The number of cases in COVID-19 pandemic is rising rapidly. There has not been a single effective proven medication for COVID-19 disease. Highest mortality has been reported among subjects who develop acute respiratory disease (ARDS). The histopathological analysis of lung specimens has given rise to theories that propose the major role of cytokine release syndrome in the development of ARDS. IL-6 has often been found to be raised in subjects having severe disease. Tocilizumab is a selective inhibitor of the IL-6 pathway and has been approved for various rheumatological diseases. Its use in COVID-19 has been evaluated following the success of other immunosuppressive drugs like steroids. The data in support of against its use in COVID19 are lacking. Similarly, the risk of early- and late-onset infections after tocilizumab in COVID-19 remains unknown. The study by Nasa et al. is a valuable addition to the evidence concerning its use. Despite multiple articles, its safety and efficacy in COVID-19 remain unknown. Caution must be used about its timing and role of IL-6 levels for disease monitoring.
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Siddiqui SS. Serum Cystatin C in Early Identification of Acute Kidney Injury in Acute Pancreatitis: Is It an Old Wine in a New Bottle?. Indian J Crit Care Med 2020; 24 (9):744-745.
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Prabu NR, Patil VP. Is Immature Granulocyte Count a Potential Prognostic Marker for Upper Gastrointestinal Tract Bleeding? A New Road to Explore. Indian J Crit Care Med 2020; 24 (9):750-752.
Incorporating the toxidrome-specific prognostic systems into the daily emergency department practice might become a standard of care in low- and middle-income countries. The PGI score is appealing because it is quick and easy, it accurately identifies high-risk patients at in-hospital mortality, and it shows promise in predicting those at low risk. Although further validation of the PGI score is required in more extensive studies, it can help direct appropriate resources to those most likely to benefit and stratify patients for testing novel clinical interventions.
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Kakkar G, Sapra H, Chugh C, Nagaiyan S. Practice Implications for Acute Ischemic Stroke during the COVID-19 Pandemic for the Indian Scenario: Realistic and Achievable Recommendations by the Society of Neurocritical Care (SNCC), India. Indian J Crit Care Med 2020; 24 (9):757-762.
COVID-19 disease caused by the SARS coronavirus has caused significant morbidity and mortality around the world ever since it was first declared as a pandemic by the World Health Organization (WHO) in March 2020. Acute neurological manifestations of this disease have also started emerging and being recognized around the world and acute ischemic stroke (AIS) or thrombotic stroke is becoming one of the major neurological illnesses related to COVID-19. The management of AIS is time-critical and major advances in its management over the recent years, such as bridging thrombolysis and mechanical thrombectomy (MT), are multidisciplinary activities requiring robust coordination and management in the acute setting. All these advances are severely challenged in the COVID-19 pandemic where severe pressures exist on the clinical resources and logistics required to deliver an effective stroke service. This is further compromised by legal and preventive measures during this pandemic like local lockdowns. Reporting of minor or initial symptoms has also been compromised due to the fear of approaching healthcare settings which are perceived as high-risk zones to catch the infection. The purpose of this document is to highlight these challenges and provide a guiding framework for the management of AIS under three principles: (a) Delivering an effective service, (b) Preventing infections within the healthcare setting, and (c) Optimizing resource utilization.
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Munjal M, Ahmed SM, Garg R, Das S, Chatterjee N, Mittal K, Javeri Y, Saxena S, Khunteta S. The Transport Medicine Society Consensus Guidelines for the Transport of Suspected or Confirmed COVID-19 Patients. Indian J Crit Care Med 2020; 24 (9):763-770.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) and has been declared as a pandemic. COVID-19 patients may require transport for diagnostic or therapeutic purposes intra- or interhospital or transport from an outside hospital to a healthcare facility. Transport of critically ill or infectious patients is always challenging and involves the integration of various tasks and manpower. The adverse events have been attributed to various factors such as a multidisciplinary team and lack of appropriate communication among team members, absence of equipment, or failure during transport, apart from physiological alteration inherent to the disease of the patient. The transport of COVID-19 patients carries an additional risk of not only the disease itself but also due to the risk of its transmission to the transport team. The human-to-human transmission of the virus can occur via respiratory droplets. So, the person involved in the transport of such patients shall be at risk and warrants appropriate steps for their safety. Appropriate planning by a well-trained transport team is an essence for the safe transport of the suspected or confirmed COVID-19 patients. The Transport Medicine Society guidelines present consensus guidelines for the safe transport of COVID-19 patients.
Disclaimer: These consensus guidelines are applicable for the safe transport of suspected or confirmed COVID-19 adult patients. These recommendations should be used in conjunction with medical management guidelines and advisories related to COVID-19. These recommendations should be adapted to the local policies prevalent at the workplace and also per agreement among the hospitals for transport (agreement between referring and receiving facilities). With the emergence of new scientific evidence, these guidelines may require modification.
Pavan K Shrivastava,
Mohamed A Soliman,
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Upadhyay S, Bagadia S, Polumuru S, Shrivastava PK, Sankar R, Vijayan L, Soliman MA, Patidar S. Tocilizumab Use in COVID-19 Cytokine-release Syndrome: Retrospective Study of Two Centers. Indian J Crit Care Med 2020; 24 (9):771-776.
Introduction: Cytokine-release syndrome (CRS) in COVID-19 patients can cause multiorgan failure and higher mortality. We used a structured protocol based on clinical, biochemical, and interleukin 6 (IL-6) criteria for the identification of the subset of patients with CRS and analyzed the use of tocilizumab for their treatment.
Materials and methods: We did a retrospective case-control analysis of all COVID-19 patients between 15 March and 15 May 2020 with severe to critical disease in ICU. They were evaluated for CRS, and 22 patients who met the criterion were given tocilizumab. The primary objective was to evaluate the effect of tocilizumab on escalation of respiratory support and ICU mortality. The secondary objectives were ICU length of stay, trends of inflammatory markers, and any adverse effects.
Results: The need for escalation of respiratory support was significantly lower in the tocilizumab group as compared to standard treatment (p = 0.001). The mortality at day 7 and 28 was also significantly lower in the tocilizumab group (p = 0.007 and p = 0.001 respectively). There was a significant reduction in C-reactive protein (CRP) who received tocilizumab (p = 0.033).
Conclusion: In our limited number of patients, timely intervention with tocilizumab in COVID-19 patients with CRS significantly improved overall ICU outcome by reducing the need for invasive ventilation and mortality.
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Patel M, Shyam R, Bharti H, Sachan R, Gupta K, Parihar A. Evaluation of Serum Cystatin C as an Early Biomarker of Acute Kidney Injury in Patients with Acute Pancreatitis. Indian J Crit Care Med 2020; 24 (9):777-782.
Introduction: Acute pancreatitis (AP) is an inflammatory process of pancreas with varying degree of involvement of regional tissues. The aim of this study was to investigate the potential use of serum cystatin C (Cys-C) for the early and accurate diagnosis of acute kidney injury (AKI) in patients of AP.
Materials and methods: This was a prospective study conducted in 1 year. Total of 215 cases of AP fulfilling the inclusion criteria were enrolled in this study. Patients suffering from chronic pancreatitis, neoplasm, chronic liver disease, and chronic kidney disease were excluded from the study. Diagnosis of AP was based on the Atlanta classification 2012. All patients were classified into a non-AKI group (n = 152) and an AKI group (n = 38) according to the dynamic changes in serum creatinine levels. Serum Cys-C was measured by particle-enhanced immune nephelometric assay.
Results: By univariate logistic regression analysis, body mass index (BMI) (OR = 1.44, 95% CI: 1.23–1.68; p < 0.001), blood urea (OR = 1.15, 95% CI: 1.06–1.23; p < 0.001), Cys-C (OR = 1.04, 95% CI: 1.01–1.07; p < 0.05), serum calcium (OR = 0.59, 95% CI: 0.41–0.86; p < 0.05), and serum lactate dehydrogenase (LDH) (OR = 1.001, 95% CI: 1.0–1.001; p < 0.05) were the significant indicators for AKI in patients with AP. Using multivariate logistic regression analysis, urinary albumin and Cys-C were independent and significant indicators of AKI in patients with AP (OR = 1.026, 95% CI: 1.01–1.07; p < 0.01). Receiver operating characteristic (ROC) curve of serum Cys-C, for AKI in patient with AP could be identified with a sensitivity of 92.06% at specificity of 96.0% [area under the curve (AUC) = 0.96, 95% CI: 0.92–0.98] by baseline serum Cys-C (cutoff value = >32.32 mg/L).
Conclusion: Increase of baseline serum Cys-C was associated with AKI in patients with AP.
Rammohan S Bhat,
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Bhardwaj V, Vikneswaran G, Rola P, Raju S, Bhat RS, Jayakumar A, Alva A. Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study. Indian J Crit Care Med 2020; 24 (9):783-789.
Background: Fluid overload is deleterious in critically ill patients. It can lead to venous congestion, thereby increasing venous pressure, theoretically increasing the backpressure, and thereby reducing renal blood flow. Venous congestion thus can be an important contributor to acute kidney injury (AKI), with no validated tools to objectively identify venous congestion bedside.
Materials and methods: Patients above 18 years admitted in ICU with a provisional diagnosis of cardiorenal syndrome were included in the study. Those with inadequate window, inferior vena cava (IVC) thrombus, and known case of cirrhosis with portal hypertension were excluded from the study. Patients underwent ultrasound examination with serial determination till AKI resolved or patient is initiated on dialysis. Venous excess ultrasound score (VEXUS) comprising inferior vena cava, hepatic vein waveform, and portal vein pulsatility was assessed.
Results: Thirty patients were enrolled for the study. The mean age was 59.53 ± 16.47 with 21 (70%) males. Mean sequential organ failure assessment (SOFA) score was 5.03 ± 1.97. Fourteen patients (46.7%) were in AKI stage 1, while eight patients (26.7%) were in AKI stage 2 and stage 3 each. Twenty patients (66.7%) had VEXUS grade III. Resolution of AKI injury showed significant correlation with improvement in VEXUS grade (p value 0.003). Similarly, there was significant association between changes in VEXUS grade and fluid balance (p value 0.006). There was no correlation between central venous pressure (CVP), left ventricular function, and right ventricular function with change in VEXUS grade.
Conclusion: The study shows that a combined grading of IVC, hepatic vein, and portal vein might reliably demonstrate venous congestion and aid in the clinical decision to perform fluid removal.
Introduction: Aluminum phosphide (AlP) ingestion for self-harm is associated with a high case-fatality rate (CFR) in low- and middle-income countries. A reliable and accurate prognostic scoring tool is required for appropriate triaging, to guide clinical decision-making, and to evaluate the efficacy of therapeutic interventions for the patients with AlP toxicity.
Materials and methods: We performed a prospective cohort study in a tertiary care hospital in north India in patients aged 15 years and over with acute AlP poisoning, investigating the parameters associated with CFR, and developing a reliable and simple prediction score.
Results: The CFR was 51% in this cohort of 105 patients. Three parameters—pH <7.25, score on Glasgow coma scale (GCS) <13, and systolic blood pressure (SBP) <87 mm Hg were most robust predictors of CFR (odds ratio; 12.614, 18.621, and 17.600, respectively; area under the receiver operating characteristic curve—0.808, 0.796, and 0.776, respectively). Based on these parameters (with 1 point to each), a prognostic score was developed, ranging from 0 to 3 points. A total score of 3 had a 98.2% specificity and a positive predictive value of 96.4%, whereas a score ≤1 had a 100% sensitivity and 100% negative predictive value.
Conclusion: A scoring system based on low pH (P), low GCS score (G), and impaired or low SBP (I) (“PGI” score) may provide a simplified predictive model for mortality in AlP poisoning.
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Bedel C, Korkut M, Avcı A, Uzun A. Immature Granulocyte Count and Percentage as New Predictors of Mortality in Patients with Upper Gastrointestinal Bleeding. Indian J Crit Care Med 2020; 24 (9):794-798.
Aims: Early identification of patients at risk of adverse outcomes may increase the survival rates in patients with upper gastrointestinal bleeding (UGIB), but this can be difficult to predict in emergencies. The aim of the study is to evaluate immature granulocyte (IG), which can be obtained from simple hemogram tests in patients with UGIB, in terms of clinical use and as a mortality marker.
Materials and methods: The patients diagnosed with UGIB between March 1, 2019, and September 30, 2019, were evaluated retrospectively. Demographic characteristics, causes of hemorrhage, clinical presentations, hemogram, and biochemistry values at ED admission and 30-day mortality status of the patients were examined. We divided the patients into groups according to their mortality status, and the groups were compared among themselves in terms of parameters.
Results: A total of 213 patients who met the inclusion criteria were included in the study. Of these patients, 139 (65.3%) were male and the mean age was 65.05 ± 16.7 years. Fifteen (7%) of them were in the nonsurvival group, while 198 (93%) were in the survival group. The efficacy of both the IG count (IGC) and IG% in predicting mortality was statistically significant (p = 0.002, p = 0.008, respectively). The sensitivity and specificity for the IGC were found as 60% and 84.4; for the IG%, they were found as 66.7% and 75.7%, respectively.
Conclusion: IGC and IG% are independent risk factors for the 30-day mortality status. These measurements are obtained from simple hemogram tests and may be useful for the evaluation of mortality in patients with UGIB.
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Zirpe K, Seta B, Gholap S, Aurangabadi K, Deshmukh AM, Wankhede P, Suryawanshi P, Vasanth S, Kurian M, Philip E, Jagtap N, Pandit E. Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand?. Indian J Crit Care Med 2020; 24 (9):799-803.
Background: Medication error in developed countries is of primary concern when there is a question of adversity to a patient\'s health, but in developing countries like India, it is just a term and its significance is undervalued. The incidence of medication error is essential to estimate the proper medical care provided in the healthcare system.
Objective: The main objective of the study is to determine the incidences of medication error in critical care unit and to evaluate its risk outcomes.
Materials and methods: This is a prospective observational study conducted over a period of 6 months in a critical care unit of a tertiary care hospital. Medication chart review method was opted for data collection. The medication errors were mainly classified as prescription, transcription, indenting, dispensing, and administration error. A total of 6,705 charts were reviewed. The NCCMERP risk index was used to evaluate the outcome of errors.
Results: Of the total 6,705 charts, 410 medication errors were found, i.e., 6.11%. The most common error is transcription error that constitutes 44.1% of the total errors, followed by prescription error 40%, and administration error 14%. The frequency of indenting and dispensing errors is negligible with 1.5% and 0.5%, respectively. The main causes of medication errors are due to incomplete prescription 50.2% and wrong doses 22.9%. In drug class, antibiotics and antihypertensive agents are most prone to medication error. About 87.1% errors belonged to the Category B of National Coordinating Council for Medication Error Reporting and Prevention risk index.
Conclusion: Majority of the errors are transcription errors followed by prescription and administration errors. Consultant doctors have to be more vigilant during prescribing and verifying the medication charts. Clinical pharmacists should act as a checkpoint at each step of medication process to identify and prevent medication errors.
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Zirpe K, Suryawanshi P, Gurav S, Deshmukh A, Pote P, Tungenwar A, Malhotra R. Increase in Cadaver Organ Donation Rate at a Tertiary Care Hospital: 23 Years of Experience. Indian J Crit Care Med 2020; 24 (9):804-808.
Background: Transplantation of Human Organ Act was passed in India in 1994 to streamline organ donation and transplantation activities. It is time to retrospect ourselves and analyze the method to increase organ donation.
Type of study: Retrospective observational analysis.
Objectives: To evaluate the change in organ donation rate and reasons for changes in rates.
Subjects: Brainstem dead declared patients whose family consented for organ donations in the last 23 years (1997–2019) at Ruby Hall Clinic, Pune, India.
Materials and methods: Retrospectively demographic data of the brainstem dead declared donors, the primary diagnoses, comorbidities, and the complete data of their management till organ retrieval was assessed.
Results: One hundred cases in the age group 15–75 years (mean 41.6 ± 15.3 years) of brainstem death consented for organ donation were retrospectively studied. The period was divided into two groups, group I and group II included study duration from 1997 to 2013 and from 2013 to 2019 respectively. During the entire period, though the major cause of donor death remained road traffic accidents (RTA) in both the groups (84.21% till 2013 vs 48.15% after 2013), the proportion of donors declared brain dead due to RTA dipped significantly after 2013 (p = 0.004) and the non-RTA causes of brain dead contributed more than RTA causes (51.85% non-RTA vs 48.15% RTA). The major contributor among non-RTA causes was intracranial bleeds (5.26% before 2013 vs 33.33% after 2013, p = 0.014). Compared to the previous 17 years (from 1997) there were more than fourfold rise in the rate of transplantation in the last 6 years (2014–2019) at our institute. Kidneys were retrieved from 90% donors followed by cornea 84%, liver 65%, heart 22%, skin 7%, lungs 6%, and pancreas 5%.
Conclusion: We have observed that the cadaveric organ donation rate significantly improved after 2013. Reasons might be widening of the donor pool by the selection of more of non-RTA brain death donors over RTA, acceptability of elderly population donor (>60 years) by our transplant teams, early identification of potential organ donor, and better protocol-based management of the cadaver organ donor.
Jumana Yusuf Haji,
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Haji JY, Subramaniam A, Ramanathan K, Rajamani A. State of Personal Protective Equipment Practice in Indian Intensive Care Units amidst COVID-19 Pandemic: A Nationwide Survey. Indian J Crit Care Med 2020; 24 (9):809-816.
Background: Optimal personal protective equipment (PPE) preparedness is key to minimize healthcare workers (HCW) infection with COVID-19. This two-phase survey evaluated PPE preparedness (adherence to Ministry of Health India (MoH) PPE-recommendations; HCW-training; PPE-inventory; PPE-breach management) in Indian intensive care units (ICU).
Materials and methods: The phase 1 survey was distributed electronically to intensivists from 481 Indian hospitals between March 25, 2020, and April 06, 2020, as part of a multinational survey. Phase 2 was repeated in 320 Indian hospitals between April 20, 2020, and April 30, 2020.
Results: Response rate was 25% from 22 states. PPE practice varied between states and between private, government, and medical colleges. Between phase 1 and phase 2, all aspects of PPE training improved: donning/doffing 43% vs 66%, respectively; p value <0.01); safe waste disposal practices (38% vs 52%; p value = 0.09); intubation training (18% vs 31%; p value = 0.05); and transport (18% vs 31%; p value = 0.05). Perception of confidence for adequate PPE-training improved from 39 to 53% (p value = 0.26). In all, 47 to 60% ICUs adhered to MoH recommendations. Wearing N95-masks at all times increased from 47 to 60% (p value = 0.89). Very few ICUs provided quantitative/qualitative N95 masks fit testing (12% vs 29%; p value <0.01). Low-cost practices like “buddy-system” for donning-doffing (27% vs 44%; p value = 0.02) and showering after PPE breach (10% vs 8%; p value = 0.63) were underutilized. There was reluctance to PPE reuse. In all, 71% were unaware/diffident about PPE inventory.
Conclusion: Despite interstate variability, most ICUs conformed to MoH recommendations. This survey conducted during initial pandemic phase demonstrated improved PPE preparedness uniformly across India with scope for further improvement. We suggest implementation of quality improvement measures to improve pandemic preparedness and minimize HCW infection rates, focused on regular PPE training, buddy system, and PPE-breach management.
Ajay Nagesh Bhat,
Venkatraya M Prabhu
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Samuel D, Bhat AN, Prabhu VM. Platelet Indices as Predictive Markers of Prognosis in Critically Ill Patients: A Prospective Study. Indian J Crit Care Med 2020; 24 (9):817-822.
Introduction: Platelets (PLTs) are dynamic blood molecules which perform multiple physiological functions. Platelet derangements are commonly encountered in intensive care units (ICUs). The relationship of PLT indices with all-cause mortality, acute physiology and chronic health evaluation IV (APACHE IV), diabetes mellitus (DM), and length of stay in ICU is debatable and hence this study was undertaken to bridge this gap of knowledge.
Materials and methods: Prospective data were collected for 20 months in the ICU of our hospital. Platelet indices were analyzed among survivors and non-survivors. Acute physiology and chronic health evaluation IV scores were used to study the relationship between PLT indices and illness severity. Receiver operating characteristic curves were constructed to compare the performances of PLT indices in predicting mortality, while the effect of DM on PLT indices was evaluated using regression analysis.
Results: A total of 170 out of 345 patients (119 survivors, 51 non-survivors) met the study criteria. Patients with decreased PLT count and plateletcrit (PCT) (p < 0.001 and 0.001, respectively), increased mean platelet volume (MPV) and platelet distribution width (PDW) (p = 0.014 and 0.004, respectively) had a significant correlation with increased risk of mortality than those with normal PLT indices. These patients also had a higher APACHE IV and acute physiology score (p < 0.001). No significant relationship was found between the PLT indices and the length of ICU stay. The influence of each PLT index adjusted to DM was significant in univariate regression analysis, whereas in multivariate only PDW had a significant influence.
Conclusion: Patients with low PLT, PCT and high MPV, PDW were associated with more severe illness, poor prognosis, and a higher risk of mortality. Platelet distribution width is the preferred PLT index in a diabetic patient to predict clinical status.
Clinical significance: Platelet indices which are routinely available can be effectively used as a morbidity and mortality indicator in critically ill patients.
Rajesh C Mishra,
Manender K Singla,
Prakash C Kowdle,
Poonam M Kapoor
Introduction: Renal replacement therapy (RRT) is utilized for patients admitted with acute kidney injury and is becoming indispensable for the treatment of critically ill patients. In low middle income and developing country like India, the epidemiological date about the practices of RRT in various hospitals setups in India are lacking. Renal replacement therapy although is being widely practiced in India, however, is not uniform or standardized. Moreover, the use of RRT beyond traditional indications has not only increased but has shifted from the ambit of the nephrologist and has come under the charge of intensivists.
Aims and objectives: The goal of the study was to record perceptions and current practices in RRT management among intensivists across Indian intensive care units (ICUs).
Materials and methods: A questionnaire including questions about hospital and ICU settings, availability of RRT, manpower availability, and RRT management in critically ill patients was formed by an expert panel of ICU physicians. The questionnaire was circulated online to Indian Society of Critical Care Medicine (ISCCM) members in October 2019.
Results: The facilities in government setups are scarce and undersupplied as compared to private or corporate setups in terms of ICU bed strength and availability of RRT. High cost of continuous renal replacement therapy (CRRT) makes their use restricted.
Conclusion: Resources of RRT in our country are limited, more in government setup. Improvement of the existing resources, training of personnel, and making RRT affordable are the challenges that need to be overcome to judiciously utilize these services to benefit critically ill patients.
Background: Coronavirus disease-2019 (COVID-19) pandemic has inundated healthcare systems globally especially resources in intensive care units (ICUs). Tracheostomy may be required in critically ill COVID-19 patients to facilitate weaning and to optimize resources like ventilator and ICU beds. Percutaneous tracheostomy (PCT) has become the standard of care globally in ICUs; however, it is considered a high-risk procedure in COVID-19 patients because of the inherent risk of aerosol generation.
Materials and methods: Patients with severe COVID-19 who were on mechanical ventilation because of respiratory failure for ≥10 days were evaluated for PCT. We developed a four-step approach from patient selection and timing, preparation, performance, and postprocedure for PCT in these patients.
Results: We evaluated our four-step protocol in four patients. One of them was non-COVID patient and rest three were COVID patients. The procedure was uneventful in all of the patients with median time of procedure and apnea is 10 minutes 30 seconds and 2 minutes 20 seconds, respectively. The tracheostomy was decannulated in two of these patients and one patient is still on ventilator.
Conclusion: We believe our four-step protocol for PCT in critically ill COVID-19 patient is simple, safe, and easily adapted in any setting with limited training and available resources. We recommend further studies to evaluate this approach in selected critically ill COVID-19 patients who need tracheostomy.
Aim: To develop a device that can reduce the exposure of aerosols to healthcare workers (HCWs) who are working in coronavirus disease-2019 (COVID-19) critical units.
Background: Barrier enclosure has recently been proposed for use during intubations where the risk of aerosolization is high. In COVID-19 outbreak, use of noninvasive respiratory support is increasing. But at the same time, it is associated with high risk of aerosol generation, leading to infections among HCWs. We have made a modification in the intubation box and hence expanded its use with an aim to reduce COVID-19 exposure.
Technique: Vacuum suction tubing was attached to wall mount, and the other end of tubing was fixed, using adhesive surgical tapes, to the inside of the roof of barrier enclosure. Keeping the vacuum suction switched-on inside the box created a negative pressure while overall air flow is into the box from outside. This led us to believe that aerosols if generated are not contaminating patient\'s vicinity. Currently, we are using barrier enclosure boxes on all patients who are on noninvasive support (noninvasive ventilation or high-flow oxygen therapy).
Conclusion and clinical significance: We believe that adding barrier enclosure with the above-mentioned negative-pressure modification will provide an opportunity to use noninvasive support widely, while at the same time, HCW\'s exposure to aerosols will be reduced.
Subhal B Dixit,
Sameer A Jog,
Khalid I Khatib,
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Dixit SB, Jog SA, Khatib KI, Rangappa P, Bandopadhyay S, Shrivastav O, Mhatre U. Current Approaches to COVID-19: Therapy and Prevention. Indian J Crit Care Med 2020; 24 (9):838-846.
The coronavirus disease-2019 (COVID-19) pandemic has affected millions of people worldwide. As our understanding of the disease is evolving, our approach to the patient management is also changing swiftly. Available new evidence is helping us take radical decisions in COVID-19 management. We searched for inclusion of the published literature on treatment of COVID-19 from around the globe. All relevant evidences available till the time of submission of this article were briefly discussed. Once advised as blanket therapy for all patients, recent reports of hydroxychloroquine with or without azithromycin indicated no potential benefit and use of such combination may increase the risk of arrhythmias. Clinical evidence with newer antivirals such as remdesivir and favipiravir is promising that can hasten the patient recovery and reduce the mortality. With steroids, evidence is much clear in that it should be used in low dose and for short period not extending beyond 7 days in moderate to severe hospitalized patients. Low-molecular-weight heparin should be initiated in all hospitalized COVID-19 patients and dose should be based on the coagulation profile and risk of thromboembolism. Immunomodulatory drugs such tocilizumab may be considered for severe and critically ill patients to improve the outcomes. Though ulinastatin can be a potential alternative immunomodulator, there is lack of clinical evidence on its usage in COVID-19. Convalescent plasma therapy can be potentially lifesaving in critically ill patients. However, there is need to generate further evidence with various such therapies. Though availability of a potent vaccine is awaited, current treatment of COVID-19 is based on available therapies, which is guided by the evidence. In this review, we discuss the potential treatments available around the globe with current evidence on each of such treatments.
Maximum antibiotic usage within hospitals occurs in critical care areas. Reasons for this usage are the moribund state of patients, invasive devices, and protocol based necessity for empiric antibiotic initiation in most critical conditions. Although unavoidable, prudent use of antibiotics (empiric and therapeutic) should be tailored based on national or if available, unit-based hospital antibiogram. This forms the footstool of every antibiotic policy formulated at tertiary care hospitals. Strict adherence to antibiotic policy formulated based on hospital antibiogram largely benefits patients and hospital-wide antimicrobial stewardship is ensured. The necessity, benefits, key targets, and usefulness of antimicrobial stewardship program (AMSP) in critical care has been elaborated in this review.
Coronavirus disease-2019 (COVID-19) outbreak began in December 2019 in China and has spread rapidly across the world. The healthcare system of each country has been affected from this situation. Undoubtedly, during this period several ethical issues have been raised. In this commentary, we aimed to make a discussion regarding the ethical issues that could be raised in the treatment of patients in the intensive care units during the COVID-19 pandemic. The objective of this article is to contribute to the wide current discussion regarding the appropriate measures that should be taken to protect the health and ensure the safety of the staff that comes in close contact with patients who are suspected or confirmed of having COVID-19.
Disposable filtering face piece respirators (FFRs) are usually not approved for routine practice of decontamination and reuse. However, such practice of decontamination and reuse may be needed only as a crisis capacity strategy to ensure continued availability. The current severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic would help us enlighten about more effective and efficient ways of decontamination and reuse. Based on the limited research available, ultraviolet irradiation, vapors of hydrogen peroxide, and moist heat showed the most promising potential methods to decontaminate FFRs. This article summarizes available research about decontamination of FFRs before reuse.
Introduction: Appropriate cause of death reporting is vital in the pandemic circumstance for effective planning of the control measures. Accurate reporting and registration of the reason for death are crucial in planning of health programs in turn contributing for the national development.
Background: All births and deaths occurring across India should be mandatorily registered per the Registration of Births and Deaths Act passed in the year 1969. The act also requires the issuance of cause of death certificate by the doctor attending the departed during his last illness. Data obtained from the cause of death certificate provides cause-specific mortality profile, which is required to analyze the health trends of the population.
Review results: This article discusses the available guidelines on the appropriate documentation of cause of death in the confirmed or suspected coronavirus disease-2019 (COVID-19) infection resulting into death.
Conclusion: Proper certification of the cause of death leads to better epidemic surveillance. Scrutiny of the clinical sequences from the cause of death certificate is useful to prioritize the allocation of resources for critical care management and to augment our knowledge about underlying causes resulting in mortality from COVID-19.
Clinical significance: Dissemination of available guidelines on proper documentation of the cause of death in confirmed/suspected COVID-19 cases will reduce the errors in cause of death reporting.
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Singh Y, Garg H, Jha S. Cardiopulmonary Resuscitation during COVID-19 Pandemic: Outcomes, Risks, and Protective Strategies for the Healthcare Workers and Ethical Considerations. Indian J Crit Care Med 2020; 24 (9):868-872.
The crisis caused by Coronavirus disease-2019 (COVID-19) pandemic has led us to safeguard ourselves and our colleagues against transmission of this highly contagious infection, while aiming for the same goals of care. In spite of the stringent measures adopted by affected countries, rising number of healthcare workers (HCWs) are getting infected, dwindling the scarce manpower at our disposal. In the pre-COVID-19 times, cardiopulmonary resuscitation (CPR) was offered unhesitantly to all patients, who had even a slim chance of achieving return of spontaneous circulation. In COVID-19 era, CPR, due to some components being high aerosol-generating procedures (AGPs), has become high-risk procedure for the HCWs. Instead of “Primum non nocere” (first do no harm), we are forced to change to “Primum non nocere ad te” (first do no harm to yourself). The challenge is therefore to provide best possible chance of survival to deserving patients, whose COVID-19 status might be unknown, without causing harm to the HCWs. In this review, we discuss the current data regarding infected HCWs, outcomes of inhospital and out-of-hospital cardiac arrests, components of CPR which are high-risk AGPs, how to safeguard the HCWs while offering CPR, and the ethical considerations when CPR is considered, in this COVID-19 era. We wish to emphasize here that there is NO EMERGENCY in a pandemic, and time must be made for donning appropriate PPE. We feel that clear policies need to be developed by the institutions to deliver CPR to correct population, in this challenging period.
Since the beginning of the Coronavirus Disease-2019 (COVID-19) outbreak, elevated D-dimer levels as an acute-phase reactant have been reported in some patients. Additionally, the patients with pneumonia are at increased risk of developing thromboembolic events. Diagnosing acute pulmonary embolism and deep vein thrombosis can be challenging in SARS-CoV2–positive patients. Here, we report four patients with COVID-19 pneumonia to highlight the possibility of acute thromboembolism in these patients. The physicians should be aware of this complication and even consider prophylactic anticoagulant therapy in proper clinical settings.
Posterior reversible encephalopathy syndrome (PRES) is characterized by headache, altered sensorium, visual disturbances, and diagnosed by magnetic resonance imaging (MRI). Here we report a case of cisplatin-induced PRES which was mimicking stroke and diagnosed by serial MRI and recovered completely on treatment, emphasizing fact that early diagnosis, removal of cause, and treatment can prevent the complication.
Manoj K. Goel,
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Goel MK, Chauhan M, Wadwa P, Maitra G, Talegaonkkar M, Dewan S. A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020; 24 (9):879-881.
Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening disease. Mortality is very high in those patients who require mechanical ventilation. Traditionally, active bleeding has been considered a contraindication for extracorporeal membrane oxygenation (ECMO) support. There is limited evidence for ECMO in DAH as rescue therapy. Herein, we describe a case of antineutrophil cytoplasmic antibodies-associated DAH with intractable hypoxemic respiratory failure. An appropriate ventilator strategy failed to improve her hypoxemia leading to imminent risk to her life. The patient was rescued with veno-venous ECMO targeting lower than usual range of anticoagulation. ECMO proved to be lifesaving in our patient who was initiated on prompt immunosuppressive therapy and plasmapheresis along with continuous veno-venous hemodiafiltration and hemodynamic support. We feel that ECMO could be considered as adjunctive therapy in severe hypoxemic respiratory failure associated with DAH after careful consideration of the risk of bleeding and a restrictive anticoagulation strategy.
Robin G Manappallil,
Pradeep P Veetil,
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Manappallil RG, Krishnan R, Veetil PP, Nambiar H, Karadan U, Anil R, Josephine B. Hypocalcemic Seizure Due to Vitamin D Deficiency. Indian J Crit Care Med 2020; 24 (9):882-884.
Aim: To emphasize the importance of vitamin D supplementation.
Background: The incidence of vitamin D deficiency has been increasing worldwide, probably due to decreased exposure to sunlight and unbalanced diet. Severe hypocalcemia following vitamin D deficiency is rather uncommon, and this leading to seizures in adults is a rare scenario.
Case description: This is the case of a 70-year-old female, a known case of coronary artery disease, who presented with one episode of seizure. Computed tomography of her brain revealed diffuse age-related atrophic changes, and electroencephalogram showed diffuse cerebral dysfunction. She was found to have severe hypocalcemia with secondary hyperparathyroidism due to vitamin D deficiency. Vitamin D bolus was given along with calcium correction, following which she improved.
Conclusion: There are a few reports of hypocalcemic seizures among children; however, the incidence is rare among adults. Calcium and vitamin D supplementation forms the mainstay of treatment.
Clinical significance: Hypocalcemic seizure is uncommon, especially among adults. Vitamin D deficiency resulting in hypocalcemic seizure, to the best of our knowledge, is an unreported scenario. This case highlights the importance of vitamin D supplementation in those with reduced sunlight exposure.
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Kaur P, Jain R, Kumar P, Randev S, Guglani V. Clinical Spectrum and Outcome of Acute Encephalitis Syndrome in Children with Scrub Typhus: A Series of Eight Cases from India. Indian J Crit Care Med 2020; 24 (9):885-887.
Scrub typhus has reemerged with a different geographical distribution and varied clinical presentation like acute encephalitis syndrome (AES), which is a less known entity in scrub typhus. In this case series, we studied the clinical profile and outcome of eight patients who presented with AES and a positive scrub serology without any other identifiable cause of encephalopathy. All these patients had fever, altered sensorium, and nuchal rigidity, while seizures were present in six (75%) patients and papilledema in two (25%) patients. Complications like shock, pulmonary edema, and gastrointestinal (GI) bleed were observed in three (37%) patients. All patients except for one responded well to the treatment and recovered completely. Scrub typhus should be suspected early in patients presenting with AES.
The current rapidly rising pandemic scenario due to the SARS COVID-19 infection is known to cause acute respiratory distress syndrome (ARDS) in severely ill patients. Meanwhile, many patients get to suffer multiple comorbidities like septicemia and acute kidney injury (AKI). Most of the critically ill mechanical ventilated patients are nowadays being given trials of prone ventilation for at least one-third duration of a day. These patients may require central venous catheter for various purposes such as fluid resuscitation, vasopressor administration, hemodialysis owing to the fact that many critically ill COVID-19 patients are going for AKI. Central venous access has a major role in accelerating the impending septicemia due to ARDS, by causing catheter-related bloodstream infection, thereby having a synergistic effect in causing sepsis. By using the unconventional methods which are used to give venous access, apart from the regularly used traditional methods of Internal Jugular, subclavian as well as femoral sites, this impending septicemia can be prevented or at least be hampered. This in turn will have major impact in the overall critically ill COVID-19-positive patient\'s outcome and will have a reduced mortality.
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Rebello G, Chettri S, Reddy M. Demographic and Clinical Profile of Invasive Staphylococcal Infections in Children Admitted to Pediatric Intensive Care Unit: A Retrospective Study. Indian J Crit Care Med 2020; 24 (9):890-891.
Objective: Staphylococcal infections are common cause of morbidity and mortality in pediatric intensive care unit (PICU). The objective of this study was to describe the clinical and microbial features, and outcome of patients with invasive staphylococcal infection.
Materials and methods: We conducted a retrospective chart review of the children admitted to PICU with invasive staphylococcal infections. Invasive staphylococcal infection was defined as clinical infection with isolation of Staphylococcus aureus from a normally sterile body site.
Results: A total of 50 children (1 month to 16 years) were identified with staphylococcal infections during the study period. There was male preponderance (75%) with high prevalence in school going children. Among these children, 36% (18) were coagulase-negative (CONS), which were excluded. Of the remaining, 64% (32) were coagulase-positive Staphylococcus aureus, 54% (27) were methicillin-resistant Staphylococcus aureus (MRSA), and 10% (5) were methicillin-susceptible Staphylococcus aureus (MSSA). Community-acquired staphylococcal infections were present in 24 children (CA-MRSA). Pneumonia with empyema was the most common 20 (62%) site of primary staphylococcal infection, followed by blood stream infection 9 (28%) and skin and soft tissue infection 3 (9%). Of the soft tissue infection, three were MRSA, with two had pyopericardium with infective endocarditis. Resistance in MSSA was found to be maximum to penicillin, erythromycin, and ciprofloxacin with no resistance with vancomycin.
Conclusion: There is an increase incidence of MRSA among community-acquired staphylococcal infections requiring intensive care management. A larger study on clinical profile of Staphylococcus infection in pediatrics is urgently needed to define the exact magnitude of the problem.