Indian Journal of Critical Care Medicine

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2021 | June | Volume 25 | Issue 6

EDITORIAL

Arun Kumar

COVID-19: Epidemiology, Case Fatalities and the Adversaries within

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:3] [Pages No:603 - 605]

PDF  |  DOI: 10.5005/jp-journals-10071-23869  |  Open Access |  How to cite  | 

EDITORIAL

Kapil Zirpe, Balkrishna D Nimavat, Sushma K Gurav

Age as Maestro or Solo Instrument in Opera of Death

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:2] [Pages No:606 - 607]

PDF  |  DOI: 10.5005/jp-journals-10071-23868  |  Open Access |  How to cite  | 

EDITORIAL

Ashit Hegde

Antibiotic Stewardship: Easy to Preach, Difficult to Practice

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:2] [Pages No:608 - 609]

PDF  |  DOI: 10.5005/jp-journals-10071-23884  |  Open Access |  How to cite  | 

EDITORIAL

Khalid I. Khatib

Increasing the Safety of Percutaneous Dilatational Tracheostomy in COVID-19 Patients

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:3] [Pages No:610 - 612]

PDF  |  DOI: 10.5005/jp-journals-10071-23876  |  Open Access |  How to cite  | 

EDITORIAL

Ganshyam Jagathkar

Acute Respiratory Distress Syndrome in the Elderly

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:2] [Pages No:613 - 614]

Keywords: Acute respiratory distress syndrome, Elderly people, Outcomes

PDF  |  DOI: 10.5005/jp-journals-10071-23877  |  Open Access |  How to cite  | 

Abstract

Acute respiratory distress syndrome (ARDS) is a commonly encountered complex syndrome of varied etiology and outcomes. The elderly population is at a high risk of developing severe ARDS with poor outcomes. The age-related changes in the immune system, structural and functional modifications of the respiratory system, and the frailty with a decrease in the physiological reserve of organ systems place them precariously for poor outcomes. However, does age alone influence the outcomes or is it the associated comorbidities that determine mortality in the elderly is not clearly known.

EDITORIAL

Deepak Govil, Divya Pal

Can We Predict Outcome In Critically Ill Elderly Patients?

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:2] [Pages No:615 - 616]

PDF  |  DOI: 10.5005/jp-journals-10071-23886  |  Open Access |  How to cite  | 

EDITORIAL

Antibiotic misuse during COVID-19 Pandemic: A Recipe for Disaster

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:3] [Pages No:617 - 619]

PDF  |  DOI: 10.5005/jp-journals-10071-23862  |  Open Access |  How to cite  | 

EDITORIAL

Sandeep Dhingra

Delirium in Pediatric Intensive Care Unit: Frequency, Causes, and Interventions

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:2] [Pages No:620 - 621]

Keywords: Delirium, Pediatric intensive care unit, Pyschobehavioral interventions

PDF  |  DOI: 10.5005/jp-journals-10071-23864  |  Open Access |  How to cite  | 

Abstract

Delirium is an acute neurologic dysfunction characterized by fluctuating alteration in awareness, attention, and cognition and is a result of an underlying medical condition or its treatment. It is associated with increased morbidity and mortality in the intensive care setting and may lead to long-term cognitive impairment in survivors. Pediatric delirium (PD) occurs in as many as 25% of critically ill children. The pathophysiology of delirium is complex and widespread screening of this entity is lacking. To diagnose PD, a high index of suspicion should be kept in the patients who are at high risk, and appropriate screening tools should be applied, as the symptoms of PD overlap with other commonly observed neurological phenomena in pediatric intensive care unit.

Original Article

Ridhima Bhatia, Kshitija Kulshrestha, Renjith Viswanath, Karthik V Iyer, Puneet Khanna, Sulagna Bhattacharjee, Ajisha Aravindan, Anju Gupta, Venkata Ganesh, Rakesh Kumar, Arshed Ayub, Shailender Kumar, Kellika Prakash, Debesh Bhoi, Manish Soneja, Rajesh Malhotra, Randeep Guleria

Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:7] [Pages No:622 - 628]

Keywords: Clinicoepidemiological features, Comorbidities, COVID-19 deceased, ICU, Mortality analysis, Multi-organ dysfunction syndrome

PDF  |  DOI: 10.5005/jp-journals-10071-23848  |  Open Access |  How to cite  | 

Abstract

Background and objective: A large number of studies describing the clinicoepidemiological features of coronavirus disease-2019 (COVID-19) patients are available but very few studies have documented similar features of the deceased. This study was aimed to describe the clinicoepidemiological features and the causes of mortality of COVID-19 deceased patients admitted in a dedicated COVID center in India. Methodology: This was a retrospective study done in adult deceased patients admitted in COVID ICU from April 4 to July 24, 2020. The clinical features, comorbidities, complications, and causes of mortality in these patients were analyzed. Pediatric deceased were analyzed separately. Results: A total of 654 adult patients were admitted in the ICU during the study period and ICU mortality was 37.7% (247/654). Among the adult deceased, 65.9% were males with a median age of 56 years [interquartile range (IQR), 41.5–65] and 94.74% had one or more comorbidities, most common being hypertension (43.3%), diabetes mellitus (34.8%), and chronic kidney disease (20.6%). The most common presenting features in these deceased were fever (75.7%), cough (68.8%), and shortness of breath (67.6%). The mean initial sequential organ failure assessment score was 9.3 ± 4.7 and 24.2% were already intubated at the time of admission. The median duration of hospital stay was 6 days (IQR, 3–11). The most common cause of death was sepsis with multi-organ failure (55.1%) followed by severe acute respiratory distress syndrome (ARDS) (25.5%). All pediatric deceased had comorbid conditions and the most common cause of death in this group was severe ARDS. Conclusion: In this cohort of adult deceased, most were young males with age less than 65 years with one or more comorbidities, hypertension being the most common. Only 5% of the deceased had no comorbidities. Sepsis with multi-organ dysfunction syndrome was the most common cause of death.

Original Article

Ökkeş H Miniksar, Mikail Özdemir

Clinical Features and Outcomes of Very Elderly Patients Admitted to the Intensive Care Unit: A Retrospective and Observational Study

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:6] [Pages No:629 - 634]

Keywords: Geriatrics, Intensive care, Mortality

PDF  |  DOI: 10.5005/jp-journals-10071-23846  |  Open Access |  How to cite  | 

Abstract

Background: In this study, we aim to describe clinical features and outcomes of very elderly (85 years old or older) patients and provide information about predictors of mortality and factors associated with the length of hospital stay (LOS). Materials and methods: We reviewed retrospectively the files of patients over 85 years old and older who were admitted to the intensive care unit (ICU) of our training and research hospital between January 2017 and December 2018. Demographic and clinical findings, treatment modalities, and outcomes were recorded. The patients who died during the ICU stay were compared to the survivors, and factors associated with mortality and LOS in the intensive care were evaluated. Results: We reviewed 2350 files, and 218 patients (58.3% females) were included. The rate of mortality was 81.7%. The factors independently associated with a higher rate of mortality were the acute physiology and chronic health evaluation (APACHE) II score; the need for mechanical ventilation (MV), or inotropic support; and the presence of coronary artery disease (CAD) or chronic kidney disease (CKD). A tracheostomy and a blood transfusion were inversely associated with mortality. We found an association between LOS and comorbidities (renal replacement, percutaneous gastrostomy, blood transfusion, and a tracheostomy). Conclusion: The rate of survival in the intensive care was low among these very elderly intensive care patients. A higher APACHE II score; application of MV or inotropic support; and the presence of CAD or CKD were associated with a higher mortality rate.

Original Article

Jyotsna Agarwal, Vikramjeet Singh, Anupam Das, Soumya S Nath, Rajeev Kumar, Manodeep Sen

Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:7] [Pages No:635 - 641]

Keywords: Antibiotic stewardship, Antimicrobial consumption, Antimicrobial resistance, Carbapenem, Colistin, Gram-negative bacteria, Gram-positive organisms

PDF  |  DOI: 10.5005/jp-journals-10071-23861  |  Open Access |  How to cite  | 

Abstract

Background: Increasing antimicrobial resistance (AMR) among common bacteria combined with the slow development of new antibiotics has posed a challenge to clinicians. Aim and objective: To demonstrate whether antimicrobial and diagnostic stewardship program (ASP and DSP)-related interventions improve antibiotic susceptibilities among common bacteria causing bloodstream infections (BSI) in patients admitted to the intensive care unit (ICU) and whether these resulted in changes in the volume of antimicrobial consumption. Materials and methods: We compared the susceptibility patterns of gram-negative bacteria (GNB) and gram-positive cocci (GPC) causing BSI and changes in the volume of antibiotics prescribed for the same before and after 2017 by a retrospective analysis. Results: Postintervention, there was increased susceptibility of all GNBs to aminoglycosides; Escherichia coli and Klebsiella spp. to beta-lactambeta-lactamase inhibitors (BLBLI) combinations; and Klebsiella spp. and Pseudomonas spp. to carbapenems. Acinetobacter spp., Klebsiella spp., and Pseudomonas spp. showed improved susceptibility to doxycycline, whereas E. coli and Klebsiella spp. showed significantly improved susceptibility to fluoroquinolones. Among GPCs, there was increased susceptibility of Staphylococcus aureus (levofloxacin, clindamycin, and aminoglycoside), coagulase-negative S. aureus (CoNS) (chloramphenicol, levofloxacin, clindamycin, and aminoglycoside), and enterococci (chloramphenicol, levofloxacin, and clindamycin). There was a significant reduction in usage of antimicrobials for the treatment of GPCs (linezolid, doxycycline, chloramphenicol, levofloxacin, BLBLI, macrolide, and cephalosporin) and GNBs (levofloxacin, cephalosporin, carbapenem, and colistin), which caused BSI. Conclusion: The present study illustrated that combined ASP and DSP interventions successfully reversed the resistance pattern of organisms causing BSI and resulted in a reduction in antibiotic utilization.

Original Article

Gunchan Paul, Parshotam L Gautam, Shruti Sharma, Mandava Venkata Sravani, M Ravi Krishna

Percutaneous Tracheostomy in COVID Era: Time to Adapt and Improvise

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:6] [Pages No:642 - 647]

Keywords: Aerosol generating medical procedures, Percutaneous dilatational tracheostomy, Tracheostomy

PDF  |  DOI: 10.5005/jp-journals-10071-23847  |  Open Access |  How to cite  | 

Abstract

Background: Percutaneous dilatation tracheostomy (PDT) is required in patients with novel coronavirus disease-2019 (COVID-19) with severe respiratory involvement, but the procedure needs modification to minimize the risk of aerosol exposure to caregivers. Aim and objective: To share the experience of apnea approach of PDT in COVID patients. Also, to demonstrate the safety of the technique for healthcare workers (HCWs) and patients with respect to hemodynamic and oxygenation parameters. The incidence of adverse events and difficulties during the procedure were also recorded. Materials and methods: According to this modified approach, percutaneous tracheostomy was performed with apnea technique during open tracheal steps (video attached) and the endotracheal tube was withdrawn to the level of cords under video-laryngoscopic guidance. Study design: A retrospective data analysis of all the tracheostomy procedures (PDT) performed with the apnea technique during the COVID era (June–September) in non-COVID and COVID patients in intensive care units (ICUs). Results: During these 4 months, 74 PDT procedures were performed in both COVID and non-COVID patients in the ICUs of our hospital. Out of these, PDT with apnea technique was performed in 45 patients (61%). This technique was successful in 44 patients (97.7%) with mean apnea time of 110 + 8.6 seconds. There was no significant (p < 0.05) change in mean arterial pressure and oxygen saturation of 15 COVID patients in pre-PDT and immediate post-PDT period. None of the six team members performing PDT had symptoms or tested positive for COVID-19. Conclusion: PDT with apnea technique can be performed to minimize the risk of aerosol exposure and does not compromise the quality of care. It is safe both for the patient and HCWs.

Original Article

Inderpaul S Sehgal, Ritesh Agarwal, Sahajal Dhooria, Kuruswamy T Prasad, Valliappan Muthu, Ashutosh N Aggarwal

Etiology and Outcomes of ARDS in the Elderly Population in an Intensive Care Unit in North India

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:7] [Pages No:648 - 654]

Keywords: Acute respiratory distress syndrome, Elderly, Pneumonia, Respiratory failure, Sepsis

PDF  |  DOI: 10.5005/jp-journals-10071-23878  |  Open Access |  How to cite  | 

Abstract

Background: Whether age would impact the outcomes in subjects with acute respiratory distress syndrome (ARDS) remains unclear. Herein, we study the effect of age as a predictor of mortality in ARDS. Materials and methods: We categorized consecutive subjects with ARDS as either ARDSelderly (age >65 years) or ARDSnonelderly (age ≤65 years) admitted to the respiratory intensive care unit (ICU) of a tertiary care hospital in North India between January 2007 and December 2019. We compared the baseline clinical and demographic characteristics, lung mechanics, and mortality between the two groups. We also analyzed the factors predicting ICU survival using multivariate logistic regression analysis. Results: We included 625 patients (ARDSelderly, 140 [22.4%] and ARDSnonelderly, 485 [77.6%]) with a mean (standard deviation) age (56.3% males) of 40.6 (17.8) years. The ARDSelderly were more likely (p = 0.0001) to have the presence of any comorbid illness compared to ARDSnonelderly. The elderly subjects had significantly higher pulmonary ARDS than the younger group. The severity of ARDS was however, similarly distributed between the two study arms. There were 224 (35.8%) deaths, and the mortality was significantly higher (p = 0.012) in the ARDSelderly than the to ARDSnonelderly (ARDSelderly vs ARDSnonelderly, 45 vs 33.2%). On multivariate logistic regression analysis, the baseline sequential organ failure assessment scores, presence of pulmonary ARDS, and the development of new organ dysfunction were the independent predictors of mortality. Conclusion: The outcomes in subjects with ARDS are dependent on the severity of illness at admission and the etiology of ARDS rather than the age alone.

Original Article

Shivani Chopra, Sangeeta Pednekar, Niteen D Karnik, Charulata Londhe, Dharmendra Pandey

A Study of the Outcome of Critically Ill Elderly Patients in a Tertiary Care Hospital Using SOFA Score

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:5] [Pages No:655 - 659]

Keywords: 48 hours, Critically ill adults, Elderly, Multi-organ dysfunction, Intensive care unit, SOFA score

PDF  |  DOI: 10.5005/jp-journals-10071-23883  |  Open Access |  How to cite  | 

Abstract

Background: With a rapidly rising geriatric population, the magnitude of elderly patients requiring intensive care is a major cause of concern. Data on critically ill geriatric patients is scarce, especially in developing countries. Aim and objective: The aim of the study is to identify the etiology, clinical profile, and outcome in elderly patients admitted to the intensive care unit (ICU) and to predict their survival using the sequential organ failure assessment (SOFA) score. Materials and methods: A prospective observational study was performed over a period of 18 months with analysis of 100 patients admitted to the ICU, above the age of 60 years, with multi-organ dysfunction. The outcome of discharge or death was studied using the SOFA score on admission, on day 2, and the delta SOFA score. Results: In this study of 100 patients, 88% of patients were in the 60–70 years age-group. The number of male and female patients was equal. Seventy percent of patients had comorbidities, of which hypertension was most common. The two most common etiologies were acute febrile illness and pneumonia. The use of mechanical ventilation, inotropic support, and serum creatinine has a significant association with the outcome. The SOFA score at admission did not have a significant association, but the score at 48 hours and delta SOFA score co-related with the outcome of the patients. Sixty-four patients got discharged; thus, there was a survival rate of 64%. Conclusion: The SOFA score at 48 hours is the most sensitive predictor of outcome, followed closely by the delta SOFA score, as compared to the SOFA score on admission, for critically ill elderly patients. There is a significant association of use of mechanical ventilation, inotropic support, and serum creatinine with the outcome.

Original Article

Harsha Sinha, Vimi Rewari, Mahesh K Arora, Ravinder K Batra, Renu Saxena

Epidemiology and Prognostic Utility of Cellular Components of Hematological System in Sepsis

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:8] [Pages No:660 - 667]

Keywords: Critically ill adults, Mortality prediction, Sepsis, Thrombocytopenia

PDF  |  DOI: 10.5005/jp-journals-10071-23874  |  Open Access |  How to cite  | 

Abstract

Background: Data are lacking on the role of cellular components of hematological system as biomarkers for prognosis of sepsis. We planned to identify if these parameters measured at admission to ICU and at 72 hours can be useful as prognostic marker in septic critically ill patients. Materials and methods: In this prospective observational study, 130 adult patients with sepsis were recruited. Various hematological study parameters (total, differential, and absolute leukocyte count, platelet count, platelet distribution width, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio) were noted at day 1 and day 3 of admission. Primary outcome was 28-day mortality, and secondary outcomes were duration of mechanical ventilation, vasopressor requirement, ICU length of stay, and requirement of renal replacement therapy. The variables were compared between two groups and using binary regression model and were evaluated as prognostic markers for 28-day mortality. Results: Data from n = 129 were analyzed. At day-28, n = 58 (44.96%) patients survived. Baseline and demographic parameters were comparable between survivors and nonsurvivors. Admission Sequential Organ Failure Assessment score was more in nonsurvivors than survivors [8 (6–8) vs 6 (4–8); p = 0.002]. In nonsurvivors, monocyte, lymphocyte, basophil, eosinophil, and platelet count were significantly less at day 1 and lymphocyte, eosinophil, basophil and platelet count were significantly less at day 3. NLR and PLR at day 3 were significantly more in nonsurvivors. On logistic regression analysis, age, thrombocytopenia on day 1, and low eosinophil count on day 3 predicted 28-day mortality (p = 0.006, p = 0.02, and p = 0.04, respectively). Conclusion: Thrombocytopenia on day 1 and eosinopenia on day 3 may predict 28-day mortality in sepsis.

Original Article

Uday Yanamandra, Vasu Vardhan, Puneet Saxena, Priyanka Singh, Amul Gupta, Deepak Mulajkar, Rajan Grewal, Velu Nair

Radiographical Spectrum of High-altitude Pulmonary Edema: A Pictorial Essay

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:7] [Pages No:668 - 674]

Keywords: Chest X-ray, High-altitude pulmonary edema, Imaging, Radiograph

PDF  |  DOI: 10.5005/jp-journals-10071-23827  |  Open Access |  How to cite  | 

Abstract

Background: High-altitude pulmonary edema (HAPE) is a common cause of hospitalization in high altitude areas with significant morbidity. The clinical presentation of HAPE can overlap with a broad spectrum of cardiopulmonary diseases. Also, it is associated with varied radiological manifestations mimicking other conditions and often leading to unnecessary and inappropriate treatment. Patients and methods: The primary aim of the study was to study the various radiological manifestations of HAPE through real-world chest radiographs. We present six different chest X-ray patterns of HAPE as a pictorial assay, at initial presentation, and after the resolution of symptoms with supplemental oxygen therapy and bed rest alone. Results: HAPE can present as bilateral symmetrical perihilar opacities, bilateral symmetrical diffuse opacities, unilateral diffuse opacities, bilateral asymmetrical focal opacities, and even lobar consolidation with lower zone or less commonly upper zonal predilection. These presentations can mimic many common conditions like heart failure, acute respiratory distress syndrome, pulmonary embolism, aspiration pneumonitis, pneumonia, malignancy, and tuberculosis. Conclusion: A holistic clinical–radiological correlation coupled with analysis of the temporal course can help high-altitude physicians in differentiating true HAPE from its mimics.

Original Article

Krishna M Gulla, Tanushree Sahoo, Suneel K Pooboni, Pranay Oza

Extracorporeal Cardiopulmonary Resuscitation in Indian Scenario: A Web-based Survey

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:5] [Pages No:675 - 679]

Keywords: Cardiac arrest, ECMO (Extracorporeal membrane oxygenation), Intensive care, Questionnaire

PDF  |  DOI: 10.5005/jp-journals-10071-23850  |  Open Access |  How to cite  | 

Abstract

Background: Practice and knowledge of extracorporeal cardiopulmonary resuscitation (ECPR) in an Indian setting is not known. The etiology could be multifactorial, such as lack of awareness, lack of facilities, and lack of finances. Unless we identify and rectify the underlying problems, utilization of this aspect of extracorporeal membrane oxygenation (ECMO) support would be difficult. Materials and methods: This cross-sectional observational study was done over 6 months in three phases: (A) Formation of questionnaire/tool kit by Delphi method for 1 month (July 2019), (B) circulation of questionnaire to participants in the form of Google Forms and data collection for 2 months (August and October 2019), and (C) analysis, compilation of data, and writing the final report over 1 month (November 2019). Results: Sixty-four participants responded. The majority of the respondents were intensivists (50%). Only six respondents (9.5%) had done ECPR at their center with median ECPRs per year of 2 (1–10). All ECPRs were being done in private sector hospitals. The most common indication for initiation was conventional cardiopulmonary resuscitation (CPR) for more than 10 minutes without return of spontaneous circulation (ROSC)(n = 4, 66%). In all cases, the intensivists took decision for the initiation of ECPR. The rest 57 did not have the experience of ECPR at their center due to lack of equipment and experience (50%) and financial issues (50%). Conclusion and clinical significance: There is a huge need to increase the awareness of the ECPR program and teams to be trained in India. We also suggest that the tertiary care medical institutions in public sector as well as the private sector that is offering critical care courses should train fellows on ECPR to employ it at times when needed to improve the outcomes of critically ill patients.

Original Article

Zohreh Amirajam, Elham Asadi-Noran, Behnam Molaei, Vahid Adiban, Mehdi Heidarzadeh, Mohammad Hassanpour-Darghah

Psychometric Properties of Nursing Delirium Screening Scale in Patients Admitted to Intensive Care Units

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:5] [Pages No:680 - 684]

Keywords: Delirium, Intensive care, Validity

PDF  |  DOI: 10.5005/jp-journals-10071-23853  |  Open Access |  How to cite  | 

Abstract

Background: Nursing Delirium Screening Scale (Nu-DESC) is a new instrument for determining delirium by nurses. The study aimed to investigate the psychometric properties of Nu-DESC and determined the sensitivity and specificity of it. Methods: Two evaluators assessed delirium by Nu-DESC in nonintubated patients admitted to intensive care unit (ICU) wards of Ardabil educational and medical centers. For determining psychometric properties of the instrument, the methods of determining content validity, structural validity, criterion validity (the DSM-5 criteria was used as a standard tool), internal consistency, and inter-rater reliability were used. Results: Ninety-six participants were assessed two times using the Nu-DESC. The mean age of the participants was 58.84, and 51 (53.1%) of them were male. Due to the high correlation of the Nu-DESC with the study criterion (DSM-5), the criterion validity of the instrument is confirmed. By using DSM-5 instrument, the cutoff score of 2 shows the best sensitivity and specificity. The kappa and alpha coefficients were obtained as r = 0.96 and α = 0.86, which indicate a good agreement between the evaluators and acceptable consistency. Conclusion: Nu-DESC can be used as an efficient and reliable instrument by nurses in the ICU. It was also found that taking medical history can help nurses to better interpret the Nu-DESC score at diagnosing delirium.

Original Article

Ahmed I Elsayed, Khaled AW Selim, Hanan E Zaghla, Hossam E Mowafy, Mohammed A Fakher

Comparison of Changes in PPV Using a Tidal Volume Challenge with a Passive Leg Raising Test to Predict Fluid Responsiveness in Patients Ventilated Using Low Tidal Volume

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:6] [Pages No:685 - 690]

Keywords: Fluid responsiveness, Passive leg raising, Pulse pressure variation, Tidal volume challenge

PDF  |  DOI: 10.5005/jp-journals-10071-23875  |  Open Access |  How to cite  | 

Abstract

Background: Tidal volume challenge pulse pressure variation (TVC-PPV) is considered one of the recent reliable dynamic indices of fluid responsiveness (FR); also, passive leg raising (PLR)-induced changes in cardiac output (CO) detected by echocardiography are considered a reliable reversible self-fluid challenge test; many patients share eligibility for both tests. Objectives: The study aimed to compare the sensitivity and specificity of both tests for the prediction of FR in mechanically ventilated patients with hemodynamic instability. Methods: We studied 46 patients. Hemodynamic parameters including PPV and CO (detected by velocity time integral (VTI) using echocardiography) recorded at tidal volume (VT) of 6 mL/kg/ideal body weight (IBW) in semi-recumbent position then recorded again after one-minute increase in TV from 6 to 8 mL/kg/IBW then recorded with PLR at TV of 6 mL/kg/IBW and finally with actual volume expansion in semi-recumbent position by 4 ml/kg bolus of crystalloid solution to define actual responders with increase of cardiac output of 15% or more. Results: Sixteen patients were responders, and thirty patients were nonresponders; responders had significant increase in PPV with TVC 6 to 8 ml/kg/IBW with best cutoff value of 3.5 with a sensitivity of 93.8% and a specificity of 93.9%. PLR test-induced changes in CO had a sensitivity of 93.9% and a specificity of 86.7% with statistically best cutoff value of 6.5% increase in CO, but sensitivity was 75% at cutoff value of 10% increase in CO. Other parameters like PPV, PPV changes with PLR test, and PPV changes with fluid expansion were less sensitive indicators. Conclusion: FR in patients with hemodynamic instability and mechanically ventilated with low tidal volume strategy can be efficiently predicted when PPV increases more than 3.5 with tidal volume challenge and when PLR induces 6.5% increase in CO monitored through VTI method by Doppler echocardiography, and both tests are equally reliable.

SYSTEMATIC REVIEW

Sanjana Nagraj, Rutu Karia, Sahar Hassanain, Prithwish Ghosh, Viraj R Shah, Abin Thomas

Role of Invasive Mechanical Ventilation and ECMO in the Management of COVID-19: A Systematic Review

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:8] [Pages No:691 - 698]

Keywords: Coronavirus disease 2019, COVID-19, Critically ill, Extracorporeal membrane oxygenation, Invasive mechanical ventilation, SARS-CoV-2 infection

PDF  |  DOI: 10.5005/jp-journals-10071-23870  |  Open Access |  How to cite  | 

Abstract

Objectives: This systematic review aims to provide insight into the outcome of extracorporeal membrane oxygenation (ECMO) and invasive mechanical ventilation use in critically ill COVID-19 patients. Data sources: Electronic databases PubMed Central and PubMed were searched from January 2020 to June 2020 for published studies about ECMO and/or invasive mechanical ventilation use in COVID-19 patients. Data Extraction and Study Selection: The search strategy retrieved 766 articles, of which 19 studies consisting of 204 patients fulfilled the inclusion criteria and were included in the analysis. Data synthesis: Primary outcomes evaluated were discharge and/or clinical improvement and mortality rate. Secondary outcomes evaluated included reported complications and the mean number of days of hospitalization for survivors. Weighted averages of included studies were calculated, and data were pooled in forest plots. Nearly, 68.1% of the patients received invasive mechanical ventilation without ECMO support, and 31.9% were placed on ECMO. Also, 22.5% of the patients were discharged and/or clinically improved and 51.5% died. Twenty-six percent of the study population deteriorated but remained alive or experienced no improvement in clinical condition. And 75.2% of those who died belonged to the non-ECMO group and 24.8% to the ECMO group. The mortality rate in the non-ECMO group was 56.8% compared to 40% in the ECMO group. Conclusion: The utility of ECMO during a pandemic is uncertain as it is a resource-intensive modality, especially when the mortality rate in severely ill patients infected with COVID-19 virus is already known to be high.

BRIEF RESEARCH COMMUNICATION

Puneet Khanna, Soumya Sarkar

Superadded Coinfections and Antibiotic Resistance in the Context of COVID-19: Where do We Stand?

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:5] [Pages No:699 - 703]

Keywords: Antibiotic resistance, Coinfections, COVID-19—coronavirus disease 2019, SARS-CoV-2—severe acute respiratory syndrome coronavirus-2

PDF  |  DOI: 10.5005/jp-journals-10071-23855  |  Open Access |  How to cite  | 

Abstract

Purpose of review: Poor outcomes in the current coronavirus disease 2019 (COVID-19) pandemic have been attributed to superadded bacterial coinfections. The World Health Organization has reported overzealous usage of broad-spectrum antibiotics during this current pandemic raising concerns of increasing antimicrobial resistance? Therefore, the knowledge of coinfection and the common pathogens during these challenging times is essential for antibiotic stewardship practices. Recent findings: The incidence of reported superimposed bacterial and viral coinfections in COVID-19 patients is around 0.04 to 17%. However, more than 70% of patients have received broad-spectrum antibiotics. The presence of a simultaneous coinfection can be suspected in patients with neutrophilic lymphocytosis and elevated procalcitonin in the setting of COVID-19. Multiplex polymerase chain reaction (PCR) panels, with its short turnaround time, aid in the definitive diagnosis of possible coinfection. Acinetobacter baumanii, Mycoplasma pneumonia, influenza virus, Aspergillus, Candida, etc., are commonly implicated pathogens. Summary: Rapid characterization of coinfection and avoidance of overzealous use of broad-spectrum antibiotics in COVID-19 patients are the key to prevent antibiotic resistance during this pandemic.

BRIEF RESEARCH COMMUNICATION

Sinan Asar, Özlem Acicbe, Mehmet S Sabaz, Furkan Tontu, Emral Canan, Zafer Cukurova, Nahit Cakar

Comparison of Respiratory and Hemodynamic Parameters of COVID-19 and Non-COVID-19 ARDS Patients

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:5] [Pages No:704 - 708]

Keywords: ARDS patients, COVID-19, Hemodynamic parameters, Transpulmonary thermodilution method

PDF  |  DOI: 10.5005/jp-journals-10071-23856  |  Open Access |  How to cite  | 

Abstract

Background: COVID-19 can cause a clinical spectrum from asymptomatic disease to life-threatening respiratory failure and acute respiratory distress syndrome (ARDS). There is an ongoing discussion whether the clinical presentation and ventilatory parameters are the same as typical ARDS or not. There is no clear understanding of how the hemodynamic parameters have been affected in COVID-19 ARDS patients. We aimed to compare hemodynamic and respiratory parameters of moderate and severe COVID-19 and non-COVID-19 ARDS patients. These patients were monitored with an advanced hemodynamic measurement system by the transpulmonary thermodilution method in prone and supine positions. Patients and methods: Data of 17 patients diagnosed with COVID-19 and 16 patients diagnosed with other types of diseases with moderate and severe ARDS, mechanically ventilated, placed in a prone position, had advanced hemodynamic measurements with PiCCO, and stayed in the intensive care unit for more than a week were analyzed retrospectively. Patient characteristics and arterial blood gases analysis recorded at admission and respiratory and advanced hemodynamic parameters during the first week were compared in prone and supine positions. Results: No difference was observed in the respiratory parameters including respiratory system compliance between COVID-19 and non-COVD-19 patients in prone and supine positions. In comparison of advanced hemodynamic parameters in the first week of intensive care, the extravascular lung water and pulmonary vascular permeability indexes measured in supine position of COVID-19 ARDS patients were found to be significantly higher than non-COVID-19 patients. Duration of prone position was significantly longer in patients diagnosed with COVID-19 ARDS. Conclusions: The results of this study suggested that COVID-19 ARDS is a variant of typical ARDS with a different pathophysiology.

BRIEF RESEARCH COMMUNICATION

Supradip Ghosh, Sonali Ghosh, Amandeep Singh, Ripenmeet Salhotra

Impact of Prophylactic Noninvasive Ventilation on Extubation Outcome: A 4-year Prospective Observational Study from a Multidisciplinary ICU

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:6] [Pages No:709 - 714]

Keywords: Efficacy of prophylactic noninvasive ventilation, High risk of extubation failure, Weaning

PDF  |  DOI: 10.5005/jp-journals-10071-23880  |  Open Access |  How to cite  | 

Abstract

Introduction: With emerging evidence supporting other interventions, there is a need to re-examine the safety and efficacy of postextubation noninvasive ventilation (NIV) support in high-risk patients. Methods: Data were collected over 4-year period from a multispeciality ICU. High-risk criteria were uniform, and the application of NIV was protocolized. Successful extubation was defined as the absence of both reintubation and NIV support at 72 hours postextubation. Results: Extubation success was achieved in 79.6%. At extubation, more patients in the failure group had chronic neurological or kidney diseases, longer days of invasive ventilation, higher sequential organ failure assessment score, and more positive fluid balance. Significant differences were also observed in the indications for prophylactic NIV between the two groups. However, in logistic regression analysis, none of these differences observed in univariate analysis was independently associated with extubation outcome. Failure of postextubation NIV was associated with higher hospital mortality (67.7 vs 10.7%, p <0.001) and longer ICU/hospital length of stay (median 10 vs 6 days, p <0.001 and 13 vs 10 days, p <0.01, respectively). No differences were observed in extubation outcomes between 2016 to 2017 and 2018 to 2019 cohorts. Conclusion: High rate of extubation failure and worse patient-centric outcomes associated with prophylactic NIV calls for a relook into the current recommendation of NIV for this indication.

Pediatric Critical Care

Ahmet Yontem, Merve Misirlioglu

Frequency and Causes of Delirium in Pediatric Intensive Care Unit: A Prospective Observational Study

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:5] [Pages No:715 - 719]

Keywords: Delirium, Frequency, Prevention, Risk factors

PDF  |  DOI: 10.5005/jp-journals-10071-23857  |  Open Access |  How to cite  | 

Abstract

Background: The number of studies evaluating delirium and its frequency in critically ill infants, children, and adolescents is increasing day by day. The primary objective of this study was to evaluate all patients hospitalized in our pediatric intensive care unit (PICU) in terms of pediatric delirium, to determine the frequency and risk factors of pediatric delirium. Patients and methods: The patients included in this study had been hospitalized in the PICU between November 1, 2018, and August 31, 2019, and were followed up for more than 48 hours. Results: Delirium was detected in 14 patients (9.9%) through regular evaluations. The Pediatric Index of Mortality 2 (PIM2) scores and the length of stay in the PICU were higher in patients with delirium (p = 0.03 and p = 0.01, respectively). The use of respiratory support, sedation-analgesia, vasoactive and corticosteroid treatments, and physical restraints were higher in patients with delirium and were statistically significant (p <0.05). Following admission to the PICU, psychosocial interventions were implemented for 76.1% of the whole cohort. Delirium developed in only five (4.5%) of the 108 patients who underwent psychosocial interventions, while it was detected in nine (26.5%) of the 34 patients who did not receive psychosocial interventions (p = 0.001). The psychosocial intervention was associated with a lower likelihood of delirium (odds ratio [OR], 0.237; p = 0.044). An increasing number of days in the PICU was independently associated with increasing odds of delirium (OR, 1.095; p = 0.037 for each day). Conclusions: We observed that the risk factors associated with delirium were similar to previous studies. Additionally, psychosocial intervention before delirium symptoms developed was associated with a lower risk of developing delirium. However, multicenter randomized controlled trials are needed on this subject.

Pediatric Critical Care

Rashmi Hooda, Narayanan Parameswaran, Mahadevan Subramanian

Serious Adverse Reactions to Anti-snake Venom in Children with Snake Envenomation: An Underappreciated Contributor to Snakebite Mortality?

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:4] [Pages No:720 - 723]

Keywords: Adverse reactions, Anti-snake venom, Horse serum, Snake envenomation

PDF  |  DOI: 10.5005/jp-journals-10071-23836  |  Open Access |  How to cite  | 

Abstract

Background: Deaths due to snakebites and serious adverse reactions to anti-snake venom (ASV) are both underreported in India. Serious adverse reactions to ASV are common, contributing significantly to mortality and morbidity. We conducted a study to determine the frequency of occurrence of severe adverse reactions to ASV in children and study the various risk factors and their outcomes. Patients and methods: We carried out a retrospective record review of all children of snake envenomation admitted in our tertiary care teaching hospital, from January 2013 to December 2016. Children aged 0 to 12 years admitted for snake envenomation and who received ASV as part of their treatment were included. Details about their management, including ASV usage and any adverse effects noted, were collected on a standard data collection form. Results: Sixty-eight children were enrolled. Hemotoxic (52.9%) envenomation was more common than neurotoxic (35.2%). Severe adverse reactions were present in 42.6%, hypotension in 38.2%, and bronchospasm in 4.4% of the children. The overall mortality rate was 16.1%, anaphylaxis to ASV contributing to 36.3% of them. Mortality was significantly higher in cases with severe adverse reactions (p = 0.005). ASV reactions were also significantly different with different manufacturers. Conclusions: There is a high frequency of occurrence of severe adverse reactions to ASV resulting in significant morbidity and mortality.

CASE REPORT

Sonali Vadi, Sourabh Phadtare, Kiran Shetty

High-flow Oxygen Therapy via Tracheostomy to Liberate COVID-19-induced ARDS from Invasive Ventilation: A Case Series

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:5] [Pages No:724 - 728]

Keywords: COVID-19-associated ARDS, High-flow oxygen therapy via tracheostomy, Patient–ventilator interaction, Ventilator-induced lung injury, Weaning from mechanical ventilation

PDF  |  DOI: 10.5005/jp-journals-10071-23858  |  Open Access |  How to cite  | 

Abstract

Lung involvement with differing phenotypes characterizes COVID-19-induced acute respiratory distress syndrome (CARDS). The liberation of these patients from mechanical ventilation has been challenging. Excessive stress and strain following increased respiratory efforts spiral their vulnerable lung tissue into ventilator-induced lung injury vortex. The use of high-flow oxygen therapy via tracheostomy (HFOTTracheal)eases weaning process. As a safe option for both the patient and the healthcare workers, HFOTTracheal was successfully employed to wean two CARDS patients from the mechanical ventilator.

CASE REPORT

Satarupa Mukherjee, Krupanandan Ravikumar, Sudeep K Kapalavai, Bala Ramachandran

A Child with Unilateral Pulmonary Edema due to Mitral Valve Rupture Following Blunt Trauma

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:3] [Pages No:729 - 731]

Keywords: Blunt trauma, Mitral valve, Unilateral pulmonary edema

PDF  |  DOI: 10.5005/jp-journals-10071-23859  |  Open Access |  How to cite  | 

Abstract

A 7-year-old boy was admitted with a history of cough and tachypnea for 1 day. There was a history of a fall from a motorcycle with some abrasions over the left arm. The child was found to have tachypnea and tachycardia and was started on noninvasive ventilation. Auscultation revealed a pansystolic murmur over the precordium. Chest X-ray revealed unilateral pulmonary edema on the right side. Echocardiography showed severe mitral regurgitation (MR) with the tear of the anterior leaflet. The child improved with diuretics and supportive care. After 3 months, he underwent surgical repair of the mitral valve. Traumatic mitral valve tear is quite rare in children. Unilateral pulmonary edema is a feature of MR with eccentric jet and is frequently misinterpreted.

CASE REPORT

Rajkumar S N Satyavolu, Roy Fischer, Rajaram Ramadoss

Upper Airway Obstruction in an Adult: An Unusual Presentation—Dissection of the Cervical Aortic Arch

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:3] [Pages No:732 - 734]

Keywords: Airway obstruction, Aorta, Aneurysm, Cervical aortic arch, Dissection

PDF  |  DOI: 10.5005/jp-journals-10071-23860  |  Open Access |  How to cite  | 

Abstract

Cervical aortic arch is a rare congenital anomaly. It is usually asymptomatic and an incidental finding but can have symptoms of cough, hoarseness of voice, and dysphagia. Although an association with aneurysmal dilatation is described, dissection of a cervical aortic arch is hitherto an unreported complication. We report a 46-year-old woman recently diagnosed with a cervical aortic arch, who presented with an acute upper airway obstruction leading to cardiorespiratory arrest secondary to spontaneous dissection of the cervical aortic arch.

LETTER TO EDITOR

Arul Janakiammal Mahendran, Sumita Agrawal, Neha Rastogi, Nitesh Gupta

Myroides: A Rare but Hard-to-crack Villain in a Critical Care Setup

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:2] [Pages No:735 - 736]

Keywords: Critically ill patients, Diabetes mellitus, Infectious diseases, Intensive critical care

PDF  |  DOI: 10.5005/jp-journals-10071-23845  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Rini Saha, Subodh K Singh, Sukhen Samanta

Fundus Examination to Guide Anticoagulation Therapy in Suspected COVID-19 in a Critical Care Unit

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:2] [Pages No:737 - 738]

Keywords: Coronavirus disease 2019, D-Dimer, Retinal vein thrombosis

PDF  |  DOI: 10.5005/jp-journals-10071-23865  |  Open Access |  How to cite  | 

LETTER TO EDITOR

Utpal Sarma, Vipul Mishra, Imliwati Aier, Veena Boswal, Jyoti Goyal

Staphylococcal Pyopericardium: A Rare and Fatal Complication Following a Common Viral Disease

[Year:2021] [Month:June] [Volume:25] [Number:6] [Pages:3] [Pages No:739 - 741]

Keywords: Dengue fever, Pyopericardium, Staphylococcal infection

PDF  |  DOI: 10.5005/jp-journals-10071-23866  |  Open Access |  How to cite  | 

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