Background: Glasgow coma scale (GCS) score is the most widely used clinical score for the initial assessment of neurologically injured patients and is also frequently used for prognostication. Other scores such as the Full Outline of UnResponsivness (FOUR) score and the Glasgow Coma Scale-Pupils (GCS-P) score have been more recently developed and are gaining popularity. This prospective cohort study was conducted to compare various scores in terms of their ability to predict outcomes at 3 months in patients with traumatic brain injury (TBI). Materials and methods: The study was carried out between October 2020 and March 2022. Patients who presented to the hospital with TBI were assessed for inclusion. Initial coma scores were assessed in the emergency department and again after 48 hours of admission. Outcome was assessed using the extended Glasgow outcome score (GOSE) at 3 months after injury. The receiver operating curve (ROC) was plotted to correlate coma scores with the outcome, and the area under the curve (AUC) was compared. Results: A total of 355 patients with TBI were assessed for eligibility, of which 204 patients were included in the study. The AUC values to predict poor outcomes for initial GCS, FOUR, and GCS-P scores were 0.75 each. The AUC values for 48-hour coma scores were 0.88, 0.87, and 0.88, respectively. Conclusion: The GCS, FOUR, and GCS-P scores were found to be comparable in predicting the functional outcome at 3 months as assessed by GOSE. However, coma scores assessed at 48 hours were better predictors of poor outcomes at 3 months than coma scores recorded initially at the time of hospital admission. How to cite this article: Chawnchhim AL, Mahajan C, Kapoor I, Sinha TP, Prabhakar H, Chaturvedi A. Comparison of Glasgow Coma Scale Full Outline of UnResponsiveness and Glasgow Coma Scale: Pupils Score for Predicting Outcome in Patients with Traumatic Brain Injury. Indian J Crit Care Med 2024;28(3):256-264.
How to cite this article: Kapoor I, Prabhakar H. Can Bispectral Index be a Point-of-care Monitor for Sleep Quality Assessment in Critically Ill Patients? Indian J Crit Care Med 2023;27(11):782-783.
BACKGROUND: The limited representation from developing countries in the original COME TOGETHER survey gave us an impetus to conduct this survey in the Indian subcontinent. METHODS: This cross-sectional online survey was conducted from August through September 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness. Fischer's exact test or the Mann-Whitney U-test was used to compare respondents who agreed or disagreed with the preestablished coma definition. Fleiss κ values were calculated to assess agreement among respondents. A p value less than 0.05 was considered statistically significant. RESULTS: The survey was completed by 130 physicians. We found substantial interrater agreement on absence of wakefulness (71.54%; κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%; κ = 0.78), and failure to respond purposefully to visual, verbal, or tactile stimuli (66.15%; κ = 0.66). Reported common etiologies of coma included traumatic brain injury (50.76%), ischemic stroke (30%), and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included the Glasgow Coma Score (92.3%) and neurological examination (60.8%). Neurological examination was the most common diagnostic tool used (100%), followed by magnetic resonance imaging (89.2%), basic laboratory studies (88.5%), and head computed tomography/angiography (86.9%). Pharmacological interventions used to stimulate arousal in patients with coma were sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the nonpharmacological interventions, sensory stimulation (57.7%) was the most commonly used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). CONCLUSIONS: Differences from the global survey were noted regarding the following: traumatic brain injury being the most common etiology of coma in India, more frequent practice of sedation interruption, less frequent use of electroencephalography in India, rare use of pharmacological neurostimulants, and home being the most common discharge disposition in India.
How to cite this article: Singhal V, Prabhakar H. Readiness of the Stroke Treatment in India: Still an Uphill Task! Indian J Crit Care Med 2023;27(9):607-608.
OBJECTIVES: Glasgow Coma Scale-Pupils (GCS-P) score has been found to be strongly related to in-hospital mortality in retrospective studies. We hypothesized that GCS-P would be better prognosticator than Glasgow Coma Scale (GCS) in patients with traumatic brain injury (TBI). METHODS: In this prospective, multicentric, observational study, GCS and GCS-P scores were noted in adult TBI patients at ICU admission. Demographic variables, relevant clinical history, clinical/radiological findings and ICU complications were also noted. Extended Glasgow Outcome scale was noted at hospital discharge and at 6 months post-injury. Logistic regression analysis was carried out to estimate the odds for poor outcome adjusted for covariates. Sensitivity, specificity, area under curve (AUC) and odds ratio are reported for poor outcome at estimated cutoff point. RESULTS: A total of 573 patients were included in this study. The predictive power for mortality, shown by the AUC, was 0.81 [95% CI: 0.77-0.85] for GCS and 0.81 [95% CI: 0.77-0.86] for GCS-P score, both being comparable. Similarly, the predictive ability for outcome at discharge and 6 months, the AUC-ROC for both GCS and GCS-P were comparable. CONCLUSIONS: GCS-P is a good predictor of mortality and poor outcome. However, the predictive performance of GCS and GCS-P for in-hospital mortality and functional outcome at discharge and at 6 months remains comparable.
Brain Injuries, Traumatic , Adult , Humans , Prospective Studies , Retrospective Studies , Brain Injuries, Traumatic/complications , Prognosis , Glasgow Coma Scale
How to cite this article: Prabhakar H. Augmenting Hypertensive Therapy in Patients with Postoperative Subarachnoid Hemorrhage: What's the Right Choice? Indian J Crit Care Med 2023;27(4):233-234.
Background: End-of-life (EOL) care is the care of terminally ill patients who are nearing their end. It includes important components like palliative care, supportive care, hospice care, patient's right to choose, and choice of medical intervention, including continuation of routine medical interventions. The aim of this survey was to assess the practices of EOL care in various critical care units in India. Methods: The participants included clinicians involved in EOL care of patients with advanced diseases in different hospital across India. We sent blast emails and posted links on social media for inviting participants to take the survey. Study data were collected and managed by using Google Forms. The collected information was automatically entered into a spread sheet and stored in a secure database. Results: In total, 91 clinicians took the survey. The years of experience, practice area, and setting had significant effect on the palliative care, terminal strategy, and prognostication in terminally ill patients (p < 0.05). Statistical analysis was done using software STATA. Descriptive statistics were performed, and results were presented as number (percentage). Conclusion: The years of work experience, the practice area, and the practice setting have a strong impact on EOL care management of terminally ill patients. There are a lot of gaps in providing EOL care for these patients. Many reforms are needed in the Indian health care system to make EOL care better. How to cite this article: Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, et al. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023;27(5):305-314.
Background: The Curing Coma Campaign (CCC) was launched by the Neurocritical Care Society (NCS) in 2019, with the purpose to bring together a diverse group of coma scientists, neurointensivists, and neurorehabilitationists. Methods: The aim of this campaign is to move beyond the limitations imposed by current definitions of coma and identify mechanisms to improve prognostication, identify test therapies, and impact outcomes. At the moment, whole approach of the CCC appears ambitiously challenging. Results: This could be true only for the Western world, such as the North America, Europe, and few developed countries. However, the whole concept of CCC may face potential challenges in the lower-middle income countries. India has several stumbling blocks that need to and can be addressed in the future, for a meaningful outcome, as envisaged in the CCC. Conclusion: India has several potential challenges, which we aim to discuss in this article. How to cite this article: Kapoor I, Mahajan C, Zirpe KG, Samavedam S, Sahoo TK, Sapra H, et al. The Curing Coma Campaign®: Concerns in the Indian Subcontinent. Indian J Crit Care Med 2023;27(2):89-92.
Background: Midline shift (MLS) of the brain is an important clinical finding diagnosed on computed tomography (CT) imaging and transcranial sonography (TCS) can help diagnose MLS at the bedside and facilitate interventions to improve outcomes. The study aimed to find an association between TCS- and CT-based assessments of MLS in patients with traumatic brain injury (TBI). Patients and methods: We included all adult patients with moderate-to-severe TBI of either gender, aged between 18 and 65 years, undergoing intracranial surgery under general anesthesia over a period of 3 months. Consciousness was assessed with the help of the Glasgow coma scale (GCS) and Glasgow coma scale-pupillary (GCS-P) score. We calculated MLS using a CT scan and TCS. Bland Altman graph along with Pearson's and Spearman's coefficient tests was used. Results: A total of 17 patients were analyzed in this study. The MLS was 0.52 ± 0.90 cm using TCS and 0.58 ± 0.39 cm using CT scan. The Pearson's correlation coefficient (r 2) of the difference between MLS measured by TCS and CT imaging was 0.002 (p < 0.05). Conclusion: Transcranial sonography could detect MLS in patients with TBI, provided a minimum time window is used between MLS measurements by TCS and CT scan. How to cite this article: Kapoor I, Pandit S, Prabhakar H, Mahajan C. Comparison between Transcranial Sonography and Computerized Tomography Scans to Assess the Midline Shift in Patients with Traumatic Brain Injury. Indian J Crit Care Med 2023;27(1):64-66.
Background: Multidrug-resistant (MDR) organisms in the critical care unit are a worldwide concern. The vulnerability to MDR infection in pediatric patients admitted in neurocritical care are due to altered mental status, immature immune system, higher risk of aspiration, and more frequent use of invasive devices. We aimed to measure the burden of MDR infection in pediatric neurosurgical intensive care unit (NSICU) patients. Methods: All pediatric patients between 1 and 18 years for intracranial and spine surgeries admitted for more than 48 hours in NSICU were enrolled in the study. If patients showed a clinical picture of pneumonia, bloodstream infection (BSI), or urinary tract infection (UTI) after receiving mechanical ventilation or an indwelling device for at least 48 hours, samples of tracheal aspirates, urine, blood, and cerebrospinal fluid (CSF) were sent for microbiological culture. We noted the type of organism, MDR infection rate, and associated risk factors. Pearson Chi-squared test and Fisher's test were used for statistical analysis; p < 0.05 was considered statistically significant. Results: A total of 274 pediatric patients were studied. In 1 year, there was a total of 1,790 patient days. The inclusive MDR infection rate was 17.3/1,000 patient days. Also, Klebsiella pneumoniae (38.7%) was the commonest MDR pathogen. The commonest source of infection was BSI (32.3%). The risk factors associated with MDR infections were the length of stay in NSICU, mechanical ventilation of more than 5 days, emergency surgery, respiratory and cardiac comorbidities, and poor nutrition status (p < 0.05). Conclusion: The MDR infection rate in our study was 17.3/1,000 patient days in pediatric patients. Also, K. pneumonia e was found to be the commonest MDR pathogen. Bloodstream was the commonest source of infection. How to cite this article: Patel S, Prabhakar H, Kapoor I. Rate of Multidrug-resistance to Antimicrobial Drugs in Patients in Pediatric Neurointensive Care. Indian J Crit Care Med 2023;27(1):67-72.
Traumatic brain injury (TBI) incurs substantial health and economic burden, as it is the leading reason for death and disability globally. Endocrine abnormalities are no longer considered a rare complication of TBI. The reported prevalence is variable across studies, depending on the time frame of injury, time and type of testing, and variability in hormonal values considered normal across different studies. The present review reports evidence on the endocrine dysfunction that can occur after TBI. Several aspects, including the pathophysiological mechanisms, clinical consequences/challenges (in the acute and chronic phases), screening and diagnostic workup, principles of therapeutic management, and insights on future directions/research agenda, are presented. The management of hypopituitarism following TBI involves hormonal replacement therapy. It is essential for health care providers to be aware of this complication because at times, symptoms may be subtle and may be mistaken to be caused by brain injury itself. There is a need for stronger evidence for establishing recommendations for optimum management so that they can be incorporated as standard of care in TBI management.
Brain Injuries, Traumatic , Brain Injuries , Hypopituitarism , Humans , Brain Injuries, Traumatic/complications , Brain Injuries, Traumatic/therapy , Hypopituitarism/diagnosis , Hypopituitarism/etiology , Hypopituitarism/therapy , Brain Injuries/complications , Brain Injuries/therapy , Brain Injuries/epidemiology , Syndrome
BACKGROUND: Preclinical studies have reported significant changes in the gut microbiome after traumatic brain injury (TBI). We hypothesized that TBI induces the growth of Proteobacteria in the human gut. Our primary outcome was to study the profile of the human fecal microbiome after TBI and the secondary outcome was to identify colonization with colistin-resistant and multidrug-resistant pathogens. METHODS: Consecutive patients with moderate-severe TBI admitted to the neurotrauma-intensive care unit within 48 hours of injury were enrolled into this observational study. Samples from rectal swabs obtained on days 0, 3, and 7 after admission were assessed for microbial growth and antibiotic resistance. Demographic data and variables such as hypotension, blood transfusion, surgery, start of nasogastric feeding, use of antibiotics, length of hospital stay and mortality were noted. RESULTS: One hundred one patients were enrolled into this study; 57 (56.4%) underwent surgery, 80 (79.2%) required blood transfusion, 15 (14.9%) had an episode of hypotension, 37 (36.6%) received enteral feed within the first 3 days, and 79 (78.2%) received antibiotics. Rectal microbiological samples were collected from 101, 95, and 85 patients on days 0, 3, and 7, respectively. All organisms isolated at the 3 time-points belonged to the Proteobacteria phylum, with Enterobacteriaceae forming the largest group. Colistin-resistant organisms were found in 17 (16.8%) of 101 patients and multidrug-resistant organisms in 25 (64.1%) of the 39 patients in whom isolates were tested against the entire panel of antimicrobials. CONCLUSION: TBI is associated with widespread colonization with Proteobacteria as early as 48 hours after injury. Colonization with colistin and multidrug-resistant organisms highlights the importance of the judicious use of antibiotics.
Brain Injuries, Traumatic , Gastrointestinal Microbiome , Hypotension , Humans , Colistin , Anti-Bacterial Agents/therapeutic use
