Journal of Acute Care

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2023 | May-August | Volume 2 | Issue 2

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Limesh Marisiddappa

Incorporating Membrane: Plasma Exchange in Critical Care

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:1] [Pages No:45 - 45]

   DOI: 10.5005/jp-journals-10089-0083  |  Open Access |  How to cite  | 


Original Article

Mohan Kumar Narava, Justin A Gopaldas, KV Venkatesha Gupta

Prognostic and Therapeutic Value of Venous to Arterial Carbon Dioxide Difference during Early Resuscitation in Critically Ill Nosocomial Septic Shock Patients

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:8] [Pages No:46 - 53]

Keywords: Central venous to arterial carbon dioxide difference, Fluid resuscitation, Nosocomial sepsis, Sepsis, Septic shock, Venoarterial difference in the partial pressure of carbon dioxide gap, 28-day mortality

   DOI: 10.5005/jp-journals-10089-0075  |  Open Access |  How to cite  | 


Introduction: Septic shock is a medical emergency. Various clinical biomarkers have been used to either prognosticate or use them for goal-directed management of the same. The venoarterial difference in the partial pressure of carbon dioxide (Pv-aCO2 gap) has been used as an alternate marker for assessing tissue hypoperfusion and to predicting mortality. Aim: To determine the therapeutic and prognostic value of central venous to arterial carbon dioxide difference during early resuscitation of critically ill nosocomial septic shock patients. Objectives: The primary objective was to predict 28-day mortality using the Pv-aCO2 gap. The secondary objectives were to compare the accuracy of lactate clearance, sequential organ failure assessment (SOFA) score against Pv-aCO2 gap as a predictor of 28-day mortality and to determine the association of fluid resuscitation and its effects on the Pv-aCO2 gap. Materials and methods: A prospective observational cohort study was performed in a tertiary care intensive care unit (ICU). A total of 50 nosocomial septic shock patients were recruited. They are from either ward admissions or those who stayed in ICU beyond 48 hours. A Pv-aCO2 gap was measured serially over 0, 3, and 6 hours. Lactate clearance at 6 hours was measured. SOFA score on days 1 and 2 of admission, fluid resuscitation in the first 6 hours, and cumulative fluid balance over 24 hours and 7 days were calculated. The patients were divided into survivors and nonsurvivors according to the outcome at 28 days. Pv-aCO2 gap was assessed in both groups. The receiver operating characteristic (ROC) curve was plotted to analyze the prognostic value of these variables in predicting 28-day mortality. Data analysis was carried out using the Statistical Package for the Social Sciences (SPSS) version 18.5 package. Results: The median values of the Pv-aCO2 gap had progressively increased in nonsurvivors (7.17, 7.70, and 8.06 mm Hg) over 0, 3, and 6 hours, respectively, whereas it progressively narrowed (6.84, 6.45, and 6.03 mm Hg) in survivors during the first 6 hours of the resuscitation period. Persistently high Pv-aCO2 gap at the end of 6 hours of resuscitation was observed in nonsurvivors, which were statistically significant (85.3 vs 43.8%, p = 0.004). Survivors and nonsurvivors received a mean crystalloid volume of 1430.8 ± 431.6 mL, irrespective of their Pv-aCO2 gap of < or >6 mm Hg. The discriminatory capacity at predicting 28-day mortality for SOFA score on days 1 and 2, lactate clearance at 6 hours, and Pv-aCO2 gap at 0, 3, and 6 hours were compared. ROC curve analysis showed that SOFA scores on days 1 and 2, lactate clearance at 6 hours, and Pv-aCO2 gap at 3 and 6 hours had predictive value to prognosticate 28-day mortality. The area under the ROC curve (AUROC) for SOFA score on days 1 and 2 was 0.907 [95% confidence interval (CI) was 0.791–0.971, p < 0.001] and 0.943 (95% CI was 0.839–0.989, p < 0.001) respectively. The AUROC for lactate clearance at 6 hours was 0.938 (95% CI was 0.743–0.947, p < 0.001). AUROC for Pv-aCO2 gap values at 3 and 6 hours were 0.814 (95% CI was 0.679–0.910, p < 0.001) and 0.865 (95% CI was 0.738–0.945, p < 0.001), respectively. Conclusion: Persistent high Pv-aCO2 gap can be used as a prognostic marker for predicting 28-day mortality in nosocomial septic shock patients. Pv-aCO2 gap at 6 hours has almost the same discriminatory capacity as SOFA score on days 1 and 2, and lactate clearance at predicting 28-day mortality. More studies are required to ascertain the value of Pv-aCO2 gap values in estimating the adequacy of fluid resuscitation in nosocomial septic shock patients.


Original Article

Xiao Jiang, Amit Kansal, Monika G Kansal, Faheem A Khan, Chee Keat Tan, Patricia Leong, Marjoyna Ortal, Rajat Tagore, Prashanth Ramesh, Shekhar Dhanvijay

Feasibility and Safety of Implementing Membrane-based Plasma Exchange in a Low-volume Center: Retrospective Single Center Experience Over 3 Years Including Multidisciplinary Survey among Clinicians

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:7] [Pages No:54 - 60]

Keywords: Feasibility, Intensive care unit, Membrane-based, Plasma exchange, Safety

   DOI: 10.5005/jp-journals-10089-0079  |  Open Access |  How to cite  | 


Background: Membranous therapeutic plasma exchange (mTPE) is less commonly used in Singapore compared to centrifuge TPE. Our study aimed to investigate the feasibility and safety of mTPE as a new service in a low-volume TPE center that was familiar and experienced with the continuous renal replacement therapy (CRRT) technique. Materials and methods: This was a single-center retrospective study of patients who underwent mTPE from 1st May 2018 to 31st July 2021, conducted at a 34-bedded mixed intensive care unit (ICU) in Singapore. Clinical data and mTPE details, including adverse events, were collected for all sessions. Multidisciplinary surveys of specialists and nurses involved were conducted thereafter in August 2021. Results: During the study period, a total of 53 mTPE sessions were done for 10 patients, of which eight (80%) were female. Of a total of 53 sessions, filter clotting despite anticoagulation occurred in seven (13%) sessions. The adverse event rate was 11.3% of all sessions. A survey of five specialists and 12 ICU nurses indicated a smooth referral process, a short setup time, and easy hands-on in implementing mTPE as a new service in the ICU. Conclusion: Our results show the feasibility and safety of introducing mTPE as a new service in ICU settings in a low-volume TPE center, with the specific logistical advantage of short training time in view of familiarity and experience with the CRRT technique. This also provided the ability to continue uninterrupted service during the pandemic and maybe a future direction for similar ICUs.



Ranajit Chatterjee, Rajesh C Mishra, Ahsina J Lopa

“Renal Replacement” to “Renal to Support” Therapy: A Narrative Review

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:4] [Pages No:61 - 64]

Keywords: Acute renal failure, Kidney, Nephritis, Renal replacement, Renal replacement therapy, Acute kidney, Renal

   DOI: 10.5005/jp-journals-10089-0055  |  Open Access |  How to cite  | 


Critically ill patients had been suffering form kidney injuires since time immemorial. Scientists and doctors coined different names through ages without fully understanding the pathophysiology and nature of injuries. It was coined as ‘Acute Bright's disease’ in the early twentieth century, ‘War Nephritis’ during the first world war only to be coined as acute renal failure in the mid 20th century. Acute kidney injury is a relatively new terminology coined in this century. As the understanding of the nature of the disease become clearer, newer modalities of treatment started evolving. Renal replacement therapy is one such modality. Again with experience, doctors found that this form of therapy is not only restricted in replacing the kidney function but also can be extended much beyond the boundaries of renal dysfunction. Thus, the term ‘Renal support’ instead of ‘Renal Replacement’ came into vogue. This narrative review will try to explore the variety of support the therapy gives to a critically ill patient.



Ashray Vasanthapuram, Kushal Pandya, M Sithi Sabeera, Deepthi K Narasimha

Hanging: A Review on Management

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:4] [Pages No:65 - 68]

Keywords: Critical care, Emergency care, Hanging

   DOI: 10.5005/jp-journals-10089-0070  |  Open Access |  How to cite  | 


Hanging is a common means of suicide worldwide. As per the Crime Records Bureau of India, hanging accounted for almost 53.6–57.8% of all suicidal deaths in 2019 and 2020, respectively. The incidence of hanging across emergency departments in India, as reported in previous studies, has varied from 5.3% and rising to 8.6% in recent times. The article aims to contribute to the understanding of the most optimal management of hanging patients in the emergency department. Hanging is defined as a form of asphyxia occurring due to the weight of the body being suspended by a ligature material around the neck. The common physical features of hanging noted in literature are facial congestion, petechiae, and cyanosis. These are considered classical signs of asphyxia. Patel et al. and Simonsen reported facial congestion in 77.5 and 52.5%, respectively. Clément et al. noted petechial hemorrhage in 46% of cases. The initial assessment of near-hanging patients begins with the advanced trauma life support (ATLS) primary survey. Airway, breathing, circulation, disability, and exposure are noted accordingly and intervened. Patients with Glasgow Coma Scale (GCS) <9 and signs of airway compromise (laryngeal fracture or tracheal trauma) require early intubation. It is worth noting that computed tomography (CT) of the neck and brain plays a crucial role in ruling out a majority of injuries associated with hanging, and it also assists in devising an effective management plan for these injuries. Over the years, the treatment and management of near-hanging have largely remained the same; however, the evaluation has changed with the advancement and easy availability of CT imaging at most centers. While the literature on the outcomes and management of hanging cases may be limited, prompt and appropriate treatment has shown to improve the chances of survival for most individuals.



Yathish Gattimallanahalli, Rajesh M Shetty, Manjunath Thimmappa, Nithya C Achaiah

Role of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Diagnosing Fever of Unknown Origin in Intensive Care Unit: A Case Report

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:3] [Pages No:69 - 71]

Keywords: Case report, Fever of unknown origin, Positron emission tomography/computed tomography, Tuberculosis

   DOI: 10.5005/jp-journals-10089-0072  |  Open Access |  How to cite  | 


Fever of unknown origin (FUO) is defined as a temperature of 101°F (38.3°C) or higher with a minimum duration of 3 weeks without an established diagnosis after an intensive 1-week investigation in the hospital. A 56-year-old gentleman with ankylosing spondylitis receiving adalimumab presented with complaints of fever, pain abdomen, and loss of appetite. The patient was thoroughly investigated with a wide array of investigations, which included blood cultures, computed tomography (CT) chest and abdomen, and colonoscopy. The patient continued to have a fever without arriving at any diagnosis. Positron emission tomography/computed tomography (PET/CT) was done, which showed increased metabolic activity in both lung bases. Bronchoalveolar lavage was done, and tuberculosis (TB) GeneXpert on the sample was positive. This demonstrates that fluorodeoxyglucose (FDG)—PET/CT plays a vital role in investigations of FUO and arriving at a diagnosis.



Pooja C Patil, Aishwarya T Kulkarni, Pradeep M Venkategowda, Anand R Sutar

Fever with Thrombocytopenia—Look beyond Infection: A Case Report

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:2] [Pages No:72 - 73]

Keywords: Case report, Fever, Promyelocytic leukemia, Thrombocytopenia, Tropical infection

   DOI: 10.5005/jp-journals-10089-0071  |  Open Access |  How to cite  | 


Introduction: Patients having fever with thrombocytopenia [febrile thrombocytopenia (FT)] is a common observation in the intensive care unit (ICU). The majority of the cases of FT are infective in origin, and rarely, FT is due to a noninfectious cause. Case Description: This is a case of a 33-year-old male who presented with complaints of fever, myalgia, and loose stools. His routine blood investigation showed thrombocytopenia but was negative for tropical infection tests. The peripheral blood smear had blast cells. Bone marrow aspiration showed hypercellular marrow with blasts of occasional Auer rods. Flow cytometry revealed polymyelocytic (PML)/retinoic acid receptor alpha (RARA) fusion-M3 type of acute myeloid leukemia (AML). This patient was diagnosed as having acute promyelocytic leukemia (APML) and treated with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). Discussion: Febrile thrombocytopenia is one of the common causes of intensive care unit (ICU) admission. It narrows the differential diagnosis among patients admitted to the hospital. Tropical infections/sepsis are the major causes of FT. Hematological malignancies account for <1–2% of FT. Conclusion: This case highlights a rare cause of FT (due to APML). High suspicion of hematological malignancies in patients having FT and early initiation of treatment can reduce morbidity and mortality.



Adithya S Chiranjeevi, Varun M Nagaraja, Pradeep M Venkategowda, Jayalakshmi M Manjunath

A Rare Case of Hemolysis, Elevated Liver Enzymes, and Low Platelets Syndrome Causing Acute Pancreatitis

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:3] [Pages No:74 - 76]

Keywords: Case report, Hemolysis, elevated liver enzymes, and low platelets syndrome, Pain abdomen, Pancreatitis, Pregnancy

   DOI: 10.5005/jp-journals-10089-0077  |  Open Access |  How to cite  | 


Most cases of acute pancreatitis (AP) in pregnancy are attributed to gallstones. The hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome causing AP is very rare. This is a case of a 26-year-old female who had a normal delivery 2 days back following a full-term pregnancy complicated with preeclampsia (PE). She presented to our hospital with a history of pain abdomen, fever, and vomiting for 2 days. She had PE for which she was treated with tablets aspirin and labetalol. Routine investigations revealed thrombocytopenia, hemolysis, elevated alanine aminotransferase (ALT), and aspartate aminotransferase (AST) suggestive of HELLP syndrome. Blood investigation revealed elevated serum amylase and lipase levels along with computed tomography (CT) of the abdomen suggestive of AP. She was diagnosed to be having HELLP syndrome-associated AP and was managed conservatively. The patient's condition and lab parameters improved gradually and discharged home in stable condition. This case report highlights a rare case of HELLP syndrome causing AP.



Chaithra B Ganapayya, Namita T Philip, Tijo T Pillikottil, Jiss A Pius

Penetrating Neck Injury—Early Surgical Airway Management: A Case Report

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:3] [Pages No:77 - 79]

Keywords: Airway injury, Case report, Penetrating neck injury, Tracheotomy

   DOI: 10.5005/jp-journals-10089-0082  |  Open Access |  How to cite  | 


Penetrating neck injury is an uncommon and rare trauma presentation with significant mortality and morbidity. They pose unique challenges to the treating physicians due to the high concentration of vital structures with the possibility of airway compromise and injuries to vessels and the digestive tract. The management often requires comprehensive assessment and a structured approach for a successful outcome. This article will provide a general overview of penetrating neck injuries, including early surgical airway management, resuscitation, and appropriate surgical repair.



Sharath Krishnaswami, Vaijayanthi Sharma, Pramod Giri, Deepak Rajappa, Pradeep Teja

Williams–Beuren Syndrome in Adulthood for Hernia Repair: Anesthetic Challenges and Tutorial on Atrial Fibrillation

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:7] [Pages No:80 - 86]

Keywords: Anticipated difficult airway, Difficult airway, Obstructive sleep apnea, Williams syndrome, Williams–Beuren syndrome

   DOI: 10.5005/jp-journals-10089-0069  |  Open Access |  How to cite  | 


Williams–Beuren syndrome (WBS) is characterized by the deletion of the long arm of chromosome 7q11.231, which encodes the elastin gene. This chromosomal abnormality leads to a complex neurodevelopmental disorder associated with dysmorphic facial and musculoskeletal features, congenital heart diseases, metabolic disturbances, and cognitive impairment. Structural cardiovascular abnormalities present in a majority of the cases may provide a potential risk of perioperative sudden cardiac death. A meticulous anesthetic technique is tailor-made to avoid increased myocardial oxygen demand with a focus on airway management, intravenous access, and anesthetic induction is employed to decrease the perioperative morbidity and mortality in WBS. Here, we present a case of the anesthetic management of a 35-year-old male with WBS who was posted for bilateral laparoscopic hernioplasty.



KM Ganesh, Pooja P Sarada

Platelet Phagocytosis: Not Always a Pathology

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:2] [Pages No:87 - 88]

Keywords: Platelet phagocytosis, Platelet satellitism, Pseudothrombocytopenia

   DOI: 10.5005/jp-journals-10089-0074  |  Open Access |  How to cite  | 


A case of pseudothrombocytopenia due to platelet phagocytosis and platelet satellitism.



Bikram K Gupta, Arnavjyoti Das, Vinod Kumar Singh, Gopinath Ramachandran

Central Venous Pressure: Just a Blast from the Past or Relevant? A Debate

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:7] [Pages No:89 - 95]

Keywords: Acute care unit, Bedside monitoring, Central venous pressure, Critical care units, Echocardiography, Fluid responsiveness, Hemodynamic monitor, Ultrasound

   DOI: 10.5005/jp-journals-10089-0073  |  Open Access |  How to cite  | 


Medical Philately

Pradeep Rangappa

Pioneers of the Cardiac Sciences

[Year:2023] [Month:May-August] [Volume:2] [Number:2] [Pages:3] [Pages No:96 - 98]

   DOI: 10.5005/jp-journals-10089-0084  |  Open Access |  How to cite  | 


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