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CRITICAL CARE UPDATE 2017 Editors Subhash Todi MD MRCP Director Department ofCritical Care Advanced Medicare Research Institute Kolkata, West Bengal, India Atul PKulkarni MD FISCCM PGDHHM FICCM Professor and Head Department of Anesthesiology, Critical Care Medicine and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Kapil Zirpe MD FCCM F1CCM Director Neuro Trauma Unit Ruby Hall Clinic Pune, Maharashtra, India The Health Sciences Publisher New Delhi I London I Panama • j ~\ 'J~: Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83Victoria Street, London SW1 H OHW (UK) Phone: +44 203170 8910 Fax: +44 (0)20 3008 6180 Email: info@.ipmedpub.com Jaypee Brothers Medical publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 ~angladesh Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bid 237, Clayton Panama City, Panama Phone: +1 507-301-0496 Fax: +1507-301-0499 Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone:+977-97412836Q8 Email: kath~andu@jaypeebrothers.com , " Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2017, Jaypee Brothers Medical Publishers The views and opinions expressed inthisbook aresolely those oftheoriginal contributor(s)/author(s) and donotnecessarily represent those ofeditor(s) ofthebook All rights reserved No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without theprior permission in writing ofthepublishers All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their : respective owners The publisher is notassociated with any product orvendor mentioned inthisbook Medical knowledge and practice cbange constantly This book is designed to provide accurate, authoritative information about the subject matter in question However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications It is the responsibility ofthe practitioner to take all appropriate safety precautions Neither the publisher northe author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material inthisbook This book is sold on the understanding thatthe publisher is notengaged in provi~ing professional medical services If such advice or services arerequired, the services of a competent medical professional should besought Every effort has been made where necessary to contact holders ofcopyright to obtain permission to reproduce copyright material Ifany have been inadvertently overlooked, the publisher will bepleased to make the necessary arrangements atthefirst opportunity Inquiries for bulk salesmaybesolicited at: jaypee@jaypeebrothers.com Critical Care Update 2017 /Subhash Todi, Atul PKulkarni, Kapil Zirpe First Edition: 2017 • ISBN: 978-93-86261-15-1 Printed at Sanat Printers iI j- l~ Contributors EDITORS Subhash Todi MD MRCP Director Department of Critical Care Advanced Medicare Research Institute Kolkata, West Bengal, India Atul PKulkarniMD FISCCM PGDHHM Professor and Head Department of Anesthesiology, Critical Care Medicine and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Kapil Zirpe MD FCCM FICCM Director Neuro Trauma Unit Ruby Hall Clinic Pune, Maharashtra, India Rahul A Pandit MD FJFICM FCICM EDIC FCCP DA Director, Department of Intensive Care Fortis Hospital and Healthcare Mumbai, Maharashtra, India Pradeep Rangappa DNB FJFICM EDIC FClCM, P9DipECHO MBA FICCM PGDMLE Senior Specialist Department of Intensive Care Columbiaasia Referral Hospital Bangalore, Karnataka, India SECTION EDITORS Arvind KBaronia MD Professor and Head Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India Rajesh Chawla MD FCCM FCCP Senior Consultant Department of Respiratory, Critical Care and Sleep Medicine Indraprastha Apollo Hospitals, New Delhi, India Shivakumar Slyer MD DNB EDIC Professor and Head Department of Critical Care Medicine Bharati Vidyapeeth Deemed University Medical College Pune, Maharashtra, India Dilip RKarnad MD FACP FRCP Consultant Department of Critical Care Jupiter Hospital Thane, Maharashtra, India Vijaya P Patil MD Professor, Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India BananiPoddarMDDNB Professor Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India Ramakrishnan NAB (Int Med) AB (Crit Care) AB (Sleep Med) MMM FACP FCCP FCCMFICCM Senior Consultant Department of Critical Care and Sleep Medicine, Apollo Hospitals Chennai, Tamil Nadu,lndi: Jayant RShelgaonkar DA MD FRCA FICCM Associate Director Department of Critical Care Aditya Birla Memorial Hospital Pune, Mahrashtra, India Shrikanth Srinivasan MD DNB FNB EDIC Senior Consultant Department of Critical Care Medicine Medanta-The Medicity Gurgaon, Haryana, India KVinodanMD DA Head Department of Anesthesia and Critical Care Medical Trust Hospital Cochin, Kerala, India Critical Care Update 2017 ~ CONTRIBUTING AUTHORS Chu-Chu A MBBS Nikhill\l Balankhe MD Devawrat RBuche MD FNB Department of Anesthesia Kingston Hospital Kingston, United Kingdom Director Department of Critical Care Orange City Hospital and Research Institute Nagpur, Maharashtra, India Clinical Associate Department of Centre for Critical Care BLK Superspeciality Hospital New Delhi, India Ankur Agrawal MDDM DMFeilow Department of Pulmonary and Critical Care Medicine Post Graduate Institute of Medicine Sciences Rohtak, Haryana, India ~ "" ""'" Vignesh C MD FNB EDIC Susruta Bandyopadhyay MD Director Department of Critical Care AMRI Hospitals Kolkata, West Bengal, India Consultant Department of Critical Care Apollo Hospitals Chennai, Tamil Nadu, India Chandrashish Chakravarty MD Vandana Agarwal MD FRCA Rajan Barokar MD EDIC MNAMSEDIC Professor Department of Anesthesia, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Director and Consultant Aditya Hospital Critical Care and Emergency Centre Nagpur, Maharashtra, India Consultant Department of ICU Apollo Gleneagles Hospitals Kolkata, West Bengal, India Rinaldo Bellomo MD FRACP FClCM Matthew JChan BMedSci PGDipEcho FAHMS Research Fellow Department of Intensive Care Austin Health Heidelberg, Victoria, Australia Nayana SAmin MD Protessor Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Andrew CArgent MBBCh Mmed MD FCPeds DCH FRCPCH Professor and Medical Director PICU Department of Pediatric Intensive Care Red Cross War Memorial Children's Hospital and University of Cape Town Cape Town, South Africa • Professor Department of Intensive Care Medicine University of Melbourne Parkville, Victoria, Australia Dhruva Chaudhry MD DNB OM Vikas Bhagat MD DOMS FICCM FICP Senior Registrar Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Mahrashtra, India Senior Professor and Head Department of Pulmonary and Critical Care Medicine Post Graduate Institute of Medicine Sciences Rohtak, Haryana, India lata Bhattacharya MD Consultant Department of Critical Care Medicine Fortis Memorial Research Institute Gurgaon, Haryana, India Gagan Brar MD FNB IDCC EDIC Pradip KBhattacharya MD FICCM Aakanksha Chawla MD FCCM FCCP Consultant Department of Critical Care and Emergency Services Narayana Health Bangalore, Karnataka, India FCCCM Senior Resident Department of Respiratory, Critical Care andSleep Medicine Indraprastha Apollo Hospitals New Delhi, India Mildhur Arora MD IDCCM Attending Consultant Department ofCritical Care Medicine Fortis Memorial Research Institute Gurgaon, Haryana, India Director Emergency and Critical Care Services Chirayu Medical College and Hospital Bhopal, Madhya Pradesh, India Vipal Chawla MD IDCCM Khusrav BBajan MD EDIC Consultant Depatement of Critical Care PD Hinduja National Hospital and Medical Research Centre Mumbai, Maharashtra, India vi Munish Chauhan MD FNB EDIC Senior Consultant Department of Anesthesiology and Critical Care JLN Cancer Hospital Bhopal, Madhya Pradesh, India Neeta Bose MD Associate Professor Department of Anesthesia GMERS Medical College Vadodara, Gujarat, India Associate Consultant Medanta Institute of Critical Care and Anesthesia Medanta-The Medicity Gurgaon, Haryana, India ," Contributors Maurizio Cecconi MD FRCA FFICM MD Supradip Ghosh Dip Intensive Care Sushma KGurav DNB IDCCM Consultant and Reader Department of Anesthesia and Intensive Care Medicine StGeorge's University Hospitals NHS Foundation Trust StGeorge's University of London London, United Kingdom Additional Director and Head Department ofCritical Care medicine Fortis Escorts Hospital Faridabad, Haryana, India Intensivist Neuro-trauma Unit Grant Medical Foundation Ruby Hall Clinic Pune, Maharashtra, India Ravi Varma Durai Pandian MD FNB EDIC Associate Consultant Department of Intensive Care Medicine Apollo Hospital Chennai, Tamil Nadu, India Raymond D MD DM EDIC Consultant Department of Critical Care Apollo Hospitals Chennai, Tamil Nadu, India Kanishka Davda DNB Fellow of National Board Department of Infectious Diseases PD Hinduja National Hospital and Medical Research Centre Mumbai, Maharashtra, India Palepu BGopal MD FRCA CCST FICCM FCCM Consultant and HOD Department of Critical Care Medicine Continental Hospitals Hyderabad, Telangana, India Prabhas PGiri MD MRCPCH Assistant Professor and In-Charge PICU Department of Pediatrics Institute of Child Health Kolkata, West Bengal, India Anish Gupta MD Fellow FNB Institute of Critical Care Medicine Max Super Speciality Hospital New Delhi, India Rahul BAmte MD IDCCM EDIC Consultant Department of Critical Care Medicine Yashoda Hospitals Hyderabad, Telangana, India Nimita Deora MSc Clinical Research Assistant Department of Anesthesiology and Critical Care Chirayu Medical College and Hospital Bhopal, Madhya Pradesh, India Deepak Govil MD FCCM EDIC FICCM Sandeep Dewan DA DNB IDCCM James Hanison FRCA Consultant Department of Anesthesia and Intensive Care Medicine Manchester Royal Infirmary United Kingdom Ashit V Hegde MD MRCP Consultant Department of Medicine and Critical Care PD Hindula National Hospital Mumbai, Maharashtra, India Javed Ismail MD DM • • Consultant Department of Pediatrics Post Graduate Institute of Medical Education and Research Chandigarh, India Jose Chacko MD DA DNB EDIC Director Department of Critical Care Medicine Medanta-The Medicity Gurgaon,_ Haryana, India Consultant and Head Department of Critical Care and Emergency Services Narayana Health Bangalore, Karnataka, India Navya Guwalani PG Gaurav Jain MD PDCC Director and Head Department ofCritical Care Medicine Fortis Memorial Research Institute Gurgaon, Haryana, India Clinical Reseacrh Officer Department of Anesthesiology and Critical Care Chirayu Medical College and Hospital Bhopal, Madhya Pradesh, India Assistant Professor Department of Anesthesiology Institute of Medical Sciences Banaras Hindu University Varanasi, Uttar Pradesh, India Jigeeshu VDivatia MD FCCM FISCCM Abhinav Gupta MD DNB FNB EDIC Professor and Head Department of Anesthesiology, Critical Care andPain Tata Memorial Hospital Mumbai, Maharashtra, India Additional Medical Superintendent and Head School of Medical Sciences and Research, Sharda Hospital Sharda University Greater Noida, Uttar Pradesh, India Subhal BDixit MD IDCCM FICCM FCCM ,Director Department of Intensive Care Sanjeevan Hospital and MJM Hospital Pune, Maharashtra, India Sachin Gupta MD IDCCM IFCCM EDIC Senior Consultant Department of Critical Care Medicine Medanta-The Medicity Gurgaon, Haryana, India Yash Javeri DAIDCCM Director Department ofCritical Care Medicine Apex Healthcare Consortium New Delhi, India Sameer AJog MD IDCCM EDIC Consultant Intensivist Department of Emergency Medicine and Critical Care Deenanath Mangeshkar Hospital Pune, Maharashtra, India vii Critical Care Update 2017 Deven Juneja DNB FNB EDIC FCCM Krishna PMulavisala MD FRCA Saumen Meur DCH MRCPCH FRCPCH CCT Principal Consultant Department of Critical Care Medicine Max Super Speciality Hospital New Delhi, India Consultant Department of Anesthesiology Global Hospitals Hyderabad, Telangana, India Consultant Pediatric Intensivist Department of Pediatric Cardiology BM Birla Heart Research Centre Kolkata, West Bengal, India Sunil Karanth MD FNB EDIC FCICM Rajesh Pande MD PDCC FICCM FCCM Sheila NMyatra MD FCCM FICCM Chairman, Consultant, and Head Department of Critical care services Manipal Health Enterprise (P) Ltd Bangalore, Karnataka, India Director BLK Center forCritical Care BLK Superspeciality Hospital New Delhi, India Professor Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, Idia Mohit Kharbanda MD IDCCM FNB Samidh BPatel MD Director Department of Critical Care Desun Hospital Kolkata, West Bengal, India In-Charge Department of Critical Care Manik Hospital and Research Center Aurangabad, Maharashtra, India Ruchira WKhasne DA DNB IDCCM Kinjal Patel MD EDAICEDIC Consultant Department of Critical Care Apollo Hospital Nashik, Maharashtra, India Clinical Assistant Department of Lab Medicine Hinduja Hospital and Medical Research Centre Mumbai, Maharashtra, India Khalid I Khatib MD Sweta Patel MD IDCCM Professor Department of Medicine Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant, Medanta Institute of Critical Care and Anesthesia Medanta-The Medicity Gurgaon, Haryana, India Harish M Maheshwarappa MD DNB Jagadeesh KN MBBS IDCCM DM EDIC Consultant, Medanta Institute of Critical Care and Anesthesia Medanta-The Medicity Gurgaon, Haryana, India Consultant and Head Department of Critical Care Medicine Yashoda Hospitals Secunderabad, Telangana, India Niranjan Kissoon FRCPC FAAP FACPE Arghya Majumdar MD DNB MR~P MCCMCPE Director and Head Department of Nephrology AMRI Hospitals Kolkata, West Bengal, India Professor Department of Pediatrics University of British Columbia and BC Children's Hospital British Columbia, Vancouver, Canada Rohit V Kodagali MD Medical Advisor Medical Department Boehringer Ingelheim Mumbai, Maharashtra, India • viii Amit M Narkhede MD DNB Senior Resident Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Prashant Nasa MD FNB EDIC ClC FCCP FICCM Specialist and Head Department of Critical Care Medicine NMC Speciality Hospital Dubai, United Arab Emirates Anand M Nikalje MD Medical Director and In-Charge Department of Medicine and Critical Care MIT Hospital and Research Institute Aurangabad, Maharashtra, India Odiraa ( Nwankwor MD MPH FAAP Consultant Department of Pediatrics Children's Regional Hospital atCooper University Hospital Camden, New Jersey, USA Consultant Department of Pediatrics Alfred I DuPont Hospital for Children Wilmington, Delaware, USA Mohan AMathew MD Director Department of Anesthesia and Critical Care Lakeshore Hospital Kochi, Kerala, India Divya Pal MD IDCCM Fellow (FNB) Critical Care Institute of Critical Care and Anesthesiology Medanta-The Medicity Gurgaon, Haryana, India Yatin Mehta MD MNAMS FRCA FAMS Sadanand SKulkarni MD FIACTA FICCM FTEE Vice-President Department of Medical Affairs and Clinical Research Fresenius Kabi India Pvt Ltd Pune, Maharashtra, India Chairman Institute of Critical Care and Anesthesiology Medanta-The Medicity Gurgaon, Haryana, India • JV Peter MD DNB MAMS FRACP FJFICM FClCM FICCM Professor and Head Medical Intensive Care Unit Christian Medical College Vellore, Tamil Nadu, India Contributors Natesh RPrabu MD DNB DM EDIC Sriram Sampath MD Manoj KSingh MD DNB FNB Specialist Registrar Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Professor and Director Department of Critical Care Medicine StJohn's Medical College and Hospital Bangalore, Karnataka, India Consultant Department of Critical Care Apollo Hospital International Ltd Ahmedabad, Gujarat, India Ramesh Venkataraman AB (1M) AB (CCM) Gauri Saroj MD IDCCM EDIC Senior Consultant Department of Critical Care Medicine Apollo Hospitals Chennai, Tamil Nadu, India Consultant Department of Critical Care Jupiter Hospital Thane, Maharashtra, India Suresh Ramasubban FACP FCCP AB Sanjith Saseedharan IDCCM EDIC Senior Consultant Department of Pulmonary and Critical Care Medicine Apollo Gleneagles Hospital Kolkata, West Bengal, India Head Department of Critical Care SL Raheja Hospital-AFortis Associate Mumbai, Maharashtra, India Banambar Ray MD FICCM Pratik Savaj DNB Omender Singh MD FCCM Director Institute of Critical Care Medicine Max-Super Speciality Hospital New Delhi, India Saswati Sinha MD IDCCM EDIC FNNCC DA FIMSA Chief Consultant Department of Critical Care and Anaesthesia' Apollo Hospitals Bhubaneswar, Odisha, India Fellow of National Board Department of Infectious Diseases PD Hinduja National Hospital and Medical Research Centre Mum,bai, Maharashtra, India Sumit Ray MD FICCM Mozammil Shafi MD FNB Senior Consultant and Vice-Chairperson Department of Critical Care and Emergency Medicine Sir Gangaram Hospital New Delhi, India Associate Consultant Institute of Critical Care and Anesthesiology Medanta-The Medicity Gurgaon, Haryana, India Camilla Rodrigues MD Prakash Shastri MD FRCA FICCM Consultant Department of Lab Medicine Hinduja Hospital and Medical Research Centre Mumbai,Maharashtra, India Senior Consultant and Vice-Chairman Department of Critical Care and Emergency Medicine SirGangaram Hospital New Delhi, India Samir Sahu MD FICCM Suhail SSiddiqui MD FCCM DM Director Department of Critical Care and Pulmonology AMRI Hospitals Bhubaneswar, Odisha, India Specialist Senior Resident Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Mahrashtra, India Arijit Samanta DA MD FNB Dinesh KSingh MD FICCM FNB trainee Department of Critical Care and Emergency Medicine Sir Gangaram Hospital New Delhi, India Professor Department of Anesthesiology Institute of Medical Sciences Banaras Hindu University Varanasi, UttarPradesh, India Consultant Department of Critical Care AMRI Hospitals Kolkata, West Bengal, India Mehul KSolanki MD FNB Consultant Department of Critical Care BAPS Yogiji Maharaj Hospital Ahmedabad, Gujarat, India Rajeev Soman MD Consultant Department of Internal Medicine and Infectious Diseases PD Hinduja National Hospital and Medical Research Centre Mumbai, Maharashtra, India Peter ESpronk MD PhD EDIC FCCP Director Department of Intensive Care Medicine Gelre Hospitals Apeldoorn Apeldoorn, The Netherlands T Shyam Sunder MD PDCC FICCM Medical Director Thumbay Hospital Hyderabad, Telangana, India Nisha Tipparaju MBBS ICU Medical Officer Thumbay Hospital Hyderabad, Telangana, India Deeksha STomar DA IDCCM IFCCM Associate Consultant Department of Critical Care Medicine Medanta-The Medicity Gurgaon, Haryana, India ix Critical Care Update 2017 Younsuck Koh MD PhD FCCM Sushma Patil MD • Sharmili Sinha MD DNB EDIC Professor Department of Pulmonary and Critical Care Medicine Asan Medical Center University of Ulsan College of Medicine Songpa-gu, Seoul, Korea Consultant In-Charge Neuro Trauma Unit, Ruby Hall Clinic Pune, Maharashtra, India Senior Consultant Department of Critical Care Medicine Apollo Hospitals Bhubaneswar, Odisha, India Mahesh Nirmalan MD FRCA PhD FFICM Faculty of Biology, Medicine and Health Consultant, Intensive Care Medicine Manchester Royal Infirmary University of Manchester and Central Manchester Foundation Trust Manchester, United Kingdom Saroj KPattnaik DNB IDeCM Consultant, Department of Critical Care Medicine, Apollo Hospitals Bhubaneswar, Odisha, India Srinivas Samavedam MD FNB EDIC FRCP Head, Department of Critical Care Virinchi Hospitals Hyderabad, Telangana, India x EDIC Sunit CSinghi MD FlAP FAMS FISCCM Consultant Intensivist Department of Emergency Medicine and Critical Care Deenanath Mangeshkar Hospital Pune, Maharashtra, India FICCMFCCM • Head Department of Critical Care Niramaya Hospital Pune, Maharashtra, India DNBDMLE Swapnil RPatharekar MD IDCCM IFCCM Sunitha BVarghese DNB IDeCM EDIC Director-Principal Maharishi Markandeshwar Institute of Medical Sciences and Research Ambala, Haryana, India Ximena Watson MbCHb Department of Anesthesia Kingston Hospital Kingston, United Kingdom Preface Dear Friends It is indeed a proud moment for Indian Society of Critical Care Medicine (ISCCM) to launch the first Critical Care Update 2017 book during itsannual congress in Kochi Over theyears, attendance atISCCM congress has been increasing exponentially and ascientific congress book highlighting the key topics discussed inthecongress was long overdue This book has around 80 chapters authored by national and international faculty covering all the major topics which will be discussed during thecongress This update will highlight therecent advances made inthefieldofcritical care with special reference to its relevance and application in resource limited settings A special section on "Economics of ICU" is worth mentioning We sincerely hope this book will be useful bothfor young intensivists to promote analytical thinking, post graduates to keep abreast of recent advances, and also to senior clinicians The publication of thls book was possible only through ajoint effortfrom themembers of theeditorial board, authors, and the publisher We hope this book willcontinue to bepublished in thefuture congresses - Subhash Todi Atul PKulkarni Kapil Zirpe .,.- ,.- r .,. ,. i CHAPTER 30:Nutrition Guidelines: What isNew? -TABLE Nutrition Risk Screening 2002 Initial riskscreening Yes IsBMI • 'No I_s_t~~ pa~!en_~_s~\le!eIX~I?(e_.9., iflintensiv~th~rap~) _ Ifthe answer is"Yes" to anyquestion, the screening in final screening isperformed Iftheanswer is"No" to allquestions, the patientis rescreened at weekly intervals If the patientisscheduled for a major operation, a i preventive nutritioncare plan isconsidered to avoid theassociated risk status y!n~1 s~!_e~n!!:~L • Impaired nutritional status • Severity of disease (increase in requirements) , Absent ' Normal nutritionalstatus : (Score 0) rMiId(Scor~-1)TW~gj,t-i~~~-;5o/~j~ 3~~~-th-~ - Normal nutritional requirement Absent (Score 0) _ .~ -" " .- ~-, Mild{Score 1) , or - Food intake below50-75% of normal requirement in - -_:_p~~~~~-~-~~~ - - - I , Moderate (Score 2) I ~ - Moderate - (Score 2) Weight loss >5% in months or BMI1 8.5-20.5 + impaired general condition or Food intake 25-50% of normal requirement in preceding week : Severe , (Score 3) Hip fracture" Chronic patients in particular with complications: Cirrhosis*, COPD* ~~!?fl~~~I!'~_~_a_ly~~~~~~!.e_~~?fl~?I?~L_ ; Majorabdominal surgery* , Stroke" : Severe pn.eumonia, hematologic malignancy _ _L Severe (Score 3) i Weight loss >5% in month(>15% in months) [ or ~ ~ -~ , Head injury Bone marrow transplantation , Intensive care (APACHE>10) : BMI 50% of the time The role of non culture-based tests (biomarkers and polymerase chain reaction) has not yet been estnblished Definite diagnosis may not always be possible or may be delayed Physicians quite often have to, therefore, resort to empiric therapy in sick patients with one or more risk factors forfungal infections Some studies have shown increased mortality with PFI20 whereas other studies (usually performed in specialized tertiary care cenrersj" have not shown any increase in mortality Early institution of antifungal therapy seems to decrease mortality But most studies suggest that PFI increase morbidity, utilization ofICU resources, and cost CONCLUSION Pancreatic fungal infections are being increasingly recognized and definitely contribute to morbidity if not \ CHAPTER 31:Fungal Sepsis in Acute Necrotizing Pancreatitis 1 S .c n e e 'y e mortality In India, most infections are caused by azole sensitive Candida Fine needle aspiration cytology of the necrotic tissue is the onlywayto confirmPFI Most patientswithriskfactors mayneed empirictherapy Fluconazole may be used forall but the most sickpatients in whom liposomal amphotericin may be preferred Appropriate early management (avoid antibiotics, feed enterally early, and avoid TPN) is probablybetter than drug prophylaxis at preventing PFI l; REFERENCES _ If, IS ·e I ts y, d n e ts ,e d It d h Wisplinghoff H, Bischoff T, Tallent SM, et at Surveillance and Control of Pathogens of Epidemiologic Importance (SCOPE) study Clin Infect Dis 2004;39:309-17 Parameswaran R, Sherchan JB, Varma DM, et atIntravascular catheter-related infections in an Indian tertiary care hospital JInfect Dev Ctries 2011 ;5:452-8 Banks PA, BollenTL, Dervenis C, et atClassification of acute pancreatitis-2012: revision of Atlanta classification and definitions by international consensus Gut 2013;62:102-11 Garcia-Vidal C, Viasus D, Carratala J.Pathogenesis of invasive fungal infections Curr Opin Infect Dis 2013;26:270-6 Chakrabarti A, Sood P, Rudramurthy SM, et al Incidence, characteristics and outcome of ICU-acquired candidemia in India Intensive Care Med 2015;41 :285-95 Gardner TB, Vege SS, Chari ST, et at Faster rate of inaial fluid resuscitation in severe acute pancreatttis diminishes in-hospital mortality Pancreatology 2009;9:770-6 de-Madaria E, Soler-Sala G, Sanchez-Paya J,et al Influence of fluid therapy on the prognosis of acute pancreatitis: a prospective cohort study Am J Gastroenterol 2011;106:1843-50 Beger HG, Rau B, Mayer J, et al Natural course ofacute pancreatitis World J Surg 1997;21 :130-5 Richter JM, Jacoby GA, Schapiro RH, et al Pancreatic abscess due to Candida albicans.Ann Intern Med.1982;97:221-2 10 Jiang K, Huang W, Yang XN, et al Present and future of prophylactic antibiotics for severe acute pancreatitis World J Gastroenterol 2012;18: 279-84 11 Vi F, Ge L, Zhao J,Lei Y, et al Meta-analysis: total parenteral nutrition versus total enteral nutraion in predicted severe acute pancreatitis Intem Med 2012;51 :523-30 12 De Waele J, Vogelaers D, Decruyenaere J,et al Infectious complications of acute pancreatitis Acta Clin Belg 2004;59:90-6 13 Grewe M, Tsiotos GG, deLeon EL, et al Fungal infection in acute necrotizing pancreatitis JAm Coli Surg 1999;188:408-14 14 Chakrab2rti A, Rao P, Tarai B, et al Candida in acute pancreatitis Surg Today 2007;37:207-11 15 Uhl W, Warshaw A,lmrie C, et al.IAP Guidelines for the Surgical Management of Acute Pancreatitis Pancreatology 2002;2:565-73 16 Banks PA, Gerzof SG, Langevin RE, et al CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome Int J Pancreatology 1995;18:265-70 17 Shrikhande S, Friess H, Issenegger C, et al Fluconazole penetration into pancreas Antimicrob Agents Chemother 2000;44:2569-71 18 Mouli VP, Vishnubhatla S, Garg PK Efficacy 01 conservative treatment, without necrosectomy, for infected pancreatic necrosis: asystematic review and meta analysis Gastroenterology 2013;144:333-40 19 De Waele JJ, Vogelaers D, Blot S, et al Fungal infections in patients with severe acute pancreatitis and the use of prophylactic therapy Clin Infect Dis 2003:37;208-13 20 Connor S, A1exakis N, Neal T, Raraty M, et al Fungal infection but not type of bacterial infection isassociated with ahigh mortality in primary and secondary infected pancreatic necrosis Dig Surg 2004;21 :297-304 21 Vege SS, Gardner TB, Chari ST, et al Outcomes of intra-abdgmin~l !ungal vs bacterial infections in severe acute pancreatitis Am J Gastroenterol 2009;104:2065-70 'e ic h n 'I, Iy d 20 d n o e ly )t 189 CHAPTER Ih ~ pa He SYI lea rei nei Acute Colonic Pseudo-obstruction Pradip KBhattacharya, Lata Bhattacharya, Navya Guwalani, Nimita Deora I_INTRODUCTION _ Acute colonic pseudo-obstruction (ACPO) is also known as Ogilvie syndrome Sir William Heneage Ogilvie in the year 1948 described two cases of colonic dilatation without mechanical obstruction Both patients had retroperitoneal tumorsinvading the splanchnic plexus leading todestruction of splanchnic nerves, semilunar ganglia, and the celiac plexus, hence the parasympathetic innervations in the colon working was unopposed.' The term "pseudo-obstruction" was proposed by Dudler,3 and the term "acute colonic pseudo-obstruction" appeared in the literature in the year 1982 when Nanni et al." used it for acute nonmechanical obstruction oflarge gut The acronym ACPO was used by Rex in his article in the year 1997.5 Presently, the term "acute colonic pseudo obstruction" is more prevalent in the literature to describe thisphenomenon," Acute colonic pseudo-obstruction is characterized by massive colonic dilatation with symptoms and signs of colonic obstruction without mechanical blockade? It generally occurs in critically ill patients with sepsis, recent surgeries, electrolyte abnormalities, and tr.auma The actual mechanism of this disorder is unknown, but it is believed that some abnormality affecting the autonomic nervous system (ANS) mightbe involved It is morecommonin male particularlywhoare olderthan 60years Areview of 400 cases of Ogilvie syndrome byVanek et al.8 in the year1986 revealed that malespresentedmorefrequently than females, with an average age of 59.9 years for males and 56.5 years for females," Of all the cases, 94.5% had an association withmedical or surgical condition like obstetric, gynecologic, or pelvic operation (19%); post-trauma orthopedics procedure (18%); infection (10%); cardiac event (10%), and neurologic event (9%).8 Otherfactors that Box 1: Associations underlying acute colonic pseudo obstruction • Medications: Narcotics, anticholinergics, laxative abuse, benzo diazepines, calcium channel blockers, interleukin, amphetamine overdose, cytotoxic drugs, antiparkinsonian agents • Medical o Neurologic: Dementia, Parkinson's disease, spinal cord disease o Metabolic: Hypokalemia, hyponatremia, hypocalcemia, hypercalcemia, diabetes, hypothyroidism o Cardiopulmonary: Mechanical ventilation, myocardial infarction, pneumonia, conqesnve heart failure, chronic obstructive pulmonary disease o Oncologic: Small cell lung cancer, multiple myeloma, acute myeloid leukemia, disseminated cancer, pelvic irradiation, retroperitoneal invasion of lumbar sympathetic nervous system o Infectious: Sepsis, Cytomegalovirus o Miscellaneous: Organ failure, alcoholism • Surgical o Obstetric: Normal pregnancy, normal delivery, cesarean section, hysterectomy o Urologic: Ethanol ablation ofrenal cancer o Inflammation: Appendicitis, cholecystitis, pancreatitis, abscess o Organ transplantation; liver, kidney, heart, lung o Trauma and orthopedic: Pelvic trauma, pelvic, hip fracture, pelvic, hip surgery, spine surgery, burns o Others: Gastrointestinal bleeding, retroperitoneal hematoma, mesenteric thrombosis, craniotomy, aortic aneurysms contributed to the development of ACPO are electrolyte disturbances and narcotic use8,9 (Box 1) ~ ~!I_Q.Lq~X!\N.!?_PA!.~Q~~r_~~~~Q_~~_ The pathogenesis of ACPO remains unknown but the most accepted theory is the imbalance in autonomic output to the colon produced byvariety offactors leading to excessive parasympathetic suppression or sympathetic stimulation.? ani are inn net (Ie, ass, ent spa cell to I abs inte effe sup imb ofir I nov, \\l ( ft_ ACUl pres diste com cant abst tymj pres, leuki How tawa respi The, whic ofSUI the c unad eXceE serial 1-3% studi, less tl peno isass A langil heroi CHAPTER 32:Acute Colonic Pseudo-obstruction lhe initial theory was an imbalance in activity of ANS with parasympathetic overactivity leading to dilatation of colon.I However, current evidence favors a relatively increased sympathetic tone and/or decreased parasympathetic tone leading to a functionally obstructing distal colon and a relaxed proximal colon." Enteric nerves contain a varietyof neurotransmitters responsible forsmoothmusclecontraction and relaxation Acetylcholine, neurokininA, and substanceP aremajorstimulatory neurotransmitters; whereasvasoactive intestinal polypeptide and nitric oxide are the inhibitory neurotransmitters Another theory suggests the interstitial cells of Cajal (ICC), present along the gastrointestinal (GI) tract in close association with smooth muscle cells, are elements of enteric nervous system It is believed as the source of the spontaneous slow waves of gut musculature (pacemaker cells).ll In one studyperformedbyJainet al., ICC were found to be absent in patients with chronic intestinal pseudo obstruction.'! Cytokines have also been found to alter the intestinal motility in an inflammatory state." The proven effectiveness of neostigmine in colonic pseudo-obstruction supports the validity of the theory suggested by Ogilvie of imbalance activityofANS Withthe progressin understanding ofintestinalmotility, ACPO has become an open avenuefor novel therapeutictargets e it o e Acute colonicpseudo-obstruction can have variable clinical presentation The most common symptoms are abdominal distension, pain, nausea, vomiting, lack of gas passage, and constipation About 40% of the patient with ACPO reports continued passage of flatus despite clinical evidence of obstruction," On clinical examination of the abdomen, tympanitic and bowel sounds are typically present The presence of marked abdominal tenderness, fever, and leukocytosis can be present as additional clinical findings However, thesefindings areneither specific norverysensitive towards definitive diagnosis These patients also have respiratory compromise due to diaphragmatic compression The above features are typical of large bowel obstruction whichis commonlyseenin patientswithACPO Ahighindex ofsuspicionwithpreexisting riskfactors is necessaryto make the clinical diagnosis Many times, if left unrecognized or unaddressed,itcan leadto perforationifthe colonicdiameter exceeds the threshold diameter of em." It becomes a serious concern when the diameter exceeds 12 em, About 1-3% ofthe patientsofACPO developperforation.v'" Several studies indicate that perforation is rare with cecal diameter lessthan 12em.However, when the diameterexceeds 14em, perforation occursin up to 23% ofthe patlents.v" Perforation is associatedwitha mortality rate of50-70%.8,15 An increasein intramural pressureleadsto ischemiawith longitudinal splitting of the serosa and tenia which leads to herniation of the mucosa The cecum is more susceptible to distension induced ischemia and perforation as it is the thinnest wall area of colon.8,IO,17 Once pressure inside the cecum exceeds that of superior mesenteric artery, pain and ischemia can occur Signs of systemic toxicity not appear until the catastrophic complications have occurred Neuroischemia develops before perforation Both ischemia and perforation give rise to high mortality in these patients In a studybyVanek et al.,the mortality increased from 26to 44% in caseswith perforatedand ischemic bowel," Advanced age and delayed interventionare additional risk factors for increased mortality," Durationof distensionalsohas a direct correlation with perforation If the distension persists for morethan days, it carriesa highriskforperforation.18 Exclusion of common causes of large bowel ileus, such as hypokalemia, hypocalcemia, hypomagnesemia, etc., earlyin the evaluationis importantforclinical diagnosis and intervention It is sometimesdifficult to distinguish between perforation or ischemia and those with uncomplicated distension Early use of diagnostic studiesis helpful to avoid such kindofconfusion ~AGNOSIS High degree of suspicion and exclusion of other causes of mechanical obstruction of colon should be the first step towards the diagnosis of ACPO The clinical presentation of ACPO and other causes of mechanical obstruction are nearly same.Tlence.ilmagirig method for diagnosis and differentiation is required Plain radiograph can be a very good diagnostic tool for perforation Serial films can be used to monitor the measurement of colonic dilatation However, the distinctionbetweenmechanical and functional obstruction cannot be made with plain radiography alone A contrast enema with computed tomography (CT) scan can be used as a useful diagnostic motility It has got sensitivity and specificity of 80% and 100%, respectively, in the diagnosis oflarge bowel obstruction." A water soluble contrast is preferred because a small risk of extravasations of barium and more importantly, the potential therapeutic effect of water soluble contrast leading to decompression of the colon." Excess contrast use should be avoided It can be appliedwithoutbowelpreparation Contrast retention may be difficult in elderly, frail, and critically ill patients Exacerbation of dehydration and electrolyte imbalance can be a problem with hypotonic contrast sol~tion.21 In a retrospective analysis done by Jacob et al., reveals an increasing trend towards the use of CT scan for the diagnosis of large bowel obstruction as compared to contrast enema.F It is observed that CT scan has largely replacedthe contrast enema for the diagnosis oflarge bowel obstiuction.F It is less problematic and requires intravenous contrast and a supine position of the patient Moreover, images can be acquired quickly in a single breath-holding time.Thesensitivity and specificity ofCT scanis96% and 93%, respectively, for the diagnosis of large bowel obstruction.l" 191 , , , SECTION 3:Gastroenterology Proximal colonic dilatation with an intermediatetransitional zone at or adjacentto the splenicflexure is-the common CT scan finding in ACPO patients ACTscan can also diagnose complications including bowel ischemia, perforation, and conditionofpericolic stnctures." Distal mechanical colonic obstruction can be investi gated with rectal examination, careful colonoscopy, CT scan (with intravenous, oral, or rectal contrast)," or water soluble contrastenema Colonoscopy can be diagnostic and therapeutic, but is often contraindicated when ischemia and perforation is suspected and can be challenging when performed in unprepared bowel and insufflation is sv\ I Colonic pseudo-obstruction l fre ! Yes f tel 3 80 of ~ No IConsult forsurgery I - 24-48 h trialof: 2-: • Keep patient fasting/NG tube/rectal tube • Stopllimit medications • Correct electrolytes • Mobilize Noresponse Noresponse aft fai I required." • ro< de bo Safe to try neostigmine? Yes no + I Neostigmine I I rConsult gastroenterologist for I~ l endoscopic decompression Noresponse OVI at; in; Conservative Management FIG 1: Management of acute colonic pseudo-obstruction Early recognition is important in the management of ACPO Close clinical monitoring in the form of physical examination (abdominal girth), abdominalradiographs, and laboratory studiesevery 12-24 hours, continuousbowelrest, nasogastric tube decompression, and rectal tube placement are a part of initial conservative management Aggressive fluid and electrolyte resuscitation and antibiotics in case of suspected infection should be started Investigation for contributing etiology, like hypothyroidism, diabetes mellitus, and other metabolic disorders, should be taken care of Narcotics along with other offending medication should be stopped Osmotic laxatives should be avoided in view of theirincreasedtendencytowards gas formatlon.f If possible, prone positionwithhip elevatedon pillow or the knee-chest position with hips held high often helps in evacuation of flatus These positions should be alternated with right and left lateral decubitus position regularly or every hourly when feasible," In general, conservative therapy should be employed for 48-72 hours unless the patient demonstrates clinical deterioration." Wegener et al reviewed 1,027 case reportsofACPO and foundthat 70% ofthe patient responded to supportive management alone with a complication rate of 6% and mortality approximately 10% Theusual duration of response to these measures is 3-5 days." In another study by Delgado-Aros et al., successful resolution is achieved in 83-96% patients within 2-6 days of conservative therapy." It is important to note that if at any point during treatment, the patient condition deteriorates, investigation for ischemia and perforation should be undertaken immediately Patients, who failto improve afterall conservative therapies mentionedabove, should be consideredforpharmacological therapy(Fig 1) 192 tri< the sig Pharmacologic management of acute colonic 'lABLEl '.' pseudo-obstruction , -~l · -· ' -· '~ -· am ·, First linetherapy', Neostigmine or 25 mg IVbolus over 3-5 \ , I , _ Repeat dose upto times if noresponse in h~ ! Salvage therapy Neostigmine 0.4-0.8 mg/hinfusion for 24 h i m i Pyri~ostigminel ?-,30 mgorally twotimes a day~ I 29.5 g of polyethylene glycol in 500mLofwater! , Adjunct to ! , prevent relapse I orally in two doses IOpioid related i ACPO i Historical drugs -j ! Naloxone - 0.4-2.0mg Intravenous injection every other day to every day ! -j ! Erythromycin, meto:loprami~:~~~pride ~ ACPO, acutecolonic pseudo-obstruction; IV, intravenous risk with inducing colonic contraction," There are number of case reports which were published in due course with erythromycin." metoclopramide." and cisapride" mentioning a beneficial effect as prokinetics in ACPO, but none of them revealed a consistent response in acute setting A 40% success rate was reported with erythromycin by Emmanuel et al with a recurrenceof 50% in treatmentof chronicpseudo-obstruction.P Theuse ofepiduralanesthesia as a block of excess sympathetic tone demonstrated a moderate response The best evidence of medical treatment is available for neostigmine Based upon the presumed pathophysiology of ACPO, Huchingnson and Griffith used neostigmine and guanethidine for ACPO 31 Neostigmine is an anticholinesterase that inhibitsacetylcholinesterase to allow increasein synaptic levels ofacetylcholine Pharmacological Management (Table 1) Multiple prospective studies have validated the use of In one review published in 1982, it was advised against the neostigmine in ACPO 32-36 Patients had improvement in use of pharmacological agents citing increased perforation symptoms with only occasional mild side effects such as ree shr inc inc inti ~-t inf ofi tre dift rec by disi soh wit et pyr pre dec witJ has ACI Ane fou: ind effil abo pro , T i I i ] ] ] :r e 10 ), e n )f a a )f 'Y Ie n w IS CHAPTER 32:Acute Colonic Pseudo-obstruction sweating and transient bradycardia Recurrence rate range from 0to 33% The optimal dose of neostigmine and administration technique remainsdebatable Adoseof2-2.5 mgbolusover 3-5 minutes intravenously was found to be successful in 80% ofthe patients afterthe first dose 25The onset of action ofintravenous neostigmine is 20-30 minutes It can be used 2-3 times in 24 hours, if satisfactory response is not seen after first dosing." If the secondor thirddoseofneostigmine fails to resolve the problem, the patient should proceed for more aggressive measures of decompression White et al described a protocol in a patient refractory to three doses of bolus neostigmine They mixed mgofneostigmine in50mL normal saline solutionand infused at a rateof0.4mg/h." An overall positive responsewasobserved in 19outof24patients ata continuous infusion rate of0.4-0.8 mg/h ofneostigmine ina randomized studyperformed byvanDerSpoel et aJ.39 Side effects with neostigmine were common in all the trials and is one ofthe reasons forexclusion ofpatients from those trials Lowheartrates, lowsystolic bloodpressures, and signs ofperforation including peritoneal signs offree airwere among the commonest reasons for exclusion All patients receiving neostigmine should be monitored and atropine should be available at the bedside to counter neostigmine induced bradycardia Contraindications to neostigmine include known hypersensitivity and mechanical urinary or intestinal obstruction Relative contraindications include ~-blockertherapy, bradycardia, asthma, acidosis, myocardial infarction, or peptic ulcer disease." Oral neostigmine is not recommended in ACPO because ofits erratic absorptionintheGI tract.Relapse aftersuccessful treatment with neostigmine has been observed in 17-38% in different studies,41-43 Polyethylene glycol (PEG) has been shown to prevent recurrence Arandomized placebo control studyconducted by Sgouros et aI suggested that there is no recurrence of distention versus 33% in placebo group when balance solution of PEG given orally aftersuccessful decompression with neostigmine or colonoscopy." A prospective randomized study conducted by O'Dea et al observed a positive response with 10-30 mg of pyridostigmine two times daily orally in patients whofailed previous treatment with neostigmine and endoscopic decompression and also less severe side effects compared with neostigmine." Methylnaltrexone, a new opioid receptor antagonist, has been found to have a potential rolein narcotic induced ACPo.46 It wastried aftera failed treatmentwithneostigmine Another new receptor antagonist, alvimopan, has been found to havea potential rolein postgastrointestinal surgery induced ACPO.47 Furtherstudiesare neededto establish the efficacy and safety of new receptor antagonist mentioned above as they may prove beneficial in treatment and Prophylaxis ofopioid inducedACPO Diatrizoate meglumine enema in relieving colonic distention was assessed in 18 patients in whom 78% of patients were found to be successfully decompressed." The mechanism is thought to be due to hyperosmolality of the enemaincreasing intracolonic fluid In patients not responding to maximal supportive and pharmacological therapy and without signs of ischemia and perforation, endoscopic decompression should be considered (Fig 1) Endoscopic Decompression In the year 1997, Kukora and Dent first time described the colonic decompression of ACPO Out of patients, were successfullytreatedwiththismethodwithoutanyrecurrence.48 Colonoscopy was the second line treatment in patients not responding to conservative measures prior to introduction ofneostigmine Colonoscopy forACPO isperformed without oral laxatives or bowel preparation Sedation in the form of benzodiazepines is recommended Narcotics are avoided in view oftheirproperty to inhibitcolonic activity Recurrences after colonoscopic decompression remain problematic, it has been reported in up to 40% of patients." In patients with recurrence, a repeated colonic decompression was achieved in 56-87% butwithhigher ratesofsubsequent cecal distention Useof tube decompression improves the overall success of decompression if placed in an area affected by ACpO 50,51 The tube is placed over a guide wire advanced through a colonoscope After loading the guide wire in appropriate place, thecolonoscope iswithdrawn withregular suction, following whicha decompression tubeispassedinto the colon overthe guide wire under fluoroscopy guidance Thedecompression tube shouldbeplaced to gravity drainage and flushed every 4-6"hours to prevent clogging In a series of 50 patients who underwent endoscopic decompression and tube placement, success rate was observed in 88% of patients About 80% success rate was observed in patients receiving tube decompression afterendoscopy as compared to 25% success in those wheretube decompression wasnot used." In another study conducted by Harig et al., out of patients had recurrence in the only colonoscopic group, whereas none had recurrence out of 11 in colonoscopy plus tube decompression group.F Placement of a percutaneous endoscopic tube is another advanced endoscopy technique known as per cutaneous endoscopy colostomy of the cecum It can be performed either through a combined endoscopic and radiology approach or in a manner analogous to placement of percutaneous endoscopy gastrostomy tube.53.54 It is considered to be safe and effective procedure in the hands of an experienced endoscopist Various techniques have been described for doing this procedure, but there are no studiesto establish superiority ofone methodoveranother The choice of technique depends on the preference of the 193 , , , SECTION 3: Gastroenterology endoscopist This approach may prove useful for patients whoare notresponding to maximal medical and endoscopic management and arepoorsurgical candidates Surgical Intervention Surgical options include cecostomy or colostomy Acute colonic pseudo-obstruction is one of the few indications for cecostomy Cecostomy is performed by limited laparotomy with a small incision overlying the cecum Laparoscopic cecostomy hasthe potential additional benefit of visualization of entire colon to diagnose unsuspected ischemia or infarction, but it is challenging in patients with massively dilated colon with huge abdominaldistention.P Laparotomy is indicated for ischemia, perforation, or if the diagnosis is not clear The diagnosis of colonic ischemia is clinical as suggested bychanges in perceived pain, physical examination finding, and laboratory and imaging data Lactic acidosis, fever, abdominal pain, and leukocytosis raise the suspicion of mucosal ischemia The CT scan often shows nonspecific colonic wall thickening and pericolic fat stranding 56 Pneumatosis and/or gas in the mesenteric veins are ominous signs associated with bowel wall thickening and are mainly due to bowel infarction." Sometimes, right hemicolectomy, and at others, total abdominal colectomy is also required depending upon the area affected Mortality rate ranges from 35to 60% withoperative interventions The high mortality associated with laparotomy due to ischemia and perforation warns for the need of early diagnosis, initiation of conservative management, and early surgical consultation lCONCLU~~9_"! _ ._ _._ _ Acute colonic pseudo-obstruction or Ogilvie syndrome is a clinical syndrome characterized bymarked colonic distention without evidence of mechanical obstruction; it complicates the hospital stay of acutely ill medical and surgical patients It carries a poor prognosis if early identification and management is not instituted Exact pathophysiology remains debatable There is no effective prevention for this problem High clinical suspicion and appropriate use of imaging techniques differentiates ACPO from other causes of mechanical obstruction of colon Initial conservative therapy successfully resolves ACPO in majority of patients Neostigmine remains the drug of choice in patients with failed response to conservative management Advances in endoscopic management also reduce the need of surgical intervention Newer therapies include oral pyridostigmine and new opioid receptor antagonist as a potential agent for nonresponders Advanced colonoscopic technique with tube decompression provides alternative options for decompression Percutaneous cecostomy may be a safe option in experienced hands In the presence of peritoneal 194 signs or perforation, surgery is the appropriate intervention ~~ _REFERENCES f."~~ ~ y •• , • Ogilvie H Large-intestine colic due to sympathetic deprivation; a new clinical syndrome BMJ 1948;2(4579):671-3 Dudley HAF, Paterson-Brown S Pseudo-obstruction Br Me