Indian Journal of Critical Care Medicine

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2024 | July | Volume 28 | Issue 7

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EDITORIAL

Saswati Sinha

Interleukin-6 in Sepsis—Promising but Yet to Be Proven

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:3] [Pages No:629 - 631]

Keywords: Acute physiology and chronic health evaluation-II, APACHE II score, Biomarkers, ICU prognostic models, Interleukin-6, Predictive model, Sepsis, Sepsis and ICU, Sequential organ failure assessment

   DOI: 10.5005/jp-journals-10071-24758  |  Open Access |  How to cite  | 

269

EDITORIAL

Kapil Dev Soni

Ultrasound-guided Arterial Cannulation: What are We Missing and Where are We Headed?

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:2] [Pages No:632 - 633]

Keywords: Acoustic shadowing, Radial artery cannulation, Systematic review and meta-analysis, Ultrasound guided

   DOI: 10.5005/jp-journals-10071-24757  |  Open Access |  How to cite  | 

280

EDITORIAL

Rajesh Mohan Shetty

Advancing the Management of Nontraumatic Brain Injuries with Hypertonic Saline and Mannitol

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:3] [Pages No:634 - 636]

Keywords: Brain Injuries, Hyperotonic solutions, Mannitol

   DOI: 10.5005/jp-journals-10071-24756  |  Open Access |  How to cite  | 

246

Original Article

Penna RV Reddy, Mounika Cherukuri, Vandana K Eshwara, Chandrashekar Udyavara Kudru, RV Krishnananda Prabhu

Diagnostic Potential of Serum Interleukin-6 in Predicting Bacteremia in Adult Patients with Sepsis: A Prospective Observational Study

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:8] [Pages No:637 - 644]

Keywords: Bacteremia, Interleukin-6, Mortality, Sepsis, Septic shock

   DOI: 10.5005/jp-journals-10071-24754  |  Open Access |  How to cite  | 

Abstract

Background: This study aimed to assess the potential of serum interleukin-6 (IL-6) as a diagnostic marker in predicting bacteremia and to determine its association with severity and outcome among sepsis patients. Materials and methods: A prospective observational study was conducted, comprising a cohort of 118 patients admitted to the ICU with suspected sepsis from January 2019 to April 2020. Results: Among the 108 patients analyzed, 60 (55.6%) were bacteremic and 48 (44.4%) were nonbacteremic. Of 60 patients with bacteremia, 13 (21.6%) had sepsis and 47 (78.3%) had septic shock. In predicting bacteremia, the area under the curve (AUC) for IL-6 was 0.512 [95% CI, 0.400–0.623]. The AUC for IL-6 in differentiating sepsis from septic shock was 0.724 [95% CI, 0.625–0.823]. The sensitivity and specificity for predicting bacteremia for IL-6 were 66% and 67%, respectively (p < 0.001). Multivariate analysis revealed that C-reactive protein (CRP) (p = 0.04) and APACHE II score (p = 0.025) were significant predictors of bacteremia, whereas lactate (p = 0.04), and APACHE II score (p < 0.001) were significant predictors of sepsis severity. Patients with elevated levels of procalcitonin PCT (p = 0.024), APACHE II (p = 0.003), and SOFA (p = 0.002) scores had significantly higher mortality rates. Conclusion: C-reactive protein and APACHE II score, lactate and APACHE II score, and PCT, SOFA, and APACHE II scores performed better in predicting bacteremia, sepsis severity, and clinical outcome, respectively compared with IL-6.

304

Original Article

Ruma Thakuria, Emmanuel Easterson Ernest, Apala Roy Chowdhury, Neha Pangasa, Choro Athiphro Kayina, Sulagna Bhattacharjee, Puneet Khanna, Dalim K Baidya, Banupriya Ravichandrane, Souvik Maitra

Oxygenation Index and Oxygen Saturation Index for Predicting Postoperative Outcome in Patients Undergoing Emergency Surgery: A Prospective Cohort Study

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:5] [Pages No:645 - 649]

Keywords: Driving pressure, Emergency surgery, Mortality, Outcome, Oxygenation index, Oxygen saturation index

   DOI: 10.5005/jp-journals-10071-24749  |  Open Access |  How to cite  | 

Abstract

Background: The OI was originally evaluated as a prognostic tool for acute hypoxemic respiratory failure in children and was an independent predictor for mortality in adult patients with acute respiratory distress syndrome (ARDS). Methods: Oxygenation index and OSI of 201 adult patients undergoing emergency surgery were evaluated at different time points. The primary objective of this study was to find the correlation between OI and OSI. The secondary objectives were to find the prognostic utility of OI and OSI for postoperative mechanical ventilation and mortality. Results: Significant statistical correlation was found between OI and OSI both at the beginning (r2 = 0.61; p < 0.001) and immediately after surgery (r2 = 0.47; p < 0.001). Oxygen saturation index at the beginning [area under the receiver operating characteristics curve (AUROC) (95% CI) 0.76 (0.62–0.89); best cutoff 3.9, sensitivity 64% and specificity 45%] and immediately after surgery [AUROC (95% CI) 0.82 (0.72–0.92); best cutoff 3.57, sensitivity 79%, and specificity 62%] were reasonable predictors of the requirement of invasive ventilatory support. Exploratory analysis reported that older age (p = 0.02), higher total leukocyte count (p = 0.002), higher arterial lactate (p = 0.02), and higher driving pressure (p < 0.001) were independently associated with hospital mortality. Conclusion: In adult patients undergoing emergency laparotomy under general anesthesia, OI and OSI were found to be correlated. Both metrics demonstrated reasonable accuracy in predicting the need for invasive ventilatory support beyond 24 hours and hospital mortality.

275

Original Article

Shashikant Sharma, Rashmi Ramachandran, Vimi Rewari, Anjan Trikha

Evaluation of Electrical Cardiometry to Assess Fluid Responsiveness in Patients with Acute Circulatory Failure: A Comparative Study with Transthoracic Echocardiography

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:7] [Pages No:650 - 656]

Keywords: Acute circulatory failure, Bland–Altman plot, Electrical cardiometry, Fluid responsiveness, Transthoracic echocardiography

   DOI: 10.5005/jp-journals-10071-24753  |  Open Access |  How to cite  | 

Abstract

Aim: Acute circulatory failure is commonly encountered in critically ill patients, that requires fluid administration as the first line of treatment. However, only 50% of patients are fluid-responsive. Identification of fluid responders is essential to avoid the harmful effects of overzealous fluid therapy. Electrical cardiometry (EC) is a non-invasive bedside tool and has proven to be as good as transthoracic echocardiography (TTE) to track changes in cardiac output. We aimed to look for an agreement between EC and TTE for tracking changes in cardiac output in adult patients with acute circulatory failure before and after the passive leg-raising maneuver. Materials and methods: Prospective comparative study, conducted at a Tertiary Care Teaching Hospital. Results: We recruited 125 patients with acute circulatory failure and found 42.4% (53 out of 125) to be fluid-responsive. The Bland–Altman plot analysis showed a mean difference of 2.08 L/min between EC and TTE, with a precision of 3.8 L/min. The limits of agreement (defined as bias ± 1.96SD), were −1.7 L/min and 5.8 L/min, respectively. The percentage of error between EC and TTE was 56% with acceptable limits of 30%. Conclusion: The percentage error beyond the acceptable limit suggests the non-interchangeability of the two techniques. More studies with larger sample sizes are required to establish the interchangeability of EC with TTE for tracking changes in cardiac output in critically ill patients with acute circulatory failure.

190

Original Article

Amarja A Havaldar, Sumithra Selvam

Nutritional Prescription in ICU Patients: Does it Matter?

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:5] [Pages No:657 - 661]

Keywords: Calorie deficit, Coefficient of variation, Glucose variability, mNUTRIC score, Nutrition prescription

   DOI: 10.5005/jp-journals-10071-24755  |  Open Access |  How to cite  | 

Abstract

Background: The nutritional status of the patients before critical illness and nutrition support given during the critical illness play an important role in the recovery. We aimed to evaluate the nutritional prescription and its effect on ICU mortality. Materials and methods: This was a prospective observational study conducted after institutional ethical committee approval (IEC 94/2018, CTRI/2018/06/014625) in a case-mixed (medical and surgical) ICU. Patients admitted to the ICU were enrolled within 24 hours of admission. The amount of calories and proteins prescribed and received by the patients was collected for 7 days. The primary outcome was ICU mortality. Results: A total of 100 patients were included. The mean age was 48.63 (16.25) years, and 62% were males. The acute physiology and chronic health evaluation (APACHE II), sequential organ failure assessment (SOFA), and modified Nutric (mNUTRIC) scores were comparable between the two groups. The ICU mortality was 30%. The calorie and protein deficits were comparable between survivors and non-survivors. Among the secondary outcomes, a significant time effect (p = 0.013) and interaction effect (p = 0.004) were noted for maximum glucose levels. The glucose variability calculated by coefficient of variation (CV) was significantly higher in non-survivors than survivors (p = 0.031). Conclusion: The calorie and protein deficits did not affect ICU mortality. The maximum glucose variability and CV were significant parameters associated with ICU mortality.

254

Original Article

Prity R Deshwal, Pramil Tiwari

Investigating the Variability among Indicators for Quantifying Antimicrobial Use in the Intensive Care Units: Analysis of Real-world Evidence

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:15] [Pages No:662 - 676]

Keywords: Antimicrobial use, Days of therapy, Defined daily dose, Length of therapy, Prescribed daily dose, Real-world evidence

   DOI: 10.5005/jp-journals-10071-24745  |  Open Access |  How to cite  | 

Abstract

This study investigated variability among four indicators for quantifying antimicrobial use in intensive care units (ICUs): defined daily doses (DDD), prescribed daily doses (PDD), duration of therapy (DOT), and length of therapy (LOT) and recommended the most clinically relevant approach. Retrospective data from patients who had received at least one antimicrobial was analyzed. Patients whose records were incomplete or expired were excluded. Duration of therapy (24433/1000 PDs) and LOTs (12832/1000 PDs) underestimated the overall consumption of antimicrobials compared with DDD of 28391/1000 PDs. Whereas PDD (46699/1000 PDs) overestimated it. Comparison analysis detected % differences of 13.94, 23.92, and 54.80% between DDD and DOT, DDD and PDD, and DDD and LOT, indicators respectively. Linear regression revealed stronger (r2 = 0.86), moderate (r2 = 0.50), and moderate (r2 =0.60) correlation between DDD and DOT, DDD and PDD and DDD and LOT indicators respectively. According to findings, combining DOT and DDD is a more practical method to quantify antimicrobial consumption in hospital ICUs.

Supplementary file

166

SYSTEMATIC REVIEW

Lipi Mishra, Chandra Rath, Bradley Wibrow, Matthew Anstey, Kwok Ho

Acoustic Shadowing to Facilitate Ultrasound Guided Arterial Cannulation: A Systematic Review and Meta-analysis of Randomized Controlled Trials

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:9] [Pages No:677 - 685]

Keywords: Acoustic shadow, Arterial cannulation, Ultrasound

   DOI: 10.5005/jp-journals-10071-24751  |  Open Access |  How to cite  | 

Abstract

Aim and background: Ultrasound-guided arterial catheterization is a frequently performed procedure. Additional techniques such as acoustic shadowing-assisted ultrasound may be useful in improving success rate. This systematic review aimed to assess the efficacy of acoustic shadowing assisted ultrasound for arterial catheterization. Materials and methods: PubMed, Medline, EMBASE, Cochrane Library, EMCARE, and MedNar were searched in January 2024. Randomized controlled trials comparing the first attempt success rate of arterial catheterization using acoustic shadowing ultrasound vs unassisted ultrasound were included. Data were pooled for risk ratios (RRs) using the random-effects model. Subgroup analysis was conducted based on a single or double acoustic line. Sensitivity analysis was undertaken after excluding pediatric data. The certainty of evidence (COE) was assessed using the GRADE framework. Results: Six randomized controlled trials (n = 777) were included. A meta-analysis found the first attempt success rate is significantly higher in the acoustic ultrasound group (n = 6, RR: 0.47, 95% CI: 0.34–0.66, p ≤ 0.00001). Hematoma formation was significantly less in the acoustic ultrasound group (n = 6, RR: 0.52, 95% CI: 0.34–0.80, p = 0.003). First attempt success was significantly higher in the single acoustic line ultrasound (USG) group compared to the unassisted ultrasound group (n = 3, RR: 0.41, 95% CI: 0.28–0.59, p ≤ 0.00001). Sensitivity analysis after excluding pediatric data was similar to the primary analysis (n = 5, RR: 0.50, 95% CI: 0.33–0.70, p ≤ 0.00001). Certainty of evidence was “Moderate” for the first attempt cannulation. Conclusions: Acoustic shadowing-assisted ultrasound improved first-attempt arterial catheterization success rate and was associated with reduced hematoma formation.

214

SYSTEMATIC REVIEW

Arnab Choudhury, Ravikant, Mukesh Bairwa, G Jithesh, Sahil Kumar, Nitin Kumar

Efficacy of Intravenous 20% Mannitol vs 3% Hypertonic Saline in Reducing Intracranial Pressure in Nontraumatic Brain Injury: A Systematic Review and Meta-analysis

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:10] [Pages No:686 - 695]

Keywords: Administration, Brain injuries, Hypertonic, Hypertonic saline, Intravenous, Intracranial pressure, Mannitol, Meta-analysis, Retrospective studies

   DOI: 10.5005/jp-journals-10071-24746  |  Open Access |  How to cite  | 

Abstract

Background: Nontraumatic brain injury encompasses various pathological processes and medical conditions that result in brain dysfunction and neurological impairment without direct physical trauma. The study aimed to assess the efficacy of intravenous administration of 20% mannitol and 3% hypertonic saline to reduce intracranial pressure in nontraumatic brain injury. Materials and methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed for study selection and data extraction. The search was conducted in the PubMed, Embase, and Scopus databases, including articles published in English from January 2003 to December 2023. Our study included randomized controlled trials, comparative studies, prospective analyses, and retrospective cohort studies. We extracted data on baseline characteristics of patients, intervention details, major outcomes, and complications. Quality assessment was performed using the Jadad scale and the Robvis assessment tool for risk of bias. Results: A total of 14 studies involving 1,536 patients were included in the analysis. Seven studies reported hypertonic saline as more effective in reducing intracranial pressure, while three studies found similar effectiveness for both interventions. Adverse events were reported in only three studies. The studies that reported complication rates ranged from 21 to 79%. A meta-analysis was conducted on five studies, showing varying rates of adverse events associated with mannitol and hypertonic saline. Conclusion: Both hypertonic saline solution and mannitol have been explored as treatment options for decreasing intracranial pressure in nontraumatic brain injuries. While some studies indicate the superiority of hypertonic saline, others report similar effectiveness between the two interventions.

270

BRIEF RESEARCH COMMUNICATION

Sashisenla Kichu, Poonam Joshi, Sunidhi Bhandari, Rakesh Lodha, K Jaykrishnan

Experiences of the Parents of Children Admitted to PICU

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:6] [Pages No:696 - 701]

Keywords: Experiences, Hospitalized children, Parents, Pediatric intensive care unit

   DOI: 10.5005/jp-journals-10071-24653  |  Open Access |  How to cite  | 

Abstract

Introduction: A pediatric intensive care unit (PICU) is a highly technological and fast-paced setting in a hospital. Objective: To explore the experiences of the parents in the critical care area of a selected tertiary care facility. Materials and methods: In a qualitative study, we interviewed 10 purposively selected parents of the children admitted to PICU using a pre-validated in-depth interview schedule. All parents, whose children were admitted to PICU for more than 5 days, who understood Hindi or English and were willing to participate in the study, were enrolled in the study. Parents of critically ill children having readmission to PICU or prolonged stay of more than 15 days and not accompanied by parents were excluded. Results: Parents had unmet needs, such as the need for information, counseling and education from the healthcare team (HCT) members, having trusting relationship with the HCT, and expecting receiving orientation of the routines and the protocols of PICU, and empathy from the various levels of PICU team. The majority of subjects expressed the desire to talk to a dedicated person for their queries. The parents had multiple feelings of distress, hopelessness, helplessness, guilt, and the fear of losing the child and used various coping strategies. Conclusion: Parents of critically ill children in the PICU have unmet needs. Healthcare team members should take initiative in relieving parental distress and improving their coping abilities.

172

CLINICAL TECHNIQUE

Rajender Kumar, Rakesh Kumar

An Indigenous Suction-assisted Laryngoscopy and Airway Decontamination Simulation System

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:4] [Pages No:702 - 705]

Keywords: Airway, Simulator, Suctioning, Suction-assisted laryngoscopy and airway decontamination

   DOI: 10.5005/jp-journals-10071-24760  |  Open Access |  How to cite  | 

Abstract

Background: Suction-assisted laryngoscopy and airway decontamination (SALAD) is a new modality and training manikins are quite costly. Few modifications have been described with their pluses and minuses. We describe a low-cost simulator that replicates fluid contamination of the airway at various flow rates and allows the practice of SALAD in vitro. Materials and methods: We modified a standard Laerdal airway management trainer with locally available equipment to simulate varying rates of continuous vomiting or hemorrhage into the airway during intubation. The effectiveness of our SALAD simulator was tested during an advanced airway workshop of the Airway Management Foundation (AMF). The workshop had a brief common presentation on the learning objective of the SALAD technique followed by a demonstration to small groups of 5–6 participants at one time with necessary instructions. This was followed by a hands-on practical learning session on the simulator. Results: One hundred and five learners used the simulator including 15 faculties and 90 participants (48 on ICU and 42 on ENT workstations). At the end of the session, the workshop faculty and participants were asked to rate their level of confidence in managing similar situations in real practice on a four-point Likert scale. All 15 faculty members and 70 out of 90 participants felt very confident in managing similar situations in real practice. Fifteen participants felt fairly confident and 5 felt slightly confident. Conclusion: In resource-limited settings, our low-cost SALAD simulator is a good educational tool for training airway managers in the skills of managing continuously and rapidly soiling airways.

174

LETTER TO THE EDITOR

Rohan Magoon, Jes Jose, Mukesh Kumar

Mirror, Mirror on the Wall; He Had a “Bypass” After All!

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:2] [Pages No:706 - 707]

Keywords: Coronary artery bypass grafting, Internal mammary grafts, Left internal thoracic artery, Pleurotomy, Postoperative pulmonary function

   DOI: 10.5005/jp-journals-10071-24684  |  Open Access |  How to cite  | 

156

LETTER TO THE EDITOR

Manish P Shukla

Author Response: Mirror, Mirror on the Wall; He Had a “Bypass” After All!

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:1] [Pages No:708 - 708]

Keywords: Coronary artery bypass grafting, Internal mammary grafts, Left internal thoracic artery, Pleurotomy, Postoperative pulmonary function

   DOI: 10.5005/jp-journals-10071-24739  |  Open Access |  How to cite  | 

118

LETTER TO THE EDITOR

Vijay Sundarsingh, Manoj Kumar, Pramela R Rodrigues

The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (pCO2 Gap) during Resuscitation Affects ICU Outcomes: A Prospective Observational Study

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:1] [Pages No:709 - 709]

Keywords: Circulatory shock, Correlation, pCO2 gap

   DOI: 10.5005/jp-journals-10071-24724  |  Open Access |  How to cite  | 

150

LETTER TO THE EDITOR

Anand M Tiwari, Kapil G Zirpe, Atul P Kulkarni

Author Response: The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (PCO2 Gap) during Resuscitation Affects ICU Outcomes: A Prospective Observational Study

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:1] [Pages No:710 - 710]

Keywords: Intensive care unit outcome, PCO2 gap, Shock

   DOI: 10.5005/jp-journals-10071-24742  |  Open Access |  How to cite  | 

156

LETTER TO THE EDITOR

Shilpushp J Bhosale, Malini Joshi, Praveen Dhakane, Ashwini D Rane, Atul P Kulkarni

Transient STEMI: Not to be Considered a Lesser Evil

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:2] [Pages No:711 - 712]

Keywords: Acute ST-elevation myocardial infarction, Coronary syndrome, Reperfusion

   DOI: 10.5005/jp-journals-10071-24752  |  Open Access |  How to cite  | 

184

LETTER TO THE EDITOR

Praveen K Das, Soumya S Nath, Samiksha Parashar

Contradictory Recommendation in the Guideline for Antibiotic Prescription

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:2] [Pages No:713 - 714]

Keywords: Antibiotic, Intra-abdominal infection, Peritonitis

   DOI: 10.5005/jp-journals-10071-24736  |  Open Access |  How to cite  | 

237

LETTER TO THE EDITOR

Soumya S Nath, Nandhini Nachimuthu, Bhagyashree, Supriya Singh

Unanswered Questions in the Guidelines for Antibiotic Prescription in Critically Ill Patients

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:2] [Pages No:715 - 716]

Keywords: 28-day mortality, Community acquired pneumonia, Hydrocortisone, Shock

   DOI: 10.5005/jp-journals-10071-24704  |  Open Access |  How to cite  | 

245

LETTER TO THE EDITOR

Gopi Chand Khilnani, Pawan Tiwari, Saurabh Mittal

Author Response: Unanswered Questions and Contradictory Statements in the Antibiotics Prescription Guidelines

[Year:2024] [Month:July] [Volume:28] [Number:7] [Pages:2] [Pages No:717 - 718]

Keywords: Antibacterial, Antibiotics, Guidelines, Intensive care unit

   DOI: 10.5005/jp-journals-10071-24750  |  Open Access |  How to cite  | 

188

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