Indian Journal of Critical Care Medicine

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2019 | November | Volume 23 | Issue 11

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Atul P Kulkarni

Simulation: Is it the Future of Training in Critical Care Medicine?

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:2] [Pages No:495 - 496]

   DOI: 10.5005/jp-journals-10071-23290  |  Open Access |  How to cite  | 


Original Article

Nitin B Mali, Milind S Tullu, Poorwa P Wandalkar, Siddharth P Deshpande, Vinod C Ingale, Nithya J Gogtay, Urmila M Thatte

Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:6] [Pages No:497 - 502]

Keywords: Gram-positive bacterial infection, Liquid chromatography mass spectrometry, Pediatric intensive care unit, Pharmacokinetics–pharmacodynamics, Vancomycin

   DOI: 10.5005/jp-journals-10071-23275  |  Open Access |  How to cite  | 


Aims and objectives: Vancomycin is a drug of choice for various gram-positive bacterial (GPB) infections and is largely prescribed to pediatric intensive care unit (PICU) patients. Despite the different pathophysiology of these patients, limited data are available on pharmacokinetics of vancomycin. There are lack of data for critically ill Indian children; hence, study was conducted to assess the steady-state pharmacokinetics in children admitted to PICU. Materials and methods: Twelve subjects (seven males, five females) aged 1–12 years were enrolled. Vancomycin (dose of 20 mg/kg per 8 hours) was infused for over 1 hour and steady-state pharmacokinetics was performed on day 3. Vancomycin concentrations were measured by the validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO). Results: The steady-state mean Cssmax was 40.94 μg/mL (±15.07), and mean AUC0–8 hours was 124.15 μg/mL (±51.27). The mean t1/2 was 4.82 hours (±2.71), Vd was 12.48 L (±4.43), and Cl was 2.08 mL/minute (±0.89). The mean AUC0–24 among 12 subjects was 372.44 μg/mL (±153.82). Among 35 measured trough concentrations, 23 (65.71%) were below, 11 (31.43%) were within, and 1 (2.86%) was above the recommended range. Conclusion: The pharmacokinetic parameters of vancomycin were comparable with previously reported studies. However, recommended trough levels (10–20 μg/mL) were not achievable with current recommended dosing of 60 mg/kg/day.


Original Article

Minal Harde, Rakesh Bhadade, Rosemarie deSouza, Mrida Jhingan

Thrombocytopenia in Pregnancy Nearing Term: A Clinical Analysis

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:6] [Pages No:503 - 508]

Keywords: Hemolysis, elevated liver enzyme, and low platelet count syndrome, Infections, Preeclampsia, Spinal anesthesia, Thrombocytopenia in pregnancy

   DOI: 10.5005/jp-journals-10071-23277  |  Open Access |  How to cite  | 


Background and aim: Thrombocytopenia in pregnancy varies from benign to severe with fetomaternal complications. We aimed to evaluate thrombocytopenia in pregnant Indian females in third trimester mainly during labor and delivery. Materials and methods: It was a prospective observational study done in a tertiary care teaching public hospital over 1 year. Consecutive 150 pregnant patients admitted to labor ward with thrombocytopenia were analyzed for etiology of thrombocytopenia, severity, mode of delivery, type of anesthesia, and fetomaternal complications. SPSS version 17 was used for the analysis. Results: Most common cause of thrombocytopenia was preeclampsia 50 (33.3%) and preeclampsia with hemolysis, elevated liver enzyme, and low platelet count syndrome (HELLP syndrome) 31 (20.7%) together followed by gestational 42 (28%). Infectious causes such as malaria, dengue, and leptospirosis were found in 19 patients (12.7%). Moderate to severe thrombocytopenia was seen in preeclampsia, preeclampsia with HELLP syndrome, and infectious etiology. Eleven patients (7.3%) developed antepartum hemorrhage (APH), 24 (16%) postpartum hemorrhage (PPH), 12 (8%) required ICU admission, and 3 (2%) mortalities were noted. Fifteen neonates (10%) needed ICU admission. Complications were observed in preeclampsia with HELLP syndrome (82%) and infectious causes (18%) and none in gestational. Sixty-eight patients underwent lower segment cesarean section (LSCS), among them 41 (27.3%) were given spinal anesthesia (SA) and none of them developed any neurological complications. Conclusion: Study widened the spectrum of causes for thrombocytopenia in pregnant patients. Preeclampsia with or without HELLP syndrome and vector-borne infections such as malaria, dengue, and leptospirosis were found to be very important causes of moderate to severe thrombocytopenia and were associated with complications. Spinal anesthesia is safe in parturients with mild thrombocytopenia. Awareness and vigilance about thrombocytopenia is vital to reduce maternal morbidity and mortality.


Original Article

Appu Suseel, Pallavi Panchu, Salish Varghese, Tijo George, Lijo Joy

An Analysis of the Efficacy of Different Teaching Modalities in Imparting Adult Cardiopulmonary Resuscitation Skills among First-year Medical Students: A Pilot Study

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:4] [Pages No:509 - 512]

Keywords: Basic life support, Cardiopulmonary resuscitation, Didactic, Manikins, Medical students, Simulation

   DOI: 10.5005/jp-journals-10071-23284  |  Open Access |  How to cite  | 


Introduction: Our current medical curriculum devotes a large percentage of time to knowledge acquisition by means of didactic lectures. Psychomotor skill acquisition takes a back seat. Certain lifesaving skills like basic life support skill training have not even made an appearance in the current curriculum. Equal time distribution to cognitive and psychomotor skills should be allotted for MBBS trainees, which is a very practical subject. Simulation can prove to be a valuable tool in imparting skill training. The present study aims to evaluate the efficacy of different teaching modalities in imparting lifesaving skills among first-year MBBS students. Materials and methods: This cross-sectional study was conducted among 33 first-year students who consented to participate. Approval was obtained from the institutional ethics committee. The students were divided into three groups, each undergoing either didactic lecture or animation-based videos or simulation studies. Pretest, posttest, and skills tests were administered to them. One-way analysis of variance (ANOVA) and paired t test were the statistical tests employed using SPSS version 21. Results: The pretest and posttest scores were comparable in the three groups while the improvement in the posttest scores in all the three groups was significant. The skills test was significantly better in the group undergoing simulation training compared to the other groups. Conclusion: Didactic, animation, and simulation are all good methods in imparting cognitive knowledge, but simulation is the method of choice in imparting psychomotor skills. Clinical significance: An overhauling of the medical curriculum to include more skills training to the budding doctors using simulation-based techniques is recommended.


Original Article

Nitin B Mali, Siddharth P Deshpande, Poorwa P Wandalkar, Vishal A Gupta, Nithya J Gogtay, Gita Nataraj, Preeti R Mehta, Urmila Thatte

Single-dose and Steady-state Pharmacokinetics of Vancomycin in Critically Ill Patients Admitted to Medical Intensive Care Unit of India

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:5] [Pages No:513 - 517]

Keywords: Critically ill, Methicillin resistance Staphylococcus aureus, Pharmacokinetics–pharmacodynamics, Single and steady state, Vancomycin

   DOI: 10.5005/jp-journals-10071-23289  |  Open Access |  How to cite  | 


Rationale: Vancomycin remains the standard of care for gram-positive bacterial infections, though there are significant developments in newer antibacterial agents. Efficacy can be improved by linking pharmacokinetic with pharmacodynamic principles, thus leading to optimum antibiotic exposure. There is scarcity of pharmacokinetic data in Indian intensive care unit (ICU) population. Materials and methods: Fifteen subjects with suspected or proven gram-positive bacterial infection of either gender between 18 years and 65 years of age were enrolled. Vancomycin at the dose of 1 g every 12 hours was administered over 1-hour period and pharmacokinetic assessments performed on blood samples collected on days 1 and 3. Vancomycin concentrations were measured on validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO). Results: The mean Cmax, elimination half-life, AUC0–12hours, volume of distribution, and clearance of single dose were 36.46 μg/mL (±14.87), 3.98 hours (±1.31), 113.51 μg/mL (±49.51), 52.01 L (±31.31), and 8.90 mL/minute (±3.29), respectively, and at steady state were 40.87 μg/mL (±19.29), 6.27 hours (±3.39), 147.94 μg/mL (±72.89), 56.39 L (±42.13), and 6.98 mL/minute (±4.48), respectively. The elimination half-life increased almost two-fold at steady state. The steady state mean AUC0–24 was 295.89 µg/mL (±153.82). Out of 45 trough levels, 32 (71.11%) concentrations were below recommended range. Conclusion: Recommended AUC0–24hours and trough concentrations were not achieved in majority of patients with current dosing, suggesting reevaluation of current vancomycin dosing. Individualized treatment based on close monitoring of vancomycin serum concentrations in critically ill patients is imperative.



Abdul Ghafur, Nitin Bansal, Vidyalakshmi Devarajan, T Raja, Jose Easow, MA Raja, Sankar Sreenivas, Balasubramaniam Ramakrishnan, SG Raman, Ramesh Nimmagadda

Retrospective Study of Nephrotoxicity Rate among Adult Patients Receiving Colistin Compared to β-lactam Antibiotics

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:5] [Pages No:518 - 522]

Keywords: Carbapenem resistance, Colistin nephrotoxicity, Risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, end-stage kidney disease score

   DOI: 10.5005/jp-journals-10071-23276  |  Open Access |  How to cite  | 


Purpose: Patients receiving colistin for carbapenem-resistant gram-negative bacteria (CR-GNB) infections generally have multiple risk factors for nephrotoxicity, so it might be possible that colistin may be erroneously blamed for the nephrotoxicity. Materials and methods: We retrospectively analyzed case records of patients who received colistin and those who received antibiotics other than colistin [carbapenem or β-lactam–β-lactamases inhibitors (βL–βLI)] for gram-negative bacteremia. Those patients with preexisting renal failure and those who received antibiotics for <72 hours were excluded from the study. Nephrotoxicity was assessed using the risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, end-stage kidney disease (RIFLE) criteria. Results: Out of the 222 patients, the colistin arm had 118 and the noncolistin arm had 104 patients. Even though the colistin arm had significantly higher number of sicker patients with neutropenia (40.7% vs 14.4%, p = 0.0001), mechanical ventilation (0.0001), having lines (0.0001), on inotropes (0.003), receiving other nephrotoxic drugs (0.0001), and higher Pitt score (p = 0.0001), there was no significant difference in the nephrotoxicity between the two arms (10.2% vs 9.6%, p = 0.89). Logistical regression showed a higher Pitt bacteremia score (p = 0.03) and a higher Charlson comorbidity index (p = 0.02), but not colistin administration (p = 0.32), were independently associated with nephrotoxicity. Conclusion: Administration of colistin was not associated with higher rates of nephrotoxicity than carbapenems or βL–βLI agents.



Girishchandra Varma, Amitabh Kulkarni, Sandeep Chaudhary, Prashant Sagar

Central Diabetes Insipidus in an Off-pump Coronary Artery Bypass Grafting Surgery

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:3] [Pages No:523 - 525]

Keywords: Central diabetes insipidus, Complications after coronary artery bypass grafting, Coronary artery bypass surgery, Diabetes insipidus

   DOI: 10.5005/jp-journals-10071-23278  |  Open Access |  How to cite  | 


Polyuria in perioperative coronary artery bypass grafting (CABG) surgery is common and mostly benign. Diabetes insipidus (DI) post-CABG is however very rare and mostly have been related with use of cardiopulmonary bypass (CPB) pump. The patient recovered completely with transient requirement of exogenous vasopressin. The central DI may be considered as a differential diagnosis in case of polyuria in the perioperative period of CABG surgery.



Jorge A Brenes-Salazar

Paclitaxel-induced Chest Pain and Left Bundle Branch Block in the Absence of Cardiac Ischemia

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:3] [Pages No:526 - 528]

   DOI: 10.5005/jp-journals-10071-23281  |  Open Access |  How to cite  | 



Jahagirdar Ashwini, Makwana Durgesh, Date Girish

Thoracic Epidural Blockade for Ventricular Tachycardia Storm in Patient with Takotsubo Cardiomyopathy

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:4] [Pages No:529 - 532]

Keywords: Epidural anesthesia, Takotsubo cardiomyopathy, Ventricular tachycardia

   DOI: 10.5005/jp-journals-10071-23282  |  Open Access |  How to cite  | 


Introduction: Takotsubo cardiomyopathy is acute nonischemic myocardial dysfunction of the left and/or right ventricle which usually recovers completely within several days to weeks. We report a case where thoracic epidural analgesia was used to manage sympathetic storm in Takotsubo cardiomyopathy. Case description: A 58-year-old diabetic female who was being treated for urinary tract infection and diabetic ketoacidosis for the past 2 days sustained an episode of pulseless ventricular tachycardia which was treated as per ACLS protocol. Troponin levels were raised, and 2D echocardiography was showing “Takotsubo cardiomyopathy” with typical apical ballooning of the left ventricle at the time of admission, and she was mechanically ventilated and receiving vasopressors. She continued to get episodes of ill-sustained ventricular tachycardia. In spite of conventional management, episodes of ill-sustained ventricular tachycardia continued, and hence, sympathetic blockade with thoracic epidural catheter was administered to control the ventricular tachycardia storm. Conclusion: Sympathetic blockade to treat ventricular tachycardia is a promising approach which needs to be validated with more evidence.



Prateek , Vandana Sharma, Himani Tak

Dengue, Guillain–Barré Syndrome, and Cerebral Infarction: A Case of Rare Complication

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:3] [Pages No:533 - 535]

Keywords: Cerebral infarction, Dengue, Guillain–Barré syndrome, Intravenous immunoglobulin

   DOI: 10.5005/jp-journals-10071-23285  |  Open Access |  How to cite  | 


Incidence of cerebral infarction after use of intravenous immunoglobulin (IVIG) for treatment of Guillain–Barré syndrome (GBS) is relatively uncommon. Here, we discuss a case of 30-year-old female who was admitted with a complain of thrombocytopenia after infection with dengue virus, who then developed GBS just after a day of discharge. But her woes did not end there, as the GBS progressed rapidly involving her respiratory muscles, leaving her in need of ventilation assistance. Her condition was further deteriorated by development of cerebral infarction that may have been precipitated by the administration of IVIG during the early course of management. Key messages: Intravenous immunoglobulin in a GBS patient with a hematological abnormality (dengue) should be used with caution. Therapeutic plasma exchange may be considered for management in cases with variable coagulability.



Abdul Rauf, Ramakant Sabharwal

Neurally Adjusted Ventilatory Assist: An Early Clue to Diagnosis of Congenital Central Hypoventilation Syndrome

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:2] [Pages No:536 - 537]

Keywords: Congenital central hypoventilation, Electrical activity of diaphragm, Neurally adjusted ventilatory assist

   DOI: 10.5005/jp-journals-10071-23286  |  Open Access |  How to cite  | 


Congenital central hypoventilation syndrome (CCHS) is characterized by shallow breathing during sleep due to negligible ventilatory sensitivity to hypercarbia and hypoxemia. It is diagnosed using a genetic test for PHOX2B mutation, which is not easily available. Neurally adjusted ventilatory assist (NAVA) is a spontaneous ventilatory mode that was designed basically for better adapting the ventilator to the patient by using electrical activity of diaphragm (EAdi) signals. We report a case of a 6-month-old infant who presented with recurrent apneas, where differential decrease in EAdi discharges during sleep using NAVA served as an early clue to the diagnosis of CCHS. Definitive diagnosis was later confirmed by genetic testing.



Teju P Thomas, Sudhaya Kumar, Rajagopal Kiran, Vincy Sabu, Abdul Gaffoor

A Rare Presentation of Fulminant Viral Myocarditis Associated with H1N1: A Series of Four Cases

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:4] [Pages No:538 - 541]

Keywords: Fulminant myocarditis, H1N1 myocarditis, Viral myocarditis

   DOI: 10.5005/jp-journals-10071-23288  |  Open Access |  How to cite  | 


The viral infection during influenza includes several complications like primary pneumonitis, ARDS, bacterial pneumonia, otitis media along with severe increase in the ongoing chronic conditions. Fulminant myocarditis as a primary manifestation of H1N1 is rare. We are reporting four cases that developed fulminant viral myocarditis caused by the H1N1 strain of influenza. These four cases were reported between October 2018 and November 2018, during the post-flood time in Kerala.



Is There Any Lower Limit of Serum Bicarbonate in Diabetic Ketoacidosis?

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:1] [Pages No:542 - 542]

Keywords: Diabetic ketoacidosis, High anion gap acidosis, Severe metabolic acidosis

   DOI: 10.5005/jp-journals-10071-23287  |  Open Access |  How to cite  | 


Diabetic ketoacidosis (DKA) is known as one of the most serious complications of diabetes and associated with significant morbidity and mortality. It consists of a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration.1 It leads to high anion gap metabolic acidosis with fall in serum bicarbonate.



Benita Florence, Ponniah Thirumalaikolundusubramanian

Anisocoria: Realities, Recognition, and Remedial Aspects

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:1] [Pages No:543 - 543]

Keywords: Nebulization, Nebulizer, Palsy

   DOI: 10.5005/jp-journals-10071-23279  |  Open Access |  How to cite  | 


The realities, recognition, and remedial aspects of anisocoria at the bedside were highlighted by Adhikari et al.,1 which is almost similar to an earlier report from India.2 Since this condition involves patient safety and clinical assessment, we would like to touch upon 3 Ps (physiological, pathological, and pharmacological) of anisocoria. First and foremost is to elicit a thorough clinical history and then to assess the case in detail which not only rules out injuries, infections, instillation, or ingestion of medicines and instigating mechanisms but also helps rule out various other life-threatening conditions.



Brajesh Kaushal, Surendra K Jangid

Norepinephrine in Sepsis: Looking beyond Vasoconstriction!

[Year:2019] [Month:November] [Volume:23] [Number:11] [Pages:1] [Pages No:544 - 544]

Keywords: Myocardial function, Norepinephrine, Sepsis, Vasoconstriction

   DOI: 10.5005/jp-journals-10071-23280  |  Open Access |  How to cite  | 


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