Epidural Steroid Injection-Procedure-related Stress (Takotsubo) Cardiomyopathy: A Rare Case.

Stress cardiomyopathy/Takotsubo cardiomyopathy (TC) is a transient and reversible acute heart failure provoked by physical or emotional stress. This case report highlights about a patient who experienced sudden onset chest pain and breathlessness following epidural steroid injection for pain secondary to prolapsed intervertebral disc. Initial clinical features, electrocardiogram, troponin levels, and transthoracic echocardiography showed features suggestive of acute coronary syndrome but the coronary angiogram was normal. The diagnosis of stress cardiomyopathy was made and managed successfully. This case report highlights one of the rare cases of procedure-related early stress cardiomyopathy. Early diagnosis and management reduce morbidity and mortality. How to cite this article: Prashanth S, Venkategowda PM. Epidural Steroid Injection-Procedure-related Stress (Takotsubo) Cardiomyopathy: A Rare Case. Indian J Crit Care Med 2022;26(4):524-525.

Intestinal mucormycosis in an adult with H1N1 pneumonia on extracorporeal membrane oxygenation.

Gastrointestinal mucormycosis involving ileum is a very rare phenomenon. We present a case of 52-year-old male, known case of diabetes mellitus requiring extracorporeal membrane oxygenation (ECMO) for H1N1 pneumonia with severe acute respiratory distress syndrome (ARDS). The patient had small bowel obstruction with impending perforation requiring emergency bowel resection and ileostomy. The resected bowel segment histopathology showed mucormycosis. He was treated with conventional Amphotericin-B and later changed to Posaconazole. The patient responded very well and was gradually weaned from ventilator and successfully discharged home. This case report highlights rare site of mucormycosis. Early diagnosis and timely intervention can reduce mortality.

Severe Amlodipine Toxicity: A Case Rescued with Extracorporeal Membrane Oxygenation.

Amlodipine is a widely prescribed drugs for the management of hypertension. Its toxicity is associated with severe myocardial depression and refractory hypotension. We present a case of a 28-year-old female known case of seizure disorder and depression who got admitted to our hospital with a history of consumption of 80 tablets of 5 mg amlodipine (total 400 mg). Patient presented to our hospital after 23 hours following consumption of the drug. Patient was managed in the intensive care unit (ICU) with mechanical ventilation support and intravenous infusion of noradrenalin, adrenalin, insulin-dextrose, and calcium gluconate. Due to refractory hypotension, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated on the same day. Patient was successfully managed and discharged home on the 8th day. This report highlights a rare case of a massive amlodipine overdose (400 mg) and ECMO as a rescue therapy. HOW TO CITE THIS ARTICLE: Sutar A, Venkategowda PM, Murthy A, Chikkaswamy SB. Severe Amlodipine Toxicity: A Case Rescued with Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(5):365-366.

Prone position and pressure control inverse ratio ventilation in H1N1 patients with severe acute respiratory distress syndrome.

AIM: To observe the 28 and 90 days mortality associated with prone position and assist control-pressure control (with inverse ratio) ventilation (ACPC-IRV). MATERIALS AND METHODS: All patients who were admitted to our medical Intensive Care Unit (ICU) who are positive for H1N1 viral infection with severe acute respiratory distress syndrome (ARDS) and requiring invasive mechanical ventilation in prone position were included in our prospective observational study. Six patients who are positive for H1N1 required invasive ventilation in prone position. These patients were planned to ventilate in prone for 16 h and in supine for 8 h daily until P/F ratio >150 with FiO2 of 0.6 or less and positive end-expiratory pressure <10 cm of H2 O. RESULTS: At admission, among these six patients the mean tidal volume generated was about 376.6 ml which was in the range of 6-8 ml/kg predicted body weight. The mean lung injury score was 3.79, mean PaO2 /FiO2 ratio was 52.66 and mean oxygenation index was 29.83. The mean duration of ventilation was 9.4 days (225.6 h). The ICU length of stay was 11.16 days. There was no mortality at 28 and 90 days. CONCLUSION: Early prone combined with ACPC-IRV in H1N1 patients having severe ARDS can be used as a rescue therapy and it should be confirmed by large observational studies.

Scrub typhus: Clinical spectrum and outcome.

BACKGROUND: Scrub typhus is one of the differential diagnoses for fever with thrombocytopenia. ARDS associated with Scrub typhus has high morbidity and mortality. AIMS: To evaluate clinical features, lab values, and outcome in patients with scrub typhus and comparison in patients with or without ARDS. METHODS: A prospective observational study was conducted on 109 patients with febrile illness and thrombocytopenia during a period of 12 months. All 109 patients were tested with both Immune-chromatography test and Weil felix test. Patients having either Immune-chromatography test/Weil felix test positive have been included and considered as scrub typhus positive whereas negative for both Immune-chromatography and Weil felix test were excluded. Clinical features, lab parameters, and outcome were evaluated in all patients with scrub typhus. Statistical analysis used in this study was T-test. RESULTS: Among 58 patients who were included (After exclusion of 51 patients among total of 109 patients) 34 patients had no ARDS and 24 patients had ARDS. The clinical feature like dyspnoea, cough, low blood pressure (MAP<65 mmHg), IVC collapsibility (by ultrasound) and laboratory parameters like decreased Hemoglobin, Hematocrit, Serum albumin, and increased serum creatinine, serum total bilirubin, SGOT, SGPT, LDH, CPK, and serum lactate were statistically significant (P < 0.0001) in scrub typhus patients group with ARDS. The higher titers of Weil-felix can be correlated with more severe form of disease according to our observation. All 34 Scrub typhus patients without ARDS recovered completely. Among 24 Scrub typhus patients with ARDS, 22 patients recovered, and 2 patients died. CONCLUSION: Scrub typhus is an important differential diagnosis in a patients having fever with thrombocytopenia. Scrub typhus associated with ARDS has high morbidity and mortality. Early diagnosis and treatment with doxycycline can prevent the occurrence of ARDS.

Laryngeal air column width ratio in predicting post extubation stridor.

AIM: Correlation of upper air column width ratio in postextubation stridor patients. MATERIALS AND METHODS: A prospective observational study was conducted in a tertiary hospital between January and December 2013. Patients who were admitted in Intensive Care Unit and intubated for >24 h were included (72 patients). The upper airway air column width ratio (air column width before extubation/air column width after intubation) was calculated and compared in patient with or without postextubation stridor. RESULTS: The incidence of stridor was 6.9% (5/72). The duration of mechanical ventilation was 5.60 ± 1.14 days and 3.91 ± 1.45 days in stridor and nonstridor group respectively. In all 5 patients who had stridor, the upper airway air column width ratio was 0.8 or less. CONCLUSION: Air column width ratio of 0.8 or less may be helpful in predicting postextubation stridor, which should be confirmed by large observational studies.

Optic nerve sheath diameter as a marker for evaluation and prognostication of intracranial pressure in Indian patients: An observational study.

BACKGROUND AND AIMS: The aim was to evaluate efficacy of optic nerve sheath diameter (ONSD) by ultrasound as a noninvasive method for detecting raised intracranial pressure (ICP) in intensive care unit, to compare with computed tomography/magnetic resonance imaging (MRI) findings of raised ICP and to prognosticate ONSD value with treatment. MATERIALS AND METHODS: We conducted a prospective, observational study on 101 adults by including 41 healthy individuals in group A as control and 60 patients in group B admitted with fever, headache, vomiting, and altered sensorium. We examined them in supine position using 10 MHz linear array probe on closed eyelid. ONSD was measured 3 mm behind the globe in each eye. A mean binocular ONSD > 4.6 mm in female and 4.8 mm in male was considered abnormal. Midline shift, edema, effacement or ONSD > 5.0 mm on T2 MRI suggestive of elevated ICP was used to evaluate ONSD accuracy. RESULTS: Group A mean ONSD was 4.6 mm in females and 4.8 mm in males. Group B mean ONSD for 17 females was 5.103 ± 0.6221 mm (P = 0.002) and for 43 males 5.081 ± 0.5799 mm (P = 0.032). Radiological sign of raised ICP was confirmed in 35 patients (females = 11 and males = 24) with high ONSD value. Sensitivity of detecting raised ICP by ONSD was 84.6% in females and 75% in males while specificity was 100% in both genders. Out of 25 patients without radiological signs of raised ICP 10 patients showed high ONSD (females = 4.735 mm and males = 4.907 mm). ONSD was well prognosticated with treatment modalities. CONCLUSION: Bedside ocular ultrasonography for measuring ONSD can be used an early test for diagnosing raised ICP as it is a noninvasive, cost effective bedside test, which can be repeated for re-evaluation.

Unexpected events occurring during the intra-hospital transport of critically ill ICU patients.

BACKGROUND: Intra-hospital transport of critically ill patients is a challenging task. However, despite the improvements in intra-hospital transport practices, adverse event incidents remain high and constitute a significant risk for the transport of the critically ill ICU patients. OBJECTIVES: To observe the number and types of unexpected-events (UEs) occurring during intra-hospital transport of critically ill ICU patients. Interventions provided along with outcome. MATERIALS AND METHODS: This was a prospective observational study of 254 intra-hospital critically-ill ICU patients of our hospital transported for diagnostic purposes during April 2012 - March 2013. The escorting intensivist completed the data of unexpected events during transport. RESULTS: A total of 254 patients were observed prospectively for UEs during intra-hospital transfer of critically ill patients. The overall UEs observed were 139 among 64 patients. Among the UEs which occurred, the maximum were miscellaneous causes [89 (64.00%)] like oxygen probe [38 (27.33%)] or ECG lead displacement [27 (19.42%)]. Major events like fall in spo2 >5% observed in 15 (10.79%) patients, BP variation > 20% from baseline in 22 (15.82%) patients, altered mental status in 5 (3.59%), and arrhythmias in 6 (4.31%) patients. Among 64 (100%) patients with UEs, 3 (2.15%) patients with serious adverse events have been aborted from transport. CONCLUSION: Unexpected-events (UEs) are common during transport of critically ill ICU patients and these adverse events can be reduced when critically ill patients are accompanied by intensivist/medically qualified person during transport and following strict transport guidelines.

Glyphosate surfactant herbicide poisoning and management.

Glyphosate is a widely used herbicide in agriculture, forestry, industrial weed control and aquatic environments. Glyphosate potential as herbicide was first reported in 1971. It is a non-selective herbicide. It can cause a wide range of clinical manifestations in human beings like skin and throat irritation to hypotension, oliguria and death. We are reporting a case of a 35-year-old male patient who was admitted to our tertiary care hospital following intentional ingestion of around 200 ml of herbicide containing glyphosate. Initially, gastric lavage done and the patient was managed with intubation and mechanical ventilation, noradrenaline and vasopressin infusion, continuous veno-venous hemodiafiltration and intravenous (IV) lipid emulsion (20% intralipid 100 ml), patient was successfully treated and discharged home. This case report emphasizes on timely systemic supportive measure as a sole method of treatment since this poison has no known specific antidote and the use of IV lipid emulsion for a successful outcome.