Objective: To study the use of serial ultrasound gastric residual volume (GRV) measurements in predicting feed intolerance in critically ill patients. Patients and methods: This study was conducted in various intensive care units (ICUs) of All India Institute of Medical Sciences, New Delhi. Forty-three critically ill patients aged more than 18 years were studied for a total of 130 enteral feeding days. Gastric residual volume was obtained by calculating the antral cross-sectional area (CSA), which is the product of anteroposterior (AP) and craniocaudal (CC) diameters of gastric antrum obtained using ultrasound in the right lateral decubitus position. A baseline measurement was done before the initiation of the enteral feed and termed GRV0, the ultrasound scanning was repeated every 1 hour for the first 4 hours and termed GRV1, GRV2, GRV3, and GRV4, respectively, and the patients were watched for feed intolerance. The receiver operating characteristic (ROC) curves were constructed to correlate the GRV at each time with feed intolerance. Results: The data from 43 medical and surgical critically ill patients were analyzed. Out of 130 feeding days, 13 were noted to be feed intolerant. Gastric residual volume at the end of the fourth hour of feed, that is, GRV4 was the best predictor of feed intolerance with 99.3% area under the curve (AUROC), sensitivity of 99%, specificity of 99.3%, and 95% CI, 0.89–0.98 followed by GRV3, with AUROC of 96% and sensitivity and specificity of 92.3 and 96%, respectively, with 95% CI, 0.92–0.99.

Background and objectives: Major adverse cardiac events (MACE) are frequent in coronavirus disease-2019 (COVID-19). Remdesivir is used worldwide for treatment in COVID-19. In this retrospective observational study, our primary objective was to assess the impact of remdesivir administration on the incidence of MACE and associated 28 day survival in critically ill patients admitted for moderate to severe COVID-19 pneumonia. Patients and methods: We analyzed the data of 437 patients admitted in intensive care unit (ICU) and divided them into two groups: R group (received remdesivir at ICU admission) and NR group (nonremdesivir) or based on the occurrence of MACE in ICU. We followed the data until discharge, death, or 28 days postadmission. Our primary objective was to investigate the log-odds of survival with remdesivir administration and a correlation/regression analysis of MACE with remdesivir administration in all included patients. Results: The incidence of MACE was 72 among 437 patients, with 17 (9.3%) patients in R group vs 55 (21.8%) in NR group (p <0.001). On performing correlation analysis between MACE and remdesivir administration, significant correlation coefficient of −0.168 (p = 0.004) was obtained. On regression analysis, the odds ratio for occurrence of MACE with remdesivir administration was 0.362 (regression coefficient: −1.014, p <0.001). It indicates a 64% decrease in the log-odds of MACE and a 16% increase in the log-odds of survival with remdesivir administration. All 72 patients with MACE had expired, suggesting a high mortality risk with cardiac complications. The odds ratio for mortality due to MACE with remdesivir administration was 0.216 (regression coefficient: −1.530, p −<0.001). It indicates a 79% decrease in the log-odds of death due to MACE with remdesivir administration. Conclusion: Our study showed significant reduction in MACE and mortality benefit in patients who received remdesivir in comparison to standard treatment.

Background: Diaphragmatic dysfunction has been increasingly documented to play a critical role to determine ventilator dependency and failure of weaning. Objective: The goal was to study the diagnostic accuracy of diaphragmatic rapid shallow breathing index (D-RSBI) as a predictor of weaning outcomes in comparison to RSBI. Materials and methods: A prospective observational study on consecutively admitted patients who were intubated and mechanically ventilated for a duration of at least 48 hours was carried out. The right hemidiaphragm displacement [diaphragm displacement (DD)] was calculated by M-mode ultrasonography, and respiratory rate (RR) and tidal volume (TV) were documented from the ventilator readings. Rapid shallow breathing index (RSBI) was measured as RR/TV (in liters); D-RSBI was calculated as RR/DD (in millimeters) and expressed as breath/minute/millimeter. Extubation failure was defined as the reinstitution of mechanical ventilation at the end of, or during the spontaneous breathing trial (SBT), re-intubation or the need of noninvasive ventilation (NIV) for the patient within 48 hours of extubation. Results: Of 101 screened patients, 50 patients met the inclusion criteria, of whom 45 patients had successful SBT, and finally, 41 patients could be successfully extubated. Hence, the overall rate of weaning failure in the study population was 18%. The areas under the receiver operator characteristic (ROC) curves for D-RSBI and RSBI were 0.97 and 0.70, respectively (p <0.0001). The Pearson's correlation among RSBI and D-RSBI was 0.81 (p-value <0.001). Conclusion: Diaphragmatic rapid shallow breathing index has a positive correlation and greater diagnostic accuracy than RSBI, the conventional weaning index.

Background: Imparting quality healthcare to the critically ill patient is associated with competence, compassion, and excellent care by healthcare professionals. It includes the development and widespread application of evidence-based interventions, following guidelines, and protocol-based care on ventilator-associated bundle approach to ensure the delivery of care to prevent ventilator-associated problems. Materials and methods: Quantitative evaluative approach, pre-experimental research, one group pre- and post-test design by the convenient method of sampling 70 staff nurses were selected. A self-structured compliance checklist was used to collect the data. Results: The level of compliance with handwashing revealed that all the samples 70 (100) have complied with the handwashing technique during the clean and sterile procedure on the patient in all three shifts and 30 (42.9%) subjects were very good in following the handwashing in the morning compared to evening and night. With regard to inserting the catheter into the ET tube gently by using an aseptic technique to perform endotracheal suctioning, 28 (40%) samples had carried out in all three shifts respectively and 50 (71.4%) were good in adhering in following all the steps. In relation to cuff pressure monitoring, it was carried out by 63 (90%) of the samples and around 43 (61.4%) subjects were found to be good in all the three shifts, respectively. Conclusion: Healthcare professionals need to adopt the protocols and policies. Implementation appropriately helps in the prevention of ventilator-associated problems, and quality care will be improved.

Background: Informative and supportive nursing care is essential to reduce complications and improve outcomes in people with chronic obstructive pulmonary disease (COPD) treated with noninvasive ventilation (NIV). The aim of this study was to determine the effect of provision of information and supportive nursing care on blood gas, vital signs, anxiety, stress, and agitation levels in people with COPD treated with NIV. Materials and methods: A randomized controlled design was used between September and December 2019. Patients with COPD treated with NIV in the intensive care unit (ICU) in a state hospital were included. A total of 60 patients, composed of 30 interventions and 30 controls, were randomly included in the sample. Provision of information and supportive nursing care was applied to the patients in the intervention group. Results: Following the intervention, the findings showed that the provision of information and supportive nursing care has a positive effect on the blood gas, vital signs, anxiety, stress, and agitation levels of patients. It was determined that the change in the averages of DASS-Anxiety, DASS-Stress, and RASS-Agitation of the intervention and control groups were statistically significant in terms of group × time (respectively, F = 41.214, p = 0.003; F = 7.561, p = 0.008; F = 65.004, p = 0.000) interaction (p <0.05). Conclusion: The provision of information and supportive nursing care is recommended to alleviate anxiety, stress, and agitation in people with COPD treated with NIV.

Background: Bacteremia is an uncommon complication of group A streptococcal (GAS) infections. The data on GAS bacteremia is scarce from developing nations such as India. Patients and methods: We performed a retrospective analysis of patients diagnosed with GAS bacteremia in a tertiary care hospital in Kerala, India over a 10-year period (2012–2021) by review of the electronic medical records (EMRs). Results: A total of 58 cases of GAS bacteremia were identified in the study period. Skin/soft tissue infection was the most common source of bacteremia. A total of 34.4% of the patients required ICU admission and the in-hospital mortality was 22.4%. All the GAS isolates were sensitive to penicillin, ampicillin, and ceftriaxone. Erythromycin and clindamycin resistance was seen in 39.7% and 24.1% isolates, respectively. Conclusion: This study shows that despite advancement in medical sciences, GAS bacteremia remains as a disease with high morbidity and mortality. A higher rate of clindamycin resistance was observed compared to previous Indian studies.

Background: The outcomes in critical illness depend on disease severity, practice protocols, workload, and access to care. This study investigates the factors affecting outcomes in mechanically ventilated coronavirus disease-2019 acute respiratory distress syndrome (COVID-19 ARDS) patients admitted in a tertiary teaching hospital intensive care unit (ICU) in Central India with reference to different time periods in pandemic. This is one of the largest series of mechanically ventilated COVID-19 ARDS patients, globally. Methods: This retrospective cohort study classified the entire data into four time periods (Period 1: April 2020 to June 2020; Period 2: July 2020 to September 2020; Period 3: October 2020 to December 2020; and Period 4: January 2021 to April 2021). We performed a multivariable-adjusted analysis to evaluate predictors of mortality, adjusted for baseline-severity, sequential organ failure assessment (SOFA score) and time period. We applied mixed-effect binomial logistic regression to model fixed-effect variables with incremental complexity. Results: Among the 56 survivors (19.4%) out of 288 mechanically ventilated patients, there was an up-gradient of survival proportion (0, 18.2, 17.4, and 28.6%) in four time periods. Symptom–intubation interval (OR 1.16; 95% CI 1.03–1.31) and driving pressures (DPs) (OR 1.17; 95% CI 1.07–1.28) were significant predictors of mortality in the model having minimal AIC and BIC values. Patients aged above 60 years also had a larger effect, but statistically insignificant effect favoring mortality (OR 1.99; 95% CI 0.92–4.27). The most complex but less parsimonious model (with higher AIC/BIC) indicated the protective odds of high steroid on mortality (OR 0.59; 95% CI 0.59–0.82). Conclusion: The outcomes in mechanically ventilated COVID-19 ARDS patients are heterogeneous across time windows and may be affected by the complex interaction of baseline risk and critical care parameters.

Background: Biomarkers have been extensively studied and used in the diagnosis and management of various diseases. The trend of biomarkers helps in prognosticating and managing critically ill patients. In resource-limited settings, the availability and feasibility of using these biomarkers are challenging. Our study aimed to see the trend of biomarkers and their effect on intensive care unit (ICU) mortality in coronavirus disease-2019 (COVID-19) patients. Materials and methods: A retrospective observational study was done from 1 April 2020 to 30 September 2020. The primary objective was to evaluate the trend of biomarkers in patients with COVID-19 pneumonia and their effect on ICU mortality. The secondary objectives were the duration of mechanical ventilation and length of ICU stay. Results: A total of 380 patients were included. The mean age was 54.9 (SD = 11.1) and 67% were males. The mean age, acute physiology and chronic health evaluation II (APACHE II) score was 29.54 (5.8). Among the biomarkers, total count (TC), ferritin, and procalcitonin (PCT) were higher in non-survivors than in survivors in bivariate analysis. The final multivariable logistic regression model showed age, APACHE II score, length of ICU stay, neutrophil:lymphocyte (NL) ratio, and ferritin as covariates. Among these variables, ferritin was the only biomarker [odds ratio (OR): 1.80, 95% confidence interval (CI) 1.17–2.77] with the APACHE II score (OR: 1.15, 95% CI 1.01–1.30) found to be significant. Conclusion: Ferritin was the only significant biomarker with higher values in non-survivors than in survivors. The trend of biomarkers was not found to be useful in predicting outcome of the patients.

Background: The coronavirus disease-2019 (COVID-19) pandemic has brought about a change in healthcare practices that are likely to persist into the foreseeable future. In particular, is the exposure risk to the healthcare practitioners in the emergency department (ED) and the intensive care units. Mitigating this issue in a low-resource setting remains challenging, and in particular, in developing nations such as India, where ED patient flows can overwhelm a system and its human resources, breaking down processes and infecting healthcare workers (HCWs). Technique: To tackle this and the possible lack of appropriate personal protective equipment (PPE), we designed and built biosafety barrier devices using local resources for use in patient stabilization, transport, and continued care in the ED or the intensive care units. Results: Four biosafety devices bio-safe levels 1 and 2, ultra-ductile portable interface of interventions in infections, and tented transport trolley for transmissibility (4T) were tested for the feasibility of usage for patient care during the pandemic with simulation. Conclusion: We anticipate that with time it may be common practice for in situ isolation of patients in the emergency departments with a suspicion of an infectious disease. With the proof of concept, simulation, hospital infection control committee (HICC) approval, and trial run, we look to close the gaps that exist in these initial innovations.

Background: With the development of coronavirus disease-2019 (COVID-19) pandemic, there is also increased risk of multiple secondary infections either disease- or drug-related. It includes many bacterial as well as invasive fungal infections. Patients and methods: There was suspicion of invasive pulmonary aspergillosis (IPA) infection in COVID-19 patients who were critically ill and had acute respiratory distress syndrome (ARDS). We did radiological evaluation and galactomannan assay in these patients. Result: We have diagnosed COVID-19-associated pulmonary aspergillosis (CAPA) in these patients and started antifungal treatment with voriconazole in all of these COVID-19 patients. Conclusion: It is very important to report such cases, so that healthcare professionals and authorities related to healthcare will be aware of and may also prepare for the increasing burden of this complication. We describe a case series of CAPA infection.

Hospital-acquired infections have been a wide-ranging concern in the medical field, as it increases mortality and incurs longer hospital stays and higher medical costs. Infection control practices and antimicrobial stewardship are thought to be emergent measures to curtail hospital-acquired infections, but adherence to such standard practices has been a concern globally, ultimately leading to poor clinical outcomes. Organisms isolated from rare sources have been reported to cause pathogenic infections in humans. Instances such as contamination of intravenous fluids and parenteral medications with gram-negative bacteria and fungus have been reported in the past. We present here, a rare outbreak of Ralstonia pickettii bacteremia from an unthought source among four critically ill patients. The epidemiological investigations confirmed the source of contagion to be fentanyl ampoules. The immediate action of disusing the batch of fentanyl ampoules was taken. Timely action and isolation precautions prevented a major outbreak within the intensive care unit (ICU).

Coronavirus disease-2019 (COVID-19) is an infectious disease caused by coronavirus/2019-nCoV. It primarily manifests as lung infection, with fever and respiratory tract symptoms. Extrapulmonary complications affecting multiple organs are commonly seen, especially in critically ill patients. The reported gastrointestinal (GI) complications include transaminitis, acute pancreatitis, mesenteric ischemia, GI bleed, and ileus. Here, we report two cases of acute abdominal pain in patients with COVID-19 in their second week of illness. One patient had mild COVID-19 disease and the other had severe disease. Both patients had diffuse abdominal tenderness and raised inflammatory markers. The diagnosis of mesenteric panniculitis (MP) was made radiologically, and demonstrated with the presence of increased density of the mesentery with fat stranding (misty mesentery). Glucocorticoid administration resulted in the complete resolution of pain. They remained pain-free at 3 months of follow-up.

Central pontine myelinolysis (CPM) classically occurs due to rapid rise in serum osmolarity. Most cases have been associated with a history of chronic alcohol abuse, malnutrition, diuretic abuse, and hyponatremia. The pathological process of CPM starts in the central pons near median raphe and spreads out “like a brush Fire” into the surrounding basis pontis. Extrapontine sites such as internal capsule, basal ganglia, cerebellum, and cerebrum can also be affected. We report a case of 60-year-old male with history of chronic alcoholism who presented to us with severe neurological deficits 10 days after his episode of severe hyponatremia.

Lance Adams syndrome is the term used to describe late post-hypoxic myoclonus. Here we describe a patient who developed action and intention myoclonus after 7 days of attempted partial hanging. The similarity of Lance Adams syndrome, which is a treatable condition to a cerebellar syndrome, and the diagnostic difficulties have been highlighted.