Indian Journal of Critical Care Medicine

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2015 | December | Volume 19 | Issue 12

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Integrative weaning index: New kid on the block!

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:2] [Pages No:701 - 702]

   DOI: 10.4103/0972-5229.171351  |  Open Access |  How to cite  | 



Ghada F. El-Baradey, Nagat S. El-Shmaa, Salwa A. Ganna

Can integrative weaning index be a routine predictor for weaning success?

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:5] [Pages No:703 - 707]

Keywords: Adult, integrative weaning index, ventilator weaning, weaning parameters, weaning protocol

   DOI: 10.4103/0972-5229.171352  |  Open Access |  How to cite  | 


Objective: To assess the effectiveness of integrative weaning index (IWI) as a predictor of weaning success. Materials and Methods: This is a prospective randomized controlled observer-blinded study and carried out on 120 patients of both sexes; patients who received mechanical ventilation for more than 24 h and met defined criteria for a weaning trial, underwent a 2-h spontaneous breathing trial with either IWI plus routine criteria of weaning (Group I n = 60) or routine criteria of weaning alone (control group) (Group C n = 60), in Group C the IWI was measured retrospective as it is not used in weaning decision. Those tolerated the trial would be immediately extubated. The primary outcome measure was the ability to maintain spontaneous, unassisted breathing for more than 48 h after extubation. Secondary outcome measures were the duration of mechanical ventilation, length of Intensive Care Unit (ICU) stay, and length of hospital stay. Results: The mean duration (hours) of mechanical ventilation and length of ICU stay (days) were significantly shorter in the Group I where the IWI was used (83.6 ± 34.3 vs. 97.49 ± 47.2 h, P = 0.002 and 5.5 ± 1.6 vs. 7.12 ± 2.3 days, P = 0.03, respectively). Weaning success rate was significantly higher in the Group I (53 vs. 34, P = 0.0001) while weaning failure rate was significantly lower in the Group I C (7 vs. 26, P = 0.0001). Conclusion: IWI is a strong predictor of both successful and failed weaning.



Bodin Khwannimit, Wachiraporn Koonrangsesomboon

Impact of positive fluid balance on mortality and length of stay in septic shock patients

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:6] [Pages No:708 - 713]

Keywords: Fluid, fluid balance, mortality, prognostic factor, septic shock

   DOI: 10.4103/0972-5229.171356  |  Open Access |  How to cite  | 


Background: Fluid management is important in critically patients. The aim of this study was to determine the relationship between fluid balance and adverse outcomes of septic shock. Methods: A retrospective study was conducted in the medical Intensive Care Unit (ICU) of a tertiary university hospital in Thailand, over a 7-year period. Results: A total of 1048 patients with an ICU mortality rate of 47% were enrolled. The median cumulative fluid intake at 24, 48, and 72 h from septic shock onset were 4.2, 7.7, and 10.5 L, respectively. Nonsurvivors had a significantly higher median cumulative fluid intake at 24, 48, and 72 h (4.6 vs. 3.9 L, 8.2 vs. 7.1 L, and 11.4 vs. 9.9 L, respectively, P < 0.001 for all). Nonsurvivors also had a significantly higher cumulative and mean fluid balance within 72 h (5.4 vs. 4.4 L and 2.8 vs. 1.6 L, P < 0.001 for both). In multivariate logistic regression analysis, mean fluid balance quartile within 72 h, was independently associated with an increase in ICU and hospital mortality. Quartile 3 and 4 have statistically significant increases in mortality compared with quartile 1 (odds ratio [95% confidence interval] 3.04 [1.9-4.48] and 4.16 [2.49-6.95] for ICU mortality and 2.75 [1.74-4.36] and 3.16 [1.87-5.35] for hospital mortality, respectively, P < 0.001 for all). In addition, the higher amount of mean fluid balance was associated with prolonged ICU stays. Conclusions: Positive fluid balance over 3 days is associated with increased ICU and hospital mortality along with prolonged ICU stays in septic shock patients.



Ibrahim Karaman, Orhan Koç, Ayşe Karaman, Derya Erdoõan, Yusuf Hakan Çavuşoõlu, Çaõatay Evrim Afşarlar, Engin Yilmaz, Ahmet Ertürk, Özlem Balci, Ismet Faruk Özgüner

Evaluation of 968 children with corrosive substance ingestion

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:5] [Pages No:714 - 718]

Keywords: Caustic ingestion, corrosive ingestion, esophageal stricture, esophagoscopy

   DOI: 10.4103/0972-5229.171377  |  Open Access |  How to cite  | 


Background and Aims: The aim of the study was to evaluate the etiology, treatment, and prognosis in children who had presented at our clinic with corrosive substance ingestion and comparison of our results with the literature. Materials and Methods: The patients were put on nil by mouth and broad-spectrum antibiotics were administered. Oral fluids were started for patients whose intraoral lesions resolved and who could swallow their saliva. Steroids were not given, a nasogastric catheter was not placed, and early endoscopy was not used. Results: A total of 968 children presented at our clinic for corrosive substance ingestion during the 22-year period. The stricture development rate was 13.5%. Alkali substance ingestion caused a stricture development rate of 23%. A total of 54 patients required 1-52 sessions (mean 15 ± 12) of dilatation. Conclusion: We do not perform early endoscopy, administer steroids, or place a nasogastric catheter at our clinic for patients who had ingested a corrosive substance. This approach has provided results similar to other series. We feel that determining the burn with early esophagoscopy when factors that prevent or decrease the development of corrosive strictures will be very important.



Jigeeshu V. Divatia, Harish Chaudhari, S. Janarthanan, Harish M. M, Siddique Suhail, Vijaya P. Patil

Agreement between inferior vena cava diameter measurements by subxiphoid versus transhepatic views

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:4] [Pages No:719 - 722]

Keywords: Fluid responsiveness, inferior vena cava collapsibility, inferior vena cava diameter, inferior vena cava distensibility, limits of agreement

   DOI: 10.4103/0972-5229.171390  |  Open Access |  How to cite  | 


Context: Correcting hypovolemia is extremely important. Central venous pressure measurement is often done to assess volume status. Measurement of inferior vena cava (IVC) is conventionally done in the subcostal view using ultrasonography. It may not be possible to obtain this view in all patients. Aims: We therefore evaluated the limits of agreement between the IVC diameter measurement and variation in subcostal and that by the lateral transhepatic view. Settings and Design: Prospective study in a tertiary care referral hospital intensive care unit. Subjects and Methods: After Institutional Ethics Committee approval and informed consent, we obtained 175 paired measurements of the IVC diameter and variation in both the views in adult mechanically ventilated patients. The measurements were carried out by experienced researchers. We then obtained the limits of agreement for minimum, maximum diameter, percentage variation of IVC in relation to respiration. Statistical Analysis Used: Bland-Altman′s limits of agreement to get precision and bias. Results: The limits of agreement were wide for minimum and maximum IVC diameter with variation of as much as 4 mm in both directions. However, the limits of agreement were much narrower when the percentage variation in relation to respiration was plotted on the Bland-Altman plot. Conclusions: We conclude that when it is not possible to obtain the subcostal view, it is possible to use the lateral transhepatic view. However, using the percentage variation in IVC size is likely to be more reliable than the absolute diameter alone. It is possible to use both views interchangeably.



Sarit Sharma, Shruti Sharma, R. S. Chhina

Chicken pox outbreak in the Intensive Care Unit of a tertiary care hospital: Lessons learnt the hard way

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:3] [Pages No:723 - 725]

Keywords: Chickenpox, herpes zoster, vaccination, varicella, varicella-zoster virus

   DOI: 10.4103/0972-5229.171397  |  Open Access |  How to cite  | 


Varicella-zoster virus (VZV) causes 2 clinically and epidemiologically distinct forms of diseases. Chickenpox (varicella) is the disease that results from primary infection with the VZV. Herpes zoster (HZ) results from the reactivation of VZV latently infecting the dorsal root ganglia. We are reporting an outbreak of varicella infection among the health care workers (HCWs) in the Intensive Care Unit (ICU) of a tertiary care hospital. We found transmission of varicella among eight HCWs of pulmonary ICU. They had a history of contact with a patient having HZ infection. Investigation of the outbreak was conducted as per guidelines. Better dissemination of information on disease transmission, isolation of infected patients inside the hospital, and adequate protection (including vaccination) for susceptible employees are important to prevent such outbreaks.



Shahla Siddiqui

Mortality profile across our Intensive Care Units: A 5-year database report from a Singapore restructured hospital

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:2] [Pages No:726 - 727]

Keywords: Acute Physiology and Chronic Health Evaluation II, Intensive Care Unit mortality, report

   DOI: 10.4103/0972-5229.171401  |  Open Access |  How to cite  | 


Intensive care remains an area of high acuity and high mortality across the globe. With a rapidly aging population, the disease burden requiring intensive care is growing. The cost of critical care also is rising with new technology becoming available rapidly. We present the all-cause mortality results of 5 years database established in a restructured, large public hospital in Singapore, looking at all three types of Intensive Care Units present in our hospital. These include medical, surgical, and coronary care units.



Abdolghader Pakniyat, Arash Yazdanbakhsh, Ghasem Moshar-mowahed, Fatimah Talebi

Hypovolemic shock following induced abortion and spontaneous heterotopic pregnancy

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:3] [Pages No:728 - 730]

Keywords: Abortion, heterotopic pregnancy, hypovolemic shock

   DOI: 10.4103/0972-5229.171407  |  Open Access |  How to cite  | 


Spontaneous heterotopic pregnancy is a rare clinical condition in which intrauterine and extrauterine pregnancies occur at the same time. It is rare, estimated to occur in 1 in 30,000 pregnancies. The case was a 38-year-old woman with spontaneously conceived heterotopic pregnancy. She was admitted to our center with hypovolemic shock. Focused assessment sonography for trauma examination in emergency department showed large amount of free fluid in peritoneal cavity. She was managed surgical laparotomy. Considering spontaneous pregnancies, physician should be aware of the possibility of heterotopic pregnancy in all reproductive age women, especially those with history of recent abortion. It can occur without any predisposing risk factors. Patients should be informed about possible side effects of nonprescription medicines, and also the health care centers must be safe peaceful environment for them without severe legal consequences.



Georgene Singh, Ari Manickam, Ramesh Chandra Rathod

Takotsubo cardiomyopathy in a patient with pituitary adenoma and secondary adrenal insufficiency

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:4] [Pages No:731 - 734]

Keywords: Pituitary adenoma, secondary adrenal insufficiency, takotsubos cardiomyopathy

   DOI: 10.4103/0972-5229.171410  |  Open Access |  How to cite  | 


We describe a case of Takotsubo cardiomyopathy in a case of pituitary macroadenoma in acute adrenal crisis. A 48-year-old man presented with acute onset altered sensorium, vomiting, and gasping. On admission, he was unresponsive and hemodynamically unstable. He was intubated and ventilated and resuscitated with fluids and inotropes. The biochemical evaluation revealed hyponatremia, hyperkalemia, and hypocortisolism. Hyponatremia was corrected with 3% hypertonic saline. Contrast enhanced computed tomography (CT) scan of the brain revealed a sellar-suprasellar mass with hypothalamic extension with no evidence of pituitary apoplexy. A diagnosis of invasive pituitary adenoma with the Addisonian crisis was made and steroid replacement was initiated. Despite volume resuscitation, he had persistent refractory hypotension, recurrent ventricular tachycardia, and metabolic acidosis. Electrocardiogram (ECG) showed ST elevation and T-wave inversion in lateral leads; cardiac-enzymes were increased suggestive of acute coronary syndrome. Transthoracic echocardiography showed severe regional wall motion abnormalities (RWMAs) involving left anterior descending territory and low ejection fraction (EF). Coronary angiogram revealed normal coronaries, apical ballooning, and severe left ventricular dysfunction, consistent with a diagnosis of Takotsubo′s cardiomyopathy. Patient was managed with angiotensin-converting enzyme inhibitors and B-blockers. He improved over few days and recovered completely. At discharge, ECG changes and RWMA resolved and EF normalized to 56%. In patients with Addisonian Crisis with persistent hypotension refractory to optimal resuscitation, possibility of Takotsubo′s cardiomyopathy should be considered. Early recognition of association of Takotsubos cardiomyopathy in neurological conditions, prompt resuscitation, and supportive care are essential to ensure favorable outcomes in this potentially lethal condition.



Udismita Baruah, Ameeta Sahni, Harish C. Sachdeva

Successful management of aluminium phosphide poisoning using intravenous lipid emulsion: Report of two cases

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:4] [Pages No:735 - 738]

Keywords: Aluminum phosphide, lipid emulsions, magnesium sulfate

   DOI: 10.4103/0972-5229.171412  |  Open Access |  How to cite  | 


Aluminum phosphide (ALP) is a cheap, easily available agricultural pesticide which causes lethal poisoning by liberation of phosphine and inhibition of cytochrome c oxidase thereby leading to cellular hypoxia. Although there is no known specific antidote, clinical trials are still going on. We present here two cases of ALP poisoning who were successfully managed by treatment with lipid emulsion and intravenous magnesium sulfate.



Kartik Munta, Palepu B. N. Gopal, Ajit Vigg

Invasive aspergillosis in near drowning nonneutropenic patient

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:4] [Pages No:739 - 742]

Keywords: Acute respiratory distress syndrome, invasive aspergillosis, near drowning, voriconazole

   DOI: 10.4103/0972-5229.171413  |  Open Access |  How to cite  | 


Invasive aspergillosis in immunosuppressed people has been well documented, but to diagnose and treat in an immunocompetent individual after near drowning, it requires early suspicion and proper empirical treatment. We report a case diagnosed to have invasive aspergillosis with systemic dissemination of the infection to the brain, gluteal muscles, and kidneys after a fall in a chemical tank of a paper manufacturing company. He was ventilated for acute respiratory distress syndrome and managed with antibiotics and vasopressors. Due to nonresolving pneumonia and positive serum galactomannan, trans-tracheal biopsy was performed which confirmed invasive aspergillosis and was treated with antifungals. With the availability of galactomannan assay and better radiological investigative modalities, occurrence of such invasive fungal infections in cases of drowning patients should be considered early in such patients and treated with appropriate antifungals.



Inderpaul Singh Sehgal, Sahajal Dhooria

Malarial pancreatitis: Case report and systematic review of the literature

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:4] [Pages No:743 - 746]

Keywords: Abdominal pain, acute respiratory distress syndrome, malaria, multiorgan dysfunction, pancreatitis

   DOI: 10.4103/0972-5229.171414  |  Open Access |  How to cite  | 


Malaria can cause a wide spectrum of clinical manifestations ranging from uncomplicated febrile illness to multiorgan failure. Pancreatitis is a rare complication of malaria with only a few reported cases. Herein, we describe a case of acute pancreatitis with multiorgan failure due to Plasmodium falciparum managed successfully with antimalarials and conservative treatment. We also perform a systematic review of literature for reports of acute pancreatitis due to Plasmodium infection.



Harish Handyal, Laura Sanchez, Rajesh Babu, Jyothisuchithra Mekala

Pregnancy with severe influenza A (H1N1) related acute respiratory distress syndrome: Report of three cases from a rural critical care unit in India

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:4] [Pages No:747 - 750]

   DOI: 10.4103/0972-5229.171416  |  Open Access |  How to cite  | 



Fatih Karatas, Suleyman Sahin, H. Gulsah Karatas, Pinar B. Karsli, Cengizhan Emre, Fatih Kivrakoglu

The highest (3600 IU) reported overdose of insulin glargine ever and management

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:2] [Pages No:750 - 751]

   DOI: 10.4103/0972-5229.171418  |  Open Access |  How to cite  | 



Kartik Munta

The role of noninvasive ventilation in mild to moderate acute respiratory distress syndrome

[Year:2015] [Month:] [Volume:19] [Number:12] [Pages:2] [Pages No:751 - 752]

   DOI: 10.4103/0972-5229.171419  |  Open Access |  How to cite  | 


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