Indian Journal of Critical Care Medicine

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2022 | November | Volume 26 | Issue 11

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EDITORIAL

Vijaya Prakash Patil, Abhishek Rajput

Finding Cost-effective Solutions: Need of the Hour

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:2] [Pages No:1163 - 1164]

Keywords: Cost-effective, Hypoxemia, Positive-end expiratory pressure, Positive expiratory pressure oxygen therapy

   DOI: 10.5005/jp-journals-10071-24358  |  Open Access |  How to cite  | 

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EDITORIAL

Ravikumar Krupanandan

Paroxysmal Sympathetic Hyperactivity: It is Time to Use the New Diagnostic Criteria

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:2] [Pages No:1165 - 1166]

Keywords: Acute brain injury, Dystonia, Paroxysmal sympathetic hyperactivity

   DOI: 10.5005/jp-journals-10071-24359  |  Open Access |  How to cite  | 

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EDITORIAL

Narayanan Parameswaran

Respiratory Syncytial Virus Infection in the Aftermath of COVID-19: Is It a Case of Old Wine in a New Bottle?

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:2] [Pages No:1167 - 1168]

Keywords: COVID-19, Pediatric intensive care unit, Respiratory syncytial virus, Risk prediction

   DOI: 10.5005/jp-journals-10071-24361  |  Open Access |  How to cite  | 

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Original Article

Nitin Dhochak, Animesh Ray, Manish Soneja, Naveet Wig, Sushil K Kabra, Rakesh Lodha

Positive Expiratory Pressure Oxygen Therapy for Respiratory Distress: A Single-arm Feasibility Trial

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:6] [Pages No:1169 - 1174]

Keywords: Acute respiratory distress, Oxygen therapy, Positive end-expiratory pressure valve, Positive expiratory pressure oxygen therapy, Positive expiratory pressure

   DOI: 10.5005/jp-journals-10071-24348  |  Open Access |  How to cite  | 

Abstract

Background: Oxygen delivery devices with positive end-expiratory pressure (PEEP) valves have been described, but high inspiratory flows may lead to poor tolerance in tachypneic patients. Positive expiratory pressure oxygen therapy (PEP-OT) using an occlusive face mask, oxygen reservoir, and PEEP valve has not been evaluated in clinical settings. Materials and methods: In a single-arm intervention trial, patients aged 19–55 years admitted with acute respiratory illness with oxygen support were enrolled. PEP-OT trial was given with PEEP of 5 and 7 cm of water over 45 minutes. Feasibility was assessed as uninterrupted completion of the PEP-OT trial. The effects of PEP-OT on cardiopulmonary physiology and adverse effects of therapy were recorded. Results: Fifteen patients (6 males) were enrolled. Fourteen patients had pneumonia and one patient had pulmonary edema. Twelve patients (80%) completed the PEP-OT trial. There was significant improvement in respiratory rate (RR) and heart rate (HR) at the end of the 45-minute PEP-OT trial (p-values 0.048 and 0.003, respectively). There was a trend toward improved SpO2 and perceived dyspnea. None of the patients developed desaturation, shock, or air leaks. Positive expiratory pressure oxygen therapy is a feasible oxygen therapy in patients with acute hypoxia. Conclusion: Positive expiratory pressure oxygen therapy seems to be safe and has a positive impact on respiratory mechanics in parenchymal respiratory pathology.

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Original Article

Thamizhkumaran Jayaraman, Raju Dhanasinghu, Santhanam Kuppusamy, Archana Gaur, Varatharajan Sakthivadivel

Bite-to-needle Time – An Extrapolative Indicator of Repercussion in Patients with Snakebite

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:4] [Pages No:1175 - 1178]

Keywords: Antisnake venom, Bite-to-needle time, Complications, Mortality, Snakebite

   DOI: 10.5005/jp-journals-10071-24344  |  Open Access |  How to cite  | 

Abstract

Background: Snakebite is a significant occupational and environmental hazard in tropical countries. The treatment of snakebite includes care of the wound, supportive care, and administration of anti-snake venom (ASV). Time is crucial to reducing the morbidity and mortality of patients. This study aimed to assess the “bite-to-needle time” with morbidity and mortality of snakebites and correlate it. Patients and methods: A total of 100 patients were included. Detailed history included the time since snakebite, bite site, species of snake, and symptoms at presentation, which included level of consciousness, cellulitis, ptosis, respiratory failure, oliguria, and bleeding manifestations. “Bite-to-needle time” was noted. Polyvalent ASV was administered in all patients. Duration of hospitalization and complications, including mortality were noted. Results: The age-group of the study population was 20–60 years. About 68% were males. Krait was the commonest species (40%), and the lower limb was the commonest bite site. Within 6 hours, 36% of patients received ASV, and between 6 and 12 hours, 30%. Patients with a bite-to-needle time of under 6 hours spent less time in the hospital and experienced fewer complications. Patients with bite-to-needle times longer than 24 hours had more ASV vials, complications, hospital-stay length, and death. Conclusion: An increase in bite-to-needle time increases the chances of systemic envenomation, hence, the severity of complications or morbidity and risk of mortality increases. The necessity of timing and the value of administering ASV on time must be emphasized to the patients.

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Original Article

Deependra Kumar Rai, Nishant Sahay

Six-month Morbidity and Mortality in Patients after Recovery from COVID-19

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:5] [Pages No:1179 - 1183]

Keywords: Hospitalization, Mortality, Post-COVID-19, Symptoms

   DOI: 10.5005/jp-journals-10071-24347  |  Open Access |  How to cite  | 

Abstract

Background: This telephonic survey was aimed to identify the proportion of coronavirus disease-2019 (COVID-19) patients who died from any cause, within 6 months of discharge from a tertiary COVID-19 care hospital. We also analyzed whether any clinical and/or laboratory variables were associated with post-discharge mortality. Materials and methods: All adult patients (age ≥18 years) who had been discharged during the period between July 2020 and August 2020 from a tertiary COVID-19-care hospital after initial hospitalization for COVID-19 were included. A telephonic interview was conducted 6 months after discharge to assess morbidity and mortality in these patients. Results: Out of the 457 patients who responded, 79 patients (17.21%) were symptomatic, and breathlessness was found as most common symptom (6.12%). Fatigue was noted in (5.93%) of study patients, followed by cough (4.59%), sleep disturbances (4.37%), and headache (2.62%). Of the 457 patients who responded, 42 patients (9.19%) required expert medical consultation for their persistent symptoms. Thirty-six patients (7.88%) required re-hospitalization for post-COVID-19 complications within 6 months of discharge. A total of 10 patients (2.18%) succumbed within 6 months of their discharge from the hospital. 6 patients were males and 4 females. Most of these patients (7/10) succumbed in the second month after discharge. Seven patients had moderate-to-severe COVID-19 disease and most of these (7/10) had not been treated in the intensive care unit (ICU). Conclusion: Post-COVID-19 mortality figures were not very high in our survey despite the high perceived risk of thromboembolic events after recovery from COVID-19. A significant proportion of patients reported persistent post-COVID-19 symptoms. Breathing difficulty was the most common symptom noted by us, closely followed by fatigue.

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Original Article

Amarja Ashok Havaldar, Jay Prakash, Sanjeev Kumar, Kaladhar Sheshala, Abhilash Chennabasappa, Ria Rachel Thomas, EA Chinny Sushmitha, Mohd Saif Khan, Raman Kumar, Srishti Kindo, Ritu Singh, Munta Kartik, Akshay Hiruyur Manjunatha Swamy, John Michael Raj, Tinku Thomas, Sumithra Selvam

Demographics and Clinical Characteristics of COVID-19-vaccinated Patients Admitted to ICU: A Multicenter Cohort Study from India (PostCoVac Study-COVID Group)

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:8] [Pages No:1184 - 1191]

Keywords: BBV152, Breakthrough infection, ChAdOx1 nCOV19, Covaxin, COVID-19, COVID vaccination, Delta variant, ICU, Multicenter study

   DOI: 10.5005/jp-journals-10071-24349  |  Open Access |  How to cite  | 

Abstract

Background: Emergency authorization and approval were given for the coronavirus disease-19 (COVID-19) vaccines. The efficacy reported after phase III trials were 70.4% and 78% for Covishield and Covaxin, respectively. In this study, we aim to analyze the risk factors, which were associated with mortality in critically ill COVID-19-vaccinated patients admitted into intensive care unit (ICU). Materials and methods: This study was conducted from April 1, 2021 to December 31, 2021 across five centers in India. Patients who had received either one or two doses of any of the COVID vaccines and developed COVID-19 were included. The ICU mortality was a primary outcome. Results: A total of 174 patients with COVID-19 illness were included in the study. The mean age was 57 years standard deviation (SD 15). Acute physiology, age and chronic health evaluation (APACHE II) score and the sequential organ failure assessment (SOFA) score were 14 (8–24.5) and 6 (4–8), respectively. Multiple variable logistic regression showed patients who have received a single dose [odds ratio (OR): 2.89, confidence interval (CI): 1.18, 7.08], neutrophil:lymphocyte (NL) ratio (OR: 1.07, CI: 1.02,1.11), and SOFA score (OR: 1.18, CI: 1.03,1.36) were associated with higher mortality. Conclusion: The mortality in the vaccinated patients admitted to the ICU was 43.68% due to COVID illness. The mortality was lower in patients who had received two doses.

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Original Article

Praveen Mathiyalagan, Tolstoy Rajangam, Kumar Bhargavi, Ramya Gnanaraj, Shanmuga Sundaram

Clinical Profile, Immediate- and Short-term Outcome of Patients with Intermediate-risk Acute Pulmonary Thromboembolism

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:6] [Pages No:1192 - 1197]

Keywords: Anticoagulants, Hemodynamics, Intermediate-risk pulmonary thromboembolism, Outcome, Thrombolysis

   DOI: 10.5005/jp-journals-10071-24351  |  Open Access |  How to cite  | 

Abstract

Background: Long-term outcomes of acute pulmonary thromboembolism (PTE) have been reported. However, the immediate- and short-term outcomes have not been reported adequately. Objectives: Primary objective was to determine the patient characteristics, and immediate- and short-term outcomes of intermediate-risk PTE, and the secondary objective was to evaluate the benefit of thrombolysis in normotensive PTE patients. Material and methods: This study included patients diagnosed with acute intermediate PTE. Patient's electrocardiography (ECG) parameters along with echocardiography (echo), etc., conducted at the time of admission, during their stay in hospital, at the time of discharge, and during follow-up were recorded. The patients were treated using thrombolysis or anticoagulants depending on hemodynamic decompensation. During follow-up, they were reassessed for echo parameters–right ventricular (RV) function and pulmonary arterial hypertension (PAH). Results: Among 55 patients, 29 (52.73%) were diagnosed with intermediate high-risk PTE and 26 (47.27%) with intermediate low-risk PTE. They were normotensive and most of them had a simplified pulmonary embolism severity index (sPESI) score <2. Typical ECG pattern S1Q3T3 along with echo patterns and elevated cardiac troponin levels were observed in most of the patients. Patients treated with thrombolytic agents showed a reduction in hemodynamic decompensation as opposed to patients treated with anticoagulants who had clinical signs of right heart failure (RHF) on follow-up after 3 months. Conclusion: This study contributes to the existing literature on outcomes of intermediate-risk PTE and the effect of thrombolysis on patients with hemodynamic stability. Thrombolysis reduced the incidence and progression of RHF in patients with hemodynamic instability.

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Original Article

Sonali Vadi, Ashwini Pednekar, Durga Suthar, Neha Sanwalka, Kiran Ghodke, Nikhil Rabade

Characteristics and Predictive Value of T-lymphocyte Subset Absolute Counts in Patients with COVID-19-associated Acute Respiratory Failure: A Retrospective Study

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:6] [Pages No:1198 - 1203]

Keywords: Acute respiratory failure, Coronavirus disease-2019, Disease severity, Severe acute respiratory syndrome CoV-2 infection, T-lymphocyte subsets

   DOI: 10.5005/jp-journals-10071-24352  |  Open Access |  How to cite  | 

Abstract

Background: Of the factors influencing severity and outcomes following coronavirus disease-2019 (COVID-19), cellular immune response has a strong impact. The spectrum of response varies from over-activation to hypo-functioning. The severe infection leads to reduction in numbers and dysfunction of T-lymphocytes/subsets. Patients and methods: This retrospective, single-center study aimed to analyze the expression of T-lymphocyte/subsets by flow cytometry and inflammation-related biomarker, serum ferritin in real-time polymerase chain reaction (RT-PCR) positive patients. According to oxygen requirements, patients were stratified into nonsevere (room air, nasal prongs, and face mask) and severe [nonrebreather mask (NRBM), noninvasive ventilation (NIV), high-flow nasal oxygen (HFNO), and invasive mechanical ventilation (IMV)] subgroups for analysis. Patients were classified into survivors and nonsurvivors. Mann–Whitney U test was used to analyze differences in T-lymphocyte and subset values when classified according to gender, the severity of COVID, outcome, and prevalence of diabetes mellitus (DM). Cross tabulations were computed for categorical data and compared using Fisher's exact test. Spearman correlation was used to analyze the correlation of T-lymphocyte and subset values with age or serum ferritin levels. p <0.05 values were considered to be statistically significant. Results: A total of 379 patients were analyzed. Significantly higher percentage of patients with DM were aged ≥61 years in both nonsevere and severe COVID groups. A significant negative correlation of CD3+, CD4+, and CD8+ was found with age. CD3+ and CD4+ absolute counts were significantly higher in females as compared to males. Patients with severe COVID had significantly lesser total lymphocyte (%), CD3+, CD4+, and CD8+ counts as compared to those with nonsevere COVID (p <0.05). T-lymphocyte subsets were reduced in patients with severe disease. A significant negative correlation of total lymphocyte (%), CD3+, CD4+, and CD8+ counts was found with serum ferritin levels. Conclusions: T-lymphocyte/subset trends are an independent risk factor for clinical prognosis. Monitoring may help in intervening in patients with disease progression.

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Pediatric Critical Care

Shipra Agrwal, Pallavi, Urmila Jhamb, Romit Saxena

Paroxysmal Sympathetic Hyperactivity in Neurocritical Children: A Pilot Study

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:6] [Pages No:1204 - 1209]

Keywords: Autonomic dysfunction, Incomplete paroxysmal sympathetic hyperactivity, Neurocritical illness, Paroxysmal sympathetic hyperactivity, Traumatic brain injury

   DOI: 10.5005/jp-journals-10071-24346  |  Open Access |  How to cite  | 

Abstract

Background: Paroxysmal sympathetic hyperactivity (PSH) is characterized by the abnormal excessive sympathetic response to acute cerebral insult. There is a paucity of data about this condition in children. This study was planned to analyze the incidence of PSH among children requiring neurocritical care and its association with the outcome. Materials and methods: The study was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital over a period of 10 months. Children of age 1 month to 12 years admitted with neurocritical illnesses were included. Children who were declared brain dead after initial resuscitation were excluded from the study. The criterion laid by Moeller et al. was used for the diagnosis for PSH. Results: During the study period, 54 children requiring neurocritical care were included in the study. The incidence of PSH was 5/54 (9.2%). Additionally, 30 (55.5%) children had less than four criteria for PSH and were termed as “incomplete PSH.” Children with all four criteria for PSH had a significantly longer duration of mechanical ventilation, PICU stay, and higher PRISM III scores. Children with less than four criteria for PSH also had a longer duration of mechanical ventilation and stay. However, there was no significant difference in mortality. Conclusion: Paroxysmal sympathetic hyperactivity is common in children with neurological illnesses admitted to the PICU and is associated with longer mechanical ventilation and stay in PICU. They also had higher illness severity scores. Timely diagnosis of the condition and appropriate management is required to improve the outcome of these children.

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Pediatric Critical Care

Arindam Ghosh, Saba Annigeri, Sunil Kumar Hemram, Pranab Kumar Dey, Sangita Mazumder

Clinico-demographic Profile and Predictors of Intensive Care Need in Children with Respiratory Syncytial Virus-associated Acute Lower Respiratory Illness during Its Recent Outbreak alongside Ongoing COVID-19 Pandemic: An Eastern Indian Perspective

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:8] [Pages No:1210 - 1217]

Keywords: Children, Coronavirus disease-2019, Eastern India, Pediatric intensive care unit, Predictors, Respiratory syncytial virus

   DOI: 10.5005/jp-journals-10071-24350  |  Open Access |  How to cite  | 

Abstract

Introduction: The objective was to delineate the clinico–epidemiological characteristics of hospitalized children with respiratory syncytial virus (RSV)-associated acute lower respiratory tract infection (RSV-ALRI) during its recent outbreak and to find out the independent predictors of pediatric intensive care unit (PICU) admission. Materials and methods: Children aged between 1 month and 12 years who tested positive for RSV were included. Multivariate analysis was performed to identify the independent predictors and predictive scores were developed from the β-coefficients. Receiver operating characteristic curve (ROC) was generated and the area under the curve (AUC) was calculated to assess the overall precision. The performance of sum scores in predicting PICU need, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios (LR+ and LR) were calculated for each cutoff value. Results: The proportion of RSV positivity was 72.58%. A total of 127 children were included with a median [interquartile range (IQR)] age of 6 (2–12) months, of whom 61.42% were males and 33.07% had underlying comorbidity. Tachypnea, cough, rhinorrhea, and fever were predominant clinical presentations while hypoxia and extrapulmonary manifestations were present in 30.71% and 14.96% of children, respectively. About 30% required PICU admission, and 24.41% developed complications. Premature birth, age below 1 year, presence of underlying CHD, and hypoxia were independent predictors. The AUC [95% confidence interval (CI)] was 0.869 (0.843−0.935). Sum score below 4 had 97.3% sensitivity and 97.1% NPV whereas sum score above 6 had 98.9% specificity, 89.7% PPV, 81.3% NPV, 46.2 LR+, and 0.83 LR to predict PICU needs. Conclusion: Awareness of these independent predictors and application of the novel scoring system will be beneficial for busy clinicians in planning the level of care needed, thereby optimizing PICU resource utilization.

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Pediatric Critical Care

Seenivasan Subramani, Narayanan Parameswaran, Ramesh Ananthkrishnan, Shilpa Abraham, Muthu Chidambaram, Ramachandran Rameshkumar, Mahadevan Subramanian

Assessment of the Endotracheal Tube Tip Position by Bedside Ultrasound in a Pediatric Intensive Care Unit: A Cross-sectional Study

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:7] [Pages No:1218 - 1224]

Keywords: Bedside ultrasound, Children, Endotracheal tube tip position

   DOI: 10.5005/jp-journals-10071-24355  |  Open Access |  How to cite  | 

Abstract

Introduction: The chest X-ray (CXR) is the standard of practice to assess the tip of the endotracheal tube (ETT) in ventilated children. In many hospitals, it takes hours to get a bedside CXR, and it has radiation exposure. The objective of this study was to find the utility of bedside ultrasound (USG), in assessing the ETT tip position in a Pediatric Intensive Care Unit (PICU). Methods: It was a prospective study conducted in the PICU of a tertiary care center involving 135 children aged from 1 month to 60 months, requiring endotracheal intubation. In this study, the authors compared the position of the ETT tip by the CXR (gold standard) and USG. The CXR was taken in children to assess the correct position of the tip of ETT. The USG was used to measure the distance between the tip of ETT and the arch of the aorta, thrice in the same patient. The mean of the three USG readings was compared with the distance between the tip of the ETT and carina in CXR. Results: The reliability of three USG readings was tested by absolute agreement coefficient in intraclass correlation (ICC), 0.986 (95% CI: 0.981–0.989). The sensitivity and specificity of the USG in identifying the correct position of the ETT tip in children when compared to CXR were 98.10% (95% CI: 93.297–99.71%) and 50.0% (95% CI: 31.30–68.70%), respectively. Conclusion: In ventilated children <60 months of age, identifying the tip of ETTs by bedside the USG has good sensitivity (98.10%) but poor specificity (50.0%).

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LETTER TO THE EDITOR

Anjali Rachel Varghese, Atul Jindal

Letter to Editor regarding “Unusual Presentation of Spontaneous Chylothorax”

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:1] [Pages No:1225 - 1225]

Keywords: Chylothorax, Chylous pleural fluid, Octreotide, Pleural fluid lactate dehydrogenase

   DOI: 10.5005/jp-journals-10071-24353  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Amita Kaul, Anurag Fursule, Sachin Shah

Author's Response to an Unusual Presentation of Spontaneous Chylothorax

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:1] [Pages No:1226 - 1226]

Keywords: Chylothorax, Pediatric intensive care unit, VATS

   DOI: 10.5005/jp-journals-10071-24345  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Habib Md Reazaul Karim, Jayanta Kumar Mitra

Reckoning the Inhaled Sedation in Critically Ill Patients (INSTINCT) Study

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:2] [Pages No:1227 - 1228]

Keywords: Age, Cost, Intensive care unit sedation, Volatile anesthetics

   DOI: 10.5005/jp-journals-10071-24356  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Atul Prabhakar Kulkarni, Shilpushp Jagannath Bhosale

Author Response to the Letter to Editor “Reckoning the Inhaled Sedation in Critically Ill Patients: INSTINCT I”

[Year:2022] [Month:November] [Volume:26] [Number:11] [Pages:1] [Pages No:1229 - 1229]

Keywords: Cost of care, Critically ill, Inhaled sedation, Intravenous sedation, Richmond agitation sedation scale, Sedation

   DOI: 10.5005/jp-journals-10071-24360  |  Open Access |  How to cite  | 

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