Indian Journal of Critical Care Medicine

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2021 | March | Volume 25 | Issue 3

EDITORIAL

Tocilizumab in COVID-19: Is the Temptation Worthwhile?

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:2] [Pages No:247 - 248]

Keywords: Cytokine storm, Tocilizumab, IL-6 blockade

PDF  |  DOI: 10.5005/jp-journals-10071-23750  |  Open Access |  How to cite  | 

EDITORIAL

Hemanshu Prabhakar

Twenty-one Days of Solitude

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:2] [Pages No:249 - 250]

Keywords: COVID-19, Lockdown, Pandemic, Trauma

PDF  |  DOI: 10.5005/jp-journals-10071-23757  |  Open Access |  How to cite  | 

Abstract

As the world is now gradually coming out of the “lockdown” phase, one can expect a change in the demographics and epidemiology of trauma. With traffic back on roads and shifting life again towards “normalcy”, it is imperative to carry out introspection and see how we can stop trauma from reaching its pre-COVID levels.

EDITORIAL

Early CT in COVID-19: Should I or Should I Not?

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:2] [Pages No:251 - 252]

Keywords: COVID-19, Ground-glass opacification, Hypoxemia, Lung CT, Role of general physicians

PDF  |  DOI: 10.5005/jp-journals-10071-23772  |  Open Access |  How to cite  | 

EDITORIAL

Sheetal Gaikwad, Vijaya P. Patil

Does Presence of Sepsis by Itself Predispose the Patients to HCAIs?

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:2] [Pages No:253 - 254]

Keywords: Health care-associated infection, Immunoparalysis, Outcome

PDF  |  DOI: 10.5005/jp-journals-10071-23771  |  Open Access |  How to cite  | 

EDITORIAL

Ram E Rajagopalan

CPIS Lung Ultrasound and the Erratic March toward Diagnostic Certainty in VAP

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:3] [Pages No:255 - 257]

Keywords: Clinical pulmonary infection score, Diagnostic imaging, Lung ultrasound, Ventilator-associated pneumonia

PDF  |  DOI: 10.5005/jp-journals-10071-23751  |  Open Access |  How to cite  | 

EDITORIAL

Ram Gopalakrishnan

Melioidosis—Commonly Missed, Yet Not Uncommon and Eminently Treatable

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:2] [Pages No:258 - 259]

Keywords: Burkholderia, Carbapenem, Melioidosis

PDF  |  DOI: 10.5005/jp-journals-10071-23749  |  Open Access |  How to cite  | 

ORIGINAL RESEARCH

Sudhir Bhandari, Govind Rankawat, Ajeet Singh

Tocilizumab: An Effective Therapy for Severely and Critically Ill COVID-19 Patients

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:7] [Pages No:260 - 266]

Keywords: COVID-19, Cytokine storm, Interleukin-6, Tocilizumab

PDF  |  DOI: 10.5005/jp-journals-10071-23747  |  Open Access |  How to cite  | 

Abstract

Background: Tocilizumab (TCZ), a monoclonal antibody against the most prevalent cytokine interleukin-6 (IL-6), is an emerging therapeutic option for COVID-19 infections. The present study was undertaken to assess the therapeutic response of TCZ therapy in severely or critically ill COVID-19 patients and its role as an effective modality of management. Methods: The present retrospective observational study included 30 admitted severely or critically ill COVID-19 patients, treated with TCZ therapy on behalf of raised IL-6 levels. The patients’ data concerning medical history, clinical manifestation, arterial blood gas analysis, mode of oxygenation, radiological imaging, and outcome were extracted from their medical records and compared pre- and post-TCZ infusion. Results: All patients of the study group had symptomatic presentations with a mean PaO2/FiO2 (P/F) ratio of 205.41 before TCZ infusion. All patients had a raised IL-6 level (mean value 206.56 pg/mL) that was extremely elevated in 90% of patients. Infusion of TCZ dramatically reduced mean body temperature (100.78–99.32°F) and the requirement for supplemental oxygen (68–48%) and improved mean SpO2 (86–89%) and mean P/F ratio (208–240) within 24 hours. Three patients on noninvasive ventilation were weaned off after TCZ infusion. Serum levels of IL-6 were raised initially but declined within 3–5 days of post-TCZ infusion. Conclusion: TCZ appears to be an effective therapeutic option in severely or critically ill COVID-19 patients with raised IL-6 levels. TCZ immediately improves the clinical status of patients by a probable mechanism of inhibition of cytokine storm and reduces COVID-19-related mortalities.

ORIGINAL RESEARCH

Sowmya Sridharan, Ram Gopalakrishnan, Panchatcharam S Nambi, Suresh Kumar, Nandini Sethuraman, V Ramasubramanian

Clinical Profile of Non-neutropenic Patients with Invasive Candidiasis: A Retrospective Study in a Tertiary Care Center

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:6] [Pages No:267 - 272]

Keywords: Candidemia, Invasive candidiasis, Serum beta-D-glucan

PDF  |  DOI: 10.5005/jp-journals-10071-23748  |  Open Access |  How to cite  | 

Abstract

Introduction: Invasive candidiasis (IC) is a major cause of morbidity and mortality in critically ill patients in the intensive care unit (ICU). In this study, we aim to analyze the clinical profile, species distribution, and susceptibility pattern of patients with IC. Methods: Case records of non-neutropenic patients ≥18 years of age with IC between January 2016 and June 2019 at a tertiary care referral hospital were analyzed. IC was defined as either candidemia or isolation of Candida species from a sterile site (such as CSF; ascitic, pleural, or pericardial fluid; or pus or tissue from an intraoperative sample) in a patient with clinical signs and symptoms of infection. Results: A total of 114 patients were analyzed, out of which 105 (92.1%) patients had bloodstream infection (BSI) due to Candida and 9 (7.9%) had IC identified from a sterile site. Central line-associated blood stream infection (27 patients, 23.6%) and a gastrointestinal source (30 patients, 26.3%) were the most common presumed sources for candidemia. The commonest species was Candida tropicalis 42 (36.8%), followed by Candida glabrata 20 (17.5%). Serum beta-D-glucan (BDG) was done only in 32 patients of the 114 (35.3%); among those who were tested, 5 (15.6%) had a BDG value of less than 80 pg/mL despite having Candida BSI. Fluconazole sensitivity was 69.5% overall. At 14 days after diagnosis of IC, 49.1% had recovered, with the remainder having an unfavorable outcome (32.4% had died and 18.4% had left against medical advice). Clinical significance: IC is a major concern in Indian ICUs, with a satisfactory outcome in only half of our patients. Serum BDG is a valuable test to diagnose blood culture–negative IC, but more studies are needed to determine its role in the exclusion of IC, as we had a small minority of patients with negative tests despite proven IC. Conclusion: We recommend sending two sets of blood cultures and serum BDG assay for all suspected patients. Initiating empiric antifungal therapy with an echinocandin is advisable, in view of increasing azole resistance and the emergence of Candida auris, with de-escalation to fluconazole for sensitive isolates after clinical stability and blood culture clearance.

ORIGINAL RESEARCH

Darpanarayan Hazra, Anmol Jindal, Joanna P Fernandes

Impact of the Lockdown due to COVID-19 Pandemic on the Spectrum and Outcome of Trauma in India

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:6] [Pages No:273 - 278]

Keywords: COVID-19, Emergency department, Lockdown, Pandemic, Road traffic accidents, Trauma

PDF  |  DOI: 10.5005/jp-journals-10071-23758  |  Open Access |  How to cite  | 

Abstract

Background: As a pre-emptive measure against the rampaging severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), the Government of India ordered an unprecedented but imperative step of a nationwide lockdown on 22nd March, 2020. The entire month of April 2020 remained in a complete national lockdown. Methodology: We conducted this retrospective study to compare the spectrum and outcome of trauma victims who presented to our emergency department (ED) from April 2020 (lockdown period) to a similar season matched control arm of April 2018 (non-lockdown period). Results: Our study groups included 403 trauma victims (trauma prevalence: 9.7%) from April 2020 as compared to 667 trauma victims (trauma prevalence: 10.8%) from April 2018 with an absolute decrease of −39.6% during the lockdown month. The intense lockdown resulted in an absolute decrease in the number of road traffic accidents (RTA) (−75.1%), sports-related injuries (−81.8%), bull gore injuries (−64.3%), workplace-related injuries (−50.0%), and fall from height (−3.5%). However, an absolute increase in the number of falls on level ground (FLG) (+95.7%), domestic trauma (+91.4%), and burn (+37.5%) patients were noted during the lockdown period. The proportion of trauma victims under the influence of alcohol, as determined by a positive blood alcohol content, was significantly lower in the lockdown period [adjusted OR: 0.34 (95% CI: 0.17–0.67); p-value: 0.002] as were RTAs [adjusted OR: 0.44 (95% CI: 0.31–0.62); p-value: <0.001], FLG [adjusted OR: 1.87 (95% CI: 1.14–3.06); p-value: 0.0], and head injuries [adjusted OR: 0.21 (95% CI: 0.13–0.3); p-value: <0.001]. Conclusion: During the stringent lockdown period of April 2020, there was a significant absolute decrease in the number of trauma victims, especially RTAs. The intense lockdown resulted in a significant decrease in the proportion of trauma victims under the influence of alcohol, head injuries, fractures, and dislocations.

ORIGINAL RESEARCH

Marzieh Aalinezhad, Fariba Alikhani, Pooya Akbari, Mostafa Haji Rezaei, Samira Soleimani, Atousa Hakamifard

Relationship between CT Severity Score and Capillary Blood Oxygen Saturation in Patients with COVID-19 Infection

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:5] [Pages No:279 - 283]

Keywords: Computed tomography, COVID-19, CT severity score, Hypoxia

PDF  |  DOI: 10.5005/jp-journals-10071-23752  |  Open Access |  How to cite  | 

Abstract

Background: COVID-19 pneumonia is responsible for the latest pandemic. Usage of pulmonary computed tomography (CT) scan is known to be an important method in the diagnosis of COVID-19. Here, we aimed to evaluate the relationship between CT severity score and capillary blood oxygen saturation in patients with COVID-19 infection. Methods and material: This is a cross-sectional study performed in 2020 on patients with COVID-19 infection. All patients underwent pulmonary CT scan and CT severity score was calculated. The initial capillary oxygen saturation by the time of admission was also collected. Data were collected and analyzed. Results: A total number of 270 patients diagnosed with COVID-19 infection entered the study. The initial mean capillary oxygen saturation was 89.65 ± 8.09%. The mean score in patients was 15.16 ± 8.08. We also indicated that 27 patients had hypoxia by the time of admission and these patients had significantly higher CT severity scores (p = 0.001). Diabetes mellitus (p = 0.001), hypertension (p = 0.001), and chronic obstructive pulmonary disease (COPD) (p = 0.03) and totally having an underlying disease (p < 0.001) were significantly associated with decreased capillary oxygen saturation. Patients with hypertension (p = 0.001) and patients with the previous medical disease (p = 0.01) had significantly higher CT severity scores than others. There was a significant reverse relationship between CT severity score and capillary oxygen saturation (r = −0.44, p < 0.001). Conclusions: We showed that there was a significant reverse relationship between CT severity score and capillary oxygen saturation which has great clinical importance. Furthermore, we indicated that previous medical history could also play an important role in CT severity score.

ORIGINAL RESEARCH

Rupali Patnaik, Afzal Azim, Arvind K Baronia, Banani Poddar, Ratender K Singh, Zafar Neyaz

Incorporating Lung Ultrasound in Clinical Pulmonary Infection Score as an Added Tool for Diagnosing Ventilator-associated Pneumonia: A Prospective Observational Study from a Tertiary Care Center

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:8] [Pages No:284 - 291]

Keywords: Air bronchogram, Clinical pulmonary infection score, Lung ultrasound, Mini-bronchoalveolar lavage, Ventilator-associated pneumonia

PDF  |  DOI: 10.5005/jp-journals-10071-23759  |  Open Access |  How to cite  | 

Abstract

Background: Clinical pulmonary infection score (CPIS) is an established diagnostic parameter for ventilator-associated pneumonia (VAP). Lung ultrasound (LUS) is an evolving tool for diagnosing VAP. Various scores have been proposed for the diagnosis of VAP, taking LUS as a parameter. We proposed whether replacing LUS with chest radiograph in CPIS criteria will add to the diagnosis of VAP. The current study was done to evaluate the diagnostic accuracy of LUS alone and in combination with clinical and microbiological criteria for VAP by replacing chest radiograph with LUS in CPIS. Materials and methods: We conducted a prospective single-center observational study including 110 patients with suspected VAP to investigate the diagnostic accuracy of LUS. Quantitative mini-bronchoalveolar lavage (mini-BAL) culture was considered the gold standard for diagnosis of VAP. Here, the authors have explored the combination of LUS, clinical, and microbiology parameters for diagnosing VAP. On replacing chest radiograph with LUS, sono-pulmonary infection score (SPIS) and modified SPIS (SPIS-mic, SPIS-cult) was formulated as a substitute for CPIS. Results: Overall LUS performance for VAP diagnosis was good with sensitivity, specificity, positive or negative predictive value, and positive or negative likelihood ratios of 91.3%, 70%, 89%, 75%, 3, and 0.1, respectively. Adding microbiology culture to LUS increased diagnostic accuracy. The areas under the curve for SPIS and modified SPIS were 0.808, 0.815, and 0.913, respectively. Conclusion: The diagnosis of VAP requires agreement between clinical, microbiological, and radiological criteria. Replacing chest radiograph with LUS in CPIS criteria (SPIS) increases diagnostic accuracy for VAP. Adding clinical and culture data to SPIS provided the highest diagnostic accuracy. Clinical parameters along with lung ultrasound increase diagnostic accuracy for VAP.

ORIGINAL RESEARCH

Abhishek Chintamani, Bala Prakash, Babu K Abraham, Ramesh Venkataraman

Incidence and Impact of Healthcare-associated Infections on Patients Primarily Admitted with Sepsis and Non-sepsis Diagnoses

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:4] [Pages No:292 - 295]

Keywords: Healthcare-associated infections, ICU-acquired infections, Organ dysfunction, Sepsis

PDF  |  DOI: 10.5005/jp-journals-10071-23760  |  Open Access |  How to cite  | 

Abstract

Objectives: To compare the incidence of healthcare-associated infections (HAI) and their outcomes between patients admitted to the ICU with sepsis and those admitted with non-sepsis diagnoses. Materials and methods: We performed a single-center, prospective, observational study of ICU patients at a tertiary level medical-surgical unit from April 2018 to October 2018. All patients admitted to the ICU with a length of stay (LOS) > 48 hours were included. Baseline data including demographics, comorbidities, and severity of illness scores were collected. Index occurrence of HAI in all these patients was noted and data regarding organ support and patient outcomes were recorded. The incidence, complications, ICU LOS, and 30-day mortality of HAI were compared between the patients admitted to ICU originally with sepsis and non-sepsis diagnoses. Results: A total of 271 patients were evaluated in our study (N = 106 for the sepsis group and N = 165 for the non-sepsis group). No significant difference between the groups was found in the incidence of HAI (29.2% in sepsis group vs 24.4% in non-sepsis group; p = 0.07). Complications (acute kidney injury (AKI): 71 vs 45%; p = 0.01, shock: 81 vs 55%; p = 0.05, need for mechanical ventilation (MV): 30 vs 15%; p = 0.04) were more common in sepsis group compared to the non-sepsis group. The ICU LOS (12.2 ± 5.2 days vs 8.8 ± 2.05 days; p = 0.01) was significantly longer in the sepsis group. There was no significant difference in 30-day mortality between the groups (45 vs 25%; p = 0.07). Conclusion: The incidence of HAI seems to be similar between patients admitted with sepsis and non-sepsis diagnoses. However, patients admitted with sepsis develop higher rates of organ failure secondary to HAI and have a longer ICU LOS compared to patients admitted with non-sepsis diagnoses. The mortality rate of HAI did not differ between these two groups.

ORIGINAL RESEARCH

Sujatha Sistla, Apurba S Sastry, Ramanathan Venkateswaran

Concordance between the National Healthcare Safety Network (NHSN) Surveillance Criteria and Clinical Pulmonary Infection Score (CPIS) Criteria for Diagnosis of Ventilator-associated Pneumonia (VAP)

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:3] [Pages No:296 - 298]

Keywords: Anesthesia and intensive care, Clinical pulmonary infection score, Ventilator-associated pneumonia, National Healthcare Safety Network

PDF  |  DOI: 10.5005/jp-journals-10071-23753  |  Open Access |  How to cite  | 

Abstract

Background: Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections among mechanically ventilated patients and the incidence rates are widely used as an index of quality of care given in an ICU. Since there is no gold standard method available to diagnose VAP, the incidence rate varies based on different criteria used for calculation. Therefore, we conducted a study to determine the concordance between the National Healthcare Safety Network (NHSN) surveillance criteria and clinical pulmonary infection score (CPIS) criteria for the diagnosis of VAP. Materials and methods: This was a prospective study that evaluated patients in the medical intensive care units (MICUs) of a tertiary care hospital, India, who were intubated for >48 hours between October 2018 and September 2019. All the patients (n = 273) were followed up daily and assessed using both CPIS and NHSN surveillance criteria for diagnosing VAP. Results: Of these 273 patients, 93 patients (34.1%) had VAP according to CPIS criteria as compared with 33 patients (12.1%) using the NHSN criteria. The corresponding rates of VAP were 39.59 vs 11.53 cases per 1,000 ventilator days, respectively. The agreement of the two sets of criteria was fairly good (kappa statistics, 0.42) Conclusion: The NHSN surveillance criteria have a lower sensitivity in detecting VAP cases and have to be modified to achieve better results.

ORIGINAL RESEARCH

Prasadini Guru, Reddy Sailaja Mundre, Nima Lawrence, Snehali Majumder, Alben Sigamani, CN Anupama, Sudeshna Adak

Validation of an Isothermal Amplification Platform for Microbial Identification and Antimicrobial Resistance Detection in Blood: A Prospective Study

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:6] [Pages No:299 - 304]

Keywords: Blood stream infection, Diagnosis, Isothermal amplification, Pathogen detection, Sepsis

PDF  |  DOI: 10.5005/jp-journals-10071-23761  |  Open Access |  How to cite  | 

Abstract

Background: Recent advances in nucleic acid amplification technique (NAAT)-based identification of pathogens in blood stream infections (BSI) have revolutionized molecular diagnostics in comparison to traditional clinical microbiology practice of blood culture. Rapid pathogen detection with point-of-care diagnostic-applicable platform is prerequisite for efficient patient management. The aim of the study is to evaluate an in-house developed, lyophilized OmiX-AMP pathogen test for the detection of top six BSI-causing bacteria along with two major antimicrobial resistance (AMR) markers of carbapenem and compare it to the traditional blood culture-based detection. Materials and methods: One hundred forty-three patients admitted to the Medical Intensive Care Unit, Narayana Hrudayalaya, Bangalore, with either suspected or proven sepsis, of either gender, of age ≥18 years were enrolled for the study. Pathogen DNA extracted from blood culture sample using OmiX pReP method was amplified at isothermal conditions and analyzed in real time using OmiX Analysis software. Results: Among the processed 143 samples, 54 were true negative, 83 were true positive, 3 were false negative, and 2 were false positive as analyzed by OmiX READ software. Gram-negative bacteria (91.3%) and gram-positive bacteria (75%) were detected with 100% specificity and 95.6% sensitivity along with the AMR marker pattern with a turnaround time of 4 hours from sample collection to results. Conclusion: OmiX-AMP pathogen test detected pathogens with 96.5% concordance in comparison to traditional blood culture. Henceforth, OmiX-AMP pathogen test could be used as a readily deployable diagnostic kit even in low-resource settings.

ORIGINAL RESEARCH

Diksha Tyagi, Manjunath B Govindagoudar, Sushmitha Jakka, Sateesh Chandra, Dhruva Chaudhry

Correlation of PaCO2 and ETCO2 in COPD Patients with Exacerbation on Mechanical Ventilation

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:5] [Pages No:305 - 309]

Keywords: Arterial carbon dioxide, Chronic obstructive pulmonary disease, End-tidal carbon dioxide, Mechanical ventilation

PDF  |  DOI: 10.5005/jp-journals-10071-23762  |  Open Access |  How to cite  | 

Abstract

Introduction: Chronic obstructive pulmonary disease (COPD) patients in hypercapnic respiratory failure require multiple arterial blood gas (ABG) analysis for monitoring. It is a painful, invasive, and expensive investigation. This study was aimed at finding an agreement between end-tidal carbon dioxide (ETCO2, a noninvasive modality) and arterial carbon dioxide (PaCO2) in COPD patients with acute exacerbation on mechanical ventilation. Materials and methods: A prospective observational study was conducted in COPD patients who required mechanical ventilation. ETCO2 was recorded by mainstream capnography along with ABG analysis. An agreement between PaCO2 and ETCO2 was assessed. The effect of various factors on correlation was also studied. Results: A total of 100 patients with COPD in hypercapnic respiratory failure were included. Seventy-three percentage of patients were managed on invasive mechanical ventilation (IMV). The mean ETCO2 and PaCO2 were 48.66 ± 15.57 mm Hg and 75.52 ± 21.9 mm Hg, respectively. There was a significant correlation between PaCO2 and ETCO2 values (r = 0.82, 95% confidence interval of r = 0.78–0.86, p <0.0001). The Bland-Altman analysis shows the mean bias as −19.4 (95% limits of agreement = −40.0–1.1). Pearson\'s correlation coefficient was 0.84 in intubated patients and 0.58 in patients on noninvasive ventilation (NIV). Pearson\'s correlation coefficient between PaCO2 and ETCO2 in subjects with consolidation, cardiomegaly, hypotension, and raised pulmonary artery pressures was 0.78, 0.86, 0.85, and 0.86, respectively. Conclusion: Mainstream ETCO2 measurement accurately predicts the PaCO2 in COPD patients on IMV. However, for patients on NIV, ETCO2 is insufficient in monitoring PaCO2 levels due to weak correlation. Clinical significance: ETCO2 can be used as a noninvasive modality in intensive care unit for monitoring the PaCO2 in COPD patients on IMV. This can reduce the requirement of arterial blood sampling to a minimum number, in turn, reducing the cost of the treatment and discomfort to the patients.

ORIGINAL RESEARCH

Ganesh Chowhan, Riddhi Kundu

Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:7] [Pages No:310 - 316]

Keywords: Fluid responsiveness, Passive leg raising, Sepsis, Transthoracic echocardiography, Velocity time integral

PDF  |  DOI: 10.5005/jp-journals-10071-23764  |  Open Access |  How to cite  | 

Abstract

Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods: After the institutional ethics committee\'s clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18–65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as “responders.” Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 (p = 0.016), 0.440 (p = 0.052), and 0.044 (p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients.

ORIGINAL RESEARCH

Chhaya V Verma, Rachna D Arora, Hetal M Mistry, Swati V Kubal, Nandini S Kolwankar, Pranali C Patil, Anushka A Dalvi, Sonal A Vichare, Akhila Natesan, Anagha N Mangaonkar, Dolly D Kanakia, Gayatri S Jere, Karan Y Bansode, Madhura R Patil, Rajvi D Sheth, Sandhya D Dudhavade, Sayali D Mhatre, Suresh K Patel, Akanksha G Mohite, Ankita N Bhavsar, Jessica E Alfonso, Maryam NA Syed, Nidhi P Savla, Riya N Rajgond, Rutuja A Bute, Samiksha M Mane, Shubham R Jaiswal, Vibhawari A Parab, Abhiram M Kasbe, Mohan A Joshi, Ramesh N Bharmal

Changes in Mode of Oxygen Delivery and Physiological Parameters with Physiotherapy in COVID-19 Patients: A Retrospective Study

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:5] [Pages No:317 - 321]

Keywords: COVID-19, Heart rate, Mode of oxygen delivery, Oxygen saturation, Physiotherapy, Retrospective study

PDF  |  DOI: 10.5005/jp-journals-10071-23763  |  Open Access |  How to cite  | 

Abstract

Background: Coronavirus disease (COVID-19) is an infectious disease caused by SARS-CoV-2, clinically presenting with common symptoms of fever, dry cough, and breathlessness within 14 days of exposure. Its severity ranges from mild to severe, latter manifesting into severe acute respiratory syndrome. As a part of multidisciplinary team, physiotherapy along with medical management was administered to patients with COVID-19 in an acute care setup. This retrospective study aims to explore various patient characteristics and will aid in identifying the impairments associated with the disease, giving a direction to the physiotherapy community in planning future management strategy to improve quality of life. Patients and methods: The present study is a unicentric study wherein prospective analysis of retrospective data of patients referred for physiotherapy from May 13 to July 31, 2020, was performed. (i) Characteristics of patients, (ii) associated comorbidities, (iii) hospital course since the time of admission to discharge, (iv) mode of oxygen delivery, (v) pre- and post-physiotherapy treatment values of oxygen saturation and heart rate, and (vi) physiotherapy treatment were recorded. The archived data were analyzed using the commercially available SPSS software version 24. Wilcoxon\'s matched pair test was used to compare pre- and post-treatment oxygen saturation and heart rate, and McNemar\'s test was used to compare mode of oxygen delivery and pre- and post-physiotherapy treatment. Results: Descriptive analysis of data showed a better outcome in terms of grade of dyspnea and rate of discharge on day 14 of physiotherapy treatment. Hence, a comparative analysis of day 1 and day 14 was performed for mode of oxygen delivery, oxygen saturation, and heart rate. A statistically significant improvement was observed in the heart rate (p = 0.001) and oxygen delivery (p = 0.000). However, no significant difference in the level of oxygen saturation was found (p = 0.6433). Conclusion: Physiotherapy treatment in conjunction with medical treatment can be effectively administered in patients with COVID-19 in acute care setup taking into consideration the health status and the hemodynamic stability of the patients. It emphasizes the role of physiotherapy in the alleviation of symptoms, facilitating early weaning and recovery enabling early discharge from the hospital.

ORIGINAL RESEARCH

B Rajyalakshmi, P Ramakrishna Reddy, Narmada Aluru

Prognostic Value of “Cycle Threshold” in Confirmed COVID-19 Patients

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:5] [Pages No:322 - 326]

Keywords: COVID-19, Cycle threshold, RT-PCR, Viral load

PDF  |  DOI: 10.5005/jp-journals-10071-23765  |  Open Access |  How to cite  | 

Abstract

Objective: To study the correlation between the cycle threshold (CT) of reverse transcription–polymerase chain reaction (RT–PCR) test in confirmed COVID-19 patients and the severity of disease. Background: RT–PCR test is a standard method for the diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections. This test is based upon the amplification of the fluorescent signal. The number of cycles that the fluorescent signal undergoes to reach the threshold is called “cycle threshold.” It is inversely related to the nucleic acid content of the sample. Patients and methods: This is a single-centered, retrospective observational study. We have included a total of 192 patients. SARS-CoV-2 infection was confirmed by the RT–PCR test. Entire data have been collected from the electronic medical records. The primary outcome was 28-day mortality, whereas the secondary outcomes were intensive care unit (ICU) admission, invasive ventilation, acute kidney injury, renal replacement therapy (RRT), shock, and COVID-19 reporting and data system (CO-RADS) score on high-resolution computed tomography of the chest, total length of stay in the hospital, and the number of ICU days and ventilator days. Results: We have calculated the mean CT value for all groups and calculated the p-value for statistical significance. For the total length of stay in the hospital and the number of ICU days and ventilator days, we applied the Pearson correlation coefficient. The p-value was statistically significant for mortality, ICU admission, and shock groups. The CT values and the length of ICU stay were inversely correlated with the statistically significant p-value. Conclusion: Low CT value is associated with increased ICU admission, high mortality, shock, and increased length of ICU stay.

BRIEF COMMUNICATION

Vithiya Ganesan, Mariappan Murugan, Raja Sundaramurthy, Geni VG Soundaram

Melioidosis in a Tertiary Care Center from South India: A 5-year Experience

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:4] [Pages No:327 - 330]

Keywords: Melioidosis, Neuromelioidosis, Osteomyelitis, Septicemia

PDF  |  DOI: 10.5005/jp-journals-10071-23766  |  Open Access |  How to cite  | 

Abstract

The present study was done with the objective to know the clinical presentation, microbiological features, and treatment outcome of melioidosis patients in our hospital, which is an emerging infection in India, and to know the differences in clinical course and outcome between bacteremic and nonbacteremic patients. This retrospective observational study was carried out over a period of 5 years from January 2015 to December 2019. Thirty-five cases of culture-confirmed melioidosis were identified with age range between 5 and 74 years. A large number of patients (n = 31) presented with uncontrolled diabetes mellitus. Six patients died of septic shock, and the outcome of eight patients was unknown as they were discharged against medical advice. There were no relapses observed. Melioidosis growing as a neglected tropical disease in India warrants awareness among all clinicians across the country.

REVIEW ARTICLE

Vitrag Shah, Darshan Trivedi

Extra Precautions while Caring for a Suspected COVID-19 Patient in an ICU beyond PPE and Hand Hygiene

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:6] [Pages No:331 - 336]

Keywords: Corona, COVID, High-flow nasal cannula (HFNC) oxygen therapy, ICU, Infection, Infection control, Mask, Nosocomial infection

PDF  |  DOI: 10.5005/jp-journals-10071-23767  |  Open Access |  How to cite  | 

Abstract

Since the diagnosis of the first case of COVID-19 in December 2019, there have been reports of several healthcare workers infected with COVID-19. It has changed the infection control practices of most ICUs all over the world. Prevention is better than cure is definitely proven true as there is no definite cure for COVID-19 yet. Personal protective equipment and hand hygiene are a must while handling any suspected COVID-19 patient. Apart from that, there are several other things, which should be followed in ICU and specifically while caring for a patient on ventilator. There are a large number of interventions done while treating any critically ill patient in ICU, which can generate aerosols and exaggerate spread of COVID-19, which include high-flow nasal cannula, NIV, nebulization, suctioning, bag and mask ventilation, endotracheal intubation, and bronchoscopy. We will be reviewing those things beyond PPE and hand hygiene along with the rationale of each of them, which can help to minimize the risk of exposure to healthcare workers and other patients in the surrounding. It will help not only to prevent COVID-19 transmission but also to reduce overall nosocomial infection rate. As per our knowledge, this will be the first paper reviewing innovative ideas to minimize the risk of infection in a comprehensive manner.

CASE REPORT

Sumanyu Suresh, Prasan K Panda

Dichlorvos Poisoning: A Mystery Case of Distributive Shock Unraveling with Atropine

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:3] [Pages No:337 - 339]

Keywords: Autonomic dysfunction, Coma, Poisoning, Shock, Survival

PDF  |  DOI: 10.5005/jp-journals-10071-23746  |  Open Access |  How to cite  | 

Abstract

Hypotension can be explained by the cardiotoxic effects of an organophosphate poison, but a distributive shock is a rare event. This is a case report of a young north Indian man who presented to the emergency room in a comatose state and distributive shock. He was initially managed with intravenous crystalloids but required inotropic therapy to maintain the desired mean arterial pressure and organ perfusion and also required mechanical ventilation. He improved during the hospital stay only after 4 days when cocktail treatment of atropine was started considering the possibility of organophosphorus toxin exposure and had tapered off the inotropes and mechanical ventilation. Dichlorvos ingestion was confirmed later on after recovery from the coma. At 4-week follow-up, he developed delayed neuropathy. This case is a torchlight toward organophosphorus poisoning presenting as a distributive shock. Atropine may be used as a cocktail treatment in distributive shock where the diagnosis is uncertain.

CASE REPORT

Braghadheeswar Thyagarajan, Casey Bryant, Ashish K Khanna

An Incidental Finding of Coronary-cameral Fistulas in a Critically Ill Patient with a Metastatic Cardiac Tumor

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:3] [Pages No:340 - 342]

Keywords: Cardiac tumor, Coronary-cameral fistulas, Metastatic melanoma

PDF  |  DOI: 10.5005/jp-journals-10071-23768  |  Open Access |  How to cite  | 

Abstract

It is extremely rare for a cardiac tumor to present with coronary-cameral fistulas. A 66-year-old Caucasian male presented with worsening dyspnea and subsequently had a cardiac catheterization for an ST-elevation myocardial infarction, revealing no evidence of coronary artery disease but multiple coronary-cameral fistulas. Venoarterial (VA) extracorporeal membrane oxygenation was initiated for a severe cardiogenic shock. Workups including a transesophageal echocardiography and a right heart catheterization led to a diagnosis of metastatic melanoma involving both ventricles of his heart. Angiogenesis is well described in melanomas and our novel case reports the extremely rare association of coronary-cameral fistulas with a metastatic cardiac melanoma.

CASE REPORT

Rita Khanoria, Rajeev Chauhan, Rashi Sarna, Summit Bloria

Re-expansion Pulmonary Edema—A Rare Entity: A Thin Line between Pulmonary and Cardiac Decompensation

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:3] [Pages No:343 - 345]

Keywords: Critically ill patient, Re-expansion pulmonary edema, Rheumatic heart disease

PDF  |  DOI: 10.5005/jp-journals-10071-23769  |  Open Access |  How to cite  | 

Abstract

Re-expansion pulmonary edema (RPE) is a rare complication that may occur after treatment of lung collapse caused by pneumothorax, atelectasis, or pleural effusion. The amount of fluid drained and the degree of pleural suction influence the development of RPE. We present a case of RPE in a critically ill patient of scrub typhus with rheumatic heart disease, after draining only 800 mL of pleural fluid, thereby proving that the complex cardiac and pulmonary interactions play an important role in the development of RPE.

CASE REPORT

Kaladhar Sheshala, Krushna Chandra Misra, Chirumamilla Hemanth, Sreekanth Appasani

Bee Sting to Boerhaave's Syndrome

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:3] [Pages No:346 - 348]

Keywords: Acute hypoxemic respiratory failure (AHRF), Anaphylactic reaction, Esophageal injury, Pneumothorax

PDF  |  DOI: 10.5005/jp-journals-10071-23770  |  Open Access |  How to cite  | 

Abstract

Boerhaave\'s syndrome is a rare condition defined as the spontaneous rupture of the esophagus that generally occurs due to retching, forceful vomiting and sometimes even spontaneously. Atypical presentation often misleads the diagnosis leading to a delay in early intervention, and a strong clinical suspicion is indeed required to diagnose the condition. Definitive treatment being surgical repair, endoscopic intervention can be attempted in nonseptic patients.

LETTER TO EDITOR

A Proposal for Dedicated “Prone Team” and “Prone Bundle of Care” in COVID-19 ICU

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:2] [Pages No:349 - 350]

Keywords: Acute respiratory distress syndrome, COVID-19, Prone Ventilation

PDF  |  DOI: 10.5005/jp-journals-10071-23754  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Alessio Cittadini, Federica Marsigli, Andrea Sica, Domenico P Santonastaso, Emanuele Russo, Emiliano Gamberini, Vanni Agnoletti

Video Laryngoscopy-guided Nasal Intubation: One More Bullet in Our Rifle

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:1] [Pages No:351 - 351]

Keywords: Critical care, COVID-19, Fiberoptic bronchoscopy, ICU, Intubation

PDF  |  DOI: 10.5005/jp-journals-10071-23755  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Charu Mahajan, Brijesh P Singh, Indu Kapoor

Phenytoin Sodium and Acetate–Maleate Buffered Balanced Salt Solutions are Physically Incompatible!

[Year:2021] [Month:March] [Volume:25] [Number:3] [Pages:1] [Pages No:352 - 352]

Keywords: Balanced salt solutions, Incompatibility, Phenytoin

PDF  |  DOI: 10.5005/jp-journals-10071-23756  |  Open Access |  How to cite  | 

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