Dilip R. Karnad

Prognostic factors in obstetric patients admitted to an Indian intensive care unit

Objectives:Obstetric patients form a significant proportion of intensive care unit admissions in countries like India, where maternal mortality is high (440 per 100,000 deliveries). We studied the diseases requiring intensive care and prognostic factors in obstetric patients. Design:Retrospective chart review. Acute Physiology and Chronic Health Evaluation (APACHE) II data were prospectively collected. Setting:Multidisciplinary intensive care unit of a public hospital in Mumbai, India. Patients:Women admitted during pregnancy or 6 wks post-partum during a 5-yr study period (1997–2001). Interventions:None. Measurements and Main Results:Four hundred fifty-three obstetric patients (age 25.5 ± 4.6 yrs [mean ± sd], mean gestational age 31 wks) were admitted (548 intensive care unit admissions per 100,000 deliveries), 138 with single organ failure and 152 with multiple organ failure. Ninety-eight women died (mortality rate 21.6%). Mortality was comparable in antepartum (n = 216) and postpartum (n = 247) admissions but increased with increasing number of organs affected. There were 236 fetal deaths (52%), of which 104 occurred before hospital admission. Median APACHE II score was 16 (interquartile range, 10–24), and standardized mortality ratio (observed deaths/predicted deaths) was 0.78. Compared with pregnant patients admitted with obstetric disorders (n = 313), those with medical diseases (n = 140) had significantly lower APACHE II scores (median 14 vs. 17) but higher observed mortality rate (28.6% vs. 18.5%; odds ratio, 1.76; 95% confidence interval, 1.08–2.87) and standardized mortality ratio (1.09 vs. 0.66). On multivariate analysis, increased mortality rate was associated with acute cardiovascular (odds ratio, 5.8), nervous system (odds ratio, 4.73) and respiratory (odds ratio, 12.9) failure, disseminated intravascular coagulation (odds ratio, 2.4), viral hepatitis (odds ratio, 5.8), intracranial hemorrhage (odds ratio, 5.4), absence of prenatal care (odds ratio, 1.94), and >24 hrs interval between onset of acute symptoms and intensive care unit admission (odds ratio, 2.3). Conclusions:Multiple organ failure is common in obstetric patients; mortality rate increases with increasing organ failure. APACHE II scores overpredict mortality rate. Standardized mortality ratio is lower in obstetric disorders than in medical disorders. Lack of prenatal care and delay in intensive care unit referral adversely affect outcome and are easily preventable.

Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: A randomized controlled trial

Objective: To determine whether metoclopramide prevents nosocomial pneumonia in intensive care unit (ICU) patients receiving enteral feeding by a nasogastric tube. Design: Prospective, randomized, controlled trial. Setting: ICU of a university hospital. Patients: A total of 305 consecutive patients requiring placement of a nasogastric tube for >24 hrs. Interventions: Patients were randomized to receive either 10 mg of metoclopramide or placebo at 8‐hr intervals through the nasogastric tube. Measurements and Main Results: A total of 174 patients received placebo and 131 received metoclopramide. Baseline characteristics in the two treatment groups were comparable. Of the 305 patients, 46 developed nosocomial pneumonia, which was 24 patients (13.7%) in the placebo group and 22 (16.8%) in the metoclopramide group (p > .05). Patients in the placebo group developed pneumonia earlier than patients receiving metoclopramide (4.46 ± 1.72 days [mean ± SD[rsqb] after ICU admission compared with 5.95 ± 1.78 days; p = .006). Subgroup analysis showed that metoclopramide did not reduce the frequency rate of pneumonia in patients with tracheal intubation (19 [25.3%] of 75 patients receiving metoclopramide vs. 21 [21.2%] of 99 patients receiving placebo) or those receiving mechanical ventilation (17 [25.6%] of 58 patients receiving metoclopramide vs. 20 [29.3%] of 78 patients receiving placebo). The mortality rate also did not differ in the two treatments groups (56% in the metoclopramide group vs. 53% in the placebo group; p > .05). Conclusions: Although metoclopramide delayed the development of nosocomial pneumonia, it did not decrease its frequency rate and had no effect on the mortality rate in critically ill patients receiving nasogastric enteral feeding.

Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients: an open label randomized trial with 0.01% potassium permanganate as control.

BACKGROUND Oral cleansing with chlorhexidine decreases the incidence of nosocomial pneumonia in patients after cardiac surgery. However, evidence of its benefit in ICU patients is conflicting. METHODS Patients admitted to the ICU of an Indian tertiary care teaching hospital were randomized to twice-daily oropharyngeal cleansing with 0.2% chlorhexidine or 0.01% potassium permanganate (control) solution. Effects on the incidence of nosocomial pneumonia during ICU stay (primary outcome) and length of ICU stay and in-hospital mortality (secondary outcomes) were studied. RESULTS Five hundred twelve patients were randomized to either the chlorhexidine group (n = 250) or the control group (n = 262). Of the 471 subjects who completed the protocol, nosocomial pneumonia developed in 16 of 224 subjects (7.1%) in the chlorhexidine group and 19 of 247 subjects (7.7%) in the control group (p = 0.82; relative risk, 0.93; 95% confidence interval, 0.49 to 1.76); intention-to-treat analysis of 21 patients in whom the cleansing protocol was not followed revealed similar results. There was no significant difference between the study and control groups in the median day of development of pneumonia (5.0 days: interquartile range [IQR], 3.0 to 7.7 vs 5.0 days: IQR, 3.0 to 6.0, respectively), median ICU stay (5.0 days: IQR, 3.0 to 8.0 vs 6.0 days: IQR, 3.0 to 8.0, respectively), and mortality (34.8% vs 28.3%, respectively). On subgroup analysis, there was no significant difference in the primary and secondary outcomes in patients on mechanical ventilation, tracheal intubation, and coma (Glasgow coma scale <or= 8). During the study period, nosocomial pneumonia developed in fewer subjects (35 of 471 subjects [7.4%]) than in the 3 months preceding and following the study (98 of 452 subjects [21.7%]; p < 0.001; relative risk, 0.34; 95% confidence interval, 0.24 to 0.49). CONCLUSIONS Oropharyngeal cleansing with 0.2% chlorhexidine solution was not superior to oral cleansing with the control solution. However, the decreased incidence of nosocomial pneumonia during the study period suggests a possible benefit of meticulous oral hygiene in ICU patients.

Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis : a randomized, controlled trial

ObjectiveTo study the effects of pharmacologically increasing gastric pH on gastric colonization and the development of pneumonia in intubated critically ill patients. DesignRandomized, controlled trial. SettingMedical ICU in a university hospital. PatientsThirty-four tracheotomized patients with tetanus. InterventionsSixteen patients received iv ranitidine to increase gastric pH >4 (ranitidine group), while 18 patients received no prophylaxis for upper gastrointestinal bleeding (control group). Measurements and Main ResultsMean gastric pH was higher in the ranitidine group (median 4.7, range 3.6 to 6.1) than in the control group (median 2.1, range 1.2 to 4.9; p < .05). Gastric colonization occurred in 15 (94%) of 16 patients who received ranitidine, 2 days (median; range 1 to 5) after intubation; gastric colonization also occurred in all control patients (median 4 days, range 1 to 9; p < .05). Pneumonia occurred in 13 (81%) of 16 patients who received ranitidine, 3 days (median, range 1 to 5) after intubation and in nine (50%) of 18 control patients (p < .01) 5 days after tracheal intubation (median, range 3 to 14; p < .01). Prior gastric colonization by the pathogen that caused pneumonia was demonstrable in nine (56%) of 16 patients who received ranitidine vs. eight (44%) of 18 control patients (p > .05). The risk for developing pneumonia in the ranitidine-treated group was highest in the first 4 days after tracheal intubation. There was no difference in the frequency of upper gastrointestinal hemorrhage in the two groups. ConclusionsPharmacologically increasing gastric pH increases the risk for developing pneumonia in intubated critically ill patients. The pneumonia occurs earlier than in untreated control patients. (Crit Care Med 1992; 20:590–593)

Severe falciparum malaria: An important cause of multiple organ failure in Indian intensive care unit patients

ObjectiveTo study the incidence and severity of multiple organ dysfunction in severe falciparum malaria. DesignProspective, observational study. SettingIntensive care unit of a tertiary care university hospital. PatientsThree hundred one consecutive patients with severe falciparum malaria admitted during the 30-month study period. InterventionsDaily assessment of clinical and biochemical variables required for calculating the Sequential Organ Failure Assessment (SOFA) score. Measurements and Main ResultsCentral nervous system failure was present in 121 patients (53 deaths). Renal failure occurred in 91 patients (48 deaths), and 33 required dialysis. Severe thrombocytopenia occurred in 114 patients (seven required platelet transfusion), and 19 patients had thrombocytopenia and disseminated intravascular coagulation; all required component therapy; 229 patients received blood transfusion for severe hemolytic anemia. Hepatic failure occurred in 77 patients (38 deaths). Respiratory failure developed in 79 patients and carried the worst outcome (70 deaths). It occurred later in the course of the illness (mean, 3.1 days; p < .001) compared with cerebral, renal, and coagulation failure (mean, 1.3–2.3 days). Regardless of the organ system involved, only 11 of 172 patients with one or no organ failure died (6.8%), whereas mortality rate increased to 48.8% in 129 patients with multiple organ failure. Other abnormalities associated with poor outcome included seizures in 54 patients (56% mortality rate), metabolic acidosis in 167 (40% mortality rate), hypoglycemia in 88 (39% mortality rate), and hemoglobinuria in 190 (33% mortality rate). Sixty patients had quinine toxicity requiring dosage reduction. Bacterial sepsis occurred in 39 patients (35 deaths) and accounted for 85% of deaths occurring after day 7. Twenty-three pregnant women had no significant difference in outcomes. Overall mortality rate was 24.6% (301 patients, 74 deaths). ConclusionsMalaria is an important cause of multiple organ failure in India. Mortality rate is 6.4% when one or fewer organs fail but increases to 48.8% with failure of two or more organs. However, outcomes are better than for similar degrees of organ failure in sepsis.

Neurologic disorders in pregnancy

Background:Neurologic dysfunction, coma, and seizures are common in obstetric patients in the intensive care unit. Objective:To review common neurologic disorders resulting in critical illness in pregnancy. Review:Obstetric disorders causing coma and seizures include eclampsia, acute fatty liver of pregnancy, and amniotic fluid embolism. Preexisting disorders such as epilepsy may worsen in one-third of pregnant patients, and seizures are common during labor. Changes in hemodynamics, blood volume, and hormonal effects on the vessel wall increase risk of bleeding from berry aneurysms and arteriovenous malformations during pregnancy and the postpartum period. Acute intermittent porphyria produces seizures and hypertension, closely mimicking eclampsia. Cerebral venous sinus thrombosis is common in postpartum patients, especially in developing countries. Brain tumors invariably enlarge during pregnancy because of fluid retention and the presence of estrogen and progesterone receptors on tumor cells. Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. Patients may be admitted to the intensive care unit with type II respiratory failure due to myasthenic crisis, Guillain-Barre syndrome and spinal cord disease. Relapses of multiple sclerosis are infrequent during pregnancy but increase in the postpartum period. Conclusions:In all instances, the effects of the disorders, diagnostic tests, and treatment on the fetus must be carefully weighed. Prompt delivery may be lifesaving for mother and fetus in conditions such as eclampsia and acute fatty liver of pregnancy; expectant treatment may be more appropriate in others.

Rheumatologic diseases in the intensive care unit: epidemiology, clinical approach, management, and outcome.

Patients with systemic rheumatic diseases may be admitted to the ICU because of worsening of or development of a new manifestation of the rheumatic disease, infections caused by immunosuppression, or adverse effects of drugs used to treat rheumatic diseases. Sometimes an unrelated, acute disorder may become life threatening because of the underlying rheumatic disorder. Rheumatoid arthritis is the most common rheumatic disease seen in ICU patients, followed by systemic lupus erythematosus and scleroderma. These three conditions together account for up to 75% of rheumatic cases admitted to the ICU. The respiratory system is the organ system most commonly affected in the acute process, followed by the renal, gastrointestinal, and nervous systems. More than 50% of admissions result from infections, and 25% to 35% result from exacerbation of the underlying rheumatic condition. In about 20% of patients, the rheumatic disorder may be diagnosed for the first time in the ICU. An aggressive approach should be pursued to establish the diagnosis of either disease exacerbation or infection. Delay in instituting appropriate immunosuppressive or antimicrobial therapy may result in multiple organ system failure and a poor outcome. The mortality rate in patients with rheumatic disease exceeds that predicted by the APACHE II or SAPS II scores and is higher than that in nonrheumatologic ICU admissions. The mortality may exceed 50% in patients admitted for infection; the prognosis is comparatively better for patients with exacerbations of disease activity. Renal failure, coma, and acute abdomen are predictors of poor outcome. Early recognition of abdominal complications requiring surgical intervention may help reduce mortality.

Quality, cost, and outcome of intensive care in a public hospital in Bombay, India.

OBJECTIVE To study the quality, cost, and benefits of intensive care in a public hospital in Bombay, India. DESIGN Prospective collection of data. SETTING Seventeen-bed medical-neurology-neurosurgery intensive care unit (ICU) of a municipal teaching hospital. PATIENTS A total of 993 consecutive ICU patients during a 16-month period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 993 patients aged 36.5 +/- 16 yrs (mean +/- SD) had a day-1 Acute Physiology and Chronic Health Evaluation (APACHE) II score of 14.9 +/- 9.6 (mean +/- SD), with a predicted mortality of 21.7%; the observed mortality was 36.2% (standardized mortality ratio = 1.67). The day-1 Therapeutic Intervention Scoring System (TISS) points were 17.7 +/- 6.2 (mean +/- SD), and total TISS points per patient were 87.6 +/- 110 (mean +/- SD). Nurse-to-patient ratio in the ICU was 3:17 and the average workload per nurse was 64.2 TISS points. The average length of stay was 5.5 days (SD = 7.1 days). The overall cost of treating 993 patients was, in Indian rupees (Rs), Rs 107,79,209 (U.S.

Prediction of mortality in an Indian intensive care unit: Comparison between APACHE II and artificial neural networks

307,997), and cost per patient per day was Rs 1,973 (U.S.

Control of heart rate versus rhythm in rheumatic atrial fibrillation: a randomized study.

57). The cost per survivor was Rs 17,029 (U.S.