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   Table of Contents - Current issue
January-June 2018
Volume 7 | Issue 1
Page Nos. 1-58

Online since Thursday, February 1, 2018

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Scientific writing p. 1
Anitha Nileshwar
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Strategies to prevent ventilator-associated lung injury in critically Ill patients p. 4
Alex Joseph, Muhammad Faisal Khan, Rajkumar Rajendram
Life-saving mechanical ventilation (MV) induces or exacerbates a range of pulmonary pathologies, collectively known as ventilator-induced lung injury if there is evidence of direct causation (i.e., in the research laboratory). However, in clinical practice, the term ventilator-associated lung injury (VALI) is more appropriate. While several factors are involved, the main drivers of the pathogenesis are regional overdistention and clinical atelectasis. This understanding has led to search for strategies to attenuate VALI and improve survival. The current approaches focus on reduction of lung stress and strain by limitation of alveolar–plateau pressure and tidal volume. Recent data suggest that control of driving pressure (plateau pressure–positive end-expiratory pressure) and mechanical power applied during ventilation may also be beneficial. More exciting are the various new techniques for MV (e.g., airway pressure release ventilation and neurally adjusted ventilatory assist), emerging alternative modalities for gas exchange (e.g., extracorporeal membrane oxygenation), and novel biological therapies (e.g., anti-inflammatory stem cells) that promise to revolutionize the management of respiratory failure and relegate VALI to the ash heap of history. However, there are currently insufficient data to recommend their use in routine clinical practice.
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Infection control in intensive care units p. 14
Chiranjay Mukhopadhyay
Infections acquired in the hospitals, especially in the intensive care unit (ICU) settings, ranging between 15% and 20%, may further lead to complications in >40% in critically ill patients. The order of incidence may vary in different settings, but the most usual causes are ventilator-associated pneumonia, intravascular catheter-associated bloodstream infection, catheter-associated urinary tract infection, posttraumatic intra-abdominal infection, and surgical site infection. These can be prevented by adequate and appropriate application of preventive strategies, which can be implemented strictly at the bedside. The basic norms for surveillance strategies, general preventive measures such as standard and isolation precautions and monitoring of antibiotic use should be followed without fail. Specific practical measures for ICU-related infections should be in place, and the monitoring of activities should be documented regularly as “bundle-care” in view of standardizing the practice, irrespective of place or person. Adequate attention, unfortunately, has not been paid for infection control measures in India for years. It is now mandatory that the essential practices are prioritized and integrated fully into regular hospital administrative procedure as a continuous process for improving quality health care.
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Strategies in patients with right ventricular failure on mechanical ventilation p. 22
Nitin Tanajirao Patil
Right ventricular failure is a complex clinical syndrome, and is a challenge for the intensivist to diagnose in critically ill patients, more so in patients receiving mechanical ventilation. Acute RV failure is a sudden deterioration of RV function and an inability of the RV to pump adequate cardiac output to the pulmonary circulation, thereby leading to inadequate cardiac output to the systemic circulation. The most common causes of acute RV failure are acute RV myocardial infarction, massive pulmonary embolism, congenital heart diseases, and severe pulmonary arterial hypertension. Over the years, RV has been considered a passive chamber of the heart and has received less focus about the way it functions and how efficiently the RV dysfunction can be managed. The National Heart Lung and Blood Institute in 2006 convened a working group to better understand the mechanisms of right ventricular dysfunction and the various ways and means to diagnose and manage right ventricular dysfunction.
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Temperature monitoring in the intensive care unit p. 28
Binila Chacko, John Victor Peter
Close monitoring and management of temperature abnormalities are crucial in the critically ill to minimize the physiological and biochemical ill effects of extremes of temperature. In the intensive care unit, core temperature monitoring using either urinary, nasopharyngeal, or esophageal temperatures is recommended. One needs to be aware of the pitfalls and fallacies of other commonly used sites.
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Screening for obstructive sleep apnea using epworth sleepiness score and berlin questionnaire: Which is better? p. 33
Ramakant Dixit, Satyadeep Verma, Kamender Singh Pawar
Background: Obstructive sleep apnea (OSA) is a highly prevalent, but underdiagnosed and undertreated disorder. There is a need for simple but accurate tool for early detection of patients based on their clinical symptoms and physical findings into high- or low-risk group and give information for urgent polysomnography (PSG) and further treatment to prevent serious consequences. Epworth Sleepiness Score (ESS) and Berlin Questionnaire (BQ) are the most popular and widely acceptable instruments for identification of high-risk patients of OSA. The aim of our study was to compare these two established and well-known sleep questionnaires regarding their ability to find out the probable cases of OSA in Indian scenario. Methods: This cross-sectional study was conducted at a tertiary care center on 72 adult patients with symptoms of sleep-related breathing disorders. All patients were asked to fill both ESS and BQ questionnaires. Subsequently, all patients were subjected to level-1 PSG. For each patient, the Apnea–hypopnoea index was calculated to assess the diagnosis and severity of OSA and to further compare the ESS and BQ questionnaires for their sensitivity (SN) in OSA patients. Results: A total of 14 (19.4%) patients were diagnosed as OSA by ESS while by BQ, 32 (44.4%) patients were diagnosed as having OSA with SN of 31% and 71.11%, respectively (P = 0.00004). The positive predictive value was 82.3% and 88.8% for ESS and BQ, respectively, with a negative predictive value of 43.6% by ESS and 63.8% by BQ questionnaires. Conclusion: ESS is a less sensitive diagnostic tool for early detection of high-risk patients of OSA in general population. BQ is a valid, reliable, and more sensitive parameter to screen patients for OSA and may help in improving the quality of life in such patients with proper OSA management.
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Comparison of extubation outcomes following T-piece trial versus pressure support/continous positive airway pressure in postsurgical patients p. 37
Lakshmi Kumar, AR Meghalakshmi, Anu Vasudevan, Sunil Rajan, Jerry Paul
Background: Pressure support with continuous positive airway pressure (CPAP) and T-piece trials are the most common spontaneous breathing trial used to test readiness for extubation. Aim: We aimed to compare extubation failures defined by the need for reintubation within 48 h following T-piece trial versus extubation directly from pressure support (PS) ventilation in postoperative patients. Patients and Methods: This was a prospective cross-sectional study conducted in the postsurgical patients. Hemodynamic parameters and respiratory variables were measured before and after weaning trials. Outcomes after extubation, need for noninvasive-assist ventilation following extubation, duration of oxygen therapy, and time of shifting from the Intensive Care Unit (ICU) were also recorded. Results: Fifty patients needed mechanical ventilation postoperatively were recruited for the study. No significant differences were seen in the rate of extubation failures between PS- and T-piece groups. Rapid shallow breathing index recorded at the start of weaning was significantly higher in the T-piece group (P < 0.001). The respiratory rate (RR) and heart rate (HR) were significantly higher (P < 0.001) and saturation lower (P = 0.035) in the group on T-piece trial. The need for respiratory assist devices, oxygenation index, length of ICU stay, duration of oxygen therapy, and mortality were comparable between the two groups. Conclusions: Outcomes of weaning are similar between T piece and CPAP/PS in patients undergoing postoperative mechanical ventilation. Weaning on T piece is associated with higher RR, HR, rapid shallow breathing, and lower saturation than weaning from CPAP/PS but does not affect the length of ICU stay, need for oxygen therapy, or mortality.
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Prospective comparative randomized controlled study to determine the optimal priming dose of atracurium p. 42
Arun Kumar Handigodu Duggappa, Shaji Mathew, Abhishek Rao Kordcal, Arun Chakravarthi, Shiyad Muhamed
Introduction: The advantages of the use of muscle relaxants in the current practice of balanced anesthesia are well documented. Most often, nondepolarizing muscle relaxants (NDMR) with minimal side effects are used to serve the purpose. Atracurium is a commonly used NDMR in day-to-day anesthetic practice, although it is not desirable for rapid sequence induction and intubation due to its late onset of action. To overcome this problem priming principle was introduced. Aim: This study aims to determine optimal priming dose of atracurium to speed up the onset of action. Patients and Methods: In this prospective randomized controlled study, 90 patients were allocated into one of the three groups by a computer-generated table of random numbers, i.e., Group A, B, and C. Total dose of atracurium used in all patients was 0.5 mg/kg body weight, including the priming dose. Each group received different priming doses of atracurium as follows: Group A received 0.05 mg/kg body weight, Group B received 0.025 mg/kg body weight, whereas Group C (control) received saline as priming dose. Results: Patients were comparable with respect to demographic data. The mean duration in seconds for train-of-four (TOF) count to reach zero were 147 s, 193, and 218 s in Group A, B, and C, respectively, with statistically significant P values. Of 60 patients who were administered atracurium as priming drug, two patient had ptosis at the end of 3 min after priming with 0.05 mg/kg body weight, with no other side effects. Conclusions: Priming principle employing atracurium reduces the time required for TOF count to reach zero by approximately 71 s while using 0.05 mg/kg body weight and by around 25 s while employing 0.025 mg/kg body weight, with clinically insignificant incidence of adverse effects.
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A clinical audit to assess the adherence of the code blue team to advanced cardiac life support protocol and its effect on the patient outcome in a Tertiary Care Hospital in Kochi, Kerala p. 46
Indhu Aynipully Jayasingh, R Athish Peter Margos, Shoba Philip
Introduction: Cardiopulmonary resuscitation is a sequence of techniques that combines chest compression with artificial ventilation to manually maintain the circulation to preserve intact brain function. The aim is to maintain circulation and breathing in a person who is in cardiac arrest until emergency aid arrives. Effective teamwork by Code Blue team raises chances of a successful outcome. The advanced cardiac life support (ACLS) guidelines were developed by the American Heart Association using the comprehensive review of resuscitation literature performed by the International Liaison Committee on Resuscitation. Aim: To assess adherence of Code Blue team to ACLS protocol, to assess outcome of resuscitation, and to compare outcome between those where ACLS guidelines were followed and those not followed. Patients and Methods: A clinical audit was done between 2014 and 2015 at Lourdes Hospital, Kochi, on inpatients aged between 30 and 80 years, with witnessed cardiac arrests/respiratory arrest. Pregnant and unwilling patients were excluded. Results: The common arrest rhythm was pulseless electrical activity, followed by asystole. ACLS protocol was followed in 58.7%. The most common deviation was usage of inappropriate drugs. Return of spontaneous circulation (ROSC) was attained in 53.3%, of which 28.5% were discharged (P < 0.05), which suggests a significant association between the adherence to ACLS protocol and ROSC. Conclusion: Although Code Blue team is ACLS trained, deviations occurred in nearly half of the resuscitations, which need to be reduced. Outcome was better in those resuscitations where the ACLS protocol was followed.
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Platypnea-orthodeoxia: Patent foramen ovale unmasked by pulmonary emboli p. 50
Grainne Gallagher, Alex Joseph, Rajkumar Rajendram
This report describes an 84 year old woman who presented with breathlessness from platypnea-orthodeoxia. This was due to a distortion of a patent foramen ovale by lower thoracic vertebral fractures which allowed a right-to-left intracardiac shunt. The right-to-left shunt was, in this case, triggered by small bilateral pulmonary emboli. Platypnea-orthodeoxia is rare, complex, and underdiagnosed. The pathogenesis requires an anatomical substrate for a shunt and a functional component that triggers reversal of the flow across it. Recognition is critical and may prevent provision of sedation, invasive ventilatory support, and vasopressor; all of which actually exacerbate right-to-left extrapulmonary shunt.
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Therapeutic implications of monitoring end-tidal carbon dioxide in submassive pulmonary embolism p. 53
Sunil Kumar Garg, Pragya Garg
While managing submassive pulmonary embolism in Intensive Care Unit, it is always a challenge to identify the parameters to identify the deterioration. It is important to understand it as further therapeutic decision about the use of thrombolytics is based on its recognition. Bedside monitoring of end-tidal carbon dioxide which is readily available, continuous, noninvasive, and nonoperator dependent can be of help in deciding on the need of thrombolytics in such cases before development of hypotension.
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Sting to the heart – Acute pulmonary edema following hymenoptera sting p. 56
Jijin Satheesh, Deepak Rajkumar Vangipuram, M Rajkumar
Hymenoptera stings have been reported earlier to cause mild local reactions to severe systemic reactions such as anaphylactic shock. Myocardial infarction following insect stings has been widely described. In this case, we describe a 64-year-old male patient who presented with pulmonary edema 4 h after the initial insult followed by a new onset myocardial infarction which was considered to be a variant of Kounis syndrome. The patient was managed in intensive care with diuretics, positive pressure ventilation, and glucocorticoids and made a complete recovery.
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