Shivesh Prakash

Post resusicitation fluid boluses in severe sepsis or septic shock: prevalence and efficacy (price study).

Introduction Administration of fluid boluses (FBs) beyond initial resuscitation in patients with severe sepsis is common and may contribute to positive fluid balance. Little is known regarding the efficacy and risk profile of this strategy. Objective To estimate the prevalence and efficacy of FBs after initial resuscitation in septic patients. Methods In a prospective study, patients with severe sepsis/septic shock were recruited after initial resuscitation and followed up for 3 days. Number, types, and volumes of FBs; resuscitation goals; and their perceived success rates were recorded. Data are presented as median (interquartile range). Results Over a 1-year period, 50 patients were recruited, 47 (94%) of them received FBs, with a total of 184 FBs (3 [2–5] per patient) administered over 72 h. On day 1, 2 (1–3) FBs, totaling 750 mL (500–1,720 mL), were administered, which comprised 52.4% (22.1%–124.2%) of the fluid balance. Low blood pressure (mean arterial pressure [MAP]) (76.0%) and increased vasopressor requirement (60.3%) were the two most common indications for FBs. Low filling pressure (70.9%) and clinical signs (79.4%) were perceived as the most successful indications. One hour after these FBs, there was a small increase in MAP (P < 0.01) and central venous pressure (P < 0.01); however, there was also concomitant increase in noradrenaline administered. There was a significant decrease in PaO2/FIO2 ratio, hemoglobin, and temperature, whereas urine output remained unchanged. Factors (Exp[b] [SE], P) (R2 = 0.296) that affected the increase in MAP were baseline MAP (−0.49 [0.057], P < 0.001) and amount of these FBs (−0.05 [0.01], P = 0.001). Cumulative fluid balance had a weak correlation with delta sequential organ failure assessment score (r = 0.32, P = 0.001) and lung injury score (r = 0.13, P = 0.02) and negative correlation with PaO2/FIO2 ratio (r = −0.28, P = 0.001). Conclusion Postresuscitation FBs are common in septic patients, meet limited success, and may be harmful.

Admission high serum sodium is not associated with increased intensive care unit mortality risk in respiratory patients

BACKGROUND Because increased serum osmolarity may be lung protective, we hypothesized that increased mortality associated with increased serum sodium would be ameliorated in critically ill patients with an acute respiratory diagnosis. METHODS Data collected within the first 24 hours of intensive care unit (ICU) admission were accessed using ANZICS CORE database. From January 2000 to December 2010, 436,209 patients were assessed. Predefined subgroups including patients with acute respiratory diagnoses were examined. The effect of serum sodium on ICU mortality was assessed with analysis adjusted for illness severity and year of admission. Results are presented as odds ratio (95% confidence interval) referenced against a serum sodium range of 135 to 144.9 mmol/L. RESULTS Overall ICU mortality was increased at each extreme of dysnatremia (U-shaped relationship). A similar trend was found in various subgroups, with the exception of patients with respiratory diagnoses where ICU mortality was not influenced by high serum sodium (odds ratio, 1.3 [0.7-1.2]) and was different from other patient groups (P<.01). Any adverse associations with hypernatremia in respiratory patients were confined to those with arterial pressure of oxygen (PaO2)/fraction of inspired oxygen (Fio2) ratios of greater than 200. CONCLUSION High admission serum sodium is associated with increased odds for ICU death, except in respiratory patients.

Early changes in serum electrolytes and acid–base status with administration of 4 % albumin

Dear Editor, In addition to differences in their effectiveness as volume expanders, different intravenous (iv) fluids have different and sometimes unexpected adverse effects. As the absence of calcium and high chloride levels in 4 % albumin (CSL Biotherapies; which contains the following: sodium 140 mmol/l, chloride 128 mmol/l, albumin 40 g/l and octanoate 6.4 mmol/l) may lead to clinically significant effects, we further analysed data from our recently conducted price study [1], after 149 fluid boluses with 4 % albumin administration. The amount of 4 % albumin administered was 500 (250–500) ml [median (IQR)] and acid–base status and serum electrolytes were analysed with an ABL700 series (Radiometer Medical ApS, Brønshøj, Denmark) before and 1 h after fluid administration. Fluid blouses with 4 % albumin resulted in a decrease in plasma ionized calcium (corrected for pH) and an increase in serum chloride and an expected change in bicarbonate, PaCO2 and ultimately pH (Table 1). There was also a decrease in the PaO2/FiO2 ratio and a decrease in haemoglobin [1] with no change in sodium, potassium or lactate levels. The decrease in calcium levels is likely due to binding of free calcium with the administered albumin which does not contain any calcium. A delayed decrease in calcium levels has been reported before in hypovolaemic trauma patients who also had multiple blood transfusions with infusion of albumin [2], but the immediate effect is not known. The rise in chloride levels seen in our study is likely a reflection of the high amounts of chloride present in 4 % albumin. This then results in a metabolic acidosis and a compensatory decrease in PaCO2 levels. The drop in PaO2/FiO2 ratio is consistent with lung oedema and a decrease in haemoglobin is suggestive of haemodilution. Even though 4 % albumin has been suggested to decrease the risk of death in patients with severe sepsis [3], we found a drop in PaO2/ FiO2 ratio after 1 h of its administration in septic patients [1]. The change in chloride and calcium levels may have a contradictory effect on the development of lung oedema. Chloride transport-driven alveolar fluid secretion is now considered a major contributor to lung oedema [4], and a transient rise in serum chloride levels after 4 % albumin administration may expedite this process. This may be counterbalanced by a transient drop in ionized calcium levels. One of the major pathways of lung injury is entry of calcium via endothelial channels and transient drop in calcium may impede this process. Of note calcium-free perfusate is often used in isolated perfused lung injury models as a negative control [5]. The interaction between the above two variables may contribute to the development of lung oedema in patients with sepsis. Future studies should focus on acute changes in these electrolyte levels after interventions such as the administration of 4 % albumin. We acknowledge that these changes are small and levels are not known after the first 1 h, although earlier but transient electrolyte effects might play a more important physiologic role in the development of pulmonary oedema than their daily levels.

Fluid bolus therapy in emergency department patients: Indications and physiological changes.

The aim of the present paper is to study the indications for fluid bolus therapy (FBT) and its associated physiological changes in ED patients.

A rare case of rapidly enlarging tracheal lobular capillary hemangioma presenting as difficult to ventilate acute asthma during pregnancy

BackgroundLobular Capillary Hemangioma (LCH) is a benign tumour that is known to be hormone responsive and have a relatively high incidence during pregnancy, the most common site being the gingival surfaces. A tracheal origin for this tumour is extremely rare, with no case reported so far in this patient population, and the only reported clinical presentation of tracheal LCH in the literature is with haemoptysis.Case presentationWe describe a case of a 23-year-old known asthmatic who presented at 32 weeks gestation with life-threatening respiratory failure resembling acute severe asthma, requiring invasive ventilation which was extremely difficult. This was subsequently found to be due to a large tracheal LCH producing a ball-valve phenomenon and predominantly expiratory airflow limitation similar to acute asthma. The endotracheal tube was advanced past the lesion under bronchoscopic guidance, and urgent Caesarean section performed due to foetal distress. The tumour was subsequently debulked and the trachea stented, facilitated by bi-femoral veno-venous extra-corporeal membrane oxygenation with relatively low dose of heparin.ConclusionTo our knowledge, this is the first report of a unique presentation and management of largest tracheal LCH so far occurring during pregnancy. Pulmonary and critical care physicians should be aware of this unique differential of refractory asthma, the aggressive nature of this benign tumour due to hormonal influences during pregnancy, and feasibility of using bi-femoral veno-venous extra-corporeal membrane oxygenation with low dose heparin as a rescue, given the high risk of bleeding.

Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study

BackgroundThe majority of human errors in healthcare originate from cognitive errors or biases. There is dearth of evidence around relative prevalence and significance of various cognitive errors amongst doctors in their first post-graduate year. This study was conducted with the objective of using high fidelity clinical simulation as a tool to study the relative occurrence of selected cognitive errors amongst doctors in their first post-graduate year.MethodsIntern simulation sessions on acute clinical problems, conducted in year 2014, were reviewed by two independent assessors with expertise in critical care. The occurrence of cognitive errors was identified using Likert scale based questionnaire and think-aloud technique. Teamwork and leadership skills were assessed using Ottawa Global Rating Scale.ResultsThe most prevalent cognitive errors included search satisfying (90%), followed by premature closure (PC) (78.6%), and anchoring (75.7%). The odds of occurrence of various cognitive errors did not change with time during internship, in contrast to teamwork and leadership skills (x2 = 11.9, P = 0.01). Anchoring appeared to be significantly associated with delay in diagnoses (P = 0.007) and occurrence of PC (P = 0.005). There was a negative association between occurrence of confirmation bias and the ability to make correct diagnosis (P = 0.05).ConclusionsOur study demonstrated a high prevalence of anchoring, premature closure, and search satisfying amongst doctors in their first post-graduate year, using high fidelity simulation as a tool. The occurrence of selected cognitive errors impaired clinical performance and their prevalence did not change with time.

Pyrazinamide-induced phototoxicity: a case report and review of literature.

A 40-year-old male presented with a fresh case of pulmonary tuberculosis and itchy oozing rashes distributed characteristically over the sun exposed areas of the skin. These rashes had developed since six days following 10 days of start of antitubercular drugs (streptomycin, isoniazid, rifampicin, pyrazinamide and ethambutol at standard dosages). A possibility of drug-induced reaction was entertained and all the antitubercular drugs were discontinued; subsequently they were reintroduced in a sequential manner starting with small dosages, gradually increasing them to their normal dose. The rashes reappeared after introduction of pyrazinamide. We tried to desensitize this very important antitubercular drug but were not successful as the rashes reappeared. The patient was labeled as having pyrazinamide-induced phototoxicity and was started on a regimen containing streptomycin, isoniazid, rifampicin, ethambutol. Five months following treatment, the patient is now sputum negative for AFB. Pyrazinamide forms the integral part of most of the short course regimens, included in all the three categories of DOTS and with increasing coverage of DOTS therapy these rare cases may well be frequently encountered.

Addition of indapamide to frusemide increases natriuresis and creatinine clearance, but not diuresis, in fluid overloaded ICU patients

BACKGROUND Fluid and sodium overload are a common problem in critically ill patients. Frusemide may result in diuresis in excess of natriuresis. The addition of indapamide may achieve a greater natriuresis, and also circumvent some of the problems associated with frusemide. The objective of this study was to examine the effect of adding indapamide to frusemide on diuresis, natriuresis, creatinine clearance and serum electrolytes. METHODS Fluid overloaded ICU patients were randomised to either intravenous frusemide (Group F) or intravenous frusemide and enteral indapamide (Group F + I). Comprehensive exclusion criteria were applied to address confounders. 24 hour urine was analysed for electrolytes and creatinine. Serum electrolytes were measured before and 24 hours after administration of diuretics. RESULTS Forty patients (20 in each group) were included in the study. The groups were similar in their baseline characteristics. Over the 24 h study period, patients in Group F + I, had a larger natriuresis (P = 0.01), chloride loss (P = 0.01) and kaliuresis (P = 0.047). Patients in Group F + I also had a greater 24 hour urinary creatinine clearance (P = 0.01). The 24 hour urine volume and fluid balance was similar between the groups. Patients in Group F had an increase in serum sodium (P = 0.04), while patients in Group F + I had a decrease in both serum chloride (P = 0.01) and peripheral oedema (P < 0.001) during the study duration. CONCLUSION In fluid overloaded ICU patients, addition of indapamide to frusemide led to a greater natriuresis and creatinine clearance. Such a strategy might be utilised in optimising sodium balance in ICU patients.

Concordance between point-of-care blood gas analysis and laboratory autoanalyzer in measurement of hemoglobin and electrolytes in critically ill patients

We tested the hypothesis that the results of the same test performed on point‐of‐care blood gas analysis (BGA) machine and automatic analyzer (AA) machine in central laboratory have high degree of concordance in critical care patients and that the two test methods could be used interchangeably.

Healthcare costs and outcomes for patients undergoing tracheostomy in an Australian tertiary level referral hospital

Objective Patients undergoing tracheostomy represent a unique cohort, as often they have prolonged hospital stay, require multi-disciplinary, resource-intensive care, and may have poor outcomes. Currently, there is a lack of data around overall healthcare cost for these patients and their outcomes in terms of morbidity and mortality. The objective of the study was to estimate healthcare costs and outcomes associated in tracheostomy patients at a tertiary level hospital in South Australia. Design Retrospective review of prospectively collected data in patients who underwent tracheostomy between July 2009 and May 2015. Methods Overall healthcare-associated costs, length of mechanical ventilation, length of intensive care unit stay, and mortality rates were assessed. Results A total of 454 patients with tracheostomies were examined. Majority of the tracheostomies (n = 386 (85%)) were performed in intensive care unit patients, predominantly using bedside percutaneous approach (85%). The median length of hospital stay was 44 (29–63) days and the in-hospital mortality rate was 20%. Overall total cost of managing a patient with tracheostomy was median