Indian Journal of Critical Care Medicine

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2022 | December | Volume 26 | Issue 12

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EDITORIAL

Hemanshu Prabhakar

The Menace of Meningitis!

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:2] [Pages No:1231 - 1232]

Keywords: Bacterial meningitis neurosurgical cerebrospinal fluid lactate, Meningitis after craniotomy, Neurocritical care, Postoperative critically Ill

   DOI: 10.5005/jp-journals-10071-24368  |  Open Access |  How to cite  | 

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EDITORIAL

Subhankar Paul, Rajesh Kumar Pande

Post-extubation Dysphagia—Early Detection by Serial Tongue Pressure Measurements: Is it Practical?

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:2] [Pages No:1233 - 1234]

Keywords: Aspiration pneumonia, Dysphagia, Mechanical ventilation

   DOI: 10.5005/jp-journals-10071-24374  |  Open Access |  How to cite  | 

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EDITORIAL

Rohit Bhowmick

Normal Anion Gap Metabolic Acidosis in Pediatric Acute Diarrhea: A Menace or an Innocent Bystander?

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:2] [Pages No:1235 - 1236]

Keywords: Acidosis, Metabolic Acidosis, Non-anion-gap metabolic acidosis, Severe dehydration

   DOI: 10.5005/jp-journals-10071-24371  |  Open Access |  How to cite  | 

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PICTORIAL ESSAY

Sonali Vadi, Ashwini Pednekar, Abhijit Raut

Spectrum of Vascular Thrombosis in Critically Ill COVID-19 Patients: From Bench to the Bedside

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:7] [Pages No:1237 - 1243]

Keywords: COVID-associated coagulopathy, Prothrombotic milieu, Severe acute respiratory syndrome coronavirus 2, Vascular thrombosis

   DOI: 10.5005/jp-journals-10071-24369  |  Open Access |  How to cite  | 

Abstract

Pro-inflammatory cytokines and procoagulant factors released by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lead to thrombosis and ischemia. Pathogenesis and clinical significance of hypercoagulability and an ensuing gamut of vascular complications are explained here.

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Original Article

Mitra Kar, Ashima Jamwal, Akanksha Dubey, Chinmoy Sahu, Sangram Singh Patel

Bacterial Meningitis among Intracranial Surgery Patients at a University Hospital in Northern India

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:9] [Pages No:1244 - 1252]

Keywords: Bacterial meningitis, External ventricular drain, Multidrug resistance, Post-neurosurgery patients, Tertiary care center

   DOI: 10.5005/jp-journals-10071-24363  |  Open Access |  How to cite  | 

Abstract

Background: Cerebrospinal infections are the cause of poor prognosis among post-neurosurgery patients owing to delay in improvement of neurological functions, leading to increased length of hospital stay, proceeding to disability or death. Methods and materials: This retrospective observational study was performed at a tertiary care center in Northern India, where all patients with bacterial cerebrospinal infections from July 2019 to July 2022 were evaluated for post-neurosurgery cerebrospinal shunt infections, and all demographic data and risk factors were extracted from the hospital information system (HIS). Results: The study includes 150 (150/1986, 7.55%) culture-confirmed cases of bacterial meningitis out of 1986 cases of suspected bacterial meningitis patients. Ninety-six (96/150, 64.0%) post-neurosurgery patients with cerebrospinal fluid (CSF) leaks were managed using external ventricular drain (EVD) or ventriculo-peritoneal (VP) shunt. Seventy-four (74/96, 77.08%) patients were managed only on EVD, whereas 22 (22/96, 22.92%) patients were managed only on VP shunt. Eighty-two (82/96, 85.4%) multidrug-resistant microorganisms (MDROs)were isolated and 70 (70/82, 85.36%) were Gram-negative bacteria, of which 56 (56/74, 75.68%) Gram-negative bacteria showed extended-spectrum beta-lactamase (ESBL)-producing character in those with an EVD, 14 (14/22, 63.63%) with a VP shunt. Among Gram-negative bacteria, Acinetobacter baumannii showed high rates of resistance: 21 (21/23, 91.30%) and 8 (8/8, 100%) were ESBL-producing A. baumannii in patients managed on EVD and VP shunt, respectively. Conclusion: This study determines the risk factors, the spectrum of pathogenic microorganisms, multidrug resistance, and the nature of intracranial lesions isolated among the patients who developed bacterial cerebrospinal infections in post-neurosurgery patients.

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Original Article

Toru Yamada, Ryoichi Ochiai, Yoshifumi Kotake

Changes in Maximum Tongue Pressure and Postoperative Dysphagia in Mechanically Ventilated Patients after Cardiovascular Surgery

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:6] [Pages No:1253 - 1258]

Keywords: Cardiovascular surgery, Dysphagia, Mechanical ventilator, Postintensive care syndrome, Tongue pressure

   DOI: 10.5005/jp-journals-10071-24365  |  Open Access |  How to cite  | 

Abstract

Background: There is no objective quantitative parameter for dysphagia, and the relationship between changes in maximum tongue pressure values and dysphagia is unknown. This study aimed to determine whether there is a difference in the change in maximal tongue pressure after extubating patients who were ventilated after cardiovascular surgery, with or without dysphagia. Materials and methods: Adult patients who underwent mechanical ventilation via endotracheal intubation following cardiovascular surgery were included. Tongue pressure was measured before cardiovascular surgery and at 6 hours; 3 and 7 days after extubation. Dysphagia was confirmed by the functional oral intake scale (FOIS) on day 7 after extubation; an FOIS level above or equal to 6 was considered “dysphagia-negative.” Results: Of 68 patients, 15 (22.1%) were in the dysphagia-positive group, which significantly showed a history of diabetes mellitus, prolonged mechanical ventilation, and postextubation hospitalization. Additionally, the postoperative C-reactive protein level was significantly higher in the dysphagia-positive group than in the dysphagia-negative group. Maximum tongue pressure was significantly lower in the dysphagia-positive group at 3 and 7 days postextubation. Using a cutoff value of 27.6 kPa in a receiver operating characteristic curve (ROC) for maximum tongue pressure at 3 days after extubation, the area under the curve (AUC) was 0.82, sensitivity was 84.9%, and specificity was 84.2%. Conclusion: Tongue pressure at 3 days after extubation is significantly lower in patients with dysphagia after cardiovascular surgery than in patients without dysphagia. If the maximum tongue pressure value is below 27.6 kPa on the third day following extubation, oral intake should be performed with caution.

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Original Article

Ram S Kaulgud, Tousif Hasan, Gulamnabi L Vanti, S Veeresh, Amruta P Uppar, Mahantesh M Kurjogi

Snake Venom-specific Phospholipase A2: A Diagnostic Marker for the Management of Snakebite Cases

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:8] [Pages No:1259 - 1266]

Keywords: Antivenom, Enzyme, Snake bite, Venom, Venom-specific phospholipase A2

   DOI: 10.5005/jp-journals-10071-24362  |  Open Access |  How to cite  | 

Abstract

Background: Snake bites are a common cause of morbidity and mortality, especially in tropical countries. Snake bites in any community are managed based on the clinical features and intravenous administration of antisnake venom (ASV). The administration of ASV is either deficient or given in excess based on clinical decisions and whole blood clotting test results. The present study is designed to analyze the level of snake venom component in the blood of snake bite in association with the clinical features. Patients and methods: Blood samples were collected from the patients admitted to Karnataka Institute of Medical (KIMS) hospital with a history of snakebite considering the inclusion criteria. Serum was collected from the blood of snakebite patients before and after ASV and used to assess the level of venom-specific phospholipase A2 (PLA2) enzyme using the enzyme-linked immunosorbent assay (ELISA) method. Results: Quantitative ELISA results revealed that the snake venom-specific PLA2 in the victim's blood was in the range of 0.3–1.27 mg/mL before the administration of ASV. However, the concentration of PLA2 after 24 hours of ASV administration was decreased in most of the patients. Further, it was observed that envenomation complications were directly proportional to the amount of snake venom-specific PLA2 found in the blood of the snakebite patient. Conclusions: The study concludes that snake venom-specific PLA2 in the blood of snakebite patients could be used as a reliable venom marker, which helps in determination of appropriate ASV dosage in snakebite patients.

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Original Article

Mallikarjun Gunjiganvi, Siddharth Rai, Rupali Bhalchandra Awale, Prabhakar Mishra, Mohan Gurjar, Devendra Gupta, Ritu Singh

Depression and Anxiety among COVID-19 Indian Intensive Care Unit Survivors: A Prospective Observational Study

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:8] [Pages No:1267 - 1274]

Keywords: Anxiety, Coronavirus disease-2019, Depression, Intensive care unit survivors, Mental health, Well-being

   DOI: 10.5005/jp-journals-10071-24370  |  Open Access |  How to cite  | 

Abstract

Background: Long-lasting physical, cognitive, and mental health sequelae including depression and anxiety are common in intensive care unit (ICU) survivors. Aim: This study was aimed to assess the immediate and medium-term mental health sequelae – depression and anxiety among coronavirus disease-2019 (COVID-19) ICU survivors. Methods: The COVID-19 ICU Survivors of a tertiary level ICU were recruited into this study from 1 July 2020 to 31 October 2020. Willing participants were circulated with an electronic questionnaire. It consisted of demographics and questionnaires related to COVID-19 disease, comorbidities, and a patient health questionnaire (PHQ-9) scale for depression, and generalized anxiety disorder (GAD-7) scale for anxiety. Responses were collected at the time of discharge. Follow-up was done at 2 weeks and 6 months. Results: Among the 133 COVID-19 ICU survivors contacted, 91 survivors submitted the baseline data at the time of discharge. Fourteen and another 11 survivors were lost to follow-up at 2 weeks and at 6 months. The median age was 52.75 and 68.1% (n = 62/91) were male. The median PHQ-9 and GAD-7 scores showed a statistically significant decrease at 2 weeks and a non-significant decrease at 6 months compared to baseline scores. The GAD-7 score was the same or worse between baselines to 2 weeks, but it reduced between baseline to 6 months for all variables and their subgroups. Conclusion: This study revealed a high prevalence of anxiety and depression in the immediate post-discharge period. These findings suggest the need for better mental rehabilitation strategies to deal with the well-being of critically ill survivors in future pandemics.

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Original Article

Supradip Ghosh, Ripenmeet Salhotra, Amandeep Singh, Aditya Lyall, Garima Arora, Niranjan Kumar, Aayush Chawla, Meenakshi Gupta

New Antibiotic Prescription Pattern in Critically Ill Patients (“Ant-critic”): Prospective Observational Study from an Indian Intensive Care Unit

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:10] [Pages No:1275 - 1284]

Keywords: Antibiotic(s), Intensive care unit, Patient outcome, Prescription process

   DOI: 10.5005/jp-journals-10071-24366  |  Open Access |  How to cite  | 

Abstract

Introduction: This study aimed to address the issue of antibiotic prescription processes in an Indian Intensive care unit (ICUs). Materials and methods:: In a prospective longitudinal study, all adult patients admitted in the ICU for 24 hours or above between 01 June 2020 and 31 July 2021 were screened for any new antibiotic prescription throughout their ICU stay. All new antibiotic prescriptions were assessed for baseline variables at prescription, any modifications during the course, and the outcome of antibiotic prescription. Results: A total of 1014 patients fulfilled entry criteria; 59.2 and 7.2% of days they were on a therapeutic or prophylactic antibiotic(s). Patients, who were prescribed therapeutic antibiotic(s), had worse ICU outcomes. A total of 49.5% of patients (502 of 1,014) received a total of 552 new antibiotic prescriptions during their ICU stay. About 92.13% of these prescriptions were empirical and blood or other specimens were sent for culture in 78.81 and 60.04% of instances. A total of 31.7% of episodes were microbiologically proven and were more likely to be prescribed by an ICU consultant. A total of 169 modifications were done in 142 prescription episodes; 73 of them after sensitivity results. Thus, the overall rate of de-escalation was 13.95%. Apart from the negative culture result (36.05%), an important reason for a relatively low rate of de-escalation was the absence of sampling (12.32%). Longer ICU stay before antibiotic prescription, underlying chronic liver disease (CLD), worse organ dysfunction, and septic shock were independently associated with unfavorable treatment outcomes. No such independent association was observed between antibiotic appropriateness and patient outcome. Conclusion: Future antibiotic stewardship strategies should address issues of high empirical prescription and poor microbiological sampling hindering the de-escalation process.

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Original Article

Raghavendra Rao, HC Deepa, Adrian Keith Noronha

Pathological Lung Patterns of COVID-19 and its Clinical Correlation to Disease Severity

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:8] [Pages No:1285 - 1292]

Keywords: Coronavirus disease-2019, Diffuse alveolar damage, Histopathology, Lung biopsy, Pneumonia

   DOI: 10.5005/jp-journals-10071-24364  |  Open Access |  How to cite  | 

Abstract

Introduction: Coronavirus disease-2019 (COVID-19) infection can result in pulmonary complications ranging from mild illness to severe life-threatening disease. There are limited studies correlating the association between the clinical course of COVID-19 and histopathological findings. This study aimed to examine the postmortem histopathological changes in lung tissue of COVID-19-positive patients and to correlate those changes with disease severity. Materials and methods: This prospective observational study was conducted in adult COVID-19-positive patients. Postmortem core needle biopsy (CNB) of the lung was done using ultrasonography guidance within 1 hour of death. Histopathological analyses were performed by two expert pulmonary pathologists. The demographic and clinical data of the patients were recorded to correlate them with histopathological findings. Results: In total, 48 patients were assessed for inclusion, and 21 patient relatives consented for the study. The median duration of illness was 21 (range 9–38) days, the predominant histopathological finding was diffuse alveolar damage (DAD) in most patients (19/21), followed by pneumonia (13/21). Exudative, intermediate, and advanced DAD patterns were seen in 9.5%, 52.4%, and 28.6% of cases, respectively. Advanced DAD was associated with a longer duration of disease. The pneumonia findings were associated with positive respiratory and blood cultures. The microvascular thrombus was seen only in one patient. Conclusion: The predominant pathological findings in our patients were DAD and pneumonia. The DAD type correlated with the duration of illness, and we attributed pneumonia findings to secondary infection. The incidence of microvascular thrombi was low, and it might reflect the effect of treatment with anticoagulation.

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Original Article

Kiran Kumar Gudivada, Shiva Kumar Narayan, Alok Narasimha, Krithika Dandinashivara Muralidhara

Evaluation of Predictors, Kinetics of Renal Recovery and Outcomes of COVID-19 Patients with Acute Kidney Injury Admitted to Intensive Care Unit: An Observational Study

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:7] [Pages No:1293 - 1299]

Keywords: Acute kidney injury, Acute kidney injury recovery, Acute kidney injury relapse, Coronavirus disease-2019, Intensive care unit

   DOI: 10.5005/jp-journals-10071-24372  |  Open Access |  How to cite  | 

Abstract

Background: The incidence of acute kidney injury (AKI) is greater than 50% among coronavirus disease-2019 (COVID-19) patients admitted to the intensive care unit (ICU). However, the literature on predictors and kinetics of renal recovery remains unclear. Patients and methods: This observational study was conducted in a 30-bedded mixed ICU of a tertiary care center from May 2020 to July 2021. A total of 200 consecutive adult COVID-19 patients who had AKI in ICU were included. Using logistic regression with the best subset selection, predictors of renal recovery were identified. Outcomes and kinetics of AKI recovery were determined. Results: Among 200 patients, 67 recovered from AKI, of which 38, 17, and 12 patients had transient AKI, persistent AKI, and acute kidney disease (AKD), respectively. A total of 25 patients had AKI relapse, primarily associated with hospital-acquired infections. Results of logistic regression showed that the combination of Acute Physiology and Chronic Health Evaluation (APACHE II) {odds ratio (OR) 1.1 [p < 0.001; 95% confidence interval (CI) 1.06–1.16]}, day onset of AKI [OR 1.6 (p = 0.001; 1.24–2.24)] and severity of AKI [OR 2.9 (p < 0.001; 2.03–4.36)] were the predictors associated with poor renal recovery. This model had sufficient discrimination with the area under the curve (AUC) of 0.86. Renal replacement therapy requirement and mortality among COVID–AKI patients were 68 and 84%, respectively. Conclusion: A higher APACHE II at admission, a longer time to onset of AKI, and the severity of AKI during ICU stay predicted poor renal recovery. Study results emphasize the need for stepping-up dialysis resources in the likely case of future waves of COVID-19. The relapse of AKI was associated with sepsis, and mortality rates were substantially high.

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Pediatric Critical Care

Lalit Takia, Arun Kumar Baranwal, Pramod Kumar Gupta, Suresh Kumar Angurana, Muralidharan Jayashree

Acute Diarrhea and Severe Dehydration in Children: Does Non-anion Gap Component of Severe Metabolic Acidemia Need More Attention?

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:8] [Pages No:1300 - 1307]

Keywords: Acute diarrhea, Alkali therapy, Bicarbonate, Metabolic acidemia, Non-anion-gap metabolic acidemia, Severe dehydration

   DOI: 10.5005/jp-journals-10071-24367  |  Open Access |  How to cite  | 

Abstract

Background: Despite significant loss of bicarbonate during acute diarrhea, pediatric data are scarce with acute diarrhea/severe dehydration (ADSD) and severe non-anion-gap metabolic acidemia (sNAGMA). We planned to study their clinical profile, critical care needs, and outcome. Patients: Children (1 month–12 years) with ADSD and sNAGMA (pH <7.2 and/or bicarbonate <15 mEq/L, and normal/mixed anion gap) admitted in Pediatric Emergency Department from January 2016 to December 2018 were enrolled. Children with pure high-anion-gap metabolic acidemia were excluded. Methods: Medical records were reviewed retrospectively. The primary outcome was time taken to resolve acidemia. Secondary outcomes were acute care area free days in 5 days (ACAFD5), and adverse outcome as composite of Pediatric Intensive Care Unit (PICU) admission and/or death. Results: Out of 929 diarrhea patients admitted for intravenous therapy, 121 (13%; median age, 4 months) had ADSD and sNAGMA. Median (IQR) pH was 7.11 (7.01–7.22); 21% patients had pH <7.00. Hyperchloremia (96%) and hypernatremia (45%) were common. About 12% patients each required inotropes and ventilation, while 58% had acute kidney injury (AKI). Median (IQR) time for resolution of acidemia among survivors was 24 (12, 24) hours. Thirty-two patients had adverse outcome. Higher grades of sNAGMA were associated with shock, AKI, coma, hypernatremia, hyperkalemia, adverse outcome, and lesser ACAFD5. Shock, ventilation, renal replacement therapy (RRT), and higher grades of sNAGMA were predictors of adverse outcome, with former two being independent predictors. Conclusions: Severe non-anion-gap metabolic acidemia in children with ADSD is associated with organ dysfunctions, dyselectrolytemias, and lesser ACAFDs. Resolution of acidemia took unacceptably longer time. Higher grades of sNAGMA were a predictor of adverse outcomes. Trials are suggested to assess the role of additional bicarbonate therapy.

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LETTER TO THE EDITOR

Rohan Magoon, Varun Suresh

A Clarion Call for a More Comprehensive Approach to Acute Respiratory Distress Syndrome Severity Categorization

[Year:2022] [Month:December] [Volume:26] [Number:12] [Pages:2] [Pages No:1308 - 1309]

Keywords: Acute respiratory distress syndrome, Mortality, Positive end expiratory pressure

   DOI: 10.5005/jp-journals-10071-24373  |  Open Access |  How to cite  | 

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