A Prospective Observational Study Comparing Oxygen Saturation/Fraction of Inspired Oxygen Ratio with Partial Pressure of Oxygen in Arterial Blood/Fraction of Inspired Oxygen Ratio among Critically Ill Patients Requiring Different Modes of Oxygen Supplementation in Intensive Care Unit.

Background: Intensive care unit (ICU) patients face a significant rise in mortality rates due to acute hypoxemic respiratory failure (AHRF). The diagnosis of AHRF is based on the PF ratio, but it has limitations in resource-constrained settings. Instead, the Kigali modification suggests using the oxygen saturation/fraction of inspired oxygen (SF) ratio. This study aims to correlate SF ratio and arterial oxygen pressure (PF) ratio in critically ill adults with hypoxemic respiratory failure, who required O2 therapy through different modes of oxygen supplementation. Materials and methods: In an ICU, a prospective observational study included 125 adult AHRF patients receiving oxygen therapy, with data collected on FiO2, PaO2, and SpO2. The SF ratio and PF ratio were calculated, and their correlation was assessed using statistical analysis. The receiver operator characteristics (ROC) curve analysis was conducted to assess the diagnostic precision of the SF ratio in identifying AHRF. Results: Data from a total of 250 samples were collected. The study showed a positive correlation (r = 0.622) between the SF ratio and the PF ratio. The SF threshold values of 252 and 321 were established for PF values of 200 and 300, respectively, featuring a sensitivity of 69% and specificity of 95%. Furthermore, it is worth noting that the PF ratio and SF ratio are interchangeable, regardless of the type of oxygen therapy, as the median values of both the PF ratio and SF ratio displayed statistical significance (p < 0.01) in both acidosis and alkalosis conditions. Conclusion: For patients with AHRF, the noninvasive SF ratio can effectively serve as a substitute for the invasive PF ratio across all oxygen supplementation modes. How to cite this article: Alur TR, Iyer SS, Shah JN, Kulkarni S, Jedge P, Patil V. A Prospective Observational Study Comparing Oxygen Saturation/Fraction of Inspired Oxygen Ratio with Partial Pressure of Oxygen in Arterial Blood/Fraction of Inspired Oxygen Ratio among Critically Ill Patients Requiring Different Modes of Oxygen Supplementation in Intensive Care Unit. Indian J Crit Care Med 2024; 28(3):251-255.

Comparison of admission GCS score to admission GCS-P and FOUR scores for prediction of outcomes among patients with traumatic brain injury in the intensive care unit in India.

BACKGROUND: This study aimed to determine the predictive power of the Full Outline of Unresponsiveness (FOUR) score and the Glasgow Coma Scale Pupil (GCS-P) score in determining outcomes for traumatic brain injury (TBI) patients. The Glasgow Outcome Scale (GOS) was used to evaluate patients at 1 month and 6 months after the injury. METHODS: We conducted a 15-month prospective observational study. It included 50 TBI patients admitted to the ICU who met our inclusion criteria. We used Pearson's correlation coefficient to relate coma scales and outcome measures. The predictive value of these scales was determined using the receiver operating characteristic (ROC) curve, calculating the area under the curve with a 99% confidence interval. All hypotheses were two-tailed, and significance was defined as P<0.01. RESULTS: In the present study, the GCS-P and FOUR scores among all patients on admission as well as in the subset of patients who were mechanically ventilated were statistically significant and strongly correlated with patient outcomes. The correlation coefficient of the GCS score compared to GCS-P and FOUR scores was higher and statistically significant. The areas under the ROC curve for the GCS, GCS-P, and FOUR scores and the number of computed tomography abnormalities were 0.912, 0.905, 0.937, and 0.324, respectively. CONCLUSIONS: The GCS, GCS-P, and FOUR scores are all excellent predictors with a strong positive linear correlation with final outcome prediction. In particular, the GCS score has the best correlation with final outcome.

Wunderlich Syndrome: Comprehensive Review of Diagnosis and Management.

Wunderlich syndrome (WS), which was named after Carl Wunderlich, is a rare clinical syndrome characterized by an acute onset of spontaneous renal hemorrhage into the subcapsular, perirenal, and/or pararenal spaces, without a history of antecedent trauma. Patients may present with a multitude of symptoms ranging from nonspecific flank or abdominal pain to serious manifestations such as hypovolemic shock. The classic symptom complex of flank pain, a flank mass, and hypovolemic shock referred to as the Lenk triad is seen in a small subset of patients. Renal neoplasms such as angiomyolipomas and clear cell renal cell carcinomas that display an increased proclivity for hemorrhage and rupture contribute to approximately 60%-65% of all cases of WS. A plethora of renal vascular diseases (aneurysms or pseudoaneurysms, arteriovenous malformations or fistulae, renal vein thrombosis, and vasculitis syndromes) account for 20%-30% of cases of WS. Rare causes of WS include renal infections, cystic diseases, calculi, kidney failure, and coagulation disorders. Cross-sectional imaging modalities, particularly multiphasic CT or MRI, are integral to the detection, localization, and characterization of the underlying causes and facilitate optimal management. However, large-volume hemorrhage at patient presentation may obscure underlying causes, particularly neoplasms. If the initial CT or MRI examination shows no contributary causes, a dedicated CT or MRI follow-up study may be warranted to establish the cause of WS. Renal arterial embolization is a useful, minimally invasive, therapeutic option in patients who present with acute or life-threatening hemorrhage and can help avoid emergency radical surgery. Accurate diagnosis of the underlying cause of WS is critical for optimal patient treatment in emergency and nonemergency clinical settings. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Stress Level and Its Determinants among Staff (Doctors and Nurses) Working in the Critical Care Unit.

Background: Very few extensive studies regarding job stressors among doctors and nurses have been conducted in India. It is important to explore the workplace to understand various stressors that adversely affect the well-being of an individual and also affect health care and needs of patients and relatives. Considering this, the present study was planned to determine stress among doctors and nurses from the critical care unit (CCU) and to find the association of stress with selected variables. Materials and methods: This observational cross-sectional study was conducted among all staff (doctors and nurses) from the CCU. Data were collected with a pilot-tested, predesigned, validated questionnaire using the Google survey tool consisting of sociodemographic details and the ICMR work stress questionnaire. Analysis of data was done with SPSS version 25. Results: Of 105 participants, 57 (54.3%) were doctors and 48 (45.7%) were nurses. A total of 48.6% (51) of participants scored 32 of 64, that is, managed stress very well, and 51.4% of participants (54) scored 65 of 95, that is, having a reasonably safe level of stress, but certain areas need improvement. Conclusion: Stress was significantly more among females and those who have sleep problems. No statistically significant difference was found between the level of stress and age, relationship with seniors, exercise, and comorbidities. How to cite this article: Patil VC, Patil SV, Shah JN, Iyer SS. Stress Level and Its Determinants among Staff (Doctors and Nurses) Working in the Critical Care Unit. Indian J Crit Care Med 2021;25(8):886-889.

Pancreas in Hereditary Syndromes: Cross-sectional Imaging Spectrum.

A wide spectrum of hereditary syndromes predispose patients to distinct pancreatic abnormalities, including cystic lesions, recurrent pancreatitis, ductal adenocarcinoma, nonductal neoplasms, and parenchymal iron deposition. While pancreatic exocrine insufficiency and recurrent pancreatitis are common manifestations in cystic fibrosis and hereditary pancreatitis, pancreatic cysts are seen in von Hippel-Lindau disease, cystic fibrosis, autosomal dominant polycystic kidney disease, and McCune-Albright syndrome. Ductal adenocarcinoma can be seen in many syndromes, including Peutz-Jeghers syndrome, familial atypical multiple mole melanoma syndrome, Lynch syndrome, hereditary breast and ovarian cancer syndrome, Li-Fraumeni syndrome, and familial pancreatic cancer syndrome. Neuroendocrine tumors are commonly seen in multiple endocrine neoplasia type 1 syndrome and von Hippel-Lindau disease. Pancreatoblastoma is an essential component of Beckwith-Wiedemann syndrome. Primary hemochromatosis is characterized by pancreatic iron deposition. Pancreatic pathologic conditions associated with genetic syndromes exhibit characteristic imaging findings. Imaging plays a pivotal role in early detection of these conditions and can positively affect the clinical outcomes of those at risk for pancreatic malignancies. Awareness of the characteristic imaging features, imaging-based screening protocols, and surveillance guidelines is crucial for radiologists to guide appropriate patient management. ©RSNA, 2021.

Insulin Resistance and Homeostatic Model Assessment in Critically Ill: Where do We Stand?

How to cite this article: Shah JN. Insulin Resistance and Homeostatic Model Assessment in Critically Ill: Where do We Stand? Indian J Crit Care Med 2021;25(12):1335-1336.

Simultaneous transurethral cystolithotripsy with holmium laser enucleation of the prostate: a prospective feasibility study and review of literature.

OBJECTIVE: To report experience with holmium laser enucleation of the prostate (HoLEP) simultaneously with transurethral holmium laser cystolithotripsy (HLC) for managing bladder outlet obstruction (BOO) and associated vesical calculi; we also review previously reported cases of managing vesical calculi and associated BOO. PATIENTS AND METHODS: The high-powered holmium laser is a very efficient multifunctional endourological instrument that effectively fragments calculi of all compositions and is capable of haemostatic cutting of tissue, resulting in minimal bleeding after prostatic resection. A prospective study was conducted from April 2003 that included 32 men who underwent simultaneous HoLEP with transurethral HLC at our institution. Demographic, laboratory, peri-operative and follow-up data were analysed. Complications during and after surgery were identified to assess the morbidity of procedure. RESULTS: The mean (range) size of bladder calculi was 34.6 (12-70) mm and the preoperative weight of the prostate was 51.9 (11-172) g. Combined HoLEP with transurethral HLC was technically feasible in all patients, and all were stone-free after surgery. The mean operative duration was 97.7 (40-230) min, the weight of prostate tissue removed 34.6 (5-88) g, and the duration of catheterization and hospital stay 29.3 h and 34.8 h, respectively. Complications during and after surgery occurred in 12.5% and 15.6% of patients, respectively; all complication were minor and none caused any residual disability to the patient. No patient required a blood transfusion or developed clot retention. CONCLUSIONS: Managing bladder stones and BOO with simultaneous transurethral HLC and HoLEP should be considered the treatment of choice for such cases. Stones of any size and composition, and prostates of practically any size can be treated endoscopically using the holmium laser, with acceptable morbidity once the technique is mastered. The review of previous reports suggested a need for a prospective study comparing endoscopic management of BOO and associated bladder stones, with medical management of BOO and extracorporeal shock wave lithotripsy/endoscopic lithotripsy for bladder stone.

A prospective, randomized trial evaluating the safety and efficacy of fibrin sealant in tubeless percutaneous nephrolithotomy.

PURPOSE: We performed a prospective, randomized trial to assess the safety and efficacy of fibrin sealant in tubeless percutaneous nephrolithotomy. MATERIALS AND METHODS: A total of 63 patients undergoing tubeless percutaneous nephrolithotomy were randomized to receive Tisseel vapor heated sealant at the end of the procedure. Fibrin sealant was instilled under direct vision in the nephrostomy tract at the end of the procedure. Patients younger than 14 years and those undergoing staged percutaneous nephrolithotomy or bilateral simultaneous percutaneous nephrolithotomy were excluded from study. Patients needing greater than 2 percutaneous tracts, those with significant bleeding or associated pyonephrosis and those with a residual stone burden were also excluded from study. The perioperative outcome in these patients (experimental group) was compared with the outcome in those undergoing tubeless percutaneous nephrolithotomy without fibrin sealant (control group). RESULTS: Fibrin sealant was instilled in 32 patients. There was no difference in the hematocrit decrease and blood transfusion requirement in the 2 groups. Patients in the experimental group experienced less postoperative pain and required less analgesia. They were discharged home 5 hours earlier than patients in the control group. However, this difference was not statistically significant. Complete stone clearance was achieved in 87.5% of patients in the experimental group and in 90.32% of controls. CONCLUSIONS: The instillation of Tisseel fibrin glue is safe for tubeless percutaneous nephrolithotomy. It is associated with less postoperative pain and a lower analgesic requirement. Additional prospective, randomized studies are required to better define its clinical role in the future.

Sequential holmium laser enucleation of the prostate and laparoscopic extraperitoneal bladder diverticulectomy: initial experience and review of literature.

BACKGROUND AND PURPOSE: Urologic applications of laparoscopy and the holmium laser have increased exponentially in the past few years. We present our experience with sequential holmium laser enucleation of the prostate (HoLEP) and extraperitoneal laparoscopic diverticulectomy for a large symptomatic bladder diverticulum and associated bladder outlet obstruction. PATIENTS AND METHOD: From June 2004 to June 2005, three patients with benign prostatic hyperplasia (BPH) and a large secondary bladder diverticulum were offered sequential HoLEP and laparoscopic extraperitoneal bladder diverticulectomy. Demographic data and perioperative outcomes were recorded. A review of the literature was performed to determine the present role of laparoscopic diverticulectomy. RESULTS: All patients underwent the planned procedure successfully. The mean operating time was 63.33 minutes for HoLEP and 246.6 minutes for diverticulectomy. Oral intake was resumed after a mean of 8.6 hours. The mean postoperative analgesia required was 146 mg of parecoxib sodium, and the mean drop in hemoglobin was 1.13 g/dL. Patients were discharged after an average of 66.6 hours. At 1-month follow-up, the average American Urological Association Score had improved from 13 to 6, the post-void [corrected] residual urine volume had decreased from 997 mL to 164 mL, and the peak uroflow rate had improved from 4.9 mL/sec to 10.4 mL/sec. These measures showed further improvement on later follow-up. A total of 30 cases of laparoscopic diverticulectomy have been reported in literature [corrected] of which only two were done extraperitoneally. CONCLUSION: Simultaneous HoLEP and laparoscopic extraperitoneal diverticulectomy is an effective strategy for the treatment of BPH with associated large bladder diverticulum.

Initial experience with hemostatic fibrin glue as adjuvant during tubeless percutaneous nephrolithotomy.

PURPOSE: To report our initial experience with hemostatic fibrin glue as an adjuvant during tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Seventeen consecutive patients underwent tubeless PCNL with injection of 2 mL of Tisseel Vapor Heated Sealant (Baxter AG, Vienna, Austria) into the percutaneous tracts at the conclusion of the procedure. The perioperative outcomes of these patients were compared retrospectively with those of a control group of 25 consecutive patients who underwent tubeless PCNL without the use of fibrin glue. The safety and efficacy of the new approach was evaluated by comparing operative time, hemoglobin drop, transfusion requirement, length of hospitalization, postoperative pain, analgesic use, and postoperative complications in the two groups. RESULTS: There was no difference in the mean drop in hemoglobin, transfusion requirement, or complications in the two groups. However, patients undergoing Tisseel tubeless PCNL required less analgesia postoperatively (P=0.05), and they were discharged an average of 7 hours earlier than the patients in the control group. There were no major postoperative complications. CONCLUSIONS: Use of fibrin glue was safe and was associated with less analgesic requirement and a shorter hospital stay. Randomized studies are needed to evaluate its clinical role in the future.

Evaluation of fluid absorption during holmium laser enucleation of prostate by breath ethanol technique.

PURPOSE: In a prospective manner we studied various factors affecting fluid absorption during HoLEP. We also simultaneously evaluated changes in serum electrolytes and hemoglobin decrease during HoLEP. MATERIALS AND METHODS: This prospective study comprised of 53 patients who underwent HoLEP at our institute. Irrigation fluid was normal saline tagged with ethanol (1% w/v). Intraoperatively a standard breath analyzer was used to monitor expired breath ethanol levels during the procedure at 10-minute intervals. Patients who absorbed irrigating fluid as indicated by positive intraoperative breath tests were considered absorbers. Serum electrolyte and hemoglobin estimations were done before and after surgery. Total irrigation time, amount of irrigation fluid used, weight of resected tissue and presence of capsular perforation were recorded. Statistical analysis was performed to observe the effects of various factors on the amount of intraoperative fluid absorption. RESULTS: Of 53 patients studied 14 (26.41%) demonstrated fluid absorption in the range of 213 to 930 ml (mean 459). Preoperative prostate weight, total irrigation time, amount of irrigation fluid used and resected tissue weight were all significantly greater in absorbers. Similarly, absorbers had a statistically significant decrease in hemoglobin level postoperatively. There was no statistically significant change in serum electrolytes between absorbers and nonabsorbers. CONCLUSIONS: Preoperative weight of prostate, total irrigation time, amount of irrigation fluid used and weight of resected tissue all directly influence the amount of fluid absorption during HoLEP. There is no significant change in serum electrolytes and no risk of the transurethral resection syndrome.

Safety and efficacy of supracostal access in tubeless percutaneous nephrolithotomy.

PURPOSE: To evaluate the feasibility and safety of supracostal access in tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From September 2004 to November 2005, tubeless PCNL using supracostal access was done for 72 patients at our institute. Patients requiring more than two percutaneous tracts or with significant intraoperative bleeding or residual stone burden were excluded from the study. The outcome of these patients was compared with that of a historic cohort of similar patients having supracostal access with routine placement of a nephrostomy tube. The two groups had comparable demographic data. RESULTS: The differences in the mean drop in hemoglobin concentration, transfusion requirement, and complication rate in the two groups were not statistically significant, with three patients in the study group and four patients in the control group requiring blood transfusion. Patients undergoing tubeless PCNL required less analgesia (P = 0.000) and were discharged a mean of 19 hours earlier (P = 0.000) than those in the control group. Complete stone clearance was achieved in 90.27% of the renal units in the study group and 86.11% of the renal units in the control group. Two patients in the study group and three patients in the control group had postoperative hydrothorax, all of whom, except for one in the control group, were managed conservatively. CONCLUSION: Supracostal access in tubeless PCNL appears to be feasible, safe, and effective, offering the advantages of a lower analgesic requirement and shorter hospital stay without increasing thoracic complications. Studies with larger numbers of patients are needed to confirm these initial findings.

Safety and efficacy of bilateral simultaneous tubeless percutaneous nephrolithotomy.

OBJECTIVES: To evaluate the feasibility and safety of bilateral simultaneous tubeless percutaneous nephrolithotomy (PCNL). METHODS: From August 2004 to January 2005, 10 patients underwent bilateral simultaneous tubeless PCNL. Patients needing more than two percutaneous tracts, having significant intraoperative bleeding, or a residual stone burden were excluded from the study group. The outcome of these 10 patients was compared with a control group of 10 patients who had previously undergone bilateral simultaneous PCNL with routine placement of a nephrostomy tube. RESULTS: The two groups had comparable demographic data, except for a greater stone burden in the right renal units in patients undergoing standard PCNL. The study and control groups needed a total of 22 and 23 tracts, respectively. The difference in the mean drop in hemoglobin, transfusion requirement, and complication rate between the two groups was not statistically significant. Patients undergoing tubeless PCNL required less analgesia (P = 0.001) and were discharged 20 hours earlier (40 versus 60 hours) than those in the control group. However, the difference in mean hospital stay was not statistically significant owing to the small sample size. Complete stone clearance was achieved in 80% of the renal units in the study group and 75% of the renal units in the control group. Three renal units in the tubeless group and four in the standard PCNL group had less than 5-mm residual fragments. CONCLUSIONS: Bilateral simultaneous tubeless PCNL appears to be a feasible, safe, and effective procedure offering potential advantages of decreased analgesic requirement and hospital stay without increasing the complications. Additional clinical studies with a larger number of patients are required to confirm these potential benefits.

Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports.

OBJECTIVE: To evaluate the status of tubeless percutaneous nephrolithotomy (PCNL) in managing renal and upper ureteric calculi, from initial experience and a review of previous reports. PATIENTS AND METHODS: From September 2004 to December 2004, 46 patients were scheduled for tubeless PCNL in a prospective study. Patients with solitary kidney, or undergoing bilateral simultaneous PCNL or requiring a supracostal access were also enrolled. Patients needing more than three percutaneous access tracts, or with significant bleeding or a significant residual stone burden necessitating a staged second-look nephroscopy were excluded. At the end of the procedure, a JJ ureteric stent was placed antegradely and a nephrostomy tube avoided. The patients' demographic data, the outcomes during and after surgery, complications, success rate, and stent-related morbidity were analysed. Previous reports were reviewed to evaluate the current status of tubeless PCNL. RESULTS: Of the 46 patients initially considered only 40 (45 renal units) were assessed. The mean stone size in these patients was 33 mm and 23 patients had multiple stones. Three patients had a serum creatinine level of >2 mg/dL (>177 micromol/L). Five patients had successful bilateral simultaneous tubeless PCNL. In all, 51 tracts were required in 45 renal units, 30 of which were supracostal. The mean decrease in haemoglobin was 1.2 g/dL and two patients required a blood transfusion after PCNL. There was no urine leakage or formation of urinoma after surgery, and no major chest complications in patients requiring a supracostal access tract, except for one with hydrothorax, managed conservatively. The mean hospital stay was 26 h and analgesic requirement 40.6 mg of diclofenac. Stones were completely cleared in 87% of renal units and 9% had residual fragments of < 5 mm. Two patients required extracorporeal lithotripsy for residual calculi. In all, 30% of patients had bothersome stent-related symptoms and 60% needed analgesics and/or antispasmodics to treat them. CONCLUSION: Tubeless PCNL was safe and effective even in patients with a solitary kidney, or with three renal access tracts or supracostal access, or with deranged renal values and in those requiring bilateral simultaneous PCNL. The literature review suggested a need for prospective, randomized studies to evaluate the role of fibrin sealant and/or cauterization of the nephrostomy tract in tubeless PCNL.