Indian Journal of Critical Care Medicine

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2017 | July | Volume 21 | Issue 7

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Mohamed Abbas

Bemiparin Versus Enoxaparin in the Prevention of Venous Thromboembolism among Intensive Care Unit Patients

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:5] [Pages No:419 - 423]

Keywords: Bemiparin, enoxaparin, Intensive Care Unit, low-molecular-weight heparin, venous thromboembolism

   DOI: 10.4103/ijccm.IJCCM_23_17  |  Open Access |  How to cite  | 


Background: Critically ill patients are considered a high-risk group for developing venous thromboembolism (VTE). Due to their impaired cardiopulmonary reserve, these VTEs may result in significant morbidity and mortality. In this study, we compared two types of low molecular weight heparin, enoxaparin, and bemiparin, as regards to their efficacy and safety in VTE prevention among Intensive Care Unit (ICU) patients. Methods: This study was a prospective, randomized trial of 100 critically ill patients who are at high risk for developing VTE were included in this study and assigned to receive subcutaneous injections of either 3500 international units (IU) anti-factor Xa of bemiparin sodium or 40 mg of enoxaparin given once a day and patient were followed for 60 days after initiation of anticoagulant therapy for the development of documented deep venous thrombosis (DVT) using bilateral lower limb venous duplex, documented pulmonary embolism using computed tomography pulmonary angiography, and complications related to injectant anticoagulant. Results: Confirmed DVT was observed in two patients (4%) in the bemiparin group compared with 10 patients (20%) in the enoxaparin group with P < 0.05. Confirmed pulmonary embolism (PE) was observed in seven patients (14%) in the enoxaparin group with no recorded cases of confirmed PE in the bemiparin group (P < 0.05). No deaths were recorded in either group. Adverse events such as ecchymosis or hematoma at the injection site were observed in one patient (2%) in the bemiparin group and eight patients (16%) in the enoxaparin group (P < 0.05). There was no significant statistical difference between both groups as regards other adverse effects and complications related to the injectant anticoagulant. Conclusion: Bemiparin was superior to enoxaparin as a prophylactic anticoagulant for VTE in critically ill patients with less adverse local complications at the injection site. The study was registered on Registration ID: NCT02795065. Registered June 8, 2016.



Shilpa A. Rao, Aditya R. Kunte

Interleukin-6: An Early Predictive Marker for Severity of Acute Pancreatitis

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:5] [Pages No:424 - 428]

Keywords: Inflammatory cytokines, interleukins, predictive markers, severe acute pancreatitis

   DOI: 10.4103/ijccm.IJCCM_478_16  |  Open Access |  How to cite  | 


Background and Aims: Interleukin (IL)-6, IL-8, IL-10, and C-reactive protein (CRP) have been evaluated for predicting outcomes of acute pancreatitis. However, there is considerable variation in their performance among different studies. We evaluate their accuracy in predicting progression to severe pancreatitis. Materials and Methods: Serum IL-6, IL-8, IL-10, and CRP levels were measured within 24 h of admission in forty patients of clinically predicted severe acute pancreatitis (SAP). Persistent organ failure (>48 h) defined SAP. The performance of inflammatory markers was evaluated in predicting the progression of pancreatitis. Results: IL-6 ≥28.90 pg/mL had a sensitivity of 62.86%, specificity of 80%, positive predictive value (PPV) of 95.65%, LR+ of 3.1429, LR− of 0.4643, and diagnostic odds ratio (DOR) of 6.7692; IL-8 ≥88.70 pg/mL had a sensitivity of 60%, specificity of 80%, PPV of 95.45%, LR+ of 3.000, LR− of 0.5000, and DOR of 6.000; IL-10 ≤5.70 pg/mL had DOR of 0.2647, sensitivity of 51.43%, specificity of 20%, PPV of 81.82%, LR+ of 0.6429, and LR− of 2.4286. CRP ≥110.00 mg/L had DOR of 2.3636, sensitivity of 37.14%, specificity of 80%, PPV of 92.86%, LR+ of 1.8571, and LR of 0.7857. Conclusions: IL-6 ≥28.90 pg/mL, measured within 48 h of onset is the best among the tested biomarkers in this study for predicting the progression to severe pancreatitis.



Hoda Chookalayi, Mohammad Hasanpour, Sajjad Jabrailzadeh, Fatemeh Sadeghpour

A Study on The Psychometric Properties of Revised-Nonverbal Pain Scale and Original-Nonverbal Pain Scale in Iranian Nonverbal-Ventilated Patients

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:7] [Pages No:429 - 435]

Keywords: Instrument, Intensive Care Unit, mechanical ventilation, pain, pain measurement

   DOI: 10.4103/ijccm.IJCCM_114_17  |  Open Access |  How to cite  | 


Background and Aims: The nonverbal pain scale is one of the instruments which study pain in nonverbal-ventilated patients with regard to the changes of behavioral and physiological indices. The purpose of the study is to survey the psychometric properties of revised-nonverbal pain scale (R-NVPS) and original-nonverbal pain scale (O-NVPS) in ventilated patients hospitalized in critical care units. Materials and Methods: Four nurses studied pain in sixty patients hospitalized in trauma, medical, neurology, and surgical critical care units using R-NVPS and O-NVPS at six times (before, during, and after nociceptive and nonnociceptive procedures). The test was repeated in 37 patients after 8–12 h. Results: Cronbach's alpha coefficient for R-NVPS and O-NVPS was 0.8 and 0.76, respectively. The inter-rater correlation coefficient during different times was r = 0.89–0.96 for R-NVPS and r = 0.80–0.87 for O-NVPS. Test-retest correlation coefficient for R-NVPS and O-NVPS was r = 0.55–0.86 and r = 0.51–0.75, respectively. The meaningful difference in pain score between nociceptive and nonnociceptive procedures (P < 0.001) and a higher pain score in patients who confirmed pain (P < 0.001) showed a discriminant and criterion validity for both scales of NVPS, respectively. Conclusions: R-NVPS and O-NVPS can both be used as valid and reliable scales in studying pain in ventilated patient. However, in comparing the items, “respiration” (R-NVPS) had a higher sensitivity than “physiology II” (O-NVPS) in assessing pain.



Liqaa A. Raffee, Shaher M. Samrah, Hani Najih Al Yousef, Mahmoud Abu Abeeleh, Khaled Z. Alawneh

Incidence, Characteristics, and Survival Trend of Cardiopulmonary Resuscitation Following In-Hospital Compared to Out-of-Hospital Cardiac Arrest in Northern Jordan

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:6] [Pages No:436 - 441]

Keywords: Arrests, cardiac, in-hospital, survival

   DOI: 10.4103/ijccm.IJCCM_15_17  |  Open Access |  How to cite  | 


Background: Cardiac arrest remains a leading cause of mortality worldwide. Early cardiopulmonary resuscitation (CPR) is the cornerstone intervention to optimize the survival rates. Objectives: The main aim of this study was to determine and compare the incidence, characteristics, risk factors, and outcomes of CPR in a referral university hospital following in-hospital cardiac arrests (IHCAs) and out-of-hospital cardiac arrest (OHCA) in Northern Jordan. Patients and Methods: Retrospective observational study of adults referred to King Abdulla University Hospital who received CPR between January 2014 and January 2015. Data were obtained from the medical recorded of included patients. The primary outcome was survival to hospital discharge. Chi-square and logistic regression analyses were performed to identify risk factors associated with survival to discharge. Results: A total of 79 OHCA and 257 IHCA were included in the study. The overall survival rate for OHCA was 2.97%. The survival rate increased to 4.3% if CPR performed before arriving the hospital. Only 22% of the OHCA cases had CPR performed mainly due to lack of knowledge and skills of bystanders. The survival rate for IHCA was 14.88%. In this study, patient survival was not associated with age, smoking habit, diabetes mellitus, cancer status, hypertension, or heart failure. Conclusion: This is the first study to describe the incidence and outcome of adult IHCA and OHCA in Jordan. The findings will serve as a benchmark to evaluate future impact of changes in service delivery, organization, and treatment for OHCA and IHCA. Furthermore, findings will urge the regulatory bodies to establish well-structured Emergency Medical Service system. Educational programs at the national level to improve public awareness of CPR intervention are crucial to improve survival rates.



Hadi Hamishehkar, Vahid Fattahi, Mehran Mesgari

The Effect of Furosemide on the Level of Neutrophil Gelatinase-Associated Lipocalin in Critically Hospitalized Patients with Acute Kidney Injury

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:6] [Pages No:442 - 447]

Keywords: Acute kidney injury, furosemide, Intensive Care Unit, plasma neutrophil gelatinase-associated lipocalin, urine neutrophil gelatinase-associated lipocalin

   DOI: 10.4103/ijccm.IJCCM_93_17  |  Open Access |  How to cite  | 


Background and Aims: Oliguric acute kidney injury (AKI), commonly attributed to a more severe degree of renal injury, is associated with poorer prognosis than nonoliguric form. The aim of this study was to determine the effect of furosemide therapy on kidney function and on the level of neutrophil gelatinase-associated lipocalin (NGAL) in critically hospitalized patients in the Intensive Care Unit (ICU). Materials and Methods: In this randomized controlled trial, 106 ICU patients with AKI were assigned into furosemide and control groups. In furosemide group, 40–80 mg of intravenous furosemide was administrated, followed by 1–5 mg/h furosemide infusion. In control group, patients received standard treatment. Serum and urinary NGAL were measured on the 1st, 3rd, and 7th days of the study. Results: The results of this study indicated that during the study, serum blood urea nitrogen levels of patients increased in both groups; this, however, was significant only in the control group (P = 0.009). Both plasma and urine NGAL decreased significantly (P < 0.05) in both groups. The findings of 28-day mortality follow-up revealed that 20% and 28% of patients died in the furosemide and the control groups, respectively. Conclusions: NGAL was not found to reflect any positive or negative effects of Furosemide in patients with AKI.



Saurabh Mittal, Vijay Hadda, Gopi C. Khilnani, Ashesh Dhunguna, Maroof Ahmad Khan

Intra- and Inter-Observer Reliability of Quadriceps Muscle Thickness Measured with Bedside Ultrasonography by Critical Care Physicians

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:5] [Pages No:448 - 452]

Keywords: Critical care physicians, muscle thickness, quadriceps, reliability, ultrasonography

   DOI: 10.4103/ijccm.IJCCM_426_16  |  Open Access |  How to cite  | 


Background: Muscle wasting is common among critically ill patients with sepsis and has a significant effect on clinical outcome. However, appropriate tool for measurement of muscle loss is debatable. Ultrasonography (USG) has been used for objective assessment of quadriceps muscle thickness among these patients; however, there is limited data on its reliability. Aims and Objective: This study was aimed to assess the reliability of quadriceps muscle thickness as measured by critical care physicians. Methodology: This cross-sectional study included twenty patients with sepsis. Quadriceps muscle thickness was measured on right mid-thigh at a predefined point by two critical care fellows using bedside USG. Intra- and inter-observer reliability of the measurements was assessed by intra-class correlation coefficient (ICC). Results: Hundred and twenty quadriceps muscle thickness measurements, three by each of the two critical care fellows, were done in twenty patients with sepsis. First, second, and third measurements (mean ± standard deviation) taken by the first observer (RK) were 35.030 ± 3.546 mm, 35.055 ± 3.307 mm, and 35.245 ± 3.027 mm, respectively. The three values recorded by the second observer (AD) were 35.585 ± 3.746 mm, 35.1 ± 3.006 mm, and 34.89 ± 2.556 mm, respectively. ICC for observer 1 and 2 was 0.925 (95% confidence interval [CI]: 0.851–0.967) and 0.835 (95% CI: 0.689–0.925), respectively. The mean difference of measurement between two observers was 0.082 mm (95% CI: −1.194–1.031). The mean ICC (95% CI) for inter-observer reliability was 0.992 (0.979–0.997); P < 0.001. Conclusions: This study shows that ultrasound is a reliable tool for the measurement of quadriceps muscle thickness by critical care physicians with excellent inter- and intra-class reliability.



M. K. Renuka, A. S. Arunkumar

Clinical Features and Outcomes of Patients with Posterior Reversible Encephalopathy Syndrome

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:4] [Pages No:453 - 456]

Keywords: Clinical features, critically ill, eclampsia, posterior reversible encephalopathy syndrome

   DOI: 10.4103/ijccm.IJCCM_79_17  |  Open Access |  How to cite  | 


Aims: The aim of this study was to study the clinical features and outcomes of patients with posterior reversible encephalopathy syndrome (PRES) admitted to the Intensive Care Unit (ICU). Subjects and Methods: All adult patients admitted to our ICU with acute onset neurologic symptoms with focal vasogenic edema on magnetic resonance imaging (MRI) were included in the study. Data were collected on demography, coexisting illness, admission severity of illness, neurological symptoms, blood pressure, treatment initiated, and MRI findings. Outcome data collected included mortality, ICU average length of stay (ALOS), number of ventilator days, and neurological disability at discharge assessed by modified Rankin scale (MRS). Results: Fourteen patients were admitted with PRES. Thirteen patients were female, and their mean age was 31.5 ± 8.3 years. Etiology of PRES included eclampsia (64.2%), lupus nephritis (21.4%), CKD (7.1%), and hypertension (n = 1 [7.1%]). The most common presenting symptom was seizure (92.8%), followed by visual disturbance (42.8%), headache (42.8%), encephalopathy (14.2%), and status epilepticus (14.2%). The Glasgow coma scale on admission was 12.3 ± 2.9. High blood pressure was seen in 12 patients 85.7%; their mean systolic and diastolic pressures were 173 ± 10.2 and 110 ± 8.6 mmHg, respectively. MRI showed that parieto-occipital region was most commonly involved (92.8%), followed by frontal lobe (42.8%). ICU ALOS was 4.35 ± 2.4 days and mean ventilator days was 1.7 ± 2.0 days. One patient (1/14 [7.4%]) died of multiorgan failure and 13 patients were discharged with no residual neurological deficit (MRS, 0). Conclusions: PRES is a potentially reversible disorder with prompt recognition and control of blood pressure.



Dharmendra Bhadauria, Kirti Naranje, Anupama Kaul

Isolated Renal Mucormycosis in Immunocompetent Children: A Report of two Cases

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:3] [Pages No:457 - 459]

Keywords: Mucormycosis, renal biopsy, zygomycosis

   DOI: 10.4103/ijccm.IJCCM_184_17  |  Open Access |  How to cite  | 


Isolated renal mucormycosis is a rare entity in children. It is potentially fatal when not detected and managed early with antifungal therapy, and surgery as and when needed. We present two immunocompetent children who developed this infection and subsequently succumbed to it. The diagnosis was established postmortem on renal biopsy specimens. We also discuss the 9 cases of isolated renal involvement in children published in literature.



Jayalaxmi S. Aihole, Pragalath Kumar

Uncommon Presentation of an Unusual Foreign Body

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:3] [Pages No:460 - 462]

Keywords: Esophagus, foreign body, pharynx

   DOI: 10.4103/ijccm.IJCCM_436_16  |  Open Access |  How to cite  | 


Esophageal foreign bodies (FBs) are common and can be the serious cause of morbidity and mortality in children. One-third of FBs, retained in the gastrointestinal tract, are found in the esophagus. Their management depends on the anatomical location, shape, size, and the duration of impaction. In children, unwitnessed esophageal FBs can present with respiratory symptoms such as stridor. Therefore, a high index of suspicion is generally required to avoid significant morbidity and mortality. We are reporting an unusual FB with unusual symptoms in a 2-year-old female child.



Devinder Midha, Amit Kumar Mandal

Ultrasound Guidance for Central Venous Catheterization: A Step Further to Prevent Malposition of Central Venous Catheter Before Radiographic Confirmation

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:3] [Pages No:463 - 465]

Keywords: Central venous catheter, malposition, ultrasound

   DOI: 10.4103/ijccm.IJCCM_61_17  |  Open Access |  How to cite  | 


Ultrasound (USG) guidance has long been used for guiding central venous catheterization. USG provides direct visualization of needle puncture through the skin into the vein. Most of the time USG guidance is just limited to puncturing of the vein and seeing guidewire entering the vein while malpositioning of catheter occurs after that which is seen later on while checking chest radiograph. Repositioning of catheter after that becomes not only difficult requiring repeated chest radiograph to reconfirm position of catheter but also increases chances of infection with repeated manipulations. USG guidance can be used for tracing both guidewire and catheter during the procedure to prevent malpositioning of catheter, thus when done at the right time can prevent complication related to malpositioning and repeated manipulations. We used linear USG probe to check malposition of guidewire and microconvex probe to confirm position of central venous catheter.



Sujith M. Thomas, A Rajalakshmi

A Rare Case of Strongyloides Hyperinfection from Hypogammaglobulinemia

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:3] [Pages No:466 - 468]

Keywords: Agammaglobulinemia, autoinfection, cell-mediated immunity, humoral immunity, parasites, Strongyloides

   DOI: 10.4103/ijccm.IJCCM_139_17  |  Open Access |  How to cite  | 


Strongyloides infection can range from asymptomatic eosinophilia to disseminated disease. Common in tropical and subtropical nations, it can lead to hyperinfection, an autoinfection increasing parasitic burden in immunocompromised. Cell-mediated immunity is important in combating parasite infection. We present a case of Strongyloides hyperinfection in hypogammaglobulinemia which was refractory to conventional treatment but responded to immunoglobulin administration with complete resolution indicating role of humoral immunity also.



Manu Goyal, Kanu Goyal, Kanimozhi Narkeesh, Asir John Samuel, Narkeesh Arumugam, Subhasish Chatterjee, Sorabh Sharma

Efficacy of Osteopathic Manipulative Treatment Approach in the Patient with Pulmonary Fibrosis in Critical Care Outpatient Department

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:4] [Pages No:469 - 472]

Keywords: Dyspnea, lung fibrosis, manual therapy, pulmonary fibrosis, visceral osteopathy

   DOI: 10.4103/0972-5229.210648  |  Open Access |  How to cite  | 


The purpose of the present case study was to explore the efficacy of osteopathic manipulative treatment (OMT) in patient with pulmonary fibrosis (PF) in the critical care outpatient department. Here, we present a 48-year-old male case with breathlessness, increased frequency of defecation, and pain in and around the nape of neck with diagnosed pulmonary fibrosis. He scored 3 on a patient-reported modified Medical Research Council (mMRC) dyspnea scale. Osteopathic examination reveals multiple somatic findings across the chest and abdominal region and treated by OMT. Pre- and post-intervention changes were assessed by the 13-item shortness of breath with daily activities (13iSOBDA). 27.2, 22, 16.4, and 11.8 were noted at the end of 1st, 2nd, 3rd, and 4th week of intervention, respectively, on 13iSOBDA while mMRC decreased from 3 to 1. OMT may be a feasible option in decreasing the symptoms of the PPF in the critical care outpatient department.



Wolfram Schummer

Cardiac Herniation with Torsion After Right Pneumonectomy

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:2] [Pages No:473 - 474]

   DOI: 10.4103/ijccm.IJCCM_60_17  |  Open Access |  How to cite  | 



Abhijit S. Nair

Is Edaravone the Future of Free Radical Scavenging in Inflammatory States?

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:2] [Pages No:475 - 476]

   DOI: 10.4103/ijccm.IJCCM_204_17  |  Open Access |  How to cite  | 



Ritesh G. Menezes

Hypothermia in Organophosphate Compound Poisoning: Recognizing the Big Chill

[Year:2017] [Month:] [Volume:21] [Number:7] [Pages:2] [Pages No:476 - 477]

   DOI: 10.4103/ijccm.IJCCM_190_17  |  Open Access |  How to cite  | 


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