Indian Journal of Critical Care Medicine

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2021 | December | Volume 25 | Issue 12

EDITORIAL

Subhash Todi

Is It a Wave or a Tsunami? That is the Question

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1331 - 1332]

Keywords: COVID-19 mortality, COVID-19, ICU admission

   DOI: 10.5005/jp-journals-10071-24060  |  Open Access |  How to cite  | 

EDITORIAL

Kapil Zirpe, Shrirang N Bamne

Compass in COVID-19 Illness: Disseminated Intravascular Coagulation/Sepsis-induced Coagulopathy Scoring in Predicting Severity

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1333 - 1334]

Keywords: COVID-19, COVID-19 infection, COVID-19 mortality, D-dimer, Pulmonary embolism, Sepsis

   DOI: 10.5005/jp-journals-10071-24061  |  Open Access |  How to cite  | 

EDITORIAL

Jignesh Shah

Insulin Resistance and Homeostatic Model Assessment in Critically Ill: Where do We Stand?

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1335 - 1336]

Keywords: Critically ill, Homeostatic model assessment-insulin resistance, Insulin resistance

   DOI: 10.5005/jp-journals-10071-24059  |  Open Access |  How to cite  | 

EDITORIAL

Shilpa Abraham

PcvCO2−PaCO2/CaO2−CcvO2 Ratio: The Holy Grail in Resuscitation!

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1337 - 1338]

Keywords: Biochemical markers, Resuscitation, Shock septic

   DOI: 10.5005/jp-journals-10071-24062  |  Open Access |  How to cite  | 

EDITORIAL

Vijai Williams, Vichithra Mohandoss

Portending Complications in Pediatric Diabetic Ketoacidosis

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1339 - 1340]

Keywords: Acute kidney injury, Cerebral edema, Diabetic ketoacidosis

   DOI: 10.5005/jp-journals-10071-24064  |  Open Access |  How to cite  | 

EDITORIAL

Jigeeshu Vasishtha Divatia

Are Mechanically Ventilated Patients with COVID-19 More Likely to Die Than Those without COVID-19? Perhaps Not

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1341 - 1342]

Keywords: Acute hypoxemic respiratory failure, APACHE IV, COVID-19 mortality, Mechanical ventilation, Mortality, Pneumonia

   DOI: 10.5005/jp-journals-10071-24065  |  Open Access |  How to cite  | 

Original Article

Kapil Zirpe, Subhal Dixit, Rahul A Pandit, Priya Ranganathan, Sayi Prasad, Zafer Khan Amanulla, Vatsal Kothari, Sourabh Ambapkar, Shrikant Shastrabuddhe, Vinod Gosavi, Mukund Joshi, Bindu Mulakavalupil, Charlotte Saldhanah, Saanvi Ambapkar, Madhura Bapte, Sweta Singh, Abhijit Deshmukh, Khalid Khatib, Anmol Zirpe, Gowri Sayiprasad, Ameya Joshi

The Second- vs First-wave COVID-19: More of the Same or a Lot Worse? A Comparison of Mortality between the Two Waves in Patients Admitted to Intensive Care Units in Nine Hospitals in Western Maharashtra

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:6] [Pages No:1343 - 1348]

Keywords: Comorbidities, COVID-19, First wave, ICU mortality, Second wave, Ventilatory support

   DOI: 10.5005/jp-journals-10071-24042  |  Open Access |  How to cite  | 

Abstract

Background: India, along with the rest of the world, faced the challenging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The second wave in India lagged behind that in the Western world, due to different timing of seasons. There is scarce data about the differences between the two waves, for intensive care unit (ICU) patients. We present the data of 3,498 patients from 9 ICUs of western Maharashtra. Materials and methods: We collected prospective data of hospitalized, RT-PCR confirmed, coronavirus-2019 (COVID-19) patients, from nine tertiary centers, after institutional ethics committee (IEC) approval. Then, we segregated and analyzed the data of patients admitted to the ICU, for comorbidities, high-resolution computed tomography (HRCT) score, ventilatory support, etc. The primary outcomes were ICU and hospital mortality. We also performed multivariable analysis for predictors of ICU mortality. Results: Overall, there were 3,498 ICU patients. In the first wave, 1,921 patients needed ICU admission, while in the second wave, 1,577 patients. Patients in the second wave had significantly higher ICU (26.1 vs 13.4%, p <0.001) and hospital mortality (29.9 vs 18.2%, p <0.001) and need for ventilatory support of any type. More patients received steroids during the second wave. On multivariable regression, male gender, ICU admission during the second wave, increasing HRCT score, and need for intubation and mechanical ventilation were significant predictors of ICU mortality. Conclusion: ICU patients admitted during the two waves were of the similar age, but there were more females, and more patients had comorbidities during the second wave. The ICU and hospital mortality were significantly higher during the second wave.

Original Article

Shanta Dutta, Aayushi Mahajan, Munisha Agarwal

Comparison of Clinical Characteristics and Outcome of Critically Ill Patients Admitted to Tertiary Care Intensive Care Units in India during the Peak Months of First and Second Waves of COVID-19 Pandemic: A Retrospective Analysis

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:8] [Pages No:1349 - 1356]

Keywords: Coronavirus disease-2019, Coronavirus disease-2019 intensive care unit, Coronavirus disease-2019 in India, Mortality, Predictors, Severity

   DOI: 10.5005/jp-journals-10071-24046  |  Open Access |  How to cite  | 

Abstract

Background: Coronavirus disease-2019 (COVID-19) continues to pose serious challenges to healthcare systems globally with the disease progressing over time in crest-trough pattern of waves. We compared the patient characteristics and outcomes of critically ill patients admitted during the first and second waves of COVID-19 pandemic. Materials and Methods: We did a retrospective analysis of medical records of critically ill patients admitted to intensive care unit (ICU) at the peak period of both waves. The data on demographics, symptoms, treatment received, and outcomes of patients were recorded. Results: Compared to first wave, significantly more females, younger age group, and those without underlying comorbidities required ICU admission during the second wave. The treatments received during both periods were similar except for preferential use of methylprednisolone over dexamethasone and proclivity of bilevel positive airway pressure (BiPAP) ventilation over high-flow nasal cannula (HFNC). There was no significant difference in the duration of ICU stay and mortality of patients. During the first wave, the factors associated with nonsurvival of patients were advanced age, comorbidities, severe disease, and a lesser number of days on HFNC. All these factors along with higher Sequential Organ Failure Assessment (SOFA) score were observed to be linked with patient nonsurvival during the second wave. Conclusion: In India, the second wave of COVID-19 significantly influenced ICU demographics with a predominance of females and young adults requiring critical care. During both time periods, patients received similar treatment except for the propensity to use methylprednisolone and BiPAP as opposed to dexamethasone and HFNC in second wave. No significant difference in ICU mortality was noted.

Original Article

Mayank Kapoor, Prasan Kumar Panda, Lokesh Kumar Saini, Yogesh Bahurupi

Disseminated Intravascular Coagulation Score and Sepsis-induced Coagulopathy Score in Prediction of COVID-19 Severity: A Retrospective Analysis

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:7] [Pages No:1357 - 1363]

Keywords: Coronavirus disease-2019, Disseminated intravascular coagulation score, Hospital mortality, Pulmonary embolism, Sepsis-induced coagulopathy score

   DOI: 10.5005/jp-journals-10071-24056  |  Open Access |  How to cite  | 

Abstract

Background: The novel disseminated intravascular coagulation (DIC) score (platelet count, prolonged prothrombin time, D-dimer, and fibrinogen) and sepsis-induced coagulopathy (SIC) score (platelet count, international normalized ratio, and sequential organ failure assessment score) are markers of coagulopathy, which, for the first time, are explored in line with the coronavirus disease-2019 (COVID-19) disease outcomes. The correlation of D-dimer with these findings is also studied. Materials and methods: A retrospective analysis of hospital-based records of 168 COVID-19 patients was done. Data including D-dimer, routine investigations, DIC, and SIC scorings (all within 3 days of admission) were collected and correlated with the outcomes. The study was conducted in a tertiary care center catering to North India\'s population. Results: Higher DIC score (1.59 ± 1.18 vs 0.96 ± 1.18), SIC score (1.60 ± 0.89 vs 0.63 ± 0.99), and D-dimer titers (1321.33 ± 1627.89 vs 583·66 ± 777.71 ng/mL) were significantly associated with severe COVID-19 disease (p <0.05). DIC score and SIC score ≥1, and D-dimer ≥1315 ng/mL for severe disease; DIC score ≥1, SIC score ≥2, and D-dimer ≥600 ng/mL for pulmonary embolism (PE); and DIC score and SIC score ≥1, and D-dimer level ≥990 ng/mL for mortality were the respective cutoff values we found from our study. Conclusion: Higher DIC scores, SIC scores, and D-dimer values are associated with severe COVID-19 disease, inhospital mortality, and PE risk. They can serve as easily accessible early markers of severe disease and prioritize hospital admissions in the presently overburdened scenario and may be used to develop prognostic prediction models.

Original Article

Sonu Sama, Gaurav Jain, Ravi Kant, Manisha Naithani, Ajit Kumar

Quantifying the Homeostatic Model Assessment of Insulin Resistance to Predict Mortality in Multi-organ Dysfunction Syndrome

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:6] [Pages No:1364 - 1369]

Keywords: Blood glucose monitoring, Critical illness, Diabetes mellitus, ICU mortality, Insulin resistance

   DOI: 10.5005/jp-journals-10071-24043  |  Open Access |  How to cite  | 

Abstract

Background: Insulin resistance is an integral component of a multi-organ dysfunction syndrome (MODS) associated with increased mortality. We determined a cutoff value for the homeostatic model assessment of insulin resistance (HOMA-IR) during an ICU admission that could predict 28-day mortality of nondiabetic MODS patients. Materials and methods: In this prospective, outcome assessor blinded cohort design, we evaluated 82 such patients for fasting blood glucose (FBG)/insulin levels (FIL) during an ICU admission and followed their outcome for 28 days. The primary outcome variable was the HOMA-IR score calculated from the above variables. The statistical tool included receiver operating characteristic curve, Youden index, and correlation and regression analysis. Results: Overall, 38 patients succumbed to their illness. The optimal cutoff value for HOMA-IR was ≥1.61 (area under curve: 0.684, sensitivity: 36.8%, specificity: 95.5%). The 28-day survival was significantly lower (p = 0.001) at HOMA-IR threshold ≥1.61 (odds ratio: 12.25, hazard ratio: 2.98). The mean HOMA-IR among survivors vs nonsurvivors was 0.76 ± 0.61 and 1.38 ± 1.14, respectively (p = 0.004). Except for FIL and FBG, HOMA-IR values did not correlate with any other baseline or outcome parameters (demographics, APACHE II/sequential organ failure assessment score, vasopressor needs, or ICU/hospital stay). On comparing these parameters across the HOMA-IR threshold, only FIL and the hospital stay varied significantly. Most of the outcome parameters, however, varied significantly among nonsurvivors vs survivors. Conclusion: The HOMA-IR is a significant predictor of mortality in MODS. Its cutoff value may assist in determining a reference range for critically ill patients. Its routine use in the light of other disease severity scores may serve in their better prognostication.

Original Article

Shyam Madabhushi, Rahul K Anand, Rashmi Ramachandran, Preet M Singh, Vimi Rewari

Temporal Evolution of the PcvCO2–PaCO2/CaO2–CcvO2 Ratio vs Serum Lactate during Resuscitation in Septic Shock

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:7] [Pages No:1370 - 1376]

Keywords: PcvCO2–PaCO2/CaO2–CcvO2 ratio, Resuscitation, Septic shock, Serum lactate

   DOI: 10.5005/jp-journals-10071-24044  |  Open Access |  How to cite  | 

Abstract

Background: Lactate as a target for resuscitation in patients with septic shock has important limitations. The PcvCO2–PaCO2/CaO2–CcvO2 ratio may be used as an alternative for the same. The primary outcome of the study is to evaluate the correlation between serum lactate and PcvCO2–PaCO2/CaO2–CcvO2 ratio measured at various time points to a maximum of 24 hours in patients with septic shock [mean arterial pressure (MAP) <65 mm Hg]. The secondary outcomes were to study the (1) relationship between the PcvCO2–PaCO2/CaO2–CcvO2 ratio and lactate clearance at 6, 12, and 24 hours as compared to the initial serum lactate, (2) to ascertain whether the PcvCO2–PaCO2/CaO2–CcvO2 ratio and the arterial lactate levels in the first 24 hours are able to predict mortality at day 28 of enrollment, and (3) to determine whether the PcvCO2–PaCO2/CaO2–CcvO2 ratio and arterial lactate are useful in discriminating survivors from nonsurvivors. Materials and methods: Thirty patients with sepsis-induced hypotension who were being actively resuscitated were enrolled. Paired arterial and central venous blood samples were obtained 0.5 hourly till stabilization of MAP and 6 hourly thereafter for the first 24 hours. Patients were followed up to day 28 of enrollment for mortality and organ system failure. Results: A positive correlation was observed between arterial lactate and PcvCO2–PaCO2/CaO2–CcvO2 ratio at 0, 6, 12, and 18 hours (R = 0.413, p = 0.02; R = 0.567, p = 0.001; R = 0.408, p = 0.025; R = 0.521, p = 0.003, respectively). No correlation was seen between PcvCO2–PaCO2/CaO2–CcvO2 ratio and lactate clearance. The subgroup analysis showed that PcvCO2–PaCO2/CaO2–CcvO2 ratio >1.696 at 24 hours of resuscitation predicted 28-day mortality (sensitivity: 80%, specificity 69.2%, area under the receiver operating characteristic curve 0.82). Conclusion: The PcvCO2–PaCO2/CaO2–CcvO2 ratio and lactate are positively correlated during the first 24 hours of active resuscitation from sepsis-induced hypotension, and a threshold of 1.696 mm Hg/mL/dL at 24 hours significantly differentiates survivors from nonsurvivors (CTRI/2017/11/010342).

Original Article

Subhash Todi, Sounak Ghosh

A Comparative Study on the Outcomes of Mechanically Ventilated COVID-19 vs Non-COVID-19 Patients with Acute Hypoxemic Respiratory Failure

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:5] [Pages No:1377 - 1381]

Keywords: Acute respiratory distress syndrome, COVID-19, Mechanical ventilation, Non-COVID-19

   DOI: 10.5005/jp-journals-10071-24009  |  Open Access |  How to cite  | 

Abstract

Background: Due to the coronavirus disease-2019 (COVID-19) pandemic, there has been a surge of patients requiring mechanical ventilation over a short period of time. The morbidity and mortality outcome in these patients have been variably reported in the published literature. Comparative analyses of ventilated COVID-19 and non-COVID-19 patients during the same time period have been lacking. Materials and methods: Prospective data for each mechanically ventilated patient was collected from both COVID-19 and non-COVID ICU for a period of 8 months. Their demographic details and disease severity scores were included. Risk-adjusted outcomes across two groups were analyzed using multivariable regression methods. Results: Crude ICU and hospital mortality were similar in COVID-19- and non-COVID-19 ventilated groups (43.8 vs 40% and 43.8 vs 41.1%, respectively; p >0.05). After risk adjustment for the severity of illness by APACHE IV, no significant differences were observed in ICU mortality (OR 1.498; 95% CI 0.669–3.327; p = 0.328) and hospital mortality (OR 1.574; 95% CI 0.707–3.504; p = 0.267). However, mechanically ventilated COVID-19 patients had increased ICU stay (OR 6.261; 95% CI 3.778–8.744; p <0.001) as well as prolonged ventilatory support (OR 4.358; 95% CI 2.910–7.424; p <0.001) when compared to non-COVID-19 patients. Conclusion: In mechanically ventilated patients, no significant differences in terms of mortality were noted between COVID-19 and non-COVID-19 patients. Mechanically ventilated COVID-19 patients had longer ICU stay and more number of days on ventilation.

Original Article

Manpreet Kaur, Richa Aggarwal, Venkata Ganesh, Rakesh Kumar, Nishant Patel, Arshad Ayub, Kapil D Soni

Clinical Course and Outcome of Critically Ill Obese Patients with COVID-19 Admitted in Intensive Care Unit of a Single Center: Our Experience and Review

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:5] [Pages No:1382 - 1386]

Keywords: Coronavirus disease-2019, Obesity, Pandemic, Predictors of mortality

   DOI: 10.5005/jp-journals-10071-24047  |  Open Access |  How to cite  | 

Abstract

Introduction: Obesity has been considered as one of the independent risk factors for a severe form of coronavirus disease-2019 (COVID-19) and relationship between obesity, critical illness, and infection is still poorly understood. We herein discuss clinical course and outcome of critically ill obese patients with COVID-19 admitted to critical care unit. Materials and methods: We retrospectively analyzed data of critically ill obese patients hospitalized with COVID-19 over a span of 6 months. Management was guided according to the institutional protocol. Collected data included demographic parameters (age, sex, comorbidities, and body mass index (BMI)), complications, inflammatory markers (interleukin (IL)-6, Ferritin), length of mechanical ventilation, length of intensive care unit (ICU) stay, and inhospital death. Results: There was no appreciable difference in terms of demographics, inflammatory markers, predictors of mortality scores, and comorbidity indices between the survivors and nonsurvivors. Among outcome analysis, there was a statistically significant difference between ventilator days between survivors and nonsurvivors (p = 0.003**). Conclusion: Obesity itself is a significant risk factor for severe COVID-19 infection; however, if efficiently managed and in a protocol-determined manner, it can have a favorable outcome.

Original Article

Sujith Mathew John, Ananth John, Darpanarayan Hazra, Sanjay Murugan, Kundavaram Paul Prabhakar Abhilash

Prevalence, Spectrum, and Outcome of Deliberate Self-harm Presenting to Emergency Department during COVID-19 Pandemic of 2020

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:8] [Pages No:1387 - 1394]

Keywords: COVID-19, Deliberate self-harm, Lockdown, Pandemic, Poisoning

   DOI: 10.5005/jp-journals-10071-24050  |  Open Access |  How to cite  | 

Abstract

Background: The coronavirus disease-2019 (COVID-19) pandemic, and the lockdown imposed, has had profound social and economic consequences and thereby implications on psychological health. This study aims to understand the effects of the pandemic and the lockdown on the prevalence, spectrum, and outcome of patients presenting with deliberate self-harm (DSH) to the emergency department (ED). Materials and methods: This was a retrospective, observational study done in the ED of a tertiary care hospital in South India on DSH victims presenting from January to August 2020, spanning the prelockdown, lockdown, and unlock phases of the pandemic, and compared with data from a similar period in 2018. Results: Our study population included 507 DSH victims (prevalence: 1.2%) from January to August 2020. The percentage of DSH cases showed a slight increase among the prelockdown (203/17,234: 1.18%), the lockdown (179/14,687: 1.22%), and the unlock phases (125/9,977: 1.25%). There was a female preponderance (286/507: 56.4%), and the mean age was 33.2 years. Of the 507 patients, 369 (72.8%) were admitted and 19 (3.7%) died. The lockdown period in 2020 showed a 40.9% absolute decrease in the number of DSH victims presenting to the ED as compared to an equivalent period in 2018. The proportion of patients taking plant poisons was significantly lower [odds ratio (OR) 0.38, 95% confidence intervals (CI) 0.18–0.81, p = 0.012] and that of corrosive ingestion was significantly higher (OR 2.94, 95% CI 1.57–5.48, p = 0.001) in the lockdown phase as compared to a lockdown-control phase of 2018. Conclusion: There was a reduction in the absolute number of patients presenting with DSH to the ED during January–August 2020, and more so during the lockdown phase (March 24–June 30), as compared to a similar period in 2018. There was no significant difference in the hospital outcome of DSH patients between the two periods.

Original Article

Deependra K Rai, Nishant Sahay, Pallavi Lohani

Clinical Characteristics and Treatment Outcomes of 293 COVID-19 Patients Admitted to the Intensive Care Unit of a Tertiary Care Hospital of Eastern India

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:7] [Pages No:1395 - 1401]

Keywords: Coronavirus disease-2019, Intensive care unit, Mortality, Predictors

   DOI: 10.5005/jp-journals-10071-24048  |  Open Access |  How to cite  | 

Abstract

Objectives of the study: The objectives of the study were to assess the mortality among critically ill coronavirus disease (COVID) patients and to look at the factors which could have a bearing on mortality of these patients presenting to our designated tertiary COVID care institute. Method: This was a retrospective observational study involving all adult patients admitted to our intensive care unit (ICU) with coronavirus disease-2019 (COVID-19) infection between June 30, 2020, and August 31, 2020. We compared patient-related factors and laboratory test results among all survivors vs nonsurvivors in our ICU with an aim to predict the factors which could predict increased risks of mortality among sick patients admitted to our ICU. Results and conclusion: The overall ICU mortality in our ICU during the study period was 76.69% and less than 5% of the patients requiring mechanical ventilation within 1 day of admission, survived. More than half of the deaths (54.66%) occurred within 5 days of ICU admission. The best predictors for mortality based upon the Cox proportional hazard ratio are increasing age, neutrophilia, increased D-dimer, prolonged stay in ICU for 1–2 weeks, and those requiring mechanical ventilation. Patients with one or more comorbidities were noted to have 16% of higher risk of death than those without any comorbidity.

Original Article

Sriram Sampath, Jeswin Baby, Bhuvana Krishna, Nandini Dendukuri, Tinku Thomas

Blood Cultures and Molecular Diagnostics in Intensive Care Units to Diagnose Sepsis: A Bayesian Latent Class Model Analysis

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:6] [Pages No:1402 - 1407]

Keywords: Bayesian analysis, Blood culture, Intensive care unit, Molecular diagnostics, Sepsis

   DOI: 10.5005/jp-journals-10071-24051  |  Open Access |  How to cite  | 

Abstract

Background: Confirmation of sepsis by standard blood cultures (STD) is often inconclusive due to slow growth and low positivity. Molecular diagnostics (MOL) are faster and may have higher positivity, but test performance can be inaccurately estimated if STD methods are used as comparators. Bayesian latent class models (LCMs) can evaluate diagnostic methods when there is no “gold standard.” Intensive care unit studies that have used LCMs to combine and compare STD and MOL method performance and estimate the prevalence of sepsis have not been described. Patients and methods: Results from an ICU sepsis study that used both tests simultaneously were analyzed. Bayesian LCMs combined prior prevalence of sepsis, prior diagnostic characteristics of the two methods, and the study results to estimate the posterior prevalence and diagnostic characteristics. Sensitivity analyses were performed using objective (published studies) and subjective (expert opinion) prior parameters. Positive predictive values (PPVs) of the prevalence of sepsis were estimated for all combinations of test results. Results: The range of posterior estimates was: sepsis prevalence (0.38–0.88), sensitivities (STD: 0.2–0.35, MOL: 0.56–0.86), and specificities (STD: 0.87–0.99, MOL: 0.72–0.95). The PPV (sepsis) of both tests being positive was (0.72–0.99). Conclusion: LCMs combined two imperfect methods to estimate prevalence, PPV, and diagnostic characteristics. The posterior estimates (STD sensitivity < MOL and STD specificity > MOL) seem to reflect the clinical experience appropriately. The high PPV when both methods show positive results can be useful for ruling in disease.

Original Article

Kapil Dev Soni, Richa Aggarwal

Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:5] [Pages No:1408 - 1412]

Keywords: In-hospital cardiac arrest, Outcomes, Prognostic factors

   DOI: 10.5005/jp-journals-10071-24057  |  Open Access |  How to cite  | 

Abstract

Background and aims: The prognosis of patients with cardiac arrest following trauma is poor. Our objectives were: (1) to determine outcomes of patients following in-hospital cardiac arrest posttrauma and admitted to the intensive care unit (ICU) and (2) to identify characteristics associated with in-hospital mortality. Materials and methods: This was a single-center retrospective analysis of patients admitted to ICU after resuscitation following in-hospital cardiac arrest between January 2017 and July 2018. Patients with isolated head injuries and multiple cardiac arrests were excluded. Bivariate analysis was done to determine a significant association between baseline characteristics and in-hospital mortality. Results: A total of 37 patients were included. About 35.1% of trauma subjects survived hospital discharge. Bivariate analysis showed positive association between admission Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores with in-hospital mortality. Other characteristics, such as age, duration of cardiopulmonary resuscitation (CPR), and serum lactate levels on admission, were not associated with in-hospital mortality. Conclusion: Despite being at lower survival following a cardiac arrest after trauma, approximately one-third of the patients survived hospital discharge. This implies that aggressive support of this population is not necessarily futile. Optimization of postresuscitation physiological factors and their impacts on outcomes for these patients need further studies.

Original Article

Tilani M Jayasinghe Arachchi, Vasanthi Pinto

Understanding the Barriers in Delirium Care in an Intensive Care Unit: A Survey of Knowledge, Attitudes, and Current Practices among Medical Professionals Working in Intensive Care Units in Teaching Hospitals of Central Province, Sri Lanka

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:8] [Pages No:1413 - 1420]

Keywords: Attitudes on delirium, Current practice, Delirium care, Knowledge on delirium, Sri Lanka delirium management

   DOI: 10.5005/jp-journals-10071-24040  |  Open Access |  How to cite  | 

Abstract

Background: Delirium is a common, underdiagnosed, and undertreated condition that increases morbidity and mortality in ICU patients which has an incidence up to 80%. Barriers that hinder optimum care of delirium include inadequate knowledge, poor attitudes, and low perceived importance of delirium care. Aim: To assess attitudes, knowledge, and current practices related to delirium care among medical professionals working in intensive care units (ICUs) in all teaching hospitals in Central Province, Sri Lanka, as there are no Sri Lankan studies on this regard. Method: A descriptive cross-sectional study was carried out among all medical professionals working in nine ICUs in all (n = 5) teaching hospitals in Central Province. Data were collected using a pretested self-administered questionnaire. Responses to questions were compared between postgraduate trainee medical officers (PG-MOs) and non-postgraduate-trainee medical officers (non-PG-MOs). Results: Eighty-eight questionnaires were analyzed. More than 80% of PGs and non-PG-MOs regarded ICU delirium as significant problem that should be screened and prevented. Forty-one percent stated confidence in diagnosing delirium. However, more than 75% of non-PG-MOs failed to recognize features of hypoactive delirium. Only 30–50% subjects in incorporated preventive methods in usual practice and more than 60% non-PG-MOs had poor knowledge and experience on delirium screening. More than 80% of the participants did not routinely screen their patients. More than 90% non-PG-MOs (p <0.05) had no recent educational exposure. Conclusion: A positive attitude toward the importance of management of delirium was observed. However, there is a discrepancy between the perceived importance and the current practice related to screening and prevention. Participants, especially non-PG-MOs, lacked knowledge on delirium screening, diagnosis, and identification of risk factors, probably related to a lack of educational exposure.

Original Article

Amit M Narkhede, Harish K Chaudhari, Natesh Prabu Ravisankar, Ujwal Dhundi, Satish Sarode, Jigeeshu Divatia

Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:6] [Pages No:1421 - 1426]

Keywords: Critically ill patients, Hospital mortality, Medical admissions, Solid organ malignancy, Unplanned admissions

   DOI: 10.5005/jp-journals-10071-24052  |  Open Access |  How to cite  | 

Abstract

Objectives: Critically ill solid organ malignancy patients admitted to intensive care unit (ICU) as unplanned medical admissions behave differently from other subsets of cancer patients (hematolymphoid malignancies and cancer patients admitted for postoperative care). These patients if appropriately selected may benefit from the ICU care. There is paucity of data on critically ill unplanned admissions of solid organ malignancies from South Asia. We analyzed data of patients with solid tumors with unplanned admissions to the ICU to determine the clinical, epidemiological characteristics, and predictors of hospital mortality in an Indian ICU. Materials and methods: This prospective, observational study was done in our 14-bedded mixed medical–surgical ICU from July 2014 to November 2015. We included all consecutive adult unplanned admissions with solid organ malignancies having ICU stay of >24 hours. Surgical admissions, hematolymphoid malignancies, advanced malignancy with no treatment options, and those cured of cancer >5 years were excluded. Results: Two hundred and thirty-five consecutive patients were included in this cohort. ICU and hospital mortalities were 36.6 and 40%, respectively. On multivariate analysis, cancer status [odds ratio (OR): 3.204; 95% confidence interval (CI): 1.271–8.078], invasive mechanical ventilation (OR: 5.940; 95% CI: 2.632–13.408), and sequential organ failure assessment (SOFA) score on the day of ICU admission (OR: 1.199; 95% CI: 1.042–1.379) were independent predictors of hospital mortality. Conclusion: Acute respiratory failure and septic shock are the common reasons of unplanned ICU admission for patients with solid organ malignancies. With good patient selection, more than half of such patients are likely to be discharged alive from the hospital.

Original Article

Amit Kumar, Nidhi Goel, Shweta Tanwar

Epidemiology of Intensive Care Unit-acquired Infections in a Tertiary Care Hospital of North India

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:7] [Pages No:1427 - 1433]

Keywords: Catheter-associated urinary tract infection, Catheter-related bloodstream infection, ICU-acquired infections, ICU mortality, Incidence, Ventilator-associated pneumonia

   DOI: 10.5005/jp-journals-10071-24058  |  Open Access |  How to cite  | 

Abstract

Background: The majority of nosocomial infections in the hospital setting are found in intensive care units (ICUs). The present study was undertaken to determine the incidence, risk factors, causative microorganisms, and outcome of various ICU-acquired infections. Materials and methods: The patients admitted to the ICU of a teaching hospital in North India were prospectively studied. Detailed history, clinical examination, acute physiology and chronic health evaluation score II, simplified acute physiology score II, sequential organ failure assessment score, and baseline investigations were recorded. Patients were assessed daily till 14th day for nosocomial infection as per Centers for Disease Control and Prevention (CDC) guidelines and were followed till death or discharge. Incidence, risk factors, and outcome parameters were calculated using Student t-test, Chi-square test, and stepwise multivariate logistic regression model. Results: The overall incidence rate of ICU infections was 27.9%. The most common ICU-acquired infection was ventilator-associated pneumonia followed by catheter-related bloodstream infection and catheter-associated urinary tract infection. Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae were implicated in most of the infections. ICU length of stay (LOS) >7 days, neurological dysfunction, endotracheal intubation, ischemic heart disease, and use of antacids/H2 blockers were significantly associated with ICU-acquired infections. The mortality rate was 32.8 and 28.8% in patients with and without ICU infections, respectively (p = 0.531). The ICU LOS (19.23 ± 12.79 days) was significantly higher in the ICU infections group (p <0.001). Conclusion: Ventilator-associated pneumonia was the most common nosocomial infection in our study. Gram-negative microorganisms were the predominant causative agents for various ICU-acquired infections. Mortality was not found to be affected but ICU LOS was significantly prolonged as a consequence of the development of ICU-acquired infection.

SYSTEMATIC REVIEW

Abhishek Singh, Yudhyavir Singh, Neha Pangasa

Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:12] [Pages No:1434 - 1445]

Keywords: Air leak, COVID-19, Pneumomediastinum, Pneumothorax, Subcutaneous emphysema

   DOI: 10.5005/jp-journals-10071-24053  |  Open Access |  How to cite  | 

Abstract

Introduction: Air leak consisting of pneumothorax, pneumomediastinum, and subcutaneous emphysema has been described as one of the complications of coronavirus disease-2019 (COVID-19) infection affecting disease course and outcome. We aimed to conduct a systematic review of published literature to highlight the risk factors, types, and outcomes in COVID-19. Method: A systematic search of PubMed, Embase, Scopus, and Google Scholar was performed from November 1, 2019, to February 28, 2021. Seventy-one studies fulfilled the inclusion criteria and 136 adult patients were included in the final analysis. Results: Majority of patients were male (75.2%) with the mean age of 58 years. Hypertension was the most common comorbidity followed by diabetes mellitus. Moreover, 12.5% of patients had a history of smoking while 11.7% had preexisting lung disease. Isolated pneumothorax (48.5%) was the most common and 17.65% had developed spontaneous pneumothorax. Mean onset time was 11.6 days and 67% of patients required an intercostal drainage tube for management. Mortality was 40%, and elderly, female gender, obese and hypertensive were at higher risk. Conclusion: COVID-19-related air leaks are associated with higher mortality and longer hospital stay and can occur even without positive pressure ventilation. History of smoking and preexisting lung disease has not been shown to increase the incidence of air leak. A well-designed study is required for a better understanding of COVID-19-related air leak.

Pediatric Critical Care

Veena Raghunathan, Ganesh Jevalikar, Maninder Dhaliwal, Dhirendra Singh, Sidharth K Sethi, Parjeet Kaur, Sunit C Singhi

Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:6] [Pages No:1446 - 1451]

Keywords: Acute kidney injury (AKI), Cerebral edema (CE), Diabetic ketoacidosis (DKA), Pediatric

   DOI: 10.5005/jp-journals-10071-24038  |  Open Access |  How to cite  | 

Abstract

Objectives: To study the clinical profile and risk factors of cerebral edema and acute kidney injury in children with diabetic ketoacidosis. Design: Retrospective review of medical records. Patients: Fifty consecutive patients (age <18 years) admitted to our pediatric intensive care unit with a diagnosis of diabetic ketoacidosis over 5 years. Materials and methods: Retrospective analysis of medical records was done, and data including patients’ age, sex, presenting features, biochemical profile including blood glucose, osmolality, urea, creatinine, and venous blood gas, electrolytes were recorded at admission, at 12 and 24 hours. Treatment details including fluid administration, rate of fall of glucose, time to resolution of diabetic ketoacidosis were noted. Complications such as cerebral edema and acute kidney injury were recorded. Patients with and without cerebral edema and acute kidney injury were compared. Variables that were significant on univariate analysis were entered in a multiple logistic regression analysis to determine the independent predictors for cerebral edema and acute kidney injury. Odds ratio and 95% confidence interval were calculated using SPSS version 22. Measurements and main results: Between November 2015 and 2020, 48 patients were admitted for a total of 50 episodes of diabetic ketoacidosis. Two patients had recurrent diabetic ketoacidosis. Median age was 9.5 years (range 1–17). Thirty-one patients (62%) had new-onset type I diabetes mellitus. Twenty-two patients (44%) presented with severe diabetic ketoacidosis. Cerebral edema and acute kidney injury were seen in 11 (22%) and 15 (30%) patients, respectively. On multiple logistic regression analysis, higher blood urea level, lower serum bicarbonate level, and higher corrected sodium levels at admission were identified to be variables independently associated with risk of cerebral edema. Conclusions: Higher corrected sodium, higher urea level, and lower serum bicarbonate levels at admission are predictive of cerebral edema in patients presenting with diabetic ketoacidosis. The severity of dehydration and acidosis in DKA appears to be a common factor responsible for the development of dysfunction of both brain and kidney.

CASE SERIES

Vivek Kakar, Anita North, Gurjyot Bajwa, Nuno Raposo, G Praveen Kumar

Long Runs and Higher Incidence of Bleeding Complications in COVID-19 Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: A Case Series from the United Arab Emirates

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:7] [Pages No:1452 - 1458]

Keywords: Acute respiratory distress syndrome, COVID-19, Extracorporeal membrane oxygenation, SARS-CoV-2

   DOI: 10.5005/jp-journals-10071-24054  |  Open Access |  How to cite  | 

Abstract

Although the pathophysiology of pulmonary disease caused by coronavirus disease-2019 (COVID-19) is not yet fully understood, successful extracorporeal membrane oxygenation (ECMO) use has been reported for COVID-19-related severe acute respiratory distress syndrome (ARDS). We report a case series of 12 patients who received long venovenous ECMO (VV ECMO) runs for refractory hypoxia (median PF ratio of 71.8, interquartile range (IQR) 53.5–78.5) from COVID-19-related ARDS. A majority (75%) of the patients were males with a median age of 44 (IQR 37–53.5). Overall, six (50%) patients survived to hospital discharge with five of them (83.3%) noted to be cerebral performance category 1 or 2 at the time of discharge. Survivors consistently showed an improvement in sequential organ failure assessment scores within 72 hours of ECMO initiation. The median ECMO duration was 28 days (IQR 13.5–50). Despite using standard anticoagulation strategy, six (50%) of our patients had one or more major bleeding episodes, which proved to be directly fatal in four (25%) patients. Although the overall outcomes of our cohort were acceptable, our patients had much longer ECMO runs (mean 38 days in survivors) and with much higher, often fatal bleeding complications. We compare our data with other published COVID-19 VV ECMO series.

CASE REPORT

Pradeep Kumar HG, A Madhusudan Kalluraya, C Jithendra, Ashwin Kumar, Sudhindra P Kanavehalli, Arul D Furtado, Ravindra Mehta

Venoarterial Extracorporeal Membrane Oxygenation is Effective in Severe Aluminum Phosphide Overdose Despite Delayed Presentation

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:3] [Pages No:1459 - 1461]

Keywords: Aluminum phosphide, ECMO, Multi-organ dysfunction

   DOI: 10.5005/jp-journals-10071-24041  |  Open Access |  How to cite  | 

Abstract

Aluminum phosphide (ALP) is a potentially lethal poison. The mortality rate in ALP overdose is close to 100%. ALP has no specific antidote, and only supportive therapy is possible, with timely extracorporeal support mentioned as a modality. We present a case of severe ALP overdose in a young female with delayed presentation (>24 hours) and multiorgan failure (MOF)/shock successfully managed with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Unique features of this case include consumption of lethal quantity of ALP (5 g), severe toxicity with MOF, and shock secondary to a delayed presentation, all of which incrementally added to a high mortality. This was managed with the help of VA-ECMO as a last option with a successful outcome. This highlights the fact that late ECMO deployment, despite absorption of a large quantity and MOF/shock/acidosis, can still be salvageable with appropriate management.

LETTER TO THE EDITOR

Sai Saran, Mallikarjun Dube, Afzal Azim

Less Costlier and Emergency Options for Intubation during Coronavirus Disease Times

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1462 - 1463]

Keywords: Aerosol-generating medical procedures, COVID-19, Emergency intubation, Endotracheal intubation

   DOI: 10.5005/jp-journals-10071-24049  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Subramanian Senthilkumaran, Namasivayam Balamurugan, Nanjundan Karthikeyan, Ponniah Thirumalaikolundusubramanian

Snakebite Mimicking Brain Death: Bedside Clues

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:1] [Pages No:1464 - 1464]

Keywords: Anti-snake venom, ICU management of snake bite, Neurotoxic snake bite

   DOI: 10.5005/jp-journals-10071-23851  |  Open Access |  How to cite  | 

Abstract

Agarwal et al.1 have successfully managed three cases of snakebites who manifested features similar to brain death but were not true brain dead. Most likely these cases might have gone on to a status of locked-in syndrome (LIS). LIS is a status in which there is complete paralysis of voluntary muscles in all parts of the body except for those that control eye movements. Moreover, this condition makes an individual completely mute and paralyzed in a conscious patient.2 In these individuals, communication may be possible through eye movements.

LETTER TO THE EDITOR

Divya Hirolli

Point-of-care Glucose Monitoring in COVID-19 Intensive Care Unit: How's It Different?

[Year:2021] [Month:December] [Volume:25] [Number:12] [Pages:2] [Pages No:1465 - 1466]

Keywords: Blood glucose monitoring, COVID-19, Glucose control

   DOI: 10.5005/jp-journals-10071-24037  |  Open Access |  How to cite  | 

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