Indian Journal of Critical Care Medicine

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2019 | April | Volume 23 | Issue 4

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Sumitra G Bakshi, Atul P. Kulkarni

Ignorance may be Bliss (for Intensivists), but not for ICU Patients!

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:2] [Pages No:161 - 162]

   DOI: 10.5005/jp-journals-10071-23143  |  Open Access |  How to cite  | 



Are We fulfilling the Hippocratic Oath?

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:1] [Pages No:163 - 163]

   DOI: 10.5005/jp-journals-10071-23144  |  Open Access |  How to cite  | 



Collaboration and Autonomy: Mere Buzzwords?

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:1] [Pages No:164 - 164]

   DOI: 10.5005/jp-journals-10071-23145  |  Open Access |  How to cite  | 



Mahnaz Modanloo, Afsaneh Mohsenpour, Hossein Rahmani, Shahram Moghaddam, Homeira Khoddam

Impact of Implementing the Critical Care Pain Observation Tool on Nurses’ Performance in Assessing and Managing Pain in the Critically Ill Patients

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:5] [Pages No:165 - 169]

Keywords: Analgesic administration, Critical care pain observation tool, Intensive care unit

   DOI: 10.5005/jp-journals-10071-23146  |  Open Access |  How to cite  | 


Background and aims: Pain management is one of the most important responsibilities of nurses in an intensive care unit (ICU). It is difficult to perform pain assessment appropriately in patients who are unable to report their pain. This study is aimed to determine the impact of implementing the critical care pain observation tool (CPOT) on the amount and frequency of analgesics’ administration in ICUs. Materials and methods: This interventional study was conducted in 2014. Sixty nurses and 240 patients were studied. This study was carried out in three phases: first the data about amount and frequency of analgesic administration were extracted from patients’ medical files. Then the CPOT was implemented into the nursing assessment process and finally, nurses’ performance regarding the amount and frequency of analgesic administration was recorded. This data obtained before and after intervention were analyzed using chi-square and independent t-test p values less than 0.05 were considered significant. Results: In this interventional study, we found that there was no difference in the demography and cause of ICU admission before and after implementation of CPOT (age p = 0.937, gender p = 0.996, and the cause of admission p = 0.996). We found that after implementing the CPOT into the nursing assessment process, the amount of analgesics administered (7.95 ± 8.77 mg vs. 11.01 ± 11.04 mg, p = 0.018) and the frequency of administration (2.91 ± 1.38 vs. 4.16 ± 0.99, p <0.001) increased significantly. Moreover, there was a significant increase in the frequency of pain assessment per patient per day in nursing practice after implementation of CPOT as compared to the practice before (7.2 ± 2.48 vs. 1.03 ± 1.63, p <0.001). The mean pain scores before and after the intervention (5.5 ± 1.08 vs.2.2 ± 0.48) were also significantly different. Conclusion: Applying CPOT, as an objective mean of pain assessment, was effective in improving the performance of ICU nurses in assessment and management of patients’ pain. It increased the amount and frequency of analgesic administration. We can recommend that COPT is a useful tool for assessment and management of pain in ICU patients and should be implemented in all ICUs.



Bhavika Ravindra Wagh, Deepa Dhananjay Godbole, Shubham Shivaji Deshmukh, Prasanna R Deshpande

Identification and Assessment of Potential Drug–Drug Interactions in Intensive Care Unit Patients

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:5] [Pages No:170 - 174]

Keywords: Intensive care unit, Monitoring and assessment, Potential drug–drug interaction

   DOI: 10.5005/jp-journals-10071-23147  |  Open Access |  How to cite  | 


Context: Intensive care unit (ICU) patients suffer from various comorbidities and usually receive complex pharmacotherapy which increases the risk of drug–drug interactions (DDIs). Aim: To identify and assess potential DDIs (pDDIs) in ICU patients. Settings and design: A prospective observational study conducted in ICU of a tertiary care hospital for a period of 6 months. Materials and methods: Patient information was noted in the data collection form and pDDIs were assessed using Micromedex® database. Statistical analysis used: Chi-square test was used to find correlation of pDDIs with patient parameters. p value was calculated keeping the significance level 0.05. Results: Total 400 subjects were included; having an average age of 55.99 ± 15.62 years with a higher percentage of males (61.75%). About 305 (76.25%) patients were found with pDDIs, showing an average of 2.93 pDDIs/patient. The findings of this study were as follows: Total interactions = 1171, contraindicated = 6 (1%), major = 715 (61%), moderate = 428 (36%), and minor = 22 (2%) pDDIs. Further, majority of pDDIs had onset of action “not specified”; documentation “fair” and probable mechanism “pharmacodynamic” in nature. Significant association of occurrence of pDDIs was found with number of drugs prescribed to patients in ICU. Conclusion: This study demonstrated a high prevalence of pDDI in ICU due to the complexity of pharmacotherapy which showed major pDDIs as the most evident (61%) while contraindicated were 1%. Further studies are needed to better explore this area which may help in realizing the goal of good clinical practice and may offer a methodology to further increase drug safety.



Harmeet Singh Rehan, Priyanka Hotha

Antimicrobial Agents-induced Hypokalemia: A Possible Causality Association

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:3] [Pages No:175 - 177]

Keywords: Adverse drug reaction, Antimicrobial agents, Hypokalemia

   DOI: 10.5005/jp-journals-10071-23148  |  Open Access |  How to cite  | 


Background: Drugs including some of the antimicrobial agents (AMAs) can cause mild to severe intensity of hypokalemia, which leads to cardiac, muscular, renal, gastrointestinal, and metabolic manifestations. Objective: To explore the possible association of AMAs use and the development of hypokalemia as an adverse drug reaction (ADR). Methodology: Retrospective analysis of spontaneously individual case safety reports (ICSRs) received during January 2015 to September 2017 for any reduction in serum potassium levels following the use of AMAs. Such ICSRs were further analyzed for age, gender, seriousness and severity of hypokalemia, outcome, concomitant drugs, management of hypokalemia, and causality assessment using WHO-UMC causality assessment scale. Result: Out of total 2,880 spontaneous ICSR, 53 had report title of hypokalemia. In almost half of these (27) ICSRs, AMAs were suspected to induced hypokalemia. Ceftriaxone (24.5%) and azithromycin (10.5%) were most suspected AMAs. Females (74.19%) aged between 21 years and 40 years experienced more AMA induced hypokalemia. The mild, moderate, and severe hypokalemia was present in 53.8%, 40.7%, and 7.4% of ICSRs, respectively. Drug–drug interaction of AMA with either furosemide, hydrocortisone and/or deriphyllin was present in six ICSRs. Causal association of all the ICSRs with AMA induced hypokalemia was possible. Conclusion: Antimicrobial agents (especially ceftriaxone and azithromycin)-induced hypokalemia alert needs to be investigated. Further, healthcare professionals are advocated to take caution by monitoring serum potassium levels routinely for such patients.



Delshad Aghamohammadi, Behrouz Dadkhah, Masoumeh Aghamohammadi

Nurse–Physician Collaboration and the Professional Autonomy of Intensive Care Units Nurses

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:4] [Pages No:178 - 181]

Keywords: Autonomy, Collaboration, Critical care unit, Nurse, Physician

   DOI: 10.5005/jp-journals-10071-23149  |  Open Access |  How to cite  | 


Background and aims: Poor collaboration between the physicians and the nurses may interfere with nursing performance in patient care. This study aimed to determine the nurse–physician collaboration and professional autonomy of intensive care nurses. Subjects and methods: This descriptive correlational study was performed on 126 nurses working in the intensive care units (ICUs) of Ardabil, Iran. The data were collected using the Jefferson scale of attitudes toward physician–nurse collaboration’ (JSAPNC) and the Dempster Practice Behavior Scale (DPBS). The results were analyzed using descriptive statistics (mean, standard deviation, and frequency) and inferential statistics (t-test, ANOVA, and Pearson). Results: The mean score of the nurse–physician collaboration was found to be 47.83 ± 3.9, which indicates good collaboration between physicians and nurses in the ICUs. The results showed that 73% of the nurses reported a moderate autonomy and 27% of them considered their autonomy to be high. There was no significant relationship between the nurse–physician collaboration and the professional autonomy of the nurses (p >0.05). Conclusion: The nurses who participated in this study had a positive attitude toward collaboration with the physicians and a moderate level of professional autonomy. Interventions may be required to further enhance the level of nurse–physician collaboration and the professional autonomy of nurses.



Yuji Takahashi, Tomohiro Sonoo, Hiromu Naraba, Hideki Hashimoto, Kensuke Nakamura

Effect of Intra-arterial Balloon Pumping for Refractory Septic Cardiomyopathy: A Case Series

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:4] [Pages No:182 - 185]

Keywords: Cardiogenic shock, Critical care, IABP, Sepsis, Septic cardiomyopathy

   DOI: 10.5005/jp-journals-10071-23150  |  Open Access |  How to cite  | 


Background and aims: Patients with septic cardiomyopathy (SCM) occasionally develop refractory cardiogenic shock, which is difficult to resolve even with the administration of standard dose of catecholamines. Although venoarterial extracorporeal membrane oxygenation (VAECMO) has recently been reported with good treatment results, there have been no evidence-based practices. Furthermore, severe SCM may be fatal if the blood pressure cannot be increased. This case series explored whether the application of intra-arterial balloon pumping (IABP) is an effective method for increasing blood pressure in patients with severe SCM. Subjects and methods: Over a 58-month period, all patients who were admitted in the emergency and critical care center and managed with IABP were investigated. Among these, data sets of patients diagnosed with SCM were evaluated retrospectively. Results: Ten patients were included in this analysis. Their mean APACHE II and SOFA scores were 26.8±7.9 and 13.9±1.7, respectively. A mean arterial pressure (MAP) increase of more than 30% was achieved in six patients, and a decrease in catecholamine index was observed in five. The effective group consisted of seven patients. The stroke volume increased in 83% of patients who were equipped with pulmonary artery or transpulmonary thermodilution catheter. Low heart rate and regular heart rhythm may be important factors for the effectiveness of IABP for cardiogenic shock caused by refractory SCM. Conclusion: Intra-arterial balloon pumping may be able to raise MAP in refractory SCM patients even with septic shock by an increase in cardiac output.



Keta Thakkar, Neeraja Ajayan, Unnikrishnan P, Manikandan Sethuraman

A Mysterious Case of Spontaneous Cervical Epidural Hematoma and Bilateral Primary Spontaneous Pneumothorax caused by a Rare Etiology

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:2] [Pages No:186 - 187]

Keywords: Primary spontaneous pneumothorax, Spontaneous spinal epidural hematoma, Vasculopathy

   DOI: 10.5005/jp-journals-10071-23151  |  Open Access |  How to cite  | 


Spontaneous spinal epidural hematoma (SSEH) is a rare disorder that can present as an acute onset of pain and radicular symptoms that mimic disk herniation. Primary spontaneous pneumothorax (PSP) can be defined as presence of air in the pleural space without apparent underlying lung disease or trauma. We describe a rare case of SSEH in cervical spine (C5–7) presenting with a novel association, a bilateral PSP, which has never been documented before. Both SSEH and spontaneous pneumothorax, though rare, can be associated with vasculopathy and our patient had signs of vasculopathy of intracranial vessels and pulmonary vasculature. Vasculopathy also needs to be considered while evaluating a case of PSP without emphysema-like changes (ELCs) and if diagnosed as the cause, pleurodesis could be considered as a part of the management to avoid the sequel of recurrent pneumothorax and prolonged ICU stay in this subset of patients.



Anudeep Saxena, Vivek Bhargava, Aditya Shreya, Anshul Patodia

Posterior Reversible Encephalopathy Syndrome in a Patient of Sepsis-induced Cardiomyopathy, Successfully Managed with Intra-aortic Balloon Pump

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:3] [Pages No:188 - 190]

Keywords: Intra-aortic balloon pump, Posterior reversible encephalopathy syndrome, Septic cardiomyopathy

   DOI: 10.5005/jp-journals-10071-23152  |  Open Access |  How to cite  | 


In patients with septic shock refractory to pharmacological agents, mechanical devices have been used successfully, although the reports are scarce. We report a case of septic shock where intra-aortic balloon pump (IABP) initiation leads to drastic improvement and survival from severe septic cardiomyopathy when conventional therapy was not effective. A 19-year-old male patient underwent surgery for adenocarcinoma descending colon. On day 8 he was reoperated for anastomotic leak and developed severe cardiomyopathy associated with septic shock, postoperatively. When he was in a vicious cycle of refractory hypotension, metabolic acidosis and severe cardiomyopathy, IABP was instituted along with other management for septic shock. Over next 3 days patient's hemodynamics improved and IABP was weaned off. While recovering from shock he developed posterior reversible encephalopathy syndrome which was promptly managed. This case report emphasizes on early institution of IABP in case of severe left ventricular dysfunction in septic shock.



Ketamine Use allows Noninvasive Ventilation in Distressed Patients with Acute Decompensated Heart Failure

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:2] [Pages No:191 - 192]

Keywords: Dissociation, Heart failure, Ketamine, NIPPV

   DOI: 10.5005/jp-journals-10071-23153  |  Open Access |  How to cite  | 


Acute decompensated heart failure (ADHF) is responsible for a heavy clinical load on busy emergency departments (EDs) across the globe and especially in India. ADHF patients may present with severe respiratory distress, dyspnea, hypoxia, and high and low blood pressures. Managing the airway of such patients can at times be challenging. Nasal cannulae, face mask, and noninvasive positive pressure ventilation (NIPPV) are the cornerstones of providing oxygenation and ventilation to such patients while some extreme cases may require endotracheal intubation and mechanical ventilation. An elderly female in severe respiratory distress and altered sensorium presented to our ED and had to be administered ketamine to facilitate proper NIPPV and avoid mechanical ventilation. She was weaned off the NIPPV in the ED itself over the next four hours. There are some case reports of using ketamine for NIPPV in asthma exacerbations, but none for the use in ADHF. Avoiding invasive mechanical ventilation via endotracheal intubation should be a constant goal and the last resort.



Prakash Shastri, Pallav Gupta

Fulminant Histoplasmosis Presenting as Pyrexia of Unknown Origin in Immunocompetent Adult Diabetic Patient

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:3] [Pages No:193 - 195]

Keywords: Bone marrow, Histoplasmosis, Immunocompetent

   DOI: 10.5005/jp-journals-10071-23154  |  Open Access |  How to cite  | 


Opportunistic infections are commonly seen in immunocompromised individuals such as those suffering from HIV infection, organ transplant recipients and connective tissue disorders. Histoplasmosis is one of the fungal opportunistic infections which is usually seen in immunosuppressed individuals but can also be seen in immunocompetent patients with frequent involvement of adrenal glands. We present a case of adult diabetic patient presenting as pyrexia of unknown origin in which bone marrow aspiration and biopsy lead to diagnosis of histoplasmosis without adrenal involvement.



Sandip Bhattacharyya

Post-cardiac Arrest Ventilator Triggering

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:1] [Pages No:196 - 196]

   DOI: 10.5005/jp-journals-10071-23155  |  Open Access |  How to cite  | 



Subodh Kumar Mahto, Ankita Sheoran, Pooja Verma, Atul Goel

A Rare and Lethal Complication of Oral Warfarin Therapy

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:2] [Pages No:197 - 198]

   DOI: 10.5005/jp-journals-10071-23156  |  Open Access |  How to cite  | 



Saurabh Mittal, Karan Madan, Nitish Aggarwal, Anita Dhar

Tuberculosis and Short Bowel: A Therapeutic Challenge

[Year:2019] [Month:April] [Volume:23] [Number:4] [Pages:1] [Pages No:199 - 199]

   DOI: 10.5005/jp-journals-10071-23157  |  Open Access |  How to cite  | 


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