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   Table of Contents - Current issue
January-March 2018
Volume 8 | Issue 1
Page Nos. 1-53

Online since Friday, March 9, 2018

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What's new in critical illness and injury science? The quest for effective and safe co-induction agents in spontaneously breathing patients undergoing general anesthesia Highly accessed article p. 1
Jason M Stroud, Michael A Rudoni, Andrew B Casabianca, Thomas J Papadimos
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Role of opioids as coinduction agent with propofol and their effect on apnea time, recovery time, and sedation score p. 4
Manisha Bhatt Dwivedi, Anisha Puri, Sankalp Dwivedi, Harinder Deol
Background: Laryngeal mask airway (LMA) is a supraglottic device which requires lesser depth of anaesthesia, evokes lesser hemodynamic response and causes lesser stimulation of airway as compared to traditional definitive airway device endotracheal tube. Its placement is possible without muscle relaxants thereby allowing maintenance of anaesthesia on spontaneous respiration thus preventing apnoea or minimizing apnoea time. Propofol, the commonly used induction agent, causes cardiorespiratory depression at higher induction doses. To attenuate this, co-induction agents combined with propofol has been a regular I/V anaesthetic technique these days. Aim: Comparing apnoea time, recovery time and sedation scores using propofol-fentanyl and propofol-butorphanol combination. Methodology: Hundred patients scheduled for various elective surgical procedures were randomly selected and divided into two groups of 50 each. As coinduction drug Group F received fentanyl and Group B received butorphanol. In both the groups induction was achieved with I/V propofol and LMA was placed. Apnoea time was noted after induction. Recovery time and sedation scores were recorded after anaesthetic agents were turned off. Results: As compared to group F apnoea time was significantly less and recovery time was significantly more in group B (P < 0.05). Statistically postoperative sedation was significantly higher in group B than in group F at 1/2 hr but clinically, majority were responding to verbal commands. At 1 hour no significant difference in sedation was noted between the groups. Conclusion: Considering respiratory and recovery profile propofol -butorphanol combination is a safer alternative to propofol-fentanyl combination for LMA insertion.
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Factors determining outcomes in adult patient undergoing mechanical ventilation: A “real-world” retrospective study in an Indian Intensive Care Unit p. 9
Khalid Ismail Khatib, Subhal Bhalchandra Dixit, Mukund Manohar Joshi
Background: Characteristics of patients admitted to intensive care units with respiratory failure (RF) and undergoing mechanical ventilation (MV) have been described for particular indications and diseases, but there are few studies in the general Intensive Care Unit (ICU) population and even lesser from developing countries. Objective: This study aims to study clinical characteristics, outcomes, and factors affecting outcomes in adult patients with RF on MV admitted to ICU. Methods: A retrospective study of medical records of all patients admitted to ICU between January 1, 2015, and March 31, 2016. Patients receiving MV for more than 6 h were included in the study. Patients younger than 12 years were excluded. Data were recorded of all patients receiving MV during this period regarding demographics, indications for MV, type and characteristics of ventilation, concomitant complications and treatment, and outcomes. Data were recorded at the initiation of MV and daily all throughout the course of MV. The main outcome measure was all-cause mortality at the end of ICU stay. Results: Of the 500 patients admitted to the ICU during the period of the study, a total of 122 patients received MV (and were included in study) for mean (standard deviation [SD]) duration of 4 (3.4) days. The mean (SD) stay in ICU and hospital was 4.49 (3.52) and 6.4 (3.6), respectively. Overall mortality for the unselected general ICU patients on MV was 67.21% while that for ARDS patients was 76.1%. The main factors independently associated with increased mortality were (i) pre-MV factors: age, Apache II scores, heart failure (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.54–3.73; P < 0.001); (ii) patient management factors: positive end-expiratory pressure (OR, 2.69; 95% CI, 0.84–8.61; P < 0.001); (iii) Factors occurring over the course of MV: PaO2/FiO2ratio < 100 (OR, 1.66; 95% CI, 0.67–4.11; P < 0.001) and development of renal failure (OR, 2.33; 95% CI, 2.05–2.42; P < 0.001) and hepatic failure (OR, 2.07; 95% CI, 1.91–2.24; P < 0.001) after initiation of MV. Conclusions: Outcomes of patients undergoing MV are dependent on various factors (including patient demographics, nature of associated morbidity, characteristics of the MV received, and conditions developing over course of MV) and these factors may be present before or develop after initiation of MV.
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Role of neomycin polymyxin sulfate solution bladder wash for prevention of catheter associated urinary tract infection in traumatic brain injury patient admitted to Intensive Care Unit: A prospective randomized study p. 17
Neeraj Kumar, Yashpal Singh, Ghanshyam Yadav, SK Mathur, Umesh Kumar Bhadani
Background: Catheter - associated urinary tract infection (CAUTI) remains a critical threat for patients in intensive care unit especially in traumatic brain injury patients with low Glasgow coma score (GCS). Almost all patients in ICU receive antibiotic either prophylactic or therapeutic based on local antibiogram of particular ICU or hospital. For prophylaxis, systemic antibiotics are used. It will be helpful to avoid systemic side effects by introducing antibiotics locally through bladder irrigation. The indwelling urinary catheter is an essential part of modern medical care. Aims and Objectives: The primary objective was to study the effect of Neomycin and Polymyxin sulphate solution for bladder wash on CAUTI in traumatic brain injury patients. The secondary objectives was to study the various organisms causing CAUTI and their antibiotic sensitivity and resistance pattern. Materials and Methods: This was a prospective randomized controlled study performed on 100 patients who met the inclusion criteria at the trauma intensive care unit of Banaras Hindu University between September and February 2016. The patients were randomized into two groups – one was the study group which received Neomycin and Polymyxin Sulphate solution bladder wash, while the other was the control group that received Normal saline bladder wash. Urine samples were collected at certain days and sent for culture and sensitivity. Results: There was significant reduction in the incidence of CAUTI in neomycin/polymyxin test group in comparison to normal saline irrigated control group.Out of 50 patients in test group 8 patients and in control group 26 patients was identified as CAUTI positive and they were statistically significant. In our study pseudomonas aeruginosa (51%) was the commonest isolated pathogen. Conclusions: Neomycin and Polymyxin Sulphate bladder wash was effective in preventing CAUTI. It can thus decrease the antibiotic usage thereby preventing the emergence of antibiotic resistance.
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Risk of acute kidney injury in critically ill surgical patients with presumed pneumonia is not impacted by choice of methicillin-resistant staphylococcus aureus therapy p. 22
Kelsey B Billups, Erica E Reed, Gary S Phillips, Kurt B Stevenson, Steven M Steinberg, Claire V Murphy
Background: Vancomycin and linezolid are standard treatment options for nosocomial methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. While acute kidney injury (AKI) is commonly attributed to vancomycin, existing data has not definitely confirmed vancomycin as an independent risk factor for AKI. Aims: This study aimed to quantify the incidence of AKI in Surgical Intensive Care Unit (ICU) patients receiving empiric vancomycin or linezolid for nosocomial pneumonia and to identify risk factors for AKI with a focus on MRSA antibiotic therapy. Materials and Methods: A retrospective cohort analysis of surgical ICU patients who received at least 48 h of vancomycin or linezolid for pneumonia was performed. Patients who received vancomycin were compared to those who received linezolid with a primary endpoint of AKI as defined by the risk/injury/failure/loss/end-stage renal disease (RIFLE) criteria. A modified RIFLE criteria assessing only changes in serum creatinine was also used. Results: One hundred one patients were evaluated (63 vancomycin and 38 linezolid). AKI occurred in 51 (81.0%) and 32 (84.2%) patients in the vancomycin and linezolid groups (P = 0.79), respectively. Using the modified RIFLE criteria, AKI occurred in 19 (30.2%) and 14 (36.8%) patients in the vancomycin and linezolid groups (P = 0.448). After adjustment for age, diabetes mellitus, Charlson comorbidity index, and concomitant nephrotoxins, there was no difference in risk of AKI between groups (P = 0.773). Conclusions: Patients who received empiric vancomycin or linezolid for nosocomial pneumonia experienced high, but similar rates of AKI. The results suggest MRSA antibacterial therapy in this setting may not be independently indicative of AKI risk, rather the risk is likely multifactorial.
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Prevalence and prognostic significance of prolonged QTc interval in emergency medical patients: A prospective observational study p. 28
Chhagan Lal Birda, Susheel Kumar, Ashish Bhalla, Navneet Sharma, Savita Kumari
Introduction: QTc interval is affected by many factors and prolongation of same may have prognostic significance. A significant number of patients admitted in medical emergency are acutely ill, have multiple comorbidities and are on medications, all of these factors might affect QTc interval and prognosis. Materials and Methods: Single-center, prospective, observational study was carried out on 279 patients of different illnesses recruited from emergency medical services attached to the Department of Internal Medicine at Postgraduate Institute of Medical Education and Research, Chandigarh, India, a tertiary care hospital. Results: Out of 279 patients, 95 were found to have prolonged QTc interval with the prevalence of 34.1%. Fifteen patients (5.4%) had markedly prolonged QTc interval (QTc >500 ms). Of various medical conditions, we found statistically significantly higher number of patients of chronic kidney disease (P = 0.047), chronic liver disease (P < 0.001), hemorrhagic cerebrovascular accident (P = 0.026), and heart failure (P = 0.009) with prolonged QTc interval. Among laboratory abnormalities, patients with low hemoglobin (P = 0.032), with deranged renal functions (P = 0.033), and with hypokalemia (P = 0.026) had a greater share of patients with prolonged QTc interval. There was no difference in duration of hospital stay and frequency of hospital mortality between two groups, although, on subgroup analysis, patients with markedly prolonged QTc interval had significantly higher hospital mortality (P = 0.029). The frequency of ventricular tachycardia was also significantly higher in patients with prolonged QTc interval (P = 0.008). Conclusion: High prevalence of prolonged QTc interval was found in Indian emergency medical patients. There was no difference in hospital mortality though on subgroup analysis, patients with markedly prolonged QTc interval had significantly more episodes of in-hospital ventricular tachycardia and hospital mortality.
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Three- versus four-factor prothrombin complex concentrate for the reversal of warfarin-induced bleeding p. 36
Tara Holt, Scott Taylor, Prasad Abraham, Wesley Mcmillian, Serena Harris, James Curtis, Tai Elder
Objective: The objective of this study was to evaluate the effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) compared to 4-factor PCC (4F-PCC) in warfarin-associated bleeding. Methods: This multicenter, retrospective, cohort study analyzed data from patients admitted between May 2011 and October 2014 who received PCC for warfarin-associated bleeding. The primary outcome was the rate of international normalized ratio (INR) normalization, defined as an INR ≤1.3, after administration of 3F-PCC compared to 4F-PCC. Other variables of interest included the incidence of additional reversal agents, new thromboembolic events, and mortality. Results: A total of 134 patients were included in the analysis. The average dose of PCC administered was 24.6 ± 9.3 units/kg versus 36.3 ± 12.8 units/kg in the 3F-PCC and 4F-PCC groups, respectively, P < 0.001. Baseline INR in the 3F-PCC and 4F-PCC groups was 3.61 ± 2.3 and 6.87 ± 2.3, respectively P < 0.001. 4F-PCC had a higher rate of INR normalization at first INR check post-PCC administration compared to 3F-PCC (84.2% vs. 51.9%, P = 0.0001). Thromboembolic events, intensive care unit and hospital length of stay, and mortality were similar among both groups. Conclusion: The use of 4F-PCC leads to a more significant reduction in INR compared to 3F-PCC though no difference in mortality or length of stay was observed. Thromboembolism rates were similar among both groups.
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Abortion may be associated with elevated risk of future hypothyroidism p. 41
Vivek Chauhan, Anurag Thakur, Gurudutt Sharma
Objective: Fetal microchimerism during pregnancy and abortion has been linked with autoimmune hypothyroidism in females. We conducted a case–control study to investigate the odds of “abortion in the past” in the newly diagnosed hypothyroid females compared to their age-matched euthyroid controls. Methods: All consecutive newly diagnosed hypothyroid females, over 1 year, were enrolled as cases. Age-matched euthyroid controls were selected from the same region. The exposure variable tested was “past history of abortion (elective or therapeutic).” Results: Totally, 120 cases and 172 controls were recruited over 1 year with a mean age of 42.2 ± 9.8 years and 41.1 ± 12.4 years, respectively. The exposure variable (abortion) was present in 71 (59%) cases and 10 (6%) controls. Odds ratio (OR): 23.5 (12.2–48.9) P < 0.0001. Autoimmunity, based on thyroid peroxidase (TPO) positivity (TPO levels ≥30 U/ml), was present in 92 (77%) of the cases; TPO was negative in 28 (33%) of cases. The exposure variable was documented in 62.4% and 50% of TPO positive and negative cases, respectively (P = 0.28). Discussion and Conclusion: The study suggests that abortion (elective or therapeutic) in the past is strongly associated with newly diagnosed hypothyroidism in females aged 42.2 ± 9.8 years; OR: 23.5 (P < 0.0001). Interestingly, abortion was associated with both, TPO positive and negative hypothyroidism.
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Takotsubo cardiomyopathy with basal hypertrophy and outflow obstruction in a patient with bowel ischemia p. 44
Ahmad Abuarqoub, Rana Garis, Hamid Shaaban, Ibrahim Khaddash, Fayez Shamoon
Basal septal hypertrophy is a rare and unique anatomical finding associated with hypertrophic cardiomyopathy (HCM). It is also described as a sigmoid hypertrophy and is linked with aging and chronic hypertension. Takotsubo cardiomyopathy is a transient cardiomyopathy that occurs during periods of high physical or emotional stress. Its occurrence with HCM is relatively common; however, this presentation occurs more often with the classic asymmetrical septal hypertrophy or the apical variant. This case demonstrates its coexistence with isolated sigmoid hypertrophy in an elderly, hypertensive female with severe ischemic bowel disease.
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Right carotid-cutaneous fistula and right carotid pseudoaneurysm formation secondary to a chronically infected polyethylene terephthalate patch p. 48
WT Hillman Terzian, Samuel Schadt, Sharvil U Sheth
Carotid endarterectomy (CEA) remains the treatment for significant carotid stenosis and stroke prevention. Approximately 100,000 CEAs are performed in the United States every year. Randomized trials have demonstrated an advantage of patch carotid angioplasty over primary closure. Complications from patches include thrombosis, transient ischemic attack, stroke, restenosis, pseudoaneurysm (PA), and infection. PA after CEA is rare, with a reported average of 0.37% of cases. We describe an unusual case of PA after polyethylene terephthalate (PTFE) patching for CEA. An 88-year-old female with Alzheimer's disease living in a nursing facility with a history of skin cancer on her right chest developed a new area of intermittent brisk bleeding on her right neck which was initially believed to be related to her skin cancer. She had a remote history of right CEA with a PTFE patch approximately a decade ago. A computed tomography angiograph-head-and-neck with showed a partially thrombosed PA in the region of her right common carotid artery bifurcation with a tract containing gas and fluid extending to the skin surface suspicious for a partially thrombosed, leaking PA. She was taken urgently to the operating room on broad-spectrum antibiotics where we performed a right neck exploration, ligation of a bleeding carotid PA by ligation of the right common, internal, and external carotid arteries, explantation of a chronically infected polyethylene terephthalate patch, and closure with a sternocleidomastoid advanced flap with multilayered closure. She was discharged to her nursing facility with 6 weeks of ceftriaxone intravenous (IV) and metronidazole IV through a peripherally inserted central catheter (PICC) line with no neurological sequelae.
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Never over until it is over: Carotid-cutaneous fistula p. 52
Craig Kornbau, Michael S Firstenberg
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