Indian Journal of Critical Care Medicine

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2019 | August | Volume 23 | Issue 8

EDITORIAL

Uma Ali

The Burden of Acute Kidney Injury in Indian Pediatric Intensive Care Units

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:1] [Pages No:349 - 349]

PDF  |  DOI: 10.5005/jp-journals-10071-23215  |  Open Access |  How to cite  | 

EDITORIAL

Glutamine Supplementation: The Pendulum Keeps on Swinging

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:2] [Pages No:350 - 351]

PDF  |  DOI: 10.5005/jp-journals-10071-23216  |  Open Access |  How to cite  | 

Original Article

Ashwini Bharat, Anita Mehta, Harish Chandra Tiwari, Bhupendra Sharma

Spectrum and Immediate Outcome of Acute Kidney Injury in a Pediatric Intensive Care Unit: A Snapshot Study from Indian Subcontinent

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:4] [Pages No:352 - 355]

Keywords: Acute kidney injury (AKI), Pediatric intensive care unit (PICU), pRIFLE, Viral encephalitis, Scrub typhus

PDF  |  DOI: 10.5005/jp-journals-10071-23217  |  Open Access |  How to cite  | 

Abstract

Background and aims: Acute kidney injury (AKI) became an important cause of mortality and morbidity in critically ill children, despite advancement in its management. In developing countries etiology of AKI are different from that of developed countries. Materials and methods: This observational study was carried out in pediatric intensive care unit (PICU) in 2 months to 18 years of critically ill children. Kidney injury was defined and categorized by the pRIFLE criteria. Results: Out of 361children, 86 children (23.8%) developed AKI at some point during admission, 275 children (age and sex matched) who did not develop kidney injury during hospitalization served as non-AKI children. Maximum cases of AKI were seen in 1–5 years of age. Maximum children of AKI were of viral encephalitis (n = 43, 50.0%) followed by scrub typhus (n = 14, 16.3%). Risk factors for the development of AKI were shock, PRISM score and longer hospital stay. In our study the mortality in AKI children (n = 30, 34.8%) was significantly higher (p = 0.005) as compared to non-AKI children (n = 56, 20.3%)). Duration on mechanical ventilation, PICU stay and hospital stay were also significantly (p = 0.001) higher in AKI children. Conclusion: AKI is common in critically ill children and associated with high mortality and morbidity.

Original Article

Zahra Vahdat Shariatpanahi, Ghazaleh Eslamian, Seyed Hossein Ardehali, Ahmad-Reza Baghestani

Effects of Early Enteral Glutamine Supplementation on Intestinal Permeability in Critically Ill Patients

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:7] [Pages No:356 - 362]

Keywords: Antiendotoxin immunoglobulin, Endotoxin, Enteral nutrition, Glutamine, Zonulin

PDF  |  DOI: 10.5005/jp-journals-10071-23218  |  Open Access |  How to cite  | 

Abstract

Background and aims: Enteral administration of glutamine has been proposed as an effective recovery of intestinal barrier function. This amino acid has a modulating effect on the reducing bacterial translocation, which can influence immune functions of the intestine. The objective was to evaluate the effects of early enteral glutamine supplementation on intestinal permeability in critically ill patients. Materials and methods: A total of 80 critically ill patients older than 18 years were randomly assigned to one of two groups according to the stratified blocked randomization by age and admission category. Consecutive participants took enteral formula plus 0.3 g/kg/day glutamine powder or enteral formula plus maltodextrin during the ICU stay for a maximum of 10 days. Plasma glutamine, endotoxin, zonulin, and antiendotoxin immunoglobulin (Ig)G/IgM concentrations were measured on days 5 and 10 of intervention. Results: Out of 80 participants, 36 patients in the glutamine group and 34 patients in the control group were included in the analysis of the outcomes. Enteral glutamine significantly reduced plasma zonulin concentration up to 40% during 10 days. This reduction was significantly greater compared with that of the placebo group (P<0.001). Endotoxin concentration decreased in both groups; this reduction was significantly greater in the glutamine group (p = 0.014). The antiendotoxin IgM and IgG antibody levels increased in the glutamine group but decreased in the control group (p <0.001). There were no significant differences in clinical outcomes between two groups. Conclusion: Early enteral glutamine supplementation led to a declined intestinal permeability in critically ill patients.

Original Article

Gurmeet S Chabbra, Sandip Bhattacharya

Noninvasive Ventilation-assisted Bronchoscopy in High-risk Hypoxemic Patients

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:5] [Pages No:363 - 367]

Keywords: Bronchoscopy, FOB, NIV, Noninvasive ventilation, Respiratory failure

PDF  |  DOI: 10.5005/jp-journals-10071-23219  |  Open Access |  How to cite  | 

Abstract

Background and aims: Hypoxemic patients undergoing fiber-optic bronchoscopy (FOB) are at risk of worsening of respiratory failure requiring mechanical ventilation due to FOB procedure itself and its complications. As patients with respiratory failure are frequently managed by non-invasive ventilation (NIV); feasibility of FOB through NIV mask has been evaluated in some studies to avoid intubation. We describe here our own case series. Materials and methods: Clinical data of 28 FOB done through NIV mask in 27 intensive care unit (ICU) patients over 6 years period at our center was collected retrospectively and analysed. Results: Study comprises 27 (17 male; 52±21.6 years age) hypoxemic (PaO2 71.3±14.2, on NIV and oxygen supplementation) patients. All FOB were done at bedside, 15 of them were given sedation for the procedure. Twenty four patients had bronchoalveolar lavage (BAL); three underwent bronchial biopsies, four brush cytology and seven transbronchial biopsies. In 10 patients lung or lobar collapse was reversed. There was no significant change between pre and post bronchoscopy ABG parameters except for improved post FOB PaO2 (p = 0.0032) and SpO2 (p = 0.0046). One patient (3.57%) developed late pneumothorax and 3 patients (10.7%) had bleeding after biopsy. Prior to bronchoscopy 17 (16 BIPAP, 1 CPAP) patients were already on NIV. Two patients required mechanical ventilation 6 hours after FOB due to subsequent clinical deterioration but could be weaned off later. One patient died on third day after FOB from acute myocardial infarction. Conclusion: Hypoxemic patients in ICU can safely undergo bedside diagnostic and simple therapeutic bronchoscopy with NIV support while mostly avoiding intubation and with low complication rates.

COMMENTARY

Sunil Shroff

Redefining Death: Urgent Need to Evolve toward a Homogeneous Definition of Death in India

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:3] [Pages No:368 - 370]

Keywords: Brainstem death, Circulatory-respiratory criteria for death, Defining death, Ethical issues, Legal issues

PDF  |  DOI: 10.5005/jp-journals-10071-23220  |  Open Access |  How to cite  | 

Abstract

The interdependent circulatory-respiratory criteria and brainstem criteria are used to define death. Continuing life-support in brainstem dead patients is a legal conundrum for the health-care professionals and an ethical worry for the society at large. There is an urgent need to revisit this subject to evolve a more uniform definition of death irrespective of the circumstances. A compelling take-home message from this discussion is to spread awareness about brainstem death amongst healthcare professionals

COMMENTARY

Manoj Kumar Sahu, Bipin C, Yatin Arora, Sarvesh Pal Singh, V Devagouru, P Rajshekar, Shiv Kumar Chaudhary

Peritoneal Dialysis in Pediatric Postoperative Cardiac Surgical Patients

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:5] [Pages No:371 - 375]

Keywords: Cardiopulmonary bypass, Pediatric cardiac surgery, Peritoneal dialysis, Postoperative period

PDF  |  DOI: 10.5005/jp-journals-10071-23221  |  Open Access |  How to cite  | 

Abstract

Background: We determined the prevalence of acute kidney injury requiring peritoneal dialysis (PD), the factors associated with early PD initiation, prolonged PD and mortality among pediatric postoperative cardiac surgical patients. Materials and Methods: The hospital records of 23 children, aged 12 years or younger, who had undergone cardiac surgery and required PD subsequently, during a 1-year period were reviewed. Demographic data, intraoperative variables, and postoperative complications were compared between survivors and nonsurvivors of PD, between the short and long duration PD groups, and between the early and late PD initiation groups. Results: Six hundred and eight pediatric patients who underwent open heart surgery were enrolled in this study. 23 (3.78%) of them required PD. When compared with survivors (n = 11), non survivors (n =12) were more likely to have a higher serum procalcitonin (p = 0.01), higher serum potassium on day 2 (p = 0.001), day 3 (p = 0.04), day of termination of PD (p = 0.001) and a lower urine output on day 3 of PD (p = 0.03). Prolonged PD was associated with time of PD initiation (p = 0.01), a higher postoperative serum creatinine on day 3 (p = 0.01) of PD initiation as well on the day of PD termination (p = 0.01) and the final outcome in terms of survival (p = 0.02). Factors significantly associated with an early PD initiation were CPB time (p = 0.04), sepsis (p = 0.02) and shorter PD duration (p = 0.003). Conclusion: PD is very useful mode of renal replacement therapy among pediatric postoperative cardiac surgical patients. The intraoperative and postoperative variables have important association with the time of PD initiation, PD duration and patient survival.

CASE REPORT

Swati Jindal, Satinder Gombar

Serotonin Syndrome in ICU—A Road Less Traveled

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:2] [Pages No:376 - 377]

Keywords: Agitation, ICU, SSRI, Serotonin syndrome

PDF  |  DOI: 10.5005/jp-journals-10071-23222  |  Open Access |  How to cite  | 

Abstract

A potentially life-threatening adverse drug reaction, serotonin syndrome (SS) may occur in patients on serotonin agonist medications. Medications responsible for SS include commonly prescribed antidepressants, anxiolytics, analgesics and antiemetics. This syndrome has been mentioned in various scenarios in perioperative setting but rarely acknowledged in intensive care unit (ICU) setting. Multiple comorbities leading to polypharmacy and serotoninergic medications place elderly patients, particularly at higher risk of SS. We wish to report a case of SS in an elderly male with depression who developed SS and required ICU admission. Most crucial point is to be able to recognize this entity whenever a patient on multiple drugs with altered sensorium is admitted to ICU.

CASE REPORT

Sailaja Kambhampati, K Lavanya

An Unusual Cause of Failed Tracheal Decannulation—A Case Report

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:2] [Pages No:378 - 379]

Keywords: Decannulation, Failure, Membrane, Vocal cords, Weaning

PDF  |  DOI: 10.5005/jp-journals-10071-23223  |  Open Access |  How to cite  | 

Abstract

Failure of decannulation may occur due to unexpected upper airway problems. However, the presence of a membrane in between the vocal cords is usually rare. We report a case of a 46-year-old female, who presented with focal seizures and progressed to status epilepticus. She was put on a mechanical ventilator because of hypoxic arrest. As she required prolonged ventilatory support, tracheostomy and gradual weaning from ventilator support to T-piece was done. Following stable hemodynamics, decannulation trial was attempted which failed. Subsequently, bronchoscopy was done to assess the upper airway. It revealed a thick membrane in between the vocal cords. Further examination with an indirect laryngoscope under general anesthesia confirmed the findings, and the membrance was excised. Decannulation was successful the very following day and the patient was discharged with stable hemodynamics.

CASE REPORT

Niraj Kumar Keyal, Sumal Thapa, Manoj Kumar Yadav

Carbimazole-induced Anaphylactic Shock: A Case Report

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:2] [Pages No:380 - 381]

Keywords: Anaphylactic shock, carbimazole, hyperthyroidism

PDF  |  DOI: 10.5005/jp-journals-10071-23224  |  Open Access |  How to cite  | 

Abstract

Carbimazole is an antithyroid drug that rarely presents as anaphylactic shock. We hereby report a case of 40-year-old female who was treated with carbimazole for thyrotoxicosis. Patient developed sweating, shortness of breath and altered sensorium after taking single dose of carbimazole. Patient was treated for anaphylactic shock. From this, we want to emphasize that carbimazole can rarely present as anaphylactic shock without any other allergic manifestation. So, patient should be counselled about this rare side effect and early approach to health care facility.

CASE REPORT

Praveen K Malik

Guidewire Mishap: An Avoidable Iatrogenic Complication

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:2] [Pages No:382 - 383]

Keywords: Central venous catheterization, Guidewire, Hemodialysis

PDF  |  DOI: 10.5005/jp-journals-10071-23225  |  Open Access |  How to cite  | 

Abstract

Central vein catheterization is a commonly used technique in indoor patients. It is mainly used for venous access, allowing administration of drugs, fluids, chemotherapy, blood components. Central vein catheterisation may lead to many complication which includes bleeding, perforation of veins and hematoma formation, thrombosis, infections, bleeding, needle stick injury, air embolism, kinking or looping of the wire tip, breakage of a guidewire, etc. We, hereby, report a case where the guidewire was lost during femoral venous catherisation. A whole guidewire embolization is completely preventable complication. It may not necessarily produce any symptoms and may remain unnoticed for long time.

CASE REPORT

Nishant Chauhan

A Rare Case of Neurogenic Pulmonary Edema Following High-voltage Electrical Injury

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:3] [Pages No:384 - 386]

Keywords: Electric shock, Lung ultrasound score, Pulmonary edema

PDF  |  DOI: 10.5005/jp-journals-10071-23226  |  Open Access |  How to cite  | 

Abstract

Electrical injuries though infrequent, are potentially devastating form of injuries which are associated with high morbidity and mortality. The severity of the injury depends upon intensity of the electrical current which is determined by the voltage and the resistance offered by the victim. These injuries vary from trivial burns to death. There have been few reports about pulmonary injuries due to electrical current but none mentioning neurogenic pulmonary edema (NPE). Here we report a young boy who when exposed to high voltage current developed neurogenic pulmonary edema and was successfully managed. Though there is no specific protocol for electrical injury but identifying the organs involved along with type of disease facilitates the management.

LETTER TO THE EDITOR

Ramesh Venkatraman

Critical Care Registries: The Next Big Stride?

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:1] [Pages No:387 - 387]

PDF  |  DOI: 10.5005/jp-journals-10071-23227  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

MK Manu Varma

Between Many Rocks and Hard Places

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:1] [Pages No:388 - 388]

PDF  |  DOI: 10.5005/jp-journals-10071-23228  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Summit Dev Bloria, Pallavi Bloria

Inflation Lines of Endotracheal Tubes: How Long Should It Be?

[Year:2019] [Month:August] [Volume:23] [Number:8] [Pages:1] [Pages No:389 - 389]

PDF  |  DOI: 10.5005/jp-journals-10071-23229  |  Open Access |  How to cite  | 

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