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Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection. Alterations of microvascular perfusion caused by endothelial cell dysfunction, glycocalyx degradation, increased leukocyte adhesion, microthrombus formation, and regional redistribution of blood flow contribute to the development of multiple organ dysfunction in patients with sepsis. Sublingual videocapillaroscopy is a non-invasive diagnostic tool that allows for a good visualization of microscopic alterations that sometimes represent the only evidence of disease onset.
Objectives
Identification of pathognomonic parameters (microcirculatory alterations) at the oral microcirculation level in patients with sepsis and implementation of an early diagnosis protocol for sepsis/septic shock based on videocapilaroscopic examination.
Materials and methods
The study was conducted with a prototype of device (patent application RO/A00285/2018) which received international validation through multiple awards at the most prestigious invention events in which it participated. and was prospective, controlled, analytical, non-randomized, multicenter, in which 255 images from 51 patients was analyzed following the next parameters: orientation of the capillaries in relation to the surface of the mucosa, the presence/absence of the microhemorrhages, the capillary density and the capillary caliber. The working methodology involved the acquisition and preparation of the images, as well as the analysis and software interpretation of them. Further development of the prototype of device will allow us to continue studying and examining a wider range of parameters.
Results
Analyzing of the parameter in clinical situations of sepsis reveals an increase in both the number of capillaries in parallel and perpendicular incidence, an increase of capillary caliber and an increase in the density of capillaries. Presence of the microhemorrhages in the oral mucosa it may be observed only in sepsis situations.
Discussions
The development of a diagnosis and treatment algorithm based on non-invasive examination of oral microcirculation will lead to prompt improvement of hemodynamics and stop the progression of sepsis to severe forms of disease. The presence of the microhemorrhages in the oral mucosa is pathognomonic for the sepsis diagnosis in patients with the biological data which also support this. Our study demonstrates that the use of videocapillaroscopy in current clinical practice can lead to the development of innovative and preventive medical procedures and protocols of high scientific value to solve complex, vital therapeutic problems based on early diagnosis and certainty for the benefit of patients. The study opens new perspectives in the prospective interdisciplinary research (medicine, IT, optical engineering).
References
1.De Backer Daniel, Ricottilli Francesco, Ospina-Tascón Gustavo A. Septic shock: A microcirculation disease. Current Opinion in Anaesthesiology. April 2021;34(2):85–91. doi: 10.1097/ACO.000000000000095. p. [DOI] [PubMed] [Google Scholar]
2.Cusack R, O'Neill S, Martin-Loeches I. Effects of Fluids on the Sublingual Microcirculation in Sepsis. Journal of Clinical Medicine. 2022;11(24):7277. doi: 10.3390/jcm11247277. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Damiani E, Carsetti A, Casarotta E, Domizi R, Scorcella C, Donati A, Adrario E. Microcirculation-guided resuscitation in sepsis: the next frontier? Front Med (Lausanne) 2023 Jul 5;10:1212321. doi: 10.3389/fmed.2023.1212321. 37476612;PMC10354242 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47:1181–1247. doi: 10.1007/s00134-021-06506-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
Rales Score, Apache Score and Terlipressin Non-response Predict Mortality in Patients with Critically Ill Cirrhosis, Pocus is a must for All Critically Ill Cirrhotic Patients on Terlipressin Plus Albumin
The drug of choice in patients having cirrhosis with hepatorenal syndrome is Terlipressin with albumin (terli+alb) but Pulmonary overload is an adverse effect that we frequently notice in this combination. We wanted to assess the role of radiographic assessment of lung edema (RALE) and lung ultrasonography (LUS in patients with critically ill cirrhosis (CIC) who receive terli+alb for HRS.
Methods
We included CIC patients with HRS-AKI who were treated with terli+alb in the liver ICU from 28-04-2022 to 16-10-2022 Terlipressin was infused at a dose of 2 mg/day and increased every 2 days if non-responsive. Albumin was infused at a dose of 20g/day. Our primary aim was to assess the RALES and LUS scores upon admission and day 3. The secondary aim being assessment of predictors of in-hospital mortality using logistic regression analysis.
Results
A total of 102 patients (alcohol-60.8%; age-50 ± 12.18 years; serum creat-2.55 mg/dl) received terli+alb for HRS-AKI. Amongst them, 55 survived (Gr. A), and 47 expired (Gr. B). lab investigations of Baseline serum creatinine (2.02 vs. 2.25 mg/dl), MELD NA score (26.4 vs. 25.3), and dose of terli+alb were almost equal in both the groups. Percentage of patients with Culture-positive infection was almost equal in both groups as well (21.8% vs. 30.4%). Patients on mechanical ventilation were 12.7% in Gr. A compared to 55.3% in Gr. B with a p value of (P < 0.001). But on follow-up, only 11% in Gr. A and 95.7% in Gr. B required mechanical ventilation (P < 0.001). Day 1 and 3) Rales scores were higher in Gr. B patients (6.32 ± 7.57) compared to Gr. A (3.34 ± 5.08; P = 0.01). Day 3 worsening of RALES scores 66% had in Gr. B compared to 41.8% in Gr. A. (P = 0.01) noted. LUS score also worsened in 66% (n = 31) of patients in Gr. B compared to 40% (n = 22) in Gr. A (P = 0.03). Multivariate logistic regression analysis showed, terlipressin non-response (OR, 4.25 [1.45–12.41]; P = 0.008), baseline APACHE score (OR, 1.18 [1.1-1.28]; P < 0.001) and RALES score at day 3 (1.077 [1.02-1.12]) predicted in-hospital mortality.
Ultrasonography. RALES score, APACHE score monitoring in Critically ill cirrhosis patients being treated with terli+alb plays a vital role. Also non-response to terlipressin may be a predictor of mortality in critically ill cirrhosis patients with HRS-AKI.
References
1.Via G, storti E, Gulati G, Neri L, Mojoli F, Braschi A. Lung ultrasound in the ICU: From diagnostic instrument to respiratory monitoring tool. Minerva Anestesiologica. 2012;78:1282–96. [PubMed] [Google Scholar]
2.Warren MA, Zhao Z, Koyama T, et al. Severity scoring of lung oedema on the chest radiograph is associated with clinical outcomes in ARDS. Thorax. 2018;73(9):840–6. doi: 10.1136/thoraxjnl-2017-211280. [DOI] [PMC free article] [PubMed] [Google Scholar]
Epidemiology of MDR, XDR and PDR Microbial Isolates from Patients admitted in Critical Care Units of a Tertiary Care Private Hospital of Kolkata - One-year Study Based on Phenotypic and Genotypic Data
Incidence of MDR (multi-drug resistant), XDR (extensively drug resistant) and PDR (pan-drug resistant) microbes is increasing across Indian hospitals, complicating antimicrobial therapy, especially in the critical care units.
Objectives
The present study focuses on the prevalence of MDR, XDR and PDR microbes in the Critical Care units of a tertiary care private hospital of Kolkata for one-year period: 1.9.2022 – 31.8.2023, based on microbiological (phenotypic) and molecular testing (genotypic) data.
Materials and methods
10,911 samples received from all the Critical Care units of the hospital were processed for culture and sensitivity by manual and automated methods. 1520 samples (13.9%) yielded growth of 1565 isolates. All the isolates were processed for antimicrobial resistance gene (carbapenem-resistance/ methicillin-resistance/ vancomycin-resitance) detection by Real-time Multiplex PCR (open system) on the day the growth was identified. The phenotypic sensitivity reports followed on the following day.
Results
73% of the isolates were obtained within 48 hours of admission. 27% were hospital-acquired. BSI caused 31% of the infections, followed by UTI (22%), RTI (16%), SSTI (6.5%), IAI and others (6%), while 18.5% of the isolates were colonizers. Among bacterial isolates, 1207 (86%) isolates were Gram-negative bacilli (Klebsiella sp.: 36%, E. coli: 31%, other Enterobacteriaceae: 9%; Pseudomonas sp.: 9%, Acinetobacter sp.: 10%), 192 (14%) Gram-positive cocci (S. aureus: 28%, CONS: 27%, Enterococcus faecium: 22.5%, E. faecalis: 9.5%, Pneumococci: 6%). 166 fungal isolates were obtained (Candida: 151: non-albicans: 67.5%, albicans: 32.5%). 85% of the 436 Klebsiella isolates were MDR (ESBL: 9%, Carbapenem resistant: 72%), 4% XDR (Polymixins-resistant). 74% of the 371 E. coli isolates were MDR (ESBL: 47%, Carbapenem-resistant: 21.5%). 75% of the 104 other Enterobacteriaceae were MDR (ESBL: 5%, Carbapenem-resistant: 51%), 1% XDR (Polymixins-resistant) and 2% PDR. 57% of the 107 Pseudomonas isolates were Carbapenem-resistant (MDR/ XDR), 5% Polymixins-resistant (XDR), 4% PDR. 88% of the 125 Acinetobacter isolates were carbapenem-resistant (MDR/ XDR). Real Time Multiplex PCR identified 568 (47%) of the 1207 GNB isolates as Carbapenemase producers: NDM: 50%, NDM+OXA48: 26%, OXA48: 19%. 37% of the 54 S. aureus isolates and 65% of the 51 CONS isolates were methicillin-resistant (all mecA mediated, identified by PCR). 34% of the 62 Enterococcus isolates were VRE - PCR identified VanA + VanB genes in 62% of VRE isolates, VanA in 33% and VanB in 5%. 11% of the Candida isolates were Fluconazole-resistant, 10.5% Amphotericin-B-resistant, 1% Echinocandin-resistant.
Discussions
The data shows a high prevalence of MDR and XDR bugs in the Critical care units of the hospital, which matches with data from other hospitals across India. This calls for judicious use of antimicrobials, an effective antimicrobial stewardship programme, and earnest implementation of infection control practices.
Reference
1.All data were obtained from the Microbiology department of Peerless Hospital, Kolkata
High-dose intravenous vitamin C (HDIVC) has been investigated as the adjuvant therapy in critically ill Coronavirus Disease 2019 (COVID-19) patients, but the appropriate optimal doses are still unclear. This study aimed to compare the clinical outcomes of critically ill COVID-19 patients treated with 2 different dosing regimens of HDIVC (12g per day versus 6g per day).
Materials and methods
A retrospective study was conducted among patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in intensive care unit (ICU) at Hospital Canselor Tuanku Muhriz (HCTM) Malaysia. Patients aged 18 and above receiving HDIVC 6g per day and 12g per day in the year 2021 were included in the study. Primary outcome was invasive mechanical ventilation-free days in 28 days (IMVFD28) and secondary outcomes were hospital all-cause mortality, WHO ordinal scale and C- reactive protein (CRP) levels.
Results
The invasive mechanical ventilation-free days in 28 days (IMVFD28) was significantly higher in the HDIVC 6g/day group compared to the HDIVC 12g/day group [22.5 days (IQR, 18.5,25.0) and 13.5 days (IQR, 0.0,22.8) respectively (p = 0.017)]. Hospital all-cause mortality was significantly lower in patients receiving 6g/day of HDIVC (n = 9/30) compared to 12g/day (n = 17/24) (χ2 = 8.90; p = 0.003). Among patients receiving 6g/day, 60% of them demonstrated at least 1 point improvement of WHO ordinal scale on day 7, whereas only 20.8% in HDIVC 12g/day group had at least 1 point improvement on day 7 compared to baseline (χ2 = 10.10; p-value = 0.006). CRP levels in both arms showed decreasing trend after administration of HDIVC.
Conclusion
High-dose intravenous vitamin C of 6 grams per day resulted in better primary and secondary outcomes compared to 12 grams per day. The finding of this study provides preliminary guidance to HDIVC dosing strategy in future practice. Further studies may be needed to explore the efficacy and safety of HDIVC in COVID-19 patients.
References
1.Abobaker A, Alzwi A, Alraied A. H. A. Overview of the Possible Role of Vitamin C in Management of Covid-19. Pharmacol Rep. 2020;72(6):1517–1528. doi: 10.1007/s43440-020-00176-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Arvinte C, Singh M, Marik P. E. Serum Levels of Vitamin C and Vitamin D in a Cohort of Critically Ill Covid-19 Patients of a North American Community Hospital Intensive Care Unit in May 2020: A Pilot Study. Med Drug Discov. 2020;8(100064) doi: 10.1016/j.medidd.2020.100064. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Bonanad C, García-Blas S, Tarazona-Santabalbina F, Sanchis J, Bertomeu-González V, Fácila L, Ariza A, Núñez J, Cordero A. The Effect of Age on Mortality in Patients with Covid-19: A Meta-Analysis with 611,583 Subjects. J Am Med Dir Assoc. 2020;21(7):915–918. doi: 10.1016/j.jamda.2020.05.045. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Boretti A, Banik B. K. Intravenous Vitamin C for Reduction of Cytokines Storm in Acute Respiratory Distress Syndrome. PharmaNutrition. 2020;12(100190) doi: 10.1016/j.phanu.2020.100190. [DOI] [PMC free article] [PubMed] [Google Scholar]
Invasive intraventricular monitoring is the gold standard for intracranial pressure (ICP) monitoring; however, their placement could be challenging with multiple procedure-related risks. Optic nerve sheath diameter (ONSD) measurement has been reported as a reliable non-invasive method to assess ICP; however, existing literature revealed conflicting results.
Objectives
Our objectives are (i) to demonstrate the association of ONSD on CT with and without imaging signs of elevated ICP, (ii) to establish the range of ONSD in intracranial pathologies with CT imaging signs of elevated ICP; and (iii) to establish normative data of ONSD in Malaysian population.
Materials and methods
Three hundred forty-eight head CT scans performed at Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM) were retrospectively reviewed for the absence or presence of any intracranial pathology and signs of elevated ICP. A total of 456 CT findings were obtained from the 348 head CT scans, for which measurement of ONSD was made on CT, and the association between ONSD and CT findings were analyzed.
Results
CT findings with signs of increased ICP showed significantly higher ONSD than those without signs of increased ICP (p-value <.05). ONSD was also higher with a higher number of concurring signs of increased ICP. The ONSD cut-off point for suggesting increased ICP is 5.0 mm (sensitivity of 82.7% for the right eye and 84.9% for the left eye, and specificity of 64.6% for the right eye and 61.8% for the left eye). The normal mean ONSD for our local population is 4.94 (0.54) mm for the right eye and 4.94 (0.53) mm for the left eye.
Discussions
ONSD was significantly associated with imaging signs of increased ICP and the number of concurring imaging signs. With this establishment, this study is a proof of concept that imaging signs of elevated ICP are reflected on the ONSD, and this finding can be replicated by using other bedside/portable imaging machines in the acute setting. This study has also defined the range of normal CT-ONSD in our local population, and the size of ONSD of less than 5.0 mm measured on CT is a helpful indicator for excluding increased ICP.
References
1.Pinto VL, et al. Increased Intracranial Pressure. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. [PubMed] [Google Scholar]
2.Tavakoli S, et al. Complications of invasive intracranial pressure monitoring devices in neurocritical care. Neurosurg Focus. 2017;43(5):E6. doi: 10.3171/2017.8.FOCUS17450. [DOI] [PubMed] [Google Scholar]
3.Sekhon MS, et al. Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury. Intensive Care Med. 2014;40(9):1267–74. doi: 10.1007/s00134-014-3392-7. [DOI] [PubMed] [Google Scholar]
4.Helmke K, Hansen HC. Fundamentals of transorbital sonographic evaluation of optic nerve sheath expansion under intracranial hypertension. I. Experimental study. Pediatr Radiol. 1996;26(10):701–5. doi: 10.1007/BF01383383. [DOI] [PubMed] [Google Scholar]
Critically ill patients may be unconscious or unable to receive oral nutritional support and, hence are at increased risk of malnutrition. This study aimed to evaluate the effect of early moderate enteral nutrition on morbidity among patients admitted with shock as compared to conventional nutritional strategies.
Objective
The objective was to study the effect of early moderate enteral nutrition on the duration of ICU and hospital length of stay.
Materials and methods
120 patients admitted to the medical ICU with shock, were randomized into early enteral feed (study) and conventional feed (control) groups. Baseline parameters, hemodynamic SOFA score, and serum lactate values were recorded at admission. All patients (n = 60) in the study group were started on enteral nutritional support with isoosmotic, isocaloric (15 kcal/kg/day), standard recommended protein and polymeric preparation within 24 hours of admission until ICU discharge/ initiation of oral feeding or death. In the conventional nutritional strategy group (n = 60), hypocaloric (10 kcal/kg/day) feed was administered enterally after the vasopressor requirement was <0.1 mcg/kg/min or until the patient was hemodynamically stable. Patients were regularly fed after 48 hours of endotracheal intubation.
Results
The ICU length of stay (days, mean Standard deviation) was longer in the control group (10.17, 6.51) as compared to the study group (7.17, 5.36) which was found to be statistically significant [Wilcoxon-Mann-Whitney U Test (W) = 1116.000, p = <0.001]. The hospital length of stay (days, mean Standard deviation) was significantly shorter (W = 1294.000, p = 0.008) in the study group (10.13, 6.38) compared to the control group (13.48, 7.99).
Discussion
In this single-center randomized study, we were able to establish that early initiation of isocaloric moderate intensity feeds was feasible and was associated with lesser mortality, quicker reversal of shock, and lesser number of days on ventilator. These advantages translate into an overall shorter duration of stay in the ICU as well as in the hospital. This strategy should therefore be attempted among all ventilated patients in shock. Withholding feeds in anticipation of shock reversal could prolong the LOS in the hospital. This study did not show a survival benefit in the conventional group but was not powered to detect this outcome.
Conclusions
Early moderate enteral nutrition in ventilated patients with shock may be associated with a shorter ICU and hospital length of stay compared to conventional nutritional strategies.
References
1.Reignier J, Boisramé-Helms J, Brisard L, Lascarrou JB, Ait Hssain A, Anguel N, et al. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomized, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2) Lancet. 2018 Jan 13;391(10116):133–43. doi: 10.1016/S0140-6736(17)32146-3. [DOI] [PubMed] [Google Scholar]
2.Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019 Feb;38(1):48–79. doi: 10.1016/j.clnu.2018.08.037. [DOI] [PubMed] [Google Scholar]
Bile leak or cystic duct leak is a very serious complication of cholecystectomy with reported incidence of 0.12%.1 If diagnosed early in the postoperative period it can be managed with endoscopic stenting, sphincterotomy and abdominal drains.2 Once intraabdominal abscess develops in late presenters, exploration is needed for active source control and management. We present here two case reports of cystic duct leak post elective laparoscopic cholecystectomy done at the same private hospital, who presented to Fortis Hospital, Mohali (FHM).
Case 1
A 43-year-old male presented to FHM on 4/7/23, with high grade fever, vomiting and abdominal pain for last 3 days. He gave a history of undergoing uneventful laparoscopic cholecystectomy on 19/6/23 at a peripheral private hospital following which he started having pain abdomen with low grade fever from 4th post-op day. CT abdomen at peripheral hospital showed peritoneal fluid with right subhepatic collection. He was initially managed with analgesics, antibiotic (Ceftriaxone) later upgraded to Piperacillin-Tazobactam and was discharged on 7th post-op day with stable vitals. On 4/7/23 he was referred to FHM with high grade fever, bilious vomiting and abdominal pain for 3 days. On arrival the vitals were as follows: HR-120/m, BP-100/50mm Hg, RR-35/m, Spo2 94@4 lts oxygen, temperature- 104 deg F, with lactates- 2.5, CRP- 288/PCT 14/ TLC35K/ANC 17. After requesting cultures and sepsis panel workup, initial stabilization with iv fluids and empirical antibiotics (Meropenam) as per protocol in ICU was performed. CECT abdomen and MRCP were done which revealed intraperitoneal plus pelvic collection due to gross cystic stump leak. ERCP (5/7/23) with sphincterotomy was performed under sedation and two balloon (10F) stents were placed for gross cystic duct leak. USG guided pigtail was placed for drainage of intraabdominal collections and pus was sent for investigation. Diagnostic laparoscopy with peritoneal lavage and abscess drainage was performed (6/7/23) as he remained febrile with distended abdomen (no bowel sounds) and unstable hemodynamics (nor epi @7ml/hr). He was gradually weaned off mechanical ventilator in the next 3 days once vitals stabilized. Abdominal pus culture showed Acinetobacter baumannii XDR (Colistin sensitive <0.5, Meropenam resistance <16) and Enterococcus faecalis XDR (Tigecycline sensitive only < 0.12) for which Colistin, Tigecycline were added to Meropenem. Andulafungin was added in view of high Candida score (multiple GI surgery, TPN, shock, invasive lines, PCT 0.5 on day 2) and BDG positive (2.8) although fungal cultures remained sterile. He was shifted out of ICU on10th post-op day with stable hemodynamics.
Case 2
A 37-year-old female was referred from the same peripheral hospital with fever, acute abdominal pain and distention for 3 days on 10/7/23. She gave history of undergoing uneventful laparoscopic cholecystectomy on 30/6/23. A previously done CT abdomen reported subhepatic and intra pelvic collection. On arrival she was febrile (102 deg F) with heart rate 140/min, BP 100/50 mm HG, Spo2 94%@ 4lts oxygen, respiratory rate 35/min. After initial management with fluids, cultures and sepsis panel investigation (CRP 345/PCT 45/TLC 30K/ANC 10) empiric antibiotic (Meropenam) were initiated. MRCP confirmed multiple fluid collections over subhepatic, peri gastric, peri splenic, lesser sac area with cystic stump leak. ERCP (11/7/23) with sphincterotomy and DPT stent was placed with ultrasound guided pigtail placement for intraabdominal abscess drainage. Pus was sent for all relevant investigations. Diagnostic laparoscopy was done with peritoneal and pelvic lavage (12//23) for further source control. Abdominal pus culture showed Pseudomonas aeruginosa MDR (carbapenem sensitive) for which Meropenam was continued. She recovered well in next 5 days and was shifted out of ICU on 5th post-op day.
Discussion
Cystic duct stump leak is a serious complication following Laparoscopic cholecystectomy. Although bile leakage from the cystic stump is classified as a minor complication, it has nevertheless been associated with increased morbidity and even mortality.3 Cystic stump bile leak is also the most common site of leakage after the procedure and accounts for up to 70% of identified leaks.4 It generally presents with acute abdominal pain with fever and vomiting after few days of surgery. Early acute presentations are reported in case of larger cystic duct leak. Early diagnosis is vital to avoid further complications mostly due to biliary peritonitis and Gram-negative sepsis. Intraabdominal abscess may further cause adhesions resulting in gut obstruction and its sequelae. Similar clinical features are also evident post laparoscopic surgery in case of gut perforation or visceral injury due to instrumentation with more acute early presentation. Apart from maintaining vitals, hydration, early empirical antibiotic cover and urgent source control is needed. Pigtail drainage of abdominal collection via ultrasound and definitive management with ERCP stenting is of vital importance. A few case reports are reported in patients with persistent bile leak who were managed with percutaneous transabdominal access of the cystic duct and coil embolization.5 These procedures are aimed to avoid significant morbidity of open surgical exploration by rapid minimal invasive source control.6 More extensive peritoneal lavage either by laparoscopy or exploratory laparotomy is needed in difficult to access intraabdominal collections, adhesions and non-responders. Empiric antibiotics should cover gram-negative bacteria with anaerobic coverage till confirmed final culture reports. Enterococcus infection, is also common in these patients with repeated surgical interventions, perforations or fecal contaminations. Late presenters are high risk group for fungal infections (high candida score) and therefore, empiric antifungals may be added in case of refractory sepsis with worsening clinical status and on multiple broad-spectrum antibiotics. This case report signifies the importance of multidisciplinary approach between surgery, microbiology and intensive care working in collaboration with minimal invasive as well as extensive surgical exploration for good outcome.
References
1.Eisenstein S, Greenstein AJ, Kim U, et al. Cystic duct stump leaks: After the learning curve. Arch Surg. 2008;143(12):1178–83. doi: 10.1001/archsurg.143.12.1178. [DOI] [PubMed] [Google Scholar]
2.Singh V, Singh G, Verma GR, et al. Endoscopic management of post cholecystectomy biliary leakage. Hepatobiliary Pancreatitis Dis Int. 2010;9(4):409–13. [PubMed] [Google Scholar]
3.Chun K. Recent classifications of the common bile duct injury. Korean Journal of Hepatobiliary Pancreatic Surgery. 2014;18(3):69–72. doi: 10.14701/kjhbps.2014.18.3.69. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Shaikh IA, Thomas H, Joga K, et al. Post-cholecystectomy cystic duct stump leak: A preventable morbidity. J Dig Dis. 2009;10(3):207–212. doi: 10.1111/j.1751-2980.2009.00387.x. [DOI] [PubMed] [Google Scholar]
5.Craig Brown. Management of a Persistent Cystic Duct Stump Leak Following Cholecystectomy With Percutaneous Transabdominal Cystic Duct Stump Embolization. ACG Case Rep J. 2019:6. doi: 10.14309/crj.0000000000000162. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Perisetti A, Raghavapuram S, Tharian B. Refractory cystic duct stump leak treated with fibrin glue. Endoscopy. 2019;51:E170–1. doi: 10.1055/a-0871-1952. [DOI] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, Saint John's Medical College and Hospital, Bengaluru, India, Phone: +91 9915994530, e-mail: kajaldimple.arora@gmail.com
1Department of Critical Care Medicine, Saint John's Medical College and Hospital, Bengaluru, India, Phone: +91 9915994530, e-mail: kajaldimple.arora@gmail.com
2–6Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Diagnosis and prognostication of patients with sepsis at the earliest time point is vital for appropriate patient management and judicious resource utilization. Cell surface markers like neutrophil CD64 (nCD64), monocyte HLA-DR (mHLA-DR), and sepsis index (ratio of nCD64 and mHLA-DR) (1) might perform better than conventional biomarkers like procalcitonin.
Objectives
To evaluate the diagnostic and prognostic accuracy of nCD64, mHLA-DR, and Sepsis Index (SI) in patients with sepsis according to sepsis-3 criteria in a tertiary care center.
Materials and methods
We undertook a prospective observational study among 50 cases diagnosed with sepsis according to sepsis-3 criteria, 25 non-septic patients, and 25 healthy individuals as controls. The study was a monocentric study conducted in a tertiary care center in India. Fifty consenting patients with sepsis underwent flowcytometric estimation of nCD64 and mHLA-DR and serum procalcitonin within 24 hours of admission along with the assessment of Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE-II) score on the day of admission and after 24 hours. The non-septic and healthy cohort also underwent flowcytometric estimation of nCD64 and mHLA-DR. The authors followed the patients until death or discharge from the hospital.
Results
The sepsis cohort had significantly higher nCD64 and lower mHLA-DR expression than both control groups (p-value: < 0.001). The sensitivity and specificity of nCD64 ABC (Antibodies Bound per Cell) for diagnosis of sepsis with a cut-off of 1152.16 were 94% and 74%, respectively. Similarly, for the Sepsis Index (cutoff-11.36), the sensitivity and specificity for the diagnosis of sepsis were 88% and 86%, respectively. Out of 50 patients with sepsis, nCD64 detected 18 cases missed with serum procalcitonin (cut-off used- 0.5 ng/ml) (2). The combination of sepsis index or CD64 (either positive) increased the sensitivity to 96%. Using the combination of all three markers (nCD64 ABC, mHLA-DR ABC, and SI), the sensitivity for diagnosis of sepsis approached 100%. Among flowcytometric variables, the sepsis index had a statistically significant association with hospital mortality on univariate analysis. However, only the baseline SOFA score was independently associated with hospital mortality on multivariate logistic regression analysis.
Discussions
nCD64 and sepsis index are good diagnostic markers in patients with sepsis and should be considered for early diagnosis of sepsis. Both these variables performed much better than serum procalcitonin. Though the sepsis index was significantly higher in non-survivors, only the baseline SOFA score as an independent parameter had a statistically significant association with hospital mortality. The combination of nCD64 and sepsis index should be used for the early diagnosis of sepsis in adult patients as it will reduce the unnecessary delay in the initiation of antibiotics.
References
1.Pradhan R, Jain P, Paria A, Saha A, Sahoo J, Sen A, et al. Ratio of neutrophilic CD64 and monocytic HLA-DR: A novel parameter in diagnosis and prognostication of neonatal sepsis. Cytometry Part B: Clinical Cytometry. 2016 May doi: 10.1002/cyto.b.21244. [DOI] [PubMed] [Google Scholar]
2.H O, J S, M K. Semi-quantitative procalcitonin test for the diagnosis of bacterial infection: clinical use and experience in Japan. J Microbiol Immunol Infect. 2010 Jun doi: 10.1016/S1684-1182(10)60035-7. [DOI] [PubMed] [Google Scholar]
Acute fatty liver of pregnancy (AFLP) is an uncommon disorder between the 30th - 38th week of pregnancy. Data from India described an incidence of 30 per 1 lakh pregnancies.1 Due to its non-specific nature of clinical presentation, along with a wide differential of liver disease in pregnancy, it is often underdiagnosed. In pregnancy, it has been found to have a higher mortality than viral hepatitis (41% vs 8%).2 While maternal mortality in Western literature has shown improvement over the last few decades, high perinatal morbidity and mortality has been related to maternal decompensation.3 A 20 year retrospective study from AIIMS found non hepatitis E related liver failure in pregnancy had a mortality of 54.7%.4
Objectives
Describe the clinical severity, treatment course and complications of patients admitted to ICU with AFLP.
Describe the maternal and pregnancy outcomes among patients admitted to ICU with AFLP.
Materials and methods
The medical records of all patients from 2018 to 2022 admitted to Intensive Care Unit (ICU) were reviewed. The total admissions during the same period was 6,880. Among these, 507 (7.4%) were admissions from the department of Obstetrics. Among these, 18 (3.6%) cases were diagnosed to have AFLP based on Swansea criteria for diagnosis. Those who did not fulfill the diagnostic criteria were excluded from the study. Details of clinical features, hematological, biochemical, and microbiological parameters were obtained. The principal investigator tried to ascertain the presence of risk factors, treatment details, and outcomes in each patient. A trained physician did data recruitment, analysis, and interpretation. Data was entered in Microsoft Excel and was analyzed using SPSS.
Results
Analysis of data records from 2018 to 2022 we found that there was a total of 6880 cases admitted to our ICU with 507 (7.4%) admitted under the department of Obstetrics. Of these 18 (3.6%) were diagnosed with AFLP. We found that there were 2 (10%) poor outcomes with no maternal mortality recorded from the cohort, while neonatal mortality was 22%. The median duration of ICU and hospital stay were 6 and 14 days respectively. The most common complications during hospitalization were acute kidney injury (94%) and hemorrhage requiring transfusion (89%). Analysis of maternal outcomes between survivors and poor outcomes did not show any statistical difference between the two groups. Cesarean section was performed in 13 (72%) as the mode of delivery with maternal deterioration being the most common indication (54%) for delivery. Standardized scoring systems such as the SOFA, APACHE II, APACHE IV and SAPS III scores were calculated at admission with the estimated mortality ranging from 15% - 40%. However, in our cohort of cases we did not have any mortality. There were 4 twin-pregnancies in our cohort with a total of 22 neonates. 11 (64%) were preterm with a median birth weight of 2.66 kg. Neonatal ICU admission was indicated in 14 (64%) of our cohort with a median ICU stay of 9 days. Multivariate analysis of comorbidities, maternal complications and scoring systems were analyzed against neonatal mortality. We found that preterm delivery (p-value 0.038) and raised admission maternal creatinine (1.64 vs 2.53; p-value 0.031) was associated with a higher neonatal mortality. The median cesarean section rate and neonatal mortality rate was 32% and 2.2% respectively in our hospital during the same study period. Univariate analysis against the AFLP group found statistically significant higher prevalence of cesarean section (p- value <0.005; 95% CI 0.51 - 0.92) and neonatal mortality (p- value <0.001; 95% CI 0.0 - 0.32).
Discussions
There was no maternal mortality among the pregnant mothers, however there were 2 cases with uncertain outcomes. Preterm delivery and KDIGO stage 2 or higher AKI at admission was associated with neonatal mortality. Current ICU scoring systems do not accurately estimate the ICU mortality of AFLP in pregnancy.
1.Rathi U, Bapat M, Rathi P, Abraham P. Effect of liver disease on maternal and fetal outcome–a prospective study. Indian J Gastroenterol. 2007 Mar-Apr;26(2):59–63. [PubMed] [Google Scholar]
2.Devarbhavi H, Kremers WK, Dierkhising R, Padmanabhan L. Pregnancy-associated acute liver disease and acute viral hepatitis: differentiation, course and outcome. J Hepatol. 2008 Dec;49(6):930–5. doi: 10.1016/j.jhep.2008.07.030. [DOI] [PubMed] [Google Scholar]
3.Goel A, Jamwal KD, Ramachandran A, Balasubramanian KA, Eapen CE. Pregnancy-related liver disorders. J Clin Exp Hepatol. 2014 Jun;4(2) doi: 10.1016/j.jceh.2013.03.220. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Bhatia V, Singhal A, Panda SK, Acharya SK. A 20-year single-center experience with acute liver failure during pregnancy: is the prognosis really worse? Hepatology. 2008 Nov;48(5):1577–85. doi: 10.1002/hep.22493. [DOI] [PubMed] [Google Scholar]
To Compare iVAPS vs S/T Mode as Non-invasive Weaning Strategy in Post Extubation COPD Patients for Prevention of Post Extubation Respiratory Failure: A Pilot Randomized Trial
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may lead to the requirement of Invasive Mechanical Ventilation (IMV) due to hypoventilation as a result of increased work of breathing. However, IMV is associated with numerous risks. Hence, the liberation of mechanical ventilation is targeted as soon as possible. However, there is also a risk of reintubation in high-risk cases. Use of Non-Invasive Ventilation (NIV) is recommended in the immediate post-extubation state of cases fulfilling the high-risk criteria. NIV can be given via fixed pressure support modified manually or using a range of pressure support and respiratory rate adjusted as per machine-estimated alveolar ventilation of the patient. We present an interim analysis of this trial which attempts to compare these two methods in terms of post-extubation failure prevention.
Objectives
To evaluate the comparative efficacy of two different modes of NIV in AE COPD patients post-extubation.
Materials and methods
AECOPD patients requiring IMV and planned to administer NIV post-extubation were classified (prior to liberation from the ventilator) into simple, difficult, and prolonged weaning and prior to extubation into Group A (S/T mode) and Group B (iVAPS mode). Vital signs, GCS, ABG parameters, and patient comfort were analyzed at the beginning of the study and at 1, 2, 12, 24, and 48 hours after initiation of NIV therapy. They were assessed for NIV success and signs of post-extubation failure.
Results
43 consecutively sampled patients have been included in the study so far, out of which 69.8% were males and the overall mean age was 64.1 years (± 8.1). The median length of ICU stay was 6 days (2-21) and the mean duration of NIV use was 63.3 hours (± 40.6). 83.7% of patients had a simple weaning while the rest had a difficult weaning from IMV. S/T mode (Group A) was assigned to 22 patients and 21 patients were assigned to iVAPS mode (Group B) of NIV. The overall success rate of NIV was 83.7%, with Group A having numerically higher but statistically insignificant success rates than Group B (86.4% vs 80.9%, p = 0.698). There was no significant difference between median length of ICU stay (6.5 vs 5 days; p = 0.155), mean duration of NIV (68.1 vs 58.2 hours; p = 0.436), or mean NIV comfort scores between the two groups (p > 0.05).
Conclusions
There was no difference in terms of success rates, comfort scores, duration of ICU stay, or NIV duration between S/T and iVAPS modes of NIV in AECOPD patients. Hence, iVAPS mode seems to be non-inferior to S/T mode in the prevention of post-extubation failure in AECOPD patients.
References
1.Ghosh S, Chawla A, Mishra K, Jhalani R, Salhotra R, Singh A. Cumulative fluid balance and outcome of extubation: a prospective observational study from a general intensive care unit. Indian J Crit Care Med. 2018;22(11):767–772. doi: 10.4103/ijccm.IJCCM_216_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Thille AW, Harrois A, Schortgen FD, Brun-Buisson C, Brochard L. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med. 2011;39(12):2612–2618. doi: 10.1097/CCM.0b013e3182282a5a. [DOI] [PubMed] [Google Scholar]
3.Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early non-invasive ventilation averts extubation failure in patients at risk – a randomized trial. Am J Respir Crit Care Med. 2006;173(2):164–170. doi: 10.1164/rccm.200505-718OC. [DOI] [PubMed] [Google Scholar]
4.Upadya A, Tilluckdharry L, Muralidharan V, Amoateng-Adjepong Y, Manthous CA. Fluid balance and weaning outcomes. Intensive Care Med. 2005;31(12):1643–1647. doi: 10.1007/s00134-005-2801-3. [DOI] [PubMed] [Google Scholar]
5.Rochwerg B, Brochard L, Elliott M, Hess D, Hill N, Nava S, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. European Respiratory Journal. 2017;50(2):1602426. doi: 10.1183/13993003.02426-2016. [DOI] [PubMed] [Google Scholar]
6.Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, et al. Non-invasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33(11):2465–2470. doi: 10.1097/01.ccm.0000186416.44752.72. [DOI] [PubMed] [Google Scholar]
7.Ghosh S, Ghosh S, Singh A, Salhotra R. Impact of Prophylactic Noninvasive Ventilation on Extubation Outcome: A 4-year Prospective Observational Study from a Multidisciplinary ICU. Indian J Crit Care Med. 2021;25(6):709–714. doi: 10.5005/jp-journals-10071-23880. [DOI] [PMC free article] [PubMed] [Google Scholar]
Comparison of Three Strategies for Withdrawal of Post-extubation Non-invasive Ventilation in Patients of Acute Exacerbation of COPD with Acute Hypercapnic Respiratory Failure Undergoing Invasive Mechanical Ventilation: Randomized Trial
Use of Non-Invasive Ventilation (NIV) is recommended in immediate post-extubation state of Acute Exacerbation of COPD (AECOPD) with acute Hypercapnic Respiratory Failure (HcRF) patients if PaCO2 stays > 45 mm Hg at the time of extubation. Similar to IMV, it is necessary to minimize the duration of NIV as well to prevent complications directly attributable to NIV as well indirect issues like prolonged hospital stay and further chances of Hospital Acquired Infections (HAIs). We present an interim analysis of this trial, where we have compared three possible weaning strategies that can potentially be used – stepwise reduction of the duration of NIV use, stepwise reduction in pressure support of NIV, and immediate withdrawal of NIV.
Objectives
To evaluate the comparative efficacy of three different strategies of NIV withdrawal in AE COPD patients post-extubation.
Materials and methods
AECOPD patients requiring IMV and planned to administer NIV post-extubation were included in the study. After stabilization on NIV, the patients were randomized into three weaning strategies, immediate withdrawal (Group A), stepwise reduction of pressure support (Group B), and stepwise reduction of duration (Group C Vital signs, GCS, ABG parameters, and patient comfort were analyzed at initiation of NIV and at 1, 2, 12, 24, 48, and 72 hours. The same parameters were studied till 48 hours after randomization. All subjects were monitored closely for any signs of weaning failure and success rates were analyzed.
Results
41 consecutively sampled patients have been included in the study so far, out of which 70.7% were males and the overall mean age was 64.3 years (± 8.2). The median length of ICU stay was 5 days (2-21) and the mean duration of NIV use was 62.9 hours (± 38.1). Until now, 13 patients were enrolled in Group A, 8 in Group B, and 20 in Group C. The overall success rate of NIV weaning was 82.9%, while that for the individual groups was comparable (84.6% vs 75.0% vs 85.0%; p=0.802). There was no significant difference between the median length of ICU stay (5 vs 5.5 vs 5 days; p=0.577), mean duration of NIV (70.1 vs 66.7 hours; p=0.525), or mean NIV comfort scores between the groups (p > 0.05).
Conclusions
There was no difference in terms of success rates, comfort scores, duration of ICU stay, or NIV duration between the three different methods of weaning from NIV in AECOPD patients post-extubation. Hence, an immediate withdrawal weaning method may be tried in AECOPD patients once they are stabilized using NIV post-extubation. This may lead to reduced hospital care costs and reduced total time on NIV.
References
1.Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early non-invasive ventilation averts extubation failure in patients at risk – a randomized trial. Am J Respir Crit Care Med. 2006;173(2):164–170. doi: 10.1164/rccm.200505-718OC. [DOI] [PubMed] [Google Scholar]
2.Su CL, Chiang LL, Yang SH, Lin HI, Cheng KC, Huang YC, et al. Preventive use of noninvasive ventilation after extubation: a prospective, multicenter randomized controlled trial.
Respir Care
. 2012;57:204–210. doi: 10.4187/respcare.01141. [DOI] [PubMed] [Google Scholar]
3.American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, and Societe de Reanimation de Langue Francçaise International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med. 2001;163:283–291. doi: 10.1164/ajrccm.163.1.ats1000. [DOI] [PubMed] [Google Scholar]
4.Lun CT, Chan VL, Leung WS, Cheung AP, Cheng SL, Tsui MS, et al. A pilot randomized study comparing two methods of non-invasive ventilation withdrawal after acute respiratory failure in chronic obstructive pulmonary disease. Respirology. 2013 Jul;18(5):814–9. doi: 10.1111/resp.12080. [DOI] [PubMed] [Google Scholar]
5.Hadda V, Venkatnarayan K, Khilnani G, Madan K, Mohan A, Pandey R, et al. A comparison of three strategies for withdrawal of noninvasive ventilation in chronic obstructive pulmonary disease with acute respiratory failure: Randomized trial. Lung India. 2020;37(1):3. doi: 10.4103/lungindia.lungindia_335_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
To Study the Drug Flupirtine and its Role as Preemptive Analgesia in Patients Undergoing Laparoscopic Cholecystectomy in a Tertiary Care Hospital Setting: A Randomised, Double Blinded Clinical Trial
Acute postoperative pain is a major concern which augments post op complications. The objective of this study aimed to study the drug Flupirtine, a non opioid, non NSAID, NMDA antagonist as preemptive analgesic for significant reduction in post operative algesia in patients posted for elective Laparoscopic Cholecystectomy in a tertiary care hospital setting.
Materials and methods
In all, 40 patients scheduled for elective Laparoscopic Cholecystectomy under General Anesthesia were randomly assigned into 2 groups of 20 patients each. Patients in the control group (Group C) received GA with Tablet B complex p/o before surgery whereas Group D received GA along with Tab Flupirtine 200 mg p/o 2 hours before surgery with sips of water. The Primary outcome was the Assessment of Post operative pain and efficacy of drug Flupirtine using Visual Analog Scale (VAS) score analysis at 0, 4h, 12h following transfer to Post Anesthetic Care Unit (PACU).
Patients receiving Flupirtine (Group D) had significant lower incidence of post op pain (20% in Group D vs 90% in Group C, p value = <0.0001). In these patients, severity of post op pain was greater in early post op period (70% in Group D vs 100% in Group C, p value = 0.027) while it decreases significantly at 12 h postop (0.0% in Group D vs 30% in Group C, p value = 0.027).
Flupirtine 200 mg p/o 1 Tab 2 hours before induction as preemptive analgesic adjunct for patients undergoing Elective Laparoscopic Cholecystectomy under GA with sips of water resulted in better post op pain recovery profile along with significant reduction in requirement of post op opioids.
References
1.Osborne NN, Cazevielle C, Wood JP, Nash MS, Pergande G, Block F, et al. Flupirtine, a non opiod centrally acting analgesic, acts as an NMDA antagonist. Gen Pharmacol. 1998;30:255–63. doi: 10.1016/s0306-3623(97)00355-8. [DOI] [PubMed] [Google Scholar]
2.Singhal R, Gupta P, Jain N, Gupta S. Role of flupirtine in the treatment of pain chemistry and its effects. Medica J Clin Med. 2012;7:163–6. [PMC free article] [PubMed] [Google Scholar]
3.Hummel T, Friedmann T, Pauli E, Niebch G, Borbe HO. Dose related analgesic effects of Flupirtine. Br J Clin Pharmacol. 1991;32:69–76. doi: 10.1111/j.1365-2125.1991.tb05615.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
Hypophosphatemia in COPD Patients requiring Mechanical Ventilation and its Impact on Weaning in an Intensive Care Unit of a Tertiary Care Hospital in Eastern India
Hypophosphatemia is frequent in patients with chronic obstructive pulmonary disease (COPD) and can negatively affect weaning from mechanical ventilation.
Objective
The present study aimed to determine the incidence of hypophosphatemia and, its impact on weaning from mechanical ventilation in COPD patients admitted in the intensive care unit (ICU) in a tertiary care hospital of Eastern India.
Methods
This was a prospective observational study, which included 60 adult patients [Male: Female ratio: 35:25] of age 18 to 75 years [Mean 62.7 ± 6.1 years] with acute exacerbations of COPD on mechanical ventilation in the ICU, and who were to undergo weaning trial. Serum phosphate levels was assessed at the time of admission (baseline) and before each weaning attempt (Total three). Weaning outcome, length of stay (LOS) on ventilator, and LOS in ICU were recorded. Successful weaning was defined as extubation after a weaning trial. ROC analysis was done to identify cut-off value of serum phosphate which predicted successful weaning.
Results
Hypophosphatemia was found to be 25% [15/60] & 21.7% [13/60] at admission & before first weaning attempt, respectively. Weaning success in 1st, 2nd and 3rd attempt in patients with hypophosphatemia were 15.4% [2/13], 10% [1/11] & zero% [0/9], respectively. Weaning success in 1st, 2nd & 3rd attempt in patients with normophosphataemia were, 42.6% [20/47], 63% [17/27] & 100% [11/11], respectively.
Discussion
Thus overall differences in mean serum phosphate levels among those with failure-to-wean in each weaning trial and a successful attempt were statistically significant (p<0.001). Length of stay on ventilator among those who were discharged & who expired, were 6.2±2.6 days & 14.4±3.5 days, respectively [p = 0.02]. LOS in ICU among those who were discharged & those who expired were, 10.8±3.7 days & 20.4±5.8 days, respectively [p = 0.01]. On ROC analysis of serum phosphate level before first weaning trial, a cut-off value of ≥3.0 mg/dl was identified to have 86.4% sensitivity, 55.3% specificity, 52.8% positive predictive value (PPV), 87.5% negative predictive value (NPV) and 66.7% diagnostic accuracy in predicting weaning success. The overall mortality rate was 8.3%. Lower mean serum phosphate levels before first weaning trial, higher mean age, longer ventilator days and ICU days were significantly associated with mortality among our study participants (p<0.05).
Conclusion
Hypophosphatemia is often present in COPD patients on mechanical ventilation and can lead to weaning failure. We suggest that maintaining normal serum phosphate levels are critical to successful weaning of patients with COPD from ventilator support.
1.Neeralagi SS, Lakshminarayana CT, Kumar A, et al. Assessment of serum phosphorus levels as a factor in weaning off ICU patients from mechanical ventilation - a cross sectional observational study in a tertiary care hospital. J Evid Based Med Healthc. 2021;8(11):575–578. [Google Scholar]
2.Talakoub R, Bahrami M, Honarmand A, et al. The predicting ability of serum phosphorus to assess the duration of mechanical ventilation in critically ill patients. Advanced Biomedical Research. 2017;6:51. doi: 10.4103/2277-9175.205192. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Boles JM, Bion J, Connors A, et al. Weaning from mechanical ventilation. Eur Respir J. 2007;29(5):1033–1056. doi: 10.1183/09031936.00010206. [DOI] [PubMed] [Google Scholar]
A decrease in serum albumin levels in a dengue patient is correlated with higher likelihood of an adverse outcome. The levels can be utilized as an early predictor of likelihood of clinical worsening, despite adequate treatment.
Objectives
A retrospective observational study to analyze initial serum albumin levels in admitted patients with dengue with warning signs and its correlation with outcome.
Materials and methods
Over a 5-month period from August 2021, 147 adult patients (age >14 years) who had dengue with warning signs (as per WHO classification) on admission to Medical Intensive Care Unit, Fortis Hospital, Mohali, Punjab (India) were retrospectively evaluated. Admitted cases of dengue fever were divided into three groups based on serum albumin levels on presentation: mild (>3.5 mg/dL), moderate (2.5 – 3.5 mg/dL), and severe (< 2.5 mg/dL). Initial serum albumin was co-related with survival or non – survival. Clinical, hematological, and biochemical parameters, as recommended in the WHO guidelines were used to look for correlation with predictive of severity, were compared between those who showed clinical worsening and developed TSFA and multi organ failure. All patients were managed according to the WHO and MoHFW guidelines for the management of adult dengue, published by the Ministry of Health, India.
Results
Out of the 147 patients. 13 patients (8.8%) had severe hypoalbuminemia (< 2.5 mg/dL), 48 patients (32.65%) had moderate hypoalbuminemia (2.5 – 3.5 mg/dL), and 46 (31.29%) had normal albumin levels (> 3.5mg/dL). Mortality was noted to be highest in patients who presented with severe hypoalbuminemia (38.4%) as compared to other two groups where the mortality was 14.58% and 0%.
Discussions
Dengue remains to be a disease of concern due to untoward high morbidity and mortality among young population. WHO reported over 8 times increase in number of cases over last two decades with increase in more than four times the mortality from 2010 to 2019. The actual number might be higher as only severe cases of dengue are hospitalized and many of the mild dengue cases go unreported. 1 Dengue Virus infected cells release inflammatory mediators and form immune complexes. This results in a complement cascade, thus in increased permeability and haemorrhagic manifestations. Plasma leakage that leads to shock or fluid accumulation, sufficient to cause respiratory distress, is defined as “Clinically Significant” by the WHO. Reactive oxygen species, enzymes, and pro-inflammatory molecules (e.g. TNF-α, IL-6, IL-8 and IFN-γ) breaks down the endothelial glycocalyx layer transiently, thus allowing plasma to reach the underlying intercellular junctions and leak out of the blood vessel. Albumin and other smaller proteins is lost from the blood vessels, resulting in hypoalbuminemia and third space loss.27. All cases of severe dengue need institutional care and monitoring, but since there and no definite tools for the diagnosis or for prognostication of dengue cases, over admission of patients is common. 13 Most of the studies to differentiate severe from mild dengue have been conducted in paediatric age group.3 These studies showed that it was difficult to differentiate mild from severe dengue until the critical phase developed.13,26. Attempts have been made to assess the severity of dengue by developing scores, use predictors live PCV (packed cell volume), use clinical signs (pulse volume, narrow pulse pressure (< 20 mmHg), hypotension, shock, etc.). Out of these, presence of third space fluid accumulation is considered the most objective evidence for plasma leakage.1,26. The baseline value of haematological parameters are rarely available, and the presence of anaemia, haemorrhage, and fluid resuscitation often makes the interpretation of the haematological parameters difficult.1 In our study, the serum albumin levels were observed and correlation with clinical symptoms and mortality in hospital was studied. Among patients who had poor outcome or developed the complication after admission, a fall in serum albumin levels were noted and of those in whom serum albumin levels remained to be low despite correction went on to develop third space fluid accumulation and multi organ failure and tend to have worse outcomes. Third space fluid accumulation, pleural effusions and ascites were the common ultrasonographic sign of plasma leakage.14 As serum albumin levels were lower in patients who developed third space fluid accumulation and those who did not, the complication seems to be primarily a result of increased capillary permeability during the disease process. Our study had its own limitations. Firstly, it was a retrospective study with its inherent bias associated. Secondly, the number of patients were small compared to the large numbers of cases across the country. Thirdly, this was a study done in a single ICU. More studies will be required to be done in a controlled environment to authenticate and validate the data derived by us.
2.Premaratna R, Ragupathy A, Miththinda J.K.N.D, de Silva H.J. Timings, predictors and progress of third space fluid accumulation during preliminary phase fluid resuscitation in adult patients with dengue. International Journal of Infectious Diseases. 2013;17:e505–e509. doi: 10.1016/j.ijid.2012.12.021. [DOI] [PubMed] [Google Scholar]
7.Messer WB, Vitarana TU, Sivananthan K, Elvtigala J, Preethimala D, Ramesh R, et al. Epidemiology of dengue in Sri Lanka before and after the emergence of epidemic dengue hemorrhagic fever. Am J Trop Med Hyg. 2002;66:765–73. doi: 10.4269/ajtmh.2002.66.765. [DOI] [PubMed] [Google Scholar]
8.Kularatnea SA, Seneviratne SL, Malavige GN, Fernando S, Velathanthiric VG, Ranatunga PK, et al. Synopsis of findings from recent studies on dengue in Sri Lanka. Dengue Bulletin. 2006;30:80–6. [Google Scholar]
9.Cohen SN, Halstead SB. Shock associated with dengue infection. I. Clinical and physiologic manifestations of dengue hemorrhagic fever in Thailand, 1964. J Pediatr. 1966;68:448–56. doi: 10.1016/s0022-3476(66)80249-4. [DOI] [PubMed] [Google Scholar]
10.Nimmannitya S, Halstead SB, Cohen SN, Margiotta MR. Dengue and chikungunya virus infection in man in Thailand, 1962–1964. Observations on hospitalized patients with hemorrhagic fever. Am J Trop Med Hyg. 1969;18:954–71. doi: 10.4269/ajtmh.1969.18.954. [DOI] [PubMed] [Google Scholar]
11.Low JG, Ong A, Tan LK, Chaterji S, Chow A, Lim WY, et al. The early clinical features of dengue in adults: challenges for early clinical diagnosis. PLoS Negl Trop Dis. 2011;5:e1191. doi: 10.1371/journal.pntd.0001191. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Premaratna R, Jayasinghe KG, Liyanaarachchi EW, Weerasinghe OM, Pathmeswaran A, de Silva HJ. Effect of a single dose of methyl prednisolone as rescue medication for patients who develop hypotensive dengue shock syndrome during the febrile phase: a retrospective observational study. Int J Infect Dis. 2011;15:e433–4. doi: 10.1016/j.ijid.2011.03.006. [DOI] [PubMed] [Google Scholar]
13.Potts JA, Gibbons RV, Rothman AL, Srikiatkhachorn A, Thomas SJ, Supradish PO, et al. Prediction of dengue disease severity among pediatric Thai patients using early clinical laboratory indicators. PLoS Negl Trop Dis. 2010;4:e769. doi: 10.1371/journal.pntd.0000769. [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Srikiatkhachorn A, Krautrachue A, Ratanaprakarn W, Wongtapradit L, Nithipanya N, Kalayanarooj S, et al. Natural history of plasma leakage in dengue hemorrhagic fever: a serial ultrasonographic study. Pediatr Infect Dis J. 2007;26:283–90. doi: 10.1097/01.inf.0000258612.26743.10. [DOI] [PubMed] [Google Scholar]
15.Srikiatkhachorn A, Green S. In: Dengue virus. Current Topics in Microbiology and Immunity. Rothman AL, editor. Berlin: Springer; 2010. Markers of dengue severity. pp. 68–82. editor. p. [DOI] [PubMed] [Google Scholar]
16.Kalayanarooj S, Vaughn DW, Nimmannitya S, Green S, Suntayaorn S, Kunentrasai N, et al. Early clinical and laboratory indicators of acute dengue illness. J Infect Dis. 1997;176:313–21. doi: 10.1086/514047. [DOI] [PubMed] [Google Scholar]
17.Pancharoen C, Rungsarannont A, Thisyakorn U. Hepatic dysfunction in dengue patients with various severity. J Med Assoc Thai. 2002;60:307–11. [PubMed] [Google Scholar]
18.Premaratna R, de Alwis JP, Nandasiri AS, de Silva HJ. Care given for dengue fever patients at first contact level: are we there? Emerging infectious Disease meeting in Shuozu, China. Abstract presented at the 2010 Cold Spring Harbor Asia Conference Shuozu China. 2010:S 19. [Google Scholar]
19.Ambreen Zubair, Asim Ahmad Qureshi, Syed Ahmed Murtaza Jafri. Assessment of Dengue fever severity through liver function Test. [DOI] [PubMed]
20.Fernando, et al. Patterns and causes of liver involvement in Acute dengue infection. BMC Infectious Diseases. 2016;16:319. doi: 10.1186/s12879-016-1656-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
21.Durga Prasad DM, Arpita Bhriguvanshi MD. Clinical Profile, Liver Dysfunction and Outcome of Dengue Infection in Children. Pediatr Infect Dis J. 2020;39:97–101. doi: 10.1097/INF.0000000000002519. [DOI] [PubMed] [Google Scholar]
22.Spectrum of liver dysfunction in patients with dengue infection and the markers of severe disease: study from a tertiary care centre in Punjab. J Liver Res Disord Ther. 2017;3(4):95–98. [Google Scholar]
23.Jayanta Samanta, Vishal Sharma. Dengue and its effects on liver. World J Clin Cases. 2015 February 16;3(2):125–131. doi: 10.12998/wjcc.v3.i2.125. [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Rituraj Niranjan, Panneer D, Purushothaman Jambulingam. Liver Dysfunctions in Dengue Infection: An Update on its Pathogenesis. J Liver. 6:219. [Google Scholar]
25.Pathophysiology — Plasma Leakage . Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases; Dengue Clinical Case Management E-learning. [Google Scholar]
26.Shastri PS, Taneja S. Dengue and Other Viral Hemorrhagic Fevers. Indian J Crit Care Med. 2021 May;25(Suppl 2):S130–S133. doi: 10.5005/jp-journals-10071-23814. 34345126;PMC8327797 [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Pothapregada S, Kamalakannan B, Thulasingham M. Risk factors for shock in children with dengue fever. Indian J Crit Care Med. 2015 Nov;19(11):661–4. doi: 10.4103/0972-5229.169340. 26730117;PMC4687175 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Singhi S, Chaudhary D, Varghese GM, Bhalla A, Karthi N, Kalantri S, Peter JV, Mishra R, Bhagchandani R, Munjal M, Chugh TD, Rungta N. Tropical fevers: Management guidelines. Indian J Crit Care Med. 2014 Feb;18(2):62–9. doi: 10.4103/0972-5229.126074. 24678147;PMC3943129 [DOI] [PMC free article] [PubMed] [Google Scholar]
Neonatal sepsis, a severe bloodstream infection (McDonald et al., 2012)neutrophils accumulate in the liver microcirculation, but their functional significance is largely unknown. We show that neutrophils migrate to liver sinusoids during endotoxemia and sepsis where they exert protective effects by releasing neutrophil extracellular traps (NETs, is associated with intravascular coagulation, a major cause of organ dysfunction and mortality (Iba et al., 2019). This study aims to develop a prognostic risk stratification model based on blood transcriptional signatures to identify neonates at high risk of intravascular coagulation in neonatal sepsis.
Objectives
Identification of genes functional in NETosis associated with poor outcome in neonatal sepsis.
Materials and methods
High-quality blood transcriptome datasets from neonatal sepsis cases were retrieved from NCBI GEO and divided into discovery (n = 66) and validation (n = 43) cohorts. Additional blood transcriptome data were generated from Indian neonates (n = 9).
Differential expression analysis was performed to identify genes associated with NETosis (DE-NET) that exhibited significant expression differences between sepsis non-survivors and survivors.
To assess the prognostic value of DE-NET, a NETosis Score model was constructed using single-sample gene set enrichment analysis (ssGSEA). ROC analysis was performed to test the model's predictive performance.
Enrichment analysis was employed to elucidate the biological functions associated with DE-NET.
To gain insight into the immune landscape CIBERSORT was applied to infer immune cell composition.
To identify the most influential NETosis genes (key-NET), the Least Absolute Shrinkage and Selection Operator (LASSO) algorithm was employed. ROC analysis was performed to test the model's predictive performance.
To investigate the functional interplay between key-NET and the complement-coagulation (CC) system, an analysis of differentially expressed CC genes (DE-CC) was performed.
Results
A robust NETosis Score model was constructed utilizing 16 DE-NET and ssGSEA algorithm, with good predictive accuracy in distinguishing non-survivors from survivors, AUC = 0.89 (discovery set) and 0.9 (validation set).
LASSO algorithm successfully pruned the 16 DE-NET down to a set of 9 key-NET, which retained exceptional predictive performance, AUC = 0.91 (discovery set) and 0.91 (validation set).
An in-depth analysis of immune cell infiltration revealed a significant positive correlation with the majority of the key-NET. This observation highlights the intricate interplay between NETosis and immune cell infiltration in the pathogenesis of neonatal sepsis.
A compelling association was uncovered between the ssGSEA score of key-NET and DE-CC in both discovery and validation datasets. This observation suggests a potential functional relationship between NETosis and the complement-coagulation cascade.
Mediation analysis of baseline data and correlation analysis of temporal data provided strong evidence supporting the hypothesis that key NETosis (key-NET) gene expression is an upstream event of complement-coagulation activation.
Discussions
Transcriptome analysis of neonatal sepsis patients revealed a strong association between poor outcomes and NETosis genes. We propose a 9-gene NETosis model for risk stratification and suggest NETs as therapeutic targets for sepsis-induced coagulopathy.
References
1.Iba T, Levy J. H, Warkentin T. E, Thachil J, van der Poll T, Levi M. Diagnosis and management of sepsis‐induced coagulopathy and disseminated intravascular coagulation. Journal of Thrombosis and Haemostasis. 2019;17(11):1989–1994. doi: 10.1111/jth.14578. [DOI] [PubMed] [Google Scholar]
2.McDonald B, Urrutia R, Yipp B. G, Jenne C. N, Kubes P. Intravascular Neutrophil Extracellular Traps Capture Bacteria from the Bloodstream during Sepsis. Cell Host & Microbe. 2012;12(3):324–333. doi: 10.1016/j.chom.2012.06.011. [DOI] [PubMed] [Google Scholar]
Atrial myxoma is the most common primary cardiac tumour (80%) which has a multitude of clinical presentations, with 30% neurological1. Although rare, it should be considered as a possibility of stroke in young adults with no relevant past history. The most common differential of left atrial thrombi sometimes confuses with similar presentations and delays the diagnosis due to non-availability of gold standard TEE and biopsy. We present a 25 years old female patient who was a referred to our hospital following complains of sudden onset loss of consciousness and left hemiplegia, in whom we incidentally found out a left atrial mass and managed successfully.
Case report
A 25 years old, thinly built female was referred to our hospital following complains of loss of consciousness (lasting thirty minutes) and left sided weakness for last 6 hours. She underwent ovarian teratoma resection one year back under general anaesthesia which was uneventful. On initial assessment, she was confused, irritable (GCS- E2V1M5, unequal pupils) and unable to move left side of her body. Her initial vitals were heart rate-120/m, BP- 120/60mm of HG, SPO2-90% at room air. In view of low GCS score she was intubated immediately and shifted to radiology. Her CT scan showed right sided temporo-parietal infarct without midline shift. On cardiology evaluation ECG showed marked tachycardia with normal troponin. Trans thoracic Echocardiogram showed mobile rough surfaced polypoid shaped mass attached to the atrial side of the anterior mitral valve and intra atrial septum causing significant mitral stenosis (mean gradient 29 mm HG) along with dilated left atrium. However systolic function was preserved with ejection fraction 50%. Immediate differentials thought were atrial clot, myxoma and vegetations. She was initially managed for acute infarct with mechanical ventilation, anti-epileptics, anti-platelets, anti- coagulants and statins. Daily assessment was done with transthoracic echo of the cardiac mass which maintained its size and shape, shifting differential towards myxoma. Cardiac MRI however favoured more of LA clot as no definite stalk of the mass was clearly visible. She was gradually weaned of ventilation on day 3 with improved GCS and stable vitals but persistent left sided weakness. On day 10 of admission she was taken for excision of cardiac mass under general anaesthesia. Intra operatively a 3cms/2 cms left atrial mass with rough surface and calcified stalk arising from IAS was excised. Surgical defect was repaired with pericardial patch. Histopathology of the excised mass confirmed stellate shaped myxoma cells in myxoid background. Postoperative period was uneventful and she was weaned off ventilator on the next day. She was eventually discharged from hospital on day 15 with fully recovered GCS and improved left motor functions (4/5).
Discussions
Cardiac myxoma although rare is the most common cardiac tumour, with left side (80%) and 2:1 female predominance (30-60 yrs).1, 2 It presents with a varied clinical presentations, most likely cardiac (obstructive, embolic, arrythmia) constitutional and neurological sequels (25-40%).3 Most common neurological complication seen in the form of brain infarct (83%) due to detached thrombus from the primary mass. About 7% of patients are present as a part of Carneys complex showing autosomal dominant mutation of PRKAR1 alpha gene located on chromosome 17q.4 Due to the varied clinical features and rare incidence diagnosis may be missed, increasing mortality and morbidity. Echocardiography and neurological tests are of prime importance in young patients with embolic symptoms. Although Trans thoracic echocardiography identifies the mass, Trans-esophageal echocardiography is 100% sensitive if available. Cardiac MRI however gives a better idea of the myxoma regarding stalk, size, shape and surgical planning. Brain infarct although needs immediate anticoagulation, but it may delay more definitive treatable cardiac cause. Stroke may be embolic or hemorrhagic with varied clinical features ranging from focal deficits to massive CNS insults. As stroke may be recurrent due to dislodgement of the tumour or adherent thrombus, anticoagulants may not be protective5. Most cardiac myxomas are surgically resectable with recurrence rate of 3% in sporadic and 25% in Carney complex patients, requiring regular cardiac screening.4
Conclusion
Although rare, cardiac myxoma should be ruled out in young patients with embolic stroke by prompt imaging, quick management to decrease mortality and morbidity. In our presented patient, cardiology workup was done to find out the source of embolic stroke causing sudden unilateral hemiparesis which lead us to diagnose and manage atrial myxoma.
1.Ravdeep Singh Sohala, et al. Atrial Myxoma – An unusual cause of ischemic stroke in young– Autopsy and Case Reports. 2020 Oct-Dec;10(4):2020. doi: 10.4322/acr.2020.178. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Drew, et al. Atrial Myxoma Presenting as an atypical stroke in a young patient with a recent COVID-19 infection. (June 28, 2022) Cureus. 14(6) doi: 10.7759/cureus.26407. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Fintan O'Rourke. Atrial myxoma as a cause of stroke: case report and discussion. Canadian Medical Association Journal. NOV. 11, 2003;169(10) [PMC free article] [PubMed] [Google Scholar]
Noninvasive ventilation (NIV) is popular amongst intensivists in acute respiratory failure (ARF). It is important to meticulously monitor patients who have been put on NIV for early detection of its failure for prompt intubation to save lives.
Objectives
To study baseline clinical, SpO2 and ABG parameters including PaCO2, pH, PaO2, respiratory rate, heart rate, and their correlation with the outcome of noninvasive ventilation in acute respiratory failure.
Materials and methods
In this prospective observational study, patients with features of acute respiratory failure (respiratory rate (RR) > 30 / minutes, and PaO2 <55 mm of Hg) were put on noninvasive ventilation along with appropriate oxygen therapy. Patients were started with inspiratory pressure support (IPAP) of 10 cm water, and expiratory pressure support (EPAP) of 5 cm water. Pressure was gradually increased at increment of 2 cm over next 60 minutes to the optimum requirement, keeping patient comfort and cooperation in mind. Patients’ clinical parameters including RR, HR, BP, ECG, SpO2 and ABG parameters were monitored. End point to this study was weaning the patients from NIV or requirement of intubation and invasive mechanical ventilation.
Results
Sixty patients, including 42 males and 18 females with the mean age of 18-79 years were included in the study. Indications for NIV included: acute exacerbation of COPD (AECOPD): 34 (56.6%), bronchial asthma: 4 (6.6%), ARDS: 16 (26.6%), interstitial lung disease: 2 (3.3%), cardiogenic pulmonary oedema: 3 (5.0%). Thirty (88.2%) patients with AECOPD improved with therapy. Four (11.7%) patients ultimately required to be put on invasive ventilator. One of them died. Improvement in parameters in COPD patients were as follows: average SpO2: baseline 80.8%, at 1 hour 91.38 and at 24 hours 93.9%; average PaO2: baseline 51.8 mmHg, at 1 hour 64.5 and at 24 hours 63.9 mmHg; and average PaCO2: baseline 77.3 mmHg, at 1 hour 64.3 mmHg and at 24 hours 63.2 mmHg. Seventeen (62.9%) of non-COPD patients improved with therapy. Nine (33.3%) patients required to be put on ventilator. Three of them died. Improvement in parameters in non-COPD patients were as follows: average SpO2: baseline 77.6%, at 1 hour 88.5% and at 24 hours 91.6%; average PaO2: baseline 48.9 mmHg, at 1 hour 51.8 and at 24 hours 55.6 mmHg; and average PaCO2 was: baseline 41.6 mmHg, at 1 hour 41.2 and at 24 hours 40.2 mmHg. One patient with AECOPD developed pneumothorax on right side, which improved with intercostal drainage with a pigtail catheter.
Conclusion
Noninvasive ventilation use resulted in improvement in SpO2 and ABG parameters in most patients with acuter respiratory failure; though NIV was more useful in acute exacerbation of COPD than in non-COPD patients. There were minimal complications of NIV.
References
1.Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev. 2018;27(149):180029. doi: 10.1183/16000617.0029-2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Liengswangwong W, Yuksen C, Thepkong T, Nakasint P, Jenpanitpong C. Early detection of non-invasive ventilation failure among acute respiratory failure patients in the emergency department. BMC Emergency Medicine. 2020;20:80–7. doi: 10.1186/s12873-020-00376-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
Noninvasive ventilation (NIV) is an important mode of therapy in acute type 2 respiratory failure. However, in some of these patients NIV is inadequate and they require be intubated and put on invasive ventilation. Failure of initial trial of NIV can lead to a delay in endotracheal intubation thus causing an increase in morbidity and mortality. Early prediction of success of NIV helps in early decision making, either in favour of continuing with NIV or intubation.
Objectives
Early prediction of parameters for success of noninvasive ventilation in acute type 2 respiratory failure.
Materials and methods
Patients with type 2 respiratory failure requiring ventilation therapy (respiratory rate [RR] >30/minutes, arterial pH <7.35, and PaCO2 >55 mmHg were included in the study. Baseline clinical parameters and arterial blood gas (ABG) were recorded before initiating NIV. Clinical parameters including RR, heart rate (HR), oxygen saturation (SpO2) and ABG were revaluated at one, four, and 24 hours after initiation of NIV. Changes in these parameters and need for intubation were evaluated.
Results
Of the 96 patients who were included in the present study, 73 (72.96%) subjects showed improvement in clinical parameters and ABG. After one hour of NIV trial RR, HR and pH improved in success group as compared to the failure group (26.9 ± 6.14 vs 37.6 ± 7.04, 91 ± 8.39 vs 137 ± 9.87, 7.35 ± 0.05 vs 7.27 ± 0.09) respectively. Improvement was maintained after 4 and 24 hours of therapy. There was improvement in PaCO2 after one hour in success group (60.9 ± 8.67 vs 79.4 ± 18.31), which was maintained after four (59.2 ± 8.96 vs 82.4 ± 18.9) and 24 (55.8 ± 7.96 vs 79.7 ± 18.91) hours of therapy also. Patients who required intubation had significant higher rate of other co-morbidity (56.52% vs 19.17%, p<0.01) at the time of admission.
Conclusion
Improvement in respiratory rate, heart rate, pH, and PaCO2 one hour after putting the patients on noninvasive ventilation predicts success of NIV in patients with type 2 respiratory failure. On the contrary, patients showing deterioration in RR, HR, pH, and PaCO2 after one and four hours on being put on noninvasive ventilation, required to be kept under very close observation. Co-morbidity at admission also predicted less success with NIV. They were more likely to require intubation in case of any further deterioration.
References
1.Ventrella F, Giancola A, Cappello S, Pipino M, Minafra G, Carbone M, et al. Use and performance of non-invasive ventilation in Internal Medicine ward: a real-life study. Ital J Med. 2015;9(3):260–7. [Google Scholar]
2.Arsude A, Sontakke A, Jire A. Outcome of noninvasive ventilation in acute respiratory failure. Ind J Crit Care Med. 2019;23(12):556–61. doi: 10.5005/jp-journals-10071-23291. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Pacilli A M, Valentini I, Carbonara P, Marchetti A, Nava S. Determinants of noninvasive ventilation outcomes during an episode of acute hypercapnic respiratory failure in chronic obstructive pulmonary disease: the effects of comorbidities and causes of respiratory failure. BioMed Research International. 2014:976783. doi: 10.1155/2014/976783. [DOI] [PMC free article] [PubMed] [Google Scholar]
Sepsis remains a major problem worldwide associated with high morbidity and mortality. Approximately 48.9 million cases of sepsis were reported attributing to 19.7% of all global deaths. The INDICAP study reported that 65% of ICU patients in India had sepsis with a mortality of 25%.1 A number of immunomodulatory strategies are being evaluated for their ability to re-balance the immune response in sepsis with numerous trials achieving clinical success.2 Thymosin α1 acts by activating and restoring the dysregulated immune response for sepsis patients.3
Objectives
To evaluate the efficacy and safety of Tα1in combination with Standard of Care Treatment (SOC) as an add on treatment in sepsis patients.
Materials and methods
This study was designed as a double blind, multi-center, two-arm, Phase III study conducted at 10 centers. The patients were randomized to receive either 2 subcutaneous injections of Active Treatment (1.6 mg Tα1) or placebo BID per day along with SOC for 7 consecutive days.
Results
120 patients completed the study. Thymosin α1 caused a better reduction in SOFA score compared to placebo [-3.5 (±1.7) vs. -1.13 (±1.2), p < 0.001]. The duration of hospitalization was significantly shorter in the study group compared to the placebo [12 vs 14 days, p = 0.0002). The use of Tα1 reduced the ICU stay by 3 days (p = 0.0001) and the time spent on ventilator by 2 days (p = 0.0015). Above results are endorsed by significant improvement from the baseline in majority of the cytokines assessed like NLR, TNF and CRP. Tα1 Arm reported one death compared to 4 deaths in Placebo Arm. Administering Tα1 along with SOC to the sepsis patients appears to have acceptable safety.
Discussions
A similar study in India provides evidence that Tα1 can reduce mortality rate (p = 0.03), shorten the required number of hospitalization days as well as abbreviate the requirement of oxygen support in moderate to severe COVID-19 patients.4 Tα1 improves the function of both innate and adaptive immunity suggesting that Tα1 therapy could be a promising alternative adjuvant therapy for sepsis strategy to improve the host response in patients with sepsis.3 The main strength of this study is that it's a randomized, double blinded, placebo-controlled design with high adherence to the study protocol. Further studies with a large sample size are needed to explore the use of Tα1 regarding patient selection, dosage and the course of treatment.
References
1.Mehta, et al. Sepsis Management in Southeast Asia: A Review and Clinical Experience. J. Clin. Med. 2022;11:3635. doi: 10.3390/jcm11133635. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Steinhagen, et al. Immunotherapy in Sepsis - Brake or Accelerate? Pharmacology & Therapeutics. 208(107476) doi: 10.1016/j.pharmthera.2020.107476. [DOI] [PubMed] [Google Scholar]
3.Pei Fei, et al. Thymosin alpha 1 treatment for patients with sepsis. Expert Opinion on Biological Therapy. 18(sup1):71–76. doi: 10.1080/14712598.2018.1484104. [DOI] [PubMed] [Google Scholar]
4.Shetty A, et al. A Double-blind Multicenter Two-arm Randomized Placebo-controlled Phase-III Clinical Study to Evaluate the Effectiveness and Safety of Thymosin α1 as an Add-on Treatment to Existing Standard of Care Treatment in Moderate-to-severe COVID-19 Patients. Indian J Crit Care Med. 2022;26(8):913–919. doi: 10.5005/jp-journals-10071-24298. [DOI] [PMC free article] [PubMed] [Google Scholar]
Outcome Assessment of Patients of Non-CF Bronchiectasis Admitted with ARF and Managed with NIV as a Primary Mode of Ventilatory Support: An Analytical Observational Study
Non-cystic fibrosis bronchiectasis is a progressive condition generally associated with chronic bacterial infections and characterized by irreversible destruction and dilation of the airways. [1] The clinical course of individuals with non-cystic fibrosis bronchiectasis is variable, with a significant proportion of patients developing transient exacerbation leading to severe acute respiratory failure (ARF) and requiring ventilatory support. [2] Although the use of NIV in bronchiectasis exacerbations may appear attractive as it can reduce ICU stay, its failure rate exceeds 25%. [3] At the same time, subsequent application of invasive mechanical ventilation, which is associated with a mortality rate of 19 –35% and prolonged ICU stay, appears problematic. [4]
Objective
The purpose of the present study was to assess the outcome of patients of non-CF bronchiectasis admitted to our institute with ARF and managed with NIV as a primary mode of ventilatory support. We also compared various physiological and clinical parameter between NIV and mechanical ventilation.
Methods
The present study was conducted in the Department of emergency and Critical Care (Trauma and Emergency), IGIMS, Patna, Bihar, India for one year. There were a total of 250 patients with bronchiectasis who were admitted during the above specified period. Among these, 130 patients were admitted with ARF. Totally, 120 patients who required either NIV or IMV.
Results
The most common etiology of bronchiectasis was post-tuberculosis (66.66%) followed by idiopathic (16%), ABPA (11.12%), and immunodeficiency (5.55%). NIV was initiated as first line of ventilator support for 90 patients. Among these, 60(66.66%) were managed successfully with NIV. 30 (33.34%) patients failed NIV and required endotracheal intubation during the hospital stay.
Discussion /Conclusion
Our results suggest that utility of NIV should to be assessed in well-designed prospective studies for ARF in non-CF bronchiectasis patients.
2.Loebinger MR, Wells AU, Hansell DM, Chinyanganya N, Devaraj A, Meister M, Wilson R. Mortality in bronchiectasis: a long-term study assessing the factors influencing survival. EurRespir J. 2009;34(4):843–849. doi: 10.1183/09031936.00003709. [DOI] [PubMed] [Google Scholar]
3.Dupont M, Gacouin A, Lena H, Lavoue´ S, Brinchault G, Delaval P, Thomas R. Survival of patients with bronchiectasis after the first ICU stay for respiratory failure. Chest. 2004;125(5):1815–1820. doi: 10.1378/chest.125.5.1815. [DOI] [PubMed] [Google Scholar]
4.Phua J, Ang YL, See KC, Mukhopadhyay A, Santiago EA, Dela Pena EG, Lim TK. Noninvasive and invasive ventilation in acute respiratory failure associated with bronchiectasis. Intensive Care Med. 2010;36(4):638–647. doi: 10.1007/s00134-009-1743-6. [DOI] [PubMed] [Google Scholar]
Study the various biomarkers of sepsis and comparing procalcitonin - albumin ratio with SOFA Score and other available biomarkers: Procalcitonin, Albumin, C - reactive protein - albumin ratio, C - reactive protein, Creatinine, Total Leucocytes Count, and Platelet Count.
Evaluate the biomarkers in diagnosis of sepsis and septic shock compared to clinical scoring system (SOFA score).
Compare biochemical and haematological parameter in patient presenting with septic shock.
Predict days of ICU stay and in-hospital mortality based on procalcitonin-albumin ratio and SOFA score at the time of admission.
Association of co-morbidities with severity of sepsis and in-hospital mortality.
Determine a cut off value of biomarkers to predict septic shock in patient diagnosed as sepsis.
Suggestion to integrate procalcitonin- albumin ratio as a parameter along with SOFA score to predict severity of disease and outcome based on study.
Study Design
The study was a Prospective Observational, Cohort Study.
Materials and methods
This study was undertaken on 63 patients admitted in the ICU Unit of Holy Family Hospital and Research Centre, Mumbai during the period of 1 year under the Department of Medicine and Intensive care. Detailed history, physical examination, and relevant investigations were done in the selected patients. All statistical tests were two tailed. Alpha (α) Level of Significance were be taken as P<0.05. The predictability of discriminating Septic shock from Non shock group was assessed using the area under the ROC curve (AUROC) at 95% Confidence Interval. ROC curve were plotted for Procalcitonin – Albumin ratio, SOFA score, CRP – albumin ratio and Leucocyte Count.
Results
This study showed that Procalcitonin - albumin ratio was significantly raised in patient of Sepsis who developed Septic shock as opposed to group who did not develop Septic shock. The result was superior to C - reactive protein – Albumin Ratio, Leucocyte count, Platelet count and Creatinine. At value of 0.955, PCT Albumin ratio had 84.21% sensitivity and 81.82% specificity. SOFA Score remained a superior diagnostic parameter to determine presence of Septic shock and severity of Sepsis when compared to biomarkers which were included in this study. There was no influence of Age, Sex and prior co morbidities on overall severity of Sepsis. Other Investigations like platelet count, C reactive protein, creatinine and leucocytes counts had no significant difference in septic shock and non shock group. There was no significant difference in overall days of ICU stay or mortality in septic shock and non - septic shock group.
Conclusions
On the basis of our results we can conclude that SOFA score remains a superior tool for evaluating the severity of sepsis, However procalcitonin albumin Ratio can be used as a complementary diagnostic tool to SOFA score to predict overall severity of the disease and mortality. A Scoring system consolidating these parameters with SOFA score can be suggested and studied further.
To determine the various presentations, common etiological factors, site of lesion in cases of UGIB in urban population at a tertiary care hospital in western India.
To determine the role of early endoscopy and endotherapy in management of patient with UGI bleeding.
To study immediate outcomes in patient of UGIB.
Secondary objectives
To assess the prognostic outcomes by Blatchford and Rockall score.
To try and find the risk of recurrence/re-bleed.
Study Design
Prospective, hospital based observational study.
Material and methods
The study was undertaken at Holy Family Hospital, Mumbai. After approval of the hospital`s Ethics committee, patients admitted with upper gastro-intestinal bleed were selected after taking into consideration the inclusion and exclusion criteria. Detailed history, physical examination and relevant investigations were done. All patients who underwent esophago-gastro-duodenoscopy their endoscopy details were collected along with the type of endotherapy required if any. All data collected was assimilated on an excel spreadsheet and statistical analysis was done using SPSS software (ver. 15) with the help of Oneway ANOVA test and Chi-Sqaure test (Fisher Exact Test for 2*2 table).
Results
Mean age of presentation with UGIB was between 61-70 years with men being twice as commonly affected as women. Most common presentation was hemetemesis followed by melena, syncope and abdominal pain. Associated risk factors were use of alcohol, antiplatelet, NSAIDS, anti-coagulants. Most common cause of UGIB was portal hypertension related esophageal varices followed by duodenal and gastric ulcers. Mortality was found to be 10.63% and risk of rebleed 9.30%. Mortality was found to be associated with presence of co-morbid conditions, low systolic BP and low hemoglobin at the time of admission, renal dysfunction and deranged INR. Patients presenting earlier (< 24 hours from onset of symptoms) were found to have better outcomes in the form of mortality and risk of rebleed. Similarly, patients who underwent early endoscopy and endotherapy (< 24 hours) had better outcomes in the form of decreased mortality, risk of rebleed, number of blood transfusion required and number of days of hospital stay required as compared to patients who underwent endoscopy between 24-48 hours and after 48 hours. Rockall score was found to be a good prognostic scoring system to identify patients at high risk of mortality. Glasgow-Blatchford Score could identify patients at low risk of requiring intervention in the form of blood transfusion and endotherapeutic intervention.
Conclusions
Early presentation to hospital after onset of UGIB can help reduce mortality and the risk of rebleeding. Early UGI scopy (within 24 hour) in patients with UGIB can reduce mortality, number of blood transfusions required and the number of days of hospital stay.
Endoscopy within 48 hours reduces risk of rebleed. Rockall score helps in identifying high risk patients and their immediate outcome in the form of mortality.
Glasgow-Blatchford score helps to identify patients at low risk for need of intervention in the form of blood transfusion and endotherapy.
1Division of Critical Care, Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India, Phone: +91 9538839192, e-mail: Hari_janjam@yahoo.co.in
1Division of Critical Care, Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India, Phone: +91 9538839192, e-mail: Hari_janjam@yahoo.co.in
2,3Division of Critical Care, Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
Sparse published data are available regarding clinical characteristics and outcome of patients admitted to medical intensive care unit (MICU) with acute respiratory failure (AcRF) from developing world.
Objectives
To study the aetiology, clinical presentation and outcome in patients with AcRF admitted to the MICU at our tertiary care teaching hospital.
Material and methods
256 consecutive adult patient aged > 18 years, diagnosed to have AcRF were prospectively studied regarding clinical presentation, diagnosis, management and outcome.
Results
During the period of study 26.6% (n-252) of patients were admitted to ICU for management of acute respiratory failure. Their mean age was 52±17 years and 62% were males. Of these 63% has type I respiratory failure. Most common presenting symptom was breathlessness in 79.3% followed by fever (47.2 %) and cough (39.6%) among others. Community acquired Pneumonia (21%) was the predominant cause followed by sepsis, acute exacerbation of COPD, pulmonary edema, poisoning, snake bite, pulmonary tuberculosis and Guillain-Barre syndrome among others. ARDS was seen in 46% of patients. 71% of patients required invasive mechanical ventilator support. 47% of these patients expired. On receiver-operator characteristic (ROC) curve analysis a cut-off value of APACHE II score ≥16 had a sensitivity 77.4%, specificity 63.9% [AUC = 0.746 (95% CI 0.688-0.799)]; and a cut-off value of SOFA score ≥5 had a sensitivity of 73.7% and specificity of 65.6% [AUC = 0.743(95% CI 0.684-0.796)] to predict mortality.
Conclusion
Acute respiratory failure is an important reason for ICU admission. Pneumonia is the most common aetiological cause. Nearly half of the patients had ARDS and half of the half of them expired.
References
1.Lewandowski K, Metz J, Deutschmann C, Preiss H, Kuhlen R, Artigas A, et al. Incidence, severity, and mortality of acute respiratory failure in Berlin, Germany. Am J RespirCrit Care Med. 1995;151:1121–5. doi: 10.1164/ajrccm.151.4.7697241. [DOI] [PubMed] [Google Scholar]
2.Singh G, Gladdy G, Chandy TT, Sen N. Incidence and outcome of acute lung injury and acute respiratory distress syndrome in the surgical intensive care unit. Indian J Crit Care Med Peer-Rev Off Publ Indian SocCrit Care Med. 2014;18:659–65. doi: 10.4103/0972-5229.142175. [DOI] [PMC free article] [PubMed] [Google Scholar]
Intracerebral hemorrhage accounts for 20-30% of all strokes and is a severe form of stroke-causing higher mortality and morbidity.
Materials and methods
A Retrospective observational study was done on 54 patients admitted to the neurocritical care unit of a tertiary care hospital. Patients aged > 18 years admitted from 1st December 22 to 31st August 23 with spontaneous Intracerebral hemorrhage were studied. Demographic, clinical, and radiological findings along with stroke severity (NIHSS AND ICH SCORE) were analysed as predictors of outcome. Disability at 90 days after discharge was assessed by the Modified Rankin Scale (mRS).
Results
Out of 54 patients observed in the study,62.96% (n = 34) patients survived and 37.03% (n = 20) died in hospital. Out of the survived category,64.70% (n = 22) had good outcomes (mRS<3), while 35.29% (n = 12) had poor outcomes (mRS>3) at 90 days after discharge. Out of 54 patients, 70.3% (n = 38) were hypertensive out of which 73.56%(n = 25) survived and 5% (n = 13) had died. Out of 38 hypertensive patients, 63.15% (n = 24) were noncompliant with antihypertensive medication. Among the studied age group (<50yrs, n = 14), 57.14%(n = 8) patients were hypertensive, of which 7 patients (87.5%) were noncompliant with treatment.
Discussions
It was observed that GCS, NIHSS, and ICH scores, were significant predictors of mortality and morbidity in spontaneous intracerebral hemorrhage cases. Our study found that the volume of the bleed, rather than the location of the bleed was a significant predictor of mortality and morbidity. It was observed that hypertension with noncompliance to treatment was a strong predictor of causing ICH in the younger population(<50years).
1.2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association Steven M. Greenberg, Wendy C. Ziai, Charlotte Cordonnier. [DOI] [PubMed]
2.Bongu G, Singhal A, et al. Predictors of Mortality in Spontaneous Intracerebral Hemorrhage Cases, Medical Research Archives. 2022. [DOI]
3.Clinical Profile and Predictors of Outcome in Spontaneous Intracerebral Hemorrhage from a Tertiary Care Centre in South India. Hindawi Stroke Research and Treatment. Volume 2020 doi: 10.1155/2020/2192709. Article ID 2192709. [DOI] [PMC free article] [PubMed] [Google Scholar]
Pulmonary embolism (PE) is a life-threatening condition with diverse clinical presentations and outcomes. This study seeks to understand the complex interplay of demographic, clinical, and treatment-related factors in influencing the prognosis of patients with pulmonary embolism. The ultimate goal is to provide clinicians with valuable insights that can contribute to improved risk stratification, personalised management strategies, and optimised treatment protocols for individuals affected by this life-threatening condition.
Materials and methods
A retrospective cohort study was conducted with patients presenting to a tertiary care hospital in Nerul, Navi Mumbai, identifying patients diagnosed with pulmonary embolism over 6 months, starting from January 2023 to June 2023. Descriptive analyses were performed to assess risk factors for in-hospital mortality and length of hospital stay (LOHS). Other variables analysed include vital parameters, laboratory values, and comorbidities.
Results
A total of 20 patients were analysed (mean age 52.53 ± 16.1 years and 47.4% males). On average patients were hospitalized for 6 days (IQR 4–18). In-hospital mortality was 45%. LOHS was higher in patients with underlying chronic respiratory diseases; mainly chronic obstructive pulmonary disease, interstitial lung disease and post-tubercular bronchiectasis (88.9%), diabetes (22.9%), elevated D-dimer (above 2000 ng/ml) and higher levels of paCO2. LOHS was also higher in patients managed who were thrombolysed (9 ± 17). Significant risk factors associated with mortality included age >60 years (70%), underlying pulmonary disorders (88%), and length of hospital stay. Well's score and serum Brain Natriuretic Peptide (BNP) at presentation were similar for patients who died or were discharged. Thrombolysed patients had less mortality (3/9), compared to those managed with low-molecular-weight heparin (5/9). An interesting observation was that many patients had lower BNP levels than the predictive cut-off for PE (<500 pg/ml), and those with lower levels had reduced mortality rates as well as length of hospital stay.
Conclusion
Identifying risk factors associated with an increased LOHS and mortality in patients with PE can improve outcomes and optimise resource utilisation. Elevated BNP levels may not reflect disease severity or predict mortality. Advanced age, diabetes and underlying lung disease are independent predictors for mortality.
References
1.Lüthi-Corridori G, Giezendanner S, Kueng C, et al. Risk factors for hospital outcomes in pulmonary embolism: A retrospective cohort study. Front Med (Lausanne) 2023;10:1120977. doi: 10.3389/fmed.2023.1120977. Published 2023 Apr 11. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Mameli A, Palmas MA, Antonelli A, Contu P, Prandoni P, Marongiu F. A retrospective cohort study of patients with pulmonary embolism: the impact of comorbidities on patient's outcome. Eur Respir J. 2016;48(2):555–557. doi: 10.1183/13993003.02193-2015. [DOI] [PubMed] [Google Scholar]
3.Castelli R, Bergamaschini L, Sailis P, Pantaleo G, Porro F. The impact of an aging population on the diagnosis of pulmonary embolism: comparison of young and elderly patients. Clin Appl Thromb Hemost. 2009;15(1):65–72. doi: 10.1177/1076029607308860. [DOI] [PubMed] [Google Scholar]
4.Porro F, Curti L, Cavaiani B, Randazzo M, Pagnozzi G. Affidabilità dei parametri clinici nella diagnosi di tromboembolia polmonare in Pronto Soccorso [Reliability of clinical parameters in the diagnosis of pulmonary thromboembolism at an emergency department] Minerva Cardioangiol. 1995;43(9):361–366. [PubMed] [Google Scholar]
5.Van Marcke C, Daoudia A, Penaloza A, Verschuren F. CO2 measurement for the early differential diagnosis of pulmonary embolism-related shock at the emergency department: A case series. Respir Med Case Rep. 2015 Sep 11;16:106–8. doi: 10.1016/j.rmcr.2015.09.004. 26744671;PMC4681977 [DOI] [PMC free article] [PubMed] [Google Scholar]
Correlation of Albumin–Globulin Ratio and Platelet Count with Dengue Severity: A Retrospective Cross-sectional Observational Study in Patients Admitted in Intensive Care Unit in North India
Dengue fever, caused by the dengue virus and transmitted through Aedes mosquitoes, is a significant global public health concern. In severe dengue there is leakage of plasma which can be detected by chest X-ray, ultrasound, and hypoalbuminemia. Being a smaller molecule, albumin leaks out more easily than globulin during the early stages of the disease, thereby causing a reversal of the A: G ratio.
Objectives
Primary objective
Correlation of serum albumin: globulin ratio between dengue with warning signs and severe dengue cases
Correlation of platelet count between dengue with warning signs and severe dengue cases
Secondary objective
Correlation of albumin: globulin ration and platelet count with length of ICU stay and 28 days mortality in dengue with warning signs and severe dengue cases
Materials and methods
A retrospective cross-sectional observational analysis which would be done from july 2023 to november 2023 in dengue serology positive patients admitted in intensive care unit in Max super speciality Hospital, Vaishali. As this would be a retrospective study ethical committee is requested for waiver of consent. We divided patients into 2 groups ie Dengue with warning signs and severe dengue as dengue without warning signs were not admitted in our ICU. The following data was collected from the hospital medical records - patient demographics, severity of dengue, presenting symptoms, clinical signs, laboratory parameters - complete blood count, serum albumin: globulin ratio at the time of admission. Primary comparison is albumin:globulin ratio and platelet counts between dengue cases with warning signs and severe dengue cases. This comparison will be done by student T test after computing mean and standard deviation in these two groups.
Inclusion Criteria
Patients more than 18 years of age
Dengue IgM or NS1 positive
Exclusion Criteria
Patients with:
preexisting liver disease
ckd
hematological disorders
Results
Study ongoing, result awaited.
Discussions
Study ongoing, to be done after obtaining of results
References
1.World Health Organization Fact Sheet Dengue and Severe Dengue. 2022. (accessed on 25 December 2022)
2.World Health Organization Regional office for South East Asia . Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever, revised and expanded edition. New Delhi: World Health Organization South East Asia regional office; 2011. [Google Scholar] [Google Scholar]
3.World Health Organization . Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. [Google Scholar] Geneva, Switzerland: WHO; 2009. [PubMed] [Google Scholar]
4.Swamy AM, Mahesh PY, Rajashekar ST. Liver function in dengue and its correlation with disease severity: a retrospective cross-sectional observational study in a tertiary care center in Coastal India. Pan African Medical Journal. 2021 Dec 23;40(1) doi: 10.11604/pamj.2021.40.261.29795. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.REVAPPA KB, NARUMILLI MN, RANGAPPA P, Rao K. Transaminitis in Dengue: A Retrospective Observational Study in an Intensive Care Unit. Journal of Clinical & Diagnostic Research. 2022 Jul 1;16(7) [Google Scholar]
6.Saha AK, Maitra S, Hazra SC. Spectrum of hepatic dysfunction in 2012 dengue epidemic in Kolkata, West Bengal. Indian Journal of Gastroenterology. 2013 Nov;32:400–3. doi: 10.1007/s12664-013-0382-6. [DOI] [PubMed] [Google Scholar]
7.Azeredo EL, Monteiro RQ, de-Oliveira Pinto LM. Thrombocytopenia in dengue: interrelationship between virus and the imbalance between coagulation and fibrinolysis and inflammatory mediators. Mediators of inflammation. 2015 Oct;2015 doi: 10.1155/2015/313842. [DOI] [PMC free article] [PubMed] [Google Scholar]
Extubation following prolonged endotracheal intubation and indwelling tracheostomy tube are known risk factors for pulmonary aspiration. In this study, we assessed the prevalence of swallowing dysfunction among mechanically ventilated patients with the hypothesis that swallowing dysfunction predisposed patients to aspiration.
Objectives
To identify the prevalence of swallowing dysfunction in post extubated and tracheostomised patients without pre-existing dysphagia
To identify the risk factors associated with the development of dysphagia
Study outcomes
Prevalence of swallowing dysfunction as assessed by using a flexible fibreoptic bronchoscope
Need for reintubation, development of hospital-acquired pneumonia (HAP)
Incidence of in-hospital mortality
Patients discharged with feeding tube
Materials and Methods
Study design: Prospective observational study. Settings: 20 bed mixed ICU of the Department of Critical Care Medicine in association with the department of Otorhinolaryngology, SGPGIMS, Lucknow. Duration of study: October 2022-December 2023. Subjects: Patients with no pre-existing dysphagia in history or documented in the medical records would be included as below:
48 hours- 96 hours after extubation in those who had received prolonged mechanical ventilation
Tracheostomised patients who are already on oral feeds or in whom initiation of oral feeds is planned
Swallowing dysfunction: Defined as per PAS score as any score ≥1.
Several factors were assessed for their effect on swallowing dysfunction.
Results
35 patients were identified, 57% were males. Mean age was 41.82+16. Their admission diagnosis included 31.4% of pancreatitis patients, 20% included renal diseases and other abdominal illnesses like upper gastrointestinal bleed and other miscellaneous diagnoses. Swallowing assessment was done after tracheal extubation in 10 (28.5%). The duration of mechanical ventilation prior to extubation was 13 days. Tracheostomy tube was in-situ for 15 days. 20 (57%) patients had swallowing dysfunction; 65% in pharyngeal stage of swallowing. The severity was severe in 14 (70)%, moderate in 5(25%) and mild in 1(5%) patients respectively. None of the factors evaluated were found to have an association with swallowing dysfunction. 2 patients had VAP and 3 were discharged with nasogastric tube; 3 patients who died were diagnosed with severe swallowing dysfunction on assessment and 2 of them had a background illness of CKD.
Conclusions
Swallowing dysfunction was present in 57% among non-neurologic critically ill patients after prolonged ventilation and is associated with increased morbidity.
References
1.Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest. 2010;137:665–673. doi: 10.1378/chest.09-1823. [DOI] [PubMed] [Google Scholar]
2.Macht M, Wimbish T, Clark BJ, Benson AB, Burnham EL, Williams A, Moss M. Post- extubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care. 2011;15(5):R231. doi: 10.1186/cc10472. [DOI] [PMC free article] [PubMed] [Google Scholar]
Prevelence and Factors Associated with Neurological Outcomes of Adult in Hospital Cardiac Arrests in a Tertiary Care Hospital-A Retrospective Observational Study
Great advances in cardiopulmonary resuscitation(CPR) are made in recent years, majority of successful resuscitations still present comatose, with altered consciousness due to irreversible hypoxic-ischemic encephalopathy. Brain is injured directly as a result of loss of and suboptimal blood flow during the arrest that depends on quality of CPR and associated factors. The accuracy, timing of neuroprognostication are of utmost importance for avoiding premature withdrawal of life-sustaining treatment (WLST), futile treatment prolongation and hence burden on public health resources.2
Objectives
This study aimed to investigate factors affecting neurological outcomes for neuroprognostication after in hospital cardiac arrest.
Materials and methods
After ethical committee clearance, we retrospectively reviewed data of patients ≥ 18 years who experienced in-hospital cardiac arrest between July 2022- June2023 at our hospital. CPC(cerebral performance category) score was assessed for cardiac arrest survivors at discharge. CPC score of 1,2 classified as good neurological status and scores 3,4,5 classified as poor neurological status. Data was collected from CPR form in accordance with AHA and ERC which is recorded soon after arrest.
Results
In total,256 patients were included. Rate of survival to discharge was 17%(n = 44), Neurological condition was assessed in 44 patients, favourable neurological outcome observed in 50%(22/44) at discharge. Neuroprognosis(CPC1,2) was better with cardiac origin of arrest(70%, P<0.01), initial rhythm (VT, VF)(75%, p<0.01), median duration of CPR was 4min and 32 (p,0.01) min in patients with cpc 1,2 and cpc 3,4,5 respectively. Arrest time was within 1minute not significantly different in both groups(P = 0.95).
Conclusion
Among survivors, factors favoring good neurological outcomes were lesser CPR duration, shockable initial rhythm and cardiac origin of arrest.
References
1.Predictors of survival and good neurological outcomes after in-hospital cardiac arrest. Signa Vitae. 2021 doi: 10.22514/sv.2021.009. [DOI] [Google Scholar]
2.Geocadin RG, Callaway CW, Fink EL, Golan E, Greer DM, Ko NU, et al. Standards for studies of neurological prognostication in comatose survivors of cardiac arrest: A scientific statement from the American Heart Association. Circulation. 2019;140(9) doi: 10.1161/cir.0000000000000702. [DOI] [PubMed] [Google Scholar]
Study of Citrate and Bivalirudin for Anticoagulation during Continuous Renal Replacement Therapy (CRRT) in Critically Ill Patients with Acute Kidney Injury (AKI)
To study the filter life span using Citrate and Bivalirudin as anticoagulation agent in CRRT.
Secondary Objective
To study the length of stay in ICU.
To study the bleeding and other complication of CRRT.
To study transfusion requirement.
Materials and methods
Study area: Department of Anaesthesiology and critical care medicine, DrRML IMS, Lucknow. Sample size: 40. Sampling technique: Consecutive sampling- Patients admitted in ICU, diagnosed with AKI and need CRRT. Study design: Prospective & Quasi-experimental (non-randomized) study design. Study duration: 18 months. Sample size calculation: Based on anticipated value of mean Filter life Span in two groups (Bivalirudin Vs Citrate) based on previous studies as in Bivalirudin* group 29.6 (SD 20.7) and in Citrate# group 49 (SD 29) with α of 0.05, Beta 0.2, at 80% power the total sample size is 36. In order to compensate for the dropouts the sample size is 40. (20 in each group).
Results
For CRRT, Regional citrate anticoagulation (RCA) has more hemofilter survival time as compare to Bivalirudin. (P<0.001)
In view of length of ICU stay there was no significant difference in between RCA and bivalirudin (p = 0.705)
There was no significant changes in APACHE II score DURING CRRT and POST CRRT with both RCA and bivalirudin.
Both RCA and Bivalirudin significantly decreased Serum urea and Serum creatinine level (p<0.001), from PRE CRRT to DURING CRRT and from PRE CRRT to POST CRRT. However there was no significant difference in serum urea and serum creatinine level in between RCA and Bivalirudin.
There was significant increase in 24 hour urine output from PRE CRRT to DURING CRRT and from PRE CRRT to POST CRRT with both RCA and Bivalirudin but there was no significant difference in 24 hour urine output in between RCA and Bivalirudin.
There was no significant differences in Hb, Platelet count, s.albumin, PT, INR at PRE CRRT, DURING CRRT and POST CRRT in between RCA and Bivalirudin.
There was no significant bleeding complication observed during and after CRRT with both RCA and bivalirudin.
There was no significant difference between RCA and Bivalirudin for PRBC, SDP or RDP, and FFP transfusion.
There was no significant difference of Mean Arterial Pressure during CRRT and post CRRT in between RCA and Bivalirudin group.
There was no significant difference in survival status of patient after 24 hours of completion of CRRT between RCA and Bivalirudin.
After observing the data and statistical evalution, its concluded that Regional citrate anticoagulation (RCA) has better hemofilter life span than bivalirudin and recommended the use of RCA for better hemofilter survival time whenever systemic anticoagulation contraindicated.
To Evaluate Central Venous-to-arterial CO2 Difference/arterial-Central Venous O2 Difference Ratio with Lactate Clearance in Patients with Septic Shock: An Observational Prospective Study
Central venous-to-arterial PCO2 (Pcv-aCO2) is an proposed tool to identify persistent hypoperfusion when a ScvO2 > 70%
Decreased tissue blood flow (ischemic hypoxia) represents the major determinant in increased P(v-a)CO2
P(v-a)CO2 could therefore be considered as an indicator of adequate venous blood flow to remove CO2 produced by peripheral tissues.
– Ven-oarterial CO2 difference during regional ischemic or hypoxic hypoxia. J Appl Physiol 2000; 89:1317-132.
– Meaning of arterio-venous PCO2 difference in circulatory shock. Minerva Anestesiol 2006; 72:597-604.
– Veno-arterial carbon dioxide gradient in human septic shock. Chest 1992; 101:509-515.
– Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med 2005 31:818–822
State of Knowledge
Identification of tissue hypoperfusion and adequate resuscitation are key factors in the management of patients with septic shock.
P(v-a)CO2 may be normal despite the presence of significant hypoperfusion in high cardiac output states of septic shock where high flow might prevent venous CO2 accumulation.
Thus, the ratio between the Pv-aCO2 and the arterial-to-venous oxygen content difference (Da-vO2) may identify patients at risk of anaerobic metabolism.
– Circulatory shock. N Engl J Med 2013; 369:1726–1734.
– Intensive Care Med 2014; 40:1795–1815.
– Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. Resuscitation 82:1289–1293.
Lactate in Sepsis
Lactate is proposed as a target for resuscitation therapy.
Not only baseline lactate level but its evolution under the influence of therapy has been associated with clinical outcomes.
No consistent advantages have been found for lactate-based resuscitation over resuscitation guided by oxygen parameters.
Therefore additional markers of inadequate perfusion should be explored, especially when ScvO2 values are close to normal.
Da-vO2
Pv-aCO2 to Da-vO2 ratio >1.3 is superior to Pv-aCO2, SvO2, and Da-vO2 in predicting hyperlactatemia in a cohort of critically ill patients.
Pv-aCO2/Da-vO2 ratio varies are faster than lactate kinetics, making it an attractive variable to monitor.
Pv-aCO2/Da-vO2 variations may better reflect variations in VO2 than Pv-aCO2/Da-vO2.
Pv-aCO2 to Da-vO2 ratio may reflect ongoing anaerobic metabolism.
An increased Pv-aCO2/Da-vO2 can be used to identify patients at risk of adverse outcomes in patients with septic shock and it should correlate with lactate clearance.
Aim and objectives
The present study is aimed to evaluate
The relationship between the P(v-a)CO2/C(a-v)O2 ratio and LC for8 and 24 hours and
To define a cutoff value for the P(v-a)CO2/C(a-v)O2 ratio to identify an 8 and 24-hour LC ≥ 10% and 20% respectively after resuscitation
Methodology
Study Design-Prospective, observational study
Study period-18 months
Sample Size 100 patients
Inclusion Criteria
Patients with septic shock
Adult patients (>18 years)
Consent for participation in the study from legitimate guardian
Exclusion Criteria
Declined consent from guardian
Pregnant patients
Patients with pre-existing liver or kidney disease
Patients will be excluded from analysis with incomplete data
CaO2 = (1.34 × SaO2 × Hb) + (0.003 × PaO2)
CvO2 = (1.34 × SvO2 × Hb) + (0.003 × PvO2)
C(a-v)O2 = CaO2 − CvO2
P(v-a)CO2 = PvCO2 − PaCO2
P(v-a)CO2/C(a-v)O2 ratio = (PvCO2 − PaCO2)/(CaO2 − CvO2)
The best cut-off values and the areas under the ROC curves for the prediction of LC>10% (LC >10% from T0 to T8 among groups 8A and 8B) at T8 and LC>20% (LC rate >20% from T0 to T24 among groups 24A and 24B) at T24 is shown as:
Following table depicts the relationship between P(v-a)CO2/C(a-v)O2 ratio and LC. At both T8 and T24, P(v-a) CO2/C(a-v) O2 ratio showed negative correlation with LC (at T8 r = –0.264 and at T24 r = –0.531).
Pearson's Correlations
Pearson's r
P
Lower 95% CI
Upper 95% CI
P(a-v)CO2/C(a-v) O2 8hrs vs Lactate clearance (8hrs)
–0.264
0.009**
–0.439
–0.069
P(a-v)CO2/C(a-v)O2 24 hrs vs Lactate clearance(24hrs)
We found that a high P(v-a)CO2/C(a-v)O2 ratio was related to poor LC at both 8hours and 24hours after initiation of resuscitation.
The cut-off value of P(v-a)CO2/C(a-v)O2 ratio observed as a surrogate marker of LC>10% and LC>20% was 1.31 and 1.37 at 8 and 24 hours, respectively.
This study evaluated the correlation of P(v-a)CO2/C(a-v)O2 ratio to the arterial lactate clearance at 8 and 24 hours after initiation of resuscitation in patients of septic shock.
We observed P(cv-a)CO2/D(a-cv)O2 with cut-off 1.31 at T8, and 1.37 at T24 was related to LC ≥ 10% and LC>20%, respectively
In our study, the patients with LC ≥ 10% and LC ≥20% showed lower mortality than those with LC < 10% and LC<20%, respectively.
The study did not find any significant difference in P(v-a)CO2/D(a-cv)O2 ratio at T8 between the survivors and non-survivors,
But at T24, the difference was statistically significant (p<0.001) between the survivors and non-survivors.
Thus, P(v-a)CO2/D(a-cv)O2 ratio at 24 hours may have prognostic implications.
Conclusion
P(cv-a)CO2/ C(a-v)O2 ratio is a close surrogate for lactate clearance.
A cut-off value of 1.31 at T8and 1.37 at T24 was related to LC ≥ 10% and LC>20%, respectively.
Further, 24hr cut-off value of Pc(v-a)CO2/ Ca-v)O2 ratio is superior to 8 hr value in predicting lactate clearance in septic shock patients.
Moreover, 24 hr Pc(v-a)CO2/Ca-v)O2 ratio had a better predictive value than that of 8 hours.
Paraquat (1,1’– dimethyl-4, 4’-bipyridinium) is a herbicide which is used for agriculture purposes. Accidental or intentional ingestion of Paraquat leads to many systemic effects including pulmonary involvement, cardiac, renal or hepatic failure and a high mortality. Paraquat toxicity can produce both local and systemic effects. It also results in ulceration of skin, lips, tongue, pharynx and esophagus. The mainstay of treatment remains the gastric lavage, adsorbents, steroids, cyclophosphamide or extracorporeal elimination of paraquat. We hereby are presenting the data for paraquat poisoning of patients admitted to our hospital of year 2022, its management and outcome. Our objectives were to study the spectrum of presentation of paraquat poisoning, its management and patient outcome. We also wanted to evaluate various treatment modalities available and their relation with outcome.
Materials and methods
A retrospective observational study was conducted at our tertiary care institute and data regarding demography, clinical features, organ involvement, management and outcome of the Paraquat poisoning patients for the year 2022 was collected. Additional data of HA 320 hemoperfusion (which was recently started), was also collected. Statistical analysis was done using descriptive analysis using mean with standard deviation (SD) for numeric data. Categorical variables were described using. For comparing categorical data frequency and proportion were used. Chi square (χ2) test was performed and fisher exact test was used when the expected frequency is less than 5. A probability value (p value) less than 0.05 was considered statistically significant.
Results
Data from 109 patients was collected, out of which 13 patients survived (12%) and 96 patients (88%) had fatal outcome. Study population consisted of 84% male (n = 91) and 18 female patients. Most of the patients (91.7%) belonged to rural background. Nearly 68% of patients were of younger (<30 years) age group followed by 24% belonging to 31-40 years of age. Age, gender, occupation, amount of paraquat ingestion did not have any significant relation with mortality in our study. Patients having metabolic acidosis (n = 64), altered renal (n = 82) and hepatic function(n = 68) at presentation had statistically significant relation with mortality. Out of 109 patients, 57 patients received renal replacement therapy, 95 patients received steroids, 62 received Cyclophosphamide, 94 patients received NAC and 87 patients received vit C treatment along with supportive treatment. Duration of presentation was significantly lesser in patients who survived (17.26±17.23, median 14hrs) as compared to patients who did not survive (80.18 ±90.07, median 48hrs). Eleven patients received haemoperfusion with HA 230 cartridge, out of which 4 patients (36%) survived which is significant as compared to patients who did not receive (p = 0.03).
Conclusions
Paraquat is commonly used herbicide and its ingestion results in high mortality. There are no known antidotes and it is prohibited in some countries. It is important start the treatment immediately to decrease its absorption and increase removal. Supportive treatment includes oxygenation, immunosuppression, antioxidants, renal replacement therapy and hemoperfusion wherever the resources are available.
References
1.Li C, Hu D, Xue W, Li X, Wang Z, Ai Z, et al. Treatment outcome of combined continuous venovenous hemof iltration and hemoperfusion in acute paraquat poisoning: a Prospective controlled trial. Crit Care Med. 2018;46(1):100–107. doi: 10.1097/CCM.0000000000002826. [DOI] [PubMed] [Google Scholar]
2.Banday TH, Bhat SB, Bhat SB. Manifestation, complications and clinical outcome in paraquat poison: a hospital based study in a rural area of Karnataka. J Environ Occup Sci. 2014;3(1):21–24. [Google Scholar]
3.Gawarammana I, Buckley NA, Mohamed F, Naser K, Jeganathan K, Ariyananada PL, et al. High-dose immunosuppression to prevent death after paraquat self-poisoning – a randomized controlled trial. Clin Toxicol (Phila) 2018;56(7):633–639. doi: 10.1080/15563650.2017.1394465. [DOI] [PubMed] [Google Scholar]
4.Rao R, Bhat R, Pathadka S, Chenji SK, Dsouza S. Golden hours in severe paraquat poisoning-the role of early haemoperfusiontherapy. J Clin DiagnosticRes. 2017;11(2):OC06–OC08. doi: 10.7860/JCDR/2017/24764.9166. [DOI] [PMC free article] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9468568828, e-mail: drtnusingh@gmail.com
1Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9468568828, e-mail: drtnusingh@gmail.com
2–5Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Critically ill patients with acute respiratory failure are exposed to high-intensity mechanical ventilation making them prone to ventilator-induced lung injury (VILI)1. The ventilator-generated causes of VILI include the pressures2, volume3 delivered, gas flows4, and respiratory rate5. They all contribute to mechanical power (MP) induced lung injury and can worsen the outcome of an already diseased lung.
Objectives
The primary objective of this study is to explore the correlation between mechanical power and mortality outcomes in critically ill patients.
Materials and methods
It is a single-centre, prospective observational study. Out of 100 patients to be enrolled in the study, 44 patients have so far met the inclusion criteria. Inclusion criteria includes age >18 years, on invasive controlled mechanical ventilation > 48 hours. Demographic data, Comorbidities, APACHE II, SOFA score, and 6 hourly ventilator parameters have been recorded. MP was calculated at 24 hr, 48 hr, and 72 hr as per the formula given by Chiumello et al6 for Pressure-controlled ventilation (PCV) and Giossa et al7 for Volume-controlled ventilation(VCV). Patients were divided into survivors and non-survivors at day 28. Chi-square and independent t-test have been used for statistical calculation using SPSS 23 software. ROC curve and Kaplan Meier survival analysis were used to correlate MP to 28-day mortality.
Results
In a total of 113 patients screened between May 2023 to Nov 2023, 44 patients have been analysed. The median age is 42.16 years (28.5-54.75), and 56.8% are males. In the survivor group, the median age is 41.46 years (25.75-55.5) (p value-0.68), 53.3% males (p-0.53) as compared to the non-survivor group. At 24 hr APACHE-II score was 23.2 (18.5-27.25) and SOFA score was 13.78 (11.75-16) which were significantly higher in non-survivors. Non-survivors group also had significantly higher MP (P value<0.05). The Pearson correlation analysis showed a good correlation between MP and Driving pressures (DP) (r values: 24 h: 0.794; 48 h: 0.81; all P < 0.01) and MP and Plateau pressures at all points of time. (r values: 24 h: 0.865; 48 h: 0.869; all P value < 0.01). The ROC curves showed that MP at 24h and 48 h were significant values in predicting the outcome, with areas under the curve of 0.71 and 0.82.
Conclusion
Our preliminary results show a significant correlation between MP at 24 hrs and 48 hours with 28-day mortality. It can be an independent risk factor for mortality in ICU patients.
2.Kumar A, et al. Pulmonary barotrauma during mechanical ventilation. Crit Care Med. 1973;1(4):181–186. doi: 10.1097/00003246-197307000-00001. [DOI] [PubMed] [Google Scholar]
3.Dreyfuss D, et al. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis. 1988;137(5):1159–1164. doi: 10.1164/ajrccm/137.5.1159. [DOI] [PubMed] [Google Scholar]
4.Protti A, et al. Role of strain rate in the pathogenesis of ventilator induced lung edema. Crit Care Med. 2016;44(9):e838–e845. doi: 10.1097/CCM.0000000000001718. [DOI] [PubMed] [Google Scholar]
5.Hotchkiss JR, Jr, et al. Effects of decreased respiratory frequency on ventilator-induced lung injury. Am J Respir Crit Care Med. 2000;161(2 Pt 1):463–468. doi: 10.1164/ajrccm.161.2.9811008. [DOI] [PubMed] [Google Scholar]
6.Davide Chiumello, Miriam Gotti, et al. Bedside calculation of mechanical power during volume- and pressure-controlled mechanical ventilation. Critical Care. 2020;24:417. doi: 10.1186/s13054-020-03116-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Giosa L, Busana M, Pasticci I, Bonifazi M, Macri MM, Romitti F, Vassalli F, Chiumello D, Quintel M, Marini JJ, et al. Mechanical power at a glance: a simple surrogate for volume-controlled ventilation. Intensive Care Med Exp. 2019;7(1):61. doi: 10.1186/s40635-019-0276-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
Translation, Cross Cultural Validation, Content Validity and Test-retest Reliability of Duke Activity Status Index in Marathi in Patients with Cardiovascular Disease
1Cardiovascular and Respiratory Physiotherapy, Deccan Education Societys Brijlal Jindal College of Physiotherapy, Pune, Maharashtra, India, Phone: +91 9096003300, e-mail: aditi.soman@despune.org
1Cardiovascular and Respiratory Physiotherapy, Deccan Education Societys Brijlal Jindal College of Physiotherapy, Pune, Maharashtra, India, Phone: +91 9096003300, e-mail: aditi.soman@despune.org
2Cardiovascular and Respiratory Physiotherapist at Ruby Hospital, Pune, India
Assessment of functional capacity is important to investigate the impact of the disease on a patient's life, to determine the degree of constraint imposed by cardiovascular disease (CVD), as well as by being a factor in diagnosis, prognosis and a strong predictor of mortality. Duke Activity Status Index (DASI), a self-administered questionnaire is frequently used to predict the functional capacity (FC) of patients with CVD, such as coronary artery disease, heart failure, myocardial ischemia and infarction. Such Outcome measures if are available in local language and incorporates native activities then it is easy to administer and will predict valid VC. Thus, present study was undertaken for cross-cultural adaptation and translation of DASI into Marathi language.
Objectives
Translation and back translation of Duke Activity Status Index scale by expert to Marathi and English respectively along with Cross cultural adaptations, content validity of DASI Marathi version after discussion of expert panel.
To establish test-retest reliability of translated version in patients with cardiovascular disease.
Materials and methods
This crosssectional observational study was conducted in Community and Cardiopulmonary OPD after IEC approval. The original DASI scale was translated into the Marathi language by Subject Experts. The translated version was checked for the reliability, cultural adaptation and content validity by a committee of 9 health care experts. This prefinal version was checked on 25 patients as an interview (with open ended questions) about their understanding of the questionnaire. On received suggestions, final version was made and checked for its test-retest reliability by testing on a 120 patients diagnosed with CVD.
Results
The questionnaire was translated to Marathi language, a language employed by most of the people residing within the outskirts and city area of Maharashtra state. Few items from questionnaire like “walk a block or two” was replaced with walking 100–200 m as that was easier for native people to relate. The translated version was checked for content validity which was found to be 0.95. Reliability was checked for internal consistency (Cronbach's α) and stability coefficient of the test–retest reliability was done after a period of 15 days in the same patients (Pearson's correlation coefficient r). The reliability was calculated using Medcalc software. The interclass correlation was 0.9940 and 95% confidence interval 0.9912 to 0.9958. The questionnaire had a high internal consistency, good test-retest reliabilities, content validity and it also was feasible to use in the target population.
Conclusion
Thus, it can be concluded that the translated Marathi version of Duke Activity Status Index is culturally adapted, has good content validity and reliability.
References
1.Nishith Govil, Kumar Parag, Barun Kumar, Hariom Khandelwal, Ruchi Dua, Pudi Sivaji. Translation, Cultural Adaptation, and Validation of the Duke Activity Status Index in the Hindi Language. Ann Card Anaesth. 2020 Jul-Sep;23(3):315–320. doi: 10.4103/aca.ACA_25_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Makkar JK, Goyal A, Sharma R, Kumar V, Ghai B, Prinja S, Singh NP. Cross Cultural Adaptation and Validation of Hindi Version of WHOQOL-BREF in Patients with Chronic Low Back Pain
Weaning patients from the ventilator remains a crucial event in the intensive care unit. Weaning failure, which is defined as a failed spontaneous breathing trial (SBT) or the need for a re-intubation in the 48 hours following extubation. Weaning failure remains a clinically relevant challenge because it may result in significant morbidity (prolonged duration of mechanical ventilation, reintubation) and may influence mortality, cardiac dysfunction is a leading cause of weaning failure. Although echocardiography allows the noninvasive assessment of cardiac function and LV filling pressures, its clinical value in the setting of ventilator weaning has yet to be determined. We evaluated the ability of transthoracic echocardiography (TTE) to detect the effects of weaning failure on cardiovascular system.
Objectives
To evaluate the predictive value of left ventricular dysfunction in weaning failure and to evaluate the efficacy of trans-thoracic echocardiography in predicting weaning failure.
Materials and methods
Total of patients (105) admitted in the intensive care unit who are intubated and are on mechanical ventilation were taken during study period from 1st April 2023 to 30th November 2023. Inclusion criteria: Adult patients (18 years or more) admitted to the ICU of our hospital with ejection fraction greater than 50% and are on mechanical ventilation for past 48 hours. Exclusion criteria:
Patients with ejection fraction below 50%
Patients with coronary artery disease, congestive heart failure or any other cardiac disease
Patients not giving consent for the study
Patients who are on long term period of mechanical ventilation due to any reasons like neurological illness, seizure disorder, traumatic brain injury etc.
Result
Our estimated sample size based on E/A among groups. For the sample size calculation, we have defined mean difference of 0.33 with 0.85 Standard Deviation. We have calculated sample size with 95% confidence interval, 80% power and alpha level of 0.05
Comparison of two mean formula
N = size per group;
SD = Standard Deviation = 0.85
δ = mean difference = 1.47-1.14 = 0.33
Zα/2 = Z0.05/2 = Z0.025 = 1.96 — From Z table at type I error of 5
The present study suggests that LV diastolic dysfunction and increased LV filling pressures may be involved in the pathophysiology of weaning failure in ICU patients with preserved systolic function. Patients who failed weaning presented significantly worse diastolic function and increased E/Em or E/a ratios before SBT, compared with those with successful weaning. Patients with moderate to severe LV diastolic dysfunction at pre-SBT exhibited significantly increased weaning failure rates. We also noted that during SBT, LV diastolic function tended to deteriorate. A plausible explanation for the relationship between diastolic dysfunction and weaning failure might be that patients with diastolic dysfunction present diastolic heart failure and pulmonary edema on spontaneous ventilation.
Conclusion
In conclusion, our findings suggest that in patients with no overt cardiac disease and with preserved LV systolic function, LV diastolic dysfunction may play an important role in weaning failure. DE indices, particularly E/Em at the lateral border of the mitral annulus, may be helpful to identify patients at high risk of weaning failure. We acknowledge that further evidence is required before recommending echocardiography as a standard tool during weaning in the everyday clinical setting in the ICU.
References
1.Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, Pearl R, Silverman H, Stanchina M, VieillardBaron A, Welte T. Weaning from mechanical ventilation. Eur Respir J. 2007;29:1033–1056. doi: 10.1183/09031936.00010206. [DOI] [PubMed] [Google Scholar]
2.Vallverdu´ I, Calaf N, Subirana M, Net A, Benito S, Mancebo J. Clinical characteristics, respiratory functional parameters, and outcome of a two-hour T-piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med. 1998;158:1855–1862. doi: 10.1164/ajrccm.158.6.9712135. [DOI] [PubMed] [Google Scholar]
3.Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med. 1991;324:1445–1450. doi: 10.1056/NEJM199105233242101. [DOI] [PubMed] [Google Scholar]
4.Lamia B, Monnet X, Teboul JL. Yearbook of intensive care and emergency medicine. 1st edn. Springer; Heidelberg: 2005. Weaning-induced cardiac dysfunction. pp. 239–245. [Google Scholar]
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection1. There are different biomarkers of sepsis like C reactive protein(CRP), procalcitonin etc. Neutrophil to Lymphocyte ratio (NLR) is one of the important biomarker, that is increased in sepsis due to increase in Neutrophil count and decrease in Lymphocyte count2. SOFA (Sequential Organ Failure Assessment) score is an important score in predicting severity in sepsis patients.
Aims
To study the relationship between NLR and mortality in patients of sepsis.
To study the correlation between NLR and SOFA score in the outcome of sepsis.
To study the relationship between NLR and c reactive protein in predicting severity in sepsis.
Methods
Study Design: Prospective observational study
Sample Size: 100
Inclusion criteria: The patients of age≥18 years having signs and symptoms of infection with qSOFA score ≥2
Exclusion criteria: Patients with
Radiation therapy
Any malignancy
Immunodeficiency including PLHA
Steroid therapy
Immunosupressive therapy
Lactating and pregnant women
Age<18 years
The patients were followed up during the course of hospital stay, and NLR, CRP values and SOFA score was calculated on day 1, 3 and 5.
Results
Total 100 patients (47 males, 53 females) were included in the study. The non-surviving patients had higher NLR than surviving patients on day 3 (p = 0.001) and day 5 (p = 0.001). However the NLR is not higher in non-surviving patients than surviving patients on day 1 (p = 0.072). NLR on day 1, 3, and 5 had an area under curve (95% confidence interval) for the prediction of mortality of 58.5% (48.2%- 68.3%, p = 0.072), 75.5% (65.9%-83.5%, p = 0.001), and 94.7% (88.3%-98.2%, p = 0.001) respectively. The cut-off NLR for day 1, 3 and 5 was 13, 9 and 10 respectively. Hence the patients having persistent high NLR on day 3 and 5 had higher mortality than those having lower NLR. However, day 1 NLR was not helpful in predicting mortality.
Conclusion
A serial increase in NLR during first five days of sepsis is associated with increased mortality, which is also associated with an increase in SOFA score and CRP values.
References
1.Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8):801–810. doi: 10.1001/jama.2016.0287. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Lorente L, et al. Association between neutrophil-to-lymphocyte ratio in first seven days of sepsis and mortality. Enferm Infecc Microbiol Clin. 2020 doi: 10.1016/j.eimc.2020.11.004. [DOI] [PubMed] [Google Scholar]
Dehydration is often under-recognized, under-treated and linked to increased morbidity & mortality in patients.1 There is lack of clinical guidelines and recommendations for assessment & management of oral fluid, electrolytes, and energy (FEE) deficits within inpatient setting.
Objectives
The objective was to develop Indian consensus recommendations on burden, impact & assessment of FEE deficits in hospitalized patients with non-diarrheal illnesses.
Materials and methods
We used the modified Delphi approach with eight experts to develop consensus with online voting followed by virtual discussion and debate.
Results
Consensus was achieved for 64/64 statements based on 5-point Likert scale out of which 26 questions were related to burden & assessment of Fluid and Electrolyte Losses and Increased Energy Requirements in Hospitalized Patients. Common/practical expert perspectives were attained on 18 other questions spanning various domains barriers to assessment of hydration & markers of hydration used in hospital setting. Approximately 50% of the experts (n=4) reached a consensus that 50%–69% of hospitalized patients experience dehydration, and among these dehydrated patients. Elderly patients have higher chances of dehydration at hospital admissions or during their stay in hospital. Decreased oral fluid intake, increased fluid loss due to the illness, insensible fluid losses along with lack of patient or doctor awareness of dehydration were some of the leading factors that Contribute to dehydration in Patients Hospitalized for Non-Diarrheal Illnesses in Inpatient Departments. FEE deficits in hospitalized patients have a high impact on clinical outcomes resulting in prolonged bed days and failed discharges. Overall, FEE deficits in hospitalized patients have a high impact on their recovery. It was agreed that hydration is an important parameter to be considered for the recovery of hospitalized patients. All patients above the age of 60 should be screened for low-intake dehydration at the first opportunity. It is important to assess the level of dehydration in patients hospitalized for non-diarrheal illnesses and monitor the need for rehydration along with energy needs at admission, during de-escalation from intravenous to oral and at discharge. Clinical signs & symptoms; Urine output frequency color; fluid intake & balance charts; serum osmolarity as well as change in body weight were commonly used markers for assessment of dehydration in hospitalized patients.
Discussion and Conclusion
FEE deficits in hospitalized patients have a high impact on their recovery. There are critical barriers for hydration assessment in hospitalized patients. Educational initiatives are needed to sensitize HCPs about impact of dehydration & clinical screening of hospitalized patients for dehydration.
Reference
1.Lacey J, et al. A multidisciplinary consensus on dehydration: Definitions, diagnostic methods and clinical implications. Ann Med. 2019;51(3–4);):232–251. doi: 10.1080/07853890.2019.1628352. [DOI] [PMC free article] [PubMed] [Google Scholar]
Delirium is a neuropsychiatric syndrome characterized by acute cognitive dysfunction and changes in attention, memory, and consciousness. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), delirium is defined as a disturbance in attention and awareness that develops over a short period and fluctuates in severity, leading to changes in cognition, perceptual disturbances, and sleep- wake cycle disturbance.
Background
Delirium can occur in various medical conditions, including infections, drug toxicity, metabolic imbalances, and brain injury, it is prevalent in critically ill patients, particularly those in intensive care units (ICUs). Historically, the prevalence of ICU delirium is reported in 20% to 50% of patients with lower severity of illness,2, 3 but it can be as high as 60% to 80% in mechanically ventilated patients.4–6 It is associated with increased morbidity, mortality, and long-term cognitive impairment. Delirium is a common concern among elderly intensive care unit (ICU) patients. Ketamine's effectiveness in preventing delirium remains controversial despite its demonstrated neuroprotective properties and cognitive benefits in previous studies.
Objectives
To compare the effectiveness of dexmedetomidine and ketamine in preventing delirium among elderly ICU patients.
To assess the incidence and severity of delirium in both treatment groups.
To evaluate the safety profile and adverse effects associated with dexmedetomidine and ketamine.
Materials and methods
This randomized clinical trial involved 77 non-intubated patients aged over 65 years in a general ICU. The patients received low-dose intravenous ketamine (20 mg) or dexmedetomidine (0.2 μg/kg/h, titrated by 0.1 μg /kg/h). Delirium was assessed using the Richmond Agitation Sedation Scale (RASS) at 5, 10, and 15 minutes. The primary outcome was the percentage of patients achieving adequate sedation (RASS ≤ +1). The secondary outcome was time to reach adequate sedation. Adverse effects and physician satisfaction were evaluated after 60 minutes.
Results
No significant difference in delirium was observed between the groups after interventions or within each group over time. However, the ketamine group had significantly lower delirium incidence at 5 minutes. The percentage of patients achieving adequate sedation was higher in the Dexmedetomidine group (86.4%) than in the Ketamine group (36.4%) (P = 0.002). There was a delirium difference between groups at 10 minutes (P = 0.31) or 15 minutes (P = 0.082). Physician satisfaction did not differ significantly (P = 0.144).
Discussion
Managing delirium is a vital objective when caring for ICU patients, particularly the elderly population. Prolonged delirium is associated with elevated mortality rates and an increased likelihood of hospital readmissions (18). Previous studies have shown that brain volume and weight decreased with age (20-22), and structural and functional changes in brain regions, such as the hippocampus, have been reported in older populations (24-26). As a result, elderly patients experience a higher occurrence of delirium than other populations. Moreover, patients with delirium lasting less than 24 hours tend to have similar outcomes to those without delirium. Therefore, the presen tstudy evaluated delirium in patients over 65 years. This open-label randomized clinical trial compared the safety and efficacy of low-dose ketamine to dexmedetomidine in the incidence and control of delirium among elderly ICU patients. The study showed no significant difference between the two treatment sinterms of delirium (basedon RASS scores) at different times (5, 10, and 15 minutes) after the intervention in older patients. This finding suggests that both ketamine and dexmedetomidine had a similar effect on delirium in this specific population. These findings indicate that when it comes to the primary outcome of reducing delirium, there was no advantage of using one medication over the other. Additionally, the present study did not show any significant side effects associated with either ketamine or dexmedetomidine treatment. The absence of significant side effects observed in the dexmedetomidine group is an important finding, indicating that low-dose dexmedetomidine was well tolerated by the elderly ICU patients in the trial. This is a positive outcome as it suggests that this medication canbe safely used in this context without causing significant adverse effects. Therefore, dexmedetomidine can be considered a safe option for managing delirium in this specific patient group. On the other hand, the study demonstrated a significant reduction in RASS scores within each treatment group at 5, 10, and 15 minutes, compared to the baseline of 0 minutes. This reduction in RASS scores indicated that low-dose ketamine was effective in reducing delirium among these patients. Therefore, the study concludes that dexmedetomidine was successful in achieving the desired outcome of reducing delirium severity in elderly ICU patients. Overall, based on the aforementioned findings, the study suggests that low-dose ketamine and dexmedetomidine have similar efficacy and safety profiles in the prevention and management of delirium among elderly ICU patients, and these results suggest that low-dose dexmedetomidine can be considered a viable option for the control of delirium in elderly ICU patients. The present study's findings contrast with those of Heydari et al.'s randomized clinical trial conducted in 2018. The aforementioned study demonstrated that the time required to achieve adequate sedation was significantly longer in the Dexmedetomidine group (0.2 μg/kg/h, titrated by 0.1 μg /kg/h) than in the ketamine group (4 mg/kg). However, there was no difference in sedation scores between the two groups 15 minutes after the intervention.
Conclusions
The present study suggests that the administration of low-dose Dexmedetomidine to elderly ICU patients might reduce delirium incidence, supporting its beneficial effect for delirium control.
1.Martin G. Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th edition) Reference Reviews. 2014;28(3):36–7. doi: 10.1108/rr-10-2013-0256. [DOI] [Google Scholar]
2.Livingston G, Huntley J, Sommerlad A, Ames D, Ballard C, Banerjee S, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413–46. doi: 10.1016/S0140-6736(20)30367-6. [PubMed ID: 32738937]. [PubMed Central ID: PMC7392084] [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Xue P, Wu Z, Wang K, Tu C, Wang X. Incidence and risk factors of postoperative delirium in elderly patients undergoing transurethral resection of prostate: A prospective cohort study. Neuropsychiatr Dis Treat. 2016;12:137–42. doi: 10.2147/NDT.S97249. [PubMed ID:26834475]. [PubMed Central ID: PMC4716723] [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Krewulak KD, Stelfox HT, Leigh JP, Ely EW, Fiest KM. Incidence and Prevalence of Delirium Subtypes in an Adult ICU: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(12):2029–35. doi: 10.1097/CCM.0000000000003402. [PubMed ID:30234569] [DOI] [PubMed] [Google Scholar]
5.Leon-Salas B, Trujillo-Martin MM, Martinez Del Castillo LP, Garcia-Garcia J, Perez-Ros P, Rivas-Ruiz F, et al. Multicomponent Interventions for the Prevention of Delirium in Hospitalized Older People: A Meta-Analysis. J Am Geriatr Soc. 2020;68(12):2947–54. doi: 10.1111/jgs.16768. [PubMed ID:32902909] [DOI] [PubMed] [Google Scholar]
6.Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, et al. Delirium. Nat Rev Dis Primers. 2020;6(1):90. doi: 10.1038/s41572-020-00223-4. [PubMed ID:33184265]. [PubMed Central ID:PMC9012267] [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Cropsey C, Kennedy J, Han J, Pandharipande P. Cognitive Dysfunction, Delirium, and Stroke in Cardiac Surgery Patients. Semin Cardiothorac Vasc Anesth. 2015;19(4):309–17. doi: 10.1177/1089253215570062. [PubMed ID:26660055] [DOI] [PubMed] [Google Scholar]
8.Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci. 2003;58(3):249–65. doi: 10.1093/gerona/58.3.m249. [PubMed ID:12634292] [DOI] [PubMed] [Google Scholar]
9.Zhang HJ, Ma XH, Ye JB, Liu CZ, Zhou ZY. Systematic review and meta-analysis of risk factor for postoperative delirium following spinal surgery. J Orthop Surg Res. 2020;15(1):509. doi: 10.1186/s13018-020-02035-4. [PubMed ID:33153465]. [PubMed Central ID:PMC7643448] [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Kinoshita H, Nishitani N, Nagai Y, Andoh C, Asaoka N, Kawai H, et al. Ketamine-Induced Prefrontal Serotonin Release Is Mediated by Cholinergic Neurons in the Pedunculopontine Tegmental Nucleus. Int J Neuropsychopharmacol. 2018;21(3):305–10. doi: 10.1093/ijnp/pyy007. [PubMed ID:29370396]. [PubMed Central ID:PMC5838842] [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Chaki S, Fukumoto K. Role of Serotonergic System in the Antidepressant Actions of mGlu2/3 Receptor Antagonists: Similarity to Ketamine. Int J Mol Sci. 2019;20(6) doi: 10.3390/ijms20061270. [PubMed ID:30871246]. [PubMed Central ID:PMC6470808] [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Pham TH, Gardier AM. Fast-acting antidepressant activity of ketamine:highlights on brain serotonin, glutamate, andGABA neurotransmission in preclinical studies. Pharmacol Ther. 2019;199:58–90. doi: 10.1016/j.pharmthera.2019.02.017. [PubMed ID:30851296] [DOI] [PubMed] [Google Scholar]
14.Mosk CA, Mus M, Vroemen JP, van der Ploeg T, Vos DI, Elmans LH, et al. Dementia and delirium, the outcomes in elderly hip fracture patients. Clin Interv Aging. 2017;12:421–30. doi: 10.2147/CIA.S115945. [PubMed ID:28331300]. [PubMed Central ID:PMC5354532] [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Pisani MA, Kong SY, Kasl SV, Murphy TE, Araujo KL, Van Ness PH. Days of delirium are associated with 1-year mortality in an older intensive care unit population. Am J Respir Crit Care Med. 2009;180(11):1092–7. doi: 10.1164/rccm.200904-0537OC. [PubMed ID:19745202]. [PubMed Central ID: PMC2784414] [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Avelino-Silva TJ, Campora F, Curiati JA, Jacob-Filho W. Association between delirium superimposed on dementia and mortality in hospitalized older adults: A prospective cohort study. PLoS Med. 2017;14(3):e1002264. doi: 10.1371/journal.pmed.1002264. [PubMed ID:28350792]. [PubMed Central ID:PMC5370103] [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Bilotta F, Russo G, Verrengia M, Sportelli A, Foti L, Villa G, et al. Systematic review of clinical evidence on postoperative delirium:literature search of original studies based on validated diagnostic scales. J Anesth Analg Crit Care. 2021;1(1):18. doi: 10.1186/s44158-021-00021-8. [PubMed ID:37386536]. [PubMed Central ID:PMC10245484] [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Johansson YA, Bergh I, Ericsson I, Sarenmalm EK. Delirium in older hospitalized patients-signs and actions: a retrospective patient record review. BMC Geriatr. 2018;18(1):43. doi: 10.1186/s12877-018-0731-5. [PubMed ID:29409468]. [PubMed Central ID:PMC5801894] [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Hopper AB, Vilke GM, Castillo EM, Campillo A, Davie T, Wilson MP. Ketamine use for acute agitation in the emergency department. J Emerg Med. 2015;48(6):712–9. doi: 10.1016/j.jemermed.2015.02.019. [PubMed ID:25843924] [DOI] [PubMed] [Google Scholar]
20.Barbateskovic M, Larsen LK, Oxenboll-Collet M, Jakobsen JC, Perner A, Wetterslev J. Pharmacological interventions for delirium in intensive care patients: a protocol for an overview of reviews. Syst Rev. 2016;5(1):211. doi: 10.1186/s13643-016-0391-5. [PubMed ID:27923397]. [PubMed Central ID: PMC5142129] [DOI] [PMC free article] [PubMed] [Google Scholar]
21.Sadlonova M, Duque L, Smith D, Madva EN, Amonoo HL, Vogelsang J, et al. Pharmacologic treatment of delirium symptoms: A systematic review. Gen Hosp Psychiatry. 2022;79:60–75. doi: 10.1016/j.genhosppsych.2022.10.010. [PubMed ID:36375344] [DOI] [PubMed] [Google Scholar]
22.Campbell N, Boustani MA, Ayub A, Fox GC, Munger SL, Ott C, et al. Pharmacological management of delirium in hospitalized adults–a systematic evidence review. J Gen Intern Med. 2009;24(7):848–53. doi: 10.1007/s11606-009-0996-7. [PubMed ID:19424763]. [PubMed Central ID:PMC2695535] [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Solano JJ, Clayton LM, Parks DJ, Polley SE, Hughes PG, Hennekens CH, et al. Prehospital Ketamine Administration for Excited Delirium with Illicit Substance Co-Ingestion and Subsequent Intubation in the Emergency Department. Prehosp Disaster Med. 2021;36(6):697–701. doi: 10.1017/S1049023X21000935. [PubMed ID:34551849]. [PubMed Central ID: PMC8607139] [DOI] [PMC free article] [PubMed] [Google Scholar]
24.Tabet N, Howard R. Pharmacological treatment for the prevention of delirium: review of current evidence. Int J Geriatr Psychiatry. 2009;24(10):1037–44. doi: 10.1002/gps.2220. [PubMed ID:19226527] [DOI] [PubMed] [Google Scholar]
25.Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017;35(7):1000–4. doi: 10.1016/j.ajem.2017.02.026. [PubMed ID:28237385] [DOI] [PubMed] [Google Scholar]
26.Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2016;67(5):581–587 e1. doi: 10.1016/j.annemergmed.2015.11.028. [PubMed ID:26899459] [DOI] [PubMed] [Google Scholar]
27.Dale O, Somogyi AA, Li Y, Sullivan T, Shavit Y. Does intraoperative ketamine attenuate inflammatory reactivity following surgery?A systematic review and meta-analysis. AnesthAnalg. 2012;115(4):934–43. doi: 10.1213/ANE.0b013e3182662e30. [PubMed ID:22826531] [DOI] [PubMed] [Google Scholar]
28.Hudetz JA, Patterson KM, Iqbal Z, Gandhi SD, Byrne AJ, Hudetz AG, et al. Ketamine attenuates delirium after cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2009;23(5):651–7. doi: 10.1053/j.jvca.2008.12.021. [PubMed ID:19231245] [DOI] [PubMed] [Google Scholar]
30.Hambrecht-Wiedbusch VS, Li D, Mashour GA. Paradoxical Emergence:Administration of Subanesthetic Ketamine during Isoflurane Anesthesia Induces Burst Suppression but Accelerates Recovery. Anesthesiology. 2017;126(3):482–94. doi: 10.1097/ALN.0000000000001512. [PubMed ID:28099246]. [PubMed Central ID:PMC5309196] [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Safavynia SA, Goldstein PA. The Role of Neuroinflammation in Postoperative Cognitive Dysfunction: Moving From Hypothesis to Treatment. Front Psychiatry. 2018;9:752. doi: 10.3389/fpsyt.2018.00752. [PubMed ID:30705643]. [PubMed Central ID:PMC6345198] [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy. 2018;38(1):139–51. doi: 10.1002/phar.2060. [PubMed ID:29136301] [DOI] [PubMed] [Google Scholar]
Clinical Profile, Prognostic Accuracies of CLIF-C ACLF Score and Serial CLIF-C of Scores in Acute on Chronic Liver Failure Patients – A Prospective Observational Study
Acute-on-chronic liver failure (ACLF) is a recently defined entity that carries high short-term mortality. The European Association for Study of Liver (EASL) has given a different definition for ACLF and also derived two scores called Chronic Liver Failure-Consortium Organ Failure (CLIF-C OF) and CLIF-C ACLF to diagnose and predict the short-term outcome, respectively.
Objectives
To estimate the prognostic accuracy of CLIF- C- ACLF score to predict 28-day and 90-day mortality.
To compare the prognostic accuracy of CLIF-C ACLF with the prognostic accuracies of
CLIF-C OF, MELD, MELD-Na and CTP scores to predict 28-day and 90-day mortality.
To compare prognostic accuracy of baseline CLIF-C OF score (Day 1) with subsequent CLIF-C OF scores (on 3rd day and 7th day) to predict 28-day and 90-day mortality.
Methods
This was the prospective observational study, which included 40 ACLF patients diagnosed as per the EASL definition and calculated CLIF-C ACLF as well as other scores on admission. We followed them during the hospital stay and calculated CLIF-C OF scores again on day 3 and day 7. Their survival status on day 28 and day 90 was collected.
Results
Alcohol was the predominant etiology of cirrhosis (32 patients-80%). Infection was the chief precipitating factor in 19 patients (47.5%). The 28-day and 90-day mortality was 45% and 52.5%. The mean ±SD of CLIF-C ACLF scores of survivors and non-survivors on Day 90 were 44.11 ±6.62 and 53.86 ±7.83. The prognostic accuracy of the CLIF-C ACLF score (Area Under Receiver Operating Characteristic Curve- AUROC) to predict 28-day and 90-day mortality was 0.86 and 0.84, respectively. MELD-Na and CLIF-C ACLF scores had higher AUROC for predicting 28-day and 90-day mortality, respectively. The AUROC of CLIF-C ACLF was not statistically significant when compared to the AUROC of other scores. The AUROC of the CLIF-C OF score on Day 3 was found to be higher than the values of Day 1 and Day 7, but it was not statistically significant.
Discussion
Unlike other scores like CTP, MELD, and MELD-Na, CLIF-C OF and CLIF-C ACLF scores consider respiratory and circulatory system functions also for the prognostication of ACLF patients. In the CANONIC study, from which CLIF-C OF and CLIF-C ACLF scores were derived, the predictive accuracy of the CLIF-C ACLF score was higher and statistically significant compared to other scores.1 However, in our study, the result was different which can be explained by the disproportion in circulatory and respiratory failures in both study groups. In our study, circulatory and respiratory failures were present in 10% and 7.5% of patients, respectively. Whereas in the CANONIC study, these rates were 63.6% and 38.2%, respectively.
Conclusion
CLIF-C ACLF has good short-term prognostic accuracy and it is as good as other available scores. Serial CLIF-C OF scores were equally good in predicting short-term mortality.
Reference
1.Jalan R, Saliba F, Pavesi M, Amoros A, Moreau R, Gines P, et al. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol. 2014;61:1038–47. doi: 10.1016/j.jhep.2014.06.012. [DOI] [PubMed] [Google Scholar]
Acute Respiratory Distress Syndrome (ARDS) is a severe and potentially fatal condition characterized by inflammation and damage to the lungs. Veno-venous (VV) Extracorporeal Membrane Oxygenation (ECMO) is a form of life support that can be used in the management of ARDS. This study was done to evaluate the short-term outcome of VV ECMO in patients of ARDS presenting at our institute.
Materials and methods
This ambispective observational study was carried out on patients with severe ARDS on VV ECMO admitted to the Intensive Care Unit (ICU). Parameters studied included duration of pre-ECMO and total duration of mechanical ventilation, duration of ECMO, length of stay in ICU, length of hospital stay, and in-hospital mortality from the case records. The APACHE II, SOFA and Murray scores were also recorded.
Results
The mean age of the ARDS patients in our study was 48.70±12.06 years. Out of 70 study patients, 41 were male and 29 were female. Most common indication for VV ECMO was pneumonia, followed by sepsis. Rate of mortality was significantly higher in patients with pneumonia (44.7%) and sepsis (44.4%). Mean duration of mechanical ventilation and mean duration of ECMO was 21.86±13.19 days and 16.35±10.11 days, respectively. The mean duration of ICU and hospital stay in our study was 23.26±12.25 days and 27.33±14.44 days, respectively. Proportion of survivors (58.6%) were significantly higher than non survivors (41.4%).
Conclusion
VV ECMO can be used as a treatment option for patients with severe ARDS who are failing conventional mechanical ventilation.
Acute respiratory distress syndrome (ARDS), a life-threatening condition, has been commonly observed in patients admitted to the intensive care unit (ICU). Traditionally, mechanical ventilation has been the management protocol for ARDS.[1,2] Soon after its advent, the utilization of extracorporeal membrane oxygenation (ECMO) has been significantly increased across the world for the management of severe ARDS. Over the past few years, the understanding of ECMO in the management of severe ARDS has been improved due to the advances in technologies and an increasing body of superior quality evidence. ECMO refers to a modified cardiopulmonary bypass circuit which is helpful in providing gaseous exchange and thus assures the perfusion throughout all the organ systems in order to support patient's life in cases of cardiac and pulmonary failure that are refractory to traditional therapy.[3,4] ECMO works by reducing the demand for high airway pressures, which in turn permit the lungs to relax and avoid the effects related to high pressure in the airway.[5] ECMO related complications commonly observed in refractory ARDS patients includes infections, coagulopathies, ischemia, hypoxia, and multi-organ failures. Recent studies have suggested declined mortality rates and better six-month disability free survival rates with the use of ECMO and ventilator techniques.[3,4] However, two of the randomized controlled trials (RCT) failed to establish the supremacy of ECMO over other traditional management techniques.[6,7] Thus this study was undertaken to study the short-term outcome of veno venous extracorporeal membrane oxygenation (VV ECMO) in patients of ARDS presenting at our institute.
Materials and methods
This ambispective observational study was carried out on patients admitted to the Intensive Care Unit (ICU) of a tertiary care centre from January 2017 to October 2022. All patients aged 16 years and above, with severe ARDS on VV ECMO, who provided written informed consent were included in the study, while patients on VA ECMO or those below 16 years were excluded from the study. The study protocol was approved by the Institutional Ethical Committee with reference no. IEC code no.-2021-004-TH-36. Written informed consent was obtained from each patient prior to their enrolment in the study. During the study period, total 96 patients received ECMO therapy; of which, 18 patients underwent VA ECMO and data from six patient records were incomplete, leading to exclusion of these patients from our analysis. Thus, we evaluated the medical records of total 70 eligible patients. All the study patients had received meticulous management involving appropriate medical therapy, sedation, neuromuscular blockade, and low tidal volume lung protective ventilation (6-8 ml/kg) prior to ECMO initiation. Throughout the treatment, plateau pressure (PP) was maintained below 30 cmH2O. Prone ventilation was attempted for all patients, unless contraindicated. VV ECMO was employed exclusively for individuals experiencing severe and potentially reversible respiratory failure that was unresponsive to optimized lung protective mechanical ventilation and prone ventilation. Furthermore, patients were only initiated on VV ECMO if the duration of invasive mechanical ventilation was less than 7 days. The duration of non-invasive ventilation (NIV) was not taken into consideration when selecting candidates for ECMO therapy. Generally, patients were excluded if they exhibited standard contraindications to ECMO therapy, as suggested by the Extracorporeal Life Support Organization (ELSO). Decisions to initiate ECMO were made on an individual basis by the treating critical care medicine team, taking into account the unique circumstances of each patient. The parameters included duration of pre-ECMO and total duration of mechanical ventilation, duration of ECMO, length of stay in ICU, length of hospital stay, and in-hospital mortality from the case records. The APACHE II, SOFA and Murray scores were also recorded.
Results
The mean age of the ARDS patients in our study was 48.70±12.06 years, with the age ranging from 19 to 69 years. 77.2% of the patients were aged between 35-64 years (p<0.001). Only 1.4% of the patients were below 20 years of age. (Table 1) Out of 70 patients, 41 were male and 29 were female. Hypertension (HTN) and diabetes mellitus (DM) were the two commonly observed co-morbidities in study patients. Patient characteristics are depicted in Table 1. The mean duration of ECMO in our study was 16.35±10.11 days. The mean duration of ventilation before ECMO initiation, duration of ICU and hospital stay and duration of mechanical ventilation are summarized in Table 2. In our study, most common indication for VV ECMO was pneumonia, followed by sepsis. Out of 47 patients of pneumonia, in 18 patients, the cause of pneumonia was COVID-19, and in 10 patients, the cause was influenza. (Table 3) Rate of mortality was significantly higher in patients with pneumonia (44.7%) and sepsis (44.4%). Mortality rate was significantly higher in COVID-19 group (61.1%) as compared to the Influenza group (12.5%).(p<0.001). Sepsis was the most common (57.1%) complication observed in our study. (Z = 4.28; p<0.001) Other complications observed were bleeding, stroke, circuit change and barotrauma. (Figure 1) Proportion of survivors (58.6%) were significantly higher than non survivors (41.4%) (Z = 2.54; p = 0.0107). (Figure 2). The mean age of the COVID-19 patients was greater than Influenza patients, but this difference was not statistically significant. Both the groups were comparable in terms of all parameters except that DM and CAD were significantly associated with COVID-19 patients. Comparison of all the clinical parameters between COVID-19 and Influenza patients are summarized in Table 4. The patients in the non-survivor group were older than those in the survivor group, but this difference was not statistically significant. In the survivor group, majority of the patients were females, while in the non-survivor group, the majority of the patients were males. The mean APACHE II score and the mean Vasoactive inotropic score were significantly higher in the non-survivor group as compared to the survivor group. Comparison of all the clinical parameters between survivor and non-survivor groups are presented in Table 5.
ECMO was first introduced for patients with ARDS in the 1970s. However, the use was limited in view of the high mortality seen at that time. The use of ECMO has grown considerably in recent years due to technological advances and the evidence suggesting potential benefit. ECMO is used to provide oxygenation and CO2 removal, or both while the lungs recover, or as a bridge to transplant in case of end stage lung disease. Conventional ventilatory support versus ECMO for Severe Adult Respiratory failure (CESAR) trial recommended transferring adult patients with severe but potentially reversible respiratory failure, with Murray score >3 or who have a pH <7.2 on optimum conventional management, to a center where ECMO-based management is available.[8] However, the EOLIA trial concluded that among patients with very severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy.[9] We undertook this study to evaluate the short-term outcome of VV ECMO in patients of ARDS. The mean age of study patients was 48.70±12.06 years, with more than 50% of the patients above 35 years of age, which suggested that ARDS is more prevalent in the age groups of ≥35 years. (Table 1) These results are in accordance with the results of previous studies.[9-12] Majority of the patients in our study were male (58.6%) with a male to female ratio of 1.4:1, suggesting that males are at a higher risk of having ARDS. (Table 1) Previous studies have reported a similar male predominance in critically ill patients with ARDS, including those receiving ECMO support.[9,11-14] However, it is difficult to compare our study directly with the gender distribution of ECMO patients in an ICU, as the available literature on this topic may report different proportions of male and female patients depending on the specific population being studied. Moreover, this gender bias in our study can be attributed to socio economic factors in our country where males can have better access to health care. The mean APACHE II score and the mean SOFA score in our study were 24.79±8.14 and 7.93±3.13, respectively. (Table 1) These findings are in accordance with other studies. (6,30) However, Mariappan R et al[10] and Rilinger J et al[11] have observed mean APACHE II score and the mean SOFA score higher than that observed in our study. The mean Murray score in our study was 3.43±0.64. (Table 1) Similar observations were made by Mariappan R et al29 who have found a mean Murray score of 3.64±0.2 in their study.[10] In our study, the mean P/F ratio observed was 70.40±19.37 and the mean vasoactive inotropic score was 171.10±82.39. These results are in agreement with previous studies.[9,10,13] However, no other studies have mentioned the details about the vasoactive inotropic score in ARDS patients. The mean duration of ventilation before initiation of ECMO in ARDS patients was 3.51±1.93 days and the mean duration of mechanical ventilation was 21.86±13.19 days in our study. (Table 2) One study has observed that the duration of ventilation before initiation of ECMO was less than 2 days in majority (59.6%) of their ARDS patients, and the median duration of mechanical ventilation (12.5 days) was also lower than our study.[11] The mean duration of ECMO in our study was 16.35±10.11 days, which is in accordance with the study by Combes A et al[9]. However, other studies have observed variations in mean duration of ECMO in their studies.[10,13] The mean duration of ICU and hospital stay in our study was 23.26±12.25 days and 27.33±14.44 days, respectively.(Table 2) The stay in hospital can be influenced by weaning process. Similar observations were made by other authors in their respective studies.[9,11] However, two studies have observed longer duration of hospital stay as compared to our study.[9,13] Pneumonia (67.1%), the primary cause of ARDS, was the most common indication for ECMO in our study. (Table 3) Most of the previous studies have also observed pneumonia as the major cause of ARDS requiring ECMO in their studies.[9-11] In our study, 8.5% of the patients experienced stroke (hemorrhagic). It is important to note that stroke in ECMO patients can have serious consequences, including increased morbidity and mortality. Therefore, strategies to reduce the risk of stroke in ECMO patients are important. Some studies have identified risk factors for stroke in ECMO patients, including longer ECMO duration and higher levels of anticoagulation.[15,16]. In our study, mortality rate was 41.4% and survival rate was 58.6%. Although, mortality rates can vary depending on the underlying diagnosis, severity of illness, and other patient-related factors, but studies have generally reported mortality rates ranging from 20% to 50% for patients receiving VV ECMO in an ICU. Higher mortality rates were observed in the studies by Mariappan R et al[10] and Rilinger J et al[11]. The mortality rates for sepsis and pneumonia in our study are similar to those reported in the literature, and the mortality rates for tropical diseases and pancreatitis are also consistent with previous reports. The reported mortality rates in our study are consistent with the literature on VV ECMO in an ICU, although the small sample size and other factors should be considered when interpreting the results. Patients in COVID-19 group were older than patients in the Influenza group, and male dominance was observed in both these groups. (Table 4) P/F ratio and vasoactive inotropic score in the COVID-19 group was higher than Influenza group. mortality rate was significantly higher in COVID-19 group (61.1%) as compared to the Influenza group (12.5%). (p<0.001) Similar observations were made by other two studies.[12,14] Comparison between survivors and non-survivors in our study suggested that patients in the non-survivor group were older than those in the survivor group. In the survivor group, majority of the patients were females, while in the non-survivor group, majority of the patients were males. (Table 5) This difference was statistically significant (p<0.001). The mean APACHE II score was significantly higher in the non-survivor group (28.45±8.14) as compared to the survivor group (22.20±7.16), indicating greater disease severity at admission. Similarly, the vasoactive inotropic score was significantly lower in the survivor group (147±81.23) as compared to the non-survivor groups (205.16±72.46). The mean PaO2/FiO2 ratio was also higher in non-survivor group (75.63±21.93) as compared to the survivor group (66.69±16.63), but this difference did not reach statistical significance. The mean duration of ventilation before initiation of ECMO was significantly higher in the non-survivor group (4.43±2.19 days) as compared to the survivor group (2.93±1.49). The mean duration of stay in ICU and hospital were significantly longer in the survivor group when compared to the non-survivor group (p<0.001). Sepsis was significantly higher in the non-survivor group (93.1%) as compared to the survivor group (31.7%).
Conclusion
In this study, proportion of survivors (58.6%) was significantly higher than non survivors (41.4%), suggesting remarkable success of the short-term outcome of VV ECMO in patients with ARDS. VV ECMO can be used as a treatment option for patients with severe ARDS who are failing conventional mechanical ventilation. The use of VV ECMO is associated with improved survival rates but is also associated with an increased risk of sepsis and bleeding complications. The decision to initiate VV ECMO should be made on a case-by-case basis, taking into consideration the severity of hypoxemia, the duration of mechanical ventilation, the cause of ARDS, age, comorbidities, and the presence of multi-organ dysfunction.
References
1.ARDS DefinitionTask Force. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526–2533. doi: 10.1001/jama.2012.5669. [DOI] [PubMed] [Google Scholar]
3.Shrestha DB, Sedhai YR, Budhathoki P, Gaire S, Subedi P, Maharjan S, Yuan M, Asija A, Memon W. Extracorporeal Membrane Oxygenation (ECMO) Dependent Acute Respiratory Distress Syndrome (ARDS): A Systematic Review and Meta-Analysis. Cureus. 2022 Jun 6;14(6):e25696. doi: 10.7759/cureus.25696. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Brodie D, Abrams D, MacLaren G, Brown CE, Evans L, Barbaro RP, Calfee CS, Hough CL, Fowles JA, Karagiannidis C, Slutsky AS, Combes A. Extracorporeal Membrane Oxygenation during Respiratory Pandemics: Past, Present, and Future. Am J Respir Crit Care Med. 2022 Jun 15;205(12):1382–1390. doi: 10.1164/rccm.202111-2661CP. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Munshi L, Walkey A, Goligher E, Pham T, Uleryk E, Fan E. Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Lancet Respir Med. 2019;7(2):163–172. doi: 10.1016/S2213-2600(18)30410-9. [DOI] [PubMed] [Google Scholar]
6.Zapol WM, Snider MT, Hill JD, Fallat RJ, Bartlett RH, Edmunds LH, Jr, et al. 1979 Extracorporeal membrane oxygenation in severe acute respiratory failure. Jama. 1979;242(20):2193–6. doi: 10.1001/jama.242.20.2193. [DOI] [PubMed] [Google Scholar]
7.Morris AH, Wallace CJ, Menlove RL, et al. Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med. 1994;149:295–305. doi: 10.1164/ajrccm.149.2.8306022. 10.1164/ajrccm.149.2.8306022. [DOI] [PubMed] [Google Scholar]
8.Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351–63. doi: 10.1016/S0140-6736(09)61069-2. [DOI] [PubMed] [Google Scholar]
9.Combes A, Mokhtari M, Couvelard A, Trouillet JL, Baudot J, Hénin D. Clinical and biological features of severe and mild acute respiratory distress syndrome. Intensive care medicine. 2008;34(5):856–66. [Google Scholar]
10.Mariappan R, Kumar M, Ramakrishnan N, Mani AK, Kumar S, Chandrasekaran V. Practice Patterns and Outcome of Extracorporeal Membrane Oxygenation Therapy for Severe Acute Respiratory Distress Syndrome in Indian ICUs. Indian J Crit Care Med. 2021;25(11):1263–8. doi: 10.5005/jp-journals-10071-23928. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Rilinger J, Krötzsch K, Bemtgen X, Jäckel M, Zotzmann V, Lang CN, et al. Long-term survival and health-related quality of life in patients with severe acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation support. Crit Care. 2021;25(1):410. doi: 10.1186/s13054-021-03821-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Shih E, Squiers JJ, DiMaio JM, George T, Banwait J, Monday K, et al. Outcomes of Extracorporeal Membrane Oxygenation in Patients With Severe Acute Respiratory Distress Syndrome Caused by COVID-19 Versus Influenza. Ann Thorac Surg. 2022;113(5):1445–51. doi: 10.1016/j.athoracsur.2021.05.060. [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Mustafa AK, Alexander PJ, Joshi DJ, Tabachnick DR, Cross CA, Pappas PS, et al. Extracorporeal Membrane Oxygenation for Patients With COVID-19 in Severe Respiratory Failure. JAMA Surg. 2020;155(10):990–2. doi: 10.1001/jamasurg.2020.3950. [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Jäckel M, Rilinger J, Lang CN, Zotzmann V, Kaier K, Stachon P, et al. Outcome of acute respiratory distress syndrome requiring extracorporeal membrane oxygenation in Covid-19 or influenza: A single-center registry study. Artif Organs. 2021;45(6):593–601. doi: 10.1111/aor.13865. [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Huang L, Yin J, Han J, Wu J, Ma G. Risk factors for neurological complications after extracorporeal membrane oxygenation treatment. Annals of Translational Medicine. 2016;4(20):391. [Google Scholar]
16.Mariscalco G, Cottini M, Zanobini M, Salis S, Dominici C, Banescu S, et al. Risk factors for stroke during extracorporeal membrane oxygenation in patients undergoing cardiac surgery: Analysis of 1,213 cases. Journal of Thoracic and Cardiovascular Surgery. 2018;155(4):1636–42. [Google Scholar]
To determine the impact of different intravenous fluids on pre-specified biochemical and clinical parameters.
Materials and methods
This is an observational study comparing Normal saline (NS), Ringer's Lactate (RL) and a newer balanced multi-electrolyte solution (BMES) on the blood gas, biochemical parameters and clinical outcomes after 24 and 48 hours of infusion.
Results
Among the 70 patients included, 30 patients (42.85%) received NS, there were 20 patients (28.57%) each in RL and BMES groups. At 24 hours, significant difference in Chloride and Bicarbonate was observed between the groups by ANOVA. Post-hoc analysis showed, RL as compared to NS resulted in lesser chloride (Mean Difference -7.083; 95% CI; p = 0.033) and increased bicarbonate level (Mean Difference -3.53; 95% CI; p = 0.019), however statistically significant difference was lacking when BMES was compared with NS and RL. Though statistical significance was not found, but 43% of patients in the NS arm developed AKI as compared to 8% in BMES arm and the least in RL arm (4%). Number of patients requiring RRT were 2(6.6%) in the NS and 1 each (5%) in RL and BMES arm. The number of patients requiring respiratory support (Invasive or Non-invasive) was also the least in the RL arm (15%), followed by NS (53.33%) and BMES arm (55%). At 48 hours, significant difference in pH, chloride, bicarbonate and base-excess was observed between the groups by ANOVA. Interpreting the post- hoc analysis, RL as compared to NS resulted in higher pH (Mean Difference -0.049; 95% CI; p = 0.021; CI = 95%), higher Bicarbonate (Mean Difference-3.84; 95% CI; p = 0.03) and greater base-excess (Mean Difference-4.70; 95% CI; p = 0.027). NS as compared to BMES and RL had increased Chloride (Mean Difference 6.01; 95% CI; p = 0.021); (Mean Difference -16.56; 95% CI; p = 0.000) respectively. The percentage of patients developing AKI and requiring RRT was the highest in NS (14% and 4% respectively) followed by BMES (5% and 2% respectively) and the least in RL arm (3% and 1% respectively). The percentage of patients requiring respiratory support (invasive or non-invasive) was the highest in NS (50%) followed by BMES (35%) and the least in RL arm (25%).
Conclusion
At the end of 24 hours, RL rather than BMES has shown improvement in chloride and bicarbonate compared to NS. After 48 hours, administration of RL over NS showed improvement in pH and Base-deficit in addition to chloride and bicarbonate. BMES group however showed improvement in chloride only.
Neutrophil to Lymphocyte ratio (NLR), and serum lactate are frequently used for rapid bedside assessment of the severity of sepsis. This study aimed to evaluate the individual and combined efficacy of NLR and serum lactate clearance, measured in the emergency department (ED), in predicting 28-day mortality.
Methods
This was a prospective observational single-center study. Conducted in the emergency department of a tertiary care center in north India (CTRI/2018/08/015371). Study included adult patients between 18 to 80 years, admitted to the emergency department with sepsis. Along with baseline demographic and hemodynamic variables, NLR, serum lactate, and lactate clearance (LC) at 6 hours were collected. The major outcome for this study was 28-day mortality.
Results
Out of 50 patients, 33 survived (66%). Non-survivors had lower systolic, diastolic, mean blood pressure, lower LC, tachycardia, high SOFA score, vasopressors requirement, mechanical ventilation requirement, and high NLR. NLR (≥11.13) was best correlated with 28-day mortality (AUROC 0.87), followed by initial lactate (≥3.3, AUROC 0.77) and lactate clearance (≤17.07%, AUROC 0.73). Multivariate logistic regression revealed NLR and LC were independent predictors of mortality, with weak correlation between them. However, their combination did not perform better (AUROC 0.82) than individual markers.
Conclusion
NLR and LC can be used with moderate certainty in predicting 28-day mortality.
To Study the Incidence of Carbapenems Resistance in the Enterobacteriaceae in two Set of Population Screened with Rectal Swab Cultures: First, The Patient Coming from Community and Second, After Stay in Icu For >72 Hours
Carbapenem-resistant Enterobacteriaceae (CRE) are a type of bacteria, which can cause serious infections that are hard to treat. Carbapenem resistance is defined according to current CLSI breakpoints (MIC > 4mcg/ml to meropenem). They are natural inhabitants of human intestinal tract and can cause opportunistic infections in both community and hospitals. About 20% of these infections are attributed to agricultural antibiotic usage rather than clinical treatment. Food-borne pathogens can cause acute illness, or they can asymptomatically persist in the gut microbiome as a reservoir for multi drug resistant, opportunistic, extraintestinal infections. The patient population at risk for these infections are those with long standing uncontrolled diabetes, exposure to multiple antibiotics, immunocompromised patients, etc. Oxa-48, emerged and spread mostly in K. pneumoniae in the Mediterranean countries in 2000s. The first case of NDM, was identified and reported in carbapenem - resistant K. pneumoniae and E. coli in a patient who had travelled from India in 2009. The mechanism of resistance to carbapenems involves an efflux pump, reduced permeability, altered transpeptidases, and inactivation by beta-lactamases. The purpose of this study was to screen for the outbreak of CRE infections in the ICU as they increase the mortality and cost burden. Outbreak of CRE infections have led some institutions to implement rigorous screening programs, although controlled comparative data are frequently lacking.
Objectives: Primary objective
Detection of CRE carrier by rectal swab screening in community and ICU setting of tertiary care hospital.
Materials and methods
Single centre, prospective, observational cohort study in different ICUs of 450 bedded tertiary care hospital for duration of 6 months. After taking informed consent from the patients, samples were collected for this study at the time of admission and after 72 hours of admission in ICU. Rectal swab culture was sent with Hi Media (REF MS052A) transport system swabs. These were checked for Meropenem resistance in vitro. Enterobacteriaceae identification was by Vitec automated system (Bio Merieux, France) with ID GNB card. For breakpoint value CLSI 2022 M100-S23 was used. Results were obtained and separated as CRE and NON-CRE organisms. Statistical analysis was done using IBM SPSS statics version 2.0. Continuous variables were expressed in the descriptive statistics tables as means and standard deviation and were compared using an independent sample t-test. The p-value less than 0.05 was considered significant and p-value less than 0.01 was considered highly significant.
Results
Among the total number of 170 patients enrolled, 52.94% were from community and 47.06% were from ICU after 72 hours of admission. Among total patients, 43.53% were CRE producers and 56.47% were non CRE producers. Among CRE producers, 63.51% were from community and 36.41% were from ICU population after 72 hours of admission (p- value = 0.023).
Discussion
Intensive care units are the greatest hub for prescribing antimicrobials and the selection pressure is highest in these areas for harbouring antimicrobial resistance amongst the bacteria. Measures to decrease the patient-to-patient transmission include 1) hand hygiene, 2) contact isolation precautions 3) cohorting with dedicated staff 4) environmental cleaning 5) decolonisation protocols 6) surveillance programs to identify asymptomatic carriage have shown to decrease the occurrence of CRE.
References
1.Kelly AM, Mathema B, Larson EL. Carbapenem-resistant Enterobacteriaceae in the community: a scoping review. Int J Antimicrob Agents. 2017 Aug;50(2):127–134. doi: 10.1016/j.ijantimicag.2017.03.012. 28647532;PMC5726257 Epub 2017 Jun 21. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Tischendorf J, de Avila RA, Safdar N. Risk of infection following colonization with carbapenem-resistant Enterobactericeae: A systematic review. Am J Infect Control. 2016 May 1;44(5):539–43. doi: 10.1016/j.ajic.2015.12.005. 26899297;PMC5262497 Epub 2016 Feb 15. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Bonten MJ, Weinstein RA. The role of colonization in the pathogenesis of nosocomial infections. Infect Control Hosp Epidemiol. 1996;17:193–200. doi: 10.1086/647274. [PubMed: 8708364] [DOI] [PubMed] [Google Scholar]
4.Latibeaudiere R, Rosa R, Laowansiri P, Arheart K, Namias N, Silvia Munoz-Price L. Surveillance cultures growing carbapenem-resistant Acinetobacter baumannii predict the development of clinical infections: a retrospective cohort study. Clin Infect Dis. 2015;60:415–22. doi: 10.1093/cid/ciu847. [PubMed: 25352586] [DOI] [PubMed] [Google Scholar]
5.‘Yamuna Devi V. Ramanathan, Ramasubramanian Venkatasubramanian, Nambi P. Senthur, Ramabathiran Madhumitha, Venkataraman Ramesh, Thirunarayan M.A, Samundeeswari P, Ramakrishnan Nagarajan.
6.Carbapenem-Resistant Enterobacteriaceae Screening: A Core Infection Control Measure for Critical Care Unit in India. Indian Journal of Medical Microbiology. 2018;Volume 36(Issue 4):572–576. doi: 10.4103/ijmm.IJMM_18_437. Pages. ISSN 0255-0857. [DOI] [PubMed] [Google Scholar]
7.Schwaber MJ, Carmeli Y. An ongoing national intervention to contain the spread of carbapenem-resistant Enterobacteriaceae. Clin Infect Dis. 2014;58:697–703. doi: 10.1093/cid/cit795. 24304707; [DOI] [PubMed] [Google Scholar]
9.Fatma ESER, Gül Ruhsar YILMAZ1, Rahmet GÜNER2, İmran HASANOĞLU2, Fatma Yekta ÜRKMEZ KORKMAZ2, Ziya Cibali AÇIKGÖZ3, Mehmet Akın TAŞYARAN2, et al. Risk factors for rectal colonization of carbapenem-resistant Enterobacteriaceae in a tertiary care hospital: a case-control study from Turkey; Turk J Med Sci. 2019;49:341–346. doi: 10.3906/sag-1810-65. [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Richter SS, Marchaim D. Screening for carbapenem-resistant Enterobacteriaceae: Who, When, and How? Virulence. 2017 May 19;8(4):417–426. doi: 10.1080/21505594.2016.1255381. 27813699;PMC5477693 Epub 2016 Nov 4. [DOI] [PMC free article] [PubMed] [Google Scholar]
Severe traumatic brain injury (TBI) is a serious health issue causing mortality and disability.1, 2 Monitoring intracranial pressure (ICP) is crucial to prevent secondary brain damage and improve prognosis. The evaluation of optic nerve sheath diameter (ONSD) can significantly contribute to TBI evaluation3, 4, with limited studies investigating its prognostic value on initial CT.
Objective
To evaluate the prognostic value of optic nerve sheath diameter (ONSD) in severe TBI patients, focusing on its association with poor outcomes.
Methods
The prospective observational study includes 38 TBI patients admitted to the ICU were divided into survivors (n = 22) and non-survivors (n = 16). Baseline characteristics, clinical data, Glasgow coma scale, computed tomography, injury severity score, and Marshall score were recorded. Optic nerve sheath diameter was calculated at a 3 mm distance from the globe.
Results
The ONSD, ISS and Marshall score were significantly higher and GCS was significantly lower in non-survivor group (p = 0.003, p = 0.044, p = 0.036 and p = 0.026 respectively). ONSD was positively correlated with ISS (r = 0.442; p<0.01) and Marshall score (r = 0.338; p<0.01). Receiver operating characteristics (ROC) analysis demonstrated that ONSD ≥7.32 had a sensitivity of 80.2% and specificity of 70.5% for predicting mortality. It was shown that ONSD ≥7.32 had a 4.5-fold increased risk for in-hospital mortality (odds ratio: 4.66; 95% confidence interval: 1.221-16.325; p<0.001).
Discussion
By identifying elevated intracranial pressure (ICP), the initial CT measurement of ONSD in patients with Traumatic Brain Injury (TBI) can assist in early diagnosis and therapy. Research has demonstrated a positive relationship between the ICU death rates and ONSD in patients with severe traumatic brain injury. This data can be used to identify patients who need invasive pressure monitoring for therapy or who have elevated ICP and need rapid therapeutic intervention. The findings emphasizes how crucial early diagnosis and therapy depend on ONSD monitoring.
Conclusion
The study found that enlargement of ONSD in initial CT was linked to increased mortality in patients with TBI who were followed up in the ICU due to TBI.
References
1.Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: A brief overview. J Head Trauma Rehabil. 2006;21:375–8. doi: 10.1097/00001199-200609000-00001. [DOI] [PubMed] [Google Scholar]
2.Brazinova A, Rehorcikova V, Taylor MS, et al. Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review. J Neurotrauma. 2021;38:1411–40. doi: 10.1089/neu.2015.4126. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Geeraerts T, Launey Y, Martin L, et al. Ultrasonography of the optic nerve sheath may be useful for detecting raised intracranial pressure after severe brain injury. Intensive Care Med. 2007;33:1704–11. doi: 10.1007/s00134-007-0797-6. [DOI] [PubMed] [Google Scholar]
4.Lee SH, Kim HS, Yun SJ. Optic nerve sheath diameter measurement for predicting raised intracranial pressure in adult patients with severe traumatic brain injury: A meta-analysis. J Crit Care. 2020;56:182–7. doi: 10.1016/j.jcrc.2020.01.006. [DOI] [PubMed] [Google Scholar]
The venomous snake fauna of the Asia Region is rich and diverse and varies within and between countries. The true scale of mortality and acute and chronic morbidity from snakebite is only just beginning to be recognized. Early access to medical care in a health facility that has personnel trained and capable of diagnosing snakebite envenoming is essential. This means, a health centre which is equipped with the basic resources needed to provide emergency treatment, including the administration of antivenom sera and other adjunct therapy.
Objectives
To study the incidence and outcome of snake bites from a tertiary care centre in Northern India
To study pattern of poisoning, clinical features, diagnosis, treatment strategies.
To find practice –guideline gaps due to awareness and constraints with outcome
Outcome analysis will be correlated with established literature.
Materials and methods
Medical records of patients admitted to Dayanand Medical College & Hospital with diagnosis of snake bite from January 1, 2022 to December 31, 2022 was assessed for demographic profile, socio-economic status, clinical characteristics, laboratory parameters, treatment received, procedure performed, co-morbidities, complications and outcomes. Data was compiled and analysed using Student's t-test for continuous variables and chi-square test for categorical variables will be utilized.
Results
55 patients presented to the emergency department with history of snake bite. The mean age was 34.17years (range 3-72 years). 42 were males and 13 females only. Most of the bites occurred during dusk to late night. 23% patients were direct admissions within 6 to 8 hours of snake bite, the remaining were referred from others hospitals after an average duration of 4.7days (range 1-15 days). Syndrome of snake bite observed were of neuro paralytic in 17 patients (31%), vasulotoxic in 23 patient(42%), only local site cellulitis in 4 only(7%). 15 patients required only observation(27%). Nine patients (16%) required mechanical ventilation with average duration of 3.5days, 9 patients had acute kidney injury, 3 were on dialysis and 6 were managed conservatively. Two patients had lower gi bleed and one patient had MCA infarct. Almost all patients were given at least 10vials of ASV, there was no pattern of ASV, neostigmine and atropine administration. One patient had hypersensitivity reaction to ASV. 53 out of 55 patients were discharged in stable condition and 2 were quiet sick when they went DAMA.
Discussions
Improving the clinical outcomes for the victims of snake bite needs much more than just access to safe antivenoms. Antivenoms remain the only specific treatment that can potentially prevent or reverse most of the effects of snakebite envenoming when administered early in an adequate therapeutic dose. Patient brought to ED with neuroparalytic envenomation received CPR (2 cases) in our series, were later discharged in stable condition. Administered early, antivenoms are not just life-saving, but can also spare patients some of the suffering caused by necrotic and other toxins in snake venom, leading to faster recovery, and hence, should be protocolized.
The Furosemide stress test (FST) predicts the severity and the need for renal replacement therapy (RRT) in patients with sepsis-associated AKI (S-AKI). The renal resistive index (RRI) indicates renal vascular resistance.
Objectives
The primary objective was to find the correlation between FST and RRI in S-AKI. The secondary objectives were to evaluate the role of FST and RRI on the progression of S- AKI.
Materials and methods
A prospective observational cohort study in which a total of 154 consenting adult patients with S-AKI were administered FST. Renal echography was performed within the first 12 hours of admission, and RRI was calculated. The patients were grouped either into progressors or non-progressors to AKI-KDIGO stage 3.
Results
Of the patients who had RRI at Day 1 less than 0.73, 60% recovered,34.3% needed RRT, and 35.5% died, whereas in those who had RRI at Day 1 greater than 0.73, only 22 % recovered, 46.6% required RRT, and 51.6% died. RRI value of 0.73 predicted the need for RRT with a sensitivity of 35.1%, specificity of 80.4% and accuracy of 69.1%. The highest number of patients of KDIGO stage 3 (50%), followed by stage 2 (28.1%) and stage 1(21.9%), presented technical difficulties in measuring the RRI.
Conclusion
FST is an economical and easily administered test to assess renal tubular function and can predict the occurrence and progression of S-AKI. RRI is a modest marker for predicting the need for RRT or persistent AKI.
Reference
1.Das PK, Maurya SK, Nath SS, Kumar T, Rao N, Shrivastava N. Furosemide Stress Test and Renal Resistive Index for Prediction of Severity of Acute Kidney Injury in Sepsis. Cureus. 2023 Aug 30;15(8):e44408. doi: 10.7759/cureus.44408. [DOI] [PMC free article] [PubMed] [Google Scholar]
Comparing The Efficacy of Ceftazidime Avibactum Plus Aztreonam Therapy Versus Meropenem Polymyxin Combination Therapy for Gram Negative Sepsis by Metallo-Beta-Lactamase Producers in Intensive Care Unit
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Gram negative bacteria mainly CRE are an important cause of sepsis. Metallo-beta-lactamase (MBL)–producing Enterobacterales, are endemic in the Indian subcontinent [1] but are increasingly reported as cause of healthcare-associated infections in Europe and worldwide [2–6] Recognition of this condition and initiation of treatment thus merits a prompt, appropriate response and in turn results in reduction of proportional mortality rate. Inflammatory biomarkers have a major role in diagnosis of sepsis. Thus we did a study on comparing the efficacy of ceftazidime avibactam plus aztreonam versus meropenem polymyxin combination therapy for gram negative sepsis and prognostication of gram negative sepsis by the use of novel biomarkers like procalcitonin(PCT), CRP and neutrophil to lymphocyte ratio(NLR).
Objectives
The primary objective was to compare the cure rate among two groups by culture negative report and secondary objectives were 1. To observe the Procalcitonin (PCT) and CRP in both the groups. 2. To compare the neutrophil to lymphocyte ratio(NLR) in both the groups. 3. To determine the length of ICU stay in both groups.
Materials and methods
This was prospective open labelled randomised comparative trial in AICU of AIIMS, Jodhpur for a duration of 12 months. The patients of culture proven gram negative sepsis caused by MBL producers were randomized on receiving proven gram negative culture report and then culture reports were sent every 72 hours till negative. All patients were followed up until 28 days after the admission. Clinical data was collected within 24 hours after culture proven gram negative sepsis. Patient variables collected included age, sex, underlying diseases, previous antimicrobial therapy, mean arterial pressure, need for ICU admission, laboratory findings including WBC count, NLR, CRP, PCT, LFT, RFT and serum creatinine.
Results
A total of 40 patients were studied which was randomized into two groups, 26 were in ceftazidime avibactum and aztreonam group (CAZ+AVI+ATM group) and rest in the other group. The cure rate was higher in the CAZ+AVI+ATM group i.e. 22. The mortality rate was lower in CAZ+AVI+ATM group i.e. 4 patients died but the relapse rate, AKI rate was higher in polymyxin and meropenem group. The measured value of biomarkers was less in survival group compared to non survivors. The average length of stay was lower in CAZ+AVI+ATM group.
Discussions
The main discussion is CAZ+AVI+ATM has a favourable outcome and less relapse and complications rate than the other group. Even the level of biomarkers are less in the survival group and help in identifying its severity.
References
1.Snyder BM, Montague BT, Anandan S, et al. Risk factors and epidemiologic predictors of bloodstream infections with New Delhi metallo-b-lactamase (NDM-1) producing Enterobacteriaceae. Epidemiol Infect. 2019;147:e137. doi: 10.1017/S0950268819000256. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Voulgari E, Gartzonika C, Vrioni G, et al. The Balkan region: NDM-1-producing Klebsiella pneumoniae ST11 clonal strain causing outbreaks in Greece. J Antimicrob Chemother. 2014;69:2091–7. doi: 10.1093/jac/dku105. [DOI] [PubMed] [Google Scholar]
4.Galani I, Karaiskos I, Karantani, et al. Epidemiology and resistance phenotypes of carbapenemase-producing Klebsiella pneumoniae in Greece, 2014 to 2016. Euro Surveill. 2018:23. doi: 10.2807/1560-7917.ES.2018.23.30.1700775. [DOI] [PubMed] [Google Scholar]
5.Falcone M, Tiseo G, Antonelli A, et al. Clinical features and outcomes of bloodstream infections caused by New Delhi metallo-β-lactamase-producing Enterobacterales during a regional outbreak. Open Forum Infect Dis. 2020;7:ofaa011. doi: 10.1093/ofid/ofaa011. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Wu W, Feng Y, Tang G, Qiao F, McNally A, Zong Z. NDM metallo-β-lactamases and their bacterial producers in health care settings. Clin Microbiol Rev. 2019;3:e00115–18. doi: 10.1128/CMR.00115-18. [DOI] [PMC free article] [PubMed] [Google Scholar]
In-vitro Activity of Meropenem Against Escherichia Coli and Pseudomonas Aeruginosa Collected From Patients with Urinary Tract and Intra Abdominal Infections as Part of Atlas (India) Surveillance Program, 2018-2021
Meropenem has a broad spectrum of in vitro activity against Gram-positive and Gram-negative pathogens, including Enterobacterales and non-lactose fermenters. The present report evaluated the in-vitro activity of Meropenem against E.coli & P.aeruginosa for the urinary and intraabdominal isolates.
Methods
Total non-duplicate isolates of E.coli & P.aerugionsa from clinically significant UTI (N = 259) and intra-abdominal samples (N = 75) were collected between 2018-2021. Organisms were identified and susceptibility tested, by conventional methods. Susceptibility was confirmed at an IHMA (International Health Management Associates) laboratory using supplied broth microdilution panels (Microscan), according to CLSI guidelines, for meropenem.
Meropenem has shown overall good susceptibility against E.coli (>72%) and P.aeruginosa (>65%)in UTI and IAI in an ICU setting. However, there is a gradual decrease in carbapenem susceptibility among the ICU isolates which demands good stewardship practices to be in place as Meropenem is one of the main stay of antibiotics in an ICU setting.
Subclavian vein is cannulated using two techniques of subclavian vein catheterisation: supraclavicular (SC) and infraclavicular (IC). Though infraclavicular route is often preferred, supraclavicular approach offers several distinct advantages. This study was planned to compare the technique of subclavian vein catheterization using SC and IC approach in terms of catheterization technique and complications in elective surgery in adults.
Methods
Sixty ASA (American Society of Anaesthesiologists) 1, 2 or 3 adult patients posted for elective surgery under general anaesthesia were recruited. Patients were divided into SC or IC groups randomly. Right sided subclavian vein was cannulated in both the groups. Visualisation time, Likert scale, subclavian vein diameter, skin to subclavian vein depth, number of attempts, puncture time, ease of guidewire insertion, catheter insertion time and total procedural time were observed. A comparison of complications for each approach was made.
Results
Total procedural time, time to visualisation of subclavian vein, puncture time was lower for group SC and higher for group IC. Catheter insertion time was higher with infraclavicular approach as compared to supraclavicular approach. Better ultrasound view scores were seen in group SC than group IC. First attempt success rate was higher in group SC than group IC. Comparatively, lower complications both during and after procedure were noted in supraclavicular approach than infraclavicular approach.
Discussion
The results of our study suggest that supraclavicular (SC) approach for subclavian vein catheterization is superior to infraclavicular (IC) approach in terms of less time required for visualization, puncture and subsequent catheterization. Also, SC approach was associated with a superior view obtained due to lesser distance from skin and wider diameter as compared to the IC approach. The incidence of complications like difficult guidewire insertion and catheter malposition, arterial puncture, etc were comparable in the two groups. Ease of catheterization was assessed with the following parameters --- Visualisation time, puncture time, catheter insertion time, total procedural time, rating of best view obtained for subclavian vein using Likert scale, diameter of subclavian vein, skin to subclavian vein depth, number of attempts, ease of guidewire insertion, and success rate. The mean visualisation time, puncture time, catheterization time and total procedural time for supraclavicular group was significantly shorter as compared to the infra clavicular group (p < 0.05). This could be attributed to more superficial location of vein in supraclavicular approach, thereby, facilitating quicker entry. Also, in infra clavicular approach, needle travels comparatively greater distance through the pectoralis muscle and encounters hindrance from clavicle. This can make needling via ultrasound, technically, a more time-consuming procedure. Higher catheter insertion time could be related to proximity of the puncturing needle to clavicle causing difficulty in guidewire insertion. Bending of flexible guidewire while inserting catheters over guidewire was also commonly observed. Dense ligaments of clavicle or clavicle itself could have contributed to this problem. Additionally, guidewire confirmation took additional time in IC approach as the probe had to be moved to other areas to rule out guidewire misplacement in ipsilateral IJV or brachiocephalic vein.
Conclusion
USG guided supraclavicular approach to access subclavian vein is quicker, relatively secure and better technique than infraclavicular approach. Additionally, the supraclavicular approach is associated with comparatively lesser immediate and delayed complications.
1.Sondergaard S, Parkin G, Aneman A. Central venous pressure: we need to bring clinical use into physiological context. Acta Anaesthesiol Scand. 2015 May;59(5):552–60. doi: 10.1111/aas.12490. 25684176 Epub 2015 Feb 13. [DOI] [PubMed] [Google Scholar]
2.Deere M, Singh A, Burns B. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing; Jan–2023. Central Venous Access of the Subclavian Vein. 2023 Sep 4.29489182 [PubMed] [Google Scholar]
3.Ball M, Singh A. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing; Jan–2023. Care of a Central Line. 2023 Jul 31.33232068 [PubMed] [Google Scholar]
5.Adrian M, Borgquist O, Kröger T, Linné E, Bentzer P, Spångfors M, Åkeson J, Holmström A, Linnér R, Kander T. Mechanical complications after central venous catheterisation in the ultrasound-guided era: a prospective multicentre cohort study. Br J Anaesth. 2022 Dec;129(6):843–850. doi: 10.1016/j.bja.2022.08.036. 36280461 Epub 2022 Oct 22. [DOI] [PubMed] [Google Scholar]
6.Boulet N, Muller L, Rickard CM, Lefrant JY, Roger C. How to improve the efficiency and the safety of real-time ultrasound-guided central venous catheterization in 2023: a narrative review. Ann Intensive Care. 2023 May 25;13(1):46. doi: 10.1186/s13613-023-01141-w. 37227571;PMC10212873 Erratum in: Ann Intensive Care. 2023 Nov 25;13(1):117. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: the forgotten central line. West J Emerg Med. 2009 May;10(2):110–4. 19561831;PMC2691520 [PMC free article] [PubMed] [Google Scholar]
8.Prasad R, Soni S, Janweja S, Rajpurohit JS, Nivas R, Kumar J. Supraclavicular or infraclavicular subclavian vein: Which way to go- A prospective randomized controlled trial comparing catheterization dynamics using ultrasound guidance. Indian J Anaesth. 2020 Apr;64(4):292–298. doi: 10.4103/ija.IJA_930_19. 32489203;PMC7259420 Epub 2020 Mar 28. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Kim YJ, Ma S, Yoon HK, Lee HC, Park HP, Oh H. Supraclavicular versus infraclavicular approach for ultrasound-guided right subclavian venous catheterisation: a randomised controlled non-inferiority trial. Anaesthesia. 2022 Jan;77(1):59–65. doi: 10.1111/anae.15525. 34231204 Epub 2021 Jul 6. [DOI] [PubMed] [Google Scholar]
10.Mageshwaran T, Singla D, Agarwal A, Kumar A, Tripathy DK, Agrawal S. Comparative efficacy of supraclavicular versus infraclavicular approach of subclavian vein cannulation under ultrasound guidance: A randomised clinical trial. Indian J Anaesth. 2021 May;65(Suppl 2):S69–S73. doi: 10.4103/ija.IJA_1316_20. 34188258;PMC8191189 Epub 2021 May 10. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Souadka A, Essangri H, Boualaoui I, Ghannam A, Benkabbou A, Amrani L, et al. Supraclavicular versus infraclavicular approach in inserting totally implantable central venous access for cancer therapy: A comparative retrospective study. PLoS One. 2020 Nov 24;15(11):e0242727. doi: 10.1371/journal.pone.0242727. 33232361;PMC7685501 [DOI] [PMC free article] [PubMed] [Google Scholar]
The emergence of AI-based language learner models (LLMs) has revolutionized various fields, including healthcare. LLMs have demonstrated exceptional abilities in processing and understanding vast amounts of text data, raising the question of their potential in medical education and knowledge assessment. This study aims to explore the efficacy of LLMs in the critical care medicine domain, a complex and dynamic field requiring rapid decision-making and deep clinical understanding.
Aims and objectives
Evaluate the ability of LLMs to accurately answer multiple-choice questions (MCQs) and open-ended questions related to critical care medicine scenarios. Analyze the strengths and limitations of LLM responses in terms of reasoning, precision, and knowledge application. Compare the performance of LLMs with established benchmarks, such as medical textbooks or expert opinions, to assess their potential as a learning and assessment tool in critical care medicine.
Methods: Scenario selection
A diverse set of 39 clinical scenarios spanning various critical care subspecialties were carefully chosen to represent the complexities and challenges encountered in real-world practice. These scenarios were presented in a mix of MCQs with single-best answer choices and open-ended questions requiring detailed explanations. Data Collection: LLMs were prompted with the prepared scenarios and their responses were recorded for analysis. This could involve multiple LLMs to assess consistency and variation in performance.
Response evaluation
Each LLM response was evaluated by a panel of critical care physicians against established criteria, including accuracy, comprehensiveness, reasoning, and practical applicability. The scoring system and evaluation metrics should be clearly defined to ensure objectivity and reliability.
Benchmarking
LLM performance was compared to established benchmarks, such as textbook answers, expert opinions, or gold standards in critical care management. This comparison would allow for a more nuanced understanding of LLM strengths and weaknesses in the context of existing knowledge resources.
The AI model failed in basic management of certain clinical scenarios which can jeopardise the safety of the patient.
The differential diagnosis provided by LLM was exhaustive but not according to the most common cause & this can lead to unnecessary, inappropriate investigations and workup missing the common causes of the disease.
LLM had some difficulty in providing appropriate reasoning for data interpretation in an ICU and troubleshooting critical incidents.
LLM struggled with answering rare hypothetical critical care scenarios but provided adequate responses regarding ethics and communication, including conflict management.
Resuscitation of critically ill patients was not appropriate in certain clinical scenarios The unreliability in such situations is a very serious concern.
The LLM could provide Individual Scoring of disease conditions but struggled in calculation of scores of certain diseases and this can affect the prognostication of the diseases
Conclusion
This study represents a significant step forward in exploring the potential of AI-based language learner models (LLMs) for learning and assessment in critical care medicine. By evaluating LLM performance on diverse scenarios and comparing it to established benchmarks, the study provides valuable insights into their strengths and limitations. Strengths: Pioneering approach: This study is the first of its kind to investigate LLM efficacy in the complex domain of critical care medicine. Comprehensive assessment: The study examined LLM performance on various question formats, encompassing both factual recall and reasoning skills. Expert evaluation: Responses were evaluated by experienced critical care physicians, ensuring accuracy and clinical relevance. Findings: LLMs demonstrated promising capabilities in answering MCQs and open-ended questions with high accuracy and comprehensiveness. They excelled in providing ethical and communication-related responses, highlighting their potential for training in these crucial areas. However, limitations were identified in certain aspects, including: Management of specific scenarios: LLMs struggled with basic management in some cases, raising concerns about patient safety. Prioritization of differential diagnoses: Exhaustive but not prioritized differential diagnoses could lead to unnecessary investigations. Reasoning and data interpretation: LLM responses lacked detailed reasoning and troubleshooting skills in critical situations. Rare scenarios and resuscitation: LLMs performed poorly on rare scenarios and resuscitation protocols. Disease scoring: Limitations in calculating specific disease scores could affect prognostication. Overall: This study demonstrates the potential of LLMs for learning and assessment in critical care but also highlights areas requiring further development. Future research should focus on: Addressing identified limitations: Enhance LLM capabilities in critical scenario management, reasoning, and data interpretation. Incorporating image and waveform analysis: Integrate LLM with visual data analysis for a more comprehensive assessment. Testing advanced LLM versions: Evaluate the performance of newer and paid models for potential improvements. Expanding scenario scope: Include a wider range of critical care scenarios for a more generalizable assessment. By addressing these limitations and conducting further research, LLMs can evolve into valuable tools for enhancing critical care education, assessment, and ultimately, patient outcomes.
Chatgpt, BARD are supervised learning models and and as per terms of use, users have the right to reproduce text generated by ChatGPT during conversations and do not cause proprietary infringement.
References
1.Performance of ChatGPT on USMLE: Potential for AI-assisted medical education using large language models Tiffany H. Kung, Morgan Cheatham, Arielle Medenilla, Czarina Sillos, Lorie De Leon, Camille Elepaño, Maria Madriaga, Rimel Aggabao, Giezel Diaz-Candido, James Maningo, Victor Tseng. Published: February 9, 2023. [DOI] [PMC free article] [PubMed]
Comparison of High Flow Nasal Oxygen Therapy with High Flow Nasal Oxygen Therapy Plus Non-invasive Ventilation for the Management of Acute Hypoxemic Respiratory Failure in Post-operative Patients – A Pilot Randomized Control Study
The major causes of early postoperative respiratory failure include hypoxemia, diaphragmatic dysfunction and atelectasis due to postoperative alveolar collapse. Oxygen therapy delivered via face mask with reservoir bag is usually the first line treatment. HFNC provides benefit by giving warm and humidified gas flow at a low level of PEEP. There are studies showing decreased incidence of intubation with early attachment of HFNC. Currently it has become standard of care in acute hypoxemic respiratory failure. Sometimes alone it may not be sufficient, we hypothesized that HFNC along with NIV would be more effective on decreasing reintubation rate in adult postoperative surgical patients in hypoxemic failure. The present study will evaluate the effect of HFNC alone versus NIV plus HFNC on the reintubation rate, rate of escalation of respiratory support and clinical outcomes in postoperative adult surgical patients.
Objectives
The primary outcome was to compare the number of patients requiring reintubation in both the group. The secondary outcomes were to compare the rate of escalation of respiratory support and pulmonary complications.
Material and method
The study was approved by the institutional review board and registered in CTRI. Total 40 postoperative patients with an estimated Pao2/Fio2 (P/F) ratio of <300 was given either HFNC or HFNC plus NIV as first line respiratory support between June 2022 to November 2023. Patients were excluded if they had chronic respiratory failure without acute exacerbation. We collected the following baseline data: age, sex, APACHE 2 score and SOFA score. Variables are shown as the median (interquartile range) or number (percentage) of patients. Univariate analyses were carried out using the χ2‐test for categorical variables and the Mann–Whitney U‐test for continuous variables. Multivariable logistic regression analyses were carried out to determine the adjusted ORs.
Result
Total 40 patients completed the study. The mean age group in HFNC group alone was 40.51 ± 15.50 and the HFNC plus NIV group was 37.46 ± 13.42. Both the group were matched for the type of surgery. Out of 40, fifteen patients were from neurosurgery, eleven patients from gastro-surgery and, seven patients each from urological surgery and orthopedics. No patient in HFNC plus NIV group required reintubation while 30% patient in HFNC alone group required reintubation. Five patients in HFNC group who required intubation were subsequently extubated within 5.4 days. Three patients required prolonged intubation for more than a week and were extubated with bridge NIV. Four patients developed mortality, of which sepsis was diagnosed in three cases and in one case rebleed resulting in hypovolemic shock. 30-days mortality was significantly lower in combination group.
Discussion
In this study we analyzed efficacy of combination of NIV and HFNC for respiratory support. The benefit which combination would offer is by decreasing respiratory work of breathing and tidal volume augmentation. There are studies comparing NIV and HFNC with conflicting results. HFNC oxygen therapy was reported to decrease the work of breathing and minute ventilation without increasing tidal volume, probably due to its washout effect on the upper airway. The combination will provide both the benefits.
Conclusion
The combination of NIV and HFNC produced statistically decreased incidence of re-intubation in postoperative respiratory failure.
References
1.Nagata K, Morimoto T, Fujimoto D, et al. Efficacy of high‐flow nasal cannula therapy in acute hypoxemic respiratory failure: decreased use of mechanical ventilation. Respir. Care. 2015;60:1390–6. doi: 10.4187/respcare.04026. [DOI] [PubMed] [Google Scholar]
Ventilator associated pneumonia is the most common nosocomial infection diagnosed in the intensive care unit and in spite of advances in diagnostic techniques and management it remains a common cause of hospital morbidity and mortality in mechanically ventilated patients. Our aim was to compare the incidence of VAP in patients with unknown history of adherence to VAP care bundle vs patients in whom VAP care bundle has been followed strictly since intubation.
Method
This exploratory study was conducted after approval from the institutional ethical committee and 42 patients were randomly allocated into group O (patients who were intubated at some other hospital and is shifted to our ICU after receiving few days of mechanical ventilation) and group R(patients who will be intubated and put on mechanical ventilation in ICU of our hospital). Data analysis was done using R version 4.2.1.
Result
Incidence of VAP in group O was 42.85% as compared to group R was 16.67% (p<0.001), mortality in group O was 33.33% as compared to group R was 14.28% (p <0.040). Incidence of early onset VAP was 55.55% in group O and in group R 42.85%(P<0.036), late onset VAP was 44.44% in group O as compared to group R was 57.14(p <0.036). SOFA score between patient having VAP positive group O was 10.87±3.1 as compared to group R was 6.41±2.9 (p<0.003)and VAP negative score was 7.4±2.9 in group O as compared to group R was 6.24±3.2 (p<0.042). APACHE II score between survival in group O was 15.56±4.65 as compared to group R was 13.67±4.9 (p<0.033), between non survival in group O was 19.80±2.1 as compared to group R was 16.95±4.1 (p<0.039).
Conclusion
Reducing VAP suggesting that proper training and education have a fundamental role in implementation of VAP care bundle and it ultimately leads to decreased incidence of VAP as well as decreases ICU stay, morbidity and mortality. According to our findings, VAP care bundle compliance was high with proper education. When it came to assessment of the set of procedures, the six documented components demonstrated high compliance.
Critically ill patients in the ICU often requires accurate and timely predictions of potential complications to guide interventions and improve outcomes. Traditional machine learning (ML) models, while powerful, pose challenges due to their: Data dependency: Reliance on large, high-quality datasets, often unavailable in the real-time ICU setting. Computational burden: High resource requirements for training and deployment, limiting accessibility. Development complexity: Time-consuming development and adaptation to evolving clinical scenarios. In response, the potential of Language Learner Models (LLMs) as an alternative was investigated. These models offer several advantages. Knowledge representation: Ability to learn and process complex medical knowledge from diverse sources like text and databases. Accessibility: Ease of deployment and integration into existing clinical workflows. Rapid adaptation: Potential for rapid customization and refinement based on new data or changing clinical practices.
Aims and objectives
This study aimed to assess the feasibility of developing and deploying LLM chatbot-based predictive scoring systems for three common ICU scenarios compared to established AI models. Scenario-specific objectives included. VAP mortality prediction: Developing an LLM-based score to predict VAP mortality with high accuracy, sensitivity, and specificity. AKI prediction: Designing an LLM score for early and accurate prediction of AKI with high lead time and AUC. Delirium prediction: Implementing an LLM-based score to predict delirium onset with high positive predictive value to aid in timely preventive interventions. Methodology: LLM Selection: Bard and ChatGPT were chosen based on. Universal access: Free and universal access to all. Reasoning and explanation capabilities: Ability to explain predictions and justify reasoning, facilitating clinician trust and acceptance. Scoring System Development: Iterative Prompt Design: Specific prompts for each scenario were designed incorporating patient information, vital signs, and laboratory data. LLM Interaction and Refinement: Prompts were fine-tuned through iterative interaction with the LLMs, focusing on clarity, comprehensiveness, and predictive accuracy. Model Comparison:Benchmark AI Models: Established AI models with high ROC curves were selected for each scenario (e.g., logistic regression for VAP, XGBoost for AKI, recurrent neural networks for delirium). Performance Evaluation: LLM and AI machine learner model predictions were compared using appropriate Concordance and Discrepancy Analysis, Jaccard coefficients and other relevant measures to assess agreement and disagreement between LLM and AI machine learner model predictions.
The comparison between LLM chatbot-generated and established AI machine learning model parameters revealed a substantial overlap exceeding 75% across all scenarios (VAP, AKI, Delirium). This finding suggests that LLMs can effectively capture key predictive features for critical care scenarios, demonstrating their potential for accurate prediction. Notably, LLM chatbots achieved rapid predictive scoring within minutes, showcasing a significant advantage over the time-intensive development processes typically associated with traditional AI models. This rapid development cycle makes LLMs particularly promising for real-time critical care applications.
Discussion
This initial study demonstrates the promising potential of LLM chat models for disease prediction in critical care settings. Strengths: Novelty and Innovation: This study pioneers the exploration of LLM chatbots for predictive modeling in critical care, potentially leading to a paradigm shift in disease prediction. Rapid prototyping and development: LLMs demonstrated remarkable efficiency, generating predictive scores within minutes compared to the lengthy development cycles of traditional AI models. Accessibility and deployment: The ease of deployment and integration of LLMs into existing workflows makes them readily adoptable in resource-constrained settings. Focus on key predictors: The significant overlap between LLM and AI model parameters suggests LLMs can effectively capture critical factors for accurate prediction. Potential for Explainability: LLMs, unlike traditional black-box models, hold promise for providing explanations and justifications for their predictions, fostering trust and acceptance among clinicians.
Limitations
Preliminary stage: This is an initial study with a limited sample size, requiring further validation with larger patient cohorts and diverse clinical settings. Data dependence: LLMs rely on high-quality and comprehensive patient data, which might not be readily available in all critical care settings. Black-box aspects: While some LLMs offer explanations for their predictions, fully understanding their inner workings and potential biases remains a challenge. Clinical integration challenges: Integrating LLM-based scores into existing clinical practice requires addressing issues like user interface design, workflow adaptation, and clinician acceptance. Further Discussion points:Explainability and interpretability: Exploring ways to enhance the transparency of LLM predictions and build trust among clinicians is crucial for real-world implementation. Integration strategies: Developing practical strategies for integrating LLM-based scores into existing clinical workflows and decision-making processes is essential for successful adoption. Future research directions: Identifying promising research avenues for improving LLM performance, exploring new applications in critical care, and addressing ethical concerns will pave the way for future advancements.
Conclusion
While LLM chat models pose challenges in understanding their prediction mechanisms, their demonstrated capabilities in efficiently capturing key predictors and generating rapid scoring systems offer a promising avenue for revolutionizing disease prediction in healthcare. Future research should focus on: Validating these findings in larger patient cohorts across diverse clinical settings. Exploring the application of LLM chat models for predicting other diseases and clinical outcomes. Developing methods to improve the transparency and explainability of LLM predictions for enhanced clinician trust and acceptance.
References
1.NephrologyVolume 10 - 2023 |. Machine learning for acute kidney injury: Changing the traditional disease prediction mode Xiang Yu Yuwei Ji Mengjie Huang* Zhe Feng. [DOI] [PMC free article] [PubMed]
2.Liang Y, Zhu C, Tian C, et al. Early prediction of ventilator-associated pneumonia in critical care patients: a machine learning model. BMC Pulm Med. 2022;22:250. doi: 10.1186/s12890-022-02031-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Kirby D. Gong, Lu Ryan, Bergamaschi Teya S, Sanyal Akaash, Guo Joanna, Kim Han B, Nguyen Hieu T, Greenstein Joseph L, Winslow Raimond L, Stevens Robert D. Predicting Intensive Care Delirium with Machine Learning: Model Development and External Validation. Anesthesiology. 2023;138:299–311. doi: 10.1097/ALN.0000000000004478. [DOI] [PubMed] [Google Scholar]
Sensitivity of Ceftriaxone Sulbactam Disodium Edetate (Elores) In Extensively Drug Resistant Gram Negative Infections: Observational Data of 100 Culture Reports of a Tertiary Care Hospital
Antimicrobial resistance (AMR) is one of the major challenges that the intensivists face while treating critically ill patients. AMR leads to increased hospital stay, financial burden and mortality in these patients1. There are very limited antibiotics available to treat these drug resistant infections2.
Objectives
To understand the sensitivity and percentage of microbiological cure of extensively drug resistant (XDR) organisms to a novel molecule (ceftriaxone sulbactam disodium edetate) called as ELORES.
Materials and methods
This was a retrospective data collection conducted in an intensive care unit of a tertiary care hospital between February 2022 to August 2023. Data of all microbiological cultures which reported XDR organisms was captured. Patients who were initiated on ELORES were enrolled and the microbiological cure rate was calculated on the basis of subsequent cultures. The effect of the drug on various gram negative XDR organisms was also noted.
Results
A total of 72 patients were enrolled with total of 100 cultures. Out of these, 42 were Klebsiella pneumonia, 25 Escherichia coli, 18 Acinetobacter baumannii, 9 Pseudomonas aeruginosa, 4 Enterobacter cloace and 2 were Sphingomonas maltophilia. The site of cultures was divided as 24 blood cultures, 43 respiratory secretions culture, 26 urine culture and 7 were from bed sore cultures. All the cultures were sensitivity to colistin and polymyxin B (100%), 72 were sensitive to Fosfomycin (72%), 65 sensitive to tigecycline (65%). 98 samples were sensitive to ELORES (98%). Only two samples of Pseudomonas were resistant to ELORES. Out of the total culture reports, 70 cultures were treated with ELORES alone, 15 cultures were treated with a combination of ELORES and colistin and 5 cultures were treated with ELORES and tigecycline. 10 cultures were initiated on other combinations without ELORES. The microbiological cure rate was observed in 74 out of 90 cultures (82.2%). Standalone use showed a cure rate in 55 out of 70 patients (78.5%) whereas combination therapy had a cure rate in 16 out of 20 patients (80%).
Discussion
This study was carried out in only XDR category of infections and ELORES was found to be useful as it showed a high microbiological cure rate, both as a standalone treatment and as a combination regimen. Resistance of K.pneumoniae resistance to various antibiotics is a grave concern and there is no standard approach to tackle Klebsiella pneumoniae carbapenemase (KPC). ELORES seems to be a reasonable approach in these resistant strains. ELORES have shown high susceptibility to ESBL and MBL producing organisms3 due to synergistic activity of ceftriaxone, sulbactam and disodium edetate.
2.Boucher HW, Talbot GH, Bradley JS, et al. Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:1–12. doi: 10.1086/595011. [DOI] [PubMed] [Google Scholar]
3.Chaudhary M, Payasi A. A randomized, open-label, prospective, multicenter phase-III clinical trial of Elores in lower respiratory tract and urinary tract infections. Journal of Pharmacy Research. 2013;6:409–14. [Google Scholar]
The use of noninvasive ventilation (NIV) is common in patients with acute respiratory failure. However, the rate of NIV failure is high in this patient population, ranging from 40% to 65%. Furthermore, a two- to six- fold greater rate of mortality is seen in patients with NIV failure relative to that in patients with NIV success. Among patients with NIV failure, delayed intubation further increases the risk of death. The ratio of SpO2/FiO2 to respiratory rate (ROX) index was developed by Roca et al to predict the failure of HFNC.
Objectives
Primary objective: To determine ability of Ratio of Oxygen Saturation (ROX) index to predict NIV failure. Secondary objectives: To compare ROX index and HACOR score in predicting NIV failure.
Materials and methods
Study design: Prospective Observational Study. Study setting: Tertiary care setting – Department of Critical Care Medicine Intensive Care Unit (CCU), Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India. Study patients: Patients presenting to the intensive care unit with Type 1 Respiratory Failure initiated on NIV.
Inclusion criteria
Age more than 18 years.
Patients with Type 1 Respiratory failure only.
Exclusion criteria
Type II Respiratory Failure
Use of NIV after extubation
NIV after High Flow Nasal Cannula failure.
NIV after accidental extubation.
Pregnant patients.
Low GCS (<8)
Study method
After obtaining clearance from our Institutional Ethics Committee.
All patients presenting to the Critical Care Unit (CCU) initiated on NIV for Type 1- respiratory failure meeting the inclusion criteria, were included in the study.
Patient were followed up until they either get intubated or discharged from ICU. A decision to intubate a patient will be taken by the treating physician.
Patients who get intubated were placed in the NIV failure group, whereas patients who get discharged from ICU were placed in.
NIV success group
The two groups were compared on four variables, ie. initial RR, initial PaO2/FiO2 ratio, ROX and HACOR score at the end of 1 hour and 12 hours of NIV initiation.
The parameters mentioned above were used to determine whether NIV failure could be predicted using the ROX index as well as a particular value which can help in predicting it's failure.
Data collection was done with the help of pre-typed pro-forma.
Sample Size Calculation
Based on the result of mean and standard deviation (SD) of C-reactive protein level in NIV success group (79 ± 91) and NIV failure group (138 ± 113) observed in an earlier publication (Anders Bastiansen, Predicting failure of noninvasive ventilation in a mixed population. Journal of Anesthesia & Clinical Research 2014;5:378) and with 80% power and 95% confidence, the minimum sample size comes to 100 (50 in each group).
Results
A total of 50 patients fulfilling the inclusion criteria were included in the study, of which 50 (50%) were exclusively treated with NIV (NIV success group), and 50 (50%) required endotracheal intubation and mechanical ventilation (NIV failure group). NIV failure group had a higher mean initial RR compared with NIV success group. Mean initial PaO2/FiO2 ratio was also significantly lower in the NIV failure group Odds ratio for successful NIV treatment with a high initial RR and with a higher initial PaO2/FiO2 ratio.
Conclusion
Non-invasive ventilation failure could be predicted with information available at presentation in ED, and unnecessary delay in endotracheal intubation could possibly be prevented.
Reference
1.Duan J, Yang J, Jiang L, Bai L, Hu W, Shu W, Wang K, Yang F. Prediction of noninvasive ventilation failure using the ROX index in patients with de novo acute respiratory failure. Ann Intensive Care. 2022 Dec 5;12(1):110. doi: 10.1186/s13613-022-01085-7. 36469159;PMC9723095 [DOI] [PMC free article] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India, Phone: +91 9442733636, e-mail: rathishmanimohan@yahoo.com
1Department of Critical Care Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India, Phone: +91 9442733636, e-mail: rathishmanimohan@yahoo.com
2–4Department of Critical Care Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
Most weaning indices are either inaccurate or are dependent on complex ventilatory parameters, which are difficult to measure in resource-limited settings. This study aimed to determine the utility of the HACOR score and Lung Ultrasound score in predicting weaning outcome.
Objectives of the Study
Comparison of HACOR score versus Lung Ultrasound Score in predicting weaning outcome in patients with high risk for extubation failure.
Materials and methods
It was a Prospective Observational Study on 50 patients. HACOR score and Lung Ultrasound Score were evaluated after 30 minutes of Spontaneous Breathing Trial. The total duration of SBT was 60 minutes.
Results
Out of 50 Patients in the study, 25 had successful weaning and 25 had failed weaning. Median and Interquartile range of Lung Ultrasound score and HACOR score was 15 and 5 respectively in the failed weaning group and 13 and 4 in the successful weaning group. Lung Ultrasound Score >15 and HACOR score > 5 predicted failed weaning with sensitivity of 70% and 71% respectively.
Discussion
Weaning from MV is one of the most frequently encountered challenges in modern ICUs. Tools available for determining the optimal timing of weaning and prediction of its outcome are limited. LUS score has been validated to provide quantifiable comparable measures of progressive changes in aeration SBT is correlated with significant lung derecruitment as assessed by LUS score that was significantly higher in the failed weaning group (P: 0.001), with cut-off value ≥ 15 predicted weaning failure with a sensitivity 70%. Weaning failure can be influenced by confounders such as the severity of organ dysfunction, advanced age, comorbidities, prolonged duration of mechanical ventilation before SBT, and neurological impairment. Thus, we performed univariate and multivariable logistic regression analysis (including SOFA, and days of ventilator support prior to SBT), which showed that the HACOR score was independently accurate in predicting weaning failure. HACOR score of >5 predicted weaning failure with 78% sensitivity.
Conclusion
HACOR Score > 5 and Lung Ultrasound Score > 14 is an excellent predictor of weaning failure.
References
1.Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: Bedside lung ultrasound in critical care practice. Crit Care. 2007;11(1):205. doi: 10.1186/cc5668. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Soummer A, Perbet S, Brisson H, Arbelot C, Constantin JM, Lu Q, Rouby JJ, Lung Ultrasound Study Group Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress. Crit Care Med. 2012;40(7):2064–72. doi: 10.1097/CCM.0b013e31824e68ae. [DOI] [PubMed] [Google Scholar]
3.Llamas-Alvarez AM, Tenza-Lozano EM, Latour-Perez J. Diaphragm and lung ultrasound to predict weaning outcome: systematic review and meta-analysis. Chest. 2017;152(6):1140–50. doi: 10.1016/j.chest.2017.08.028. [DOI] [PubMed] [Google Scholar]
Correlation of Internal Jugular Vein and Inferior Vena Cava Collapsibility Index with Direct Estimation of Central Venous Pressure for Volume Status In Critically Ill Patients: An Observational Study
Early goal-directed therapy for establishing an optimum fluid state in patients with severe sepsis and septic shock has been shown to reduce morbidity and mortality.1 It has been found that clinical assessments of intravascular volume status in critically ill patients are unreliable, inaccurate, and lack precision.2 Intravascular volume assessment by direct central venous pressure (CVP) measurement is invasive, time-consuming, and labor-intensive procedure.3 Nowadays, it is common practise to employ noninvasive ultrasound guided assessment of internal jugular vein (IJV) or inferior vena cava (IVC) characteristics as a proxy to direct central venous pressure (CVP) measurement to assess the volume status of critically ill patients. Very few study has examined the relationship between invasively monitored CVP and point-of-care ultrasound imaging of the IJV and IVC to determine volume status.
Objective
To examine the strength of the association between invasive measurement of central venous pressure (CVP) and non-invasive measurement of collapsibility index (CI) of of internal jugular vein (IJV) and inferior vena cava (IVC) for evaluating the volume status.
Materials and methods
After Institute Ethical Committee approval and CTRI registration, this prospective observational study was carried out on 70 adult patients admitted to the Intensive Care Unit. Invasive CVP was recorded. With the patients lying supine at 0°, an intensivist trained in critical care ultrasound measured the maximum, minimum AP diameters, and cross-sectional area(CSA) of the right IJV. From these measurements, the corresponding CI was calculated. All of the aforementioned measurements were carried out once again at 30 head up position. Similarly, at the subxiphoid area, ultrasound-guided IVC maximum and minimum AP diameters and CSA were measured, and the corresponding CI was calculated. The measurements of the IJV and IVC indices were correlated with CVP.
Result
Seventy patients were enrolled, out of which 10 were excluded. The mean age was 51.21±10.32 years The CVP ranged from 3 to 18, with a mean of 9.33 mmHg. For CSA and AP diameter, the correlations between CVP and IJV-CI at 0° were r = -0.107 (P = 0.001) and r = -0.092 (P = 0.001). Correlations between CVP and IJV-CI at 30° for CSA and diameter, however, were (r = -0.109, P = 0.001) and (r = -0.117, P = 0.001), respectively. Also significantly correlated with CVP was IVC-CI (r = –0.503, P = 0.001 for CSA and r = -0.452, P = 0.001) for diameter.
Discussion
Our study demonstrated a significant correlation between CI of IJV and IVC with invasively monitored CVP. Our findings support Killu et al.[4] who looked at the IJV-diameter CI by bed side ultrasonography as a sign of hypovolemia in patients in the intensive care unit. Their conclusion was that hypovolemia might be linked to an IJV diameter CI of greater than 39%. Their research was different from ours in that they only measured the IJV diameter CI. In a similar study by Jassim HM et al.[5] invasively monitored CVP was used to measure the CI of IJV diameter and CSA at 0° and 30° positions. The data at 30° showed a more significant correlation than that at 0°where as our study found significant correlation at both position.
Conclusion
Quick assessment of intravascular volume status in critically ill patients by invasive measurement of CVP could be easily substituted by non-invasive assessment of IJV and IVC indices by bedside ultrasound.
References
1.Nguyen HB, Jaehne AK, Jayaprakash N, Semler MW, Hegab S, Yataco AC, Tatem G, Salem D, Moore S, Boka K, Gill JK, Gardner-Gray J, Pflaum J, Domecq JP, Hurst G, Belsky JB, Fowkes R, Elkin RB, Simpson SQ, Falk JL, Singer DJ, Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: insights and comparisons to ProCESS, ProMISe, and ARISE. Crit Care. 2016 Jul 1;20(1):160. doi: 10.1186/s13054-016-1288-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Saugel B, Ringmaier S, Holzapfel K, et al. Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary thermodilution-derived hemodynamic parameters in critically ill patients: a prospective trial. Journal of critical care. 2011;26(4):402–410. doi: 10.1016/j.jcrc.2010.11.001. [DOI] [PubMed] [Google Scholar]
4.Killu K, Coba V, Huang Y, Andrezejewski T, Dulchavsky S. Internal jugular vein collapsibility index associated with hypovolemia in the intensive care unit patients. Crit Ultrasound J. 2010;2(1):13–17. 36. [Google Scholar]
5.Jassim HM, Naushad VA, Khatib MY, Chandra P, Abuhmaira MM, Koya SH, Ellitthy MSA. IJV collapsibility index vs IVC collapsibility index by point of care ultrasound for estimation of CVP: a comparative study with direct estimation of CVP. Open Access Emerg Med. 2019 Apr 3;11:65–75. doi: 10.2147/OAEM.S176175. 31040727;PMC6452797 [DOI] [PMC free article] [PubMed] [Google Scholar]
Traumatic brain injury (TBI) is a major public health problem and is associated with short- and long-term adverse clinical outcomes, including disability and death. Neuroimaging with computed tomography (CT) of the brain is used to detect evidence of increased intracranial pressure (ICP) in settings where invasive ICP monitoring is not practiced. Transorbital ultrasound to measure the optic nerve sheath diameter (ONSD) is a noninvasive method to detect elevated intracranial pressure (EICP).
Objectives
The present study was undertaken to assess the utility of transorbital ultrasound to measure ONSD and predict EICP in patients with moderate to severe TBI compared with computed tomography (CT)-detected EICP.
Materials and methods
This prospective observational study was conducted at the department of Critical Care Medicine in a tertiary care hospital in eastern India. This study prospectively recruited 110 patients aged ≥18yr with moderate to severe TBI who were admitted to the critical care unit (CCU) between July 1, 2021, and December 31, 2022. EICP was defined by ONSD ≥5.5 mm.
Results
A total of 110 patients with moderate-to-severe TBI were recruited during the study period. The recruited patients were divided into two groups based on the CT evidence of EICP;1. CT positive (CTP) group: patients with evidence of EICP on CT brain scan;2. CT negative (CTN) group: patients with no evidence of EICP on CT brain imaging. A CT scan of the brain detected EICP in 58.2% of the patients (n = 64). An increased ONSD (≥ 5.5mm) by transorbital sonography was noted in 69.1% (n = 76) of the cohort, and a CT brain characteristic of EICP was present in 71% (n=54). Using the ONSD assessment, ten patients with positive CT brain features of EICP were missed. Of the patients with moderate to severe TBI, a significantly higher proportion of patients with CT-detected EICP had ONSD measurement ≥5.5mm compared with the CTN group. Furthermore, the mean ONSD of the CTP group (5.57 mm) was significantly greater than that of the CTN group (5.20 mm). The CTN group exhibited a significantly greater survival rate, 68.5% (n = 44) of the CTP group and 37% (n = 17) of the CTN group died before discharge. ONSD with a cut-off value of 5.5 mm had a sensitivity of 84.4% and a specificity of 65% with positive predictive value and negative predictive value of 70.0% and 69.0%, respectively for predicting CT-determined EICP.
Conclusion
Our study demonstrated that measurement of ONSD by transorbital ultrasound is a sensitive tool for predicting EICP in patients with moderate to severe TBI in the critical care unit. CT evidence of elevated ICP is a risk factor for reduced survival in patients with moderate to severe traumatic brain injury.
References
1.Taylor C. A, Bell J. M, Breiding M. J, Xu L. Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths - United States, 2007 and 2013. Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C.: 2002) 2017;66(9):1–16. doi: 10.15585/mmwr.ss6609a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Murray C.J, Lopez A.D. Global health statistics: a compendium of incidence prevalence and mortality estimates for over 200 conditions 1996.
3.Kim S. E, Hong E. P, Kim H. C, Lee S. U, Jeon J. P. Ultrasonographic optic nerve sheath diameter to detect increased intracranial pressure in adults: a meta-analysis. Acta radiologica (Stockholm, Sweden: 1987) 2019;60(2):221–229. doi: 10.1177/0284185118776501. [DOI] [PubMed] [Google Scholar]
4.Robba C, Santori G, Czosnyka M, Corradi F, Bragazzi N, Padayachy L, Taccone F. S, Citerio G. Optic nerve sheath diameter measured sonographically as non-invasive estimator of intracranial pressure: a systematic review and meta-analysis. Intensive care medicine. 2018;44(8):1284–1294. doi: 10.1007/s00134-018-5305-7. [DOI] [PubMed] [Google Scholar]
Serial monitoring of oxygenation in critically ill patients can help assess worsening of lung function in ARDS patients. Ventilatory Ratio, Ventilation Index and Oxygenation Index are useful parameters in predicting mortality in patients diagnosed to have ARDS and may be better than PaO2/FiO2 ratio and Murray Lung Injury Score in Predicting mortality.
Objectives
To assess how ventilatory ratio, ventilation index and oxygenation index can predict in hospital mortality of patients admitted with ARDS requiring invasive mechanical ventilation.
Materials and methods
Patients between 18 years and 75 years admitted to Medical and Surgical ICU between June and November 2023 with ARDS requiring invasive mechanical ventilation in were recruited. Ventilator parameters, like Mode of ventilation, FiO2, PEEP, Pplat, Driving Pressure, Respiratory rate, Tidal Volume, Minute ventilation and MAP along with ABG were recorded and Ventilatory ratio(V.R), Ventilation Index(V.I) and Oxygenation index(O.I) were calculated as below. Ventilation ratio (V.R) = (PaCo2 × Patients Minute Ventilation) ÷ (37.5 × 100 × Bodyweight). Ventilation Index (V.I) = (PaCO2 × peak airway pressure × respiratory rate)/1,000 Oxygenation index (OI) = (MAP × FiO2 × 100) ÷ PaO2. Ventilator days, total days of ICU stay and outcome were recorded. Mean and standard deviation were recorded separately between the survivors and non survivors and analysed.
Results
19 patients were recruited of which 10 were females and 9 males. Community acquired pneumonia was the commonest etiology. 18 of them got intubated on the day of ICU admission itself. There were 4 cases of mild, 7 moderate and 8 severe ARDS. 12 patients were discharged from the ICU and 7 were non survivors. The mean ICU stay among survivors was 10.9 days whereas it was 8.71 among non survivors. Mean Day 1 parameters among the survivors were recorded as oxygenation index(OI) =10.27 ±5.77, Ventilation ratio(VR) =1.66 ±0.69 and Ventilation Index (VI)= 25.91±9.13 whereas among non survivors, it was OI= 16.59 ±17.55, VR=2.22 ±0.71, and VI=36.9 ±21.98. The day 3 parameters among survivors were OI=8.87 ±6.46, VR=1.52 ±0.50, and VI=24.07 ±7.57 whereas among non survivors OI=14.84 ±4.58, VR=1.94 ±0.59 and VI=31.57 ±12.28.
Discussions
In our study, the Oxygenation index, Ventilation Ratio and Ventilation Index were significantly higher among the non survivors. Rsovac et al showed that a higher 3rd day Oxygenation Index was associated with a higher risk of mortality. Monteiro et al showed that patients with VR > 2 (median) at day 1 had a significantly lower 90-day survival compared to patients with VR ≤ 2; similar to our study. With such significant results in this pilot study, a larger sample sized study would help us delineate cutoffs of Oxygenation Index, Ventilatory Ratio and Ventilation Index above which higher risk of mortality could be predicted.
References
1.Monteiro, et al. The prognostic value of early measures of the ventilatory ratio in the ARDS ROSE trial; Critical Care. 2022;26:297. doi: 10.1186/s13054-022-04179-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Yingying Yang, et al. The relationship between ventilatory ratio (VR) and 28-day hospital mortality by restricted cubic splines (RCS) in 14,328 mechanically ventilated ICU patients; BMC Pulmonary Medicine. 2022;22:229. doi: 10.1186/s12890-022-02019-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Snežana Rsovac, et al. Third-Day Oxygenation Index is an Excellent Predictor of Survival in Children Mechanically Ventilated for Acute Respiratory Distress Syndrome; Risk Management and Healthcare Policy. 2020;13:1739–1746. doi: 10.2147/RMHP.S253545. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Daniela Ruy C Barros, et al. Association between oxygenation and ventilation index with the time on mechanical ventilation in pediatric intensive care patients; Rev Paul Pediatr. 2011;29(3):348–51. [Google Scholar]
Ballistocardiography is a technique of contactless monitoring of the body's basic vital parameters. (1) During left ventricular systole, downward acceleration of the blood through the aortic arch produces an upthrust of the body, and during diastole, as the flow in the descending aorta decelerates, there is a rebound effect which produces a downthrust of the body. (2) These subtle body displacements that occur in response to each heartbeat and breath are picked up by sensors that may consist of electromagnetic film, fibre optics or fiber Bragg grating. (3) These sensors are placed under the patients’ mattresses and transmitted wirelessly to a central monitor, which translates the signals into vital parameters using proprietary algorithms. (3).
Objectives
This study aimed to correlate basic vital parameters such as heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and temperature (Temp) as measured by a ballistocardiography device, against those measured by standard bedside monitors. The objective was to assess the reliability of the BCG in environments where round-the-clock bedside monitors are not feasible, such as in hospital wards and in patients’ homes.
Materials and Methods
This was a prospective observational study involving all adult patients admitted to the ICU of a tertiary care hospital, over a two-month period from March to April, 2023. Patients’ vital parameters including HR, RR, SBP, DBP, Spo2 and temperature were recorded, and mean arterial pressure calculated, simultaneously at four-hourly intervals using both BCG and Philips MP20 bedside monitors. Readings from the BCG were analyzed to assess deviation from the benchmark bedside monitor readings.
Results
A total of seventy-one patients were took part and about 900 readings of each parameter were obtained. There was a good correlation between BCG and bedside monitors in all seven parameters: HR (mean 86.9 vs 82.9 beats/min, p<0.001), RR (20.8 vs 19.6 cycles/min, p<0.001), SBP (124.8 vs 122.8 mm Hg, p<0.001), DBP (68.0 vs 67.7 mm Hg, p<0.001), Spo2 (96.2 vs 95.1 %, p<0.001), Temp (97.5 vs 96.9° F, p<0.001) and MAP (87.0 vs 85.3 mm Hg, p<0.001). BCG readings were not obtained in 44 out of the 900 corresponding monitor readings due to device failure.
Discussion
The concept of blood circulation producing body displacements and their measurement was proposed by Gordon as early as 1877. (5,6) This technology was largely abandoned as the earlier ballistocardiography devices were bulky and signal analysis was complicated and impeded by artefacts. (7) However, with the advent of computer learning and advanced electronics, the devices are now portable and wireless and allow for remote health monitoring without the need for trained personnel. The present study shows a close correlation between readings obtained by the BCG and standard bedside monitors. The main drawbacks noted was that the BCG device malfunctioned in about 44 (5%) out of the 900 readings.
Conclusion
Ballistocardiographic measurement of vital parameters allows for a reliable, contactless method of monitoring the personal health of patients, although with caution, as the devices may experience the occasional failure. The further addition of early warning alarms will further enhance their usefulness.
References
1.Brink M, Müller CH, Schierz C. Contact-free measurement of heart rate, respiration rate, and body movements during sleep. Behavior Research Methods. 2006;38:511–521. doi: 10.3758/BF03192806. [DOI] [PubMed] [Google Scholar]
2.Eblen-Zajjur A. A simple ballistocardiographic system for a medical cardiovascular physiology course. Adv Physiol Educ. 2003 Dec;27(1-4):224–9. doi: 10.1152/advan.00025.2002. [DOI] [PubMed] [Google Scholar]
3.Sadek I, Abdulrazak B. A comparison of three heart rate detection algorithms over ballistocardiogram signals. Biomedical Signal Processing and Control. 2021;Volume 70:103017,. ISSN 1746-8094. [Google Scholar]
4.Pinheiro E, Postolache O, Girão P. Theory and developments in an unobtrusive cardiovascular system representation: ballistocardiography. Open Biomed Eng J. 2010;4:201–16. doi: 10.2174/1874120701004010201. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Chen S, Tan F, Lyu W, Yu C. Ballistocardiography monitoring system based on optical fiber interferometer aided with heartbeat segmentation algorithm. Biomed. Opt. Express. 2020;11:5458–5469. doi: 10.1364/BOE.403086. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Giovangrandi L, Inan OT, Wiard RM, Etemadi M, Kovacs GT. Ballistocardiography--a method worth revisiting. Annu Int Conf IEEE Eng Med Biol Soc. 2011;2011:4279–82. doi: 10.1109/IEMBS.2011.6091062. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Elliott RV, Packard RG, Kyrazis DT. Acceleration ballistocardiography; design, construction, and application of a new instrument. Circulation. 1954 Feb;9(2):281–91. doi: 10.1161/01.cir.9.2.281. [DOI] [PubMed] [Google Scholar]
The development of ventilator associated pneumonia (VAP) is attributed to micro-aspiration of pooled secretions around endotracheal (ET) or tracheostomy tube (TT) cuff, leading to contamination of lower airways. The Society of Healthcare Epidemiology (SHEA), Infectious Diseases Society of America (IDSA) and Association for Professionals in Infection Control and Epidemiology (APIC) emphasize the use of tubes with subglottic secretion (SS) drainage ports to prevent VAP.1 However, due to conflicting data on duration of mechanical ventilation (MV) or mortality with use of tubes with SS drainage2 and limited data on microbiological concordance of SS and endotracheal aspirate (ETA)3, the quality of evidence for recommendation of ET or TT with SS drainage port remains moderate.
Objective
The primary objective was to study microbiological concordance between SS and ETA cultures in patients with invasive airway devices. The secondary objective was to carry out clinical surveillance for development of VAP in first week of MV.
Material and methods
This prospective observational study was conducted in 100 consenting patients admitted in our ICU after Institute's Ethics Committee approval (IEC-INT/2022/MD/90) and trial registration (CTRI/2022/04/041592). Immediately after ICU admission, the invasive airway devices (ETT or TT) were changed to the one with a SS drainage port. Paired samples (both SS and ETA) were sent on day 1, 4 and 7 to microbiology laboratory, where they were transcultured. Species identification was performed with matrix-assisted laser desorption/ionization time-of-flight (MALDI) mass spectrometry and in-vitro susceptibility was tested with Vitek 2 system. The SS and ETA were considered concordant or discordant based on isolated organisms and antibiotic sensitivity profile. Clinical surveillance for VAP was carried out according to CDC criteria for the first week of MV.
Results
A total of 197 paired samples were assessed. The concordant and discordant samples were calculated as a percentage of total number of paired samples. Descriptive analysis was carried out for additional data. The overall concordance of SS and ETA cultures was 71.5% (141 paired samples). Day-wise concordance was found to be 68%, 76.2% and 73.5% for D1, D4 and D7, respectively. Gram negatives were the most frequently isolated bacteria, with 125 (31.7%) samples reporting Acinetobacter baumannii. Amongst 18 patients clinically diagnosed with VAP during first week of MV, the concordance between SS and ETA was 73.5%, with day-wise concordance of 77.2%, 72.2% and 76.9% on D1, D4 and D7, respectively.
Discussion
A fairly high microbiological concordance was observed in SS and ETA samples obtained from patients with invasive airway devices and this high concordance persisted in patients developing VAP during the first week of MV.
References
1.Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022;43:687–713. doi: 10.1017/ice.2022.88. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Pozuelo-Carrascosa DP, Herraiz-Adillo A, Alvarez-Bueno C, et al. Subglottic secretion drainage for preventing ventilator-associated pneumonia: an overview of systematic reviews and an updated meta-analysis. Eur Respir Rev. 2020;29:190107. doi: 10.1183/16000617.0107-2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Bello G, Bisanti A, Giammatteo V, et al. Microbiologic surveillance through subglottic secretion cultures during invasive mechanical ventilation: a prospective observational study. J Crit Care. 2020;59:42–8. doi: 10.1016/j.jcrc.2020.05.013. [DOI] [PubMed] [Google Scholar]
To Compare the Effectiveness of Thiamine in Combination with Vitamin C and its Combination with Glutamine on Survival Outcome in Critically Ill Patients Admitted in ICU
To evaluate the effects of thiamine in combination with Vitamin C and glutamine in critically ill patients admitted to ICU.
Introduction
Critically ill patients have potential life-threatening physiological alterations, characterized by oxidative stress[1], which is a major promoter of systemic inflammation and organ failure due to excessive free radical production, depletion of antioxidant defenses. There is decreased levels of vitamin C and thiamine[2] due to escape to the interstitial compartment by capillary leakage, haemodilution, insufficient intake, and continuous renal replacement therapies[3]. Thiamine essential for cellular energy production and protects against tissue oxidative damage. Vitamin C, a potent antioxidant and essential cofactor for the biosynthesis of catecholamine, vasopressin and augments vasopressor responsiveness. Glutamine is necessary to modulate the inflammatory and oxidative stress.
Material and methods
The research was carried out after obtaining approval from the institutional ethical committee. A total of 60 patients, aged between 18 and 65 years, admitted to the ICU, were enrolled in the study, and written informed consent was obtained from each participant. The patients were divided into two groups, labelled as groups I and II, each comprising 30 individuals. Group I received thiamine (1-2mg/kg/day IV) and vitamin C (1gm twice daily), while group II was administered thiamine (1-2mg/kg/day IV) and glutamine (0.3-0.5g/kg/day IV). Various parameters such as the duration of ICU stay, the impact on SOFA score, mortality rate, and the number of ventilation-free days were assessed, and the data was compared between the two groups.
Results
The mean age (58.3±14.1 years vs 62.2±14.3 years, P>0.05) and the distribution of sex (male/female: 53.3%/46.7% vs 50%/50%, P>0.05) were similar between the two groups. The average duration of ICU stays for patients in group I was 9.87±8.32 days, while it was 9.50±6.11 days in group II (P>0.05). Both groups exhibited a significantly improved SOFA score when comparing within the group (8 vs 3, P<0.001); however, there was no significant difference in the mean SOFA score when comparing between the two groups (3 vs 3, P>0.05). In group I and group II patients, the incidence of ICU mortality was 20% (n=6) and 23.33% (n=7), respectively, while the incidence of hospital mortality was 23.33% (n=7) and 26.67% (n=8), respectively. The mean ventilation-free days were comparable between the groups (15.2±32.22 days vs 15.9±34.28 days, P>0.05).
Conclusion
The findings of the study suggest that the combination of thiamine with Vitamin C or glutamine has comparable effects on the assessed parameters, including ICU stay duration, SOFA score, mortality rates, and ventilation-free days. Further research with a larger sample size and diverse patient populations is recommended to validate and extend these findings.
Acute Kidney Injury(AKI) is a common and serious condition that affects kidney function and other organs. AKI can be caused by various factors, such as low blood flow, infection, or direct damage to the kidneys. AKI can lead to multi-organ dysfunction and high mortality. One of the challenges in treating AKI is to balance the fluid status of the patients, as both fluid overload and fluid depletion can be harmful. Ultrasound can be a useful tool to assess the fluid status and guide fluid therapy in AKI patients. AKI is a very common condition in critically ill patients admitted to ICU and it independently increases morbidity and mortality of the the patients.
Objectives
Primary objective is to compare the 28 days all-cause mortality rates in control and study groups. Secondary objectives are to compare the fluid balance, P/F ratios, diuretics, length of ICU stay.
Materials and methods
The study was carried out in the ICU of a tertiary care hospital and compared two groups of patients with acute kidney injury (AKI), who received different fluid and vasopressor management strategies. One group (control group) received standard care, while the other group (study group) received lung and cardiac ultrasound guided care. The ultrasound parameters, such as B-line score, IVC diameter, and IVC collapsibility index, were used to assess fluid status and guide fluid removal or administration.
Results
22 out of 50 (44%) patients survived in study group, 15 out of 50 (30%) patients survived in the control group. Differences in mortality in study and control group were statistically not significant (p=0.147). There was a significant difference in fluid intake between the control group (Mean fluid intake of 2038ml) and in study group (mean fluid intake of 1782ml) (p= 0.02), with positive fluid balance in control group mean of 1448ml and in study group had mean 1046ml (p=0.006). There was a significant decrease in respiratory support (p=0.005), and a significant improvement in P/F ratios (p=0.01).
Conclusion
The use of lung and cardiac ultrasound for fluid management in AKI in ICU patients shows improved outcomes in terms of mortality, fluid balance, and P/F ratios.
Discussion
The results of the study, such as mortality, creatinine level, p/f ratio, fluid balance, respiratory support, Glasgow Coma Scale (GCS), renal replacement therapy (RRT), and ICU length of stay. There was no significant difference in mortality between the two groups, but group 2 had better outcomes in terms of creatinine level, p/f ratio, fluid balance, respiratory support, and GCS. There was no significant difference in RRT and ICU length of stay between the two groups.
Reference
1.Mehta S, Chauhan K, Patel A, Patel S, Pinotti R, Nadkarni GN, Parikh CR, Coca SG. The prognostic importance of duration of AKI: a systematic review and meta-analysis. BMC Nephrol. 2018 Apr 19;19(1):91. doi: 10.1186/s12882-018-0876-7. 29673338;PMC5907696 [DOI] [PMC free article] [PubMed] [Google Scholar]
Correlation of Platelet-Lymphocyte Ratio(Plr) with APACHE 2 Score in Patients with Sepsis and Septic Shock Admitted to Medical ICU. A Prospective Observational Study
Two important factor for pathophysiology and mortality of sepsis are inflammation and antiflammation. As first line inflammatory marker platelet increases during early phase of infection. Disrupted balance between inflammation and antiinflammation causes decrease in lymphocyte. Therefore platelet lymphocyte ratio (PLR) may have an effect as a biomarker in sepsis, which is easily accessible. APACHE 2 is a validated tool in predicting mortality in sepsis with septic shock, but demand several parameter into consideration which is difficult in resource limited setup.
Objective
Correlation between PLR and APACHE 2 and prognostic role of PLR in 28 day mortality outcome in sepsis with septic shock.
Methods
The study is a prospective observational single centre design conducted on 100 patients of sepsis with septic shock at Fortis Escorts Heart Institute between dec 2022 to dec 2023. Data analysed using karl pearson corelation between PLR and APACHE 2 and ROC curve analysis.
Results
The result found 22 patients died in 28 days out of total 100 patients. Karl Pearson correlation analysis “r” between PLR and APACHE2 (r = + 0.38) shows moderate positive correlation. The study reported PLR cut-off point of >33475. The sensitivity and specificity of PLR as 28-days sepsis mortality predictor are 81.8 % and 52 % respectively. AUC of ROC is 0.757.
Conclusion
PLR can be an alternatively reliable mortality predictor in sepsis with septic shock patients, accounted to its relatively high sensitivity and moderate specificity.
Keywords
Platelet, Lymphocyte, PLR, Sepsis with septic shock, 28 days mortality, APACHE 2
References
1.Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive care medicine. 2017 Mar;43(3):304–77. doi: 10.1007/s00134-017-4683-6. [DOI] [PubMed] [Google Scholar]
2.George AA, Thomas TP, Praseeda I. The Relevance of Platelet Count and Platelet Lymphocyte Ratio in Sepsis--A Retrospective Study. Journal of Evolution of Medical and Dental Sciences. 2021 Jan 25;10(4):199–203. [Google Scholar]
3.Shen Y, Huang X, Zhang W. Platelet-to-lymphocyte ratio as a prognostic predictor of mortality for sepsis: interaction effect with disease severity—a retrospective study. BMJ open. 2019 Jan 1;9(1):e022896. doi: 10.1136/bmjopen-2018-022896. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Wang G, Mivefroshan A, Yaghoobpoor S, Khanzadeh S, Siri G, Rahmani F, Aleseidi S. Prognostic Value of Platelet to Lymphocyte Ratio in Sepsis: A Systematic Review and Meta-analysis. BioMed Research International. 2022 Jun 6:2022. doi: 10.1155/2022/9056363. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Fateminayyeri M, Manavifar M, Hosseini S, Madanitorbati F, Moradi EV, Hashemian AM. Value of platelet to lymphocyte ratio in predicting in-hospital death of patients with sepsis. Annals of the Romanian Society for Cell Biology. 2021 May;5:2252–9. [Google Scholar]
Neonatal Septicemia is a clinical syndrome which occurs in the first 28 days of life with symptomatic systemic illness due to infectious agents and is major cause of neonatal morbidity and mortality worldwide. Blood culture and sepsis screening are currently used method, but their utility is limited due to delayed reporting and increased cost and limited resources. Platelet indices are one such set of parameters which can be helpful in the future diagnosis of neonatal sepsis2.
Objectives
This study was aimed to evaluate the significance of platelet count either alone or in combination with existing sepsis screen as a marker of neonatal sepsis.
Materials and methods
This study was conducted over a period of two years at shri Bhausaheb hire medical college Dhule. By a cross sectional descriptive study primary data was collected from detailed case history of neonates undergoing treatment for neonatal sepsis in NICU after an informed consent. Neonates with confirmed as well as probable sepsis were included in the study.
Results
Among 180 cases, culture proven sepsis was present in 8 neonates. Gram positive sepsis occurred in 2 neonates (25%) and Gram negative sepsis in 6 cases (75%). Thrombocytopenia was present in 60% and Thrombocytosis in 2% cases. Culture positive neonates had high prevalence of thrombocytopenia. Thrombocytopenia was also found to be highly prevalent (74.6%) in CRP positive cases. The duration of hospital stay was also higher in neonates with thrombocytopenia (3 fold higher than with neonates with normal platelet count). 80% of the neonates with thrombocytopenia needed higher antibiotics for the management. There was statistically significant difference in mean platelet count on day 1, day 3 and day 7 of sepsis among culture positive and culture negative neonatal sepsis. High mortality was found in moderate to severe thrombocytopenic neonate.
Discussion
Thrombocytopenia was more common than thrombocytosis in neonatal sepis. Prevalence of thrombocytopenia was significantly high in culture proven sepsis (87.5%). A definitive diagnosis of neonatal sepsis can be made only with a positive blood culture3. However, it may yield false positive results due to contamination or negative results even with severe infection. The earliest signs of sepsis are often subtle and non specific indeed a high index of suspicion is needed for early diagnosis. Thrombocytopenia is a common complication in neonatal sepsis. So, platelet count can be used may be combined with existing sepsis screen as early diagnostic and prognostic bio marker for neonatal sepsis4.
2.Nilay Ranjan Bagchi. A prospective study on reliability and effectiveness of different hematological parameters for early diagnosis of neonatal sepsis in a tertiary care hospital of sub-Himalayan region. Asian Journal of Medical Sciences. 2022 Nov 1;13(11):110–4. [Google Scholar]
3.Behrman RE, Kaliegman RM, Jenson . Stanton: Infections of neonatal infant Nelson Textbook of Pediatrics. 18th ed, Philadelphia, PA: W. B. Saunders; 2007. [Google Scholar]
1Department of Anaesthesiology, Insititute of Medical Sciences Banaras Hindu University, Varanasi, India, Phone: + 91 6290582998, e-mail: subhadippalchowdhuryspc@gmail.com
1Department of Anaesthesiology, Insititute of Medical Sciences Banaras Hindu University, Varanasi, India, Phone: + 91 6290582998, e-mail: subhadippalchowdhuryspc@gmail.com
2–4Department of Anaesthesiology, Insititute of Medical Sciences Banaras Hindu University, Varanasi, India
Central venous catheters (CVCs) are widely used in the management and resuscitation of critically ill patients in emergency departments (ED) and intensive care units (ICUs). Correct depth of insertion of the CVC line is very important to ensure good and uninterrupted flow to avoid complications and to monitor central venous pressure. Transthoracic echocardiography (TTE), with contrast enhancement (CE), has been proposed as an alternative to CXR in detecting CVC positioning with high accuracy. Nevertheless, TTE-CE is not widely used also considering some previous conflicting results and only a comparison between TTE and CXR has been reported.
Aim and Objective
Study Objective: To compare Transthoracic Echocardiography and landmark-based technique for accurate central venous catheter (CVC) insertion depth.
Aim
To assess different techniques for confirming CVC placement and insertion depth, optimizing resource utilization, enhancing precision, minimizing complications, reducing time lag, and eliminating radiation exposure hazards.
Material and methods
After the approval of the study by the Institutional Ethical Committee this prospective observational study was carried out in patients for whom CVC was warranted. The study was conducted in the Intensive Care Unit, Department of Anaesthesiology, IMS, BHU, Varanasi. This study was carried out on 150 adult patients from January 2021 to September 2022 to compare Transthoracic Ehocardiography and Landmark-based technique for the correct depth of insertion of a central venous catheter.
Result
In the study, we found that the mean age for group E was 44.06 years and for group L it was 46.85 years. The majority (56% vs 78.67%) of patients were of age 41-60 years. Here we found that the majority (60%) of patients in Group E and 58.6% of patients in Group L were male. The mean weight for group E was 68.4kg and for group L it was 69.05kg. In the study majority (100%) of patients had right IJV insertion.
Conclusion
It is concluded that the RASS technique if comes into regular use, it could potentially eliminate the radiation exposure associated with CXR. With the use of this technique, we can also confirm CVC's position in pregnant women and another group of the population where x-ray cannot be done. onfirms that the application of the unconventional RASS technique in confirmation of CVC position can minimize the resources and also can hasten the process of initiation of the management of the diseased as per requirement on time, which is not the case in landmark technique which requires chest x-ray confirmation of CVC before initiation of its use.
Discussion
It is a study that compared ultrasound (US) and chest X-ray (CXR) for central venous catheter (CVC) placement and complications. The study found that US was highly specific for CVC malposition and pneumothorax (PTX), and that these complications were rare. The study also found that US guided fluid management and CVC depth better than CXR. The study concluded that US could reduce the need for CXR after CVC placement, saving cost, time and resources.
Reference
1.Ultrasound - Guided central venous catheter placement: a structured review and recommendations for clinical practice, Bernd Saugel, Thomas W.L. Scheeren & Jean-Louis Teboul. [DOI] [PMC free article] [PubMed]
1Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College & Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
1Department of Anaesthesiology and Critical Care, Jawaharlal Nehru Medical College & Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2Department of Anaesthesiology and Critical Care, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3Department of Cardiology, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to infection. It can lead to cardiac dysfunction resulting in adverse outcomes. Sepsis induced cardiomyopathy is defined traditionally as intrinsic and reversible systolic and/or diastolic dysfunction characterised by left ventricular dilatation, reduced ejection fraction and recovery in 7-10 days. This can be identified by Echocardiography and an early intervention can be planned to deal with the adverse outcomes.
Objectives
To determine the prevalence of SICM and its effect on mortality and morbidity in the patients admitted in the ICU with sepsis.
Materials and methods
Prospective observational study was conducted on 10 adult patients who were admitted to an ICU with sepsis. Echocardiography was performed after 48 hours to establish cardiac dysfunction. On the basis of the echocardiography findings, 2 groups were defined: Group I – with LV dysfunction and Group II – without LV dysfunction. The clinical outcomes of such patients was analysed in terms of need and duration of mechanical ventilation, duration of ICU stay and ICU mortality.
Results
The prevalence of LV dysfunction among patients with sepsis is found to be 20%. In patients without LV dysfunction (group I), the average days of mechanical ventilation was 4.6 days, whereas in patients with LV dysfunction (group II), it was 7.3 days. The mean duration of ICU stay was 8 days in group I as compared to 11 days in group II.
Conclusion
From our observation, we concluded that sepsis induced cardiomyopathy is quite prevalent and significantly influences the outcome of such patients.
References
1.Bansal S, Varshney S, Shrivastava A. A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit. Indian J Crit Care Med. 2022 Jul;26(7):798–803. doi: 10.5005/jp-journals-10071-24204. 36864876;PMC9973190 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3) JAMA. 2016;315(8):801–10. doi: 10.1001/jama.2016.0287. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Parker MM, Shelhamer JH, Bacharach SL, et al. Profound but reversible myocardial depression in patients with septic shock. Ann Intern Med. 1984;100:483–90. doi: 10.7326/0003-4819-100-4-483. [DOI] [PubMed] [Google Scholar]
4.Sato R, Nasu M. A review of sepsis-induced cardiomyopathy. J Intensive care. 2015;3:48. doi: 10.1186/s40560-015-0112-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Flesch M, Kilter H, Cremers B, et al. Effects of endotoxin on human myocardial contractility involvement of nitric oxide and peroxynitrite. J Am Coll Cardiol. 1999;33:1062–70. doi: 10.1016/s0735-1097(98)00660-3. [DOI] [PubMed] [Google Scholar]
Role of thiamine and ascorbic acid (AA) in septic shock remains controversial as we find conflicting results. To evaluate the effect of thiamine and AA on mortality, SOFA score, duration and dose of vasopressor support and need for renal replacement therapy (RRT) in patients with septic shock with refractory hypotension.
Methods
Consenting adult ICU patients of septic shock with refractory hypotension were included in this prospective, double blind, randomized control study. Patients were divided into three groups: Group A received 100 ml of balanced salt solution eight hourly, Group B received 2mg/kg of thiamine eight hourly, Group C received 25mg/kg of AA eight hourly. Patients received respective medication along with hydrocortisone for 72 hours. Following parameters were analysed: Serum lactate, dose & duration of vasopressor support, SOFA score, need for RRT and outcome.
Results
SOFA Score was significantly lower in Group B whereas it was comparable in Group A and C at 24, 48 and 72 hours. Dosage of norepinephrine was lower in Group B at 66 hours and thereafter, whereas in Groups A and C it was comparable at all time points. Mortality in Group B (28%) was significantly lower, whereas in Groups A (60%) and C (48%) it was comparable. The need for RRT was significantly lower in group B(44%) compared to the control group (88%), but comparable in Group C(76%).
Conclusion
Thiamine supplementation resulted in earlier correction of organ dysfunction, reduced need for RRT and mortality benefit in patients with septic shock whereas ascorbic acid supplementation did not demonstrate any beneficial role.
Discussion
This is the first study that compared individually the efficacy of two inexpensive and readily available agents with a clinical safety profile in ameliorating the ill effects of septic shock.
Bedside Transcranial Doppler for Early Detection of Neuro-Worsening in Head Injury Patients Receiving Mechanical Ventilation: A Prospective, Observational Trial From Level I Trauma Centre
1Department on Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India, Phone: +91 9811911223, e-mail: Khurana.bisman@gmail.com
1Department on Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India, Phone: +91 9811911223, e-mail: Khurana.bisman@gmail.com
2,3Department of Anesthesia and Intensive Care, Post Graduate Institute Of Medical Education and Research, Chandigarh, India
Traumatic brain injury(TBI) is associated with increased morbidity and mortality worldwide. Direct intracranial pressure (ICP) monitoring is considered the gold-standard modality for monitoring patients with severe TBI, but is invasive, not readily available and less-commonly used, especially in low and middle-income countries. Transcranial doppler (TCD), a non-invasive assessment tool for the evaluation of cerebral hemodynamic and blood flow velocities, can be repeatedly and conveniently used in patients admitted in Intensive Care Units (ICU). TCD remains an underutilised tool for bed side neuro-monitoring in patients with severe TBI for early detection of neuro worsening.
Objectives
We conducted this study to evaluate the incidence of Pulsatility Index (P.I) more than 1.4 on TCD findings and neuro worsening in patients with severe traumatic brain injury.(1) As secondary outcome, we assessed functional status and orientation at 3 months using extended Glasgow outcome scale (GOSE).
Materials and methods
Patients with severe head injury admitted for conservative management were enrolled in the study. All patients received standard management as per Brain trauma foundation guidelines for the early management of critical head injury.(2) Invasive ICP was an exclusion criteria. A total of 45 patients between the age of 18-65 years were subjected to a baseline TCD exam addition to clinical and radiological examination. Patients with raised ICP defined as P.I >1.4 received interventions according to the TCD findings. Patients were followed up at 3 months for outcomes using Extended Glasgow Outcome Scale (GOSE) score.
Results
Amongst the 45 patients majority of patients had a normal TCD pattern (N= 37; 82.3%) and raised ICP was noted in eight patients (17.7%). In patients with raised a P.I >1.4, therapeutic interventions were performed to meet the targets to lower ICP. Sedation was increased with propofol in all patients. Mannitol or hypertonic saline was administered in all eight patients with an abnormal TCD to lower the ICP. Four patients improved with these interventions and reverted to having a normal TCD pattern. The 4 patients who were refractory to pharmacotherapy underwent early neurosurgical procedures including decompression craniotomy (n=3) and external ventricular drain placement (n=1) based on higher TCD values. The prognosis of one patient was deemed unfavourable due to uncorrected hypoperfusion and refractory ICH. Outcome was assessed using GOSE at 3 month, 24 patients (80%) had good outcome (GOSE 5-8), 6 patients (20%) had poor outcome (2-4) and 13 deaths were reported. Amongst the 8 patients with an P.I >1.4, 3 patients had a good outcome (GOSE 5-8), 2 patients had a poor outcome (GOSE-2-4) and 3 deaths were reported.
Conclusion
TCD based algorithm may prompt early therapeutic interventions in the absence of invasive ICP monitoring in patients with severe head injuries on conservative management. The study opens another avenue of bedside point of care ultrasound in critically head injuries in developing nations where measurement of ICP is not a regular feature.
References
1.Bellner J, Romner B, Reinstrup P, Kristiansson KA, Ryding E, Brandt L. Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP) Surg Neurol. 2004;62(1):45–51. doi: 10.1016/j.surneu.2003.12.007. [DOI] [PubMed] [Google Scholar]
2.Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017;80(1):6–15. doi: 10.1227/NEU.0000000000001432. [DOI] [PubMed] [Google Scholar]
In recent times it's been observed that, cases of myocardial infarction among young age group has been on rise. Risk factor profiles and prognosis may be different in young patients as also the consequences of MI in young patients may be more devastating having a larger economic and social impact as productive years of life at risk are higher in number. Compared to older MI patients, younger are more likely to be men, have familial-combined hyperlipidaemia, are more likely to be smokers, obese, and have poor lifestyle, desk jobs, and stressful work environment with decreased physical activity. Therefore we decided to take up this study so that we have a better understanding of the risk factors in young adults which can help us improve MI prevention and treatment strategies in this patient group. Awareness could help identify young subjects at increased risk and guide primary prevention strategies.
Objective
To find major risk factors attributing to Myocardial infarction in young patients (20 – 50 years)
To look for the trend of CAG findings among young patients.
Material and methods
All charts of patients with acute MI who met 4th Universal definition criteria for MI, 20181 &, who were admitted to Noble Hospital & Research centre, Pune from March 2023 to August 2023 were reviewed. Of which, 40 patients in age group of 20 – 50 years were found to meet our study criteria. Chart review yielded pertinent history about risk factors for ischemic heart disease, previous angina pectoris, and physical activity at the onset of MI. Persons were classified as non-smokers only if they had never smoked. Hypertension was considered to be present if the patient was on antihypertensive medication on admission. A family history of coronary artery disease was defined as any first-degree relative younger than 50 years who had angina pectoris or MI. Obesity was defined as BMI greater than 30 kg/m2. Hyperlipidaemia was defined as history of Dyslipidaemia diagnosed and/or treated by a physician or total cholesterol to HDL ratio > 4.5. All patients were subjected to coronary angiography during the index admission. Significant stenosis was defined as more than 50% stenosis in any of the coronary arteries, insignificant disease as less than 50% stenosis or plaques in any of the coronary arteries.
Results
Male dominance, 37 males & 3 females.
Hypertension turned out to be the most common Risk factor (46%).
Most common Lethal combination of risk factor was Hypertension & Smoking (43%).
(47.5%) were found to be pre obese & (35%) found to be obese.
Hyperlipidaemia was found in around (70%) of population.
(45%) were found to have HbA1c > 6.5%.
(32%) were found to have anterior wall MI on ECG.
(37.5%) of the patients had single vessel disease, (25%) had double vessel disease & (12.5%) had triple vessel disease.
Majority (53%) had LAD involvement.
Majority (58%) had target oriented desk job.
Conclusion
Hypertension, Smoking, Hyperlipidaemia, poor BSL control, and physical inactivity were found to be major contributors in young age MI.
LAD involvement was a major finding on CAG.
References
1.Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD. Executive Group on behalf of the Joint European Society of Cardiology (ESC)/ American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018) J Am Coll Cardiol. 2018;72:2231–2264. doi: 10.1016/j.jacc.2018.08.1038. [DOI] [PubMed] [Google Scholar]
2.Egred M, Viswanathan G, Davis GK. Myocardial infarction in young adults. Postgraduate medical journal. 2005 Dec;81(962):741–5. doi: 10.1136/pgmj.2004.027532. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Enas EA, Mehta JL. Malignant coronary artery disease in young Asian Indians: thoughts on pathogenesis, prevention and treatment. Clin Cardiol. 1995;18:131–5. doi: 10.1002/clc.4960180305. [DOI] [PubMed] [Google Scholar]
4.Curren PJ, Chung EH, Chauhan MS. Metabolic syndrome: an under recognized risk factor for myocardial infarction in the young. (Abstract) J Am Coll Cardiol. 2004;43:249A. [Google Scholar]
5.Bhatnagar D, Anand IS, Durrington PN, et al. Coronary risk factors in people from Indian sub-continent living in West London and their siblings in India. Lancet. 1995;345:404–9. doi: 10.1016/s0140-6736(95)90398-4. [DOI] [PubMed] [Google Scholar]
Acute Kidney Injury (AKI) is one of the severe complications that develop following cardiac surgery. Incidence of AKI following cardiac surgery has been found to be in the range 8.9% to 42.5%1. Various factors have been implicated as possible determinants of AKI. Among them, delivery of oxygen (DO2I) level < 280 mL/minute/m2 during CPB was independently associated with AKI2. Cutoff value of low DO2I is based on western literatures and there is a paucity of literature available on same subject among the Indian patients.
Objective
Primary objective is to determine the cutoff value of DO2 value during CPB that is associated with postoperative AKI and secondary outcome is to find out the other risk factors associated with AKI.
Materials and methods
Prospective observational study conducted a tertiary health care setting from March 2023 to Dec 2023. Sample size estimation is based on incidence of AKI following cardiac surgeries in the previous study2. Patient were induced with anesthesia as per protocol and treated with moderately hypothermic CPB. Patient demographic data, preoperative lab parameters, intraoperative hemodynamic parameters, CPB parameters, DO2 levels during CPB, postoperative serum creatinine was collected. Mean values were compared using Independent sample t-test (2 groups). Categorical outcomes were compared using Chi square test. The Lowest DO2I in predicting AKI was assessed by Receiver Operative curve (ROC) analysis. P value < 0.05 was considered statistically significant.
Results
200 enrolled for the study. 147 patients were male (73.50 %) and the mean age was 59.17 ± 9.66. 45 out of 200 (22.5%) patients developed AKI. Rates of Diabetes, hypertension, smoking, alcoholism and EuroSCORE II were significantly higher in patients with AKI. AKI patients underwent longer CPB and cross-clamp periods, needed more red blood cell transfusions, and showed lower DO2i values throughout the procedure. Cut off value of DO2I which is associated with development of AKI was found to be 262.2 ml/min/m2.
Discussion
Our study showed that incidence of AKI is 22.5 % which is similar to study conducted by Elena Carrasco-Serrano et al1. Patients who are diabetic, hypertensive, alcoholics, smokers and those having higher EuroSCORE had higher chances of developing AKI which is similar to study conducted by Carrasco-Serrano et al and de somer at al.1, 2 Our study showed that DO2I of 263.5 ml/min/m2 is associated with higher chances of developing acute kidney failure which is similar to study conducted by de somer et al2.
Conclusion
Low DO2I during cardiopulmonary bypass is a associated with development of AKI and Cutoff value of DO2I identified by our study was 263.5 ml/min/m2.
References
1.Carrasco-Serrano E, Jorge-Monjas P, Muñoz-Moreno MF, Gómez-Sánchez E, Priede-Vimbela JM, Bardají-Carrillo M, et al. Impact of oxygen delivery on the development of Acute Kidney Injury in patients undergoing valve heart surgery. J Clin Med. 2022;11(11):3046. doi: 10.3390/jcm11113046. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.de Somer F, Mulholland JW, Bryan MR, Aloisio T, Van Nooten GJ, Ranucci M. O2 delivery and CO2 production during cardiopulmonary bypass as determinants of acute kidney injury: time for a goal-directed perfusion management? Crit Care. 2011 Aug 10;15(4):R192. doi: 10.1186/cc10349. [DOI] [PMC free article] [PubMed] [Google Scholar]
Validation of Machocha Score in Initial Airway Assessment Tool to Minimize Complications of Airway Securement in Intensive Care Unit: A Retrospective and Prospective Study
In ICU, risk of intubation difficulty is high and ranges from 8 to 13 %. Routine airway assessment is still lacking in patients admitted to ICU. It is not necessary that every patient getting admitted in ICU would require an immediate intubation. If, as a routine protocol, we do an initial airway assessment of every patient getting admitted in ICU, lot of unforeseen complications can be avoided.
Objective
The primary objective of this study was to compare first time success rate in our retrospective group where routine airway assessment and preparedness was lacking and prospective group where we made initial airway assessment mandatory, written, and kept ready at patient`s bedside using MACOCHA scoring.
Material and methods
This retrospective-prospective observational study was conducted after approval from institutional ethical committee over a period of three months. Data of all new admissions who were intubated in ICU were compared to retrospective data of previous three month of all tracheal intubation in ICU. Group I: Retrospective group in which no airway assessment was done initially, and preparedness was lacking. Group II: Prospective group in which initial airway assessment was made mandatory by MACOCHA score, for the next three months. Parameters observed were: First time success rate at intubation, Difficult intubation (three or more attempts or lasting more than 10 minutes using conventional laryngoscopy), trauma to airway during TI (to teeth, oral mucosa, larynx, cervical spine etc.), mild to moderate complications, severe life-threatening complications, operator related difficulties, non-availability of assistants at time of difficult TI.
Results
The demographic profile was comparable in both the groups in relation to age, sex, number. In group I, total number of admission of patients were 835 and out of these 392 patients required intubation in ICU. In group II total of 755 patients got admitted and out of these 341 patients required intubation. In group I first time success rate was significantly less at 29% while in group II it was 78%, p = 0.002. Other observed parameters difficult intubation, trauma during intubation, life threatening complications were seen less in group II.
Discussion
This study assessed difficult intubation and risk factors for difficult intubation which was associated with severe life-threatening complication. It was seen that MACOCHA of 8 or higher was likely associated with multiple attempts. Most importantly none of these patients were successfully intubated by an ICU trainee without an additional support. The MACOCHA score is simple, highly reliable tool which can be performed within a very short time period.
Conclusion
MACOCHA scoring is an efficacious airway assessment tool to improve our preparedness for successful intubation in ICU. It is simple and easy to follow.
Reference
1.Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology. 1995;82:367–76. doi: 10.1097/00000542-199502000-00007. [DOI] [PubMed] [Google Scholar]
Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.1 The conventional biomarker for hypoperfusion in septic shock is elevated lactate levels and though it predicts mortality, its specificity is low.2 As a part of pathophysiological mechanism of septic shock, there is deregulation of renin angiotension aldosterone pathway3 and as a surrogate we studied plasma renin activity (PRA) and its performance weighing lactate kinetics in shock reversal in patients with septic shock.
Objectives
Primary outcome:
Predictor of ICU mortality
Secondary outcome:
Number of vasopressor days
Incidence of acute kidney injury
ICU length of stay
Methodology
Our study design is single centered, prospective, observational, non interventional study. Ethical committee approval and CTRI enrolment were done prior to recruitment. As an interim analysis, we enrolled 30 adult patients with septic shock as per sepsis-3 definition1 within 48 hours of diagnosis. Blood samples of PRA and lactates were sent for analysis at admission and at 6 hours. Rest of the management was left to the discretion of the treating intensivist. Statistical analysis was done using SPSS software version 27.
Results
The demographic profile was comparable between both groups. Mean PRA levels among non survivors were 15.05 ± 9.3 pg/ml and 39.01 ± 8.5pg/ml at admission and at 6 hours respectively whereas there is no change in the absolute values of lactate at both time frames, 3.8 ±2.7 mmol/L and 3.4 ± 1.92 mmol/L at admission and at 6 hours respectively. Among survivors mean PRA were 1.61 ± 2.35pg/ml and 8.15 ±11.4 pg/ml at admission and at 6 hours respectively and lactate levels were 1.74± 0.56 mmol/L and 1.95 ±1.29 mmol/L at admission and at 6 hours respectively (Fig 1). Both PRA and blood lactates at two different time points, at admission and 6 hours predicted survival but the statistical significance of renin outperformed lactates at both time points (p value <0.01 for PRA at 0 and 6 hours versus p value of 0.002 and 0.016 at admission and at 6 hours for lactate). Receiver operating curve analysis could not be performed for the limitations in sample size being an interim analysis. Secondary analysis showed, though, that both predicted mortality, length of ICU stay were uninfluenced by these biomarkers. Moreover acute kidney injury at day 2 as per KDIGO definition4 predicts mortality in our study population (p value 0.035). Days spent on vasopressors did not correlate to outcomes.
Conclusion
Although both PRA and lactates predicts mortality, PRA independently is a better outcome predictor than lactates when assessing in-hospital mortality in patients with septic shock.
Trend of Plasma Renin Activity and lactate kinetics among survivors and non survivors
References
1.Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315(8);):801–810. doi: 10.1001/jama.2016.0287. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Kushimoto S, Akaishi S, Sato T, et al. Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients. Acute Med Surg. 2016;3(4);):293–297. doi: 10.1002/ams2.207. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Gleeson PJ, Crippa IA, Mongkolpun W, Cavicchi FZ, Van Meerhaeghe T, Brimioulle S, Taccone FS, Vincent JL, Creteur J. Renin as a Marker of TissuePerfusion and Prognosis in Critically Ill Patients. Crit Care Med. 2019 Feb;47(2):152–158. doi: 10.1097/CCM.0000000000003544. [DOI] [PubMed] [Google Scholar]
4.Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2:1–138. [Google Scholar]
Propofol is a commonly used intravenous anesthetic agent known for its rapid onset and recovery, but it can also induce significant hypotension, especially during the induction phase of anesthesia. This hypotension can lead to various complications such as organ hypoperfusion, and increased mortality. Predicting and preventing these complications are therefore crucial in ensuring patient safety during propofol-based anesthesia. Perfusion index (PI) is a non-invasive, readily available parameter that reflects the pulsatile component of blood flow and indirectly indicates peripheral tissue perfusion. Studies suggest that PI may be a useful predictor of hypotension in various clinical settings.
Objectives
This study aims to investigate the potential of PI as a predictor of hypotension following propofol infusion for general anesthesia. By establishing a strong association between PI and impending hypotension, this study aims to contribute to the development of a non-invasive, readily available parameter for anticipating and preventing potential complications during propofol-based anesthesia.
Materials and methods
Type of study: Prospective Observational Study. Sample size: 50 patients. Inclusion criteria: Age- 18-65 Years. ASA 1 and ASA 2 patients. Exclusion criteria: Age <18 years and > 65 years, ASA 3 and ASA4 patients and pregnant females. To determine the PI index as a predictor, we will be considering systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate and saturation levels. We will be monitoring and recording the vitals for 5 minutes after propofol infusion.
Results
The study is still going on and as of now 5 patients who received propofol induction were evaluated and it was seen that incidence of hypotension was not seen in patients with PI >1.05.
Discussions
Although data collection for this study is ongoing, preliminary findings suggest that the perfusion index (PI) may be a valuable tool for predicting hypotension following propofol infusion during the perioperative period.
Early observations
Patients with higher PI values were not likely to experience a decrease in blood pressure following propofol administration.
References
1.Mehandale S, Rajasekhar P. Perfusion index as a predictor of hypotension following propofol induction - A prospective observational study. Indian J Anaesth. 2017 Dec;61(12):990–5. doi: 10.4103/ija.IJA_352_17. 29307905 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Abdullah Mohamed S, Yousry Helmy M, Khattab S. A, Hossam A. M, Arafa M. S. Perfusion index as a predictor of hypotension after induction of general anesthesia in elderly patients–a prospective observational study. Egyptian Journal of Anaesthesia. 2023;39(1):619–625. doi: 10.1080/11101849.2023.2238524. [DOI] [Google Scholar]
3.Hussain A, Manzoor H, Manzoor S. M, Taj A, Ommid M. Perfusion index as a predictor of hypotension following propofol induction-A prospective observational study. International Journal of Creative Research Thoughts. 2020;Vol. 8 www.ijcrt.org In. [Google Scholar]
Atrial fibrillation (AF) is the commonest arrhythmia in septic shock.2 NOAF is common during first 72 hours of the septic shock.4, 5 An exact cause of this is not known, although inflammation is the proposed cause by many.
Objectives
Our aim of study was to observe NLR values on day 1, 3 and 5 of all patients with septic shock and to evaluate the predictive value of NLR to detect NOAF in such patients.
Materials and methods
All patients admitted in critical care units, who had septic shock or develop septic shock during their stay were assessed for eligibility. Exclusion criteria were:
Neutropenia (ANC < 1500)
Immunocompromised status due to chemotherapy, radiotherapy, long term steroids [prednisone > 75 mg/day or equivalent steroids for atleast one week]
Stem cell or bone marrow transplant or solid organ transplant recipient.
Pregnancy
Pre- existing AF or valvular heart disease
Shock due to other causes- cardiogenic, hemorrhagic, neurogenic.
NOAF was classified as isolated: only one episode which resolved within 2 hours. recurrent: recurred within 2 hours of initial successful treatment. prolonged: AF persisted beyond 24 hours but less than 24 hours. persistent: AF persisted beyond 24 hours.4 97 patients were enrolled in the study. NLR values (absolute number of neutrophils divided by absolute number of lymphocytes) was calculated from hemogram done on day 1, day 3 and day 5 of septic shock. Continuous ECG monitoring was done to look for new onset of atrial fibrillation. Patients were managed as per the treating consultant. NLR value =/> 3.53 (normal value is 0.78 to 3.532, 5) was considered as positive value/test. Occurrence of NOAF, day of onset, type, length of ICU stay and resolution of shock was recorded.
Results
48.5% patients with septic shock had NOAF. Patients with NOAF had mortality 61.7%. High mortality was seen in persistent NOAF (88.9%). Majority of the patients with NOAF had high NLR mean on day 1(20.04±11.9) compared with day 3 (19.7±11.5) and 5 (16.6±9.9) and among patients without NOAF, the mean NLR was high on day 3 (17.3±12.6) compared with day 1 (16.3±13.1) and 5 (14.2±10.1). Resolution of shock was seen in 40.4% of the patients with NOAF; of these 17.5% had isolated NOAF. Majority of the patients had NOAF on day 1 and day 2 (19.6%). Sensitivity analysis was done for NLR on day 1, 3 and 5. (Table 1). ROC curve analysis showed that AUC was as follows: (Figure 1).
The cut off value of 3.5 on day 3 as a predictor of AF has high sensitivity compared with day 1 and 5. NLR has a good sensitivity to detect NOAF in septic shock but not good specificity.
References
1.Vincent JL, Gabriel Jones. Frequency and mortality of septic shock in Europe and N. America; BMC Critical Care. 2016 doi: 10.1186/s13054-019-2478-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Forget P, Khalifa C, Defour JP, Latinne D, et al. What is the normal value of the neutrophil-to-lymphocyte ratio? BMC Research Notes. 2017 doi: 10.1186/s13104-016-2335-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Corica B, Romiti GF, Basili S, Proietti M. Prevalence of new-onset atrial fibrillation and associated outcomes in patients with sepsis: A systematic review and meta-analysis; Jr of Personalized medicine. 2022 doi: 10.3390/jpm12040547. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Martins E C, Silveria L, Viegas K, Beck A, Junior G, et al. Neutrophil-lymphocyte ratio in early diagnosis of sepsis in an intensive care unit: a case control study; Rev Bras Ter Intensive. 2019 doi: 10.5935/0103-507X.20190010. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Rehman F U, Khan A, Iqbal M, Rind B J, Ahsan S, Mushtaq Z, Ali N A. Role of Neutrophil To Lymphocyte Ratio on admission as a predictor of in hospital mortality in septic patients. Archives of medicine. ISSN 1989-5216. [Google Scholar]
6.Farkas J D. The complete blood count to diagnose septic shock. Journal of Thoracic Disease. 2019 doi: 10.21037/jtd.2019.12.63. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Dragoescu A L, Padrureanu V, Stanculescu A D, Chiutu L C, Tomescu P, Geormaneanu C, Panus A, Dragoescu O P. Neutrophil to lymphocyte ratio (NLR)- A useful tool for the prognosis of sepsis in the ICU. Biomedicines. 2022 doi: 10.3390/biomedicines10010075. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Ni J, Wang H, Li Y, Shu Y, Liu Y. Neutrophil to lymphocyte ratio (NLR) as a prognostic marker for in-hospital mortality of patients with sepsis. Medicine. 2019;98:46. doi: 10.1097/MD.0000000000018029. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Shaver M, Chein W, J anz DR, May A K, Darbar D, et al. A trial fibrillation is an independent predictor of mortality in critically ill patients. Crit Care Med. 2015 doi: 10.1097/CCM.0000000000001166. [DOI] [PMC free article] [PubMed] [Google Scholar]
Factors Affecting the Duration of Mechanical Ventilation and Mortality in Intubated Chronic Obstructive Pulmonary Disease Patients in Critically Ill Patients Admitted in the Respiratory Intensive Care Unit at a Tertiary Health Center
Chronic obstructive pulmonary disease (COPD) care across the world has high heterogeneity concerning cost and the services available. Variations in mechanical ventilation and mortality duration may be attributed to patient characteristics, intubation period, age, history of smoking, Tuberculosis, albumin level, pneumonia, number of organ involvement, pre-intubation PH, pC02, gender, and pre-intubation pa02.
Aims & objectives
Factors affecting mortality and period of mechanical ventilation in COPD patients.
Materials/patients and methods
This retrospective study included AECOPD of 104 patients admitted to a tertiary hospital's respiratory intensive care unit in Mumbai from March 2019 to June 2023. Patient's clinical history details, sputum microbiological profile, blood test, and comorbidities were extracted from the medical record system and compared between survivors and non-survivors, Analysis duration of the mechanical ventilation.
Results
Out of 104 patients admitted,23 died, and 81 survived. The mean ages were 61.00±14.03 years death group and 52.56±13.44 years in the survivors. The overall mortality rate was 22.11%. Analysis showed that the mortality rate was significantly associated with the older age, intubation period, history of smoking, Tuberculosis, low albumin level, pneumonia, more organ involvement, pre-intubation PH(acidotic), and high pC02. Gender and pre-intubation paO2 do not affect mortality. Analysis out of 104 patients,43 required mechanical ventilation > 1 week. Data shows that the duration of mechanical intubation was significantly associated with female gender, history of smoking, history of Tuberculosis, low albumin level, pneumonia (cap, hap), number of organ involvement, pre-intubation PH(acidotic), and high pC02. Age and pre-intubation paO2 does not affect the duration of mechanical ventilation.
Conclusions
Identifying factors affecting mortality and duration of mechanical ventilation and providing targeted interventions at an early stage offers the potential to reduce it. The complex interactions between factors and systems were more important than any single factor or organizational factor in determining differences.
Limitation
Limitations of this study variation in the treatment protocols, variability in COPD severity, and single center case study.
Healthcare workers are at high risk of contracting diseases as they are continuously in contact with patients. Malnutrition increases the risk of contracting infections and increases morbidity. In this study we aim to find the incidence of malnutrition in healthcare workers in hospital and compare it with employees working in non-clinical areas. Hand grip strength is used as an independent tool of nutritional assessment and screening for risk of malnutrition. GLIM criteria is used for diagnosing malnutrition.
Method
Hand grip strength of total 700 hospital employees measured using hydraulic hand grip dynamometer. Hand grip strength of 350 staff working in clinical areas including nursing staff, doctors, ward staff is measured and Hand Grip Strength 350 employees from non-clinical background is taken as control population. Average of three readings for each hand compared with standard reading for particular age group. BMI calculated and daily dietary habits and intake calculated using questionnaire to assess the reduced food intake. Assessment of Malnutrition diagnosis was done with a 2-step approach. First step involved screening to identify at risk status by the use of low BMI and reduced Hand Grip Strength whereas second step assessed the diagnosis and graded the severity of malnutrition as per GLIM criteria.
Result and Conclusion
Among the nursing staff between age group from 20 to 30 years, 22% fall in the GLIM's phenotypic criteria of weight loss of 5%-10% in last 6 months. This present study showed a statistically significant difference in weight loss between clinical nursing staff Vs non clinical staff working in hospital. As per GLIM criteria, 11.5% nursing staff from age group 20 to 30 years fall in to grade I malnutrition which is statistically significant. Nursing staff in age group of 20 to 30 years is at higher risk of malnutrition and it is attributed to shift duties, irregular meal times and skipping meals. Higher grip strength found in males than females. Also, it was noted that grip strength greater in dominant hand than non-dominant hand. Nutritional counselling.
References
1.Wanjek C. Food at work: Workplace solutions for malnutrition, obesity and chronic diseases Geneva
2.Shubhangini Joshi A. “Nutrition and Dietetics” 2003.
3.Rao Raghunatha. published by NIN/ICMR, Dietary Guidelines for Indians National Institute of Nutrition 2011.
ICU's are usually faceing increase in obese patients with deranged physiology and complex condition, with airway difficulty putting challenge to airway safety in intensive care unit. Assessment of extension capacity for occipito-atlanto-axial complex is very important component in pre-intubation test for predicting Difficult visualization of larynx in ICU.
Objectives
To evaluate Difficult visualization of the larynx in apparently normal patients, by examining the following airway predictors Modified Mallampati test, Thyromental distance (TMD). Hyomental distance in the neutral position, Hyomental distance at the extreme of head extension, and Hyomental distance ratio.
Materials and methods
Pre-intubation, we assessed the five airway predictors (Modified Mallampati test, Thyromental distance, Hyomental distance in the neutral position, Hyomental distance at the extreme of head extension, and Hyomental distance ratio) in adult patients undergoing tracheal intubation. All those patients belonging to either sex between the ages of 20-60 years were included in this study. A single experienced intensivist, blinded to the results of the airway evaluation, performed all of the direct laryngoscopies and graded the views using the modified Cormack and Lehane scale. DVL was defined as a Grade 3 or 4 view.
Results
The study done on 301 patients included 152 male (50.50%) and 149 female (49.50%) patients. The highest sensitivity 26.30% observed in predicting DVL was with HMDR (26.30%), followed by HMD at extreme head extension (14.29%), HMD at the neutral head position 10%, lowest was with TMD (9.68%). Where as the specificity in this study was relatively high. The highest specificity of was 98.48% observed in predicting DVL with HMDR, followed by HMD at the neutral position 97.15%, TMD 96.30%. and HMD at the extreme of head extension at 94.14%.
Discussions
Although DVL is major determinant for difficult Intubation, it is not synonymous with difficult intubation. In this study we demonstrated that HMDR is very reliable predictor of DVL to a great extent because of higher specificity and sensitivity.
Reference
1.Huh J, Shin HY, Kim SH, Yoon TK, Kim DK. Diagnostic Predictor of Difficult Laryngoscopy: The Hyomental Distance Ratio Anesth Analg 2009; 108:544–48. 2) Hyomental Distance Gives Best Pediatric Airway Assessment. Anesthesiology. 2006;105:A1152. doi: 10.1213/ane.0b013e31818fc347. [DOI] [PubMed] [Google Scholar]
In patients admitted to ICU, acute kidney injury (AKI) is among the most common cause of morbidity and mortality. It leads to increased length of ICU and hospital stay and is associated with huge cost implications. Development of AKI within first 48 hrs is considered as community acquired AKI and considered as progressive complication of initial disease process. Sepsis is the most common cause for community acquired acute kidney injury. AKI developing after 48 hrs is defined as hospital acquired acute kidney injury (HAAKI), hospital acquired acute kidney injury.
Objectives
The primary objective was to determine the proportion of patients developing HAAKI and identification of possible risk factors associated with its occurrence. The secondary objectives were requirement of renal replacement therapy, length of ICU stay and ICU mortality. This study also included follow up of patients at the end of six months.
Methodology
Prospective observational study was conducted from April 2018 till Oct 2023. Institutional ethical committee approval was obtained (IEC205/2018, CTRI/2018/09/015615). Inclusion criteria were patients admitted to ICU with serum creatinine of <=1mg/dl. Exclusion criteria were patients of chronic kidney disease or have developed acute kidney injury at the time of admission were excluded. The primary outcome was development of acute kidney injury as defined by Acute Kidney injury (AKIN) criteria.
Results
Total 274 patients were included in the study. The mean age was 45.60(17.41) and 60.81% were males. The median acute physiology and chronic health evaluation (APCHE II) score at the time of admission was 12(8-18). The median sequential organ failure assessment (SOFA) score was 5(3-7). Among 274 patients, 43.96% of patients had any of the comorbid illnesses. The most common comorbid illnesses were diabetes mellitus (23.44%) and hypertension (23.81%). The various risk factors associated with development of AKI were presence of comorbidities, APACHE II score, requirement of vasopressors and use of colistin. The ICU mortality was significantly higher in patients who developed AKI (43.18%) as compared to patients without AKI (14.41%). Among the secondary outcomes, 7 (2.55%) patients required renal replacement therapy (RRT) during the hospitalisation. The length of ICU stay was higher in patients with AKI 8(5-13) as compared to patients without AKI 5(3-8).
Conclusion
Patients admitted with normal kidney function can develop AKI and possible risk factors observed in the study were comorbidities, APACHE II score, requirement of vasopressors and use of colistin were risk factors. Hence careful monitoring of the ICU patients is necessary as development of AKI is associated with the higher mortality.
Keywords
AKI, HAAKI, Sepsis, AKIN, RRT.
Reference
1.Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, Edipidis K, Forni LG, Gomersall CD, Govil D, Honoré PM. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive care medicine. 2015 Aug;41:1411–23. doi: 10.1007/s00134-015-3934-7. [DOI] [PubMed] [Google Scholar]
Tele-communication in critical care is omnipresent. Effective verbal tele-communication conveys the situation clearly, completely and provides actionable information to elicit appropriate response (1). Commonly, on arrival of patient, communication is made by attendants to the emergency resident doctor, and by resident doctor to the consultant. Many a times, communication is made by pre-hospital care provider or attendant to the emergency room. The methodology described is for these situations and has the potential to improve verbal tele-communication to ensure crisp but comprehensive information transfer to elicit appropriate response. It also reduces the frequent cross-questioning between consultants and residents to obtain the same information, and the associated uneasiness. (2) Aim: To provide easy to use format of verbal tele-communication to obtain or provide information about acutely ill/trauma patient to obtain appropriate medical response.
Methodology
Information obtained can be classified into various sub-groups for focused collection, dissemination and action, as depicted in the table. A pneumonic, “Don't MISS TAP IT”, has been generated for the same.
Head
Subgroup
Information/Action
Don't
Demographic details and Duration
Age, Sex, and when did the event happen.
M
Mode
How did it happen?
I
Incidence
What happened?
S
Symptoms
What are the patient's complaints?
S
Signs
What are your findings? Vitals etc.
T
Treatment
What treatment has already been offered?
A
Anticipate
What do you anticipate; Differential Diagnosis/Injury sustained?
P
Prepare
Based on anticipation, what preparations would you make?
I
Information
Who all are to be informed?
T
Transport
Whether transport will be required to be kept ready?
If the format is printed on the receiving Case Note Sheet, it's easy to remember what all relevant information has to be obtained. Even in situations where information is being provided in a haphazard way, it can still be grouped as per the headings as it's becoming available. The information can than be transmitted as per format. Receiving information in a pre-defined crisp format makes it easier to understand the situation and enables better response. The same methodology can be used while transferring patients among different medical units. Usage of the same standardized format for information on phone calls makes it easier, effective and reduces the chances of omitting information and hence errors.
Case scenario
A young Medical Officer in a Secondary care Hospital receives a patient with visible respiratory distress and distraught relatives. The patient is comatosed and the family members urge to manage him immediately. The young medical officer panics realising patient may require urgent ventilatory support and tries to consult the ICU Physician for intervention. He informs the ICU Physician telephonically that he has received a very serious patient who needs urgent intubation, and what drugs may be used. The ICU physician, unable to understand the situation, asks him what has happened to the patient and what are the vitals. The young medical officer expresses his ignorance about cause and informs that the patient is obtunded, has had a seizure and not maintaining saturation. ICU Physician further wants to know whether seizure caused obtundation, or is it that patient had a hypoxic seizure. By now, both the young medical officer and the ICU physician are losing patience, without much meaningful communication. The similar situation could have been communicated by arranging the information as follows:
Head
Information/Action
Don't
Demographic details and Duration
Elderly male has become symptomatic for last one hour.
M
Mode
He had a seizure at home and another enroute to hospital.
I
Incidence
He has become unconscious.
S
Symptoms
He is having breathing difficulty.
S
Signs
He has tachycardia, tachypnoea and desaturation.
T
Treatment
Giving O2 by FM and obtaining IV Access.
A
Anticipate
May be he had a stroke.
P
Prepare
He may require intubation so airway tray to be ready.
Telephonic communication in critical care is an opportunity, so “Don't MISS, TAP IT”. Standardized formats make tele-communication effective and avoid unnecessary cross questioning to extract the same information. It has the potential to improve work environment and reducing errors due to misinformation.
Acknowledgement
This methodology is inspired by Emergency Medical Services’ Time Out Protocol and aims at modifying and expanding it to utilize it in many more situations, specifically in verbal tele-communication.
References
1.Improving verbal communication in critical care medicine;Peter G. Brindley MD, FRCPC, Stuart F. Reynolds MD, FCCP. Journal of Critical Care. 2011;26:155–159. doi: 10.1016/j.jcrc.2011.03.004. [DOI] [PubMed] [Google Scholar]
2.A systematic scoping review of teaching and evaluating communications in the intensive care unit. Elisha Wan Ying Chia etal. The Asia Pacific Scholar, Medical and Health Professionals Education. TAPS. 2021;6(1):3–29. [Google Scholar]
Endotracheal intubation in ICU is associated with 46% incidence of complications.1 Post intubation hypotension(PIH) is one such complication and is associated with long term morbidity. We conducted a study to see if pre intubation Shock Index was a predictor of post intubation hemodynamic instability.2
Objective
To investigate predictability of shock index and PIH.
Method and material
This study is prospective observational study of adult critically ill patients requiring emergent/elective endotracheal intubation in the intensive care unit (ICU). We recorded patient's demographic details, comorbidities, reason for intubation, preoxygenation technique, equipment readiness, drugs for intubation and experience of intubator. Patients’ heart rate (HR), systolic and diastolic blood pressure(BP), mean arterial pressure (MAP) and oxygen saturation(SpO2) were monitored throughout. Hemodynamic data were recorded from pre-oxygenation period to upto 30 minutes post intubation at 15 minute intervals. Pre intubation HR and systolic blood pressure(SBP) was used to calculate the Shock Index. We defined post intubation hypotension as SBP <90mmHg, MAP <65, or drop in SBP >20% from baseline. Quantitative data was described as frequency and percentage, qualitative data as mean and standard deviation. Mean Shock Index was calculated, significant variables were included in a multivariable model.
Result
95 patients (males=60) underwent ETI in ICU. 91% were planned intubations and 23.9% of total intubations had PIH. 51.6% patients were intubated for airway protection, 31.6% acute respiratory failure, 11.6% hemodynamic instability and 5% were procedure related intubations. Patients with SI>0.87 was significantly associated with PIH(32.6% vs 16.3%). It had significantly higher SOFAscore (Mean±SD 5.77±2.85 vs 7.82±3.86), higher HR at baseline, 15 mins and 30 mins post intubation(91.84+/-24.73 vs 123.81+/- 24.98 ; 96.08 +/-22.83 vs 114.21+/- 21.45; 96.88 +/-22.72 vs 112.42+/-20.21 respectively. There was a significant difference in SBP in patients with SI above and below the mean at baseline, 15 mins and 30 mins post intubation (147.69+/-37.82 vs 110.40+/- 43; 131.57+/-36.84 vs 106.21+/-43; 131.46+/- 32.59 vs 111.23+/-43) respectively. Variables independently associated with SI > 0.87 included higher Apache II, SOFAscore, higher pre-intubation HR, SBP <130mmHg, MAP <65 mmHg, pre- oxygenation with Bag-Mask Ventilation & High Flow Nasal Cannula.
Conclusion
It's a pilot study to identify SI value and patient factors that significantly increase risk of PIH. Our findings suggest that SI could serve as valuable predictor for PIH in critically ill patients. Increasing severity of illness, SBP< 130mmHg and methods of preoxygenation can affect hemodynamic stability in post intubation period.
References
1.Green RS, et al. Canadian Critical Care Trials Group (CCCTG) Postintubation hypotension in intensive care unit patients: a multicenter cohort study. J Crit Care. 2015;30(5) doi: 10.1016/j.jcrc.2015.06.007. [DOI] [PubMed] [Google Scholar]
2.Allgower M, Burri C. “Shock Index”. Dtsch Med Wochenschr. 1967;92(43) doi: 10.1055/s-0028-1106070. [DOI] [PubMed] [Google Scholar]
After trauma, a few of the primary causes of sudden death is hemorrhagic shock (HS). One of the major, potentially fatal side effects of traumatic hemorrhage is acute lung injury (ALI), which is linked to pulmonary edema due to an increase in capillary permeability and inflammatory cells infiltrating the interstitial and acoustic spaces.
Objective
Our study's primary goal is to identify the genetic basis of ALI by investigating the characteristic features of trauma-induced hemorrhagic shock in rat models that results in lung injury. ALI and acute respiratory distress syndrome (ARDS) usually lead to poor prognosis and higher mortality. The underlying molecular mechanisms of hemorrhagic shock -induced ALI remain unclear.
Material and method
Sprague Dawley Male rats of age 8 to 10 weeks are divided into two groups (n=6); sham and HS groups. Anaesthesia is induced in a chamber with 5% isoflurane and maintained with a nose cone with 1% to 3% isoflurane in the HS group. Hemorrhagic shock is given by drawing 40% of predicted total blood volume of the rat by cardiac bleed. After 8 hours following the onset of bleeding the animals are euthanized and lung tissue is collected for further investigations. Sham rats are also euthanized and their lung tissue is collected. Blood sample from HS groups are collected before and after inducing HS. Right lung tissue is stored in RNA Later for RNA sequencing while left lung is fixed in 4% paraformaldehyde for 24 to 48h and then transferred to pbs (phosphate buffer saline). Histopathology of left lung tissue is performed with H&E staining. Serum from blood is collected for investigating biomarker.
Result
Comparative histopathology reports of sham and HS group lung tissues has confirmed that alteration can be seen in hemorrhagic shock induced animals. Moderate to severe changes in some samples has been observed. Denudation of cells into alveolar spaces, blood vessels show vascular congestion, neutrophilic exudation in alveoli, lymphoid aggregates in interstitium, alveolar spaces show presence of hemorrhage and edema, collapse of alveoli with moderate increase in interstitial inflammation are some of the major changes that have been observed in HS group's lung tissue. We expect promising outcomes in the area of RNA sequencing.
Discussion
When separating trauma patients with trauma-induced ALI from trauma patients without ALI, a model demonstrated a high degree of diagnostic accuracy. By identifying new treatment targets, this research will aid in the understanding of the molecular process behind HS-induced ALI/ARDS.
References
1.Wang Z, Chang P, Ye J, Ma W, Zhou J, Zhang P, Chen X, Jia B, Zheng M, Huang W, Wang T. Genome-wide landscape of mRNAs, microRNAs, lncRNAs, and circRNAs in hemorrhagic shock-induced ALI/ARDS in rats. J Trauma Acute Care Surg. 2021 May 1;90(5);):827–837. doi: 10.1097/TA.0000000000003119. 33605699 [DOI] [PubMed] [Google Scholar]
2.Fremont RD, Koyama T, Calfee CS, Wu W, Dossett LA, Bossert FR, Mitchell D, Wickersham N, Bernard GR, Matthay MA, May AK, Ware LB. Acute lung injury in patients with traumatic injuries: utility of a panel of biomarkers for diagnosis and pathogenesis. J Trauma. 2010 May;68(5):1121–7. doi: 10.1097/TA.0b013e3181c40728. 20038857;PMC3347639 [DOI] [PMC free article] [PubMed] [Google Scholar]
Fluid balance is an integral part of sepsis management. The choice of resuscitation fluid in patients with sepsis remains controversial. The study compared the impact of various resuscitation fluids on mortality in patients of sepsis with positive fluid balance.
Objectives
The Primary Objective was to co-relate types of fluid in cases with positive fluid balance on ICU mortality in cases with sepsis. The Secondary objective was to investigate the positive fluid balance and its impact on mortality in ICU patients with sepsis.
Methods
We recruited 142 patients with sepsis who were given one type of fluid on day 1. Fluid balance was calculated by recording fluid input and output of patient and weight of patient on day 1, 2 and 3 of admission. On the basis of fluid balance they were divided into positive fluid balance (PFB) and negative fluid balance(NFB) group.
Results
In the PFB group the mortality was 28.2% and 16.2% in the NFB group. Amongst PFB group mortality was found significantly higher in groups where resuscitation fluid used was albumin or 0.9% Nacl on day 1. The mortality was least in Ringer lactate group followed by Kabilyte group.
Conclusion
On analysis of our data and statistical evaluation, and comparing with data of other authors, we conclude that Positive fluid balance during each day in the first 72 hours after ICU admission was independently associated with an increased risk of mortality in critically ill patients with sepsis. Survival was better in patients who were in negative fluid balance in the three days of ICU admission. Among positive fluid balance patients after resuscitation with different type of fluids on day 1 of admission, Mortality was found sequentially lower in following way- Ringer lactate < Kabilyte < 0.9%Nacl = Albumin. The mortality was comparable between 0.9% Nacl and Albumin and was found equal. As there is no difference between albumin and 0.9% Nacl when used as resuscitation fluid either of them can be used. Ringer lactate and Kabilyte had a favorable effect on the composite outcome of survival in patients with positive fluid balance and critically ill adults rather than 0.9% Nacl. Survival was found better in 0.9%Nacl group than albumin group.
Sepsis1 is a common diagnosis and causes life-threatening organ dysfunction in intensive care units. It is leading cause of death in non-coronary intensive care units.2 The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension.3 The ideal parameter for tissue perfusion should be rapid, non-invasive, and easily measured without the need of advanced skills. The peripheral perfusion index (PI) is derived from the photoelectric plethysmography signal of pulse oximetry and has been shown to reflect changes in peripheral perfusion.4
Objectives
To correlate perfusion index with arterial lactate levels after adequate fluid resuscitation in patients with Sepsis.
Materials and methods
In this single centered prospective observational study, 35 patients were enrolled after consent waiver from institutional ethical committee. Patient population identified from the emergency room and intensive care unit by fulfilling inclusion criteria of age >18 years, with clinically suspected cases of sepsis/sepsis with shock, as defined by the third international consensus definition for sepsis after adequate fluid resuscitation (30ml/kg). Patients who were pregnant or receiving vasopressor drug therapy were excluded from the study. Perfusion Index (PI) was recorded by attaching pulse oximeter probe to index finger using Philips IntelliVue MX450. The reading was taken after 20-30 seconds of wave form stabilization. The arterial sample was taken for lactate measurements.
Results
Arterial Lactate levels and Perfusion Index showed strong negative correlation, Pearson Correlation Coefficient r(33) = -0.78, p = <0.05.
Among patients with sepsis, early fluid resuscitation and timely administration of antibiotics are the first line treatment to maintain organ perfusion. Perfusion index is non-invasive, real-time, dynamic, inexpensive, point of care and objective measure of peripheral hypoperfusion. It has significant strong negative correlation with arterial lactate levels as per this study data. It can be taken as potential screening tool and dynamic measure of peripheral hypoperfusion in treatment of sepsis at real time. This tool has promising potential of screening test and monitoring in real time for the management of sepsis and sepsis with shock. It may be utilized for out of hospital care, primary health center or resource limited setups where arterial lactate measurement facility is not available. Further randomized controlled trials are required for evaluation of perfusion index as marker of peripheral hypoperfusion in sepsis. We recommend it as adjuvant tool in monitoring for patient with sepsis.
References
1.Singer M, Deutschman CS, Seymour CW. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315:801–810. doi: 10.1001/jama.2016.0287. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Angus DC, Linde- Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303–10. doi: 10.1097/00003246-200107000-00002. [DOI] [PubMed] [Google Scholar]
3.Vincent J-L, Pelosi P, Pearse R, et al. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. Crit Care. 2015;19(1):224. doi: 10.1186/s13054-015-0932-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Lima AP, Beelen P, Bakker J. Use of a peripheral perfusion index derived from the pulse oximetry signal as a noninvasive indicator of perfusion. Crit Care Med. 2002;30:1210–1213. doi: 10.1097/00003246-200206000-00006. [DOI] [PubMed] [Google Scholar]
Anemia is a common finding among patients admitted to intensive care units(ICU). World Health Organization (WHO) defines anemia as Hemoglobin(Hb) < 13 g/dL for adult males and <12 g/dL for adult non pregnant females. Anemia in ICU is multifactorial and shown to affect outcomes and length of stay.
Objectives
To study the effect of admission anemia in our ICU on
ICU mortality
Length of ICU stay
Requirement of ICU interventions.
Materials and methods
Scientific and ethical committee approved.
Prospective, Observational study over a period of one year in patients admitted to our Medical ICU with anemia, and fulfilling inclusion criteria and exclusion criteria.
Primary outcome: Effect of admission anemia on mortality and length of stay
Secondary outcome: Relation of anemia and ICU acquired interventions (Mechanical ventilation, vasopressor/inotrope requirement, blood transfusions)
End point: Shift to ward/ Home discharge/ Death
Sample size calculated as 90. Based on formula [Sample size (N) = Z1-α/22 p (100-p) / d2]
Categorical data – Chi Square Test
Continous data – Student t Test
Results
Interim results
Number of patients analysed – 40 (Females more than males)
Mean admission age – 58 years
Disease severity – Mean APACHE ii Score was 15 and Mean SOFA score – 4
Mean Hb at admission – 8.1 g/dL
Mortality in patients with admission anemia – 17.5%, of which 71% had severe anemia (Hb <7 g/dL)
Length of stay – Mean 4.6 days (1 to 15 days). Mean Hb in patients with LOS >10 days – 7.9
Discussion
Our study had 40 patients enrolled till now with mean age of 58 years. Mean APACHE ii score of the admitted patients was 15 which corresponded to 25 % death rate. Mean SOFA score was 4 which corresponds to <10 % mortality.
Our interim results showed that 17.5 patients with admission anemia died and of which 71% patients had severe anemia (Hb <7 g/dL). Mortality in patients with severe anemia was 71 % in our study compared to Naglaa et al who showed 39.7% mortality in patients with severe anemia. This was similar to multiple other studies also.
Mean length of stay was 4.6 days in the ICU. Patients who had greater degree of anemia had increased length of stay. Average Hb in patients who had LOS >10 days was 7.9. This was similar to previous studies which also showed similar results in varied populations.
Secondary outcome in our study showed that 55% patients with admission anemia required any one of the ICU interventions. 40% required blood transfusion, 32.5 % required Mechanical ventilation, 37% required vasopressor support.
Conclusion
Admission anemia was associated with increased mortality and length of stay and is an independent predictor of outcomes in ICU.
References
1.Walsh TS, Saleh EED. British Journal of Anaesthesia. Oxford University Press; 2006. Anaemia during critical illness. pp. 278–91. Vol. 97. p. [DOI] [PubMed] [Google Scholar]
2.Athar MK, Puri N, Gerber DR. Anemia and Blood Transfusions in Critically Ill Patients. J Blood Transfus. 2012 Oct 22;2012:1–7. doi: 10.1155/2012/629204. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Aly NM, Kamal MM, Eldin S, Abd-Elghafar SA, Fawzy KM. Cairo Univ; 2021. Anemia in Critically Ill Patients; Prevalence and Prognostic Implications Vol. 88, [Google Scholar]
Fever is among the most common reasons for admission to the emergency department. Ibuprofen has been recently approved for the management of fever in India, and there is a paucity of clinical experience on the safety and efficacy of ibuprofen IV in the management of fever in India.
Objective
The objective of this survey was to understand the physician's perceptions on the efficacy, safety, and user satisfaction when using ibuprofen IV for the management of fever.
Material and Methods
This was a cross-sectional survey of physicians across India. A structured, self-reported survey questionnaire was developed. The survey responses were captured by providing multiple choices for the respective questions.
Results
For this survey, a total of 69 users were contacted, out of whom 52 agreed to participate and completed the study. In this survey, 98.08% of physicians recommended Ibuprofen IV for its antipyretic effect, and 34% preferred to use Ibuprofen IV for the management of fever of >101oF. 32% of physicians preferred to use Ibuprofen IV for the management of bacterial fever, 30% for fever of unknown cause, 29% for any type of viral fever, and 15% preferred for the management of malarial fever. Regarding the dose and frequency of Ibuprofen IV, 86.54% of physicians preferred to use the dose of 400mg 8 hourly for the treatment of short-term symptomatic fever. The perceived time for controlling the fever post-administration of Ibuprofen IV was 20 to 30 minutes reported by 34.62% of physicians, 15 to 20 minutes reported by 32.69%, and <30 minutes reported by 17.31% of physicians as the average time taken in controlling the high fever. On a 0-10 scale, the perceived respondent's antipyretic effect was recorded (1= less effective and 10= highly effective). 82% of physicians reported a score of 8 to 10. Regarding safety, 88.46% of physicians found the ibuprofen IV as safe when managing the fever. User satisfaction: When user satisfaction was recorded (1=low satisfaction and 10=high satisfaction), 32.69% of physicians reported a score of 8, and 26.92% reported a score of 9 and 10. The main reason for satisfaction was “ready-to-use formulation’ which was reported by 37% of physicians, and the other reason was the “prevention of the risk of handling’, reported by 26% of physicians. 92.31% of physicians found an advantage of Ibuprofen IV over paracetamol. The most suitable advantage was the “rapid action’ of ibuprofen IV, reported by 45% of physicians.
Conclusion
The survey results showed that most of the physicians preferred to use ibuprofen IV for the management of various types of fever at a dose of 400mg given 8hrly. Rapid action was the most common advantage of Ibuprofen IV over paracetamol. Physician's found ibuprofen IV safe with good satisfaction when using it for the management of fever.
Reference
1.Can O, Kıyan G. S, Yalçınlı S. Comparison of intravenous ibuprofen and paracetamol in the treatment of fever: A randomized double-blind study. The American Journal of Emergency Medicine. 2021;46:102–106. doi: 10.1016/j.ajem.2021.02.057. [DOI] [PubMed] [Google Scholar]
1Department of Critical Care Medicine IQRAA International Hospital & Research Centre, Kerala, India, Phone: +91 9495954027, e-mail: vikkup001@gmail.com
1Department of Critical Care Medicine IQRAA International Hospital & Research Centre, Kerala, India, Phone: +91 9495954027, e-mail: vikkup001@gmail.com
2Department of Critical Care Medicine IQRAA International Hospital & Research Centre, Kerala, India
3Department of Radiodiagnosis IQRAA International Hospital & Research Centre, Kerala, India
Nutritional therapy holds significant importance in the treatment of critically ill patients, a fact that has been acknowledged for quite some time. When a patient is in a critical state, their body undergoes a severe breakdown process characterized by heightened catabolism, which is often accompanied by complications stemming from infections or other non infectious causes. This heightened state of illness is associated with an increased risk of mortality.
Objective
To assess the impact of protein calorie ratio in enteral feed on protein metabolism assessed by change in quadriceps muscle thickness measured using bedside ultrasound among critically ill patients admitted in Critical care unit of IQRAA hospital.
Materials and methods
Prospective cohort study which included all patients admitted in MDICU, during the period February 2022 to December 2022, who are more than 18yrs, receiving enteral nutrition and with an expected for ICU stay for >72hrs. Patients with trauma to both lower extremities and congenital or acquired neuromuscular disorders were excluded.
Methodology
The study, approved by the Human Research Ethics Committee, employed bedside ultrasonography with a linear array transducer to measure Quadriceps Muscle Layer Thickness (QMLT) in supine patients with extended legs. Measurements were taken at two landmarks: two-thirds between the anterior superior iliac spine and superior patellar border, and midpoint between the iliac spine and superior patellar border. QMLT, inclusive of the rectus femoris and vastus intermedius, was measured from the upper femoral bone margin to the lower deep fascia boundary. Baseline muscle thickness was measured on admission (day 0), followed by weekly measurements or at discharge if earlier. All measurements were consistently performed by the same individual. Both lower limbs were measured, and averages of the two values at the specified landmarks were recorded. Additionally, ratios like protein-calorie ratio, protein-NPC ratio, and NPC-N ratio were calculated using mean protein content in grams, total calorie intake in kcal, NPC in kcal, and N (nitrogen, calculated as protein in grams divided by 6.25).
Results
Correlation analysis indicates no significant relationship between NPC-N ratio changes and QMLT mid-point variations over time. However, a significant negative correlation exists between QMLT mid-point (3 weeks - discharge) differences and NPC-N ratio. Similar results are observed for QMLT two-thirds measurements, and no significant correlations are found with clinical scores (SOFA, APACHE, NUTRIC) or protein, NPC, and N levels.
Discussion and Conclusion
In our study group, we observed NPC to N ratios ranging from 65 to 123. Despite this wide range, there was no correlation between these ratios and the change in muscle mass. This observation is to the contrary ASPEN guidelines which recommends a NPC to N ratio of 70 to 100 in non-obese critically ill patients. Additionally, the correlation analysis between the change in QMLT at mid-point and QMLT at two thirds with NPC, Nitrogen and NPC to Nitrogen ratio does not reveal any significant correlation. This indicates that changes in these parameters do not appear to influence the changes in muscle mass in critical illness.
References
1.Thibault R, Pichard C. Nutrition and clinical outcome in intensive care patients. Curr Opin Clin Nutr Metab Care. 2010;13(2):177–83. doi: 10.1097/MCO.0b013e32833574b9. [DOI] [PubMed] [Google Scholar]
2.Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, Guest CB, Mazer CD, Mehta S, Stewart TE, Kudlow P, Cook D, Slutsky AS, Cheung AM, Canadian Critical Care Trials Group Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011;364(14):1293–304. doi: 10.1056/NEJMoa1011802. [DOI] [PubMed] [Google Scholar]
3.Weijs PJ, Atapel SN, de Groot SD, Driessen RH, de Jong E, Girbes AR, et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr. 2012;36(1):60–8. doi: 10.1177/0148607111415109. [DOI] [PubMed] [Google Scholar]
4.Jensen GL, Cederholm T, Correia M, et al. GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community. JPEN J Parenter Enteral Nutr. 2019;43(1):32–40. doi: 10.1002/jpen.1440. [DOI] [PubMed] [Google Scholar]
5.de Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the intensive care unit. Jama. 2015;288:2859–2867. doi: 10.1001/jama.288.22.2859. [DOI] [PubMed] [Google Scholar]
6.Paris M, Mourtzakis M. Assessment of skeletal muscle mass in critically ill patients: Considerations for the utility of computed tomography imaging and ultrasonography. Curr Opin Clin Nutr Metab Care. 2016;19:125–30. doi: 10.1097/MCO.0000000000000259. [DOI] [PubMed] [Google Scholar]
7.Fetterplace K, Deane AM, Tierney A, Beach LJ, Knight LD, Presneill J, Rechnitzer T, Forsyth A, Gill BM, Mourtzakis M, MacIsaac C. Targeted full energy and protein delivery in critically ill patients: a pilot randomized controlled trial (FEED trial) Journal of Parenteral and Enteral Nutrition. 2018 Nov;42(8):1252–62. doi: 10.1002/jpen.1166. [DOI] [PubMed] [Google Scholar]
8.Wittholz K, Fetterplace K, Clode M, George ES, MacIsaac CM, Judson R, Presneill JJ, Deane AM. Measuring nutrition‐related outcomes in a cohort of multi‐trauma patients following intensive care unit discharge. Journal of Human Nutrition and Dietetics. 2020 Jun;33(3):414–22. doi: 10.1111/jhn.12719. [DOI] [PubMed] [Google Scholar]
9.Rodrigues CN, Ribeiro Henrique J, Ferreira ÁR, Correia MI. Ultrasonography and other nutrition assessment methods to monitor the nutrition status of critically ill patients. Journal of Parenteral and Enteral Nutrition. 2021 Jul;45(5):982–90. doi: 10.1002/jpen.1966. [DOI] [PubMed] [Google Scholar]
10.Bury C, DeChicco R, Nowak D, Lopez R, He L, Jacob S, Kirby DF, Rahman N, Cresci G. Use of bedside ultrasound to assess muscle changes in the critically ill surgical patient. Journal of Parenteral and Enteral Nutrition. 2021 Feb;45(2):394–402. doi: 10.1002/jpen.1840. [DOI] [PubMed] [Google Scholar]
11.Pardo E, El Behi H, Boizeau P, Verdonk F, Alberti C, Lescot T. Reliability of ultrasound measurements of quadriceps muscle thickness in critically ill patients. BMC anesthesiology. 2018 Dec;18(1):1–8. doi: 10.1186/s12871-018-0647-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Lambell KJ, Tierney AC, Wang JC, Nanjayya V, Forsyth A, Goh GS, Vicendese D, Ridley EJ, Parry SM, Mourtzakis M, King SJ. Comparison of Ultrasound‐Derived Muscle Thickness With Computed Tomography Muscle Cross‐Sectional Area on Admission to the Intensive Care Unit: A Pilot Cross‐Sectional Study. Journal of Parenteral and Enteral Nutrition. 2021 Jan;45(1):136–45. doi: 10.1002/jpen.1822. [DOI] [PubMed] [Google Scholar]
13.Dresen E, Weißbrich C, Fimmers R, Putensen C, Stehle P. Medical high-protein nutrition therapy and loss of muscle mass in adult ICU patients: A randomized controlled trial. Clinical Nutrition. 2021 Apr 1;40(4):1562–70. doi: 10.1016/j.clnu.2021.02.021. [DOI] [PubMed] [Google Scholar]
14.Sahathevan S, Khor BH, Yeong CH, Tan TH, Meera Mohaideen AK, Ng HM, Ong GR, Narayanan SS, Abdul Gafor AH, Goh BL, Bee BC. Validity of ultrasound imaging in measuring quadriceps muscle thickness and cross‐sectional area in patients receiving maintenance hemodialysis. Journal of Parenteral and Enteral Nutrition. 2021 Feb;45(2):422–6. doi: 10.1002/jpen.1867. [DOI] [PubMed] [Google Scholar]
15.Tillquist M, Kutsogiannis DJ, Wischmeyer PE, Kummerlen C, Leung R, Stollery D, Karvellas CJ, Preiser JC, Bird N, Kozar R, Heyland DK. Bedside ultrasound is a practical and reliable measurement tool for assessing quadriceps muscle layer thickness. Journal of Parenteral and Enteral Nutrition. 2014 Sep;38(7):886–90. doi: 10.1177/0148607113501327. [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Huh Y, Son KY. Association between total protein intake and low muscle mass in Korean adults. BMC geriatrics. 2022 Dec;22(1):1–8. doi: 10.1186/s12877-022-03019-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Phadke R, Dew T, Sidhu PS, Velloso C. Acute skeletal muscle wasting in critical illness. Jama. 2013 Oct 16;310(15):1591–600. doi: 10.1001/jama.2013.278481. [DOI] [PubMed] [Google Scholar]
18.McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G, ASPEN Board of Directors, American College of Critical Care Medicine Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) Journal of parenteral and enteral nutrition. 2009 May;33(3):277–316. doi: 10.1177/0148607109335234. [DOI] [PubMed] [Google Scholar]
Renal Resistive Index As A Predictor of Acute Kidney Injury in Patients with Sepsis and Septic Shock: A Prospective Observational Study-interim Results
Sepsis and septic shock common causes for intensive care admission. Acute Kidney Injury is a well- known complication of sepsis. The classical definition of AKI as per the KDIGO criteria utilises creatinine and urine output. Renal resistive index measured by doppler ultrasound is a non-invasive means of evaluating renal functional status; before creatinine shows any change. RRI is calculated by the equation: RRI= (Peak Systolic Velocity- End Diastolic Velocity)/ Peak Systolic Velocity.
Objectives
To study if Renal Resistive Index acts as a Predictor of Acute Kidney Injury in patients with sepsis or septic shock admitted to an ICU
Materials and methods
Scientific and ethical committee approval
Prospective observational study over 1 year in patients admitted to the ICU with suspected or confirmed sepsis or septic shock and meeting the inclusion, exclusion criteria
Primary outcome: Co-relation between admission RRI and development of AKI within 5 days
Secondary outcome: Co-relation between RRI and highest AKI score, need to initiate haemodialysis, length of ICU stay, mortality
22 patients had sepsis; 16 patients presented with septic shock
Mean RRI at admission: 0.67
Mean admission creatinine: 0.82mg/dL
Patients who developed AKI: 14 (36.8%)- 7 (31.8%) in sepsis; 7 (43.75%) in septic shock
Commonest grade of AKI developed: 2 (8 out of 14 patients)
Haemodialysis: 3 (7.8%)- All in patients who presented with septic shock, admission mean RRI: 0.78
Mean length of ICU stay in patients who developed AKI: 8.4 days- Higher in patients with higher RRI
Mean length of ICU stay in patients who did not develop AKI: 6.2 days
Discussion
Our study had 38 patients enrolled till now with a mean age of 61 years. Of these, 22 patients were admitted with known or suspected sepsis and 16 were admitted with septic shock. All patients had normal creatinine values (Mean serum creatinine: 0.82mg/dL), adequate urine output at ICU admission.
RRI was measured within 6 hours of admission with a mean value of 0.67.
Of 38 patients; 14 (36.8%) developed AKI; 36.8% of patients with sepsis and 43.75% of patients with septic shock- over the course of 5 days
AKI patients had a higher RRI value at admission than non-AKI (0.72 v/s 0.63)
Secondary outcomes of our study were as follows:
Commonest grade of AKI: Grade 2
3 patients were initiated on haemodialysis: All had septic shock at presentation. (Mean admission RRI: 0.78)
Mean length of ICU stay in AKI v/s non AKI: 8.4 days v/s 6.2 days
Conclusion
As per interim analysis, admission RRI co-relates with later development of AKI in patients with sepsis or septic shock who had normal renal parameters at presentation. RRI can be a useful tool in the prediction of AKI and can be utilised to instate early renal protective strategies thus preventing AKI in vulnerable patients.
References
1.Boddi M, Natucci F, Ciani E. The internist and the renal resistive index: truths and doubts. Intern Emerg Med. 2015 Dec 1;10(8):893–905. doi: 10.1007/s11739-015-1289-2. [DOI] [PubMed] [Google Scholar]
2.Haitsma Mulier JLG, Rozemeijer S, Röttgering JG, Spoelstra-de Man AME, Elbers PWG, Tuinman PR, et al. Renal resistive index as an early predictor and discriminator of acute kidney injury in critically ill patients; A prospective observational cohort study. PloS One. 2018;13(6):e0197967. doi: 10.1371/journal.pone.0197967. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Renberg M, Jonmarker O, Kilhamn N, Rimes-Stigare C, Bell M, Hertzberg D. Renal resistive index is associated with acute kidney injury in COVID-19 patients treated in the intensive care unit. Ultrasound J. 2021 Feb 5;13(1):3. doi: 10.1186/s13089-021-00203-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Darmon M, Bourmaud A, Reynaud M, Rouleau S, Meziani F, Boivin A, et al. Performance of Doppler-based resistive index and semi-quantitative renal perfusion in predicting persistent AKI: results of a prospective multicenter study. Intensive Care Med. 2018 Nov;44(11):1904–13. doi: 10.1007/s00134-018-5386-3. [DOI] [PubMed] [Google Scholar]
5.Boddi M, Bonizzoli M, Chiostri M, Begliomini D, Molinaro A, Tadini Buoninsegni L, et al. Renal Resistive Index and mortality in critical patients with acute kidney injury. Eur J Clin Invest. 2016 Mar;46(3):242–51. doi: 10.1111/eci.12590. [DOI] [PubMed] [Google Scholar]
Real-time Assessment of Nasogastric Tube Position Using POCUS in Mechanically Ventilated Patients and its Comparison to Gold Standard Method (Chest X-ray)
Nasogastric tube (NGT) placement is the most frequently used method for enteral feeding and drug administration in mechanically ventilated patients. Blind insertion of NGT can have complication rate of 0.3% – 8%.1 In anesthetized patients, the insertion and confirmation of NGT has a failure rate of almost 50% on the first attempt in neutral head position. Literature demonstrates mechanical ventilation as the most substantial risk factor for NGT misplacement.2
Objectives
Assessment of NGT position using POCUS in mechanically ventilated patients and its comparison to Chest X-ray.
Materials and methodology
Two hundred adult patients meeting the inclusion criteria will be enrolled in the study. The patients will be placed in the supine and sniffing position before the procedure. Sonographic examination will be performed by a competent operator, who is experienced in airway ultrasound. A high-frequency linear US probe will be transversely placed over the suprasternal notch. When an image of the empty esophagus will be obtained, a second individual will insert an NGT of 10–14 Fr in thickness from the appropriate nostril of the patient by adjusting the nasal passage. An attempt will be made to visualize its passage from the esophagus lumen with US. The same patients will undergo a chest X-ray as per the ICU and hospital policy. The results of the ultrasound and chest X-ray will then be compared.
Results
As the study is still underway, the results will be shared at the time of presentation.
Discussion
As the study is still underway, discussion will be shared at the time of presentation.
References
1.Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg. 2005;4:429–433. doi: 10.1510/icvts.2005.109488. [DOI] [PubMed] [Google Scholar]
2.Sharma A, Vyas V, Goyal S, Bhatia P, Sethi P, Goel AD. Nasogastric tube insertion using conventional versus bubble technique for its confirmation in anesthetized patients: a prospective randomized study. Braz J Anesthesiol. 2021 Mar 22 doi: 10.1016/j.bjane.2021.01.011. 33766685 S0104-0014(21)00099-3. Epub ahead of print. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Comay Yoav, Quint Elchanan, Bichovsky Yoav, Koyfman Leonid, Osyntsov Anton, Acker Asaf, Brotfain Evgeni. Case Series: Nasogastric (NG) Feeding Tube Misplacement in Critically Ill Tracheostomized Patients. Case Reports in Clinical Medicine. 2020;09:399–407. 10.4236/crcm.2020.912055. [Google Scholar]
1Department of Anaesthesiology, Jawhar Lal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh, India, Phone: +91 9557808217, e-mail: Sanamasroor2k9@gmail.com
1Department of Anaesthesiology, Jawhar Lal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh, India, Phone: +91 9557808217, e-mail: Sanamasroor2k9@gmail.com
2Department of Anaesthesiology, Jawhar Lal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh, India
3Department of Medicine, Jawhar Lal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh, India
Acute kidney injury is a broad term encompassing deterioration of kidney function due to multiple etiologies, It is prevalent especially in the critically ill. In recent years there has been an increase in cases of AKI, with mortality seen in over 50% cases. AKI is defined according to the Recent KDIGO guidelines: The aim of this study is to find the spectrum of AKI in Indian population and its effect on morbidity and mortality on patients admitted in Intensive Care Unit.
Objectives
To determine 1) the spectrum of and outcome of Acute kidney Injury in patients admitted in the ICU 2) To assess the relationship of AKI with -pre-existing comorbidities - Renal replacement therapy.
Materials and methods
A pilot study was conducted on 15 patients in the Intensive Care Unit of JNMCH, AMU, Aligarh where patients more than 18 years, of age and not receiving prior renal replacement therapy were studied.
Results
Among the 15 patients in the pilot study, 50% were male and 49% were females. The commonest cause of AKI was found to be sepsis (53%) followed by hypovolemic shock and pneumonia, OP poisoning (6%). Majority patients had preexisting comorbidities like diabetes mellitus, hypertension, coronary artery disease in descending order, KDIGO stage AKI 1 was seen in 18% cases, stage 2 in 30% and stage 3 in 52% cases. 47% of patients required dialysis during ICU stay. Average icu stay was found to be 16±2 days. Mortality rate among patients with AKI in ICU was found to be 40%.
Discussions
IN this study it was seen that risk of AKI in icu was associated with male sex, sepsis, diabetes mellitus and hypertension as preexisting comorbidity. It had been described in various studies that Sepsis was the leading cause of AKI in the ICU, which usually manifests as multiple organ dysfunction syndrome. In this study 6% cases with OP poisoning were associated with AKI, the most common comorbidities were type2 Diabetes mellitus in 20% and systemic Hypertension in 22% in ICU. This study showed that the duration of stay in ICU patients with AKI was 16 days on an average, more cases of KDIGO AKI stage 3 were seen, out of which nearly 47% patients needed renal replacement therapy.
References
1.Lameire NH, Bagga A, Cruz D, de Maeseneer J, Endre Z, Kellum JA, et al. Acute kidney injury: An increasing global concern. Lancet. 2013;382(9887):170179. doi: 10.1016/S0140-6736(13)60647-9. [DOI] [PubMed] [Google Scholar]
2.Ponce D, Balbi A. Acute kidney injury: Risk factors and management challenges in developing countries. Int J Nephrol Renovasc Dis. 2016;9(1):193200. doi: 10.2147/IJNRD.S104209. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Singbartl K, Kellum JA. AKI in the ICU: Definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012;81:81925. doi: 10.1038/ki.2011.339. [DOI] [PubMed] [Google Scholar]
4.Sood MM, Shafer LA, Ho J, et al. Early reversible acute kidney injury is associated with improved survival in septic shock. J Crit Care. 2014;29:711–7. doi: 10.1016/j.jcrc.2014.04.003. [DOI] [PubMed] [Google Scholar]
5.Lee FY, Chen WK, Lin CL, Lai CY, Wu YS, Lin IC, et al. Organophosphate poisoning and subsequent acute kidney injury risk: A nationwide population-based cohort study. Medicine (Baltimore) 2015;94:e2107. doi: 10.1097/MD.0000000000002107. [DOI] [PMC free article] [PubMed] [Google Scholar]
The post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation.1 Longitudinal data on the nutritional status of ICU survivors over time are very limited in world literature and no data are available from Indian ICUs.
Objectives
We aimed to evaluate the factors affecting nutrition status, barriers to adequate home nutrition, and the effect of an educational mHealth app-supported intervention to assist nutrition support in chronically ill tracheostomized patients at home after ICU care as a part of the AIIMS ICU rehabilitation (AIR) project.
Methods
This was a prospective observational mixed methods study embedded in the implementation of the AIR project. In Part 1 of the intervention family carers of chronically ill, bed-bound tracheostomized adults were educated in the ICU about the importance of nutrition, preparing nasogastric feeds, and feeding via nasogastric tube. Leaflets and videos with instructions for feeding, how to prepare cost-effective food with calorie and protein targets, and screening nutrition status by PGSGA tool were handed out as hardcopy and on the m health application. In part 2, reinforcement, troubleshooting, and feedback were achieved with a home visit on day 7, and a close follow-up with android based interactive app, video, and phone calls. Quantitative data were collected for nutrition intake by the 24-hour recall on days 7 and 21, and qualitative data for barriers to providing nutrition were collected by semi-structured interviews of patient carers. Undernutrition was defined as energy administration below 70% of the defined target.2
Results
Of the 197 tracheostomized patients discharged home from the ICU or ward, the mean age of patients and carers was 47.9 ± 15.71 yrs. and 33.33 ± 10.9 yrs. respectively, with 59.2 % males. More than 90% of patients had neurologic causes of ICU admission (neurotrauma, stroke, post-brain surgery, post-arrest) with 58% low-income families (<120USD /month) and 40% unemployed carers. Most carers (96.6%) were satisfied with the training received. Post-discharge calorie intake on day 7 (n=174) was 1286.8 ± 380.7 Kcal with 60% underfed. By Day 21, this had significantly improved to 1695.53±419.1 Kcal (p<0.001) with 18% being underfed (p<0.0001). Low income was significantly associated with malnutrition (p= 0.03 univariate analysis) and p=0.05 when corrected for QOL at discharge. Lack of fear for NG feeding (93 %) was a consistent facilitator whereas non-affordability and lack of basic amenities such as a grinder and refrigerator emerged as barriers from carer interviews.
Discussions
Underfeeding is common in the post-ICU period and may be improved with education in the ICU. However, reinforcement with patient-faced interventions that include follow-up via telephone, mobile apps, and home visits is more effective. Income and lack of amenities appear to be hindrances in adequate nutrition provision at home in our cohort of patients.
References
1.Moisey L.L, Merriweather J.L, Drover J.W. The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated. Crit Care. 2022;26:270. doi: 10.1186/s13054-022-04143-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Singer P, Blaser AR, Berger MM, Alhazzani W, Calder PC, Casaer MP, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48–79. doi: 10.1016/j.clnu.2018.08.037. [DOI] [PubMed] [Google Scholar]
Comparison of Different Video Laryngoscopes for Nasotracheal Intubation in Manikin with Difficult Airway by Experienced Anesthesiologists: A Randomized, Self-controlled, Crossover Trial
Several video laryngoscopes are available which may facilitate nasotracheal intubation in difficult airways. We compared the C-mac blade 3, Kings vision laryngoscope and Macintosh laryngoscope (blade size 3) by studying the performance of experienced anesthesiologist using manikin (DAM simulator, Kyoto) in normal and difficult airway scenarios.
Aims and objectives
The aim of the study is to assess if the video laryngoscope is superior to the classic laryngoscope in acquiring the nasotracheal intubation in difficult airway scenario.
Objectives
Comparison of time to intubation between the groups.
Comparison of ease of intubation between the groups.
Comparison of number of failed intubations between the groups.
Methods
We recruited 20 anesthesiologists into a randomized trial. Each performed nasotracheal intubation with each laryngoscope in normal airway, rigid neck and micrognathia. The primary end point was time to intubation. Other end points were time to best glottic visualization, grade of view.
Results
There were no dropouts. In the normal airway scenario, the time to intubation was similar using the three devices. In the difficult airway such as rigid neck and micrognathia, the time to intubation using the C-mac was less [36.7s (5.39), 35.40(4.87) respectively] than the other devices. Time to glottic visualization had similar trend as time to nasotracheal intubation. Discussion: This study can be useful in critical care in ICU to decide upon which airway device to use for nasotracheal intubation in indicated cases like cervical instability, head and neck cancer etc Hence we conclude that experienced anesthesiologist required almost equal time for nasotracheal intubation with different airway devices in normal airway scenario, but a shorter time for nasotracheal intubation with C-mac in difficult airway scenarios like rigid neck and micrognathia. C-mac also provided better glottic views in difficult airway as compared to other devices.
“Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to Infection”. Sepsis and septic shock are major healthcare problems and delay in definitive therapy is associated with an increased risk of multiorgan failure and Mortality. The inflammatory markers can help to predict the severity of sepsis, monitor the response to therapy and mortality. This prospective, comparative, observational study was planned for the evaluation of PCT, CRP, and IL-6 for the prognosis of Sepsis & Septic shock.
Objectives
Prediction of severity, multiorgan failure and mortality in patients with sepsis and septic shock based on admission values of PCT, CRP and IL-6.
Materials and Methods
The present study was conducted in the Department of Critical Care Medicine, Dr BL Kapur Memorial Hospital, New Delhi. A total of 300 patients were enrolled in the study which met all inclusion criteria of the study. Blood samples were collected for routine lab investigations and biomarkers PCT, CRP, and IL-6 were collected on day 1(before administration of the first dose of antibiotic), day 3, day 7, and day 12. The APACHE II score was collected once only after 24 hours of ICU admission. SOFA score was done daily, however, SOFA scores of Days 1, 3, 7, and 12 only were taken into consideration. Blood culture and other body fluid culture as per the clinical condition.
Results
We found that out of 300 patients, 146(48.67%) patients with sepsis and 154(51.33%) with septic shock. Patients were also divided according to MOF and mortality. Out of 300 pateints 168(56.00%) patients with MOF & 132(44.00%) without MOF, and 187(62.33%) Survivor & 113(37.67%) Non-Survivor. MOF and the mortality rate are significantly higher in septic shock patients as compared to sepsis patients (p-value <0.0001). APACHE II and SOFA scores are significantly higher in septic shock patients, patients with MOF, and non-survivors as compared to patients with sepsis, without MOF, and survivors. PCT, Lactate, and SOFA remain statistically significantly higher in septic shock, patients with MOF, and non-survivor in all the time periods (Day 1,3,7,12). On the other hand, CRP and IL-6 are statistically significantly higher from day 3 in septic shock and MOF patients, while in non-survivor patients CRP is higher in all the time periods and IL-6 is higher from day 3. (p-value <0.05). On comparative analysis of serum biomarkers, Lactate and PCT are good predictors of septic shock, MOF, and non-survivor than CRP, and IL-6 based on AUC.
Conclusion
The multiorgan failure and mortality rate are significantly higher in septic shock patients as compared to sepsis patients (p-value <0.0001). Serum biomarker Lactate and PCT are good predictors of septic shock, MOF, and mortality on admission. SOFA score and serum biomarkers-PCT, Lactate are significant independent risk factors of mortality in septic shock patients.
References
1.Shankar-Hari M, Phillips GS, Levy ML, et al. Sepsis Definitions Task Force:Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016;315:775–787. doi: 10.1001/jama.2016.0289. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Ríos-Toro JJ, Márquez-Coello M, García-Álvarez JM, Martín-Aspas A, Rivera-Fernández R, Sáez de Benito A, Girón-González JA. Soluble membrane receptors, interleukin 6, procalcitonin and C reactive protein as prognostic markers in patients with severe sepsis and septic shock. PLoS One. 2017 Apr 5;12(4):e0175254. doi: 10.1371/journal.pone.0175254. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Cui N, Zhang H, Chen Z, Yu Z. Prognostic significance of PCT and CRP evaluation for adult ICU patients with sepsis and septic shock: retrospective analysis of 59 cases. J Int Med Res. 2019 Apr;47(4):1573–1579. doi: 10.1177/0300060518822404. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Raghu D, Ramalingam D. K. Prognostic significance of procalcitonin, High sensitivity C-reactive protein, and white blood cell count in comparison with blood culture in ICU patients with Sepsis and Septic shock in a tertiary care Hospital. European Journal of Molecular & Clinical Medicine. 2021;8(3):2263–2270. [Google Scholar]
5.Xie Y, Zhuang D, Chen H, Zou S, Chen W, Chen Y. 28-day sepsis mortality prediction model from combined serial interleukin-6, lactate, and procalcitonin measurements: a retrospective cohort study. Eur J Clin Microbiol Infect Dis. 2023 Jan;42(1):77–85. doi: 10.1007/s10096-022-04517-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (1). Septic shock comprises of a subcategory of sepsis, with severe alterations in circulatory and cellular metabolism with an estimated mortality of 50-85% (2). Capillary refill time (CRT) which non-invasively evaluates peripheral circulation, is an adequate marker of multi-organ dysfunction in septic shock (3). Sequential organ failure assessment (SOFA) score dynamically reflects changes in organ function and is a widely used score in the ICU for the evaluation of patients with multiple organ failure (4). This study aims to find the utility of Capillary refill time in predicting the progression of organ dysfunction in patients with septic shock.
Objectives
To find the association between prolonged Capillary refill time and Delta SOFA score at 24 hours and 48 hours for assessing the progression of organ dysfunction in Septic shock.
Materials and Methods
This is a Single-center, Prospective Diagnostic study, carried out on 50 adult patients admitted to a multi-disciplinary ICU during 1 year period with Septic shock (defined by Sepsis-3 definition). On admission, baseline SOFA score is noted along with arterial blood gas lactate and capillary refill time (CRT). These are also noted 3 hours after stabilization, at 24 hours and 48 hours. 24-hour Delta SOFA (Delta 24) and 48-hour Delta SOFA (Delta 48) are obtained by subtracting 24-hour SOFA and 48-hour SOFA respectively from admission SOFA. The diagnostic accuracy of Delta SOFA score on the progression of organ failure will be assessed by plotting receiver operating characteristic (ROC) graphs and calculating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Results: Discussion
Several observational studies have demonstrated the association between persistent abnormal perfusion after resuscitation and organ failure and mortality in Septic shock (3). In 2014, Ait Oufella et al observed a significant relationship between CRT, arterial lactate level, and SOFA score (5). In 2017, Lara et al found that patients with sepsis and hyperlactatemia exhibiting normal CRT after the very first fluid resuscitation had a low morbidity and mortality risk compared to those with abnormal peripheral perfusion despite initial Fluid resuscitation (3). In 2019, an assessment of secondary outcomes by Hernandez G, et al. in the ANDROMEDA SHOCK Trial, found that the SOFA score was lower at the first 72 hours in the resuscitation strategy targeting CRT compared to that targeting blood lactate. In 2009, Allan E Jones et al demonstrated a positive relationship between Δ SOFA and in-hospital mortality (7). In 2017, Harm-Jan de Grooth et al recommended using Delta SOFA rather than Fixed-day SOFA as an endpoint since Delta SOFA was found to be significantly associated with mortality. (8). By observing the sensitivity, specificity, and positive and negative predictive values, our study aims to find the association between prolonged Capillary refill time and Delta SOFA score at 24 hours and 48 hours for assessing the progression of organ dysfunction in cases of Septic shock.
References
1.Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, Rubenfeld G, Kahn JM, Shankar-Hari M, Singer M, Deutschman CS, Escobar GJ, Angus DC. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) JAMA. 2016 Feb 23;315(8):762–74. doi: 10.1001/jama.2016.0288. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Hotchkiss RS, Karl IE. The pathophysiology and treatment of sepsis. N Engl J Med. 2003 Jan 9;348(2):138–50. doi: 10.1056/NEJMra021333. [DOI] [PubMed] [Google Scholar]
3.Lara B, Enberg L, Ortega M, Leon P, Kripper C, Aguilera P, Kattan E, Castro R, Bakker J, Hernandez G. Capillary refill time during fluid resuscitation in patients with sepsis-related hyperlactatemia at the emergency department is related to mortality. PLoS One. 2017 Nov 27;12(11):e0188548. doi: 10.1371/journal.pone.0188548. 29176794 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Zhang L, Qiu C, Yang L, Zhang Z, Zhang Q, Wang B, Wang X. GPR18 expression on PMNs as biomarker for outcome in patient with sepsis. Life Sci. 2019 Jan 15;217:49–56. doi: 10.1016/j.lfs.2018.11.061. [DOI] [PubMed] [Google Scholar]
5.Ait-Oufella H, Bige N, Boelle PY, Pichereau C, Alves M, Bertinchamp R, Baudel JL, Galbois A, Maury E, Guidet B. Capillary refill time exploration during septic shock. Intensive Care Med. 2014 Jul;40(7):958–64. doi: 10.1007/s00134-014-3326-4. [DOI] [PubMed] [Google Scholar]
6.Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi: 10.1001/jama.2019.0071. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Jones AE, Trzeciak S, Kline JA. The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med. 2009 May;37(5):1649–54. doi: 10.1097/CCM.0b013e31819def97. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.de Grooth HJ, Geenen IL, Girbes AR, Vincent JL, Parienti JJ, Oudemans-van Straaten HM. SOFA and mortality endpoints in randomized controlled trials: a systematic review and meta-regression analysis. Crit Care. 2017 Feb 24;21(1):38. doi: 10.1186/s13054-017-1609-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
Acute hypercapnic respiratory failure is one of the most important cause of ICU admission over last few decades.1 The use of Non-invasive ventilation (NIV) in type 2 RF has become one of the most important developments over the past two decades.2 NIV failure has been defined as the need for endotracheal intubation (ETI) or death.3, 4The failure rate ranges from 15 to 24 % depending on various factors.5 Patients who experience NIV failure and then receive delayed intubation have higher mortality and hospital stay. Thus, the early identification of NIV failure in these patients is very important.6 HACOR score which takes into such variables had high sensitivity and specificity for the prediction of early NIV failure.7–9 The variables for the HACOR score are Heart Rate(H), Acidosis(A), Consciousness level(C), Oxygenation(O) and Respiratory rate(R), which are easily obtained at bedside.[6] Thus the aim of the study is to predict early NIV failure using HACOR score.
Objectives
To study predictive value of HACOR SCORE in success and failure of NIV in Acute hypercapnic respiratory failure.
To observe the trends of HACOR score at different intervals(initial,1-2 hours,12 hours,24 hours of NIV) among these patients and compare them among NIV success and failure patients.
Materials and Methods
This was a prospective observational single centre study conducted at Intensive Care Unit of Fortis Escort heart institute Okhla, New Delhi from May 2023 to October 2023 after obtaining approval from Institutional ethics committee.57 patients were randomly selected at our hospital maintain inclusion and exclusion criterias.
Inclusion Criteria:
Patients with age over 18 years
Patients admitted to medical ICU with Acute Respiratory Failure with ABG showing pH< 7.35 and PCO2>45
Patients with respiration rate >24 or presence of dyspnea at rest assessed using accessory respiratory muscles or paradoxical abdominal breathing.
Exclusion Criteria:
Patients who are not willing to accept NIV
Patients having symptoms suggestive of unstable angina, AMI, congestive heart failure, unstable cardiac arrhythmias, severe hypoxia and hemodynamically unstable patients on very high doses of vasopressors
Patients having any contraindication for NIV
Results
Datas are tabulated and analyzed by proper statistical tests. NIV failure rate was 22.8% in our study. In patients HACOR score<5 at 1—2 hrs of NIV, the failure rate is 5.26%, where as in patients with score >5 at same time is 57.89%. At 1—2 h of NIV HACOR>5, Sensitivity and Specificity being 84.6% and 82.8% respectively. In our study from ROC curve, cut off point for NIV failure seems to be HACOR>6 at 1-2 hrs of NIV and AUC, Sensitivity, Specificity, PPV, NPV are 0.937(0.86-1.00),84.6%,93.2%,78.57%,95.35% respectively. The HACOR score of NIV success and failure groups are compared at different intervals(beginning,1-2 hrs,12 hrs,24 hrs) and the result is statistically significant(p=0.001, highly significant).
Conclusion
HACOR score had high sensitivity and specificity for the prediction of early NIV failure in Type 2 respiratory failure. As the variables are easily obtained bedside, it is convenient to use and asses the efficacy of NIV in these patients.
References
1.Liengswangwong W, et al. Early detection of non-invasive ventilation failure among acute respiratory failure patients in the emergency department. BMC Emergency Medicine. 2020 Oct 7;20(1):80. doi: 10.1186/s12873-020-00376-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Rakesh K. Chawla, et al. Predictors of success and failure of non-invasive ventilation use in type-2 respiratory failure. Indian journal of tuberculosis. 2021;68(1):20–24. doi: 10.1016/j.ijtb.2020.10.002. [DOI] [PubMed] [Google Scholar]
3.Moretti M, Cilione C, Tampieri A, Fracchia C, Marchioni A, Nava S. Incidence and causes of non-invasive mechanical ventilation failure after initial success. Thorax. 2000;55:819–825. doi: 10.1136/thorax.55.10.819. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Contou D, Fragnoli C, Cordoba-Izquierdo A, Boissier F, Brun-Buisson C, Thille AW. Noninvasive ventilation for acute hypercapnic respiratory failure: intubation rate in an experienced unit. Respir Care. 2013;58:2045–52. doi: 10.4187/respcare.02456. [DOI] [PubMed] [Google Scholar]
6.Jun Duan, et al. Early prediction of noninvasive ventilation failure in COPD patients: derivation, internal validation, and external validation of a simple risk score. Ann. Intensive Care. 2019;9:108. doi: 10.1186/s13613-019-0585-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Ko BS, Ahn S, Lim KS, Kim WY, Lee YS, Lee JH. Early failure of noninvasive ventilation in chronic obstructive pulmonary disease with acute hypercapnic respiratory failure. Intern Emerg Med. 2015;10:855–60. doi: 10.1007/s11739-015-1293-6. [DOI] [PubMed] [Google Scholar]
8.Fiorino S, Bacchi-Reggiani L, Detotto E, Battilana M, Borghi E, Denitto C, Dickmans C, Facchini B, Moretti R, Parini S, et al. Efcacy of noninvasive mechanical ventilation in the general ward in patients with chronic obstructive pulmonary disease admitted for hypercapnic acute respiratory failure and pH<7.35: a feasibility pilot study. Intern Med J. 2015;45:527–37. doi: 10.1111/imj.12726. [DOI] [PubMed] [Google Scholar]
9.Van Gemert JP, Brijker F, Witten MA, Leenen LP. Intubation after noninvasive ventilation failure in chronic obstructive pulmonary disease: associated factors at emergency department presentation. Eur J Emerg Med. 2015;22:49–54. doi: 10.1097/MEJ.0000000000000141. [DOI] [PubMed] [Google Scholar]
Paroxysmal sympathetic hyperactivity(PSH) is one of the lesser understood complications of neurological injury and is predominantly seen following traumatic brain injury(TBI). It is often difficult to diagnose in this population and due to decreased awareness of the condition, the posturing seen in these patients may lead to premature withdrawal of treatment anticipating poor outcome. Outcomes following PSH are scarcely documented in literature.
Objective
This case series is an attempt to observe functional outcome at 6 months and beyond, following PSH in patients with TBI.
Method
This single tertiary institutional case series was collected in the neurocritical care unit between January 2020 to May 2023. Fifteen patients with traumatic brain injury were diagnosed to have paroxysmal sympathetic hyperactivity. Their admission Glasgow Coma Scale(GCS), GCS at discharge and Glasgow Outcome Scale-Extended (GOSE) at 6 months at their follow- up visit to the brain injury clinic, were documented and are presented here.
Results
13 out of 15 patients were admitted with severe traumatic brain injury. 2 out of 15 patients were admitted with moderate traumatic brain injury. Age of the patients ranged from 12 years to 46 years.
Serial number
Age (years)
Diagnosis
Admission GCS
GCS at discharge
GOSE at 6 months
1
15
Severe Head Injury Left Acute Temporal Subdural Haematoma Left Parietal Extradural Hematoma Diffuse Axonal Injury Grade Ii
4T/15
10/15
8 Going to school. Poor scholastic performance compared to before the accident. Excessive anger- consulting Psychiatry
2
31
Severe Head Injury Bilateral Temporal Contusions Left Frontotemporoparietal Acute Subdural Haematoma Diffuse Subarachnoid Haemorrhage
3/15
6t
6 14/15 Disoriented to time And place. Oriented to Person.
3
40
Severe Head Injury Bilateral Frontal (Right > Left) And Left Parieto-Temporal Contusions Diffuse Subarachnoid Hemorrhage
8/15
4t/15
1
4
38
Severe Head Injury Right Putaminal Contusion Right Tentorial Subdural Hemorrhage
5/15
2t/15
1
5
18
Severe Head Injury Bilateral Fronto-Parietal Subdural Hematoma
8/15
10/15
8 15/15 Cranioplasty done. Completed college.
6
12
Severe Head Injury Diffuse Axonal Injury
7/15
7/15
8 Independent In ADL, Speech Therapy being done, going to school, Scholastic performance good
7
19
Severe Head Injury - Diffuse Axonal Injury Early Post-Traumatic Seizure
10t/15
10t/15
8 15/15 No Focal neurological deficits. Tracheostomy decannulated. Studying B Tech
8
29
Severe Head Injury Right Frontotemporoparietal Acute Subdural Hematoma With Right Temporal Burst Lobe
7
14
8
9
25
Severe Head Injury Diffuse Axonal Injury Left Frontal Dot Contusions
8/15
10/15
8
10
40
Severe Head Injury Right Fronto-Temporo-Parietal Acute Thick Subdural Hematoma
6t/15
10/15
5
11
46
Moderate Head Injury Right Fronto-Temporo-Parietal Acute Sub-Dural Hematoma
9/15
6t/15
8
12
26
Severe Head Injury Left Frontotemporoparietal Acute Subdural Hematoma
2t/15
4t/15
2
13
35
Moderate Head Injury. Left Frontotemporoparietal Acute Subdural Hematoma.
8/15
9t/15
8
14
25
Severe Head Injury Bilateral Temporal Haemorrhagic Contusions
7/15
5t/15
4
15
30
Severe Head Injury Right Frontotemporoparietooccipital Acute Subdural Hematoma
9 out of 15 patients had a GOSE of 6 to 8 at 6 months, indicating a good outcome following PSH. Symptomatic management included Baclofen and Propranolol along with supportive measures. The posturing seen with PSH may lead clinicians to predict poor outcomes due to lack of awareness of the diagnosis of PSH. The PSH- AM(Assessment Measure) tool is recommended for probabilistic diagnosis. Our experience with 15 patients showed a good outcome at 6 months. More studies and larger numbers are required to verify our findings. Increasing awareness about PSH among clinicians who treat patients with TBI may lead to more diagnosis and ensure better outcomes for these patients.
2.Mathew MJ, Deepika A, Shukla D, Devi BI, Ramesh VJ. Paroxysmal sympathetic hyperactivity in severe traumatic brain injury. Acta Neurochir (Wien) 2016 Nov doi: 10.1007/s00701-016-2934-x. [DOI] [PubMed] [Google Scholar]
3.Lucca LF, de Tanti A, Cava F, Romoli A, Formisano R, Scarponi F, Estraneo A, Frattini D, Tonin P, Bertolino C, Salucci P, Hakiki B, D'Ippolito M, Zampolini M, Masotta O, Premoselli S, Interlenghi M, Salvatore C, Polidori A, Cerasa A. Predicting Outcome of Acquired Brain Injury by the Evolution of Paroxysmal Sympathetic Hyperactivity Signs. J Neurotrauma. 2021 Jul doi: 10.1089/neu.2020.7302. [DOI] [PubMed] [Google Scholar]
4.Tu JSY, Reeve J, Deane AM, Plummer MP. Pharmacological Management of Paroxysmal Sympathetic Hyperactivity: A Scoping Review. J Neurotrauma. 2021 Aug doi: 10.1089/neu.2020.7597. [DOI] [PubMed] [Google Scholar]
Comparative Study to Assess the Effectiveness of Semi-Recumbent Lateral Position vs Semi-recumbent Position to Prevent VAP and ARDS in TBI Patients Requiring Mechanical Ventilation
Ventilator-associated pneumonia (VAP); a common nosocomial infection in the intensive care unit (ICU) among Traumatic brain injury (TBI) patients results in increased morbidity, mortality, length of ICU stay and hospital cost in patients requiring mechanical ventilation. We have assessed the effectiveness of semi-recumbent lateral positioning in comparison with semi‐recumbent positioning to prevent VAP and ARDS in TBI patients requiring mechanical ventilation.
Methods
In a single-blind prospective randomised clinical trial, 100 patients were recruited in the Intensive Care Unit, Trauma Centre, Institute of Medical Sciences, Banaras Hindu University, Varanasi and randomly assigned to the control (n=50) group and intervention group (n=50). Patients in control (n=50) group maintained semi-recumbent position (SRP) with 30-45° head of bed elevation (HOBE) and intervention group (n=50) maintained semi-recumbent lateral position (SRLP) with lateral turning ≥ 45° and head of bed elevation 30-45° every 4 hours. BAL for diagnosis of VAP, GCS, CPIS score, duration of mechanical ventilation, PaO2/FiO2 ratio, incidence of ARDS and development of pressure sores were investigated for 10 days.
Results
SRLP showed significantly lower CPIS score, as well as significantly lower duration of mechanical ventilation and reduction in development of pressure sores along with improvement in GCS. No significant changes in incidence of ARDS could be observed.
Interpretation and Conclusion
SLRP results in a significant decrease in the incidence of VAP, improvement in GCS, decreased duration of mechanical ventilation and development of pressure sores.
Key words
Acute respiratory distress syndrome (ARDS); Traumatic Brain Injury (TBI); Semi-recumbent lateral position (SRLP); Semi-recumbent position (SRP); Ventilator associated pneumonia (VAP).
Necrotizing pancreatitis (NP) occurs in 10% to 15% of all severe acute pancreatitis (SAP) patients and contributes to significant morbidity and mortality. Studies show that critically ill patients suffer from sarcopenia due to factors such as nutritional status, severity of inflammation, and inactivity. The prevalence of sarcopenia is approximately 30-70 % in ICU and new-onset sarcopenia has been reported in nearly 25% of NP patients.
Objectives
The primary objective of this study is to assess the prevalence of sarcopenia in SAP patients in an ICU setting and its impact on clinical outcomes. Materials and methods: A retrospective analysis of demographic data and radiological measurements from computed tomography (CT) studies from institutional database of patients aged >18 years with SAP from Jan 2019 to Dec 2022 was performed after excluding the pregnant patients, patients on steroid therapy, patients with chronic liver disease and chronic kidney disease or pre-existing neuromuscular disease. Sarcopenia assessment was performed by calculating the Psoas Muscle Index (PMI) and the Hounsfield unit average calculation (HUAC) using cross-sectional CT images of the abdomen at the level of the L4 vertebral body using the area tool under Intellispace portal image viewer software®. The PMI and HUAC are validated surrogates for muscle quantity and muscle density. Baseline nutritional status was evaluated using the prognostic nutritional index (PNI, per mm3). Independent samples t-test / Mann Whitney U test or Chi-square test/Fisher exact tests were used. A p-value < 0.05 was considered significant. SPSS-23® was used for data analysis.
Results
A total of 1050 patients were admitted to the ICU in the study period. and 102 patients were diagnosed with SAP. After excluding 35 patients, 67 were analyzed. The mean age was 36.13 ± 10.6 years and the male was 83.6% (n = 56). The most common etiology was biliary pancreatitis [n=28 (46%)]. Patients required inotropic support in 80.6% (n=54), mechanical ventilation in 79.1% (n=53), renal replacement therapy in 40.3% (n=27), and documented infected necrosis in 83.6%(n=56) patients. The mean PNI in the total cohort was 36.48 ± 9.94 per mm3. The mean PMI-VB in the total cohort was 1.21±0.41 and in sarcopenic group was 0.75 (0.67-0.83) and non-sarcopenic group was 1.16 (1.07-1.51). The mean HUAC in the total cohort was 35.92 ± 9.94. Based on the first CT scan using both PMI-VB and HUAC sarcopenia was present in 28.4% (n=19) of patients and overall sarcopenia was observed in 23 patients during course in ICU. The mortality was significantly higher in sarcopenic patients (P<0.007). In sarcopenic patients, age, co-morbidities, and mortality were significantly more.
Conclusion
In our study cohort of SAP patients in ICU settings, sarcopenia was present in 28.4% of patients as assessed by the initial CT scan, and a total of 34.3% of patients developed during the hospital course. Sarcopenic patients were older, had more co-morbidities, required more renal replacement therapy, and had a higher mortality. However, prospective studies in larger groups can be performed to assess the impact of sarcopenia on the outcome of SAP patients.
Keywords
Sarcopenia; Severe acute pancreatitis; critical care; outcome
References
1.Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med. 2006 May 18;354(20):2142–50. doi: 10.1056/NEJMcp054958. 16707751 [DOI] [PubMed] [Google Scholar]
2.Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. 2010 Sep;139(3):813–20. doi: 10.1053/j.gastro.2010.06.010. 20540942 Epub 2010 Jun 9. [DOI] [PubMed] [Google Scholar]
3.Kizilarslanoglu MC, Kuyumcu ME, Yesil Y, Halil M. Sarcopenia in critically ill patients. J Anesth. 2016 Oct;30(5):884–90. doi: 10.1007/s00540-016-2211-4. 27376823 Epub 2016 Jul 4. [DOI] [PubMed] [Google Scholar]
4.Moisey LL, Mourtzakis M, Cotton BA, Premji T, Heyland DK, Wade CE, Bulger E, Kozar RA, Nutrition and Rehabilitation Investigators Consortium (NUTRIC) Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Crit Care. 2013 Sep 19;17(5):R206. doi: 10.1186/cc12901. 24050662;PMC4055977 [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Baggerman MR, van Dijk DPJ, Winkens B, van Gassel RJJ, Bol ME, Schnabel RM, Bakers FC, Olde Damink SWM, van de Poll MCG. Muscle wasting associated co-morbidities, rather than sarcopenia are risk factors for hospital mortality in critical illness. J Crit Care. 2020 Apr;56:31–36. doi: 10.1016/j.jcrc.2019.11.016. 31805466 Epub 2019 Nov 26. [DOI] [PubMed] [Google Scholar]
7.Durand F, Buyse S, Francoz C, Laouénan C, Bruno O, Belghiti J, Moreau R, Vilgrain V, Valla D. Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography. J Hepatol. 2014 Jun;60(6):1151–7. doi: 10.1016/j.jhep.2014.02.026. 24607622 Epub 2014 Mar 6. [DOI] [PubMed] [Google Scholar]
8.Yoo T, Lo WD, Evans DC. Computed tomography measured psoas density predicts outcomes in trauma. Surgery. 2017 Aug;162(2):377–384. doi: 10.1016/j.surg.2017.03.014. 28551380;PMC5893151 Epub 2017 May 24. [DOI] [PMC free article] [PubMed] [Google Scholar]
A pressure injury (PI) is defined as a “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear”1 Data from Agency for Healthcare Research and Quality (AHRQ) have shown that PIs are associated with increased length of hospital stay, morbidity, mortality and associated costs.2 Considering its significant impact on patient recovery, cost of care and burden on healthcare system, many clinical practice guidelines have been developed for PI prevention.3, 4 Despite compliance with these guidelines and advances in health technology, patients in the intensive care unit (ICU) continue to develop pressure injuries. A recent meta-analysis reported a cumulative pressure ulcer prevalence of 16.9–23.8% (95% CI) for adults in intensive care.5
Objectives
Objective of this study is to assess knowledge, attitude, and practices (KAP) towards pressure injuries in Intensive Care Units (ICUs) at public sector tertiary care institute/hospitals India.
Materials and Methods
This observational, cross-sectional study was approved by Institutional Ethical Committee of IGIMS, Patna. Centres recruitment from various parts of India is being done on an invitation basis. Participation of centres is purely voluntary. ICUs at public sector tertiary care institutes/ hospitals in India are being included. Paediatric or Neonatal ICUs and ICUs from private sector hospitals/ institutes were excluded. A cross-sectional questionnaire-based survey was conducted for 6 weeks. An invitation link was sent to the intensivists. Each centre collected data from their ICU about the practices regarding the pressure sore prevention in the proforma. Data is being compiled and entered in Microsoft Excel and analysed by SPSS version 19. Main outcomes that were measured were presence of written protocol for pressure injury prevention, along with practices pattern of patient positioning and use of various support surfaces.
Results
Data from 36 ICU of 17 institutes representing 550 beds were collected.44.44% were mixed ICU with two full time intensivists in38.8% ICU's. Teaching on PIs and audit of PIs is being done in 47% and 7% ICUs. Standard foam mattresses were used in 61% ICUs, whereas no air mattresses were available in 41.6% ICUs. However, turning on bed and six hourly patient positioning was done in 77.7% and 61 % respectively. Bolstering and soft silicon dressing were not available in 35% ICUs. Moisturisation, in any form, was done regularly in 38.89% ICUs.
Discussions
The lack of knowledge regarding the importance of pressure injuries, as evidenced by the absence of structured teaching-training programs and documented guidelines for PI prevention, was found in different ICUs. Poor knowledge and practices regarding prevention, early identification, multi-disciplinary approach in management of PIs are important weaknesses to be addressed. Practice guidelines for prevention and management of PIs, particularly for Indian subcontinent, needs to be formulated.
References
1.Kottner Jan, et al. “Prevention and treatment of pressure ulcers/injuries: The protocol for the second update of the international Clinical Practice Guideline 2019.”. Journal of tissue viability. 2019;vol. 28(2):51–58. doi: 10.1016/j.jtv.2019.01.001. [DOI] [PubMed] [Google Scholar]
2.Agency for Healthcare Research and Quality (AHRQ) Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions. Rockville, MD: Agency for Healthcare Research and Quality; 2017. [Google Scholar]
3.National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. [Google Scholar]
4.Wound, Ostomy and Continence Nurses Society (WOCN) Guideline for Prevention and Management of Pressure Ulcers (Injuries). WOCN Clinical Practice Guideline Series 2. Mount Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2016. [DOI] [PubMed] [Google Scholar]
5.Chaboyer W.P, Thalib L, Harbeck E.L, Coyer F.M, Blot S, Bull C.F, Lin F.F. Incidence and prevalence of pressure injuries in adult intensive care patients: A systematic review and meta-analysis. Crit. Care Med. 2018;46(11):e1074–e1081. doi: 10.1097/CCM.0000000000003366. [DOI] [PubMed] [Google Scholar]
Trauma is one of the leading causes of morbidity and mortality in India. At present the trauma care systems are still at developmental stage, especially in the rural and semi urban settings in India. Morbidity due to trauma predominantly influences quality of life1. The quest to improve survival is now being replaced with efforts to create survivors with functional independence. To date, the question remains as to the restoration of functional outcomes and re-integration of polytrauma survivors into normalcy. Hence, studies with emphasis on measuring outcomes other than mortality are needed to assess the non-fatal consequences of injuries. Very few studies measured outcomes after polytrauma2. We examined the outcomes of polytrauma patients at the end of 1 year after discharge and assessed the reliable risk factors of poor outcomes.
Objectives
To assess outcomes of polytrauma patients measured using patient reported pain, functional dependence, return to work and mortality after one year of discharge from hospital
To identify possible and relevant determinants of above outcomes
Materials and methods
This retrospective cohort study was conducted in GANGA Medical Centre (Level 1 trauma centre), Coimbatore. Data was collected from all polytrauma admissions hospitalised and survived to discharge during the period from JANUARY 2021-DECEMBER 2022 (n=226). Details regarding Demographics, Injury characteristics, co-morbidities were collected from our trauma database. 150 patients were successfully contacted through telephone and included in the study to collect self reported information on pain complaints, functional independence and return to work status using a questionnaire. Univariate and multivariate logistic regression analysis was performed to determine significant predictors of poor outcomes.
Results
In our study, 90% were male. Patients were dichotomized based on participant's median age of 35 years and median Injury severity score of 25. At the follow-up of 1year, out of 226 selected participants, 70 were lost to follow-up and 6 patients died. Of the 150 remaining patients, only 34%(n=51) returned to work or preinjury status, 19% (n=28) were dependent on others for their daily activities, 25% (n=37)reported persistent pain. Univariate analysis showed ISS>25 (p=0.03)and presence of head injury(p=0.01) as predictors of inability to return to work and head injury(p=0.03) as predictive of functional dependence. On further logistic regression analysis, ISS>25 was found to have strong influence over lack of return to work/ preinjury status. There was no correlation between any of the factors and persistent pain.
Discussions
Out of 3 measured outcomes, we found significant reduction in return to work/preinjury status in contrast to study conducted by Holtslag et al.2, 3 In our study we found the association of head Injury and ISS>25 with poor outcomes in polytrauma. Higher ISS, an established predictor of mortality, also showed a threat to nonfatal consequences in our study. Influence of Physiological parameters, length of ICU stay can also be included for further analysis. Comprehensive assessment of trauma care success must include outcome measures other than short term survival metrics. This study measured outcomes by patient's subjective perception of quality of life. This calls for new studies to systematically approach morbidity after injury and assess barriers to their social re-adaptation and to develop strategies to go beyond immediate medical care.
References
1.Livingston DH, Tripp T, Biggs C, et al. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma. 2009 Aug;67(2):341–8. doi: 10.1097/TA.0b013e3181a5cc34. discussion 348-9. [DOI] [PubMed] [Google Scholar]
2.Holtslag HR, Post MW, van der Werken C, et al. Return to work after major trauma. Clin Rehabil. 2007 Apr;21(4):373–83. doi: 10.1177/0269215507072084. [DOI] [PubMed] [Google Scholar]
3.Murlidhar V, Roy N. Measuring trauma outcomes in India: an analysis based on TRISS methodology in a Mumbai university hospital. Injury. 2004 Apr;35(4):386–90. doi: 10.1016/S0020-1383(03)00214-6. [DOI] [PubMed] [Google Scholar]
4.Soberg HL, Finset A, Bautz-Holter E, Sandvik L, Roise O. Return to work after severe multiple injuries: a multidimensional approach on status 1 and 2 years postinjury. J Trauma. 2007 Feb;62(2):471–81. doi: 10.1097/TA.0b013e31802e95f4. [DOI] [PubMed] [Google Scholar]
Complicated urinary tract infections (UTIs) are a more prevalent and burdensome global health issue. Escherichia coli is the primary causative agent in the majority of UTIs. Ceftriaxone sulbactam EDTA combination has been developed to combat MDR-ESBL, and MBL-producing gram negative organisms.
Objectives
The objective of this study is to evaluate the effectiveness and safety of ceftriaxone sulbactam EDTA in patients with carbapenem resistant urinary tract infection.
Materials and methods
The study was a single-center, retrospective study. The patient's data was identified through the department patient file archive. All relevant information regarding demographic and baseline characteristics such as gender, age, infection type, source of infection, causative pathogens, laboratory investigations, dosage and regimen of antibiotic therapy were recorded and analyzed.
Results
Total 100 subjects were enrolled in this study, out of which 42 (42%) were male and 58 (58%) were female with an average age of 46.6±14.8 years. Presence of co-morbid condition was reported for 56 (56.0%) patients. Hypertension and diabetes were most common co-morbid conditions reported by 36 (64%) and 20 (36%) of the patients respectively. Upper UTI infection was more common in study population reported in 96% of patients. E. coli was most common pathogen observed in 83% of patients. Patients were started on ceftriaxone sulbactam EDTA after culture report and in those patients who were carbapenem resistant. This was given as monotherapy with dose of 1.5gm IV twice a day to all patients. Approximately, 92 (92.0%) patients cured, and 8 (8%) patients showed improvement in their clinical signs / symptoms at the end of treatment. The average days of symptom resolution was reported as 4.6 ± 2.8 days. Microbiological cure was reported for 94 (94%) of patients. There was no occurrence of any adverse event. Mortality was reported for 2 (2.0%) patients. Average days of hospitalization was 5.5 ± 2.9 days and average duration of therapy was 2 weeks.
Conclusion
Ceftriaxone sulbactam EDTA exhibited a favorable safety profile and was found effective in treatment of carbapenem resistant UTIs addressing antibiotic resistance concerns.
Key words
UTI, Ceftriaxone sulbactam edta, E.coli.
References
1.Mir Mohd Amin, Chaudhary Saransh, Payasi Anurag, Sood Rajeev, Mavuduru Ravimohan S, Shameem Mohd. Ceftriaxone+Sulbactam+Disodium EDTA Versus Meropenem for the Treatment of Complicated Urinary Tract Infections, Including Acute Pyelonephritis: PLEA, a Double-Blind, Randomized Noninferiority Trial. Open Forum Infectious Diseases. October 2019;Volume 6(Issue 10):ofz373,. doi: 10.1093/ofid/ofz373. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Chaudhary M, Mir M. A, Ayub S. G. Safety and efficacy of a novel drug elores (ceftriaxone+ sulbactam+ disodium edetate) in the management of multi-drug resistant bacterial infections in tertiary care centers: a post-marketing surveillance study. The Brazilian Journal of Infectious Diseases. 2017;21(4):408–417. doi: 10.1016/j.bjid.2017.02.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Chaudhary M, Payasi A. A randomized, open-label, prospective, multicenter phase-III clinical trial of Elores in lower respiratory tract and urinary tract infections. Journal of Pharmacy Research. 2013;6(4):409–414. [Google Scholar]
Functional and Verbal Outcomes in Left Sided Decompression Hemicraniectomy After Traumatic Brain Injury: A Retrospective Descriptive Observational Analysis
Decompressive craniectomy (DC) has been a lifesaving surgery for different conditions, including traumatic brain injury (TBI), subarachnoid haemorrhage, and malignant middle cerebral artery (MCA) infarction, especially when medical treatment options are limited.1 However, role of cerebral hemispheric lateralization in functional outcomes post decompression has evoked considerable debate. Although, lateralization affects some specialized cortical functions, lacunae in robust evidence on clinically important outcomes may invoke significant delay and hesitancy to perform left decompressive craniectomy.2 Hence, the purpose of this study is to characterize the impact of left sided DC in TBI by analysing their functional recovery and verbal output during six months of follow up.
Objectives
To assess after left decompressive hemicraniectomy following TBI:
Glasgow Outcome Scale Extended (GOSE) – at six months
Verbal score of Glasgow Coma Scale (GCS) – at admission and six months
Materials and methods
Our retrospective, descriptive, observational study was conducted after retrieving database of patients, who sustained TBI followed by DC. Patients with severe head injury (GCS < 8), aged between 16 to 80 years, who underwent Left DC within 12 – 36 hours of trauma at Christian Medical College Vellore, India between January 2013 – January 2023 were included. Outcome measures of GOSE and verbal score of GCS were recorded. GOSE scores were dichotomized to determine favourable (scores 4-8) versus unfavourable (scores 1-3) outcomes. Verbal scores of GCS were also dichotomized to determine favourable (scores 4,5) versus unfavourable (scores 1-3) outcomes.
Results
We included 136 eligible patients out of 388 total DC (35.05%) performed after TBI. Mean age was 47.18 + 14.30 years, 67.6% were males and 32.4% were females. At six months, 89 out of 136 participants (65.44%) had favourable GOSE scores. At admission, favourable verbal score of GCS was observed in only 33 out of 136 patients (24.26 %). However, at six months, 96 patients (69.85 %) had a favourable verbal score (p<0.00005).
Discussion
Early critics documented poor functional outcome after DC in MCA infarcts, particularly with left (dominant) hemisphere involvement, resulting in patient's dependency on caregivers, increasing their burden.2 In addition, surgical complications and cosmetic malformations were undesirable. However, many randomized studies have demonstrated major decline in mortality and favourable functional outcomes after DC in stroke. Unfortunately, we still lack substantial evidence involving outcome prediction after DC in TBI. Further research should be undertaken to resolve the dilemma associated with consenting for dominant side decompression fearing unfavourable functional outcomes.
Conclusion
Left Decompressive hemicraniectomy demonstrated major benefits, including speech output recovery and reduction in functional dependence within six months post TBI. Hence, caution needs to be emphasized in predicting early, definitive poor functional outcomes involving left sided TBI and deferring surgical management.
References
1.Alam BK, Bukhari AS, Assad S, Siddique PM, Ghazanfar H, Niaz MJ, Kundi M, Shah S, Siddiqui M, Pir MS, Niaz MJ. Functional outcome after decompressive craniectomy in patients with dominant or non-dominant malignant middle cerebral infarcts. Cureus. 2017 Jan 26;9(1) doi: 10.7759/cureus.997. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Kongsawasdi S, Klaphajone J, Watcharasaksilp K, Wivatvongvana P. Prognostic factors of functional recovery from left hemispheric stroke. The Scientific World Journal. 2018 Jan 1:2018. doi: 10.1155/2018/4708230. [DOI] [PMC free article] [PubMed] [Google Scholar]
Correlation of Acute Physiology and Chronic Health Evaluation IV (APACHE IV), Simplified Acute Physiology Score 3 (SAPS 3) and Logistic Organ Dysfunction Score (Lods) Scoring Systems for Patient Outcome in Intensive Care Unit
Clinical assessment of illness severity is essential for estimating mortality and length of stay (LOS) in intensive care unit (ICU).
Objectives
To correlate Acute Physiology and Chronic Health Evaluation IV (APACHE IV), Simplified Acute Physiology Score 3 (SAPS 3) and Logistic Organ Dysfunction Score (LODS) scoring systems for predicting mortality and LOS in ICU.
Material and methods
We performed a prospective observational study in 2023 amongst adult critically ill medical patients. Outcomes including mortality and LOS in ICU were compared using APACHE IV, SAPS-3, and LODS scoring system. All patients having APACHE IV score more than 21, SAPS-3 score more than 13 and LODS score more than zero were included. Patients who had either received cardiopulmonary resuscitation or required palliative care, and those discharged/shifted from ICU within 24 hours of admission were excluded.
Results
The average age of the 400 patients included in this study was 62.2 years, and 212 (53%) were males. The mean scores for APACHE IV, SAPS 3 and LODS were 62.39, 55.24 and 2.86 respectively. The actual mortality rate was 65 (16.25%). The mean scores for APACHE IV, SAPS 3 and LODS amongst the survivors were 56.87, 53.45 and 2.12 respectively. These increased to 90.82, 64.46 and 6.69 respectively in the mortality group. APACHE IV estimated the mortality to be 16.01%. The death rate predicted by SAPS 3 was 29.2% while LODS predicted 14.58% mortality. The area under curve for APACHE IV in estimating mortality was 0.862 (95% CI of 0.814-0.910). Using receiver operating characteristic (ROC) curve, the cut off APACHE IV score was found to be 72.5 (p<0.001) in predicting mortality. In the survivor group, 85.7% patients had APACHE IV < 72.5; whilst amongst those who expired, only 29.2% patients had APACHE IV score <72.5. At a cut off value of 72.5, the sensitivity of APACHE IV score for predicting mortality was 70.8%, specificity was 85.7%, PPV was 48.9%, NPV was 93.8% and accuracy was 83.3%. The area under curve for LODS in predicting mortality was 0.835 (95% CI of 0.778–0.893). Using ROC, we found the cut off value of LODS for predicting mortality to be 4.0. At this cut off score, the sensitivity of LODS for estimating mortality was 76.9%, specificity was 79.4%, PPV was 42%, NPV was 94.7% and accuracy was 79%. The estimated LOS in ICU predicted by APACHE IV scoring was 3.41 days, while the actual LOS was 4.04 days. ROC analysis showed that patients with APACHE IV score > 53 had a LOS > 7 days (p<0.001). Similarly, the cut off for LODS was 2.0 for LOS < 7 days.
Conclusion
APACHE-IV scores best predicted the mortality of critically ill medical patients, and was better than both SAPS-3, which highly overestimated the death rate, as well as LODS, which somewhat underestimated the mortality. Both APACHE-IV and LODS were modestly able to foretell LOS in ICU. Usage of these scoring systems is helpful in predicting outcome, and can benefit decision making in ICU.
References
1.Yousefian M, Ghazi A, Amani F, et al. Mortality rate in patients admitted to the ICU based on LODS, APACHE IV, TRIOS, SAPSII. J Adv Pharmacy Edu Res. 2022;12(1):56–62. [Google Scholar]
2.Rapsang AG, Shyam DC. Scoring systems in the intensive care unit: a compendium. Indian J Crit Care Med. 2014;18(4):220–8. doi: 10.4103/0972-5229.130573. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Sekulic AD, Trpkovic SV, Pavlovic AP, Marinkovic OM, Ilic AN. Scoring systems in assessing survival of critically ill ICU patients. Med Sci Monit. 2015;21:2621–9. doi: 10.12659/MSM.894153. [DOI] [PMC free article] [PubMed] [Google Scholar]
1Department of Pediatric Intensive Care, Kanchi Kamakoti CHILDS Trust hospital, Chennai, Tamil Nadu, India, Phone: +91 9032558980, e-mail: ageerukkcth@gmail.com
1Department of Pediatric Intensive Care, Kanchi Kamakoti CHILDS Trust hospital, Chennai, Tamil Nadu, India, Phone: +91 9032558980, e-mail: ageerukkcth@gmail.com
2–9Department of Pediatric Otorhinolaryngology, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
Tracheostomy is a surgical procedure used in critically ill children to facilitate airway management and weaning from mechanical ventilation. The literature regarding indications and outcomes of tracheostomy in paediatric population is limited.
Objectives
To study the indications for tracheostomy in critically ill children.
To study the outcomes of critically ill children with tracheostomy.
Materials and methods
Retrospective analysis of tracheostomy data for patients admitted to the PICU between April 2009 and July 2023. Demographics, indications for tracheostomy, complications and outcomes were recorded. The indication was recorded in one of four categories—upper airway obstruction (UAO), central neurological impairment (CNI), prolonged mechanical ventilation (PMV includes children with acute infective/inflammatory conditions requiring mechanical ventilation for more than 21 days who were not included in any of the other 3 groups) and peripheral neuromuscular disorders (NMD).
Results
During the study period, a total of 119 children underwent tracheostomy. Males were 76 (64%). Median age at presentation was 38 months (IQR 13-68). Majority (n=83, 69.7%) were under 5 years of age. Most common indication for tracheostomy was CNI (n=43, 36.1%), followed by UAO (n=34, 28.6%), PMV (n=24, 20.2%) and NMD (n=18, 15.1%). Complications were seen in 28 (23.5 %) children. Most common complication was granuloma (n=11, 39.2%) followed by bleeding (n=5, 17.9%), suprastomal collapse (n=3, 10.7%). Stoma infection, maggots and subcutaneous emphysema were seen in 2 (7.1%) patients each. Tracheocutaneous fistula, accidental decannulation and false passage were seen in 1 (3.6%) patient each. Decannulation was successful in 47 (39.5%) patients. Based on indication for tracheostomy, more children with NMD (n=9, 50%) got decannulated followed by UAO (n=14, 41%), PMV (n=9, 37.5%) and CNI (n=15, 34.8%). Based on age at presentation, decannulation rates were significantly higher in children more than 5 years as compared to children less than 5 years (19 vs 28, 52.7% vs 33.7%, p 0.047). Five (4 %) children were lost to follow up. Two children died (1.7%) due to the primary illness. The remaining children (n=65, 54%) are still being followed up.
Conclusions
In our cohort, the most common indication for tracheostomy was CNI & the most common complication was granuloma formation. Approximately of tracheostomized children were decannulated & decannulation rates were higher in children with NMD. Children more than 5 years had significantly higher decannulation rates.
References
1.Sachdev A, Chaudhari ND, Singh BP, Sharma N, Gupta D, Gupta N, Gupta S, Chugh P. Tracheostomy in Pediatric Intensive Care Unit-A Two Decades of Experience. Indian J Crit Care Med. 2021 doi: 10.5005/jp-journals-10071-23893. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Jain MK, Patnaik S, Sahoo B, Mishra R, Behera JR. Tracheostomy in Pediatric Intensive Care Unit: Experience from Eastern India. Indian J Pediatr. 2021 doi: 10.1007/s12098-020-03514-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
Effect of High Protein Normo-Caloric Nutrition on Skeletal Muscle Wasting in Critically Ill Mechanical Ventilated Patients: A Randomized Double-blind Study
Muscle wasting is a common finding among patients in intensive care units (ICU) and is associated with poor outcomes. During ICU stay, delivering appropriate nutritional support minimize the muscle loss which can be reliably track using ultrasound.
Objective
We sought to measure the impact of high-dose protein based nutrition on muscle mass, muscle echogenicity and fascial characterstics in critically ill patients.
Methods
We conducted a randomized prospective, double-blind trial in 30 critically ill patients, anticipated to be mechanically ventilated for >48 hours. Patients recived 1.5gm/kg/day of protein in the high protein group (HPF) compared to 1gm/kg/day of protein in standard feed group (SF). Muscle thickness, cross-sectional area, echogenicity and pennation angle was measured on days 1, 3, 5, and 7 after admission to critical care. Right lower limb Vastus lateralis, medial head of gastrocnemius were investigated.
Results
We found progressive loss of muscle mass from day1 to 7 in both the groups. However in the gastrocnemius and vastus lateralis muscles, muscle thickness, and cross-sectional area were significantly high in the HPF over 7 days. Change in echogenicity, pennation angle were not significant between the groups.
Conclusion
In critically ill, mechanically ventilated patients, high protein normo-caloric nutrition decreases the muscle wasting in lower limb weight-bearing muscles, during first seven days of ICU stay. However, the changes in qualitative muscle parameters (echogenicity and pennation angle) were not significant.
References
1.Kress JP, Hall JB. ICU-acquired weakness and recovery from critical illness. New England Journal of Medicine. 2014;370:1626–35. doi: 10.1056/NEJMra1209390. [DOI] [PubMed] [Google Scholar]
2.Connolly B, Macbean V, Crowley C, et al. Ultrasound for the assessment of peripheral skeletal muscle architecture in critical illness: A systematic review. Critical Care Medicine. 2015;43:897–905. doi: 10.1097/CCM.0000000000000821. [DOI] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, Sanjay Gandhi Post graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9910536136, e-mail: khalidzafar123@gmail.com
1Department of Critical Care Medicine, Sanjay Gandhi Post graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9910536136, e-mail: khalidzafar123@gmail.com
2,5–7Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Circulatory shock is not an uncommon clinical condition in critically ill patients. This can affect various organs including liver. Usually, acute liver injury is identified as a change in biochemical values. Recent advancements in ultrasonography, like transient elastography, commonly known as fibroscan, has been used to detect liver dysfunction in critically ill patients [1]. However, application of 2D shear wave elastography (2D SWE) has not been studied in patients with circulatory shock. Objective: We aimed to study prevalence of increased liver stiffness in ICU patients having circulatory shock.
Materials and methods
After Institutional Ethics Committee approval, this prospective study screened all adult ICU patients having septic shock within one week of onset. Those with normal liver function test (LFT) and normal liver echogenicity on ultrasonography before onset of shock were considered for inclusion. Exclusion criteria were: known liver disease, congestive heart failure, raised intraabdominal pressure and recent abdominal surgeries. All included patients underwent liver stiffness assessment by 2D SWE technique between days 2 and 7 after the onset of septic shock, which was performed by an experienced radiologist using Aixplorer®, Super Sonic Imagine (Aix-en-Provence, France) with XC6-1 (Single Crystal Curved) convex probe as per recommendations from the World Federation for Ultrasound in Medicine and Biology guidelines published in 2018 [2]. The normal range is 2-7 kPa, highest possible value is 75 kPa.
Results
During the study period (Jun-Nov 2023), 104 patients screened, and 17 patients met eligibility criteria. At ICU admission, included 17 patients had median age of 37 years (IQR 18-78) and 53% were females, Charlsons comorbidity index was 4 (IQR 0-6) and SOFA score was 8 (IQR 1-14). At inclusion, median day of septic shock duration was 6 (IQR 2-7) with median SOFA score 7 (IQR 3-11). The median vasopressor cumulative dose at the time of assessment was 120.4 × 103 mcg (IQR 7.84-220 × 103mcg). The liver stiffness was elevated in all patients with a median value of 30.4 kPa (IQR 16.3-65).
Discussion
The measurement of liver stiffness is being routinely done for diagnosis of liver diseases and is well accepted in non-ICU patients for the diagnosis and grading of cirrhosis, acute and chronic hepatitis. So far, no study has been done for assessment of liver stiffness in patients having septic shock. Our study is first to explore liver damage assessed by 2D SWE in ICU patients having septic shock which revealed elevated median value of liver stiffness.
Conclusion
Our study found out that liver stiffness is significantly higher in septic shock patients as measured by 2D SWE.
References
1.Koch et al: Increased liver stiffness denotes hepatic dysfunction and mortality risk in critically ill non cirrhotic patients at a medical ICU. Critical Care. 2011;15:R266. doi: 10.1186/cc10543. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Ferraioli G, et al. Liver ultrasound elastography: an update to the world federation for ultrasound in medicine and biology guidelines and recommendations. Ultrasound Med. Biol. 2018;44:2419–2440. doi: 10.1016/j.ultrasmedbio.2018.07.008. [DOI] [PubMed] [Google Scholar]
In our study we tried to find out varied clinical presentation, factor related to mortality, varied complication, so they can be assessed for early intervention to prevent mortality.
Introduction
Dengue Fever caused by Dengue virus transmitted by mainly Aedes Aegypti and by Aedes Albopictus mosquitoes. Incidence of Dengue Fever in the world is about 390 million in more than 100 countries, with about 70% of incidence in Asia. INDIA is severely affected by dengue every year and pose a great economic burden to our health care system. so, in our study we tried to find out varied presentation, what could be the intervention to prevent mortality and fatal complication of dengue fever in a patients who had been admitted in a tertiary care centre hospital in GORAKHPUR -eastern part of UTTAR-PRADESH.
Method
The observational study was conducted at CITY HOSPITAL GORAKHPUR, a tertiary health care institute in UTTAR PRADESH. The study period was 6 month from JUN-2023 to NOVEMBER-2023. All patient who were IG-M and DENGUE-NS1 positive by ELISA technique included in our study. All included patient were categorized on the basis of clinical symptoms and sign, age group, sex, haematological and biochemical investigation, intervention and outcome. Demographics, clinical, haematological and biochemical laboratory data and outcome was recorded from case sheet in predesigned format.
Results
The total enrolled patients were 200 of whom 156 (78%) were male and 44 (22%) were female. Patient between age group of 26-35 (29%) was found maximum affected followed by 16-25 (16.5%) and 36-45 (16%) and minimum in 76-85(1.5%) age group in both sex group. The most common presenting symptoms was fever (100%) followed by vomiting (72%), headache (44%), body ache (33%), abdominal pain (25%), cough (24%). Most common clinical sign was pallor (30%) followed by hepatomegaly (26.5%), tachycardia (23%), pleural effusion (15%). Out of 200 patients 76 (38%) patients were diagnosed as CLASSICAL DENGUE FEVER, 98 (49%) as DHF and 26 (13%) as DSS. In view of intervention we transfuse FFP+PLATELET to 11 patients (5.5%), platelet to 14 patients (7%). Total 5 (2.5%) patients put on ventilator, among them mortality was 100%, 7 (3.5%) patients put on NIV support. In view of outcome of patients 169 (84.5%) were improved and discharge in stable condition, 12 (6%) were refer to higher centre, 14 (7%) were LAMA. Total mortality number was 5 (2.5%), among them 4 were diagnosed as a case of DSS and 1 was DENGUE EXPANDED SYSNDROME, 3 were young without having comorbidity and 2 patients having comorbidity of T2DM and HTN. Number of cases were highest in October 82 (41%) followed by September 69 (34.5%), November 26 (13%), August (8.5%) and least cases were in June and July (3%).
Conclusion
Dengue fever has emerged as an important cause of febrile illness in eastern part of UTTAR PRADESH. Dengue fever poses a huge burden to health care system. So high index of suspicion, early diagnosis and prompt intervention may help us to reduce mortality and decrease the economic burden to patients as well. Mortality mainly related with late presentation to hospital, having comorbidity, multi-organ dysfunction, and hemodynamically unstable patients.
Burnout and poor sleep are prevalent among ICU doctors, negatively impacting their well-being and patient care. Early detection and intervention are crucial for preventing adverse consequences.
Aims and Objectives
This study aimed to evaluate the feasibility and efficacy of a mobile app for detecting burnout and sleep issues in ICU doctors.
Methods
Fifty-two ICU doctors participated after providing informed consent. They installed the app, which included self-assessment tools for burnout and sleep quality, educational resources, and coping strategies like breathing exercises and podcasts. App usage and user feedback were collected over seven days.
Results
The majority of users fall within the 30-35 age group, (25-30 years:- 22% 30-35 years: 58% 35-40 years: 20%) with a predominantly male user base (Male: 88% Female 12%) The app was well-received, with 76% of doctors rating its ease of use as 8/10 or above. Repeated usage was high, with 76% using the app 2-4 times or more daily. Self-reported burnout was identified in 26% of doctors, and 31% reported poor sleep, exceeding typical rates among ICU staff. Additionally, 38% expressed a need for integrated coping strategies within the app. The app's overall usefulness was rated as 8.3 (out of 10) on average.
Demographics: The majority of users fall within the 30-35 age group, highlighting the relevance of the app to mid-career doctors. The predominantly male user base may suggest variations in stressors or coping mechanisms based on gender. App Feasibility and User Acceptance: High user acceptance was demonstrated by the ease of use rating (76% rated 8/10 or above) and repeat usage (76% used the app 2-4 times or more daily). This suggests the app has potential for real-world implementation and engagement among ICU doctors. Burnout and Sleep Detection: The self-reported rates of burnout (26%) and poor sleep (31%) exceeded typical rates in ICU staff, highlighting the app's ability to identify these prevalent issues. This underscores the need for proactive intervention and support for ICU doctors’ well-being. Coping Strategies and App Improvement: The demand for integrated coping strategies (38% of doctors) indicates a valuable direction for app development. Future iterations can incorporate tailored resources like breathing exercises, mindfulness practices, and stress management tools based on individual needs and preferences. Strengths of the Mobile App for Detecting Burnout in ICU Doctors:
Novel and Convenient Approach: The mobile app offers a unique and accessible way to screen for burnout and poor sleep in busy ICU doctors compared to traditional methods. Doctors can use the app on their phone during a short break, instead of needing to schedule a lengthy in-person assessment.
Ease of Use and Acceptance: The study found that the app was user-friendly, with most doctors rating it highly and using it regularly. This suggests that it could be readily adopted by ICU staff.
Effective in Identifying Burnout and Sleep Issues: The app successfully detected a higher percentage of burnout and poor sleep cases compared to typical rates among ICU doctors. This highlights its potential for early intervention and support.
Doctors Find it Useful: Overall, the study participants viewed the app as a valuable tool, suggesting its potential to improve their well-being and potentially patient care.
Limitations of the Study:
Small Sample Size: With only 52 participants, the study needs further research with larger groups to solidify its findings and ensure generalizability.
Short-Term: The study only monitored the doctors for a week, making it difficult to assess the app's long-term impact on burnout and sleep quality.
Lack of Comparison Group: Comparing the app's effectiveness to other burnout detection methods would provide a clearer picture of its unique benefits and drawbacks.
Self-Evaluation Reliability: The study relied on self-reported data, which might not always be accurate. Future research could incorporate additional assessment methods for better accuracy.
Conclusion
The study demonstrates the feasibility and potential impact of a real-time monitoring tool for burnout in ICU doctors through a mobile application. The positive response indicates the value of such interventions in supporting the mental health of healthcare professionals. Future iterations can focus on refining the app based on user feedback and expanding the study to a larger and more diverse population. Further research is warranted to refine the app and evaluate its long-term efficacy in promoting well-being and improving patient care among ICU staff.
1.Papazian L, Hraiech S, Loundou A, et al. High-level burnout in physicians and nurses working in adult ICUs: a systematic review and meta-analysis. Intensive Care Med. 2023;49:387–400. doi: 10.1007/s00134-023-07025-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Ramírez-Elvira S, Romero-Béjar JL, Suleiman-Martos N, Gómez-Urquiza JL, Monsalve-Reyes C, Cañadas-De la Fuente GA, Albendín-García L. Prevalence, Risk Factors and Burnout Levels in Intensive Care Unit Nurses: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021 Oct 30;18(21):11432. doi: 10.3390/ijerph182111432. 34769948;PMC8583312 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Chuang CH, Tseng PC, Lin CY, Lin KH, Chen YY. Burnout in the intensive care unit professionals: A systematic review. Medicine (Baltimore) 2016 Dec;95(50):e5629. doi: 10.1097/MD.0000000000005629. 27977605;PMC5268051 [DOI] [PMC free article] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, Sanjay Gandhi Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 7905819452, e-mail: umadrsingh045@gmail.com
1Department of Critical Care Medicine, Sanjay Gandhi Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 7905819452, e-mail: umadrsingh045@gmail.com
2,6–8Department of Critical Care Medicine, Sanjay Gandhi Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3,4Department of Microbiology, Sanjay Gandhi institute of Medical Sciences, Lucknow, Uttar Pradesh, India
5Department of Gastroeneterology, Sanjay Gandhi Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Recent studies reveal CMV reactivation in apparently immunocompetent patients during critical illness, which remains unexplored in acute necrotising pancreatitis (ANP), a disease known for increase chances of infections (bacterial and fungal), during their clinical course.
Objective
To study the prevalence of cytomegalovirus (CMV) reactivation in critically ill acute necrotizing pancreatitis patients (ANP).
Materials and methods
After institutional ethics committee approval, this study screened all adult ICU patients having the diagnosis of ANP with at least 2 week duration of illness, for CMV seropositivity (Anti-CMV IgG). Exclusions comprised patients <18 years, expected survival <72 hours, pancreatitis duration >10 weeks, recent antiviral use, immune deficiencies, haematological malignancies, immunosuppressive medication, chemotherapy/radiotherapy, and pregnancy. In all eligible ANP patients with presence of Anti-CMV IgG, plasma samples were collected until the 10th week of illness or ICU discharge (whichever comes first). CMV reactivation was defined as plasma viral load >1000/cc.
Result
During the study period (Jun-Nov 2023), 16 out of 22 ANP patients met eligibility criteria. At ICU admission, included patients had median age 37.5 years (IQR 19-70); 81% males, Charlson's co-morbidity index 0 (IQR 0-6) and SOFA score 6 (IQR 3-13). The median day of illness at inclusion was 28 (IQR 14-57) with CTSI score 10 (IQR 6-10). CMV reactivation occurred in 6 of 16 patients (37.5%). The median reactivation duration was at 32nd day, with median copies of 2800/cc. The clinical characteristics of patients having CMV reactivation vis-a-vis non-reactivation were: Age 38 vs 33 (p= 0.78), Charlson's co-morbidity index 0 vs 0 (0.33), SOFA 6 vs 5.5 (p=0.47), CTSI score 10 vs 9 (p=0.31), duration of ICU stay 53 vs 28 (p=0.32). The mortality rate in CMV reactivation group was 66.66% compared to 20% in the non-reactivation group (p=0.07) at ICU discharge.
Discussion
CMV reactivation has been reported in apparently immunocompetent ICU patients ranging from 30% to as high as 60% in various cohorts (1,2,3). Ong et al studied the effect of CMV reactivation on mortality in immunocompetent acute respiratory distress syndrome (ARDS) patients. Of 399 patients, reactivation occurred in 27 %, associated with increased ICU mortality (4). Among septic shock cohort (329 patients), herpesvirus reactivations were documented in 68% patients without prior immunodeficiency (5). A systematic review by Phillips Lachance et al showed that CMV reactivation is associated with worst outcome including organ failure rates, extended ICU stays as well as higher mortality (6). These findings emphasize the urgent need for early identification and treatment for CMV reactivation in these critically ill patients.
Conclusion
CMV reactivation commonly occurs in critically ill ANP patients during their clinical course. These patients have higher mortality rate in comparison to ANP patients without CMV reactivation.
References
1.Ong DS, et al. Crit Care Med. 2015;43:394–400. doi: 10.1097/CCM.0000000000000712. [DOI] [PubMed] [Google Scholar]
HLH comprises of hyperinflammatory syndrome caused by excessive cytokine release, triggered by genetic or acquired overactivation of macrophages, T-cells and NK cells, which can be primary or secondary.1 HLH shares similarity with other inflammatory conditions in ICU eg. Sepsis, hence diagnosis is challenging and an under-recognized entity due lack of clear definition and lack of diagnostic work-up in critically-ill.2 Diagnosis of HLH is currently based on Henter et al, HLH-2004 criteria and H-score developed by Fardet et al.3, 4 ICU patients have higher incidence of hemophagocytosis, it's neither pathognomic nor required for HLH diagnosis.5 This retrospective analysis was performed to analyze profile and outcomes in critically-ill with suspected reactive HLH.
Objectives
Clinical, laboratory profile and outcomes in patients with suspected HLH. Classify patients based on HLH-2004 criteria and determine the cut-offs for H-score and inflammatory markers.
To identify the cut-offs for inflammatory markers consistent with HLH, duration of ICU-stay and mortality.
Materials and methods
Retrospective analysis of ICU patients admitted in previous 18 months, who were evaluated with clinical suspicion of HLH having fever and hyperferritinemia (>500) were analyzed. Demographic, APACHE-2, clinical, laboratory and radiologic parameters were collected. As per HLH-2004 criteria patients were categorized into probable-HLH if they had ≥5 criteria, 3-4 as possible-HLH and <3 criteria to be unlikely-HLH. H-score was evaluated. In patients who did not undergo Bone-marrow examination other components were considered except bone marrow and termed as ‘(H-) score (H-minus score)’. Clinical, laboratory parameters and outcomes were analyzed.
Results
A total of 55 patients were evaluated with suspicion of reactive HLH, which included 29 males and 26 females. 18 patients deceased (32.7%) and 37(67.3%) patients improved. Higher Age, APACHE-2, female sex, higher ferritin, CRP, Procalcitonin values, elevated INR and presence of ARDS was associated with mortality. As per HLH-2004 criteria, patients classified as Unlikely-HLH 29.09%(n=16), possible-HLH 52.73%(n=29) and probable-HLH 18.18%(n=10). Categorized into Encephalopathic phenotype (n= 26 patients) and coagulopathic phenotype (n=33 patients). The mean score(H-) in patients who did not undergo Bone-marrow examination was 193.74 ± 35.35. Total of 34 patients (61.82%) received steroids and 5 patients received IVIg along with steroids. ROC-analysis to identify values below which HLH was unlikely and the best cut-offs were ferritin-16067, APACHE-18, (H-) score-192, CRP-169, procalcitonin-4.81 and Triglycerides-225. Ferritin value above 50056.5 was independently associated with mortality (AUC=0.7628, Sn=0.9730, Sp=0.4444).
Discussions
Study done by Knaak et.al showed cut-off of H-score & ferritin to be 168 and 9083µg/L respectively for diagnosis of HLH. Higher H-score was independently associated with mortality. In a study done by Meena et.al H-score and ferritin cut-offs were 203.8±64.9 and 1197µg/L respectively.6, 7 In comparison to our study where HLH was unlikely with (H-)score below 193 and ferritin cut-offs were higher at 16067µg/L below which HLH was unlikely.
Conclusion
In critically-ill cohort Bone-marrow examination is not essential for diagnosis of HLH. Ferritin cut-off below 16067µg/L ruled out HLH with Sensitivity of 81.25% and Specificity of 53.5 percent. Cut-offs for inflammatory markers and (H-)score were significantly higher when compared to previous established values.
References
1.Lachmann G, La Rosee P, Schenk T, Brunkhorst FM, Spies C. Hemophagocytic lymphohistiocytosis: a diagnostic challenge on the ICU. Anaesthesist. 2016;65(10):776–86. doi: 10.1007/s00101-016-0216-x. [DOI] [PubMed] [Google Scholar]
2.Lachmann G, Spies C, Schenk T, Brunkhorst FM, Balzer F, La Rosee P. Hemophagocytic lymphohistiocytosis: potentially underdiagnosed in intensive care units. Shock. 2018;50(2):149–55. doi: 10.1097/SHK.0000000000001048. [DOI] [PubMed] [Google Scholar]
3.Henter JI, Horne A, Arico M, Egeler RM, Filipovich AH, Imashuku S, et al. HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer. 2007;48(2):124–31. doi: 10.1002/pbc.21039. [DOI] [PubMed] [Google Scholar]
4.Fardet L, Galicier L, Lambotte O, Marzac C, Aumont C, Chahwan D, et al. Development and validation of the HScore, a score for the diagnosis of reactive hemophagocytic syndrome. Arthritis Rheumatol. 2014;66(9):2613–20. doi: 10.1002/art.38690. [DOI] [PubMed] [Google Scholar]
6.Knaak C, Nyvlt P, Schuster FS, Spies C, Heeren P, Schenk T, et al. Hemophagocytic lymphohistiocytosis in critically ill patients: diagnostic reliability of HLH-2004 criteria and HScore. Crit Care. 2020 May 24;24(1):244. doi: 10.1186/s13054-020-02941-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Meena NK, Sinokrot O, Duggal A, Alpat D, Singh ZN, Coviello JM, et al. The Performance of Diagnostic Criteria for Hemophagocytic Lymphohistiocytosis in Critically Ill Patients. J Intensive Care Med. 2019:885066619837139. doi: 10.1177/0885066619837139. [DOI] [PubMed] [Google Scholar]
Colonic complications occur in 1% patients with acute pancreatitis with 6-40% occurring with necrotizing pancreatitis.1, Research has been done to detect inflammatory changes at mesentery /mesocolon for early detection and better prediction of mortality and morbidity.2Due to better sensitivity, Magnetic Resonance Imaging (MRI) was considered superior in detection of colonic changes.3 It still has a lot of disadvantages esp. in critically ill patients. Computed Tomography(CT) is also equivalent to MRI in detecting changes in mesentry.5Correlation between colonic wall thickening at CT and the clinical course has already been established in non-necrotizing pancreatitis.6 The aim of this study was to define radiological objective parameters to predict early outcome of patients with severe acute necrotizing pancreatitis. This was a prospective, analytical study correlating colonic involvement and outcome of patients in severe acute necrotizing pancreatitis(SAP).
Objectives
To study computed tomography (CT) scan findings of collections around colon in patients with acute necrotizing pancreatitis and its association with clinical course i.e. intra-abdominal infection, need of drain/surgery and survival at ICU discharge.
Material and methods
All patients with acute necrotizing pancreatitis requiring ICU were considered for inclusion. Exclusion criteria were: age <18 years or pregnancy. In this prospective observational study, all available CT scans of abdomen were reviewed which were done from 2nd to 6th week of pancreatitis or ICU stay and findings were looked for colonic involvement and were classified in to involvement of mesocolon, colon involvement and if yes than <180 degree or more.
Results
During study period, serial CT scans of abdomen were analyzed for 48 included patients with median age 38.05±13.99years (34 male). Out of 48 patients with AP mesocolon and colonic involvement was 35 & 44 respectively, with only mesocolon involvement was found in 13. Mean APACHE II score in survivor & non survivor group was 11.61±5.94 & 15.81±6.60 respectively with p-value 0.027. ICU stay in survivor & non survivor group was 21(8-26.50) & 27(20-47) days respectively with p- value 0.018. Frequency of non survivor in mesocolon(n=35) and non mesocolon(n=13) group was 20(57.1%) & 7(53.8%) respectively with p-value 0.838. Frequency of non survivor in colon <180° (n=22) and colon >180° (n=22) group was 11 (50%) & 14(63.6%) respectively with p- value 0.361. There was no significant difference in survival time of the patients, between mesocolon (p>0.05) and colon (p>0.05) respectively.
Discussion
As a well-established diagnostic tool for acute pancreatitis, CT scans are used to guide and plan procedure. Its applicability for identifying collections near mesocolons is unknown. In this study, multi-detector helical CT enables the procurement of high-resolution images, contributing to the presentation of transverse mesocolon involvement in cases of SAP. We believe that some of the previously described points of view, which include radiologic-anatomical information, can assist the clinician to select more appropriate treatment modalities for certain instances. Nevertheless, there is no mortality benefit associated with early detection. However, this research can help direct future investigations into the development of distinct phenotypes in acute necrotizing pancreatitis as acute respiratory distress syndrome.
References
1.Ravindra KV, Sikora SS, Kumar A, Kapoor VK, Saxena R, Kaushik SP. Colonic necrosis is an adverse prognostic factor in pancreatic necrosis. Br J Surg. 1995;82:109–110. doi: 10.1002/bjs.1800820136. [DOI] [PubMed] [Google Scholar]
2.Chi XX, Zhang XM, Chen TW, Huang XH, Yang L, et al. The Normal Transverse Mesocolon and Involvement of the Mesocolon in Acute Pancreatitis: An MRI Study. PLoS ONE. 2014;9(4):e93687. doi: 10.1371/journal.pone.0093687. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Hirota M, Kimura Y, Ishiko T, Beppu T, Yamashita Y, et al. Visualization of the heterogeneous internal structure of so-called “pancreatic necrosis” by magnetic resonance imaging in acute necrotizing pancreatitis. Pancreas. 2002;25(1):63–7. doi: 10.1097/00006676-200207000-00015. [DOI] [PubMed] [Google Scholar]
4.Ji YF, Zhang XM, Mitchell DG, Li XH, Chen TW, Li Y, Bao ZG, Tang W, Xiao B, Huang XH, Yang L. Gastrointestinal tract involvement in acute pancreatitis: initial findings and follow-up by magnetic resonance imaging. Quant Imaging Med Surg. 2017;7(6):641–653. doi: 10.21037/qims.2017.12.03. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Kim JH, Ha HK, Sohn MJ, Shin BS, Lee YS, et al. Usefulness of MR imaging for diseases of the small intestine: comparison with CT. Korean J Radiol. 2000;1(1):43–50. doi: 10.3348/kjr.2000.1.1.43. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Xiao B, Zhang XM. Magnetic resonance imaging for acute pan- creatitis. World J Radiol. 2010;2(8):298–308. doi: 10.4329/wjr.v2.i8.298. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Schepers NJ, Bakker OJ, Besselink MG, et al. Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis. Gut. 2019;68:1044–1051. doi: 10.1136/gutjnl-2017-314657. [DOI] [PubMed] [Google Scholar]
Despite low TB incidence in Castellon and La Plana-Vila-Real health departments (2013-2016), elimination remains challenging, especially in marginalized populations. However, TB elimination is challenging. It is frequent to find patients with TB, whose disease is very difficult to control because these patients are often marginalized and homeless. The rise in ETB cases adds complexity to TB epidemiology, necessitating targeted control measures.
Objectives
The objective of this study was to identify associated factors in pulmonary tuberculosis (PTB) in comparison to extrapulmonary tuberculosis (ETB) and examine the epidemiological characteristics of these conditions to guide control and prevention strategies.
Materials and methods
A 2013-2016 case-case study in Valencia, Spain, compared pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (ETB) incidences using Hospital General Castellon and La Plana-Vila-Real data. PTB patients were cases, ETB patients controls. Directed acyclic graphs guided factor selection, and logistic regression estimated adjusted odds ratios (AORs).
Results
This study examined 50 PTB and 57 ETB patients, with microbiological confirmation rates of 89.8% and 54.7%. Annual median incidence rates were 6.8 and 3.5 per 100,000 for PTB and ETB. PTB patients, generally younger with a higher male proportion, had risk factors like smoking tobacco (AOR = 3.84; 95% CI = 1.49-8.97), social problems (AOR = 3.47; 95% CI = 1.41-10.66), and TB contact (AOR = 2.42; 95% CI = 1.57-5.64). No-smoking and no-drug abuse interaction significantly decreased PTB risk (AOR = 0.34; 95% CI = 0.22-0.51).
Discussions
This study underscores PTB-ETB distinctions, with PTB linked to social issues, smoking, and TB contact, and reduced by no-smoking/no-drug abuse. ETB associates variably with Maghreb birthplace and HIV. Comparative studies support a 70% PTB, 30% ETB ratio, emphasizing smoking and alcohol. ETB suggests recent infection/reactivation, influenced by immunodeficiencies and genetics. Risk factors involve immunosuppression, long-term diseases, age, gender, race, and ethnicity. ETB rate variations may result from immigration, delayed treatment, underreporting, and genetic diversity. PTB shows higher drug resistance, with minimal multidrug resistance. In conclusion, this research sheds light on the nuanced differences between PTB and ETB, emphasizing the importance of tailored strategies for each form of tuberculosis. The identified risk factors underscore the multifaceted nature of these diseases, requiring targeted interventions for effective control and prevention.
References
1.Arnedo-Pena A, Romeu-Garcia MA, Meseguer-Ferrer N, Vivas-Fornas I, Vizcaino-Batllés A, Safont-Adsuara L, Bellido-Blasco JB, Moreno-Muñoz R. Pulmonary versus extrapulmonary tuberculosis associated factors: a case-case study. Microbiology insights. 2019 Apr;12:1178636119840362. doi: 10.1177/1178636119840362. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Gambhir HS, Kaushik RM, Kaushik R, Sindhwani G. Tobacco smoking-associated risk for tuberculosis: a case-control study. International health. 2010 Sep 1;2(3):216–22. doi: 10.1016/j.inhe.2010.07.001. [DOI] [PubMed] [Google Scholar]
3.Kolappan C, Gopi PG, Subramani R, Narayanan PR. Selected biological and behavioural risk factors associated with pulmonary tuberculosis. The International Journal of Tuberculosis and Lung Disease. 2007 Sep 1;11(9):999–1003. [PubMed] [Google Scholar]
Patients admitted to ICU are subject to frequent blood sampling for a variety of blood tests. This blood sampling can cause a drop in haemoglobin and haemotocrit levels. The objective of our Audit is to evaluate the influence of daily phlebotomy on patient's haemoglobin level at our ICU.
Methods
We prospectively enrolled 111 patients from ICU 1 and 87 patients from ICU2 totally 198 patients. Patients with acute blood loss were excluded. For each patient we recorded the diagnosis, age, sex, haemoglobin, haematocrit, blood volume drawn in standardized vials, number of blood tests ordered per day, fluid balance per day, sample drawn from arterial line or not and number of ICU days.
Results
ICU 1: Among 111 patients 80 patients were male and 31 patients were female and 70 patients had arterial line and 41 patients didn't have arterial line. Average blood sent to lab was 46.3 ml and discarded blood volume was 57.3 ml. The average admission Hb 12.26 g/dl, discharge Hb 11.16 g/dl. The Hb drop was 1.1 g/dl (percentage drop was 9.9%). ICU 2: Among 87 patients 63 patients were male and 24 patients were female and 55 patients had arterial line and 27 patients didn't have arterial line. 10 out of 87 patients required transfusion of a total 7 units of PRBC. Average blood sent to lab was 43 ml and discarded blood volume was 40 ml. The average admission Hb 11.09 g/dl, discharge Hb 9.07 g/dl. The Hb drop was 2.02 g/dl (percentage drop was 23.9%). Presence of arterial line and sampling from it, leads to significant blood being discarded. Longer the ICU stay, more is the sampling rate and discarded blood volume.
Conclusion
Blood sampling contributes to anaemia among ICU patients,
We should limit the daily tests undertaken, meticulously avoiding unnecessary requests.
Non discord arterial line usage suggested to avoid discarded blood volume.
References
1.RCOA audit recipe
2.Cioc A, Fodor R, Benedek O, Moldovan A, Copotoiu SM. Blood sampling as a cause of anemia in a general ICU - a pilot study. Rom J Anaesth Intensive Care. 2015 Apr;22(1):13–16. 28913450;PMC5505326 [PMC free article] [PubMed] [Google Scholar]
Acute respiratory distress syndrome (ARDS) includes spectrum of conditions with different etiologies, pulmonary and extrapulmonary. Vasoactive Intestinal Peptide (VIP) is a hormone localized in the lungs. It has protective functions in lung. Aviptadil is a synthetic Vasoactive Intestinal Peptide (VIP) and has been studied in various respiratory disease. Recently clinical trials have been conducted for the use of Aviptadil in ARDS associated with COVID-19 which showed reduction in mortality and hospital stay. We have used Aviptadil in patients with ARDS other than COVID-19.
Objectives
Utility of intravenous Aviptadil in patients with ARDS.
Materials and methods
We included patients aged more than 18 years, admitting in ICU with moderate to severe ARDS prespecified on the Berlin definition, P/F ratio of < 150. We excluded pregnant female, chronic organ failure and end stage malignancies. Written informed consent of the guardian was taken. Aviptadil was given daily for 3 days as an intravenous infusion administered via infusion pump over 12 hours in escalating dose. On the first day the dose was 0.166mcg/kg/hr, second day 0.332mcg/kg/hr and third day it was given at 0.489mcg/kg/hr. All clinical parameters, adverse effects, arterial blood gases and imaging were noted.
Results
Between May 2023 to October 2023, 7 patients were enrolled. All patients were male. Average age was 35 years. Two patients had moderate while 5 had severe ARDS with mean P/F ratio was 88± 8. All patients had sepsis related ARDS. Of 7 patients 2 were having pulmonary cause for ARDS, both had community acquired pneumonia with causative agent of influenza A virus in one patient while no pathogen found in second patient, 3 patients had scrub typhus, one had sepsis with Fournier gangrene and one had sepsis with necrotizing fascitis of abdominal and chest wall. Two patients had diabetes. One patient had history of ischaemic heart disease. Six patients were mechanically ventilated while one was managed with high flow nasal oxygen therapy. Five patients were started with Aviptadil within 24 hours of admission while 2 were started after 72 hours. Two patients received only two doses due to adverse event, one had hypotension while other had intracranial bleed. Rest five patients received all three doses. Five patients developed septic shock. Three had acute kidney injury. Three of seven patients expired making mortality rate of 42%. Cause of death was sepsis with multiorgan dysfunction in all three patients. One patient who was on HFNO was weaned over next 3 days and discharged from ICU, while other three patients who were ventilated, were gradually weaned from ventilator with mean time of 4±2 days and extubated. Radiological resolution was observed over 6±2 days. Factors contributing to death were severity of ARDS, septic shock, and AKI.
Discussions
Mortality in severe ARDS comprises 45- 54%. Aviptadil has multiple mechanisms with hypothesized actions includes it defends AT-II cells, prevents cytokine storm, and increases the lung's oxygen concentration and gas exchange. Aviptadil has some role in reducing mortality in COVID-19 related ARDS. Role in non COVID-19 ARDS still needs to be evaluated.
References
1.Ferguson ND, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive care medicine. 2012 Oct;38:1573–82. doi: 10.1007/s00134-012-2682-1. [DOI] [PubMed] [Google Scholar]
2.ARDS Definition Task Force; Ranieri VM et al. JAMA. 2012 Jun 20;307(23):2526–33. doi: 10.1001/jama.2012.5669. 22797452 [DOI] [PubMed] [Google Scholar]
3.Youssef JG, et al. The use of IV vasoactive intestinal peptide (aviptadil) in patients with critical COVID-19 respiratory failure: results of a 60-day randomized controlled trial. Crit Care Med. 2022;50:1545–54. doi: 10.1097/CCM.0000000000005660. [DOI] [PMC free article] [PubMed] [Google Scholar]
Hyponatremia is a common electrolyte imbalance in the elderly, often associated with various clinical conditions. However, its relationship with renal function, especially in the context of urinary tract infections (UTI), remains relatively unexplored in non-diabetic elderly populations.
Objectives
This study aimed to investigate the correlation between hyponatremia and glomerular filtration rate (GFR) status in elderly patients without diabetes suffering from UTIs, assessing the impact of GFR on the outcomes associated with hyponatremia in this specific population.
Materials and methods
The present observational study was conducted at the Department of Medicine, Prasad Institute of Medical Sciences in Lucknow, India. This study involving 50 elderly patients (aged 65 and above) without diabetes admitted for UTIs. Serum sodium levels and GFR status were measured at admission, and patients were categorized based on their GFR status. Clinical outcomes, including the severity of hyponatremia, length of hospital stay, need for intensive care, and mortality, were assessed and correlated with GFR levels.
Results
Among the 50 elderly non-diabetic patients with UTIs, hyponatremia was observed in X% of cases, with varying severity correlating with GFR status. Patients with lower GFR demonstrated a higher prevalence of severe hyponatremia. Additionally, a significant association was found between reduced GFR and adverse clinical outcomes, including prolonged hospital stays and increased mortality rates among hyponatremic patients with UTIs.
Discussions
This study sheds light on the association between hyponatremia, GFR status, and clinical outcomes in non-diabetic elderly individuals hospitalized due to UTIs. The findings indicate a notable correlation between reduced GFR and the incidence and severity of hyponatremia in this specific patient population. The prevalence of hyponatremia among these elderly patients with UTIs was significant, with varying degrees of severity linked to lower GFR levels. Notably, patients with reduced GFR displayed a higher likelihood of developing severe hyponatremia. Furthermore, there was a discernible link between decreased GFR and adverse clinical outcomes. Patients with both hyponatremia and lower GFR experienced prolonged hospital stays and increased mortality rates compared to those with higher GFR levels. This study underscores the relevance of evaluating GFR status in elderly non-diabetic patients presenting with UTIs and concurrent hyponatremia. Understanding this association may aid in risk stratification and the development of more targeted management approaches for this vulnerable population. Identifying these risk factors early in the clinical course could help optimize patient care and potentially improve outcomes in such cases. However, further research is warranted to elucidate the precise mechanisms underlying this relationship and to validate these findings in larger cohorts or diverse clinical settings.
References
1.Tavare AN, Murray D. Central pontine myelinolysis. N Engl J Med. 2016;374(7):e8. doi: 10.1056/NEJMicm1504134. [DOI] [PubMed] [Google Scholar]
2.Singh TD, Fugate JE, Rabinstein AA. Central pontine and extrapontine myelinolysis: a systematic review. Eur J Neurol. 2014;21(12):1443–1450. doi: 10.1111/ene.12571. [DOI] [PubMed] [Google Scholar]
3.Liamis G, Elisaf M. Treatment of hyponatremia: what the clinician needs to know. J Nephrol Res. 2015;1(1):19–21. [Google Scholar]
4.Spasovski G, Vanholder R, Allolio B, et al. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant. 2014;29(Suppl 2):i1–i39. doi: 10.1093/ndt/gfu040. [DOI] [PubMed] [Google Scholar]
Tuberculosis (TB) requiring intensive care unit (ICU) admission is a rare entity but it is known to have a grave prognosis when compared to patients admitted with severe pneumonia.1
Objectives
This is a prospective observational study where we have aimed to study the clinical and radiological profile of patients admitted to ICU with tuberculosis.
Materials and methods
All the patients admitted to ICU with a diagnosis of tuberculosis from January 2023 to November 2023 were included.
Results
A total of 14 TB patients (10 females, mean age 36 yrs.) admitted to ICU were included. Most common etiology for ICU admission was respiratory failure requiring mechanical ventilation. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II score at admission was 13.1±5.6 and 10 of 14 (71%) patients required mechanical ventilation. The in-hospital mortality was 8 of 14 (57%). The factors associated with mortality were: need for mechanical ventilation, sepsis, acute respiratory distress syndrome, and nosocomial pneumonia.
Discussions
About 3.4% of the hospitalized tubercular patients need admission to the intensive care unit.2 Even though India is a high burden country, data on TB patients requiring ICU admission is scarce. In a single center study from India, only 1.7% of patients had active tuberculosis. Out of which, 55.5% had disseminated tuberculosis, 30% had miliary tuberculosis, and 28% had tuberculosis-related acute respiratory distress syndrome (ARDS).3
References
1.Erbes R, Oettel K, Raffenberg M, Mauch H, Schmidt-Ioanas M, Lode H. Characteristics and outcome of patients with active pulmonary tuberculosis requiring intensive care. Eur Respir J. 2006 Jun;27(6):1223–8. doi: 10.1183/09031936.06.00088105. 16481385 Epub 2006 Feb 15. [DOI] [PubMed] [Google Scholar]
2.Muthu V, Agarwal R, Dhooria S, Aggarwal AN, Behera D, Sehgal IS. Outcome of critically ill subjects with tuberculosis: systematic review and meta-analysis. Respir Care. 2018;63(12):1541–1554. doi: 10.4187/respcare.06190. [DOI] [PubMed] [Google Scholar]
3.Muthu V, Dhooria S, Agarwal R, Prasad KT, Aggarwal AN, Behera D, et al. Profile of patients with active tuberculosis admitted to a Respiratory Intensive Care Unit in a Tertiary Care Center of North India. Indian J Crit Care Med. 2018;22(2):63–66. doi: 10.4103/ijccm.IJCCM_491_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
Ventilator-associated pneumonia(VAP) is defined as the pneumonia occurring in patients on mechanical ventilation for at least 48 hours and is characterized by a new or progressive infiltrate on chest X-ray, signs of systemic infection, any change in the characteristic of sputum/phlegm, and detecting the causative agent/organism. It remains a common cause of morbidity and mortality in mechanically ventilated patients. “Ventilator bundle” is a set of best-practice guidelines for patients receiving mechanical ventilation that the American Association of Critical-Care Nurses (AACN) recommended as a means of minimising the occurrence of VAP.
Objectives
Primary objective: Compare the incidence of VAP in patients with unknown history of adherence to VAP care bundle vs patients in whom VAP care bundle has been followed strictly since intubation.
Secondary Objective
Effect of implementation of VAP care bundle on number of ventilator free days, length of ICU stay & mortality.
Materials and method
Study design- Exploratory study Patients admitted in ICU needing invasive mechanical ventilation for respiratory support Patients assigned in two groups 42 each Group O: patients who were intubated at some other hospital and shifted to ICU after few days of mechanical ventilation. Group R: patients who were intubated and put on mechanical ventilation in ICU of our hospital. After group allocation we introduced VAP care bundle in our ICU setup.
Result
The overall incidence of VAP was 42.85% in the Group O and 16.67% in the Group R. The difference between the groups was statistically significant when analysed using chi square test.
Discussion
The data obtained in the study shows that the application of the bundle had a satisfactory result in reducing VAP suggesting that proper training and education have a fundamental role in implementation of VAP care bundle and it leads to decreased incidence of VAP, decreased ICU stay, morbidity and mortality.
References
1.Sungung Kwak et al in 2022: [9]The aim of this study was to measure VAP prevention practices among ICU nurses, we developed and validated a tool. A tool development step and a tool verification step were included in this methodological Review of Literature Page | 47 investigation, which followed the DeVellis-recommended process
2.Monique Eva Vargas Cardoso et al in 2021:Conducted a study to evaluate the impact of a prevention bundle for Mechanical Ventilation Associated Pneumonia in a Intensive Care Unit. Aintensive care unit served as the setting for this quantitative, quasi-experimental study
3.Elyse Ladbrook BN et al in 2021: [8]Economic decision-making in the healthcare industry must be evidence-based. However, studies describing the financial results Review of Literature Page | 46 of care bundles for ventilator-associated pneumonia (VAP) have not yet undergone a systematic review. The characteristics and conclusions of studies on the financial effects of implementing VAP bundles were examined in this scoping review
Evaluation of the Predictive Role of Serial Plasma BNP Measurement in Assessing Fluid Status and Development of Acute Kidney Injury in Critically Ill Patients
As serum creatinine is unable to identify early renal tubular injury before the decrease in GFR, an early and reliable biomarker of AKI is needed. Due to doubtful efficacy, high cost, use of other novel biomarkers are limited. None of them simultaneously address the risk of AKI and fluid status. Studies have correlated BNP levels with development of AKI and shown that BNP as a marker of fluid overload in haemodialysis patients separately. Therefore, the hypothesis of this study is that serial BNP level measurement can predict development of AKI and fluid status in critically ill patients and also it has the potential to be a convenient cost-effective marker to titrate fluid management to avoid overload and Acute kidney Injury in those patients.
Aims and Objectives
To investigate whether BNP can predict the Renal outcome (AKI) of critically ill patients.
To investigate whether serial plasma BNP measurement can be used to assess fluid status of the patient.
Materials and methods
After obtaining approval from institutional ethics committee and CTRI registration, this Prospective Observational Single Centre study is being conducted. Patients after admission, without any exclusion criteria, screened through high-risk screening criteria for developing AKI as proposed by KIDIGO and ECG/Echocardiogram obtained to rule out any existing heart disease and reduced EF. Plasma BNP levels along with SOFA/APACHE II scores, other laboratory parameters, lung USG for B-line scoring and IVC diameter to detect fluid overload obtained on admission (D0), after 24 hours (D1) and after 48 hours (D2). Patient's vitals and daily intake/output also recorded and CRF maintained for statistical analysis. A priory analysis done by using Point Biserial Model keeping effect size 0.3, alpha error 0.05 and power of study 0.95 and deduced to be 111.
Result and analysis
Total 74 patients recruited, among which 9 patient's data are missing. Rest 65 patients are further divided into 2 groups: AKI group and Non- AKI group. Similarly, those 65 patients are divided into another two groups: Fluid Overload (FO) and non-fluid overload (NFO) group. Mean age of all the groups are comparable. Total 33 (50.8%) patients developed AKI and 20 (30.8%) patients developed fluid overload within 48 hours of admission. Higher incidence of AKI observed among males (p=0.025). Out of 33 patients developed AKI, 16 (48.5%) developed fluid overload (p =0.003). Mean BNP (pg/ml) at D0, D1, D2 are higher in AKI group as compared to non-AKI group (171.82/98.77; 296.96/146.83; 526.44/227.46 respectively) [p<0.05]. Mean of Delta BNP are also higher in AKI group at day 0 to day 1, at day 1 to day 2 and day 0 to day 2, (131.70/89.53; 32.90/29.27; 213.60/157.87 respectively) but statistically not significant. Similarly, mean BNP (pg/ml) at D0, D1, D2 are significantly (p <0.05) higher in FO group as compared to NFO group (182.39/115.17; 386.245/150.516; 735.60/220.87 respectively). Mean of Delta BNP are also significantly (p<0.05) higher in FO group (177.42/81.39; 45.91/24.09; 320.84/126.31 respectively. Study is still ongoing; these findings are till date.
Conclusion
Higher plasma BNP level is significantly correlated with higher risk of development of AKI in critically ill patients and have potential to be used as a predictor for AKI in ICU. Higher plasma BNP and delta -BNP are also significantly associated with development of Fluid overload and can be used to assess fluid status of the patients in ICU.
4.Korkeila M, Ruokonen E, Takala J. Costs of care, long-term prognosis and quality of life in patients requiring renal replacement therapy during intensive care. Intensive Care Med [Internet] 2000 Dec [cited 2022 Jul 6];26(12):1824–31. doi: 10.1007/s001340000726. http://link.springer.com/10.1007/s001340000726 Available from: [DOI] [PubMed] [Google Scholar]
5.Metnitz PGH, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients*: Critical Care Medicine [Internet] 2002 Sep [cited 2022 Jul 6];30(9):2051–8. doi: 10.1097/00003246-200209000-00016. http://journals.lww.com/00003246-200209000-00016 Available from: [DOI] [PubMed] [Google Scholar]
7.Bagshaw SM, George C, Dinu I, Bellomo R. A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrology Dialysis Transplantation [Internet] 2007 Jan 8 [cited 2022 Jul 6];23(4):1203–10. doi: 10.1093/ndt/gfm744. https://academic.oup.com/ndt/article-lookup/doi/10.1093/ndt/gfm744 Available from: [DOI] [PubMed] [Google Scholar]
8.Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE*: Critical Care Medicine [Internet] 2007 Aug [cited 2022 Jul 6];35(8):1837–43. doi: 10.1097/01.CCM.0000277041.13090.0A. http://journals.lww.com/00003246-200708000-00004 Available from: [DOI] [PubMed] [Google Scholar]
12.Jotwani V, Katz R, Ix JH, Gutiérrez OM, Bennett M, Parikh CR, et al. Urinary biomarkers of kidney tubular damage and risk of cardiovascular disease and mortality in elders. American Journal of Kidney Diseases [Internet] 2018 Aug [cited 2022 Jul 6];72(2):205–13. doi: 10.1053/j.ajkd.2017.12.013. https://linkinghub.elsevier.com/retrieve/pii/S0272638618301045 Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Tujios SR, Hynan LS, Vazquez MA, Larson AM, Seremba E, Sanders CM, et al. Risk factors and outcomes of acute kidney injury in patients with acute liver failure. Clinical Gastroenterology and Hepatology [Internet] 2015 Feb [cited 2022 Jul 6];13(2):352–9. doi: 10.1016/j.cgh.2014.07.011. https://linkinghub.elsevier.com/retrieve/pii/S1542356514009859 Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL, et al. The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock. Am J Respir Crit Care Med [Internet] 2016 Feb [cited 2022 Jul 6];193(3):281–7. doi: 10.1164/rccm.201505-0995OC. https://www.atsjournals.org/doi/10.1164/rccm.201505-0995OC Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Druml W, Lax F, Grimm G, Schneeweiss B, Lenz K, Laggner AN. Acute renal failure in the elderly 1975- 1990. Clin Nephrol. 1994 Jun;41(6):342–9. [PubMed] [Google Scholar]
21.Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney International [Internet] 2009 Aug [cited 2022 Jul 6];76(4):422–7. doi: 10.1038/ki.2009.159. https://linkinghub.elsevier.com/retrieve/pii/S0085253815539756 Available from: [DOI] [PubMed] [Google Scholar]
22.Sivalingam M, Vilar E, Mathavakkannan S, Farrington K. The role of natriuretic peptides in volume assessment and mortality prediction in Haemodialysis patients. BMC Nephrol [Internet] 2015 Dec [cited 2022 Jul 6];16(1):218. doi: 10.1186/s12882-015-0212-4. http://www.biomedcentral.com/1471-2369/16/218 Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Chou YH, Chen YF, Lin SL. More is not better: Fluid therapy in critically ill patients with acute kidney injury. Journal of the Formosan Medical Association [Internet] 2013 Mar [cited 2022 Jul 6];112(3):112–4. doi: 10.1016/j.jfma.2012.05.007. https://linkinghub.elsevier.com/retrieve/pii/S092966461200304X Available from: [DOI] [PubMed] [Google Scholar]
24.Prowle JR, Kirwan CJ, Bellomo R. Fluid management for the prevention and attenuation of acute kidney injury. Nat Rev Nephrol [Internet] 2014 Jan [cited 2022 Jul 6];10(1):37–47. doi: 10.1038/nrneph.2013.232. http://www.nature.com/articles/nrneph.2013.232 Available from: [DOI] [PubMed] [Google Scholar]
26.Chazot C, Rozes M, Vo-Van C, Deleaval P, Hurot JM, Lorriaux C, et al. Brain natriuretic peptide is a marker of fluid overload in incident hemodialysis patients. Cardiorenal Med [Internet] 2017 [cited 2022 Jul 6];7(3):218–26. doi: 10.1159/000471815. https://www.karger.com/Article/FullText/471815 Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Li X, Liu C, Mao Z, Qi S, Song R, Zhou F. Brain natriuretic peptide for predicting contrast-induced acute kidney injury in patients with acute coronary syndrome undergoing coronary angiography: a systematic review and meta-analysis. Journal of Interventional Cardiology [Internet] 2020 Sep 19 [cited 2022 Jul 6];2020:e1035089. doi: 10.1155/2020/1035089. https://www.hindawi.com/journals/jitc/2020/1035089/ Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
28.de Cal M, Haapio M, Cruz DN, Lentini P, House AA, Bobek I, et al. B-type natriuretic peptide in the critically ill with acute kidney injury. International Journal of Nephrology [Internet] 2011 [cited 2022 Jul 6];2011:1–6. doi: 10.4061/2011/951629. http://www.hindawi.com/journals/ijn/2011/951629/ Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Chae MS, Park H, Choi HJ, Park M, Chung HS, Hong SH, et al. Role of serum levels of intraoperative brain natriuretic peptide for predicting acute kidney injury in living donor liver transplantation. Saeb Parsy K, editor. PLoS ONE [Internet] 2018 Dec 17 [cited 2022 Jul 6];13(12):e0209164. doi: 10.1371/journal.pone.0209164. https://dx.plos.org/10.1371/journal.pone.0209164 Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Naruse H, Ishii J, Takahashi H, Kitagawa F, Nishimura H, Kawai H, et al. Predicting acute kidney injury using urinary liver-type fatty-acid binding protein and serum N-terminal pro-B-type natriuretic peptide levels in patients treated at medical cardiac intensive care units. Crit Care [Internet] 2018 Dec [cited 2022 Jul 6];22(1):197. doi: 10.1186/s13054-018-2120-z. https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2120-z Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Chou YH, Chen YF, Pan SY, Huang TM, Yang FJ, Shen WC, et al. The role of brain natriuretic peptide in predicting renal outcome and fluid management in critically ill patients. Journal of the Formosan Medical Association [Internet] 2015 Dec [cited 2022 Jul 6];114(12):1187–96. doi: 10.1016/j.jfma.2015.10.015. https://linkinghub.elsevier.com/retrieve/pii/S0929664615003587 Available from: [DOI] [PubMed] [Google Scholar]
Thyroid hormone levels play a pivotal role in regulating bodily functions, and disruptions in these levels are frequently observed in critically ill individuals, particularly those in intensive care units (ICUs).
Objectives
This study aimed to explore the connection between thyroid function and sepsis, drawing correlations with the acute physiology and chronic health evaluation II (APACHE II) score.
Materials and methods
The present cross-sectional study was conducted at the Department of Medicine, Prasad Institute of Medical Sciences in Lucknow, India. A total of 38 patients aged 18 years or more fulfilling the sepsis criteria were included in the study. Through clinical and systemic examinations, their severity of illness and outcome prediction were assessed using the APACHE II score. Patients were categorized into two groups based on survival outcome: survivors and nonsurvivors.
Results
Among the 38 patients, 25 were male and 13 were female, with an average age of 46.48 ± 20.37 years. Type 2 diabetes mellitus emerged as the most prevalent comorbidity, while pneumonia and pyelonephritis were the primary diagnoses. Notably, nonsurvivors exhibited higher mean APACHE II scores than survivors (31.35 ± 7.36 vs. 17.68 ± 8.57; p < 0.001). Interestingly, among nonsurvivors, there was an inverse correlation between APACHE II scores and fT3 and fT4 levels, while a positive correlation was observed with TSH levels.
Discussions
The study's findings showcase a noteworthy association between thyroid profile and outcomes in critically ill sepsis patients. The correlation observed between the acute physiology and chronic health evaluation II (APACHE II) score and thyroid hormone levels, particularly fT3, fT4, and TSH, among nonsurvivors indicates a potential role of thyroid function in predicting morbidity and mortality in ICU settings for septic patients. This suggests that thyroid assessment, when integrated with the APACHE II scoring system, might offer a more comprehensive prognostic marker for evaluating ICU outcomes in sepsis cases. Further investigations and larger-scale studies are warranted to validate these correlations and better understand the precise role of thyroid function in predicting outcomes in critically ill patients with sepsis.
References
1.Van den Berghe G, de Zegher F, Bouillon R. Clinical review 95: Acute and prolonged critical illness as different neuroendocrine paradigms. J Clin Endocrinol Metab. 1998;83:1827–34. doi: 10.1210/jcem.83.6.4763. [DOI] [PubMed] [Google Scholar]
2.Van den Berghe G. Endocrine evaluation of patients with critical illness. Endocrinol Metab Clin North Am. 2003;32:385–410. doi: 10.1016/s0889-8529(03)00005-7. [DOI] [PubMed] [Google Scholar]
3.Slag MF, Morley JE, Elson MK, Crowson TW, Nuttall FQ, Shafer RB. Hypothyroxinemia in critically ill patients as a predictor of high mortality. JAMA. 1981;245:43–5. [PubMed] [Google Scholar]
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally. Information regarding predictors of short-term outcomes in patients with exacerbation of COPD could help in stratifying patients and guide medical decision-making.
Objectives
The aim of this study was to compare PEARL, DECAF & E-DECAF scores.
Materials and methods
100 patients presenting with an acute exacerbation of COPD (AECOPD) were included in the study and obtained results were analyzed.
Results
Parameters of DECAF score (Dyspnea, Eosinopenia, Consolidation, respiratory Acidosis and atrial Fibrillation) showed a statistically significant value to the mortality; dyspnea (p=0.0011), eosinopenia (p<0.0001), Consolidation (p<0.0001), acidemia (p<0.0001). Each variable in PEARL index (Previous admissions, e-MRCD score, Age of the patient and evidence of right and left ventricular failure) showed a statistically significant association with in-hospital mortality except for left ventricular failure. Elevated BUN levels, hypoalbuminemia, anemia and hyponatremia were associated with mortality. These parameters along with previous admissions were added to DECAF score and an E-DECAF score was formulated. The AUROC for PEARL, DECAF & E-DECAF was 0.821, 0.899 & 0.982 respectively. The sensitivity and specificity of E-DECAF score was 92.6% and 98.6% respectively.
Discussions
Exacerbations represent an important event in the natural history of COPD. They are associated with significant morbidity and mortality. In this scenario, it is important to stratify the patients accurately. Prognostication is difficult to achieve without a valid scoring system.
References
1.GOLD- Global strategy for the diagnosis, management and prevention of Chronic Obstructive Pulmonary Disease
2.Wedzicha JA, Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet. 2007;370(9589):786–96. doi: 10.1016/S0140-6736(07)61382-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Seemungal TA, Donaldson GC, Paul EA, Bestall JC, Jeffries DJ, Wedzicha JA. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998;157(5 Pt 1):1418–22. doi: 10.1164/ajrccm.157.5.9709032. [DOI] [PubMed] [Google Scholar]
4.Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–128. doi: 10.1016/S0140-6736(12)61728-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
Sepsis is the most commonly encountered condition in the critical care setup accounting for the leading cause of morbidity and mortality. The sensitivity and specificity of single lactate concentrations as markers of tissue hypoperfusion have been debated. With this study we compared lactate kinetics and lactate-albumin ratio with APACHE II score in predicting in- hospital mortality.
Objectives
To compare lactate kinetics and lactate-albumin ratio with APACHE II score in predicting the in-hospital mortality in sepsis patients.
Materials and method
In our study, 150 sepsis patients were included using the NEWS score and lactate values were noted at the time of diagnosis of sepsis (0 hour), then at 6 hours. Lactate clearance were calculated at 6 hours and lactate- albumin ratio were calculated using the 0 hour values. The patients were followed up for a period of 28 days, outcomes were noted and data analysis was done accordingly.
Results and discussion
The mean age group in our study was 65 + 18 years. The in-hospital mortality was found to be 48.4 %. Our study showed that when compared individually, lactate kinetics (< 10%, sensitivity 55%, specificity 64%) and lactate-albumin ratio (>1.45, specificity 64%, sensitivity 66%) were not found to be better predictors of mortality when compared with APACHE II score (mean 18.4 + 8.2, sensitivity 70%, specificity 68.4%). However, when the lactate kinetics were combined with lactate- albumin ratio (sensitivity 78%, specificity 74%, p <0.05) they were found to be better predictors of mortality in sepsis patients as compared to the APACHE II score.
References
1.Chertoff J, Chisum M, Garcia B, Lascano J. Lactate kinetics in sepsis and septic shock: a review of the literature and rationale for further research. J Intensive Care. 2015 Oct 6;3:39. doi: 10.1186/s40560-015-0105-4. 26445673;PMC4594907 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, Bellamy SL, Christie JD. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med. 2009 May;37(5):1670–7. doi: 10.1097/CCM.0b013e31819fcf68. 19325467 [DOI] [PubMed] [Google Scholar]
3.Bou Chebl R, Jamali S, Sabra M, Safa R, Berbari I, Shami A, Makki M, Tamim H, Abou Dagher G. Lactate/Albumin Ratio as a Predictor of In-Hospital Mortality in Septic Patients Presenting to the Emergency Department. Front Med (Lausanne) 2020 Sep 22;7:550182. doi: 10.3389/fmed.2020.550182. 33072780;PMC7536276 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Nguyen HB, Rivers EP, Knoblich BP, Jacobsen G, Muzzin A, Ressler JA, Tomlanovich MC. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004 Aug;32(8):1637–42. doi: 10.1097/01.ccm.0000132904.35713.a7. 15286537 [DOI] [PubMed] [Google Scholar]
Gram negative sepsis is initiated by an endotoxin binding with toll like receptors (TLR) which activates major intracellular pathways triggering production of pro inflammatory cytokines (TNFα & IL1), inflammatory cascade, systemic signs and organ dysfunction. Mycobacterium w is a non-pathogenic cultivable atypical mycobacterium which is potent poly TLR antagonist. Mycobacterium w (Heat Killed) injection has 0.5 × 109 bacilli per 0.1 ml. Administration of this immunomodulator may halt the inflammatory cascade.
Objectives
To see Change in - SOFA score, IL-6 levels (inflammatory marker), Duration of ICU stay & Mortality, after injection of heat killed Mycobacterium w in sepsis patients.
Materials and methods
This randomized controlled trial is being conducted in Department of Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna. Patients > 18 yrs and < 65 yrs of age, presenting with sepsis (on Noradrenaline >0.2 µg/kg/min) were included in this study. Patients with history of allergic reaction, pregnant & lactating women, septic skin conditions were excluded. Being a pilot study total 20 patients meeting the inclusion criteria were included. Based on informed consent they were randomly divided into 2 groups (10 patients each), Study group and Controls. Their baseline demographic characters (age, sex), SOFA scores and IL 6 levels were compared. Study group received intradermal injection (ID) of immunomodulator- Mycobacterium w 0.3 ml/day for 3 days (intervention) along with standard treatment. Controls received standard treatment. Both Study group and Controls were assessed for the change in- SOFA score, IL-6 levels, duration of ICU stay and mortality. Following intervention all the measured parameters were be presented as mean and compared between the two groups. (paired and unpaired t tests) Results (interim analysis): Mean age in Study & Control groups was comparable. (55yrs & 49yrs) Mean pre intervention SOFA scores in Study & Control groups were comparable. (13 & 11.6) Mean pre & post intervention SOFA score in Study group showed no change. (13 & 13) Mean pre & post intervention IL 6 levels in Study group showed significant decrease post intervention. (577 & 394 pg/ml) There was significant difference in mortality in Study group & Controls. (3 & 5) Discussion: In our study after administration of Mycobacterium w, in patients of sepsis on Noradrenaline infusion >0.2 µg/kg/min, there was significant decrease in IL 6 levels & mortality, although SOFA scores didn't show any change. Lack of protocol regarding appropriate time of administration of immunomodulator was a limitation in our study, further larger studies will give us a better understanding of it. To conclude, administration of Mycobacterium w may lead to potential benefit in sepsis by immunomodulation, but ours is a pilot study with small sample size and larger studies are needed to come to any definite conclusion.
References
1.Panacek EA, Marshall JC, Albertson TE, Johnson DH, Johnson S, MacArthur RD, et al. Efficacy and safety of the monoclonal anti-tumor necrosis factor antibody F(ab’)2 fragment afelimomab in patients with severe sepsis and elevated IL-6 levels. Crit Care Med. 2004;32(11):2173–82. doi: 10.1097/01.ccm.0000145229.59014.6c. [DOI] [PubMed] [Google Scholar]
2.Opal SM, Laterre PF, Francois B, LaRosa SP, Angus DC, Mira JP, et al. Effect of eritoran, an antagonist of MD2-TLR4, on mortality in patients with severe sepsis: the ACCESS randomized trial. JAMA. 2013;309(11):1154–62. doi: 10.1001/jama.2013.2194. [DOI] [PubMed] [Google Scholar]
3.Boomer JS, To K, Chang KC, Takasu O, Osborne DF, Walton AH, et al. Immunosuppression in patients who die of sepsis and multiple organ failure. JAMA. 2011;306(23):2594–605. doi: 10.1001/jama.2011.1829. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Talwar GP, Zaheer SA, Mukherjee R, Walia R, Misra RS, Sharma AK, et al. Immunotherapeutic effects of a vaccine based on a saprophytic cultivable mycobacterium, Mycobacterium w in multibacillary leprosy patients. Vaccine. 1990;8(2):121–9. doi: 10.1016/0264-410x(90)90134-8. [DOI] [PubMed] [Google Scholar]
1Department of Pediatric Intensive Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India, Phone: +91 9446689777, e-mail: arathywilson@gmail.com
1Department of Pediatric Intensive Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India, Phone: +91 9446689777, e-mail: arathywilson@gmail.com
2,4,7–11Department of Pediatric Intensive Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
3,5Department of Pediatric Otorhinolaryngology, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
Endotracheal intubation is a lifesaving procedure but is fraught with risk of airway injuries. Post-intubation airway injuries can range from minor laryngeal edema to severe subglottic stenosis. There is limited data about post-intubation airway injuries in children. The reported incidence varies from 1 to 4%.
Objectives
To study the outcome of children with intubation related airway injuries.
To analyze the risk factors associated with intubation related airway injuries.
Materials and methods
Retrospective observational case-control study between August 2014 to October 2023 in a tertiary care pediatric intensive care unit. All children under 18 years who underwent airway endoscopy for suspected intubation related airway injuries were included. Children with evidence of airway injury were considered cases and those with normal endoscopy findings were considered controls. Demographic details, risk factors for laryngeal injuries, endoscopic findings, procedures done, and outcome were collected.
Results
Out of 1,748 children ventilated during the study period, 55 patients who developed stridor and/or upper-airway obstruction symptoms underwent airway endoscopy. Twenty-one patients had normal airway examination findings (controls) and 34 patients had evidence of various degrees of airway injury (cases). The median age group was 5 months (IQR 1.0-48.0) in the cases compared to 13 months (IQR 4.75-53.5) in the controls. Median duration of ventilation was 9 days in both cases (IQR 5.5-18.0) and controls (IQR 5.5-10.0) respectively. The most common indication for intubation was respiratory distress in both cases (n=21, 61.8%) and controls (n=8, 38.1%). Comparison of risk factors associated with post-intubation airway injuries in both case and control groups are mentioned in table no 1.
Laryngeal edema (n=12, 35.3%) was the most common finding, followed by granulation tissue (n=9, 26.5%), and soft membrane/band (n=8, 23.5%). Majority (n=28, 82.4%) were treated with local steroid application, while 11 (32.4%) required membrane and/or granulation excision. Four (12.5%) children required tracheostomy. One child had sub-glottic stenosis grade III requiring laryngotracheal reconstruction. Using univariate logistic regression, intubation at other hospitals (p 0.016), bigger size ET tube for age (p 0.052), reintubation (p 0.001) and duration of ventilation ≥ 25 days (p 0.035) were associated with higher risk of post-intubation laryngeal injuries. Using multivariate logistic regression, reintubation is independently associated with higher risk for airway injuries (OR – 16.97, CI 3.207-89.884, p 0.001).
Conclusion
Incidence of post intubation airway injuries in our study was 1.94 per 100 ventilated patients. Reintubation is an independent risk factor associated with post-intubation airway injuries. Most children were managed with minor airway procedures, while one child with severe airway injury required laryngo-tracheal reconstruction. References: 1)Karma L, Laurence P, Kishore S. Intubation related Laryngeal Injuries in Pediatric Population. Frontiers in Pediatrics. 2021 Feb; Vol 9: 1-8. 2)V. Rangachari, I. Sundararajan, V. Sumathi, K. Krishna Kumar. Laryngeal sequelae following prolonged intubation: A prospective study. Journal of Critical Care Medicine. 2006; 10(3): 171-175.
Uncorrected hypovolemia and fluid overload may result in detrimental consequences. Measurement of corrected carotid flow time (ccFT) using point-of-care ultrasound (POCUS) has been proposed as a feasible, non-invasive means of determining fluid responsiveness. Our study aims to use methods which are simpler, feasible and easily reproducible with a lesser learning curve which can differentiate fluid responders from non-responders.
Objective
To analyse and comparison of changes in corrected carotid flow time in undifferentiated shock.
Materials and methods
Patients above the age of 18 years old, in undifferentiated shock on mechanical ventilation were administered a mini fluid challenge of 4ml/kg was administered over 5 mins. Fluid responders classified as > 10% increase in Left Ventricular Outflow Tract VTI post fluid challenge. Carotid artery ultrasound was done and carotid flow time and corrected carotid flow time using the Woodey's formula: FT corrected = FT measured +1.29(Heart rate -60) was measured before a fluid challenge and 2 minutes after a fluid challenge. Carotid artery velocity time integral was also calculated.
Results
34 patients were enrolled, 26 patients (76.47%) were fluid responsive, non-responders were 8 in number (23.53%). The AUROC for carotid flow time is 0.688, with a best cut off of 7.93 (sensitivity 65.38% and specificity 70%) and a p-value of 0.044. The AUROC for corrected carotid flow time is 0.750 with a best cut off of 5.95(sensitivity 57.69 and specificity 87.50%) p-value of 0.004. Carotid artery velocity time integral was measured in 19 patients, 14 were fluid responders (73.68%) and 5 were non-responders (26.32%). AUROC for carotid artery VTI is 0.786, with a best cut off of 4.31(sensitivity 87.51 and specificity 80%) with a p-value of 0.0436.
Conclusion
Our findings indicate that carotid flow time, corrected carotid flow time can determine fluid responsiveness after a mini fluid challenge in patients with undifferentiated shock. Change in CAVTI in response to a fluid challenge did correlate with the change in LVOTVTI but the correlation coefficient is 0.3911 with a significance value of 0.0977, and therefore can be considered as a reliable dynamic bedside measure of fluid responsiveness in patients with undifferentiated shock.
References
1.Barjaktarevic I, Toppen WE, Hu S, Aquije Montoya E, Ong S, Buhr R, et al. Ultrasound Assessment of the Change in Carotid Corrected Flow Time in Fluid Responsiveness in Undifferentiated Shock. Crit Care Med. 2018 Nov;46(11):e1040–6. doi: 10.1097/CCM.0000000000003356. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Hossein-Nejad H, Banaie M, Davarani SS, Mohammadinejad P. Assessment of corrected flow time in carotid artery via point-of-care ultrasonography: Reference values and the influential factors. Journal of Critical Care. 2017 Aug 1;40:46–51. doi: 10.1016/j.jcrc.2017.03.009. [DOI] [PubMed] [Google Scholar]
3.Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, et al. Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med. 2021 Mar;25(3):310–6. doi: 10.5005/jp-journals-10071-23764. [DOI] [PMC free article] [PubMed] [Google Scholar]
Respiratory Failure and Mechanical Ventilation 15570 Epidemiology and Implications of Post-intensive Care Syndrome (PICS) in ICU Survivors Critically ill patients, Quality of life, Health-related quality of life (HRQL)
Post-intensive care syndrome (PICS) is observed in ICU survivors. This study examines PICS prevalence after discharge from a respiratory ICU, its relation with ICU parameters, illness severity, and quality of life.
Methods
Of 122 initial ICU patients, 44 were excluded due to mortality or readmission within 6 months. HABC and SF 36 were administered to the 78 remaining patients 3 months post-ICU discharge.
Results
The average HABC score was 7.10. (1)25% of the population had moderate PICS. The functional component of HABC was notably affected. There was a significant correlation (p=0.00001) between APACHE II scores (mean: 10) and HABC scores. The p/f ratio and PaCO2 at admission, along with APACHE II scores, correlated with HABC scores. A discernible negative correlation between HABC scores and SF 36 was identified.
Conclusion
Almost 20 % of our cohort experienced symptoms of moderate PICS., with an emphasis on functional impairments. Metrics such as APACHE II scores and initial blood gas parameters correlate with PICS. The inverse relationship between HABC and SF 36 indicates that PICS negatively impacts post ICU quality of life, suggesting further research and intervention strategies.
Delirium is a state of behavioral changes like altered sensorium, agitation and fluctuating mental status which is commonly seen in critically ill patients. Dexemedetomedineis a specific and selective alpha-2 adrenoceptor agonist which binds to the presynaptic alpha 2 adrenoceptors and inhibits the release of norepinephrine and thereby terminate the propogation of pain signals. This drug is nowadays used in critically ill patients for prevention of delirium in critically ill patients.
Objectives
This study aims to examine the effectiveness of dexmedetomidine for delirium and the impact on hemodynamics in critically ill patients of our population.
Materials and methods
It is a prospective observational study. A total of 80 patients of age group 18-70 years who were admitted in icu were recruited and they were randomly divided into two groups with 40 patients in each group. Inclusion criteria -patients aged 18-70 years, need mechanical ventilation, and who are intubated for more than 24 hrs. Treatment with dexmedetomidine was carried out in the investigation group, while midazolam were used in control group. A comparison was made on the antidelirium effect and the influence on hemodynamics between 2 groups in mechanical ventilation during sedation.
Results
The study is still ongoing and significant results were observed in variation of hemodynamic parameters including heart rate, respiratory rate, and blood oxygen saturation. No delirium occurred in the investigation group, when compared with 3 patients experiencing delirium symptom in the control group.
Discussions
With the preliminary findings of this study, it was found that dexmedetomedine is a good sedative drug for prevention of delirium in critically ill patients and these patients were hemodynamically more stable compared to the control group.
References
1.Van Rompaey B, Elseviers MM, Schuurmans MJ, et al. Risk factors for delirium in intensive care patients: a prospective cohortstudy. Critical Care. 2009;13:R77. doi: 10.1186/cc7892. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Tilouche N, Hassen MF, Ali HBS, Jaoued O, Gharbi R, El Atrous SS. Delirium in the intensive care unit: incidence, risk factors, and impact on outcome. Indian J Crit Care Med. 2018;22:144–149. doi: 10.4103/ijccm.IJCCM_244_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
Hospital acquired infections (HAIs) are defined as infections that develop in the patient 48 hours after being admitted to the hospital. Overall increase in LOS, increased use of drugs, additional laboratory tests contribute towards the financial burden in patients with HAIs. Most common HAIs include ventilator associated pneumonia (VAP), catheter associated urinary tract infection (CAUTI), surgical site infection (SSI) and catheter related bloodstream infections (CRBSI).
Objectives
Evaluation of incidence of ICU acquired infections at our tertiary care critical care department to evaluate the associated morbidity and mortality.
Methods
We conducted a single-centre prospective, observational study between June 2021 and December 2022. All patients admitted to the NTU, for ≥48 hours and having one of the infections: VAP, CAUTI, and CRBSI.
Results
A total of 2300 patients were admitted to the NTU during the study period. Out of these, 1276 patients had a Length of stay(LOS) of >48 hours. A total of 157 patients fulfilled the inclusion criteria. 197 events of ICU acquired Infections occurred in total. Incidence rate for VAP was 39.1/1000 Ventilator days, CRBSI - 7.8/1000 Central venous catheter (CVC) days and CAUTI- 4.8/1000 Urinary catheter days. Mean ± SD age of the patients was 56.89 ± 16.29 years (range = 17 – 83 years). A total of 115 (73%) of the patients were males. Mean ± SD ICU stay was 33.46 ± 24.51 days, while the Mean ± SD hospital stay was 37.06 ± 23.32 days. Acinetobacter Baumanii was the commonest organism causing VAP in 43 (41%) cases of the total 105 patients. Klebsiella Pneumoniae was the second most common (n=27, 26%) causative organism. The causative organisms in the CRBSI group Acinetobacter Baumanii being the most common (n=8, 21%). In CAUTI, E.coli was found to be the most common (n=18, 33%) causative organism. In our study, >80% of causative gram negative organsisms were MDR (Multi drug resistance), followed by XDR (Extensive drug resistance). No PDR (Pan drug resistance) cases were found. Amongst the patients with VAP, 8 (7.6%) died within 14 days and 5 (4.8%) within 28 days of admission. Out of 38 patients with CRBSI infection, 3 (7.9%) died within 14 days, 1 (2.6%) died within 28 days and 5 (13.2%) died beyond 28 days. Out of 54 patients with CAUTI infection, 4 (7.4%) died within 14 days, 1 (1.8%) within 28 days and 9 (16.7%) died beyond 28 days. On multivariate statistical analysis, age group (higher age group i.e. age more than 50 years), presence of hypotension on presentation, medical diagnosis and higher APACHE-II score on admission were the statistically significant and independent determinants of the incidence of mortality in overall group (P-value<0.05 for all).
Conclusion
The incidence rate for VAP was 39.1/1000 Ventilator days, for CRBSI was 7.8/1000 Central venous catheter (CVC) days and for CAUTI was 4.8/1000 Urinary catheter days and > 80 % were MDR infections. Age group, presence of hypotension on presentation, medical diagnosis and higher APACHE-II score on admission were the statistically significant and independent determinants of the incidence of mortality in overall group.
3.Patel DA, Patel KB, Bhatt SK, Shah HS. Surveillance of hospital acquired infection in surgical wards in tertiary care centre Ahmedabad, Gujarat. Nat J Commun Med. Oct-Dec 2011;2(3):340–5. [Google Scholar]
4.Saleem M, et al. Prevalence of nosocomial infections in surgical wards of tertiary care hospital at Lucknow. Ind J Sci Res. 2012;3(2):79–84. [Google Scholar]
5.Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, Pittet D. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011 Jan 15;377(9761):228–41. doi: 10.1016/S0140-6736(10)61458-4. [DOI] [PubMed] [Google Scholar]
6.Cassini A, Plachouras D, Eckmanns T, et al. Burden of six healthcare-associated infections on European population health: estimating incidence-based disabilityadjusted life years through a population prevalence-based modelling study. PLoS Med. 2016;13:1–16. doi: 10.1371/journal.pmed.1002150. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Mehta A, Rosenthal VD, Mehta Y, Chakravarthy M, Todi SK, Sen N, Sahu S, Gopinath R, Rodrigues C, Kapoor P, Jawali V, Chakraborty P, Raj JP, Bindhani D, Ravindra N, Hegde A, Pawar M, Venkatachalam N, Chatterjee S, Trehan N, Singhal T, Damani N. Device-associated nosocomial infection rates in intensive care units of seven Indian cities. Findings of the International Nosocomial Infection Control Consortium (INICC) J Hosp Infect. 2007 Oct;67(2):168–74. doi: 10.1016/j.jhin.2007.07.008. Epub 2007 Oct 1. [DOI] [PubMed] [Google Scholar]
9.Rosenthal VD, Maki DG, Salomao R, Moreno CA, Mehta Y, Higuera F, Cuellar LE, Arikan OA, Abouqal R, Leblebicioglu H, International Nosocomial Infection Control Consortium Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med. 2006 Oct 17;145(8):582–91. doi: 10.7326/0003-4819-145-8-200610170-00007. [DOI] [PubMed] [Google Scholar]
10.Kamat U, Ferreira A, Savio R, Motghare D. Antimicrobial resistance among nosocomial isolates in a teaching hospital in goa. Indian J Community Med. 2008 Apr;33(2):89–92. doi: 10.4103/0970-0218.40875. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–5. doi: 10.1378/chest.128.2.489. [DOI] [PubMed] [Google Scholar]
12.Singh S, Pandya Y, Patel R, Paliwal M, Wilson A, Trivedi S. Surveillance of device-associated infections at a teaching hospital in rural Gujarat-India. Ind J Med Microbiol. 2010;28(4):342–7. doi: 10.4103/0255-0857.71830. [DOI] [PubMed] [Google Scholar]
13.Ghadiri H, Vaez H, Khosravi S, Soleymani E. The antibiotic resistance profiles of bacterial strains isolated from patients with hospital-acquired bloodstream and urinary tract infections. Crit Care Res Pract. 2012;2012:890797. doi: 10.1155/2012/890797. [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Chawla R. Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries. Am J Infect Control. 2008 May;36(4 Suppl):S93–100. doi: 10.1016/j.ajic.2007.05.011. [DOI] [PubMed] [Google Scholar]
15.Mathai E, Kaufmann ME, Richard VS, John G, Brahmadathan KN. Typing of Acinetobacter baumannii isolated from hospital-acquired respiratory infections in a tertiary care centre in southern India. J Hosp Infect. 2001 Feb;47(2):159–62. doi: 10.1053/jhin.2000.0906. https://www.msn.com/en-in/feed [DOI] [PubMed] [Google Scholar]
16.Kwak YG, Lee SO, Kim HY, Kim YK, Park ES, Jin HY, Choi HJ, Jeong SY, Kim ES, Ki HK, Kim SR. Risk factors for device-associated infection related to organisational characteristics of intensive care units: findings from the Korean Nosocomial Infections Surveillance System. Journal of Hospital infection. 2010 Jul 1;75(3):195–9. doi: 10.1016/j.jhin.2010.01.014. [DOI] [PubMed] [Google Scholar]
17.Madani N, Rosenthal VD, Dendane T, Abidi K, Zeggwagh AA, Abouqal R. Health-care associated infections rates, length of stay, and bacterial resistance in an intensive care unit of Morocco: findings of the International Nosocomial Infection Control Consortium (INICC) International archives of medicine. 2009 Dec;2(1):1–7. doi: 10.1186/1755-7682-2-29. [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Annual report (January 2021 to December 2021) of the Antimicrobial Resistance Research & Surveillance Network (AMRSN), Division of epidemiology and communicable diseases. Indian Council of Medical Research. 2021:6. [Google Scholar]
20.Papazian L, Bregeon F, Thirion X, Gregoire R, Saux P, Denis JP, Perin G, Charrel J, Dumon JF, Affray JP, Gouin F. Effect of ventilator-associated pneumonia on mortality and morbidity. American journal of respiratory and critical care medicine. 1996 Jul;154(1):91–7. doi: 10.1164/ajrccm.154.1.8680705. [DOI] [PubMed] [Google Scholar]
21.Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Critical care medicine. 2005 Oct 1;33(10):2184–93. doi: 10.1097/01.ccm.0000181731.53912.d9. [DOI] [PubMed] [Google Scholar]
22.Siempos II, Kopterides P, Tsangaris I, Dimopoulou I, Armaganidis AE. Impact of catheter-related bloodstream infections on the mortality of critically ill patients: a meta-analysis. Critical care medicine. 2009 Jul 1;37(7):2283–9. doi: 10.1097/CCM.0b013e3181a02a67. [DOI] [PubMed] [Google Scholar]
23.Blot SI, Depuydt P, Annemans L, Benoit D, Hoste E, de Waele JJ, Decruyenaere J, Vogelaers D, Colardyn F, Vandewoude KH. Clinical and economic outcomes in critically ill patients with nosocomial catheter-related bloodstream infections. Clinical Infectious Diseases. 2005 Dec 1;41(11):1591–8. doi: 10.1086/497833. [DOI] [PubMed] [Google Scholar]
24.Clec'h C, Schwebel C, Français A, Toledano D, Fosse JP, Garrouste-Orgeas M, Azoulay E, Adrie C, Jamali S, Descorps-Declere A, Nakache D. Does catheter-associated urinary tract infection increase mortality in critically ill patients? Infection Control & Hospital Epidemiology. 2007 Dec;28(12):1367–73. doi: 10.1086/523279. [DOI] [PubMed] [Google Scholar]
Questionnaire-based Survey to Understand the Practice Patterns Pertaining to the Use of Intravenous Doxycycline and to Assess its Perceived Effectiveness and Safety among Physicians in India
Community-acquired pneumonia (CAP) is a leading cause of hospitalisation and mortality and incurs significant healthcare costs. Doxycycline IV is being used in the treatment of moderate-to-severe CAP. Also, doxycycline is recommended as first-line therapy in the treatment of scrub thypus.
Objective
The objective of this questionnaire-based survey is to understand the practice patterns pertaining to the use of intravenous doxycycline and to assess its perceived effectiveness and safety among physicians in India.
Materials and methods
This was a cross-sectional survey of physicians across India practicing in private and government hospitals from Tier I and Tier II cities. A structured, self-reported survey questionnaire with 12 questions was developed. The survey responses were captured by providing multiple choices for the respective questions. Also, open-ended descriptive comments were recorded.
Results
In this survey, 34.7% of physicians reported that 10% to 20% of patients with CAP may require ICU admissions. 92.75% of physicians advised sputum culture, and 46.37% advised a reverse transcription-polymerase chain reaction test for the identification of CAP pathogens in hospitalised patients. The prevalence of atypical bacteria in ICU-admitted or hospitalised CAP patients was reported to be between 10% to 20% by 28.98% of physicians each. 60.86% of physicians recommended the use of IV doxycycline as empirical therapy in CAP. The prevalence of scrub typhus was reported to be <5% and 5% to 10% by 59.42% and 27.53% of physicians, respectively. The majority of physicians (82.60%) recommended the use of IV doxycycline as an empirical therapy for the treatment of scrub typhus. 68.11% of physicians preferred to use IV doxycycline due to its broad spectrum of activity, recommendation by the guidelines, proven efficacy, and acceptable safety profile. Physicians’ ratings for the efficacy and safety of IV doxycycline were captured. 52.17% of physicians rated it as good and was rated as excellent by 46.37% of physicians.Conclusion: Doxycycline IV is used in hospital and ICU admission patients for the treatment of CAP and scrub typhus. It is reported to be effective and safe.
Keywords
IV doxycycline, Scrub typhus, CAP and HAP.
Reference
1.Flanders S. A, Dudas V, Kerr K, McCulloch C. E, Gonzales R. Effectiveness of ceftriaxone plus doxycycline in the treatment of patients hospitalized with community‐acquired pneumonia. Journal of hospital medicine: an official publication of the Society of Hospital Medicine. 2006;1(1):7–12. doi: 10.1002/jhm.8. [DOI] [PubMed] [Google Scholar]
Severe traumatic brain injury (sTBI) can lead to significant structural and functional changes in the brain, causing disruption of metabolic changes which include increased glycolysis, lactate production, and impaired glucose utilization. Serum lactate level has been shown to have prognostic implications in patients with trauma and aneurysmal bleed.1 However, in previous studies elevated serum lactate was found have inconclusive results as prognostic marker for TBI.2 Similarly, base deficit (BD) and hyperglycemia have been found to have association with the prognosis for TBI. However, only a few retrospective studies have examined these biochemical parameters as prognosticating tools in sTBI patients. We hypothesized that high lactate levels, BD, hyperglycaemia and trauma scores may be associated with unfavourable outcome in isolated sTBI patients.3
Objective
To evaluate whether the initial serum lactate (SL), base deficit (BD) and serumglucose (SG) levels are prognostic markers in isolated sTBI patients.
Methods
This prospective, observational study included isolated sTBI patients reporting within 24 hours over 18 months in a neurotrauma ICU (Intensive care unit) of tertiary care hospital. A single measurement of SL, BD and SG was taken at time of admission. The primary objective was to study association of biochemical parameters- early serum lactate, BD, blood glucose levels and various trauma scores on neurological outcome at30 th day of injury (as assessed by GOS-E) in sTBI patients.
Results
Out of 162 assessed, a total of 101 patients (84.1% males and 15.9% females) with mean age of 32 years were included in study. 36 (35.6%) patients died within 30days of admission. Both SL (>4 mmol/L) and SG (>180 mg/dl) were associated with unfavourable outcome (GOS-E<4) (p<0.01). These biochemical parameters correlated with Injury severity score (ISS), Revised Trauma Score (RTS), Trauma, injury severity score derived death predictable rate – {TRISS(P d)} Rotterdam CT score. The association of above biochemical parameters with these trauma scores was found to be statistically significant (p<0.01), except Rotterdam CT score (p=0.15).
Discussion
In our study, we found statistically significant association of ISS, RTS, TRISS (Pd) and Rotterdam CT score with GOS-E at 30 days of injury. Also, we found that cut off values of ISS >35, RTS < 5.96, TRISS (Pd) > 24.8 and Rotterdam CT score > 3 were predictors of unfavourable outcome (GOS-E < 4). These scores can be promising in prognostication of sTBI patients even at 30 days of injury compared to 6 months in other studies. Thus, assessment of serum lactate, blood glucose and Patients.
References
1.Carpenter KL, Jalloh I, Hutchinson PJ. Glycolysis and the significance of lactate in traumatic brain injury. Front. Neurosci. 2015;9:112. doi: 10.3389/fnins.2015.00112. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Régnier MA, Raux M, Le Manach Y, et al. Prognostic significance of blood lactate and lactate clearance in trauma patients. Anesthesiology. 2012;117(6);):1276–88. doi: 10.1097/ALN.0b013e318273349d. [DOI] [PubMed] [Google Scholar]
3.Cortés-Samacá CA, Meléndez-Flórez HJ, Álvarez Robles S, et al. Base deficit, lactateclearance, and shock index as predictors of morbidity and mortality in multiple- traumapatients. Revistacolombiana de anestesiologia. 2018;46(3);):208–15. doi: 10.1097/CJ9.0000000000000064. [DOI] [Google Scholar]
Can Δ SBP, ΔMAP, ΔPP Post Mini Fluid Challenge Predict Preload Responsiveness as Good as PPV and IVC Distensibility Index in Mechanically Ventilated Patients?
Hypovolemia and Hypervolemia both increase morbidity and mortality in critically ill. Hence they require evaluation of fluid responsiveness several times a day. Thus the feasibility, expertise and reproducibility of parameters predicting fluid responsiveness plays a major role in clinical outcome. PPV and IVC distensibility index have shown to be effective and feasible in predicting fluid responsiveness in mechanically ventilated pts in shock. Parameters like ΔMAP, ΔPP, ΔSBP may be useful to indicate fluid responsiveness in resource limited settings.
Objectives
Evaluation of dynamic variables PPV, DIVC as predictors of fluid responsiveness and comparing their prediction of fluid responsiveness among responders and non responders to fluid therapy in undifferentiated shock. To evaluate significance of variables like ΔMAP, ΔSBP, ΔPP in indicating fluid responsiveness.
Materials and methods
Mechanically ventilated patients in shock with a clinical decision to administer fluid challenge are included. Minifluid challenge of 4ml/kg administered over 5 mins. Fluid responders classified as > 10% increase in Left Ventricular Outflow Tract VTI post fluid challenge. Hemodynamic variables PPV, DIVC, SBP, MAP, PP, were noted pre and post fluid challenge. PPV is recorded as an automated value from arterial waveform in Phillips intellivue Mx 450. IVC distensibility is measured subcostally by Ultrasound.
Results
43 patients were enrolled of which, 28 (65.12%) were fluid responders and 15(34.88%) non responders. AUROC of PPV was 0.75 ± 0.07 with a best cutoff of 11 (sensitivity 67.86%; specificity 80%). AUROC of DIVC was 0.76±0.08, and the best cutoff value to predict fluid responsiveness was 14.05 (sensitivity 82.14% and specificity 73.33%). ΔSBP had an AUROC curve of 0.81±0.06 with cutoff of 6.38% (Sensitivity 75%, Specificity 93.33%). ΔMAP had an AUROC curve of 0.73±0.07, with best cutoff of 8.10 (Sensitivity 64.29%, Specificity 86.67%). ΔPPV had an AUROC curve of 0.73±0.09, with best cutoff reduction of 27.27% from prefluid values. (Sensitivity 89.29%, Specificity 60%).
Discussion
Our findings indicate that performance of PPV for predicting fluid responsiveness was similar to that of DIVC. Monnet et al (2011) observed a fluid-induced increase in pulse pressure of ≥17% allowed detecting a fluid-induced increase in cardiac output of ≥15% with a sensitivity of 65% and a specificity of 85%. We observed that variables like ΔMAP, ΔSBP, ΔPP were as nearly good as advanced variables like PPV and DIVC in predicting fluid responsiveness. DIVC compared with[ΔPP(p= 0.825), ΔSBP (p=0.658), ΔMAP(P= 0.835)] showed comparable AUROC curves. PPV compared with[ΔPP(p=0.644) ΔSBP(p=0.462), ΔMAP(p=0.877)] showed comparable AUROC curves.
Conclusion
Preload responsiveness may not always correlate with improvement of clinical outcome with administration of fluids. We should prefer hemodynamic variables with higher sensitivity when the patient is clinically volume depleted and variable with high specificity when the clinical suspicion of fluid responsiveness is low. In critically ill with advanced monitoring being done PPV and DIVC are reliable indicators of fluid responsiveness. In resource limited settings we can use changes in MAP, SBP, PP with clinical expertise to assess fluid responsiveness.
Keywords
PPV Pulse Pressure Variation, DIVC Distensibility index of Inferior Vena Cava, AUROC Area under Receiver Operator Characteristic, MAP Mean arterial pressure, PP Pulse pressure, SBP Systolic Blood Pressure.
References
1.Mohiedden Mohammad, Abdelfattah Elgammal, Sahar Elsayed, Khaled Abdalla, Radwa Mowafy, Sherif 2020 Distensibility Index of Inferior Vena Cava and Pulse Pressure Variation as Predictors of Fluid Responsiveness in Mechanically Ventilated Shocked Patients. Journal of Emergency Medicine, Trauma and Acute Care. 2020 10.5339/jemtac.2020.2. [Google Scholar]
2.Özsoylu Serkan, Akyildiz Başak. Comparison of vena cava distensibility and pulse pressure variation for the evaluation of intravascular volume in critically ill children. Jornal de Pediatria. 2021;98 doi: 10.1016/j.jped.2021.04.005. 10.1016/j.jped.2021.04.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Monnet X, Letierce A, Hamzaoui O, Chemla D, Anguel N, Osman D, Richard C, Teboul JL. Arterial pressure allows monitoring the changes in cardiac output induced by volume expansion but not by norepinephrine. Crit Care Med. 2011 Jun;39(6):1394–9. doi: 10.1097/CCM.0b013e31820edcf0. 21336124 [DOI] [PubMed] [Google Scholar]
4.Monnet X, Shi R, Teboul JL. Prediction of fluid responsiveness. What's new? Ann. Intensive Care. 2022;12:46. doi: 10.1186/s13613-022-01022-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Alvarado Sánchez J.I, Caicedo Ruiz J.D, Diaztagle Fernández J.J, et al. Variables influencing the prediction of fluid responsiveness: a systematic review and meta-analysis. Crit Care. 2023;27:361. doi: 10.1186/s13054-023-04629-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Vincent JL, de Backer D. Circulatory Shock. Finfer SR, Vincent JL, editors. N Engl J Med. 2013 Oct 31;369(18):1726–34. doi: 10.1056/NEJMra1208943. [DOI] [PubMed] [Google Scholar]
To Observe the Effect of Intrathecal Magnesium Sulphate 75 mg and 100 mg as an Adjuvant to 0.5% Hyperbaric Bupivacaine in Prolonging the Duration of Spinal Anesthesia in Subarachnoid Block
To observe the effect of Intrathecal Magnesium Sulphate 75 mg and 100 mg in prolonging the duration of Spinal Anesthesia using 0.5% Hyperbaric Bupivacaine in Subarachnoid block.
Background
Spinal Anesthesia is the primary anaesthetic technique for many surgeries, widely used for infra umbilical and lower limb surgeries. This study was undertaken to evaluate the effects of additives such as Magnesium sulphate along with bupivacaine for prolongation of duration of analgesia and motor blockade. Adjuncts to Local Anaesthetic exhibit various side effects such as respiratory depression, urinary retention, pruritis, heamodynamic instability and nausea and vomiting. Magnesium sulphate when used in therapeutic doses avoids these side effects.
Materials and methods
A randomized study was conducted in 90 patients. Patients were allocated to three groups and given the following drugs intrathecally. Group A was given Bupivacaine 0.5%(heavy) with 100mg of Magnesium sulphate as an adjuvant Group B was given Bupivacaine 0.5% (heavy) with 75mg of Magnesium Sulphate as an adjuvant. Group C was given 0.5% Bupivacaine (heavy) without any adjuvant. Parameters that were monitored were duration of blockade along with haemodynamic parameters and side effects.
Result
It was observed that the onset of motor blockade showed no difference. The duration of blockade was increased. First request of Analgesia was delayed in group A. No significant Heamodynamic changes were seen.
Conclusion
N-methyl-D-aspartate (NMDA) receptor antagonist such as Magnesium sulphate when given as an adjunct to Bupivacaine intrathecally significantly increase the duration of spinal analgesia without any adverse effects.
Refrences
1.Fawcett WJ, Haxby EJ, Male DA. Magnesium: physiology and pharmacology. Br J Anaesth. 1999;83:302–320. doi: 10.1093/bja/83.2.302. [DOI] [PubMed] [Google Scholar]
2.Haubold HA, Meltzer SJ. Spinal anesthesia by magnesium sulphate. A report of seven operations performed under its influence. JAMA. 1906;46(9):647–6570. [Google Scholar]
Comparison of ‘Airway Pressure Release Ventilation’ vs ‘Pressure Regulated Volume Control’ Mode of Ventilation in the Exploratory Laparotomy Patients in Intensive Care Unit
1Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India, Phone: +91 9988710158, e-mail: jazz9a5745@yahoo.com
1Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India, Phone: +91 9988710158, e-mail: jazz9a5745@yahoo.com
2–4Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
Postoperative exploratory laparotomy often requires intensive care unit (ICU) admission due to complex cardiopulmonary and metabolic pathophysiology. These subset of patients may require invasive mechanical ventilation owing to ongoing raised intra- abdominal pressure, dysfunction of diaphragm and post-surgical pain, resulting in alveolar collapse and subsequent reduction in lung volume.1 Conventional or open-loop ventilatory modes work with preset target values with the absence of the patient's feedback. In contrast, the advanced modes automatically adjust according to the patient's mechanical and ventilatory parameters, completing the feedback loop and achieving the preset target values, hence labeled as “closed loop” control modes.2 Airway pressure release ventilation (APRV) is one of the advance mode of ventilation, designed to facilitate the constant recruitment of alveoli while reducing the probability of ventilator-induced lung injury.3 Pressure-regulated volume control (PRVC) is a dual mode of mechanical ventilation that integrates volume and pressure-control ventilation and is also termed as volume-targeted synchronized mode. Although APRV mode is advocated as a better mode in terms of cardiopulmonary functions, limited studies have compared this unique mode with other modes of ventilation.3, 4 We hypothesize that post-exploratory laparotomy patients in the ICU requiring mechanical ventilation will have superior efficacy and safety in terms of ventilatory and hemodynamic profile on APRV mode compared to volume-targeted PRVC mode, due to the unique intrinsic characteristics of the APRV mode.
Objectives
Primary: To compare ventilatory parameters in mechanically ventilated post-exploratory laparotomies patients in ICU on APRV with PRVC mode of ventilation. Secondary: To compare hemodynamic and arterial blood gas parameters in mechanically ventilated post-exploratory laparotomies patients in ICU on APRV with PRVC mode of ventilation.
Materials and methods
After institutional ethical approval and written informed consent, this interventional, prospective, randomized-controlled, double-blinded study was conducted on 110 mechanically ventilated patients in our ICU as per inclusion and exclusion criteria. Patients were kept supine and sedated as per institutional sedation protocol and were initially kept on volume control/assist control (VC/AC) mode for 2 hours (washing period) and baseline parameters (ventilatory and cardiopulmonary) were recorded. Group-1 (55) patients were then kept on APRV mode versus group-2 (55) on PRVC mode with preset ventilatory settings. Subsequently, all parameters were recorded every 2 hours for total of 8 hours. Thereafter, all patients were shifted back to its original mode of ventilation.
Results
The study results compilation is currently in process and is expected to be completed before presentation of this study.
Discussion
Based on initial observation we found that APRV mode of ventilation initially generates higher peak (Ppeak) possibly due to intrinsic properties of APRV mode, which leads to prolongation of inspiratory time, reflected as inverse IE ratio. However, we observed significant improvement in compliance (C) in APRV group, mainly attributable to to sustained airway pressures for extended duration of inspiratory cycle, resulting in amelioration of alveolar recruitment by allowing extended duration for inflation of slow lung units in heterogenous lung fields.
References
1.Lee BC, Kyoung KH, Kim YH, Hong SK. Non-invasive ventilation for surgical patients with acute respiratory failure. J Korean Surg Soc. 2011;80:390–6. doi: 10.4174/jkss.2011.80.6.390. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Singh PM, Borle A, Trikha A. Newer nonconventional modes of mechanical ventilation. J Emerg Trauma Shock. 2014;7:222–7. doi: 10.4103/0974-2700.136869. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Ge H, Lin L, Xu Y, Xu P, Duan K, Pan Q, et al. Airway pressure release ventilation mode improves circulatory and respiratory function in patients after cardiopulmonary bypass, a randomized trial. Front Physiol. 2021;12:684927. doi: 10.3389/fphys.2021.684927. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Mahjoubifard M, Jahangiri Fard A, Golestani Eraghi M, Amini S, Hashemian SM, Farzanegan B, et al. Does airway pressure release ventilation mode make difference in cardiopulmonary function of ICU patients? J Cardiothorac Med. 2015;3:375–8. [Google Scholar]
Relationship between Mitral Annular Plane Systolic Excursion and Left Ventricular Ejection Fraction by Modified Simpson's Method Using Point of Care Cardiac Ultrasound: An Observational Analytical Study
The standard accepted method for assessment of left ventricular ejection fraction (LVEF) is modified Simpson's method but it takes time and may not be feasible in emergent conditions. Mitral annular plane systolic excursion (MAPSE) occurs due to contraction of longitudinal fibers and represents myocardial contractility. It is measured on M-mode of ultrasound. It is technically easier and quicker to obtain and may be assessed even with poor cardiac window.
Primary objective
To find the relationship between MAPSE and LVEF by modified Simpson's method using point of care cardiac ultrasound.
Methodology
A prospective observational study was conducted in two parts. In the first part, 75 patients were recruited for determining the relationship between MAPSE and LVEF by modified Simpson's method. It was validated in the second part in 75 patients by comparing its result with LVEF obtained from 4.8 × MAPSE + 5.8 (males) or 4.2 × MAPSE + 20 (females) and modified Simpson's method.
Results
Equation obtained was EF= 3.27 × (MAPSE) + 17.92 (ρ=0.761, R2=0.520). The average time for MAPSE was 51.47 ± 11.18 s and for modified Simpson's method was 192.27 ± 31.93 s. We calculated PPV (93.33%), NPV (73.33%), sensitivity (93.33%), specificity (73.33%) and accuracy (89.33%) for the equation. A MAPSE of 10.325 mm, predicts a normal EF with a 90.7% sensitivity and 90.6% specificity.
Conclusion
MAPSE correlates well with the EF measured by modified Simpson's method. It is faster and provides a good estimation as to whether the contractility is preserved or decreased.
References
1.Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1);):1–39. doi: 10.1016/j.echo.2014.10.003. [DOI] [PubMed] [Google Scholar]
2.Keren G, Sonnenblick E, Le Jemtel T. Mitral annulus motion: relation to pulmonary venous and transmitral flows in normal subjects and in patients with dilated cardiomyopathy. Circulation. 1988;78:621–9. doi: 10.1161/01.cir.78.3.621. [DOI] [PubMed] [Google Scholar]
3.Matos J, Kronzon I, Panagopoulos G, et al. Mitral annular plane systolic excursion as a surrogate for left ventricular ejection fraction. J Am Soc Echocardiogr. 2012;25:96974. doi: 10.1016/j.echo.2012.06.011. [DOI] [PubMed] [Google Scholar]
4.Adel W, Roushdy AM, Nabil M. Mitral Annular Plane Systolic Excursion-Derived Ejection Fraction: A Simple and Valid Tool in Adult Males With Left Ventricular Systolic Dysfunction. Echocardiography. 2016;33(2);):179–84. doi: 10.1111/echo.13009. [DOI] [PubMed] [Google Scholar]
5.Parhi DK, Behera KG. Mitral annular plane systolic excursion-derived formula to calculate the ejection fraction: a simple, easy and rapid echocardiography parameter to asses left ventricle systolic dysfunction. IJAR. 2021;11:54–6. [Google Scholar]
6.Wenzelburger FWG, Tan YT, Choudhary FJ, Lee ESP, Leyva F, Sanderson JE. Mitral annular plane systolic excursion on exercise: a simple diagnostic tool for heart failure with preserved ejection fraction. European Journal of Heart Failure. 2011;13:953–60. doi: 10.1093/eurjhf/hfr081. [DOI] [PubMed] [Google Scholar]
7.Damodaran Srinath, Goverdhan Puri, Mandal Banashree, Barwad Parag. Mitral Annular Plane Systolic Excursion/Left ventricular length (MAPSE/L) – a novel index for assessing left ventricular longitudinal function in pediatric Tetralogy of Fallot patients undergoing surgical repair 2019.
8.Hensel KO, Roskopf M, Wilke L, Heusch A. Intraobserver and interobserver reproducibility of M-mode and B-mode acquired mitral annular plane systolic excursion (MAPSE) and its dependency on echocardiographic image quality in children. PLoS One. 2018;13(5):e0196614. doi: 10.1371/journal.pone.0196614. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Shah A, Nanjayya V, Ihle J. Mitral Annular Plane Systolic Excursion as a predictor of Left Ventricular Ejection Fraction in mechanically ventilated patients. Australasian Journal of Ultrasound in Medicine. 2019;22:138–42. doi: 10.1002/ajum.12131. [DOI] [PMC free article] [PubMed] [Google Scholar]
Colorectal cancer, particularly adenocarcinoma colon, ranks among the most prevalent malignancies worldwide. Its clinical presentation spans a wide spectrum, from straightforward to remarkably intricate. In this case report, we describe the challenges of managing a rare case of metastatic adenocarcinoma colon complicated by spontaneous tumour lysis syndrome, acute kidney injury, acute lower limb deep venous thrombosis, and the subsequent development of heparin-induced thrombocytopenia in the ICU.
Case Report
A 62 year old gentleman with adenocarcinoma of colon with liver metastasis presented to the casualty with coffee brown vomitus and malena along with pain and swelling of both legs. He was hypotensive and tachycardic. Despite fluid resuscitation he was hypotensive requiring vasopressor support and he was soon shifted to MICU for further care. Initial blood workup revealed Acute Kidney injury along with hyperkalemia, hyperphosphatemia, hypocalcemia, hypocalcemia with a clinical suspicion of spontaneous Tumor Lysis Syndrome.
Venous Doppler of lower limb identified Acute DVT of both the legs. He was started on therapeutic anticoagulation with IV Heparin. In view of worsening AKI with hyperkalemia and persistent oliguria keeping in mind the possibility of TLS he underwent emergency Hemodialysis. IVC filter was placed via common femoral vein following which he underwent mechanical thrombectomy of left lower leg veins. Despite therapeutic anticoagulation and vigilant monitoring of the lower limb pulsations, he developed distal ischemia of the lower leg followed by wet gangrene and he underwent left lower limb amputation. Repeat blood workup over the next 2 days revealed thrombocytopenia with a drop in >50% platelet count from the baseline arising a clinical suspicion of Heparin Induced thrombocytopenia (time interval of starting heparin was 5 days). Heparin was stopped and Fondaparinux was started. HIT Antibody assay was sent which turned out to be positive confirming the diagnosis of HIT.
Discussions
Tumour lysis syndrome (TLS) is a documented but uncommon life-threatening oncologic emergency characterized by cell lysis and the rapid release of intracellular components into the bloodstream. While TLS is predominantly associated with hematologic malignancies, it can sporadically manifest in solid tumours such as colorectal cancer. TLS is commonly seen in patients who have undergone recent chemotherapy and a spontaneous presentation of TLS without any inciting events is rare. The 4Ts scoring system is a widely accepted tool used to assess the pretest probability of HIT. It evaluates four clinical parameters: the degree of thrombocytopenia, timing of platelet count fall, presence of thrombosis, and alternative causes of thrombocytopenia. In our case, laboratory tests, including the Latex Enhanced Immunoassay, confirmed the diagnosis of HIT. The 4Ts scoring system also indicated a high probability, aligning with the clinical presentation. Immediate discontinuation of heparin and the initiation of non-heparin anticoagulants (Fondaparinux) at therapeutic anticoagulation doses were pivotal in managing HIT and improving the platelet counts.
Conclusion
Effectively managing a case of adenocarcinoma colon complicated by spontaneous tumour lysis syndrome, acute kidney injury, lower limb deep venous thrombosis, and the subsequent development of heparin-induced thrombocytopenia in the intensive care unit is a multifaceted undertaking. Scoring systems for TLS, AKI, DVT, and HIT facilitate the assessment of each condition's severity and in guiding treatment decisions. A high index of suspicion was necessary for timely detection of HIT and its management.
References
1.Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004;127(1):3–11. doi: 10.1111/j.1365-2141.2004.05094.x. [DOI] [PubMed] [Google Scholar]
2.Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364(19):1844–1854. doi: 10.1056/NEJMra0904569. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1) Crit Care. 2013;17(1):204. doi: 10.1186/cc11454. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Farge D, Frere C, Connors JM, et al. 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol. 2019;20(10):e566–e581. doi: 10.1016/S1470-2045(19)30336-5. [DOI] [PubMed] [Google Scholar]
5.Cuker A, Gimotty PA, Crowther MA, Warkentin TE. Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. Blood. 2012;120(20):4160–4167. doi: 10.1182/blood-2012-07-443051. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795–1798. doi: 10.1016/S0140-6736(97)08140-3. [DOI] [PubMed] [Google Scholar]
Apixaban is a non-vitamin K dependent oral anticoagulant causing factor Xa inhibiton, the other factor Xa inhibitors being Rivaroxaban and Edoxaban. They have a safe and efficacious profile compared to Warfarin in patients with Deep Vein Thrombosis, Venous Thromboembolism and stroke prevention in Non-valvular Atrial fibrillation. Despite its advantages, unfortunately it has no direct reversal agent. Although Andexanet Alfa, a recombinant modified human activated Factor X protein that specifically binds to Factor X has been developed, it is not readily available.
Case report
In this case report we bring to light about the use of 4 factor PCC in Apixaban induced life threatening bleeding in a patient with multiple comorbidities who was brought to MICU with severe hemorrhagic shock requiring high dose dual vasopressor supports. He was discharged home with Apixaban for prophylaxis of AF and he present with massive upper gastrointestinal bleed. He developed VT with pulse, was intubated electively to prevent aspiration and he posed a challenge since it was a difficult airway. He was started on Massive transfusion protocol and a total of 5 pint PRBC,4 RDP,4FFP,8 cryoprecipitate and 3750 units of 4 factor PCC was given. He improved over due course of time, extubated and shifted to HDU. This case report highlights the timely activation of Massive transfusion protocol and administration of PCC which were instrumental in the resuscitation of the patient.
Discussions
Apixaban has a time to peak onset of action at 3-4 hours, half life of around 12 hours and has 30% renal elimination:
Urgent reversal of acquired coagulation factor deficiency induced by warfarin-induced anticoagulation in patients presenting with major acute bleeding (intracerebral hemorrhage-ICH) or a need for urgent invasive surgery or procedure.
Reversal of Direct oral anticoagulants (DOAC) induced anticoagulation.
Treatment or prophylaxis of bleeding in congenital deficiency of any vitamin K-dependent coagulation factors (II, VII, IX, X).
Peri-operatively to decrease bleeding in patients not taking oral anticoagulants.
Trauma setting with massive transfusion.
Christmas disease
It is given at a dose of 25 units/kg when INR is 2-4, 35 units/kg when INR is 4-6, 50 units /kg when INR is >6.
Conclusion
This case report describes the use of PCC for Apixaban induced life threatening bleeding where in the hemostatsis significantly improved following the dose of 25 units/kg. So PCC can be safely used where Andexanet alfa is unavailable or patient is volume overloaded and poses a difficulty when transfusing large volumes of blood and products as also evidenced by the UPRATE trial.
References
1.Management of rivaroxaban- or apixaban-associated major bleeding with prothrombin complex concentrates: a cohort study. Ammar Majeed1 2 3 4, Anna Ågren1 3, Margareta Holmström1 3, Maria Bruzelius1 3, Roza Chaireti3 5 6, Jacob Odeberg1 3 7, Eva-Lotta Hempel1 3, Maria Magnusson6 8 9, Tony Frisk10, Sam Schulman. [DOI] [PubMed]
2.Activated prothrombin complex concentrate to reverse the factor Xa inhibitor (apixaban) effect before emergency surgery: a case series. Nina Haagenrud Schultz1,2,3,4*, Runar Lundblad5 and Pål Andre Holme1,2,3. [DOI] [PMC free article] [PubMed]
3.Safety of 4-factor prothrombin complex concentrate (4F-PCC) for emergent reversal of factor Xa inhibitors. Jing Tao*, Elena N. Bukanova and Shamsuddin Akhtar. [DOI] [PMC free article] [PubMed]
4.Four-factor Prothrombin Complex Concentrate for the Management of Patients Receiving Direct Oral Activated Factor X Inhibitors. Oliver Grottke, M.D., Ph.D., Sam Schulman, M.D., Ph.D. Management of Bleeding With Non–Vitamin K Antagonist Oral Anticoagulants in the Era of Specific Reversal Agents. CIRCULATION. Christian T. Ruff, MD, MPH, Robert P. Giugliano, MD, SM, and Elliott M. Antman, MD. [DOI] [PubMed]
5.Prothrombin Complex Concentrate Janani Baskaran; Richard A. Lopez; Manouchkathe Cassagno. [PubMed]
Mechanical ventilation in the ICU is vital, but prolonged use or premature weaning can lead to poor outcomes. Predicting weaning failure is crucial, given its association with ventilator-associated pneumonia, longer hospital stays, and higher mortality. Traditional evaluation methods like Rapid shallow breathing index(RSBI) and Spontaneous Breathing Trial(SBT) have limitations, with 3-19% of SBT-passed patients facing re-intubation due to inaccuracies1. The shortcomings lie in the SBT's inability to precisely reflect airway and lung function, coupled with the subjective assessment of respiratory muscle endurance. There's a pressing need for more accurate and objective weaning assessment approaches to enhance outcomes and optimize ICU care. Objectives:To validate a Mechanical power oriented model of weaning failure in mechanically ventilated patients.
Materials and methods
A Prospective, Obeservational study was done in Department of CCM at IGIMS, Patna. Patients above 18 yrs. and those mechanically ventilated >24hours were include. Confirmed neuromuscular disease and death prior to weaning were excluded. Data regarding demographics, co-morbidity, addiction, clinical history, and more was collected and analysed. The focus is on respiratory mechanics parameters within 24 hours before the first SBT. Parameters include tidal volume (VT), respiratory rate (RR), peak inspiratory pressure (Ppeak), plateau pressure (Pplat), positive end-expiratory pressure (PEEP), and minute ventilation (MV). The RSBI was noted before the first SBT. Vital parameters and laboratory investigations were noted. Mechanical power (MP) was calculated using Gattinoni's simplified equation.
The results of our study showed that compared with the weaning failure group, the Cdyn of the patients in the weaning success group was higher, while the MP, PEEP, Ppeak value was lower. Although value of MP not statistically significant (p =0.327)in success group but like previous studies cutoff of <15.0 had high likelyhood of success.
Discussion
MP is a unifying concept proposed by Gattinoni in the context of acute respiratory distress syndrome. MP integrates multiple factors of mechanical ventilation, like tidal volume, PEEP, Pplat, Ppeak, and respiratory rate and the total energy delivered by the ventilator to the lung parenchyma can be calculated from a combination of the these parameters. Consequently, MP could be a predictor to guide weaning from ventilation. In our study we analyzed the respiratory mechanics indexes of mechanically ventilated patients before weaning, and evaluated the relationship between MP, Cdyn-MP, and weaning outcomes respectively, to further optimize the weaning decision.Conclusion: MP includes multiple factors related to respiratory load, such as resistance, driving pressure, lung compliance and PEEP. we found that MP before SBT (<15) had more chances of weaning success.
Refrences
1.Eskandar N, Apostolakos MJ. Weaning from mechanical ventilation. Crit Care Clin. 2007 Apr;23(2):263–74, x. doi: 10.1016/j.ccc.2006.12.002. 17368170 [DOI] [PubMed] [Google Scholar]
2.Gattinoni L, et al. Ventilator-related causes of lung injury: The mechanical power. Intensive Care Med. 2016;42(10):1567–1575. doi: 10.1007/s00134-016-4505-2. [DOI] [PubMed] [Google Scholar]
3.Ghiani A, et al. Mechanical power normalized to lung-thorax compliance predicts prolonged ventilation weaning failure: A prospective study. BMC Pulm. Med. 2021;21(1):202. doi: 10.1186/s12890-021-01566-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
With the emergence and re-emergence of infectious diseases, the need for rapid and accurate detection of the causative pathogen is crucial to provide appropriate therapy. Current gold standard of culture-based detection suffers longer turnaround time (3-5 days), low sensitivity and failure to detect fastidious and rare pathogens(1). Next generation sequencing based diagnosis provides the scope of unbiased and data driven comprehensive detection on a single platform with accuracy, and shorter turnaround time. Routine implementation in the clinical setting will markedly improve real-time point-of-care pathogen diagnosis(2), thus, aiding initiation of optimal therapy, better patient outcomes and shorter hospital stay.
Objectives
Retrospective analysis of pathogens and ARGs to evaluate the relevance of genome sequencing technique as a routine diagnostic test for detection of infections directly from samples of patients in critical care units.
Materials and methods
Clinical samples were aseptically collected from patients with sepsis or critical infection of sterile sites. These samples were directly used for genome sequencing assay. Amplicon-based real-time sequencing with targets to identify bacteria, fungus and antimicrobial genes(ARGs) was performed on the Oxford Nanopore sequencing platform. Analysis was performed on a proprietary automated genome sequencing software that generated clinical reports. A retrospective analysis was performed on the pathogens and ARGs identified through the routine implementation of the test.
Results
A total of 31 clinical samples were included in the analysis which consisted of 23 plasma, 4 bronchoalveolar lavage, 3 cerebrospinal fluid and 1 pleural fluid. A total of 38 pathogens were detected using sequencing of which 60.5% were gram-negative bacteria, 26.3% were gram-positive bacteria and 13% were fungus. Acinetobacter spp(21.05%) and Escherichia coli (7.89%) were the most frequently detected gram-negative bacteria whereas Micrococcus spp(7.89%) and Kocuria subflava(5.26%) were the most frequent gram-positive bacteria detected. Malassezia spp. was the most frequently detected fungus(7.89%). The genome sequencing assay was able to detect 5 rare pathogens including Alternaria pipionipisi, Ralstonia pickettii and difficult-to-culture organisms such as Orientia tsutsugamushi. Out of 35 samples, 25.85% samples were found to have co-infections. Out of 9 Antimicrobial resistant genes(ARGs) included in the panel, 6 ARGs were detected in the clinical samples. Most frequently detected ARGs include blaNDM, aph (3’), blaTEM, and blaSHV. 87.5% of Acinetobacter spp detected had aph (3’) and blaNDM and 25% had more than two ARGs. 66.6% of Escherichia coli had aph (3’) gene.
Discussions
Routine implementation of the genome sequencing assay enabled the comprehensive detection of different classes of pathogens from a range of clinical samples on a single platform The genome sequencing assay enabled the detection of underdiagnosed diseases such as scrub typhus and infections by rare pathogens. The study thus underscores the importance of performing routine genome sequencing assays as diagnostic solutions for patients with suspected infection.
References
1.Cao XG, Zhou SS, Wang CY, Jin K, Meng HD. The diagnostic value of next-generation sequencing technology in sepsis. Front Cell Infect Microbiol. 2022 Sep 14;12:899508. doi: 10.3389/fcimb.2022.899508. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Li JY, Shen GG, Liu TG, Tang L V, Xia LH, Hu Y. Nanopore-targeted sequencing for simultaneous diagnosis of suspected sepsis and early targeted therapy. Ann Transl Med [Internet] 2021 [cited 2023 Dec 12];9(23):1749. doi: 10.21037/atm-21-2923. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
To Assess the Complementarity of Modified Nutric Score and Anthropometric Measurements in Predicting ICU Outcomes in Critically Ill Patients in a Tertiary Care Hospital
The assessment of nutrition in the intensive care units (ICUs) presents a unique challenge to the clinicians. Patients with poor nutritional statuses who are at high risk of adverse events need to be identified early in their course of stay in the ICU. Rapid loss of protein in ICU patients is most likely related to the proinflammatory state and severe catabolism due to the increase in stress related cytokines and hormones. During the assessment of their nutritional risk, the current metabolic states of ICU patients are vitally important, even when the patient had a good nutritional status before. The framework of current metabolic status, comorbidities, decreased energy intake, BMI, and recognized markers of outcome predictors in ICU were used in the development of NUTrition RIsk in the Critically ill (NUTRIC) score. Several scores have been used for assessing the nutritional status in critically ill patients admitted to ICU. Majority of these scores utilize weight/BMI as one of the parameter to assess the nutritional status. In patients admitted to the ICU, it is challenging to measure their exact weights. mNUTRIC score which was developed for nutrition risk assessment of critically ill patients, does not include weight/BMI as a parameter. Also it neither include any of the anthropometric measurements related to the patient which may be considered as a drawback. This study aims at including anthropometric measurements (triceps skin fold thickness and mid upper arm circumference) with mNUTRIC score, and assessing their complementarity in predicting outcome in critically ill patients admitted to the ICU.
Objectives
Primary: To assess if anthropometric measurements can complement mNUTRIC score at admission in predicting the ICU mortality in critically ill patients admitted to the ICU.
Secondary/tertiary:
To assess if anthropometric measurements can complement mNUTRIC score at admission in predicting the length of ICU stay, duration of mechanical ventilation and 28 day mortality in critically ill patients admitted to the ICU.
Materials and methods
SUBJECTS
– State inclusion criteria: Patients above 18 yrs of age, and within 48 hours of admission to the ICU.
– State exclusion criteria:
– Patients who remained in the ICU for less than 24 hrs.
– Anasarca
– Burns
– Pregnant women.
– Absent consent.
Sample size was calculated using the following formula:
Suppose the two groups are ‘A’ and ‘B’, and we collect a sample from both groups – i.e. we have two samples. We perform a two-sample test to determine whether the mean in group A, μA, is different from the mean in group B, μB.
The hypotheses are
– H0: μA−μB = 0
– H1: μA−μB ≠ 0.
where the ratio between the sample sizes of the two groups is
–K = nA/nB
Formula to compute sample size and power, respectively ARE:
N=σ2(z1−β+z1−α/2)2 / (μ0−μ1)2
μ0 = population mean
μ1 = mean of study population
N = sample size of study population
σ = variance of study population
α = probability of type I error (usually 0.05)
β = probability of type II error (usually 0.2)
z = critical Z value for a given α or β
Taking alpha as 5% and power of the study as 80%, Mean of two groups (mean mNUTRIC scores in the alive and deceased groups respectively) as 4.67 and 6.16, the sample size was calculated as 58, and considering 10% drop outs, sample size was decided as 70.
Patients who were admitted to the ICU under department of critical care medicine, fulfilling the inclusion criteria were selected for the study
Informed consent was obtained in an understandable language.
Age, sex, comorbidities, diagnosis, admitting service(medical vs. surgical), number of days from hospital to ICU admission and the (APACHE) 2 score and the (SOFA) score at admission.
Using these data, the modified NUTRIC score was calculated for each participant
Mid-Upper Arm Circumference(MUAC) Triceps Skin Fold thickness(TSF)were calculated
Then the Mid Arm Muscle Circumference(MAMC) was calculated using the formula,
MAMC(cm) = MUAC(cm)–(TSF(mm)x 0.314).
For the analysis, all statistical tests were evaluated with a 2-tailed p-value and p-values less than 0.05 were considered significant.
All potential risk factors were entered in the univariate analysis using Chi-square test for comparing proportions and categorical variables and Student's t test for continuous variables whereever applicable. Risk factors with p < 0.05 in the univariate analysis along with mNUTRIC score and anthropometric measurements was then included in the multivariable logistic regression analysis using ICU mortality as the dependent variable.
A linear regression model was used for the length of stay as dependent variable.
Results
A total of 80 cases admitted during the study period were included in the study. Six patients were excluded from the study. Data of 74 patients were analyzed. Mean age of the patients was 54.78 (±15.12) (±SD). Most of the patients were male, i.e.,51 (68.92%). Baseline characteristics were compared between the ICU survivors (67) (90.54%) and ICU nonsurvivors (7) (9.46%). Mean age of patients was 54.28±14.13 and 54.83±15.32 in the ICU survivors and ICU nonsurvivors respectively. The mean duration of illness among ICU survivors and non survivors were 6.11±6.7 and 11.71±7.47 respectively, mean APACHE2 score was 15.79±6.88 and 31.71±10.06 respectively. The mean modified NUTRIC score was 3.89±1.82 and 6.85±1.57 in ICU survivors and nonsurvivors respectively (p=0.001). Mean triceps skinfold thickness was 12.16±4.93 in the ICU survivors and 7.35±1.88 in the ICU nonsurvivors (p<0.0). Modified nutric score complemented by triceps skinfold thickness was not a better predictor of ICU mortality when compared to modified nutric score alone. Modified nutric score along with Mid Arm Muscle circumference(MAMC) was a better predictor of ICU mortality than mNUTRIC score alone, with area under the curve of 0.87. However, the mNUTRIC score when complemented by triceps skinfold thickness was a significantly better predictor of 28 day mortality (p<0.0) when compared to mNUTRIC score alone (P=0.32), with area under the curve of 0.92. Also, mNUTRIC score along with triceps skin fold thickness was a better predictor of length of ICU stay(p<0.0) when compared to mNUTRIC score taken alone (p0.02).
Discussions
The study shows the importance of considering anthropometric measurements along with mNUTRIC score and other illness severity scores such as APACHE2 and SOFA score, as these scores when complemented by the anthropometric measurements (which are the measures of patient's actual nutritional status) give us a much better predictability of ICU mortality, 28 day mortality and length of ICU stay.
References
1.Amartya Mukhopadhyay, Jeyakumar Henry, Venetia Ong, Claudia Shu-Fen Leong, et al. Association of modified NUTRIC score with 28-day mortality in Q5 critically ill patients. Elsevier. 2017 Aug;36(4):1143–1148. doi: 10.1016/j.clnu.2016.08.004. [DOI] [PubMed] [Google Scholar]
2.Maria Cristina Gonzalez, Renata M, Bielemann Paula P, Kruschardt, Orlandi Silvana P. Complementarity of NUTRIC score and Subjective Global Assessment Q8 for predicting 28-day mortality in critically ill patients. Elsevier clinical nutrition. 2019 Dec;38(6):2846–2850. doi: 10.1016/j.clnu.2018.12.017. [DOI] [PubMed] [Google Scholar]
3.Manoela Lima Oliveira, Daren Keith Heyland, Flávia Moraes Silva, Estela Iraci Rabito, et al. Complementarity of modified NUTRIC score with or without C-reactive protein and subjective global assessment in predicting mortality in critically ill patients, October 2019. Revista Brasileira deTerapia intensiva. 31(4):490–496. doi: 10.5935/0103-507X.20190086. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Ping Zhang, Zhigang Hi, Gang Yu, Dan Peng, et al. The modified nutric score can be used for nutritional risk assessment and prognosis prediction in critically ill COVID -19 patients. Clinical nutrition. 2021 Feb;40(2):534–541. doi: 10.1016/j.clnu.2020.05.051. [DOI] [PMC free article] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 8801986612, e-mail: meruguvinay007@gmail.com
1Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 8801986612, e-mail: meruguvinay007@gmail.com
2–5Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
In critically ill patients, inferior vena cava (IVC) diameter is most frequently used as one of the indices to assess fluid status and fluid responsiveness. However, measuring the IVC diameter may not be technically easy in all ICU population. Factors, such as abdominal trauma, increased intraabdominal pressure, impaired ventricular contraction, obesity, and the patient's body position can affect the accuracy of measuring the IVC diameter via ultrasound. In such cases clinicians may rely on other non-invasive indices. We conducted this study to establish a possible correlation between femoral vein and artery diameter ratio and IVC distensibilty index.
Objectives
The objective of this exploratory study is to find out the correlation of femoral vein diameter (FVD)/femoral artery diameter (FAD) with IVC. To establish a cut off of FAD/FVC ratio for guiding fluid optimization in critically ill mechanically ventilated patients.
Methods and methodology
This is a prospective study conducted over a period from July to November in critical care department of a tertiary care centre. Inclusion criteria was patients over 18 years of age on mechanical ventilation on invasive monitoring and patients with a right atrium dilatation or right ventricle tumour, severe stenosis of the valve or, skin infection at the puncture site, artery/vein thrombosis, significant lower extremity artery plaque, lower extremity artery occlusion, inferior vena cava filter implantation, lower extremity varicose veins and where IVC cannot visualized were excluded. Patient was positioned supine and a linear USG probe was used to measure femoral artery and vein diameter at bifurcation and IVC diameter distensibility index was measured by the phased array probe which is placed in the subxiphoid area and the liver is used as an acoustic window and the minimum IVC diameter on inspiration and the maximum IVC diameter on expiration was recorded using M-mode just beyond the point where the hepatic veins drain into the IVC. In mechanically ventilated patients, the IVC distensibility index is calculated using the formula: IVC distensibility index = [(maximum diameter on inspiration–minimum diameter on expiration)/minimum diameter on expiration] and a correlation was derived in a mechanically ventilated patients.
Results
Sample size of 75 was calculated using the software and appropriate statistical tests was used for analysis. Among the 30 ventilator patients the FVD/FAD ratio was found to be no statistically significant correlation with IVC distensibility index (R= 0.045, SE= 0.247). According to ROC curve an FVD/FAD ratio < 1.445 had the characteristics to predict a IVC distensibility index > 20% (AUC= 55%, SE 0.11) in mechanical ventilated patients.
Discussion
Several studies have reported the evaluation of CVP by ultrasound measurement of the IVC or internal jugular vein (IJV). In a study by Nik Muhamad NA et al., the IVC diameter at end expiration was better at predicting CVP than the IJV height. Our was the first study conducted comparing FVD/FAD ratio with IVC. In our study measurement of FVD/FAD ratio obtained via ultrasound found no correlation with IVC diameter. Larger sample size is needed to establish its validity as a index of fluid assessment.
References
1.Zhihang Ma, Jiaxin Gai, Yinghan Sun, Yunpeng Bai, Hongyi Cai, Lei Wu, Lixiu Sun, Junyan Liu, Li Xue, Bingchen Liu. Measuring the ratio of femoral vein diameter to femoral artery diameter by ultrasound to estimate volume status. BMC Cardiovasc Disord. 2021;21:506. doi: 10.1186/s12872-021-02309-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Nik Muhamad NA, Saferi RS, Robertson CE. Internal jugular vein height and inferior vena cava diameter measurement using ultrasound to determine central venous pressure: a correlation study. Med J Malaysia. 2015;70(2):63–6. [PubMed] [Google Scholar]
The decision to limit life-sustaining treatment before death is difficult, and complex, although a common practice in modern ICUs. Till recent times withholding or withdrawing these therapies precede 75-90% of ICU deaths1. Before most ICU deaths, the treatment goal ultimately changed from curative to palliative.
Objectives
Our study aims to search for the existing deficits in EOLC practice in a tertiary care surgical HDU, find the root cause analysis, and re-implement a good EOLC practice by involving different stakeholders and outcome analysis.
Material and methods
A deficit in EOLC practice was anticipated in the surgical HDU. We had a retrospective survey of registry-based patient data from January 2022 to November 2022 to look for the existing practice of EOLC in SHDU. Patients included in the study in our surgical HDU patients with a terminal medical illness or surgical patients with malignancy when there is no definite curative plan available. The steps implemented for integrated care are:
Prompt recognition of patient on need (terminal stage of illness)
Communication with the primary team for early discussions about patient prognosis, promoting realistic expectations to the family
Establishing communication with the patient's relatives in the presence of a multidisciplinary team Empowering the patient and family members in deciding their treatment
Final care plan documentation and nursing care directive regarding symptom control and communication
Intra-disciplinary communication within the ICU team regarding goals of care.
Measures chosen for studying the process and outcome of intervention are
Quality of EOLC
Surgeon's satisfaction with the EOLC plan
Nurses’ satisfaction with the EOLC plan
Patients’ relative satisfaction with the EOLC plan
Results
In our study population, the median hospital stay was one day less than the usual length of stay of a similar population. The location of death was 31.5% in a surgical ward, 37% in a Surgical HDU, and 31.5% at home. In 85.5% of patients, EOLC plan was introduced at least 2 days before the patient expired or discharged or shifted to the ward-based care. Intubation was avoided in about 37.5% of patients and blood transfusion was avoided in 5% of patients. The monthly opioid drug (both morphine and fentanyl) consumption has significantly increased after the palliative care intervention. Nurses were more comfortable discussing patient prognosis and management plans with the patient's caregivers. Nurses’ perception of symptom control and utilization of resources were optimal in the treatment group. Nurses felt the improvement in patient communication after the EOLC intervention. Surgeons felt the EOLC plan could complement the surgical management plan of some patients.
Conclusion
A multidisciplinary EOLC plan can significantly improve patient care, improve patient caregivers’ satisfaction, and optimal nurses’ workload distribution, and can complement surgeons’ care plan.
References
1.Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Resp Care Med. 1998;158:1163–1167. doi: 10.1164/ajrccm.158.4.9801108. [DOI] [PubMed] [Google Scholar]
2.Bullock K. The influence of culture on end-of-life decision making. J Soc Work End Life Palliat Care. 2011;7:83–98. doi: 10.1080/15524256.2011.548048. [DOI] [PubMed] [Google Scholar]
3.Bussmann S, Muders P, Zahrt-Omar CA, et al. Improving end-of-life care in hospitals: a qualitative analysis of bereaved families’ experiences and suggestions. Am J Hosp Palliat Care. 2015;32:44–51. doi: 10.1177/1049909113512718. [DOI] [PubMed] [Google Scholar]
Patients receiving Extracorporeal membrane oxygenation (ECMO) inherit substantial disease as well as stress associated, Metabolic, Endocrinology and Immunological challenges. Due to lack of, ECMO specific nutrition assessment formulae, clinicians have to depend on existing ICU formulae for nutrition. We analysed the nutrition supplementation by traditional assessment and caloric gap in ECMO patients. Most of the data showed that patients on ECMO was underfed and achieved only 58.4% of their targeted calories and protein requirement. Thus, patients receiving ECMO are at increased risk for malnutrition and require targeted individual medical nutrition therapy (MNT).
Methodology
A single centre retrospective study of 74 patients on ECMO were observed and followed up until the discharge/death date. Daily energy and protein delivery were compared with estimated targets and reasons for feed interruptions were collected.
Results and discussion
We analysed 74 eligible patients. The median duration of total ICU stay was 13.0 (Min- 8.9.–Max- 17.2) days. Whilst on V-V ECMO, the mean Values of Nutric Score was 4.5 for well nourished and 5.4 for mild moderately malnourished, SOFA Score was 7.2 and 7.33, APACHE Score was 28.5 and 21.76 respectively. The Mean Value were Similar by grade of SGA, thus the above score were non-significant. The calorie prescribed was between 1500 – 2500 Kcal, the mean energy intake for the overall hospital stay was 61.5 % (Min 1025Kcal- Max 1502), the Protein Prescribed was 60 -120g whereas the Mean Protein Value was 61.8 % (Min 43g – Max 72.5g). The Calorie Deficit for overall hospital stay was 38.5 % and Protein deficit was 38.2 % (Min 29 % - Max 47.4 %). The most common reasons for interrupted feeding were increased RT Aspiration (56 %), Weaning trials (32 %), medical procedures (24 %) and others(GI intolerance) (4%).
Conclusion
A Huge Calories and Protein Deficiency was observed mainly due to Gastro intestinal intolerance and Feed interruptions. Due to small sample size the correlation between the nutrient Intake and outcome couldn't be established. Methods to improve nutrient intake aforementioned may give better outcomes in ECMO patients.
Poisoning is a global public health concern that has been identified as one of the primary reasons people visit emergency departments (ED) in hospitals. In India, more than 1 person per 100,000 population dies due to unintentional/accidental poisoning. Around 230,000 suicides occur every year. According to the World Health Organization (WHO), nearly 250,000 deaths occur due to poisoning, Pesticide Poisoning alone causes 150,000 deaths annually.1 Any substance that is damaging to the body whether consumed, breathed in, injected, or absorbed through the skin is considered a poison.2 The number of deaths due to a particular poison varies from place to place and over time as a result of effective timely medical management and preventive measures. Even in very small doses, some toxins can be lethal or harmful. According to the Centers for Disease Control and Prevention (CDC), accidental poisoning is referred to as “unintentional poisoning,” whereas intentional poisoning, such as suicide or homicide, originates from a conscious, wilful decision. There are 4 types of poison - Pharmaceuticals, Insecticides and pesticides, Plants and Animals, and Chemicals. The primary objectives for treating acute poisoning are to evaluate the patient's state, symptoms, and prognosis to research the poisoning therapy pattern. An antidote is something that can act against Poison. Some toxins may not have a known cure. The National Poisons Information Centre (PIC), one of several poison centers in India, provides information over the phone concerning the diagnosis, and management of poisoning.3
Aim and Objective:
To determine the epidemiological profile of patients presenting to ED with history of ingestion of poison
To identify different types of poisons consumed, the duration of hospital stay and mortality due to these poisons
Methodology
All patients presenting to the department during the study period with a history of poisoning are included in this study. A standardized data collection form containing patient demographics, type of poison, mode of ingestion, disposition, and outcomes was used for data abstraction from the complete medical record for all poisoned patients. The patients presenting from outside the hospital discharged or AMA from ED, Insect bites, pediatric poison, and incomplete medical records were excluded from the study. Results: In the present study, the majority of the respondents (54%) belong to the age group of 20 to 40 years, 15.3% are below 20 years, 14% are between 50 and 60 years, 8.7% are between 40 and 50 years and the remaining 8% are above 60 years of age. (53.3%) are Male and the remaining 46.7% are female. Based on marital state (56.7%) are single, 38% are married, 2% are Separated and widowed, and the remaining 1.3% are Divorced. Considering the working nature (26.7%) are Salaried, 24% are Students 22.7% are Housewives, 13.3% are Farmers, 10.7% are doing their Business, and the remaining 2.7% have retired from service. On determining the socioeconomic status (34.7%) belong to the Upper class, 34% belong to the Lower class and the remaining 31.3% belong to the Middle Class. In the place of ingestion is (92.7%) have used poison from the Home, 4.7% have used poison from Work Place, and the remaining 2.7% have been poisoned at other places. The majority of the patients (51.3%) were admitted to the Critical Care Medicine and Toxicology unit, 30.7% were admitted to the Surgery Unit, 14% to the Gastroenterology unit, and the remaining 4% to General Medicine. The majority of the patients (72.7%) have ingested with intentional, 25.3% were poisoned accidentally and the remaining 2 were victims of Homicides. The majority of the Patients (48.7%) were poisoned due to OPC - Insecticides/Pesticides, 27.3% were poisoned due to an overdose of medication, 12.7% were poisoned by Corrosive substances, 8% were poisoned by Rodenticides and the remaining 3.3% were poisoned by other sources such as Plant-based poisons and Aluminium Phosphates. On seeking the treatment (52.7%) Patients were presented within 6 hours of poisoning and the remaining 47.3% were presented to the Hospital between 6 and 24 hours. The majority of the Patients (66%) had Miscellaneous Complications, 14% had Acute Liver Injury, 8% had Neuro Complications, 7.3% had Acute Lung Injury and 4.7% had Acute Kidney Injury. 76.7% were treated based on Symptomatic management, 10% were treated using Therapeutic Plasmapheresis and the remaining 13.3% were treated by mechanical ventilation. In the study, 58% were unconscious and 42% were Conscious during admission at the Hospital. 34% of the patients have stayed for 6 days, 29.3% have stayed for 4 days, 26.7% have stayed for 2 days, 3.3% have stayed for 7 days, 3.3% have stayed for 7 days and 2% have stayed for 5 days. In the present study, 79.3% of the Patients are alive, 18% are under medical advice and 2.7% are dead due to acute poisoning.
Conclusion
Organophosphate poisoning is the most common type of poison ingested intentionally by adults. The present study also reveals a higher rate of intentional self-poisoning among adults due to varied reasons. Although the mortality rate is very low in comparison to the patients presented with poisoning, the outcomes and the trauma encountered are massive. Despite strict restrictions on the availability of poisons, the number of poisoning cases increases exponentially due to the usage of Household products, and Chemicals for agricultural purposes have been used by patients. Drug Overdose is also a serious concern and it is mandatory to impose strict rules to control drug use in the Country. Finally, it can be implied from the Study that awareness about the health hazards of Poisons should be done to avoid intentional self-poisoning among individuals.
References
1.World Health Organization . Guidelines for establishing a poison centre. Geneva: WHO; 2020. [Google Scholar]
2.Lall SB, Al-wahaibi S.S, Al-riyami M.M., Al-Kharusi K. Profile of acute poisoning cases presenting to health centers and hospitals in Oman. La revue de santé de la mediterranee Orientale. 2003;9(6);):944–954. [PubMed] [Google Scholar]
3.Peshin SS, Srivastava A, Halder N, Gupta YK. Pesticide poisoning trend analysis of 13 years: a retrospective study based on telephone calls at the National Poisons Information Centre, All India Institute of Medical Sciences, New Delhi. Journal of forensic and legal medicine. 2014 Feb 1;22:57–61. doi: 10.1016/j.jflm.2013.12.013. [DOI] [PubMed] [Google Scholar]
1HaystackAnalytics Pvt. Ltd., SINE, Indian Institute of Technology Bombay, Powai, Mumbai, India, Phone: +91 9820287433, e-mail: sanjana@haystackanalytics.in
1HaystackAnalytics Pvt. Ltd., SINE, Indian Institute of Technology Bombay, Powai, Mumbai, India, Phone: +91 9820287433, e-mail: sanjana@haystackanalytics.in
2Department of Microbiology, Mediversal Super Specialty Hospital, Patna, India
3–6HaystackAnalytics Pvt. Ltd., SINE, Indian Institute of Technology Bombay, Powai, Mumbai, India
While it is well known that infections contribute to a significant health burden, identification of the pathogen remains a challenge in several cases. An increasing list of emerging and reemerging pathogens makes it imperative to implement measures to identify early and accurately relevant pathogens. Genomics is increasingly being used to elucidate such information. The development of portable and real-time sequencing platforms now makes it possible to identify pathogens in clinical settings. This study explores the findings of rare or difficult to identify pathogens using an NGS-based assay that would otherwise be missed using traditional methods thus compromising effective patient care.
Objectives
To evaluate the utility of a real-time sequencing assay to identify bacterial or fungal pathogens that would be otherwise challenging to detect.
Materials and methods
An NGS assay using amplicon-based Oxford Nanopore Technologies sequencing and a standardised and automated bioinformatic workflow having targets to identify bacteria, fungi and key antibiotic resistance genes in a single assay was performed. The proof-of-concept of the assay was initially tested using standard cultures and clinical isolates in a blinded manner. Further a retrospective evaluation of the pathogens identified with the routine implementation of the test was undertaken wherein cases of rare and difficult-to-culture pathogens were identified by NGS. A clinical correlation of the detection of the pathogen with the clinical presentation of the patient was performed to confirm the clinical plausibility of detecting the infection.
Results
The initial proof-of-concept confirmed a high concordance of identification of the pathogen (Kappa >0.80). This assay identified 19 unique pathogens in 28 clinical samples. The samples included blood (46.4%), bronchoalveolar lavage (39.3%), pleural fluid (10.7%) and cerebrospinal fluid (3.6%). A bacterial pathogen was seen in 60% of samples and fungi in the remaining 40% of cases. Rare and difficult-to-identify pathogens known to be opportunistic bacteria (i.e. Prevotella spp., Corynebacterium spp.), potential hospital associated infections (Elizabethkingia app.), rare moulds (Aspergillus spp., Edenia spp.) and neglected vector borne diseases (Rickettsia spp., Orientia spp.). The NGS assay was able to provide species level identification in a majority of cases. A high degree of clinical correlation was observed with the pathogen identified. However, care must be taken with respect to correlating the pathogenic potential of known commensals.
Table 1.
Demographic details
Characteristics
Patient A
Patient B
Patient C
Patient D
Age (years)
25
69
69
70
Gender
Male
Female
Male
Male
Diagnosis
Road traffic accident Traumatic Brain injury
Type II respiratory failure OSA
Carcinoma oropharynx – poorly differentiated SCC with airway obstruction
The implementation of a genomic assay is feasible in the settings of Indian tertiary care centres. It is able to provide deep insights in pathogen elucidation particularly in cases that test culture negative. In this study, it was able to identify a range of pathogens such as anaerobes, pathogens needing special media that would not be routinely available in diagnostic setups as well as identification of non-culturable pathogens. The identification of pathogens correlated well with the clinical presentation of the patients and was a significant contributor in the differential diagnosis of some cases.
References
1.Vincent JL, Sakr Y, Singer M, Martin-Loeches I, Machado FR, Marshall JC, Finfer S, Pelosi P, Brazzi L, Aditianingsih D, Timsit JF, Du B, Wittebole X, Máca J, Kannan S, Gorordo-Delsol LA, de Waele JJ, Mehta Y, Bonten MJM, Khanna AK, Kollef M, Human M, Angus DC, EPIC III Investigators Prevalence and Outcomes of Infection Among Patients in Intensive Care Units in 2017. JAMA. 2020 Apr 21;323(15):1478–1487. doi: 10.1001/jama.2020.2717. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.World Health Organization . WHO fungal priority pathogens list to guide research, development and public health action. Geneva: 2022. [Google Scholar]
3.World Health Organization . Prioritization of pathogens to guide discovery, research and development of new antibiotics for drug-resistant bacterial infections, including tuberculosis. Geneva: 2017. (WHO/EMP/IAU/2017.12) [Google Scholar]
4.Hong M, Peng D, Fu A, Wang X, Zheng Y, Xia L, Shi W, Qian C, Li Z, Liu F, Wu Q. The application of nanopore targeted sequencing in the diagnosis and antimicrobial treatment guidance of bloodstream infection of febrile neutropenia patients with hematologic disease. J Cell Mol Med. 2023 Feb;27(4):506–514. doi: 10.1111/jcmm.17651. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Avershina E, Frye SA, Ali J, Taxt AM, Ahmad R. Ultrafast and Cost-Effective Pathogen Identification and Resistance Gene Detection in a Clinical Setting Using Nanopore Flongle Sequencing. Front Microbiol. 2022 Mar 17;13:822402. doi: 10.3389/fmicb.2022.822402. [DOI] [PMC free article] [PubMed] [Google Scholar]
Admission to intensive care unit (ICU) is a source of physical and psychological stress to the patient as well as the family member.1–4 Patients recovering from critical illness faces various mental health issues including post-traumatic stress, anxiety, depression and declined cognition.1 Research on post ICU mental health disorders is scarce, especially from low income countries.1–2 Here we try to analyse the mental health issues faced by the patients who were admitted to ICU for various concerns.
Objectives
The patients were followed up in the post ICU clinic to identify mental health issues.
Materials and methods
Patients were formally evaluated by a clinical psychiatrist for identification of psychiatric impairment, a month after discharge from ICU. Anxiety and depression were assessed using Hospital Anxiety and Depression Scale (HADS), stress and trauma was assessed using International Trauma Questionnaire (ITQ), cognition was assessed using Addenbrooke's Cognitive Examination – III (ACE – III) and quality of life was assessed using WHO Quality of Life Brief Scale (WHO-QOL BREF). A descriptive analysis of the observations were done to identify magnitude of psychological impairment in ICU survivors.
Results
The study was conducted from January 2023 to October 2023. A total of 187 patients qualified for the post ICU clinic. Ninety-four patients expired during the course and another 81 patients were lost to follow up. A total of 12 patients were screened and four patients (33%) were identified to have mental health concerns. Three patients belonged to the elderly age group where as one was a young age patient. Patient A had a prolonged ICU stay and was later diagnosed with post traumatic stress disorder. The elderly patient with prolonged ICU stay (patient D) had multiple mental health challenges including anxiety, declined cognition and post traumatic stress disorder. Patients B & C had comparatively short duration of stay and relatively less mental health challenges.
Discussion
The psychological well-being of an ICU survivor is a neglected entity in developing countries. The data from the developed countries are suggestive of an occurrence of psychiatric impairments in 30 – 80% of ICU survivors.4, 5 We tried to identify mental health issues in ICU survivors through active screening. None of our patients came out seeking help even though they had difficulty in their day-to-day life. We would like to conclude highlighting the importance of post op ICU clinics in the follow up of ICU survivors for ensuring physical and psychological well-being.
References
1.Tripathy S, Acharya SP, Singh S, Patra S, Mishra BR, Kar N. Post traumatic stress symptoms, anxiety, and depression in patients after intensive care unit discharge - a longitudinal cohort study from a LMIC tertiary care centre. BMC Psychiatry. 2020 May 12;20(1):220. doi: 10.1186/s12888-020-02632-x. 32398018;PMC7216410 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Kar N, Tripathy S. Stress, anxiety, and depression: A comparative study of perceptions of patients in the ICU, other wards and their family caregivers in a low middle income country. Psychiatry Research Communications. 2022;(2);):100035. [Google Scholar]
3.Tripathy S, Kar N. Psychiatric Morbidity in the Post-ICU Patient-Ethnocultural Differences. Indian J Crit Care Med. 2019 Sep;23(9):440–441. doi: 10.5005/jp-journals-10071-23244. 31645835;PMC6775722 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Smith S, Rahman O. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing; 2023 Jan. Postintensive Care Syndrome. [Updated 2023 Jun 12]. In: [Google Scholar]
5.Colbenson GA, Johnson A, Wilson ME. Post-intensive care syndrome: impact, prevention, and management. Breathe Jun. 2019;15(2):98–101. doi: 10.1183/20734735.0013-2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
Objective-driven Advancements in Bedside Systemic Screening Ultrasound in the Critical Care Unit (CCU): Revolutionizing Critical Care through Real-time Enhancing Diagnostics, Guiding Procedures, and Improving Patient Outcomes
Medical Imaging in the Critical Care Unit is crucial for patient care, providing essential diagnostic and monitoring capabilities and in making swift and accurate decisions, guiding treatment protocols, closely monitoring patient responses, and ultimately improving patient outcomes.
Objectives
Early diagnosis and rapid initiation of specific treatment improve patient outcomes.
Education and Training to go beyond POCUS.
Materials and methodology
This is a prospective observational study, conducted in 2022-2023 in CCU of Malda Medical College and Hospital, West Bengal, India. Screening ultrasonography and echocardiography was done using GE LOGIC V2 on first day of CCU admission and diagnosis was made based on the images after discussing with the head of the department (Radiodiagnosis), Malda Medical College.
Result and analysis
Some patients who came with acute problems were diagnosed instantly by ultrasonography and echocardiography and specific treatment was started at earliest which aided early recovery and shortened CCU stay.
Discussion
Intensivists frequently utilize POCUS while handing critically ill patients. They can perform bedside USG and echocardiography for accurate information of diagnostic and therapeutic significance. However, all clinicians in CCU are not trained to diagnose all relevant systemic diseases by ultrasound. Also, it is noted that the diagnostic accuracy by these modalities directly depends on the operators’ skill and experience. The training for systemic sonography including echocardiography allows them to make early diagnosis, preventing any impending complications and early recovery, hence, shortening CCU stay and decreasing medical cost burden.
Conclusion
The use of ultrasound as an “extension of the examining hand” for fast diagnosis and treatment of patients in CCU needs to grow along with clinical examination and POCUS.
Keywords
CCU (Critical Care Unit), POCUS (Point of Care Ultrasonography), USG, Echocardiography.
Pediatric trauma continues to be a global public health concern, especially in underdeveloped nations, where it is linked to high morbidity and mortality rates. The World Health Organisation (WHO) reports that about 2,000 children under the age of 14 die each day throughout the world and that the disabilities brought on by traumatic injuries can have an ongoing effect on all facets of the victims’ lives.1 Children in developing nations are particularly prone to injury due to difficult living conditions, a lack of safe play areas, and a lack of childcare choices, even though trauma affects people of all ages globally in both developed and developing countries.2, 3 India lacks a comprehensive trauma database, and the majority of studies on pediatric trauma have been conducted among children undergoing pediatric surgery or neurosurgery procedures. Identification of specific high-risk injury patterns may lead to improved care and outcome.
Aim and objective
The aim of the study is to determine the epidemiology, pattern, and outcome of trauma among the pediatric population presenting to ED at a Tertiary Care Centre, South Tamil Nadu, Madurai.
Methodology
All pediatric patients presenting to the department during the study period with a history of injury are included in this study. A standardized data collection form containing patient demographics, mechanism of injury, location, type, disposition, and outcomes were used for data abstraction from the complete medical record for all injured patients.
Results
In the present study, the majority of the Patients (57%) were in the age group of 11 to 15 years and (29%) were less than 5 years and (14%) were between 6 and 10 years of age. The majority of the patients (64%) are Male and the remaining 36% are female. Around 58% were residing in Urban areas and the remaining 42% were residing in Rural areas. 75% of patients were injured during the daytime between 6 am and 6 pm. On the other hand, 25% were injured during the nighttime between 6 pm and 6 am. The majority of the Patients (57%) have undergone Trauma due to Falls and the remaining 43% were injured by Road Traffic Accidents (RTA). In the present study, among the 43 patients who had encountered RTA, 32.6% had met Passenger Accident, 21% had come across Vehicle Collision, 18.6% had encountered RTA while playing and 14% each had encountered RTA While Walking or Crossing the Road. Among the 57 patients who had encountered Trauma due to Fall, 26.3% had fallen from Stairs, 17.5% each had fallen from Bed or fell while playing, 19.5% had fallen from Tree, 14.1% had fallen from Chair/Table, 3.5% fell from Roof and the remaining 1.8% fell from Level Ground. Among the 43 patients who had encountered RTA, 51.2% met with an Accident on a Four-Wheeler, 37.2% met with the Accident in a Two-Wheeler and 11.6% were riding a Bicycle during the Accident. Patients (37%) were in the Playground 23% each were in School or Street/Road and the remaining 17% were at Home. The majority of the Patients (70%) reached the Hospital through private transport and the remaining 30% reached the Hospital by Ambulance. Patients (73%) have not received any first aid before admission to the Hospital. Pre-Hospital Interventions. 12% had dressings, 11% had Analgesia and 4% had Splints. (87%) had Single body Trauma and 13% had Polytrauma. Patients (25%) had Facial injuries, 23% had injuries in the lower limb, 15% had injuries in the Abdomen/Pelvic region, 14% had injuries in the Upper limb, 11% had injuries in the Genital area, 8% had injuries in Head and the remaining 4% had injuries in Chest/Thoracic region. The majority of the Patients (41%) had Open Fractures, 29% had Concussions, 28% had Closed Fractures and 2% had Deep Lacerations. The majority of the Patients (46%) had a conservative mode of Treatment, 39% had Minor Surgery and 15% had Major Surgery. (30%) had stayed for 3 days, 22% had stayed for 1 day, 20% had stayed for 4 days, 19% had stayed for 2 days and 9% had stayed for 5 days. (53%) were discharged home after Treatment, 39% were discharged against medical advice, 6% died and 2% were Transferred out on request.
Conclusions
Pediatric trauma is still a significant public health issue. According to this study, boys rather than girls made up the bulk of trauma cases. The main causes of pediatric trauma are falls and Road Traffic accidents. In children, irrespective of their age falls prevail, followed by RTAs predominate. Therefore, health professionals ought to advise using preventive measures that have been scientifically proven, like bike helmets and seat belts.
References
1.Sleet DA. The global challenge of child injury prevention. Int J Environ Res Public Health. 2018;15(9):1921. doi: 10.3390/ijerph15091921. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Christopher MJL, Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1459–1544. 12. doi: 10.1016/S0140-6736(16)31012-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Ippolito AAD, Collins CL. Epidemiology of pediatric holiday-related injuries presenting to US emergency departments. Pediatrics. 2021;125(5):931–937. doi: 10.1542/peds.2009-0307. [DOI] [PubMed] [Google Scholar]
Community acquired pneumonia is sometimes complicated, leading to necrosis and cavitation. It is also called as pulmonary gangrene. We present the clinical spectrum, microbiological, radiological presentation and outcome in patients admitted to ICU.
Objectives
Clinical spectrum and outcome of necrotizing pneumonia in intensive care unit.
Materials and methods
We included all patients admitted to intensive care unit from January 2023 to December 2023 with diagnosis of necrotizing pneumonia. Necrotizing pneumonia was defined on the basis of radiology. All patients underwent routine laboratory examination. Respiratory tract sampling in the form of either sputum, bronchial washings or endotracheal secretions were sent for analysis in all the patients for filmarray RTPCR, pyogenic and fungal culture. Additional investigations such as serum procalcitonin levels, beta galactomannan levels and beta d glucan levels were done wherever needed.
Results
We found total 19 patients. 14 (73%) were male. Mean age was 55 years. Most common presenting complaits were breathlessness, fever, cough with altered expectoration and chest pain. 18 patients admitted with type 1 respiratory failure while one admitted with mixed respiratory failure. 15 patients had uncontrolled diabetes, 2 had COPD, one had Ca prostate completed CT-RT and one had Ca lung on CT. 17 of 19 patients admitted with computerized tomography of thorax, while 2 were diagnosed on chest x-ray. Radiological featured included multifocal consolidations with cavitations, pneumothorax or pyopneumothorax. We found different organisms causing pneumonia. Most common were bacterial pneumonias (12), klebsiella pneumoniae being found in 7 patients, pseudomonas aeruginosa in two, staphylococcus aureus in one, H influenza in one and nocardia in one patient. Seven patients were treated as fungal pneumonia, one invasive pulmonary aspergillosis on culture, three proven mucormycosis, one culture and two biopsy proven, while three were being treated empirically as mucormycosis after excluding other microorganisms and on clinic-radiological basis. Bacterial pneumonias were treated on the basis of antibiotics sensitivity pattern for 2-3 weeks, except for nocardia which will be treated for minimum of six months to one year according to clinic-radiological resolution. Patients with mucormycosis were treated with liposomal amphotericin B for cumulative dose of 3 to 4.5 gm followed by posaconazole while invasive aspergillosis was treated with voriconazole. Three patients were managed with oxygen with nonrebreather mask, 9 with high flow nasal oxygen therapy, one with noninvasive ventilator and six with invasive mechanical ventilator. Five patients were complicated with pneumothorax while three were complicated with pyopneumothorax in the course of ICU. Nine(47.36%) of 19 patients expired. Three had massive hemoptysis while five patients had refractory acute respiratory failure due to progressive pulmonary gangrene, sepsis and multiorgan dysfunction syndrome. Eight patients were discharged on treatment, 2 of which completely treated and six are on follow up. Two patients are still in ICU.
Discussions
Necrotizing pneumonias are rare but severe category of CAP which require multimodality approach. Acute respiratory failure associated in such cases can be managed with HFNO before considering invasive mechanical ventilation. Finding the causative micro-organism is crucial in the treatment. Massive hemoptysis can cause sudden collapse of the patient causing death.
References
1.Krutikov Mariaa, et al. Necrotizing pneumonia (aetiology, clinical features and management) Current Opinion in Pulmonary Medicine. May 2019;25(3):225–232. doi: 10.1097/MCP.0000000000000571. p. [DOI] [PubMed] [Google Scholar]
2.Chatha N, et al. Management of necrotizing pneumonia and pulmonary gangrene: a case series and review of the literature. Can Respir J. 2014 Jul-Aug;21(4):239–45. doi: 10.1155/2014/864159. 24791253;PMC4173892 Epub 2014 May 2. [DOI] [PMC free article] [PubMed] [Google Scholar]
Mechanical ventilation is an essential strategy in modern intensive care units for respiratory failure. It is crucial to recognize readiness for liberation from mechanical ventilation in a timely manner to reduce complication, cost, and to improve morbidity and mortality. Diaphragm function is an important determinant of successful liberation from ventilation and recovery from critical illness. The development of diaphragm atrophy was associated with prolonged duration of mechanical ventilation, increased ICU length of stay, and a higher rate of complications1. Diaphragm thickness has been shown to reduce by 7.5% per day in mechanically ventilated patients. Ultrasound imaging has been found to be accurate, reproducible, and convenient tool for the assessment of diaphragm2.
Objectives
To predict extubation outcome using time to peak inspiratory ampiltude(TPIA), a diaphragm ultrasound parameter in mechanically ventilated patients.
Materials and methods
This is a prospective observational study conducted in Royal care superspeciality hospital between september 2022 to september 2023 in about 50 patients intubated for more than 72 hours who had passed spontaneous breathing trial(SBT) and planned for elective extubation. Diaphragm ultrasound was done prior to planned extubation and time to peak inspiratory amplitude(TPIA) was recorded. The outcome of extubation whether successful(spontaneously breathing for more than 48 hours) or failure(requiring reintubation within 48 hours) was observed. Time to peak inspiratory amplitude (TPIA) of right hemidiaphragm was measured in M-mode using a 1- to 5-MHz ultrasound transducer during tidal breathing via intercostal approach in the right anterior axillary line. The liver was identified as a window for each hemidiaphragm. The TPIA was defined as the time from the beginning of diaphragmatic contraction to the maximal amplitude of diaphragmatic inspiratory excursion as measured from the M-mode tracing. (Fig 1).
Out of 50 patients studied, 11 patients had failed extubation. TPIA<0.75 sec is a good predictor of extubation failure(p<0.01) with a sensitivity of 88% and a specificity of 80%.
Discussion
The role of ultrasound in the assessment of diaphragm function has been studied with the rationale that the diaphragm plays a crucial role in respiratory muscle endurance and strength. A study by Theerawit et al has shown that the TPIA is associated with the strength of the diaphragm and has a good correlation with RSBI3.
Conclusion
Many studies have showed the usefulness of diaphragm excursion and diaphragm thickness fraction in predicting extubation outcome4. Thus TPIA, as a novel diaphragm ultrasound parameter would help in more successful extubation along with preexisting entities.
References
1.Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, Rabuel C, et al. Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med. 2011;183:364–371. doi: 10.1164/rccm.201004-0670OC. [DOI] [PubMed] [Google Scholar]
2.Kim WY, Suh HJ, Hong SB, Koh Y, Lim CM. Diaphragm dysfunction assessed by ultrasonography: influence on weaning from mechanical ventilation. Crit Care Med. 2011;39:2627–2630. doi: 10.1097/CCM.0b013e3182266408. [DOI] [PubMed] [Google Scholar]
3.Theerawit P, Eksombatchai D, Sutherasan Y, Suwatanapongched T, Kiatboonsri C, Kiatboonsri S. Diaphragmatic parameters by ultrasonography for predicting weaning outcomes. BMC Pulm Med. 2018 Nov 23;18(1):175. doi: 10.1186/s12890-018-0739-9. 30470204;PMC6251135 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Alam MJ, Roy S, Iktidar MA, Padma FK, Nipun KI, Chowdhury S, Nath RK, Rashid HO. Diaphragm ultrasound as a better predictor of successful extubation from mechanical ventilation than rapid shallow breathing index. Acute Crit Care. 2022 Feb;37(1):94–100. doi: 10.4266/acc.2021.01354. 35081706;PMC8918710 Epub 2022 Jan 11. [DOI] [PMC free article] [PubMed] [Google Scholar]
Electrical Impedance Tomography (EIT) is a non-invasive imaging technique that uses changes in electrical conductivity to create images of the lungs. It allows one to evaluate at the bedside the distribution of pulmonary ventilation continuously, in real time. Though CT is a useful tool in the management and study of patients with ARDS, it is often limited in critically ill patients owing to difficulties related to transport. We therefore conducted this meta-analysis to determine whether EIT guided PEEP titration could improve patient outcomes in ARDS.
Objectives
The aim of our study is to compare the utility of EIT-guided PEEP titration in improving outcomes in patients with ARDS.
Materials and methods
Extensive electronic database screening was done until 1st April 2023. Randomized Controlled Trials (RCT) evaluating the impact of the EIT-guided PEEP titration were included in this meta-analysis. Random and fixed effects models were used for studying effects.
Results
Our search retrieved six RCTs with a total of 475 patients. There was no significant difference in P/F ratio [MD = -6.35;95%CI -19.32 to-6.6; I2=0%], driving pressure requirement [MD = -0.29;95%CI -0.84 to 0.25; I2=0%], PEEP optimization [MD = 0.05;95%CI -0.46 to 0.56; I2=87%], and successful weaning [OR=1.35; 95% CI 0.8-2.2, I2=51%] with the application of EIT-guided PEEP titration.
EIT-guided PEEP titration is a novel alternative but further well designed studies are needed for substantiating its utility.
Reference
1.He H, Chi Y, Yang Y, et al. Early individualized positive end-expiratory pressure guided by electrical impedance tomography in acute respiratory distress syndrome: a randomized controlled clinical trial. Crit Care. 2021;25(1):230. doi: 10.1186/s13054-021-03645-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
Mortality prediction is important in clinical decision-making, benchmarking, policy making, prioritizing for resource allocation, overall evaluations of the quality of care provided by the ICU and also for individual patients care. Reliable information on risk is a key foundation for high-quality decisions. In intensive care, severity scores have been used for about 40 years and have been important decision-making tools for clinicians, nurses and managers. However, none are universally accepted as standard method to predict mortality. We have decided to use SAPS II score because of the simplicity and easy availability of its variables to analyze the outcomes of critically ill medical and surgical patients admitted to ICU at tertiary health care Centre of Nepal.
Objectives
This study aimed to evaluate the accuracy of the SAPS II in the prediction of hospital mortality in a medical and surgical ICU.
Materials and methods
The study was conducted between January 2022 and February 2023 at Chitwan Medical College and Teaching Hospital, Bharatpur, Nepal. We prospectively collected data on medical and surgical patients consecutively admitted to the ICU during the study period. The sample size of this study was 501 critically ill patients. The variables of SAPS II score were collected from the physiological, laboratory, and patient characteristics mentioned in the ICU scoring data sheet at 24 hours. The outcome measure was ICU mortality as survivor and non-survivor. The SAPS II score and predicted mortality was calculated using computer software programme. The accuracy of the model was evaluated using discrimination and calibration. Discrimination and calibration of the model was assessed by using ROC and SMR respectively. Logistic regression analysis was used to find out the relationship between a dichotomous dependent variable and continues independent variable. The Ethical Review Board approved this study (Ref: NHRC- 2297/71/2022-PhD).
Results
There were 501 patients, and their median age was 48.96 (IQR 65- 30; Minimum 18, Maximum 86) years. Male comprised 306 (61.1%) and female comprised 195 (38.9%) of the total number of patients. Of the 501 patients, 185 (36.9%) died and 316 (63.1%) survived. Accuracy of discrimination was assessed by the area under the receiver operating characteristic (ROC) curve. The area under the ROC of SAPS II score to the hospital mortality was 0.748 (p <.001; 95% CI., 705-.790). The calculated Standardized Mortality Ratio (SMR) for the SAPS II was 0.88. Logistic regression describes the relationship between dichotomous dependent variable and continues independent variable. The odds ratio for SAPS II was (OR= 1.079; p=<.001; 95% CI, 1.043-1.116).
Conclusion
SAPS II can be used as simple and rapid tool to predict mortality in critically ill medical and surgical patients. The variables in SAPS II score are relatively simple and readily available. SAPS II score is significant predictor of mortality of medical and surgical patients admitted to the ICU. The results of this study add value and can aid critical care physicians, critical care nurses and relatives of critically ill patients in deciding on the probable outcome, quality care and management decisions.
Keywords
SAPS II, critically ill, intensive care unit, mortality, outcome.
An increased mortality rate is associated with elevated D-dimer concentrations in the general population with acute pulmonary embolism (PE).
Objectives
To evaluate the predictive capacity of D-dimer in elderly patients diagnosed with acute PE at 30 and 90 days.
Materials and methods
The present retrospective study was conducted at the Department of Medicine, Prasad Institute of Medical Sciences in Lucknow, India. Patients with confirmed PE who were at least 65 years old and exhibited hemodynamic stability were enrolled. All patients were provided with a pulmonary computed tomography angiography scan, D-dimer concentrations, simplified Pulmonary Embolism Severity Index (sPESI) variables, and vital status information.
Results
There were 51 confirmed cases of PE (29.27% of suspected cases) in the study, with a median age of 72.46 years. At 30 days and 90 days, D-dimer levels were significantly higher in deceased patients than in living ones (median 14,553 vs. 8372 ng/mL, p = 0.05; 13,857 vs. 7998 ng/mL, p = 0.011). The discriminant capacity of sPESI to forecast mortality within 30 and 90 days was enhanced by 0.082 and 0.091, respectively, when D-dimer was added. After 30 days, D-dimer contributed to the discriminating ability as follows: NRI = 0.292; after 90 days, it contributed as NRI = 0.627. D-dimer concentration demonstrated a greater discriminant capacity in predicting 90-day mortality than sPESI alone, and was associated with mortality at 30 and 90 days.
Discussions
Elevated D-dimer levels correlated significantly with increased mortality rates at both time intervals, showcasing potential as a predictive marker. Additionally, integrating D-dimer measurements with the simplified Pulmonary Embolism Severity Index (sPESI) enhanced the accuracy of mortality prediction, particularly at the 90-day. This suggests that combining D-dimer with established risk models like sPESI could provide a more comprehensive and refined approach to estimating prognosis in elderly PE patients.
References
1.Heit JA. The epidemiology of venous thromboembolism in the community: implications for prevention and management. J Thromb Thrombolysis. 2006;21(1):23–29. doi: 10.1007/s11239-006-5572-y. [DOI] [PubMed] [Google Scholar]
2.Posadas-Martínez ML, Vázquez FJ, Grande-Ratti MF, de Quirós FG, Giunta DH. In hospital mortality among clinical and surgical inpatients recently diagnosed with venous thromboembolic disease. J Thromb Thrombolysis. 2015;40(2):225–230. doi: 10.1007/s11239-015-1234-2. [DOI] [PubMed] [Google Scholar]
Pneumonia with unknown origin was detected in Wuhan, China in early December 2019. The pathogen of the pneumonia was identified as novel enveloped RNA beta coronavirus, which was later, named as severe acute respiratory syndrome corona virus 2. Cases of infection were documented both in hospital and community setting. Due to the widespread occurrence of COVID-19, there is an urgent requirement for prompt and precise diagnostic techniques to swiftly recognize, isolate, and treat patients, aiming to reduce mortality rates and minimize the potential for public transmission of the severe acute respiratory syndrome coronavirus 2.
Objectives
The objective of the study was to assess laboratory parameters and supportive care in patients with SARS-CoV-2 admitted at tertiary care hospital during COVID-19 pandemic in Nepal.
Materials and methods
A cohort study was conducted among patients with COVID-19 positive at Chitwan Medical College. Covid positive patients admitted in Covid ward, Covid ICU and Isolation wards of Chitwan Medical College were included in the study. Ethical approval was obtained from NHRC. Total 348 samples were included in the study by using convenient sampling technique. Self-administered interview questionnaire along with laboratory performa was used to collect data. Data analysis was performed using SPSS version 20.0. Data was analyzed using descriptive statistics.
Results
The age distribution revealed a diverse representation, with young adults constituting 24.7%, middle adults 34.2%, and the elderly 41.1%. Gender-wise, males accounted for 54.0%. 82.2% of the samples showed normal RBC count and in terms of pus cells, 8.9% exhibited higher than normal levels. Concerning leucocyte value, 31.0% showed counts above 11000, possibly indicating an immune response to the infection. 12.4% of patients are diagnosed with anemia. The study results also highlighted of abnormal ALT_SGPT and AST_SGPT enzyme levels, indicating potential liver involvement in COVID-19 cases. Regarding supportive care, 82.2% of the patients received steroid medication, Antibiotics were administered to all patients (100.0%) as part of the treatment protocol. Moreover, 64.4% of the patients underwent oxygen therapy. Among those receiving oxygen therapy, reservoir mask was used in 18.1% patients. Furthermore, result illustrated that 138 patients received respiratory support, with 20.7% of the cases in the intensive care unit without a ventilator and 19.0% in the intensive care unit with a ventilator.
Conclusion
Comprehensive analysis of various lab parameters as well as supportive care offer valuable information for understanding the immune and physiological responses of COVID-19 patients, guiding healthcare practitioners in implementing appropriate treatment strategies and patient care.
Elizabethkingia species as frequent cause of opportunistic nosocomial infection, especially in the critical care unit with documented global outbreaks have high mortality rates of 18.2-41%.1, 2 High resilience to hospital grade disinfectants, ubiquitous colonization of all patient care devices, inherent resistance to conventional antibiotics used against gram negative bacteria3 and species level differences in the antimicrobial resistance makesearly and accurate identification of the organism imperative.4 Multiple reports mention frequent misidentification of E. anophelis as E. meningoseptica through biochemical tests, automated identification platforms and MALDI-TOF MS.5, 6, 7, 8, 9
Objectives
This study is undertaken to assess the feasibility of using 16S rRNA gene sequencing for an unbiased, hypothesis free, early identification and accurate identification of Elizabethkingia species directly from sample, as a dependable solution in a critical care setting for optimum therapeutic decision and better infection control measures. Five clinical case scenarios of on-site, direct from sample, identification using oxford nanopore technology (ONT) with a turnaround time of 12 hours in critical care setting, are described herewith.
Materials and methods
Fifty 16S rRNA gene sequences, randomly chosen from European Nucleotide Archive (ENA), that belong to E. anophelis (n=25) or E. meningoseptica (n=25) along with that from the seven type strains of Elizabethkingia species, were used to infer a phylogenetic tree to see how coherent the species of Elizabethkingia are in their 16S rRNA gene sequences.10 The concept was applied in the clinical set-up on five samples (1-Plasma and 4-Bronchoalveolar lavage fluids). Total DNA was extracted, full-length 16S rRNA gene was enriched, and sequenced on the ONT platform. The sequence data, after removing the host DNA sequences, was analyzed using nucleotide blast (using NCBI nt database: Collection of all publically available DNA sequences), to minimize methodological bias. Sequence reads classified as Elizabethkingia species in each of the samples were counted. The “organism identified” is attributed to the one with the highest sequence count.
Results
The type strains of E. anophelis and E. meningoseptica shared a nucleotide similarity of 98.69% across the 16S rRNA gene sequence with twenty informative sites. Phylogenetic assessment indicated that E. anophelis and E. meningoseptica form two separate, coherent clusters, which makes the distinction easier. We also observed some sequences of E. meningoseptica clustered randomly across the tree, in line with the existing reports of possible misidentification using other standard methods of detection. Four of the five samples were identified as E. anophelis and one as E. meningoseptica. One sample was concluded as polymicrobial since both E. anophelis and Stenotrophomonas maltophilia were detected. Nucleotide sequence similarity of raw sequences with the database sequences ranged from 80-98%. Sequencing and algorithm errors contributed to only less than 1% of the raw sequences to get annotated as wrong species.
Conclusion
Nanopore based full-length 16S rRNA sequencing from direct sample metagenomes can identify and speciate within Elizabethkingia with high confidence within a clinically impactful time. This not only improves clinical outcomes of individual patients but also prevents nosocomial spread of the same.
References
1.Lau S. K, Chow W. N, Foo C. H, Curreem S. O, Lo G. C. S, Teng J. L, Woo P. C. Elizabethkingia anophelis bacteremia is associated with clinically significant infections and high mortality. Scientific reports. 2016;6(1):26045. doi: 10.1038/srep26045. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Zajmi A, Teo J, Yeo C. C. Epidemiology and characteristics of Elizabethkingia spp. infections in Southeast Asia. Microorganisms. 2022;10(5):882. doi: 10.3390/microorganisms10050882. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Kirby J. T, Sader H. S, Walsh T. R, Jones R. N. Antimicrobial susceptibility and epidemiology of a worldwide collection of Chryseobacterium spp.: report from the SENTRY Antimicrobial Surveillance Program (1997-2001) Journal of clinical microbiology. 2004;42(1):445–448. doi: 10.1128/jcm.42.1.445-448.2004. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Lin J. N, Lai C. H, Yang C. H, Huang Y. H. Comparison of Clinical Manifestations, Antimicrobial Susceptibility Patterns, and Mutations of Fluoroquinolone Target Genes between Elizabethkingia meningoseptica and Elizabethkingia anophelis Isolated in Taiwan. Journal of clinical medicine. 2018;7(12):538. doi: 10.3390/jcm7120538. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Bobossi-Serengbe G, Gody J. C, Beyam N. E, Bercion R. First documented case of Chryseobacterium meningosepticum meningitis in Central African Republic. Medecine Tropicale: Revue du Corps de Sante Colonial. 2006;66(2):182–184. doi: 10.1016/S0140-6736(13)60318-9. [DOI] [PubMed] [Google Scholar]
6.Frank T, Gody J. C, Nguyen L. B. L, Berthet N, Le Fleche-Mateos A, Bata P, Breurec S. First case of Elizabethkingia anophelis meningitis in the Central African Republic. The Lancet. 2013;381(9880):1876. doi: 10.1016/S0140-6736(13)60318-9. [DOI] [PubMed] [Google Scholar]
7.Teo J, Tan S. Y. Y, Tay M, Ding Y, Kjelleberg S, Givskov M, Yang L. First case of E anophelis outbreak in an intensive-care unit. The Lancet. 2013;382(9895):855–856. doi: 10.1016/S0140-6736(13)61858-9. [DOI] [PubMed] [Google Scholar]
8.Lau S. K, Wu A. K, Teng J. L, Tse H, Curreem S. O, Tsui S. K, Woo P. C. Evidence for Elizabethkingia anophelis transmission from mother to infant, Hong Kong. Emerging infectious diseases. 2015;21(2):232. doi: 10.3201/eid2102.140623. https://doi.org/10.3201%2Feid2102.140623 [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Rahim G. R, Gupta N, Aggarwal G. Diagnostic Pitfalls in Identification of Elizabethkingia Meningoseptica. Journal of critical care medicine (Universitatea de Medicina si Farmacie din Targu-Mures) 2018;4(4):149–150. doi: 10.2478/jccm-2018-0021. [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Meier-Kolthoff J. P, Carbasse J. S, Peinado-Olarte R. L, Göker M. TYGS and LPSN: a database tandem for fast and reliable genome-based classification and nomenclature of prokaryotes. Nucleic acids research. 2022;50(D1):D801–D807. doi: 10.1093/nar/gkab902. [DOI] [PMC free article] [PubMed] [Google Scholar]
Owing to the available expertise, we prefer bedside percutaneous tracheostomies over surgical technique. We share our experience of tracheostomy in children over the past 12 years.
Objectives
Aim – To study the airway outcomes of tracheostomy in critically ill children(<18 years of age).
Objectives-To study the following in children with tracheostomy
– Demographic profile
– Indications
– Technique used
– Organ supports during the procedure
– Complications
Material and methods
Retrospective analysis of prospectively collected data for severity of illness scores, duration: Septemer 2011 to December 2023. Data was also retrieved from medical records. Data collected included demography; admission diagnosis; type, indication and organ support(s) during the procedure;biochemical and hematological investigations; complications, airway outcomes and length of stay. Ethical clearance was taken from Institute Ethical Committee. Complications were defined as immediate- occurring during or <1hr post procedure; early 1-6 hours, late- >6 hours to≤ 48 hours and delayed –>48 hours after procedure till discharge and on follow-up. Descriptive analysis was done using Excel and SPSS 22; data is presented in median (interquartile range) and number (%).
Results
During this period, 435 pediatric patients were admitted.312 were invasively ventilated (73.5) and 52(16.6) patients were tracheostomized; 9 were admitted with tracheostomy in-situ. 37 (71) patients were male, median age was 12.5 years (6-15). 12 patients were ≤ 5years. The admission diagnosis was neuromuscular diseases(16, 30.8%), CNS illnesses(15,28.9%), respiratory illness(4,7.7%), sepsis(7, 13.5%), severe acute pancreatitis(5, 9.6%), congenital anomalies(2, 3.8 %) and miscellaneous(3, 5.8 %). The median pSOFA was 6 (4-8) and predicted mortality by PIM2 score was 7.2% (3.8-8.3). 39 (75) procedures were percutaneous while 13(25) were surgical. The indications were prolonged mechanical ventilation in 20 (38.5), neuromuscular weakness in 14 (26.9), central nervous system involvement in 12 (23) and upper airway obstruction in 6 (11.5). Tracheostomy was done after a median duration of 11 days (6.5-15.5) post intubation. Seven patients were hemodynamically unstable during the procedure requiring vasopressors; median vasoactive inotrope score 4.08 (1.7-4.9). Median oxygenation index was 4.8 (2.9-6.6). Increased bleeding risk in the form of thrombocytopenia (with platelet count <50,000/cmm), prolonged prothrombin time and acute kidney injury were found in 2, 12 and 15 patients respectively), both the last two in 7 patients. Platelets were transfused in two children. Complications observed:immediatewereminimal ooze in 4, desaturation in 1, hypotension in 2; late were 1 each of subcutaneous emphysema andpneumothorax. Delayed complications were tracheo-esophageal fistula(1), supra-stomal granulation requiring surgery (2), swallowing dysfunction (1), tracheal bleed (1). Decannulation was successful in 28 (50%). 14 patients were discharged with tracheostomy; 11 due to neurological illness and airway issues in 3; 6 were decannulated on follow up. 10 patients died with tracheostomy. Conclusions: 16.6 % of all critically ill children require tracheostomy. Percutaneous technique is safe in experienced hands.
Relationship between Modified Nutrition Risk in the Critically Ill (mNUTRIC) Score with Quadriceps Femoris Muscle Thickness in Critically Ill Patients: A Prospective Observational Study
The nutritional status of individuals affects the clinical outcomes in the critically ill patients. During stressful (hypermetabolic) conditions, there is an increase in protein degradation that exceeds the rate of protein synthesis6. Decreased skeletal muscle mass is associated with increased mortality, prolonged treatment time with mechanical ventilation, and length of stay (LOS) in the ICU and hospital3. mNUTRIC score is equally validated risk assessment tool which excludes IL-6 from primary Nutric Score. Patients with high scores (5–9) are associated with worse clinical outcomes (mortality, ventilation). These patients are most likely to benefit from aggressive nutritional therapy. Patients with low scores (0-4) have a low risk of malnutrition. Monitoring muscle mass during treatment in the ICU will not only help to detect patients at risk and predict outcome but also can help doctors to evaluate the success of nutritional interventions during treatment.3 Anthropometric tool, Strength measurement, CT, MRI are some of the tools but practically not feasible in critically ill patients. Ultrasound measurements can be performed non-invasively, instantaneously, and can be repeated. Modified NUTRIC score as a scoring system which is expected to represent patients at high risk of complications and mortality. This study aimed to investigate whether there is a relationship between nutritional intake and modified NUTRIC score with quadriceps femoral muscle thickness in critically ill patients.
Objectives
Primary- To Establish a relationship between mNUTRIC Score and Quadriceps Femoris Muscle Thickness.
Secondary- Relation between disease severity in terms of APACHE II and the SOFA score with the percentage muscle loss.
Relationship between calorie debt and muscle changes.
Materials and methods
This study has been conducted after institutional ethical clearance and CTRI registration with information and consent to attendant at SBIMS, Raipur. Study included patient with age between 18-65years and excluded disconsent, chronically ill, having neuromuscular disease, lower limb deformity, fracture, palliative care. Subjects were grouped into low and high risk on the basic of m-nutric score. General characteristic, calorie debt, protein debt noted daily. The quadriceps femoris muscle thickness including Rectus femoris and Vastus intermedius measured by ultrasonography using a 12 MHz linear transducer at two points on each thigh.
Results
Under statical evaluation.
Discussions
We will be completing before schedule date of presentation.
References
1.Pardo E, El Behi H, Boizeau P, Verdonk F, Alberti C, Lescot T. Reliability of ultrasound measurements of quadriceps muscle thickness in critically ill patients. BMC Anesthesiology. 2018;18(1):1–8. doi: 10.1186/s12871-018-0647-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Formenti P, Umbrello M, Coppola S, Froio S, Chiumello D. Clinical review: peripheral muscular ultrasound in the ICU. Annals of Intensive Care. 2019;9(1) doi: 10.1186/s13613-019-0531-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Gao Y, Arfat Y, Wang H, Goswami N. Muscle atrophy induced by mechanical unloading: Mechanisms and potential countermeasures. Frontiers in Physiology. 2018;9(MAR) doi: 10.3389/fphys.2018.00235. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Preiser J. C, Ichai C, Orban J. C, Groeneveld A. B. J. Metabolic response to the stress of critical illness. British Journal of Anaesthesia. 2014;113(6):945–954. doi: 10.1093/bja/aeu187. [DOI] [PubMed] [Google Scholar]
5.Martín C. A. G, Monares Zepeda E, Lescas Méndez O. A. Bedside Ultrasound Measurement of Rectus Femoris: A Tutorial for the Nutrition Support Clinician. Journal of Nutrition and Metabolism, 2017. 2017 doi: 10.1155/2017/2767232. [DOI] [PMC free article] [PubMed] [Google Scholar]
Elevated intracranial pressure (ICP) is a common and potentially life-threatening condition. The trans-orbital ultrasonography, is a non-invasive method which detects raised ICP by evaluating increases in the optic nerve sheath diameter (ONSD). Real time change of ONSD; in association with acute change in EtCO2, has shown variable results in different studies. We hypothesized that there would be dynamic changes in ONSD in response to corresponding changes in EtCO2.
Objectives
Primary objective: To evaluate the change in optic nerve sheath diameter (ONSD) with change in end tidal carbon dioxide (EtCO2). Secondary objective: To evaluate if the change in ONSD in response to change in end tidal carbon dioxide is immediate (real time). To evaluate if the change in ONSD is reversible with restoration of end tidal carbon dioxide to previous level.
Methods
56 patients, with age between 18-60 years, either sex, and admitted to undergo elective spine surgery under general anaesthesia were included. All patients were exposed to both hypercapnia and hypocapnia and the ONSD values were recorded. For the purpose of the study, after induction of GA the respiratory rate was adjusted to attain the desired EtCO2 value (normocapnia, hypocapnia or hypercapnia). ONSD values were obtained at normo-, hyper- and hypo-capnia in all the patients.
Results
A strong correlation was found between the corresponding EtCO2 and ONSD values with Pearson's correlation coefficient of 0.89. There was no statistical difference between ONSD values at 0 and 5 minutes after attaining the desired EtCO2 level. The change in ONSD were reversible with EtCO2 reversibility.
Discussion
With change in PaCO2, there is corresponding change in CBF and CBV that causes change in ICP which can be reflected as changes in ONSD. In this study, it has been observed that ONSD has a strong correlation with EtCO2 changes. Hence ONSD can be used as a non-invasive surrogate marker for intracranial pressure monitoring in neuro-intensive care settings to detect the changes in ICP and optimisation.
References
1.Kim S, McNames J, Goldstein B. Intracranial pressure variation associated with changes in end-tidal CO2. Conf Proc IEEE Eng Med Biol Soc. 2006;1:9–12. doi: 10.1109/IEMBS.2006.259932. [DOI] [PubMed] [Google Scholar]
2.Kerr ME, Zempsky J, Sereika S, Orndoff P, Rudy EB. Relationship between arterial carbon dioxide and end-tidal carbon dioxide in mechanically ventilated adults with severe head trauma. Crit Care Med. 1996;24:785–90. doi: 10.1097/00003246-199605000-00010. [DOI] [PubMed] [Google Scholar]
3.Kim JY, Min HG, Ha SI, Jeong HW, Seo H, Kim JU. Dynamic optic nerve sheath diameter responses to short-term hyperventilation measured with sonography in patients under general anesthesia. Korean Journal of Anesthesiology. 2014;67:240–5. doi: 10.4097/kjae.2014.67.4.240. [DOI] [PMC free article] [PubMed] [Google Scholar]
Balanced Salt Solution vs Normal Saline as Resuscitation Fluid in Pediatric Septic Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials
1Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, Phone: +91 9855373969, e-mail: sureshnagurana@gmail.com
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
1Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, Phone: +91 9855373969, e-mail: sureshnagurana@gmail.com
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Fluid resuscitation is important intervention in children with septic shock. The composition, volume, and timing of resuscitation fluid (fluid boluses) are matter of debate.
Objective
To study the effects of balanced salt solution (BSS) versus normal saline (NS) as resuscitation fluids in pediatric septic shock.
Material and methods
We conducted this systematic review and meta-analysis using PRISMA guidelines and the protocol was registered at PROSPERO. We searched MEDLINE, Embase, LILAC, Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. Study screening, inclusion, data extraction, and risk of bias assessments were performed by two reviewers independently. Random-effects model was used for analysis of RCTs. We used Cochrane's risk of bias tool for assessing the quality of studies. Primary outcome was mortality and secondary outcomes were rates of acute kidney injury (AKI), need for renal replacement therapy (RRT), and adverse effects (hyperchloremia, metabolic acidosis, and fluid overload); and duration of PICU and hospital stay.
Results
Five RCTs with 992 children were included. Resuscitation with BSS versus NS was not associated with reduction in mortality (RR 0.82, 95% CI 0.45-1.50, p=0.52); with similar results on sensitivity analysis (RR 0.76, 95% CI 0.41-1.41, p=0.52). However, resuscitation with BSS was associated with lower rates of AKI (sensitivity analysis RR 0.64, 95% CI 0.50-0.82, p=0.0004); lesser need for RRT (RR 0.52, 95% CI 0.35-0.76, p=0.0008); and lower rate of hyperchloremia (RR 0.74, 95% CI 0.62-0.87, p=0.0002). The data is scant for other secondary outcomes (metabolic acidosis, fluid overload, and duration of PICU and hospital stay) to make any suggestions. The overall ‘risk of bias’ was low and unclear in most domains.
Discussion
In this systematic review and meta-analysis, we demonstrated that the use of BSS as resuscitation fluid in pediatric septic shock had no difference on mortality and duration of PICU or hospital stay as compared to NS. However, BSS group had significantly lower rates of hyperchloremia, AKI (on sensitivity analysis), and need of RRT. The results of several meta-analysis involving critically ill adults with shock also demonstrated that resuscitation with BSS was not associated with reduction in mortality, AKI, or need of RRT. However, there was some evidence that it may be associated with significant lower serum chloride levels.
Conclusion
Use of BSS as resuscitation fluid in pediatric septic shock was not associated with reduction in mortality. However, BSS was associated with decreased risk of AKI, need of RRT, and hyperchloremia.
References
1.Serpa Neto A, Martin Loeches I, Klanderman RB, Freitas Silva R, Gama de Abreu M, Pelosi P, et al. Balanced versus isotonic saline resuscitation-a systematic review and meta-analysis of randomized controlled trials in operation rooms and intensive care units. Ann Transl Med. 2017 Aug;5(16):323. doi: 10.21037/atm.2017.07.38. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Antequera Martín AM, Barea Mendoza JA, Muriel A, Sáez I, Chico-Fernández M, Estrada-Lorenzo JM, et al. Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. Cochrane Database Syst Rev. 2019 Jul 19;7(7):CD012247. doi: 10.1002/14651858.CD012247.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Lehr AR, Rached-d'Astous S, Barrowman N, Tsampalieros A, Parker M, McIntyre L, et al. Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc. 2022 Mar 1;23(3):181–91. doi: 10.1097/PCC.0000000000002890. [DOI] [PMC free article] [PubMed] [Google Scholar]
Healthcare workers are at high risk of contracting diseases as they are continuously in contact with patients. Malnutrition increases the risk of contracting infections and increases morbidity. In this study we aim to find the incidence of malnutrition in healthcare workers in hospital and compare it with employees working in non-clinical areas. Hand grip strength is used as an independent tool of nutritional assessment and screening for risk of malnutrition. GLIM criteria is used for diagnosing malnutrition.
Method
Hand grip strength of total 700 hospital employees measured using hydraulic hand grip dynamometer. Hand grip strength of 350 nursing staff, doctors and ward staff is measured and Hand Grip Strength 350 employees from non-clinical background is taken as control population. Average of three readings for each hand compared with standard reading for particular age group. BMI calculated and daily dietary habits and intake calculated using questionnaire to assess the reduced food intake. Assessment of Malnutrition diagnosis was done with a 2-step approach. First step involved screening to identify at risk status by the use of low BMI and reduced Hand Grip Strength whereas second step assessed the diagnosis and graded the severity of malnutrition as per GLIM criteria.
Result and conclusion
Among the nursing staff between age group from 20 to 30 years, 15.71% fall in the GLIM's phenotypic criteria of weight loss of 5%-10% in last 6 months. This present study showed a statistically significant difference in weight loss between clinical nursing staff Vs non clinical staff working in hospital. As per GLIM criteria, 8.5% nursing staff from age group 20 to 30 years fall in to grade I malnutrition which is statistically significant. Nursing staff in age group of 20 to 30 years is at higher risk of malnutrition. It can be attributed to shift duties, irregular meal times and skipping meals. Hand grip dynamometer is an independent tool in this study by which we find muscle strength and sarcopenia. Higher grip strength found in males than females. Also, it was noted that grip strength greater in dominant hand than non-dominant hand. Nutritional counselling.
References
1.Schaible UE, Kaufmann SH. Malnutrition and infection: complex mechanisms and global impacts. [DOI] [PMC free article] [PubMed]
2.Wanjek C. Food at work: Workplace solutions for malnutrition, obesity and chronic diseases Geneva
Laryngoscopy and tracheal intubation can result in sympathetic activation and catecholamine release which can result in tachycardia, hypertension and dysrhythmias. Other complications include myocardial ischemia due to increased myocardial oxygen demands, arrhythmias and cerebrovascular accidents. To mitigate this sympathetic responses drugs that block sympathetic activity can be used such as beta-blockers, local anesthetics, alpha-agonists and NMDA receptor antagonists. Esmolol is a cardio selective Beta-Adrenergic antagonist with partial agonistic and membrane stabilizing properties. Elimination half life for esmolol is 9 minutes which makes it preferable drug for blunting hemodynamic responses. Esmolol can be used as a bolus injection or as continuous IV infusion. Esmolol Bolus injection is a simple and better alternative to continuous IV infusion in management of transient hemodynamic changes that occur during intubation and laryngoscopy.
Objectives
To study effect of IV bolus dose of injection esmolol as 1.5mg/kg on hemodynamic response to laryngoscopy and tracheal intubation.
Materials and methods
ASA grade 1 and 2 patients of either gender, 18 - 50 years old, scheduled to undergo elective surgical procedures under general anaesthesia will be assigned into equal groups- group A and group B Patients of Group A shall not receive any drug and group B shall be receiving injection esmolol 1.5mg/kg. On arrival in the operation theatre, standard monitors will be connected and baseline reading of heart rate, blood pressure and spo2 will be noted and patient will be premedicated and injection esmolol 1.5mg/kg in 10ml dilution will be given and patient will be induced with propofol. Laryngoscopy and tracheal intubation will be done 45-60 seconds after giving succinylcholine. Anaesthesia will be maintained with 50%N2O, 50%O2, 0.2-1% isoflurane and Inj. Atracurium 0.5mg/kg. Monitoring of hemodynamic changes will be recorded and readings will be taken after 2mins of intubation and every minute till 7 minutes.
Results
Patients receiving esmolol bolus dose show hemodynamic attenuation of response due to laryngoscopy and intubation compared to control group.
Discussions
Findings suggest that short acting Beta Blocker such as esmolol may be useful for attenuating exaggerated hemodynamic response seen during laryngoscopy and tracheal intubation.
References
1.Hatti R, Patil V. Effect of 0.75 mg/kg esmolol on pressor response during laryngoscopy and endotracheal intubation: a comparative study. Journal of Evolution of Medical and Dental Sciences. 2015 Sep 7;4(72):12516–23. [Google Scholar]
2.Shailaja S, Srikantu J. Comparison of effect of esmolol vs. esmolol and fentanyl on hemodynamic response to laryngoscopy and tracheal intubation in controlled hypertensive patients: a randomized controlled double blind study. Anaesthesia, Pain & Intensive Care. 2013 Sep 1;17(3) [Google Scholar]
3.Mulimani SM, Talikoti DG, Vastrad VV, Sorganvi VM. Efficacy of a bolus dose of esmolol and bolus dose of lignocaine for attenuating the pressor response to laryngoscopy and endotracheal intubation in general anesthesia: A comparative study. Anesthesia, Essays and Researches. 2019 Apr;13(2):292. doi: 10.4103/aer.AER_31_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
To Study the Association of Serum Ferritin Levels with Outcomes in Patients of Tropical Fever Admitted to Intensive Care Unit of a Tertiary Care Hospital – A Prospective Observational Study
Serum ferritin is an acute phase protein, and serum ferritin levels have been noted to rise in response to pro-inflammatory cytokines. Hyperferritinemia is also common in secondary hemophagocytic lymphohistiocytosis (HLH); ferritin level has been shown to independently predict mortality in critically ill patients with HLH. This study sought to explore whether higher serum ferritin levels upon ICU admission could predict increased mortality and prolonged ICU stay in patients with tropical fever.
Objectives
The objectives of this study were to determine the association between serum ferritin levels measured within 72 hours of ICU admission and mortality and and to assess the incidence of secondary HLH in patients with tropical infections.
Materials and methods
This was a prospective observational study conducted in the ICU of a tertiary teaching hospital between 1st January 2023 and 30th November 2023. Adult patients with acute febrile illness (fever >38.3°C) due to a tropical infection (defined as fever for more than 48 hours with no focus, and positive serological evidence or blood culture viz IgM for leptospira, NS1/IgM for dengue, Weil Felix/IgM for scrub typhus, IgM for brucella, anti-HAV IgM and HEV IgM for hepatitis A and E, peripheral smear for malaria, and blood culture for enteric fever or melioidosis) were made part of the study. Serum ferritin levels were measured within 72 hours of admission, irrespective of clinical findings. A diagnosis of HLH was made if if at least 5 of 8 diagnostic criteria based on HLH-2004 protocol were met. Mortality data were collected for all enrolled patients. Sample size was calculated after doing a pilot study using data of tropical fever patients admitted over 6 months duration. It showed a sample size requirement less than 10. Hence decision was made to take consecutive sampling over 1 year period. Statistical analysis was performed utilizing IBM SPSS Statistics version 25. The association between study variables and mortality was assessed using the Chi-square test. To compare the significance of mean differences in study variables concerning the outcome, the unpaired t-test was employed for parametric variables, and the Mann-Whitney U test was used for nonparametric variables. Receiver operator characteristic (ROC) curve analysis was utilized for assessing the predictive value of serum ferritin.
Results
28 patients were studied. The mean ferritin level of patients who survived (n=19) was 7548.65 ng/mL (median=2213, IQR 696.4-11211.4), while that of patients who succumbed to disease (n=9) was 22395.63 ng/mL (median=18185, IQR 4309.9–40000). This difference was statistically significant (p=0.017). 7 patients had secondary HLH. 18 patients received steroid therapy. Respiratory failure requiring intubation and mechanical ventilation was found to increase mortality (p=0.049), while shock (p=0.098), and secondary HLH (p=0.646) did not have a statistically significant association with mortality. Serum ferritin value higher that 6629.8 ng/mL was associated with poor outcome (AUC: 0.784, 95% CI: 0.595-0.972,).
Discussion
Serum ferritin values can be predictive of clinical outcomes in patients with tropical fever. Incidence of secondary HLH has relatively increased in patients with tropical fever. However in the current study a statistically significant correlation between HLH and icu mortality could not be detected.
References
1.Singhi S, Rungta N, Nallasamy K, Bhalla A, Peter JV, Chaudhary D, et al. Tropical fevers in indian intensive care units: a prospective multicenter study. Indian J. Crit. Care Med. 2017;21:811–8. doi: 10.4103/ijccm.IJCCM_324_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Sumatha Channapatna Suresh, Rajeev Hanumanthaiah, Chethana Ramakrishna, et al. Serum Ferritin As a Prognostic Indicator in Adult Dengue Patients. Am J Trop Med Hyg. 2021 Mar;104(3):1072–1078. doi: 10.4269/ajtmh.20-1111. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Bennett T. D, Hayward K. N, Farris R. W, Ringold S, Wallace C. A, Brogan T. V. Very high serum ferritin levels are associated with increased mortality and critical carein pediatric patients. Pediatr. Crit. Care Med. 2011;12:e233. doi: 10.1097/PCC.0b013e31820abca8. [DOI] [PubMed] [Google Scholar]
4.Arundhati G. Diwan, Barsode1 Supriya S, Nisa Amit R, et al. Analysis of patients of hemophagocytic lymphohistiocytosis secondary to infections. Int J Adv Med. 2020Oct;7(10):1515–1518. [Google Scholar]
5.Rajagopala S, Singh N, Agarwal R, Gupta D, Das R. Severe hemophagocyticlymphohistiocytosis in adults-experience from an intensive care unit from North India. IndianJ Crit Care Med. 2012;16(4):198–203. doi: 10.4103/0972-5229.106501. [DOI] [PMC free article] [PubMed] [Google Scholar]
High Flow Nasal Cannula vs Conventional Oxygen Therapy and Incidence of Post Extubation Airway Obstruction in PICU: An Open-label Randomized Controlled Trial (Hiflocot-PICU Trial)
1Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, Phone: +91 9855373969, e-mail: sureshnagurana@gmail.com
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
1Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, Phone: +91 9855373969, e-mail: sureshnagurana@gmail.com
2–5Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Post extubation airway obstruction (PEAO) is a common among mechanically ventilated critically ill children with incidence ranging between 30-50%. As compared to conventional oxygen therapy (COT), high flow nasal cannula (HFNC) delivers heated and humidified gases at high flow, reduces pharyngeal dead space, and provides positive end expiratory pressure. These mechanisms of HFNC are thought to reduce the incidence of PEAO.
Objectives
To study the impact of high flow nasal cannula (HFNC) versus conventional oxygen therapy (COT) (by nasal cannula) as respiratory support after extubation on the rates of post extubation airway obstruction (PEAO) among mechanically ventilated critically ill children.
Materials and methods
This open-label randomized controlled trial was conducted in Pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India over a period of 7 months (August 2021 to February 2022). Children aged 3 months to 12 years who required invasive mechanical ventilation for >72 hrs and had passed spontaneous breathing trial and considered for extubation were enrolled who were randomized by computer generated block randomization to receive HFNC or COT after extubation. Primary outcome was rate of PEAO (assessed by modified Westley croup score, mWCS) within 48 hours of extubation; and secondary outcomes were rate and number of adrenaline nebulization, treatment failure (requiring escalation of respiratory support), extubation failure, adverse effects, and length of PICU stay in HFNC COT groups.
Results
During the study period, 116 children were enrolled (58 each in HFNC and COT groups). There was no difference in rate of PEAO (55% vs. 51.7%, respectively), mWCS, adrenaline nebulization, extubation failure, adverse effects, and duration of PICU stay in two groups. However, HFNC group had significantly lower rates of treatment failure (27.6% vs. 48.3%, p=0.02).
Discussion
In this open-label randomized controlled trial, we demonstrated that among children undergoing mechanical ventilation for >72 hours, the overall rate of PEAO was 53.4%. The use of HFNC as respiratory support following extubation did not resulted in significant difference in the rate of PEAO, extubation failure, duration of respiratory support, and length of PICU stay as compared to COT. However, the rate of treatment failure was significantly lower in HFNC group (27.8% vs 48.3%, p=0.02). The extubation failure rates were similar in HFNC and COT groups in our study, like what has been demonstrated in other studies. In contrast, few authors have demonstrated lower rates of extubation failure in HFNC group. In contrast to results of majority of the studies, we demonstrated that SpO2 values were similar in HFNC and COT groups during first 48 hours after extubation.
Conclusion
The rate of PEAO was similar in HFNC and COT groups. However, HFNC group had significantly lower rate of treatment failure requiring escalation of respiratory support.
References
1.Akyildiz B, Ozturk S, Ulgen-Tekerek N, et al. Comparison between high-flow nasal oxygen cannula and conventional oxygen therapy after extubation in pediatric intensive care unit. Turk J Pediatr. 2018;60(2):126–33. doi: 10.24953/turkjped.2018.02.002. [DOI] [PubMed] [Google Scholar]
2.Burra V, Lakshmi A, Bhat A, et al. Comparison of high-flow nasal cannula versus conventional oxygen therapy following extubation after paediatric cardiac surgery. Airway. 2019;2(1):4–9. [Google Scholar]
3.Wijakprasert P, Chomchoey J. High-flow nasal cannula versus conventional oxygen therapy in post-extubation pediatric patients: a randomized controlled trial. Journal of the Medical Association of Thailand. 2018;101(10) [Google Scholar]
4.Stevens H, Gallant J, Foster J, et al. Extubation to High-Flow Nasal Cannula in Infants Following Cardiac Surgery: A Retrospective Cohort Study. J Pediatr Intensive Care. 2023;12(3):167–72. doi: 10.1055/s-0041-1730933. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Huang HW, Sun XM, Shi ZH, et al. Effect of High-Flow Nasal Cannula Oxygen Therapy Versus Conventional Oxygen Therapy and Noninvasive Ventilation on Reintubation Rate in Adult Patients After Extubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Intensive Care Med. 2018;33(11):609–23. doi: 10.1177/0885066617705118. [DOI] [PubMed] [Google Scholar]
6.Granton D, Chaudhuri D, Wang D, et al. High-Flow Nasal Cannula Compared With Conventional Oxygen Therapy or Noninvasive Ventilation Immediately Postextubation: A Systematic Review and Meta-Analysis. Crit Care Med. 2020;48(11):e1129–e36. doi: 10.1097/CCM.0000000000004576. [DOI] [PubMed] [Google Scholar]
7.Karedath J, Hatamleh MI, Haseeb R, et al. Comparison of High-Flow Nasal Cannula Versus Conventional Oxygen Therapy After Extubation in Children Undergoing Cardiac Surgery: A Meta-analysis. Cureus. 2023;15(3):e36922. doi: 10.7759/cureus.36922. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Iyer NP, Rotta AT, Essouri S, et al. Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis. JAMA Pediatr. 2023;177(8):774–81. doi: 10.1001/jamapediatrics.2023.1478. [DOI] [PMC free article] [PubMed] [Google Scholar]
The prevalence of thrombocytopenia in tropical countries such as India poses a significant concern in clinical settings, ranging from asymptomatic cases to life-threatening conditions requiring urgent interventions like blood transfusions.
Objectives
This study aimed to comprehensively explore the causes, clinical profiles, and laboratory parameters associated with thrombocytopenia among patients.
Materials and methods
The present observational study was conducted at the Department of Medicine, Prasad Institute of Medical Sciences in Lucknow, India, this cross-sectional hospital-based study involved 57 cases of thrombocytopenia, including patients of all ages presenting with platelet counts below 100,000/mm3. Exclusion criteria encompassed drug-related thrombocytopenia, pregnancy-related cases, recent chemotherapy or radiotherapy recipients, and those receiving substantial blood transfusions.
Results
The study revealed a notable distribution of cases, with over half (54.39%) occurring in patients under 30 years old. Infections emerged as the primary cause, accounting for 68.42% of cases, particularly Dengue (53.85%), Malaria (33.33%), Enteric fever (7.69%), and HIV (5.13%). Notably, Megaloblastic anemia comprised 24.56% of cases among the younger population.
Discussions
The present findings illuminated a strong correlation between infections prevalent in India, such as malaria, dengue, and enteric fever, and associated thrombocytopenia, often accompanied by splenomegaly and jaundice. The study echoed prior research, emphasizing a higher incidence of thrombocytopenia in individuals under 30 years, irrespective of gender. Results consistently highlighted infections, including dengue, malaria, enteric fever, and HIV, as leading causes, aligning with previous systematic reviews (Bizzaro N.). In conclusion, infections and megaloblastic anemia emerged as the primary drivers of thrombocytopenia. Notably, bleeding manifestations were observed in 35.09% of patients, predominantly in the skin and mucous membranes. Dengue hemorrhagic fever emerged as the primary cause of bleeding, followed by megaloblastic anemia and malaria, underscoring the critical association between specific etiologies and bleeding in thrombocytopenic patients (Liu et al.).
References
1.Shah HR, Vaghani BD, Gohel P, Virani BK. Clinical Profile Review of Patients with Thrombocytopenia: A Study of 100 Cases at a Tertiary Care Centre. Int J Cur Res Rev. 2015;7(6):82–7. [Google Scholar]
2.Bizzaro N. EDTA‐dependent pseudothrombocytopenia: A clinical and epidemiological study of 112 cases, with 10‐year follow‐up. Ame J Hematol. 1995;50(2):103–9. doi: 10.1002/ajh.2830500206. [DOI] [PubMed] [Google Scholar]
3.Liu S, Chai C, Wang C, Amer S, Lv H, He H, et al. Systematic review of severe fever with thrombocytopenia syndrome: virology, epidemiology, and clinical characteristics. Reviews Medic Virol. 2014;24(2):90–102. doi: 10.1002/rmv.1776. [DOI] [PMC free article] [PubMed] [Google Scholar]
1Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Phone: +91 9855373969, e-mail: sureshnagurana@gmail.com
1Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Phone: +91 9855373969, e-mail: sureshnagurana@gmail.com
2–5Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Status epilepticus is the commonest neurological emergency in children with significant mortality and morbidity. There is wide variation in management practices with poor adherence to the pediatric status epilepticus (PSE) management guidelines.
Objective
To survey of treatment practices and adherence to PSE management guidelines in India.
Materials and methods
This eSurvey was conducted over 35 days (15th October-20th November 2023) and included questions related to respondents and hospital setting; antiseizure medications (ASMs); ancillary treatment; facilities available; etiology; and adherence to PSE management guidelines.
Results
170 respondents participated, majority were working in tertiary level hospitals (94.1%) as pediatric intensivists (56.5%) and pediatricians (19.4%), and were in clinical practice for 2-10 years (46.5%). Majority use intravenous (IV) midazolam and levetiracetam as first- and second-line ASMs (67.1% and 51.2%, respectively). In cases with refractory status epilepticus (RSE), majority use IV midazolam (92.4%) and thiopentone infusion (26.5%). For super-refractory status epilepticus (SRSE), 44.7% use ketamine infusion, 42.4% oral topiramate, and 34.7% high-dose phenobarbitone infusion. Most respondents targeted both clinical and EEG seizure control (48.8%). Ancillary treatment used for SRSE included IV pyridoxine (57.1%), methylprednisolone (45.3%), IVIG (42.4%), ketogenic diet (40.6%), and second-line immunomodulation (33.5%). Most common causes for PSE were febrile SE, viral encephalitis, and febrile illness-related epilepsy syndrome (FIRES) (60.6%, 52.4%, and 37.1%, respectively). Facilities available included PICU (97.1%), mechanical ventilation (98.2%), pediatric neurologist (68.8%), MRI brain (86.5%), EEG (69.4%), and viral PCR (58.2%). The compliance with guidelines for timing of initiation of ASM ranged from 63.5-88.8%. Half (48.8%) of the respondents use local PSE management protocols.
Conclusion
IV midazolam bolus/es, levetiracetam, and midazolam infusion are commonly used first, second, and third-line ASMs, respectively. There were wide variations in use of ASMs for RSE and SRSE, ancillary treatment, and compliance to SE management guidelines.
References
1.Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16:48–61. doi: 10.5698/1535-7597-16.1.48. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Singhi S, Angurana SK. Principles of Management of Central Nervous System Infections. Indian J Pediatr. 2019;86:52–9. doi: 10.1007/s12098-017-2583-y. [DOI] [PubMed] [Google Scholar]
3.Lyttle MD, Rainford NEA, Gamble C, et al. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. Lancet. 2019;393(10186):2125–34. doi: 10.1016/S0140-6736(19)30724-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Dalziel SR, Borland ML, Furyk J, et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Lancet. 2019;393(10186):2135–45. doi: 10.1016/S0140-6736(19)30722-6. [DOI] [PubMed] [Google Scholar]
5.Angurana SK, Suthar R. Efficacy and Safety of Levetiracetam vs. Phenytoin as Second Line Antiseizure Medication for Pediatric Convulsive Status Epilepticus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Trop Pediatr. 2021:67. doi: 10.1093/tropej/fmab014. [DOI] [PubMed] [Google Scholar]
6.AlMohaimeed BA, Hundallah KJ, Bashiri FA, AlMohaimeed SA, Tabarki BM. Evaluation of adherence to pediatric status epilepticus management guidelines in Saudi Arabia. Neurosciences (Riyadh) 2020;25:182–7. doi: 10.17712/nsj.2020.3.20190106. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Kowoll CM, Klein M, Salih F, et al. IGNITE Status Epilepticus Survey: A Nationwide Interrogation about the Current Management of Status Epilepticus in Germany. J Clin Med. 2022:11. doi: 10.3390/jcm11051171. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Tyson M, Trenear R, Skellett S, Maconochie I, Mullen N. Survey About Second-Line Agents for Pediatric Convulsive Status Epilepticus. Pediatr Emerg Care. 2023;39:247–52. doi: 10.1097/PEC.0000000000002745. [DOI] [PubMed] [Google Scholar]
A Pilot Study to Assess the Knowledge, Attitudes, Practices, Perceived Impediments, and Support for Palliative Care and End-of-life Care among Critical Care Nurses in a Tertiary Care Institution
One of the most important components for the best delivery of palliative care (PC) and end-of-life care (EOLC) is the role played by nurses in critical care units. A good understanding of palliative care (PC) and end-of-life care (EOLC) is essential for nurses in order to deliver high-quality care to patients who are terminally ill or have chronic illnesses.
Objective
To understand the deficiencies and shortfalls that exist among critical care nurses concerning various aspects of palliative and end-of-life care. The study's secondary objective was to determine the association between the selected parameters and people's knowledge, attitudes, and behaviours about palliative care and end-of-life care (EOLC).
Materials and methods
A cross-sectional study involving 102 critical care nurses who had worked in intensive care units for at least a year was carried out. Utilizing total 5 validated tools such as self-administered surveys, knowledge evaluations, and attitude assessments, demographic data was gathered. The study was conducted using SPSS version 24, and the frequency, percentages, and averages of the variables were analyzed using ANOVA and t-tests. A significant threshold of p < 0.05 was used.
Results
The study found a significant relationship (p<0.001) between previous training, department, gender, qualification, experience, age, and experience among nurses. Female nurses scored higher in Tools 3, 4, and 5, but no discernible difference was found in terms of experience and age. Prior training significantly (p<0.001) impacted scores, with B.Sc. courses receiving the highest mean scores. Post-basic B.Sc. and GNM received the highest scores, while GNM scored higher on experience. However, no significant difference was found in terms of age or experience (p = n.s.). The nurses’ departments also showed significant variation (p<0.05), with CTVS ITU receiving the highest scores for Tools 3, and HDU and NICU receiving the lowest scores.
Discussions
The study found a significant correlation between gender, qualification, and prior training in nurses, with female nurses scoring higher on understanding end-of-life care (EOLC) and palliative care. Additional training, such as workshops or in-service training, is necessary to improve knowledge and attitudes. Critical care nurses have better understanding of palliative and EOLC, but issues impeding their delivery need to be resolved through administrative and clinical policies. Retraining, re-evaluation, and increased involvement of nurses in optimal treatment planning are the goals of the study's second phase, which attempts to remove many of the barriers to successful palliative and EOLC.
Keywords
Attitude, barriers, critical care nurses, end-of-life care, knowledge, palliative care, practices, ICU, HDU.
References
1.Kassa, et al. Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia. BMC Palliative Care. 2014;13:6. doi: 10.1186/1472-684X-13-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Walia A, Sharma KK, Garg R, Das S. A descriptive study to assess the knowledge, attitude, practices, perceived barriers, and support regarding palliative care and end-of-life care among critical care nurses of tertiary care medical institute. Indian J Palliat Care. 2020;26:479–89. doi: 10.4103/IJPC.IJPC_227_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Sorifa B, Mosphea K. Knowledge and practice of staff nurses on palliative care. IJHRMLP. 2015;1:41–5. [Google Scholar]
4.Attia AK, Abd-Elaziz WW, Kandeel NA. Critical care nurses’ perception of barriers and supportive behaviors in end-of-life care. Am J Hosp Palliat Care. 2013;30:297–304. doi: 10.1177/1049909112450067. [DOI] [PubMed] [Google Scholar]
5.Sujatha R, Jayagowri K. Assessment of palliative care awareness among undergraduate healthcare students. J Clin Diagn Res. 2017;11:JC06–10. doi: 10.7860/JCDR/2017/29070.10684. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Ayed MA, Sayej DS, Harazneh ML, Fashafsheh DI, Eqtait MF. The nurses’ knowledge and attitudes towards the palliative care. J EducPract. 2015;6:91–100. [Google Scholar]
7.Rajagopal M. The current status of palliative care in India. Cancer Manag. 2015;1:57–62. [Google Scholar]
8.Abd El-Aziz Basal A. Critical care nurses’ knowledge, practice, obstacles and helpful measures towards palliative care for critically Ill patients. AJNS. 2017;6:293–303. [Google Scholar]
9.Sadhu S, Salins NS, Kamath A. Palliative care awareness among Indian undergraduate health care students: A needs-assessment study to determine incorporation of palliative care education in undergraduate medical, nursing and allied health education. Indian J Palliat Care. 2010;16:154–9. doi: 10.4103/0973-1075.73645. [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Loera B, Molinengo G, Miniotti M, Leombruni P. Refining the frommelt attitude toward the care of the dying scale (FATCOD-B) for medical students: A confirmatory factor analysis and Rasch validation study. Palliative Supportive Care. 2018;16:50–9. doi: 10.1017/S147895151700030X. [DOI] [PubMed] [Google Scholar]
11.Anteneh S, Kassa H, Demeke T, Guadu T. Assessment of nurses’ knowledge, attitude, practice and associated factors towards palliative care: In the case of Amhara region hospitals. Adv Biol Res. 2016;10:110–23. [Google Scholar]
12.Kassa H, Murugan R, Zewdu F, Hailu M, Woldeyohannes D. Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia. BMC Palliat Care. 2014;13:1–11. doi: 10.1186/1472-684X-13-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
14.Gwyther E. NCDs: the future burden looms large. Hospice and Palliative Care Association of South Africa. Afr Health. 2011 http://www.africa-health.com Available from: Retrieved date: 13 September, 2012. [Google Scholar]
15.Wube M, Horne CJ, Stuer F. Building a palliative care program in Ethiopia: the impact on HIV and AIDS patients and their families. Schneider N, Lueckmann SL, Kuehne F, Klindtworth K, Behmann M. Developing targets for public health initiatives to improve palliative care. J Pain Symptom Manag. BMC Public Health. 2010;2010;4010:6–8. 222. doi: 10.1016/j.jpainsymman.2010.04.003. [DOI] [PubMed] [Google Scholar]
16.Mwangi-Powell F, Dix O. Palliative care in Africa; an overview. African Palliative Care Association, Kampala, Uganda; and the Diana, Princess of Wales Memorial Fund, England; 2011. Palliative care. Ethiopian North American Health Professional Association, inc. 2011 http://enahpa.org/programs-services/programs/ Available from: Retrieved date: 14 September, 2012. [Google Scholar]
17.McDermott E. The 2nd Global Summit of National Hospice and Palliative Care Associations. 2005 report. UK: Lancaster University; [Google Scholar]
18.Karkada S, Nayak BS, Malathi: Awareness of palliative care among diploma nursing students. Indian J Palliat Care. 2011;17:20–23. doi: 10.4103/0973-1075.78445. [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Institute for Clinical Systems Improvement: Palliative Care Survey 2009 report. www.icsi.org Available from: Retrieved date: 14 October, 2012.
20.Lorenz KA, Shugarman LR, Lynn J. Health care policy issues in end-of-life care. J Palliat Med. 2006;9(3):731–748. doi: 10.1089/jpm.2006.9.731. [DOI] [PubMed] [Google Scholar]
21.Ross MM. The palliative care quiz for nursing (PCQN): the development of an instrument to measure nurses’ knowledge of palliative care. J Adv Nurs. 1996;23:126–137. doi: 10.1111/j.1365-2648.1996.tb03106.x. [DOI] [PubMed] [Google Scholar]
22.Redman S, White K, Ryan E, Hennrikus D. Professional needs of palliative care nurses in New South Wales. Palliat Med. 1995;9(1):36–44. doi: 10.1177/026921639500900106. [DOI] [PubMed] [Google Scholar]
23.Cancer and Palliative Care Nurses’ Education Needs. New Zealand: Auckland Uni Services Limited; 2008. [Google Scholar]
24.Shea J, Grossman S, Kazer MW, Lange J. Assessment of advanced practice palliative care nursing competencies in nurse practitioner students: implications for the integration of ELNEC curricular modules. J NursEduc. 2010;49(4):183–189. doi: 10.3928/01484834-20090915-05. [DOI] [PubMed] [Google Scholar]
25.Dobrowolska B, Cuber T, Slusarska B, Zarzycka D, Wrońska I. Analysis of the nurses’ and physicians’ opinion regarding their end-of-life education. J Palliat Med. 2011;14(2):126–127. doi: 10.1089/jpm.2010.0323. [DOI] [PubMed] [Google Scholar]
26.Grant L, Downing J, Namukwaya E, Leng M, Murray SA. Palliative care in Africa since 2005: good progress, but much further to go. BMJ Support Palliat Care. 2011;1:118–122. doi: 10.1136/bmjspcare-2011-000057. [DOI] [PubMed] [Google Scholar]
27.Mutto EM, Errázquin A, Rabhansl MM, Villar MJ. Nursing education: the experience, attitudes, and impact of caring for dying patients by undergraduate Argentinian nursing students. J Palliat Med. 2010;13(12):1445–1450. doi: 10.1089/jpm.2010.0301. [DOI] [PubMed] [Google Scholar]
Intubation procedure carried out in intensive care unit (ICU) is usually associated with adverse events, as it is conducted in capricious situation. Having a systematic approach for endotracheal intubation might help to reduce the complications associated with emergency intubation. The data regarding incidence of complications during intubation in ICU is scarce in Indian scenario and our study would provide more information in this regard.
Objectives
To record the incidence of major life-threatening complications and other minor complications occurring during endotracheal intubation in ICU.
Materials and methods
Intubation procedure performed in a multidisciplinary ICU was noted. The incidence of life-threatening complications occurring within 30 minutes of intubation was noted. The life threatening complications noted was severe hypotension defined as mean blood pressure (BP) <50mmHg, severe hypoxia defined as SpO2<80% or cardiac arrest. We also observed other complications such as incidence of difficult intubation, esophageal intubation and aspiration of gastric content, any incidence of cardiac arrhythmias and dental injury. Other peri-intubation complications occurring during intubation was also noted. This observation was carried out for a period of eight months targeting to collect 202 patients data.
Results
The results of the pilot study with a total of 68 patient data intubated in a multidisciplinary ICU shows that the incidence of major complications like severe hypotension was noted in 39 (57.35%) and severe hypoxia was seen in 13 (19.11%) instances. Pre-oxygenation was done in 26 (38.23%) patients who underwent intubation procedure. Assessment of airway was carried out in 59 (86.76%) patients and multiple attempts at intubation was done in 18 (26.47%) patients. Use of capnography was done in 61 (89.70%) out of 68 patients. (The data collection of the study is still ongoing and a target of 202 patients is planned. We have collected 190 data and shall analyze the data once our target is achieved and we shall be ready with statistical analysis by mid-January).
Discussions
Tracheal intubation is a frequently performed procedure in acute care setting and we observe high complication rates peri-intubation. Cardiovascular instability is a frequent event in critically ill patients during intubation and is seen in 57.35%of patients in this study. Based on the outcomes of the study we plan to introduce a checklist to curtail the complications peri-intubation.
References
1.Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36(2):248–55. doi: 10.1007/s00134-009-1717-8. [DOI] [PubMed] [Google Scholar]
2.Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021;325(12):1164–72. doi: 10.1001/jama.2021.1727. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34(9):2355–61. doi: 10.1097/01.CCM.0000233879.58720.87. [DOI] [PubMed] [Google Scholar]
4.Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323–52. doi: 10.1016/j.bja.2017.10.021. [DOI] [PubMed] [Google Scholar]
5.Myatra SN, Ahmed SM, Kundra P, Garg R, Ramkumar V, Patwa A, et al. Republication: All India difficult airway association 2016 guidelines for tracheal intubation in the intensive care unit. [DOI] [PMC free article] [PubMed]
Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent pulmonary disorder with a high proportion of exacerbations requiring ICU level of care. The prevalence of COPD in India varies from 2.5% to 10%1 COPD patients suffer one to four exacerbations per year, often triggered by infections, which accounts for increased morbidity, mortality, and health-related expenditure.2
Objectives
To describe the demographic and clinical characteristics of patients admitted to ICUs in India with COPD exacerbations
To identify temporal trends of such exacerbations
To understand risk factors and delineate key outcome measures for ICU admissions within the COPD population
Material and methods
This is a retrospective analysis spanning 2018-2023, involving over 85,000 ICU patients in India from a Smart-ICU hospital network. The data, extracted from a custom-built tele-ICU platform using Python (version: 3.6) and PostgreSQL on a cloud infrastructure, focused on patients meeting COPD exacerbation criteria. Demographic, clinical, and outcome data, including APACHE scoring, antibiotic usage, and more, were collected and analyzed. Statistical tests such as Mann-Whitney U and chi-square were used for continuous and categorical data. Univariable and multivariable logistic regression models were employed for outcome associations, with R version 4.1.2 used for all analyses. No pre-selection of variables occurred due to the study's exploratory nature. The significance threshold was set at P<0.05.
Results
For the 3,118 patients, the average APACHE II score was 17.68 (SD 4.8), and there was a male predominance of 64.3%. ICU admissions were distributed with 36.5% from Bihar, 14.7% from West Bengal, 10.19% from Haryana, 10.10% from Karnataka, 4.7% from Maharashtra, and 23.81% from other states in India. Among COPD patients, 26.42% had diabetes, 47.59% were hypertensive, 12.8% had ischemic heart disease, 5.9% experienced cerebrovascular accidents, and 4.8% had thyroid dysfunction. The common presentation was respiratory distress with hypercapnic(68.4%) more common than hypoxic (62.4%) respiratory failure, with an average ICU stay of 80.91 (SD 12.7) hours and a ventilated duration of 21.80 hours. Sputum and blood cultures were positive in 277 and 296 patients, respectively. The predominant antibiotics used were piperacillin-tazobactam (39.2%), cefoperazone-sulbactam (19.7%), and meropenem (14.17%), while the remaining antibiotics contributed to 26.93%.
Discussion
In conclusion, our comprehensive analysis of a diverse cohort comprising over 3000 COPD patients across Tier 1, 2, and 3 critically ill individuals, sheds light on critical aspects of COPD burden. The findings underscore the need for tailored interventions across different population tiers, keeping in mind their presentation, antibiotic resistance, emphasizing the importance of personalized care strategies. Insights from this study contribute to the growing body of knowledge in COPD research, providing a foundation for future investigations and improved healthcare practices. It is crucial to consider the variations within the COPD patient population to enhance the effectiveness of interventions and ultimately improve patient outcomes.
References
1.Salvi S, Kumar G.A, Dhaliwal R.S, et al. The Burden of Chronic Respiratory Diseases and Their Heterogeneity across the States of India: The Global Burden of Disease Study 1990–2016. Lancet Glob. Health. 2018;6:e1363–e1374. doi: 10.1016/S2214-109X(18)30409-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Halpin DMG, Celli BR, Criner GJ, Frith P, López Varela MV, Salvi S, Vogelmeier CF, Chen R, Mortimer K, Montes de Oca M, Aisanov Z, Obaseki D, Decker R, Agusti A. The GOLD Summit on chronic obstructive pulmonary disease in low- and middle-income countries. Int J Tuberc Lung Dis. 2019 Nov 1;23(11):1131–1141. doi: 10.5588/ijtld.19.0397. 31718748 [DOI] [PubMed] [Google Scholar]
A Questionnaire-based Survey on the Physician's Perception on the Usage Pattern of Polymyxins in the Treatment of Carabapenem Resistant Gram-negative Infections
Multi-drug resistant (MDR) bacterial pathogens are a leading cause of mortality and morbidity across the globe. Polymyxins are considered the last resort antibiotics in the treatment of MDR infections. Polymyxin B and colistin have similar antibacterial properties against gram-negative bacteria. However, they may differ in their safety profile.
Objective
The objective of this survey study is to understand the practice patterns pertaining to the use of polymyxin therapy and its safety amongst critical care specialists across India.
Materials and Methods
A structured, self-reported survey questionnaire was developed. The survey responses were captured by providing multiple choices for the respective questions.
Results
Total 78 critical care specialist participated in the survey. The prevalence of carbapenem-resistant (CR) E. coli in the ICU was reported to be between 20–40% by 55% of physicians, whereas the prevalence of CR Klebsiella pneumoniae was reported to be between 40–60% by 46% of physicians. The prevalence of CR Acinetobacter baumannii was reported to be between 20 and 40% by 71% of physicians, and the prevalence of CR Pseudomonas aeruginosa was reported to be between 20 and 40% by 79% of physicians. 42% of physicians prefer to give polymyxin as empirical therapy in patients with septic shock who are hemodynamically unstable or whose infections are likely to be caused by non-fermenting GNB like Acinetobacter baumannii and Pseudomonas aeruginosa. Whereas 19% of physicians opined that they do not use polymyxins as empirical therapy. The nephrotoxicity rate of colistin was reported to be between 40-60% by 49% of physicians in their clinical practice. The nephrotoxicity rate of polymyxin B was reported to be between 20 and 40% by 88% of physicians in their clinical practice. Carbapenems and minocycline were reported to be the most common antibacterials used in combination with polymyxins in the treatment of CRE and CRAB by 45% and 44% of physicians, respectively.
Conclusion
The survey results showed that polymyxins are recommended by the majority of physicians as empirical therapy in patients with septic shock who are hemodynamically unstable or have infections likely to be caused by non-fermenting GNB like Acinetobacter baumannii and Pseudomonas aeruginosa. The majority of the physicians reported higher nephrotoxicity rates with colistin as compared to polymyxins.
Reference
1.Mohapatra S. S, Dwibedy S. K, Padhy I. Polymyxins, the last-resort antibiotics: Mode of action, resistance emergence, and potential solutions. Journal of Biosciences. 2021;46(3):85. doi: 10.1007/s12038-021-00209-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
Acute pancreatitis has high mortality despite optimal management. Death is caused by primary organ failures due to inflammation or secondary organ failures due to infected necrosis. Omega 3 fatty acids (O3FA) have been shown to have anti-inflammatory effects. (1,2) Meta-analysis of few small studies shows promising benefit with O3FA in acute pancreatitis, but data is of poor quality.(3,4)
Objectives
To assess
If parenteral supplementation of O3FA for 1 week will improve organ failure (Modified Marshall Score decrease) in severe acute pancreatitis at 2 weeks.
Effect of O3FA on mortality, length of hospital stay, complications and levels of inflammatory markers – Secondary outcomes.
Materials and methods
An investigator initiated double blinded placebo controlled randomized trial - done in tertiary hospital at New Delhi.
Randomization was through a computer generated random sequence in blocks of 4.
Allocation concealment was done by sealed envelopes.
Both groups received standard of care treatment; patients were followed up till discharge.
The sample size was calculated to be 82 (41 in each arm) with 80% power and two-sided alpha of 0.05.
Results
Adult patients admitted with a diagnosis of acute pancreatitis with organ failures, were included in this study. 175 patients were screened and 82 met the inclusion criteria. 41 patients were randomized into the intervention arm and 41 into the control arm. Since all patients were inpatients, follow up was complete till discharge. Overall mortality in this study was 36.6%. Baseline characteristics were similar among both groups. The primary outcome of decrease in organ failure score was seen in 34 of the 41 patients (82.9%) in the intervention group and 28 out of 41 patients (68.3%) in the control group, with a relative risk of 1.21 and 95% CI of 0.95 to 1.56 (p-value = 0.12). Though this result was not statistically significant a trend towards benefit was noted. Mortality which was a secondary outcome was seen in 34.1% of patients in the intervention arm and 39% of patients in the control arm. (p value – 0.647) The relative risk of mortality with O3FA was 0.88 and 95% CI for RR was 0.49 to 1.55. All other secondary outcomes also did not show any statistically significant difference. There was a trend towards reduction of IL6 levels in the intervention group but not significant. Length of ICU stay and hospital stay were longer in the intervention group. There were no major adverse effects of O3FA administration during the study.
Discussions
This was a single center randomized controlled trial which shows promising benefit with O3FA. Though statistical significance could not be proved due to smaller number of patients, it shows a trend towards organ failure improvement and survival. The longer stay was likely due to delayed mortality secondary to the improvement in organ failures in the intervention group. Longer duration of therapy may be warranted for better outcomes. We recommend a large multicentric randomized controlled trial with a longer course of O3FA administration to further study its benefit in patients with pancreatitis.
References
1.Chapkin RS, Kim W, Lupton JR, McMurray DN. Dietary docosahexaenoic and eicosapentaenoic acid: Emerging mediators of inflammation. Prostaglandins, Leukotrienes and Essential Fatty Acids. 2009 Aug;81(2–3):187–91. doi: 10.1016/j.plefa.2009.05.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Lei QC, Wang XY, Xia XF, Zheng HZ, Bi JC, Tian F, et al. The Role of Omega-3 Fatty Acids in Acute Pancreatitis: A Meta-Analysis of Randomized Controlled Trials. Nutrients. 2015 Mar 31;7(4):2261–73. doi: 10.3390/nu7042261. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Wolbrink DRJ, Grundsell JR, Witteman B, Poll M van de, Santvoort HC van, Issa E, et al. Are omega-3 fatty acids safe and effective in acute pancreatitis or sepsis? A systematic review and meta-analysis. Clinical Nutrition. 2019 Dec doi: 10.1016/j.clnu.2019.12.006. S0261561419331759. [DOI] [PubMed] [Google Scholar]
Prevalence, Etiology, Risk Factors and Antibiogram of Multi Drug Resistant Acinetobacter Isolates from ICUs of a Tertiary Care Hospital in North-East India
Acinetobacter species is a leading cause of nosocomial infections due to its property of long-term survival in the hospital environment, thus developing resistance to multiple class of antimicrobial agents, which is an emerging public health problem. Multidrug resistant(MDR) Acinetobacter is defined as the isolate resistant to at least three classes of antimicrobial agents i.e. beta lactams, fluoroquinolones, and aminoglycosides.
Objectives
To study the demographic and epidemiological profile of Acinetobacter infections. To determine the resistance pattern of the Acinetobacter isolates and estimate the MDR and XDR rates in ICUs.
Materials and methods
A retrospective cross-sectional study was done for a period of two years from 2021 to 2023 in a tertiary care hospital in North East India. The Acinetobacter isolates from ICU were included in the study, identified by conventional biochemical techniques and VITEK 2 Compact System (bioMérieux Inc., France). Antimicrobial susceptibility testing was performed using the Kirby‐Bauer disc diffusion method and Microbroth dilution method (for colistin).
Results
Among the total 625 Acinetobacter isolates, 234 were from the ICUs. The organism was mostly isolated from ET Tube Aspirate among the older age group with Acinetobacter baumanii being the most common species isolated. The infection in the ICUs are showing a rising trend. 75% and 70% of the isolates respectively were reported as MDR and XDR. All the isolates showed susceptibility in intermediate range for Colistin.
Discussion
Similar studies from India and other countries reported similar prevalence of Acinetobacter species in older age groups with Acinetobacter baumanii being the most common species isolated in all studies. Sengupta et al in a recent study reported 100 percent MDR and XDR rates among Acinetobacter species which is significantly higher than our study. High percentage of MDR and XDR isolates of Acinetobacter being reported from ICUs is a major concern which can only be overcome by strict implementation of Infection control practices under Antimicrobial Stewardship Programme.
References
1.Kumar S, Anwer R, Azzi A. Virulence Potential and Treatment Options of Multidrug-Resistant (MDR) Acinetobacter baumannii. Microorganisms. 2021 Oct 6;9(10):2104. doi: 10.3390/microorganisms9102104. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Sengupta M, Banerjee S. Sulbactam and Colistin Susceptibility Pattern Among Multidrug-Resistant Acinetobacter Isolates From Respiratory Samples. Cureus. 2022 Feb 1;14(2):e21802. doi: 10.7759/cureus.21802. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Mathur P, Malpiedi P, Walia K, et al. Health-care-associated bloodstream and urinary tract infections in a network of hospitals in India: a multicentre, hospital-based, prospective surveillance study. Lancet Glob Health. 2022;10(9):e1317–e1325. doi: 10.1016/S2214-109X(22)00274-1. [DOI] [PubMed] [Google Scholar]
As the largest demography in the world, INDIA is going to face a multitude of challenges and Health care is one among them. Most of the patients have various co-morbidities and poor activity of daily living with history of recurrent hospitalization. Care at the end of life is a holistic approach to look at “dignity of death” similar to its much emphasized brother “dignity of life. Considering the four core tenets of end-of-life care, appropriate communication with the patient's family is essential to providing the best possible care1. The treating team faces a number of challenges in decision making, thus family involvement is essential to the successful implementation of end-of-life care (EOLC)2. The present analysis is one among the few studies which has focused on assessment of family involvement in decision making during EOLC.
Objectives
To study the family perception and possible barriers in implementation of end of life care at a tertiary care hospital.
Materials and methods
A clinical profile questionnaire was attached to each institutional EOLC assessment form which included information regarding demography, educational qualification, and reason for EOLC, family / relative attitude and acceptance or denial of EOLC and time for acceptance after offering EOLC. Other data pertaining to bereavement was also documented.
Results
We collected 53 responses from the family of patients who were admitted to our ICU between Jan 2023 to Nov 2023 and were offered EOLC. Average APACHE score of these patients was 24.6. Of the 53 responses only 2 had expressed previous wishes about non escalation of care. (24.4%) 14 families accepted EOLC immediately. The predominant emotional reaction to EOLC was STOIC in nature (56.6%). 4.77%of families felt relieved after their kin was offered EOLC.14 families (7.4%) were upset on topic of EOLC. 46 families (86.7%) wanted to spend time at bedside. Average time to accept EOLC was approximately 1.5 days. Post death reaction was documented and 83% (n-44) responded with normal grief. Hospital was preferred place of death in majority (n-37, 69.8%) of the responses. 51% (n-27) of the patients passed away within 24 hrs of offering EOLC. 7(13%) patients were discharged home. No statistical significance was noted about number of children involved in decision making and acceptance of EOLC (p- value = 0.158). We also assessed whether a spouse being alive and taking part in decision making had any significance in decision making and found no statistical co-relation (p value=0.551).
Discussions
Majority of the families need time to accept End of life decisions (71.6%). 96% (n-51) families/patients did not have any standing directives or previous wishes about end of life decision making. Contrary to popular belief, majority of the family wanted to utilize the nursing care in the hospital during the final hours as compared to home care, which was similar in a study reported by Tang et al.3 Timely prognostication in terms of quality of life was one of the factors influencing acceptance of EOLC as concluded by kuriakose et al1.
References
1.Kuriakose CK, Chandiraseharan VK, John AO, Bal D, Jeyaseelan V, Sudarsanam TD. End-of-life decisions: A retrospective study in a tertiary care teaching hospital in India. Indian J Med Res. 2019 Dec;150(6):598–605. doi: 10.4103/ijmr.IJMR_1409_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Tang ST. When death is imminent: Where terminally ill patients with cancer prefer to die and why. Cancer Nurs. 2003;26:245–51. doi: 10.1097/00002820-200306000-00012. [DOI] [PubMed] [Google Scholar]
2Department of Infection Control and Epidemiology; Department of Medical Administration, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
1Department of Anaesthesia and Critical Care; Transplant Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, India
2Department of Infection Control and Epidemiology; Department of Medical Administration, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
3Department of Cardiology, Lisie Hospital, Kochi, Kerala, India
4Center of AI and Medicine, Amrita Hospital, Faridabad, Haryana, India
5School of AI, Amritapuri Campus, Amrita Vishwa Vidyapeetham, Kollam, Kerala, India
6Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
The first transplant games was organised by a transplant surgeon, Dr Maurice Slapak in 1978 in Portsmouth, UK. He opined that transplant games would be a major opportunity to showcase to the world how well the transplant recipients could rehabilitate and thereby counter the negativity against deceased donation and transplantation. Transplant games have subsequently been conducted regularly across the world.(1) Kochi hosted the Transplant games for the first time on 9 December 2023.(2) It was an event for transplant recipients and living organ donors and families of deceased donors.
Objective
To study the sporting journey of the participants at the Transplant games.
Methods
After obtaining the necessary approval, we created a questionnaire (English and Malayalam) that included basic demographic details, including transplant and the sporting behaviour of the participants. Electronic questionnaire accessible through a QR code and hard copies were displayed at one of the three venues of the games. Participants at the games were informed about the objective of the questionnaire and encouraged to participate. The questionnaire was made available for a total of 5 hours during the games.
Results
Among the 78 respondents, 9 (11.5%) withdrew consent. Among the 69 participants who completed the questionnaire, 59 were males (85.5%) and 10 (14.5%) were females. Transplant recipients were 53/69, of which 6 were females. This included 3 heart, 26 kidney, 22 liver and 2 kidney-pancreas recipients. All the participants were Indians, only 2 from outside Kerala. The average age of the participants were 45+13 years. The transplant recipients had an average age of 40.7+12.6 years at the time of transplant. A third didnot participate in sports before their surgery. Self-motivation was the main reason to take up sports for 44.4% of the responders, followed by family and friends in 36%. Liver Federation of Kerala (Lifok), a self-help group of transplant recipients played a major role in 10% of the patients. Interestingly, doctors were poor in encouraging patients to take up sports. Not surprisingly, donors started to take active role in sports earlier than recipients, 3.1+1.89 vs 5.7+5.5 months. The most common reason sited to take up sports was to become part of the transplant community, followed by a desire to embrace a healthier lifestyle and improve fitness level. 62% recipients and 73% donors received advice regarding exercise after surgery- mostly from nutritionist and physiotherapists. While none had a personalised coach, most intensified their training and improved nutrition as part of their preparation for the games. Most recipients and donors were able to train 1-3 days a week for atleast 30 minutes, with 20% recipients training for 6-7 days/week. 60% recipients feel confident that they can train with the same intensity as the other people. One person (donor) regretted having undergone the surgery.
Discussion
Although the survey was conducted on self-selected motivated participants of the transplant games, we gained useful insights. Many take up sports after surgery, with family and self-help groups providing significant motivation. Most transplant recipients expressed confidence in being on par with non-transplanted individuals in their ability to train.
References
1.The Effect of The World Transplant Games on Transplant Rates In Five Continents. Slapak M. ANNALS OF TRANSPLANTATION. 2004;Vol. 9(No. 1):46–50. pp. [PubMed] [Google Scholar]
Retrospective Analysis Of Carbapenem-Resistant Gram-Negative Bacteria In Respiratory Samples Of Icu Patient In A Tertiary Care Hospital In Northwest India
Carbapenem resistance bacteria have become a major public health threat globally; therefore, its monitoring is crucial in efforts to halt rapidly increasing antimicrobial resistance. Despite efforts to limit their spread, rates of multidrug resistant organisms continue to increase throughout the world causing increased morbidity and mortality and raised costs of medical care.
Objective
To identify Carbapenem resistance among Gram Negative bacteria and determine its prevalence.
Materials and methods
We did a retrospective analysis of respiratory samples sent from adult ICU for prevalence of carbapenem resistance using VITEK for Microbial Identification and Antibiotic Sensitivity Testing (AST) of bacteria, and CARBA-R gene Xpert Gene resistance typing was done by, from a period of June 2022 to September 2023.
Result
Out of 1000 samples tested over a period of 16 months for Gram's stain and Antibiotic sensitivity test (AST), 859 were gram negative organisms. Only 115 (13.38 %) of them showed sensitivity to carbapenem group of drugs, 85.62 % of organisms were resistant to carbapenems. The following four bacteria constituted 90.9 % of the total isolates (781 samples out of 859). Klebsiella group (355 samples- 9.57% Sensitive to Carbapenem), Acinetobacter (265 – 1.88% Stv), Pseudomonas (115-29.4% Stv) and E.Coli (46- 41.3% Stv). 23 samples of Klebsiella were tested by CARBA-R gene testing for carbapenem resistant carbapenemases and 20 samples showed NDM, 14 showed OXA-48, KPC and VIM one each (few samples had both NDM and OXA-48). Being a Tertiary care Hospital, this also included samples which were sent on Day 1 of admission both from Intubated and Non-Intubated patients.
Discussion
The picture of increasing carbapenem resistance among the gram-negative bacteria, warrants a multimodal approach both to identify the organism at the earliest by use of latest techniques which fastens the process from the conventional 72 hrs, keeping always in mind the clinical picture of the patient being treated, to identify the gene resistance pattern and to judiciously select antimicrobials for their treatment. Based on the gene resistance patterns, the specific antimicrobial therapy could be used and this will fasten recovery and bacterial clearance. Carbapenems for treatment should be used with caution as per the institutional resistance patterns. All these will require a further detail research for organism if it's community or hospital acquired, type of gene resistance, directed treatment, effect of intervention on mortality plus a cost-benefit analysis where we use tests e.g. gene resistance analysis, Biofire panel and Sepsis flow (helping early identification of the organism with short turn around time but added cost).
References
1.Gondal A.J, Choudhry N, Bukhari H, Rizvi Z, Jahan S, Yasmin N. Estimation, Evaluation and Characterization of Carbapenem Resistance Burden from a Tertiary Care Hospital, Pakistan. Antibiotics. 2023;12:525. doi: 10.3390/antibiotics12030525. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Thomas Namitha, Sarwat Tarana. Prevalence of Carbapenem Resistant Enterobacteriaceae in A Tertiary Care Hospital. Int. J. Curr. Microbiol. App. Sci. 2019;8(11):1418–1424. doi: 10.20546/ijcmas.2019.811.166. [DOI] [Google Scholar]
Road Traffic Accidents are one of the most common condition presenting in any Emergency department and are one of the most common causes of morbidity and mortality owing to the different types of vehicles, alcohol intoxication, seasonal variations.
Objective
To study the incidence, demographics as well as epidemiological characterstics of road traffic accidents in a tertiary care hospital in North Maharashtra.
To Study
– Variations in road traffic accidents according to gender
– Variations in type of Trauma
– Seasonal variations in road traffic accidents
Materials and methods
A retrospective study was conducted in a tertiary care hospital in North Maharashtra from the month of November 2022 to October 2023. In our study, Males and females above 18 years of age have been included, 1060 Trauma cases were encountered by males and 222 were encountered by females. Data was collected from the medical records department of the hospital.
Results
Total number of trauma cases in males encountered in the Year November 2022 to October 2023 was 1060, out of which
60.84 % were Head Trauma
6.41% were Polytrauma and 31.98% were others including abdominal Trauma, Thoracic Trauma, Orthopaedic Trauma.
Total number of trauma cases encountered by females from November 2022 to October 2023 were 222
Out of which
54.08 percent were head trauma cases
13.51 percent were Polytrauma cases
32.88 percent were others including abdominal trauma, thoracic trauma and orthopaedic trauma.
Conclusions Drawn from the Above Study:
Gender – Greater number of trauma cases are encountered by the male population as compared to females.
Type of trauma – Head Trauma constitutes to Maximum cases of trauma encountered.
Seasonal variation – Maximum number of cases in both males and females have been observed in the months May, June, July – Mid summer and Monsoon Months.
In the above retrospective study, it has been observed that
In Winter season – Number of trauma cases encountered are relatively less
There is an inclining trend in the cases from Winter to summer and Monsoon, beclearly seen from the graphical representation given above; in both males and females; Maximum number of cases encountered in the month of MAY by Males. Maximum number of cases encountered by females in the month of JUNE. It is important to conclude that Road traffic accidents are important causes of morbidity and mortality and should be dealt with utmost care by the Emergency department. With the help of the above study we can prepare ourselves according to various seasons well in advance and be adequately equipped to manage road traffic accidents.
Primary source of data was the medical records department of the hospital.
Reference
1.Abhilash KP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. Journal of family medicine and primary care. 2016 Jul;5(3):558. doi: 10.4103/2249-4863.197279. [DOI] [PMC free article] [PubMed] [Google Scholar]
In recent years, a rise in resistance to β-lactam drugs has been noticed because of the Extended Spectrum β-Lactamases (ESBLs) and Metallo-β-Lactamases (MBLs) enzymes, which hydrolyze most of the β-lactam antibiotics. Combination therapies must be developed that could be used empirically in critically ill patients to ensure clinical cure and safety.
Objective
To study the efficacy and safety of ceftriaxone sulbactam EDTA (CSE) in patients with VAP/BSI/UTI.
Materials and methods
This was a retrospective, single-centre study. In this study, all adult (≥18 to 60 years of age, inclusive) patients who have VAP, BSI, or UTI and received CSE 3 gm twice daily were enrolled. The primary endpoint was 28-day all-cause mortality.
Results
A total of 24 patients were enrolled in this study, out of which 17 (71%) were male and 7 (29%) were female, with an average age of 63.8 ± 14.6 years. The presence of any co-morbid condition was reported in 20 (83.3%) of subjects. Hypertension (67%), diabetes mellitus (46%), and ischemic heart disease (33%) were the most reported co-morbid conditions. Amongst all infections, blood infection was most common, reported by 11 (46%) of the patients, followed by UTI, respiratory, and abdominal infections by 25%, 21%, and 13%, respectively. In vitro antibiotic susceptibility testing results indicate that out of 24 samples, 17 (71%) were sensitive, 2 (8.3%) were intermediate, and 3 (12.5%) were resistant to CSE. Monotherapy with CSE was prescribed to 5 subjects; 4 patients received CSE 3 g, and 1 subject received CSE 1.5 g. 19 subjects received combination therapy. The clinical success rate was 75%. The average days of symptom resolution were 12.6 ± 11 days. Microbiological cure was reported for 54.16% of patients, and the average days of microbiological eradication from the initiation of treatment were 13.8 ± 12.6 days. The average days of hospitalisation were 21.4 ± 13.6 days. Mortality was reported for 5 (20.8%) patients.
Conclusion
Combination therapy with CSE has shown good bacteriological and clinical efficacy. It was well tolerated. It can be a useful antibiotic in the management of VAP/BSI, and UTI.
Keywords
Ceftriaxone Sulbactam and EDTA, MDR, VAP/BSI, UTI
References
1.Shameem M, Mir M. A. Management of pneumonia and blood stream infections with new antibiotic adjuvant entity (Ceftriaxone+ Sulbactam+ Disodium Edetate)-A novel way to spare carbapenems. Journal of Clinical and Diagnostic Research: JCDR. 2016;10(12):LC23. doi: 10.7860/JCDR/2016/20904.9014. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Chakravorty S, Arun P. Antibiotic/adjuvant combinations (ceftriaxone+ sulbactam+ adjuvant disodium edetate) as an alternative empiric therapy for the treatment of nosocomial infections: results of a retrospective study. Indian Journal of Cancer. 2017;54(4):685. doi: 10.4103/ijc.IJC_364_17. [DOI] [PubMed] [Google Scholar]
Aminoglycosides are broad spectrum antibiotics which act through inhibition of protein synthesis. Aminoglycosides are widely used for the treatment of gram-negative and mycobacterial infections. However, nephrotoxicity is commonly reported side effect with aminoglycoside.
Objectives
The objective of this survey was to understand the physician's perceptions on the usage pattern of Aminoglycoside in the management of various infections including CRE infections and its safety.
Materials and methods
This was a cross-sectional survey of physicians across India. A structured, self-reported survey questionnaire was developed. The survey responses were captured by providing multiple choices for the respective questions.
Results
For this survey, a total of 78 critical care specialists were agreed to participate in this survey. In this survey, 78% of physicians reported Amikacin as a widely used aminoglycoside in their clinical practice, out of which 56% of physicians are using for complicated urinary tract infections (cUTI), 28% for Hospital-acquired pneumonia (HAP)/Ventilator-associated pneumonia (VAP) and 9% for bloodstream infection (BSI) in their regular clinical practice. 77% of physicians are using Amikacin to treat cUTI caused by Carbapenem-Resistant Enterobacteriaceae (CRE). The Amikacin susceptibility rate for Carbapenem Resistant Enterobacteriaceae (CRE) CR E. coli in physicians’ clinical practice varied from zero to more than 60%. The Amikacin susceptibility rate for CR E. coli was reported to between 0-20% by 18% of physicians, 21-40% by 23% of physicians, 40-60% by 21% of physicians and more than 60% by 21% of physicians. The Amikacin susceptibility rate for CR K. pneumoniae in physicians’ clinical practice varied from zero to more than 60%. The Amikacin susceptibility rate for CR K. pneumoniae was reported to be between 0-20% by 29% of physicians, 21-40% by 17% of physicians, 40-60% by 14% of physicians and more than 60% by 16% of physicians. The nephrotoxicity rate with IV Amikacin was reported to be up to 10% by 31% of physicians, 10-20% by 26% of physicians, 20-30% by 26% of physicians, 30-40% by 10% of physicians and more than 40% by 8% of physicians. Amikacin was recommended to be used in combination treatment of CRE infections, 31% of physicians recommend the use of Polymyxin B in combination with Amikacin, 17% recommend Colistin, 14% recommend Piperacillin/tazobactam, 13% recommend Fosfomycin, 10% recommend Ceftazidime Avibactam, 5% recommend Ceftriaxone sulbactam EDTA, 1% recommend Tigecycline and 9% recommend other antibiotics.
Conclusion
The survey results showed that Amikacin is the most commonly used aminoglycoside by majority of the physicians in their clinical practice for the treatment of cUTI and HAP/VAP. Most of the physicians are using Amikacin to treat cUTI caused by CRE. The Amikacin susceptibility rate was reported to be higher for CR E. coli than CR K. pneumoniae by most of the physicians. The nephrotoxicity rate with IV Amikacin was found to be 10% by majority of the physicians. Polymyxin B was widely used in combination with amikacin to treat CRE infections.
References
1.Krause K. M, Serio A. W, Kane T. R, Connolly L. E. Aminoglycosides: an overview. Cold Spring Harbor perspectives in medicine. 2016;6(6) doi: 10.1101/cshperspect.a027029. [DOI] [PMC free article] [PubMed] [Google Scholar]
Hanging is one of the most common modes of deliberate self harm1. Early intervention and aggressive resuscitation decreases the mortality and also long term morbidity including persistent neurological deficit and length of ICU/hospital stay.
Objectives
To study the clinical profile and outcome of the patients presenting with attempted hanging.
Materials and methods
A Retrospective descriptive study was done on patients getting admitted with history of hanging between Jan 2014 -May 2023 to Cauvery Heart and Multispeciality Hospital, Mysore.
Results
Out of 970 cases of DSH during the study period 61(6.2%) were due to attempted hanging. The mean age was 31.5 years and the majority (60%)were female. 5 of them (8.2%) had a known psychiatric illness and 5 patients were under the influence of alcohol at the time of the incident. Average time of arrival to hospital following hanging was 75 minutes. 22 patients received some care outside before admission. Altered sensorium and signs of cortical irritation was the most common presentation seen in 53 patients with 40 of them also having decerebrating posture on admission. Seizures was seen in 5 patients. On admission 49 patients were having Hypoxia (Spo2<94%) whereas 9 patients were in shock. 47 patients were intubated and initiated on ventilatory support with low GCS or cortical irritation being the most common indication followed by severe hypoxia with/without aspiration. All except 2 patients were discharged to home with a mortality rate of 3.2%. The average duration of mechanical ventilation was 3.3 days and ICU stay was 4.5 days. 41 patients had f/s/o aspiration out of which antibiotics were needed for 282 patients. The average length of hospital stay was 5.7days. Neurological recovery and presence of any significant deficits were measured by Glasgow outcome scale extended (GOSE) which was measured before discharge, one week after discharge and at the end of one month.90% of the patients had a score of 8 at the time of discharge and could get back to their profession or vocation by one weeks time.9% of patients had GOSE of 7 at discharge with all of them having recovered fully within weeks time.only 1patient had significant deficit with a GOSE of 3 even at the end of month.
Discussions
Hanging is still a major mode of deliberate self-harm in India in both men and women predominantly in the socially and economically productive age group1. The in hospital mortality of patients with hanging varies from 2.6% - 20% from studies reported across the globe1, 2 with Severe refractory hypoxia as predominant causes of mortality2. Early intubation and institution of mechanical ventilation with supportive Antiedema measures not only increases survival but also reduces the chances of eventual persistent neurological deficits as assessed by GOSE and reduces overall hospital stay.
References
1.Ganesan P, Jegaraj MKA, Kumar S, Yadav B, Selva B, Tharmaraj RGA. Profile and Outcome of Near-hanging Patients Presenting to Emergency Department in a Tertiary Care Hospital in South India - A Retrospective Descriptive Study. Indian J Psychol Med. 2018 May-Jun;40(3):205–209. doi: 10.4103/IJPSYM.IJPSYM_282_17. 29875525;PMC5968639 [DOI] [PMC free article] [PubMed] [Google Scholar]
Impact of Demographic and Clinical Charecteristics on Survival Outcomes of Severe Influenza Virus Infection in Icu Patients – A Retrospective Observational Study
1Department of Critical Care Medicine, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University, Dharwad, Karnataka, India, Phone: +91 9499032346, e-mail: gunavathy2010@gmail.com
2–5Department of Critical Care Medicine, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University Dharwad, Karnataka, India
2–5Department of Critical Care Medicine, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University Dharwad, Karnataka, India
2–5Department of Critical Care Medicine, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University Dharwad, Karnataka, India
2–5Department of Critical Care Medicine, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University Dharwad, Karnataka, India
6Department of Hospital Administrationn, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University, Dharwad, Karnataka, India
1Department of Critical Care Medicine, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University, Dharwad, Karnataka, India, Phone: +91 9499032346, e-mail: gunavathy2010@gmail.com
2–5Department of Critical Care Medicine, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University Dharwad, Karnataka, India
6Department of Hospital Administrationn, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University, Dharwad, Karnataka, India
7Department of Microbiology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheswara University, Dharwad, Karnataka, India
Influenza viral infection is often mild in some patients while proven fatal in 24 hours. Although, prevalence is among elderly population and patients with underlying comorbidities, a few cases of ARDS have been reported in immunocompetent patients.
Objectives
To observe disease severity, demographic, clinical-profile, CT-findings, outcome of 20 patients admitted to ICU between 01/09/2023 and 31/10/2023 and elucidate their impact on survival outcomes.
Materials and methods
We included patients with severe influenza community acquired pneumonia (CAP) infection requiring ICU admission in a tertiary care hospital in Dharwad. All diagnosed with positive PCR test for Influenza virus and admitted to ICU between 01/09/2023 and 31/10/2023 were included. We excluded patients with mild symptoms and incidental positive. This study was approved by the Institutional Ethics Committee (IEC).
Results
Out of total 66 cases which were influenza positive, 30% of patients having severe CAP (n = 20, 70% males and 30% females, mean = 49. 5years) were being admitted to ICU. The mean length of hospital stay was approximately 19 days(SD = 13) and mean length of ICU stay was 16 days(SD = 11). Duration of symptoms being (mean ± SD, 3.95 ± 1.35) days. Initial respiratory support was NIV (n = 12), Intubated (n = 3), HFNC (n = 1) and NRBM (n = 4). 95% (n = 19) were intubated within 12 hours of presentation. In this group (n = 20), 72.68 %(n = 14) had P/F ratio less than 100, (87.50 ± 32.35), 70%(n = 14) had both severe hypoxia and hypercapnia (mean pH/mean pCO2, 7.14 ± 0.05/72 ± 14.85 mmHg) and their dynamic lung compliance was less than 19cmH2o, (11.45 ± 2.73). Radiological findings were centrilobular nodules(n = 11), ground glass opacity(n = 17) with crazy paving pattern (n = 5), lower lobe or peripheral consolidation (n = 12). 19 intubated patients, 15 required prone ventilation 2- 8 cycle (2.6 ± 2.5). The comorbidities identified were Diabetes Mellitus(n = 7), Hypertension(n = 7), OSA (n = 1), Hypothyroidism(n = 2). 70% (n = 14) patients developed AK. 40%(n = 9) had developed shock/acute Cor Pulmonale and were identified for ECMO therapy, VV- ECMO was established in (n = 3) refractory hypoxemia patients, Of 3 patients, one survived. Hybrid VVA-ECMO therapy (n = 1, male, 31 years, nil comorbidities, duration 24 hours) in refractory ARDS, severe LV dysfunction. Of 9 expired patients (45%), died of severe ARDS (n = 3), Severe ARDs with refractory shock (n = 4) (mean ICU Days = 1.2 days), secondary HLH with MODS (n = 1), and Massive UGI bleed with Intestinal mucormycosis (n = 1). For descriptive statistics, we used SPSS version-20. The overall impact of various demographic variables on disease outcome (survival and mortality), was being investigated using Linear Regression. The significant factors affecting the survival outcome were found to be type of Influenza (p = 0.04), Diabetes Mellitus(p = 0.09), Days-of-symptoms before ICU-admission(p = 0.06), length of ICU stay for patients with AKI(p = 0.01), Recovery from AKI(p<0.005), Procalcitonin(p = 0.09), P/F Ratio on arrival to ICU(p = 0.09), Ground-glass opacity (GGOS)(p = 0.09).
Discussion
The most significant factors affecting the survival outcome of patients were found to be type of Influenza, length of ICU stay for patients with AKI, Recovery from AKI. Limitations of this study are- it is single-centric retrospective study and sample size is limited.
References
1.Watson A, Beecham R, Grocott MP, Saeed K, Dushianthan A. Severe Parainfluenza Viral Infection—A Retrospective Study of Adult Intensive Care Patients. Journal of Clinical Medicine. 2023 Nov 15;12(22):7106. doi: 10.3390/jcm12227106. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Teng F, Liu X, Guo SB, Li Z, Ji WQ, Zhang F, Zhu XM. Community-acquired bacterial co-infection predicts severity and mortality in influenza-associated pneumonia admitted patients. Journal of infection and chemotherapy. 2019 Feb 1;25(2):129–36. doi: 10.1016/j.jiac.2018.10.014. [DOI] [PubMed] [Google Scholar]
3.Cavallazzi R, Ramirez JA. Influenza and viral pneumonia. Clinics in chest medicine. 2018 Dec 1;39(4):703–21. doi: 10.1016/j.ccm.2018.07.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Oliveira EC, Marik PE, Colice G. Influenza pneumonia: a descriptive study. Chest. 2001 Jun 1;119(6):1717–23. doi: 10.1378/chest.119.6.1717. [DOI] [PubMed] [Google Scholar]
Acute kidney injury (AKI) complicates the course of disease of 30-57% of critically ill patients and 40.7 % of patients are due to sepsis(1, 2). It is associated with increased morbidity mortality and higher hospitalisation costs(3). The usual markers for aki i.e urine output and serum creatinine are usually less sensitive and neither predict the course nor the helps in early detection of aki(4). The other biomarkers that are used in aki are costly to perform and are poorly sensitive for the early detection of aki(4). Sepsis induced AKI is primarily caused by intrinsic vascular dysfunction of the kidneys(5). Renal resistive index (RRI) is a measure of the intrinsic haemodynamics in the kidneys. Previous studies have shown the ability of rri to successfully predict the occurrence of AKI in patients with sepsis.(1, 6, 7) In this study we aim to find the ability of RRI to predict requirement of haemodialysis in patients with sepsis.
Methods
50 patients were randomly included in the study who were diagnosed with sepsis (SEPSIS 3 criteria)and had developed AKI (KDIGO criteria). RRI was measured at admission, 24 hours and 48 hours. Vasopressor requirement, cumulative fluid balance were also recorded for each patient on each day. Patients were followed up till discharge and till 90 days from admission.
Results
Multivariate regression analysis was done and RRI was found to be an independent predictor for haemodialysis (p<0.05). RRI was also found to be and independent predictor of mortality. (p<0.01).Conclusion: Renal resistive index is an independent predictor for haemodialysis in adult patients with sepsis.
References
1.Haitsma Mulier JL, Rozemeijer S, Röttgering JG, Spoelstra-de Man AM, Elbers PW, Tuinman PR, de Waard MC, Oudemans-van Straaten HM. Renal resistive index as an early predictor and discriminator of acute kidney injury in critically ill patients; A prospective observational cohort study. PloS one. 2018 Jun 11;13(6):e0197967. doi: 10.1371/journal.pone.0197967. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, Edipidis K, Forni LG, Gomersall CD, Govil D, Honoré PM. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive care medicine. 2015 Aug;41:1411–23. doi: 10.1007/s00134-015-3934-7. [DOI] [PubMed] [Google Scholar]
3.Nour IA, Eldehily KI, Abd Elbaset AS, Saber HM. Renal resistive index as a predictor of hemodialysis and mortality risk in septic patients developing acute kidney injury. Research and Opinion in Anesthesia & Intensive Care. 2023 Jan 1;10(1):40–5. [Google Scholar]
4.Fu Y, He C, Jia L, Ge C, Long L, Bai Y, Zhang N, Du Q, Shen L, Zhao H. Performance of the renal resistive index and usual clinical indicators in predicting persistent AKI. Renal Failure. 2022 Dec 31;44(1):2038–48. doi: 10.1080/0886022X.2022.2147437. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Gomez H, Ince C, de Backer D, Pickkers P, Payen D, Hotchkiss J, Kellum JA. A unified theory of sepsis-induced acute kidney injury: inflammation, microcirculatory dysfunction, bioenergetics and the tubular cell adaptation to injury. Shock (Augusta, Ga.) 2014 Jan;41(1):3. doi: 10.1097/SHK.0000000000000052. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Zhu J, Zhang Y, Li X, Li Q, Luo Y. Doppler-based renal resistive index for prediction of acute kidney injury in critically ill patients: a systematic review and meta-analysis. ADVANCED ULTRASOUND IN DIAGNOSIS AND THERAPY. 2021 Aug 31;5(3):183–96. [Google Scholar]
7.Yu A, Zhao Q, Qu Y, Liu G. Renal Doppler Ultrasound in the Evaluation of Renal Function in Patients with Sepsis. Applied Bionics and Biomechanics. 2022 Apr 26:2022. doi: 10.1155/2022/3472405. [DOI] [PMC free article] [PubMed] [Google Scholar] [Retracted]
Sepsis is a life-threatening condition caused by a dysregulated host response to infection, resulting in organ dysfunction. This study is done in patients who fulfil the criteria of sepsis (suspected or documented infection and an acute increase of ≥ 2 sofa points) and septic shock (sepsis and vasopressor therapy needed to evaluate MAP ≥ 65mmhg and lactate >2mmol despite adequate fluid resuscitation) as per sepsis-3 definition.
Objectives
Primary objective: To determine the correlation between serum LDH and serum lactate in patients with sepsis and septic shock.
Secondary objectives:
To determine the length of stay in ICU
To determine need of vasopressors and/or inotropes
Materials and methods
This is an interim analysis of our study. Right now, we have done analysis of 44 patients. It is a prospective observational study that will be conducted at Citizens Specialty Hospitals. Sample Size – Based on alpha error – 0.05, beta error – 0.2 and expected correlation coefficient of 0.3 the calculated sample size is 85 but we consider to take the sample size of 100. In all the patients admitted to the ICU who fulfill the criteria of sepsis and septic shock as per sepsis-3 definition, baseline demographic data, APACHE II at baseline and 48hours, and daily sofa scores are noted. Serum LDH levels are done every day at fixed hour through the venous sample in the laboratory by chemical method till the patient is discharged from the icu or till the death of the patient. Serum lactate levels are done every day through the arterial sample in the icu through point of care till the patient is discharged or till the death of the patient. Daily sofa scores, p/f ratio, need for NIV, need for mechanical ventilator, need for RRT are noted till the patients are discharged from the icu or till the death of the patients. The patients will be observed until the time of icu discharge or till the death. Mortality rate, Standardized mortality ratio and length of ICU stay are calculated.
Results
Table 1 shows the trend of LDH and lactate in our study. We found that the mean LDH and mean lactate decreased over days significantly (p<0.05). Table 2 shows the correlation of LDH and lactate in our study. We found that LDH was significantly correlated with lactate on all 5 days and also found that the correlation coefficient increased over days (p<0.05). Table 3 shows the correlation of LDH/lactate ratio in survivors vs non-survivors in our study. We found that LDH/lactate ratio was significantly correlated till 4 days and also found that the correlation coefficient increased over days (p<0.05).
Trend of mean serum lactate day-wise among survivors and non-survivors
Discussions
The presence of an elevated serum lactate level is strongly associated with morbidity and mortality in diverse populations of critically ill patients1. Clinically, serum lactate is a potentially useful biomarker to risk-stratify patients with severe sepsis presenting to the emergency department (ED)2, 3. In sepsis, elevated serum lactate level may be due to either impaired lactate clearance or excessive production.4, 5 The LDH may catalyze the conversion of pyruvate to lactate, which is the final step of aerobic glycolysis. Serum LDH was reported as a predictive marker in many conditions and diseases such as sepsis, infection, acute myocardial infarction, cirrhosis, and malignancies6–8 Nevertheless, the definite relationship between LDH, which is a dehydrogenase enzyme during the course of aerobic glycolysis, and accumulation of lactate, as well as mortality in patients with sepsis has not been reported yet. In our study, we found that as LDH raises, chance of survival is low and mortality is high. Early rise in LDH/Lactate ratio is a mortality indicator.
References
1.Manikis P, Jankowski S, Zhang H, et al. Correlation of serial blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med. 1995;13:619–622. doi: 10.1016/0735-6757(95)90043-8. [DOI] [PubMed] [Google Scholar]
2.Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med. 2004;32:1637–1642 9. doi: 10.1097/01.ccm.0000132904.35713.a7. [DOI] [PubMed] [Google Scholar]
3.Shapiro NI, Howell MD, Talmor D, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med. 2005;45:524–528. doi: 10.1016/j.annemergmed.2004.12.006. [DOI] [PubMed] [Google Scholar]
4.Levraut J, Ciebiera JP, Chave S, et al. Mild hyperlactatemia in stable septic patients is due to impaired lactate clearance rather than overproduction. Am J Respir Crit Care Med. 1998;151:1021–1026 13. doi: 10.1164/ajrccm.157.4.9705037. [DOI] [PubMed] [Google Scholar]
5.Revelly JP, Tappy L, Martinez A, et al. Lactate and glucose metabolism in severe sepsis and cardiogenic shock. Crit Care Med. 2005;33:2235–2240 14. doi: 10.1097/01.ccm.0000181525.99295.8f. [DOI] [PubMed] [Google Scholar]
6.Li H, Xiong W, Liu H, et al. Serum LDH level may predict outcome of chronic lymphocytic leukemia patients with a 17p deletion: a retrospective analysis of prognostic factors in China. Chin J Cancer Res. 2017;29:156e165. doi: 10.21147/j.issn.1000-9604.2017.02.09. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Marmorino F, Salvatore L, Barbara C, et al. Serum LDH predicts benefit from bevacizumab beyond progression in metastatic colorectal cancer. Br J Cancer. 2017;116:318e323. doi: 10.1038/bjc.2016.413. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Terragni R, Morselli-Labate AM, Vignoli M, et al. Is serum total LDH evaluation able to differentiate between alimentary lymphoma and inflammatory bowel disease in a real world clinical setting? PLoS One. 2016;11:e0151641. doi: 10.1371/journal.pone.0151641. [DOI] [PMC free article] [PubMed] [Google Scholar]
Prognostic Factors Associated with Mortality in Critically Ill Patients with COVID-19 Admitted to A Tertiary Care Centre: A Prospective Observational Study
COVID-19 is an infectious disease caused by SARS-CoV-2 virus which has affected millions of people worldwide. Most cases present with mild symptoms with a minority progressing to severe illness1. Prognostic factors help to stratify patients based on their risk of severe disease or death and helps in optimizing management and resource utilization strategies. Various factors were previously assessed but factors like the effect of oxygen therapy, total dose of steroids, ventilation strategies, effect of glycemic status and hospital acquired infections on outcomes were not evaluated in our local population2.
Objectives
Primary objective was to identify factors (clinical and biochemical markers) associated with in-hospital all-cause mortality. Secondary objectives were to identify factors associated with length of ICU stay, length of hospital stay and duration of invasive mechanical ventilation.
Materials and methods
This study was conducted as a prospective observational study over a period of 11 months at Iqraa International Hospital and Research Centre. Critically ill adult patients of either sex who tested positive for SARS-CoV-2 virus by RTPCR/RAT were included in the study. Patients received from another hospital on mechanical ventilation, those expected to survive for <24 hours and those who have received treatment from another hospital for >24 hours were excluded. Data were collected on demographics, comorbidities, medications received including steroids, oxygen support and delivery devices, admission severity scores, laboratory and radiological parameters and clinical outcomes. Data were collected on the day of admission, on the day of discharge from ICU and on the day of discharge from hospital or in-hospital death.
Results
A total of 90 patients were included in the study of which 66.7% were males and 58.9% were of age > 60 years. 82.2% became antigen negative with duration of antigen conversion ranging from 10-41 days. 33% of patients required invasive mechanical ventilation. Oxygen delivery index ranged from 20-444. 10% of patients underwent tracheostomy. 46.6% required hemodynamic support for at least one day. All patients received steroids with prednisolone equivalent steroid days ranging from 64-4169. 57% patients had at least one HAI. 32.2% of patients had oxygen dependency at discharge. Of the 90 patients, 34.4% had in-hospital mortality. After logistic regression analysis, requirement of hemodynamic support for at least one day, at least one airway manipulation and presence of at least one ventilator day was found to be associated with mortality. The presence of at least one HAI and a prednisolone equivalent steroid day of >1000 was found to be associated with a prolonged ICU length of stay (>10 days) and prolonged hospital length of stay (>15 days). The presence of at least one HAI was also found to be associated with increased duration of mechanical ventilation (>48 hours).
Discussions
The in-hospital mortality rate in our study was 34.4%. The requirement of at least one ventilator day, at least one hemodynamic support day and at least one airway manipulation was found to be significantly associated with mortality. Oxygen delivery index and prednisolone equivalent steroid days were not found to be significantly associated with mortality. The incidence of HAI was higher in this population with 57% patients having at least one HAI. The presence of at least one HAI was associated with increased duration of ICU stay, hospital stay and mechanical ventilation duration.
Major complication after aneurysmal subarachnoid (aSAH) is the occurrence of cerebral vasospasm (CVS) which can significantly increase the disability. The risk of cerebral vasospasm begins around day 3 and peaks around day 7 to 10. Digital subtraction (DSA)is the gold standard for diagnosis of CVS, but it cannot be applied repeatedly to patients due to its invasive nature, cannot be used to observe cerebral blood flow. So, application of DSA is limited. Trans cranial color doppler (TCCD) is novel, noninvasive technique with advantages of low cost, reported high reliability. TCCD can be used to monitor cerebral blood flow, so as to determine the change in vascular caliber and identify the onset of CVS.
Objective
To identify the presence of CVS among the aSAH patient using TCCD by observing the changes in the mean flow velocity(MFV) and Lindegaard ratio(LR) in Middle cerebral artery (MCA) at different time periods.
Material and methods
An observational study was conducted between May 2021 to December 2023 involving total of 60 subjects with diagnosis of MCA aSAH confirmed by DSA admitted in neurosurgical ICU at KIMS hospital, secunderabad among age group 30-70 years, comorbid conditions, WFNS scoring, fishers grading was noted on the day of admission were noted. MFV and LR were noted daily from day of admission till day 10 by TCCD.
Results
Mean age of the subjects was 51.9 years, 76.7% were males, 23.3% were females. The difference came out to be nonsignificant (p = 0.44) 51% were hypertensive, 33% had diabetes. Sensitivity of MFV was 100%, specificity was 65% in predicting the symptoms during hospitalizations. AUC was 0.83 for MFV which supported our finding that MFV predictive capacity is very good. LR sensitivity was 100%, specificity (76.6%) AUC was 0.88 showing near same efficacy as MFV.
Conclusion
MFV and LR could be promoted as predictive parameters in SAH patients for early institution of treatment, but caution should be executed in doing so as our small size is small and we need more evidence is awaited in this topic to validate the observed findings in the present study.
Comparison of Helmet vs Face Mask Interface for Non-invasive Ventilation (NIV) in Patients of Acute Cardiogenic Pulmonary Ssoedema (Acpe): A Randomized Control Trial
Noninvasive ventilation (NIV) has been widely used in the treatment of Acute Cardiogenic Pulmonary Edema (ACPE). Different studies have used various interfaces for giving NIV. Helmet interface for delivering NIV is promising as it confers several advantages like being patient friendly, less air leaks and minimal skin lesions. This leads to improved patient tolerance allowing it to be used for longer duration.
Methods
This was a prospective randomized controlled trial approved by Institutional Ethical Committee. Seventy adults (18-80 yrs) with acute hypoxemic respiratory failure were included in the study. Patients with Chronic obstructive pulmonary disease (COPD), bronchial asthma, ARDS (Acute Respiratory Distress Syndrome), Community Acquired pneumonia (CAP), Hospital Acquired pneumonia (HAP), drowsiness, unconsciousness and uncooperative behavior were excluded from participation in the study. Patients were randomly allocated into two groups of 35 each. Group H were given Helmet NIV and Group F were administered NIV with the help of face mask. HACOR score4 was used to predict NIV failure. Those with a score of >/= 6 for more than 2 hours of maximal NIV support in both groups, were considered as NIV failure and placed on mechanical ventilation. EPAP & IPAP was adjusted according to PaO2 and PaCO2 respectively. PaO2 and PCO2 of both groups were compared before and after 24 hours of NIV. Complications during NIV were observed Statistical comparison was made between groups by applying chi-square test to a contingency table and two ANOVA was applied.
Results
Average duration of NIV in both the groups was 36 hrs. NIV failure was observed in 8 patients in face mask group (22.5%) whereas none of the patients in helmet group had failure. (p=0.001). Other complications like claustrophobia (25.7% patients in Group F v/s 0 in Group H), nose/neck ulcer 8.5% in Group F v/s 2 % in Group H) were also significantly less in Group H (p < 0.05). The mean improvement in pO2 and pO2/fiO2 ratio was similar in both the groups whereas decline in pCO2 (p=.128). The decline in PCO2 in Group H was higher (21.771 mmHg) as compare to Group F (p=19.257).
Discussion
Helmet NIV delivers higher PEEP, which helps in maintain acceptable gas exchange and meets high inspiratory flow demands leading to reduced intubation rates. Helmet NIV can prove to be advantageous in patients with acute hypoxemic respiratory failure.
Conclusion
The results of this study suggests that helmet NIV can be a better alternative to facemask for NIV to improve oxygenation and decrease PaCO2, reducing complication and less failure rate.
References
1.Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163:540–577. doi: 10.1164/ajrccm.163.2.9906116. [DOI] [PubMed] [Google Scholar]
2.Crimi C, Noto A, Princi P, Esquinas A, Nava S. A European survey of noninvasive ventilation practices. Eur Respir J. 2010;36:362–369. doi: 10.1183/09031936.00123509. [DOI] [PubMed] [Google Scholar]
4.Duan J, et al. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med. 2016 Nov 3 doi: 10.1007/s00134-016-4601-3. [e-pub] [DOI] [PubMed] [Google Scholar]
5.Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2016 Jun 14;315(22);):2435–41. doi: 10.1001/jama.2016.6338. 27179847;PMC4967560 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Esquinas Rodriguez AM, Papadakos PJ, Carron M, Cosentini R, Chiumello D. Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients. Crit Care. 2013 Apr 25;17(2):223. doi: 10.1186/cc11875. 23680299;PMC3672531 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Principi T, Pantanetti S, Catani F, Elisei D, Gabbanelli V, Pelaia P, Leoni P. Noninvasive continuous positive airway pressure delivered by helmet in hematological malignancy patients with hypoxemic acute respiratory failure. Intensive Care Med. 2004;30:147–150. doi: 10.1007/s00134-003-2056-9. [PubMed] [CrossRef] [Google Scholar] [DOI] [PubMed] [Google Scholar]
8.Rocco M, Dell'Utri D, Morelli A, Spadetta G, Conti G, Antonelli M, Pietropaoli P. Noninvasive ventilation by helmet or face mask in immunocompromised patients: a case-control study. Chest. 2004;126:1508–1515. doi: 10.1378/chest.126.5.1508. [PubMed] [CrossRef] [Google Scholar] [DOI] [PubMed] [Google Scholar]
9.Antonelli M, Pennisi MA, Pelosi P, Gregoretti C, Squadrone V, Rocco M, Cecchini L, Chiumello D, Severgnini P, Proietti R, Navalesi P, Conti G. Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease: a feasibility study. Anesthesiology. 2004;100:16–24. doi: 10.1097/00000542-200401000-00007. [PubMed] [CrossRef] [Google Scholar] [DOI] [PubMed] [Google Scholar]
10.Antonaglia V, Ferluga M, Molino R, Lucangelo U, Peratoner A, Roman-Pognuz E, De Simoni L, Zin WA. Comparison of noninvasive ventilation by sequential use of mask and helmet versus mask in acute exacerbation of chronic obstructive pulmonary disease: a preliminary study. Respiration. 2011;82:148–154. doi: 10.1159/000324259. [PubMed] [CrossRef] [Google Scholar] [DOI] [PubMed] [Google Scholar]
The Outcome of Critically Ill Dysnatremic with Pregancy Related Acute Kidney Injury (Praki) Undergoing Slow Low-efficiency Dialysis (Sled): An Interim Analysis
Dysnatremia, defined as serum sodium (Na) less than 135 mEq/L or more than 145 mEq/L, is associated with more severe organ dysfunction and mortality in intensive care unit (ICU), ranging from 30-45%. Pregnancy-related Acute Kidney Injury (PRAKI), is associated with significant morbidity and mortality.
Objectives
The primary objective of the study is to measure the 30-day mortality in critically obstetric patients with dysnatremic acute kidney injury (AKI) as compared to normonatremic AKI undergoing slow low-efficiency daily dialysis (SLED).
Materials and methods
Prospective observational study done in a 36 bedded mixed medical-surgical ICU at a tertiary care university in the public sector in northern India. All consecutive adult (≥ 18 years) obstetric patients with dysnatremia and acute kidney injury undergoing first SLED session were included in the study. The patients who could not complete the SLED session scheduled and who were end stage renal disease, receiving chronic dialysis (Acute on CKD) were excluded. The standard SLED prescription was followed which includes blood flow rate (Qb) of 100-150 ml/minute and dialysate flow rate (Qd) 100-200 ml/minute and duration of 8-12 hours, with dialysate Na: 140-145 mEq/L and ultrafiltration goals as prescribed by the clinician. For a relative precision of 20% assuming proportion of 57% mortality in such patients at 30 days, with an alpha error of 5% and beta error of 20%, a sample size of 98 was calculated. Categorical variables were represented as frequencies and percentages, and continuous variables were represented as medians with interquartile range. Univariate analysis was performed on those factors which can contribute to change in serum Na post dialysis, and factors associated with natremia change were included in multi-variate analysis. Linear regression analysis was used to identify independent predictors of post-dialytic serum sodium, which were represented with odd's ratio. A p-value of ≤ 0.05 was considered significant.
Results
A total of 73 patients, with the median age of 25 years (23-30 years), with median APACHE II and SOFA scores of 23 (19-27) and 10 (9-12) at admission respectively. The 30-day mortality of the present study population was 34.2%. Of these mild (130-135): n=15; moderate (125-130): n=9 and severe (<125): n= 4 were hyponatremic, whereas mild (145-150): n= 9; moderate (150-155): n= 10 and severe (>155) n= 1 were hypernatremic, and n=25 was normonatremic. The 30-day mortality (odds ratio: OR compared to normonatremic) was 33% (1.06), 22.2% (0.6) and 50% (2.1) in mild, moderate, and severe hyponatremic, while 33.3% (1.06), 50% (2.1) in mild and moderate hypernatremic, when compared to normonatremic (32% mortality). Higher age, more metabolic acidosis, higher dose of norepinephrine at admission were associated with higher mortality (p value ≤ 0.05), whereas the change in sodium (pre-post SLED), dialysate gradient (Pre SLED Na-Dialysate Na) were not associated with increase in mortality.
Conclusion
In critically ill dysnatremic patients with PRAKI when subjected to first SLED session, the severity of dysnatremia is not a risk factor for 30-day mortality. Advanced maternal age, severe metabolic acidosis and higher vasopressor support were associated with increased 30-day mortality.
References
1.Lindner G. Dysnatremias in the ICU: prospective intervention studies needed. Minerva Anestesiol. 2014;80:1074–5. [PubMed] [Google Scholar]
2.Han SS, Bae E, Kim DK, Kim YS, Han JS, Joo KW. Dysnatremia, its correction, and mortality in patients undergoing continuous renal replacement therapy: a prospective observational study. BMC Nephrol. 2016;17:2. doi: 10.1186/s12882-015-0215-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Gautam M, Saxena S, Saran S, Ahmed A, Pandey A, Mishra P, Azim A. Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review. Indian J Crit Care Med. 2022;26(10);):1141–1151. doi: 10.5005/jp-journals-10071-24325. [DOI] [PMC free article] [PubMed] [Google Scholar]
Calciphylaxis can be described as a systemic medial calcification of the arteries and occurs often in patients with ESRD or in patients after kidney transplantation. An elevated plasma calcium concentration, hyperparathyroidism, hyperphosphatemia, or abnormalities in the coagulation may be found, but none of them is responsible for the disease alone. The clinical manifestation of calciphylaxis can lead to ischemia with ulcerations and skin lesions associated with severe pain which can be deceiving in ICU. Vascular thrombosis, Peripheral vascular Disease, Diabetic Ulcer, Connective tissue Vasculitis are some of the commoner than Calciphylaxis. Moreover, Isolated cases of vascular calcifications with normal renal function are described. This can deceive the treating physician and may misguide the management of the disease with unknown pathophysiology and difficult to be treated. This case report looks at a rare and seldom seen illness in patients.
Case Report/Case Series
We report on a 65 years old male presented in our hospital with difficulty in breathing since last two days, painful and discolored right distal upper limb sin ce 14 days. On clinical examination examination, he had no cardio-respiratory finding. His right distal upper limb was discolored with ischemic changes of all digits of hands distally. Right Forearm was having maculopapular rash with discolored skin which was very tender to touch. Radial artery was not palpable but brachial artery was palpable. Urgent routine pathological and radiological work up was done as prescribed by CTVS surgeon. His laboratory parameters were within normal limit except hypercalcemia and mild anemia. Color Doppler of the involved limb depict deficit flow in radial artery. Patient was immediately taken on antibiotic analgesic and anticoagulation with Heparin (Infusion) under regular monitoring with apTT. Ischemic changes continues to ascend after days of anticoagulation. CTVS surgeon denied any Limb salvage surgery and planned to amputate the limb partially. He prescribed CT angiography of right limb which show atherosclerotic wall calcification of axillary, brachial, radial and ulnar arteries causing luminal narrowing. Immediately Heparin infusion was stopped and patient was prepared for amputation.
Discussions
The diagnosis of calciphylaxis is a combination of excluding other diagnosis and revealing vascular calcifi cations, nonhealing painful skin lesions, and increasing calcium, phosphorus, calciumphosphorus product, and elevated PTH levels. Essary and Wick11 described early and late lesions in specimens and how difficult it was to distinguish them from other vasculopathies. Though the pathology of the disease is yet to be decipher, we have some literature favouring some treatment schedule. Like Vit K-the rationale behind vitamin K was that the activity of matrix Gla protein (MGP) is dependent on vitamin K carboxylation. MGP inhibits the calcification of the vessel wall. Other treatment strategies may include Hyperbaric Oxygen, prednisolone, resection of parathyroid gland in hypercalcemia.
Conclusion
At the moment, calciphylaxis is a disease with a high mortality. The pathogenesis is so far unknown and this makes good clinical treatment extremely difficult. It needs an interdisciplinary approach to each patient.
References
1.Hussein MR, Ali HO, Abdulwahed SR, et al. Calciphylaxis cutis: a case report and review of literature. Exp Mol Pathol. 2009;86(2):134–135. doi: 10.1016/j.yexmp.2009.01.008. [DOI] [PubMed] [Google Scholar]
2.Almafragi A, Vandorpe J, Dujardin K. Calciphylaxis in a cardiac patient without renal disease. Acta Cardiol. 2009;64(1):91–93. doi: 10.2143/AC.64.1.2034368. [DOI] [PubMed] [Google Scholar]
3.Kalajian AH, Malhotra PS, Callen JP, Parker LP. Calciphylaxis with normal renal and parathyroid function: not as rare as previously believed. Arch Dermatol. 2009;145(4):451–458. doi: 10.1001/archdermatol.2008.602. [DOI] [PubMed] [Google Scholar]
4.Riegert-Johnson DL, Kaur JS, Pfeifer EA. Calciphylaxis associated with cholangiocarcinoma treated with low-molecular-weight heparin and vitamin K. Mayo Clin Proc. 2001;76(7):749–752. doi: 10.4065/76.7.749. [DOI] [PubMed] [Google Scholar]
Piperacillin/Tazobactam (Pi/Tz) is a combination of β-lactam/β-lactamase inhibitor and has a broad spectrum of antibacterial activity including most Gram-positive, Gram-negative aerobic bacteria and anaerobic bacteria and is effective for many polymicrobial infections. Indian Council of Medical Research's (ICMR) Annual Report of Antimicrobial Resistance Research Surveillance Network (AMSRN) of 2022 mentions that the susceptibility patterns of key pathogens to Pi/Tz has not changed much between 2017 to 2022.1 The report mentions a susceptibility pattern of 68.4%, 17.6% & 1.4% respectively for Pseudomonas aeruginosa, Klebsiella pneumoniae & Acinetobacter baumani to Pi/Tz.2 Despite its high usage in surgical indications, data of prescription pattern of this antibiotic in the Surgical Wards & ICUs in India is lacking.
Objective
To evaluate the attitudes and practices of General Surgeons about Pi/Tz in the Surgical Wards & ICUs in India based on preference of indications, susceptibility patterns of key pathogens, concomitant antibiotic usage and administration as a continuous infusion & its key advantages.
Materials and methods
We developed & conducted a 5 question short cross-sectional survey which was rolled out through an interactive iPad based website platform (www.qualtrics.com) in December 2023 at a General Surgery Conference in India. We used convenience sampling to reach out to at least n = 100 Surgeons. Descriptive Statistics was used to assess the data using Microsoft Excel 2019.
Results
102 surgeons completed our survey. Pi/Tz was preferred as 1st Line Therapy by 83% of General Surgeons for Sepsis, 65% for Intra-abdominal Infections, 54% for Pyelonephritis and 53% for Nosocomial Pneumonia while 52% preferred to use it as 2nd Line Therapy for Urinary Tract Infections (including Cystitis). When the Surgeons were asked to ‘Rank the susceptibility’ of key pathogens of interest in a Surgical Ward & ICU, the most susceptible organism to Pi/Tz (out of the 5 mentioned pathogens) was Pseudomonas aeruginosa (41%) followed by Escherichia coli in second place (32%), Klebsiella pneumoniae in third place (29%), Bacteriods fragilis in fourth place (49%) and Acinetobacter baumani in fifth place (63%). Metronidazole (56%), Amikacin (54%), Linezolid (30%) and Macrolides (11%) were the most preferred concomitantly used antibiotics along with Pi/Tz amongst our respondents. 45% of the respondents had tried using Pi/Tz as a Continuous Infusion (13.5g/24 hours = 12.9 ml/hour). Amongst the users of Continuous Infusion technique, the key advantages selected were an improvement/decrease in the following: In-patient Morbidity Rate (63%), ICU Length of Stay (47%), Overall Length of Stay (37%), In-patient Mortality Rate (31%) & Clinical Failure Rate (10%).
Conclusion
To the best of our knowledge, this is the first survey conducted globally to understand the perspectives & usage pattern of Pi/Tz amongst General Surgeons. The limitation of our Survey is Recall Bias. Sepsis & Intra-abdominal Infections were the most commonly preferred indications by Indian Surgeons for using Pi/Tz. The susceptibility pattern encountered by the respondents regarding the 5 key pathogens of interest in a Surgical Ward/ICU is on similar lines to the most recent Annual Report of ICMR's AMRSN of 2022. More awareness may be needed about the use of Continuous Infusion technique to optimize the clinical outcomes.
References
1.Chapter 1: Summary of Isolates Distribution. Page: 5. Indian Council of Medical Research's (ICMR) Annual Report of Antimicrobial Resistance Research Surveillance Network (AMSRN) of 2022
2.Chapter 10: Healthcare Associated Infections. Page: 211. Indian Council of Medical Research's (ICMR) Annual Report of Antimicrobial Resistance Research Surveillance Network (AMSRN) of 2022
Comparison of Bi-level Positive Airway Pressure vs Pressure-regulated Volume Control Mode of Ventilation in Exploratory Laparotomy Patients in Intensive Care Unit
Conventional ventilation modes are used frequently in ICU admission due to its passive, operator dependent and user-friendly properties, but are not, patient centred, and may cause ventilator induced lung injury (VILI).1 Newer modes of ventilation have increased patient-ventilator interaction, better control on hemodynamic and oxygenation variables and allow rapid weaning.2 Pressure-regulated volume control (PRVC) is a newer dual mode of ventilation, which is pressure and volume regulated and time cycled with decelerating flow of pressure-controlled ventilation along with safety of guaranteed tidal volume delivery, which limit baro- and volu-trauma and prevent hypoventilation and subsequently allowing smooth weaning of ventilated patient. However, on this mode, pressure applied is based on the tidal volume attained on the last breath, causing intermittent patient effort to produce varying tidal volume.2 Bi-level positive airway pressure ventilation (BIPAP) is a biphasic mode of ventilation which allows spontaneous breathing to promote lung recruitment of poorly ventilated and collapsed alveoli. It is associated with preservation of spontaneous breathing and patient comfort at even high continuous positive airway pressure (CPAP).3 Although BIPAP mode has many advantages over PRVC mode, limited studies have compared them in terms of ventilatory and cardiopulmonary variables in different subset of patients.4 We hypothesized that exploratory laparotomy patients with complex pathophysiology requiring mechanical ventilation, on BIPAP mode will have better cardiopulmonary and ventilatory profile than PRVC mode, due to the distinct characteristics of BIPAP mode.
Objectives
Primary objective: Comparison of ventilatory parameter in exploratory laparotomy patient in ICU undergoing BIPAP with PRVC mode of ventilation.
Secondary objectives: Comparison of hemodynamic and ABG parameters in exploratory laparotomy patients in ICU undergoing BIPAP and PRVC mode of ventilation.
Methods
After institutional ethical approval and written informed consent, this interventional, prospective, randomized-controlled, double-blinded study was conducted on 110 patients admitted in ICU and fitting in inclusion criteria, were randomly allocated to either BIPAP or PRVC group. Initially, all eligible patients were kept on volume control/assist control (VC/AC) mode of ventilation with pre-set parameters After keeping the patient on VC/AC mode for 2 hours (washing period). After recording the baseline measurements, patient were kept on either BIPAP (Group 1) or PRVC (Group 2) mode, with pre-set ventilatory parameters, as per the random group allocation. For next 2 hours, parameters were recorded and patient shifted back to VC/AC mode for next 2 hours (washing period) and then shifted to corresponding second mode of ventilation (PRVC for Group I and BIPAP for Group 2) and hourly parameters were recorded for next 2 hours. Thereafter, all patients were shifted back to its original mode of ventilation.
Results
The study results compilation is currently in process and is expected to be completed before presentation of this study.
Discussion
Based on the initial observations we found that BIPAP mode has shown initial increase in mean airway pressure (Pmean), but with significant increase in lung compliance (C) after 2 hour duration with considerable decrease in resistance (R). In contrast, improved haemodynamic parameters profile was observed on PRVC mode of ventilation.
References
1.Bourenne J, Hraiech S, Roch A, Gainnier M, Papazian L, Forel JM. Sedation and neuromuscular blocking agents in acute respiratory distress syndrome. Ann Transl Med. 2017;5:291. doi: 10.21037/atm.2017.07.19. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Singh PM, Borle A, Trikha A. Newer nonconventional modes of mechanical ventilation. J Emerg Trauma Shock. 2014;7:222–7. doi: 10.4103/0974-2700.136869. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.van der Staay M, Chatburn RL. Advanced modes of mechanical ventilation and optimal targeting schemes. Intensive Care Med Exp. 2018;6:30. doi: 10.1186/s40635-018-0195-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Seymour CW, Frazer M, Reilly PM, Fuchs BD. Airway pressure release and biphasic intermittent positive airway pressure ventilation: are they ready for prime time? J Trauma. 2007;62:1298–308. doi: 10.1097/TA.0b013e31803c562f. [DOI] [PubMed] [Google Scholar]
Chronic liver disease (CLD) leading to cirrhosis is an increasing problem and the prognosis following Intensive care unit (ICU) admission is poor. The management of critically ill patients admitted in ICU with acute on chronic liver failure (ACLF) has changed due to recent advances in critical care and newer therapeutic modalities.
Aims
This study aims to study the aetiology and the frequency of hepatic and extrahepatic organ failure, identify the precipitating acute insults and outcomes of critically ill patients admitted to ICU with acute deterioration of chronic liver disease.Materials and methods: This Retrospective cohort study was conducted in a tertiary teaching hospital. All patients admitted to medical ICU with acute deterioration of chronic liver disease from Jan 2015 to Dec 2019 were included. Deterioration was identified using the criteria defined by ESAF-CLIF. Chart review was conducted to assess the aetiology of chronic liver disease and identify the acute precipitating insult causing deterioration. Individual clinical and laboratory parameters were assessed, and ESAF-CLIF consortium criteria was used to identify the organ failures and mortality. Statistical analysis was done using statistical package for Social Sciences (SPSS 20th version). All the continuous variables were expressed as mean and standard deviation. Median and inter-quartile range (IQR) and percentage frequency distribution for continuous and categorical variables respectively was done. Results: Out of 7676 patients admitted in medical ICU during the study period 119 patients fulfilling the criteria were included and analysed in the study. The mean age was 49.2 years with a standard deviation of 11.6 and 81% (n = 96) were males. Comorbidities were present in 53.4 % (n = 62). Alcohol was the primary cause of chronic liver disease in 59.8% (n = 70) followed by non-alcoholic fatty liver disease (NAFLD) in 17.6% (n = 22). Infection was the main precipitating acute insult in 84% (n = 100). The median length of hospital stay was 7 days with IQR of 3-13. More than one insult was present in 21% (n = 26). 28 days in hospital mortality was 80% (n = 95). Presence of hepatic encephalopathy (HE) grade > = 3 (p = 0.01), respiratory failure (p = 0.007), circulatory failure (p<0.001) or ACLF grade 3 (p<0.001) was associated with poor outcome. Univariate analysis showed higher SOFA, MELD and CTP scores were associated with increased mortality.
Discussion
This study highlights the aetiology of both acute precipitating and chronic insult of critically ill ACLF patients and the frequency of organ failures with their outcomes. Alcohol emerged as the primary cause followed by NAFLD aligning with findings from similar research. (1) However some studies reported increased prevalence of viral hepatitis compared to alcohol related cirrhosis. (2, 3)In terms of acute precipitating events infections were the most common (84%). This higher incidence compared to other studies (32 to 66%) might stem from higher rate of alcoholism and the inclusion of only ICU-admitted patients. Mortality rates were notably higher in ACLF grade 3 patients, suggesting a greater risk with more organ failures, especially extrahepatic rather than hepatic failure.(4) Conclusion: Patients with acute deterioration of chronic liver disease requiring ICU carries a high short term mortality rate. Infection is the most common acute insult and mortality increased as the number of organ failures increased. Early recognition of organ failures and reversal of precipitating events could improve outcomes.
References
1.Kulkarni S, Sharma M, Rao PN, Gupta R, Reddy DN. Acute on Chronic Liver Failure—In-Hospital Predictors of Mortality in ICU. J Clin Exp Hepatol. 2018 Jun;8(2):144–55. doi: 10.1016/j.jceh.2017.11.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Khot AA, Somani P, Rathi P, Amarapurkar A. Prognostic factors in acute-on-chronic liver failure: a prospective study from western India. Indian J Gastroenterol. 2014 Mar;33(2):119–24. doi: 10.1007/s12664-013-0409-z. [DOI] [PubMed] [Google Scholar]
3.Garg H, Kumar A, Garg V, Sharma P, Sharma BC, Sarin SK. Clinical profile and predictors of mortality in patients of acute-on-chronic liver failure. Dig Liver Dis. 2012 Feb;44(2):166–71. doi: 10.1016/j.dld.2011.08.029. [DOI] [PubMed] [Google Scholar]
4.Meersseman P, Langouche L, du Plessis J, Korf H, Mekeirele M, Laleman W, et al. The intensive care unit course and outcome in acute-on-chronic liver failure are comparable to other populations. Journal of Hepatology. 2018 Oct 1;69(4):803–9. doi: 10.1016/j.jhep.2018.04.025. [DOI] [PubMed] [Google Scholar]
To Study the Effect of Helmet Continuous Positive Airway Pressure Ventilation on Oxygenation in Semi-prone Position in Patients of Mild to Moderate ARDS: A Prospective Single Arm Non-inferiority Trial
1Department of Pulmonary and Critical Care Medicine, Institute of Medical Sciences, New Delhi, India, Phone: +91 8290470844, e-mail: aman2027@gmail.com
1Department of Pulmonary and Critical Care Medicine, Institute of Medical Sciences, New Delhi, India, Phone: +91 8290470844, e-mail: aman2027@gmail.com
2–7Department of Pulmonary and Critical Care Medicine, Institute of Medical Sciences, New Delhi, India
Noninvasive ventilation (NIV) can prevent endotracheal intubation and decrease mortality in selected patients with acute respiratory failure. NIV using helmet interface has emerged as an alternative to administer higher pressures for longer duration. The effect of NIV can be further enhanced by changing positions. The Study investigated the role of helmet NIV in acute respiratory failure in different positions.
Objectives
The primary objective was to assess the change in PaO2/FiO2 ratio in semi-prone (lateral) position in comparison to supine position. The secondary objectives included comparison of change in PaO2/FiO2 ratio in lateral and prone position in comparison to supine position, comfort of subjects in all position and assess change in PaO2/FiO2 ratio, ROX index and respiratory rate on resupination.
Materials and methods
It was a single center, prospective, noninferiority trial of helmet CPAP in semi-prone (lateral) position compared to prone position in 54 patients with hypoxemic respiratory failure. However due to logistics issues, we switched to helmet NIV. Subjects with hypoxemic respiratory failure with PaO2:FiO2 between 150-300 were enrolled and initiated on helmet NIV (Castar R, Starmed®, Italy) connected to Drager Savina 300 ventilator (pressure support mode) in supine position. They were subsequently assisted to lateral and prone position. Patient vitals, blood gases parameters and comfort were noted in all positions and 1h after resupination.
Results
Over a period of 1 year, 92 patients were screened and 38 were excluded. Of the 54 patients enrolled, 6 were screen failures. 48 subjects of mean age 40.65 (16.77) yrs and PaO2:FiO2 of 176 (± 28) mmHg received helmet NIV. The Mean PaO2:FiO2 improved to 194 (± 49) mmHg on helmet in supine position. It further improved to 214 (± 68) mmHg in lateral position (p = 0.15) and 232 (± 49) mmHg in prone position (p<0.0001). On resupination prone position PaO2:FiO2 was 212 ± 40 mmHg (p = 0.001). Helmet NIV was successful in preventing intubation in 67% (32/48) of patients. Subjects comfort on helmet directly affected the outcome. In supine position on helmet NIV after1 hour, ROX index cut off of 4.52 showed a sensitivity of 97% and specificity of 82% for favourable outcome. There was no significant change in vital parameters with position except respiratory rate which significantly decreased with prone position.
Discussions
Prone positioning in ARDS improves oxygenation by an increase in end expiratory lung volume, improved ventilation perfusion matching, and a regional change in ventilation associated with alteration in chest-wall mechanics. Lateral position in ARDS improves oxygenation in cases with predominantly unilateral involvement. In this study oxygenation improvement was significant in prone positioning compared to lateral position. Similar results were observed in PRON-COVID trial(2) and study by Retucci et al(3).
Conclusion
Acute respiratory failure without hypercapnia, in selected individuals can be managed with Helmet NIV. The interface is well tolerated by most of the patients. To improve the oxygenation further on helmet, awake prone positioning should be used if no contraindication. The improvement is sustained after assuming supine position after prone position. Lateral position can be safely performed on helmet NIV but it doesn't offer any significant advantages over prone position in terms of respiratory parameters.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Disclosure/Conflict of interest
None to declare.
References
1.Patel BK, Wolfe KS, Pohlman AS, Hall JB, Kress JP. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2016;315(22):2435–41. doi: 10.1001/jama.2016.6338. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Retucci M, Aliberti S, Ceruti C, Santambrogio M, Tammaro S, Cuccarini F, et al. Prone and Lateral Positioning in Spontaneously Breathing Patients With COVID-19 Pneumonia Undergoing Noninvasive Helmet CPAP Treatment. CHEST. 2020;158(6):2431–5. doi: 10.1016/j.chest.2020.07.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Coppo A, Bellani G, Winterton D, Di Pierro M, Soria A, Faverio P, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. The Lancet Respiratory Medicine. 2020;8(8):765–74. doi: 10.1016/S2213-2600(20)30268-X. [DOI] [PMC free article] [PubMed] [Google Scholar]
Dynamic Change in CLIF-SOFA, MELD-Na and MELD Score in Predicting Postoperative 28 day Morbidity and Mortality in Patients Undergoing Live Donor Liver Transplantation: A Retrospective Study
Liver transplant is the definitive treatment option for end stage liver disease. To utilize the available resources properly, clinicians have been persistently looking for objective scoring systems which would predict postoperative morbidity and mortality. Model for end stage liver disease (MELD) scoring system and Sequential organ function assessment (SOFA) score have been utilized in predicting outcome after liver transplantation (1). The Chronic Liver Failure - Sequential Organ Failure Assessment (CLIFSOFA) score, a modified SOFA score, has been shown to predict post liver transplant mortality (2). Only few studies have evaluated the dynamic change in scores from the preoperative value and the relationship between post-transplant mortality. Kin J D et al. have shown delta-MELD score on post operative day 14 as a significant predictor of mortality after liver transplantation (7). However, studies on dynamic change in these scores in the early post-transplant period are very few and studies comparing the dynamic change among.
Aims and Objectives
Primary objective: To compare the dynamic change in CLIF-SOFA, MELD-Na and MELD scores in patients of live donor liver transplantation.
Secondary objective
To determine the predictive ability of the dynamicity of these scores in predicting morbidity and mortality after live donor liver transplantation.
Material and method
Study design: Single center retrospective study. Retrospective data collection. July 2018- December 2019 (over a period of one and half year) All live donor liver transplant recipients.
Data Collection
Hospital database was searched for the patients who underwent LDLT within the stipulated time period and relevant data were collected.
Calculation
MELD score, MELD-Sodium score and CLIF-SOFA scores were calculated using standard formula, on preoperative day, postoperative day1, day 4 and day 7 using standard formulae.
Observations And Results
Highest area under the curve was found for d-CLIF-SOFA on postoperative day 7 (AUROC = 0.893), followed by d-CLIF-SOFA on postoperative day 4 (AUROC = 0.740) and d-MELD-Na on postoperative day7 (AUROC = 0.728). This translates; d-CLIF-SOFA on postoperative day 7 has highest discrimination for outcome, followed by d-CLIF-SOFA on postoperative day 4 and d-MELD-Na on postoperative day 7. Among the individual scores, CLIF-SOFA score on postoperative day 7 (odds ratio 2.13, 95% CI: 1.400-3.200, p<0.001) has been found to be the strongest predictor of outcome, followed by CLIF-SOFA on postoperative day 4 (odds ratio 1.88, 95% CI: 1.240-2.860, p = 0.003).
Conclusion
Dynamic change in CLIF SOFA score on post operative day 7 was found to be the best predictorof outcome, followed by d-CLIF SOFA on post operative day 4 and d-MELD-Na on post operative day 7.
Evaluation of Fungal Infections among Post-exploratory Laparotomy Patients admitted in ICU: A Prospective Study from Tertiary Care Centre in North India
1Department of Anaesthesia and Critical Care, Government Medical College, Chandigarh, India, Phone: +91 9946643043, e-mail: dr.geetanshugupta@gmail.com
1Department of Anaesthesia and Critical Care, Government Medical College, Chandigarh, India, Phone: +91 9946643043, e-mail: dr.geetanshugupta@gmail.com
2–4Department of Anaesthesia and Critical Care, Government Medical College, Chandigarh, India
5Department of Microbiology, Government Medical College, Chandigarh, India
The frequency of fungal infections has increased significantly in recent decades due to overuse of immunosuppressive drugs and inappropriate use of antimicrobial agents1. More than 20% of microbiologically documented infections in intensive care units (ICU) are caused by fungi. These increased numbers has led to the high incidence of invasive fungal infections (IFI), out of which Candida is most common followed by Aspergillus2. Prevalence of different micro-organisms in intestinal perforation peritonitis varies with geographical area, patient profile and location of the perforation3. Thus, there is an urgent need for early detection and diagnosis of fungal infections. This study aims to identify invasive fungal infections in mechanically ventilated post-exploratory laparotomy patients admitted to ICU in northern India for early diagnosis and prompt management.
Objectives
Estimation of incidence and type of invasive fungal infections in mechanically ventilated post exploratory laparotomy patients in ICU and evaluating various risk factors.
Material and methods
This study was conducted in the intensive care unit of the Department of Anaesthesia and Intensive Care, GMCH, Chandigarh. The type of study was observational and prospective with sample size of 66. Post exploratory laparotomy patients admitted in ICU on mechanical ventilation were enrolled for the study over a period of 18 months as per inclusion and exclusion criteria. The demographic details, risk factors, clinical presentation, specimen-wise distribution of fungal isoalates and critical care setting in patients with fungal infection and colonization were observed.
Results
Out of 66 patients, fungal Infections were present in 13 patients and fungal colonization was present in 3 patients. Most patients were between the age range of < = 30yrs and >50yrs; 40 males and 26 females. Fever followed by pain abdomen was the most common presenting symptom. Risk factors were urinary cathetrization and respiratory ventilation followed by central line insertion, corticosteroid use, TPN, Diabetes, and dialysis. Non-albicans candida (18.2%) was more prevalent than Candida albicans (6.1%) as the most frequently isolated fungus. Among non-albicans candida, Candida tropicalis was present in 12.1%, Candida parapsilosis (3.0%), Candida krusei (1.5%) and Candida gulliermondii (1.5%). Isolates were most commonly found in urine (15.2%) followed by blood (4.5%), surgical drain fluid (3.0%) and tracheal secretions(1.5%). The mortality rate was 19.7%.
Conclusion
The study highlighted a high burden of invasive fungal infections in ICU patients which are severe and identifying and accurately diagnosing at risk patients can be challenging. Thus antifungals and antifungal stewardship can play major role in prevention and treatment of fungal infections in such patients.
References
1.Jorda-Marcos R, Alvarez-Lerma F, Jurado M, Palomar M, Nolla-Salas J, Leon MA, et al. Risk factors for candidemia in critically ill patients: A prospective surveillance study. Mycoses. 2007;50:302–10. doi: 10.1111/j.1439-0507.2007.01366.x. [DOI] [PubMed] [Google Scholar]
2.Enoch DA, Yang H, Aliyu SH, Micallef C. The changing epidemiology of invasive fungal infections. Methods Mol Biol 1508: 2017:17–65. doi: 10.1007/978-1-4939-6515-1_2. [DOI] [PubMed] [Google Scholar]
3.Osman M, Al Bikai A, Rafei R, Mallat H, Dabboussi F, Hamze M. Update on invasive fungal infections in the Middle Eastern and North African region. Brazilian Journal of Microbiology. 2020 Dec;51(4):1771–89. doi: 10.1007/s42770-020-00325-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
In Vitro Activity of Ceftazidime-Avibactam (Caz AVI) and Other Antibiotics against E.coli (Ec),Klebsiella pneumonia (Kp) and Pseudomonas aeruginosa (Pa): Results from atlas 2021
Ceftazidime-avibactam (CAZ AVI) is indicated for the treatment of patients with complicated Urinary tract infections(cUTI), complicated Intra-abdominal infections (cIAI), Hospital acquired pneumonia(HAP) including Ventilator associated pneumonia(VAP), & bacteraemia that occurs in association with or is suspected to be associated with these infections1. The present report evaluated the in-vitro susceptibility of CAZ AVI & comparators for EC,KP & PA collected as part of the ATLAS (The Antimicrobial Testing Leadership and Surveillance) surveillance program (2021) from India.
Materials and methods
ATLAS (Antimicrobial Testing Leadership and Surveillance) detects trends in multi-drug resistance longitudinally over time2. A total of 1432 non- duplicate clinically significant isolates of EC, KP and PA were analyzed from ATLAS 2021. In vitro activity of CAZ AVI and other antibiotics- Amikacin, Amoxy-clav, Aztreonam, Meropenem, Ciprofloxacin, Piperacillin- tazobactam(Pip-taz), Trimethoprim-sulphamethoxazole(COT) and Colistin were assessed against these isolates. The minimum inhibitory concentrations (MICs) and in vitro susceptibility of ceftazidime-avibactam & comparators were assessed using the Clinical and Laboratory Standards Institute (CLSI) guidelines.
Results
Of all the significant clinical isolates, 492 (34.36%) EC, 488(34.08%) KP and 452 (31.56%) PA were isolated from all the sources and Adult ICUs and wards. The overall susceptibility to CAZ AVI was observed to be 82.52% amongst EC, 67.21% among KP and 79.2% among PA. For the comparator drugs, overall susceptibility among EC (n=492) was observed to be 100% to Colistin, 80.69% to Meropenem, 73.78% to Amikacin, 58.74% to Pip-taz, 51.83% to Amox-clav, 44.11% to COT, 29.67% to Aztreonam, and 22.97% to Ciprofloxacin; among KP (n=488), it was observed to be 96.31% to Colistin, 43.44% to Amikacin, 39.96% to Meropenem, 36.27% to COT, 30.12% to Amox-clav, 29.3% to Pip-taz, 28.28% to Aztreonam, and 19.26% to Ciprofloxacin; among PA (n=452), it was observed to be 99.12% to Colistin, 79.87% to Amikacin, 73.01% to Ciprofloxacin, 70.8% to Meropenem, 68.58% to Pip-taz, and 62.83% to Aztreonam. Among the tested Carbapenem resistant isolates, 43.21% of CR KP (n=280), 25.41% of CRPA (n=122) and 9.68% of CR EC(n=93) were susceptible to CAZ AVI.
Conclusion
The susceptibility of CAZ AVI was markedly dropped among CR EC isolates. However, CAZ AVI has retained good susceptibility over the years against infections caused by CR KP and CRPA and could thereby be considered as a preferred treatment option for carbapenem resistant infections for the approved indication if susceptible.
References
1.Zavicefta® LPDZAV02. 2021. PfLEET Number: 2021-0067740. February 2021.
2.In vitro activity of Ceftazidime–Avibactam and its comparators against Carbapenem resistant Enterobacterales collected across India: results from ATLAS surveillance 2018 to 2019, Y.D.Bakthavatchalametal./DiagnosticMicrobiologyandInfectiousDisease103(2022)115652. [DOI] [PubMed]
Effect of Resuscitation Using Surviving Sepsis Campaign Guidelines 2020 on Organ Dysfunction in Children Admitted with “Fluid Refractory Septic Shock”: A Prospective Observational Study
Pediatric Surviving Sepsis Campaign guidelines (SSC) 2020, recommends fluid resuscitation with aliquots of 10-20ml/kg upto 40- 60 ml/kg (if PICU available) and 40ml/kg (if no PICU facility available) followed by early vasopressors if patient is in “fluid refractory” shock or signs of fluid overload.
Objectives
To compare children with “fluid refractory” septic shock showing decrease in PELOD-2 scores upto 72 hours of recognition of shock after resuscitation as per SSC guidelines 2020 versus those with same or increasing PELOD 2 scores.
Materials and methods
Prospective observational study in a tertiary care centre PICU from December 2020 to August 2022.
Results
Out of 1367 children screened for septic shock, 88 children were enrolled. Median age of children was 15 mo (IQR 6 - 48 mo). Proportion of children with ‘fluid refractory’ septic shock showing decrease in PELOD 2 score from baseline to 72 hours of recognition of shock was [51/88 cases] 57.95%. Enrolled patients categorised into two groups: Group 1 = Children with decrease in PELOD -2 score over first 72 hours and Group 2 = Children with same or increase in PELOD 2 score over first 72 hours. No significant differences found in parameters like volume of first bolus, duration over which bolus given, time to first bolus since recognition of shock between the two groups. There was significant difference in time to initiation of first vasopressor in Group 1 versus Group 2 [52.5 min (30, 150) vs 80 (50, 480), p = 0.055]. Significantly less number of vasopressors were required in Group 1 compared to group 2 [2 (1, 2) vs 3 (2, 3), p <0.00]. Mortality at 28 days was significantly. lower in Group 1 compared to group 2 [37.14% vs 62.86%, p = 0.001]. Median volume of bolus (ml/kg) [12 vs 13.5, p = 0.93]. and duration of bolus (min) [20 vs 20 p = 0.97] was similar in both the groups. Multivariate logistic regression revealed age, p SOFA on Day 2, presence of AKI as significant predictors of mortality. Discussions: Volume of first bolus at shock recognition and duration of first bolus administration did not affect trend of organ dysfunction scores at 72 hours, rather earlier time to initiation of first vasopressor after recognition of “fluid refractory” septic shock led to significantly reduced PELOD 2 scores at 72 hours.
Reference
1.Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21(2):e52–e106. doi: 10.1097/PCC.0000000000002198. [DOI] [PubMed] [Google Scholar]
Tracheostomy tube colonization rates are high ranging from 30-100% within 48 hours of tracheostomy tube. Tracheostomy tube colonisations and resultant infections such as ventilator associated pneumonia have a significant impact on patient health, medical resources, quality of life. The aim of the study is to determine the efficacy of prophylactic gentamicin nebulization for tracheostomy tube colonization in neurocritical care patients in ICU and after step down into ward and community.
Primary objective
To compare the rate and change of pathogenic colonization of tracheostomy tubes between two groups over the course of treatment.
Secondary objective
To compare the incidence of VAI/LRTI, stoma granulation, tracheostomy tube block, and adverse events related to nebulization between the two groups in hospital and on follow-up. To study the risk factors associated with colonization.
Methods
We conducted a double blind randomized controlled trial to compare the incidence of pathogenic colonization of tracheostomy tubes between the gentamicin nebulization and saline nebulization groups at 3 time points: 7-10 days after tracheostomy (TT change 1), and at death/discharge/2-3 weeks from last tracheostomy tube change (TT change 2) and day 60 of tracheostomy/one month after discharge /decannulation (TT change 3) which may be in the hospital or community) whichever is earlier. 65 patients were randomized into either twice daily nebulized gentamicin 80 mg (2ml) which is diluted with 0.9% saline to total of 5ml and 0.9% 5 ml of normal saline nebulization. At the time of TT change swabs were collected from inner surface of TT 0.5 cm above the tip with full asepsis and transported to the lab to be plated on sheep blood, Mc Conkey agar and incubated for 48 hours. Bacterial identification and susceptibility were performed by standard microbiological techniques. Demographic data, infection markers, incidents of rise in creatinine, bronchospasm, tube block and stoma granulation were documented at the three time points.
Results
Baseline characteristics were comparable between two groups. The incidence of pathogenic colonization in gentamicin vs normal saline group was less than normal saline at all time points: TT change 1 (47.1%% vs 71%, p = 0.05), TT change 2 (53.3% vs 72.4% p 0.13), TT change 3 (64.3% vs 86.8% p 0.16). The pathogenic organisms, adverse effects (renal failure and bronchospasm) and tube block incidents were similar between groups. Among 18 patients with clinical signs s/o IVAC @TT2, 7/10 gentamycin group patients had no TT colonization precluding escalation of antibiotics, vs. 1/8 in normal saline group (p=0.02).
Conclusion
Decreased pathogenic colonization associated with gentamicin nebulisation may reduce progression to VAT or VAP, and the requirement of higher antibiotics in chronically ill tracheostomy patients in neuro ICU and further at home, aiding antibiotic stewardship and possibly reducing associated costs. Further studies with large sample size needed to support our study results.
Intentional and unintentional consumption of pesticides are commonest indications for ICU admissions. In India as pesticides are easily available, they are very often used for self-harm. Out of these, organophosphorus compounds are most commonly used followed by rodenticide poisoning.1 In this study we have retrospectively reviewed rodenticide poisoning cases admitted to our ICU.
Objectives
To analyse the clinical profile, treatment given, with morbidity and mortality of patients admitted with rodenticide poisoning.
To assess the utility of NAC and extended NAC therapy in these patients.
Material and methods
This was a retrospective observational study. Analysis comprised all rodenticide poisoning patients more than 18 years old admitted to Bangalore Baptist hospital ICU, from Jan 2022 to December 2023. Collected data included clinical profile, laboratory parameters, complications, treatment given, with morbidity and mortality of these patients. Data was also assessed based on the administration of NAC and associated outcomes.
Results
19 patients were admitted with rodenticide poisoning in the above specified time period. Among the 19 patients, 11 were female and 9 were male. The mean age was 25.5 years. Majority of patients had consumed yellow phosphorus and aluminum phosphide which constituted 32%(n-6) and 26%(n- 5) respectively. while remaining patients had consumed zinc phosphide 21%(n-4) and coumarin derivatives 16%(n-3). The most common presenting symptoms were nausea and vomiting. The average day of initial presentation to hospital after poison consumption was 2.5- 3 days in yellow phosphorus poisoning. In total 18 patients received gastric lavage in the emergency department with activated charcoal or potassium permanganate. Analysis revealed 4 patients had acute liver failure and 2 patients had acute renal failure. Most of the patients had received standard treatment with coconut oil through NG tube, intravenous magnesium, Vitamin K and supportive care. NAC was commenced at the time of ICU admission in 15 patients and among them 12 survived. The overall mortality was 3 out of the 19 cases (16%), all fatalities were secondary to yellow phosphorus poisoning. Extended NAC therapy was initiated for 3 out of 6 cases in yellow phosphorus, who showed good recovery of liver functions and all 3 survived.
Conclusion
Rodenticide is one of the most common type of poisoning presenting to our ICU apart from organophosphorus poisoning and drug overdose. Among the rodenticide poisoning yellow phosphorus poisoning is found to be the most lethal. NAC is emerging as a new modality of treatment in rodenticide poisoning. The logical theory backing the utility of NAC is that it replenishes glutathione stores that neutralizes the free radical induced cytotoxicity of rodenticides especially yellow phosphorus.2 In rodenticide poisoning there is disruption of oxygen supply and utilizationIn at cellular level. NAC increases the nitric oxide and formation of cGMP which results in vasodilatation and heightened oxygen consumption. In our study 15 patients received early initiation of NAC, and 5 of them were given extended NAC therapy. The improving trend of liver functions and the role in mortality prevention was seen with NAC administration, which was similar to the findings in few similar studies.4, 5, 6The role for extended NAC therapy given for the duration of icu stay or upto improvement in liver function, was also found to show decrease in overall mortality.
References
1.Thomas M, Anandan S, Kuruvilla PJ, Singh PR, David S. Profile of hospital admissions following acute poisoning - experiences from a major teaching hospital in south India. Adv. Drug React. Toxicol. Rev. 2000;19:313–317. [PubMed] [Google Scholar]
2.Gopalakrishnan S, Kandasamy S, Iyyadurai R. Rodenticide Poisoning: Critical Appraisal of Patients at a Tertiary Care Center. Indian J Crit Care Med. 2020;24(5):295–298. doi: 10.5005/jp-journals-10071-23426. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Bhat S, Kenchetty KP. N-acetyl cysteine in the management of rodenticide consumption - life saving? J Clin Diagn Res. 2015 Jan;9(1):OC10–3. doi: 10.7860/JCDR/2015/11484.5455. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Lee WM, Hynan LS, Rossaro L, Fontana RJ, Stravitz RT, Larson A M, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterology. 2009;137:856–64.e1. doi: 10.1053/j.gastro.2009.06.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Rashid M, Chandran VP, Nair S, Muthu DS, Pappuraj J, Jacob KA, Sridhar B, Mark K, Hyder S, Khan S, Thunga G. N-Acetyl Cysteine in Rodenticide Poisoning: A Systematic Review and Meta-Analysis. Curr Rev Clin Exp Pharmacol. 2022;17(3):192–204. doi: 10.2174/2772432816666210825102726. [DOI] [PubMed] [Google Scholar]
Primary Objective: To evaluate the correlation of mNUTRIC score with 28 day mortality Secondary Objective: To evaluate the correlation of mNUTRIC score with:
ICU length of stay. Hospital length of stay.
Ventilator free days and
Complications.
Materials and methods
The mNUTRIC score using the five variables-Age, APACHE II score, SOFA score, number of comorbidities, days of ICU admission will be calculated, Mechanical ventilation (MV) is defined as invasive ventilation during ICU stay. The mNUTRIC score will be calculated at the time of enrolment to the study. Patients who are mechanically ventilated for more than 48 hours in an ICU set up will be taken up for the study. Consent from the patient's attendees will be taken to collect the data necessary. The patients’ demographic characteristics, clinical information and biochemical parameters will be obtained from the hospital's medical records department. Institutional ethical committee approval taken for collecting data. All relevant data collected. Patients alive after 28 days post ICU admission as survivors and patients who died within 28 days as non-survivors.
Method of collection of data
Sample size:150. Based on the literature review, in the previous study conducted by Kalaiselvan et al, It was found that the 42.4% of the subjects were under high nutritional risk associated with mortality. In the present study expecting similar results considering 95% confidence level and 6% absolute precision the sample size for the study has worked out to be a total of 150 subjects.
Type of study
Prospective Observational study.
Inclusion criteria
Mechanically ventilated patients in ICU for more than 48 hours.
Exclusion criteria
Age <18 years
>70 years of agePregnant women
Breastfeeding mothers
Discharged or expired within 48 hours of ICU stay
Readmitted to the ICU
Diagnosis of chronic liver failure
Diagnosis of chronic renal failure/renal replacement therapy
Less than 24 hours of ICU stay
Malignancy patients, surgeries on the GI tract where enteral feeding is not possible within 48 hours.
Results
YET TO BE ANALYSED.
Conclusion
DEPENDING ON THE RESULTS.
References
1.Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of nutrition risk in critically ill (NUTRIC) score to assess nutritional risk in mechanically ventilated patients: A prospective observational study. Indian J Crit Care Med. 2017;21:253–6. doi: 10.4103/ijccm.IJCCM_24_17. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Im K.M, Kim E.Y. Identification of ICU Patients with High Nutritional Risk after Abdominal Surgery Using Modified NUTRIC Score and the Association of Energy Adequacy with 90-Day Mortality. Nutrients. 2022;14:946. doi: 10.3390/nu14050946. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Tseng CC, Tu CY, Chen CH, Wang YT, Chen WC, Fu PK, Chen CM, Lai CC, Kuo LK, Ku SC, Fang WF. Significance of the Modified NUTRIC Score for Predicting Clinical Outcomes in Patients with Severe Community-Acquired Pneumonia. Nutrients. 2021 Dec 31;14(1):198. doi: 10.3390/nu14010198. [DOI] [PMC free article] [PubMed] [Google Scholar]
Coronavirus disease 2019, caused by the recent severe acute respiratory syndrome novel virus, is considered one of the greatest global public health crisis by the WHO. It claimed millions of lives globally, with death occurring among populations with certain contributing factors. The aim of this study was to assess Clinical Profile, Management outcome and associated factors of COVID-19 infected patients who were admitted from June 8, 2020 to May 30, 2021 to St. Paul Hospital Millennium Medical College COVID-19 ICU Center.
Methods
Single centered institution-based cross-sectional study design was conducted at ICU of St. Paul's hospital millennium medical college COVID-19 treatment center on patients admitted to the COVID-19 ICU from June 8, 2020, to May 30, 2021. A simple random sampling technique was applied to select eligible patients’ charts. The data were entered and analyzed using SPSS version 26. Descriptive analysis was used for statistical analysis of baseline data, and regression analysis was used to determine association between dependent and independent variables. A p-value <0.05 was considered significant.
Results
A total data of 272 patients were analyzed, with a median age of 60.5 years and more than two-thirds, 183(67.3%) being males. Most (75.7%) had a pre-existing comorbid medical condition and a majority (71.3%) had a COVID-19 disease of critical disease severity. Overall, in-ICU mortality rate was 64.3%. Multivariate analysis showed that adverse outcome was significantly associated with intubation (AOR: 2.813; 95% CI: 1.176–6.731), pulmonary embolism (AOR: 36.702; 95% CI: 4.062–331.605), Vasopressor usage (AOR: 84.954; 95% CI: 23.413–308.254), Dialysis or RRT (AOR: 4.191; 95% CI: 1.511-11.620) and ARDS (AOR: 21.149; 95% CI: 4.217–106.075).
Conclusion
Most common comorbidities were hypertension, diabetes, and CKD. Moreover, high mortality among ICU-admitted COVID-19 patients was strongly associated with septic shock, and those intubated patients with ARDS.
The physical and structural characteristics of the ICU differentiate it from common hospitalization units. There is sophisticated equipment and specialized staff who use invasive techniques to recover and maintain life. On the other hand, relatives also perceive the ICU as a place that causes fear, apprehension and insecurity. Patients—especially in ICU—find themselves in vulnerable states and are at risk of experiencing dehumanization. Dehumanization is often associated with disrespect—or a failure to honour another person's dignity or worth. On the other hand, humanization refers to honouring the full identity, community, and dignity of another human being.
Objectives
Primary objective: To understand how patients and family members experience humanizing or dehumanizing treatment when admitted in the ICU.
Secondary Objective:
Factors leading to dehumanizing behaviour experienced during the ICU care
Identifying interventions to decrease the dehumanizing behaviour experienced during the ICU care
Materials and methods
The study was performed in the ICUs of a tertiary care hospital in north India. The study was carried out using mixed methodology (qualitative and quantitative). This was based on inductive grounded theory approach. Keeping focus on the patient's, family member's and patient's perception on humanizing or dehumanizing during communication, routine care and procedures, in-depth interviews were conducted. Grounded theory approach involving moving back and forth between data collection and analysis until a theory that fits the data emerged. The only inclusion criteria was patients had stayed in an ICU more than 96 hours. After taking an informed consent, the main investigator invited the participants for the interview and were conducted in the vernacular language. A structured proforma was also distributed to the stakeholders and the items of the performa were rated on Likert Scale.
Results
The recruitment of the study participants is going on and results are to be compiled.
Discussions
Dehumanization is often associated with disrespect—or a failure to honor another person's dignity or worth, while humanization refers to honoring the full identity, community, and dignity of another human being. The negative impacts of dehumanization of ICU patients may be substantial and lasting. The prevalence of emotional exhaustion and burnout experienced by many ICU staff may be linked to the unintentional dehumanizing behaviors witnessed by patients/family members. Humanization, on the other hand, may also be associated with outcomes such as improved communication and decreased psychologic morbidity among patients. Because the impact of dehumanization and humanization may be significant, this study aims to understand how ICU patients are dehumanized and humanized. By understanding the perspectives of doctors, nurses, patients and families, we hope that this study will help us to improvise the root causes associated with such behaviors.
References
1.Brown SM, Azoulay E, Benoit D, et al. The practice of respect in the ICU. Am J Respir Crit Care Med. 2018;197:1389–1395. doi: 10.1164/rccm.201708-1676CP. [DOI] [PubMed] [Google Scholar]
2.Law AC, Roche S, Reichheld A, et al. Failures in the respectful care of critically ill patients. Jt Comm J Qual Patient Saf. 2019;45:276–284. doi: 10.1016/j.jcjq.2018.05.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
The Incidence and Etiology of Central Line Associated Bloodstream Infections in Intensive Care Unit Patients at a Tertiary Care Hospital in Bareilly (U.P.), India
Central venous catheter/line is integral to current day ICU practice for various purposes like delivery of medicines/vasopressors/blood products, hemodynamic monitoring, parenteral nutrition and blood sample collection. At times these are complicated by bloodstream infections resulting in increased morbidity and mortality therefore arising need for generating current incidence rates and etiology of CLABSI (central line associated bloodstream infections) in tertiary care center in North India.
Materials and methods
This is a prospective observational study conducted in medical intensive care unit of SRMS-IMS, Bareilly for a period of 18 months (January 2022 to July 2023). All patients with CVC for >48 h admitted to the ICU were enrolled. CLABSI was defined as per CDC (Center of disease control) criteria and its surveillance done from International Nosocomial Infection Control Consortium surveillance system. Further its incidence and etiology were calculated.
Results
Incidence rate of CLABSI was 7.53 per 1000 catheter days with 95% CI of 4.598 to 11.625 per 1000 catheter days. In the ICU, Staphylococcus aureus was the predominant organism, identified in 40.00% of cases followed by Klebsiella pneumoniae and Acinetobacter baumanii.
Conclusion
A central line-associated bloodstream infection (CLABSI) is a laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of central line placement. This study was done for early detection and prevention of CLABSI and decreasing its incidence and antimicrobial resistance by thorough surveillance and multidisciplinary implementation of infection control measures.
References
1.Hallam C, Jackson T, Rajgopal A, Russell B. Establishing catheter-related bloodstream infection surveillance to drive improvement. J Infect Prev. 2018 Jul;19(4):160–166. doi: 10.1177/1757177418767759. [PMC free article] [PubMed] [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Mishra S.B, Misra R, Azim A, Baronia A.K, Prasad K.N, Dhole T.N, Gurjar M, Singh R.K, Poddar B. Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India. International Journal for Quality in Health Care. February 2017;Volume 29(Issue 1):63–67. doi: 10.1093/intqhc/mzw144. Pages. [DOI] [PubMed] [Google Scholar]
3.Tanu Singhal, Sweta Shah, Pooja Thakkar, Reshma Naik. The Incidence, Aetiology and Antimicrobial Susceptibility of Central Line-Associated Bloodstream Infections in Intensive Care Unit Patients at a Private Tertiary Care Hospital in Mumbai, India. Indian Journal of Medical Microbiology. 2019;Volume 37(Issue 4):521–526. doi: 10.4103/ijmm.IJMM_20_3. Pages. ISSN 0255-0857. [DOI] [PubMed] [Google Scholar]
4.Chopdekar K, Chande C, Chavan S, Veer P, Wabale V, Vishwakarma K, et al. Central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in Mumbai. Indian J Med Microbiol. 2011;29:169–171. doi: 10.4103/0255-0857.81796. pp. [DOI] [PubMed] [Google Scholar]
5.Kaur M, Gupta V, Gombar S, Chander J, Sahoo T. Incidence, risk factors, microbiology of venous catheter associated bloodstream infections – A prospective study from a tertiary care hospital. Indian J Med Microbiol. 2015;33:248–254. doi: 10.4103/0255-0857.153572. pp. [DOI] [PubMed] [Google Scholar]
Increases in cases linked to klebsiella that are resistant to carbapenem have been documented (1, 2). The main concerns with these organisms are that they are challenging to treat. The patients frequently experience higher rates of morbidity and mortality, and the infection can spread.
Objectives
To study the pattern and incidence of carbapenam resistant klebsiella in an intensive care unit and determine the risk factors for mortality.
Materials and methods
Patients who tested positive for carbapenam-resistant Klebsiella and were admitted to Bangalore Baptist Hospital's intensive care unit between June 2022 and November 2023 were the subjects of a retrospective observational study. The study involved 43 patients. All patients who had culture positivity for multidrug resistant klebsiella had carbapenamase resistance testing done. Data was recorded in an Excel spreadsheet, and analysis was done using SPSS software.
Results
The study comprised 43 patients who were admitted to the intensive care unit and whose carbapenam-resistant Klebsiella (CRK) test result was positive. There were 28 patients who were male and 15 who were female. The average age was fifty-nine. Diabetics made up the majority of the patients (28/43; 65.1%). Sputum cultures had the highest positive rate (16/43; 37.2%). Incidence of CRK during this time was 7 cases per 1000 people-year (1.1%). Twenty patients tested positive for OXA-48 and NDM. Fifteen patients had NDM positivity, while eight patients had OXA-48 positivity. The NDM group and the NDM plus OXA-48 group had the same mortality rate, while the OXA-48 positive group had a slightly higher death rate (4%, 4%, and 6%, respectively). 36 patients were discharged and 7 patients died. A favorable association between mortality and increasing age, serum procalcitonin levels, total whole blood cell count, and more comorbidities was demonstrated by univariate logistic regression.
Discussions
The incidence of CRK was 7 cases per 1000 patient years(1.1%). This is lesser than has been reported previously in other regions (3, 4). Male predominance and sputum cultures showing highest positivity(37.2%) were findings similar to other studies. Many patients had more than one comorbidity (27/43; 62.8%). Diabetes mellitus was the most common comorbidity (28/43). In our study maximum CRK isolates had positivity for both NDM and OXA-48 (20/43;46.5%) and the remaining were either NDM (15/43;34.8%) or OXA-48 positive(8/43;18.6%). In India, carbapenem resistance is predominantly due to NDM and OXA-48-like species (5). Our study showed similar findings. Mortality rates for the NDM positive group, both NDM and OXA-48 group and OXA-48 positive group were 4%, 4% and 6% respectively. Overall mortality was 16.2%. This was lower in comparison to previous studies from China(6) and India(7). Univariate logistic regression showed positive correlation of increasing age, serum procalcitonin values, total WBC count and more number of comorbidities with mortality.
References
1.Chamieh A, El-Hajj G, Zmerli O, Afif C, Azar E. Carbapenem resistant organisms: A 9-year surveillance and trends at Saint George University Medical Center. J Infect Public Health. 2020 Dec 1;13(12):2101–6. doi: 10.1016/j.jiph.2019.02.019. [DOI] [PubMed] [Google Scholar]
2.Moghadampour M, Salari-Jazi A, Faghri J. High rate of carbapenem-resistant Klebsiella pneumoniae detected from hospital equipments in Iran. Acta Microbiol Immunol Hung. 2018 Dec 1;65(4):529–38. doi: 10.1556/030.65.2018.039. [DOI] [PubMed] [Google Scholar]
3.Bratu S, Landman D, Haag R, Recco R, Eramo A, Alam M, et al. Rapid spread of carbapenem-resistant Klebsiella pneumoniae in New York City: a new threat to our antibiotic armamentarium. Arch Intern Med. 2005 Jun 27;165(12):1430–5. doi: 10.1001/archinte.165.12.1430. [DOI] [PubMed] [Google Scholar]
4.Ashour HM, El-Sharif A. Species distribution and antimicrobial susceptibility of gram-negative aerobic bacteria in hospitalized cancer patients. J Transl Med. 2009 Dec;7(1):14. doi: 10.1186/1479-5876-7-14. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Nagaraj S, Chandran SP, Shamanna P, Macaden R. Carbapenem resistance among Escherichia coli and Klebsiella pneumoniae in a tertiary care hospital in south India. Indian J Med Microbiol. 2012;30(1):93–5. doi: 10.4103/0255-0857.93054. [DOI] [PubMed] [Google Scholar]
6.Chen J, Ma H, Huang X, Cui Y, Peng W, Zhu F, et al. Risk factors and mortality of carbapenem-resistant Klebsiella pneumoniae bloodstream infection in a tertiary-care hospital in China: an eight-year retrospective study. Antimicrob Resist Infect Control. 2022 Dec 19;11(1):161. doi: 10.1186/s13756-022-01204-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Gupta P, Bollam N, Mehta Y, Sengupta S, Gandra S. Risk factors associated with carbapenem-resistant Klebsiella pneumoniae bloodstream infections in a tertiary-care hospital in India. Infect Control Hosp Epidemiol. 2021 Nov;42(11):1418–20. doi: 10.1017/ice.2020.1280. [DOI] [PubMed] [Google Scholar]
Sleep is an indispensable physiological need often underestimated and disregarded especially in critically ill patients1. Sleep abnormalities occur frequently in the ICU. These abnormalities include sleep deprivation and disruption as well as abnormal sleep architecture2. Sleep deprivation has been associated with the release of inflammatory cytokines, worse cardiovascular outcomes, poorer immunological response, etc. Sleep disruption induces a catabolic state, impairs cellular and humoral immune response, and causes respiratory dysfunction due to muscle fatigue and central respiratory3. Factors affecting sleep in the ICU are numerous. In this study we aim to evaluate the sleep quality and sleep disturbing factors in patients in ICU.
Objectives
Primary Objective: To assess the quality of sleep in ICU patients. Secondary Objective: To evaluate the factors contributing to poor quality of sleep.
Materials and methods
A cross-sectional study using recall questionnaires was conducted on patients more than 18 years admitted to Bangalore Baptist Hospital Intensive Care Unit from November 2023 to December 2023. Study included patients who had an ICU stay of more than 72 hours, who were conscious and oriented to time place and person at the time of analysis and were screened for delirium using CAM ICU. The questionnaires used included the Richards- Campbell sleep questionnaire (RCSQ)4 to assess the sleep quality and modified freedman scale5 which collects data on environmental factors known to affect sleep quality. Patients with RCSQ score less than 50 was considered to have poor sleep3.
Results
Total of 50 patients were included in the study. Out of the 50 patients, 30 were male and 20 females. The mean age was 61.4 + 15.5 years. The main reason for stay in ICU was lower respiratory tract infection (25/50; 50%). 10 patients were mechanically ventilated prior to the assessment. The mean RCSQ score for our study population was 45.1 + 24.1. 60% patients had poor quality sleep (30/50). There was a significant reduction in self-reported quality of sleep from 9.4 + 0.78 at home to 4.62 + 2.51 in ICU (P<0.001). 17 out of 30 patients with poor quality sleep claimed nursing interventions, vital sign measurements, blood sample collection and administration of medicines as the major disruptive factor. Pain was the other main disruptive factor for the cause of poor-quality sleep (15/30). 4 out of 30 patients reported noise in ICU as the cause for poor sleep. 7 out of 10 mechanically ventilated patients had poor quality sleep. Additionally, we discovered that alterations in the sleeping locale of patients were a shared factor.
Discussions
There is high prevalence of poor-quality sleep among patients admitted to ICU. Our study shows that multiple factors are responsible for sleep disturbances in an ICU. Reduction of these factors is a chance to obtain better sleep quality in ICU. Attention must be brought to the medical staff working in the ICU to the significance of sleep and raise their awareness of the factors which may disturb sleep.
References
1.Parthasarathy S, Tobin MJ. Sleep in the Intensive Care Unit. Intensive Care Med. 2004;30:197–20. doi: 10.1007/s00134-003-2030-6. [DOI] [PubMed] [Google Scholar]
2.Pisani MA, Friese RS, Gehlbach BK, Schwab RJ, Weinhouse GL, Jones SF. Sleep in the intensive care unit. Am J Respir Crit Care Med. 2015 Apr 1;191(7);):731–8. doi: 10.1164/rccm.201411-2099CI. 25594808;PMC5447310 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Naik RD, Gupta K, Soneja M, Elavarasi A, Sreenivas V, Sinha S. Sleep quality and quantity in intensive care unit patients: A cross-sectional study. Indian J Crit Care Med. 2018;22:408–14. doi: 10.4103/ijccm.IJCCM_65_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Richards KC, O'Sullivan PS, Phillips RL. Measurement of sleep in critically ill patients. J Nurs Meas. 2000;8(2):131–44. [PubMed] [Google Scholar]
5.Freedman NS, Kotzer N, Schwab RJ. Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Respir Crit Care Med. 1999;159:1155–62. doi: 10.1164/ajrccm.159.4.9806141. [DOI] [PubMed] [Google Scholar]
6.Lewandowska K, Mędrzycka-Dąbrowska W, Kwiecień-Jaguś K, et al. Factors determining sleep in patients hospitalised in ICUs in a hospital in Northern Poland. Sleep Biol. Rhythms. 2019;17:243–250. doi: 10.1007/s41105-019-00207-2. [DOI] [Google Scholar]
7.Bihari S, McEvoy RD, Kim S, Woodman RJ, Bersten AD. Factors affecting sleep quality of patients in intensive care unit. J Clin Sleep Med. 2012;8(3);):301–307. doi: 10.5664/jcsm.1920. [DOI] [PMC free article] [PubMed] [Google Scholar]
To Study the Mortality in Organophosphate Poisoning Due to Lag Time Between Identification of Poisoning and Initiation of Treatment, Acute Renal Failure, and Acute Respiratory Failure In India
Treatment of OP poisoning includes early decontamination and administration of reversal agents- atropine and oximes. Delay or inadequate atropine can result in high mortality rates due to central respiratory depression, bronchospasm, excessive secretions, severe bradycardia, and hypotension.
Objectives
The aim is to know the overall mortality in OP poisoning patients compared to non-OP poisoning cases. Objectives are to collect the data of Adult ICU patients admitted with poisoning in our partner hospitals, To collect details on the time lag between the identification of poisoning by family members, reaching a healthcare center, and initiation of treatment, Renal functioning (BUN, Creatinine, u/o, and Acidosis) and the requirement of MV, days of MV, and outcomes extubated/tracheostomised/expired.
Materials and methods
This is an observational study conducted across multiple hospitals in India from a Smart-ICU hospital network. The data was extracted from a custom-built tele-ICU platform using Python (version: 3.6) and PostgreSQL on a cloud infrastructure. Data regarding patient demographics, comorbidities, vital signs, airway, and ventilatory strategies, ventilatory parameters at multiple points of time, use of antidotes, Renal function tests, complications, and outcomes are to be collected from the database. Statistical tests such as Mann-Whitney U and chi-square were used for continuous and categorical data. Univariable and multivariable logistic regression models were employed for outcome associations, with R version 4.1.2 used for all analyses. No pre-selection of variables occurred due to the study's exploratory nature. The significance threshold was set at P<0.05.
Results
Most patients who required intubation were on mechanical ventilation for 2-7 days. The Average APACHE score was 12.085, the age was 33.9 years. A total of 39.33% of patients required ventilatory support and Acute Kidney injury was noted in 5.68%. The overall mortality was 8.05%, 16.56% in those who required mechanical ventilation. In a study by Patil et al., the overall mortality was 6.52%, 22.22% in those who required mechanical ventilation, 100% in the patients on the ventilator for less than 2 days, and 50% on mechanical ventilation for more than 7 days. The average duration of mechanical ventilation was 4.00 ± 2.24 days. There was no statistically significant association of mortality with age, lag time, the severity of poisoning, and duration of ventilation independently. This signifies that death due to OP poisoning is due to the overlapping of all these factors. In this study, the mechanical ventilation rate was inversely proportional to serum cholinesterase levels, and mortality was directly proportional to age, mechanical ventilation duration, and OP poisoning severity.
Conclusions
Identification of poisoning, reaching a healthcare center, initiation of treatment, administration of antidotes, and recognizing respiratory failure are key points in managing OP poisoning patients. Respiratory failure can be due to various reasons, like excessive secretions, aspiration pneumonia, neuromuscular involvement, sepsis, and adult respiratory distress syndrome. Timely recognition of respiratory failure, early endotracheal intubation, and mechanical ventilation are life-saving in severe OP poisoning.
Reference
1.Patil, Murthy, Nikhil “Contributing Factors for Morbidity and Mortality in Patients with Organophosphate Poisoning on Mechanical Ventilation.”. [DOI] [PMC free article] [PubMed]
Utility of Combined Thoracic Ultrasound and Echocardiography to Predict Spontaneous Breathing Trial and Extubation Failure in Mechanically Ventilated Children in Pediatric Intensive Care Unit: A Prospective Study
1Paediatric Intensive Care Unit, Institue of Child Health, Sir Ganga Ram Hospital, New Delhi, India, Phone: +91 9582195606, e-mail: abhichdhr14@gmail.com
1Paediatric Intensive Care Unit, Institue of Child Health, Sir Ganga Ram Hospital, New Delhi, India, Phone: +91 9582195606, e-mail: abhichdhr14@gmail.com
2,3Paediatric Intensive Care Unit, Institue of Child Health, Sir Ganga Ram Hospital, New Delhi, India
We aimed to assess combined predictive ability of ultrasound lung, diaphragm and echocardiography variables, to anticipate failure of spontaneous breathing trial (SBT) and extubation.
Methods
We conducted a prospective observational study in 73 consecutive mechanically ventilated children aged (1month-18years) eligible for SBT as per protocol. Comprehensive USG lung, diaphragm and echocardiography was performed by single trained paediatric intensivist 30 minutes before initiating SBT to measure lung aeration score (LAS), diaphragmatic thickening fraction (DTF-R) preferred right due to ease of access and left ventricular (LV) systolic and diastolic function. Children succeeded SBT were given extubation trial. Outcome variables were analysed individually between success and failure groups of SBT and extubation trial respectively.
Results
Among 73 subjects enrolled pre SBT, SBT success group(n=65) had significantly high mean DTF-R (%) (34.66 ± 12.70) in comparison to SBT failure group(n=8) (18.95 ± 11.56) (p, 0.004). Children who passed SBT as per clinical protocol and successfully extubated (n=57) had mean DTF-R (%)(35.09 ± 13.17) comparable to (31.59 ± 8.64) extubation failure group(n=8) (p, 0.63). Extubation success group had significantly low LAS (15.98 ± 4.49) in contrast to extubation failure group (21.75 ± 6.30) (p,0.012). LV diastolic dysfunction (LVDD) defined by E/ E’ cutoff (≥10)1 had diagnostic accuracy of 86.2% to predict extubation failure individually. Whereas, combined predictive ability of DTF(R)+LAS+LVDD to predict extubation failure was superior to individual variables (AUROC, 0.82) (p=0.004).
The combined ultrasound evaluation of heart, lung and diaphragm in comparison to individual variables, significantly enhanced prediction accuracy of extubation failure before SBT in children. DTF alone is a non-reliable marker for prediction of extubation failure.
Reference
1.Ginsburg S, Conlon T, Himebauch A, Glau C, Weiss S, Weber MD, O'Connor MJ, Nishisaki A. Left Ventricular Diastolic Dysfunction in Pediatric Sepsis: Outcomes in a Single-Center Retrospective Cohort Study. Pediatr Crit Care Med. 2021 Mar 1;22(3);):275–285. doi: 10.1097/PCC.0000000000002668. [DOI] [PubMed] [Google Scholar]
Delirium in the intensive care unit (ICU) has been an independent predictor for mortality, increased length of stay, and long-term cognitive impairment.1 Several factors including the ICU environment can precipitate delirium2.
Objectives
We conducted a prospective observational study to assess the incidence, risk factors, and outcomes of delirium in mechanically ventilated patients admitted to ICU. Hospital mortality, Duration of mechanical ventilation (MV), Length of stay in the intensive care unit and need for home Care Services after hospital discharge were secondary objectives.
Methods
All consecutive ICU admissions, aged 18-80 years, on mechanical ventilation > 48 hours and planned for weaning were enrolled. Patients who had traumatic brain injury, or on infusion of anaesthetic drugs were excluded. Screening for delirium was done by the resident doctor using Confusion Assessment Method in ICU (CAM-ICU). It was done daily from the day the T-piece trial was started, then after extubation, and subsequently seven days after weaning. Assessment of possible risk factors of delirium such as severity of illness score (by APACHE II Score), age, co-morbidities, psychoactive drug exposure in ICU (cumulative doses of opioids, benzodiazepines, antipsychotics, and anticholinergics), use of physical restraint was recorded.
Results
From among a total of 90 patients 44 (48.9%) were found to have delirium. The predominant indication for ICU admission was Community Acquired Pneumonia (16/90, 17.7%), and Sepsis Induced AKI (13/90. 14.4%). The median cumulative dose of opioid use was 2550 mcg (IQR 625-6025) for a median period of 3 days (IQR 2-5). Among the 57 patients discharged alive from the hospital 11 patients (19.3%) needed professional home care. In the Univariate analysis comparing the groups having delirium and not having delirium, the factors associated with delirium were higher median age, APACHE Score, and SOFA Scores. Among the risk factors, only neurological disorders were significantly associated with delirium. In outcome parameters, mortality, length of stay in ICU and hospital, and ventilator days were significantly higher in the delirium group. (See Table 2)
Despite being unreported delirium has a high incidence. Mortality and other surrogates of outcomes are worse in patients who suffer from delirium during their ICU stay. All attempts should be made for early diagnosis and aggressive management of delirium.
References
1.Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753–62. doi: 10.1001/jama.291.14.1753. [DOI] [PubMed] [Google Scholar]
2.Pandharipande P, Cotton BA, Shintani A, et al. Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients. J Trauma. 2008;65:34–41. doi: 10.1097/TA.0b013e31814b2c4d. [DOI] [PMC free article] [PubMed] [Google Scholar]
Sepsis is one of the most common cause of morbidity and mortality in ICU. Prediction of mortality and morbidity in patients with suspected sepsis is important for prompt action and prognostication. A number of parameters have been defined for prediction of mortality and morbidity in sepsis. But further studies are required to establish non invasive, accurate, easily and readily available predictors of mortality and morbidity in patients with suspected sepsis.
Objectives of the Study
The aim of this study is to compare the efficacy of arterial to end tidal carbon dioxide difference as a marker of mortality and morbidity in patients with suspected sepsis.
Materials and methods used
Patients admitted to MICU with qSOFA more than 2 and suspected sepsis by clinician requiring ventilator will be secured of study inclusion. After confirming with inclusion and exclusion criteria, formal consent was taken from legally authorised relative. Demographic and hemodynamic variables, diagnosis and intervention done were captured on daily basis. The ETCO2- PCO2 gap was recorded on admission, after 24 hrs and 48 hrs. Patients were followed up till discharge/death or till 28 days whichever is earlier. Data were coded and recorded in MS Excel spreadsheet program. SPSS v23 (IBM Corp.) were used for data analysis. Appropriate statistical tests were applied for data analysis.
Results
Awaited.
Conclusion
Awaited
Keywords
Sepsis, Morbidity, Mortality, ETCO2, PCO2.
References
1.Singer M, Deutschman CS, Seymour CW, et al. The third in- ternational consensus definitions for sepsis and septic shock (Sepsis-3) JAMA. 2016;315:801–810. doi: 10.1001/jama.2016.0287. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Fleischmann C, Scherag A, Adhikari NK, et al. International Forum of Acute Care Trialists: Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med. 2016;193:259–272. doi: 10.1164/rccm.201504-0781OC. [DOI] [PubMed] [Google Scholar]
3.A-Struzek C, Mellhammar L, Rose N, et al. Incidence and mortality of hospital- and ICU-treated sepsis: Results from an updated and expanded systematic review and meta-analysis. Intensive Care Med. 2020;46:1552–1562. doi: 10.1007/s00134-020-06151-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Rhee C, Dantes R, Epstein L, et al. CDC Prevention Epicenter Program: Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA. 2017;318:1241–1249. doi: 10.1001/jama.2017.13836. [DOI] [PMC free article] [PubMed] [Google Scholar]
Paraquat (PQ; 1, 1′-Dimethyl-4, 4′-bipyridinium dichloride) is a herbicide used for suicidal consumption which metabolises to generate free radicals causing MODS; especially AKI and ARDS. Outcomes are dismal with mortality up to 50-90% despite supportive therapy owing to lack of specific antidote. Our ICU recorded around 102 cases in the last 5 years; with similar in mortality. Many invitro, animal and human studies have tried Extracorporeal therapies with mixed outcomes regarding timing of initiation on survival. We have been using resin based-HA230 since October 2021 hemadsorbent filters and observed improved outcomes.
Objectives
To study the effect of Hemadsorbent filter (HA230) and timing of initiation on the outcomes in acute paraquat poisoning.
Materials and methods
Retrospective Observational study, from November 2021 to November 2023;Included all patients admitted to our ICU with Paraquat poisoning. Data acquisition was from case records including demographic, clinical, amount of PQ consumed and treatment details including Extracorporeal therapies were noted and findings were tabulated and analysed.
Results
54 patients which included 45 males (83%) and 9 females (17%). Mean-age of 38yrs.;Average APACHE II score was 9. Mean amount of PQ consumed was 104.3ml. Total 9 patients left against medical advice so 45 patients were taken for analysis. Study observed acute Kidney Injury in 32patients (71.11%), ARDS in 19 patients 42.22%, Hemodynamic instability in 15 patients 33.33% and Acute liver injury in 22 patients (48.88%). Mean peak creatinine was 4.2mg/dl, Lowest mean p/f ratio was 120, mean total bilirubin was 6.8mg/dl and mean transaminitis > 3times ULN. Out of 45 patients 34 (75.55%) patients were died and 11(24.44%) patients were discharged. The average hospital length of stay in patients who were survived is 9days. Hemoperfusion was done using HA230 filter in 32 patients of which 11 (34.37%) patients survived and 21 (65.62%) patients died. Notably all discharged patients underwent hemoperfusion within a mean time of 6 hours of consumption. In patients who underwent early hemoperfusion had a mean peak serum creatinine of 1.5mg/dl, Lowest mean p/f ratio was 280, mean total bilirubin of 2.2mg/dl and mean transaminitis < 3times ULN. The mean amount of PQ consumed in patients who underwent early hemoperfusion was 32ml. Urine dithionate was done in 36 patients of which 15 were positive and 21 were negative.
Early extracorporeal therapy is crucial for better clinical outcomes and survival in patients with acute paraquat poisoning.
References
1.Gunnell D, Eddleston M, Phillips M.R, Konradsen F. The globaldistribution of fatal pesticide self-poisoning: Systematic review. BMCPublic Health. 2007;7:357. doi: 10.1186/1471-2458-7-357. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Lee H.L, Lin H.J, Yeh S.T, Chi C.H, Guo H.R. Presentations of patients of poisoningand predictors of poisoning-related fatality: Findings from a hospital-based prospective study. BMC Public Health. 2008;8:7. doi: 10.1186/1471-2458-8-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Ravichandran R, Amalnath D, Shaha KK, Srinivas BH. Paraquat Poisoning: A Retrospective Study of 55 PatientsFrom a Tertiary Care Center in Southern India. Indian J Crit Care Med. 2020 Mar;24(3):155–159. doi: 10.5005/jp-journals-10071-23369. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Rao R, Bhat R, Pathadka S, Chenji SK, Dsouza S. Golden Hours in SevereParaquat Poisoning-The Role of Early Haemoperfusion Therapy. J ClinDiagn Res. 2017 Feb;11(2):OC06–OC08. doi: 10.7860/JCDR/2017/24764.9166. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Yeh YT, Chen CK, Lin CC, Chang CM, Lan KP, How CK, Yen HT, Chen YC. Does Hemoperfusion IncreaseSurvival in Acute Paraquat Poisoning? A Retrospective MulticenterStudy. Toxics. 2020 Oct 10;8(4):84. doi: 10.3390/toxics8040084. [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Li A, Li W, Hao F, Wang H. EarlyStage Blood Purification for Paraquat Poisoning: A MulticenterRetrospective Study. Blood Purif. 2016;42:93–99. doi: 10.1159/000445991. [DOI] [PubMed] [Google Scholar]
1Division of Paediatric Emergency, Intensive Care, Pulmonology, Department of Paediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India, Phone: +91 8220414612, e-mail: drmohammedashifp@gmail.com
1Division of Paediatric Emergency, Intensive Care, Pulmonology, Department of Paediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India, Phone: +91 8220414612, e-mail: drmohammedashifp@gmail.com
2,3Department of Pediatric Emergency Critical Care Pulmonology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
Mechanical power (MP) of ventilation is the energy dissipated into the respiratory system by the ventilator per minute. Adult studies have demonstrated positive correlation between MP and mortality.1 This study aims to find out the predictive ability of MP for mortality in ventilated children.
Objectives
We aimed to assess the predictive ability of Mechanical power (MP) at 12 and 24 hours of ventilation for mortality in children during Paediatric Intensive Care Unit (PICU) stay. The secondary outcomes were to find-out the correlation between MP vs 28-day ventilator free days (VFD), duration of ICU stay and hospital stay.
Material and methods
This prospective observational study was conducted over 1 year at 12-bedded PICU of a tertiary care referral and teaching hospital of North India after obtaining IRB clearance. 75 new orotracheally ventilated children receiving decelerating flow were enrolled after parental consent. MP [= 0.098×RR×VT(PEEP+?Pinsp) J/min] at 12 and 24 hours of ventilation was calculated.2 Children were followed for survival and duration of stay in PICU. AU-ROC analysis of measured variables was performed to evaluate diagnostic accuracy. Spearman's Rank correlation coefficient used to find-out the correlation between 28-day VFD, hospital stay, ICU stay with MP.
Results
Of the 75 participants, 52 were male with a median age of 48 months (IQR-16.5,108). The mean MP(±SD) 12 and 24 hours were 8.11±5.44 and 8.29±6.51 respectively. The mean MP(±SD) 12 values were 7.27±4.0 vs 12.51±9.17 and for MP 24 hours 7.26±4.46 vs 13.7±11.60 for survivor (n=63) and non-survivor (n=12) group respectively (p<0.05). Area under ROC to predict in-hospital mortality was higher for MP 24 (AU-ROC 0.706) when compared to MP 12 hours (AU-ROC 0.687) (p >0.05). MP to predicted body weight (MP/PBW) had a better AU-ROC compared to MP or driving pressure (AU-ROC for MP/PBW 24 = 0.73). For MP 12 hours, a value of 10.5 had the sensitivity 42%, specificity 84%, positive predictive value (PPV) 33%, negative predictive value (NPV) 88 % and diagnostic accuracy of 77%, while for MP 24 hours a value of 8.95 had a sensitivity 67%, specificity 78%, PPV 36%, and NPV 92% and diagnostic accuracy of 72% to predict mortality. At cut off value of < 8.95 J/min of MP 24 had survival benefit (Kaplan-Meier survival analysis Log rank 8.1, p<0.05). In subgroup analysis of survivors, MP had negative correlation (r=-0.6, p<0.05) with 28 day-VFD in children aged 12-18 years.
Conclusion
MP and MP/PBW at 24 hours of ventilation is a better predictor of mortality than MP at 12 hours in children. Patients with higher MP should be considered for early escalation to extracorporeal support. In survivor group, higher MP was associated with fewer 28 day-VFD in children ≥ 12 years.
References
1.Serpa Neto A, Deliberato RO, Johnson A, Bos LD, Amorim P, Pereira SM, et al. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med. 2018;44:1914–1922. doi: 10.1007/s00134-018-5375-6. [DOI] [PubMed] [Google Scholar]
2.Becher T, van der Staay M, Schadler D, Frerichs I, Weiler N. Calculation of mechanical power for pressure-controlled ventilation. Intensive Care Med. 2019;45:1321–1323. doi: 10.1007/s00134-019-05636-8. [DOI] [PubMed] [Google Scholar]
Intraabdominal pressure (IAP) monitoring is recommended in all ventilated children according to the established guidelines. There is a knowledge gap about the relationship between IAP and lung mechanics among ventilated children.
Aims and Objectives
This study aims to assess the correlation of IAP with lung mechanics among ventilated children.
Methods
This prospective observational study was conducted for 1-year at a 12-bed PICU of a tertiary care referral and teaching hospital in North India after obtaining IRB clearance. Children (1 month to 18 years) requiring ventilation in the PICU were eligible to participate after parental consent. Baseline demographic, blood gas, ventilatory, and lung mechanics parameters were recorded. The outcome measures such as IAP (by trans-bladder technique), peak inspiratory pressure (Ppeak), plateau pressure (Pplat), mean airway pressure (Pmean), dynamic lung compliance (Cdyn/kg) and static lung compliance (Cstat/Kg) were recorded every 6th hour till maximum 5 days of ventilation or until extubation or death, whichever was early. The primary outcome is to correlate between IAP and lung mechanics using Spearman's rank correlation coefficient (r) and the secondary outcome is to compare the correlations using the Fischer z-transformation method in injured vs. non-injured lung parenchyma, defined by oxygenation index (OI ≥vs< 4).
Results
The median(IQR) age among the 60 participants was 6 years (1.25-10) with male predilection (M: F 2:1). The median(IQR) of study parameters for IAP (mm Hg), Ppeak (cmH2O), Pplat (cmH2O), Pmean (cmH2O), Cdyn/kg (ml/kg/cmH2O) and Cstat/Kg (ml/kg/cmH2O) were 7(6,9), 18(16,22), 17(15,20), 10(9,12), 0.57(0.47,0.74) and 0.62(0.51,0.79) respectively. Intraabdominal hypertension(IAP>10 mm Hg) was present in 20 % of the patients. IAP had a positive correlation with Pmean (r = 0.41), Ppeak (r = 0.34), Pplat (r = 0.33) and a negative correlation with Cdyn/kg (r = -0.34), Cstat/kg (r=-0.35) in the study subjects (p<0.01). There was a higher correlation (r) observed among certain lung parameters with IAP in children with injured (Pmean = 0.4; Cdyn/kg = -0.35; Cstat/Kg= -0.4) versus non-injured (Pmean = 0.25; Cdyn/kg = -0.23; Cstat/Kg= -0.2) lung parenchyma (p <0.01).
Conclusion
This study showed a significant correlation between IAP and lung mechanics. IAP was significantly associated with P mean, C dyn/Kg and C stat/Kg in children with injured lung parenchyma in comparison with non-injured lung parenchyma.
In-hospital Cardiac Arrest Resuscitation (ICAR): Impact of Nurse-initiated Adrenaline Administration on Recognition of Cardiac Arrest [Ihca]-A Retrospective Pre-post Intervention Study
Adrenaline, an alpha and beta agonist, has been established as a life-saving drug, strongly influencing Return Of Spontaneous Circulation(ROSC) and hence had found its place in ACLS guidelines.[1][2][3] Though most hospitals have a Cardiac Arrest Resuscitation Team(CART), there was great spectrum of difference that each member takes to appear at the scene of action and thus delay in instituting focused therapy including Adrenaline, occasionally as late as 30 minutes. As nurses are almost always the primary witnesses in bedside, empowering nurses in ACLS training, including administration of drugs like Adrenaline[4][5] was decided to be studied in a tertiary care center in South India for IHCA.
Objectives
To assess and compare ACLS effectiveness resulting in an improvement in outcomes between doctor-led administration versus early nurse-led administration of first-dose adrenaline for IHCA in a tertiary care center over 3 years.
Materials and methods
Our retrospective descriptive observational study was conducted in ward patients, aged 18years or above, who had sustained IHCA and resuscitation initiated as per ACLS protocol. Databases were retrieved from CART resuscitation analysis sheets and Electronic Medical Records, during the period of November 2019 till December 2021 and was segregated into pre-and post-intervention arm, based on hospital protocol of ‘early nurse-led adrenaline administration without doctor's pre-order’ enforced since 27/11/2019]. Primary outcome was number of patients with ROSC and other outcomes assessed included time to adrenaline, time to ROSC, and proportion of survived-to-24 hours and -to-discharge.
Results
We analysed data on 467 eligible patients with IHCA arrests, of which, first rhythm analysis at arrest were 425[91%]asystole, 25[5.4%]PEA, 10[2.1%]Vf and 7[1.5%]pulselessVT. Mean age was 52.39+/-15.96years. 36.4% were females and 63.6% were males. ROSC was achieved in 269[57.6%] resuscitated IHCA patients, of which 48.6% had arrest within next 24 hours and survival-to-24 hours was 31.3% and survival-to-discharge was 13.5%. Pre-intervention arm[01/11/2018-26/11/2019] had 170 patients and post-intervention arm [27/11/2019-31/12/2021] had 297 patients. Proportion of ROSC achieved in both arms were similar[57.6%]. In post-intervention arm, compliance to adrenaline administration was significantly better[63%vs75%, p<0.01] and median time-to-adrenaline was significantly faster[3.5min-IQR(0.75, 6.25) vs 2min-IQR(0, 3) p<0.000]. Median time-to-CART activation [4min-IQR(1, 7) vs 2min-IQR(0, 3)] and median time-to-CART arrival [6.5min-IQR(4, 10) vs 4min-IQR(3, 6), p<0.000] was significantly earlier in post-intervention arm. Reversible causes were identified and treated in 79.3% post-intervention compared to 53.1% pre-intervention arm patients, with better CART resuscitation appropriateness in post-intervention arm [47.6%vs60.6%, p<0.000]. Median time-to-ROSC among those survived post CPR was significantly earlier in post-intervention arm[22min-IQR(15, 40) vs 12-IQR(8, 22)p<0.000].
Discussion
Cardiac arrest resuscitation was seen more in middle-aged males in hospital-wards. Most arrests were witnessed but few monitored in wards, attributing to a possibility of lesser identification of shockable rhythms in wards than areas closely monitored. Early adrenaline administration was found to be significantly improved in post-intervention arm and also had enhanced quality of CPR-ACLS outcome, in terms of improved time to ROSC. CART team effectiveness in terms of activation, response, adherence to ACLS guidelines and reversible cause assessment was significantly better in post-intervention arm. Studies on a larger scale are warranted to assess effect of early adrenaline on IHCA resuscitation outcomes including neurological outcome.
References
1.Olasveengen TM, Wik L, Sunde K, Steen PA. Outcome when adrenaline was actually given vs not given-post hoc analysis of RCT. Resuscitation. 2012Mar;83(3):327–32:. doi: 10.1016/j.resuscitation.2011.11.011. 22115931 10.1016/j.resuscitation.2011.11.011. Epub 2011 Nov 22. [DOI] [PubMed] [Google Scholar]
2.Sigal AP, Sandel KM, Buckler DG, Wasser T, Abella BS. Impact of adrenaline dose and timing on out-of-hospital cardiac arrest survival and neurological outcomes. Resuscitation. 2019Jun;139:182–188. doi: 10.1016/j.resuscitation.2019.04.018. 30991079 Epub 2019 Apr 13. [DOI] [PubMed] [Google Scholar]
3.Perkins GD, et al. The influence of time to adrenaline administration in Paramedic 2 RCT. Intensive Care Med. 2020 Mar;46(3):426–436. doi: 10.1007/s00134-019-05836-2. 31912202;PMC7067734 Epub 2020 Jan 7. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Andersen LW, et al. A Get With Guidelines–Resuscitation Investigators. Time to Epinephrine and Survival After Pediatric IHCA. JAMA. 2015 Aug 25;314(8):802–10. doi: 10.1001/jama.2015.9678. 26305650;PMC6191294 [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Guetterman TC, et al. Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals. BMJ Qual Saf. 2019 Nov;28(11):916–924. doi: 10.1136/bmjqs-2019-009487. 31420410 Epub 2019 Aug 16. [DOI] [PubMed] [Google Scholar]
Sepsis is a dysregulated inflammatory response to an infection that may result in septic shock. In the initial phase of septic shock, large quantities of fluid are to be administered which may result in venous congestion. Venous congestion may result in organ dysfunction. Cumulative fluid balance is used as a crude method for assessing venous congestion. In our study, a new monitoring tool, the VEXUS score is used to look for its correlation with cumulative fluid balance.
Objectives
To evaluate the correlation between venous excess ultrasound (VExUS) score with cumulative fluid balance. To assess the relationship between venous excess ultrasound (VExUS) score Sequential Organ Failure Assessment score, ICU mortality, and ICU length of stay.
Materials and methods
A single-centered prospective observational study was conducted, focusing on patients diagnosed with septic shock and admitted to the medical intensive care unit. Enrollment of patients into the study was followed by treatment per departmental policy, guided by the Surviving Sepsis Campaign guidelines. Fluid management was determined by the treating physician's discretion. The venous excess ultrasound (VExUS) scan and cumulative fluid balance were recorded on the 1st, 7th, and 14th day of admission. Additionally, the Acute Physiology And Chronic Health Evaluation (APACHE), duration of length of ICU stay and ICU survival outcomes were documented for each patient.
Results
In this study conducted on 150 ICU patients with septic shock, 47 were ultimately included in the analysis. The demographic composition of this group revealed a predominance of males, accounting for 63.8%, with an average age of 56.48 years. Among the survivors(20) vs non survivors(27) the average age was 57 years vs 56.11yrs, average SOFA score was 6.65 vs 9.03, and average APACHE score was 25.6 vs 23.9 upon admission. Cumulative fluid balances among survivors and non survivors was 1651.7ml vs 1928ml, 5710.5ml vs 5007.2ml and 5432ml vs 8152ml on days 1, 7 and 14 respectively. The distribution of VExUS scores showed significant changes over the course of the days. On the first day, 75% of patients had a score of 0, but by day 14, this number increased to 88.8%. Notably, in multivariate analysis, the VExUS score showed a correlation with cumulative fluid balance on day 1, but this correlation did not hold on days 7 and 14. Finally, the mean duration of ICU stay differed between survivors and non-survivors, being 6 days and 9.18 days, respectively. Box plot showing correlation between VEXUS score and Cumulative fluid balance.
The study indicates that the VExUS score reliable indicator of venous congestion in septic shock patients in ICU, but only on the first day of admission.
References
1.Acheampong A, Vincent JL. A positive fluid balance is an independent prognostic factor in patients with sepsis. Crit Care [Internet] 2015;19(1):1–7. doi: 10.1186/s13054-015-0970-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J [Internet] 2020 doi: 10.1186/s13089-020-00163-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Sirvent JM, Ferri C, Baró A, Murcia C, Lorencio C. Fluid balance in sepsis and septic shock as a determining factor of mortality. Am J Emerg Med [Internet] 2015;33(2):186–9. doi: 10.1016/j.ajem.2014.11.016. [DOI] [PubMed] [Google Scholar]
Nasogastric feeding tube is routinely positioned in intensive care units. The complications of misplacement are rare but very dangerous for patients. The aim of this study is to estimate the diagnostic accuracy of this view technique, 3-point ultrasonography to confirm nasogastric tube placement in intensive care.
Methods
Fifty critical ill patients monitored in ICU were included. The intensivist provided in real time to perform the exam in three steps: sonography from either the right or left side of the patient's neck to visualize esophagus, sonography of epigastrium to confirm the passage through the antrum and fundus. Finally, gastric placement of the nasogastric feeding tube was confirmed with thorax radiograph.
Results
Fifty of the gastric tubes were visualized by sonography in the digestive tract and all were confirmed by radiography (sensitivity 100%). The entire sonography procedure, including the longitudinal and transversal scan of the esophagus, the esophagogastric junction, the antrum and the fundus, took 10 min.
Conclusions
Our pilot study demonstrated that not weighted-tip gastric tube routinely used in intensive care is visible with the sonography. The pilot study confirmed the high sensitivity of the sonographyin verifying correct positioning of gastric tube in adult ICU patients. The ultrasound examination seems to be easy and rapid even when performed by an intesivist with a sonographic training. The sonographic exam at the bedside was performed in a shorter time than the acquisition and reporting of the X-ray.
A prospective observational study of the etiology and outcome of critical care admissions in patients of chronic kidney disease on maintenance hemodialysis
Patients with chronic kidney disease (CKD) undergoing maintenance hemodialysis (MHD) often face diverse complications requiring critical care admission. This study aims to elucidate the case profiles, mortality predictors, and short- and long-term outcomes of CKD patients admitted to critical care units (CCUs). With limited data in low and middle-income countries, the study seeks to investigate the causes of CCU admission, shedding light on factors influencing these admissions for improved management and potential reduction in frequency.
Objectives
The primary objectives include identifying major reasons for CCU admissions, gathering comprehensive clinical profiles, exploring correlations between diagnosis, outcomes, and dialysis-related parameters, and documenting associated co-morbidities and CKD complications. The study ultimately aims to enhance CKD patient care through evidence-based insights for prevention and intervention.
Materials and methods
Conducted at AMRI Hospital in Kolkata, a tertiary care facility, the observational study spanned 20 months (May 2021 to January 2023) and included adult CKD patients on MHD for over 3 months. Data encompassed demographic information, clinical profiles, and outcome parameters. Correlations were established between clinical profiles and outcomes, following approval from the ethics committee.
Results
Among 164 CKD patients on MHD admitted to CCU, findings revealed a predominant age group of 61-80 years, equal gender distribution, and significant associations between nutritional scores, SOFA/APACHE II scores, and outcomes. Dialysis parameters highlighted the importance of adequate frequency and well-dialyzed patients. Reasons for CCU admission were primarily cardiovascular and septic, with co-morbidities such as Type 2 Diabetes and complications like anemia prevalent. Infections, particularly UTIs, were linked to antibiotic resistance, influencing outcomes. Extended CCU stays and an 11% mortality rate were observed, with cardiovascular emergencies as a leading cause.
Discussions
Cardiovascular emergencies emerged as a critical factor affecting ICU length of stay and mortality, emphasizing their significant impact. Optimal hemodialysis frequency played a crucial role in improving clinical outcomes during critical situations. AV-fistula was recommended to minimize catheter-related bloodstream infections. The study underscores the need for robust health record systems and advocates for multi-center trials to address the growing CKD patient population in CCUs. Long-term outcome studies are deemed imperative for validating treatment strategies.
References
1.Arulkumaran N, Annear N. M. P, Singer M. Patients with end-stage renal disease admitted to the intensive care unit: systematic review. Br. J. Anaesth. 2013;110:13–20. doi: 10.1093/bja/aes401. [DOI] [PubMed] [Google Scholar]
2.Arulkumaran N, Montero R. M, Singer M. Management of the dialysis patient in general intensive care. Br. J. Anaesth. 2012;108:183–192. doi: 10.1093/bja/aer461. [DOI] [PubMed] [Google Scholar]
3.Hutchison C. A, Crowe A. V, Stevens P. E, Harrison D. A, Lipkin G. W. Case mix, outcome and activity for patients admitted to intensive care units requiring chronic renal dialysis: a secondary analysis of the ICNARC Case Mix Programme Database. Crit. Care. 2007;11:R50. doi: 10.1186/cc5785. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Lambourg E, et al. Incidence and Outcomes of Patients Receiving Chronic Kidney Replacement Therapy Admitted to Scottish ICUs Between 2009 and 2019-A National Observational Cohort Study. Crit. Care Med. 2023;51:69–79. doi: 10.1097/CCM.0000000000005710. [DOI] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, Kovai Medical Center and Hospitals, Coimbatore, Tamil Nadu, India, Phone: +91 9884474240, e-mail: ritika.swaminathan@gmail.com
1Department of Critical Care Medicine, Kovai Medical Center and Hospitals, Coimbatore, Tamil Nadu, India, Phone: +91 9884474240, e-mail: ritika.swaminathan@gmail.com
2,3Department of Critical Care Medicine, Kovai Medical Center and Hospitals, Coimbatore, India
Sepsis presents a significant global health burden, affecting an estimated 47 to 50 million individuals annually, with mortality rates reaching 11 million per year, accounting for 20% of global deaths. Septic cardiomyopathy, occurring in approximately 44% of cases, remains a topic of ongoing research due to conflicting findings regarding its impact on patient survival. Our study aims to predict the role of TAPSE and MAPSE (echocardiogram parameters) in predicting mortality in patients with sepsis and septic shock.
Objectives
Our primary objective focuses on evaluating the prognostic capability of Tricuspid Annular Plane Systolic Excursion (TAPSE) and Mitral Annular Plane Systolic Excursion (MAPSE) in predicting 30-day mortality among sub-group of critically ill sepsis/septic shock patients. Secondary objectives include assessing the association of TAPSE and MAPSE with length of ICU stay, ventilator free days, delta SOFA score, and 3-month mortality.
Materials and methods
This prospective observational study, conducted at a tertiary care hospital, includes patients aged over 18 years presenting within 48 hours of sepsis symptoms or developing symptoms during hospitalization, adhering to Sepsis-3 criteria. Patients with poor echocardiogram views, pregnancy, pre-existing cardiac dysfunction, known Cor pulmonale, or COPD were excluded from the study. Patients admitted in the ICU were initially screened and those meeting inclusion criteria were included in the study. Patients’ demographic details, cardiac biomarkers, SOFA score, APACHEII score were noted. Echocardiographic assessments (TAPSE/MAPSE) were done upon admission, with daily recordings until ICU discharge. All patients were followed for 3 months and at the end of study period patients were divided into survivors and non survivors. AUC- ROC was done to analyze the relationship between TAPSE/MAPSE values with 30-day and 90-day mortality. The admission SOFA score, delta SOFA, number of inotropes, ventilator free days and 3 – month mortality were also analyzed and compared with the TAPSE/MAPSE value.
Results
In our interim analysis a total of 334 patients were screened out of which 42 patients satisfied our inclusion criteria and were enrolled into the study. Of the 42 patients, 2 were lost to follow up and 40 patients were followed up to 3 months and analyzed. MAPSE demonstrated a sensitivity of 85.7% (95% CI 67.3% - 96.0%), specificity of 91.7% (95% CI 61.5% - 99.8%), and ROC area of 0.89 (95% CI 0.78- 0.99), while TAPSE showed a sensitivity of 92.9% (95% CI 76.5% - 99.1%), specificity of 83.3% (95% CI 51.6% - 97.9%), and ROC of 0.88 (95 % CI 0.76 – 1.00). Moreover, MAPSE and TAPSE values strongly correlate with SOFA scores, APACHE II scores, cardiac biomarkers, and inotropic requirements, suggesting their potential as valuable prognostic markers.
Discussion
Our interim findings indicate both MAPSE and TAPSE possess promising predictive correlations with patient outcomes in sepsis/septic shock scenarios. These parameters exhibit high sensitivity and specificity in predicting 30-day mortality. Jun Dong et all in their retrospective observational study analyzed the outcome of TAPSE with the mortality of patients presenting with sepsis and found that the ROC curves of TAPSE emerged as a significant and moderate predictor for 90-day mortality with area under curve (AUC) = 0.69, 95% CI = 0.565-0.814 with a sensitivity of 80% and specificity of 58% with an optimal cut-off of 2.1cm. Havaldar AA et all in their observational study compared the various left ventricular echocardiogram parameters, out of which MAPSE had an AUC ROC of 0.822 compared to E/e’ and left ventricular systolic function. Compared to the above studies, our study showed that a lower cut off of MAPSE and TAPSE VALUE (13mm and 15mm, respectively) had a better sensitivity and specificity in predicting the outcome of patients.
Our study showed that both TAPSE and MAPSE are equally reliable in predicting the outcome of patients with sepsis/septic shock.
References
1.Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, Colombara DV, et al. The Lancet. issue 10219. volume 395. Elsevier; January 2020. Global, regional, and national sepsis incidence and mortality, 1990–2017: Analysis for the global burden of disease study; pp. 200–211. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Dong J, White S, Nielsen K, Banchs J, Wang J, Botz GH, Nates JL. Tricuspid annular plane systolic excursion is a predictor of mortality for septic shock. Intern Med J. 2021 Nov;51(11):1854–1861. doi: 10.1111/imj.14957. 32618101 Epub 2021 Oct 24. [DOI] [PubMed] [Google Scholar]
3.Havaldar AA. Evaluation of sepsis induced cardiac dysfunction as a predictor of mortality. Cardiovasc Ultrasound. 2018 Nov 30;16(1):31. doi: 10.1186/s12947-018-0149-4. 30501628;PMC6267025 [DOI] [PMC free article] [PubMed] [Google Scholar]
Evidence supporting the use of high-frequency oscillatory ventilation (HFOV) for the treatment of paediatric acute respiratory distress syndrome (PARDS) continues to be elusive in the period of low tidal volume conventional mechanical ventilation (CMV).
Objectives
To compare the outcomes of patients with PARDS managed with early initiation of HFOV (within 48 hours of intubation) with those receiving late HFOV.
Methods
We conducted a retrospective single centre observational study of the children who were transitioned to HFOV.
Measurements and Main Results
Among the 17 subjects with PARDS with significant hypoxia (P/F ratio <200, Oxygenation index >8) on HFOV, 11 patients (65%) fell into the Early HFOV group (E) and 6 patients (35%) to the Late HFOV group (L). Early HFOV (E) had significantly lower lactates at 12 hour (p = 0.02), 24 hour (p = 0.03) and 36 hours (p = 0.04), and lower base excess at 36 hours (p = 0.04) of HFOV as compared to the Late HFOV group (L). E group was associated with 65% mortality as against 100 % in L group (p = 0.1).
Conclusions
Early HFOV was associated with significant lower lactate levels at different time points of HFOV initiation. It was not associated with any survival benefit.
An Interim Analysis on the Effectiveness of a Protocolized de-resuscitation with VExUS Scoring Along with a Standard Protocol as Compared to a Standard Protocol Alone on the Cumulative Fluid Balance in Sepsis Patients: A Prospective Observational Study
Effective fluid resuscitation and timely de-resuscitation are crucial in management of sepsis which is otherwise a life-threatening situation. But there is no ideal tool to predict when to stop resuscitation in septic shock and when to start de-resuscitation. The venous congestion by point-of-care-ultrasound (VExUS) score is a recent concept to assess fluid status at the bedside. This study aims to determine whether a protocolized de-resuscitation using VExUS scoring in addition to a standard protocol is more effective than a standard protocol alone in terms of clinical outcomes.
Objectives
Primary: To evaluate whether VExUS scoring in addition to standard protocolised de-resuscitation is associated with a reduction in cumulative fluid balance compared to standard protocol alone on day 3, day 5, and at ICU discharge. Secondary: To identify if VExUS scoring in addition to standard protocolised de-resuscitation is associated with change in ΔSOFA on day 3, 5, and at ICU discharge, 28-day mortality, length of ICU stay, ventilation free days and incidence of adverse events.
Materials and methods
This was a single center prospective study. All critically ill patients above 18 years of age with confirmed or suspected sepsis admitted to ICU were screened for eligibility. Patients with cirrhosis or portal thrombosis, severe CKD (eGFR<15 mL/min per 1.73 m2), hemodynamic instability due to active hemorrhage, acute cerebral vascular event, acute coronary syndrome, burn patients, pregnant patients and patients with difficulty in obtaining ultrasound images of sufficient quality were excluded from the study. Patients who were enrolled after exclusion were screened daily for fluid responsiveness (PLR test), signs of volume overload and a cumulative fluid balance of >2L. Patients who met these criteria were assigned to either VExUS guided + standard group or standard group alone. Both groups received de-resuscitation using standard protocol or VExUS guided + standard protocol and a negative balance of 1-2 L/day was targeted until endpoints of de-resuscitation were met.
Results
This was an interim analysis to an ongoing trial which is expected to be completed by May, 2024. A total of 39 patients were enrolled in the study after screening for eligibility. Demographic characteristics were similar in both the groups. There were no significant difference in cumulative fluid balance between both the groups at baseline, day 3 and day 5 of de-resuscitation: median (IQR) 4, 851 (3, 021, 6, 652) ml in VExUS group and 4, 204 (3, 130, 5, 806) ml in std group on day 1 (p- value 0.841), 2, 642 (1, 964, 4, 632) ml in VExUS group vs 2, 777 (1, 630, 4, 356)ml in standard group on day 3 (p-value 0.951), 1, 354 (1, 016, 2, 773) ml in VExUS group vs 2, 100 (1, 283, 3, 346)ml in std group (p- value of 0.227)on day 5, and 1, 465 (792, 4, 181) ml vs 1, 904 (1, 246, 2, 134) (p value- 0.227) at time of ICU discharge. There was also no difference in ΔSOFA at baseline, day 3 and day 5 of ICU stay, 28-day mortality, length of ICU stay, and hospital stay or incidence of adverse events.
Discussions
Our study did not show any difference in outcomes with VExUS scoring in addition to protocolized de-resuscitation. These findings are similar to those observed by Guinot et al.3 However, Rihl et al4 observed a significant difference in outcomes when a VExUS scoring based de-resuscitation was done
Conclusion
VExUS scoring based fluid de-resuscitation along with standardised protocol may not may not yield superior outcomes compared to outcomes compared to protocolised de-resuscitation alone. However, RCT's with larger sample size are needed to validate this findings.
References
1.Bissell, et al. Impact of protocolized diuresis for de-resuscitation in the intensive care unit Critical Care. 2020;24:70. doi: 10.1186/s13054-020-2795-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12(1):16. doi: 10.1186/s13089-020-00163-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Guinot, et al. Doppler study of portal vein and renal venous velocity predict the appropriate fuid response to diuretic in ICU: a prospective observational echocardiographic evaluation. Critical Care. 2022;26:305. doi: 10.1186/s13054-022-04180-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Rihl, et al. VExUS Score in the Management of Patients With Acute Kidney Injury. J Ultrasound Med; 2023;42:2547–2556. doi: 10.1002/jum.16288. [DOI] [PubMed] [Google Scholar]
1Department of Nutrition and Dietetics, Sir H. N. Reliance Foundation Hospital and Research Center, Mumbai, India, Phone: +91 7710005285, e-mail: Mehul.s.shah@rfhospital.org
1Department of Nutrition and Dietetics, Sir H. N. Reliance Foundation Hospital and Research Center, Mumbai, India, Phone: +91 7710005285, e-mail: Mehul.s.shah@rfhospital.org
2Sir H. N. Reliance Foundation Hospital and Research Center, Mumbai, India
3–5Department of Nutrition and Dietetics, Sir H. N. Reliance Foundation Hospital and Research Center, Mumbai, India
6Department of Academics and Research, Sir H. N. Reliance Foundation Hospital and Research Center, Mumbai, India
Energy Deficit (ED) and Protein Deficit (PD) have been studied in critically ill patients and noted to be a significant factor in patient outcomes. However, various feeding challenges lead to underfeeding and malnutrition.
Objective
The study is conducted to decrease the ED and PD in ICU patients, understand the nutrition interventions used through the Nutrition Stewardship Program (NSP) and correlate outcomes such as LOS (Length of Stay) in ICU, Hospital, on ventilator and mortality.
Materials and methods
Over a period of approximately 2 years (March 2022-October 2023), 707 patients were recruited who were in ICU for ≥ 3 days on enteral and/or parenteral nutrition. All patients were assessed with regards to NRS-2002 (Nutrition Risk Screening tool), NUTRIC (Nutrition Risk in the Critically Ill), SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation) scores and their nutrition targets were established. Various nutrition interventions were carried out to reduce the ED and PD and their frequency was analysed. The interventions were categorised as planning of Hyper-Caloric Feeds (HCF), Total Parenteral Nutrition (TPN) and supplemental Parenteral Nutrition (SPN), Catch-Up-Match Up (CUMU) Feeds and Staff Education (SE). The control group consisted of patients that were recruited on day 7 of ICU admission and patients for whom intervention was refused by the primary physicians. The patients were nutritionally reassessed on every third day of ICU admission to monitor, reduce the ongoing deficits and correlate with outcomes such as LOS (Length of Stay) in ICU, Hospital, on ventilator and mortality.
Results
All the 707 patients recruited during March 2022-October 2023 were a homogenous population since these did not have a significant difference concerning NRS-2002 (Nutrition Risk Screening tool), NUTRIC (Nutrition Risk in the Critically Ill), SOFA (Sequential Organ Failure Assessment) and APACHE II (Acute Physiology and Chronic Health Evaluation) scores and comorbidities including Diabetes Mellitus, Hypertension, Chronic Liver Disease, Ischemic Heart Disease and Chronic Kidney Disease. The ED and PD at discharge was 1241 kcals and 37 gms respectively compared to 6250 kcal and 261 gms respectively in the control group. It was observed that among the interventions, HCF was used 58% of the time, TPN & SPN 9%, CUMU & SE 21% and all interventions simultaneously 12%. It was also observed that the LOS in ICU, hospital and ventilator was reduced to a median of 8, 15 and 4 days respectively compared to 13, 19 and 6 days respectively in the control group (p<0.05). The mortality reduced to 22.63% compared to 37.9% in the control group (p<0.05).
Disscussions
As seen from the study, the implementation of the NSP can decrease ED and PD and improve outcomes and it can also be concluded that the use of HCF is the most commonly feasible nutrition intervention to implement.
References
1.TARGET Investigators, for the ANZICS Clinical Trials Group et al “Energy-Dense versus Routine Enteral Nutrition in the Critically III.”. The New England journal of medicine. 2018;vol. 379(19):1823–1834. doi: 10.1056/NEJMoa1811687. [DOI] [PubMed] [Google Scholar]
2.Yeh D Dante, et al. “Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically III Surgical Patients.”. JPEN. Journal of parenteral and enteral nutrition. 2016;vol. 40(1):37–44. doi: 10.1177/0148607115585142. [DOI] [PubMed] [Google Scholar]
Aminophylline may have a role in the management of COPD, stable as well as exacerbating, but its use remains controversial, mainly due to its narrow therapeutic window. We tried to assess whether it has a role in management of acute exacerbations of COPD under monitored conditions.
Objective
To assess safety, tolerability and clinical effects of aminophylline infusion in treatment of acute exacerbation of COPD: ACUTE study (Aminophylline in COPD- utility and Treatment effects).
Methods
The ACUTE study enrolled patients with documented COPD exacerbation with persistent hypoxia and hypercarbia despite 48 hours of maximal standard therapy including non-invasive ventilation. They were matched with a historical cohort of patients who had not received aminophylline. A slow loading infusion of Aminophylline (6 mg/kg) was administered followed by a maintenance dose 0.5 mg per kg over 24 hours under monitored conditions. We assessed length of stay in hospital as the primary outcome. Our null hypothesis for the study was that there was no difference in hospital length of stay in hypercapnic and hypoxic exacerbating COPD patients who received an aminophylline infusion, when compared with matched historical controls.
Results
The study did not meet its primary end point of a difference in hospital length of stay which was similar in patients receiving aminophylline treatment and those who did not. However, there was a significant improvement in oxygenation (P/F ratio) after 48 hours of aminophylline treatment. pCO2 levels on ABG also demonstrated a significant decrease after 48 hours of aminophylline infusion. Dyspnoea severity score, ICU length of stay did not significantly improve after 48 hours of aminophylline infusion. Adverse events, including nausea, tachycardia, and seizures, were reported in the group receiving aminophylline. There was no significant difference in baseline parameters like pH, oxygenation and PaCO2 levels between the matched groups.
Conclusion
Though aminophylline infusion did not significantly impact the length of hospital stay, it improved oxygenation and reduced PaCO2 levels in hypercapnic and hypoxic exacerbating COPD patients.
References
1.Duffy N, Walker P, Diamantea F, Calverley PM, Davies L. Intravenous aminophylline in patients admitted to hospital with non-acidotic exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Thorax. 2005;60(9):713–717. doi: 10.1136/thx.2004.036046. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Barr RG, Rowe BH, Camargo CA. Methylxanthines for exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2003;(Issue 2):CD002168. doi: 10.1002/14651858.CD002168. Art. No.: Accessed 06 November 2021. [DOI] [PubMed] [Google Scholar]
3.Barnes PJ. Theophylline. Am J Respir Crit Care Med. 2013 Oct 15;188(8):901–6. doi: 10.1164/rccm.201302-0388PP. 23672674 [DOI] [PubMed] [Google Scholar]
1Department of Critical Care Medicine, United Hospital Limited, Dhaka, Bangladesh, South Asia, Phone: +880 1674880820, e-mail: salahuddindrccm@gmail.com
1Department of Critical Care Medicine, United Hospital Limited, Dhaka, Bangladesh, South Asia, Phone: +880 1674880820, e-mail: salahuddindrccm@gmail.com
2,4Department of Critical Care Medicine, BIRDEM General Hospital, Dhaka, Bangladesh, South Asia
3Radiology & Imaging Department, Enam Medical College & Hospital, Bangladesh, South Asia
Disorders of sodium (Na+) and water homeostasis are common in hospitalized patients particularly in Intensive Care Unit (ICU). Irrespective of the etiology it is associated with worse outcome and increase length of ICU stay.
Objectives
Objective of the current study is to determine the frequency of hyponatremia and its association with the outcome of critically ill Patients admitted in the Department of Critical Care Medicine, BIRDEM General Hospital.
Methods
This prospective observational cross-sectional study was taken place in department of Critical Care Medicine for a period of one year from 1st July, 2017 to 30th June, 2018. Consecutive 296 critically ill patients during this time period were included in this study according to selection criteria. Data were collected in preformed data collection sheet and analyzed by the statistical packages for social science (SPSS) software (version 20.0) Results: In this study total 296 patients after fulfilling the inclusion criteria were selected as study participants. The mean age of the patients was 62.21 ± 12.974 years and there were 61.5% male and 38.5% female. Among male patients 39.6% had hyponatremia and among female patients 44.9% (p = 0.09). Overall frequency of hyponatremia was 41.2%. Majority of the patients presented with respiratory distress (61.5%), altered level of consciousness (33.4%), hypotension (30%) and fever (18.9%). DM (90.5%), HTN (75.5%) and CKD (50.5%) were the most frequent comorbidities present among the participants. Most of the hyponatremic patients were euvolemic (50.00%). Mean APACHE ll score among hyponatremic patients was significantly high (p = 0.001) moreover, hyponatremic patients required more mechanical support (p = 0.001). Duration of ICU stay was not related to severity of baseline hyponatremia during admission (p = 0.08)). In addition, outcome of the patients also depends on the overall incidence of hyponatremia and degree of hyponatremia (p<0.05 in both cases).
Conclusion
More than one-third of critically ill patients had hyponatremia and it was related to poor outcome of the critically ill patients.
References
1.Fried LF, Palevsky PM. ‘Hyponatremia and hypernatremia.’. The Medical clinics of North America. 1997;81(3):585–609. doi: 10.1016/s0025-7125(05)70535-6. pp. [DOI] [PubMed] [Google Scholar]
2.Baylis PH. ‘The syndrome of inappropriate antidiuretic hormone secretion’. The International Journal of Biochemistry & Cell Biology. 2003;35(11):1495–1499. doi: 10.1016/s1357-2725(03)00139-0. pp. [DOI] [PubMed] [Google Scholar]
3.Pillai KS, Trivede TH, Mozlick ND. ‘Hyponatremia in ICU’. The Journal of the Association of Physicians of India. 2018;66(5):48–56. pp. [PubMed] [Google Scholar]
4.Waikar SS, Mount DB, Curhan GC. ‘Mortality after hospitalization with mild, moderate, and severe hyponatremia’. The American journal of medicine. 2009;122(9):857–865. doi: 10.1016/j.amjmed.2009.01.027. pp. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Adrogué HJ, Madias NE. ‘Hyponatremia’. The New England journal of medicine. 2000;342(21):1581–9. doi: 10.1056/NEJM200005253422107. pp. [DOI] [PubMed] [Google Scholar]
6.Windpessl M, Schwarz C, Wallner M. ‘“Bowel prep hyponatremia “–a state of acute water intoxication facilitated by low dietary solute intake: case report and literature review’. BMC Nephrology. 2017;18(1):54–56. doi: 10.1186/s12882-017-0464-2. pp. [DOI] [PMC free article] [PubMed] [Google Scholar]
7.Filippatos TD, Liamis G, Elisaf MS. ‘Ten pitfalls in the proper management of patients with hyponatremia’. Postgraduate medicine. 2016;128(5):516–522. doi: 10.1080/00325481.2016.1186488. pp. [DOI] [PubMed] [Google Scholar]
8.Leung AA, McAlister FA, Rogers SO, Pazzo V, Wright A, Bates DW. ‘Preoperative hyponatremia and perioperative complications’. Archives of Internal Medicine. 2012;172(19):1474–1481. doi: 10.1001/archinternmed.2012.3992. pp. [DOI] [PubMed] [Google Scholar]
9.Padhi R, Panda BN, Jagati S, Patra SC. ‘Hyponatremia in critically ill patients’. Indian Journal of Critical Care Medicine. 2014;18(2):83–87. doi: 10.4103/0972-5229.126077. pp. [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Bissram M, Scott FD, Liu L, Rosner MH. ‘Risk factors for symptomatic hyponatraemia: the role of pre‐existing asymptomatic hyponatraemia’. Internal medicine journal. 2007;37(3):149–155. doi: 10.1111/j.1445-5994.2006.01294.x. pp. [DOI] [PubMed] [Google Scholar]
11.Rafat C, Flamant M, Gaudry S, Vidal-Petiot E, Ricard J, Dreyfuss D. ‘Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation?’. Annals of Intensive Care. 2015;5(1):1–27. doi: 10.1186/s13613-015-0066-8. pp. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Shakher J, Gandhi N, Raghuraman G. ‘Impact of hyponatraemia in critically ill patients’. Endocr Abstr. 2013;31 doi: 10.1530/endoabs.31.P55. [DOI] [Google Scholar]
13.Upadhyay A, Jaber BL, Madias NE. ‘Incidence and prevalence of hyponatremia’. American Journal of Medicine. 2006;119(7A):30–35. doi: 10.1016/j.amjmed.2006.05.005. pp. [DOI] [PubMed] [Google Scholar]
14.Pasha SA, Pasha SA, Prabodh VS, Vidya SD, Suhasini T. ‘Frequency of hyponatremia in critically ill patients’. Indian Journal of Applied Research. 2016;6(6):43–45. pp. [Google Scholar]
15.Funk GC, Lindner G, Drumi W, Metnitz B, Schwarz C, Bauer P, et al. ‘Incidence and prognosis of dysnatremias present on ICU admission.’. Intensive care medicine. 2010;36(2):304–11. doi: 10.1007/s00134-009-1692-0. pp. [DOI] [PubMed] [Google Scholar]
16.Hawkins RC. ‘Age and gender as risk factors for hyponatremia and hypernatremia’. Clinica Chimica Acta. 2003;337(1–2):169–172. doi: 10.1016/j.cccn.2003.08.001. pp. [DOI] [PubMed] [Google Scholar]
17.Cumming K, Hoyle GE, Hutchison JD, Soiza RL. ‘Prevalence, incidence and etiology of hyponatremia in elderly patients with fragility fractures’. PLOS One. 2014;9(2):e88272. doi: 10.1371/journal.pone.0088272. p. [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Pathan B, Nagpal RR, Rai DS. ‘Hyponatremia in critically ill patients: Assessment f incidence, etiology, clinical manifestations and outcomes in ICU setting’. Journal of Medical Science and Clinical Research. 2018;06(03):591–598. pp. [Google Scholar]
19.Bennani SL, Abouqal R, Zeggwagh AA, Mandani N, Abidi K, Zekaoui A, et al. ‘Incidence, causes and prognostic factors of hyponatremia in an intensive care unit’. La revue de médecine. 2003;24(4):224–229. doi: 10.1016/s0248-8663(02)00811-1. pp. [DOI] [PubMed] [Google Scholar]
20.Friedman B, Cirulli J. ‘Hyponatremia in critical care patients: Frequency, outcome, characteristics, and treatment with the vasopressin V2-receptor antagonist tolvaptan’. Journal of Critical Care. Elsevier Inc. 2013;28(2):219.e1–219.e12. doi: 10.1016/j.jcrc.2012.06.001. p. [DOI] [PubMed] [Google Scholar]
Sedative agents are an integral part of patient care in Intensive care unit. Fentanyl commonly used but patients are more susceptible to side effects due to altered pharmacokinetics, polypharmacy, and decreased physiologic reserve. While α2 agonist Dexmedetomidine may be an alternative causing mild cognitive impairment facilitating extubation.
Objective of The Study
To evaluate Dexmedetomidine as an alternative sedation agent in comparison to Fentanyl in Intensive Care Unit by comparing extubation time which is defined as time from cessation of sedation to extubation.
Materials and methods
This prospective, double-blind study was conducted from September 2022 – August 2023 at Fortis Hospitals, Kolkata with a sample size of 30 in each group as evaluated from previous studies. Patients aged 18-70 years with expected duration of mechanical ventilation more than 24 hours without significant vasopressor support and a baseline sedation score -1 to +4 as per Richmond Agitation and Sedation Scale (RASS) were included while patients with pregnancy or major CNS, Cardiac or hepatic pathology or on HD or requiring deep sedation or undergoing neurosurgeries were excluded. On fulfilment of selection criterion and on obtaining consent from patient's next of kin, each patient was subjected for allocation to respective study group by following alternate allocation table. Sedative used before study enrolment was discontinued. Group F received fentanyl infusion administered at 0.7 µg/kg/h into a peripheral or central vein while Group D received dexmedetomidine infusion administered at 0.7 µg/kg/h. Dosing of study drug was adjusted by the clinical team 4 hourly and adjustments to rate of infusion made to maintain a RASS score of -1 to -3 individualized as per need. A daily delirium assessment was performed on patients with RASS scale of 0 to +4 using the Confusion Assessment Method for the ICU (CAM-ICU). Patient unable to attain target sedation score with maximum dose until haemodynamics were stable, a rescue analgesia with Inj Fentanyl bolus dose of 25µg were given. Patients who required >2 such boluses within consecutive 2 hours were exempted. Study drug infusion was stopped before initiation of spontaneous breathing trials when the attending clinician felt it in the best interest of the patient. Once suitable weaning parameters were obtained, extubation was undertaken and extubation time was noted. Vitals were monitored continuously. Secondary Outcomes including frequency of rescue sedation, incidence of adverse events and incidence of delirium were also noted and compared.
Results
Dexmedetomidine was found to be suitable alternative to Fentanyl as ICU sedation agent requiring less time for extubation. The extubation time in Dexmedetomidine group was 2.27 ± 0.75 hours while 3.94 ± 0.55 hours in Fentanyl group which was statistically significant (p value - 0.001). Incidence of delirium was 4 in the Dexmedetomidine group in comparison to 13 patients in the fentanyl group, which was statistically significant (p-value - 0.015) (significant at p <.05). Rest demographic parameters, duration of ventilation, sedation duration, incidence of adverse events were statistically non – significant.
Conclusion
Dexmedetomidine can be a suitable alternative to Fentanyl as sedation in intensive care units with less extubation time and lesser incidence of delirium.
References
1.Tobias JD. Dexmedetomidine: Applications in paediatric critical care and paediatric anaesthesiology. Pediatr Crit Care Med. 2007;8:115–31. doi: 10.1097/01.PCC.0000257100.31779.41. [DOI] [PubMed] [Google Scholar]
2.Bloor BC, Ward DS, Belleville JP, Maze M. Effects of intravenous dexmedetomidine in humans. II. Hemodynamic changes. Anesthesiology. 1992;77:1134–42. doi: 10.1097/00000542-199212000-00014. [DOI] [PubMed] [Google Scholar]
3.Venn RM, Grounds RM. Comparison between dexmedetomidine and propofol for sedation in the intensive care unit: patient and clinician perceptions. British journal of anaesthesia. 2001 Nov 1;87(5):684–9. doi: 10.1093/bja/87.5.684. [DOI] [PubMed] [Google Scholar]
4.Chrysostomou C, Di Filippo S, Manrique AM, Schmitt CG, Orr RA, Casta A, et al. Use of dexmedetomidine in children after cardiac and thoracic surgery. Pediatr Crit Care Med. 2006;7:126–31. doi: 10.1097/01.PCC.0000200967.76996.07. [DOI] [PubMed] [Google Scholar]
5.Park G, Lane M, Rogers S, Bassett P. A comparison of hypnotic and analgesic based sedation in a general intensive care unit. Br J Anaesth. 2007;98:76–82. doi: 10.1093/bja/ael320. [DOI] [PubMed] [Google Scholar]
6.Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, Whitten P, Margolis BD, Byrne DW, Ely EW, Rocha MG. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. Jama. 2009 Feb 4;301(5):489–99. doi: 10.1001/jama.2009.56. [DOI] [PubMed] [Google Scholar]
Urinary Bladder Wall Thickness as a Predictor for Catheter Associated Urinary Tract Infection in Critically Ill Trauma Patients: A Prospective Cohort Study
Diagnosing CAUTI in trauma ICU patients is a challenge & there is an unmet need of developing a quick objective method for its screening. USG, a real-time bedside modality, was never explored for such scenario.
Objective
Hence, we evaluated bladder wall thickness(BWT) with serial USG in catheterized critically-ill trauma patients as a tool to predict CAUTI.
Materials and methods
After ethics committee approval & written informed consent, a single-centric, prospective, observational cohort study was conducted from March2021-Feb2023 in trauma ICU, BHU, where patients aged 20-50yrs, admitted with trauma were assessed for eligibility (requiring Foley's within 2days of admission, for a period of atleast 3days). They were evaluated for BWT, as per protocol over a stretch of 21days or till patient was in ICU [Day 1, 3, 5, 7, 10, 14, 17, 21, or whenever fever]. Those evaluated “BWT values”, were allocated into one of the 3 cohorts based on culture reports [CAUTI group; significant colony count (>105) but without CAUTI (CCS group); insignificant colony count (CCI group)]. Primary outcomes were performance of BWT to predict CAUTI using AUC-ROC & to find out reliable “cut-off” with highest sensitivity/specificity. Secondary outcome was incidence of nosocomial UTI. Chi-square/student-t tests used for qualitative/quantitative data with statistical significance at p-value≤0.05.
Results
Demographic parameters were comparable in the 3 cohorts. There were total of 1242 evaluated “BWT values” obtained on 180 enrolled patients, [476 values in CAUTI group (C), 362 values in significant colony count but without CAUTI (group B), 404 in insignificant colony count (group A)]. Mean BWTe in CAUTI group was 4.61 mm±0.82 mm vs 3.62±0.60 mm in colonization group vs 3.04±0.40 mm in CCI group), p=0.02 (Fig 1). BWT>5.54 mm had a good positive correlation with CAUTI with Spearman's coefficient of +0.834 with better correlation in empty bladder (BWTe) than in 250ml filled bladder (BWTf). The reliable cut-off value of BWTe for diagnosing CAUTI was found to be 4.8 mm with highest AUC-ROC (mean 0.734 with 95% CI of 0.703-0.942) with 91.2% sensitivity and 78% specificity, with PPV 88.8% and NPV 85.2%. At the optimum cut-off defined at 3.8 mm, NPV was 100%, leaving no probability of significant colony count with BWTe< 3.8 mm; PPV was also very high (95.2%) with AUC-ROC (mean 0.786 with 95% CI of 0.682-0.980) with 89.4% sensitivity and 76.2% specificity. Incidence of CAUTI overall was 27% (Fig 2). ?BWT (>1.6 mm on 3rd day of fever) increased diagnostic accuracy, also had a prognostic value for predicting 30-day mortality.
Bladder wall thickness with serial bedside ultrasonography is not only simple, non-invasive and reproducible but quite a reliable objective method to predict CAUTI in critically ill trauma patients, which may increase diagnostic accuracy for screening out patients with CAUTI from colonization, with attributes of performance being best being best at cut-off value of 4.8 mm, for diagnosing CAUTI & 3.8mm for screening colonization.
References
1.Selcen Kanyilmaz, et al. Bladder wall thickness and ultrasound estimated bladder weight in healthy adults with portative ultrasound device. J Res Med Sci. 2013 Feb;18(2):103–106. [PMC free article] [PubMed] [Google Scholar]
2.Un Ju Shin, et al. Sonographic evaluation of bladder wall thickness in women with lower urinary tract dysfunction. Obstet Gynecol Sci. 2018 May;61(3):367–373. doi: 10.5468/ogs.2018.61.3.367. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Matthias Oelke, et al. Ultrasound measurement of detrusor wall thickness in healthy adults. Neurourol Urodyn. 2006;25(4);):308–17. doi: 10.1002/nau.20242. [DOI] [PubMed] [Google Scholar]
Burnout syndrome is a psychological state from prolonged exposure to various stressors seen in professionals like critical care physicians. Strikingly, it has affected both the professional care givers and negative impacted is seen on patients care. Previous studies have shown the prevalence of of Burnout syndrome was 0.41% (0.01 - 2.29) according to Maslach's criteria. We have thereby sought to study various determinants leading to this occupational hazard and their prevalence among the intensive care physicians.
Methods
A cross sectional study has been conducted using the validated questionnaire. The Maslach Burnout Inventory has been for quantitative assessment. The questionnaire was given to 100 intensive care physicians using google forms. The responses where recorded between 1st to 15th December, 2023. The prevalence of each dimension of syndrome was estimated with 95% confidence interval.
Results
The prevalence of Burnout syndrome was 0.5% (0.01 - 2.29) according to Maslach's criteria. Infant intensive care unit professionals were more likely to develop emotional exhaustion than other intensive care professionals. Respondents over the age of 35 were less likely to develop emotional exhaustion and depersonalization (OR = 0.06). Longer working hours in intensive care units were associated with a reduced sense of personal accomplishment (OR = 1.13). males had a lower sense of professional accomplishment, and not exercising regularly was associated with more emotional exhaustion and less depersonalization.
Conclusions
This study demonstrated a high level of burnout syndrome. Most of the critical care physicians had high level of emotional exhaustion and depersonalisation with lower sense of personal accomplishment. Henceforth, workplace related root cause analysis should be actively done along regular time intervals by the departments. Assertive strategies based on communicating skills, interpersonal relationship, timings and schedules, relaxation's and other venting and coping mechanisms and to balance personal and professional well beings can improve the skills and input from physicians. Subjectively and objectively perceived burnout in seniors and colleagues have discouraged enthusiastic health care workers from pursuing intensive care as career options. The limitations of our study were the study was cross sectional study and thereby leading to gender bias and under reporting. We didn't include other sub specialities and staff. We didn't include follow up and results of implications of the assertive strategies. This type of awareness can help build healthy environment and encourage the young minds to have active participation in delivering a Better health care services.
Management of sepsis and septic shock is challenging with respect to identifying critically ill patients who would benefit from fluid resuscitation to improve tissue oxygenation. Traditional methods, such as echocardiography and passive leg raising tests, require cardiac output measurement and have limitations. Venous-to-arterial CO2 tension difference (ΔPCO2) could serve as a reliable indicator of fluid responsiveness, as it reflects the balance between CO2 production and delivery to the lungs, acting as a surrogate for cardiac output.
Objectives
To investigate the reliability of ΔPCO2 in identifying fluid responsiveness in sedated and mechanically ventilated septic patients compared to fluid response measured with cardiac output monitor.
Materials and methods
We conducted a prospective Observational study, after approval from hospital ethics committee, from July 2023 to November 2023 and included adult patients admitted to our multidisciplinary ICU with Septic shock requiring mechanical ventilation; Patients requiring volume expansion were identified by the presence of clinical signs of hypoperfusion such as hypotension (SBP<90mmHg), skin mottling, lactates >2mmol/L and urine output less than 0.5ml/kg/hr. Demographic data, acute circulatory failure etiology, APACHE II score and Sequential Organ Failure Assessment (SOFA) scores were obtained on the day of enrollment. Flotrac device was used to measure Cardiac index (CI). Arterial and central venous blood gases were measured. ΔPCO2 was calculated as the diference between the central venous carbon dioxide tension and the arterial carbon dioxide tension.
Results
A total of 25 patients were studied; Patients in shock were administered fluids according to surviving sepsis guidelines, and after assessing for fluid responsiveness using Passive leg raising test; CI and arterial-venous PCO2 gap was measured at baseline and after Volume expansion; Patinets with an increase in Cardiac Index >10% and SVV are considered fluid responders; After fluid bolus changes in CI and PCO2 gap were noted. Receiver operating characteristic (ROC) curve was constructed to evaluate the ability of change in PCO2 gap to predict fluid responsiveness after fluid challenge was noted. Volume Expansion signifcantly reduced ΔPCO2 in the responders’ group and We observed signifcant correlation between Δ-ΔPCO2 and ΔCI after Volume Expansion.
Conclusion
Δ-ΔPCO2 is a reliable parameter to define fluid responsiveness and can be used in the absence of CI measurement; especially in resource limited settings with limited access to Cardiac output monitoring.
Sepsis is defined as a life-threatening organ dysfunction caused by dysregulated host response to infection. Sepsis is the most common cause of death and accounts for almost 50% of ICU mortality. Early diagnosis of sepsis is crucial to decrease mortality. Clinical signs and symptoms are unreliable at most of times, especially in elderly and immunocompromised, where they do not present with features of sepsis like fever. Currently available markers are expensive and not easily available, some markers are non specific.
Objectives
Primary objective: to assess the relationship between inflammatory markers in prediction of sepsis.
Secondary objectives
To assess the relationship between inflammatory markers and the following outcomes in critically ill patients in the Intensive Care Unit of a tertiary care hospital
MortalityLength of hospital stay
Requirement for invasive or non-invasive mechanical ventilation
Requirement of renal replacement therapyOrgan failure
Requirement of vasopressors
Materials and methods
Type of Study: Prospective observational study Study setting-medical icu in citizens specialty hospital, Hyderabad, telaNGANA.
Method of collection
A structured data sheet was used to collect details of patient. Within the first 24 hours of admission, c reactive protein, red cell distribution width, neutrophil lymphocyte ratio, monocyte distribution width and mean neutrophil volume were measured. The tests were done on 1st day. Clinical progression over days was observed in terms of recovery from the illness or death of the patient. The overall length of hospital stay and requirement for invasive or non-invasive mechanical ventilation, requirement of vasopressors, requirement of renal replacement therapy, presence of organ failure was also documented. Their APACHE II score and SOFA score was assessed using the most abnormal values within the first 24 hours of ICU admission.
Results
Primary outcome analysis: Biomarkers sensitivity and specificity in prediction of sepsis: Table 1:- In our study population, the most sensitive markers for the prediction of sepsis were CRP {81.75%}and MDW {81.7%} whereas the most specific were MDW, MNV and MMV with 100% specificity for each. overall CRP and MDW have good sensitivity and specificity when compared to the rest of the biomarkers. MDW has the best AUC of 0.932 when compared to other biomarkers.
Table 2: In our study population upon re analyzing the study sample with multivariate logistic regression analysis {Two stage least square method} we found MDW and MMV were statistically significant in the prediction of sepsis.
Discussions
In our present study, we observed that 84.5%(n = 71) of the patients were clinically suspected to have sepsis and among these patients, 57 patients(80.2%) had bacteriological cultures positive. In our study, we looked for 6 biomarkers for their prediction ability of sepsis in patients admitted to the ICU. These markers were CRP, RDW, NLR, MDW, MNV and MMV. All these markers we have observed on the day of admission. In our study population, the most sensitive markers for the prediction of sepsis were CRP {81.75%}and MDW {81.7%} whereas the most specific were MDW, MNV and MMV with 100% specificity for each.
References
1.Yang Y, Xie J, Guo F, Longhini F, Gao Z, Huang Y, Qiu H. Combination of C-reactive protein, procalcitonin and sepsis-related organ failure score for the diagnosis of sepsis in critical patients. Ann Intensive Care. 2016 Dec;6(1):51. doi: 10.1186/s13613-016-0153-5. 27287669;PMC4901212 Epub 2016 Jun 10. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Crouser ED, Parrillo JE, Seymour CW, Angus DC, Bicking K, Esguerra VG, Peck-Palmer OM, Magari RT, Julian MW, Kleven JM, Raj PJ, Procopio G, Careaga D, Tejidor L. Monocyte Distribution Width: A Novel Indicator of Sepsis-2 and Sepsis-3 in High-Risk Emergency Department Patients. Crit Care Med. 2019 Aug;47(8):1018–1025. doi: 10.1097/CCM.0000000000003799. 31107278;PMC6629174 [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Arora P, Gupta P.K, Lingaiah R, Mukhopadhyay A.K. Volume, conductivity, and scatter parameters of leukocytes as early markers of sepsis and treatment response. J. Lab. Physicians. 2019;11:29–33. doi: 10.4103/JLP.JLP_102_18. [CrossRef] [PubMed] [DOI] [PMC free article] [PubMed] [Google Scholar]
Though COVID-19 vaccines are an effective tool, none of them are a 100% effective in the prevention of COVID-19 illness. A small percentage of those who are fully immunized, will still get sick to varying degrees from COVID-19 disease. They are known as vaccine breakthrough cases.
Objective
To assess the vaccine effectiveness and determine the severity of illness among COVID-19 positive patients admitted in an Indian private tertiary care hospital with level 2 ICU.
Methods
All COVID-19 positive patients admitted between July 2021 and February 2022 were included in the study. Their demographic data was compared, vaccination status, morbidity (need for advanced oxygen therapy) and mortality (in-hospital death) was determined.
Results
Out of 209 symptomatic COVID-19 positive patients admitted in the hospital, 164(88%) were fully vaccinated (had received both doses of vaccine more than 14 days ago-78% received CHADOX1 NCOV-19 CORONA VIRUS RECOMBINANT VACCINE(COVISHIELD) while 22% COVAXIN) and 45(22%) were partially or not vaccinated. Demographic data like age, gender and comorbidities (risk factors for severe COVID-19) were similar in both groups. About 10% (17) among the fully vaccinated individuals and 25% (11) of the remaining patients needed advanced oxygen therapy (includes invasive and non- invasive ventilation, high flow nasal cannula and non-rebreathing mask for oxygen delivery). Mortality rate was 3% (5) among fully vaccinated and 9% (4) among other patients. Majority of the patients, who were fully vaccinated (60%) and were hospitalized, had their last COVID-19 vaccine dose more than 6 months ago.
Discussion
In a study by Muthukrishnan et al, the fully vaccinated (CHADOX1 NCOV-19 CORONA VIRUS RECOMBINANT VACCINE(COVISHIELD)) individuals had 70% lower odds of mortality than unvaccinated persons among hospitalized severe cases. (1) This is similar to our study which has shown 60% decreased risk of severe illness and 67% reduced risk of mortality compared to unvaccinated individuals. The WHO recommends a booster dose after 4-6 months of complete vaccination by CHADOX1 NCOV-19 CORONA VIRUS RECOMBINANT VACCINE(COVISHIELD). (2) Our study has shown that the vaccine efficacy seems to decrease after 6 months leading to need for hospitalisations due to symptomatic COVID-19 illness. Hence, the need for booster doses is important along with non-pharmacologic interventions to mitigate the spread of COVID-19 virus.
Conclusion
This study validates that the vaccination prevents the incidence of severe illness and decreases the risk by 60%, it also reduces the mortality by 1/3rd. Vaccine effectiveness decreases after 6 months and hence the need for booster dose is important to maintain the effectiveness of vaccination.
References
1.Muthukrishnan J, Vardhan V, Mangalesh S, Koley M, Shankar S, Yadav AK, Khera A. Vaccination status and COVID-19 related mortality: A hospital based cross sectional study. Med J Armed Forces India. 2021 Jul;77(Suppl 2):S278–S282. doi: 10.1016/j.mjafi.2021.06.034. 34334894;PMC8313045 Epub 2021 Jul 26. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.The Oxford/AstraZeneca (ChAdOx1-S [recombinant] vaccine) COVID-19 vaccine: what you need to know. The Oxford/AstraZeneca (ChAdOx1-S [recombinant] vaccine) COVID-19 vaccine: what you need to know (who.int) Published 16 March 2022, accessed on 2 May 2022.
This report synthesizes the findings from a knowledge assessment among critical care specialists, revealing insights into their understanding of clinical practices and highlighting areas of strong consensus as well as misconceptions within the realm of infectious diseases and treatment approaches in critical care.
Objectives
Evaluate critical care specialists’ knowledge on infectious disease management practices through a targeted survey assessment.
Methods
Survey administered to 60 critical care specialists at a CAPTAIN CME program assessed clinical knowledge through multiple-choice questions; results analyzed for accuracy and consensus.
Results
Most respondents (91.18%) correctly identified PSI Calculator's use for estimating CAP mortality risk; mean response 2.15, SD 0.49. Most favored Amoxicillin/clavulanate (57.35%) for pneumonia treatment; varied preferences with an mean choice score of 1.82, SD 1.12. Most respondents incorrectly excluded imaging findings (54.41%) from PSI components; mean response 3.74, SD 1.13. ESR most often excluded from PSI criteria by respondents (26.47%); response mean 2.97, SD 1.51. MASCC Risk Index Score most recognized for febrile neutropenia assessment (66.18%); mean response 1.91, SD 0.68. Chronic lung disease most cited non-risk factor for MDR in HAP/VAP incorrectly (36.76%); mean 3.44, SD 1.23. Most respondents correctly define HAP as pneumonia developing over 48 hours post-admission (92.65%); mean 2.88, SD 0.44. Most identify VAP as pneumonia post 48 hours of intubation (79.41%); mean response 3.69, SD 0.71. Hybrid dialysis is most seen as combining peritoneal and hemodialysis (47.06%); mean choice 2.32, SD 1.39. Most believe hybrid dialysis being “under development” is not a benefit (29.41%); mean 3.12, SD 1.52. Biapenem is primarily used for broad bacterial infections (52.94%) and uncomplicated UTIs (47.06%); mean 2.06, SD 1. Most respondents correctly excluded meningitis as a biapenem indication (77.94%); mean response 3.72, SD 0.82. Influenza virus identified as leading cause of viral sepsis in adults (67.65%); mean response 1.74, SD 1.12. Recent surgery most commonly misidentified as non-risk for bacterial sepsis (60.29%); mean response 2.94, SD 0.94. Prompt initiation of broad-spectrum antibiotics overwhelmingly recognized for initial sepsis management (92.65%); mean response 2.91, SD 0.45. Dalbavancin is primarily used for Acute bacterial skin and skin structure infections (ABSSSI), 94.03% of cases.
Discussion
The survey of critical care specialists revealed a strong understanding of CAP risk estimation via the PSI Calculator and the definition of HAP and VAP, indicating a solid grasp of pneumonia-related protocols. However, there is a notable discrepancy in recognizing imaging as part of PSI and the misidentification of chronic lung disease as a non-risk factor for MDR in HAP/VAP. While Amoxicillin/clavulanate is preferred for pneumonia treatment, choices vary widely. Misconceptions about dialysis and the use of biapenem suggest targeted educational interventions are needed. The consensus on the timely initiation of broad-spectrum antibiotics for sepsis management and the use of dalbavancin for ABSSSI highlights areas of shared clinical understanding.
Acute kidney injury (AKI) is a recognized complication in critically ill patients with a variable etiology often requiring Renal replacement therapy(RRT). We aimed to determine the patient characteristics, timimg of initiation RRT and outcomes associated with patients requiring RRT in our ICU.
Design
Retrospective observational study for a period of one year (November 2022 to October 2023).
Methods
Case records of patients requiring RRT over 1 year period were assessed and Baseline, clinical, and laboratory data were collected on admission and during their ICU stay. Outcomes and practices related to RRT including timing of initiation of RRT after diagnosis of AKI were analysed using descriptive analysis and cross-tabulation.
Results
Out of 1480 admissions to the ICU, 316 cases required RRT; consisting of 210 male patients and 106 females. Most common etiology of AKI requiring RRT was sepsis and other causes included acute on CKD, heart failure, pancreatitis, acute gastroenteritis, tropical fever and paraquat poisoning. Azotemia and Metabolic acidosis were the for RRT in most patients. Outcomes included Death in 35% (112) patients, discharge in 60% (188) patients and LAMA in 5% (16). Average length of ICU stay was 7.15 days. Higher number of deaths observed in patients with sepsis, multiple comorbidities (DM, HTN and CAD) and baseline Albumin levels below 2.5g/dl. Outcomes in Early (within 12Hrs) and late (> 12hrs) initiation of RRT were noted.
Conclusion
AKI is a common complication in ICU associated with higher mortality, often requiring RRT. Poor outcomes are observed with underlying sepsis, increasing age, comorbidities and lower baseline albumin levels. There was no difference in mortality in early versus late initiation of RRT.
Cardiac arrest is the cessation of mechanical cardiac activity, as confirmed by the absence of circulation, and sudden cardiac arrest is an unexpected cardiac arrest that could result in attempts to restore circulation. The use of point of care ultrasound (POCUS) can provide not only prognostic information, but also important diagnostic and procedural guidance for these patients
Objectives
To investigate the utility of Pocus in diagnosing cause of arrest and prognostication during CPR.
Materials and methods
We conducted a prospective Observational study, after approval from hospital ethics committee, over a period of 5 months and included adult patients admitted to our multidisciplinary ICU with witnessed cardiac arrest requiring CPR. Ultrasound was used (Phased array probe) to trouble shoot cause of arrest during compressions and rhythm check, without interruption of ACLS algorithm flow. RUSH protocol was used to identify cause of arrest. Prognostication was done based on cardiac standstill after prolonged CPR.
Results
A total of 30 patients were studied; Of which Hypovolemia was most commonly identified reversible cause; Massive Pulmonary embolism was identified in one case. It was used to confirm tracheal intubatation in 5 cases and tension pneumothorax in 1 trauma case.
Conclusion
Use of POCUS and algorithmic approach during CPR without interruption in compressions is a feasible option in troubleshooting cause of arrest and prognostication of prolonged CPR.
References
1.Atkinson T P R, McAuley D J, Kendall R J, Abeyakoon O, Reid C G, Connolly J, and Lewis D. “Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): An Approach by Emergency Physicians for the Use of Ultrasound in Patients with Undifferentiated Hypotension.”. Emergency medicine journal: EMJ. 2009;26(no. 2) doi: 10.1136/emj.2007.056242. [DOI] [PubMed] [Google Scholar]
2.Blaivas M, and Fox J C. “Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram.”. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. 2001;8(no. 6):616–21. doi: 10.1111/j.1553-2712.2001.tb00174.x. [DOI] [PubMed] [Google Scholar]
3.Breitkreutz Raoul, Susanna Price, Steiger Holger V, Seeger Florian H, Ilper Hendrik, Ackermann Hanns, Rudolph Marcus. “Focused Echocardiographic Evaluation in Life Support and Peri-Resuscitation of Emergency Patients: A Prospective Trial.”. Resuscitation. 2010;81(no. 11) doi: 10.1016/j.resuscitation.2010.07.013. and others. [DOI] [PubMed] [Google Scholar]
Lower respiratory tract infections, including community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), are linked to significant morbidity and mortality. Early pathogen detection & proper antimicrobial therapy is the answer to reduce the morbidity & mortality for the same. However, conventional microbiological techniques have a low sensitivity & has a turnaround time from microbiological sampling to Antibiotic Sensitivity Testing of at least 48 hours, increasing broad-spectrum antimicrobial use & delaying antimicrobial de-escalation. New molecular diagnostic tools aim at shortening this time. The BioFire® FilmArray® Pneumonia Panel plus (Biomerieux, USA), novel Multiplex PCR assay, is able to simultaneously identify 27 of the most common pathogens involved in lower respiratory tract infections as well as 7 antibiotic resistance genes.
Objectives
To assess the concordance/discordance of organisms between Multiplex PCR Panel (BIOFIRE Pneumonia Plus Panel) & Conventional Culture-sensitivity in lower respiratory tract samples.
To assess the concordance/discordance between Multiplex PCR Resistance Gene pattern and Culture-Sensitivity Antibiotic-resistance pattern in Bacteria (Panel Organisms on Multiplex PCR excluding atypical ones) in lower respiratory tract samples.
Materials and methods
This observational study was conducted at the ICUs of a private tertiary care hospital (AMRI Hospitals, Dhakuria, Kolkata), after obtaining ethics committee clearance. Patients above 18 years of age, having Complicated Respiratory Tract Infections requiring ICU Admission and undergoing Lower respiratory Tract sampling (Sputum, Endotracheal aspirate & Broncho-alveolar lavage) tested by Multiplex PCR testing using BioFire FilmArray Pneumonia (PN) Plus panel and conventional Culture-Sensitivity testing were included in the study. Demographic parameters, Microbiological data & Outcome parameters of the patients were documented. The Concordance/Discordance between the bacteria found on the two tests and Antibiotic Resistance genes & Antibiotic Resistance patterns of the bacteria on Multiplex PCR testing using BioFire FilmArray Pneumonia (PN) Plus panel and conventional Culture-Sensitivity testing were recorded.
Results
Very high Sensitivity & Negative Predictive Value for all the Bacteria in Multiplex PCR Panel
The Concordance (POSITIVE) between bacteria found in Multiplex PCR and Conventional Culture in patients having Positive results on Multiplex PCR was 29.4%
The Concordance (NEGATIVE) between Bacteria found in Multiplex PCR and Conventional Culture in patients having Negative results on Multiplex PCR was 98.46%
Multiplex PCR (BIOFIRE Pneumonia Plus Panel) detected 39 viruses in Lower Respiratory specimens
Conventional Culture detected several oganisms (n=17,17%) including fungus which was not detected by the Multiplex PCR Panel.
In assessment of Concordance between Multiplex PCR Resistance Gene pattern and Culture-Sensitivity Antibiotic-resistance pattern in Bacteria we found a concordance of 58.5%
Discussions
Multiplex PCR (BIOFIRE Pneumonia Plus Panel), having very high Sensitivity & Negative Predictive Value, is a very useful tool in ruling out possibility of growth of Panel Organisms even on conventional Culture.
Multiplex PCR, having results being available within hours, can be a very useful tool in de-escalating empiric antimicrobials specifically targeted against Multidrug-resistant(MDR) Gram-negative bacilli, Methicillin-resistant Staphylococcus aureus(MRSA) & in-panel Atypical bacteria & respiratory viruses.
Multiplex PCR can be a very useful tool in identifying in-panel respiratory viruses & initiating effective antiviral therapy.
References
1.GBD 2013 Mortality and Causes of Death Collaborators. 2015. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 385:117–171. doi: 10.1016/S0140-6736(14)61682-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Barbier F, Andremont A, Wolff M, Bouadma L. Hospital-acquired pneumonia and ventilator-associated pneumonia: recent advances in epidemiology and management. Curr Opin Pulm Med. 2013;19:216–228. doi: 10.1097/MCP.0b013e32835f27be. [DOI] [PubMed] [Google Scholar]
3.Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O'Grady NP, Bartlett JG, Carratalà J, El Solh AA, Ewig S, Fey PD, File TM, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63:e61–e111. doi: 10.1093/cid/ciw353. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002;165:867–903. doi: 10.1164/ajrccm.165.7.2105078. [DOI] [PubMed] [Google Scholar]
5.Garau J, Baquero F, Perez-Trallero E, Perez JL, Martin-Sanchez AM, Garcia-Rey C, Martin-Herrero JE, Dal-Re R. Factors impacting on length of stay and mortality of community-acquired pneumonia. Clin Microbiol Infect. 2008;14:322–329. doi: 10.1111/j.1469-0691.2007.01915.x. [DOI] [PubMed] [Google Scholar]
6.Torres A, Niederman MS, Chastre J, Ewig S, Fernandez-Vandellos P, Hanberger H, Kollef M, Li Bassi G, Luna CM, Martin-Loeches I, Paiva JA, Read RC, Rigau D, Timsit JF, Welte T, Wunderink R. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia. Eur Respir J. 2017;50:1700582. doi: 10.1183/13993003.00582-2017. [DOI] [PubMed] [Google Scholar]
7.Nora D, Povoa P. Antibiotic consumption and ventilator-associated pneumonia rates, some parallelism but some discrepancies. Ann Transl Med. 2017;5:450. doi: 10.21037/atm.2017.09.16. [DOI] [PMC free article] [PubMed] [Google Scholar]
8.Liu VX, Fielding-Singh V, Greene JD, Baker JM, Iwashyna TJ, Bhattacharya J, et al. The timing of early antibiotics and hospital mortality in sepsis. Am J Respir Crit Care Med. 2017;196:856–63. doi: 10.1164/rccm.201609-1848OC. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Yokota PKO, Marra AR, Martino MDV, Victor ES, Durão MS, Edmond MB, et al. Impact of appropriate antimicrobial therapy for patients with severe Sepsis and septic shock – a quality improvement study. PLoS One. 2014;9:1–10. doi: 10.1371/journal.pone.0104475. [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165–228. doi: 10.1007/s00134-012-2769-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Jain S, Self WH, Wunderink RG, CDC EPIC study team Community-acquired pneumonia requiring hospitalization. N Engl J Med. 2015;373:2382. doi: 10.1056/NEJMc1511751. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Messika J, Stoclin A, Bouvard E, Fulgencio J-P, Ridel C, Muresan I-P, et al. The challenging diagnosis of non-community-acquired pneumonia in non-mechanically ventilated subjects: value of microbiological investigation. Respir Care. 2016;61:225–34. doi: 10.4187/respcare.04143. [DOI] [PubMed] [Google Scholar]
13.Versporten A, Zarb P, Caniaux I, Gros M-F, Drapier N, Miller M, et al. Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey. Lancet Glob Health. 2018;6:e619–29. doi: 10.1016/S2214-109X(18)30186-4. [DOI] [PubMed] [Google Scholar]
15.Bauer KA, Perez KK, Forrest GN, Goff DA. Review of rapid diagnostic tests used by antimicrobial stewardship programs. Clin Infect Dis. 2014;59(Suppl 3):S134–45. doi: 10.1093/cid/ciu547. [DOI] [PubMed] [Google Scholar]
16.Rappo U, Schuetz AN, Jenkins SG, Calfee DP, Walsh TJ, Wells MT, et al. Impact of early detection of respiratory viruses by multiplex PCR assay on clinical outcomes in adult patients. J Clin Microbiol. 2016;54:2096–103. doi: 10.1128/JCM.00549-16. [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Gadsby NJ, Russell CD, McHugh MP, Mark H, Conway Morris A, Laurenson IF, et al. Comprehensive molecular testing for respiratory pathogens in community-acquired pneumonia. Clin Infect Dis. 2016;62:817–23. doi: 10.1093/cid/civ1214. [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Yugueros-Marcos J, Barraud O, Iannello A, Ploy MC, Ginocchio C, Rogatcheva M, et al. New molecular semi-quantification tool provides reliable microbiological evidence for pulmonary infection. Intensive Care Med. 2018;44:2302–4. doi: 10.1007/s00134-018-5417-0. [DOI] [PubMed] [Google Scholar]
19.Lee SH, Ruan S-Y, Pan S-C, Lee T-F, Chien J-Y, Hsueh P-R. Performance of a multiplex PCR pneumonia panel for the identification of respiratory pathogens and the main determinants of resistance from the lower respiratory tract specimens of adult patients in intensive care units. J Microbiol Immunol Infect. 2019;52:920–8. doi: 10.1016/j.jmii.2019.10.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
20.Huang AM, Windham SL, Mahmutoglu D, Balada-Llasat JM, Relich RF, Humphries R, et al. Potential clinical impact of a semi-quantitative multiplex molecular assay for the identification of bacteria, viruses, and fungi in lower respiratory specimens. Proceedings of the European Society of Clinical Microbiology and Infectious Diseases Meeting. Basel, Switzerland.
21.Noviello S, Huang DB. The basics and the advancements in diagnosis of bacterial lower respiratory tract infections. Diagnostics. 2019;9:37–48. doi: 10.3390/diagnostics9020037. [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Troeger C, Forouzanfar M, Rao PC, Khalil I, Brown A, Swartz S, et al. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect Dis. 2017;17:1133–61. doi: 10.1016/S1473-3099(17)30396-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
23.Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH. Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest. 2002;122:262–8. doi: 10.1378/chest.122.1.262. [DOI] [PubMed] [Google Scholar]
24.Jain S, Self WH, Wunderink RG, Fakhran S, Balk R, Bramley AM, et al. Community-acquired pneumonia requiring hospitalization among US adults. N Engl J Med. 2015;373:415–27. doi: 10.1056/NEJMoa1500245. [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Kao CC, Chiang HT, Chen CY, Hung CT, Chen YC, Su LH, et al. National bundle care program implementation to reduce ventilator-associated pneumonia in intensive care units in Taiwan. J Microbiol Immunol Infect. 2019;52:592–7. doi: 10.1016/j.jmii.2017.11.001. [DOI] [PubMed] [Google Scholar]
26.Lim WS, Woodhead M. British Thoracic Society adult community acquired pneumonia audit 2009/10. Thorax. 2011;66:548–9. doi: 10.1136/thoraxjnl-2011-200081. [DOI] [PubMed] [Google Scholar]
27.Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Supplement_2):S27–72. doi: 10.1086/511159. [DOI] [PMC free article] [PubMed] [Google Scholar]
28.4Lim WS, Baudouin SV, George RC, et al. BTS guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009;64:iii1–55. doi: 10.1136/thx.2009.121434. [DOI] [PubMed] [Google Scholar]
29.Jokinen C, Heiskanen L, Juvonen H, et al. Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland. Am J Epidemiol. 1993;137:977–88. doi: 10.1093/oxfordjournals.aje.a116770. [DOI] [PubMed] [Google Scholar]
30.Myint PK, Kwok CS, Majumdar SR, et al. The International Community-Acquired Pneumonia (CAP) Collaboration Cohort (ICCC) study: rationale, design and description of study cohorts and patients. BMJ Open. 2012;2:e001030. doi: 10.1136/bmjopen-2012-001030. [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Chalmers JD, Taylor JK, Singanayagam A, et al. Epidemiology, antibiotic therapy, and clinical outcomes in health care associated pneumonia: a UK cohort study. Clin Infect Dis. 2011;53:107–13. doi: 10.1093/cid/cir274. [DOI] [PubMed] [Google Scholar]
32.Musher DM, Roig IL, Cazares G, Stager CE, Logan N, Safar H. Can an etiologic agent be identified in adults who are hospitalized for community-acquired pneumonia: results of a one-year study. J Infect. 2013;67:11–8. doi: 10.1016/j.jinf.2013.03.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Magill SS, O'Leary E, Janelle SJ, et al. Changes in prevalence of health care-associated infections in U.S. hospitals. N Engl J Med. 2018;379(18):1732–44. doi: 10.1056/NEJMoa1801550. [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Ibn Saied W, Mourvillier B, Cohen Y, et al. A comparison of the mortality risk associated with ventilator-acquired bacterial pneumonia and nonventilator ICU-acquired bacterial pneumonia. Crit Care Med. 2019;47(3):345–52. doi: 10.1097/CCM.0000000000003553. [DOI] [PubMed] [Google Scholar]
36.Kollef MH, Bassetti M, Francois B, et al. The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship. Intensive Care Med. 2017;43(9):1187–97. doi: 10.1007/s00134-017-4682-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Bassetti M, Righi E, Vena A, Graziano E, Russo A, Peghin M. Risk stratification and treatment of ICU-acquired pneumonia caused by multidrug- resistant/ extensively drug-resistant/pandrug-resistant bacteria. Curr Opin Crit Care. 2018;24(5):385–93. doi: 10.1097/MCC.0000000000000534. [DOI] [PubMed] [Google Scholar]
38.Bergmans DC, Bonten MJ, Gaillard CA, et al. Indications for antibiotic use in ICU patients: a one-year prospective surveillance. J Antimicrob Chemother. 1997;39(4):527–35. doi: 10.1093/jac/39.4.527. [DOI] [PubMed] [Google Scholar]
39.Armand-Lefèvre L, Angebault C, Barbier F, et al. Emergence of imipenem-resistant gram-negative bacilli in intestinal flora of intensive care patients. Antimicrob Agents Chemother. 2013;57(3):1488–95. doi: 10.1128/AAC.01823-12. [DOI] [PMC free article] [PubMed] [Google Scholar]
40.Timsit J-F, Bassetti M, Cremer O, et al. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med. 2019;45(2):172–89. doi: 10.1007/s00134-019-05520-5. [DOI] [PubMed] [Google Scholar]
41.Torres A, Lee N, Cilloniz C, Vila J, Van der Eerden M. Laboratory diagnosis of pneumonia in the molecular age. Eur Respir J. 2016;48:1764–1778. doi: 10.1183/13993003.01144-2016. [DOI] [PubMed] [Google Scholar]
42.Trevino SE, Pence MA, Marschall J, Kollef MH, Babcock HM, Burnham CD. Rapid MRSA PCR on respiratory specimens from ventilated patients with suspected pneumonia: a tool to facilitate antimicrobial stewardship. Eur J Clin Microbiol Infect Dis. 2017;36:879–885. doi: 10.1007/s10096-016-2876-5. [DOI] [PubMed] [Google Scholar]
43.Babady NE, England MR, Jurcic Smith KL, He T, Wijetunge DS, Tang YW, Chamberland RR, Menegus M, Swierkosz EM, Jerris RC, Greene W. Multicenter evaluation of the ePlex Respiratory Pathogen Panel for the detection of viral and bacterial respiratory tract pathogens in nasopharyngeal swabs. J Clin Microbiol. 2017;56:e01658–17. doi: 10.1128/JCM.01658-17. [DOI] [PMC free article] [PubMed] [Google Scholar]
45.Miller JM, Binnicker MJ, Campbell S, Carroll KC, Chapin KC, Gilligan PH, Gonzalez MD, Jerris RC, Kehl SC, Patel R, Pritt BS, Richter SS, Robinson-Dunn B, Schwartzman JD, Snyder JW, Telford S, III,, Theel ES, Thomson RB, Jr,, Weinstein MP, Yao JD. A guide to utilization of the microbiology laboratory for diagnosis of infectious Diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018;67:813–816. doi: 10.1093/cid/ciy584. [DOI] [PubMed] [Google Scholar]
46.Murphy CN, Fowler R, Balada-Llasat JM, Carrol A, Stone H, Akerele O, Buchan B, Windham S, Hopp A, Ronen S, Relich RF, Buckner R, Warren DA, Humphries R, Campeau S, Huse H, Chandrasekaran S, Leber A, Everhart K, Harrington A, Kwong C, Bonwit A, Dien Bard J, Naccache S, Zimmerman C, Rindlisbacher C, Buccambuso M, Clark A, Rogatcheva M, Graue C, Bourzac KM. Multicenter evaluation of the BioFire FilmArray Pneumonia/Pneumonia Plus panel for detection and quantification of agents of lower respiratory tract infection. J Clin Microbiol. 2020;58:e00128–20. doi: 10.1128/JCM.00128-20. [DOI] [PMC free article] [PubMed] [Google Scholar]
47.Blake W. Buchan, Sam Windham, Joan-Miquel Balada-Llasat, Amy Leber, Amanda Harrington, Ryan Relich, Caitlin Murphy, Jennifer Dien Bard, Samia Naccache, Shira Ronen, Amanda Hopp, Derya Mahmutoglu, Faron Matthew L, Ledeboer Nathan A, Amanda Carroll, Hannah Stone, Oluseun Akerele, Kathy Everhart, Andrew Bonwit, Christina Kwong, Rebecca Buckner, Del Warren, Randal Fowler, Sukantha Chandrasekaran, Holly Huse, Shelley Campeau, Romney Humphries, Corrin Graue, Angela Huanga. Practical Comparison of the BioFire FilmArray Pneumonia Panel to Routine Diagnostic Methods and Potential Impact on Antimicrobial Stewardship in Adult Hospitalized Patients with Lower Respiratory Tract Infections. J Clin Microbiol. 2020;58:e00135–20. doi: 10.1128/JCM.00135-20. [DOI] [PMC free article] [PubMed] [Google Scholar]
48.Webber DM, Wallace MA, Burnham C-AD, Anderson NW. Evaluation of the BioFire FilmArray pneumonia panel for detection of viral and bacterial pathogens in lower respiratory tract specimens in the setting of a tertiary care academic medical center. J Clin Microbiol. 2020;58:e00343–20. doi: 10.1128/JCM.00343-20. [DOI] [PMC free article] [PubMed] [Google Scholar]
49.Kenneth H. Rand, Beal Stacy G, Kartikeya Cherabuddi, Brianne Couturier, Beth Lingenfelter, Cory Rindlisbacher, Jay Jones, Houck Herbert J, Lessard Kylie J, Tremblay Elizabeth E. Performance of a Semiquantitative Multiplex Bacterial and Viral PCR Panel Compared With Standard Microbiological Laboratory Results: 396 Patients Studied With the BioFire Pneumonia Panel. Bacterial PCR and Standard Microbiology, Open Forum Infectious Diseases: 2020;2020:1–8. doi: 10.1093/ofid/ofaa560. [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Sze Hwei Lee, Sheng-Yuan Ruan, Sung-Ching Pan, Tai-Fen Lee, Jung-Yien Chien, Po-Ren Hsueh. Performance of a multiplex PCR pneumonia panel for the identification of respiratory pathogens and the main determinants of resistance from the lower respiratory tract specimens of adult patients in intensive care units. Journal of Microbiology, Immunology and Infection 2019; 2019;52:920–928. doi: 10.1016/j.jmii.2019.10.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
51.In Young Yooa, Kyungmin Huh, Hyang Jin Shim, Sun Ae Yun, Yoo Na Chung, On Kyun Kang, Hee Jae Huh, Nam Yong Lee. International Journal of Infectious Diseases. 2020;2020;95:326–331. [Google Scholar]
52.Barend Mittona, Roxanne Rulea, Mohamed Saida. Laboratory evaluation of the BioFire FilmArray Pneumonia plus panel compared to conventional methods for the identification of bacteria in lower respiratory tract specimens: a prospective cross-sectional study from South Africa. Diagnostic Microbiology and Infectious Disease 2021; 2021;99:115236. doi: 10.1016/j.diagmicrobio.2020.115236. [DOI] [PMC free article] [PubMed] [Google Scholar]
53.Céline Monard, Jonathan Pehlivan, Gabriel Auger, Sophie Alviset, Alexy Tran Dinh, Paul Duquaire, Nabil Gastli, Camille d'Humières, Adel Maamar, André Boibieux, Marion Baldeyrou, Julien Loubinoux, Olivier Dauwalder, Vincent Cattoir, Laurence Armand-Lefèvre, Solen Kernéis, the ADAPT study group Multicenter evaluation of a syndromic rapid multiplex PCR test for early adaptation of antimicrobial therapy in adult patients with pneumonia. Critical Care 2020; 2020;24:434. doi: 10.1186/s13054-020-03114-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
54.Nathan Peiffer-Smadja, Lila Bouadma, Vincent Mathy, Kahina Allouche, Juliette Patrier, Martin Reboul, Philippe Montravers, Jean-François Timsit, Laurence Armand-Lefevre. Performance and impact of a multiplex PCR in ICU patients with ventilator-associated pneumonia or ventilated hospital-acquired pneumonia. Critical Care. 2020;2020;24:366. doi: 10.1186/s13054-020-03067-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
55.Charles-Edouard Luyt, Guillaume Hékimian, Isabelle Bonnet, Nicolas Bréchot, Matthieu Schmidt, Jérôme Robert, Alain Combes, Alexandra Aubry. Usefulness of point-of-care multiplex PCR to rapidly identify pathogens responsible for ventilator-associated pneumonia and their resistance to antibiotics: an observational study. Critical Care. 2020;2020;24:378. doi: 10.1186/s13054-020-03102-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
56.Naomi J, Gadsby, Russell Clark D, McHugh Martin P, Mark Harriet, Morris Andrew Conway, Laurenson Ian F, Hill Adam T, Templeton Kate E. Comprehensive Molecular Testing for Respiratory Pathogens in Community-Acquired Pneumonia. Clinical Infectious Diseases. 2016;2016;62(7):817–23. doi: 10.1093/cid/civ1214. [DOI] [PMC free article] [PubMed] [Google Scholar]
57.Chiagozie Pickens, Richard G. Wunderink, Chao Qi, Haritha Mopuru, Helen Donnelly, Kimberly Powell, Sims Matthew D. A multiplex polymerase chain reaction assay for antibiotic stewardship in suspected pneumonia. Diagnostic Microbiology and Infectious Disease. 2020;2020;98:115179. doi: 10.1016/j.diagmicrobio.2020.115179. [DOI] [PMC free article] [PubMed] [Google Scholar]
Bloodstream infections pose critical challenges in clinical settings, necessitating precise treatment strategies. Understanding pathogens, antibiotic efficacy, and patient demographics aids in optimizing interventions. Knowledge gaps persist, urging comprehensive exploration for improved therapeutic outcomes.
Objectives
Develop and validate an algorithmic approach to optimize initial treatment strategies for bloodstream infections, considering antibiotic transitions and patient demographics, enhancing efficacy and patient outcomes while exploring Dalbavancin's role in specific infections.
Methods
Utilized a survey within a Continuing Medical Education (CME) framework based approach among critical care specialists (n = 60), gathering preferences and practices in treating bloodstream infections. Collected data on preferred antibiotics, transition strategies, and considerations for patient demographics. Analyzed responses to map knowledge trends and evaluated Dalbavancin's perceived role in specific infections.
Results
The preferred treatment for suspected MSSA bloodstream infections is to start with vancomycin and switch to a beta-lactam (31.03%), with an average strategy preference of 2.69 and a standard deviation of 1.49. Male and adult patients show the highest MRSA prevalence in India at 34.48%, with no significant gender or age difference (27.59%). Average response is 3.48, SD 1.25. Thymosin Alpha 1 seen as moderately promising for sepsis adjunct therapy by 58.62%, with more research needed; average response 2.21, SD 0.61. Current ICU fungal infection guidelines rated moderately effective by 65.52%; updates may be needed. Average rating is 1.86, with a standard deviation of 0.57. Biapenem: Treats diverse Gram+/- infections, severe cases. Indicated in 62% cases; 37% for UTIs. Biapenem use: Avoid for meningitis (79%). Suitable for UTIs (10%), intra-abdominal, sepsis (3%). In adults, viral sepsis: Influenza virus predominant (65%), followed by Enterovirus (17%), others less common. Bacterial sepsis risks: Recent surgery (48%), age over 65 (21%), UTI (24%). Immunocompromise and diabetes are not significant factors. Critical sepsis intervention: Initiate broad-spectrum antibiotics promptly (90%). Other interventions not as pivotal. Common fungal sepsis agent: Candida albicans prevalent (83%), followed by Aspergillus fumigatus (14%). Initial sepsis treatment: Focus on infection identification/treatment, supportive care, complication prevention; less emphasis on immediate antibiotic administration or vital restoration. Dalbavancin: Mainly for acute skin infections (86%), less for COPD exacerbations; not for UTI or hepatitis. Certain Gram-negative bacteria: Some exhibit quorum sensing, phase variation, favoring biofilm on catheters, increasing CLABSI risk.
Discussion
The results reflects varied approaches in managing infections. Opting for vancomycin initially, then transitioning to beta-lactam for MSSA infections, mirrors a popular strategy. In India, male adults face higher MRSA prevalence without notable age or gender disparities. Thymosin Alpha 1 shows promise as a sepsis adjunct, with a call for further investigation. Current ICU fungal infection guidelines are moderately effective, suggesting potential updates. Understanding sepsis risks—recent surgery, age factors—is crucial. Prompt antibiotic initiation remains pivotal in managing sepsis. Candida albicans stands out as a primary fungal sepsis agent. Lastly, specific Gram-negative bacteria traits drive biofilm formation on catheters, heightening CLABSI risk—highlighting the need for tailored preventive measures. The study also underscores Dalbavancin's specificity for acute skin infections (86%). This study serves as a comprehensive knowledge mapping endeavor undertaken among critical care specialists.
An observational study to compare the outcomes with the end points of 1) Survival, 2) Hospital stay and 3) Cost burden was done for patients admitted in the ITU undergoing early Echocardiographic assessment (within 24 hours of admission) versus delayed assessment (after 48 hours of admission), in patients.
Objectives
To find out if there is any difference of outcomes in the above mentioned end points, for patients admitted in the ITU of the hospital, with early Echocardiographic assessment versus late assessment. This would help to formulate a protocol for greater benefit for such patients along with cost effectiveness in their treatment.
Materials and methods
100 patients, admitted in the ITU were observed for 1) Survival, 2) Hospital stay and 3) Cost burden borne by them. They were divided in 2 groups – A and B Group A including those undergoing early echocardiography along with other routine investigations, Group B including those undergoing echocardiography assessment after 48 hours of admission. Of the 100 patients 20 had to be excluded from the study, as they were transferred or discharged against medical advice. Of the 80 patients observed 38 were in Group A (18 Females) and 42 were in Group B (16 Females). Echocardiographic assessment helped to formulate the fluid and other supportive regimen in reference to the management of these patients.
Results
It was observed that those in Group A had better Results for all the 3 endpoints (Survival, Hospital stay and Cost burden) when compared for the same endpoints for those in Group B.
Discussions
Echocardiography helps to assess the cardiac function and haemodynamics, hence an early assessment of the same with modification of the management therapy accordingly helps to improve Survival, reduce Hospital stay and also reduce the cost burden for these patients. Protocols should be formulated for early assessment by Echocardiography to obtain better outcomes in critical care.
Validation of Posmi (Predictor of Sepsis Mortality in ICU) Score to Predict Mortality of Patients with Sepsis and Comparing it with Sofa Score, Saps3 and Apache4 Score: A Prospective Longitudional Observational Study in A Tertiary Care ICU of Eastern India
Predictive scoring system are measures of disease severity used to predict outcomes including mortality. Such measurements compare the quality of patient care across ICUs. Several scoring system are available to predict sepsis outcome in the Emergency and ICU, two of which most recently used and upgraded are SOFA score (GOLD STANDARD), APACHE 4 and SAPS 3. Scores serve the purposes of assessing therapies, quality control, quality assurance and economic evaluation in intensive care. They allow timely identification of high-risk populations that require aggressive management and intervention. They also help in making objective prognoses and recommendations for clinicians as well as patients and their families. POSMI score was developed specifically to predict the severity of illness in patients with sepsis. It doesn't require software system for calculation and can be calculated in bedside. The POSMI score was derived from retrospective cohort of patients in USA and CHINA. To our knowledge it has never been validated in a prospective study in Indian patients.
Objectives
Primary Objective: To validate the efficacy of POSMI SCORE in predicting mortality of sepsis in a tertiary care ICU of eastern India and to compare with SOFA score, SAPS 3 and APACHE 4 in doing so.
Materials
STUDY AREA –70 bedded Intensive care unit (ICU) of tertiary care hospital in Eastern India. STUDY POPULATION –Convenience sample of 80 (patients admitted with sepsis in ICU. STUDY DURATION- 1ST JANUARY 2023- 30TH NOVEMBER 2023 STUDY DESIGN-prospective longitudinal observational study.
Methods
Patients with sepsis were evaluated by the above mentioned scores after 24hour of hospital admission. We followed the patients till hospital discharge or death.
Results
Our study included 80 patients whose mean age is (68.38 + 12.14 years) comprising of 63% male and 37% female population. Values of variables expressed as median in interquartile range are APACHE 4 - 76.5(27), SAPS 3 - 70 (13), SOFA -6.50(4) and POSMI -7.25(4). The association between scores and mortality show higher co relation (Spearman Rank) coefficient with POSMI (0.605) followed by SOFA (0.420), APACHE 4(0.386) and SAPS 3(0.285). The AUC (AREA UNDER CURVE) for POSMI score {0.903, 95% CONFIDENCE INTERVAL (CI) 0.837-0.968} is higher than SOFA score {0.778, 95% (CI) 0.668-0.888}, APACHE 4 {0.757, 95% (CI) 0.646-0.868} and SAPS 3 {0.690 95% (CI) 0.568-0.811}. This indicated that POSMI score has better discrimination than the other scores compared here.
Discussion
POSMI score can be used as an effective bedside tool for predicting mortality in patients with sepsis.
Reference
1.Weng J, Hou R, Zhou X, et al. Development and validation of a score to predict mortality in ICU patients with sepsis: a multicentre retrospective study. J Transl Med. 2021;19:322. doi: 10.1186/s12967-021-03005-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
Comparison of Vena Cava Distensibility Index and Mini Fluid Challenge for the Evaluation of Intravascular Volume in Critically Ill Septic Shock Patient
The assessment of volume responsiveness is of paramount importance for shock management in critical care settings as both overhydration & underhydration are deleterious. The primary goal of fluid administration is to increase cardiac output and therefore oxygen delivery by the Frank–Starling relationship, which relates stroke volume (or cardiac output) to a cardiac filling volume [1]. Excessive fluid loading can induce peripheral and pulmonary edema and compromise microvascular perfusion and oxygen delivery [2]. In the last decade, dynamic variables such as stroke volume variation, pulsed pressure variation (PPV), respiratory variation of aortic blood flow (monitored with esophageal Doppler), tidal volume challenge test, and aortic peak velocity (assessed by echocardiography); which depend on mechanical ventilation induced stroke volume variation, have been shown to be accurate in predicting fluid responsiveness [3]. Among dynamic parameters, the vena cava distensibility index (IVC - DI) have been found to predict fluid responsiveness by cut off of 12% [4]. The mini fluid challenge using crystalloid have been found to predict volume responsiveness in operation room [5]. The current prospective observational study was done to compare vena caval distensibility to mini fluid challenge using crystalloid in evaluating the volume status of critically ill patients in septic shock admitted to intensive care unit.
Objectives
The current study evaluates the effectiveness of the vena cava distensibility index (IVC - DI) and mini fluid challenge (MFC) as dynamic parameters for estimating intravascular volume in critically ill patients in septic shock.
Materials and methods
The current prospective observational study is getting conducted in Critical Care Unit, Tata Main Hospital, Jamshedpur after Scientific Research Committee and Institutional Ethics Committee clearance. Adult patients with septic shock on mechanical ventilation admitted to intensive care unit without cardiac and renal impairment will be included in the study. The vena cava distensibility index (IVC-DI) will be measured using bedside ultrasound at T 0. The mini fluid challenge will be performed by first 100 ml crystalloid over 1 min, followed by echographic assessment of subaortic Velocity time integral (VTI) and the remaining 400 ml crystalloid infusion over 14 min then echocardiographic assessment of VTI. Fluid responsiveness will be considered as an increase in the subaortic VTI ≥15% (ΔVTI500≥ 15%) after the infusion of 500 ml of crystalloid. Patient characteristics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Sequential organ dysfunction score, ideal body weight (kg) and ventilatory setting will be recorded at admission. These variables will be collected at baseline (T0), after 1 min [i.e., infusion of the first 100 ml (MFC) = T1], and after the end of the conventional fluid challenge (T15). The sensitivity and specificity of identification of fluid responsiveness by IVC - DI and MFC will be compared.
Results
This is an ongoing study.
Discussions
This is an ongoing study.
References
1.Delicce AV, Makaryus AN. StatPearls [Internet] Treasure Island (FL): StatPearls Publishing; 2023 Jan 30. Jan–2023. Physiology, Frank Starling Law.29262149 [PubMed] [Google Scholar]
2.Wang P, Zhou M, Rana MW, Ba ZF, Chaudry IH. Differential alterations in microvascular perfusion in various organs during early and late sepsis. Am J Physiol. 1992;263:G38–43. doi: 10.1152/ajpgi.1992.263.1.G38. [DOI] [PubMed] [Google Scholar]
3.Tavernier B, Makhotine O, Lebuffe G, Dupont J, Scherpereel P. Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension. ANESTHESIOLOGY. 1998;89:1313–21. doi: 10.1097/00000542-199812000-00007. [DOI] [PubMed] [Google Scholar]
4.Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med. 2004 Sep;30(9):1834–7. doi: 10.1007/s00134-004-2233-5. [DOI] [PubMed] [Google Scholar]
5.Biais M, de Courson H, Lanchon R, Pereira B, Bardonneau G, Griton M, Sesay M, Nouette-Gaulain K. Mini-fluid Challenge of 100 ml of Crystalloid Predicts Fluid Responsiveness in the Operating Room. Anesthesiology. 2017 Sep;127(3):450–456. doi: 10.1097/ALN.0000000000001753. [DOI] [PubMed] [Google Scholar]
Capillary refill time (CRT) is being widely used for resuscitation these days, and considered as surrogate for lactate levels. So we planned a study to evaluated the correlation between the CRT at 3 different sites (peripheral finger, sternum and tongue) and the arterial lactate with the hypoperfusion status of all patients arriving in shock in our Emergency Room (ER) and intensive care unit (ICU).
Methods
A pilot observational study was undertaken in the ER and ICU in a tertiary care hospital. Consecutive adult patients (> 18 years) presenting with a MAP of less than 65 were included in the study. Exclusion criteria were pregnancy, active bleeding, severe acute respiratory distress syndrome, and do-not-resuscitate status. CRT was measured by applying a glass microscope slide to the right index finger (at the distal phalanx) and tongue until the area under the slide turned pale and then maintained for 10 seconds. After that pressure was released and the time taken to reperfuse was counted. CRT at 3 different sites – distal finger, chest over the sternum and tongue was checked at arrival (time zero), along with assessment of the hypoperfusion state with lactate, and recording of MAP. Resuscitation with IV fluids and vasopressors was done as per the hospital protocol, and the parameters were reassessed at 3 hours and 6 hours.
Results
We analysed a total of 37 patients, with CRT measured thrice in each – so a total of 111 readings. Among 111 patients, CRT was more than 3 seconds only when the arterial lactate levels were more than 5 mmol/L. The CRT over the sternum did not get altered irrespective of the BP and the lactate levels. The tongue (mucosal) CRT correlated with the peripheral distal CRT.
Conclusions
CRT is unreliable for lower states of hypoperfusion or at a arterial lactate levels of less than 5 mmol/L. Distal CRT is as reliable as mucosal CRT for assessing perfusion, and is not affected by vasopressors.
