Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India.

Background: Noninvasive ventilation (NIV) is an established first-line treatment of acute respiratory failure both in emergency departments (ED) and intensive care unit (ICU) settings. It is however not always successful. Materials and methods: Prospective, observational study was done among patients above 18 years presenting with acute respiratory failure initiated on NIV. Patients were placed in one of two groups covering successful NIV treatment and NIV failure. Two groups were compared on four variables: initial respiratory rate (RR), initial high-sensitivity C-reactive protein (hs-CRP), PaO2/FiO2 ratio (p/f ratio), and heart rate, acidosis, consciousness, oxygenation, and respiratory rate (HACOR) score at the end of 1 hour of initiation of NIV. Results: A total of 104 patients fulfilling the inclusion criteria were included in the study, of which 55 (52.88%) were exclusively treated with NIV (NIV success group), and 49 (47.11%) required endotracheal intubation and mechanical ventilation (NIV failure group). Noninvasive ventilation failure group had a higher mean initial RR compared with NIV success group (40.65 ± 3.88 vs 31.98 ± 3.15, p <0.001). Mean initial PaO2/FiO2 ratio was also significantly lower in the NIV failure group (184.57 ± 50.33 vs 277.29 ± 34.70, p <0.001). Odds ratio for successful NIV treatment with a high initial RR was 0.503 (95% confidence interval (CI), 0.390-0.649) and with a higher initial PaO2/FiO2 ratio was 1.053 (95% CI: 1.032-1.071 and with a HACOR score of >5 at the end of 1 hour of initiation of NIV was highly associated with NIV failure (p <0.001). A high initial level of hs-CRP was 0.949 (95% CI: 0.927-0.970). Conclusion: Noninvasive ventilation failure could be predicted with information available at presentation in ED, and unnecessary delay in endotracheal intubation could possibly be prevented. How to cite this article: Mathen PG, Kumar KPG, Mohan N, Sreekrishnan TP, Nair SB, Krishnan AK, et al. Prediction of Noninvasive Ventilation Failure in a Mixed Population Visiting the Emergency Department in a Tertiary Care Center in India. Indian J Crit Care Med 2022;26(10):1115-1119.

The bane of coastal marine environment: A fatal case of Vibrio vulnificus associated cellulitis and septicaemia.

Vibrio vulnificus is a Gram negative motile bacterium known to cause fatal septicaemia and wound infection. It is commonly associated with the consumption of under-cooked seafood or exposure to marine environment. We report a case of a 55 year old male patient, who was presented with right lower limb cellulitis and septicaemia due to V. vulnificus. V. vulnificus infection in India are rare. However, increasing reports of V. vulnificus from India recommends considering the pathogen while dealing necrotising fasciitis especially in the proximity of marine environment.

Initial choice of antibiotic in recurrent spontaneous bacterial peritonitis: A retrospective study.

CONTEXT: Spontaneous bacterial peritonitis (SBP) is a commonly encountered infection seen in the setting of ascites secondary to advanced liver disease. Recurrence of SBP is common and is associated with high mortality. This study was designed to recognize a better initial choice of antibiotic in case of recurrent SBP - a third-generation cephalosporin or a carbapenem. AIMS: This study aims to determine a better initial choice of antibiotic in case of recurrent SBP and to compare the all-cause mortality among two different groups of patients treated with a third-generation cephalosporin and a carbapenem. SETTINGS AND DESIGN: This study was conducted among fifty patients presenting with recurrent SBP visiting the emergency department (ED) at a tertiary care center and who were subsequently admitted in a gastroenterology intensive care unit, during a period of 1 year. SUBJECTS AND METHODS: This is a retrospective, observational study conducted among patients with chronic liver disease and diagnosed with recurrent SBP visiting the ED at a tertiary care center in South India treated with either of two classes of antibiotics - third-generation cephalosporins or carbapenems, and their outcomes were compared. Recurrence is defined as an episode of SBP after resolution of the first index case of SBP within 1 year. STATISTICAL ANALYSIS USED: Statistical analysis was done using IBM SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were represented as percentages, and all continuous variables were represented as mean ± standard deviation. To test the statistical significance of the association of categorical variables with the outcome, Chi-square test was used. P <0.05 was considered statistically significant. RESULTS: A total of fifty patients with recurrent SBP were included in the study, of which 44 (88%) patients were male and 6 patients were female (12%). Twenty-nine (58%) patients survived and 21 (42%) patients expired within 28 days. Twenty-seven (54%) patients were treated with third-generation cephalosporins and 23 (46%) were treated with carbapenems. It was observed that mortality was statistically significantly lower among patients treated with carbapenem (P = 0.001). The incidence of acute kidney injury was also lower among patients treated with a carbapenem than patients treated with a third-generation cephalosporin (40.7% vs. 59.25%, respectively). CONCLUSIONS: Initiation of a carbapenem significantly reduced the all-cause mortality when compared to a third-generation cephalosporin as an initial antibiotic of choice in recurrent SBP.

The Eminence of Neutrophil-lymphocyte Count Ratio in Predicting Bacteremia for Community-acquired Infections at an Emergency Medicine Department in a Tertiary Care Setting.

INTRODUCTION: The changes in the white blood cells counts and other blood parameters are well-recognized feature in sepsis. A ratio between neutrophils and lymphocytes can be used as a screening marker in sepsis. Even though new markers such as Procalcitonin and adrenomedullin have been rolled out in the field, implementation of these markers has been hindered by cost, accessibility, and proper validation. We looked for the ability of simple neutrophil-lymphocyte count ratio (NLCR) when compared to the gold standard blood culture method in predicting bacteremia, on patients presented to emergency department (ED) with features of suspected community-acquired infections. MATERIALS AND METHODS: A comparative study done on 258 adult patients, admitted with suspected features of community-acquired infections. The study group included all patients who had positive blood culture results on index presentation at ED. Patients with hematological, chronic liver and retroviral diseases, patients receiving chemotherapy, and steroid medications were excluded from the study. The study group was compared with gender- and age-matched control group who were also admitted with a suspicion of the same, but in whom the blood culture results were negative. RESULTS: There was no statistically significant difference for predicting bacteremia by NLCR (>4.63) and culture positivity methods (P = 1.00). NLCR of > 4.63 predicts bacteremia with an accuracy of 84.9%. CONCLUSION: In our setting, NLCR performs equally well with culture positivity, in detecting severe infection at the early phase of disease. The NLCR may, therefore, be used as a suitable screening marker at ED for suspected community-acquired infections.

Electrocardiogram-guided Technique: An Alternative Method for Confirming Central Venous Catheter Tip Placement.

BACKGROUND: The current standard followed for assessing central venous catheter (CVC) tip placement location is through radiological confirmation using chest X-ray (CXR). Placement of CVCs under electrocardiogram (ECG) guidance may save cost and time compared to CXR. OBJECTIVE: The objective of this study is to compare the accurate placement of the CVC tip using anatomical landmark technique with ECG-guided technique. Another objective is to compare CVC placement time and postprocedural complications between the two techniques. METHODS AND MATERIALS: A total of 144 adult individuals, who were critically ill and required CVC placement in the Emergency Department, were included for the study. Study duration was 6 months. Anatomical landmark and ECG-guided groups were assigned 72 participants each. Analyses were performed using t and Chi square-tests. RESULTS: It was observed that 13 (18%) in the landmark technique were malpositioned as compared to none in the ECG-guided technique (P = 0.000). The landmark group had 22 (30.6%) participants with arrhythmias during the procedure, compared to none in the ECG-guided group (P = 0.000). The landmark group revealed that 30 (41.7%) of the CVC were overinserted and required immediate repositioning, compared to none in the ECG-guided group (P = 0.000). CONCLUSION: ECG-guided technique was found to be more accurate for CVC tip placement than the anatomical landmark technique. Furthermore, the ECG-guided technique was more time-effective and had less complications than the anatomical landmark technique. Hence, ECG-guided CVC placement is relatively accurate, efficient, and safe and can be considered as an alternative method to conventional radiography for confirmation of CVC tip placement.

Camphor Poisoning: A Rare Cause of Acute Symptomatic Seizures in Children.

Camphor is a toxic compound easily available over the counter, which can cause fatal seizures in children when ingested. It is available in several forms and is commonly used in Indian households, especially for religious rituals and for its cough-suppressive and nasal-decongestant effect. The toxic effect remains unknown in most homes. Seizures are usually well controlled with intravenous benzodiazepines, and recurrences of seizures are rarely reported.

A Case Report on Pregabalin-Induced Eosinophilia.

This is a case report on a 77-year-old diabetic patient with peripheral neuropathy and paresthesias in his feet, for which he was treated with pregabalin. During the therapy, his eosinophil level was high (60.3%). Pregabalin was stopped, and after one month his differential eosinophil had dropped dramatically, to 7.3%. Based on the Naranjo Adverse Drug Reaction scale, it is probable that the eosinophilia was induced by pregabalin, as the Naranjo probability score was calculated to be 8. BACKGROUND: Pregabalin, a structural derivative of the inhibitory neurotransmitter gamma amino butyric acid, has antiepileptic, analgesic, and anxiolytic properties; therefore, it is used for painful diabetic neuropathy, postherpetic neuralgia, fibromyalgia, and neuropathic pain associated with spinal-cord injury and as adjunctive therapy in refractory partial seizures. The common adverse side effects include somnolence, weight gain, dizziness, peripheral edema, abnormal constipation, thirst, and blurring of vision. CASE REPORT: This is a case report on a 77-year-old diabetic patient with peripheral neuropathy and paresthesias in his feet (with a nocturnal preponderance), for which he was treated with pregabalin. During the pregabalin therapy, his eosinophil level was high (60.3%). Pregabalin was stopped, and after one month his differential eosinophil had dropped dramatically, to 7.3%. Based on the Naranjo Adverse Drug Reaction scale, it is probable that the eosinophilia was induced by pregabalin, as the Naranjo probability score was calculated to be 8. CONCLUSION: The incidence of eosinophilia attributable to pregabalin is very rare and warranted discontinuation of the drug.

Managing hypophosphatemia in critically ill patients: a report on an under-diagnosed electrolyte anomaly.

WHAT IS KNOWN AND OBJECTIVE: Correction of acute hypophosphatemia leaves no long-term complications, but failure to recognize and treat an acute situation can be fatal. CASE SUMMARY: A 65-year-old female presented to the Emergency department with complaints of abdominal pain, multiple episodes of watery stools and vomiting for 3 days. On the 3rd day, she developed abdominal distension and breathlessness and was referred to this hospital for further management and finally diagnosed with hypophosphatemia. WHAT IS NEW AND CONCLUSION: As hypophosphatemia is often underestimated, this case report emphasizes the importance of correcting hypophosphatemia in all critically ill patients.