Indian Journal of Critical Care Medicine

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2023 | December | Volume 27 | Issue 12

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Ashit Hegde

Risk of Bleeding in Dengue: Making Predictions is Difficult Especially about the Future

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:865 - 866]

Keywords: Dengue, Dengue and thrombocytopenia, Dengue predictors of bleeding, Platelet transfusion dengue

   DOI: 10.5005/jp-journals-10071-24618  |  Open Access |  How to cite  | 



Shrirang Nagorao Bamne, Kapil Zirpe

Bundle of Neurocare in ICH

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:867 - 868]

Keywords: Coagulopathy, Hematoma, Stroke

   DOI: 10.5005/jp-journals-10071-24610  |  Open Access |  How to cite  | 



Natesh Prabu Ravisankar, Ritu Singh, Mohan Gurjar

Collaborative Research in Critical Care Medicine: A Way Forward to High-impact Publications from India

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:869 - 870]

Keywords: Critical care, Publications, Quality, Randomized controlled trial, Research

   DOI: 10.5005/jp-journals-10071-24614  |  Open Access |  How to cite  | 



Anuj M Clerk

Are “High-alert Medication” Used Safely in Intensive Care Units?

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:871 - 872]

Keywords: Critically ill patients, High alert medications, Medication errors, Patient safety

   DOI: 10.5005/jp-journals-10071-24603  |  Open Access |  How to cite  | 



Mullai Baalaaji AR

Pediatric Burns—Time to Collaborate Together

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:3] [Pages No:873 - 875]

Keywords: Burns, Pediatric trauma, Pediatric intensive care

   DOI: 10.5005/jp-journals-10071-24604  |  Open Access |  How to cite  | 



Binila Chacko, Nagarajan Ramakrishnan, John Victor Peter

Approach to Intensive Care Costing and Provision of Cost-effective Care

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:12] [Pages No:876 - 887]

Keywords: Cost analysis, Cost-effectiveness, Cost utility

   DOI: 10.5005/jp-journals-10071-24576  |  Open Access |  How to cite  | 


Intensive care unit (ICU) service is resource-intense, finite, and valuable. The outcome of critically ill patients has improved because of a better understanding of disease pathology, technological developments, and newer treatment modalities. These improvements have however come at a price, with ICUs contributing significantly to health budgets. Several costing tools are used to assess cost. Accurate assessment has been hampered by the lack of standardized methodology and the heterogeneity of ICUs. In a costing exercise, the level of disaggregation (micro-costing vs gross-costing) and the method of costing (top-down vs bottom-up) need to be considered. Intensive care unit costing also needs to be viewed from the perspective of stakeholders. While all stakeholders aim to provide quality health care, objectives may vary. For the public health care provider, the focus is on optimizing expenditure; for the private health care provider it is bottomline; for a patient, it is affordability; for an insurance service provider, it is minimizing payout; and for the regulator, it is ensuring quality standards and fair pricing. The field of health economics deals with the application of the principles of cost-minimization, cost-effectiveness, cost-utility, and cost-benefit to identify treatments that result in the best outcome at the lowest cost, without limiting resources to other competing interests. In the ICU setting, studies on the efficient use of available resources, and interventions that reduce cost and minimize avoidable cost, would not only translate to cost savings, lives saved, and quality-adjusted life years gained but also enable policymakers to better allocate health care resources.


Original Article

Priya Logia, Velmurugan Selvam, Vetriselvan Parasuraman, MK Renuka, Ram Eachambadi Rajagopalan

Predictors of Clinically Significant Bleeding in Thrombocytopenic Dengue Patients Admitted to Intensive Care Unit: A Retrospective Study

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:7] [Pages No:888 - 894]

Keywords: Clinically significant bleeding, Dengue, India, Intensive care unit, Predictors

   DOI: 10.5005/jp-journals-10071-24574  |  Open Access |  How to cite  | 


Background: Recognition of clinically significant bleeding (CSB) is vital for effective management of dengue patients. The primary objective was to identify the predictors of CSB among dengue patients and to formulate a simple scoring system. The secondary objective was to compare the grades of bleeding and severity of thrombocytopenia. Materials and methods: We conducted a retrospective study of adults aged above 18 years with dengue, admitted to the intensive care unit (ICU) of a tertiary care hospital in South India from 2015 to 2021. Demographic, clinical, and laboratory variables on admission were collected. The association of clinically significant bleeding with the above parameters was assessed by univariate and multivariate analysis. Results: A total of 9,817 dengue cases were hospitalized during the study period. A total of 120 patients with thrombocytopenia (<100000 cells/mm3) were admitted to the ICU and of them 38 (31.6%) had CSB. On univariate analysis fever, sequential organ function assessment (SOFA) score, elevated activated partial thromboplastin time (aPTT), and altered sensorium were significantly associated with CSB. The multivariate model identified SOFA score [adjusted odds ratio (aOR): 1.52; 95% confidence interval (CI): 1.11–2.08], temperature >38.3°C (aOR: 2.71; 95% CI: 1.1–6.47) and elevated aPTT > 40 seconds (aOR: 4.66; 95% CI: 1.42–15.3) as independent risk factors. A clinical predictive score was developed incorporating these three parameters. The performance of the score identified by the receiver operating characteristic (ROC) curve [area under the curve (AUC): 0.81; 95% CI: 0.73–0.91] demonstrated a sensitivity of 81% and specificity of 77%. Conclusion: This study revealed that temperature above 38.3°C, elevated aPTT, and an increase in SOFA score were identified as independent risk factors for CSB. A clinical predictive score derived from these variables can identify patients likely to develop CSB.


Original Article

Awatif K Alsarrai Al-Alawi, Darpanarayan Hazra, Mohammed Jumaiel Khalfan Al-Hassani, Amjad Said Abdullah Al-Jamoudi

Unveiling the Crystal Ball: Predictors of Adverse Outcomes in Intracerebral Hemorrhage Patients

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:7] [Pages No:895 - 901]

Keywords: Cerebrovascular accident, Emergency room, Intracerebral hemorrhage, Poor outcome, Stroke

   DOI: 10.5005/jp-journals-10071-24578  |  Open Access |  How to cite  | 


Introduction: Intracerebral hemorrhage (ICH) is a severe form of stroke with substantial morbidity and mortality worldwide. Despite its impact, research has often focused on ischemic strokes, making ICH an essential area to explore. Methods: A retrospective cohort study spanning 5 years was conducted in an Oman-based tertiary care teaching hospital's emergency room. Data from patients diagnosed with spontaneous ICH, confirmed by cranial CT scans, were analyzed. Ethical approval was obtained. Results: Among 163 emergency room (ER)-presented patients with ICH, 89 met the inclusion criteria. Most were male (69.66%), with hypertension (69/89) and diabetes mellitus (43/89) being common comorbidities. Hematoma size was a crucial predictor of poor outcomes, especially for larger hematomas (>60 cm3). Midline shift, intraventricular hemorrhages, elevated systolic and diastolic blood pressure, and low Glasgow Coma Scale (GCS) scores were significantly associated with unfavorable outcomes. However, variables such as age, gender, history of heart disease, hypertension, diabetes, and anticoagulant use did not show significant associations with disability outcomes. Favorable outcomes (mRS <3) were observed in 47.2% of patients, while 30.3% had a major disability (mRS 3–5), and 22.5% succumbed to their illness (mRS 6). Conclusion: This study enhances our understanding of ICH outcomes, highlighting the importance of hematoma size, midline shift, intraventricular hemorrhage, blood pressure control, and GCS scores in predicting disability. Future research could explore additional prognostic factors and interventions for ICH patients.


Original Article

Sameer Jog, Vikram L Narasimhan, Prasad Anant Rajhans, Prasad Vasant Akole, Balasaheb Pawar, Bhagyashri Bhurke, Nilesh Mahale, Shailaja Chavan, Pradip Dalvi, Prasanna Marudwar, Dnyaneshwar Diwane, Manasi Sanjay Shahane, Shradha Gugale, Harshwardhan Singh Pawar

Mottling in Septic Shock: Ethnicity and Skin Color Matter

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:8] [Pages No:902 - 909]

Keywords: Capillary refill time, Non-white skin colored patient population, Outcome, Septic shock, Skin mottling

   DOI: 10.5005/jp-journals-10071-24586  |  Open Access |  How to cite  | 


Background: Skin mottling as a clinical perfusion marker in septic shock is significantly associated with severity and outcome in white-skinned population and its validity as a clinical sign in dark-skinned population is not known. The objectives of this study were to evaluate mottling in septic shock in the Indian ethnic population who has different skin color as compared to the white-skinned population and to assess mottling as an outcome predictor with capillary refill time (CRT) and other biochemical parameters which are the established clinical markers of perfusion in septic shock. Materials and methods: We conducted a prospective observational study of patients with skin color categories 21–34 on the von Luschan scale or Fitzprick type IV–VI who had septic shock needing a high dose of norepinephrine ≥0.2 μg/kg/min after fluid optimization. The study was conducted in a mixed medical-surgical ICU over 12 months. Two blinded experts (a Dermatologist and a plastic surgeon) independently classified the skin type, validated the occurrence of mottling, and scored mottling in our patients. We recorded the demographics, hemodynamic variables, and mottling score and observed the incidence of mottling and its correlation with predictors of the severity of septic shock. We also compared CRT, arterial lactate, central venous oxygen saturation, and venoarterial PCO2 gap with occurrence of mottling in septic shock patients. Results: We included 108 patients with age 61 ± 16 years. Mean Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores at enrolment were 10.3–21.9, respectively. Incidence of mottling was 20.3% (22/108). CRT >3 seconds was observed in 50.9% (55/108). Development of mottling was significantly associated with 90-day mortality; 20/22 (90.9%) patients died in the mottling group versus 58/86 (65.1%) in the non-mottling group (p = 0.028). Capillary refill time >3 seconds did not corelate with mortality; 40/55 (72.7%) Patients with CRT >3 seconds died versus 32/53 (60.4%) patients died in CRT ≤3 seconds group. Occurrence of mottling could predict mortality; positive predictive value of 90.9% which was comparable to positive predictive value of lactate levels >4 mmol/L, i.e., 94.1%. Conclusion: The incidence of mottling in septic shock is much less in patients of Indian ethnicity with brown skin color than in white-skinned population. Occurrence of mottling and not delayed CRT, is a better predictor of outcome in this setting.


Original Article

Bharath Kumar Tirupakuzhi Vijayaraghavan, Ramesh Venkataraman, Yamunadevi Ramanathan, Saravanan Margabandhu, Devachandran Jayakumar, Pratheema Ramachandran, Neill KJ Adhikari, Francois Lamontagne, Ruxandra Pinto, Marie-Hélène Masse, Julie Ménard, Sheila Sprague, Nagarajan Ramakrishnan

A Pilot Feasibility Randomized Controlled Trial of Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit: The Lessening Organ Dysfunction with Vitamin C-India (LOVIT-India) Trial

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:7] [Pages No:910 - 916]

Keywords: Ascorbic acid, Developing countries, Randomized controlled trial, Sepsis

   DOI: 10.5005/jp-journals-10071-24587  |  Open Access |  How to cite  | 


Background: The burden of sepsis is high in India and is associated with substantial morbidity and mortality. Vitamin C, an endogenous antioxidant, may improve patient outcomes. Methods: This was a parallel-group pilot feasibility randomized controlled trial conducted at 2 intensive care units in India. Adult patients (≥18 years) with proven or suspected infection as the main diagnosis and needing a continuous intravenous vasopressor infusion were randomized to intravenous vitamin C (50 mg/kg every 6 hours for a maximum of 16 doses) or matching placebo. Primary outcomes were related to protocol adherence and feasibility (enrollment per month). The key secondary outcome was the composite of mortality or persistent organ dysfunction (POD) at day 28 after randomization. Results: 60 patients were screened, 51 were eligible, 32 were randomized, and 30 were included in the analysis (randomized/eligible ratio: 0.63). The overall rate of enrollment was 1.5 patients per month. The median (IQR) age was 63.5 (51.0, 70.0) and 70.0% of the patients were male. In both arms, all patients received ≥90% of scheduled doses of the study drug. No patient received open-label vitamin C and there were no deviations from the glucose monitoring protocol. The composite outcome of mortality or POD at day 28 occurred in 56.3% (9/16) in the vitamin C arm as compared to 42.9% (6/14) in the placebo arm [RR: 1.31 (95% CI: 0.62, 2.76), p = 0.47]. Conclusion: In this pilot feasibility randomized controlled trial of vitamin C for adult patients with sepsis, protocol adherence was excellent and feasibility endpoints were met. Trial registration: CTRI/2020/03/024371.


Original Article

Priya J Aradhya, Ravina Ravi, Ballaekere Jayaram Subhash Chandra, Madhan Ramesh, Sri Harsha Chalasani

Assessment of Medication Safety Incidents Associated with High-alert Medication Use in Intensive Care Setting: A Clinical Pharmacist Approach

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:6] [Pages No:917 - 922]

Keywords: Contributing factors, High-alert medications, Medication error, Patient safety

   DOI: 10.5005/jp-journals-10071-24588  |  Open Access |  How to cite  | 


Background: High-alert medications (HAMs) potentiate heightened risk of causing patient harm ranging from 0.24 to 89.6 errors per 100 prescriptions. High-alert medications are crucially utilized in the intensive care settings (ICUs) due to their excellent potential in delivering therapeutic efficacy, yet these medications could cause severe harm if used inappropriately. Despite the cautious use of these medications, medication safety issues persist, which compromises patient safety. Methods: A prospective interventional study was conducted in ICUs for a period of 6 months. The HAMs were adopted from the Institute for Safe Medication Practices (ISMP) list of HAMs that were used. A suitably designed medication error assessment form was used to capture the necessary data, including demographics, medications, medication error, and the contributing factors. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) index was used to categorize the medication errors (MEs). The error rate was calculated using error rate formula. Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were presented in frequencies and percentages. Results: A total of 165 patients were enrolled during the study period, with 98 (59.4%) being male and 67 (40.6%) female. The majority [54 (32.73%)] of the study participants belonged to the 61–70 age range. A total of 204 MEs were reported, of which [92 (41.5%)] errors were prescribing errors, followed by documentation errors [69 (33.82%)] and administration errors [43 (21.08%)]. The baseline medication error rate was noted to be 160.12/1,000 patient days. Potassium chloride, tramadol, propranolol, aspirin, insulin, and metoprolol were identified as the most common HAMs to cause errors. According to NCC MERP classification, 41.18% were categorized as category B, followed by category C (35.78%). An overall of 666 contributing factors (CFs) were identified for 204 errors. Stress (24.32%) was the most common factor that contributed to the MEs, followed by workload (21.47%). Conclusion: While great strides have been adopted in error prevention, yet the goal of making HAM errors “never” event has not been achieved. Thus, an active surveillance by a clinical pharmacist could support the healthcare team in promoting patient care.


Original Article

M Vijayakumar, Velmurugan Selvam, MK Renuka, Ram Eachambadi Rajagopalan

The Comparative Efficacy of Ceftazidime–Avibactam with or without Aztreonam vs Polymyxins for Carbapenem-resistant Enterobacteriaceae Infections: A Prospective Observational Cohort Study

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:7] [Pages No:923 - 929]

Keywords: Aztreonam, Carbapenem-resistant enterobacterales, Carbapenem-resistant enterobacteriaceae, Cohort study, Ceftazidime–avibactam, Colistin, Intensive care unit, Observational study, Polymyxin B, Prospective

   DOI: 10.5005/jp-journals-10071-24577  |  Open Access |  How to cite  | 


Background: Carbapenem-resistant enterobacteriaceae (CRE) is associated with high mortality in critically ill patients, with limited treatment options. This study aims to compare clinical response, microbiological response, and mortality in patients treated with ceftazidime–avibactam with or without aztreonam (CAZ–AVI + AZT) and colistin or polymyxin B (polymyxins) in CRE infections. Materials and methods: This single-center prospective observational study included adult patients with CRE infections treated with CAZ–AVI+AZT or polymyxins between January 2022 and December 2022 at a Tertiary Care Medical Center in India. The clinical response, microbiological response, and mortality were compared between the two groups using a Cox multivariate regression model adjusted for the baseline SOFA score and comorbidities. Results: A total of 89 patients were enrolled, with 59 (66%) patients receiving CAZ–AVI + AZT and 30 receiving polymyxins. Baseline demographics and clinical characteristics were similar between the two groups. The Cox multivariate regression analysis showed a statistically significant difference in clinical failure on day 14 with the CAZ–AVI + AZT group vs polymyxins (HR = 0.78, 95% CI 0.63–0.95, p = 0.018). There was no difference in microbiological failure (HR = 1.08, 95% CI 0.66–1.77, p = 0.76), microbiological relapse (HR = 0.75, 95% CI 0.36–3.02, p = 0.62), and hospital mortality (HR = 1.04, 95% CI 0.75–1.43, p = 0.796) between the two groups. Conclusion: Treatment with ceftazidime–avibactam with or without aztreonam for CRE infections associated with a better clinical response compared with polymyxins monotherapy but without any difference in microbiological response or mortality.


Original Article

André Luiz Cordeiro, Adriele Souza, Carolina Ribeiro de Brito Lima, Jaclene Araújo, Hayssa Mascarenhas, André Guimarães

Analysis of Different Tidal Volumes on Ventilatory Mechanics and Arterial Blood Gas Variables in Patients Undergoing Cardiac Surgery

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:4] [Pages No:930 - 933]

Keywords: Arterial blood gas analysis, Cardiac surgery, Mechanical ventilation

   DOI: 10.5005/jp-journals-10071-24582  |  Open Access |  How to cite  | 


Introduction: Cardiovascular diseases have been increasing gradually each year, and their incidence has reached 80%. Mechanical ventilation (MV) is essential in the postoperative period of cardiac surgery (CS) due to anesthetic induction. The tidal volume (TV) is a parameter that depends on the conditions of the respiratory system mechanics, aiming at the reduction of dynamic hyperinflation. Objective: Analyze the effect of different TVs on blood gas analysis variables and respiratory mechanics in patients submitted to CS. Materials and methods: This was an uncontrolled randomized clinical trial. Patients were randomized by lottery into the following two groups: One group was ventilated with a TV of 6 mL/kg; while the other received a TV of 8 mL/kg. After 30 minutes of admission with the VT, blood gas analysis data were evaluated, such as pH, oxygen arterial pressure (PaO2), arterial pressure of carbon dioxide (PaCO2), and peripheral oxygen saturation (SpO2). The evaluation of respiratory mechanics was composed of static and dynamic compliance, airway resistance, and driving pressure. Results: A total of 78 patients were included, 58% of whom were males with a mean age of 55 ± 13 years. It was observed that there were no significant differences regarding respiratory mechanics, only the driving pressure presented statistical significance, the group 6 mL/kg was 8.3 ± 2.5 in the group 8 mL/kg 10.4 ± 2.1 presenting a value of (p < 0.001). Conclusion: Based on the findings of the present study, we conclude that different TVs do not significantly alter the blood gas variables and do not influence the respiratory mechanics of patients undergoing CS.



K Yashaswini, AV Lalitha, GS Naresh Kanna, Abha Rani Kujur, John A Michael Raj

Clinical Profile of Children with Burns in a Tertiary Care Hospital

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:5] [Pages No:934 - 938]

Keywords: Fluids, Mortality, Total burns surface area

   DOI: 10.5005/jp-journals-10071-24592  |  Open Access |  How to cite  | 


Background: Optimal resuscitation measures and outcome predictors in cases of burns are not studied in pediatric population, though it accounts for one of the leading causes of non-fatal injuries in the pediatric age group. Objective: We describe the clinical profile and outcome predictors in children admitted with burns. Materials and methods: This retrospective cohort study included all children between 1 month and 18 years admitted to pediatric intensive care unit (PICU) with burns from January 2015 to December 2020. The total burns surface area (TBSA) was assessed and treated as per unit protocol. Illness severity score (PRISM III) and pediatric logistic organ dysfunction (PELOD-II) on day 1 and subsequently was noted. Resuscitation requirements including inotropes and colloids were evaluated. Outcome parameters like need for mechanical ventilation, renal replacement therapy, duration of hospital stay, PICU stay, and mortality were assessed. Results: Of 286 children admitted with burns, 99 had PICU admissions, and of these 59% were males with median (IQR) age 36 (13,72) months. Multivariate logistic regression analysis showed TBSA >40% [adjusted odds ratio (AOR) 4.62 [1.11–19.32] p-value < 0.036]. Cox regression for 28 day mortality was significant only for PELOD day 1 (heart rate (HR) 1.22 [1.05–1.41]). Conclusion: Higher resuscitation requirements with higher organ dysfunction scores may predict mortality in pediatric burns warranting further study for standardization of care.



Status Epilepticus is Not Uncommon as the First Presentation of PRES the Diagnosis of Which Requires the Exclusion of All Differential Diagnoses

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:939 - 940]

Keywords: Acute, disseminated encephalomyelitis, Epilepsy, Posterior reversible encephalopathy syndrome, Status epilepticus

   DOI: 10.5005/jp-journals-10071-24542  |  Open Access |  How to cite  | 



Pratibha Prasad

Author Reply: Letter about Status Epilepticus as a Presenting Feature

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:941 - 942]

Keywords: Posterior reversible encephalopathy syndrome, Seizures, Status epilepticus

   DOI: 10.5005/jp-journals-10071-24570  |  Open Access |  How to cite  | 



Sounira Mehri

Before VAN can be Recommended as a Means of Assessing ELVO, Its Reliability must be Proven by Appropriate Studies

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:943 - 944]

Keywords: Acute ischemic stroke, Ischemic stroke, Large vessel occlusion, Outcome, Stroke thrombolysis, Vision aphasia neglect score

   DOI: 10.5005/jp-journals-10071-24528  |  Open Access |  How to cite  | 



Aishwarya Krishnan

Author Response

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:945 - 946]

Keywords: Aphasia, Cerebrovascular accident, Emergent large-vessel occlusion stroke, Neglect, Vision aphasia neglect

   DOI: 10.5005/jp-journals-10071-24573  |  Open Access |  How to cite  | 



Factors Requiring Improvement for Timely and Effective Treatment of Acute Stroke

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:947 - 948]

Keywords: Acute stroke, Multimodal MRI, Stroke management, Thrombectomy, Thrombolysis

   DOI: 10.5005/jp-journals-10071-24580  |  Open Access |  How to cite  | 



Aviral Shah, Arundhati Diwan

Author Response: Factors Requiring Improvement for Timely and Effective Treatment of Acute Stroke

[Year:2023] [Month:December] [Volume:27] [Number:12] [Pages:2] [Pages No:949 - 950]

Keywords: Ischemic stroke, Stroke management, Thrombolysis

   DOI: 10.5005/jp-journals-10071-24591  |  Open Access |  How to cite  | 


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