis of this infection and Lemierre′s syndrome should always be considered as a potential cause of sepsis in an otherwise healthy patient.



Ashish Garg, Soutik Panda

Severe suicidal digoxin and propranolol toxicity with insulin overdose

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:3] [Pages No:173 - 175]

Keywords: Digoxin toxicity, hemoperfusion, propranolol

   DOI: 10.4103/0972-5229.128709  |  Open Access |  How to cite  | 


We present a case of a 32-year-old male doctor, with type I diabetes mellitus on daily insulin therapy, who allegedly consumed large doses of digoxin and propranolol along with simultaneous administration of large dose of insulin with suicidal intent. Initial investigations revealed serum digoxin levels of 7.5 ng/ml, serum insulin 500 μIU/ml, and serum C-peptide 0.43 ng/ml. He was managed with charcoal-based hemoperfusion for digoxin overdose along with injection glucagon for propranolol overdose. His blood sugar levels were maintained with continuous infusion of 20% dextrose till the patient was allowed to take oral diet. Significant clinical improvement was noticed with this therapy which was evident by progressively declining serum digoxin levels, normalization of pulse rate, and adequate blood glucose levels. Finally, with a good hemodynamic profile and a serum digoxin level well within normal limits, he was discharged following consultation with a psychiatrist.



Priyanka Chaudhry, Deborah I. Friedman, Wengui Yu

Unilateral pupillary mydriasis from nebulized ipratropium bromide: A false sign of brain herniation in the intensive care unit

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:2] [Pages No:176 - 177]

Keywords: Anisocoria, hemiparesis, ipratropium bromide, mydriasis, uncal herniation

   DOI: 10.4103/0972-5229.128710  |  Open Access |  How to cite  | 


Although there are many causes of anisocoria in the intensive care setting, the development of unilateral mydriasis in patients with intracranial hemorrhage or tumor is a neurological emergency, as it may herald the onset of uncal herniation. We describe two patients with a hemiparesis from neurosurgical disorder who subsequently developed a fixed and dilated pupil. The pupillary abnormality was caused by nebulized ipratropium bromide in both cases, and resolved when the medication was discontinued. Nebulized ipratropium may leak from the mask into ipsilateral eye and cause mydriasis in patients with facial weakness. This benign cause of anisocoria in the intensive care setting is distinguished from uncal herniation by the laterality of neurologic findings, and lack of mental status change, ptosis, and extraocular movement impairment.



Deepak Hanumanthaiah, Kumar Ramanathan

Olanzepine-induced neuroleptic malignant syndrome in a case of multiple sclerosis

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:3] [Pages No:178 - 180]

Keywords: Multiple sclerosis, neurolept malignant syndrome, olanzepine

   DOI: 10.4103/0972-5229.128711  |  Open Access |  How to cite  | 


Suspicion of neuroleptic malignant syndrome (NMS) is a frequent cause of emergent psychiatric consultation. Despite early recognition, NMS has remained a syndrome that causes high rates of morbidity and mortality. A 25-year-old male with multiple sclerosis presented to the accident and emergency department and E with ataxia. He was started on steroids. On the third day, he became tearful and anxious. A diagnosis of multiple sclerosis-induced psychosis was made and he was started on olanzepine 2.5 mg BD. On the sixth day the patient was tachypneic and had tachycardia. Temperature recorded in the axilla was 45°C. Patient was intubated and electively ventilated. A diagnosis of NMS was made and treated accordingly. This case report highlights the importance of recognizing and treating NMS in a patient on anti-psychotics.



Buddhika Widyaratna Peiris Habaragamuwa, Palitha Dissanayaka

N-acetylcystein in dengue associated severe hepatitis

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:2] [Pages No:181 - 182]

Keywords: Dengue hepatitis, Dengue fever, N-acetylcystein, severe hepatitis

   DOI: 10.4103/0972-5229.128712  |  Open Access |  How to cite  | 


Although, N-acetylcystein (NAC) has shown benefit in non-acetaminophen related liver failure, it was not well studies in dengue associated severe hepatitis. We report a case of dengue hemorrhagic fever associated severe hepatitis (encephalopathy grade 2-drowsy and intermittent disorientation) treated with NAC resulted in good outcome without hepatic transplantation.



S. Manimala Rao

Correlation of clinical and laboratory parameters in dengue fever patients and its usefulness as bedside markers

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:2] [Pages No:183 - 184]

   DOI: 10.4103/0972-5229.128713  |  Open Access |  How to cite  | 



Mathew Joseph, Ranjith K. Moorthy, Bijesh R. Nair

Bilateral pupillary dilatation with normal intracranial pressure

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:2] [Pages No:184 - 185]

   DOI: 10.4103/0972-5229.128714  |  Open Access |  How to cite  | 



Rishya Manikam, Arbid Khamis

Snakebite and severe hypertension: Looking for the Holy Grail

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:1] [Pages No:186 - 186]

   DOI: 10.4103/0972-5229.128715  |  Open Access |  How to cite  | 



Martina Stichlberger, Wolfgang Lederer

All that seems sepsis is not sepsis: However, is this case report really a case of catastrophic antiphospholipid syndrome?

[Year:2014] [Month:March] [Volume:18] [Number:3] [Pages:1] [Pages No:187 - 187]

   DOI: 10.4103/0972-5229.128716  |  Open Access |  How to cite  | 


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