Diagnosis and management of invasive fungal diseases in non-neutropenic ICU patients, with focus on candidiasis and aspergillosis: a comprehensive review.

Invasive fungal diseases pose a significant threat to non-neutropenic ICU patients, with Candida and Aspergillus infections being the most common. However, diagnosing these infections in the ICU population remains challenging due to overlapping clinical features, poor sensitivity of blood cultures, and invasive sampling requirements. The classical host criteria for defining invasive fungal disease do not fully apply to ICU patients, leading to missed or delayed diagnoses. Recent advancements have improved our understanding of invasive fungal diseases, leading to revised definitions and diagnostic criteria. However, the diagnostic difficulties in ICU patients remain unresolved, highlighting the need for further research and evidence generation. Invasive candidiasis is the most prevalent form of invasive fungal disease in non-neutropenic ICU patients, presenting as candidemia and deep-seated candidiasis. Diagnosis relies on positive blood cultures or histopathology, while non-culture-based techniques such as beta-D-glucan assay and PCR-based tests show promise. Invasive aspergillosis predominantly manifests as invasive pulmonary aspergillosis in ICU patients, often associated with comorbidities and respiratory deterioration in viral pneumonia. Diagnosis remains challenging due to poor sensitivity of blood cultures and difficulties in performing lung biopsies. Various diagnostic criteria have been proposed, including mycological evidence, clinical/radiological factors and expanded list of host factors. Non-culture-based techniques such as galactomannan assay and PCR-based tests can aid in diagnosis. Antifungal management involves tailored therapy based on guidelines and individual patient factors. The complexity of diagnosing and managing invasive fungal diseases in ICU patients underscore the importance of ongoing research and the need for updated diagnostic criteria and treatment approaches. Invasive fungal disease, Invasive fungal infection, Invasive candidiasis, Invasive aspergillosis, Antifungal drugs.

Analysis of Causes of Hepatic Dysfunction in Obstetric Patients in India: A Systematic Review.

BACKGROUND: Epidemiology of liver disease in obstetric patients shows geographical variation depending upon the prevalence of preeclampsia, viral hepatitis, and tropical vector-borne diseases like malaria, leptospirosis, etc. We undertook the current systematic review to analyze the causes of hepatic dysfunction in obstetric patients in India and identify the gaps in the literature and reporting. MATERIALS AND METHODS: We did a systematic review of studies reporting the causes of hepatic dysfunction in obstetric patients in India. A methodological quality assessment was done using a five-point questionnaire. RESULTS: A total of 21 studies qualified for evaluation. The rate of hepatic dysfunction among obstetric patients in India ranged from 0.15 to 3.3% with a mean and median rate of 1.49 and 0.93%, respectively. Preeclampsia/HELLP (mean = 36.0%, median = 31.4%, range: 3.6-83.8%) and viral hepatitis (mean = 34.1%, median = 35.5%, range: 5.1-61.8%) were the commonest causes of hepatic dysfunction. Other causes were intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, tropical fever (malaria, leptospirosis, dengue, scrub typhus), etc. Maternal mortality ranged from 1.4 to 40% (mean = 12.6%, median = 10.0%) and perinatal mortality was between 16.4 and 38.70% (mean = 31.75%, median = 35.5%). CONCLUSION: There is moderate quality evidence to show that preeclampsia/HELLP and viral hepatitis are the commonest causes of hepatic dysfunction in obstetric patients in India. HOW TO CITE THIS ARTICLE: Ahmed A, Saxena S, Pandey A, Mishra P, Azim A. Analysis of Causes of Hepatic Dysfunction in Obstetric Patients in India: A Systematic Review. Indian J Crit Care Med 2022;26(1):114-122.

Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review.

Background: Pregnancy-related acute kidney injury (PRAKI) is an important cause of fetomaternal mortality and morbidity in developing countries. We undertook a systematic review to identify the causes of PRAKI among obstetric patients in India. Materials and methods: We systematically searched PubMed, MEDLINE, Embase, and Google Scholar using appropriate search terminology between 1 January 2010 to 31 December 2021. Studies reporting the etiology of PRAKI among obstetric patients (pregnant and within 42 days postpartum) in India were included for evaluation. Studies done in any other geographical location besides India were excluded. We also excluded studies done in any one trimester or any specific subgroup of patients [e.g., postpartum acute kidney injury (AKI), postabortal AKI]. A five-point questionnaire was used to assess the risk of bias in included studies. The results were synthesized as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results: A total number of 7 studies with 477 participants were included for analysis. All were single-center descriptive observational studies either done in tertiary care public or private hospitals. Sepsis (mean, 41.9%; median, 49.4%; and range, 6-56.1%) was the most common cause of PRAKI followed by hemorrhage (mean, 22.1%; median, 23.5%; and range, 8.3-38.5%) and pregnancy-induced hypertension (mean, 20.9%; median, 20.7; and range, 11.5-39%). Among these seven studies, five were of moderate quality, one was of high quality, and another one was of low quality. Our study is limited due to the lack of consensus definition of PRAKI in literature and heterogeneity in reporting methods. Our study highlights the need for a structured reporting format for PRAKI to understand the true disease burden and take control measures. Conclusion: There is a moderate quality of evidence to suggest that sepsis followed by hemorrhage and pregnancy-induced hypertension are the commonest causes of PRAKI in India. How to cite this article: Gautam M, Saxena S, Saran S, Ahmed A, Pandey A, Mishra P, et al. Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review. Indian J Crit Care Med 2022;26(10):1141-1151.

Engineering Solutions for Preventing Airborne Transmission in Hospitals with Resource Limitation and Demand Surge.

Among the various strategies for the prevention of airborne transmission, engineering measures are placed high in the hierarchy of control. Modern hospitals in high-income countries have mechanical systems of building ventilation also called HVAC (heating, ventilation, and air-conditioning) but installation and maintenance of such systems is a challenging and resource-intensive task. Even when the state-of-the-art technology was used to build airborne infection isolation rooms (AIIRs), recommended standards were often not met in field studies. The current coronavirus disease-2019 pandemic has highlighted the need to find cost-effective and less resource-intensive engineering solutions. Moreover, there is a need for the involvement of interdisciplinary teams to find innovative infection control solutions and doctors are frequently lacking in their understanding of building ventilation-related problems as well as their possible solutions. The current article describes building ventilation strategies (natural ventilation and hybrid ventilation) for hospitals where HVAC systems are either lacking or do not meet the recommended standards. Other measures like the use of portable air cleaning technologies and temporary negative-pressure rooms can be used as supplementary strategies in situations of demand surge. It can be easily understood that thermal comfort is compromised in buildings that are not mechanically fitted with HVAC systems, therefore the given building ventilation strategies are more helpful when climatic conditions are moderate or other measures are combined to maintain thermal comfort. HOW TO CITE THIS ARTICLE: Zia H, Singh R, Seth M, Ahmed A, Azim A. Engineering Solutions for Preventing Airborne Transmission in Hospitals with Resource Limitation and Demand Surge. Indian J Crit Care Med 2021;25(4):453-460.

Fetomaternal Acid-Base Balance and Electrolytes during Pregnancy.

A pregnant mother undergoes significant changes in acid-base status as well as sodium and calcium metabolism to combat her physiological needs of pregnancy. Pregnant patients experience mild respiratory alkalosis due to the stimulation of the respiratory center by progesterone. This is associated with a corresponding increase in bicarbonate excretion by kidneys; as a result, the pH remains slightly high (7.40-7.45) but within the normal range. Pregnant women are predisposed to starvation ketosis as compared to nonpregnant states due to relative insulin resistance and increased production of the counter-regulatory hormone. Physiological mild hyponatremia occurs during pregnancy due to increased AVP secretion caused by resetting of osmoreceptors in the hypothalamus at a lower osmolality, but values below 130 mEq/L require a diagnostic workup and intervention. Gestational diabetes insipidus can occur due to increased production or decreased destruction of enzyme vasopressinase. Secretion of parathyroid hormone-related peptide by the placenta and breasts and two- to three-fold increased calcium and phosphate absorption in the maternal gut are the key changes in calcium metabolism during pregnancy. Though rare, both hypo- and hypercalcemia in pregnancy are associated with significant maternofetal morbidity and mortality. How to cite this article: Ahmed A. Fetomaternal Acid-Base Balance and Electrolytes during Pregnancy. Indian J Crit Care Med 2021; 25(Suppl 3):S193-S199.

Emergency Laparotomies: Causes, Pathophysiology, and Outcomes.

Emergency laparotomies have remained a challenging entity since many decades. Only during the past 10 years, serious efforts have been made to improve their outcome by conducting audits and designing care pathways. Indications for emergency laparotomies can be broadly classified into trauma and non-trauma surgeries, which are either done for control of hemorrhage or/and done for control of sepsis and organ dysfunction. Goal-directed resuscitation for septic/hemorrhagic shock, consultant-led multidisciplinary teams, and timely transfer to intensive care units form core principles of management for these patients. Global inequity in access to standard and affordable emergency surgeries is an area of concern requiring integrated efforts at international level. How to cite this article: Ahmed A, Azim A. Emergency Laparotomies: Causes, Pathophysiology, and Outcomes. Indian J Crit Care Med 2020;24(Suppl 4):S183-S189.

Selecting Journal for Publication in the Era of "Haste Predatory Journals and COVID-19".

How to cite this article: Siddiqui S, Ahmed A, Azim A. Selecting Journal for Publication in the Era of "Haste Predatory Journals and COVID-19". Indian J Crit Care Med 2020;24(12):1284-1285.

Difficult tracheal intubation in critically ill.

BACKGROUND: Endotracheal intubation in critically ill is a high-risk procedure requiring significant expertise in airway handling as well as understanding of pathophysiology of the disease process. MAIN BODY: Critically ill patients are prone for hypotension and hypoxemia in the immediate post-intubation phase due to blunting of compensatory sympathetic response. Preoxygenation without NIV is frequently suboptimal, as alveolar flooding cause loss of alveolar capillary interface in many of these patients. All these factors, along with relative fluid deficit, neuromuscular fatigue and coexistent organ dysfunction lead to physiologically difficult airway. Airway in ICU can be classified as anatomically difficult, physiologically difficult and anatomically as well as physiologically difficult. Though rapid sequence intubation is the recommended method for securing airway in these patients, other methods like delayed sequence intubation awake intubation and double setup approach can be used in specific subgroups. Further research is needed in this field to set guidelines and fine tune airway management for patients with specific organ failure or dysfunction. CONCLUSION: Airway in ICU should be managed according to the physiological as well as the anatomical abnormalities.

External Validation of Risk Prediction Scores for Invasive Candidiasis in a Medical/Surgical Intensive Care Unit: An Observational Study.

BACKGROUND: The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. METHODS: We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostrosky's clinical prediction rule (CPR). Patients' characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. RESULTS: Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%-47%, along with negative predictive values (NPVs) in the range of 84%-96% in the subgroup analysis. CONCLUSION: Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy.

Invasive Candidiasis in Severe Acute Pancreatitis: Experience from a Tertiary Care Teaching Hospital.

BACKGROUND: Invasive candidiasis (IC) is associated with increased morbidity in severe acute pancreatitis (SAP). There is limited information regarding the predisposing factors, Candida species distribution and in vitro susceptibility. METHODOLOGY: Current data have been derived from a larger prospective nonintervention study conducted on 200 critically ill patients which was done to study the antifungal prescription practices, collect epidemiological data, and perform an external validation of risk prediction models for IC under senior research associateship program of Council of Scientific and Industrial Research New Delhi. Of these critically ill patients, thirty had SAP and were included for analysis. RESULTS: There were 23 males and 7 females. Out of eight patients (27%) who developed IC, three had isolated candidemia, two had isolated deep-seated candidiasis while three had both candidemia and deep-seated candidiasis. SAP patients with IC had a longer duration of Intensive Care Unit stay, hospital stay, days on mechanical ventilation and duration of shock. Mortality was not different between SAP patients with or without IC. CONCLUSION: There is a high rate of Candida infection in SAP. More studies are needed to generate epidemiological data and develop antifungal stewardship in this subset of high-risk population.

Hypocalcemia in acute pancreatitis revisited.

Hypocalcemia is a frequent finding in acute pancreatitis. Severe hypocalcemia can present with neurological as well as cardiovascular manifestations. Correction of hypocalcemia by parenteral calcium infusion remains a controversial topic as intracellular calcium overload is the central mechanism of acinar cell injury in pancreatitis. The current article deals with the art and science of calcium correction in pancreatitis patients.

Nutrition in neurocritical care.

Adequate nutritional therapy is essential for recovery from critical illness. Nutritional requirement varies in different patients and varies daily in a single patient. Both under and over feeding are associated with complications. Besides this, not all patients behave in a similar way to nutritional therapy. Appropriate nutritional therapy requires identification of patients "at nutritional risk" and providing aggressive nutritional support to them. The current article deals with nutritional support in critical illness with special emphasis on neurocritical care patients.

Control of corruption in healthcare.

A recently published article on corruption in Indian healthcare in the BMJ has triggered a hot debate and numerous responses (1, 2, 3, 4). We do agree that corruption in Indian healthcare is a colossal issue and needs to be tackled urgently (5). However, we want to highlight that corruption in healthcare is not a local phenomenon confined to the Indian subcontinent, though India does serve as a good case study and intervention area due to the magnitude of the problem and the country's large population (6). Good governance, strict rules, transparency and zero tolerance are some of the strategies prescribed everywhere to tackle corruption. However, those entrusted with implementing good governance and strict rules in India need to go through a process of introspection to carry out their duties in a responsible fashion. At present, it looks like a no-win situation. In this article, we recommend education in medical ethics as the major intervention for dealing with corruption in healthcare.

Invasive candidiasis in non neutropenic critically ill - need for region-specific management guidelines.

Use of antifungal agents has increased over past few decades. A number of risk factors such as immunosuppression, broad spectrum antibiotics, dialysis, pancreatitis, surgery, etc., have been linked with the increased risk of invasive candidiasis. Though there are various guidelines available for the use of antifungal therapy, local/regional epidemiology plays an important role in determining the appropriate choice of agent in situations where the offending organism is not known (i.e. empirical, prophylactic or preemptive therapy). Developing countries like India need to generate their own epidemiological data to facilitate appropriate use of antifungal therapy. In this article, the authors have highlighted the need for region-specific policies/guidelines for treatment of invasive candidiasis. Currently available Indian literature on candidemia epidemiology has also been summarized here.

Risk prediction for invasive candidiasis.

Over past few years, treatment of invasive candidiasis (IC) has evolved from targeted therapy to prophylaxis, pre-emptive and empirical therapy. Numerous predisposing factors for IC have been grouped together in various combinations to design risk prediction models. These models in general have shown good negative predictive value, but poor positive predictive value. They are useful in selecting the population which is less likely to benefit from empirical antifungal therapy and thus prevent overuse of antifungal agents. Current article deals with various risk prediction models for IC and their external validation studies.