A Survey on Workplace Violence Experienced by Critical Care Physicians.

INTRODUCTION: Workplace violence (WPV) has been defined as, "violent acts including physical assault and threats of assault directed toward personnel at work or on duty". Healthcare staff are at highest risk of WPV among the professionals and it is more common among the critical care services. Prevalence of WPV among doctors all over the world is around 56-80% and in Indian scenario, it is around 40.8-75%. There is scarcity of studies on WPV among doctors from India. To our knowledge, this is the first of its kind survey conducted to know about the incidence of WPV amongst critical care physicians in India. MATERIALS AND METHODS: This survey was conducted after taking due ethical committee clearance amongst critical care physicians attending a critical care conference. The purpose of the study was informed to the participants and a pretested, self-administered, semi-structured questionnaire was distributed among them for their voluntary and anonymous response. RESULTS: Out of 160 delegates who were given the questionnaire, 118 responses were collected and their forms were analyzed. Maximum responses (84%) received were of age group 20-40 years. Seventy-two percent respondents experienced WPV during their work hours. Most common type of violence reported was verbal violence (67%). Sixty-five percent respondents reported that poor communication was the leading cause of WPV. Due to WPV, most of the respondents (60%) had to change their place and pattern of work. Proper communication (76%) was the most common measure among multiple measures suggested by respondents for avoiding WPV. Eighty-three (98%) respondents opined that conflict management should be part of regular curriculum in medical education. CONCLUSION: Improving the communication skills amongst critical care physicians, teaching doctors about conflict management in their regular curriculum of medical education, spreading awareness in public about patient rights and taking initiatives in propagating an idea to "Fight against the diseases and not against the doctors" are the key measures to combat WPV. HOW TO CITE THIS ARTICLE: Kumar NS, Munta K, Kumar JR, Rao SM, Dnyaneshwar M, Harde Y. A Survey on Workplace Violence Experienced by Critical Care Physicians. Indian J Crit Care Med 2019;23(7):295-301.

Comparision of Analgesic Efficacy of Tramadol Infusion Versus Tramadol Plus Ondansetron Infusion In Medical Intensive Care Unit.

BACKGROUND: Tramadol, a preferred analgesic due to its less respiratory depression. It also has a central action that blocks the reuptake and enhances the release of serotonin at spinal antinociceptive pathways. Ondansetron, an antiemetic is a serotonin receptor antagonist. Due to the contradictory actions of the two drugs, co-administration of these drugs resulted in higher usage of tramadol. All these studies were done in the postoperative period. AIM: The aim of this study is to evaluate the analgesic efficacy of tramadol infusion versus tramadol plus ondansetron infusion in Medical Intensive Care Unit (ICU) patients. MATERIALS AND METHODS: After Institutional Ethical Committee approval, 50 patients who experience pain other than postoperative pain were enrolled and randomized into two groups. Both the groups initially received 50 mg of tramadol intravenously over 10 min followed by Group T+O received 10 mg/h tramadol + 0.4 mg/h ondansetron as an infusion. Group T received 10 mg/h tramadol as infusion. Hemodynamic parameters along with pain assessment using Verbal Rating Scale (VRS) were analyzed at 0, 3, 6, 12, and 24 h. Rescue analgesia was administered if VRS >4. Side effects were noted by condition scoring criteria (CSC) scale. RESULTS: Rescue analgesia was administered at 3 h, for three patients in T+O Group and 1 patient in T Group, but this is not statistically significant (P = 0.153). No rescue analgesia was required in both the groups at any other point of time. There was fall in heart rate, systolic and diastolic blood pressures, respiratory rate at 0, 3, 6, 12, and 24 h in both the groups but not statistically significant. Grade 1 sedation of CSC scale was observed in two patients of Group T+O and one patient in Group T but not statistically significant (P = 0.153). No nausea and vomiting were seen. CONCLUSIONS: We conclude that co-administration of tramadol and ondansetron can be practiced in medical ICU patients without any higher requirement in dosage of tramadol.

End-tidal capnography and upper airway ultrasonography in the rapid confirmation of endotracheal tube placement in patients requiring intubation for general anaesthesia.

BACKGROUND AND AIMS: Confirmation of correct endotracheal tube placement is essential immediately after intubation for general anaesthesia. In this study, we have compared upper airway ultrasonography (USG) with reference to capnography for rapid confirmation of endotracheal tube placement after general anaesthesia. METHODS: A prospective, single centre, observational study was conducted on 100 patients requiring tracheal intubation for general anaesthesia. Both capnography and upper airway USG were performed immediately after intubation to confirm the endotracheal tube (ETT) placement. Sensitivity, specificity, and positive and negative predictive values of upper airway USG were determined against capnography as the reference method. Agreement between the methods and time required to determine ETT placement by the two methods were assessed with kappa statistics and Student's t-test. RESULTS: Upper airway USG detected all five cases of oesophageal intubation, but could not detect five patients with correct tracheal intubation. Upper airway USG had a sensitivity of 96.84% (95% confidence interval [CI]: 94.25%-96.84%), specificity of 100% (95% CI: 50.6%-100%), positive predictive value of 100% (95% CI: 97.3%-100%) and negative predictive value of 62.5% (95% CI: 31.6%-62.5%). Kappa value was found to be 0.76, indicating a good agreement between upper airway USG and capnography for confirmation of ETT placement. Time taken for confirmation of ETT by capnography was 8.989 ± 1.043 s vs. 12.0 ± 1.318 s for upper airway USG (P < 0.001). CONCLUSION: Both capnography and upper airway USG may be used as primary procedures for the confirmation of ETT placement.

Secondary Sjogren's Syndrome Presenting with Distal Tubular Acidosis and Quadriparesis.

A 52-year-old female patient was admitted to Intensive Care Unit with complaints of quadriparesis. Investigations revealed distal renal tubular acidosis (DRTA) secondary to Sjogren's syndrome with involvement of the parotid and thyroid glands. Laboratory investigations showed hyperchloremic metabolic acidosis and an alkaline urine pH with clinical signs of sicca syndrome. Sjogren's syndrome is associated with DRTA and occurrences of quadriparetic hypokalemia, nephrolithiasis, and osteomalacia can be prevented with early diagnosis and lifelong treatment with potassium and alkali replacement.

Severe Hypothermia Causing Ventricular Arrhythmia in Organophosphorus Poisoning.

Organophosphorus poisoning cases are routinely treated across all Intensive Care Units adjoining the rural areas where agriculture is the main source of income. We present a unique case of severe hypothermia seen in a case of organophosphorus poisoning, which led to electrocardiogram disturbances and life-threatening arrhythmias.

Prone position and pressure control inverse ratio ventilation in H1N1 patients with severe acute respiratory distress syndrome.

AIM: To observe the 28 and 90 days mortality associated with prone position and assist control-pressure control (with inverse ratio) ventilation (ACPC-IRV). MATERIALS AND METHODS: All patients who were admitted to our medical Intensive Care Unit (ICU) who are positive for H1N1 viral infection with severe acute respiratory distress syndrome (ARDS) and requiring invasive mechanical ventilation in prone position were included in our prospective observational study. Six patients who are positive for H1N1 required invasive ventilation in prone position. These patients were planned to ventilate in prone for 16 h and in supine for 8 h daily until P/F ratio >150 with FiO2 of 0.6 or less and positive end-expiratory pressure <10 cm of H2 O. RESULTS: At admission, among these six patients the mean tidal volume generated was about 376.6 ml which was in the range of 6-8 ml/kg predicted body weight. The mean lung injury score was 3.79, mean PaO2 /FiO2 ratio was 52.66 and mean oxygenation index was 29.83. The mean duration of ventilation was 9.4 days (225.6 h). The ICU length of stay was 11.16 days. There was no mortality at 28 and 90 days. CONCLUSION: Early prone combined with ACPC-IRV in H1N1 patients having severe ARDS can be used as a rescue therapy and it should be confirmed by large observational studies.

Correlation of measurement of optic nerve sheath diameter using ultrasound with magnetic resonance imaging.

BACKGROUND AND AIMS: Analysis to correlate the measurements of optic nerve sheath diameter (ONSD) obtained by using ultrasound to magnetic resonance imaging (MRI) techniques in order to establish the accuracy of ocular sonography as a noninvasive modality for detecting raised intracranial pressure (ICP). MATERIALS AND METHODS: A prospective, observational study was performed in 100 cases of adult meningoencephalitis patients admitted to Intensive Care Unit in whom MRI was performed for neurodiagnosis. ONSD was measured in such patients, 3 mm behind the globe in each eye. A mean binocular ONSD >4.6 mm in female and 4.8 mm in male was taken as cut-off values for diagnosing raised ICP. This was compared with ONSD measured on T2-weighted MRI image measured 3 mm behind the globe. The reading obtained from both the methods were compared with Bland-Altman analysis for correlation and the findings were tabulated. RESULTS: The mean ONSD values measured with ultrasonography (USG) and MRI for female were 5.48 ± 0.43 mm and 5.68 ± 0.44 mm and for male were 5.40 ± 0.37 mm and 5.56 ± 0.38 mm, respectively. The mean age of the female and male was 53.90 ± 17.84 and 56.06 ± 15.67 years, respectively. On comparing ultrasound with MRI-derived ONSD values, we found acceptable agreement between both methods for measurements at a depth of 3 mm (r = 0.02, P < 0.001). CONCLUSION: In our study, we have found a good correlation between ocular USG and MRI of ONSD. The study has shown agreement with the fact that ocular sonography can be used as a noninvasive tool for detecting raised ICP with accuracy.

Stress levels of critical care doctors in India: A national survey.

BACKGROUND: Doctors working in critical care units are prone to higher stress due to various factors such as higher mortality and morbidity, demanding service conditions and need for higher knowledge and technical skill. AIM: The aim was to evaluate the stress level and the causative stressors in doctors working in critical care units in India. MATERIALS AND METHODS: A two modality questionnaire-based cross-sectional survey was conducted. In manual mode, randomly selected delegates attending the annual congress of Indian Society of Critical Care Medicine filled the questionnaire. In the electronic mode, the questionnaires were E-mailed to critical care doctors. These questionnaires were based on General Health Questionnaire-12 (GHQ-12). Completely filled 242 responses were utilized for comparative and correlation analysis. RESULTS: Prevalence of moderate to severe stress level was 40% with a mean score of 2 on GHQ-12 scale. Too much responsibility at times and managing VIP patients ranked as the top two stressors studied, while the difficult relationship with colleagues and sexual harassment were the least. Intensivists were spending longest hours in the Intensive Care Unit (ICU) followed by pulmonologists and anesthetists. The mean number of ICU bed critical care doctors entrusted with was 13.2 ± 6.3. Substance abuse to relieve stress was reported as alcohol (21%), anxiolytic or antidepressants (18%) and smoking (14%). CONCLUSION: Despite the higher workload, stress levels measured in our survey in Indian critical care doctors were lower compared to International data. Substantiation of this data through a wider study and broad-based measures to improve the quality of critical care units and quality of the lives of these doctors is the need of the hour.

Invasive aspergillosis in near drowning nonneutropenic patient.

Invasive aspergillosis in immunosuppressed people has been well documented, but to diagnose and treat in an immunocompetent individual after near drowning, it requires early suspicion and proper empirical treatment. We report a case diagnosed to have invasive aspergillosis with systemic dissemination of the infection to the brain, gluteal muscles, and kidneys after a fall in a chemical tank of a paper manufacturing company. He was ventilated for acute respiratory distress syndrome and managed with antibiotics and vasopressors. Due to nonresolving pneumonia and positive serum galactomannan, trans-tracheal biopsy was performed which confirmed invasive aspergillosis and was treated with antifungals. With the availability of galactomannan assay and better radiological investigative modalities, occurrence of such invasive fungal infections in cases of drowning patients should be considered early in such patients and treated with appropriate antifungals.