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Arttawejkul P, Reutrakul S, Muntham D, Chirakalwasan N. Effect of Nighttime Earplugs and Eye Masks on Sleep Quality in Intensive Care Unit Patients. Indian J Crit Care Med 2020; 24 (1):6-10.
Purpose: Poor sleep quality in intensive care unit (ICU) can be associated with poor outcome. Excessive noise and lights in ICU are known to disrupt patients’ sleep by causing arousals. Study design: A prospective randomized controlled study. Materials and methods: The patients admitted to the medical ICU were prospectively included and randomized to receive earplugs and eye masks or no intervention during their first 5 nights in ICU. Their arousal index and other sleep parameters were measured during the first night by polysomnography. Secondary outcomes including wrist actigraphy profiles and subjective sleep quality were recorded during all study nights. Results: Seventeen patients were enrolled. Eight patients were randomized to earplugs and eye masks group and nine patients were randomized to control group during their first 5 nights in the ICU. The use of earplugs and eye masks demonstrated the trend toward lower arousal index during the first night (21.15 (14.60) vs 42.10 (18.20) events per hour, p = 0.086) and increased activity index (activity count/hour) (16.12 (7.99) vs 10.84 (10.39) count/hour, p = 0.059) compared to control group. Polysomnography and actigraphy did not demonstrate good agreement. Conclusion: The use of earplugs and eye masks has a trend toward reduction in arousal index and increased activity in patients admitted to ICU. Limited sample size most likely explained insignificant difference in outcomes. Wrist actigraphy did not accurately measure sleep parameters in ICU patients. Trial registration: www.clinicaltrials.in.th, TCTR20170727003.
Background: Burn injuries in adults can be complicated due to various underlying factors. Of all the co-morbidities complicating wound healing and prognosis of the patient post burn injury, diabetes mellitus is the most common in India. We therefore aimed to explore the epidemiology, interventions, complications, and outcomes in diabetic patients with burn injury. Aim: To analyze demographic characteristics, clinical and microbiological profile and outcome of diabetic burns patients in comparison with nondiabetic burns patients. Materials and methods: This study was a retrospective analysis of diabetic and nondiabetic burns patients admitted to Apollo speciality clinics, Vanagaram, a tertiary care facility in Chennai over a period of 3 years. Data such as age, gender, type and degree of burns, percentage of burns and length of stay, mortality rate, infection rate, type of infections, surgical procedures, and medical complications were analyzed in comparison with nondiabetic burns patients. Results: Among ninety-four burns patients admitted to our hospital over a period of 3 years, 18 patients (19%) were diabetics and 76 patients (81%) were nondiabetics. Mean age of diabetics was 58.2 years (SD-17.1) and nondiabetics was 36.3 years (SD-16.4). Surgical intervention with split skin graft was performed in 50% of diabetics and 48.7% of nondiabetics. Average length of stay of diabetics was 12.6 days and nondiabetics was 16.2 days (p value: 0.334). Diabetic patients with burns were noted to have higher rate of infection (67% vs 61.8%, p value: 0.803) and mortality (44% vs 35.5%, p value: 0.482). Conclusion: The clinical course is different between diabetic and nondiabetic patients with burns injury. Although length of stay and surgical interventions were not significantly different, diabetes as a comorbidity appears to increase the risk of infections and mortality in patients with burns.
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Khodare A, Kale P, Pindi G, Joy L, Khillan V. Incidence, Microbiological Profile, and Impact of Preventive Measures on Central Line-associated Bloodstream Infection in Liver Care Intensive Care Unit. Indian J Crit Care Med 2020; 24 (1):17-22.
Aims and objectives: Central line-associated bloodstream infection (CLABSI) is among one of the preventable healthcare-associated infections (HAIs). The data for the CLABSI rate in liver care intensive care unit (LCICU) patients are scarce, so the present study was conducted to ascertain the CLABSI rate, the microbiological profile, and the impact of preventive measures for reduction of infection. Materials and methods: This is a prospective observational study done on LCICU patients during the period of January 2017–December 2018. We followed up patients on the central venous catheter for the development of CLABSI as a part of routine surveillance of HAIs. The impact of introduction and implementation of the CLABSI bundle to reduce the CLABSI rate was analyzed and the microbiological profile of infection was determined. Results: During the study period, the total number of patients admitted in LCICU were 1,336 (648 in 2017 and 688 in 2018) and a total of 995 central lines were inserted for various indications. A total of 57 patients were meeting the CLABSI criteria among 7,324 central line catheter days of surveillance. In year 2017, rate of CLABSI was 11.78/1,000 catheter days and after implementation of the bundle in 2018 the rate reduced to 3.99/1,000 catheter days. Gram-negative organisms (86%) predominated with Pseudomonas aeruginosa being the most common pathogen (19.3%). Out of 49 isolates of gram-negative bacilli (GNB), 40 (81.6%) were multidrug resistant (MDR) and 9 (18.4%) were pan-drug resistant. Conclusion: We found significant reduction in the CLABSI rate after implementation of the bundle of care. Gram-negative bacilli were the most common pathogen in our study and antimicrobial resistance was very high, which suggest hospital environment as a source of infection. Clinical significance: Knowledge of the microbiological profile and the preventive strategy of CLABSI is essential for prevention and timely initiation of the most appropriate anti-infective therapy, if it happens.
Halita J Pinto,
Thankappan S Sanil
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Pinto HJ, D’silva F, Sanil TS. Knowledge and Practices of Endotracheal Suctioning amongst Nursing Professionals: A Systematic Review. Indian J Crit Care Med 2020; 24 (1):23-32.
Introduction: Ventilator-associated pneumonia, a common cause of mortality and morbidity, is commonly seen among patients with endotracheal intubation due to unsafe suctioning practices by health professionals. Objective: A systematic review was conducted to explore the gaps in the existing practices of nurses and thus proposing comprehensive guidelines for safe practice. Materials and methods: A two-phase strategy was adopted to identify the studies through a comprehensive electronic search in PubMed, Google Scholar, ProQuest, Ovid, and Helinet Summon by using predefined keywords within a year limit of 2002–2016. The quality of studies was reviewed using tools endorsed by Joanna Briggs Institute. This review was conducted according to the guidelines described in the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Qualitative data were described through the process of metasynthesis. Quantitative analysis was performed to combine the competent quantitative evidences to identify knowledge and practices of endotracheal suctioning (ETS). Results: Thirty studies had been subjected for metasynthesis, among which six provided relevant information for quantitative analysis. Quantitative analysis of the studies reported that only 36% of the nurses had assessed patients prior to suctioning and had knowledge about the size of the suction catheter while only 46% were aware of the appropriate suction pressure to be used for ETS. Handwashing compliance prior to suctioning was observed in only 62% of the nurses. It is reported that, despite the awareness on possible complications, nurses fail to adhere to the recommended practice guidelines. Conclusion: The current review would explore the best evidence-based practices (EBPs) among nurses related to ETS, which would ensure quality care to critically ill patients.
Piotr F Czempik,
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Czempik PF, Jarosińska A, Machlowska K, Pluta M. Impact of Light Intensity on Sleep of Patients in the Intensive Care Unit: A Prospective Observational Study. Indian J Crit Care Med 2020; 24 (1):33-37.
Aims and objectives: Sleep deprivation in the intensive care unit (ICU) has been linked to numerous complications. Light levels might impact the sleep of patients in the ICU. The aim of the study was to measure light levels during sleep-protected time in the ICU and to assess the impact of light intensity on sleep quantity/quality. Materials and methods: This prospective, observational study was conducted in a 10-bed, mixed surgical/medical ICU. For measuring light levels, a commercially available smartphone application was used. The measurements were performed between 23:30 and 06:15 hours at 15-minute intervals. To assess sleep quantity, we used Patient\'s Sleep Observation Behavioral Tool and to assess sleep quality, we used Richards-Campbell Sleep Scale. Results: The median number of time points at which patients were asleep was 20 (interquartile range, IQR 14–23) out of 25 (5 hours). The median self-reported quality of sleep (overall score) was 49 (IQR 28–71). The median values for individual questions are: question 1 (sleep depth)—54.0 (IQR 37–78), question 2 (sleep latency)—40.5 (IQR 6–90), question 3 (awakenings)—52.5 (IQR 28–76), question 4 (returning to sleep)—25.5 (IQR 11–78), and question 5 (sleep quality)—67.5 (IQR 5–76). No correlation was found between self-reported sleep quality and time spent asleep (p = 0.36). There was no correlation between average light levels during sleep-protected time and sleep quantity (p = 0.42)/sleep quality (p = 0.13). There was a correlation between average (13 ± 5 lux) light levels before sleep-protected time and sleep quality (p = 0.008). Conclusion: Mean light levels of 11 ± 9 lux during sleep-protected time have no negative impact on quantity and quality of sleep in intensive care unit patients. Light levels up to 18 lux directly before falling asleep improve patients’ self-reported quality of sleep in the ICU. Clinical significance: Finding safe levels of light intensity during sleep-protected time in ICU.
Manoj Y Singh,
Objective: The study aimed to evaluate the effect of a single after-hours rapid response team (RRT) calls on patient outcome. Design: A retrospective cohort study of RRT-call data over a 3-year period. Setting: A 600-bedded, tertiary referral, public university hospital. Participants: All adult patients who had a single RRT-call during their hospital stay. Intervention: None. Main outcomes measures: The primary outcome was to compare all-cause in-hospital mortality. The secondary outcomes were to study the hourly variation of RRT-calls and the mortality rate. Results: Of the total 5,108 RRT-calls recorded, 1,916 patients had a single RRT-call. Eight hundred and sixty-one RRT-calls occurred during work-hours (08:00–17:59 hours) and 1,055 during after-hours (18:00–7:59). The all-cause in-hospital mortality was higher (15.07% vs 9.75%, OR 1.64, 95% CI 1.24–2.17, p value 0.001) in patients who had an after-hours RRT-call. This difference remained statistically significant after multivariate regression analysis (OR 1.50, 95% CI 1.11–2.01, p value 0.001). We noted a lower frequency of hourly RRT-calls after-hours but were associated with higher hourly mortality rates. There was no difference in outcomes for patients who were admitted to ICU post-RRT-call. Conclusion: Patients having an after-hour RRT-call appear to have a higher risk for hospital mortality. No causal mechanism could be identified other than a decrease in hourly RRT usage during after-hours.
Background: This study was designed to evaluate the patient characteristics and outcomes of in-hospital cardiac arrest (IHCA). Materials and methods: We carried out a single-center, 5-year, retrospective chart review and analysis of resuscitation data for age, gender, body mass index (BMI), length of stay (LOS) until cardiac arrest, survival of initial IHCA, survival to hospital discharge, primary medical service, and determination of the etiology of cardiac arrest. Results: A total of 500 cases occurred with a mean LOS of 8.5 days until the initial IHCA. Overall, 79.5% survived the initial IHCA and 32.4% survived to discharge. As LOS increased, there was an increase in the proportion of pulmonary and metabolic etiologies. Logistic regression analysis adjusting for BMI, gender, age, LOS, and primary medical service were on a surgical service significant for survival to discharge (p = 0.0007) and LOS <9 days significant for survival of IHCA (p = 0.018). Conclusion: There are a number of causes of IHCA, and the incidence of death and respiratory related IHCA etiologies increase with LOS. Length of stay carries the highest weight when predicting survival of IHCA. Also, there is a higher rate of survival to discharge when on a primary surgical service.
Ali A Ghamari,
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Yousefi B, Sanaie S, Ghamari AA, Soleimanpour H, Karimian A, Mahmoodpoor A. Red Cell Distribution Width as a Novel Prognostic Marker in Multiple Clinical Studies. Indian J Crit Care Med 2020; 24 (1):49-54.
Red cell distribution width (RDW), which is a quantitative method applied for the measurement of anisocytosis, is the most reliable and inexpensive method for differentiation of iron deficiency anemia and thalassemia trait. An increase in its rate reflects a great heterogeneity in the size of red blood cells (RBCs). Recent studies have shown a significant relationship between RDW and the risk of morbidity and mortality in patients with multiple diseases. A strong association is established between changes in RDW and the risk of adverse outcome in patients with heart failure in multiple studies. In this review, we try to focus on the association and correlation between the increase in RDW and different outcomes of common diseases that may be related to RDW and based on the results of various studies, we are trying to introduce RDW as a diagnostic indicator for these diseases.
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Hegde A, Gupta V, Ahdal J, Qamra A, Motlekar S, Jain R. Methicillin-resistant Staphylococcus aureus in Intensive Care Unit Setting of India: A Review of Clinical Burden, Patterns of Prevalence, Preventive Measures, and Future Strategies. Indian J Crit Care Med 2020; 24 (1):55-62.
Aim: The aim of this review article is not only to analyze the clinical burden of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care unit (ICU) setting of India, along with the patterns of prevalence and its prevention measures, but also to focus on the new anti-MRSA research molecules which are in late stage of clinical development. Background: Methicillin resistance is reported to be present in 13–47% of Staphylococcus aureus infections in India. Therapeutic options to combat MRSA are becoming less, because of emerging resistance to multiple classes of antibiotics. Intensive care units are the harbinger of multidrug-resistant organisms including MRSA and are responsible for its spread within the hospital. The emergence of MRSA in ICUs is associated with poor clinical outcomes, high morbidity, mortality, and escalating treatment costs. There is an urgency to bolster the antibiotic pipeline targeting MRSA. The research efforts for antibiotic development need to match with the pace of emergence of resistance, and new antibiotics are needed to control the impending threat of untreatable MRSA infections. Review results: Fortunately, several potential antibiotic agents are in the pipeline and the future of MRSA management appears reassuring. Clinical significance: The authors believe that this knowledge may help form the basis for strategic allocation of current healthcare resources and the future needs.
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Erdoğan S, Çakır D, Bozkurt T, Karakayalı B, Kalın S, Koç B, Sözeri B. Hemophagocytic Lymphohistiocytosis Related to Tuberculosis Disease. Indian J Crit Care Med 2020; 24 (1):63-65.
Hemophagocytic lymphohistiocytosis (HLH) is a rare, albeit potentially fatal, condition in which fever, hepatosplenomegaly, and cytopenia predominate the clinical picture. Although it may be primary, it may also develop secondary to various etiologies. Herein, we aimed to report a patient who was diagnosed with pulmonary tuberculosis, developed fever and cytopenia during follow-up, and received immunomodulatory therapy together with antituberculosis therapy for the diagnosis of HLH. Sequencing of PRF1 showed heterozygous mutation. Although primary HLH has been detected in infants and children, genetic mutation of genes should be considered a differential diagnosis of HLH even in the adolescent.
The annual incidence rates of venous thromboembolism are approximately 1 per 1,000 persons per year in adult population. Deep vein thrombosis (DVT) most frequently occurs in the setting of underlying illness, and anatomical abnormalities are rarely considered as an etiology for it. A well-described anatomical cause for DVT is “May-Thurner syndrome” (MTS), which occurs as a result of compression of the left common iliac vein by the overlying right common iliac artery. This syndrome most often affects young to middle-aged women. Pulmonary embolism (PE) occurs very rarely in these patients. Anticoagulation therapy alone is not enough in these patients. We report a case of 27-year-old male who had both left DVT and PE caused by MTS and was treated with endovascular management along with long-term anticoagulation.
A 28-year-old male was admitted with a history of sudden onset headache, multiple episodes of vomiting, gait disturbance with swaying toward right side, and blurring of vision for 2 days. The patient was conscious, cooperative, and oriented, and his vitals were normal. Bilateral gaze-evoked nystagmus was present. Motor and sensory examinations were within normal limit, and deep tendon reflexes were 2+ in all four limbs. Cerebellar examination reveals positive finger–nose test and dysdiadochokinesia on right side. A computed tomography of head showed acute intraparenchymal hemorrhage in right cerebellar hemisphere with effacement of fourth ventricle and mild hydrocephalus. Computed tomography angiography of cerebral vessels was normal. The coagulation profile (international normalized ratio: 1.02), renal function test, and liver function tests were within normal limit. Urine toxicology screen was positive for tetrahydrocannabinoid. The patient was diagnosed with right cerebellar bleed and cannabis abuse. The patient managed conservatively with intravenous mannitol and was discharged in hemodynamic stable condition.
Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular transmission, which presents with fluctuating and variable weakness in ocular, bulbar, limb, and respiratory muscles resulting from an antibody-mediated, T-cell-dependent immunologic attack on the postsynaptic membrane of the neuromuscular junction. Although treatment of MG and myasthenic crisis is based on few specific principles, it is highly individualized. We report a successfully treated case of refractory myasthenic crisis who was on a ventilator for 7 months (210 days), perhaps the longest from India, and required multiple cycles of plasma exchange, intravenous immunoglobulin infusion, and one cycle of rituximab. It exemplifies the role of highly individualized therapy and interdisciplinary cooperation in management of refractory myasthenic crisis.
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Morkar DN, Agarwal R, Patil RS. Coxsackie Myocarditis with Severe Methicillin-resistant Staphylococcus aureus Sepsis, Multi-organ Dysfunction Syndrome, and Posterior Epidural Spinal Abscess: A Case Report. Indian J Crit Care Med 2020; 24 (1):73-76.
Aim: The aim of this paper is to present an interesting case of viral myocarditis complicated by sepsis, its sequelae, including multi-organ dysfunction syndrome, and the approach to manage it successfully. Background: Viral myocarditis is an inflammatory disease of myocardium, often leading to residual heart disease. Commonly, dengue and Coxsackie B viruses are the causative agents. Patients usually present with dyspnea, fever, and signs of heart failure. A possibility of bacterial sepsis should not be overlooked, given similar presentations may occur. Case description: A 21-year-old male presented with acute onset breathlessness, fever, chills, and severe neck pain. On a detailed workup, he was found to have features suggestive of viral myocarditis, bacterial sepsis, with bilateral pleural loculations, a posterior epidural spinal abscess. Elimination of infectious foci, along with a decision to stick to the ongoing antibiotics, instead of stepping up to the last available ones proved beneficial. Meticulous balance of diuretics and inotropes saved the patient\'s life from what turned out to be coxsackie myocarditis. Conclusion: Here, we present the case of a young male who came in with congestive heart failure due to Coxsackie myocarditis and his condition complicated by severe sepsis. Clinical significance: Up to 10% of the cases of coxsackie myocarditis progress to chronic dilated cardiomyopathy. The management is usually conservative, and antiviral agents have shown no role in speedy recovery. Elimination of infectious foci aggressively is of prime importance in the treatment of bacterial sepsis. A careful balance of inotropes, diuretics, and fluid management is needed to get the patient into remission in such cases.
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Arora J, Sehgal L, Satpathy H. Intensive Care Unit Management of a Patient with Tracheal Rent Repair Following Laryngopharyngoesophagectomy. Indian J Crit Care Med 2020; 24 (1):77-79.
Tracheal injuries are one of the potentially fatal complications following laryngopharyngeal and esophageal surgeries. The patient developed tracheal rent during laryngopharyngoesophagectomy. The injury was diagnosed intraoperative and repaired. However, it did not heal, and the patient developed tracheopleural fistula. Right thoracotomy and latissimus dorsi flap was done under general anesthesia. Postsurgery, the patient was shifted to intensive care unit (ICU), where he developed respiratory distress not improving, with increasing oxygen flows. To avoid damage to the repair, under bronchoscopic guidance bilateral selective mainstem bronchial intubations were done using cuffed 5.0 mm regular endotracheal tubes (ETTs), and ventilation was supported on pressure control ventilation mode. The ventilator support was weaned off to pressure support ventilation mode on postoperative day (POD) 1. On POD2, ETTs were removed under bronchoscopic guidance and were replaced by 7 mm ID long and adjustable flange tracheostomy tube with the tip just above the carina. The cuff was kept deflated, and oxygen with the high flow was provided through a tracheostomy. The high flow was weaned off after 5 days. Later, the patient was managed conservatively by regular chest physiotherapy, antibiotics, bronchoscopic pulmonary toileting, nebulizations, and appropriate antimicrobial therapy. Patient was discharged in stable condition from ICU and hospital.
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Chitransh V, Sheikh WR, Snehy A. Guidewire Entrapped in the Right Ventricle: A Rare Complication of Hemodialysis Catheter Insertion. Indian J Crit Care Med 2020; 24 (1):80-81.