Dr K K Aggarwal

Azharuddin’s son Ayazuddin a victim of missed resuscitation during the Golden Hour?

Ayazuddin (19), son of former cricketer and Moradabad MP Mohammad Azharuddin, died on 16th September (2011) five days after being critically injured in a road accident in Hyderabad. He was critically injured when his 1000 CC Suzuki skidded on the Outer Ring Road at Puppalguda on Sunday. His cousin died on the same day.

Ayazuddin suffered a cardiac arrest on his way to the hospital. He responded to resuscitation and was later operated on to stop the bleeding from his lung and kidney. His kidneys were also damaged. Commuters on the route alerted the police and a patrol vehicle from a nearby police station arrived soon. The police team failed to get an ambulance and had to take the profusely bleeding cousins in their patrol vehicle to the hospital, losing an hour in the process.

Medically the lesson is that opportunity to save him was list as the precious first hour was missed of resuscitation.  The “Golden Hour” concept emphasizes the increased risk of death and the need for rapid intervention during the first hour of care following major trauma. Rapid intervention improves the outcome of injured patients (obstructed airway, tension pneumothorax, severe hemorrhage).

Death in road traffic accident can be a part of trimodal distribution of mortality (death at the scene; death 1 to 4 hours after injury; and death weeks later, generally in an intensive care setting) or bimodal distribution (death at the scene or within the first 4 hours).

The current thinking is that relatively few patients die after the first 24 hours following injury. The large majority of deaths occurs either at the scene or within the first four hours after the patient reaches a trauma center. This is true only when the patient gets medical care within the first hour. The care involves fluid resuscitation and control of the bleeding.

Ventilator-associated tracheobronchitis

Ventilator-associated tracheobronchitis (VAT) has the same clinical implications as ventilator-associated pneumonia (VAP). An observational study of 28 patients with VAT and 83 patients with VAP [1] showed that VAT groups had a similar length of intensive care unit stay, length of hospital stay, duration of mechanical ventilation, survival rate to discharge, need for tracheostomy, and need for antibiotics.

Ventilator induced diaphragmatic atrophy

Controlled mechanical ventilation can lead to a very rapid type of disuse atrophy involving the diaphragmatic muscle fibers. An observational study found that diaphragmatic strength decreased progressively during mechanical ventilation and that long-term (>24 hours) mechanical ventilation was associated with diaphragmatic muscle injury, atrophy, and proteolysis compared to short-term mechanical ventilation (2-3 hours).(2)

Starting enteral nutrition in a patient on ventilator

Starting enteral nutrition with a low infusion rate improves tolerability, compared to initiation at the target rate. A randomized study of 200 mechanically ventilated patients showed that enteral feeding ( at the target rate or at 10 mL/hr for six days before being incrementally increased to the target rate) showed no differences in mortality, ventilator-free days, or ICU-free days, but the group that began at the target rate had more episodes of elevated gastric residual volumes and a trend toward more diarrhea. (3)

References
1. Dallas J, Skrupky L, Abebe N, et al. Ventilator-associated tracheobronchitis in a mixed surgical and medical ICU population. Chest 2011;139:513-8.
2. Jaber S, Petrof BJ, Jung B, et al. Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med 2011;183:364-71.
3. Rice TW, Mogan S, Hays MA, et al. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med 2011;39:967-74.

New Delhi metallo-beta-lactamase (NDM-1)

Enterobacteriaceae isolates carrying a novel MBL gene, the New Delhi metallo-beta-lactamase (NDM-1) was first described in December 2009 in India with Klebsiella pneumoniae (1). Later, it was described in patients who had traveled to and undergone procedures in India and Pakistan (2). Cases were also reported in Asia, Europe, and North America (2-4). Isolates have also included E. coli and Enterobacter cloacae (2).

Risk factors

1. Recent treatment with carbapenem
2. Indwelling urinary or venous catheters
3. Severe illness (5)
4. NDM-1 can inactivate all beta-lactams except aztreonam.

Salient points

1.    It is an important emerging resistant pathogen (6).

2.     NDM1 isolates are susceptible to colistin or tigecycline

3.    The susceptibility is short-lived.

4.     NDM-1 has been identified in public water supplies in India (7)

References

1. Yong D, Toleman MA, Giske CG, et al. Characterization of a new metallo-beta-lactamase gene, bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother 2009;53:5046.
2. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597.
3. Centers for Disease Control and Prevention (CDC). Detection of Enterobacteriaceae isolates carrying metallo-beta-lactamase – United States, 2010. MMWR Morb Mortal Wkly Rep 2010;59:750.
4. Sidjabat H, Nimmo GR, Walsh TR, et al. Carbapenem resistance in Klebsiella pneumoniae due to the New Delhi Metallo-β-lactamase. Clin Infect Dis 2011;52:481.
5. Deshpande P, Shetty A, Kapadia F, et al. New Delhi metallo 1: have carbapenems met their doom? Clin Infect Dis 2010;51:1222.
6. Nordmann P, Poirel L, Toleman MA, Walsh TR. Does broad-spectrum {beta}-lactam resistance due to NDM-1 herald the end of the antibiotic era for treatment of infections caused by Gram-negative bacteria? J Antimicrob Chemother 2011;66:689.
7. Walsh TR, Weeks J, Livermore DM, Toleman MA. Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study. Lancet Infect Dis 2011;11:355.