Gentle Sunder Shrestha

Intravenous ketamine for treatment of super-refractory convulsive status epilepticus with septic shock: A report of two cases.

Refractory and super-refractory status epilepticus is a life-threatening neurological emergency, associated with high morbidity and mortality. Treatment should be aimed to stop seizure and to avoid cerebral damage and another morbidity. Published data about effectiveness, safety and outcome of various therapies and treatment approaches are sparse and are mainly based on small case series and retrospective data. Here we report successful management of two cases of super-refractory status epilepticus refractory to anesthetic therapy with midazolam and complicated by septic shock, managed successfully with ketamine infusion.

International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries

www.thelancet.com/infection Vol 17 September 2017 893 pro grammes re-affirms the power of a multidisciplinary approach. A winning team knows that teamwork is what makes the dream work; clinicians, infection prevention professionals, pharmacists, microbiologists, nurses, and an ever-expanding number of health-care professionals involved at the clinical interface form a whole that is greater than the sum of its parts. Only five of the 32 studies included in Baur and colleagues’ meta-analysis were from low-income or middle-income countries, where multidisciplinary teams are rarely found outside of central hospitals. In these settings, we need to re-examine our perception of what an antibiotic stewardship programme looks like. The success of pharmacist-led stewardship programmes highlights a model that builds stewardship teams around this key cadre of health professional. And what of stewardship programmes at the community level? We need to look to non-traditional stewards, such as community health workers and members of the public, in settings where health-care professionals are a scarce resource. Non-traditional stewards need to join us in a partnership that looks beyond what can be offered in high-resource settings. Decreasing antibiotic resistance while preserving the effectiveness of antibiotics is the dream and antibiotic stewardship is the team captain. Baur and colleagues have provided the ammunition to convey this important message to antibiotic stewardship naysayers, policy makers, and stakeholders. The results of Baur and colleagues’ meta-analysis are an important advocacy tool, and one that we should use in support of developing winning teams. If we get antibiotic stewardship right, the real winner will be the patient who avoids infection by a drug-resistant bacterium or C difficile, now and in the future, as we preserve antibiotics for the generations to come.

Apnea testing with continuous positive airway pressure for the diagnosis of brain death in a patient with poor baseline oxygenation status.

Apnea testing is a key component in the clinical diagnosis of brain death. Patients with poor baseline oxygenation may not tolerate the standard 8-10 min apnea testing with oxygen insufflation through tracheal tube. No studies have assessed the safety and feasibility of other methods of oxygenation during apnea testing in these types of patients. Here, we safely performed apnea testing in a patient with baseline PaO2 of 99.1 mm Hg at 100% oxygen. We used continuous positive airway pressure (CPAP) of 10 cm of H2O and 100% oxygen at the flow rate of 12 L/min using the circle system of anesthesia machine. After 10 min of apnea testing, PaO2 decreased to 75.7 mm Hg. There was a significant rise in PaCO2 and fall in pH, but without hemodynamic instability, arrhythmias, or desaturation. Thus, the apnea test was declared positive. CPAP can be a valuable, feasible and safe means of oxygenation during apnea testing in patients with poor baseline oxygenation, thus avoiding the need for ancillary tests.

Colistin and tigecycline for management of external ventricular device-related ventriculitis due to multidrug-resistant Acinetobacter baumannii

Acinetobacter baumannii is an important cause of nosocomial ventriculitis associated with external ventricular device (EVD). It is frequently multidrug resistant (MDR), carries a poor outcome, and is difficult to treat. We report a case of MDR Acinetobacter ventriculitis treated with intravenous and intraventricular colistin together with intravenous tigecycline. The patient developed nephrotoxicity and poor neurological outcome despite microbiological cure. Careful implementation of bundle of measures to minimize EVD-associated ventriculitis is valuable.

Composition of the Sepsis Definitions Task Force

That is not the case. Rather, SIRS may be useful in the presumptive diagnosis of infection. However, SIRS is not specific nor particularly sensitive for infection. As an example, Churpek and colleagues1 reported that 50% of hospital inpatients have SIRS at least once in their hospital stay, and many of these patients will not have infection nor require antibiotic therapy. Conversely, 64% of the 66 522 non–intensive care unit (ICU) patients in the University of Pittsburgh Medical Center validation cohort had 0 or 1 SIRS criteria at the time they were cultured and treated for suspected infection. The article also did not suggest that what was previously called “sepsis” be eliminated from the diagnostic spectrum. Rather, it should be simply and correctly identified as “infection.” We are surprised by the concern expressed by these authors and Dr Townsend and colleagues that the new definitions will delay the diagnosis of sepsis and negatively affect survival. Treatment should not be delayed until patients deteriorate to fulfill 2 or more qSOFA criteria. We would expect management to be similar to that provided to the 1 in 8 infected patients with new-onset organ failure who were admitted to Australasian ICUs despite having fewer than 2 SIRS criteria and previously would not have qualified as “septic.”2 The new criteria were based on analysis of more than 850 000 hospitalized patients with suspected infection.3 Such an exercise has not previously been undertaken and SIRS has never been scrutinized so comprehensively. This analysis underpinned the development of the qSOFA criteria for rapid assessment of patients with suspected infection likely to have poor outcomes. Both SIRS and qSOFA were compared using data abstracted from varying time windows both before and after cultures were sent and antibiotics started. In this analysis, qSOFA showed superior predictive validity. Nonetheless, we encourage prospective confirmation of these findings in different health care settings. We are also unaware of any prospective interventional studies using SIRS alone as an entry criterion. All the cited studies showing mortality benefits through quality improvement programs involved patients who had established organ dysfunction (ie, “sepsis” in the new definition). To die from infection requires development of organ dysfunction; therefore the new definition cannot increase absolute mortality. The large increase in discharge coding for sepsis4 has lowered relative mortality but increased absolute numbers of patients dying. This trend was observed irrespective of the coding method used, but the choice of method affected estimates of incidence and absolute mortality. A major aim of the new definitions is to reduce this inconsistency. Townsend and colleagues share the concerns of CMS about the new definitions. We are encouraged that CMS will track and test application of a SOFA score of 2 or greater and qSOFA. Multiple groups worldwide are already engaged in this process. We are confident that this measured approach will lead to a reconciliation of any differences with existing quality improvement parameters, improving the care of septic patients. We agree with Dr Singh and colleagues that an updated SOFA score should be developed as part of the next iteration of the definitions. The SOFA score simply records vasopressor usage and dosage that are decided at the local (hospital) level, notwithstanding consensus recommendations. Rather than discouraging efforts to detect sepsis early in its course, as voiced by Schneider-Lindner and colleagues, the new definition specifically highlights the 2 key characteristics of sepsis—namely, organ dysfunction and a dysregulated host response. Use of this new definition should lead researchers to focus on developing early, more-sensitive means to detect the presence of these 2 key components that differentiate infection from sepsis.

Gender Parity in Critical Care Medicine

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. These documents inform and shape patient care around the world. In this Perspective we discuss the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities, and government. We propose five strategies to ensure gender parity within critical care medicine.

Delivering neurocritical care in resource-challenged environments.

Purpose of reviewResource-challenged environments of low and middle-income countries face a significant burden of neurocritical illness. This review attempts to elaborate on the multiple barriers to delivering neurocritical care in these settings and the possible solutions to overcome such barriers. Recent findingsEpidemiology of neurocritical illness appears to have changed over time in low and middle-income countries. In addition to neuro-infection, noncommunicable neurological illnesses like stroke, traumatic brain injury, and traumatic spinal cord injury pose a significant neurocritical burden in resource-limited settings. Many barriers that exist hinder effective delivery of neurocritical care in resource-challenged environments. Very little information exists about the neurocritical care capacity. Research and publications are few. Intensive care unit beds and trained personnel are significantly lacking. Awareness about the risk factors of preventable conditions, including stroke, is lacking. Prehospital care and trauma systems are poorly developed. There should be attempts to leverage neurocritical care in these settings with focus on promoting research, local training, capacity building, preventive measures like vaccination, raising awareness, and developing prehospital care. SummaryConsidering the disease burden and potentials to improve outcome, attempts should be made to develop neurocritical care in resource-challenged environments. Video abstracthttp://links.lww.com/COCC/A11.

Comparison of acute physiology and chronic health evaluation II and acute physiology and chronic health evaluation IV to predict intensive care unit mortality.

Context: Clinical assessment of severity of illness is an essential component of medical practice to predict the outcome of critically ill-patient. Acute Physiology and Chronic Health Evaluation (APACHE) model is one of the widely used scoring systems. Aims: This study was designed to evaluate the Performance of APACHE II and IV scoring systems in our Intensive Care Unit (ICU). Settings and Design: A prospective study in 6 bedded ICU, including 76 patients all above 15 years. Subjects and Methods: APACHE II and APACHE IV scores were calculated based on the worst values in the first 24 h of admission. All enrolled patients were followed, and outcome was recorded as survivors or nonsurvivors. Statistical Analysis Used: SPSS version 17. Results: The mean APACHE score was significantly higher among nonsurvivors than survivors (P < 0.005). Discrimination for APACHE II and APACHE IV was fair with area under receiver operating characteristic curve of 0.73 and 0.79 respectively. The cut-off point with best Youden index for APACHE II was 17 and for APACHE IV was 85. Above cut-off point, mortality was higher for both models (P < 0.005). Hosmer–Lemeshow Chi-square coefficient test showed better calibration for APACHE II than APACHE IV. A positive correlation was seen between the models with Spearmans correlation coefficient of 0.748 (P < 0.01). Conclusions: Discrimination was better for APACHE IV than APACHE II model however Calibration was better for APACHE II than APACHE IV model in our study. There was good correlation between the two models observed in our study.

Comparison between long- and short-axis techniques for ultrasound-guided cannulation of internal jugular vein

Context: Real-time ultrasound guidance for internal jugular (IJ) vein cannulation enhances safety and success. Aims: This study aims to compare the long- and short-axis (LA and SA) approaches for ultrasound-guided IJ vein cannulation. Subjects and Methods: Patients undergoing surgery and in intensive care unit requiring central venous cannulation were randomized to undergo either LA or SA ultrasound-guided cannulation of the IJ vein by a skilled anesthesiologist. First pass success, the number of needle passes, time required for insertion of guidewire, and complications were documented for each procedure. Results: The IJ vein was successfully cannulated in all patients. There are no significant differences between the two groups in terms of gender, diameter of IJ vein, margin of safety, and time required for insertion of guidewire. There was also no significant difference between the two groups in terms of side of IJ vein cannulated, patient on mechanical ventilation, number of skin puncture, number of needle redirections, first pass success, and carotid puncture. However, there is a significant relationship between the diameter of IJ vein with first pass (18.18 ± 4.72 vs. 15.21 ± 4.24; P < 0.004) and margin of safety with of incidence of carotid puncture (12.15 ± 4.03 vs. 6.59 ± 3.13; P < 0.016). Conclusions: Both techniques have similar outcomes when used for IJ vein cannulation.

Exacerbation of phantom limb pain following spinal anaesthesia: A case report and review of the literatures

Phantom limb pain has been reported in patients with lower limb amputation during subsequent spinal anaesthesia. No therapy has been proven to be uniformly effective. Here, we report a case managed successfully with ketamine and magnesium sulphate.