Indian Journal of Critical Care Medicine

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2023 | March | Volume 27 | Issue 3

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Ganshyam Jagathkar

Elderly in the ICU

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:2] [Pages No:157 - 158]

Keywords: Acute physiology and chronic health evaluation II, Chronic obstructive pulmonary disease, Elderly, ICE-CUB, Intensive care unit, Renal replacement therapy, Simplified acute physiology score, Very old intensive care patients 2 study outcomes

   DOI: 10.5005/jp-journals-10071-24422  |  Open Access |  How to cite  | 



Whetting the Rapid Diagnostic Tools for Sepsis

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:2] [Pages No:159 - 160]

Keywords: Biomarkers, Early sepsis, Neutrophil gelatinase-associated lipocalin

   DOI: 10.5005/jp-journals-10071-24429  |  Open Access |  How to cite  | 



Mullai Baalaaji AR

Postoperative Care of Pediatric Brain Tumors: Let's Work Together

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:2] [Pages No:161 - 162]

Keywords: Brain tumor, Critical care oncology, Neurocritical care, Pediatric intensive care unit, Postoperative complications

   DOI: 10.5005/jp-journals-10071-24421  |  Open Access |  How to cite  | 


View Point

Sanika Jayant Patil, Reshma Ambulkar, Atul Prabhakar Kulkarni

Patient Safety in Intensive Care Unit: What can We Do Better?

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:3] [Pages No:163 - 165]

Keywords: Communication skills, Complication, Intensive care unit, Patient safety

   DOI: 10.5005/jp-journals-10071-24415  |  Open Access |  How to cite  | 


Patient safety is an important step in providing high-quality health care. Every intensive care unit (ICU) is unique and its needs would be different; it is thus necessary to build a safety culture based on local and cultural characteristics. Various measures such as regular training, the use of bundles of care, and a blame-free environment can promote patient safety in ICUs. These measures are simple to implement even in resource-limiting settings and can go a long way in improving patient outcomes in our country.


Original Article

Pruthvi Prabhudev, Kusugodlu Ramamoorthi, Raviraja V Acharya

A Clinical and Demographic Profile of Elderly (>65 Years) in the Medical Intensive Care Units of a Tertiary Care Center

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:10] [Pages No:166 - 175]

Keywords: Acute kidney injury, APACHE II, Blood culture, Elderly, Gram-negative infection, Hemodialysis, Intensive care units, Pneumonia, Procalcitonin, Sepsis

   DOI: 10.5005/jp-journals-10071-24416  |  Open Access |  How to cite  | 


Background: The elderly population in India is expected to increase to 319 million by 2050. Managing critically ill elderly patients in intensive care units (ICUs) is a difficult task. Proper planning and development of healthcare infrastructure are of prime importance to face this challenge. Objectives: To study the clinical profile and outcomes of elderly patients admitted to the medical ICUs. Materials and methods: A time-bound, prospective observational study on elderly patients admitted to medical ICUs for more than 48 hours was conducted from March 2019 to September 2020. The demographic, biochemical, hematologic, and microbiological data on antibiotic susceptibility patterns on various organisms and procalcitonin (PCT) reports were collected. Acute Physiology and Chronic Health Evaluation II (APACHE II) score was calculated. Various treatment modalities, such as mechanical ventilation, inotropes, hemodialysis, antibiotics, culture report in sepsis patients, and length of ICU stay were collected. Results: The age of the patients and the length of their ICU stay were not significantly associated with outcomes. Sepsis and APACHE II scores are significantly associated with outcomes. Receipt of mechanical ventilation, vasopressor support, and hemodialysis are significantly associated with mortality (p < 0.001). Conclusion: The patients’ ages were not significantly associated with outcomes. The most common cause of death among elderly patients was found to be sepsis, followed by pneumonia. In elderly ICU patients, gram-negative organisms are the most common causative agents in bloodstream infections. The APACHE II score, sepsis, receipt of mechanical ventilation, vasopressor support, and hemodialysis are significantly associated with mortality.


Original Article

Anna Paul, Nalini Sarah Newbigging, Mahasampath Gowri, Jithin Sam Varghese, Arun Jose Nell, Aditya John Binu, George M Varghese

Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:7] [Pages No:176 - 182]

Keywords: Bacteremia, Biomarker, Emergency department, Neutrophil gelatinase-associated lipocalin, Sepsis, Systemic inflammatory Response Syndrome, quick sequential organ failure assessment

   DOI: 10.5005/jp-journals-10071-24419  |  Open Access |  How to cite  | 


Background: Bacterial sepsis is associated with significant morbidity and mortality. However, to date, there is no single test that predicts sepsis with reproducible results. We proposed that using a combination of clinical and laboratory parameters and a novel biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL) may aid in early diagnosis. Method: A prospective cohort study was conducted at a tertiary care center in South India (June 2017 to April 2018) on patients with acute febrile episodes fulfilling the Systemic Inflammatory Response Syndrome (SIRS) criteria. Plasma NGAL and standard clinical and laboratory parameters were collected at the admission. Bacterial sepsis was diagnosed based on blood culture positivity or clinical diagnosis. Clinically relevant plasma NGAL cut-off values were identified using the receive operating characteristic (ROC) curve. Clinically relevant clinical parameters along with plasma NGAL's risk ratios estimated from the multivariable Poisson regression model were rounded and used as weights to create a new scoring tool. Results: Of 100 patients enrolled, 37 had bacterial sepsis. The optimal plasma NGAL cut-off value to predict sepsis was 570 ng/mL [area under the curve (AUC): 0.69]. The NGAL sepsis screening tool consists of the following clinical parameter: diabetes mellitus, the presence of rigors, quick sequential organ failure assessment (qSOFA) >2, a clear focus of infection, and the plasma NGAL >570 ng/mL. A score of <3 ruled out bacterial sepsis and a score >7 were highly suggestive of bacterial sepsis with an interval likelihood ratio (LR) of 7.77. Conclusion: The NGAL sepsis screening tool with a score >7 can be used in the emergency department (ED) to identify bacterial sepsis.


Original Article

Kiran Kumar Gudivada, Sriram Sampath

Cefoperazone-induced Coagulopathy in Critically Ill Patients Admitted to Intensive Care Unit

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:7] [Pages No:183 - 189]

Keywords: Cefoperazone, Coagulopathy, Critically ill adults, International normalized ratio elevation, Vitamin

   DOI: 10.5005/jp-journals-10071-24417  |  Open Access |  How to cite  | 


Background: N-methylthiotetrazole side chain (NMTT) of cefoperazone was attributed to inhibit the vitamin K epoxide enzyme. This mechanism is similar to warfarin; thus, vitamin K was suggested to antagonize the hematological effects of cefoperazone. The literature on critically ill patients receiving cefoperazone and its clinical significance on bleeding diathesis is sparse. Objectives: To assess the incidence of cefoperazone-induced coagulopathy (CIC), its clinical impact on bleeding episodes, and transfusion requirements. Predisposing factors and the role of prophylactic and therapeutic vitamin K were evaluated. Materials and methods: Prospective observational study of adult intensive care unit (ICU) patients (>18 years) receiving cefoperazone between December 2017 and December 2018. We excluded those on warfarin, those with preexisting elevated prothrombin time/international normalized ratio (PT/INR), and with bleeding manifestations. Relevant laboratory investigations and specific outcomes were noted for 6 days following therapy. Panel data regression was used to determine predictors of coagulopathy. Results: Among 65 patients, 17 (26%) had probable CIC. Hypoalbuminemia and vancomycin co-administration were risk factors for CIC. Hemoglobin drops and blood transfusions were not different between INR non-elevated and elevated groups (11 vs 8 gm/dL; p = 0.06 and 11 vs 8 units; p = 0.23, respectively). Prophylactic vitamin K did not offer any benefit toward preventing INR elevation. Therapeutic vitamin K significantly reduced INR when elevated [absolute risk reduction (ARR):57.5% and number needed to treat (NNT):1.7]. Conclusion: Results of this study revealed that CIC is not uncommon in ICUs. Based on the findings of the study, we suggest INR monitoring in patients receiving nephrotoxic agents and patients with hypoalbuminemia. We also recommend vitamin K administration in patients with elevated INR.


Original Article

Navaneeth Pattereth, Shafneed Chaliyadan, Roshan Mathew, Chandan J Das, Nayer Jamshed

The Role of Triple Rule-out CT in an Indian Emergency Setting

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:5] [Pages No:190 - 194]

Keywords: Coronary artery disease, Computerized tomography angiography, Emergency medicine

   DOI: 10.5005/jp-journals-10071-24423  |  Open Access |  How to cite  | 


Background: Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way. Materials and methods: Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings. Results: Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89–25.95 mSv). Conclusion: Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases.


Original Article

Heydar Ghayem, Mohammad Reza Heidari, Bahman Aghaei, Reza Norouzadeh

The Effect of Training the Nonverbal Pain Scale (NVPS) on the Ability of Nurses to Monitor the Pain of Patients in the Intensive Care Unit

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:6] [Pages No:195 - 200]

Keywords: Intensive care unit, Nonverbal pain scale, Nursing, Pain monitoring

   DOI: 10.5005/jp-journals-10071-24425  |  Open Access |  How to cite  | 


Introduction: Pain in the intensive care unit is a silent fact. Considering the positive features of the nonverbal pain scale (NVPS) in assessing the pain of non-verbal patients, this study investigates the effect of training the NVPS on the ability of nurses to monitor the pain of patients in the intensive care unit. Materials and methods: In this semi-experimental study, the effect of the NVPS training on the ability of 50 intensive care unit (ICU) nurses of Imam Khomeini Hospital affiliated to Ahvaz University of Medical Sciences was investigated. At first, the ability to diagnose the presence and intensity of pain was checked by a checklist. Then the nurses were taught how to use the scale correctly. After 2 weeks of training completion, the ability to correctly use the scale was measured again. Data analysis was performed using descriptive statistics (mean and standard deviation) and inferential statistics (McNemar, Chi-squared, paired t-test, and Fisher's exact test) in SPSS software version 16. Results: After the training on the non-verbal pain scale, there was a significant difference between the intervention and control groups in diagnosing the presence of pain related to changing the patient's position (p = 0.023). Also, nurses ability to diagnose pain intensity during airway suction increased fourfold and for physiotherapy procedures twice as much as before training. Conclusion: Nonverbal pain scale training improves ICU nurses ability in diagnosing the presence and severity of pain in nonverbal patients.


Original Article

Mehran Bahramian, Parmida Shahbazi, Nima Hemmati, Parisa Mohebzadeh, Arvin Najafi

Extremity Fractures as the Most Common Missed Injuries: A Prospective Cohort in Intensive Care Unit Admitted Multiple Trauma Patients

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:4] [Pages No:201 - 204]

Keywords: Abbreviated injury scale, Care unit, Extremity, Intensive, Missed injury, Trauma

   DOI: 10.5005/jp-journals-10071-24426  |  Open Access |  How to cite  | 


Background: Although an intensive care unit (ICU) admission is a risk factor for missed injury, there has been some disagreement on whether missed injuries in trauma ICU patients have a longer length of stay (LOS). With this in mind, these patients’ frequency of missed injuries and related factors were investigated. Materials and methods: This was a prospective cohort study on multiple trauma injury patients in a tertiary referral trauma center's trauma intensive care unit (TICU) from March 2020 to March 2021. A tertiary survey was conducted in the TICU by attending physicians to find the types I and II missed injuries (any injury discovered after primary and secondary surveys during the hospital stay). A logistic regression model was designed for predictors of missed injuries in ICU-admitted multiple trauma patients. Results: Out of 290 study participants, 1,430 injuries were found, and of those injuries, 74 cases (25.5%) had missed injuries. In other words, there were 103 missed injuries, resulting in a missed injury detection rate of 7.2%. The most frequently missed injuries (43.4%) were concluded as extremities fractures. The regression model showed that the patients with missed injuries are prone to longer TICU LOS [odds ratio (OR) = 1.15; p = 0.033], and cases who underwent a computed tomography (CT) scan are less likely to have missed injuries (OR = 0.04; p < 0.001). The abbreviated injury scale (AIS) range was 1–3 in missed injuries. Conclusion: Our research underlines the importance of finding missed injuries and the necessity of CT scan to decrease them. In teaching centers, life-threatening injuries decrease with increasing visits and examination times. Although these missed injuries do not increase mortality, they cause longer TICU LOS and costs.


Pediatric Critical Care

Surunchana Lerdsirisopon, Sukanya Kanta, Lalida Kongkiattikul

Factors Influencing Prolonged Intensive Care Unit Length of Stay after Craniotomy for Intracranial Tumor in Children: A 10-year Analysis from a University Hospital

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:7] [Pages No:205 - 211]

Keywords: Brain tumor, Craniotomy, Length of stay, Pediatric intensive care unit, Postoperative complications

   DOI: 10.5005/jp-journals-10071-24418  |  Open Access |  How to cite  | 


Background: Postoperative intensive care unit (ICU) admission is routinely practiced in pediatric and adult craniotomy. This study aims to identify the factors associated with an ICU stay of more than one day (prolonged ICU stay, PIS) after pediatric brain tumor surgery. Methods: Medical records of children who underwent craniotomy for brain tumor during a 10-year period were reviewed and analyzed. Perioperative variables were examined and compared between the one-day ICU stay (ODIS) and PIS groups. Results: A total of 314 craniotomies performed on 302 patients was included. Patients requiring postoperative ICU care for more than a day represented 37.9% of the sample. Significant factors found in the multivariate analysis affecting prolonged ICU length of stay included operative time ≥360 minutes (adjusted odds ratio [AOR], 2.438; 95% confidence interval [CI]: 1.223–4.861; p = 0.011), presence of an endotracheal (ET) tube (AOR, 7.469; 95% CI: 3.779–14.762; p < 0.001), and external ventricular drain (EVD) at ICU admission (AOR, 2.512; 95% CI: 1.458–4.330; p = 0.001). Conclusion: While most children undergoing a craniotomy for brain tumor need a postoperative ICU care of ≤1 day, slightly more than a one-third in our study stayed longer. The prediction of a PIS can be beneficial for optimal resource utilization, increasing ICU bed turnover rate, reduction of operation cancellation, and improved preparation for parent expectations.


Pediatric Critical Care

Adil Ahmed Khan, Pramod Kumar Gupta, Arun Kumar Baranwal, Tanushree Sahoo

Comparison of Blood Pressure Measurements by Currently Available Multiparameter Monitors and Mercury Column Sphygmomanometer in Patients Admitted in Pediatric Intensive Care Unit

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:10] [Pages No:212 - 221]

Keywords: Auscultatory method, Automated oscillometric device, Hypotension, Mercury column sphygmomanometer, Multiparameter monitors, Non-invasive blood pressure, Pediatric emergency room, Pediatric intensive care unit, Shock

   DOI: 10.5005/jp-journals-10071-24424  |  Open Access |  How to cite  | 


Background: The multiparameter monitor (MPM) is replacing mercury column sphygmomanometers (MCS) in acute care settings. However, data on the former's accuracy in critically ill children are scarce and mostly extrapolated from adults. We compared non-invasive blood pressure (NIBP) measurements by MPMs with MCS in pediatric intensive care unit (PICU). Patients: Adequately sedated and hemodynamically stabilized children (age, 1–144 months) were prospectively enrolled. Materials and methods: Three NIBP measurements were obtained from MCS (Diamond®, India) and MPM (Intellivue MX800® or Ultraview SL®) in rapid succession in the upper limb resting in supine position. Respective three measurements were averaged to obtain a paired set of NIBP readings, one each from MCS and MPM. Such readings were obtained thrice a day. NIBP readings were then compared, and agreement was assessed. Results: From 39 children [median age (IQR), 30 (10–72) months], 1,690 sets of NIBP readings were obtained. A-third of readings were from infants and children >96 months, while 383 (22.6%) readings were from patients on inotropes. Multiparameter monitors gave significantly higher NIBP readings compared to MCS [median systolic blood pressure (SBP), 6.5 (6.4–6.7 mm Hg); diastolic blood pressure (DBP), 4.5 (4.3–4.6 mm Hg); mean arterial pressure (MAP), 5.3 (5.1–5.4 mm Hg); p < 0.05]. It was consistent across age, gender, and critical care characteristics. Multiparameter monitors overestimated SBP in 80% of readings beyond the maximal clinically acceptable difference (MCAD). Conclusions: Non-invasive blood pressure readings from MCS and MPMs are not interchangeable; SBP was 6–7 mm Hg higher with the latter. Overestimation beyond MCAD was overwhelming. Caution is required while classifying systolic hypotension with MPMs. Confirmation with auscultatory methods is advisable. More studies are required to evaluate currently available MPMs in different pediatric age groups.



Saurabh Chandrakar

Nebulized Heparin to Reduce COVID-19-induced Acute Lung Injury: A Prospective Observational Study

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:3] [Pages No:222 - 224]

Keywords: Acute respiratory distress syndrome, COVID-19, Nebulized heparin

   DOI: 10.5005/jp-journals-10071-24420  |  Open Access |  How to cite  | 


Background: High mortality due to COVID-19 disease has been a serious concern, a few of the causes being disseminated intravascular coagulation (DIC) and venous thromboembolism. Considering this, some experts have used heparin. However, its role still needs to be validated. Materials and methods: This study predicts the role of nebulized heparin in decreasing the severity of lung injury caused by COVID-19. Thirty patients admitted with COVID-19 acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) of All India Institute of Medical Sciences, Rishikesh, were included in this study, which was conducted over a period of 3 months. Patients were nebulized with 2 mL of heparin 5,000 units/mL IV formulation diluted with 3 mL of 0.9% sodium chloride, every 6 hours for a total duration of 7 days. Improvement in oxygenation (ratio of partial pressure of oxygen in blood and fraction of inspired oxygen delivered, pO2/FiO2 ratio) was calculated as the primary outcome. Other parameters like effect on inflammatory markers (neutrophil-lymphocyte ratio, total leukocyte count, interleukin (IL-6), and D-dimer values), time to liberate from mechanical ventilation, and hospital stay were calculated as secondary outcomes. Results: In our study population, the mean age was 54.5 years and the majority of patients were males (79.0%). All patients received prone ventilation and none of them required tracheostomy. However, 5 patients (16.6%) succumbed to illness. After nebulization with unfractionated heparin, no statistically significant difference was seen in the neutrophil-lymphocyte ratio (mean = 6.87, p = 0.318) and interleukin (IL-6) levels (mean = 62.85, p = 0.6) over 7 days. Similarly, the D-dimer level also had no statistically significant change (mean = 1853.73 p = 0.570). However, there was a statistically significant improvement in oxygenation (pO2/FiO2 ratio) over 7 days (mean = 184.96, p = 0.00). Similarly, there was a significant improvement in PaO2 (84.17 ± 33.82) and SO2 (92.30 ± 3.49). Although, no significant changes were seen in the partial pressure of carbon dioxide on nebulized heparin administration. Conclusion: Administration of nebulized heparin in COVID-19 pneumonia with mild ARDS may improve oxygenation and result in the improvement of inflammatory markers with variable sensitivity and specificity.




[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:1] [Pages No:225 - 225]

Keywords: Endotracheal intubation, Endotracheal tube tip position, Point-of-care ultrasound

   DOI: 10.5005/jp-journals-10071-24427  |  Open Access |  How to cite  | 



Seenivasan Subramani

Authors' Reply on: FOCUS more on POCUS

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:2] [Pages No:226 - 227]

Keywords: Endotracheal intubation, Endotracheal position, Ultrasound

   DOI: 10.5005/jp-journals-10071-24428  |  Open Access |  How to cite  | 



Hiccups before a Pulmonary Embolism Speak against This as a Cause

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:1] [Pages No:228 - 228]

Keywords: Craniotomy, Hiccups, Posterior inferior cerebellar artery, Pulmonary embolism, Stroke

   DOI: 10.5005/jp-journals-10071-24413  |  Open Access |  How to cite  | 



Amit Goyal, Kumari Pallavi, Anand Keshav Awasthy

In Response to Author: Hiccups before a Pulmonary Embolism Speak against This as a Cause

[Year:2023] [Month:March] [Volume:27] [Number:3] [Pages:1] [Pages No:229 - 229]

Keywords: Persistent hiccups, Pulmonary embolism, Stroke

   DOI: 10.5005/jp-journals-10071-24414  |  Open Access |  How to cite  | 


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