Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study.

Background: Holistic intensive care management involves the treatment of critically ill patients in the intensive care unit (ICU) as well as catering to family psychosocial needs helping in bettering satisfaction/perception of care. There is scarce data in the Indian intensive care setting regarding the same, especially in times of increasing end-of-life practices. Our study aimed to determine the factors impacting family perception/satisfaction with intensive care. Materials and methods: A total of 336 family bystanders of patients in ICU with more than 72 hours of stay were surveyed using family satisfaction in the ICU 24 revised (FS-ICU 24R) questionnaire. Results: Multivariable logistic regression analysis showed that the significant factors associated with the satisfaction among bystanders of ICU patients were the treatment of patient's physical symptoms like pain/breathlessness (Adjusted OR 3.73, p = 0.003), ICU staff's approach to family's need consideration (Adjusted OR 4.44, p < 0.001), concern and care towards patients' family (Adjusted OR 2.67, p = 0.023). Participation in patient care, ICU waiting room atmosphere, and emotional support are the other factors independently associated with satisfaction with ICU care. Family satisfaction was not associated with the patient's survival (p = 0.331, Chi-square test) or the length of ICU (p = 0.328, Chi-square test) and hospital stay (p = 0.865, Chi-square test). Conclusion: Treatment of a patient's physical symptoms like pain, approach to family's needs consideration, and concern/care towards the patient's family are independent factors associated with optimal satisfaction among family members of ICU patients, which even takes precedence over the survival outcomes or length of ICU stay. How to cite this article: Atri V, Bhatt MT, Chaudhuri S, Mitra A, Maddani SS, Ravindranath S. Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study. Indian J Crit Care Med 2024;28(5):483-494.

Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study.

Background: Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Methods: Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Results: Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878-0.978. Kaplan-Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log-rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955-1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. Conclusion: The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care. How to cite this article: Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, et al. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024;28(5):453-460.

Comparison between a low-cost model (CPR Pillow) and a mannequin in training hands only cardiopulmonary resuscitation (CPR): A randomised trial.

Introduction: CPR is an important lifesaving skill that can improve outcomes of patients in cardiac arrest. Mass training of hands-only CPR is one of the ways to spread information and teach this skill. Need for expensive CPR mannequins are a limiting factor in conducting such mass training programmes. This study assessed the effectiveness of a low-cost CPR pillow model in training hands-only CPR. Methodology: Two hundred and six undergraduate students underwent a two-hour CPR training session. They were randomly divided into two groups - mannequin group and CPR pillow group and practiced hands-only CPR on a standard mannequin and a low-cost CPR pillow model, respectively. Knowledge, attitude, and skill acquisition were objectively assessed and compared between the two groups. Results: There was no statistical difference in hand positioning, chest compression rate and fraction, depth and overall CPR score between the two groups trained via mannequin and CPR Pillow (P > 0.05). The CPR pillow group had better percentage of chest recoil as compared to the mannequin group (86% vs 73%; P < 0.001). Conclusion: The use of low-cost homemade CPR devices such as our CPR pillow model is an acceptable alternative to mannequin for training hands-only CPR to lay rescuers.

Incorporation of plasma Vitamin C levels to modified nutritional risk in critically ill score as the novel Vitamin C nutritional risk in critically ill score in sepsis subjects as an early predictor of multidrug-resistant bacteria: A prospective observational study.

Background: On intensive care unit (ICU) admission, it is difficult to predict which patient may harbor multidrug-resistant (MDR) bacteria. MDR is the nonsusceptibility of bacteria to at least one antibiotic in three or more antimicrobial categories. Vitamin C inhibits bacterial biofilms, and its incorporation into the modified nutritional risk in critically ill (mNUTRIC) scores may help predict MDR bacterial sepsis early. Methods: A prospective observational study was conducted on adult subjects with sepsis. Plasma Vitamin C level was estimated within 24 h of ICU admission, and it was incorporated into the mNUTRIC score (designated as Vitamin C nutritional risk in critically ill [vNUTRIC]). Multivariable logistic regression was performed to determine if vNUTRIC was an independent predictor of MDR bacterial culture in sepsis subjects. The receiver operating characteristic curve was plotted to determine the vNUTRIC cutoff score for predicting MDR bacterial culture. Results: A total of 103 patients were recruited. The bacterial culture-positive sepsis subjects were 58/103, with 49/58 culture-positive subjects having MDR. The vNUTRIC score on ICU admission in the MDR bacteria group was 6.71 ± 1.92 versus 5.42 ± 2.2 in the non-MDR bacteria group (P = 0.003, Independent Student's t-test). High vNUTRIC score ≥6 on admission is associated with MDR bacteria (P = 0.042 Chi-Square test), and is a predictor of MDR bacteria (P = 0.003, AUC 0.671, 95% confidence interval [0.568-0.775], sensitivity 71%, specificity 48%). Logistic regression showed that the vNUTRIC score is an independent predictor of MDR bacteria. CONCLUSION: High vNUTRIC score (≥6) on ICU admission in sepsis subjects is associated with MDR bacteria.

Risk Factors of Decreased Abdominal Expiratory Muscle Thickness in Mechanically Ventilated Critically Ill Patients-The mNUTRIC Score is an Independent Predictor.

Background: The expiratory abdominal skeletal muscles are an important component of the respiratory muscle pump, and their reduced thickness has been associated with difficult weaning. There is no objective score that may help clinicians to predict expiratory abdominal muscle thinning. Patients and methods: This was a single-center retrospective study on 81 patients undergoing weaning from mechanical ventilation. The thickness of the four abdominal expiratory muscles-rectus abdominis (RA), internal oblique (IO), external oblique (EO), and transversus abdominis (TA) on the day of the first spontaneous breathing trial (SBT), was obtained. The various parameters of the patients with thinner RA, IO, EO, and TA below the determined thickness cut-off values, predicting difficult weaning was analyzed. Results: Modified nutritional risk in critically ill (mNUTRIC) score was found to be an independent predictor of thinner IO muscle after logistic regression analysis [p = 0.001, adjusted OR 2.33, 95% CI (1.394-3.892)]. The mNUTRIC score was also an independent predictor of thinner EO (p = 0.014, adjusted OR 1.57) and RA muscle (p = 0.002, adjusted OR 1.69). The mNUTRIC cutoff score ≥4 predicted thinner IO (AUC 0.813, p < 0.001 sensitivity 71%, specificity 77%) and thinner EO (AUC 0.738, p < 0.001, 71% sensitivity, 67% specificity). The mNUTRIC score ≥3 predicted that at least one out of the four abdominal expiratory muscles will be thin (AUC 0.849, p < 0.001, 95% CI [0.763-0.935], sensitivity 87.5%, specificity 59%). Conclusion: The mNUTRIC score is an independent predictor of thinner abdominal expiratory muscles in mechanically ventilated critically ill patients. How to cite this article: Vishwas P, Amara V, Maddani SS, Chaudhuri S, Podder S. Risk Factors of Decreased Abdominal Expiratory Muscle Thickness in Mechanically Ventilated Critically Ill Patients-The mNUTRIC Score is an Independent Predictor. Indian J Crit Care Med 2023;27(1):8-15.

Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study.

Aim: To determine the utility of the HACOR score in predicting weaning failure in resource-limited settings. Objectives: The primary objective was to determine a cut-off value of the HACOR score, sensitivity, and specificity to predict failed weaning. The secondary objective was to determine which out of five components of the score was significantly different between the successful weaning and the failed weaning groups. Introduction: Most weaning indices are either inaccurate or are dependent on complex ventilatory parameters, which are difficult to measure in resource-limited settings. This study aimed to determine the utility of the HACOR score consisting of heart rate, acidosis, consciousness level, oxygenation, and respiratory rate as a predictor of weaning in the intensive care unit. Materials and methods: It was a prospective observational study on 120 patients between 18 and 90 years. The HACOR score was evaluated at 30 minutes of spontaneous breathing trial (SBT). The total duration of SBT was 120 minutes. Results: Out of 120 patients, 83 (69.2%) had successful weaning, whereas 37 (30.8%) had weaning failure. The median and interquartile range (IQR) of the HACOR score in the successful weaning group was 2 (0-3) and 6 (5-8) in the failed weaning group (p-value <0.001). There was a significant difference in each of the five components of the HACOR score between the successful and failed weaning groups (p <0.05). HACOR score ≥5 predicted failed weaning, sensitivity 83.8%, specificity 96.4%, area under the curve (AUC) 0.950, and 95% confidence interval (CI) [0.907-0.993], p <0.001. Multivariable logistic regression analysis showed that HACOR score ≥5 is an independent predictor of weaning failure [p <0.001, 95% CI (1.9-4.2), adjusted odds ratio 2.82]. Conclusion: A HACOR score ≥5 is an excellent predictor of weaning failure. This score may be useful as a weaning strategy in the intensive care unit. How to cite this article: Chaudhuri S, Gupta N, Adhikari SD, Todur P, Maddani SS, Rao S. Utility of the One-time HACOR Score as a Predictor of Weaning Failure from Mechanical Ventilation: A Prospective Observational Study. Indian J Crit Care Med 2022;26(8):900-905. Ethical approval: Prior to the commencement of the study, Institutional Ethics Committee permission was obtained (IEC: 197/2021) and Clinical Trial Registry of India (CTRI) registration was done before recruitment (CTRI/2021/07/035139). We obtained written informed consent from the legally authorized representative prior to recruiting patients for the study.

Evaluation of Abdominal Expiratory Muscle Thickness Pattern, Diaphragmatic Excursion, and Lung Ultrasound Score in Critically Ill Patients and Their Association with Weaning Patterns: A Prospective Observational Study.

Introduction: The expiratory muscles are an indispensable component of respiratory function in critically ill patients, yet is often overlooked. We evaluated the association of abdominal expiratory muscles thickness pattern with weaning. Materials and methods: This was a single-center, prospective observational study done on 81 adult mechanically ventilated patients who underwent the weaning process. Results: Sixteen patients had simple weaning and 65 patients had either difficult or prolonged weaning. The mean and standard deviation (SD) of the thickness of expiratory abdominal muscles-rectus abdominis (RA), internal oblique (IO), external oblique (EO), and transversus abdominis (TA) were significantly more in patients with simple weaning than those with difficult or prolonged weaning. The receiver operating curve (ROC) of expiratory muscles showed RA, IO, EO, TA cut-offs 0.638, 0.492, 0.315, and 0.253 cm, respectively, to predict simple weaning. The pattern of expiratory muscle thickness RA > IO > EO > TA was maintained in both simple and difficult/prolonged weaning groups (p = 0.362). The ROC of diaphragmatic excursion (DE) for predicting simple weaning had cut-off 1.79 cm. The lung ultrasound score (LUS) was 5.75 ± 3.32 in the simple weaning group, compared to 9.71 ± 5.18 in the difficult/prolonged weaning group (p = 0.005). Conclusion: Abdominal expiratory muscles were significantly thicker in patients with simple weaning compared to those with difficult or prolonged weaning. The pattern of expiratory muscle thickness followed the pattern of RA > IO > EO > TA in both simple weaning and difficult or prolonged weaning groups. DE >1.79 cm predicted simple weaning and LUS was significantly lesser in patients with simple weaning (CTRI/2020/11/028895). How to cite this article: Amara V, Vishwas P, Maddani SS, Natarajan S, Chaudhuri S. Evaluation of Abdominal Expiratory Muscle Thickness Pattern, Diaphragmatic Excursion, and Lung Ultrasound Score in Critically Ill Patients and Their Association with Weaning Patterns: A Prospective Observational Study. Indian J Crit Care Med 2022;26(3):307-313.

Evaluation of the quality of cardiopulmonary resuscitation provided by the emergency response team at a tertiary care hospital.

Background and Aims: Chest compression fraction is the proportion of time spent on chest compression during cardiopulmonary resuscitation (CPR). The aims of this study were to know the quality of CPR provided during in-hospital cardiac arrest (IHCA) by analysing the chest compression fraction and to see the correlation of chest compression fraction with return of spontaneous circulation (ROSC) in the hospital setting. Methods: This prospective observational study was conducted in patients aged >18 years who developed IHCA. An observer would assess the quality of CPR provided by noting the time spent on chest compression. The chest compression fraction was calculated and correlated in patients with ROSC and without ROSC. Patients who survived were followed until discharge, and their neurological score was determined using the cerebral performance category (CPC). Results: We included 126 patients in the study; the mean chest compression fraction achieved was 78% (standard deviation [SD] ± 5). A total of 73 (58%) patients achieved ROSC and among them, 11 patients (9%) survived to hospital discharge. We found that the patients with ROSC had a significantly higher chest compression fraction of 80% (SD ± 5), as compared to 75% (SD ± 5), in whom ROSC could not be achieved. A multivariate logistic regression test showed higher odds (1.125) of ROSC in patients with high chest compression fraction. The mean CPC among the survivors was 1.4 (SD ± 0.5). Conclusion: Our study shows that health-care providers in our hospital provide high-quality CPR, and chest compression fraction is independently associated with ROSC in IHCA.

Pathological Lung Patterns of COVID-19 and its Clinical Correlation to Disease Severity.

Introduction: Coronavirus disease-2019 (COVID-19) infection can result in pulmonary complications ranging from mild illness to severe life-threatening disease. There are limited studies correlating the association between the clinical course of COVID-19 and histopathological findings. This study aimed to examine the postmortem histopathological changes in lung tissue of COVID-19-positive patients and to correlate those changes with disease severity. Materials and methods: This prospective observational study was conducted in adult COVID-19-positive patients. Postmortem core needle biopsy (CNB) of the lung was done using ultrasonography guidance within 1 hour of death. Histopathological analyses were performed by two expert pulmonary pathologists. The demographic and clinical data of the patients were recorded to correlate them with histopathological findings. Results: In total, 48 patients were assessed for inclusion, and 21 patient relatives consented for the study. The median duration of illness was 21 (range 9-38) days, the predominant histopathological finding was diffuse alveolar damage (DAD) in most patients (19/21), followed by pneumonia (13/21). Exudative, intermediate, and advanced DAD patterns were seen in 9.5%, 52.4%, and 28.6% of cases, respectively. Advanced DAD was associated with a longer duration of disease. The pneumonia findings were associated with positive respiratory and blood cultures. The microvascular thrombus was seen only in one patient. Conclusion: The predominant pathological findings in our patients were DAD and pneumonia. The DAD type correlated with the duration of illness, and we attributed pneumonia findings to secondary infection. The incidence of microvascular thrombi was low, and it might reflect the effect of treatment with anticoagulation. How to cite this article: Maddani SS, Rao R, Deepa HC, Noronha AK, Chaudhuri S, Vishwas P. Pathological Lung Patterns of COVID-19 and its Clinical Correlation to Disease Severity. Indian J Crit Care Med 2022;26(12):1285-1292.

Utility of the Modified Nutritional Risk in the Critically ill Score as an Outcome Predictor in All-Cause Acute Respiratory Distress Syndrome and Acute Febrile Illness-Induced Acute Respiratory Distress Syndrome.

Introduction: Nutritional risk in the Critically Ill (NUTRIC) score is a predictor of adverse outcomes in the critically ill, and its utility in a specific population of critically ill has been recommended. We aimed to study the utility of modified NUTRIC (mNUTRIC) score as a mortality predictor in acute febrile illness (AFI)-induced acute respiratory distress syndrome (ARDS) and all-cause ARDS patients. Methods: We recorded data from two prospective observational ARDS studies conducted at a single-center tertiary care hospital to evaluate the utility of the mNUTRIC score as an independent mortality predictor in all-cause ARDS and AFI-ARDS. A total of 216 all-cause ARDS patients were included, of which 73 were AFI-ARDS and 143 were non-AFI ARDS. Results: Mortality of AFI-ARDS was 16/73 (21.9%) compared to 62/143 (43.35%) in non-AFI ARDS (P = 0.002). There were no significant differences in severity of ARDS in AFI-ARDS and non-AFI ARDS groups (P = 0.504). The mNUTRIC score was found to be an independent predictor of mortality in all-cause ARDS patients (n = 216) and AFI-ARDS patients (n = 73) after Cox regression multivariable analysis. In all-cause ARDS, the mNUTRIC score had an area under the curve (AUC) of 0.778, cutoff ≥4, 82.1% sensitivity, and 65.9% specificity as a predictor of mortality. In AFI-ARDS, the mNUTRIC score had an AUC of 0.769, cutoff ≥4, 81.3% sensitivity, 66.67% specificity, and P = 0.001 as a predictor of mortality. Conclusion: The mNUTRIC score is an independent mortality predictor for all-cause ARDS and AFI-ARDS patients. AFI-ARDS has significantly lesser mortality than non-AFI ARDS.

Correlation of Serum Albumin Level to Lung Ultrasound Score and Its Role as Predictors of Outcome in Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study.

BACKGROUND: There is ambiguity in the literature regarding hypoalbuminemia as a cause of extravascular lung water and acute respiratory distress syndrome (ARDS) outcomes. The aim of the study was to determine if low serum albumin on admission leads to lung deaeration and higher lung ultrasound score (LUSS) in ARDS patients. Patients and Methods. It was a prospective observational study in which 110 ARDS patients aged between 18 and 70 years were recruited. Serum albumin level and lung ultrasound score were assessed on the day of ICU admission. Length of ICU stay and hospital mortality were recorded. RESULTS: The mean and standard deviation of serum albumin level in mild, moderate, and severe ARDS was 2.92 ± 0.65 g/dL, 2.91 ± 0.77 g/dL, and 3.21 ± 0.85 g/dL, respectively. Albumin level was not correlated to the global LUSS (Pearson correlation r -0.006, p=0.949) and basal LUSS (r -0.066, p=0.513). The cut-off value of albumin for predicting a prolonged length of ICU stay (≥10 days) in ARDS patients was <3.25 g/dL with AUC 0.623, p < 0.05, sensitivity of 86.67%, specificity of 45.45%, and 95% confidence interval (CI) [0.513-0.732], and on multivariate analysis it increased the odds of prolonged ICU stay by 8.9 times (Hosmer and Lemeshow p value 0.810, 95% CI [2.760-28.72]). Serum albumin at admission was not a predictor of mortality. LUSS on the day of admission was not useful to predict either a prolonged length of ICU stay or mortality. Basal LUSS contributed about 56% of the global LUSS in mild and moderate ARDS, and 53% in severe ARDS. CONCLUSION: Serum albumin level was unrelated to LUSS on admission in ARDS patients. Albumin level <3.25 g/dL increased the chances of a prolonged length of ICU stay (≥10 days) but was not associated with an increase in mortality. LUSS on the day of admission could not predict either a prolonged length of ICU stay or mortality. This trial is registered with CTRI/2019/11/021857.

Neutrophil-Lymphocyte Ratio in Patients with COVID-19 as a Simple Tool to Predict Requirement of Admission to a Critical Care Unit.

INTRODUCTION: Coronavirus disease-2019 (COVID-19) pandemic has overloaded the healthcare system beyond its functional capacity. Late referral to higher levels of care may be one of the factors associated with higher mortality. Therefore, we aimed to find simple demographic and laboratory parameters which predict the requirement of admission to a critical care unit. MATERIALS AND METHODS: A case-control study was undertaken in adult age population >18 years, admitted in a dedicated COVID hospital in South India. A total of 50 patients with severe disease (cases) were compared with 143 mild or asymptomatic cases (controls). Those demographic and laboratory parameters that were found to be significant on univariate analysis were used for multiple logistic regression analysis. RESULTS: Univariate analysis of demographic and laboratory data showed higher age, male sex, presence of diabetes mellitus, higher values of C-reactive protein, ferritin, D-dimer, neutrophil-lymphocyte ratio (NLR), and lactate dehydrogenase to be significantly associated with cases. Multivariate logistic regression analysis of these significant variables showed NLR and ferritin to be the independent predictors of the requirement of admission to a critical care unit. The receiver-operating characteristic curve showed an NLR value of 5.2 and a ferritin value of 462 µg/L that were able to predict the requirement of admission in critical care units. CONCLUSION: High ferritin and NLR were independent predictors of the requirement of admission in critical care units. NLR is a simple tool that can be used in resource-limited settings for triage and early referral to higher levels of care. HOW TO CITE THIS ARTICLE: Maddani SS, Gupta N, Umakanth S, Joylin S, Saravu K. Neutrophil-Lymphocyte Ratio in Patients with COVID-19 as a Simple Tool to Predict Requirement of Admission to a Critical Care Unit. Indian J Crit Care Med 2021;25(5):535-539.

A Multicenter Questionnaire-based Study to Know the Awareness and Medical Treatment Plan of Physicians Involved in the Management of COVID-19 Patients.

INTRODUCTION: The pandemic coronavirus disease 2019 (COVID-19) is on the rise in our country and there is no specific treatment modality available presently. The treatment of the disease largely remains symptomatic but repurposed drugs used to treat other disease conditions are being used to treat moderate to severe form of the disease. As the clinical trials for these drugs are ongoing, we conducted this survey to know the physicians' medical treatment plan for COVID-19 patients. MATERIALS AND METHODS: It was a web-based questionnaire study. Institutional ethical committee clearance was taken before the commencement of the study. There were a total of 17 questions, the first 6 being about the demographics, place of work, and whether the clinician was involved in the care of COVID-19 patients. Subsequent 11 questions were to assess physician's awareness and plan of the medical management of the COVID-19 patients. RESULTS: The majority of the clinicians were aware of the various treatment modalities available for the treatment of COVID-19. Regarding the plan for use of hydroxychloroquine (HCQ), 55% of the total respondents intended to use the drug in combination with azithromycin, even as 62% agreed that there was no clear evidence yet. About 90% of all clinicians, from junior residents to consultants, were monitoring electrocardiogram (ECG) during HCQ therapy; however, there were 10% of physicians who were not practicing ECG monitoring. About 68% of clinicians were aware of the various therapeutic options being tested, like convalescent plasma, lopinavir-ritonavir, and 64% knew about remdesivir. There was divergence regarding the use of steroids in a cytokine storm among the physicians, with only 39% of consultants planning to use steroids whereas about 50% of junior residents and 79% of junior consultants were planning to use the drug. CONCLUSION: The majority of the clinicians involved in the management of COVID-19 were aware of the various drug modalities available for treatment. However, more emphasis on the adverse effects and possible drug interactions is required. There is disaccord regarding the use of steroids in cytokine storm in COVID-19 and further guidelines and educational programs should address these issues. CLINICAL SIGNIFICANCE: Clinicians have to be made more aware of the possible adverse effects and drug interactions of the medications used for the treatment of COVID-19. The treatment of the serious, cytokine storm syndrome and the role of steroids must be elucidated as soon as it is feasible. HOW TO CITE THIS ARTICLE: Maddani SS, Chaudhuri S, Deepa HC, Amara V. A Multicenter Questionnaire-based Study to Know the Awareness and Medical Treatment Plan of Physicians Involved in the Management of COVID-19 Patients. Indian J Crit Care Med 2020;24(10):919-925.

A Multicenter Cross-sectional Questionnaire-based Study to Know the Practices and Strategies of Ventilatory Management of COVID-19 Patients among the Treating Physicians.

INTRODUCTION: COVID-19 has been declared a pandemic by the World Health Organization (WHO). Many of the COVID-19 patients develop acute respiratory distress syndrome (ARDS) and require ventilatory support based on their severity for which conventional strategies are being used along with few newer strategies. We conducted this multicenter survey to know the physician's current ventilation strategies adopted for the care of COVID-19 patients. MATERIALS AND METHODS: The survey was conducted after taking the ethical committee clearance. The web-based multicenter, cross-sectional questionnaire study was sent to physicians, who were involved in the management of COVID-19 patients. The questionnaire was segregated into three parts: part one consisted of general information and consent form, part two was concerned regarding demographic characteristics, and part three was concerned about their practices and strategies for ventilation of COVID-19 patients. RESULTS: A total of 223 responders replied for the questionnaire; 190 participated in the study saying that they are involved in the management of COVID-19 patients. The answers to the questionnaires were expressed as a percentage of total responses. 86% of the respondents said they have a designated intensive care unit (ICU) and 89% of the responders said they have an intubation/extubation protocol for suspect/confirmed COVID-19 patients. The responses of junior residents (JRs), senior residents (SRs), assistant professors/junior consultants, and professors/consultants were analyzed separately, and a few significant differences were observed. 39% of JRs were aware of prone ventilation as the most effective rescue ventilation strategy compared to 69% of consultants/professors. Extracorporeal membranous oxygenation (ECMO) strategy was also more significant in consultants/professors (40%) vs JRs (12%). The responders were also diverged based on medical college and corporate hospitals, and their responses were noted. Most commonly, responders in the corporate hospitals had a facility to ventilate COVID-19 patients in a negative pressure isolation facility compared to a nonnegative pressure room isolation facility in medical colleges. CONCLUSION: Most of the responders were practicing ventilation strategies in a standard manner. JRs need to undergo further training in a few aspects of the ventilatory management, and also, they need to update themselves with newer treatment modalities as they keep evolving. Medical colleges are providing at par facility compared to corporate hospitals except for few advance care facilities. CLINICAL SIGNIFICANCE: This study highlights the current practice of ventilatory management of COVID-19 patients, which is satisfactory. The survey can be used to develop study tools, to educate resident doctors, to further improve quality of care of critical COVID-19 patients. HOW TO CITE THIS ARTICLE: Maddani SS, Deepa HC, Rao S, Chaudhuri S. A Multicenter Cross-sectional Questionnaire-based Study to know the Practices and Strategies of Ventilatory Management of COVID-19 Patients among the Treating Physicians. Indian J Crit Care Med 2020;24(8):643-648.

Management of ventilator associated pneumonia with a new antibiotic adjuvant entity (ceftriaxone+sulbactam+disodium edetate) - A novel approach to spare carbapenems.

BACKGROUND: Ventilator associated pneumonia (VAP) is one of the most serious nosocomial infections in Intensive Care Unit (ICU). The aim of this study was to evaluate a new approach to spare the carbapenems for the management of patients diagnosed with VAP due to Acinetobacter baumannii (A. baumannii). METHOD: This retrospective study was conducted on VAP patients presenting for treatment at tertiary care centre between May 2014 and March 2016. The case sheets of patients who have been treated for VAP with meropenem, antibiotic adjuvant entity (AAE) and colistin were analysed. RESULTS: Out of 113 patients analysed, 24 (21.3%) patients were having VAP due to MDR A. baumannii. Microbial sensitivity has shown that 87.5% of patients were sensitive to AAE and colistin whereas all of them were resistant to meropenem, imipenem and gentamycin. The mean treatment durations were 12.4±2.1, 13.2±2.4 and 14.3±2.1days for AAE, meropenem+colistin and AAE+colistin treatment groups. In AAE susceptible patients, the mean treatment duration and cost could be reduced by 23-24% and 43-53% if AAE is used empirically. In AAE-resistant patients, the mean treatment duration and cost could be reduced by 21% and 26% if AAE+colistin regime is used empirically instead of meropenem followed by AAE+colistin. CONCLUSIONS: Clinical assessment with microbial eradication and pharmaco-economic evaluation clearly shows benefits in using AAE empirically in the management of A. baumannii infected VAP cases.