An Observational Study on the Effects of Delayed Initiation of End-of-Life Care in Terminally ill Young Adults in the Intensive Care Unit.

INTRODUCTION: The early initiation of end-of-life (EOL) care in terminally ill patients in the intensive care unit (ICU) offers distinct advantages but requires the consent and cooperation of the patients or their relatives. The terminally ill young adults pose distinct set of challenges. The present study was conducted to measure the prevalence and identify and compare the risk factors for the delayed initiation of EOL in terminally ill young adults. METHODS: The retrospective study was conducted in a mixed medical-surgical 7-bedded ICU after extracting the medical records of all terminally ill young adults in the age group of 20-40 years admitted between June 2014 and November 2018. Only "treatment futile" patients were eligible for inclusion. The patients already on EOL care or with unproven diagnosis were excluded from the study. The commencement of EOL care was divided into (a) normal group (N) and (b) late group (L). The two groups were compared with respect to the demographic factors, outcome, and patient satisfaction level. The factors responsible for the delay were investigated. All statistical analyses were performed using software SPSS 21.0 (SPSS, Inc., Chicago, IL, USA). RESULTS: Out of 66 terminally ill young adults with treatment futility, 23 (38.9%) were in the N group and 36 (61.1%) were in the L group (0.8 ± 0.4 days vs. 3.1 ± 1.6 days; P = 0.01). The education level and social and family support of the relatives of the N group were higher (P = 0.03; P - 0.04). The N group had lesser drug consumption of ICU resource usage (14.7% vs. 36.1%, P = 0.01; 18.5% vs. 24.7%, P = 0.04). There was no difference in the duration of mechanical ventilation, ICU stay, and satisfaction level at the time of discharge (or death) from the ICU. CONCLUSIONS: Our study found a high prevalence of delayed initiation of EOL care in terminally ill young adults and identified the factors responsible for them. The normal initiation of EOL care reduced the usage of medications and resources without affecting the level of patient satisfaction.

Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients.

INTRODUCTION: Early initiation of end-of-life (EOL) care in terminally ill patients can reduce the administration of unnecessary medications, minimize laboratory and radiological investigations, and avoid procedures that can provoke untoward complications without substantial benefits. This retrospective observational study was performed to compare early vs late initiation of EOL care in terminally ill ICU patients after the recognition of treatment futility. MATERIALS AND METHODS: The medical records of all patients who were considered to be terminally ill any time after ICU admission between January 2014 and December 2018 were extracted from the ICU database. The patients who were recognized for treatment futility were eligible for inclusion. The patients who were already on EOL care prior to the ICU admission or whose diagnosis was unconfirmed were excluded from the study. The treatment futility was a subjective decision jointly undertaken by the primary physician and the intensivist based upon the disease stage and the available therapeutic options. The commencement of EOL care after recognition of treatment futility was divided into (a) early group (EG)-within 48 hours of decision of treatment futility and (b) late group (LG)-after 48 hours of recognition of treatment futility. Both the groups were compared for (a) ICU mortality, (b) length of ICU stay, (c) number of antibiotic-free days, (d) number of ventilator-free days, (e) number of medical and/or surgical interventions (insertion of central lines, drains, IABP, etc.), (f) number of blood and radiological investigations, and (g) satisfaction level of family members. RESULTS: Out of 107 terminally ill patients with diagnosis of treatment futility, 64 patients (59.8%) underwent early initiation of EOL against delayed initiation in 43 (40.2%) patients (1.3 ± 0.4 days vs 5.1 ± 1.6 days; p = 0.01). The patients in the late initiation group were younger in age (49 ± 3.6 years vs 66 ± 5.3 years; p = 0.03). The number of antibiotic-free days was higher in the early initiation group (12 ± 5.2 days vs 6 ± 7.5; p = 0.02). The number of medical and surgical interventions was lesser in the early initiation group (3.0 ± 0.7 episodes vs 12 ± 3.9 episodes; p = 0.007). The late initiation of EOL was caused by prognostic dilemma (30.2%), reluctance of the family members (44.1%), ambivalence of the primary physician (18.6%), and hesitancy of the intensivist (6.9%). The satisfaction level of the family members was similar in both the groups. CONCLUSION: We conclude that delayed initiation of EOL care in terminally ill ICU patients after recognition of treatment futility can increase the antibiotic usage and medical and/or surgical interventions with no effect on the satisfaction level of the family members. HOW TO CITE THIS ARTICLE: Choudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(6):404-408.

A Comparison of Acute Physiology and Chronic Health Evaluation II Score and Serum Procalcitonin Change for Predicting Mortality in Acute Pancreatitis.

INTRODUCTION: The prediction of mortality in acute pancreatitis (AP) is a useful estimate for effective treatment. Scoring systems such as acute physiology and chronic health evaluation (APACHE) II, computed tomography (CT) severity index (CTSI), bedside index of severity in acute pancreatitis (BISAP), etc., are used for prediction. Biomarkers like C-reactive protein (CRP) and procalcitonin (PCT) are also considered useful for prognostication. The aim of this retrospective study was to correlate the changes in serum PCT level with APACHE II score between admission and 48 hours as mortality predictor in AP. MATERIALS AND METHODS: The observational study was conducted in a cohort of 42 patients admitted consecutively in the seven-bedded general intensive care unit (ICU) of our institute between June 2016 and May 2018, with the diagnosis of AP. The APACHE II score and serum PCT level at admission and 48 hours were retrieved from the hospital database. The change in APACHE II and PCT level was compared between ICU "survivors" and "nonsurvivors." The predictive accuracy of APACHE II and PCT was measured using area under receiver-operator characteristics (ROC) curve. A p value <0.05 was considered as significant. RESULTS: Of the 42 patients enrolled, 30 patients (71.42%) were survivors and 12 (28.58%) were nonsurvivors. The median APACHE II score in nonsurvivors increased from 16 (7-19) to 23 (11-29) and remained unchanged at 16 (9-19 at admission; 10-22 at 48 hours) in survivors. The median PCT levels increased from 3.8 (1.2-5.6) to 6.2 (1.9-12.5) in nonsurvivors and decreased from 3.8 (1.2-5.6) to 2.2 (0.6-2.9) in survivors. Serum PCT change compared better than the APACHE II score change among survivors (r = 0.455, p = 0.011) with a mean (±standard deviation SD) change of 1.41 (±1.59). CONCLUSION: The change in serum PCT and APACHE II between admission and 48 hours correlates well and is useful for mortality prediction in AP. Serum PCT change compares better than APACHE II score change in survivors. HOW TO CITE THIS ARTICLE: Choudhuri AH, Duggal S, Biswas PS, Uppal R. A Comparison of Acute Physiology and Chronic Health Evaluation II Score and Serum Procalcitonin Change for Predicting Mortality in Acute Pancreatitis. Indian J Crit Care Med 2020;24(3):190-194.

Epidemiology of Multidrug Resistant Infections after Inter-ICU Transfer in India.

BACKGROUND AND AIMS: The patients in the intensive care unit (ICU) are often infected with multidrug resistant (MDR) organisms. When they are transferred to other ICUs, they can expand the reservoir of MDR organisms and pose a threat to the infection control program. The present observational study was undertaken to describe the epidemiology and compare the outcome of MDR and non-MDR infections after inter ICU patient transfer. MATERIALS AND METHODS: A retrospective study was conducted in a cohort of 134 consecutive admitted patients in a tertiary care ICU from other ICUs. The primary objective was to measure the prevalence of MDR and non-MDR infections. The secondary objective was to compare the outcome between MDR and non-MDR group and identify the factors independently associated with mortality for each group. RESULTS: Among 134 patients, 89 had infections (66.4%) and in 29 (21.6%) were due to MDR organisms. The most common organism was Klebsiella in the MDR and E. coli in the non-MDR group. There was no difference between the groups in mortality, duration of mechanical ventilation and length of ICU stay. The duration of mechanical ventilation and ICU stay >7 days was independently associated with mortality in the MDR group. No association was found in the non-MDR group. CONCLUSION: The study demonstrates a high prevalence of MDR infections after inter ICU transfer. There is no difference in outcome between the groups, but the mortality in the MDR group is independently associated with a longer duration of mechanical ventilation and ICU stay. HOW TO CITE THIS ARTICLE: Choudhuri AH, Ahuja B, Biswas PS, Uppal R. Epidemiology of Multidrug Resistant Infections after Inter-ICU Transfer in India. Indian Journal of Critical Care Medicine, January 2019;23(1):1-6.

Epidemiology and risk factors for multidrug-resistant bacteria in critically ill patients with liver disease.

BACKGROUND AND AIMS: The critically ill patients with liver disease are vulnerable to infections in both community and hospital settings. The nosocomial infections are often caused by multidrug-resistant (MDR) bacteria. The present observational study was conducted to describe the epidemiology, course, and outcome of MDR bacterial infection and identify the risk factors of such infection in critically ill patients with liver disease. MATERIALS AND METHODS: A retrospective observational study was conducted on 106 consecutive critically patients with liver disease admitted in the Intensive Care Unit between March 2015 and February 2017. The MDR and non-MDR (non-MDR) groups were compared and the risk factors identified by multivariate analysis. RESULTS: Out of the 106 patients enrolled in the study, 23 patients had infections caused by MDR bacteria. The MDR-infected patients had severe liver disease (Child-Pugh score 11 ± 2.3 vs. 7 ± 3.9; P = 0.04), longer duration of antibiotic usage (6 ± 2.7 days vs. 2 ± 1.5 days; P = 0.04), greater use of total parenteral nutrition (TPN) (73.9% vs. 62.6%; P = 0.04), and more concurrent antifungal administration (60.8% vs. 38.5%; P = 0.04). The mortality was higher in MDR group (hazard ratio = 1.86; P < 0.05). The independent predictors of MDR bacterial infection were Child-Pugh score >10, prior carbapenem use, antibiotic use for more than 10 days, TPN use, and concurrent antifungal administration. CONCLUSION: The study demonstrated a high prevalence of MDR bacterial infection in critically ill patients with a higher mortality over non-MDR bacterial infection and also identified the independent predictors of such infections.

Epidemiology and characteristics of nosocomial infections in critically ill patients in a tertiary care Intensive Care Unit of Northern India.

BACKGROUND AND AIMS: The prevalence of nosocomial infection is higher in the Intensive Care Unit (ICU) than other areas of the hospital. The present observational study was undertaken to describe the epidemiology and characteristics of nosocomial infections acquired in a tertiary care ICU and the impact of the various risk factors in their causation. MATERIALS AND METHODS: A retrospective study was conducted on the prospectively collected data of 153 consecutive patients admitted in a tertiary care ICU between July 2014 and December 2015. The primary objective was to assess the epidemiology of ICU-acquired bacterial infections in terms of the incidence of new infections, causative organism, and site. The secondary end point was to assess the risk factors for developing ICU-acquired infections. RESULTS: Out of the 153 patients enrolled in the study, 87 had an ICU-acquired nosocomial infection (58.86%). The most common organism responsible for infection was Klebsiella pneumoniae (37%), and the most common infection was pneumonia (33%). The duration of mechanical ventilation and length of ICU stay were significantly prolonged in patients developing nosocomial infections. There was no difference in mortality between the groups. The multivariate analyses identified intubation longer than 7 days, urinary catheterization >7 days, duration of mechanical ventilation more than 7 days, and ICU length of stay longer than 7 days as independent risk factors for nosocomial infections. CONCLUSION: The study demonstrated a high incidence of nosocomial infection in the ICU and identified the risk factors for acquisition of nosocomial infections in the ICU.

Influence of Admission Source on the Outcome of Patients in an Intensive Care Unit.

AIM OF THE STUDY: The admission in the Intensive Care Unit (ICU) occurs from various sources, and the outcome depends on a complex interplay of various factors. This observational study was undertaken to describe the epidemiology and compare the differences among patients admitted in a tertiary care ICU directly from the emergency room, wards, and ICUs of other hospitals. MATERIALS AND METHODS: A retrospective study was conducted on 153 consecutive patients admitted from various sources in a tertiary care ICU between July 2014 and December 2015. The primary endpoint of the study was the influence of the admission source on ICU mortality. The secondary endpoints were the comparison of the duration of mechanical ventilation, length of ICU stay, and the ICU complication rates between the groups. RESULTS: Out of the 153 patients enrolled, the mortality of patients admitted from the ICUs of other hospital were significantly higher than the patients admitted directly from the emergency room or wards/operating rooms (60.5% vs. 48.2% vs. 31.9%; P = 0.02). The incidence of ventilator-associated lung injury was lower in the patients admitted directly from the emergency room (23.4% vs. 50% vs. 50%; P = 0.03). Multivariate logistic regression analysis revealed higher age, increased disease severity, longer duration of mechanical ventilation, and longer ICU stay as independent predictors of mortality in the patients shifted from the ICUs of other hospitals. CONCLUSION: The study demonstrated a higher risk of ICU mortality among patients shifted from the ICUs of other hospitals and identified the independent predictors of mortality.

Use of single-lumen tube for minimally invasive and hybrid esophagectomies with prone thoracoscopic dissection: case series.

Minimally invasive and hybrid minimally invasive esophagectomy (MIE) is a technically challenging procedure. Anesthesia for the same is equally challenging due to special requirements of the video-assisted thoracoscopic technique used and shared operative and respiratory fields. Standard ventilatory strategy for this kind of surgery has been 1-lung ventilation with the help of a double-lumen tube. Prone positioning for thoracoscopic dissection facilitates gravity-dependant collapse of the operative side lung induced by a unilateral capnothorax, thus making the use of single-lumen endotracheal tube a feasible option for this surgery. We report our experience of 10 consecutive cases of minimally invasive esophagectomy conducted in prone position at our center and the use of single-lumen endotracheal tube for ventilation.

Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study.

BACKGROUND: Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative. MATERIALS AND METHODS: This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP. RESULTS: During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037). CONCLUSION: MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.

Predictors of postoperative pulmonary complications after liver resection: Results from a tertiary care intensive care unit.

BACKGROUND: Postoperative pulmonary complication (PPC) is a serious complication after liver surgery and is a major cause of mortality and morbidity in the intensive care unit (ICU). Therefore, the early identification of risk factors of PPCs may help to reduce the adverse outcomes. OBJECTIVE: The aim of this retrospective study was to determine the predictors of PPCs in patients undergoing hepatic resection. DESIGN: Retrospective, observational. METHODS: The patients admitted after hepatic resection in the gastrosurgical ICU of our institute between October 2009 and June 2013 was identified. The ICU charts were retrieved from the database to identify patients who developed PPCs. A comparison of risk factors was made between the patients who developed PPC (PPC group) against the patients who did not (no-PPC group). RESULTS: Of 117 patients with hepatic resection, 28 patients developed PPCs. Among these, pneumonia accounted for 12 (42.8%) followed by atelectasis in 8 (28.5%) and pleural effusion in 3 (10.7%). Among the patients developing PPCs, 16 patients were over a 70-year-old (57.1%), 21 patients were smokers (75%) and 8 patients (28.5%) had chronic obstructive pulmonary disease (COPD). The requirement for blood transfusion and duration of mechanical ventilation were greater in the patients developing PPC (2000 ± 340 vs. 1000 ± 210 ml; 10 ± 4.5 vs. 3 ± 1.3 days). CONCLUSION: Old age, chronic smoking, COPD, increased blood product transfusion, increased duration of mechanical ventilation and increased length of ICU stay increased the relative risk of PPC, presence of diabetes and occurrence of surgical complications (leak, dehiscence, etc.) were independent predictive variables for the development of PPC.

Beware of "curare cleft" like changes during unilateral capnothorax.

Capnography is a standard monitoring tool during general anaesthesia. Diaphragmatic movement with the weaning of muscle relaxant effect produces the characteristic "curare cleft" on capnography. Various artefacts can mimick this trace intraoperatively. Cautious interpretation and identification of these is essential to avoid any undue overdosing of the patients with muscle relaxants. We report "curare cleft" like artefact during ventilation with a single lumen tube in a patient with unilateral capnothorax undergoing minimally invasive esophagectomy.

Predictors of septic shock following anastomotic leak after major gastrointestinal surgery: An audit from a tertiary care institute.

BACKGROUND: Anastomotic leak is a serious complication after major gastrointestinal surgery and majority of deaths occur due to septic shock. Therefore, the early identification of risk factors of septic shock may help reduce the adverse outcomes. OBJECTIVE: The aim of this audit was to determine the predictors of septic shock in patients with anastomotic leak after major gastrointestinal surgery. DESIGN: Retrospective, audit. MATERIALS AND METHODS: The patients admitted in the gastrosurgical intensive care unit ICU) of our institute between September 2009 and April 2012 with anastomotic leakage after surgery were identified. The ICU charts were retrieved from the database to identify the patients progressing to septic shock. A comparison of risk factors was made between the patients who developed septic shock (septic shock group) against the patients who did not (non-septic shock group). RESULTS: The study sample comprised of 103 patients with anastomotic leak, of which 72 patients developed septic shock. The septic shock group had a higher APACHE II score, lower MAP, and higher HR at the time of ICU admission. They received greater transfusion of packed red blood cells during their ICU stay. Septic shock was more common after pancreaticojejunostomy and hepaticojejunostomy leaks. CONCLUSION: Presence of malignancy, chronic obstructive pulmonary disease (COPD), packed red blood cell transfusion, bacteremia, and hepaticojejunostomy or pancreaticojejunostomy leaks were independent predictors of mortality and length of ICU stay. To the best of our knowledge there are no available studies in the literature on the predictors of risk factors of septic shock in patients with anastomotic leakage.

Influence of non-surgical risk factors on anastomotic leakage after major gastrointestinal surgery: Audit from a tertiary care teaching institute.

CONTEXT: The occurence of anastomotic leakage after gastointestinal resection and anastomosis is associated with significant mortality and morbidity. AIMS: There is dearth of evidence in the literature on the influence of various non-surgical factors in causing anastomotic leakage although many studies have identified their possible role. MATERIALS AND METHODS: A retrospective audit of all the anastomotic leakages occurring between September 2009 and April 2012 in our institute was performed to identify the potential non-surgical factors that can influence anastomotic leakage. A total of 137 out of 1246 patients who developed anastmotic leak were analyzed. All the potential non-surgical causes of anastomotic leakage available in the literature were analyzed by univariate analysis and stepwise multiple logistic regression analysis was done after adjusting for the type of surgery. An intergroup comparison among the patients based on the type of surgery was also performed. RESULTS: THE FOLLOWING FACTORS WERE FOUND TO BE INDEPENDENTLY ASSOCIATED WITH INCREASED RISK OF ANASTOMOTIC LEAK: (1) albumin <3.5 g/dl, (2) anemia <8 g/dl, (3) hypotension (4) use of inotropes, and (5) blood transfusion. The majority of anastomotic leaks occurred after pancreatic surgeries followed by esophagectomies and occurred least after colonic resections. The risk for anastomotic leak was four times more in patients who required inotropic support in the perioperative period and three times more in patients who developed hypotension. CONCLUSIONS: Our study is the first retrospective audit to identify the influence of non-surgical factors for anastomotic leakage and the need for further observational studies in this direction.

Successful double lumen tube insertion in a patient with unanticipated laryngeal and tracheal web.

A 45-year-old female patient admitted for surgical management of carcinoma esophagus, presented with difficulty in insertion of left-sided 37 F and 35 F double lumen tube (Mallinckrodt® Broncho-Cath). Fiberoptic bronchoscopy revealed a subglottic web in the larynx just below the vocal cords and a tracheal web just above the carina. Differential lung ventilation could be achieved with a 35 F internal diameter double lumen tube (Portex® Blueline® Endobronchial tube).