Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study.

PURPOSE: The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65-80 years) and very elderly (> 80 years) intensive care unit (ICU) patients. METHODS: We prospectively described new written orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (NIV) use], and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States). RESULTS: We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission [67 (33.2%) vs. 128 (21.9%); p = 0.002]. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients [4 (2-8) vs. 7 (4-13) days, p = 0.02]. Very elderly and elderly patients had similar rates of direct extubation [39 (19.3%) vs. 113 (19.3%)], direct tracheostomy [10 (5%) vs. 40 (6.8%)], initial SBT [105 (52%) vs. 302 (51.5%)] and initial successful SBT [84 (80%) vs. 245 (81.1%)]. Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality [26 (12.9%) vs. 38 (6.5%)]. Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission. CONCLUSIONS: Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.

Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit.

Deep vein thrombosis (DVT) is a preventable complication of critical illness, and this guideline aims to convey a pragmatic approach to the problem. Guidelines have multiplied over the last decade, and their utility has become increasingly conflicted as the reader interprets all suggestions or recommendations as something that must be followed. The nuances of grade of recommendation vs level of evidence are often ignored, and the difference between a "we suggest" vs a "we recommend" is overlooked. There is a general unease among clinicians that failure to follow the guidelines translates to poor medical practice and legal culpability. We attempt to overcome these limitations by highlighting ambiguity when it occurs and refraining from dogmatic recommendations in the absence of robust evidence. Readers and practitioners may find the lack of specific recommendations unsatisfactory, but we believe that true ambiguity is better than inaccurate certainty. We have attempted to comply with the guidelines on how to create guidelines.1 And to overcome the poor compliance with these guidelines.2 Some observers have expressed concern that DVT prophylaxis guidelines may cause more harm than good.3 We have placed greater emphasis on large randomized controlled trials (RCTs) with clinical end point and de-emphasized RCTs with surrogate end points and also de-emphasized hypothesis generating studies (observational studies, small RCTs, and meta-analysis of these studies). We have de-emphasized RCTs in non-intensive care unit populations like postoperative patients or those with cancer and stroke. We have also considered resource limitation settings and have avoided recommending costly and poorly proven therapeutic options. How to cite this article: Jagiasi BG, Chhallani AA, Dixit SB, Kumar R, Pandit RA, Govil D, et al. Indian Society of Critical Care Medicine Consensus Statement for Prevention of Venous Thromboembolism in the Critical Care Unit. Indian J Crit Care Med 2022;26(S2):S51-S65.

Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study.

BACKGROUND: We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010-2011. METHODS: An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs. RESULTS: On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality. CONCLUSIONS: Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927). HOW TO CITE THIS ARTICLE: Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093-1107.

Ventilator Weaning and Discontinuation Practices for Critically Ill Patients.

Importance: Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice. Objective: To describe practice variation in IMV discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs). Design, Setting, and Participants: Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US). Exposures: Receiving IMV. Main Outcomes and Measures: Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes. Results: Among 1868 patients (median [interquartile range] age, 61.8 [48.9-73.1] years; 1173 [62.8%] men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 [81.8%] successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 [4.7%] vs 96 [10.3%]; absolute difference, 5.6% [95% CI, 2.6%-8.6%]), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days [95% CI, 0.7-1.6]), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days [95% CI, 0.8-2.4]). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 [17.2%] vs 67 [8.8%]; absolute difference, 8.4% [95% CI, 2.0%-14.7%]), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days [95% CI, 1.6-3.6]), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days [95% CI, 1.1-5.2]). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days [95% CI, 3.7-4.5]), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days [95% CI, 4.0-6.3]), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days [95% CI, 6.0-11.0]). Conclusions and Relevance: In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally. Trial Registration: ClinicalTrials.gov Identifier: NCT03955874.

Sepsis: An Evolutionary Perspective (Sepsis through the Eyes of a Microbe vs Clinical Sepsis through the Eyes of an Intensivist).

"Change of gene frequency in population" is the most fundamental concept of evolutionary biology. Human sepsis is a quantitative biological war between microbial genes and human genes, fought through their respective phenotypes. The prize of this war is an increase of gene frequency. Stating that sepsis is caused by a dysregulated host response is missing one half of the septic syndrome. Clinicians may gain a different perspective into the many intricacies of sepsis by conceptualizing it as an adaptive evolutionary process, rather than an abnormal physiological state. Clinicians may also get a deeper perspective by seeing it as a genotypic evolutionary process of natural selection rather than a phenotypic pathophysiological event. How to cite this article: Kapadia FN. Sepsis: An Evolutionary Perspective (Sepsis through the Eyes of a Microbe vs Clinical Sepsis through the Eyes of an Intensivist). Indian J Crit Care Med 2020;24(12):1165-1168.

Variation in the practice of discontinuing mechanical ventilation in critically ill adults: study protocol for an international prospective observational study.

INTRODUCTION: Research supports the use of specific strategies to discontinue mechanical ventilation (MV) in critically ill patients. Little is known about how clinicians actually wean and discontinue MV in practice or the association between different discontinuation strategies and outcomes. The primary objective of this study is to describe international practices in the use of (1) daily screening for readiness to discontinue MV, (2) modes of MV used before initial discontinuation attempts, (3) weaning and spontaneous breathing trial (SBT) protocols, (4) SBT techniques and (5) sedation and mobilisation practices to facilitate weaning and discontinuation. The secondary objectives are to identify patient characteristics and time-dependent factors associated with use of selected strategies, investigate associations between SBT outcome (failure vs success) and outcomes, explore differences between patients who undergo an SBT early versus later in their intensive care unit (ICU) stay, and investigate the associations between different SBT techniques and humidification strategies on outcomes. METHODS AND ANALYSIS: We will conduct an international, prospective, observational study of MV discontinuation practices among critically ill adults who receive invasive MV for at least 24 hours at approximately 150 ICUs in six geographic regions (Canada, USA, UK, Europe, India and Australia/New Zealand). Research personnel at participating ICUs will collect demographic data, data to characterise the initial strategy or event that facilitated discontinuation of MV (direct extubation, direct tracheostomy, initial successful SBT, initial failed SBT or death before any attempt could be made), clinical outcomes and site information. We aim to collect data on at least 10 non-death discontinuation events in each ICU (at least 1500 non-death discontinuation events). ETHICS AND DISSEMINATION: This study received Research Ethics Approval from St. Michael's Hospital (11-024) Research ethics approval will be sought from all participating sites. The results will be disseminated through publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03955874.

International Practice Variation in Weaning Critically Ill Adults from Invasive Mechanical Ventilation.

RATIONALE: Randomized trials and meta-analyses have informed several aspects of weaning. Results are rarely replicated in practice, as evidence is applied in intensive care units that differ from the settings in which it was generated. OBJECTIVES: We aimed to: 1) describe weaning practice variation (identifying weaning candidates, conducting spontaneous breathing trials, using ventilator modes, and other aspects of care during weaning); 2) characterize regional differences in weaning practices; and 3) identify factors associated with practice variation. METHODS: We conducted a cross-sectional, self-administered, international postal survey of adult intensivist members of regional critical care societies from six geographic regions, including Canada, India, the United Kingdom, Europe, Australia/New Zealand, and the United States. We worked with societies to randomly select potential respondents from membership lists and administer questionnaires with the goal of obtaining 200 responses per region. RESULTS: We analyzed 1,144 questionnaires (Canada, 156; India, 136; United Kingdom, 219; Europe, 260; Australia/New Zealand, 196; United States, 177). Across regions, most respondents screened patients once daily to identify spontaneous breathing trials candidates (regional range, 70.0%-95.6%) and less often screened twice daily (range, 12.2%-33.1%) or more than twice daily (range, 1.6%-18.2%). To wean patients, most respondents used pressure support alone (range, 31.0%-71.7%) or with spontaneous breathing trials (range, 35.7%-68.1%). To conduct spontaneous breathing trials, respondents predominantly used pressure support with positive end-expiratory pressure (range, 56.5%-72.3%) and T-piece (8.9%-59.5%). Across regions, we found important variation in screening frequency, spontaneous breathing trials techniques; ventilator modes, written directives to guide care, noninvasive ventilation; and the roles played by available personnel in various aspects of weaning. CONCLUSIONS: Our findings document the presence and extent of practice variation in ventilator weaning on an international scale, and highlight the multidisciplinary and collaborative nature of weaning.

Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study.

AIMS: To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). PATIENTS AND METHODS: An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. RESULTS: On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. CONCLUSIONS: The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.

A prolonged observational study of tracheal tube displacements: Benchmarking an incidence <0.5-1% in a medical-surgical adult intensive care unit.

BACKGROUND AND AIMS: Tracheal tubes are commonly used in intensive care unit (ICU) and lead to complications like displacements. The primary aim of the study was to evaluate if the rate of tracheal tube displacement benchmarked at <1% per patient and <0.5% per tracheal tube day, could be sustained over a prolonged period. The secondary aim was to document the patterns of all forms airway accident and to evaluate their consequences. SUBJECTS AND METHODS: This was a prospective observational study of Intubated and ventilated patients in a General Medical-Surgical Adult ICU. The incidence of accidental extubation, self extubation, partial displacement and blockages of tracheal tubes were recorded. RESULTS: The overall tracheal tube displacement rate was 61/10,112 (0.6%) per patient and 61/28,464 (0.22%) per tracheal tube day. There were 30 additional incidents of blockage, kinking or biting of the tracheal tube. Physiological consequences-69 were mild, 10 moderate, 12 major and one death. Of the 91 accidents, 30 were partly and 30 were completely preventable. 76 incidents involved an endotracheal tube (54 displaced, 12 blocked and 10 bitten-kinked) and 15 a tracheostomy tube (seven displaced and eight blocked). Accidents were more common in medical than surgical patients (medical = 48, cardiac surgical = 17 and other surgical/trauma = 26). CONCLUSION: Tracheal tube displacement rate in a mixed medical-surgical adult ICU was maintained below the pre-set benchmark of <1% per patient and <0.5% per intubated day over nearly a decade.

Cerebral hyperperfusion syndrome after endovascular reconstruction of carotid artery in high-flow carotid-jugular fistula.

We describe the occurrence of cerebral hyperperfusion syndrome (CHS) in a case of long-standing carotid-jugular fistula (CJF) treated by endovascular reconstruction of the carotid artery. A 43-year-old male with a high-flow CJF between the internal carotid artery (ICA) and internal jugular vein underwent endovascular reconstruction of the carotid artery using a stent graft. After treatment, the patient developed CHS. The patient succumbed to a large intracranial bleed in the left external capsule and parietal lobe on the fifth postoperative day. CHS following endovascular reconstruction of carotid artery is rare. We present the first reported case of CHS following endovascular reconstruction of ICA. A review of literature for patients treated by endovascular rerouting of blood flow to the cerebral parenchyma associated with hyperperfusion syndrome has been performed.

Cerebral and spinal air embolism following percutaneous nephrolithotomy.

We present a case report of cerebral and spinal air embolism following percutaneous nephrolithotomy in a patient without evidence of intra-cardiac defects or prepulmonary A-V shunts. The position of the patient during the incidence determined the site of eventual lodgement of air emboli in the arterial circulation. We suspect that the time of onset of symptoms following the procedure may be the clue to the path followed by air emboli.

Prospective comparison of eubacterial PCR and measurement of procalcitonin levels with blood culture for diagnosing septicemia in intensive care unit patients.

Rapid identification of infection has a major impact on the clinical course, management, and outcome of critically ill intensive care unit (ICU) patients. We compared the results of PCR and procalcitonin with blood culture for ICU patients suspected of having septicemia. Ninety patients (60 patients meeting the criteria for sepsis and 30 patients not meeting the criteria for sepsis) were evaluated. Compared with blood culture as the gold standard, the sensitivity, specificity, and positive and negative predictive values for PCR were 100%, 43.33%, 46.87%, and 100%, respectively, and for procalcitonin were 100%, 61.66%, 56.6%, and 100%, respectively. The average times required to produce a final result were as follows: PCR, 10 h; blood culture, 33 h; procalcitonin, 45 min. Both PCR and procalcitonin may be useful as rapid tests for detecting septicemia but compared with blood cultures lacked specificity.

Effects of mobile phone use on specific intensive care unit devices.

BACKGROUND AND AIMS: To observe the effects of mobile phone use in the vicinity of medical devices used in a critical care setting. SUBJECTS AND METHODS: Electromagnetic interference (EMI) was tested by using two types of mobile phones - GSM and CDMA. Mobile phones were placed at a distance of one foot from three medical devices - syringe pump, mechanical ventilator, and the bedside monitor - in switch off, standby, and talking modes of the phone. Medical devices were observed for any interference caused by the electromagnetic radiations (EMR) from the mobile phones. RESULTS: Out of the three medical devices that were tested, EMI occurred while using the mobile phone in the vicinity of the syringe pump, in the 'talk mode.' The mean variation observed in the calculated and delivered volume of the syringe pump was 2.66 ml. Mechanical ventilator did not show any specific adverse effects with mobile phone use in the one-foot vicinity. No other adverse effects or unexplained malfunctions or shutdown of the syringe pump, mechanical ventilator, or the bedside monitor was noted during the study period of 36 hours. CONCLUSION: EMI from mobile phones have an adverse effect on the medical devices used in critical care setup. They should be used at least one foot away from the diameter of the syringe pump.

An improved method of elimination of DNA from PCR reagents.

OBJECTIVE: The presence of exogenous DNA in commercially available polymerase chain reaction (PCR) reagent preparations is a serious problem when amplifying conserved regions of bacteria. The preferred and currently in-use method of decontamination using 8-methoxypsoralen (8-MOP) and UVA requires re-standardization of decontamination with increasing concentrations of 8-MOP and UVA irradiation timings, if the DNA load of reagents is high due to lot-to-lot differences. The objective of this study was to develop a decontamination method, which would (i) work at the minimum reported concentration of 8-MOP and UVA irridation timings; and (ii) take care of inter-batch DNA-load variability of reagents. MATERIALS AND METHODS: The improved method described here was formulated after studying the exact molecular mechanism of action of 8-MOP with DNA. The successful working of the method was experimentally proven and validated with 6-7 new batches of PCR reagents. The sensitivity of eubacterial PCR, after using the new method of decontamination, to be used clinically was checked with both the spiked specimens and the actual clinical specimens. RESULTS AND DISCUSSION: The new method was found to work at the same starting parameters of 8-MOP and UVA in such situations. The increased efficiency of this method was found to be due to the synergistic effect of both the selective treatment of Taq DNA polymerase and the split-irradiation approach.

Special issues in the patient with renal failure.

Renal failure commonly occurs in an ICU as part of the evolution of an underlying disease process. Appropriate and rapid resuscitation and treatment prevents or reverses prerenal insults. Patients usually make a complete recovery if the disease process is reversible and the renal injury mild or moderate. More severe degrees of renal injury initially require conservative management with attention to maintaining a diuresis, preventing fluid, electrolyte, and acid-base imbalances, and ensuring adequate nutrition. Renal replacement therapy is required for the more severe forms of renal failure. Continuous forms of RRT are gaining favor as they are associated with less hemodynamic instability, though current evidence does not demonstrate any clear outcome benefit. Mortality is high when the severe form of ARF is established. ARF may have some attributable mortality, but the poor outcome is usually related more to the underlying medical problems and concurrent multisystem derangements.