Indian Journal of Critical Care Medicine

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2020 | December | Volume 24 | Issue 12

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Adrenomedullin in Sepsis: Finally, a Friend or an Enemy?

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:3] [Pages No:1151 - 1153]

   DOI: 10.5005/jp-journals-10071-23669  |  Open Access |  How to cite  | 


Adrenomedullin (ADM) is a 52 amino acid containing free circulating vasoactive peptide hormone found to be active in various pathophysiological states including sepsis. High ADM levels at admission have been correlated with vasopressor requirements, organ dysfunction, and mortality in sepsis patients. ADM stimulation results in vasodilation and loss of vascular resistance in humans resulting in hypotension with the potential for negative impact in septic shock. However, in vitro human and animal experiments have shown that ADM decreases hyperpermeability and capillary leak, thus having an endothelial barrier stabilizing effect during septic shock. Adrenomedullin thus appears to be a double-edged weapon. This editorial critically reviews the article by Daga et al. who evaluated serum ADM as a prognostic marker to review the gender-related difference in mortality pattern, and also the correlation of ADM level to APACHE II and SOFA scores. The role of adrenomedullin in sepsis and the potential developments in the future have been discussed concisely.



Thromboelastogram to Detect Hypercoagulability in Critically Ill COVID-19 Patients: Has Its Time Come?

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:2] [Pages No:1154 - 1155]

   DOI: 10.5005/jp-journals-10071-23678  |  Open Access |  How to cite  | 



Physiological Effects of N95 FFP and Personal Protective Equipment in Healthcare Workers in COVID ICU: A Prospective Cohort Study

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:2] [Pages No:1156 - 1157]

   DOI: 10.5005/jp-journals-10071-23690  |  Open Access |  How to cite  | 



Lalit Singh

Role of Prophylactic Noninvasive Ventilation in Patients at High Risk of Extubation Failure

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:3] [Pages No:1158 - 1160]

   DOI: 10.5005/jp-journals-10071-23692  |  Open Access |  How to cite  | 



Shilpushp J Bhosale

Crystal Gazing: Myth or Reality for Critical Care for COVID-19 Patients?

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:2] [Pages No:1161 - 1162]

   DOI: 10.5005/jp-journals-10071-23694  |  Open Access |  How to cite  | 


Efforts are continuing worldwide to understand the epidemiology, pathogenesis, and treatments for coronavirus disease-2019 (COVID-19). However, at the moment treatment remains supportive with oxygen therapy, steroids, repurposed antivirals, and prevention of multiple organ dysfunction by using immunomodulators. COVID-19 remains challenging since the disease spectrum varies from asymptomatic infection to severe acute respiratory distress syndrome (ARDS) with high fatality rates. It is thus necessary to predict clinical outcomes and risk-stratify patients for ensuring early intensive care unit (ICU) admissions. An important aspect is building surge capacity, managing and optimizing therapeutic and operational resources. So far, data have been scarce, particularly from India, to identify predictors of poor outcomes and mortality early in the course of the disease. Risk models need to be developed in larger patient cohorts and the models need to be simple and easy to employ at the onset of the disease process to predict the risk of severe disease, need for mechanical ventilation, ICU length of stay (LOS), and mortality.



Vrajesh Udani

Posterior Reversible Encephalopathy Syndrome: An Expanding Phenotype

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:2] [Pages No:1163 - 1164]

   DOI: 10.5005/jp-journals-10071-23696  |  Open Access |  How to cite  | 



Sepsis: An Evolutionary Perspective (Sepsis through the Eyes of a Microbe vs Clinical Sepsis through the Eyes of an Intensivist)

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:4] [Pages No:1165 - 1168]

   DOI: 10.5005/jp-journals-10071-23670  |  Open Access |  How to cite  | 


“Change of gene frequency in population” is the most fundamental concept of evolutionary biology. Human sepsis is a quantitative biological war between microbial genes and human genes, fought through their respective phenotypes. The prize of this war is an increase of gene frequency. Stating that sepsis is caused by a dysregulated host response is missing one half of the septic syndrome. Clinicians may gain a different perspective into the many intricacies of sepsis by conceptualizing it as an adaptive evolutionary process, rather than an abnormal physiological state. Clinicians may also get a deeper perspective by seeing it as a genotypic evolutionary process of natural selection rather than a phenotypic pathophysiological event.


Original Article

Arin Choudhury, Meena Singh, Deepa Kerketta Khurana, Saumya Sharma

Physiological Effects of N95 FFP and PPE in Healthcare Workers in COVID Intensive Care Unit: A Prospective Cohort Study

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1169 - 1173]

   DOI: 10.5005/jp-journals-10071-23671  |  Open Access |  How to cite  | 


Background: Healthcare workers (HCWs) are at increased risk of exposure to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Personal protective equipment (PPE) is mandated for HCWs. However, the physiological effects on the HCWs while working in the protective gear remains unexplored. This study aimed to assess the physiological effects of the prolonged use of PPE on HCWs. Materials and methods: Seventy-five HCWs, aged 18–50 years were enrolled in this prospective, observational, cohort study. The physiological variables [heart rate, oxygen saturation, and perfusion index (PI)] were recorded at the start of duty, 4 hours after wearing N95 filtering facepiece respirator (FFR), pre-donning, and post-doffing. The rating of perceived exertion (RPE) score and modified Borg scale for dyspnea was evaluated. The physiological variables were represented as the mean ± standard deviation. Wilcoxon signed-rank test was used to show any difference in RPE and modified Borg scale for dyspnea. A p value of <0.05 was considered significant. Results: There is a statistically significant difference in the physiological parameters post-doffing compared with baseline: Heart rate (p < 0.001); oxygen saturation (p < 0.001); PI (p < 0.001). RPE score showed increased discomfort with continuous use of N95 FFR. However, exertion increased only marginally. The major adverse effects noted with PPE use were fogging, headache, tiredness, difficulty in breathing, and mask soakage, with a resultant mean duration of donning to be 3.1 hours. Conclusion: The use of PPE can result in considerable changes in the physiological variables of healthy HCWs. The side effects may lead to excessive exhaustion and increased tiredness after prolonged shifts in the intensive care unit (ICU) while wearing PPE.


Original Article

Aakanksha Chawla Jain, Sudha Kansal, Raman Sardana, Roseleen K Bali, Sujoy Kar, Rajesh Chawla

A Retrospective Observational Study to Determine the Early Predictors of In-hospital Mortality at Admission with COVID-19

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:6] [Pages No:1174 - 1179]

   DOI: 10.5005/jp-journals-10071-23683  |  Open Access |  How to cite  | 


Introduction: Coronavirus disease-2019 (COVID-19) systemic illness caused by a novel coronavirus severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been spreading across the world. The objective of this study is to identify the clinical and laboratory variables as predictors of in-hospital death at the time of admission in a tertiary care hospital in India. Materials and methods: Demographic profile, clinical, and laboratory variables of 425 patients admitted from April to June 2020 with symptoms and laboratory-confirmed diagnosis through real-time polymerase chain reaction (RT-PCR) were studied. Descriptive statistics, an association of these variables, logistic regression, and CART models were developed to identify early predictors of in-hospital death. Results: Twenty-two patients (5.17%) had expired in course of their hospital stay. The median age [interquartile range (IQR)] of the patients admitted was 49 years (21–77 years). Gender distribution was male — 73.38% (mortality rate 5.83%) and female—26.62% (mortality rate 3.34%). The study shows higher association for age (>47 years) [odds ratio (OR) 4.52], male gender (OR 1.78), shortness of breath (OR 2.02), oxygen saturation <93% (OR 9.32), respiratory rate >24 (OR 5.31), comorbidities like diabetes (OR 2.70), hypertension (OR 2.12), and coronary artery disease (OR 3.18) toward overall mortality. The significant associations in laboratory variables include lymphopenia (<12%) (OR 8.74), C-reactive protein (CRP) (OR 1.99), ferritin (OR 3.18), and lactate dehydrogenase (LDH) (OR 3.37). Using this statistically significant 16 clinical and laboratory variables, the logistic regression model had an area under receiver operating characteristic (ROC) curve of 0.86 (train) and 0.75 (test). Conclusion: Age above 47 years, associated with comorbidities like hypertension and diabetes, with oxygen saturation below 93%, tachycardia, and deranged laboratory variables like lymphopenia and raised CRP, LDH, and ferritin are important predictors of in-hospital mortality.


Original Article

Govind Mawari, Shashank Singh, Tarun Kumar Mishra

Adrenomedullin and Its Possible Role in Improved Survival in Female Patients with Sepsis: A Study in the South East Asian Region

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1180 - 1184]

   DOI: 10.5005/jp-journals-10071-23672  |  Open Access |  How to cite  | 


Aims and objectives: Serum adrenomedullin (ADM) as a prognostic biomarker to study the gender-related differences in mortality pattern and its correlation with the sequential organ failure assessment (SOFA) and acute physiologic assessment and chronic health evaluation II (APACHE II) scores in patients of sepsis. Measurements and main results: Eighty patients of sepsis of which 36 were males and 44 were females, were taken in the study as per sepsis III guidelines. They were followed up for a period of 28 days. Serum ADM was measured on day 1 and day 5. The endpoint was mortality or survival at day 28 after admission. The death rate among males was higher, with 23 of the total 36 (63.89%) patients having died when compared with females in which 25 patients out of 44 (56.82%) had died. The observed mortality rates correlated well with average APACHE II scores. The average APACHE II score was slightly higher in males (29 ± 8.97) when compared with females (27.02 ± 8.69). Similarly, day 1 SOFA and mean SOFA values were higher in males (10.22 ± 5.36) and (10.73 ± 6.01) when compared with females (8.27 ± 4.79) and (8.89 ± 5.6), respectively. Males despite having higher mortality rates, higher APACHE II, SOFA, and mean SOFA values were still having less mean levels of serum ADM (454.40 ± 81.13 pg/mL) when compared with females (479.62 ± 126.97 pg/mL). Conclusion: Adrenomedullin is a protective neurohormone with antibacterial and anti-inflammatory properties. It is elevated in all patients with sepsis but the rise is more so in the female when compared with males. Higher ADM levels in females may suggest the protective effect of ADM as a part of the general protective neurohormonal stress response, which may explain the low death rate in females in sepsis.


Original Article

Ranupriya Jhalani, Satyanarayan Nagar, Abhay S Bhadauria, Kirtee Mishra

Outcome of Prophylactic Noninvasive Ventilation Following Planned Extubation in High-risk Patients: A Two-year Prospective Observational Study from a General Intensive Care Unit

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:8] [Pages No:1185 - 1192]

   DOI: 10.5005/jp-journals-10071-23673  |  Open Access |  How to cite  | 


Introduction: Prophylactic use of noninvasive ventilation (NIV) is recommended following extubation in patients at high risk of extubation failure. In a prospective cohort study, we examined the impact of prophylactic NIV in this subset of patients, potentially exploring the risk factors for extubation failure in them and the impact of extubation failure on organ function. We also explored the effect of fluid balance on extubation failure or success in this high-risk patient subgroup. Materials and methods: Consecutive adult patients (≥18 years) admitted in the mixed intensive care unit (ICU) of a tertiary care center, between January 1, 2018, and December 31, 2019, who passed a spontaneous breathing trial (SBT) following at least 12 hours of invasive mechanical ventilation and put on prophylactic NIV for being at a high risk of extubation failure, were prospectively followed throughout their hospital stay. Extubation failure was defined as developing respiratory failure within 72 hours postextubation requiring reintubation or still requiring NIV support at 72 hours postextubation. Results: A total of 85 patients were included in the study. 11.8% of patients had extubation failure at 72 hours with an overall reintubation rate of 10.5%. Higher age (p < 0.05), longer duration of invasive ventilation (p < 0.05), and higher sequential organ failure assessment (SOFA) score at extubation (p < 0.05) were identified as risk factors for extubation failure in univariate analysis. However, in the multivariate analysis, only a higher SOFA score remained statistically significant in forward logistic regression analysis (p < 0.05). We found a clear trend toward worsening organ function score in the extubation failure group in the first 72 hours postextubation, suggesting extubation failure as a risk factor for organ dysfunction. Cumulative fluid balance was higher both at extubation and in subsequent 3 days postextubation in the failure group, but the differences were not statistically significant. Conclusion: Higher age, longer duration of invasive ventilation, and higher baseline SOFA score at extubation remain risk factors for extubation failure even in this high-risk subset of patients on prophylactic NIV. Extubation failure is associated with the worsening of organ function. A trend toward higher cumulative fluid balance both at extubation and postextubation, suggests aggressive de-resuscitation as a potentially helpful strategy in preventing extubation failure.


Original Article

Shivali Arya, Ajay Bahl

Epidemiology of Trauma Patients Admitted to a Trauma Center in New Delhi, India

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1193 - 1197]

   DOI: 10.5005/jp-journals-10071-23605  |  Open Access |  How to cite  | 


Introduction: The rapid economic and automobile growth in India leads to a rapid increase in road traffic accidents (RTAs) and factors affecting it. This study evaluates the epidemiology of trauma patients’ reports to the major trauma center in New Delhi, India. Materials and methods: The 1,583 patients over 6 months reporting to the casualty of the trauma center attached to Lok Nayak Hospital, New Delhi were included in the study. The patients reporting to the outpatient department as follow-up visits were not included in the study. The data were collected with the help of a structured pro forma. Results: The data depicted the RTAs as the most common cause affecting adults between 20 years and 40 years. The study reports other risk factors like alcohol intoxication and motorcycle riders. Mostly, the patients present in a semiconscious and disoriented state requiring fluid resuscitation. Abrasions and bruises in the extremities stand out as the most common injury pattern. The fractures suffered were the most common injury suffered by the patients. Conclusion: Our study shows that RTAs and workplace injuries are the predominant causes of trauma affecting mostly the adults. This study defines the correlation of various parameters with causation and distribution of the trauma in the sample population. This study was performed to improve the understanding of the mode of trauma, severity of injuries, and outcome in our hospital, so that effective prevention and comprehensive management strategies could be made. Clinical significance: This study signifies the fundamental study for the occurrence, distribution, and prevention of trauma in the society. The acquisition of knowledge of different patterns of trauma patients along with other descriptive factors helps to understand the causation of this disease as well as development of preventive measures. This can form the basis of hospital and regional trauma management strategies.


Original Article

Meghna Haldar

Interrater Reliability of Four Neurological Scales for Patients Presenting to the Emergency Department

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:3] [Pages No:1198 - 1200]

   DOI: 10.5005/jp-journals-10071-23603  |  Open Access |  How to cite  | 


Background: Altered mental status (AMS) comprises a group of clinical symptoms rather than a specific diagnosis. A variety of neurological scales have been used to monitor these patients, including the Glasgow coma scale (GCS), AVPU (alert, responds to verbal stimuli, responds to painful stimuli, unresponsive) scale, and ACDU (alert, confused, drowsy, unresponsive) scale. The simplified motor scale (SMS) has been found to be a potential replacement for the GCS. In this study, we compare the interrater reliability of the GCS (individual components), AVPU, ACDU, and SMS to patients presenting to the ED with AMS. Materials and methods: This was a prospective observational study conducted in the emergency department of an urban tertiary-care hospital in New Delhi, India. Patients with AMS (traumatic and nontraumatic) presenting to the ED were assessed by two emergency physicians within 10 minutes of each other using the four neurological scales. Percentage agreement and kappa coefficient score were used to determine interrater reliability for SMS, individual components of GCS, AVPU, and ACDU. Results: The SMS had the best inter-rater percent agreement with 83.91% (95% CI 77.7–88.6%), followed by ACDU which was 76.44% (95% CI 69.0–81.6%), AVPU 75.29% (95% CI 67.8–80.6%), GCS Eye 74.14% (95% CI 66.6–79.6%), GCS Verbal 67.82% (95% CI 60.6–74.3%), and GCS Motor was 64.94% (95% CI 57.6–71.6%).The kappa coefficient for SMS was 0.75 (95% CI 0.67–0.83), followed by GCS Eye which was 0.63 (95% CI 0.54–0.72), AVPU 0.62 (95% CI 0.52–0.72), ACDU 0.60 (95% CI 0.49–0.71), and GCS Verbal 0.58 (0.49–0.66) and GCS Motor was 0.53 (95% CI 0.44–0.63). Conclusion: It can be said that SMS has the best interrater reliability in the ED and can be recommended for clinical use in the emergency departments for patients presenting with AMS.


Original Article

Sarah Williams, Kiran Batra, Manish Mohanka, Srinivas Bollineni, Vaidehi Kaza, Fernando Torres, Amit Banga

Insult to Injury: Development of Alveolar Hemorrhage after Initiation of Extracorporeal Membrane Oxygenation

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1201 - 1205]

   DOI: 10.5005/jp-journals-10071-23677  |  Open Access |  How to cite  | 


Background: Extracorporeal membrane oxygenation (ECMO) is associated with complications that are separate from the underlying diagnoses that require its use. One of the foremost complications of ECMO is a high incidence of bleeding, including alveolar hemorrhage (AH), which is believed to be due to both prophylactic anticoagulation and critical illness-induced systemic coagulopathy. However, akin to systemic inflammatory response syndrome after cardiopulmonary bypass, ECMO causes widespread systemic inflammation and acute lung injury, which likely further predisposes patients to AH. The burden of clinically significant AH among patients on ECMO for advanced lung disease remains unknown. Patients and methods: Charts of patients with advanced lung disease who required ECMO at a single institution were reviewed. The clinical course and variables of patients who developed AH and those who did not were compared. Results: This report describes five patients who developed AH after initiation of venovenous ECMO for refractory hypoxemia. Clinical and laboratory variables did not predict the development or the prognosis of AH. Two of these patients with refractory hypoxemia and AH were treated with pulse-dose corticosteroids, with a dramatic response in one case. Conclusion: The acute decompensation of the patients and response to corticosteroids suggest AH was mediated by a systemic inflammatory process, as opposed to coagulopathy alone. Judicious use of steroids may be considered among select patients who develop AH without symptoms of systemic coagulopathy after initiation of ECMO.


Original Article

Angela P Dariano, Cecilia FL Couto, Bibiana A Rubin, Gilberto Friedman

Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:7] [Pages No:1206 - 1212]

   DOI: 10.5005/jp-journals-10071-23674  |  Open Access |  How to cite  | 


Aim and objective: The aim and objective of this study is to test the effect of an optimized caloric supply in the first week of intensive care unit (ICU) stay in mechanically ventilated patients on the ability to perform their activities of daily living (ADL) in the long-term. Materials and methods: A prospective observational study comparing patients who achieved an adequate caloric target (≥80%) vs those whose target was inadequate (<80%). The primary outcome under study is the instrumental ADL (IADL) scale after 6 months of discharge. Results: Ninety-two patients were evaluated in the ICU and 50 were alive at 6 months. Follow-up was lost for 3 patients and 47 patients were evaluated at ICU and after 6 months. Thirty-four patients reached the energetic target and 13 did not reach it. There was no significant variation in IADL. Conclusion: The energy adequacy in the first week of hospitalization was achieved by most survivors; however, this conduct does not seem to have influenced the ability to perform ADL after 6 months of discharge.


Original Article

Abhay Singh, Nidhi Yaduvanshi

A Comparative In Vitro Sensitivity Study of “Ceftriaxone–Sulbactam–EDTA” and Various Antibiotics against Gram-negative Bacterial Isolates from Intensive Care Unit

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1213 - 1217]

   DOI: 10.5005/jp-journals-10071-23573  |  Open Access |  How to cite  | 


Introduction: A rapid increase in multidrug-resistant (MDR) strains is being seen across the globe especially in the Southeast Asian region, including India. Carbapenems and colistin form the mainstay of treatment against gram-negative pathogens, especially extended-spectrum beta-lactamase (ESBL)- and metallo-beta-lactamse (MBL)-producing isolates. However, due to increased resistance to carbapenems and toxicity of colistin, especially in intensive care units (ICUs), carbapenem-sparing antibiotics like ceftriaxone–sulbactam–EDTA (CSE) combination needs to be evaluated. Materials and methods: Bacterial isolates cultured from various clinical samples from all ICUs for a period of 9 months were evaluated. Bacterial identification was performed by matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) and antibiotic susceptibility testing were performed by disk diffusion and E test method. Antibiogram of various antibiotics was noted. Extended-spectrum beta-lactamase- and MBL-producing bacteria were identified by phenotypic methods. Antibiotic sensitivity results of CSE were compared with the comparator drugs like colistin, carbapenems, and tigecycline in Enterobacteriaceae, Acinetobacter spp., and Pseudomonas spp. along with ESBL and MBL producers. Results: A total of 2,760 samples of blood, cerebrospinal fluid (CSF), respiratory samples, tissue, and pus were collected from ICUs with maximum isolates from pus (37%) followed by respiratory samples (31%) and blood (27%). Escherichia coli and Klebsiella pneumoniae were the predominant gram-negative pathogens accounting for 56% of the isolates followed by Acinetobacter spp. (23%) and Pseudomonas spp. (15%). Extended-spectrum beta-lactamase screening was positive for 57% (1,069/1,877) isolates; whereas 43% (732/1,877) were MBL producers. According to the antibiotic susceptibility results, CSE was the most effective antibiotic showing 94% sensitivity for carbapenem-sensitive Enterobacteriaceae and 97% for carbapenem-resistant Acinetobacter and Pseudomonas spp. Among the other drugs, colistin was found to be the most effective showing almost 95% sensitivity in both the Enterobacteriaceae and non-Enterobacteriaceae group (both ESBL + OXA/NDM). Ceftriaxone–sulbactam–EDTA was also found much more effective (95%) as compared to Colistin (89%) toward ESBL- and MBL-producing strains of Enterobacteriaceae and non-Enterobacteriaceae group. Among the carbapenems, imipenem was the most effective drug against Enterobacteriaceae showing 34% sensitivity and ertapenem proved to be least effective. Conclusion: In our present study, CSE emerged as a potent antibacterial agent against MDR gram-negative infections; both for ESBL as well as MBL producers. Hence, in light of present study, we strongly recommend inclusion of CSE in routine sensitivity panel and may be used as a carbapenem- and colistin-sparing drug and a promising option against ESBL and MBL producers especially in ICU.



Vijay B Talla, Annapurna Chiluka

Thromboelastography Profile of Patients with COVID-19 Admitted to Intensive Care Unit: A Single-center Retrospective Study from India

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1218 - 1222]

   DOI: 10.5005/jp-journals-10071-23675  |  Open Access |  How to cite  | 


Coronavirus disease (COVID-19) causes thromboinflammation resulting in a high incidence of venous thromboembolism (VTE) events, which occur in significant numbers despite giving standard thromboprophylaxis with low-molecular-weight heparins. Various markers and tests have been evaluated and found to have a strong association with the worse prognosis of the disease. Common coagulation markers like D-dimer and fibrinogen give more of a static picture of coagulation, whereas viscoelastic tests like thromboelastography (TEG) provide an understanding of the coagulation function and help in better interpretation. We conducted a retrospective analysis of TEG values of 32 patients with COVID-19 admitted to the intensive care unit (ICU). Hypercoagulation as defined by TEG-coagulation index (CI) higher than the upper limit of the normal reference range (NRR) is found in 62.5% of the patients. There is also a clear representation of hypercoagulability as reflected by TEG-R, TEG-K, and TEG-LY30 values lower than or toward the lower limit of NRR, and TEG-ANGLE, TEG-MA, and TEG-CI values higher than or toward the upper limit of NRR which is more pronounced in severe forms of the disease, both in comparison to NRRs and other non-COVID ICU patients. Findings are similar to that of earlier studies in patients with COVID-19 except for the LY30, which is retained in the majority of our patients. Thromboelastography can be a useful tool to understand and screen for COVID-19-related hypercoagulability and may help predict VTE events. The potential of TEG to determine the optimal anticoagulant therapy needs to be evaluated in larger prospective studies.


Pediatric Critical Care

Chinmay K Behera, Mukesh K Jain, Reshmi Mishra, Pratap K Jena, Santosh K Dash, Ranjan K Sahoo

Clinico-radiological Profile of Posterior Reversible Encephalopathy Syndrome and Its Associated Risk Factors in PICU: A Single-center Experience from a Tertiary Care Hospital in Bhubaneswar, Odisha

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:7] [Pages No:1223 - 1229]

   DOI: 10.5005/jp-journals-10071-23680  |  Open Access |  How to cite  | 


Objective: Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiographic entity of heterogeneous etiologies having similar clinical and neuroimaging features. Pediatric data are sparse, making early diagnosis challenging, which needs a high index of suspicion. So, we conducted this study to evaluate clinico-radiological features, associated risk factors, etiology, and outcome in children. Materials and methods: This is a retrospective case series of patients, diagnosed as having PRES and followed up at a tertiary care hospital in Eastern India between September 2016 and December 2019. Results: Among 16 patients with a median age of 9.5 years [interquartile range (IQR) 8–13.75] and a male preponderance (75%), common underlying diseases were post-streptococcal glomerulonephritis (56.3%) and renovascular hypertension (12.5%). Acute elevation of blood pressure was found in all patients (n = 16). The neurological symptom was seizure (87.5%), mental changes (68.75%), headache (43.8%), vomiting (31.3%), and visual disturbances (31.3%). The most common triggering factor was hypertension (100%), use of mycophenolate mofetil and prednisolone (12.5%), and hemodialysis (12.5%). Anemia was present in 15 (93.4%) patients at the time of admission. All showed abnormal neuroimaging with 55% having atypical involvement. The most common site was the parietal-occipital cortex (88%), frontal and temporal lobe (44% cases each), and the cerebellum (13%). Clinical recovery was followed by a radiological resolution in all survived except in one, who developed visual impairment. Conclusion: Posterior reversible encephalopathy syndrome should be considered in the differential diagnosis of patients who present with acute neurological disturbances and underlying diseases such as renal disorders, vasculitis, malignancy, and use of immunosuppressant accompanied by hypertension. Early diagnosis and treatment of comorbid conditions are of paramount importance for the early reversal of the syndrome.


Pediatric Critical Care

Ritu , Urmila Jhamb

Dexamethasone in Prevention of Postextubation Stridor in Ventilated Children: A Randomized, Double-blinded, Placebo-controlled Trial

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:6] [Pages No:1230 - 1235]

   DOI: 10.5005/jp-journals-10071-23679  |  Open Access |  How to cite  | 


Background and aims: Postextubation stridor (PES) is a serious complication in ventilated patients which increases the length of stay in intensive care units (ICUs). We studied the efficacy of dexamethasone in prevention of PES in ventilated children. Materials and methods: A randomized, double–blinded, placebo-controlled trial was carried out in pediatric ICU. Children (2 months to 12 years) who underwent mechanical ventilation for 48 hours were randomized into two groups to receive either dexamethasone at 0.15 mg/kg/dose or normal saline for 6 doses with first dose given 6–12 hours prior to planned extubation. Patients were hourly monitored for vital signs and appearance of stridor using Westley croup score (WCS) within 72 hours after extubation. Whenever the score exceeded 4, nebulized adrenaline (1:1,000 at 0.5 mL/kg/dose) was given. The primary outcome was occurrence of PES. Results: Dexamethasone group comprised of 42 children while placebo group had 38 children. Baseline characteristics of two groups were similar. Overall PES occurred in 48.7% patients, 42.8% (18/42) in dexamethasone group, and 55.2% (21/38) in placebo group [p = 0.26, odds ratio (OR) 95% confidence interval (CI) = 0.60 (0.25–1.47)]. WCS >4 was present in 28.5% (12/42) of dexamethasone group vs 47.3% (18/38) of placebo group [p = 0.08, OR (95% CI) = 0.37 (0.12–1.06)]. There was no difference in reintubation rates in two groups [p = 0.9, OR (95% CI) = 1.06 (0.32–3.51)]. Conclusion: We found no beneficial role of the studied dose of dexamethasone (0.15 mg/kg) over placebo on the incidence of PES.



Gunjan Chanchalani

Awake Proning: Current Evidence and Practical Considerations

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:6] [Pages No:1236 - 1241]

   DOI: 10.5005/jp-journals-10071-23684  |  Open Access |  How to cite  | 


Prone positioning has been shown to improve oxygenation for decades. However, proning in awake, non-intubated patients gained acceptance in the last few months since the onset of coronavirus (COVID-19) pandemic. To overcome the shortage of ventilators, to decrease the overwhelming burden on intensive care beds in the pandemic era, and also as invasive ventilation was associated with poor outcomes, proning of awake, spontaneously breathing patients gathered momentum. Being an intervention with minimal risk and requiring minimum assistance, it is now a globally accepted therapy to improve oxygenation in acute hypoxemic respiratory failure in COVID-19 patients. We thus reviewed the literature of awake proning in non-intubated patients and described a safe protocol to practice the same.



Vikas Agarwal

Neutrophil CD64 a Diagnostic and Prognostic Marker of Sepsis in Adult Critically Ill Patients: A Brief Review

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:9] [Pages No:1242 - 1250]

   DOI: 10.5005/jp-journals-10071-23558  |  Open Access |  How to cite  | 


Introduction: Sepsis is a life-threatening organ dysfunction with increased incidence of morbidity and mortality. Early diagnosis and prompt therapeutic intervention is the cornerstone of sepsis care. Biomarkers play an important role in sepsis having both diagnostic and prognostic implications. Neutrophil CD64 (nCD64) is a useful candidate biomarker for sepsis. Neutrophil CD64 also known as Fc receptor 1 (FcR1), is a high-affinity receptor present on neutrophils for Fc part of immunoglobulin-G (IgG) heavy chain. Its expression gets strongly upregulated in response to proinflammatory cytokines of infection within 4–6 hours. Neutrophil CD64 integrates function involving both innate and adaptive immune responses. The aim of this review is to present literature about nCD64 as a diagnostic and prognostic marker in patients with sepsis/septic shock. Background: The authors searched articles over 13 years, i.e., from 2006 to 2019. They included articles written in English only and further reviewed the reference list of selected articles to obtain potentially relevant articles. Reviews, letters, commentaries, correspondences, case reports, conference abstracts, expert opinions, editorials, and animal experiments were excluded. Articles involving pediatric patients (≤18 years) were also excluded. Review results: Several studies have indicated that nCD64 is a highly sensitive and specific marker for the diagnosis of sepsis. Various combinations of biomarkers have been used with nCD64 for a better diagnostic value. Neutrophil CD64 as a prognostic marker in critically ill patients needs to be explored more. Most of the existing literatures have highlighted its prognostic utility based on single value at enrolment. There are limited literatures on prognostic implications of serial trend and kinetics of nCD64. Conclusion: Neutrophil CD64 is a useful diagnostic and prognostic marker of sepsis in critically ill patients. Additional studies are needed on nCD64 in sepsis based on sepsis-3 criteria. Further trials with large sample size are needed to establish prognostic implications of serial nCD64 trend.



Sanjeev Arya, Bhuwan Tiwari, Shantanu Belwal, Sanjay Saxena

What Every Intensivist should Know about Impairment of Cardiac Function and Arrhythmias in Liver Disease Patients: A Review

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1251 - 1255]

   DOI: 10.5005/jp-journals-10071-23695  |  Open Access |  How to cite  | 


Objectives: Impairment of cardiac function and arrhythmias often coexist in patients with liver diseases. Many studies have proved this coexistence and put forward various theories toward its pathophysiology. This narrative review tries to find the answers with supporting evidence on five main questions: • Do high serum bilirubin levels have a strong association with cardiac arrhythmias? • Can corrected QT interval (QTc) be relied upon for predicting a risk factor toward imminent arrhythmias? • Is there an association between QTc prolongation and mortality? • Are high serum bilirubin and cardiac dysfunction closely associated? • What is the probable pathophysiology behind this association? Materials and methods: Clinical evidence was obtained by using search engines, namely, Cochrane Library, PubMed, and Google Scholar. Studies published in journals in the English language, between January 1969 and December 2019, which mentioned the relationship between cardiac arrhythmia and liver disease, were included. We used the keywords: jaundice, bilirubin, arrhythmia, ECG, QTc interval, QT dispersion, liver, and cirrhosis. Relevant animal or human studies answering the five main questions were extracted and reviewed. Conclusion: The evidence included in our review sheds light on the fact that approximately 50% of liver cirrhosis cases develop cirrhotic cardiomyopathy (CC) and there has been an association between liver abnormalities and cardiac pathology. The present review also supports that there exists a strong association between high levels of serum bilirubin levels and cardiac arrhythmias, QTc value can be relied upon as a risk factor for predicting imminent arrhythmias, and that it is associated with mortality. Its basic pathophysiology can be explained by the potential action of bile acids in prolonging the QT interval. It also causes cardiac hypertrophy and apoptosis of cardiomyocytes leading to cardiac dysfunction.



Amin Al Haj Moussa, Ata Ur Rehman Maaz, Nesreen Faqih, Manu Sundaram

Critically Ill Pediatric Oncology Patients: What the Intensivist Needs to Know? Pediatric Critical Care Medicine

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:8] [Pages No:1256 - 1263]

   DOI: 10.5005/jp-journals-10071-23693  |  Open Access |  How to cite  | 


Cancer is an evolving cause of morbidity and mortality in children worldwide. In recent decades, there has been a significant increase in the survival of children with cancer, after applying new methods and treatment protocols in practice. However, the complexity of the disease itself, as well as the intensity and toxicity of treatment is such that many children require admission to the pediatric intensive care unit (PICU) which should be well equipped and led by personnel who have adequate training and expertise to provide optimum care to these complex patients. Most oncology patients who require PICU admission categorized into oncological emergencies, and/or decompensation from treatment and its side effects. In this study, we provide a summary of the essential and most recent evidence-based recommendations from published reviews and articles to aid PICU physicians and to ensure the best treatment and outcome possible for the children with such disease.



Nilanchal Chakraborty, Hrishikesh Kumar

Intravenous Immunoglobulin may Reverse Multisystem Inflammation in COVID-19 Pneumonitis and Guillain–Barré Syndrome

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:5] [Pages No:1264 - 1268]

   DOI: 10.5005/jp-journals-10071-23688  |  Open Access |  How to cite  | 


Introduction: The novel coronavirus disease 2019 (COVID-19) poses an unprecedented crisis for public health, although several potential therapies have been provisionally applied but a unified consensus is yet to be achieved. Case description: A 75-year-old man, COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) positive on admission, presented with acute onset progressively ascending weakness of all four limbs. Nerve conduction velocity (NCV) study suggested acute demyelinating and axonal type of motor polyradiculoneuropathy. Hence, Guillain–Barré syndrome (GBS) related to COVID-19 infection was considered. His respiratory status worsened to severe acute respiratory distress syndrome (ARDS) on the second week of illness. He was started on intravenous immunoglobulin (IVIg) dosed over 5 days. His ventilator support started to improve after the 10th day of admission. His inflammatory markers started to improve, ventilator supports were weaned down and he was extubated on the 17th day of illness. Intravenous immunoglobulin is rich in viral immunoglobulin G (IgG), competitively binds Fcy receptor, preventing SARS-CoV-2 spike protein from attaching to the angiotensin-converting enzyme 2 (ACE 2) receptor, inhibiting viral entry into the cell. Clinical significance: Intravenous immunoglobulin can inhibit the production of inflammatory factors and decrease inflammatory injury, multisystem inflammation (MSI) in SARS-CoV-2. Conclusion: While the use of hyperimmune globulin requires a tedious job of collection from convalescent patients with verified and adequate titers, the use of IVIg could be an easier option to modulate the immune storm and faster recovery in SARS-CoV-2.



Yashaswini Kenchappa, Shalini Hegde, Maria Bukelo

Caught Off Guard with COVID-19 Bowel Gangrene: A Case Report

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:3] [Pages No:1269 - 1271]

   DOI: 10.5005/jp-journals-10071-23681  |  Open Access |  How to cite  | 


Background: Isolated and predominant gastrointestinal presentation in coronavirus disease 2019 (COVID-19) is reported less often. With evolving evidence that gastrointestinal tract can be a portal of entry, multiplication, primary site of affliction and symptomatic manifestation, and source of infectivity through prolonged fecal shedding of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), it is essential that isolated gastrointestinal symptoms can also be a mode of presentation of this novel virus and illness. Case description: The index case is a 10-year-old female child who presented with acute onset abdominal pain. Emergency surgery showed extensive gangrenous small bowel. The small bowel had herniated into a transmesenteric defect near the mid-ileum and was obstructed. Reverse-transcription polymerase chain reaction for SARS-CoV2 sent as preoperative work-up turned positive. The histopathology showed platelet aggregate thrombus in the venules with patent adjacent arterioles. Conclusion: This is probably the first reported case of COVID-19-related bowel gangrene.



Sonam Agrawal, Prateek K Panda, Indar K Sharawat, Nowneet K Bhat

Pulmonary Embolism in Children: A Case Series

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:4] [Pages No:1272 - 1275]

   DOI: 10.5005/jp-journals-10071-23682  |  Open Access |  How to cite  | 


Background: Pulmonary embolism (PE) is a life-threatening event with a mortality of ~10%. It is relatively uncommon in children and literature regarding the condition is sparse. In adults, the classical clinical presentation is with pleuritic chest pain, hemoptysis, and dyspnea, whereas in children, the presentation is often nonspecific. Materials and methods: Clinical features, risk factors, and outcome of children with PE presenting to our unit between December, 19 and March, 2020 were recorded. Results: Four children [mean age: 10 (6–16) years, 3 females], all presenting with tachycardia and dyspnea were diagnosed with PE. Different risk factors such as deep vein thrombosis, nephrotic syndrome, softtissue infection, and infective endocarditis (IE) were identified in all patients. One child died while others responded to anticoagulation. Conclusion: We aim to highlight the importance of timely recognition of PE in children with known risk factors for the same. Early recognition and timely treatment of PE are critical to save lives.



COVID-19-associated Severe Multisystem Inflammatory Syndrome in Children with Encephalopathy and Neuropathy in an Adolescent Girl with the Successful Outcome: An Unusual Presentation

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:3] [Pages No:1276 - 1278]

   DOI: 10.5005/jp-journals-10071-23685  |  Open Access |  How to cite  | 


Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the coronavirus disease 2019 (COVID-19) pandemic. This hyperinflammatory syndrome usually presents with multiorgan dysfunction, predominantly affecting cardiovascular, mucocutaneous, and gastrointestinal systems. However, few children have mild neurological symptoms at admission. Till now, severe neurological manifestations as a part of this spectrum have hardly been reported. This case report describes an adolescent girl with severe MIS-C who presented with multiorgan failure and suffered dual neurological insult, involving both the central and peripheral nervous systems.



Ravikumar Subbarayan, Santhosh Anand, Sathishkumar Selvaraj

Emergency Pancreaticoduodenectomy for Exsanguinating Ampullary Malignancy

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:2] [Pages No:1279 - 1280]

   DOI: 10.5005/jp-journals-10071-23676  |  Open Access |  How to cite  | 



Sourav Burman, Pradeep B Sharma, Mayank Tyagi

Transport Circuit during COVID-19 Crisis: A Simple Modification of the Bain's Circuit for Safety of Healthcare Workers

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:3] [Pages No:1281 - 1283]

   DOI: 10.5005/jp-journals-10071-23686  |  Open Access |  How to cite  | 



Saba Siddiqui

Selecting Journal for Publication in the Era of “Haste Predatory Journals and COVID-19”

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:2] [Pages No:1284 - 1285]

   DOI: 10.5005/jp-journals-10071-23687  |  Open Access |  How to cite  | 



Georgios Papathanakos, Ioannis Andrianopoulos, Athanasios Papathanasiou, Dimitra Lepida, Vasilios Koulouras

Adapting in the COVID-19 Era

[Year:2020] [Month:December] [Volume:24] [Number:12] [Pages:2] [Pages No:1286 - 1287]

   DOI: 10.5005/jp-journals-10071-23689  |  Open Access |  How to cite  | 


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