Efficacy of melatonin in decreasing the incidence of delirium in critically ill adults: a randomized controlled trial.

OBJECTIVE: To determine whether enteral melatonin decreases the incidence of delirium in critically ill adults. METHODS: In this randomized controlled trial, adults were admitted to the intensive care unit and received either usual standard care alone (Control Group) or in combination with 3mg of enteral melatonin once a day at 9 PM (Melatonin Group). Concealment of allocation was done by serially numbered opaque sealed envelopes. The intensivist assessing delirium and the investigator performing the data analysis were blinded to the group allocation. The primary outcome was the incidence of delirium within 24 hours of the intensive care unit stay. The secondary outcomes were the incidence of delirium on Days 3 and 7, intensive care unit mortality, length of intensive care unit stay, duration of mechanical ventilation and Glasgow outcome score (at discharge). RESULTS: We included 108 patients in the final analysis, with 54 patients in each group. At 24 hours of intensive care unit stay, there was no difference in the incidence of delirium between Melatonin and Control Groups (29.6 versus 46.2%; RR = 0.6; 95%CI 0.38 - 1.05; p = 0.11). No secondary outcome showed a statistically significant difference. CONCLUSION: Enteral melatonin 3mg is not more effective at decreasing the incidence of delirium than standard care is in critically ill adults.

Medication Prescription Errors in the Intensive Care Unit: Prospective Observational Study.

Introduction: The WHO launched a 5-year global initiative to address the problem of medication errors on March 29, 2017, targeting a decrease in severe and avoidable medication-related harm by 50% in all the countries. Since prescription errors are preventable, this study was conducted to determine incidence and severity of medication prescription errors (MPEs). Settings and design: Intensive care unit of a tertiary care academic hospital, prospective observational study. Methods and materials: For all patients admitted in a medical ICU, baseline data (demographic, APACHE II, length of ICU stay, and days of mechanical ventilation) were noted. Treatment charts were reviewed daily, and each prescription was compared against a master chart prepared using standardized references to study the incidence of prescription errors. Severity classification was done using National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) classification. Mean and median, along with standard deviation and interquartile range, were calculated for all quantitative variables. Multivariate linear regression analysis model was used. Results: Out of the total 24,572 medication orders, 2,624 had prescription errors, an error rate of 10.7% (95% CI, 10.3-11.1). When analyzed for severity, 1,757 (7.15%) (95% CI, 6.8-7.5) MPEs did not result in patient harm and 867 (3.52%) (95% CI, 3.3-3.8) MPEs required interventions and/or resulted in patient harm. Patients with deranged creatinine (p <0.001) and INR (p = 0.024) had higher number of severe MPEs. Conclusion: The incidence of MPEs in the medical ICU at the tertiary care hospital was 10.7%, 3.52% being severe errors. How to cite this article: Kumar M, Sahni N, Shafiq N, Yaddanapudi LN. Medication Prescription Errors in the Intensive Care Unit: Prospective Observational Study. Indian J Crit Care Med 2022;26(5):555-559.

Use of convalescent plasma for COVID-19 in India: A review & practical guidelines.

Convalescent plasma (CP) therapy is one of the promising therapies being tried for COVID-19 patients. This passive immunity mode involves separating preformed antibodies against SARS-CoV-2 from a recently recovered COVID-19 patient and infusing it into a patient with active disease or an exposed individual for prophylaxis. Its advantages include ease of production, rapid deployment, specificity against the target infectious agent, and scalability. In the current pandemic, it has been used on a large scale across the globe and also in India. However, unequivocal proof of efficacy and effectiveness in COVID-19 is still not available. Various CP therapy parameters such as donor selection, antibody quantification, timing of use, and dosing need to be considered before its use. The current review attempts to summarize the available evidence and provide recommendations for setting up CP protocols in clinical and research settings.

Relationship of substance dependence and time to RT-PCR negative status in patients with COVID-19 infection.

BACKGROUND: To date, no study has evaluated the association of alcohol dependence with the outcome of the COVID-19 infection. AIM: The current study aimed to evaluate the association of substance dependence (alcohol and tobacco) with the outcome (i.e., time to have two consecutive negative test reports) of the COVID-19 infection. RESULTS: The mean age of the study participants (n = 95) was 37.2 yrs (SD-13.2). More than half of the participants were males. About one-fourth (N = 25; 26.3 %) were consuming various substances in a dependent pattern. Alcohol dependence was present in 21 participants (22.1 %), and Tobacco dependence was present in 10.5 % of participants. Even after using gender, age, and physical illness as covariates, patients with any kind of substance dependence had a significantly lower chance of having a negative report on RT-PCR on 14th day, 18th 23rd day. CONCLUSION: Persons with substance dependence takes a longer time to test negative on RT-PCR, once diagnosed with COVID-19 infection. Mental health professionals involved in the care of patients with COVID-19 should accordingly prepare these patients for a possible longer hospital stay to reduce the distress associated with prolongation of hospital stay.

Critical events during intra-hospital transport of critically ill patients to and from intensive care unit.

OBJECTIVES: Intensive care unit (ICU) patients are at an increased risk of many catastrophic events during intrahospital transport (IHT) for various procedures. This study was planned to determine the incidence and types of adverse events occurring during the transport of critically ill patients in a tertiary care hospital. METHODS: This prospective observational study was conducted in the ICU of a tertiary care hospital for 8 months after ethical clearance from the institute ethics committee. All patients transported out of the ICU during the audit period for diagnostic or therapeutic procedures were included in the study. Vitals and several study parameters were recorded before, during, and after shifting patients to and from the ICU. Various critical events were noted during transport and classified into major and minor critical events based on the presence and absence of potential consequences that lead to a change of therapy during transport. RESULTS: One hundred and sixty patients were studied for consecutive IHT to and from the ICU. The patients were transported for imaging studies (58.1%), minor surgery (31.8%), major surgery (2.5%), and other procedures (7.5%). A total of 248 critical events were observed in 104 IHTs (65%; 95% confidence interval [95% CI]: 57.4%-72.1%). Hence, an average of 2.38 critical events occurred per IHT. There were 31 major events among the 248 critical events (12.5%; 95% CI: 8.8%-17.1%). CONCLUSIONS: Standard guidelines about the accompanying personnel and monitoring need to be followed during IHT. Conduct of minor surgical procedures in the ICU and better bedside diagnostic procedures may be considered for the future.

Lived experiences of the corona survivors (patients admitted in COVID wards): A narrative real-life documented summaries of internalized guilt, shame, stigma, anger.

COVID-19 pandemic has emerged as a disaster for the human beings. All the Governments across the globe have been preparing to deal with this medical emergency, which is known to be associated with mortality in about 5% of the sufferers. Gradually, it is seen that, many patients with COVID-19 infection have mild symptoms or are asymptomatic. Due to the risk of infecting others, persons with COVID-19 infection are kept in isolation wards. Because of the isolation, the fear of death, and associated stigma, many patients with COVID-19 infection go through mental distress. In this report, we discuss the experience of 3 persons diagnosed with COVId-19 infection and admitted to the COVID ward.

Full Outline of UnResponsiveness score versus Glasgow Coma Scale in critically ill patients with altered sensorium: A comparison of inter-observer variability and outcomes.

BACKGROUND AND AIMS: Glasgow Coma scale (GCS), the most widely used tool for evaluation of the level of consciousness has various limitations. The Full Outline of UnResponsiveness (FOUR) score is a possible alternative. The present study was designed to examine the inter-rater reliability and outcome predictability of these scores in the Intensive Care Unit (ICU). METHODS: The GCS and FOUR scores of 111 adult patients with altered sensorium, admitted to the ICU, were assessed as early as possible after admission by the Senior Resident (SR), Junior Resident (JR) and Staff Nurse (SN) of ICU. The outcomes measured survival and modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) of the patients at discharge. RESULTS: The inter-observer agreement was measured using the kappa ('k') statistic. For GCS it was higher (k = 0.472 to 0.555) than FOUR score (k = 0.352 to 0.448). A higher 'k' score in either score was recorded between SR and JR. Linear regression analysis showed no significant association of either score with the duration of ICU stay or mechanical ventilation. Survival in ICU was correlated with both GCS and FOUR scores on logistic regression. GOS and mRS were correlated with either GCS or FOUR scores on ordinal regression. CONCLUSION: The inter-observer agreement with FOUR score was not superior to GCS in this study, possibly due to lack of familiarity with the FOUR score. Both the scores were statistically correlated with the rate of survival.

Delirium in Intensive Care Unit: Phenomenology, Subtypes, and Factor Structure of Symptoms.

AIM: This study aimed to explore the phenomenology, motor subtypes, and factor structure of symptom profile of delirium in patients admitted to the intensive care unit (ICU). METHODS: Consecutive patients aged ≥16 years admitted in an ICU were screened daily for delirium using confusion assessment method-ICU. Patients diagnosed to have delirium as per Diagnostic and Statistical Manual fourth revision, text revision (DSM-IVTR) criteria were assessed with Delirium Rating Scale-Revised 98 (DRS-R 98) and Memorial Delirium Assessment Scale (MDAS). Motor subtypes of delirium were assessed with amended Delirium Motor Symptom Scale. RESULTS: Sixty-six patients were evaluated for delirium, of which 45 (68%) patients developed delirium at point of their ICU stay. All patients had sleep-wake cycle disturbances, followed by motor symptoms (retardation - 80%; agitation - 73.3%). As per MDAS assessment, all the subjects had disturbances in the consciousness and sleep-wake cycle disturbances, and a substantial majority also had attention difficulties (93.3%) and motor symptoms (93.3%). Hypoactive subtype (47%) was the most common motoric subtype of delirium. Factor analysis revealed three-factor model for DRS-R 98, MDAS, and combining items of the two. CONCLUSION: Phenomenology of delirium in ICU setting is similar to that of the non-ICU settings. The factor analysis consistently demonstrated a three factor solution, with a robust attention-arousal factor, and overlapping cognitive (core vs. non-core) motor factors.

Intensive Care Unit delirium: A wide gap between actual prevalence and psychiatric referral.

BACKGROUND AND AIMS: The study aimed to assess the rates of delirium in an Intensive Care Unit (ICU) prospectively assessed with a delirium screening instrument and confirmed through psychiatrist evaluation. In addition, the referral rate to psychiatric consultation liaison services from the same ICU was assessed through the rates of psychiatric referral over the previous 10 years. MATERIAL AND METHODS: In the prospective part of the study, consecutive patients aged 16 years or more admitted to the ICU of a tertiary care hospital were assessed daily for delirium using confusion assessment method for the ICU, a validated instrument that can be used for both mechanically ventilated and nonventilated patient by trained heath care personnel. Retrospectively, records of patients referred to psychiatric referral team for delirium from the ICU over the last 10 years were drawn out and the referral rate was calculated. RESULTS: In the prospective study, 109 patients were recruited of which 43 patients remained comatose throughout their ICU stay and could not be assessed for delirium. Of the 66 assessable patients, 45 (68.2% prevalence rate) patients developed delirium. Incidence rate of delirium was 59.6%. In contrast, the retrospective study showed that only 53 cases out of 3094 admissions in ICU over 10 years (1.71%) were referred to psychiatry consultation liaison team for management of delirium. In the prospective study, hypoactive delirium was the most common subtype of delirium. CONCLUSION: There is a mismatch between the incidence and prevalence of delirium in ICU patients prospectively diagnosed with structured, validated instruments and the diagnosis of delirium in cases referred to psychiatry consultation-liaison services.

Perioperative predictors of morbidity and mortality following cardiac surgery under cardiopulmonary bypass.

BACKGROUND: Prediction of outcome after cardiac surgery is difficult despite a number of models using pre-, intra- and post-operative factors. Ideally, risk factors operating in all three phases of the patients' stay in the hospital should be incorporated into any outcome prediction model. The aim of the present study was to identify the perioperative risk factors associated with morbidity, mortality and length of stay in the recovery room (LOSR) and length of stay in the hospital (LOSH). METHODS: Eighty-eight adults of either sex, patients undergoing elective open cardiac surgery were studied prospectively. The ability of a number of pre-, intra- and post-operative factors to predict outcome in the form of mortality, immediate morbidity (LOSR) and intermediate morbidity (LOSH) was assessed. RESULTS: Factors associated with higher mortality were preoperative prothrombin index (PTI), American Society of Anesthesiology-Physical Status (ASA-PS) grade, Cardiac Anaesthesia Risk Evaluation (CARE) score and New York Heart Association (NYHA) class, intraoperative duration of cardiopulmonary bypass (DCPB), number of inotropes used while coming off cardiopulmonary bypass and postoperatively, Acute Physiology and Chronic Health Evaluation (APACHE) II excluding the Glassgow Comma Scale (GCS) component and the number of inotropes used. Immediate morbidity was associated with preoperative PTI, inotrope usage intra- and post-operatively and the APACHE score. Intermediate morbidity was associated with DCPB and intra- and post-operative inotrope usage. Individual surgeon influenced the LOSR and the LOSH. CONCLUSION: APACHE score, a general purpose severity of illness score, was relatively ineffective in the postoperative period because of sedation, neuromuscular blockade and elective ventilation used in a number of these patients. The preoperative and intraoperative factors like CARE, ASA-PS grade, NYHA, DCPB and number of inotropes used influencing morbidity and mortality are consistent with the literature, despite the small size of our sample.

Effect of prophylactic ondansetron on postoperative nausea and vomiting in patients on preoperative steroids undergoing craniotomy for supratentorial tumors.

The exact incidence of postoperative nausea and vomiting (PONV) in patients on steroids undergoing neurosurgical procedures is not known. This prospective randomized double-blind study was planned to know the efficacy of prophylactic ondansetron in the prevention of PONV in patients on steroids as compared with placebo. Seventy adult patients of either sex who had received preoperative steroids (dexamethasone) for at least 24 hours and were scheduled to undergo craniotomy for supratentorial tumors were included. Patients were randomly allocated using a randomization chart to 1 of the 2 groups to receive either ondansetron 4 mg (group O) or 0.9% saline (group S) intravenously at the time of dural closure. Numeric Rating Scale score for nausea and pain intensity was recorded preoperatively and till 24 hours postoperatively. The 6-hour postoperative nausea score was significantly lower in group O [median, 0; interquartile range (IQR), 0 to 20] than in group S (median, 20; IQR, 0 to 20) (P<0.05). The incidence of vomiting was lower in group O (23%) than in group S (46%) (P<0.05). The total number of emetic episodes, the number of doses of rescue antiemetics given in the first 6 postoperative hours, and the total number of rescue antiemetics given were significantly lower in group O than in group S (P<0.05). Intravenous administration of 4 mg of ondansetron at the time of dural closure was effective in reducing the incidence of PONV and the rescue antiemetics requirement in patients on preoperative steroids undergoing craniotomy for supratentorial tumors.