Indian Journal of Critical Care Medicine

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2023 | January | Volume 27 | Issue 1

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EDITORIAL

Nimisha Abdul Majeed, Prashant Nasa

Expiratory Muscles of Respiration and Weaning Failure: What do We Know So Far?

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:3] [Pages No:1 - 3]

Keywords: Bedside ultrasound, Critical illness polyneuropathy, Mechanical ventilator weaning, Muscle weakness, Respiratory mechanics, Respiratory muscle

   DOI: 10.5005/jp-journals-10071-24381  |  Open Access |  How to cite  | 

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EDITORIAL

Anant Vikram Pachisia, Deepak Govil

Ultrasound-guided Bedside Percutaneous Transhepatic Biliary Drainage in Critically Ill: A Friend Indeed

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:2] [Pages No:4 - 5]

Keywords: Bedside ultrasound, Biliary drainage, Critically ill, Percutaneous

   DOI: 10.5005/jp-journals-10071-24393  |  Open Access |  How to cite  | 

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EDITORIAL

Shrishu R Kamath

Multidrug Resistance: The Growing Menace in PICU

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:2] [Pages No:6 - 7]

Keywords: Antimicrobial agents, Antibiotic stewardship, Multidrug resistance

   DOI: 10.5005/jp-journals-10071-24394  |  Open Access |  How to cite  | 

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Original Article

P Vishwas, Vedaghosh Amara, Sagar Shanmukhappa Maddani, Souvik Chaudhuri, Suvajit Podder

Risk Factors of Decreased Abdominal Expiratory Muscle Thickness in Mechanically Ventilated Critically Ill Patients—The mNUTRIC Score is an Independent Predictor

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:8] [Pages No:8 - 15]

Keywords: Abdominal expiratory muscle thickness, Internal oblique muscle, mNUTRIC score

   DOI: 10.5005/jp-journals-10071-24375  |  Open Access |  How to cite  | 

Abstract

Background: The expiratory abdominal skeletal muscles are an important component of the respiratory muscle pump, and their reduced thickness has been associated with difficult weaning. There is no objective score that may help clinicians to predict expiratory abdominal muscle thinning. Patients and methods: This was a single-center retrospective study on 81 patients undergoing weaning from mechanical ventilation. The thickness of the four abdominal expiratory muscles—rectus abdominis (RA), internal oblique (IO), external oblique (EO), and transversus abdominis (TA) on the day of the first spontaneous breathing trial (SBT), was obtained. The various parameters of the patients with thinner RA, IO, EO, and TA below the determined thickness cut-off values, predicting difficult weaning was analyzed. Results: Modified nutritional risk in critically ill (mNUTRIC) score was found to be an independent predictor of thinner IO muscle after logistic regression analysis [p = 0.001, adjusted OR 2.33, 95% CI (1.394–3.892)]. The mNUTRIC score was also an independent predictor of thinner EO (p = 0.014, adjusted OR 1.57) and RA muscle (p = 0.002, adjusted OR 1.69). The mNUTRIC cutoff score ≥4 predicted thinner IO (AUC 0.813, p < 0.001 sensitivity 71%, specificity 77%) and thinner EO (AUC 0.738, p < 0.001, 71% sensitivity, 67% specificity). The mNUTRIC score ≥3 predicted that at least one out of the four abdominal expiratory muscles will be thin (AUC 0.849, p < 0.001, 95% CI [0.763–0.935], sensitivity 87.5%, specificity 59%). Conclusion: The mNUTRIC score is an independent predictor of thinner abdominal expiratory muscles in mechanically ventilated critically ill patients.

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Original Article

Jitender Singh, Tara Prasad Tripathy, Ranjan Patel, Karamvir Chandel

Is Ultrasound-guided Bedside Percutaneous Transhepatic Biliary Drainage Safe and Feasible in Critically Ill Patients with Severe Cholangitis? A Preliminary Single-center Experience

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:6] [Pages No:16 - 21]

Keywords: Bedside percutaneous transhepatic biliary drainage, Cholangitis, Critically ill

   DOI: 10.5005/jp-journals-10071-24379  |  Open Access |  How to cite  | 

Abstract

Background and aim: Severe cholangitis secondary to biliary obstruction carries high mortality unless biliary drainage is performed urgently. Owing to various patient-related and logistical issues, bedside biliary drainage is considered a salvage therapeutic option. This study aims to evaluate the safety and efficacy of ultrasonography (USG)-guided biliary drainage at the bedside in patients with severe cholangitis admitted to the intensive care unit (ICU). Materials and methods: A total of 20 patients with severe cholangitis admitted to ICU who underwent bedside percutaneous transhepatic biliary drainage (PTBD) under USG guidance were retrospectively evaluated. Clinical outcomes, details about the PTBD procedure, and complications were recorded and analyzed. Results: Among 20 patients, 13 were male and 7 were female with a mean age of 50.5 years. The most common cause of biliary obstruction was gall bladder malignancy (45%, n = 9) followed by cholangiocarcinoma (25%, n = 5). Left- and right-sided PTBD was performed in 40% (n = 8) and 35% (n = 7) patients, respectively, while 25% (n = 5) of patients underwent bilateral PTBD. The technical success rate was 100%. A total of 65% (n = 13) of patients were discharged from ICU upon improvement while the remaining 35% (n = 7) died despite bedside PTBD. None of the patients had any major procedure-related complications. Conclusions: Ultrsound-guided bedside PTBD seems to be a safe and effective option in critically ill patients with severe cholangitis when shifting of patients is not feasible.

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Original Article

Kapil Dev Soni, Abhishek Singh, Abhay Tyagi, Yudhyavir Singh, Richa Aggarwal, Anjan Trikha

Risk Factors and Outcomes of Post-traumatic Acute Kidney Injury Requiring Renal Replacement Therapy: A Case–Control Study

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:4] [Pages No:22 - 25]

Keywords: Acute kidney injury, Crush syndrome, Hemorrhagic shock, Renal replacement therapy, Trauma

   DOI: 10.5005/jp-journals-10071-24380  |  Open Access |  How to cite  | 

Abstract

Background: Acute kidney injury (AKI) following severe trauma is common. However, the requirement of renal replacement therapy (RRT) in these patients is rare and is associated with high morbidity and mortality. The primary objective of this study was to identify odds of risk factors, in particular, hypotension at presentation, for the requirement of RRT in patients with AKI following trauma. Methods: We performed a case–control study involving patients who were admitted to the intensive care unit (ICU) at a level I trauma center for at least 24 hours. The primary outcome measure was a study of the odds of risk factors associated with the requirement of RRT in such patients. Univariate comparisons and multiple logistic regression analyses were done to identify other risk factors. Results: The presence of crush injury, sepsis, and elevated serum creatinine (sCr) on arrival were identified to be independent risk factors for RRT requirement. Hypotension and exposure to radiocontrast or nephrotoxic antimicrobials were not found to be associated with the need for RRT. Acute kidney injury requiring RRT was associated with significantly increased ICU length of stay (15 days vs 5 days; p < 0.001) and higher mortality (83% vs 35%; p < 0.001). Conclusion: The presence of crush injury, sepsis, and elevated sCr on presentation were identified to be independent risk factors while hypotension association was insignificant for AKI requiring RRT in our investigation.

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Original Article

Fatih Cemal Tekin, Ramazan Köylü, Öznur Köylü, Muammer Kunt

Factors Related to Resuscitation Success and Prognosis of Cardiopulmonary Arrest Cases

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:6] [Pages No:26 - 31]

Keywords: Clinical outcomes, Cardiopulmonary arrest, Prognosis, Resuscitation

   DOI: 10.5005/jp-journals-10071-24382  |  Open Access |  How to cite  | 

Abstract

Background: In cases where return of spontaneous circulation (ROSC) is provided in the Emergency Department (ED) after cardiopulmonary arrest (CA), it is important to investigate the parameters affecting ROSC rates, to determine the factors affecting the survival status and prognosis in the short and medium term, and to determine to what extent these factors affect the prognosis. Materials and methods: This is a cross-sectional study that retrospectively investigates the factors affecting the success of resuscitation over a 5-year period in out-of-hospital cardiac arrest (OHCA) cases. Results: We determined that ROSC was achieved in 26.1% of 1616 adult cardiopulmonary arrest cases, 14.8% survived the first 24 hours, and 3.8% were discharged from the hospital. Conclusion: We determined that ROSC decreased by 21% with a 1-mg increase in the amount of adrenaline used, by 98% with a 1 mmol/L increase in HCO3 (std) value, by 27% with a 1 mmol/L increase in BE (B) value, and by 15% with a 1 mmol/L increase in lactate value. In terms of short-term survival, we found that a 1 mmol/L increase in lactate value reduced the probability of survival by 12%, and a 1 mEq/L increase in K value decreased the probability by 29%. With regard to the probability of survival in the medium term, we determined that the growth in age by 1 year decreased the probability by 4%, and the increase in K value by 1 mEq/L decreased the probability by 35%.

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Original Article

Natesh Prabu Ravisankar, Carol Shayne D'Silva, Manu Manjula Krishnappa Gowda Varma, Thomas Isiah Sudarsan, Sriram Sampath, Tinku Thomas, Bhuvana Krishna

Fogging of Protective Eyewear in Intensive Care Unit and a Comparative Study of Techniques to Reduce It

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:6] [Pages No:32 - 37]

Keywords: Fogging, Fogging impairing vision, Protective eyewear, Soap coating

   DOI: 10.5005/jp-journals-10071-24383  |  Open Access |  How to cite  | 

Abstract

Background: Fogging of protective eyewear (PEW) can hinder routine work in the intensive care unit (ICU). The prevalence of fogging impairing vision (FIV) and the technique that reduces fogging have not been evaluated previously. Methods: After donning personal protective equipment (PPE) with an N95 mask, the healthcare workers (HCWs) sequentially tried plain PEW, soap-coated PEW, PEW worn at a distance over the PPE hood, and the use of tape over a mask. The vision (distant and near) was checked before wearing PEW and with each technique. The prevalence of fogging and FIV, that is, change in vision in either eye was estimated and compared among various techniques. Mixed-effects logistic regression was used to analyze factors affecting fogging and to compare techniques. Room temperature, room humidity, and lens temperature were measured during the study. Results: A total of 125 HCWs participated (151 observations) and the prevalence of FIV was 66.7%. The fogging of PEW, as well as the extent of PEW fogging, was least with soap coating followed by a mask with tape and goggles worn at a distance. The FIV was significantly lesser only with the mask with tape with an odds ratio (OR) [confidence interval CI)] of 0.45 (0.25–0.82). The prevalence of fogging while at work in the COVID ICU was 38%. Conclusion: The prevalence of FIV is 66%. Application of tape over the mask can avoid disturbances in vision best. Soap coating of the PEW and PEW worn at distance from the eyes are potential alternatives.

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Original Article

Kanwalpreet Sodhi, Ruchira Wasudeo Khasne, Gunjan Chanchalani, Ganshyam Jagathkar, Venkat Raman Kola, Mahesh Mishra, Shrikant Sahasrabudhe, Rajesh C Mishra, Amrish Patel, Ankur R Bhavsa, Haider Abbas, Pragyan Kumar Routray, Pramod Sood, Prasad Anant Rajhans, Reshu Gupta, Kapil Dev Soni, Manender Kumar

Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:14] [Pages No:38 - 51]

Keywords: Advanced trauma life support-trained emergency room physician, e-FAST, Trauma, Trauma center, Trauma code, Trauma team

   DOI: 10.5005/jp-journals-10071-24384  |  Open Access |  How to cite  | 

Abstract

Background: Trauma is the leading cause of death in India resulting in a significant public health burden. Indian Society of Critical Care Medicine (ISCCM) has established a trauma network committee to understand current practices and identify the gaps and challenges in trauma management in Indian settings. Material and methods: An online survey-based, cross-sectional, descriptive study was conducted with high-priority research questions based on hospital profile, resource availability, and trauma management protocols. Results: Data from 483 centers were analyzed. A significant difference was observed in infrastructure, resource utilization, and management protocols in different types of hospitals and between small and big size hospitals across different tier cities in India (p < 0.05). The advanced trauma life support (ATLS)-trained emergency room (ER) physician had a significant impact on infrastructure organization and trauma management protocols (p < 0.05). On multivariate analysis, the highest impact of ATLS-trained ER physicians was on the use of extended focused assessment with sonography in trauma (eFAST) (2.909 times), followed by hospital trauma code (2.778 times), dedicated trauma team (1.952 times), and following trauma scores (1.651 times). Conclusion: We found that majority of the centers are well equipped with optimal infrastructure, ATLS-trained physician, and management protocols. Still many aspects of trauma management need to be prioritized. There should be proactive involvement at an organizational level to manage trauma patients with a multidisciplinary approach. This survey gives us a deep insight into the current scenario of trauma care and can guide to strengthen across the country.

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Original Article

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

Association of Mortality with Lymphocyte Subset in Patients with COVID-19-associated Acute Respiratory Failure: A Subgroup Analysis

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:5] [Pages No:52 - 56]

Keywords: Acute respiratory failure, COVID-19 infection, Outcomes, Severe acute respiratory syndrome coronavirus 2, T-lymphocyte subsets

   DOI: 10.5005/jp-journals-10071-24392  |  Open Access |  How to cite  | 

Abstract

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes pneumonia and lymphopenia. We investigated the predictive value of T-lymphocyte subset absolute counts for outcomes following coronavirus disease-2019 (COVID-19)-associated acute respiratory failure (C-ARF). Patients and methods: A retrospective chart review of adult patients with C-ARF was undertaken from 23 March 2020 to 20 November 2021 to obtain relevant data. Patients were divided into two groups based on survival. The T-lymphocyte subsets were determined by flow cytometric analysis. A binomial logistic regression was performed to ascertain factors affecting survival. Cut-off values to differentiate between survivors and non-survivors were identified with the receiver operating characteristic (ROC) analysis. Results: A total of 379 patients were analyzed. Age was negatively correlated with survival. Non-survivors had significantly lower T-lymphocyte subset absolute counts than survivors. Serum ferritin levels were significantly higher in non-survivors. Baseline lymphocyte (%) and a subset were predictive of survival in patients [lymphocyte (%) <5.65%, CD3+ <321 cells/µL, CD4+ <205 cells/µL, CD8+ <103 cells/µL]. Conclusions: Lower T-lymphocyte subsets were associated with higher mortality in patients with C-ARF. Monitoring trends may help in identifying patients at increased risk of poor outcomes.

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Original Article

Shanta Chandrasekaran, VP Chandrasekaran, Dhruva Nandi, Ranganath Sathyanarayan Setty, Obuli Srinivasan, Karuna Nidhi Kaur

Assessment of Awareness Level Regarding Organ Donation among Healthcare Professionals and Students in India

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:7] [Pages No:57 - 63]

Keywords: Awareness, India, Organ donation

   DOI: 10.5005/jp-journals-10071-24387  |  Open Access |  How to cite  | 

Abstract

Introduction: Organ donation can be a life-saving opportunity for patients with severe organ failure. In India, the rate of organ donation of the deceased Indian population is exceptionally low. This necessitates enhancing awareness regarding organ donation among health care professionals and students, which can motivate the general population. Aim: To assess and analyze the awareness level of healthcare professionals and students on organ donation in order to suggest potential strategies regarding improvement of awareness and willingness towards organ donation. Materials and methods: A cross-sectional online and offline survey was conducted at the national level between July 2022 and September 2022. Indian healthcare professionals as well as students of various fraternities were included. The Snowball sampling technique was used for data collection. Statistical analysis was undertaken using the statistical package for the social sciences (SPSS) software, version 25. Results: A total of 1,303 respondents were enrolled in this study. The majority of the participants were students (66.5%) residing in southern India (89.6%) pursuing medical profession (88.9%). The predominant age group was 18–24 years (73.9%). The awareness level regarding organ donation among healthcare professionals and students was 69%. Healthcare professionals and respondents aged 40 years and above had better awareness levels regarding organ donation which was reported as statistically significant (p < 0.001). Conclusion: Healthcare professionals and students awareness about organ donation need to be improved. Strategies including but not limited to prioritizing employment and education to the first relatives of the deceased organ donor should be implemented by the government to legally improve organ donation willingness.

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BRIEF RESEARCH COMMUNICATION

Indu Kapoor, Sneha Pandit, Hemanshu Prabhakar, Charu Mahajan

Comparison between Transcranial Sonography and Computerized Tomography Scans to Assess the Midline Shift in Patients with Traumatic Brain Injury

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:3] [Pages No:64 - 66]

Keywords: Computed tomography, Sonography, Traumatic brain injury

   DOI: 10.5005/jp-journals-10071-24376  |  Open Access |  How to cite  | 

Abstract

Background: Midline shift (MLS) of the brain is an important clinical finding diagnosed on computed tomography (CT) imaging and transcranial sonography (TCS) can help diagnose MLS at the bedside and facilitate interventions to improve outcomes. The study aimed to find an association between TCS- and CT-based assessments of MLS in patients with traumatic brain injury (TBI). Patients and methods: We included all adult patients with moderate-to-severe TBI of either gender, aged between 18 and 65 years, undergoing intracranial surgery under general anesthesia over a period of 3 months. Consciousness was assessed with the help of the Glasgow coma scale (GCS) and Glasgow coma scale-pupillary (GCS-P) score. We calculated MLS using a CT scan and TCS. Bland Altman graph along with Pearson's and Spearman's coefficient tests was used. Results: A total of 17 patients were analyzed in this study. The MLS was 0.52 ± 0.90 cm using TCS and 0.58 ± 0.39 cm using CT scan. The Pearson's correlation coefficient (r2) of the difference between MLS measured by TCS and CT imaging was 0.002 (p < 0.05). Conclusion: Transcranial sonography could detect MLS in patients with TBI, provided a minimum time window is used between MLS measurements by TCS and CT scan.

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Pediatric Critical Care

Swapnil Patel, Hemanshu Prabhakar, Indu Kapoor

Rate of Multidrug-resistance to Antimicrobial Drugs in Patients in Pediatric Neurointensive Care

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:6] [Pages No:67 - 72]

Keywords: Antimicrobial drugs, Multidrug-resistance, Neurointensive care, Pediatric

   DOI: 10.5005/jp-journals-10071-24377  |  Open Access |  How to cite  | 

Abstract

Background: Multidrug-resistant (MDR) organisms in the critical care unit are a worldwide concern. The vulnerability to MDR infection in pediatric patients admitted in neurocritical care are due to altered mental status, immature immune system, higher risk of aspiration, and more frequent use of invasive devices. We aimed to measure the burden of MDR infection in pediatric neurosurgical intensive care unit (NSICU) patients. Methods: All pediatric patients between 1 and 18 years for intracranial and spine surgeries admitted for more than 48 hours in NSICU were enrolled in the study. If patients showed a clinical picture of pneumonia, bloodstream infection (BSI), or urinary tract infection (UTI) after receiving mechanical ventilation or an indwelling device for at least 48 hours, samples of tracheal aspirates, urine, blood, and cerebrospinal fluid (CSF) were sent for microbiological culture. We noted the type of organism, MDR infection rate, and associated risk factors. Pearson Chi-squared test and Fisher's test were used for statistical analysis; p < 0.05 was considered statistically significant. Results: A total of 274 pediatric patients were studied. In 1 year, there was a total of 1,790 patient days. The inclusive MDR infection rate was 17.3/1,000 patient days. Also, Klebsiella pneumoniae (38.7%) was the commonest MDR pathogen. The commonest source of infection was BSI (32.3%). The risk factors associated with MDR infections were the length of stay in NSICU, mechanical ventilation of more than 5 days, emergency surgery, respiratory and cardiac comorbidities, and poor nutrition status (p < 0.05). Conclusion: The MDR infection rate in our study was 17.3/1,000 patient days in pediatric patients. Also, K. pneumoniae was found to be the commonest MDR pathogen. Bloodstream was the commonest source of infection.

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LETTER TO THE EDITOR

Seema Seema, Saurabh Trivedi, Sri Rama Ananta Nagabhushanam Padala, Molli Kiran

A Rare Cause of Gross Hematuria Due to Placing a Patient with Distended Bladder in Prone Position

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:2] [Pages No:73 - 74]

Keywords: Distended bladder, Hematuria, Prone position

   DOI: 10.5005/jp-journals-10071-24378  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Chandana Gajjala, Atul Jindal

COVID-19 and T Cells: Do T Cells Really Matter?

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:1] [Pages No:75 - 75]

Keywords: Coronavirus disease-2019, Lymphopenia, T cells

   DOI: 10.5005/jp-journals-10071-24385  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

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

In Response to Author: COVID-19 and T Cells: Do T Cells Really Matter?

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:1] [Pages No:76 - 76]

Keywords: COVID-19 acute respiratory failure, T-lymphocytes, T-lymphocyte subset

   DOI: 10.5005/jp-journals-10071-24386  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Saranya Chandrasegarane, Rahul Kumar Amte

Medical Emergency Team: A Game Changer in the Wards

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:1] [Pages No:77 - 77]

Keywords: Cardiac arrest, Critically ill adults, Medical emergency team, Modified early warning scores

   DOI: 10.5005/jp-journals-10071-24388  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Anjishnujit Bandyopadhyay, Sunaakshi Puri, Vighnesh Ashok

Fiberoptic Bronchoscope-guided vs Mini-surgical Technique of Percutaneous Dilatational Tracheostomy in Intensive Care Units: A Comment

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:1] [Pages No:78 - 78]

Keywords: Intensive care unit, Mini-surgical tracheostomy, Percutaneous dilatational tracheostomy

   DOI: 10.5005/jp-journals-10071-24389  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Kambagiri Pratyusha, Atul Jindal

Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance: Views

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:1] [Pages No:79 - 79]

Keywords: Diarrhea, Feed intolerance, Gastric residual volume

   DOI: 10.5005/jp-journals-10071-24390  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Vineeta Venkateswaran, Kapil Dev Soni, Anjan Trikha

“There is No Easy Way to Say This…”: Communication Challenges in the COVID-19 Intensive Care Unit

[Year:2023] [Month:January] [Volume:27] [Number:1] [Pages:2] [Pages No:80 - 81]

Keywords: Communication, Coronavirus disease-2019, Intensive care unit, Mental health, Personal protective equipment, Personal protective equipment-related health problems

   DOI: 10.5005/jp-journals-10071-24391  |  Open Access |  How to cite  | 

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