A pragmatic calibration of the ROX index to predict outcome of nasal high-flow therapy in India.

PURPOSE: Identifying thresholds at which the ROX index would satisfactorily predict HFNC failure across heterogenous resourced contexts is necessary for clinical use. METHODS: Patients ≥18 years admitted to 30 diverse ICUs across 10 states in India who required HFNC for respiratory support were retrospectively included in this study. Patient data and hourly ROX indices were then analyzed and contextualized to clinical outcomes as well as with ROX index thresholds in other regions of the world. MEASUREMENTS AND MAIN RESULTS: Among the 614 patients included, 276 (44.9%) required respiratory escalation. Pneumonia was the most common diagnosis on admission. Receiver operating characteristic curve analysis revealed that a baseline ROX score of 7.86 was similar to 4.88 in other populations which was confirmed by Kaplan-Mier curves (hazard ratio,3.58 (2.72-4.69, p < 0.001)). ROX scores at 11.84 or 5.89 had roles in screening and confirming HFNC failure. The index performed poorly in a subset of patients who died without respiratory escalation. The ROX index was most predictive in the initial hours of ICU admission and a longer duration of HFNC was associated with more severe outcomes. CONCLUSIONS: When optimally calibrated this index can using a method that can reliably predict the risk of HFNC failure among ICU patients from diverse settings.

A Proof-of-Concept Model for Implementing a "Smart-NICU" to Improve Infant Mortality.

Low- and middle-income countries face limited critical care capacity due to constraints in staffing, resources, and technology. "Smart ICUs" that integrate telehealth to augment care delivery, communication, and data integration have the potential to bridge these gaps and reduce preventable morbidity and mortality. While their efficacy has been well validated in adult populations, applications of Smart-ICU services in the neonatal population have not been studied. Neonatal intensive care units (NICUs) in India using a common Smart-NICU platform, developed by CloudPhysician, utilize a hub-and-spokes framework along with locally designed technology to facilitate remote patient care in collaboration with local health systems. In this article, we investigate the operational characteristics and performance outcomes for Smart-NICU deployment from the 18 NICUs and 214 beds deployed to date. These findings highlight the potential impact of Smart-NICUs and establish generalizable principles for implementation in low-resource settings.

Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018).

BACKGROUND: A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels. AIM: To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions. METHODS: The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23rd-August 25th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status. RESULTS: There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability. CONCLUSION: In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Application of Lung Ultrasound in Critical Care Setting: A Review.

This article reviews the use of thoracic ultrasound in the intensive care unit (ICU). The focus of this article is to review the basic terminology and clinical applications of thoracic ultrasound. The diagnostic approach to a breathless patient, the blue protocol, is presented in a simplified flow chart. The diagnostic application of thoracic ultrasound in lung parenchymal and pleural diseases, role in bedside procedures, diaphragmatic assessment, and lung recruitment are described. Recent updates discussed in this review help support its increasingly indispensable role in the emergent and critical care setting.

Antibiotic Prescription Practices for Surgical Prophylaxis in India: An Observational Study.

Perioperative prophylactic antibiotics following surgeries have been shown to reduce surgical site infections, and their administration is common practice. Despite clear guidelines regarding this being set forth by the Infectious Disease Society of America (IDSA), adherence to them is yet to translate to common practice in many parts of the world. A retrospective chart review of 409 patients who underwent elective surgeries over a period of 7 months at three different hospitals in India was performed. In-hospital antibiotic prescriptions of these patients were examined for any apparent inappropriateness (use of antibiotics with coverage broader than the target microbes and use of antibiotics with overlapping spectrum of target microbes). Four hundred ninety-five (48.9%) of the 1,012 patient intensive care unit (ICU) days had apparent inappropriateness in the choice of their prophylactic antibiotics and only 3.2% of the antibiotic units used were in accordance with the present IDSA guidelines. Injudicious use of broad-spectrum antibiotics for surgical prophylaxis is prevalent in low- and middle-income countries such as India. This poses the risk of emergence of resistant microorganisms in these areas and their potential spread across the borders. There is an acute need for diligent antibiotic stewardship programs in these areas to curb such practices.

Use of home telemedicine for critical illness rehabilitation: an Indian success story.

One-fifth of healthcare beneficiaries in developed nations get discharged from hospitals to physician supervised skilled nursing care facilities. In low-income and middle-income countries like India, postdischarge skilled nursing facilities are at a very nascent stage and largely underequipped in terms of infrastructure, skilled nursing and physician staff to manage complicated patients. Hence the responsibility of management of such patients lies largely with their families. We present a case where a 26-year-old man with Duchenne Muscular Dystrophy who became ventilator dependent following major surgeries was weaned off his ventilator and rehabilitated back to his prehospital state. This was done at his home with visiting nurses and rehabilitation services under telemedicine supervision by a critical care specialist. Use of telemedicine services could be a viable and cost-effective option to ensure adherence to evidence-based medicine and standardisation of care in resource limited countries such as India.

Utilization of Thoracic Ultrasound for Confirmation of Central Venous Catheter Placement and Exclusion of Pneumothorax: A Novel Technique in Real-Time Application.

AIM: To evaluate the safety and utility of ultrasonography as a tool to confirm central venous catheter (CVC) position and to exclude insertion-related pneumothorax in place of chest radiography (CXR) in a tertiary medical intensive care unit (ICU). METHODS: We randomized 60 consecutive medical ICU patients to conventional or ultrasound groups for CVC placement. Both groups had CVCs inserted under ultrasound guidance. The intervention group underwent real-time transthoracic echocardiography to assist in catheter positioning and chest ultrasonography for exclusion of pneumothorax. Our primary end point was reduction in CXR use. The secondary end point was time elapsed from the end of procedure to the availability of CVC for use. χ2 test was used to compare the 2 groups for the primary end point. T test was used to compare the 2 groups for the secondary end point. RESULTS: Thirty patients were randomized to the conventional group and 30 were randomized to the ultrasound group. One patient was excluded in the control group since the procedure needed to be aborted. Patient characteristics were well matched for age, body mass index, and acute physiologic assessment and chronic health evaluation (APACHE III) scores. There was a 56.7% ( P < .0001) reduction in CXR use in the ultrasound arm. Mean time to use was 53.6 minutes in the control group and 25 minutes in the ultrasound arm ( P = .0015). Mean time required to complete the procedure was 27.7 minutes in the control group and 24.1 minutes in the ultrasound group ( P = .2053). No pneumothorax was detected in either arm. CONCLUSION: Ultrasound-guided CVC placement and positioning with a minor modification in technique reduced the use of bedside CXR and reduced the time to use of the CVC.

Polysomnographic Heart Rate Variability Indices and Atrial Ectopy Associated with Incident Atrial Fibrillation Risk in Older Community-dwelling Men.

BACKGROUND: Autonomic dysfunction contributes to atrial fibrillation (AF). OBJECTIVE: We hypothesized that polysomnogram (PSG)-based heart rate variability (HRV) autonomic function biomarkers are associated with incident AF and these associations are modified by measures of sleep disordered breathing (SDB). METHODS: 2350 participants of a multi-center prospective study (Outcomes of Sleep Disorders in Older Men Study) without baseline AF underwent sleep studies with incident adjudicated AF follow up (8.0 ± 2.6 years). Cox proportional hazard models were used to analyze sleep study-ECG spectral HRV indices [low and high frequency power (LF, HF), LF/HF] and time domain indices [mean of normal to normal beats (MNN), short and long term variability (STV, LTV) and STV/LTV] and premature atrial contractions (PACs) and incident AF (HR and 95% CI). Statistical interactions between HRV and SDB were examined. Models were adjusted for age, race, body mass index, waist circumference, cardiac medications, co-morbid diseases, alcohol use and study site. RESULTS: Lower LF/HF and lower LF were associated with higher AF incidence (LF/HF Q1 vs. Q4: 1.46, 1.02-2.08, LF Q1 vs. Q4: 1.46, 1.02-2.10). Higher STV/LTV was associated with an increased risk of AF (p-trend= 0.028). The highest PAC quartile had a 3-fold increased AF risk (2.99, 1.94-4.62) compared to the lowest quartile. A significant interaction of obstructive apnea was observed in the LF-AF relationship (0.045). CONCLUSIONS: Sleep-related reduced sympathovagal balance (LF/HF) and increased atrial ectopy are independently associated with future AF; a relationship modified by obstructive apnea.