Management of CRE Infections: High Time for an RCT?

How to cite this article: Kundu R, Chowdhury SR. Management of CRE Infections: High Time for an RCT? Indian J Crit Care Med 2024;28(5):511.

Takeaways from the Recarbrio Conundrum: Has the FDA Jumped the Gun?

Recarbrio is a novel antibiotic approved by US-FDA. It was initially found to be useful in treating various resistant gram negative infections. A recent investigation revealed lack of methodological and scientific integrity behind the process of FDA approval for this drug. This incident is a lesson for us that we shall not consider FDA clearance as the gold standard before approving any drug in the Indian market or start using it before having adequate data from our own clinical settings.

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

How to cite this article: Chowdhury SR, Kundu R. Commentary on "Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit." Indian J Crit Care Med 2023;27(8):596.

The association between nutritional risk index and ICU outcomes across hematologic malignancy patients with acute respiratory failure.

Patients with hematological malignancies (HM) are at risk of acute respiratory failure (ARF). Malnutrition, a common association with HM, has the potential to influence ICU outcomes. Geriatric nutritional risk index (G-NRI) is a score derived from albumin and weight, which reflects risk of protein-energy malnutrition. We evaluated the association between G-NRI at ICU admission and ICU mortality in HM patients with ARF. We conducted a single center retrospective study of ventilated HM patients between 2014 and 2018. We calculated G-NRI for all patients using their ICU admission albumin and weight. Our primary outcome was ICU mortality. Secondary outcomes included duration of mechanical ventilation and ICU length of stay. Two hundred eighty patients were admitted to the ICU requiring ventilation. Median age was 62 years (IQR 51-68), 42% (n = 118) were females, and median SOFA score was 11 (IQR 9-14). The most common type of HM was acute leukemia (54%) and 40% underwent hematopoietic cell transplant. Median G-NRI was 87 (IQR 79-99). ICU mortality was 51% (n = 143) with a median duration of ventilation of 4 days (IQR 2-7). Mortality across those at severe malnutrition (NRI < 83.5) was 59% (65/111) compared to 46% (76/164) across those with moderate-no risk (p = 0.047). On multivariable analysis, severe NRI (OR 2.34, 95% CI 1.04-5.27, p = 0.04) was significantly associated with ICU mortality. In this single center, exploratory study, severe G-NRI was prognostic of ICU mortality in HM patients admitted with respiratory failure.

Diaphragmatic Rapid Shallow Breathing Index: A Simple Tool to Give more Power to Predict Weaning?

How to cite this article: Kundu R, Srinivasan S. Diaphragmatic Rapid Shallow Breathing Index: A Simple Tool to Give more Power to Predict Weaning? Indian J Crit Care Med 2022;26(9):985-986.

Trendelenburg in Acute Respiratory Distress Syndrome: Should We Do More than Proning?

How to cite this article: Datta PK, Kundu R. Trendelenburg in Acute Respiratory Distress Syndrome: Should We Do More than Proning? Indian J Crit Care Med 2022;26(8):976-977.

Necrotizing Soft Tissue Infections: More than What Meets the Eye.

How to cite this article: Kundu R, Srinivasan S. Necrotizing Soft Tissue Infections: More than What Meets the Eye. Indian J Crit Care Med 2022;26(4):411-413.

In Response to: Is the Carotid Artery a Window to the Left Ventricle?

We think correlation of Doppler ultrasound derived CA-VTI and echocardiography derived SV needs further exploration in a larger sample and in various models of hypovolemia and shock under ideal measurement conditions before concluding whether carotid artery can be considered a true window to the left ventricle. How to cite this article: Kundu R, Maitra S, Chowhan G, Baidya DK. In Response to: Is the Carotid Artery a Window to the Left Ventricle? Indian J Crit Care Med 2022;26(3):407.

Integrated ultrasound protocol in predicting weaning success and extubation failure: a prospective observational study.

BACKGROUND: Difficulty in weaning from mechanical ventilation is encountered in appro-ximately 20% of patients in the intensive care unit. We assessed the utility of a combined lung, diaphragmatic, and cardiac ultrasound protocol to predict extubation failure. MATERIAL: All patients extubated following a successful spontaneous breathing trial (SBT) were included in the study. Lung ultrasonography score (LUS), diaphragmatic thickness fraction (DTF), changes in velocity time integral (VTI) to passive leg raise at the beginning of SBT, and change in LUS following SBT were recorded. RESULTS: A total of 60 patients who underwent successful SBT were included in the study. Twenty-seven patients required either non-invasive or invasive mechanical ventilation during the next 48 hours and were classified as weaning failure (Group F). The remaining 33 patients were designated as weaning success (Group S). Compared to group S, patients in Group F had significantly longer ICU length of stay (6.96 ± 4.30 days vs. 11.66 ± 3.85 days, P < 0.001), higher LUS change during SBT (1 [0-2] vs. 2 [1-4], P < 0.001), lower DTF (30.87 ± 5.32 vs. 27.88 ± 6.24, P = 0.04), and showed lower VTI increment to PLR (13.63 ± 3.44 vs. 9.11 ± 4.59, P < 0.001). Using a binary logistic regression model, DTF < 26% (odds ratio 6.20, 95% CI: 1.06-36.04) and VTI change to PLR < 10.2% (odds ratio 6.16, 95% CI: 1.14-33.13) were found to be significant predictors of weaning failure (P < 0.05). The AUROC for VTI and DTF for predicting weaning failure were 0.79 and 0.64, respectively. CONCLUSIONS: An integrated ultrasound protocol using a combination of lung, diaphragm, and cardiac sonography was a reliable predictor of weaning failure.

Onset Time of Spinal Anaesthesia in Pregnant Females in Knee-Chest Position: A Randomized Controlled Study.

OBJECTIVE: To assess the efficacy of knee-chest position in shortening the time of spinal induction in pregnant women undergoing elective cesarean section. We also assessed for any untoward adverse events that might limit their usefulness in real-life clinical scenarios. METHODS: Prospective, randomized controlled study was done in maternity operating room of tertiary care institution in 45 ASA II pregnant women undergoing elective cesarean section under spinal anaesthesia. Patients were randomly assigned to groups S (supine) and K (kneechest position). After performing subarachnoid block (9 mg of 0.5% hyperbaric bupivacaine and 25 µg fentanyl) in the sitting position, women in group K were maintained in the knee-chest position for 60 seconds. Time to attain block height of T6 and maximum sensory blockade, intraoperative hemodynamics, Bromage score, intraoperative fluid, vasopressor requirement, and respiratory parameters were recorded. The newborn was evaluated using Apgar scores at 1 and 5 minutes. RESULTS: Data of 45 patients were analyzed. Time to attain T6 block height (group K=2.1 ± 0.65 minutes, 95% CI: 1.83-2.39; group S=6.4 ± 0.77 minutes, 95% CI: 6.10-6.78) and time to achieve maximum sensory block height were significantly lower in group K (group K=3.2 ± 1.35 minutes, 95% CI: 2.61-3.78; group S=6.6 ± 0.89 min, CI: 6.19-6.98). The degree of motor block was higher in group K than that of group S at 2 minutes (P=.0002), 4 minutes (P < .0001), and 6 minutes (P < .0001), with no difference at 8 minutes. No statistically significant difference was observed in fluids and vasopressors requirement intraoperatively. CONCLUSIONS: This study provides evidence that the onset of adequate surgical anaesthesia for the cesarean section can be hastened by placing the patient in the knee-chest position for a minute after performing the subarachnoid block in the sitting position.

Accuracy of predictive equations in guiding tracheal intubation depth in children: A prospective study.

BACKGROUND: Accurate insertion depth of endotracheal tube (ETT) in children has been predicted using the demographic variables, such as age, weight, and height. Middle finger length showed good correlation with ETT depth measurement in children aged 4-14 years. AIMS: The primary objective was to correlate the actual ETT insertion depth with the depth derived from middle finger length, age, weight, and height formulae in children aged 1-4 years. The secondary objective was to find the most accurate formula for prediction of ETT insertion depth. METHODS: This prospective parallel group study was done in 50 american society of anesthesiologists 1 or 2 children aged 1-4 years undergoing elective surgery under general anesthesia. Children with difficult airway, finger anomalies, or syndromic associations were excluded. Age, weight, height, and middle finger length of all children were measured. Depth of orally inserted uncuffed ETT and tracheal length was measured by fiberoptic bronchoscopy. The actual ETT depth was correlated with the depth calculated from different formulae. RESULTS: The mean middle finger length was 4.42 ± 0.50 cm, age was 2.64 ± 1.07 years, weight was 12.28 ± 2.84 kg, and height was 82.89 ± 16.23 cm. The mean tracheal length was 6.42 ± 0.96 cm. The mean depth of ETT was actual depth (12.89 ± 1.09 cm), middle finger depth (13.23 ± 1.53cm; p = .001; 95%CI 0.12-0.50), age-based depth 1(3.31 ± 0.53 cm; 95%CI 0.37-1.44; p = .001), weight-based depth (14.14 ± 1.42 cm; 95% CI 0.10-0.51; p = .004), and height-based depth (13.73 ± 0.94 cm; 95% CI 0.15-0.77; p = .004). Middle finger length and age-based formulae showed higher number of accurate placements (58% each). Weight- (74%) and height (64%)-derived formulae gave a higher number of distal ETT placements. CONCLUSION: Formulas based on the demographic variables and middle finger length showed good correlation with the actual ETT depth in children aged 1-4 years. The percentage of accurate ETT depth placements was higher with middle finger length and age-based formulae.

Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock.

Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods: After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18-65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as "responders." Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 (p = 0.016), 0.440 (p = 0.052), and 0.044 (p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients. How to cite this article: Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, et al. Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021;25(3):310-316. CTRI/Trial Reg No: www.ctri.nic.in, CTRI/2017/11/010434.

Parturient with Acute Abdomen.

Management of a parturient with an acute abdomen presents unique challenges. We aim to review the common obstetric and nonobstetric causes for acute abdomen in pregnancy, approach to diagnosis, the role of imaging, and management including the scope and timing of operative intervention. How to cite this article: Kundu R, Srinivasan S. Parturient with Acute Abdomen. Indian J Crit Care Med 2021;25(Suppl 3):S223-S229.

AMBU® LMA® in Children With Cleft Palate for Ophthalmic Surgery: A Case Report.

Airway management remains a challenge in children, and the presence of a cleft palate further complicates the scenario. Endotracheal intubation, although definitive and most preferred, may be avoided for certain short-duration procedures wherein the use of laryngeal mask airway can allow quicker emergence. We present the successful airway management of 2 pediatric patients with cleft palate undergoing ophthalmological surgery, using AMBU® LMA® as the airway device of choice, which was further used as a rescue airway device in an emergent situation of "difficult to ventilate."

Anesthetic Management of a Unique Case of Double-Outlet Right Ventricle With Glenn Shunt for Cesarean Delivery: A Case Report.

Double-outlet right ventricle is a rare congenital cardiac anomaly resulting in intracardiac mixing of oxygenated and deoxygenated blood. Surgical palliation involves staged conversion to Fontan circulation, with an intermediate stage using a Glenn shunt. We report the case of a patient at 36 weeks of gestation, with a partially palliated double-outlet right ventricle and a Glenn shunt, who presented with severe dyspnea and worsening cyanosis. After preoperative optimization, a combined spinal-epidural technique was successfully used for cesarean delivery. The anesthetic concerns and perioperative management of patients with complex cardiac physiology are discussed in this report. Carefully titrated combined spinal-epidural technique can be safe and effective for such cases.