Indian Journal of Critical Care Medicine

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2021 | April | Volume 25 | Issue 4

EDITORIAL

Bhuvana Krishna

A Shot in the Dark!: RAAS Inhibitors Cause Severe COVID-19 Infection

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:353 - 354]

Keywords: COVID-19 infection, Renin angiotensin aldosterone system, Severe

PDF  |  DOI: 10.5005/jp-journals-10071-23796  |  Open Access |  How to cite  | 

EDITORIAL

Niraj Tyagi

Prevalence of Blood Stream Infections and Their Etiology in COVID-19 Patients: A Tale of Two Cities

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:3] [Pages No:355 - 357]

Keywords: Antibiotic treatments, Antiviral therapy, COVID-19

PDF  |  DOI: 10.5005/jp-journals-10071-23797  |  Open Access |  How to cite  | 

EDITORIAL

Asif Ahmed

Corona Collateral Damage Syndrome: Perception of the Damage

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:358 - 359]

Keywords: Damage, Health care worker, Survey,Corona

PDF  |  DOI: 10.5005/jp-journals-10071-23799  |  Open Access |  How to cite  | 

EDITORIAL

Kishore Pichamuthu

Optic Nerve Sheath Ultrasound: Where Do We Go from Here?

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:360 - 361]

Keywords: Raised intracranial pressure, Optic nerve sheath diameter, Optic nerve ultrasound

PDF  |  DOI: 10.5005/jp-journals-10071-23795  |  Open Access |  How to cite  | 

EDITORIAL

Susruta Bandyopadhyay

Profile of Obstetric Patients in Intensive Care Unit and Untold Stories behind Maternal Deaths and Life-threatening Complications

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:362 - 363]

Keywords: Obstetric critical care, Pregnancy-induced hypertension, Venous thromboembolism,Major obstetric hemorrhage, Maternal mortality

PDF  |  DOI: 10.5005/jp-journals-10071-23798  |  Open Access |  How to cite  | 

EDITORIAL

Tanmay Banerjee, Avijatri Datta

Spectrum of Plant Toxin and Deliberate Self-poisoning

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:364 - 365]

Keywords: Plant poison, Thevetia, Toxicology,Cerbera, Datura, Deliberate self-poisoning, Nerium, Oleander

PDF  |  DOI: 10.5005/jp-journals-10071-23800  |  Open Access |  How to cite  | 

ORIGINAL RESEARCH

Paidi Ramakrishna Reddy, Srinivas Samavedam, Narmada Aluru, Rajyalakshmi Boggu

Comparison of Severity of COVID-19 Infection among Patients using RAAS Inhibitors and Non-RAAS Inhibitors

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:3] [Pages No:366 - 368]

Keywords: Renin angiotensin aldosterone system, Serum ferritin, Serum interleukin-6,ACE inhibitors, Angiotensin receptor blocker, COVID-19, D dimer, Interleukin-6

PDF  |  DOI: 10.5005/jp-journals-10071-23774  |  Open Access |  How to cite  | 

Abstract

Aims and objective: The aim of the article was to study the safety profile of renin-angiotensin-aldosterone system (RAAS) inhibitor in COVID-19-affected Indian patients. Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for COVID-19 infection. There has been uncertainty about use of RAAS inhibitors in COVID-19. The association of RAAS inhibitors with severity of infection and clinical outcomes was addressed in this study. Materials and methods: This is a single-center retrospective study from Indian intensive care unit (ICU). A total of 138 were included, who were divided into group A (RAAS inhibitor) and group B (non-RAAS inhibitor). They are followed up till ICU stay during which peak levels of ferritin, D dimer, interleukin-6 were noted (primary outcome). The number of ventilator days, ICU length of stay, and ICU outcome also compared. Results: Of 138 patients, 18 are included in group A and 120, in group B. There is no difference in peak levels (mean) D dimer [5,893 vs 7,710, p 0.46], ferritin [2,388 vs 3,635, p 0.56], interleukin-6 [9,597 vs 3,625, p 0.06]. There is no difference in number of ventilator days (2.2 vs 1.78, p 0.53) and ICU length of stay (6.5 vs 6.1, p 0.74). Conclusion: RAAS inhibitors can be safely continued in COVID-19 infection. It is not associated with an increase in severity of infection, ICU length of stay, and mortality.

ORIGINAL RESEARCH

Ekadashi Rajni, Vishnu K Garg, Daisy Bacchani, Richa Sharma, Rajat Vohra, Vedprakash Mamoria, Hemant Malhotra

Prevalence of Bloodstream Infections and their Etiology in COVID-19 Patients Admitted in a Tertiary Care Hospital in Jaipur

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:5] [Pages No:369 - 373]

Keywords: Bloodstream, Coinfections, COVID-19,Antibiotic stewardship, Sepsis., Antimicrobial resistance, Bacteremia, Blood culture, Blood epidemiology

PDF  |  DOI: 10.5005/jp-journals-10071-23781  |  Open Access |  How to cite  | 

Abstract

Background: World is in grip of COVID-19 pandemic right now. Majority of studies center around its epidemiological and clinical characteristics. Information regarding secondary bacterial infections is limited. This retrospective observational study was done to determine the prevalence and characteristics of bloodstream infections in COVID-19 patients admitted in a tertiary care center in Jaipur. Patients and methods: All blood cultures received from COVID-19 positive patients admitted in designated COVID care ICUs and wards were included in the study. A predesigned pretested questionnaire was used to collect relevant data. Blood cultures were done using BD BACTEC™ FX40, and identification and antimicrobial susceptibility testing of isolates were done by VITEK® 2 COMPACT. Results: One thousand five hundred seventy-eight (1578) COVID-19 positive patients were admitted in center during 5-month study period from whom 158 blood cultures were received. Out of these, 15 (9.4%) were positive. Median age of patients with positive blood culture was 54 years and included 10 males and 5 females. Ten (67%) patients needed intensive care in ICU. Significant correlation of blood culture positivity was found with parameters like ICU admission, presence of an indwelling device, underlying comorbidity, raised biochemical markers, and adverse clinical outcome. Conclusions: Incidence of bloodstream infections is low for COVID-19 patients. Antibiotic prophylaxis needs to be used with caution, and prompt discontinuation should be done based on clinical judgment.

ORIGINAL RESEARCH

Swagata Tripathy, Bharath KT Vijayaraghavan, Manoj K Panigrahi, Asha P Shetty, Rashan Haniffa, Rajesh C Mishra, Abi Beane

Collateral Impact of the COVID-19 Pandemic on Acute Care of Non-COVID Patients: An Internet-based Survey of Critical Care and Emergency Personnel

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:8] [Pages No:374 - 381]

Keywords: Service delivery, Survey,Acute care, COVID-19, LMIC, Pandemic

PDF  |  DOI: 10.5005/jp-journals-10071-23782  |  Open Access |  How to cite  | 

Abstract

Purpose: The impact of disruption to the care of non-coronavirus disease (COVID) patients (COVID collateral damage syndrome-CCDS) is largely unknown in resource-limited settings. We investigated CCDS as perceived by healthcare workers (HCWs) providing acute and critical care services in India. Methods: A clinician and nurse codesigned and validated an internet-based survey, which was disseminated to HCWs using a multiple frame sampling technique. Results: Responses were received from 468 HCWs (completion rate 84%); at the time of the survey, 48% were working in critical care, 41% aged 30 to 40 years, and 53% represented public institutions. Respondents perceived a decrease in service utilization and disruption to time-sensitive acute interventions (60.1% and 40.8%, respectively), with fear of infection (score, 63.0; standard deviation (SD), 31.8) and restrictions due to lockdown (61.4; SD 32.5) being cited as the causes of service disruption. Being overwhelmed or lack of protective equipment was perceived to contribute less to CCDS. Insistence on COVID test results X2 (p = 0.02) and duty-avoidance (p < 0.01) was perceived as significant causes for CCDS by HCWs from private hospitals and those in leadership roles, respectively. Conclusions: Fear of infection and the effect of lockdown were perceived as important contributors to CCDS resulting in disruption to services and decreased service utilization. Perceptions were influenced by HCWs’ role and hospital organizational structure.

ORIGINAL RESEARCH

Indu Kapoor, Jaya Wanchoo, Charu Mahajan, Vasudha Singhal, Hirok Roy, Subodh Kumar, Rupali Brahma, Chandrakant Prasad, Mani Kalaivani, Hemanshu Prabhakar, Arvind Chaturvedi

Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:6] [Pages No:382 - 387]

Keywords: Intracranial pressure, Neurocritical care, Neurocritically ill, Optic nerve sheath diameter, Percutaneous tracheostomy

PDF  |  DOI: 10.5005/jp-journals-10071-23783  |  Open Access |  How to cite  | 

Abstract

Highlights • Like any other surgical procedures, PCT procedure can cause fluctuation in ICP in neurocritically ill patients. • Noninvasive ICP monitoring by measuring ONSD using bedside ultrasound would be very helpful in these patients who do not have invasive ICP catheter in situ due to nonavailability, institutional protocol, or any other reason. • Measuring ONSD in neurocritically ill patients undergoing PCT procedure would help clinicians for early recognition and management of raised ICP, which would further add on to the overall outcome of the patient. Abstract Background: Elective percutaneous tracheostomy [PCT] is the widely performed procedure in neurocritically ill patients as an airway management choice in neurocritical care unit [NICU]. Intracranial pressure [ICP] is a vital parameter to be monitored in these patients while undergoing any surgical procedure including PCT. Optic nerve sheath diameter [ONSD], being a surrogate of ICP, can be done bedside and carries less complications than invasive ICP monitoring. The aim of our study was to assess the effect of PCT on ONSD at different stages of PCT. Patient and methods: A total of 158 patients with various intracranial pathologies scheduled for PCT in NICU were screened for eligibility in our study. We assessed mean values of ONSD, HR, MBP, and SpO2 for changes over various time points during PCT using generalized estimating equation (GEE). A p value of <0.05 was considered significant. Results: A total of 135 patients who underwent PCT were analyzed for the study. The values of ONSD changed significantly at different stages of PCT procedure compared to baseline. The baseline ONSD value was 0.39 ± 0.05 cm. ONSD rose significantly to 0.40 ± 0.06 cm during positioning, 0.41 ± 0.06 cm during skin incision, 0.42 ± 0.07 cm during dilatation of tract, 0.41 ± 0.07 cm during insertion of tracheostomy, and 0.41 ± 0.06 cm at the end of the procedure. Conclusions: PCT leads to a significant rise of ONSD values during all stages of PCT. The available evidences point toward detrimental rise in ICP during PCT. ICP can be monitored noninvasively by measuring ONSD using bedside ultrasound.

ORIGINAL RESEARCH

Heena Gupta, Nikita Gandotra, Ruhi Mahajan

Profile of Obstetric Patients in Intensive Care Unit: A Retrospective Study from a Tertiary Care Centre in North India

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:4] [Pages No:388 - 391]

Keywords: Maternal mortality, Pregnancy, Pregnancy complications,Intensive care units

PDF  |  DOI: 10.5005/jp-journals-10071-23775  |  Open Access |  How to cite  | 

Abstract

Background: Critically ill obstetric patients constitute a small number of intensive care unit (ICU) admissions. Physiological changes in pregnancy along with certain pregnancy-specific diseases may cause a rapid worsening of the health status of the patient necessitating ICU care. The present study aims to study the clinical profile of the obstetric patients requiring ICU care. Materials and methods: It was a retrospective analysis of pregnant/postpartum (up to 6 weeks) admissions over a period of 18 months. Results: Over these 18 months, 127 women required ICU admission. The most common reasons for ICU admission were obstetric hemorrhage (37.79%) and (pre)eclampsia (28.35%). Ten patients presented with antepartum hemorrhage (placenta previa, placenta accreta, placenta increta). The rest of the patients (n = 38) had atonic postpartum hemorrhage with five having severe anemia. Among the nonobstetric causes (n = 26/127), ICU admission was the most common among those with preexisting heart diseases (n = 10; 7.87%). Forty-nine patients were ventilated mechanically (38.58%), with eclampsia being the most common primary diagnosis (n = 23). We observed 10 maternal deaths (7.87%) with septicemia being the most important cause of death. Conclusions: Maternal and child health has become an important measure of human and social development. Early diagnosis and prompt treatment of high-risk obstetric patients in a dedicated obstetric ICU in tertiary hospitals can prevent severe maternal morbidity and improve maternal care.

ORIGINAL RESEARCH

Kundavaram P. P. Abhilash, Sanjay Murugan, Abel S Rabbi, Sharon Pradeeptha, Roshini Pradeep, Karthik Gunasekaran

Deliberate Self-poisoning due to Plant Toxins: Verdant Footprints of the Past into the Present

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:6] [Pages No:392 - 397]

Keywords: Deliberate self-poisoning, Emergency department, Oduvanthalai, Oleander, Plant poisons

PDF  |  DOI: 10.5005/jp-journals-10071-23784  |  Open Access |  How to cite  | 

Abstract

Background: Plant poisoning is one of the common methods of deliberate self-poisoning (DSP). Exposure to plants and its consequence account for a considerable number of deaths in rural India. Methodology: This retrospective observational study was conducted in the emergency department of a large tertiary care hospital in South India over a period of 2 years and recruited patients who presented with DSP from plant poisoning. Results: During the study period, 150 cases of plant poisoning were included. The mean (standard deviation) age of presentation was 31.4 (12.2) years. The most common type of plant poison consumed was oleander (63%) followed by oduvanthalai (50%), Strychnos nux-vomica (3%), datura (3%), and others, which comprised about 5.3% included henna (1.3%), cactus (1.3%), and a case each of castor, Gloriosa superba, Adenanthera pavonina, and Abrus precatorius. Patients in age-group 16 to 30 years had the highest rate of ingestion. The seasonal pattern was found to peak in the month of April. Gastric lavage was done in 102/150:68%. Consumption of decoction [odds ratio (OR): 5, 95% confidence interval (CI): 2.27–14.00, p value: <0.001] and metabolic acidosis (pH <7.35) (OR: 11.48, 95% CI: 4.17–31.57, p value: <0.001) were more common in oduvanthalai poisoning as compared to oleander. The mortality among plant poisoning was 9.3% (14/150). Conclusion: Our study sheds light on the spectrum of local plants consumed for DSP. Oleander and oduvanthalai were most commonly used for DSP. Consuming a decoction of leaves leading to severe metabolic acidosis at presentation is seen associated with oduvanthalai poisoning.

ORIGINAL RESEARCH

Malini Joshi, Ranjeet Milmile, Pravin Dhakane, Shilpushp J Bhosale, Atul P Kulkarni

Incidence and Predictors of Acute Kidney Injury in Patients Undergoing Elective Hepatic Resection for Malignant Tumors: A 3-year Prospective Observational Study

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:7] [Pages No:398 - 404]

Keywords: Acute kidney injury, Hepatic resection, Obesity, Postoperative mechanical ventilation, Postoperative morbidity, Postoperative mortality, Predictors of outcome

PDF  |  DOI: 10.5005/jp-journals-10071-23776  |  Open Access |  How to cite  | 

Abstract

Background: Acute kidney injury (AKI) is common in patients undergoing major surgeries, and leads to the need for renal replacement therapy and increased morbidity, intensive care unit (ICU) and hospital length of stay (LOS), cost, and mortality. We evaluated the incidence and predictors of postoperative AKI in patients undergoing hepatic resections and their short-term outcomes. Methods: This prospective observational study was conducted over a 3-year period in 180 patients undergoing elective hepatic resections for a variety of indications. We used the Acute Kidney Injury Network criteria to determine the incidence of AKI at 72 hours. Perioperative variables contributing to the development of AKI and the short-term postoperative outcomes of patients were evaluated. Results: Postoperative AKI occurred in 29.4% of patients. Persistent renal dysfunction was seen in five patients. Development of AKI was associated with hepatic failure (18.5 vs 5.5%, p < 0.005), prolonged ICU (2 vs 1 days, p < 0.001) and hospital LOS (11 vs 8 days, p < 0.004), and increased ICU and hospital mortality (9.6 vs 1.4%, p < 0.02). Age [OR (odds ratio) 1.033, 95% CI (confidence interval) 1.003–1.065, p = 0.03], BMI (body mass index) (OR 1.131, 95% CI 1.043–1.227, p = 0.003), and need for postoperative ventilation (OR 3.456, 95% CI 1.593–7.495, p = 0.002) were independent predictors of AKI. Conclusions: AKI after elective hepatic resection occurred in nearly one-third of our patients. Persistent renal dysfunction was seen in five patients. Age, BMI, and need for postoperative ventilation were independent predictors of postoperative AKI. (CTRI reg. No.: CTRI/2016/06/007044).

ORIGINAL RESEARCH

Elif O Tutuncu, Zerrin D Dundar, Ibrahim Kilinc, Aziz Tutuncu, Sedat Kocak, Abdullah S Girisgin

Prognostic Value of Immunosuppressive Acidic Protein (IAP) and Oxidative Stress Status in Critically Ill Patients

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:6] [Pages No:405 - 410]

Keywords: In-hospital mortality, Interleukins, Oxidative stress,Immunosuppressive acidic protein

PDF  |  DOI: 10.5005/jp-journals-10071-23788  |  Open Access |  How to cite  | 

Abstract

Introduction: The aim of this study was to determine the prognostic value of admission immunosuppressive acidic protein (IAP), interleukin-6 (IL-6), total oxidant status (TOS), and total antioxidant status (TAS) in 161 critically ill patients. Materials and methods: This prospective observational study was carried out in the Emergency Department ICU for 6 months. Critically ill patients were included in the study consecutively. The main outcomes were the need for early mechanical ventilation (MV) and in-hospital mortality. Results: The mean age of 161 patients was 66.5 ± 17.1 years. The median IL-6 levels of patients who required early MV were significantly higher than of the patients who required no MV (p < 0.001), and the median IL-6 levels in the non-survivors were significantly higher than in the survivors (p < 0.001). The median IAP levels were not significantly different between the groups (p = 0.464 for early MV and p = 0.340 for the in-hospital mortality group). The AUCs of IL-6 and TOS for predicting in-hospital mortality were 0.819 and 0.608, respectively. Conclusion: The IAP level on admission to ICU is ineffective in predicting the need for early MV and in-hospital mortality; however, IL-6 level on admission is a strong prognostic predictor in critically ill patients. Our findings showed that the burden of oxidative stress was high in general ICU patients. Clinical significance: Our study showed that increased oxidative stress is an important problem in critically ill patients. If measures are taken to reduce oxidative stress by physicians, the prognosis of critically ill patients will be better.

ORIGINAL RESEARCH

Sara Saeidi, Bita Dadpour, Lida Jarahi, Anahita A Ghamsari, Mahdi J Nooghabi

Clinical Predictive Values in Botulism, A 10-year Survey

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:5] [Pages No:411 - 415]

Keywords: Botulism, Clinical toxicology, Foodborne, Predictive, Prognostic factors

PDF  |  DOI: 10.5005/jp-journals-10071-23777  |  Open Access |  How to cite  | 

Abstract

Background: Botulism occurs periodically or in outbreaks in Iran. Botulism is lethal and accordingly a considerable issue in environmental health, although it is uncommon. This study was performed to evaluate the potential predictive factors in foodborne botulism in a 10-year span. Patients and methods: All medical records from patients with foodborne botulism admitted to Imam Reza Hospital in 10 years (2005–2015) were analyzed retrospectively. Results: 61 cases were included (38 men, mean age ± SD 28.93 ± 19.14 years). All cases were treated with antitoxin. 6.6% of cases died. Canned beans were correlated with the admission to intensive care unit (ICU), and also, it increased the length of ICU stay significantly (P = 0.007 and 0.023, respectively). The incidence of dizziness and diplopia significantly induced excess demands for higher doses of antitoxin (P = 0.038 and 0.023, respectively). Risk of dysphagia was remarkably higher in cases with ptosis (P = 0.039, odds ratio: 3). While in this study, time elapsed between the onset of clinical manifestations and antitoxin administration was correlated with the occurrence of dysphagia, constipation, and blurred vision, and early treatment did not improve the outcomes. Multiple analysis of potential variables by a logistic regression model disclosed that the independent significant factors affecting mortality were the need for mechanical ventilation (P = 0.000), dyspnea (P = 0.044), general weakness (P = 0.044), and lack of consciousness (P = 0.008) at the time of admission. Conclusions: Taking clinical signs and symptoms into account upon patient arrival is important and, of course, is a key to further management in the emergency setting.

ORIGINAL RESEARCH

Bijoy Das, Sanchita Saha, Feroz Kabir, Sazzad Hossain

Effect of Graded Early Mobilization on Psychomotor Status and Length of Intensive Care Unit Stay in Mechanically Ventilated Patients

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:5] [Pages No:416 - 420]

Keywords: Functional status, Graded early mobilization, Intensive care unit, Mechanical ventilation, Psychological status, Physiotherapy

PDF  |  DOI: 10.5005/jp-journals-10071-23789  |  Open Access |  How to cite  | 

Abstract

Introduction: The main purpose of this study was to evaluate the effectiveness of graded early mobilization on psychomotor status and duration of ICU stay of patients with mechanical ventilation. Method: Design: Quasi-experimental study. Setting: BRB Hospitals Limited, Dhaka, Bangladesh. A reputed 500-beddedgeneral hospital with 30 ICU beds. Participants: A total of 30 patients were selected as participants in the study from the hospital. 15 patients were included in the ICU treatment group and the remaining 15 were in the intervention group using the purposive sampling method. Scales used: Functional independence measure (FIM) scale and 7 point generalized anxiety depression (GAD-7) scale. Intervention: Graded early mobilization was provided as an intervention to all participants of the intervention group by a professionally qualified ICU physiotherapist for 10 sessions. Most of the patients received multiple sessions of intervention within a day. Results: In the control group mean FIM score was 17.40 (SD±4.88), and in the intervention group mean score was 65.70 (SD±12.18). The mean difference was statistically significant in the ‘t’ test (p-value > 0.001). In the control group, the mean GAD-7 score was 19.50 (SD±2.71), and in the intervention group the mean GAD-7 score was 7.5 (SD±2.59). The mean difference was statistically significant in the ‘t’ test. (p-value > 0.001). The mean length of ICU stay in the control group was 5.60 (SD±1.07) and in the intervention group it was 3.10 (SD±0.56). The mean difference was statistically significant in the ‘t’ test (p-value > 0.001). Conclusion: This research showed that graded early mobilization was highly effective to improve the motor and psychological status of mechanically ventilated patients and reduce their length of ICU stay.

ORIGINAL RESEARCH

Aarti Sangale, Vivek Bhat, Rohini Kelkar, Sanjay Biswas

Microbiology of Ventilator-associated Pneumonia in a Tertiary Care Cancer Hospital

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:8] [Pages No:421 - 428]

Keywords: NDBAL: Nondirect bronchoalveolar lavage, VAP: Ventilator-associated pneumonia,CRAB: Carbapenem-resistant A. baumannii (CRAB), MDROs: Multidrug-Resistant Organisms

PDF  |  DOI: 10.5005/jp-journals-10071-23790  |  Open Access |  How to cite  | 

Abstract

Background and aims: Ventilator-associated pneumonia (VAP) is an important cause of healthcare-associated infections, resulting in prolonged hospitalization with increased morbidity and mortality. Knowledge of predominant local pathogens and their antimicrobial susceptibility patterns helps in selection of appropriate initial antibiotic therapy in these critical cases. The objective of this study is to characterize the microbiology and antimicrobial susceptibility patterns of VAP isolates in a tertiary cancer center. Subjects and methods: This is a 4-year qualitative observational study carried out at a tertiary care cancer hospital in Mumbai. All nondirect bronchoalveolar lavage specimens from patients with a clinical suspicion of VAP sent from the critical care unit to the department of microbiology were processed as per standard laboratory procedures. All isolates were identified to species level and an antimicrobial susceptibility testing was performed by the Kirby–Bauer disk diffusion method and/or the VITEK 2 automated identification and susceptibility system, according to Clinical and Laboratory Standards Institute guidelines. Results: The study comprised 1,074 patients: 710 (66.10%) men and 364 (33.90%) women. A total of 827 bacterial isolates were obtained with 780 (94.32%) gram-negative organisms and 47 (5.68%) gram-positive organisms; of which Acinetobacter baumannii (38.7%), Pseudomonas aeruginosa (17.5%), and Klebsiella pneumoniae (16.6%) were the commonest. Of gram-negative bacilli, multidrug-resistant organisms constituted 87.50% and were susceptible to colistin. Conclusions: VAP is associated with pathogens, such as A. baumannii, P. aeruginosa, and K. pneumoniae in our setting. High rates of resistance to aminoglycosides, β-lactam-β-lactamase inhibitor combinations, and carbapenems were noted.

ORIGINAL RESEARCH

Hossein Davari, Abbasali Ebrahimian, Soraya Rezayei, Maedeh Tourdeh

The Effect of Lavender Aromatherapy on Sleep Quality and Physiological Indicators in Patients after CABG Surgery: A Clinical Trial Study

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:6] [Pages No:429 - 434]

Keywords: Aromatherapy, Physiological indicators, Sleep quality

PDF  |  DOI: 10.5005/jp-journals-10071-23785  |  Open Access |  How to cite  | 

Abstract

Background: Sleep disorders occur in the first days after heart surgery. One of the major causes of sleep disorders after coronary artery bypass graft (CABG) is subsequent changes in physiological indicators, such as systolic blood pressure (BP), respiratory rate (RR), saturation of oxygen (O2), and heart rate (RR). This study is aimed to determine the effect of lavender aromatherapy on patients’ sleep quality and physiological indicators after CABG. Patients and methods: This study was a randomized clinical trial. Patients after CABG surgery were randomly allocated into the lavender and distilled water groups. Patients in the intervention group inhaled lavender while those in the control group inhaled distilled water for 10 hours. Sleep quality and physiological postoperative data were collected for 3 days. Data were analyzed using repeated measurement test, sample t-test, and chi-square test. Results: Repeated measurement test showed no significant difference between the lavender and distilled water groups in terms of systolic BP, RR, O2 saturation, HR, and body temperature after matching the effect of time and its interactive effect with the intervention (p > 0.05). This test revealed a significant difference between the lavender and distilled water groups in terms of sleep quality (p < 0.001), such that the sleep quality was higher in the lavender group. Conclusion: Lavender aromatherapy can increase patients’ sleep quality after CABG surgery. However, it cannot completely treat sleep disorders in such patients. Furthermore, aromatherapy with lavender does not affect the physiological parameters, such as HR, BP, RR, and O2 saturation.

PAEDIATRIC CRITICAL CARE

Mihir Sarkar, Satyabrata Roychowdhoury, Subhajit Bhakta, Sumantra Raut, Mousumi Nandi

Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation?

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:6] [Pages No:435 - 440]

Keywords: Tracheostomy,Mechanical ventilation, Outcome, Pediatric intensive care

PDF  |  DOI: 10.5005/jp-journals-10071-23791  |  Open Access |  How to cite  | 

Abstract

Introduction: With the advancement of pediatric critical care services across India, many children require prolonged mechanical ventilation (MV), and tracheostomy is recommended to them. However, many pediatric intensivists have concerns regarding the safety, feasibility, and outcome of tracheostomy. We aimed to analyze clinical characteristics, indication, duration, and outcome of tracheostomized children with respect to timing of tracheostomy. Method: We conducted a retrospective study from the hospital clinical database of consecutive patients below 12 years who had undergone tracheostomy after admission into the pediatric intensive care unit (PICU) for prolonged ventilation (≥96 hours) from January 2015 to December 2019. The study was approved by the Institutional Ethics Committee. Patients were divided into two groups: tracheostomies done within 14 days of MV (early tracheostomy) and patients with tracheostomies performed after 14 days (late tracheostomy). Patients’ age, sex, indications, complications, decannulation rate, length of MV, PICU, and hospital stay were analyzed. Results: Of the 1,425 patients on invasive MV, 87 (6.1%) patients required tracheostomy after a mean 13.37 days of MV. The most common indication was encephalopathy 32 (36.7%) followed by acute respiratory distress syndrome 20 (22.9%). Factors like higher pediatric logistic organ dysfunction score, vasoactive inotrop score, incidence of pretracheostomy ventilator-associated pneumonia, and difficulty in obtaining parental consent were associated with late tracheostomy. The early tracheostomy group had a higher decannulation rate (odds ratio, 5.17; p, 0.01) and weaning rate (odds ratio, 5.94; p, 0.032). The late tracheostomy group needed a longer duration of MV, PICU, and hospital stay. Complications of tracheostomy were less in the early tracheostomy patients (odds ratio, 2.95; p, 0.03). Conclusion: Early tracheostomy was associated with lower complications, higher successful weaning rates, and less utilization of intensive care facilities in patients receiving prolonged MV. Clinical significance: In the context of scarcity of data on the timing of tracheostomy in children with prolonged ventilation (≥96 hours) the study shows that early (<14 days) tracheostomy is associated with a better outcome.

REVIEW ARTICLE

Rajesh M Shetty, ArunKumar Namachivayam

Evidence for Chloroquine/Hydroxychloroquine in the Treatment of COVID-19

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:12] [Pages No:441 - 452]

Keywords: Acute hypoxemic respiratory failure (AHRF), Chloroquine, Coronavirus disease 2019, COVID-19 drug treatment, Hydroxychloroquine

PDF  |  DOI: 10.5005/jp-journals-10071-23773  |  Open Access |  How to cite  | 

Abstract

Introduction: Given the current lack of an approved and effective treatment or vaccine for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), repositioning old drugs for use as an antiviral treatment is an interesting strategy because knowledge about these drugs’ safety profile, posology, and drug interactions is already known. Chloroquine and hydroxychloroquine, widely used as antimalarial and autoimmune disease drugs, have recently been reported as a potential broad-spectrum antiviral drug. Background: The in vitro antiviral activity of chloroquine has been identified since the late 1960s. However, antiviral mechanisms of chloroquine remain speculative. Several clinical trials have been conducted to test the efficacy and safety of chloroquine or hydroxychloroquine in the treatment of COVID-19-associated pneumonia. The quality of the studies and the outcomes are evaluated in this systematic review and meta-analysis. Review results: Literature review revealed 23 clinical studies. Only 9 of 23 studies were randomized controlled trials. Of nine randomized controlled trials, only study by Skipper et al. was deemed to be at low risk of bias. All studies evaluated variedwith different outcomes. Mechanical ventilation and virological clearance were the only common outcomes evaluated in more than two studies. Virological clearance odds ratio (OR) was 1.25 (95% confidence interval [CI] of 0.57–2.73; Chi2 = 0.83; I2 = 0%). GRADE quality of evidence was downgraded by three levels to very low due to concerns about the risk of bias, inconsistency, and imprecision. For mechanical ventilation, OR was 1.09 (95% CI 0.80–1.50; Chi2 = 0; I2 = 0). GRADE quality of evidence was downgraded by two levels to low due to concerns about the risk of bias and imprecision. There was no statistically significant difference between the groups for these two outcomes. Conclusion: As per the available evidence, based on our review, we conclude that hydroxychloroquine/chloroquine has not shown to be beneficial when used for the treatment of patients with COVID-19 pneumonia.

REVIEW ARTICLE

Hina Zia, Ritu Singh, Manu Seth, Armin Ahmed, Afzal Azim

Engineering Solutions for Preventing Airborne Transmission in Hospitals with Resource Limitation and Demand Surge

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:8] [Pages No:453 - 460]

Keywords: Hybrid ventilation, Natural ventilation, Temporary negative-pressure rooms, Ventilation systems,Airborne transmission, Air cleaning technologies

PDF  |  DOI: 10.5005/jp-journals-10071-23792  |  Open Access |  How to cite  | 

Abstract

Among the various strategies for the prevention of airborne transmission, engineering measures are placed high in the hierarchy of control. Modern hospitals in high-income countries have mechanical systems of building ventilation also called HVAC (heating, ventilation, and air-conditioning) but installation and maintenance of such systems is a challenging and resource-intensive task. Even when the state-of-the-art technology was used to build airborne infection isolation rooms (AIIRs), recommended standards were often not met in field studies. The current COVID-19 pandemic has highlighted the need to find cost-effective and less resource-intensive engineering solutions. Moreover, there is a need for the involvement of interdisciplinary teams to find innovative infection control solutions and doctors are frequently lacking in their understanding of building ventilation-related problems as well as their possible solutions. The current article describes building ventilation strategies (natural ventilation and hybrid ventilation) for hospitals where HVAC systems are either lacking or do not meet the recommended standards. Other measures like the use of portable air cleaning technologies and temporary negative-pressure rooms can be used as supplementary strategies in situations of demand surge. It can be easily understood that thermal comfort is compromised in buildings that are not mechanically fitted with HVAC systems, therefore the given building ventilation strategies are more helpful when climatic conditions are moderate or other measures are combined to maintain thermal comfort.

CASE REPORT

Abhyuday Kumar, Neeraj Kumar, Shettru K Arun, Subhajit Ghosh, Arunima Pattanayak

Acute Peripheral Arterial Thrombosis in COVID-19 Patients on Therapeutic Anticoagulation

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:461 - 462]

Keywords: Thrombosis,Artery, COVID-19, Intensive care, Low-molecular-weight heparin

PDF  |  DOI: 10.5005/jp-journals-10071-23793  |  Open Access |  How to cite  | 

Abstract

COVID-19 disease is often complicated by venous thrombosis and embolism. However, arterial thrombosis in a patient already on therapeutic anticoagulation is a rare occurrence. In one patient, we found thrombosis of the radial artery leading to ischemia of the fingers and lateral part of the palm. In another patient, thrombosis was found in the anterior tibial artery, resulting in ischemia of the limb and amputation. Both these patients were on a therapeutic dose of low-molecular-weight heparin. In both cases, heparin infusion was started but with little benefit. It is suggested that intensified anticoagulation should be done in patients at high-risk venous thrombosis, and prompt interventional thrombectomy should be done in cases of failure of pharmacological anticoagulation.

CASE REPORT

Amarjeet Kumar, Abhyuday Kumar, Ajeet Kumar, Neeraj Kumar, Chandni Sinha, Veena Singh

Multiple Peaked Cytokine Storm: Is Multiple Exposures to the COVID-19 Virus a Possible Cause?

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:463 - 464]

Keywords: Acute respiratory distress syndrome, COVID-19, Cytokine storm, Interleukin-6

PDF  |  DOI: 10.5005/jp-journals-10071-23786  |  Open Access |  How to cite  | 

Abstract

Severe acute respiratory syndrome coronavirus 2 is the pathogen that causes coronavirus disease 2019 (COVID-19). Recent studies have shown that the “cytokine storm” (high concentration of proinflammatory cytokines) may contribute to the mortality of COVID-19. Repeated exposure to the virus can lead to a dose-dependent immune response that may be associated with more disease severity and higher mortality. Sudden deterioration/increased oxygen consumption after initial improvement may be due to multiple surges of cytokines storm within a short period, the possible cause may be due to multiple exposures within the incubation period. We hypothesize that multiple surges in cytokines storm in some patients may be due to multiple exposures of the same patient within the incubation period, sepsis, or other inflammatory lesions inside the body. In our cases, sepsis as a cause of cytokine storm was ruled out by doing the procalcitonin test, which was within the normal limit.

CASE REPORT

MB Adarsh, Anitha Abraham, P Kavitha, Meera M Nandakumar, Raman S Vaman

Severe Thrombocytopenia in COVID-19: A Conundrum in Dengue-endemic Areas

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:465 - 466]

Keywords: COVID-19, Dengue, Thrombocytopenia

PDF  |  DOI: 10.5005/jp-journals-10071-23778  |  Open Access |  How to cite  | 

Abstract

Thrombocytopenia in COVID-19 can be attributed to multiple factors. Most often it is disease related. It is usually mild and if severe often associated with severe COVID-19 disease. It can also be due to drugs (Remdesivir, Tocilizumab) or coinfection with other viruses. Here we report two cases of severe thrombocytopenia in COVID-19 due to dengue coinfection. Most often the thrombocytopenia in dengue is self-resolving, and a careful “wait and watch” should suffice unlike COVID-19, where steroids can help if the cytopenia is due to cytokine storm or immune-mediated effects.

CASE REPORT

Poonam Kumari, Amarjeet Kumar, Chandni Sinha, Ajeet Kumar, Prabhat K Singh, SK Arun

Off-label Use of Itolizumab in Patients with COVID-19 ARDS: Our Clinical Experience in a Dedicated COVID Center

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:3] [Pages No:467 - 469]

Keywords: Acute respiratory distress syndrome (ARDS), COVID-19, Cytokine storm, Itolizumab, Monoclonal antibody

PDF  |  DOI: 10.5005/jp-journals-10071-23787  |  Open Access |  How to cite  | 

Abstract

Severe acute respiratory syndrome coronavirus 2 has affected millions of people worldwide. This pandemic requires newer medical management strategies to control the morbidity and mortality associated with the disease. Several approaches, including global targeting of inflammation or neutralizing a single key inflammatory mediator, are being employed to cope with cytokine storms in COVID-19. The role of anti-inflammatory biologics, such as acalabrutinib, tocilizumab, anakinra, and itolizumab can become relevant. Itolizumab is a humanized recombinant immunoglobulin G1 monoclonal antibody. It targets the extracellular, scavenger receptor cysteine-rich (SRCR) distal domain 1 of CD6 and is responsible for priming, activation, and differentiation of T-cells. Itolizumab has been approved by the Drug Controller General of India for the treatment of COVID 19 in India. Here, we shared our clinical experience of 20 patients having moderate acute respiratory distress syndrome (ARDS) due to COVID-19 on treatment with itolizumab. We observed the mortality benefit with single-dose itolizumab (1.6 mg/kg) in patients having moderate COVID-19 ARDS.

LETTER TO EDITOR

Soumya Sarkar, Puneet Khanna

In Pursuit of Freedom from COVID-19 Awareness in India: An Infodemiological Analysis

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:3] [Pages No:470 - 472]

Keywords: COVID-19, Epidemiology, Google trend

PDF  |  DOI: 10.5005/jp-journals-10071-23780  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Bharat Paliwal, Pradeep K Bhatia, Manoj Kamal, Anamika Purohit

Personal Protective Equipment and Fire

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:1] [Pages No:473 - 473]

Keywords: Aerosol, Coronavirus, COVID-19, Fire, Personal protective equipment

PDF  |  DOI: 10.5005/jp-journals-10071-23779  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Abhyuday Kumar, Neeraj Kumar, Dharani Lenin, Amarjeet Kumar, Shaheen Ahmad

Second-degree Heart Block Caused by Itolizumab-induced Infusion Reaction in COVID-19

[Year:2021] [Month:April] [Volume:25] [Number:4] [Pages:2] [Pages No:474 - 475]

Keywords: Itolizumab,Adverse drug reaction, COVID-19, Heart block

PDF  |  DOI: 10.5005/jp-journals-10071-23794  |  Open Access |  How to cite  | 

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