Carotid Blood Flow as a Surrogate for Pulse Contour Analysis in Assessment of Fluid Responsiveness: A Prospective, Observational, Single-Centre Study (Contour Study).

Background and objectives The quest for an accurate and reliable non-invasive method of assessing cardiac output in critically ill patients is still ongoing. Carotid artery Doppler is a promising non-invasive, reproducible, and feasible bedside monitor. So we compared the change in cardiac output derived from arterial pressure waveforms (pulse contour analysis) with that from carotid artery Doppler-derived measurements, in post-major elective abdominal surgery patients. Materials and methods We conducted a prospective observational study in 30 adult post-major elective abdominal surgery patients admitted to the Gastroenterology and Liver Transplant intensive care unit postoperatively on mechanical ventilator support, who were found to be fluid responsive clinically on passive leg raise (PLR) test. Demographics and vasopressor support were recorded. Hemodynamic parameters including heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), cardiac output (CO) using arterial pulse contour analysis (Vigileo monitor/FloTrac® sensor; Edwards Lifesciences, Irvine, California, United States), and carotid blood flow (CBF) were recorded on the baseline, pre- and post- PLR, and post fluid bolus administration. Balanced salt solution at the rate of 6ml/kg over 20 minutes was given as a fluid bolus. Results Of the 30 patients who were included in the study, 16 patients (53.3%) were on vasopressor support, mean (± SD) age of the patients was 52.93 (± 8.13) years. There was a significant increase in the SBP (mmHg) pre- to post-PLR, that is, 112.2±15.57 and 118.7±14.96, respectively (p-value = 0.001). Also from pre-PLR to post-fluid bolus administration, the increase in SBP was significant, 112.2±15.57 and 121.93±13.96, respectively (p-value = 0.001). The change in cardiac output measured using Vigileo and CBF from pre- to post-PLR (7.66±1.45 to 9.14±1.76, p< 0.001 for Vigileo and 8.10±1.66 to 9.72±1.99, p<0.001 for CBF) and pre-PLR to post fluid administration (7.66±1.45 to 9.39±1.77, p< 0.001 for Vigileo and 8.10±1.66 to 10.31±2.26, p< 0.001 for CBF) were significant. There was a positive correlation between the change in cardiac output as measured from arterial pulse contour analysis technique (Vigileo) and that measured from CBF (r=0.884) pre- and post-PLR. There was a significant correlation between cardiac output measurements derived from two techniques, before PLR, after PLR, and after fluid expansion (p< 0.001 for each variable). The change in cardiac output before PLR and after fluid expansion was also correlated by both the techniques (correlation coefficient being, r=0.781). Conclusion There was a significant positive correlation of the CO (absolute and change) measurements pre- and post-interventions (that is, PLR and fluid bolus administration) as made by pulse contour analysis (Vigileo) and by CBF in post-surgical patients. Pulse wave Doppler of CBF could be used as a surrogate for invasive measures of CO measurement for prediction of fluid responsiveness in this subgroup. Further larger studies can be performed to validate the same.

Fluid Responsiveness in Critically Ill Patients Using Carotid Peak Systolic Velocity Variability: A New Frontier.

Background and objectives A fluid responder is a patient who can increase his stroke volume/ cardiac output by more than 10%-15% after a fluid bolus. Left ventricular outflow tract (LVOT) velocity time integral (VTI) variability is widely used as an adynamic parameter of fluid responsiveness, but a transthoracic echo view of LVOT VTI is often time-consuming and, at times, difficult to achieve. So, in the quest for another parameter that might equally be a good surrogate marker of stroke volume variation, carotid peak systolic velocity (CPSV) variation has been studied. The objective was to assess CPSV variation in patients who are already fluid responders. Methods The sample size was calculated considering a minimum correlation coefficient of 0.5. Adult patients in whom the physician wanted to give a fluid bolus and whose average LVOT VTI was more than 15% over 3 respiratory cycles were included in the study. Demographic variables, along with hemodynamic parameters such as heart rate, blood pressure, the need for vasopressors, mode of breathing (spontaneous or mechanical ventilation), and CPSV variation,were noted and averaged over three respiratory cycles. Fluid bolus (Plasmalyte) 6 ml/kg bolus over 10-15 minutes. Post-fluid hemodynamic variables, along with averaged LVOT VTI over three respiratory cycles and averaged CPSV variation over three respiratory cycles, are noted. Results Thirty adult patients were evaluated in the study. In spontaneously breathing patients (n=12), the average CPSV variation expressed as mean + standard deviation before and after fluid administration of 6ml/kg of ideal body weight was 14.1 ± 3.4 and 5.4 ± 2.6, respectively (p < 0.05). In mechanically ventilated patients (n=18), the average CPSV variation expressed as mean + standard deviation before and after fluid administration of 6ml/kg of ideal body weight fluid was 15 ± 5.3 and 6.5 ± 3.1, respectively (p <0.005). Overall, there was a statistically significant positive correlation between LVOT VTI variation and CPSV variation before fluid therapy (correlation coefficient 0.56 and p-value 0.001) and a statistically significant moderate positive correlation post-fluid therapy (correlation coefficient 0.37 and p-value 0.043). Conclusion We found a significant decrease in CPSV variation post-fluid administration in patients who are fluid responders, which mimics a decrease in stroke volume variation after fluid administration in patients who are fluid responsive.

Delirium Assessment in Intensive Care Unit: A Need for Higher Regard!

How to cite this article: Govil D, Pal D. Delirium Assessment in Intensive Care Unit: A Need for Higher Regard! Indian J Crit Care Med 2022;26(6):661-662.

An overview and assessment of the existing technological options for management and resource recovery from beach wrack and dredged sediments: An environmental and economic perspective.

The present work discusses the problems and management options of beach wrack and dredged sediments. Beach wrack and dredged sediments near the shores have affected the coastal ecosystem, badly. The piles of beach wrack residues might be a significant emitter of greenhouse gases (GHGs) and dredged sediment is a substantial source of heavy metals and other pollutants. The recovery of valuable resources such as metals and nutrients from these so-called "wastes" is a sustainable strategy to enhance the resilience of the coastal ecosystem and management. The beach wrack meadows can be a potential source for green energy production. Even the demand for biodegradable polymers can be supplied by utilizing the waste beach wracks. The residues of beach wrack species like Posidonia oceanica, Zostera marina, Ulva spc. and Enhalus acorodies can be very beneficial species in terms of economic growth. Red algae have been the most favored and efficient candidate for methane yield. In case of dredged sediment, dewatering of sediment is an essential step for successful resource extraction. Although, extraction methods are almost similar to that applied for soil treatment, which includes pretreatment, physical partitioning, washing, thermal treatment, biological extraction, and immobilization. The fractionation study can be a beneficial tool for determining the metal species present in the sediment. Immobilization techniques are successful but continuous monitoring is required. The vitrification technique is highly effective but very expensive. Thermal treatment is useful for volatile metals such as mercury (Hg), but costs are high. Biological extractions are comparatively cheap but time-consuming. Henceforth, very few extraction methods are available for sediment and required further advancement in this field.

Can We Predict Outcome In Critically Ill Elderly Patients?

How to cite this article: Govil D, Pal D. Can We Predict Outcome in Critically Ill Elderly Patients? Indian J Crit Care Med 2021;25(6):615-616.

Gastrointestinal Motility Disorders in Critically Ill.

Gastrointestinal (GI) motility disorders are a common problem in the intensive care unit (ICU) and are associated with increased morbidity, complications like feeding intolerance, malnutrition, bacterial translocation, sepsis, multiple organ failure, prolonged hospital stay and increased risk of mortality. Several risk factors in intensive care setting that contribute to GI dysmotility include mechanical ventilation, vasopressor support, use of opioids, etc. Degree of GI motility dysfunction correlates with severity of critical illness. So, it is important to identify the dysfunction early so that targeted therapy could be prescribed to prevent worsening of clinical outcomes. How to cite this article: Govil D, Pal D. Gastrointestinal Motility Disorders in Critically Ill. Indian J Crit Care Med 2020;24(Suppl 4):S179-S182.

Percutaneous Tracheostomy under Real-time Ultrasound Guidance in Coagulopathic Patients: A Single-center Experience.

OBJECTIVE: To examine the safety and complications associated with percutaneous tracheostomy (PT) in critically ill coagulopathic patients under real-time ultrasound guidance. MATERIALS AND METHODS: Coagulopathy was defined as international normalized ratio (INR) ≥1.5 or thrombocytopenia (platelet count ≤50,000/mm3). Neck anatomy was assessed for all patients before the procedure and was characterized as excellent, good, satisfactory, and unsatisfactory based on the number of vessels in the path of needle. Percutaneous tracheostomy was performed under real-time ultrasound (USG) guidance, with certain modifications to the technique, and patients in both groups were assessed for immediate complications including bleeding. RESULTS: Six hundred and fifty-two patients underwent USG-guided PT. Three hundred and forty-five (52.9%) were coagulopathic before the procedure. Ninety-nine patients (15.2%) had an excellent neck anatomy on USG scan, and 112 patients (62 in coagulopathy group vs 50 in noncoagulopathy group, p value 0.386) had an unsatisfactory neck anatomy for tracheostomy. A total of 42 events of immediate complications were noted in 37 patients (5.7%). No difference was seen in the rate of immediate complications in both groups (5.8% in coagulopathy group vs 5.5% in noncoagulopathy group, p value 0.886). The incidence of minor bleeding in coagulopathic patients was 14 patients (4.1%) and 7 (2.3%) in those without coagulopathy, and this difference was not statistically different (p value-0.199). In the subgroup analysis of patients with significant coagulopathy and unsatisfactory anatomy, no difference was observed in the incidence of immediate complications. CONCLUSION: This study shows the efficacy and safety of real-time ultrasound-guided PT, even in patients with coagulopathy. HOW TO CITE THIS ARTICLE: Kumar P, Govil D, Patel SJ, Jagadeesh KN, Gupta S, Srinivasan S, et al. Percutaneous Tracheostomy under Real-time Ultrasound Guidance in Coagulopathic Patients: A Single-center Experience. Indian J Crit Care Med 2020;24(2):122-127.

An approach to counter sediment toxicity by immobilization of heavy metals using waste fish scale derived biosorbent.

The utilization of fish scale-derived biosorbent for immobilization of cadmium and lead in polluted sediment was thoroughly investigated in this study. Fish scale (FS) biomass was chemically and physically treated. The FS biomass treated with acid (0.1 M HCl), alkali (0.1 M NaOH) and hydrothermally, showed minimum removal capacity. While, FS treated hydrothermally along with acid showed the maximum removal efficiency of metal ions. We used different dosages (0%, 2.5%, 5%, 10%, 15%, and 20%) of FS biosorbent in the sediment. Isotherm modelling showed that this biosorbent can hold 89.30 and 92.65 mg/g of Cd and Pb on its surface. This indicated that prepared FS biosorbent has enough potential to adsorb Cd and Pb ions on its surface from the sediment. Compared to the control, sediment treated with 20% FS showed the highest immobilization capacities for Pb (92.9%), and Cd (87.9%). The values of partition coefficient (Kd) increased by 83% for Pb and 78% for Cd, which specified that availability of free ions of Pb and Cd in the aquatic system was successfully decreased. The sediment treated with 20% FS biosorbent showed 70-80% immobilization of Cd and Pb from mobile and exchangeable fractions that ultimately decreased the bioavailability of metal ions to the biota. Inclusively, compared to control, sediment served with 20% FS biosorbent showed higher level of Pb and Cd ions in residual fraction near by 80%. The prepared FS biosorbent had shown its potential in immobilizing the Cd and Pb ions from sediment as a cheap and ecologically feasible method for amendment.

Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography.

How to cite this article: Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019;23(Suppl 3):S202-S206.

Heavy metal speciation, leaching and toxicity status of a tropical rain-fed river Damodar, India.

Speciations of metals were assessed in a tropical rain-fed river, flowing through the highly economically important part of the India. The pattern of distribution of heavy metals (Cd, Co, Cr, Cu, Mn, Ni, Pb and Zn) were evaluated in water and sediment along with mineralogical characterization, changes with different water quality parameters and their respective health hazard to the local population along the Damodar River basin during pre-monsoon and post-monsoon seasons. The outcome of the speciation analysis using MINTEQ indicated that free metal ions, carbonate, chloride and sulfate ions were predominantly in anionic inorganic fractions, while in cationic inorganic fractions metal loads were negligible. Metals loads were higher in sediment phase than in the aqueous phase. The estimated values of Igeo in river sediment during both the seasons showed that most of the metals were found in the Igeo class 0-1 which represents unpolluted to moderately polluted sediment status. The result of partition coefficient indicated the strong retention capability of Cr, Pb, Co and Mn, while Cd, Zn, Cu and Ni have resilient mobility capacity. The mineralogical analysis of sediment samples indicated that in Damodar River, quartz, kaolinite and calcite minerals were dominantly present. The hazard index values of Cd, Co and Cr were > 1 in river water, which suggested potential health risk for the children. A combination of pragmatic, computational and statistical relationship between ionic species and fractions of metals represented a strong persuasion for identifying the alikeness among the different sites of the river.

Seasonal variation of heavy metals in water, sediment, and highly consumed cultured fish (Labeo rohita and Labeo bata) and potential health risk assessment in aquaculture pond of the coal city, Dhanbad (India).

The extent of heavy metal pollution and their impact on the various component of urban aquaculture pond (India) were investigated on the basis of seasonal variation. The water, sediment, and fish samples (Labeo rohita and Labeo bata) were collected and analyzed to assess the metal toxicity. In the sediment, geoaccumulation index (Igeo), contamination factor (CF), pollution load index (PLI), and ecological risk index (ERI) were calculated. The estimated daily dietary intake (EDI) for As, Cd, Cr, Mn, Pb, and Zn was estimated in adult and children on the basis an average amount of fish consumed by the Indian people and its associated health hazard with was also assessed in terms of target hazard quotients (THQs). The concentration of metals in all the analyzed samples was found higher during pre-monsoon season. While, in case of fish, L. bata species has higher metal accumulation rate during both the seasons than the L. rohita because of their bottom dweller feeding habit. The order of metals in L. bata muscles is Zn > Mn > Pb > Cr > As > Cd. The Igeo value for Zn (2.66 to 3.68) was found to be highest and followed by Cd (1.65 to 3.52) and Pb (1.52 to 2.55) indicating moderate to highly polluted sediment quality. The values of ERI were significantly high during pre-monsoon period and varied from 319 to 557, representing very high metal contamination. From the human health perspective, present study highlighted that the local inhabitants who rely on this valuable pond for fish consumption are exposed chronically to As and Pb pollution due to higher THQ values, especially from the intake of L. bata.