Treatment challenges in the management of difficult-to-treat gram-positive infections: A consensus view apropos therapeutic role of novel anti-MRSA antibiotics, levonadifloxacin (IV) and alalevonadifloxacin (oral).

PURPOSE: Treatment of antibiotic-resistant Gram-positive infections (GPIs), including methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly difficult, particularly in patients with multiple co-morbidities who require antibiotics with greater safety and a consistent pharmacokinetic/pharmacodynamic (PK/PD) profile. Such difficult-to-treat GPIs are often associated with poor outcomes, extended hospital stay and increased expenditure. This can be partly attributed to the limited safety and aberrant PK/PD profile of existing anti-MRSA antibiotics. In this context, intravenous levonadifloxacin and its oral prodrug alalevonadifloxacin are novel anti-MRSA antibiotics that have significant advantages over conventional anti-Gram-positive antibiotics. The purpose of this paper was to generate a consensus on the optimal use of levonadifloxacin and alalevonadifloxacin for tackling resistant Gram-positive infections in patients with multiple co-morbidities. METHOD: Using a modified Delphi approach that combines critical appraisal of evidence and expert opinion, therapeutic use of levonadifloxacin and alalevonadifloxacin in various clinical scenarios and specific unmet conditions was deliberated. Fifteen expert members from medicine, critical-care, emergency, microbiology, and intensive-care disciplines participated and voted on 11 pre-conceived statements. When there was at least 70 % agreement, a consensus was reached. RESULTS: Following the voting, agreements were reached on 10 out of the 11 statements. Broadly, a consensus was reached in defining the therapeutic role of levonadifloxacin and alalevonadifloxacin in the treatment of various clinical indications involving resistant Gram-positive pathogens, including MRSA, in patients with co-morbidities, such as co-existing or increased risk for kidney dysfunction or hepatic disease and/or immunosuppression; also, in therapeutically challenging conditions caused by Gram-positive bacteria such as bacteraemia, bone and joint infection, diabetic foot infection, febrile neutropenia, and hospital-acquired pneumonia. CONCLUSIONS: This consensus supports the therapeutic use of levonadifloxacin and alalevonadifloxacin in the treatment of antibiotic-resistant GPIs, including those caused by MRSA and certain polymicrobial infections, in patients with multiple co-morbidities requiring drug with adequate safety and consistent efficacy.

Association of hyperglycaemia at-admission & diabetes mellitus with 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection: A retrospective study.

Background & objectives: The association between hyperglycaemia at admission, diabetes mellitus (DM) status and mortality in hospitalized SARS-CoV-2 infected patients is not clear. The purpose of this study was to determine the relationship between DM, at-admission hyperglycaemia and 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection requiring intensive care. Methods: All consecutive moderate-to-severe patients with SARS-CoV-2 infection admitted to the intensive care units (ICUs) over six months were enrolled in this single-centre, retrospective study. The predicators for 28 day mortality were analysed from the independent variables including DM status and hyperglycaemia at-admission. Results: Four hundred and fifty two patients with SARS-CoV-2 were admitted to the ICU, with a mean age of 58.5±13.4 yr, 78.5 per cent being male, HbA1c of 7.2 per cent (6.3-8.8) and 63.7 per cent having DM. Overall, 28 day mortality was 48.9 per cent. In univariate analysis, mortality in diabetes patients was comparable with non-diabetes (47.9 vs. 50.6%, P=0.58), while it was significantly higher in hyperglycaemic group (60.4 vs. 35.8%, P<0.001). In multivariate Cox regression analysis, after adjusting for age, sex and comorbidities, hyperglycaemia at-admission was an independent risk factor of mortality [hazard ratio (HR) 1.45, 95% confidence interval (CI) (1.06-1.99), P<0.05]. Interpretation & conclusions: This study showed that the presence of hyperglycaemia at-admission in critically ill SARS-CoV-2 patients was an independent predictor of 28 day mortality. However, the findings may be susceptible to unmeasured confounding, and more research from prospective studies is required.

New insights into development and mortality of COVID-19-associated pulmonary aspergillosis in a homogenous cohort of 1161 intensive care patients.

BACKGROUND: COVID-19-associated pulmonary aspergillosis (CAPA) has been widely reported but homogenous large cohort studies are needed to gain real-world insights about the disease. METHODS: We collected clinical and laboratory data of 1161 patients hospitalised at our Institute from March 2020 to August 2021, defined their CAPA pathology, and analysed the data of CAPA/non-CAPA and deceased/survived CAPA patients using univariable and multivariable models. RESULTS: The overall prevalence and mortality of CAPA in our homogenous cohort of 1161 patients were 6.4% and 47.3%, respectively. The mortality of CAPA was higher than that of non-CAPA patients (hazard ratio: 1.8 [95% confidence interval: 1.1-2.8]). Diabetes (odds ratio [OR] 1.92 [1.15-3.21]); persistent fever (2.54 [1.17-5.53]); hemoptysis (7.91 [4.45-14.06]); and lung lesions of cavitation (8.78 [2.27-34.03]), consolidation (9.06 [2.03-40.39]), and nodules (8.26 [2.39-28.58]) were associated with development of CAPA by multivariable analysis. Acute respiratory distress syndrome (ARDS) (2.68 [1.09-6.55]), a high computed tomography score index (OR 1.18 [1.08-1.29]; p < .001), and pulse glucocorticoid treatment (HR 4.0 [1.3-9.2]) were associated with mortality of the disease. Whereas neutrophilic leukocytosis (development: 1.09 [1.03-1.15] and mortality: 1.17 [1.08-1.28]) and lymphopenia (development: 0.68 [0.51-0.91] and mortality: 0.40 [0.20-0.83]) were associated with the development as well as mortality of CAPA. CONCLUSION: We observed a low but likely underestimated prevalence of CAPA in our study. CAPA is a disease with high mortality and diabetes is a significant factor for its development while ARDS and pulse glucocorticoid treatment are significant factors for its mortality. Cellular immune dysregulation may have a central role in CAPA from its development to mortality.

Role of low-dose tissue plasminogen activator in patients with refractory hypoxia due to presumed microthrombi in pulmonary vasculature in coronavirus disease 2019: A case series and review of the literature.

Severe hypoxia due to coronavirus disease 2019 (COVID-19) is challenging in the intensive care unit (ICU). It is often unresponsive to mechanical ventilation at high positive end-expiratory pressure and the fraction of inspired oxygen combination. The cause of such worsening hypoxia may be microvascular thrombosis in the pulmonary vascular system because of the procoagulant nature of COVID-19 infection. Confirming the diagnosis with computed tomographic pulmonary angiography is not always possible, as the patients are too sick to be shifted. Tissue plasminogen activator (tPA) is recommended for pulmonary thromboembolism with hypotension and worsening hypoxia, as confirmed by computed tomography pulmonary angiography. However, its role in worsening hypoxia because of presumed microthrombi in the pulmonary vasculature in COVID-19 is unclear. We present six cases from our ICU where we used low-dose tPA in COVID-19 refractory hypoxia with presumed microthrombi in the pulmonary vasculature (oligemic lung field, refractory hypoxia, increased D dimer, electrocardiographic features of pulmonary embolism, and right ventricular strain on echocardiography). Oxygenation improved within 6 h and was maintained for up to 48 h in all patients. Therefore, there is a possible role of microthrombi in the mechanism of hypoxia in this setting. An early decision to start low-dose tPA may improve the outcome. However, all patients finally succumbed to sepsis and multiorgan failure later in their course. A systematic review of the literature has also been performed on the mechanism of thrombosis and the use of tPA in hypoxia due to COVID-19.

A questionnaire-based study on quality and adequacy of clinical communication between physician and family members of admitted Covid-19 patients.

OBJECTIVE: To assess adequacy of present means of clinical communication between physicians and (Covid-19) patients' family members, to analyse their perspectives and recommend felicitous practices for virtual conversation during ongoing pandemic. METHODS: Cross-sectional questionnaire-based (20 questions) anonymous online survey was conducted including patient's relatives (Group-1) and treating physicians (Group-2), through Google Forms. RESULTS: Response Rate was 82.5%. Group-1 and Group-2 included 155 and 204 respondents respectively. Group-1 preferred update by resident doctors (39%), twice a day (41.9%), daily case-summaries (80%) and hand-written document/electronic messages (53%,31%) as consent. Whereas Group-2 favored update by senior consultants (63%), daily one appraisal (55.9%) and scanned copies of hand written consent (81%) before high-risk procedures. The groups broadly agreed on the desired duration for a fruitful discussion (5-10 min) and designating one responsible person from the family for daily appraisal. CONCLUSION: Use of modern techniques/technologies of communication (voice/video calls, texts) during the ongoing pandemic is acceptable to majority. PRACTICE IMPLICATIONS: Study proposes a senior physician should communicate to a designated responsible family member at-least once a day for stable and twice a day for critical covid patients (more if patient's health condition changes), either by voice or video calls for 5-10 min.

A novel epidemiological scoring system for the prediction of mortality in COVID-19 patients.

BACKGROUND: Most of the reported risk score models for coronavirus disease 2019 (COVID-19) mortality are based on the levels of inflammatory markers, comorbidities or various treatment modalities, and there is a paucity of risk score models based on clinical symptoms and comorbidities. METHODS: To address this need, age, clinical symptoms and comorbidities were used to develop a COVID-19 scoring system (CSS) for early prediction of mortality in severe COVID-19 patients. The CSS was developed with scores ranging from 0 to 9. A higher score indicates higher risk with good discrimination quality presented by Mann Whitney U test and area under receiver operating characteristic curve (AUROC). RESULTS: Patient age of ≥60 y, cough, breathlessness, diabetes and any other comorbidity (with or without diabetes) are significant and independent risk factors for non-survival among COVID-19 patients. The CSS showed good sensitivity and specificity (i.e. 74.1% and 78.5% at CSS≥5, respectively), with an overall diagnostic accuracy of 82.8%, which was close to the diagnostic accuracy detected in the validation cohort (81.9%). In the validation cohort, high (8-9), medium (5-7) and low (0-4) CSS groups had 54.80%, 28.60% and 6.5% observed mortality, respectively, which was very close to the predicted mortality (62.40%, 27.60% and 5.2%, respectively, by scoring cohort). CONCLUSIONS: The CSS shows a positive relationship between a higher score and proportion of mortality and, as its validation showed, it is useful for the prediction of risk of mortality in COVID-19 patients at an early stage, so that referral for triage and admission can be predetermined even before admission to hospital.

Quality of Life After Intensive Care Unit Discharge in a Tertiary Care Hospital in India: Cost Effectiveness Analyis.

BACKGROUND: Improvements in intensive care in the last few decades have shifted the focus from mortality to quality of life of survivors as a more important outcome measure. Allocation of public resources towards intensive care is an important challenge for healthcare administrators. This challenge is made more arduous in resource limited countries like India. Thus, it is imperative to consider patient centerd outcomes and resource utilisation to guide allocation of funds. The aim of this study was to evaluate the quality of life of long-term survivors, and to perform cost-effectiveness and cost-utility analysis. METHODS: Data was retrieved from the records and included age, gender, admission diagnosis, length of ICU stay and mortality. Costing methodology used was top down approach. Quality of life was assessed by SF 36 scoring which was done with personal interview and telephonically. Cost-effectiveness analysis was done on the basis of years of life added. Cost utility was done by QALY gained. RESULTS: A total of 1232 adult patients were admitted in the period with 758 (61%) being successfully discharged from ICU with a mortality rate of 39%. Out of 758, we could contact 113 (15%) patients. 86 patients were alive at the time of contact who could fill the forms for quality of life. The patients discharged from ICU had scores almost similar to the general population. Lesser scores were noted in physical functioning and general health perceptions, though this difference was not statistically significant. The life years gained were significantly more in younger patients. The cost per life gained was more in patients aged more than 50 years compared to those who were younger. CONCLUSION: The quality of life after survival from ICU is as good as in the general population. The intensive care provided in our ICU is cost effective. HOW TO CITE THIS ARTICLE: Mishra SB, Poddar B et al, Quality of Life After Intensive Care Unit Discharge in a Tertiary Care Hospital in India: Cost Effectiveness Analysis. Indian J Crit Care Med 2019;23(3):122-126.

Early pH Change Predicts Intensive Care Unit Mortality.

AIM OF THE STUDY: Metabolic acidosis is associated with increased mortality in critically ill patients. We hypothesized that early correction of acidosis of presumed metabolic origin results in improved outcomes. PATIENTS AND METHODS: We conducted a prospective, observational study from February 2015 to June 2016 in a 12 bed mixed intensive care unit (ICU) of a 1000 bed tertiary care hospital in the north of India. ICU patients aged above 18 years with an admission pH ≥7.0 to <7.35 of presumed metabolic origin were included. Arterial blood gas parameters including pH, PaO2, PaCO2, HCO3 -, Na+, K+, Cl-, anion gap (AG), base excess, and lactate at 0, 6, and 24 h along with other standard laboratory investigations were recorded. The primary outcome was to assess the impact of early pH changes on mortality at day 28 of ICU. RESULTS: A total of 104 patients with 60.6% males and 91.3% medical patients were included in the study. Sepsis of lung origin (60.6%) was the predominant etiology. By day 28, 68 (65.4%) patients had died. Median age was 49.5 years, weight 61.7 kg, Sequential Organ Failure Assessment, and Acute Physiologic and Chronic Health Evaluation II scores were 16 and 12, respectively. Nonsurvivors had a higher vasopressor index (P < 0.01), lactate and central venous oxygen saturation (P < 0.05), and lower pH (P < 0.05). A pH correction/change of ≥1.16% during the first 24 h had the best receiver operating characteristic for predicting survival at day 28, with area under the curve (95% confidence interval, 0.72 [0.62-0.82], P < 0.05) compared to HCO3 -, BE, lactate, and AG. CONCLUSIONS: Metabolic acidosis is associated with higher mortality in ICU. The rate of change in pH may better predict ICU mortality than other metabolic indices.

Correlation of Neutrophil CD64 with Clinical Profile and Outcome of Sepsis Patients during Intensive Care Unit Stay.

INTRODUCTION: Neutrophil CD64 (nCD64) has been found to identify sepsis from nonseptic patients. It is also reported to be a predictor of survival and severity of sepsis. The goal of this study was to correlate serial nCD64 with Intensive Care Unit (ICU) outcome and severity of sepsis. MATERIALS AND METHODS: A prospective observational study was conducted in 12-bedded critical care unit of a tertiary care center. Adult patients with sepsis were included in this study. Demographics, illness severity scores, clinical parameters, laboratory data, and 28-day outcome were recorded. Serial nCD64 analysis was done (on days 0, 4, and 8) in consecutive patients. RESULTS: Fifty-one consecutive patients were included in the study. Median Acute Physiology and Chronic Health Evaluation II was 16 (12-20) and mean Sequential Organ Failure Assessment was 9 (8-10). Compared to survivors, nonsurvivors had higher nCD64 on day 8 (P = 0.001). nCD64 was higher in the septic shock group compared to sepsis group on days 0 and 8 (P < 0.05). Survivors showed improving trend of nCD64 over time while nonsurvivors did not. This trend was similar in the presence or absence of septic shock. nCD64 count was a good predictor of the septic shock on day 0 (area under the curve [AUC] = 0.747, P = 0.010) and moderate predictor at day 8 (AUC = 0.679, P = 0.028). CONCLUSION: Monitoring serial nCD64 during ICU stay may be helpful in determining the clinical course of septic patients.

Comparison of Hemodynamic Monitoring between Transesophageal Doppler and Ultrasonography-Guided Inferior Vena Cava Distensibility in Supine versus Prone Position: A Pilot Study.

INTRODUCTION: Lung-protective ventilation strategy and prone positioning are the strategies practiced to manage patients suffering from acute respiratory distress syndrome (ARDS). Inferior Vena Cava Distensibility (dIVC) Index has been used for predicting fluid responsiveness (FR) in supine position. We conducted this study to observe the utility of dIVC in prone position in ARDS patients and compare it with esophageal Doppler (ED) parameters. MATERIALS AND METHODS: After ethical clearance, a prospective observational pilot study was conducted in a 12-bedded tertiary care hospital. Adult ARDS patients who were treated with prone ventilation were included. Informed consent was taken from the relatives. IVC was visualized through right lateral approach both in supine and prone positions. We compared IVC distensibility and ED parameters, first in 45° head up and then in prone. FR was defined as an increase in the stroke volume of ≥15% as measured by ED. The patients with dIVC >18% were assumed to be fluid responsive. Statistical analysis was done using SPSS software version 20. RESULTS: Twenty-five patients met the inclusion criteria. ARDS was (mean P/F ratio 116.64 ± 44.76) mostly due to pulmonary etiology. Out of 25 patients, 10 patients were fluid responsive based on dIVC (cutoff >18%) in supine position. When compared to ED values after passive leg raising, dIVC had a sensitivity and specificity of 77.78% and 81.25%, respectively, in predicting FR with a moderate-to-absolute agreement between the two methods. IVC distensibility showed statistically significant negative correlation with corrected flow time (FTc) values both in supine and in prone positions. CONCLUSION: IVC variability can be observed in acute respiratory distress syndrome patients in prone position. Inferior Vena Cava Distensibility correlates with flow time in both the positions.

Diaphragm thickening fraction to predict weaning-a prospective exploratory study.

BACKGROUND: Diaphragm ultrasound (DUS) is a well-established point of care modality for assessment of dimensional and functional aspects of the diaphragm. Amongst various measures, diaphragmatic thickening fraction (DTf) is more comprehensive. However, there is still uncertainty about its capability to predict weaning from mechanical ventilation (MV). The present prospective observational exploratory study assessed the diaphragm at variable negative pressure triggers (NPTs) with US to predict weaning in ICU patients. METHODS: Adult ICU patients about to receive their first T-piece were included in the study. Linear and curvilinear US probes were used to measure right side diaphragm characteristics first at pressure support ventilation (PSV) of 8 cmH2O with positive end expiratory pressure (PEEP) of 5 cmH2O against NPTs of 2, 4, and 6 cmH2O and then later during their first T-piece. The measured variables were then categorized into simple weaning (SW) and complicated weaning (CW) groups and their outcomes analyzed. RESULTS: Sixty-four (M:F, 40:24) medical (55/64, 86%) patients were included in the study. Sepsis of lung origin (65.5%) was the dominant reason for MV. There were 33 and 31 patients in the SW and CW groups, respectively. DTf predicts SW with a cutoff ≥ 25.5, 26.5, 25.5, and 24.5 for 2, 4, and 6 NPTs and T-piece, respectively, with ≥ 0.90 ROC AUC. At NPT of 2, DTf had the highest sensitivity of 97% and specificity of 81% [ROC AUC (CI), 0.91 (0.84-0.99); p < 0.001]. CONCLUSIONS: DTf may successfully predict SW and also help identify patients ready to wean prior to a T-piece trial.

The Effects of Atorvastatin on Inflammatory Responses and Mortality in Septic Shock: A Single-center, Randomized Controlled Trial.

AIM OF THE STUDY: Pleiotropic effect of statins can modulate inflammation in septic shock. We tested the hypothesis whether statins can reduce mortality in septic shock. PATIENTS AND METHODS: We conducted a randomized double-blinded trial with treatment (40 mg dose of atorvastatin for 7 days) and control (placebo) arm in adult septic shock patients admitted to the Intensive Care Unit. Primary (28-day mortality) and secondary (vasopressor-, ventilation-, and renal replacement therapy-free days) outcomes, with lipid profile and adverse effects, were documented. Inflammatory biomarkers (interleukin [IL]-1, IL-6, tumor-necrosis-factor [TNF]-α, interferon [IFN], and C-reactive protein [CRP]), were also measured before (day 1 [D1]) and after start of trial drug (D4 and D7). RESULTS: Seventy-three septic shock patients with 36 and 37 included in the atorvastatin and placebo group, respectively. Both groups were equally matched. Twenty-eight-day mortality, event-free days, lipid profile, and adverse effects were also not significantly different between groups. Reduced levels of IL-1, IL-6, TNF-α, IFN, and CRP were observed in the atorvastatin group. Also observed were significant day-wise changes in inflammatory biomarkers. CONCLUSIONS: Atorvastatin-induced changes in inflammatory biomarkers did not confer mortality benefit in septic shock (ClinicalTrials.govNCT02681653).

External Validation of Risk Prediction Scores for Invasive Candidiasis in a Medical/Surgical Intensive Care Unit: An Observational Study.

BACKGROUND: The aim of this study was to conduct external validation of risk prediction scores for invasive candidiasis. METHODS: We conducted a prospective observational study in a 12-bedded adult medical/surgical Intensive Care Unit (ICU) to evaluate Candida score >3, colonization index (CI) >0.5, corrected CI >0.4 (CCI), and Ostrosky's clinical prediction rule (CPR). Patients' characteristics and risk factors for invasive candidiasis were noted. Patients were divided into two groups; invasive candidiasis and no-invasive candidiasis. RESULTS: Of 198 patients, 17 developed invasive candidiasis. Discriminatory power (area under receiver operator curve [AUROC]) for Candida score, CI, CCI, and CPR were 0.66, 0.67, 0.63, and 0.62, respectively. A large number of patients in the no-invasive candidiasis group (114 out of 181) were exposed to antifungal agents during their stay in ICU. Subgroup analysis was carried out after excluding such patients from no-invasive candidiasis group. AUROC of Candida score, CI, CCI, and CPR were 0.7, 0.7, 0.65, and 0.72, respectively, and positive predictive values (PPVs) were in the range of 25%-47%, along with negative predictive values (NPVs) in the range of 84%-96% in the subgroup analysis. CONCLUSION: Currently available risk prediction scores have good NPV but poor PPV. They are useful for selecting patients who are not likely to benefit from antifungal therapy.

Thromboelastography for Evaluation of Coagulopathy in Nonbleeding Patients with Sepsis at Intensive Care Unit Admission.

BACKGROUND: Thromboelastography (TEG) is a global test of coagulation which analyzes the whole coagulation process. TEG is popular in trauma, liver transplant, and cardiac surgeries, but studies in sepsis are limited. We have assessed the utility of TEG for evaluating coagulopathy in nonbleeding patients with sepsis. MATERIALS AND METHODS: A prospective, observational study was done in 12-bedded Intensive Care Unit (ICU) of a tertiary care hospital in North India, during May 2014-November 2014. After ethical clearance, all patients at ICU admission with sepsis were included in the study. Exclusion criteria were age <18 years, plasma/platelet transfusion before admission, patients on oral antiplatelets/anticoagulants, or with underlying hematological disorders. At admission, blood samples for TEG were analyzed by kaolin-based TEG analyzer within an hour of collecting 2.7 ml citrated blood from arterial line. TEG parameters included reaction time (R), K time (K), alpha angle (a), maximum amplitude (MA), coagulation index (CI), and lysis index (LY 30). RESULTS: In TEG, mean values of R, K, a, MA, CI, and LY30 were 6.45 ± 2.59 (min), 1.67 ± 0.96 (min), 66.37 ± 10.44 (0), 67.08 ± 10.33 (mm), 0.63 ± 3.46, and 2.23 ± 4.08 (%), respectively. In conventional coagulation assay (CCA), mean values of international normalized ratio (INR), platelet, and fibrinogen were 1.63 ± 0.57, 153.96 ± 99.16 (×103 /mm3), and 301.33 ± 112.82 (mg/dl), respectively. In those with deranged INR (INR ≥1.6), 60% were normocoagulable and 20% were hypercoagulable. Similarly, 81% patients with thrombocytopenia (platelet count <1,00,000/mL) were normocoagulable. CONCLUSION: TEG could differentiate among normocoagulant, hypocoagulant, hypercoagulant states (unlike CCAs). Patients with septic shock had trend toward hypocoagulant state while those without shock had trend toward hypercoagulant state.

The practice of tracheostomy decannulation-a systematic review.

Decannulation is an essential step towards liberating tracheostomized patients from mechanical ventilation. However, despite its perceived importance, there is no universally accepted protocol for this vital transition. Presence of an intact sensorium coordinated swallowing and protective coughing are often the minimum requirements for a successful decannulation. Objective criteria for each of these may help better the clinical judgement of decannulation. In this systematic review on decannulation, we focus attention to this important aspect of tracheostomy care.

Comparison between marked versus unmarked introducer needle in real-time ultrasound-guided central vein cannulation: A prospective randomized study.

INTRODUCTION: Introducer needle tip is not clearly visible during the real-time ultrasound (US)-guided central vein cannulation (CVC). Blind tip leads to mechanical complications. This study was designed to evaluate whether real-time US-guided CVC with a marked introducer needle is superior to the existing unmarked needle. METHODOLOGY: Sixty-two critically ill patients aged 18-60 years of either sex were included in the study. The patients were randomized into two groups based on whether a marked or unmarked introducer needle was used. Both groups underwent real-time US-guided CVC by a single experienced operator. Aseptically, introducer needle was indented with markings spaced 0.5 cm (single marking) and every 1 cm (double marking). This needle was used in the marked group. Approximate depths (centimeter) of the anterior and posterior wall of the internal jugular vein, anterior wall of the internal carotid artery, and lung pleura were appreciated from the midpoint of the probe in short-axis view at the level of the cricoid cartilage. Access time (seconds) was recorded using a stopwatch. A number of attempts and complications such as arterial puncture, hematoma, and pneumothorax of either procedure were compared. RESULTS: Both marked needle and unmarked needle groups were comparable with regard to age, gender, severity scores, platelet counts, prothrombin time, and distance from the midpoint of the probe to the vein, artery, and pleura and skin-to-guide wire insertion access time. However, an average number of attempts (P = 0.03) and complications such as hematoma were significantly lower (P = 0.02) with the marked introducer needle group. Pneumothorax was not reported in any of the groups. CONCLUSION: Our study supports the idea that marked introducer needle can further reduce the iatrogenic complications of US-guided CVC.

Right heart in septic shock: prospective observational study.

BACKGROUND: The right heart often receives less attention during echocardiography. The situation is no different in septic shock. We prospectively investigated the echocardiographic indices of the right heart in septic shock adult patients. METHODS: Septic shock ICU patients within 24 h of admission were subjected to transthoracic echocardiography (TTE) as per the 2005 guidelines from the American Society of Echocardiography. RESULTS: Eighty-eight septic shock patients (M:F = 52:36) underwent TTE. Thirty-six patients survived. Significant differences in demographic and biochemical (laboratory and metabolic) parameters, severity scores, life-support therapies (vasopressors, ventilation), and length of ICU stay were observed between survivors and non-survivors. Right heart abnormalities of chamber dimension and systolic and diastolic function existed in 79, 25, and 86 % of patients, respectively. Right ventricle subcostal wall thickness (91 %), pulse Doppler myocardial performance index (73 %), and E/E' (63 %) were the predominant abnormalities in chamber dimension, systolic function, and diastolic function of the right heart, respectively. However, the presence of these abnormalities did not signify poor survival in our study. CONCLUSIONS: Right heart dimensional and functional abnormalities exist in high proportions in septic shock. However, their predictability of poor outcomes remains questionable.

Sustained low-efficiency dialysis in septic shock: Hemodynamic tolerability and efficacy.

AIM OF THE STUDY: Acute kidney injury (AKI) in septic shock has poor outcomes. Sustained low-efficiency dialysis (SLED) is increasingly replacing continuous renal replacement therapy as the preferred modality in Intensive Care Units (ICUs). However, the essential aspects of hemodynamic tolerability and efficacy of SLED in septic shock AKI has been minimally studied. PATIENTS AND METHODS: We describe hemodynamic tolerability using modified vasopressor index (VI) and vasopressor dependency (VD) and efficacy using a combination of Kt/v, correction of acidosis, electrolyte, and fluid overload. Adult ICU patients of septic shock in AKI requiring SLED were included in this study. RESULTS: One hundred and twenty-four patients of septic shock AKI requiring SLED were enrolled in the study. There were 74 nonsurvivors (NSs). Approximately, 56% (278/498) of the sessions in which vasopressors were required were studied. Metabolic acidosis (49%) was the predominant indication for the initiation of SLED in these patients. Baseline characteristics between survivors and NSs were comparable, except for age, severity scores, AKI stage, and coexisting illness. VI and VD prior to the initiation of SLED and delta VI and VD during SLED were significantly higher in NSs. Hemodynamic tolerability and efficacy of SLED was achievable only at lower vasopressor doses. CONCLUSION: VI, VD, and combination of Kt/v together with correction of acidosis, electrolyte, and fluid overload can be used to describe hemodynamic tolerability and efficacy of SLED in septic shock AKI. However, at higher vasopressor doses in septic shock, hemodynamic tolerability and efficacy of SLED requires further evidence.

Carbapenem-resistant Acinetobacter ventilator-associated pneumonia: Clinical characteristics and outcome.

OBJECTIVE: To study the clinical characteristics and 28-days mortality in patients with ventilator-associated pneumonia (VAP) due to carbapenem-resistant Acinetobacter (CRA). DESIGN: Retrospective, observational, cohort study. SETTING: Intensive care unit (ICU) of a university hospital. MATERIALS AND METHODS: Microbiologically confirmed VAP due to CRA infection. INTERVENTION: None. RESULTS: Out of 87 patients with VAP due to CRA, 60 (69%) were male; whose median age was 51 years; 73 (84%) patients were medical; 26 (30%) had history of hospitalization in last 3 months; median acute physiology and chronic health evaluation (APACHE) II was 15 and median SOFA 9 at admission; primary reason for ICU admission was respiratory failure (34%); 46 (53%) patients had more than 2 organ failure at ICU admission; median length of ICU stay was 19 days; 66 (76%) patients need vasoactive agents during ICU stay, whereas 55 (63%) patients had renal failure; median duration of mechanical ventilation was 17 days; 22 (25%) patients had acute respiratory distress syndrome (ARDS) during ICU stay; 72 (83%) patients had exposure to carbapenem before inclusion in the study; 33 (38%) patients had same organism at other sites. In the follow-up, 47 (54%) patient survived at 28 days after having VAP; whereas only 40 (46%) patients were discharged from the hospital. CONCLUSIONS: CRA-VAP has high crude mortality. Advanced age; severity of illness and presence of pneumonia at ICU admission; and presence of shock, ARDS and renal failure have impact on outcome in these patients.

Use of optimized ultrasound axis along with marked introducer needle to prevent mechanical complications of internal jugular vein catheterization.

Internal jugular vein (IJV) catheterization is a routine technique in the intensive care unit. Ultrasound (US) guided central venous catheter (CVC) insertion is now the recommended standard. However, mechanical complications still occur due to non-visualization of the introducer needle tip during US guidance. This may result in arterial or posterior venous wall puncture or pneumothorax. We describe a new technique of (IJV) catheterization using US, initially the depth of the IJV from the skin is measured in short-axis and then using real time US long-axis view guidance a marked introducer needle is advanced towards the IJV to the defined depth measured earlier in the short axis and the IJV is identified, assessed and cannulated for the CVC insertion. Our technique is simple and may reduce mechanical complications of US guided CVC insertion.