Indian Journal of Critical Care Medicine

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Volume 26, Number 5, May 2022

EDITORIAL

Harsh Sapra

“No Time to Die” – Saving the Neurons

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:537 - 538]

Keywords: Door-to-needle time, Stroke, Thrombolysis

   DOI: 10.5005/jp-journals-10071-24221  |  Open Access |  How to cite  | 

EDITORIAL

Deven Juneja, Anjali Mishra

Medication Prescription Errors in Intensive Care Unit: An Avoidable Menace

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:539 - 540]

Keywords: Incidence, Intensive care unit, Medication nonadherence

   DOI: 10.5005/jp-journals-10071-24215  |  Open Access |  How to cite  | 

EDITORIAL

Ashit Hegde

Candida auris is Coming

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:541 - 542]

Keywords: C. auris, Candidaemia, Infection control practices

   DOI: 10.5005/jp-journals-10071-24223  |  Open Access |  How to cite  | 

EDITORIAL

Ashok K Pannu, Ashish Bhalla

Secondary Hemophagocytic Lymphohistiocytosis: Think of the Devil Lurking!

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:543 - 544]

Keywords: Adult, Critically ill, Hemophagocytic lymphohistiocytosis, Hemophagocytic syndrome, Infections, Macrophage activation syndrome

   DOI: 10.5005/jp-journals-10071-24216  |  Open Access |  How to cite  | 

EDITORIAL

Uma Ali

Time for Precision Medicine in the Diagnosis of Acute Kidney Injury

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:545 - 546]

   DOI: 10.5005/jp-journals-10071-24220  |  Open Access |  How to cite  | 

Original Article

Ankur Verma, Shivani Sarda, Sanjay Jaiswal, Amit Batra, Meghna Haldar, Wasil R Sheikh, Amit Vishen, Palak Khanna, Rinkey Ahuja, Abbas A Khatai

Rapid Thrombolysis Protocol: Results from a Before-and-after Study

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:6] [Pages No:547 - 552]

Keywords: Ischemia, Rapid thrombolysis protocol, Stroke, Thrombolysis, Tissue plasminogen activator

   DOI: 10.5005/jp-journals-10071-24217  |  Open Access |  How to cite  | 

Abstract

Objective: Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes. Methods: This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay. Results: Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98–62.31) and 34.91 minutes (95% CI 29.64–40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57–54.59) and 41.89% (95% CI 31.32–53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44–47.87) in pre-intervention group and 54.05% (95% CI 42.78–64.93) in post-intervention group had discharge mRS 0–2. Conclusion: The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients.

Original Article

Mandeep Kumar, Neeru Sahni, Nusrat Shafiq, Lakshminarayana Yaddanapudi

Medication Prescription Errors in the Intensive Care Unit: Prospective Observational Study

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:5] [Pages No:553 - 557]

Keywords: Critically ill, Intensive care unit, Medication errors, Prescription

   DOI: 10.5005/jp-journals-10071-24148  |  Open Access |  How to cite  | 

Abstract

Introduction: The WHO launched a 5-year global initiative to address the problem of medication errors on March 29, 2017, targeting a decrease in severe and avoidable medication-related harm by 50% in all the countries. Since prescription errors are preventable, this study was conducted to determine incidence and severity of medication prescription errors (MPEs). Settings and design: Intensive care unit of a tertiary care academic hospital, prospective observational study. Methods and materials: For all patients admitted in a medical ICU, baseline data (demographic, APACHE II, length of ICU stay, and days of mechanical ventilation) were noted. Treatment charts were reviewed daily, and each prescription was compared against a master chart prepared using standardized references to study the incidence of prescription errors. Severity classification was done using National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) classification. Mean and median, along with standard deviation and interquartile range, were calculated for all quantitative variables. Multivariate linear regression analysis model was used. Results: Out of the total 24,572 medication orders, 2,624 had prescription errors, an error rate of 10.7% (95% CI, 10.3–11.1). When analyzed for severity, 1,757 (7.15%) (95% CI, 6.8–7.5) MPEs did not result in patient harm and 867 (3.52%) (95% CI, 3.3–3.8) MPEs required interventions and/or resulted in patient harm. Patients with deranged creatinine (p <0.001) and INR (p = 0.024) had higher number of severe MPEs. Conclusion: The incidence of MPEs in the medical ICU at the tertiary care hospital was 10.7%, 3.52% being severe errors.

Original Article

Parikshit S Prayag, Sampada Patwardhan, Shweta Panchakshari, Prasad A Rajhans, Amrita Prayag

The Dominance of Candida auris: A Single-center Experience of 79 Episodes of Candidemia from Western India

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:4] [Pages No:558 - 561]

Keywords: Candida, Candida auris, Candidemia, Invasive candidiasis

   DOI: 10.5005/jp-journals-10071-24152  |  Open Access |  How to cite  | 

Abstract

Introduction: Invasive candidiasis is a serious infection seen in hospitalized or immunocompromised patients. Mortality rates for candidemia can be as high as 30–60%. Candida auris is an emerging species of candida and is increasingly becoming a global public health problem. Methods: This was a retrospective observational study, in which we analyzed 79 episodes of candidemia. Blood cultures were done using the Bactec™ FX blood culturing instrument (Becton, Dickinson and Company Sparks, Maryland, USA). Species identification was done using VITEK® 2 YST panels (bioMérieux Inc., Durham, North Carolina, USA). Antifungal susceptibility testing was performed using VITEK® 2 AST-YSO8 panels (bioMérieux Inc., Durham, North Carolina, USA). Results: Among the 79 episodes, the most common species was found to be C. auris (43.03% of all the episodes). Candida tropicalis was found to be the second most common species in patients admitted to our hospital with candidemia. All the isolates of C. auris were resistant to fluconazole, while 32.35 % of the isolates were also resistant to amphotericin B. Crude mortality in patients with C. auris candidemia was higher than the crude mortality for the other species. Conclusion: This is the first study from India where C. auris was seen as the most predominant species among patients admitted with candidemia. This is a serious issue given the high rates of fluconazole resistance, mortality, and cost of therapy associated with C. auris bloodstream infections. Urgent attention needs to be diverted to infection control practices and antimicrobial stewardship programs.

Original Article

Farhan Fazal, Nitin Gupta, DK Mitra, G Satpathy, SK Panda, PK Chaturvedi, Naval K Vikram, RM Pandey, Naveet Wig

Clinical Profile, Treatment, and Outcome of Patients with Secondary Hemophagocytic Lymphohistiocytosis in Critically Ill Patients: A Prospective Observational Study

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:4] [Pages No:562 - 565]

Keywords: BM score, Ferritin, Hemophagocytic lymphohistiocytosis, H score, Infection

   DOI: 10.5005/jp-journals-10071-24136  |  Open Access |  How to cite  | 

Abstract

Introduction: The objective of the study was to evaluate the clinical profile and outcome of patients with secondary hemophagocytic lymphohistiocytosis (HLH) in critically ill patients. Materials and methods: A prospective observational study was conducted where critically ill adult patients presenting with fever and bicytopenia were evaluated according to the HLH-2004 diagnostic criteria for the presence of secondary HLH. The underlying trigger, clinical profile, treatment, and outcome of patients with HLH were analyzed. Results: Of the 76 critically ill patients with fever and bicytopenia, 33 (43%) patients were diagnosed with HLH. The following triggers for HLH were identified: bacterial infections (23%), fungal infections (10%), viral infections (10%), parasitic infections (10%), autoimmune diseases (13%), and malignancy (8%). A total of 78% of the HLH cases received steroids, but the use of steroids was not associated with improvement in mortality. Conclusion: There is a high prevalence of HLH in patients presenting with fever and bicytopenia in critically ill adult patients. Infections were identified as the most common trigger of HLH.

Original Article

Kobra Ghorbanzadeh, Abbas Ebadi, Mohammadali Hosseini, Sadat Seyed Bagher Maddah, Hamidreza Khankeh, Maryam Khoshbakht Pishkhani, Vahid Adiban

Factors Influencing the Decision-making of Healthcare Providers Regarding the Transition of Patients from the Intensive Care Unit to the General Ward in Iran: A Qualitative Study

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:6] [Pages No:566 - 571]

Keywords: Decision-making, Intensive care unit, Patient, Transition

   DOI: 10.5005/jp-journals-10071-24211  |  Open Access |  How to cite  | 

Abstract

Background: The process of making decisions to discharge patients from the intensive care unit (ICU) is very complex and risky, and decisions need to be made under time constraints and based on fair allocation of resources. In this situation, decision-making requires team participation, which is often accompanied by tension and conflict between team members and sometimes family members, which in turn affects patient safety and quality of care. Objectives: The aim of this study was to explore the experiences and perceptions of physicians and nurses regarding the decision-making process in transition of patients from the ICU to the general ward. Methods: This qualitative study was conducted based on purposive sampling among six nurses and six physicians in Governmental teaching hospitals. The data collection process was conducted from July 2018 to January 2019 through a semistructured interview. Interviews were transcribed and data analysis was accomplished according to the steps proposed by Graneheim and Lundman (2004). Results: Data analysis revealed six themes that reflected factors influencing decision-making in transition of patients from the ICU to the general ward: contingent decision-making, risky decision-making, lack of coherence in team decision-making, differences in clinical judgment, legal and ethical responsibility, and lack of clear criteria. Conclusion: The process of decision-making regarding patient transfer from the ICU is a complex and stressful one. It is affected by situations, team participation, clinical judgment skill, legal issues, and multifactorial challenges. To improve decision-making processes, we need to develop abilities and knowledge and design proper interventions to achieve a principled and correct decision-making process.

Original Article

Zeinab Hosseinpoor, Behrooz Farzanegan, Shadi Baniasadi

Comparing Important and Well-documented Potential Drug–Drug Interactions between Emergency, Medical, and Surgical ICUs of a Respiratory Referral Center

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:5] [Pages No:572 - 576]

Keywords: Drug–drug interactions, Intensive care unit, Potential drug–drug interaction, Prevalence

   DOI: 10.5005/jp-journals-10071-23902  |  Open Access |  How to cite  | 

Abstract

Introduction: Drug–drug interaction (DDI) is one of the major healthcare challenges in intensive care units (ICUs). The prevalence of DDIs and interacting drug pairs may vary between different types of ICUs. This study aimed to compare the frequency and nature of important and well-documented potential DDIs (pDDIs) in three types of ICUs. Methods: A prospective study was conducted in medical (M), surgical (S), and emergency (E) ICUs of a tertiary referral center for respiratory diseases. A pharmacist checked the patients’ files three days in a week for 6 months. The pDDIs were identified using the Lexi-Interact database. Interactions with a severity rating of D (modify regimen) and X (avoid combination) and with a reliability rating of good and excellent were considered important and well-documented. These pDDIs were evaluated in terms of drug combinations, mechanisms of interaction, and clinical management. Results: One hundred eighty-nine patients admitted to MICU, SICU, and EICU were included in the study. The percentage of patients who experienced at least one important and well-documented pDDI was 18.8% in MICU, 11.1% in SICU, and 11.8% in EICU. The most common drug pairs causing important and well-documented interactions were atracurium + hydrocortisone in MICU, meropenem + valproic acid in MICU and EICU, and aspirin + warfarin in SICU. Conclusion: The current study shows different frequency and nature of pDDIs between three types of ICUs. We recommend conducting similar studies in other settings to develop evidence-based guidance on clinically relevant pDDIs in different types of ICUs.

Original Article

Upendra Hansda, Swagata Tripathy, Alok Kumar Sahoo, Itimayee Panda, Asha P Shetty, Jayanta Kumar Mitra, Kasturi Sanyal, Mahalingam Venkateshan, Nanda Kumar Paniyadi, Parnandi Bhaskar Rao, Sujata Mahapatra

Home Care of Tracheostomized Chronically Critically Ill Patients: A Study of Caregivers’ Burden and Comparison with the Burden of Palliative Care Patients in India

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:5] [Pages No:577 - 581]

Keywords: Caregiver burden, Chronically ill, Critically ill, Palliative, Rehabilitation, Tracheostomy

   DOI: 10.5005/jp-journals-10071-24151  |  Open Access |  How to cite  | 

Abstract

Introduction: Chronically critically ill (CCI) patients often have high costs of care and poor outcomes. Disease management programs offering home care may reduce costs but needs buy-in from informal caregivers. An understanding of caregiver burden in this population is lacking. We aimed to study the caregiver burden, its change over time, and factors affecting it, in post-ICU tracheostomized patients. We compared the caregiver burden among CCI carers to that of palliative caregivers. Methods: Informal caregivers of thirty chronically critically ill tracheostomized patients (CGcci) were administered the Caregivers Burden Scale (CBS) tool at discharge, 2 and 4 weeks after discharge. A one-point assessment of burden was made in 30 caregivers of patients enrolled in Pain and Palliative care clinic (CGpc). Linear mixed models for repeated measures were used to analyze score of CGcci over time and compared to the burden in physical, psychologic, economic, time, and social domains between groups. Results: All 60 caregivers were young (33-35 years), predominantly male, and children of the patients. Both CGcci and CGpc had moderate burden score of 60.5 (14.7) vs 61.5 (13), respectively. Physical burden (11.5 vs 8) was greater in CGcci (p = 0.001) compared to psychologic domain (10 vs 12.5) in CGpc (p = 0.01). Burden score over all domains in CGcci decreased rapidly from 67.5 (8) to 55 (16.5) (p = 0.001) in the first month after discharge. Conclusion: Burden of care among caregivers of tracheostomized chronically critically ill patients is comparable to those of palliative caregivers and reduces significantly with time. CTRI: 2020/11/029443 (registered on: 27/11/2020)

Original Article

Kulbeer Kaur, Kajal Jain, Manisha Biswal, Surinder Kaur Dayal

Ventilator-associated Events Surveillance in a Trauma Intensive Care Unit: A Prospective Study of Incidence, Predictive Values, Sensitivity, Specificity, Accuracy, and Concordance with Ventilator-associated Pneumonia

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:7] [Pages No:582 - 588]

Keywords: Infection-related ventilator-associated complication, Possible ventilator-associated pneumonia, Ventilator-associated condition, Ventilator-associated events, Ventilator-associated pneumonia

   DOI: 10.5005/jp-journals-10071-24157  |  Open Access |  How to cite  | 

Abstract

Introduction: The Centre of Disease Control and Prevention (CDC) introduced a new definition of ventilator-associated events (VAEs) in 2013 in place of longstanding ventilator-associated pneumonia (VAP) definition. Three entities under VAE, ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP), were introduced. Objectives: To assess the incidence of all VAEs in a tertiary care trauma ICU and to find the predictive value of VAE and sensitivity of VAE definitions for VAP. Design: Cohort prospective study at trauma intensive care unit (ICU) of PGIMER, Chandigarh, from July 2018 till June 2019. Method: Patients admitted in trauma ICU were checked for VAP and VAE criteria defined by CDC. Results: Four hundred and sixty five patients were observed. Around 378 patients were included in the study with 4046 patient days and 3031 mechanical ventilation (MV) days. Incidence rate of PVAP, IVAC, VAC, and VAP was 2.97, 6.60, 10.23, and 9.24 per 1000 ventilator days, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of diagnosing VAP were 0.61, 0.97, 0.68, and 0.97 for VAC; 0.80, 0.97, 0.57, and 0.99 for IVAC; and 0.78, 0.94, 0.25, and 0.9 for PVAP, respectively. Kendall\'s W test showed that there was very poor concordance between VAP and VAE.

Original Article

Mit Chaudhari, Nagina Agarwal

Study of Significance of Serum Lactate Kinetics in Sepsis as Mortality Predictor

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:5] [Pages No:589 - 593]

Keywords: Lactate kinetics, Lactate clearance, Mortality prediction, Sepsis, Serum lactate

   DOI: 10.5005/jp-journals-10071-23935  |  Open Access |  How to cite  | 

Abstract

Introduction: Sepsis is one of the leading causes of death worldwide. Serum lactate is being used in sepsis for diagnostic and prognostic purposes for years now. In this study, we shed light over a novel use of lactate in form of various clearance parameters to determine mortality in septic patients at the 28th day. Materials and method: In our study, 200 patients with sepsis were included using quick sequential organ failure assessment (qSOFA) score and their lactate levels were measured at the time of admission (0 hour) and 24 hours after admission. Lactate clearance parameters (absolute and relative lactate clearance, lactate clearance rate) were calculated. All patients were followed up for a period of 28 days to determine the outcome, and data analysis was done accordingly. Results and conclusion: Our study showed that higher SOFA score, qSOFA score, and serum lactate levels were associated with increased 28th-day mortality. Low absolute, relative lactate clearance and lactate clearance rate were also associated with poor outcomes. The best cutoffs to predict poor outcomes were serum lactate level at 24 hours ≥4 mmol/L and relative lactate clearance ≤40.3% with good sensitivity and specificity.

Original Article

Mohd Saif Khan, Jay Prakash, Sudipto Banerjee, Pradip K Bhattacharya, Raman Kumar, Deepak K Nirala

High-flow Nasal Oxygen Therapy in COVID-19 Critically Ill Patients with Acute Hypoxemic Respiratory Failure: A Prospective Observational Cohort Study

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:8] [Pages No:594 - 601]

Keywords: Acute hypoxemic respiratory failure, COVID-19, High-flow nasal oxygen therapy

   DOI: 10.5005/jp-journals-10071-24167  |  Open Access |  How to cite  | 

Abstract

Background: Coronavirus disease-2019 (COVID-19) is prone to acute hypoxemic respiratory failure (AHRF). Because tracheal intubation is associated with a higher risk of death in these patients, AHRF employs high-flow nasal oxygen therapy (HFNOT). The goal of this study was to assess the effect of HFNOT on oxygenation status as well as different predictors of HFNOT failure. Methods: A prospective observational cohort study was conducted in COVID-positive critically ill adult patients (age >18 years) with AHRF, who were unable to maintain SpO2 >90% on a non-rebreathing face mask at an oxygen flow ≥15 L/minute. Respiratory variables (PaO2/FiO2, SpO2, and RR) before HFNOT (baseline) and then at 1 hour, 6 hours, 7th day, and 14th day after HFNOT application were recorded. Borg CR10 scale and visual analogue scale were used to evaluate the subjective sensation of dyspnea and comfort level, respectively. As needed, Student\'s t, Mann–Whitney U, or Wilcoxon signed-rank tests were performed. To find parameters linked to HFNOT failure, multivariate logistic regression and receiver-operating characteristic (ROC) analysis were employed. Results: A total of 114 patients were enrolled in the study, with an HFNOT failure rate of 29%. The median PaO2/FiO2 ratio at baseline (before the initiation of HFNOT) was 99.5 (80–110) which significantly increased at various time points (1 hour, 6 hours, 7th day, and 14th day) after HFNOT initiation in the successful group. Patients reported significant improvement in sensation of breathlessness [9 (8–10), 3 (2–4); p <0.001] as well as in comfort level [2 (1–2), 8 (4–9); p <0.001]. Multivariate logistic regression analysis, sequential organ failure assessment (SOFA) score >7, acute physiology and chronic health evaluation (APACHE) II score >20, admission P/F ratio <100, D-dimer >2 mg/L, IL-6 >40 pg/mL, random blood sugar (RBS) >250 mg/dL, and 6 hours ROX Index <3.5 were independent prognostic factors of HFNOT failure. Conclusion: The use of HFNOT significantly increased the oxygenation levels in COVID-19 patients with AHRF at various time periods after HFNOT beginning. Age, SOFA score, APACHE II score, ROX score, admission P/F ratio, IL-6, D-dimer, and RBS were independent prognostic factors of HFNOT failure in this cohort.

Original Article

Sukhyanti Kerai, Pallavi Doda, Kirti N Saxena

Professional Quality of Life in Intensive Care Unit Professionals during COVID-19 Pandemic: A Prospective Observational Cross-sectional Study

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:9] [Pages No:602 - 610]

Keywords: Burnout, Compassion fatigue, COVID-19 pandemic, Intensive care units, Professional

   DOI: 10.5005/jp-journals-10071-24212  |  Open Access |  How to cite  | 

Abstract

Background and aims: The coronavirus disease-2019 (COVID-19) has significant positive and negative impacts on the professional life of intensive care unit (ICU) professionals. This study was conducted to evaluate compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS) in ICU professionals and to study demographic and occupational variables related to them. Methods: This prospective observational study was undertaken on ICU professionals involved in direct care of critically ill COVID-19 patients. The online questionnaire consisting of demographic, work-related parameters, and Professional Quality of Life Scale version 5 (ProQOL 5) was sent to 1,080 ICU healthcare workers. The subgroups of ProQOL 5, CS, BO, and STS were calculated and compared across study parameters. Linear regression was performed to evaluate variables which were independently associated with ProQOL. Results: The response rate in the present study was 39.8%, and after evaluation, 320 responses were found eligible for final analysis. There was predominance of average levels of CS, BO, and STS. Female gender, contractual job, lesser work experience, greater workload, and COVID-19 infection in close acquittance of participants were factors observed to independently associated with increase in negative aspects of ProQOL (BO and STS). Further, increase in duty hours and COVID-19 infection in close social circle were observed to independently decrease positive aspects (CS). Conclusion: This study shows that despite majority of respondents reporting moderate levels BO and STS, CS is maintained during the COVID-19crisis. The identification of risk factors is vital to support ICU professionals by targeted interventions.

Original Article

Ketan V Kargirwar, Darshana Rathod, Vivek Kumar, Mayur Patel, Mehul Shah, Himanshu Choudhury, Kavita Shalia

Clinical Profile of Patients with Severe Acute Respiratory Syndrome Coronavirus 2 Infection Developing Pulmonary Barotrauma on Mechanical Ventilation

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:6] [Pages No:611 - 616]

Keywords: Barotrauma, ICU, Mechanical ventilation, Severe acute respiratory syndrome coronavirus 2

   DOI: 10.5005/jp-journals-10071-24149  |  Open Access |  How to cite  | 

Abstract

Background: There is limited information on clinical profile and outcomes of patients on mechanical ventilation (MV) who developed pulmonary barotrauma (PBT) in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients and methods: In a retrospective observational study, all SARS-CoV-2 pneumonia patients admitted from March 28, 2020, to August 31, 2020, at Sir HN Reliance Foundation Hospital and Research Center and Seven Hills Hospital (Reliance Facility), Mumbai, India, of 18 years and above on MV and developed PBT, were included. Results: A total of 14 SARS-CoV-2 patients of 45 on MV (31.0%) developed PBT of 1,029 hospitalized. All patients were male and divided as per admission into PaO2/FiO2 (P/F) ≤100 (median 80) and P/F >100 (median 222) group. Pneumothorax developed in seven and six cases of P/F ≤100 and P/F >100 groups, respectively. Three patients in each group developed subcutaneous emphysema, while four developed pneumomediastinum in P/F >100 group. Twelve patients (7, P/F ≤100, and 5, P/F >100) were on invasive, while two (P/F >100) were on noninvasive MV. The mean P/F on the day of PBT was reduced by 27.5 and 65.3%, while peak inspiratory pressure was elevated with a median of 36 and 28 cm H2O in P/F ≤100 and P/F >100 groups, respectively. The median highest tidal volume (420 mL), positive-end expiratory pressure (8 vs 6 cm H2O) on the day of PBT, and length of hospital stay (11 vs 25 days) did not differ between two groups. Survival was 28.6% (4/14). Conclusion: SARS-CoV-2 patients requiring MV with PBT had poor outcomes. Clinicians should be vigilant about the diagnosis of PBT.

Original Article

Maulin K Shah, Mital Parikh, Dhavalkumar Prajapati, Punam Bhende, Abhishek Prajapati, Sunil H Chhajwani, Krushan Yajnik, Jaishree Ganjiwale, Jyoti G Mannari, Bhalendu Vaishnav

Safety and Tolerability of Remdesivir in Patients with End-stage Renal Disease on Maintenance Hemodialysis

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:7] [Pages No:617 - 623]

Keywords: End-stage renal disease, Hemodialysis, Remdesivir, SARS-Cov-2

   DOI: 10.5005/jp-journals-10071-24168  |  Open Access |  How to cite  | 

Abstract

Introduction: The use of remdesivir is not recommended in patients with end-stage renal disease with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection unless potential advantage offset disadvantage due to limited safety data. Our objective was to assess the safety of remdesivir in patients with end-stage renal failure and evaluate the outcome of this vulnerable group. Methodology: We carried out a retrospective observational study in dialysis-dependent end-stage renal disease patients with SARS-CoV-2 infection who received a standard 5-day course of remdesivir (powder form) from June 2020 to December 2020. Oxygen requirement, hemogram, inflammatory markers, and liver function tests before and after remdesivir treatment were compared. Result: We found thirty-nine such patients with mean age of patients 58.79 ± 12.13 years. Diabetes mellitus, hypertension, and cardiac diseases were present in 58.97, 87.17, and 23.07% of patients, respectively. Mean oxygen saturation on admission was 85.41% (±7.73). There were no events of hepatotoxicity, altered behavior, or infusion reaction. There was statistically significant improvement in total leukocyte count, absolute lymphocyte counts, and C-reactive protein (p value <0.001, 0.01, and 0.02, respectively) post remdesivir treatment. A total of 60% of patients had improved oxygenation while 13% of patients had no change in oxygen requirement after completion of remdesivir course. Mortality in our study was 28.21%. We did not find any significant benefit of early remdesivir administration (3–6 days of illness) on mortality or days of hospitalization. Conclusion: The use of remdesivir in end-stage kidney disease is safe. Improvement in oxygenation was significant when baseline oxygen requirement was less. It requires prospective controlled trials with larger population to assess its impact on mortality.

Original Article

Swarnima Singh, Kunal Singh

Blood Urea Nitrogen/Albumin Ratio and Mortality Risk in Patients with COVID-19

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:6] [Pages No:624 - 629]

Keywords: Blood urea nitrogen/albumin ratio, COVID-19, COVID-19 mortality, C-reactive protein, D-dimer, Hypoalbuminemia

   DOI: 10.5005/jp-journals-10071-24150  |  Open Access |  How to cite  | 

Abstract

Introduction: We researched blood urea nitrogen (BUN), albumin and their ratio (BAR), and compared them with C-reactive protein (CRP), D-dimer, and computed tomography severity scores (CT-SS), to predict inhospital mortality. Methods: One-hundred and thirty-one coronavirus disease-2019 (COVID-19)-confirmed patients brought to the emergency department (ED) were dispensed to the survivor or non-survivor group, in light of inhospital mortality. Information on age, gender, complaints, comorbidities, laboratory parameters, and outcome were gathered from the patient\'s record files. Results: The median BUN, mean total protein, mean albumin, median BAR, median creatinine, median CRP, and median D-dimer were recorded. CT-SS were utilized in categorizing the patient as mild, moderate, and severe. Inhospital mortality occurred in 42 (32.06%) patients (non-survivor group) and did not occur in 89 (67.94%) patients (survivor group). The median BUN (mg/dL) and BAR (mg/g) values were significantly raised in the non-survivor group than in the survivor group [BUN: 23.48 (7.51–62.75) and 20.66 (4.07–74.67), respectively (p = 0.009); BAR: 8.33 mg/g (2.07–21.86) and 6.11 mg/g (1.26–23.33); (p = 0.0003)]. The mean albumin levels (g/dL) in the non-survivor group were significantly lower than in the survivor group [2.96 ± 0.35 and 3.27 ± 0.35, respectively (p <0.0001)]. Albumin with an odd\'s ratio of 6.14 performed the best in predicting inhospital mortality, followed by D-dimer (4.98). BAR and CRP had similar outcome of 3.75; BUN showed an OR of 3.13 at the selected cutoff value. Conclusion: The BUN, albumin, and BAR were found to be dependable predictors of inhospital mortality in COVID-19 patients, with albumin (hypoalbuminemia) performing even better.

BRIEF RESEARCH COMMUNICATION

Ashima Sharma, Aravind Ranjan

Veterans Health Administration COVID-19 Index to Risk Stratify the Geriatric Population with COVID-19 Infection

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:630 - 631]

Keywords: Charlson comorbidity index, COVID-19, Vaccination, Veterans Health Administration COVID-19 vaco index

   DOI: 10.5005/jp-journals-10071-24176  |  Open Access |  How to cite  | 

Abstract

The risk for severe illness with coronavirus disease-2019 (COVID-19) increases with age, with older adults at highest risk. Adults 65-years-old and older who were fully vaccinated with an mRNA COVID-19 vaccine had a 94% reduction in risk of COVID-19 hospitalizations, and vaccination was 64% effective among those who were partially vaccinated.

PAEDIATRIC CRITICAL CARE

Sudeep K Kapalavai, Ravikumar Krupanandan, Kalaimaran Sadasivam

Usefulness of Urinary Neutrophil Gelatinase-associated Lipocalin as a Predictor of Acute Kidney Injury in Critically Ill Children

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:5] [Pages No:632 - 636]

Keywords: Acute kidney injury, Critically ill children, Pediatric acute kidney injury, Urinary neutrophil gelatinase-associated lipocalin

   DOI: 10.5005/jp-journals-10071-24147  |  Open Access |  How to cite  | 

Abstract

Background: Acute kidney injury (AKI) is common among critically ill children. The current definitions of AKI rely on serum creatinine and urine output, which may not be deranged until late in the course of the illness. There has been a lot of work in search of novel biomarkers to define and predict AKI, and urinary neutrophil gelatinase-associated lipocalin (NGAL) is a promising one. We planned to study the usefulness of urinary NGAL in predicting AKI. Patients and methods: Children in the age group of 1 month to 18 years admitted to the pediatric intensive care unit (PICU) from September 2016 to December 2017 were enrolled. Children with preexisting kidney disease, urinary tract infection (UTI), postsurgical patients, or children with expected duration of stay <48 hours were excluded. Data regarding demographics, clinical features, and laboratory parameters were collected. Urinary NGAL was sent within 6 hours of admission. Children were classified to have AKI based upon the Pediatric Risk, Injury, Failure, Loss, End Stage Renal Disease (pRIFLE) criteria. Using receiver operating characteristic (ROC) curves, sensitivity, specificity, and area under the curve (AUC) for admission creatinine and urinary NGAL to predict AKI were deduced. Results: One hundred and thirty children were included. Out of 130 children, 59 (45.4%) developed AKI. Urinary NGAL at admission to the PICU >88.5 ng/mL had a sensitivity of 81.4% and specificity of 83.6% in detecting AKI while its AUC to detect AKI was 0.842 (95% confidence interval (CI) 0.765–0.918). Urinary NGAL predicted AKI in 17 (28.8%) of 59 patients at least 24 hours earlier than serum creatinine. Mortality rates in patients with and without AKI were 18.6 and 2.8%, respectively. Conclusion: Urinary NGAL has good sensitivity and specificity in detecting AKI and predicts AKI earlier than creatinine in a significant number of patients.

CASE REPORT

Rohit Patnaik, Shruthi Kulkarni, Nupur Karan

Dengue and HELLP: Beware of the Masquerade

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:637 - 638]

Keywords: Caesarean section, Dengue fever, Fetomaternal outcome, HELLP syndrome, Obstetric ICU

   DOI: 10.5005/jp-journals-10071-24213  |  Open Access |  How to cite  | 

Abstract

HELLP is a syndrome characterized by hemolysis, elevated liver enzymes, and low platelets. It is a rare complication of pregnancy and is usually associated with pre-eclampsia. However, 10–20% cases of HELLP can present without hypertension. Dengue fever is an arboviral-borne tropical illness that is characterized with fever, thrombocytopenia, and bleeding manifestations. We present a case of a primigravida with HELLP syndrome masquerading in the background of dengue fever. Unique features to this case report include delayed presentation of HELLP syndrome with normotension which can have overlapping features with dengue fever, especially in term pregnancy. This case highlights the need of strict vigilance in cases of dengue fever with pregnancy.

CASE REPORT

Dhruva Sharma, Deeksha S Tomar, Sachin Gupta

Non-hypertension-associated Posterior Reversible Encephalopathy Syndrome in COVID-19

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:639 - 640]

Keywords: COVID-19 infection, Inflammation, Posterior reversible encephalopathy syndrome

   DOI: 10.5005/jp-journals-10071-24218  |  Open Access |  How to cite  | 

Abstract

Background: Coronavirus disease-2019 (COVID-19) infection-related neurological events are not uncommon but presenting as posterior reversible encephalopathy syndrome (PRES) without hypertension is a very rare presentation and requires a high index of suspicion. Case summary: We report a case of a middle-aged female who presented with severe COVID-19 disease with no neurological symptoms. She complained of diminished vision on day 7 of the illness and underwent an MRI brain to rule out an ischemic stroke but the findings were suggestive of PRES. She had no episode of hypertension during the hospital stay. Probably severe COVID-related inflammation was the reason for such a presentation. Conservative management resolved the issue and her symptoms weaned off. Conclusion: Severe COVID disease can lead to PRES-like symptoms and requires neuroimaging to validate it. Conservative management is the best treatment for such patients.

CASE REPORT

M Nithish Mukunthan, Vimal Bhardwaj

Cardiac Pacing a Rare Cause of Ventilator Auto Triggering

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:3] [Pages No:641 - 643]

Keywords: Epicardial pacing, Flow trigger, Inadvertent triggering, Pacemaker, Respiratory alkalosis, Ventilator auto triggering, Ventilator waveforms

   DOI: 10.5005/jp-journals-10071-24219  |  Open Access |  How to cite  | 

Abstract

Ventilator auto triggering is an avoidable complication in ventilators, if left unnoticed can lead to deleterious effects. There are various causes for ventilator auto triggering. Though rare, there are some cardiac causes for inadvertent ventilator triggering. We report a case of 44-years-old male paced with atrial epicardial wires postcoronary artery bypass. The wires were close to the right phrenic nerve, causing the right diaphragm to contract in synchronization with the heartbeat. This caused ventilator auto triggering and ended up delivering inadvertent breaths. The pacemaker output was immediately reduced to the required minimum to continue pacing the heart and decrease phrenic nerve stimulation. This caused immediate changes in ventilator waveform and auto triggering was completely stopped and the patient could be successfully weaned off the ventilator. This case report emphasizes he need for timely recognition of alteration in ventilator waveforms and early intervention to avert any untoward events.

CASE REPORT

Rahul T Chakor, Prachi P Barvalia, Swaleha Nadaf, Varun Manjunath

Encephaloradiculoneuropathy: A Rare Manifestation of COVID-19 Infection

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:3] [Pages No:644 - 646]

Keywords: Acute encephalitis, COVID-19 infection, Critical illness polyneuromyopathy, Guillain-Barré syndrome

   DOI: 10.5005/jp-journals-10071-24222  |  Open Access |  How to cite  | 

Abstract

Neurological complications are being recognized as important outcomes of the coronavirus disease-2019 (COVID-19) pandemic. We report a rare case of both the central nervous system (CNS) and peripheral nervous system (PNS) involvement, encephalitis with polyradiculoneuropathy in a single patient of COVID infection.

CASE REPORT

Ram Narayanan Ganapathiram, Sonia Hudson

Multisystem Inflammatory Syndrome in Adult Following COVID-19 Vaccination (MIS-AV)

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:2] [Pages No:647 - 648]

Keywords: ARDS, COVID-19, Critically ill adults

   DOI: 10.5005/jp-journals-10071-24214  |  Open Access |  How to cite  | 

Abstract

The last 2 years have been dominated by coronavirus disease-2019 (COVID-19), its various presentations, complications, and their management. The first COVID-19 vaccine, produced by Pfizer-BioNTech, was granted regulatory approval on December 2, 2020, by the UK medicines regulator medicines and healthcare products regulatory agency (MHRA). It was evaluated for emergency use authorization (EUA) status by the US Food and Drug Administration (FDA) and in several other countries. Following millions of doses, during the early months of 2021, reports of side effects of the vaccines began to emerge. In this case report, we discuss the case of a 22-year-old female patient who presented with fever and confusion, with later progression to multiple organ failure, following administration of Pfizer-BioNTech vaccine. She was successfully treated with intravenous (IV) immunoglobulin (Ig) and high-dose IV corticosteroids. This case report is unique as lymph node biopsy was carried out—this showed marked suppurative inflammation with vasculitic changes, thus supporting the diagnosis.

LETTER TO THE EDITOR

Rohan Magoon

Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:1] [Pages No:649 - 649]

Keywords: Albumin, Functional outcomes, Hemorrhagic stroke, Inflammation, Inflammatory biomarker, Neutrophil–lymphocyte ratio

   DOI: 10.5005/jp-journals-10071-24206  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Sethu Babu, Mathew Pulicken, Arun K Thazhathuveedu

Author Response to the Manuscript “Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus”

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:1] [Pages No:650 - 650]

Keywords: Intracerebral hemorrhage, Neutrophil/Lymphocyte ratio, Serum albumin, Systemic inflammatory response syndrome

   DOI: 10.5005/jp-journals-10071-24207  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Ilenia Di Paola, Mario Graziano, Palmiro Cornetta

Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter (TONS Trial)

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:1] [Pages No:651 - 651]

Keywords: Anesthetists, A-scan, B-scan, Optic nerve sheath diameter, Ophthalmology, Surgery

   DOI: 10.5005/jp-journals-10071-24208  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Indu Kapoor

Reply to Letter to Editor: Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:1] [Pages No:652 - 652]

Keywords: Intracranial pressure, Optic nerve sheath diameter, Tracheostomy

   DOI: 10.5005/jp-journals-10071-24209  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Prasan K Panda, Shridhar Pattar, Budha O Singh, Taranjeet Cheema

Primary Hypothyroidism Presenting as Cardiac Tamponade

[Year:2022] [Month:May] [Volume:26] [Number:5] [Pages:3] [Pages No:653 - 655]

Keywords: Hypothyroidism, Pericardial effusion, Pericardiocentesis, Thyroxine replacement

   DOI: 10.5005/jp-journals-10071-24210  |  Open Access |  How to cite  | 

Abstract

Hypothyroidism is commonly associated with pericardial effusion, but it can be rarely complicated by cardiac tamponade. We report a case series of two patients who presented with shortness of breath and distension of the abdomen, progressing to generalized edema. Each of them was found to have cardiac tamponade at presentation and eventually diagnosed with hypothyroidism. They were managed by urgent pericardiocentesis followed by intermittent drainage of the collected pericardial effusion along with thyroxine replacement to which they responded. The presence of cardiac tamponade with bradycardia should raise a suspicion of a hypothyroid etiology. Early diagnosis and treatment of hypothyroidism are essential to prevent such complications.

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