Indian Journal of Critical Care Medicine

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2020 | November | Volume 24 | Issue 11

EDITORIAL

Balasaheb D Bande

Critically Ill Obstetric Patients and Fetomaternal Outcome

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:3] [Pages No:1005 - 1007]

Keywords: Fetomaternal outcome, Maternal mortality ratio, Obstetric critical care

PDF  |  DOI: 10.5005/jp-journals-10071-23650  |  Open Access |  How to cite  | 

Abstract

Reduction in the maternal mortality ratio (MMR) continues to be a worldwide challenge. With repeated analytical studies done over decades, it has become possible to identify the significant contributors to this challenge. Right from low socioeconomic status to the availability of recent technological advances, many factors need attention and prioritization. Obstetric hemorrhage remains an important cause followed by hypertensive disorders of pregnancy and sepsis. In this issue of IJCCM, Miglani et al. have highlighted the various levels of the delays, which are significant contributors to the high MMR. In other preventive strategies, efforts will be needed to improve patient education, infrastructure, availability of trained manpower, blood storage facilities, timely referrals, transport facilities, etc., at peripheral levels. In the tertiary care centers, there is an increased need for trained manpower in critical care, the obstetric medical emergency team as a new concept, aggressive teamwork in intensive care unit (ICU) and operation theaters, the use of advanced technologies and newer drugs, etc. It will remain a tough challenge to reduce global MMR to 70 per 100,000 live births, as per plans by the United Nations, by the year 2030.

EDITORIAL

Amol T Kothekar

Combined Cardiopulmonary Ultrasound: A Treatment Changing Modality in Acute Respiratory Failure

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1008 - 1009]

Keywords: BLUE protocol, Lung ultrasound, Respiratory insufficiency, Transthoracic echocardiography

PDF  |  DOI: 10.5005/jp-journals-10071-23651  |  Open Access |  How to cite  | 

EDITORIAL

Parthasarathi Bhattacharyya

Multisystem Inflammatory Syndrome of Children Related to SARS-CoV-2: A Novel Experience in Children with a Novel Virus

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1010 - 1011]

Keywords: Kawasaki disease, Multisystem inflammatory syndrome in children, SARS-CoV-2

PDF  |  DOI: 10.5005/jp-journals-10071-23652  |  Open Access |  How to cite  | 

Abstract

Severe acute respiratory syndrome-coronavirus-2 (SARS CoV-2) is a novel virus. There has been an increasing number of case reports on multisystem inflammatory syndrome in children (MIS-C) but the global and population-specific incidence of MIS-C particularly in Asian countries, its causal relationship with SARS-CoV-2 and its immunopathogenesis remain unknown. Emerging questions on how the pathophysiology of MIS-C differs from that of Kawasaki disease (KD) and non-KD inflammatory syndromes need to be answered. Genetic factors influencing the incidence of MIS-C in the different ethnic populations are to be explored. What happens to the children with MIS-C, in the long run, remains unknown to date. Multicenter clinical trials are needed to establish optimal treatment and follow-up for MIS-C.

EDITORIAL

Niraj Tyagi

Where Has All the “HES” Gone: A Case in Point vs “Crusade” to Obscurity

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1012 - 1013]

Keywords: Colloids, Critical illness, Crystalloids, Fluid therapy, Hydroxyethyl starch, ICU mortality,Acute kidney injury

PDF  |  DOI: 10.5005/jp-journals-10071-23654  |  Open Access |  How to cite  | 

EDITORIAL

Shivakumar Iyer

Dietary Fiber: Is It Hype or Useful?

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:1] [Pages No:1014 - 1014]

Keywords: Intensive care unit, Short-chain fatty acids,Dietary fiber, Enteral Nutrition

PDF  |  DOI: 10.5005/jp-journals-10071-23655  |  Open Access |  How to cite  | 

EDITORIAL

Immunomodulation and COVID-19: Is There a Winning Combination?

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:3] [Pages No:1015 - 1017]

Keywords: COVID-19, Immunomodulation, SARS-CoV-2, Tocilizumab

PDF  |  DOI: 10.5005/jp-journals-10071-23691  |  Open Access |  How to cite  | 

Abstract

Coronavirus disease-2019 (COVID-19) has been testing the boundaries of science on several fronts. Pharmacotherapy has seen the highs of several drugs being tried as the best option as well as the lows of no drug proven to be effective. In this edition of the Indian Journal of Critical Care Medicine, Mahale et al. retrospectively evaluated a combination of drugs targeted at immunomodulation.

EDITORIAL

Sarfaraz Rahiman

Does Pediatric Index of Mortality “Score” in Colombia?

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1018 - 1019]

Keywords: Severity of illness scoring,Pediatric index of mortality, Pediatric intensive care unit

PDF  |  DOI: 10.5005/jp-journals-10071-23647  |  Open Access |  How to cite  | 

Abstract

Pediatric index of mortality (PIM)-2 and PIM3 are the most recent versions of severity of illness scoring generated from a pediatric intensive care unit (PICU) population in Australia and the United Kingdom. The authors present a single-center evaluation of a performance of these scores in a PICU in Colombia. PIM3 seemed to demonstrate a marginally better performance at predicting mortality, although the discrimination was similar for both scores. Incorporation of this approach to the rest of the units throughout the country would help with benchmarking PICU performance.

RESEARCH ARTICLE

Nilesh Mahale, Prasad Rajhans, Vikram L Narasimhan, Gauri Oak, Srinath Marreddy, Amruta Bedekar, Harshwardhan S Pawar, Prasad Akole, Balasaheb Pawar, Bhagyashri Bhurke, Shailaja Chavan, Parikshit Prayag, Bharat Purandare, Pradip Dalvi, Vishnu Telbhare, Prasanna Marudwar, Dnyaneshwar Diwane, Manasi Shahane, Amrita Prayag, Shradha Gugale, Shreyas Bhor, Sameer Jog

A Retrospective Observational Study of Hypoxic COVID-19 Patients Treated with Immunomodulatory Drugs in a Tertiary Care Hospital

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:8] [Pages No:1020 - 1027]

Keywords: Acute respiratory distress syndrome, Coronavirus disease-2019, Immunomodulatory drugs, Resource-limited settings

PDF  |  DOI: 10.5005/jp-journals-10071-23599  |  Open Access |  How to cite  | 

Abstract

Objectives: To describe the demographics and evaluate the clinical outcomes of hypoxic coronavirus disease-2019 (COVID-19) patients treated with different immunomodulatory (IM) drugs in a resource-limited setting. Materials and methods: We conducted a retrospective cohort study of these patients admitted to our hospital between March 22 and May 31, 2020. Data were abstracted from multiple electronic data sources or patient charts to provide information on patient characteristics, clinical, laboratory variables, and outcomes. Results: A total of 134 patients met the inclusion criteria and were followed up till June 7, 2020. The median age of the patients was 55.6 years (range 20–89 years) and 68% were men. At least one comorbidity was seen in 72% of the patients with diabetes (44%) and hypertension (46%) being the most common. At triage, fever (82%), shortness of breath (77%), and cough (61%) were the most common presenting symptoms. A PaO2/FiO2 ratio less than 300 was seen in 60%, and 4.5% required invasive mechanical ventilation within 72 hours of hospital admission. Five immunomodulatory agents (hydroxychloroquine, methylprednisolone, colchicine, etoricoxib, and tocilizumab) were administered in different combinations. Overall, in-hospital mortality was 26.9%, and 32% required mechanical ventilation. Around 69% of patients were discharged home. Five variables (SpO2, PaO2/FiO2 ratio, leucocytosis, lymphopenia, and creatinine) on admission were found to be significant in the patients who died. Conclusion: Our study provides the characteristics and outcomes of hypoxic COVID-19 patients treated with IM drugs in varied combination. Five independent variables were strong predictors of mortality.

RESEARCH ARTICLE

Matthias Jacob, Sambit Sahu, Yogendra P Singh, Yatin Mehta, Kuang-Yao Yang, Shuenn-Wen Kuo, Farooq Memom, Shirish Prayag, Rajesh Pande, Nirmal Jaiswal, Tan C Cheng, Amit Mandal, Shanti R Deva, Mohan Mathew, Vineya Rai, Luah Wah, Gopinath Ramachandran, Rajesh Chawla, ZA Khan, JV Divatia, Rajesh Mishra, Pravin Amin, Jayant Shelgaokar, Bernhard Zwissler, Hugo Van Aken, Christian Ertmer

A Prospective Observational Study of Rational Fluid Therapy in Asian Intensive Care Units: Another Puzzle Piece in Fluid Therapy

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:9] [Pages No:1028 - 1036]

Keywords: Crystalloids, Fluid therapy, Hydroxyethyl starch,Acute kidney injury, Colloids, Critical illness

PDF  |  DOI: 10.5005/jp-journals-10071-23653  |  Open Access |  How to cite  | 

Abstract

Introduction: Fluid therapy in critically ill patients, especially timing and fluid choice, is controversial. Previous randomized trials produced conflicting results. This observational study evaluated the effect of colloid use on 90-day mortality and acute kidney injury (RIFLE F) within the Rational Fluid Therapy in Asia (RaFTA) registry in intensive care units. Materials and methods: RaFTA is a prospective, observational study in Asian intensive care unit (ICU) patients focusing on fluid therapy and related outcomes. Logistic regression was performed to identify risk factors for increased 90-day mortality and acute kidney injury (AKI). Results: Twenty-four study centers joined the RaFTA registry and collected 3,187 patient data sets from November 2011 to September 2012. A follow-up was done 90 days after ICU admission. For 90-day mortality, significant risk factors in the overall population were sepsis at admission (OR 2.185 [1.799; 2.654], p < 0.001), cumulative fluid balance (OR 1.032 [1.018; 1.047], p < 0.001), and the use of vasopressors (OR 3.409 [2.694; 4.312], p < 0.001). The use of colloids was associated with a reduced risk of 90-day mortality (OR 0.655 [0.478; 0.900], p = 0.009). The initial colloid dose was not associated with an increased risk for AKI (OR 1.094 [0.754; 1.588], p = 0.635). Conclusion: RaFTA adds the important finding that colloid use was not associated with increased 90-day mortality or AKI after adjustment for baseline patient condition. Clinical significance: Early resuscitation with colloids showed potential mortality benefit in the present analysis. Elucidating these findings may be an approach for future research.

RESEARCH ARTICLE

Surbhi Khurana, Nidhi Bhardwaj, Subodh Kumar, Sushma Sagar, Rahul Pal, Kapil Dev Soni, Richa Aggarwal, Rajesh Malhotra, Purva Mathur

Crosstalk between T Helper Cell Subsets and Their Roles in Immunopathogenesis and Outcome of Polytrauma Patients

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:8] [Pages No:1037 - 1044]

Keywords: Th-9, Tr1, Trauma,iTregs, nTregs, Th-17, Th-22, Th-3

PDF  |  DOI: 10.5005/jp-journals-10071-23577  |  Open Access |  How to cite  | 

Abstract

Purpose: One of the leading causes of morbidity and early-age mortality across the globe is trauma. It disrupts immune system homeostasis and intensely affects the innate and adaptive immune responses, predisposing patients to posttrauma complications and poor outcomes. Most of the studies on posttrauma cellular immune response have been centered on the T helper-1-T helper-2 imbalances after trauma. This study was conducted to understand the role of circulating novel T helper cells in the acute posttraumatic period and clinical outcome of trauma patients. Materials and methods: Signature cytokines and transcription factors of circulating Th (T helper)-9, Th-17, Th-22, and regulatory T helper cells were studied using flowcytometry along with serum biomarkers in 49 patients with polytraumatic injuries admitted to a tertiary care hospital. The patients were followed up until their outcome. The results were correlated with their clinical outcomes. Results: In patients who died, higher nTreg, iTreg, Tr1 (early-phase), and higher IRF4+Th-9, IL17+ Th-17, and RORγT+ Th-17 (mid-phase) were seen. However, by the late phase, only RORγT+ Th-17 remained higher. Serum IL-6 and PCT were found to be consistently higher. In survivors, higher Th-3 (early phase), Th-22 (mid-phase), and IRF4+Th-9, IL17+ Th-17, nTreg, Th-3 (late phase) were observed to have played a protective role. Serum IL-2, IL-4, IL-17A and IL-22 were significantly higher in survivors. Conclusion: Different T helper subsets were observed to be playing pathogenic and protective roles in different phases of trauma and could be used for early prognostication and make way for noninvasive management of critically injured trauma patients by immunomodulation.

RESEARCH ARTICLE

Abbasali Ebrahimian, Seyyed-Mohammad-Taghi Shahcheragh, Ali Fakhr-Movahedi

Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:6] [Pages No:1045 - 1050]

Keywords: SOFA,Emergency department, mSOFA, Nontraumatic patients, qSOFA, qSOFA-65

PDF  |  DOI: 10.5005/jp-journals-10071-23656  |  Open Access |  How to cite  | 

Abstract

Introduction: This study was proposed to compare the ability and accuracy of modified sequential organ failure assessment (mSOFA), quick SOFA (qSOFA), and qSOFA-65 in predicting the status of nontraumatic patients referred to hospital emergency departments (EDs). Materials and methods: This study was a prospective design that performed on the 746 nontraumatic patients referred to the ED. Each patient data was collected using a demographic questionnaire, mSOFA, qSOFA, and qSOFA-65 scales. Related variables of each scale were recorded based on patients’ medical records. Then, the outcome of each patient in the ED was followed up and recorded. The severity and specificity of each scale were estimated by the area under receiver operating characteristic (AUROC) curve at 99% confidence interval (CI). Results: The mean and standard deviation of scores were as follows: mSOFA = 4.40 ± 2.58, qSOFA = 0.50 ± 0.70, and qSOFA-65 = 0.92 ± 0.96. Patients requiring admission to the intensive care unit (ICU) were identified with AUROC curve as follows: mSOFA = 0.882 (99% CI = 0.778–0.865); qSOFA = 0.717 (99% CI = 0.662–0.773); and qSOFA-65 = 0.771 (99% CI = 0.721–0.820), which showed that mSOFA has higher sensitivity and specificity than the other two scales in identifying patients requiring admission to the ICU. Conclusion: All three scales were found to be reliable for identifying nontraumatic patients at risk of death and patients requiring admission to the ICU. However, since the time and data required to complete qSOFA and qSOFA-65 are much less than those of mSOFA, it is recommended that qSOFA and especially qSOFA-65 be used in ED to identify critically ill nontraumatic patients.

RESEARCH ARTICLE

Kaweesak Chittawatanarat, Suthat Surawang, Piyawan Simapaisan, Kunchit Judprasong

Jerusalem Artichoke Powder Mixed in Enteral Feeding for Patients Who have Diarrhea in Surgical Intensive Care Unit: A Method of Preparation and a Pilot Study

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:6] [Pages No:1051 - 1056]

Keywords: Diarrhea, Fructans, Jerusalem artichoke, Soluble fiber, Surgical critically ill

PDF  |  DOI: 10.5005/jp-journals-10071-23575  |  Open Access |  How to cite  | 

Abstract

Aim and objective: The Jerusalem artichoke (Helianthus tuberosus L.) is a tuber with high soluble fiber. The objective of this study was to demonstrate the method of preparation and pilot test this substance as an additive to enteral feeding. Materials and methods: We processed Jerusalem artichoke into a 600 micrometers powder, tested its properties, and pilot tested its use in patients who had diarrhea (King\'s stool score ≥12) in a surgical intensive care unit. Two grams of Jerusalem artichoke powder were mixed in each 100 mL of hospital enteral feeding formula and administered for 5 days. Results: Artichoke powder slightly increased the viscosity of enteral feeding formula. The dietary fiber content of the mixture was 20.8–21.6 g% and the content of fructans was 66.0–71.5 g%. In the pilot study in 11 patients, diarrhea was improved (diarrhea score < 12) in 7/11 (63.6%) patients by day 5. Improvement in diarrhea started on day 2 [median different diarrhea score (interquartile range): −4 (−8 to 0); p = 0.03] and peaked by days 4 and 5 [−7(−10 to −3); p < 0.01 and −8(−12 to −4); p < 0.01, respectively]. There were no complications during the study except three patients had a high gastric residual volume (>200 mL). Conclusion: Processed powder of Jerusalem artichoke tuber has a high fiber content and increases viscosity of enteral feeding solutions only slightly. When administered as part of enteral nutrition to critically ill surgical patients, the diarrhea score improves in most patients.

RESEARCH ARTICLE

Sunil Kumar, Shreya C Gattani, Akshay H Baheti, Ayush Dubey

Comparison of the Performance of APACHE II, SOFA, and mNUTRIC Scoring Systems in Critically Ill Patients: A 2-year Cross-sectional Study

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:5] [Pages No:1057 - 1061]

Keywords: Modified nutrition risk in critically ill, Scoring systems, Sequential organ failure assessment,Acute physiology and chronic health evaluation II, Intensive care unit

PDF  |  DOI: 10.5005/jp-journals-10071-23549  |  Open Access |  How to cite  | 

Abstract

Aims and objectives: Different severity scores are being used to assess outcomes in intensive care unit, but variable data had been reported so far per their performance. Main objective of this study is to compare performance of acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), and modified nutrition risk in critically ill (mNUTRIC) scoring systems regarding the outcomes in the form of morbidity and mortality in medical intensive care unit (MICU) at rural tertiary-care health center. Materials and methods: In this cross-sectional study, 1,990 patients older than 18 years admitted in the ICU were enrolled. Age, gender, diagnosis, intubation, comorbidities, APACHE II, SOFA scores, m NUTRIC score, MICU stays in days, and need of mechanical ventilation were noted. Results: When we compared different score with mortality, APACHE-II was having sensitivity of 89.9% and specificity of 97.6%; SOFA had 90.1% sensitivity and 96.6% specificity; while mNUTRIC score had 97.2% sensitivity and 74.0% specificity. APACHE-II score had sensitivity of 93.4%, SOFA had 90.5%, and mNUTRIC score 92.3% with low specificity of 76.5% in predicting requirement of mechanical ventilation. mNUTRIC score and ICU length of stay showed moderate positive correlation (p value = <0.001). Conclusion: All the three scores were comparable in sensitivity and specificity in predicting outcomes in the form of mortality, need of mechanical ventilation, and length of ICU stays. mNUTRIC score was more sensitive than others, and as it was based on nutritional status, hence more weightage should be given on this score.

RESEARCH ARTICLE

Bapi Barman, Anit Parihar, Neera Kohli, Avinash Agarwal, Durgesh K Dwivedi, Gangotri Kumari

Impact of Bedside Combined Cardiopulmonary Ultrasound on Etiological Diagnosis and Treatment of Acute Respiratory Failure in Critically Ill Patients

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:9] [Pages No:1062 - 1070]

Keywords: Transthoracic echocardiography,Acute respiratory failure, Combined ultrasound approach, Critical care, Impact assessment, Lung ultrasound

PDF  |  DOI: 10.5005/jp-journals-10071-23661  |  Open Access |  How to cite  | 

Abstract

Aims and objectives: To prospectively evaluate the impact of cardiopulmonary ultrasound (CPUS) on etiological diagnosis and treatment of critically ill acute respiratory failure (ARF) patients. Design: This is a prospective observational study conducted in a general intensive care unit (ICU) of a tertiary care center in India. Patients over 18 years old with presence of one of the objective criteria of ARF. Patients either consecutively admitted for ARF to ICU or already admitted to ICU for a different reason but later developed ARF during their hospital stay. Written informed consent in local language was obtained from next of kin. Interventions: All included patients underwent bedside CPUS including lung ultrasound (US) and transthoracic echocardiography plus targeted venous US by single investigator, blinded to clinical data. The US diagnosis of ARF etiology was shared with treating intensivist. Initial clinical diagnosis (ICD) and treatment plan (made before US) of each patient were compared with post-US clinical diagnosis and treatment plan. The changes in diagnosis and treatment up to 24 hours post-US were considered as impact of US. Results: Mean age of 108 included patients was 45.7 ± 20.4 years (standard deviation). The ICD was correct in 67.5% (73/108) cases, whereas the combined CPUS yielded correct etiological diagnosis in 88% (95/108) cases. Among the 108 included patients, etiological diagnosis of ARF was altered after CPUS in 40 (37%) patients, which included “diagnosis changed” in 18 (17%) and “diagnosis added” in 22 (20%). Treatment plan was changed in 39 (36%) patients after CPUS, which included surgical interventions in 17 (16%), changes in medical therapy in 12 (11%), and changes in ventilation strategy in 4 (3.5%) patients. Conclusion: This study demonstrates that use of combined US approach as an initial test in ARF, improves diagnostic accuracy for identification of underlying etiology, and frequently changes clinical diagnosis and/or treatment.

RESEARCH ARTICLE

Urvashi Miglani, Anjali P Pathak, Poonam Laul, Sushmita Sarangi, Shalini Gandhi, Sanjeev Miglani, Anish Laul

A Study of Clinical Profile and Fetomaternal Outcome of Obstetric Patients Admitted to Intensive Care Unit: A Prospective Hospital-based Study

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:6] [Pages No:1071 - 1076]

Keywords: Delays, Fetomaternal outcome, Intensive care unit, Intensive care unit mortality, Intensive care, Obstetric, Pregnancy

PDF  |  DOI: 10.5005/jp-journals-10071-23657  |  Open Access |  How to cite  | 

Abstract

Aims and objectives: To study clinical profile of obstetric patients admitted to intensive care unit (ICU) and to analyze the relation of demographic factors such as age, parity, literacy level, socioeconomic status, acute physiology and chronic health evaluation II (APACHE II) score, and level of delay with fetomaternal outcome. Design: It is a prospective cross-sectional observational study. Materials and methods: After admission to ICU a detailed history, analysis of basic demographic variables along with level of delay was done. APACHE II score was calculated. These parameters were correlated with fetomaternal outcome. The Chi-squared test was used to compare categorical variables. The one-way analysis of variance was used to compare the continuous variables among the strata with Tukey\'s post hoc test. Results: Incidence of obstetric ICU admission was 0.77%. Mean age was 26.03 years. Most common indication of ICU admission was obstetrical hemorrhage (37.1%) followed by hypertensive disorders of pregnancy (25.8%). Type I delay was the most common followed by type II delay. Mean APACHE II score was 14.77 ± 6.85. Observed mortality rate (30.6%) was found to be higher than predicted mortality rate (25%). APACHE II score was significantly high in the presence of level 1 (p = 0.003) and level 2 delays (p = 0.0001). Also, it was significantly increased with the duration of delays. Conclusion: Unbooked and referred cases had high incidence of ICU admission. The presence of delay was associated with poor outcome.

RESEARCH ARTICLE

Mitul P Chavda, Adrian Pakavakis, David Ernest

Does Obesity Influence the Outcome of the Patients Following a Cardiac Arrest?

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:4] [Pages No:1077 - 1080]

Keywords: Body mass index, Cardiac arrest, Intensive care, Obesity

PDF  |  DOI: 10.5005/jp-journals-10071-23665  |  Open Access |  How to cite  | 

Abstract

Background: Obesity is one of the major risk factors for cardiovascular and peripheral vascular diseases. However, the obesity paradox confers survival benefits in heart failure and cardiac surgery patients. Studies examining the outcomes of obese patients following cardiac arrest provided conflicting results. Objective: To study the association between obesity and outcome in patients following cardiac arrest. Materials and methods: We conducted a retrospective cohort study at a tertiary intensive care unit (ICU). Data were collected from medical records between January 1, 2018 and December 31, 2018, for all adult ICU patients who were admitted to our ICU following a cardiac arrest. Data collected included demographics, anthropometrics, and details of the cardiac arrest. The primary outcome was survival to hospital discharge. Secondary outcomes were duration of mechanical ventilation, ICU, and hospital length of stay. Results: A total of 126 patients were admitted to the ICU following a cardiac arrest during the study period, of whom 14 patients were excluded due to missing body mass index (BMI) data. Seventy-six patients were non-obese (BMI <30) and 36 patients were obese (BMI ≥30). There was no difference in survival to hospital discharge between obese and non-obese patients (52.8 vs 59.2%, p = 0.52, OR = 0.77, 95% CI 0.35–1.71). Moreover, there was no difference between obese and non-obese patients in ICU length of stay (81.50 vs 76.0 hours, p = 0.42), hospital length of stay (9 vs 10 days, p = 0.63), and duration of mechanical ventilation (55 vs 43 hours, p = 0.30). In the logistical regression analysis, BMI was not associated with improved survival (OR = 0.97, 95% CI 0.92–1.03, p = 0.23). Conclusion: For patients admitted to ICU following cardiac arrest, we could not show that obesity improves survival, length of stay, or duration of mechanical ventilation.

RESEARCH ARTICLE

Burnout and Resilience among Frontline Nurses during COVID-19 Pandemic: A Cross-sectional Study in the Emergency Department of a Tertiary Care Center, North India

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:8] [Pages No:1081 - 1088]

Keywords: Frontline nurses, Hardiness, Optimism, Resilience,Burnout, COVID-19 pandemic, Emergency nurses, Emotional exhaustion

PDF  |  DOI: 10.5005/jp-journals-10071-23667  |  Open Access |  How to cite  | 

Abstract

Background: The COVID-19 pandemic had a massive impact on healthcare systems, increasing the risks of psychological distress in health professionals. Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job and is defined by the three dimensions of emotional exhaustion, cynicism, and personal inefficacy. Methodology: A cross-sectional descriptive design was used to assess the burnout and resilience among frontline nurses in the emergency department of a tertiary care center in North India during COVID-19 pandemic. The sample consisted of 120 frontline nurses working in the emergency department, selected by a simple random sampling method. Data were collected using the Maslach burnout inventory-general survey and the Connor–Davidson Resilience Scale. Results: The nurses in the emergency during pandemic experienced a moderate-to-severe level of burnout in emotional exhaustion (29.13 ± 10.30) and depersonalization (12.90 ± 4.67) but mild-to-moderate level of burnout in reduced personal accomplishment (37.68 ± 5.17) and showed a moderate to a high level of resilience (77.77 ± 12.41). The two metrics of burnout viz., emotional exhaustion and personal inefficacy had a significantly negative correlation with resilience among the frontline nurses in the emergency (r = 0.25, p < 0.05 and r = 0.31, p < 0.01, respectively). A significant negative correlation has been identified between burnout and resilience that informs the role of resilience in alleviating burnout during this pandemic. Conclusion: Effective interventions for improving resilience are needed to relieve nurses’ burnout and workplace stressors. Also, the administration should ensure a healthy workplace and adopt a positive attitude and harmonious relationship with the frontline workers in the mitigation of the pandemic.

Pediatric Critical Care

Lakshmi Shobhavat, Rekha Solomon, Sudha Rao, Isha Bhagat, Sanjay Prabhu, Shakuntala Prabhu, Manoj Chandrakar, Minnie Bodhanwala

Multisystem Inflammatory Syndrome in Children: Clinical Features and Management—Intensive Care Experience from a Pediatric Public Hospital in Western India

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:6] [Pages No:1089 - 1094]

Keywords: PICU, PIMS-TS, Refractory shock, SARS-CoV2,Antibody, COVID-19, Intensive care, MIS-C

PDF  |  DOI: 10.5005/jp-journals-10071-23658  |  Open Access |  How to cite  | 

Abstract

Background: Multisystem inflammatory syndrome (MIS) associated with severe acute respiratory syndrome coronavirus (SARS-CoV-2) (MIS-C) in children is being increasingly reported across the world. Materials and methods: Children fulfilling the World Health Organization criteria of MIS-C needing pediatric intensive care unit between April 15 and July 26, 2020 were studied. Results: There were 21 patients with median age of 7 years [interquartile range (IQR) 1.9–12.1], of which 11 were females. SARS-CoV-2 real-time polymerase chain reaction positive in 8/21 and/or antibody positive 16/21. Fever was present in all patients, and gastrointestinal symptoms being second most frequent (16/21). One child had aplastic anemia, while the rest had no comorbidities. Nearly all presented with shock (n = 20/21) and 90% needed vasoactive drugs with a median Vasoactive Inotropic Score of 40 (IQR 20–95). Thirteen children needed ventilatory support and one needed peritoneal dialysis. Nine children had left ventricular dysfunction and five had dilatation of coronaries on echocardiography. Inflammatory markers C-reactive protein [98 mg/dL (IQR 89–119)], serum ferritin [710 mg/dL (IQR 422–1,609)], and serum interleukin-6 levels [215 ng/L (IQR 43–527)] were uniformly elevated. Eighteen children received pulse methyl-prednisolone, eleven intravenous immunoglobulins, and four tocilizumab. Eighteen children (86%) were discharged home while three died. Conclusion: In our cohort, MIS-C was seen in previously healthy children with fever, gastrointestinal symptoms, and shock. Early and aggressive management of shock and immune modulation with methyl-prednisolone and intravenous immunoglobulin were used.

Pediatric Critical Care

Deyanira Quiñónez-López, Daniela Patino-Hernandez, César A Zuluaga, Ángel A García, Oscar M Muñoz-Velandia

Comparison of Performance of the Pediatric Index of Mortality (PIM)-2 and PIM-3 Scores in the Pediatric Intensive Care Unit of a High Complexity Institution

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:8] [Pages No:1095 - 1102]

Keywords: Mortality, Pediatric intensive care unit, Pediatrics, Risk assessment

PDF  |  DOI: 10.5005/jp-journals-10071-23659  |  Open Access |  How to cite  | 

Abstract

Objective: To determine the performance of each of the available pediatric index of mortality (PIM) scores, by assessing the capability for discrimination and calibration in patients admitted to a pediatric intensive care unit in Bogotá. Design and setting: We designed a retrospective, observational cohort study, which included all patients aged between a month and 17 years and 364 days, admitted to the pediatric intensive care unit of a high complexity university hospital between April 1, 2016 and December 31, 2018. We analyzed the standardized mortality ratio, discrimination, calibration, and net reclassification index (NRI) for each model. Results: A total of 722 patients were included, the mortality rate was 3.74%, and for PIM-3, the ratio between expected and observed mortality was 0.66 [confidence interval (CI) 0.40–1.05] for PIM-2 and 1.00 (CI 0.59–1.68) for PIM-3. The Hosmer–Lemeshow (HL) test suggests inadequate calibration for PIM-2 (HL = 13.18, p = 0.11) and adequate calibration for PIM-3 (HL = 28.08, p < 0.01). The area under the diagnostic performance curves for PIM-2 and PIM-3 were 0.87 (95% CI 0.80–0.94) and 0.89 (95% CI 0.82–0.95), respectively. The NRI was −27.1%. PIM-3 classified survivors better than PIM-2, but inadequately classified nonsurvivors. Conclusion: Although both models show adequate discrimination ability, PIM-3 shows a better correlation between predicted risk score and observed mortality. Thus, it may be a useful tool for measuring the internal processes of intensive care units in Colombia and for making comparisons between groups of similar characteristics.

BRIEF COMMUNICATION

Radhapriya Yalamanchi, Bipin Chandra Dasari, Lavanya Narra, Abraham Oomman, Pramod Kumar, Rajeshwari Nayak, Refai Showkathali

Cardiac Intensive Care Unit Admissions during COVID-19 Pandemic—A Single Center Experience

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:3] [Pages No:1103 - 1105]

Keywords: Acute coronary syndrome, Pulmonary embolism, Acute decompensated heart failure, Admissions, Cardiac emergency, Cardiac intensive care unit, COVID-19, Lockdown, Pandemic

PDF  |  DOI: 10.5005/jp-journals-10071-23660  |  Open Access |  How to cite  | 

Abstract

Aim: The impact of coronavirus disease 2019 (COVID-19) lockdown on cardiac emergency admissions to hospitals has been reported previously. We aimed to study the emergency room (ER) admissions to cardiac intensive care unit (CICU) at a tertiary care center during that period and compare this with admissions during the same time frame in the previous years. Materials and methods: This is a retrospective observational study of patients admitted to the CICU during the pandemic period from March 22 to August 1 (inclusive) of 2020 and compared this with CICU admissions in the same time frame in the previous 2 years (2018 and 2019). Results: During the study period in 2020, a total of 216 patients (age 59 ± 14 years) were admitted via ER, which is a 33% and 30% decline in admissions compared to 2019 (n = 322, age 63 ± 12 years) and 2018 (n = 307, age 62 ± 13), respectively. The decline in admissions with the primary diagnosis of acute coronary syndrome (ACS), acute decompensated heart failure, arrhythmia, and other diagnoses during the study period in 2020 were 27%, 38%, 62%, and 59%, respectively, while there was a 50% increase in acute pulmonary embolism admission compared to the mean admission in 2018 and 2019. Weekly admission rates gradually increased from less than 10 per week in the first 3 weeks to >15 by eighth week of the study period in 2020, while the trend was same throughout the study period in the previous 2 years. The CICU mortality rate in 2020 study period was 4.6% compared to 3.9% in 2018 (p = 0.83) and 5.6% in 2019 (p = 0.70). The in-hospital mortality of these patients was also similar in all 3 years (6.5%, 7.8%, and 7.9% in 2018, 2019, and 2020, respectively; p = 0.61). Conclusion: Our study showed that CICU admissions during COVID-19 lockdown had declined compared to the previous years in a large tertiary center in India. Government and health organizations should educate the public early on during the pandemic about the consequences of ignoring other acute medical problems such as ACS, provide various measures for them to reach hospital early, and give reassurance with the best practices adopted in hospitals to avoid contracting the virus from the hospital environment.

Original Article

Nang S Choupoo, Saurabh K Das, Rudrashish Haldar, Hillol Sarkar, Resma Tewari, Sumit Ray

Evaluating the Efficacy and Safety of the Existing Repurposed Pharmacological Agents for Treating COVID-19: A Meta-analysis and Systematic Review of Clinical Trials

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:8] [Pages No:1106 - 1113]

Keywords: SARS-CoV-2,Chloroquine, Convalescent plasma, Coronavirus, COVID-19, Hydroxychloroquine, Lopinavir, Ritonavir

PDF  |  DOI: 10.5005/jp-journals-10071-23664  |  Open Access |  How to cite  | 

Abstract

Purpose: The present study systematically searched important medical databases, assessed the quality of available pieces of evidence, and performed a meta-analysis to test the efficacy of different therapeutic options currently available for treating COVID-19. Materials and methods: PubMed, CNKI, LILACS, Koreamed, WHO clinical trial registry, and medRxiv were searched since December 2019. Any observational or controlled study that tested the efficacy of any pharmacological intervention in COVID-19 patients either prospectively or retrospectively was included in the qualitative analysis. We assessed outcomes as dichotomous variables, i.e., a patient having a positive clinical outcome. Relative risks/risk ratios (RR) having a 95% confidence interval (CI) were derived. Studies conforming to inclusion criteria were pooled using the random-effect model. Results: Nine trials on hydroxychloroquine (HCQ), six studies on antiviral, four studies on monoclonal antibodies, two on corticosteroids, two on convalescent plasma (CP), and one on interferon-α2b were included in the systematic review. Meta-analysis containing six scientific trials and analyzing 522 patients revealed that the relative risk of positive clinical outcomes with HCQ treatment was 1.042 (95% CI, 0.884 to 1.874) with a number needed to treat (NNT) of 12.6. A meta-analysis of two studies analyzing 285 patients showed that the relative risk of clinical resolution with lopinavir and ritonavir combination was 1.152 (95% CI 0.709 to 1.87). Out of various antiviral used, the only remdesivir showed a positive result in a case series. Monoclonal antibodies showed decreased C-reactive protein, decreased oxygen, and ventilator requirements. A corticosteroid may increase mortality with increased dose. Two small case series on CP showed some promising results. Conclusion: The study showed slightly favorable results with HCQ, monoclonal antibodies, remdesivir, and CP in treating COVID-19 patients. Further research is warranted in establishing the efficacy of studied interventions. PROSPERO identifier: CRD42020180979

REVIEW ARTICLE

Amol T Kothekar

Basic Principles of Disinfection and Sterilization in Intensive Care and Anesthesia and Their Applications during COVID-19 Pandemic

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:11] [Pages No:1114 - 1124]

Keywords: Sterilization,Chemical methods of sterilization, COVID-19 pandemic, Disinfection, Physical methods of sterilization, Personal protective equipment, Resterilization, Reuse

PDF  |  DOI: 10.5005/jp-journals-10071-23562  |  Open Access |  How to cite  | 

Abstract

Understanding the concepts of disinfection, sterilization, cleaning and asepsis is of prime importance to prevent transmission of infection to patients and to protect healthcare workers (HCWs). Proper disinfection of surfaces after cleaning, an important consideration at all times, has assumed special significance during the current pandemic. The global shortage of disposable equipment such as personal protective equipment (PPE), specifically N95 masks and surgical 3 ply masks, and other items makes the HCWs vulnerable to transmission of infection while caring for these patients. Therefore, resterilization of such items has assumed equal importance. Cleaning, the first step in the process of sterilization, is of vital importance to reduce bioburden. The type of disinfection required depends on the nature of the equipment and its intended use. For example, critical items need high-level decontamination. In this narrative review, we elaborate on the methods of decontamination and sterilization. Many chemicals can be used for both sterilization and disinfection, and the difference lies in the concentration of the chemical and exposure time. We have also summarized strategies which can be used for resterilization of single-use items, in view of the shortages caused by the current pandemic.

REVIEW ARTICLE

Nithya C Achaiah, Sindhu B Subbarajasetty, Rajesh M Shetty

R0 and Re of COVID-19: Can We Predict When the Pandemic Outbreak will be Contained?

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:3] [Pages No:1125 - 1127]

Keywords: COVID-19, COVID-19 pandemic, R naught, R0, Re for COVID-19

PDF  |  DOI: 10.5005/jp-journals-10071-23649  |  Open Access |  How to cite  | 

Abstract

R0 (R naught) is the basic reproduction number, also known as basic reproduction ratio or rate which is an epidemiological metric used to measure the transmissibility of infectious agents. R0 is a derivative of the following variables—the duration of infectivity after the patient gets infected, the likelihood of transmission of infection per contact between a susceptible person and an infectious individual, and the contact rate. R0 is usually estimated retrospectively from serial epidemiological data or using theoretical mathematical models. Epidemiologists can calculate R0 using contact-tracing data, the most common method is to use cumulative incidence data. When mathematical models are used, R0 values are estimated using ordinary differential equations. R0 of COVID-19 as initially estimated by the World Health Organization (WHO) was between 1.4 and 2.4. The forecast is of critical importance as it will help the governments to have an estimate as well as strategize quickly to avoid any unfavorable condition.

CASE REPORT

Kai M Chan, Yu C Ng, Hing Y So

An Unusual Pattern of Dyssynchronous Breathing due to Expiratory Flow Obstruction in the Scavenging System Caused by the Weight of Water Condensate

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:4] [Pages No:1128 - 1131]

Keywords: Heated humidifier, Patient-ventilator dyssynchrony, Rebreathing, Scavenging system,Equipment failure, Expiratory flow obstruction

PDF  |  DOI: 10.5005/jp-journals-10071-23666  |  Open Access |  How to cite  | 

Abstract

Background: Patient-ventilator dyssynchrony is commonly due to patient pathophysiologic factors and imprecise ventilator settings. In unusual circumstances, such dyssynchrony can also be due to faults within the equipment preventing from its normal operation during assisted mechanical ventilation. Case description: We report a patient showing an unusual pattern of dyssynchronous breathing related to a blocked scavenging system caused by the failure of its rod valve to open. Collection of water condensate inside its reservoir bag leading to a weight drag and deformation of its shape was found to be the cause. Specifically, our patient manifested as failure to trigger with the development of high positive end-expiratory pressure (PEEP) and paradoxical pressure changes during pressure support ventilation. Conclusion: Water condensation distal to the ventilator exhaust gas outlet may not be immediately apparent. Clinicians should remain alert with patient-ventilator dyssynchrony, especially with an unusual pattern, as it may signify equipment faults, such as expiratory gas flow obstruction within the scavenging system.

CASE REPORT

Utpal Sarma, Vipul Mishra, Jyoti Goel, Sanjeev Yadav, Shreya Sharma, Rohit K Sherawat

COVID-19 Pneumonia with Delayed Viral Clearance in a Patient with Active Drug-resistant Pulmonary Tuberculosis

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:3] [Pages No:1132 - 1134]

Keywords: Delayed viral clearance, Pulmonary tuberculosis, Severe acute respiratory syndrome corona virus 2

PDF  |  DOI: 10.5005/jp-journals-10071-23662  |  Open Access |  How to cite  | 

Abstract

COVID pneumonia patient presents with fever, cough, and breathing difficulty. Many respiratory pathogens have such clinical presentations and pulmonary tuberculosis (PTB) is one of them, which is prevalent in the Indian subcontinent. Herein, we are presenting a case of dual infection with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) and drug-resistant PTB [likely multidrug resistance (MDR)] in a patient with chronic kidney disease (CKD) and type 2 diabetes mellitus, a clinical course further complicated by a prolonged viral clearance.

CASE REPORT

Surya Y Prakash, Munta Kartik, S. Rao, Yogesh R Harde

Challenges Faced in Managing an Adult Uncorrected Tetralogy of Fallot Patient with Pneumonia and Septic Shock in the Intensive Care Unit

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1135 - 1136]

Keywords: Fluid resuscitation, Sepsis, Uncorrected adult tetralogy of Fallot, Ventilation,Cyanotic congenital heart disease

PDF  |  DOI: 10.5005/jp-journals-10071-23648  |  Open Access |  How to cite  | 

Abstract

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. We present a 61-year-old uncorrected TOF patient who presented with sepsis and acute respiratory failure. At presentation, the patient had tachypnea, tachycardia, and oxygen saturation (SpO2) 64%. Chest X-ray (CXR) showed bilateral basal opacities. 2D echo revealed left ventricular dysfunction, infundibulum stenosis, pulmonary atresia, overriding of the aorta, and ventricular septal defect. A provisional diagnosis of community-acquired pneumonia with septic shock with uncorrected TOF was made. He received empirical antibiotics, ventilatory support, and supportive care. Ventilator weaning was done accepting an arbitrary baseline SpO2 of 70–75% and lactate-guided volume resuscitation led to a successful outcome. Coronary angiogram showed collaterals. This case report illustrates the dilemmas faced in treating a critically ill uncorrected TOF. To the best of our knowledge, this case could be the oldest surviving uncorrected TOF patient in the Indian population.

CASE REPORT

Vijetha Nagendra, Keta Deepak Thakkar, Ajay Hrishi, Unnikrishnan Prathapadas

A Rare Case of Rhinocerebral Mucormycosis Presenting as Garcin Syndrome and Acute Ischemic Stroke

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1137 - 1138]

Keywords: Acute ischemic stroke, Garcin syndrome, Multiorgan dysfunction, Rhinocerebral mucormycosis

PDF  |  DOI: 10.5005/jp-journals-10071-23643  |  Open Access |  How to cite  | 

Abstract

Background: Mucormycosis is a rare fungal infection affecting immunocompromised patients, with the rhinocerebral variant as the most common presentation.1 Garcin syndrome is the progressive involvement of the cranial nerves resulting in total unilateral paralysis of cranial nerves, absence of sensory or motor deficits, and not associated with features of raised intracranial pressure.2 We report a case of invasive rhinocerebral mucormycosis presenting as Garcin syndrome and acute ischemic stroke.

LETTER TO THE EDITOR

Soumya Sarkar, Puneet Khanna

Eyes Have It: From COVID-19 Perspective

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1139 - 1140]

Keywords: Adverse drug reactions, COVID-19, Emergency department, Eyecare, Pharmacovigilance, Trigger tool

PDF  |  DOI: 10.5005/jp-journals-10071-23644  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1141 - 1142]

Keywords: Diabetes mellitus,Coronavirus disease 2019, Diabetic ketoacidosis

PDF  |  DOI: 10.5005/jp-journals-10071-23595  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Parvathy R Nair

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1143 - 1144]

Keywords: Coronavirus, Mechanical ventilation, Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio

PDF  |  DOI: 10.5005/jp-journals-10071-23663  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Mohan P Patel, Vivek B Kute, Jitendra Goswami, Manish R Balwani

Hospitals may Become “Disease Hotspots” for COVID-19 amid Shortage of Personal Protective Equipment

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1145 - 1146]

Keywords: Coronavirus disease 2019, Occupational health, Prevention

PDF  |  DOI: 10.5005/jp-journals-10071-23645  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

R Natesh Prabu, Amol T Kothekar

Using Transthoracic Echocardiography to Predict Fluid Responsiveness after Passive Leg Raising Test: Caution Needed

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:2] [Pages No:1147 - 1148]

Keywords: Passive leg raising, Transthoracic echocardiography, Velocity-time integral

PDF  |  DOI: 10.5005/jp-journals-10071-23646  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Ahmed A El Nawawy, Passent M Farghaly, Hadir M Hassouna

Reply to “Using Transthoracic Echocardiography to Predict Fluid Responsiveness after Passive Leg Raising Test: Caution Needed”

[Year:2020] [Month:November] [Volume:24] [Number:11] [Pages:1] [Pages No:1149 - 1149]

PDF  |  DOI: 10.5005/jp-journals-10071-23668  |  Open Access |  How to cite  | 

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