Indian Journal of Critical Care Medicine

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2014 | May | Volume 18 | Issue 5

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Ashu Mathai

Benchmarking critical care processes: Reaching standards of excellence!

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:265 - 266]

   DOI: 10.4103/0972-5229.132462  |  Open Access |  How to cite  | 



Translating intentions to prescriptions: Mind the gap!

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:267 - 268]

   DOI: 10.4103/0972-5229.132463  |  Open Access |  How to cite  | 



Raj Kumar Mani, John Victor Peter

Association between glycemic variability and mortality: How robust is the evidence?

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:269 - 270]

   DOI: 10.4103/0972-5229.132464  |  Open Access |  How to cite  | 



Dexmedetomidine: Toward a paradigm shift in ICU sedation

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:271 - 272]

   DOI: 10.4103/0972-5229.132465  |  Open Access |  How to cite  | 



Pandurang C. Tekawade, Shruti S. Nath, Sharad S. Pachpute, Sanjay S. Saverkar, Rupali A. Bhise, Aarti C. Chavan, Sholly J. Varghese, Vidya U. Kantak, Rohini V. Kshirsagar, Vaishali A. Neve, Samona O. D′souza

A prolonged observational study of tracheal tube displacements: Benchmarking an incidence <0.5-1% in a medical-surgical adult intensive care unit

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:5] [Pages No:273 - 277]

Keywords: Airway accidents, endotracheal tube, tracheostomy tube, unplanned extubation

   DOI: 10.4103/0972-5229.132466  |  Open Access |  How to cite  | 


Background and Aims: Tracheal tubes are commonly used in intensive care unit (ICU) and lead to complications like displacements. The primary aim of the study was to evaluate if the rate of tracheal tube displacement benchmarked at <1% per patient and <0.5% per tracheal tube day, could be sustained over a prolonged period. The secondary aim was to document the patterns of all forms airway accident and to evaluate their consequences. Subjects and Methods: This was a prospective observational study of Intubated and ventilated patients in a General Medical-Surgical Adult ICU. The incidence of accidental extubation, self extubation, partial displacement and blockages of tracheal tubes were recorded. Results: The overall tracheal tube displacement rate was 61/10,112 (0.6%) per patient and 61/28,464 (0.22%) per tracheal tube day. There were 30 additional incidents of blockage, kinking or biting of the tracheal tube. Physiological consequences-69 were mild, 10 moderate, 12 major and one death. Of the 91 accidents, 30 were partly and 30 were completely preventable. 76 incidents involved an endotracheal tube (54 displaced, 12 blocked and 10 bitten-kinked) and 15 a tracheostomy tube (seven displaced and eight blocked). Accidents were more common in medical than surgical patients (medical = 48, cardiac surgical = 17 and other surgical/trauma = 26). Conclusion: Tracheal tube displacement rate in a mixed medical-surgical adult ICU was maintained below the pre-set benchmark of <1% per patient and <0.5% per intubated day over nearly a decade.



Rohan P. Christian, Devang A. Rana, Supriya D. Malhotra, Varsha J. Patel

Evaluation of rationality in prescribing, adherence to treatment guidelines, and direct cost of treatment in intensive cardiac care unit: A prospective observational study

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:3] [Pages No:278 - 280]

Keywords: Acute coronary syndrome, direct treatment cost, drug utilization, intensive cardiac care unit

   DOI: 10.4103/0972-5229.132482  |  Open Access |  How to cite  | 


Background: Cardiovascular diseases (CVDs) remain the most common cause of sudden death. Hence, appropriate drug therapy in intensive cardiac care unit (ICCU) is crucial in managing cardiovascular emergencies and to decrease morbidity and mortality. Objective: To evaluate prescribing pattern of drugs and direct cost of therapy in patients admitted in ICCU. Materials and Methods: Patients admitted in ICCU of a tertiary care teaching hospital were enrolled. Demographic data, clinical history, and complete drug therapy received during their stay in ICCU were noted. Data were analyzed for drug utilization pattern and direct cost of treatment calculated using patient′s hospital and pharmacy bills. Rationality of therapy was evaluated based on American College of Cardiology/American Heart Association (ACC/AHA) guidelines. Result: Data of 170 patients were collected over 2 months. Mean age of patients was 54.67 ± 13.42 years. Male to female ratio was 2.33:1. Most common comorbid condition was hypertension 76 (44.7%). Most common diagnosis was acute coronary syndrome (ACS) 49.4%. Mean stay in ICCU was 4.42 ± 1.9 days. Mean number of drugs prescribed per patient was 11.43 ± 2.85. Antiplatelet drugs were the most frequently prescribed drug group (86.5%). Mean cost of pharmacotherapy per patient was `2701.24 ± 3111.94. Mean direct cost of treatment per patient was ₹0564.74 ± 14968.70. Parenteral drugs constituted 42% of total drugs and 90% of total cost of pharmacotherapy. Cost of pharmacotherapy was positively correlated with number of drugs (P = 0.000) and duration of stay (P = 0.027). Conclusion: Antiplatelet drugs were the most frequently prescribed drug group. Mean number of drugs per encounter were high, which contributed to the higher cost of pharmacotherapy. ACC/AHA guidelines were followed in majority of the cases.



Mahuya Bhattacharya

Glycemic variability and outcome in critically ill

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:6] [Pages No:285 - 290]

Keywords: Critically ill, glycemic lability index, glycemic variability, hypoglycemia, intensive care unit mortality

   DOI: 10.4103/0972-5229.132484  |  Open Access |  How to cite  | 


Background: Acute hyperglycemia, hypoglycemia and glycemic variability (GV) have been found to be the three principal domains of glycemic control, which can adversely affect patient outcome. GV may be the confounding factor in tight glycemic control trials in surgical and medical patient. Objective: This study was conducted to establish if there was any relationship between GV and intensive care unit (ICU) mortality in the Indian context. Study Design: A retrospective review of a large cohort of prospectively collected database. Setting: Adult Medical/Surgical/Trauma/Neuro ICU of a tertiary care hospital. Patient Population: All patients who had four or more blood glucose measured during the ICU stay. Outcome: ICU mortality. Result: 2208 patients with a total of 11,335 blood glucose values were analyzed. GV measured by the standard deviation (SD) of mean blood glucose and glycemic lability index (GLI), both were significantly (P < 0.001) associated with ICU mortality. This relationship was maintained (odds ratio (OR): 2.023, 95% confidence interval (CI): 1.483-2.758) even after excluding patients with hypoglycemia (<60 mg/dl). Patients with blood glucose values in the euglycemic range but highest SD had higher mortality (54%) compared to mortality (24%) in patients above the euglycemic range. Similarly patients with blood sugar values below the average for study cohort and high GLI, another marker of GV had higher mortality (OR: 5.62, CI: 3.865-8.198) than compared to patients in the hyperglycemic range, reflecting the importance of GV as a prognostic marker in patients with blood sugar in the euglycemic range. Conclusion: This study demonstrated that high glucose variability is associated with increased ICU mortality in a large heterogeneous cohort of ICU patients. This effect was particularly evident among patients in the euglycemic range.



Prerana N. Shah, Vaibhao Dongre, Vijay Patil, Sarla Pandya, Ashish Mungantiwar, Amol Choulwar

Comparison of post-operative ICU sedation between dexmedetomidine and propofol in Indian population

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:6] [Pages No:291 - 296]

Keywords: Dexmedetomidine, intensive care unit sedation, propofol

   DOI: 10.4103/0972-5229.132485  |  Open Access |  How to cite  | 


Context: Critically ill patients requiring mechanical ventilation frequently need sedatives and analgesics to facilitate their care. Dexmedetomidine, a short-acting alpha-2-agonist, possesses anxiolytic, anesthetic, hypnotic, and analgesic properties. Aims: The objective of this study was to evaluate the efficacy and safety of dexmedetomidine in comparison to propofol in the management of sedation for post-operative intensive care unit (ICU) patients, as a sedative agent. Settings and Design: Teaching hospital, A phase III, prospective, open, randomized and comparative. Materials and Methods: Thirty patients who were ambulatory and who required the post-operative mechanical ventilation or post-operative sedation were enrolled, in which 15 patients received Dexmedetomidine and remaining 15 patients received propofol. All these patients were treated for the period of 8 to 24 h. Statistical Analysis Used: Data were analyzed using Student′s t-test and Chi-square test. The value of P < 0.05 was considered as statistically significant. Results: Demographic data were comparable. Pulse rate, respiratory rate and blood pressure were comparable. Depth of sedation and extubation time were similar. To maintain analgesia throughout the study period, patients receiving propofol infusions required significantly more analgesics than patients receiving Dexmedetomidine. Conclusions: Dexmedetomidine appears to be a safe and acceptable ICU sedative agent when both the clinician′s and patient′s perspectives are considered.



Arti Muley, Chaitri Shah, Jitendra Lakhani, Mani Bapna, Jigar Mehta

To identify morbidity and mortality predictors in acute organophosphate poisoning

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:4] [Pages No:297 - 300]

Keywords: Acute organophosphorus poisoning, glasgow coma scale, morbidity, serum acetylcholinesterase, SpO 2, time elapsed after exposure

   DOI: 10.4103/0972-5229.132488  |  Open Access |  How to cite  | 


Background: Organophosphorus poisoning remains an important cause of morbidity and mortality, but no definite parameters have been identified as predictors of outcome. Prediction of morbidity at presentation might help in decision making in places of limited resources like rural settings in developing countries. Materials and Methods: A total of 76 cases were included in this retrospective cohort study. Logged relative risk of requirement of mechanical ventilation and hospital stay >7 days was measured in patients with serum acetylcholinesterase (s. acetylcholinesterase) <1000 versus >1000, presenting in <2 h versus ≥ 2 h after exposure, with Glasgow Coma Scale (GCS) ≤12 versus >12 and in patients with SpO 2 <85% versus ≥85% at room air at presentation. Results: S. acetylcholinesterase <1000, time elapsed after ingestion to presentation ≥ 2 h and SpO 2 (at room air) at presentation <85% were found to have positive association with requirement of ventilation. GCS ≤ 12 had a significant association with both requirement of ventilation and hospital stay >7 days. Conclusion: S. acetylcholinesterase, SpO 2 at room air, GCS, and duration of exposure at presentation can be used to identify the requirement of special care in acute organophosphorus poisoning. This can aid in decision making regarding admission to intensive care unit and referral in the places with limited resources.



Gagan Brar

Bedside ultrasonography: Applications in critical care: Part I

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:9] [Pages No:301 - 309]

Keywords: Critical care, imaging, ultrasonography

   DOI: 10.4103/0972-5229.132492  |  Open Access |  How to cite  | 


There is increasing interest in the use of ultrasound to assess and guide the management of critically ill patients. The ability to carry out quick examinations by the bedside to answer specific clinical queries as well as repeatability are clear advantages in an acute care setting. In addition, delays associated with transfer of patients out of the Intensive Care Unit (ICU) and exposure to ionizing radiation may also be avoided. Ultrasonographic imaging looks set to evolve and complement clinical examination of acutely ill patients, offering quick answers by the bedside. In this two-part narrative review, we describe the applications of ultrasonography with a special focus on the management of the critically ill. Part I explores the utility of echocardiography in the ICU, with emphasis on its usefulness in the management of hemodynamically unstable patients. We also discuss lung ultrasonography - a vastly underutilized technology for several years, until intensivists began to realize its usefulness, and obvious advantages over chest radiography. Ultrasonography is rapidly emerging as an important tool in the hands of intensive care physicians.



Arvind Baronia

Current concepts in combination antibiotic therapy for critically ill patients

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:5] [Pages No:310 - 314]

Keywords: Carbapenem-resistant enterobacteriaceae, combination antibiotic therapy, Klebsiella pneumoniae carbapenemase, sepsis

   DOI: 10.4103/0972-5229.132495  |  Open Access |  How to cite  | 


Widespread emergence of multidrug resistant (MDR) bacterial pathogens is a problem of global dimension. MDR infections are difficult to treat and frequently associated with high mortality. More than one antibiotic is commonly used to treat such infections, but scientific evidence does not favor use of combination therapy in most cases. However, there are certain subgroups where combination therapy may be beneficial, e.g. sepsis due to carbapenem-resistant Enterobacteriaceae (CRE), bacteremic pneumococcal pneumonia, and patients with multiple organ failure. Well-designed prospective studies are needed to clearly define the role of combination therapy in these subgroups.



Annil Mahajan, Vivek Mahajan, Vishal R. Tandon, Vijay Khajuria, Zahid Gillani, Vijant Chandail

Fatal adverse drug reactions: Experience of adverse drug reactions in a tertiary care teaching hospital of North India - A case series

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:5] [Pages No:315 - 319]

Keywords: Adverse drug reactions, drug safety, fatal ADR, mortality

   DOI: 10.4103/0972-5229.132499  |  Open Access |  How to cite  | 


Medical burden of fatal adverse drug reactions (FADRs) is significant. The epidemiological data on FADR do exist from the western world, but there is scanty from India. We hereby report a case series of FADRs recorded in a 2 years period. Point prevalence of FADRs was 0.223%. Point prevalence of all cause death in the hospital was 1.20%. The drugs causing FADRs were injection bupivacaine, amphotericin B, directly observed treatment short-course Category-1, injection streptokinase, and tablet ferrous sulfate. All these FADR were labeled as possible expect one case as probable. All FADR were labeled as type A. In three out of five the central nervous system was involved, while the hepatic system and multiorgan failure accounted for one case each. Two cases each were acute and subacute, while one was latent in nature. Reporting of FADRs shall go a long way in patient safety.



Alka Chandra, Amrendra Pathak, Anu Kapur, Neha Russia, Nikhil Bhasin

Urinothorax: A rare cause of severe respiratory distress

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:3] [Pages No:320 - 322]

Keywords: Percutaneous nephrolithotomy, pleural effusion, urinothorax

   DOI: 10.4103/0972-5229.132501  |  Open Access |  How to cite  | 


A case of massive right pleural effusion in a postoperative patient of percutaneous nephrolithotomy leading to severe respiratory distress is reported. A high degree of clinical suspicion and prompt intervention by insertion of an intercostal drainage tube prevented the patient from going in to respiratory failure. The development of arrhythmias confused the picture increasing the morbidity of the patient. However, the patient was managed in an intensive care unit with intercostal chest tube insertion and antiarrhythmic agents. After correction of the specific cause of the effusion the intercostal tube was removed on the 4 th day without further recurrence of the effusion.



Ankur Gupta, S.K. Nagrani, Sanjay Raina, Shakti Jain

Invasive pulmonary aspergillosis in an immunocompetent patient with severe dengue fever

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:3] [Pages No:323 - 325]

Keywords: Dengue fever, fungal pneumonia, invasive pulmonary aspergillosis

   DOI: 10.4103/0972-5229.132505  |  Open Access |  How to cite  | 


We report a case of a 65-year-old female diagnosed with sever dengue fever. She started showing recovery from dengue fever with medical management. On day 6 of admission, she had leukocytosis, altered mental sensorium, and hemoptysis. Chest tomography showed air space consolidation with multiple nodules in the left upper and middle lobe sputum and bronchoalveolar lavage cultures were positive for Aspergillus flavus. The patient showed improvement with voriconazole and therapy was continued for 6 weeks.



Subodh Banzal

Shock: A possible presenting manifestation of autoimmune polyendocrine syndrome type II

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:326 - 327]

Keywords: Addison′s disease, hypogonadism, Schmidt syndrome

   DOI: 10.4103/0972-5229.132507  |  Open Access |  How to cite  | 


Autoimmune polyendocrine syndrome Type II (APS II), also known as polyglandular autoimmune syndrome Type II or Schmidt syndrome, is constellations of multiple endocrine gland insufficiencies. It is a rare, but most common of the immunoendocrinopathy syndrome. It is characterized by the obligatory occurrence of autoimmune Addison′s disease in combination with thyroid autoimmune diseases and/or Type I diabetes, hypogonadism, hypophysitis, myasthenia gravis, vitiligo, alopecia, pernicious anemia, and celiac disease. Here, we report a case of 38-year-old female patient presented with shock, further diagnosed to have APS II.



Dnyaneshwar P. Mutkule, Pradeep M. Venkategowda, Kranthi Mahendrakar

Glyphosate surfactant herbicide poisoning and management

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:3] [Pages No:328 - 330]

Keywords: Gastric lavage, glyphosate, intravenous fat emulsion, poisoning, surfactant herbicide

   DOI: 10.4103/0972-5229.132508  |  Open Access |  How to cite  | 


Glyphosate is a widely used herbicide in agriculture, forestry, industrial weed control and aquatic environments. Glyphosate potential as herbicide was first reported in 1971. It is a non-selective herbicide. It can cause a wide range of clinical manifestations in human beings like skin and throat irritation to hypotension, oliguria and death. We are reporting a case of a 35-year-old male patient who was admitted to our tertiary care hospital following intentional ingestion of around 200 ml of herbicide containing glyphosate. Initially, gastric lavage done and the patient was managed with intubation and mechanical ventilation, noradrenaline and vasopressin infusion, continuous veno-venous hemodiafiltration and intravenous (IV) lipid emulsion (20% intralipid 100 ml), patient was successfully treated and discharged home. This case report emphasizes on timely systemic supportive measure as a sole method of treatment since this poison has no known specific antidote and the use of IV lipid emulsion for a successful outcome.



Gentle Sunder Shrestha, Roshana Amatya, Gopal Sedain, Pramesh Shrestha, Subhash Acharya, Sandip Bhandari, Diptesh Aryal, Bikram Gajurel, Moda Marhatta

Apnea testing with continuous positive airway pressure for the diagnosis of brain death in a patient with poor baseline oxygenation status

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:3] [Pages No:331 - 333]

Keywords: Apnea test, brain death, poor baseline oxygenation

   DOI: 10.4103/0972-5229.132510  |  Open Access |  How to cite  | 


Apnea testing is a key component in the clinical diagnosis of brain death. Patients with poor baseline oxygenation may not tolerate the standard 8-10 min apnea testing with oxygen insufflation through tracheal tube. No studies have assessed the safety and feasibility of other methods of oxygenation during apnea testing in these types of patients. Here, we safely performed apnea testing in a patient with baseline PaO 2 of 99.1 mm Hg at 100% oxygen. We used continuous positive airway pressure (CPAP) of 10 cm of H 2 O and 100% oxygen at the flow rate of 12 L/min using the circle system of anesthesia machine. After 10 min of apnea testing, PaO 2 decreased to 75.7 mm Hg. There was a significant rise in PaCO 2 and fall in pH, but without hemodynamic instability, arrhythmias, or desaturation. Thus, the apnea test was declared positive. CPAP can be a valuable, feasible and safe means of oxygenation during apnea testing in patients with poor baseline oxygenation, thus avoiding the need for ancillary tests.



M. Kumar, V. Poovazhagi, S. Anbalagan, N. Devasena

Rhino-orbito-cerebral mucormycosis in a child with diabetic ketoacidosis

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:334 - 335]

   DOI: 10.4103/0972-5229.132512  |  Open Access |  How to cite  | 



Curious association between Plasmodium vivax malaria and nontraumatic acute subdural hematoma

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:335 - 336]

   DOI: 10.4103/0972-5229.132513  |  Open Access |  How to cite  | 



Himmatrao Bawaskar

Burnout in the intensive care unit: Beware of turning to ash!

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:336 - 337]

   DOI: 10.4103/0972-5229.132514  |  Open Access |  How to cite  | 



Beuy Joob

2009 pandemic influenza A (H1N1) infection in Saurashtra region, India

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:2] [Pages No:337 - 338]

   DOI: 10.4103/0972-5229.132516  |  Open Access |  How to cite  | 


Authors' reply

Rajesh K. Chudasama, Pramod B. Verma, Chikitsa D. Amin, Bharat Gohel, Dinkar Savariya, Rakesh Ninama

Author′s Reply

[Year:2014] [Month:May] [Volume:18] [Number:5] [Pages:1] [Pages No:338 - 338]

   DOI: 10.5005/ijccm-18-5-338  |  Open Access |  How to cite  | 


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