Karthik Rao

ESBL E. coli Urosepsis Resulting in Endogenous Panophthalmitis Requiring Evisceration of the Eye in a Diabetic Patient

A primary infection in a remote site resulting in vision threatening complications like panophthalmitis in a person who is not immune-compromised is rare. We report a case of endogenous bilateral bacterial endophthalmitis progressing into panophthalmitis in one eye requiring evisceration of that eye. A patient admitted with severe ESBL E. coli urosepsis was effectively treated with source control (bilateral DJ stenting for hydroureteronephrosis) and antibiotics. She was found to have features suggestive of bilateral conjunctivitis which progressed to panophthalmitis possibly due to delay in appropriate diagnosis and treatment. Diagnosis requires a very high index of suspicion if eye involvement is noted in a patient with features of bacteraemia and early intervention could possibly produce better outcomes. To our knowledge, this is the first case of ESBL E. coli urosepsis complicated by microbiologically confirmed panophthalmitis.

Outcome of patients admitted to a tertiary referral intensive care unit with urosepsis needing source control

Introduction: Urosepsis is one of the common causes of admission to the Intensive Care Unit (ICU). It has traditionally been treated with antibiotics, but surgical management with Double J [DJ] ureteral stents is gaining popularity. This study compares patients with complicated urosepsis who underwent surgical source control by ureteral stenting with those managed medically. Materials and Methods: The study enrolled patients admitted to a tertiary adult ICU with a diagnosis of urosepsis over a period of 2 years. The primary outcomes were renal replacement therapy (RRT) requirement and ICU mortality. The secondary outcomes were ICU and hospital length of stay, ventilator-free days, and inotrope free days. Patients were divided those with obstructive and nonobstructive urinary tract infection (UTI). Results: A total of 58 patients met the criteria, of who 32 had obstructive UTI and were included in Group A, with the remaining 26 with nonobstructive UTI comprised Group B. In Group A, 27 patients underwent source control with ureteral DJ stenting, three patients recovered with medical management, and two who were advised source control did not consent to the procedure. Seventeen patients in Group A and seven patients in Group B required RRT (P = 0.044). There was no significant difference in ICU mortality, hospital mortality, and 28 days survival between the two groups. Conclusion: With early source control, obstructive UTI outcomes were comparable to nonobstructive UTI. However, despite undergoing ureteric stenting, more patients with obstructive UTI required RRT than those with nonobstructive UTI.

Pseudocholinesterase as a predictor of mortality and morbidity in organophosphorus poisoning

Background: Organophosphorus (OP) pesticide poisoning is a major clinical and public health problem in India. Mortality rate remains high at 15%–30%. Aims: This prospective, observational study examines the relationship between pseudocholinesterase (PChE) activity and morbidity and mortality in OP poisoning. Setting and Design: OP poisoning cases admitted to a tertiary care center Intensive Care Unit (ICU) over 5 years from 2010 to 2014 were studied. Methods: Patients <16 years of age, those on steroids and those with neuromuscular weakness, were excluded from the study. Serum PChE level at admission was estimated and the severity of poisoning assessed accordingly. Primary outcome measures were ICU length of stay and ventilator-free days. Secondary outcome measures included vasopressor-free days, amount of atropine given, hospital length of stay, and ICU mortality. Results: There were 37 patients included in the study, aged between 24 and 44 years, of which 65% were male. They were divided into two groups according to PChE levels. Group A with PChE levels more than 1000 IU/L had twenty patients and Group B with levels <1000 IU/L had 17 patients. Group B had longer ICU length of stay (P < 0.001) and fewer ventilator-free days (P < 0.001). They also had a fewer vasopressor-free days and a longer stay in hospital. Conclusions: PChE level at presentation is a reliable indicator of the severity of OP poisoning and a predictor of the need for mechanical ventilation and the duration of stay in the ICU.

Efficacy of conivaptan and hypertonic (3%) saline in treating hyponatremia due to syndrome of inappropriate antidiuretic hormone in a tertiary Intensive Care Unit.

Background: Hyponatremia is one of the most common electrolyte abnormalities encountered in clinical practice and has a significant impact on morbidity and mortality in hospitalized patients. The optimal management of hyponatremia is still evolving. Over the last decade, vaptans have been increasingly used in clinical practice with promising results. Materials and Methods: The study included eighty patients with symptomatic hyponatremia due to syndrome of inappropriate antidiuretic hormone (SIADH) admitted and treated in Intensive Care Unit (ICU) with either conivaptan or hypertonic (3%) saline. They were compared for time taken to achieve normal serum sodium, length of ICU and hospital stay, and adverse effects. Results: The demographic data and serum sodium levels at admission were comparable between the two groups. After initiating correction, sodium levels at 6, 12, and 24 h were similar between the two groups. However, at 48 h, patients in the conivaptan group (Group C) had higher sodium levels (133.0 ± 3.8 mEq/L) as compared to hypertonic saline group (Group HS) (128.9 ± 2.6 mEq/L), which was statistically significant (P < 0.001). The length of ICU stay was less in the Group C (3.35 ± 0.89 days) when compared with the Group HS (4.61 ± 0.91 days) (P < 0.001). There was no significant difference in mortality between the two groups. Conclusion: In patients with symptomatic hyponatremia due to SIADH, conivaptan with its aquaresis property can achieve a significantly better sodium correction, resulting in reduced ICU and hospital stay with no significant adverse effects.

Postoperative nutrition practices in abdominal surgery patients in a tertiary referral hospital Intensive Care Unit: A prospective analysis

Background: Benefit of early enteral feeds in surgical patients admitted to Intensive Care Units (ICUs) has been emphasized by several studies. Apprehensions about anastomotic leaks in gastrointestinal surgical patients prevent initiation of early enteral nutrition (EN). The impact of these practices on outcome in Indian scenario is less studied. Aims: This study compares the impact of early EN (within 48 h after surgery) with late EN (48 h postsurgery) on outcomes in abdominal surgical ICU patients. Settings and Design: Postabdominal surgery patients admitted to a tertiary referral hospital ICU over a 2-year period were analyzed. Methods: Only patients directly admitted to ICU after abdominal surgery were included in this study. ICU stay>3 days was considered as prolonged; with average ICU length of stay (LOS) for this ICU being 3 days. The primary outcome was in-patient mortality. ICU LOS, hospital LOS, infection rates, and ventilator days were secondary outcome measures. Acute Physiology and Chronic Health Evaluation II scores were calculated. SPSS and Microsoft Excel were used for analysis. Results: Of 91 ICU patients included, 58 received early EN and 33 late EN. Hospital LOS and infection rates were less in early EN group. Use of parenteral nutrition (odds ratio [OR] 5.25, 95% confidence interval (CI); P = 0.003) and number of nil-per-oral days (OR 8.25, 95% CI; P ≤ 0.001) were other predictors of prolonged LOS. Conclusions: Early EN in postabdominal surgery ICU patients was associated with reduced hospital LOS and infection rates. ICU LOS, duration of mechanical ventilation and mortality rates did not vary.

Myxoedema coma in adults: Experience from a tertiary referral hospital intensive care unit

Myxoedema coma is an uncommon, life-threatening form of long-standing, neglected hypothyroidism.[1] It is 3–10 times more common in women.[2] It commonly occurs in elderly with a peak incidence in the seventh decade.[3] We considered persistent surface body temperature of less than 96°F (>3 readings in spite of rewarming efforts) as hypothermia (considering the tropical climate in India.[4] Most common precipitants include exposure to cold, infection, drugs, haemorrhage, hypoxia, hypercapnia, hypoglycaemia, sepsis, and adrenal insufficiency.[3] We report a retrospective analysis of six cases in our intensive care unit (ICU).

Post-surgical Infective Endocarditis Involving Chordae Tendinae: A Rare Presentation

Transient bacteraemia following surgical procedures is a relatively common, but concomitant infective endocarditis in patient without any risk factor is a rare event. To the best of our knowledge, this is one of the few case reports of infective endocarditis following a urology procedure. We report a 57-year-old lady with pyelonephritis and renal calculus who developed vegetation’s on chordae tendinae following renal surgery.