Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator.

Background and purpose: Weaning from a mechanical ventilator is a milestone in the recovery of seriously ill patients in Intensive care. Failure to wean and re-intubation adversely affects the outcome. The method of mechanical ventilation (MV) varies between different ICUs and so does the practice of weaning. Therefore, updated guidelines based on contemporary literature are designed to guide intensivists in modern ICUs. This is the first ISCCM Consensus Statement on weaning complied by a committee on weaning. The recommendations are intended to be used by all the members of the ICU (Intensivists, Registrars, Nurses, and Respiratory Therapists). Methods: A Committee on weaning from MV, formed by the Indian Society of Critical Care Medicine (ISCCM) has formulated this statement on weaning from mechanical ventilators in intensive care units (ICUs) after a review of the literature. Literature was first circulated among expert committee members and allotted sections to each member. Sections of the statement written by sectional authors were peer-reviewed on multiple occasions through virtual meetings. After the final manuscript is accepted by all the committee members, it is submitted for peer review by central guideline committee of ISCCM. Once approved it has passed through review by the Editorial Board of IJCCM before it is published here as "ISCCM consensus statement on weaning from mechanical ventilator". As per the standard accepted for all its guidelines of ISCCM, we followed the modified grading of recommendations assessment, development and evaluation (GRADE) system to classify the quality of evidence and strength of recommendation. Cost-benefit, risk-benefit analysis, and feasibility of implementation in Indian ICUs are considered by the committee along with the strength of evidence. Type of ventilators and their modes, ICU staffing pattern, availability of critical care nurses, Respiratory therapists, and day vs night time staffing are aspects considered while recommending for or against any aspect of weaning. Result: This document makes recommendation on various aspects of weaning, namely, definition, timing, weaning criteria, method of weaning, diagnosis of failure to wean, defining difficult to wean, Use of NIV, HFOV as adjunct to weaning, role of tracheostomy in weaning, weaning in of long term ventilated patients, role of physiotherapy, mobilization in weaning, Role of nutrition in weaning, role of diaphragmatic ultrasound in weaning prediction etc. Out of 42 questions addressed; the committee provided 39 recommendations and refrained from 3 questions. Of these 39; 32 are based on evidence and 7 are based on expert opinion of the committee members. It provides 27 strong recommendations and 12 weak recommendations (suggestions). Conclusion: This guideline gives extensive review on weaning from mechanical ventilator and provides various recommendations on weaning from mechanical ventilator. Though all efforts are made to make is as updated as possible one needs to review any guideline periodically to keep it in line with upcoming concepts and standards. How to cite this article: Clerk AM, Shah RJ, Kothari J, Sodhi K, Vadi S, Bhattacharya PK, et al. Position Statement of ISCCM Committee on Weaning from Mechanical Ventilator. Indian J Crit Care Med 2024;28(S2):S233-S248.

Modified NUTRIC Score as a Predictor of All-cause Mortality in Critically Ill Patients: A Systematic Review and Meta-analysis.

Purpose: The purpose of our meta-analysis was to look at the impact of modified nutrition risk in the critically ill (mNUTRIC) on mortality in patients with critical illness. Materials and methods: Literature relevant to this meta-analysis was searched in PubMed, Web of Science, and Cochrane Library till 26 August 2023. Prospective or retrospective studies, patients >18 years of age, studies that reported on mortality and mNUTRIC (mNUTRIC cut-off score) were included. The QUIPS tool was used to evaluate the risk for bias in prognostic factors. Results: A total of 31 studies on mNUTRIC score, involving 13,271 patients were included. The summary area under the curve (sAUC) of 0.80 (95% CI: 0.76-0.83) illustrates the mNUTRIC score's strong discrimination. The pooled sensitivity was 0.79 (95% CI: 0.74-0.84) and pooled specificity was 0.68 (95% CI: 0.63-0.73). We found no discernible variation in the mNUTRIC's prediction accuracy among cut-off values of <5 and >5 in our subgroup analysis and sAUC values were 0.82 (95% CI: 0.78-0.85) and 0.78 (95% CI: 0.74-0.81), respectively. Conclusion: We observed that mNUTRIC can discriminate between critically ill individuals and predict their mortality. Prospero: CRD42023460292. How to cite this article: Prakash J, Verma S, Shrivastava P, Saran K, Kumari A, Raj K, et al. Modified NUTRIC Score as a Predictor of All-cause Mortality in Critically Ill Patients: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2024;28(5):495-503.

Guidelines for Antibiotics Prescription in Critically Ill Patients.

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

ISCCM Position Statement for Improving Gender Balance in Critical Care Medicine.

Gender disparity in Critical Care Medicine (CCM) persists globally, with women being underrepresented. Female Intensivists remain a minority, facing challenges in academic and leadership positions at the workplace and within academic societies. The Indian Society of Critical Care Medicine (ISCCM) recognized the need for addressing issues related to gender parity and constituted its first Diversity Equity and Inclusion (DEI) Committee in 2023. Through a Delphi process involving 38 Panelists including 53% women, consensus and stability were achieved for 18 statements (95%). From these 18 consensus statements, 15 position statements were drafted to address gender balance issues in CCM. These statements advocate for equal opportunities in recruitment, workplace inclusivity, prevention of harassment, and improved female representation in leadership roles, nominated positions, and conferences. While the consensus reflects a significant step toward gender equity, further efforts are required to implement, advocate, and evaluate the impact of these measures. The ISCCM position statements offer valuable guidance for promoting gender balance within society and the CCM community. How to cite this article: Sathe P, Shukla U, Kapadia FN, Ray S, Chanchalani G, Nasa P, et al. ISCCM Position Statement for Improving Gender Balance in Critical Care Medicine. Indian J Crit Care Med 2024;28(S2):S288-S296.

High-flow Nasal Oxygen Therapy in COVID-19 Critically Ill Patients with Acute Hypoxemic Respiratory Failure: A Prospective Observational Cohort Study.

Background: Coronavirus disease-2019 (COVID-19) is prone to acute hypoxemic respiratory failure (AHRF). Because tracheal intubation is associated with a higher risk of death in these patients, AHRF employs high-flow nasal oxygen therapy (HFNOT). The goal of this study was to assess the effect of HFNOT on oxygenation status as well as different predictors of HFNOT failure. Methods: A prospective observational cohort study was conducted in COVID-positive critically ill adult patients (age >18 years) with AHRF, who were unable to maintain SpO2 >90% on a non-rebreathing face mask at an oxygen flow ≥15 L/minute. Respiratory variables (PaO2/FiO2, SpO2, and RR) before HFNOT (baseline) and then at 1 hour, 6 hours, 7th day, and 14th day after HFNOT application were recorded. Borg CR10 scale and visual analogue scale were used to evaluate the subjective sensation of dyspnea and comfort level, respectively. As needed, Student's t, Mann-Whitney U, or Wilcoxon signed-rank tests were performed. To find parameters linked to HFNOT failure, multivariate logistic regression and receiver operating characteristic (ROC) analysis were employed. Results: A total of 114 patients were enrolled in the study, with an HFNOT failure rate of 29%. The median PaO2/FiO2 ratio at baseline (before the initiation of HFNOT) was 99.5 (80-110) which significantly increased at various time points (1 hour, 6 hours, 7th day, and 14th day) after HFNOT initiation in the successful group. Patients reported significant improvement in sensation of breathlessness [9 (8-10), 3 (2-4); p <0.001] as well as in comfort level [2 (1-2), 8 (4-9); p <0.001]. Multivariate logistic regression analysis, sequential organ failure assessment (SOFA) score >7, acute physiology and chronic health evaluation (APACHE) II score >20, admission P/F ratio <100, D-dimer >2 mg/L, IL-6 >40 pg/mL, random blood sugar (RBS) >250 mg/dL, and 6 hours ROX Index <3.5 were independent prognostic factors of HFNOT failure. Conclusion: The use of HFNOT significantly increased the oxygenation levels in COVID-19 patients with AHRF at various time periods after HFNOT beginning. Age, SOFA score, APACHE II score, ROX score, admission P/F ratio, IL-6, D-dimer, and RBS were independent prognostic factors of HFNOT failure in this cohort. How to cite this article: Khan MS, Prakash J, Banerjee S, Bhattacharya PK, Kumar R, Nirala DK. High-flow Nasal Oxygen Therapy in COVID-19 Critically Ill Patients with Acute Hypoxemic Respiratory Failure: A Prospective Observational Cohort Study. Indian J Crit Care Med 2022;26(5):596-603.

Impact of COVID-19 on Psychological and Emotional Well-being of Healthcare Workers.

BACKGROUND: Coronavirus disease-2019 (COVID-19) in the last few months has disrupted the healthcare system globally. The objective of this study is to assess the impact of the COVID-19 pandemic on the psychological and emotional well-being of healthcare workers (HCWs). MATERIALS AND METHODS: We conducted an online, cross-sectional, multinational survey, assessing anxiety [using Generalized Anxiety Disorder (GAD) Scale: GAD-2 and GAD-7], depression (using Center for Epidemiologic Studies Depression Scale), and insomnia (using Insomnia Severity Index Scale), among HCWs across India, the Middle East, and North America. We used univariate and bivariate logistic regression to identify risk factors for psychological distress. RESULTS: The prevalence of clinically significant anxiety, depression, and insomnia was 41.4%, 48.0%, and 31.3%, respectively. On bivariate logistic regression, lack of social or emotional support to HCWs was independently associated with anxiety [odds ratio (OR), 3.81 (2.84-3.90)], depression [OR, 6.29 (4.50-8.79)], and insomnia [OR, 3.79 (2.81-5.110]. Female gender and self-COVID-19 were independent risk factors for anxiety [OR, 3.71 (1.53-9.03) and 1.71 (1.23-2.38)] and depression [OR, 1.72 (1.27-2.31) and 1.62 (1.14-2.30)], respectively. Frontliners were independently associated with insomnia [OR, 1.68 (1.23-2.29)]. CONCLUSION: COVID-19 pandemic has a high prevalence of anxiety, depression, and insomnia among HCWs. Female gender, frontliners, self-COVID-19, and absence of social or emotional support are the independent risk factors for psychological distress. HOW TO CITE THIS ARTICLE: Bhattacharya PK, Prakash J. Impact of COVID-19 on Psychological and Emotional Well-being of Healthcare Workers. Indian J Crit Care Med 2021;25(5):479-481.

Post-COVID-19 Pulmonary Fibrosis: A Lifesaving Challenge.

How to cite this article: Prakash J, Bhattacharya PK, Priye S, Kumar N. Post-COVID-19 Pulmonary Fibrosis: A Lifesaving Challenge. Indian J Crit Care Med 2021;25(1):104-105.

Morphine-Induced Fever: A Case Series.

The most common cause of postoperative fever is infection. Other causes include cancer, iatrogenic causes, venous thromboembolism, secondary to prosthetic implants, and pyrexia of unknown origin. Here, we describe five cases of opioid-induced pyrexia. In all cases, an injection of morphine was given for postoperative analgesia and all those patients developed fever. All the possible causes of fever were excluded and then opioid was substituted with non-steroidal anti-inflammatory agents. Fever subsided in all the cases. Cessation of the offending drug led to the resolution of the fever in all five cases, and the patient required subsequent supportive care. However, adjunctive pharmacotherapy may also be needed in some patients.