Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3
Many patients develop hyponatremia during the course of their ICU management. Such groups of patients can be easily managed by increasing their dietary protein intake. Because of fixed urinary osmolarity in SIADH, increasing the dietary osmoles by increasing their dietary protein intake will lead to increase in urinary output and improvement in hyponatremia.[3] Moreover, increasing protein intake in critically ill will leads to better patient outcome. Studies have suggested that the use of higher protein concentration in nutritional therapy for critically ill patients may help to reduce mortality.[4,5]
Sunil Kumar Garg
Department of Medicine and Critical Care, Sarvodaya Hospital, Sector‑8, Faridabad, Haryana, India
Correspondence: Dr. Sunil Kumar Garg, 219, Pocket‑D, Mayur Vihar, Phase 2, New Delhi ‑ 110091, India. E‑mail: [email protected]
References 1.
2. 3. 4.
5.
Malhotra I, Gopinath S, Janga KC, Greenberg S, Sharma SK, Tarkovsky R. Unpredictable nature of tolvaptan in treatment of hypervolemic hyponatremia: Case review on role of vaptans. Case Rep Endocrinol 2014;2014:807054. Dahl E, Gluud LL, Kimer N, Krag A. Meta‑analysis: The safety and efficacy of vaptans (tolvaptan, satavaptan and lixivaptan) in cirrhosis with ascites or hyponatraemia. Aliment Pharmacol Ther 2012;36:619‑26. Berl T. Impact of solute intake on urine flow and water excretion. J Am Soc Nephrol 2008;19:1076‑8. Alberda C, Gramlich L, Jones N, Jeejeebhoy K, Day AG, Dhaliwal R, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observational study. Intensive Care Med 2009;35:1728‑37. Weijs PJ, Stapel SN, de Groot SD, Driessen RH, de Jong E, Girbes AR, et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: A prospective observational cohort study. JPEN J Parenter Enteral Nutr 2012;36:60‑8. Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152784
Rhabdomyolysis in lumbar spinal surgery: Early detection is crucial Sir, Rhabdomyolysis (RM) after neurosurgical procedure is a rare event. We report a case of RM following 190
lumbar surgery and discuss the importance of early recognition. A 22‑year‑old male underwent resection of L3 giant cell tumor in right lateral position. The patient weighed 96 kg with a body mass index (BMI) of 35.6 kg/m2 with no comorbidities. General anesthesia was administered with oxygen, nitrous oxide, isoflurane, propofol, and morphine. Surgery lasted for 9 h. On 1st postoperative day, he developed severe pain with a progressive increase in girth of the right thigh. Doppler study ruled out deep venous thrombosis. Next day, he developed tachycardia, tachypnea, and icterus. Concurrently, he had oliguria. Investigations showed a high serum creatinine (1.63 mg/dl), creatine phosphokinase (CPK) (29,100 U/L) and deranged liver function (total bilirubin 1.5 mg%, direct 0.5 mg%, aspartate aminotransferase 209 U/L, alanine aminotransferase 185 U/L, alkaline phosphate 372 U/L). A diagnosis of RM was made, and the patient was treated with liberal hydration to maintain urine output of at least 100 ml/h along with alkalinization of urine. Clinically and serologically, he started to improve and was ambulated and discharged in a week. There are only a few reported cases of RM after neurosurgical procedures, with several risk factors being proposed. Lateral positioning in posterior fossa tumor resection and minimally invasive spinal surgeries have been reported as probable cause in 9 patients.[1] Van Gompel et al. reviewed 10 cases of RM after neurosurgery in supine or prone positions for cranial and spinal pathologies, and found obesity and prolonged surgery as common risk factors.[2] Woernle et al. studied 150 patients with routine CPK analysis before and after surgery to determine the effect of position. They correlated raised CPK not only with lateral position, but also with the use of intraoperative monitoring, and hypothesized it to be due to the absence of pharmacological relaxation during monitoring.[3] In our case, several of these factors contributed to the development of RM. The patient was obese (BMI of 35.8 kg/m2), had a long surgery (9 h) in right lateral position. Use of isoflurane is thought to stress an unstable sarcolemmal membrane causing increased permeability resulting in an influx of calcium and leak of intracellular potassium and creatinine kinase from myocytes.[4] Acute renal failure (ARF) is the most dangerous complication of RM, with prompt recognition and early therapy determining the outcome. Adequate rehydration to maintain hourly urine output of 100–300 ml is the main component of
Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3
management to prevent ARF, with alkalization of urine to maintain pH >7.5. The kidney disease improving global outcomes recommends against the use of diuretics to maintain an adequate output (level 1 B).[5] Hemodialysis is required if the kidneys do not respond. Rhabdomyolysis is a rare but potentially life‑threatening postoperative complication in neurosurgery, with obesity, lateral position, and prolonged surgery being common risk factors. A high index of suspicion and early recognition helps prevent renal shutdown.
Raghvendra Nayak, Bijesh Ravindran Nair, Shalini Nair1, Mathew Joseph1
Department of Neurosurgery, Christian Medical College, 1Department of Neurological Sciences, Christian Medical College, Neurological ICU, Vellore, Tamil Nadu, India
Correspondence: Dr. Shalini Nair, Department of Neurological Sciences, Christian Medical College, Neurological ICU, Vellore, Tamil Nadu, India. E‑mail: [email protected]
References 1. 2. 3. 4. 5.
Dakwar E, Rifkin SI, Volcan IJ, Goodrich JA, Uribe JS. Rhabdomyolysis and acute renal failure following minimally invasive spine surgery:Report of 5 cases. J Neurosurg Spine 2011;14:785‑8. Van Gompel JJ, Khan YA, Bloomfield EL, Pallanch JF, Atkinson JL. Rhabdomyolysis after transnasal repair of anterior basal encephalocele. Surg Neurol 2009;72:757‑60. Woernle CM, Sarnthein J, Foit NA, Krayenbühl N. Enhanced serum creatine kinase after neurosurgery in lateral position and intraoperative neurophysiological monitoring. Clin Neurol Neurosurg 2013;115:266‑9. Farrell PT. Anaesthesia‑induced rhabdomyolysis causing cardiac arrest: Case report and review of anaesthesia and the dystrophinopathies. Anaesth Intensive Care 1994;22:597‑601. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012;2:37‑68. Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152786
Geriatric Critical Care in India Sir, I read with great interest the article by Sodhi et al. and the accompanying editorial published in the latest issue of your journal.[1,2] I was surprised to note that there was
no reference to our research article in either of these, considering that it is the first (and only) prospective long‑term data of elderly patients in Indian Intensive Care Units (ICUs).[3] India being a developing country is unique in its socioeconomic diversity and health delivery systems. We understand routine predictors such as APACHE II scores and treatment modalities are important for evaluating outcomes of critical illness in geriatric patients. However, an outcome analysis would be incomplete without an assessment of the baseline characteristics of the patients like economic, nutritional, and educational status. This gives a true estimate of the long‑term outcome in geriatric patients after discharge from an ICU. Further, this information proves vital to pinpoint predictors for planning treatment and counselling families. It may also be worthwhile to look independently at the outcomes of the very old patients (>75 years) when considering resource allocation or prognostication. In our prospective study of 109 (215 screened) elderly patients (>65 years age), overall mortality at discharge from ICU was 12% which increased to 30% and 47% at 1 and 12 month (s) respectively. Similar to the findings of Sacanella et al., when the cohort was divided into younger old (>65–74 years) and the very old (>75 years), the latter had significantly higher rates of mechanical ventilation and worse premorbid functional status than the young old (P 65 years ‑ 6.2%; >75 years ‑ 20.5%) was significantly different (P = 0.02); at 28 days and 12 months, however, this difference lessened. On a univariate analysis, the predictive factors of short‑term (28 day) mortality were APACHE II score, length of ICU stay, nutrition status, and premorbid functional status. The predictive factors of long‑term mortality were age, APACHE II score, and length of ICU stay, nutrition status, premorbid functional status, and presence of delirium at admission or during ICU stay. On a multivariate analysis, the factors associated with short‑term mortality were the APACHE II score P = 0.02; odds ratio (OR) 1.1 (1.0–1.2) and premorbid functional status P = 0.03; OR 0.2 (0.1–0.8). Long‑term mortality, on multivariate analysis showed association with APACHE II score P = 0.000; OR 1.2 (1.1–1.4), high risk of malnutrition on admission by malnutrition universal screening tool (MUST) screening P = 0.01; OR 0.01 (0.01–0.60) and presence of delirium P = 0.03; OR 0.32 (0.04–1.5). A Kaplan Meier survival analysis at 12 months showed a significant survival association with the grades of MUST score (log Rank test P = 0.012). Overall, 75% of survivors had a good functional outcome (ability to perform 4 out of 6 activities of daily 191
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Many patients develop hyponatremia during the course of their ICU management. Such groups of patients can be easily managed by increasing their dietary protein intake. Because of fixed urinary osmolarity in SIADH, increasing the dietary osmoles by increasing their dietary protein intake will lead to increase in urinary output and improvement in hyponatremia.[3] Moreover, increasing protein intake in critically ill will leads to better patient outcome. Studies have suggested that the use of higher protein concentration in nutritional therapy for critically ill patients may help to reduce mortality.[4,5]
Sunil Kumar Garg
Department of Medicine and Critical Care, Sarvodaya Hospital, Sector‑8, Faridabad, Haryana, India
Correspondence: Dr. Sunil Kumar Garg, 219, Pocket‑D, Mayur Vihar, Phase 2, New Delhi ‑ 110091, India. E‑mail: [email protected]
References 1.
2. 3. 4.
5.
Malhotra I, Gopinath S, Janga KC, Greenberg S, Sharma SK, Tarkovsky R. Unpredictable nature of tolvaptan in treatment of hypervolemic hyponatremia: Case review on role of vaptans. Case Rep Endocrinol 2014;2014:807054. Dahl E, Gluud LL, Kimer N, Krag A. Meta‑analysis: The safety and efficacy of vaptans (tolvaptan, satavaptan and lixivaptan) in cirrhosis with ascites or hyponatraemia. Aliment Pharmacol Ther 2012;36:619‑26. Berl T. Impact of solute intake on urine flow and water excretion. J Am Soc Nephrol 2008;19:1076‑8. Alberda C, Gramlich L, Jones N, Jeejeebhoy K, Day AG, Dhaliwal R, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observational study. Intensive Care Med 2009;35:1728‑37. Weijs PJ, Stapel SN, de Groot SD, Driessen RH, de Jong E, Girbes AR, et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: A prospective observational cohort study. JPEN J Parenter Enteral Nutr 2012;36:60‑8. Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152784
Rhabdomyolysis in lumbar spinal surgery: Early detection is crucial Sir, Rhabdomyolysis (RM) after neurosurgical procedure is a rare event. We report a case of RM following 190
lumbar surgery and discuss the importance of early recognition. A 22‑year‑old male underwent resection of L3 giant cell tumor in right lateral position. The patient weighed 96 kg with a body mass index (BMI) of 35.6 kg/m2 with no comorbidities. General anesthesia was administered with oxygen, nitrous oxide, isoflurane, propofol, and morphine. Surgery lasted for 9 h. On 1st postoperative day, he developed severe pain with a progressive increase in girth of the right thigh. Doppler study ruled out deep venous thrombosis. Next day, he developed tachycardia, tachypnea, and icterus. Concurrently, he had oliguria. Investigations showed a high serum creatinine (1.63 mg/dl), creatine phosphokinase (CPK) (29,100 U/L) and deranged liver function (total bilirubin 1.5 mg%, direct 0.5 mg%, aspartate aminotransferase 209 U/L, alanine aminotransferase 185 U/L, alkaline phosphate 372 U/L). A diagnosis of RM was made, and the patient was treated with liberal hydration to maintain urine output of at least 100 ml/h along with alkalinization of urine. Clinically and serologically, he started to improve and was ambulated and discharged in a week. There are only a few reported cases of RM after neurosurgical procedures, with several risk factors being proposed. Lateral positioning in posterior fossa tumor resection and minimally invasive spinal surgeries have been reported as probable cause in 9 patients.[1] Van Gompel et al. reviewed 10 cases of RM after neurosurgery in supine or prone positions for cranial and spinal pathologies, and found obesity and prolonged surgery as common risk factors.[2] Woernle et al. studied 150 patients with routine CPK analysis before and after surgery to determine the effect of position. They correlated raised CPK not only with lateral position, but also with the use of intraoperative monitoring, and hypothesized it to be due to the absence of pharmacological relaxation during monitoring.[3] In our case, several of these factors contributed to the development of RM. The patient was obese (BMI of 35.8 kg/m2), had a long surgery (9 h) in right lateral position. Use of isoflurane is thought to stress an unstable sarcolemmal membrane causing increased permeability resulting in an influx of calcium and leak of intracellular potassium and creatinine kinase from myocytes.[4] Acute renal failure (ARF) is the most dangerous complication of RM, with prompt recognition and early therapy determining the outcome. Adequate rehydration to maintain hourly urine output of 100–300 ml is the main component of
Indian Journal of Critical Care Medicine March 2015 Vol 19 Issue 3
management to prevent ARF, with alkalization of urine to maintain pH >7.5. The kidney disease improving global outcomes recommends against the use of diuretics to maintain an adequate output (level 1 B).[5] Hemodialysis is required if the kidneys do not respond. Rhabdomyolysis is a rare but potentially life‑threatening postoperative complication in neurosurgery, with obesity, lateral position, and prolonged surgery being common risk factors. A high index of suspicion and early recognition helps prevent renal shutdown.
Raghvendra Nayak, Bijesh Ravindran Nair, Shalini Nair1, Mathew Joseph1
Department of Neurosurgery, Christian Medical College, 1Department of Neurological Sciences, Christian Medical College, Neurological ICU, Vellore, Tamil Nadu, India
Correspondence: Dr. Shalini Nair, Department of Neurological Sciences, Christian Medical College, Neurological ICU, Vellore, Tamil Nadu, India. E‑mail: [email protected]
References 1. 2. 3. 4. 5.
Dakwar E, Rifkin SI, Volcan IJ, Goodrich JA, Uribe JS. Rhabdomyolysis and acute renal failure following minimally invasive spine surgery:Report of 5 cases. J Neurosurg Spine 2011;14:785‑8. Van Gompel JJ, Khan YA, Bloomfield EL, Pallanch JF, Atkinson JL. Rhabdomyolysis after transnasal repair of anterior basal encephalocele. Surg Neurol 2009;72:757‑60. Woernle CM, Sarnthein J, Foit NA, Krayenbühl N. Enhanced serum creatine kinase after neurosurgery in lateral position and intraoperative neurophysiological monitoring. Clin Neurol Neurosurg 2013;115:266‑9. Farrell PT. Anaesthesia‑induced rhabdomyolysis causing cardiac arrest: Case report and review of anaesthesia and the dystrophinopathies. Anaesth Intensive Care 1994;22:597‑601. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl 2012;2:37‑68. Access this article online Quick Response Code:
Website: www.ijccm.org
DOI: 10.4103/0972-5229.152786
Geriatric Critical Care in India Sir, I read with great interest the article by Sodhi et al. and the accompanying editorial published in the latest issue of your journal.[1,2] I was surprised to note that there was
no reference to our research article in either of these, considering that it is the first (and only) prospective long‑term data of elderly patients in Indian Intensive Care Units (ICUs).[3] India being a developing country is unique in its socioeconomic diversity and health delivery systems. We understand routine predictors such as APACHE II scores and treatment modalities are important for evaluating outcomes of critical illness in geriatric patients. However, an outcome analysis would be incomplete without an assessment of the baseline characteristics of the patients like economic, nutritional, and educational status. This gives a true estimate of the long‑term outcome in geriatric patients after discharge from an ICU. Further, this information proves vital to pinpoint predictors for planning treatment and counselling families. It may also be worthwhile to look independently at the outcomes of the very old patients (>75 years) when considering resource allocation or prognostication. In our prospective study of 109 (215 screened) elderly patients (>65 years age), overall mortality at discharge from ICU was 12% which increased to 30% and 47% at 1 and 12 month (s) respectively. Similar to the findings of Sacanella et al., when the cohort was divided into younger old (>65–74 years) and the very old (>75 years), the latter had significantly higher rates of mechanical ventilation and worse premorbid functional status than the young old (P 65 years ‑ 6.2%; >75 years ‑ 20.5%) was significantly different (P = 0.02); at 28 days and 12 months, however, this difference lessened. On a univariate analysis, the predictive factors of short‑term (28 day) mortality were APACHE II score, length of ICU stay, nutrition status, and premorbid functional status. The predictive factors of long‑term mortality were age, APACHE II score, and length of ICU stay, nutrition status, premorbid functional status, and presence of delirium at admission or during ICU stay. On a multivariate analysis, the factors associated with short‑term mortality were the APACHE II score P = 0.02; odds ratio (OR) 1.1 (1.0–1.2) and premorbid functional status P = 0.03; OR 0.2 (0.1–0.8). Long‑term mortality, on multivariate analysis showed association with APACHE II score P = 0.000; OR 1.2 (1.1–1.4), high risk of malnutrition on admission by malnutrition universal screening tool (MUST) screening P = 0.01; OR 0.01 (0.01–0.60) and presence of delirium P = 0.03; OR 0.32 (0.04–1.5). A Kaplan Meier survival analysis at 12 months showed a significant survival association with the grades of MUST score (log Rank test P = 0.012). Overall, 75% of survivors had a good functional outcome (ability to perform 4 out of 6 activities of daily 191
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
