Indian Journal of Critical Care Medicine

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2019 | October | Volume 23 | Issue 10

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Mystery of PCO2 Gap in Sepsis

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:2] [Pages No:443 - 444]

   DOI: 10.5005/jp-journals-10071-23260  |  Open Access |  How to cite  | 


Original Article

Neeraj Mangla, Ravi Bokarvadia, Joy Varghese, Jayanthi Venkataraman

Scoring Systems that Predict Mortality at Admission in End-stage Liver Disease

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:4] [Pages No:445 - 448]

Keywords: Cirrhosis, Emergency, Mortality

   DOI: 10.5005/jp-journals-10071-23261  |  Open Access |  How to cite  | 


Background: Various scoring systems have been developed to assess the severity and survival in end-stage liver disease. Aim of the study: Prospective study to compare and analyze the efficacy of scoring systems in predicting mortality in ESLD patients who present with cirrhosis specific complications to the emergency room. Materials and methods: This prospective, single point study was conducted over a two year period from September 2014 to August 2016 among 162 ESLD patients seeking admission to the emergency unit of Gleneagles Global Health City, Chennai. Baseline investigations incorporated hemogram, liver biochemical parameters, coagulation parameters (PT/INR), serum creatinine, serum electrolytes and blood gas analysis, to calculate the CTP score, MELD, MELD-Na, MESO, iMELD, Updated MELD, UKELD, SOFA and APACHE II. Comparison of MELD snd non MELD scores were done between survivors and nonsurvivors. The mortality rate for the same admission was calculated. Results: Of the 162 patients requiring emergency admision, 148 were men (91.4%). The median age of patients was 56 years (range 25–75 years). The cause for liver cirrhosis was alcohol followed by nonalcoholic steatohepatitis and hepatitis B. The indications for emergency admissions were fever, tense ascites, reduced urine output and altered sensorium. Thirty patients (18.5%) expired during the same admission. The predictive accuracy of all scores for predicting mortality by ROC curves was between 0.7 and 0.8 (p < 0.05). Conclusion: Although, all scores appear to be equally good, simple scores like CTP and MELD is all that is required to ascertain the prognosis of patients seeking emergency admission.


Original Article

David Theophilo Araujo, Vinícius Brenner Felice, Andre Felipe Meregalli

Value of Central Venous to Arterial CO2 Difference after Early Goal-directed Therapy in Septic Shock Patients

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:5] [Pages No:449 - 453]

Keywords: Central venous saturation, Lactate, Mortality, Septic shock, Venous to arterial difference of CO2

   DOI: 10.5005/jp-journals-10071-23262  |  Open Access |  How to cite  | 


Background and aims: Venous to arterial difference of carbon dioxide (Pv–aCO2) tracks tissue blood flow. We aimed to evaluate if Pv–aCO2 measured from a superior central vein sample is a prognostic index (ICU length of stay, SOFA score, 28th mortality rate) just after early goal-directed therapy (EGDT)comparing its ICU admission values between patients with normal and abnormal (>6 mm Hg) Pv–aCO2. As secondary objectives, we evaluated the relationship of Pv–aCO2 with other variables of perfusion during the 24 hours that followed EGDT. Materials and methods: Prospective observational study conducted in an academic ICU adult septic shock patients after a 6-hour complete EGTD. Hemodynamic measurements, arterial/central venous blood gases, and arterial lactate were obtained on ICU admission and after 6, 18 and 24 hours. Results: Sixty patients were included. Admission Pv–aCO2 values showed no prognostic value. Admission Pv–aCO2 (ROC curve 0.527 [CI 95% 0.394 to 0.658]) values showed low specificity and sensitivity as predictors of mortality. There was a difference observed in the mean Pv–aCO2 between nonsurvivors (NS) and survivors (S) after 6 hours. Central venous oxygen saturation (ScvO2) and Pv–aCO2 showed significant correlation (R2 = –0.41, P < 0.0001). Patients with normal ScvO2 (>70%) and abnormal Pv–aCO2 (>6 mm Hg) showed higher SOFA scores. Normal Pv–aCO2 group cleared their lactate levels in comparison to the abnormal Pv–aCO2 group. Conclusion: In septic shock, admission Pv–aCO2 after EGDT is not related to worse outcomes. An abnormal Pv–aCO2 along with a normal ScvO2 is related to organ dysfunction.


Original Article

Luciane de Fraga Gomes Martins, Wagner da Silva Naue, Amanda Soares Skueresky, Tanara Bianchi, Alexandre Simões Dias, Luiz Forgiarini Jr.

Effects of Combined Tracheal Suctioning and Expiratory Pause: A Crossover Randomized Clinical Trial

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:4] [Pages No:454 - 457]

Keywords: Aspirated secretions, Bronchial hygiene, Endotracheal aspiration, Intensive care unit, Respiratory therapy

   DOI: 10.5005/jp-journals-10071-23263  |  Open Access |  How to cite  | 


Aims: Our aim is to compare volume of suctioned secretion, respiratory mechanics, and hemodynamic parameters in intubated patients undergoing closed-system endotracheal suctioning alone (control group) versus closed-system tracheal suctioning with an expiratory pause (intervention group). Settings and design: Randomized crossover clinical trial. Materials and methods: Patients who had been on mechanical ventilation for more than 24 hours were randomly assigned to receive closed-system suctioning alone or closed-system suctioning with an expiratory pause on the ventilator. The following variables were evaluated: heart rate, respiratory rate, mean arterial pressure, peripheral arterial oxygen saturation, peak inspiratory pressure, mechanical ventilator circuit pressure during aspiration, exhaled tidal volume, dynamic compliance, resistance, and weight of suctioned secretion. Statistical analysis: Compared using the paired t-test and general linear model analysis of variance for normally distributed variables (as confirmed by the Kolmogorov-Smirnov test). The Wilcoxon test was used for variables with a nonparametric distribution, while the Chi-square test and Fisher's exact test were used for categorical variables. Results: The sample comprised 31 patients (mean age, 61.1 ± 18.2 years). The amount of secretion suctioned was significantly higher in the intervention group than in the control group (1.6 g vs 0.45 g; p = 0.0001). There were no significant changes in hemodynamic parameters or respiratory mechanics when comparing pre- and postprocedure time points. Conclusion: The combination of closed-system endotracheal suctioning and an expiratory pause significantly increased the amount of secretion suctioned compared to conventional suctioning without expiratory pause. Key messages: Combination of closed-system endotracheal suctioning and an expiratory pause significantly increased the amount of secretion suctioned.


Original Article

Bhavna Gupta, Kamna Kakkar, Lalit Gupta

Role of High-flow Nasal Oxygen Therapy in Cases with Pulmonary Hypertension in an Intensive Care Unit Setting

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:4] [Pages No:458 - 461]

Keywords: High-flow nasal cannula, High-flow nasal oxygen therapy, Pulmonary hypertension

   DOI: 10.5005/jp-journals-10071-23264  |  Open Access |  How to cite  | 


High-flow nasal oxygen therapy warms and humidifies gases, allows better clearance of secretions, along with providing added benefits like preventing dehydration of airway surface, while decreasing atelectasis and thereby, offering comfort to the patient. While its effect on critically ill patients is still in its pioneering phase, there is lack of substantial evidence on the use of high-flow nasal cannula in cardiac patients with type I respiratory failure. We found it worthwhile to share our experience of its use in elderly and postpartum patients with moderate-to-severe pulmonary hypertension, with associated comorbidities and type I respiratory failure, with do-not-intubate or defer intubation status. In patients with pulmonary hypertension (PHT) and respiratory failure, endotracheal intubation followed by initiation of mechanical ventilation may have detrimental hemodynamic effects. Increase in lung volumes and decrease in functional residual capacity lead to increase in pulmonary hypertension and right ventricle afterload. If a patient has right heart failure, lung hyperinflation can fatally reduce cardiac output. High-flow nasal oxygen therapy may be of an advantage in these scenarios.


Original Article

Mohamed Hisham

Stress and Burnout among Intensive Care Unit Healthcare Professionals in an Indian Tertiary Care Hospital

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:5] [Pages No:462 - 466]

Keywords: Burnout syndrome, Healthcare workers, Job stress

   DOI: 10.5005/jp-journals-10071-23265  |  Open Access |  How to cite  | 


Intensive care unit (ICU) healthcare professionals work under a stressful environment which can lead to burnout syndrome. We conducted this study to evaluate the prevalence of stress and burnout syndrome among doctors and other healthcare professionals in ICU. We also evaluated the individual contributing factors for stress and burnout syndrome among these ICU healthcare workers. The cross-sectional survey was conducted among the healthcare professionals (doctors, nurses, clinical pharmacists, respiratory therapists and physiotherapists) in the ICUs of multispecialty hospital in south India. The survey was conducted using well-accepted tools which included job satisfaction scale, perceived stress scale and Maslach burnout inventory–human service survey. Overall, 204 healthcare professionals completed the survey. The prevalence of high burnout in our study was 80% which included 6% (n = 12) of doctors and 69% (n = 140) of nurses. Our study showed statistically significant correlation between level of job satisfaction and the level of burnout. There was a significant correlation between the level of stress and the emotional exhaustion and depersonalization domains of Maslach burnout inventory. Critical care societies and institutional committees should step forward to draft policies and benchmarks to curb the causes of stress, reduce burnout and to increase the job satisfaction.


Original Article

Roopa Kancherla, Ramanathan Palaniappan Ramanathan, Bobbe Appalaraju, Srinivas Rajagopala

Pulmonary Nocardiosis Presenting as Exacerbation of Chronic Pulmonary Disease

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:8] [Pages No:467 - 474]

   DOI: 10.5005/jp-journals-10071-23270  |  Open Access |  How to cite  | 


Background: Pulmonary nocardiosis (PN) occurs in chronic pulmonary disease (CPD) in the absence of traditional risk factors. Clinical features that differentiate bacterial exacerbations (AE-CPDb) from PN-related exacerbations (AE-CPDPN) are not well described. Objectives: To describe a series of AE-CPDPN without traditional risk factors and compare clinical features, radiology and outcomes with age, gender and CLD-type matched AE-CPDb. Materials and methods: Single-center retrospective review and case-control study. Results: AE-CPDPN had longer duration of symptoms and more leukocytosis at hospitalization. AE-CPDb patients were sicker with more chronic respiratory failure (OR 33.3, p = 0.01), cardiac disease and pulmonary hypertension (OR 6.2, p = 0.008) at diagnosis. More patients with AE-CPDb were discharged on domiciliary oxygen (OR 5.27, p = 0.01). On logistic regression, AE-CPDPN was independently associated with mechanical ventilation (OR 22.3, p = 0.01), length of hospital stay (median difference, 4 days, p = 0.016) but not to hospital mortality. 22.7% of AE-CPDPN died. Respiratory failure requiring oxygen, NIPPV or mechanical ventilation was associated with mortality in AE-CPDPN. Conclusion: PN is a rare cause of AE-CPD and can be suspected by longer symptom duration, more leukocytosis, consolidation and cavitation. AE-CPDPN is associated with longer hospital stay and mechanical ventilation. Respiratory failure is associated with mortality in AE-CPDPN. Key messages: Pulmonary nocardiosis can present in advanced chronic lung disease as an exacerbation in the absence of traditional risk factors like immunosuppression. Bronchiectasis, followed by chronic obstructive pulmonary disease are the most common chronic lung disease risk factors. Pulmonary nocardiosis is a rare cause of acute exacerbation of chronic pulmonary disease (CPD). Compared to exacerbations of CPD due to bacterial infections, nocardiosis-related exacerbations (CPDPN) were independently related to need for mechanical ventilation and length of hospital stay. Respiratory failure requiring oxygen, noninvasive ventilation and mechanical ventilation are associated with mortality in AE-CPDPN.



Sayanta Thakur

Advances in Vasodilatory Shock: A Concise Review

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:6] [Pages No:475 - 480]

Keywords: Hypotension, Sepsis, Shock, Vasodilatory shock

   DOI: 10.5005/jp-journals-10071-23266  |  Open Access |  How to cite  | 


Vasodilatory shock is a critical manifestation of cardiovascular failure. There is uncontrolled vasodilation and vascular hyporesponsiveness to endogenous vasoconstrictors, causing the failure of physiologic vasoregulatory mechanisms. Unfortunately, only few randomized studies exist to guide clinical management and hemodynamic stabilization in patients who do not respond to the standard approach of managing vasodilatory shock. The present review offers the latest updates in management of this important clinical entity and a guidance framework for future research.



Sadik Mohammed, Sunit Kumar Gupta

Pulmonary Hyperinfection with Strongyloides stercoralis in an Immunocompetent Patient

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:3] [Pages No:481 - 483]

Keywords: Hyperinfection syndrome, Laparotomy, Pulmonary strongyloidosis, Radiology, Sputum examination

   DOI: 10.5005/jp-journals-10071-23267  |  Open Access |  How to cite  | 


Strongyloids stercoralis is a unique parasite as it has the capability of completing its life cycle entirely within the human host. The immune system of the host plays an important role in keeping the infection under control but when there is a breach in this system the infection may flare up and leads to hyperinfection. In immunocompetent patients, gastrointestinal manipulation could be an inciting trigger leading to translocation of larva into the systemic circulation and development of hyperinfection syndrome. We report a case where infection with S. stercoralis lead to hyperinfection in patient with intact immune system following laparotomy.



Nikhat Sultana, K Subba Reddy, Munshi I Alam

Intraventricular Bleed Secondary to Intraventricular Antibiotics: A Case Report

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:2] [Pages No:484 - 485]

Keywords: CNS infection, Intraventricular antibiotics

   DOI: 10.5005/jp-journals-10071-23268  |  Open Access |  How to cite  | 


In case of multidrug resistant CNS infection use of intraventricular antibiotics are considered which have their own undesirable effects.1 An adult male patient who presented with multidrug resistant infection secondary to procedures done to facilitate to drain cerebrospinal fluid. Secondary to intraventricular antibiotic administration patient developed an intraparenchymal bleed with intraventricular extension; as a result of the bleed there was persistently raised intracranial pressure (ICP). The harmful effects of intraventricular antibiotics have to always be considered before taking a decision to start it. Appropriate precaution and low threshold of suspicion is required to rule out complications.



Gopal Chawla, Naveen Dutt, Ramniwas , Nishant Kumar Chauhan

A Rare Case of Neurogenic Pulmonary Edema Following High-voltage Electrical Injury

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:3] [Pages No:486 - 488]

Keywords: Electric shock, Lung ultrasound score, Pulmonary edema

   DOI: 10.5005/jp-journals-10071-23269  |  Open Access |  How to cite  | 


Electrical injuries though infrequent, are potentially devastating form of injuries which are associated with high morbidity and mortality. The severity of the injury depends upon intensity of the electrical current which is determined by the voltage and the resistance offered by the victim. These injuries vary from trivial burns to death. There have been few reports about pulmonary injuries due to electrical current but none mentioning neurogenic pulmonary edema (NPE). Here we report a young boy who when exposed to high-voltage current developed neurogenic pulmonary edema and was successfully managed. Though there is no specific protocol for electrical injury but identifying the organs involved along with type of disease facilitates the management.



Sibel Yavuz, Gokhan Tumgor, Aysun Karabay Bayazıt

Trientine-induced Rhabdomyolysis in an Adolescent with Wilson's Disease

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:2] [Pages No:489 - 490]

Keywords: Continued renal replacement therapy, Rhabdomyolysis, Trientine

   DOI: 10.5005/jp-journals-10071-23271  |  Open Access |  How to cite  | 


Background: Drugs are very important in the etiology of nontraumatic rhabdomyolysis. Case descriptions: A 16-year-old male patient with Wilson's disease was admitted for myoclonic contractions. Oral trientine was started for neurological problems and tremor on the hands due to D-penicillamine 1 month ago. Patient was oligoanuric, and his creatine kinase level was 15197 U/L. Rhabdomyolysis was associated with trientine, and trientine treatment was stopped. Hemodiafiltration was performed. The patient began to urinate on the 24th day. Conclusion: This is the first pediatric patient with rhabdomyolysis induced by trientine. Drugs used should be questioned carefully in patients with rhabdomyolysis.



Should We Use DSI or not—What does the PADIS 2018 Guidelines Recommend?

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:1] [Pages No:491 - 491]

   DOI: 10.5005/jp-journals-10071-23272  |  Open Access |  How to cite  | 



Jayendra R Gohil

Adrenaline before Unconventional Therapy for Status Asthamaticus

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:1] [Pages No:492 - 492]

   DOI: 10.5005/jp-journals-10071-23273  |  Open Access |  How to cite  | 



Ankit Luthra

Critically Ill Obstetric Patients: Much more than Meets the Eye

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:1] [Pages No:493 - 493]

   DOI: 10.5005/jp-journals-10071-23274  |  Open Access |  How to cite  | 



Value of Routine Sonographic Screening of Internal Jugular Vein to Detect Catheter Related Thrombosis in Intensive Care Unit

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:1] [Pages No:494 - 494]

   DOI: 10.5005/ijccm-23-10-474  |  Open Access |  How to cite  | 



Therapeutic Plasma Exchange Practices in Intensive Care Unit

[Year:2019] [Month:October] [Volume:23] [Number:10] [Pages:1] [Pages No:495 - 495]

   DOI: 10.5005/ijccm-23-10-475  |  Open Access |  How to cite  | 


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