Indian Journal of Critical Care Medicine

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2015 | October | Volume 19 | Issue 10

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Alladi Mohan, J. Harikrishna

Noninvasive ventilation as first-line treatment for acute respiratory distress syndrome: The time is not ripe yet!

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:3] [Pages No:571 - 573]

   DOI: 10.4103/0972-5229.167031  |  Open Access |  How to cite  | 



Akash Pandhare

Bacterial resistance in India: Studying plasma antibiotic levels

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:2] [Pages No:574 - 575]

   DOI: 10.4103/0972-5229.167032  |  Open Access |  How to cite  | 



Hamidreza Jamaati, Arvin Najafi, Farima Kahe, Zahra Karimi, Zarghamhossein Ahmadi, Mohammadreza Bolursaz, Mohammadreza Masjedi, Aliakbar Velayati, Seied Hashemian

Assessment of the EuroSCORE risk scoring system for patients undergoing coronary artery bypass graft surgery in a group of Iranian patients

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:4] [Pages No:576 - 579]

Keywords: Coronary artery bypass graft, European System for Cardiac Operative Risk Evaluation, mortality, risk stratification, scoring system, validity

   DOI: 10.4103/0972-5229.167033  |  Open Access |  How to cite  | 


Background and Aims: Previous studies around the world indicated validity and accuracy of European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk scoring system we evaluated the EuroSCORE risk scoring system for patients undergoing coronary artery bypass graft (CABG) surgery in a group of Iranian patients. Materials and Methods: In this cohort 2220 patients more than 18 years, who were performed CABG surgery in Massih Daneshvari Hospital, from January 2004 to March 2010 were recruited. Predicted mortality risk scores were calculated using logistic EuroSCORE and Acute Physiology and Chronic Health Evaluation II (APACHE II) and compared with observed mortality. Calibration was measured by the Hosmer-Lemeshow (HL) test and discrimination by using the receiver operating characteristic (ROC) curve area. Results: Of the 2220 patients, in hospital deaths occurred in 270 patients (mortality rate of 12.2%). The accuracy of mortality prediction in the logistic EuroSCORE and APACHE II model was 89.1%; in the local EuroSCORE (logistic) was 91.89%; and in the local EuroSCORE support vector machines (SVM) was 98.6%. The area under curve for ROC curve, was 0.724 (95% confidence interval [CI]: 0.57-0.88) for logistic EuroSCORE; 0.836 (95% CI: 0.731-0.942) for local EuroSCORE (logistic); 0.978 (95% CI: 0.937-1) for Local EuroSCORE (SVM); and 0.832 (95% CI: 0.723-0.941) for APACHE II model. The HL test showed good calibration for the local EuroSCORE (SVM), APACHE II model and local EuroSCORE (logistic) (P = 0.823, P = 0.748 and P = 0.06 respectively); but there was a significant difference between expected and observed mortality according to EuroSCORE model (P = 0.033). Conclusion: We detected logistic EuroSCORE risk model is not applicable on Iranian patients undergoing CABG surgery.



John Victor Peter, George John, Petra Graham, Shoma Rao, Michael Pinsky

Patterns of central venous oxygen saturation, lactate and veno-arterial CO 2 difference in patients with septic shock

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:7] [Pages No:580 - 586]

Keywords: Metabolic, microcirculation, outcome, resuscitation, septic

   DOI: 10.4103/0972-5229.167035  |  Open Access |  How to cite  | 


Background and Aims: Tissue hypoperfusion is reflected by metabolic parameters such as lactate, central venous oxygen saturation (ScvO 2) and the veno-arterial CO 2 (vaCO 2) difference. We studied the relation of these parameters over time and with outcome in patients with severe septic shock. Materials and Methods: In this single-center, prospective observational cohort study, adult patients (≥18 years) with circulatory shock were included. Echocardiography and simultaneous arterial and venous blood gases were done on enrolment (0 h) and at 24, 48 and 72 h. The partial pressure of CO 2, lactate and ScvO 2 were recorded from the central venous blood samples. The vaCO 2 was calculated as the difference in CO 2 between paired venous and arterial blood gas samples. Results: Of the 104 patients with circulatory shock, 79 patients (44 males) with septic shock aged 49.8 (standard deviation ± 14.6) years and with sequential organ failure assessment (SOFA) score of 11.0 ± 3.4 were included. 71 patients (89.9%) were ventilated (11.4 ± 12.3 ventilator-free days). The duration of hospitalization was 16.6 ± 12.8 days and hospital mortality 50.6%. Lactate significantly decreased over time with a greater decrement in survivors than nonsurvivors (−0.35 vs. −0.10, P < 0.001). For every l/min increase in cardiac output, vaCO 2 decreased by 0.34 mmHg (P = 0.006). There was no association between ScvO 2 and mortality (P = 0.930). 0 h SOFA and vaCO 2 ≤6 mmHg were strongly associated (P = 0.005, P = 0.018, respectively) with higher odds of mortality. However, this association was evident only in those with ScvO 2 >70% and not in ScvO 2 ≤70%. Conclusion: In septic shock, vaCO 2 ≤6 mmHg is independently associated with mortality, particularly in those with normalized ScvO 2 consistent with metabolic microcirculatory abnormalities in these patients.



B. Abhilash, Chakra Tripathi, Anoop Gogia, Girish Meshram, Manu Kumar, B. Suraj

Pharmacokinetic/pharmacodynamic profiling of imipenem in patients admitted to an intensive care unit in India: A nonrandomized, cross-sectional, analytical, open-labeled study

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:6] [Pages No:587 - 592]

Keywords: Antibiotic-resistance, critically ill patients, imipenem, intensive care unit, pharmacokinetics/pharmacodynamics

   DOI: 10.4103/0972-5229.167036  |  Open Access |  How to cite  | 


Background and Aim: Widespread use of imipenem in intensive care units (ICUs) in India has led to the development of numerous carbapenemase-producing strains of pathogens. The altered pathophysiological state in critically ill patients could lead to subtherapeutic antibiotic levels. Hence, the aim of this study was to investigate the variability in the pharmacokinetic and pharmacodynamic profile of imipenem in critically ill patients admitted to an ICU in India. Materials and Methods: Plasma concentration of imipenem was determined in critically ill patients using high performance liquid chromatography, at different time points, by grouping them according to their locus of infection. The elimination half-life (t½) and volume of distribution (V d) values were also computed. The patients with imipenem trough concentration values below the minimum inhibitory concentration (MIC) and 5 times the MIC for the isolated pathogen were determined. Results: The difference in the plasma imipenem concentration between the gastrointestinal and the nongastrointestinal groups was significant at 2 h (P = 0.015) following drug dosing; while the difference was significant between the skin/cellulitis and nonskin/cellulitus groups at 2 h (P = 0.008), after drug dosing. The imipenem levels were above the MIC and 5 times the MIC for the isolated organism in 96.67% and 50% of the patients, respectively. Conclusions: The pharmacokinetic profile of imipenem does not vary according to the locus of an infection in critically ill patients. Imipenem, 3 g/day intermittent dosing, maintains a plasma concentration which is adequate to treat most infections encountered in patients admitted to an ICU. However, a change in the dosing regimen is suggested for patients infected with organisms having MIC values above 4 mg/L.



Soumik Chaudhuri, Inderpaul Sehgal

A study on the role of noninvasive ventilation in mild-to-moderate acute respiratory distress syndrome

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:7] [Pages No:593 - 599]

Keywords: Acute hypoxemic respiratory failure, acute lung injury, acute respiratory distress syndrome, mechanical ventilation, noninvasive ventilation

   DOI: 10.4103/0972-5229.167037  |  Open Access |  How to cite  | 


Aim: There is sparse data on the role of noninvasive ventilation (NIV) in acute respiratory distress syndrome (ARDS) from India. Herein, we report our experience with the use of NIV in mild to moderate ARDS. Materials and Methods: This was a prospective observational study involving consecutive subjects of ARDS treated with NIV using an oronasal mask. Patients were monitored clinically with serial arterial blood gas analysis. The success of NIV, duration of NIV use, Intensive Care Unit stay, hospital mortality, and improvement in clinical and blood gas parameters were assessed. The success of NIV was defined as prevention of endotracheal intubation. Results: A total of 41 subjects (27 women, mean age: 30.9 years) were included in the study. Tropical infections followed by abdominal sepsis were the most common causes of ARDS. The use of NIV was successful in 18 (44%) subjects, while 23 subjects required intubation. The median time to intubation was 3 h. Overall, 19 (46.3%) deaths were encountered, all in those requiring invasive ventilation. The mean duration of ventilation was significantly higher in the intubated patients (7.1 vs. 2.6 days, P = 0.004). Univariate analysis revealed a lack of improvement in PaO 2 /FiO 2 at 1 h and high baseline Acute Physiology and Chronic Health Evaluation II (APACHE II) as predictors of NIV failure. Conclusions: Use of NIV in mild to moderate ARDS helped in avoiding intubation in about 44% of the subjects. A baseline APACHE II score of >17 and a PaO 2 /FiO 2 ratio <150 at 1 h predicts NIV failure.



Jerome Rambaud, Isabelle Guellec, Julia Guilbert, Sylvain Renolleau

Venoarterial extracorporeal membrane oxygenation support for neonatal and pediatric refractory septic shock

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:6] [Pages No:600 - 605]

Keywords: Extracorporeal membrane oxygenation, neonatal, pediatric, refractory, septic shock

   DOI: 10.4103/0972-5229.167038  |  Open Access |  How to cite  | 


Objective: To report our institutional experience of veno-arterial extracorporeal membrane oxygenation (VA ECMO) in children with refractory septic shock. Materials and Methods: We retrospectively reviewed our ECMO database to identify patients who received VA ECMO for septic shock from January 2004 to June 2013 at our Pediatric Intensive Care Unit in Armand-Trousseau Hospital. We included all neonates and children up to the age of 18 years who received VA ECMO for septic shock. For each patient, we collected the pre-ECMO inotrope score, clinical circulatory and ventilatory parameters, infecting organism, ECMO duration and complications, and length of hospital stay. Main Results: The study included 14 neonates and 8 older children (the pediatric population, with a mean age of 30 months, range: 1-113 months). Survival was 64% among newborns and 50% among pediatric patients. Multiorgan failure or severity scores did not show any correlation with mortality (Pediatric Logistic Organ Dysfunction score, P = 0.94; the score for neonatal acute physiology-perinatal extension II, P = 0.34). In the pediatric population, the inotrope score was higher in the survivor group (127.5 vs. 332.5, P = 0.07). Blood samples taken shortly before cannulation showed that pH (P = 0.27), lactate level (P = 0.33), PaO2/FiO2 ratio (P = 0.49), or oxygenation index (P = 0.35) showed no correlation to success or failure of ECMO. Conclusion: ECMO can be safely used to resuscitate and support children with refractory septic shock. We recommend that patients with oliguria whose lactate level has not decreased within 6 h of starting maximum drug therapy be transferred to an ECMO referral center.



Abhishek Biswas

Right heart failure in acute respiratory distress syndrome: An unappreciated albeit a potential target for intervention in the management of the disease

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:4] [Pages No:606 - 609]

Keywords: Acute cor pulmonale, acute respiratory distress syndrome, protective ventilation, pulmonary vascular dysfunction

   DOI: 10.4103/0972-5229.167039  |  Open Access |  How to cite  | 


Mortality from acute respiratory distress syndrome (ARDS) has gone down recently. In spite of this trend, the absolute numbers continue to be high even with improvements in ventilator strategies and a better understanding of fluid management with this disease. A possible reason for this could be an under-recognized involvement of the pulmonary vasculature and the right side of the heart in ARDS. The right heart is not designed to function under situations leading to acute elevations in afterload as seen in ARDS, and hence it decompensates. This brief review focuses on the magnitude of the problem, its detection in the intensive care unit, and recognizes the beneficial effect of prone-positioning on the pulmonary vasculature and right heart.



Anton A. Kasatkin, Aleksandr Urakov, Anna Nigmatullina

The dynamics of changing internal jugular veins diameter based on increasing head elevation angle

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:3] [Pages No:610 - 612]

Keywords: Internal jugular vein, intracranial pressure, ultrasound scanning

   DOI: 10.4103/0972-5229.167040  |  Open Access |  How to cite  | 


Context: Venous outflow from the cranial cavity occurs mainly through the internal jugular vein (IJV). The increase in venous outflow through IJV is possible by head elevation. IJV collapse may indicate the reduction of blood volume in the vein and show the head elevation effectiveness. Aims: The aim of this study is to examine the impact of head elevation on IJV size. Subjects and Methods: IJV ultrasound scanning in 31 healthy volunteers was carried after gradual head elevation at 15°, 30°, and 45°. Maximum and minimum IJV diameters were recorded. Mean ± standard deviation, median, range, and collapsibility index were calculated. Results: Thirty-one volunteers were involved (19 males), their average age was 37.0 ± 11.5 years. Increasing the head elevation angle by 15°, 30° and 45° resulted in a decrease in IJV diameter in the right and left sides in all patients. The occurrence of the vein walls collapse corresponds to the collapsibility index equal to 100%. The results showed that 100% collapsibility index was recorded in 6 patients (19%) at 15° head elevation, in 12 patients (39%) at 30°, in 11 patients (35%) at 45°. In two volunteers (6%), 100% collapsibility index was not recorded even at maximum 45° head elevation. Conclusions: Ultrasound IJV scanning during gradual head elevation together with the collapsibility index calculation could be useful guidance for the venous outflow assessment. In order to prove and extend the study findings, more research is needed.



Kanav Anand, Krishna Gulla, P.K. Pruthi

Continuous renal replacement therapy in children with severe sepsis and multiorgan dysfunction - A pilot study on timing of initiation

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:5] [Pages No:613 - 617]

Keywords: Humans, Intensive Care Units, multiple organ failure, pediatrics, renal replacement therapy, sepsis, treatment outcome

   DOI: 10.4103/0972-5229.167044  |  Open Access |  How to cite  | 


Objective: Scanty literature is available regarding continuous renal replacement therapy (CRRT) utility in severe sepsis with multiorgan dysfunction syndrome (MODS) from developing countries. Author unit′s experience in pediatric CRRT is described and outcome of early initiation of CRRT with sepsis and MODS is assessed. Materials and Methods: Children aged <16 years with sepsis and MODS who required CRRT from September 2010 to February 2015 were analyzed on demographic factors, timing of initiation of CRRT, mode of CRRT, effect of CRRT onhemodynamics, oxygenation parameters, and outcome. Results: Twenty-seven children required CRRT (male - 16). The median age was 11 years (range 1.1-16). Twenty-one had severe sepsis with MODS. Eighteen patients were given CRRT within 48 h of admission to Intensive Care Unit (ICU). Statistically significant improvement in the P/F ratio, decrement in plateau pressure and vasoactive-inotropic score were noted in survivor group compared to nonsurvivor group (P = 0.022, 0.00, and 0.03, respectively). There was no statistically significant difference in duration of ICU stay, fluid overload, CRRT duration, PRISM score at 12 and 24 h, percentage of decrease in inotrope score, plateau pressure, and percentage of increase in P/F ratio in relation to timing of CRRT initiation. However, the survival rate was 61.1% (11/18) who received CRRT within 48 h of ICU admission compared to 33.3% (3/9) who received after 48 h (P = 0.0001). Conclusion: Our study emphasizes the CRRT role in improving the oxygenation status and hemodynamics. Survival benefit may be expected in those children who receive CRRT early in the course of sepsis. However, multicenter RCTs are required to prove mortality benefit.



Gentle Sunder Shrestha, Subhash Acharya, Niraj Keyal, Hem Paneru, Pramesh Shrestha

Successful lumbar puncture with Taylor′s approach for the diagnostic workup of meningitis in a patient with Ankylosing spondylitis

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:3] [Pages No:618 - 620]

Keywords: Ankylosing spondylitis, difficult lumbar puncture, meningitis, Taylor′s approach

   DOI: 10.4103/0972-5229.167053  |  Open Access |  How to cite  | 


Meningitis and encephalitis are the neurological emergencies. As the clinical findings lack specificity, once suspected, cerebrospinal fluid (CSF) analysis should be performed and parenteral antimicrobials should be administered without delay. Lumbar puncture can be technically challenging in patients with ankylosing spondylitis due to ossification of ligaments and obliteration of interspinous spaces. Here, we present a case of ankylosing spondylitis where attempts for lumbar puncture by conventional approach failed. CSF sample was successfully obtained by Taylor′s approach.



Vikas Sikri, Alok Jain

A rare case of idiopathic cluster of differentiation 4 + T-cell lymphocytopenia presenting with disseminated tubercular infection

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:3] [Pages No:621 - 623]

Keywords: Cryptococcal meningitis, disseminated tuberculosis, idiopathic cluster of differentiation 4 + T-cell lymphocytopenia, immunodeficiency, opportunistic infections

   DOI: 10.4103/0972-5229.167054  |  Open Access |  How to cite  | 


Idiopathic cluster of differentiation 4 + (CD4 +) T-cell lymphocytopenia is a rare heterogeneous clinical syndrome characterized by low absolute CD4 counts on two different occasions without any evidence of other known cause of immunodeficiency including human immunodeficiency virus (HIV), infections or drugs associated with fall in CD4 + count. Also referred to as severe unexplained HIV seronegative immune suppression by the World Health Organization, it was first described by Centers for Disease Control in 1992 in patients with opportunistic infections who were negative for HIV but had low CD4 counts. Patients typically present with opportunistic infections, malignancies, or autoimmune disorders. There have been case reports on opportunistic infections such as cryptococcal meningitis or non-Mycobacterium tuberculosis infections in these patients. However, no case of disseminated M. tuberculosis has been reported as such in Indian literature. We present a case of disseminated tuberculosis with low CD4 counts without any evidence of HIV infection.



Syed Muzaffar

Correlation of measurement of optic nerve sheath diameter with ultrasound and magnetic resonance imaging

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:1] [Pages No:624 - 624]

   DOI: 10.4103/0972-5229.167055  |  Open Access |  How to cite  | 



Consent in cognitively intact quadriplegic patient: Is it different

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:1] [Pages No:625 - 625]

   DOI: 10.4103/0972-5229.167056  |  Open Access |  How to cite  | 



Arun Maheshwari, Monish Raut

Masseter spasm after muscle relaxant

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:1] [Pages No:626 - 626]

   DOI: 10.4103/0972-5229.167057  |  Open Access |  How to cite  | 



R. K. Mani

Retraction: Successful management of massive intraoperative pulmonary fat embolism with percutaneous cardiopulmonary support

[Year:2015] [Month:] [Volume:19] [Number:10] [Pages:1] [Pages No:627 - 627]

   DOI: 10.4103/0972-5229.167059  |  Open Access |  How to cite  | 


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