A world-wide study on delirium assessments and presence of protocols.

BACKGROUND: Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities. OBJECTIVE: To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols. DESIGN: Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023. SETTING: Cross-sectional online survey including hospitals, rehabilitation and long-term facilities. METHODS: Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers. RESULTS: Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions. CONCLUSION: Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.

Association of Noninvasive Respiratory Support with Extubation Outcomes in Brain-injured Patients Receiving Mechanical Ventilation: A Secondary Analysis of the ENIO Prospective Observational Study.

Rationale: Noninvasive respiratory support using a high-flow nasal cannula (HFNC) or noninvasive positive pressure ventilation (NIPPV) can decrease the risk of reintubation in patients being liberated from mechanical ventilation, but effects in patients with acute brain injury (ABI) are unknown. Objectives: To evaluate the association between postextubation noninvasive respiratory support and reintubation in patients with ABI being liberated from mechanical ventilation. Methods: This was a secondary analysis of a prospective, observational study of mechanically ventilated patients with ABI (clinicaltrials.gov identifier NCT03400904). The primary endpoint was reintubation during ICU admission. We used mixed-effects logistic regression models with patient-level covariates and random intercepts for hospital and country to evaluate the association between prophylactic (i.e., planned) HFNC or NIPPV and reintubation. Measurements and Main Results: 1,115 patients were included from 62 hospitals and 19 countries, of whom 267 received HFNC or NIPPV following extubation (23.9%). Compared with conventional oxygen therapy, neither prophylactic HFNC nor NIPPV was associated with decreased odds of reintubation (respectively, odds ratios of 0.97 [95% confidence interval, 0.54-1.73] and 0.63 [0.30-1.32]). Findings remained consistent in sensitivity analyses accounting for alternate adjustment procedures, missing data, shorter time frames of the primary endpoint, and competing risks precluding reintubation. In a Bayesian analysis using skeptical and data-driven priors, the probabilities of reduced reintubation ranged from 17% to 34% for HFNC and from 46% to 74% for NIPPV. Conclusions: In a large cohort of brain-injured patients undergoing liberation from mechanical ventilation, prophylactic use of HFNC and NIPPV were not associated with reintubation. Prospective trials are needed to confirm treatment effects in this population. Primary study registered with www.clinicaltrials.gov (NCT03400904).

Red Blood Cell Transfusion in the Intensive Care Unit.

Importance: Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice. Objective: To evaluate and describe ICU RBC transfusion practices worldwide. Design, Setting, and Participants: International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks. Exposure: ICU stay. Main Outcomes and Measures: The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused. Results: Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL. Conclusions and Relevance: RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.

Sheehan's Syndrome unmasked by dengue fever: A case report and review of literature.

Sheehan's syndrome is a pituitary disease resulting from severe postpartum hemorrhage and can present with varying degrees of pituitary insufficiency. Although its incidence is decreasing in developed countries, it continues to be one of the most common causes of hypopituitarism in underdeveloped and developing countries. Here, we report a case of Sheehan's syndrome which was diagnosed following an episode of severe dengue infection, in a 38-year-old female.

Who Cares About Me? The Need of the Hour is to Improve Awareness and Quality of End-of-life Care Practices in Indian Intensive Care Units.

How to cite this article: Singh U, Maurya I, Gurjar M. Who Cares About Me? The Need of the Hour is to Improve Awareness and Quality of End-of-life Care Practices in Indian Intensive Care Units. Indian J Crit Care Med 2023;27(8):523-525.

Towards Achieving Nutrition Goal in Critically Ill Patients: Need a Simple Yet Effective Bedside Tool.

How to cite this article: Wali S, Gutte SH, Gurjar M. Towards Achieving Nutrition Goal in Critically Ill Patients: Need a Simple Yet Effective Bedside Tool. Indian J Crit Care Med 2023;27(6):379-380.

Collaborative Research in Critical Care Medicine: A Way Forward to High-impact Publications from India.

How to cite this article: Ravisankar NP, Singh R, Gurjar M. Collaborative Research in Critical Care Medicine: A Way Forward to High-impact Publications from India. Indian J Crit Care Med 2023;27(12):869-870.

Association of hyperglycaemia at-admission & diabetes mellitus with 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection: A retrospective study.

Background & objectives: The association between hyperglycaemia at admission, diabetes mellitus (DM) status and mortality in hospitalized SARS-CoV-2 infected patients is not clear. The purpose of this study was to determine the relationship between DM, at-admission hyperglycaemia and 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection requiring intensive care. Methods: All consecutive moderate-to-severe patients with SARS-CoV-2 infection admitted to the intensive care units (ICUs) over six months were enrolled in this single-centre, retrospective study. The predicators for 28 day mortality were analysed from the independent variables including DM status and hyperglycaemia at-admission. Results: Four hundred and fifty two patients with SARS-CoV-2 were admitted to the ICU, with a mean age of 58.5±13.4 yr, 78.5 per cent being male, HbA1c of 7.2 per cent (6.3-8.8) and 63.7 per cent having DM. Overall, 28 day mortality was 48.9 per cent. In univariate analysis, mortality in diabetes patients was comparable with non-diabetes (47.9 vs. 50.6%, P=0.58), while it was significantly higher in hyperglycaemic group (60.4 vs. 35.8%, P<0.001). In multivariate Cox regression analysis, after adjusting for age, sex and comorbidities, hyperglycaemia at-admission was an independent risk factor of mortality [hazard ratio (HR) 1.45, 95% confidence interval (CI) (1.06-1.99), P<0.05]. Interpretation & conclusions: This study showed that the presence of hyperglycaemia at-admission in critically ill SARS-CoV-2 patients was an independent predictor of 28 day mortality. However, the findings may be susceptible to unmeasured confounding, and more research from prospective studies is required.

A Rare Case Report of Intra-abdominal Mucormycosis Complicating Acute Pancreatitis.

Intra-abdominal infections are known to complicate the course of acute pancreatitis. Invasive fungal infections (Candida spp.) are not the uncommon microorganisms which isolate from intra-abdominal specimen in acute necrotizing pancreatitis. However, we are reporting first case of invasive gastric mucormycosis in a postpartum acute pancreatitis patient. How to cite this article: Bhaskar BK, Gutte SH, Gurjar M, Saran S, Rahul R, Sengar P. A Rare Case Report of Intra-abdominal Mucormycosis Complicating Acute Pancreatitis. Indian J Crit Care Med 2022;26(6):736-738.

Depression and Anxiety among COVID-19 Indian Intensive Care Unit Survivors: A Prospective Observational Study.

Background: Long-lasting physical, cognitive, and mental health sequelae including depression and anxiety are common in intensive care unit (ICU) survivors. Aim: This study was aimed to assess the immediate and medium-term mental health sequelae-depression and anxiety among coronavirus disease-2019 (COVID-19) ICU survivors. Materials and methods: The COVID-19 ICU survivors of a tertiary level ICU were recruited into this study from 1 July 2020 to 31 October 2020. Willing participants were circulated with an electronic questionnaire. It consisted of demographics and questionnaires related to COVID-19 disease, comorbidities, and a patient health questionnaire (PHQ-9) scale for depression, and generalized anxiety disorder (GAD-7) scale for anxiety. Responses were collected at the time of discharge. Follow-up was done at 2 weeks and 6 months. Results: Among the 133 COVID-19 ICU survivors contacted, 91 survivors submitted the baseline data at the time of discharge. Fourteen and another 11 survivors were lost to follow-up at 2 weeks and at 6 months. The median age was 52.75 and 68.1% (n = 62/91) were male. The median PHQ-9 and GAD-7 scores showed a statistically significant decrease at 2 weeks and a non-significant decrease at 6 months compared to baseline scores. The GAD-7 score was the same or worse between baselines to 2 weeks, but it reduced between baseline to 6 months for all variables and their subgroups. Conclusion: This study revealed a high prevalence of anxiety and depression in the immediate post-discharge period. These findings suggest the need for better mental rehabilitation strategies to deal with the well-being of critically ill survivors in future pandemics. How to cite this article: Gunjiganvi M, Rai S, Awale RB, Mishra P, Gurjar M, Gupta D, et al. Depression and Anxiety among COVID-19 Indian Intensive Care Unit Survivors: A Prospective Observational Study. Indian J Crit Care Med 2022;26(12):1267-1274.

Cytomegalovirus Coinfection in Critically Ill Patients with Novel Coronavirus-2019 Disease: Pathogens or Spectators?

Coronavirus disease-2019 (COVID-19) pandemic is raging all over the world. As we are delving more into management of COVID-19, certain new challenges are emerging. One of these is emergence or reactivation of viral infections belonging to Herpesviridae family, especially cytomegalovirus (CMV). Although we have come across the threat of fungal and resistant bacterial infections, experience regarding reactivation or coinfection with concomitant viral infections like CMV during the COVID pandemic is still limited. Whether CMV is a bystander or pathogen is difficult to say categorically and needs further research. In this case series, we intend to describe three patients of COVID-19 with CMV coinfections. To our knowledge, this is the first case series from India. How to cite this article: Siddiqui SS, Chatterjee S, Yadav A, Rai N, Agrawal A, Gurjar M, et al. Cytomegalovirus Coinfection in Critically Ill Patients with Novel Coronavirus-2019 Disease: Pathogens or Spectators? Indian J Crit Care Med 2022;26(3):376-380.

Incorporating Lung Ultrasound in Clinical Pulmonary Infection Score as an Added Tool for Diagnosing Ventilator-associated Pneumonia: A Prospective Observational Study from a Tertiary Care Center.

Background: Clinical pulmonary infection score (CPIS) is an established diagnostic parameter for ventilator-associated pneumonia (VAP). Lung ultrasound (LUS) is an evolving tool for diagnosing VAP. Various scores have been proposed for the diagnosis of VAP, taking LUS as a parameter. We proposed whether replacing LUS with chest radiograph in CPIS criteria will add to the diagnosis of VAP. The current study was done to evaluate the diagnostic accuracy of LUS alone and in combination with clinical and microbiological criteria for VAP by replacing chest radiograph with LUS in CPIS. Materials and methods: We conducted a prospective single-center observational study including 110 patients with suspected VAP to investigate the diagnostic accuracy of LUS. Quantitative mini-bronchoalveolar lavage (mini-BAL) culture was considered the gold standard for diagnosis of VAP. Here, the authors have explored the combination of LUS, clinical, and microbiology parameters for diagnosing VAP. On replacing chest radiograph with LUS, sono-pulmonary infection score (SPIS) and modified SPIS (SPIS-mic, SPIS-cult) was formulated as a substitute for CPIS. Results: Overall LUS performance for VAP diagnosis was good with sensitivity, specificity, positive or negative predictive value, and positive or negative likelihood ratios of 91.3%, 70%, 89%, 75%, 3, and 0.1, respectively. Adding microbiology culture to LUS increased diagnostic accuracy. The areas under the curve for SPIS and modified SPIS were 0.808, 0.815, and 0.913, respectively. Conclusion: The diagnosis of VAP requires agreement between clinical, microbiological, and radiological criteria. Replacing chest radiograph with LUS in CPIS criteria (SPIS) increases diagnostic accuracy for VAP. Adding clinical and culture data to SPIS provided the highest diagnostic accuracy. Clinical parameters along with lung ultrasound increase diagnostic accuracy for VAP. How to cite this article: Samanta S, Patnaik R, Azim A, Gurjar M, Baronia AK, Poddar B, et al. Incorporating Lung Ultrasound in Clinical Pulmonary Infection Score as an Added Tool for Diagnosing Ventilator-associated Pneumonia: A Prospective Observational Study from a Tertiary Care Center. Indian J Crit Care Med 2021;25(3):284-291.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19.

INTRODUCTION: There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids. METHODS: A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round. RESULTS: Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs. CONCLUSION: The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring. HOW TO CITE THIS ARTICLE: How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Heating, ventilation and air conditioning (HVAC) in intensive care unit.

The aim of this review is to describe variation in standards and guidelines on 'heating, ventilation and air-conditioning (HVAC)' system maintenance in the intensive care units, across the world, which is required to maintain good 'indoor air quality' as an important non-pharmacological strategy in preventing hospital-acquired infections. An online search and review of standards and guidelines published by various societies including American Institute of Architects (AIA), American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Centers for Disease Control and Prevention (CDC), Department of Health Estates and Facilities Division, Health Technical Memorandum 2025 (HTM) and Healthcare Infection Control Practices Advisory Committee (HICPAC) along with various national expert committee consensus statements, regional and hospital-based protocols available in a public domain were retrieved. Selected publications and textbooks describing HVAC structural aspects were also reviewed, and we described the basic structural details of HVAC system as well as variations in the practised standards of HVAC system in the ICU, worldwide. In summary, there is a need of universal standards for HVAC system with a specific mention on the type of ICU, which should be incorporated into existing infection control practice guidelines.

Effect of Prone Positioning on Intraocular Pressure in Patients With Acute Respiratory Distress Syndrome.

OBJECTIVES: To evaluate the effect of prolonged duration of prone position (with head laterally rotated) on intraocular pressure in acute respiratory distress syndrome patients. DESIGN: Prospective observational study. SETTING: University hospital ICU. PATIENTS: Twenty-five acute respiratory distress syndrome patients, age 60 years (51-67 yr), Sequential Organ Failure Assessment score 10 (10-12), PaO2/FIO2 ratio of 90 (65-120), and all in septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intraocular pressure (in mm Hg) measured by hand-held applanation tonometer, at different time points. Before prone (in both eyes): at 30-45° head-end elevation position (THE pre-prone), in supine position just before turning prone (Tsupine pre-prone); during prone (in nondependent eye): at 10 minutes (T10 prone), 30 minutes (T30 prone), and at just before end of prone session (Tend-prone). After end of prone session (both eyes): at 5 minutes (T5 supine post-prone), 10 minutes (T10 HE post-prone), 15 minutes (T15 HE post-prone), and 30 minutes (T30 HE post-prone). Median duration of prone position was 14 hours (12-18 hr). Median intraocular pressure increased significantly (p ≤ 0.001) in both eyes. In dependent eye, from 15 (12-19) at THE pre-prone to 24, 21, 19, and 16 at T5 supine post-prone, T10 HE post-prone, T15 HE post-prone, and T30 HE post-prone respectively, whereas in nondependent eye from 14 (12-18.5) at THE pre-prone to 23, 25, 32, 25, 22, 20, and 17 at T10 prone, T30 prone, Tend-prone, T5 supine post-prone, T10 HE post-prone, T15 HE post-prone, and T30 HE post-prone respectively. Bland-Altman plot analysis showed significant linear relationship (r = 0.789; p ≤ 0.001) with good agreement between rise in mean intraocular pressure of the both eyes (dependent eye and nondependent eye) with their paired differences after the end of different duration of prone session (T5 supine post-prone). CONCLUSIONS: There is significant increase in intraocular pressure due to prone positioning among acute respiratory distress syndrome patients. Intraocular pressure increases as early as 10 minutes after proning, with increasing trend during prone position, which persisted even at 30 minutes after the end of post prone session although with decreasing trend.

Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center.

AIMS: To estimate the prevalence of antibiotic de-escalation at admission in patients referred to a tertiary hospital in India. The secondary outcomes were the adequacy of empirical antibiotic therapy and culture positivity rates in the de-escalated group. MATERIALS AND METHODS: A prospective observational study, in a 20-bedded intensive care unit (ICU) of tertiary care hospital. Patients >18 years, surviving > 48 hours, were included (June- December 2017). Demographic data, previous cultures, and antibiotics from other hospitals, laboratory parameters in the first 24 hours, and severity of illness were noted. Changes made in antibiotic therapy within 48 hours were recorded. Patients were analyzed into three groups: "No change"-empiric therapy was maintained, "Escalation"-switch to or addition of an antibiotic with a broader spectrum, and "De-escalation"-switch to or interruption of a drug class. RESULTS: The total number of patients eligible was 75. The mean age of the population is 43.38 (SD + 3.4) and groups were comparable in terms of mean sequential organ failure assessment score (SOFA) and acute physiology, age, chronic health evaluation (APACHE) 2. The prevalence of de-escalation was 60% at admission. The escalation group consisted of 24%. Sixteen percent patients belonged to no change group. Results showed that 38% of patients were on carbapenems, dual gram negative was given to 26%, and empirical methicillin-resistant staphylococcus aureus (MRSA) coverage was 28% on admission. CONCLUSION: Our study aims to provide data about actual practices in the Indian scenario. It highlights the generous use of high-end antibiotics in the community. Indian practices are far cry from theoretical teaching and western data. The need for antibiotic stewardship program in our country for both public and private health sectors is the need of the hour. HOW TO CITE THIS ARTICLE: Singh R, Azim A, Gurjar M, Poddar B, Baronia AK. Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center. Indian Journal of Critical Care Medicine, January 2019;23(1):7-10.

Quality of Life After Intensive Care Unit Discharge in a Tertiary Care Hospital in India: Cost Effectiveness Analyis.

BACKGROUND: Improvements in intensive care in the last few decades have shifted the focus from mortality to quality of life of survivors as a more important outcome measure. Allocation of public resources towards intensive care is an important challenge for healthcare administrators. This challenge is made more arduous in resource limited countries like India. Thus, it is imperative to consider patient centerd outcomes and resource utilisation to guide allocation of funds. The aim of this study was to evaluate the quality of life of long-term survivors, and to perform cost-effectiveness and cost-utility analysis. METHODS: Data was retrieved from the records and included age, gender, admission diagnosis, length of ICU stay and mortality. Costing methodology used was top down approach. Quality of life was assessed by SF 36 scoring which was done with personal interview and telephonically. Cost-effectiveness analysis was done on the basis of years of life added. Cost utility was done by QALY gained. RESULTS: A total of 1232 adult patients were admitted in the period with 758 (61%) being successfully discharged from ICU with a mortality rate of 39%. Out of 758, we could contact 113 (15%) patients. 86 patients were alive at the time of contact who could fill the forms for quality of life. The patients discharged from ICU had scores almost similar to the general population. Lesser scores were noted in physical functioning and general health perceptions, though this difference was not statistically significant. The life years gained were significantly more in younger patients. The cost per life gained was more in patients aged more than 50 years compared to those who were younger. CONCLUSION: The quality of life after survival from ICU is as good as in the general population. The intensive care provided in our ICU is cost effective. HOW TO CITE THIS ARTICLE: Mishra SB, Poddar B et al, Quality of Life After Intensive Care Unit Discharge in a Tertiary Care Hospital in India: Cost Effectiveness Analysis. Indian J Crit Care Med 2019;23(3):122-126.

Significance of Mini Bronchoalveolar Lavage Fluid Amylase Level in Ventilator-Associated Pneumonia: A Prospective Observational Study.

OBJECTIVES: Aspiration of oropharyngeal or gastric contents in intubated patients can lead to ventilator-associated pneumonia. Amylase in respiratory secretion has been reported as a possible marker of aspiration. We studied whether elevated α-amylase in mini bronchoalveolar lavage specimens can be suggestive of ventilator-associated pneumonia in intubated patients with high clinical suspicion. DESIGN: Prospective single-center observational study. SETTING: Department of Critical Care Medicine, tertiary care academic institute. PATIENTS: Adult patients on mechanical ventilation for more than 48 hours with with clinically suspected ventilator-associated pneumonia as per defined criteria, admitted between December 2014 and May 2016. METHODS: Mini bronchoalveolar lavage samples were collected within 72 hours of endotracheal intubation. Samples were sent for α-amylase level assay and quantitative culture. Ventilator-associated pneumonia was confirmed from mini bronchoalveolar lavage microbial culture of greater than or equal to 10 cfu/mL, and patients were divided into ventilator-associated pneumonia and no ventilator-associated pneumonia groups. Pre- and postintubation risk factors for aspiration were also noted. RESULTS: The prevalence of ventilator-associated pneumonia was 64.9% among 151 patients in whom it was clinically suspected. Median (interquartile range) mini bronchoalveolar lavage α-amylase levels in ventilator-associated pneumonia and no ventilator-associated pneumonia groups on the day of study inclusion were 287 U/L (164-860 U/L) and 94 U/L (59-236 U/L), respectively (p < 0.001). Median (interquartile range) α-amylase levels in patients with 0, 1, 2, and 3 preintubation risk factors were 65 U/L (35-106 U/L), 200 U/L (113-349 U/L), 867 U/L (353-1,425 U/L), and 3,453 U/L (1,865-4,304 U/L), respectively (p < 0.001) and 472 U/L (164-1,452 U/L) and 731 U/L (203-1,403 U/L) in patients with 1 and 2 postintubation risk factors, respectively (p < 0.001). A mini bronchoalveolar lavage α-amylase of 163 U/L or more yielded sensitivity and specificity of 73% and 68.6%, respectively, with area under the receiver operating characteristic curve of 0.746 (95% CI, 0.66-0.83). CONCLUSIONS: Patients with ventilator-associated pneumonia within 72 hours from intubation have significantly elevated α-amylase concentrations in mini bronchoalveolar lavage fluid. Mini bronchoalveolar lavage α-amylase concentrations increase with increasing number of aspiration risk factors.

Early pH Change Predicts Intensive Care Unit Mortality.

AIM OF THE STUDY: Metabolic acidosis is associated with increased mortality in critically ill patients. We hypothesized that early correction of acidosis of presumed metabolic origin results in improved outcomes. PATIENTS AND METHODS: We conducted a prospective, observational study from February 2015 to June 2016 in a 12 bed mixed intensive care unit (ICU) of a 1000 bed tertiary care hospital in the north of India. ICU patients aged above 18 years with an admission pH ≥7.0 to <7.35 of presumed metabolic origin were included. Arterial blood gas parameters including pH, PaO2, PaCO2, HCO3 -, Na+, K+, Cl-, anion gap (AG), base excess, and lactate at 0, 6, and 24 h along with other standard laboratory investigations were recorded. The primary outcome was to assess the impact of early pH changes on mortality at day 28 of ICU. RESULTS: A total of 104 patients with 60.6% males and 91.3% medical patients were included in the study. Sepsis of lung origin (60.6%) was the predominant etiology. By day 28, 68 (65.4%) patients had died. Median age was 49.5 years, weight 61.7 kg, Sequential Organ Failure Assessment, and Acute Physiologic and Chronic Health Evaluation II scores were 16 and 12, respectively. Nonsurvivors had a higher vasopressor index (P < 0.01), lactate and central venous oxygen saturation (P < 0.05), and lower pH (P < 0.05). A pH correction/change of ≥1.16% during the first 24 h had the best receiver operating characteristic for predicting survival at day 28, with area under the curve (95% confidence interval, 0.72 [0.62-0.82], P < 0.05) compared to HCO3 -, BE, lactate, and AG. CONCLUSIONS: Metabolic acidosis is associated with higher mortality in ICU. The rate of change in pH may better predict ICU mortality than other metabolic indices.

Disseminated Pyomyositis Due to Burkholderia cepacia: A Case Report.

Pyomyositis is a tropical infection affecting skeletal muscles manifesting as high-grade fever with pain in the affected limbs usually caused by Gram-positive microorganisms. Gram-negative organisms causing pyomyositis is uncommon but has been reported. Burkholderia cepacia is a Gram-negative nonfermenter causing opportunistic infections in immunocompromised patients, has been reported to cause pyomyositis only once before. We report a case of B. cepacia pyomyositis in a patient with no history of immunocompromised status, manifesting as disseminated infection with hemophagocytic syndrome presenting to our intensive care unit.