Epidemiology and Outcomes of HIN1 Pneumonia in ICU.

Introduction: Pandemic influenza H1N1/09 emerged for the first time in April 2009 and has spread widely across India since then. The number of cases have increased over time with the increasing need for respiratory support, causing significant morbidity and mortality. We evaluated the clinical course and outcomes of patients infected with Influenza A (H1N1) admitted to three multidisciplinary intensive care units (ICU) in Chennai. Materials and methods: We performed a combined retrospective and prospective observational study of all patients admitted with H1N1 pneumonia at three multidisciplinary ICUs in Chennai from October 1, 2018, to January 31, 2019. Data including demographics, risk factors, and clinical courses were recorded. Outcome data including mortality was tracked up to 28 days. Results: A total of 167 patients were admitted during the study period of which 154 were included in this analysis. The mean age of presentation was 58.2 ± 15.6 years and 59.1% of them were males. The mean acute physiology and chronic health evaluation (APACHE) IV and sequential organ failure assessment (SOFA) scores were 62.8 ± 23.2 and 5.8 ± 3.9 respectively. Oxygen delivery devices were required in 25.3% for a mean duration of 26.5 ± 5.7 hours. Non-invasive ventilation or high-flow nasal cannula (HFNC) was needed in 33.1% of patients for 59.9 ± 64.5 hours. The proportion of patients requiring mechanical ventilation was 41.6%. Rescue measures in the form of proning, use of inhaled nitric oxide (iNO), and extracorporeal membrane oxygenation (ECMO) were initiated for refractory hypoxemia in 26.6%, 14.1%, and 6.3% respectively. The mean duration of ventilator support was 8.5 ± 8 days. Tracheostomy was required in 20.3% of patients and 7.8% were ventilator dependent at 28 days. The mean ICU and Hospital length of stay were 8.3 ± 10.3 and 12.2 ± 14.1 days respectively and overall 28-day mortality was 20.1%. Conclusion: A significant proportion of H1N1 patients admitted to the ICU required high-level respiratory support including non-invasive ventilation (NIV), HFNC, or invasive ventilation. Deployment of rescue therapies was common and the overall mortality rate was similar to those reported from Western countries. How to cite this article: Golagana V, Venkataraman R, Mani AK, Rajan ER, Ramakrishnan N, Vidyasagar DD. Epidemiology and Outcomes of HIN1 Pneumonia in ICU. Indian J Crit Care Med 2023;27(7):470-474.

Impact of COVID-19 on non-COVID intensive care unit service utilization, case mix and outcomes: A registry-based analysis from India.

Background: Coronavirus disease 2019 (COVID-19) has been responsible for over 3.4 million deaths globally and over 25 million cases in India. As part of the response, India imposed a nation-wide lockdown and prioritized COVID-19 care in hospitals and intensive care units (ICUs). Leveraging data from the Indian Registry of IntenSive care, we sought to understand the impact of the COVID-19 pandemic on critical care service utilization, case-mix, and clinical outcomes in non-COVID ICUs.  Methods: We included all consecutive patients admitted between 1 st October 2019 and 27 th September 2020. Data were extracted from the registry database and included patients admitted to the non-COVID or general ICUs at each of the sites. Outcomes included measures of resource-availability, utilisation, case-mix, acuity, and demand for ICU beds. We used a Mann-Whitney test to compare the pre-pandemic period (October 2019 - February 2020) to the pandemic period (March-September 2020). In addition, we also compared the period of intense lockdown (March-May 31 st 2020) with the pre-pandemic period. Results: There were 3424 patient encounters in the pre-pandemic period and 3524 encounters in the pandemic period. Comparing these periods, weekly admissions declined (median [Q1 Q3] 160 [145,168] to 113 [98.5,134]; p=0.00002); unit turnover declined (median [Q1 Q3] 12.1 [11.32,13] to 8.58 [7.24,10], p<0.00001), and APACHE II score increased (median [Q1 Q3] 19 [19,20] to 21 [20,22] ; p<0.00001). Unadjusted ICU mortality increased (9.3% to 11.7%, p=0.01519) and the length of ICU stay was similar (median [Q1 Q3] 2.11 [2, 2] vs. 2.24 [2, 3] days; p=0.15096). Conclusion: Our registry-based analysis of the impact of COVID-19 on non-COVID critical care demonstrates significant disruptions to healthcare utilization during the pandemic and an increase in the severity of illness.

Practice Patterns and Outcome of Extracorporeal Membrane Oxygenation Therapy for Severe Acute Respiratory Distress Syndrome in Indian ICUs.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is increasingly used in managing patients with severe acute respiratory distress syndrome (ARDS). The aim of the study is to describe the practice of ECMO and evaluate the outcomes in patients with severe ARDS in Indian intensive care units (ICUs). METHODS: Data of 39 patients with severe ARDS managed with ECMO in two tertiary centers between 2012 and 2018 were retrospectively studied. RESULTS: The mean age of the patient was 44.6 ± 13.5 years and 51% were female. Primary ARDS due to viral pneumonia was the common indication for ECMO. Mean APACHE II and Murray scores were 32.3 ± 7.8 and 3.64 ± 0.21, respectively. Prone ventilation and/or inhaled nitric oxide were used in 69.3% of the patients prior to ECMO therapy. Among 39 patients, 38 patients were managed with venovenous ECMO and 1 patient was managed with venoarterial ECMO. Average ECMO duration was 9.4 ± 6.9 days. Among the 17 (43.5%) patients successfully weaned off ECMO, 15 (38.5%) survived to discharge home. The average ICU and hospital length of stay were 18.9 ± 15.5 and 20.6 ± 16.6 days, respectively. While, sepsis was the common complication noted in 19 (49%) patients, bleeding and thrombotic complications were also noted in six and two patients, respectively. CONCLUSION: In conclusion, ECMO support was used as rescue therapy in severe ARDS with a survival rate of 39%. Sepsis was the common complication of ECMO followed by bleeding and thrombosis. HOW TO CITE THIS ARTICLE: Mariappan R, Kumar M, Ramakrishnan N, Mani AK, Kumar S, Chandrasekaran V. Practice Patterns and Outcome of Extracorporeal Membrane Oxygenation Therapy for Severe Acute Respiratory Distress Syndrome in Indian ICUs. Indian J Crit Care Med 2021;25(11):1263-1268.

Implementing an intensive care registry in India: preliminary results of the case-mix program and an opportunity for quality improvement and research.

Background: The epidemiology of critical illness in India is distinct from high-income countries. However, limited data exist on resource availability, staffing patterns, case-mix and outcomes from critical illness. Critical care registries, by enabling a continual evaluation of service provision, epidemiology, resource availability and quality, can bridge these gaps in information. In January 2019, we established the Indian Registry of IntenSive care to map capacity and describe case-mix and outcomes. In this report, we describe the implementation process, preliminary results, opportunities for improvement, challenges and future directions. Methods: All adult and paediatric ICUs in India were eligible to join if they committed to entering data for ICU admissions. Data are collected by a designated representative through the electronic data collection platform of the registry. IRIS hosts data on a secure cloud-based server and access to the data is restricted to designated personnel and is protected with standard firewall and a valid secure socket layer (SSL) certificate. Each participating ICU owns and has access to its own data. All participating units have access to de-identified network-wide aggregate data which enables benchmarking and comparison. Results: The registry currently includes 14 adult and 1 paediatric ICU in the network (232 adult ICU beds and 9 paediatric ICU beds). There have been 8721 patient encounters with a mean age of 56.9 (SD 18.9); 61.4% of patients were male and admissions to participating ICUs were predominantly unplanned (87.5%). At admission, most patients (61.5%) received antibiotics, 17.3% needed vasopressors, and 23.7% were mechanically ventilated. Mortality for the entire cohort was 9%.  Data availability for demographics, clinical parameters, and indicators of admission severity was greater than 95%. Conclusions: IRIS represents a successful model for the continual evaluation of critical illness epidemiology in India and provides a framework for the deployment of multi-centre quality improvement and context-relevant clinical research.

Hemodialysis for Lactic Acidosis.

Lactic acidosis (Type A) is common in critically ill patients and usually treated by correcting the underlying etiology. We present the case of a young female who presented with life-threatening lactic acidosis secondary to hematological malignancy. Timely initiation of hemodialysis was lifesaving. The case highlights the importance of considering Type B lactic acidosis (in this case secondary to a hematological malignancy) and also initiating renal replacement therapy when routine measures are ineffective.

Metastatic Endogenous Endophthalmitis: A Rare Presentation with Methicillin-resistant Staphylococcus aureus Prostatic Abscess.

A 62-year-old male with the previous history of uncontrolled diabetes and hypertension on irregular treatment presented with a history of fever, dysuria, and urinary retention with progressive painful loss of vision over a period of 2 days. His eye examination showed hypopyon, and he was diagnosed to have rapidly progressive endogenous endophthalmitis. He was started on vancomycin and piperacillin-tazobactam empirically. His blood and urine cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Transesophageal echocardiography ruled out infective endocarditis. Intravitreal injection of vancomycin and ceftazidime was given. Vitreous culture also grew MRSA. A workup for possible source revealed multiple prostatic abscesses on the transrectal ultrasound. Antibiotic was changed to daptomycin in view of high vancomycin minimum inhibitory concentration. His vision was improved at the time of discharge.

A case of acute paraplegia that improved with dialysis.

Acute severe hyperkalemia can present as acute paraplegia independent of cardiac effects, even though cardiac muscle is more sensitive to serum potassium changes. We managed a patient with acute hyperkalemic paralysis who did not have threatening cardiac/electrocardiographic manifestations. The limb weakness became normal after hemodialysis.