Author Response: The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (PCO2 Gap) during Resuscitation Affects ICU Outcomes: A Prospective Observational Study.

How to cite this article: Tiwari AM, Zirpe KG, Kulkarni AP. Author Response: The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (PCO2 Gap) During Resuscitation Affects ICU Outcomes: A Prospective Observational Study. Indian J Crit Care Med 2024;28(7):710.

Transient STEMI: Not to be Considered a Lesser Evil.

How to cite this article: Bhosale SJ, Joshi M, Dhakane P, Rane AD, Kulkarni AP. Transient STEMI: Not to be Considered a Lesser Evil. Indian J Crit Care Med 2024;28(7):711-712.

The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (PCO2 Gap) during Resuscitation Affects ICU Outcomes: A Prospective Observational Study.

Introduction: The usual methods of perfusion assessment in patients with shock, such as capillary refill time, skin mottling, and serial serum lactate measurements have many limitations. Veno-arterial difference in the partial pressure of carbon dioxide (PCO2 gap) is advocated being more reliable. We evaluated serial change in PCO2 gap during resuscitation in circulatory shock and its effect on ICU outcomes. Materials and methods: This prospective observational study included 110 adults with circulatory shock. Patients were resuscitated as per current standards of care. We recorded invasive arterial pressure, urine output, cardiac index (CI), PCO2 gap at ICU admission at 6, 12, and 24 hours, and various patient outcomes. Results: Significant decrease in PCO2 gap was observed at 6 h and was accompanied by improvement in serum lactate, mean arterial pressure, CI and urine output in (n = 61). We compared these patients with those in whom this decrease did not occur (n = 49). Mortality and ICU LOS was significantly lower in patients with low PCO2 gap, while more patients with high PCO2 gap required RRT. Conclusion: We found that a persistently high PCO2 gap at 6 and 12 h following resuscitation in patients with shock of various etiologies, was associated with increased mortality, need for RRT and increased ICU LOS. High PCO2 gap had a moderate discriminative ability to predict mortality. How to cite this article: Zirpe KG, Tiwari AM, Kulkarni AP, Vaidya HS, Gurav SK, Deshmukh AM, et al. The Evolution of Central Venous-to-arterial Carbon Dioxide Difference (PCO2 Gap) during Resuscitation Affects ICU Outcomes: A Prospective Observational Study. Indian J Crit Care Med 2024;28(4):349-354.

The multifaceted nature of plant acid phosphatases: purification, biochemical features, and applications.

Acid phosphatases (EC 3.1.3.2) are the enzymes that catalyse transphosphorylation reactions and promotes the hydrolysis of numerous orthophosphate esters in acidic media, as a crucial element for the metabolism of phosphate in tissues. Inorganic phosphate (Pi) utilisation and scavenging, as well as the turnover of Pi-rich sources found in plant vacuoles, are major processes in which intracellular and secretory acid phosphatases function. Therefore, a thorough understanding of these enzymes' structural characteristics, specificity, and physiochemical properties is required to comprehend the function of acid phosphatases in plant energy metabolism. Furthermore, acid phosphatases are gaining increasing importance in industrial biotechnology due to their involvement in transphosphorylation processes and their ability to reduce phosphate levels in food products. Hence, this review aims to provide a comprehensive overview of the purification methods employed for isolating acid phosphatases from diverse plant sources, as well as their structural and functional properties. Additionally, the review explores the potential applications of these enzymes in various fields.

Laparoscopic subcutaneous onlay mesh repair for ventral hernia: Our early experience.

Introduction: Repair of the ventral hernia is an ongoing challenge in surgery, and a number of surgical techniques have been developed ranging from direct suturing techniques to the use of various mesh types in different planes of the abdominal wall to close the defect and strengthen the musculofascial tissue. Laparoscopic subcutaneous onlay mesh (SCOM) repair is a novel procedure developed recently for ventral hernia repair. We would like to share our experience with laparoscopic SCOM repair. Patients and Methods: This is a prospective observational study of patients who have undergone ventral hernia repair at Bangalore Endoscopic Surgery Training Institute and Research Centre from June 2020 to June 2022. A total of 20 patients are included in this study. Statistical Analysis Used: The data were entered into MS Excel and analysed. Results: A total of 20 patients underwent SCOM repair with a defect size measuring up to 8 cm × 8 cm and a mean operative time of 117 min. Three patients had seroma formation and one patient had surgical site infection. No recurrence is seen after 1-year 2-month follow-up. Conclusion: SCOM repair is the newer approach to ventral hernia repair with the advantage over open onlay mesh repair in terms of less pain and better cosmesis. SCOM repair avoids intraperitoneal dissection which may lead to visceral injuries as well as subsequent intraperitoneal adhesions. The acceptance of such surgeries would depend on further long-term studies.

Patient Safety in Intensive Care Unit: What can We Do Better?

Patient safety is an important step in providing high-quality health care. Every intensive care unit (ICU) is unique and its needs would be different; it is thus necessary to build a safety culture based on local and cultural characteristics. Various measures such as regular training, the use of bundles of care, and a blame-free environment can promote patient safety in ICUs. These measures are simple to implement even in resource-limiting settings and can go a long way in improving patient outcomes in our country. How to cite this article: Patil SJ, Ambulkar R, Kulkarni AP. Patient Safety in Intensive Care Unit: What can We Do Better? Indian J Crit Care Med 2023;27(3):163-165.

Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study).

Background: Critically ill patients are frequently transported to various locations within the hospital for diagnostic and therapeutic purposes, which increases the risk of adverse events (AEs). This multicenter prospective observational study was undertaken to determine the incidence of AEs related to intrahospital transport, their severity, and their effects on patient outcomes. Patients and methods: We included consecutive unstable critically ill patients requiring intrahospital transport, across 15 Indian tertiary care centers over 5 months (October 11, 2022-February 20, 2023). Apart from the demographics and severity of illness, data related to transport itself, such as indications and destination, incidence of AEs, their category and treatment required, and patient outcomes, were recorded in a standard form. Results: Eight hundred and ninety-three patients were transported on 1065 occasions out of the intensive care unit (ICU). The mean (SD) acute physiology and chronic health evaluation II score of the patients was 15.38 (±7.35). One hundred and two AEs occurred, wherein cardiovascular instability was the most common occurrence (31, 30.4%). Two patients had cardiac arrest immediately after transport. Acute physiology and chronic health evaluation II [odds ratio (OR): 1.02, 95% confidence interval (CI) - 1.00-1.05, p = 0.04], emergent transport (OR: 5.11, 95% CI - 3.32-7.88, p = 0.00), and team composition (OR: 5.34, 95% CI - 1.63-17.5, p = 0.00) during transport were found to be independent predictors of AEs. Conclusion: We found a high incidence of AEs during intrahospital transport of critically ill patients. These events were more common during emergent transports and when the patients were transported by doctors. Transport by itself was not related to ICU mortality. We feel that stabilization of the patients before transport and adherence to a standardized protocol may help in minimizing the AEs, thereby enhancing patient safety. How to cite this article: Zirpe KG, Tiwari AM, Kulkarni AP, Govil D, Dixit SB, Munjal M, et al. Adverse Events during Intrahospital Transport of Critically Ill Patients: A Multicenter, Prospective, Observational Study (I-TOUCH Study). Indian J Crit Care Med 2023;27(9):635-641.

Memores Acti Prudentes Future!

How to cite this article: Kulkarni AP, Govil D. Memores Acti Prudentes Future! Indian J Crit Care Med 2022;26(1):1.

General Severity of Illness Scoring Systems and COVID-19 Mortality Predictions: Is "Old Still Gold?"

How to cite this article: Siddiqui SS, Patnaik R, Kulkarni AP. General Severity of Illness Scoring Systems and COVID-19 Mortality Predictions: Is "Old Still Gold?" Indian J Crit Care Med 2022;26(4):416-418.

Author Response to the Letter to Editor "Reckoning the Inhaled Sedation in Critically Ill Patients: INSTINCT I".

How to cite this article: Kulkarni AP, Bhosale SJ. Author Response to the Letter to Editor "Reckoning the Inhaled Sedation in Critically Ill Patients: INSTINCT I". Indian J Crit Care Med 2022;26(11):1229.

Great Expectations: Care Bundles can only be as Effective as the Component Elements!

How to cite this article: Mitra LG, Kulkarni AP. Great Expectations: Care Bundles can only be as Effective as the Component Elements! Indian J Crit Care Med 2022;26(10):1074-1075.

Can we Reconcile Evidence-based Medicine with Personalized Medicine: Poised on a Cusp!

How to cite this article: Kulkarni AP, Mishra RC. Can we Reconcile Evidence-based Medicine with Personalized Medicine: Poised on a Cusp! Indian J Crit Care Med 2022;26(S2):S1-S2.

Accuracy of Estimated Continuous Cardiac Output Monitoring (esCCO) Using Pulse Wave Transit Time (PWTT) Compared to Arterial Pressure-based CO (APCO) Measurement during Major Surgeries.

Background: Pulse wave transit time is a novel method of estimating continuous cardiac output (esCCO). Since there are not many studies evaluating esCCO, we compared it with arterial pressure based cardiac output (APCO) method (FloTrac). Methods: In this prospective single-center observational study, we included 50 adult patients planned to undergo supramajor oncosurgeries, where major blood loss and extensive fluid shifts were expected. Cardiac output (CO) measurements were obtained by both methods at five distinct time points, giving us 250 paired readings of stroke volume index (SVI) and cardiac index (CI). We analyzed these readings using Pearson's correlation coefficient and Bland-Altman plots, along with other appropriate statistical tests. Results: There was significant correlation between CI and SVI measured by the esCCO and APCO. Bland-Altman plot analysis for CI showed a bias of -0.44 L/minute/m2, precision of 0.74, and the limits of agreement of -1.89 and +1.01, while the percentage error was 46.29%. Bland-Altman analysis for SVI showed a bias -5.07 mL with a precision of 9.36, and the limits of agreement to be -23.4 to +13.28. The percentage error was 46.56%. Conclusion: This study demonstrated that esCCO tended to underestimate the CI to a large degree, particularly while estimating the cardiac output in the lower range. We found that the limits of agreement between two methods were wide, which are not likely to be clinically acceptable. Further studies with larger number of data points, obtained in a similar subset of patients, for cardiac output measurement in the perioperative period will certainly help determine if pulse wave transit time (PWTT) is here to stay (CTRI No.: CTRI/2019/08/020543). How to cite this article: Joshi M, Rathod R, Bhosale SJ, Kulkarni AP. Accuracy of Estimated Continuous Cardiac Output Monitoring (esCCO) Using Pulse Wave Transit Time (PWTT) Compared to Arterial Pressure-based CO (APCO) Measurement during Major Surgeries. Indian J Crit Care Med 2022;26(4):496-500.

Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness.

Background: Fluid boluses are used in hemodynamically unstable patients with presumed hypovolemia, to improve tissue perfusion, in the perioperative period. Now less invasive methods, such as pulse pressure variation (PPV) and stroke volume variation (SVV) are increasingly being used. We investigated correlation between carotid and brachial artery velocity time integral (VTI) and compared both with PPV and SVV. Methods: We recruited 27 patients undergoing supra-major abdominal surgeries. When indicated (hypotension or increased lactate), a fluid bolus was given after measuring carotid and brachial artery VTI, PPV, and SVV. The change in SV was noted and patients were categorized as responders if the SV increased by >15%. We performed Bland Altman Agreement and calculated best sensitivity and specificity for the parameters. Results: Patients were found to be fluid responders on 29 instances. The correlation between PPV, SVV, carotid and brachial artery VTI was poor and the limits of agreement between them were wide. The Area under Curve (AUC) for PPV was 0.69, for SVV was 0.63, while those of Carotid and Brachial artery VTI (TAP and flow) were (0.53 and 0.54 for carotid) and (0.51 and 0.56 for brachial) respectively. Conclusion: We found poor agreement and weak correlation between both VTi (TAP and flow) measured at carotid and brachial arteries, suggesting that the readings at brachial vessel cannot be used interchangeably with those at carotid artery. The PPV and SVV were better than these parameters for predicting fluid responsiveness; however, their predictive ability (AUROC), sensitivity and specificity were much lower than previously reported. Further studies in this area are therefore required (CTRI Reg No: CTRI/2017/08/009243). How to cite this article: Joshi M, Dhakane P, Bhosale SJ, Phulambrikar R, Kulkarni AP. Correlation between Carotid and Brachial Artery Velocity Time Integral and Their Comparison to Pulse Pressure Variation and Stroke Volume Variation for Assessing Fluid Responsiveness. Indian J Crit Care Med 2022;26(2):179-184.

Utility of Stewart's Approach to Diagnose Missed Complex Acid-Base Disorders as Compared to Bicarbonate-anion Gap-based Methodology in Critically Ill Patients: An Observational Study.

BACKGROUND: Traditional arterial blood gas (ABG) analysis may miss out on some metabolic acid-base disorders. We prospectively compared Stewart's approach in critically ill patients to traditional bicarbonate-anion gap-based methods (with and without correction for albumin) to diagnose acid-base disorders. PATIENTS AND METHODS: Five hundred ABG samples from medical or surgical patients in the ICU were analyzed with traditional bicarbonate-anion gap-based methodology with and without correction for albumin and Stewart's biochemical approach. The primary outcome identification of additional metabolic disorders diagnosed with Stewart's approach in comparison to bicarbonate system-based approaches. We also looked at the correlation between the strong ion gap (SIG) and the albumin-corrected anion gap (acAnion Gap). RESULTS: Stewart's approach detected missed metabolic disorders in 58 (11.6%) blood gas results reported as "within normal limits" with the bicarbonate-uncorrected anion gap approach. In 50 (10%) of these ABGs, the acAnion Gap approach was able to diagnose the missed metabolic disorders. Thus, the albumin-corrected anion gap method had a similar diagnostic performance to Stewart's approach, as it missed additional disorders in only eight (1.6%) blood gases. CONCLUSION: In this study, we found that the acAnion Gap approach was similar in diagnostic performance to Stewart's approach. We feel that the corrected anion gap approach can be safely used if a ready calculator for Stewart's approach is not available. HOW TO CITE THIS ARTICLE: Paliwal R, Pakavakis A, Divatia JV, Kulkarni AP. Utility of Stewart's Approach to Diagnose Missed Complex Acid-Base Disorders as Compared to Bicarbonate-anion Gap-based Methodology in Critically Ill Patients: An Observational Study. Indian J Crit Care Med 2022;26(1):23-32.

Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study).

Aim: Sedation is essential during invasive mechanical ventilation, and conventionally intravenous analgesic and sedative drugs are used. Sedation with inhaled anesthetics using anesthesia conserving device (ACD) is an alternative. There is no data on the safety and ease of use of AnaConDa™ from India. Materials and methods: After IEC approval and informed consent, we used AnaConDa™-S for Isoflurane sedation in 50 hemodynamically stable (need for <0.5 µg/kg/min of Noradrenaline infusion), ASA I and II patients aged 18-80 years, undergoing elective mechanical ventilation for up to 24 hours after elective oncosurgeries. Patients with mental obtundation (GCS <14), or if pregnant, were excluded. The primary outcome was time spent between RASS scores of -3 and -4, while secondary outcomes were incidence of delirium, technical problems with AnaConDa™, and adverse systemic effects of isoflurane. Bolus doses of isoflurane 0.2-0.5 mL were given if the Richmond agitation sedation scale (RASS) score was not achieved. Results: Fifty patients received isoflurane infusion for a median of 720 (IQR 630-900) minutes, and all remained in the target sedation range. Median time to awakening [19 (IQR, 5-85) minutes], to follow simple verbal commands [20 (IQR 5-180) minutes], and extubation after stopping the infusion of isoflurane was quick [100 (10-470) minutes]. All patients remained hemodynamically stable. None of the patients had delirium. Conclusion: Target sedation levels were achieved with initial boluses of isoflurane using AnaConDa™-S. Isoflurane sedation delivery using AnaConDa™-S is safe and feasible. How to cite this article: Kulkarni AP, Bhosale SJ, Kalvit KR, Sahu TK, Mohanty R, Dhas MM, et al. Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med 2022;26(8):906-912.

ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill.

Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients. How to cite this article: Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al. ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76.

Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics.

How to cite this article: Khilnani GC, Tiwari P, Zirpe KG, Chaudhary D, Govil D, Dixit S, et al. Guidelines for the Use of Procalcitonin for Rational Use of Antibiotics. Indian J Crit Care Med 2022;26(S2):S77-S94.

Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM.

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give "real-world" criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs. How to cite this article: Zirpe KG, Tiwari AM, Pandit RA, Govil D, Mishra RC, Samavedam S, et al. Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM. Indian J Crit Care Med 2022;26(S2):S43-S50.

Development of Force Sensor System Based on Tri-Axial Fiber Bragg Grating with Flexure Structure.

Fiber Bragg grating (FBG) sensors have an advantage over optical sensors in that they are lightweight, easy to terminate, and have a high flexibility and a low cost. Additionally, FBG is highly sensitive to strain and temperature, which is why it has been used in FBG force sensor systems for cardiac catheterization. When manually inserting the catheter, the physician should sense the force at the catheter tip under the limitation of power (<0.5 N). The FBG force sensor can be optimal for a catheter as it can be small, low-cost, easy to manufacture, free of electromagnetic interference, and is materially biocompatible with humans. In this study, FBG fibers mounted on two different flexure structures were designed and simulated using ANSYS simulation software to verify their sensitivity and durability for use in a catheter tip. The selected flexure was combined with three FBGs and an interrogator to obtain the wavelength signals. To obtain a calibration curve, the FBG sensor obtained data on the change in wavelength with force at a high resolution of 0.01 N within the 0.1-0.5 N range. The calibration curve was used in the force sensor system by the LabVIEW program to measure the unknown force values in real time.