Purpose: The aim of this study is to determine the clinical efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy in children presented with respiratory distress. Study Design: This was a randomized controlled study. Materials and Methods: Infants and children aged between 1 month to 5 years who were admitted to our tertiary referral center for respiratory distress (July 1, 2014 to March 31, 2015) and met the inclusion criteria were recruited. Interventions: Infants and children hospitalized with respiratory distress were randomized into two groups of interventions. All clinical data, for example, respiratory score, pulse rate, and respiratory rate were recorded. The results were subsequently analyzed. Results: A total of 98 respiratory distress children were enrolled during the study period. Only 4 children (8.2%) failed in HFNC therapy, compared with 10 children (20.4%) in conventional oxygen therapy group (P = 0.09). After adjusted for body weight, underlying diseases, and respiratory distress score, there was an 85% reduction in the odds of treatment failure in HFNC therapy group (adjusted odds ratio 0.15, 95% confidence interval 0.03–0.66, P = 0.01). Most children in HFNC therapy group had significant improvement in clinical respiratory score, heart rate, and respiratory rate at 240, 360, and 120 min compared with conventional oxygen therapy (P = 0.03, 0.04, and 0.03). Conclusion: HFNC therapy revealed a potential clinical advantage in management children hospitalized with respiratory distress compared with conventional respiratory therapy. The early use of HFNC in children with moderate-to-severe respiratory distress may prevent endotracheal tube intubation. Trial Register: TCTR 20170222007.

Purpose of the Study: Data regarding the use of noninvasive ventilation (NIV) for treatment of acute respiratory failure (ARF) among patients with noncystic fibrosis (CF) bronchiectasis are limited. We intend to describe our experience with NIV use in this setting. Methodology: This was a retrospective study which included 99 patients with bronchiectasis and ARF who required either NIV or invasive mechanical ventilation (IMV). Results: NIV was started as the primary modality of ventilatory support in 81 (66.3%) patients. Fifty-three (65.4%) patients were managed successfully with NIV. Twenty-eight (34.56%) patients failed NIV and required endotracheal intubation. Reasons for NIV failure were worsening or nonimprovement of ventilatory or oxygenation parameters (n = 15), hypotension (n = 6), worsening of sensorium (n = 3), and intolerance (n = 4). None of the patients failed NIV due to excessive respiratory secretions. The rate of correction of arterial blood gases was comparable between NIV and IMV groups. The total duration of stay (median [interquartile range] days) in hospital was comparable between patients treated with NIV and IMV (8 [7–10] vs. 11 [5–11]; P = 0.99), respectively. The mortality rate between NIV and IMV groups were statistically comparable (8.64% vs. 16.6%; P = 0.08). High APACHE score at admission was associated with NIV failure (odd's ratio [95% confidence interval]: 1.21 (1.07–1.38)]. Conclusions: NIV is feasible for management of ARF with non-CF bronchiectasis. High APACHE may predict NIV failure among these patients.

Background: Mortality prediction in the Intensive Care Unit (ICU) setting is complex, and there are several scoring systems utilized for this process. The Acute Physiology and Chronic Health Evaluation (APACHE) II has been the most widely used scoring system; although, the more recent APACHE IV is considered an updated and advanced prediction model. However, these two systems may not give similar mortality predictions. Objectives: The aim of this study is to compare the mortality prediction ability of APACHE II and APACHE IV scoring systems among patients admitted to a tertiary care ICU. Methods: In this prospective longitudinal observational study, APACHE II and APACHE IV scores of ICU patients were computed using an online calculator. The outcome of the ICU admissions for all the patients was collected as discharged or deceased. The data were analyzed to compare the discrimination and calibration of the mortality prediction ability of the two scores. Results: Out of the 1670 patients' data analyzed, the area under the receiver operating characteristic of APACHE II score was 0.906 (95% confidence interval [CI] – 0.890–0.992), and APACHE IV score was 0.881 (95% CI – 0.862–0.890). The mean predicted mortality rate of the study population as given by the APACHE II scoring system was 44.8 ± 26.7 and as given by APACHE IV scoring system was 29.1 ± 28.5. The observed mortality rate was 22.4%. Conclusions: The APACHE II and IV scoring systems have comparable discrimination ability, but the calibration of APACHE IV seems to be better than that of APACHE II. There is a need to recalibrate the scales with weights derived from the Indian population.

Introduction: This study was planned to explore the clinical and hematological profile of febrile neutropenia (FN) in Indian children with focus on correlation of degree of neutropenia with fever and procalcitonin (PCT) level and the utility of serum PCT levels in cases of FN. Materials and Methods: Children below 12 years, receiving chemotherapy for hematological malignancy having oral temperature more than 100°F and absolute neutrophil count (ANC) below 500/mm³ were included. The aim of this study was to observe the clinicohematological profile of FN and utility of serum PCT levels in neutropenic patients. PCT was done by two-step two-site electrochemiluminescence immunoassay. Serum PCT values were reported as nanogram/ml. Results: Four categories were made based on serum PCT levels which had negative correlation with ANC but no correlation with microbiologically detected infections. Discussion: PCT is generally used to support the diagnosis of bacterial infection or sepsis in the emergency department or to monitor the treatment of sepsis with regard to reviewing antimicrobial treatment. The use of PCT has been well established as a marker for infection in adults and in nonneutropenic children, but similar data are lacking in pediatric population, more so in children with FN in Indian contexts. This study aims to fulfill this lacuna. Conclusion: The higher levels of PCT had a high negative correlation with ANC but low correlation with microbiologically detected infections.

Objectives: Focused transthoracic echocardiography (fTTE) in critical care can be used to assess patient's volume status, ventricular contractility, right ventricle chamber size, and valvular abnormalities. The objective of the study was to assess the competency of intensivists in performing fTTE in Intensive Care Unit (ICU) patients after a brief training course by cardiologist using a specific ECHO protocol. Methods: One hundred and four patients in ICU were recruited for this prospective observational study over a period of 12 months. Intensivists were trained for 60 h (2 h/day for 30 days). Intensivists performed fTTE in 82 ICU patients using a specific ECHO protocol developed in consensus with cardiologists. Each patient was assessed by an intensivist and two blinded cardiologists. At the end of the study period, the competency of intensivists was compared with two cardiologists and analyzed using intraclass correlation coefficient (ICC). Results: There were excellent agreement between intensivists and cardiologists in terms of measuring ejection fraction (ICC estimate was 0.973–0.987), valvular function (ICC estimate for mitral valve was 0.940–0.972; ICC estimate for aortic valve was 0.872–0.940), and ICC estimate for pulmonary hypertension was 0.929–0.967. Good reliability has been found for the assessment of volume status with inferior vena cava diameter (ICC estimate for assessing hypovolemia was 0.790–0.902). Conclusion: Intensivists with requisite training in TTE were able to perform focused echocardiography with comparable accuracy to that of cardiologists. Further studies are required to elucidate the therapeutic implications of fTTE performed by the intensivists.

Aim: The aim was to describe which elements of nurses' knowledge, training needs, behavior, and attitude can prevent Medication errors (Acronym MEs) in the emergency department during all steps of the administration of intravenous (IV) medications. Methods: An anonymous questionnaire made up of 43 items has been drafted and delivered to a sample of 103 nurses of a university hospital in Rome. The study has been supported by specific literature review. Results: Majority of the sample (94%) answered that topics related to the preparation and administration of IV medications were covered during the basic course while 63.2% only during the postbasic course. Only 15.6% of nurses judged excellent their level of knowledge about preparation and administration of IV medications while 89.3% considered that it is important to improve their knowledge; 85.6% said that the teaching about the use of IV medications should be increased during the degree course they attended; 30.3% agreed that specific postgraduate courses on the use of IV drugs should be designed. Moreover, only 22% of the sample believed that the coaching of new recruit nurses is critical to prevent errors. Conclusion: The sample showed appropriate knowledge, positive attitudes, and right behavior related to the preparation and administration of IV medications. The skills that nurses must have in pharmacology are still rising, both due to the safety of drug therapy and to the increasing number of drugs available; the result is that nurses have to update their knowledge regularly.

Background: Tramadol, a preferred analgesic due to its less respiratory depression. It also has a central action that blocks the reuptake and enhances the release of serotonin at spinal antinociceptive pathways. Ondansetron, an antiemetic is a serotonin receptor antagonist. Due to the contradictory actions of the two drugs, co-administration of these drugs resulted in higher usage of tramadol. All these studies were done in the postoperative period. Aim: The aim of this study is to evaluate the analgesic efficacy of tramadol infusion versus tramadol plus ondansetron infusion in Medical Intensive Care Unit (ICU) patients. Materials and Methods: After Institutional Ethical Committee approval, 50 patients who experience pain other than postoperative pain were enrolled and randomized into two groups. Both the groups initially received 50 mg of tramadol intravenously over 10 min followed by Group T+O received 10 mg/h tramadol + 0.4 mg/h ondansetron as an infusion. Group T received 10 mg/h tramadol as infusion. Hemodynamic parameters along with pain assessment using Verbal Rating Scale (VRS) were analyzed at 0, 3, 6, 12, and 24 h. Rescue analgesia was administered if VRS >4. Side effects were noted by condition scoring criteria (CSC) scale. Results: Rescue analgesia was administered at 3 h, for three patients in T+O Group and 1 patient in T Group, but this is not statistically significant (P = 0.153). No rescue analgesia was required in both the groups at any other point of time. There was fall in heart rate, systolic and diastolic blood pressures, respiratory rate at 0, 3, 6, 12, and 24 h in both the groups but not statistically significant. Grade 1 sedation of CSC scale was observed in two patients of Group T+O and one patient in Group T but not statistically significant (P = 0.153). No nausea and vomiting were seen. Conclusions: We conclude that co-administration of tramadol and ondansetron can be practiced in medical ICU patients without any higher requirement in dosage of tramadol.

Catheter-associated urinary tract infection (CAUTI) is the leading cause of hospital-acquired infections in hospitalized patients in medical and surgical wards, but it is still commonly underdiagnosed in critically ill patients despite a higher device usage rate. The most commonly employed diagnostic criteria for such diagnosis come from the Infectious Disease Society of America and Centers for Disease Control and Prevention National Health Safety Network surveillance definition. It is surprising that no separate diagnostic criteria of CAUTI exist, for the critically ill patients – though these patients are of a different class of patients' altogether, due to decreased immunity, existence on multiple organ supports, and invasive lines, and an inability to communicate with a clinician. In this review, we highlight the difficulties in applying the available guidelines to diagnose CAUTI in critically ill patients. We also suggest an algorithm for the diagnosis of CAUTI in these patients.

The clinical and etiological pattern of ventilated newborns, their outcome in relation to morbidity and mortality was studied with 50 ventilated newborns, including outborns. M:f ratio was 2.1:1. The most common gestational age 28–36 weeks (60%) and mostly were appropriate for gestational age (66%). Survival rate 40% (20/50) being directly proportional to the gestational age and intrauterine growth pattern (P < 0.01). Babies by LSCS Lower Segment Cessarian Section survived more than born by normal vaginal delivery (46.7% vs. 37.1%). More outborn survival could be related to their advanced gestational age on presentation. The initial assessment of APGAR score of >7 had a better outcome (56.3%; P < 0.03). The most common indication of ventilation was hyaline membrane disease (19/50) but the survival rate best in babies with meconium aspiration syndrome (54.5%). The most prevalent complication was sepsis (survival rate 60%) while conditions such as shock, intraventricular hemorrhage, disseminated intravascular coagulation, air leak syndrome, and pulmonary hemorrhage had 100% mortality. Thus, the outcome as survival is constrained by many factors; newborn's profile, conditions at birth, and postnatal resuscitation.

Background: The (1,3)-β-D-glucan assay (BDG) is recommended for the early diagnosis of invasive candidiasis (IC). Methods: Records of 154 critically ill adults with suspected IC, on whom BDG was done, were analyzed. Patients were divided into three groups: Group A (confirmed IC), Group B (alternative diagnosis or cause of severe sepsis), and Group C (high candidal score and positive BDG [>80 pg/mL] but without a confirmed diagnosis of IC). Results: Mean BDG levels were significantly higher in Group A (n = 32) as compared to Group B (n = 60) and Group C (n = 62) (448.75 ± 88.30 vs. 144.46 ± 82.49 vs. 292.90 ± 137.0 pg/mL; P < 0.001). Discontinuation of empiric antifungal therapy based on a value <80 resulted in cost savings of 14,000 INR per day per patient. Conclusion: A BDG value of <80 pg/ml facilitates early discontinuation of empirical antifungal therapy, with considerable cost savings.

Idiopathic systemic capillary leak syndrome (ISCLS) is a very rare life-threatening disorder characterized by recurrent episodes of hypotension, hemoconcentration, and hypoalbuminemia. It is caused by transient endothelial dysfunction, leading to plasma leakage from intravascular to interstitial space. Here, we report a case of ISCLS with recurrent episodes of capillary leak which required a long-term prophylaxis with beta-2 adrenergic receptor agonist and theophylline. Although ISCLS is the rare entity, associated morbidity and mortality require physician's awareness to provide timely therapy. Under-recognition in the medical community and rarity of this syndrome has precluded analysis in rational clinical trial designs that are necessary to determine targeted and adequate therapy. This report is meant to enhance awareness of ISCLS among physician's community.

Aortocaval fistulas (ACFs) are rare with varied etiologies. Symptoms can be acute or delayed with predominant manifestations being high output cardiac failure. Acute coronary syndrome due to ACF has not been widely reported. We present a case of a 68-year-old male who presented with signs and symptoms suggestive of acute coronary syndrome. This was confirmed by electrocardiogram changes and a rise in cardiac enzymes. A large abdominal aortic aneurysm was diagnosed initially by imaging without evidence of leak or rupture. A coronary angiogram showed only mild diffuse disease. On further reviewing, the computerized tomography imaging revealed an ACF. This was subsequently repaired with rapid improvement in his condition. Acute coronary syndrome is an unusual presentation of ACF with inadequately understood pathophysiological mechanisms. Prompt diagnosis and surgical management of this fistula are paramount to reduce mortality and morbidity.

Mucormycosis is an aggressive fungal infection caused by zygomycetes from the order of Mucorales. Immunocompromised patients or patients with comorbidities are susceptible to this infection. There are many forms of mucormycosis such as rhino-orbito-cerebral, cutaneous, gastrointestinal, and pulmonary. Cutaneous mucormycosis is rare in trauma patients with no comorbidities. Morel-Lavallée lesions are rare degloving injuries in trauma patients. We report a case of cutaneous mucormycosis in a trauma patient with the Morel-Lavallée lesions.

Hypokalemia is a serious and life-threatening clinical condition. We present a case of a 45-year-old male, with known hyperthyroidism presenting with profound tremor, irritability, quadriparesis, and labored breathing since morning, on the day of admission. Arterial blood gas analysis showed severe hypokalemia. Patient's vital was stabilized and patient's oxygen saturation was maintained on oxygen inhalation. Intravenous potassium chloride infusion was administered with regular monitoring of vitals and electrolytes. Patient's symptoms improved. Thyroid function testing showed high free T3 (tri-iodothyronine) and free T4 (thyroxine) with low thyroid-stimulating hormone concentration in the serum, indicating thyrotoxic hypokalemic periodic paralysis. Treatment with antithyroid drug carbimazole resulted in an improvement during the follow-up visit. Hypokalemia is believed to be a consequence of a massive shift due to increased sodium–potassium–adenosine triphosphatase (Na⁺K⁺ATPase) pump activity in the presence of elevated thyroid hormones.

Hypertriglyceridemia (HTG) is the third leading cause of acute pancreatitis (APs) worldwide which is invariably associated with elevated pancreatic enzyme levels. We present a case of HTG-induced recurrent AP with normal serum amylase and lipase levels in a patient of Syndrome Z.

The year 2009–2010 saw H1N1 influenza outbreaks occurring in almost all countries of the world, causing the WHO to declare it a pandemic of an alert level of 6. In India, H1N1 influenza outbreaks were again reported in late 2014 and early 2015. Since then, sporadic cases of H1N1 influenza have been reported. H1N1 influenza usually presents itself with respiratory tract symptoms. In a minority of patients, abdominal symptoms may occur as well. Acute influenza-associated encephalopathy/encephalitis mostly occurs in the pediatric population, whereas in adults, it is a rare complication. The incidence of neurological complications appears to have increased after the 2009 H1N1 influenza A virus pandemic. We would like to draw attention to an adult patient case who initially presented with respiratory symptoms but then deteriorated and developed encephalitis, which is rarely reported. As per literature reviewed by Victoria Bangualid and Judith Berger on PubMed, only 21 cases of neurological complications were found in adult influenza A patients, out of whom 8 had encephalopathy.