Lurking Danger: Emerging Evidence.

How to cite this article: Gopal PB. Lurking Danger: Emerging Evidence. Indian J Crit Care Med 2024;28(2):93-94.

Recent advancements in critical care: Part I.

Medical colleges are now developing or refurbishing their anaesthesia intensive care units. In most teaching colleges, the residency post includes working in the critical care unit (CCU). Critical care is a rapidly evolving and popular super-speciality for postgraduate students. In some hospitals, anaesthesiologists play a key role in the management of the CCU. As perioperative physicians, all anaesthesiologists should be aware of the recent advancements in diagnostic and monitoring gadgets and investigations in critical care so that they may manage perioperative events effectively. Haemodynamic monitoring gives us warning signs about the change in the internal milieu of the patient. Point-of-care ultrasonography helps in rapid differential diagnosis. Point-of-care diagnostics give us instant bed-side information on the condition of a patient. Biomarkers help in confirming diagnosis, in monitoring, treatment, and providing prognosis. Molecular diagnostics guide anaesthesiologists in providing specific treatment to a causative agent. This article touches upon all of these management strategies in critical care and attempts to put forth the recent advancements in this speciality.

Recent advances in critical care: Part II.

With the increasing number of critically ill patients being admitted to intensive care units (ICUs), newer techniques and treatment modalities continue to evolve for their adequate management. Thus, it has become imperative to understand existing tools and resources, and utilise or repurpose them to achieve better results that can decrease morbidity and mortality. In this writeup, we chose five areas of interest, including analgosedation, role of colloids, recent advancements in the management of respiratory failure, the role of extracorporeal membrane oxygenation, and newer antimicrobials. The role of analgosedation in the critically ill has gained importance with focus on post-ICU syndromes, and albumin has re-entered the fray as a possible repairer of the injured glycocalyx. The coronavirus disease 2019 (COVID-19) pandemic forced us to relook at various ventilator strategies and mechanical support for the failing circulation has now become more common with clear end-points. Rising microbial antibiotic resistance has opened up the research on newer antibiotics.

Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM.

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give "real-world" criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs. How to cite this article: Zirpe KG, Tiwari AM, Pandit RA, Govil D, Mishra RC, Samavedam S, et al. Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM. Indian J Crit Care Med 2022;26(S2):S43-S50.

Therapeutic Approaches in Modulating the Inflammatory and Immunological Response in Patients With Sepsis, Acute Respiratory Distress Syndrome, and Pancreatitis: An Expert Opinion Review.

Immunomodulation has long been an adjunct approach in treating critically ill patients with sepsis, acute respiratory distress syndrome (ARDS), and acute pancreatitis (AP). Hyperactive immune response with immunopathogenesis leads to organ dysfunction and alters the clinical outcomes in critically ill. Though the immune response in the critically ill might have been overlooked, it has gathered greater attention during this novel coronavirus disease 2019 (COVID-19) pandemic. Modulating hyperactive immune response, the cytokine storm, especially with steroids, has shown to improve the outcomes in COVID-19 patients. In this review, we find that immune response pathogenesis in critically ill patients with sepsis, ARDS, and AP is nearly similar. The use of immunomodulators such as steroids, broad-spectrum serine protease inhibitors such as ulinastatin, thymosin alpha, intravenous immunoglobulins, and therapies such as CytoSorb and therapeutic plasma exchange may help in improving the clinical outcomes in these conditions. As the experience of the majority of physicians in using such therapeutics may be limited, we provide our expert comments regarding immunomodulation to optimize outcomes in patients with sepsis/septic shock, ARDS, and AP.

The Clasp of CLABSI.

How to cite this article: Gopal PB. The Clasp of CLABSI. Indian J Crit Care Med 2020;24(1):3-5.

Quality Indicators Compliance Survey in Indian Intensive Care Units.

CONTEXT: The quality of health care and outcomes of Intensive Care Unit (ICU) have been a major subject of discussion in the past decade. Quality indicators in ICUs maintain an order of uniformity and standard care of delivery across ICUs. AIMS: In this study, we tried to analyze the percentage compliance of quality indicators in ICU across our country. METHODS: Four hundred complete questionnaire forms were collected in two stages by means of conducting a survey and through email responses to the survey questionnaire. Data were tabulated and evaluated in percentage responses. RESULTS: Monitoring of infection control measures such as hand hygiene (77%), monitoring of ICU-acquired infections (>75%), and quality and policy measures (>70%) were promising. Improvements are required in following end-of-life pathways (52%) and staffing patterns in ICU. ICU discharge timings (41%), standardized mortality ratio monitoring (39%), and multidisciplinary rounds (58%) in ICUs are few areas we need to develop further. CONCLUSION: The future of critical care looks promising with growing number of trained intensivists and hospitals functioning with an average ICU bed strength of 30-40. Such surveys need to be performed regularly to improve the patient care and safety across ICUs.

Induced hypothermia for trauma-related ARDS.

We report a case of 27-year-old male with lung contusions related acute respiratory distress syndrome (ARDS) managed by ARDSNet guidelines and additional hypothermia. On 4(th) day, post trauma partial pressure of oxygen dropped to 38 mm of mercury (Hg), not improving even on high positive end-expiratory pressure of 18 cm water (H2O), inverse ratio ventilation and fraction of inspired oxygen of 1. Extracorporeal membrane oxygenation was ruled out due to the risk of hemorrhage from trauma sites. Thereafter, hypothermia along with muscle paralysis was considered to reduce total body oxygen consumption. Patient's condition improved under hypothermia, and he was extubated and taken up for fracture fixation surgeries and discharged later in stable condition.

Stress levels of critical care doctors in India: A national survey.

BACKGROUND: Doctors working in critical care units are prone to higher stress due to various factors such as higher mortality and morbidity, demanding service conditions and need for higher knowledge and technical skill. AIM: The aim was to evaluate the stress level and the causative stressors in doctors working in critical care units in India. MATERIALS AND METHODS: A two modality questionnaire-based cross-sectional survey was conducted. In manual mode, randomly selected delegates attending the annual congress of Indian Society of Critical Care Medicine filled the questionnaire. In the electronic mode, the questionnaires were E-mailed to critical care doctors. These questionnaires were based on General Health Questionnaire-12 (GHQ-12). Completely filled 242 responses were utilized for comparative and correlation analysis. RESULTS: Prevalence of moderate to severe stress level was 40% with a mean score of 2 on GHQ-12 scale. Too much responsibility at times and managing VIP patients ranked as the top two stressors studied, while the difficult relationship with colleagues and sexual harassment were the least. Intensivists were spending longest hours in the Intensive Care Unit (ICU) followed by pulmonologists and anesthetists. The mean number of ICU bed critical care doctors entrusted with was 13.2 ± 6.3. Substance abuse to relieve stress was reported as alcohol (21%), anxiolytic or antidepressants (18%) and smoking (14%). CONCLUSION: Despite the higher workload, stress levels measured in our survey in Indian critical care doctors were lower compared to International data. Substantiation of this data through a wider study and broad-based measures to improve the quality of critical care units and quality of the lives of these doctors is the need of the hour.

Invasive aspergillosis in near drowning nonneutropenic patient.

Invasive aspergillosis in immunosuppressed people has been well documented, but to diagnose and treat in an immunocompetent individual after near drowning, it requires early suspicion and proper empirical treatment. We report a case diagnosed to have invasive aspergillosis with systemic dissemination of the infection to the brain, gluteal muscles, and kidneys after a fall in a chemical tank of a paper manufacturing company. He was ventilated for acute respiratory distress syndrome and managed with antibiotics and vasopressors. Due to nonresolving pneumonia and positive serum galactomannan, trans-tracheal biopsy was performed which confirmed invasive aspergillosis and was treated with antifungals. With the availability of galactomannan assay and better radiological investigative modalities, occurrence of such invasive fungal infections in cases of drowning patients should be considered early in such patients and treated with appropriate antifungals.

Profile and outcome of patients with liver cirrhosis requiring mechanical ventilation.

OBJECTIVE: Few studies have addressed the outcome of patients with cirrhosis requiring mechanical ventilation (MV). We aimed to investigate the short-term outcome of such patients. METHODS: Retrospective review of data of 73 consecutive patients with cirrhosis requiring MV over a 2-year period (2006-2008). Data on patient's characteristics, reason for MV, the presence of other organ failure, and first day Acute Physiology Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), Child-Pugh (CP), and Model for End-Stage Liver Disease (MELD) scores were collected, with 30-day mortality being the primary outcome measure. RESULTS: Observed mortality in ICU and at 30 days was 75.3% and 87.7%, respectively. Area under curve was 0.77 (95% CI, 0.65-0.86) for APACHE II, 0.94 (95% CI, 0.85-0.98) for SOFA, 0.83 (95% CI, 0.7-0.96) for CP, and 0.93 (95% CI, 0.85-0.98) for MELD (P = .096) in predicting 30-day mortality. By univariate analysis, indication for intubation (P = .001), need for vasopressor support (P = .002), the presence of renal failure (P < .03), and duration of MV (P < .001) were significantly associated with mortality. On multivariate analysis, only duration of MV (adjusted odds ratio 0.63, 95% CI: 0.42-0.95, P = .03) was the independent predictor of mortality with a majority of patients, 51/64 (79.7%), dying in the first 48 hours of intubation. CONCLUSIONS: Patients with cirrhosis requiring MV have a dismal prognosis. Such patients and their families should be informed about the overall outcome to assist their decisions about life support and intensive care, outside the transplant setting. Prognostic scores, especially SOFA and MELD, may aid in determining which patients may benefit from aggressive therapy.

Outcome of patients with end stage renal disease admitted to an intensive care unit in India.

AIMS: We sought to determine outcome and evaluate performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores upon admission in predicting 30-day mortality of end-stage renal disease (ESRD) patients admitted in ICU. METHODS: This prospective observational cohort study examined 73 consecutive ESRD patients admitted in an ICU of a tertiary care institute over 15 months. Primary outcome measure was 30-day mortality. Data on patient characteristics, reason for ICU admission, cause of ESRD, mode of renal replacement, and use of mechanical ventilation (MV) or inotropes were recorded. The APACHE 2 and SOFA scores were calculated based on admission characteristics. RESULTS: First-day median APACHE II, SOFA, and APACHE II-predicted hospital mortality rates were 26 (14-49), 7 (4-17), and 56.9% (18.6-97.4%), respectively. Observed ICU and 30-day mortality rates were 27.4%, and 41.1%, respectively. During the ICU course, MV and inotropic support was required in 27 (37%) and 23 (35.1%) patients, respectively. Need for MV (p < 0.001) and inotropic support (p < 0.001) were predictors of 30-day mortality in univariate analysis. Area under receiver operating characteristic curve for APACHE II in predicting 30-day mortality was 0.86 (95% CI, 0.76-0.93) compared with 0.92 (95% CI, 0.83-0.97) for SOFA score (p = 0.16). CONCLUSIONS: Outcome of ESRD patients admitted to ICU is poor, especially if they require other organ support. APACHE II and SOFA scores perform well as predictors of 30-day mortality.

Scoring systems in acute pancreatitis: which one to use in intensive care units?

PURPOSE: The aim of the study was to assess and compare the efficacy of various scoring systems in predicting the severity and outcome of patients with acute pancreatitis (AP) admitted in intensive care unit (ICU). METHODS: Prospective, single institution review of 55 consecutive AP patients admitted in ICU during a 2-year period. Disease severity scores and mortality predictions were calculated using the collected data in the first 48 hours of ICU admission for Ranson and Glasgow scores and in the first 24 hours for other scores. RESULTS: Forty-two patients (76.4%) developed severe pancreatitis. Intensive care unit and 30-day mortality was 18.2% and 27.3%, respectively. Use of mechanical ventilation (MV) was an independent predictor of outcome on multivariate analysis with lack of MV being protective (adjusted odds ratio, 0.003; 95% confidence interval [CI], 0.00001-0.67; P = .04). All scoring systems had comparable accuracy in predicting severity and 30-day mortality, but sequential organ failure assessment (SOFA) score had greater efficacy with its area under curve for predicting severity and 30-day mortality being 0.81 (95% CI, 0.69-0.92) and 0.93 (95% CI, 0.85-0.99), respectively. Sensitivity and specificity (SOFA score, >4) was 76.2% and 69.2%, respectively, for predicting severity, and sensitivity and specificity (SOFA score, >8) was 86.7% and 90%, respectively, for predicting 30-day mortality. CONCLUSIONS: Use of MV is an independent predictor of outcome in AP patients admitted to ICU. Although all scoring systems had reliable accuracy in predicting severity and outcome, SOFA score performed better with additional advantages of easy applicability and timely assessment.

Ultrasound-guided femoral dialysis access placement: a single-center randomized trial.

BACKGROUND AND OBJECTIVES: Insertion of dialysis catheters (DCs) is a prerequisite for successful initiation of hemodialysis. We attempted to determine if ultrasonography-guided (USG) insertion was superior and safer than the anatomical landmark-guided technique (ALT) for the femoral vein (FV). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a randomized prospective study on 110 patients requiring FV DCs in a tertiary care hospital. Patients were randomized into two groups: USG and ALT. Data were collected on demography, operator experience, and side of insertion. The USG group had their catheters inserted under USG guidance, whereas the ALT group had their DC inserted by ALT. Outcome measures included successful insertion of DC, number of attempts, and complications. RESULTS: Both groups were comparable regarding age and gender of patients, operator experience, and the side of catheterization. The overall success rate was 89.1%, with 80% using ALT and 98.2% under USG guidance (P = 0.002). First attempt success rate was 54.5% in the ALT group as compared with 85.5% in the USG group (P = 0.000). The complication rate was 18.2% in the ALT group and 5.5% in the USG group (P = 0.039). The odds ratio (OR) for complications with two or more attempts was 10.73 with a relative risk (RR) of 3.2. The OR for successful insertion using USG was 13.5 (95% CI: 1.7 to 108.7). CONCLUSIONS: USG significantly improves success rate, reduces number of attempts, and decreases the incidence of complications related to FV DC insertion.

Critical care issues in adult liver transplantation.

Over the last decade, liver transplantation has become an operational reality in our part of the world. As a result, clinicians working in an intensive care unit are more likely to be exposed to these patients in the immediate postoperative period, and thus, it is important that they have a working knowledge of the common complications, when they are likely to occur, and how to deal with them. The main focus of this review is to address the variety of critical care issues in liver transplant recipients and to impress upon the need to provide favorable circumstances for the new liver to start functioning and maintain the function of other organs to aid in this process.

Role of steroids in septic shock: assessment of knowledge, attitudes and practices among intensivists practising in Hyderabad.

CONTEXT: Use of steroids in septic shock is an issue of contention, more so with two major trials reporting conflicting results. AIMS: To assess the current knowledge, attitudes and practices (KAP) related to the role of steroids in septic shock among intensivists practising in Hyderabad. SETTING, DESIGN, MATERIALS AND METHODS: Questionnaires containing 10 questions pertaining to the role of steroids in septic shock, were distributed to 76 intensivists during the monthly critical care meeting. RESULTS: A great majority of intensivists (82%) agreed that the role of steroids is restricted to septic shock not responding to vasopressors. There was no clear consensus regarding the role of corticotropin stimulation test or the timing of total cortisol level testing, if it has to be performed. Hydrocortisone was clearly the choice of steroid for most intensivists and intravenous bolus injection being the preferred route of administration. There was no agreement regarding the dose of steroids, the role of fludrocortisone and whether steroids should be tapered. Most of the respondents did not extend the steroid therapy beyond seven days and the most common side effect reported was hyperglycemia. CONCLUSION: There is a lot of ambiguity in the knowledge, attitudes or practices regarding role of steroids in septic shock among intensivists in Hyderabad. Uniform policies and protocols need to be devised at institutional level, with multispecialty inputs, and doctors need to be familiarized accordingly.

Concurrent administration of heparin and activated protein C in a patient with pulmonary embolism and severe sepsis with positive outcome.

Results of the PROWESS trial suggested that heparin may reduce the efficacy of recombinant human activated protein C (rhAPC) and the XPRESS study also showed increased bleeding complications in patients receiving heparin with rhAPC. Although it has been shown that heparin prophylaxis may be used along with rhAPC, no study has shown the interaction between continuous heparin infusion and rhAPC. Here, we report a case of severe sepsis with pulmonary embolism who was concurrently administered heparin and rhAPC infusions, with positive results and no bleeding complications.

Outcome of patients with liver cirrhosis admitted to a specialty liver intensive care unit in India.

PURPOSE: The study aimed to describe the clinical outcome of patients with liver cirrhosis admitted to intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) in predicting mortality. METHODS: In this prospective study of patients with cirrhosis admitted to the ICU, demographic data, APACHE II score, SOFA score, presence of acute renal failure (ARF), need for organ support, and mortality were collected. RESULTS: The observed mortality in ICU and at 30 days among 104 patients was 42.3% (95% confidence interval [CI], 32.7%-52.0%) and 56.7% (95% CI, 47.0%-66.4%), respectively. Area under the receiver operating characteristic curve for first-day APACHE II in predicting 30-day mortality was 0.90 (95% CI, 0.83-0.96) and 0.93 (95% CI, 0.88-0.98) for SOFA score (P = .24). On multivariate analysis, ARF (adjusted odds ratio, 7.7; 95% CI, 1.09-54.64) and mechanical ventilation (adjusted odds ratio, 277.6; 95% CI, 12.83-6004.94) were significantly associated with mortality. CONCLUSIONS: Presence of ARF and need for mechanical ventilation are associated with high mortality in patients with liver cirrhosis admitted to the ICU. Acute Physiology and Chronic Health Evaluation II and SOFA are good prognostic models in predicting 30-day mortality and do not differ in performance.