Dilip R. Karnad

This position statement reviews the evidence and rationale for the management of severe peripartum infections with a special focus on tropical infections and is tailored for resource-limited settings.

Malaria is a worldwide health concern, but a great majority of cases occur in tropical countries like India. With almost 95% of Indian population living in malaria endemic regions, India contributes to most of the global malaria cases and deaths, outside of African countries. Despite significant advances towards malaria control and eradication, mortality associated with severe malaria remains particularly high. Changing epidemiology, vulnerable patient population, overlapping symptomatology, and limited availability of parenteral preparations of artemisinin derivatives pose significant challenges in management of severe malaria. Further, the dearth of large-scale randomized trials from the developing countries makes it difficult to establish evidence-based guidelines pertaining to their situation. Thus, this position paper aims to provide guidance to critical care physicians across the country on managing patients with severe malaria in intensive care units (ICUs).

Tetanus is caused by an exotoxin, tetanospasmin, produced by Clostridium tetani, an anaerobic gram-positive bacillus.Tetanospasmin prevents the release of inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the spinal cord, brainstem motor nuclei, and the brain, producing muscle rigidity and tonic spasms.Trismus (lockjaw), dysphagia, laryngeal spasms, rigidity of limbs and paraspinal muscles, and opisthotonic posture are common.Frequent severe spasms triggered by touch, pain, bright light, or sounds may produce apnea and rhabdomyolysis.Autonomic overactivity occurs in severe tetanus causing labile hypertension, tachycardia, increased secretions, sweating, and urinary retention. Dysautonomia is difficult to manage and is a common cause of mortality; magnesium sulfate infusion is often used.Antibiotics (penicillin or metronidazole) and wound care reduce toxin production and human tetanus immune globulin neutralizes the circulating toxin.Nasogastric tube placement for feeding and medications is needed.Early elective tracheostomy is performed in moderate or severe tetanus to prevent aspiration and laryngeal stridor.Benzodiazepines help reduce rigidity, spasms, and autonomic dysfunction. Large doses of diazepam (0.2–1 mg/kg/h) are administered via nasogastric tube.Neuromuscular blocking agents and mechanical ventilation are used for refractory spasms.Mortality ranges from 5% to 50%.

How to cite this article: Karnad DR, Patil VP, Kulkarni AP. Tropical Infections in the Indian Intensive Care Units: The Tip of the Iceberg! Indian J Crit Care Med 2021; 25(Suppl 2):S115–S117.

How to cite this article: Karnad DR, Amin P. An Approach to a Patient with Tropical Infection in the Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S118–S121.

Narkhede AM, Karnad DR. Preeclampsia and Related Problems. Indian J Crit Care Med 2021;25(Suppl 3):S261–S266.

Background: Eleven criteria correlating electrocardiogram (ECG) findings with reduced left ventricular ejection fraction (LVEF) have been previously published. These have not been compared head‐to‐head in a single study. We studied their value as a screening test to identify patients with reduced LVEF estimated by cardiac magnetic resonance (CMR) imaging.Methods: ECGs and CMR from 548 patients (age 61 + 11 years, 79% male) with previous myocardial infarction (MI), from the DETERMINE and PRE‐DETERMINE studies, were analyzed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each criterion for identifying patients with LVEF ≤ 30% and ≤ 40% were studied. A useful screening test should have high sensitivity and NPV.Results: Mean LVEF was 40% (SD = 11%); 264 patients (48.2%) had LVEF ≤ 40%, and 96 patients (17.5%) had LVEF ≤ 30%. Six of 11 criteria were associated with a significant lower LVEF, but had poor sensitivity to identify LVEF ≤ 30% (range 2.1%–55.2%) or LVEF ≤ 40% (1.1%–51.1%); NPVs were good for LVEF ≤ 30% (range 82.8%–85.9%) but not for LVEF ≤ 40% (range 52.1%–60.6%). Goldberger's third criterion (RV4/SV4 < 1) and combinations of maximal QRS duration > 124 ms + either Goldberger's third criterion or Goldberger's first criterion (SV1 or SV2 + RV5 or RV6 ≥ 3.5 mV) had high specificity (95.4%–100%) for LVEF ≤ 40%, although seen in only 48 (8.8%) patients; predictive values were similar on subgroup analysis.Conclusions: None of the ECG criteria qualified as a good screening test. Three criteria had high specificity for LVEF ≤ 40%, although seen in < 9% of patients. Whether other ECG criteria can better identify LV dysfunction remains to be determined.

How to cite this article: Saraf S, Karnad DR. Goal-directed Therapy: Does It Work in Postcardiac Surgery Patients, Unlike in Sepsis? Indian J Crit Care Med 2020;24(5):287–288.