Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM.

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give "real-world" criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs. How to cite this article: Zirpe KG, Tiwari AM, Pandit RA, Govil D, Mishra RC, Samavedam S, et al. Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM. Indian J Crit Care Med 2022;26(S2):S43-S50.

Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review.

INTRODUCTION: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening, allergic reactions affecting the skin and mucous membranes. SJS is considered to be a milder form with less than 10% of body surface area (BSA) involvement. We report successful management of two cases of SJS and TEN. Firstly, a case of a 24-year-old female who presented with rashes over face, chest, and upper limbs after the oral intake of ciprofloxacin and local application of moxifloxacin eye drops. She developed high-grade fever and difficulty in breathing requiring intubation and lung-protective mechanical ventilation and was treated with high-dose methylprednisolone, azithromycin, soframycin skin dressings, and topical ocular antibiotics. Secondly, another case of a 16-year-old female who developed bullous eruptions over the trunk, arms, hands, face, and sole involving 60% of BSA, after oral intake of albendazole. She was diagnosed as TEN and successfully managed with sterile silver nitrate, soframycin dressings, and antibiotics. KEY MESSAGE: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening, allergic reactions affecting the skin and mucous membranes. Early identification, withdrawal of the suspected drug, and early transfer to a specialized center decrease mortality. HOW TO CITE THIS ARTICLE: Arora R, Pande RK, Panwar S, Gupta V. Drug-related Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Review. Indian J Crit Care Med 2021;25(5):575-579.

Arterial Blood Gas: Bowling Wide and Poor Wicketkeeping.

Arterial blood gas (ABG) is an essential point-of-care test to identify the pH, metabolic, and respiratory status of critically ill patients. In addition, it provides useful information about co-oximetry, lactate, electrolytes, and other parameters. Studies show that it is widely prescribed but the impact of ABG result on clinical care is limited. Protocols addressing effective utilization of ABG can address and help in minimizing cost and complications. How to cite this article: Pande RK. Arterial Blood Gas: Bowling Wide and Poor Wicketkeeping. Indian J Crit Care Med 2021;25(2):119-120.

Gastrointestinal Stomas and Fistulas: What is Lost and What to Do?

Abnormal connections between gastrointestinal tract (GIT) and skin are called enterocutaneous fistulas (ECFs). Presence of ECF is associated with significant morbidity and mortality. A stoma refers to a surgically created opening in the abdomen to divert feces or urine to the outside of the body, to compensate for partial or complete loss of bowel function. Gastrointestinal (GI) stomas and postoperative ECFs present a unique challenge to the intensivist due to development of malnutrition, dehydration, and sepsis leading to high morbidity and mortality. This review focuses on the basic concepts about the type of fistula and stomas, their indications and complications, and management. Principles of clinical management include replacement of fluid and electrolyte losses, control of sepsis along with reducing fistula output, prevention of malnutrition and psychological support, and skin care. How to cite this article: Pande RK, Gupta A. Gastrointestinal Stomas and Fistulas: What is Lost and What to Do? Indian J Crit Care Med 2020;24(Suppl 4):S175-S178.

Procedures in COVID-19 Patients: Part-I.

The number of cases with novel coronavirus disease-2019 (COVID-19) infection is increasing every day in the world, and India contributes a substantial proportion of this burden. Critical care specialists have accepted the challenges associated with the COVID-19 pandemic and are frontline warriors in this war. They have worked hard in streamlining workflow isolation of positive patients, clinical management of critically ill patients, and infection prevention practices. With no end in sight for this pandemic, intensive care unit (ICU) practitioners, hospital administrators, and policy makers have to join hands to prepare for the surge in critical care bed capacity. In this position article, we offer several suggestions on important interventions to the ICU practitioners for better management of critically ill patients. This position article highlights key interventions for COVID-19 treatment and covers several important issues such as endotracheal intubation and tracheostomy (surgical vs PCT), nebulization, bronchoscopy, and invasive procedures such as central venous catheters, arterial lines, and HD catheters. How to cite this article: Pande RK, Bhalla A, SN Myatra, Yaddanpuddi LN, Gupta S, Sahoo TK, et al. Procedures in COVID-19 Patients: Part-I. Indian J Crit Care Med 2020;24(Suppl 5):S263-S271.

Procedures in COVID-19 Patients: Part-II.

Critical care in the era of novel coronavirus disease-2019 (COVID-19) infection has multiple challenges including management of the patient, underlying comorbidities, and the complications. With no end in sight to the pandemic, intensive care unit (ICU) practitioners and hospital administrators have to join hands to prepare for the long battle ahead. Critically ill COVID-19 patients need imaging or image-guided interventions in one form or the other including X-rays, ultrasonography (USG), echocardiography (ECHO), and CT scan. These patients often require renal replacement therapy (RRT) for either the preexisting chronic renal insufficiency or acutely developing kidney injury. Another important component of care is transfer of the patient to and fro from the ICU or to higher care centers. Most of the ICUs are equipped with modern facilities but with increasing number of patients a large number of makeshift arrangements are being made for managing these patients. This position paper outlines important tips to formulate protocols and procedures for critically ill patients, who are managed in the ICU. How to cite this article: Pande RK, Bhalla A, Myatra SN, Yaddanpuddi LN, Gupta S, Sahoo TK, et al. Procedures in COVID-19 Patients: Part-II. Indian J Crit Care Med 2020;24(Suppl 5):S272-S279.

Behavioral Pain Assessment Tool: Yet Another Attempt to Measure Pain in Sedated and Ventilated Patients!

The interesting study by Mitra et al. in this issue explores this newly developed pain assessment tool- Behavior pain assessment tool (BPAT) for critical patients who cannot communicate. The authors explored the tool in a prospective survey in 400 adults, noncomatose intensive care unit (ICU) patients. BPAT scoring was done within 2-3 hours of admission in ICU, followed by every day in the morning, and also before and after ICU procedures associated with pain. The BPAT scoring was done by untrained senior residents independent of each other. Majority of the patients had BPAT score of ≤3 (initial score in 83.5% and baseline score in 74.5% patients). In all, 56.5% patients had a postprocedure pain score of ≤3, highlighting the role of institutional sedation-analgesia protocol, as all patients received either morphine or fentanyl infusion along with midazolam infusion. Grimace was the most liked behavior (67%) by the observers, whereas closed eyes was the least liked (59%). Closed eyes behavior was felt to have poor utility in paralyzed, ventilated patients. Authors feel that as verbal and bodily responses could not be assessed in these patients, the BPAT can be further modified to observe pain in such patients. The behaviors like verbal complaints, muscle rigidity, and clenched fist were also liked less. For most behavior patterns liked by observers, the κ coefficient was quite high (>0.9). The BPAT tool was found easy to understand (93.3%) and apply (91.8%) by untrained observers. Most observers (59.25%) considered that the time spent on calculating BPAT was short, although the timelines have not been defined. The study again confirms that sedated, paralyzed, and ventilated patients are the most difficult group for assessment of pain. Interobserver variability may lead to subjective bias. The study has not looked at the impact of BPAT scoring on reduction or adjustment of opioid needs of these patients. Further studies may throw more light on the practical applications of BPAT score, and comparative studies between BPAT, behavioral pain scale (BPS), and critical-care pain observation tool (CPOT) would be very interesting. HOW TO CITE THIS ARTICLE: Pande RK. Behavioral Pain Assessment Tool: Yet Another Attempt to Measure Pain in Sedated and Ventilated Patients!. Indian J Crit Care Med 2020;24(8):617-618.