Diaphragmatic excursion: does it predict successful weaning from mechanical ventilation?

Objective: To measure the diaphragmatic excursion and its outcome on weaning from mechanical ventilation

Study Design: Cross-sectional comparative study

Place and Duration of Study: Medical Intensive Care Unit [ICU], Military Hospital [MH], Rawalpindi, Pakistan, from January to December 2014

Methodology: Diaphragmatic excursion [DE] in cm was measured through ultrasound by marking liver and spleen displacement in patients who fulfilled the criteria of removal from ventilatory support. The patients were followed up for 48 hours and classified according to the outcome as successful weaning and weaning failure

Results: Out of 100 cases, 76 patients had a successful weaning while 24 had a failed weaning outcome. At a diaphragmatic excursion of 1.2 cm and more, out of 67 cases, 60 had a successful weaning [89.55%] while 7 cases [10.45%] had a weaning failure. At an excursion of less than 1.2 cm, 17 out of 33 cases [51.5%] had successful weaning while 16 [48.48%] had weaning failure. At this cut off point [1.2 cm], the sensitivity and specificity for successful weaning were 78.95% and 70.83%, respectively. The positive and negative likelihood ratio [LR] for these values being 2.70 and 0.29, respectively. The positive predictive value was 82.35% and negative predictive value 60.00%

Conclusion: Ultrasonographic measurement of diaphragmatic excursion is a good method for predicting weaning outcome from mechanical ventilation

Frequency of positive tuberculin skin test in BCG-vaccinated asymptomatic adults in Pakistan

To determine the frequency of positive tuberculin skin test [TST] in BCG-vaccinated asymptomatic healthy Pakistani adults. Cross sectional study. The study was carried out in Military Hospital, Rawalpindi in 2008 over six months. One hundred and thirty six individuals fulfilling inclusion and exclusion criteria of study were recruited after consent. They were subjected to TST [Mantoux test] and results were interpreted after 72 hours of injection. Test was recorded as positive if the indurated area was >/= 10 mm, and strongly positive if >/= 15 mm. All participants were male with the mean age of 26.35 +/- 6.164 years. The overall frequency of positive TST was 41.2%. Out of these, 9.6% were strongly positive. In healthy, BCG-vaccinated adult Pakistani population, TST is found to be positive in high frequency, and even induration of more than 15 mm was seen in significant number. In view of low specificity, TST should not be relied upon for the diagnosis of active tuberculosis [TB]

Bilateral emphysematous pyelonephritis

A 63 year old male, known diabetic for 10 years and a known case of Ischemic Heart Disease for almost same duration, on regular treatment presented in a peripheral hospital with 4 days history of jerky movement of left half of body, fever, cough and urinary incontinence. Examination revealed bibasal crackles in chest; tenderness in right lumber region and upper motor neuron type weakness in left half of body. Investigations revealed Hb 15.1, TLC 17.8, platelet count of 28,000, numerous RBCs and Pus cells in urine. LFTs were normal. There was no ketonuria and DIC screen was negative. Serum urea and creatinine done on alternate days showed a rising trend with max serum urea 34.8 mmol/L and serum creatinine 1138 umol/L five days following admission. Hepatitis serology was negative. Culture of urine showed growth of Escherichia coli as well as candida species. CT scan Brain revealed right Parietal lobe infarct. USG Abdomen revealed air lucencies in subcapsular and cortical region of both kidneys suggesting bilateral emphysematous pyelonephritis. CT scan abdomen confirmed bilateral emphysematous pyelonephritis [R>L] with extension of air lucencies in perinephric spaces and prominence of gerota's fascia bilaterally. Right kidney was at the verge of bursting. Case was discussed with Urologist and Anesthetist but patient was unfit for surgery because of existing comorbid conditions. Aggressive conservative management was started including antibiotics [intravenous Tazocin] based on urine c/s and intravenous Fluconazole alongwith alternate