Evaluation of Predictors, Kinetics of Renal Recovery and Outcomes of COVID-19 Patients with Acute Kidney Injury Admitted to Intensive Care Unit: An Observational Study.

Background: The incidence of acute kidney injury (AKI) is greater than 50% among coronavirus disease-2019 (COVID-19) patients admitted to the intensive care unit (ICU). However, the literature on predictors and kinetics of renal recovery remains unclear. Patients and methods: This observational study was conducted in a 30-bedded mixed ICU of a tertiary care center from May 2020 to July 2021. A total of 200 consecutive adult COVID-19 patients who had AKI in ICU were included. Using logistic regression with the best subset selection, predictors of renal recovery were identified. Outcomes and kinetics of AKI recovery were determined. Results: Among 200 patients, 67 recovered from AKI, of which 38, 17, and 12 patients had transient AKI, persistent AKI, and acute kidney disease (AKD), respectively. A total of 25 patients had AKI relapse, primarily associated with hospital-acquired infections. Results of logistic regression showed that the combination of Acute Physiology and Chronic Health Evaluation (APACHE II) {odds ratio (OR) 1.1 [p < 0.001; 95% confidence interval (CI) 1.06-1.16]}, day onset of AKI [OR 1.6 (p = 0.001; 1.24-2.24)] and severity of AKI [OR 2.9 (p < 0.001; 2.03-4.36)] were the predictors associated with poor renal recovery. This model had sufficient discrimination with the area under the curve (AUC) of 0.86. Renal replacement therapy requirement and mortality among COVID-AKI patients were 68 and 84%, respectively. Conclusion: A higher APACHE II at admission, a longer time to onset of AKI, and the severity of AKI during ICU stay predicted poor renal recovery. Study results emphasize the need for stepping-up dialysis resources in the likely case of future waves of COVID-19. The relapse of AKI was associated with sepsis, and mortality rates were substantially high. How to cite this article: Gudivada KK, Narayan SK, Narasimha A, Krishna B, Muralidhara KD. Evaluation of Predictors, Kinetics of Renal Recovery and Outcomes of COVID-19 Patients with Acute Kidney Injury Admitted to Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2022;26(12):1293-1299.

Associated Risk Factors and Clinical Outcomes of Bloodstream Infections among COVID-19 Intensive Care Unit Patients in a Tertiary Care Hospital.

Introduction: The COVID-19 infection is an ongoing public health crisis causing millions of deaths worldwide. COVID-19 patients admitted to the intensive care unit (ICU) are more vulnerable to acquire secondary bloodstream infections (sBSIs) which cause a significant morbidity and mortality. Thus, we aim to assess the risk factors of sBSIs and outcomes in COVID-19 ICU patients. Methods: One hundred blood culture samples with growth (cases) and other 100 blood culture with no growth(controls) were collected.. All the demographic data, laboratory data and antimicrobial resistance pattern were analysed . Blood culture bottle received in the Microbiology laboratory were loaded into Automated blood culture system. Flagged bottles were processed for final identification by MALDI TOF and automated antibiotic susceptibility testing. Flagged bottles were processed for final identification by MALDI TOF and automated antibiotic susceptibility testing. Results: Raised C-reactive protein (CRP) (P = 0.0035), interleukin-6 (P = 0.0404), mechanical ventilation (MV) (P = 0.024), prior antimicrobial exposure (P = 0.002), longer ICU stay with median 11 days (P = 0.022), and higher mortality rate (P = 0.001) were significantly associated with the BSI. A significant proportion of BSIs were Gram-negative bacteria (n = 115) such as Acinetobacter baumannii 38 (33%) and Klebsiella pneumoniae 30 (26%). Monomicrobial organisms in blood yielded a higher proportion in our study 72 (72%). The highest resistance for Acinetobacter species (50) was observed with ceftazidime 29 (96.6%) amikacin 48 (96%), meropenem 48 (96%), cefotaxime 47 (94%), ciprofloxacin 46 (92%), and netilmicin 46 (92%). K. pneumoniae was highly resistant to cefotaxime 29 (96.6%), ceftazidime 29 (96.6%), ciprofloxacin 22 (73.3%), and cefuroxime 21 (70%). Among Gram-positive organisms, Enterococcus species showed that a resistance for high-level gentamicin and penicillin was 66.6%. Conclusions: Raised CRP, need of MV, prior antimicrobial exposure, and longer ICU stay should alarm clinicians for BSI. Hence, our study highlights the associated risk factors for BSI and emphasizes adherence to hospital infection control policies and antibiotic stewardship program.

Ultrasonography in cardiopulmonary emergencies.

The utilization of ultrasound has rapidly increased over the past few decades due to its ease of use, wider availability of portable machines, broad applicability, non-invasiveness, and real-time imaging. A varied spectrum of clinical conditions such as diverse lung pathologies and various etiologies of acute circulatory failure can be rapidly ascertained using bedside ultrasonography. It has been shown that lung ultrasonography has more sensitivity than chest x-ray in detecting pulmonary congestion in heart failure, subpleural lung consolidation in pneumonia, and characterizing and detecting even minimal pleural effusions. This review gives an overview of the application of ultrasonography in the evaluation of cardiopulmonary failure which is the most commonly encountered clinical entity in the emergency room (ER). The most feasible bedside tests to predict fluid responsiveness are described in this review. Lastly, essential ultrasonographic protocols that are useful for systematic examination of critically ill patients were presented.

Outcomes of patients with thrombotic thrombocytopenic purpura treated in an intensive care unit.

Background Thrombotic thrombocytopenic purpura (TTP) is a multisystem disorder characterized by widespread microthrombosis that can predispose to multiple organ failure. The literature is sparse on the outcomes of critically ill patients with TTP managed in intensive care units (ICUs). We aimed to determine the mortality of ICU patients admitted with TTP and evaluate the predictors of survival. We also compared the incidence of nosocomial infection among those who did or did not receive plasma exchange (PE). Methods We conducted a retrospective study in a tertiary ICU. Two authors screened patients for eligibility from the hospital information system based on peripheral smear reports. Adult critically ill TTP patients managed in ICU were included. Patients with a diagnosis of haemolytic uraemic syndrome, autoimmune causes of haemolysis and pregnancy-related conditions, etc. were excluded. Two authors extracted data from medical charts. No imputation of missing variables was done. Non-parametric statistics were used to report data. Statistical analyses were performed using Stata version 16. Results Of the 535 records that were screened, 33 patients were deemed eligible. Mortality among TTP patients was 14 (42%). The women to men ratio was 7:3. At admission, greater degree of anaemia, thrombocytopenia, and higher lactate dehydrogenase levels were observed in non-survivors compared to survivors (5.4 g/dl [4.8-7.1] v. 7.6 g/dl [6.1-8.9], p=0.05; 17x103 µl v. 21x103 µl, p=0.63; and 2987 (1904-3614) U/L v. 2126 U/L (1941-3319), p=0.71; respectively]. Nineteen (57%) patients had acute kidney injury (AKI), of which 11 survived: 6 recovered completely from renal failure and 5 progressed to end-stage renal disease. Nosocomial infection rates were not different among those receiving and not receiving PE therapy (7 [33%] v. 3 [25%], respectively). Conclusion TTP is more common in women and has a high mortality. Older age, low haemoglobin and higher platelet transfusions are predictors of poor survival. Nosocomial infection rates were similar irrespective of receiving PE therapy.