Afzal Azim

Salbutamol, beclomethasone or sodium chromoglycate suppress coughing induced byiv fentanyl

PurposeFentanyl, a synthetic opioid, is a popular choice amongst anesthesiologists in the operating room. Preinductioniv fentanyl bolus is associated with coughing in 28–45% of patients. Coughing due to fentanyl is not always benign and at times may be explosive requiring immediate intervention. We have studied the role of aerosol inhalation of salbutamol, beclomethasone and sodium chromoglycate in preventing fentanyl induced coughing and have compared their efficacy.MethodsTwo hundred patients aged 18–60 yr, undergoing elective laparoscopic cholecystectomy were randomized into four groups of 50 each. Group I served as control, while Groups II, III and IV received an aerosol inhalation of salbutamol, beclomethasone or sodium chromoglycate 15 min prior to entering the operating room. Followingiv fentanyl (2 μg · kg−1) the incidence of cough was recorded and graded as mild (1–2), moderate (3–5) and severe (> 5) depending on the number of coughs observed. Results were analyzed using‘z’ and Fischer’s Exact test. AP value of < 0.05 was considered significant.ResultsThe incidence of cough was 28% in the control group, 6%, 0% and 4% in the salbutamol, beclomethasone and sodium chromoglycate groups respectively. Occurrence of cough was significantly low (P ≤ 0.05) in the treatment groups, however the difference amongst the groups was not significant (P ≥ 0.05).ConclusionThe use of salbutamol, beclomethasone or sodium chromoglycate aerosol 15 min prior toiv fentanyl administration minimizes fentanyl-induced coughing.ZusammenfassungObjectifLe fentanyl, un opioïde synthétique, est très utilisé par les anesthésiologistes en salle d’opération. L’administration iv d’un bolus de fentanyl avant l’induction de l’anesthésie est associée à de ia toux chez 28–45 % des patients. Cette toux, pas toujours bénigne, peut parfois même être expiosive et nécessiter une intervention immédiate. Nous avons étudié ie rôie de l’inhaiation de salbutamol, de béclométhasone et de chromoglycate de sodium en aérosols dans la prévention de la toux induite par le fentanyl et nous avons comparé leur efficacité.MéthodeDeux cents patients de 18 à 60 ans, devant subir une cholécystectomie laparoscopique réglée ont été répartis au hasard en quatre groupes de 50. Le groupe I a servi de témoin, tandis que les groupes II, III et IV ont inhalé du salbutamol, de la béclométhasone ou du chromoglycate de sodium en aérosol, 15 min avant d’entrer dans la salle d’opération. Après l’administration iv de 2 μg · kg−1 de fentanyl, l’incidence de toux a été enregistrée et cotée comme légère (1–2), modérée (3–5) et sévère (> 5) selon le nombre d’accès de toux observés. Les résultats ont été analysés selon le test“Z” et le test exact de Fischer. Une valeur de P ≤ 0,05 a été considérée significative.RésultatsLincidence de toux a été respectivement de 28 % dans le groupe témoin, 6 %, 0 % et 4 % dans les groupes de salbutamol, béclométhasone et chromoglycate de sodium. L’occurrence de toux a été signifcativement faible (P ≤ 0,05) dans les groupes expérimentaux, même si la différence intergroupe n’a pas été significative (P − > 0,05).ConclusionL’usage de salbutamol, de béclométhasone ou de chromoglycate de sodium en aérosol, 15 min avant l’administration iv de fentanyl, réduit la toux induite par le fentanyl.

Managing aluminum phosphide poisonings.

Aluminum phosphide (AlP) is a cheap, effective and commonly used pesticide. However, unfortunately, it is now one of the most common causes of poisoning among agricultural pesticides. It liberates lethal phosphine gas when it comes in contact either with atmospheric moisture or with hydrochloric acid in the stomach. The mechanism of toxicity includes cellular hypoxia due to the effect on mitochondria, inhibition of cytochrome C oxidase and formation of highly reactive hydroxyl radicals. The signs and symptoms are nonspecific and instantaneous. The toxicity of AlP particularly affects the cardiac and vascular tissues, which manifest as profound and refractory hypotension, congestive heart failure and electrocardiographic abnormalities. The diagnosis of AlP usually depends on clinical suspicion or history, but can be made easily by the simple silver nitrate test on gastric content or on breath. Due to no known specific antidote, management remains primarily supportive care. Early arrival, resuscitation, diagnosis, decrease the exposure of poison (by gastric lavage with KMnO4, coconut oil), intensive monitoring and supportive therapy may result in good outcome. Prompt and adequate cardiovascular support is important and core in the management to attain adequate tissue perfusion, oxygenation and physiologic metabolic milieu compatible with life until the tissue poison levels are reduced and spontaneous circulation is restored. In most of the studies, poor prognostic factors were presence of acidosis and shock. The overall outcome improved in the last decade due to better and advanced intensive care management.

Epidemiology of bacterial colonization at intensive care unit admission with emphasis on extended-spectrum β-lactamase- and metallo-β-lactamase-producing Gram-negative bacteria - an Indian experience

An important risk factor for nosocomial infection in an intensive care unit (ICU) is prior colonization. This study was undertaken to determine the spectrum of bacterial colonization and predisposing risk factors in patients being admitted to an ICU in India, with special emphasis on extended-spectrum beta-lactamase (ESBL)- and metallo-beta-lactamase (MBL)-producing Gram-negative bacteria. Nasal, oral and rectal swab samples were collected and processed for isolation of ESBL-producing Gram-negative bacteria and MBL-producing Pseudomonas aeruginosa and Acinetobacter species. Bacterial colonization (of one or more sites) on admission was detected in 51 out of 96 patients included in the study. Non-fermenters, i.e. P. aeruginosa and Acinetobacter baumannii, were the most common colonizers, present in 37 patients, with simultaneous colonization in 12 patients. A total of 16 patients were colonized with MBL-producing members of the family Enterobacteriaceae, out of which 11 isolates (from 5 patients) were also carrying ESBL-encoding genes. As for MBLs, most of our patients have shown colonization with ESBL-producing bacteria. On admission, 47 of 51 patients (92 %) have been colonized by ESBL-producing members of the family Enterobacteriaceae, at one or more of the three anatomical sites. The most common MBL subtype was bla(IMP) (51.56 %), whereas bla(CTX) was the most common gene (84.9 %) identified among ESBL producers. Risk factors for colonization on admission to the ICU were hospitalization for more than 48 h, use of >or=3 groups of antibiotics, co-morbidities and mechanical ventilation for more than 48 h prior to ICU admission. There is an increasing incidence of MBLs and ESBLs in the Indian population. The identified risk factors can be used as a guide for empiric antibiotic therapy targeted to these resistant bacteria.

Metabolic profiling in human lung injuries by high-resolution nuclear magnetic resonance spectroscopy of bronchoalveolar lavage fluid (BALF)

We present a method for identifying biomarkers in human lung injury. The method is based on high-resolution nuclear magnetic resonance (NMR) spectroscopy applied to bronchoalveolar lavage fluid (BALF) collected from lungs of critically ill patients. This biological fluid can be obtained by bronchoscopic and non-bronchoscopic methods. The type of lung injury in acute respiratory failure presenting as acute lung injury (ALI) and its severe form, acute respiratory distress syndrome (ARDS), continues to challenge critical care physicians. We characterize different metabolites in BAL fluid by non-bronchoscopic method (mBALF) for better diagnosis and understanding of ALI/ARDS by NMR spectroscopy. NMR spectra of mBALF collected from 30 patients (9 controls, 10 ARDS and 11 ALI) were analyzed for the identification of biomarkers. Statistical methods such as principal components analysis and partial least square discriminant analysis were carried out on 1H NMR spectrum of mBALF to identify biomarker responsible for separation among different lung injuries classes (ALI and ARDS) and normal lungs. The corresponding correlation of biomarkers with metabolic cycle has given insight into metabolism of lung injuries in critically ill patients. Our study shows statistically significant differentiation of various metabolites concentration in mBALF collected from lungs of ALI, ARDS and healthy control patients, making NMR spectroscopy as a possible new method of characterizing human lung injury.

Prospective comparison of new Japanese Association for Acute Medicine (JAAM) DIC and International Society of Thrombosis and Hemostasis (ISTH) DIC score in critically ill septic patients

INTRODUCTION We prospectively compared the new Japanese Association for Acute Medicine (JAAM) score with the International Society of Thrombosis and Hemostasis (ISTH) score for diagnosis of disseminated intravascular coagulation (DIC) in septic patients admitted in a general critical care intensive care unit. MATERIAL AND METHOD Septic patients with platelet count of <150 × 10(9)/L were included. Both DIC scores were estimated from day 1 to day 4 along with APACHE II and SOFA scores. RESULTS Out of the 148 blood samples drawn from 42 patients (28 male & 14 female) the JAAM and ISTH DIC scores had an overall significant agreement (k=0.246, p<0.001) in 83 samples. JAAM score had higher diagnostic rates on all four days. Significant (p ≤ 0.001) day wise variation existed in JAAM and ISTH DIC scores. Correlation between JAAM DIC and ISTH DIC scores on day 1 (r=0.631) & day 4 (r=0.609) was significant (p<0.001). Pneumonia was the predominant cause of sepsis. Twenty seven (64.3%) patients died during their stay in ICU. Amongst DIC patients both severity scores (SOFA/APACHE II) and DIC scores (JAAM/ISTH) did not discriminate between survivors and non-survivors. Health care associated infection (p=0.040), high lactate levels (p=0.020) on day 1 and high procalcitonin levels (p=0.036) were found to have significant discriminating ability between survivors and non-survivors. Significantly shorter length of stay was observed amongst non-survivors (p=0.002). CONCLUSIONS In sepsis the JAAM DIC score identified most of the patients diagnosed by the overt ISTH criteria, but failed to discriminate between survivors and non-survivors amongst DIC patients.

Procalcitonin kinetics as a prognostic marker in severe sepsis/septic shock

Background and Aims: To evaluate the prognostic value of change (fall) in serum procalcitonin level (PCT) in critically ill adults with severe sepsis/septic shock. Methods: This was a prospective observational study in a general purpose Intensive Care Unit of a teaching Institute. PCT was measured at admission (D0) and after 72–96 h (D4) by electrochemi-luminescence immunoassay (BRAHMS PCT kit) in adults (>18 years) admitted with severe sepsis or septic shock. Change in procalcitonin values from D0 to D4 was correlated with the primary outcome, that is, 28 days mortality. All results are reported as median (interquartile range). Results: A total of 171 (100 males) of 181 patients were included. The median age was 46 years (range 19–79). 137 patients were in septic shock and 34 in severe sepsis. The sequential organ failure assessment (SOFA) score in all patients was 11 (9–14).91 (53.2%) patients survived at 28 days (survivors). The baseline procalcitonin was similar in two groups (3.48 [1.04–15.85] vs. 5.27 [1.81–23.57] ng/ml in survivors and nonsurvivors [NS] respectively). The procalcitonin change was 1.58 (0.20–8.52) in survivors and 0.28 (–1.38–6.17) in NS (P = 0.01). The C-statistic of percentage change in procalcitonin from D0 to D4 to predict survival was 0.73 (95% confidence interval [CI]: 0.65–0.82) when compared to 0.78 (95% CI: 0.71–0.86) for change of SOFA score. For an absolute fall in procalcitonin of >1 ng/ml, a 70% fall predicted survival with 75% sensitivity and 64% specificity. Conclusions: In critically ill-patients with severe sepsis/septic shock, change (fall) in procalcitonin is associated with good outcome.

Risk prediction for invasive candidiasis

Over past few years, treatment of invasive candidiasis (IC) has evolved from targeted therapy to prophylaxis, pre-emptive and empirical therapy. Numerous predisposing factors for IC have been grouped together in various combinations to design risk prediction models. These models in general have shown good negative predictive value, but poor positive predictive value. They are useful in selecting the population which is less likely to benefit from empirical antifungal therapy and thus prevent overuse of antifungal agents. Current article deals with various risk prediction models for IC and their external validation studies.

Carbapenem-resistant Acinetobacter ventilator-associated pneumonia: Clinical characteristics and outcome.

Objective: To study the clinical characteristics and 28-days mortality in patients with ventilator-associated pneumonia (VAP) due to carbapenem-resistant Acinetobacter (CRA). Design: Retrospective, observational, cohort study. Setting: Intensive care unit (ICU) of a university hospital. Materials and Methods: Microbiologically confirmed VAP due to CRA infection. Intervention: None. Results: Out of 87 patients with VAP due to CRA, 60 (69%) were male; whose median age was 51 years; 73 (84%) patients were medical; 26 (30%) had history of hospitalization in last 3 months; median acute physiology and chronic health evaluation (APACHE) II was 15 and median SOFA 9 at admission; primary reason for ICU admission was respiratory failure (34%); 46 (53%) patients had more than 2 organ failure at ICU admission; median length of ICU stay was 19 days; 66 (76%) patients need vasoactive agents during ICU stay, whereas 55 (63%) patients had renal failure; median duration of mechanical ventilation was 17 days; 22 (25%) patients had acute respiratory distress syndrome (ARDS) during ICU stay; 72 (83%) patients had exposure to carbapenem before inclusion in the study; 33 (38%) patients had same organism at other sites. In the follow-up, 47 (54%) patient survived at 28 days after having VAP; whereas only 40 (46%) patients were discharged from the hospital. Conclusions: CRA-VAP has high crude mortality. Advanced age; severity of illness and presence of pneumonia at ICU admission; and presence of shock, ARDS and renal failure have impact on outcome in these patients.

Accidental guide-wire loss during central venous catheterization: A report of two life-threatening cases

A 40‐year‐old female was transferred to our intensive care unit (ICU) with severe acute pancreatitis and respiratory distress. During initial management it was noticed that 7.5‐Fr central venous catheter (CVC), placed in her right subclavian vein during her prior hospitalization, was nonfunctional. Hence, right‐sided internal jugular vein was canulated. Reviewing her chest X‐ray (taken 2 dayspreviously) we were surprised to identify a guide wire along with the first CVC [Figure 1]. The guide wire could be felt after pulling the CVC out for a few centimeters but it seemed to be stuck within the catheter. We fixed the guide‐wire CVC assembly with artery forceps and gently pulled the entire assembly intact.

Clinical manifestations of co-infection with malaria and leptospirosis

Though both malaria and leptospirosis are frequent in the tropics, co-infections are under-recognized due to overlapping of clinical features. Here, we reviewed clinical manifestations of published co-infection along with our three cases. Out of a total of 18 patients, nine patients (50%) required ICU admission. Almost all patients had prodromal symptoms in the form of fever, headache and myalgia. Seven patients (37%) had altered sensorium, three patients (17%) had hypotension at admission, and 11 patients (61%) had acute kidney injury (AKI). Pulmonary manifestations in the form of pulmonary bleeding were present in four cases (22%). Three (17%) patients had acute lung injury/ acute respiratory distress syndrome. Almost 55% patients had DIC in the form of altered prothrombin time, activated partial thromboplastin time and low fibrinogen level. Four patients (22%) had subconjuctival suffusion, two of them had haematuria, while one presented with nasal bleeding. All patients had altered liver function tests. Of all the 18 patients, 17 (94%) survived, while one died.