Indian Journal of Critical Care Medicine

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Volume 25, Number 10, October 2021

EDITORIAL

Raj Kumar Mani

INDICAPS II: A Bird's Eye View of the Indian Intensive Care Landscape

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1087 - 1088]

Keywords: End-of-life care, ICU management, ICU mortality, Indian intensive care unit, Intensive care, Left against medical advice

PDF  |  DOI: 10.5005/jp-journals-10071-24003  |  Open Access |  How to cite  | 

EDITORIAL

Balasaheb D Bande

Use of Tofacitinib in the Management of COVID-19 Pneumonia

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1089 - 1090]

Keywords: COVID-19, JAK/STAT, Tofacitinib

PDF  |  DOI: 10.5005/jp-journals-10071-24004  |  Open Access |  How to cite  | 

EDITORIAL

Banani Poddar

Critically Ill Pediatric Oncology Patients: A Difficult-to-treat Population

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1091 - 1092]

Keywords: Children, Critical care oncology, Hemato-oncology

PDF  |  DOI: 10.5005/jp-journals-10071-24017  |  Open Access |  How to cite  | 

Original Article

Jigeeshu Vasishtha Divatia, Yatin Mehta, Deepak Govil, Kapil Zirpe, Pravin R Amin, Nagarajan Ramakrishnan, Farhad N Kapadia, Mrinal Sircar, Samir Sahu, Pradip Kumar Bhattacharya, Sheila Nainan Myatra, Srinivas Samavedam, Subhal Dixit, Rajesh Kumar Pande, Sujata N Mehta, Ramesh Venkataraman, Khusrav Bajan, Vivek Kumar, Rahul Harne, Leelavati Thakur, Darshana Rathod, Prachee Sathe, Sushma Gurav, Carol D'Silva, Shaik Arif Pasha, Subhash Kumar Todi, the INDICAPS-II investigators

Intensive Care in India in 2018–2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:15] [Pages No:1093 - 1107]

Keywords: Adult, Health care, India, Intensive care units, Mortality, Patients, Process assessment

PDF  |  DOI: 10.5005/jp-journals-10071-23965  |  Open Access |  How to cite  | 

Abstract

Background: We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010–2011. Methods: An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs. Results: On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality. Conclusions: Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care. Registered at clinicaltrials.gov (NCT03631927).

Original Article

Neeraj Kumar, Sanjeev Kumar, Abhyuday Kumar, Divendu Bhushan, Amarjeet Kumar, Ajeet Kumar, Veena Singh, Prabhat K Singh

The COSEVAST Study Outcome: Evidence of COVID-19 Severity Proportionate to Surge in Arterial Stiffness

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:7] [Pages No:1113 - 1119]

Keywords: Arterial stiffness, COVID-19, COVID-19 ARDS, Endothelial injury, Intensive care unit

PDF  |  DOI: 10.5005/jp-journals-10071-24000  |  Open Access |  How to cite  | 

Abstract

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection affects the cardiovascular system at many levels. It initially infects endothelial cells, inducing marked endothelial damage and inflammation. However, there was no empirical evidence of functional compromise of arterial walls. Aims and objective: Our primary objective was to study functional arterial damage in coronavirus disease 2019 (COVID-19) and establish the noninvasive measurement of arterial stiffness as an independent marker of disease severity. Materials and methods: We recorded the arterial stiffness of 23 mild, 21 moderate, and 20 severe COVID-19 patients grouped on the latest National Institute of Health (NIH) severity criteria. We observed arterial stiffness of COVID-19 patients with standard parameters like noninvasive estimated carotid–femoral pulse wave velocity (cfPWV), age-normalized increase in cfPWV (ANI_cfPWV), age-normalized increase in aortic augmentation pressure (ANI_AugP), and heart rate-normalized augmentation index (HRN_AIx). All the parameters were also corrected for statistically significant confounding factors. Results: Moderate and severe COVID-19 patients have extremely significantly elevated arterial stiffness than mild patients. In mild patients, cfPWV (829.1 ± 139.2 cm/second) was significantly lower than both moderate (1067 ± 152.5 cm/second, p <0.0001) and severe (1416 ± 253.9 cm/second, p <0.0001) patients. ANI_cfPWV in moderate and severe patients was significantly higher than mild patients (mild: 101.2 ± 126.1 cm/second; moderate: 279 ± 114.4 cm/second; severe: 580.1 ± 216.4 cm/second; intergroup p <0.0001). The results even after correction for significant confounding factors did not show any considerable change in the increasing trend of arterial stiffness. Conclusion: This study establishes the functional deterioration of arteries in proportion to the severity of COVID-19.

Original Article

Kamini N Reddy, Jignesh Shah, Shivakumar Iyer, Monidipa Chowdhury, Naveen Yerrapalem, Neeraja Pasalkar, Prashant P Jedge

Direct Medical Cost Analysis of Indian COVID-19 Patients Requiring Critical Care Admission

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:6] [Pages No:1120 - 1125]

Keywords: Cost, COVID-19, Intensive care unit

PDF  |  DOI: 10.5005/jp-journals-10071-23991  |  Open Access |  How to cite  | 

Abstract

Introduction: Intensive care unit (ICU) admission is required for approximately 25% of patients affected with coronavirus disease-19 (COVID-19) and imposes a high economic burden on patients in resource-limited settings. Method: We conducted a retrospective direct medical care cost analysis of COVID-19 patients requiring ICU admission after obtaining the Institutional Ethics Committee approval. Data were obtained from the records of patients admitted to the COVID-19 ICU of a tertiary care trust teaching hospital from June 2020 to December 2020. Direct costs were analyzed and correlated with various demographic variables and clinical outcomes. Results: A total of 176 patients were included (males—76%). The median direct medical cost for a median stay of 13 days was INR 202248.5 ($ 2742.91). Hospital drugs and disposables accounted for 20% of the total cost followed by bed charges (19%), equipment charges (17%), biosafety protective gear (15.5%), pathological and radiological tests (15%), clinical management (7.6%), and biomedical waste management (1.6%). Government schemes accounted for 79% of medical claims followed by directly paying patients (12.5%) and private insurance (8.5%). The cost was significantly higher in patients with diabetes mellitus and sepsis and in those requiring mechanical ventilation (MV) (p <0.05). Shorter lead time to hospital admission and lesser length of hospital stay were associated with significant lower direct cost. Conclusion: Direct medical care cost is substantial for COVID-19 patients requiring ICU admission. This cost is significantly associated with increased ICU and hospital stay, longer lead time to admission, diabetes mellitus, sepsis, and those who need high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and MV.

Original Article

Rohini M Surve, Rajeeb K Mishra, Soumya R Malla, Sriganesh Kamath, Dhritiman R Chakrabarti, Karthik Kulanthaivelu, Mahendranath Musunuru

Clinical Characteristics and Outcomes of Critically Ill Neurological Patients with COVID-19 Infection in Neuro-intensive Care Unit: A Retrospective Study

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:7] [Pages No:1126 - 1132]

Keywords: COVID-19, Mortality, Neurocritical care, Neurological functional outcome, Predictors of outcome

PDF  |  DOI: 10.5005/jp-journals-10071-23989  |  Open Access |  How to cite  | 

Abstract

Background: There are insufficient data about clinical outcomes in critically ill neurological patients with concomitant coronavirus disease (COVID-19). This study describes the clinical characteristics, predictors of mortality, and clinical outcomes in COVID-19-positive neurological patients managed in a dedicated COVID-19 neurointensive care unit (CNICU). Methods: This single-center, retrospective cohort study was conducted in critically ill neurological and neurosurgical patients with concomitant COVID-19 infection admitted to the CNICU at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, from July to November 2020. Patients’ demographic, clinical, laboratory, imaging, treatment, and outcome data were retrieved from the manual and electronic medical records. Predictors of mortality and neurological outcome were identified using logistic regression. Results: During the study period, 50 COVID-19-positive neurological patients were admitted to the CNICU. Six patients were excluded from the analysis as they were managed in the CNICU for <24 hours. A poor outcome, defined as death or motor Glasgow Coma Scale <5 at hospital discharge, was observed in 34 of 44 patients (77.27%) with inhospital mortality in 26 of 44 patients (59%). Worst modified sequential organ failure assessment (MSOFA) score, lactate dehydrogenase maximum levels (LDHmax), and lymphocyte count were predictors of inhospital mortality with an odds ratio (OR) of 1.88, 1.01, and 0.87, respectively, whereas worst MSOFA and LDHmax levels were predictors for poor neurological outcome with OR of 1.99 and 1.01, respectively. Conclusions: Mortality is high in neurological patients with concomitant COVID-19 infection. Elevated inflammatory markers of COVID-19 suggest the role of systemic inflammation on clinical outcomes. Predictors of mortality and poor outcome were higher MSOFA score and elevated LDH levels. Additionally, lymphopenia was associated with mortality.

Original Article

Canan Akkus, Hakan Yilmaz, Rahime Duran, Suleyman Diker, Semih Celik, Cevdet Duran

Neutrophil-to-lymphocyte and Platelet-to-lymphocyte Ratios in those with Pulmonary Embolism in the Course of Coronavirus Disease 2019

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:4] [Pages No:1133 - 1136]

Keywords: COVID-19, Hematological changes, Neutrophil-to-lymphocyte ratio, Platelet-to-lymphocyte ratio, Pulmonary embolism

PDF  |  DOI: 10.5005/jp-journals-10071-23998  |  Open Access |  How to cite  | 

Abstract

Background: To investigate the levels of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios in those having a pulmonary embolism (PE) in the course of coronavirus disease 2019 (COVID-19). Methods: The records of those having COVID-19 were retrospectively obtained from the hospital automation system. NLR and PLR were measured with the help of patients’ blood cell counts. Results: Of 1,452 COVID-19 patients, 17 (1.2%) were diagnosed with PE. Compared with the controls, while leukocyte (p = 0.001), neutrophil (p <0.001), and neutrophil percentages, (p = 0.001) and NLR (p <0.001) and PLR (p = 0.006) had higher values, lymphocyte count (p = 0.004) and lymphocyte percentage (p <0.001) showed lower values in the patients with PE. Compared to the survivors, the non-survivors were found to have increased leukocyte (p <0.001), neutrophil (p <0.001), and neutrophil percentages (p <0.001), NLR (p <0.001) and PLR (p <0.001), and decreased lymphocyte (p <0.001) counts and percentage (p <0.001), hemoglobin (p = 0.005), hematocrit (p = 0.012), and platelet counts (p <0.001). While NLR and PLR cutoffs were found as 4.338 and 187.83 in predicting PE, the cutoff values of NLR and PLR were, respectively, 4.301 and 172.5 in predicting mortality. The logistic regression analysis also revealed that all hematological parameters had no effects on the development of PE. Conclusion: Although NLR and PLR had higher scores in PE patients, no relationship was determined between the levels of NLR and PLR and PE development. Further prospective studies including larger populations are required to enlighten the increased NLR and PLR in PE patients having COVID-19.

Original Article

Onkar K Jha, Sunny Kumar, Saurabh Mehra, Mrinal Sircar, Rajesh Gupta

Helmet NIV in Acute Hypoxemic Respiratory Failure due to COVID-19: Change in PaO2/FiO2 Ratio a Predictor of Success

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:10] [Pages No:1137 - 1146]

Keywords: Acute hypoxemic respiratory failure, Acute respiratory distress syndrome, COVID pneumonia, COVID-19, Helmet, Noninvasive mechanical ventilation, PaO2/FiO2 ratio

PDF  |  DOI: 10.5005/jp-journals-10071-23992  |  Open Access |  How to cite  | 

Abstract

In acute respiratory failure due to severe coronavirus disease 2019 (COVID-19) pneumonia, mechanical ventilation remains challenging and may result in high mortality. The use of noninvasive ventilation (NIV) may delay required invasive ventilation, increase adverse outcomes, and have a potential aerosol risk to caregivers. Data of 30 patients were collected from patient files and analyzed. Twenty-one (70%) patients were weaned successfully after helmet-NIV support (NIV success group), and invasive mechanical ventilation was required in 9 (30%) patients (NIV failure group) of which 8 (26.7%) patients died. In NIV success vs failure patients, the mean baseline PaO2/FiO2 ratio (PFR) (147.2 ± 57.9 vs 156.8 ± 59.0 mm Hg; p = 0.683) and PFR before initiation of helmet (132.3 ± 46.9 vs 121.6 ± 32.7 mm Hg; p = 0.541) were comparable. The NIV success group demonstrated a progressive improvement in PFR in comparison with the failure group at 2 hours (158.8 ± 56.1 vs 118.7 ± 40.7 mm Hg; p = 0.063) and 24 hours (PFR-24) (204.4 ± 94.3 vs 121.3 ± 32.6; p = 0.016). As predictor variables, PFR-24 and change (delta) in PFR at 24 hours from baseline or helmet initiation (dPFR-24) were significantly associated with NIV success in univariate analysis but similar significance could not be reflected in multivariate analysis perhaps due to a small sample size of the study. The PFR-24 cutoff of 161 mm Hg and dPFR-24 cutoff of −1.44 mm Hg discriminate NIV success and failure groups with the area under curve (confidence interval) of 0.78 (0.62–0.95); p = 0.015 and 0.74 (0.55–0.93); p = 0.039, respectively. Helmet interface NIV may be a safe and effective tool for the management of patients with severe COVID-19 pneumonia with acute respiratory failure. More studies are needed to further evaluate the role of helmet NIV especially in patients with initial PFR <150 mm Hg to define PFR/dPFR cutoff at the earliest time point for prediction of helmet-NIV success.

Original Article

Amrita Bhattacharyya, Rajeshwari Subramaniam, Dalim K Baidya, Praveen Aggarwal, Naveet Wig

Effect of Early Administration of Vitamin D on Clinical Outcome in Critically Ill Sepsis Patients: A Randomized Placebo-controlled Trial

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:8] [Pages No:1147 - 1154]

Keywords: Intensive care unit outcomes, Sepsis, Vitamin D

PDF  |  DOI: 10.5005/jp-journals-10071-23993  |  Open Access |  How to cite  | 

Abstract

Background: Administration of vitamin D to unselected heterogeneous critically ill patients did not demonstrate outcome benefit. The current study was undertaken to identify if early administration of vitamin D can reduce intensive care unit (ICU) length of stay and improve clinical outcomes in critically ill patients with sepsis. Methods: This single-center randomized double-blind placebo-controlled trial was done in the ICU and emergency inpatient ward of a tertiary care teaching institute in New Delhi, India. A total of 126 adult patients aged 18 to 80 years of either sex diagnosed to have sepsis were included within 24 hours of admission to the hospital and randomized into vitamin D or placebo groups. The patients in the intervention group received vitamin D3 540,000 units dissolved in 45 mL of milk. The placebo group received 45 mL of milk. Results: The median length of ICU stay (8 vs 9 days; p = 0.32), median length of hospital stay (12 vs 12 days; p = 0.33), median duration of vasopressors requirement (4 vs 3 days; p = 0.84), median duration of mechanical ventilation (5 vs 7 days; p = 0.23), requirement of tracheostomy (34 vs 39%; p = 0.71), and 90-day mortality [35 vs 46%; p = 0.29; HR 0.72 (0.42–1.24)] were similar in vitamin D and placebo arm. A subgroup analysis in patients with severe vitamin D deficiency (vitamin D <12 ng/mL) revealed a significantly decreased incidence of tracheostomy (28 vs 57%; p = 0.04), a trend toward decreased 90-day mortality [34 vs 66%; p = 0.08; HR 0.44 (0.19–1.01)], and duration of mechanical ventilation (6 vs 11 days; p = 0.05) in patients receiving vitamin D. Conclusion: Administration of large-dose vitamin D within 24 hours of admission does not reduce the length of ICU stay in critically ill sepsis patients.

Original Article

Joshua Vijay Joseph, Mamta Madhiyazhagan, Ramgopal Roshan, Sudhakar Geratala Dhanapal, Sivanandan Arul, Kundavaram Paul Prabhakar Abhilash

Factors Affecting the Time to First Dose Antibiotic in Sepsis in Acute Emergency

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:6] [Pages No:1155 - 1160]

Keywords: Antibiotics, Blood culture, Emergency department, qSOFA, Sepsis

PDF  |  DOI: 10.5005/jp-journals-10071-23994  |  Open Access |  How to cite  | 

Abstract

Background: The Surviving Sepsis Campaign recommends the administration of antibiotics within 1 hour of triage time in sepsis patients. The purpose of this study was to determine the factors affecting the time to first dose antibiotics in sepsis patients presenting to the emergency department (ED). Methods: We conducted a prospective observational study on factors affecting the time to first dose antibiotics in patients with sepsis presenting to the ED over a period of 7 months (July 2019 to January 2020). The purpose of this study was to determine the factors affecting the time to first dose antibiotics in sepsis patients. Results: During the study period, a total of 410 patients with a mean age of 51.6 years were presented to the ED with sepsis. Majority was triaged to priority 1 (84.8%). The median door to antibiotic time was 50 minutes (IQR, 40–90). Two-thirds (68%) of the patients (279) received antibiotics within 60 minutes. The blood culture positivity rate was 22.9%, and the contamination rate was 6%. The most common factors for the delay were atypical presentation (36.6%) and unknown focus of infection (36.6%). Triage to non-acute areas of the ED (priority 2) was associated with delayed antibiotic administration [odds ratio (OR), 7.3; 95% confidence interval (CI), 4.03–13.36; p-value <0.001]. Patients presented with cellulitis and necrotizing soft tissue infection (NSTI) had received antibiotics within an hour compared to other diagnoses (18.3 vs 8.4%; OR, 2.4; 95% CI, 1.2–4.9; p = 0.009). Conclusion: Two-thirds of our patients received their first dose of antibiotics within an hour of presentation to the ED. Triage to lower priorities was an independent risk factor for delay in first-dose antibiotic administration, and patients presented with an obvious focus of infections like cellulitis and NSTI received their first dose of antibiotic much earlier when compared to other diagnoses.

Original Article

Carlos DG da Silveira, Flávio PJ de Vasconcelos, Edmilson B Moura, Bruno TG da Silveira, Flávio FP Amorim, Lumie S Shintaku, Rosália B de Santana, Pedro LP Argotte, Sheila F da Silva, Marcelo de Oliveira Maia, Fabio F Amorim

Thyroid Function, Reverse Triiodothyronine, and Mortality in Critically Ill Clinical Patients

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:6] [Pages No:1161 - 1166]

Keywords: Intensive care units, Mortality, Reverse, Thyroid gland, Thyroid hormones, Triiodothyronine

PDF  |  DOI: 10.5005/jp-journals-10071-24001  |  Open Access |  How to cite  | 

Abstract

Background: To evaluate the association of thyroid hormones changes, including increased reverse triiodothyronine (rT3) level, with critically ill clinical patients\' mortality. Patients and methods: This study analyzed the observational data prospectively collected over 8 months (2018) in an adult intensive care unit (ICU) in Brasilia, Brazil. All consecutive ICU-admitted clinical patients were included. Thyroxine (T4), free thyroxine (fT4), triiodothyronine (T3), free triiodothyronine (fT3), rT3, and thyroid-stimulating hormone (TSH) were collected within 48 hours of ICU admission. Patients with hypothyroidism or hyperthyroidism who were previously diagnosed were excluded. Results: Of 353 included patients, age was 68.5 ± 19.0 years, sequential organ failure assessment (SOFA) score was 3.3 ± 2.9, and Acute Physiology and Chronic Health Evaluation II (APACHE II) was 17.1 ± 7.9. ICU mortality was 17.6% (n = 62). Non-survivor patients had a higher incidence of increased rT3 (69.3 vs 59.2%, p = 0.042), lower incidence of low T4 (4.8 vs 9.7%, p = 0.045), and increased age (75.2 ± 16.3 years vs 67.1 ± 19.3 years, p = 0.001), SOFA (3.0 ± 0.4 vs 2.8 ± 2.6, p <0.001), and APACHE II (23.5 ± 7.5 vs 15.7 ± 7.2, p <0.001). Alterations in other thyroid hormones did not show association with mortality. Increased rT3 [odds ratio (OR): 2.436; 95% confidence interval (CI): 1.023–5.800; p = 0.020] and APACHE II (OR: 1.083, 95% CI: 1.012–1.158; p = 0.044) were associated with ICU mortality in the multivariate analysis. Conclusion: Increased rT3 was independently associated with increased ICU mortality. In contrast, other thyroid hormone alterations did not show an association with mortality. Determining rT3 levels may be a helpful test to identify an increased risk for ICU mortality in clinical patients.

Original Article

Hannock Devadoss, Pawan Sharma, Vipin V Nair, Simarjit S Rehsi, Nilanjan Roy, Pankaj P Rao

Diagnostic Accuracy of e-FAST in Stable Blunt Trauma Chest: A Prospective Analysis of 110 Cases at a Tertiary Care Center

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:6] [Pages No:1167 - 1172]

Keywords: e-FAST, Fractures, Hemothorax, NCCT, Pneumomediastinum, Pneumothorax, Surgical fixation

PDF  |  DOI: 10.5005/jp-journals-10071-23995  |  Open Access |  How to cite  | 

Abstract

Background: Focused assessment with sonography in trauma (FAST) is an important adjunct and an extension of the clinical examination in an emergency setting for the last three decades. e-FAST visualizes the lung bases and injuries related to the lungs in addition to the intra-abdominal and pericardial bleed. In trauma patients, time is precious. Noncontrast computed tomography (NCCT) chest is the gold standard for the evaluation of blunt trauma chest. However, it is cumbersome and time-consuming and leads to increased morbidity and mortality. Therefore, evaluation of trauma patients at the trauma bay with e-FAST which is available at all times will not only save time but also the lives of trauma patients. Our endeavor is to find whether e-FAST can be substituted for NCCT for assessing injuries accurately in a stable blunt trauma patient. Patient and methods: Prospective observational study was conducted in a tertiary care trauma center during the period of November 2017 to 2019. Of the 197 patients presenting to the trauma surgeon in the trauma center, 110 were included in the study after satisfying the inclusion criteria. Eighty-seven patients being hemodynamically unstable were excluded from the study. Results: There was no statistical significance in the comparative data between the groups and all with “p” values more than 0.05. This accepts the null hypothesis and establishes the fact that there is no difference between NCCT chest which is the gold standard for chest blunt trauma and e-FAST. Conclusion: We conclude that e-FAST is a better adjunct to the diagnosis and management of blunt trauma chest patients.

View Point

Rajesh Panda, Divya Hirolli, Dalim K Baidya

Aftermath of COVID-19 and Critical Care in India

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:3] [Pages No:1173 - 1175]

Keywords: Antimicrobial resistance, COVID-19, Opportunistic infection

PDF  |  DOI: 10.5005/jp-journals-10071-23987  |  Open Access |  How to cite  | 

Abstract

The coronavirus disease-2019 (COVID-19) pandemic had overwhelmed the healthcare system and forced many patients to be treated at home with oxygen, antibiotics, and steroids, particularly during the second wave. There was increased misuse of antimicrobials in hospitals as well as unguarded self-prescription of these medications among the common people. We are likely to see an increase in the incidence of antimicrobial resistance (AMR), change in the susceptibility pattern of the organisms causing community-acquired infections, and an increase in opportunistic bacterial, tubercular, viral, and fungal infections.

BRIEF RESEARCH COMMUNICATION

Bharat Mehra, Mukul Pandey, Dhiren Gupta, Tania Oberoi, Nameet Jerath, Rachna Sharma, Naresh Lal, Chandrasekhar Singha, Bhavana Malhotra, Vinamra Manocha, Ashish K Simalti, Yogesh Arya, Sandeep K Dugaya, Swati Kalra, Amar J Chitkara, Anil Sachdev, Neeraj Gupta

COVID-19-associated Multisystem Inflammatory Syndrome in Children: A Multicentric Retrospective Cohort Study

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:7] [Pages No:1176 - 1182]

Keywords: Corticosteroids, Hyperinflammation, Intravenous Immunoglobulin—IVIG, Kawasaki disease, Multisystem inflammatory syndrome in children (MIS-C), SARS-CoV-2

PDF  |  DOI: 10.5005/jp-journals-10071-23996  |  Open Access |  How to cite  | 

Abstract

Background: Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the COVID-19 pandemic. Materials and methods: Demography, clinical, and laboratory variables of children admitted from April to September 2020 with MIS-C were studied retrospectively at eight hospitals in Delhi, India. Results: We identified 120 patients [median age: 7 years (interquartile range (IQR): 4–10)] with male-to-female ratio of 2.3:1. Overall, 73 out of 120 children (60.8%) presented with shock, 63 (52.5%) required inopressor support, and 51 (43%) required respiratory support. We categorized the cohort into three observed clinical phenotypes: MIS-C with shock (n = 63), MIS-C with Kawasaki disease (KD) (n = 23), and MIS-C without shock and KD (n = 34). Atypical presentations were hypothermia, orchitis, meningoencephalitis, demyelination, polyneuropathy, pancreatitis, and appendicitis. Ninety-four percent had laboratory evidence of SARS-CoV-2 (78.3%, seropositive and 15.8%, RT-PCR positive). The median C-reactive protein (CRP) was 136 mg/L (IQR, 63.5–212.5) and ferritin was 543 ng/mL (IQR, 225–1,127). More than 90% received immunomodulatory therapy (intravenous immunoglobulins and/or steroids) with an excellent outcome (96% survived). CRP and absolute neutrophil count (ANC) were correlated statistically with severity. Conclusion: MIS-C data from Delhi are presented. Rising CRP and ANC predict the severe MIS-C.

Pediatric Critical Care

Shilpushp J Bhosale, Malini Joshi, Vijaya P Patil, Amol T Kothekar, Sheila Nainan Myatra, Jigeeshu V Divatia, Atul P Kulkarni

Epidemiology and Predictors of Hospital Outcomes of Critically Ill Pediatric Oncology Patients: A Retrospective Study

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:6] [Pages No:1183 - 1188]

Keywords: Critical care oncology, Hematooncology, Hospital mortality, ICU mortality, ICU outcomes, Intensive care in pediatric cancer, Pediatric cancers, Solid tumors

PDF  |  DOI: 10.5005/jp-journals-10071-23984  |  Open Access |  How to cite  | 

Abstract

Background: The number of pediatric oncology patients admitted to the intensive care unit (ICU) has increased, and their hospital outcomes are improving. Since scarce data are available about this patient population, we conducted this retrospective study to evaluate the epidemiology and predictors of hospital outcomes. Materials and methods: We included all children with cancers who were admitted to our ICU over 1 year. We excluded children admitted after elective surgery and those following bone marrow transplant. We collected data about demographics, admission diagnosis, type of malignancies, and ICU interventions. The primary outcome was the hospital outcome. The secondary outcomes were ICU length of stay (LOS), and ICU and hospital mortality. We analyzed the predictors of hospital outcome. Results: Two hundred pediatric oncology patients were admitted from November 1, 2014 to October 30, 2015. Seventy-eight children had solid organ malignancies, and the rest had hematological malignancies. Hematooncology malignancy patients had significantly higher hospital mortality than those with solid organ malignancies. (61.5 vs 34.6%, p = 0.015). On multivariate regression analysis, mechanical ventilation [odds ratio (OR), 14.64; 95% confidence interval (CI): 1.23–165.05; p <0.030], inotropes (OR, 9.81; 95% CI: 1.222–78.66; p <0.032), and the presence of coagulopathy (OR, 3.86; 95% CI: 1.568–9.514; p <0.003) were independent predictors of hospital mortality. Conclusion: In this retrospective cohort of 200 children with malignancies, we found that children with hematologic cancer had significantly higher hospital mortality as compared to those with solid tumors. The need for mechanical ventilation, use of inotrope infusion, and coagulopathy were independent predictors of mortality.

Pediatric Critical Care

Serkan Özsoylu, Adem Dursun, Binnaz Çelik

Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:4] [Pages No:1189 - 1192]

Keywords: Critically ill children, Hemolytic uremic syndrome, Pediatric intensive care, Plasma exchange

PDF  |  DOI: 10.5005/jp-journals-10071-23985  |  Open Access |  How to cite  | 

Abstract

Aim and objective: To examine the clinical characteristics, indications, and complications of patients undergoing therapeutic plasma exchange (TPE) in our pediatric intensive care unit (PICU). Materials and methods: Patients who underwent therapeutic plasma exchange between January 2018 and January 2020 in the PICU were included in the study. Demographic, clinical, and laboratory data of patients were obtained retrospectively from medical records. A venous catheter was placed into subclavian, femoral, or jugular veins. The number of plasmapheresis sessions for each patient was determined by observing the course of the disease and clinical improvement. Patients were monitored for vital signs during the plasmapheresis process. Complications directly associated with TPE were recorded. Results: During the 2-year study period, 105 TPE sessions were performed in 25 patients (15 males/10 females). The median age was 84 months (6–204), and the median body weight was 32 kg (8–75). Renal disorders and sepsis were the most common group, and about 48% of patients were in these groups. The most common diagnoses were sepsis with multi-organ dysfunction syndrome in seven patients and followed by hemolytic uremic syndrome (five patients) and Guillain–Barre syndrome (three patients). Nausea (6.7%) and hypocalcemia (6.7%) were the most common complications of patients associated with the procedure. Premature discontinuation of the procedure were not seen due to complications. Complications were treated with symptomatic therapy. Conclusion: TPE is an effective treatment that can be safely used for pediatric patients with developments in PICUs. Nevertheless, TPE should be performed by experienced staff at a specialized center to minimize the risk of complications.

CASE SERIES

Sangam Yadav, Ankur Sharma, Nikhil Kothari, Pradeep K Bhatia, Shilpa Goyal, Amit Goyal

Mucormycosis: A Case Series of Patients Admitted in Non-COVID-19 Intensive Care Unit of a Tertiary Care Center during the Second Wave

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:4] [Pages No:1193 - 1196]

Keywords: COVID-19, Intensive care unit, Mucormycosis

PDF  |  DOI: 10.5005/jp-journals-10071-23986  |  Open Access |  How to cite  | 

Abstract

Rhino-orbital-cerebral mucormycosis is an invasive fungal infection associated with mortality of 25–62%. There has been a surge in the number of cases during this second wave of coronavirus disease-2019 (COVID-19) in India. We report 10 cases of mucormycosis admitted to our adult intensive care unit. After reviewing the patient\'s information, we found that 60% of patients had received steroids, and most had uncontrolled blood sugar levels. Most patients received treatment with surgical debridement and antifungal, although the mortality rate was as high as 40%. We report two unique cases of renal and gastrointestinal mucormycosis as well. We concluded that poor glycemic control was the primary etiology behind the rise in the number of cases. Our report also stresses the importance of early surgical intervention and suggests further research comparing the efficacy of combination antifungal therapy versus single antifungal (amphotericin B) to help resource-limited settings in these times of drug crisis.

CASE REPORT

Elisabeth Paramythiotou, Mitrakou Cornelia, Savva Athinna, Antoniadou Anastasia, Armaganidis Apostolos, Dimopoulos George

Phlegmonous Gastritis and Streptoccocal Toxic Shock Syndrome: An Almost Lethal Combination

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:4] [Pages No:1197 - 1200]

Keywords: Multi-organ failure, Phlegmonous gastritis, Septic shock, Streptococcus group A

PDF  |  DOI: 10.5005/jp-journals-10071-23997  |  Open Access |  How to cite  | 

Abstract

We report a case of phlegmonous gastritis in a 70-year-old woman without any predisposing factors, presenting with high fever, epigastric pain, and vomiting complicated by septic shock and multi-organ failure. The ultrasound and the computed tomography scan showed thickening of the stomach wall. Streptococcus pyogenes was isolated in the blood, thereby establishing the diagnosis of streptococcal toxic shock syndrome. An exploratory laparotomy excluded the need for a gastrectomy, and the patient was successfully treated with antibiotics. A short review of phlegmonous gastritis caused by S. pyogenes during the last 12 years is also presented.

CASE REPORT

Sunil K Garg, Pragya Garg

Autoimmune Hemolytic Anemia in Intensive Care Unit and Blood Transfusion: Lesson Learnt—A Case Report

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1201 - 1202]

Keywords: Antiglobulin test, Autoantibodies, Autoimmune hemolytic anemia, Cross-matching incompatibility

PDF  |  DOI: 10.5005/jp-journals-10071-23999  |  Open Access |  How to cite  | 

Abstract

Clinicians are often in a difficult situation while managing severe anemia due to autoimmune hemolysis in intensive care unit (ICU). It is hard to get properly cross-matched blood due to the presence of autoantibody in the patient\'s serum. Still, such patients should not be devoid of transfusion.

CASE REPORT

Sunil K Garg, Pragya Garg

Differential Diagnosis of Ketoacidosis in Hyperglycemic Alcoholic Diabetic Patient: Role of Insulin

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1203 - 1204]

Keywords: Alcoholic ketoacidosis, Binge drinking, Diabetic ketoacidosis, High anion gap, Ketonemia

PDF  |  DOI: 10.5005/jp-journals-10071-23988  |  Open Access |  How to cite  | 

Abstract

It is important to differentiate between diabetic ketoacidosis (DKA) and alcoholic ketoacidosis (AKA) in an alcoholic diabetic patient since it has significant management implications. Ketoacidosis in an alcoholic diabetic patient is a diagnostic challenge as both these clinical entities have metabolic acidosis with high anion gap. Most patients with DKA have hyperglycemia. The majority of AKA patients present with normal or low glucose levels; however, AKA may also present with high glucose levels, more so in diabetics. The situation becomes quite perplexing when an alcoholic diabetic patient presents with hyperglycemia since it can be attributed to DKA or AKA.

LETTER TO EDITOR

Sunil K Garg, Pragya Garg

Pain Control and Opioid Use in ICU should be a Quality Parameter

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1205 - 1206]

PDF  |  DOI: 10.5005/jp-journals-10071-23979  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Vettakkara KM Niyas, Sivankom D Rahulan, Rajalakshmi Arjun, Aswathy Sasidharan

ICU-acquired Candidemia in COVID-19 Patients: An Experience from a Tertiary Care Hospital in Kerala, South India

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1207 - 1208]

PDF  |  DOI: 10.5005/jp-journals-10071-23980  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Bhavana Kayarat, Puneet Khanna

Posaconazole in the Prevention of COVID-19-associated Mucormycosis: A Concerning Contributor to the Rise in Antifungal Resistance

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:2] [Pages No:1209 - 1210]

PDF  |  DOI: 10.5005/jp-journals-10071-23981  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Abhijeet Anand, Reecha Panghal, Paridhi Kaler, Saurabh Saigal, Rajesh Panda, Saiteja Kodamanchili, Krishnkant Bhardwaj, TB Gowthaman

Reanalyzing the Mortality Analysis of COVID-19 Deaths in a Tertiary Care Center in India

[Year:2021] [Month:October] [Volume:25] [Number:10] [Pages:1] [Pages No:1211 - 1211]

PDF  |  DOI: 10.5005/jp-journals-10071-23982  |  Open Access |  How to cite  | 

journal videos

Video 1: Normal Lung Scan

Diagnostic Accuracy of e-FAST in Stable Blunt Trauma Chest: A Prospective Analysis of 110 Cases at a Tertiary Care Center

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Video 2: Hemothorax

Diagnostic Accuracy of e-FAST in Stable Blunt Trauma Chest: A Prospective Analysis of 110 Cases at a Tertiary Care Center

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