Shakti Bedanta Mishra

A pilot randomized controlled trial of comparison between extended daily hemodialysis and continuous veno-venous hemodialysis in patients of acute kidney injury with septic shock

Aim of Study: Acute kidney injury (AKI) is common in patients of septic shock. There is sparse data comparing sustained low-efficiency dialysis (SLED) and continuous renal replacement therapy (CRRT) in patients with septic shock. Materials and Methods: This is a prospective randomized study in a 12-bedded medical intensive care unit. After clearance from institutes ethics committee and obtaining informed consent from the relatives, sixty adult patients with septic shock who were to undergo dialysis for AKI were included in the study. They were randomly assigned to SLED or CRRT group. Hemodynamic instability was defined as in terms of vasopressor dependency (VD). The worst value of VD during the dialysis session was taken into consideration. The primary objective was look at hemodynamic changes and secondarily into the efficacy. Results: The demographic data were comparable between the sixty patients randomized to thirty in each group. Delta VD and delta vasopressor index (DVI) were similar in SLED group compared to the CRRT group. CRRT group had better efficacy in terms of both equivalent renal urea clearance though fluid balance was not significantly better in CRRT group. Conclusion: SLED is a viable modality of renal replacement therapy in patients with septic shock as the hemodynamic effects are similar to CRRT.

Sustained low-efficiency dialysis in septic shock: Hemodynamic tolerability and efficacy

Aim of the Study: Acute kidney injury (AKI) in septic shock has poor outcomes. Sustained low-efficiency dialysis (SLED) is increasingly replacing continuous renal replacement therapy as the preferred modality in Intensive Care Units (ICUs). However, the essential aspects of hemodynamic tolerability and efficacy of SLED in septic shock AKI has been minimally studied. Patients and Methods: We describe hemodynamic tolerability using modified vasopressor index (VI) and vasopressor dependency (VD) and efficacy using a combination of Kt/v, correction of acidosis, electrolyte, and fluid overload. Adult ICU patients of septic shock in AKI requiring SLED were included in this study. Results: One hundred and twenty-four patients of septic shock AKI requiring SLED were enrolled in the study. There were 74 nonsurvivors (NSs). Approximately, 56% (278/498) of the sessions in which vasopressors were required were studied. Metabolic acidosis (49%) was the predominant indication for the initiation of SLED in these patients. Baseline characteristics between survivors and NSs were comparable, except for age, severity scores, AKI stage, and coexisting illness. VI and VD prior to the initiation of SLED and delta VI and VD during SLED were significantly higher in NSs. Hemodynamic tolerability and efficacy of SLED was achievable only at lower vasopressor doses. Conclusion: VI, VD, and combination of Kt/v together with correction of acidosis, electrolyte, and fluid overload can be used to describe hemodynamic tolerability and efficacy of SLED in septic shock AKI. However, at higher vasopressor doses in septic shock, hemodynamic tolerability and efficacy of SLED requires further evidence.

Ventilator-associated complications: A study to evaluate the effectiveness of a planned teaching program for intensive care unit staff nurses-an Indian experience.

The role of nursing staff is important for both prevention and early diagnosis of complications associated with mechanical ventilation. The objective of our study was to assess the knowledge of nurses working in an intensive care unit for at least 6 months regarding ventilator-associated complications and its prevention. A quasiexperimental study was conducted using a questionnaire with 50 questions formulated by the panel of experts. A planned teaching program was developed based on related literature regarding ventilator-associated complications and its prevention and was presented to the staff nurses. The level of knowledge of the nursing staff was assessed before and after the workshop. Fifty nurses were included in the study. Among the staff nurses, 53.40% had average knowledge regarding ventilator-associated complications. Posttest, 77.20% of the total score was obtained for ventilator-associated complications. Regular training programs can be effective in improving the knowledge of nursing staff.

Antimicrobial dosing in critically ill patients with sepsis-induced acute kidney injury

Sir, We read with interest the article by Anish Kumar et al.[1] It is an extremely important issue in critical care settings considering the incidence and high mortality rates associated with sepsis and the subsequent development of acute kidney injury (AKI). The antibiotics are one of the most important armamentarium in dealing with this problem. If we do not get the right dose at right time then it not only increases mortality, but also leads to subsequent development of infection with resistant organisms. The article adds to our improved understanding of the usage of antibiotics in septic AKI patients. The article has very well elaborated the factors that can affect the dosing of the antibiotics and how to give the appropriate dosage for most of the commonly used antibiotics. There has been a significant epidemiological shift in the resistance patterns in intensive care unit (ICU) worldwide. Multidrug-resistant Pseudomonas and Acinetobacter have been the prototypical nosocomial pathogens for the past few decades. These organisms may be eclipsed by a rapidly growing global epidemic of cephalosporin and carbapenem-resistant Enterobacteriaceae. These organisms have been detected in India since 2006.[2] They continue to be a major source of nosocomial infections especially in Indian ICUs. The use of colistin and tigecycline to deal with the changed epidemiology has increased in ICUs.[3] These drugs have their own unique pharmacokinetic and pharmacodynamic profile. This review does not highlight about the factors that may affect the pharmacokinetic s and dynamics of these drugs in AKI. The dosing regimen of colistin may also vary with different modalities of renal replacement therapy, and needs to be discussed as recommended by different authors.[4,5] The renal toxicity of colistin is said to be overestimated in past studies. We need new studies to look for dosing of colistin especially in septic AKI patients and reviews must address this issue.

Multiple myeloma presenting as acute pancreatitis

A 36 year old male presented to the emergency department with severe epigastric pain, nausea, vomiting without hematemesis, diarrhea and anorexia. He presented with respiratory distress, shock and fever at the emergency. He was intubated and shifted to the intensive care unit with the diagnosis of acute pancreatitis with hypercalcemia and an elevated amylase and lipases well as thrombocytopenia and elevated creatinine. CT scan of abdomen was done which showed lytic bone lesions in the spine and necrosis of the pancrease. He was evaluated for multiple myeloma and it was confirmed in a bone marrow biopsy. Multiple myeloma usually is seen in patients aged more than 60 yrs. The typical presentation of multiple myeloma is anemia, back pain, and an elevated sedimentation rate. Patients with multiple myeloma have hypercalcemia but its rarely manifested as acute pancreatitis. This case shows a rare presentation of multiple myeloma as acute pancreatitis in a younger adult.

Acetazolamide and Invasive Mechanical Ventilation for Patients With COPD--Reply.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported being an unpaid board member of the American Lyme Disease Foundation; being a consultant for Baxter for the Lyme vaccination program; providing expert testimony for litigation involving Lyme disease and babesiosis; receiving grants (to his institution) from the National Institutes of Health, Immunetics, Rarecyte, BioMerieux, and the Institute for Systems Biology; receiving payment for lectures from various medical centers and professional organizations; holding stock in Abbott; and receiving travel expenses from the Infectious Disease Society of America. No other disclosures are reported.

Impact of dialysis practice patterns on outcomes in acute kidney injury in Intensive Care Unit

Sir, We read with interest the article on outcomes in acute kidney injury (AKI) by Annigeri et al.[1] They have very well compared the change of their practice of dialysis in view of indications and process of dialysis with resultant significant change in mortality. The authors think that some aspects need to be considered in this study. Severe organ edema was chosen as an indication for dialysis. The definition used for this indication is not clearly defined in the manuscript. The comparison of hemodynamics between continuous renal replacement therapy (CRRT) and prolonged intermittent renal replacement therapy (PIRRT) does not add much value to the study as the choice of dialysis was based on the hemodynamics. The authors think an objective assessment of hemodynamics during the dialysis sessions comparing PIRRT and CRRT would have given some more information as studies are available which have tried to explain the hemodynamic effects with the use of vasopressor dependency and vasopressor index.[2] The aim of RRT was targeted to control blood urea nitrogen. This is a target used in chronic renal failure, but its utility in a patient in AKI who is undergoing dialysis for metabolic acidosis and fluid overload is doubtful.[3] The efficacy of PIRRT to achieve the targets should have been compared with CRRT. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with Intensive Care Unit mortality in critically ill

Sir, We read with great interest, the article on the relationship between glycated hemoglobin (HbA1c), Intensive Care Unit (ICU) admission blood sugar and glucose control with ICU mortality in critically ill patients by Mahmmodpor et al.[1] The literature on glycemic control in intensive care is taking turns from its earlier publication by van den Berghe done 13 years back, that stress hyperglycemia increases mortality and morbidity. Subsequent studies suggested that intensive glucose control increases hypoglycemic episodes (NICE-SUGAR study),[2] and recently researchers have stressed the importance of glycemic variability. This study, again suggests the need for HbA1c in all patients with hyperglycemia presenting to intensive care for the diagnosis of occult diabetes mellitus or stress-induced hyperglycemia (SIH), with SIH associated with more mortality, especially in patients with trauma, as elucidated in previous studies.[3,4] We need more clarifications from the authors regarding the study with reference to the points listed below: The sample size of 500 seems to be arbitrarily chosen a priori, the justification of targeting this sample size is not clear in the methodology The targets for blood sugar in septic and nonseptic patients should have been a range rather than a fixed value. We don’t think its justified to use an arterial line for the sole purpose of glucose monitoring. The initial sample could have been sent to the central laboratory along with HbA1c, for better accuracy (central laboratory > arterial blood gas analyzer > arterial blood sample by glucometer > venous blood sample by glucometer > capillary sample by glucometer)[5] The mortality cannot be attributed to the level of HbA1c alone as the baseline APACHE 2 scores are significantly different. It would have been more informative if they had described the data while grouping the patients between levels of HbA1c[4] There is limited data given in this study regarding baseline body mass index to interpret the existing paradox in diabetics, patients on corticosteroids (which would have continued in few patients in this study, as the data analysis mentions that 48.4% of patients were on drugs), patients on vasopressors and the details of nutrition. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest

Comparison between sustained low-efficiencydialysis (SLED) and continuous renal replacement therapy (CRRT) in patients of septic shock: a randomized controlled trial.

Acute Kidney Injury is common in patients of septic shock. There is sparse data comparing SLED and CRRT in septic shock patients.

Scrub typhus and acute respiratory distress syndrome.

Sir, We read with interest the article on scrub typhus by Venkategowda et al.[1] They have very well highlighted the fact that scrub typhus is an important differential diagnosis in patients getting admitted with fever and thrombocytopenia. A high index of suspicion and early antibiotics for the management of rickettsial diseases decrease the morbidity and mortality. Acute respiratory distress syndrome (ARDS) is one of the complications of scrub typhus.[2] Its a manifestation of the severity of respiratory system involvement. Pathological data from lung biopsy from patients developing ARDS in scrub typhus patients have shown that there is evidence of diffuse alveolar damage with hyaline membrane formation suggesting the damage is because of inflammatory mediators.[3] This is similar in patients who develop ARDS due to systemic inflammation like in sepsis. In this study, the most of the patient who had ARDS also had acute kidney injury (75%), acute liver failure (58.3%), and shock (70%). This shows that ARDS is a part of the multi-organ dysfunction, which affects patients with scrub typhus. We thus feel that classifying patients into with and without ARDS does not help in clinical management of these patients. Table 2 of the article could have been better presented in two separate tables as patients on mechanical ventilation and 28 days mortality are in percentages and probably printed as mean ± standard deviation due to typographical error. The data would have been better presented as median with interquartile range as the population is small and using mean has some limitations. It would have been better if the statistical tools used in the analysis had been described in the text. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.