Indian Journal of Critical Care Medicine

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2023 | July | Volume 27 | Issue 7

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EDITORIAL

Ashit Hegde

Early Antibiotics in Septic Shock: A Desirable Goal but “Curb Your Enthusiasm”

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:2] [Pages No:459 - 460]

Keywords: Antibiotics, Guidelines, Intensive care unit, Sepsis bundles, Septic shock

   DOI: 10.5005/jp-journals-10071-24494  |  Open Access |  How to cite  | 

312

EDITORIAL

Sachin Gupta, Deeksha Singh Tomar

Influenza A (H1N1): Now is it a Thing of the Past?

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:2] [Pages No:461 - 462]

Keywords: Acute respiratory distress syndrome, Extracorporeal membrane oxygenation, H1N1 influenza

   DOI: 10.5005/jp-journals-10071-24490  |  Open Access |  How to cite  | 

316

EDITORIAL

Narayanan Parameswaran

Vitamin D and Its Myriad Disease Associations: Can the Heart be Left Behind?

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:2] [Pages No:463 - 464]

Keywords: Children, Dilated cardiomyopathy, Vitamin D deficiency

   DOI: 10.5005/jp-journals-10071-24491  |  Open Access |  How to cite  | 

298

Original Article

Rafael Barberena Moraes, Jaqueline Sangiogo Haas, Josi Vidart, Rafael Nicolaidis, Caroline Deutschendorf, Miriane Melo Silveira Moretti, Gilberto Friedman, Daiandy Silva

A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:5] [Pages No:465 - 469]

Keywords: Antibiotic, Quality improvement, Sepsis, Septic shock

   DOI: 10.5005/jp-journals-10071-24483  |  Open Access |  How to cite  | 

Abstract

Objectives: We carried out this work with the aim of assessing the effectiveness of a set of interventions over time for the administration of antibiotics. Design: Prospective observational study. Setting: Patients admitted to the emergency room and ICU of the hospital where the study was conducted are evaluated daily for some sociodemographic and clinical variables. Among them are some quality indicators, such as the time between the diagnosis of sepsis or septic shock until the start of the infusion of antibiotics. This indicator reflects several aspects related to a set of assistance measures (adequacy of antibiotic dispensation, rapid response team (RRT), sepsis care quality improvement program, antimicrobial management program, improvements in emergency department assistance). Patients or participants: Patients with sepsis or septic shock were admitted to the ICU of a university and public hospital in southern Brazil. Main variables of interest: The time between the diagnosis of sepsis or septic shock and the beginning of the infusion of antibiotics. Results: Between 2013 and 2018, 1676 patients were evaluated. The mean time for antibiotic infusion decreased from 6.1 ± 8.6 hours to 1.7 ± 2.9 hours (p < 0.001). The percentage of patients who received antibiotics in the first hour increased from 20.7 to 59.0% (p < 0.001). Conclusion: In this study, we demonstrated that a set of actions adopted in a large tertiary hospital was associated with decreased time to start antibiotic therapy in septic patients.

415

Original Article

Vinya Golagana, Ashwin K Mani, Ebenezer Rabindra Rajan, Dedeepiya Devaprasad Vidyasagar

Epidemiology and Outcomes of HIN1 Pneumonia in ICU

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:5] [Pages No:470 - 474]

Keywords: H1N1 pandemic influenza, Pandemic, Reverse transcription polymerase chain reaction

   DOI: 10.5005/jp-journals-10071-24493  |  Open Access |  How to cite  | 

Abstract

Introduction: Pandemic influenza H1N1/09 emerged for the first time in April 2009 and has spread widely across India since then. The number of cases have increased over time with the increasing need for respiratory support, causing significant morbidity and mortality. We evaluated the clinical course and outcomes of patients infected with Influenza A (H1N1) admitted to three multidisciplinary intensive care units (ICU) in Chennai. Materials and methods: We performed a combined retrospective and prospective observational study of all patients admitted with H1N1 pneumonia at three multidisciplinary ICUs in Chennai from October 1, 2018, to January 31, 2019. Data including demographics, risk factors, and clinical courses were recorded. Outcome data including mortality was tracked up to 28 days. Results: A total of 167 patients were admitted during the study period of which 154 were included in this analysis. The mean age of presentation was 58.2 ± 15.6 years and 59.1% of them were males. The mean acute physiology and chronic health evaluation (APACHE) IV and sequential organ failure assessment (SOFA) scores were 62.8 ± 23.2 and 5.8 ± 3.9 respectively. Oxygen delivery devices were required in 25.3% for a mean duration of 26.5 ± 5.7 hours. Non-invasive ventilation or high-flow nasal cannula (HFNC) was needed in 33.1% of patients for 59.9 ± 64.5 hours. The proportion of patients requiring mechanical ventilation was 41.6%. Rescue measures in the form of proning, use of inhaled nitric oxide (iNO), and extracorporeal membrane oxygenation (ECMO) were initiated for refractory hypoxemia in 26.6%, 14.1%, and 6.3% respectively. The mean duration of ventilator support was 8.5 ± 8 days. Tracheostomy was required in 20.3% of patients and 7.8% were ventilator dependent at 28 days. The mean ICU and Hospital length of stay were 8.3 ± 10.3 and 12.2 ± 14.1 days respectively and overall 28-day mortality was 20.1%. Conclusion: A significant proportion of H1N1 patients admitted to the ICU required high-level respiratory support including non-invasive ventilation (NIV), HFNC, or invasive ventilation. Deployment of rescue therapies was common and the overall mortality rate was similar to those reported from Western countries.

459

Original Article

Aishwarya Krishnan, Madhu Srinivasarangan, Sriharsha Jagadish, Adarsh Singarahalli Bheemanna, Abhijith Sivasankar

The Efficacy of Vision, Aphasia, Neglect Assessment in Predicting Emergent Large Vessel Occlusion in Patients Presenting with a Cerebrovascular Accident to the Emergency Department

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:7] [Pages No:475 - 481]

Keywords: Aphasia, Cerebrovascular accident, Emergency Department, Emergent large vessel occlusion stroke, Magnetic resonance angiography, Magnetic resonance imaging, National Institute of Health Stroke Severity, Neglect, Vision

   DOI: 10.5005/jp-journals-10071-24485  |  Open Access |  How to cite  | 

Abstract

Background: Early identification of patients with an emergent large vessel occlusion (ELVO) ischemic stroke is crucial in the Emergency Department (ED), as they are the ideal candidates for endovascular therapy. With this study, we have attempted to use Vision, Aphasia, Neglect (VAN) screening tool in the ED for rapid identification of ELVO ischemic stroke and compared its performance with the National Institute of Health Stroke Severity (NIHSS) scale. Materials and methods: A prospective observational study was conducted in the ED of a tertiary care hospital over 18 months among all suspected stroke patients. Vision, aphasia, neglect and NIHSS scores were calculated on arrival. Magnetic resonance imaging + magnetic resonance angiography (MRI + MRA) were taken as gold standard. Results: This study found that VAN identified ELVO with 85.19% sensitivity (p-value < 0.0001), 88.64% specificity (p-value < 0.0001), and 87% diagnostic accuracy, with respect to the gold standard test. Vision, aphasia, neglect had a positive predictive value (PPV) and negative predictive value (NPV) of 82.14% and 90.7%, respectively. Time taken to perform VAN score in the ED was on average 2 minutes. National Institute of Health Stroke Severity detected ELVO with a sensitivity of 88%, specificity of 51.11%, a PPV of 53.33%, and a NPV of 88.4%. Diagnostic accuracy was 66%, and it took approximately 5 minutes to perform. When both scores were applied together for ELVO detection, NPV was 100%. Conclusion: Vision, Aphasia, Neglect score as well as NIHSS scale are both tools for clinical prediction of ELVO with VAN having a better diagnostic accuracy and utility as a screening tool in the ED.

485

Original Article

Akriti Bajracharya, Dikshya Devkota

Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:6] [Pages No:482 - 487]

Keywords: Lung aeration, Lung ultrasound, Mechanical ventilation, Spontaneous breathing trial, Weaning, Weaning success

   DOI: 10.5005/jp-journals-10071-24487  |  Open Access |  How to cite  | 

Abstract

Introduction: Spontaneous breathing trial (SBT) is always successful in mechanically ventilated patients. This study was conducted to assess the prediction of successful SBT and extubation of trachea by bedside lung ultrasound in mechanically ventilated patients. Methodology: This was a prospective observational study for 1 year conducted at a tertiary teaching hospital ICU on 102 patients with age more than 18 years and who were mechanically ventilated for more than 24 hours. Bedside lung ultrasound was used to assess the lung ultrasound score (LUS) and lung profiles in patients who clinically met the criteria for SBT. The LUS at the beginning of SBT and 30 minutes after SBT were used to predict the successful SBT and tracheal extubation. Result: Spontaneous breathing trial and tracheal extubation were successful in 73 (71.6%) and 57 (55.8%) of the patients. The AUC for lung ultrasound in predicting successful SBT at the beginning and 30 minutes of SBT were 0.781 (CI 95% 0.674–0.888, p < 0.001) and 0.841 (CI 95% 0.742–0.941, p < 0.001) with a cut-off value of 17.5 and 19.5, respectively. Similarly, AUC for LUS in relation to tracheal extubation was 0.786 (CI 95% 0.694–0.879, p < 0.001) and 0.841(CI 95% 0.756–0.925, p < 0.001) at 0 and 30 minutes. About 57.5% of the patients with A profiles tolerated successful SBT while 48.3% of the patients having C profile had failed SBT (p < 0.001). COPD, lung ultrasound, higher SOFA score, and longer duration of mechanical ventilation had a statistically significant negative correlation with successful SBT. Conclusion: Lower LUS and A profiles lung ultrasound are associated with more successful weaning and tracheal extubation in mechanically ventilated patients.

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Original Article

Pratibha Prasad

Status Epilepticus as a Presenting Feature in Posterior Reversible Encephalopathy Syndrome: Tertiary Care Center Experience

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:5] [Pages No:488 - 492]

Keywords: Antenatal care, Autoimmune disorder, Eclampsia, Seizures, Status epilepticus

   DOI: 10.5005/jp-journals-10071-24492  |  Open Access |  How to cite  | 

Abstract

Background: Though epileptic seizures are common in posterior reversible encephalopathy syndrome (PRES), status epilepticus (SE) as the presenting feature is rare. Objective: To study the clinical spectrum and outcome of patients with SE as presenting feature of PRES. Methods: This is a retrospective study. PRES was diagnosed based on the clinical features and imaging findings on brain MRI (n = 40) which became normal after 6 months follow-up imaging. Patients with SE as the initial manifestation of PRES were identified. Baseline information regarding the clinical presentation, etiology, past history of illness, treatment history, imaging findings, EEG and long-term clinical outcome. Result: Seizure was the most common presentation seen in 31 patients (77.5%). The etiologies in PRES were preeclampsia, or eclampsia [n = 33 (82.5%)], hypertensive encephalopathy [n = 3 (7.5%)], systemic lupus erythematosus (SLE), AIP, and chronic renal failure (CRF) in one patient each [n = 01 (2.5%)]. Brain MRI showed the involvement of parieto-occipital lobes (n = 33 [82.5%]) mostly. Status epilepticus (generalized convulsive) was the presenting feature in eight cases (20%). Among them, five cases (0.5%) had a history of chronic epilepsy. In the remaining three patients, SLE and acute intermittent porphyria, CRF precipitated the SE. Conclusion: The study highlights the clinico-etiological spectrum of PRES and the identification of SE within its context leading to the early diagnosis and management if treated early. The role of antenatal care is important for the identification and treatment of etiologies, blood pressure, proper antiepileptic drug compliance and appropriate counseling.

442

Original Article

Sahil Gupta, Gayatri Bhatia, Rajesh Sagar, Sushma Sagar

Assessment of Psychological Well-being Among Medical Professionals Working with Patients Who Suffer from Physical Trauma: An Observational Study from India

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:10] [Pages No:493 - 502]

Keywords: Burnout, Healthcare professionals, Professional quality of life, Secondary traumatic stress, Trauma

   DOI: 10.5005/jp-journals-10071-24488  |  Open Access |  How to cite  | 

Abstract

Background: Healthcare providers working with victims of physical trauma are exposed to significant human suffering at work. This may place them at risk of burnout, secondary traumatic stress (STS), and other psychological disturbances. This study aimed to evaluate the professional quality of life and psychological well-being among trauma professionals. Methodology: This was a cross-sectional study conducted among 153 staff members (nursing officers, resident doctors, and faculty) of a Level 1 trauma center in North India. The Professional Quality of Life (ProQoL-5) and Depression, Anxiety, and Stress (DASS-21) Scales were used. Results: More than 50% of the participants had a moderate risk of burnout and STS. In addition, 54% of participants reported having anxiety, 40% stress, and 36% depressive symptoms. Depression, anxiety, and stress were all strongly predicted by burnout and STS. Conclusion: Psychological distress symptoms were seen in a significant portion of professionals working in the trauma center. Workplace interventions for the promotion of psychological well-being among trauma professionals are recommended.

420

PEDIATRIC CRITICAL CARE MEDICINE

Ramaning Loni, Sara Zameer, Fareedul Ahmed Hasan, Ittrat Abbas, Hager Mesrati, John George, Gabriel Fox, Arjun C Dey, Alan Finan

Vitamin-D Status and Clinical Outcomes in Critically Ill Children

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:7] [Pages No:503 - 509]

Keywords: Children, Critical illnesses, Vitamin-D levels

   DOI: 10.5005/jp-journals-10071-24486  |  Open Access |  How to cite  | 

Abstract

Aims and background: To study if 25-hydroxy cholecalciferol levels correlate with clinical outcomes in a cohort of critically ill children requiring pediatric intensive care unit (PICU) admission. Materials and methods: All children between the ages of 1 month and 14 years admitted to a PICU were included in this study. The vitamin-D level was measured within 24 hours of admission to the PICU for each patient. The patient's clinical details, vitamin-D levels, and biochemical parameters were collected. Results: There were 119 critically ill children (47 females and 72 males) admitted to our PICU. A total of 56 children were in the vitamin-D-deficient group, giving a prevalence of 47.05%. Sixty-three children had either insufficient or normal levels of 25(OH)D. Mean serum 25-OH cholecalciferol was 22.82 ± 16.48 nmol/L. There were no significant differences in O2 utilization, ventilation requirement, length of PICU stay, or the frequencies of use of antibiotics and steroids between the groups. The overall mortality rate in this study was 5.8% (three children died in the deficient group as compared with four in the insufficient/normal group). Conclusion: Even though vitamin-D deficiency was highly prevalent in the PICU, there were no statistically significant differences in O2 utilization, length of PICU stay, duration of mechanical ventilation, the use of antibiotics/steroids, and mortality outcome for both deficient and insufficient/normal groups.

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PEDIATRIC CRITICAL CARE MEDICINE

Surjeet Kumar, Manjinder Singh Randhawa, Suresh K Angurana, Karthi Nallasamy, Arun Bansal, Manoj Rohit Kumar, Naresh Sachdeva, Muralidharan Jayashree

Clinical Profile, Intensive Care Needs and Outcome of Children with Dilated Cardiomyopathy Associated with Vitamin D Deficiency: A 5-year PICU Experience

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:5] [Pages No:510 - 514]

Keywords: Inotropes, Intensive care units, Pediatric intensive care units, Vitamin D deficiency

   DOI: 10.5005/jp-journals-10071-24484  |  Open Access |  How to cite  | 

Abstract

Aim: To describe the clinical profile, treatment details, intensive care needs, and long-term outcome of children with dilated cardiomyopathy (DCM) associated with Vitamin D deficiency (VDD). Materials and methods: Case records of 14 children with DCM associated with VDD [25(OH)D3 levels <20 ng/mL] admitted to the pediatric intensive care unit (PICU) of a tertiary care teaching hospital between January 2017 and December 2021 were retrospectively analyzed for clinical features, echocardiographic findings, treatment details, intensive care needs, and outcomes. Results: The median (IQR) age was 6 (2–9) months and 71% (n=10) were males. The common modes of presentation included respiratory distress or failure (78.6%), congestive cardiac failure (71.4%), cardiogenic shock (37.5%), and seizures and encephalopathy (14.3% each). The median (IQR) serum calcium was 8.7 (7–9.5) mg%, ionized calcium 0.7 (0.7–1.1) mmol/L, alkaline phosphatase 343 (316–415) IU/L, phosphate 3.5 (2.6–4.5) mg%, PTH 115 (66–228) pg/mL, and 25(OH)D3 5 (3–7) ng/mL. The median (IQR) left ventricular ejection fraction (LVEF) at admission was 22 (17–25)%. The treatment included intravenous calcium infusion (35.7%), vitamin D supplementation in all (57.1% parenteral and 42.9% oral), mechanical ventilation (35.7%), and vasoactive drugs (57.1%). There was no mortality. The median (IQR) duration of PICU and hospital stay was 76 (31–98) hours and 6 (4.7–10) days, respectively. Out of 14 children, 10 (71.4%) were followed-up till median (IQR) of 10 (7–58) months. All were asymptomatic and had normal LEVF (except one had residual moderate mitral regurgitation). Conclusion: Vitamin D deficiency is a potentially treatable and reversible cause of DCM in children.

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LETTER TO THE EDITOR

Arunkumaar Srinivasan, Vishnu Naidu, Ponnusamy Dhivya

Arterial Line Placement Using Modified Seldinger Technique: A Novel Approach

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:2] [Pages No:515 - 516]

Keywords: Arterial cannulation, Seldinger technique, Vascular access device

   DOI: 10.5005/jp-journals-10071-24489  |  Open Access |  How to cite  | 

374

BRIEF RESEARCH COMMUNICATION

Márcio Manozzo Boniatti, Wagner Luis Nedel, Marcos Frata Rihl, Patricia Schwarz, Edino Parolo, Miriane Melo Silveira Moretti, Thiago Costa Lisboa

Effect of Cyproheptadine on Ventilatory Support-free Days in Critically Ill Patients with COVID-19: An Open-label, Randomized Clinical Trial

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:5] [Pages No:517 - 521]

Keywords: Coronavirus disease 2019, Cyproheptadine, Intensive care unit, Serotonin, Ventilatory support

   DOI: 10.5005/jp-journals-10071-24482  |  Open Access |  How to cite  | 

Abstract

Background: Serotonin is a mediator of pulmonary hypoxic vasoconstriction. Experimental studies have shown that serotonin-mediated pulmonary vasoconstriction can be inhibited by cyproheptadine. The aim of this study is to assess whether treatment with cyproheptadine compared to usual care increases ventilatory support-free days during the first 28 days in patients with coronavirus disease 2019 (COVID-19) requiring ventilatory support. Materials and methods: This randomized, single-center, open-label clinical trial included patients who were admitted to the intensive care unit (ICU) requiring ventilatory support due to COVID-19. Patients allocated to the intervention group received cyproheptadine for 10 days. The primary outcome was ventilator-free days during the first 28 days. Results: Nineteen patients were randomized to receive cyproheptadine and 21 to the control group. The number of ventilatory support-free days during the first 28 days was not different between the two groups (15.0; 95% CI, 0.0–24.0 days in the control group vs 7.0; 95% CI, 0.0–19.0 days in the intervention group; p = 0.284). Conclusion: In patients with COVID-19 and in need of ventilatory support, the use of cyproheptadine plus usual care, compared with usual care alone, did not increase the number of ventilatory support-free days in 28 days.

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Book Review

Farhad N Kapadia

Controversies in Critical Care

[Year:2023] [Month:July] [Volume:27] [Number:7] [Pages:1] [Pages No:522 - 522]

   DOI: 10.5005/ijccm-27-7-522  |  Open Access |  How to cite  | 

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