J.P. Sharma

Targeted temperature management: Current evidence and practices in critical care

Targeted temperature management (TTM) in todays modern era, especially in intensive care units represents a promising multifaceted therapy for a variety of conditions. Though hypothermia is being used since Hippocratic era, the renewed interest of late has been since early 21st century. There have been multiple advancements in this field and varieties of cooling devices are available at present. TTM requires careful titration of its depth, duration and rewarming as it is associated with side-effects. The purpose of this review is to find out the best evidence-based clinical practice criteria of therapeutic hypothermia in critical care settings. TTM is an unique therapeutic modality for salvaging neurological tissue viability in critically ill patients viz. Post-cardiac arrest, traumatic brain injury (TBI), meningitis, acute liver failure and stroke. TTM is standard of care in post-cardiac arrest situations; there has been a lot of controversy of late regarding temperature ranges to be used for the same. In patients with TBI, it reduces intracranial pressure, but has not shown any favorable neurologic outcome. Hypothermia is generally accepted treatment for hypoxic ischemic encephalopathy in newborns. The current available technology to induce and maintain hypothermia allows for precise temperature control. Future studies should focus on optimizing hypothermic treatment to full benefit of our patients and its application in other clinical scenarios.

Comment on Debaty et al.: Impact of intra-arrest therapeutic hypothermia in outcomes of prehospital cardiac arrest: a randomized controlled trial

Dear Editor, We read the recent article by Debaty et al. [1] with great interest. The methodology used in this trial is of high quality, but the participants were a non-selected study population, of which 80 % were patients with a nonshockable rhythm and, therefore, barely 20 % had a shockable rhythm. This is in contrast to earlier hypothermia trials which included patients with a shockable rhythm, such as ventricular fibrillation (VF) or ventricular tachycardia (VT), as well as a recent, large multicenter observational study by Vaahersalo et al. [2] involving Finnish adults, of whom the majority had shockable rhythms. The 2010 American Heart Association guidelines for post-cardiac arrest care recommend that patients who have experienced out-of-hospital cardiac arrest (OHCA) caused by VF/ VT should receive therapeutic hypothermia (Class I) and that theraupetic hypothermia ‘‘may be considered’’ after in-hospital cardiac arrest (IHCA) and OHCA caused by nonshockable rhythms (Class IIb) [3]. Based on the excellent clinical results obtained with therapeutic hypothermia in patients with shockable rhythms, therapeutic hypothermia has been widely advocated in such cases [4]. There are at yet no large randomized controlled trials evaluating the clinical impact of hypothermia in patients who have been resuscitated from a non-shockable OHCA [4]. Thus, the use of theraupetic hypothermia in OHCA patients with a nonshockable rhythm is still under debate. Cardiac arrest with nonshockable rhythm, such as asystole, is known to have a poor prognosis in comparison to a common arrhythmia in cardiac arrest, such as VF/VT. Including the former patients in a study refutes the benefit of therapeutic hypothermia, if any. Neuron-specific enolase (NSE) is a marker of neurological injury, with higher levels associated with poor prognosis. In a recent study by Calderon et al. [5], NSE values of [49.5 ng/mL at 48 h and[10.59 ng/ mL at 72 h predicted mortality. In the study by Debaty et al. [1], the patients had median NSE levels of 96.7 lg/ml in the intra-arrest therapeutic hypothermia group (IATH) at 24 h, which can be considered as quite high levels. These high levels indicate that neurological injury in this patient population was already extensive and that therapeutic hypothermia would be of no use. Debaty et al. [1] report the survival rate at 1 month to be 7 % in the IATH group versus 5 % in hospital cooling group, which is quite low compared to that reported in previous hypothermia trials. Thus, we suggest that the results of this study cannot be generalized as the results of this this trial pertain to a specific patient population which already has a poor prognosis. Conflicts of interest None.

A cat has 9 lives: The dilemma of diagnosing non hodgkin's lymphoma in intensive care unit

Non hodgkins lymphoma is a common haematological malignancy characterized by abnormal clonal proliferation of T-cells, B-cells or both. The incidence of non hodgkins lymphoma is rapidly rising. The diagnosis and management of NHL presents as a challenge in developing countries like India due to high prevalence of tuberculosis, cost and poor patient compliance. We describe an unusual case of a patient who presented as a diagnostic dilemma and took 8 diagnosis before finally being confirmed as a case of NHL. A suspicion for NHL should always be kept in mind in a patient presenting with pneumonia, bilateral pulmonary infiltrates and eosinophilia.

Mapping the characteristics of critical care facilities: Assessment, distribution, and level of critical care facilities from central India

Background: In low- and middle-income countries such as India, where health systems are weak, the number of available Critical Care Unit (Intensive Care Unit [ICU]) beds is expected to be low. There is no study from the Indian subcontinent that has reported the characteristics and distribution of existing ICUs. We performed this study to understand the characteristics and distribution of ICUs in Madhya Pradesh (MP) state of Central India. We also aimed to develop a consensus scoring system and internally validate it to define levels of care and to improve health system planning and to strengthen referral networks in the state. Methods: We obtained a list of potential ICU facilities from various sources and then performed a cross-sectional survey by visiting each facility and determining characteristics for each facility. We collected variables with respect to infrastructure, human resources, equipment, support services, procedures performed, training courses conducted, and in-place policies or standard operating procedure documents. Results: We identified a total of 123 ICUs in MP. Of 123 ICUs, 35 were level 1 facilities, 74 were level 2 facilities, and only 14 were level 3 facilities. Overall, there were 0.17 facilities per 100,000 population (95* confidence interval [CI] 0.14–0.20 per 100,000 populations). There were a total of 1816 ICU beds in the state, with an average of 2.5 beds per 100,000 population (95* CI 2.4–2.6 per 100,000 population). Of the total number of ICU beds, 250 are in level 1, 1141 are in level 2, and 425 are in level 3 facilities. This amounts to 0.34, 1.57, and 0.59 ICU beds per 100,000 population for levels 1, 2, and 3, respectively. Conclusion: This study could just be an eye opener for our healthcare authorities at both state and national levels to estimate the proportion of ICU beds per lac population. Similar mapping of intensive care services from other States will generate national data that is hitherto unknown.

Amber in chamber an enigmatous right atrial mass in a neonate

The incidence of fungal infection is increasing worldwide. Although fungal infection is common in adults, few cases have been reported in the neonatal population. We report a case of the preterm neonate of 34 weeks who developed respiratory distress on 2 nd day and was initiated on mechanical ventilation. Treatment was instituted for sepsis, but the patient continued to deteriorate. Two-dimensional echocardiography revealed a large right atrial mass, which eventually turned out to be fungal ball. Intense surgical and medical management led to a speedy recovery of the patient. We stress on the early use of echocardiography in atypical presentation of neonatal septicemia along with routine investigations to help in early recognition of source of infection. This can be of great value in initiating definitive management and improving survival rate in such patients.