Journal of Acute Care

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2022 | September-December | Volume 1 | Issue 3

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EDITORIAL

Muralidhar Kanchi, Vibhu R Kshettry

Can High-volume Centers in India Serve as Anesthesiology, Critical Care and Emergency Medicine Training Locations for African Physicians?

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:2] [Pages No:119 - 120]

   DOI: 10.5005/jp-journals-10089-0039  |  Open Access |  How to cite  | 

221

EDITORIAL

Soumya S Nath, Rajeev Kumar, N Nandhini

Glimmer of Hope in the Trends of Antimicrobial Resistance

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:3] [Pages No:121 - 123]

   DOI: 10.5005/jp-journals-10089-0052  |  Open Access |  How to cite  | 

211

Original Article

Appropriateness of Antibiotics in Sepsis Patients at a Tertiary Referral ICU

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:4] [Pages No:124 - 127]

Keywords: Empirical antibiotic, ICU mortality, 28-day mortality, ICU length of stay, Antibiotic resistance

   DOI: 10.5005/jp-journals-10089-0057  |  Open Access |  How to cite  | 

Abstract

Background: Sepsis is a life-threatening condition that requires the early use of appropriate empirical antibiotics. However, sepsis outcomes are often complicated by the increased incidence of antibiotic resistance, which is attributed to the use of inappropriate antibiotics. Antibiotics are termed inappropriate when the suspected pathogen is resistant to the drug administered or when there is a delay in administration. Materials and methods: This is a prospective observational study that aims to compare the impact of appropriate antimicrobial therapy (AAT) and inappropriate antimicrobial therapy (IAAT) on the outcome of sepsis or septic shock cases in the intensive care unit (ICU). Primary outcome measures included ICU mortality and 28-day mortality, and secondary outcome measures, vasopressor free days (VFD), hemodialysis free days (HFD), ventilator free days, ICU length of stay (LOS), and oxygen requirement days. Results: Out of 100 patients included in the study, 49 patients received AAT and had a lower ICU mortality compared to the 51 patients who received IAAT (10 vs 31%, p = 0.009) and also 28-day mortality (14 vs 37%, p = 0.009). ICU LOS was also shorter in those receiving AAT. Conclusion: The use of appropriate and timely antibiotics can lead to decreased mortality and morbidity in patients with sepsis. This requires an understanding of the prevailing local microbiological flora and the local antibiograms and the use of standardized protocols.

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Original Article

Pooja Natarajan, Nishant R Rajadhyaksha, Noel MP Samy, Satish C Govind, Madhu N Rajadhyaksha, Vikneswaran Gunaseelan, M Thiruthani Kumaran

New Insight into Right Ventricle Dysfunction in COVID-19

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:7] [Pages No:128 - 134]

Keywords: Coronavirus disease 2019, Predictive accuracy, Right ventricular strain, Severe acute respiratory syndrome coronavirus 2, Speckle tracking echocardiography, Strain

   DOI: 10.5005/jp-journals-10089-0047  |  Open Access |  How to cite  | 

Abstract

Introduction: The coronavirus disease 2019 (COVID-19) is known to cause right ventricular (RV) dysfunction. While conventional parameters of RV function may prove to be less precise, more variable, and less sensitive to predict the requirement of mechanical ventilation (MV), noninvasive ventilation (NIV) and 30-day mortality, speckle tracking echocardiography may indicate RV dysfunction early in the course of the disease. This study was aimed to determine if RV strain parameters have greater accuracy for the prediction of the requirement of MV, NIV, and mortality compared to conventional indices of RV function. Materials: Point of care echocardiographic assessment was conducted bedside on the day of admission to the intensive care unit (ICU) on 101 subjects suffering from COVID-19. Conventional parameters included tricuspid annular plane systolic excursion (TAPSE), RV ejection fraction (RVEF), and left ventricular (LV) ejection fraction (LVEF) and advanced echocardiographic parameters namely RV free wall strain length (RVFWSL) and RV 4-chamber strain length (RV4CSL) were used to assess RV function. Results: The RVFWSL was −16.15 (±3.29) in nonsurvivors compared to −24.94 (±5.62) in survivors. A similar trend was noticed in RV4CSL which was −13.61 (±5.30) in nonsurvivors when compared to survivors (−22.37 ± 4.56). Receiver operating characteristic (ROC) area under the curve (AUC) for predicting the need for NIV, MV, and mortality was plotted for both the strain and conventional echo parameters. The AUC values predicting the requirement of NIV were 0.92 (0.86–0.97), 0.91 (0.85–0.96), 0.14 (0.07–0.21), 0.18 (0.10–0.27), and 0.14 (0.06–0.22); (p < 0.001 for all parameters) for RVFWSL, RV4CSL, TAPSE, RVEF, and LVEF, respectively. The AUC values for predicting the requirement of MV were 0.90 (0.84–0.97), 0.92 (0.87–0.97), 0.10 (0.03–0.16), 0.09 (0.03–0.15), and 0.10 (0.04–0.16); (p < 0.001 for all parameters) with respect to RVFWSL, RV4CSL, TAPSE, RVEF, and LVEF, respectively. The AUC values for predicting mortality were 0.90 (0.84–0.97), 0.93 (0.88–0.97), 0.12 (0.05–0.19), 0.09 (0.03–0.15), and 0.09 (0.03–0.15); (p < 0.01) with respect to RVFWSL, RV4CSL, TAPSE, RVEF, and LVEF, respectively. Conclusion: The RV strain parameters namely RVFWSL and RV4CSL were significantly better predictors of MV, NIV, and 30-day mortality in patients admitted to COVID ICU.

264

REVIEW ARTICLE

David J Berman, Kumar Belani

Malignant Hyperthermia: A Review

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:6] [Pages No:135 - 140]

Keywords: Anesthesiology, Dantrolene, Genetic disease, Hypermetabolic state, Malignant hyperthermia, Ryanodine receptor

   DOI: 10.5005/jp-journals-10089-0043  |  Open Access |  How to cite  | 

Abstract

Malignant hyperthermia (MH) is a complex pharmacogenetic condition associated with the development of a hypermetabolic state when exposed to specific “triggering” anesthetic medications. These inciting agents include all potent inhalational anesthetics (e.g., halothane, sevoflurane, desflurane, isoflurane) and succinylcholine. While poorly understood, mutations in the ryanodine receptor are thought to play a pathogenic role in this genetic condition: these mutations are typically inherited in an autosomal dominant fashion or may be de novo mutations. The mainstay of treatment for patients with a history or family history of MH is avoidance of these triggering anesthetic agents. If a crisis occurs, discontinuation of the offending agent, prompt expert consultation, and targeted therapy with dantrolene have decreased the mortality of this condition from >70 to <10%. Future directions for MH research include more accurate genetic testing, a better understanding of the disease mechanism, and continued research for the optimal management of MH crises.

311

VIEWPOINT

Squeeze the Pipes in Septic Shock

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:2] [Pages No:141 - 142]

Keywords: Intravenous fluid, Septic shock, Vasopressors

   DOI: 10.5005/jp-journals-10089-0051  |  Open Access |  How to cite  | 

Abstract

Rationale for fluid resuscitation is to increase mean systemic filling pressure, venous return, and cardiac output by increasing circulatory stressed volume. However, several conditions must be fulfilled to achieve desirable outcomes from fluid resuscitation. Vasopressors are also important components of resuscitation in septic shock (SS) and can potentially supplement the beneficial effects of fluid. However, the potential benefits of vasopressors must be weighed against several harms associated with vasopressors. Risks associated with vasopressors are more pronounced with underfilling of circulation and in higher doses. Current physiological and clinical evidence support intravenous fluids as the first-line resuscitation agent in SS with vasopressor infusion as a supplement to the same.

346

VIEWPOINT

Septic Shock: First Fill the Pipes Up

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:3] [Pages No:143 - 145]

Keywords: Intravenous fluid, Septic shock, Vasopressors

   DOI: 10.5005/jp-journals-10089-0049  |  Open Access |  How to cite  | 

Abstract

The rationale for fluid resuscitation is to increase mean systemic filling pressure (Pmsf), venous return, and cardiac output by increasing circulatory stressed volume. However, several conditions must be fulfilled to achieve desirable outcomes from fluid resuscitation. Vasopressors are also important components of resuscitation in septic shock and can potentially supplement the beneficial effects of fluid. However, the potential benefits of vasopressors must be weighed against several harms associated with vasopressors. Risks associated with vasopressors are more pronounced with underfilling of circulation and in higher doses. Current physiological and clinical evidence supports intravenous fluids as the first-line resuscitation agent in septic shock, with vasopressor infusion as a supplement to the same.

200

COMMENTARY

Septic Shock Resuscitation: Continuous Fluids or Early Vasopressors?

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:2] [Pages No:146 - 147]

   DOI: 10.5005/jp-journals-10089-0050  |  Open Access |  How to cite  | 

Abstract

Whether to fill up the pipes fully with fluids before starting vasopressors or whether to start vasopressors early, even with half-filled pipes during septic shock resuscitation, has been intensely debated in recent times. There are concerns about both approaches.

199

CASE REPORT

Sharath Krishnaswami, Lakshmi R Patil

A Case of Absent Right Pulmonary Artery for Unifocalization: Perioperative Management

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:3] [Pages No:148 - 150]

Keywords: Dilated right atrium/right ventricle, Perioperative management, Unifocalization, Unilateral absent right pulmonary artery

   DOI: 10.5005/jp-journals-10089-0048  |  Open Access |  How to cite  | 

Abstract

Unilateral absence of a pulmonary artery (UAPA) is a rare congenital condition and coexists with cardiovascular abnormalities such as cyanotic heart disease or cardiac septal defects; however, it can also occur in isolation. Patients with isolated UAPA can progress without symptoms into late adulthood but usually present with dyspnea, chest pain, hemoptysis, or recurrent infections. There are no reported guidelines on the treatment of UAPA. The plan of treatment is based on the presenting symptoms, pulmonary artery (PA) anatomy, aortopulmonary collaterals, associated cardiovascular anomalies, and pulmonary hypertension. The objectives of unifocalization are to consolidate the multiple sources of pulmonary blood flow, to unite the multiple pulmonary collateral arteries, and to remodel a new central artery that can be created with a prosthetic conduit. Usually, a modified Blalock-Taussig shunt, a surgical systemic pulmonary shunt, is used to perfuse the pulmonary arteries. The perioperative course and management of a case of UAPA for unifocalization have rarely been reported in the literature. Here, we discuss the perioperative management of a case of unilateral absence of the right PA (RPA) for unifocalization.

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CASE REPORT

Babli Kumari, Sarfaraz Ahmad

An Unusual Case of Type I Crigler–Najjar Disease in a Young Adult: A Case Report

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:3] [Pages No:151 - 153]

Keywords: Crigler–Najjar syndrome, Hyperbilirubinemia in young adult, Unconjugated hyperbilirubin

   DOI: 10.5005/jp-journals-10089-0040  |  Open Access |  How to cite  | 

Abstract

Crigler-Najjar syndrome (CNS) is a genetic disorder. It has a mostly autosomal recessive pattern of inheritance. Unconjugated to conjugated bilirubin conversion in the liver requires the enzyme Uridine 5’-diphosphate-glucuronosyltransferase (UDP-glucuronosyltransferase), which is absent or exhibits low activity in CNS. It is a significant contributor to congenital nonhemolytic jaundice. Following an aberrant gene mutation causes an increase in the bilirubin burden in the blood and is inherited within families. We present a case of a 22-year-old man who has had type I CNS since birth. There is minimal neurological damage, but there is a considerable increase in unconjugated bilirubin. Phenobarbital therapy had no impact on the reduction of bilirubin load. The primary goal is to reduce unconjugated bilirubin, although liver transplantation is the only curative treatment option for type I CNS.

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CASE REPORT

Mayur Rama K Chillal, Khalil Ibrahim A Kharusi, Nabil K Al-Hashemi

Iatrogenic Soft Palate Injury Secondary to Intubation Using Glidescope® Video Laryngoscope in the Emergency Room

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:2] [Pages No:154 - 155]

Keywords: Airway injury, Glidescope video laryngoscope, Iatrogenic, Intubation

   DOI: 10.5005/jp-journals-10089-0054  |  Open Access |  How to cite  | 

Abstract

Intubation in the emergency room (ER) is a challenging task by itself, as the operator has very little time to assess the airway of the patient in an emergency situation. This race against time to secure the airway creates a loophole for iatrogenic airway injuries. Though the usage of airway gadgets for intubation in ER, is a very common process, one cannot completely rule out the risk of airway injury using these gadgets. This is the first case where we report iatrogenic airway injury caused to the soft palate while intubation in ER using a Glidescope® video laryngoscope. This case report discusses the various aspects of causes, prevention, and approach to iatrogenic airway injuries

344

CASE REPORT

G Madhu, AK Ajith Kumar, Narayana Swamy Moola

Alveolar Hemorrhage: A Rare Complication in Dengue

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:2] [Pages No:156 - 157]

Keywords: Dengue, Dengue pneumonitis, Hemorrhage, Severe dengue infection

   DOI: 10.5005/jp-journals-10089-0045  |  Open Access |  How to cite  | 

Abstract

Dengue is a major public health problem in India. This is the most common arthropod-borne viral infection caused by Flavivirus. According to the World Health Organization, 2009, dengue is classified as dengue with or without warning sign and severe dengue. Severe dengue infection can present with severe plasma leakage, severe bleeding, or severe organ dysfunction; if left untreated, death is inevitable. Alveolar hemorrhage is one of the rare but severe hemorrhagic manifestations, rarely reported in dengue which is only limited to few case reports. Here we are reporting as case of severe dengue presenting as diffuse alveolar hemorrhage.

200

Medical Philately

History of Airway and Tracheostomy through Philately

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:4] [Pages No:158 - 161]

Keywords: Airway, History, Philately, Tracheostomy

   DOI: 10.5005/jp-journals-10089-0053  |  Open Access |  How to cite  | 

Abstract

The history of airway and tracheostomy dates back to the 1st century AD with references to the airway made in the works of Abulcasis (936–1013 AD), followed by Avicenna (980–1037 AD), Avenzoar (1091–1161 AD), and Andreas Vesalius (1514–1564). Orotracheal intubation was first performed by French physiologist Bichat along with Desault between 1793 and 1795. References to scientific resuscitation are found in the works of Francois Magendie as early as 1800. This article dwells into the life of these great personalities through postage stamps, who have chartered the pathway to present-day modern resuscitation.

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INTERESTING IMAGE

Abhishek Samprathi

A Pleural ‘Tamponade’!

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:1] [Pages No:162 - 162]

Keywords: Bedside ultrasound, Obstructive shock, Pleural effusion

   DOI: 10.5005/jp-journals-10089-0044  |  Open Access |  How to cite  | 

204

TUTORIAL

Owais Tisekar, AK Ajith Kumar, Justin A Gopaldas, Rajeev C Mathews, Ranjeeta Adhikary

A Case Report of Necrotic Lung Abscess due to Nocardia Otitidiscaviarum

[Year:2022] [Month:September-December] [Volume:1] [Number:3] [Pages:5] [Pages No:163 - 167]

Keywords: Immunocompetent, Lung abscess, Nocardia, Otitidiscaviarum

   DOI: 10.5005/jp-journals-10089-0037  |  Open Access |  How to cite  | 

Abstract

Nocardia is a cause of localized or disseminated infection in humans. Nocardia otitidiscaviarum (N. otitidiscaviarum) is an infrequent cause of nocardiosis, accounting for <5% of the cases. N. otitidiscaviarum primarily affects the lungs, skin, and brain, with the lungs being the most common site. Diagnosis can be a challenge, and it requires a high index of suspicion among clinicians. A 52-year-old gentleman presented to our hospital with a 2-month history of fever, cough, and progressive breathlessness. He was started on a high-flow nasal cannula (HFNC) for respiratory failure. The positron emission tomography (PET) showed a left lower lobe mass lesion with a maximum standardized uptake value (SUV) of 17.4. The histopathological findings of the computed tomography (CT)-guided mass biopsy were consistent with an abscess. The identification of Nocardia species was made by Kinyoun staining after decolorization with 1% of sulfuric acid. According to the drug-sensitivity test, the patient was started on trimethoprim/sulfamethoxazole along with imipenem/cilastatin. There was clinical improvement in 3–4 days and the patient was weaned off the HFNC support. Nocardiosis should be an essential consideration for the differential diagnosis of many bacterial, fungal, and viral infections, even in immunocompetent individuals. Early diagnosis and treatment help to improve survival.

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