Indian Journal of Critical Care Medicine

Register      Login

Table of Content

2021 | September | Volume 25 | Issue 9

EDITORIAL

Subhash Todi

Clearing the Fog on the Use of N95 Mask

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:961 - 962]

PDF  |  DOI: 10.5005/jp-journals-10071-23976  |  Open Access |  How to cite  | 

EDITORIAL

Velmurugan Selvam, Shrikanth Srinivasan

Age-adjusted Charlson Comorbidity Index: A Simple Tool, but Needs Further Validation in COVID-19 Patients

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:963 - 964]

PDF  |  DOI: 10.5005/jp-journals-10071-23973  |  Open Access |  How to cite  | 

EDITORIAL

Critical Illness in COVID-19: A Sobering Experience for the Intensivist

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:965 - 966]

PDF  |  DOI: 10.5005/jp-journals-10071-23983  |  Open Access |  How to cite  | 

EDITORIAL

Praveen Kumar G, Vivek Kakar

Custodian of Oxygen Monitoring: Is There a Winner?

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:967 - 968]

PDF  |  DOI: 10.5005/jp-journals-10071-23970  |  Open Access |  How to cite  | 

EDITORIAL

Harsh Sapra

Intensive Care Unit-acquired Weakness: A Frequent but Under-recognized Threat

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:3] [Pages No:969 - 971]

PDF  |  DOI: 10.5005/jp-journals-10071-23990  |  Open Access |  How to cite  | 

EDITORIAL

Sachin Gupta, Deeksha S Tomar

NGAL for Preeclampsia: How Sure are We?

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:972 - 973]

PDF  |  DOI: 10.5005/jp-journals-10071-23969  |  Open Access |  How to cite  | 

EDITORIAL

Mullai Baalaaji AR

Weaning from Mechanical Ventilation in Children: Are We Getting It Right?

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:974 - 975]

PDF  |  DOI: 10.5005/jp-journals-10071-23974  |  Open Access |  How to cite  | 

Original Article

Sandy Kyaw, Moira Johns, Rimen Lim, Warren C Stewart, Natalia Rojas, Solomon R Thambiraj, Yahya Shehabi

Prediction of N95 Respirator Fit from Fogging of Eyeglasses: A Pilot Study

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:5] [Pages No:976 - 980]

Keywords: Eyeglasses, Healthcare workers, Infectious disease, Intensive care, N95 respirators, Occupational health

PDF  |  DOI: 10.5005/jp-journals-10071-23947  |  Open Access |  How to cite  | 

Abstract

Aim and objective: Fogging of eyeglasses while wearing N95 respirators is common. It is commonly held that the N95 respirator has a poor fit if there is fogging of eyeglasses. We conducted this prospective, pilot study to determine if fogging of eyeglasses predicts poor fit of N95 respirator. Materials and methods: Seventy volunteer healthcare workers from a tertiary intensive care unit in Sydney, Australia participated. The participants donned one of the following N95 respirators: three-panel flat-fold respirator (3M 1870), cup-shaped respirator (3M 1860), or a duckbill respirator. After a satisfactory “user seal check” as recommended by the manufacturer, the participants donned eyeglasses and checked for fogging. A quantitative fit test (QnFT) of the respirator was then performed (using PortaCount Respirator Fit Tester 8048, TSI Inc., Minnesota, USA). A fit factor of <100 on quantitative fit testing indicates poor fit. The sensitivity and specificity for fogging of eyeglasses (index test) to predict the poor fit of N95 respirator was determined, compared to QnFT (gold standard test). Results: Fogging of eyeglasses as a predictor of poor respirator fit (i.e., fit factor <100 on QnFT) had sensitivity of 71% (95% CI, 54–85%) and specificity 46% (95% CI, 29–63%). The odds ratio of fogging as a predictor for poor fit was 2.10 (95% CI, 0.78–5.67), with a two-tailed p-value of 0.22 (not significant). The receiver operating characteristic curve for fogging of eyeglasses as a diagnostic test had the area under the curve of 0.59. Conclusion: Fogging of eyeglasses is neither a sensitive nor a specific predictor for poor fit of N95 respirators.

Original Article

Moira Johns, Sandy Kyaw, Rimen Lim, Warren C Stewart, Solomon R Thambiraj, Yahya Shehabi, David W Collins, Claudia M Whyte

Fit Factor Change on Quantitative Fit Testing of Duckbill N95 Respirators with the Use of Safety Goggles

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:6] [Pages No:981 - 986]

Keywords: Eyeglasses, HCW (Healthcare workers), Infectious diseases, Intensive care, N95 MASK, N95 respirators, Occupational injury, Personal protective equipment, Safety

PDF  |  DOI: 10.5005/jp-journals-10071-23972  |  Open Access |  How to cite  | 

Abstract

N95 respirators and safety goggles are important components of personal protective equipment to reduce the spread of airborne infections, such as COVID-19, among healthcare workers. Poor N95 respirator seal may reduce its protective effect, thereby increasing transmission. Quantitative fit testing is an established way of assessing the N95 respirator fit, which provides a quantitative measure for seal, called the fit factor. Duckbill N95 respirators frequently fail the fit test. We hypothesized that using safety goggles with a wraparound elastic headband will increase their fit-factor by reinforcing the seal between the face and the upper margin of the respirator. We studied the effect of safety goggles with a wraparound elastic headband (3M™ Chemical Splash Resistant Goggles, ID 70006982741) on the fit factor of two types of Duckbill N95 respirators (Halyard FLUIDSHIELD*3, Model 99SA070M, and ProShield® N95 Model TN01-11) in 63 healthy volunteers in a nonrandomized, before-and-after intervention study design. The mean fit factor increased from 69.4 to 169.1 increased from 17/63 (27%) to 46/63 (73%) after the intervention (p <0.0001, OR 3 [95% CI = 4.9–1223]). This is the first study to explore the impact of safety goggles on N95 respirator fit. We conclude that the use of safety goggles with a wraparound elastic headband increases the fit factor of the tested Duckbill N95 respirators.

Original Article

Vishal Shanbhag, Arjun NR, Souvik Chaudhuri, Akhilesh K Pandey

Utility of Age-adjusted Charlson Comorbidity Index as a Predictor of Need for Invasive Mechanical Ventilation, Length of Hospital Stay, and Survival in COVID-19 Patients

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:5] [Pages No:987 - 991]

Keywords: Age-adjusted Charlson comorbidity index, Coronavirus disease 2019, Invasive mechanical ventilation, Length of hospital stay, Mortality, Remdesivir

PDF  |  DOI: 10.5005/jp-journals-10071-23946  |  Open Access |  How to cite  | 

Abstract

Background: Multiple parameters may be used to prognosticate coronavirus disease-2019 (COVID-19) patients, which are often expensive laboratory or radiological investigations. We evaluated the utility of age-adjusted Charlson comorbidity index (CCI) as a predictor of outcome in COVID-19 patients treated with remdesivir. Materials and methods: This was a single-center, retrospective study on 126 COVID-19 patients treated with remdesivir. The age-adjusted CCI, length of hospital stay (LOS), need for invasive mechanical ventilation (IMV), and survival were recorded. Results: The mean and standard deviation (SD) of age-adjusted CCI were 3.37 and 2.186, respectively. Eighty-six patients (70.5%) had age-adjusted CCI ≤4, and 36 (29.5%) had age-adjusted CCI >4. Among patients with age-adjusted CCI ≤4, 20 (23.3%) required IMV, whereas in those with age-adjusted CCI >4, 19 (52.8%) required IMV (p <0.05, Pearson\'s chi-square test). In those with age-adjusted CCI ≤4, the mortality was 18.6%, whereas it was 41.7% in patients with age-adjusted CCI >4 (p <0.05, Pearson\'s chi-square test). The receiver operating curve (ROC) of age-adjusted CCI for predicting the mortality had an area under the curve (AUC) of 0.709, p = 0.001, and sensitivity 68%, specificity 62%, and 95% confidence interval (CI) [0.608, 0.810], for a cutoff score >4. The ROC for age-adjusted CCI for predicting the need for IMV had an AUC of 0.696, p = 0.001, and sensitivity 67%, specificity 63%, and 95% CI [0.594, 0.797], for a cutoff score >4. ROC for age-adjusted CCI as a predictor of prolonged LOS (≥14 days) was insignificant. Conclusion: In COVID-19 patients, the age-adjusted CCI is an independent predictor of the need for IMV (score >4) and mortality (score >4) but is not useful to predict LOS (CTRI/2020/11/029266).

Original Article

Rahul A Pandit, BN Gagana, Charudatt Vaity, Bindu Mulakavalupil, Jitendra S Choudhary, Vivek Jain, Pramila M Chandan, Harsh Joshi

Clinical Characteristics and Outcomes of COVID-19 Patients Hospitalized in Intensive Care Unit

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:9] [Pages No:992 - 1000]

Keywords: COVID-19, ICU, Outcomes

PDF  |  DOI: 10.5005/jp-journals-10071-23945  |  Open Access |  How to cite  | 

Abstract

Background: Meta-analysis and clinical studies suggest coronavirus disease-2019 (COVID-19) patients in ICU have a high mortality rate of 30–45%, which has evolved as a function of criteria of admission and the management modalities. Materials and methods: We conducted a retrospective evaluation for characteristics and outcomes in critical care set up across six months. Results: 514 patients (74.3% males and 25.6% females) were evaluated. 9.72% (n = 50) patients expired, 78% (n = 39) were males. Mean age (years) was 57 (±14, range 64, 95% CI 55–58). 65.7% (n = 338) were of age more than 50 years, of which 71.5% (n = 242) were males. Males at 20% higher risk for death than women. (RR = 1.2, 95% CI 0.66–2.31, p = 0.61 NS). There was 18% less risk of mortality in female vs male with comorbidities (RR 0.82, 95% CI 0.67–1.12, p = 0.32 NS). Risk for mortality in diabetics was significantly increased by 116% vs nondiabetics. (RR 2.16, p = 0.0055, 95% CI 1.28–3.67). Highly significant risk of mortality in age group >50 years (3.13 times higher) vs age ≤50 years. (RR 3.18, 95% CI 1.71–8.64, p = 0.0003). 50.2% had moderate ARDS at admission. High flow nasal cannula was used in 47.2%. There is 5.79 times more likelihood to be on the ventilator with moderate to severe ARDS vs mild ARDS (RR = 5.79, 95% CI 3.10–11.05, p <0.0001). Risk for death was six times higher for patients on ventilator vs not on ventilator (RR = 6.08, 95% CI 3.49–10.59, p <0.0001). The mean number of days on ventilator for patients who underwent tracheostomy (n = 49) was 14 days as compared to 6.6 days in patients who were extubated (n = 57) (p <0.0001). P/F ratio had negative correlation with number of days of hospitalisation (Pearson r -0.391, 95% CI -0.46– -0.31, p <0.0001). 67% less chances of mortality in patients on steroids (RR = 0.33, 95% CI 0.19–60, p = 0.0012). Mean duration of ICU stay (days) was 8 (± 5, range 29, 95% CI 7.5–8.4). Conclusions: We observed that a strict adherence to the basic principles of ARDS management resulted in a lower mortality in ICU setting.

Original Article

Sheetal Babu, Kundavaram PP Abhilash, Subramani Kandasamy, Mahasampath Gowri

Association between SpO2/FiO2 Ratio and PaO2/FiO2 Ratio in Different Modes of Oxygen Supplementation

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:5] [Pages No:1001 - 1005]

Keywords: Arterial blood gas (ABG), Acute hypoxemic respiratory failure (AHRF), Acute respiratory distress syndrome (ARDS), Oxygen supplementation, PaO2/FiO2 ratio, Pulse oximetry, SaO2/FiO2 ratio

PDF  |  DOI: 10.5005/jp-journals-10071-23977  |  Open Access |  How to cite  | 

Abstract

Background: Acute hypoxemic respiratory failure (AHRF) is a major factor for increased mortality in the intensive care unit (ICU). We hypothesized that the noninvasive index SpO2/FiO2 (SF) ratio can be used as a surrogate to invasive index PaO2/FiO2 (PF) as SF ratio correlates with PF ratio in all modes of oxygen supplementation. Patients and methods: Patients with acute respiratory failure admitted to the intensive care unit were enrolled in this retrospective cross-sectional study. Fraction of inspired oxygen (FiO2), method of oxygen supplementation, and partial pressure of arterial oxygen (PaO2) were noted from the ABG reports in the medical records. The corresponding SpO2 was noted from the nurse\'s chart. The calculated SF and PF ratios were recorded, and correlation between the same was noted in different methods of oxygen administration. Results: A total of 300-sample data were collected. Pearson\'s correlation was used to quantify the relationship between the variables. The study showed a positive correlation, r = 0.66 (p <0.001), between PF ratio and SF ratio. SF threshold values were 285 and 323 for corresponding PF values of 200 and 300 with a sensitivity and specificity in the range of 70 to 80%. In addition, SF and PF could also be used interchangeably irrespective of the mode of oxygen supplementation, as the median values of PF ratio (p = 0.06) and SF ratio (p = 0.88) were not statistically significant. Conclusion: In patients with AHRF, the noninvasive SF ratio can be used as a surrogate to invasive index PF in all modes of oxygen supplementation.

Original Article

Skaria Baby, Christina George, Narjeet M Osahan

Intensive Care Unit-acquired Neuromuscular Weakness: A Prospective Study on Incidence, Clinical Course, and Outcomes

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:7] [Pages No:1006 - 1012]

Keywords: Intensive care unit, Medical Research Council score, Neuromuscular weakness

PDF  |  DOI: 10.5005/jp-journals-10071-23975  |  Open Access |  How to cite  | 

Abstract

Background: Neuromuscular weakness may manifest subsequent to critical illness in intensive care unit (ICU) patients. This weakness termed as “ICU-acquired weakness” (ICUAW) has a significant bearing on the length of mechanical ventilation, duration of ICU stays, long-term disability, and survival rate. Early identification of ICUAW helps in planning appropriate strategies, as well as in predicting the prognosis and long-term outcomes of these patients. Aims and objectives: To identify the incidence of new-onset neuromuscular weakness developing among patients admitted in the ICU (ICUAW) and study its clinical course and impact on the duration of ICU stay. Methods: This prospective observational study evaluated patients admitted to the ICU over a period of 1 year and 3 months (November 1, 2015, to January 31, 2017). All patients fulfilling the inclusion and exclusion criteria were evaluated with the Medical Research Council (MRC) score for muscle strength. Patients with an average score <4 were diagnosed with ICUAW. Included patients were examined on alternate days to study the clinical progression of the weakness till ICU discharge or death of the patient. The duration of ICU stay was noted. Results and conclusion: The study revealed a significant association of ICUAW with age, Acute Physiology And Chronic Health Evaluation (APACHE II) Score, duration of mechanical ventilation, and ICU mortality. The incidence of the weakness was found to be 7.83% among the patients who survived and 50% among those patients who did not survive critical illness.

Original Article

Asha Tyagi, Pooja Yadav, Rashmi Salhotra, Shukla Das, Praveen K Singh, Devansh Garg

Acute Kidney Injury in Severe Preeclamptic Patients Admitted to Intensive Care Unit: Epidemiology and Role of Serum Neutrophil Gelatinase-associated Lipocalcin

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:7] [Pages No:1013 - 1019]

Keywords: Acute kidney injury, Intensive care unit, Neutrophil gelatinase-associated lipocalcin, Preeclampsia, Pregnancy

PDF  |  DOI: 10.5005/jp-journals-10071-23966  |  Open Access |  How to cite  | 

Abstract

Background: Patients with preeclampsia admitted to the intensive care unit (ICU) may have risk factors for acute kidney injury (AKI). Although the use of neutrophil gelatinase-associated lipocalcin (NGAL) to predict AKI is previously validated, we could locate only scanty data regarding the epidemiology of AKI and role of NGAL in preeclamptic patients admitted to ICU. Methods: Patients with preeclampsia admitted to our ICU were included. The incidence and severity of AKI during the entire ICU stay were assessed using kidney disease improving global outcomes criteria, while the a priori risk factors and serum NGAL were also evaluated. Results: A total of 52 preeclamptic patients admitted to ICU were included, among whom the majority had eclampsia (75%). AKI developed in 25 (48.1%) patients with stages 1, 2, and 3 in 56, 36, and 8%, respectively. The incidence of sepsis (16 vs 0%), shock (40 vs 7.4%), and anemia (84 vs 59.3%) was significantly greater in patients with AKI (p < 0.05). ICU mortality (28 vs 3.7%), duration of ICU, and hospital stay were significantly higher in patients who developed AKI (p < 0.05). There was no association of serum NGAL [274 (240–335) ng/mL] with AKI or the mortality (p = 0.725, 0.861); there was, however, a significant discriminatory value for eclampsia [p = 0.019; area under curve = 0.736 (95% confidence interval: 0.569–0.904)]. Conclusions: Although AKI is common among patients with preeclampsia admitted to ICU, serum NGAL does not predict its occurrence.

Original Article

Srivatsa Angraje, Manikantan Sekar, Biswajit Mishra, Jayakumar Matcha

Outcome of Plasma Exchange in Acute Liver Failure due to Yellow Phosphorus Poisoning: A Single-center Experience

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:6] [Pages No:1020 - 1025]

Keywords: Acute liver failure, Plasma exchange, Poisoning, Yellow phosphorus

PDF  |  DOI: 10.5005/jp-journals-10071-23971  |  Open Access |  How to cite  | 

Abstract

Background: Yellow phosphorus (YP) is a protoplasmic poison that causes acute liver failure (ALF) for which liver transplantation is the definitive modality. Hereby, we present our clinical data on the role of plasma exchange (PE) in ALF due to YP poisoning when liver transplantation is not readily available. Methods: Our study is a prospective observational type, conducted between January 2017 and January 2020, which included patients with ALF due to YP poisoning requiring PE. Clinical features, quantity of poison consumed, and laboratory data before and after PE were noted, and the outcome was documented. Results: This study had 10 patients. The mean age was 30 years. The ratio of male to female being 1.5:1. The amount of YP consumed (median) was 10 gm. Six patients consumed ≤10 gm and four consumed >10 gm. The mean of total PE sessions was 3.3. Seven patients (70%) had recovery from ALF, out of which five had consumed <10 gm of YP. Among patients who recovered after consuming YP, the mean day to get admitted to the hospital was 3.6 ± 1.81 (p = 0.017) and the time to start PE was 4.86 ± 1.67 days (p = 0.033). Three patients did not recover from ALF, of whom two expired. Peak total bilirubin (mg/dL) decreased to 2.76 from 9.29 (p = 0.005), serum glutamic oxaloacetic transaminase to 53.5 from 530 (IU/L) (p = 0.005), serum glutamic pyruvic transaminase to 54.5 from 378 (IU/L) (p = 0.005), international normalized ratio to 1.08 from 2.26 (p = 0.008), prothrombin time(s) decreased to 13.3 from 25.5 (p = 0.013), and activated partial thromboplastin time(s) to 24.6 from 40.8 (p = 0.007) post-PE sessions. Conclusions: Our study revealed that the patient outcome depends on the quantity of poison consumed, duration of hospitalization, and time to start PE from the day of YP consumption. PE may be considered as a bridge to liver transplant in ALF patients.

Original Article

Pooneh Barati, Somayeh Ghafari, Mahmood Saghaei

Comparative Assessment of the Effects of Two Methods of Pressure Support Adjustment on Respiratory Distress in Patients under Mechanical Ventilation Admitted to Intensive Care Units

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:5] [Pages No:1026 - 1030]

Keywords: Intensive care unit, Mechanical ventilation, Pressure support, Respiratory distress

PDF  |  DOI: 10.5005/jp-journals-10071-23960  |  Open Access |  How to cite  | 

Abstract

Background: Incorrect adjustment of the respiratory parameters of the mechanical ventilator increases respiratory distress and work of breathing (WOB) in mechanically ventilated patients. The accurate adjustment of pressure support increases the patient\'s comfort and decreases respiratory distress and WOB, etc.; thus, the present study was conducted to compare the effects of two pressure support adjustment methods on respiratory distress in patients under mechanical ventilation to investigate whether the rapid shallow breathing index (RSBI) method can reduce patients’ respiratory distress more and faster than the tidal volume (VT) and respiratory rate (RR) methods. Patients and methods: The study was conducted in 2020 on 56 mechanically ventilated patients with respiratory distress. The patients’ respiratory distress was first measured using RSBI and the respiratory distress observation scale (RDOS). The pressure support was then adjusted in the patients according to the RSBI (in the trial group, n = 33) and VT and RR (in the control group, n = 23). The patients’ respiratory distress was measured again in both groups 15 and 30 minutes after the pressure support adjustment. Results: The results showed no significant differences between the two groups in the mean RSBI and RDOS before (p = 0.374, p = 0.657 respectively) and 30 (p = 0.103, p = 0.218 respectively) minutes after the adjustment of the pressure support, but these mean values differed significantly (p = 0.025 for RSBI and p = 0.044 for RDOS) between the groups 15 minutes after the adjustment. Moreover, the interaction effect of the group * time for RDOS has become significant nonlinearly (p = 0.037), but none of the interaction effects of the group * time were significant for RSBI (linear: p = 0.531; nonlinear: p = 0.272). Conclusion: These two methods finally reduced the patients’ respiratory distress almost equally, but RSBI method can relieve the patients’ respiratory distress faster than the VT and RR methods. Key message: VT, RR, and RSBI methods finally reduced the patients’ respiratory distress almost equally, but RSBI method can relieve the patients’ respiratory distress faster than the VT and RR methods.

Original Article

Prasanna V Vanamail, Kalpana Balakrishnan, Sarojini Prahlad, Punitha Chockalingam, Radhika Dash, Dinesh K Soundararajan

Ultrasonographic Assessment of Diaphragmatic Inspiratory Amplitude and Its Association with Postoperative Pulmonary Complications in Upper Abdominal Surgery: A Prospective, Longitudinal, Observational Study

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:9] [Pages No:1031 - 1039]

Keywords: Diaphragm excursion, Diaphragmatic dysfunction, Diaphragmatic inspiratory amplitude, Gastrectomy, Pancreaticoduodenectomy, Pneumonia, Postoperative, Pulmonary complications, Ultrasound, Upper abdominal surgery

PDF  |  DOI: 10.5005/jp-journals-10071-23962  |  Open Access |  How to cite  | 

Abstract

Background: Diaphragmatic dysfunction following upper abdominal surgery is less recognized due to a lack of diagnostic modality for bedside evaluation. We used point-of-care ultrasound to evaluate the diaphragmatic inspiratory amplitude (DIA) in upper abdominal surgery for cancer. Our primary hypothesis was DIA would be reduced in the immediate postoperative period in patients with postoperative pulmonary complications (PPCs). Our aim was to identify an optimal cutoff of DIA for the diagnosis of PPCs. Methods: We conducted a prospective, observational study in patients aged 18–75 years undergoing elective, upper abdominal oncological surgeries under combined general and epidural anesthesia. Ultrasound evaluation of the diaphragm was done by measuring the DIA in the right and left hemidiaphragms during quiet and deep breathing on the day before surgery and postoperative days (PODs) 1, 2, and 3. Patients were followed up for PPCs until POD 7. The linear mixed-effects model examined the association between DIA and PPCs and other perioperative factors. Receiver-operating characteristics analysis was done to determine the optimal cutoff of DIA in diagnosing PPCs. Results: DIA measured in the 162 patients showed a significant decrease in their absolute values postoperatively from its preoperative baseline measurement. This decrease in DIA was significantly associated with PPC [right hemidiaphragm, β = −0.17, 95% confidence interval (CI) −0.31 to −0.02, p = 0.001 during quiet breathing; left hemidiaphragm, β = −0.24, 95% CI = −0.44 to −0.04, p = 0.018 and β = −0.40, 95% CI = −0.71 to −0.09, p = 0.012 during quiet and deep breathing, respectively]. A cutoff value of DIA of left hemidiaphragm at 1.3 cm during quiet breathing and 1.6 cm during deep breathing had a sensitivity of 77 and 75%, respectively, in their ability to diagnose PPCs [left hemidiaphragm quiet breathing, area under the curve (AUC): 0.653, 95% CI 0.539–0.768, p = 0.015; left hemidiaphragm deep breathing, AUC: 0.675, 95% CI 0.577–0.773, p = 0.007]. Conclusion: Following upper abdominal surgery, the DIA is decreased and associated with PPCs. DIA of left hemidiaphragm less than 1.3 cm during quiet breathing and 1.6 cm during deep breathing has a sensitivity of 77 and 75%, respectively, in diagnosing PPCs following upper abdominal surgery.

Supplementary Files

Original Article

Hashim Mohammad, Gaurav Jain, Ankit Agarwal, Sana Kausar, Sonu Sama

Application of Endotracheal Tube Cuff Pressure Monitoring during Percutaneous Dilatational Tracheostomy: A Novel Technique

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:1040 - 1041]

Keywords: Endotracheal tube cuff pressure manometer, Endotracheal tube positioning, Percutaneous dilatational tracheostomy

PDF  |  DOI: 10.5005/jp-journals-10071-23961  |  Open Access |  How to cite  | 

Abstract

Endotracheal tube (ETT) cuff pressure monitoring during percutaneous dilatational tracheostomy (PDT) procedure is an easy-to-use innovative addition to the standard blind technique in a resource-limited setting. This technique can be carried out without disconnecting the breathing circuit, resulting in a lower risk of infectious aerosol generation.

Original Article

Rajesh K Mishra, Aparna Pande, Rashmi Ramachandran, Anjan Trikha, Preet M Singh, Vimi Rewari

Effect of Change in Body Weight on Clinical Outcomes in Critically Ill Patients

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:7] [Pages No:1042 - 1048]

Keywords: Body weight, Fluid balance, Intensive care unit, Mortality

PDF  |  DOI: 10.5005/jp-journals-10071-23978  |  Open Access |  How to cite  | 

Abstract

Background: Intravenous fluid optimization is an essential component of managing patients in a critical care setting. A cumulative positive fluid balance is consistent with poor outcomes in patients admitted to the intensive care unit (ICU). The overall utility of net cumulative fluid balance as a surrogate for assessing fluid overload has been interrogated. Materials and methods: This study was a prospective single-center observational study, which was done to correlate body weight changes with fluid balance in ICU patients and evaluate its impact on clinical outcomes. Inclusion criteria consisted of adult patients who were admitted to the critical care unit on specialized beds with integrated weighing scales between September 2017 and December 2018. The evaluation of the effect of changes in body weight on ICU survival was the primary objective of the study. Results: We enrolled 105 patients in this study. The ICU mortality was 23.80% with non-survivors showing more weight gain than the survivors. Statistically significant weight gain was documented in the non-survivors on days 3 and 4 (1.9 vs 1.05; p = 0.0084 and 2.6 vs 1.6; p = 0.0030) of ICU admission. Non-survivors had greater cumulative positive fluid balance on fourth, fifth, and sixth days post-ICU admission when compared to survivors (3586 vs 1659 mL, p = 0.0322; 5418 vs 1255 mL, p = 0.0017; and 5430 vs 2305 mL p = 0.0264, respectively). In multivariate regression analysis, cumulative fluid balance did not correlate with days on mechanical ventilation or length of stay in ICU. Changes in body weight and cumulative fluid balance showed a good correlation. Conclusion: In patients admitted to the ICU, weight gain on third and fourth days of admission is concordant with increased ICU mortality. Body weight changes were seen to correlate well with the cumulative fluid balance.

View Point

Midhun Mohan, Lloyd F Joy, Arun Sivasankar, Shoukath Ali, Biju Vareed Meckattuparamban

“Compassion Cannot Choose:” A Call for Family-centered Critical Care during the COVID-19 Pandemic

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:1049 - 1050]

Keywords: Compassion, COVID-19, Family presence, Family-centered critical care, Intensive care unit

PDF  |  DOI: 10.5005/jp-journals-10071-23957  |  Open Access |  How to cite  | 

Abstract

Compassion has been one of the greatest virtues of healthcare professionals. In the early phase of the pandemic, a lot of caution was essential, and restrictions were imposed on the hospital visitation of the COVID-19 patients by their family members. The healthcare system was overburdened, and the healthcare workers were apprehensive about the new virus and the rising mortality. Compassion and family-centered care took a step back as survival of the pandemic became the ultimate goal of mankind. “COVID-19 patients admitted to the critical care units, their loved ones and the healthcare professionals caring for these patients took the brunt of the emotional and psychological impacts of the pandemic.” However, as we have moved more than a year into the pandemic, knowledge and resources we gained may be leveraged to provide family-centered critical care for COVID-19 patients. Family presence in intensive care units (ICUs) has been associated with higher satisfaction with care, collaboration with the medical team, shared decision-making, reduced delirium, and optimized end-of-life care of COVID-19 patients. The policymakers should review the restrictions, consider a holistic approach, and take appropriate actions to provide safe family-centered critical care for COVID-19 patients.

SYSTEMATIC REVIEW

Sibtain Ahmed, Maheen Mansoor, Muhammad S Shaikh, Imran Siddiqui

Presepsin as a Predictive Biomarker of Severity in COVID-19: A Systematic Review

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:4] [Pages No:1051 - 1054]

Keywords: COVID-19, Presepsin, Prognosis, Severe COVID, Systematic review

PDF  |  DOI: 10.5005/jp-journals-10071-23967  |  Open Access |  How to cite  | 

Abstract

Background: The aim of this review is to evaluate the global scientific literature on the utility of plasma presepsin (PSP) as a prognostic biomarker in a homogeneous group of coronavirus disease 2019 (COVID-19) positive cases. Data retrieval: A systematic review utilizing Medline (PubMed interface), LitCovid NLM, World Health Organization (WHO)–global literature on coronavirus disease, and EBSCO CINAHL Plus was undertaken. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) group guidelines. The quality of individual evidence and possible risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) tool. A narrative synthesis-based conclusion was compiled. Results: A total of three articles passed through the predefined screening criteria and were included in the review. Methodological quality was evaluated to be acceptable. The aggregate study population was summed up to be 167 COVID-19 positive cases, who had undergone analysis of plasma PSP levels for the prediction of severity and mortality. Based on different PSP cutoffs utilized, a statistically significant association between PSP and COVID-19 severity was reported. Conclusion: PSP appears as a promising prognostic biomarker of COVID-19 progression. As data are scarce on its utility, large cross-sectional studies are needed.

BRIEF RESEARCH COMMUNICATION

Kapil G Zirpe, Rahul Pandit, Rajesh Pande, Abhijit M Deshmukh, Saiprasad Patil, Sagar Bhagat, Hanmant Barkate

A Real-world Study on Prescription Pattern of Fosfomycin in Critical Care Patients

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:4] [Pages No:1055 - 1058]

Keywords: Critically ill adults, Fosfomycin, Retrospective study

PDF  |  DOI: 10.5005/jp-journals-10071-23958  |  Open Access |  How to cite  | 

Abstract

Background: This study presents a real-world scenario for prescription pattern, efficacy, and safety data on the current clinical use of intravenous fosfomycin in critically ill patients in Indian settings. Patients and methods: This was a retrospective cohort study conducted for a period of 10 months among critically ill patients admitted to hospital\'s critical care unit. The primary objective of the study was to analyze the prescription pattern of intravenous fosfomycin, and the secondary objective was to evaluate the safety profile and patient outcomes. Results: A total of 309 patients were enrolled, and they were diagnosed with bacteremia (45.3%), pneumonia (15.85%), septic shock (14.24%), and urinary tract infections (UTI) (13.91%). The average dose of fosfomycin given was 11.7 ± 4.06 gm/day. The average duration of the therapy was 4.85 ± 3.59 days with a median duration of 4 days. Fosfomycin was given at 8 hourly dosing frequency to maximum (45.6%) cases. Hypokalemia was the most observed adverse event. The overall survival was seen in 55% of patients. Conclusion: Our data suggest that UTI, infection caused by Escherichia coli, and a daily dose of >12 g were associated with better clinical outcomes. The overall survival of critically ill patients receiving fosfomycin was 55%.

Pediatric Critical Care

Rashmi Kishore, Urmila Jhamb

Effect of Protocolized Weaning and Spontaneous Breathing Trial vs Conventional Weaning on Duration of Mechanical Ventilation: A Randomized Controlled Trial

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:7] [Pages No:1059 - 1065]

Keywords: Extubation failure, Extubation readiness trial, Mechanical ventilation, Spontaneous breathing trial, Weaning

PDF  |  DOI: 10.5005/jp-journals-10071-23944  |  Open Access |  How to cite  | 

Abstract

Background: Identifying ventilated patients ready for extubation is a challenge for clinicians. Premature extubation increases risks of reintubation while delayed weaning increases complications of prolonged ventilation. We compared the duration of mechanical ventilation (MV) and extubation failure in children extubated using a weaning protocol based on pressure support spontaneous breathing trial (PS SBT) vs those extubated after nonprotocolized physician-directed weaning. Patients and methods: A prospective randomized controlled trial was conducted in the pediatric intensive care unit of a tertiary care hospital in children ventilated for ≥24 hours. All eligible patients underwent daily screening and were randomized once found fit. The intervention group underwent PS SBT of 2 hours duration followed by a T-piece trial and extubation. Controls underwent conventional weaning with synchronized intermittent mandatory ventilation mode and a T-piece trial before extubation. Results: Eighty patients were randomized into two groups of 40 each. About 77.5% of patients passed the PS SBT on the first attempt. No statistical difference was found either in the duration of MV between the two groups [median (interquartile range) in days: 4.77 (2.89, 9.46) in controls and 4.94 (2.23, 6.35) in cases, p = 0.62] or in the rate of extubation failure (13% and 10.5%, p = 1). Mortality was found to be significantly higher in the reintubated patients compared to those not reintubated in both groups (p = 0.002 in cases and 0.005 in controls). Conclusion: Weaning using PS SBT-based protocol though did not shorten the duration of MV, it was found to be safe for assessing extubation readiness and did not increase extubation failure (CTRI no—CTRI/2018/04/013270).

Supplementary Files

CASE SERIES

Parth Sudhendu Patel, Sudhendu Patel, Vidhi Shah, Varsha Aswani, Mahendra Narwaria

Early Experience of High-dose Intravenous Mycobacterium w in Critically Ill Patients of COVID-19

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:3] [Pages No:1066 - 1068]

Keywords: COVID-19, Immune dysregulation, Immunomodulator, Mycobacterium w

PDF  |  DOI: 10.5005/jp-journals-10071-23963  |  Open Access |  How to cite  | 

Abstract

Background: Immune dysregulation is one of the main reasons for mortality and morbidity in coronavirus disease 2019 (COVID-19). Mycobacterium w (Mw) is recently approved for gram-negative sepsis. Moreover, it is also found effective in COVID-19 patients in previous studies. The traditional route of administration for Mw is intradermal, which has a limitation of administering 0.1 mL per injection and local injection site reaction. Intravenous (IV) administration of Mw has not been explored in COVID-19. We report the retrospective analysis of six critically ill COVID-19 patients who received Mw (IV). Patients and methods: At baseline, all patients in this case series required O2 supplementation, and their inflammatory biomarkers were elevated. All patients received 0.6 mL Mw (high-dose) in normal saline along with the standard-of-care treatment. Results: After Mw administration, gradual improvement in O2 requirement was observed and patients were discharged from the hospital with no mortality. A reduction in mean C-reactive protein (CRP) (51.48–18.52 mg/dL), interleukin-6 (IL-6) (260.22–14.47 pg/mL), and FiO2 (81.67–43.33) was also observed. No side effects were observed with the use of Mw by IV route. Conclusion: Use of 0.6 mL Mw by IV route in this case series was associated with decreased O2 supplementation without any side effects in critically ill patients of COVID-19.

CASE REPORT

Prahlad Prabhudesai, Indu Khosla, Satish Kulkarni, Manish Kumar Arya, Abha Pandey, Namrata Yadav

Bilateral Whole Lung Lavage in Hereditary Pulmonary Alveolar Proteinosis in a 4-year-old Child Using Extracorporeal Membrane Oxygenation

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:4] [Pages No:1069 - 1072]

Keywords: Extracorporeal membrane oxygenation, Pulmonary alveolar proteinosis, Whole lung lavage

PDF  |  DOI: 10.5005/jp-journals-10071-23968  |  Open Access |  How to cite  | 

Abstract

The hereditary form of pulmonary alveolar proteinosis (PAP) is an uncommon entity. We report a case of PAP due to colony-stimulating factor 2 receptor alpha (CSF2RA) gene mutation. The standard of care includes whole lung lavage (WLL). We faced two challenges: Firstly, a severely hypoxemic patient, and secondly, the nonavailability of appropriate size of double-lumen endotracheal tube for pediatric patients for a WLL while permitting single-lung ventilation. Hence, we performed WLL using venovenous extracorporeal membrane oxygenation (VV ECMO) with a successful outcome. The patient has been discharged and is off oxygen support since more than a year. There are only a few case reports of children having hereditary PAP treated with WLL using ECMO in Indian and Western literature.

LETTER TO THE EDITOR

Jyoti Burad, Sonali Kodange

Neuroleptic Malignant Syndrome due to Atypical Antipsychotics in a COVID-19-positive Pregnant Woman

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:1073 - 1074]

Keywords: Antipsychotics, COVID-19, Fever, Muscle rigidity, Neuroleptic malignant syndrome, Pregnancy

PDF  |  DOI: 10.5005/jp-journals-10071-23959  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Justin A Gopaldas, Ajith Kumar AK

Ventilator -associated Pneumonia and Lung Ultrasound: Finally, What is between the Ears Matters

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:1075 - 1076]

Keywords: Accuracy, Diagnosis, Hospital-acquired infections, Lung ultrasound, Ventilator-associated pneumonia

PDF  |  DOI: 10.5005/jp-journals-10071-23936  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Differing Sensitivity of COVID-19 PCR Tests and Consequences of the False-negative Report: A Small Observation

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:1077 - 1078]

Keywords: COVID-19 infection, COVID-19 patient, Diagnosis test, SARS-CoV-2 RT-PCR

PDF  |  DOI: 10.5005/jp-journals-10071-23937  |  Open Access |  How to cite  | 

Abstract

The world at large cannot afford to miss even a single case of COVID-19 because of its far-reaching consequences; therefore, the diagnostic development to achieve test with much higher sensitivity should be made available at a mass level as early as possible.

LETTER TO THE EDITOR

Sayan Nath

Mucormycosis in COVID-19: Is Zinc a Silent Killer in India?

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:1079 - 1080]

Keywords: COVID-19, Mucormycosis, Zinc

PDF  |  DOI: 10.5005/jp-journals-10071-23938  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Pranav Shrivastava, Abhinav Das

Simple Mobile Application for Calculating “Ergotrauma” Made Using an Excel Sheet

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:1] [Pages No:1081 - 1081]

Keywords: Ergotrauma, Formula, Mobile application

PDF  |  DOI: 10.5005/jp-journals-10071-23948  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Akshaya K Das

Opium Addiction: Practical Issues in ICU

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:2] [Pages No:1082 - 1083]

Keywords: ICU, Opiod abuse, Opium

PDF  |  DOI: 10.5005/jp-journals-10071-23939  |  Open Access |  How to cite  | 

Erratum

Quality Improvement Initiative to Reduce Intravenous Line-related Infiltration and Phlebitis Incidence in Pediatric Emergency Room

[Year:2021] [Month:September] [Volume:25] [Number:9] [Pages:3] [Pages No:1084 - 1086]

Keywords: Infiltration, Pediatric emergency, Phlebitis, Quality improvement

PDF  |  DOI: 10.5005/jp-journals-10071-24002  |  Open Access |  How to cite  | 

Abstract

Old Abstract: Objective: To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital. Method: The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale were to grade the extent of two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change, introduction of infection control nurse and quality improvement (QI) team formations were implement in different Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” was outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were process measures. Result: The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9 and 96.1% to 45 and 55%, respectively, postimplementation of all PDSA cycles. Conclusion: Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation help in sustaining the goal and attaining long-term success. New Abstract: Aim and objective: To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital. Materials and methods: The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale used to grade the extent of the two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change and introduction of infection control nurse. These interventions were implemented in sequential Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” were the outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were the process measures. Result: The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9% and 96.1% to 45% and 55%, respectively, after implementation of all PDSA cycles. Conclusion: Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation helped in sustaining the goal and attaining long-term success.

© Jaypee Brothers Medical Publishers (P) LTD.