Indian Journal of Critical Care Medicine

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2016 | December | Volume 20 | Issue 12

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Sunil Katyal, Nikhil Gautam, Gaganjot Kaur, Preetveen Sandhu

Comparison of patient-ventilator asynchrony during pressure support ventilation and proportional assist ventilation modes in surgical Intensive Care Unit: A randomized crossover study

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:6] [Pages No:689 - 694]

Keywords: Patient-ventilator dyssynchrony, pressure support ventilation, proportional assist ventilation

   DOI: 10.4103/0972-5229.195701  |  Open Access |  How to cite  | 


Background: The patient-ventilator asynchrony is almost observed in all modes of ventilation, and this asynchrony affects lung mechanics adversely resulting in deleterious outcome. Innovations and advances in ventilator technology have been trying to overcome this problem by designing newer modes of ventilation. Pressure support ventilation (PSV) is a commonly used flow-cycled mode where a constant pressure is delivered by ventilator. Proportional assist ventilation (PAV) is a new dynamic inspiratory pressure assistance and is supposed to be better than PSV for synchrony and tolerance, but reports are still controversial. Moreover, most of these studies are conducted in chronic obstructive pulmonary disease patients with respiratory failure; the results of these studies may not be applicable to surgical patients. Thus, we proposed to do compare these two modes in surgical Intensive Care Unit (ICU) patients as a randomized crossover study. Aims: Comparison of patient-ventilator asynchrony between PSV and PAV plus (PAV+) in surgical patients while weaning. Subjects and Methods: After approval by the Hospital Ethics Committee, we enrolled twenty patients from surgical ICU of tertiary care institute. The patients were ventilated with pressure support mode (PSV) and PAV+ for 12 h as a crossover from one mode to another after 6 h while weaning. Results: Average age and weight of patients were 41.80 ± 15.20 years (mean ± standard deviation [SD]) and 66.50 ± 12.47 (mean ± SD) kg, respectively. Comparing the asynchronies between the two modes, the mean number of total asynchronous recorded breaths in PSV was 7.05 ± 0.83 and 4.35 ± 5.62, respectively, during sleep and awake state, while the same were 6.75 ± 112.24 and 10.85 ± 11.33 in PAV+. Conclusion: Both PSV and PAV+ modes of ventilation performed similarly for patient-ventilator synchrony in surgical patients. In surgical patients with acute respiratory failure, dynamic inspiratory pressure assistance modalities are not superior to PSV with respect to cardiorespiratory function.



Luis Sanchez-Hurtado, Adrian Ángeles-Veléz, Brigette Tejeda-Huezo, Juan García-Cruz, Teresa Juárez-Cedillo

Validation of a prognostic score for mortality in elderly patients admitted to Intensive Care Unit

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:6] [Pages No:695 - 700]

Keywords: Elderly, Intensive Care Unit, mortality, prognostic scores, Simplified Acute Physiology Score 3

   DOI: 10.4103/0972-5229.195702  |  Open Access |  How to cite  | 


Context: The performance of a prognostic score must be evaluated prior to being used. The aim of the present study was to evaluate the predictive ability of hospital mortality of Simplified Acute Physiology Score 3 (SAPS 3) score in elderly patients admitted to Intensive Care Units (ICUs). Aims: The aim of the present study was to evaluate the SAPS 3 score predictive ability of hospital mortality in elderly patients admitted to ICU. Settings and Design: This study was conducted as a prospective cohort, in two mixed ICUs. Patients and Methods: Two hundred and eleven elderly patients were included. Interventions: None. We compared the predictive accuracy of SAPS 3 measured at the first hour at ICU and Acute Physiology and Chronic Health Evaluation II (APACHE II) measured with the worst values in the first 24 h at ICU. The patients were followed until hospital discharge. Statistical Analysis Used: Evaluation of discrimination through area under curve receiver operating characteristic (aROC) and calibration by Hosmer-Lemeshow (HL) test. Results: The median age was 68 years. The hospital mortality rate was 35.54%. The mean value of SAPS 3 was 62.54 ± 12.51 and APACHE II was 17.46 ± 6.77. The mortality predicted by APACHE II was 24.98 ± 19.96 and for standard SAPS 3 equation 41.18 ± 22.34. The discrimination for SAPS 3 model was aROC = 0.68 (0.62-0.75) and to APACHE II aROC = 0.70 (0.63-0.78). Calibration: APACHE II with HL 10.127 P = 0.26, and standard SAPS 3 equation HL 7.204 P = 0.51. Conclusions: In this study, the prognostic model of SAPS 3 was not found to be accurate in predicting mortality in geriatric patients requiring ICU admission.



Arvind Kumar Baronia, Shakti Mishra, Ratender Singh

Sustained low-efficiency dialysis in septic shock: Hemodynamic tolerability and efficacy

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:7] [Pages No:701 - 707]

Keywords: Acute kidney injury, efficacy of dialysis, hemodynamic tolerability, septic shock, sustained low-efficiency dialysis

   DOI: 10.4103/0972-5229.195704  |  Open Access |  How to cite  | 


Aim of the Study: Acute kidney injury (AKI) in septic shock has poor outcomes. Sustained low-efficiency dialysis (SLED) is increasingly replacing continuous renal replacement therapy as the preferred modality in Intensive Care Units (ICUs). However, the essential aspects of hemodynamic tolerability and efficacy of SLED in septic shock AKI has been minimally studied. Patients and Methods: We describe hemodynamic tolerability using modified vasopressor index (VI) and vasopressor dependency (VD) and efficacy using a combination of Kt/v, correction of acidosis, electrolyte, and fluid overload. Adult ICU patients of septic shock in AKI requiring SLED were included in this study. Results: One hundred and twenty-four patients of septic shock AKI requiring SLED were enrolled in the study. There were 74 nonsurvivors (NSs). Approximately, 56% (278/498) of the sessions in which vasopressors were required were studied. Metabolic acidosis (49%) was the predominant indication for the initiation of SLED in these patients. Baseline characteristics between survivors and NSs were comparable, except for age, severity scores, AKI stage, and coexisting illness. VI and VD prior to the initiation of SLED and delta VI and VD during SLED were significantly higher in NSs. Hemodynamic tolerability and efficacy of SLED was achievable only at lower vasopressor doses. Conclusion: VI, VD, and combination of Kt/v together with correction of acidosis, electrolyte, and fluid overload can be used to describe hemodynamic tolerability and efficacy of SLED in septic shock AKI. However, at higher vasopressor doses in septic shock, hemodynamic tolerability and efficacy of SLED requires further evidence.



Manjri Garg, Jyotsna Sen, Sandeep Goyal

Comparative evaluation of central venous pressure and sonographic inferior vena cava variability in assessing fluid responsiveness in septic shock

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:6] [Pages No:708 - 713]

Keywords: Central venous pressure, fluid responsiveness, hypovolemia, septic shock, sonographic inferior vena cava variability

   DOI: 10.4103/0972-5229.195706  |  Open Access |  How to cite  | 


Objective: Fluid infusion, the most critical step in the resuscitation of patients with septic shock, needs preferably continuous invasive hemodynamic monitoring. The study was planned to evaluate the efficacy of ultrasonographically measured inferior vena cava collapsibility index (IVC CI) in comparison to central venous pressure (CVP) in predicting fluid responsiveness in septic shock. Materials and Methods: Thirty-six patients of septic shock requiring ventilatory support (invasive/noninvasive) were included. Patients with congestive heart failure, raised intra-abdominal pressure, and poor echo window were excluded from the study. They were randomly divided into two groups based on mode of fluid resuscitation - Group I (CVP) and Group II (IVC CI). Primary end-points were mean arterial pressure (MAP) of ≥65 mmHg and CVP >12 mmHg or IVC CI <20% in Groups I and II, respectively. Patients were followed till achievement of end-points or maximum of 6 h. Outcome variables (pulse rate, MAP, urine output, pH, base deficit, and ScvO 2) were serially measured till the end of the study. Survival at 2 and 4 weeks was used as secondary end-point. Results: Primary end-point was reached in 31 patients (15 in Group I and 16 in Group II). Fluid infusion, by either method, had increased CVP and decreased IVC CI with resultant negative correlation between them (Pearson correlation coefficient -0.626). There was no significant difference in the amount of fluid infused and time to reach end-point in two groups. Comparison in outcome variables at baseline and end-point showed no significant difference including mortality. Conclusion: CVP and IVC CI are negatively correlated with fluid resuscitation, and both methods can be used for resuscitation, with IVC CI being noninferior to CVP.



Ipe Jacob, Sridhar Reddy, Pradeep Rangappa, Rajeswari Janakiraman

Efficacy of conivaptan and hypertonic (3%) saline in treating hyponatremia due to syndrome of inappropriate antidiuretic hormone in a tertiary Intensive Care Unit

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:5] [Pages No:714 - 718]

Keywords: Conivaptan, hypertonic saline, hyponatremia, syndrome of inappropriate antidiuretic hormone

   DOI: 10.4103/0972-5229.195708  |  Open Access |  How to cite  | 


Background: Hyponatremia is one of the most common electrolyte abnormalities encountered in clinical practice and has a significant impact on morbidity and mortality in hospitalized patients. The optimal management of hyponatremia is still evolving. Over the last decade, vaptans have been increasingly used in clinical practice with promising results. Materials and Methods: The study included eighty patients with symptomatic hyponatremia due to syndrome of inappropriate antidiuretic hormone (SIADH) admitted and treated in Intensive Care Unit (ICU) with either conivaptan or hypertonic (3%) saline. They were compared for time taken to achieve normal serum sodium, length of ICU and hospital stay, and adverse effects. Results: The demographic data and serum sodium levels at admission were comparable between the two groups. After initiating correction, sodium levels at 6, 12, and 24 h were similar between the two groups. However, at 48 h, patients in the conivaptan group (Group C) had higher sodium levels (133.0 ± 3.8 mEq/L) as compared to hypertonic saline group (Group HS) (128.9 ± 2.6 mEq/L), which was statistically significant (P < 0.001). The length of ICU stay was less in the Group C (3.35 ± 0.89 days) when compared with the Group HS (4.61 ± 0.91 days) (P < 0.001). There was no significant difference in mortality between the two groups. Conclusion: In patients with symptomatic hyponatremia due to SIADH, conivaptan with its \"aquaresis\" property can achieve a significantly better sodium correction, resulting in reduced ICU and hospital stay with no significant adverse effects.



Naman Agrawal

Sympathetic crashing acute pulmonary edema

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:5] [Pages No:719 - 723]

Keywords: Diuretics, emergency department, high-dose nitroglycerin, noninvasive ventilation, pulmonary edema, sympathetic crashing acute pulmonary edema

   DOI: 10.4103/0972-5229.195710  |  Open Access |  How to cite  | 


Sympathetic crashing acute pulmonary edema (SCAPE) is the extreme end of the spectrum of acute pulmonary edema. It is important to understand this disease as it is relatively common in the emergency department (ED) and has better outcomes when managed appropriately. The patients have an abrupt redistribution of fluid in the lungs, and when treated promptly and effectively, these patients will rapidly recover. Noninvasive ventilation and intravenous nitrates are the mainstay of treatment which should be started within minutes of the patient′s arrival to the ED. Use of morphine and intravenous loop diuretics, although popular, has poor scientific evidence.



Sayed Marashi, Maryam Farahani, Davood Soroosh

Thoughts on the current management of acute aluminum phosphide toxicity and proposals for therapy: An Evidence-based review

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:7] [Pages No:724 - 730]

Keywords: Aluminum phosphide, new therapies, phosphine, toxicity

   DOI: 10.4103/0972-5229.195712  |  Open Access |  How to cite  | 


The majority of aluminum phosphide (ALP) toxicity cases are suicidal attempts. Despite advances in critical care medicine, the mortality rate of ALP remains very high. Unfortunately, knowledge on the toxicokinetics of ALP is very low. An obsolete idea was proposed that inhibition of complex IV of cytochrome C oxidase is responsible for multiorgan dysfunction. However, based on human studies, this effect might be insignificant. Thus, a novel idea proposes that the main mechanism might be vascular wall integrity disruption. The low frequency of acute toxicity and unanswered questions about the toxicokinetics and toxicodynamics has led to leaden advances of novel treatments. The aim of this review was to evaluate problems regarding current treatment protocols and propose new ideas based on updated information. For this purpose, we reviewed all available articles on the management of ALP poisoning published to date. Considering failure of conventional therapies on maintaining systolic blood pressure, correcting acid-base disturbances, and support cardiac function, the previous treatment protocols have been overruled. However, repudiate of conventional treatments in this deadly condition is not without penalties for the health-care provider. The introduction of new therapies including refuse of gastric lavage with water-soluble compounds, administration of a high molecular weight colloidal solution for fluid resuscitation and termination using sodium bicarbonate, and vasoactive agents has been prospected to improve patient survival. This protocol is in early clinical evaluation; nevertheless, it appears to improve patient′s survival; hence, future randomized trials should be performed to support their effectiveness.



Birinder Paul

Unseen face of varicella-zoster infection in adults

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:4] [Pages No:731 - 734]

Keywords: Acquired protein-S deficiency, cortical venous sinus thrombosis, deep vein thrombosis, hypercoagulability, pulmonary embolism, varicella-zoster infection

   DOI: 10.4103/0972-5229.195713  |  Open Access |  How to cite  | 


Varicella infection is common in children caused by varicella-zoster virus (VZV). VZV is known to cause cerebral arterial vasculopathy and antibody-mediated hypercoagulable state leading to thrombotic complications in children. Such complications in adults are very rare. We report three cases that represent the unseen face of primary varicella infection in adults. Simultaneous involvement of cortical venous sinus thrombosis and deep vein thrombosis leading to clot in right atrium and pulmonary embolism in first case; cortical venous sinus thrombosis in second case; and deep vein thrombosis in third case. Early diagnosis and management can help prevent associated morbidity and mortality.



Jianguo Zhou, Chao Chen, Guoping Lu, Yun Cao

Neonatal extracorporeal membrane oxygenation: A case report and current state in Mainland China

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:4] [Pages No:735 - 738]

Keywords: Extracorporeal membrane oxygenation, Group B streptococcus, Mainland China, neonate

   DOI: 10.4103/0972-5229.195715  |  Open Access |  How to cite  | 


We report the first successful treatment of extracorporeal membrane oxygenation (ECMO) in a neonate with Group B streptococcus (GBS) sepsis and cardiorespiratory failure, and further conduct a literature review in the experience of neonatal ECMO utility in Mainland China. A term neonate with cardiorespiratory failure secondary to GBS sepsis was put on venous-arterial ECMO at 23 h of age. After 273 h of ECMO running, the patient was saved and without major complications. The comprehensive literature review demonstrated that there were 22 neonates received ECMO previously in Mainland China, 14 of 22 of the patients are cases with congenital heart defects. The overall survival rate was 41% (9/22). Neonatal ECMO was underdeveloped in Mainland, China. Moreover, it does provide a chance of survival for neonates who have a grave prognosis by conventional treatment.



Acute pesticide ingestion managed with yohimbine as a rescue therapy

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:3] [Pages No:739 - 741]

Keywords: Amitraz poisoning, poisoning, yohimbine

   DOI: 10.4103/0972-5229.195716  |  Open Access |  How to cite  | 


Amitraz is used as a pesticide in agricultural and veterinary medicine. It is primarily a central α2 adrenergic agonist and known to cause central nervous system depression, convulsions, respiratory depression, and bradycardia on severe intoxication. We report a case of a 3-year-old child who presented with accidental ingestion of amitraz solution with signs of severe poisoning. There is no specific antidote of amitraz poisoning in humans, however, animal experiments with α2 adrenergic antagonists such as yohimbine and atimepazole have been successful. The child was managed besides intensive management with enteral yohimbine, and he regained consciousness in 18 h and was successfully weaned off mechanical ventilation.



Nisha Jose, Ajay Mishra, Vignesh Chandiraseharan, Thambu Sudarsanam

Chlorantraniliprole: An unusual insecticide poisoning in humans

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:3] [Pages No:742 - 744]

Keywords: Chlorantraniliprole, Mobitz Type I atrioventricular block, ryanodine

   DOI: 10.4103/0972-5229.195718  |  Open Access |  How to cite  | 


A 26-year-old female presented with deliberate self-harm using chlorantraniliprole, an unknown substance in human toxicology. She developed symptomatic Mobitz Type I atrioventricular block during observation, for which a temporary pacemaker was inserted. She reverted to sinus rhythm after 48 h and was discharged. Although claimed to be nontoxic to humans, chlorantraniliprole, an insecticide, could cause conduction defects by activating ryanodine receptors. To the best of our knowledge, this is the first case of chlorantraniliprole poisoning reported in the medical literature.



Sudhir Kumar, Chenna Reddy, Subhashini Prabhakar

Bilateral putaminal necrosis in a comatose patient with metabolic acidosis

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:4] [Pages No:745 - 748]

Keywords: Coma, high anion gap, metabolic acidosis, methanol toxicity, putaminal necrosis

   DOI: 10.4103/0972-5229.195720  |  Open Access |  How to cite  | 


We present a case of acute-onset coma in a young woman, associated with metabolic acidosis, respiratory distress, and hypotension. Magnetic resonance imaging of the brain done on day 2 of admission showed features of bilateral putaminal necrosis. History of methanol ingestion, though not forthcoming at admission, was confirmed later after the patient regained consciousness. A final diagnosis of methyl alcohol toxicity resulting in severe metabolic acidosis, coma, and bilateral blindness was made. This case is reported to emphasize the point that the finding of bilateral putaminal necrosis in a patient with coma and metabolic acidosis is virtually diagnostic of methyl alcohol toxicity even in the absence of any positive history.



S. Rao

Acute respiratory failure in scrub typhus patients

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:1] [Pages No:749 - 749]

   DOI: 10.4103/0972-5229.195722  |  Open Access |  How to cite  | 



P. Sai Saran

Risk factors for early invasive fungal disease in critically ill patients

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:1] [Pages No:750 - 750]

   DOI: 10.4103/0972-5229.195723  |  Open Access |  How to cite  | 



T. Dharmalingam, Vivekananda Gunasekaran

Overcoming a difficult nasogastric tube insertion procedure with a video laryngoscope (C-Mac®)

[Year:2016] [Month:] [Volume:20] [Number:12] [Pages:2] [Pages No:751 - 752]

   DOI: 10.4103/0972-5229.195756  |  Open Access |  How to cite  | 


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