Indian Journal of Critical Care Medicine

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2016 | February | Volume 20 | Issue 2

EDITORIAL

Glucose control in critically ill diabetic: Not so sweet

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:2] [Pages No:65 - 66]

   DOI: 10.4103/0972-5229.175937  |  Open Access |  How to cite  | 

RESEARCH ARTICLE

Hadi Hamishehkar, Kamran Shadvar, Afshin Iranpour, Mohammadtaghi Beigmohammadi

Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with ICU mortality in critically ill patients

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:5] [Pages No:67 - 71]

Keywords: Blood sugar, critically ill patients, glucose control, hemoglobin A1c, mortality

   DOI: 10.4103/0972-5229.175938  |  Open Access |  How to cite  | 

Abstract

Background and Aims: The association between hyperglycemia and mortality is believed to be influenced by the presence of diabetes mellitus (DM). In this study, we evaluated the effect of preexisting hyperglycemia on the association between acute blood glucose management and mortality in critically ill patients. The primary objective of the study was the relationship between HbA1c and mortality in critically ill patients. Secondary objectives of the study were relationship between Intensive Care Unit (ICU) admission blood glucose and glucose control during ICU stay with mortality in critically ill patients. Materials and Methods: Five hundred patients admitted to two ICUs were enrolled. Blood sugar and hemoglobin A1c (HbA1c) concentrations on ICU admission were measured. Age, sex, history of DM, comorbidities, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, hypoglycemic episodes, drug history, mortality, and development of acute kidney injury and liver failure were noted for all patients. Results: Without considering the history of diabetes, nonsurvivors had significantly higher HbA1c values compared to survivors (7.25 ± 1.87 vs. 6.05 ± 1.22, respectively, P < 0.001). Blood glucose levels in ICU admission showed a significant correlation with risk of death (P < 0.006, confidence interval [CI]: 1.004–1.02, relative risk [RR]: 1.01). Logistic regression analysis revealed that HbA1c increased the risk of death; with each increase in HbA1c level, the risk of death doubled. However, this relationship was not statistically significant (P: 0.161, CI: 0.933–1.58, RR: 1.2). Conclusions: Acute hyperglycemia significantly affects mortality in the critically ill patients; this relation is also influenced by chronic hyperglycemia.

RESEARCH ARTICLE

Rujipat Samransamruajkit, Nuanchan Prapphal, Jitladda Deerojanawong, Suchada Sritippayawan, Chavisa Rassameehirun, Khemmachart Pongsanon, Sumalee Huntrakul

A comparison of clinical efficacy between high frequency oscillatory ventilation and conventional ventilation with lung volume recruitment in pediatric acute respiratory distress syndrome: A randomized controlled trial

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:6] [Pages No:72 - 77]

Keywords: Conventional ventilation, high frequency oscillatory ventilation, lung volume recruitment maneuver, oxygenation

   DOI: 10.4103/0972-5229.175940  |  Open Access |  How to cite  | 

Abstract

Purpose: To determine the efficacy of lung volume recruitment maneuver (LVRM) with high frequency oscillatory ventilation (HFOV) on oxygenation, hemodynamic alteration, and clinical outcomes when compared to conventional mechanical ventilation (CV) in children with severe acute respiratory distress syndrome (ARDS). Materials: We performed a randomized controlled trial and enrolled pediatric patients who were diagnosed to have severe ARDS upon pediatric intensive care unit (PICU) admission. LVRM protocol combined with HFOV or conventional mechanical ventilation was used. Baseline characteristic data, oxygenation, hemodynamic parameters, and clinical outcomes were recorded. Results: Eighteen children with severe ARDS were enrolled in our study. The primary cause of ARDS was pneumonia (91.7%). Their mean age was 47.7 ± 61.2 (m) and body weight was 25.3 ± 27.1 (kg). Their initial pediatric risk of mortality score 3 and pediatric logistic organ dysfunction were 12 ± 9.2 and 15.9 ± 12.8, respectively. The initial mean oxygen index was 24.5 ± 10.4, and mean PaO2/FiO2 was 80.6 ± 25. There was no difference in oxygen parameters at baseline the between two groups. There was a significant increase in PaO2/FiO2 (119.2 ± 41.1, 49.6 ± 30.6, P = 0.01*) response after 1 h of LVRM with HFOV compare to CV. Hemodynamic and serious complications were not significantly affected after LVRM. The overall PICU mortality of our severe ARDS at 28 days was 16.7%. Three patients in CV with LVRM group failed to wean oxygen requirement and were cross-over to HFOV group. Conclusions: HFOV combined with LVRM in severe pediatric ARDS had superior oxygenation and tended to have better clinical effect over CV. There is no significant effect on hemodynamic parameters. Moreover, no serious complication was noted.

RESEARCH ARTICLE

Mudalipalayam N. Sivakumar, Ganesh Veerasekar

Impact of clinical pharmacist in an Indian Intensive Care Unit

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:6] [Pages No:78 - 83]

Keywords: Adverse drug reaction, critical care pharmacist, drug interaction, medication error

   DOI: 10.4103/0972-5229.175931  |  Open Access |  How to cite  | 

Abstract

Background and Objectives: A critically ill patient is treated and reviewed by physicians from different specialties; hence, polypharmacy is a very common. This study was conducted to assess the impact and effectiveness of having a clinical pharmacist in an Indian Intensive Care Unit (ICU). It also evaluates the clinical pharmacist interventions with a focus on optimizing the quality of pharmacotherapy and patient safety. Materials and Methods: The prospective, observational study was carried out in medical and surgical/trauma ICU over a period of 1 year. All detected drug-related problems and interventions were categorized based on the Pharmaceutical Care Network Europe system. Results: During the study period, average monthly census of 1032 patients got treated in the ICUs. A total of 986 pharmaceutical interventions due to drug-related problems were documented, whereof medication errors accounted for 42.6% (n = 420), drug of choice problem 15.4% (n = 152), drug-drug interactions were 15.1% (n = 149), Y-site drug incompatibility was 13.7% (n = 135), drug dosing problems were 4.8% (n = 47), drug duplications reported were 4.6% (n = 45), and adverse drug reactions documented were 3.8% (n = 38). Drug dosing adjustment done by the clinical pharmacist included 140 (11.9%) renal dose, 62 (5.2%) hepatic dose, 17 (1.4%) pediatric dose, and 104 (8.8%) insulin dosing modifications. A total of 577 drug and poison information queries were answered by the clinical pharmacist. Conclusion: Clinical pharmacist as a part of multidisciplinary team in our study was associated with a substantially lower rate of adverse drug event caused by medication errors, drug interactions, and drug incompatibilities.

RESEARCH ARTICLE

Sumana Baidya, Ranjeeta S. Acharya, Michel W. Coppieters

Physiotherapy practice patterns in Intensive Care Units of Nepal: A multicenter survey

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:7] [Pages No:84 - 90]

Keywords: Intensive Care Units, multicenter survey, Nepal, physiotherapy

   DOI: 10.4103/0972-5229.175939  |  Open Access |  How to cite  | 

Abstract

Context: As physiotherapy (PT) is a young profession in Nepal, there is a dearth of insight into the common practices of physiotherapists in critical care. Aims: To identify the availability of PT services in Intensive Care Units (ICUs) and articulate the common practices by physiotherapists in ICUs of Nepal. Settings and Design: All tertiary care hospitals across Nepal with ICU facility via an exploratory cross-sectional survey. Subjects and Methods: An existing questionnaire was distributed to all the physiotherapists currently working in ICUs of Nepal with 2 years of experience. The survey was sent via E-mail or given in person to 86 physiotherapists. Statistical Analysis Used: Descriptive and inferential statistics according to nature of data. Results: The response rate was 60% (n = 52). In the majority of hospitals (68%), PT service was provided only after a physician consultation, and few hospitals (13%) had established hospital criteria for PT in ICUs. Private hospitals (57.1%) were providing PT service in weekends compared to government hospitals (32.1%) (P = 0.17). The likelihood of routine PT involvement varied significantly with the clinical scenarios (highest 71.2% status cerebrovascular accident, lowest 3.8% myocardial infarction, P < 0.001). The most preferred PT treatment was chest PT (53.8%) and positioning (21.2%) while least preferred was therapeutic exercise (3.8%) irrespective of clinical scenarios. Conclusions: There is a lack of regular PT service during weekends in ICUs of Nepal. Most of the cases are treated by physiotherapists only after physician\'s referral. The preferred intervention seems to be limited only to chest PT and physiotherapists are not practicing therapeutic exercise and functional mobility training to a great extent.

RESEARCH ARTICLE

Sugata Dasgupta, Dipasri Bhattacharya, Shipti Shradha Singh, Arunima Chaudhuri, Sourav Das Choudhury

Airway accidents in critical care unit: A 3-year retrospective study in a Public Teaching Hospital of Eastern India

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:6] [Pages No:91 - 96]

Keywords: Airway accidents, blocked tube, endotracheal tube, tracheostomy, unplanned extubations

   DOI: 10.4103/0972-5229.175946  |  Open Access |  How to cite  | 

Abstract

Background: Although tracheal tubes are essential devices to control and protect airway in a critical care unit (CCU), they are not free from complications. Aims: To document the incidence and nature of airway accidents in the CCU of a government teaching hospital in Eastern India. Methods: Retrospective analysis of all airway accidents in a 5-bedded (medical and surgical) CCU. The number, types, timing, and severity of airway accidents were analyzed. Results: The total accident rate was 19 in 233 intubated and/or tracheostomized patients over 1657 tube days (TDs) during 3 years. Fourteen occurred in 232 endotracheally intubated patients over 1075 endotracheal tube (ETT) days, and five occurred in 44 tracheostomized patients over 580 tracheostomy TDs. Fifteen accidents were due to blocked tubes. Rest four were unplanned extubations (UEs), all being accidental extubations. All blockages occurred during night shifts and all UEs during day shifts. Five accidents were mild, the rest moderate. No major accident led to cardiorespiratory arrest or death. All blockages occurred after 7th day of intubation. The outcome of accidents were more favorable in tracheostomy group compared to ETT group (P = 0.001). Conclusions: The prevalence of airway accidents was 8.2 accidents per 100 patients. Blockages were the most common accidents followed by UEs. Ten out of the 15 blockages and all 4 UEs were in endotracheally intubated patients. Tracheostomized patients had 5 blockages and no UEs.

REVIEW ARTICLE

Jayita Deodhar, Naveen Salins, Mary Ann Muckaden

Intensive Care Unit death and factors influencing family satisfaction of Intensive Care Unit care

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:7] [Pages No:97 - 103]

Keywords: Death, family satisfaction of care, Intensive Care Unit

   DOI: 10.4103/0972-5229.175942  |  Open Access |  How to cite  | 

Abstract

Introduction: Family satisfaction of Intensive Care Unit (FS-ICU) care is believed to be associated with ICU survival and ICU outcomes. A review of literature was done to determine factors influencing FS-ICU care in ICU deaths. Results: Factors that positively influenced FS-ICU care were (a) communication: Honesty, accuracy, active listening, emphatic statements, consistency, and clarity; (b) family support: Respect, compassion, courtesy, considering family needs and wishes, and emotional and spiritual support; (c) family meetings: Meaningful explanation and frequency of meetings; (d) decision-making: Shared decision-making; (e) end of life care support: Support during foregoing life-sustaining interventions and staggered withdrawal of life support; (f) ICU environment: Flexibility of visiting hours and safe hospital environment; and (g) other factors: Control of pain and physical symptoms, palliative care consultation, and family-centered care. Factors that negatively influenced FS-ICU care were (a) communication: Incomplete information and unable to interpret information provided; (b) family support: Lack of emotional and spiritual support; (c) family meetings: Conflicts and short family meetings; (d) end of life care support: Resuscitation at end of life, mechanical ventilation on day of death, ICU death of an elderly, prolonged use of life-sustaining treatment, and unfamiliar technology; and (e) ICU environment: Restrictive visitation policies and families denied access to see the dying loved ones. Conclusion: Families of the patients admitted to ICU value respect, compassion, empathy, communication, involvement in decision-making, pain and symptom relief, avoiding futile medical interventions, and dignified end of life care.

BRIEF COMMUNICATION

Sanjay Pandey, Mettu Srinivas Reddy, Akila Rajakumar, Balaji Pillai, Jothi Clara J. Micheal, Ravindranath Kancherla, Mohamed Rela

Safe emergency evacuation of a Tertiary Care Hospital during the “once in a century” floods in Chennai, India

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:5] [Pages No:104 - 108]

Keywords: Emergency, evacuation, flood

   DOI: 10.4103/0972-5229.175933  |  Open Access |  How to cite  | 

Abstract

The coastal city of Chennai, India, was inundated by unprecedented heavy rains during the last week of November 2015, in what was billed as a “once in a century” floods. Over 350 people lost their lives in the floods. Global Hospital, a 250-bedded tertiary care hospital in Chennai, was heavily flooded leaving more than 100 patients and their relatives stranded inside with access totally cutoff from the rest of the world. This article describes how these patients, many in the Intensive Care Unit on ventilators, were safely managed within the hospital for over 48 h on very limited power supply and resources and then safely evacuated by fishing boats to three other city hospitals. Careful planning, anticipating hazards, identifying critical areas, effective communication and team work contributed to the successful management of this situation.

BRIEF COMMUNICATION

Minal Harde, Hemlata Iyer, Amol Jatale, Sagar Tiwatne

A comparative study of epidural catheter colonization and infection in Intensive Care Unit and wards in a Tertiary Care Public Hospital

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:5] [Pages No:109 - 113]

Keywords: Epidural catheter infection, epidural catheterization, epidural colonization

   DOI: 10.4103/0972-5229.175943  |  Open Access |  How to cite  | 

Abstract

Infection is a potentially serious complication of epidural analgesia and with an increase in its use in wards there is a necessity to demonstrate its safety. We aimed to compare the incidence of colonization of epidural catheters retained for short duration (for 48 h) postoperative analgesia in postanesthesia care unit and wards. It was a prospective observational study done in a tertiary care teaching public hospital over a period of 2 years and included 400 patients with 200 each belonged to two groups PACU and ward. We also studied epidural tip culture pattern, skin swab culture at the entry point of the catheter, their relation to each other and whether colonization is equivalent to infection. Data were analyzed using statistical software GraphPad. Overall positive tip culture was 6% (24), of them 7% (14) were from PACU and 5% (10) were from ward (P = 0.5285). Positive skin swab culture was 38% (150), of them 20% (80) were from PACU and 18% (70) were from ward (P = 0.3526). The relation between positive tip culture and positive skin swab culture in same patients is extremely significant showing a strong linear relationship (95% confidence interval = 0.1053–0.2289). The most common microorganism isolated was Staphylococcus epidermidis. No patient had signs of local or epidural infection. There is no difference in the incidence of epidural catheter tip culture and skin swab culture of patients from the general ward and PACU. Epidural analgesia can be administered safely for 48 h in general wards without added risk of infection. The presence of positive tip culture is not a predictor of epidural space infection, and colonization is not equivalent to infection; hence, routine culture is not needed. Bacterial migration from the skin along the epidural track is the most common mode of bacterial colonization; hence, strict asepsis is necessary.

CASE REPORT

Ebru Atike Ongun, Reha Artan, Aysen Bingol, Oguz Dursun

A rare aspect of Crohn's disease: Pulmonary involvement in a child

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:3] [Pages No:114 - 116]

Keywords: Acute respiratory distress syndrome, colectomy, Crohn, infliximab, pulmonary

   DOI: 10.4103/0972-5229.175941  |  Open Access |  How to cite  | 

Abstract

Crohn\'s disease (CD), known as the disease of gastrointestinal system, is a granulamatous systemic disorder with extraintestinal manifestations including the respiratory system. The resemblance in the embriological origins and the immunities of both organ systems\' mucosae, also the circulating immune complexes and the autoantibodies are accepted as contributing factors. The shift of inflammation may become prominent when the colon is removed after colectomy and independent of the bowel disease activity; pulmonary involvement may be exarbecated. In the pediatric population, CD associated pulmonary involvement is very rare, mainly in the form of subclinical alterations and the data are limited mostly to case reports. Therefore, it is possibly overlooked since the diagnosis relies on suspicion. We represent a 5-year-old CD patient with previous bronchiolitis episodes that might have resulted from CD-associated pulmonary involvement; whom later developed severe pneumonia resulting in acute respiratory distress syndrome and bronchiectasia following a colectomy operation.

CASE REPORT

Gentle Sunder Shrestha, Bishesh Sharma Poudyal, Gopal Sedain, Khandokar Imran Mahmud, Niranja Acharya

Cerebral venous thrombosis presenting with intracerebral hemorrhage in a patient with paroxysmal nocturnal hemoglobinuria

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:3] [Pages No:117 - 119]

Keywords: Cerebral venous thrombosis, intracerebral hemorrhage, paroxysmal nocturnal hemoglobinuria

   DOI: 10.4103/0972-5229.175948  |  Open Access |  How to cite  | 

Abstract

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke. Paroxysmal nocturnal hemoglobinuria (PNH) is a rare type of hemolytic anemia, frequently associated with thrombophilia. PNH may rarely present with CVT. Approximately, one-third of the patients with CVT develop cerebral hemorrhage. Here, we present a rare combination of CVT presenting with intracerebral hemorrhage in a patient with PNH. High index of suspicion is needed to avoid misdiagnosis. Patient was successfully managed with anticoagulation therapy.

CASE REPORT

Sanjay Prakash, Chaturbhuj Rathore

Serotonin syndrome presenting as surgical emergency: A report of two cases

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:3] [Pages No:120 - 122]

Keywords: Autonomic dysfunction, clonus, cyproheptadine, serotonin syndrome

   DOI: 10.4103/0972-5229.175944  |  Open Access |  How to cite  | 

Abstract

Serotonin syndrome (SS) is an iatrogenic, drug-induced clinical syndrome caused by serotoninergic hyperstimulation. The diagnosis of SS is easily overlooked as most physicians (up to 85%) are unaware of this syndrome as a clinical entity. Diagnosis is also difficult due to its protean manifestations which can mimic a variety of medical conditions. Herein, we describe two cases of SS, who initially presented to the Surgical Department as surgical emergencies. The first case developed urinary retention after the administration of sertraline. The second case developed features mimicking acute intestinal obstruction. Both cases responded to the removal of offending agents and administration of cyproheptadine. There is a need to increase the awareness of SS among physicians because of the widespread use of serotonergic agents all around the world.

CASE REPORT

Jyoti Narayan Sahoo

Should we do early and frequent charcoal hemoperfusion in phenytoin toxicity?

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:3] [Pages No:123 - 125]

Keywords: Charcoal hemoperfusion, hemodialysis, phenytoin toxicity

   DOI: 10.4103/0972-5229.175936  |  Open Access |  How to cite  | 

Abstract

Phenytoin toxicity or adverse drug reaction is common due to its narrow therapeutic window. Mild and moderate toxicity require supportive care and enteral activated charcoal. In severe toxicity, charcoal hemoperfusion (CHP) have been shown to decrease serum phenytoin half-life and early recovery. Here, we report two cases with phenytoin toxicity who showed marked clinical improvement after early and frequent CHP treatment.

LETTERS TO THE EDITOR

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

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:1] [Pages No:126 - 126]

   DOI: 10.4103/0972-5229.175945  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Sudha Chandelia, Nand Kishore Dubey

Warfarin-induced raised international normalized ratio is further prolonged by pantoprazole

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:2] [Pages No:127 - 128]

   DOI: 10.4103/0972-5229.175934  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Ritesh G. Menezes, Florence Benita

Synthetic cow dung powder poisoning: Therapeutic aspects

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:2] [Pages No:128 - 129]

   DOI: 10.4103/0972-5229.175949  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Noninvasive ventilation in acute respiratory distress syndrome: A long way ahead

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:2] [Pages No:129 - 130]

   DOI: 10.4103/0972-5229.175947  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Subrata Kumar Singha, Smita Kujur

Unusual manufacturing defect of the endotracheal tube: Problem revisited

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:2] [Pages No:130 - 131]

   DOI: 10.4103/0972-5229.175935  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Viroj Wiwanitkit, Beuy Joob

Risk factors for shock in dengue fever

[Year:2016] [Month:] [Volume:20] [Number:2] [Pages:2] [Pages No:131 - 132]

   DOI: 10.4103/0972-5229.175932  |  Open Access |  How to cite  | 

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