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Chatterjee S, Todi S. Transfer Time from the Intensive Care Unit and Patient Outcome: A Retrospective Analysis from a Tertiary Care Hospital in India. Indian J Crit Care Med 2019; 23 (3):115-121.
Background and aims: Patients’ outcome after ICU transfer reflect hospital\'s post-ICU care status. This study assessed association of after-hour ICU transfer on patient outcome.
Subjects and methods: Single-centre, retrospective analysis of data between March 2016 to April 2017 at a tertiary-care hospital in India. Patient data were collected on all consecutive ICU admissions during study period. Patients were categorized according to ICU transfer time into daytime (08:00–19:59 hours) and after-hour (20:00–07:59 hours). Patients transferred to other ICUs/hospitals, died in ICU, or discharged home from ICU were excluded. Only first ICU admission was considered for outcome analysis. Primary outcome-hospital mortality; secondary outcomes-ICU re-admission and hospital length of stay (LOS). All analysis were adjusted for illness severity.
Results: Of 1857 patients admitted during study period,1356 were eligible for study; 53.9% were males and 383(28%) patients transferred during after-hour. Mean age of two groups (daytime vs. after-hour 65.7±15.2 vs. 66.3±16.2 years) was similar (p = 0.7). Mean APACHE IV score was comparable between daytime vs. after-hour transfers (45.6±20.4 vs 46.8±22; p = 0.05). Unadjusted hospital mortality rate of after-hour-transfers was significantly higher compared to daytime-transfers (7.1% vs. 4.1%; p = 0.02). After adjustment with illness severity, after-hour-transfers were associated with significantly higher hospital mortality compared to daytime-transfers (aOR1.7, 95%CI 1.1,2.8; p = 0.04). Median duration of hospital LOS and ICU re-admission though higher for after-hour-transfers, was not statistically significant in adjusted analysis (aORhospital-LOS1.1, 95% CI 0.8, 1.4, p = 0.5; aORreadmission 1.6, 95% CI 0.9,2.7; p = 0.06 respectively).
Conclusion: After-hour-transfers from ICU is associated with significantly higher hospital mortality. Hospital LOS and readmission rates are similar for daytime and after-hour-transfers.
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Mishra SB, Poddar B, Kasimahanti R, Singh RK, Baronia AK. Quality of Life After Intensive Care Unit Discharge in a Tertiary Care Hospital in India: Cost Effectiveness Analyis. Indian J Crit Care Med 2019; 23 (3):122-126.
Background: Improvements in intensive care in the last few decades have shifted the focus from mortality to quality of life of survivors as a more important outcome measure. Allocation of public resources towards intensive care is an important challenge for health care administrators. This challenge is made more arduous in resource limited countries like India. Thus, it is imperative to consider patient centred outcomes and resource utilisation to guide allocation of funds. The aim of this study was to evaluate the quality of life of long-term survivors, and to perform cost-effectiveness and cost-utility analysis.
Methods: Data was retrieved from the records and included age, gender, admission diagnosis, length of ICU stay & mortality. Costing methodology used was top down approach. Quality of life was assessed by SF 36 scoring which was done with personal interview and telephonically. Cost effectiveness analysis was done on the basis of years of life added. Cost utility was done by QALY gained.
Results: A total of 1232 adult patients were admitted in the period with 758 (61%) being successfully discharged from ICU with a mortality rate of 39%. Out of 758, we could contact 113 (15%) patients. 86 patients were alive at the time of contact who could fill the forms for quality of life. The patients discharged from ICU had scores almost similar to the general population. Lesser scores were noted in physical functioning and general health perceptions, though this difference was not statistically significant. The life years gained were significantly more in younger patients. The cost per life gained was more in patients aged more than 50 years compared to those who were younger.
Conclusion: The quality of life after survival from ICU is as good as in the general population. The intensive care provided in our ICU is cost effective.
Daghmouri M Aziz,
Objective: To evaluate the interest of cerebrospinal fluid (CSF) lactate assay for the diagnosis of post-neurosurgical bacterial meningitis (PBM).
Methods: We conducted at our neurosurgical resuscitation unit a prospective study of patients who underwent elective or emergency craniotomy. Lumbar puncture was performed in all patients who had clinical suspicion of PBM for CSF culture and cytological and chemical analysis (glucose, protein, lactate). The diagnosis of PBM is made according to the criteria proposed by the Center for Disease Control and Prevention (CDC). Receiver Operating Characteristic (ROC) was used to determine the diagnostic accuracy of CSF lactate.
Results: 72 patients were studied and only 32 of them had the clinical and biological criteria of the diagnosis of PBM. Median CSF lactate was 6.18 mmol/L for PBM versus 2.63 mmol/L for no PBM (p < 0.001). CSF lactate may predict the presence PBM, with a AUC of 0.98 and NPV of 99.1. The analysis of Youden\'s index also confirms the good diagnostic power of CSF lactate, with a value of 83 at a cut-off value of 4 mmol/L, with a sensitivity of 92.3 and specificity of 91.6%.
Conclusion: Our study shows that the CSF lactate as an indicator for PBM. It is a fast and simple test that can help the clinician to optimize the management of PBM and decrease premature cessation of antibiotics.
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Gattupalli V, Jain K, Samra T. Lung Ultrasound as a Bedside Tool for Assessment of Extravascular Lung Water in Critically Ill Head Injured Patients: An Observational Study. Indian J Crit Care Med 2019; 23 (3):131-134.
Introduction: Extra Vascular Lung Water (EVLW) is defined as the amount of fluid in the interstitial and alveolar spaces. Primary aim of this study was to assess EVLW using lung USG (B lines >3 per lung field) in critically ill head injured patients.
Methods: Intubated adult patients admitted in Trauma ICU with head injury (GCS 4-15) were assessed by daily chest x ray and lung ultrasonography. Lung water content was graded based on the number of B lines per ICS with score ranging from 0-32 and categorized as low pulmonary fluid burden (0-10), moderate fluid burden (11-20) and high fluid burden (21-32).
Results: 140 critically ill head injured patients were assessed for eligibility and 20 excluded. Incidence of increased EVLW using lung USG was 61.66% (74/120) and the incidence reported using chest x ray was 40.83%(49/120) and the difference was statistically significant (p value <0.001). Increased EVLW significantly increased the duration of weaning, mechanical ventilation and ICU stay (p value <0.05). Significant association was observed between APACHE II, SAPS II and GCS at admission to ICU with presence of EVLW (p value ≤0.001). Mean delay in identification of EVLW by chest x ray compared to lung ultrasound was 1.42±0.76 days.
Conclusion: Lung ultrasound is better than CXR for early detection of increased EVLW in critically ill head injured patients and has prognostic relevance as increased EVLW prolongs duration of mechanical ventilation and ICU stay.
Resham Lal Gurung,
Edwin Chuen Ping Seet,
Su Chi Lim
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Siddiqui S, Gurung RL, Liu S, Seet EC, Lim SC. Genetic Polymorphisms and Cytokine Profile of Different Ethnicities in Septic Shock Patients, and their Association with Mortality. Indian J Crit Care Med 2019; 23 (3):135-138.
Objective: The outcomes of sepsis and septic shock patients are heterogonous, with a variable response despite standardized care. The aim of this study was to explore the racial differences in septic shock outcomes, and their association with genetic polymorphisms and cytokine levels in an Asian population.
Design: This was an observational cohort study,
Setting: Intensive Care units of a 500 bedded tertiary care hospital in Singapore.
Patients: 198 patients (73 Chinese, 73 Malay and 52 Indian and others) admitted to the Khoo Teck Puat Hospital Intensive Care Unit between August 2016 and June 2017, with a diagnosis of severe sepsis (according to) were enrolled.
Interventions: Plasma interlukin-6 (IL-6), interlukin-10 (IL-10) and Tumour necrosis factor-a (TNFa) were measured using a highly sensitive quantitative sandwich enzyme-linked immunosorbent assay (ELISA) (BioVendor, Modrice, Czech Republic). The gene panel studied included 16 genes.
Measurements and Main Results: The rs7038903 common variant in SVEP1 gene showed significant association with sepsis severity independent of other variants in ordinal logistic and linear regression model (p=0.001 and p=0.002 respectively). Moreover, the association between rs7038903 and increased hazard for death remained significant after further adjusting for cytokines level. Interestingly, significant differences were seen in plasma IL6 in individuals with or without rs7038903 C allele (28pg/ml (IQR 12-86) vs 90pg/ml (IQR 49-155); P=0.022) in patients with severe sepsis in the Malay ethnic group.
Conclusions: Our study shows a promising polymorphism in SVEP1 gene (rs7038903) which is associated with sepsis shock and 28 days mortality, independent of age, gender, and method of diagnosis and SOFA score. Collectively, while our findings so far have shown the additional value or measuring cytokines and genetic markers in sepsis outcomes in the local population, further large scare studies are needed in a heterogeneous septic population with a rigorous analysis to know the significance of our findings.
Rubina K Mahajan,
Parshotam L Gautam,
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Mahajan RK, Gautam PL, Paul G. Retrospective Evaluation of Patients Leaving against Medical Advice in a Tertiary Care Teaching Hospital. Indian J Crit Care Med 2019; 23 (3):139-142.
Context: Leaving against medical advice (LAMA) is a worldwide healthcare problem, occurring due to various contributing factors, seen more commonly in developing countries like ours.
Aims: To retrospectively study the prevalence of LAMA alongwith its affecting factors.
Settings and Design: We screened the hospital record for one year, of a tertiary care teaching hospital, after obtaining approval from the institutional ethical committee. Patient demography, disease characteristics and status at the time of LAMA were noted and statistically analysed.
Results: During the study period, 4.95% patients took LAMA.The mean age was 47.2±21 years (range newborn to 103 years) with 2:1 Male: Female ratio. Forty nine percent of patients resided in rural areas and around 1/3rd were dependent on others for their living. The mean length of stay in hospital was 6.1±9.3 days. Around 60% patients required mechanical ventilation and 51% patients had been explained guarded prognosis. About 53% of patients taking LAMA were admitted in medical wards, trauma being the most common diagnosis (17.2%). History of alcohol abuse and poisoning with suicidal intent was seen in 11.47% and 3.9% respectively.
Conclusions: The number of patients taking LAMA from our country is quite high. This necessitates formulation and implementation of strategies to reduce the prevalence of AMA discharges like further investigations to look into the causes contributing to patients taking LAMA, attending to substance abuse issues, recognizing psychological factors & strengthening the social systems, encouraging insurance cover, helping patients’ treatment expenses through charity care and optimizing healthcare delivery and patient centred policies.
Key Messages: LAMA is a global health issue precipitated by unemployment and alcohol abuse, commonly taken due to financial reasons. This necessitates a strong social system and national health insurance schemes to reduce the cost of treatment.
Background: Leaving against medical advice (LAMA) is a common health concern seen worldwide. It has variable incidence and reasons depending upon disease, geographical region and type of health care system.
Methods: We approached anaesthesiologists and intensivists for their opinion through ISA and ISCCM contact database using Monkey Survey of 22 questions covering geographical area, type of health care system, incidence, reasons, type of disease, expected outcome of LAMA patients etc.
Results: We received only 1154 responses. Only 584 answered all questions. Out of 1154, only 313 respondents were from government medical colleges or hospitals while remaining responses were from private and corporate sector. Most hospitals had >100 beds. ICUs were semi-closed and supervised by critical-care physicians. LAMA incidence was maximum from ICU (45%) followed by ward (32%) and emergency (25%). Most patients of LAMA had ICU stay for >1week (60%). 80% of the respondents opined that financial constraints are the most common reason of LAMA. Unsatisfactory care was rarely considered as a factor for LAMA. Approximately 40% patients had advanced malignancy or disease. Nearly 2/3rd strongly believed that insurance cover may reduce the LAMA rate.
Conclusion: Most patients get LAMA from the ICU after a stay of week. Financial constraints, terminal medical illness, malignancy and sepsis are major causes of LAMA. Remedial methods suggested to decrease the incidence include a good national health policy by the state; improved communication between the patient, care givers and heath-care team; practice of palliative and end-of-life care support; and lastly, awareness among the people about advance directives.
We describe a case series of seven culture proven melioidosis patients presenting during 2014 to 2016 in Madurai, south Tamilnadu. Skin, soft tissue, bone and joint infections were common. All of them were middle aged men except one case. All the cases were reported during the monsoon season. Predisposing factors include diabetes and alcoholism. Despite many case reports and studies from South India, melioidosis still remains undiagnosed, hence underreported from many centres. Delayed diagnosis leads way to sepsis and other complications. Awareness about the preventive measures, earlier clinical and laboratory identification, and appropriate management of severe sepsis are required to reduce the burden of this disease
Superior vena cava (SVC) syndrome is classically thought of as a complication of malignancy. However, SVC syndrome secondary to indwelling central venous catheters (CVC) is another important entity. Amongst those with CVCs who develop SVC syndrome, the majority are attributed to thrombosis. Aside from thrombosis, CVCs can lead to SVC syndrome secondary to mechanical obstruction of blood flow in an already narrowed vessel.
We present the first case of hyperacute SVC syndrome that developed within 6 hours of insertion of a CVC into a patient\'s right internal jugular vein alongside a pre-existing right internal jugular tunnelled dialysis line. With removal of the line, the patient\'s symptoms resolved completely within hours. The patient also was found to have stenosis of superior vena cava, likely secondary to multiple instrumentations.
Physicians must be diligent to monitor for this complication in patients who have had previous instrumentations of major vessels when inserting CVCs.
Sai Praveen Haranath,
Cyanide toxicity is a fatal condition if not detected and treated in stipulated time1. Lack of rapid detection modalities, and nonspecific nature of clinical presentation make the diagnosis more challenging2. Cherry red colour of blood might be the only clue sometimes. We present a case of sudden onset altered sensorium which was detected as cyanide poisoning and treated successfully with antidots, on the basis of central venous blood colour and corroborative presentation.
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Bhagawati G, Bhardwaj A, Sajikumar R, Singh SP, Prajapati S. Bacteraemia by Chryseobacterium indologenes in a patient with Lung Cancer: A Clinical and Microbiological Investigation. Indian J Crit Care Med 2019; 23 (3):157-159.
We present a case of bacteraemia by an unsual, instrinsically multidrug resistant organism, Chryseobacterium indologenes in a 59 year old gentleman with squamous cell carcinoma of lung with multiple metastasis. Despite of treating as per sensitivity report after isolating Chryseobacterium indologenes, patient could not be survived. The pathogenicity and predictability of the organism towards antibiotics, both in –vivo and in-vitro needs further research.