Indian Journal of Critical Care Medicine

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2020 | July | Volume 24 | Issue 7

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Shirish Prayag

Respiratory Care for Severe COVID-19

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:3] [Pages No:493 - 495]

   DOI: 10.5005/jp-journals-10071-23509  |  Open Access |  How to cite  | 


Coronavirus disease-2019 (COVID-19) pandemic has put a severe strain on the healthcare services around the globe. Among the most affected areas of the hospital is critical care. A large number of patients of COVID-19 need critical care especially respiratory care. The acute hypoxemic respiratory failure (AHRF) due to COVID-19 needs careful understanding and strategies for management. Research in AHRF due to COVID-19 has progressed rapidly over the last 6 months.



Atul P Kulkarni

Deconstructing DISSECT—Percutaneous Tracheostomy in India

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:496 - 497]

   DOI: 10.5005/jp-journals-10071-23494  |  Open Access |  How to cite  | 



Can We Place Central Venous Catheter Safely in Intensive Care Units?

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:498 - 499]

   DOI: 10.5005/jp-journals-10071-23510  |  Open Access |  How to cite  | 



Rajat Choudhuri

Critical Care Research in Elderly Population: An Uncharted Territory

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:500 - 501]

   DOI: 10.5005/jp-journals-10071-23492  |  Open Access |  How to cite  | 



Ramesh Venkataraman

Bundling Out Catheter-associated Urinary Tract Infection

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:502 - 503]

   DOI: 10.5005/jp-journals-10071-23493  |  Open Access |  How to cite  | 



Prone for COVID: Are You Awake?

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:504 - 505]

   DOI: 10.5005/jp-journals-10071-23497  |  Open Access |  How to cite  | 



Anand S Malani

Cosmetic Ventilators (Co-V) for COVID-19

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:3] [Pages No:506 - 508]

   DOI: 10.5005/jp-journals-10071-23436  |  Open Access |  How to cite  | 


The COVID-19 pandemic has infiltrated all over our lives in every aspect and led to complete lockdown in almost every country and affected millions of people. It has overwhelmed the healthcare systems even of the most developed nations and this could be our future as well if situation is not controlled. We might fall short of ICU beds, ventilators, and trained manpower. Having understood that, many companies or even individuals have started to produce new and innovative kind of ventilators which prima facie are not at par with the standard ICU ventilators. Such ventilators, if approved for use in COVID-19 acute respiratory distress syndrome (ARDS), may not be of much use and rather cause harm. This commentary shall deal with the basics of COVID-19 ARDS, basics of an ICU ventilator, innovative low-cost ventilators, and the stark differences between the two and why their use may not be appropriate in the condition of our concern.


Original Article

Urvi Shukla, Siddharth Chavali, Prashant Mukta, Amol Mapari, Anjali Vyas

Initial Experience of Critically Ill Patients with COVID-19 in Western India: A Case Series

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:5] [Pages No:509 - 513]

   DOI: 10.5005/jp-journals-10071-23477  |  Open Access |  How to cite  | 


Background: The novel coronavirus, named SARS-CoV-2, was first described in December 2019 as a cluster of pneumonia cases in Wuhan, China. It has since been declared a pandemic, with substantial mortality. Materials and methods: In our case series, we describe the clinical presentation, characteristics, and outcomes of our initial experience of managing 24 critically ill COVID-19 patients at a designated COVID-19 ICU in Western India. Results: Median age of the patients was 54 years, and 58% were males. All patients presented with moderate to severe acute respiratory distress syndrome (ARDS); however, only 37.5% failed trials of awake proning and required mechanical ventilation. Patients who received mechanical ventilation typically matched the H-phenotype of COVID-19 pneumonia, and 55.5% of these patients were successfully extubated. Conclusion: The most common reason for ICU admission in our series of 24 patients with severe COVID-19 was hypoxemic respiratory failure, which responded well to conservative measures such as awake proning and oxygen supplementation. Mortality in our case series was 16.7%.


Original Article

Dhruva Choudhry, Zubair Mohamed, Nilanchal Chakrabortty, Kanchi VV Gupta

Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT)

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:13] [Pages No:514 - 526]

   DOI: 10.5005/jp-journals-10071-23441  |  Open Access |  How to cite  | 


Introduction: Tracheostomy is among the common procedures performed in the intensive care unit (ICU), with percutaneous dilatational tracheostomy (PDT) being the preferred technique. We sought to understand the current practice of tracheostomy in Indian ICUs. Materials and methods: A pan-India multicenter prospective observational study, endorsed and peer-reviewed by the Indian Society of Critical Care Medicine (ISCCM), on various aspects of tracheostomy performed in critically ill patients was conducted between September 1, 2019 and December 31, 2019. The SPSS software was used for the statistical analysis. Cross tables were generated and the chi-square test was used for testing of association. The p value < 0.05 was considered statistically significant. Results: Out of 67 ICUs that participated, 88.1% were from private sector hospitals. A total of 923 tracheostomies were performed during the study period; out of which, 666 were PDT and 257 were surgical tracheostomy (ST). Coagulopathic patients received more platelet transfusion [p = 0.037 with platelet count (PC) < 50 × 109, p = 0.021 with PC 50–100 × 109] and fresh frozen plasma transfusion in the ST group (p = 0.0001). The performance of PDT vs ST by day 7 of admission was 28.4% vs 21% (p = 0.023). The single dilator technique (60.4%) was the preferred technique for PDT followed by the Grigg's forceps and then the multiple dilator technique. Fiberoptic bronchoscope (FOB) and ultrasonography (USG) were used in 29.3% and 16.8%, respectively, for guidance during tracheostomy. Most of the PDTs were performed by a trained intensivist (74.2%), whereas ST was mostly done by an ENT surgeon (56.8%). Percutaneous dilatational tracheostomy resulted in less hemorrhagic (2.6% vs 7%, p = 0.002) and desaturation complications (2.3% vs 6.6%, p = 0.001) as compared to ST. The duration of procedure was shorter in the PDT group (average shortening by 9.2 minutes) and the ventilator-free days (VFD) were higher in the PDT group. The cost was less in PDT by approximately Rs. 13,104. Conclusion: Percutaneous dilatational tracheostomy, especially the single dilator technique, is preferred by clinicians in Indian ICUs. The incidence of minor complications like hemorrhagic episodes is lower with PDT. Percutaneous dilatational tracheostomy was found to be cheaper on cost per patient basis as compared to ST (with or without complications).


Original Article

AR Manudeep, BP Manjula, US Dinesh Kumar

Comparison of Peres’ Formula and Radiological Landmark Formula for Optimal Depth of Insertion of Right Internal Jugular Venous Catheters

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:4] [Pages No:527 - 530]

   DOI: 10.5005/jp-journals-10071-23478  |  Open Access |  How to cite  | 


Background: Central venous catheterization is a vital procedure for volume resuscitation, infusion of drugs, and for central venous pressure monitoring in the perioperative period and intensive care unit (ICU). It is associated with position-related complications like arrhythmias, thrombosis, tamponade, etc. Several methods are used to calculate the catheter insertion depth so as to prevent these position-related complications. Objective: To compare Peres’ formula and radiological landmark formula for central venous catheter insertion depth through right internal jugular vein (IJV) by the anterior approach. Materials and methods: A total of 102 patients posted for elective cardiac surgery were selected and divided into two equal groups—Peres’ group (group P) and radiological landmark group (group R). Central venous catheterization of right IJV was done under ultrasound (USG) guidance. In group P, central venous catheter insertion depth was calculated as height (cm)/10. In group R, central venous catheter insertion depth was calculated by adding the distances from the puncture point to the right sternoclavicular joint and on chest X-ray the distance from the right sternoclavicular joint to carina. After insertion, the catheter tip position was confirmed using transesophageal echocardiography (TEE) in both the groups. Results: About 49% of the catheters in group P and 74.5% in group R were positioned optimally as confirmed by TEE, which was statistically significant. No complications were observed in both the groups. Conclusion: Radiological landmark formula is superior to Peres’ formula for measuring optimal depth of insertion of right internal jugular venous catheter.


Original Article

Zineb Zeggwagh, Khalid Abidi, Mohamed NZ Kettani, Amina Iraqi, Tarek Dendane, Amine Ali Zeggwagh

Health-related Quality of Life Evaluated by MOS SF-36 in the Elderly Patients 1 Month before ICU Admission and 3 Months after ICU Discharge

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:8] [Pages No:531 - 538]

   DOI: 10.5005/jp-journals-10071-23489  |  Open Access |  How to cite  | 


Objectives: The aims of this study were to evaluate changes in health-related quality of life (HRQoL) before ICU admission and after ICU discharge in elderly patients and to determine predictors of this HRQoL. Materials and methods: This prospective study has been realized in the medical ICU (August 2012-March 2013). All patients 65 years of age or older who were hospitalized for ≥48 hours in our medical ICU have been included. The HRQoL was assessed 1 month prior to ICU admission in all the patients at admission and 3 months after ICU discharge for survivors using the Arabic version of MOS SF-36 questionnaire. Results: We enrolled 118 patients (66 M: 55.9% and 52 F: 44.1%). The mean age was 72 ± 6 years. ICU mortality rate was 47.5% and three-month mortality rate was 55.1%. The reliability and validity of MOS SF-36 were satisfactory. Among the 53 survivors at follow-up, the subscales of MOS SF-36 decreased significantly at 3 months after ICU stay except the “Bodily Pain”. The physical component score (PCS) and mental component score (MCS) decreased also significantly. The independent factors strongly associated with PCS and its variations were: age (β = −1.56, p = 0.001), prior functional status (β = −22.10, p = 0.002) and SAPSII (β = −0.16, p = 0.04). For MCS, these factors were: live alone (β = 16.50, p = 0.006), previous functional status (β = −9.09, p = 0.008) and existence of education level (β = 2.98, p = 0.037). Conclusion: We demonstrated a fall in the physical and psychical aspects of HRQoL 3 months after ICU discharge in the elderly patients. In addition to factors such as age, prior functional status and severity of illness, family status and educational level seem decisive in the post-ICU HRQoL.


Original Article

Comparison of Commercially Available Balanced Salt Solution and Ringer's Lactate on Extent of Correction of Metabolic Acidosis in Critically Ill Patients

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:5] [Pages No:539 - 543]

   DOI: 10.5005/jp-journals-10071-23488  |  Open Access |  How to cite  | 


Introduction: Appropriate early fluid resuscitation is ubiquitous for critically ill patients with metabolic acidosis. Owing to harmful effects of normal saline, commercially prepared balanced salt solutions are being used. However, there is no study comparing use of Ringer's lactate (RL) and commercially available balanced salt solutions in critically ill patients. Materials and methods: A randomized controlled trial was conducted during July 2016 to December 2017. Fifty adult patients admitted to intensive care unit with metabolic acidosis were randomized into group RL or group acetate solution (AC). Respective trial fluid was administered at 20 mL/kg/hour for first hour and 10 mL/kg/hour for second hour. Arterial blood gas analysis samples were taken 15 minutes apart. The fluid resuscitation was continued till pH got corrected to 7.3 or 2 hours, whichever was earlier. The primary aim was to compare time to correct metabolic acidosis in both the groups. The secondary outcomes were the extent of correction of metabolic acidosis, total volume of fluid used, and total cost per patient. Results: Demographic parameters, APACHE II score, and baseline investigations were comparable. The metabolic acidosis got corrected in 12 patients in group AC and 10 patients in group RL (p value = 0.66). The mean time for correction of metabolic acidosis was 57 ± 3.85 minutes in group RL and 56.25 ± 4.22 minutes in group AC (p value =0.95). The extent of correction of metabolic acidosis and total volume of fluid used was also comparable (p value = 0.05). However, the cost of fluid used was significantly higher in group AC (p value < 0.01). Conclusion: During administration of balanced salt solutions, RL or AC, in critically ill patients with metabolic acidosis, AC did not confer any advantage in time to or extent of correction of metabolic acidosis. Clinical significance: There is no difference in acid–base status with use of different types of balanced salt solutions for resuscitation in critically ill patients.


Original Article

Kathiresan Jeyashree, Ramesh Arunagiri

Impact of Care Bundle Implementation on Incidence of Catheter-associated Urinary Tract Infection: A Comparative Study in the Intensive Care Units of a Tertiary Care Teaching Hospital in South India

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:7] [Pages No:544 - 550]

   DOI: 10.5005/jp-journals-10071-23473  |  Open Access |  How to cite  | 


Introduction: Implementation of evidence-based infection control practices is the need of the hour for every institute to reduce the device-associated infections, which directly reflects the quality of care. As catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection, the study was planned to evaluate the impact of the catheter care bundle in reducing CAUTI incidence. Material and methods: The prospective interventional study before and after the trial study was carried out in adult intensive care units over a period of 9 months (April–June 2017—pre-implementation phase; July–September 2017—training of healthcare worker and implementation of catheter care bundle; October–December 2017—post-implementation phase). Catheter-associated urinary tract infection rates pre- and post-implementation were expressed as incidence rates with Poisson confidence interval. Results: Statistically significant reduction was found in the incidence of CAUTI (60%—from 10.7 to 4.5 per 1,000 catheter days). The key factors that contributed were significant reduction in device utilization ratio (from 0.71 to 0.56) and average catheter days per patient (from 4.8 to 3.7). This holistic approach has resulted in less incidence of CAUTI even among patients with risk factors and prolonged catheter days. Neuro ICU showed drastic improvement compared to other ICUs due to the poor baseline status of their care practices. Conclusion: Adherence to all elements of care bundle brought a significant decrease in CAUTI. Implementing care bundle and auditing the adherence to each element should be included as a part of routine hospital infection control committee (HICC) practices. Clinical significance: Hospital-acquired infection directly reflects on the quality care of the hospital. Bundle care is an “all or none” phenomenon. Adherence to each element will have some influence in reducing CAUTI in terms of reducing the device utilization ratio and average catheter days per patient. Auditing the care bundle adherence is having a positive influence on the outcome.


Original Article

Hadi A Rabee, Raghad Tanbour, Zaher Nazzal, Yousef Hamshari, Yousef Habash, Ahmad Anaya, Abbas Iter, Mohammad Gharbeyah, Dina Abugaber

Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:6] [Pages No:551 - 556]

   DOI: 10.5005/jp-journals-10071-23474  |  Open Access |  How to cite  | 


Background: Sepsis syndrome is an emerging healthcare problem, especially in critically ill patients, regardless whether it's community- or hospital-acquired sepsis. This study evaluates the characteristics of these patients, in addition to the type, source, and outcome of sepsis and septic shock, in a university tertiary hospital in Palestine. It also studies the most common organisms encountered in these patients. Materials and methods: This is retrospective observational chart review study of all adult admissions to the intensive care unit over a period of 2 years. The presence of sepsis and septic shock was assessed and documented based on the Third International Consensus Definitions (Sepsis-3). Data regarding demographics, severity, comorbidities, source of infection, microbiology, length of stay, and outcomes (dead/alive at discharge from ICU) were recorded. Results: A total number of 174 patients were included. The mean age was 57.4 years, with cardiovascular diseases and diabetes being the leading comorbidities encountered in them. Respiratory infections were the most common site of sepsis, found in around 71% of patients, followed by urinary tract infections. More than 70% of cases were due to hospital-acquired infections (HAIs). Acinetobacter species were the most common gram-negative organisms encountered, while Enterococcus was the most common gram-positive organisms. Around 54% of patients had multidrug-resistant organisms. The average length of stay in the ICU was 8 days. The average mortality rate was 39.7%, which is higher among septic shock patients. Conclusion: Both sepsis and septic shock carry high morbidity and mortality rates, and they are very frequent among critically ill patients. Special care and developing management bundles are crucial in controlling and preventing this threat.



Shoma V Rao, R Udhayachandar, Vasudha B Rao, Nithin A Raju, Juliana JJ Nesaraj, Subramani Kandasamy, Prasanna Samuel

Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:6] [Pages No:557 - 562]

   DOI: 10.5005/jp-journals-10071-23495  |  Open Access |  How to cite  | 


Severe hypoxemic respiratory failure is frequently managed with invasive mechanical ventilation with or without prone position (PP). We describe 13 cases of nonhypercapnic acute hypoxemic respiratory failure (AHRF) of varied etiology, who were treated successfully in PP without the need for intubation. Noninvasive ventilation (NIV), high-flow oxygen via nasal cannula, supplementary oxygen with venturi face mask, or nasal cannula were used variedly in these patients. Mechanical ventilatory support is offered to patients with AHRF when other methods, such as NIV and oxygen via high-flow nasal cannula, fail. Invasive mechanical ventilation is fraught with complications which could be immediate, ranging from worsening of hypoxemia, worsening hemodynamics, loss of airway, and even death. Late complications could be ventilator-associated pneumonia, biotrauma, tracheal stenosis, etc. Prone position is known to improve oxygenation and outcome in adult respiratory distress syndrome. We postulated that positioning an unintubated patient with AHRF in PP will improve oxygenation and avoid the need for invasive mechanical ventilation and thereby its complications. Here, we describe a series of 13 patients with hypoxemic respiratory of varied etiology, who were successfully treated in the PP without endotracheal intubation. Two patients (15.4%) had mild, nine (69.2%) had moderate, and two (15.4%) had severe hypoxemia. Oxygenation as assessed by PaO2/FiO2 ratio in supine position was 154 ± 52, which improved to 328 ± 65 after PP. Alveolar to arterial (A-a) O2 gradient improved from a median of 170.5 mm Hg interquartile range (IQR) (127.8, 309.7) in supine position to 49.1 mm Hg IQR (45.0, 56.6) after PP. This improvement in oxygenation took a median of 46 hours, IQR (24, 109). Thus, voluntary PP maneuver improved oxygenation and avoided endotracheal intubation in a select group of patients with hypoxemic respiratory failure. This maneuver may be relevant in the ongoing novel coronavirus disease pandemic by potentially reducing endotracheal intubation and the need for ventilator and therefore better utilization of critical care services.



Vital Role of Ultrasound in the Era of COVID-19: Arriving at the Right Diagnosis Real Time

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:563 - 564]

   DOI: 10.5005/jp-journals-10071-23490  |  Open Access |  How to cite  | 


Ultrasound has become an integral part for assessment of critically ill patients. It has helped in diagnosing and treating critically ill patients. The added advantage of ultrasonography is that it is a fantastic diagnostic tool that is easily available at the bedside, repeatable, more objective, and has a steep learning curve. It has become fifth vital assessment along with inspection, palpation, percussion, and auscultation. In the current scenario of COVID-19 pandemic, the disease caused by virus ranges from mild influenza-like illness to severe acute respiratory illness (SARI). Among the patients developing SARI, few require hospitalization and might need intensive care management. As a critical care specialist, we need to keep our antenna up to look for other causes for SARI due to non-COVID etiology as well. This article describes algorithmic approach and vital role of ultrasonography while managing patients with respiratory distress.



Manish Munjal, Adarsh Eshappa Setra

Systemic Involvement of Novel Coronavirus (COVID-19): A Review of Literature

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:5] [Pages No:565 - 569]

   DOI: 10.5005/jp-journals-10071-23498  |  Open Access |  How to cite  | 


COVID-19 outbreak has caused a pandemonium in modern world. As the virus has spread its tentacles across nations, territories, and continents, the civilized society has been compelled to face an unprecedented situation, never experienced before during peacetime. We are being introduced to an ever-growing new terminologies: “social distancing,” “lockdown,” “stay safe,” “key workers,” “self-quarantine,” “work-from-home,” and so on. Many countries across the globe have closed their borders, airlines have been grounded, movement of public transports has come to a grinding halt, and personal vehicular movements have been restricted or barred. In the past couple of months, we have witnessed mayhem in an unprecedented scale: social, economic, food security, education, business, travel, and freedom of movements are all casualties of this pandemic. Our experience about this virus and its epidemiology is limited, and mostly the treatment for symptomatic patients is supportive. However, it has been observed that COVID-19 not only attacks the respiratory system; rather it may involve other systems also from the beginning of infection or subsequent to respiratory infection. In this article, we attempt to describe the systemic involvement of COVID-19 based on the currently available experiences. This description is up to date as of now, but as more experiences are pouring from different corners of the world, almost every day, newer knowledge and information will crop up by the time this article is published.



Dwaipayan S Chakraborty, Suparna Chatterjee

Past, Present, and Future of Remdesivir: An Overview of the Antiviral in Recent Times

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:5] [Pages No:570 - 574]

   DOI: 10.5005/jp-journals-10071-23491  |  Open Access |  How to cite  | 


In the current COVID-19 pandemic, evidence to justify the use of any specific antiviral drug with proven efficacy is not yet available. Antiviral drug development always remains a challenge to the scientists. Remdesivir has emerged as a promising molecule, based on results of clinical trials and observational studies and has receieved marketing approval for COVID-19 treatment under “emergency use authorization” in countries such as United States. Remdesivir is a newer antiviral drug that acts as an RNA-dependent RNA polymerase (RdRp) inhibitor targeting the viral genome replication process. Therapeutic efficacy was first demonstrated by suppressing viral replication in Ebola-infected rhesus monkeys. It is available for parenteral use with reasonable safety and tolerability profile. Multiple clinical trials are going on in many countries to evaluate its safety, efficacy and tolerability. Positive outcome will make the drug capable of meeting the demand generated by both the current pandemic and future outbreak.



Sachin A Adukia, Radhika S Ruhatiya, Ramya B Manjunath, Gagan N Jain

Extrapulmonary Features of COVID-19: A Concise Review

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:6] [Pages No:575 - 580]

   DOI: 10.5005/jp-journals-10071-23476  |  Open Access |  How to cite  | 


Typical manifestations of coronavirus disease (COVID-19) involve the upper and lower respiratory tract. But as the pandemic surges, we are encountering numerous case reports and series of extrapulmonary presentations of COVID-19 in the outpatient department. Abundant retrospective data have also cited various extrapulmonary complications in the hospitalized COVID-19 patients. This knowledge needs to be condensed and disseminated in order to improve COVID-19 surveillance and to reduce the accidental exposure of healthcare workers. Our review suggests that gastrointestinal tract, cardiovascular system, nervous system, renal system, and manifestations due to hematological abnormalities are common masqueraders to watch out for.



Devendiran Anandhi, K. N. J. Prakash Raju, Vivekanandan Muthu Pillai, Vadivelu Kumaresan

The First Case Series Report of Typhonium trilobatum Tuber Poisoning in Humans

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:4] [Pages No:581 - 584]

   DOI: 10.5005/jp-journals-10071-23479  |  Open Access |  How to cite  | 


Typhonium is a genus belonging to the Araceae family, native to southern Asia and Australia. In folk medicine, Typhonium is used for its analgesic, anti-inflammatory, antidiarrheal, and wound-healing properties. We report a toxidrome of airway compromise due to Typhonium trilobatum tuber ingestion. We present an interesting case series of four patients who consumed raw tuber of T. trilobatum with suicidal thoughts. They exhibited a constellation of symptoms such as swelling of lips and tongue, drooling of saliva, and severe throat pain. One patient had significant upper airway edema and severe respiratory distress requiring emergency endotracheal intubation. Laboratory investigations were grossly normal in all four individuals, expect for mild asymptomatic hypokalemia in one and eosinophilia in another patient. We successfully managed all our patients with repeated adrenaline nebulization, antihistamines, and steroids. Typhonium is believed to be a beneficial herb. Toxicity of Typhonium is not reported much in the literature till date. An emergency department (ED) physician should be aware of this tuber toxicity as it presents with airway compromise, which resolves over hours. The symptoms are due to the local effects of calcium oxalate crystals in the tuber. Airway management is the priority and repeated adrenaline nebulization together with supportive care is advised.



Maria Denzil, Pradeep E Haranahalli, Soumik Susmita, Sheetal Chaurasia

A Unique Case of Arterial Thrombosis and Recurrent CVA in ICU: Unfathomable Presentation of an Occult Malignancy

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:4] [Pages No:585 - 588]

   DOI: 10.5005/jp-journals-10071-23481  |  Open Access |  How to cite  | 


Introduction: Critically ill patients may present with prothrombotic manifestations. Carcinoma cervix with prothrombotic manifestations are not common. Arterial thrombosis in such cases is very rare. We present a case of carcinoma cervix which posed a diagnostic dilemma and difficulty in localizing primary. This patient also had recurrent strokes and cardiac metastasis with metastatic arterial thrombosis. Case description: A 34-year-old lady presented with a history of acute lower limb ischemia and recurrent strokes. Transthoracic echocardiography showed valvular vegetations. Prothrombotic and infective endocarditis workup were negative. Histopathological examination (HPE) of clot showed metastatic squamous cells. Contrast CT of chest and abdomen only showed mediastinal lymphadenopathy. Endobronchial ultrasound (EBUS) with mediastinal lymph node biopsy showed metastatic squamous cells. As the patient gave a history of hysterectomy, Pap smear from the vault was sent, which was suggestive of high grade squamous intraepithelial neoplasia. Palliative chemotherapy was started. The patient made a good recovery and was discharged home in a stable condition. Conclusion: Arterial thrombosis is an uncommon manifestation of occult malignancy. Carcinoma cervix usually does not metastasize to heart, brain, and arteries, which was the case in our patient. A high index of suspicion and systematic evaluation can clinch the diagnosis even when rare complications of malignancy are presented by critically ill patients. Clinical significance: Any unprovoked thrombotic episodes should be extensively worked up for occult malignancies. We present a case demonstrating challenges faced by critical care physicians and benefits of methodical evaluation when confronted with unusual presentation of a malignancy.



Vinod Sharma

Indications for Proning in Acute Respiratory Distress Syndrome: Expanding the Horizon!

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:3] [Pages No:589 - 591]

   DOI: 10.5005/jp-journals-10071-23480  |  Open Access |  How to cite  | 


Background: Previously prone positioning (PP) was described in addition to invasive mechanical ventilation and it has been known to reduced mortality and improve oxygenation in patients of ARDS. Recently novel timing of prone positioning was described with the use of high-frequency nasal cannula (HFNC) and noninvasive ventilation (NIV) in patients of acute respiratory distress syndrome (ARDS) to avoid the intubation. Here we would like to share a case of severe ARDS where prone positioning was used in a step further ahead. Case description: A 38-year-old gentleman presented with the complaints of progressive breathlessness, dry cough and fever for 7 days. Patient was diagnosed as a case of H1N1 pneumonia with severe ARDS. Patient was initially managed with invasive mechanical ventilation according to ARDS-Net protocol. Despite persistent hypoxia he was put on prone positioning for consecutive 4 days. Patient was extubated after 10 days of mechanical ventilation and put on HFNC in view of persistent high oxygen requirement. At this point of time, we attempted prone positioning in addition to HFNC. Patient was comfortable on prone position and put himself in the same condition for prolonged periods. His oxygenation showed a remarkable improvement from PaO2 of 63 (before prone positioning) to 136 mm Hg (after prone positioning). Oxygen supplementation was later tapered off and subsequently, he improved and was shifted to ward. Conclusion: Prone positioning is a harmless and still extremely effective intervention which can and should be utilized at all steps of ARDS-management.



Youjin Chang, Tae-Gyu Kim, Sun-Yoon Chung

High-flow Nasal Cannula-induced Tension Pneumocephalus

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:4] [Pages No:592 - 595]

   DOI: 10.5005/jp-journals-10071-23482  |  Open Access |  How to cite  | 


High-flow nasal cannula (HFNC) therapy has been established as a promising oxygen treatment with various advantages for respiratory mechanics. One of the main mechanisms is to provide positive airway pressure. This effect could reduce lung injury and improve oxygenation; conversely, it may cause a complication of positive pressure ventilation. However, data are scarce regarding the possible adverse effects, particularly in adults. We report a patient who developed HFNC-induced tension pneumocephalus from an unrecognized skull base fracture. Physicians should be cautious when applying HFNC to patients with suspected skull base or paranasal sinus fracture, especially when applying a higher flow rate.



Yohan Soreze, Jean-Eudes Piloquet, Alain Amblard, Isabelle Constant, Jerome Rambaud, Pierre-Louis Léger

Sevoflurane Sedation with AnaConDa-S Device for a Child Undergoing Extracorporeal Membrane Oxygenation

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:3] [Pages No:596 - 598]

   DOI: 10.5005/jp-journals-10071-23487  |  Open Access |  How to cite  | 


Background: Deep sedation in critically ill children undergoing extracorporeal membrane oxygenation (ECMO) can be challenging. Volatile anesthetics like sevoflurane can be a good alternative for patients hospitalized in pediatric intensive care units, in whom adequate sedation is difficult to obtain. Case description: We report here the first pediatric case of a patient under extracorporeal membrane oxygenation receiving sedation by sevoflurane using the AnaConDa-S device. This 2-year-old girl, suffering from congenital diaphragmatic hernia, was put on extracorporeal membrane oxygenation due to a persistent pulmonary hypertension following metapneumovirus infection. Despite high doses of drugs, neither satisfactory sedation nor analgesia could be reached. Sevoflurane allowed her to be released and we were able to wean her from certain drugs. Her physiological parameters and the indicators of pain and sedation improved. Conclusion: Anesthesia using sevoflurane with the AnaConDa-S device is efficient for children under ECMO. Clinical significance: This is the first pediatric report on anesthesia with sevoflurane under ECMO.



Sheikha Albadi, Hafidh Al-Hadi, Sunil K Nadar

Knowledge and Attitudes toward Basic Life Support among Medical Students in Oman

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:599 - 600]

   DOI: 10.5005/jp-journals-10071-23475  |  Open Access |  How to cite  | 


Background: This study aimed to assess the level of knowledge regarding the basic life support (BLS) and attitudes related to BLS training and to identify the factors affecting these among medical students in Oman. Materials and methods: This prospective cross-sectional questionnaire-based study was carried out during the period July 2017 to February 2018 at Medical College of Sultan Qaboos University, Muscat, Oman. Validated questionnaires in English were distributed among undergraduate medical students from 1st to 7th years. Results: A total of 304 medical students completed the questionnaire with a response rate of 82.7%. The mean knowledge score of the participants was slightly high (5.5 ± 2.1) and median score of 5. About 53.6% of the participants had insufficient knowledge level. The scores increased with increase in the year of training. More than half (64.5%) of the participants had no previous BLS training. Students who attended previous BLS training showed higher knowledge scores (p < 0.001). Majority of the participants (97.4%) supported including of BLS in the undergraduate medical curriculum. Majority of the students (74%) were not reluctant to perform BLS on a stranger, although there was some reluctance among the female students. Conclusion: Our findings show that medical students in Oman had insufficient knowledge about BLS. However, they showed positive attitudes toward BLS training and were not reluctant to provide BLS to a stranger if required. These highlights the importance to provide sufficient BLS training for medical students early in their course.



Saroj Kumar Pattnaik

Skin Incision—To Give or Not in Tracheostomy

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:1] [Pages No:601 - 601]

   DOI: 10.5005/jp-journals-10071-23483  |  Open Access |  How to cite  | 



Reply to ‘Skin Incision: To Give or Not in Tracheostomy’

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:1] [Pages No:602 - 602]

   DOI: 10.5005/jp-journals-10071-23484  |  Open Access |  How to cite  | 



Bhanavathu Kishansing Naik

Critical Illness Polyneuromyopathy and the Diagnostic Dilemma

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:1] [Pages No:603 - 603]

   DOI: 10.5005/jp-journals-10071-23485  |  Open Access |  How to cite  | 


Critical illness polyneuromyopathy is a growing concern in intensive care units, but its presentation within 24–48 hours of admission is very unusual. Such presentations should be carefully scrutinized, especially in the presence of severe hypokalemia.



Madhulika Mahashabde, Gaurav Ashok Chaudhary, Gangadharam Kanchi, Shalesh Rohatgi, Prajwal Rao, Rahul Patil, Varun Nallamothu

Reply to the Letter to Editor Regarding “An Unusual Case of Critical Illness Polyneuromyopathy”

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:604 - 605]

   DOI: 10.5005/jp-journals-10071-23499  |  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.1 We report one such case of young female who was admitted with undiagnosed type I diabetes mellitus with diabetic ketoacidosis with severe hypokalemia with sepsis developed acute-onset quadriplegia and diaphragmatic palsy within 72 hours of ICU admission. Detailed investigation led to the diagnosis of critical illness polyneuromyopathy. In view of high morbidity, mortality, and poor prognosis, a guided approach to diagnoses and treatment 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.



Rajnish Kumar

In Response to Guidewire Entrapped in the Right Ventricle: A Rare Complication of Hemodialysis Catheter Insertion

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:2] [Pages No:606 - 607]

   DOI: 10.5005/jp-journals-10071-23486  |  Open Access |  How to cite  | 


Verma et al. meticulously prevented the further complications once they recognize the entrapped guidewire in the right ventricle. Authors were very correct to mention overzealous insertion of the guidewire without watching the monitor, which may lead to such complications; however, every time monitor is not available for assistance. The Seldinger technique is routinely used for inserting central venous (CV) and hemodialysis (HD) catheters; however, both are different entities and their designs and lengths including of their guidewires vary. During guidewire insertions, simply adhering to the safe length may prevent or minimize many guidewire-related complications.



Varun Chitransh

Reply to in Response to Guidewire Entrapped in the Right Ventricle

[Year:2020] [Month:July] [Volume:24] [Number:7] [Pages:1] [Pages No:608 - 608]

   DOI: 10.5005/jp-journals-10071-23500  |  Open Access |  How to cite  | 


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