Indian Journal of Critical Care Medicine

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2006 | October | Volume 10 | Issue 4

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EDITORIAL

J. V. Divatia

Delirium in the ICU

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:4] [Pages No:215 - 218]

   DOI: 10.4103/0972-5229.29838  |  Open Access |  How to cite  | 

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RESEARCH ARTICLE

Azim Honarmand, Mohammadreza Safavi

The new injury severity score: A more accurate predictor of need ventilator and time ventilated in trauma patients than the injury severity score

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:6] [Pages No:219 - 224]

Keywords: Injury severity score, intubation, mechanical ventilation, new injury severity score

   DOI: 10.4103/0972-5229.29839  |  Open Access |  How to cite  | 

Abstract

Objectives: This study validates the accuracy of the injury severity score (ISS) and the new injury severity score (NISS) systems for prediction of need for intubation (NI), need for mechanical ventilation (NMV) and duration of MV (DMV) in intensive care unit (ICU) trauma patient admissions. Design: On the day of admission, data were collected from each patient to compute the ISS and NISS. Setting: Prospective cohort study. Materials and Methods: One hundred and ten nonselected trauma patients were included in our study in a consecutive period of six months. Results: The predictive accuracies of the ISS and the NISS were compared using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow (H-L) statistics for the logistic regression model of ICU admission. For prediction of NI, the best cut-off points were 22 for ISS and 27 for NISS. The positive prediction value was 91.6% in NISS and 87.8% in ISS. The Youden index had best cut-off points at 0.47 for NISS and 0.57 for ISS. The area under ROC curve was 0.79 in the ISS and 0.86 in the ISS. There were statistical differences among NISS with ISS in terms of Youden Index and the area under the ROC curve (P < 0.05). For the prediction of NMV, NISS yielded significantly better results in the area under the ROC curve and Youden index than those of ISS (P < 0.05). None of the two scoring systems provided good discrimination in prediction of more than three or five days assisted-ventilation under MV. Conclusions: For prediction of NI or NMV, the NISS has better accuracy than ISS.

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RESEARCH ARTICLE

Nissar Shaikh

Necrotizing fasciitis: A decade of surgical intensive care experience

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:5] [Pages No:225 - 229]

Keywords: Foot, leg, necrotizing fasciitis, streptococci, type 1

   DOI: 10.4103/0972-5229.29840  |  Open Access |  How to cite  | 

Abstract

Necrotizing fasciitis is a rare disease, potentially limb and life-threatening infection of fascia, subcutaneous tissue with occasionally muscular involvement. Necrotizing faciitis is a surgical emergency with high morbidity and mortality. Aim: Aim of this study was to analyze presentation, microbiology, surgical, resuscitative management and outcome of this devastating soft tissue infection. Materials and Methods: The medical records of necrotizing fasciitis patients treated in surgical intensive care unit (SICU) of our hospital from Jan 1995 to Feb 2005 were reviewed retrospectively. Results: Ninety-four patients with necrotizing fasciitis were treated in the surgical intensive care unit during the review period. Necrotizing fasciitis accounted for 1.15% of total admissions to our SICU. The mean age of our patients was 48.6 years, 75.5% of the cases were male. Diabetes mellitus was the most common comorbid disease (56.4%), 24.5% patients had hypertension, 14.9% patients had coronary artery disease, 9.6% had renal disease and 6.4% cases were obese. History of operation (11.7%) was most common predisposing factor in our patients. All patients had leucocytosis at admission to the hospital. Mean duration of symptoms was 3.4 days. Mean number of surgical debridement was 2.1, mean sequential organ failure assessment (SOFA) score at admission to SICU was 8.6, 56.38% cases were type 1 necrotizing fasciitis and 43.61% had type 2 infection. Streptococci were most common bacteria isolated (52.1%), commonest regions of the body affected by necrotizing fasciitis were the leg and the foot. Mean intubated days and intensive care unit (ICU) stay were 4.8 and 7.6 days respectively. Mean fluid, blood, fresh frozen plasma and platelets concentrate received in first 24 hours were 4.8 liters, 2.0 units, 3.9 units and 1.6 units respectively. Most commonly used antibiotics were piperacillin with tazobactum and clindamycin. Common complication was ventricular tachycardia (6.4). 46.8% patients had multi organ dysfunction, 15 of them died giving a mortality of 16% in this study. Conclusion: Necrotizing fasciitis is more common in males, diabetes mellitus was the most common comorbid disease, type 1-necrotizing fasciitis was more common and the most common regions of the body affected by necrotizing fasciitis were the leg and the foot.

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RESEARCH ARTICLE

Devi Prasad Hegde, G. N. Kumaraswamy, Ratan Gupta, T. N. Girish

Correlation of mixed venous and central venous oxygen saturation and its relation to cardiac index

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:5] [Pages No:230 - 234]

Keywords: Cardiac index, central venous oxygen saturation, mixed venous oxygen saturation, shock

   DOI: 10.4103/0972-5229.29841  |  Open Access |  How to cite  | 

Abstract

Background and Aim: The clinical applicability of substitution of central venous oxygen saturation for mixed venous oxygen saturations in monitoring global tissue hypoxia is still a matter of controversy. Hence aim of the study is comparison of paired samples of mixed venous and central venous oxygen saturation and comparison in relation to cardiac index in varying hemodynamic conditions. Materials and Methods: Prospective clinical observation: Postoperative cardiac surgical ITU: 60 adult patients, >18 years of age of either sex: A PAC was inserted through ® IJV, triple lumen catheter was inserted through ® IJV. Blood samples were taken from distal tip of PAC and central venous catheters. An arterial blood sample was drawn from either radial or femoral arterial line. Measurements: Continuous cardiac output monitoring. Analysis of blood samples for hemoglobin concentration and oxygen saturation. Mixed venous oxygen saturations and central venous oxygen saturations were compared. The study was carried over a period of 30h in the postoperative period and samples were taken at 6h intervals. Patients were classified into three groups as follows depending on the CI: Low (< 2.5 L/m 2), medium (2.5-4 L/m 2), high (> 4 L/m2) and correlated with Svo 2 and Scvo 2. Results: 298 Comparative sets of samples were obtained. Svo 2 was consistently lower than Scvo 2 throughout the study period. The difference was statistically significant. By using Bland - Altman plot, the mean difference between Svo 2 and Scvo 2 (Svo 2 -Scvo 2) was - 2.9% ± 5.14 and confidence limits are + 7.17% and - 12.97%. The co-efficient r is > 0.7 throughout the study period for all paired samples. The correlation Svo 2 and Scvo 2 with cardiac index in all the three groups were >0.7. Conclusion: Scvo 2 and Svo 2 are closely related and are interchangeable. Even though individual values differ trends in Scvo2 may be substituted for trend in Svo 2

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REVIEW ARTICLE

A. Rudra, S. Chatterjee, J. Kirtania, S. Sengupta, G. Moitra, S. Sirohia, R. Wankhade, S. Banerjee

Postoperative delirium

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:6] [Pages No:235 - 240]

Keywords: Delirium, postoperative complications

   DOI: 10.4103/0972-5229.29842  |  Open Access |  How to cite  | 

Abstract

Postoperative delirium (POD) is frequently under diagnosed and more often than not, under treated. It is the final common manifestation of multiple neurotransmitter abnormalities; with features of impaired cognition, fluctuating consciousness and a disturbed sleep-awake cycle. At least 15% of elderly patients undergoing major procedures have POD, with an associated increase in mortality. Various risk factors and batteries of clinical examination have been devised to diagnose delirium, followed by a multifaceted approach to treatment, using biopsychological along with pharmacological intervention.

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REVIEW ARTICLE

A. Rudra, S. Chatterjee, S. Sengupta, S. Sirohia, R. Wankhade, T. Das

Fluid resuscitation in trauma

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:9] [Pages No:241 - 249]

Keywords: Fluid therapy, resuscitation, body fluids, water-electrolyte balance, trauma

   DOI: 10.4103/0972-5229.29843  |  Open Access |  How to cite  | 

Abstract

Appropriate fluid replacement is an essential component of trauma fluid resuscitation. Once hemorrhage is controlled, restoration of normovolemia is a priority. In the presence of uncontrolled haemorrhage, aggressive fluid management may be harmful. The crystalloid-colloid debate continues but existing clinical practice is more likely to reflect local biases rather than evidence based medicine. Colloids vary substantially in their pharmacology and pharmacokinetics, and the experimental finding based on one colloid cannot be extrapolated reliably to another. In the initial stages of trauma resuscitation the precise fluid used is probably not important as long as an appropriate volume is given. Later, when the microcirculation is ′leaky′, there may be some advantages to high or medium weight colloids such as hydroxyethyl starch. Hypertonic saline solutions may have some benefit in patients with head injuries. A number of hemoglobin solutions are under development, but one of the most promising of these has been withdrawn recently. It is highly likely that at least one of these solutions will eventually become routine therapy for trauma patient resuscitation. In the meantime, contrary to traditional teaching, recent data suggest that restrictive strategy of red cell transfusion may improve outcome in some critically ill patients.

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SHORT COMMUNICATION

Shivesh Prakash

Carbapenem sensitivity profile amongst bacterial isolates from clinical specimens in Kanpur city

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:4] [Pages No:250 - 253]

Keywords: Carbapenem resistance, Kanpur

   DOI: 10.4103/0972-5229.29844  |  Open Access |  How to cite  | 

Abstract

Emerging antibiotic resistance against carbapenems is a serious issue and urgent measures are required to curb such development of resistance. There is paucity of data on the prevalence of carbapenem resistance in the Indian literature. This study involves a retrospective analysis of culture and sensitivity data on 174 clinical specimens obtained from different hospitals in Kanpur. Of the specimens, 15% grew bacilli which were resistant to at least one of the carbapenems. Of these bacilli 92% were resistant to Meropenem and sensitive to Imipenem. Only one specimen, that of urine grew E-coli which was resistant to Imipenem but sensitive to Meropenem. Staphylococcus aureus constituted majority (77%) of the resistant bacilli. E-coli were the second most common resistant bacilli to be isolated. Pseudomonas aeruginosa constituted 8% (2) of the resistant bacilli. Mengiococcus isolated once from a cerebrospinal fluid specimen was sensitive to Imipenem but resistant to Meropenem. Of the E-coli isolates 3% (3) were resistant. Results indicate alarming increase in the incidence of carbapenem resistance.

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CASE REPORT

Nevin Kollannoor Chinnan, Ashraf Ibrahim Mohamed Shabaan, Sudheer D. Palkar

Delayed life-threatening hemothorax without rib fractures after blunt chest trauma

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:3] [Pages No:254 - 256]

Keywords: Blunt chest trauma, delayed hemothorax

   DOI: 10.4103/0972-5229.29845  |  Open Access |  How to cite  | 

Abstract

Delayed hemothorax in blunt chest trauma is described as a late presentation of hemothorax after a normal chest X-ray on admission. To detect this clinical entity a repeat chest X-ray is advised after six hours, especially when the first radiograph reveals rib or thoracic vertebral fractures or any significant injury to the thoracic viscera. However, this repeats chest X-ray examination is often not done in patients in whom a significant thoracic trauma has been excluded in the primary and secondary survey. Here, we discuss a case of massive delayed hemothorax after 16 hours of the blunt chest trauma despite a near normal admission chest X-ray and absence of significant chest trauma in the primary and secondary surveys.

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CASE REPORT

H. Narendra, K. R. Baghavan

Guide-wire embolism during subclavian vein catheterization by Seldinger technique

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:3] [Pages No:257 - 259]

Keywords: Central venous catheterization, complications, guide-wire embolism, seldinger technique

   DOI: 10.4103/0972-5229.29846  |  Open Access |  How to cite  | 

Abstract

Percutaneous cannulation of central veins by Seldinger technique is a popular approach in intensive care settings. We report a case of embolization of a complete guide-wire during such a procedure. Our case differs from the few earlier reported cases in that subclavian vein was the entry site. While reviewing the available literature, we discuss few reasons and management of such a mishap.

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CASE REPORT

Vivek , L. F. Tauro, M. Roshan, N. Hegde, K. S. Bhat

Multidrug resistant malaria in splenectomized patient

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:4] [Pages No:260 - 263]

Keywords: Malaria, multidrug resistant malaria, splenectomy

   DOI: 10.4103/0972-5229.29847  |  Open Access |  How to cite  | 

Abstract

Malaria is a dangerous infection in splenectomized individuals. In endemic areas, managing malaria in such individuals is a clinical challenge. In the tropics, death from malaria after splenectomy has been reported, but no formal study has been undertaken. Here we discuss a case of multidrug resistant malaria in a splenectomized patient, managed by antimalarial drugs and exchange transfusion with a successful outcome.

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Teaching Aids

A. Rudra, S. Pal, A. Acharjee

Postoperative fever

[Year:2006] [Month:October] [Volume:10] [Number:4] [Pages:8] [Pages No:264 - 271]

Keywords: Postoperative, fever

   DOI: 10.4103/0972-5229.29848  |  Open Access |  How to cite  | 

Abstract

Postoperative fever is one of the most common problems seen in the postoperative ward. Most cases of fever immediately following surgery are self-limiting. The appearance of postoperative fever is not limited to specific types of surgery. Fever can occur immediately after surgery and seen to be related directly to the operation or may occur sometime after the surgery as a result of an infection at the surgical site or infections that involve organs distant from the surgery. Therefore, during evaluating postoperative fever, it is important to recognize when a wait - and - see approach is appropriate, when further work-up is needed and when immediate action is indicated.

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