Vipin Kauts

Pancreatic injury in patients with septic shock: A literature review

Sepsis and septic shock are life threatening condition associated with high mortality rate in critically-ill patients. This high mortality is mainly related to the inadequacy between oxygen delivery and cellular demand leading to the onset of multiorgan dysfunction. Whether this multiorgan failure affect the pancreas is not fully investigated. In fact, pancreatic injury may occur because of ischemia, overwhelming inflammatory response, oxidative stress, cellular apoptosis and/or metabolic derangement. Increased serum amylase and/or lipase levels are common in patients with septic shock. However, imaging test rarely reveal significant pancreatic damage. Whether pancreatic dysfunction does affect the prognosis of patients with septic shock or not is still a matter of debate. In fact, only few studies with limited sample size assessed the clinical relevance of the pancreatic injury in this group of patients. In this review, we aimed to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. Our main finding is that pancreatic injury does not significantly affect the outcome in septic shock patients. Hence, increased serum pancreatic enzymes without clinical features of acute pancreatitis do not require further imaging investigations and specific therapeutic intervention.

Effectiveness of Systemic Fluconazole in Adult Patients With Asymptomatic Candiduria: A Systematic Review and Meta-Analysis.

Asymptomatic candiduria is a common finding in hospitalized patients. Its management modalities are still a matter of debate. Urinary catheter should be removed or replaced in all cases. In the current meta-analysis, we aimed to compare 2 different strategies in term of candida clearance from the urinary tract: Systemic fluconazole versus conservative management. A systematic search was performed in Pubmed, Web of science, and Cochrane Library database by 2 investigators. Three studies were included (421 patients). Data were extracted and the quality of each study was assessed. Systemic fluconazole was associated with a significantly higher short-term clearance of the funguria after 14 days of treatment [odds ratio = 0.43; confidence interval (CI) 95% (0.26–0.65)]. No significant heterogeneity was found among the included studies (Q statistic test = 0.38; I2 = 0). In conclusion, fluconazole significantly hasten short-term candida clearance from the urinary tract.

Factors associated with increased pancreatic enzymes in septic patients: a prospective study

BackgroundThe perfusion of splanchnic organs is deeply altered in patients with septic shock. The aim of the study is to identify the predictive factors of septic shock-induced increase of serum lipase and amylase and to assess and evaluate its prognostic impact.MethodsWe conducted a prospective observational study. All adult patients admitted with septic shock were eligible for our study. Serum lipase and amylase were measured on admission. Patients with and those without increased pancreatic enzymes were compared. Predictive factors of pancreatic insult identified by the univariate analysis were integrated in a stepwise multivariate analysis. Odds ratios (OR) with the 95% confidence interval (CI) were calculated accordingly. Second, the sensitivity and the specificity of amylase and lipase to predict intensive care unit (ICU) mortality were identified through the Receiver Operator Curve.ResultsFifty patients were included. Median [quartiles] age was 68.5 [58–81] years. The APACHE II score was 26 [20–31]. Twenty-three patients (46%) had increased serum amylase and/or serum lipase. Diabetes mellitus (OR = 16; 95% CI [1.7–153.5]; p = 0.016), increased blood urea nitrogen (OR = 1.12; 95% CI [1.02–1.20], p = 0.016), and decreased C-reactive protein (OR = 0.97; 95% CI [0.96–0.99]; p = 0.027) were identified as independent factors predicting increased pancreatic enzymes. Twenty patients (40%) died in the ICU. Neither serum amylase level nor serum lipase level was significantly different between survivors and non-survivors (respectively 49 [27.7–106] versus 85.1 [20.1–165] UI/L; p = 0.7 and 165 [88–316] versus 120 [65.5–592] UI/L; p = 0.952).ConclusionIncrease of pancreatic enzymes is common in patients with septic shock. Diabetes and impaired renal function are predictive of increased pancreatic enzymes. Such finding does not carry any negative prognostic value.

An Evaluation of Contemporary Cardiac Output Monitors

Measurements of CO were not available until 1970, when Swan et al introduced the flow-directed balloon-tipped pulmonary artery catheter (PAC); this catheter is inserted at the bedside and is considered the gold standard for accurate CO measurements1,2. Recently, minimally invasive and non-invasive alternative CO monitors have emerged that not only overcome the PAC’s invasive limitations, but are also able to guide fluid optimization, which has been shown to improve the outcome after major surgery3.

Foreign Body Aspiration Presenting as Life-Threatening Bronchial Asthma

A two-year-old male, a known case of bronchial asthma was admitted as a case of exacerbation of asthma. He did not improve with standard treatment and required invasive ventilator support twice during his admission. The chest x-rays only showed hyperinflation but CT scan of the thorax revealed a foreign body (a piece of Betel nut) lodged in the right main bronchus. It was removed under bronchoscopic guidance.

A Modification of the Initial Surgical Steps in Percutaneous Dilatational Tracheostomy

The percutaneous dilatational method or serial dilator technique for tracheostomy was described by Ciaglia et al in 1985 1 . Since then, at least five other techniques for the procedure have been described: the Rapitrach method (1989), Griggs guide wire dilating forceps method (1990), the retrograde percutaneous trans-laryngeal tracheostomy (1997), Ciaglia Blue Rhino technique (2000) and the PercuTwist technique (2002) 2-6 . The initial surgical steps described in most methods include, after positioning of the patient and painting of the neck with an antiseptic, local infiltration of lignocaine, followed by skin incision, and thereafter, tracheal puncture and guide wire insertion.

Development and Evaluation of a Medical Communication Scale

Objective: To evaluate the degree of communication with patients and their relatives based on a predesigned medical communication scale. Design: A Prospective random sample assessment study. Setting: Intensive Care Unit, King Hamad University Hospital. Method: We studied the scale randomly in 50 adult patients admitted to ICU. The degree of communication with the patient’s next of kin was assessed by a native English speaking intensivist according to a scale designed for the purpose. Result: Twenty-three (46%) relatives required the help of an interpreter for communication (class 4). Full communication was possible with 15 (30%) relatives (class 2). Twelve (24%) relatives did not have a full grasp of the working language or were informed to a below average level or were unwilling or uninterested in obtaining further knowledge. There was no relative with whom communication was impossible (class 5) nor was there any well-informed relative with whom communication was fully fluent (class 1). Conclusion: The medical communication scale can help the physician to objectively quantify the ease or difficulty in communication with the patient’s relatives. In the ethnically mixed workforce of our hospital, while the physician could fully communicate with many relatives, a significant percentage of the relatives were not proficient in the working language of the hospital and required the help of an interpreter to communicate with the physician.

Do Not Resuscitate ( DNR ) Policies in the ICU : The Time Has Come for Openness and Change

Cardiopulmonary resuscitation (CPR) is the emergency medical procedure used in an attempt to restart circulation and breathing in a patient after the heartbeat and/or breathing have ceased. The most basic form of CPR involves giving artificial breaths and external chest compressions while advanced CPR includes, in addition to basic CPR, placement of an advanced airway, giving electric shocks and medications 1 .