Indian Journal of Critical Care Medicine

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2024 | May | Volume 28 | Issue 5

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EDITORIAL

Raj Kumar Mani

Physician Perspectives on the Quality of Dying in Indian ICUs: A Call to Attention

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:3] [Pages No:411 - 413]

Keywords: Dignity, End of life care communication, End of life discussions

   DOI: 10.5005/jp-journals-10071-24714  |  Open Access |  How to cite  | 

354

EDITORIAL

Bhuvana Krishna

Day and Time of Admission to ICU Affects Patient Outcome: An Illogical Belief?

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:2] [Pages No:414 - 415]

Keywords: Intensive care units mortality, Manpower, Time of admission

   DOI: 10.5005/jp-journals-10071-24721  |  Open Access |  How to cite  | 

314

EDITORIAL

Niraj Tyagi

ABG Analyzer for Electrolyte Measurement in ICU Patients: To Do or Not to Do

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:3] [Pages No:416 - 418]

Keywords: ABG electrolytes, Autoanalyzer, ICU, Laboratory research, Potassium, Sodium, Turnaround time

   DOI: 10.5005/jp-journals-10071-24722  |  Open Access |  How to cite  | 

452

EDITORIAL

Vivek Kumar

VeXUS: Do Not Drown in the ExCESS

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:3] [Pages No:419 - 421]

Keywords: Acute kidney injury, Children, Organ perfusion, Right ventricular dysfunction, Venous congestion, Venous excess in ultrasound score

   DOI: 10.5005/jp-journals-10071-24711  |  Open Access |  How to cite  | 

579

EDITORIAL

Sumalatha Arunachala, Jeevan Kumar

mNUTRIC Score in ICU Mortality Prediction: An Emerging Frontier or Yet Another Transient Trend?

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:2] [Pages No:422 - 423]

Keywords: Acute physiology and chronic health evaluation II, Artificial intelligence, ICU mortality, Inflammation, Malnutrition, Mortality prediction, Modified nutrition risk in critically ill score

   DOI: 10.5005/jp-journals-10071-24713  |  Open Access |  How to cite  | 

397

Original Article

Shivakumar Iyer, Rutula N Sonawane, Jignesh Shah, Naveen Salins

Semiotics of ICU Physicians’ Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:12] [Pages No:424 - 435]

Keywords: End-of-life care, Good death, Intensive care unit, Physician, Quality of dying, Views

   DOI: 10.5005/jp-journals-10071-24696  |  Open Access |  How to cite  | 

Abstract

Background and aim: While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. Methods: There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. Results: About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients’ and families’ choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Conclusion: Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians.

526

Original Article

Mahuya Bhattacharyya, Subhash K Todi

Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:6] [Pages No:436 - 441]

Keywords: Admission timings, Critically ill patients, Intensive care unit outcome, Length of stay, Mortality, Readmission

   DOI: 10.5005/jp-journals-10071-24694  |  Open Access |  How to cite  | 

Abstract

Background: The current study aimed to assess any association between intensive care unit (ICU) and hospital outcomes with ICU admission timings of critically ill patients. Methods: Retrospective observational single-center study involving all adult admissions. Each patient admission was categorized in “after-hours” (08:00 p.m.–07:59 a.m.), or “normal-hours” (08:00 a.m.–07:59 p.m.), “Weekday” (Monday–Saturday), or “Weekend” (Sunday), “Same day” (admission directly to ICU) or “other day admission” (admission to ICU after a hospital stay of ≥24 hours). Intensive care unit and hospital mortality, length of stay (LOS), and ICU readmission were assessed for any association with different admission timings. Results: Among 3,029 patients, 54.2% (1,668) were male, with mean age 66.49 (SD ± 15.69) years, mean acute physiology and chronic health evaluation-IV (APACHE-IV) score 55.5 (SD ± 26.3). Around 86.1% of admission occurred during weekdays, 13.9% on weekends, 57.4% normal-hours, 42.6% after-hours, 66.3% same day and 33.7% other day admission. Intensive care unit and hospital mortality were 10.8 and 14.2% respectively. Neither ICU nor hospital mortality were significantly different among patients admitted normal vs after-hours (p = 0.32, 0.23), and weekdays vs weekends (p = 0.09, 0.93), nor was ICU LOS (p = 0.21, 0.74). Intensive care unit and hospital mortality (p = 0.001), DORB (p = 0.001), hospital LOS (p = 0.001), and readmission to ICU (p = 0.001) were significantly higher in the other day admission group compared to same-day admission. In a multivariate regression analysis age, APACHE IV score along with other day admission to ICU did have a significant effect on both ICU and hospital mortality. Conclusion: Intensive care unit and hospital mortality and LOS did not differ significantly with hours or days of ICU admission though they were significantly higher in other day admission groups.

401

Original Article

RN Devaki, Prajna Kasargod, AN Roopa Urs, N Chandrika

A Retrospective Database Analysis to Investigate if Electrolytes in Venous Blood are Equivalent to the Levels in Arterial Blood

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:5] [Pages No:442 - 446]

Keywords: Chloride, Laboratory research, Potassium, Sodium, Turnaround time

   DOI: 10.5005/jp-journals-10071-24702  |  Open Access |  How to cite  | 

Abstract

Background: In a critically ill patient, when an arterial blood sample is processed on an arterial blood gas (ABG) analyzer, it also measures electrolytes apart from analyzing the blood gases. The turnaround time for ABG analysis is way too less compared to the conventional electrolyte analysis with a serum sample. Objective: This study intends to investigate whether values of electrolytes estimated in arterial blood can substitute the routinely practiced method. Materials and methods: This is a retrospective cross-sectional study. The source of data is patients’ reports of serum electrolytes and ABG analysis from the Clinical Biochemistry laboratory, CIMS Teaching Hospital, Chamarajanagar between January and June 2021. The electrolytes report of 200 patients from whom both arterial and venous blood samples were sent to the Clinical Biochemistry laboratory on the same day and at the same time for analysis were selected. The data was compiled, compared, and correlated using a suitable statistical tool. Results: The mean and standard deviation of sodium (135.62 ± 5.20 in venous vs 134.08 ± 8.49 in arterial blood), potassium (4.20 ± 0.64 vs 3.80 ± 0.75), and chloride (102.28 ± 4.99 vs 96.33 ± 8.11) were observed. However, when the concordance correlation coefficient and Bland-Altman plot analysis were made there was no agreement between electrolytes analyzed on serum in an autoanalyzer with that of ABG analyzer. Conclusion: We conclude that the electrolytes measured by a conventional autoanalyzer on a serum sample cannot be replaced by values analyzed on a blood gas analyzer.

309

Original Article

Rajeswari Natraj, Anu Kirthiga Bhaskaran, Philippe Rola, Korbin Haycock, Matthew TT Siuba, Suchitra Ranjit

Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:6] [Pages No:447 - 452]

Keywords: Acute kidney injury, Children, Right ventricular dysfunction, Venous congestion, Venous excess ultrasound

   DOI: 10.5005/jp-journals-10071-24705  |  Open Access |  How to cite  | 

Abstract

Background: Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys. Primary objective: To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion. Methods and results: This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD. Conclusion: VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI.

600

Original Article

Shwethapriya Rao, Sagar Shanmukhappa Maddani, Souvik Chaudhuri, Margiben T Bhatt, Shubhada Karanth, Anuja Damani, Krithika Rao, Naveen Salins

Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:8] [Pages No:453 - 460]

Keywords: Mortality, Palliative care, Paraquat poisoning, Predictors, Referral triggers

   DOI: 10.5005/jp-journals-10071-24708  |  Open Access |  How to cite  | 

Abstract

Background: Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Methods: Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Results: Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878–0.978. Kaplan–Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log–rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955–1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. Conclusion: The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care.

430

Original Article

Vashemane K Vineeth, Panchatcharam S Nambi, Ram Gopalakrishnan, Nandini Sethuraman, Yamunadevi Ramanathan, Chitra Chandran, Venkatasubramanian Ramasubramanian

Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:6] [Pages No:461 - 466]

Keywords: Antimicrobial stewardship, Blood culture identification 2, Flagged cultures, Polymyxin

   DOI: 10.5005/jp-journals-10071-24709  |  Open Access |  How to cite  | 

Abstract

Background: The availability of rapid diagnostic platforms for positive blood cultures has accelerated the speed at which the clinical microbiology laboratory can identify the causative organism and facilitate early appropriate antimicrobial therapy. There is a paucity of data regarding the clinical utility of the blood culture identification 2 (BCID2) panel test and its correlation with phenotypic drug susceptibility testing (DST) in flagged blood culture bottles from intensive care units (ICUs) in countries such as India, which have high rates of multidrug-resistant gram-negative bacteria (MDR-GNB). Materials and methods: We conducted a retrospective observational study in a tertiary care ICU on 200 patients above 18 years of age in whom a BCID2 test was ordered when blood cultures flagged positive. Results: We found 99% concordance between BCID2 and cultures in the identification of bacteria and yeasts and 96.5% concordance between phenotypic and genotypic DST. Furthermore, BCID2 was available about 1.5 days earlier than conventional ID and DST and played a key role in tailoring antimicrobials in 82.5% of the patients. Polymyxin-based therapy was discontinued earlier after an empiric dose in 138 patients (69%) based on BCID2 reports. Conclusion: In critically ill patients with monomicrobial bacteremia, BCID2 rapidly identifies bacteria and antimicrobial resistance (AMR) genes and is significantly faster than conventional culture and sensitivity testing. Antibiotics were escalated in more than a third of patients and de-escalated in almost a fifth on the same day. We recommend that all ICUs routinely incorporate the test in their antibiotic decision-making process and in antimicrobial stewardship.

448

Original Article

Gamonmas Ekkapat, Wirinaree Kampitak, Nonthikorn Theerasuwipakorn, Jirapat Kittipongpattana, Phatthanaphol Engsusophon, Jeerath Phannajit, Nalin Chokengarmwong

A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:8] [Pages No:467 - 474]

Keywords: Dexmedetomidine, Geriatric anesthesia, Hip fracture surgery, Postoperative delirium, Propofol

   DOI: 10.5005/jp-journals-10071-24710  |  Open Access |  How to cite  | 

Abstract

Aims and background: The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery. Materials and methods: This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to –1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay. Results: 108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups. Conclusion: This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate.

643

Original Article

Janhvi Gupta, Sujit Kshirsagar, Sanyogita Naik, Anandkumar Pande

Comparative Evaluation of Mortality Predictors in Trauma Patients: A Prospective Single-center Observational Study Assessing Injury Severity Score Revised Trauma Score Trauma and Injury Severity Score and Acute Physiology and Chronic Health Evaluation II Scores

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:8] [Pages No:475 - 482]

Keywords: Mortality, Road traffic accidents, Severity scores, Trauma

   DOI: 10.5005/jp-journals-10071-24664  |  Open Access |  How to cite  | 

Abstract

Aim: This prospective cohort study aimed to compare the predictive accuracy of outcome (survival/death) among trauma patients using various prognostic scores. Methods: Over 3 months, 240 trauma patients in a tertiary care hospital were assessed for demographic details, trauma characteristics, vital signs, Glasgow coma scale, arterial blood gas values, and lab markers. Injury severity score (ISS), revised trauma score (RTS), trauma and injury severity score (TRISS), and acute physiology and chronic health evaluation II (APACHE II) were applied at admission, 24 hours, and 48 hours post-admission. Results: Road traffic accidents (55.83%) were the primary cause of trauma, followed by falls (33.75%) and violence (10.41%). The all-cause mortality rate was 23.33%, with 34.16% requiring ICU admission. Head injuries (65.83%) were both the most frequent injury site and cause of mortality. Conclusion: Analysis indicated that APACHE II outperformed other scores in predicting outcomes, with ISS following closely. The study concludes that trauma severity correlates with ICU admission and mortality, emphasizing APACHE II as a superior predictor, particularly for traumatic brain injuries leading to ICU admission and mortality. Clinical significance: This study contributes to the existing body of knowledge by addressing the gap in comparing prognostic abilities among scoring systems for trauma patients. The unexpected superiority of APACHE II suggests its potential as a valuable tool in predicting outcomes in this specific patient population.

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Original Article

Viha Atri, Margiben Tusharbhai Bhatt, Souvik Chaudhuri, Aarohi Mitra, Sagar Shanmukhappa Maddani, Sunil Ravindranath

Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:12] [Pages No:483 - 494]

Keywords: Decision-making, Family, Family satisfaction in the ICU 24 revised, Consideration of need, Intensive care, Treatment of physical symptoms, Perception, Satisfaction, Treatment outcome

   DOI: 10.5005/jp-journals-10071-24621  |  Open Access |  How to cite  | 

Abstract

Background: Holistic intensive care management involves the treatment of critically ill patients in the intensive care unit (ICU) as well as catering to family psychosocial needs helping in bettering satisfaction/perception of care. There is scarce data in the Indian intensive care setting regarding the same, especially in times of increasing end-of-life practices. Our study aimed to determine the factors impacting family perception/satisfaction with intensive care. Materials and methods: A total of 336 family bystanders of patients in ICU with more than 72 hours of stay were surveyed using family satisfaction in the ICU 24 revised (FS-ICU 24R) questionnaire. Results: Multivariable logistic regression analysis showed that the significant factors associated with the satisfaction among bystanders of ICU patients were the treatment of patient's physical symptoms like pain/breathlessness (Adjusted OR 3.73, p = 0.003), ICU staff's approach to family's need consideration (Adjusted OR 4.44, p < 0.001), concern and care towards patients’ family (Adjusted OR 2.67, p = 0.023). Participation in patient care, ICU waiting room atmosphere, and emotional support are the other factors independently associated with satisfaction with ICU care. Family satisfaction was not associated with the patient's survival (p = 0.331, Chi-square test) or the length of ICU (p = 0.328, Chi-square test) and hospital stay (p = 0.865, Chi-square test). Conclusion: Treatment of a patient's physical symptoms like pain, approach to family's needs consideration, and concern/care towards the patient's family are independent factors associated with optimal satisfaction among family members of ICU patients, which even takes precedence over the survival outcomes or length of ICU stay.

425

SYSTEMATIC REVIEW

Jay Prakash, Saket Verma, Priyanka Shrivastava, Khushboo Saran, Archana Kumari, Kunal Raj, Amit Kumar, Hemant N Ray, Pradip K Bhattacharya

Modified NUTRIC Score as a Predictor of All-cause Mortality in Critically Ill Patients: A Systematic Review and Meta-analysis

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:9] [Pages No:495 - 503]

Keywords: Critically ill patients, Meta-analysis, Modified NUTRIC score, Mortality prediction, Systematic review

   DOI: 10.5005/jp-journals-10071-24706  |  Open Access |  How to cite  | 

Abstract

Purpose: The purpose of our meta-analysis was to look at the impact of modified nutrition risk in the critically ill (mNUTRIC) on mortality in patients with critical illness. Materials and methods: Literature relevant to this meta-analysis was searched in PubMed, Web of Science, and Cochrane Library till 26 August 2023. Prospective or retrospective studies, patients >18 years of age, studies that reported on mortality and mNUTRIC (mNUTRIC cut-off score) were included. The QUIPS tool was used to evaluate the risk for bias in prognostic factors. Results: A total of 31 studies on mNUTRIC score, involving 13,271 patients were included. The summary area under the curve (sAUC) of 0.80 (95% CI: 0.76–0.83) illustrates the mNUTRIC score's strong discrimination. The pooled sensitivity was 0.79 (95% CI: 0.74–0.84) and pooled specificity was 0.68 (95% CI: 0.63–0.73). We found no discernible variation in the mNUTRIC's prediction accuracy among cut-off values of <5 and >5 in our subgroup analysis and sAUC values were 0.82 (95% CI: 0.78–0.85) and 0.78 (95% CI: 0.74–0.81), respectively. Conclusion: We observed that mNUTRIC can discriminate between critically ill individuals and predict their mortality.

400

PEDIATRIC CRITICAL CARE MEDICINE

Renu Suthar, Suresh Kumar Angurana, Karthi Nallasamy, Arun Bansal, Jayashree Muralidharan

Survey of Pediatric Status Epilepticus Treatment Practices and Adherence to Management Guidelines (Pedi-SPECTRUM e-Survey)

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:7] [Pages No:504 - 510]

Keywords: Antiseizure medications, Midazolam, Nonconvulsive status epilepticus, Status epilepticus, Thiopentone

   DOI: 10.5005/jp-journals-10071-24707  |  Open Access |  How to cite  | 

Abstract

Aim: Survey of treatment practices and adherence to pediatric status epilepticus (PSE) management guidelines in India. Methods: This eSurvey was conducted over 35 days (15th October to 20th November 2023) and included questions related to hospital setting; antiseizure medications (ASMs); ancillary treatment; facilities available; etiology; and adherence to PSE management guidelines. Results: A total of 170 respondents participated, majority of them were working in tertiary level hospitals (94.1%) as pediatric intensivists (56.5%) and pediatricians (19.4%), and were in clinical practice for 2–10 years (46.5%). Majority use intravenous (IV) midazolam and levetiracetam as first- and second-line ASMs (67.1 and 51.2%, respectively). In cases with refractory status epilepticus (RSE), the most commonly used ASM is midazolam infusion (92.4%). For super-refractory status epilepticus (SRSE), the commonly used third-line ASMs include midazolam infusion (34.1%), thiopentone infusion (26.5%), high dose phenobarbitone (18.2%), and ketamine infusion (15.3%). Overall, in cases with SRSE, 44.7% respondents use ketamine infusion, 42.5% use add-on oral topiramate, and 34.7% use high-dose phenobarbitone (1–3 mg/kg/hour) infusion. Most respondents targeted both clinical and EEG seizure control (48.8%). Ancillary treatment used for SRSE included IV pyridoxine (57.1%), methylprednisolone (45.3%), IVIG (42.4%), ketogenic diet (40.6%), and second-line immunomodulation (33.5%). Most common causes were febrile SE, viral encephalitis, and febrile illness-related epilepsy syndrome (60.6%, 52.4%, and 37.1%, respectively). Facilities available included pediatric intensive care units (PICU) (97.1%), mechanical ventilation (98.2%), pediatric neurologist (68.8%), MRI brain (86.5%), EEG (69.4%), and viral PCR (58.2%). The compliance with guidelines for timing of initiation of ASM ranged from 63.5 to 88.8%. Conclusion: Intravenous midazolam bolus/es, levetiracetam, and midazolam infusion are commonly used first-, second-, and third-line ASMs, respectively. There were wide variations in use of ASMs for RSE and SRSE, ancillary treatment, and compliance to PSE management guidelines.

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LETTER TO THE EDITOR

Riddhi Kundu, Sumit R Chowdhury

Management of CRE Infections: High Time for an RCT?

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:1] [Pages No:511 - 511]

Keywords: Antibacterial, Antibiotic-resistance, Carbapenem-resistant enterobacterales

   DOI: 10.5005/jp-journals-10071-24646  |  Open Access |  How to cite  | 

334

LETTER TO THE EDITOR

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

Author Response

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:1] [Pages No:512 - 512]

Keywords: Antibacterial, Carbapenem-resistant enterobacterales, Critically ill adults, Observational study, Prospective study

   DOI: 10.5005/jp-journals-10071-24699  |  Open Access |  How to cite  | 

238

LETTER TO THE EDITOR

Siddannagoud Salotagi, Abinaya Kannan, Atul Jindal

Eternal Hunt: Unravelling the Challenge of CRE, the Quest for Perfection Continues!

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:2] [Pages No:513 - 514]

Keywords: Carbapenem-resistant enterobacteriaceae, Hospital-acquired infections

   DOI: 10.5005/jp-journals-10071-24639  |  Open Access |  How to cite  | 

270

LETTER TO THE EDITOR

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

Author Response

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:1] [Pages No:515 - 515]

Keywords: Carbapenem-resistant enterobacterales, Ceftazidime-avibactam, Critically ill patients, Sequential organ failure assessment

   DOI: 10.5005/jp-journals-10071-24701  |  Open Access |  How to cite  | 

285

LETTER TO THE EDITOR

Josef Finsterer

Before Diagnosing Paroxysmal Sympathetic Hyperactivity in PICU Patients Alternative Conditions must be Considered

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:2] [Pages No:516 - 517]

Keywords: Paroxysmal sympathetic hyperactivity, Pediatric, PICU, Sympathetic overactivity, Vegetative nervous system

   DOI: 10.5005/jp-journals-10071-24645  |  Open Access |  How to cite  | 

238

LETTER TO THE EDITOR

Shipra Agrwal, Pallavi, Urmila Jhamb, Romit Saxena

Author Response

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:2] [Pages No:518 - 519]

Keywords: Neuroimaging, Paroxysmal sympathetic hyperactivity, Pediatric intensive care unit

   DOI: 10.5005/jp-journals-10071-24703  |  Open Access |  How to cite  | 

206

LETTER TO THE EDITOR

Meenupriya Arasu, Akhil Kant Singh, Akshay LaguduvaH

A Simple Adaptation for the Convenient Application of Incentive Spirometry in Tracheostomized Critically Ill Patients

[Year:2024] [Month:May] [Volume:28] [Number:5] [Pages:2] [Pages No:520 - 521]

Keywords: Incentive spirometry, Inspiratory muscle training, Tracheostomy

   DOI: 10.5005/jp-journals-10071-24712  |  Open Access |  How to cite  | 

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