Toxicoepidemiology of Acute Poisoning: A Classic Tale of Two Indias.

How to cite this article: Singh O, Juneja D, Nasa P. Toxicoepidemiology of Acute Poisoning: A Classic Tale of Two Indias. Indian J Crit Care Med 2024;28(4):315-316.

Cytomegalovirus infection in non-immunocompromised critically ill patients: A management perspective.

Critically ill patients are a vulnerable group at high risk of developing secondary infections. High disease severity, prolonged intensive care unit (ICU) stay, sepsis, and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections, including cytomegalovirus (CMV). CMV seroconversion has been reported in up to 33% of ICU patients, but its impact on patient outcomes remains a matter of debate. Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/ acquired immuno deficiency syndrome, the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous. Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement. Hence, a better understanding of the symptomatology, diagnostics, and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions.

Comparison between presepsin, procalcitonin, and CRP as biomarkers to diagnose sepsis in critically ill patients.

Background and Aims: Mortality associated with sepsis continues to remain high. Early diagnosis and aggressive management may improve outcomes. Biomarkers may help in early diagnosis, but the search for an ideal biomarker continues. Presepsin has been introduced as a new biomarker, however, it still needs validation before its use becomes routine. In this study, we aimed to compare the efficacy of various biomarkers in patients with suspected sepsis. Material and Methods: A retrospective analysis of 100 patients with suspected infection, admitted in the medical intensive care unit (ICU) was conducted. Diagnosis of sepsis was made on the basis of the current surviving sepsis guidelines criteria. Results: Out of 100 patients, 70 were diagnosed to have sepsis, and overall ICU mortality was 22%. Overall, C-reactive protein (CRP) was positive in 98, procalcitonin in 75, and presepsin in 64 patients. For diagnosis of sepsis the sensitivity, specificity, and AUC, respectively, for CRP was 98.6%, 3.3%, and 0.725. For procalcitonin (>0.5 ng/ml) it was 87.1%, 53.3%, and 0.776, and for procalcitonin (>1 ng/ml) 70%, 70%, and 0.816, respectively. For presepsin sensitivity, specificity, and AUC, respectively, for diagnosis of sepsis was 77.1%, 66.7%, and 0.734. For ICU mortality, sensitivity and specificity for CRP was 95.5% and 1.3%, for procalcitonin (>0.5) 72.7% and 24.4.%, for procalcitonin (>1) 59.1% and 42.3%, and for presepsin 61.5% and 27.3%, respectively. Conclusion: Inflammatory markers may be raised in a large proportion of ICU patients, even in those without sepsis. Procalcitnonin and presepsin had similar efficacy in diagnosing sepsis. However, none of the three biomarkers studied were accurate in predicting ICU mortality.

Clinical course and outcomes of cancer patients admitted in medical ICU with sepsis.

Background and aims: Sepsis is not only a leading cause of intensive care unit (ICU) admission but also one of the variables which affect outcomes of cancer patients. We aimed to assess the clinical characteristics, clinical course, mortality and risk factors associated with 30-day mortality in medical oncology patients admitted in a multi-disciplinary medical ICU. Methods: We conducted a retrospective analysis of 435 consecutive cancer patients admitted in medical ICU over a 28 months period. Patients were divided into two groups based on the presence of sepsis at the time of ICU admission. Data regarding baseline patient characteristics, clinical and laboratory data, need for organ support and 30-day mortality were collected. Sepsis patients were further classified as 30-day survivors and non-survivors and risk factors for mortality in these patients were determined. Results: Overall 30-day mortality was 57.8%. It was significantly higher in sepsis group patients (73.9%) as compared to non-sepsis patients (46.6%) (p < 0.001). Most common reason for ICU admission in non-sepsis group was respiratory distress (51.4%) followed by altered sensorium (28.4%). Presence of metastasis [odds ratio, OR: 3.89 (95% confidence interval, CI: 1.536-9.901)], high lactate [OR: 1.374 (95% CI: 1.024-1.843)] and need of invasive mechanical ventilator (IMV) support [OR: 7.634 (95% CI: 2.519-23.256)] or vasopressor support [OR: 3.268 (95% CI: 1.179-9.090)] were directly associated with 30-day mortality. Conclusion: Critically ill cancer patients admitted with sepsis had high mortality. Presence of metastasis, high lactate and need of IMV or vasopressor support was associated with worse prognosis in cancer patients admitted with sepsis in ICU.

Sodium-glucose Cotransporter-2 Inhibitors induced euglycemic diabetic ketoacidosis: A meta summary of case reports.

BACKGROUND: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are commonly prescribed to manage patients with diabetes mellitus. These agents may rarely lead to the development of euglycemic diabetic ketoacidosis (EDKA), which may complicate the disease course of these patients. AIM: To analyze the demographic profile, predisposing factors, symptomology, clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series. METHODS: We performed a systematic search of PubMed, Science Direct, Google Scholar and Reference Citation Analysis databases using the terms "canagliflozin" OR "empagliflozin" OR "dapagliflozin" OR "SGLT2 inhibitors" OR "Sodium-glucose cotransporter-2" AND "euglycemia" OR "euglycemic diabetic ketoacidosis" OR "metabolic acidosis". The inclusion criteria were: (1) Case reports or case series with individual patient details; and (2) Reported EDKA secondary to SGLT2i. Furthermore, the data were filtered from the literature published in the English language and on adults (> 18 years). We excluded: (1) Conference abstracts; and (2) Case reports or series which did not have individual biochemical data. All the case reports and case series were evaluated. The data extracted included patient demographics, clinical symptomatology, clinical interventions, intensive care unit course, need for organ support and outcomes. RESULTS: Overall, 108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included. The majority of patients were females (54.4%, n = 92), and the commonly reported symptoms were gastrointestinal (nausea/vomiting 65.1%, abdominal pain 37.3%) and respiratory (breathlessness 30.8%). One hundred and forty-nine (88.2%) patients had underlying type II diabetes, and the most commonly involved SGLT-2 inhibitor reported was empagliflozin (46.8%). A triggering factor was reported in most patients (78.7%), the commonest being acute severe infection (37.9%), which included patients with sepsis, coronavirus disease 2019, other viral illnesses, and acute pancreatitis. 61.5% were reported to require intensive unit care, but only a minority of patients required organ support in the form of invasive mechanical ventilation (13%), vasopressors (6.5%) or renal replacement therapy (5.9%). The overall mortality rate was only 2.4%. CONCLUSION: Patients on SGLT2i may rarely develop EDKA, especially in the presence of certain predisposing factors, including severe acute infections and following major surgery. The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels, which may make the diagnosis challenging. Outcomes of EDKA are good if recognized early and corrective actions are taken. Hence, physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.

Upper extremity deep vein thrombosis: An intensivist's perspective.

Upper extremity deep vein thrombosis (UEDVT) is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients. Increasing cancer incidence, prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT. It is also associated with high rates of complications like pulmonary embolism, post-thrombotic syndrome and recurrent thrombosis. Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT; hence, a high suspicion index is required for diagnosis. Doppler ultrasound is commonly employed for diagnosis, but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients. Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies. Anticoagulant therapy alone is sufficient in most patients, and thrombolysis and surgical decompression is seldom indicated. The outcome depends on the cause and underlying comorbidities.

Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients: A comparative observational study.

BACKGROUND: As per the latest Surviving Sepsis Campaign guidelines, fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization. Nevertheless, raised lactate levels should be interpreted in the clinical context, as there may be other causes of elevated lactate levels. Thus, it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation, and exploring alternative resuscitation targets should be an essential research priority in sepsis. AIM: To compare the 28-d mortality in two clinical patterns of septic shock: hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context. METHODS: This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context (Group 1, n = 95) and patients with hyperlactatemia in a non-hypoperfusion context (Group 2, n = 40). Hypoperfusion context was defined by a central venous saturation less than 70%, central venous-arterial PCO2 gradient [P(cv-a)CO2] ≥ 6 mmHg, and capillary refilling time (CRT) ≥ 4 s. The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h, 3 h, and 6 h. All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals. Nominal categorical data were compared using the χ2 or Fisher's exact test. Non-normally distributed continuous variables were compared using the Mann-Whitney U test. Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate, CRT, and metabolic perfusion parameters to predict the 28-d all-cause mortality. A P value of < 0.05 was considered significant. RESULTS: Patient demographics, comorbidities, baseline laboratory, vital parameters, source of infection, baseline lactate levels, and lactate clearance at 3 h and 6 h, Sequential Organ Failure scores, need for invasive mechanical ventilation, days on mechanical ventilation, and renal replacement therapy-free days within 28 d, duration of intensive care unit stay, and hospital stay were comparable between the two groups. The stratification of patients into hypoperfusion and non-hypoperfusion context did not result in a significantly different 28-d mortality (24% vs 15%, respectively; P = 0.234). However, the patients within the hypoperfusion context with high P(cv-a)CO2 and CRT (P = 0.022) at baseline had significantly higher mortality than Group 2. The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P > 0.05 at all measured intervals. Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion (18.88 ± 9.04 vs 21.08 ± 8.76; P = 0.011). The mean lactate levels and lactate clearance at 3 h and 6 h, CRT, P(cv-a)CO2 at 0 h, 3 h, and 6 h were found to be associated with 28-d mortality in patients with septic shock, with lactate levels at 6 h having the best predictive value (area under the curve lactate at 6 h: 0.845). CONCLUSION: Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality, although patients with hypoperfusion displayed a more severe circulatory dysfunction. Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters. Persistently high P(cv-a)CO2 (> 6 mmHg) or increased CRT (> 4 s) at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients.

Approach to thromboelastography-based transfusion in cirrhosis: An alternative perspective on coagulation disorders.

Viscoelastic tests, specifically thromboelastography and rotational thromboelastometry, are increasingly being used in the management of postoperative bleeding in surgical intensive care units (ICUs). However, life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs, especially those with underlying liver dysfunction. Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications. Compared to conventional coagulation tests, a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices, which may aid physicians in making a rapid diagnosis and instituting early interventions. These tests may help predict bleeding and rationalize the use of blood products in these patients.

Role of cerebrospinal fluid lactate in diagnosing meningitis in critically ill patients.

BACKGROUND: Meningitis is a life-threatening clinical condition associated with high mortality and morbidity. Early diagnosis and specific treatment may improve outcomes. Lack of specific clinical signs or tests make the diagnosis challenging. AIM: To assess the efficacy of cerebrospinal fluid (CSF) lactate in diagnosing meningitis in critically ill patients. METHODS: A prospective, observational cohort study was carried out in a neuro-medical intensive care unit (ICU) over a 22 mo period. Adult patients, with suspected meningitis admitted in ICU, were serially recruited. Patients who refused consent, those with peripheral sensorineural deficit, or with any contraindication to lumber puncture were excluded. CSF cytology, bio-chemistry, lactates, culture and polymerase chain reaction based meningo-encephalitis panel were evaluated. Patients were divided in two groups based on clinical diagnosis of meningitis. The efficacy of CSF lactate in diagnosing meningitis was evaluated and compared with other tests. RESULTS: Seventy-one patients were included and 23 were diagnosed with meningitis. The mean values of CSF total leucocyte count (TLC), proteins and lactates were significantly higher in meningitis group. There was a significant correlation of CSF lactate levels with CSF cultures and meningo-encephalitis panel. CSF lactate (> 2.72 mmol/L) showed good accuracy in diagnosing meningitis with an area under the curve of 0.81 (95% confidence interval: 0.69-0.93), sensitivity of 82.6%, and specificity 72.9%. These values were comparable to those of CSF TLC and protein. Twelve patients with bacterial meningitis had significantly higher CSF lactate (8.9 ± 4.7 mmol/L) than those with non-bacterial meningitis (4.2 ± 3.8 mmol/L), P = 0.006. CONCLUSION: CSF lactate may be used to aid in our diagnosis of meningitis in ICU patients. CSF lactate (> 2.72 mmol/L) showed good accuracy, sensitivity, and specificity in diagnosing meningitis and may also help to differentiate between bacterial and non-bacterial meningitis.

Bedside ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure in nontraumatic neuro-critically ill patients.

BACKGROUND: Delay in treatment of raised intracranial pressure (ICP) leads to poor clinical outcomes. Optic nerve sheath diameter (ONSD) by ultrasonography (US-ONSD) has shown good accuracy in traumatic brain injury and neurosurgical patients to diagnose raised ICP. However, there is a dearth of data in neuro-medical intensive care unit (ICU) where the spectrum of disease is different. AIM: To validate the diagnostic accuracy of ONSD in non-traumatic neuro-critically ill patients. METHODS: We prospectively enrolled 114 patients who had clinically suspected raised ICP due to non-traumatic causes admitted in neuro-medical ICU. US-ONSD was performed according to ALARA principles. A cut-off more than 5.7 mm was taken as significantly raised. Raised ONSD was corelated with raised ICP on radiological imaging. Clinical history, general and systemic examination findings, SOFA and APACHE 2 score and patient outcomes were recorded. RESULTS: There was significant association between raised ONSD and raised ICP on imaging (P < 0.001). The sensitivity, specificity, positive and negative predictive value at this cut-off was 77.55%, 89.06%, 84.44% and 83.82% respectively. The positive and negative likelihood ratio was 7.09 and 0.25. The area under the receiver operating characteristic curves was 0.844. Using Youden's index the best cut off value for ONSD was 5.75 mm. Raised ONSD was associated with lower age (P = 0.007), poorer Glasgow Coma Scale (P = 0.009) and greater need for surgical intervention (P = 0.006) whereas no statistically significant association was found between raised ONSD and SOFA score, APACHE II score or ICU mortality. Our limitations were that it was a single centre study and we did not perform serial measurements or ONSD pre- and post-treatment or procedures for raised ICP. CONCLUSION: ONSD can be used as a screening a test to detect raised ICP in a medical ICU and as a trigger to initiate further management of raised ICP. ONSD can be beneficial in ruling out a diagnosis in a low-prevalence population and rule in a diagnosis in a high-prevalence population.

Scoring systems in critically ill: Which one to use in cancer patients?

BACKGROUND: Scoring systems have not been evaluated in oncology patients. We aimed to assess the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, APACHE IV, Simplified Acute Physiology Score (SAPS) II, SAPS III, Mortality Probability Model (MPM) II0 and Sequential Organ Failure Assessment (SOFA) score in critically ill oncology patients. AIM: To compare the efficacy of seven commonly employed scoring systems to predict outcomes of critically ill cancer patients. METHODS: We conducted a retrospective analysis of 400 consecutive cancer patients admitted in the medical intensive care unit over a two-year period. Primary outcome was hospital mortality and the secondary outcome measure was comparison of various scoring systems in predicting hospital mortality. RESULTS: In our study, the overall intensive care unit and hospital mortality was 43.5% and 57.8%, respectively. All of the seven tested scores underestimated mortality. The mortality as predicted by MPM II0 predicted death rate (PDR) was nearest to the actual mortality followed by that predicted by APACHE II, with a standardized mortality rate (SMR) of 1.305 and 1.547, respectively. The best calibration was shown by the APACHE III score (χ 2 = 4.704, P = 0.788). On the other hand, SOFA score (χ 2 = 15.966, P = 0.025) had the worst calibration, although the difference was not statistically significant. All of the seven scores had acceptable discrimination with good efficacy however, SAPS III PDR and MPM II0 PDR (AUROC = 0.762), had a better performance as compared to others. The correlation between the different scoring systems was significant (P < 0.001). CONCLUSION: All the severity scores were tested under-predicted mortality in the present study. As the difference in efficacy and performance was not statistically significant, the choice of scoring system used may depend on the ease of use and local preferences.

Role of high dose vitamin C in management of hospitalised COVID-19 patients: A minireview.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the most dreadful viruses the mankind has witnessed. It has caused world-wide havoc and wrecked human life. In our quest to find therapeutic options to counter this threat, several drugs have been tried, with varying success. Certain agents like corticosteroids, some anti-virals and immunosuppressive drugs have been found useful in improving clinical outcomes. Vitamin C, a water-soluble vitamin with good safety profile, has been tried to reduce progression and im-prove outcomes of patients with coronavirus disease 2019 (COVID-19). Because of its anti-oxidant and immunomodulatory properties, the role of vitamin C has expanded well beyond the management of scurvy and it is increasingly been employed in the treatment of critically ill patients with sepsis, septic shock, acute pancreatitis and even cancer. However, in spite of many case series, observational studies and even randomised control trials, the role of vitamin C remains ambiguous. In this review, we will be discussing the scientific rationale and the current clinical evidence for using high dose vitamin C in the management of COVID-19 patients.

Air leaks in COVID-19.

Coronavirus disease 2019 (COVID-19) continues to create havoc and may present with myriad complications involving many organ systems. However, the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected. There is a high incidence of air leaks in patients with COVID-19, leading to acute worsening of clinical condition. The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and un-derlying lung disease. The exact pathophysiology of air leaks with COVID-19 remains unclear, but multiple factors may play a role in their development. A significant proportion of air leaks may be asymptomatic; hence, a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality. These air leaks may even develop weeks to months after the disease onset, leading to acute deterioration in the post-COVID period. Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.

Secondary infections modify the overall course of hospitalized patients with COVID-19: a retrospective study from a network of hospitals across North India.

Objective: To gain better insight into the extent of secondary bacterial and fungal infections in hospitalized patients in India, and to assess how these alter the course of coronavirus disease 2019 (COVID-19) so that control measures can be suggested. Methods: In this retrospective, multicentre study, the data of all patients who tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on reverse transcriptase polymerase chain reaction (RT-PCR), admitted to hospital between March 2020 and July 2021, were accessed from the electronic health records of a network of 10 hospitals across five states in North India. Results: Of 19,852 patients testing positive for SARS-CoV-2 on RT-PCR and admitted to the study hospitals during the study period, 1940 (9.8%) patients developed secondary infections (SIs). Patients with SIs were, on average, 8 years older than patients without SIs (median age 62.6 vs 54.3 years; P<0.001). The risk of SIs was significantly (P<0.001) associated with age, severity of disease at admission, diabetes, admission to the intensive care unit (ICU), and ventilator use. The most common site of infection was urine (41.7%), followed by blood (30.8%) and sputum/bronchoalveolar lavage/endotracheal fluid (24.8%); the least common was pus/wound discharge (2.6%). Gram-negative bacilli (GNB) were the most common organisms (63.2%), followed by Gram-positive cocci (GPC) (19.6%) and fungi (17.3%). Most patients with SIs were on multiple antimicrobials. The most commonly used antibiotics against GNB were beta-lactam/beta-lactamase inhibitors (76.9%), carbapenems (57.7%), cephalosporins (53.9%), and antibiotics against carbapenem-resistant Enterobacteriaceae (47.1%). Empirical use of antibiotics against GPC was seen in 58.9% of patients with SIs, and empirical use of antifungals was observed in 56.9% of patients with SIs. The average length of hospital stay for patients with SIs was almost twice as long as that of patients without SIs (median 13 vs 7 days). Overall mortality among patients with SIs (40.3%) was more than eight times higher than that among patients without SIs (4.6%). Only 1.2% of patients with SIs with mild COVID-19 at admission died, compared with 17.5% of those with moderate COVID-19 at admission and 58.5% of those with severe COVID-19 at admission (P<0.001). The mortality rate was highest in patients with bloodstream infections (49.8%), followed by those with hospital-acquired pneumonia (47.9%), urinary tract infections (29.4%), and skin and soft tissue infections (29.4%). The mortality rate in patients with diabetes with SIs was 45.2%, compared with 34.3% in those without diabetes (P<0.001). Conclusions: SIs complicate the course of patients hospitalized with COVID-19. These patients tend to have a much longer hospital stay, a higher requirement for oxygen and ICU care, and a significantly higher mortality rate compared with those without SIs. The groups most vulnerable to SIs are patients with more severe COVID-19, elderly patients and patients with diabetes. Judicious empirical use of combination antimicrobials in these groups of vulnerable patients can save lives. It is desirable to have region- or country-specific guidelines for appropriate use of antibiotics and antifungals to prevent their overuse.

Candida Score: a Predictor of Mortality in Patients with Candidemia.

BACKGROUND: Candida score has been developed and used for identifying patients at risk for developing Candida infections. However, its usefulness in predicting outcome of patients with candidemia has not been evaluated. We aimed to determine the risk factors for mortality in patients with candidemia admitted to an Indian medical intensive care unit (ICU). METHODS: We conducted a retrospective cohort analysis of 56 patients with candidemia presented in 18 months duration. Baseline patient characteristics, ICU course and outcome were noted and Candida score was calculated. We conducted analysis based on the primary outcome measure of ICU mortality. RESULTS: Out of 3,142 ICU admissions, the incidence of candidemia was 17.8/1,000 admissions. The mean interval between ICU admission and candidemia was 12.9 ± 14.4 days. C. tropicalis was the commonest species isolated from 28.6% isolates, followed by Candida albicans (21.4%) and C. glabrata (12.5%). The mean length of ICU stay was 22.9 ± 28 days and hospital stay was 30.1 ± 30.2 days. Crude ICU mortality was 33.93%. There was no statistically significant difference between mortality of patients with albicans and non-albicans candidemia (p=0.732). On multivariate analysis, only two factors, previous antifungal therapy (p=0.004, OR=101.4, 95% CI=4.52-227.7) and Candida score >3 (p=0.028, OR=13.2, 95% CI=1.3-125) were found to be independently predicting mortality. CONCLUSION: Candida infection is generally late-onset and is associated with a prolonged ICU and hospital stay, and a high mortality. Candida non-albicans infection was more common but there was no difference in mortality among patients with C. albicans and non-albicans infection. Previous antifungal therapy and Candida score were found to be independently predicting mortality.

Practice Pattern of Critical Care Physicians in India for Use of Corticosteroids in COVID-19.

Introduction: Steroids are recommended as the standard of care in managing severe COVID-19. However, several questions remain unanswered regarding the prescription of steroids which led to differing opinions and practice. We surveyed practice patterns of critical care physicians in India for the use of corticosteroids in COVID-19. Methods: This was a nationwide, cross-sectional, online, knowledge attitude practice-based survey, among intensivists for corticosteroid use in COVID-19. The survey questionnaire had seven questions for demographic data and 14 questions in the core survey. Results: 384 responses were analyzed from different parts of the country. A majority (81.2%) agreed that steroids improved oxygenation and survival chances. 88.3% agreed that steroids are indicated because of their anti-inflammatory properties, and should be prescribed in patients with moderate (75.8%), severe (59.9%), or critical (41.1%) COVID-19. 68.8% of physicians start steroids on the basis of "need for oxygen therapy" and hyperglycemia (85.2%) was the most commonly reported complication. 59.1% prefer prescribing methylprednisolone followed by Dexamethasone (38.8%). 51.8% preferred to use low dose steroids, and 59.1% have used "pulse steroids''. Rather than a fixed duration of therapy, 66.9% of the respondents rely on "clinical improvement" before stopping steroids, even if it meant continuing steroids for prolonged periods beyond 14 days (34.1%). 57.8% always taper steroids before stopping. Conclusions: We found wide variation in the practice patterns of critical care physicians in India for use of Corticosteroids in COVID-19. The dilemma regarding when to initiate, type of steroid, dose, and duration of therapy still persist emphasizing the need for further research.

Effectiveness of convalescent plasma in Indian patients with COVID-19.

BACKGROUND: Convalescent plasma (CP) is being used as a treatment option in hospitalized patients with COVID-19. Till date, there is conflicting evidence on efficacy of CP in reducing COVID-19 related mortality. OBJECTIVE: To evaluate the effect of CP on 28-day mortality reduction in patients with COVID-19. METHODS: We did a multi-centre, retrospective case control observational study from 1st May 2020 to 31st August 2020. A total of 1079 adult patients with moderate and severe COVID-19 requiring oxygen, were reviewed. Of these, 694 patients were admitted to ICU. Out of these, 333 were given CP along with best supportive care and remaining 361 received best supportive care only. RESULTS: In the overall group of 1079 patients, mortality in plasma vs no plasma group was statistically not significant (22.4% vs 18.5%; p = 0.125; OR = 1.27, 95% CI: 0.94--1.72). However, in patients with COVID-19 admitted to ICU, mortality was significantly lower in plasma group (25.5% vs 33.2%; p = 0.026; OR = 0.69, 95%CI: 0.50-0.96). This benefit of reduced mortality was most seen in age group 60 to 74 years (26.7% vs 43.0%; p = 0.004; OR = 0.48, 95% CI: 0.29-0.80), driven mostly by females of this age group (23.1% vs 53.5%; p = 0.013; OR = 0.26, 95% CI: 0.09-0.78). Significant difference in mortality was observed in patients with one comorbidity (22.3% vs 36.5%; p = 0.004; OR = 0.50, 95% CI: 0.31-0.80). Moreover, patients on ventilator had significantly lower mortality in the plasma arm (37.2% vs 49.3%; p = 0.009; OR = 0.61, 95% CI: 0.42-0.89); particularly so for patients on invasive mechanical ventilation (63.9% vs 82.9%; p = 0.014; OR = 0.37, 95% CI: 0.16-0.83). CONCLUSION: The use of CP was associated with reduced mortality in COVID-19 elderly patients admitted in ICU, above 60 years of age, particularly females, those with comorbidities and especially those who required some form of ventilation.

Hepatitis A Virus-induced Severe Hemolysis Complicated by Severe Glucose-6-Phosphate Dehydrogenase Deficiency.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an x-linked recessive genetic disorder with mutation in the G6PD gene. Defect in the enzyme G6PD causes red blood cells (RBCs) to breakdown prematurely causing hemolytic anemia. Hemolytic anemia is also a known hematological complication associated with viral hepatitis. In such patients, hemolysis may be more severe if there is any secondary injury to RBC in the form of membrane defect, oxidative stress, or enzyme deficiency like in G6PD deficiency. Here, we present a case of an adult, not previously diagnosed with G6PD deficiency, who presented with viral hepatitis, severe hemolysis, and multiorgan failure.

Clinical Profile, Intensive Care Unit Course, and Outcome of Patients Admitted in Intensive Care Unit with Chikungunya.

OBJECTIVE: Chikungunya is generally a mild disease, rarely requiring Intensive Care Unit (ICU) admission. However, certain populations may develop organ dysfunction necessitating ICU admission. The purpose of the study was to assess the clinical profile and course of chikungunya patients admitted to the ICU, and to ascertain factors linked with poor outcome. METHODS: All patients with chikungunya admitted to ICU were included in the study. Admission Acute Physiology and Chronic Health Evaluation (APACHE) II score and sequential organ failure assessment (SOFA) score were calculated. Primary outcome measured was 28-day mortality and secondary outcomes measured were length of hospital and ICU stay and the need for vasopressor support, renal replacement therapy (RRT), and mechanical ventilation (MV). Logistic regression analysis was performed to identify factors predicting mortality. RESULTS: The most common complaints were fever (96.67%) and altered sensorium (56.67%). Mean admission APACHE II and SOFA scores were 17.28 ± 7.9 and 7.15 ± 4.2, respectively. Fifty-one patients had underlying comorbidities. Vasopressors were required by 46.76%; RRT by 26.67%, and MV by 58.33%, respectively. The 28-day mortality was 36.67%. High APACHE II score (odds ratio: 1.535; 95% confidence interval: 1.053-2.237; P = 0.026) and need for dialysis (odds ratio: 833.221; 95% confidence interval: 1.853-374,664.825; P = 0.031) could independently predict mortality. CONCLUSIONS: Patients with chikungunya fever may require ICU admission for organ failure. They are generally elderly patients with underlying comorbidities. Despite aggressive resuscitation and organ support, these patients are at high risk of death. Admission APACHE II score and need for dialysis may predict patients at higher risk of death.

Resurgence of Polymyxin B for MDR/XDR Gram-Negative Infections: An Overview of Current Evidence.

Polymyxin B has resurged in recent years as a last resort therapy for Gram-negative multidrug-resistant (MDR) and extremely drug resistant (XDR) infections. Understanding newer evidence on polymyxin B is necessary to guide clinical decision making. Here, we present a literature review of polymyxin B in Gram-negative infections with update on its pharmacology.