The efficacy of ultrasound-guided triple nerve block (ilioinguinal, iliohypogastric, and genitofemoral) versus unilateral subarachnoid block for inguinal hernia surgery in adults: a randomized controlled trial.

INTRODUCTION: The present study was carried out to evaluate the efficacy of ultrasound-guided triple nerve block (ilioinguinal, iliohypogastric, and genitofemoral) versus unilateral subarachnoid block for adult male patients undergoing unilateral inguinal hernia surgery. MATERIAL AND METHODS: Sixty ASA I-III adult male patients > 18 years old, scheduled for unilateral inguinal hernia surgery were randomly allocated into 2 groups of 30 patients each. In Group A ( n = 30) the patients received ultrasound-guided nerve block (ilioinguinal, iliohypogastric, and genitofemoral), and in Group B ( n = 30) the patients received unilateral subarachnoid block. The primary outcome was to assess postoperative analgesic efficacy (visual analogue scale [VAS] scores at rest and during coughing/ambulation). The secondary outcomes were time to first rescue analgesia with morphine, the total dose of morphine used as rescue analgesia, urinary retention, time to first micturition, time to first unassisted walking, and time to discharge from the surgical recovery room. RESULTS: The mean pain scores at 1, 2, 4, and 6 hours during rest and during coughing/ambulation were significantly lower in Group A when compared to patients in Group B ( P < 0.001). There was no requirement for rescue analgesic opioids in Group A ( P < 0.001). Mean time to first micturition and mobilization occurred earlier in Group A, leading to early discharge from the recovery room ( P < 0.001). No major side effects were observed in any of the study groups. CONCLUSIONS: Ultrasound-guided triple nerve block technique can be used as a sole anaesthetic technique for inguinal hernia surgery because it not only provides optimal anaesthesia intra-operatively but also has a favourable analgesic and opioid-sparing efficacy in the early postoperative period with minimal adverse effects.

A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit.

Introduction: Sepsis leads to left and/or right ventricular systolic and/or diastolic dysfunction resulting in adverse outcomes. Myocardial dysfunction can be diagnosed by echocardiography (ECHO) and early intervention can be planned. There are lacunae in Indian literature regarding the true incidence of septic cardiomyopathy and its influence on the outcome of patients admitted to intensive care unit (ICU). Materials and methods: This prospective observational study was conducted on patients consecutively admitted with sepsis to the ICU of a tertiary care hospital in North India. In these patients, ECHO was performed after 48-72 hours to establish left ventricular (LV) dysfunction, in whom the ICU outcome was analyzed. Result: The incidence of LV dysfunction was 14%. About 42.86% of patients had isolated systolic dysfunction, 7.14% of patients had isolated diastolic dysfunction, and 50.00% of patients had combined LV systolic and diastolic dysfunctions. The average days of mechanical ventilation in patients without LV dysfunction group (group I) was 2.41 ± 3.82 days as compared to 4.43 ± 4.27 days in patients with LV dysfunction (group II) (p = 0.034). Incidence of all-cause ICU mortality was 11 (12.79%) in group I and 3 (21.43%) in group II (p = 0.409). The mean duration of stay in ICU was 8.26 ± 4.41 days in group I as compared to 13.21 ± 6.83 days in group II. Conclusion: We concluded that sepsis-induced cardiomyopathy (SICM) in ICU is quite prevalent and clinically significant. All-cause ICU mortality and length of ICU stay are prolonged in patients with SICM. How to cite this article: Bansal S, Varshney S, Shrivastava A. A Prospective Observational Study to Determine Incidence and Outcome of Sepsis-induced Cardiomyopathy in an Intensive Care Unit. Indian J Crit Care Med 2022;26(7):798-803.

Impact of early versus late tracheostomy on patient outcomes in a tertiary care multispeciality ICU.

BACKGROUND AND AIMS: Tracheostomy is a commonly performed procedure in critically ill patients because patients requiring chronic mechanical ventilation (MV) are rising by as much as 5.5% per year. The controversy on likely benefits of early versus late tracheostomy is ongoing. We aimed to study the impact of early versus late tracheostomy on patient outcomes. MATERIAL AND METHODS: A retrospective observational study was performed in intensive care unit (ICU) patients who underwent tracheostomy in a 31-bedded multispeciality ICU of a 350-bedded tertiary care hospital, over a period of 1 year. Data collected included the age, sex, APACHE II score, indication for tracheostomy, timing of procedure, whether surgical or percutaneous, any complication, MV days, ICU stay, and patient outcome. Patients were divided into two groups for statistical comparison: early ≤7 days and late >7 days of MV. RESULTS: A total of 102 patients underwent tracheostomy over the study period, of which 19 were excluded because of inadequate data and exclusion criteria. Of the 83 study patients, 60 had percutaneous, while 23 had surgical tracheostomy. About 51 (61.45%) had early, while 32 (38.55%) had late tracheostomy. On statistical analysis, there was a significant difference in MV days (5 vs 12.5 days, P = 0.002), ICU stay (10 vs 16 days, P = 0.004), mortality (21.6% vs 43.8%, P = 0.032), and decannulation rate (29.41% vs 6.25%, P = 0.009). No difference was observed in hospital stay or complication rates. CONCLUSION: Early tracheostomy is associated with both morbidity and mortality benefits. Patients requiring MV should be given an option of early tracheostomy.

A comparative study on the efficacy of dexmedetomidine and tramadol on post-spinal anesthesia shivering.

BACKGROUND: Shivering is a common postanesthesia adverse event with multiple etiologies. At present tramadol is a widely used drug for the control of shivering. However, tramadol may cause a lot of nausea and vomiting. Hence, the need to find a better drug with less of side effects. The aim of this study was to compare the efficacy of dexmedetomidine and tramadol in the treatment of post-spinal anesthesia (SA) shivering as well as to compare their side-effect profile. MATERIALS AND METHODS: This prospective, double-blind, randomized controlled trial was conducted in a tertiary care hospital. A total of 100 patients having shivering after SA were enrolled, out of which fifty received dexmedetomidine (Group A) and 50 received tramadol (Group B). The response rate, time to cessation of shivering and side effects (if any) was noted. All the results were analyzed using Student's t-test and Chi-square test. RESULTS: All patients who received dexmedetomidine as well as tramadol had cessation of shivering. The time to cessation of shivering was significantly less with dexmedetomidine (174.12 ± 14.366 s) than with tramadol (277.06 ± 23.374 s) (P < 0.001). The recurrence rate of shivering with dexmedetomidine was less (6%) as compared to tramadol (16%). Nausea and vomiting was found to be higher in the case of tramadol. On the other hand, dexmedetomidine caused moderate sedation (modified Ramsay sedation score = 3-4) from which the patient could be easily awoken up. CONCLUSION: Dexmedetomidine offers better results than tramadol with fewer side effects.

Institutional resuscitation protocols: do they affect cardiopulmonary resuscitation outcomes? A 6-year study in a single tertiary-care centre.

PURPOSE: Despite advances in cardiopulmonary resuscitation and widespread life-support trainings, the outcomes of resuscitation are variable. There is a definitive need for organizational inputs to strengthen the resuscitation process. Our hospital authorities introduced certain changes at the organizational level in our in-house resuscitation protocol. We aimed to study the impact of these changes on the outcomes of resuscitation. METHODS: The hospital code blue committee decided to reformulate the resuscitation protocols and reframe the code blue team. Various initiatives were taken in the form of infrastructural changes, procurement of equipment, organising certified training programs, conduct of mock code and simulation drills etc. A prospective and retrospective observational study was made over 6 years: a pre-intervention period, which included all cardiac arrests from January 2007 to December 2009, before the implementation of the program, and a post-intervention period from January 2010 to December 2012, after the implementation of the program. The outcomes of interest were response time, immediate survival, day/night survival and survival to discharge ratio. RESULTS: 2,164 in-hospital cardiac arrests were included in the study, 1,042 during the pre-intervention period and 1,122 during the post-intervention period. The survival percentage increased from 26.7 to 40.8 % (p < 0.05), and the survival to discharge ratio increased from 23.4 to 66.6 % (p < 0.05). Both day- and night-time survival improved (p < 0.05) and response time improved from 4 to 1.5 min. CONCLUSIONS: A strong hospital-based resuscitation policy with well-defined protocols and infrastructure has potential synergistic effect and plays a big role in improving the outcomes of resuscitation.

Do Intensive Care Unit treatment modalities predict mortality in geriatric patients: An observational study from an Indian Intensive Care Unit.

BACKGROUND: Ageing being a global phenomenon, increasing number of elderly patients are admitted to Intensive Care Units (ICU). Hence, there is a need for continued research on outcomes of ICU treatment in the elderly. OBJECTIVES: Examine age-related difference in outcomes of geriatric ICU patients. Analyze ICU treatment modalities predicting mortality in patients >65 years of age. MATERIALS AND METHODS: A retrospective observational study was conducted in 2317 patients admitted in a multi-specialty ICU of a tertiary care hospital over 2-year study period from January 1, 2011 to December 31, 2012. A clinical database was collected which included age, sex, specialty under which admitted, APACHE-II and SOFA scores, patient outcome, average length of ICU stay, and the treatment modalities used in ICU including mechanical ventilation, inotropes, hemodialysis, and tracheostomy. Patients were divided into two groups: <65 years (Control group) and >65 years (Geriatric age group). RESULTS: The observed overall ICU mortality rate in the study population was 19.6%; no statistical difference was observed between the control and geriatric age group in overall mortality (P > 0.05). Mechanical ventilation (P = 0.003, odds ratio [OR] =0.573, 95% confidence interval [CI] =0.390-0.843) and use of inotropes (P = 0.018, OR = 0.661, 95% CI = 0.456-0.958) were found to be predictors of mortality in elderly population. On multivariate analysis, inotropic support was found to be an independent ICU treatment modality predicting mortality in the geriatric age group (ß coefficient = 1.221, P = 0.000). CONCLUSION: Intensive Care Unit mortality rates increased in the geriatric population requiring mechanical ventilation and inotropes during ICU stay. Only inotropic support could be identified as independent risk factor for mortality.

Convulsions in a critically ill patient on hemodialysis: Possible role of low dose colistin.

The increasing prevalence of multi-drug resistant Gram-negative pathogens in intensive care units has led to the revival of colistin. Colistin had gone into disrepute in early 1970s because of numerous reports of adverse renal and neurological effects. The renewed interest in colistin has also revived the discussion about its toxicity. The neurotoxicity reported in literature is usually with higher doses of colistin. We present a case report of seizures in a critically ill-patient, possibly with low dose colistin. A 47-year-old hypertensive female with chronic kidney disease-5 with sepsis on colistimethate sodium 1 million units (80 mg), intravenous once daily, developed paresthesias and seizures on 12(th) day of therapy, which were subsequently controlled after withdrawl of the drug. To conclude, colistin should be considered as a cause of convulsions in critically ill-patients with renal failure, even when given in low dose and patient receiving intermittent hemodialysis, when other obvious causes have been ruled out. When possible, cessation of therapy may be considered.

Implications of dedicated tracheostomy care nurse program on outcomes.

PURPOSE: Tracheostomy is a common occurrence in intensive care units (ICU), and a greater number of tracheostomized patients are shifted from ICU to non-critical areas. Tracheostomy care needs a multidisciplinary approach, particularly involving the nurses, and complications such as tube blockage, infection, and bleeding can be prevented by good bedside nursing. The aim was to study the impact of dedicated tracheostomy care nurse program on outcomes of tracheostomized patients. METHODS: A tracheostomy care nurse program was improvised by the critical care physicians, with the objective of improving care of tracheostomized patients, wherein nursing staff from noncritical areas were selected for training purposes. The training included evidence-based knowledge and hands-on training. After a written assessment and a skill test, they were certified as 'Tracheostomy Care Nurse.' At least one of the tracheostomy care nurses was supposed to be responsible for tracheostomy care in specific wards. Comparative data of two periods, a pre-intervention period from January 2011 to November 2011 and a post-intervention period from December 2011 to October 2012, were analyzed. RESULTS: During the pre-intervention period, of 82 tracheostomized patients, 28 (34.15 %) had complications including 20 (24.39 %) readmissions to the ICU. During the post-intervention period, 107 patients had a tracheostomy, of which 7 (6.54 %) had complications with only 2 (1.87 %) readmissions, which was significant (p < 0.05). Decannulations nonsignificantly increased during the post-intervention period (25 vs. 16 %, p > 0.05). The average length of hospital stay (ALOS) decreased from 36 to 27 days (p < 0.05). CONCLUSION: The support of a specialist tracheostomy nurse can decrease complication rates and readmissions to the ICU and reduce ALOS.

An observation of impact of neurological consultations in intensive care patients: Case series of 23 patients.

OBJECTIVE: The objective of the present study was to assess the impact of neurological consultation and intervention upon patient outcome in intensive care unit (ICU). SETTINGS: A retrospective observational study was conducted in the 24-bedded multispecialty ICU of a 350 bedded tertiary care hospital over 8 months period, from January 2011 to August 2011. Critically, ill-patients with varied neurological symptomatology affecting the course of illness and ICU discharge were included. Neurological consult sought for, investigations ordered by the neurologist, interventions carried out, treatment started and the impact of such treatment on the outcome of patients were noted. The length of ICU stay was also noted. RESULTS: Over a period of 8 months, there were 864 ICU admissions. On neurological consult, 23 patients had a positive finding affecting the outcome: 5 patients were diagnosed to have parkinson's disease, 4 patients had neuromuscular disease, 9 patients had high creatinine phosphokinase levels, 2 patients had restless legs syndrome and 3 patients were diagnosed to have seizure disorder. CONCLUSIONS: On being examined and investigated by neurologist, a variety of co-existing neurological disorders could be diagnosed and if managed early, patients had a faster recovery, rapid weaning and early discharge from the ICU.

Knowledge of infection control practices among intensive care nurses in a tertiary care hospital.

BACKGROUND: The threat of hospital-acquired infections persists despite advances in the health care system. A lack of knowledge regarding infection control practices among health care workers decreases compliance with these practices. We conducted a study to assess the knowledge of infection control practices among nursing professionals at our hospital. METHODS: In total, 100 nurses in the intensive care units at our hospital were given a questionnaire with 40 multiple choice questions, including 10 questions each regarding hand hygiene, standard and transmission-based precautions, care bundles and general infection control practices. The responses were scored as percentages. RESULTS: The overall knowledge and awareness regarding different infection control practices were excellent (>90% positive responses) in 5% of the nursing professionals, good (80-90% positive responses) in 37%, average (70-80% positive responses) in 40% and below average (<70% positive responses) in 18%. CONCLUSION: The infection control knowledge among the nurses was fairly good; however, there is still a wide scope of improvement with regular educational programs and in-house training.

Refractory hyperkalemia related to heparin abuse.

Hyperkalemia is a potentially life-threatening condition, which may occur in many clinical settings. Heparin-induced hyperkalemia is less well-recognized than other side effects of heparin therapy. Even lesser known is heparin abuse amongst drug addicts. We report a case of fatal hyperkalemia related to long-term heparin abuse, which was refractory to anti-hyperkalemia therapy including hemodialysis. The objective is to alert the clinicians to possible abuse of heparin in drug addicts, which can be a cause for refractory hyperkalemia. We also briefly review the available literature on heparin-induced hyperkalemia.

Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital.

BACKGROUND: Guidelines on performing cardiopulmonary resuscitation (CPR) have been published from time to time, and formal training programs are conducted based on these guidelines. Very few data are available in world literature highlighting the impact of these trainings on CPR outcome. AIM: The aim of our study was to evaluate the impact of the American Heart Association (AHA)-certified basic life support (BLS) and advanced cardiac life support (ACLS) provider course on the outcomes of CPR in our hospital. MATERIALS AND METHODS: An AHA-certified BLS and ACLS provider training programme was conducted in our hospital in the first week of October 2009, in which all doctors in the code blue team and intensive care units were given training. The retrospective study was performed over an 18-month period. All in-hospital adult cardiac arrest victims in the pre-BLS/ACLS training period (January 2009 to September 2009) and the post-BLS/ACLS training period (October 2009 to June 2010) were included in the study. We compared the outcomes of CPR between these two study periods. RESULTS: There were a total of 627 in-hospital cardiac arrests, 284 during the pre-BLS/ACLS training period and 343 during the post-BLS/ACLS training period. In the pre-BLS/ACLS training period, 52 patients (18.3%) had return of spontaneous circulation, compared with 97 patients (28.3%) in the post-BLS/ACLS training period (P < 0.005). Survival to hospital discharge was also significantly higher in the post-BLS/ACLS training period (67 patients, 69.1%) than in the pre-BLS/ACLS training period (12 patients, 23.1%) (P < 0.0001). CONCLUSION: Formal certified BLS and ACLS training of healthcare professionals leads to definitive improvement in the outcome of CPR.