Deceased organ donors in an intensive care unit (ICU) are the richest source of organs for transplantation. Careful donor maintenance plays a vital role in the successful functioning of the organ in the recipient. Aims: Early identification of brain stem death (BSD) in the ICU, problems and management in donor maintenance till retrieval are the main objectives. Materials and Methods: BSD was identified in a level I trauma center over a period of eight years (1996-2004) using UK code. After screening for fitness, they were maintained to achieve normothermia, systolic BP > 90 mm Hg, CVP 8-10 cm water, urine output > 80 ml/hour and normal acid base balance. Results: 168 cases of BSD were maintained, 30 with identity unknown. Common transient complications noted were hypotension (68%), hypokalemia (62%), hypothermia (12%), diabetes insipidus (70%). Brain stem death was identified early and resuscitated to maintain normal tissue perfusion. 17 (12.3%) consent for organ donation was obtained. Organs (24 kidneys and one liver) were retrieved from 12 donors. Four donors sustained cardiac arrest before retrieval. Conclusion: Early recognition of brain stem death and prompty correction of hemodyanamic instability is the key to deceased donor maintenance. Optimal care of potential donor translates to care of multiple recipients.

Purpose: The esophageal Doppler monitoring (EDM) has emerged as an alternative to the pulmonary artery catheter (PAC). The purpose of this study is to better define its role in the ICU. Materials and Methods: Retrospective review of Hemosonic[TM] 100 EDM probe use between 2003 and 2005. Patient- and EDM-related characteristics, indications, complications, resuscitation end points (lactate, base excess - BE, left ventricular ejection time - LVET) were recorded. Comparisons between EDM and PAC were made. Results: Thirty-nine patients were monitored using the EDM. EDM-guided interventions resulted in significantly improved lactate, BE and LVET (all, P < 0.01). The change in BE correlated with change in LVET (R=0.7143, P < 0.0002). Cardiac output (CO) measurements by EDM and PAC were compared using the Bland-Altman method (mean = 0.0167, standard deviation = 0.9351, variance = 0.8745, 95% CI -1.854 to 1.887), which demonstrated that the EDM tended to underestimate CO in the lower ranges of measurements and overestimate CO in the upper ranges. Conclusions: EDM may be most helpful in ventilated/sedated patients requiring short-term hemodynamic monitoring. When compared to PAC, the EDM tends to underestimate CO in the lower range and overestimate CO in the upper range of measurements. We recommend EDM use concurrently with end-points of resuscitation.

Background and Aims: The study evaluates the utility of therapeutic intervention scoring system (TISS-28) in quantifying the resource utilization, costs and predicting outcome of critically ill patients. Materials and Methods: TISS-28 was prospectively applied to patients consecutively admitted to the intensive care units (ICU) of three public teaching hospitals and two private hospitals in Trinidad on a daily basis for a period of eight weeks. Demographic data, diagnoses on admission, nurse-patient ratio, ICU length of stay and hospital outcomes were recorded. Simplified acute physiology score (SAPS)-II was applied for all adult patients. Costs were calculated from data collected from the public hospitals in relation to TISS-28 score. Results: TISS-28 scores of five hundred and ninety-five patient-days were analyzed. The median daily TISS-28 per patient was 27 [24.5, 30.6 quartiles (IQR)]; the median day-1 TISS-28 score was 29 (25, 33 IQR) and the median last day TISS-28 score was 25 (21, 30 IQR). The overall average TISS per nurse was 26.2 per day. The mean cost per patient per day was 414 US dollars. The discriminatory function of day-1 TISS-28 as a prognostic scoring system was less compared to SAPS II as shown by the area under the receiver operating characteristic curve (0.65 compared to 0.71). Conclusions: TISS-28 is useful for evaluating the resource utilization and costs and may not be useful as a prognostic scoring system

Introduction: The frequency of invasive mycoses has increased dramatically during the past two decades owing to medical advances such as intensive cancer chemotherapy, broad-spectrum antimicrobial therapy, invasive medical devices, organ transplantation, human immunodeficiency virus (HIV) disease epidemic and an expanding aging population. There were few Indian studies regarding the incidence and risk factors for candidemia. Hence the aim of this work was to evaluate the changes in the prevalence of candidemia and invasive candidiasis in a tertiary care hospital and also to assess the risk factors and predictors of mortality Materials and Methods: Nonsystematic review of patients with candidemia/invasive candidiasis was done during the period 1999 to 2004. All in-patients who had shown signs and symptoms of nosocomial blood stream infection were screened for candidial infection. Among these, 29 patients had candidemia/invasive candidiasis. Demographic and clinical data of these patients were recorded on a standardized form, which included age, sex, site of isolation, infectious diagnosis, underlying conditions, predisposing factors, catheter status and clinical outcome. The data were collected during the years of 1999 to 2004, which is divided into two time periods (1999-2001 and 2002-2004). Data collected during these different time spans are compared with each other. Results: A total of 255 patients were screened during the study period. Among these, 100 patients were screened during the period 1999-2001 and 155 patients were screened during the year 2002-2004. Out of these patients, 29 showed positive cultures in blood or other sterile site (ascitic fluid, bronchial aspirate and urine from suprapubic puncture). Out of these, 24 were males and five were females. The most common risk factor was use of intravenous canulae (62.1%), followed by prolonged use of antibiotics (34.5%) and HIV infection (24.1%). There were no statistically significant differences in the risk factors during the two different study periods. Candida was mainly isolated from blood (75.9%). Other sources included ascitic fluid (10.4%), bronchial aspirate (3.4%), sputum (3.4%) and urine (6.9%). Distributions of sources were comparable during the two study periods. Candida albicans, Candida tropicalis and Candida parapsilosis caused 89.7%, 3.4%, 6.9% of the candidemia episodes respectively. The overall mortality was 51.7%. Conclusion: The present study emphasizes the importance of candidemia among hospitalized patients. Continued surveillance of candidemia will be important to track trends of this serious infection and to document changes in its epidemiological features. More active screening in high-risk groups should be done to avoid diagnostic delay. Risk factors like prolonged use of multiple antibiotics, central venous catheters, mechanical ventilation and prolonged hospital stay should be restricted whenever possible. Timely use of antiretroviral drugs and other measures to improve the immunity of HIV patients may help to decrease the incidence of candidemia in this patient population.

Ingestion of copper sulphate is an uncommon mode of poisoning in the Indian subcontinent. Cases are mainly suicidal in nature. The clinical course of the copper sulphate intoxicated patient is often complex involving intravascular hemolysis, jaundice and renal failure. The treatment is mainly supportive. In severe cases methemoglobinemia needs treatment. Mortality is quite high in severe cases. A comprehensive review of the clinical presentation and management of copper sulphate poisoning is done.

There have been important advances in the science of neonatal resuscitation and various international resuscitation committees have formulated evidence-based recommendations for the performance of resuscitation at birth. The new guidelines for resuscitation at birth were developed by International Liaison Committee on Resuscitation (ILCOR) and were presented at 2005 International Consensus Conference on Emergency Cardiovascular Care and Cardiopulmonary Resuscitation Science with treatment Recommendations. The European Resuscitation Council (ERC) and American Heart Association (AHA) further tailored the guidelines to meet their specific needs. In this article we have discussed the new resuscitation guidelines for newborns issued by ILCOR, American Heart Association and European Resuscitation Council.

The natural history of chronic obstructive pulmonary disease (COPD) is characterized by progressive decrements in expiratory airflow, increments in end-expired pulmonary volume, hypoxaemia, hypercapnia and the progression of pulmonary arterial hypertension (PAH). Noninvasive positive pressure ventilation (NPPV) treatment is increasingly used for the treatment of acute and chronic respiratory failure in patients with COPD. NPPV can increase PaO₂ and decrease PaCO₂ by correcting the gas exchange in such patients. The acute effect of NPPV on decreasing PAP is seen in patients with respiratory failure, probably due to the effect on cardiac output. Here, a case with COPD whose respiratory acidosis and PAH rapidly improved by NPPV was presented and therefore we suggested to perform an echocardiographic assessment to reveal an improvement of PAH as well as respiratory acidosis, hypercapnia and hypoxemia with that treatment.

Internal jugular vein is the preferred route for central venous cannulation because of easy accessibility and high success rate. Arterial puncture is the most common complication, the reported incidence being 9.3%. However, brachial plexus palsy following arterial puncture is a rare complication of this procedure. We report a case of brachial plexus palsy due to compression by right subclavian pseudoaneurysm as a result of internal jugular vein cannulation in chronic renal failure patient.

Pancreatic injury following blunt abdominal trauma is rare as compared to other visceral organs. Isolated injury to the pancreas is even more rare. The clinical presentation is subtle resulting in delayed treatment with high morbidity and mortality. A three-year-old female child presented with vomiting 18h following a motor vehicle accident. She was hemodynamically stable with no external signs of injury. Investigations revealed hyperamylasemia and isolated grade III pancreatic injury. Laparotomy with distal pancreatic resection and splenectomy was done. A high degree of clinical suspicion with due consideration to the mechanism of injury is the key to good outcome in these patients. Major ductal injury is the critical issue in the management and a number of therapeutic choices are available specific to the location of the insult.

There is a growing concern about the rapid rise in resistance of Staphylococcus aureus to antimicrobial agents. Our objective was to determine the prevalence and pattern of antibiotic sensitivity among Methicillin-resistant and Methicillin-sensitive Staphylococcus aureus in Surat, South Gujarat, India. Covering the period of three months from August-2004 to October 2004, we processed the samples of Pus, Urine, Blood, high vaginal swabs, Sputum, throat swabs, drains and ear swabs received from New Civil Hospital, Surat. Total 135 Staphylococci were isolated, out of which, 48 (35.55%) were coagulase positive. These coagulase positive Staphylococci isolates were screened for Methicillin-resistance by a slide latex agglutination kit for the rapid detection of PBP2′ (Penicillin binding protein 2a). Sensitivity to amikacin, erythromycin, clindamycin and tetracycline were also carried out following Kirbey Bauer disc diffusion method. Methicillin resistance among the Staphylococcus aureus isolates was 39.5%. Resistance to all antibiotics tested among the Methicillin-resistance and Methicillin-sensitive, staphylococci was found to be 26.3% and 6.8% respectively, which is statistically significant. Methicillin-resistance is a useful marker in selecting appropriate antimicrobial agents for treatment of infections caused by S. aureus changing pattern of resistance of S. aureus makes its periodic surveillance mandatory.