The latest medical research on Critical Care
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Request AccessPaCO2 Association with Outcomes of Patients with Traumatic Brain Injury at High Altitude: A Prospective Single-Center Cohort Study.
Neurocritical CarePartial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes.
This is a prospective single-center cohort of consecutive patients with TBI admitted to a trauma center located at 2600 m above sea level. An unfavorable outcome was defined as a Glasgow Outcome Scale-Extended (GOSE) score < 4 at the 6-month follow-up.
We had a total of 81 patients with complete data, 80% (65/81) were men, and the median (interquartile range) age was 36 (25-50) years. Median Glasgow Coma Scale (GCS) score on admission was 9 (6-14); 49% (40/81) of patients had severe TBI (GCS 3-8), 32% (26/81) had moderate TBI (GCS 12-9), and 18% (15/81) had mild TBI (GCS 13-15). The median (interquartile range) Abbreviated Injury Score of the head (AISh) was 3 (2-4). The frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), the median GOSE was 4 (2-5), and the median 6-month mortality rate was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, (median age 49 [30-72] vs. 29 [22-41] years, P < 0.01), had lower admission GCS scores (6 [4-8] vs. 13 [8-15], P < 0.01), had higher AISh scores (4 [4-4] vs. 3 [2-4], P < 0.01), had higher Acute Physiology and Chronic Health disease Classification System II scores (17 [15-23] vs. 10 [6-14], P < 0.01), had higher Charlson scores (0 [0-2] vs. 0 [0-0], P < 0.01), and had higher PaCO2 levels (mean 35 ± 8 vs. 32 ± 6 mm Hg, P < 0.01). In a multivariate analysis, age (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.1-1.30, P < 0.01), AISh (OR 4.7, 95% CI 1.55-21.0, P < 0.05), and PaCO2 levels (OR 1.23, 95% CI 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4, 95% CI 1.61-28.5, P = 0.017) and PaCO2 levels (OR 1.36, 95% CI 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome.
Higher PaCO2 levels are associated with an unfavorable outcome in ventilated patients with TBI. These results underscore the importance of PaCO2 levels in patients with TBI and whether it should be adjusted for populations living at higher altitudes.
Novel Therapeutic Approaches in Connective Tissue Disease-Associated Interstitial Lung Disease.
Seminars in Respiratory and CriticalConnective tissue diseases (CTD) comprise a group of autoimmune diseases that can affect multiple organs in the body including the lungs. The most ...
Diagnostic Identification of Acute Brain Dysfunction in Pediatric Sepsis and Septic Shock in the Electronic Health Record: A Comparison of Four Definitions in a Reference Dataset.
Pediatric Critical Care MedicineAcute brain dysfunction (ABD) in pediatric sepsis has a prevalence of 20%, but can be difficult to identify. Our previously validated ABD computational phenotype (CPABD) used variables obtained from the electronic health record indicative of clinician concern for acute neurologic or behavioral change. We tested whether the CPABD has better diagnostic performance to identify confirmed ABD than other definitions using the Glasgow Coma Scale or delirium scores.
The test dataset comprised 527 children with sepsis/septic shock managed between 2011 and 2021 with a prevalence (pretest probability) of confirmed ABD of 30% (159/527).
CPABD was based on use of neuroimaging, electroencephalogram, and/or administration of new antipsychotic medication. We compared the performance of the CPABD with three GCS/delirium-based definitions of ABD-Proulx et al, International Pediatric Sepsis Consensus Conference, and Pediatric Organ Dysfunction Information Update Mandate. The posttest probability of identifying ABD was highest in CPABD (0.84) compared with other definitions. CPABD also had the highest sensitivity (83%; 95% CI, 76-89%) and specificity (93%; 95% CI, 90-96%). The false discovery rate was lowest in CPABD (1-in-6) as was the false omission rate (1-in-14). Finally, the prevalence threshold for the definitions varied, with the CPABD being the definition closest to 20%.
In our curated dataset of pediatric sepsis/septic shock, CPABD had favorable characteristics to identify confirmed ABD compared with GCS/delirium-based definitions. The CPABD can be used to further study the impact of ABD in studies using large electronic health datasets.
Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot safety and feasibility randomised controlled trial.
Intensive Care MedicineCritically ill patients are vulnerable to penicillin allergy labels that may be incorrect. The validity of skin testing in intensive care units (ICUs) is uncertain. Many penicillin allergy labels are low risk, and validated tools exist to identify those amenable to direct oral challenge. This pilot randomised controlled trial explored the feasibility, safety, and validity of direct enteral challenge for low-risk penicillin allergy labels in critical illness.
Consenting patients with a low-risk penicillin allergy label (PAL) (PEN-FAST risk assessment score < 3) in four ICUs (Melbourne, Australia) were randomised 1:1 to penicillin (250 mg amoxicillin or implicated penicillin) direct enteral challenge versus routine care (2-h post-randomisation observation for each arm). Repeat challenge was performed post -ICU in the intervention arm. Patients were reviewed at 24 h and 5 days after each challenge/observation.
We screened 533 patients. 130 (24.4%) were eligible and 80/130 (61.5%) enrolled (age median 64.5 years (interquartile range, IQR 53.5, 74), PEN-FAST median 1 (IQR 0,1)), with 40 (50%) randomised to direct enteral challenge. A positive challenge rate of 2.5% was identified. No antibiotic-associated serious adverse events were identified. 32/40 (80%) received a repeat challenge (zero positive). Post-randomisation, 13 (32%) of the intervention arm and 4 (10%) of the control arm received penicillin (odds ratio, OR 4.33 [1.27, 14.78] p = 0.019).
These findings support the safety, validity, and feasibility of direct enteral challenge for critically ill patients with PEN-FAST assessed low-risk penicillin allergy. The absence of false negative results was confirmed by subsequent negative repeat challenges. A relatively low recruitment to screened ratio suggests that more inclusive eligibility criteria and integration of allergy assessment into routine ICU processes are needed to optimise allergy delabelling in critical illness.
Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital.
Indian Journal of Critical Care MedicineThe availability of rapid diagnostic platforms for positive blood cultures has accelerated the speed at which the clinical microbiology laboratory can identify the causative organism and facilitate early appropriate antimicrobial therapy. There is a paucity of data regarding the clinical utility of the blood culture identification 2 (BCID2) panel test and its correlation with phenotypic drug susceptibility testing (DST) in flagged blood culture bottles from intensive care units (ICUs) in countries such as India, which have high rates of multidrug-resistant gram-negative bacteria (MDR-GNB).
We conducted a retrospective observational study in a tertiary care ICU on 200 patients above 18 years of age in whom a BCID2 test was ordered when blood cultures flagged positive.
We found 99% concordance between BCID2 and cultures in the identification of bacteria and yeasts and 96.5% concordance between phenotypic and genotypic DST. Furthermore, BCID2 was available about 1.5 days earlier than conventional ID and DST and played a key role in tailoring antimicrobials in 82.5% of the patients. Polymyxin-based therapy was discontinued earlier after an empiric dose in 138 patients (69%) based on BCID2 reports.
In critically ill patients with monomicrobial bacteremia, BCID2 rapidly identifies bacteria and antimicrobial resistance (AMR) genes and is significantly faster than conventional culture and sensitivity testing. Antibiotics were escalated in more than a third of patients and de-escalated in almost a fifth on the same day. We recommend that all ICUs routinely incorporate the test in their antibiotic decision-making process and in antimicrobial stewardship.
Vineeth VK, Nambi PS, Gopalakrishnan R, Sethuraman N, Ramanathan Y, Chandran C, et al. Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2024;28(5):461-466.
Modified NUTRIC Score as a Predictor of All-cause Mortality in Critically Ill Patients: A Systematic Review and Meta-analysis.
Indian Journal of Critical Care MedicineThe purpose of our meta-analysis was to look at the impact of modified nutrition risk in the critically ill (mNUTRIC) on mortality in patients with critical illness.
Literature relevant to this meta-analysis was searched in PubMed, Web of Science, and Cochrane Library till 26 August 2023. Prospective or retrospective studies, patients >18 years of age, studies that reported on mortality and mNUTRIC (mNUTRIC cut-off score) were included. The QUIPS tool was used to evaluate the risk for bias in prognostic factors.
A total of 31 studies on mNUTRIC score, involving 13,271 patients were included. The summary area under the curve (sAUC) of 0.80 (95% CI: 0.76-0.83) illustrates the mNUTRIC score's strong discrimination. The pooled sensitivity was 0.79 (95% CI: 0.74-0.84) and pooled specificity was 0.68 (95% CI: 0.63-0.73). We found no discernible variation in the mNUTRIC's prediction accuracy among cut-off values of <5 and >5 in our subgroup analysis and sAUC values were 0.82 (95% CI: 0.78-0.85) and 0.78 (95% CI: 0.74-0.81), respectively.
We observed that mNUTRIC can discriminate between critically ill individuals and predict their mortality.
CRD42023460292.
Prakash J, Verma S, Shrivastava P, Saran K, Kumari A, Raj K, et al. Modified NUTRIC Score as a Predictor of All-cause Mortality in Critically Ill Patients: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2024;28(5):495-503.
Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction.
Indian Journal of Critical Care MedicineRight ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys.
To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion.
This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD.
VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI.
Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024;28(5):447-452.
Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India.
Indian Journal of Critical Care MedicineThe current study aimed to assess any association between intensive care unit (ICU) and hospital outcomes with ICU admission timings of critically ill patients.
Retrospective observational single-center study involving all adult admissions. Each patient admission was categorized in "after-hours" (08:00 p.m.-07:59 a.m.), or "normal-hours" (08:00 a.m.-07:59 p.m.), "Weekday" (Monday-Saturday), or "Weekend" (Sunday), "Same day" (admission directly to ICU) or "other day admission" (admission to ICU after a hospital stay of ≥24 hours). Intensive care unit and hospital mortality, length of stay (LOS), and ICU readmission were assessed for any association with different admission timings.
Among 3,029 patients, 54.2% (1,668) were male, with mean age 66.49 (SD ± 15.69) years, mean acute physiology and chronic health evaluation-IV (APACHE-IV) score 55.5 (SD ± 26.3). Around 86.1% of admission occurred during weekdays, 13.9% on weekends, 57.4% normal-hours, 42.6% after-hours, 66.3% same day and 33.7% other day admission. Intensive care unit and hospital mortality were 10.8 and 14.2% respectively. Neither ICU nor hospital mortality were significantly different among patients admitted normal vs after-hours (p = 0.32, 0.23), and weekdays vs weekends (p = 0.09, 0.93), nor was ICU LOS (p = 0.21, 0.74). Intensive care unit and hospital mortality (p = 0.001), DORB (p = 0.001), hospital LOS (p = 0.001), and readmission to ICU (p = 0.001) were significantly higher in the other day admission group compared to same-day admission. In a multivariate regression analysis age, APACHE IV score along with other day admission to ICU did have a significant effect on both ICU and hospital mortality.
Intensive care unit and hospital mortality and LOS did not differ significantly with hours or days of ICU admission though they were significantly higher in other day admission groups.
Bhattacharyya M, Todi SK. Effect of Admission Day and Time on Patient Outcome: An Observational Study in Intensive Care Units of a Tertiary Care Hospital in India. Indian J Crit Care Med 2024;28(5):436-441.
Family's Perceived Needs and Satisfaction with Intensive Care Services: A Questionnaire-based Prospective Observational Study.
Indian J Crit Care MedicineHolistic 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.
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.
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).
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.
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.
A Retrospective Database Analysis to Investigate if Electrolytes in Venous Blood are Equivalent to the Levels in Arterial Blood.
Indian J Crit Care MedicineIn a critically ill patient, when an arterial blood sample is processed on an arterial blood gas (ABG) analyzer, it also measures electrolytes apart from analyzing the blood gases. The turnaround time for ABG analysis is way too less compared to the conventional electrolyte analysis with a serum sample.
This study intends to investigate whether values of electrolytes estimated in arterial blood can substitute the routinely practiced method.
This is a retrospective cross-sectional study. The source of data is patients' reports of serum electrolytes and ABG analysis from the Clinical Biochemistry laboratory, CIMS Teaching Hospital, Chamarajanagar between January and June 2021. The electrolytes report of 200 patients from whom both arterial and venous blood samples were sent to the Clinical Biochemistry laboratory on the same day and at the same time for analysis were selected. The data was compiled, compared, and correlated using a suitable statistical tool.
The mean and standard deviation of sodium (135.62 ± 5.20 in venous vs 134.08 ± 8.49 in arterial blood), potassium (4.20 ± 0.64 vs 3.80 ± 0.75), and chloride (102.28 ± 4.99 vs 96.33 ± 8.11) were observed. However, when the concordance correlation coefficient and Bland-Altman plot analysis were made there was no agreement between electrolytes analyzed on serum in an autoanalyzer with that of ABG analyzer.
We conclude that the electrolytes measured by a conventional autoanalyzer on a serum sample cannot be replaced by values analyzed on a blood gas analyzer.
Devaki RN, Kasargod P, Roopa Urs AN, Chandrika N. A Retrospective Database Analysis to Investigate if Electrolytes in Venous Blood are Equivalent to the Levels in Arterial Blood. Indian J Crit Care Med 2024;28(5):442-446.
Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study.
Indian J Crit Care MedicineWhile intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored.
There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes.
About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC.
Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians.
Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.
Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study.
Indian J Crit Care MedicinePatients 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.
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.
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.
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.
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.
