Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience.

Background: Regional citrate anticoagulation (RCA) has emerged as a treatment modality that reduces bleeding risk and filter clotting. With initial experience of using RCA with continuous renal replacement therapy (CRRT), we have formulated a working protocol based on published literature. Objective: The study aimed to evaluate the protocol for routine use of RCA during CRRT requiring anticoagulation and evaluation of filter life. Methodology: It is a single-center, open-label, prospective, non-randomized, non-interventional, single-arm, observational study conducted at a tertiary care hospital between September 2022 and July 2023. All adult patients with acute kidney injury (AKI) or hyperammonemia requiring CRRT and necessitating the use of anticoagulation were enrolled in the study. The study used Prisma Flex M100 AN 69 dialyzer on Prisma Flex (Baxter) CRRT machines during continuous venovenous hemodiafiltration (CVVHDF). The targeted CRRT dose in all the study patients was 25-30 mL/kg/hour. Based on the published literature, we have developed a working protocol (Appendix 1) for managing patients on CRRT using RCA. Results: A total of 159 patients were analyzed for the study. The median [interquartile range (IQR)] filter life using RCA was 30 (12-55) hours. Filter clotting was observed in 33.3% of patients. Citrate accumulation was present in 52.25% of patients, but no CRRT was discontinued as citrate accumulation resolved after following the corrective steps in the protocol. None of the patients had citrate toxicity. Chronic liver disease (CLD) (p ≤ 0.001) and those who were post-living donor liver transplant recipients (p = 0.004) had a statistically significant increase in citrate accumulation. Also, patients who had higher lactate at baseline (6 hours post-CRRT initiation), had a higher chance of citrate accumulation. Conclusion: Our RCA protocol provides a safe approach to regional anticoagulation during CRRT in critically ill patients. How to cite this article: Pachisia AV, Kumar GP, Harne R, Jagadeesh KN, Patel SJ, Pal D, et al. Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience. Indian J Crit Care Med 2024;28(9):859-865.

Comparison between Effect of Indirect Calorimetry vs Weight-based Equation (25 kcal/kg/day)-guided Nutrition on Quadriceps Muscle Thickness as Assessed by Bedside Ultrasonography in Medical Intensive Care Unit Patients: A Randomized Clinical Trial.

Aim and background: Sarcopenia is a substantial contributor to intensive care unit (ICU)-acquired weakness and is associated with significant short- and long-term outcomes. It can, however, be mitigated by providing appropriate nutrition. Indirect calorimetry (IC) is believed to be the gold standard in determining caloric targets in the dynamic environment of critical illness. We conducted this study to compare the effect of IC vs weight-based (25 kcal/kg/day) feeding on quadriceps muscle thickness (QMT) by ultrasound in critically ill patients. Materials and methods: A prospective study was conducted on 60 mechanically ventilated patients randomized to two groups [weight-based equation (WBE) group or the IC group] in medical ICU after obtaining institutional ethics committee approval, and fed accordingly. The right QMT measurement using ultrasound and caloric targets were documented on day 1, 3 and 7 and analyzed statistically. The IC readings were obtained from the metabolic cart E-COVX ModuleTM. Results: The baseline demographics, APACHE-II, NUTRIC score, and SOFA scores on day 1, 3, and 7 were comparable between the two groups. The resting energy expenditure (REE) obtained in the IC group was significantly less than the WBE energy targets and the former were fed with significantly less calories. A significantly less percent reduction of QMT in the IC group compared with the WBE group was observed from day 1 to day 3, day 3 to day 7, and day 1 to day 7. Conclusion: From our study, we conclude that IC-REE-based nutrition is associated with lesser reduction in QMT and lesser calories fed in critically ill mechanically ventilated patients compared from WBE. CTRI registration-CTRI/2023/01/049119. How to cite this article: Chandrasekaran A, Pal D, Harne R, Patel SJ, Jagadeesh KN, Pachisia AV, et al. Comparison between Effect of Indirect Calorimetry vs Weight-based Equation (25 kcal/kg/day)-guided Nutrition on Quadriceps Muscle Thickness as Assessed by Bedside Ultrasonography in Medical Intensive Care Unit Patients: A Randomized Clinical Trial. Indian J Crit Care Med 2024;28(6):587-594.

Competencies for Point-of-care Ultrasonography in ICU: An ISCCM Expert Panel Practice Recommendation.

How to cite this article: Srinivasan S, Kumar PG, Govil D, Gupta S, Kumar V, Pichamuthu K, et al. Competencies for Point-of-care Ultrasonography in ICU: An ISCCM Expert Panel Practice Recommendation. Indian J Crit Care Med 2022;26(S2):S7-S12.

Percutaneous Tracheostomy under Real-time Ultrasound Guidance in Coagulopathic Patients: A Single-center Experience.

OBJECTIVE: To examine the safety and complications associated with percutaneous tracheostomy (PT) in critically ill coagulopathic patients under real-time ultrasound guidance. MATERIALS AND METHODS: Coagulopathy was defined as international normalized ratio (INR) ≥1.5 or thrombocytopenia (platelet count ≤50,000/mm3). Neck anatomy was assessed for all patients before the procedure and was characterized as excellent, good, satisfactory, and unsatisfactory based on the number of vessels in the path of needle. Percutaneous tracheostomy was performed under real-time ultrasound (USG) guidance, with certain modifications to the technique, and patients in both groups were assessed for immediate complications including bleeding. RESULTS: Six hundred and fifty-two patients underwent USG-guided PT. Three hundred and forty-five (52.9%) were coagulopathic before the procedure. Ninety-nine patients (15.2%) had an excellent neck anatomy on USG scan, and 112 patients (62 in coagulopathy group vs 50 in noncoagulopathy group, p value 0.386) had an unsatisfactory neck anatomy for tracheostomy. A total of 42 events of immediate complications were noted in 37 patients (5.7%). No difference was seen in the rate of immediate complications in both groups (5.8% in coagulopathy group vs 5.5% in noncoagulopathy group, p value 0.886). The incidence of minor bleeding in coagulopathic patients was 14 patients (4.1%) and 7 (2.3%) in those without coagulopathy, and this difference was not statistically different (p value-0.199). In the subgroup analysis of patients with significant coagulopathy and unsatisfactory anatomy, no difference was observed in the incidence of immediate complications. CONCLUSION: This study shows the efficacy and safety of real-time ultrasound-guided PT, even in patients with coagulopathy. HOW TO CITE THIS ARTICLE: Kumar P, Govil D, Patel SJ, Jagadeesh KN, Gupta S, Srinivasan S, et al. Percutaneous Tracheostomy under Real-time Ultrasound Guidance in Coagulopathic Patients: A Single-center Experience. Indian J Crit Care Med 2020;24(2):122-127.

Incidence of posterior wall penetration during internal jugular vein cannulation: A comparison of two techniques using real-time ultrasound.

BACKGROUND AND AIMS: The true incidence of penetration of the posterior wall (through-and-through puncture) of the internal jugular vein (IJV) during cannulation is unknown. This may have implications if there is hematoma formation, penetration and/or inadvertent cannulation of an underlying carotid artery. This study compared the incidence of posterior wall puncture during IJV cannulation using ultrasound guidance versus traditional landmarks-guided technique. METHODS: One hundred and seventy adult patients admitted to a gastro-liver Intensive Care Unit who required central venous lines were randomly divided into Group A: IJV cannulation using anatomical landmark-guided technique and Group B: IJV cannulation using real-time ultrasound guidance. In both groups, a second investigator followed the needle path using real-time ultrasound. The incidence of posterior wall puncture, number of attempts for successful cannulation, incidence of inadvertent arterial punctures and occurrence of complications such as hematoma formation and pneumothorax were recorded. RESULTS: Significantly more (37/80, 46%) patients in Group A had posterior wall puncture compared to 19/90 (21%) in Group B. Incidence of arterial puncture was 8/80 (10%) in Group A, 5/90 (5.5%) in Group B. The number of attempts for venous cannulation and hematoma formation was significantly less in Group B. CONCLUSION: Real-time ultrasound-guided IJV cannulation significantly reduces but does not wholly eliminate the incidence of posterior venous wall penetrations. It also significantly reduces the incidence of inadvertent arterial punctures and number of attempts for successful cannulation.

Pediatric liquid medicaments - Are they cariogenic? An in vitro study.

AIM: Young and chronically sick children receive a variety of oral liquid medications on a routine and regular basis. These pharmaceutical preparations are cariogenic and acidogenic in nature. Hence, the present study was taken up to determine the cariogenic potential of the commonly prescribed pediatric liquid medicaments. MATERIALS AND METHODS: Eight commonly used pediatric liquid medicaments (PLM) were selected and their endogenous pH was measured using a pH electrode meter. The sugar content in them was estimated using High Performance Liquid Chromatography (HPLC). The effect of PLM on Streptococcus mutans was assessed by the ditch plate method. RESULTS: The pH of the liquid medicaments ranged between 6.05 (Salbid(®)) and 7.71 (Theopid(®)). Sucrose was observed in 7 PLM and glucose in 5 PLM. The highest concentration of sucrose was seen in Crocin(®). The lowest concentration of sucrose was seen with Althrocin(®). Both the antibiotic PLMs inhibited the S. mutans growth. Zevit(®) promoted the growth of S. mutans. CONCLUSION: The pH and concentration of sugars of pediatric liquid medicaments can pose as a threat to dental health, especially in chronically sick children, who are on long-term medications.

Reliability of Broadrick flag in determination of curve of Spee in Indian population.

INTRODUCTION: Occlusion and occlusal plane is the primary criteria in fabrication of posterior restorations. The simplest method of establishment of occlusal plane is through the use of Broadrick occlusal plane analyzer. AIMS: This study aims to know the reliability of Broadrick flag in determination of curve of Spee with different proposed radii in different skeletal relation in Indian population. MATERIALS AND METHODS: Male and female dentulous subjects were selected randomly. Maxillary and mandibular full arch impressions were made; casts were prepared and mounted in semiadjustable articulator using face bow transfer. Broadrick occlusal plane analyzer was mounted on upper member of articulator. Analysis was done using the proposed radii of curvature. The same procedure was repeated by taking different radii with variations of ½ inch, difference was measured by metal caliper, tabulated and subjected to statistical analysis. RESULTS: Results showed that Indian subjects show minor variations in radii, but most of the subjects confirmed the radii, which was proposed by the Lynch CD and McConnell RJ. CONCLUSION: Statistical analysis confirmed that proposed radii confirms to existing occlusal plane for different skeletal relationships. Broadrick occlusal plane analyzer is a reliable tool with the proposed radii for Indian population.

A comparative study to determine the wettability and castability of different elastomeric impression materials.

AIM: The aim of this study was to determine the wettability of different hydrophilic and hydrophobic elastomeric impression materials and the gypsum castability. MATERIALS AND METHODS: The wettability was evaluated by determining the contact angles of different elastomeric impression materials. The contact angle was determined by placing a drop of aqueous solution of calcium sulfate dihydrate on the flat surface of impression material and specimens were measured using a profile projector. Gypsum castability was determined by counting the number of voids formed in the die stone cast made from the impressions of a aluminum die. The voids were counted using an diopter magnifying lens. RESULTS: Polyether, different viscosities of polyvinyl siloxane, and condensation silicone impression materials exhibited low contact angle values and least number of voids in the die stone cast when compared with polysulfide impression material. CONCLUSION: There was significant correlation between the contact angle and voids formed in the die stone casts when fabricating die stone casts from various elastomeric impression material impressions. CLINICAL SIGNIFICANCE: Accurate reproduction of prepared tooth or edentulous arch is of clinical importance in the fabrication of a fixed or removable prosthesis. Inaccuracies in the replication processes will ultimately have an adverse effect on the fit and adaptation of final restoration. The interaction is determined in part by hydrophilic and hydrophobic nature of the elastomeric impression material. Inadequate wetting of an impression results in voids in the stone casts.

3D echocardiography: "The most powerful predictor of masked CVD in metabolic syndrome".

UNLABELLED: AIMS & OBJECTIVE: To evaluate the impact of the Metabolic Syndrome (MetS) on various echo variables by 3D Echocardiography. MATERIALS AND METHODS: 100 patients of MetS from indoor and outdoor patient departments were subjected to Echocardiographic and Carotid Doppler evaluation. They were divided into three groups: Group A, Group B and Group C on the basis of age <40 yrs, 40-60 yrs and >60 yrs respectively. The echo variables included left ventricular myocardial performance index (LVMPI), left ventricular mass index (LVMi), left ventricular diastolic dysfunction (LVDD), systolic function (LVEF), left atrial volume index (LAVi) and composite common carotid intima media thickness (CCIMT). RESULTS: The mean LVMPI was abnormal in all the groups and showed an increasing trend with prolonged LVMPI (> 0.4) in 74% of the total population. Prolonged LVMPI in Group A, Group B and Group C were 12.1%, 52.7% and 35.1% respectively. There was also a strong correlation between LVMPI & LVDD (p-value < 0.0001). Only 9% had systolic dysfunction (LVEF < 50%), but 68% of patients had abnormal diastolic function, of which 53% had grade I LVDD, 12% had grade II LVDD and 3% had grade III diastolic dysfunction. None of our patients had grade IV diastolic dysfunction. The mean LA Vi was normal in all the groups, but LAVi increased with worsening LVDD. The mean LVMi indexed to Body Surface Area (BSA) was normal in all the groups, but showed a statistically significant increasing trend from Group A to Group C (p-value < 0.05). Statistically significant higher LVMi values were observed for males as compared to females (p-value < 0.0001). On analysis of patients having left ventricular hypertrophy (LVH), 76% had concentric remodeling; only 11 % had concentric hypertrophy, but none had eccentric hypertrophy. Most of our patients in Group B & Group C had higher mean Composite CCIMT (0.73 +/- 0.33 & 0.84 +/- 0.42 respectively) which was statistically very significant (p-value < 0.001) CONCLUSION: Metabolic Syndrome is associated with masked cardiovascular disease (CVD) as evident by 3D Echo in this series of patients. LVMPI was an early indicator and the most robust marker of early LVDD. Impaired relaxation was highly prevalent; while LAVi was less robust predictor of LVDD in this series of patients. Concentric left ventricular remodeling was the most common pattern of LVH. Most of our series of patients had increased Composite CCIMT. Thus 3D Echocardiography has great potential and is very useful for early detection and timely therapeutic interventions in patients with subclinical CVD in MetS.