Indian Journal of Critical Care Medicine

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2018 | June | Volume 22 | Issue 6

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K. P. Suraj, E. Jyothi Jyothi, R. Rakhi

Role of domiciliary noninvasive ventilation in chronic obstructive pulmonary disease patients requiring repeated admissions with acute Type II respiratory failure: A prospective cohort study

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:5] [Pages No:397 - 401]

Keywords: Acute exacerbation of chronic obstructive pulmonary disease, home mechanical ventilation, hypercapnic respiratory failure, long-term noninvasive ventilation, noninvasive ventilation

   DOI: 10.4103/ijccm.IJCCM_61_18  |  Open Access |  How to cite  | 


Background: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with acute hypercapnic respiratory failure (AHRF) is associated with high mortality and increased risk for further exacerbations and hospitalization. While there is ample evidence regarding the benefit of noninvasive ventilation (NIV) during AECOPD, evidence supporting long-term noninvasive ventilation (LTNIV) for more stable COPD patients is limited. Objective: The aim of this study is to assess the effectiveness of LTNIV in COPD patients requiring frequent hospital admissions and NIV support for AHRF. Materials and Methods: A prospective cohort study including 120 patients having survived an admission requiring NIV support for AHRF due to COPD, with a history of ≥3 similar episodes in the past year. Patients were advised LTNIV (30) with standard treatment, or (90) standard treatment alone. Both groups were followed up for 1 year. Among non-NIV group 10 died, and 8 lost follow-up, whereas two died in NIV group. The primary endpoint was death. Data of remaining 100 patients were analyzed for other objectives-number of readmissions, AHRF, Intensive Care Unit (ICU)/ventilator requirement, dyspnea, quality of life, exercise tolerance, lung function, and arterial blood gases. Results: LTNIV group had 40% reduction in mortality (6.6% vs. 11.1%). There was significant reduction in number of hospital admissions (28.6% vs. 84.7%: P <0.05), ICU admissions (7.1% vs. 56.9%: P = 0.01), ventilator requirement (3.6% vs. 30.6%: P = 0.003), AHRF (7.1% vs. 48.6%: P = 0.000) and improvement in partial arterial CO2pressure (39.8 ± 2.1 vs. 57.03 ± 3.7 mmHg) and severe respiratory insufficiency score (P < 0.05) among LTNIV group, but no significant change in lung function and exercise tolerance. Conclusion: Patients tolerated LTNIV well and had a better outcome compared to those without NIV. LTNIV may be considered in patients with recurrent AHRF.



Wan Fadzlina Wan Muhd Shukeri, Ummu Kulthum Jamaludin, Fatanah Suhaimi, Normy Norafiza Abd Razak, Azrina Md Ralib

Levels and diagnostic value of model-based insulin sensitivity in sepsis: A preliminary study

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:6] [Pages No:402 - 407]

Keywords: Critical care, diagnosis, insulin sensitivity, model-based, sepsis

   DOI: 10.4103/ijccm.IJCCM_92_18  |  Open Access |  How to cite  | 


Background and Aims: Currently, there is a lack of real-time metric with high sensitivity and specificity to diagnose sepsis. Insulin sensitivity (SI) may be determined in real-time using mathematical glucose-insulin models; however, its effectiveness as a diagnostic test of sepsis is unknown. Our aims were to determine the levels and diagnostic value of model-based SI for identification of sepsis in critically ill patients. Materials and Methods: In this retrospective, cohort study, we analyzed SI levels in septic (n = 18) and nonseptic (n = 20) patients at 1 (baseline), 4, 8, 12, 16, 20, and 24 h of their Intensive Care Unit admission. Patients with diabetes mellitus Type I or Type II were excluded from the study. The SI levels were derived by fitting the blood glucose levels, insulin infusion and glucose input rates into the Intensive Control of Insulin-Nutrition-Glucose model. Results: The median SI levels were significantly lower in the sepsis than in the nonsepsis at all follow-up time points. The areas under the receiver operating characteristic curve of the model-based SI at baseline for discriminating sepsis from nonsepsis was 0.814 (95% confidence interval, 0.675–0.953). The optimal cutoff point of the SI test was 1.573 × 10−4 L/mu/min. At this cutoff point, the sensitivity was 77.8%, specificity was 75%, positive predictive value was 73.7%, and negative predictive value was 78.9%. Conclusions: Model-based SI ruled in and ruled out sepsis with fairly high sensitivity and specificity in our critically ill nondiabetic patients. These findings can be used as a foundation for further, prospective investigation in this area.



Sanjeev Sinha, Ramavath Devendra Naik, Kartik Gupta, Arunmozhimaran Elavarasi, V. Sreenivas

Sleep quality and quantity in intensive care unit patients: A cross-sectional study

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:7] [Pages No:408 - 414]

Keywords: Actigraphy, Intensive Care Unit, Richards-Campbell Sleep Questionnaire, sleep quality

   DOI: 10.4103/ijccm.IJCCM_65_18  |  Open Access |  How to cite  | 


Introduction: Lack of restorative sleep and altered sleep-wake cycle is a frequent problem among patients admitted to the Intensive Care Unit (ICU). This study was conducted to estimate the prevalence of poor sleep and patient's perspective of factors governing poor sleep in the ICU. Materials and Methods: A cross-sectional study was performed in medical ICU of a tertiary care hospital. A total of 32 patients admitted to the ICU for at least 24 h were recruited. A 72-h actigraphy was done followed by a subjective assessment of sleep quality by the Richards-Campbell Sleep Questionnaire (RCSQ). Patient's perspective of sleep quality and quantity and possible risk factors for poor sleep were recorded. Results: Poor sleep (defined as RCSQ <50, sensitivity 88% and specificity 87%) was found in 15 out of the 32 patients (47%). The prevalence of poor sleep was higher among patients on mechanical ventilation (n = 15) (66.7% vs. 33.3%, P < 0.05). Patients with poor sleep had higher age (median age [in years] 42.8 vs. 31.4, P = 0.008), acute physiology, and chronic health evaluation II score (mean 14 ± 5.15 vs. 9.3 ± 5.64, P = 0.02), SAPS 3 score (62.7 ± 8.9 vs. 45.6 ± 10.5, P ≤ 0.0001), and worse actigraphy parameters. Only 55.63% of total sleep time was in the night (2200–0600). All patients had discomfort from indwelling catheters and suctioning of endotracheal tubes. All patients suggested that there be a minimum interruption in the sleep for interventions or medications. Conclusion: There is a high prevalence of poor sleep among patients admitted to the ICU. There is a dire need to minimize untimely interventions and design nonpharmacological techniques to allow patients to sleep comfortably.



Koroush Ebrahimi, Ali Akbar Raigani, Rostam Jalali

Determining and comparing predictive and intensity value of severity scores – “Sequential organ failure assessment score,” “Acute physiology and chronic health Evaluation 4,” and “Poisoning severity score” – in short-term clinical outcome of patients with poisoning in an ICU

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:7] [Pages No:415 - 421]

Keywords: Acute Physiology and Chronic Health Evaluation 4, clinical outcome, Poisoning Severity Score, poisoning, predictive value, Sequential Organ Failure Assessment score

   DOI: 10.4103/ijccm.IJCCM_238_17  |  Open Access |  How to cite  | 


Introduction: Today, poisoning is one of the problems of society and it is always one of the ten leading causes of death among youth. This study aimed to determine and compare the predictive and intensity value of three standard criteria of “Sequential Organ Failure Assessment (SOFA) score,” “Acute Physiology and Chronic Health Evaluation (APACHE) 4,” and “Poisoning Severity Score (PSS)” in short-term clinical outcome of poisoned patients. Methods: The prospective study conducted on 120 patients of critical care units. Data were collected using a demographic form and three criteria forms. The researcher was visiting the critical care unit daily and was filling out the demographic form of each patient in the first 24 h of hospital admission. The data were analyzed using SPSS version 16. Results: The results showed the mean age of patients was 35.73 ± 18.46 years with the most frequency among male patients (66.7%). The mean of criteria scores of “SOFA score,” “APACHE 4,” and “PSS” was 7.3 ± 2.97, P = 0.009; 62.43 ± 12.48, P = 0.58; and 2.4 ± 0.5, P = 0.001, respectively. The accuracy, sensitivity, specificity, positive and negative predictive values, and area under the curve of “SOFA score,” “APACHE 4,” and “PSS” were 86.2, 70.6, 94.4, 98.6, 36.2, 0.897; 83.5, 90.2, 44.4, 90.2, 44.4, 0.808; and 16.7, 100, 2, 100, 15.3, 0.786, respectively. Predicted mortality rate in “SOFA score” and “APACHE 4” was 18.7% ±20.2% and 2.63% ±2.6%, respectively. Real mortality rate, predictive duration of hospitalization by APACHE 4 criteria, and real duration of hospitalization were 15%, 1.79 ± 1.35, and 4.04 ± 4.08, respectively. Conclusion: The study showed that “SOFA score” was more predictive in clinical outcomes due to poisoning and it is recommended to poisoning centers as effective criteria.



Siddharth P. Deshpande, Nithya J. Gogtay, Nitin B. Mali, Chandrahas T. Deshmukh, Urmila M. Thatte

A prospective antibacterial utilization study in pediatric intensive care unit of a tertiary referral center

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:5] [Pages No:422 - 426]

Keywords: Antibacterials, drug utilization, encounter, indicators, Pediatric Intensive Care Unit

   DOI: 10.4103/ijccm.IJCCM_365_17  |  Open Access |  How to cite  | 


Purpose: Antibacterials are commonly prescribed to Pediatric Intensive Care Unit (PICU) patients. However, inappropriate antibacterial prescriptions lead to increases in antibacterial resistance, treatment cost, duration of treatment, and poor clinical outcome. The antibacterial utilization study assesses the prescription patterns and if necessary recommends the interventions to improve antibacterial prescriptions. Hence, the present prospective groundwork was conducted. Materials and Methods: The study was conducted over the period of 6 months (April 18 to October 20, 2014). The demographics and drug use details were captured daily from patients admitted to PICU to assess World Health Organization indicators. Results: A total of 200 patients enrolled, among them 119 males and 81 females. There were 12.46 (±6.16) drugs prescribed per patient, of which 2.38 (±1.48) were antibacterials. Among the total drug prescribed, 18.49% were antibacterials and 97% patients received at least one antibacterial. Ceftriaxone (49.48%) was the most commonly prescribed antibacterial, while imipenem (2.58%) and colistin (2.06%) use was very low. A total of 80.95% antibacterials were prescribed by generic name, 94.88% were administered intravenously, and 80.76% were prescribed from hospital pharmacy. The average length of PICU stay was 6.15 days (±6.20), the average length of antibacterial treatment was 6.08 days (±6.27), and the average length of empirical antibacterial treatment was 5.50 days (±5.40). The cost of antibacterial therapy per patient was Indian rupees 824.64 (±235.35). In 27 patients, bacterial culture test was positive and of whom 21 received antibacterials as per sensitivity pattern. Conclusions: The use of antibacterials was not indiscriminately high but more prescriptions per sensitivity pattern are required.



Valluri Anil Kumar, Bobba Ushasree Reddy, Veldurti Ananta Kiran Kumar, R. Lakshman Kumar, Mundlapudi Jahnavi

Speech and swallowing function outcome following early tracheostomy in patients who underwent neurosurgical intervention

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:4] [Pages No:427 - 430]

Keywords: Neurotrauma, tracheostomy, traumatic brain injury

   DOI: 10.4103/ijccm.IJCCM_31_18  |  Open Access |  How to cite  | 


Background: Evaluation of late-onset speech and swallowing complications of tracheostomy on neurotrauma cases, as the most common intensive care unit procedure, needs to be evaluated. Objectives: A prospective study conducted in a tertiary care teaching hospital to find the late-onset speech and swallowing complications of tracheostomy in neurotrauma cases. Materials and Methods: This prospective observational study was conducted in the intensive care unit on intubated patients needing elective tracheostomy at a tertiary care teaching institute in South India with a dedicated referral trauma center. A data collection tool was prepared to find age, gender, date of admission, tracheostomy, and discharge, contact address and number, initial and final diagnosis, initial Glasgow Coma Scale (GCS) on admission and subsequent GCS before and after tracheostomy, ventilator settings before and after the tracheostomy, procedure and intraoperative complications, type of cannula used, details of decannulation, and respiratory difficulties. Results: In our study among 69 cases between 16 and 75 years' age range with mean 46.67 ± 16.65, majority were males (75.36%) and 60 were cranial cases (86.96%). Of the alive cases (21 [30.43%]) who underwent tracheostomy; 18 were performed in operation theater and 3 as bedside procedure. Major problems reported were: Speech problems (not able to phonate) (9), feeble voice (6), pain while speaking (6), and reduced loudness (6), frequent throat clearing while speaking (4), cough while speaking (3); breathlessness while speaking (1), gasping while speaking (1) and vocal tiredness (1); aspirations (2) and painful swallowing (1). Conclusions: Our study suggested that though, majority of neurotrauma patients require tracheostomy for long term ventilator support and associated speech and swallowing problems are expected.



B Renymol, Dhanya Palappallil, N Ambili

Study on clinical profile and predictors of mortality in Cerbera odollam poisoning

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:4] [Pages No:431 - 434]

Keywords: Cerbera odollam, mortality predictors, poisoning

   DOI: 10.4103/ijccm.IJCCM_469_17  |  Open Access |  How to cite  | 


Context: Cerbera odollam is a tree native to South Asia. It belongs to the poisonous Apocynaceae family. Deliberate self-harm with fruit of this plant is a major clinical problem in the developing world. Ingestion of C. odollam kernels is the cause of deaths in more than half of Kerala's plant poisoning deaths. The data on clinical features and complications of C.odollam poisoning are sparse, apart from a few case reports and limited studies. Aims: The present study was done to find the mode of presentation, complications, need for cardiac pacing, inhospital mortality, and the predictors of mortality in patients with C. odollam poisoning. Settings and Design: This was a retrospective study conducted in the department of general medicine in a tertiary care center in Alappuzha district, Kerala. The study period was for 1 year from January 1, 2016, to December 31, 2016. Subjects and Methods: All the patients admitted with a history of ingestion of odollam during the study period were included in the study. Data were collected from case records. The study was approved by the institutional ethics committee and research committee (IEC/TDMCA/EC3.dated29/11/201). Statistical Analysis Used: The data were analyzed using SPSS 16 for Windows (SPSS Inc., Chicago, IL, USA). Results: In this study, 102 patients were identified with C. odollam poisoning, and the mortality rate was 16.7%. Electrocardiogram (ECG) changes were common in our patients, and we observed different types of heart block in the same ECG itself. Ingestion of more than two kernels of odollam, late presentation to hospital, vomiting, bradycardia, hypotension, hyperkalemia, and more severe ECG changes were associated with significantly higher mortality in this study. Conclusions: C. odollam poisoning is a common method of deliberate self-harm in Kerala. It carries a high mortality rate, and the predictors of mortality include vomiting, bradycardia, hypotension, hyperkalemia, and the presence of severe ECG changes.



Comparison of lung ultrasound-based weaning indices with rapid shallow breathing index: Are they helpful?

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:6] [Pages No:435 - 440]

Keywords: Extubation predictor, lung ultrasound, rapid shallow breathing index, weaning process

   DOI: 10.4103/ijccm.IJCCM_331_17  |  Open Access |  How to cite  | 


Background and Aims: The diaphragm is considered the main respiratory muscle and difficulty in weaning can occur because of impaired diaphragmatic function. Hence, monitoring diaphragmatic function is important. The aim of this study is to assess the ability of various lung ultrasound (US) indices and the rapid shallow breathing index (RSBI) to predict the outcome of the weaning process and compare them with RSBI. Materials and Methods: This was a prospective study conducted on patients admitted to critical care unit at a tertiary care hospital in north India from February 2017 to June 2017. Patients were put to spontaneous breathing trial (SBT) when they met the weaning criteria. Initial US was done immediately after putting the patient on SBT to check anatomy of the diaphragm and rule out patients according to exclusion criteria. This was followed by complete lung US (LUS) after 20 min of SBT. Results: The RSBI performed better than all other parameters, with an area under the curve (AUC) of 0.996. The sensitivity and specificity is 100%. Only comparable to RSBI is the speed of diaphragmic contraction (DC) which has AUC of 0.93. All other parameters had an AUC <0.8. Moreover, the DC and LUS score are strongly positively correlated with RSBI, whereas diaphragmic excursion and diaphragmic thickness fraction (DTF %) are weakly correlated. Conclusion: In Intensive Care Unit, RSBI is the best clinical tool for weaning, and DC is found to be the best parameter for weaning among the US-based weaning parameters. It can even be a substitute for RSBI, in today's world of real-time monitoring methods.



K. N. Gopala Krishna, Sinha Sanjib, Dhrithiman Chakrabarti, R. C. Mundlamuri, Nitin Manohar, P. Mariamma, P. Satishchandra, G. S. Umamaheswara Rao

A comparative study of midazolam and target-controlled propofol infusion in the treatment of refractory status epilepticus

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:8] [Pages No:441 - 448]

Keywords: Midazolam, outcome, propofol, refractory status epilepticus, super refractory status, target-controlled infusion

   DOI: 10.4103/ijccm.IJCCM_327_17  |  Open Access |  How to cite  | 


Background: The recommended treatment for refractory status epilepticus (RSE) is the use of anesthetic agents, but evidence regarding the agent of choice is lacking. This study was designed to compare target-controlled infusion of propofol versus midazolam for the treatment of RSE regarding seizure control and complications. Methods: This prospective, randomized study recruited 23 adult patients with RSE due to any etiology and treated with either propofol or midazolam titrated to clinical seizure cessation and gradual tapering thereafter. The primary outcome measure was seizure control and the secondary outcomes were duration of the Intensive Care Unit stay and duration of mechanical ventilation, occurrence of super RSE (SRSE), and complications. Results: We recruited 23 patients (male:female = 18:5) into this study (propofol Group-11; midazolam Group-12). Overall, seizure control was noted in 34.8%, with successful seizure control in 45% of patients in the propofol group and 25% in midazolam group (P = 0.4). Mortality was similar in both the groups (propofol group [8/11; 72.7%] compared to the midazolam group [7/12; 58.3%] [P = 0.667]). The duration of hospital stay was significantly shorter in the propofol group compared to midazolam (P = 0.02). The overall incidence of SRSE was 69.5% in this study. The complication rate was not significantly different between the groups. Conclusions: The choice of anesthetic agent does not seem to affect the overall outcome in RSE and SRSE. Target-controlled propofol infusion was found to be equal in its efficacy to midazolam for the treatment of RSE. High mortality might be due to SRSE secondary to the underlying brain pathology.



Tewari Vineeta, Sandhu Megha

Is my patient still alive?

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:5] [Pages No:449 - 453]

Keywords: Alive, death, intensive care, trust, ventilator

   DOI: 10.4103/ijccm.IJCCM_529_17  |  Open Access |  How to cite  | 


The modern-day health-care firmament is fighting one of its biggest battles of mistrust, the seeds of which have been sown over the years and the roots seem to run deep. There is a substantial misunderstanding about the complexities of intensive care treatments, especially the life support interventions. A critically ill patient on ventilator is often perceived by the families to be dead. Such misconceptions have a huge negative impact on the already friable doctor–patient relationship. The paper presents an overview of the problem and deliberates on the possible theories of such misunderstandings and chariness. An attempt is made to suggest the steps that could be taken to address this complicated issue.



Viswas Chhapola, Sandeep Kanwal

Hepatomyoencephalopathy secondary to Cassia occidentalis poisoning: Report of three cases from North India

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:3] [Pages No:454 - 456]

Keywords: Accidental poisoning, acute hepatomyoencephalopathy syndrome, Cassia occidentalis, phytotoxin, plant poisoning

   DOI: 10.4103/ijccm.IJCCM_85_18  |  Open Access |  How to cite  | 


Cassia occidentalis is an annual tropical shrub causing toxicity in cattle. However, human case reports of its poisoning are scarce. We, here, report three young children, residents of Western Uttar Pradesh in North India, who presented with lethargy, jaundice, and altered sensorium after consumption of Cassia seeds. The toxidrome was defined as hepatomyoencephalopathy. The children were resuscitated, managed for acute liver failure, and subsequently discharged without sequel. Although few studies have previously documented this association, this is the first such case series documenting a direct causal relationship of Cassia to hepatomyoencephalopathy syndrome. Public and clinician awareness regarding this syndrome mimicking viral encephalitis has the potential to prevent further outbreaks.



Anand Bandachar Mamdapur, R. Madhusudan, Mustafa Samir

Therapeutic Red Cell Exchange Transfusion as an Adjuvant Therapy for Management of Sickle Cell Crisis in Adults

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:3] [Pages No:457 - 459]

Keywords: Intensive Care Unit, red cell exchange transfusion, sickle cell crisis

   DOI: 10.4103/ijccm.IJCCM_23_18  |  Open Access |  How to cite  | 


Sickle cell crisis is an acute clinical condition, caused due to capillary occlusion by the deformed red blood cells, leading to vaso-occlusive status. Vaso-occlusion is an emergency condition requiring intensive care admission and carries a high mortality. Sickle cell crisis is usually managed with hydration, analgesics, and supportive care. Therapeutic red cell exchange transfusion is advised as an adjuvant, for the management of sickle cell crisis, and it is mainly practiced in the pediatric population. We report an adult case of sickle cell crisis managed with therapeutic red cell exchange transfusion in Intensive Care Unit and successful outcome in patient management.



Alexandre Vagh Weinmann, Charlotte Beaucreux, Kevin Kearns, Clément Dubost

Keep an Eye on the Intracranial Pressure, Thanks to the Optic Nerve Sheath Diameter

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:3] [Pages No:460 - 462]

Keywords: Brain hemodynamics, cerebral Doppler, cerebral monitoring, coma, optic nerve sheath diameter

   DOI: 10.4103/ijccm.IJCCM_446_17  |  Open Access |  How to cite  | 


Neurological examination on sedated patients is challenging and no gold standard monitoring is currently available. We report the case of a patient deeply sedated for the management of acute respiratory distress syndrome secondary to pneumonia. Delay in awakening led to cerebral exploration by transcranial Doppler (TCD) and measurement of optic nerve sheath diameter (ONSD). Abnormal values of ONSD prompted immediate brain computed tomography scan that confirmed high intracranial pressure (ICP) due to multiple deep parenchymal hematomas. Despite raised ICP, values obtained by TCD were normal, thanks to the persistence of cerebral autoregulation. This case highlights the interest of combining noninvasive techniques for neurological examination, especially for sedated patients.



Diane C. McLaughlin, Jorge M. Mallea, Lauren K. Ng

Hyperammonemia Presenting as Refractory Status Epilepticus after Lung Transplant in a Patient Positive for Ureaplasma parvum

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:3] [Pages No:463 - 465]

Keywords: Cerebral edema, hyperammonemia, lung transplantation, seizures, status epilepticus

   DOI: 10.4103/ijccm.IJCCM_356_17  |  Open Access |  How to cite  | 


Hyperammonemia is a rare complication of lung transplant with a high mortality rate. It presents as encephalopathy and progresses to seizures, status epilepticus, coma, cerebral edema, and brain death. Multiple treatments have been documented including administration of medications, gut decontamination, and dialysis. However, no definitive treatments exist and mortality remains between 67% and 75%. We present the case of a 65-year-old male with idiopathic pulmonary fibrosis who developed refractory status epilepticus secondary to hyperammonemia following lung transplant. The patient presented on postoperative day 7 with super-refractory status epilepticus and normal computed tomography scan of the head. Hyperammonemia was suspected due to refractory seizures and confirmed with peak ammonia level >1000 μmol/L. Despite aggressive treatment, the patient developed global cerebral edema and died. Postmortem investigations revealed that the patient was positive for Ureaplasma parvum. Additional studies are needed to elucidate the exact mechanism of disease and investigate successful treatment options.



Ali Jendoubi, Mouna Rkhami, Skander Guediche

Fatal Cerebellar Hemorrhage Complicating Pneumococcal Meningitis: Are Anticoagulants the Hidden Enemy?

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:2] [Pages No:466 - 467]

   DOI: 10.4103/ijccm.IJCCM_513_17  |  Open Access |  How to cite  | 



A Letter in Response to “Diagnosing Catheter-Associated Urinary Tract Infection in Critically ill Patients: Do the Guidelines Help?”

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:2] [Pages No:467 - 468]

   DOI: 10.4103/ijccm.IJCCM_225_18  |  Open Access |  How to cite  | 



Mayank Kumar, Tuhin Mistry, Subrata Singha, Mamta Sinha

Ultrasonography-Guided Internal Jugular Venous Catheterization: Unusual Position and Unusual Circumstances

[Year:2018] [Month:] [Volume:22] [Number:6] [Pages:2] [Pages No:468 - 469]

   DOI: 10.4103/ijccm.IJCCM_280_17  |  Open Access |  How to cite  | 


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