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BACKGROUND: India, along with the rest of the world, faced the challenging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The second wave in India lagged behind that in the Western world, due to different timing of seasons. There is scarce data about the differences between the two waves, for intensive care unit (ICU) patients. We present the data of 3,498 patients from 9 ICUs of western Maharashtra. MATERIALS AND METHODS: We collected prospective data of hospitalized, RT-PCR confirmed, coronavirus-2019 (COVID-19) patients, from nine tertiary centers, after institutional ethics committee (IEC) approval. Then, we segregated and analyzed the data of patients admitted to the ICU, for comorbidities, high-resolution computed tomography (HRCT) score, ventilatory support, etc. The primary outcomes were ICU and hospital mortality. We also performed multivariable analysis for predictors of ICU mortality. RESULTS: Overall, there were 3,498 ICU patients. In the first wave, 1,921 patients needed ICU admission, while in the second wave, 1,577 patients. Patients in the second wave had significantly higher ICU (26.1 vs 13.4%, p <0.001) and hospital mortality (29.9 vs 18.2%, p <0.001) and need for ventilatory support of any type. More patients received steroids during the second wave. On multivariable regression, male gender, ICU admission during the second wave, increasing HRCT score, and need for intubation and mechanical ventilation were significant predictors of ICU mortality. CONCLUSION: ICU patients admitted during the two waves were of the similar age, but there were more females, and more patients had comorbidities during the second wave. The ICU and hospital mortality were significantly higher during the second wave. HOW TO CITE THIS ARTICLE: Zirpe KG, Dixit S, Kulkarni AP, Pandit RA, Ranganathan P, Prasad S, et al. The Second- vs First-wave COVID-19: More of the Same or a Lot Worse? A Comparison of Mortality between the Two Waves in Patients Admitted to Intensive Care Units in Nine Hospitals in Western Maharashtra. Indian J Crit Care Med 2021; 25(12):1343-1348.
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Dengue-related mortality has significantly reduced with early and appropriate fluid resuscitation. However, we continue to see dengue-related fatalities in patients despite early intervention and advanced critical care support. This was a retrospective study conducted at a tertiary care private hospital in Mumbai, India. All patients dying of dengue in the calendar year 2017 were studied. Details related to age, gender, condition at presentation, laboratory parameters, treatment administered, and time to death were abstracted from case records. A total of 575 patients with a diagnosis of dengue were admitted to the hospital in 2017, of which 15 died (mortality rate 2.6%). Four patients died in the emergency medical unit; 11 patients who died after admission to the inpatient unit had multi-organ dysfunction at the time of presentation, with shock, severe liver dysfunction, and severe metabolic acidosis. Only 4/11 patients had hemoconcentration, and 10/11 patients had high white cell counts. In five patients where serum ferritin was performed, it was more than 40,000 ng/mL. Death occurred at a median time of 2 days after hospitalization despite good supportive care. Although there is scope for improvement of supportive care in these patients, it appears that other interventions are urgently needed to improve outcomes in severe dengue. This calls for more research into the immunopathology of dengue, evaluation of anti-inflammatory drugs, intravenous immunoglobulins, antivirals, and improved vaccines.
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Dengue/diagnóstico , Dengue Grave/diagnóstico , Adolescente , Adulto , Anciano , Niño , Preescolar , Cuidados Críticos , Dengue/inmunología , Dengue/terapia , Dengue/virología , Femenino , Fluidoterapia , Hospitalización , Hospitales Privados , Humanos , India , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Dengue Grave/inmunología , Dengue Grave/terapia , Dengue Grave/virología , Atención Terciaria de Salud , Adulto JovenRESUMEN
Metastatic spinal cord compression is a devastating complication of cancer. Patients may often require high doses of opioids that may cause side effects, myoclonus being one such. A 63-year-old male suffering from malignant spinal cord compression was admitted to our institution. The primary team managed him conservatively with pharmacotherapy with no relief of pain, and he experienced myoclonus and sedation as adverse effects. A continuous cervical epidural catheter with local anesthetic infusion was inserted for 5 days to control his pain. This relieved his pain, which was sustained even after we removed the epidural catheter on day 5, for up to 64 days until the time of his death. Continuous cervical epidural local anesthetic infusions may help with refractory pain by deafferentation of noxious stimuli. Central neuraxial blocks may be a valuable rescue in selected patients.
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BACKGROUND: Surgical site infections are a threat to patient safety. However, in India, data on their rates stratified by surgical procedure are not available. METHODS: From January 2005 to December 2011, the International Nosocomial Infection Control Consortium (INICC) conducted a cohort prospective surveillance study on surgical site infections in 10 hospitals in 6 Indian cities. CDC National Healthcare Safety Network (CDC-NHSN) methods were applied and surgical procedures were classified into 11 types, according to the ninth edition of the International Classification of Diseases. RESULTS: We documented 1189 surgical site infections, associated with 28 340 surgical procedures (4.2%; 95% CI: 4.0-4.4). Surgical site infections rates were compared with INICC and CDC-NHSN reports, respectively: 4.3% for coronary bypass with chest and donor incision (4.5% vs 2.9%); 8.3% for breast surgery (1.7% vs 2.3%); 6.5% for cardiac surgery (5.6% vs 1.3%); 6.0% for exploratory abdominal surgery (4.1% vs 2.0%), among others. CONCLUSIONS: In most types of surgical procedures, surgical site infections rates were higher than those reported by the CDC-NHSN, but similar to INICC. This study is an important advancement towards the knowledge of surgical site infections epidemiology in the participating Indian hospitals that will allow us to introduce targeted interventions.
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Infección Hospitalaria/epidemiología , Hospitales , Infección de la Herida Quirúrgica/epidemiología , Población Urbana , Femenino , Humanos , India/epidemiología , Control de Infecciones , Estudios ProspectivosRESUMEN
OBJECTIVE: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach on central line-associated bloodstream infection (CLABSI) rates in eight cities of India. METHODS: This was a prospective, before-and-after cohort study of 35650 patients hospitalized in 16 adult intensive care units of 11 hospitals. During the baseline period, outcome surveillance of CLABSI was performed, applying the definitions of the CDC/NHSN (US Centers for Disease Control and Prevention/National Healthcare Safety Network). During the intervention, the INICC approach was implemented, which included a bundle of interventions, education, outcome surveillance, process surveillance, feedback on CLABSI rates and consequences, and performance feedback. Random effects Poisson regression was used for clustering of CLABSI rates across time periods. RESULTS: During the baseline period, 9472 central line (CL)-days and 61 CLABSIs were recorded; during the intervention period, 80898 CL-days and 404 CLABSIs were recorded. The baseline rate was 6.4 CLABSIs per 1000 CL-days, which was reduced to 3.9 CLABSIs per 1000 CL-days in the second year and maintained for 36 months of follow-up, accounting for a 53% CLABSI rate reduction (incidence rate ratio 0.47, 95% confidence interval 0.31-0.70; p=0.0001). CONCLUSIONS: Implementing the six components of the INICC approach simultaneously was associated with a significant reduction in the CLABSI rate in India, which remained stable during 36 months of follow-up.
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Infecciones Relacionadas con Catéteres/epidemiología , Infecciones Relacionadas con Catéteres/prevención & control , Infección Hospitalaria/epidemiología , Infección Hospitalaria/prevención & control , Unidades de Cuidados Intensivos , Adulto , Anciano , Infecciones Relacionadas con Catéteres/microbiología , Infección Hospitalaria/microbiología , Femenino , Humanos , India/epidemiología , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Oral cleansing with chlorhexidine decreases the incidence of nosocomial pneumonia in patients after cardiac surgery. However, evidence of its benefit in ICU patients is conflicting. METHODS: Patients admitted to the ICU of an Indian tertiary care teaching hospital were randomized to twice-daily oropharyngeal cleansing with 0.2% chlorhexidine or 0.01% potassium permanganate (control) solution. Effects on the incidence of nosocomial pneumonia during ICU stay (primary outcome) and length of ICU stay and in-hospital mortality (secondary outcomes) were studied. RESULTS: Five hundred twelve patients were randomized to either the chlorhexidine group (n = 250) or the control group (n = 262). Of the 471 subjects who completed the protocol, nosocomial pneumonia developed in 16 of 224 subjects (7.1%) in the chlorhexidine group and 19 of 247 subjects (7.7%) in the control group (p = 0.82; relative risk, 0.93; 95% confidence interval, 0.49 to 1.76); intention-to-treat analysis of 21 patients in whom the cleansing protocol was not followed revealed similar results. There was no significant difference between the study and control groups in the median day of development of pneumonia (5.0 days: interquartile range [IQR], 3.0 to 7.7 vs 5.0 days: IQR, 3.0 to 6.0, respectively), median ICU stay (5.0 days: IQR, 3.0 to 8.0 vs 6.0 days: IQR, 3.0 to 8.0, respectively), and mortality (34.8% vs 28.3%, respectively). On subgroup analysis, there was no significant difference in the primary and secondary outcomes in patients on mechanical ventilation, tracheal intubation, and coma (Glasgow coma scale Asunto(s)
Clorhexidina/administración & dosificación
, Neumonía Bacteriana/prevención & control
, Neumonía Asociada al Ventilador/prevención & control
, Administración Oral
, Adulto
, Antiinfecciosos Locales/administración & dosificación
, Enfermedad Crítica
, Infección Hospitalaria/prevención & control
, Nutrición Enteral
, Femenino
, Humanos
, Intubación Intratraqueal
, Tiempo de Internación
, Masculino
, Persona de Mediana Edad
, Orofaringe/microbiología
, Neumonía Bacteriana/microbiología
, Neumonía Asociada al Ventilador/microbiología
, Permanganato de Potasio/administración & dosificación
, Adulto Joven
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Certain arthropod-borne infections are common in tropical regions because of favorable climatic conditions. Water-borne infections like leptospirosis are common due to contamination of water especially during the monsoon floods. Infections like malaria, leptospirosis, dengue fever and typhus sometimes cause life threatening organ dysfunction and have several overlapping features. Most patients present with classicial clinical syndromes: fever and thrombocytopenia are common in dengue, malaria and leptospirosis; coagulopathy is frequent in leptospirosis and viral hepatitis. Hepatorenal syndrome is seen in leptospirosis, falciparum malaria and scrub typhus. The pulmonary renal syndrome is caused by falciparium malaria, leptospirosis, Hantavirus infection and scrub typhus. Fever with altered mental status is produced by bacterial meningitis, Japanese B encephalitis, cerebral malarial, typhoid encephalopathy and fulminant hepatic failure due to viral hepatitis. Subtle differences in features of the organ failure exist among these infections. The diagnosis in some of these diseases is made by demonstration of antibodies in serum, and these may be negative in the first week of the illness. Hence empiric therapy for more than one disorder may be justified in a small proportion of cases. In addition to specific anti-infective therapy, management of organ dysfunction includes use of mechanical ventilation, vasopressor drugs, continuous renal replacement therapy and blood products. Timely transfer of these patients to well-equipped ICUs with experience in managing these cases can considerably decrease mortality and morbidity.
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Infecciones/epidemiología , Unidades de Cuidados Intensivos/estadística & datos numéricos , Clima Tropical , Microbiología del Agua , Animales , Dengue/diagnóstico , Dengue/terapia , Encefalitis Japonesa/diagnóstico , Encefalitis Japonesa/terapia , Infecciones por Hantavirus/diagnóstico , Infecciones por Hantavirus/terapia , Humanos , Infecciones/parasitología , Infecciones/virología , Leptospirosis/diagnóstico , Leptospirosis/terapia , Malaria Falciparum/diagnóstico , Malaria Falciparum/terapia , Tifus Epidémico Transmitido por Piojos/diagnóstico , Tifus Epidémico Transmitido por Piojos/terapia , Agua/parasitologíaRESUMEN
Fever is defined as a core body temperature of >38.3 degrees C or 101 degrees F. About 50% of fevers in the ICU are due to infectious causes. Absence of fever in patients with infection heralds a poor prognosis. Temperatures between 102 degrees F-106 degrees F are more likely to be due to infection. The common infectious causes of fever are pneumonia, urosepsis, line infections and intraabdominal infections. Temperatures <102 degrees F or >106 degrees F are usually due to non-infectious causes like deep venous thrombosis, infusion reactions, aspiration, drug fever and the neuroleptic malignant syndrome. Fever should be distinguished from hyperthermia as antipyretics are ineffective in the latter. Inappropriate use of antibiotics selects resistant bacterial strains, but delay in treating infection could increase mortality. A structured approach is therefore required in order to correctly diagnose and treat fever in critically ill patients.