Indian Journal of Critical Care Medicine

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2017 | December | Volume 21 | Issue 12

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Prakash Shastri, Rajesh Bhagchandani, Sunit Singhi, J. V. Peter, T. D. Chugh, for Indian Society of Critical Care Medicine Research Group

Tropical fevers in Indian intensive care units: A prospective multicenter study

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:8] [Pages No:811 - 818]

Keywords: Dengue, encephalitis, India, Intensive Care Unit, malaria, scrub typhus, tropical infections

   DOI: 10.4103/ijccm.IJCCM_324_17  |  Open Access |  How to cite  | 


Background and Aims: Infections in tropics often present as undifferentiated fevers with organ failures. We conducted this nationwide study to identify the prevalence, profile, resource utilization, and outcome of tropical fevers in Indian Intensive Care Units (ICUs). Materials and Methods: This was a multicenter prospective observational study done in 34 ICUs across India (July 2013–September 2014). Critically ill adults and children with nonlocalizing fever >48 h and onset < 14 days with any of the following: thrombocytopenia/rash, respiratory distress, renal failure, encephalopathy, jaundice, or multiorgan failure were enrolled consecutively. Results: Of 456 cases enrolled, 173 were children <12 years. More than half of the participants (58.7%) presented in postmonsoon months (August–October). Thrombocytopenia/rash was the most common presentation (60%) followed by respiratory distress (46%), encephalopathy (28.5%), renal failure (23.5%), jaundice (20%), and multiorgan failure (19%). An etiology could be established in 365 (80.5%) cases. Dengue (n = 105.23%) was the most common followed by scrub typhus (n = 83.18%), encephalitis/meningitis (n = 44.9.6%), malaria (n = 37.8%), and bacterial sepsis (n = 32.7%). Nearly, half (35% invasive; 12% noninvasive) received mechanical ventilation, a quarter (23.4%) required vasoactive therapy in first 24 h and 9% received renal replacement therapy. Median (interquartile range) ICU and hospital length of stay were 4 (3–7) and 7 (5–11.3) days. At 28 days, 76.2% survived without disability, 4.4% had some disability, and 18.4% died. Mortality was higher (27% vs. 15%) in patients with undiagnosed etiology (P < 0.01). On multivariate analysis, multiorgan dysfunction syndrome at admission (odds ratio [95% confidence interval]-2.8 [1.8–6.6]), day 1 Sequential Organ Failure Assessment score (1.2 [1.0–1.3]), and the need for invasive ventilation (8.3 [3.4–20]) were the only independent predictors of unfavorable outcome. Conclusions: Dengue, scrub typhus, encephalitis, and malaria are the major tropical fevers in Indian ICUs. The data support a syndromic approach, point of care tests, and empiric antimicrobial therapy recommended by Indian Society of Critical Care Medicine in 2014.



Prakash Babaliche, Siddharth Madnani, Sajal Kamat

Clinical profile of patients admitted with hyponatremia in the medical intensive care unit

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:6] [Pages No:819 - 824]

Keywords: Hyponatremia, moderate and severe hyponatremia, serum sodium, syndrome of inappropriate antidiuretic hormone secretion, tuberculosis

   DOI: 10.4103/ijccm.IJCCM_257_17  |  Open Access |  How to cite  | 


Background and Aims: Hyponatremia is the predominant electrolyte abnormality with an incidence rate of approximately 22%. It is the leading cause of morbidity and mortality with scarce data in Indian intensive care settings. The aim of this study is to evaluate the clinical features and etiology of hyponatremia in patients admitted to an Intensive Care Unit (ICU) of a tertiary care hospital. Materials and Methods: A 1-year prospective cross-sectional observational study was conducted, including 100 adult patients with moderate-to-severe hyponatremia admitted to the Medical ICU. Patients underwent investigations such as serum creatinine, blood urea nitrogen, serum osmolality, serum sodium, urine sodium, and urine osmolality, sputum culture, cerebrospinal fluid analysis, and neuroimaging. Data were analyzed using independent sample t-test, Chi-square test, and Fisher's exact test. Results: Vomiting (28) followed by confusion (26) was the most common complaint. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) (46) was the most common etiology for hyponatremia, and euvolemic hypoosmolar hyponatremia (50) was the most common type of hyponatremia. Confusion was significantly high in patients with severe hyponatremia as compared to patients with moderate hyponatremia (22 vs. 4, P < 0.001). In majority of the patients (46), SIADH was the main cause of euvolemic type of hyponatremia (P < 0.001). Increased urine sodium levels were observed in patients with SIADH (46), renal dysfunction (12), and drug-induced etiology (8, P < 0.001). Conclusion: Patients with hyponatremia secondary to an infectious cause should be meticulously screened for tuberculosis. The timely and effective treatment of hyponatremia is determined by the effective understanding of pathophysiology and associated risk factors of hyponatremia.



Abdul Ghafur, T. Raja, M. A. Raja, S. G. Raman, Balaji Venkatachalam

Monotherapy versus combination therapy against nonbacteremic carbapenem-resistant gram-negative infections: a retrospective observational study

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:5] [Pages No:825 - 829]

Keywords: Colistin-based combination therapy, colistin monotherapy, New Delhi metallo-beta-lactamase, extensively drug resistant, Gram-negative bacteria

   DOI: 10.4103/ijccm.IJCCM_243_17  |  Open Access |  How to cite  | 


Background: Superiority of colistin–carbapenem combination therapy (CCCT) over colistin monotherapy (CMT) against carbapenem-resistant Gram-negative bacterial (CRGNB) infections is not conclusively proven. Aim: The aim of the current study was to analyze the effectiveness of both strategies against CRGNB nonbacteremic infections. Design: This was a retrospective observational cohort study. Subjects and Methods: Case record analysis of patients who had CRGNB nonbacteremic infections identified over a period of 4 years (January 2012–December 2015) was done by medical record review at a tertiary care center in India. Statistical Analysis: P < 0.05 was considered as significant. Multivariate analysis was performed using Cox regression. Results: Out of 153 patients (pneumonia 115, urinary tract infection 17, complicated skin and soft-tissue infection 18, intra-abdominal infection 1, and meningitis 2), 92 patients received CCCT and 61 received CMT. Univariate analysis revealed higher Acute Physiology and Chronic Health Evaluation II (APACHE II) score, pneumonia as the diagnosis, and Klebsiella as the causative organism to be the risk factors for higher 28-day mortality (P = 0.036, 0.006, 0.016, respectively). Combination therapy had no significant impact on mortality (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.327–2.535, P = 0.857). Multivariate analysis revealed that higher APACHE II score and infection due to Klebsiella were found to be independent risk factors for higher mortality (OR = 3.16 and 4.9, 95% CI = 1.34–7.4 and 2.19–11.2, P = 0.008 and 0.0001, respectively). Conclusions: In our retrospective single-center series of CRGNB nonbacteremic infections, CCCT was not superior to CMT. Multicenter large observational studies or prospective randomized clinical trials are the need of the hour.



Priyanka Gupta, Pratima Gupta, Biswaroop Chatterjee, Garima Mittal, Shashank Prateek, Aroop Mohanty

Evaluation of Candida scoring systems to predict early candidemia: A prospective and observational study at a tertiary care hospital, Uttarakhand

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:6] [Pages No:830 - 835]

Keywords: Candida scoring systems, candidemia, Intensive Care Unit

   DOI: 10.4103/ijccm.IJCCM_159_17  |  Open Access |  How to cite  | 


Background: Candidemia in critically ill patients is usually a severe and life-threatening condition. Furthermore, due to its nonspecific presentation, it is difficult to diagnose leading to delayed treatment, prolonged hospitalization, and increased health-care costs with increase in morbidity and mortality. Objectives: In view of lack of data on “Candida scoring systems,” this study was designed to evaluate the effectiveness of these scoring systems in predicting the development of candidemia among the Intensive Care Unit patients. Materials and Methods: The “Candida score” was calculated at the onset of systemic inflammatory response syndrome, sepsis, or shock. Various scoring systems were compared using the area under the receiver operating characteristic curve. Results: Among all three bedside risk scoring systems to predict candidemia both Leon score and Wenzel score offered significant discrimination between candidemic and noncandidemic patients with P = 0.000 and 0.001, respectively. The area under the curve for the scoring systems was 0.946 (95% confidence interval [CI] = 0.89–1) and 0.818 (95% CI = 0.687–0.949). Conclusion: Leon scoring system was found to have highest specificity, diagnostic accuracy, and positive likelihood ratio among all. Thus, we might conclude that a Leon score of ≥2.5 was most suitable for diagnosis of candidemia with significant accuracy and shortening of turnaround time when compared to the gold standard of blood culture. To the best of our knowledge, this is the first report on the subject.



P. Jyothinath

Antioxidant therapy in patients with severe aluminum phosphide poisoning: A pilot study

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:5] [Pages No:836 - 840]

Keywords: Aluminum phosphide, N-acetyl cysteine, oxidative stress, poisoning

   DOI: 10.4103/0972-5229.220744  |  Open Access |  How to cite  | 


Background: N-acetyl cysteine (NAC) is a powerful antioxidant and has been used extensively in the treatment of paracetamol overdose with great success. Aluminum phosphide (ALP) ingestion results in significant oxidative stress. In this study, we evaluated the effects of NAC on mortality in patients with severe ALP poisoning. Subjects and Methods: This prospective intervention study was carried out in the emergency medical unit attached to the Nehru Hospital at PGIMER, Chandigarh, over a period of 1 year. All the patients presenting with severe ALP poisoning were randomized into two group. The treatment group received NAC in the dose of 150 mg/kg intravenous over 1 h, followed by 50 mg/kg over 4 h, followed by 100 mg/kg 16 h in 5% dextrose. The placebo group received 5% dextrose. The primary end point was mortality. Results: A total of 50 patients were recruited. The baseline parameters were comparable in both groups. The survivors in the treatment group received 19 g of NAC, but the nonsurvivors received only 12.15 g of NAC. The overall mortality in the study group was 88% with 87.5% mortality in the treatment group and 88.5% in the placebo group. Conclusions: Antioxidant therapy in the form of NAC in severe ALP poisoning did not confer any survival benefit.



Kiran Gudivada

Evaluation of quality indicators in an Indian intensive care unit using “CHITRA” database

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:6] [Pages No:841 - 846]

Keywords: Benchmark, critically ill, intensive care, quality indicators

   DOI: 10.4103/ijccm.IJCCM_303_17  |  Open Access |  How to cite  | 


Background: Quality indicators (QIs) are essential for maintaining quality of care in the critically ill. The Indian Society of Critical Care Medicine proposed benchmarks and enabled Indian Intensive Care Units (ICUs) to capture data in an electronic database: Customized Health in Intensive Care Trainable Research and Analysis (CHITRA) tool. The purpose of this study is to report QIs in an Indian ICU using this database. Materials and Methods: Data from patients admitted to ICU between October 2015 and January 2017 were entered into CHITRA. The following QIs were analyzed: standardized mortality ratio (SMR), length of ICU stay (LOS-ICU), pressure ulcer (PU) rate, patient fall rate (FR), ICU readmission rate, reintubation rate, ventilator-associated condition (VAC), central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and iatrogenic pneumothorax rate. Results: A total of 2642 patient's information was suitable for analysis. Median age of ICU admission was 53 years (interquartile range [IQR]: 36–65), with a mean APACHE score of 18 (SD 7.7). Median LOS-ICU was 3 days (IQR 2–6) and SMR was 1.1 (95% confidence interval 1.05–1.38). Pneumothorax rate, PU rate, and FR were 2.6, 4.1, and 0.3 per 1000 respectively, whereas readmission rate was 0.7% and reintubation rate was 3.5%. VAC, CLABSI, and CAUTI were 8.5, 23, 3.1 per 1000 ventilator and catheter days, respectively. Conclusion: This study has successfully evaluated a range of QIs in a mixed ICU of a tertiary hospital utilizing CHITRA database.



Shahram Amini, Hasan Abbaspour, Negar Morovatdar, Hojat Robabi, Ghasem Soltani, Mohammad Tashnizi

Risk factors and outcome of acute kidney injury after congenital heart surgery: A prospective observational study

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:5] [Pages No:847 - 851]

Keywords: Acute kidney injury, congenital heart surgery, outcome, prediction

   DOI: 10.4103/ijccm.IJCCM_459_16  |  Open Access |  How to cite  | 


Backgrounds and Aims: Acute kidney injury (AKI) is a frequent event after congenital heart surgery with increased mortality and morbidity. We investigated frequency, risk factors, and associated morbidity and mortality of AKI after pediatric cardiac surgery at a single institution. Methods: Children undergoing congenital heart surgery from March 2013 to February 2016 were assessed for development of AKI based on modified pediatric Risk, Injury, Failure, Loss, and End-stage renal disease criteria. They were also investigated for predictive risk factors, associated mortality, and morbidity including duration of mechanical ventilation, Intensive Care Unit (ICU), and hospital length of stay. Results: Five hundred and nineteen patients were recruited during the study period including 259 (49.9%) males and 260 (50.1%) females. AKI was seen in 150 (28.9%) patients including 101 (67.3%), 42 (28%), and 7 (4.7%) cases with risk, injury, and failure stages, respectively. Patients with AKI had longer ventilation time (P = 0.002), ICU (P = 0.05), and hospital (P = 0.56) stay. Mortality was seen in 31 (2.7%) and 44 (11.9%) patients with and without AKI, respectively (P = 0.01). After multivariable logistic regression, there was an association between AKI and preoperative abnormal levels of creatinine (adjusted odds ratio [aOR] = 0.47, 95% confidence interval [CI] 0.22–1.01; P = 0.05), presence of cyanotic heart disease (aOR = 1.97, 95% CI = 1.15–3.2; P = 0.01), duration of surgery (aOR = 1.05/10 min, 95% CI = 1.01–1.08; P = 0.007), and elevated lactate level (aOR = 1.14, 95% CI = 1.03–1.3; P = 0.01). Conclusion: The presence of cyanotic heart disease, duration of surgery, elevated postoperative lactate level, and likely preoperative creatinine level were independent risk factors for the development of AKI after congenital heart surgery.



Nithin Raju, Shoma Rao, J. Joel, Gijoe Jacob, Arun Anil, S. Gowri

Predictive value of serum myoglobin and creatine phosphokinase for development of acute kidney injury in traumatic rhabdomyolysis

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:5] [Pages No:852 - 856]

Keywords: Acute kidney injury, crush protocol, myoglobin, rhabdomyolysis

   DOI: 10.4103/ijccm.IJCCM_186_17  |  Open Access |  How to cite  | 


Introduction: Rhabdomyolysis (RM) is a condition where there is injury to striated muscle fibers causing release of myoglobin, creatine phosphokinase (CPK), and other intracellular contents into the circulation. High myoglobin levels cause acute kidney injury (AKI). Trauma is the most common cause of RM and development of complications related to the degree of myoglobin released. Currently, the degree of RM is assessed and treatment is instituted based on serum CPK. As myoglobin is the direct cause of AKI, we set out to determine if serum myoglobin is a more reliable predictor than CPK for the development of AKI in traumatic RM. Methodology: A prospective observational study of 90 patients was admitted to the surgical Intensive Care Unit/high dependency unit of a tertiary hospital with traumatic RM whose serum CPK >5000 U/L. Along with standard treatment including intravascular volume optimization and hemodynamic stabilization, they were treated with “crush protocol.” Daily/twice a day, serum CPK and myoglobin were estimated. Categorical data are expressed as frequency and percentage, and the continuous variables are presented as mean (standard deviation) or median (interquartile range) based on normality. Other statistical analyses were done using the Chi-square test, independent t-test, and rank sum test based on normality. Results: Fourteen out of 90 patients developed AKI and one patient required renal replacement therapy. CPK value of >12,000 U/l was identified to have 64% sensitivity and 56% specificity for developing AKI whereas serum myoglobin value of >5000 ng/ml was identified to have 78% sensitivity and 77% specificity for developing AKI. Conclusion: Following traumatic RM, in patients on “crush protocol,” serum myoglobin is a more sensitive and specific test than serum CPK, for predicting AKI.



O. T. Ahammed Nizar, Pratheeksha Rai, Shobhana Rao, M. Shenoy

Plasmapheresis: A retrospective audit of procedures from a tertiary care center in Southern India

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:4] [Pages No:857 - 860]

Keywords: Complications, dialysis, fluid replacement, plasma exchange

   DOI: 10.4103/ijccm.IJCCM_177_17  |  Open Access |  How to cite  | 


Introduction: The term plasmapheresis/plasma exchange refers to the removal of the plasma component of blood and its replacement with various fluids. Plasma Exchange (PE) has been used to treat a variety of conditions that are associated with an aberrant immune response. We undertook this retrospective study aiming to look at plasmapheresis procedures conducted in the nephrology department over a fixed time period. Materials and Methods: Retrospective analysis of PE procedures from January 2013 to October 2016 was conducted in the nephrology and Intensive Care Unit of a tertiary care teaching hospital. The goal was to achieve a total removal of 150–200 ml/plasma per kg body weight. As replacement, we used a standard protocol of 100 ml of 20% albumin in 1 L of normal saline and 2–3 units of fresh frozen plasma. All results were expressed as mean ± standard deviation and statistical analysis was done using the Student's t-test for continuous and Fisher's exact test for categorical data. Results: A total of 192 procedures performed on 40 patients (22 males and 18 females). Age ranged from 15 to 79 years with a mean age of 37.5 years. Guillain–Barre syndrome accounted for 67.5% (>two-third of causes) for PE. Vascular access was femoral catheter in 27 (67.5%) and internal jugular catheter in 13 (32.5%). Mild hypotension occurred in 15 procedures (7.8%) of patients and allergic reactions such as rashes and chills occurred in 5 cycles (2.6%). A total of 36 patients (90%) showed significant improvement in condition, 2 did not show any change, while one worsened and one died due to respiratory complications. Conclusion: Our small series of data of plasmapheresis procedures from nephrology perspective has reaffirmed the safety and efficacy of the therapy in an experienced setup.



Divya Khurana, Shilpa A. Deoke

Thrombocytopenia in critically ill patients: Clinical and laboratorial behavior and its correlation with short-term outcome during hospitalization

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:4] [Pages No:861 - 864]

Keywords: Critically ill patients, prognostic marker, thrombocytopenia

   DOI: 10.4103/ijccm.IJCCM_279_17  |  Open Access |  How to cite  | 


Background: Thrombocytopenia, being among the most common laboratory abnormality, found in Intensive Care Unit (ICU) patients is commonly associated with sepsis and disseminated intravascular coagulation. Declining platelet counts are associated with higher mortality rates. Thus, thrombocytopenia can be used as a prognostic marker in critically ill patients. Methodology: A prospective observational study was conducted on patients fulfilling the inclusion criteria and were evaluated for complete medical history, clinical, and laboratorial examination. Short-term outcome of the patient was correlated with thrombocytopenia. Results: The incidence of thrombocytopenia in ICU patients was 37.57%, and mortality was 44%. Higher mortality rate was found among patients with acute febrile illnesses, respiratory diseases, and sepsis (P = 0.08, 0.22, 0.41 respectively). The mortality was higher in patients with platelet counts <100,000/μl (P = 0.0008) and whose platelet levels declined on day 3 or 5 (P = 0.0001). Conclusions: Low as well as declining platelet counts are markers of severity of critical patients and are directly related to prognosis and mortality of patients in ICU.



Tim Stephens, Arjen M. Dondorp, Anuruddha Padeniya, Ambepitiyawaduge De Silva, Kaushila Thilakasiri, Priyantha Athapattu, Palitha G. Mahipala, Ponsuge Sigera

Practices and perspectives in cardiopulmonary resuscitation attempts and the use of do not attempt resuscitation orders: A cross-sectional survey in Sri Lanka

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:4] [Pages No:865 - 868]

Keywords: Cardiopulmonary resuscitation, critical care, do not attempt cardiopulmonary resuscitation, resource-limited, resuscitation

   DOI: 10.4103/ijccm.IJCCM_314_17  |  Open Access |  How to cite  | 


Objective: The objective of this study is to describe the characteristics of in-hospital cardiopulmonary resuscitation (CPR) attempts, the perspectives of junior doctors involved in those attempts and the use of do not attempt resuscitation (DNAR) orders. Methods: A cross-sectional telephone survey aimed at intern doctors working in all medical/surgical wards in government hospitals. Interns were interviewed based on the above objective. Results: A total of 42 CPR attempts from 82 hospitals (338 wards) were reported, 3 of which were excluded as the participating doctor was unavailable for interview. 16 (4.7%) wards had at least 1 patient with an informal DNAR order. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt, of which 6 occurred on wards with an informal DNAR order in place. 39 resuscitations were attempted. Survival at 24 h was 2 (5.1%). In 5 (13%) attempts, CPR was the only intervention reported. On 25 (64%) occasions, doctors were “not at all” or “only a little bit surprised” by the arrest. Conclusions: CPR attempts before death in hospitals across Sri Lanka is prevalent. DNAR use remains uncommon.



P. V. Shiji, Chandni Radhakrishnan

Cerebral venous thrombosis after intravenous immunoglobulin therapy in immune thrombocytopenic purpura

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:3] [Pages No:869 - 871]

Keywords: Immune thrombocytopenic purpura, intravenous immunoglobulin, venous thrombosis

   DOI: 10.4103/ijccm.IJCCM_308_17  |  Open Access |  How to cite  | 


A common misconception is that immune thrombocytopenic purpura (ITP) causes only bleeding diathesis. From this case vignette of a young male with ITP who had cerebral venous thrombosis, we highlight the importance of considering venous thrombosis in such patients when they present with focal cerebral signs.



Himmatrao Bawaskar, Pramodini H. Bawaskar, Parag H. Bawaskar

Rabies: A novel clinical presentation

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:3] [Pages No:872 - 874]

Keywords: Elapid venom, GABA, glycoprotein, NMDA, rabies

   DOI: 10.4103/ijccm.IJCCM_245_13  |  Open Access |  How to cite  | 


Rabies is a fatal disease. Saliva of a rabid dog is a rich source of rabies virus. We report a patient who suffered of rabies, who was infected by abrasion caused by the nails of a rabid dog. Dogs often lick their nails and thereby transfer the rabies virus-contaminated saliva to their claws. Despite treatment in our Intensive Care Unit and application of various pharmacological antidotes, we were unable to prevent the fatal outcome.



Chung-Tat Lun, Henry Yuen, George Ng, Sheung-On So, Anne Leung, Kang-Yiu Lai

Metformin-associated lactic acidosis requiring intensive care in a regional hospital in Hong Kong and predictive factors for mortality

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:3] [Pages No:875 - 877]

   DOI: 10.4103/ijccm.IJCCM_210_17  |  Open Access |  How to cite  | 



Bibhukalyani Das, Indranil Ghosh, Sukalyan Purakayastha

Reversible myocardial dysfunction after subarachnoid bleed

[Year:2017] [Month:] [Volume:21] [Number:12] [Pages:3] [Pages No:877 - 879]

   DOI: 10.4103/ijccm.IJCCM_374_17  |  Open Access |  How to cite  | 


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