Clinical Scoring and Ultrasound-Based Diaphragm Assessment in Predicting Extubation Failure in Neurointensive Care Unit: A Single-Center Observational Study.

BACKGROUND: Patients in the neurointensive care unit (NICU) fail extubation despite successful weaning from mechanical ventilation. Parameters currently used in the general intensive care unit do not accurately predict extubation success in the NICU. In this study, peak cough expiratory flow rate, ultrasound-based diaphragm function assessment, and comprehensive clinical scoring systems were measured to determine whether these new variables, in isolation or combination, could predict extubation failure successfully in the NICU. METHODS: All adult patients extubated after 48 h of mechanical ventilation in the NICU of a single tertiary care center were recruited into the prospective cohort. The patient's cough peak expiratory flow rate (C-PEFR), diaphragm function, and clinical scores were measured before extubation. C-PEFR was measured using a hand-held spirometer, diaphragm function (excursion, thickness fraction, and diaphragm contraction velocity on coughing) was assessed using ultrasound, and the clinical scores included the visual pursuit, swallowing, age, Glasgow Coma Scale for extubation (VISAGE) and respiratory insufficiency scale-intubated (RIS-i) scores. The patients requiring reintubation within 48 h were considered as extubation failure. Univariate and multivariate logistic regression analyses were done to identify predictors of extubation failure. RESULTS: Of the 193 patients screened, 43 were recruited, and 15 had extubation failure (20.9%). Patients with extubation failure had higher RIS-i scores (p < 0.001) and lower VISAGE scores (p = 0.043). The C-PEFR and diaphragm function (excursions and contraction velocity on coughing) were lower in patients with extubation failure but not statistically significant. The variables with p < 0.2 in univariate analysis (RIS-i, VISAGE, and diaphragm cough velocity) were subjected to multivariate regression analysis. RIS-I score remained an independent predictor (odds ratio 3.691, 95% confidence interval 1.5-8.67, p = 0.004). In a receiver operating characteristic analysis, the area under the curve for RIS-i was 0.963. An RIS-i score of 2 or more had 94% specificity and 89% sensitivity for predicting extubation failure. CONCLUSIONS: The RIS-i score predicts extubation failure in NICU patients. The addition of ultrasound-based diaphragm measurements to the RIS-i score to improve prediction accuracy needs further study. Clinical trial registration Clinical Trials Registry of India identifier CTRI/2021/03/031923.

Bygone Ether: Theriac to Obstinate Hiccups-Food for Thought!

How to cite this article: Hirolli D, Panda R, Baidya DK. Bygone Ether: Theriac to Obstinate Hiccups-Food for Thought! Indian J Crit Care Med 2022;26(7):884.

Development of an institutional protocol for percutaneous dilatational tracheostomy in critically ill COVID-19 patients: Initial experience.

Background and Aims: Percutaneous dilatational tracheostomy (PDT) may improve the outcome in critically ill COVID-19 patients on mechanical ventilation. However, the timing of performing tracheostomy may be controversial, and it is an aerosol-generating procedure with a potential risk of viral exposure to healthcare workers. Material and Methods: An operational protocol for performing PDT was made and subsequently followed in a designated COVID-19 ICU. Critically ill adult patients on mechanical ventilators who underwent PDT were included in this retrospective cohort study. Case files were retrospectively reviewed and patient characteristics, clinical outcome, and procedure-related details were noted. Results: Forty-one patients were included in the analysis. The median age was 49 (39-67) years, and 41.5% of patients were females. The median duration of mechanical ventilation before tracheostomy was 10 (8-16) days, and the median (IQR) PaO2/FiO2 ratio on the day of PDT was 155 (125-180) mm Hg. Further, 48.8% of patients had transient desaturation to SpO2 <90%, and 41.5% survived to ICU discharge. None of the health care providers involved in PDT developed any symptoms of COVID 19. Conclusion: This descriptive study demonstrates the feasibility, implementation, and apparent safety of the PDT protocol developed at our institution.

Point-of-care Glucose Monitoring in COVID-19 Intensive Care Unit: How's It Different?

How to cite this article: Panda R, Hirolli D, Baidya DK. Point-of-care Glucose Monitoring in COVID-19 Intensive Care Unit: How's It Different? Indian J Crit Care Med 2021;25(12):1465-1466.

Aftermath of COVID-19 and Critical Care in India.

The coronavirus disease-2019 (COVID-19) pandemic had overwhelmed the healthcare system and forced many patients to be treated at home with oxygen, antibiotics, and steroids, particularly during the second wave. There was increased misuse of antimicrobials in hospitals as well as unguarded self-prescription of these medications among the common people. We are likely to see an increase in the incidence of antimicrobial resistance (AMR), change in the susceptibility pattern of the organisms causing community-acquired infections, and an increase in opportunistic bacterial, tubercular, viral, and fungal infections. How to cite this article: Panda R, Hirolli D, Baidya DK. Aftermath of COVID-19 and Critical Care in India. Indian J Crit Care Med 2021; 25(10):1173-1175.

Inadvertent Intravenous Administration of Milk in Postoperative Intensive Care Unit: Sequelae and Management.

Tubing misconnections is an unfortunate and rare occurrence in intensive care units, but the complication is grossly underreported as it is often attributed to human error rather than device failure. This potential underreporting of a complication causes concern because it can be prevented by making an appropriate device design and increase awareness among health care workers. In this case report, we have discussed an enteral feed misconnection to an intravenous cannula has led to respiratory distress and acute kidney injury in a patient admitted to the postoperative intensive care unit. We propose a standard operating protocol for management in such a scenario and the role of ventilation-perfusion (V/Q) scan as an alternative to conventional computed tomography pulmonary angiogram (CTPA) in acute kidney injury patients.

Role of anesthesiologist in managing a rare case of homicidal cut-throat injury.

Management of homicidal cut-throat injuries requires a multi-disciplinary approach. The role of an anesthesiologist in instituting an airway using an endotracheal intubation or tracheostomy before wound exploration and repair of transected tissues, is challenging, as, such injuries are most of the time associated with distortion of the normal anatomy of the airway. We hereby report a case of 60-year-old lady diagnosed as homicidal cut-throat injury with vocal cords exposed externally and injury of thyroid cartilage and pharyngeal muscles. Patients with cut-throat injury may present with airway compromise, aspiration, and acute blood loss with hypoxemia because of injury to the airway and major vessels. Securing an airway becomes the first priority in patients with cut-throat injuries. It could be done by an endotracheal intubation, cricothyroidotomy, or by an emergency tracheostomy. For the effective management of patients with a cut-throat injury, there is a need for a multidisciplinary approach by a team consisting of an otorhinolaryngologist, anesthesiologist, and a psychiatrist.