Indian Journal of Critical Care Medicine

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2023 | April | Volume 27 | Issue 4

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EDITORIAL

Adarsh Ramakrishnan, Nagarajan Ramakrishnan

Critical Care Delivery in India: Stats, State(s) and Strategies

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:2] [Pages No:231 - 232]

Keywords: Critical care delivery, Intensive care unit, Need analysis

   DOI: 10.5005/jp-journals-10071-24445  |  Open Access |  How to cite  | 

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EDITORIAL

Hemanshu Prabhakar

Augmenting Hypertensive Therapy in Patients with Postoperative Subarachnoid Hemorrhage: What's the Right Choice?

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:2] [Pages No:233 - 234]

Keywords: Cerebral blood flow velocity, Norepinephrine, Subarachnoid haemorrhage

   DOI: 10.5005/jp-journals-10071-24441  |  Open Access |  How to cite  | 

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EDITORIAL

Optic Nerve Sheath Diameter and Sodium Levels: A Friend of a Friend is Still a Stranger

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:2] [Pages No:235 - 236]

Keywords: Emergency department, Hyponatremia, Optic nerve sheath diameter, Osmotic demyelination syndrome, Raised intracranial pressure

   DOI: 10.5005/jp-journals-10071-24444  |  Open Access |  How to cite  | 

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Original Article

D Prabu, V Gousalya, M Rajmohan, M Dinesh Dhamodhar, VV Bharathwaj, R Sindhu, S Sathiyapriya

Need Analysis of Indian Critical Health Care Delivery in Government Sectors and Its Impact on the General Public: A Time to Revamp Public Health Care Infrastructure

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:9] [Pages No:237 - 245]

Keywords: Critical care, Critical care doctors, Critical care nurses, Human resources, ICU beds, Infrastructure, Manpower, Medicines, Ventilators

   DOI: 10.5005/jp-journals-10071-24442  |  Open Access |  How to cite  | 

Abstract

Background: Poverty is directly linked to public health care delivery in many ways and dimensions. Every aspect of the human sphere is preplanned, but a health crisis is the only emergency which pushes humanity into severe economic stress. Therefore, every nation aims to safeguard its citizens from a health crisis. In this aspect, India needs to improve its public health infrastructure in order to protect its citizens and save them from poverty. Objectives: (1) To assess the current pitfalls in public critical health care delivery, (2) to analyze whether the health care delivery matches the requirements of its population in every state, (3) to produce solutions and guidelines to overcome the stress in this priority area. Materials and methods: Data regarding the critical care workforce, which includes critical care doctors and nurses, were taken from official websites and other sources. Critical care infrastructure data were retrieved from the Internet sources. Data were validated by consulting state government sources and cross-checked for bias elimination. The data were analyzed using the “Statistical Package for Social Sciences” software version 20, and were presented using descriptive statistics. Results: There is a 1:10 percentage of deficit in the case of critical care workforce and infrastructure when compared with its need analysis. Critical care medicine specialists are in 1:75 when compared to other specialties. Conclusion: Overall, the public sector critical care needs a total boost through out of box solutions. According to the Stockholm International Peace Research Institute (SIPRI), India spent the third most on defense in the world in 2021. India spent 76.6 billion dollars on its military in 2021, up 33% from 2012 and 0.9% from 2020. However, since India is considered a fast-growing economy, there is still a huge disparity in critical care. Without resetting critical health care, India cannot grow in welfare indices even if it is among the top gross domestic product (GDP) countries.

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Original Article

Juliet Joji Varghese, Basemath Morris, Panchatcharam Senthur Nambi, Ramasubramanian Venkatasubramanian

“Nurse—The Archer” Fighting Against the Hidden Enemy

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:8] [Pages No:246 - 253]

Keywords: Bundle compliance, Central line-associated bloodstream infections, Coronavirus disease-2019, Critical care unit, Infection control, Staff nurses

   DOI: 10.5005/jp-journals-10071-24432  |  Open Access |  How to cite  | 

Abstract

Background and aim: The coronavirus disease-2019 (COVID-19) pandemic is a global threat spreading like a wildfire and taking the world by its storm. It has challenged the healthcare delivery systems and disrupted them in a way no one ever imagined before. We at Apollo Hospitals, Chennai, Tamil Nadu, India received many patients in the COVID critical care unit (CCU) and found a gradual lack of bundle care compliance resulting in an upsurge of central line-associated bloodstream infection (CLABSI) amid the patients. Materials and methods: A qualitative research approach and quasi-experimental research design were selected to assess the knowledge of the 150 frontline COVID CCU nurses regarding the CLABSI bundle and its prevention strategies. Results: This study revealed that 57% [mean (M) = 12.6; standard deviation (SD) = 2.37] of nurses had inadequate knowledge of the CLABSI bundle and its prevention strategies, in the pretest and scored 80% (M = 6.7; SD = 2.28) in the post-test, with “t” = 22.06 at p < 0.00001 after the hands-on training. The percentage of compliance to CLABSI bundle care increased to 83% and thereafter in an increasing trend. This was clearly evident through the reduction in the preventable CLABSI rate among critically ill COVID-19 patients. Conclusion: Nurses are on the frontline in preventing and controlling healthcare-associated infections (HAIs). Fighting with all the visible and invisible challenges, our research focused on hands-on training for frontline warriors to adhere to the CLABSI bundle care which drove us to the reduction in preventable CLABSI rate in our hospital through improved CLABSI bundle compliance.

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Original Article

Manjunatha Lakshmegowda, Radhakrishnan Muthuchellapan, Megha Sharma, S Umamaheswara Rao Ganne, Dhritiman Chakrabarti, Sindhupriya Muthukalai

The Effect of Pharmacologically Induced Blood Pressure Manipulation on Cardiac Output and Cerebral Blood Flow Velocity in Patients with Aneurysmal Subarachnoid Hemorrhage

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:6] [Pages No:254 - 259]

Keywords: Blood pressure, Cardiac output, Cerebral blood flow velocity, Cerebral vasospasm, Subarachnoid Hemorrhage, Transcranial Doppler

   DOI: 10.5005/jp-journals-10071-24435  |  Open Access |  How to cite  | 

Abstract

Background: Vasopressors are used in patients with subarachnoid hemorrhage (SAH) to increase blood pressure with the idea of reversing the ischemic process. The current study is designed to evaluate the changes in systemic and cerebral hemodynamics, including cerebral blood flow autoregulation, at different pharmacologically augmented blood pressure levels using norepinephrine in patients with spontaneous aneurysmal SAH following surgery. Materials and methods: This prospective observational study was carried out in patients with ruptured anterior circulation aneurysms who underwent surgical clipping and required norepinephrine infusion. Postoperatively, when the treating physician decided to start a vasopressor, norepinephrine infusion was started at 0.05 µg/kg/min. The infusion rate was increased by 0.05 µg/kg/min every 5 minutes to achieve a 20% and then 40% increase in the systolic blood pressure (SBP). When the blood pressure stabilized at each level for 5 minutes, hemodynamic and transcranial doppler (TCD) parameters in the middle cerebral artery (MCA) were recorded. Results: Peak systolic, end-diastolic, and mean flow velocities in the MCA increased with targeted blood pressure increase in the hemispheres with impaired autoregulation and not in the hemispheres with intact autoregulation. The interaction of changes in TCD flow velocities between hemispheres with and without intact autoregulation was significant (p < 0.001). Cardiac output changes following norepinephrine infusion were not significant (p = 0.113). Conclusion: Hypertensive therapy with norepinephrine increases cerebral blood flow velocity only when autoregulation is impaired, an effect that is desirable in patients with focal cerebral ischemia following SAH.

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Original Article

Shweta P Panchakshari, Preeti S Ajapuje, Namita P Mahale, Sadanand S Naik, Sharwari Narawade, Anand Athavale

Therapeutic Drug Monitoring of Isavuconazole: Lessons Learnt from a Real-life Setting in a Tertiary Care Center in India

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:5] [Pages No:260 - 264]

Keywords: Aspergillosis, Drug monitoring, Fungal infections, Fungus, Isavuconazole, Mold infections, Mucormycosis, Therapeutic drug monitoring

   DOI: 10.5005/jp-journals-10071-24443  |  Open Access |  How to cite  | 

Abstract

Introduction: Isavuconazole is an emerging therapeutic option for invasive infections caused by molds, especially aspergillosis and mucormycosis. Isavuconazole has predictable pharmacokinetics and good bioavailability. These attributes have led to some doubts regarding the need for therapeutic drug monitoring (TDM). There are no data from India regarding TDM for isavuconazole. Methods: A retrospective analysis of 50 patients who received oral isavuconazole for therapeutic purposes. Plasma isavuconazole levels were measured using a reversed phase high-performance liquid chromatography (HPLC) and UV detector with acetonitrile (ACN) as protein precipitating solvent. Results: Of the 50 cases, 5 (10.0%) patients had subtherapeutic levels, while 45 (90.0%) had therapeutic levels. Higher body weight and solid organ transplantation (SOT) were significantly associated with subtherapeutic levels of isavuconazole (p-value < 0.05 for all). Receipt of a SOT was the only independent and statistically significant factor which was associated with subtherapeutic levels of isavuconazole (p-value < 0.05). Conclusion: Our study reemphasizes the need of TDM for isavuconazole and adds to the growing evidence for the need to obtain drug levels. Factors associated with subtherapeutic levels of isavuconazole need to be assessed in larger studies to help identify those patients who are at risk of having subtherapeutic drug levels.

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Original Article

Sangeeta Sahoo, Satyabrata Guru, Nitish Topno, Nishit Kumar Sahoo

Sonographic Optic Nerve Sheath Diameter as a Guide for Correction of Hyponatremia in the Emergency Department: A Cross-sectional Study

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:5] [Pages No:265 - 269]

Keywords: Electrolyte imbalance, Emergency department, Hyponatremia, Optic nerve sheath diameter, Ultrasonography

   DOI: 10.5005/jp-journals-10071-24438  |  Open Access |  How to cite  | 

Abstract

Background: Monitoring sodium levels during the correction of hyponatremia is essential. There is cell swelling due to the movement of water from extracellular to intracellular by osmotic effect in hyponatremia. The cellular swelling in a closed space causes increased intracranial pressure (ICP). The raised ICP correlates with the optic nerve sheath diameter (ONSD). So, the research question was whether the ONSD can be used as a guide for the correction of hyponatremia. Methods: It was a prospective observational study conducted on patients with serum sodium below 135 mEq/L presented to the emergency department (ED). The ONSD was measured at the time of presentation and discharge of the patient. The receiver operating characteristic curve (ROC) and area under the curve (AUC) were used to test the predictive ability of the ONSD to diagnose hyponatremia. Results: A total of 54 subjects were included in the study. The mean sodium level was 109.3 mEq/L at presentation. The mean ONSD on the right side was 6.24 ± 0.71 mm and on the left side was 6.26 ± 0.64 mm at presentation to ED. The mean ONSD on the right side was 5.81 ± 0.58 mm and on the left side was 5.79 ± 0.56 mm at discharge. The ONSD was not able to predict the sodium level measured both by laboratory and POC methods. Conclusion: The ONSD failed to predict the sodium level in patients with hyponatremia during the correction. The change in ONSD did not correlate with the change in sodium level.

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Original Article

Pooja Bihani, Sadik Mohammed, Sukhdev Rao, Rishabh Jaju, Sarita Janweja

Assessment of Knowledge, Barrier in Implementation, and Compliance to Ventilator Bundle among Resident Doctors and Nurses Working in Intensive Care Units of a Tertiary Care Center of Western India: A Cross-sectional Survey

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:7] [Pages No:270 - 276]

Keywords: Intensive care unit, Knowledge level, Questionnaire, Ventilator bundle, Ventilator-associated pneumonia

   DOI: 10.5005/jp-journals-10071-24434  |  Open Access |  How to cite  | 

Abstract

Introduction: Appropriate implementation of a ventilator bundle (VB) is the key step in the prevention of ventilator-associated pneumonia (VAP). However, knowledge and compliance of critical care staff for VB are inconsistent in developing countries. This cross-sectional survey was planned to evaluate critical care practitioners’ knowledge of, adherence to, and barriers toward implementation of VB in the ICUs of a tertiary care institute. Methodology: All registered nurses and resident doctors who are direct care providers to patients of the ICU were included. Two sets of questionnaires were given to access knowledge and to identify potential barriers in the implementation of VB. To determine compliance with the VB, direct observation was done for three nonconsecutive days, and mean compliance per component of the bundle and overall compliance to VB was determined. Data were analyzed using descriptive and analytic statistics. Results: Of these 75 participants, 43 (57.33%) were resident doctors and 32 (42.67%) were staff nurses. The median knowledge score of resident doctors and staff nurses for VB was 7 (range 3–10) and 6 (range 2–9), respectively, with an overall score of 7 (range 2–10). Self-reported adherence to individual components of VB ranged from 75% to 95%, among these, adherence to oral care protocol, including use of chlorhexidine oral rinse, was most, and adherence to DVT prophylaxis was least. The most common potential barriers identified were fear of potential adverse effects and unawareness of guidelines. Conclusion: Considerable gap is observed between knowledge and implementation of VB among critical care practitioners. Despite knowledge, fear of adverse events and lack of proper training are key barriers in implementation of VB.

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Original Article

Ahmed El-Sayed Mohamed El-Sayed Bsar, Samia Abdel-Rahman El-Wakiel, Mona Abdel-Hameed El-Harrisi, Amr Shaaban Hafez Elshafei

Frequency and Risk Factors of Hypophosphatemia in Patients Admitted to Emergency Intensive Care Unit in Zagazig University Hospitals

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:6] [Pages No:277 - 282]

Keywords: Accidental poisoning, Acute hypoxemic respiratory failure, Adolescent, Cardiac output blood pressure

   DOI: 10.5005/jp-journals-10071-24431  |  Open Access |  How to cite  | 

Abstract

Background: Inorganic phosphate is a major electrolyte that participates in many functional and integral processes in the human body. Low Pi levels may lead to multiple organ dysfunction. It is estimated to occur in 40–80% of intensive care unit (ICU) patients. However, it may be ignored during the initial evaluation in ICU. Materials and methods: This prospective cross-sectional study included 500 adult ICU cases in two groups; a group with normal Pi levels and a group with hypophosphatemia. All admitted patients were subjected to full history taking, and clinical, laboratory, and radiological evaluation. Collected data were coded, processed, and analyzed using statistical package for social sciences (SPSS) software. Results: Among 500 adult ICU patients; 56.8% had normal phosphate levels while the remaining 43.2% had low phosphate levels. Patients in the hypophosphatemia group were associated with a significantly higher Acute Physiological and Chronic Health Evaluation (APACHE II) score, a longer hospital and ICU stay, a higher incidence of mechanical ventilation use with a longer duration on it, and a significantly higher mortality rate. Conclusion: Risk factors for hypophosphatemia include a higher APACHE II score, longer stay in the hospital and ICU, a higher ratio of mechanical ventilation, and a higher mortality rate.

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Original Article

Meryem Türkan Işik, Rana Can Özdemir

Intensive Care Nurses’ Fears about Returning to Work after Recovering from COVID-19: A Qualitative Study

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:6] [Pages No:283 - 288]

Keywords: Coronavirus disease-2019 patient, Care ethics, Experiencing coronavirus disease-2019, Intensive care nurse

   DOI: 10.5005/jp-journals-10071-24430  |  Open Access |  How to cite  | 

Abstract

Background: Experiencing coronavirus disease-2019 (COVID-19) disease is a difficult and exhaustive process. Intensive care unit (ICU) nurses return to the ICU after recovering from COVID-19. Aim: This study was planned to determine the care difficulties and ethical problems faced by ICU nurses returning to work after being diagnosed with COVID-19. Method: In-depth interview technique was used in this qualitative study. This study was conducted between January 28 and March 3 2021 with 20 nurses diagnosed with COVID-19, working in an ICU. Data were collected using face-to-face interviews with semi-structured questions. Results: Average age of the participating nurses was 27 ± 5.8; 14 of them were not planning to leave the profession; 13 felt confused about the pandemic process and all experienced some ethical problems related to the care process. Conclusion: Long work hours during the pandemic negatively affect ICU nurses’ psychology. After experiencing the disease, the ethical sensitivity of the nurses in this group providing care to patients increased. Determining the difficulties and ethical problems experienced by ICU nurses after recovering from COVID-19 can be a guide in increasing ethical sensitivity.

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Original Article

Shipra Roy, Shrimanjunath Sankanagoudar, Pradeep Kumar Bhatia, Praveen Sharma

Comparison of Diagnostic Accuracy of Presepsin and Procalcitonin for Sepsis in Critically Ill Patients: A Prospective Observational Study

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:5] [Pages No:289 - 293]

Keywords: Presepsin, Procalcitonin, Sepsis

   DOI: 10.5005/jp-journals-10071-24439  |  Open Access |  How to cite  | 

Abstract

Objective: Early diagnosis of sepsis is crucial to institute appropriate therapy and then to avert a possible negative outcome. We planned this study to evaluate the diagnostic value of presepsin, its sensitivity and specificity for diagnosing sepsis in critically ill patients, and its ability to prognosticate the outcome of sepsis. Methods: In this prospective observational study, adult patients admitted to the intensive care unit (ICU) at our institute were screened, and those with features suggestive of sepsis were recruited into the study. Procalcitonin (PCT) and presepsin were assessed on the day of admission and day 7 of the ICU stay, apart from routine investigations. Patients were followed for outcome in terms of mortality till 28 days. Results: The study comprised 82 patients who satisfied the inclusion criteria. Presepsin sensitivity for sepsis diagnosis was determined to be 78%, while that of PCT was determined to be 69%. This gave a combined sensitivity of presepsin and PCT of 93% when used in parallel for the diagnosis of sepsis. Conclusion: A combination of PCT and presepsin provides higher sensitivity and can be used to screen for sepsis in the ICU.

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LETTER TO THE EDITOR

Sunaakshi Puri, Anjishnujit Bandyopadhyay

Harmonizing the Septic Shock Terminology: Need of the Hour

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:2] [Pages No:294 - 295]

Keywords: Catecholamine resistance, Refractory shock, Sepsis

   DOI: 10.5005/jp-journals-10071-24433  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Dilip Kumar Venkatesan, Anil Kumar Goel

Fluid Bolus: How Much More?

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:1] [Pages No:296 - 296]

Keywords: Fluid overload, Fluid responsiveness, Passive leg raising

   DOI: 10.5005/jp-journals-10071-24436  |  Open Access |  How to cite  | 

Abstract

Fluid bolus in critically ill children is always a matter of concern and has to be balanced between benefits and harms. While optimizing pre-load is important in the golden hour period, fluid overload is a concern in ICU stay. Various dynamic parameters both clinical and device-guided assessment can help in optimizing fluid therapy.

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LETTER TO THE EDITOR

Nitin Choudhary

Deliberating a Re(n)al-world Research Setting

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:1] [Pages No:297 - 297]

Keywords: Acute kidney injury, Contrast agents, Hypoalbuminemia, Postoperative renal insult, Vasopressors

   DOI: 10.5005/jp-journals-10071-24437  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Kambagiri Pratyusha

Normal Anion Gap: A Knowledge Gap

[Year:2023] [Month:April] [Volume:27] [Number:4] [Pages:1] [Pages No:298 - 298]

Keywords: Acute diarrhea, Non-anion gap metabolic acidosis, Severe dehydration

   DOI: 10.5005/jp-journals-10071-24440  |  Open Access |  How to cite  | 

Abstract

We studied with great interest the article titled “Acute diarrhea and severe dehydration in children: Does non-anion gap component of severe metabolic acidemia need more attention?” by Takia L et al. and would express our views about the same. Normal anion gap metabolic acidosis (NAGMA) is a common entity following stool loss of bicarbonate during an acute diarrheal illness. Several studies have shown that there is a higher incidence of hyperchloremic acidosis and acute kidney injury (AKI) with normal saline (NS) when compared to balanced crystalloids like Ringer's lactate (RL) or balanced salt solutions like plasmalyte. We would like to know about the type of resuscitation fluid used in the study population as it would affect the degree of resolution of acidemia. As per the World Health Organization (WHO) guidelines, rehydration therapy for children with severe acute malnutrition (SAM) is different from other children including the fluid used for bolus, i.e., RL and oral rehydration solution (ORS), i.e., rehydration solution for malnourished (ReSoMal). We would like to know if the study population included SAM children and a subgroup analysis of the same was done as SAM is an independent risk factor for mortality and morbidity. We suggest to plan studies on cognitive outcome of these children.

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