Critical Care Communication May June 2013 Issue

Critical Care C O M M U N I C AT I O N S

A BI-MONTHLY NEWSLETTER OF INDIAN SOCIETY OF CRITICAL CARE ME DI C I N E Volume 8.3  may-june, 2013 C O N T E N T S  ISCCM News Headlines............................1  ISCCM Elections 2013 Appeal..................1  Editorial.....................................................2  Editorial Board 2012-2013.........................2  President's Desk.........................................3  General Secretary's Desk...........................4  International Conference on Shock, Hemodynamic Monitoring & Therapy and Tutorials in Hemodynamic Monitoring & Therapy in Critical Care 2013 (THEMATICC’13)..............................4  Installation of New Team of Nagpur ISCCM...........................................4  College News..............................................5  ISCCM New Chapter & New Branch EC Members..........................5  Notice for Elections 2013...........................6  Multiprofessional Critical Care Course – A Report......................................7  Abdominal Compartment SyndromeThe Pressure is On................................ 8-10  Advertisement.......................................... 10  Appeal to all ISCCM Branches to Celebrate ISCCM Foundation Day........... 11  MAHA CRITICON 2013.......................... 11  Best of Brussels 2013............................... 11  DCCS 2013................................................ 11  A Pictorial Journey to CRITICARE 2013................................ 12-15  Calender of Events................................... 15

www.isccm.org

 ISCCM NewsHeadlines  ISCCM declares war against " Tropical Fever"  ISCCM day on 9th October. All ISCCM Branches to observe the day with theme of "War against Tropical Fever"  Criticare 2014 - Jaipur Calling - Register Now  Criticare 2013 Kolkata a grand success  First Multi-professional Course appreciated  New branches formed in Chhatishgarh, Rohtak and Punjab  ISCCM election Process for the next EC starts, be a part of mainstream. Register your email ID and Mobile phone Number ISCCM Elections 2013 Appeal Please update your Email ID and Register your mobile phone no with ISCCM Dear Members

 Journal Scan........................................ 16-18  Welcome New Members to the ISCCM family...................................... 18-19  CRITICARE 2014.....................................20

Free and fair elections are the foundation of any democratic society. ISCCM elections are now held online only. It is therefore, imperative that ISCCM has email ids and mobile phone nos. of all its members for registering them on the

Editorial Office

electoral rolls. You are therefore, requested to please update your email ids

Dr. Shivakumar Iyer

and mobile numbers as soon as possible. Election participation has been only

Indian Society of Critical Care Medicine, (ISCCM) Pune Branch

30% in ISCCM election 2012. Please visit our website www.isscm.org for

Karnik Heritage, Flat No 08, 3rd floor, Sadubhau Kelkar Road, Off F. C. Road, Pune - 411004, Maharashtra

following this task. I will be in touch with all branch secretaries for continuing

Phone : 020-25532320 (from 11 am to 3 pm) emails : newsletter@isccm.org Published By :

Indian Society of Critical Care Medicine For Free Circulation Amongst Medical Professional

downloading the membership update form. All branches have special duty for this important work for ISCCM election 2013.

Dr. Shivakumar Iyer Chairperson Election Commission • presidentelect@isccm.org Dr. Manish Munjal • Dr. Kapil Zirpe • Dr. Susruta Bandopadhyay Members Election Commission

Unit 6, First Floor, Hind Service Industries Premises Co-operative Society, Near Chaitya Bhoomi, Off Veer Savarkar Marg, Dadar, Mumbai – 400028

We request our esteemed readers to send

Tel. 022-24444737 • Telefax :022-24460348 email : isccm1@gmail.com • isccm1@vsnl.net

at newsletter@isccm.org

their valued feedback, suggestions & views

2

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

Editorial

D

ear ISCCM members,

The ISCCM Kolkata conference 2013 was a great success and was appreciated by both delegates and faculty. I admire the entire Kolkata 2013 organizing committee for their perseverance & hard work in the face of great adversity. The pictorial journey of Kolkata 2013 amply demonstrates the successful conference.

Dr. Shivakumar Iyer Editor, The Critical Care Communications President-Elect, ISCCM suchetashiva@gmail.com

The Indian college has been quite active and has organized 2 webinars and the highly appreciated multiprofessional board review course which was jointly organized by the ICCM (ISCCM) and the SCCM. Dr. Chawla’s efforts must be lauded in taking the ICCM forward.

Dr. Rungta continues to take Critical Care to places. He announced financial aid for organizing CME’s on tropical fevers, as also for other CME’s in smaller towns (without ISCCM members) at the recent ISCCM executive committee. Such initiatives will help spread ISCCM’s message to all parts of the country. Members are requested to apply to the ISCCM finance committee for this aid.

There is plenty on the conference calendar in the coming months. Apart from the upcoming Jaipur 2014 ISCCM & APACCM conference we have the 'Best of Brussels' meeting (ISCCM Pune), the Mahacriticon conference (Maharashtra chapter ISCCM Kolhapur), the international THEMATTICC conference on hemodynamic monitoring (ISCCM Mumbai) and DCCS (ISCCM Delhi branch) Elections are round the corner. I have a new team Dr. Manish Munjal, Dr. Kapil Zirpe, and Dr. Susruta Bandopadhyay. We have the onerous task of implementing a host of new changes in the election process. I request all members to have a look at the election section of the ISCCM constitution on the website. Please send your nominations and also take the trouble to update your contact details. We have tried to make the process easier in order to get more members to participate in the elections.

Finally, I would like to request all of you to send articles for “Critical Care Communications”

Editorial Board 2012-2013 Editor in Chief

Dr. Shivakumar Iyer, Pune 09822051719  suchetashiva@gmail.com

Deputy Editor

Dr. Jayant Shelgaonkar

Dr. Krishan Chugh

098812288205  jshelgaonkar@gmail.com

chughk2000@yahoo.co.in

MEMBERS North Zone

West Zone

South Zone

Central Zone

East Zone

Dr. Jignesh Shah

Dr. Suninder Arora

Dr. Vijaya Patil

Dr. Palepu Gopal

Dr. Ranvir Tyagi

Dr. Arindam Kar

09324256057 drshahjignesh78@gmail.com

drssarora@gmail.com

09819883535 vijayappatil@yahoo.com

09000361678 palepu_gopal@hotmail.com

09837047812 drranvirstyagi@gmail.com

jagulam2006@gmail.com

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

President's Desk

3

Dr. Narendra Rungta MD, FISCCM, FCCM

President, ISCCM • drnrungta@gmail.com

I

Power to you

ndian Society of CCM has grown from strength to strength and has matured over the years. It may be any field, be it professionally, be in numbers, be its democratic character - ISCCM has proven its character and strength every time it has faced challenges. Right decision at the right time by the leadership of the society has taken it to enviable world levels. We started our training courses for doctors when others were thinking about it. Now, we have re-enforced our training programs with graduate doctors training course. This will meet our long standing need of creating a workforce of Critical Care professionals for reducing morbidity and mortality of critically sick patients in semi-urban and rural areas where majority of India lives.

We all know, we cannot do meaningful critical care without trained nurses, therefore, we have introduced the IDCCN – the Indian Diploma in Critical Care Nursing. This course will be available with all approved centres for IDCCM and also with approved teachers of ISCCM. This will give a big boost to Critical Care in India and strengthen the human resource need of Critical Care Medicine in our country in coming years.

It has been felt over the years, that ISCCM should have a strong federal structure in relation to its branches with some regulatory controls. With that background, the society is fully structured on the same philosophy with almost 75 branches.

They are expected to follow ISCCM constitution in letter and spirit but are free to run their own programs and maintain their financial sovereignty. The center needs all the branches to hold their elections in time and get their financial accounts audited and share it with the centre in time. The executive committee is very happy to see that branches solve their own problems within their own members and seldom involve the EC of ISCCM other than in exceptional circumstances. At this I must say and salute the branches for being so disciplined and constitution abiding.

The constitutional amendments achieved this year in AGM at Kolkata will have far reaching implication in inducing multi fold participation of more and more members and next generation leadership in running the affairs of the society.

The tenure of the President and the General Secretary will now be only for one year instead of two years. The General Secretary post as been opened to any location in the country.

These and many more changes in the constitution should definitely stimulate many of you from different parts of our country who have been looking forward to participate in process of leadership for the society in coming years The financial health of the society is at its best ever. The

society has been spending significant funds in education and training. Of late, we have even embarked upon taking research projects in a big way. This will help us generate our own data which will form a significant basis for future research. ICU registration is the beginning of the same. You are all requested to register your ICUs at the website of our society i.e. www.isccm.org. The executive committee feels that we must ensure complete financial security for the future generation of ISCCM and therefore will invest significantly for more office space and guest house properties for our travelling friends. This will be achieved as fast as possible.

This year we have declared “War Against Critical Tropical Fever”. This will also be the theme of ISCCM day on 9th October 2013. This will also be a major topic in coming Criticare 2014 at Jaipur. The society has also constituted an expert committee to form guidelines for managing these patients in ICU and thus reduce morbidity and mortality of such patients. You are all requested to participate in a big way in the celebration of ISCCM day in your area on 9th October 2013. Creation of awareness, early referral and proper early intervention will form the main plank of ISCCM day. Dr Anand Dongre and Dr Anand Nikhalje have already started working on this and have sent multiple mails to all of you. More mails, information and suggestion will come to you. However, please start preparing and don’t wait. You are capable and eligible to do your own home work on this subject.

Last but not the least, the Criticare 2014 is coming up at Jaipur in February 2014. This is in association with APACCM and CCNS, and will be the largest ever held Critical Care conference in this part of world. We have been hunting for new talent to be faculty, as we are trying to give maximum representation to Indian faculty. There is serious attempt to strike a balance between providing platform for importing and sharing of latest information and techniques in Critical Care medicine and to make it look a truely Indian conference of Indian Intensivists for Indian Intensivists. Register your self ASAP and save money. If you want to participate in workshops, don’t wait until last only to be disappointed later. Few workshops are already on the brink of getting fully subscribed.

Jaipur is calling “Padharo Mhare Des “. Visit our website www.criticare2014.com.

By the time, this Bulletin reaches your hands, the election process for the next Executive Committee would have already started. I invite you to join the leadership to run the affairs of the society and take part in our electronic election process.

Thank you.

4

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

General Secretary's Desk Dr. Atul P Kulkarni

General Secretary, ISCCM

G

reetings to all new and old members of ISCCM! I am sure many of you will have availed yourselves of the exciting scientific feast at the 19th annual conference held at Kolkata. It was a wonderful conference and I for one enjoyed myself tremendously.

Those who could not come missed a feast.

The perpetual lament in all my messages has been lack of complete electronic contact data (e-mail addresses and mobile nos.). I urge all those members whose contact data is incorrect to rectify this, so as to receive notices of webinars, and other messages from the ISCCM headquarters.

This year in July we will see the second year of DM (Critical Care Medicine) in India, a feat of which we can be proud of.

I would also like to take this opportunity to welcome all of you to Mumbai to attend International Conference on Shock, Hemodynamic Monitoring & Therapy along with the annual workshop fixture THEMATICC 2013 from 20-22nd September 2013. We have prominent international faculty, Dr Daniel De Backer (Brussels), Professor Sheldon Magder (Canada), Dr Mahesan Nirmalan (UK), Professor Jean Louis Teboul (France) and Professor Azriel Perel (Israel) along with the

national faculty. Please hurry since we have limited (250) registrations.

Lastly but not the least, The Young Talent Hunt!

Please send in your videos on selected topics , if you are young (< 40 years), have not been a speaker at our National Conference, because this year we have an innovative idea to select young talent in critical care. I have written to all of you regarding this by e-mail and all branches will also hold local competitions to select young talent. I foresee interesting times ahead!

With warm regards

International Conference on Shock, Hemodynamic Monitoring & Therapy and Tutorials in Hemodynamic Monitoring & Therapy in Critical Care 2013 (THEMATICC’13)

D

Main Conference : 20-21st September 2013  THEMATICC’13 : 22 September 2013

ear Friends

Hemodynamic monitoring and interventions to normalise the hemodynamic parameters are one of the most common interventions in critical care. We have long felt that there was no comprehensive course dealing with all aspects of haemodynamic monitoring, interpretation and appropriate therapeutic approach. To overcome this lacuna, Department of Anaesthesiology, Critical Care & Pain, Tata Memorial Hospital and Mumbai branch of Indian Society of Critical Care Medicine started organising a two day workshop on hemodynamic monitoring called Tutorials in Hemodynamic Monitoring & Therapy in Critical Care (THEMATICC) in 2004. Since this year is the 10th year, we have decided to celebrate the occasion by organising an International Conference on Shock, Hemodynamic Monitoring & Therapy along with the annual workshop fixture THEMATICC 2013 from 20-22nd September 2013.

faculty who have done a pioneering work in various areas relating to cardiovascular physiology, hemodynamic monitoring and therapeutic approaches to management of shock. The confirmed speakers include Dr Daniel De Backer (Belgium), Professor Sheldon Magder (Canada), Dr Mahesan Nirmalan (UK), Professor Jean Louis Teboul (France) and Professor Azriel Perel (Israel) along with prominent national faculty. An exciting scientific feast awaits us. Our auditorium is small therefore we can accept only 250 registrations for the main conference and only 60 registrations for the THEMATICC 2013. We have therefore only two categories of registrations ISCCM members and ISCCM non-members and the registration fees will not change as the conference approaches. We shall be unable to accept any spot registrations. The registration form can be downloaded from the ISCCM website – www.isccm.org. We look forward to seeing you in Mumbai during September 2013.

We look forward to hearing from some eminent international

Warm regards

Dr. JV Divatia

Organising Chairperson

Dr CK Jani

Organising Co-Chairperson

Dr. Vijaya Patil

Dr. Atul Kulkarni

Organising Secretaries

 Installation of New Team of Nagpur Isccm  Executive committee Chairperson Dr. Girish Deshpande Secretary

Dr. Jayesh Timane Treasurer Dr. Sudhir Chafle Executive COMMITTEE Members

The new Chairperson Nagpur ISCCM branch Dr. Girish Deshpande (2nd from right), Dr. Jayesh Timane (1st from right) and their team (standing).

Dr. Nirmal Jaiswal (3rd from left) was the chief guest and Dr. Shivakumar Iyer was the guest of honour. Also present are the outgoing chairperson Dr. Anand Dongre (2nd from left) and outgoing secretary Dr. Deepak Jeswani (extreme left)

Dr. Arif Hussain  Dr.V. E.Tambe  Dr. Satish Deopujari Dr. Nirmal Jaiswal  Dr. Rajan Barokar Dr. Ravindra Sarnaik  Dr. S. K. Deshpande Dr. (Mrs.) (Maj) D. Buche  Dr. Anand Dongre Executive COMMITTEE Members Dr. Mahesh Sarda  Dr.Tushar Pande Dr. Imran Noormohammed  Dr. Shahnawaz Siddidui Dr. Hari Gupta  Dr. Atul Somani  Dr. Amol Sagdeo Dr. Swapna Khanzode

5

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

CollegeNews

T

he past few months have been action filled for the college thanks to the exams conducted in the months of February/ March (IDCCM) and April (IFCCM). Special thanks to all the Chief Examiners who helped to conduct the exams in their institutions and all the other examiners who participated and ensured that the results were declared on time.

86 candidates appeared for the theory exams of IDCCM held during Criticare 2013 in Kolkata on Feb 28, 2013. 76 of these candidates passed and a total of 96 candidates (including repeat takers) appeared for the practical exams held in three different centers in March.

Sixteen candidates appeared for the IFCCM exams held in April. Of note five of these candidates were from the alternative pathway.

Seven of these candidates were deemed successful. With growing interest in IFCCM, it was decided in the recent College Board Meeting & Executive Committee meeting that a mid-year registration for IFCCM would be initiated effective this year. Candidates interested in pursuing IFCCM may now register and commence their training on April 1st (with deadline for registration being May 31st) or October 1st (with deadline for registration being November 30th). To start with we will also have a mid-year exam during the last weekend in the months of October at one center only this year.

Post MBBS Course which was started in 2012,

Dr. N. Ramakrishnan AB (Int Med), AB (Crit Care), MMM, FACP, FCCP, FCCM, FICCM Secretary, Indian College of Critical Care Medicine has aroused significant interest and the first batch of candidates will appear for the exam in 2014. Although it was initially considered to have a mid-term exam after one year of training, the College Board and Executive Committee have subsequently decided not to conduct the mid-term exam and directly allow the registered candidates to appear for the exam, after completing two years of training. Further, it has also been approved that candidates with post MBBS Certificate course would be treated on par with diploma candidates and be allowed to register for two year training for the course IDCCM. Another new course to be started this year would be the Indian Diploma in Critical Care Nursing. Thanks to Dr. Prakash Shastri’s commitment and efforts, the syllabus is now in place. This course will be initiated in July 2013 and further details will soon be posted on our website.

New institutions are being accredited for our training programs and efforts are also underway for the re-accreditation process. All institutions/teachers are requested to kindly

send the completed re-accreditation forms to Dr. Dhruva Chaudhry before May 31, 2013 failing which they may not be allowed to accept candidates for the July 2013 batch.

We are very happy to inform that the Multidisciplinary Critical Care Review Course was conducted in collaboration with Society of Critical Care Medicine (SCCM, USA) from April 19-21 in New Delhi. This was well attended and appreciated. We are incorporating some of the concepts used in this course to fine tune our two day Comprehensive Critical Care Course (4C) which will be widely offered soon.

The webinar series continues to be widely popular and appreciated. We will continue to plan webinars for the next few months.

Branches and institutions that are interested in conducting a webinar with a focused theme may formally submit a proposal for consideration.

We will soon start accepting nominations for Fellowship of Indian College of Critical Care Medicine (FICCM 2014). Please do check the college section of our website(www.isccm.org) periodically for updates Sincerely.

 ISCCM New Chapter & New Branch EC Members  Punjab Chapter

Chattisgarh Chapter

Rohtak Branch

Executive committee

Executive committee

Executive committee

Chairperson

Chairperson

Chairperson

Dr. Sunit Singhi

Dr. R.K. Rath

Dr. Dhruva Chaudhry

Secretary

Secretary

Secretary

Dr. Rajesh Mahajan

Dr.Trinath Dash

Dr. Kundan Mittal

Treasurer

Treasurer

Treasurer

Dr. Abhishek Kumar

Dr. Lal Mohd

Dr. Prashant Kumar

Executive COMMITTEE Members

Executive COMMITTEE Members

Executive COMMITTEE Members

Dr.Vikas Bansal  Dr. Pankaj Soni Dr. A.K. Mandal  Dr. R.S. Bedi

Dr. Rashmi Verma  Dr. S.K. Kamra Dr. Lal Mohammad

Dr. Jagdish Dureja  Dr. Jatin Lal Dr.Vikas Siwach  Dr.Viral Sangwan Dr. Nandita Kad  Dr. Atulya Atreja

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The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

Notice for Elections 2013 Circular No. 1/2013 Election of Office Bearers and Members of the Executive Committee for 2014-2016

• One President Dr. Narendra Rungta • Two Vice Presidents Dr. Deepak Govil Dr. N. Ramakrishnan

• One General Secretary Dr. Atul Kulkarni • One Treasurer Dr. Sheila Myatra •

Four Executive Committee Members Dr. Anand Dongre Dr. Diptimala Agarwal Dr. Rakesh Pande Dr. Abraham Babu K.

•

Zonal Members North Zone : Dr. Suninder S. Arora West Zone : Dr. Vijaya P. Patil East Zone : Dr. Arindam Kar South Zone : Dr. Palepu B. Gopal Central Zone : Dr. Ranvir Tyagi

Therefore election for the following Office Bearers and elected members of the Executive Committee for 2014-2016 will be held and nominations are hereby invited for them.

1. One President Elect 2. One Vice President (The elected VP should not be of the same zone as the present vice president)

5. One Secretary (from Headquarters) 6. Four Executive Committee Elected Members (of which not more than 3 shall be from the same Zone) 7. Five Zone members (one of each zone) 4.1 Eligibility

4.1.1

For the post of President-Elect / Vice President, General Secretary and Treasurer the candidate should have been elected and not nominated for 4 (Four) years as follows; on the National Executive Committee for a minimum of 2 (two) terms i.e. total 4

4.1.2 For all other positions, membership of the society for at least 5 years is mandatory. For re- eligibility to contest election for any post on the National Executive Committee the candidate must have attended at least 2(two) out of the last 4 (four) Executive Committee Meetings held in both years of his/her previous term. In case of such absence the member shall not be eligible to contest elections for one term (i.e. two years) and can contest after this term is over.

4.1.2.1 For re-eligibility to contest election for the post of Vice-Presidents, on the National Executive Committee the candidate must have attended at least 3 (three) Executive Committee Meetings out of the 4 (four) last Executive Committee Meetings held in the term that he/she had served on the National Executive Committee.

(This will be applicable to members serving on the National Executive Committee on or after February 1, 2008).

4.1.3 No member shall be eligible to seek election for more than 2 (two) tenures as Vice-President, Gen. Secretary, Treasurer, or Elected Member of the Executive Committee.

4.1.3.1 The term for President, Presidentelect, Immediate past president, General Secretary, Treasurer, Secretary is one year and for Vice President two years, excepting the forthcoming elections (August 2013) when President-Elect will have 2 years tenure followed by one year each as President and Immediate Past President. The term for Executive Committee & Zonal member is two years. Only members from the zone can vote for the zonal members.

3. One General Secretary (open to anywhere in country) 4. One Treasurer (from Headquarters)

of posts held in the EC. After completing 8 years in the EC, the member can contest only for the post of President. Thus the President shall remain on the EC for 11 years i. e. 8 years as EC member in any capacity and 1 year each as President elect, President and Immediate Past President.

(four) years in the National Executive Committee or 1 (one) term of 2 (two) years in the National Executive Committee and 2 (two) years as office bearer in the City Branch Executive Committee, the 2 (two) terms not running concurrently.

Election of Office Bearers of the Executive Committee for 2013-2014. Members are hereby informed that the following persons will retire in AGM 2014.

4.1.6 No member except the President shall be on the executive committee for more than eight years regardless

4.1.4 The President/President-Elect shall not seek election for any position in the Executive Committee after completing his / her tenure. However he / she can be nominated on the executive committee as may be decided by the Executive Committee provided his tenure in EC does not exceed 11 years.

4.2.6.1 Canvassing in any form will result in automatic disqualification from the election process. This includes emails, SMS etc.,

The nomination paper which shall set out the candidate’s name, address and the office for which the candidate is nominated, shall be proposed by one valid member and duly signed by the candidate, signifying his/her willingness to stand for the election and to serve on the Executive Committee if elected. There shall be a separate nomination paper for each candidate, and for each post. These nominations must reach the General Secretary not later than 15th June by 5.00 P.M. For every post, the nomination paper must be accompanied by a sum of Rs.5000/(Rupees five thousand only) from a candidate, in the form of a demand draft payable at Mumbai.

A nomination paper not accompanied by a Bank Draft of Rs.5000/-, shall be deemed invalid. A short bio-data not exceeding 200 words, should accompany the nomination and should or it can also be sent as soft copy along with a photograph (compulsory).

The proceeding after this will be taken over by the election commissioner. The Election Commission shall inform by EMAIL the contesting candidate of all the nominations received for the post they are contesting, and if any one wishes to withdraw his/her nomination, he/she should inform the Election Commissioner in writing or from the official e-mail address (i.e. registered with ISCCM headquarters previously) on or before the 30TH of June by 5.00 P.M. No member of ISCCM EC except those in Election Commission will in any manner interfere in the election process.

Dr. Atul Kulkarni, General Secretary ISCCM Dead lines of election procedure

Last date to receive the nomination at ISCCM Office 15th June 2013 Last date for withdrawal : 30th June 2013 by 5 pm

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The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

Multiprofessional Critical Care Course â&#x20AC;&#x201C; A Repor t 19-21 April, 2013 ď&#x201A;§ Hotel Taj Mahal, Delhi breakout sessions included Trauma, Mechanical Ventilation and Sepsis.

I

ndian College of Critical Care Medicine of Indian Society of Critical Care Medicine organized a three day Multiprofessional Critical Care Course (MCCRC) of Society of Critical Care Medicine (USA) at Hotel Taj Mahal, New Delhi from 19 to 21 April 2013.

This is for the first time that such programme was organised in India.

There was an overwhelming response from all over India. 150 delegates attended this three days long programme. Dr. Rajesh Chawla, Vice-Chancellor of Indian College of Critical

Care Medicine was the Course Director for the MCCRC. The programme was held in the very relaxing ambience of Hotel Taj Mahal, New Delhi.

On the first day the topics covered included Cardiology, Trauma and Neurological emergencies. In the afternoon there were problem based learning breakout sessions where cases on Arrhythmia, ABG and Hemodynamic Monitoring were discussed.

The second day itinerary covered topics related to Respiratory medicine, Neurology and the

On the third day the Obstetric Critical Care, Infections, Nutrition, Endocrine emergencies were covered in great detail. The faculty from SCCM (USA) included Dr. Marc Shapiro, Dr. Marie Baldisseri, Dr. Daniel Sweeney and Dr. Gregory Botz. The Indian faculty included Dr. J.V. Divatia, Dr. Rajesh Chawla, Dr. Shiva Kumar Iyer, Dr. Narendra Rungta, Dr. Prakash Shastri, Dr. Dhruva Chaudhary, Dr. Rajesh Pande, Dr. Raj Kumar Mani, Dr. Suninder Singh Arora and Dr. Avdhesh Bansal. All participants were very happy with the quality of talks. They were given hard copy of all slides and a book on Multiprofessional Critical Care Course. On the same lines Indian College of Indian Society of Critical Care Medicine is developing its own course Comprehensive Critical Care Course (4Cs) which will be officially launched in August in Mumbai.

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The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

Abdominal Compartment Syndrome - The Pressure is On Dr. Yash Javeri, Consultant intensivist, Max Hospital Saket Background

Categories

Compartment syndrome occurs when a fixed compartment, defined by myofascial boundaries or bone, are subjected to increased pressure, leading to ischemia and organ dysfunction. The abdominal compartment syndrome (ACS) is the development of physiologic dysfunction in intra-abdominal and extra abdominal organs as the result of increased intra-abdominal pressure (IAP).

The elevated IAP is a function of the rate of fluid accumulation within the abdominal cavity and the compliance of the abdomen.

The pressure-volume curve for the abdominal cavity is nonlinear. Due to the decreasing compliance of the abdomen, as fluid within the peritoneal cavity progressively accumulates, a greater increase in IAP results.

The ACS may occur in patients with a variety of conditions in which increased IAP occurs.

Primary or acute ACS: This occurs when intra-abdominal pathology is directly and proximally responsible for the compartment syndrome.

Clinical settings commonly associated with the syndrome include ruptured abdominal aortic aneurysm, ascites and intraperitoneal hemorrhage. Organ dysfunction caused by intra-abdominal hypertension (IAH) is considered to be abdominal compartment syndrome. The dysfunction may be respiratory insufficiency secondary to compromised tidal volumes, decreased urine output caused by falling renal perfusion, or any organ dysfunction caused by increased abdominal compartment pressure.

Secondary ACS: This occurs when no visible intra-abdominal injury is present but injuries outside the abdomen cause fluid accumulation.

Chronic ACS: This occurs in the presence of cirrhosis and ascites, often in the later stages of the disease.

Recurrent ACS: in which the patient has recovered from the ACS once but because of secondary insults the cycle begins again. This variety is associated with very high mortality rate.

Grades Grade I

IAP 12 - 15 mmHg

Grade II

IAP 16 - 20 mmHg

Grade III

IAP 21 - 25 mmHg

Grade IV

IAP > 25mmHg

Systemic manifestations of ACS Increased IAP results in dysfunction of the respiratory, cardiovascular, renal and neurological systems.

0-5 mmHg

Typical ICU patient

5-7 mmHg

Post-laparotomy patient

10-15 mmHg

Patient with septic shock

15-25 mmHg

Patient with acute abdomen

25-40 mmHg

Normal Abdominal Pressure

0

Abdominal Hypertension

Organ Dysfunction

Abdominal compartment syndrome was recognized clinically in the 19th century when Marey and Burt observed its association with worsening respiratory function. In the early 20th century, Emerson’s animal experiments demonstrated mortality associated with abdominal compartment syndrome.

5 10 15 20 25 30 35 Intra-abdominal Pressure (mmHg)

The dynamics of IAP

40

Renal system: Oliguria develops despite measured normal or mildly elevated CVP and PAWP. The renal vein and inferior vena cava are compressed. In addition, renal vascular resistance increases several fold in ACS. Direct compression of the renal parenchyma also contributes to the renal dysfunction.

 Patients should be screened for IAH / ACS risk factors upon ICU admission and with new or progressive organ failure.  If two or more risk factors are present a baseline IAP measurement should be obtained.  If IAH is present serial IAP measurement should be performed throughout the patient’s critical illness.

Patient has PvVO or more risk factors for IAH/ACS upon either ICU admission or in the presence of new or progressive organ failure

Measure patient’s IAP to establish baseline pressure AP measurement shot d be: 1. Expressed in mmHg (1 mmHg-1.36 cm H2O 2. Measured at end-expiration 3. Performed in the spine position 4. Zeroed at the iliac crest in the mid-axillary line 5. Performed with an instillation volume of no greater than 25 ml of saline [1 mL/kg for children up to 20 kg] 6. Measured 30-60 seconds after instillation to allow for bladder detrusor muscle relaxation (for bladder technique) 7. Measured in the absence of active abdominal muscle contractions

Sustained IAP ≥ 12 mmHg?

YES

Abdominal Compartment Syndrome

Cardiovascular system: As the IAP increases, central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), and systemic vascular resistance increase,due to an increased pleural pressure secondary to the increased IAP.Cardiac output (CO) decreases progressively as the IAP increases.

Intravenous volume expansion will increase the cardiac output and central filling pressures in ACS, but will not correct the other manifestations of ACS, including depressed renal function and splanchnic bloodflow.

An actual depression of myocardial function occurs with ACS due to marked increase in afterload, as well as impairment of venous return.

INTRA-ABDOMINAL HYPERTENSION (IAH) ASSESSMENT ALGORITHM

IAP Range Normal adult

Respiratory system: The hemidiaphragms are elevated due to the increased IAP. A decrease in thoracic volume and compliance results. Peak inspiratory pressure and pulmonary vascular resistance increase.

Ventilation perfusion abnormalities occur.

Increasing PEEP is required to oxygenate the patient.

NO

Patient has IAH

Patient does not have IAH

Notify patient’s doctor of elevated IAP. Proceed to IAH/ACS management algorithm.

Observer patient. Recheck IAP if patient deteriorates clinically.

Risk Factors for IAH / ACS 1. Diminished abdominal wall compliance  Acute respiratory failure especially with elevated intrathoracic pressure.  Abdominal surgery with primary fascial or tight closure  Major trauma / barns  Prone positioning head A bed > 30 degrees  High body mass index (BMI) central obesity 2. Increased intra-luminal contents  Gastroparesis  Ileus  Colonic pseudo-obstruction 3. Increased abdominal contents  Hemoperitoneum / pneumoperitoneum  Ascites / liver dysunction 4. Capillary leak/fluid resuscitation  Acidosis (pH<72)  Hypotension  hypothermic (core temperature <33oC) Polytransfusion (>10 units of blood / 24 hrs) Coagulopathy (platelets 55000/mm3 OR partial thromboplastin time (PIT) > 2 times normal OR prothrombin time (PIT) <50% OR international standardised ratio (INR) > 15)  Massive fluid resusctation (>5L/24 hours)  Pancreatitis  Oliguria  Sepsis  Major trauma/burns  Damage control laparotomy

Grade I Grade II Grade III Grade IV

IAH Gradina IAP 12-15 mmHg IAP 16-20 mmHg IAP 21-25 mmHg IAP ≥ 25 mmHg

Abbreviations IAH-intra-abdominal hypertension ACS-abdominal compartment syndrome IAP-intra-abdominal pressure

Adapted from Intensive Care Medicine 2006:32(11):1722-1732 & 2007:33(6):951-962

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The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

prosthetic material, and vacuum systems are most often used.The abdomen may be opened in the intensive care unit, however, the operating room is preferable. If the abdomen is opened in the ICU, the operating room must be prepared to accept the patient if surgically correctable bleeding is identified at the time of decompressive laparotomy. A forced fascial closure of the abdomen should be avoided, such as in patients with massive retroperitoneal hematoma, visceral edema, or intra-abdominal packs.

Oliguria is often the earliest sign of ACS and anuria follows if the IAP is not reduced.

Abdominal and visceral effects: Clinically, the abdominal girth increases and the abdomen becomes more tense as the IAP increases. Splanchnic blood flow decreases as ACS develops. These studies have identified physiologic derangements that occur with increased IAP which may play a role in the development of SIRS in patients with ACS. Abdominal perfusion pressure (APP) = mean arterial pressure (MAP) minus intraabdominal pressure (IAP) = MAP - IAP. APP assesses not only the severity of IAP, but also the relative adequacy of abdominal blood flow APP should be maintained above 50–60 mmHg in patients with IAH/ACS .

Central nervous system: Elevated IAP resulted in increased intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP).The proposed mechanism is functional obstruction of jugular venous drainage due to the elevated pleural pressures and CVP. Eyes: Increased IAP has been associated with the rupture of retinal capillaries, resulting in the sudden onset of decreased central vision (valsalva retinopathy).

Patient Monitor Saline Bag

The AbViser system integrates directly with the patient’s Foley catheter, transducer and monitoring system. Its unique valves allow clinicians to easily infuse saline into the bladder and rapidily measure IntraAbdominal Pressure.

“Home Made” Pressure Transducer Technique is utilized for IAP monitoring at many centres. The technique is not well standardized and often shows variable results. However ease of availability and low cost are major benefits.

Pressure Transducer

Zeroing Stopcock

AbViser Valve Tubing Patient’s Bladder

AbViser Valve

Urinary Catheter

Tape

 The choice (and success) of the medical management strategies listed below is strongly related to both the etiology of the patient’s IAH/ACS and the patients clinical situation. Theapproprateness of each intervention should always be considered prior to implementing these interventions in any individual patient.  The interventions should be applied in a stepwise fashion until the patient’s intra-abdominal pressure (IAP) decreases.  If there is no response to a particular intervention therapy should be esclated to the next step in the algorthm.

Patient has IAP ≥ 12 mmHg Begin medical management to reduce IAP

Step 3

Step 2

Step 1

Measure IAP / APP at least every 4-6 hours or continuously.

Titrate therapy to maintain IAP ≥ 15 mmHg and APP ≥ 60 mmHg

Step 4

Fluid-Column Manometry

Infusion Tubing

IAH / ACS MEDICAL MANAGEMENT ALGORITHM

To diagnose and intervene early in the course of ACS, a high index of suspicion must be maintained.Clinically, the syndrome consists of the association of abdominal distension with increasing peak inspiratory pressures, increased central venous pressure (if the patient is euvolemic), oliguria, and hypercarbia.Often, a diagnosis of ACS should be made on the basis of clinical suspicion and decompressive laparotomy performed without attempts at measuring IAP. In the early phases of ACS, when oliguria may be the only sign, measurement of IAP is useful.

Measurement of bladder pressure, measurement of the gastric pressure, or measurement of the IAP using a long femoral venous catheter placed in the inferior vena cava. The most accurate and simple way to determine the IAP is indirectly by measurement of the bladder pressure using a Foley catheter. The bladder pressure is essentially equivalent to the IAP.

Double Check Valve

Monitor Cable

Surgical interventions: If these medical treatments fail, decompressive laparotomy has been shown to effectively reduce IAP and improve organ function in critically ill patients.

Open abdomen treatment, or laparostomy, was initially intended for patients with diffuse intraabdominal infections, but open abdomen treatment—either prophylactic or therapeutic—is becoming more common in the ICU. Several techniques to cover the open abdomen are available, but the Bogota bag,

Diagnosis

Measurement of IAP

Infusion Syringe

Evacuate intraluminal contents

Evacuate intra abdominal space occupying lesions

Improve abdominal wall compliance

Optimize fluid administration

Optimize systemic regional perfustion

Insert nasogastric and/or rectal tube

Abdominal ultrasound to identify lesions

Ensure adequate sedation & analgesia

Avoid excessive fluid resucitation

Goal-directed fluid resuscitation

Remove Constrictive dressings, abdominal eschars

Aim for zero to negative fluid balance by day 3

Maintain abdominal perfusion pressure (APP) ≥ 60 mmHg Hemodynamic monitoring to guide lesuscitation

Intitate gastro / coloprokinetic agents

Minimize esteral nutrition

Abdominal computed tomography to identify lesions

Avoid prone position head of bed ≥ 20 degrees

Resuscitate using hypertonic fluids colloids

Administer enemas

Percutaneous catheter drainage

Consider reverse Trendrlenberg position

Fluid removal through judicious diuresis once stable

Consider colonoscopic decompression

Consider surgical evacuation of lesions

Consider neuromuscular blockade

Consider hemodialysis/ ultrafiltration

Vasoactive medications to keep APP ≥ 60 mmHg

Discontinue enteral nutrition

If IAP > 25 mmHg (and or APP < 50 mmHg) and new organ dysfunction/failure is present patient’s IAH ACS is refractory to medical management. Strongly consider surgical abdominal decompression.

Adopted from Intensive Care Medicine 2006;32(11):1722-1732 & 2007/33(6):951-962

Urinary Drain Tubing

10

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine Definitions. Intensive Care Med 32:1722–1732

and Emergency Medicine. Berlin, Germany, Springer-Verlag, 2001.

Summary ACS is a potentially lethal condition caused by any event that produces intra-abdominal hypertension and causes ischemia of the peritoneal organs. Pathophysiological effects are wide-ranging and predispose patients to multiorgan dysfunction syndrome.

Hemodynamic, respiratory, renal, and neurological abnormalities are classic findings. Urgent medical management and/ or decompressive laparotomy can decrease morbidity and mortality.

3.

Foy HM, et al. Reinforced silicone elastomer sheeting, an improved method of temporary abdominal closure in damage control laparotomy. American Journal of Surgery.

185(5):498–501, May 2003.

4.

Saggi B, Sugerman H, Ivatury R, Bloomfield G. Abdominal compartment syndrome. J Trauma. 1998;45:597-609.

5.

References 1.

Bailey J, Shapiro MJ. Abdominal compartment syndrome.

Critical Care.

4(1):23–29, e-published January 24, 2000

2.

Malbrain ML. Intra-abdominal pressure in the intensive care unit: Clinical tool or toy?

In Vincent JL (ed), Yearbook of Intensive Care

6.

Abdominal Compartment Syndrome Edited

by Rao Ivatury, Michael Cheatham, Manu Malbrain, and Michael Sugrue Landes Biosciences (2006) Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D’Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A (2006) Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I.

7.

Malbrain ML, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, Del Turco M, Wilmer A, Brienza N, Malcangi V, et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med. 2005;33:315–322.

8.

Al-Bahrani AZ, Abid GH, Holt A, McCloy RF, Benson J, Eddleston J, Ammori BJ. Clinical relevance of intra-abdominal hypertension in patients with severe acute pancreatitis.

Pancreas. 2008;36:39–43.

9.

De Waele JJ, Hoste E, Blot SI, Decruyenaere J, Colardyn F. Intra-abdominal hypertension in patients with severe acute pancreatitis. Crit Care. 2005;9:R452–R457.

10.

Pupelis G, Austrums E, Snippe K, Berzins M. Clinical significance of increased intraabdominal pressure in severe acute pancreatitis. Acta Chir Belg. 2002;102:71–74.

The views expressed in this article are the author's own and the editorial board of CCC or ISCCM are not responsible for the same.

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www.criticare2014.com www.apaccm2014.com

BLOCK YOUR DATES Conference : 14-16 February, 2014 Workshop : 17-18 February, 2014

Jaipur CRITICARE 2014 14 - 18 February, 2014

A JOINT MEETING OF 20TH ANNUAL CONFERENCE OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE & 18TH ASIA-PACIFIC CONGRESS OF CRITICAL CARE MEDICINE 2ND ANNUAL CONFERENCE OF CRITICAL CARE NURSES SOCIETY

11

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

APPEAL TO ALL ISCCM BRANCHES

Celebrate 9th OCTOBER 2013

ISCCM FOUNDATION DAY Theme : “CRITICAL ILLNESS IN TROPICAL FEVER” ISCCM plans to celebrate ISCCM DAY by creating an awareness regarding tropical diseases among health professionals and the lay public.

Branches are requested to hold CME & public awareness programme along with poster presentation on same day.

Detailed program with standard powerpoint presentations, posters and information leaflets is being prepared.

Please send your suggestions asap to andydongre@hotmail. com ISCCM DAY Committee Dr. Anand Dongre  Dr. Anand Nikalje Dr. Manish Munjal  Dr. Palepu Gopal

We request our esteemed readers to send their valued feedback, suggestions & views at newsletter@isccm.org

ISCCM

2013

Delhi Critical Care Symposium

11th Annual Conference of Society of Critical Care Medicine - Delhi (A Delhi & NCR Branch of Indian Society of Critical Care Medicine)

16th-18th August 2013 India Habitat Centre, New Delhi

Theme: Challenges in Critical Care WORKSHOPS

FEE

1. Mechanical Ventilation

4500

2. Basic Pediatric Intensive Care Course (BPICC)

2500

3. Hemodynamic monitoring

2500

4. Ultrasound in Emergency & Critical Care

5000

5. Bronchoscopy with PCT

2500

6. Critical Care Nursing

2500

7. Fellowship Preparatory Course for Post Graduates 25000 1000 8. Ethical issues in critical care

Pre-Conference Workshops: 16th-17th August 2013 Workshops Venue: At Various Hospitals Conference: 18th August 2013 Conference Venue: India Habitat Centre Organized by Society of Critical Care Medicine- Delhi (A Delhi & NCR Branch of Indian Society of Critical Care Medicine)

Register Online at

www.isccmdelhi.com CONFERENCE SECRETARIAT Dr. Rajesh Pande Conference Coordinator Ms. Kavita Sharma 9811895550 SUMMIT

ALPCORD NETWORK Event & Conferences Management Company Pvt. Ltd.

Organsing Secretary, DCCS 2013 Society of Critical Care Medicine Delhi (A Branch of Indian Society of Critical Care Medicine) 805/59 Shakuntla Tower, Nehru Place, New Delhi - 110019 Tel.: 011-41007180 (M) 9811895550 Email ID : isccmdelhichapter@gmail.com,

12

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

A Pictorial Journey to CRITICARE 2013

ACCESSIBLE  ACCOUNTABLE  AFFORDABLE CARE 19th Annual Congress of the Indian Society of Critical Care Medicine & International Critical Care Congress (CRITICARE 2013) Science City, Kolkata  Scientific Congress : 1st to 3rd March, 2013  Workshop : 4th to 5th March, 2013

Organized by : ISCCM Kolkata Branch, West Bengal, INDIA  Venue  Science City

Welcome address : Prof Bibhu Kalyani Das, Chairperson Reception Committee

Convocation of Indian College of Critical Care Medicine

Banquet : Nicco Park, Wet O Wild – The cultural programme was conducted by renowned singer Babul Supriyo and group

Cultural Programme

Presidential Oration: Taking Critical Care to places by Dr. Narendra Rungta

Inauguration : Swami Suparnanandaji and Vice Chancellor Calcutta University, Prof Suranjan Das

13

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

ISCCM Oration : Application of Quality Systems in Critical Care by Dr. Banambar Ray

Hansraj Naayar award: Received by Dr. Susovan Mitra for his research work titled â&#x20AC;&#x2DC;Vinayaka coma scale, new coma scale in emergency roomâ&#x20AC;&#x2122; from Vinayaka Mission Kirupanda Variyar Medical College, Salem, Tamilnadu, India

Free Paper and Poster Session

Plenary Session

Thematic Session

Panel Discussion

Meet the Experts

Our International Faculties

Claudio Roncho

Jean Louis Teboul

Jean Louis Vincent

Konrad Reinhart

Marco Raineri

Daniel Talmor

Anand Kumar

Edgar Jimenez

Robert Balk

Carol Thompson (President SCCM)

Mervyn Singer

Marin Kollef

Wes Ely

Jeff Lipman

Charles Gommersal

14

The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

Exhibit Stalls

Pediatric

Publications CME Book

Souvenir

Abstracts (selected) published in Suppl Issue of IJCCM

Compendium For the first time a compendium book has been published which has identified the research work originated from India during the last five years.

Valedictory

Organizing Committee

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The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

Workshop

â&#x20AC;˘ The following workshops were conducted in different Hospitals of Kolkata and in Science City from 4th to 6th March 2013. â&#x20AC;˘ Advanced Cardiac Life Support (ACLS), Fundamental Critical Care Support ( FCCS), Hospital Disaster Management Course, Comprehensive Trauma Life Support Course (CTLS), Ultrasound in Emergency and Critical Care Unit, Mechanical Ventilation, Hemodynamic Monitoring, Critical Care Nursing, Antibiotic Stewardship & Infection Control, Airway Management Workshop, Learning through Simulations, Basic Assessment & Support in Intensive Care, Neuro Critical Care Course, Nutrition in Critical Care Course, Research & Publication, Extra Corporeal Support in ICU, Physical Rehabilitation and Respiratory Therapy, Nephro Critical Care Provider course, Nephro Critical Care Instructor course, Toxicology, Comprehensive Critical Care Course and Paediatric Critical Care Workshop.

Criticare 2014, Jaipur

Calender of Events May 2013 May 25th, 2013 2.00 pm - 5.00 pm June 2013 June 8th to 9th, 2013 June 12th to 15th, 2013 July 2013 July 9th and 10th, 2013 July 11th and 12th, 2013 July 13th and 14th, 2013 July 12th to 14th, 2013 August 2013 August 17th 2013 Aug 28th to 1st Sept, 2013 September 2013 September 20th to 22nd, 2013 October 2013 Oct 5th to 9th, 2013 November 2013 November 9th 2013

4th Indian College of Critical Care Medicine (ISCCM) Webinar

Coordinator : Dr. Pravin Amin

Basic support and support in Intensive care (BASIC), Columbiaasia Referral Hospital, Bangalore

Contact : Dr. Pradeep Rangappa, Secretary, ISCCM - Bangalore. email : drpradeepr@aol.com www.kenes.com/espnic

http://webstream.communications.powerstream.net/008/00151/ isccm/250513/

24th Annual meeting of European society of Paediatric and Neonatal Intensive care, Netherland ISCCM Pune , Intensive Care Review Course, Pune

Contact : Ms Vidula- 09011026332; Dr Subhal Dixit- 9822050240 ISCCM Pune, Workshops on hemodynamic monitoring, Mechanical Contact : Ms Vidula- 09011026332; Ventilation and Ultrasound, ECHO in ICU, Pune Dr Subhal Dixit- 9822050240 Best of Brussels Conference (Top 50 lectures), ISCCM, Pune Contact : Dr Subhal Dixit- 9822050240, Dr Kapil Zirpe- 9822844212 Intensive Care in Asia- Oppurtunities and Challenges, Singapore. www.sg-anzics.com USG and ECHO workshop, Manipal Hospital, Bangalore First WFSICCM Congress, Durban, Africa.

Contact : Dr. Pradeep Rangappa, Secretary, ISCCM-Bangalore. email: drpradeepr@aol.com www.criticalcare2013.com

THEMATICC 2013 and International Conference on Shock, Hemodynamic Monitoring and Therapy

Contact person : Dr. Vijaya Patil (09819883535) or Dr. Atul Kulkarni (09869077526)

ESICM LIVES 2013, Paris, France

www.esicm.org

Mechanical Ventilation workshop, Narayana Hrudayalaya, Bangalore

Contact : Dr Pradeep Rangappa, Secretary, ISCCM, Bangalore email : drpradeepr@aol.com

Turgeon, Alexis F. MD, MSc, FRCPC; Lauzier, François MD, MSc, FRCPC et al; for the Canadian Critical Care Trials Group Critical Care Medicine: April 2013 - Volume 41 - Issue 4 - p 1017–1026 Accurate prognostic information in patients with severe traumatic brain injury remains limited, but mortality following the withdrawal of life-sustaining therapies is high and variable across centers.We designed a survey to understand attitudes of physicians caring for patients with severe traumatic brain injury toward the determination of prognosis and clinical decision making on the level of care.

This group conducted a cross-sectional study of intensivists, neurosurgeons, and neurologists that participate in the care of patients with severe traumatic brain injury at all Canadian level 1 and level 2 trauma centers. No interventions were done.

The main outcome measure was physicians’ perceptions of prognosis and recommendations on the level of care.

Main Results: The response rate was 64% (455/712).

Most respondents (65%) reported that an accurate prediction of prognosis would be most helpful during the first 7 days. Most respondents (>80%) identified bedside monitoring, clinical exam, and imaging to be useful for evaluating prognosis, whereas fewer considered electrophysiology tests (<60%) and biomarkers (<15%).

In a case-based scenario, approximately one-third of respondents agreed, one-third were neutral, and onethird disagreed that the patient prognosis would be unfavorable at one year. About 10% were comfortable recommending withdrawal of life-sustaining therapies.

Conclusions: A significant variation in perceptions of neurologic prognosis and in clinical decision making on the level of care was found among Canadian intensivists, neurosurgeons, and neurologists. Improved understanding of the factors that can accurately predict prognosis for patients with traumatic brain injury is urgently needed.

Acute Kidney Injury in the Critically Ill: Is Iodinated Contrast Medium Really Harmful?* Ehrmann, Stephan MD; Badin, Julie MD et al.

Critical Care Medicine: April 2013 - Volume 41 - Issue 4 - p 1017–1026 Objectives: To assess whether the use of iodinated contrast medium increases the incidence of acute kidney injury in ICU patients, compared with patients not receiving iodinated contrast medium.

Prospective observational matched cohort study.

This study was conducted in two ICUs in two tertiary teaching hospitals.

A total of 380 adults were included (20% more than once), before an iodinated contrast medium infusion (contrast inclusions, n = 307) or before an intrahospital transfer without iodinated contrast medium infusion (control inclusions, n = 170). No interventions were done.

Measurements and Main Results: Among contrast inclusions, iodinated contrast medium–associated acute kidney injury occurred after 23 administrations (7.5%)

JOU

RNA

L SC

Determination of Neurologic Prognosis and Clinical Decision Making in Adult Patients With Severe Traumatic Brain Injury: A Survey of Canadian Intensivists, Neurosurgeons, and Neurologists

A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

AN

16

The Critical Care Communications

according to the Acute Kidney Injury Network definition (stage ≥ 1, over 48 hr). As expected, a broader definition (≥ 25% increase in serum creatinine over 72 hr) yielded a greater incidence (16%). In 146 pairs of contrast and control inclusions, matched on propensity for iodinated contrast medium infusion, the incidence of acute kidney injury was similar (absolute difference in incidence, 0%; 95% confidence interval, –5.2; 5.2%), Acute Kidney Injury Network definition). Hospital mortality was also similar in 71 contrast and 71 control patients included only once and matched the same way. Contrary to iodinated contrast medium infusion (odds ratio, 1.57; 95% confidence interval, 0.69–3.53), the Sequential Organ Failure Assessment score at inclusion (odds ratio, 1.18; 95% confidence interval, 1.07–1.31) and the number of other nephrotoxic agents (odds ratio, 1.38; 95% confidence interval, 1.03–1.85) were independent risk factors for acute kidney injury.

Conclusions: The specific toxic effect of monomeric nonionic low-osmolar iodinated contrast medium in ICU patients with multiple renal aggressions seemed minimal.

Severity of disease and the global nephrotoxic burden were risk factors for acute kidney injury, regardless of iodinated contrast medium infusion.

Proton Pump Inhibitors Versus Histamine 2 Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients: A Systematic Review and Meta-Analysis Alhazzani, Waleed MD; Alenezi, Farhan MD; et al.

Critical Care Medicine: March 2013 - Volume 41 - Issue 3 - p 693–705 Critically ill patients may develop bleeding caused by stress ulceration. Acid suppression is commonly prescribed for patients at risk of stress ulcer bleeding.

Whether proton pump inhibitors are more effective than histamine 2 receptor antagonists is unclear.

Objectives: To determine the efficacy and safety of proton pump inhibitors vs. histamine 2 receptor antagonists for the prevention of upper gastrointestinal bleeding in the ICU. Search Methods: The Authors searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ACPJC, CINHAL, online trials registries (clinicaltrials.gov, ISRCTN Register,WHO ICTRP), conference proceedings databases, and reference lists of relevant articles.

Selection Criteria: Randomized controlled parallel group trials comparing proton pump inhibitors to histamine 2 receptor antagonists for the prevention of upper gastrointestinal bleeding in critically ill patients, published before March 2012.

Data Collection and Analysis: Two reviewers independently applied eligibility criteria, assessed quality, and extracted data.The primary outcomes were clinically important upper gastrointestinal bleeding and overt upper gastrointestinal bleeding; secondary outcomes were nosocomial pneumonia, ICU mortality, ICU length of stay, and Clostridium difficile infection.Trial authors were contacted for additional or clarifying information.

Results: Fourteen trials enrolling a total of 1,720 patients were included. Proton pump inhibitors were more effective than histamine 2 receptor antagonists at reducing clinically important upper gastrointestinal bleeding (relative risk 0.36; 95% confidence interval 0.19– 0.68; p = 0.002; I2 = 0%) and overt upper gastrointestinal

Dr. Jayant Shelgaonkar

Director, ICU, Aditya Birla Hospital, Pune

bleeding (relative risk 0.35; 95% confidence interval 0.21– 0.59; p < 0.0001; I2 = 15%). There were no differences between proton pump inhibitors and histamine 2 receptor antagonists in the risk of nosocomial pneumonia (relative risk 1.06; 95% confidence interval 0.73–1.52; p = 0.76; I2 = 0%), ICU mortality (relative risk 1.01; 95% confidence interval 0.83–1.24; p = 0.91; I2 = 0%), or ICU length of stay (mean difference -0.54 days; 95% confidence interval -2.20 to 1.13; p = 0.53;I2 = 39%). No trials reported on C. difficile infection.

Conclusions: In critically ill patients, proton pump inhibitors seem to be more effective than histamine 2 receptor antagonists in preventing clinically important and overt upper gastrointestinal bleeding.The robustness of this conclusion is limited by the trial methodology, differences between lower and higher quality trials, sparse data, and possible publication bias. Authors observed no differences between drugs in the risk of pneumonia, death, or ICU length of stay.

Single-Dose Etomidate Is Not Associated With Increased Mortality in ICU Patients With Sepsis: Analysis of a Large Electronic ICU Database* McPhee, Laura C. DO; Badawi, Omar PharmD, MPH et al.

Critical Care Medicine: March 2013 - Volume 41 - Issue 3 p 774–783 Retrospective analyses of several trials suggest etomidate may be unsafe for intubation in patients with sepsis. We evaluated the association of etomidate and mortality in a large cohort of septic patients to determine if singledose etomidate was associated with increased in-hospital mortality.

Design and Setting: Retrospective cohort study at the Philips eICU Research Institute ICU clinical database. No interventions were done.

Patients: Among 741,036 patients monitored from 2008 through 2010, the authors identified 2,014 adults intubated in the ICU 4–96 hrs after admission, having clinical criteria consistent with sepsis, severe sepsis, or septic shock. In all, 1,102 patients received etomidate and 912 received other induction agents for intubation.

Measurements and Main Results: The primary endpoint was in-hospital mortality, but they also evaluated demographic and clinical factors, severity of illness, ICU mortality, ICU length of stay, hospital length of stay, ventilator days, and vasopressor days. Competing risk Cox proportional hazard regression models were used for primary outcomes. Demographics and illness severity were similar between the groups. Hospital mortality was similar between the groups (37.2% vs. 37.8%, p = 0.77), as were ICU mortality (30.1% vs. 30.2%, p = 0.99), ICU length of stay (8.7 days vs. 8.9 days, p = 0.66), and hospital length of stay (15.2 vs. 14.6 days, p = 0.31). More patients in the etomidate group received steroids before and after intubation (52.9% vs. 44.5%, p < 0.001), but vasopressor use and duration of mechanical ventilation were similar. No regression model showed an independent association of etomidate with mortality, shock, duration of mechanical ventilation, ICU or hospital length of stay, or vasopressor use. A hospital mortality model limited to only patients with septic shock (n = 650) also showed no association of etomidate and hospital mortality.

Conclusion: In a mixed-diagnosis group of critically ill patients with sepsis, severe sepsis, and septic shock, single-dose etomidate administration for intubation in the ICU was not associated with higher mortality or other adverse clinical outcomes.

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The Critical Care Communications A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine

Renaissance of base deficit for the initial assessment of trauma patients: A base deficitbased classification for hypovolemic shock developed on data from 16,305 patients derived from the Trauma Register DGU® Manuel Mutschler et al. and the Trauma Register DGU The recognition and management of hypovolemic shock still remain an important task during initial trauma assessment. Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality. The aim of this study was to introduce and validate a new classification of hypovolemic shock based upon base deficit (BD) at emergency department (ED) arrival.

Between 2002 and 2010, 16,305 patients were retrieved from the TraumaRegister DGU® database, classified into four strata of worsening BD [class I (BD ≤ 2 mmol/l), class II (BD > 2.0 to 6.0 mmol/l), class III (BD > 6.0 to 10 mmol/l) and class IV (BD > 10 mmol/l)] and assessed for demographics, injury characteristics, transfusion requirements and fluid resuscitation. This new BD-based classification was validated to the current ATLS classification of hypovolemic shock.

With worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (± 11.9) in class I to 36.7 (± 17.6) in class IV, while mortality increased in parallel from 7.4% to 51.5%. Decreasing hemoglobin and prothrombin ratios as well as the amount of transfusions and fluid resuscitation paralleled the increasing frequency of hypovolemic shock within the four classes.

The number of blood units transfused increased from 1.5 (± 5.9) in class I patients to 20.3 (± 27.3) in class IV patients. Massive transfusion rates increased from 5% in class I to 52% in class IV. The new introduced BD-based classification of hypovolemic shock discriminated transfusion requirements, massive transfusion and mortality rates significantly better compared to the conventional ATLS classification of hypovolemic shock (p < 0.001).

this benefit after planned extubation in patients with acute respiratory failure of various etiologies remains to be elucidated. The aim of this study was to determine the efficacy of NIV applied immediately after planned extubation in contrast to oxygen mask (OM) in patients with acute respiratory failure (ARF).

A randomized, prospective, controlled, unblinded clinical study in a single center of a 24-bed adult general ICU in a university hospital was carried out in a 12-month period. Included patients met extubation criteria with at least 72 hours of mechanical ventilation due to acute respiratory failure, after following the ICU weaning protocol. Patients were randomized immediately before elective extubation, being randomly allocated to one of the study groups: NIV or OM.We compared both groups regarding gas exchange 15 minutes, 2 hours and 24 hours after extubation, re-intubation rate after 48 hours, duration of mechanical ventilation, ICU length of stay and hospital mortality.

Results : Forty patients were randomized to receive NIV (20 patients) or OM (20 patients) after the following extubation criteria were met: pressure support (PSV) of 7 cmH2O, positive end expiratory pressure (PEEP) of 5 cmH2O, oxygen inspiratory fraction (FiO2) < 40%, arterial oxygen saturation (SaO2) > 90%, ratio of respiratory rate and tidal volume in liters (f/TV) < 105.

Comparing the 20 patients (NIV) versus the 18 patients (OM) that finished the study forty-eight hours after extubation, the rate of re-intubation in NIV group was 5% and 39% in OM group (p=0.016). Relative risk for re-intubation was 0.13 (CI=0.017-0.946). Absolute risk reduction for re-intubation showed a decrease of 33.9%, and analysis of the number needed to treat was 3. No difference was found in the length of ICU stay (p=0.681).

Hospital mortality was 0% in NIV group and 22.2% in OM group (p= 0.041).

Conclusions : In this study population, NIV prevented 48 hours re-intubation if applied immediately after elective extubation in patients with more than three days of ARF when compared to OM group.

Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units:The FINNRESUSCI study Jukka Vaahersalo, Pamela Hiltunen, et al Int Care Med; Volume 39, Issue 5 / May , 2013, Pages 826 – 837

BD may be superior to the current ATLS classification of hypovolemic shock in identifying the presence of hypovolemic shock and in risk stratifying patients in need of early blood product transfusion.

The Authors aimed to evaluate post-resuscitation care, implementation of therapeutic hypothermia (TH) and outcomes of intensive care unit (ICU)-treated out-ofhospital cardiac arrest (OHCA) patients in Finland.

Non-invasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: A randomized controlled trial

They included all adult OHCA patients admitted to 21 ICUs in Finland from March 1, 2010 to February 28, 2011 in this prospective observational study. Patients were followed (mortality and neurological outcome evaluated

by Cerebral Performance Categories, CPC) within 1 year after cardiac arrest.

Susana R Ornico, Suzana M Lobo, et al.

Critical Care 2013, 17:R39 Noninvasive ventilation (NIV) as a weaning facilitating strategy in predominantly chronic obstructive pulmonary disease (COPD) mechanically ventilated patients is associated with reduced ventilator associated pneumonia, total duration of mechanical ventilation, length of intensive care unit (ICU) and hospital stay and mortality. However,

This study included 548 patients treated after OHCA. Of those, 311 patients (56.8 %) had a shockable initial rhythm (incidence of 7.4/100,000/year) and 237 patients (43.2 %) had a non-shockable rhythm (incidence of 5.6/100,000/year). At ICU admission, 504 (92 %) patients were unconscious. TH was given to 241/281 (85.8 %) unconscious patients resuscitated from shockable rhythms, with unfavourable 1-year neurological outcome (CPC 3–4–5) in 42.0 % with TH versus 77.5 % without TH (p < 0.001).TH was given to 70/223 (31.4 %) unconscious patients resuscitated from non-shockable rhythms, with 1-year CPC of 3–4–5 in 80.6 % (54/70) with TH versus 84.0 % (126/153) without TH (p = 0.56). This lack of

difference remained after adjustment for propensity to receive TH in patients with non-shockable rhythms.

Conclusion : One-year unfavourable neurological outcome of patients with shockable rhythms after TH was lower than in previous randomized controlled trials. However, our results do not support use of TH in patients with non-shockable rhythms.

Intermittent pneumatic compression to prevent venous thromboembolism in patients with high risk of bleeding hospitalized in intensive care units:The CIREA1 randomized trial Philippe Vignon, Pierre-François Dequin, et al Int Care Med, Volume 39, Issue 5 / May , 2013 Pages 872 – 880 Venous thromboembolism (VTE) is a frequent and serious problem in intensive care units (ICU). Anticoagulant treatments have demonstrated their efficacy in preventing VTE. However, when the bleeding risk is high, they are contraindicated, and mechanical devices are recommended. To date, mechanical prophylaxis has not been rigorously evaluated in any trials in ICU patients.

In this multicenter, open-label, randomized trial with blinded evaluation of endpoints, the authors randomly assigned 407 patients with a high risk of bleeding to receive intermittent pneumatic compression (IPC) associated with graduated compression stockings (GCS) or GCS alone for 6 days during their ICU stay.The primary endpoint was the occurrence of a VTE between days 1 and 6, including nonfatal symptomatic documented VTE, or death due to a pulmonary embolism, or asymptomatic deep vein thrombosis detected by ultrasonography systematically performed on day 6.

The primary outcome was assessed in 363 patients (89.2 %). By day 6, the incidence of the primary outcome was 5.6 % (10 of 179 patients) in the IPC + GCS group and 9.2 % (17 of 184 patients) in the GCS group (relative risk 0.60; 95 % confidence interval 0.28–1.28;p = 0.19).

Tolerance of IPC was poor in only 12 patients (6.0 %).

No intergroup difference in mortality rate was observed.

Conclusions : With the limitation of a low statistical power, our results do not support the superiority of the combination of IPC + GCS compared to GCS alone to prevent VTE in ICU patients at high risk of bleeding.

Early Identification of Patients at Risk for Difficult Intubation in the Intensive Care Unit Development and Validation of the MACOCHA Score in a Multicenter Cohort Study Audrey De Jong1, Nicolas Molinari2, Nicolas Terzi3, et al. Network for the Frida-Réa Study Group* American J of Resp and Crit Care Med,Vol. 187, No. 8 (2013), pp. 832-839.

Rationale: Difficult intubation in the intensive care unit (ICU) is a challenging issue.

Objectives: To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications.

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Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations.

Measurements and Main Results: In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist).

From the β parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85–0.94).

In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76–0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86–0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001).

Conclusions: Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU.

A Multicenter Randomized Trial of Atorvastatin Therapy in Intensive Care Patients with Severe Sepsis Peter Kruger, Michael Bailey et al and ANZSTATInS Investigators–ANZICS Clinical Trials Group Am J of Resp and Critical Care Medicine, Vol. 187, No. 7 (2013), pp. 743-750.

Observational studies link statin therapy with improved outcomes in patients with severe sepsis.

Objectives: To test whether atorvastatin therapy affects biologic and clinical outcomes in critically ill patients with severe sepsis.

Phase II, multicenter, prospective, randomized, doubleblind, placebo-controlled trial stratified by site and prior statin use.A cohort of 250 critically ill patients (123 statins,

127 placebo) with severe sepsis were administrated either atorvastatin (20 mg daily) or matched placebo.

Measurements and Main Results:There was no difference in IL-6 concentrations (primary end point) between the atorvastatin and placebo groups (P = 0.76) and no interaction between treatment group and time to suggest that the groups behaved differently over time (P = 0.26). Baseline plasma IL-6 was lower among previous statin users (129 [87–191] vs. 244 [187–317] pg/ml; P = 0.01). There was no difference in length of stay, change in Sequential Organ Failure Assessment scores or mortality at intensive care unit discharge, hospital discharge, 28- or 90-day (15% vs. 19%), or adverse effects between the two groups. Cholesterol was lower in patients treated with atorvastatin (2.4 [0.07] vs. 2.6 [0.06] mmol/L; P = 0.006).

In the predefined group of 77 prior statin users, those randomized to placebo had a greater 28-day mortality (28% vs. 5%; P = 0.01) compared with those who received atorvastatin. The difference was not statistically significant at 90 days (28% vs. 11%; P = 0.06).

Conclusions: Atorvastatin therapy in severe sepsis did not affect IL-6 levels. Prior statin use was associated with a lower baseline IL-6 concentration and continuation of atorvastatin in this cohort was associated with improved survival.

Welcome New Members to the ISCCM family 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49

Anirban Chattopadhyay,Hindusthan Naka Jayant Bhandari, Indore Dinesh Singhal, Sri Ganganagar Gurtej Singh Dhaliwal, Sriganga Nagar Rajat Choudhruri, Kolkata Ujjawal Sharma, Siliguri Ajay Mishra, Ramgarh Naveen Sidde Gowda, Tumkur Navneet Garg, Meerut Sushmita Banerjee, Kolkata Joydip Maitra, Kolkata Devender Singh Khurana, Chandigarh Vippan Gongireddy, Hyderabad Banwari Lal, Faridabad Vasim Raja, Jaipur Manoj Kumar Chaurasia, Gultekdi Arvind Dawle, Nanded Sushil Kumar Shukla, Kanpur Rajneesh Kumar Mishra, Agra Beena Daniel, Aurangabad Shoba Menon, Mumbai Sreekanth Yelliboina, Hyderabad Chaitanya Challa, Hyderabad Asha Babar, Satara Biswabikash Mohanty, New Delhi Satish Babar, Dist Satara Janmejaya Nayak, Bhubaneswar Shashidhar Pulgam, Nalgonda (Dist) Sujit Raj, Mangalore Mrinmoy Das, Kolkata Rahul Kubde, Dist Amravati Poonam Bharambe, Pune Sunil Shah, Vadodara Sunil Jain, Jabalpur Shanti Prakash Kujur, Bilaspur Devpriya Lakra, Raipur Gopakumar Pillai, Thiruvanthapuram Arun Vijayakumar, Trivandrum Ashish Kumar Srivastava, Varanasi Bishnu Prasad Sahu, Dist - Ganjam Anjali Zade, Vadodara Jaimin Shah, Gotri Kirandeep Chetia, Jorhat Gurmeet Singh Sandhu, Jabalpur Badari Narayana H.K., Mysore Vinod Kumar Pandey, Dhanbad Harsoor Sidharameshwar, Bangalore Devika Rani Duaggappa, Bangalore Nagender Gupta E., Mahabub Nagar

LM-13/C-277 ALM-13/B-471 LM-13/S-989 LM-13/D-377 LM-13/C-278 LM-13/S-990 LM-13/M-532 LM-13/G-470 LM-13/G-471 LM-13/B-472 ALM-13/M-533 LM-13/K-612 LM-13/G-472 LM-13/L-63 ALM-13/R-393 ALM-13/C-279 LM-13/D-378 LM-13/S-991 LM-13/M-534 LM-13/D-379 LM-13/M-535 LM-13/Y-36 LM-13/C-280 LM-13/B-473 LM-13/M-536 LM-13/B-474 ALM-13/N-190 LM-13/P-550 LM-13/R-394 LM-13/D-380 LM-13/K-613 LM-13/B-475 LM-13/S-992 LM-13/J-312 LM-13/K-614 LM-13/L-64 LM-13/P-551 LM-13/V-209 LM-13/S-993 LM-13/S-994 LM-13/Z-10 ALM-13/S-995 LM-13/C-281 LM-13/S-996 LM-13/K-615 LM-13/P-552 LM-13/S-997 LM-13/D-381 LM-13/E-17

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Kaushik Parmar, Porbandar Adil Al- Amry, Oman Said Ali Azhanshi, Oman Farhana I.M Al Othmani, Oman Saud Salim Al -Ismaili, Oman Manisha Paul, Oman Jagdishchandra S Dhakaan, Rajkot Jayshree Thakkar, Ahmedabad Dilip Kumar Sinha, Kanpur Siddharth Jain, Surat Bilal Ahmed Kavare, Belgaum Bhagirath Dodiya, Gujarat Suchay Parikh, Surat Aloka Samantaray, Tirupati Mukund Kulkarni, Dist Belgaum Mohammed Al Ghafri, Oman Anant Chaudhary, Lucknow Ashit Naik, Post - Shankar Nagar Sanjay Chhabra, Jalandhar Gopal Krishan Singla, Jalandhar Gurmeet Kaur Anand, Jalandhar Mrinal Taye, Guwahati Pollov Borah, Dibrugarh Neha Vora, Dist - Barelliy Pankaj Nilapwar, Pune Ashwini Malhotra, New Delhi Vipin Agarwal, Modi Nagar Mohd Saif Khan, Bangalore Murupudi Nageswara Rao, Vijaywada Trinath Dash, Bhillai Chandrashish Chakravarty, Kolkata Kamal Singh, Chandigarh Navdeep Goyal, Ludhiana Sushant Charde, Nagpur Noble Gracious SS, Thiruvananthapuram Praveen Namboodiri, Kollam Yesoda Papineni, Vishakhapatnam Sunjay Ahluwalia, Vishakhapatnam Kandimalla Chowdary, Vishakhapatnam Jayesh Shah, Valsad Pooja Sarada, Bengaluru Himanshu Chauhan, Meerut Ajay Prasad Hrishi, Trivandrum Beena Unnikrishnan, Trivandrum Biju C Nair, Trivandrum Unnikrishna Varma, Trivandrum Kevin Jacob, Trivandrum Ravindra Wankhede, Kolkata Ravi Patel, Banaskantha

LM-13/P-553 International Life Member-13/A-380 International Life Member-13/A-381 International Life Member-13/O-13 International Life Member-13/I-34 LM (SAARC)-13/P-554 LM-13/D-382 LM-13/T-220 LM-13/S-998 LM-13/J-313 LM-13/K-616 LM-13/D-383 LM-13/P-555 LM-13/S-999 ALM-13/K-617 International Life Member-13/G-473 LM-13/C-282 LM-13/N-191 LM-13/C-283 LM-13/S-1000 LM-13/A-382 LM-13/T-221 LM-13/B-476 ALM-13/V-210 ALM-13/N-192 LM-13/M-519 LM-13/A-371 LM-13/K-592 LM-13/R-382 LM-13/D-371 LM-13/C-270 LM-13/S-956 LM-13/G-454 LM-13/S-957 LM-13/C-271 LM-13/N-184 LM-13/P-530 LM-13/A-372 LM-13/C-272 LM-13/S-958 LM-13/S-959 LM-13/C-273 LM-13/H-82 LM-13/U-41 LM-13/N-185 LM-13/V-203 LM-13/J-306 LM-13/W-47 ALM-13/P-531

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Chetan Shirodkar, North - Goa Ravikumar Malladad, Haveri Ullas Gopalakrishna, Bangalore Chandani Kaneria, Vyara Pratibha Dhingra, Nagpur Langpoklakpam Singh, Imphal Chandan Suresh, Bangalore Mohan Kumar Mahadevaiah, Bangalore Archana Sinha, Mohali Raman Deep Singh, Jalandhar Kamalakar Pawar, Nagpur Ketankumar Chaudhary, Mehsana Serajul Haque Ansari, Agra Saikishore Sathavalli, Palavakkam Kranti Mahendrakar, Mahabubnagar Santosh Kumar, Nagpur Aluru Narmada, Hyderabad Michi Gumbo, Faridabad Bidyutbikas Gharami, Dist 24 Parganas South Sudeep Pathak, Bhopal Tinkal Patel, Surat Pallavi Somkuwar, Mumbai Anil Aurora, Jabalpur Arif Iqbal, New Delhi Hiranmay Bhattacharjya, Duliajan Bhawna Sirohi, Mumbai Sharanya Kumar, Bangalore Sangamesh Kunakeri, Bidar Shashank Kadam, Pune Venkataraman Guru Prakash, Bangalore Amit Kocheta, Bhopal Madhulika Erraguntla, Hyderabad Monisha Sahai, Jaipur Leena Patil, Jalgaon Rasweth Krishnamoorthy, Trichy Sonika Katiyar, Lucknow Vijayant Yadav, Gurgaon Iti Shri, Ghaziabad Muruganantham Mahalingam, Ahemdabad Anjali Modak, Nagpur Pritam Singh, Chandigarh Suresh Babu R, Trivandrum Siddheshwar Bawkar, Mumbai Praveen Peddapyata, Hyderabad Chinmoy Kumar Maity, Kolkata Ishan Kanzaria, Dist - Rajkot Vallish Bhardwaj, Chennai V.Arun Kumar, Theni Dist Payal Ganjsinghani, Hoshngabad Subhasish Jamuda, Dist - Jajpur Bhawna Gupta, New Delhi Rajkumar Motwani, Sardar Nagar Punitkumar Raval, Himmatnagar Raviraj Gurav, Solapur Ashok Sharma, Faridabad Kangkan Handique, Dispur Anirban Biswas, Esat Kolkata Vidyadhara Lakkappan, North Kanara Dist Shaunak Swaminarayan, Ahemdabad Dipesh Fataniya, Ahemdabad Achint Narang, 21 Rakpur Milind Sanap, Pune Dhananjay Khatavkar, Aurangabad Jitensinh Vadher, Porbandar Yusuf Bhambhani, Porbandar Akshay Shrivastava, Rewa Madhana Gopal Palaniappan, Erode Pratheema R, Chennai Manju Mathew, Chennai Himansu Mishra, Chennai Ghanshyam Verma, Distt- Sehore Gangaprasad Gangadhar, Calicut Ashok Rout, Bhubaneswar Sajith Damodaran, Kozhikode Bharatsing Rathod, Nagpur Mehul Netare, Thane Mohan Pujar, Mumbai Amrish Bukkawar, Chandrapur Riddhi Vaghela, Deesa Anandan S.P.S., Titupur Dist Vijayanand Palaniswamy, Coimbatore Sahish Kamat, New Delhi

LM-13/S-960 LM-13/M-520 LM-13/G-455 LM-13/K-593 LM-13/D-372 LM-13/S-961 LM-13/S-962 LM-13/M-521 LM-13/S-963 LM-13/S-964 LM-13/P-532 LM-13/C-274 LM-13/A-373 LM-13/S-965 LM-13/M-522 LM-13/K-594 LM-13/N-186 LM-13/G-456 LM-13/G-457 LM-13/P-533 LM-13/P-534 LM-13/S-966 LM-13/A-374 ALM-13/I-32 LM-13/B-452 LM-13/S-967 LM-13/K-595 LM-13/K-596 LM-13/K-597 LM-13/P-535 LM-13/K-598 LM-13/E-16 LM-13/S-968 LM-13/P-536 LM-13/K-599 LM-13/K-600 LM-13/Y-35 LM-13/S-969 LM-13/M-523 LM-13/M-524 LM-13/S-970 LM-13/R-383 LM-13/B-453 LM-13/K-601 LM-13/M-525 LM-13/K-602 LM-13/B-454 LM-13/K-603 LM-13/G-458 LM-13/J-307 LM-13/G-459 LM-13/M-526 LM-13/R-384 LM-13/G-460 LM-13/S-971 LM-13/H-83 ALM-13/B-455 LM-13/L-60 LM-13/S-972 LM-13/F-19 LM-13/N-187 LM-13/S-973 LM-13/K-604 LM-13/V-204 LM-13/B-456 LM-13/S-974 LM-13/P-537 LM-13/R-385 LM-13/M-527 LM-13/M-528 LM-13/V-205 LM-13/G-461 LM-13/R-386 LM-13/D-373 LM-13/R-387 ALM-13/N-188 LM-13/P-538 LM-13/B-457 ALM-13/V-206 LM-13/S-975 LM-13/P-539 LM-13/K-605

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Imran Gafoor, Raipur Anil Kumar Agarwal, Agra Vijay Anand S, Vellore Dattatrey Goswami, Dist - Junagarh Pradipta Bhattacharya, Kolkata Sandya E.P, Bangalore Mohamed Mubarak Ali, Chennai Niju M L, Thiruvananthapuram Anand S.V, Thivandrum Chandra Shekhar Pardhi, Bhopal P.N Kiran Kumar, Anantapur Keshav Goyal, New Delhi Sachin Deore, Nashik Nisheeth Parameswaran, Chennai Karthik Pandian K.S., Hosur Vasudha Rao, Vellore Dipika Chaoudhury, Guwahati Raj Kishore Singh, Gorakhpur Mehul Patel, Patan Amitkumar Rupala, Rajkot Dileep Kumar Sethi, Alwar Pradhan Bhagirathi, Bhubaneswar Naveen Jain, New Delhi Subhendu Mishra, Jamshedpur Anand Mishra, Jamshedpur Barani Selvan Ramalingam, Mudaliarpet Shamila Shaikh, Mumbai Balasubramaniam Jeyaraj, Tirunelveli Khyati D Bilimoria, Pune Iftekhar Alam, Faridabad Nand Kishore Kalra, Yamuna Nagar Rajesh Shetty, Bangalore L.V Ramakrishna Akkina, Hyderabad Punitkumar Ghetia, Rajkot Karthiraj Natarajan, Coimbatore Yogesh Dholakia, Veraval Hyacinth Paljor, Delhi Yoel Dewa Paljor, Delhi Manu Kumar, Ghaziabad Alpana Bawa, New Delhi Annabatula Chandra Rao, Raipur Hester Gideon S, Tirunelveli (DT) Manish Bathija, Mumbai Vivek Badada, Agra Anil Kumar, Ghaziabad Amit Jain, Dist - Jhansi Arun Kumar B.C., Bangalore Chintan Tijoriwala, Mumbai Manoj Kumar Gupta, Varanasi Anil Kumar Bajaj, Gurgaon Deeksha Singh Tomar, Gurgaon Gaurav Kochhar, Gurgaon Pradeepkumar Hiremath, Rabkavi Smita Sharma, New Delhi Bandana, Hebbal Bhavesh Gandhi, Nerul Sandeep Kadam, Pune Deepak Singh, Dist - Saharanpur Vinod Kumar Lalwani, Raipur Kushal Shah, Ahemdabad Rajkumar Baranwal, Raipur Mahendra Bagul, Hyderabad Asif Iqbal, Kolkata Sanchita Garg, Mohali Chetan Sharma, Mumbai Pushparajgiri Shankaracharya, Gondia Rohan Bhandare, Raigad Raghunath Misra, Ghaziabad Bhagwan Parmar, Dist Junagarh Anusuya S.R, Bangalore Pushpa Priyadarshani, Pune Syed Ashraf Ali, New Delhi Sagar Patil, Mumbai Vinayak Gudekar, Thane Pavan Bade, Aurangabad Vishalkumar Sadatia, Dist- Rajkot Riaz Dastagir, Chennai Sidharth Bawa, New Delhi Mayur Bharali, Guwahati Amit Jain, Sagar Shalini Vinod, Palarivattom

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www.criticare2014.com www.apaccm2014.com

Jaipur CRITICARE 2014 14 - 18 February, 2014

A JOINT MEETING OF

20TH ANNUAL CONFERENCE OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE & 18TH ASIA-PACIFIC CONGRESS OF CRITICAL CARE MEDICINE 2ND ANNUAL CONFERENCE OF CRITICAL CARE NURSES SOCIETY

Its all first - ISCCM, APACCM & CCNS together  Its Jaipur

 The Charm of Awesome historic Sisodiya Rani Gardens

 Talent at its best

 Its Rendezvous Birla Auditorium

 The Mystic Rajputana Hospitlaity at its best

 Weather at it best

 Just think of Coming

 Jambooree of Knowledge, skill, training, workshop, fellowship and celebrations

TENTATIVE INTERNATIONAL FACULT Y  Mitch Levy, USA  Neil mcintyre, USA  Luciano Gatinoni, Italy

 Sangita Mehta, Canada  Anthony Mclean, Australia  Marine Kollef, USA

 Niranajn Kisson, Canada  Vinay Nadkarni, USA  Peter Remensberger, Switzerland

 Edgar Jimiens, USA  Younchuk Koh, Korea  Marc Saphiro, USA

 Luca Neri, Italy  Ravindra Mehta, USA

BEST OF INDIAN FACULTY, A BLEND OF EXPERIENCE AND FRESH TALENT FROM EAST TO WEST AND NORTH TO SOUTH TOP SESSIONS ON

 Sepsis

 Tropical Fever

 Multiorgan Failure

 Reviews

 Antibiotcs

 Ventilation

 The Talk of the town

 Whats in store for future

PLENARIES, SEMI PLENARIES, PANEL DISCUSSIONS, ORATIONS, AWARDS, MEET THE EXPERTS, THEME SESSIONS, SPONSORED SESSIONS, PARALLEL ADULT, PEDIATRIC AND NURSING SESSIONS AS NEVER BEFORE

Above All - You will have the Newly Discovered Indian Talent on the fore Dr. H. Bagaria

Organising Chairman

Conference Secretariat

Dr. Manish Munjal

Organising Secretary

Dr. Narendra Rungta

President, ISCCM Congress Chairman & Chairman, Scientific Committee

Dr. Manish Munjal Organising Secretary

Jeevan Rekha Critical Care and Trauma Hospital Mahal Yojna, Central Spine, Near Akshay Patra Temple, Jagatpura, Jaipur 302025 INDIA Tel. : +91 141 515 50 50 • (Direct) +91 141 515 50 75 • Fa x : 011 4582 3473 e-mail : Dr. Narendra Rungta [drnrungta@jeevanrekhahospital.in] Dr. Manish Munjal [drmmunjal@hotmail.com • manish@jeevanrekhahospital.in]

Published By : Indian Society of Critical Care Medicine For Free Circulation Amongst Medical Professional Unit 6, First Floor, Hind Service Industries Premises Co-operative Society, Near Chaitya Bhoomi, Off Veer Savarkar Marg, Dadar, Mumbai – 400028 Tel.: 022-24444737 • Telefax: 022-24460348 • email: isccm1@gmail.com • isccm1@vsnl.net Printed at : urvi compugraphics • 022-2494 5863 • email : urvi@urvi.cc

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Dr. Shivakumar Iyer

Karnik Heritage, Flat No 08, 3rd floor, Sadubhau Kelkar Road, Off F. C. Road, Pune - 411004, Maharashtra. Phone : 020-25532320 (from 11 am to 3 pm)

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