Krishnaswamy Sundararajan

Posttraumatic stress disorder in close Relatives of Intensive Care unit patients’ Evaluation (PRICE) study

BACKGROUND There is a high risk of post-traumatic stress disorder (PTSD) in relatives of intensive care unit (ICU) patients. AIMS To determine the prevalence and predictors of symptoms of PTSD in relatives of an Australian critically ill population. METHODS 108 consecutive patients staying >48 h in a mixed, level three ICU were identified. On day three of admission, their next-of-kin were contacted and consent obtained for a telephonic questionnaire to be done at 90 days after ICU discharge. This consisted of the Hospital Anxiety and Depression Scale and the Impact of Event Scale-Revised (IES-R) questionnaires administered to relatives at 90 days post-discharge from the ICU. An IES-R score of >26 was used to define PTSD symptoms. RESULTS Eight subjects were excluded because the next-of-kin details were unavailable. 37 other subjects refused to participate. Out of a total of 108, 63 family members were included, including 49 next-of-kin of patients who survived. The prevalence of PTSD symptoms was 41.2% (26/63, 95% CI 29.0-54.4%). The anxiety score was found to be a predictor of PTSD symptoms (relative risk=1.07; 95% CI 1.00-1.14, p=0.05). CONCLUSION There is a high prevalence of PTSD symptoms in next-of-kin of Australian patients admitted to the ICU. High anxiety scores were a predictor for developing PTSD symptoms.

Diurnal variation in the performance of rapid response systems: the role of critical care services—a review article

The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT.There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor.The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states.For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.

Metformin-associated lactic acidosis presenting as an ischemic gut in a patient who then survived a cardiac arrest: a case report

IntroductionLactic acidosis is the most common cause of metabolic acidosis in hospitalized patients. It is recognized as a potential complication of metformin use, particularly in patients with risk factors such as renal dysfunction, liver disease, and heavy alcohol ingestion. These conditions are associated with systemic hypoxemia, which may be caused by cardiorespiratory disease, major surgery, sepsis, dehydration, old age, and overdose. The reported frequency of lactic acidosis is 0.06 per 1000 patient-years, mostly in patients with predisposing factors. This case is important because it details the seriousness of metformin-associated lactic acidosis in a critically ill patient and because, to the best of our knowledge, our patient survived with minimal residual defect despite experiencing a cardiac arrest.Case presentationA 66-year-old Caucasian woman presented to our hospital with profound lactic acidosis, which was initially thought to be ischemic gut. She then survived an in-hospital pulseless electrical activity arrest.ConclusionMetformin-associated lactic acidosis is a diagnosis by exclusion; however, a high degree of clinical suspicion supplemented by prompt multisystem organ support can significantly influence the outcome in critically ill patients.

The Effect of Exogenous Glucose-Dependent Insulinotropic Polypeptide in Combination With Glucagon-Like Peptide-1 on Glycemia in the Critically Ill

OBJECTIVE Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) have additive insulinotropic effects when coadministered in health. We aimed to determine whether GIP confers additional glucose lowering to that of GLP-1 in the critically ill. RESEARCH DESIGN AND METHODS Twenty mechanically ventilated critically ill patients without known diabetes were studied in a prospective, randomized, double-blind, crossover fashion on 2 consecutive days. Between T0 and T420 minutes, GLP-1 (1.2 pmol/kg · min−1) was infused intravenously with either GIP (2 pmol/kg · min−1) or 0.9% saline. Between T60 and T420 minutes, nutrient liquid was infused into the small intestine at 1.5 kcal/min. RESULTS Adding GIP did not alter blood glucose or insulin responses to small intestinal nutrient. GIP increased glucagon concentrations slightly before nutrient delivery (P = 0.03), but not thereafter. CONCLUSIONS The addition of GIP to GLP-1 does not result in additional glucose-lowering or insulinotropic effects in critically ill patients with acute-onset hyperglycemia.

Hospital overnight and evaluation of systems and timelines study: A point prevalence study of practice in Australia and New Zealand ☆

BACKGROUND Diurnal variation in the performance of rapid response systems has not been fully elucidated. Afferent limb failure (ALF) is a significant problem and is an important measure of performance of rapid response systems. OBJECTIVE To determine the diurnal variation in the detection and response to acute patient deterioration as measured by ALF, completeness of patient observations (Respiratory rate (RR); Pulse rate (PR) and Systolic blood pressure (SBP), and to explore the diurnal variation in the consequences of ALF in unanticipated admissions to the Intensive care unit (ICU) from the ward. DESIGN, SETTING AND PARTICIPANTS Point Prevalence study conducted on two days in 2012 in 41 ICUs in Australia and New Zealand, examining emergency (unanticipated) admissions to the ICU from the ward. RESULTS 51 patients from the ward were admitted as an emergency to the ICU following a rapid response team call, of whom 48 patients had complete datasets and were enrolled; 32 (67%) were men. The prevalence of ALF was 37.5% (18/48). Median age was 62.5 (IQR 51.5-74.0), Median APACHE II score was 21.0 (IQR 17-26). There was no diurnal variation in the prevalence of ALF (day 28% versus night 28%; p=0.92), patient observations documented over time (p=0.78 for RR, p=0.95 for PR and p=0.74 for SBP) or 28-day mortality (p=0.24). There was a significant diurnal variation between the least recorded observation (SBP) and the most recorded observation (PR) (p<0.01). ALF was more likely (day and night) if a complete set of observations had been taken (p<0.01). CONCLUSION The prevalence of ALF amongst patients admitted to the ICU from the ward is high. SBP is the least recorded patient observation. This study was unable to identify a diurnal variation in the prevalence of ALF, its consequences (i.e. mortality) and the completeness of patient observations. Observational studies with a larger sample are required to explore this important problem.

Elderly patients are at high risk of night-time admission to the intensive care unit following a rapid response team call

Previous studies have shown that elderly patients (age ≥65 years) are less likely to be admitted to the intensive care unit following a rapid response team call and have high hospital mortality rates. This study has shown that elderly patients have a significantly higher probability of being admitted to an intensive care unit following a rapid response team call at night than during the day. However, at no time are they at greater risk than younger patients of incomplete vital sign recording, a failure to escalate care for acute deterioration or mortality.

Predictors and outcomes of acute pancreatitis in critically ill patients presenting to the emergency department of a tertiary referral centre in Australia

To provide a current review of the clinical characteristics, predictors and outcomes in critically ill patients presenting to the ED with acute pancreatitis and subsequently admitted to an intensive care unit (ICU) of a tertiary referral centre in Australia.

Therapeutic paradox: nimodipine attenuates severe coronary spasm following coronary artery graft surgery in a high-risk vasoplegic cancer patient

A 54-year-old man was admitted to our hospital with a non-ST elevation myocardial infarction. Angiogram revealed severe left main coronary artery stenosis. He had a history of resected colorectal carcinoma with liver metastases that had remained dormant on capecitabine. Overnight he developed unstable angina with anterior ST depression, which resolved with a glyceryl trinitrate (GTN) infusion. Coronary artery bypass graft (CABG) was performed the following day with three grafts (i.e. left internal mammary artery (LIMA)-left anterior descending artery, saphenous vein graft (SVG)-obtuse marginal and SVG-posterior descending artery). Eight hours post-surgery he developed cardiogenic shock with 3-mm ST elevation anteriorly (Fig. 1). This necessitated a significant increase in vasoactive supports with noradrenaline 40 μg/min (previously 5 μg/min with a target mean arterial pressure of 70 mmHg), adrenaline at 10 μg/min and vasopressin at 0.04 μg/min. An urgent angiogram confirmed severe coronary spasm of the native vessels and LIMA graft (Fig. 2). Multiple doses of intracoronary GTN did not improve the spasm. A dose of 1.6 mg (8 × 200 μg) was administered down LIMA, 1.2 mg (6 × 200 μg was administered down native left main coronary artery and 1 mg (5 × 200 μg) was administered down each SVG. Verapamil intracoronary would have been a reasonable alternative; however, the patient had a couple of sinus pauses, which was perhaps a relative contraindication. Hence, the decision to persevere with escalating doses of GTN was considered as imperative. As the patient was in shock, percutaneous coronary intervention was attempted to multiple areas, which improved the proximal blood flow with minimal effect. Intra-aortic balloon pump (IABP) was inserted in view of haemodynamic instability. A transthoracic echocardiogram revealed profound regional wall motion abnormalities, while the following cardiac indices obtained from a pulmonary artery catheter revealed a vasoplegic state: cardiac index 2.5 L/min/ m, systemic vascular resistance index of 1092 DSm/cm, pulmonary artery occlusion pressure 12 mmHg, left ventricular stroke work index 28 g-m/m and central venous pressure 13 mmHg. Intravenous nimodipine was commenced within an hour of IABP deployment while the patient was still on significant vasopressors. Nimodipine was chosen as it allowed more cautious titration given its shorter half-life and undergoes minimal renal elimination negating dose adjustments in renal impairment. An angiogram done subsequently showed remarkable improvement in the degree of vasospasm. Vasopressors and IABP requirements reduced over the next few hours and negated the commissioning of extra corporeal membrane

The devil is in the detail: Acute Guillain-Barré syndrome camouflaged as neurosarcoidosis in a critically ill patient admitted to an Intensive Care Unit

Guillain–Barré syndrome (GBS) is an acute demyelinating polyneuropathy, usually evoked by antecedent infection. Sarcoidosis is a multisystem chronic granulomatous disorder with neurological involvement occurring in a minority. We present a case of a 43-year-old Caucasian man who presented with acute ascending polyradiculoneuropathy with a recent diagnosis of pulmonary sarcoidosis. The absence of acute flaccid paralysis excluded a clinical diagnosis of GBS in the first instance. Subsequently, a rapid onset of proximal weakness with multi-organ failure led to the diagnosis of GBS, which necessitated intravenous immunoglobulin and plasmapheresis to which the patient responded adequately, and he was subsequently discharged home. Neurosarcoidosis often masquerades as other disorders, leading to a diagnostic dilemma; also, the occurrence of a GBS-like clinical phenotype secondary to neurosarcoidosis may make diagnosing coexisting GBS a therapeutic challenge. This article not only serves to exemplify the rare association of neurosarcoidosis with GBS but also highlights the need for a high index of clinical suspicion for GBS and accurate history taking in any patient who may present with rapidly progressing weakness to an Intensive Care Unit.

The prevalence of unrecognised diabetes and critical-illness induced hyperglycaemia in critically ill patients: a prospective observational study

ESICM LIVES 2013 26th Annual Congress Paris, France 5–9 October This supplement issue of the official ESICM/ESPNIC journal Intensive Care Medicine contains abstracts of scientific papers presented at the 26th Annual Congress of the European Society of Intensive Care Medicine. The abstracts appear in order of presentation from Monday 7 October to Wednesday 9 October 2013. The same abstract numbering is used in the Congress Final Programme. This supplement was not sponsored by outside commercial interests; it was funded entirely by the society’s own resources. DOI:10.1007/s00134-013-3095-5 123 26th ANNUAL CONGRESS—PARIS, FRANCE—5–9 OCTOBER 2013 26th ANNUAL CONGRESS—PARIS, FRANCE—5–9 OCTOBER 2013