Indian Journal of Critical Care Medicine

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2021 | January | Volume 25 | Issue 1

EDITORIAL

Raymond D Savio

Procalcitonin (in COVID-19): The Incessant Quest

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:2] [Pages No:1 - 2]

Keywords: Procalcitonin, Prognosis, Risk prediction,Biomarker, COVID-19, Pandemic

PDF  |  DOI: 10.5005/jp-journals-10071-23698  |  Open Access |  How to cite  | 

EDITORIAL

Prasad A Rajhans, Purushotham Godavarthy

COVID-19 Combat Fatigue among the Healthcare Workers: The Time for Retrospection and Action

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:3] [Pages No:3 - 5]

Keywords: Burnout, COVID-19, Healthcare workers, Psychological stress

PDF  |  DOI: 10.5005/jp-journals-10071-23699  |  Open Access |  How to cite  | 

Abstract

The present pandemic caused by the novel coronavirus has battered the healthcare infrastructure all around the globe. The doctors, nurses, and healthcare staff—the COVID warriors—have plunged themselves in line of fire to keep the population safe and alive. Around 87,000 healthcare workers (HCWs) have been infected and 573 have died till August in India alone. With no sight of pandemic ebbing anytime soon and patient load in hospitals refusing to come down, combat fatigue has set in these HCWs. The very people whose life mission is caring for others are on the verge of collective collapse physically and emotionally. There is an urgent need to retrospect the problems faced by the HCWs in the previous months, recognize, and preventive measures initiated at the earliest to prevent further loss and burnout among these battle-hardened frontline soldiers.

EDITORIAL

Ankit Sharma

Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:2] [Pages No:6 - 7]

Keywords: Opium toxicity, QT prolongation,Depolarization

PDF  |  DOI: 10.5005/jp-journals-10071-23704  |  Open Access |  How to cite  | 

EDITORIAL

Kishore Pichamuthu

Lung Ultrasound: COVID-19's Silver Lining

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:2] [Pages No:8 - 9]

Keywords: B-lines, Chest X-ray, COVID-19, Lung ultrasound, Shred sign

PDF  |  DOI: 10.5005/jp-journals-10071-23703  |  Open Access |  How to cite  | 

EDITORIAL

Manu Sundaram, Manjush Karthika

Respiratory Mechanics: To Balance the Mechanical Breaths!!

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:2] [Pages No:10 - 11]

PDF  |  DOI: 10.5005/jp-journals-10071-23700  |  Open Access |  How to cite  | 

COMMENTARY

Aditya Kapoor, Arvind Kumar Baronia, Afzal Azim, Gaurav Agarwal, Narayan Prasad, Richa Mishra, Vivek Anand Saraswat

Breathability and Safety Testing of Personal Protective Equipment: “Human-comfort” Factor Remains Undefined

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:4] [Pages No:12 - 15]

Keywords: COVID-19, Comfort fit testing, Healthcare workers, Personal protective equipment

PDF  |  DOI: 10.5005/jp-journals-10071-23598  |  Open Access |  How to cite  | 

Abstract

Healthcare systems all over the world have been enormously affected by the COVID-19 pandemic. Healthcare workers (HCWs) taking care of these patients need personal protective equipments (PPEs) standardized for full protection from droplets and aerosols carrying viral load to variable distances. There has been a surge of manufacturers supplying these protective gears in India and regulatory agencies have issued technical specifications pertaining to PPEs focusing solely on synthetic blood penetration tests (SBPTs) and keeping the upper limit of non-woven fabric to 95 g/m2 (GSM). These PPE specifications are silent on air permeability (AP) and water/moisture vapor transmission rate (WVTR/MVTR) of the fabric. As a result, most of the PPE kits, despite having appropriate SBPT certifications from regulatory agencies, have extremely poor permeability and breathability. The acceptability of PPEs by HCWs can be vastly improved when the end-users are proactively invited to participate in “comfort testing” of PPEs before getting issuance of certification for marketing. “Field testing” or “end-user trials” in which HCWs don the PPE and assess it for comfort while performing different types of clinical work, e.g., in intensive care units (ICUs), operation theaters, cath labs, etc., also takes into account a hitherto often ignored “human-comfort-factor” that not only enhances the understanding of HCWs about the need for the PPEs but can also motivate them to use it without worrying about discomfort. We hereby propose that comfort fit testing (COmfort and Material Fit is an Obviously Required Test) should be a part of the mandatory testing and certification process for PPE, so that the industry invests wisely in manufacturing PPE kits that are not only certified for fabric but are also tested for comfort factors.

RESEARCH ARTICLE

Ravindranath Sunil, Margiben T Bhatt, Tumkur Venkatesh Bhumika, Nitha Thomas, Amitha Puranik, Souvik Chaudhuri, Rao Shwethapriya

Weathering the Storm: Psychological Impact of COVID-19 Pandemic on Clinical and Nonclinical Healthcare Workers in India

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:5] [Pages No:16 - 20]

Keywords: Insomnia, Pandemic, Stress,Anxiety, Coronavirus disease 2019, Depression, Healthcare workers

PDF  |  DOI: 10.5005/jp-journals-10071-23702  |  Open Access |  How to cite  | 

Abstract

Background: Coronavirus disease-2019 (COVID-19) pandemic has exposed healthcare workers (HCWs) to a unique set of challenges and stressors. Our frontline workers are under tremendous psychological pressure because of the ever-rising crisis. This study was done to assess the magnitude of the psychological impact of the COVID-19 pandemic on clinical and nonclinical HCWs in India. Materials and methods: It was a cross-sectional, online survey that was done from June 1, 2020, to July 4, 2020. A total of 313 clinical and nonclinical HCWs, who were directly or indirectly involved in patient care, participated in the study. The psychological impact was assessed in terms of four variables: insomnia, anxiety, depression, and stress. Insomnia was assessed by the Insomnia Severity Index (ISI). Anxiety and depression were assessed via the Patient Health Questionnaire-4 (PHQ-4), which included a 2-item anxiety scale and a 2-item depression scale (PHQ-2). Stress was assessed via the Perceived Stress Scale (PSS). We also compared the psychological impact of this pandemic between clinical and nonclinical HCWs. Results: 7.3% of HCWs were having moderate insomnia, 3.8% had severe insomnia, and 20.8% were having subthreshold insomnia. Severe anxiety and depression were found in 6.7% of respondents. 8.0 and 32.3% of the respondents had moderate and mild anxiety–depression, respectively. 6.4% had high perceived stress. 47.6 and 46.0% of the respondents had moderate and low stress, respectively. There was a statistically significant difference in severe insomnia between clinical and nonclinical HCWs, whereas no significant difference in anxiety, depression, and stress between clinical and nonclinical HCWs. Conclusion: This study suggests that psychological morbidity is prevalent among both clinical and nonclinical HCWs and both males and females. Early intervention may be beneficial to prevent this issue.

RESEARCH ARTICLE

Lovely Thomas, Binila Chacko, Samuel Jupudi, Alice Mathuram, Tina George, Karthik Gunasekaran, Sudha J Rajan, Ronald AB Carey, John V Peter

Clinical Profile and Outcome of Critically Ill Patients with Tuberculosis

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:8] [Pages No:21 - 28]

Keywords: Critically ill patients, Gene Xpert, Mortality, Tuberculosis

PDF  |  DOI: 10.5005/jp-journals-10071-23503  |  Open Access |  How to cite  | 

Abstract

Aim and objective: Although studies have described the clinical profile of patients admitted to the intensive care unit (ICU) with tuberculosis, it is unclear if the type of tuberculosis (pulmonary, extrapulmonary, or disseminated) impacts outcome. Matrials and methods: Demographic data, microbiology, treatment, and outcomes over 5 years (2012–16) were obtained from electronic records. Patients were categorized as pulmonary, extrapulmonary, or disseminated tuberculosis. Comparisons were done using t test and Fisher\'s exact test as appropriate. Predictors of outcome were explored using bivariate and multivariate logistic regression analysis and expressed as odds ratio (OR) with 95% confidence intervals (CI). Results: Of the 428 ICU admissions with suspected tuberculosis, 212 (121 male) patients with mean (standard deviation) age of 41.9 (16.7) years and APACHE-II score of 20.8 (6.6) were diagnosed as pulmonary (n = 55) and extrapulmonary (n = 52) or disseminated tuberculosis (n = 105). In 50.5%, the diagnosis of tuberculosis was established during the current ICU admission when they presented with organ dysfunction. Overall, microbiological confirmation was possible in 75.5%; 14 (10.3%) isolates were Rifampicin resistant. ICU admission was required primarily for ventilation (n = 176; 83%) and hemodynamic instability (n = 67; 32%). Hospital mortality was 50%. Outcomes were similar in the three groups except for longer duration of stay (p value = 0.04) in disseminated tuberculosis. On multivariate logistic regression analysis, pulmonary tuberculosis (OR 2.83; 95% CI 1.15–6.95) and vasoactive treatment (OR 15.8; 95% CI 6.4–39.2) were independently associated with death; need for ventilation predicted mortality perfectly. Conclusion: In this cohort of patients admitted to ICU with tuberculosis, 50% were newly diagnosed during ICU admission. Pulmonary site of involvement and need for organ support are independent risk factors for death.

RESEARCH ARTICLE

Hassan Mitwally, Mohamed O Saad, Sara Mahmoud, Adham Mohamed

Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses vs Continuous Infusion in Septic Shock: A Retrospective Study

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:5] [Pages No:29 - 33]

Keywords: Hydrocortisone, Hyperglycemia, Intermittent boluses, Septic shock,Continuous infusion

PDF  |  DOI: 10.5005/jp-journals-10071-23501  |  Open Access |  How to cite  | 

Abstract

Introduction: Hydrocortisone showed to be effective in reducing the time until reversal of shock when added to standard therapy in managing septic shock. Hyperglycemia is one of the common adverse effects associated with corticosteroid treatment. However, the difference in hyperglycemia risk with different methods of hydrocortisone administration is not clear. The objective of this study was to evaluate the risk of hyperglycemia of intermittent hydrocortisone boluses vs continuous infusion in septic shock patients. Materials and methods: This was a retrospective observational study. Data were collected from the electronic medical records of eligible patients admitted to intensive care units. All patients admitted with septic shock who received noradrenaline and hydrocortisone were included. Only patients who exceeded 200 mg/day of hydrocortisone were excluded. The primary outcome was mean blood glucose. Results: A total of 108 patients (with 3,021 blood glucose readings) were included in the final analysis. Seventy-six patients received hydrocortisone as intermittent boluses (70.3%), and 32 patients (29.7%) received continuous infusion. For the primary outcome, no statistically or clinically significant difference was found in the blood glucose estimated marginal mean: 8.58 mmol/L (95% confidence interval [CI]; 8.01–9.16) in the bolus group and 8.9 mmol/L (95% CI; 7.99–9.82) in the infusion group with a mean difference of 0.32 mmol/L (95% CI; −0.77 to 1.41). For secondary outcomes, no difference was found between the two groups in mortality, length of stay, reversal of shock, or hypoglycemic events. Conclusion: Intermittent boluses of hydrocortisone were not associated with a higher risk of hyperglycemia than continuous infusion in septic shock patients.

RESEARCH ARTICLE

Sneha Mohan, Sristi Patodia, Sudha Kumaravel, Ramesh Venkataraman, Bharath Kumar Tirupakuzhi Vijayaraghavan

Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:9] [Pages No:34 - 42]

Keywords: Intensive care units, Quality improvement, Rehabilitation

PDF  |  DOI: 10.5005/jp-journals-10071-23438  |  Open Access |  How to cite  | 

Abstract

Background: Patients in the intensive care unit (ICU) are subjected to prolonged bed rest secondary to critical illness and related therapies. Data suggest that such bed rest can have adverse consequences on the post-discharge quality of life. There is limited data from India on mobilization practices. We undertook a quality improvement (QI) initiative to understand our mobilization practices, identify challenges, and test interventions. Materials and methods: We carried out a three-phase QI project, and the study was conducted in our 24-bedded ICU. Pre-intervention and post-intervention mobilization performance and scores were analyzed. We also recorded data on adverse events and barriers to mobilization. Descriptive statistics were used to report all the results. Results: A total of 140 patients (1,033 patient days) and 207 patients (932 patient days) were included in our initial audit and post-implementation audit, respectively. In pre-implementation, 31.3% of patients were mobilized with an average mobility score of 2 and this improved to 57.9% with average mobility score of 3.4. Additionally, we demonstrated improvements in the mobility scores of our intubated patients (49.8% achieving a mobility score of 3–5 as compared to 16.7%). Conclusion: A multidisciplinary approach is feasible and resulted in significant improvements in early mobilization among critically ill adults.

RESEARCH ARTICLE

Hamid R Javadi, Seyed M Mirakbari, Abbas Allami, Zohreh Yazdi, Kimia Katebi

Opium-associated QT Interval Prolongation: A Cross-sectional Comparative Study

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:5] [Pages No:43 - 47]

Keywords: Opium, QT interval, QT prolongation,Opioids

PDF  |  DOI: 10.5005/jp-journals-10071-23596  |  Open Access |  How to cite  | 

Abstract

Background: Toxicity and side effects of long-term use of opioids are well studied, but little information exists regarding electrophysiological disturbances of opium consumption. While natural opium has been regarded safe to a great extent among traditional communities, concerns are emerging owing to the available evidence of QT prolongation that have been exposed during recent outcome surveillance of patients under opioid use. Potential QT prolonging interactions would raise a higher level of such concern in opium users during COVID pandemic and warrant attention. Materials and methods: This study was designed to detect the prevalence of QTc prolongation among opium users and nonusers. Two groups were compared with regard to gender, age, and median QTc interval. Normal and prolonged QTc intervals of user group were compared with respect to age, sex, dose of opium consumption, and duration of opium consumption. Results: 123 opium users and 39 controls were investigated. Median QTc interval in opium user and non-user group was 460 vs 386 milliseconds, respectively (p value < 0.001). In all, 59.3%, (95% CI: 50.51–67.62%) of cases and none of non-user had prolonged QTc interval (p value < 0.001). There was no significance between normal and prolonged QTc intervals with respect to dose and duration of opium use. Conclusion: This study indicated that opium consumption is associated with QTc prolongation. This prolongation does not relate to dose and duration of opium use. Further study is propounded to assess the clinical significance of these results and to determine risk rating of opium compared to other opioids in this regard.

RESEARCH ARTICLE

Nitish Kumar, Deepak Malviya, Soumya S Nath, Shivani Rastogi, Vishal Upadhyay

Comparison of the Efficacy of Different Arterial Waveform-derived Variables (Pulse Pressure Variation, Stroke Volume Variation, Systolic Pressure Variation) for Fluid Responsiveness in Hemodynamically Unstable Mechanically Ventilated Critically Ill Patients

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:6] [Pages No:48 - 53]

Keywords: Cardiac index, Positive end expiratory pressure, Pulse pressure variation, Stroke volume variation, Systolic pressure variation

PDF  |  DOI: 10.5005/jp-journals-10071-23440  |  Open Access |  How to cite  | 

Abstract

Introduction: This study was conducted to assess fluid responsiveness in critically ill patients to avoid various complications of fluid overload. Material and methods: This study was done in an ICU of a tertiary care hospital after approval from the institute ethical committee over 18 months. A total of 54 consenting adult patients were included in the study. Patients were hemodynamically unstable requiring mechanical ventilation, had acute circulatory failure, or those with at least one clinical sign of inadequate tissue perfusion. All patients were ventilated using tidal volume of 6–8 mL/kg, RR—12–15/minutes, positive end expiratory pressure (PEEP)—5 cm of water, and plateau pressure was kept below 30 cm water. They were sedated throughout the study. The arterial line and the central venous catheter were placed and connected to Vigileo-FloTrac transducer (Edward Lifesciences). Patients were classified into responder and nonresponder groups on the basis of the cardiac index (CI) after fluid challenge of 10 mL/kg of normal saline over 30 minutes. Pulse pressure variation (PPV), stroke volume variation (SVV), and systolic pressure variation (SPV) were assessed and compared at baseline, 30 minutes, and 60 minutes. Results: In our study we found that PPV and SVV were significantly lower among responders than nonresponders at 30 minutes and insignificant at 60 minutes. Stroke volume variation was 10.28 ± 1.76 in the responder compared to 12.28 ± 4.42 (p = 0.02) at 30 minutes and PPV was 15.28 ± 6.94 in responders while it was 20.03 ± 4.35 in nonresponders (p = 0.01). We found SPV was insignificant at all time periods among both groups. Conclusion: We can conclude that initial assessment for fluid responsiveness in critically ill mechanically ventilated patients should be based on PPV and SVV to prevent complications of fluid overload and their consequences.

RESEARCH ARTICLE

Sonali Vadi

Correlation of Oxygen Index, Oxygen Saturation Index, and PaO2/FiO2 Ratio in Invasive Mechanically Ventilated Adults

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:2] [Pages No:54 - 55]

Keywords: Invasive mechanical ventilation, Oxygenation index, Oxygen saturation index, PaO2/FiO2 ratio

PDF  |  DOI: 10.5005/jp-journals-10071-23506  |  Open Access |  How to cite  | 

Abstract

Background: With the oxygen saturation index (OSI) being a noninvasive surrogate for oxygen index (OI) and P/F ratio, examining the correlation between PaO2/FiO2 (P/F ratio), OI, and OSI in mechanically ventilated adults will benefit in those settings where arterial blood gas monitoring is not readily accessible. Materials and methods: Data were collected for patients ≥18 years who were under invasive (endotracheal intubation) mechanical ventilation at medical or surgical wards in a tertiary care hospital. Results: After natural log transformation, the correlations between P/F ratio and OI (r = −0.94) and OI and OSI (r = 0.82) were strong, but weaker between P/F ratio and OSI (r = −0.69). Conclusion: Future bigger studies are needed to evaluate whether monitoring OSI and/or OI over P/F ratio will impact treatment outcomes.

RESEARCH ARTICLE

Suhail S Siddiqui, Natesh R Prabu, Harish K Chaudhari, Amit M Narkhede, Satish V Sarode, Ujwal Dhundi, Jigeeshu V Divatia, Atul P Kulkarni

Epidemiology, Clinical Characteristics, and Prognostic Factors in Critically Ill Patients with Hematolymphoid Malignancy

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:6] [Pages No:56 - 61]

Keywords: Predictors of hospital mortality, Sequential Organ Failure Assessment Score (SOFA), Simplified Acute Physiology Score III,Hematolymphoid malignancy, Mechanical ventilation, Multivariate analysis, Neutropenia

PDF  |  DOI: 10.5005/jp-journals-10071-23469  |  Open Access |  How to cite  | 

Abstract

Objective: Despite advances in the field of oncology and intensive care, the outcomes of hematolymphoid malignancy (HLM) patients admitted to ICU are poor. This study was carried out to look at the demographic data, clinical features, and predictors of hospital mortality in these patients. Materials and methods: We prospectively studied 101 adult critically ill patients with HLM admitted to the 14-bedded mixed medical surgical ICU of a tertiary care cancer center. Out of 101 patients, end-of-life care decisions were taken in 7 patients, who were excluded from the outcome analysis. Predictors of in-hospital mortality were evaluated using univariate and multivariate analysis. Results: The ICU and in-hospital mortality recorded in our study were 48.9 and 54.3%, respectively. Neutropenia at ICU admission, Simplified Acute Physiology Score III (SAPS III) score, and mechanical ventilation (MV) within 24 hours of ICU admission were associated with in-hospital mortality on univariate analysis. On multivariate logistic regression analysis, neutropenia at ICU admission (OR 4.621; 95% CI, 1.2–17.357) and MV within 24 hours of ICU admission (OR 2.728; 95% CI, 1.077–6.912) were independent predictors of in-hospital mortality. Conclusion: The HLM patients needing critical care have high acuity of illness, and acute respiratory failure is the commonest reason for ICU admission in these patients. In our study, the ICU survival was more than 50% and more than 45% patients were discharged alive from the hospital. We found a need for MV within 24 hours of ICU admission and presence of neutropenia at ICU admission to be independent predictors of hospital mortality in our study.

RESEARCH ARTICLE

Ryota Kuroiwa, Yoshihisa Tateishi, Taku Oshima, Takeshi Inagaki, Seiichiro Furukawa, Ryo Takemura, Yohei Kawasaki, Astushi Murata

Mechanical Insufflation-exsufflation for the Prevention of Ventilator-associated Pneumonia in Intensive Care Units: A Retrospective Cohort Study

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:5] [Pages No:62 - 66]

Keywords: Airway clearance, Chest physical therapy, Critically ill patients, Mechanical insufflation-exsufflation, Ventilator-associated pneumonia

PDF  |  DOI: 10.5005/jp-journals-10071-23508  |  Open Access |  How to cite  | 

Abstract

Aim: Ventilator-associated pneumonia (VAP) is the most common intensive care unit (ICU)-acquired infection. The current study aimed to assess the efficacy of mechanical insufflation-exsufflation (MI-E) in preventing VAP in critically ill patients. Materials and methods: This retrospective cohort study was conducted at the ICU of Chiba University Hospital between January 2014 and September 2017. The inclusion criteria were patients who required invasive mechanical ventilation ≥48 hours and those who underwent rehabilitation, including chest physical therapy (CPT). In 2015, the study institution started the use of MI-E in patients with impaired cough reflex. From January to December 2014, patients undergoing CPT were classified under the historical control group, and those who received treatment using MI-E from January 2015 to September 2017 were included in the intervention group. The patients received treatment using MI-E via the endotracheal or tracheostomy tube, with insufflation-exsufflation pressure of 15–40 cm H2O. The treatment frequency was one to three sessions daily, and a physical therapist who is experienced in using MI-E facilitated the treatment. Results: From January 2015 to September 2017, 11 patients received treatment using MI-E. Of the 169 patients screened in 2014, 19 underwent CPT. The incidence of VAP was significantly different between the CPT and MI-E groups (84.2% [16/19] vs 26.4% [3/11], p = 0.011). After adjusting for covariates, a multivariate logistic regression analysis was performed, and results showed that the covariates were not associated with the incidence of VAP. Conclusion: This retrospective cohort study suggests that the use of MI-E in critically ill patients is independently associated with a reduced incidence of VAP. Clinical significance: Assessing the efficacy of MI-E to prevent VAP.

REVIEW ARTICLE

Vikas Bhagat, Rahul A Pandit, Shwetha Ambapurkar, Manju Sengar, Atul P Kulkarni

Drug Interactions between Antimicrobial and Immunosuppressive Agents in Solid Organ Transplant Recipients

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:10] [Pages No:67 - 76]

Keywords: Antimicrobials, Solid organ transplant, Calcineurin inhibitors, Corticosteroids, Drug–drug interaction, Immunosuppressants, Intravenous immunoglobulin, Monoclonal antibodies, mTOR inhibitors

PDF  |  DOI: 10.5005/jp-journals-10071-23439  |  Open Access |  How to cite  | 

Abstract

The number of allogeneic solid organ and bone marrow transplants is increasing all over the world. To prevent transplant rejection and treat acute rejection of transplant, immunosuppressant drugs are used. The outcomes of solid organ transplants have dramatically improved over last 30 years, due to availability of multiple immunosuppressive agents, with varied mechanisms of action. The use of intense immunosuppression makes the individual having undergone solid organ transplant at the risk of several serious infections, which may prove fatal. To prevent and treat these infections (when they occur), patients are often given antimicrobial prophylaxis and therapy. The use of antimicrobials can interfere with the metabolism of the immunosuppressants, and may put the patient at risk of developing severe adverse effects due to unwanted increase or decrease in the serum levels of immunosuppressive agents. Knowledge of these interactions is essential for successful management of solid organ transplant patients. We therefore decided to review the literature and present the interactions that commonly occur between these two life-saving groups of drugs.

REVIEW ARTICLE

Sibtain Ahmed, Lena Jafri, Zahra Hoodbhoy, Imran Siddiqui

Prognostic Value of Serum Procalcitonin in COVID-19 Patients: A Systematic Review

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:8] [Pages No:77 - 84]

Keywords: COVID-19, Procalcitonin, Prognostic biomarker, Systematic review

PDF  |  DOI: 10.5005/jp-journals-10071-23706  |  Open Access |  How to cite  | 

Abstract

Background: This study is aimed at reviewing the published literature on the prognostic role of serum procalcitonin (PCT) in COVID-19 cases. Data retrieval: We systematically reviewed the literature available on PubMed, MEDLINE, LitCovid NLM, and WHO: to assess the utility of PCT in prognosis of coronavirus disease. Scrutiny for eligible studies comprising articles that have evaluated the prognostic utility of PCT and data compilation was undertaken by two separate investigators. Original articles in human subjects reporting the prognostic role of PCT in adult COVID-19 patients were included. The Quality in Prognosis Studies (QUIPS) tool was utilized to assess the strength of evidence. Results were reported as narrative syntheses. Results: Out of the total 426 citations, 52 articles passed through screening. The quality of evidence and methodology of included studies was overall acceptable. The total sample size of the studies comprised of 15,296 COVID-19-positive subjects. Majority of the studies were from China, i.e., 40 (77%). The PCT cut-off utilized was 0.05 ng/mL by 18 (35%) studies, followed by 0.5 ng/mL by 9 (17.5%). Eighty five percent (n = 44) studies reported statistically significant association (p value < 0.05) between PCT and severity. Conclusion: Procalcitonin appears as a promising prognostic biomarker of COVID-19 progression in conjunction with the clinical context.

BRIEF COMMUNICATION

Srikant Behera, Choro A Kayina, Bikash R Ray

Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:3] [Pages No:85 - 87]

Keywords: Severe acute respiratory syndrome coronavirus 2, Shred sign,Chest X-ray, COVID-19, Lung ultrasound

PDF  |  DOI: 10.5005/jp-journals-10071-23705  |  Open Access |  How to cite  | 

Abstract

Background: Coronavirus disease 2019 (COVID-19) is a type of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 pneumonia has characteristic radiological features. Recent evidence indicates usefulness of chest X-ray and lung ultrasound (LUS) in detecting COVID-19 pneumonia. Materials and methods: In this prospective observational study, chest X-ray and LUS features of 50 adults with COVID-19 pneumonia at the time of presentation were described. Results: Chest X-ray findings were present in 96% of patients, whereas all patients have ultrasound finding. Proportion (95% CI) of patients having bilateral opacities in chest X-ray was 96% (86.5–98.9%), ground glass opacity 74% (60.5–84.1%), and consolidation 50% (36.7–63.4%). In LUS, shred sign and thickened pleura was present in all patients recruited in this study. Air bronchogram was present in at least one area in 80% of all patients and B-lines score of more than 2 was present in at least one lung area in 84% patients. Number of lung areas with “shred sign” were higher in hypoxemic (p = 0.005) and tachypneic (p = 0.006) patients and pleura line abnormalities were present in more lung areas in hypoxemic patients (p = 0.03). Conclusion: According to our study, LUS is a useful tool not only in diagnosing, but it also correlates with requirement of respiratory support in COVID-19 patients.

Pediatric Critical Care

Cinara Andreolio, Jefferson P Piva, Francisco Bruno, Tais S da Rocha, Pedro CR Garcia

Airway Resistance and Respiratory Compliance in Children with Acute Viral Bronchiolitis Requiring Mechanical Ventilation Support

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:6] [Pages No:88 - 93]

Keywords: Airway resistance, Lung compliance, Mechanical ventilation, Pediatrics, Viral bronchiolitis

PDF  |  DOI: 10.5005/jp-journals-10071-23594  |  Open Access |  How to cite  | 

Abstract

Background: Acute viral bronchiolitis (AVB) is a very frequent disease that affects the lower airways of young children increasing the inspiratory and expiratory resistance in variable degree as well as reducing the pulmonary compliance. It would be desirable to know whether these variables are associated with the outcome. Objectives: To evaluate the respiratory mechanics in infants with AVB requiring mechanical ventilation (MV) support and to evaluate if respiratory mechanics predict outcomes in children with AVB supported on MV. To evaluate the respiratory mechanics in infants with AVB submitted to MV. Materials and methods: A prospective observational study was conducted in two pediatric intensive care units (PICUs) between February 2016 and March 2017. Included were infants (1 month to 1 year old) admitted with AVB and requiring MV for >48 hours. Auto-PEEP, dynamic compliance (Cdyn), static compliance (Cstat), expiratory resistance (ExRes), and inspiratory resistance (InRes) were evaluated once daily on the second and third day of MV. Results: A total of 64 infants (median age of 2.8 months and a mean weight of 4.8 ± 1.7 kg) were evaluated. A mean positive inspiratory pressure (PIP) of 31.5 ± 5.2 cmH2O, positive end-expiratory pressure (PEEP) of 5.5 ± 1.4 cmH2O, resulting in a mean airway pressure (MAP) of 12.5 ± 2.2 cmH2O and delta pressure of 22.5 ± 4.4 cmH2O without difference between the two hospitals. Measurements of respiratory mechanics showed high values of InRes and ExRes (median 142 [IQ25–75 106–180] cmH2O/L/s and 158 [IQ25–75 130–195.3] cmH2O/L/s, respectively), accompanied by decreased Cdyn and Cstat (0.46 ± 0.19 and 0.81 ± 0.25 mL/kg/cmH2O, respectively). None of the variables was associated with mortality, length of MV, or length of PICU stay. Conclusion: Infants with AVB requiring MV support present very high InRes and ExRes values. These findings might be the reason for the aggressive ventilatory parameters, especially PIP, required to ventilate this group of children with lower airway obstruction. Clinical significance: Monitoring respiratory mechanics could represent a useful tool to guide the ventilatory strategy to be adopted in patients with AVB.

CASE REPORT

Sudheer Tale, Soibam P Meitei, Vipul Prakash, Arjun Negi, Mayank Mishra, Girish Sindhwani

Bronchoscopic Cryotherapy for Acute Hypoxemic Respiratory Failure in Three Mechanically Ventilated Patients: A Case Series

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:3] [Pages No:94 - 96]

Keywords: Acute hypoxemic respiratory failure, Cryoextraction, Fiberoptic bronchoscopy, Intensive care unit, Lung collapse,Acute airway obstruction

PDF  |  DOI: 10.5005/jp-journals-10071-23707  |  Open Access |  How to cite  | 

Abstract

Endobronchial blood clots or mucus plugs can present with minimal symptoms or acute airway obstruction in the intensive care unit (ICU) patients. Acute airway obstruction can lead to rapid worsening of dyspnea owing to poor oxygenation due to collapse of the lung. Prompt recognition and treatment of this condition can translate into a successful outcome by decreasing morbidity and mortality and facilitating successful weaning of these patients. When conventional methods fail to relieve the obstruction, cryoextraction a novel technique, may prove to be a useful alternative for the removal of these clots and mucus plugs. Cryoextraction is best performed with rigid bronchoscopic intubation. However, in certain conditions, it may be used with a flexible fiberoptic bronchoscope (FOB) through an endotracheal tube, especially when bedside procedure is required in ICU patients. In this series, three cases are being discussed where bedside flexible bronchoscopy-guided cryoextraction was done leading to a successful resolution of acute hypoxemic respiratory failure.

CASE REPORT

Mohamed Mortada, Alaeldin Ali, Vickrant Malhotra, Kandy Koul, Aanchal Singh

Cardioembolic Stroke with Peripartum Cardiomyopathy: An Unusual Presentation

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:3] [Pages No:97 - 99]

Keywords: Cardioembolic stroke, Peripartum cardiomyopathy, Stroke with peripartum cardiomyopathy

PDF  |  DOI: 10.5005/jp-journals-10071-23708  |  Open Access |  How to cite  | 

Abstract

Cardioembolic stroke in a patient with peripartum cardiomyopathy (PPCM) patient is rare despite a higher incidence of thromboembolic events. We report a case of acute right middle cerebral artery territory cardioembolic stroke in a postpartum female as the initial presenting feature of PPCM. The patient was thrombolyzed with intravenous alteplase and had an almost complete neurological recovery.

CASE REPORT

Sweety Shinde

A Rare Quadruple Association: Fibromuscular Dysplasia, Giant Splenic Artery Aneurysm, Extrahepatic Portal Hypertension, and Hypersplenism

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:4] [Pages No:100 - 103]

Keywords: Extrahepatic portal hypertension, Fibromuscular dysplasia, Hypersplenism, Non-cirrhotic portal hypertension, Pancytopenia, Portal cavernoma, Splenic artery aneurysm

PDF  |  DOI: 10.5005/jp-journals-10071-23710  |  Open Access |  How to cite  | 

Abstract

Fibromuscular dysplasia (FMD) is a non-atherosclerotic, non-inflammatory vascular lesion. It is a very rare cause of splenic artery aneurysm (SAA). An 18-year-old girl presented with hematemesis, melena, pancytopenia, and splenomegaly. Endoscopy showed esophageal varices. Computed tomography angiography showed splenic infarct and a giant splenic artery aneurysm. Portal vein showed cavernous transformation with enlarged periportal and lienorenal collaterals. The liver and pancreas were unremarkable. Microscopy of the SAA revealed intimal fibroplasia and medial dysplasia. Symptoms of extrahepatic portal hypertension were relieved by aneurysmectomy, thus proving SAA as the underlying cause. Pancytopenia was reversed post-splenectomy, thus proving hypersplenism. This is the first-ever report showing a quadruple association of FMD, splenic artery aneurysm, extrahepatic portal hypertension, and hypersplenism. Key messages: Fibromuscular dysplasia can present as a giant aneurysm of the splenic artery. The resultant extrahepatic portal hypertension and splenomegaly can result in hypersplenism. Splenectomy and aneurysmectomy can reverse pancytopenia and portal hypertension.

LETTER TO THE EDITOR

Jay Prakash, Pradip K Bhattacharya, Shio Priye, Naveen Kumar

Post-COVID-19 Pulmonary Fibrosis: A Lifesaving Challenge

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:2] [Pages No:104 - 105]

Keywords: Coronavirus disease 2019, Pulmonary fibrosis,Consequences

PDF  |  DOI: 10.5005/jp-journals-10071-23709  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Enrico Baldi

Lack of Cardiopulmonary Resuscitation Knowledge among Young Medical Doctors: A Worldwide Issue

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:1] [Pages No:106 - 106]

Keywords: Cardiopulmonary resuscitation, Medical education, Medical student

PDF  |  DOI: 10.5005/jp-journals-10071-23701  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Karapparambil Vineeth Chandran, Siju V Abraham

In Response to the Letter to the Editor Submitted Titled “Lack of CPR Knowledge among Young Medical Doctors: A Worldwide Issue”

[Year:2021] [Month:January] [Volume:25] [Number:1] [Pages:1] [Pages No:107 - 107]

Keywords: Basic life support, Cardiopulmonary resuscitation (CPR), Young doctors

PDF  |  DOI: 10.5005/jp-journals-10071-23697  |  Open Access |  How to cite  | 

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