Indian Journal of Critical Care Medicine

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2022 | October | Volume 26 | Issue S2

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EDITORIAL

Atul Prabhakar Kulkarni, Rajesh Chandra Mishra

Can we Reconcile Evidence-based Medicine with Personalized Medicine: Poised on a Cusp!

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:2] [Pages No:S1 - S2]

Keywords: Aggregated n-of-1 studies, Evidence-based medicine, N-of-1 studies, Personalized medicine, Randomized controlled trials

   DOI: 10.5005/jp-journals-10071-24354  |  Open Access |  How to cite  | 

188

GUIDELINES

Rajesh C Mishra, Sharmili Sinha, Deepak Govil, Ranajit Chatterjee, Vivek Gupta, Vinay Singhal, Valentine Alexander Lobo, Rajeev A Annigeri, Sunil Karanth, Ahsina Jahan Lopa, Ahsan Ahmed, Roop Kishen, Rajesh Pande, Yash Javeri, Dhruva Chaudhry, Arindam Kar

Renal Replacement Therapy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendation

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:4] [Pages No:S3 - S6]

Keywords: Acute kidney injury, Continuous renal replacement therapy, Intensivist, Multidisciplinary team

   DOI: 10.5005/jp-journals-10071-24278  |  Open Access |  How to cite  | 

Abstract

Acute kidney injury (AKI) contributes significantly to morbidity and mortality in ICU patients. The cause of AKI may be multifactorial and the management strategies focus primarily on the prevention of AKI along with optimization of hemodynamics. However, those who do not respond to medical management may require renal replacement therapy (RRT). The various options include intermittent and continuous therapies. Continuous therapy is preferred in hemodynamically unstable patients requiring moderate to high dose vasoactive drugs. A multidisciplinary approach is advocated in the management of critically ill patients with multi-organ dysfunction in ICU. However, an intensivist is a primary physician involved in life-saving interventions and key decisions. This RRT practice recommendation has been made after appropriate discussion with intensivists and nephrologists representing diversified critical care practices in Indian ICUs. The basic aim of this document is to optimize renal replacement practices (initiation and management) with the help of trained intensivists in the management of AKI patients effectively and promptly. The recommendations represent opinions and practice patterns and are not based solely on evidence or a systematic literature review. However, various existing guidelines and literature have been reviewed to support the recommendations. A trained intensivist must be involved in the management of AKI patients in ICU at all levels of care, including identifying a patient requiring RRT, writing a prescription and its modification as per the patient's metabolic need, and discontinuation of therapy on renal recovery. Nevertheless, the involvement of the nephrology team in AKI management is paramount. Appropriate documentation is strongly recommended not only to ensure quality assurance but also to help future research as well.

292

GUIDELINES

Rajesh C Mishra, Kanwalpreet Sodhi, Kowdle Chandrasekhar Prakash, Niraj Tyagi, Gunjan Chanchalani, Rajeev A Annigeri, Deepak Govil, Raymond D Savio, Balasubramanian Subbarayan, Nitin Arora, Ranajit Chatterjee, Jose Chacko, Ruchira W Khasne, Rajasekara M Chakravarthi, Nita George, Ahsan Ahmed, Yash Javeri, Akshay K Chhallani, Reshu G Khanikar, Saravanan Margabandhu, Ahsina J Lopa, Dhruva Chaudhry, Srinivas Samavedam, Arindam Kar, Subhal B Dixit, Palepu Gopal

ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:30] [Pages No:S13 - S42]

Keywords: Acute kidney injury, Biomarkers, Continuous renal replacement therapy (CRRT), ECMO, Guidelines, Renal replacement therapy

   DOI: 10.5005/jp-journals-10071-24109  |  Open Access |  How to cite  | 

Abstract

Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI.

321

GUIDELINES

Kapil G Zirpe, Anand M Tiwari, Rahul A Pandit, Deepak Govil, Rajesh C Mishra, Srinivas Samavedam, Palepu B Gopal, Atul P Kulkarni, Subramanian Swaminathan, Subhal B Dixit, Arindam Kar, Rajesh K Pande, Dhruva Chaudhry

Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:8] [Pages No:S43 - S50]

Keywords: Brain death, Donor age, Donor evaluation, Expanded criteria donor, Intensivist, Transplantation

   DOI: 10.5005/jp-journals-10071-24190  |  Open Access |  How to cite  | 

Abstract

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give “real-world” criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs.

215

GUIDELINES

Bharat G Jagiasi, Akshaykumar A Chhallani, Subhal B Dixit, Rishi Kumar, Rahul A Pandit, Deepak Govil, Shirish Prayag, Kapil G Zirpe, Rajesh C Mishra, Gunjan Chanchalani, Farhad N Kapadia

Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:15] [Pages No:S51 - S65]

Keywords: Acute pulmonary embolism, Deep vein thrombosis, Guidelines, Intensive care unit mortality

   DOI: 10.5005/jp-journals-10071-24195  |  Open Access |  How to cite  | 

Abstract

Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a “we suggest” vs a “we recommend” is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options.

316

GUIDELINES

Atul Prabhakar Kulkarni, Deepak Govil, Srinivas Samavedam, Shrikanth Srinivasan, Suresh Ramasubban, Ramesh Venkataraman, Kishore Pichamuthu, Sameer Arvind Jog, Jigeeshu V Divatia, Sheila Nainan Myatra

ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:11] [Pages No:S66 - S76]

Keywords: Arterial lactate, Cardiac output measurement, Central venous oxygen saturation, Critically ill adults, Echocardiography, Hemodynamic monitoring, Static parameters, Thermodilution cardiac output, Transpulmonary thermodilution

   DOI: 10.5005/jp-journals-10071-24301  |  Open Access |  How to cite  | 

Abstract

Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients.

339

GUIDELINES

Gopi Chand Khilnani, Pawan Tiwari, Kapil Gangadhar Zirpe, Dhruva Chaudhry, Deepak Govil, Subhal Dixit, Subhash Kumar Todi, Vijay Hadda, Neetu Jain, Manjunath B Govindagoudar, Srinivas Samavedam, Simant Kumar Jha, Niraj Tyagi, Madhusudan R Jaju, Anita Sharma

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:18] [Pages No:S77 - S94]

Keywords: Antibiotics, Guidelines, Procalcitonin, Sepsis, Stewardship

   DOI: 10.5005/jp-journals-10071-24326  |  Open Access |  How to cite  | 

349

GUIDELINES

G Praveen Kumar, Deepak Govil, Sachin Gupta, Vivek Kumar, Anuj M Clerk, Amol T Kothekar, Pradeep M D'Costa, Kedar Toraskar, Kapil D Soni, Jojo K John, Sweta J Patel, KN Jagadeesh, Chacko Jose, Dhruva Chaudhry, Rajesh C Mishra, Arindam Kar

Competencies for Point-of-care Ultrasonography in ICU: An ISCCM Expert Panel Practice Recommendation

[Year:2022] [Month:October] [Volume:26] [Number:S2] [Pages:6] [Pages No:7 - 12]

Keywords: Central venous catheter, Competencies, Critical care, Deep vein thrombosis, Echocardiography, e fast, Lung ultrasound, Optic nerve sheath diameter, Point-of-care, Point-of-care ultrasound

   DOI: 10.5005/jp-journals-10071-24199  |  Open Access |  How to cite  | 

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