John Prakash Raj

Role of quantitative endotracheal aspirate and cultures as a surveillance and diagnostic tool for ventilator associated pneumonia: a pilot study.

BACKGROUND Accurate diagnosis and appropriate treatment of ventilator associated pneumonia (VAP) is crucial for good outcomes. Endotracheal suctioning is performed in ventilated patients as part of routine care and for tracheal toileting. AIM We evaluated if quantitative endotracheal aspirate (ETA) was a suitable alternative to bronchoalveolar lavage (BAL) for suspected VAP. In addition we assessed if surveillance ETA guided antibiotic selection for subsequent VAP. SETTING AND DESIGN Prospective study in the surgical intensive care unit (ICU) of a tertiary hospital in India. MATERIALS AND METHODS Two hundred consecutive patients with mean (standard deviation) APACHE II score of 12.3+/-5 and requiring mechanical ventilation beyond 48 hours underwent surveillance ETA cultures. A second ETA and BAL were performed if the patient developed features of VAP. The threshold for microbiological diagnosis of VAP was taken as 10 5 colony forming units/ml (cfu/ml) for ETA and 10 4 cfu/ml for BAL. STATISTICAL ANALYSIS The sensitivity and specificity of surveillance and concurrent ETA aspirate cultures were compared with BAL cultures. RESULTS VAP was suspected clinically and corroborated radiologically in 27/177 patients (15.3%). Although microbiological support for VAP was obtained by ETA in 19 patients, bronchoscopy was possible only in 13 patients, 8 of whom had isolates at significant threshold. Of the 16 organisms isolated from BAL, 11 were of significant threshold with 9/11 (82%) BAL isolates having a similar antibiogram to a concurrent ETA. Only one BAL isolate (9%), at significant threshold, was not isolated on a concurrent ETA. On the other hand just 6/11 BAL isolates (55%) had an identical antibiogram to surveillance ETA. BAL had 3 additional isolates (27%) at significant threshold not isolated on surveillance ETA. CONCLUSIONS Concurrent quantitative ETA could substitute BAL cultures for VAP. Surveillance ETA at 48 hours of ventilation does not appear to assist with antibiotic selection for a subsequent VAP.

Subcutaneous bronchogenic cyst.

A34-year-old man presented with a swelling in the suprasternal notch since birth that progressed in size with age. Apart from being a source of embarrassment, the swelling was not associated with any symptom. Clinical examination revealed a 5 5 cm nontender fluctuant subcutaneous swelling in the suprasternal notch. The swelling was brilliantly transilluminant (Fig 1). Preoperative laboratory investigations were normal. Ultrasound evaluation revealed thick-walled cystic swelling of 5.9 2 cm with internal echogenic material seen in the lower neck in midline. With the clinical diagnosis of congenital cyst, the patient underwent the excision of the swelling. Preoperative findings revealed a cystic mass of 4.5 3.5 l.5 cm with congested outer surface containing white gelatinous material. Histopathological examination revealed a cyst wall composed of fibrocollagenous tissue containing few smooth-muscle bundles, lined by ciliated pseudostratified columnar epithelial cells, admixed with goblet cells. Bronchogenic cysts are rare congenital anomalies that are usually located in the mediastinum or lung parenchyma. They are very rare in the neck and are thought to result from abnormal development of the tracheobronchial system. An abnormal budding of the tracheobronchial system between the 22nd and 33rd days of gestation and persistence of such a bud may give rise to bronchogenic cyst. In addition, abnormal migration of a bud may occur during the course of development and rest in different intrathoracic or extrathoracic locations. Maier has classified bronchogenic cysts according to site into paratracheal, carinal, hilar, paraesophageal, and atypical (diaphragm, abdomen, skin, subcutaneous tissue, and supraclavicular region). Most of the cervical bronchogenic cysts are in the midline, usually the upper cervical region. Bronchogenic cysts of the lateral

Persistent chyle leak following radical neck dissection: a solution that can be the solution.

A case report of a chyle leak following radical neck dissection for residual lymph nodal disease performed after chemoradiation for nasopharyngeal carcinoma. This is the first case report of the use of cyanoacrylate for a persistent chyle leak following radical neck dissection.

Role of critical care in urological sepsis

Infections arising from the urinary tract may either elicit a Systemic Inflammatory Response Syndrome or result in Sepsis. This may progress to severe sepsis with associated multi-organ dysfunction and perfusion abnormalities, including hypotension. The mortality associated with sepsis is high, reaching up to 46% in patients with septic shock. Infections arising from the urinary tract may arise either following a primary pathology in the urinary tract or may be acquired as a nosocomial infection. Most of these infections are caused by gram negative organisms, though occasionally gram positive organisms and fungi can infect the urinary tract under certain circumstances. Evaluation of a patient with sepsis should include establishing the diagnosis based on standard criteria, a search for the source and appropriate microbial cultures. Management of these patients requires aggressive fluid resuscitation to achieve well defined goals. This may need to be accompanied by the use of vasopressors and mechanical ventilation. Antimicrobial therapy based on the likely causative organism should be initiated, pending the culture results. Appropriate source control measures should also be taken. Prompt recognition, aggressive resuscitation and appropriate source control measures along with appropriate antimicrobial therapy will help to reduce the mortality in patients with urosepsis.

Angiosarcoma of the scalp

A70-year-old man presented with 6 weeks’ duration of hyperpigmented, blue-black nodular lesions on the left parieto-temporal region of scalp. The lesion started as an erythematous macule behind the angle of left eye and rapidly spread with nodule formation and bled to touch in due course of time. This rapid spread occurred while the patient was still in the ward, with treatment planned for a period of 4 to 5 days. On examination, there were hyperpigmented nodular, soft, compressible lesions with ulcerated surfaces that bled to touch over the left frontal, parieto-temporal area with ecchymotic lesions at the periphery making the margins indistinct. Examination of the neck revealed a 1 1 cm firm mobile node in the ipsilateral level II and V. Biopsy of the scalp nodule showed a tumor composed of irregular vascular channels lined by plump endothelial cells with vesicular nuclei and prominent nucleoli surrounded by lymphocytes and plasma cells. The neoplastic cells were positive for CD34, vimentin, and CD34. Angiosarcomas are rare malignant tumors composed of vascular endothelial cells that can originate from either blood vessels or lymphatic channels. They account for 1% to 3% of all soft tissue sarcomas and are rare in the head and neck region and comprise less than 0.1% of all cancers in that region. Although they are rare, 50% of angiosarcomas occur in the head and neck region. It is also referred to as malignant angioendothelioma, malignant hemangioendothelioma, lymphangioendothelioma, hemangiosarcoma, hemangioblastoma, lymphangiosarcoma, malignant angioma, and malignant endothelioma. They are seen in males 3 to 4 times more frequently than in females, with a median age of 61 to 67 years. Although trauma, previous irradiation, longstanding lymphedema, exposure to thorium dioxide, vinyl chloride, insecticides, anabolic steroids, and synthetic estrogens have all been thought of as etiologic factors, its cause is unknown. The scalp and facial skin are the most common areas followed by nasopharynx, larynx, nose, middle ear, paranasal sinuses, thyroid, orbit, and oral cavity. They usually present as progressive multiple separate foci of vascular reddish colored macules, blue-black nodules with ulcerated surface and

Correlation between lung injury score and serum albumin levels in patients at risk for developing acute lung injury

This is a prospective observational study of 100 consecutive patients who were at risk for developing acute lung injury and were admitted into the surgical intensive care unit. We found a highly significant correlation between an increase in serum albumin levels and a fall in lung injury score and vice versa (r = -0.51, P = 0.000). A highly significant association was also found between mortality, fall in serum albumin levels, rise in lung injury score, and a higher simplified acute physiology score at admission (P = 0.000).

Metachronous bilateral mucoepidermoid carcinoma of the parotid gland.

We report a very rare case of bilateral muco-epidermoid carcinoma of the parotid gland that underwent bilateral parotidectomy with neck dissections and radiotherapy. This case has done well for three years and suggests that metachronous bilateral mucoepidermoid carcinoma of the parotid gland, if treated as per the merits of each side, has a reasonable survival.

Factors influencing nursing care in a surgical intensive care unit

Context: The total time spent in nursing care depends on the type of patient and the patients condition. We analysed factors that influenced the time spent in nursing a patient. Aims : To analyse the factors in a patients condition that influenced time spent in nursing a patient. Materials and Methods: This study was performed in the Surgical Intensive Care Unit of a tertiary referral centre, over a period of one month. The total time spent on a patient in nursing care for the first 24 hours of admission, was recorded. This time was divided into time for routine nursing care, time for interventions, time for monitoring and time for administering medications. Statistical analysis used: A backward stepwise linear regression analysis using the age, sex, diagnosis, type of admission and ventilatory status as variables, was done. Results: Patients admitted after elective surgery required less time (852.4 ± 234.1 minutes), than those admitted after either emergency surgery (1069.5 ± 187.3 minutes), or directly from the ward or the emergency room (1253.7 ± 42.1 minutes). Patients who were ventilated required more time (1111.5 ± 132.5 minutes), than those brought on a T-piece (732.2 ± 134.8 minutes or extubated (639.5 ± 155.6 minutes). The regression analysis showed that only the type of admission and the ventilatory status significantly affected the time. Conclusions : This study showed that the type of admission and ventilatory status significantly influenced the time spent in nursing care. This will help optimal utilization of nursing resources.

Subclavian vein catheterization: A rare complication

Percutaneous subclavian vein catheterization is a widely used procedure for a variety of purposes. We describe here a previously unreported complication of this procedure.