Indian Journal of Critical Care Medicine

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2017 | March | Volume 21 | Issue 3

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Ahmad Ali, Yahya Atiya, Rudo Lufuno Mathivha, Joel M. Dulhunty

Changes in B.type Natriuretic Peptide and Related Hemodynamic Parameters Following a Fluid Challenge in Critically Ill Patients with Severe Sepsis or Septic Shock

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:5] [Pages No:117 - 121]

Keywords: B-type natriuretic peptide, critically ill, fluid challenge, hemodynamic, intensive care, sepsis, severe sepsis, shock

   DOI: 10.4103/ijccm.IJCCM_318_16  |  Open Access |  How to cite  | 


Context: Severe sepsis or septic shock. Aims: The aim of this study is to examine the effect of a fluid challenge on the B-type natriuretic peptide (BNP) and the hemodynamic state. Settings and Design: This observational study was conducted in an intensivist-led academic, mixed medical-surgical Intensive Care Unit. Subjects and Methods: Focused transthoracic echocardiogram, plasma BNP, and hemodynamic measurements were recorded at baseline and following a 500 ml fluid challenge in thirty patients. Independent predictors of the percentage (%) change in stroke volume (SV) were sought. Next, these independent predictors were assessed for a relationship with the percentage change in BNP. Statistical Analysis Used: Multiple linear regressions, Wilcoxon rank-sum test, t-test, and Pearson's correlation were used. Data analysis was carried out using SAS. The 5% significance level was used. Results: Using a multiple regression models, the percentage increase in SV was independently predicted by the percentage increase in mean arterial pressure, left ventricular end-diastolic volume/dimension (LVEDV/LVEDd), ejection fraction, and a decrease in Acute Physiology and Chronic Health Evaluation II score (P < 0.0001). Preload, measured using LVEDV1 (before the fluid challenge) was significantly larger in the fluid nonresponders (%SV increase <15%) vs. the responders (%SV increase ≥15%). Finally, the percentage change in BNP was positively correlated with left ventricular size at end diastole LVEDd, r = 0.4, P < 0.035). Conclusions: An increase in BNP soon after a fluid challenge may have some predictive utility of a large LVEDd, which in turn can be used to independently predict the SV response to a fluid challenge.



Richa Lal, Arvind K. Baronia, Kirti Mahadeorao Naranje, Arpita Bhriguvanshi, Ratender K. Singh

Blood Glucose Variability and Outcomes in Critically III Children

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:5] [Pages No:122 - 126]

Keywords: Blood glucose abnormalities, hyperglycemia, mortality, multiorgan dysfunction syndrome, variability

   DOI: 10.4103/ijccm.IJCCM_364_16  |  Open Access |  How to cite  | 


Objectives: To find the incidence of hyperglycemia (blood glucose [BG] ≥150 mg/dl), hypoglycemia (BG ≤60 mg/dl), and variability (presence of hypoglycemia and hyperglycemia) in critically ill children in the 1st week of Intensive Care Unit (ICU) stay and their association with mortality, length of ICU stay, and organ dysfunction. Materials and Methods: The design was a retrospective observational cohort study. Consecutive children ≤18 years of age admitted from March 2003 to April 2012 in a combined adult and pediatric closed ICU. Relevant data were collected from chart review and hospital database. Results: Out of 258 patients included, isolated hyperglycemia was seen in 139 (53.9%) and was unrelated to mortality and morbidity. Isolated variability in BG was noted in 76 (29.5%) patients and hypoglycemia was seen in 9 (3.5%) patients. BG variability was independently associated with multiorgan dysfunction syndrome on multivariate analysis (adjusted odds ratio [OR]: 7.1; 95% confidence interval [CI]: 1.6–31.1). Those with BG variability had longer ICU stay (11 days vs. 4 days, on log-rank test, P = 0.001). Insulin use was associated with the occurrence of variability (adjusted OR: 3.6; 95% CI: 1.8–7.0). Conclusion: Glucose disorders were frequently observed in critically ill children. BG variability was associated with multiorgan dysfunction and increased ICU stay.



Mohammed Meziane, Sidi Driss El El Jaouhari, Abdelghafour ElKoundi, Mustapha Bensghir, Hicham Baba, Redouane Ahtil, Khalil Aboulaala, Hicham Balkhi, Charki Haimeur

Unplanned Intensive Care Unit Admission following Elective Surgical Adverse Events: Incidence, Patient Characteristics, Preventability, and Outcome

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:4] [Pages No:127 - 130]

Keywords: Adverse events, elective surgery, outcomes, preventability, unplanned Intensive Care Unit admission

   DOI: 10.4103/ijccm.IJCCM_428_16  |  Open Access |  How to cite  | 


Context: Adverse events (AEs) are a persistent and an important reason for Intensive Care Unit (ICU) admission. They lead to death, disability at the time of discharge, unplanned ICU admission (UIA), and prolonged hospital stay. They impose large financial costs on health-care systems. Aims: This study aimed to determine the incidence, patient characteristics, type, preventability, and outcome of UIA following elective surgical AE. Settings and Design: This is a single-center prospective study. Methods: Analysis of 15,372 elective surgical procedures was performed. We defined UIA as an ICU admission that was not anticipated preoperatively but was due to an AE occurring within 5 days after elective surgery. Statistical Analysis: Descriptive analysis using SPSS software version 18 was used for statistical analysis. Results: There were 75 UIA (0.48%) recorded during the 2-year study period. The average age of patients was 54.64 ± 18.02 years. There was no sex predominance, and the majority of our patients had an American Society of Anesthesiologist classes 1 and 2. Nearly 29% of the UIA occurred after abdominal surgery and 22% after a trauma surgery. Regarding the causes of UIA, we observed that 44 UIA (58.7%) were related to surgical AE, 24 (32%) to anesthetic AE, and 7 (9.3%) to postoperative AE caused by care defects. Twenty-three UIA were judged as potentially preventable (30.7%). UIA was associated with negative outcomes, including increased use of ICU-specific interventions and high mortality rate (20%). Conclusions: Our analysis of UIA is a quality control exercise that helps identify high-risk patient groups and patterns of anesthesia or surgical care requiring improvement.



Eric Shih Hsiung Lee, Danny Tse Jiann Lim, Juvel Mabao Taculod, Juliet Tolentino Sahagun, Joerie Pasive Otero, Kaimin Teo, Will Ne-Hooi Loh, Addy Yong Hui Tan

Factors Associated with Reintubation in an Intensive Care Unit: A Prospective Observational Study

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:7] [Pages No:131 - 137]

Keywords: Extubation failure, mechanical ventilation, risk factors

   DOI: 10.4103/ijccm.IJCCM_452_16  |  Open Access |  How to cite  | 


Background and Aims: The objective of the study was to determine the incidence of failed extubations in our Intensive Care Unit (ICU) and identify associated clinical factors. Materials and Methods: A prospective observational study of mechanically ventilated patients who underwent extubation attempts in our (predominantly surgical) ICU was undertaken from July 2012 to August 2013. The primary endpoint was the need for nonelective reintubation within 72 h of extubation. Clinical data of the reintubated patients were compared with those who were successfully extubated to identify factors associated with reintubation. Results: Five hundred and eight extubation attempts were documented, 38 (7.5%) of which were unsuccessful. On multivariate analysis, the following clinical factors were found to be associated with an increased risk of failed extubation: unplanned extubations (adjusted odds ratio [OR] 5.8), the use of noninvasive ventilation (NIV) postextubation (adjusted OR 3.2), and sepsis (adjusted OR 2.9). Patient demographic factors, other premorbid and comorbid medical conditions, and differences of laboratory parameters did not appear to significantly influence reintubation rates in our study. Conclusions: Our study has demonstrated a relatively low reintubation rate, likely due to inclusion of elective admissions/intubations in our patient population. Unplanned extubations, the use of NIV postextubation, and sepsis were associated with increased reintubation risk, reinforcing the need for increased vigilance in this subgroup of patients after extubation.



Clément Delmas, Jean-Marie Conil, Simon Sztajnic, Bernard Georges, Caroline Biendel, Camille Dambrin, Michel Galinier, Vincent Minville, Olivier Fourcade, Stein Silva, Bertrand Marcheix

Early Prediction of 3.month Survival of Patients in Refractory Cardiogenic Shock and Cardiac Arrest on Extracorporeal Life Support

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:8] [Pages No:138 - 145]

Keywords: Cardiac arrest, cardiogenic shock, extracorporeal life support, extracorporeal membrane oxygenation

   DOI: 10.4103/ijccm.IJCCM_32_17  |  Open Access |  How to cite  | 


Background: Extracorporeal life support (ECLS) holds the promise of significant improvement of the survival of patient in refractory cardiogenic shock (CS) or cardiac arrest (CA). Nevertheless, it remains to be shown to which extent these highly invasive supportive techniques could improve long-term patient's outcome. Methods: The outcomes of 82 adult ECLS patients at our institution between January 2012 and December 2013 were retrospectively analyzed. Results: Patients were essentially men (64.7%) and are 54 years old. Preexisting ischemic (53.7%) and dilated cardiomyopathy (14.6%) were frequent. ECLS indications were shared equally between CA and CS. ECLS-specific adverse effects as hemorrhage (30%) and infection (50%) were frequent. ECLS was effective for 43 patients (54%) with recovery for 35 (43%), 5 (6%) heart transplant, and 3 (4%) left ventricular assist device support. Mortality rate at 30 days was 59.8%, but long-term and 3-month survival rates were similar of 31.7%. Initial plasma lactate levels >5.3 mmol/L and glomerular filtration rate <43 ml/min/1.73 m2 were significantly associated with 3-month mortality (risk ratio [RR] 2.58 [1.21–5.48]; P = 0.014; RR 2.10 [1.1–4]; P = 0.024, respectively). Long-term follow-up had shown patients paucisymptomatic (64% New York Heart Association 1–2) and autonomic (activities of daily living [ADL] score 6 ± 1.5). Conclusion: In case of refractory CA or CS, lactates and renal function at ECLS initiation could serve as outcome predictor for risk stratification and ECLS indication.



Sabyasachi Das, Pankaj Kundra, Amit Shah, Syed Moied Ahmed, Apeksh Patwa, Ubaradka S. Raveendra, Sumalatha Radhakrishna Shetty, Jeson Rajan Doctor, Dilip K. Pawar, Singaravelu Ramesh

Republication: All India Difficult Airway Association 2016 Guidelines for Tracheal Intubation in the Intensive Care Unit

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:8] [Pages No:146 - 153]

Keywords: Complications, emergency department, intensive care, intubation bundle, ketamine, noninvasive positive pressure ventilation, tracheal intubation

   DOI: 10.4103/ijccm.IJCCM_57_17  |  Open Access |  How to cite  | 


Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often lifesaving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with under evaluation of the airway and suboptimal response to preoxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; Wherever, robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the (AIDAA) and Indian Society of Anaesthesiologists. Noninvasive positive pressure ventilation for preoxygenation provides adequate oxygen stores during TI for patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnea before hypoxemia sets in. High flow nasal cannula oxygenation at 60–70 L/min may also increase safety during intubation of critically ill patients. Stable hemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.


Round Table

Sarman Singh, Ashok Rattan, Neeraj Goel, Vivek Nangia, Vikas Manchanda, Supradip Ghosh, Debashish Dhar, Vinod Singh, Chand Wattal, Sonal Saxena, Jaswinder Kaur Oberoi, B.K. Rao, Iqbal Kaur, Sanghamitra Datta, Sharmila Sen Gupta

Convergence of Minds: For Better Patient Outcome in Intensive Care Unit Infections

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:6] [Pages No:154 - 159]

Keywords: Antimicrobial stewardship, clinical microbiologists, critical care, Intensive Care Unit, synergy

   DOI: 10.4103/ijccm.IJCCM_365_16  |  Open Access |  How to cite  | 


Background: There is emergence of resistance to the last-line antibiotics such as carbapenems in Intensive Care Units (ICUs), leaving little effective therapeutic options. Since there are no more newer antibiotics in the armamentarium in the near future, it has become imperative that we harness the interdisciplinary knowledge for the best clinical outcome of the patient. Aims: The aim of the conference was to utilize the synergies between the clinical microbiologists and critical care specialists for better patient care and clinical outcome. Materials and Methods: A combined continuing medical education program (CME) under the aegis of the Indian Association of Medical Microbiologists – Delhi Chapter and the Indian Society of Critical Care Medicine, Delhi and national capital region was organized to share their expertise on the various topics covering epidemiology, diagnosis, management, and prevention of hospital-acquired infections in ICUs. Results: It was agreed that synergy between the clinical microbiologists and critical care medicine is required in understanding the scope of laboratory tests, investigative pathway testing, hospital epidemiology, and optimum use of antibiotics. A consensus on the use of rapid diagnostics such as point-of-care tests, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and molecular tests for the early diagnosis of infectious disease was made. It was agreed that stewardship activities along with hospital infection control practices should be further strengthened for better utilization of the antibiotics. Through this CME, we identified the barriers and actionables for appropriate antimicrobial usage in Indian ICUs. Conclusions: A close coordination between clinical microbiology and critical care medicine opens up avenues to improve antimicrobial prescription practices.



Anton A. Kasatkin, Aleksandr L. Urakov, Anna R. Nigmatullina

Using Ultrasonography to Determine Optimal Head-down Tilt Position Angle in Patients before Catheterization of the Internal Jugular Vein

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:3] [Pages No:160 - 162]

Keywords: Internal jugular vein, respiratory-based internal jugular vein excursion, ultrasound scanning

   DOI: 10.4103/ijccm.IJCCM_299_16  |  Open Access |  How to cite  | 


Context: It is believed that 15°–25° head-down tilt position increases the internal jugular vein cross-sectional area (IJV CSA). The increase in IJV CSA before puncture reduces the risk of its perforation. This pattern was not observed in all patients. We assumed that the absence of respiratory-based IJV excursion is one of the criteria of head-down tilt position effectiveness. Aims: The aim of this study is to determine the head-down tilt angle, which ensures the absence of the respiratory-based IJV excursion. Subjects and Methods: Prospective study included twenty adult patients. The IJVs scanning was carried out in 1 min after placing the patients in a horizontal position on their back and in 1 min after placing them in the head-down tilt position at 5°, 10°, 15°, and 20° tilt angles. Results: We found that collapsibility index of <9% indicating the absence of respiratory-based IJV excursion was recorded in 25% of patients in the horizontal supine position. In this case, placing the patients in the Trendelenburg position for IJV catheterization may not be indicated. In 65% of the patients, the respiratory-based excursion was not observed at 10° head-down tilt position. Only 35% of the patients required 15° head-down tilt position. Conclusions: In clinical settings, the disappearance of respiratory-based vein excursion on the ultrasound scanner screen can be considered as criteria of the head-down tilt position effectiveness.



Amir Anushiravani, Seyed Masoom Masoompour

Assessing the Performance of a Medical Intensive Care Unit: A 5-year single-center Experience

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:4] [Pages No:163 - 166]

Keywords: Intensive Care Unit, mortality, performance

   DOI: 10.4103/ijccm.IJCCM_420_16  |  Open Access |  How to cite  | 


Patient care in the Intensive Care Unit (ICU) is complex and expensive, serving to provide optimal outcome as well as the adequate use of resources. Our objective was to determine variables associated with admission practices, processes of care, and clinical outcomes for critically ill patients. Admission records of a 10-bed ICU were gathered during a 5-year period. Variables such as average length of stay, bed turnover, bed occupancy rate, and turnover interval were evaluated. Of the 1719 patients evaluated, 54% were men. Mortality was highest between 10 pm and 2 am. There was no significant difference in ICU mortality during different days of the week. We showed that nonoffice hour admissions were not associated with poorer clinical outcomes, and significant differences in ICU mortality and ICU length of stay were not seen. Moreover, hospital mortality rates were not significantly higher for patients admitted to our ICU on weekends, at nights, or any day of the week.



J Indirakshi, A Sunnesh, M Aruna, M. Hari Krishna Reddy, Anil C. V. Kumar, V Sarat Chandra, B Sangeetha, D.T. Katyarmal, R Ram, V. Siva Kumar

Toxic Epidermal Necrolysis and Acute Kidney Injury due to Glyphosate Ingestion

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:3] [Pages No:167 - 169]

Keywords: Acute kidney injury, glyphosate, hemodialysis, toxic epidermal necrolysis

   DOI: 10.4103/ijccm.IJCCM_423_16  |  Open Access |  How to cite  | 


The literature, particularly from India, is scarce on the renal effects of glyphosate poisoning. Glyphosate causes toxicity not only after its ingestion but also after dermal exposure by inhalation route and on eye exposure. We present a patient report of glyphosate consumption which resulted in toxic epidermal necrolysis – the first report after glyphosate consumption and acute kidney injury.



Ram Narayan, Mansoor C. Abdulla, Jemshad Alungal

Transient Distal Renal Tubular Acidosis in Organophosphate Poisoning

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:2] [Pages No:170 - 171]

Keywords: Chlorpyrifos, distal renal tubular acidosis, hypokalemia, organophosphate, ventricular arrhythmias

   DOI: 10.4103/ijccm.IJCCM_298_16  |  Open Access |  How to cite  | 


Renal complications due to organophosphate poisoning are very rare. We are presenting a unique case of transient distal renal tubular acidosis due to organophosphate poisoning, which to the best of our knowledge is the first of its kind. An elderly female after deliberate self-harm with ingestion of chlorpyrifos had multiple ventricular arrhythmias due to hypokalemia secondary to distal renal tubular acidosis which improved completely after treatment.



Mrugank M. Bhavsar, T.V. Devarajan, P. Senthur Nembi, Ashwin K. Mani

Metastatic Endogenous Endophthalmitis: A Rare Presentation with Methicillin-resistant Staphylococcus aureus Prostatic Abscess

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:4] [Pages No:172 - 175]

Keywords: Endophthalmitis, methicillin-resistant Staphylococcus aureus, prostatic abscess, transrectal ultrasound, vancomycin

   DOI: 10.4103/ijccm.IJCCM_375_16  |  Open Access |  How to cite  | 


A 62-year-old male with the previous history of uncontrolled diabetes and hypertension on irregular treatment presented with a history of fever, dysuria, and urinary retention with progressive painful loss of vision over a period of 2 days. His eye examination showed hypopyon, and he was diagnosed to have rapidly progressive endogenous endophthalmitis. He was started on vancomycin and piperacillin-tazobactam empirically. His blood and urine cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Transesophageal echocardiography ruled out infective endocarditis. Intravitreal injection of vancomycin and ceftazidime was given. Vitreous culture also grew MRSA. A workup for possible source revealed multiple prostatic abscesses on the transrectal ultrasound. Antibiotic was changed to daptomycin in view of high vancomycin minimum inhibitory concentration. His vision was improved at the time of discharge.



Pradeep Kumar Sharma, Maneesh Kumar, Dinesh Kumar Yadav

Severe Hypertriglyceridemia Causing Pancreatitis in a Child with New-onset Type-I Diabetes Mellitus Presenting with Diabetic Ketoacidosis

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:6] [Pages No:176 - 181]

Keywords: Diabetic ketoacidosis, pancreatitis, severe hypertriglyceridemia

   DOI: 10.4103/ijccm.IJCCM_281_16  |  Open Access |  How to cite  | 


The triad of pancreatitis, hypertriglyceridemia, and diabetic ketoacidosis and its treatment has not been extensively discussed in the pediatric literature. We report a 4-year-old child with severe hypertriglyceridemia, pancreatitis, and diabetic ketoacidosis. Hypertriglyceridemia and pancreatitis with diabetic ketoacidosis can be successfully managed with insulin and hydration therapy in children. Early recognition of this triad is important as insulin requirements, recovery duration, and prognosis can be altered.



Mundilipalayam Sivakumar, R Senthil Kumar, P Nandakumar

Ludwig's Angina: A Nightmare Worsened by Adverse Drug Reaction to Antibiotics

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:3] [Pages No:179 - 181]

Keywords: Angioneurotic edema, hypersensitivity, submandibular infection

   DOI: 10.4103/ijccm.IJCCM_189_15  |  Open Access |  How to cite  | 


A 52-year-old obese gentleman presented to the hospital with complaints of fever and shortness of breath for 10 days. He was admitted in the ward and treated for acute exacerbation of asthma. He was shifted to the Intensive Care Unit (ICU) for persistent fever, neck swelling, airway obstruction and desaturation. Ludwig's angina was suspected and computed tomography of neck confirmed it. A difficult airway was anticipated and preceded with surgical tracheostomy. The patient had hypersensitivity reactions to piperacillin/tazobactam; hence, he was treated with clindamycin and metronidazole. The patient improved and was discharged after five days of ICU stay and 12 days of hospitalization. This case summarizes the rare incidence of Ludwig's angina with antibiotic adverse reactions. If angioneurotic edema is coincidental with features of Ludwig's angina, it becomes more challenging. Early identification, securing the airway, and antibiotic administration are the keystone to better survival.



Sayed Marashi, Maryam Vasheghani Farahani

Sophism in the Management of Acute Aluminum Phosphide Poisoning may Cause Patient Harm

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:1] [Pages No:182 - 182]

   DOI: 10.4103/ijccm.IJCCM_39_17  |  Open Access |  How to cite  | 



Gaurav Singh Tomar

Volatile Anesthetic for Management of Super-refractory Status Epilepticus

[Year:2017] [Month:] [Volume:21] [Number:3] [Pages:1] [Pages No:183 - 183]

   DOI: 10.4103/ijccm.IJCCM_235_16  |  Open Access |  How to cite  | 


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