Relationship of Endotracheal Tube Cuff Pressures with Changes in Body Positions of Critically Ill Patients on Mechanical Ventilation: An Observational Study.

Aims and background: Endotracheal tube cuff pressure (ETCP) is an important factor to determine the development of complications associated with invasive mechanical ventilation. To avoid preventable complications arising out of immobilization, frequent changes in body positioning are necessary. Such variations in body position can affect ETCP in critically ill patients who are on mechanical ventilation. So, our study aimed to assess the effect of changes in body position on ETCP in patients who are on mechanical ventilation. Materials and methods: This prospective observational study included 31 critically ill intubated patients. Each study subject was first placed in a neutral starting position with a 30º head elevation. Then, they were subjected to a sequential change in body position based on the 16 most used positions as part of the critical care unit's (CCUs) daily routine. Endotracheal tube cuff pressure was measured after each position change. Data were analyzed using standard statistical tests. Results: Statistically significant difference in ETCP was observed during anteflexion of neck, hyperextension of neck, left lateral flexion of neck, right lateral flexion of neck, left lateral rotation of neck, right lateral rotation of neck, 10o recumbent position, supine position, Trendelenburg position, and right lateral 30° and 45° positions. Maximum increase in ETCP was seen during anteflexion of neck (31 ± 4.5; 22-42 cm H2O). Conclusion: Our study demonstrates significant deviations in ETCP from the recommended range following changes in the body position of mechanically ventilated patients, highlighting the need for the measurement of ETCP after each position change and maintenance of the same within the target range. How to cite this article: Roy O, Dasgupta S, Chandra A, Biswas P, Choudhury A, Ghosh S, et al. Relationship of Endotracheal Tube Cuff Pressures with Changes in Body Positions of Critically Ill Patients on Mechanical Ventilation: An Observational Study. Indian J Crit Care Med 2024;28(1):36-40.

Multiple cutaneous and uterine leiomyomatosis: Reed's syndrome.

Reed's syndrome (RS) is a rare autosomal-dominant disorder characterised by multiple cutaneous and uterine leiomyomas, with a strong tendency for renal cell carcinoma (RCC) development. A woman in her 50s, who had previously undergone total abdominal hysterectomy due to multiple uterine leiomyomas, presented with painful nodules on her trunk and right arm for the past 6 years. These nodules were confirmed as leiomyomas through histopathology. Diagnosis of RS was established through clinicopathological correlation and positive family history, particularly her mother's. Early-onset uterine leiomyomas in patients with a similar family history should raise suspicion for RS, necessitating vigilant long-term follow-up. RCC detection requires mandatory renal imaging. Screening family members and providing genetic counselling are crucial.

Aseptic meningitis following spinal anaesthesia: An uncommon and challenging diagnosis.

Drug-induced aseptic meningitis (DIAM) or chemical meningitis following spinal anaesthesia has rarely been reported. DIAM is caused by meningeal inflammation due to intrathecally administered drugs or secondary to systemic immunological hypersensitivity. We hereby present a case of a young adult with aseptic meningitis following neuraxial anaesthesia possibly provoked by bupivacaine. The initial cerebrospinal fluid (CSF) picture revealed neutrophilic pleocytosis and normal glycorrhachia. CSF culture was negative. The patient was put on invasive mechanical ventilation and started on intravenous antibiotics. There was a rapid improvement in clinical condition without any residual neurological deficit within the next few days. Aseptic meningitis following neuraxial anaesthesia can be prevented by strict aseptic protocols and careful inspection of visible impurities while administering the intrathecal drug. Detailed history taking, clinical examination, and focused investigations can distinguish between bacterial and chemical meningitis. Appropriate diagnosis of this entity may guide the treatment regimen, reducing hospital stay and cost.

Rational quality and cost of critical care systems are more important than individual considerations: a view from India.

Critical or Intensive Care Units (CCU/ICUs) play a crucial role in treating critically ill patients, but they contribute significantly to healthcare costs. In India and many other resource-limited countries, private ICU treatment is largely unaffordable for the poor and even a section of the middle class, who are not substantially insured. It is essential for all stakeholders involved in critical care to prioritize quality and cost-effectiveness. To ensure quality assurance, legally binding quality standards must be developed collaboratively by the government, professional bodies, hospital administrators, and domain experts. Regulatory benchmarks relevant to different types of ICUs can enforce adherence and transparency. Telemedicine, referral systems, and interhospital transport need improvement. Addressing attrition rates among staff and greater empowerment of formally qualified registered intensivists in the private hospitals can enhance outcomes and cost control. Long-term post-ICU recovery care is often unaffordable or unavailable in many parts of the world. Engaging families in home care and providing training in basic caregiving tasks can improve outcomes and reduce costs. In areas with limited access to qualified professionals, training of lay community caregivers and practitioners can be beneficial. Multidisciplinary post-ICU clinics and necessary telephonic handholding can support home-based patients and their families. Standardizing prices of essential necessities and promoting rational practices are crucial. System-wide efforts and novel approaches like decentralization of critical care services are necessary to ensure holistic quality and cost-effectiveness, particularly in densely populated countries with resource limitations. These innovations will not only improve care but also enhance preparedness for future pandemics.

Dengue and Scrub Typhus Coinfection: A Diagnostic Dilemma.

Due to overlapping clinical features, scrub typhus infection may be missed in presence of dengue. Concurrent infection with those two pathogens is rare and creates a diagnostic dilemma. We present a case of a 65-year-old male who was admitted with a high-grade fever and maculopapular rash. A complete hemogram revealed thrombocytopenia with raised hematocrit and positive diagnostic tests for dengue. The patient was treated conservatively with intravenous fluids and antipyretic medications in response to which the hematocrit improved, and the rash disappeared. But fever with thrombocytopenia continued to persist. On further clinical examination, a small eschar was noted on his abdomen. Doxycycline was started upon which the fever subsided, and thrombocytopenia improved. This case illustrates the importance of early recognition of coinfection in unremitting febrile illness in tropical countries to prevent potentially dangerous complications.

Loeffler's Syndrome and Multifocal Cutaneous Larva Migrans: Case report of an uncommon occurrence and review of the literature.

Cutaneous larva migrans (CLM) is a zoonotic skin disease that is frequently diagnosed in tropical and subtropical countries. Loeffler's syndrome (LS) is a transient respiratory ailment characterised by pulmonary infiltration along with peripheral eosinophilia and commonly follows parasitic infestation. We report a 33-year-old male patient who presented to a tertiary care hospital in eastern India in 2019 with LS that was attributed secondary to multifocal CLM. Treatment with seven-day course of oral albendazole (400 mg daily) coupled with nebulisation (levosalbutamol and budesonide) led to complete resolution of cutaneous lesions and respiratory complaints within two weeks. There was complete resolution of pulmonary pathology at four-weeks follow-up.

Gram-negative bacillary meningitis in an immunocompetent adult.

Escherichia coli is a rare cause of community-acquired meningitis comprising about 1% of adult cases. However, it is a common pathogen in neonatal meningitis and in nosocomial setting (especially after penetrating craniocerebral injury or subsequent to neurosurgical procedures). We report a middle-aged woman, who was admitted with features of acute meningitis and subsequent investigations revealed E. coli growth in cerebrospinal fluid culture. The case is distinctive as no additional predisposing risk factors associated with gram-negative bacillary meningitis (traumatic brain injury, neurosurgical procedures, malignancy, immunosuppressive therapy, HIV infection, chronic alcoholism and diabetes) were present. She was treated with intravenous antibiotics as per sensitivity reports and discharged in clinically stable condition, without any residual neurological deficit.

Transverse erythronychia: A unique nail manifestation of COVID-19 infection and brief review of COVID-19 associated nail changes.

Over the past 2 years, a plethora of mucocutaneous manifestations have been described to be associated with coronavirus 2019 (COVID-19) infection. Nail changes attributed to COVID-19 have rarely been documented in the literature. We describe here a unique nail finding 'transverse erythronychia' due to COVID-19 and review the literature on the diverse nail pathology attributed to the disease.

Bickerstaff encephalitis: An uncommon sequalae of a bacterial infection.

Bickerstaff brainstem encephalitis (BBE) is a rare neurological disorder characterised by the presence of the triad of ophthalmoplegia, ataxia and altered consciousness. It is thought to be associated to an autoimmune condition triggered by an antecedent infection. Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi, and it is associated with myriads of neurological complications. We hereby present an unusual case of BBE in a young lady, who was probably a sequalae of scrub typhus infection. Bickerstaff brainstem encephalitis in association with scrub typhus has not been reported till date.