Effect of Change in Sodium after Slow Low-Efficiency Dialysis in Critically Ill Patients with Acute Kidney Injury.

INTRODUCTION: The effect of sodium (Na) correction by slow low-efficiency dialysis (SLED) in dysnatremic (135 mEq/L <Na >145 mEq/L) critically ill patients is unclear. METHODS: Prospective observational study enrolled dysnatremic critically ill adult patients with acute kidney injury undergoing the first SLED as cases and normonatremic patients as controls. Baseline and SLED-related parameters and 30-day mortality were noted. RESULTS: 100 dysnatremic and 51 normonatremic patients were included, with a median age of 31 (25-52) years and median admission SOFA scores of 10 (9-12). Patients with dysnatremia at study inclusion had a mortality of 53%, with the highest mortality in severe hypernatremia (Na >160 mEq/L) (75%), followed by those with severe hyponatremia (Na <120 mEq/L) (68.6%). SLED-associated natremia change >10 mEq/L was significantly associated with mortality, in patients with mild dysnatremia and normonatremia (Na: 130-150) (p < 0.001), and not in those with moderate to severe dysnatremia (Na <130 and Na >150) (p = 0.72). Upon multivariate logistic regression analysis, a model with pre-SLED pH, dialyzate-pre-SLED Na difference, and duration of SLED significantly predicted SLED-associated natremia change (R2 0.18, p = 0.001). CONCLUSIONS: SLED can be safely and effectively performed in critically ill adults with dysnatremia requiring renal replacement therapy with mortality comparable to normonatremic controls.

The impact of a "short-term" basic intensive care training program on the knowledge of nonintensivist doctors during the COVID-19 pandemic: An experience from a population-dense low- and middle-income country.

BACKGROUND: The utility of basic intensive care unit (ICU) training comprising a "1-day course" has been scientifically evaluated and reported in very few studies, with almost no such study from resource-limited settings. AIM: The study assessed the utility of basic ICU training comprising of a "1-day course" in increasing the knowledge of nonintensivist doctors. MATERIALS AND METHODS: This is an observational study conducted at a medical university in North India in 2020. The participants were nonintensivist doctors attending the course. The course was designed by intensivists, and it had four domains. The participants were categorised on the basis of their duration of ICU experience and broad speciality. Pretest and posttest was administered, which was analysed to ascertain the gain in the knowledge score. RESULTS: A total of 252 participants were included, of which the majority were from the clinical medicine speciality (85.3%) and had ICU experience of 1-6 months (47.6%). There was a significant improvement in the mean total score of the participants after training from 14/25 to 19/25, with a mean difference (MD) of 5.02 (p < 0.001). Based on ICU experience, in groups I (<1 month), II (1-6 months), and III (>6 months), there was a significant improvement in the total score of the participants after training with MD with 95% confidence interval (CI) limits of 5.27 (4.65-5.90), 4.70 (4.38-5.02), and 5.33 (4.89-5.78), respectively. In the clinical surgery specialty (n = 37), there was a significant improvement in the total score after training from 11/25 to 16.4/25 with an MD (95% CI limits) of 5.38 (4.4-6.3). Similarly, in the clinical medicine group (n = 215), the MD (95% CI limits) score after training was 4.95 (4.71-5.20), from 14.5/25 to 19.5/25. In feedback, more than half of the participants showed interest in joining ICU after training. CONCLUSIONS: Training nonintensivist doctors for 1 day can be useful in improving their knowledge, regardless of their prior ICU experience and speciality.

Cardiac tamponade and basilar artery aneurysm following leptospirosis: A case report.

Complications involving the heart are rare in leptospirosis, and cardiac tamponade is still rarer. We report the case of a 42-year-old hypertensive woman who presented with complaints of cough for 2 months and breathlessness for 1 month. One month later, she developed shortness of breath and loss of consciousness. The patient had a history of hemiparesis. Serum anti-Leptospira immunoglobulin M ELISA was positive. Ultrasound showed pericardial tamponade and hemorrhagic collection. Two-dimensional echocardiography showed minimal effusion posterior to the left ventricle and no effusion present to the right ventricle. High-resolution computerized tomography revealed patchy areas of ground glass opacities in bilateral upper and bilateral lower lobes, prominent bronchovascular markings bilaterally, and minimal pericardial thickening. Magnetic resonance imaging of the brain showed small chronic infarcts in bilateral corona radiata and basal ganglia. A magnetic resonance angiogram of the brain showed a basilar top aneurysm, which was an incidental finding. No signs of rupture of the aneurysm were seen. Digital subtraction angiography showed 50%-70% stenosis at the junction of the V3-V4 segments of the vertebral artery. The right lower limb immobilization, along with ecosprin, ivabradine, amlodipine, and fluconazole, was started, to which the patient responded well.

Approach to new-onset facial nerve palsy in a critically ill patient: A case report.

Lower motor type of facial nerve palsy (Bell's palsy) is one of the most common types of facial nerve palsy, with well-defined management with steroids and antivirals for patients attending outpatient clinics. The diagnosis and management of facial nerve palsy in critically ill patients require an individualized approach, as there may be many other causes like soft-tissue compression due to facial edema which can occur as a complication of prone ventilation and severe subcutaneous emphysema. This report highlights the challenges in the management of new-onset facial nerve palsy diagnosed in the intensive care unit (ICU) for a patient on mechanical ventilation, and creates a necessity for a standard operating protocol for the management of such scenarios in ICU.

Fulminant acute fatty liver of pregnancy presenting with multi-organ failure: A case series.

Liver disease in pregnancy can be classified into pregnancy-related, liver disease coincident with pregnancy or preexisting liver disease. Acute fatty liver of pregnancy (AFLP) is a rare liver disorder that is caused by defects in mitochondrial beta (ß) oxidation of fatty acids. In view of its fulminant presentation and rapid progression to multiple organ failure (MOF), AFLP carries high maternal and fetal mortality. These patients are commonly present in the third trimester of pregnancy with gastrointestinal symptoms and complications such as hypoglycemia, lactic acidosis, hyperammonemia, leukocytosis, liver dysfunction, coagulopathy, and renal dysfunction. Diagnosis is mostly based on the Swansea diagnostic criteria and by excluding other etiologies of liver dysfunction. Liver biopsy is rarely performed owing to underlying coagulopathy and thrombocytopenia. In this case series, we intend to share our experience of managing four cases of AFLP that were admitted to the intensive care unit with fetal demise and MOF.

Effects of Killari earthquake on the paleo-channel of Tirna River Basin from Central India using anisotropy of magnetic susceptibility.

The Killari Earthquake (Moment magnitude 6.1) of September 30, 1993, occurred in the state of Maharashtra, India, has an epicenter (18°03' N, 76°33' E) located at ~ 40 km SSW of Killari Town. The ~ 125 km long basin of Tirna River, close to the Killari Town, currently occupies the area that has witnessed episodic intra-cratonic earthquakes, including the Killari Earthquake, during last 800 years. The anisotropy of magnetic susceptibility (AMS) study was performed on ~ 233 soft sedimentary core samples from six successions located in the upper to lower stream of the Tirna River basin in the present study in order to evaluate the effects of earthquake on the river flow dynamics and its future consequence. The AMS Kmax orientations of the samples from the upper reach of the river section suggest that the sedimentation in this part of the river was controlled by a N-S to NNW-SSE fluvial regime with a low or medium flow velocity. In the middle reaches of the basin, an abrupt shift in the palaeo-flow direction occurred to W-E with low velocity flow. However, a NW-SE higher palaeo-flow regime is identified in the following central part of the basin in down-stream direction, followed by a low-velocity palaeo-flow regime at the lower reach of the Tirna basin. We attribute the sudden high flow velocity regime in the central part of the river basin to an enhanced gradient of the river that resulted from the reactivation of a NW-SE fault transecting the Tirna River basin at the Killari Town. As the NW-SE faulting in regional scale is attributed as the main cause of Killari Earthquake, the reactivation of this fault, thus, could enhance the further possibility of an earthquake in near future, and hence leading to devastating flood in the almost flat-lying downstream part of the Tirna River.