Indian Journal of Critical Care Medicine

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2019 | June | Volume 23 | Issue 6

EDITORIAL

The Need to Start at the Bench

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:1] [Pages No:245 - 245]

PDF  |  DOI: 10.5005/jp-journals-10071-23172  |  Open Access |  How to cite  | 

EDITORIAL

Data is the New Gold!

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:1] [Pages No:246 - 246]

PDF  |  DOI: 10.5005/jp-journals-10071-23173  |  Open Access |  How to cite  | 

BASIC SCIENCE AND EXPERIMENTAL RESEARCH

Ohad Ronen, Israel Rosin, Uri Zeev Taitelman, Edward Altman

Comparison of Ciaglia and Griggs Percutaneous Tracheostomy Techniques – A Biomechanical Animal Study

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:4] [Pages No:247 - 250]

Keywords: Animal model, Biomechanics, Percutaneous tracheostomy

PDF  |  DOI: 10.5005/jp-journals-10071-23174  |  Open Access |  How to cite  | 

Abstract

Background and aims: The two most common commercial percutaneous dilation tracheotomy (PDT) sets apply different techniques. Our aim was to investigate the biomechanical properties of these two techniques on an animal model, that simulate a human trachea. Subjects and methods: Biomechanical properties of the different steps of the Ciaglia Blue Rhino® and Griggs Portex® techniques were measured on 20 pig cadavers. Results: We found that the use of the two different devices created equal sized openings in the trachea (p > 0.05). The force needed to insert the Griggs forceps was 1.8 kg average compared to 2.51 kg using the Ciaglia dilator (p <0.00001). The calculated total energy expenditure in the Ciaglia Blue Rhino® kit was 1.46 times greater than the Griggs Portex® kit (p <0.0001). This was mainly due to the amount of energy required during the final dilator stage, which was 4 times more using the Ciaglia Blue Rhino® dilator than the Portex® Griggs-dilator forceps. Conclusion: We conducted a series of biomechanical properties experiments on an animal model of PDT using two popular commercial kits – Griggs Portex® guidewire dilating forceps by Smiths Medical and Ciaglia Blue-Rhino® by Cook Medical. The Ciaglia technique required almost 50% more energy to perform a PDT (p <0.0001), mainly because of the force exerted during the final dilator insertion stage compared to the Griggs forceps. Further research is needed to examine if these properties are related to some of the PDT complications.

Original Article

Manu Varma MK

Secular Trends in An Indian Intensive Care Unit-database Derived Epidemiology: The Stride Study

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:7] [Pages No:251 - 257]

Keywords: Customized Health in Intensive Care Trainable Research and Analysis tool (CHITRA), International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD 10), Admission Diagnosis, Comorbidity, Intensive Care Unit (ICU)

PDF  |  DOI: 10.5005/jp-journals-10071-23175  |  Open Access |  How to cite  | 

Abstract

Context: The Indian Society of Critical Care Medicine (ISCCM), had taken an initiative to enable all Indian ICUs (Intensive Care Unit) to capture and store relevant data in a systematic manner in an electronic database: “CHITRA” (Customized Health in Intensive Care Trainable Research and Analysis tool). Aims: This study was aimed at capturing, and summarising longitudinal epidemiological data from a single tertiary care hospital ICU (Intensive Care Unit), based on a pre-existing database and the CHITRA (Customized Health in Intensive Care Trainable Research and Analysis tool) system. Settings and design: Prospective Observational Methods and material: Data was extracted from two databases, a pre-existing database, arbitrarily named pre-CHITRA (January 2006 to April 2014), and the CHITRATM database (October 2015 to January 2018). Diagnoses of the patients admitted were tabulated using the ICD10 (International Statistical Classification of Diseases and Related Health Problems 10th Revision) coding format. The outcomes were summarised and cross tabulated. Statistical analysis used: Cross tabulations were used to display summarized data, analysis of outcomes were done using t test and regression analyses, and correspondence analysis was used to explore associations of descriptors. Results: A total of 18940 patients were admitted, with a male preponderance, and the median age was fifty-two years. Most of admissions were from emergency (62%). The age (0.3, p = 0.000, CI (0.2 - 0.38)) and mean APACHE II score of patients had increased over the years (0.18, p = 0.000 CI (0.12-0.25). The ICU mortality had decreased significantly over the years (–0.04, p = 0.000, CI (–0.05 to –0.03)). The most common admission diagnosis in the pre-CHITRA database was general symptoms and signs (ICD10 R50-R69), and in the CHITRA database was Type 1 Respiratory failure (ICD 10 J96.90). Conclusion: This study has shown the utility of the CHITRA system in capturing epidemiological data from a single centre.

Original Article

Mubina Begum Bijapur, Nazeer Ahmed Kudligi, Shaik Asma

Central Venous Blood Gas Analysis: An Alternative to Arterial Blood Gas Analysis for pH, PCO2, Bicarbonate, Sodium, Potassium and Chloride in the Intensive Care Unit Patients

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:5] [Pages No:258 - 262]

Keywords: Agreement, Arterial blood gas analysis, Central venous blood, Correlation, Electrolytes

PDF  |  DOI: 10.5005/jp-journals-10071-23176  |  Open Access |  How to cite  | 

Abstract

Aims: Arterial blood gas (ABG) analysis is a frequently ordered test in intensive care unit (ICU) and can analyze electrolyte in addition to pH and blood gases. Venous blood gas (VBG) analysis is a safer procedure and may be an alternative for ABG. Electrolyte estimation by auto analyzer usually takes 20–30 minutes. This study was aimed to investigate the correlation of pH, PCO2, bicarbonate, sodium, potassium, and chloride (electrolytes) between ABG and central VBG in ICU patients. Materials and methods: This was a prospective observational study conducted in medical college hospital ICU. Adult patients requiring ABG and electrolyte estimation as a part of their clinical care were consecutively included in the study. Patients having any intravenous infusion or who were pregnant were excluded. Venous samples were taken within 2 minutes of arterial sampling from in situ central line. Data were analyzed using Bland-Altman methods. Results: A total of 110 patient\'s paired blood samples were analyzed. The mean difference between arterial and central venous values of pH, PCO2, bicarbonate, sodium, potassium, and chloride was 0.04 units, –5.84 mm Hg, 0.89 mmol/L, –1.8 mEq/L, –0.04 mEq/L, and –0.89 mEq/L, respectively. The correlation coefficients for pH, PCO2, HCO3–, sodium, potassium, and chloride were 0.799, 0.831, 0.892, 0.652, 0.599 and 0.730, respectively. Limits of agreement (95%) were within acceptable limits. Conclusion: Central venous pH, PCO2, and bicarbonate may be an acceptable substitute for ABG in patients admitted in the ICU. However caution should be exercised while applying electrolyte measurements.

Original Article

Esra Kockuzu, Benan Bayrakcý, Selman Kesici, Agop Cýtak, Bulent Karapýnar, Serhat Emeksiz, Ayþe Berna Anýl, Tanýl Kendirli, Ufuk Yukselmis, Esra Sevketoglu, Þukru Paksu, Onur Kutlu, Hasan Agýn, Dincer Yýldýzdas, Halil Keskin, Gokhan Kalkan, Arzu Hasanoglu, Mutlu Uysal Yazýcý, Guntulu Sýk, Arda Kýlýnc, Fatih Durak, Oktay Perk, Mey Talip, Nazik Yener, Selcuk Uzuner

Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs during the Winter Season in Turkey

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:7] [Pages No:263 - 269]

Keywords: Mortality, Multi organ failure, Pediatric intensive care unit, Seasonal, Viruses

PDF  |  DOI: 10.5005/jp-journals-10071-23177  |  Open Access |  How to cite  | 

Abstract

Objectives: To analyze the course of seasonal viral infections of respiratory tract in patients hospitalized in pediatric intensive care units (PICU) of 16 centers in Turkey. Materials and methods: It is a retrospective, observational, and multicenter study conducted in 16 tertiary PICUs in Turkey includes a total of 302 children with viral cause in the nasal swab which required PICU admission with no interventions. Results: Median age of patients was 12 months. Respiratory syncytial virus (RSV) was more common in patients over one year of age whereas influenza, human Bocavirus in patients above a year of age was more common (p <0.05). Clinical presentations influencing mortality were neurologic symptoms, tachycardia, hypoxia, hypotension, elevated lactate, and acidosis. The critical pH value related with mortality was ≤7.10, and critical PCO2≥60 mm Hg. Conclusion: Our findings demonstrate that patients with neurological symptoms, tachycardia, hypoxia, hypotension, acidosis, impaired liver, and renal function at the time of admission exhibit more severe mortal progressions. Presence of acidosis and multiorgan failure was found to be predictor for mortality. Knowledge of clinical presentation and age-related variations among seasonal viruses may give a clue about severe course and prognosis. By presenting the analyzed data of 302 PICU admissions, current study reveals severity of viral respiratory tract infections and release tips for handling them.

Original Article

Mahesha Padyana, Sunil Karanth, Shriram Vaidya, Justin Aryabhat Gopaldas

Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:4] [Pages No:270 - 273]

Keywords: APACHE, Dengue fever, SOFA, Severe Dengue, Transaminitis

PDF  |  DOI: 10.5005/jp-journals-10071-23178  |  Open Access |  How to cite  | 

Abstract

Background: India is one of the seven identified countries in South-East Asia region regularly reporting dengue fever (DF)/dengue hemorrhagic fever (DHF) outbreaks. Even though the dengue prodrome and evolution of illness are most often similar in many patients, progress and outcome may differ significantly depending on the severity of illness as well as treatment instituted. We studied the clinical manifestations, outcome and factors predicting mortality of serology confirmed dengue fever cases admitted in Multidisciplinary Intensive Care Unit (MICU) of a high acuity healthcare facility in India. Methodology: All patients with serology proven dengue fever admitted to MICU between 1st July 2015 and1st December 2015 were included in the study. Clinical presentation, laboratory findings, severity of illness scores and outcome were recorded. Results: Majority of the patients (58.4%) belonged to 21–40 year age group. Hepatic (96.8%) followed by hematological (79.2%) involvement were the most common findings. CNS involvement observed among 27%. Survival to hospital discharge was 78.9%. Respiratory and gastrointestinal system involvement was associated with increased mortality. Acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and shock were the clinical syndromes associated with mortality. Serum lactate, aspartate transaminase (AST) and alanine transaminase (ALT) were significantly elevated among non survivors. Significant difference in sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) scores was also observed among survivors and non survivors. Conclusion: Organ system involvement and higher disease severity scores are strong predictors of mortality. High index of suspicion for atypical manifestations of dengue is warranted.

BRIEF COMMUNICATION

Harpreet Singh, Ashok Pannu

Dengue: Uncommon Neurological Presentations of a Common Tropical Illness

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:2] [Pages No:274 - 275]

PDF  |  DOI: 10.5005/jp-journals-10071-23179  |  Open Access |  How to cite  | 

Abstract

Dengue is a common arthropod-borne flavivirus and commonly manifests as fever, bleeding diathesis, and capillary leak syndrome. Neurological manifestations are uncommon except for encephalopathy. We have recently had the opportunity of observing two patients with rare neurological complications of dengue, transverse myelitis, and Guillain-Barre syndrome. Both the cases had good neurological recovery with steroid and intravenous immunoglobulin, respectively.

CASE REPORT

Sneha Madkaiker

Catastrophic Antiphospholid Syndrome – An Unusual Case Report

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:5] [Pages No:276 - 280]

Keywords: Catastrophic antiphospholipid syndrome, Cerebral infarcts, Lupus anticoagulant, Purpura, Renal failure

PDF  |  DOI: 10.5005/jp-journals-10071-23180  |  Open Access |  How to cite  | 

Abstract

Antiphospholipid syndrome (APLS) is characterised by venous or arterial thrombosis and/or adverse pregnancy outcome in the presence of persistent laboratory evidence of antiphospholipid antibodies. Catastrophic Antiphospholipid Syndrome (CAPS) is a severe and rare form of antiphospholipid syndrome characterised by multiple site thrombosis involving small, medium and large blood vessels occurring over a short period of time (usually 1 week) causing multiorgan failure. We present an unusual case of left upper limb acute arterial thrombosis with purpura fulminans like skin lesions precipitated by swine flu (H1N1) infection with adult respiratory distress syndrome subsequently developing acute renal failure, retinal infarcts, multiple acute cerebral infarcts, cardiac valvular vegetations and hemolytic anemia with recurrent bleeding episodes. A positive lupus anticoagulant confirmed the diagnosis of CAPS. In spite of early initiation of triple therapy (anticoagulation, high dose steroids, plasmapheresis) our patient did not survive. This rare case of probable CAPS is presented with an aim to study the clinical manifestations, laboratory findings, efficacy of therapy and prognosis in the medical ICU.

CASE REPORT

Sudheer Tale, Soumitra Ghosh

A Case of Life-threatening Amlodipine and Atenolol Overdose

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:3] [Pages No:281 - 283]

Keywords: Amlodipine, Atenolol, Bradycardia, Hypotension, Hyperinsulinaemia/euglycaemia therapy

PDF  |  DOI: 10.5005/jp-journals-10071-23181  |  Open Access |  How to cite  | 

Abstract

Treating a patient of amlodipine-atenolol poisoning is nightmare for a physician. In high dose both the drugs individually cause severe bradycardia and hypotension. In combination they cause severe cardiovascular depression. Here we report a case of 66-year-old obese, hypertensive, depressed male, who presented to emergency 9 hours after consumption of 25 tablets of amlodipine-atenolol (5 mg+50 mg). On evaluation, he had refractory bradycardia, hypotension and acute kidney injury (AKI). Eventually he developed cardiac arrest. He was revived after 5 minutes of cardio-pulmonary resuscitation (CPR). He was successfully managed with gastric lavage, fluids, inotropes, atropine, isoprenaline and subsequently with calcium gluconate infusion, high-dose insulin euglycemia therapy (HIET) and lipid emulsion therapy. Glucagon infusion was also planned but it was not available. Patient hemodynamics improved and on 8th day he got the discharge. Our case exemplifies the importance of timely and aggressive management of lethal overdose of amlodipine-atenolol poisoning.

CASE REPORT

Deepak Sharma, Abhishek M Prajapati, Dhruv M Shah

Review of a Case of Paraquat Poisoning in a Tertiary Care Rural-based ICU

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:3] [Pages No:284 - 286]

Keywords: ARDS, Charcoal hemoperfusion, Paraquat poisoning

PDF  |  DOI: 10.5005/jp-journals-10071-23182  |  Open Access |  How to cite  | 

Abstract

Paraquat (1,1\'-dimethyl-4, 4\'-dipyridylium) is a broad-spectrum liquid herbicide associated with both accidental and intentional ingestion leading to severe and often fatal toxicity.1 Paraquat is actively taken up against a concentration gradient into lung tissue leading to pneumonitis and lung fibrosis. Paraquat also causes renal and liver injury.2 There are few case publications of paraquat poisoning and only few of them have reported that renal failure has ensued before acute respiratory distress syndrome (ARDS). Our patient presented with above lethal dose intake of paraquat containing substance and we did gastric lavage followed by charcoal hemoperfusion and hemodialysis but patient could not be saved despite optimum efforts suggesting the high fatality of this kind of poisoning.

LETTER TO THE EDITOR

Ratnesh Kumar Shukla

Colistin for Treatment of Multidrug Resistant Central Nervous System Infection: A Triple Route Therapy!

[Year:2019] [Month:June] [Volume:23] [Number:6] [Pages:1] [Pages No:287 - 287]

PDF  |  DOI: 10.5005/jp-journals-10071-23183  |  Open Access |  How to cite  | 

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