Journal of Nepalese Society of Critical Care Medicine

Linezolid for treatment of ventriculoperitoneal shunt meningitis caused by Methicillin resistant Staphylococcus aureus not responding to Vancomycin.

Niraj Kumar Keyal — 2024-01-24

Methicillin resistant Staphylococcus aureus is a common cause of ventriculoperitoneal shunt meningitis. It carries high morbidity and mortality. We present a case of 8-year male who presented with extradural hematoma secondary to trauma. The patient underwent craniotomy and evacuation of hematoma. Ventriculoperitoneal shunt was placed for hydrocephalus and was discharged home. After one month, he developed fever, abdominal pain and altered sensorium and was diagnosed as pyogenic meningitis secondary to Methicillin resistant Staphylococcus aureus. Patient was treated with Vancomycin and Meropenem and the shunt was exteriorized, but there was no clinical improvement over next three days. Linezolid was initiated. After two days, there was improvement in fever and headache. The distal end of shunt was removed. After 21 days of medical and surgical management of meningitis and hydrocephalus, patient was discharged home. Linezolid may be helpful as a second line treatment of Methicillin resistant Staphylococcus aureus associated ventriculoperitoneal shunt meningitis in patients who fail to respond to Vancomycin.

High carbohydrate diet induced hypokalemic periodic paralysis: A case report

Shikha K. Shah — 2024-01-24

Hypokalemic periodic paralysis (HypoKPP) is a rare disorder characterised by the sudden onset of muscle weakness associated with low serum potassium levels. A 54-year-old man was admitted to the hospital with an abrupt onset of weakness in his right upper and lower extremities which slowly progressed to involve his left upper and lower extremities. He reported having consumed a carbohydrate-rich meal the day before the episode. Laboratory tests indicated severe hypokalemia with a serum potassium level of 2.3 mEq/L. He was treated with intravenous potassium chloride and his paralysis resolved after correction of hypokalemia. The patient was discharged on potassium supplementation and dietary guidelines were advised.

Supporting critical care medicine in low-resource settings

Jean-Louis Vincent — 2024-01-24

Not available

Critical care management of acute ischemic stroke – An overview of current concepts

Deep Sengupta — 2024-01-24

Acute ischemic stroke is a major cause of morbidity and mortality globally. Early recognition and prompt revascularisation are the cornerstones of treatment. Advances in the management of stroke, notably with the endovascular interventions has led to improved functional outcomes. Identification of stroke subtype, timely decision making, institution of specific therapy and periprocedural care in an intensive care unit make the difference between a favourable and an unfavourable outcome. To this effect, dedicated stroke centres, multidisciplinary teams with trained experts and critical care management play an important role. Improvements in the understanding of the disease process, ever expanding literature and development of promising novel therapeutic strategies, not withstanding, stroke is still a leading cause of acquired long term disability and mortality worldwide. End of life care and associated decision making precariousness, pose a significant prognostication challenge to the critical care team. The aim of this review is to discuss the current evidence regarding diagnosis, revascularisation modalities and optimal critical care management strategies.

Admission time and outcomes of patients admitted to intensive care unit in a tertiary hospital in Nepal: an observational study

Ashmita Paudel — 2024-01-24

Background and aims: Time of admission to the intensive care unit may have a significant impact on the outcome. However, there is scarcity of published literature regarding admission hours and outcomes from low-income and middle-income countries like Nepal. The aim of this study was to compare the outcome of patients admitted to intensive care units at office hours and off hours.

Methods: This observational study was conducted in the intensive care units of Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Data from 1 January 2020 to 31 December 2022, over a period of three years, were curated from the ICU registry. Patients were divided into two groups based on the time of admission to intensive care unit: 1) office hours (from 9:00 am till 4:59 pm that day) and 2) off hours (5:00 pm to 8:59 am next day, including Saturdays and public holidays).

Results: Among 3733 patients admitted to ICU, 3242 patients were enrolled for analysis. There were no significant differences in mortality rate as well as average duration of mechanical ventilation between two groups. The average length of stay was however longer by 1 day among patients admitted during off hours compared to office hours.

Conclusion: The time of admission in ICU has no significant effect on the outcome of patients. Off hour ICU admission is not associated with poor patient outcomes compared to office hours.

Comparison of intravenous ketamine and fentanyl sedation in duration of mechanical ventilation in intensive care unit

Raveesh Mishra — 2024-01-24

Background and aims: To compare the duration of mechanical ventilation in patients receiving ketamine compared to fentanyl for sedation in mechanically ventilated patients in intensive care unit.

Methods: One hundred and six patients requiring mechanical ventilation were randomized to receive continuous intravenous infusion of either ketamine (1 mg/kg bolus followed by 0.4 to 0.8 mg/kg/h) or fentanyl (1mcg/kg bolus followed by 0.3-0.5 mcg/kg/min) with the dose titrated to achieve Richmond Agitation Sedation Scale (RASS) score of 0 to -1 and Behavioral Pain Scale (BPS) score of 3 to 7. The primary outcome was the duration of mechanical ventilation. Secondary outcomes were sedation score, analgesia score and need of vasopressors.

Results: The mean duration of ventilation was 2.5±0.6 days and 2.2±1.0 days (p=0.1) in patients receiving ketamine and fentanyl respectively. More patients required vasopressors: 27 (50.9%) vs 9 (17%) in patients receiving fentanyl compared to ketamine (p<0.05). There were no significant changes in hemodynamic variables after the initiation of the study drug in both the groups. Infusion was discontinued for adverse effects in seven (13%) patients in both the groups.

Conclusion: When compared with fentanyl, continuous ketamine infusion was tolerated similarly by critically ill adults, with similar duration of mechanical ventilation. Ketamine sedation was associated with decreased requirement for vasopressors.