Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study.

Background: Holistic intensive care management involves the treatment of critically ill patients in the intensive care unit (ICU) as well as catering to family psychosocial needs helping in bettering satisfaction/perception of care. There is scarce data in the Indian intensive care setting regarding the same, especially in times of increasing end-of-life practices. Our study aimed to determine the factors impacting family perception/satisfaction with intensive care. Materials and methods: A total of 336 family bystanders of patients in ICU with more than 72 hours of stay were surveyed using family satisfaction in the ICU 24 revised (FS-ICU 24R) questionnaire. Results: Multivariable logistic regression analysis showed that the significant factors associated with the satisfaction among bystanders of ICU patients were the treatment of patient's physical symptoms like pain/breathlessness (Adjusted OR 3.73, p = 0.003), ICU staff's approach to family's need consideration (Adjusted OR 4.44, p < 0.001), concern and care towards patients' family (Adjusted OR 2.67, p = 0.023). Participation in patient care, ICU waiting room atmosphere, and emotional support are the other factors independently associated with satisfaction with ICU care. Family satisfaction was not associated with the patient's survival (p = 0.331, Chi-square test) or the length of ICU (p = 0.328, Chi-square test) and hospital stay (p = 0.865, Chi-square test). Conclusion: Treatment of a patient's physical symptoms like pain, approach to family's needs consideration, and concern/care towards the patient's family are independent factors associated with optimal satisfaction among family members of ICU patients, which even takes precedence over the survival outcomes or length of ICU stay. How to cite this article: Atri V, Bhatt MT, Chaudhuri S, Mitra A, Maddani SS, Ravindranath S. Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study. Indian J Crit Care Med 2024;28(5):483-494.

Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study.

Background: Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Methods: Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Results: Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878-0.978. Kaplan-Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log-rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955-1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. Conclusion: The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care. How to cite this article: Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, et al. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024;28(5):453-460.

Risk Factors of Decreased Abdominal Expiratory Muscle Thickness in Mechanically Ventilated Critically Ill Patients-The mNUTRIC Score is an Independent Predictor.

Background: The expiratory abdominal skeletal muscles are an important component of the respiratory muscle pump, and their reduced thickness has been associated with difficult weaning. There is no objective score that may help clinicians to predict expiratory abdominal muscle thinning. Patients and methods: This was a single-center retrospective study on 81 patients undergoing weaning from mechanical ventilation. The thickness of the four abdominal expiratory muscles-rectus abdominis (RA), internal oblique (IO), external oblique (EO), and transversus abdominis (TA) on the day of the first spontaneous breathing trial (SBT), was obtained. The various parameters of the patients with thinner RA, IO, EO, and TA below the determined thickness cut-off values, predicting difficult weaning was analyzed. Results: Modified nutritional risk in critically ill (mNUTRIC) score was found to be an independent predictor of thinner IO muscle after logistic regression analysis [p = 0.001, adjusted OR 2.33, 95% CI (1.394-3.892)]. The mNUTRIC score was also an independent predictor of thinner EO (p = 0.014, adjusted OR 1.57) and RA muscle (p = 0.002, adjusted OR 1.69). The mNUTRIC cutoff score ≥4 predicted thinner IO (AUC 0.813, p < 0.001 sensitivity 71%, specificity 77%) and thinner EO (AUC 0.738, p < 0.001, 71% sensitivity, 67% specificity). The mNUTRIC score ≥3 predicted that at least one out of the four abdominal expiratory muscles will be thin (AUC 0.849, p < 0.001, 95% CI [0.763-0.935], sensitivity 87.5%, specificity 59%). Conclusion: The mNUTRIC score is an independent predictor of thinner abdominal expiratory muscles in mechanically ventilated critically ill patients. How to cite this article: Vishwas P, Amara V, Maddani SS, Chaudhuri S, Podder S. Risk Factors of Decreased Abdominal Expiratory Muscle Thickness in Mechanically Ventilated Critically Ill Patients-The mNUTRIC Score is an Independent Predictor. Indian J Crit Care Med 2023;27(1):8-15.

Pathological Lung Patterns of COVID-19 and its Clinical Correlation to Disease Severity.

Introduction: Coronavirus disease-2019 (COVID-19) infection can result in pulmonary complications ranging from mild illness to severe life-threatening disease. There are limited studies correlating the association between the clinical course of COVID-19 and histopathological findings. This study aimed to examine the postmortem histopathological changes in lung tissue of COVID-19-positive patients and to correlate those changes with disease severity. Materials and methods: This prospective observational study was conducted in adult COVID-19-positive patients. Postmortem core needle biopsy (CNB) of the lung was done using ultrasonography guidance within 1 hour of death. Histopathological analyses were performed by two expert pulmonary pathologists. The demographic and clinical data of the patients were recorded to correlate them with histopathological findings. Results: In total, 48 patients were assessed for inclusion, and 21 patient relatives consented for the study. The median duration of illness was 21 (range 9-38) days, the predominant histopathological finding was diffuse alveolar damage (DAD) in most patients (19/21), followed by pneumonia (13/21). Exudative, intermediate, and advanced DAD patterns were seen in 9.5%, 52.4%, and 28.6% of cases, respectively. Advanced DAD was associated with a longer duration of disease. The pneumonia findings were associated with positive respiratory and blood cultures. The microvascular thrombus was seen only in one patient. Conclusion: The predominant pathological findings in our patients were DAD and pneumonia. The DAD type correlated with the duration of illness, and we attributed pneumonia findings to secondary infection. The incidence of microvascular thrombi was low, and it might reflect the effect of treatment with anticoagulation. How to cite this article: Maddani SS, Rao R, Deepa HC, Noronha AK, Chaudhuri S, Vishwas P. Pathological Lung Patterns of COVID-19 and its Clinical Correlation to Disease Severity. Indian J Crit Care Med 2022;26(12):1285-1292.

Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study.

Aim: To determine the utility of the HACOR score in predicting weaning failure in resource-limited settings. Objectives: The primary objective was to determine a cut-off value of the HACOR score, sensitivity, and specificity to predict failed weaning. The secondary objective was to determine which out of five components of the score was significantly different between the successful weaning and the failed weaning groups. Introduction: Most weaning indices are either inaccurate or are dependent on complex ventilatory parameters, which are difficult to measure in resource-limited settings. This study aimed to determine the utility of the HACOR score consisting of heart rate, acidosis, consciousness level, oxygenation, and respiratory rate as a predictor of weaning in the intensive care unit. Materials and methods: It was a prospective observational study on 120 patients between 18 and 90 years. The HACOR score was evaluated at 30 minutes of spontaneous breathing trial (SBT). The total duration of SBT was 120 minutes. Results: Out of 120 patients, 83 (69.2%) had successful weaning, whereas 37 (30.8%) had weaning failure. The median and interquartile range (IQR) of the HACOR score in the successful weaning group was 2 (0-3) and 6 (5-8) in the failed weaning group (p-value <0.001). There was a significant difference in each of the five components of the HACOR score between the successful and failed weaning groups (p <0.05). HACOR score ≥5 predicted failed weaning, sensitivity 83.8%, specificity 96.4%, area under the curve (AUC) 0.950, and 95% confidence interval (CI) [0.907-0.993], p <0.001. Multivariable logistic regression analysis showed that HACOR score ≥5 is an independent predictor of weaning failure [p <0.001, 95% CI (1.9-4.2), adjusted odds ratio 2.82]. Conclusion: A HACOR score ≥5 is an excellent predictor of weaning failure. This score may be useful as a weaning strategy in the intensive care unit. How to cite this article: Chaudhuri S, Gupta N, Adhikari SD, Todur P, Maddani SS, Rao S. Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study. Indian J Crit Care Med 2022;26(8):900-905. Ethical approval: Prior to the commencement of the study, Institutional Ethics Committee permission was obtained (IEC: 197/2021) and Clinical Trial Registry of India (CTRI) registration was done before recruitment (CTRI/2021/07/035139). We obtained written informed consent from the legally authorized representative prior to recruiting patients for the study.

Impact of Shared Decision-Making on Family Satisfaction With Intensive Care Services: 'Share With Care' has a New Meaning in ICU.

Background: Physician's clinical inputs and informed bystander opinions are essential for successful intensive care unit (ICU) patient outcomes. There is insufficient data regarding the impact of shared decision-making on treatment outcomes and family satisfaction in Indian ICU settings. We aimed to determine the effect of shared decision-making factors on family satisfaction with ICU services. Patients and Methods: Family bystanders of 336 ICU patients with a stay >72 hours were conveniently surveyed across 13 months prospectively using Family Satisfaction in the Intensive Care Unit 24 Revised (FS-ICU 24R) questionnaire. We analyzed the responses to determine shared decision-making factors impacting family satisfaction. Results: Univariate analysis of ten variables of FS-ICU 24R questionnaire decision-making subscale revealed that consistency of information (OR 8.71, P < 0.001), honesty of information (OR 7.04, P < 0.001), and frequency of communication with doctors (OR 6.25, P < 0.001) were associated with highest odds of family involvement and satisfaction. Multivariable logistic regression showed that consistency of information (adjusted OR 3.85, P < 0.001) and frequent doctor communication (adjusted OR 2.22, P = 0.02) were independent predictors associated with family satisfaction. The number of decision-makers (P = 0.463) or family's prior ICU experience (P = 0.430) was not associated with family satisfaction. Conclusion: A consistent and honest effort to cater to the family's information needs and frequent physician-bystander interaction is essential for family's satisfaction with ICU services. This even outweighs other decision-making factors such as number of decision-makers and their prior ICU experience. Incorporating shared decision-making in counseling should be a continuing practice.Trial registry name: Clinical Trials Registry - India.Registration number: CTRI/2022/09/045571.

Incorporation of plasma Vitamin C levels to modified nutritional risk in critically ill score as the novel Vitamin C nutritional risk in critically ill score in sepsis subjects as an early predictor of multidrug-resistant bacteria: A prospective observational study.

Background: On intensive care unit (ICU) admission, it is difficult to predict which patient may harbor multidrug-resistant (MDR) bacteria. MDR is the nonsusceptibility of bacteria to at least one antibiotic in three or more antimicrobial categories. Vitamin C inhibits bacterial biofilms, and its incorporation into the modified nutritional risk in critically ill (mNUTRIC) scores may help predict MDR bacterial sepsis early. Methods: A prospective observational study was conducted on adult subjects with sepsis. Plasma Vitamin C level was estimated within 24 h of ICU admission, and it was incorporated into the mNUTRIC score (designated as Vitamin C nutritional risk in critically ill [vNUTRIC]). Multivariable logistic regression was performed to determine if vNUTRIC was an independent predictor of MDR bacterial culture in sepsis subjects. The receiver operating characteristic curve was plotted to determine the vNUTRIC cutoff score for predicting MDR bacterial culture. Results: A total of 103 patients were recruited. The bacterial culture-positive sepsis subjects were 58/103, with 49/58 culture-positive subjects having MDR. The vNUTRIC score on ICU admission in the MDR bacteria group was 6.71 ± 1.92 versus 5.42 ± 2.2 in the non-MDR bacteria group (P = 0.003, Independent Student's t-test). High vNUTRIC score ≥6 on admission is associated with MDR bacteria (P = 0.042 Chi-Square test), and is a predictor of MDR bacteria (P = 0.003, AUC 0.671, 95% confidence interval [0.568-0.775], sensitivity 71%, specificity 48%). Logistic regression showed that the vNUTRIC score is an independent predictor of MDR bacteria. CONCLUSION: High vNUTRIC score (≥6) on ICU admission in sepsis subjects is associated with MDR bacteria.