Indian Journal of Critical Care Medicine

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2015 | June | Volume 19 | Issue 6

EDITORIAL

Can we predict neurological outcome following out-of-hospital cardiac arrest (OHCA) and therapeutic hypothermia?

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:3] [Pages No:301 - 303]

PDF  |  DOI: 10.4103/0972-5229.158253  |  Open Access |  How to cite  | 

RESEARCH ARTICLE

Mohammed Ishaq Ruknuddeen, Rajaram Ramadoss, V. Rajajee, Luke E. Grzeskowiak, Ram E. Rajagopalan

Early clinical prediction of neurological outcome following out of hospital cardiac arrest managed with therapeutic hypothermia

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:7] [Pages No:304 - 310]

Keywords: Neurological outcome, out of hospital cardiac arrest, therapeutic hypothermia

PDF  |  DOI: 10.4103/0972-5229.158256  |  Open Access |  How to cite  | 

Abstract

Background: Therapeutic hypothermia (TH) may improve neurological outcome in comatose patients following out of hospital cardiac arrest (OHCA). The reliability of clinical prediction of neurological outcome following TH remains unclear. In particular, there is very limited data on survival and predictors of neurological outcome following TH for OHCA from resource-constrained settings in general and South Asia in specific. Objective: The objective was to identify factors predicting unfavorable neurological outcome at hospital discharge in comatose survivors of OHCA treated with hypothermia. Design: Retrospective chart review. Setting: Urban 200-bed hospital in Chennai, India. Methods: Predictors of unfavorable neurological outcome (cerebral performance category score [3-5]) at hospital discharge were evaluated among patients admitted between January 2006 and December 2012 following OHCA treated with TH. Hypothermia was induced with cold intravenous saline bolus, ice packs and cold-water spray with bedside fan. Predictors of unfavorable neurological outcome were examined through multivariate exact logistic regression analysis. Results: A total of 121 patients were included with 106/121 (87%) experiencing the unfavorable neurological outcome. Independent predictors of unfavorable neurological outcome included: Status myoclonus <24 h (odds ratio [OR] 21.79, 95% confidence interval [CI] 2.89-Infinite), absent brainstem reflexes (OR 50.09, 6.55-Infinite), and motor response worse than flexion on day 3 (OR 99.41, 12.21-Infinite). All 3 variables had 100% specificity and positive predictive value. Conclusion: Status myoclonus within 24 h, absence of brainstem reflexes and motor response worse than flexion on day 3 reliably predict unfavorable neurological outcome in comatose patients with OHCA treated with TH.

RESEARCH ARTICLE

Mohammad Amin Fallahzadeh, Sophia T. Abdehou, Jafar Hassanzadeh, Fatemeh Fallhzadeh, Mohammad Hossein Fallahzadeh, Leila Malekmakan

Pattern of in-hospital pediatric mortality over a 3-year period at University teaching hospitals in Iran

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:5] [Pages No:311 - 315]

Keywords: Causes, children, hospital admission, mortality, underlying diseases

PDF  |  DOI: 10.4103/0972-5229.158257  |  Open Access |  How to cite  | 

Abstract

Introduction: Causes of death are different and very important for policy makers in different regions. This study was designed to analyze the data for our in-patient children mortality. Materials and Methods: In this cross-sectional study from March 2011 to March 2013, all patients from 2 months to 18 years who died in pediatric intensive care unit, emergency room or medical pediatric wards in the teaching hospitals were studied. Results: From a total of 18,915 admissions during a 2-year-period, 256 deaths occurred with a mean age of 4.3 ± 5 years and mortality 1.35%. An underlying disease was present in 70.7% of the patients and in 88.5% of them the leading causes of death were related to the underlying diseases. The most common underlying diseases were congenital heart disease and cardiomyopathy in 50 (27.6%). The four main causes of deaths were sepsis (14.8%), pneumonia (14.5%), congestive heart failure (9.8%), and hepatic encephalopathy (9.8%). Conclusion: We may conclude that after sepsis and pneumonia, congestive heart failure, and hepatic encephalopathy are the leading causes of death. Most patients who died had underlying diseases including malignancies, heart and liver diseases as the most common causes.

ORIGINAL ARTICLE

Baburao Kanthamani Pramod Sagar, Molly Mary Thabah, B.H. Srinivas, Sreejith Parameswaran

Pulmonary-renal syndromes: Experience from an Indian Intensive Care Unit

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:10] [Pages No:316 - 325]

Keywords: Crescentic glomerulonephritis, diffuse alveolar hemorrhage, pulmonary-renal, rapidly progressive renal failure, systemic lupus erythrematosus

PDF  |  DOI: 10.4103/0972-5229.158261  |  Open Access |  How to cite  | 

Abstract

Background: The etiology of patients presenting with pulmonary-renal syndrome (PRS) to Intensive Care Units (ICUs) in India is not previously reported. Aims: The aim was to describe the prevalence, etiology, clinical manifestations, and outcomes of PRS in an Indian ICU and identify variables that differentiate immunologic causes of PRS from tropical syndromes presenting with PRS. Materials and Methods: We conducted a prospective observational study of all patients presenting with PRS over 1-year. Clinical characteristics of patients with \"definite PRS\" were compared with those with \"PRS mimics.\" Results: We saw 27 patients with \"provisional PRS\" over the said duration; this included 13 patients with \"definite PRS\" and 14 with \"PRS mimics.\" The clinical symptoms were similar, but patients with PRS were younger and presented with longer symptom duration. Ninety-two percent of the PRS cohort required mechanical ventilation, 77% required vasopressors and 61.5% required dialysis within 48 h of ICU admission. The etiologic diagnosis of PRS was made after ICU admission in 61.5%. Systemic lupus erythrematosus (54%) was the most common diagnosis. A combination of biopsy and serology was needed in the majority (69%, 9/13). Pulse methylprednisolone (92%) and cyclophosphamide (61.5%) was the most common protocol employed. Patients with PRS had more alveolar hemorrhage, hypoxemia and higher mortality (69%) when compared to \"PRS mimics.\" Conclusion: The spectrum of PRS is different in the tropics and tropical syndromes presenting with PRS are not uncommon. Multicentric studies are needed to further characterize the burden, etiology, treatment protocols, and outcomes of PRS in India.

RESEARCH ARTICLE

Tarun K. George, David Chase, John Victor Peter, Sowmya Satyendra, R. Kavitha, Leah Raju George, Vineeth Varghese Thomas

Association between a prolonged corrected QT interval and outcomes in patients in a medical Intensive Care Unit

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:7] [Pages No:326 - 332]

Keywords: India, predictors, QT prolongation,Critical care, electrocardiography, intensive care unit

PDF  |  DOI: 10.4103/0972-5229.158271  |  Open Access |  How to cite  | 

Abstract

Introduction: Patients admitted into a medical Intensive Care Unit (ICU) have varying illnesses and risk factors. An electrocardiogram (ECG) is a useful tool to assess the cardiac status. The aim of the study was to determine the prevalence of QT prolongation of the ECG in patients admitted to a medical ICU in a tertiary hospital, to assess outcomes in terms of mortality, cardiovascular events, and duration of ICU stay. Materials and Methods: Prospective observational study, 6 months duration, assessing the prevalence of prolonged corrected QT interval (QTc) at admission into a medical ICU. A QTc calculated by Bazett′s formula, of >440 ms for males and >460 ms for females was considered prolonged. Details of illness, clinical and lab parameters were monitored. Results: The total number of patients screened was 182. There was a high prevalence of prolonged QTc (30%) on admission to the ICU. This reduced to 19% on day 3 (P = 0.011). In patients with a prolonged QTc the odds ratio of adverse outcome from ICU was 3.17 (confidence interval [CI]: 1.52-6.63) (P = 0.001) and of adverse outcome for hospital stay was 2.27 (CI: 1.11-4.66) (P = 0.014). In the study, 35% of all patients received drugs with QT prolonging action. Of patients with a prolonged QTc at admission 18 (35%) received a QT prolonging drug. Conclusions: We found that prolonged QTc is common (30%) in our medical ICU at admission and a large proportion (35%) received drugs capable of prolonging QT interval. These patients with QTc prolongation have a higher odds ratio for adverse outcomes.

REVIEW ARTICLE

A. K. Baronia, Rungmei S.K. Marak

Invasive candidiasis in non neutropenic critically ill - need for region-specific management guidelines

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:7] [Pages No:333 - 339]

Keywords: Antifungal prescription, candidemia, critically ill, epidemiology

PDF  |  DOI: 10.4103/0972-5229.158273  |  Open Access |  How to cite  | 

Abstract

Use of antifungal agents has increased over past few decades. A number of risk factors such as immunosuppression, broad spectrum antibiotics, dialysis, pancreatitis, surgery, etc., have been linked with the increased risk of invasive candidiasis. Though there are various guidelines available for the use of antifungal therapy, local/regional epidemiology plays an important role in determining the appropriate choice of agent in situations where the offending organism is not known (i.e. empirical, prophylactic or preemptive therapy). Developing countries like India need to generate their own epidemiological data to facilitate appropriate use of antifungal therapy. In this article, the authors have highlighted the need for region-specific policies/guidelines for treatment of invasive candidiasis. Currently available Indian literature on candidemia epidemiology has also been summarized here.

REVIEW ARTICLE

Rashmi Ranjan Das, Jhuma Sankar, Nishanth Dev

High-dose versus low-dose antivenom in the treatment of poisonous snake bites: A systematic review

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:10] [Pages No:340 - 349]

Keywords: evidence, snake anti-venom, snake bite,Clinical trials

PDF  |  DOI: 10.4103/0972-5229.158275  |  Open Access |  How to cite  | 

Abstract

Though snake antivenom (SAV) is the mainstay of therapy for poisonous snake bites, there is no universally accepted standard regimen regarding the optimum dose (low vs. high). We therefore, undertook this systematic review to address this important research question. We searched all the published literature through the major electronic databases till August 2014. Randomized clinical trials (RCTs) were included. Eligible trials compared low versus high dose SAV in poisonous snake bite. The review has been registered at PROSPERO (Registration number: CRD42014009700). Of 36 citations retrieved, a total of 5 RCTs (n = 473) were included in the final analyses. Three trials were open-label, 4 conducted in Indian sub-continent and 1 in Brazil. The doses of SAV varied in the high dose group from 40 ml to 550 ml, and in the low dose group from 20 ml to 220 ml. There was no significant difference between the two groups for any of the outcomes except duration of hospital stay, which was lower in the low dose group. The GRADE evidence generated was of \"very low quality.\" Low-dose SAV is equivalent or may be superior to high-dose SAV in management of poisonous snake bite. Low dose is also highly cost-effective as compared to the high dose. But the GRADE evidence generated was of \"very low quality\" as most were open label trials. Further trials are needed to make definitive recommendations regarding the dose and these should also include children <9 years of age.

CASE REPORT

Vikas Khillan, Neha Rathor, Dipanjan Panda

Catheter associated mycobacteremia: Opening new fronts in infection control

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:3] [Pages No:350 - 352]

Keywords: Biofilm, chemo port, mycobacteremia, Mycobacterium fortuitum, totally implanted central venous device

PDF  |  DOI: 10.4103/0972-5229.158277  |  Open Access |  How to cite  | 

Abstract

Mycobacterium fortuitum is a rapidly growing Mycobacterium ubiquitous in nature, known to form biofilms. This property increases its propensity to colonize the in situ central line and makes it a prospective threat for nosocomial infection. We report a case of 48-year-old female with carcinoma cecum who reported to us with clinical illness and neutropenia while on chemotherapy via totally implanted central venous device, postlaparoscopic-assisted right hemicolectomy.

REVIEW ARTICLE

Gagandeep Dhillon, Akshata S. Kamat, K.P. Mulavisala

Induced hypothermia for trauma-related ARDS

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:3] [Pages No:353 - 355]

Keywords: Acute respiratory distress syndrome, hypothermia, hypoxia, trauma

PDF  |  DOI: 10.4103/0972-5229.158278  |  Open Access |  How to cite  | 

Abstract

We report a case of 27-year-old male with lung contusions related acute respiratory distress syndrome (ARDS) managed by ARDSNet guidelines and additional hypothermia. On 4 th day, post trauma partial pressure of oxygen dropped to 38 mm of mercury (Hg), not improving even on high positive end-expiratory pressure of 18 cm water (H 2 O), inverse ratio ventilation and fraction of inspired oxygen of 1. Extracorporeal membrane oxygenation was ruled out due to the risk of hemorrhage from trauma sites. Thereafter, hypothermia along with muscle paralysis was considered to reduce total body oxygen consumption. Patient′s condition improved under hypothermia, and he was extubated and taken up for fracture fixation surgeries and discharged later in stable condition.

REVIEW ARTICLE

Gentle Sunder Shrestha, Pankaj Joshi, Santosh Chhetri, Krishna Bhattarai, Subhash Prasad Acharya

Intranasal midazolam for rapid sedation of an agitated patient

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:3] [Pages No:356 - 358]

Keywords: Difficult intravenous access, intensive care unit, intranasal midazolam

PDF  |  DOI: 10.4103/0972-5229.158279  |  Open Access |  How to cite  | 

Abstract

Rapidly, establishing a difficult intravenous access in a dangerously agitated patient is a real challenge. Intranasal midazolam has been shown to be effective and safe for rapidly sedating patients before anesthesia, for procedural sedation and for control of seizure. Here, we report a patient in intensive care unit who was on mechanical ventilation and on inotropic support for management of septic shock and who turned out extremely agitated after accidental catheter removal. Intravenous access was successfully established following sedation with intranasal midazolam, using ultrasound guidance.

CASE REPORT

Behzad Maghsoudi, Hossein Haddad, Pooya Vatankhah, Alireza Rasekhi, Abbas Rahimi Jaberi

Post-operative quadriplegia as the initial manifestation of tumefactive multiple sclerosis

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:3] [Pages No:359 - 361]

Keywords: postoperation, quadriplegia, tumefactive,Multiple sclerosis

PDF  |  DOI: 10.4103/0972-5229.158281  |  Open Access |  How to cite  | 

Abstract

Post-operative quadriplegia is a rarely encountered complication and not previously reported as the initial presentation of tumefactive multiple sclerosis. We present an unusual case of a patient with such manifestation and atypical lesions on brain magnetic resonance imaging. The patient was treated with methyl prednisolone pulse therapy and showed a dramatic response. Uncommon neurologic diseases can have very unusual presentations, which should be taken into consideration when encountered with such patients. Considering this fact will help physicians in better decision-making and proper treatment planning.

LETTER TO EDITOR

Om Prakash Sanjeev

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:1] [Pages No:362 - 362]

DOI: 10.4103/0972-5229.158282  |  Open Access |  How to cite  | 

LETTERS TO THE EDITOR

Rakhee Goyal, K. NarmadhaLakshmi

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:2] [Pages No:362 - 363]

DOI: 10.4103/0972-5229.158284  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Jigeeshu V. Divatia, Raghu S. Thota

WhatsApp: What an App!

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:3] [Pages No:363 - 365]

PDF  |  DOI: 10.4103/0972-5229.158288  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Kartik Munta, Rahul Amte, Pradeep M. Venkategowda, Jaydeep Ray Chaudhary

Accidental placement of central venous catheter tip into internal mammary vein

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:2] [Pages No:365 - 366]

PDF  |  DOI: 10.4103/0972-5229.158290  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Srujana Mohanty, Bijayini Behera

Scrub typhus: Clinical spectrum and outcome

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:2] [Pages No:366 - 367]

PDF  |  DOI: 10.4103/0972-5229.158292  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Arun Maheshwari, Monish Raut

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:1] [Pages No:368 - 368]

DOI: 10.4103/0972-5229.158293  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Paul Birinder, Gunchan Paul, Gautam Parshotam

Catheter-based therapy for acute pulmonary embolism: Lifesaving in a clinical dilemma!

[Year:2015] [Month:] [Volume:19] [Number:6] [Pages:2] [Pages No:370 - 371]

PDF  |  DOI: 10.4103/0972-5229.158297  |  Open Access |  How to cite  | 

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