Author Response.

How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. Author Response. Indian J Crit Care Med 2024;28(5):515.

Author Response.

How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. Author Response. Indian J Crit Care Med 2024;28(5):512.

The Comparative Efficacy of Ceftazidime-Avibactam with or without Aztreonam vs Polymyxins for Carbapenem-resistant Enterobacteriaceae Infections: A Prospective Observational Cohort Study.

Background: Carbapenem-resistant enterobacteriaceae (CRE) is associated with high mortality in critically ill patients, with limited treatment options. This study aims to compare clinical response, microbiological response, and mortality in patients treated with ceftazidime-avibactam with or without aztreonam (CAZ-AVI + AZT) and colistin or polymyxin B (polymyxins) in CRE infections. Materials and methods: This single-center prospective observational study included adult patients with CRE infections treated with CAZ-AVI+AZT or polymyxins between January 2022 and December 2022 at a Tertiary Care Medical Center in India. The clinical response, microbiological response, and mortality were compared between the two groups using a Cox multivariate regression model adjusted for the baseline SOFA score and comorbidities. Results: A total of 89 patients were enrolled, with 59 (66%) patients receiving CAZ-AVI + AZT and 30 receiving polymyxins. Baseline demographics and clinical characteristics were similar between the two groups. The Cox multivariate regression analysis showed a statistically significant difference in clinical failure on day 14 with the CAZ-AVI + AZT group vs polymyxins (HR = 0.78, 95% CI 0.63-0.95, p = 0.018). There was no difference in microbiological failure (HR = 1.08, 95% CI 0.66-1.77, p = 0.76), microbiological relapse (HR = 0.75, 95% CI 0.36-3.02, p = 0.62), and hospital mortality (HR = 1.04, 95% CI 0.75-1.43, p = 0.796) between the two groups. Conclusion: Treatment with ceftazidime-avibactam with or without aztreonam for CRE infections associated with a better clinical response compared with polymyxins monotherapy but without any difference in microbiological response or mortality. How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. The Comparative Efficacy of Ceftazidime-Avibactam with or without Aztreonam vs Polymyxins for Carbapenem-resistant Enterobacteriaceae Infections: A Prospective Observational Cohort Study. Indian J Crit Care Med 2023;27(12):923-929.

Predictors of Clinically Significant Bleeding in Thrombocytopenic Dengue Patients Admitted to Intensive Care Unit: A Retrospective Study.

Background: Recognition of clinically significant bleeding (CSB) is vital for effective management of dengue patients. The primary objective was to identify the predictors of CSB among dengue patients and to formulate a simple scoring system. The secondary objective was to compare the grades of bleeding and severity of thrombocytopenia. Materials and methods: We conducted a retrospective study of adults aged above 18 years with dengue, admitted to the intensive care unit (ICU) of a tertiary care hospital in South India from 2015 to 2021. Demographic, clinical, and laboratory variables on admission were collected. The association of clinically significant bleeding with the above parameters was assessed by univariate and multivariate analysis. Results: A total of 9,817 dengue cases were hospitalized during the study period. A total of 120 patients with thrombocytopenia (<100000 cells/mm3) were admitted to the ICU and of them 38 (31.6%) had CSB. On univariate analysis fever, sequential organ function assessment (SOFA) score, elevated activated partial thromboplastin time (aPTT), and altered sensorium were significantly associated with CSB. The multivariate model identified SOFA score [adjusted odds ratio (aOR): 1.52; 95% confidence interval (CI): 1.11-2.08], temperature >38.3°C (aOR: 2.71; 95% CI: 1.1-6.47) and elevated aPTT > 40 seconds (aOR: 4.66; 95% CI: 1.42-15.3) as independent risk factors. A clinical predictive score was developed incorporating these three parameters. The performance of the score identified by the receiver operating characteristic (ROC) curve [area under the curve (AUC): 0.81; 95% CI: 0.73-0.91] demonstrated a sensitivity of 81% and specificity of 77%. Conclusion: This study revealed that temperature above 38.3°C, elevated aPTT, and an increase in SOFA score were identified as independent risk factors for CSB. A clinical predictive score derived from these variables can identify patients likely to develop CSB. How to cite this article: Logia P, Selvam V, Parasuraman V, Renuka MK, Rajagopalan RE. Predictors of Clinically Significant Bleeding in Thrombocytopenic Dengue Patients Admitted to Intensive Care Unit: A Retrospective Study. Indian J Crit Care Med 2023;27(12):888-894.

End-expiratory Occlusion Test and Mini-fluid Challenge Test for Predicting Fluid Responsiveness in Acute Circulatory Failure.

Introduction: Predicting which patients with acute circulatory failure will respond to the fluid by an increase in cardiac output is a daily challenge. End-expiratory occlusion test (EEOT) and mini-fluid challenge (MFC) can be used for assessing fluid responsiveness in patients with spontaneous breathing activity, cardiac arrhythmias, low-tidal volume and/or low lung compliance. Methods: The objective of the study is to evaluate the value of EEOT and MFC-induced rise in left ventricular outflow tract (LVOT) velocity time integral (VTI) in predicting fluid responsiveness in acute circulatory failure in comparison to the passive leg-raising (PLR) test. Hundred critically ill ventilated and sedated patients with acute circulatory failure were studied. LVOT VTI was measured by transthoracic echocardiography before and after EEOT (interrupting the ventilator at end-expiration over 15 s), and before and after MFC (100 ml of Ringer lactate was infused over 1 min). The variation of LVOT VTI after EEOT and the MFC was calculated from the baseline. Sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) curve of LVOT VTI after EEOT and MFC to predict fluid responsiveness were determined. Results: After PLR, stroke volume (SV) increased by ≥12% in 49 patients, who were defined as responders and 34 patients in whom the increase in SV <12% were defined as nonresponders. A cutoff of 9.1% Change in VTI after MFC (ΔVTIMFC) predicted fluid responsiveness with an AUROC of 0.96 (P < 0.001) with sensitivity and specificity of 91.5% and 88.9%, respectively. Change in VTI after EEOT (ΔVTIEEOT) >4.3% predicted fluid responsiveness with sensitivity and specificity 89.4% and 88.9%, respectively, with an AUROC of 0.97 (P < 0.001), but in 17 patients, EEOT was not possible because triggering of the ventilator by the patient's inspiratory effort. Conclusion: In conclusion, in mechanically ventilated patients with acute circulatory failure Δ VTIMFC and Δ VTI EEOT accurately predicts fluid responsiveness.

Doppler-estimated Carotid and Brachial Artery Flow as Surrogate for Cardiac Output: Needs Further Validation.

Selvam V, Srinivasan S. Doppler-estimated Carotid and Brachial Artery Flow as Surrogate for Cardiac Output: Needs Further Validation. Indian J Crit Care Med 2022;26(2):159-160.

Age-adjusted Charlson Comorbidity Index: A Simple Tool, but Needs Further Validation in COVID-19 Patients.

How to cite this article: Selvam V, Srinivasan S. Age-adjusted Charlson Comorbidity Index: A Simple Tool, but Needs Further Validation in COVID-19 Patients. Indian J Crit Care Med 2021;25(9):963-964.

Neonicotinoid Poisoning and Management.

Neonicotinoids are a newer class of insecticides, which act on postsynaptic nicotinic acetylcholine esterase receptors. Its use is gradually increasing over recent years due to its better safety profile compared to other commonly used pesticides like organophosphates, organochlorides, carbamates, and pyrethroids. The better toxicological profile is attributed to more selectivity for insects compared to mammals and decreased penetration through the blood-brain barrier. Common symptoms of self-poisoning described are dizziness, hypertension, tachycardia, nausea, vomiting, eye irritation, dermatitis, and oral mucosal lesions. Mortality due to poisoning is less than 3%. Till date, there is no specific antidote for neonicotinoid poisoning and management of poisoning is symptomatic and supportive. HOW TO CITE THIS ARTICLE: Selvam V, Srinivasan S. Neonicotinoid Poisoning and Management. Indian J Crit Care Med 2019;23(Suppl 4):S260-S262.