Diaphragmatic Rapid Shallow Breathing Index: A Simple Tool to Give more Power to Predict Weaning?

How to cite this article: Kundu R, Srinivasan S. Diaphragmatic Rapid Shallow Breathing Index: A Simple Tool to Give more Power to Predict Weaning? Indian J Crit Care Med 2022;26(9):985-986.

Necrotizing Soft Tissue Infections: More than What Meets the Eye.

How to cite this article: Kundu R, Srinivasan S. Necrotizing Soft Tissue Infections: More than What Meets the Eye. Indian J Crit Care Med 2022;26(4):411-413.

Doppler-estimated Carotid and Brachial Artery Flow as Surrogate for Cardiac Output: Needs Further Validation.

Selvam V, Srinivasan S. Doppler-estimated Carotid and Brachial Artery Flow as Surrogate for Cardiac Output: Needs Further Validation. Indian J Crit Care Med 2022;26(2):159-160.

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.

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.

Parturient with Acute Abdomen.

Management of a parturient with an acute abdomen presents unique challenges. We aim to review the common obstetric and nonobstetric causes for acute abdomen in pregnancy, approach to diagnosis, the role of imaging, and management including the scope and timing of operative intervention. How to cite this article: Kundu R, Srinivasan S. Parturient with Acute Abdomen. Indian J Crit Care Med 2021;25(Suppl 3):S223-S229.

Age-adjusted Charlson Comorbidity Index: A Simple Tool, but Needs Further Validation in COVID-19 Patients.

How to cite this article: Selvam V, Srinivasan S. Age-adjusted Charlson Comorbidity Index: A Simple Tool, but Needs Further Validation in COVID-19 Patients. Indian J Crit Care Med 2021;25(9):963-964.

COVID-19 ARDS: Can Systemic Oxygenation Utilization Guide Oxygen Therapy?

How to cite this article: Srinivasan S, Panigrahy AK. COVID-19 ARDS: Can Systemic Oxygenation Utilization Guide Oxygen Therapy? Indian J Crit Care Med 2021;25(2):115-116.

Maternal Health: The Mirror of Our Healthcare System.

Krishna B, Kulkarni AP, Srinivasan S. Maternal Health: The Mirror of Our Healthcare System. Indian J Crit Care Med 2021;25(Suppl 3):S187-S188.

Gastrointestinal Manifestations of Systemic Diseases in Critically Ill.

Systemic disorders can have gastrointestinal (GI) manifestations which are characterized by nausea, vomiting, diarrhea, constipation, abdominal pain, jaundice, and abnormal liver function tests. These gastrointestinal symptoms can be signs of various immunologic, infectious, and endocrine diseases. Gastrointestinal manifestations can be the first signs and symptoms for which the patient can be admitted in a critical care unit. In this article, we will discuss the GI manifestations of various topical diseases, endocrine diseases, and immunological diseases which are the major bulk of patients in intensive care unit (ICU). How to cite this article: Panigrahy AK, Srinivasan S. Gastrointestinal Manifestations of Systemic Diseases in Critically Ill. Indian J Crit Care Med 2020;24(Suppl 4):S190-S192.

Basic Critical Care for Management of COVID-19 Patients: Position Paper of Indian Society of Critical Care Medicine, Part-I.

With more than 23 million infections and more than 814,000 deaths worldwide, the coronavirus disease-2019 (COVID-19) pandemic is still far from over. Several classes of drugs including antivirals, antiretrovirals, anti-inflammatory, immunomodulatory, and antibiotics have been tried with varying levels of success. Still, there is lack of any specific therapy to deal with this infection. Although less than 30% of these patients require intensive care unit admission, morbidity and mortality in this subgroup of patients remain high. Hence, it becomes imperative to have general principles to guide intensivists managing these patients. However, as the literature emerges, these recommendations may change and hence, frequent updates may be required. How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of Indian Society of Critical Care Medicine, Part-I. Indian J Crit Care Med 2020;24(Suppl 5):S244-S253.

Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II.

In a resource-limited country like India, rationing of scarce critical care resources might be required to ensure appropriate delivery of care to the critically ill patients suffering from COVID-19 infection. Most of these patients require critical care support because of respiratory failure or presence of multiorgan dysfunction syndrome. As there is no pharmacological therapy available, respiratory support in the form of supplemental oxygen, noninvasive ventilation, and invasive mechanical ventilation remains mainstay of care in intensive care units. As there is still dearth of direct evidence, most of the data are extrapolated from the experience gained from the management of general critical care patients. How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020;24(Suppl 5):S254-S262.

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.

Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations.

BACKGROUND AND AIM: Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs. MATERIALS AND METHODS: All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation. RESULTS: After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity. CONCLUSION: This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients. HOW TO CITE THIS ARTICLE: Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31-S42.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020.

BACKGROUND AND PURPOSE: Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines. METHODS: This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared. RESULTS: This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level. CONCLUSION: In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time. ABBREVIATIONS LIST: ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization. HOW TO CITE THIS ARTICLE: Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6-S30.

A Shift in Time Saves .

How to cite this article: Srinivasan S. A Shift in Time Saves ……. Indian J Crit Care Med 2019;23(3):109-110.

Neonicotinoid Poisoning and Management.

Neonicotinoids are a newer class of insecticides, which act on postsynaptic nicotinic acetylcholine esterase receptors. Its use is gradually increasing over recent years due to its better safety profile compared to other commonly used pesticides like organophosphates, organochlorides, carbamates, and pyrethroids. The better toxicological profile is attributed to more selectivity for insects compared to mammals and decreased penetration through the blood-brain barrier. Common symptoms of self-poisoning described are dizziness, hypertension, tachycardia, nausea, vomiting, eye irritation, dermatitis, and oral mucosal lesions. Mortality due to poisoning is less than 3%. Till date, there is no specific antidote for neonicotinoid poisoning and management of poisoning is symptomatic and supportive. HOW TO CITE THIS ARTICLE: Selvam V, Srinivasan S. Neonicotinoid Poisoning and Management. Indian J Crit Care Med 2019;23(Suppl 4):S260-S262.

Epidemiological Analysis of Extended-Spectrum Beta-Lactamase-Producing Bacterial Infections in Adult Live Donor Liver Transplant Patients.

INTRODUCTION: Bacterial infections are a leading cause of morbidity and mortality in patients receiving solid-organ transplants. Extended-spectrum beta-lactamases (ESBL) pathogens are the most important pathogenic bacteria infecting these patients. AIM: This study aims to evaluate for the incidence and characteristics of ESBL-positive organism, to look for the clinical outcomes in ESBL-positive infected cases, and to evaluate and draft the antibiotic policy in posttransplant patients during the first 28 days posttransplant. MATERIALS AND METHODS: This is a retrospective data analysis of liver transplant recipients infected with ESBL culture-positive infections. All the culture sites such as blood, urine, and endotracheal tube aspirates were screened for the first ESBL infection they had and noted. This data were collected till day 28 posttransplant. The antibiotic susceptibility pattern and the most common organism were also noted. RESULTS: A total of 484 patients was screened and 116 patients had ESBL-positive cultures. Out of these, 54 patients had infections and 62 patients were ESBL colonizers. The primary infection site was abdominal fluid (40.7%), with Klebsiella accounting for most of the ESBL infections. Colistin was the most sensitive antibiotic followed by tigecycline. The overall mortality was 11.4% and 31 out of 54 ESBL-infected patients died. CONCLUSIONS: Infections with ESBL-producing organism in liver transplant recipients has a high mortality and very limited therapeutic options.

Role of Point-of-Care Ultrasonography for the Management of Sepsis and Septic Shock.

BACKGROUND: Sepsis and septic shock remain a major cause of morbidity and mortality globally. In recent years, the outcome of patients with sepsis and septic shock has gradually improved, in part due to early recognition and timely appropriate management. Bedside physical examination can be of limited value to identify the source of infection and to decide appropriate management. Moreover, the clinical status of these patients can change rapidly, as a part of disease progression or in response to treatment or intervention. METHODS: Research articles, review papers and online contents related to point-of-care ultrasound for the management of patients with sepsis and septic shock were reviewed. RESULTS: Point-of-care ultrasonography can be a valuable bedside tool to rapidly identify the potential source of infection and associated organ dysfunction. It can also help to guide management to predict fluid responsiveness by assessing the variation of inferior venacava with respiration, ventricular size and aortic flow variation. Response to various interventions like a fluid challenge or administration of inotropes can be assessed at the bedside. Point-of-care ultrasound can also enhance safety and increase the success of bedside procedures like central venous cannulation and drainage of pleural effusion. CONCLUSION: Bedside ultrasound can help to individualize management of patients with sepsis and septic shock and may potentially improve patient outcome.