Indian Journal of Critical Care Medicine

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2019 | July | Volume 23 | Issue 7

EDITORIAL

Charles Lynch and His Vestigial Legacy—Workplace Lynching

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:2] [Pages No:289 - 290]

PDF  |  DOI: 10.5005/jp-journals-10071-23199  |  Open Access |  How to cite  | 

EDITORIAL

Sheila Myatra

Improving Hand Hygiene Practices to Reduce CLABSI Rates: Nurses Education Integral for Success

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:3] [Pages No:291 - 293]

PDF  |  DOI: 10.5005/jp-journals-10071-23200  |  Open Access |  How to cite  | 

EDITORIAL

Deeksha Singh Tomar

Septic Shock and Troponin I: Are They in a Relationship?

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:1] [Pages No:294 - 294]

PDF  |  DOI: 10.5005/jp-journals-10071-23201  |  Open Access |  How to cite  | 

Original Article

Kartik Munta, J Raj Kumar, S Manimala Rao, M Dnyaneshwar, Yogesh Harde

A Survey on Workplace Violence Experienced by Critical Care Physicians

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:7] [Pages No:295 - 301]

Keywords: Critical care physicians, Communication, Verbal violence, Workplace violence

PDF  |  DOI: 10.5005/jp-journals-10071-23202  |  Open Access |  How to cite  | 

Abstract

Introduction: Workplace violence (WPV) has been defined as, “violent acts including physical assault and threats of assault directed toward personnel at work or on duty”. Healthcare staff are at highest risk of WPV among the professionals and it is more common among the critical care services. Prevalence of WPV among doctors all over the world is around 56–80% and in Indian scenario, it is around 40.8–75%. There is scarcity of studies on WPV among doctors from India. To our knowledge, this is the first of its kind survey conducted to know about the incidence of WPV amongst critical care physicians in India. Materials and Methods: This survey was conducted after taking due ethical committee clearance amongst critical care physicians attending a critical care conference. The purpose of the study was informed to the participants and a pretested, self-administered, semi-structured questionnaire was distributed among them for their voluntary and anonymous response. Results: Out of 160 delegates who were given the questionnaire, 118 responses were collected and their forms were analyzed. Maximum responses (84%) received were of age group 20–40 years. Seventy-two percent respondents experienced WPV during their work hours. Most common type of violence reported was verbal violence (67%). Sixty-five percent respondents reported that poor communication was the leading cause of WPV. Due to WPV, most of the respondents (60%) had to change their place and pattern of work. Proper communication (76%) was the most common measure among multiple measures suggested by respondents for avoiding WPV. Eighty-three (98%) respondents opined that conflict management should be part of regular curriculum in medical education. Conclusion: Improving the communication skills amongst critical care physicians, teaching doctors about conflict management in their regular curriculum of medical education, spreading awareness in public about patient rights and taking initiatives in propagating an idea to “Fight against the diseases and not against the doctors” are the key measures to combat WPV.

Original Article

Parshotam Lal Gautam, Sarit Sharma, Amandeep Kaur, Neha Bhatia, Gurpreet Singh, Paawanjot Kaur, Anhad Kumar

Questionnaire-based Evaluation of Factors Leading to Patient-physician Distrust and Violence against Healthcare Workers

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:8] [Pages No:302 - 309]

Keywords: Communication, Healthcare workers (HCWs), Patient physician distrust, Workplace Violence (WPV)

PDF  |  DOI: 10.5005/jp-journals-10071-23203  |  Open Access |  How to cite  | 

Abstract

Background: Rising incidents of aggression and violence against healthcare workers (HCWs) is widening the rift between the patients and their caregivers. So, aim of the study was to evaluate the perceptions of healthcare workers (HCWs) and patient\'s attendants about factors responsible for widespread violence and patient-physician distrust. Materials and methods: An anonymous, questionnaire-based, cross-sectional study was conducted over a period of one year in a tertiary care teaching institute. Performas, adapted from WHO published questionnaire and translated to local language, were administered separately to HCWs and attendants. Responses generated were collected and analyzed. Results: Out of 295 HCWs, 11 (3.7%) HCWs faced physical violence, whereas verbal abuse was faced by 147 (50%) HCWs. A higher number of incidents of physical violence (91%) and verbal abuse (64%) were faced by HCWs in the age group of 20-30 years. Verbal abuse was faced by 49.3% of nurses, 53% of junior residents, 61% of senior residents and 36% of consultants. Out of 158 incidents of workplace violence (WPV), maximum occurred in ICUs (62.0%) and emergency (21%). Unexpected death, unexpected complication, extended hospital stay, staff shortage and unexpected bill were some of the factors perceived to be responsible for WPV. Conclusion: HCWs commonly face violence from patient\'s attendants resulting in stressful and fearful environment at the healthcare facility. Dedicated sessions on good communication and counseling for HCWs and better security arrangements at the hospitals are the need of the hour and also in the best interest of HCWs and patients.

Original Article

Catriona Frankling, Jaimin Patel, Ben Sharif, Teresa Melody, Joyce Yeung, Fang Gao, Tamas Szakmany

A Snapshot of Compliance with the Sepsis Six Care Bundle in Two Acute Hospitals in the West Midlands, UK

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:6] [Pages No:310 - 315]

PDF  |  DOI: 10.5005/jp-journals-10071-23204  |  Open Access |  How to cite  | 

Abstract

Background: The sepsis six care bundle has been adopted by hospitals in England and Wales for the management of patients with sepsis, with the aim of increasing survival when all elements of the bundle are achieved. Aim: To assess compliance with the Sepsis Six Care Bundle in two acute NHS hospitals in the West Midlands. Materials and Methods: Adults admitted to hospital over a 24-hour period were screened for sepsis. Sepsis was identified using the Systemic Inflammatory Response (SIRS) criteria and the quick sequential organ failure assessment (qSOFA) score. Adherence to the Sepsis Six Care Bundle was assessed. Results: 249 patients were screened and 24 patients were identified as having sepsis (9.6%). One patient received all six elements of the bundle. Compliance was highest for giving intravenous fluids (58.3%) and antibiotics (58.3%), and lowest for measuring urine output (16.7%). Conclusions: Further research is needed to establish the reasons for low compliance.

Original Article

Ranjita Acharya, Snigdha Ipsita

Impact of Nursing Education on CLABSI Rates: An Experience from a Tertiary Care Hospital in Eastern India

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:4] [Pages No:316 - 319]

Keywords: Central line associated bloodstream infections, hand hygiene

PDF  |  DOI: 10.5005/jp-journals-10071-23205  |  Open Access |  How to cite  | 

Abstract

Background and Aims: Central line associated bloodstream infections (CLABSI) have a higher incidence in the intensive care units of developing countries. Materials and Methods: The baseline CLABSI rate in intensive care unit (ICU) was evaluated for 6 months. An educational program for nurses on basic hand hygiene steps was conducted. Objective assessment tests were done to assess their knowledge and percentage of non-compliance with hand hygiene practice. CLABSI rate over the post-intervention 6 month period was assessed. Results: Thirty-four nurses were enrolled. The pre-intervention CLABSI rate was 12.5 per 1000 catheter days, pretest score15.9 +/- 3.35 and 53.4% opportunities for hand hygiene were missed. Post workshop, there was significant (p=0.02) decrease in CLABSI rate i.e. 8.6, improvement in test score17.76+/-2.1(p=0.011) and missed opportunities decreased to 33.75%. 6 months post intervention, percentage of noncompliance with hand hygiene practice were 51.75% and test score was 17 ± 2. Discussion: The effectiveness of educational program on hand hygiene compliance was reflected in the improvement of posttest score, reduced number of missed opportunities and reduction of CLABSI rates in ICU. The posttest scores and hand hygiene compliance, however, decreased 6 months post-intervention necessitating repeated feedbacks and reminders. Conclusion: Educational interventions on hand hygiene can have a significant impact in CLABSI control particularly in ICUs with a high infection rate and resource constraints.

Original Article

Ali Jendoubi, Salma Jerbi, Elaa Maamar, Ahmed Abbess, Zied Samoud, Lamia Kanzari, Ilhem Boutiba, Salma Ghedira, Mohamed Houissa

Prognostic Value of High-sensitivity Troponin I in Patients with Septic Shock: A Prospective Observational Study

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:6] [Pages No:320 - 325]

Keywords: High-sensitivity cardiac troponin, Mortality, Prognosis, Septic shock

PDF  |  DOI: 10.5005/jp-journals-10071-23206  |  Open Access |  How to cite  | 

Abstract

Background: Myocardial dysfunction is one of the mechanisms involved in the pathophysiology of septic shock. The role of troponin as a surrogate of myocardial injury in septic shock is still debated. The aim of this study was to assess the prognostic value of high-sensitivity cardiac troponin I (hs-cTnI) assay in predicting 28-day mortality in patients with septic shock. Materials and Methods: Prospective study including 75 patients with septic shock admitted to a medico-surgical ICU from January to December 2017. Patients under the age of 18 years, known pregnancy and patients in post–cardiac arrest were excluded. Clinical and demographic data including age, gender, comorbidities, SAPS II and SOFA scores were collected. Hs-cTnI was measured soon after admission and 12, 24, 48 and 72 after. Receiver operating characteristic (ROC) analysis was performed to identify the most useful troponin I cut-off level for the prediction of 28-day mortality. A p <0.05 was considered significant. Results: Seventy-five (M/F = 53/22) patients with septic shock were included in the study. The median SOFA and SAPS II scores were 10 and 42, respectively. The median duration of mechanical ventilation was 8 days and the median length of ICU stay was 11 days. The 28-day mortality was 54.6%. We found a high prevalence (47%) of elevated hs-cTnI in patients with septic shock. Median hs-cTnI on admission in the whole group was 36 ng/L. The 28-day mortality was found to be related to age (p <0.001), SAPS II score (p = 0.001), mean arterial pressure (p = 0.038), lactate (p <0.001) and glomerular filtration rate (p <0.001). Hs-cTnI levels were significantly higher in non-survival group than survival one at all time points: H12 (p = 0.006), H24 (p = 0.003), H48 (p = 0.005) and H72 (p=0.001). In multivariate analysis, hs-cTnI at H72 was independently associated with 28-day mortality. Conclusion: Hs-cTnI elevation at 72 hours was associated with 28-day mortality in septic shock patients.

RESEARCH ARTICLE

Manohar NM Bhat, Ramesh Venkatraman, Senthilkumar Rajagopalan

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

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:3] [Pages No:326 - 328]

Keywords: Central venous cannulation, CLABSI, Internal jugular vein (IJV), Sonography, Thrombosis

PDF  |  DOI: 10.5005/jp-journals-10071-23207  |  Open Access |  How to cite  | 

Abstract

Background and Aims: Internal jugular vein (IJV) cannulation is a common procedure in the ICU with thrombosis being an uncommon, albeit serious complication. Thrombosis is one of the important complications of IJV cannulation. This study aims to evaluate the use of ultrasound screening by intensivists to assess the incidence of catheter-related IJV thrombosis in ICU. Materials and Methods: Fifty consecutive IJV cannulations meeting the inclusion criteria were analyzed in the ICU. Duplex scanning and color doppler sonography were performed by the intensivist on day 3, 6, 9, 12 and 15 after cannulation. The thrombus, when detected, was confirmed independently by a radiologist. The patient demographics, the type of catheter, laterality and the mean duration of catheterization were recorded. Risk factors like presence of circulatory shock, thrombocytosis, DIC, liver disease, and absence of chemoprophylaxis for DVT were documented. Results: A total of 39 patients and 50 cannulations were studied. The mean age of patients was 56.5±16.2 years and mean duration of catheterization was 6.6±2.1 days. We found a 38% (19/50) incidence of thrombosis in our study. There was 100% correlation in detection of thrombosis by the intensivist and the radiologist. The thrombus was detected at 6.9±2.1 days after cannulation. All the patients who developed thrombosis had one or more risk factors. The most common risk factor was circulatory shock (40%). Central line associated blood stream infection (CLABSI) was seen only in the patients in whom IJV thrombus was detected (5/19). Conclusion: Catheter-related IJV thrombosis is a frequent complication in ICU patients and is associated with the increased risk of CLABSI. Ultrasound screening is simple, feasible and accurate in diagnosing IJV thrombosis.

REVIEW ARTICLE

Karen Ruby Lionel

Head Rules Over the Heart: Cardiac Manifestations of Cerebral Disorders

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:7] [Pages No:329 - 335]

Keywords: Neurocardiac axis, Neurocardiology, Neurological disorders

PDF  |  DOI: 10.5005/jp-journals-10071-23208  |  Open Access |  How to cite  | 

Abstract

The Brain-Heart interaction is becoming increasingly important as the underlying pathophysiological mechanisms become better understood. “Neurocardiology” is a new field which explores the pathophysiological interplay of the brain and cardiovascular systems. Brain-heart cross-talk presents as a result of direct stimulation of some areas of the brain, leading to a sympathetic or parasympathetic response or it may present as a result of a neuroendocrine response attributing to a clinical picture of a sympathetic storm. It manifests as cardiac rhythm disturbances, hemodynamic perturbations and in the worst scenarios as cardiac failure and death. Brain-Heart interaction (BHI) is most commonly encountered in traumatic brain injury and subarachnoid hemorrhage presenting as dramatic electrocardiographic changes, neurogenic stunned myocardium or even as ventricular fibrillation. A well-known example of BHI is the panic disorders and emotional stress resulting in Tako-tsubo syndrome giving rise to supraventricular and ventricular tachycardias and transient left ventricular dysfunction. In this review article, we will discuss cardiovascular changes caused due to the disorders of specific brain regions such as the insular cortex, brainstem, prefrontal cortex, hippocampus and the hypothalamus; neuro-cardiac reflexes namely the Cushing\'s reflex, the Trigemino-cardiac reflex and the Vagal reflex; and other pathological states such as neurogenic stunned myocardium /Takotsubo cardiomyopathy. There is a growing interest among intensivists and anesthesiologists in brain heart interactions as there are an increasing number of cases being reported and there is a need to address unanswered questions, such as the incidence of these interactions, the multifactorial pathogenesis, individual susceptibility, the role of medications, and optimal management. Key Messages: BHI contribute in a significant way to the morbidity and mortality of neurological conditions such as traumatic brain injury, subarachnoid hemorrhage, cerebral infarction and status epilepticus. Constant vigilance and a high index of suspicion have to be exercised by clinicians to avoid misdiagnosis or delayed recognition. The entire clinical team involved in patient care should be aware of brain heart interaction to recognize these potentially life-threatening scenarios.

BRIEF COMMUNICATION

Rema Menon, Ramesh Venkatraman, Pratheema Ramachandran

Therapeutic Plasma Exchange Practices in Intensive Care Unit

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:3] [Pages No:336 - 338]

Keywords: Apheresis, Crystalloids, Plasma, Plasmapheresis, Therapeutic plasma exchange

PDF  |  DOI: 10.5005/jp-journals-10071-23209  |  Open Access |  How to cite  | 

Abstract

Objective: To observe the indications, practices and outcome of therapeutic plasma exchange (TPE) in a tertiary care ICU. Materials and Methods: The study involves retrospective analysis of 56 patients who underwent TPE between May 2011 and August 2013. Data relating to demographics, diagnosis, category of indication, number of sessions, volume and type of replacement solutions were collected. Results: Category I indications were 50%, with a mean of 3.32 sessions per patient. Per session volume exchanged was 9775.1 ± 11812.9 mL and replacement volume was 7414 ± 6993.03 mL. Fresh frozen plasma (FFP), crystalloids, cryopoorplasma and PRBC constituted 62.9%, 22%, 9.9% and 5.3% of volume replacement, respectively. TPE was terminated in three patients for Transfusion Associated Acute Lung Injury (TRALI), hypotension and cardiac arrest respectively. Clinical improvement was noted in 82% of patients and overall mortality rate was 12.5%. Conclusion: TPE is feasible and well tolerated in ICU with favorable disease resolution and outcome. Common indications included sickle cell and myasthenia crisis and blood products were the most commonly used for volume replacement.

CASE REPORT

Parag Shankarrao Dekate, Satyanarayana Reddy, VSV Prasad, Sudha Boda, Lokesh Saini, Prashant Patil

An Uncommon Cause of Hypertensive Urgency in Young Adolescent: Case Report

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:3] [Pages No:339 - 341]

Keywords: Angiography, Anti-hypertensive, Mid aortic syndrome, Percutaneous dilatation

PDF  |  DOI: 10.5005/jp-journals-10071-23210  |  Open Access |  How to cite  | 

Abstract

Mid aortic syndrome is rare cause of hypertensive urgency in children with poor outcome if left untreated, high index of suspicion with prompt management is the key to survival with good outcome. A 12-year-old boy was presented with fever, puffiness of face, and breathing difficulty. Clinically, he had hypertension with differential pulsation and BP in upper and lower limbs. He had peak systolic gradient of 80 mm Hg between upper and lower limb. His echocardiography and CT angiography was suggestive of significant isolated 80% narrowing of abdominal aorta without involvement any other large vessels. Percutaneous balloon dilatation of aorta was done considering multiple parameters. Post procedure, there was significant improvement in BP and we could wean his multiple anti-hypertensive drugs to keep his blood pressures below 95th centile. His BP remained control with minimum upper and lower limb gradient on follow up of almost 1 year. Key message: Mid aortic syndrome is most uncommon amongst them. With prompt diagnosis and proper selection of therapeutic options like balloon dilatation or surgical correction, it has good prognosis. Aortic narrowing because of different diseases is an uncommon cause of HT urgency in children.

CASE REPORT

Florence Benita, Sambathkumar Sasikumar

5-oxoprolinuria (Pyroglutamic Aciduria) and Metabolic Acidosis: Unraveling the Mystery

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:2] [Pages No:342 - 343]

Keywords: 5-oxoprolinuria, Metabolic acidosis, N-acetyl cysteine, Paracetamol therapy, Recovery, Risk/precipitating factors

PDF  |  DOI: 10.5005/jp-journals-10071-23211  |  Open Access |  How to cite  | 

Abstract

A case of high anion gap metabolic acidosis (HAGMA) and high level of 5-oxoprolinuria were noticed in an elderly female of 66 years who had multiple risk/precipitating factors and recovered well with N-acetyl cysteine infusion. This is reported in view of its rarity and to create awareness of this entity among medical students and practicing physicians who handles such cases in emergency room or critical care unit. Moreover they have to remember and investigate the cases of metabolic acidosis for 5-oxoprolinuia especially in susceptible individuals who are on paracetamol with or without other precipitating factors.

LETTER TO THE EDITOR

Aiko Tanaka, Tomonori Yamashita, Yukiko Koyama, Akinori Uchiyama, Yuji Fujino

Predictors of Successful Extubation in Reintubated Patients: The Impact of Fluid Balance during the 24 Hours Prior to Extubation

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:2] [Pages No:344 - 345]

PDF  |  DOI: 10.5005/jp-journals-10071-23212  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Shreya Das Adhikari, Raunaq Chakraborty, Mohammad Shoaib Budoo

An Elementary Cause of Anisocoria in Intensive Care Unit

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:1] [Pages No:346 - 346]

PDF  |  DOI: 10.5005/jp-journals-10071-23213  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Niraj Kumar Keyal, Raju Shrestha, Sumal Thapa, Pooja Adhikari

Krait Snake Bite Presenting as a Cerebral Salt Wasting

[Year:2019] [Month:July] [Volume:23] [Number:7] [Pages:2] [Pages No:347 - 348]

PDF  |  DOI: 10.5005/jp-journals-10071-23214  |  Open Access |  How to cite  | 

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