254 Indian Journal of Critical Care April 2016 Vol 20 Issue 4

Med 2015;19:703‑7. Access this article online 2. Nemer SN, Barbas CS, Caldeira JB, Cárias TC, Santos RG, Almeida LC, et al. A new integrative weaning index of discontinuation Quick Response Code: from . Crit Care 2009;13:R152. Website: 3. Madani J, Saghafinia M, Nezhad H, Ebadi A, Ghochani A, Tavasoli F, www.ijccm.org et al. Validity of integrative weaning index of discontinuation from mechanical ventilation in Iranian ICUs. Thrita 2013;2:62‑8. DOI: 10.4103/0972-5229.180056

This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows How to cite this article: Gupta S, Govil D. Can integrative weaning index be a routine others to remix, tweak, and build upon the work non‑commercially, as long as the predictor for weaning success?. Indian J Crit Care Med 2016;20:253-4. author is credited and the new creations are licensed under the identical terms.

1. The sample size of 500 seems to be arbitrarily chosen Relationship between a priori, the justification of targeting this sample size is not clear in the methodology glycated hemoglobin, 2. The targets for blood sugar in septic and nonseptic patients should have been a range rather than a fixed value. We don’t think it’s justified to use an for the sole purpose of . The initial admission blood sugar sample could have been sent to the central laboratory and glucose control along with HbA1c, for better accuracy (central laboratory > arterial blood gas analyzer > arterial with Intensive Care Unit blood sample by glucometer > venous blood sample by glucometer > capillary sample by glucometer)[5] mortality in critically ill 3. The mortality cannot be attributed to the level of HbA1c alone as the baseline APACHE 2 scores are significantly different. It would have been more Sir, informative if they had described the data while We read with great interest, the article on the grouping the patients between levels of HbA1c[4] relationship between glycated hemoglobin (HbA1c), 4. There is limited data given in this study Intensive Care Unit (ICU) admission blood sugar and regarding baseline body mass index to interpret glucose control with ICU mortality in critically ill patients the existing paradox in diabetics, patient’s on by Mahmmodpor et al.[1] corticosteroids (which would have continued in few patients in this study, as the data analysis The literature on glycemic control in intensive care mentions that 48.4% of patients were on drugs), is taking turns from its earlier publication by van den patient’s on vasopressors and the details of Berghe done 13 years back, that hyperglycemia nutrition. increases mortality and morbidity. Subsequent studies suggested that intensive glucose control increases Financial support and sponsorship [2] hypoglycemic episodes (NICE‑SUGAR study), and Nil. recently researchers have stressed the importance of glycemic variability. Conflicts of interest There are no conflicts of interest. This study, again suggests the need for HbA1c in all patients with hyperglycemia presenting to intensive care for the diagnosis of occult mellitus or P. V. Sai Saran, Shakti Bedanta Mishra, stress‑induced hyperglycemia (SIH), with SIH associated Pralay Shankar Ghosh, Afzal Azim Department of Critical Care Medicine, SGPGIMS, Lucknow, with more mortality, especially in patients with trauma, Uttar Pradesh, India as elucidated in previous studies.[3,4] Correspondence: Dr. Afzal Azim, Department of Critical Care Medicine, SGPGIMS, Lucknow ‑ 226 014, We need more clarifications from the authors regarding Uttar Pradesh, India. the study with reference to the points listed below: E‑mail: [email protected]

Page no. 56 Indian Journal of Critical Care Medicine April 2016 Vol 20 Issue 4 255

References This is an open access article distributed under the terms of the Creative 1. Mahmmodpor A, Hamishekar H, Shadvar K, Beigmohammadi M, Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the Iranpour A, Sanaie S. Relationship between glycated hemoglobin, author is credited and the new creations are licensed under the identical terms. intensive care unit admission blood sugar and glucose control with ICU mortality in critically ill patients. Indian J Crit Care Med Access this article online 2016;20:67‑71. Quick Response Code: 2. NICE‑SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Website: Blair D, Foster D, et al. Intensive versus conventional glucose control www.ijccm.org in critically ill patients. N Engl J Med 2009;360:1283‑97. 3. Bosarge PL, Shoultz TH, Griffin RL, Kerby JD. Stress‑induced hyperglycemia is associated with higher mortality in severe traumatic DOI: 10.4103/0972-5229.180057 brain injury. J Trauma Acute Care Surg 2015;79:289‑94. 4. Kerby JD, Griffin RL, MacLennan P, Rue LW 3rd. Stress‑induced hyperglycemia, not diabetic hyperglycemia, is associated with higher mortality in trauma. Ann Surg 2012;256:446‑52. How to cite this article: Sai Saran PV, Mishra SB, Ghosh PS, Azim A. Relationship 5. Alexander S, Raymond F, Nicola M. Glycemic control in the between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose intensive care unit: Between safety and benefit. Isr Med Assoc J control with Intensive Care Unit mortality in critically ill. Indian J Crit Care Med 2012;14:260‑6. 2016;20:254-5.

Mental stress commences with impulses from high The ATAK complex brain cortical centers that are relayed through the limbic system to hypothalamus resulting in the release of (, Takotsubo, corticotropin‑releasing hormone (main coordinator of the mental stress response) and norepinephrine, serotonin, , and acetylcholine, proopiomelanocortin, adrenocorticotropic hormone, glucagon, growth hormone, and homocysteine Kounis hypersensitivity that stimulate sympathetic nervous system. These ‑associated coronary substances can induce heightened cardiovascular activity, endothelial injury, induction of adhesion syndrome) in molecules on the endothelial cells, to which recruited inflammatory cells adhere and translocate to the neurological conditions arterial wall and finally myocardial damage. An acute phase response is engendered, resulting in production of cytokines interleukin‑1 (IL‑1), IL‑6, tumor necrosis Sir, factor‑alpha, acute phase proteins, macrophage, mast Takotsubo syndrome, transient left ventricular cell, and platelet activation that eventually culminate in apical ballooning, takotsubo cardiomyopathy, apical the development of Kounis syndrome.[2] ballooning syndrome, atypical apical ballooning, ampulla cardiomyopathy, broken heart syndrome, transient Stress‑induced cytokine production has been left ventricular dysfunction syndrome, and stress incriminated for multivessel coronary artery spasm cardiomyopathy were named after a round‑bottomed at epicardial or microvascular levels that induce and narrow‑necked fishing pot – takotsubo in Japanese takotsubo cardiomyopathy. Inflammatory mediators – for trapping octopus because of its resemblance to left released during anaphylaxis can induce coronary ventriculogram. In the interesting report published in spasm and takotsubo syndrome and adrenaline given Indian Journal of Critical Care Medicine,[1] a 48‑year‑old man for anaphylaxis might contribute to coronary spasm with progressive loss of vision, , tachycardia, and transient takotsubo syndrome. Adrenaline and and acidosis was found to have takotsubo syndrome noradrenaline released by the renin–angiotensin– while the coronary arteries were normal. Computerized aldosterone system together with histamine stimulate tomography revealed dense sellar–suprasellar mass the release of more catecholamines by direct action lesion extending into the hypothalamus resembling on the adrenal medullary cells. Administration pituitary adenoma with hypocortisolism suggesting of catecholamines for hemodynamic support of hypopituitarism. With dobutamine, atenolol, and anaphylactic would also increase the plasma noradrenaline, his condition improved. This case raises catecholamines. Catecholamine increase in patients some issues concerning neurological conditions, mental with angina, renders blood platelets more sensitive stress adrenaline, anaphylaxis, and Kounis syndrome. and more prone to aggregation and thrombosis.

Page no. 57