Indian Journal of Critical Care Medicine

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2019 | February | Volume 23 | Issue 2

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Thoracic Epidural Analgesia for Severe Acute Pancreatitis: Quo Vadis Intensivist?

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:2] [Pages No:59 - 60]

   DOI: 10.5005/jp-journals-10071-23117  |  Open Access |  How to cite  | 



Beena Hosdurg Bhaskar, Shalini Shenoy Mulki, Sangeetha Joshi

Molecular Characterization of Extended Spectrum â-lactamase and Carbapenemase Producing Klebsiella pneumoniae from a Tertiary Care Hospital

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:6] [Pages No:61 - 66]

Keywords: AmpC, Carbapenemase, Extended spectrum â-lactamase, Metallo â-lactamase

   DOI: 10.5005/jp-journals-10071-23118  |  Open Access |  How to cite  | 


Objective: The extended-spectrum beta-lactamase (ESBL) and carbapenemase producing gram-negative bacteria among the members of Enterobacteriaceae are of major health concern globally. The present study was carried out to determine proportion and genetic characterization of ESBL and carbapenemase producing Klebsiella pneumoniae strains isolated from intensive care units of a tertiary care hospital. Materials and methods: A total of 250 non-duplicate K. pneumoniae isolates were recovered from various clinical specimens from our intensive care units from May 2014 to May 2015. Antibiotic susceptibility testing was performed as recommended by Clinical and Laboratory Standard Institute. Phenotypic identification of ESBL and carbapenemase producing isolates were confirmed by the double-disk synergy test, modified Hodge test, imipenem and imipenem-EDTA combined test, respectively. Molecular characterization of â-lactamase genes were performed by polymerase chain reaction. Results: Out of 250 Klebsiella pneumonaie, 84% isolates were ESBL producers, 66% were carbapenem resistant based on their reduced susceptibility to imipenem, meropenem and ertapenem. Among these 165 carbapenem resistant isolates, 9.7% were positive for blaNDM-1 and these isolates were also found to be positive for one or more bla genes. Co-carriage of AmpC in ESBL and carbapenem resistant isolates were 7.8% and 3.6%, respectively and were negative for blaKPC genes. Conclusion: The study indicated the prevalence of ESBLs and blaNDM-1, with additional bla genes and AmpC among the K. pneumoniae isolates in our intensive care units. NDM-1 producing Enterobacteriaceae is a growing health care problem. Detection of the prevalence of antibacterial resistance pattern helps towards improved antibiotic policy and empirical antibiotic treatment.



Vishnu Kumar Garg, Seema Mishra, Nishkarsh Gupta, Bharti Sachidanand, Vinod Kumar, Hitender Gautam

Microbial and Antibiotic Susceptibility Profile among Isolates of Clinical Samples of Cancer Patients admitted in the Intensive-care Unit at Regional Tertiary Care Cancer Center: A Retrospective Observational Study

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:6] [Pages No:67 - 72]

Keywords: Antibiotics, Antibiotic susceptibility, Cancer, Culture, Multidrug resistance

   DOI: 10.5005/jp-journals-10071-23119  |  Open Access |  How to cite  | 


Cancer patients in intensive care unit (ICU) are vulnerable for developing multidrug resistant nosocomial infections. The antimicrobial resistance due to inappropriate use of antibiotics results in significant morbidity and mortality in these cancer patients. The present retrospective study was done to describe the antimicrobial sensitivity pattern of common organisms in isolates of clinical samples of patients admitted in ICU at our tertiary care cancer center. Materials and methods: The study was carried out at ICU of a regional tertiary care cancer center for a period of 1 year from October 2016 to September 2017. All clinical samples were collected and processed for culture and antibiotic susceptibility testing were carried out on isolates as per Clinical Laboratory Standard Institute guidelines. Results: A total of 644 specimens were collected. Escherichia coli, Acinetobacter spp., Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus spp. were most commonly encountered. In positive bacterial cultures, majority were Gram-negative isolates (84.14 %). Klebsiella was the most common gram-negative isolate (34.78%) and Enterococcus spp. were the most common Gram-positive isolates (61.53%). A high level of resistance to various antibiotics was noted among Gram-negative bacteria compared to Gram-positive isolates. Majority of the Gram-negative isolates were sensitive to Imipenem, Meropenem, and Colistin sensitivity among Gram-negative isolates was 100%. Linezolid, Teicoplanin and Vancomycin were most sensitive antimicrobials against the Gram-positive bacteria. Conclusion: Regular monitoring of the pattern of resistance of bacteriological isolates in cancer patients is critical to develop antibiotic policy to combat these infections and reduce morbidity and mortality.



Rameshbabu Homanna Javali, Krishnamoorthy , Akkamahadevi Patil, Suraj , Sriharsha

Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:5] [Pages No:73 - 77]

Keywords: Elderly, Injury severity score, Mortality, New injury severity score, Revised trauma score, Trauma and injury severity score, Trauma

   DOI: 10.5005/jp-journals-10071-23120  |  Open Access |  How to cite  | 


Objectives: This study tests the accuracy of the Injury Severity Score (ISS), New Injury Severity Score (NISS), Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS) in prediction of mortality in cases of geriatric trauma. Design: Prospective observational study Materials and methods: This was a prospective observational study on two hundred elderly trauma patients who were admitted to JSS Hospital, Mysuru over a consecutive period of 18 months between December 2016 to May 2018. On the day of admission, data were collected from each patient to compute the ISS, NISS, RTS, and TRISS. Results: Mean age of patients was 66.35 years. Most common mechanism of injury was road traffic accident (94.0%) with mortality of 17.0%. The predictive accuracies of the ISS, NISS, RTS and the TRISS were compared using receiver operator characteristic (ROC) curves for the prediction of mortality. Best cutoff points for predicting mortality in elderly trauma patient using TRISS system was a score of 91.6 (sensitivity 97%, specificity of 88%, area under ROC curve 0.972), similarly cutoff point under the NISS was score of 17(91%, 93%, 0.970); for ISS best cutoff point was at 15(91%, 89%, 0.963) and for RTS it was 7.108(97%,80%,0.947). There were statistical differences among ISS, NISS, RTS and TRISS in terms of area under the ROC curve (p <0.0001). Conclusion: TRISS was the strongest predictor of mortality in elderly trauma patients when compared to the ISS, NISS and RTS.



K Baby Sailaja

Critically Ill Obstetric Admissions to an Intensive Care Unit: A Prospective Analysis from a Tertiary Care University Hospital in South India

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:5] [Pages No:78 - 82]

Keywords: Maternal outcome, Mechanical ventilation, Obstetric critical care, Postpartum, PRES

   DOI: 10.5005/jp-journals-10071-237121  |  Open Access |  How to cite  | 


Background: Critically ill obstetric patients represent a small proportion of intensive care unit (ICU) admissions. Physiological changes of pregnancy along with pregnancy specific diseases may lead to rapid deterioration of the health status of the parturient warranting ICU care. The present study aims to study the clinical profile and outcomes of the obstetric patients requiring ICU care. Study design and settings: Prospective observational study in the multidisciplinary ICU of a tertiary care teaching hospital conducted for a period of 2 years. Materials and methods: Demographic details, indication for ICU admission, severity of illness scores, interventions, complications and outcomes of the consecutive obstetric patients transferred to ICU were studied. Results: Ninety-one patients were admitted (26 per 1000 deliveries) to the ICU. Majority of them were postpartum (84.6%) and unbooked or referred (63.8%). Hypertensive disorders (24.2%) and obstetric hemorrhage (23.1%) were the major cause for admission to ICU. Forty three patients (47.3%) underwent cesarean delivery. Mechanical ventilation (54.9%), blood transfusion (46%), vasopressor therapy (22%) and dialysis (9.9%) were the various interventions provided in the ICU. Patients with sepsis had high mortality accounting for one third of ICU mortality. The ICU mortality rate was 9.9%. Conclusion: The present study showed a clinical profile and outcomes similar to the current scenario of critically ill obstetric patients nationwide. Further studies with a larger sample size may provide a better insight in this population.



Sowmya Madihalli JanardhanIyengar, Bhaskar Murthy Venkateshmurthy, Yeshaswini Katari

Family Satisfaction in a Medical College Multidisciplinary Intensive Care Unit (ICU)—How Can We Improve?

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:6] [Pages No:83 - 88]

Keywords: Family satisfaction, Intensive care, Questionnaire

   DOI: 10.5005/jp-journals-10071-23122  |  Open Access |  How to cite  | 


Background and Aims: In recent years, patient and family-centered implications are being recognized as important outcome measures and one of the quality indicators of health care system worldwide. Most of the Intensive Care Unit patients cannot make decisions themselves, accordingly family members are surrogate decision-makers and judges of care quality. This study was conducted as a prospective observational study using Family Satisfaction-Intensive Care Unit questionnaire to ascertain the level of family satisfaction of care and their involvement in the decision making process of their patient's treatment. Materials and methods: The study was conducted over 3 months with 100 family members by FS-ICU questionnaire survey method. After 48 hours of ICU admission, the questionnaire was administered to an eligible family member by a resident who was not involved in the treatment of the patient, in a language understood by them (English/Kannada). Each question was scored using 5 point Likert response Scale and the scores were transformed into 0 (least satisfied) to 100 (most satisfied) scale. Results: Satisfaction with overall care was 65.31±23.62 (FS-ICU/Care). Satisfaction with decision making process was 73.06±22.154 (FS-ICU/ DM). Individual factors which contributed to lower scores were management of pain and agitation of the patient, waiting room atmosphere and emotional support. Conclusion: This study identified the individual factors which contributed to the high and low satisfaction scores. With this baseline data as reference, there is scope to enhance the aspects of quality care for patients and their family members.



Yash Raj Gupta, Gargi Rai, Arun Gupta

Effect of Segmental Thoracic Epidural Block on Pancreatitis Induced Organ Dysfunction: A Preliminary Study

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:6] [Pages No:89 - 94]

Keywords: Pancreatitis, Procalcitonin, Sepsis, Thoracic epidural block

   DOI: 10.5005/jp-journals-10071-23123  |  Open Access |  How to cite  | 


Background: This preliminary randomized controlled study evaluated effect of thoracic epidural block (TEB) on progression of acute pancreatitis induced organ dysfunction/failure. Materials and Methods: Patients with predicted severe acute pancreatitis, without contraindication to TEB were randomized to receive (group TE) or not receive a TEB (group NTE) (n = 16 each). For group TE, TEB was performed at T8-9 or T9-10 vertebral level, with infusion of ropivacaine (0.2%) along with fentanyl 2 μg/mL; in group NTE, intravenous morphine was used instead, both interventions titrated to NRS of <4. SOFA score was assessed daily till discharge from ICU, and aggregate SOFA calculated by summing worst scores for each of organ system during ICU stay as primary outcome measure. Other surrogate measures of patient outcome were recorded as secondary objectives. Results: Aggregate SOFA score was statistically similar between both groups (group NTE: 3 [2 - 4]; group TE: 5 [2 - 6]) (P = 0.379); but there was trend of improvement in SOFA score in group TE versus a worsening in group NTE. Duration of hospital stay, and number of patients requiring mechanical ventilation were statistically similar; mortality was insignificantly lesser for group TE (12.5% versus 6.6%; p = 1.000). Fall in serum procalcitonin was significantly greater for group TE. Conclusion: Thoracic epidural was associated with insignificant clinical trend towards better organ functions and lesser mortality; along with significantly greater fall in serum procalcitonin. These are encouraging results that could guide future use of thoracic epidural in acute pancreatitis for its non-analgesic benefits.



Shinichi Fukuhara, Yoshimichi Yamaguchi, Yoshiyuki Uetani, Yoshinobu Akasaka

Lung Ultrasound in Children with Acute Respiratory Failure: Comparison between Chest X-Ray, Chest Computed Tomography, and Lung Ultrasound: A Case Series

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:4] [Pages No:95 - 98]

Keywords: Lung ultrasound, Acute respiratory failure, Children, Chest X-ray, Chest CT

   DOI: 10.5005/jp-journals-10071-23124  |  Open Access |  How to cite  | 


Respiratory failure is one of the most common and critical problems in pediatric wards. Assessments by chest X-rays (CXRs) are common and prevalent for determining the cause of respiratory failure in children. However, CXRs can be misinterpretated. Some patients may require further evaluation with other tools, such as chest computed tomography (CCT). Lung ultrasound (LUS) has proven useful for detecting lung abnormalities with respiratory failure in adults, but its usefulness in children is still not clear. We present a series of eight children who were admitted in a tertiary children's hospital. Each child underwent CXR, CCT, and LUS. In seven of eight cases, both LUS and CCT were able to detect abnormal findings. However, the radiological findings in CXRs were not sufficient. These cases included children with pleural effusion that was comorbid with consolidation, or cases with substantial consolidation that required thoracentesis or proper physical therapy. Key messages: LUS can be beneficial for evaluating children with respiratory failure that are admitted in pediatric intensive care unit (PICU) and may contribute towards appropriate therapy for children.



A Kodiatte Abraham, John Livingston

Hemotoxic Snakebite Presenting with Bilateral Blindness Due to Ischemic Occipital Infarcts

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:3] [Pages No:99 - 101]

Keywords: Cortical blindness, Hemotoxic snakebite, Ischemic infarcts

   DOI: 10.5005/jp-journals-10071-23125  |  Open Access |  How to cite  | 


Cerebrovascular complications are rare following a Viperidae snake envenomation, let alone ischemic ones. This catastrophic hemorrhaging cascade is widely known to cause a wide array of manifestations. Its manifestations can range from skin bleeds to fatal intracranial or organ hemorrhages. Our patient had cortical blindness secondary to an ischemic occipital infarct following a hemotoxic snakebite - a seemingly distinct oxymoron. The physician should be mindful of the fact that a hemotoxic snakebite can deceptively bring in ischemic attacks as well. Toxic vasculitis, thrombotic angiopathies, widespread vasospasm and endothelial damage are believed to shoulder a part of the disease process that can bring about tissue ischemia. Key Messages: Hemotoxic snake envenomation can have devastating effects. Apart from dealing with the threat of coagulopathy, the physician must also be alert to the ironical ischemic aftermath that can equally bring in misery. Our patient had one such complication-bilateral cortical blindness resulting from bilateral occipital ischemic infarcts. The physician must be aware that a hemotoxic snakebite can even instigate ischemic dilemmas, i.e. cerebrovascular infarcts, as well.



Evan J Wiens, Colette M Seifer, Clarence Khoo

Inadvertent Removal of a Right Ventricular Pacemaker Lead by a Knotted Transvenous Pacing Wire

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:2] [Pages No:102 - 103]

Keywords: Knot, Loop, Right ventricular lead, Transvenous pacemaker

   DOI: 10.5005/jp-journals-10071-23126  |  Open Access |  How to cite  | 


We report an unusual complication of permanent pacemaker (PPM) implantation in a patient with a temporary transvenous pacemaker (TVP) in situ, in which the TVP lead formed a knot around the newly-placed right ventricular (RV) lead, complicating TVP removal. The case underscores the fact that suboptimal TVP lead placement, such as looping in the RV, can result in complications during implantation of a permanent pacemaker.



Manoj Kumar Sahu, Uma Balasubramaniam, C Bipin, Sarvesh Pal Singh, Sachin Talwar

Elizabethkingia Meningoseptica: An Emerging Nosocomial Pathogen Causing Septicemia in Critically Ill Patients

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:2] [Pages No:104 - 105]

Keywords: Elezabethkingia meningoseptica, Intensive care unit, Pediatric cardiac surgery, Sepsis

   DOI: 10.5005/jp-journals-10071-23127  |  Open Access |  How to cite  | 


Elizabethkingia meningoseptica (E. meningoseptica), is an opportunistic Gram-negative bacteria, normally found in water and soil, notorious for causing nosocomial infections in extremes of ages and immunocompromised patients. It is now emerging as a serious nosocomial pathogen, intrinsically resistant to several commonly used antibiotics (e.g. beta-lactams, aminoglycosides, carbapenems and colistin etc. and a cause of high mortality in critically ill patients in intensive care units (ICUs). We report the first case of E. meningoseptica sepsis in a 5 month old child after open heart surgery for transposition of great arteries, initially on extracorporeal membrane oxygenation, then prolonged mechanical ventilation, with various invasive devices, inotropes and exposed to broad spectrum antibiotics in our ICU. The case highlights the potential risk factors responsible for E.meningoseptica sepsis. Its unusual pattern of resistance to many commonly used antibiotics makes this organism difficult to treat.



Sayan Malakar, Bhagwan Dass Negi, Katyayani Dutt, Sujeet Raina

Intravascular Hemolysis in Aluminium Phosphide Poisoning

[Year:2019] [Month:February] [Volume:23] [Number:2] [Pages:2] [Pages No:106 - 107]

Keywords: Aluminum phosphide, Hemolysis, Intravascular, Poisoning

   DOI: 10.5005/jp-journals-10071-23128  |  Open Access |  How to cite  | 


Hemolysis associated with aluminum phosphide poisoning is very rare. Intravascular hemolysis in presence of glucose-6-phosphate dehydrogenase (G6PD) deficiency has been reported rarely in literature. We are reporting a case of young male patient with history of aluminum phosphide poisoning and complicated with intravascular hemolysis without G6PD deficiency. It has been reported only once in the literature.


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