Journal of Acute Care

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Volume 3, Number 1, January-April 2024
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Muralidhar Kanchi

The Safety of Concomitant/simultaneous Cardiac and Noncardiac Surgery

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:3] [Pages No:1 - 3]

   DOI: 10.5005/jp-journals-10089-0094  |  Open Access |  How to cite  | 


Original Article

Lutphun Nahar, Raghu Bheemaiah

Approach to Noncardiac Surgery in Cardiac Patients: Feasibility of Simultaneous Cardiac and Noncardiac Surgery

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:4] [Pages No:4 - 7]

Keywords: Cardiac surgery, Coronary artery bypass grafting, Noncardiac surgery, Simultaneous surgery

   DOI: 10.5005/jp-journals-10089-0099  |  Open Access |  How to cite  | 


The study aimed to investigate the feasibility of simultaneous cardiac and noncardiac surgery at a tertiary care high-volume center. The clinical records of all patients who underwent simultaneous cardiac and noncardiac surgery between July 2017 and July 2022 were reviewed. Preoperative, intraoperative, and postoperative clinical data were collected and analyzed. Patients were followed up to hospital discharge. Fourteen patients underwent simultaneous cardiac and noncardiac surgery. Patients were hemodynamically stable throughout the follow-up. Postoperative elective intermittent positive pressure ventilation (IPPV) duration was 4–8 hours (mean 5.4 ± 1.1 hours). The intensive care unit (ICU) stay varied between 3 and 22 (mean of 7.9 ± 6.4) days, and the total hospital stay varied from 8 to 30 (mean of 13.8 ± 6.8) days. None of the patients developed postoperative complications, namely bleeding needing re-exploration, pulmonary infection with hypoxemia, acute renal failure, or wound infection. There were no perioperative major adverse cardiac events such as myocardial infarction, heart failure, significant life-threatening arrhythmia, cardiac arrest, or acute ischemic stroke during the index hospital stay. There was no mortality in this cohort. Simultaneous cardiac and noncardiac surgery in patients who are suffering from heart disease is safe and feasible with a satisfactory postoperative outcome when stepwise stratification and evaluation during the preoperative period and efficient and expert management during the perioperative period have been executed.


Original Article

Sucharita Das, Vinay P, Sharanya Majumdar

Ultrasound-guided In-plane vs Out-of-plane Approach for Radial Arterial Cannulation after Transradial Cardiac Catheterization: A Randomized Prospective Study

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:4] [Pages No:8 - 11]

Keywords: Coronary artery bypass grafting, Long-axis in-plane, Short-axis out-of-plane, Transradial artery catheterization, Ultrasonography

   DOI: 10.5005/jp-journals-10089-0107  |  Open Access |  How to cite  | 


Background: Arterial cannulation is a common and essential procedure that is necessary for obtaining arterial blood samples and continuously monitoring blood pressure. However, there may be difficulties with cannulating the radial artery (RA) after the RA has been used for transradial catheterization for coronary angiography in patients in patients scheduled for cardiac surgery. This study's main goal was to compare the ease of RA cannulation following a previous transradial catheterization for diagnostic purposes using ultrasound (US) by utilizing two distinct approaches—the in-plane (long-axis) method and the out-of-plane (short-axis) method. Materials and methods: In a prospective observational study, patients who underwent coronary artery bypass grafting (CABG) surgery after transradial catheterization for coronary angiography were randomly allocated to one of two groups—(1) the short-axis out-of-plane (SA-OOP) group or (2) the long-axis in-plane (LA-IP) group. Using US to compare the two methods, the following parameters were taken into account—(1) success rate of the first pass, (2) time it took for ultrasonic localization, (3) anteroposterior arterial diameter, (4) distance between the skin and the artery, (5) total number of attempts, (6) cannulation time, (7) procedure-related complications; (8) failure rate, and (9) number of cannulas used. Results: The 116 participants in our study were divided into two groups—the 58 members of the SA-OOP group and the 58 members of the LA-IP group. Cannulation proved to be successful in 110 of the 116 patients. A total of 56 of 58 patients in the LA-IP group were successfully cannulated, compared to 54 of 58 patients in the SA-OOP group. The mean ultrasonic localization time in the SA-OOP group was 6.87 ± 2.5 seconds [mean ± standard deviation (SD)], and that in the LA-IP group was 18.18 ± 2.3 (mean ± SD), the difference was statistically significant. The occurrence of posterior wall damage as a complication was significantly higher in the SA-OOP group (10/54) than in the LA-IP group (2/56). There were no significant differences in time taken for cannula insertion, skin-to-artery distance, arterial diameter, number of attempts, number of cannulas used, other complications, and first-pass success rate. Conclusion: The findings of this study suggest that the LA-IP technique is more efficient than the SA-OOP technique for RA cannula insertion after a previous transradial artery catheterization.



Shaeel Ashraf, Divendu Bhushan, Mariyam Zaheer

Healthcare-associated Infection Surveillance in Low- and Middle-income Countries: Challenges, Opportunities, and the Way Forward

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:6] [Pages No:12 - 17]

Keywords: Healthcare-associated infections surveillance, Healthcare-associated infections, International collaboration, Patient safety, Risk factors

   DOI: 10.5005/jp-journals-10089-0078  |  Open Access |  How to cite  | 


With a substantial impact on patient morbidity and mortality, healthcare-associated infections (HAIs) are a significant public health concern. HAI surveillance plays a critical role in preventing and controlling these infections by providing accurate and timely data on the burden, trends, and risk factors associated with HAIs. In recent years, significant progress has been made in the development and implementation of HAI surveillance systems, both in high-income and low- and middle-income countries (LMICs). However, there are still many challenges that must be addressed, including resource limitations, lack of standardization, and data quality issues. This review provides a comprehensive overview of HAI surveillance, including its history, evolution, methods, tools, strengths, limitations, challenges, and opportunities. It highlights the importance of international collaboration and partnerships in strengthening HAI surveillance systems, as well as the need for continued research and improvement in this area. The findings of this review have important implications for policy and practice in HAI surveillance. They underscore the need for ongoing efforts to standardize and improve the quality of HAI surveillance data, as well as the importance of investing in emerging technologies and methods that can enhance the efficiency and accuracy of these systems. The review also highlights the critical role of international collaboration and partnerships in addressing the global burden of HAIs and provides recommendations for applying lessons learned from successful programs to other settings.



Enrico J Hartono, Septian A Permana, Vincent Kurniawan P Pratama

Measurement of Pancreatic Stone Protein for Diagnosis of Sepsis in ICU Compared with C-reactive Protein and Procalcitonin: A Systematic Review

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:5] [Pages No:18 - 22]

Keywords: C-reactive protein, Diagnosis, Intensive care, Pancreatic stone protein, Procalcitonin, Sepsis

   DOI: 10.5005/jp-journals-10089-0080  |  Open Access |  How to cite  | 


Background: Sepsis remains a significant challenge in the intensive care unit (ICU), with prompt diagnosis and management being critical to improve patient outcomes. Biomarkers have emerged as valuable tools in identifying and predicting sepsis outcomes, with procalcitonin (PCT), pancreatic stone protein (PSP), and C-reactive protein (CRP) being three promising candidates. This systematic review is aimed to analyze and contrast the diagnostic accuracy of PCT, PSP, and CRP for sepsis in the ICU. Materials and methods: Literature was reviewed to examine the different diagnostic performances of the three biomarkers. The PubMed Central, PubMed, ScienceDirect, OxfordAcademic, SpringerLink, and Cochrane Database were searched in July 2023. The data regarding the area under curve–receiver operating characteristics (AUC–ROC) of the biomarkers were extracted. The Newcastle–Ottawa Quality Assessment Scale for Cohort Studies was used for evaluating included studies. Results: Three studies (n = 858) that examined the three biomarkers in adult patients admitted to the ICU were included. The biomarker PSP, along with the other two compared biomarkers, performs well and is proven reliable in diagnosing sepsis in adult patients hospitalized in the ICU. Conclusion: PSP, along with PCT and CRP, has shown reliability as a marker in diagnosing sepsis. This systemic review only emphasizes the accuracy of the three biomarkers in question.



Ketan Agarwal, Vishnu Shankar Ojha, Ratnadeep Biswas, Divendu Bhushan

Hepatic Hydrothorax in the Background of Minimal or No Ascites: A Case Report

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:3] [Pages No:23 - 25]

Keywords: Ascites, Case report, Exudates and transudates, Hepatic hydrothorax, Pleural effusion, Portal hypertension

   DOI: 10.5005/jp-journals-10089-0081  |  Open Access |  How to cite  | 


Aim and background: Chronic liver disease (CLD) is a progressive deterioration of liver function that usually remains asymptomatic for long periods of time. An uncommon complication of long-standing portal hypertension with end-stage liver disease is hepatic hydrothorax. Case description: Here, we present an unusual case of an asymptomatic CLD patient presenting with sudden onset dyspnea. The chest X-ray showed pleural effusion in the right middle and lower zones. Biochemical analysis of the pleural fluid confirmed the transudative nature of the fluid. Minimal ascites were noted, which could not be tapped. A diagnosis of hepatic hydrothorax was made, and the patient showed marked improvement following the initiation of therapy with diuretics and β-blockers. Conclusion: Negative intrathoracic pressure in the pleural cavity during inspiration, coupled with the presence of small fenestrations in the diaphragm and the transdiaphragmatic lymphatics, favors the flow of fluid across these fenestrations and into the pleural cavity leading to hepatic hydrothorax. Clinical significance: The absence of ascites should not be used as a criterion to preclude a diagnosis of hepatic hydrothorax. Timely interventions, including both medical and surgical modalities, should be initiated for its management, but the patient may ultimately require liver transplantation.



Prannoy George Mathen, Navneet Sharma, Deba Prasad Dhibar

A Rare Case of Medial Medullary Syndrome Following Neuroparalytic Snakebite: A Case Report

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:2] [Pages No:26 - 27]

Keywords: Case report, Hypoglossal nerve palsy, Infarction, Medial medullary syndrome, Snakebite, Tracheostomy

   DOI: 10.5005/jp-journals-10089-0093  |  Open Access |  How to cite  | 


Neuroparalytic snake envenomation is a commonly reported emergency in India and other tropical countries. We report a young male with no prior comorbidities, who presented with acute quadriparesis with bulbar involvement following snake bite. He was intubated in the emergency department (ED) for airway protection and was treated with polyvalent anti-snake venom (ASV) and shifted to medical intensive care unit (ICU), where he was treated supportively and gradually weaned off from ventilator after successful spontaneous breathing trial (SBT). Postextubation he was diagnosed to have hypoglossal palsy, and subsequently was re-intubated in view of suspected aspiration. A diffusion weighted magnetic resonance imaging (DW-MRI) revealed bilateral medial medullary infarct. MR-Angiogram revealed no abnormalities. All other causes for young stroke were ruled out. He underwent percutaneous tracheostomy and was treated with antiplatelets, statin, neurorehabilitation. He was later discharged home with good neck holding and limb power of 4/5 in all four limbs. This rare case reaffirms that acute stroke in a young individual from a tropical country should rise the suspicion of snake envenomation after ruling out other causes, among the treating acute care physicians.



Poonam P Rai, Justin A Gopaldas, Suhas Aithal, Nikhil Narayanaswamy, Deepak Padmanabhan, Balaraju Doddaiah

Neuraxial Modulation in Electrical Storm: A Case Report

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:4] [Pages No:28 - 31]

Keywords: Antiarrhythmic agents, Case report, Electrical storm, Mexiletine, Myocardial ischemia, Neuraxial modulation, Stellate ganglion block, Surgical sympathectomy, Sympatholytic therapy, Ventricular arrhythmia

   DOI: 10.5005/jp-journals-10089-0100  |  Open Access |  How to cite  | 


Aims and background: Management of unstable and refractory electrical storm (ES) requires a multidisciplinary approach in an intensive care unit (ICU). A dysregulated autonomic system is understood to be the cause of perpetual arrhythmogenesis. Case description: We present a case of refractory ES precipitated by myocardial ischemia (MI), which was promptly managed with primary percutaneous coronary intervention (PPCI). Despite successful reperfusion with PPCI, the patient continued to have arrhythmias for a prolonged period than expected. Due to refractory arrhythmia, escalation of antiarrhythmic drugs (AADs) along with sequential sympatholytic therapy was undertaken. Conclusion: The use of neuraxial modulation [initially stellate ganglion block (SGB) followed by surgical sympathectomy] may lead to the control of arrhythmia and hemodynamic stability in this difficult subset of patients. Clinical significance: Unstable ES is due to inappropriate sympathetic system activation and there is mounting evidence in support of neuraxial modulation as the main modality rather than escalating traditional AADs.



Ritika Sharma, Pooja Natarajan, Rohan Makwana, Varun Shetty

Transesophageal Echocardiography-guided Left Ventricular Transapical Cannulation of Aorta in Acute Stanford Type: An Aortic Dissection: A Case Report

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:3] [Pages No:32 - 34]

Keywords: Case report, Stanford type A acute aortic dissection, Transapical aortic cannulation, Transesophageal echocardiography

   DOI: 10.5005/jp-journals-10089-0101  |  Open Access |  How to cite  | 


We present a safe technique of transapical left ventricular (LV) cannulation under the guidance of a transesophageal echocardiogram (TEE) in a case of acute aortic dissection. This technique ensures the perfusion of the true lumen avoiding malperfusion syndromes. Case description: A 44-year-old male presented to the hospital with a history of acute chest pain. This gentleman was a chronic smoker, alcoholic, and known to suffer from hypertension to diabetes mellitus. Transthoracic echocardiography and computerized tomography of the chest revealed acute Stanford type A aortic dissection. He underwent emergent hemiarch and ascending aorta replacement under cardiopulmonary bypass (CPB). TEE-guided LV transapical cannulation was done with a 24 Fr size straight arterial cannula, which was directed to the aorta through the aortic valve for arterial return from CPB. The patient was cooled to 26°C with a total CPB time being 285 minutes and a total aortic cross-clamp time of 156 minutes. With the aid of retrograde cerebral perfusion (RCP) through superior vena cava cannulation and later antegrade cerebral perfusion (ACP) through innominate and left common carotid artery, hemiarch of the aorta was replaced and circulation restarted. Following this, the ascending aorta replacement was completed. Surgery was successful and the patient was discharged home on the 10th postoperative day. Conclusion: Left ventricular (LV) transapical cannulation can be performed safely with TEE guidance to ensure a safe perfusion strategy. Acute aortic dissection is a serious life-threatening condition; therefore, a safe strategic plan is very crucial for a successful outcome of surgery. TEE helps to guide the accurate placement of the aortic cannula through the LV apex into the true lumen of the aorta and ensures adequate perfusion.



Pradeep M Venkategowda, Pooja C Patil

Nonhepatic Hyperammonemia Secondary to Escherichia coli Urinary Tract Infection

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:3] [Pages No:35 - 37]

Keywords: Ammonia, Case report, Escherichia coli, Nonhepatic, Urease

   DOI: 10.5005/jp-journals-10089-0102  |  Open Access |  How to cite  | 


Critically ill patients with hyperammonemia (HA) may suffer high morbidity and mortality. A 78-year-old male presented to a tertiary care hospital with a history of increased drowsiness for 3 days associated with intermittent fever and burning micturition. He was a known case of type 2 diabetes mellitus, systemic hypertension, and ischemic heart disease. Ultrasound abdomen revealed a thickening of the urinary bladder suggestive of cystitis. The renal and kidney function tests were normal. The serum ammonia level was 88 mg/dL (normal levels <40 mg/dL). Urine culture grew Escherichia coli (E. coli). Diagnosis as urinary tract infection (UTI) with E. coli and HA was made and the patient managed with parenteral meropenem, insulin, intravenous fluids, antihypertensives, low protein, and high-calorie diet. The patient's clinical condition improved gradually and later discharged home in hemodynamically stable condition. This case report highlights a rare case of HA secondary to E. coli-related UTI.



Ripenmeet Salhotra, Nitish Parmar, Aayush Chawla

Finding Safe Driving Pressure

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:3] [Pages No:38 - 40]

Keywords: Acute care medicine, Acute respiratory distress syndrome, Critical care unit, Mechanical ventilation

   DOI: 10.5005/jp-journals-10089-0096  |  Open Access |  How to cite  | 


Driving pressure (ΔP) has been directly associated with mortality in acute respiratory distress syndrome (ARDS) and should be monitored and limited to <15 cm of water. Its calculation in a passively ventilated patient is straightforward but requires invasive and expensive techniques like esophageal pressure monitoring in patients with spontaneous respiratory effort. Recently described novel bedside techniques can be used to estimate ΔP in patients on assisted mechanical ventilation.



Gunchan Paul, Rubina K Mahajan

Open vs Closed Intensive Care Unit: Pro–Con Debate

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:3] [Pages No:41 - 43]

Keywords: Closed intensive care unit, Intensive care unit model, Intensivist, Open intensive care unit, Organizational structure

   DOI: 10.5005/jp-journals-10089-0104  |  Open Access |  How to cite  | 


An intensive care physician has expertise in diagnosing, managing, and follow up of critically ill or injured patients. There is no doubt that such patients should be evaluated by an intensivist, but which structural model of intensive care unit (ICU)—open or closed? Who should be the decision maker of the critically ill patient? Should definitions of ICU organization be cast in stone? These questions dwindle in the minds of physicians who care for the critically ill in many parts of the world. This article brings forth the advantages and limitations of both types of organizational structures and proposes the way forward.



Bharath Kumar, Rishika Jandial, Pradeep M Venkategowda, Ranjitha Raj

Pregabalin-associated Pulmonary Thromboembolism

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:5] [Pages No:44 - 48]

Keywords: Breathlessness, Neuropathy, Pregabalin, Pulmonary thromboembolism

   DOI: 10.5005/jp-journals-10089-0089  |  Open Access |  How to cite  | 


Pregabalin is a commonly prescribed medicine for the treatment of diabetic neuropathy. The adverse effect of this drug on long-term use remains unknown. This is a case of a 47-year-old female who presented to hospital with a history of shortness of breath. She was a known case of with diabetic neuropathy receiving pregabalin 75 mg orally once a day. The patient had a heart rate of 112 beats/minute, blood pressure of 102/52 mm Hg, respiratory rate of 28/minute, peripheral oxygenation saturation of 88% on room air, and D-dimer of 2.29 mg/L. Transthoracic echocardiography [two-dimensional (2D)] showed paradoxical motion of intraventricular septum (IVS), elevation in pulmonary artery systolic pressure (50 mm Hg), mild right atrial/right ventricular (RA/RV) dilatation and normal left ventricular (LV) systolic function. Chest X-ray suggestive of left middle zone haziness. Computed tomography of pulmonary angiogram (CTPA) showed a thrombus at the left main pulmonary artery. The other risk factors for pulmonary embolism (PE) were absent. Hence, a diagnosis of acute pulmonary thromboembolism (PTE) secondary to drug-induced (pregabalin) was made and managed with tenecteplase, heparin, and later rivaroxaban. The patient improved and was discharged home in hemodynamically stable condition. This case report highlights a case of pregabalin-associated PTE. Early diagnosis and management can reduce morbidity and mortality.



Uday B Khanolkar, Meemansa Kashyap Buch, Bagirath Raghuraman, Barendra Kumar Raut, Satish C Govind, Devi Prasad Shetty

TricValve: A Palliative Therapy for Inoperable Tricuspid Regurgitation

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:5] [Pages No:49 - 53]

Keywords: Tricuspid edge-to-edge repair, Tricuspid regurgitation, TricValve, Tricuspid valve insufficiency

   DOI: 10.5005/jp-journals-10089-0109  |  Open Access |  How to cite  | 


Patients having isolated severe tricuspid regurgitation (TR) due to primary or secondary etiology continue to suffer from right heart dysfunction with or without clinical manifestations of systemic venous congestion. They often do not respond to conventional medical therapy and show poor quality of life (QoL) outcome measures. The available options for the management of severe tricuspid valve regurgitation include surgical replacement of the tricuspid valve and/or its repair in cases undergoing concomitant left heart valve surgery, provided the patients belong to acceptable surgical risk and do not have overt right heart dysfunction (class I level C). Patients who do not qualify for surgical repair or replacement are candidates for medical management. Recent advances have introduced transcatheter options for the treatment of moderate to severe TR for improved outcomes of QoL and relief of symptoms. We present the case of a patient who underwent a TricValve implantation, which is a novel transcatheter-based heterotopic bicaval system for the management of severe functional TR.



Pradeep M Venkategowda, Varun M Nagaraja

The Myths and Facts about Corrected Calcium Levels

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:2] [Pages No:54 - 55]

   DOI: 10.5005/jp-journals-10089-0103  |  Open Access |  How to cite  | 


Medical Philately

Pradeep Rangappa, Ipe Jacob

Lindbergh and His Contribution to Extracorporeal Gas Exchange

[Year:2024] [Month:January-April] [Volume:3] [Number:1] [Pages:2] [Pages No:56 - 57]

   DOI: 10.5005/jp-journals-10089-0108  |  Open Access |  How to cite  | 


journal videos

Showing arterial cannula entering the aortic valve in midesophageal LV long-axis view through the LV apex

Transesophageal Echocardiography-guided Left Ventricular Transapical Cannulation of Aorta in Acute Stanford Type: An Aortic Dissection: A Case Report

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TricValve fluoroscopy

TricValve: A Palliative Therapy for Inoperable Tricuspid Regurgitation

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Superior vena cava 2D

TricValve: A Palliative Therapy for Inoperable Tricuspid Regurgitation

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Superior vena cava 3D

TricValve: A Palliative Therapy for Inoperable Tricuspid Regurgitation

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Inferior vena cava 2D

TricValve: A Palliative Therapy for Inoperable Tricuspid Regurgitation

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Inferior vena cava 3D

TricValve: A Palliative Therapy for Inoperable Tricuspid Regurgitation

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