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   Table of Contents - Current issue
Coverpage
July-December 2017
Volume 6 | Issue 2
Page Nos. 791-836

Online since Tuesday, August 8, 2017

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EDITORIAL  

Cardiopulmonary resuscitation in adult patients in prone position p. 791
Pawan Nanjangud, Anitha Nileshwar
DOI:10.4103/ijrc.ijrc_3_17  
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REVIEW ARTICLES Top

Emergency front of neck access p. 793
Martin Ince, Venkata Krishnakar Melachuri
DOI:10.4103/ijrc.ijrc_7_17  
The “Can't Intubate, Can't Oxygenate” (CICO) situation, while rare, is one of the most emergent and stressful scenarios ever faced by airway practitioners. Failure to provide adequate oxygenation can rapidly result in hypoxic brain injury and death. Emergency front of neck access provides a last resort, lifesaving route for the invasive oxygenation of patients. Adequate forward planning as well as recognition of at-risk patients is critical to avoidance of CICO situations. Multiple strategies exist for performing emergency front of neck access, and much debate exist as to which strategy is superior. All airway practitioners should be trained in at least one method of emergency front of neck access, as it may be required in unfamiliar environments at any time. A thorough understanding of the anatomy involved is important to avoid complications, and regular training has been shown to be vital to the maintenance of the skill. It is often the case that front of neck access is performed too late and a great emphasis has been placed on promoting a timely performance of the procedure.
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Tracheostomy tube displacement: An update on emergency airway management p. 800
Rajkumar Rajendram, Muhammad Faisal Khan, Alex Joseph
DOI:10.4103/ijrc.ijrc_12_17  
The formation of tracheal stomas and insertion of tracheostomy tubes is increasing in frequency. Although tracheostomy tube displacement is uncommon, the associated mortality is high. This is because rapid intervention is required, management is often difficult and even specialists in airway management often have limited experience with tracheostomized patients. Anyone caring for a patient with a tracheostomy should be aware of the clinical presentation of tracheostomy tube displacement and be able to manage it rapidly. This review describes the application of fundamental principles of airway management to tracheostomy tube displacement to reinforce its similarity to most other airway emergencies. The first and most important question is: Does the airway need to be re-secured? If so can the tracheostomy be reinserted easily? Assessment of the patient's upper airway must determine whether translaryngeal oxygenation and endotracheal intubation are possible. Information about the other factors that influence management can be obtained from the medical records about the formation of the tracheal stoma. Even airway specialists find it challenging to acquire and process this information to formulate an appropriate management plan, off the cuff, in the heat of the moment. Hence, multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies recommend that this information be displayed on posters at the bedside. This poster should also be accompanied by a written plan for emergency orotracheal intubation or tracheostomy replacement in the event of an airway emergency. All the equipment required to execute these plans should be immediately available at the bedside.
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Liver support devices: Bridge to transplant or recovery p. 807
Nandhini Anamthuruthil Joseph, Lakshmi Krishna Kumar
DOI:10.4103/ijrc.ijrc_11_17  
Liver failure, whether acute or acute on chronic, is a devastating disease with a very high mortality and morbidity. The recent therapeutic advances, especially liver transplant, have given reason for optimism to the ever-rising population affected by this disease. However, scarcity of organs and lack of resources make this an option that only few can afford. The hunt for an artificial device to assist or replace the functions of the liver has been on the rise since the past 40 years. These devices are classified into artificial and bioartificial liver (BAL) assist devices. Artificial liver devices such as molecular adsorbent recirculating system, Prometheus, single-pass albumin dialysis, and selective plasma filtration therapy are mostly aimed at taking over the blood purification systems of the liver. BAL-assisted devices incorporate hepatic cell lines to obtain a more comprehensive coverage of the complex functions of the liver. These include extracorporeal liver assist device, modular extracorporeal liver support, HepatAssist, and Amsterdam Medical Centre-BAL. Development of an ideal liver assist device has been difficult due to the complexity of the functions of the organ. The initial studies on these devices are promising but inconclusive. Therapeutic plasma exchange seems to have a very favorable profile in the treatment of these patients and has been successfully used in a large number of patients. To arrive at a more definitive conclusion of the usefulness of these devices in the management of liver failure, large randomized multicentric studies with more objective end points need to be carried out. A literature review was performed using PubMed and library searches to collect the recent studies in this regard. This review aims to provide a myopic view of the advances that have been made in the development and usefulness of these liver assist devices.
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Role of physiotherapy in weaning of patients from mechanical ventilation in the Intensive Care Unit Highly accessed article p. 813
Anup Bhat, Lenny T Vasanthan, Abraham Samuel Babu
DOI:10.4103/ijrc.ijrc_8_17  
Admission to an Intensive Care Unit (ICU) initiates an interprofessional and interdisciplinary approach to bring the patient back to health with normal or near normal function. Physiotherapists play a vital role in restoring function to the patient. The role of physiotherapy (PT) in the ICU has moved from primarily being one of only respiratory care to one that also encompasses early rehabilitation and exercise training. Early mobilization in the ICU has gained prominence in the recent years and is becoming standard practice across many centers. However, the impact on weaning with these interventions is not known. This review highlights the dysfunctions from an ICU admission and the rationale for instituting early PT in the ICU. In addition, evidence from systematic reviews and meta-analysis is reviewed to determine the impact of PT interventions on weaning. Evidence suggests the benefit of active mobilization and inspiratory muscle training in facilitating weaning. In addition, these interventions along with neuromuscular electrical stimulation further improve physical function and reduce the risk of critical illness polyneuromyopathy. Therefore, early PT does have significant functional benefits to ICU patients. However, more studies are required to determine how various interventions and intensities of exercise training improve weaning outcomes.
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ORIGINAL ARTICLES Top

A prospective observational study to evaluate the severity assessment scores in community-acquired pneumonia for adult patients p. 820
Akhila Babu, Nybin Jose, Jona Jose
DOI:10.4103/ijrc.ijrc_16_17  
Introduction: Assessment of severity is the first step for determining whether a patient diagnosed with community-acquired pneumonia (CAP) needs to be admitted to the hospital or can be treated on outpatient basis. Aim: This study compares the ability of three severity scoring systems, systolic blood pressure, multilobar chest radiography involvement, albumin level, respiratory rate, tachycardia, confusion, oxygenation, and arterial pH (SMART-COP), confusion, urea nitrogen, respiratory rate, blood pressure less than 90/60 mm Hg and age over 65 years (CURB-65), and pneumonia severity index (PSI) to predict the need for mechanical ventilation and inotropic support among adult patients admitted to the hospital. Methodology: This was an observational study conducted on patients admitted from March 2016 to July 2016 to the Intensive Care Unit (ICU). Demographic data, severity scores from CURB-65, PSI, and SMART-COP, were documented. Patients were followed up for the need for mechanical ventilatory/inotropic support. The overall mortality of patients with CAP was recorded. Results: A total of eighty patients with CAP were included in this study. Forty-seven (59%) were male. A CURB-65 severity score ≥2 had a sensitivity, specificity, and negative predictive value (NPV) of 85.7%, 47.5%, and 9.7%, respectively, for ICU admission. For a PSI severity score ≥4, the sensitivity, specificity, and NPV were 71.4%, 46.8%, and 18.6%. SMART-COP severity score >3 had a sensitivity, specificity, and NPV of 85.7%, 62.4%, and 20.7%, respectively. In predicting inotropic support, CURB-65 (PSI, SMART-COP) had sensitivity of 85.4% (80.5%, 90.2%), specificity of 64.1% (64.1%, 81.5%) and NPV of 19.4% (24.2%, 28.8%). Conclusions: SMART-COP scoring system is superior to CURB-65 and PSI in predicting the need for mechanical ventilation and inotropic support.
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Concordance between microorganisms isolated from subglottic secretions and bronchoalveolar lavage fluid in patients with ventilator associated pneumonia in Intensive Care Unit p. 824
Kapil Alias Mohit Chilana, Latha Sarma, Nandan Putti, Sambit Sahu, Suchira Chillana
DOI:10.4103/ijrc.ijrc_15_17  
Introduction: Nosocomial pneumonia is a common complication in critically ill patients. Mechanical ventilation has been consistently identified as the greatest risk factor for the development of nosocomial pneumonia. Aims: The purpose of the current study is to find the concordance between microorganisms cultured from subglottic secretions and bronchoalveolar lavage fluid (BALF) and to assess the effectiveness of subglottic suctioning for prevention of ventilator-associated pneumonia (VAP). Patients and Methods: This was a prospective, interventional, cohort study. Patients between 15 and 85 years who developed VAP after receiving mechanical ventilation were enrolled in the study. They were randomly divided into two groups: Group No Subglottic Secretion Drainage (NSSD) and Group Continuous Subglottic Secretion Drainage (CSSD). Results: The mean age of the patients was 56 ± 13 years. Fifty-eight percent were males and 42% were females. The incidence of VAP among NSSD group was 41.7% and in CSSD group was 25%. The coefficient of correlation was calculated for the microorganisms cultured in subglottic and BALF using Pearson's correlation. The correlation coefficient was 0.78 for the entire population (P = 0.01). In the NSSD group, it was 0.82 (P = 0.01), and in the CSSD group, it was 0.76 (P = 0.01). The mean Intensive Care Unit (ICU) stay is maximum in NSSD group (12.9 ± 1.84 days) compared to CSSD group (9.2 ± 1.17 days). Conclusion: The concordance of organism grown in subglottic secretions and BALF culture is higher in NSSD group as compared to CSSD group. CSSD is an effective means of reducing the number of ventilator days and ICU stay.
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Perception and knowledge of tuberculosis and its services among slum dwellers in Chhattisgarh p. 828
Janmejaya Samal
DOI:10.4103/ijrc.ijrc_10_17  
Background: The level of knowledge and behavior of tuberculosis (TB) patients and the vulnerable population can affect the control of TB in a particular community. Objective: The main objective of this study was to assess the level of knowledge and behavior regarding TB among slum dwellers in Chhattisgarh, India. Materials and Methods: A total of 100 families were selected from two different slum areas in Durg district of Chhattisgarh through simple random sampling technique. A structured questionnaire was used to collect the information from the slum dwellers. Results: Ninety-five percent of the respondents knew that TB is caused by bacteria, 82% knew that TB is transmissible, 63% were aware of different modes of TB transmission, 97% could tell about the symptoms of TB, and 76% of participants were aware about the curability of TB. Seventy-five percent of the slum dwellers were aware that TB treatment is free of cost at public health facilities; 68% were aware that TB is preventable, and 91% could tell about various preventive measures of TB. It was observed from this study that the slum dwellers have relatively poor knowledge about the modes of TB transmission and its preventability showing that proper health education approaches must be implemented to bring down this knowledge gap. Conclusion: Health education and awareness programs need to be carried out to further improve the knowledge of slum dwellers. This would ensure their seeking proper help at appropriate time and place and take precautionary measures against contracting TB.
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CASE REPORTS Top

Pneumothorax after insertion of nasogastric tube p. 832
Muhammad Faisal Khan, Rajkumar Rajendram, Mohammed Ahmed Abdou
DOI:10.4103/ijrc.ijrc_4_17  
A 65-year-old man was admitted to the Intensive Care Unit (ICU) for invasive mechanical ventilation after a significant intraventricular bleed. When his nasogastric tube (NGT) was accidentally removed, a new NGT was inserted blind. The pH of the thick green aspirate was under five and so enteral feeding was restarted. However, the patient subsequently deteriorated with rapidly worsening respiratory failure and invasive ventilation was required. An X-ray revealed misplacement of the NGT into the right lung with consolidation, pleural effusion, and pneumothorax. This highlights that indirect techniques to check NGT position (e.g., air insufflation and abdominal auscultation, aspirate appearance and pH) are unreliable. Even X-ray only detects misplacement after the event and mistakes have occurred because previous X-rays from the same patient have erroneously been reviewed. Only real-time visualization can prevent bronchopulmonary misplacement and the associated risks of pneumothorax and microbial contamination. The authors' current practice is therefore to use laryngoscopy, endoscopy, or fluoroscopy for insertion of all NGT in patients in ICU with impaired airway protective reflexes.
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Weaning in asthmatics: A finely supervised action p. 835
Sunil Kumar Garg, Pragya Garg
DOI:10.4103/ijrc.ijrc_14_17  
Respiratory failure from severe asthma is a potentially reversible, life-threatening condition. Since asthma involves bronchospasm and mucous plugging, it causes increased pressure difference between peak and plateau pressure. The increased pressure difference between the two can be due to ventilatory strategy of asthma itself which involves increased inspiratory flow rate and square flow pattern to increase expiratory time. It is important that clinicians managing such patients understand the use of mechanical ventilation since wrong interpretation may lead to inappropriate decision making during weaning.
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