Indian Journal of Critical Care Medicine

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2018 | August | Volume 22 | Issue 8

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Saurabh Chaturvedi, Prabhaker Mishra, Ravi Mishra, Pralay Shankar Ghosh, Harshit Singh, Arvind Kumar Baronia, Ratender Kumar Singh

Correlation of neutrophil CD64 with clinical profile and outcome of sepsis patients during intensive care unit stay

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:6] [Pages No:569 - 574]

Keywords: Antibiotics, biomarkers, Intensive Care Unit, neutrophil CD64, prognosis, sepsis

   DOI: 10.4103/ijccm.IJCCM_228_18  |  Open Access |  How to cite  | 


Introduction: Neutrophil CD64 (nCD64) has been found to identify sepsis from nonseptic patients. It is also reported to be a predictor of survival and severity of sepsis. The goal of this study was to correlate serial nCD64 with Intensive Care Unit (ICU) outcome and severity of sepsis. Materials and Methods: A prospective observational study was conducted in 12-bedded critical care unit of a tertiary care center. Adult patients with sepsis were included in this study. Demographics, illness severity scores, clinical parameters, laboratory data, and 28-day outcome were recorded. Serial nCD64 analysis was done (on days 0, 4, and 8) in consecutive patients. Results: Fifty-one consecutive patients were included in the study. Median Acute Physiology and Chronic Health Evaluation II was 16 (12–20) and mean Sequential Organ Failure Assessment was 9 (8–10). Compared to survivors, nonsurvivors had higher nCD64 on day 8 (P = 0.001). nCD64 was higher in the septic shock group compared to sepsis group on days 0 and 8 (P < 0.05). Survivors showed improving trend of nCD64 over time while nonsurvivors did not. This trend was similar in the presence or absence of septic shock. nCD64 count was a good predictor of the septic shock on day 0 (area under the curve [AUC] = 0.747, P = 0.010) and moderate predictor at day 8 (AUC = 0.679, P = 0.028). Conclusion: Monitoring serial nCD64 during ICU stay may be helpful in determining the clinical course of septic patients.



Hossein Ghasemian-Nik, Raheb Ghorbani

Development a reverse triage system based on modified sequential organ failure assessment for increasing the critical care surge capacity

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:5] [Pages No:575 - 579]

Keywords: Modified sequential organ failure, reverse triage, surge capacity

   DOI: 10.4103/ijccm.IJCCM_47_18  |  Open Access |  How to cite  | 


Context: The capacity completeness are one of the serious problems in the bed's managements of the critical care units in a crisis and disaster situation. Reverse triage can help to hospital surge capacity in this situations. Aims: The aim of this study was to develop a reverse triage system based on Modified Sequential Organ Failure Assessment (MSOFA) for increasing critical care surge capacity. Settings and Design: This study was a prospective design that performed on the medical patients in critical care unit. Subjects and Methods: The MSOFA score for each patient was calculated in admission time and be continued until discharging time from critical care unit. Statistical Analysis Used: The Cox regression method was used to determine the relative risk values. At last, the patients were divided into three levels for reverse triage. Results: Four hundred and twenty patients were participated in this study. The mean of patients' MSOFA scores in the 1st day of admission in Critical Care was 5.40 ± 3.8. The relative risk of internal patients discharge from critical care was (8.2%). Death relative risks were <25%, higher than 70% and between 25.1% and 69.9% for three color level of green, black, and red, respectively. Conclusion: The MSOFA scores can contribute to the design a leveling system for discharging patients from critical care unit. Based on this system, the members of the caring team can predict the final health status of the patient.



Senthilkumar Rajagopalan

What happens to patients discharged against medical advice?

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:5] [Pages No:580 - 584]

Keywords: APACHE score, Critical Care Unit, discharge against medical advice, mortality, standard mortality rate

   DOI: 10.4103/ijccm.IJCCM_101_18  |  Open Access |  How to cite  | 


Introduction: Discharge against medical advice (DAMA) when requested by family members of patients in Indian Critical Care Units (CCUs) leads to loss of follow-up and unknown patient outcomes. Exclusion of these patients from research analysis and quality audits confounds these results. We hence explored the proportion of patients leaving DAMA, reasons, and their outcomes at 30 and 90 days. Methods: This was a prospective study of CCU patients admitted from July 2013 to February 2014. All patients, who were DAMA during this period, were included in this study. Demographics, APACHE data, and outcomes were collected and compared to patients discharged regularly during the same period. Outcomes of DAMA patients at 30 and 90 days were gathered by telephone follow-up. Results: Among the 663 patients admitted to the CCU, 15.1% (100 patients) were DAMA. The baseline APACHE score of the DAMA group was higher than the regular discharge group (29.5 ± 8.6 vs. 26.1 ± 10.3; P = 0.002). During the 30-day follow-up, 23% were alive, 56% dead, and 21% could not be contacted. At 90 days, mortality was 62% and survivors decreased to 14%. Common reasons for DAMA were – wanting to take the patient to another hospital (21%), reluctance for further treatments (12%), financial constraints (9%), and overall poor prognosis (7%). Conclusion: A significant proportion of patients in the CCU get DAMA despite high severity of illness. Understanding the outcomes of these patients will help refine CCU quality audit reports and research study results.



Durjoy K. Shome, Ahmed Jaradat, Ahmed I. Mahozi, Ali S. Sinan, Ali Ebrahim, Mohammed Alrahim, Mohammad S. Ebraheem, Eman J. Mansoor, Kameela S. Majed, Sheikh A. Azeez Pasha

The platelet count and its implications in sickle cell disease patients admitted for intensive care

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:6] [Pages No:585 - 590]

Keywords: Acute physiology, chronic health evaluation II, multi-organ dysfunction score, platelets, sickle cell disease, thrombocytopenia

   DOI: 10.4103/ijccm.IJCCM_49_18  |  Open Access |  How to cite  | 


Background and Aims: In sickle cell disease (SCD) patients admitted for intensive care, evaluation of platelet counts in different types of sickle cell complications and its prognostic relevance are not well-studied. Illuminating these aspects were the objectives of this study. Materials and Methods: A chart review of 136 adult SCD patients consecutively admitted to our Intensive Care Unit (ICU) was done. The prognosis on day 1 was assessed by Acute Physiology and Chronic Health Evaluation (APACHE II) and multiple organ dysfunction scores (MODS). Receiver operating characteristic (ROC) curves evaluated the ability of platelet counts, MODS, and APACHE II scores to predict survival. Results: The most common types of crises were severe pain (n = 53), acute chest syndrome (n = 40), and infection (n = 18); 17 patients were nonsurvivors. Platelet counts varied widely (range, 19–838 × 109/L) with thrombocytopenia (n = 30) and thrombocytosis (n = 11). Counts correlated directly with leukocytes and reticulocytes; inversely with lactate dehydrogenase, APACHE, and MODS scores. Areas under ROC curve for platelets, MODS, and APACHE scores to predict survival were 0.73, 0.85, and 0.93, respectively. Conclusions: In severe sickle cell crisis thrombocytopenia is more common than thrombocytosis. In the ICU, day 1 platelet counts correlate inversely with prognostic scores and are significantly reduced in multi-organ failure and nonsurvivors. A platelet count above 175 × 109/L predicts patient survival with high specificity and positive predictive value but lacks sensitivity.



Poonam Arora, Vivek Verma, Nikhil Gautam, J.P. Sharma

Retrospective evaluation of patients who leave against medical advice in a tertiary teaching care institute

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:6] [Pages No:591 - 596]

Keywords: Discharge against medical advice, emergency ward, leave against medical advice

   DOI: 10.4103/ijccm.IJCCM_375_17  |  Open Access |  How to cite  | 


Context: Discharge against medical advice or leave against medical advice (DAMA or LAMA) is a global phenomenon. The magnitude of LAMA phenomenon has a wide geographical variation. LAMA reasons are an area of concern for all involved in health-care delivery system. Aims and Objectives: The study aimed to evaluate cases of LAMA retrospectively in a tertiary teaching care institute (1) to find the magnitude of LAMA cases (2) to evaluate demographic and patient characteristics of these cases. Subjects and Methods: We screened hospital record of a referral institute over 1 year after approval from IEC and ICMR, New Delhi. Patient demographics and disease characteristics were noted and statistically analyzed after compilation. Results: A total of 47,583 patients were admitted in the year 2015 through emergency and outpatient department. One thousand five hundred and fifty-six (3.3%) patients got DAMA. The mean age of patient excluding infants was 46.64 ± 20.55 years. There were 62.9% of males. Average hospital stay of these cases was 4.09 ± 4.39 days. Most of the patients (70%) belonged to medical specialties and had longer stay as compared to surgical specialties. Most of LAMA patients were suffering from infections, trauma, and malignancies. Most of the patients had LAMA from ward (62%) followed by Intensive Care Unit (ICU) (28.8%) and emergency (9.2%). In 592 (38%) of LAMA patients, the reason for leaving was not clear. The common cited reasons for LAMA were financial (27.6%) and poor prognosis (20.5%). Conclusions: About 3.3% of patients left hospital against medical advice in our retrospective analysis. Most of these cases did so from ward followed by ICU. Financial reasons and expected poor outcome played a significant role.



Anand Jaiswal, Amartya Chakraborti, Pushpendra Verma, Ritu Singhal

A prospective study of fungal colonization and invasive fungal disease in long-term mechanically ventilated patients in a respiratory intensive care unit

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:5] [Pages No:597 - 601]

Keywords: Fungal colonization, invasive fungal disease, mechanical ventilation, respiratory Intensive Care Unit

   DOI: 10.4103/ijccm.IJCCM_181_18  |  Open Access |  How to cite  | 


Background: Long-term mechanical ventilation in an Intensive Care Unit (ICU) exposes the patient to fungal colonization and invasive fungal disease due to the presence of indwelling catheters, administration of broad-spectrum antibiotics, and intravenous corticosteroids. A study is hence required to study the risk factors and incidence of fungal infection in these patients. Methods: A prospective observational study was carried out in the respiratory ICU of a tertiary care hospital for a period of approximately 1 year in which patients on mechanical ventilation (>7 days) were enrolled. Blood, urine, and endotracheal aspirate (ETA) of these patients were sent for fungal culture on day 1 and day 7 of mechanical ventilation. Fiberoptic bronchoscopy was done on day 7 and bronchoalveolar lavage along with transbronchial lung biopsy (TBLB) were sent for fungal culture. Results: During 7 days of ventilation, there was a statistically significant increase in the proportion of culture-positive ETA and urine samples. Overall, Candida albicans emerged as the most common colonizer. Blood candidemia was seen in 10% of patients on day 7 of mechanical ventilation. Fungal invasion of the lung, as evidenced by fungal culture-positive TBLB specimens, was seen in 17% of patients. Diabetes was found to be a statistically significant risk factor for respiratory and urinary tract colonization as well as invasive fungal disease. Conclusion: Long-term mechanical ventilation (>7 days) is strongly associated with fungal colonization of the respiratory tract and urinary tract. Appropriate prophylactic antifungals may be given and infection control practices to be observed to ensure minimum colonization and therefore infection in such settings.



Mahendra Kumar, Shubham Lahan, Gaurav Verma

Role of intra-abdominal pressure in early acute kidney injury: A prospective cohort study in critically Ill obstetric patients

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:6] [Pages No:602 - 607]

Keywords: Acute kidney injury, intra-abdominal hypertension, intra-abdominal pressure

   DOI: 10.4103/ijccm.IJCCM_170_18  |  Open Access |  How to cite  | 


Aims: This prospective cohort study evaluated intra-abdominal pressure (IAP) and its role in causing acute kidney injury (AKI) in critically ill obstetric patients and utility of urinary neutrophil gelatinase-associated lipocalin (NGAL) to predict AKI. Methods: A total of 50 eligible obstetric patients admitted to our Intensive Care Unit were enrolled and daily IAP measured using indwelling Foley catheter. Early AKI was diagnosed as per the KDIGO criteria and urine assessed for NGAL using ELISA. Results: AKI was seen in 54% and intra-abdominal hypertension (IAH) in 21% patients. In patients with and without AKI, there was statistically similar IAP on day 1 (P = 0.542) and day 2 (P = 0.907) as well as incidence of IAH (19% vs. 23%) (P = 0.766). Area under receiver operating characteristic curve (AUC) for IAP to predict early AKI was 0.499 (95% confidence interval [CI]: 0.325–0.673) (P = 0.992). Urinary NGAL concentration was significantly greater in patients with early AKI compared to those without (P = 0.006); AUC for urinary NGAL to detect early AKI was 0.734 (95% CI: 0.583–0.884) (P = 0.006) and optimal cutoff was 53.7 ng/ml. Conclusions: IAH and AKI are common in critically ill obstetric patients. While IAP does not correlate with early AKI, NGAL is useful to predict AKI.



Surya Joseph, Siddharth Bhattacharjee, Praveen Sreekumar

A hot body in a cold room hyperthermia secondary to rapid diuresis in cardiac failure; the perils of rapid fluid shifts

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:3] [Pages No:608 - 610]

Keywords: Cardiac failure, causes, diuresis, fever, hyperthermia, pump failure, rapid diuresis

   DOI: 10.4103/ijccm.IJCCM_179_18  |  Open Access |  How to cite  | 


A 66-year-old man was admitted with anasarca and congestive cardiac failure. He was started on intravenous diuretics and fluid restriction and lost nearly 35 kg of fluids in 13 days. He then developed hyperthermia and delirium. An extensive workup was inconclusive. Analysis of his inpatient fluid balance chart revealed the chance association of massive fluid loss and hyperthermia. Rapid diuresis-induced hyperthermia and volume contraction were considered, and his fluid balance was adjusted. Within 2 days, his temperature normalized and he regained consciousness. Hyperthermia and its causative mechanism are discussed in this article.



Acute reversible ischemic stroke after snake bite

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:2] [Pages No:611 - 612]

Keywords: Snake bite, hemiplegia, ischemic stroke, reversible

   DOI: 10.4103/ijccm.IJCCM_455_17  |  Open Access |  How to cite  | 


Snake bite is very common in India. Ischemic stroke after snake bite has been described in the literature sparsely. Furthermore, the onset of stroke and its clinical reversibility is a rarity. Here, we present a case of snake bite with ischemic stroke which has clinically reversible outcome.



K.G. Mathew, Rakesh Sanker, Vikas Singhal

Acute suppurative thyroiditis with thyroid abscess by Klebsiella pneumoniae: An unusual presentation

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:3] [Pages No:613 - 615]

Keywords: Acute suppurative thyroiditis, Klebsiella pneumoniae, thyroid abscess

   DOI: 10.4103/ijccm.IJCCM_151_18  |  Open Access |  How to cite  | 


Acute suppurative thyroiditis with thyroid abscess is very uncommon cause of thyroiditis. Thyroid infection in a diabetic patient is commonly labeled to the relative immunosuppressive state of diabetes mellitus. We present a case of a diabetic patient showing clinical symptoms of acute thyroiditis with progressing dysphagia, who was diagnosed as thyroid abscess as a result of Klebsiella pneumoniae. The infection in the absence of other significant history was initially considered de novo; however, on extensive evaluation was associated with other distant primary source of the same microbe. The patient was managed with minimally invasive drainage of abscess and intravenous antibiotics.



Rajani Gubbala, Nagalakshmikanth Reddy Mayaluri, K.P. Raghavendra

Severe adult-onset still's disease mimicking systemic infection

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:3] [Pages No:616 - 618]

Keywords: Adult-onset Still's disease, fever, procalcitonin

   DOI: 10.4103/ijccm.IJCCM_208_18  |  Open Access |  How to cite  | 


Adult-onset Still's disease (AOSD) is an uncommon entity that can mimic infection. Patients present with fever for more than 1-week, joint pain, and rash. We report a case of 22-year-old male who presented with fever, sore throat, and abdominal pain. During hospitalization, he had multiple episodes of tachycardia and tachypnea requiring mechanical ventilation. The patient had elevated white blood cell count, procalcitonin, and troponin. He was extensively investigated and diagnosed as AOSD. He responded to steroids and was discharged on day 20.



Uncommon cause of acute liver failure with encephalopathy

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:2] [Pages No:619 - 620]

   DOI: 10.4103/ijccm.IJCCM_244_18  |  Open Access |  How to cite  | 



Monalisa Nayak, Sunil Kumar Jena

Pseudo bulbar palsy: A rare cause of extubation failure

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:2] [Pages No:620 - 621]

   DOI: 10.4103/ijccm.IJCCM_78_18  |  Open Access |  How to cite  | 



Ajay Yadav

Unusual cause of hypotension in a polytrauma victim: A case of fahr's syndrome

[Year:2018] [Month:] [Volume:22] [Number:8] [Pages:3] [Pages No:621 - 623]

   DOI: 10.4103/ijccm.IJCCM_2_18  |  Open Access |  How to cite  | 


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