Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia.

How to cite this article: Gangireddy S, Jindal A. Beyond the Nasal Prongs: A Joust of Oxygen Delivery Methods in Post-op Hypoxemia. Indian J Crit Care Med 2024;28(6):625.

To C or not to C? Designing a Pragmatic Trial to Deploy a Novel Immunomodulatory Therapy to Fight Organ Dysfunction in Sepsis.

Angadi VM, Jindal A. To C or not to C? Designing a Pragmatic Trial to Deploy a Novel Immunomodulatory Therapy to Fight Organ Dysfunction in Sepsis. Indian J Crit Care Med 2024;28(3):311.

Methylene Blue in Septic Shock-A Novel Weapon in Our Arsenal: Are Utility Studies Highlighting its Futility?

How to cite this article: Angadi VM, Jindal A. Methylene Blue in Septic Shock-A Novel Weapon in Our Arsenal: Are Utility Studies Highlighting its Futility? Indian J Crit Care Med 2024;28(1):89.

Eternal Hunt: Unravelling the Challenge of CRE, the Quest for Perfection Continues!

How to cite this article: Salotagi S, Kannan A, Jindal A. Eternal Hunt: Unravelling the Challenge of CRE, the Quest for Perfection Continues! Indian J Crit Care Med 2024;28(5):513-514.

Normal Anion Gap: A Knowledge Gap.

We studied with great interest the article titled "Acute diarrhea and severe dehydration in children: Does non-anion gap component of severe metabolic acidemia need more attention?" by Takia L et al. and would express our views about the same. Normal anion gap metabolic acidosis (NAGMA) is a common entity following stool loss of bicarbonate during an acute diarrheal illness. Several studies have shown that there is a higher incidence of hyperchloremic acidosis and acute kidney injury (AKI) with normal saline (NS) when compared to balanced crystalloids like Ringer's lactate (RL) or balanced salt solutions like plasmalyte. We would like to know about the type of resuscitation fluid used in the study population as it would affect the degree of resolution of acidemia. As per the World Health Organization (WHO) guidelines, rehydration therapy for children with severe acute malnutrition (SAM) is different from other children including the fluid used for bolus, i.e., RL and oral rehydration solution (ORS), i.e., rehydration solution for malnourished (ReSoMal). We would like to know if the study population included SAM children and a subgroup analysis of the same was done as SAM is an independent risk factor for mortality and morbidity. We suggest to plan studies on cognitive outcome of these children. How to cite this article: Pratyusha K, Jindal A. Normal Anion Gap: A Knowledge Gap. Indian J Crit Care Med 2023;27(4):298.

Non-invasive Ventilation Failure - Predict and Protect.

Modified heart rate, acidosis, consciousness, oxygenation and respiratory rate (HACOR) score takes into consideration pneumonia, cardiogenic pulmonary edema, pulmonary acute respiratory distress syndrome (ARDS), immunosuppression, septic shock, and the sequential organ failure assessment (SOFA) score prior to non-invasive mechanical ventilation (NIV) that would impact the success of NIV and are commonly seen in patients presenting to the emergency. Propensity score matching could have been done for similar distribution of baseline characteristics. Specific objective criteria are needed to define respiratory failure requiring intubation. How to cite this article: Pratyusha K, Jindal A. Non-invasive Ventilation Failure - Predict and Protect. Indian J Crit Care Med 2023;27(2):149.

Paroxysmal Sympathetic Hypertension: An Underdiagnosed Entity or a Diagnostic Difficulty?

How to cite this article: Pratyusha K, Jindal A. Paroxysmal Sympathetic Hypertension: An Underdiagnosed Entity or a Diagnostic Difficulty? Indian J Crit Care Med 2023;27(2):151.

Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score!

How to cite this article: Kannan A, Jindal A. Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score! Indian J Crit Care Med 2023;27(2):150.

Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance: Views.

How to cite this article: Pratyusha K, Jindal A. Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance: Views. Indian J Crit Care Med 2023;27(1):79.

COVID-19 and T Cells: Do T Cells Really Matter?

How to cite this article: Gajjala C, Jindal, A. COVID-19 and T Cells: Do T Cells Really Matter? Indian J Crit Care Med 2023;27(1):75.

Lung Ultrasound Score: Does It Really Predict Extubation Failure?

How to cite this article: Salotagi S, Kannan A, Jindal A. Lung Ultrasound Score: Does It Really Predict Extubation Failure? Indian J Crit Care Med 2023;27(11):855-856.

Genomic characterization unravelling the causative role of SARS-CoV-2 Delta variant of lineage B.1.617.2 in 2nd wave of COVID-19 pandemic in Chhattisgarh, India.

COVID-19 pandemic 2nd wave catastrophic effect in the state of Chhattisgarh, India, from where no exclusive genomic data yet published, has prompted us to undertake this study to unearth the causative variant. Whole-genome sequencing of SARS-CoV-2 isolated from COVID-19 infected nine vaccinated healthcare workers (HCW), thirty mild/moderate, seventeen severe, and twenty-seven deceased patients, was performed. The significant predominance of the SARS-CoV-2 variant of concern (VOC), Delta (lineage B.1.617.2) identified in sixty-four (77.1%) cases in contrast to B.1 and its sublineage in eleven (13.2%), variant under monitoring (VUM), Kappa (lineage B.1.617.1) in five (6.0%) and another VOC Alpha (lineage B.1.1.7) in three (3.6%) cases respectively (p < 0.05, χ2 = 162.49). 88.8% vaccine breakthrough, 60% mild/moderate, 94.4% severe and 81.5% dead patients were infected by Delta. Kappa presents exclusively in mild/moderate, Alpha in vaccine breakthrough, mild/moderate, and dead patient and B.1 and its sublineages in mild, severe, and dead patient categories. Delta variant spike mutation of T19R, G142D, E156G, L452R, and deletion (F157 and R158) helps in escaping antibody response, T478K and D614G enhance viral affinity with ACE2 receptor while P681R and D950N result in higher replication and transmissibility by cleaving S1/S2 at furin site. We conclude that Delta variant predominant role along with co-occurrence of Kappa, Alpha, and B.1 variant during COVID-19 2nd wave pandemic in Chhattisgarh may pose a potential threat of future outbreak through hybrid variant evolution. Thus, intensive genomic surveillance for monitoring variant evolution and a more efficacious vaccine against the Delta and Alpha variants are required.

Letter to Editor regarding "Unusual Presentation of Spontaneous Chylothorax".

How to cite this article: Varghese AR, Jindal A. Letter to Editor regarding "Unusual Presentation of Spontaneous Chylothorax". Indian J Crit Care Med 2022;26(11):1225.

When all that should close remains open: a tale of gastroschisis, exstrophy of bladder, spina bifida and limb defects.

A primigravida in the extremist-affected region of a third-world nation gave birth to a newborn who was remotely consulted through video rounds from the capital of the state. Unfortunately, these abnormalities are often overlooked and left untreated. The baby had multiple limb defects, gastroschisis, exstrophy of the bladder and spina bifida. Tragically, the newborn did not survive due to the lack of clinical and surgical expertise in the area. It is crucial to emphasise the importance of establishing e-clinics for expectant mothers in underserved areas, providing them with access to high-quality anomaly scans.

"Antimicrobial utilization in a paediatric intensive care unit in India: A step towards strengthening antimicrobial stewardship practices".

Antimicrobials are frequently used in critically ill children admitted to the Paediatric Intensive Care Unit (PICU). The antimicrobial use data from Indian PICUs is limited using standard metrics such as Days of therapy (DOT). This study aimed to determine the baseline trend of antimicrobial use in PICU of a tertiary care teaching hospital of Raipur district of Chhattisgarh, India using standard metrics with the goal of developing facility-wide antibiotic policy and strengthening the antimicrobial stewardship activities. This active surveillance was conducted over a period of 18 months, from November 1, 2019, to March 21, 2021, in patients aged one month to 14 years who were admitted for ≥ 48 hours to the PICU at a tertiary care teaching hospital of Raipur District. Data on patient characteristics, antimicrobial indications, antimicrobial prescription information, and clinical outcomes were collected using pre-designed data abstraction forms. The descriptive statistic was used to represent the results. The antimicrobial consumption was analyzed according to the WHO AWaRe Class (Access, Watch, and Reserve groups) of antibiotics. The antimicrobial consumption was expressed as DOT/1000 patient-days (PD). A total of 216 patients were surveyed during the study period. The average number of antimicrobials prescribed per hospitalisation was 2.60 (range: 1-12), with 97.22% administered via parenteral route. Overall, DOT/1000-PD was 1318. The consumption of Watch Group antimicrobials was highest with 949 DOT/1000-PD, followed by Access (215) and Reserve Group (154), respectively. Ceftriaxone (208 DOT/1000 PD) was the most commonly prescribed antimicrobial agent, followed by Vancomycin (201), Meropenem (175), Piperacillin-Tazobactam (122) and Colistin (91). The patients who were escalated (28.24%) from empirical antimicrobial therapy had longer median PICU stay (8 days) compared those who were de-escalated (23.6%). Targeted therapy was given in 10.2% patients. The overall mortality rate was 14.35% and was higher (29.3%) in patients in whom empirical therapy was escalated compared to those who were de-escalated or continued. The study established a benchmark for antimicrobials use in the PICU and highlighted priority areas for antimicrobial stewardship intervention to enhance de-escalation rates, enhance targeted therapy, and reduce the overuse of antimicrobials especially belonging to the reserve group.

A Hybrid Form of Telemedicine and Quality Improvement: A Unique Way to Extend Intensive Care Services to Neonates.

OBJECTIVES: To evaluate the impact of hybrid support (tele-mentoring and conventional support) on adverse outcome among neonates admitted to 10 special newborn care units (SNCUs) in Chhattisgarh. METHODS: This before-and-after study was conducted at 10 SNCUs in Chhattisgarh in 2022. Conventional support was given earlier and later, that was supplemented with tele-rounds which were carried out using Skype technology. The principal investigator (PI) visited each unit for one day per month to kickstart quality improvement (QI) projects and provide guidance. Patient outcome data were collected on clinical sepsis proportion, IV fluid usage, antibiotic usage, length of stay, referral and mortality. RESULTS: A total of 2807 babies across 10 units were assessed. This was retrospectively correlated with 5169 babies in these units in the year before the intervention was started. The percentage of clinical neonatal sepsis cases decreased from 53.4% to 29.4% (P < 0.05). IV fluid usage dropped from 40% to 22.2% (P < 0.05). The initiation and continuation of kangaroo mother care (KMC) increased from 55.5% to 93.8% (P < 0.05). The average length of stay decreased from 5.5 ± 0.97 d to 4 ± 0.2 d (P < 0.05). Oxygen utilization decreased from 39.3% to 33.6% (P < 0.05). The proportion of antibiotic usage decreased from 50.2% to 39.7% (P < 0.05). The mortality rate decreased from 8.18% to 6.99% (P < 0.05). Referral rate decreased from 13.12% to 11.93% (P < 0.05). CONCLUSIONS: The implementation of a QI package through hybrid support, which includes tele-mentoring, supportive supervision visits, and local QI project advocacy, proves to be an effective approach in enhancing newborn intensive care.

A multicentre, double-blind, placebo-controlled randomized trial of Mycobacterium w in critically ill patients with COVID-19 (ARMY-2).

BACKGROUND: Mycobacterium w (Mw), an immunomodulator, resulted in better clinical status in severe coronavirus infectious disease 19 (COVID-19) but no survival benefit in a previous study. Herein, we investigate whether Mw could improve clinical outcomes and survival in COVID-19. MATERIALS AND METHODS: In a multicentric, randomized, double-blind, parallel-group, placebo-controlled trial, we randomized hospitalized subjects with severe COVID-19 to receive either 0.3 mL/day of Mw intradermally or a matching placebo for three consecutive days. The primary outcome was 28-day mortality. The co-primary outcome was the distribution of clinical status assessed on a seven-point ordinal scale ranging from discharged (category 1) to death (category 7) on study days 14, 21, and 28. The key secondary outcomes were the change in sequential organ failure assessment (SOFA) score on days 7 and 14 compared to the baseline, treatment-emergent adverse events, and others. RESULTS: We included 273 subjects (136 Mw, 137 placebo). The use of Mw did not improve 28-day survival (Mw vs. placebo, 18 [13.2%] vs. 12 [8.8%], P = 0.259) or the clinical status on days 14 (odds ratio [OR], 1.33; 95% confidence intervals [CI], 0.79-2.3), 21 (OR, 1.49; 95% CI, 0.83-2.7) or 28 (OR, 1.49; 95% CI, 0.79-2.8) between the two study arms. There was no difference in the delta SOFA score or other secondary outcomes between the two groups. We observed higher injection site reactions with Mw. CONCLUSION: Mw did not reduce 28-day mortality or improve clinical status on days 14, 21 and 28 compared to placebo in patients with severe COVID-19. [Trial identifier: CTRI/2020/04/024846].

A Curious Case of an Accented Extra Nose.

There have been about 60 cases of supernumerary nostril reported. We encountered a 38 weeker, male child with supernumerary nostril and midline congenital nevus which was later locally excised. The uniqueness of our case is the presence of an entirely well-formed nostril perched on top on the normal nose.