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Behera D, Prasad K, Aggarwal AN. Profile of Patients with Active Tuberculosis Admitted to a Respiratory Intensive Care Unit in a Tertiary Care Center of North India. Indian J Crit Care Med 2018; 22 (2):63-66.
Background: There is a paucity of literature regarding outcome of critically ill patients with tuberculosis (TB) from India. Herein, we describe our experience of patients with active TB admitted to a Respiratory Intensive Care Unit (RICU) of a tertiary care hospital.
Methods: This was a retrospective analysis of all the patients admitted with active TB. The baseline clinical, demographic, ICU parameters and mortality were recorded. A multivariate logistic regression analysis was performed to identify factors predicting mortality.
Results: A total 3630 patients were admitted to the ICU during the study period; of these, 63 (1.7%) patients (mean [standard deviation (SD)] age 37.3  years, 55.6% females) were admitted with active TB. Fifty-seven patients were mechanically ventilated (56, invasive and 1, noninvasive) for a mean (SD) duration of 7.5 (9.1) days. Respiratory failure was the most common indication for mechanical ventilation. TB-related acute respiratory distress syndrome was seen in 18 (28.6%) patients. There were 28 deaths (44.4%) during the study period. On a multivariate logistic regression analysis, a high baseline Acute Physiology and Chronic Health Evaluation II (APACHE II) score (odds ratio [OR] [95 confidence interval (CI)], 1.12 [1.02–1.23]) and delta Sequential Organ Failure Assessment (SOFA) (OR [95 CI], 1.39 [1.00–1.94]) were the independent predictors of mortality.
Conclusion: TB was an uncommon cause of ICU admission even in a high TB burden country. Critically ill patients with TB had high mortality. A higher APACHE II score and delta SOFA were independent predictors of ICU mortality.
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Makris D, Petinaki E, Tsolaki V, Manoulakas E, Mantzarlis K, Apostolopoulou O, Sfyras D, Zakynthinos E. Colistin versus Colistin Combined with Ampicillin. Sulbactam for Multiresistant Acinetobacter baumannii Ventilator. Associated Pneumonia Treatment: An Open. Label Prospective Study. Indian J Crit Care Med 2018; 22 (2):67-77.
Background: Retrospective studies have reported good clinical success rates using colistin as monotherapy to treat Acinetobacter baumannii ventilator-associated pneumonia (VAP), comparable to that obtained with colistin combined with other antibiotics. However, inadequate penetration into the pulmonary parenchyma for colistin has been shown in animal models.
Aim: The aim of the study was to study prospectively the outcome, measured as clinical response and survival, of intravenously administered colistin versus colistin combined with high-dose ampicillin-sulbactam in Intensive Care Unit (ICU) patients with multiresistant A. baumannii VAP. Methods and Subjects: This prospective, open-label, randomized study included consecutive patients who developed microbiologically documented VAP due to A. baumannii with carbapenem-resistant strains but susceptible to colistin and ampicillin-sulbactam. Seventy-four patients were screened, but finally, 39 participants were enrolled and finished the study Patients received colistin (Group A – 19 patients) or colistin and ampicillin/sulbactam (Group B – 20 patients). The clinical response of VAP was assessed on day 4th to 5th of treatment (early response). If therapy was considered unsuccessful after this period, ampicillin/sulbactam was added in Group A or changed therapy in B.
Results: Early cure rates in Group A and B were 15.8% and 70%, respectively (P = 0.001). Multiple regression analysis revealed that combination treatment (odds ratio [OR]: 43.6, 95% confidence interval [CI]: 3.594–530.9) and Sequential Organ Failure Assessment score <8 (OR: 0.022, 95% CI: 0.001–0.43) were independently associated with favorable clinical response. APACHE II score ≤15 (OR: 0.049, 95% CI: 0.003–0.0942) and an early favorable response to treatment (OR: 244.4, 95% CI: 2.151–27850.9) were associated with survival and discharge from ICU.
Conclusion: Combination therapy with colistin and a high dose of ampicillin/sulbactam was associated with a more favorable clinical response to VAP due to carbapenem-resistant A. baumannii than colistin monotherapy.
Background and Aims: Several biomarkers are used in the diagnosis of bacteremia. Procalcitonin (PCT) is more specific than other biomarkers in differentiating bacterial and nonbacterial inflammation. It was aimed to evaluate the diagnostic and prognostic value of PCT in bacteremic patients in Intensive Care Unit (ICU).
Materials and Methods: A total of 156 patients diagnosed with noninfectious systemic inflammatory response syndrome, sepsis, and severe sepsis/septic shock in ICU between December 2014 and July 2015 were evaluated in this prospective cohort study.
Results: The study group consisted of 64 (41%) bacteremic patients and the control group consisted of 92 (59%) nonbacteremic patients. The overall mortality rate was 60.3%. Although PCT levels in the bacteremic group (11.9 ± 21.5 ng/dL) were higher than nonbacteremic group (5.9 ± 11.5 ng/dL), this difference was not significant (P = 0.168). The mean levels of PCT in bacteremic patients with Gram-negative bacteria were 16.3 ± 27.6 ng/dL, whereas Gram-positive bacteria were 7.3 ± 10.7 ng/dL (P = 0.145). The mean PCT levels were significantly higher in nonsurvivors compared to survivors (10.1 ± 18.0 vs. 5.7 ± 13.7 ng/dL; P < 0.001).
Conclusions: PCT may be an effective biomarker for diagnosing sepsis and predicting disease severity and mortality. There is a need for further well-designed studies to confirm the diagnostic and prognostic value of PCT in septic patients in critical care.
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Sinha R, Roychowdhoury S, Mukhopadhyay S, Ghosh P, Dutta K, Ghosh S. Comparative Study between Noninvasive Continuous Positive Airway Pressure and Hot Humidified High-flow Nasal Cannulae as a Mode of Respiratory Support in Infants with Acute Bronchiolitis in Pediatric Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2018; 22 (2):85-90.
Background: Early initiation of appropriate noninvasive respiratory support is utmost important intervention to avoid mechanical ventilation in severe bronchiolitis.
Aim: This study aims to compare noninvasive continuous positive airway pressure (nCPAP) and hot humidified high-flow nasal cannulae (HHHFNC) as modes of respiratory support in infants with severe bronchiolitis.
Methods: Prospective, randomized, open-label pilot study done in a tertiary-care hospital Pediatric Intensive Care Unit (PICU). Participants: 31 infants (excluding neonates) clinically diagnosed with acute bronchiolitis having peripheral capillary oxygen saturation (SpO2) <92% (with room air oxygen); Respiratory Distress Assessment Index (RDAI) ≥11.
Intervention: nCPAP (n = 16) or HHHFNC (n = 15), initiated at enrollment. Primary outcome: Reduction of need of mechanical ventilation assessed by improvements in (i) SpO2% (ii) heart rate (HR); respiratory rate; (iii) partial pressure of carbon dioxide; (iv) partial pressure of oxygen; (v) COMFORT Score; (vi) RDAI from preintervention value. Secondary outcome: (i) total duration of noninvasive ventilation support; (ii) PICU length of stay; and (iii) incidence of nasal injury (NI).
Results: Mean age was 3.41 ± 1.11 months (95% confidence interval 2.58–4.23). Compared to nCPAP, HHHFNC was better tolerated as indicated by better normalization of HR (P < 0.001); better COMFORT Score (P < 0.003) and lower incidence of NI (46.66% vs. 75%; P = 0.21). Improvements in other outcome measures were comparable for both groups. For both methods, no major patient complications occurred.
Conclusion: HHHFNC is an emerging alternative to nCPAP in the management of infants with acute bronchiolitis.
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Abbas Q, Raheem A, Haque AU. Relationship of Serum Procalcitonin, C-reactive Protein, and Lactic Acid to Organ Failure and Outcome in Critically Ill Pediatric Population. Indian J Crit Care Med 2018; 22 (2):91-95.
Objective: To evaluate the clinical and prognostic utility of procalcitonin (PCT), C-reactive protein (CRP), and lactic acid in children admitted to the Pediatric Intensive Care Unit (PICU) of a university teaching hospital.
Materials and Methods: Medical records of children (1 month–16 years) tested for serum PCT at the time of admission in the PICU of our hospital from July 1, 2013, to January 15, 2015, were reviewed. Within 24 h of admission, the Pediatric Risk of Mortality Score, blood cultures, white blood cell count, neutrophil counts, serum CRP, plasma lactic acid, and PCT were noted. Patient outcome was assessed at hospital discharge, and the patients were divided into nonsurvivors and survivors.
Results: A total of 167 children being admitted to the PICU were enrolled. The median age of the study population was 3 years (0–16 years), with 58.6% being males. Nonsurvivors had significantly higher lactic acid (4.7 mmol/L [2.07–7.6]; P < 0.05) than that of the survivors (2 mmol/L [1.3–3]; P < 0.05). In addition, nonsurvivors (94.4%; P < 0.05) had greater incidence of multiple organ dysfunction syndrome (MODS) than that of the survivors (38.05%; P < 0.05). Binary logistic regression showed age, MODS, and lactic acid to be associated with mortality.
Conclusions: This study found that in comparison to PCT and CRP, high plasma lactic acid levels are associated with the development of all-cause MODS and worse outcome in critically ill children admitted in PICU. Prediction of prognosis based on the lactic acid alone may contribute to improve patient management, but further studies are required to endorse our findings.
Luis Alejandro Sanchez-Hurtado,
Brigette C. Tejeda-Huezo,
Abraham A. Cano-Oviedo,
Saira S. Gomez-Flores,
José A. Baltazar-Torres
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Sanchez-Hurtado LA, Lugo-Cob R, Tejeda-Huezo BC, Esquivel-Chávez A, Cano-Oviedo AA, Zamora-Varela S, Gomez-Flores SS, Arvizu-Tachiquin P, Baltazar-Torres JA. Serum Estradiol Level at Intensive Care Unit Admission and Mortality in Critically Ill Patients. Indian J Crit Care Med 2018; 22 (2):96-99.
Context: It has been observed that sex hormones may play a role in inflammatory processes and mortality of critically ill patients.
Aims: The aim was evaluated the relationship between serum estradiol level at Intensive Care Unit (ICU) admission and mortality of critically ill patients.
Settings and Design: This study was a prospective cohort conducted in one mixed ICU.
Subjects and Methods: In heterogeneous group of critically ill patients admitted to the ICU, we measured serum estradiol at admission time.
Statistical Analysis Used: The discrimination to predict mortality of serum estradiol level was assessed by the receiver-operating curve (ROC) curve and its association with mortality by logistic regression analysis.
Results: We included 131 patients, 57.3% of which were male. The serum estradiol level measured at ICU admission was significantly higher in nonsurvivors than in survivors: 116 versus 67.2 pg/mL, respectively (P < 0.0001). The area under the ROC of serum estradiol level to predict mortality was 0.74 (P < 0.0001). Serum estradiol level ≥97.9 pg/mL had sensitivity of 60%, specificity of 90%, positive predictive value of 64%, negative predictive value of 88%, positive likelihood ratio of 6, and negative likelihood ratio of 0.44, for predicting mortality. In multivariate analysis, it had relative risk of 6.47 (P = 0.002) for ICU mortality.
Conclusions: The serum estradiol level is elevated in critically ill patients, regardless of gender, especially in those who die. It has good discriminative capacity to predict mortality, and it is an independent risk factor for death in this group of patients.
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Sharma P, Prem V, Jain S. Immediate Effects of Acapella® on Dynamic Lung Compliance in Mechanically Ventilated Patients with Acute Respiratory Distress Syndrome: A Case Series. Indian J Crit Care Med 2018; 22 (2):100-102.
Background and Aims: One potential complication of acute respiratory distress syndrome (ARDS) is reduced dynamic compliance, saturation for peripheral oxygenation (SpO2) and increased sputum in patients that are mechanically ventilated. Airway clearance technique is the treatment given for patients on mechanically ventilator with ARDS. The purpose of the case series is to know the immediate effects of Acapella® on dynamic lung compliance (Cdyn) in subject with ARDS.
Subjects and Methods: Patients who are on ventilator for more than 48hrs were included in the study. Readings for Cdyn, SpO2were noted at baseline, immediately post treatment, 10, 20, 30 and 60minutes. Pre and post treatment sputum volume was also noted.
Results: Five patients were included with age range of 25 to 75 years. Clinical improvement was seen immediately after treatment in Cdyn and SpO2. There was not much change in sputum volume.
Conclusion: Acapella® increased the dynamic compliance of lungs and sputum clearance in mechanically ventilated ARDS patients.
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Gupta A. Colistin-resistant Klebsiella pneumoniae in Surgical Polytrauma Intensive Care Unit of Level-1 Trauma Center: First Case Series from Trauma Patients in India. Indian J Crit Care Med 2018; 22 (2):103-106.
Introduction: There have been isolated case reports and reports of outbreak of colistin-resistant Klebsiella from various parts of the world but only two from India and that too from oncology centers. We report cluster of colistin-resistant Klebsiella pneumonia bloodstream infection cases from our surgical trauma Intensive Care Unit.
Methodology: The study was carried out in surgical ICU of Level-I trauma center. Retrospective analysis of all the five patients with CRK was done. Demographic data, antibiotic exposure throughout the hospital stay, hospital course, and clinical outcome were analyzed.
Results: Out of 5 patients, 4 were young males (mean age of 23.5 years) without comorbidities and had undergone exploratory laparotomy following blunt trauma abdomen. 3 patients were chronic patients and had been on carbapenem and colistin 11–20 days before isolation whereas 2 patienst had isolation of CRK just within 7 days of admission. Out of the five patients, 3 patients survived and 2 had fatal outcome.
Conclusions: CRK is an emerging and challenging pathogen in polytrauma victims - There was an outbreak of CRK in our ICU that could be contained with infection control measures.
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Saha A, Giri PP, Roy J. Scrub Typhus – A Major Cause of Pediatric Intensive Care Admission and Multiple Organ Dysfunction Syndrome: A Single-Center Experience from India. Indian J Crit Care Med 2018; 22 (2):107-110.
Aim of the Study: Scrub typhus has been globally recognized as an emerging infectious disease contributing significantly to pyrexia of unknown origin (PUO) and a potential cause of multiorgan dysfunction syndrome (MODS). We studied the incidence of scrub typhus as a cause of pediatric intensive care unit (PICU) admission and MODS in our hospital and its clinical and laboratory characteristics to measure the incidence of MODS caused by scrub typhus.
Materials and Methods: This study was done in a pediatric teaching hospital in Kolkata, India. Records of patients admitted with PUO from March 2012 to December 2015 were reviewed. Rathi–Goodman–Aghai scoring system was used to identify potential ST patients and confirmed by serological testing. Clinical characteristics, laboratory findings, and treatment response were noted of those needing PICU admissions.
Results: Ninety-seven cases of scrub typhus have been identified during that period. PICU admission was needed in 30 of them (31%) which contributed 8.43% of total PICU admissions. Among these 30 patients, 16 (53%) developed MODS which contributed 18.29% of total MODS admitted in PICU. Septic shock was the most common manifestation in as many as 18 (60%) patients followed by encephalopathy in 13 (43%). Patients were treated with either doxycycline alone or in combination with azithromycin. Mean time to complete defervescence was 32 h after first dose of doxycycline. The outcome was excellent without a single mortality.
Conclusion: Scrub typhus is an important cause of MODS in this part of the world, especially in fevers associated with features as identified and not responding to conventional antibiotics.
Overdose of cardiovascular medications such as beta blockers and calcium channel blockers cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances. In addition to conventional management of limiting absorption, increasing elimination and hemodynamic support intravenous (IV) calcium infusion, hyperinsulinemia-euglycemia therapy, glucagon infusion, and IV lipid emulsion have been tried. Extracorporeal circulatory assist device support has been reported as a rescue therapy in overdose refractory to maximal medical therapy. We report three patients with cardiovascular medication overdose presenting with profound cardiovascular instability refractory to medical therapy. Venoarterial extracorporeal membrane oxygenation support (VA ECMO) was initiated to provide hemodynamic support. Despite the occurrence of device-associated complications, the outcome was good and all patients survived. VA ECMO may be considered in patients with severe refractory shock due to cardiotoxic medication overdose.
Fondaparinux, a pentasaccharide administered for heparin-induced thrombocytopenia (HIT), can lead to the occurrence of thrombocytopenia. This patient underwent aortic stent graft placement for Salmonella paratyphi A-infected abdominal aortic aneurysm. Fondaparinux was administered for anticoagulation that led to a dramatic decline in his platelet counts. Investigations revealed HIT profile, PF4/heparin by particle gel immunoassay to be positive. Fondaparinux, a prescribed anticoagulant for HIT can paradoxically predispose to thrombocytopenia.
High-dose continuous midazolam therapy has been used successfully for control of refractory status epilepticus. However, normal anion gap (AG) metabolic acidosis, a deleterious complication of this therapy is underrecognized. Even though previously reported in an isolated case report in a pediatric patient, we observed similar complication in an adult patient. Stereotyped normal AG metabolic acidosis along with hypotension developed on two occasions during high-dose continuous midazolam hydrochloride infusion that reverted rapidly following cessation of the infusion.
Susanna K.P. Lau
We report a 21-year-old young male with Lemierre\'s syndrome presented as tonsillitis and Fusobacterium septicemia with respiratory failure and required intensive care. Lemierre\'s syndrome is the septic embolic complication of recent pharyngeal illness. Fusobacterium spp. accounts for the majority of cases. High index of suspicion is needed and prolonged antibiotic is advised. It is seldom seen in intensive care but should never be forgotten.
Pulmonary nocardiosis is a rare disease, which mainly affects immunocompromised hosts such as uncontrolled diabetics; HIV patients; and patients on immunosuppressive therapies such as anticancer drugs, systemic steroids, and transplant recipients. The diagnosis is often missed and delayed, resulting in inappropriate treatment and thus higher mortality. We are reporting a case of pulmonary nocardiosis with acute presentation in an immune-competent host, who presented with community-acquired pneumonia to the Intensive Care Unit. Clinical expertise with multiple high-end and interventional investigations timely confirmed the case as pulmonary nocardiosis. Conservative management with medications led to her complete recovery.