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   Table of Contents - Current issue
July-September 2018
Volume 8 | Issue 3
Page Nos. 115-180

Online since Monday, August 27, 2018

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What's new in critical illness and injury science?: Revalidation of vasoactive–ventilation–renal scoring in predicting outcome in postcardiac surgery children and the importance of replicating studies Highly accessed article p. 115
Thomas John Papadimos
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Acute care for the three leading causes of mortality in lower-middle-income countries: A systematic review Highly accessed article p. 117
Cassidy M Dahn, Olindi Wijesekera, Grace E Garcia, Konrad Karasek, Gabrielle A Jacquet
According to the World Health Organization, the three leading causes of mortality in lower-middle-income countries (LMIC) are ischemic heart disease (IHD), stroke, and lower respiratory infections (LRIs), causing 111.8, 68.8, and 51.5 annual deaths per 100,000, respectively. Due to barriers to healthcare, patients frequently present in critical stages of these diseases. Measured implementations in critical care in LMIC have been published; however, the literature has not been formally reviewed. We performed a systematic review of the literature indexed in PubMed as of October 2017. Abstracts were limited to human studies in English, French, and Spanish, conducted in LMIC, and containing quantitative data on acute care of IHD, stroke, and LRI. The search resulted in 4994 unique abstracts. Through multiple rounds of screening using criteria determined a priori, 161 manuscripts were identified: 38 for IHD, 20 for stroke, 26 for adult LRI, and 78 for pediatric LRI. These studies, predominantly from Asia, demonstrate successful diagnostic and treatment measures used in providing acute care for patients in LMIC. Given that, only four manuscripts originated in Central or South America, original research from these areas is lacking. IHD, stroke, and LRIs are significant causes of mortality, especially in LMIC. Diagnostic and therapeutic interventions for IHD (monitoring, medications, thrombolytics, percutaneous intervention, coronary artery bypass graft), stroke (therapeutic hypothermia, medications, and thrombolytics), and LRI (oxygen saturation measurement, diagnostic ultrasound, administration of oxygen, appropriate antibiotics, and other medications) have been studied in LMIC and published.
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Vasoactive-ventilation-renal score in predicting outcome postcardiac surgery in children p. 143
Shahzad Alam, Shalini Akunuri, Akanksha Jain, Rufaida Mazahir, Rajesh Hegde
Objective: The objective of this study was to evaluate vasoactive-ventilation-renal (VVR) score to predict outcome postcardiac surgery in children and establish the time at which the score is best to predict outcome. Materials and Methods: This prospective cohort included children ≤18 years recovering from cardiac surgery for congenital heart disease. Data were collected from the Intensive Care Unit (ICU) and vasoactive-inotropic score (VIS) and VVR scores calculated at admission, 24 h, and 48 h postoperatively. Outcome of interest was prolonged length of ICU stay (defined as length of stay [LOS] in the upper 25th percentile) and ICU mortality. Correlation between the outcome and scores was obtained and receiver operating characteristic (ROC) curves generated. Independent association of the scores with the outcome was also established. Results: One thousand ninety-seven patients were enrolled with a median age of 24 months (range: 2 days–18 years) including 14.6% with single ventricle physiology. Pediatric ICU LOS >89 h was considered prolonged, and mortality was 2.2%. VVR score correlated better with outcome and had greater area under the curve (AUC) for ROC curve than the corresponding VIS at each study time point. The AUC of ROC curve for VVR score was greatest at 48 h for predicting both prolonged LOS (0.87) and mortality (0.92). VVR score at 48 h remains strongly associated with both prolonged LOS (odds ratio [OR] – 1.24; P = 0.000) and mortality (OR – 1.16; P = 0.000). Conclusion: VVR score is effective and robust bedside method to predict prolonged LOS and mortality postpediatric cardiac surgery. VVR score at 48 h was the best to predict outcome.
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The relationship between fluid resuscitation and intra-abdominal hypertension in patients with blunt abdominal trauma p. 149
Soudabeh Vatankhah, Rahim Ali Sheikhi, Mohammad Heidari, Parisa Moradimajd
Background: Excessive fluid administration for saving patients from hypovolemic shocks is one of the main causes of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The purpose of this paper is to survey the relationship between fluid resuscitation and increase intra-abdominal pressure (IAP). Materials and Methods: The present descriptive-analytical study recruited 100 patients with confirmed abdominal trauma and presenting to emergency departments. The cases with high IAP measured through the bladder were identified as developing ACS in case of having comorbidities involving two of the following systems: respiratory system, renal system or cardiovascular system. The volume of the fluids administered was compared in the first 24 h in subjects with and without ACS. Results: Of 100 patients with abdominal trauma, whose IAP was measured, 28 cases developed ACS. The mean volume of the fluids received was found to be significantly higher in the patients with ACS (8772 ml) compared to in those without (5404 ml). As a complication of excessive fluid administration, IAH can seriously threaten the patient's life. Conclusions: Excessive fluid resuscitation causes ACS among the critically ill or injured patients such as abdominal trauma, pelvic fracture and intra-abdominal organ injuries hence to prevent this complication in all patients requiring short-term excessive administration of fluids, great care, and sensitivity are required to constantly control IAP and adjust the fluid administration.
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The acute care diagnostics collaboration: performance assessment of contrast-enhanced ultrasound compared to abdominal computed tomography and conventional ultrasound in an emergency trauma score bayesian clinical decision scheme p. 154
Amado Alejandro Baez, Laila Cochon
Background: Bayes' theorem describes the probability of an event, based on conditions that might be related to the event.[1] We developed the Bayesian Diagnostic Gains (BDG) method as a simple tool for interpreting diagnostic impact.[2],[3],[4],[5],[6],[7] Aim: We aimed to evaluate the clinical diagnostic impact of contrast-enhanced ultrasound (CEUS) compared to traditional abdominal computed tomography (CT) and standard ultrasound (US) in a Bayesian Clinical Decision Scheme. Materials and Methods: Our mathematical method uses Bayesian Diagnostic Gains (BDG) model. For the purposes of our model, the EMTRAS was used as pretest probability and stratified as low risk (0–3 points = 10%), moderate risk (4–6 points = 42%), and high risk (7–12 points = 80%) based on mortality risk. Sensitivity and specificity for US, CT, and CEUS were obtained from pooled data and used to calculate LR- and LR+. Bayesian/Fagan nomogram was used to attain posttest probabilities using baseline probability of an event on the first axis (PRE), with LR on the second axis, and read off the pos-test probability (POST) on the third axis. For the nomogram analysis, the pretest probability (Pre) scoring for the EMTRAS score was obtained using the original EMTRAS data. Posttest probabilities were obtained based on the Bayes/Fagan Nomgram. Relative diagnostic gain (RDG) and absolute diagnostic gain (ADG) were calculated based on the differences deducted from pre- and post-test probabilities. IBM® SPSS® Statistics 20 was used for analysis and modeling. ANOVA was used for association between EMTRAS, CT scan, and CEUS, where P value set at 0.05. Results: Pooled data for Sensitivity (Se), Specificity (Sp), LR+, and LR- were obtained for US (Se = 45.7%, Sp = 91.8%, LR+ = 5.57, and LR- = 0.59), CEUS (Se 91.4%, Sp 100%, LR+ 91, and LR-0.09), and CT (Se = 94.8%, SP = 98.7%, LR+ = 73, and LR- =0.05). ANOVA analysis for LR+ and LR- showed no significant difference (P < 0.8745 and P < 0.9841). Comparison of CT and CEUS did not yield statistically significant differences for LR+ (P < 0.1). Conclusion: In this Bayesian model, the diagnostic performance of CEUS was found to be similar to traditional abdominal CT. The greatest diagnostic gain was observed in low pretest positive LR groups.
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Inferior vena cava diameter as a guide in hypotensive patients for appropriate saline therapy: An observational study p. 160
Mojtaba Chardoli, Mitra Ahmadi, Omid Shafe, Hooman Bakhshandeh
Background: Knowledge of intravascular volume (IV) status of a hypotensive patient is of utmost importance. Clinical evaluation and central venous pressure (CVP) measurement are routinely used as a guide for evaluation of IV in these patients. However, clinical assessment may be inaccurate, and CVP measurement is invasive. Moreover, CVP changes slowly with saline therapy, which is unfavorable for fluid resuscitation. Aim: Our aim is to find the correlation and sensitivity of inferior vena cava (IVC) diameter measured by ultrasound to provide a noninvasive method for evaluation of IV among patients with hypotension and hypovolemia in the emergency department (ED). Methods: We measured the IVC diameter of hypotensive patients before and after saline therapy. As all of the patients had central venous line (CV-line) in place, CVP was also measured before and after. Using MedCalc and SPSS software the correlation between these two was determined as expressed with “r.” Then, receiver operating characteristic (ROC) curve was sketched. Results: Ninety-nine patients, 49 (49.5%) males, were evaluated. Mean systolic blood pressure was 90 mmHg with a mean hazard ratio about 104. IVC diameter was 7.44 ± 5.13 mm before and 9.84 ± 5.29 after (P = 0.002) saline therapy. There was a high correlation between IVC diameter and CVP (r = 0.941, P < 0.0001 before saline therapy and r = 0.95, P < 0.0001 after saline therapy). ROC curve for IVC diameter shows a very high sensitivity for all criteria values. Conclusion: IVC diameter measurement using ultrasonography has excellent correlation with CVP. This method is very sensitive to rapid IV changes thus useful to guide saline therapy in hypotensive patients referred to ED. However, its use in certain subsets of patients' needs further studies.
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Prognostic significance of nonthyroidal illness syndrome in critically ill adult patients with sepsis p. 165
Rajesh Padhi, Sobhitendu Kabi, Baikuntha Nath Panda, Snehalata Jagati
Aim: This study was performed to investigate the association of non-thyroidal illness syndrome (NTIS) with 28-day mortality in adults with sepsis. Methods: We performed a prospective observational analysis of adult patients with sepsis. Patients' demographic data, comorbidities, the blood test results including thyroid hormone analysis at admission, Acute Physiologic and Chronic Health Evaluation II score and Sequential Organ Failure Assessment score were compared between 28-day survivors and non-survivors. Further patients were divided into 3 groups; non-NTIS, NTIS group A (low total tri-iodothyronine (T3) and NTIS group B (low T3 with low thyroxine (T4). Multivariate Cox proportional hazards regression analysis was performed to determine the risk factors for mortality. Results: A total of 360 patients were included, and overall mortality was 30%. The mortality of non-NTIS patients was 13.4%; group A, 50.1%, and group B 69.1% (P < .001). The median T3 (IQR) in non-survivors and survivors was 0.74 (0.56–1.17) and1.58 (0.91–2.13) and median free T3 (IQR) 2.40 (1.13-3.01) and 4.03 (3.03-7.13) respectively (P < .001). In Cox proportional hazards analysis, NTIS group A (hazard ratio, 1.66; 95% confidence interval [CI], 1.00-2.76) and group B (hazard ratio, 2.57; 95% CI, 1.53-4.34). The area under the receiver-operating curve of NTIS groups was 0.68 (95% CI, 0.63-0.72). Conclusion: The T3 and free T3 were significantly lower in non-survivors compared with that in survivors and that a combination of low T3 with low T4 was associated with greater mortality than low T3 alone. A lower free T3 is independently associated with 28-day mortality.
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Multidrug-resistant Burkholderia cepacia bacteremia in an immunocompetent adult diagnosed with dengue and scrub coinfection: A rare case report p. 173
Sai Saran, Afzal Azim, Mohan Gurjar
Burkholderia cepacia is an opportunistic nosocomial pathogen causing infections in immunocompromised hosts. Infection by Burkholderia in an immunocompetent host is a rare entity. We report a case of dengue and scrub coinfection complicated by B. cepacia bloodstream infection along with literature review of such infections in immunocompetent adults. Before the introduction of automated technologies, it was difficult to differentiate this organism from other aerobic Gram-negative nonfermenters, which have different intrinsic resistance profiles. Furthermore, Burkholderia has intrinsic as well as acquired resistance to various antimicrobials but not commonly to ceftazidime. To our knowledge, ours is the first case of multidrug-resistant B. cepacia infection in an immunocompetent host to be reported till date.
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Massive air embolism while removing a central venous catheter p. 176
Gil Myeong Seong, Jaechun Lee, Misun Kim, Jay Chol Choi, Su Wan Kim
Air embolism is a rare but mostly iatrogenic complication of medical or surgical procedures and may have a serious outcome. On the removal of a central venous catheter (CVC), minor carelessness can lead to a venous air embolism sometimes accompanied by arterial embolism. We experienced the case of a 61-year-old male who suffered from a paradoxical systemic air embolism while we removed a CVC. Immediate resuscitation and venovenous extracorporeal membrane oxygenation support saved his life. Multiple end-organ damage related to the systemic air embolism was noted, including the kidney, liver, and brain. In echocardiography, multiple air bubbles and an atrial septal defect were observed. An air embolism is preventable with appropriate precautions and techniques. Therefore, it is important to identify errors and prevent occurrence.
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Undiagnosed autoimmune hepatitis causing prolonged mechanical ventilation p. 179
David W Mattingley, Thomas J Papadimos
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