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Joshi R, Kumar S, Bhaskar S, Saigal S, Pakhare A, Sharma J, Sabde Y, Bhattacharya P. Mapping the characteristics of critical care facilities: Assessment, distribution, and level of critical care facilities from central India. Indian J Crit Care Med 2017; 21 (10):625-633.
Background: In low- and middle-income countries such as India, where health systems are weak, the number of available Critical Care Unit (Intensive Care Unit [ICU]) beds is expected to be low. There is no study from the Indian subcontinent that has reported the characteristics and distribution of existing ICUs. We performed this study to understand the characteristics and distribution of ICUs in Madhya Pradesh (MP) state of Central India. We also aimed to develop a consensus scoring system and internally validate it to define levels of care and to improve health system planning and to strengthen referral networks in the state.
Methods: We obtained a list of potential ICU facilities from various sources and then performed a cross-sectional survey by visiting each facility and determining characteristics for each facility. We collected variables with respect to infrastructure, human resources, equipment, support services, procedures performed, training courses conducted, and in-place policies or standard operating procedure documents.
Results: We identified a total of 123 ICUs in MP. Of 123 ICUs, 35 were level 1 facilities, 74 were level 2 facilities, and only 14 were level 3 facilities. Overall, there were 0.17 facilities per 100,000 population (95% confidence interval [CI] 0.14–0.20 per 100,000 populations). There were a total of 1816 ICU beds in the state, with an average of 2.5 beds per 100,000 population (95% CI 2.4–2.6 per 100,000 population). Of the total number of ICU beds, 250 are in level 1, 1141 are in level 2, and 425 are in level 3 facilities. This amounts to 0.34, 1.57, and 0.59 ICU beds per 100,000 population for levels 1, 2, and 3, respectively.
Conclusion: This study could just be an eye opener for our healthcare authorities at both state and national levels to estimate the proportion of ICU beds per lac population. Similar mapping of intensive care services from other States will generate national data that is hitherto unknown.
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Ghiasi F, Sadeghian M, Emami M, Kiaie B, Mousavi S. A pilot study of nebulized heparin for prevention of ventilator induced lung injury: Comparative effects with an inhaled corticosteroid. Indian J Crit Care Med 2017; 21 (10):634-639.
Background: Ventilator-induced lung injury (VILI) is a side effect of mechanical ventilation. Lung inflammation and pulmonary activation of coagulation are induced by mechanical stress. Clinical and preclinical studies show that heparin possesses anti-inflammatory properties. Therefore, we assessed the effects of nebulized heparin in VILI.
Methods: Sixty critically ill adult patients who require mechanical ventilation for more than 48 h were included in this prospective, nonrandomized controlled study. Patients received nebulized heparin (10,000 U every 6 h) for 5 days. The matched control group received nebulized budesonide as routine practice in our center. This study assessed changes in partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2) and rapid shallow breathing index (RSBI) during the study as primary endpoints.
Results: The average daily PaO2/FiO2ratio was not statistically significant between both groups (187 ± 11.6 vs. 171 ± 11.6, P = 0.35). The RSBI also did not differ between groups (P = 0.58). Heparin administration was associated with a higher number of ventilator-free days among survivors but not significantly (7.7 ± 10.6 vs. 5.1 ± 8, 95% confidence interval − 2.2–7.5, P = 0.28). Successful weaning from mechanical ventilation was higher in the heparin group (P = 0.42). We did not observe any serious or increased adverse effects from nebulized heparin.
Conclusion: The results of this study show that the overall effectiveness of nebulized heparin is at least as comparable with a potent corticosteroid (budesonide). Heparin could be a safe and effective modality for patients who at risk of VILI.
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Chivukula U, Hariharan M, Rana S, Thomas M, Andrew A. Enhancing hospital well-being and minimizing intensive care unit trauma: Cushioning effects of psychosocial care. Indian J Crit Care Med 2017; 21 (10):640-645.
Context: Hospitalization has the potential to induce hospital anxiety, while admission in the Intensive Care Unit (ICU) is found to surpass the anxiety and result in what is termed as “ICU Trauma.”
Aims: This study aimed to determine the impact of psychosocial care and quality of ICU on ICU trauma and hospital well-being in patients who underwent coronary artery bypass grafting (CABG).
Settings and Design: This correlational study involved 250 CABG patients, who were recruited from five major corporate hospitals.
Participants and Methods: The ICU Psychosocial Care Scale, Hospital Wellbeing Scale, and ICU Trauma Scale were used. Each of the participants was assessed individually. The ICU Practices Checklist was used to assess the environment of the ICU in the hospital.
Statistical Analysis Used: Descriptive statistics, correlation, and simple and multiple linear regression analyses were done.
Results: The results revealed the significant contribution of psychosocial care in ICU in enhancing hospital well-being as well as minimizing ICU trauma of patients who underwent CABG. The results of multiple regressions clearly indicated that psychosocial care was a powerful predictor of hospital well-being and ICU trauma.
Conclusions: Although psychosocial care was not a component of hospital well-being and had a negative correlation with ICU trauma, it contributed significantly with a cushioning effect to minimize trauma and helped enhance the feelings and experiences of well-being among patients in ICU.
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Kumar S, Baronia A K, Singh R. The effects of atorvastatin on inflammatory responses and mortality in septic shock: A single-center, randomized controlled trial. Indian J Crit Care Med 2017; 21 (10):646-654.
Aim of the Study: Pleiotropic effect of statins can modulate inflammation in septic shock. We tested the hypothesis whether statins can reduce mortality in septic shock.
Patients and Methods: We conducted a randomized double-blinded trial with treatment (40 mg dose of atorvastatin for 7 days) and control (placebo) arm in adult septic shock patients admitted to the Intensive Care Unit. Primary (28-day mortality) and secondary (vasopressor-, ventilation-, and renal replacement therapy-free days) outcomes, with lipid profile and adverse effects, were documented. Inflammatory biomarkers (interleukin [IL]-1, IL-6, tumor-necrosis-factor [TNF]-α, interferon [IFN], and C-reactive protein [CRP]), were also measured before (day 1 [D1]) and after start of trial drug (D4 and D7).
Results: Seventy-three septic shock patients with 36 and 37 included in the atorvastatin and placebo group, respectively. Both groups were equally matched. Twenty-eight-day mortality, event-free days, lipid profile, and adverse effects were also not significantly different between groups. Reduced levels of IL-1, IL-6, TNF-α, IFN, and CRP were observed in the atorvastatin group. Also observed were significant day-wise changes in inflammatory biomarkers.
Conclusions: Atorvastatin-induced changes in inflammatory biomarkers did not confer mortality benefit in septic shock (ClinicalTrials.govNCT02681653).
Background: Intensive Care Unit (ICU) nurses have a vital role in the implementation of end of life (EOL) care. There is limited data on the attitude of ICU nurses toward EOL and palliation.
Aim: This study aimed to investigate knowledge, attitude, and beliefs of intensive care nurses in eastern India toward EOL.
Materials and Methods: A self-administered questionnaire was distributed to delegates in two regional critical care nurses\' training programs.
Results: Of 178 questionnaires distributed, 138 completed, with a response rate of 75.5%. About half (48.5%) had more than 1 year ICU experience. A majority (81.9%) agreed that nurses should be involved in and initiate (62.3%) EOL discussions. Terms “EOL care or palliative care in ICU” were new for 19.6%; 21% and 55.8% disagreed with allowing peaceful death in terminal patients and unrestricted family visits, respectively. Work experience was associated with wanting unrestricted family visitation, discontinuing monitoring and investigations at EOL, equating withholding and withdrawal of treatment, and being a part of EOL team discussions (P = 0.005, 0.01, 0.01, and 0.001), respectively. Religiousness was associated with a greater desire to initiate EOL discussions (P = 0.001).
Conclusion: Greater emphasis on palliative care in critical care curriculum may improve awareness among critical care nurses.
Background: Vitamin D is a pleiotropic hormone essential for optimal health. Critical illness in children is a major cause of significant health-care utilization and mortality around the world. The association of Vitamin D deficiency (VDD) in critically ill adults has been well-studied, in comparison, the importance of Vitamin D in pediatric critical illness has been much less studied.
Aim and Objectives: This study aimed to assess Vitamin D status and its determinants in patients admitted to a pediatric intensive care unit (PICU) in North of Turkey. We also investigated the association between Vitamin D status and clinical outcomes.
Materials and Methods: All patients aged 1 month to 18 years admitted to the PICU of a tertiary care hospital who had levels of 25-hydroxy Vitamin D available within 24 h of admission were included in this retrospective study. VDD was defined as <20 ng/mL levels.
Results: VDD was observed in 120 (58.5%) children. In multivariable linear regression model, only identified patient age and winter season as statistically associated with VDD. Vitamin D deficient patients were older and heavier and were more likely to receive catecholamine. There was no association between Vitamin D deficiency and other illness severity factors including mortality.
Conclusions: Hypovitaminosis D occurrence was high in critically ill children and was associated with higher vasopressor requirement but not with other markers of illness severity including mortality.
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Sharma J, Kaur M, Mustafi S, Singh M, Sharma A, Dhir V. Comparison of awareness of patient parameters between two groups of caregivers in intensive care unit. Indian J Crit Care Med 2017; 21 (10):665-670.
Aim of the Study: The overlap in the scope of duties performed by two core groups of Intensive Care Unit caregivers, the doctors and nurses may lead to gaps in awareness of patient-related parameters among them. Our study tested the hypothesis that there is no difference in the awareness of patient-related parameters between the two study groups (doctors and nurses).
Materials and Methods: A questionnaire-based study, incorporating various aspects of a patient\'s medical care was designed. Pro forma for 100 patients was filled by doctors and nurses divided into two groups of 100 each (50 junior residents [JRs] and 50 senior residents [SRs] in the doctors\' group). Statistical analysis of categorical data was done by Chi-squared test and interval data by t-test. A subgroup analysis was done for comparison between nurses SRs and JRs as independent groups. P < 0.05 was considered statistically significant.
Results: There was no statistically significant difference between the two groups (doctors and nurses) in terms of percentage of correct responses in the questionnaire (P = 0.655). A highly significant difference between the knowledge of SRs and nurses was found with a P = 0.0001. P < 0.0001 was calculated for the SRs versus JRs which was highly significant.
Conclusions: As a group, doctors (SRs and JRs) did not reflect any difference in awareness of patient-related parameters when compared to nurses. However, SRs were more knowledgeable about the patient-related parameters when compared independently with the JRs and the nurses.
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Malik R, Sangwan V. Dyspnea, eosinopenia, consolidation, acidemia and atrial fibrillation score and BAP-65 score, tools for prediction of mortality in acute exacerbations of chronic obstructive pulmonary disease: A comparative pilot study. Indian J Crit Care Med 2017; 21 (10):671-677.
Introduction: Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) being common and often fatal, prognostic tools in AECOPD are lacking.
Materials and Methods: A prospective, observational study was carried out in fifty patients of AECOPD admitted in A and E department. Dyspnea, Eosinopenia, Consolidation, Acidemia and atrial Fibrillation (DECAF) score and elevated blood urea nitrogen, altered mental status, pulse >109, age >65 (BAP-65) score were calculated. Dyspnea was scored using extended Medical Research Council Dyspnoea score. Data were collected and analyzed using SPSS 17.0 software.
Results: Forty-one patients were discharged and 9 (18%) died during treatment. Patients who were discharged and patients who died during hospital stay were compared. There was no significant difference in terms of sociodemographic variables, presence of comorbidities, and other markers of disease severity. A significant difference was found in blood counts, blood urea, serum creatinine, acidotic respiratory failure, and atrial fibrillation. A higher value of DECAF score and BAP-65 score was found more commonly in patients who died. Sensitivity for prediction of mortality for DECAF score and BAP-65 score was 100% and specificity was 34.1% and 63.4%, respectively. Sensitivity for prediction of need for invasive ventilation for DECAF score and BAP-65 score was 80% and 100%, respectively, and specificity was 80% and 60%, respectively.
Conclusion: Both DECAF and BAP-65 scores were found to be good predictors of mortality and need for ventilation in this pilot study.
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Gupta A, Gupta S K, Kant S, Misra P, Majumdar A, Misra M. Epidemiological study of patients of road traffic injuries attending emergency department of a trauma center in New Delhi. Indian J Crit Care Med 2017; 21 (10):678-683.
Background and Aims: There is paucity of data regarding some of the lesser known contextual and epidemiological factors with respect to road traffic injuries (RTIs). The objective was to study the epidemiological profile of RTI victims attending an emergency department of a tertiary care trauma center.
Methods: The present study was a hospital-based cross-sectional study conducted in the emergency department of a tertiary care trauma center in New Delhi. All patients of RTI attending the emergency department during the designated data collection days were included in the study. Patients brought dead were excluded from the study. A semi-structured interview schedule was developed for collecting data on various domains such as sociodemographic characteristics, vehicle-related factors, accident site-related factors, personal protection measures, contextual factors, and prehospital care-related factors.
Results: A total of 984 patients and informants were approached and finally data of 900 participants were analyzed after excluding those who refused participation and those for whom incomplete data were available. Out of 900 RTI victims, 756 were male (84.0%) and 144 (16.0%) were female. Mean age of the victims was 32.7 years. Most of the victims, i.e., 377 out of 900 (41.9%) were occupants rather than drivers. Majority of victim\'s vehicle meeting accidents were motorized two-wheelers (53.4%), and majority of the colliding vehicle was a four-wheeler (39.3%). Helmet use was found to be low (63.3%), but seat belt use was particularly low (32.4%). Most accidents (28%) happened between midnight and 6 A.M. More than half of the victims were in a hurry on the day of the accident. An ambulance was used to transport the victims in only 14.6% cases.
Conclusion: In road traffic accidents some lesser known epidemiological data were generated that may be useful in defining preventive measures.
Effective nursing management strategies for adults with severe traumatic brain injury (STBI) are still a remarkable issue and a difficult task for neurologists, neurosurgeons, and neuronurses. A list of justified indications and scientific rationale for nursing management of these patients are continuously evolving. The objectives of the study are to analyze the pertinently available research and clinical studies that demonstrate the nursing management strategies for adults with STBI and to synthesize the available evidence based on the review. A comprehensive literature search was made in following databases such as Google Scholar, Cochrane, J-Gate, ProQuest, and ScienceDirect for retrieving the related studies. In the included studies, data were extracted and evaluated according to the objective. Narrative analysis was adopted to write this review. Patients with STBI have poor prognosis and require quality care for maximizing patients\' survival. With a thorough knowledge and discernment of care of such patients, nurses can improve these patients\' neurological outcomes.
Capillary leak syndrome is a unique complication that follows Russell\'s viper envenomation. This syndrome has a very high fatality rate and is characterized by parotid swelling, chemosis, periorbital edema, hypotension, albuminuria, hypoalbuminemia, and hemoconcentration. This syndrome is frequently recognized from the southern parts of India, especially from the state of Kerala. It has been postulated that a vascular apoptosis inducing component of Russell\'s viper venom that is not neutralized by the commercially available anti-snake venom (ASV) is responsible for this complication as it occurs even after adequate doses of ASV administration in most cases. Acute kidney injury often requiring dialysis is invariably present in all patients because of reduced renal perfusion and ischemic acute tubular necrosis as a result of hypotension. Management mainly involves aggressive fluid resuscitation to maintain adequate tissue perfusion. There are no other proven effective treatment modalities, except a few reports of successful treatment with plasmapheresis. Methylprednisolone pulse therapy, terbutaline, aminophylline, and intravenous immunoglobulin are other treatment modalities tried.
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Negi A, Anand M, Singh A, Kumar A, Prasad K. Assessment of doripenem, meropenem, and imipenem against respiratory isolates of Pseudomonas aeroginosa in a tertiary care hospital of north India. Indian J Crit Care Med 2017; 21 (10):703-706.
Objective: Pseudomonas aeruginosa is one of the leading pathogen causing healthcare-associated infections, particularly in immunocompromised and critically ill patients. The development of carbapenem resistance in P. aeruginosa infections is worrisome. Data specifically comparing the susceptibility of the three available carbapenems are lacking in the Indian subcontinent.
Materials and Methods: We evaluated the minimum inhibitory concentrations (MICs) of the three commonly used carbapenems– imipenem, meropenem, and doripenem against, 435 P. aeruginosa isolates obtained from respiratory samples and compared their susceptibility patterns to determine the best possible carbapenem among those available that may be used in combination regimes.
Results: Overall, 222 (51.0%) of isolates were susceptible to doripenem followed by imipenem 206 (47.3%) and meropenem 195 (44.8%), respectively. Two hundred and sixty-two (60.23%) strains were intermediate or resistant to at least one carbapenem. The MIC90of all three carbapenems was >32 μg/ml while the MIC50of meropenem was 16 μg/ml which was higher than MIC50of both imipenem (4 μg/ml) and doripenem (2 μg/ml).
Conclusion: Our study revealed that doripenem exerted better in vitro activity against the tested bacteria compared to imipenem and meropenem, but the difference was not statistically significant.
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Vasani V, Konar S, Satish S. Hypercapnic respiratory failure in case of chiari 1.5 malformation: Case Report and review of the literature. Indian J Crit Care Med 2017; 21 (10):707-709.
Type 2 respiratory failure is defined as hypercapnia associated with hypoxia. Chiari 1.5 is known as herniation of the cerebellar tonsils along with brain stem and fourth ventricle. We report a 35-year-old male who presented with acute hypercapnic respiratory failure (Type 2), without any preexisting neurological or respiratory abnormality. Analysis of blood gases in emergency revealed a pH of 7.12, pCO2of 132 mmHg, and arterial oxygen tension of 118 mm Hg. He was intubated and ventilated. Magnetic resonance imaging brain revealed herniation of the cerebellar tonsils along with brain stem and fourth ventricle. The patient underwent surgery and gradually weaned off. He was mobilized and discharged on day 6. Acute respiratory failure has not been reported with Chiari 1.5 malformation. The lesson to be learned from this case is that craniospinal pathology must be looked for in a patient with hypercapnic respiratory failure.
Rocuronium is commonly used in preference to suxamethonium for rapid sequence induction in the Intensive Care Unit (ICU). We describe a patient who suffered significant neck trauma following a suicide attempt. On initial presentation to accident and emergency, he was an easy intubation with a Grade 1 view obtained at laryngoscopy. After surgery to repair his neck laceration, he was extubated and discharged from ICU. He later developed a severe aspiration pneumonia and required reintubation. After induction and paralysis with suxamethonium, the best view at laryngoscopy was a Grade 3 despite the use of different laryngoscopes. As the muscle paralysis wore off the patient began breathing. This produced bubbles in the back of the patient\'s pharynx which directed the clinician to the laryngeal inlet to allow successful intubation. In this case, the short duration of action of suxamethonium significantly aided intubation due to the return of spontaneous breathing by the patient.