Hyponatremia in ICU.

Background: Hyponatremia is defined as serum sodium level <135 meq/L. It is the most common electrolyte abnormality seen in hospital admissions worldwide. The proportion is even higher in the ICU setting. A wide variety of factors influence the outcome of the hyponatremic patient. Present study is designed to approach to analyse etiology, clinical features, co-morbid factors, severity of hyponatremia, rate of correction, and impact of treatment on outcome of these diverse group of patients in ICU. Aims: 1) To find proportion of patients presenting with hyponatremia and requiring medical ICU admission in a tertiary care set up. 2) To study the etiology and clinical features of hyponatremia in patients requiring ICU admission. 3) To compare and study the effect of various factors on the outcome of hyponatremic patients in the ICU. Methods: This study was a cross-sectional observational study in tertiary care hospital. All indoor general medicine ward admissions over a period of 18 months were screened for the presence of hyponatremia and patients requiring Medical ICU care and satisfying inclusion criteria were studied. Serial serum electrolytes and urine sodium were tested for all patients in the ICU satisfying the inclusion criteria. Type of fluid given and daily correction of serum sodium of all patients were noted. Outcome was measured in terms of mortality, duration of stay in ICU, number of days required for sodium correction and complications of treatment if any. Patients were followed up till hospital discharge or death.. Results: In this study, 5.2% of total admissions had hyponatremia. Among the ICU admissions, the different symptoms attributed to hyponatremia included nausea (69.3%), malaise (80%), drowsiness (61.3%), confusion (41.3%), lethargy (24%), frequent falls (1.3%), convulsions (2.7%), altered sensorium (41.3%) and delirium (9.3%). SIADH was the most common cause of hyponatremia in these patients (32%). Serum sodium levels of patients on admission ranged from 82 - 133 meq/L, with average serum sodium being 124meq/L. Overall mortality among the hyponatremic ICU admissions was 26/75, 34.6%, which was higher than the total ICU mortality of 26% in same duration (p = 0.1). There was a significant increase in duration of stay in ICU in patients with various co-morbidities (p=0.003). There was a significant association between Glasgow Coma Scale (GCS) and serum sodium levels, (p = 0.002). Blood pressure and hydration status did not significantly influence outcome. Lower serum sodium on admission was associated with a lower survival (p= 0.041). Sodium correction of < 5 m eq/day was associated with an increased mortality(p = 0.04), whereas sodium correction of > 10 m eq/day was not associated with increased mortality, but an increased risk of EPM, which was seen in one patient. Conclusion: Most common cause of hyponatremia in ICU patients is SIADH. Longer duration of stay is seen in the presence of different co-morbidities. A lower GCS and a lower serum sodium on admission is associated with lower survival. Type of fluid used for hyponatremia correction did not influence the outcome. Under correction of hyponatremia in first 24 hours or inadequate correction was associated with a poorer outcome. Overcorrection was not associated with any survival benefit, but was associated with risk of EPM.

Snake Bite Envenomation in a Tertiary Care Centre.

Background: In India, it is estimated that up to 20,000 people die annually from snake bites. The present study was carried to out to estimate the snake bite related epidemiology, predictors of severity, relationship between type of snake, clinical severity, complications, outcome and usage pattern of polyvalent anti snake venom (ASV) in a tertiary care center. Methods: All indoor patients admitted in our institute with definitive history of bite by a snake, with or without presence of fang marks, Evidence of cellulitis, acute onset of neurotoxicity or bleeding diathesis were serially recruited in the study. Results: The majority of cases were in the range of 21- 40 years (54.7%). There were 82.8% males (53/64), 17.2% females (11/64) and 60.9% (39/64) bites were during day time. Upper limb bites were seen in 34% (22/64) of the patients and lower limb bites in 54% (35/64), and axial body bites in 6%. There were 43.8% (28/64) vasculotoxic bites, 34.4% (22/64) neurotoxic bites and 20.3% (14/64) non-poisonous bites. Viper was the most common (9%) identified snake, followed by krait (5%). References from Rural Health Centers were 57.8% (57/64), 11% were from Primary health centers and rest from private sector. Anti snake venom (ASV) was received by 68.75% (44/64) patients before reaching tertiary care. Local swelling was present in 90.6% (58/64) patients, Systemic bleeding was seen in 35.9% (23/64), and Neuromuscular weakness in 35.9% (23/64) patients. Complications like Respiratory paralysis developed in 18.75% (12/64), Acute kidney injury in 12% (8/64), DIC in 9% (6/64), and hepatic involvement in 7% (5/64) of snake bite patients. Blood transfusion was required in 20.3% (13/64) p<0.001), 18.75% (12/64) required Mechanical ventilation (p=0.001), 4 received hemodailysis and 4 required ionotropic support (p<0.001). Improvement was seen in 57.8% (37/64), morbidity during hospital stay was seen in 39% (25/64) and 2 patients expired (3%). ASV was received within 4 hours in 67% (42/64) patients, 22.5% (14/64) received ASV between 4 to 24 hours and remaining after 24 hours (p=0.016). Total ASV requierment was 24.05 vials in patients who improved and 34.4vials in patients in Morbid group and 29.0 vials in mortality group (p>0.05). The SSS score amongst improved was 4.76 ± 2.46 whereas among morbid, it was 8.48 ± 1.75 and amongst expired, it was 8.5 ± 0.707 (p<0.05). Conclusions: Patients requiring various supportive treatments like blood transfusion, Inotropes, Haemodialysis and Mechanical ventilation, had a statistically significant correlation with poor outcome. Early administration of ASV that is within 4 hours was, associated with better outcome. The total amount of ASV (in vials) had no a significant correlation with outcome. Snakebite Severity Score correlates significantly with early recovery in vasculotoxic snake bites (p=0.03).

Mortality in Malaria: Intensive Care (MIMIC).

Background: While global incidence of malaria has fallen in last decade, it continues to be an important cause of mortality and morbidity in acutely ill febrile patients. Many patients with complicated malaria require ICU care. In past it was believed that vivax is a benign form of malaria, but now all complications of malaria are reported in vivax. . Aims and Objectives: 1. To find out proportion of patients with plasmodium vivax and plasmodium falciparum malaria requiring treatment in Medical ICU. 2. To compare clinical profile and severity of illness in these patients. 3. To study treatment received including organ support requirement in these patients and compare outcome in patients with vivax and falciparum malaria. Results: During study period total 932 patients were diagnosed as confirmed malaria (601 vivax, 240 falciparum and 91 mixed) and 107 (vivax 74, falciparum 20, mixed 13) required ICU admission. Common symptoms observed apart from fever were, oliguria (48), dyspnea(41), bleeding (29), hemoptysis (15) and petechial rash (13). Mean BUN and creatinine and PT INR of falciparum/mixed malaria patients was significantly higher and HCO3 and pH significantly lower than vivax patients. But PaO2/FiO2 of vivax patient was significantly lower as compared falciparum/mixed patients. There was no significant difference between two groups with regards to requirement of supportive treatment like inotropes (11/70 vs 5/30, p=0.858), mechanical ventilation (28/70 vs 7/30, p=0.17), platelet transfusion (24/70 vs 9/30, p=0.853) and renal replacement therapy (5/70 vs 3/30 p=0.936). Out of 100 patients, 21 patients expired. Mortality in mixed malaria group (4/12, 33.3%) and vivax group ( 16/70, 22.9%) was more as compared to falciparum group (1/18, 5.6%, < 0.05). Conclusions: Incidence of Plasmodium vivax malaria is higher compared to falciparum malaria in hospitalized patients and higher percentage of these need ICU care. Most common complications of malaria are thrombocytopenia followed by renal failure, hepatic dysfunction, ARDS, shock and cerebral dysfunction respectively. Mortality was higher in vivax and mixed malaria compared to falciparum. Higher SOFA score (Sequential organ failure assessment score), lower GCS score (Glasgow coma scale), hypotension, ARDS and metabolic acidosis are predictors of mortality.

Metronidazole-Induced Encephalopathy in Chronic Diarrhoea.

Metronidazole-induced encephalopathy (MIE) is a rare cause of drug-induced toxic encephalopathy. We report the clinical and neuroimaging findings of a patient with chronic diarrhoea who developed metronidazole-induced encephalopathy. After the drug was discontinued there was complete reversal of the condition.

Intravenous administration of ulinastatin (human urinary trypsin inhibitor) in severe sepsis: a multicenter randomized controlled study.

PURPOSE: Ulinastatin, a serine protease inhibitor, inhibits several pro-inflammatory proteases and decreases inflammatory cytokine levels and mortality in experimental sepsis. We studied the effect of ulinastatin on 28-day all-cause mortality in a double-blind trial in patients with severe sepsis in seven Indian hospitals. METHODS: Patients with sepsis were randomized within 48 h of onset of one or more organ failures to receive intravenous administration of ulinastatin (200,000 IU) or placebo 12 hourly for 5 days. RESULTS: Of 122 randomized subjects, 114 completed the study (55 receiving ulinastatin, 59 receiving placebo). At baseline, the mean APACHE II score was 13.4 (SD = 4.4), 48 (42 %) patients were receiving mechanical ventilation, 58 (51 %) were on vasopressors, and 35 % had multiple organ failure. In the modified intention-to-treat analysis (patients receiving six or more doses of study drugs), 28-day all-cause mortality was 7.3 % with ulinastatin (4 deaths) versus 20.3 % (12 deaths) with placebo (p = 0.045). On multivariate analysis too, treatment with ulinastatin (odds ratio 0.26, 95 % CI 0.07-0.95; p = 0.042) independently decreased 28-day all-cause mortality. However, the mortality difference did not reach statistical significance in the intention-to-treat analysis [10.2 % (6/59 deaths) with ulinastatin versus 20.6 % (13/63 deaths) in the placebo group; p = 0.11]. The ulinastatin group had lower incidence of new-onset organ failure (10 vs. 26 patients, p = 0.003), more ventilator-free days (mean ± SD 19.4 ± 10.6 days vs. 10.2 ± 12.5 days, p = 0.019), and shorter hospital stay (11.8 ± 7.1 days vs. 24.2 ± 7.2 days, p < 0.001). CONCLUSIONS: In this pilot study, intravenous administration of ulinastatin reduced mortality in patients with severe sepsis in the modified intention-to-treat analysis, but not in the intention-to-treat analysis.

Bilateral breast in brothers - abreast.

Gynecomastia is a common occurrence in pubertal age group, and is physiological in up to 65 percent of cases. When occurs in the family it should be investigated in order not to miss on a treatable etiology. Two brothers within the same family, presenting with bilateral gynecomastia of different causes and requiring different treatment are presented.

Efficacy and safety of intravenous ulinastatin versus placebo along with standard supportive care in subjects with mild or severe acute pancreatitis.

BACKGROUND: Ulinastatin is reported to inhibit pro-inflammatory markers and also inhibits coagulation and fibrinolysis. The drug is available in East Asia for the treatment of acute pancreatitis. AIM: To study the effect of addition of ulinastatin to standard care on mortality and morbidity in Indian subjects with acute pancreatitis. DESIGN: Randomized, double-blind, placebo-controlled, multi-centre trial across 15 centres in India. METHODS: Subjects, aged 18 to 70 years, with acute pancreatitis and elevated serum C-reactive protein (CRP) levels, were eligible for enrolment. Acute pancreatitis was diagnosed if the patient had at least two of the following criteria: suggestive abdominal pain, serum amylase and/or lipase > 3 times upper limit of normal, and imaging findings of acute pancreatitis. Subjects were classified as having mild or severe acute pancreatitis on the basis of the APACHE II score (< 8 mild, > or = 8 severe). Standard care was given to all subjects as per the treating physician's protocol. Eligible subjects were randomized to receive intravenous infusion of 200,000 IU ulinastatin or placebo in 100 mL of 0.9% saline given over one hour every 12 hours for 5 days. RESULTS: Of 135 randomized subjects, 129 completed the study (mild 62, severe 67). Pancreatitis was due to alcohol intake in a majority (81%) of subjects. Baseline characteristics were similar between the ulinastatin and placebo groups. Efficacy was evaluated in subjects who had received at least 3 days (6 doses) of ulinastatin/placebo. One subject with severe pancreatitis in the ulinastatin group versus six in the placebo group died (p = 0.048). New organ dysfunction developed in 5 ulinastatin vs 4 placebo group subjects (p = 0.744) with mild pancreatitis and 12 ulinastatin vs 29 placebo group subjects (p = 0.0026) with severe pancreatitis. Adverse events were significantly lower in subjects with severe pancreatitis in the ulinastatin group as compared to the placebo group (p = 0.00001). Reduction in serum CRP was not different between the groups. Median hospitalization was shorter by one day in the ulinastatin group; the difference was not significant. There was no infusion-related adverse event. CONCLUSIONS: Ulinastatin prevents new organ dysfunction and reduces mortality in subjects with severe pancreatitis.

An unusual cause of flash pulmonary oedema.

We report a case of young woman who presented with acute cardiogenic pulmonary oedema and respiratory failure. She underwent emergent endotracheal intubation and was transferred to the intensive care unit. She responded to intravenous diuretics and positive pressure ventilation. Subsequent workup revealed that she had Graves' disease and was in thyrotoxic crisis. Therapy with propranolol and propylthiouracil was instituted to which she showed remarkable improvement.

Acute aortic syndrome--penetrating atherosclerotic ulcer with contained rupture managed by endovascular stent-grafting.

We present the case of a hypertensive male who came with acute onset of severe backache and hypotension. Emergency imaging revealed a penetrating atherosclerotic ulcer of descending thoracic aorta with contained rupture and bilateral hemothorax. Initially stabilised with medical management, this patient went on to undergo endovascular stent-grafting. The sequence of clinical events of this uncommon entity and the relatively novel interventional modality are reviewed.

Reversible steatohepatosis in a young boy with brittle type 1 diabetes mellitus: mauriac syndrome.

A 14-year-old male, diagnosed case of type 1 diabetes mellitus since 1 year, presented with uncontrolled blood glucose levels, non-compliance with insulin therapy and recurrent admissions with diabetic ketoacidosis. His blood glucose levels were difficult to control with wide fluctuations in insulin requirement. He had absent secondary sexual characteristics and hepatomegaly. Liver biopsy showed macrovesicularsteatosis without fibrosis or inflammation. Many glycogenated nuclei were present. He was started on intensive insulin therapy, whereby he showed subsequent regression of hepatomegaly and onset of pubertal spurt.

Pancreatic ascites in the setting of portal hypertension.

Pancreatic ascites is a rare cause of ascites and develops largely as a complication of chronic pancreatitis or sometimes due to duct injury during surgical procedures. The entity may mimic spontaneous bacterial peritonitis or ascites due to portal hypertension. Here, the authors discuss a case of pancreatic ascites developing in the setting of alcoholic liver disease with portal hypertension. The patient had features of chronic pancreatitis with pancreatic duct fistula and was managed with stenting of the pancreatic duct.

Renal tubular acidosis due to Wilson's disease presenting as metabolic bone disease.

Two sisters presented with lower limb deformity and difficulty in walking without support. Both had short stature; however, neurodevelopment and secondary sexual characters were normal. Abdominal examination revealed splenomegaly and ophthalmic examination showed presence of Kayser-Fleischer (K-F) rings. Diagnosis of Wilson's disease was confirmed with low serum copper and ceruloplasmin levels. Further investigations revealed urinary acidification defect with hypercalciuria pointing towards distal renal tubular acidosis. Both patients were started on copper chelation therapy and showed gradual radiographic improvement in osteopaenia.

Suprasellar tuberculoma presenting as panhypopituitarism.

Suprasellar tuberculomas are exceptionally rare. We present the case of a middle aged male who presented with generalised apathy and meningism of two weeks duration. Neuroimaging was suggestive of tuberculomas in suprasellar cistern, while endocrinological investigation showed panhypopituitarism manifesting as pituitary hypothyroidism, hypocortisolism, and hyperprolactinemia. Cerebrospinal fluid examination showed lymphocytic reaction with raised proteins. A diagnosis of suprasellar tuberculoma with panhypopituitarism was made. The patient was started on antituberculous treatment and hormone replacement which led to remarkable improvement in condition of patient and resolution of tuberculous granuloma in follow up imaging.