Aerosol drug therapy in critically ill patients (Aero-in-ICU study): A multicentre prospective observational cohort study.

BACKGROUND: In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs). METHODS: After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device. RESULTS: From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV. CONCLUSION: Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used.

The impact of a "short-term" basic intensive care training program on the knowledge of nonintensivist doctors during the COVID-19 pandemic: An experience from a population-dense low- and middle-income country.

BACKGROUND: The utility of basic intensive care unit (ICU) training comprising a "1-day course" has been scientifically evaluated and reported in very few studies, with almost no such study from resource-limited settings. AIM: The study assessed the utility of basic ICU training comprising of a "1-day course" in increasing the knowledge of nonintensivist doctors. MATERIALS AND METHODS: This is an observational study conducted at a medical university in North India in 2020. The participants were nonintensivist doctors attending the course. The course was designed by intensivists, and it had four domains. The participants were categorised on the basis of their duration of ICU experience and broad speciality. Pretest and posttest was administered, which was analysed to ascertain the gain in the knowledge score. RESULTS: A total of 252 participants were included, of which the majority were from the clinical medicine speciality (85.3%) and had ICU experience of 1-6 months (47.6%). There was a significant improvement in the mean total score of the participants after training from 14/25 to 19/25, with a mean difference (MD) of 5.02 (p < 0.001). Based on ICU experience, in groups I (<1 month), II (1-6 months), and III (>6 months), there was a significant improvement in the total score of the participants after training with MD with 95% confidence interval (CI) limits of 5.27 (4.65-5.90), 4.70 (4.38-5.02), and 5.33 (4.89-5.78), respectively. In the clinical surgery specialty (n = 37), there was a significant improvement in the total score after training from 11/25 to 16.4/25 with an MD (95% CI limits) of 5.38 (4.4-6.3). Similarly, in the clinical medicine group (n = 215), the MD (95% CI limits) score after training was 4.95 (4.71-5.20), from 14.5/25 to 19.5/25. In feedback, more than half of the participants showed interest in joining ICU after training. CONCLUSIONS: Training nonintensivist doctors for 1 day can be useful in improving their knowledge, regardless of their prior ICU experience and speciality.

A Challenging Diagnosis of Sheehan's Syndrome in Non-obstetric Critical Care and Emergency Settings: A Case Series of Five Patients with Varied Presentations.

Sheehan's syndrome is a life-threatening endocrine emergency seen in postpartum females secondary to ischemic pituitary necrosis. It is a frequent cause of hypopituitarism in developing countries that occurs secondary to postpartum haemorrhage (PPH). Patients with Sheehan's syndrome often present with organ dysfunctions in critical care settings, secondary to stressors precipitating the underlying hormonal deficiencies. The initial clinical picture of Sheehan's syndrome may mimic some other disease, leading to misdiagnosis and diagnostic delay. Strict vigilance, timely diagnosis, and appropriate management are essential to avoid diagnostic delay and to improve the patient outcome. In this case series, we describe 5 cases of previously undiagnosed Sheehan's syndrome (including young, middle aged and postmenopausal females) that presented to critical care and emergency settings with organ failures.

Approach to new-onset facial nerve palsy in a critically ill patient: A case report.

Lower motor type of facial nerve palsy (Bell's palsy) is one of the most common types of facial nerve palsy, with well-defined management with steroids and antivirals for patients attending outpatient clinics. The diagnosis and management of facial nerve palsy in critically ill patients require an individualized approach, as there may be many other causes like soft-tissue compression due to facial edema which can occur as a complication of prone ventilation and severe subcutaneous emphysema. This report highlights the challenges in the management of new-onset facial nerve palsy diagnosed in the intensive care unit (ICU) for a patient on mechanical ventilation, and creates a necessity for a standard operating protocol for the management of such scenarios in ICU.

Nerve Conduction Studies: What an Intensivist should Know?

How to cite this article: Saran S, Qavi A. Nerve Conduction Studies: What an Intensivist should Know? Indian J Crit Care Med 2022;26(6):759-760.

A Rare Case Report of Intra-abdominal Mucormycosis Complicating Acute Pancreatitis.

Intra-abdominal infections are known to complicate the course of acute pancreatitis. Invasive fungal infections (Candida spp.) are not the uncommon microorganisms which isolate from intra-abdominal specimen in acute necrotizing pancreatitis. However, we are reporting first case of invasive gastric mucormycosis in a postpartum acute pancreatitis patient. How to cite this article: Bhaskar BK, Gutte SH, Gurjar M, Saran S, Rahul R, Sengar P. A Rare Case Report of Intra-abdominal Mucormycosis Complicating Acute Pancreatitis. Indian J Crit Care Med 2022;26(6):736-738.

Ultrasound for thigh muscle thickness is a valuable tool in the diagnosis of sarcopenia in Indian patients with predialysis chronic kidney disease.

Objectives: Patients with chronic kidney disease (CKD) are known to develop sarcopenia, an aging-related disorder, with low muscle mass, strength and physical performance. Ultrasound-derived thigh muscle and rectus femoris thickness (TMT and RFT) can be measured easily in clinical practice, but need validation for use in predialysis CKD (stages III through V) for muscle mass estimation. The study aims to compare ultrasound-derived TMT and RFT with bioelectrical impedance analysis (BIA)-derived muscle mass estimation in the diagnosis of sarcopenia in predialysis CKD. Methods: Patients with stable CKD stage III, IV, V and not yet on dialysis were recruited, and underwent anthropometric assessment, BIA and ultrasound examination of midthigh region. Appendicular skeletal muscle index (ASMI)/height2 derived from BIA was taken as a standard for the diagnosis of low muscle mass. Gait speed and handgrip were also measured. The Asian Working Group criteria were applied. Cutoff values for low muscle mass by TMT and RFT were obtained using receiver operator curve (ROC) analysis. Results: Of the total of 117 enrolled study participants, 52 (45%) had low muscle mass, 34 (29%) had sarcopenia, of whom 79% were male, majority (38%) were CKD stage IV and had a mean age of 58 years. Using ROC analysis, TMT cutoffs of 19 mm in males and 17 mm in females were computed. Comparison of TMT cutoffs and ASMI/h2 showed good agreement between the 2 methods using Bland-Altman plots. Conclusions: Ultrasound-derived TMT and RFT can be used for muscle mass estimation in the diagnosis of sarcopenia.

Identifying and Implementing Strategies to Reduce the Risk of Self-Contamination of Health Care Workers Caused by Doffing of Personal Protective Equipment During the COVID-19 Pandemic.

During the current coronavirus disease (COVID-19) pandemic, it is estimated that tens of thousands of health care workers have been infected. The doffing of personal protective equipment (PPE) has been identified an important place and procedure that might influence the self-contamination of health care workers. More recent evidence suggests that, in addition to existing infection control standards, there is an urgent need for the incorporation of various recent information and advancements pertaining to structure and process to reduce the self-contamination of health care workers during the doffing of PPE.

Phosphate Intake and Removal in Predominantly Vegetarian Patients on Twice-Weekly Hemodialysis.

Background: Hyperphosphatemia is linked to increased mortality and morbidity in patients on hemodialysis. Currently, the phosphate intake and dialytic removal in predominantly vegetarian patients on twice-weekly dialysis is not well studied. Materials and methods: This prospective, study recruited patients on twice-weekly dialysis of at least 3 months duration. Baseline clinical variables were measured. Dietary protein and phosphorus intake was assessed using a validated food frequency questionnaire. Phosphate binder use was assessed, hourly blood was collected for serum phosphorus during dialysis, and spent dialysate was collected to estimate cumulative phosphorus removal during the session. Results: Forty (67%) of the 60 patients studied were vegetarians. Twenty-eight (48%) were hyperphosphatemic, and 15 (25%) had serum parathormone (PTH) >500 pg/ml. The mean phosphorus intake was 1247 (±312) mg/day, the mean serum phosphorus was 5.49 (±2.01) mg/dl, and the mean dialytic phosphorus removal was 910 (±383) mg/session. Up to 67% of the study population took calcium-based phosphate binders, 25% took sevelamer carbonate, and 40% took activated vitamin D preparation. The lowest tertiles of phosphorus intake correlated with low energy-adjusted protein intake and hypoalbuminemia. Hyperphosphatemic subjects had better nutritional indices (mid-upper arm circumference and body mass index). Dietary intake and serum phosphorus levels were not mutually associated, but both were strongly correlated with total phosphorus removal in the spent dialysate. Serum phosphorus levels fell by 32% by thefirst hour of hemodialysis. Conclusion: Twice-weekly dialysis is often practised in resource-limited Asian countries. However, due to a predominantly vegetarian diet, hyperphosphatemia was noted only in up to half of the patients, despite twice-weekly hemodialysis schedules. This reinforces the fact that plant-based dietary phosphate is less well absorbed.

Fulminant acute fatty liver of pregnancy presenting with multi-organ failure: A case series.

Liver disease in pregnancy can be classified into pregnancy-related, liver disease coincident with pregnancy or preexisting liver disease. Acute fatty liver of pregnancy (AFLP) is a rare liver disorder that is caused by defects in mitochondrial beta (ß) oxidation of fatty acids. In view of its fulminant presentation and rapid progression to multiple organ failure (MOF), AFLP carries high maternal and fetal mortality. These patients are commonly present in the third trimester of pregnancy with gastrointestinal symptoms and complications such as hypoglycemia, lactic acidosis, hyperammonemia, leukocytosis, liver dysfunction, coagulopathy, and renal dysfunction. Diagnosis is mostly based on the Swansea diagnostic criteria and by excluding other etiologies of liver dysfunction. Liver biopsy is rarely performed owing to underlying coagulopathy and thrombocytopenia. In this case series, we intend to share our experience of managing four cases of AFLP that were admitted to the intensive care unit with fetal demise and MOF.

Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review.

Background: Pregnancy-related acute kidney injury (PRAKI) is an important cause of fetomaternal mortality and morbidity in developing countries. We undertook a systematic review to identify the causes of PRAKI among obstetric patients in India. Materials and methods: We systematically searched PubMed, MEDLINE, Embase, and Google Scholar using appropriate search terminology between 1 January 2010 to 31 December 2021. Studies reporting the etiology of PRAKI among obstetric patients (pregnant and within 42 days postpartum) in India were included for evaluation. Studies done in any other geographical location besides India were excluded. We also excluded studies done in any one trimester or any specific subgroup of patients [e.g., postpartum acute kidney injury (AKI), postabortal AKI]. A five-point questionnaire was used to assess the risk of bias in included studies. The results were synthesized as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results: A total number of 7 studies with 477 participants were included for analysis. All were single-center descriptive observational studies either done in tertiary care public or private hospitals. Sepsis (mean, 41.9%; median, 49.4%; and range, 6-56.1%) was the most common cause of PRAKI followed by hemorrhage (mean, 22.1%; median, 23.5%; and range, 8.3-38.5%) and pregnancy-induced hypertension (mean, 20.9%; median, 20.7; and range, 11.5-39%). Among these seven studies, five were of moderate quality, one was of high quality, and another one was of low quality. Our study is limited due to the lack of consensus definition of PRAKI in literature and heterogeneity in reporting methods. Our study highlights the need for a structured reporting format for PRAKI to understand the true disease burden and take control measures. Conclusion: There is a moderate quality of evidence to suggest that sepsis followed by hemorrhage and pregnancy-induced hypertension are the commonest causes of PRAKI in India. How to cite this article: Gautam M, Saxena S, Saran S, Ahmed A, Pandey A, Mishra P, et al. Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review. Indian J Crit Care Med 2022;26(10):1141-1151.

CPR in COVID-19: Should We Use the PAPR to Keep the Savior Safe?

Saran S. CPR in COVID-19: Should We Use the PAPR to Keep the Savior Safe? Indian J Crit Care Med 2021;25(8):950.

Predialytic versus Intradialytic Nutrition: A Study to Assess Effects on Intradialytic Blood Pressure, Dialysis Adequacy, and Urea Removal.

BACKGROUND: Provision of oral protein in hemodialysis (HD) is desirable due to improved compliance to protein requirements and better nutritional status, but the risks of hypotension and underdialysis need to be considered. This study compared 2 different timings for administering oral nutritional supplements (ONS), predialysis and mid-dialysis, with respect to hemodynamics, dialysis adequacy, urea removal, and tolerability. METHODS: This single-center, prospective crossover study analyzed 72 stable patients with ESRD on twice a week maintenance HD with a mean age of 38.7 (±11.2) years and a dialysis vintage of 28.2 (±13.1) months. In the first week, all the patients received ONS (450 kcal energy, 20 g protein) 1 h prior to start of dialysis (group 1) and in the next week, the supplement was administered after 2 h of start of dialysis (group 2), with a predialysis fasting period of at least 3 h in both groups. Blood pressures, serum, and spent dialysate samples were collected and nausea occurrence was noted by severity. RESULTS: Predialytic intake (group 1) was associated with higher predialysis and 1st hour blood urea, dialysis adequacy, and urea removal than group 2. Both groups achieved mean Kt/V > 1.2, and the occurrence of symptomatic hypotensive episodes and nausea was not significantly different between the groups. On repeated measures ANOVA, changes in blood urea over time showed significant group effect. CONCLUSIONS: Predialytic supplementation was associated with better dialysis adequacy and urea removal than intradialytic supplementation. However, both timings were equally tolerated and not associated with underdialysis.

Less Costlier and Emergency Options for Intubation during Coronavirus Disease Times.

How to cite this article: Saran S, Dube M, Azim A. Less Costlier and Emergency Options for Intubation during Coronavirus Disease Times. Indian J Crit Care Med 2021;25(12):1462-1463.