Indian Journal of Critical Care Medicine

Register      Login

Table of Content

2018 | December | Volume 22 | Issue 12

Total Views


Naveen Agnihotri, Ajju Agnihotri

Turnaround time for red blood cell transfusion in the hospitalized patient: A single-center “Blood Ordering, Requisitioning, Blood Bank, Issue (of Blood), and Transfusion Delay” study

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:6] [Pages No:825 - 830]

Keywords: Blood arrangement, blood transfusion, delay, turnaround time

   DOI: 10.4103/ijccm.IJCCM_403_18  |  Open Access |  How to cite  | 


Background and Aim: The turnaround time (TAT) for blood transfusion (BT) is an important quality indicator for the health-care institutions undertaking this procedure. There is no established national or international benchmark for this TAT due to the dearth of a published literature. We thus studied the TAT and the contributory procedures leading to delay in commencing a red blood cell transfusion in the hospitalized patient. Materials and Methods: Delay was captured for the blood order transcription, requisitioning and sampling by the nurse, blood bank (BB) processing, blood issue, and the transfusion commencement in the hospitalized patients. The study was done prospectively over a 1-year period and involved all the patient locations spread over six floors in a tertiary care accredited hospital. Results: A total of 2022 blood requests were analyzed during the study period. Most (73%) of the blood requests were marked as urgent by the treating unit. The average time from ordering to initiation of BT was 135 min in our study. BB processes (compatibility testing and issue) comprised approximately 47% of this delay (63 min), while rest of the delay happened in the processes (ordering 13 min, sample transport 34 min, and BT commencement 25 min) outside the BB (72 min). Conclusion: Majority of the delay for blood transfusion happens due to the processes outside blood bank premises. Understanding the steps where delay happens has the potential to reduce the turnaround time for lifesaving procedures such as blood transfusion in the hospitalized patients.



Azrina Ralib, Suhaila Nanyan, Nur Ramly, Lim Har, Tan Cheng, Mohd Mat Nor

Acute kidney injury in Malaysian intensive care setting: Incidences, risk factors, and outcome

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:5] [Pages No:831 - 835]

Keywords: Acute kidney injury, epidemiology, intensive care unit, mortality, risk factors

   DOI: 10.4103/ijccm.IJCCM_193_18  |  Open Access |  How to cite  | 


Introduction: Acute kidney injury (AKI) is common in the intensive care unit (ICU) with a high risk of morbidity and mortality. The high incidence of AKI in our population may be attributed to sepsis. We investigated the incidence, risk factors, and outcome of AKI in four tertiary Malaysian ICUs. We also evaluated its association with sepsis. Materials and Methods: This retrospective cohort study extracted de-identified data from the Malaysian Registry of Intensive Care in four Malaysian tertiary ICUs between January 2010 and December 2014. The study was registered under the NMRR and approved by the ethics committee. AKI was defined as twice the baseline creatinine or urine output <0.5 ml/kg/h for 12 h. Results: Of 26,663 patients, 24.2% had AKI within 24 h of admission. Patients with AKI were older and had higher severity of illness compared to those without AKI. AKI patients had a longer duration of mechanical ventilation, length of ICU, and hospital stay. Age, Simplified Acute Physiological II Score, and the presence of sepsis and preexisting hypertension, chronic cardiovascular disease independently associated with AKI. About 32.3% had sepsis. Patients with both AKI and sepsis had the highest risk of mortality (relative risk 3.43 [3.34–3.53]). Conclusions: AKI is common in our ICU, with higher morbidity and mortality. Independent risk factors of AKI include age, the severity of illness, sepsis and preexisting hypertension, and chronic cardiovascular disease. AKI independently contributes to mortality. The presence of AKI and sepsis increased the risk of mortality by three times.



Arvind Kumar Baronia, Prabhaker Mishra, Pralay Ghosh, Ratender Singh

Comparison of hemodynamic monitoring between transesophageal Doppler and ultrasonography-guided inferior vena cava distensibility in supine versus prone position: A pilot study

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:6] [Pages No:836 - 841]

Keywords: Acute respiratory distress syndrome, esophageal Doppler, inferior vena cava, prone

   DOI: 10.4103/ijccm.IJCCM_432_18  |  Open Access |  How to cite  | 


Introduction: Lung-protective ventilation strategy and prone positioning are the strategies practiced to manage patients suffering from acute respiratory distress syndrome (ARDS). Inferior Vena Cava Distensibility (dIVC) Index has been used for predicting fluid responsiveness (FR) in supine position. We conducted this study to observe the utility of dIVC in prone position in ARDS patients and compare it with esophageal Doppler (ED) parameters. Materials and Methods: After ethical clearance, a prospective observational pilot study was conducted in a 12-bedded tertiary care hospital. Adult ARDS patients who were treated with prone ventilation were included. Informed consent was taken from the relatives. IVC was visualized through right lateral approach both in supine and prone positions. We compared IVC distensibility and ED parameters, first in 45° head up and then in prone. FR was defined as an increase in the stroke volume of ≥15% as measured by ED. The patients with dIVC >18% were assumed to be fluid responsive. Statistical analysis was done using SPSS software version 20. Results: Twenty-five patients met the inclusion criteria. ARDS was (mean P/F ratio 116.64 ± 44.76) mostly due to pulmonary etiology. Out of 25 patients, 10 patients were fluid responsive based on dIVC (cutoff >18%) in supine position. When compared to ED values after passive leg raising, dIVC had a sensitivity and specificity of 77.78% and 81.25%, respectively, in predicting FR with a moderate-to-absolute agreement between the two methods. IVC distensibility showed statistically significant negative correlation with corrected flow time (FTc) values both in supine and in prone positions. Conclusion: IVC variability can be observed in acute respiratory distress syndrome patients in prone position. Inferior Vena Cava Distensibility correlates with flow time in both the positions.



Keertana Badrinath, Monica Shekhar, Moturu Sreelakshmi, Meenakshi Srinivasan, Girish Thunga, Sreedharan Nair, Karthik Nileshwar, Athira Balakrishnan, Vijayanarayana Kunhikatta

Comparison of various severity assessment scoring systems in patients with sepsis in a tertiary care teaching hospital

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:4] [Pages No:842 - 845]

Keywords: Acute Physiology and Chronic Health Evaluation II, Mortality in Emergency Department Sepsis, Predisposition, Infection, Response, and Organ Dysfunction, Sepsis, Sequential Organ Failure Assessment

   DOI: 10.4103/ijccm.IJCCM_322_18  |  Open Access |  How to cite  | 


Background: Sepsis is a complex condition defined by the systemic response to infection. Severity assessment scoring systems are used to aid the physician in deciding whether aggressive treatment is needed or not. In this study, various severity assessment scoring systems, namely Acute Physiology and Chronic Health Evaluation II (APACHE II), Rapid Emergency Medicine Score (REMS), Sequential Organ Failure Assessment (SOFA), Multiple Organ Dysfunction Score (MODS), Predisposition, Infection, Response, and Organ Dysfunction (PIRO), and Mortality in Emergency Department Sepsis (MEDS), were compared to assess their sensitivity and specificity. Materials and Methods: A prospective cohort study was conducted over 6 months. The study was conducted in the intensive care unit (ICU) of a tertiary care teaching hospital. All patients above 18 years of age with confirmed sepsis diagnosis and a well-defined outcome were included in the study. Results: A total of 193 patients were included in the study. The mean age was 57.2 ± 15.3 (mean ± standard deviation) years. Majority of the patients were male, 125 (64.76%). Overall mortality was 108 (55.9%). The calculated area under the receiver operating characteristic curve was 0.86 (95% confidence interval [CI]: 0.80–0.90) for APACHE II, 0.81 (95% CI: 0.75–0.87) for REMS, 0.80 (95% CI: 0.74–0.86) for SOFA, 0.74 (95% CI: 0.67–0.80) for MODS, 0.78 (95% CI: 0.71–0.84) for PIRO, and 0.77 (95% CI: 0.71–0.83) for MEDS. Sensitivity and specificity for APACHE II were 81.5 and 75.3, respectively. Conclusions: In our study, APACHE II score was found to be the most sensitive and specific in predicting the severity of sepsis compared to other scores.



Kawiwan Limprayoon, Rojanee Lertbunrian, Rattapon Uppala, Chutima Samathakanee, Pravit Jetanachai, Nopparat Thamsiri

The utilization of the surviving sepsis campaign care bundles in the treatment of pediatric patients with severe sepsis or septic shock in a resource-limited environment: A prospective multicenter trial

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:6] [Pages No:846 - 851]

Keywords: Decrease in mortality, multicenter, pediatric, septic shock, severe sepsis, surviving sepsis campaign care bundles

   DOI: 10.4103/ijccm.IJCCM_367_18  |  Open Access |  How to cite  | 


Background: Sepsis is a common condition affecting the lives of infants and children worldwide. Although implementation of the surviving sepsis campaign (SSC) care bundles was once believed to be effective in reducing sepsis mortality rates, the approach has recently been questioned. Methods: The study was a prospective, interventional, multicenter trial. Infants and children aged 1 month to 15 years in seven different large academic centers in Thailand who had been diagnosed with severe sepsis or septic shock. They were given treatment based on the SSC care bundles. Results: A total of 519 children with severe sepsis or septic shock were enrolled in the study. Among these, 188 were assigned to the intervention group and 331 were recruited to the historical case–control group. There were no significant differences in the baseline clinical characteristics. The intervention group was administered a significantly higher fluid bolus than was the control group (28.3 ± 17.2 cc/kg vs. 17.7 ± 10.6 cc/kg; P = 0.02) with early vasopressor used (1.5 ± 0.7 h) compared to control group (7.4 ± 2.4 h, P < 0.05). More importantly, our sepsis mortality reduced significantly from 37% ± 20.7% during the preintervention period to 19.4% ± 14.3% during the postintervention period (P < 0.001). Conclusion: Our study demonstrated a significant reduction in sepsis mortality after the implementation of the SSC care bundles. Early diagnosis of the disease, optimum hemodynamic resuscitation, and timely antibiotic administration are the key elements of sepsis management.



Bhawna Garg, Nirmal Kumar, Pooja Anthwal, Ayush Manchanda

Six-hour sepsis bundle decreases mortality: Truth or illusion – A prospective observational study

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:6] [Pages No:852 - 857]

Keywords: Lactate clearance, mortality, pediatric index of mortality-2 score, sepsis bundle, septic shock

   DOI: 10.4103/ijccm.IJCCM_147_18  |  Open Access |  How to cite  | 


Aim: The aim of the study is to evaluate whether 6-h sepsis bundle component compliance (complete vs. incomplete) decreases mortality in pediatric patients with severe sepsis and septic shock. Methodology: The study was conducted at a tertiary care hospital. Patients aged 1 month–13 years admitted to pediatric intensive care unit with severe sepsis, or septic shock were prospectively enrolled. The clinical data and blood investigations required for sepsis bundle were recorded. Predicted mortality was calculated at admission by the online pediatric index of mortality-2 (PIM-2) score calculator. Patients who fulfilled all the components of 6-h sepsis bundle were taken as compliant while failure to fulfill even a single component rendered them noncompliant. The outcome was recorded as died or discharged. Results: Of 116 patients, 90 (77.59%) had 100% sepsis bundle component compliance and were taken into the compliant group while the rest 26 (22.41%) were noncompliant. Forty out of 90 patients (44.4%) died in compliant group in comparison to 5 out of 26 (19.3%) in noncompliant group, P = 0.020. The pre- and post-interventional lactates were significantly higher in compliant group as compared to the noncompliant group, P < 0.0001 and 0.019, respectively. Rising lactate level parallels increasing predicted mortality by PIM-2 score in compliant group, but this association failed to reach significance in noncompliant group which can be attributed to less number of subjects available in this group. Conclusion: Irrespective of sepsis bundle compliance (complete/incomplete), outcome depends on the severity of illness reflected by high lactate and predicted mortality.



Sanjay Gupta, Fahd Al Khaleefah, Ibrahim Al Harbi, Fiaz Ahmed, Sinimol Jabar, Marilou Torre, Sunitha Mathias

An intervention study for the prevention and control of health care-associated infection in the critical cares area of a tertiary care hospital in Saudi Arabia

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:4] [Pages No:858 - 861]

Keywords: Critical care area, healthcare-associated infections, impact, intervention, prevention and control

   DOI: 10.4103/ijccm.IJCCM_270_18  |  Open Access |  How to cite  | 


Introduction: Healthcare-associated infections (HAIs) are an infection that patients acquire during receiving treatment and care for the medical or surgical problem. Objective: The objective of this study is to find the patterns of HAIs cases in the hospital and to know the impact of the intervention on prevention and control of health care associated infection. Methodology: This was prospective interventional study. Results: The majority of cases of HAIs was reported from intensive care unit 47%. The most common site involved due to HAIs was catheter-associated urinary tract infection followed by central line-associated bloodstream infection. During the study period, around 28% reduction of cases were reported. During 6 months period (March to August 2016), around 540 cases were admitted in the critical care areas out of that 32 cases were reported as HAIs (5.9%) for the same period from (March to August 2017) was (3.4%), that difference came to be a statistically significant (χ2 = 4.12, P = 0.042, df = 1). Conclusion: This small study showed that strict implementation of care bundles with good compliance of hand hygiene, Personal protective equipment and antibiotic stewardship are helpful for prevention and control of hospital acquired infections. This study also demonstrated significant (28%) reduction of hospital acquired infections during the study period.



Vijoy Jha, K. V. Padmaprakash

Extracorporeal treatment in the management of acute poisoning: What an intensivist should know?

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:8] [Pages No:862 - 869]

Keywords: End-stage kidney disease, extracorporeal treatment, hemoperfusion, intermittent hemodialysis

   DOI: 10.4103/ijccm.IJCCM_425_18  |  Open Access |  How to cite  | 


Extracorporeal treatment (ECTR) represents a treatment modality promoting removal of endogenous or exogenous poisons and supporting or temporarily replacing a vital organ. This article aims to provide a brief overview of the technical aspects and the potential indications and limitations of the different ECTRs, highlighting the important characteristics of poison amenable to ECTR and the most appropriate prescriptions used in the setting of acute poisoning. The various principles that govern poison elimination by ECTR (diffusion, convection, adsorption, and centrifugation) and how components of the ECTR can be adjusted to maximize clearance have also being discussed.



Agus Foead, Amuthaganesh Mathialagan, Raghu Varadarajan, Michael Larvin

Management of symmetrical peripheral gangrene

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:5] [Pages No:870 - 874]

Keywords: Disseminated intravascular coagulation, microthrombosis, procoagulant–anticoagulant balance, purpura fulminans, symmetrical peripheral gangrene

   DOI: 10.4103/ijccm.IJCCM_379_18  |  Open Access |  How to cite  | 


Symmetrical peripheral gangrene (SPG) is a rare, debilitating disease that deserves more widespread concern among the medical fraternities. The objective of this review is to outline the etiology, pathology findings, and management practices of SPG. About 18%–40% mortality rate was reported, and survivors have high frequency of multiple limb amputations. SPG is the hallmark of disseminated intravascular coagulation (DIC). The main pathogenesis theory, to date, is microthrombosis associated with disturbed procoagulant–anticoagulant balance. The treatment of SPG is largely anecdotal and theoretically involves heparin-based anticoagulation and substitution of natural anticoagulants. Early recognition, prompt management of DIC, and underlying conditions may halt the progression of the disease. The multicenter randomized controlled trial should be set up to formulate the proper treatment guidelines.



Bandya Sahoo, Mukesh Jain

Dilemmas and challenges in treating seronegative autoimmune encephalitis in Indian children

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:4] [Pages No:875 - 878]

Keywords: Autoimmune encephalitis, children, clinical clues, seronegative

   DOI: 10.4103/ijccm.IJCCM_98_18  |  Open Access |  How to cite  | 


Objective: The main objective is to assess the challenges in diagnosis and treatment while managing seronegative cases of autoimmune encephalitis (AIE) in Indian children. Methods: A cohort study of patients with AIE was done where clinical presentations, investigations, management were analyzed and these patients were followed up to assess the evolution of the disease. Results: Nine patients were included in the study. Four patients presented with super-refractory status epilepticus (SRSE). Other presentations were behavioral change, hemiplegia, and autonomic dysfunction. Initial magnetic resonance imaging brain was suggestive of AIE in two patients. Only two were seropositive for cerebrospinal fluid (CSF) autoimmune panel. Five patients responded to the first-line immunotherapy and four required the second-line immunotherapy. Conclusion: The possibility of autoimmune encephalitis should be considered in patients with super-refractory status epilepticus. A large proportion of children with suspected AE may be “seronegative.” A trial of immunotherapy should be given to these children when there is a strong clinical suspicion of autoimmune encephalitis even in the absence of cerebrospinal fluid autoantibodies.



Gagan Brar, Bhargav Mundlapudi

Bilateral lower cranial nerve palsy after closed head injury: A case report and review of literature

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:4] [Pages No:879 - 882]

Keywords: Bilateral, closed head injury, lower cranial nerves, whiplash injury

   DOI: 10.4103/ijccm.IJCCM_476_18  |  Open Access |  How to cite  | 


Paralysis of the lower cranial nerves is uncommon after closed head injuries. Most cases reported are unilateral and associated with base of skull fractures, usually involving the occipital condyles. Bilateral lower cranial nerve palsy is even less common, with only a handful of cases reported in literature. A 17-year-old girl presented to us after she was involved in a side-on collision with a car while driving a scooter. She sustained traumatic brain injury requiring mechanical ventilation. Detailed neurological evaluation revealed bilateral paralysis of the IXth, Xth, and XIIth cranial nerves with no evidence of a fracture of the base of skull or brain stem injury. A traction type of injury to the nerves arising from a whiplash mechanism may have led to paralysis of the lower cranial nerves in our patient. An exhaustive review of literature revealed 11 reports of bilateral lower cranial nerve palsy associated with closed head injuries; there were only four cases without underlying fracture of the occipital condyles. Our patient made a complete recovery over a period of 4 months. A traction type of injury to the lower cranial nerves may occur due to a whiplash mechanism. This type of injury may be associated with a favorable outcome.



Johannes Heymer, Andreas Lienig, Joachim Löffler, Tobias Schilling, Daniel Räpple

Extreme metabolic alkalosis and acute kidney injury in a 38-year-old male patient

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:3] [Pages No:883 - 885]

Keywords: Duodenal stenosis, metabolic alkalosis, vomiting

   DOI: 10.4103/ijccm.IJCCM_180_18  |  Open Access |  How to cite  | 


Repeated vomiting may lead to profound loss of fluid and electrolytes. We describe a case with life-threatening acid-base disturbances due to vomiting. A 38-year-old man presented to an emergency department with weakness and decreased urine output after having vomited up to 20 times per day over a period of 7 days. Arterial blood gas analysis revealed a metabolic alkalosis with partial respiratory compensation. Initial management consisted of oxygen therapy and intravenous fluid therapy with normal saline and potassium chloride. To prevent further gastric losses of HCl, proton-pump inhibitors and metoclopramide were administered. The vomiting was caused most likely by a temporary duodenal stenosis due to portal hypertension of unknown etiology. In our opinion, this case demonstrates the successful management of a life-threatening condition by simple measures. Despite extensive diagnostic procedures, the effective treatment of the underlying condition consisted of watchful waiting.



Tushar Vidhale

Multiple splenic abscesses in a case of enteric fever: Salvaging spleen through pigtail drainage and antibiotics is a good alternative approach

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:3] [Pages No:886 - 888]

Keywords: Antibiotics, percutaneous pigtail drainage, splenectomy, splenic abscess

   DOI: 10.4103/ijccm.IJCCM_405_18  |  Open Access |  How to cite  | 


Splenic abscess is a rare complication of enteric fever in developing countries. This is seen mostly solitary rather than being multiple and can be fatal if untreated. In general clinical practice, multiple splenic abscesses or thick pus with septations may require splenectomy. Here, we report a rare case of enteric fever with multiple splenic abscesses in a young immunocompetent male who was successfully managed with antibiotics and percutaneous pigtail drainage of pus from the larger cavity.



Ajai Tentu

Junctional rhythm: A rare sign in leptospirosis

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:3] [Pages No:889 - 891]

Keywords: Atrioventricular block, junctional rhythm, leptospirosis, Weil's disease

   DOI: 10.4103/ijccm.IJCCM_437_18  |  Open Access |  How to cite  | 


Leptospirosis is an important re-emerging infectious disease. Leptospirosis has been estimated to affect tens of millions of humans annually with a case fatality rate ranging from 5% to 25%; however, it is underreported due to the lack of clinical suspicion and barriers to diagnostic capacity. A 33-year-old healthy male presented with a history of fever of 2-day duration. His examination revealed icterus. His workup did not show any significant findings except for a mild transaminitis and a rise in serum creatinine by 0.5 mg/dl. Later, the patient developed bradycardia. An ELISA test for Leptospira antibodies was positive. The patient recovered after a course of intravenous antibiotics. Leptospirosis should be considered early in the diagnosis of any patient who presents with acute, nonspecific febrile illness with multiorgan involvement. Our case had an atypical presentation with involvement of the cardiovascular system in the form of junctional rhythm.



Ipe Jacob, Thejeswini Mahadevaiah

A Rare case of Listeria monocytogenes meningitis in an immunocompetent adult

[Year:2018] [Month:] [Volume:22] [Number:12] [Pages:2] [Pages No:892 - 893]

   DOI: 10.4103/ijccm.IJCCM_173_18  |  Open Access |  How to cite  | 


© Jaypee Brothers Medical Publishers (P) LTD.