Ratender K Singh

Procalcitonin kinetics as a prognostic marker in severe sepsis/septic shock

Background and Aims: To evaluate the prognostic value of change (fall) in serum procalcitonin level (PCT) in critically ill adults with severe sepsis/septic shock. Methods: This was a prospective observational study in a general purpose Intensive Care Unit of a teaching Institute. PCT was measured at admission (D0) and after 72–96 h (D4) by electrochemi-luminescence immunoassay (BRAHMS PCT kit) in adults (>18 years) admitted with severe sepsis or septic shock. Change in procalcitonin values from D0 to D4 was correlated with the primary outcome, that is, 28 days mortality. All results are reported as median (interquartile range). Results: A total of 171 (100 males) of 181 patients were included. The median age was 46 years (range 19–79). 137 patients were in septic shock and 34 in severe sepsis. The sequential organ failure assessment (SOFA) score in all patients was 11 (9–14).91 (53.2%) patients survived at 28 days (survivors). The baseline procalcitonin was similar in two groups (3.48 [1.04–15.85] vs. 5.27 [1.81–23.57] ng/ml in survivors and nonsurvivors [NS] respectively). The procalcitonin change was 1.58 (0.20–8.52) in survivors and 0.28 (–1.38–6.17) in NS (P = 0.01). The C-statistic of percentage change in procalcitonin from D0 to D4 to predict survival was 0.73 (95% confidence interval [CI]: 0.65–0.82) when compared to 0.78 (95% CI: 0.71–0.86) for change of SOFA score. For an absolute fall in procalcitonin of >1 ng/ml, a 70% fall predicted survival with 75% sensitivity and 64% specificity. Conclusions: In critically ill-patients with severe sepsis/septic shock, change (fall) in procalcitonin is associated with good outcome.

Carbapenem-resistant Acinetobacter ventilator-associated pneumonia: Clinical characteristics and outcome.

Objective: To study the clinical characteristics and 28-days mortality in patients with ventilator-associated pneumonia (VAP) due to carbapenem-resistant Acinetobacter (CRA). Design: Retrospective, observational, cohort study. Setting: Intensive care unit (ICU) of a university hospital. Materials and Methods: Microbiologically confirmed VAP due to CRA infection. Intervention: None. Results: Out of 87 patients with VAP due to CRA, 60 (69%) were male; whose median age was 51 years; 73 (84%) patients were medical; 26 (30%) had history of hospitalization in last 3 months; median acute physiology and chronic health evaluation (APACHE) II was 15 and median SOFA 9 at admission; primary reason for ICU admission was respiratory failure (34%); 46 (53%) patients had more than 2 organ failure at ICU admission; median length of ICU stay was 19 days; 66 (76%) patients need vasoactive agents during ICU stay, whereas 55 (63%) patients had renal failure; median duration of mechanical ventilation was 17 days; 22 (25%) patients had acute respiratory distress syndrome (ARDS) during ICU stay; 72 (83%) patients had exposure to carbapenem before inclusion in the study; 33 (38%) patients had same organism at other sites. In the follow-up, 47 (54%) patient survived at 28 days after having VAP; whereas only 40 (46%) patients were discharged from the hospital. Conclusions: CRA-VAP has high crude mortality. Advanced age; severity of illness and presence of pneumonia at ICU admission; and presence of shock, ARDS and renal failure have impact on outcome in these patients.

Clinical manifestations of co-infection with malaria and leptospirosis

Though both malaria and leptospirosis are frequent in the tropics, co-infections are under-recognized due to overlapping of clinical features. Here, we reviewed clinical manifestations of published co-infection along with our three cases. Out of a total of 18 patients, nine patients (50%) required ICU admission. Almost all patients had prodromal symptoms in the form of fever, headache and myalgia. Seven patients (37%) had altered sensorium, three patients (17%) had hypotension at admission, and 11 patients (61%) had acute kidney injury (AKI). Pulmonary manifestations in the form of pulmonary bleeding were present in four cases (22%). Three (17%) patients had acute lung injury/ acute respiratory distress syndrome. Almost 55% patients had DIC in the form of altered prothrombin time, activated partial thromboplastin time and low fibrinogen level. Four patients (22%) had subconjuctival suffusion, two of them had haematuria, while one presented with nasal bleeding. All patients had altered liver function tests. Of all the 18 patients, 17 (94%) survived, while one died.

Staphylococcal sepsis presenting as pulmonary embolism.

Deep vein thrombosis in children is rare and is often secondary to a predisposing condition. Staphylococcal sepsis following furunculosis and complicated by deep vein thrombosis and septic pulmonary emboli in a fourteen-yr-old boy is presented. He was managed successfully with antibiotics and anticoagulation.

Impact of an educational intervention on errors in death certification: An observational study from the intensive care unit of a tertiary care teaching hospital.

Background: A high incidence of errors occur while filling up death certificates in hospitals. The purpose of this study was to analyze the impact of an educational intervention on errors in death certification in an intensive care unit (ICU). Patients admitted to ICUs by virtue of being critically ill have a higher mortality than other hospitalized patients. This study was designed to see if any improvement could be brought about in filling death certificates. Materials and Methods: Educating sessions, interactive workshops, and monthly audits for the department resident doctors were conducted. One hundred and fifty death certificates were audited for major and minor errors (75 before and 75 after the educational intervention) over a period of 18 months. Fishers exact test was applied to statistically analyze the data. Results: There was a significant decrease in major errors like mechanism without underlying cause of death (60.0 vs. 14.6%, P < 0.001), competing causes (88.0 vs. 13.3%, P < 0.001), and improper sequencing (89.3 vs. 36.0%, P < 0.001). There was also a significant decrease in minor errors such as use of abbreviations (89.3 vs. 29.3%, P < 0.001) and no time intervals (100.0 vs. 22.6%, P < 0.001). Conclusion: Authors conclude that death certification errors can be significantly reduced by educational interventional programs.

Continuous hypertonic saline for acute liver failure

Acute liver failure (ALF) is a clinical condition with high mortality. The most common cause of death in ALF is cerebral edema. We present a 12-year-old boy with hepatitis A-related acute liver failure in grade IV hepatic encephalopathy successfully managed in the ICU using continuous hypertonic saline as the preferred osmotherapy.

Septic acute kidney injury in critically ill Indian patients

Acute kidney injury (AKI) is an independent variable for poor outcome in critically ill patients. The pathophysiology of septic AKI is distinct from that of non-septic AKI. We studied the clinical profile and outcome of septic AKI since such data is sparse in Indian patients. In this single-center retrospective, observational, cohort study, septic AKI has been found with high incidence (31%) and overall mortality was 52%. Age, number of non-renal organ failure, and APACHE II score were found as significant predictors of outcome in this population.

Deep-vein thrombosis and septic pulmonary emboli in methicillin-sensitive Staphylococcus aureus infection

Abstract Deep-vein thrombosis (DVT) in children is most often secondary to a predisposing cause. DVT and septic pulmonary emboli in staphylococcal sepsis has been described most often with methicillin-resistant Staphylococcus aureus. The clinical features of four previously healthy children with community-acquired, methicillin-sensitive Staphylococcus aureus sepsis associated with DVT are described.

The practice of tracheostomy decannulation—a systematic review

Decannulation is an essential step towards liberating tracheostomized patients from mechanical ventilation. However, despite its perceived importance, there is no universally accepted protocol for this vital transition. Presence of an intact sensorium coordinated swallowing and protective coughing are often the minimum requirements for a successful decannulation. Objective criteria for each of these may help better the clinical judgement of decannulation. In this systematic review on decannulation, we focus attention to this important aspect of tracheostomy care.

Acute methotrexate toxicity presenting as multiorgan failure and acute pneumonitis: A rare case report

Acute methotrexate toxicity rarely presents as medical emergency in form of multiorgan failure. Acute pneumonitis following low-dose methotrexate is rarely reported in literature. It is important to recognize this, as the drug must be discontinued immediately and rescue measures in form of folinic acid and hydration instituted promptly.