Effect of Change in Sodium after Slow Low-Efficiency Dialysis in Critically Ill Patients with Acute Kidney Injury.

INTRODUCTION: The effect of sodium (Na) correction by slow low-efficiency dialysis (SLED) in dysnatremic (135 mEq/L <Na >145 mEq/L) critically ill patients is unclear. METHODS: Prospective observational study enrolled dysnatremic critically ill adult patients with acute kidney injury undergoing the first SLED as cases and normonatremic patients as controls. Baseline and SLED-related parameters and 30-day mortality were noted. RESULTS: 100 dysnatremic and 51 normonatremic patients were included, with a median age of 31 (25-52) years and median admission SOFA scores of 10 (9-12). Patients with dysnatremia at study inclusion had a mortality of 53%, with the highest mortality in severe hypernatremia (Na >160 mEq/L) (75%), followed by those with severe hyponatremia (Na <120 mEq/L) (68.6%). SLED-associated natremia change >10 mEq/L was significantly associated with mortality, in patients with mild dysnatremia and normonatremia (Na: 130-150) (p < 0.001), and not in those with moderate to severe dysnatremia (Na <130 and Na >150) (p = 0.72). Upon multivariate logistic regression analysis, a model with pre-SLED pH, dialyzate-pre-SLED Na difference, and duration of SLED significantly predicted SLED-associated natremia change (R2 0.18, p = 0.001). CONCLUSIONS: SLED can be safely and effectively performed in critically ill adults with dysnatremia requiring renal replacement therapy with mortality comparable to normonatremic controls.

The impact of a "short-term" basic intensive care training program on the knowledge of nonintensivist doctors during the COVID-19 pandemic: An experience from a population-dense low- and middle-income country.

BACKGROUND: The utility of basic intensive care unit (ICU) training comprising a "1-day course" has been scientifically evaluated and reported in very few studies, with almost no such study from resource-limited settings. AIM: The study assessed the utility of basic ICU training comprising of a "1-day course" in increasing the knowledge of nonintensivist doctors. MATERIALS AND METHODS: This is an observational study conducted at a medical university in North India in 2020. The participants were nonintensivist doctors attending the course. The course was designed by intensivists, and it had four domains. The participants were categorised on the basis of their duration of ICU experience and broad speciality. Pretest and posttest was administered, which was analysed to ascertain the gain in the knowledge score. RESULTS: A total of 252 participants were included, of which the majority were from the clinical medicine speciality (85.3%) and had ICU experience of 1-6 months (47.6%). There was a significant improvement in the mean total score of the participants after training from 14/25 to 19/25, with a mean difference (MD) of 5.02 (p < 0.001). Based on ICU experience, in groups I (<1 month), II (1-6 months), and III (>6 months), there was a significant improvement in the total score of the participants after training with MD with 95% confidence interval (CI) limits of 5.27 (4.65-5.90), 4.70 (4.38-5.02), and 5.33 (4.89-5.78), respectively. In the clinical surgery specialty (n = 37), there was a significant improvement in the total score after training from 11/25 to 16.4/25 with an MD (95% CI limits) of 5.38 (4.4-6.3). Similarly, in the clinical medicine group (n = 215), the MD (95% CI limits) score after training was 4.95 (4.71-5.20), from 14.5/25 to 19.5/25. In feedback, more than half of the participants showed interest in joining ICU after training. CONCLUSIONS: Training nonintensivist doctors for 1 day can be useful in improving their knowledge, regardless of their prior ICU experience and speciality.

The evolution of clot strength in critically ill COVID-19 patients: a prospective observational thromboelastography study.

The authors have done commendable work in exploring the utility of a comprehensive viscoelastic test for assessment of the coagulation cascade in Coronavirus disease 2019 (COVID-19) patients. This article published in your esteemed journal in November 2021 "The evolution of clot strength in critically-ill COVID-19 patients: a prospective observational thromboelastography study" found hypercoagulability in most of the patients at Intensive Care Unit (ICU) admission and also noted a persistently increased fibrin contribution to clot strength. However, we would like to comment upon a few points which may be of importance to the readers.

Acute Methanol Toxicity: Clinical Correlation with Autopsy Findings, a Descriptive Study.

BACKGROUND: Methyl alcohol poisoning or deaths from drinking illegally brewed cheap alcohol which is often spiked with chemicals to increase its potency are frequent in India. Many outbreaks from different parts of the country have been reported from time to time. A total of 11,830 lives were lost between 2006 and 2015 due to the consumption of spurious liquor in the country. The symptoms can range from mild to severe depending upon factors like the amount of exposure and time of presentation. AIMS AND OBJECTIVES: The present study was designed to describe the clinical presentation, management, and outcome of the patients during a recent methanol outbreak that can form a basis for diagnosis and management. This study also highlights the salient autopsy findings and their correlation with clinical features. MATERIALS AND METHODS: It is a retrospective, descriptive study discussing clinical features of patients with methanol intoxication, their outcome, and the clinical correlation with autopsy findings of patients who succumbed to death. The study was conducted at King George's Medical University, Lucknow. The patients were enrolled from a methanol intoxication outbreak in Barabanki district on 28th May 2019 followed by a similar outbreak in Sitapur district two days later. RESULTS: A total of 33 patients were included in this study based on predefined clinical characteristics. The average amount of alcohol consumed was about 223 mL (range: 100-300 mL). The majority of patients had onset of symptoms between 12 and 24 hours. All patients had gastrointestinal symptoms, 97% of patients had visual disturbances, 91% of patients had central nervous system manifestation while frank coma was observed in 15% of patients. Decreased urine output was reported in 6% of patients. About 90% of patients had metabolic acidosis. Out of 33 patients included in this study, 30 patients were discharged in stable condition while two died and one absconded. Autopsy findings revealed marked cerebral edema and hyperemia, hyperemic heart, and congested lungs in all the patients. One patient showed putaminal necrosis which is characteristic of methanol poisoning. Kidneys in two cases were hyperemic and show parenchymal degeneration which co-relates with both patients being anuric. CONCLUSION: Methanol intoxication is a serious problem in developing countries like ours. Timely intervention is an important factor in reducing mortality among these patients. The study highlights the very important fact that methanol intoxication can be managed at the very ground level with minimal resources (as available) if intervened and recognized in time.

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.

Cytomegalovirus Coinfection in Critically Ill Patients with Novel Coronavirus-2019 Disease: Pathogens or Spectators?

Coronavirus disease-2019 (COVID-19) pandemic is raging all over the world. As we are delving more into management of COVID-19, certain new challenges are emerging. One of these is emergence or reactivation of viral infections belonging to Herpesviridae family, especially cytomegalovirus (CMV). Although we have come across the threat of fungal and resistant bacterial infections, experience regarding reactivation or coinfection with concomitant viral infections like CMV during the COVID pandemic is still limited. Whether CMV is a bystander or pathogen is difficult to say categorically and needs further research. In this case series, we intend to describe three patients of COVID-19 with CMV coinfections. To our knowledge, this is the first case series from India. How to cite this article: Siddiqui SS, Chatterjee S, Yadav A, Rai N, Agrawal A, Gurjar M, et al. Cytomegalovirus Coinfection in Critically Ill Patients with Novel Coronavirus-2019 Disease: Pathogens or Spectators? Indian J Crit Care Med 2022;26(3):376-380.

Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study.

OBJECTIVES: Critically ill solid organ malignancy patients admitted to intensive care unit (ICU) as unplanned medical admissions behave differently from other subsets of cancer patients (hematolymphoid malignancies and cancer patients admitted for postoperative care). These patients if appropriately selected may benefit from the ICU care. There is paucity of data on critically ill unplanned admissions of solid organ malignancies from South Asia. We analyzed data of patients with solid tumors with unplanned admissions to the ICU to determine the clinical, epidemiological characteristics, and predictors of hospital mortality in an Indian ICU. MATERIALS AND METHODS: This prospective, observational study was done in our 14-bedded mixed medical-surgical ICU from July 2014 to November 2015. We included all consecutive adult unplanned admissions with solid organ malignancies having ICU stay of >24 hours. Surgical admissions, hematolymphoid malignancies, advanced malignancy with no treatment options, and those cured of cancer >5 years were excluded. RESULTS: Two hundred and thirty-five consecutive patients were included in this cohort. ICU and hospital mortalities were 36.6 and 40%, respectively. On multivariate analysis, cancer status [odds ratio (OR): 3.204; 95% confidence interval (CI): 1.271-8.078], invasive mechanical ventilation (OR: 5.940; 95% CI: 2.632-13.408), and sequential organ failure assessment (SOFA) score on the day of ICU admission (OR: 1.199; 95% CI: 1.042-1.379) were independent predictors of hospital mortality. CONCLUSION: Acute respiratory failure and septic shock are the common reasons of unplanned ICU admission for patients with solid organ malignancies. With good patient selection, more than half of such patients are likely to be discharged alive from the hospital. HOW TO CITE THIS ARTICLE: Siddiqui SS, Narkhede AM, Chaudhari HK, Ravisankar NP, Dhundi U, Sarode S, et al. Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study. Indian J Crit Care Med 2021;25(12):1421-1426.

Epidemiology, Clinical Characteristics, and Prognostic Factors in Critically Ill Patients with Hematolymphoid Malignancy.

OBJECTIVE: Despite advances in the field of oncology and intensive care, the outcomes of hematolymphoid malignancy (HLM) patients admitted to ICU are poor. This study was carried out to look at the demographic data, clinical features, and predictors of hospital mortality in these patients. MATERIALS AND METHODS: We prospectively studied 101 adult critically ill patients with HLM admitted to the 14-bedded mixed medical surgical ICU of a tertiary care cancer center. Out of 101 patients, end-of-life care decisions were taken in 7 patients, who were excluded from the outcome analysis. Predictors of in-hospital mortality were evaluated using univariate and multivariate analysis. RESULTS: The ICU and in-hospital mortality recorded in our study were 48.9 and 54.3%, respectively. Neutropenia at ICU admission, Simplified Acute Physiology Score III (SAPS III) score, and mechanical ventilation (MV) within 24 hours of ICU admission were associated with in-hospital mortality on univariate analysis. On multivariate logistic regression analysis, neutropenia at ICU admission (OR 4.621; 95% CI, 1.2-17.357) and MV within 24 hours of ICU admission (OR 2.728; 95% CI, 1.077-6.912) were independent predictors of in-hospital mortality. CONCLUSION: The HLM patients needing critical care have high acuity of illness, and acute respiratory failure is the commonest reason for ICU admission in these patients. In our study, the ICU survival was more than 50% and more than 45% patients were discharged alive from the hospital. We found a need for MV within 24 hours of ICU admission and presence of neutropenia at ICU admission to be independent predictors of hospital mortality in our study. HOW TO CITE THIS ARTICLE: Siddiqui SS, Prabu NR, Chaudhari HK, Narkhede AM, Sarode SV, Dhundi U, et al. Epidemiology, Clinical Characteristics, and Prognostic Factors in Critically Ill Patients with Hematolymphoid Malignancy. Indian J Crit Care Med 2021;25(1):56-61.

Serum Cystatin C in Early Identification of Acute Kidney Injury in Acute Pancreatitis: Is It an Old Wine in a New Bottle?

How to cite this article: Siddiqui SS. Serum Cystatin C in Early Identification of Acute Kidney Injury in Acute Pancreatitis: Is It an Old Wine in a New Bottle? Indian J Crit Care Med 2020;24(9):744-745.

Training and Delivery of Critical Care Medicine in India: Concerns Revealed by COVID-19 Pandemic.

How to cite this article: Ozair A, Agrawal A, Siddiqui SS. Training and Delivery of Critical Care Medicine in India: Concerns Revealed by COVID-19 Pandemic. Indian J Crit Care Med 2020;24(4):285-286.

Evaluation and Validation of Four Scoring Systems: the APACHE IV, SAPS III, MPM0 II, and ICMM in Critically Ill Cancer Patients.

BACKGROUND AND AIMS: To evaluate and validate four severity-of-illness scores, acute physiology and chronic health evaluation IV (APACHE IV), simplified acute physiology score III (SAPS III), mortality probability models II at 0 hours (MPM0 II), and ICU cancer mortality model (ICMM), in a prospective cohort of critically ill cancer patients. MATERIALS AND METHODS: Single-center, prospective observational study performed in a 14-bedded combined medical-surgical ICU of a tertiary care cancer center of India, from July 2014 to November 2015. Score performance was judged by discrimination and calibration, using the area under receiver-operating characteristics (ROC) curve and Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: A total of 431 patients were included in the study. Intensive care unit (ICU) and hospital mortality were 37.4% and 41.1%, respectively. The area under ROC curve for APACHE IV, SAPS III, MPM0 II, and ICMM were 0.73, 0.70, 0.67, and 0.67, respectively. Calibration as calculated by Hosmer-Lemeshow analysis type C statistics for APACHE IV, SAPS III, MPM0 II, and ICMM shows good calibration with Chi-square values of 5.32, 9.285, 9.873, and 9.855 and p values of 0.723, 0.319, 0.274, and 0.275, respectively. CONCLUSION: All the four models had moderate discrimination and good calibration. However, none of the mortality prediction models could accurately discriminate between survivors and nonsurvivors in our patients. HOW TO CITE THIS ARTICLE: Siddiqui SS, Narkhede AM, Kulkarni AP, Prabu NR, Chaudhari HK, Divatia JV, et al. Evaluation and Validation of Four Scoring Systems: the APACHE IV, SAPS III, MPM0 II, and ICMM in Critically Ill Cancer Patients. Indian J Crit Care Med 2020;24(4):263-269.

Benefits of and Untoward Events during Intrahospital Transport of Pediatric Intensive Care Unit Patients.

BACKGROUND AND AIMS: The transport of critically ill patients for procedures or imaging outside the Intensive Care Unit (ICU) is potentially hazardous; hence, the transport process must be organized and efficient. The literature about benefits of and untoward events (UEs) during intrahospital transport of pediatric critically ill patient is scarce. We, therefore, audited the UEs during and benefits of intrahospital transport of critically ill pediatric patients in our ICU. SUBJECTS AND METHODS: Eighty critically ill pediatric (<18 years) cancer patients, transported from the ICU for either diagnostic or therapeutic procedure over a period of 6 months, were included in the study. The data collected included the destination (computed tomography scan, intervention radiology, magnetic resonance imaging scan, and operation theater), accompanying medical personnel, UEs, and benefits obtained during transport. RESULTS: Among eighty pediatric patients, the median age was 8 years (range 2-17 years). During the transport, four (5%) patients required endotracheal intubation, three (3.75%) patients required intercostal drain placement, and six (7.5%) patients required cardiopulmonary resuscitation. Accidental removal of central venous catheter was reported in three (3.75%) patients, drain came out in four (5%) patients, and three (3.75%) patients had accidental extubation. Transport indirectly led to a change in antibiotic therapy in 24 (30%) patients and directly helped in change of therapy in the form of interventions in 20 (25%) patients. CONCLUSION: Critically ill children can be transported safely with adequate pretransport preparations, which may help in avoiding major UEs and benefit the patient by change in the therapy.

Complications of tracheal intubation in critically ill pediatric cancer patients.

BACKGROUND AND AIMS: The oncologists are treating cancer more aggressively, leading to increase in number of pediatric admissions to the ICU. Due to anatomical and physiological differences, pediatric patients are at high risk of complications during intubation. We evaluated the incidence of complications during intubations in pediatric patients in our ICU. SUBJECTS AND METHODS: We performed retrospective analysis of complications occurring during intubation in 42 pediatric patients. All intubations were orotracheal. We recorded number of attempts at intubation, need for use of intubation adjuncts and complications during laryngoscopy and intubation. The incidence of difficult intubation, hypoxia, and severe cardiovascular collapse was also noted. RESULTS: Complications occurred during 13 (31%) intubations. Hypoxia and severe cardiovascular collapse occurred in during 7 (16.7%) intubations each, while 4 patients (9.5%) (n=4) had cardiac arrest during intubation. Thirty three (78.6%) intubations were successful in first attempt and difficult intubation was recorded in 4 patients. CONCLUSION: Critically ill pediatric cancer patients have a high rate of complications during intubation.

Complications and benefits of intrahospital transport of adult Intensive Care Unit patients.

BACKGROUND: The transport of critically ill patients for procedures or tests outside the Intensive Care Unit (ICU) is potentially hazardous; hence, the transport process must be organized and efficient. Plenty of data is available on pre- and inter-hospital transport of patients; the data on intrahospital transport of patients are limited. We audited the complications and benefits of intrahospital transport of critically ill patients in our tertiary care center over 6 months. MATERIALS AND METHODS: One hundred and twenty adult critically ill cancer patients transported from the ICU for either diagnostic or therapeutic procedure over 6 months were included. The data collected include the destination, the accompanying person, total time spent outside the ICU, and any adverse events and adverse change in vitals. RESULTS: Among the 120 adult patients, 5 (4.1%) required endotracheal intubation, 5 (4.1%) required intercostal drain placement, and 20 (16.7%) required cardiopulmonary resuscitation (CPR). Dislodgement of central venous catheter occurred in 2 (1.6%) patients, drain came out in 3 (2.5%) patients, orogastric tube came out in 1 (0.8%) patient, 2 (1.6%) patients self-extubated, and in one patient, tracheostomy tube was dislodged. The adverse events were more in patients who spent more than 60 min outside the ICU, particularly requirement of CPR (18 [25%] vs. 2 [4.2%], ≤60 min vs. >60 min, respectively) with P < 0.05. Transport led to change in therapy in 32 (26.7%) patients. CONCLUSION: Transport in critically ill cancer patients is more hazardous and needs adequate pretransport preparations. Transport in spite being hazardous may lead to a beneficial change in therapy in a significant number of patients.