Indian Journal of Critical Care Medicine

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2022 | January | Volume 26 | Issue 1

EDITORIAL

Deepak Govil

Memores Acti Prudentes Future!

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:1] [Pages No:1 - 1]

   DOI: 10.5005/jp-journals-10071-24101  |  Open Access |  How to cite  | 

EDITORIAL

Outcome of Hemorrhagic Stroke: Host Immune Response can Be a Prediction Tool!

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:3] [Pages No:2 - 4]

Keywords: Acute brain injury, Assessment, Biomarkers, Hemorrhage subarachnoid, Intracerebral hemorrhage, Leukocytes, Patient outcome, White blood cells

   DOI: 10.5005/jp-journals-10071-24095  |  Open Access |  How to cite  | 

EDITORIAL

Justin Aryabhat Gopaldas

Revisiting Stewart's Approach toward Assessment of Unidentified or Complex Acid–Base Disorders

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:2] [Pages No:5 - 6]

Keywords: Acid–Base disturbance, Albumin-corrected anion gap, Bicarbonate-based arterial blood gas analysis, High anion gap metabolic acidosis, Metabolic acidosis, Metabolic alkalosis, Stewart's approach

   DOI: 10.5005/jp-journals-10071-24099  |  Open Access |  How to cite  | 

EDITORIAL

Mozammil Shafi

Differentiating Cardiac and Pulmonary Causes of Dyspnea: Is Point-of-care Ultrasound the Ultimate Tool?

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:2] [Pages No:7 - 8]

Keywords: Dyspnea, Dyspnea differentiation index, Point-of-care ultrasound

   DOI: 10.5005/jp-journals-10071-24098  |  Open Access |  How to cite  | 

EDITORIAL

Measurement of Interleukin-6 Levels in COVID: Illuminative or Illogical?

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:2] [Pages No:9 - 10]

Keywords: COVID-19 mortality, Interleukin-6 receptor antagonists, Interleukin-6

   DOI: 10.5005/jp-journals-10071-24102  |  Open Access |  How to cite  | 

EDITORIAL

Susruta Bandyopadhyay

COVID-19: Don't Forget the Heart

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:2] [Pages No:11 - 12]

   DOI: 10.5005/jp-journals-10071-24067  |  Open Access |  How to cite  | 

EDITORIAL

Ajith Kumar AK

Mortality Prediction in the ICU: The Daunting Task of Predicting the Unpredictable

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:2] [Pages No:13 - 14]

Keywords: ICU mortality, Mortality prediction, Predictive model

   DOI: 10.5005/jp-journals-10071-24063  |  Open Access |  How to cite  | 

EDITORIAL

Bindu George, Nayanthara Joachim

Evolving Techniques in RSI: Can the Choice of Induction Agent Matter in Securing a Definitive Airway in Emergency Settings?

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:3] [Pages No:15 - 17]

Keywords: Airway management, Endotracheal intubation, Etomidate, Intravenous anesthetics, Ketamine, Rapid sequence intubation

   DOI: 10.5005/jp-journals-10071-24100  |  Open Access |  How to cite  | 

Original Article

Sethu Babu, Mathew Pulicken, Arun K Thazhathuveedu

Peripheral Blood Neutrophil-to-lymphocyte Ratio as a Predictor of Functional Outcomes in Patients with Hemorrhagic Stroke

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:5] [Pages No:18 - 22]

Keywords: Functional outcomes, Hemorrhagic stroke, Intracranial hemorrhage, Modified Rankin scale, Neutrophil-to-lymphocyte ratio, The ICH score

   DOI: 10.5005/jp-journals-10071-24074  |  Open Access |  How to cite  | 

Abstract

Background: Peripheral blood neutrophil-to-lymphocyte ratio (NLR) has recently emerged as a prognostic biomarker in many disease states. The aim of this study was to evaluate the diagnostic utility of NLR to predict poor functional outcomes in patients with hemorrhagic stroke and to compare it with the intracranial hemorrhage (ICH) score. Materials and methods: Patients who presented to the emergency department with clinical features suggestive of stroke were evaluated with computed tomography (CT) brain to identify ICH. The ICH scores and NLR were estimated at the time of admission. Modified Rankin Scale (mRS) score equal to or greater than 3 at 90 days was used to define poor functional outcomes (major disability or death). Receiver operating characteristic (ROC) curve was plotted with NLR and the ICH score to analyze and compare their discriminative ability to predict poor functional outcomes. Results: A total of 158 patients were recruited for the study. One hundred and seven patients were found to have poor functional outcomes as per their mRS score at 90 days. The mean NLR and the ICH scores at presentation were significantly higher for the poor outcome group (6.57 and 2.83) compared to the good outcome group (2.75 and 1.49). The ROC analysis revealed that both NLR and the ICH scores were good predictors of functional outcomes at 90 days with area under the curve (AUC) of 0.814 and 0.819, respectively. The sensitivity and specificity of NLR were 84 and 66.3% and those of the ICH score were 66.7 and 78.3% to predict poor functional outcomes. Conclusion: In patients with hemorrhagic stroke, NLR at admission is a good predictor of functional outcomes at 90 days. When compared to the ICH score, NLR is more sensitive but less specific in predicting poor functional outcomes.

Original Article

Rohit Paliwal, Adrian Pakavakis, Jigeeshu V Divatia

Utility of Stewart's Approach to Diagnose Missed Complex Acid–Base Disorders as Compared to Bicarbonate-anion Gap-based Methodology in Critically Ill Patients: An Observational Study

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:10] [Pages No:23 - 32]

Keywords: Albumin-corrected anion gap, Anion gap, Bicarbonate-based ABG analysis, Stewart's approach, Strong ion difference, Unidentified strong ions

   DOI: 10.5005/jp-journals-10071-24077  |  Open Access |  How to cite  | 

Abstract

Background: Traditional arterial blood gas (ABG) analysis may miss out on some metabolic acid–base disorders. We prospectively compared Stewart's approach in critically ill patients to traditional bicarbonate-anion gap-based methods (with and without correction for albumin) to diagnose acid–base disorders. Patients and methods: Five hundred ABG samples from medical or surgical patients in the ICU were analyzed with traditional bicarbonate-anion gap-based methodology with and without correction for albumin and Stewart's biochemical approach. The primary outcome identification of additional metabolic disorders diagnosed with Stewart's approach in comparison to bicarbonate system-based approaches. We also looked at the correlation between the strong ion gap (SIG) and the albumin-corrected anion gap (acAnion Gap). Results: Stewart's approach detected missed metabolic disorders in 58 (11.6%) blood gas results reported as “within normal limits” with the bicarbonate-uncorrected anion gap approach. In 50 (10%) of these ABGs, the acAnion Gap approach was able to diagnose the missed metabolic disorders. Thus, the albumin-corrected anion gap method had a similar diagnostic performance to Stewart's approach, as it missed additional disorders in only eight (1.6%) blood gases. Conclusion: In this study, we found that the acAnion Gap approach was similar in diagnostic performance to Stewart's approach. We feel that the corrected anion gap approach can be safely used if a ready calculator for Stewart's approach is not available.

Supplementary Material

Original Article

Gina M Chandy, Sowmya Sathyendra, Darpanarayan Hazra, Kundavaram PP Abhilash

Differentiating Cardiac and Pulmonary Causes of Dyspnea Using Ultrasonography and Dyspnea Discrimination Index

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:6] [Pages No:33 - 38]

Keywords: Cardiac dyspnea, Dyspnea, Dyspnea Discrimination Index, Pulmonary dyspnea, Ultrasonography

   DOI: 10.5005/jp-journals-10071-24089  |  Open Access |  How to cite  | 

Abstract

Background: One of the most common reasons for emergency room (ER) visits is acute dyspnea. The challenge is in differentiating a cardiac and pulmonary cause of acute breathlessness. Hence, we have studied the effectiveness of the dyspnea discrimination index (DDI) used in conjunction with ultrasonography (USG) in distinguishing between cardiac and pulmonary causes of dyspnea. Methods: This was a prospective study conducted in the ER and general medicine wards to evaluate the efficacy of the DDI and USG in dyspneic patients. Data were entered in a standard data sheet and analysis was done using SPSS software. Results: The majority of the patients were between the ages of 45 and 60, with a male predominance. Risk factors like smoking were more common in the pulmonary group (36%). Pulmonary cause of breathlessness was seen in 62% of patients and cardiac pathology was noted in 28%. The mean (SD) DDI value and DDI% are as follows: pulmonary group (DDI)—5.47 (SD: 2.82); cardiac group (DDI)—8.34 (SD: 3.75); pulmonary group (DDI%)—1.31 (SD: 0.68); cardiac group (DDI%)—2.34 (SD: 1.14). There was a significant difference in DDI% between the pulmonary and cardiac groups (p = 0.001). DDI was found to have a sensitivity and specificity of 77.3% and 70%, respectively. While for DDI%, sensitivity and specificity were 72.7% and 72%, respectively. Lung USG had 98% sensitivity and 95.5% specificity, with a narrow confidence interval. The positive likelihood ratio was noted to be 21.6, indicating a very high post-test probability. Conclusion: The DDI and USG in conjunction had good discriminative power, when it came to distinguishing between cardiac and pulmonary causes of dyspnea. USG had a high specificity and sensitivity, making it suitable for identifying the cause of dyspnea in a tertiary care ER setting.

Original Article

Dhruv Talwar, Sunil Kumar, Sourya Acharya, Nitin Raisinghani, Sparsh Madaan, Vidyashree Hulkoti, Annadatha Akhilesh, Shivam Khanna, Divit Shah, Shubham Nimkar

Interleukin 6 and Its Correlation with COVID-19 in Terms of Outcomes in an Intensive Care Unit of a Rural Hospital: A Cross-sectional Study

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:4] [Pages No:39 - 42]

Keywords: COVID-19, High-resolution computed tomography score, Interleukin 6, Neutrophil:lymphocyte ratio

   DOI: 10.5005/jp-journals-10071-24075  |  Open Access |  How to cite  | 

Abstract

Background: Interleukin 6 (IL-6) encoded by the gene coded as IL 6 acts as a proinflammatory cytokine as well as an anti-inflammatory myokine. It is postulated that IL 6 is associated directly with the severity of coronavirus disease-2019 (COVID-19). Another domain that is thought to predict the severity of COVID-19 is the neutrophil:lymphocyte (N:L) ratio; a higher N:L ratio is postulated to be related to more severe outcomes. Thus, the present study was aimed to establish a correlation of COVID-19 with IL-6 in terms of clinical outcomes. We had also tried to find the relationship between IL-6 and N:L ratio and high-resolution computed tomography (HRCT) score. Methods: We have conducted a cross-sectional study of 200 patients who were admitted to the intensive care unit (ICU) with reverse transcriptase-polymerase chain reaction (RT-PCR) positive for COVID-19 from January to May 2021. Serum IL-6, N:L ratio, and HRCT chest were conducted on admission. Result: Out of 200 patients who were admitted to the ICU with COVID-19, while the IL-6 was higher in patients with increased N:L ratio and HRCT score, the association of IL-6 with clinical outcomes in terms of discharged and expired was found to be statistically not significant. Conclusion: Serum IL-6 was found not to be a potent marker for clinical outcomes in ICU patients in terms of death vs survived. However, the IL-6 levels on admission can be correlated with the computed tomography (CT) severity scores as well as N:L ratio of patients admitted to an ICU.

Original Article

Deepalakshmi Kaliyaperumal, Kumar Bhargavi, Karthikeyan Ramaraju, Krishna S Nair, Sudha Ramalingam, Murali Alagesan

Electrocardiographic Changes in COVID-19 Patients: A Hospital-based Descriptive Study

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:6] [Pages No:43 - 48]

Keywords: Coronavirus disease-2019, Electrocardiogram change, Rate abnormalities, ST-T changes

   DOI: 10.5005/jp-journals-10071-24045  |  Open Access |  How to cite  | 

Abstract

Background: Coronavirus disease-2019 (COVID-19) infection is a multisystem disease not restricted to the lungs. It has a negative impact on the cardiovascular system by causing myocardial damage, vascular inflammation, plaque instability, and myocardial infarction. The presence of myocardial injury is a poor prognostic sign. Electrocardiogram (ECG), a simple bedside diagnostic test with high prognostic value, can be employed to assess early cardiovascular involvement in such patients. Various abnormalities in ECG like ST-T changes, arrhythmia, and conduction defects have been reported in COVID-19. We aimed to find out the ECG abnormalities of COVID-19 patients. Methods: We performed a cross-sectional, hospital-based descriptive study among 315 COVID-19 in-patients who underwent ECG recording on admission. Patients’ clinical profiles were noted from their records, and the ECG abnormalities were studied. Results: Among the abnormal ECGs 255 (81%), rhythm abnormalities were seen in 9 patients (2.9%), rate abnormalities in 115 patients (36.5%), and prolonged PR interval in 2.9%. Short QRS complex was seen in 8.3%. QT interval was prolonged in 8.3% of the patients. Significant changes in the ST and T segments (42.9%) were observed. In logistic regression analysis, ischemic changes in ECG were associated with systemic hypertension and respiratory failure. Conclusion: In our study, COVID-19 patients had ischemic changes, rate, rhythm abnormalities, and conduction defects in their ECG. With this ongoing pandemic of COVID-19 and limited health resources, ECG—a simple bedside noninvasive tool is highly beneficial and helps in the early diagnosis and management of cardiac injury.

Original Article

Burhan Sami Kalın, Süleyman Özçaylak, İhsan Solmaz, Jehat Kılıç

Assessment of Risk Factors for Mortality in Patients in Medical Intensive Care Unit of a Tertiary Hospital

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:4] [Pages No:49 - 52]

Keywords: Albumin, Comorbidity, Creatinine, Intensive care unit, Mortality

   DOI: 10.5005/jp-journals-10071-24092  |  Open Access |  How to cite  | 

Abstract

Background: Knowing the risk factors for patients in intensive care units (ICUs) facilitates patient's management. The goal of this study was to determine the risk agents that influence our medical ICU mortality. Patients and methods: This 11-month retrospective trial was managed in the medical ICU. In this study, 340 patients who were followed up for at least 24 hours in ICUs were accepted. The clinical data on patients were recorded retrospectively, and the mortality-related factors were analyzed. A regression analysis was also performed to determine the independent risk factors for ICU mortality. Results: The median age was 73 (53–82) years. The death rate was 23.8%. Length of stay (LOS) in ICU was 3 (2–5) days, and APACHE-II (acute physiologic and chronic health evaluation) score was 19 (13–25). The prevalence of chronic diseases was not dissimilar except acute and chronic renal failures among survivors and deceased patients (p >0.05). Acute and chronic renal failures were higher in deceased patients than in survivors and were statistically important [107 (41.3%) vs 47 (58%), p = 0.008] and 38 (14.7%) vs 22 (27.2%), p = 0.01], respectively. In the binary logistic regression analysis, age, APACHE II score, need for invasive mechanical ventilation (IMV), decreased serum albumin levels, and increased creatinine levels were established to be independent risk factors for death [(OR (odds ratio): 1.045 (1.009–1.081), p = 0.013, OR: 1.076 (21.008–1.150), p = 0.029, OR: 19.655 (6.337–60.963), p = 0.001), OR: 2.673 (1.191–6.024), p = 0.017, OR: 1.422 (1.106–1.831), p = 0.006)], respectively. Conclusion: The most significant risk agents of death were determined through high APACHE II score, decreased serum albumin levels, and increased creatinine levels.

Original Article

Gaurav Lambe, Dia Mansukhani, Shanaz Khodaiji, Anjali Shetty, Camilla Rodrigues, Farhad Kapadia

Immune Modulation and Cytomegalovirus Reactivation in Sepsis-induced Immunosuppression: A Pilot Study

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:9] [Pages No:53 - 61]

Keywords: Cytomegalovirus reactivation, Interleukin-10, Interleukin-6, Immunosuppression, Programmed death-1, Sepsis, Tregs

   DOI: 10.5005/jp-journals-10071-24079  |  Open Access |  How to cite  | 

Abstract

Introduction: Sepsis is a life-threatening condition caused due to dysregulated immune response to an infection and progressive immunosuppression. Reactivation of cytomegalovirus (CMV) occurs frequently in sepsis and is found associated with adverse outcomes. The study objective was to evaluate the association between incidence of CMV reactivation and immune alteration in sepsis-induced immunosuppression in patients with prolonged sepsis. Patients and methods: Patients admitted to intensive care unit (ICU), with severe sepsis and CMV immunoglobulin G (IgG) seropositivity, were prospectively enrolled. Other manifest immune suppression causes were excluded. Samples were collected on enrolment and further once a week until day 21 or death/discharge. CMV viral load was quantified using qPCR. Lymphocyte subset analysis (CD3+, CD4+, CD8+, CD19+, CD16+/CD56+, and CD25+CD127− regulatory T cells), human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes, programmed death-1 (PD-1) expression on T lymphocytes, and proinflammatory (interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ)), anti-inflammatory cytokines levels (IL-2, IL-4, and IL-10) were analyzed by flow cytometry as markers for immunosuppression. Results: A total of 25 CMV IgG-positive patients and 11 healthy controls were included. CMV reactivation occurred in 20 patients. Patients with CMV reactivation had T-cell lymphopenia. PD-1 expression on CD4+ and CD8+ T cells was markedly elevated (p <0.02) in CMV-reactivated patients compared to nonreactivated patients. HLA-DR expression was significantly low on monocytes in all septic patients (p <0.01) compared to healthy controls. IL-6 levels showed elevation at day 7, whereas IL-10 was found to be significantly higher from day 0 in CMV-reactivated group. Conclusion: Our study concluded that immune suppression markers and cytokine levels in patients with severe sepsis were found to be significantly associated with the incidence of CMV reactivation.

Original Article

Sukhyanti Kerai, Rahil Singh, Kirti N Saxena, Suraj D Desai, Anju R Bhalotra

A Retrospective Study on Experience of High-flow Nasal Cannula Oxygen in Critically Ill COVID-19 Adult Patients Admitted to Intensive Care Unit

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:5] [Pages No:62 - 66]

Keywords: Acute hypoxemic respiratory failure (AHRF), COVID-19, High-flow nasal cannula (HFNC) oxygen therapy, Intensive care unit

   DOI: 10.5005/jp-journals-10071-24097  |  Open Access |  How to cite  | 

Abstract

Background: The use of high-flow nasal cannula (HFNC) in coronavirus disease-2019 (COVID-19) patients is debated due to its uncertain benefits and risks of aerosol dispersion. This retrospective study was aimed to assess the outcome of treatment with HFNC therapy in adult COVID-19 patients with acute hypoxemic respiratory failure (AHRF) admitted in intensive care units (ICU) and to assess the factors affecting outcome. Material and methods: We retrieved electronic medical records of all COVID-19 patients who received HFNC for respiratory support after failure to maintain adequate oxygenation with conventional oxygen devices, between June 1 and August 31, 2020. The data retrieved were statistically analyzed. Results: A total number of 558 COVID-19 patients were admitted to ICUs, out of which 139 patients were identified to be on HFNC and 85 met the inclusion criteria for the study. The success rate of 48.2% with HFNC was observed in these patients. The patients recorded to experience HFNC success were of young age and having higher baseline oxygen saturation compared to those who had its failure. The ROX indices post-initiation were observed to be significantly higher in the success group (p ≤0.001). Awake-prone positioning while receiving HFNC was followed by around more patients in the success group (p <0.001). On multivariate logistic regression analysis, baseline oxygen saturation, awake-prone positioning, and number of days on HFNC were found to be independently affected outcome with HFNC. Conclusion: Almost half of the cases of moderate-to-severe COVID-19 pneumonia can be managed successfully with HFNC, without the need of mechanical ventilation.

Original Article

Sarath Chandran, Aswathy Sasidharan, Suresh Chandran

Clinical Performance of FilmArray Meningitis/Encephalitis Multiplex Polymerase Chain Reaction Panel in Central Nervous System Infections

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:4] [Pages No:67 - 70]

Keywords: Acute meningitis, Encephalopathy, Polymerase chain reaction

   DOI: 10.5005/jp-journals-10071-24078  |  Open Access |  How to cite  | 

Abstract

Introduction: Early identification of etiology is very important for initiating appropriate therapy promptly in patients with meningoencephalitis (ME). BioFire FilmArray® meningitis/encephalitis (FA-ME) panel is a fully automated multiplex polymerase chain reaction (PCR) that detects 14 pathogens simultaneously in an hour. There is a dearth of studies highlighting its usefulness in ME syndrome in Indian patients. Materials and methods: We performed a retrospective analysis of patients, admitted to the Kerala Institute of Medical Sciences Hospital, Thiruvananthapuram, Kerala, South India, with meningitis/encephalitis syndrome who underwent the multiplex PCR test on cerebrospinal fluid (CSF) over a period of 2 years from 2016 to 2018. Patients presenting with clinical diagnosis of acute meningitis, encephalitis, or ME who underwent CSF FA-ME panel were studied. The performance of the FA-ME panel was compared to CSF bacterial culture. Results: Two-hundred and fifty-nine patients between December 2016 and December 2018 underwent the FA-ME test in CSF. FA-ME test detected pathogens in 61 (23.6%) out of 259 patients with ME syndrome. Among the pathogens detected by FA-ME panel, enterovirus was the commonest accounting for 29 cases (47.5%), followed by varicella in 11 patients (18%) and pneumococci in 9 (14.8%). CSF bacterial culture yield was low, positive only in 8 (3%) out of 259 cases, and matched with FA-ME panel in only one sample that grew Streptococcus pneumoniae. Bacterial culture yielded seven pathogens in those whose FA-ME panels were negative. Conclusion: FA-ME panel improves diagnostic yield as compared to bacterial culture (26.3 vs 3%). FA-ME test helps in the early initiation of targeted antibiotic therapy and greater antibiotic de-escalation.

Original Article

Prakash Tendulkar, Pragya Pandey, Prasan K Panda, Ajeet S Bhadoria, Poorvi Kulshreshtha

Descriptive Epidemiology of COVID-19 Deaths during the First Wave of Pandemic in India: A Single-center Experience

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:5] [Pages No:71 - 75]

Keywords: Coronavirus disease 2019, Mortality, Risk factors

   DOI: 10.5005/jp-journals-10071-24085  |  Open Access |  How to cite  | 

Abstract

Background: With the looming threat of recurrent waves of coronavirus disease-2019 (COVID-19) in the presence of mutated strains, it is of paramount importance to understand the demographic and clinical attributes of COVID-19 related mortalities in each pandemic wave. This could help policy makers, public health experts, and clinicians to better plan preventive and management strategies to curb COVID-19 related mortality. Materials and methods: This was a hospital record-based, retrospective cross-sectional descriptive study, at a tertiary care hospital in Rishikesh, India. The study included all deceased patients between March 2020 and January 2021 (first wave) who had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription polymerase chain reaction (RT-PCR) and were hospitalized. The study was done to describe demography, clinical presentation, laboratory parameters, treatment given, and associated complications of all COVID-19 deaths. Result: Out of 424 mortalities, 298 (70.38%) were males and 126 (29.62%) were females. Mean age of patients was 55.85 ± 16.24 years, out of which 19.5% were less than 45 years old, 33.6% were 45–60 years old, and 41.8% were more than 60 years old. Comorbidity in the form of type II diabetes mellitus was present in 41.4% [95% CI (41.4–51.1)], hypertension in 39.8% [95% CI (35.1–44.6)], and coronary artery disease (CAD) in 15.2% [95% CI (11.8–18.8)]. At the time of presentation, shortness of breath was present in 73.6% [95% CI (69.1–77.7)], fever in 64.92% [95% CI (60.1–69.4)], and cough in 46.1%, [95% CI (41.1–50.8)]. Deranged laboratory parameters were lymphopenia in 90.2% [95% CI (86.8–92.7)], transaminitis in 59.7% [95% CI (54.8–64.3)], and hypercreatinemia in 37.7% [95% CI (33.1–42.5)]. Complications manifested were acute respiratory distress syndrome (ARDS) in 78.3% [95% CI (74–82.1)] and shock in 54.7% [95% CI (49.8–59.5)]. Median time duration between onset of symptom and hospital admission was 5 days (interquartile range (IQR) = 3–5 days) and median length of hospital stay was 9 days (IQR = 4–14 days). Conclusion: During the first pandemic wave, COVID-19 related mortality was 2.37 times higher among males, 2.14 times in the age group >60 than <45 years. The most common associated comorbidities (>40%) were type II diabetes mellitus and hypertension. The most common associated symptoms (>60%) were shortness of breath and fever. Lymphopenia was seen in >90% cases while liver involvement in 60% and kidney in 38% cases. Median hospital stay was doubled the prehospital illness.

Original Article

Sukhyanti Kerai, Rahil Singh, Kirti N Saxena, Suraj D Desai

Assessment of Risk Factors for Coronavirus Disease-2019 in Healthcare Workers: A Case–Control Study

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:9] [Pages No:76 - 84]

Keywords: COVID-19, Healthcare workers, Risk factors

   DOI: 10.5005/jp-journals-10071-24071  |  Open Access |  How to cite  | 

Abstract

Background and aims: With the rise of coronavirus disease-2019 (COVID-19) cases globally, the infection among frontline healthcare workers (HCWs) escalates many folds. There is, however, limited literature from low middle-income countries regarding risk factors for COVID-19 infection in HCWs. We conducted a case–control study to evaluate the risk factors of COVID-19 infection to HCWs. Materials and methods: This case–control study was conducted in a designated COVID-19 hospital. Eighty-one HCWs involved in direct care of COVID-19 patients, identified as cases, and 266 were recruited as controls. Telephonic interviews with participants were conducted, and information regarding demographic variables, chemoprophylaxis, exposure to infected patients, and adherence to infection prevention and control (IPC) measures was collected. Results: We observed a statistically significant difference in the number of times training session for IPC measures attended by HCWs (p = 0.02), performance of aerosol-generating medical procedures (AGMPs) (p <0.001), practices of donning and doffing of personal protective equipment (PPE) (p <0.001), hand hygiene (p <0.001), and decontamination of highly touched surfaces (p <0.001). Logistic regression analysis revealed if the decontamination of highly touched surfaces is decreased by one unit, the odds of getting COVID-19 infection is multiplied by a factor of 0.41 and AGMPs decrease the risk of being a case by 0.76. Conclusion: This study highlighted that inadequate observation of IPC methods increases the risk of COVID-19 infection to frontline HCWs, whereas performance of AGMPs does not enhance the risk. In this study, HCWs undertaking an AGMP, because of concern of acquiring infection, were more diligent during procedures and hence had lesser infection.

Original Article

Saurabh Trivedi, Revadi Gouroumourty, Brahmam Dodda, Amit Karna, Pranav Shrivastava, Aqeel Hussain, Vikas Gupta, Gankalyan Behera, Vaishali Waindeskar

Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:9] [Pages No:85 - 93]

Keywords: COVID-19 patients, Intensive care, Mortality, Tracheostomy, Weaning success

   DOI: 10.5005/jp-journals-10071-24080  |  Open Access |  How to cite  | 

Abstract

Background: Tracheostomy is integral in long-term intensive care of coronavirus disease-2019 (COVID-19) patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. Materials and methods: We conducted a retrospective, single-center, observational study of severe COVID-19 patients who underwent elective tracheostomy (n = 65) during critical care in a tertiary care institute in Central India from May 1, 2020, to April 30, 2021. Data were collected from Medical records, ICU charts, and follow-up visits by patient. A primary objective was to study the clinical characteristics, tracheostomy complications, weaning outcomes, and mortality at 28 and 60 days of ICU admission. We categorized the cohort into two groups (deceased and survivor) and studied association of clinical parameters with 28-day mortality. Cox Proportional regression analysis was applied to calculate the hazard ratio among the predictors of mortality with p value <0.05 as significant. Results: Elective tracheostomy was done in 69 of 436 (15.8%) patients on invasive mechanical ventilation, of which 65 were included. Tracheostomy was percutaneous in 45/65 (69%) and surgical in 20/65 (31%) with timing from intubation as early in 41/65 and late in 24/65 with most common indication as weaning failure followed by anticipated prolonged ventilation. Tracheostomy complications were present in 29/65 (45%) patients with no difference in complication rates between timing and type of tracheostomy. Downsizing, decannulation, and weaning were successful in 22%, 32 (49%), and 35/65 (54%) patients after tracheostomy. The 28-day mortality was 30/65 (46%). The fractional inspired oxygen concentration (FiO2) requirement in survivors was lower (0.4–0.6, p = 0.015) with a higher PaO2/FiO2 ratio (118–200, p = 0.033). Early tracheostomy within 7 days of intubation was not associated with weaning or survival benefit. Conclusions: We suggest that tracheostomy should be delayed to after 7 days of intubation, especially till FiO2 reduces to 0.5 with improvement in PaO2/FiO2 for better outcomes and avoiding a wasted procedure (CTRI/2021/07/034768). Study Highlights: Tracheostomy is integral in care of COVID-19 patients needing prolonged ventilation. There is no difference in complications in early/late or percutaneous dilatational/surgical technique. We observed successful weaning post-tracheostomy in 54% patients. Mortality at 28 days was 46%. Early tracheostomy within 7 days of intubation did not improve weaning or survival.

BRIEF RESEARCH COMMUNICATION

Jamileh Ramazani, Mohammad Hosseini

Prediction of Mortality in the Medical Intensive Care Unit with Serial Full Outline of Unresponsiveness Score in Elderly Patients

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:6] [Pages No:94 - 99]

Keywords: Elderly, Full outline of unresponsiveness score, Medical intensive care, Nonsurvivors, Survivors

   DOI: 10.5005/jp-journals-10071-24094  |  Open Access |  How to cite  | 

Abstract

Background: Advanced age is one of the key risk factors for mortality and morbidity in intensive care units. The full outline of unresponsiveness (FOUR) score has been developed and introduced to address the limitations of the Glasgow Coma Scale (GCS). The current study aimed to evaluate the ability of the FOUR score in predicting the outcomes (survivors, nonsurvivors). Materials and methods: This observational study of 168 consecutive elderly patients admitted to medical intensive care during the 14 months carried out prospectively. FOUR score in the 24, 48, and 72 hours of admission, and demographic characteristics of all elderly patients were calculated, then recorded. The receiver operating characteristic (ROC) curve, logistic regression, and Hosmer-Lemeshow test were used (95% confidence interval) for statistical analysis. Results: FOUR scores in 24, 48, and 72 hours between survivors and nonsurvivors (p <0.0001, p <0.0001, and p <0.0001, respectively) were statistically different. The discrimination power of FOUR score 24 hours of admission was excellent [area under ROC (AUC): 85.7% [standard error (SE)]: 2.8%]; it was acceptable for 48 and 72 hours of admission [AUC: 76.3% (SE: 3.6%), AUC: 75/0% (SE: 3.8%), respectively]. The FOUR score of 24 and 48 hours (x2 = 10.06, p = 0.261, x2 = 6.82, p = 0.448, respectively) showed acceptable calibration. Conclusions: The FOUR score is a suitable scoring system for prognostication of outcomes in critically ill elderly patients. The FOUR score 24 hours of admission was superior in terms of discrimination power than 48 and 72 hours, but better calibration power belonged to FOUR score 48 hours.

BRIEF RESEARCH COMMUNICATION

Sonali Vadi, Sagar Shah, Sumiran Bajpe, Nimmi George, Arya Santhosh, Neha Sanwalka, Aparna Ramakrishnan

Mental Health Indices of Intensive Care Unit and Emergency Room Frontliners during the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic in India

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:8] [Pages No:100 - 107]

Keywords: Emergency room, Frontline healthcare workers, Intensive care unit, Mental health survey, Severe acute respiratory syndrome coronavirus 2 pandemic

   DOI: 10.5005/jp-journals-10071-24081  |  Open Access |  How to cite  | 

Abstract

Background: The contagious coronavirus disease-2019 (COVID-19) pandemic has had a significant psychological impact on healthcare workers. Intensive care unit (ICU) and emergency room (ER) providers have functioned in an environment of fear for their health as well as their family well-being. Aim and objective: The aim and objective of the article was to study mental health disorders (anxiety, depression, stress, post-traumatic stress disorder (PTSD), and sleep quality) in frontliners and to identify factors affecting mental health indices. Materials and methods: A survey of 153 doctors and nurses working in ICU and ER was conducted from December 2020 to January 2021 using questionnaire with clinically validated scales: Acute Stress Disorder Scale, Perceived Stress Scale, Beck's Depression Inventory (BDI), Zung Self-rating Anxiety Scale (SAS), Global Pittsburgh Sleep Quality Index (PSQI), Multidimensional Scale of Perceived Social Support (MSPS), and New General Self-efficacy (NGSE) Scale. Analysis was performed to identify of gender, age, place of work, self-efficacy, and social support using logistic regression. Results: Of the 153 participants, 21.6% had PTSD, 88.6% had moderate to high stress, 16.3% had anxiety, and 59.5% had poor sleep. Of these, the majority were females and those aged ≤30 years. Males had lesser depression, anxiety, and poor sleep compared to females (p <0.05). Participants working in ER reported higher stress as compared to those working in ICU (p <0.05). PTSD, perceived stress, depression, anxiety, and poor sleep were higher in participants with low-to-moderate perceived self-efficacy as compared to participants with high self-efficacy (p <0.05). Conclusion: This study reveals significant psychological distress among ER and ICU frontliners during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, a typical high-acuity environment during the nonpandemic times.

SYSTEMATIC REVIEW

Saurabh C Sharda, Mandip S Bhatia

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:6] [Pages No:108 - 113]

Keywords: Airway management, Endotracheal intubation, Etomidate, Intravenous anesthetics, Ketamine, Rapid sequence intubation

   DOI: 10.5005/jp-journals-10071-24086  |  Open Access |  How to cite  | 

Abstract

Aims and objectives: The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. Materials and methods: For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and ClinicalTrials.gov between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. Results: Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31–0.91; I2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95–1.36; I2 = 16%). Conclusion: The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate.

SYSTEMATIC REVIEW

Armin Ahmed, Sulekha Saxena, Amita Pandey, Prabhakar Mishra, Afzal Azim

Analysis of Causes of Hepatic Dysfunction in Obstetric Patients in India: A Systematic Review

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:9] [Pages No:114 - 122]

Keywords: Hepatic dysfunction, Obstetric patients, Preeclampsia, Viral hepatitis

   DOI: 10.5005/jp-journals-10071-24083  |  Open Access |  How to cite  | 

Abstract

Background: Epidemiology of liver disease in obstetric patients shows geographical variation depending upon the prevalence of preeclampsia, viral hepatitis, and tropical vector-borne diseases like malaria, leptospirosis, etc. We undertook the current systematic review to analyze the causes of hepatic dysfunction in obstetric patients in India and identify the gaps in the literature and reporting. Materials and methods: We did a systematic review of studies reporting the causes of hepatic dysfunction in obstetric patients in India. A methodological quality assessment was done using a five-point questionnaire. Results: A total of 21 studies qualified for evaluation. The rate of hepatic dysfunction among obstetric patients in India ranged from 0.15 to 3.3% with a mean and median rate of 1.49 and 0.93%, respectively. Preeclampsia/HELLP (mean = 36.0%, median = 31.4%, range: 3.6–83.8%) and viral hepatitis (mean = 34.1%, median = 35.5%, range: 5.1–61.8%) were the commonest causes of hepatic dysfunction. Other causes were intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, tropical fever (malaria, leptospirosis, dengue, scrub typhus), etc. Maternal mortality ranged from 1.4 to 40% (mean = 12.6%, median = 10.0%) and perinatal mortality was between 16.4 and 38.70% (mean = 31.75%, median = 35.5%). Conclusion: There is moderate quality evidence to show that preeclampsia/HELLP and viral hepatitis are the commonest causes of hepatic dysfunction in obstetric patients in India.

CASE SERIES

Edwin Pathrose, Nikhil M Bhagwat, David Chandy

“The Bitter Truth of Sugar”—Euglycemic Diabetic Ketoacidosis due to Sodium-glucose Cotransporter-2 Inhibitors: A Case Series

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:4] [Pages No:123 - 126]

Keywords: Euglycemia, Gliflozins, Glycosuria, High anion gap metabolic acidosis, Intensive care unit, Oral hypoglycemic agents, Sodium-glucose cotransporter-2 inhibitors

   DOI: 10.5005/jp-journals-10071-24076  |  Open Access |  How to cite  | 

Abstract

Diabetic ketoacidosis (DKA) is an acute and major complication of diabetes mellitus (DM), both type I and type II. Biochemically, DKA consists of a triad of blood sugar levels greater than 250 mg/dL, ketonemia of greater than 3 mmol/L and/or significant ketonuria, and a blood pH less than 7.3 with an increased anion gap. Currently, the sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are widely used in management of type II diabetes. There have been several reports of an association between euglycemic diabetic ketoacidosis (EuDKA) and SGLT-2i agents. We present three different patients who were on SGLT-2i therapy who developed recurrent EuDKA postprocedure or sepsis. We believe that prolonged treatment (5–6 days) with intravenous (IV) insulin with glucose until resolution of glycosuria can be considered as an inexpensive marker of resolution of EuDKA. Moreover, the recommended duration for discontinuation of these drugs prior to elective procedures should be longer than 3 days.

CASE REPORT

Krithika Varshini, Vithiya Ganesan, Jhansi Charles

Aerococcus viridans Bacteremia: A Rare Case Report from India

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:2] [Pages No:127 - 128]

Keywords: Aeorococcus, Aerococcus viridans, Bloodstream infection

   DOI: 10.5005/jp-journals-10071-24072  |  Open Access |  How to cite  | 

Abstract

Aerococci are fastidious, gram-positive Streptococcus-like organisms widely distributed in the hospital environment. Aerococcus viridans is primarily an opportunistic pathogen. Very few cases of A. viridans bacteremia have been reported so far probably because of its misidentification as streptococci. Here we report an interesting case of A. viridans bacteremia.

CASE REPORT

Smita Sharma, Gyanendra Agrawal, Suryasnata Das

COVID-19-associated Pulmonary Cryptococcosis: A Rare Case Presentation

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:4] [Pages No:129 - 132]

Keywords: Corticosteroids, COVID-19, Pulmonary cryptococcosis, Uncontrolled diabetes mellitus

   DOI: 10.5005/jp-journals-10071-24084  |  Open Access |  How to cite  | 

Abstract

Multiple case reports and case series report a surge in opportunistic infections like aspergillosis, mucormycosis, and reactivation of cytomegalovirus infection in coronavirus disease-2019 (COVID-19) patients. We hereby report the first case to the best of our knowledge of pulmonary cryptococcosis in a patient who had successfully recovered from severe COVID-19 illness. The pulmonary cryptococcosis spectrum ranges from asymptomatic infection to frank acute respiratory distress syndrome leading to respiratory failure. Pulmonary cryptococcosis is often underdiagnosed because its clinical presentation, radiographic features, and serologic laboratory investigations are generally inconclusive. The saprophytic colonization of fungus as opposed to invasive disease cannot be assessed from either culture of sputum or currently available serologic tests. Pulmonary cryptococcosis close association with COVID-19 can be further established with reporting of more cases. Hereby, we propose the term CAPC (COVID-19-associated pulmonary cryptococcosis) for such cases.

CASE REPORT

Pongpat Klumusuk, Pattarin Pirompanich

Unilateral Pulmonary Contusion after Cardiopulmonary Resuscitation Complicated by Delayed Obstructive Atelectasis: A Case Report and Review of the Literature

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:3] [Pages No:133 - 135]

Keywords: Bronchoscopy, Cardiopulmonary resuscitation, Obstructive atelectasis, Unilateral pulmonary contusion

   DOI: 10.5005/jp-journals-10071-24082  |  Open Access |  How to cite  | 

Abstract

We present a previously healthy 57-year-old man who had a sudden cardiac arrest intraoperatively and developed unilateral pulmonary contusion shortly after cardiopulmonary resuscitation. He was gradually improved by supportive management. But, several days later he had worsening of respiratory symptoms and obstructive atelectasis was proven by bronchoscope finding of thick mucus plugging left main bronchus. These are rarely recognized but important post-resuscitation complications. Early detection is crucial to improve outcome.

CASE REPORT

Ayhan Yaman

Severe Rhabdomyolysis and Acute Renal Failure Treated by Continuous Venovenous Hemodiafiltration in a Child with Diabetic Ketoacidosis

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:3] [Pages No:136 - 138]

Keywords: Acute renal failure, Continuous venovenous hemodiafiltration, Critically ill, Diabetic ketoacidosis, Hypophosphatemia, Intensive care unit, Mechanical ventilation

   DOI: 10.5005/jp-journals-10071-24093  |  Open Access |  How to cite  | 

Abstract

Diabetic ketoacidosis (DKA) is the most serious hyperglycemic emergency in patients with type I diabetes mellitus and is associated with significant morbidity and mortality. DKA may be a life-threatening condition due to severe clinical and biological impairments and treatment-associated complications [cerebral edema, acute respiratory failure, acute renal failure (ARF), hypokalemia, hypophosphatemia]. The development of ARF with rhabdomyolysis is a rare but potentially lethal disorder in children with DKA with an estimated mortality of about 50%. Continuous renal replacement therapy is commonly used in intensive care units to provide renal replacement and fluid management. We successfully treated a 13-year-old boy with continuous venovenous hemodiafiltration, who had been diagnosed with severe DKA, complicated with hypophosphatemia-induced acute respiratory failure, rhabdomyolysis and ARF, persistent acidosis, and coma.

LETTER TO THE EDITOR

Kaustuv Dutta, Parthasarathy Satishchandra, Monjuri Borkotokey

Medium-chain Triglyceride Ketogenic Diet as a Treatment Strategy for Adult Super-refractory Status Epilepticus

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:2] [Pages No:139 - 140]

Keywords: Classic ketogenic diet, Hypoxic-ischemic brain injury, Medium-chain triglyceride ketogenic diet, Refractory status epilepticus, Super-refractory status epilepticus

   DOI: 10.5005/jp-journals-10071-24073  |  Open Access |  How to cite  | 

LETTER TO THE EDITOR

Ragesh R Nair, Pawan K Singh, Jeetendra Sharma, Isha Gambhir, Shivangi Khanna, Amit Kumar Jain, Rohan Haldar, Vikrant S Bhar

An Unusual Case of Pancytopenia: The Lessons Learnt

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:4] [Pages No:141 - 144]

Keywords: Abnormal megakaryocytes, Arsenic poisoning, Erythroid dysplasia

   DOI: 10.5005/jp-journals-10071-24087  |  Open Access |  How to cite  | 

Abstract

Pancytopenia is a common hematological abnormality encountered in clinical practice. We here report a 36-year-old male who presented to emergency department with complaints of weakness of bilateral lower limbs, burning sensation in all four limbs with history of loose stools, and vomiting 5 days back. The complete blood count of patient showed pancytopenia with no circulating atypical cells. Bone marrow examination performed showed nonspecific but characteristic findings. After excluding the possibility of infective etiology, a possibility of heavy metal toxicity was suspected in multidisciplinary meeting. The urine and blood levels of arsenic done came out very high, and a diagnosis of arsenic poisoning was made. Patient had multisystemic involvement with features characteristic of arsenic poisoning. The present case was a diagnostic challenge in face of nonforthcoming history. This case beautifully highlighted the importance of multidepartmental approach in such cases to arrive at unerring diagnosis and the unique bone marrow findings, although nonspecific were sufficient enough to indicate the possibility of acute insult to the hematopoiesis.

LETTER TO THE EDITOR

Sujith M Thomas, Muraleedharan Raman, Wilson Aloysius, Bhuvanesh Mahendran

Multisystem Inflammatory Syndrome in Adults and Adolescents Associated with COVID-19 Infection: A Single-center Experience

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:4] [Pages No:145 - 148]

Keywords: Clinical features, COVID-19 infection, Multisystem inflammatory syndrome in adults

   DOI: 10.5005/jp-journals-10071-24066  |  Open Access |  How to cite  | 

A Thank You Note for Our Reviewers

[Year:2022] [Month:January] [Volume:26] [Number:1] [Pages:5] [Pages No:149 - 153]

   DOI: 10.5005/ijccm-26-1-149  |  Open Access |  How to cite  | 

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