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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 9 | Issue 4
Page Nos. 155-231

Online since Wednesday, December 11, 2019

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EDITORIAL  

What's new in critical illness and injury science? Utility of central venous oxygen saturation to risk stratify septic patients p. 155
Jennifer L Stahl, Andrew C Miller
DOI:10.4103/IJCIIS.IJCIIS_100_19  
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ORIGINAL ARTICLES Top

Clinical evaluation of Ambu® Aura-i™ – A new intubating laryngeal mask airway as an independent ventilatory device and a conduit for tracheal intubation in pediatric patients p. 157
Triveni M Rangaswamy, Avnish Bharadwaj, Priyanka Jain
DOI:10.4103/IJCIIS.IJCIIS_11_19  
Background: Ambu® Aura-i™, a recently introduced second generation supraglottic airway device has been designed to function as an independent ventilatory device as well as a conduit for passage of conventional cuffed tracheal tubes through it. There is dearth of literature on experience of tracheal intubation through intubating laryngeal mask airway (ILMA) in paediatric age group. This study was conducted to study the ventilatory effectiveness and the intubating characteristics of Ambu® Aura-i™ in paediatric patients. Aim: To study the effectiveness of Ambu ® Aura-i ™ as a supraglottic device for its ventilatory effectiveness and intubation characteristics in paediatric patients. Objectives: To study the Ventilatory effectiveness of Ambu ® Aura-i ™ in terms of: 1) Time taken in insertion of Ambu ® Aura-i ™. 2) No of attempts made for successful insertion of Ambu ® Aura-i™. 3) Tidal volume attained on positive pressure ventilation. 4) Etco2, Spo2 and Leak pressure achieved. To study the Intubating characterstics of Ambu ® Aura-i ™ in terms of :- 1) Grade of alignment of the ventilating orifice achieved in relation to the larynx in the fibre optic view. 2) Time taken in intubation through Ambu ® Aura-i ™. 3) Number of attempts made in intubation. 4) Time taken for removal of the Ambu ® Aura-i ™ after intubation through it has been accomplished. Method: Sixty three children undergoing elective surgery under general anaesthesia requiring intubation of trachea, weighing between 5-30 kg were stratified into 3 groups (n= 21) each. Ambu® Aura-i™ size 1.5 , 2.0 ,2.5 were used based on their body weight for airway management. Ventilatory effectiveness was studied in terms of success rate, number of attempts made at insertion, time taken in insertion, tidal volume delivered and leak pressure achieved. Intubating characterstics studied during fibreoptic guided tracheal intubation included grade of alignment of the ventilating orifice achieved in relation to the larynx in fibre optic view, time taken in fibreoptic guided tracheal intubation, success rate and number of attempts made at intubation. Time taken in removal of the device and complications observed were also recorded. Results: Ambu® Aura-i™ insertion, fibreoptic guided tracheal intubation and device removal were successful in all the patients in first attempt. The mean time taken in successful device insertion was 10.83±2.04 sec. The mean tidal volume delivered was 7.88±1.33 ml/kg body weight and mean leak pressure achieved was 16.27±5.2 cm H2O. The fibreoptic guided intubation was possible in first attempt in 100% of the patients (n=63). The Fibre optic view was grade 1 in 82.55% patients (n=52 /63) and grade 2 in 17.46% (n=11/ 63) patients. The mean time taken in fibre optic guided intubation was 12.68 ±2.82 sec. The mean time taken in removal of the device over the tracheal tube was 12.27 sec. There was no significant incidence of trauma to soft tissues, sore throat, laryngospasm or hoarseness of voice. Conclusion: On the basis of observations of this study, we conclude that Ambu ® Aura-i ™ is not only an effective ventilatoy device, but also an excellent conduit for fibre optic guided intubation using conventional uncuffed endotracheal tube in paediatric patients. Ambu ® Aura-i ™ , is also valuable for establishing rapid airway access in emergent difficult paediatric airway.
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Role of central venous oxygen saturation in prognostication of patients with severe sepsis and septic shock in emergency medical services p. 164
Susheel Kumar, Gauri Jangpangi, Ashish Bhalla, Navneet Sharma
DOI:10.4103/IJCIIS.IJCIIS_19_19  
Introduction: All the components of early goal-directed therapy, especially central venous oxygen saturation (ScvO2) as one of the endpoints of resuscitation, may not have mortality benefit, more so after results of the Australasian Resuscitation of Sepsis Evaluation, A Randomized Trial of Protocol-Based Care for Early Septic Shock, and The Protocolised Management in Sepsis trials. However, extrapolating results from trials undertaken in the developed world may not be entirely appropriate. Materials and Methods: In this prospective observational study conducted in the emergency medical services, we aimed to find out the mean baseline ScvO2in a cohort of 200 patients presenting with severe sepsis/septic shock and its prognostic significance. The measurement of ScvO2was performed by sampling blood from the superior vena cava through the central venous catheter. Results: The mean age of patients was 46.70 ± 17.64 years. The mean ScvO2at baseline of the study cohort was 65.95 ± 20.70%. Based on initial ScvO2values, 104 (52%) patients had a lower ScvO2level, a priori classified as the hypoxic group. Sixty-five (32.5%) patients had an initial ScvO2level in between 70 and 89%, categorized as normoxic group, and the remaining 31 (15.5%) patients had high ScvO2, leveled as the hyperoxic group. Sixty-six (33%) patients had hospital mortality. Of 104 hypoxemic patients, 28 (26.9%) had hospital mortality. In this group, the mean ScvO2value in 28 nonsurvivors at baseline and after 6 h of resuscitation was 46.21 ±16.66% and 48.82 ±18.81%, respectively. Twenty-five (38.5%) patients had hospital mortality among 65 patients with baseline ScvO2value in the normoxic range. Hospital mortality figure stood at 13 (41.9%) patients in the hyperoxic group. Among patients in the hyperoxic group, the mean serum lactate value at baseline in nonsurvivors was 4.52 ± 2.95 mmol/L, significantly higher as compared to the mean value of 2.89 ± 1.55 mmol/L in survivors. The hyperoxia group had higher hospital mortality though it was not statistically significant. Conclusion: The mean baseline ScvO2was lower in our study cohort. In the hypoxic group, patients with hospital mortality had persistently lower ScvO2level during the first 6 h of resuscitation. Importantly, higher mortality in the hyperoxic group with high serum lactate emphasizes the point that ScvO2value should be analyzed along with serum lactate levels as complimentary resuscitation endpoints.
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Single center experience of managing methanol poisoning in the hilly state of uttarakhand: A cross sectional study p. 172
Manish Kumar, Nidhi Kaeley, Vempalli Nagasubramanyam, Bharat Bhushan Bhardwaj, Subodh Kumar, Ankita Kabi, Poonam Arora, Mridul Dhar
DOI:10.4103/IJCIIS.IJCIIS_49_19  
Background: In this article, we describe our experience in managing one of the worst tragedies of an outbreak of methanol poisoning in the state of Uttarakhand in February 2019. It was reported that more than 100 people of Uttarakhand and neighboring districts of Uttar Pradesh succumbed to death after consuming this toxic alcohol laced with methanol. Materials and Methods: Demographic, clinical, and biochemical data were collected retrospectively from the hospital record section of the tertiary care hospital in the state of Uttarakhand. Results: Ninety-three patients of methanol poisoning were attended by the emergency medicine department of our hospital. The mean age of the patients was 38.9 ± 10.3 years. Majority of the patients were males (92/93). The most common clinical symptoms were gastrointestinal (56; 60.2%) followed by neurological (21; 22.6%) and respiratory (18; 19.3%). Most of the patients presented within 12–24 h after consumption of methanol. The mean of latent time of presentation was 4.8 ± 2.6 h. The mean values of pH, bicarbonate levels, lactate, and base deficit were 7.13 ± 0.6, 12.3 ± 6.4, 2.6 ± 0.8, and 15.6 ± 3.8 mmol/l, respectively. Acute kidney injury (26; 27.9%), blurring of vision (9; 9.6%), and sepsis (6, 6.4%) were common complications. Seven patients (7.5%) succumbed to death. Intensive alkali therapy was the main modality of treatment. Ethanol therapy was useful in patients resistant to alkali therapy. Sixteen (17.2%) patients with acute methanol poisoning were dialyzed once. Conclusion: Patients with acute methanol poisoning have varied presentations. Gastrointestinal symptoms are the most common presentation. Such outbreaks account for the heavy toll of mortality and morbidity in the society. Prompt diagnosis and a protocol based treatment can have a significant impact on the outcome of these patients. Thus, public health warning should be immediately issued with initial presentation of the casualties.
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Latin America intensive care unit disaster preparedness: Results from a web-based attitudes and perceptions survey p. 177
Amado Alejandro Baez, Kaitlin McIntyre
DOI:10.4103/IJCIIS.IJCIIS_61_18  
Background: Disasters burden on hospital emergency intensive care units (ICUs). This burden is increased in Latin America (LATAM) where hospital resources, intrahospital disaster simulations, and perceived level of preparedness vary greatly among different communities. The objective of the study was to assess LATAM ICU leaders' knowledge and attitudes regarding disaster preparedness. Methods: We developed a ten-item, web-based knowledge and attitude survey administered via LATAM ICU leaders online forums. Descriptive statistics were used. Epi Info™ software was used for analysis. Chi-square and Fisher's exact test with P < 0.05 were implemented for statistical significance, and odds ratio was used to measure the strength of association among variables. Results: There were 68 respondents in the survey. 13/68 respondents felt prepared for disasters. 16/68 worked at hospitals with 250+ beds and 52/68 represented hospitals with <250 beds. 23/68 participated in hospital committees for disaster, 24/68 participated in simulations or drills, and 22/68 participated in trainings or courses for disasters. Feeling prepared for disasters did not correlate with hospital size (odds ratio [OR] = 2.87 [95% confidence interval (CI): 0.83–9.92], P = 0.91), participation in hospital committees for disaster (OR = 3.10 [95% CI: 1.02–9.26], P = 0.08), and participation in simulations or drills (OR = 2.78 [95% CI: 0.93–8.29], P = 0.11), but participation in disaster trainings and courses appeared to directly correlate with the perception of being prepared (OR = 3.43 [95% CI: 1.13–10.41], P = 0.03). Conclusion: Among the 68 centers represented, the majority did not feel their institution to be adequately prepared for disasters, but training appeared to change that perception. A small sample size represents the major limitation of this study.
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Prone ventilation in H1N1 virus-associated severe acute respiratory distress syndrome: A case series p. 182
Jyoti Narayan Sahoo, Mohan Gurjar, Krantimaya Mohanty, Kalpana Majhi, G Sradhanjali
DOI:10.4103/IJCIIS.IJCIIS_62_18  
Background: Management of H1N1 viral infection-associated acute respiratory distress syndrome (ARDS) has primarily been focused on lung protective ventilation strategies, despite that mortality remains high (up to 45%). Other measures to improve survival are prone position ventilation (PPV) and extracorporeal membrane oxygenation. There is scarcity of literature on the use of prone ventilation in H1N1-associated ARDS patients. Methods: In this retrospective study, all adult patients admitted to medical intensive care unit (ICU) with H1N1 viral pneumonia having severe ARDS and requiring prone ventilation as a rescue therapy for severe hypoxemia were reviewed. The patients were considered to turn prone if PaO2/FiO2ratio was <100 cmH2O and PaCO2was >45 cmH2O; if no progressive improvement was seen in PaO2/FiO2over a period of 4 h, then patients were considered to turn back to supine. Measurements were obtained in supine (baseline) and PPV, after 30–60 min and then 4–6 hourly. Results: Eleven adult patients with severe ARDS were ventilated in prone position. Their age range was 26–59 years. The worst PaO2/FiO2ratio range on the day of invasive ventilation was 48–100 (median 79). A total of 39 PPV sessions were done, with a range of 1–8 prone sessions per patient (median three sessions). Out of the 39 PPV sessions, PaO2/FiO2ratio and PaCO2responder were 38 (97.4%) and 27 (69.2%) sessions, respectively. The median ICU stay and mechanical ventilation days were 15 (range: 3–26) and 12 (range: 2–22) days, respectively. The common complication observed due to PPV was pressure ulcer. At ICU discharge, all except two patients survived. Conclusion: PPV improves oxygenation when started early with adequate duration and should be considered in all severe ARDS cases secondary to H1N1 viral infection.
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Initial choice of antibiotic in recurrent spontaneous bacterial peritonitis: A retrospective study p. 187
Gayathri Vasanthakumari Sasidharan Nair, Prannoy George Mathen, M Gopalakrishna Pillai, KP Gireesh Kumar, KK Velayudhan, TP Sreekrishnan
DOI:10.4103/IJCIIS.IJCIIS_49_18  
Context: Spontaneous bacterial peritonitis (SBP) is a commonly encountered infection seen in the setting of ascites secondary to advanced liver disease. Recurrence of SBP is common and is associated with high mortality. This study was designed to recognize a better initial choice of antibiotic in case of recurrent SBP – a third-generation cephalosporin or a carbapenem. Aims: This study aims to determine a better initial choice of antibiotic in case of recurrent SBP and to compare the all-cause mortality among two different groups of patients treated with a third-generation cephalosporin and a carbapenem. Settings and Design: This study was conducted among fifty patients presenting with recurrent SBP visiting the emergency department (ED) at a tertiary care center and who were subsequently admitted in a gastroenterology intensive care unit, during a period of 1 year. Subjects and Methods: This is a retrospective, observational study conducted among patients with chronic liver disease and diagnosed with recurrent SBP visiting the ED at a tertiary care center in South India treated with either of two classes of antibiotics – third-generation cephalosporins or carbapenems, and their outcomes were compared. Recurrence is defined as an episode of SBP after resolution of the first index case of SBP within 1 year. Statistical Analysis Used: Statistical analysis was done using IBM SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were represented as percentages, and all continuous variables were represented as mean ± standard deviation. To test the statistical significance of the association of categorical variables with the outcome, Chi-square test was used. P <0.05 was considered statistically significant. Results: A total of fifty patients with recurrent SBP were included in the study, of which 44 (88%) patients were male and 6 patients were female (12%). Twenty-nine (58%) patients survived and 21 (42%) patients expired within 28 days. Twenty-seven (54%) patients were treated with third-generation cephalosporins and 23 (46%) were treated with carbapenems. It was observed that mortality was statistically significantly lower among patients treated with carbapenem (P = 0.001). The incidence of acute kidney injury was also lower among patients treated with a carbapenem than patients treated with a third-generation cephalosporin (40.7% vs. 59.25%, respectively). Conclusions: Initiation of a carbapenem significantly reduced the all-cause mortality when compared to a third-generation cephalosporin as an initial antibiotic of choice in recurrent SBP.
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CASE REPORTS Top

Emergency anesthetic management of an achondroplastic elderly gravida with polytrauma p. 191
Abhay Tyagi, Christopher Dass, Nageswara Tangirala Rao, Kapil Dev Soni
DOI:10.4103/IJCIIS.IJCIIS_56_19  
A 42-year-old pregnant female, diagnosed with achondroplasia, presented to our trauma center with multiple injuries after being involved in a motor vehicle accident. During her hospitalization, she underwent multiple surgeries and required admission in the intensive care unit. We describe the emergency anesthetic management of this patient, highlighting the effects of skeletal dysplasia on airway, cardiorespiratory system, and ventilatory mechanics. These effects, when superimposed upon with physiological changes of pregnancy, can lead to an unanticipated ventilatory challenge as we describe in this report.
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Scrub typhus – A case series from the state of Sikkim, India p. 194
Aroop Mohanty, Ankita Kabi, Pratima Gupta, Mithilesh Kumar Jha, U Sasi Rekha, Anusha Krishna Raj
DOI:10.4103/IJCIIS.IJCIIS_50_19  
Scrub typhus is one of the leading causes of acute febrile illness in India. It is associated with rash and often an eschar, which responds dramatically to antibiotics. In some cases, it results in serious illness leading to multiple organ involvement and finally death. The various clinical manifestations of scrub typhus arise mainly due to systemic vasculitis, caused by direct effects of organism as well as exaggerated immune response. The disease course is often complicated, leading to mortality in the absence of treatment. Here, in this case series, we describe three cases depicting the typical manifestations which a patient of scrub typhus can present with highlighting the fact that high index of clinical suspicion is of utmost importance for this deadly disease.
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A rare case of hypokalemic ventricular tachycardia in a patient with thyrotoxic periodic paralysis p. 199
Bader Abu Ghalyoun, Ibrahim Khaddash, Dema Shamoon, Hamid Shaaban, Michael Hanna, Satish Tiyyagura, Mourad Ismail
DOI:10.4103/IJCIIS.IJCIIS_39_17  
Thyrotoxic periodic paralysis (TPP) is a potentially fatal complication of hyperthyroidism, characterized by recurrent muscle paralysis and hypokalemia. We present a case of a 32-year-old apparently healthy male patient, who presented with acute paraparesis associated with hypokalemia (K: 1.6 mmol/L), complicated by ventricular tachycardia (VT). Advanced cardiac life support was initiated with an amiodarone infusion, and eventually QRS complex narrowed and wide complex tachycardia resolved. Intravenous potassium chloride (KCl) 40 mEq over 2–3 h and oral KCL 40 mEq were administered to treat the electrolyte imbalance. Patient paralysis was quickly reversed; motor function was regained with movement of the lower extremities. This case highlights the importance of early recognition and prompt treatment of TPP as a differential diagnosis for muscle weakness, especially in the setting of severe hypokalemia. It is important to pay attention to the possibility of the development of lethal VT associated with hypokalemia in the setting of hyperthyroidism and thyrotoxic paralysis.
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Swan-Ganz catheter causing anaphylactic shock: A rare case report p. 203
Muhammad Usman Asghar, Sanwal Singh Mehta, Hira Asif Cheema, Krishna Kommineni
DOI:10.4103/IJCIIS.IJCIIS_42_19  
Latex-induced anaphylactic reactions are often underestimated in patients having procedures in a catheterization lab, intensive care units, or in operating rooms. Most physicians are not aware that almost all balloons in the Swan-Ganz catheter (SGC) are made up of latex. Direct exposure of these latex balloons in the blood can cause severe anaphylactic reactions, even in patients with no previous history of allergies. We present a case of a 53-year-old male, who underwent a SGC placement for cardiovascular evaluation. Immediately after the SGC insertion, he developed circulatory shock. On further investigation, we discovered that SGC balloon contained latex as one of the components. Physicians should be aware of latex-based products such as SGC balloon, which can cause anaphylactic shock even in case of no prior allergies to latex.
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CONFERENCE ABSTRACTS AND REPORTS Top

Selected long abstracts from the St. Luke's university health network quality awards program (2018) p. 206
Diana M Tarone, Donna Sabol
DOI:10.4103/IJCIIS.IJCIIS_42_19  
The St. Luke's Annual Quality Awards Program was created in 2008 to promote innovation and quality improvement throughout the network. The awards ceremony is held annually in conjunction with National Healthcare Quality Week in October. The program is open to all nine campuses in our network and other entities including inpatient and outpatient units, and both clinical and nonclinical areas that contribute to our high-quality care and excellent patient outcomes. Here we include selected long abstracts representing some of the most meritorious quality project submissions for the past two academic years. The following core competencies are addressed in this article: Interpersonal and communication skills, Medical knowledge, Patient care, Practice-based learning and improvement, Professionalism, Systems-based practice.
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