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Introduction: The usual methods of perfusion assessment in patients with shock, such as capillary refill time, skin mottling, and serial serum lactate measurements have many limitations. Veno-arterial difference in the partial pressure of carbon dioxide (PCO2 gap) is advocated being more reliable. We evaluated serial change in PCO2 gap during resuscitation in circulatory shock and its effect on ICU outcomes. Materials and methods: This prospective observational study included 110 adults with circulatory shock. Patients were resuscitated as per current standards of care. We recorded invasive arterial pressure, urine output, cardiac index (CI), PCO2 gap at ICU admission at 6, 12, and 24 hours, and various patient outcomes. Results: Significant decrease in PCO2 gap was observed at 6 h and was accompanied by improvement in serum lactate, mean arterial pressure, CI and urine output in (n = 61). We compared these patients with those in whom this decrease did not occur (n = 49). Mortality and ICU LOS was significantly lower in patients with low PCO2 gap, while more patients with high PCO2 gap required RRT. Conclusion: We found that a persistently high PCO2 gap at 6 and 12 h following resuscitation in patients with shock of various etiologies, was associated with increased mortality, need for RRT and increased ICU LOS. High PCO2 gap had a moderate discriminative ability to predict mortality. [ABSTRACT FROM AUTHOR]

Background: Despite significant loss of bicarbonate during acute diarrhea, pediatric data are scarce with acute diarrhea/severe dehydration (ADSD) and severe non-anion-gap metabolic acidemia (sNAGMA). We planned to study their clinical profile, critical care needs, and outcome. Patients: Children (1 month-12 years) with ADSD and sNAGMA (pH <7.2 and/or bicarbonate <15 mEq/L, and normal/mixed anion gap) admitted in Pediatric Emergency Department from January 2016 to December 2018 were enrolled. Children with pure high-anion-gap metabolic acidemia were excluded. Methods: Medical records were reviewed retrospectively. The primary outcome was time taken to resolve acidemia. Secondary outcomes were acute care area free days in 5 days (ACAFD5), and adverse outcome as composite of Pediatric Intensive Care Unit (PICU) admission and/or death. Results: Out of 929 diarrhea patients admitted for intravenous therapy, 121 (13%; median age, 4 months) had ADSD and sNAGMA. Median (IQR) pH was 7.11 (7.01-7.22); 21% patients had pH <7.00. Hyperchloremia (96%) and hypernatremia (45%) were common. About 12% patients each required inotropes and ventilation, while 58% had acute kidney injury (AKI). Median (IQR) time for resolution of acidemia among survivors was 24 (12, 24) hours. Thirty-two patients had adverse outcome. Higher grades of sNAGMA were associated with shock, AKI, coma, hypernatremia, hyperkalemia, adverse outcome, and lesser ACAFD5. Shock, ventilation, renal replacement therapy (RRT), and higher grades of sNAGMA were predictors of adverse outcome, with former two being independent predictors. Conclusions: Severe non-anion-gap metabolic acidemia in children with ADSD is associated with organ dysfunctions, dyselectrolytemias, and lesser ACAFDs. Resolution of acidemia took unacceptably longer time. Higher grades of sNAGMA were a predictor of adverse outcomes. Trials are suggested to assess the role of additional bicarbonate therapy. [ABSTRACT FROM AUTHOR]

Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. [ABSTRACT FROM AUTHOR]

Background: Tidal volume challenge pulse pressure variation (TVC-PPV) is considered one of the recent reliable dynamic indices of fluid responsiveness (FR); also, passive leg raising (PLR)-induced changes in cardiac output (CO) detected by echocardiography are considered a reliable reversible self-fluid challenge test; many patients share eligibility for both tests. Objectives: The study aimed to compare the sensitivity and specificity of both tests for the prediction of FR in mechanically ventilated patients with hemodynamic instability. Methods: We studied 46 patients. Hemodynamic parameters including PPV and CO (detected by velocity time integral (VTI) using echocardiography) recorded at tidal volume (VT) of 6 mL/kg/ideal body weight (IBW) in semi-recumbent position then recorded again after one-minute increase in TV from 6 to 8 mL/kg/IBW then recorded with PLR at TV of 6 mL/kg/IBW and finally with actual volume expansion in semi-recumbent position by 4 ml/kg bolus of crystalloid solution to define actual responders with increase of cardiac output of 15% or more. Results: Sixteen patients were responders, and thirty patients were nonresponders; responders had significant increase in PPV with TVC 6 to 8 ml/kg/IBW with best cutoff value of 3.5 with a sensitivity of 93.8% and a specificity of 93.9%. PLR test-induced changes in CO had a sensitivity of 93.9% and a specificity of 86.7% with statistically best cutoff value of 6.5% increase in CO, but sensitivity was 75% at cutoff value of 10% increase in CO. Other parameters like PPV, PPV changes with PLR test, and PPV changes with fluid expansion were less sensitive indicators. Conclusion: FR in patients with hemodynamic instability and mechanically ventilated with low tidal volume strategy can be efficiently predicted when PPV increases more than 3.5 with tidal volume challenge and when PLR induces 6.5% increase in CO monitored through VTI method by Doppler echocardiography, and both tests are equally reliable. [ABSTRACT FROM AUTHOR]

Objectives: To compare the incidence of healthcare-associated infections (HAI) and their outcomes between patients admitted to the ICU with sepsis and those admitted with non-sepsis diagnoses. Materials and methods: We performed a single-center, prospective, observational study of ICU patients at a tertiary level medical-surgical unit from April 2018 to October 2018. All patients admitted to the ICU with a length of stay (LOS) > 48 hours were included. Baseline data including demographics, co-morbidities, and severity of illness scores were collected. Index occurrence of HAI in all these patients was noted and data regarding organ support and patient outcomes were recorded. The incidence, complications, ICU LOS, and 30-day mortality of HAI were compared between the patients admitted to ICU originally with sepsis and non-sepsis diagnoses. Results: A total of 271 patients were evaluated in our study (N = 106 for the sepsis group and N = 165 for the non-sepsis group). No significant difference between the groups was found in the incidence of HAI (29.2% in sepsis group vs 24.4% in non-sepsis group; p = 0.07). Complications (acute kidney injury (AKI): 71 vs 45%; p = 0.01, shock: 81 vs 55%; p = 0.05, need for mechanical ventilation (MV): 30 vs 15%; p = 0.04) were more common in sepsis group compared to the non-sepsis group. The ICU LOS (12.2 ± 5.2 days vs 8.8 ± 2.05 days; p = 0.01) was significantly longer in the sepsis group. There was no significant difference in 30-day mortality between the groups (45 vs 25%; p = 0.07). Conclusions: The incidence of HAI seems to be similar between patients admitted with sepsis and non-sepsis diagnoses. However, patients admitted with sepsis develop higher rates of organ failure secondary to HAI and have a longer ICU LOS compared to patients admitted with non-sepsis diagnoses. The mortality rate of HAI did not differ between these two groups. [ABSTRACT FROM AUTHOR]

Background: Multisystem inflammatory syndrome (MIS) associated with severe acute respiratory syndrome coronavirus (SARS-CoV-2) (MIS-C) in children is being increasingly reported across the world. Materials and methods: Children fulfilling the World Health Organization criteria of MIS-C needing pediatric intensive care unit between April 15 and July 26, 2020 were studied. Results: There were 21 patients with median age of 7 years [interquartile range (IQR) 1.9-12.1], of which 11 were females. SARS-CoV-2 real-time polymerase chain reaction positive in 8/21 and/or antibody positive 16/21. Fever was present in all patients, and gastrointestinal symptoms being second most frequent (16/21). One child had aplastic anemia, while the rest had no comorbidities. Nearly all presented with shock (n = 20/21) and 90% needed vasoactive drugs with a median Vasoactive Inotropic Score of 40 (IQR 20--95). Thirteen children needed ventilatory support and one needed peritoneal dialysis. Nine children had left ventricular dysfunction and five had dilatation of coronaries on echocardiography. Inflammatory markers C-reactive protein [98 mg/dL (IQR 89-119)], serum ferritin [710 mg/dL (IQR 422-1,609)], and serum interleukin-6 levels [215 ng/L (IQR 43-527)] were uniformly elevated. Eighteen children received pulse methyl-prednisolone, eleven intravenous immunoglobulins, and four tocilizumab. Eighteen children (86%) were discharged home while three died. Conclusion: In our cohort, MIS-C was seen in previously healthy children with fever, gastrointestinal symptoms, and shock. Early and aggressive management of shock and immune modulation with methyl-prednisolone and intravenous immunoglobulin were used. [ABSTRACT FROM AUTHOR]

Introduction: Obstetric patients are a special group of patients whose management is challenged by concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy. Materials and methods: A prospective analysis of all obstetric patients admitted to the critical care department was done to assess reasons for transfer to the critical care unit (CCU) and the interventions required for management of these patients. Results: Between June 2013 and September 2017, obstetric admission comprised 95 women (5.9%) of the total critical care admissions. There were 77 patients (81.1%) who were discharged from the hospital and 18 patients (18.9%) died. In most of the cases, the primary reasons for shifting the patient to the CCU were severe preeclampsia with pulmonary edema (22.1%), eclampsia (8.4%), acute respiratory distress syndrome (ARDS) (14.7%), and hypovolemic shock in antepartum hemorrhage (APH) and postpartum hemorrhage (PPH) (10.5 and 13.7%, respectively). It was seen that 73 patients (76.8%) required ventilator support, 58 patients (57.4%) required vasopressor support, and intensive hemodynamic monitoring and blood/blood products were transfused in 55 patients (54.5%). The need for ventilator support was more in patients with a lower PaO2/FiO2 and a higher APACHE II score. Patients with a high severity of illness score and a lower PaO2/FiO2 had higher odds of requiring vasopressors. Low hemoglobin at the time of transfer to the CCU and a prolonged hospital stay were found to predict the need for blood transfusion. Conclusion: Obstetric patients are susceptible to critical illnesses but timely management improves the outcome of these young women. [ABSTRACT FROM AUTHOR]

Introduction: Nontraumatic undifferentiated hypotension is one of the common and challenging critical presentations in the emergency department (ED) due to the difficulty in diagnosing the etiology of shock. In the present study, an attempt was made to test point-of-care ultrasound (PoCUS) as an early approach to improve the accuracy of diagnosis and to narrow the differentials in cases of nontraumatic undifferentiated hypotension. Materials and methods: This is a prospective explorative study conducted in the ED of a tertiary care hospital over a period of 18 months. A total of 100 patients were included in the study. All patients >18 years of age with systolic blood pressure <90 mm Hg with at least one sign or symptom of hypoperfusion were included in the study. Patients referred from another hospital as shock, history of trauma, and history suggestive of orthostatic hypotension and presented with symptomatic postural hypotension as the only chief complaint were excluded. All the patients who met the inclusion/exclusion criteria underwent detailed clinical and multi-organ PoCUS evaluation by two different observers. Assessment of the lungs, cardia, abdomen, aorta, inferior vena cava (IVC), and leg veins during the PoCUS examination was done. A third observer combined the clinical evaluation and the PoCUS findings. All patients were followed through for their final diagnosis at the time of discharge. First, the diagnosis after clinical evaluation alone was compared to the final diagnosis. Then the diagnoses based on the findings of PoCUS alone were compared with the final diagnosis. Last, the diagnosis obtained on combining the data of clinical evaluation with that of PoCUS was compared to the final diagnosis. The data were analyzed based on their reliability indices, accuracy, and the Cohen's kappa coefficient. Results: Diagnoses based on clinical evaluation alone and POCUS alone were found to be accurate in 45% and 47% of patients, respectively. But on combining the findings of clinical evaluation with PoCUS, the accuracy increased to 89%. The most common etiology of shock was found to be distributive shock present in 38% of patients with sepsis being the most common subtype. In patients with obstructive shock, combined clinical evaluation with PoCUS was in perfect agreement with Cohen's kappa coefficient (κ) = 1 and those with distributive shock were in substantial agreement with Cohen's kappa coefficient (κ) = 0717. The overall kappa correlation of the combined evaluation with PoCUS was 0.89, which shows an almost perfect agreement with the final diagnosis. Conclusion: This study demonstrates the accuracy and reliability of PoCUS as an easy and valuable bedside tool when added to the clinical evaluation. It helps in narrowing the differentials and thereby guiding early goal-directed therapy in nontraumatic, undifferentiated hypotension patients presenting to the ED. [ABSTRACT FROM AUTHOR]

Aim: To assess the accuracy of the passive leg raising (PLR) test to anticipate fluid responsiveness in critically ill children under age of 5 years. Materials and methods: A prospective observational study was conducted, in a university hospital pediatric intensive care unit from June 1, 2017, to January 30, 2018. Hemodynamic parameters including stroke volume using bedside transthoracic echocardiography were assessed at baseline I (45° semi-recumbent position), after PLR, at baseline II, and following fluid challenge. Changes in the stroke volume (delta SV) and in the cardiac index (CI) were recorded after PLR and fluid challenge. Findings: Delta SV of 10% after PLR was an excellent discriminator of the fluid responsiveness with an area under ROC (AUC) of 0.81 (95% CI 0.68-0.9) with a sensitivity of 65.38% and a specificity of 100%. The change in CI of 8.7% after PLR was a significant discriminator of fluid responsiveness with an AUC of 0.7 (95% CI 0.56-0.81) with 57.78% sensitivity and 91.67% specificity. Conclusion: Passive leg raising can identify nonresponders among seriously ill children under the age of 5 years but it cannot identify all responders with certainty. Clinical significance: Passive leg raising is reliable test in under 5 year-old-children if performed appropriately using bedside echocardiography for the measurement of its transient effect. [ABSTRACT FROM AUTHOR]

Background: Sepsis-induced myocardial dysfunction has implications on outcome. For lack of echocardiography in resource-limited settings, myocardial biomarkers may be an alternative monitoring tool. Objective: This study was planned to explore the longitudinal behavior of creatine phosphokinase-MB (CPK-MB) in children with sepsis with and without shock, and its correlation with clinical and echocardiographic parameters over the first 10 days. Design: Prospective observational study. Setting: Tertiary care hospital in a lower-middle-income economy of South Asia. Patients: Children (3 months to 12 years) with nonshock sepsis (NSS) (n = 40) and septic shock survivors (SSSs) (n = 40) after optimal resuscitation. Patients with catecholamine refractory shock, preexisting heart disease, and cardiorespiratory event within the past 1 month were excluded from the study. Measurements and main results: Pediatric logistic organ dysfunction (PeLOD) score, vasoactive inotrope score (VIS), CPK-MB, and echocardiographic measures of myocardial function were recorded on days 1, 3, 7, and 10. Echocardiography was repeated at 1 month. Both groups were similar at baseline. The SSSs had higher CPK-MB (180 vs 53 IU/L; p < 0.001) and PeLOD score (2 ± 0.4 vs 11.7 ± 5.1, p < 0.001) on day 1 compared to the NSS children. More than half of the SSS and none of the NSS patients had myocardial dysfunction. Reduction in CPK-MB over 10 days correlated well with improvement in PeLOD (p < 0.01), VIS (p = 0.04), and echocardiographic measures of myocardial dysfunction (p < 0.05) among SSSs. At 1 month follow-up, all had normal echocardiography. Conclusion: The SSSs had markedly elevated CPK-MB, and its fall paralleled the improvement in clinical status and myocardial dysfunctions. The CPK-MB could be a potential monitoring tool for septic cardiomyopathy in resource-limited settings. [ABSTRACT FROM AUTHOR]

Vasodilatory shock is a critical manifestation of cardiovascular failure. There is uncontrolled vasodilation and vascular hyporesponsiveness to endogenous vasoconstrictors, causing the failure of physiologic vasoregulatory mechanisms. Unfortunately, only few randomized studies exist to guide clinical management and hemodynamic stabilization in patients who do not respond to the standard approach of managing vasodilatory shock. The present review offers the latest updates in management of this important clinical entity and a guidance framework for future research. [ABSTRACT FROM AUTHOR]

Background and aims: Acute kidney injury (AKI) became an important cause of mortality and morbidity in critically ill children, despite advancement in its management. In developing countries etiology of AKI are different from that of developed countries. Materials and methods: This observational study was carried out in pediatric intensive care unit (PICU) in 2 months to18 years of critically ill children. Kidney injury was defined and categorized by the pRIFLE criteria. Results: Out of 361children, 86 children (23.8%) developed AKI at some point during admission, 275 children (age and sex matched) who did not develop kidney injury during hospitalization served as non-AKI children. Maximum cases of AKI were seen in 1-5 years of age. Maximum children of AKI were of viral encephalitis (n = 43, 50.0%) followed by scrub typhus (n = 14, 16.3%). Risk factors for the development of AKI were shock, PRISM score and longer hospital stay. In our study the mortality in AKI children (n = 30, 34.8%) was significantly higher (p = 0.005) as compared to non-AKI children (n = 56, 20.3%)). Duration on mechanical ventilation, PICU stay and hospital stay were also significantly (p = 0.001) higher in AKI children. Conclusion: AKI is common in critically ill children and associated with high mortality and morbidity. [ABSTRACT FROM AUTHOR]

Scrub typhus has reemerged with a different geographical distribution and varied clinical presentation like acute encephalitis syndrome (AES), which is a less known entity in scrub typhus. In this case series, we studied the clinical profile and outcome of eight patients who presented with AES and a positive scrub serology without any other identifiable cause of encephalopathy. All these patients had fever, altered sensorium, and nuchal rigidity, while seizures were present in six (75%) patients and papilledema in two (25%) patients. Complications like shock, pulmonary edema, and gastrointestinal (GI) bleed were observed in three (37%) patients. All patients except for one responded well to the treatment and recovered completely. Scrub typhus should be suspected early in patients presenting with AES. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization guidelines provide suggestions on early recognition and treatment of severe dengue (SD); however, mortality in this group can be high and is related both to disease severity and the treatment complications. Subjects and Methods: In this prospective observational study, we report our results where standard therapy (ST) was enhanced by Intensive Care Unit (ICU) supportive measures that have proven beneficial in other conditions that share similar pathophysiology of capillary leak and fluid overload. These include early albumin for crystalloid-refractory shock, proactive monitoring for symptomatic abdominal compartment syndrome (ACS), application of a high-risk intubation management protocol, and other therapies. We compared outcomes in a matched retrospective cohort who received ST. Results: We found improved outcomes using these interventions in patients with the most devastating forms of dengue (ST+ group). We could demonstrate decreased positive fluid balance on days 1-3 and less symptomatic ACS that necessitated invasive percutaneous drainage (7.7% in ST+ group vs. 30% in ST group, P = 0.025). Other benefits in ST+ group included lower intubation and positive pressure ventilation requirements (18.4% in ST+ vs. 53.3% in ST, P = 0.003), lower incidence of major hemorrhage and acute kidney injury, and reduced pediatric ICU stays and mortality (2.6% in ST+ group vs. 26% in ST group, P = 0.004). Conclusion: Children with SD with refractory shock are at extremely high mortality risk. We describe the proactive application of several targeted ICU supportive interventions in addition to ST and could show that these interventions resulted in decreased resuscitation morbidity and improved outcomes in SD. [ABSTRACT FROM AUTHOR]

Background: The early prediction of acute kidney injury (AKI) by the current clinical and laboratory methods remains inadequate. Neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising noninvasive biomarker of kidney injury in shock. The aim of this study was to assess the ability of urinary NGAL (uNGAL) to predict AKI in adult Intensive Care Unit (ICU) patients. Materials and Methods: We prospectively studied 70 patients with circulatory shock admitted to the ICU over a period of 1 year. uNGAL was analyzed at ICU admission and after 24 h. Risk, injury, failure, loss, and end-stage kidney criteria were calculated at admission and for consecutive 4 days. The primary outcome was AKI defined as an increase in creatinine of at least 50% from baseline or a reduction in urine output to <0.5 ml/ kg/h for 6 h. Results: uNGAL was a good diagnostic marker for AKI development; at day 1, the cutoff value 48.54 ng/mL had a sensitivity and specificity of 79.49 and 73.14, respectively, and the area under the curve (AUC) of 0.82 (95% confidence interval [CI], 0.75-0.87) for predicting AKI. At day 2, the cutoff value 190.92 ng/mL had a sensitivity and specificity of 90.0 and 64.66, respectively, and the AUC of 0.76 (95% CI, 0.70-0.88) for predicting AKI. Conclusion: uNGAL could be a good early predictor biomarker of AKI following circulatory shock. [ABSTRACT FROM AUTHOR]

An 18-year-old male with history of polysubstance abuse presented to the emergency department with intractable vomiting, diarrhea, and abdominal pain for one day after the consumption of kratom. Examination revealed arterial hypotension, tachycardia, and prolonged capillary refill. Laboratory studies showed white blood cell count (WBC) of 23.6 x 109/L, serum creatinine 4.0 mg/dL, lactate 6 mmol/L, and procalcitonin >200 ng/mL. Urine and blood drug screen were unremarkable. Radiology and echocardiogram were noncontributory. He received fluid resuscitation and broad spectrum antibiotics. Vasopressors were subsequently added to manage persistent shock. He remained afebrile, and his blood cultures were negative. His shock and associated organ dysfunctions improved over the next 72 hours. On discharge, his procalcitonin level decreased to 9.55 ng/mL, leukocytosis resolved, and the creatinine returned to baseline. This case describes an extremely rare presentation related to kratom, an herb marketed as an opioid alternative, with significant potential for addiction and withdrawal syndrome. [ABSTRACT FROM AUTHOR]

The clinical and etiological pattern of ventilated newborns, their outcome in relation to morbidity and mortality was studied with 50 ventilated newborns, including outborns. M:f ratio was 2.1:1. The most common gestational age 28–36 weeks (60%) and mostly were appropriate for gestational age (66%). Survival rate 40% (20/50) being directly proportional to the gestational age and intrauterine growth pattern (P < 0.01). Babies by LSCS Lower Segment Cessarian Section survived more than born by normal vaginal delivery (46.7% vs. 37.1%). More outborn survival could be related to their advanced gestational age on presentation. The initial assessment of APGAR score of >7 had a better outcome (56.3%; P < 0.03). The most common indication of ventilation was hyaline membrane disease (19/50) but the survival rate best in babies with meconium aspiration syndrome (54.5%). The most prevalent complication was sepsis (survival rate 60%) while conditions such as shock, intraventricular hemorrhage, disseminated intravascular coagulation, air leak syndrome, and pulmonary hemorrhage had 100% mortality. Thus, the outcome as survival is constrained by many factors; newborn's profile, conditions at birth, and postnatal resuscitation. [ABSTRACT FROM AUTHOR]

Hexavalent chromium compounds are most commonly used in printing, dyeing, plastics and rayon manufacturing. Poisoning in children by ammonium dichromate, an odorless and bright orange-red crystal, are rarely reported. Acute poisoning will result in death due to multi-organ failure. The target organs that are affected by this poison are the respiratory system, kidneys, liver, eyes and skin. On ingestion, initially there is a relative lack of severe symptoms and signs. Hence, the delay in seeking medical attention could lead to the increased rate of mortality. In this case study, we report the ingestion of ammonium dichromate by a child. Despite appropriate management, such as hepatic supportive measures and plasma transfusion, the toxicity progressed to multi-organ failure and death. [ABSTRACT FROM AUTHOR]

Objective: The objective of the following study is to evaluate the associations between single nucleotide polymorphisms (SNPs) in the Heat Shock Protein 70 (HSP70) gene, gene expression of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) and medical intensive care unit (MICU) stay and organ failure in sepsis. Materials and Methods: MICU patients with sepsis were genotyped for rs1061581, rs2227956, rs1008438 and rs1043618 polymorphisms in HSP70 gene using polymerase chain reaction (PCR)-restriction fragment length polymorphism analysis or allele-specific PCR. Messenger ribonucleic acid (mRNA) expression of IL-6 and TNF-∝ were quantitated in peripheral blood lymphocytes. Outcomes were recorded. Results: 108 patients (48 male) aged 40.7 ± 16.0 (mean ± standard deviation) years included HINI infection (36), scrub typhus (29) and urosepsis (12). Seventy-one (65.7%) had dysfunction of three or more organ systems, 66 patients (61.1%) were treated by mechanical ventilation, 21 (19.4%) needed dialysis. ICU stay was 9.3 ± 7.3 days. Mortality was 38.9%. One or more SNPs were noted in 101/108 (93.5%) and organ failure was noted in only 1/7 patients without a single SNP. The A allelotypes of rs1061581 and rs1008438 were associated with hematological dysfunction (P = 0.03 and 0.07) and longer ICU stay (P = 0.05 and 0.04), whereas IL-6 and TNF-α mRNA levels were associated with central nervous system dysfunction. Conclusions: HSP70 genotypes may determine some adverse outcomes in patients with sepsis. [ABSTRACT FROM AUTHOR]

Introduction: Several studies have shown that the number of B-lines was related to the amount of extravascular lung water (EVLW). In our study, we aimed to demonstrate the magnitude of the incremental B-lines in shock patients with positive net fluid balance and the association with gas exchange impairment. Materials and Methods: We performed trans-thoracic ultrasound at admission (T0) and at follow-up period (TFL) to demonstrate the change of B lines (▵B-lines) after fluid therapy. We compared the total B-line score (TBS) at T0 and TFL and calculated the Pearson's correlation coefficient between the ▵ B-lines and PaO2/FiO2 ratio. Results: A total of 20 patients were analyzed. All patients had septic shock. Net fluid balance was + 2228.05 ± 1982.15 ml. The TBS at T0 and TFL were 36.6 ± 23.73 and 63.80 ± 29.25 (P < 0.01). The ▵ B-lines along anterior axillary line (AAL) correlated to the ▵ TBS (r = 0.90, P < 0.01). The ▵ B-lines along AAL had inverse correlation to PaO2/FiO2 ratio (r = -0.704, P < 0.05). The increase of B-lines ⩾ 10 was related to the decrease of PaO2/FiO2 ratio. The inter-observer reliability between two ultrasound readers was high (r = 0.92, P < 0.01). Discussion: The number of B-lines increased in shock patients with positive net fluid balance and correlated to impaired oxygenation. These data supported the benefit of ultrasound for assessing the EVLW. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes. Objective: The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery. Design: Retrospective, audit. Materials and Methods: The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group). Results: The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks. Conclusion: Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage. [ABSTRACT FROM AUTHOR]

Background and Aims: Pediatric index of mortality (PIM) 2 score is one of the severity scoring systems being used for predicting outcome of patients admitted to intensive care units (ICUs). The aim of the present study was to evaluate the usefulness of PIM2 score in predicting mortality in a tertiary care pediatric ICU (PICU) and to assess the associated factors in predicting mortality such as presence of shock, need for assisted ventilation and Glasgow coma scale <8. Materials and Methods: This was a prospective observation study done at tertiary care PICU from May 2011 to July 2011. Consecutive 119 patients admitted to PICU (aged 1 month to 12 years) were enrolled in the study. PIM2 scoring was done for all patients. The outcome was recorded as death or discharge. The associated factors for mortality were analyzed with SPSS 17. Results: PIM2 score discriminated between death and survival at a 99.8 cut-off, with area under receiver operating characteristic curve 0.843 with 95% confidence interval (CI) (0.765, 0.903). Most patients were referred late to this hospital, which explains higher death rate (46.2%), lesser length of hospital stay (mean 2.98 days) in the mortality group, and increased rate of mechanical ventilation (68.1%). Presence of shock was independently associated with mortality, as evidenced by binary logistic regression. Conclusion: PIM2 score discriminated well between survivors and death at PICU. Presence of shock was significantly associated with mortality. [ABSTRACT FROM AUTHOR]

Spontaneous heterotopic pregnancy is a rare clinical condition in which intrauterine and extrauterine pregnancies occur at the same time. It is rare, estimated to occur in 1 in 30,000 pregnancies. The case was a 38-year-old woman with spontaneously conceived heterotopic pregnancy. She was admitted to our center with hypovolemic shock. Focused assessment sonography for trauma examination in emergency department showed large amount of free fluid in peritoneal cavity. She was managed surgical laparotomy. Considering spontaneous pregnancies, physician should be aware of the possibility of heterotopic pregnancy in all reproductive age women, especially those with history of recent abortion. It can occur without any predisposing risk factors. Patients should be informed about possible side effects of nonprescription medicines, and also the health care centers must be safe peaceful environment for them without severe legal consequences. [ABSTRACT FROM AUTHOR]

Background and Aim: The clinical applicability of substitution of central venous oxygen saturation for mixed venous oxygen saturations in monitoring global tissue hypoxia is still a matter of controversy. Hence aim of the study is comparison of paired samples of mixed venous and central venous oxygen saturation and comparison in relation to cardiac index in varying hemodynamic conditions. Materials and Methods: Prospective clinical observation: Postoperative cardiac surgical ITU: 60 adult patients, >18 years of age of either sex: A PAC was inserted through® IJV, triple lumen catheter was inserted through® IJV. Blood samples were taken from distal tip of PAC and central venous catheters. An arterial blood sample was drawn from either radial or femoral arterial line. Measurements: Continuous cardiac output monitoring. Analysis of blood samples for hemoglobin concentration and oxygen saturation. Mixed venous oxygen saturations and central venous oxygen saturations were compared. The study was carried over a period of 30h in the postoperative period and samples were taken at 6h intervals. Patients were classified into three groups as follows depending on the CI: Low (< 2.5 L/m2), medium (2.5-4 L/m2), high (> 4 L/ m2) and correlated with Svo2 and Scvo2. Results: 298 Comparative sets of samples were obtained. Svo2 was consistently lower than Scvo2 throughout the study period. The difference was statistically significant. By using Bland - Altman plot, the mean difference between Svo2 and Scvo2 (Svo2-Scvo2) was - 2.9% ± 5.14 and confidence limits are + 7.17% and - 12.97%. The co-efficient r is > 0.7 throughout the study period for all paired samples. The correlation Svo2 and Scvo2 with cardiac index in all the three groups were >0.7. Conclusion: Scvo2 and Svo2 are closely related and are interchangeable. Even though individual values differ trends in Scvo2 may be substituted for trend in Svo2 [ABSTRACT FROM AUTHOR]

Autoimmune polyglandular syndrome (AIPS) is a heterogeneous condition characterized by the loss of immune tolerance and resultant dysfunction of multiple endocrine organs. Although this condition is insidious in nature, it frequently presents initially as adrenal insufficiency (AI). For patients in shock, physicians routinely assess for infections, volume depletion as well as cardiogenic and iatrogenic causes of shock. However, the case described in this report emphasizes the need for high suspicion of AI syndrome when the etiology of shock remains unclear after primary assessment. A subsequent evaluation for autoimmune etiology, especially in young adults in appropriate clinical setting, may also be warranted. [ABSTRACT FROM AUTHOR]

This is a review of the use of colloid and crystalloid in shock. The article discusses the pathophysiological consequences of ischaemia and shock; reviews the underlying physiology of fluid compartments and how they may be affected by disease; examines the physiological determinants of intravenous (IV) fluid use; and finally reviews the literature on colloid and crystalloid use for the management of shock. [ABSTRACT FROM AUTHOR]

Congenital factor X (FX) deficiency is a rare coagulation disorder of autosomal recessive inheritance, characterized by bleeding of variable severity. Bleeding severity generally correlates with the level of FX functional activity and severe bleeding usually occurs in moderate and severe deficiency, when FX coagulant activity is <5%. FX activity above 10% is infrequently associated with severe bleeding. Here we report the rare occurrence of life-threatening massive spontaneous intraperitoneal bleeding with hypovolemic shock, resulting from spontaneous rupture of an ovarian luteal cyst in a 25-year-old FX deficiency carrier woman, with a FX activity of 26%. She was managed successfully conservatively, with fresh frozen plasma and packed red blood cell transfusions and she showed gradual improvement. The case is being reported to discuss the diagnosis and management of this rare inherited coagulation disorder. [ABSTRACT FROM AUTHOR]

Amlodipine is a commonly prescribed calcium channel blocker. Its toxicity is the leading cause of drug overdose seen in the practice of cardiovascular medicine. It can lead to profound hypotension and shock. Management involves early and aggressive supportive measures and calcium infusion in large doses to overcome competitive blockade. We report one such case that presented with amlodipine overdose and was successfully managed. [ABSTRACT FROM AUTHOR]

Cyanide toxicity is a fatal condition if not detected and treated in stipulated time1. Lack of rapid detection modalities, and nonspecific nature of clinical presentation make the diagnosis more challenging2. Cherry red colour of blood might be the only clue sometimes. We present a case of sudden onset altered sensorium which was detected as cyanide poisoning and treated successfully with antidots, on the basis of central venous blood colour and corroborative presentation. [ABSTRACT FROM AUTHOR]

Catastrophic antiphospholipid antibody syndrome (CAPS) resembles severe sepsis in its acute presentation, with features of systemic inflammatory response syndrome (SIRS) leading to multiple organ dysfunction. Infections are the best known triggers of CAPS. This emphasizes the need for early diagnosis and aggressive treatment as the mortality is as high as 50%. We present a 42-year-old woman who developed SIRS postoperatively and was eventually diagnosed as CAPS [ABSTRACT FROM AUTHOR]

The article presents a medical case wherein a 45 year old male who was chronic alcoholic for 20 years was admitted in a state of shock. Topics discussed include his complains of abdominal pain and vomiting for 10 days duration and the patient was semiconscious on examination, abdominal examination showed distended abdomen and guarding and rigidity palpation and examination showed ecchymosis found the flanks and near the axilla may be due to formation of methemalbumin due to pancreatitis.

A letter to the editor is presented in response to the article "Risk factors for shock in children with dengue fever" by S. Pothapregada and colleagues, published in the previous issues of the journal.

A letter to the editor is presented regarding a case study of a 34-year-old man with shock and respiratory failure and was given a rapid ultrasound in shock (RUSH) protocol.

Autoimmune polyendocrine syndrome Type II (APS II), also known as polyglandular autoimmune syndrome Type II or Schmidt syndrome, is constellations of multiple endocrine gland insufficiencies. It is a rare, but most common of the immunoendocrinopathy syndrome. It is characterized by the obligatory occurrence of autoimmune Addison's disease in combination with thyroid autoimmune diseases and/or Type I diabetes , hypogonadism , hypophysitis , myasthenia gravis , vitiligo , alopecia , pernicious anemia , and celiac disease. Here, we report a case of 38-year-old female patient presented with shock, further diagnosed to have APS II. [ABSTRACT FROM AUTHOR]

The author reflects on the accurate and rapid measurement of pathophysiological unbalances. He states that standard arterial blood gas (ABG) can be a cost-effective and acceptable replacement for the expensive cooximetry when evaluating central venous oxygen saturation (ScVO2) on patients with shock. He also mentions that improve technology increase treatment and monitoring costs which results in critical practice become less affordable especially in developing countries.

A letter to the editor is presented discussing a case of pseudoleukopenia due to ethylenediaminetetraacetate induced leukoagglutination.