Prithwis Bhattacharyya

Association of biofilm production with multidrug resistance among clinical isolates of Acinetobacter baumannii and Pseudomonas aeruginosa from intensive care unit

Background and Aims: Given choice, bacteria prefer a community-based, surface-bound colony to an individual existence. The inclination for bacteria to become surface bound is so ubiquitous in diverse ecosystems that it suggests a strong survival strategy and selective advantage for surface dwellers over their free-ranging counterparts. Virtually any surface, biotic or abiotic (animal, mineral, or vegetable) is suitable for bacterial colonization and biofilm formation. Thus, a biofilm is “a functional consortium of microorganisms organized within an extensive exopolymeric matrix.” Materials and Methods: The present study was undertaken to detect biofilm production from the repertoire stocks of Acinetobacter baumannii (A. baumannii) and Pseudomonas aeruginosa (P. aeruginosa) obtained from clinical specimens. The tube method was performed to qualitatively detect biofilm production. Results: A total of 109 isolates of both organisms were included in the study, out of which 42% (46/109) isolates showed biofilm detection. Among the biofilm producers, 57% of P. aeruginosa and 73% of A. baumannii showed multidrug resistance (MDR) pattern which was statistically significant in comparison to nonbiofilm producers (P < 0.001). Conclusion: To the best of our knowledge, this is the only study to have tested the biofilm production in both P. aeruginosa and A. baumannii in a single study. Biofilm production and MDR pattern were found to be significantly higher in A. baumannii than P. aeruginosa. Antibiotic resistance was significantly higher among biofilm producing P. aeruginosa than non producers. Similarly, antibiotic resistance was significantly higher among biofilm producing A. baumannii than non producers.

Fractured tracheostomy tube as foreign body bronchus: Our experience with three cases

OBJECTIVE Tracheostomy tubes are extensively used in paediatric age group for airway issues. Their fracture and lodgement into trachea is an acute emergency requiring urgent intervention. CASES We report three such paediatric cases having tracheostomy tube fracture and aspiration into trachea with different presentations and treatment outcomes. RESULTS One patient was successfully managed with bronchoscopy and fractured tube removal. One patient succumbed to asphyxia before any intervention. The third patient was having supratubal tracheal stenosis making things more dangerous, but was managed successfully by tracheoscopy through tracheostomy opening with removal of fractured tube. CONCLUSION Immediate identification is the key to successful management of this rare but life threatening situation. In the presence of tracheal stenosis above the tracheostomy opening, situation becomes more dangerous with very limited options for management.

Pacemakers and implantable cardioverter defibrillators - general and anesthetic considerations

A pacemaking system consists of an impulse generator and lead or leads to carry the electrical impulse to the patients heart. Pacemaker and implantable cardioverter defibrillator codes were made to describe the type of pacemaker or implantable cardioverter defibrillator implanted. Indications for pacing and implantable cardioverter defibrillator implantation were given by the American College of Cardiologists. Certain pacemakers have magnet-operated reed switches incorporated; however, magnet application can have serious adverse effects; hence, devices should be considered programmable unless known otherwise. When a device patient undergoes any procedure (with or without anesthesia), special precautions have to be observed including a focused history/physical examination, interrogation of pacemaker before and after the procedure, emergency drugs/temporary pacing and defibrillation, reprogramming of pacemaker and disabling certain pacemaker functions if required, monitoring of electrolyte and metabolic disturbance and avoiding certain drugs and equipments that can interfere with pacemaker function. If unanticipated device interactions are found, consider discontinuation of the procedure until the source of interference can be eliminated or managed and all corrective measures should be taken to ensure proper pacemaker function should be done. Post procedure, the cardiac rate and rhythm should be monitored continuously and emergency drugs and equipments should be kept ready and consultation with a cardiologist or a pacemaker-implantable cardioverter defibrillator service may be necessary.

Disseminated intravascular coagulation in malaria: A case report.

Disseminated intravascular coagulation (DIC) is seen in <5% of patients with severe Plasmodium falciparum malaria and is more common in cerebral malaria. Here, we report the diagnosis and management of a case of severe P. falciparum malaria with DIC.

Comparison of effectiveness of class lecture versus workshop-based teaching of basic life support on acquiring practice skills among the health care providers.

Background: Basic life support (BLS) is an integral part of emergency medical care. Studies have shown poor knowledge of it among health care providers who are usually taught BLS by lecture-based teachings in classes. Objectives: This study is designed to assess the effectiveness of class lecture versus workshop-based teaching of BLS on acquiring the practice skills on mannequin. Methods: After ethical approval and informed consent from the participants, the present study was conducted among the health care providers. Participants were grouped in lecture-based class teaching and workshop-based teaching. They were then asked to practice BLS on mannequin (Resusci Anne with QCPR) and evaluated as per performance parameters based on American Heart Association BLS. Statistical analyses are done by Fishers exact t-test using GraphPad INSTAT software and P< 0.05 is taken as significant. Results: There were 55 participants in lecture-based teaching and 50 in workshop-based teaching group. There is no statistical difference in recognition of arrest, checking pulse, and starting chest compression (P > 0.05). Though more than 83% of lecture-based teaching group has started chest compression as compared 96% of workshop group; only 49% of the participants of lecture-based group performed quality chest compression as compared to 82% of other group (P = 0.0005). The workshop group also performed better bag mask ventilation and defibrillation (P < 0.0001). Conclusion: Workshop-based BLS teaching is more effective and lecture-based class teaching better is replaced in medical education curriculum.

Diagnostic accuracy of delirium assessment methods in critical care patients

Purpose: Delirium is a disorder of decreased ability to focus, sustain or shift attention, change in cognition and or perception. The main objective was to evaluate the diagnostic accuracy of Confusion Assessment Method for the ICU (CAM‐ICU) and Intensive Care Delirium Screening Checklist (ICDSC) among the nursing and medical staff in a multidisciplinary ICU. Methods and material: Three hundred ten verbally communicating and non‐communicating patients (mean age in years 47.9, standard deviation [SD] 14.5, mean Acute Physiology and Chronic Health Evaluation II score 13.8, SD 6.4) were assessed by a psychiatrist, nurse and intensivist for delirium. Inter‐rater agreement was measured by Cohens kappa coefficient. Sensitivity, specificity, predictive values, likelihood ratios and diagnostic odds ratio (DOR) were calculated. Results: CAM‐ICU showed higher sensitivity and DOR (84%, 86.1) compared to ICDSC (78%, 36.9). ICDSC had specificity and positive predictive value (94.5%, 92%) equal to that of CAM‐ICU. For both the assessment methods (CAM‐ICU and ICDSC), DORs for intensivists (120.5, 53.0) were relatively higher than nurses (67.0, 27.0). Conclusions: In our mixed ICU population, CAM‐ICU remained more sensitive than ICDSC. Though sensitivity and DOR were higher for medical staff, other diagnostic parameters were similar for both medical and nursing staff. HighlightsCAM‐ICU was found to be a better delirium assessment tool than the ICDSC.The results of the assessment tools whether performed by the intensivists or the nurses were comparable.Sepsis, benzodiazepines, mechanical ventilation, and APACHE II >16 were the risk factors to develop delirium.

A retrospective study of endotracheal or tracheostomy tube blockage and their impact on the patients in an intensive care unit

Background: Endotracheal and tracheostomy tube (TT) blockage is a common airway accident in Intensive Care Unit (ICU). Although tube blockage is rarely fatal, it has a major impact on the quality of ICU care and the family of the patient. The present study is aimed to assess the tube accidents; primarily, the number, timing, the cause of tube blockage in intubated patients and its impact along with the risk of blockage in relation to respiratory diseases, demography, and on-tube duration. Materials and Methods: After the Ethical Committee approval, the study was conducted in a mixed ICU. Data were collected retrospectively from the ICU assessment record of patients admitted from November 2012 to October 2014. The total numbers of intubated patients and the duration of intubation were recorded. Patients who were intubated for >24 h were evaluated for risk analysis. Data were analyzed using InStat software with Fishers exact test and unpaired t-test. Results: There were 105 episodes of tube blockage in 72 out of 975 intubated patients during 3797 tube days resulting in five cardiac arrests and one death. Endotracheal tube tubes tend to get blocked earlier than TT tubes (6.30 vs. 8.09 days). The risk of tube blockage increases significantly in patients having ventilator-associated pneumonia (VAP) and who have been intubated for 5 days or more (P < 0.0001). Conclusions: Fatality from tube blockage is rare but causes preventable death. Hence, tube change for ongoing airway management between 5 and 7 days is probably justifiable, especially in patients with VAP.

How useful is extravascular lung water measurement in managing lung injury in intensive care unit

Context: The primary goal of septic shock management is optimization of organ perfusion, often at the risk of overloading the interstitium and causing pulmonary edema. The conventionally used end points of resuscitation do not generally include volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). Aims: This study aimed to assess the prognostic value of EVLWI and PVPI by calculating their correlation with the severity of lung injury. Settings and Design: This prospective observational study included twenty mechanically ventilated critically ill patients with Acute Physiology and Chronic Health Evaluation score (APACHE II) >20. Subjects and Methods: EVLWI and PVPI were measured using transpulmonary thermodilution, and simultaneously, PaO2:FiO2 ratio, alveolar-arterial gradient of oxygen (AaDO2), and chest radiograph scores from two radiologists were obtained. Statistical Analysis: The correlation of EVLWI and PVPI with chest radiograph scores, PaO2:FiO2 ratio, and AaDO2 were calculated. The inter-observer agreement between the two radiologists was tested using kappa test. Results: EVLWI and PVPI correlated modestly with PaO2:FiO2 (r = −0.32, P = 0.0004; r = −0.39, P = 0.0001). There was a better correlation of EVLWI and PVPI with PaO2:FiO2 ratio (r = −0.71, P < 0.0001; r = −0.58, P = 0.0001) in the acute respiratory distress syndrome (ARDS) subgroup. The EVLWI values correlated significantly with corresponding chest radiograph scores (r = 0.71, P < 0.0001 for observer 1 and r = 0.68, P < 0.0001 for observer 2). Conclusions: EVLWI and PVPI may have a prognostic significance in the assessment of lung injury in septic shock patients with ARDS. Further research is required to reveal the usefulness of EVLWI as an end point of fluid resuscitation in the management of septic shock with ARDS.

Scrub typhus masquerading as HELLP syndrome and puerperal sepsis in an asymptomatic malaria patient.

Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied presentations. However, clinical malaria or scrub typhus is unusual without fever. On the other hand, altered sensorium with or without fever, dehydration, hemorrhage and hemolysis may lead to low blood pressure. Presence of toxic granules and elevated band forms in such patients can even mimic sepsis. When such a patient is in the peripartum period, it creates a strong clinical dilemma for the physician especially in unbooked obstetric cases. We present such a case where a 26-year-old unbooked female presented on second postpartum day with severe anemia, altered sensorium, difficulty in breathing along with jaundice and gum bleeding without history of fever. Rapid diagnostic test for malaria was negative and no eschar was seen. These parameters suggested a diagnosis of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet) syndrome with or without puerperal sepsis. Subsequently she was diagnosed as having asymptomatic malaria and scrub typhus and responded to the treatment of it. The biochemical changes suggestive of HELLP syndrome also subsided. We present this case to emphasize the fact that mere absence of fever and eschar does not rule out scrub typhus. It should also be considered as a differential diagnosis in patients with symptoms and signs suggesting HELLP syndrome. Asymptomatic malaria can complicate case scenario towards puerperal sepsis by giving false toxic granules and band form in such situations.

Dexmedetomidine in Attenuation of Haemodynamic Response and Dose Sparing Effect on Opioid and Anaesthetic Agents in Patients undergoing Laparoscopic Cholecystectomy- A Randomized Study

INTRODUCTION Perioperative procedures are stressful and lead to haemodynamic instability with potentially devastating consequences. Dexmedetomidine is found to have many of the desired characteristics that are required in perioperative period. AIM To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc-Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant. RESULTS Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The Minimum Alveolar Concentration (MAC) requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective. CONCLUSION Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.