Indian Journal of Critical Care Medicine

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2018 | October | Volume 22 | Issue 10

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Batsalya Arjyal, Rakesh Mandal

Clinical profile and outcome of patients with acute poisoning admitted in intensive care unit of tertiary care center in Eastern Nepal

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:6] [Pages No:691 - 696]

Keywords: Acute poisoning, intensive care unit, mortality, organophosphorous

   DOI: 10.4103/ijccm.IJCCM_207_18  |  Open Access |  How to cite  | 


Background: Acute poisoning is a common health-care problem requiring admission in the intensive care unit (ICU) in the developing countries. The study was conducted to assess the epidemiological parameters of acute poisoning and factors affecting clinical course and outcome of the patients in ICU in the eastern part of Nepal. Methodology: This was a prospective observational study conducted at ICU of tertiary care hospital in the eastern part of Nepal for the duration of 2 years. All the acute poisoning cases admitted in the ICU were studied for epidemiological profiles, poisoning characteristics, and various clinical factors affecting the outcome of the patients. Results: Eighty-five patients with acute poisoning were included in the study. Suicidal attempt leading to acute poisoning was seen in majority of the young population. Majority of the poisoning was due to the organophosphorous compounds (43.5%). Patients with organophosphorous poisoning had a significantly longer duration of ICU stay (P = 0.020). The survival of the patients was significantly affected by age, duration of presentation to the hospital, Glasgow Coma Scale, Sequential Organ Failure Assessment score, need for mechanical ventilation, duration of ICU stay, hepatic failure, coagulopathy, and need for vasoactive drugs (P < 0.05). The independent predictors of mortality observed in the study were age, delayed presentation to the hospital, hepatic failure, and need for mechanical ventilation. Conclusion: Organophosphorous poisoning was the most common acute poisoning in young population leading to the ICU admission. Older age, delayed initiation of the resuscitative measures, need for mechanical ventilation, and hepatic failure significantly affected the mortality.



Prabhaker Mishra, Sujay Samanta, Ratender Singh, Arvind K. Baronia

Early pH change predicts intensive care unit mortality

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:9] [Pages No:697 - 705]

Keywords: Metabolic acidosis, mortality, pH change

   DOI: 10.4103/ijccm.IJCCM_129_18  |  Open Access |  How to cite  | 


Aim of the Study: Metabolic acidosis is associated with increased mortality in critically ill patients. We hypothesized that early correction of acidosis of presumed metabolic origin results in improved outcomes. Patients and Methods: We conducted a prospective, observational study from February 2015 to June 2016 in a 12 bed mixed intensive care unit (ICU) of a 1000 bed tertiary care hospital in the north of India. ICU patients aged above 18 years with an admission pH ≥7.0 to <7.35 of presumed metabolic origin were included. Arterial blood gas parameters including pH, PaO2, PaCO2, HCO3, Na+, K+, Cl, anion gap (AG), base excess, and lactate at 0, 6, and 24 h along with other standard laboratory investigations were recorded. The primary outcome was to assess the impact of early pH changes on mortality at day 28 of ICU. Results: A total of 104 patients with 60.6% males and 91.3% medical patients were included in the study. Sepsis of lung origin (60.6%) was the predominant etiology. By day 28, 68 (65.4%) patients had died. Median age was 49.5 years, weight 61.7 kg, Sequential Organ Failure Assessment, and Acute Physiologic and Chronic Health Evaluation II scores were 16 and 12, respectively. Nonsurvivors had a higher vasopressor index (P < 0.01), lactate and central venous oxygen saturation (P < 0.05), and lower pH (P < 0.05). A pH correction/change of ≥1.16% during the first 24 h had the best receiver operating characteristic for predicting survival at day 28, with area under the curve (95% confidence interval, 0.72 [0.62–0.82], P < 0.05) compared to HCO3-, BE, lactate, and AG. Conclusions: Metabolic acidosis is associated with higher mortality in ICU. The rate of change in pH may better predict ICU mortality than other metabolic indices.



Susheel Kumar, Prasanth Balasubramanian, Navneet Sharma

Critical illness scoring systems: Sequential organ failure assessment, Acute Physiology and Chronic Health Evaluation II, and quick sequential organ failure assessment to predict the clinical outcomes in scrub typhus patients with organ dysfunctions

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:5] [Pages No:706 - 710]

Keywords: Acute Physiology and Chronic Health Evaluation II, organ dysfunction, quick sequential organ failure assessment, scrub typhus, sequential organ failure assessment

   DOI: 10.4103/ijccm.IJCCM_254_18  |  Open Access |  How to cite  | 


Background and Aim: Scrub typhus (ST) is an acute infectious disease of variable severity caused by Orientia (formerly Rickettsia) tsutsugamushi. The disease can be complicated by organ dysfunctions and the case fatality rate (CFR) is approximately 15%, which further rises with the development of severe complications. We studied the clinical features of the ST and the performance of critical illness scoring systems (CISSs) – Acute Physiology and Chronic Health Evaluation (APACHE) II, sequential organ failure assessment (SOFA), and quick SOFA (qSOFA) in predicting the clinical outcomes in complicated ST (cST) patients admitted to the emergency department. Study Design and Methods: A prospective observational study was done in 50 patients diagnosed to have cST with one or more organ dysfunctions. Clinical features and laboratory parameters were recorded and the patients were followed up until the end of their stay in the hospital. APACHE II, SOFA, and qSOFA scores at admission were calculated and were analyzed in predicting the clinical outcomes. Results: The median SOFA, APACHE II, and qSOFA scores of the cohort were 7 (interquartile range [IQR] = 13–22), 8 (IQR = 5–11), and 2 (IQR = 1–3), respectively. The median duration of in-hospital stay was 9 (IQR 5–11) days and overall CFR was 8%. On bivariate analysis, both SOFA (P = 0.031) and qSOFA (P = 0.001) predicted mortality. However, only SOFA score correlated with the in-hospital stay duration (Pearson's correlation = 0.311, P = 0.028). Conclusion: Among the three CISSs studied, the SOFA score correlated with in-hospital stay duration and mortality, whereas the qSOFA score formed a simple as well as a convenient tool in predicting the mortality in patients of cST with organ dysfunction.



Girish Rajadhyaksha, Ameena Meah

Spectrum of diseases/conditions exhibiting hemostatic abnormalities in patients admitted to a medical intensive care unit of a tertiary care hospital

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:7] [Pages No:711 - 717]

Keywords: Acute Physiology and Chronic Health Evaluation II score, bleeding, intensive care unit, transfusion, tropical diseases

   DOI: 10.4103/ijccm.IJCCM_505_17  |  Open Access |  How to cite  | 


Background and Aims: In a medical intensive care unit (MICU), many patients develop hemostatic abnormalities, ranging from abnormal clotting tests to frank bleeding. The aim of this study was to assess the etiology of diseases that present with bleeding, its common bleeding manifestations, incidence, MICU stay, mortality, and transfusion requirements in an Indian setup and also to assess if the Acute Physiology and Chronic Health Evaluation II (APACHE II) score can be used as a predictor for blood transfusion requirements. Materials and Methods: Between July 2013 and August 2014, 200 patients with clinically significant bleeding admitted in the MICU were prospectively evaluated. Detailed history, examination, laboratory investigations, APACHE II score, and requirement of blood products were also noted. The endpoints were discharge or death. Results: The spectrum of diseases that presented with bleeding was 47 patients with malaria (23.5%) followed by 36 acute undifferentiated febrile illness (18.0%), 33 dengue (16.5%), 30 leptospirosis (15.0%), 31 acute fulminant hepatitis (15.5%), 14 sepsis (7.0%), and the rest nine miscellaneous causes. The most common bleeding manifestation observed was hematuria in 62/200 (31%). Among the patients studied, 126 expired (63%) and 74 survived (37%). Of the 200 patients, 48/200 (24%) received packed cells, 78/200 (39%) fresh frozen plasma, and 82/200 (41%) platelets. Conclusions: Tropical diseases formed the majority of admissions with bleeding manifestations. Thrombocytopenia is an important marker to predict mortality and also has a significant association with MICU stay. APACHE II score was found to be a good predictor of blood transfusion requirements.



Sandeep Mahajan, Prayas Sethi, Hiren Anghan

Clinical and laboratory features associated with acute kidney injury in severe malaria

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:5] [Pages No:718 - 722]

Keywords: Acute kidney injury, critically ill, severe malaria

   DOI: 10.4103/ijccm.IJCCM_468_17  |  Open Access |  How to cite  | 


Introduction: Critically ill severe malaria constitutes one of the major hospital admissions in Indian setting. Clinical studies identifying the factors associated with acute kidney injury (AKI) in malaria are lacking. This study aimed to identify these factors. Methods: This prospective observational study was conducted in a tertiary care center of North India. All adult patients with severe malaria were studied during 2012–2014. Results: The study included 79 patients and AKI was observed in 36 patients. Of these 79 patients, 52.7% were Plasmodium falciparum positive and 47.2% were Plasmodium vivax positive. In AKI patients, thrombocytopenia and jaundice were the most common other complications seen. Among P. vivax malarial patients, 17 (36%) patients had AKI. Features associated with AKI among patients admitted with P. vivax malaria were as follows: tachycardia (adjusted relative risk [RR]: 3.9; 95% confidence interval [CI]: 1.1–13.7), direct hyperbilirubinemia (adjusted RR: 4.7; 95% CI: 1.4–15.2), anemia (adjusted RR: 6; 95% CI: 1.7–22.4), and sepsis (adjusted RR: 3.3; 95% CI: 1.1–13.7). The presence of tachycardia, acidosis, cerebral malaria, acute respiratory distress syndrome/acute lung injury, hypotensive shock, and poor Glasgow Coma Scale were associated with higher mortality in patients with AKI. Patients who required mechanical ventilation and/or vasopressor support had higher mortality. Conclusion: P. vivax is an important cause of severe malaria with AKI in our setting. Various other clinical features are associated with AKI and related mortality.



Jigeeshu V. Divatia, Nitin Mali, Siddharth P. Deshpande, Niteen D. Karnik, Nithya J. Gogtay, Renuka P. Munshi, Sanjay C. Wagle, Kannan Sridharan

A multicentric, prospective, observational antibacterial utilization study in Indian tertiary referral centers

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:7] [Pages No:723 - 729]

Keywords: Antibacterial resistance, antibacterials, indicators, medical intensive care unit, public and private hospitals

   DOI: 10.4103/ijccm.IJCCM_197_18  |  Open Access |  How to cite  | 


Rationale: Antibacterials are largely prescribed to the intensive care unit (ICU) patients due to high prevalence of infections. However, appropriate use of antibacterials is imperative; since the misuse of antibacterials increases antibacterial resistance and ultimately, it has negative impact on health care and economic system. Hence, continuous antibacterials prescription assessments are very important to judge and improve prescription patterns. The present work was carried out at public and private hospitals to assess the differences in antibacterial prescribing pattern. Methods: The present study was conducted at three public and two private hospitals over the period of 14 months. Demographic and drug use details were captured daily from patients admitted to medical ICUs to assess the World Health Organization indicators. Results: A total of 700 patients were enrolled across the five centers (140 per center), among them 424 were male and 276 were female. Average number of drugs and antibacterials prescribed at public hospitals are significantly higher than the private hospital. However, percentage of antibacterial agents prescribed at public hospitals was significantly lower than the private hospitals (P = 0.0381). Private hospitals had significantly lower percentage of antibacterial agents prescribed by generic name (P < 0.0001). Differences in change of antibacterial agents required were not statistically significantly different (P = 0.1888); however, significant difference was observed in percentage of patients who received antibacterial treatment as per sensitivity pattern (P = 0.0385) between public and private hospitals. Significantly higher mortality was observed in public hospitals compared to private hospitals (<0.0001). Conclusions: More generic prescriptions and more number of prescriptions as per the sensitivity pattern are required at each public and private hospital.



Helmut Schiffl

Timing of renal replacement therapy in acute kidney injury: Shedding new light on an old controversy

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:3] [Pages No:730 - 732]

Keywords: Acute kidney injury, furosemide stress test, renal replacement therapy

   DOI: 10.4103/ijccm.IJCCM_295_18  |  Open Access |  How to cite  | 


Critically ill patients with severe acute kidney injury (AKI-D) require renal replacement therapy (RRT) increasingly. However, the optimal timing of initiation of RRT for non-life-threatening indications of AKI remains unknown. There is a debate as to whether different philosophies of RRT initiation (early vs. delayed) confer a survival benefit. Lowering the threshold for RRT initiation, however, inevitably leads to more critically ill patients receiving unnecessary RRT. The relevant proportion of nonprogressing early stage AKI patients with spontaneous kidney recovery is a matter of severe concern because RRT has potentially lethal complications and is expensive. Moreover, these patients should be excluded from randomized trials. The furosemide stress test in critically ill patients with early stages of AKI serves as a novel tubular function test to identify those patients with severe and progressive AKI-D. Future trials to validate findings of a promising pilot study are warranted.



Jayagowri Karthikeyan, Sujatha Rajaragupathy

Diagnostic usefulness of serum albumin as a predictor of diabetic ketoacidosis

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:4] [Pages No:733 - 736]

Keywords: Albumin, diabetes mellitus, ketoacidosis

   DOI: 10.4103/ijccm.IJCCM_91_18  |  Open Access |  How to cite  | 


Context: Diabetes mellitus is one of the most prevalent diseases worldwide. One of the acute complications of diabetes mellitus is diabetic ketoacidosis. It becomes essential for the healthcare physicians to identify the individuals who are likely to be prone to the development of ketosis. Serum albumin levels may be a cost-effective and simple parameter to prognosticate the risk of ketosis. Aims: This study was done to find a relationship between serum albumin levels and ketonuria. Settings and Design: After ethical approval, this prospective case–control study was carried out in patients diagnosed as type-2 diabetes mellitus. Subjects and Methods: Serum albumin levels were measured by bromo cresol green method. Measurement of urine ketones was done manually using dipsticks, a semi-quantitative manual method. Statistical Analysis Used: Student's t-test was used to compare continuous variables and Chi-square test for categorical variables. Pearson's correlation was done to establish correlation. Results: In the normoalbuminemic group, 72% were ketones negative and only 28% had positive ketones in urine, while in the hypoalbuminemic group, 50.7% had negative urine ketones and 49.3% had positive ketonuria. The mean value for ketones in urine was 9.7 mg/dL in the hypoalbuminemic group, but it was only 4.3 mg/dL in the normoalbuminemic group. Pearson's correlation between serum albumin and urine ketone levels was performed and the r-value was found to be −0.305. Conclusions: Serum albumin levels may predict the occurrence of ketosis in diabetic patients.



Robert Da Costa, Pezad Doctor, Kaustubh Mahajan, Vidyadhara G. Lakkappan

Bilateral phrenic nerve palsy in a diabetic causing respiratory failure

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:3] [Pages No:737 - 739]

Keywords: Diabetes neuropathy, phrenic nerve, respiratory failure

   DOI: 10.4103/ijccm.IJCCM_261_18  |  Open Access |  How to cite  | 


Neuropathy is one of the major reasons of morbidity in diabetes mellitus (DM). We presented a 64-year-old male who was a case of type 2 DM for >6 years. He presented with orthopnea and respiratory failure secondary to bilateral phrenic neuropathy and resultant diaphragmatic palsy. Clinical examination, ultrasound, and nerve conduction studies confirmed the bilateral involvement of the phrenic nerves. Phrenic neuropathy may be an important, albeit a rare complication of diabetes, and hence, diaphragmatic dysfunction associated with diabetic phrenic neuropathy should be considered in any patient with unexplained breathlessness, orthopnea, and respiratory failure.



Pritam Kataria, Pradip Kendre, Apurva Patel, Nahush Tahiliani, Sushant Ikhar

Methotrexate-induced toxic epidermal necrolysis: A rare case report and review of literature

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:3] [Pages No:740 - 742]

Keywords: Acute lymphoblastic leukemia, methotrexate, toxic epidermal necrolysis

   DOI: 10.4103/ijccm.IJCCM_212_18  |  Open Access |  How to cite  | 


Acute lymphoblastic leukemia (ALL) is the most common malignancy in pediatric patients, and it is characterized by the presence of malignant lymphoblasts within the bone marrow and peripheral blood. The treatment of ALL involves induction, consolidation, reinduction, and maintenance therapy. Consolidation therapy in ALL-Berlin-Frankfurt-Münster 90 protocol involves the use of high-dose methotrexate (HDMTX, 5 g/m2) over 24 h as continuous infusion. The adverse effects due to HDMTX include renal dysfunction in 2%–12% patients, which can lead to increased systemic MTX exposure, leading to further myelosuppression, mucositis, hepatotoxicity, skin toxicity, and, in severe cases, multiorgan failure. Dermatologic toxicity due to MTX includes morbilliform drug rash, photoreactivation, photoenhancement, and skin hyperpigmentation. Stevens–Johnson syndrome and toxic epidermal necrolysis (TEN) are rare and possibly fatal reaction which can occur with MTX. Here, we describe a patient with B-cell ALL who developed TEN after administration of HDMTX.



Supriya D'souza, Shalini Saksena, Manju Butani

Calming the electrical storm: Use of stellate ganglion block and thoracic epidural in intractable ventricular tachycardia

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:3] [Pages No:743 - 745]

Keywords: Stellate ganglion block, thoracic epidural analgesia, ventricular arrhythmias

   DOI: 10.4103/ijccm.IJCCM_33_18  |  Open Access |  How to cite  | 


Imbalances in the autonomic nervous system contribute to ventricular tachyarrhythmias. Sympatholysis with thoracic epidural analgesia or a stellate ganglion block attenuates myocardial excitability and the proarrhythmic effects of sympathetic hyperactivity.



Shashi Prakash

Anti-voltage-gated potassium channel antibody syndrome: A rare cause of hyponatremia in intensive care unit

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:3] [Pages No:746 - 748]

Keywords: Anti-voltage-gated potassium channel antibody syndrome, hypokalemia, hyponatremia, seizure, syndrome of inappropriate antidiuretic hormone secretion

   DOI: 10.4103/ijccm.IJCCM_480_17  |  Open Access |  How to cite  | 


Hyponatremia causing seizure is a common cause for admission in the critical care unit. Here, we describe a peculiar case of seizure due to hyponatremia, associated with anti-voltage-gated potassium channel antibody syndrome. This case emphasizes that how a proper workup can unveil unusual but potentially treatable causes of hyponatremia. The hallmark of this syndrome is that neurological symptoms may relapse or progress if the disorder is not recognized in time. This case report emphasizes the point that how a keen observation may decode subtle signs of the grave but potentially treatable pathologies.



Rohit Vohra

Refractory status asthmaticus: A case for unconventional therapies

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:4] [Pages No:749 - 752]

Keywords: Extracorporeal membrane oxygenation, isoflurane, status asthmaticus

   DOI: 10.4103/ijccm.IJCCM_191_18  |  Open Access |  How to cite  | 


Status Asthmaticus is a common reason for Emergency Room visits in children. Most of the asthma flares are successfully managed by use of β agonist and steroids. If these therapies fail to halt the progression of asthma, a number of medical therapies may be used to treat it. However, the data supporting the use of these therapies are conflicting. We present successful use of Extracorporeal Membrane Oxygenation and isoflurane in a child with Refractory Status Asthmaticus.



Bhaskar Shahbabu, Ajai Tentu, Anshu Kumar

Artesunate-induced severe autoimmune hemolytic anemia in complicated malaria

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:4] [Pages No:753 - 756]

Keywords: Anemia, artesunate, autoimmune hemolytic anemia, hemolytic, malaria

   DOI: 10.4103/ijccm.IJCCM_298_18  |  Open Access |  How to cite  | 


Autoimmune hemolytic anemia (AIHA) is a very rare cause of anemia in a case of malaria and drug-induced AIHA is even rarer. A 50-year old patient with a history of fever for 8 days was diagnosed with a case of complicated malaria with mixed infection having initial parasite index of 45%. He showed good response on initial therapy with artesunate (parasite count reduced to <1%) but his haemoglobin (Hb) continued to drop from 12 g% to 4.9 g% over a course of 11 days. Direct coombs test was positive with reduced haptoglobin and increased lactate dehydrogenase suggesting AIHA. The patient was put on steroids and transfused with saline washed O-negative blood. He gradually recovered over 8 weeks with Hb level rising up to 12 g%. This is a rare case of AIHA following treatment of severe malaria with parenteral artesunate suggesting of the drug immune-related mechanism.



Sandeep Chopra, Vikas Sikri

“BROAD effect: Bradycardia in obstructive airway disease”An unusual phenomenon: A case report

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:3] [Pages No:757 - 759]

Keywords: Bradycardia, noninvasive ventilation, recurrent

   DOI: 10.4103/ijccm.IJCCM_285_18  |  Open Access |  How to cite  | 


Non Invasive Ventilation (NIV) is frequently used in Obstructive Airway Disease (OAD) especially COPD (Chronic Obstructive Pulmonary Disease). Patients often get hypoxic or retain carbon dioxide during attempts to feed the patient orally or trial of intermittent support. However, patient developing sudden bradycardia by mere taking off the mask and reverting to sinus rhythm as soon as mask is put back is extremely rare. We present one such case that was also a treatment challenge for us. Recurrent bradycardia in COPD, with repeatability on discontinuation of Non Invasive Ventilation (NIV) is an extremely rare condition with not much reports/studies in the medical literature. The mechanisms leading to such an event are poorly understood. To the best of our knowledge, it's the first case to be reported from India.



Tanvir Samra, Deepanshu Dhiman, Vikas Saini, Sameer Sethi

Targeting the venous confluence of pirogoff for central venous cannulation insertion, when internal jugular vein cannulation is difficult: A three-step approach

[Year:2018] [Month:] [Volume:22] [Number:10] [Pages:2] [Pages No:760 - 761]

   DOI: 10.4103/ijccm.IJCCM_331_18  |  Open Access |  How to cite  | 


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