New Antibiotic Prescription Pattern in Critically Ill Patients ("Ant-critic"): Prospective Observational Study from an Indian Intensive Care Unit.

Introduction: This study aimed to address the issue of antibiotic prescription processes in an Indian Intensive care unit (ICUs). Materials and methods: In a prospective longitudinal study, all adult patients admitted in the ICU for 24 hours or above between 01 June 2020 and 31 July 2021 were screened for any new antibiotic prescription throughout their ICU stay. All new antibiotic prescriptions were assessed for baseline variables at prescription, any modifications during the course, and the outcome of antibiotic prescription. Results: A total of 1014 patients fulfilled entry criteria; 59.2 and 7.2% of days they were on a therapeutic and prophylactic antibiotic(s). Patients, who were prescribed therapeutic antibiotic(s), had worse ICU outcomes. A total of 49.5% of patients (502 of 1,014) received a total of 552 new antibiotic prescriptions during their ICU stay. About 92.13% of these prescriptions were empirical and blood or other specimens were sent for culture in 78.81 and 60.04% of instances. A total of 31.7% of episodes were microbiologically proven and were more likely to be prescribed by an ICU consultant. A total of 169 modifications were done in 142 prescription episodes; 73 of them after sensitivity results. Thus, the overall rate of de-escalation was 13.95%. Apart from the negative culture result (36.05%), an important reason for a relatively low rate of de-escalation was the absence of sampling (12.32%). Longer ICU stay before antibiotic prescription, underlying chronic liver disease (CLD), worse organ dysfunction, and septic shock were independently associated with unfavorable treatment outcomes. No such independent association was observed between antibiotic appropriateness and patient outcome. Conclusion: Future antibiotic stewardship strategies should address issues of high empirical prescription and poor microbiological sampling hindering the de-escalation process. How to cite this article: Ghosh S, Salhotra R, Singh A, Lyall A, Arora G, Kumar N, et al. New Antibiotic Prescription Pattern in Critically Ill Patients ("Ant-critic"): Prospective Observational Study from an Indian Intensive Care Unit. Indian J Crit Care Med 2022;26(12):1275-1284.

Implementation of a Revised Montpellier Bundle on the Outcome of Intubation in Critically Ill Patients: A Quality Improvement Project.

Introduction: The feasibility of implementing a revised Montpellier intubation bundle incorporating recent evidences was tested in a quality-improvement project. It was hypothesized that this "Care Bundle" implementation would reduce intubation-related complications. Materials and methods: The project was conducted in an 18-bedded multidisciplinary intensive care unit (ICU). Baseline data for intubations were collected over 3-month "Control Period". During the 2-month "Interphase", a revised intubation bundle was developed, and staff members involved in the intubation process were extensively trained on different aspects of intubation with emphasis on bundle components. Various components of the bundle were pre-intubation fluid loading, pre-oxygenation with NIV plus PS, positive-pressure ventilation post-induction, succinylcholine as a first-line induction agent, routine use of stylet, and lung recruitment within 2 minutes of intubation. Intubation data were collected again in the 3-month "Intervention Period". Results: Data were collected for 61 and 64 intubations, respectively, during control and intervention periods. There was significant improvement in compliance to five of six-bundle components; improvement in pre-intubation fluid loading during the intervention period did not reach statistical significance. Overall, at least 3 components of the bundle were complied within over 92% of intubations in the intervention period. However, whole-bundle compliance was limited to 14.3%. Incidences of major complications were reduced significantly in the intervention period (23.8% vs 45.9%, p = 0.01). There was significant reduction in profound hypotension (21.77% vs 29.51%, p = 0.04) and a nonsignificant 11.89% reduction in profound hypoxemia. There were no differences in minor complications. Conclusion: Implementation of an evidence-based revised Montpellier intubation bundle is feasible and it reduces major complications related to endotracheal intubation. How to cite this article: Ghosh S, Salhotra R, Arora G, Lyall A, Singh A, Kumar N, et al. Implementation of a Revised Montpellier Bundle on the Outcome of Intubation in Critically Ill Patients: A Quality Improvement Project. Indian J Crit Care Med 2022;26(10):1106-1114.

Outcome of Prophylactic Noninvasive Ventilation Following Planned Extubation in High-risk Patients: A Two-year Prospective Observational Study from a General Intensive Care Unit.

INTRODUCTION: Prophylactic use of noninvasive ventilation (NIV) is recommended following extubation in patients at high risk of extubation failure. In a prospective cohort study, we examined the impact of prophylactic NIV in this subset of patients, potentially exploring the risk factors for extubation failure in them and the impact of extubation failure on organ function. We also explored the effect of fluid balance on extubation failure or success in this high-risk patient subgroup. MATERIALS AND METHODS: Consecutive adult patients (≥18 years) admitted in the mixed intensive care unit (ICU) of a tertiary care center, between January 1, 2018, and December 31, 2019, who passed a spontaneous breathing trial (SBT) following at least 12 hours of invasive mechanical ventilation and put on prophylactic NIV for being at a high risk of extubation failure, were prospectively followed throughout their hospital stay. Extubation failure was defined as developing respiratory failure within 72 hours postextubation requiring reintubation or still requiring NIV support at 72 hours postextubation. RESULTS: A total of 85 patients were included in the study. 11.8% of patients had extubation failure at 72 hours with an overall reintubation rate of 10.5%. Higher age (p < 0.05), longer duration of invasive ventilation (p < 0.05), and higher sequential organ failure assessment (SOFA) score at extubation (p < 0.05) were identified as risk factors for extubation failure in univariate analysis. However, in the multivariate analysis, only a higher SOFA score remained statistically significant in forward logistic regression analysis (p < 0.05). We found a clear trend toward worsening organ function score in the extubation failure group in the first 72 hours postextubation, suggesting extubation failure as a risk factor for organ dysfunction. Cumulative fluid balance was higher both at extubation and in subsequent 3 days postextubation in the failure group, but the differences were not statistically significant. CONCLUSION: Higher age, longer duration of invasive ventilation, and higher baseline SOFA score at extubation remain risk factors for extubation failure even in this high-risk subset of patients on prophylactic NIV. Extubation failure is associated with the worsening of organ function. A trend toward higher cumulative fluid balance both at extubation and postextubation, suggests aggressive de-resuscitation as a potentially helpful strategy in preventing extubation failure. HOW TO CITE THIS ARTICLE: Ghosh S, Chawla A, Jhalani R, Salhotra R, Arora G, Nagar S, et al. Outcome of Prophylactic Noninvasive Ventilation Following Planned Extubation in High-risk Patients: A Two-year Prospective Observational Study from a General Intensive Care Unit. Indian J Crit Care Med 2020;24(12):1185-1192.

Cumulative Fluid Balance and Outcome of Extubation: A Prospective Observational Study from a General Intensive Care Unit.

INTRODUCTION: This study was aimed to examine the impact of cumulative fluid balance on extubation failure following planned extubation. METHODS: Consecutive adult patients (≥16 years) admitted in a general intensive care unit (ICU), between January 1, 2016, and December 31, 2017, mechanically ventilated for at least 24 h and extubated following successful spontaneous breathing trial, were prospectively evaluated. RESULTS: The cumulative fluid balance at extubation was significantly higher in the extubation failure group (median 4336.5 ml vs. 2752 ml, P = 0.036). The area under the receiver operating characteristic curve for cumulative balance to predict extubation failure was 0.6 (95% confidence interval [CI]: 0.504-0.697) with optimal cutoff value of 3490 ml (sensitivity and specificity of 60% and 59.5%, respectively). Other risk factors for extubation failure identified by univariate analysis were the duration of mechanical ventilation at extubation, chronic kidney or neurological disease, heart rate, and respiratory rate. In multiple regression model, the cumulative fluid balance >3490 ml retained its predictive potential for extubation failure (odds ratio = 2.191, 95% CI = 1.015-4.730). CONCLUSIONS: Our result validates the association between higher cumulative fluid balance and extubation failure in an Indian ICU. A future randomized control trial may examine any role of therapeutic diuresis/ultrafiltration in preventing failed extubation in patients who fulfill the readiness to wean criteria with cumulative net fluid balance ≥3490 ml.

Unusual surgical emergency in a patient of dengue haemorrhagic fever: spontaneous rectus sheath haematoma leading to abdominal compartment syndrome.

Abdominal compartment syndrome (ACS) is an uncommon complication of dengue haemorrhagic fever (DHF), described so far only in association with fluid refractory shock and high-volume resuscitation. We describe an unusual case of ACS in a patient of DHF where raised intra-abdominal pressure was due to spontaneous rectus sheath haematoma causing external compression. Early recognition of the haematoma, constant vigilance and timely decision for surgical intervention could salvage the patient with complete recovery of organ function.