Indian Journal of Critical Care Medicine

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2020 | February | Volume 24 | Issue 2

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Aditya Kapoor

Is Sepsis a Cardiac Nemesis? Exploring New Vistas

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:2] [Pages No:83 - 84]

   DOI: 10.5005/jp-journals-10071-23319  |  Open Access |  How to cite  | 



Percutaneous Tracheostomy in Coagulopathic Patients: Proceed with Caution

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:3] [Pages No:85 - 87]

   DOI: 10.5005/jp-journals-10071-23360  |  Open Access |  How to cite  | 



Shilpushp Bhosale

Is A Problem Shared, A Problem Halved? Not Always! The Novel Coronavirus COVID-19 Outbreak

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:2] [Pages No:88 - 89]

   DOI: 10.5005/jp-journals-10071-23365  |  Open Access |  How to cite  | 


Original Article

Sachin P Sasane, Madhavi M Telang, Zeyad F Alrais, Ali HNS Alrahma

Percutaneous Tracheostomy in Patients at High Risk of Bleeding Complications: A Retrospective Single-center Experience

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:5] [Pages No:90 - 94]

Keywords: Bleeding complications, Intensive care, Percutaneous dilatational tracheostomy

   DOI: 10.5005/jp-journals-10071-23341  |  Open Access |  How to cite  | 


Aims: To study the bleeding complications in patients undergoing percutaneous tracheostomy and who are at high risk of these complications (due to thrombocytopenia, use of anticoagulant or antiplatelet agents, and difficult anatomy). Materials and methods: A retrospective study was undertaken, which included all patients undergoing percutaneous tracheostomy in the medical intensive care unit (MICU) of Rashid Hospital, Dubai, over a period of 15 months. Percutaneous tracheostomy was performed by senior medical intensivists using the single-tapered dilator technique under fiber optic bronchoscopic guidance. All patients underwent ultrasonographic evaluation of the neck to look for difficult anatomy and to determine the size of tracheostomy tube, etc. Patients were divided into two groups, those who were deemed to be at high risk of bleeding complications were compared with patients without any risk factors for bleeding complications. Other complications such as pneumothorax and tracheal leak were also looked for and were documented, if present. The data were summarized using descriptive statistics and the Fischer's exact test of significance was used for frequency distribution cross tables, at 5% level of significance (p value cutoff <0.05). Results: One hundred and fifty-nine patients underwent percutaneous tracheostomy during the period of study. The age-group of patients ranged from 21 years to 104 years and males were predominant (65.41%). Of the 87 (54.71%) patients with one or more risk factors for bleeding, 53 (60.92%) patients had at least one risk factor for bleeding complications, while 34 (39.08%) had more than one risk factors. Bleeding was seen in total of two patients out of which one patient was in the group at risk of bleeding complications. Conclusion: Percutaneous tracheostomy is a relatively safe procedure with very low rate of complications when performed with due precautions. Even in patients deemed to be at high risk of complications, the rate of complications is very low.


Original Article

Sunil Nanjarapalle, Aloka Samantaray, Sivakumar Vishnubhotla

Red Cell Distribution Width as a Severity Marker on the Outcome of Patients with Acute Kidney Injury on Renal Replacement Therapy

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:4] [Pages No:95 - 98]

Keywords: Acute kidney injury, Disease severity, Hospital mortality

   DOI: 10.5005/jp-journals-10071-23342  |  Open Access |  How to cite  | 


Background: Acute kidney injury (AKI) requiring dialysis is associated with high mortality and morbidity. Red blood cell distribution width (RDW) has been shown as a predictor of mortality in different subsets of patients admitted to intensive care unit (ICU). This study compares the predictive ability of RDW and other severity illness prognostic models on 30 days mortality in adult patients admitted to ICUs with AKI necessitating dialysis. Materials and methods: Thirty patients were evaluated using five different prognostic scoring models. Sequential organ failure assessment (SOFA) score, acute tubular necrosis-individual severity index (ATN-ISI), version II of acute physiology and chronic health evaluation (APACHE II), vasoactive-inotropic score (VIS), version II of simplified acute physiology score (SAPS II), and RDW as a marker were used to prognosticate the severity of illness. The scores were calculated using the values of clinical and laboratory parameters at the time of admission. Results: The prognostic abilities of the scores were compared for their discriminatory power using receiver-operating characteristic (ROC) curves. The area under the ROC curve (AROC) of RDW was 0.904, SOFA score was 0.828, ATN-ISI was 0.743, SAPS was 0.857, and APACHE II score was 0.828. Vasoactive-inotropic score has the lowest discriminatory power with AROC of 0.487. Red blood cell distribution width has a strong and significant correlation with APACHE II and SOFA scores and a weak relation with ATN-ISI score and SAPS II. Conclusion: Red blood cell distribution width has a better predictive ability than other disease severity scoring systems to predict mortality in an adult AKI patient admitted to ICU with need for renal replacement therapy (RRT).


Original Article

Rudrarpan Chatterjee, Nitesh Parab, Basavaraj Sajjan, Vidya S Nagar

Comparison of Acute Physiology and Chronic Health Evaluation II, Modified Computed Tomography Severity Index, and Bedside Index for Severity in Acute Pancreatitis Score in Predicting the Severity of Acute Pancreatitis

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:5] [Pages No:99 - 103]

Keywords: Acute pancreatitis, Acute physiology and chronic health evaluation II, Atlanta classification, Bedside index for severity in acute pancreatitis, Computed tomography severity index

   DOI: 10.5005/jp-journals-10071-23343  |  Open Access |  How to cite  | 


Aims of this study: Severe acute pancreatitis has been defined recently based on the persistence of organ failure at 48 hours of admission. The bedside index for severity in acute pancreatitis (BISAP) score, a simplified scoring system to predict severity of acute pancreatitis, is proposed to be useful in early risk stratification of acute pancreatitis. Our aim was to prospectively compare BISAP score with the already established acute physiology and chronic health evaluation II (APACHE II) and modified computed tomography severity index (CTSI) scores in predicting the severity of acute pancreatitis. Materials and methods: A total of 87 consecutive cases presenting with the first attack of acute pancreatitis were included in the study. Acute physiology and chronic health evaluation II and BISAP scores were calculated from the worst parameters in the first 24 hours, and modified CTSI was reported at 48 hours of admission. Receiver-operating characteristic (ROC) curves were plotted, and predictive accuracy of each score was calculated from the area under the curve. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each score. Results: A total of 20 patients (23%) had severe acute pancreatitis with a total of 11 mortalities (12.64%), 10 of them in the severe acute pancreatitis group. Acute physiology and chronic health evaluation II, modified CTSI, and BISAP score all correlated well with each other. Modified CTSI and BISAP score also correlated with duration of hospital stay. Areas under the curve for APACHE II (≥8), modified CTSI (≥8), and BISAP score (≥2) were 0.826, 0.806, and 0.811, respectively, suggesting similar predictive accuracy. Conclusion: The BISAP score was similar to APACHE II and modified CTSI in terms of accuracy, sensitivity, specificity, and NPV. It is much easier to calculate and a useful risk stratification tool. It should be used for early triage and referral to a high dependency unit.


Original Article

Umeshkumar Athiraman, Rene Tempelhoff, Menelaos Karanikolas

Effects of Hypoxic and Ischemic Clinical Conditions on the Outcomes of Acute Ischemic Stroke Patients

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:5] [Pages No:104 - 108]

Keywords: Acute ischemic stroke, Hypoxic conditioning, Ischemic conditioning

   DOI: 10.5005/jp-journals-10071-23349  |  Open Access |  How to cite  | 


Background: Several studies have shown the neuroprotective role afforded by hypoxic and ischemic preconditioning in cerebrovascular disorders. There are several clinical conditions which simulate the hypoxic and ischemic conditioning in humans. The aim of this retrospective study is to identify whether the presence of any clinical scenarios mimicking the hypoxic and ischemic conditions prior to the current acute ischemic stroke (AIS) has a neuroprotective role in these patients. Materials and methods: Data were collected for patients >18 years of age who underwent endovascular treatment for AIS from January 2009 to June 2015. A good outcome was defined as modified Rankin score (mRS) of 0 to 3 at discharge and a poor outcome as mRS of 4–6. A logistic regression analysis was performed to identify independent predictors of outcomes at discharge in both groups. A p value of <0.05 was considered statistically significant for all analyses. Results: A total of 102 patients, aged 67 ± 16 years with median preprocedural National Institute of Health Stroke Scale (NIHSS) score 17.5 (1–36), were included. Twenty-one (21%) patients had a good outcome (mRS: 0–3) and 81 (79%) had a poor outcome (mRS: 4–6). A logistic regression analysis identified higher NIHSS score [odds ratio (OR): 1.251, confidence interval (CI): 1.11–1.40, p = 0.0002] and history of transient ischemic attack (TIA; OR: 7.881, CI: 1.05–21.01, p < 0.04) as predictors of a poor outcome at discharge. Conclusion: Our data suggest that the occurrence of TIA preceding an AIS may be associated with the poor outcomes in patients with AIS, although this finding needs confirmation in larger studies.


Original Article

Geddam Deepthi, Praveen Kumar-M

Longitudinal Study of CPK-MB and Echocardiographic Measures of Myocardial Dysfunction in Pediatric Sepsis: Are Patients with Shock Different from Those without?

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:7] [Pages No:109 - 115]

Keywords: Cardiac biomarkers, Creatine kinase-MB, Echocardiography, Myocardial dysfunction, Sepsis, Septic shock

   DOI: 10.5005/jp-journals-10071-23340  |  Open Access |  How to cite  | 


Background: Sepsis-induced myocardial dysfunction has implications on outcome. For lack of echocardiography in resource-limited settings, myocardial biomarkers may be an alternative monitoring tool. Objective: This study was planned to explore the longitudinal behavior of creatine phosphokinase-MB (CPK-MB) in children with sepsis with and without shock, and its correlation with clinical and echocardiographic parameters over the first 10 days. Design: Prospective observational study. Setting: Tertiary care hospital in a lower-middle-income economy of South Asia. Patients: Children (3 months to 12 years) with nonshock sepsis (NSS) (n = 40) and septic shock survivors (SSSs) (n = 40) after optimal resuscitation. Patients with catecholamine refractory shock, preexisting heart disease, and cardiorespiratory event within the past 1 month were excluded from the study. Measurements and main results: Pediatric logistic organ dysfunction (PeLOD) score, vasoactive inotrope score (VIS), CPK-MB, and echocardiographic measures of myocardial function were recorded on days 1, 3, 7, and 10. Echocardiography was repeated at 1 month. Both groups were similar at baseline. The SSSs had higher CPK-MB (180 vs 53 IU/L; p < 0.001) and PeLOD score (2 ± 0.4 vs 11.7 ± 5.1, p < 0.001) on day 1 compared to the NSS children. More than half of the SSS and none of the NSS patients had myocardial dysfunction. Reduction in CPK-MB over 10 days correlated well with improvement in PeLOD (p < 0.01), VIS (p = 0.04), and echocardiographic measures of myocardial dysfunction (p < 0.05) among SSSs. At 1 month follow-up, all had normal echocardiography. Conclusion: The SSSs had markedly elevated CPK-MB, and its fall paralleled the improvement in clinical status and myocardial dysfunctions. The CPK-MB could be a potential monitoring tool for septic cardiomyopathy in resource-limited settings.


Original Article

Justor Banda, Natasha Chenga, Suwilanji Nambaya, Tela Bulaya, Seter Siziya

Predictors of Acute Kidney Injury and Mortality in Intensive Care Unit at a Teaching Tertiary Hospital_ID

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:6] [Pages No:116 - 121]

Keywords: Acute kidney injury, Intensive care unit, Mortality, Predictors

   DOI: 10.5005/jp-journals-10071-23352  |  Open Access |  How to cite  | 


Background and aims: Despite the increased rates of acute kidney injury (AKI) in intensive care units (ICU) and associated mortality, information on the epidemiology of AKI is sparse in sub-Saharan Africa (SSA). We investigated the rates and predictors of AKI and associated mortality in a tertiary ICU. Materials and methods: This retrospective study analyzed 280 hospital records of patients admitted to the ICU at a tertiary teaching hospital who were aged ≥15 years from January 2017 to May 31, 2018. The outcome parameters of the study were rates of AKI in the ICU, associated risk factors, and mortalities. Acute kidney injury and ICU mortality were established by the multivariate logistic analysis. Results: The median age was 36 years (IQR 28, 52). The rate of AKI was 52.9%, and the presence of human immunodeficiency virus (HIV) and oliguria was 2.3-fold (0.004) and 4-fold (0.016) positive predictors of ICU-AKI, respectively. Male gender (0.003), diabetes mellitus (DM) (0.010), respiratory disease (0.001), inotropes (0.004), and ventilator support (0.017) were predictors for ICU mortality after controlling for confounders. Conclusion: The rate of AKI is significantly higher in a referral tertiary hospital in Zambia compared to developed countries and the presence of HIV and noncommunicable diseases such as DM impacts severely on outcomes.



Sweta J Patel, KN Jagadeesh, Mozammil Shafi, Srinivas Monanga, Vipal Chawla

Percutaneous Tracheostomy under Real-time Ultrasound Guidance in Coagulopathic Patients: A Single-center Experience

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:6] [Pages No:122 - 127]

Keywords: Airway, Coagulopathy, Percutaneous tracheostomy, Ultrasound

   DOI: 10.5005/jp-journals-10071-23344  |  Open Access |  How to cite  | 


Objective: To examine the safety and complications associated with percutaneous tracheostomy (PT) in critically ill coagulopathic patients under real-time ultrasound guidance. Materials and methods: Coagulopathy was defined as international normalized ratio (INR) ≥1.5 or thrombocytopenia (platelet count ≤50,000/mm3). Neck anatomy was assessed for all patients before the procedure and was characterized as excellent, good, satisfactory, and unsatisfactory based on the number of vessels in the path of needle. Percutaneous tracheostomy was performed under real-time ultrasound (USG) guidance, with certain modifications to the technique, and patients in both groups were assessed for immediate complications including bleeding. Results: Six hundred and fifty-two patients underwent USG-guided PT. Three hundred and forty-five (52.9%) were coagulopathic before the procedure. Ninety-nine patients (15.2%) had an excellent neck anatomy on USG scan, and 112 patients (62 in coagulopathy group vs 50 in noncoagulopathy group, p value 0.386) had an unsatisfactory neck anatomy for tracheostomy. A total of 42 events of immediate complications were noted in 37 patients (5.7%). No difference was seen in the rate of immediate complications in both groups (5.8% in coagulopathy group vs 5.5% in noncoagulopathy group, p value 0.886). The incidence of minor bleeding in coagulopathic patients was 14 patients (4.1%) and 7 (2.3%) in those without coagulopathy, and this difference was not statistically different (p value—0.199). In the subgroup analysis of patients with significant coagulopathy and unsatisfactory anatomy, no difference was observed in the incidence of immediate complications. Conclusion: This study shows the efficacy and safety of real-time ultrasound-guided PT, even in patients with coagulopathy.



Clarice L Barboza, Cristina OS Valete, André RA da Silva

Bundle Adherence of Intravenous Antibiotic Fluid Resuscitation and Vasopressor in Children with Severe Sepsis or Septic Shock

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:5] [Pages No:128 - 132]

Keywords: Antibiotic, Bundle, Fluid resuscitation, Pediatric intensive care unit, Sepsis

   DOI: 10.5005/jp-journals-10071-23336  |  Open Access |  How to cite  | 


Objective: The aim of this study was to measure the effects of a bundle of interventions in children admitted with severe sepsis or septic shock in the first hour after diagnosis on mortality. Materials and methods: A retrospective study was conducted at a pediatric intensive care unit (PICU) between January 2014 and January 2016. Three interventions (intravenous [IV] antibiotic, fluid boluses, and vasopressor administration) applied in the first hour of severe sepsis or septic shock diagnosis were analyzed according to their adherence rates. The main outcome was mortality. Odds ratios were calculated. Results: Of a total of 530 PICU admissions, 105 patients met the criteria for sepsis, 53 (50.5%) with severe sepsis and 52 (49.5%) with septic shock. Seventy-two (68.6%) patients received IV antibiotic within the first hour, 65 (61.9%) received IV fluid bolus, and 55 (53.3%) received a vasopressor drug. Fifty-two (49.5%) patients received concomitant IV antibiotics and fluid bolus. Blood cultures were collected before IV antibiotic administration in 87 (82.9%) out of 105 patients. Thirteen (12.4%) patients died, 1 with severe sepsis and 12 with septic shock. In a univariate analysis, the odds ratios for death and IV antibiotic were 6.39 (p value = 0.081, 95% CI = 0.795–51.465), 4.77 for fluid bolus between 21 and 40 mL/kg (p value = 0.013, 95% CI = 1.395–16.336), and 3.23 for vasopressor administration (p value < 0.0001, 95% CI = 1.734–6.018). In a multivariate analysis, the odds ratio of fluid bolus between 21 and 40 mL/kg was 42.66 (p value = 0.005, 95% CI = 3.117–583.841) and noradrenaline use was 23.93 (p value = 0.010, 95% CI = 2.124–269.750). Conclusion: Adherence was observed for more than half of the single interventions as IV antibiotic, fluid resuscitation, and vasopressor administration in the first hour. The antibiotic administration alone was not associated with high mortality. Vasopressor administration was related to higher mortality but moderate fluid bolus was a protective factor associated with lower mortality.



Gaurav Chaudhary

An Unusual Case of Critical Illness Polyneuromyopathy

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:3] [Pages No:133 - 135]

Keywords: Diabetic Ketoacidosis, Intravenous immunoglobulin, Quadriplegia, Severe hypokalemia

   DOI: 10.5005/jp-journals-10071-23346  |  Open Access |  How to cite  | 


Critical illness myopathy (CIM), critical illness polyneuropathy (CIP), and critical illness polyneuromyopathy (CIPNM) are the group of disorders that are commonly presented as neuromuscular weakness in intensive care unit (ICU) settings. They are responsible for prolonged ICU stay and failure to wean off from mechanical ventilation. We report a case of young female who was admitted with undiagnosed type I diabetes mellitus with diabetic ketoacidosis, severe hypokalemia, sepsis developed acute onset quadriplegia, and diaphragmatic palsy within 72 hours of ICU admission. On detailed investigation, CIPNM was diagnosed. In view of high morbidity, mortality, and poor prognosis, a guided approach to diagnose and treat in earliest possible duration might give better improvement and outcome of the illness. Despite all the odds, our patient showed good clinical improvement and finally got discharged.



Ali Asghar, Bushra Salim, Saqiba Tahir, Fahad Islam, Muhammad F Khan

Awareness during Cardiopulmonary Resuscitation

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:2] [Pages No:136 - 137]

Keywords: Cardiopulmonary resuscitation, Life support, Responsiveness

   DOI: 10.5005/jp-journals-10071-23345  |  Open Access |  How to cite  | 


Checking responsiveness is the mainstay in cardiopulmonary resuscitation (CPR). It is rare in the clinical situation when the patient requires resuscitation despite the presence of wakefulness. We report a case in which the patient presented with flat arterial line and absence carotid pulse while he was awake. A thorough literature review will also be discussed.



Megha Sharma, Ullas K Gopalakrishna

Case of Near Fatal Massive Intracerebral Bleed Secondary to Cerebral Venous Thrombosis in a Patient with Dengue and Refractory Thrombocytopenia

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:3] [Pages No:138 - 140]

Keywords: Cerebral venous thrombosis, Dengue, Eltrombopag, Thrombocytopenia

   DOI: 10.5005/jp-journals-10071-23351  |  Open Access |  How to cite  | 


We present a case of dengue with refractory thrombocytopenia who developed cerebral venous thrombosis (CVT) with intraparenchymal hemorrhage warranting surgical decompression. Patient was concluded to have secondary immune thrombocytopenic purpura (ITP) which remained refractory to high dose steroids, IVIg therapy, but responded to thrombopoietin receptor (TPO-R) agonist, eltrombopag.



Mathangi Krishnakumar, Muthuchellapan Radhakrishnan, Dwarakanath Srinivas

Acute Pancreatitis in a Patient with Subarachnoid Hemorrhage: A Causal Link or a Mere Coincidence?

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:2] [Pages No:141 - 142]

Keywords: Encephalopathy, Meningitis, Pancreatitis, Sepsis, Subarachnoid hemorrhage

   DOI: 10.5005/jp-journals-10071-23348  |  Open Access |  How to cite  | 


Both subarachnoid hemorrhage (SAH) and acute pancreatitis (AP) are associated with systemic inflammatory response leading to extracerebral multiple organ dysfunction. In this case report, we describe an adult male, who developed AP in the postoperative period following surgical clipping of an anterior communicating artery aneurysm. The diagnosis of pancreatitis got delayed because the patient showed signs of systemic inflammation which would also been seen following SAH.



R Hari Prasad, Varuna Vyas

Atypical Presentation of Crimean–Congo Hemorrhagic Fever as Ascending Paralysis with Rhabdomyolysis

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:2] [Pages No:143 - 144]

Keywords: Crimean–Congo hemorrhagic fever, Paralysis, Rhabdomyolysis

   DOI: 10.5005/jp-journals-10071-23347  |  Open Access |  How to cite  | 


Crimean–Congo hemorrhagic fever (CCHF) is a tick-borne disease caused by a arbovirus. It is asymptomatic in infected animals but a serious threat to the health of individuals. In human, it starts with nonspecific febrile diseases and progresses into severe hemorrhagic syndrome with high-casual fatality. Here, we report a case of CCHF with atypical presentation of ascending paralysis and rhabdomyolysis.



Viresh Swami, TK Anjan Kumar

Tuberculosis and Tumor Lysis Syndrome—Coincidence or Coexistent: A Case Report

[Year:2020] [Month:February] [Volume:24] [Number:2] [Pages:3] [Pages No:145 - 147]

Keywords: Bone marrow tuberculosis, Pediatric extrapulmonary tuberculosis, Severe sepsis with hyperuricemia, Tuberculosis with pancytopenia, Tumor lysis syndrome

   DOI: 10.5005/jp-journals-10071-23359  |  Open Access |  How to cite  | 


Extrapulmonary tuberculosis (TB) involving bone marrow can present with various manifestations, including pancytopenia, maturation arrest, hemophagocytic lymphohistiocytosis (HLH), or infiltration of the bone marrow by caseating or noncaseating granulomas causing reversible or irreversible fibrosis. Tumor lysis syndrome (TLS) is an oncologic emergency resulting from massive tumor cell lysis. Children with TB with bone marrow involvement may also present with laboratory features of TLS resulting from high catabolism and concomitant acute kidney injury (AKI), making the diagnosis difficult at times. We present a case of disseminated TB who presented to emergency with pancytopenia, AKI, and laboratory features of TLS.


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