Candidaemia and Central Line-Associated Candidaemia in a Network of Indian ICUs: Impact of COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Candidaemia is a potentially life-threatening emergency in the intensive care units (ICUs). Surveillance using common protocols in a large network of hospitals would give meaningful estimates of the burden of candidaemia and central line associated candidaemia in low resource settings. We undertook this study to understand the burden and epidemiology of candidaemia in multiple ICUs of India, leveraging the previously established healthcare-associated infections (HAI) surveillance network. Our aim was also to assess the impact that the pandemic of COVID-19 had on the rates and associated mortality of candidaemia. METHODS: This study included adult patients from 67 Indian ICUs in the AIIMS-HAI surveillance network that conducted BSI surveillance in COVID-19 and non-COVID-19 ICUs during and before the COVID-19 pandemic periods. Hospitals identified healthcare-associated candidaemia and central line associated candidaemia and reported clinical and microbiological data to the network as per established and previously published protocols. RESULTS: A total of 401,601 patient days and 126,051 central line days were reported during the study period. A total of 377 events of candidaemia were recorded. The overall rate of candidaemia in our network was 0.93/1000 patient days. The rate of candidaemia in COVID-19 ICUs (2.52/1000 patient days) was significantly higher than in non-COVID-19 ICUs (1.05/patient days) during the pandemic period. The rate of central line associated candidaemia in COVID-19 ICUs (4.53/1000 central line days) was also significantly higher than in non-COVID-19 ICUs (1.73/1000 central line days) during the pandemic period. Mortality in COVID-19 ICUs associated with candidaemia (61%) was higher than that in non-COVID-19 ICUs (41%). A total of 435 Candida spp. were isolated. C. tropicalis (26.7%) was the most common species. C. auris accounted for 17.5% of all isolates and had a high mortality. CONCLUSION: Patients in ICUs with COVID-19 infections have a much higher risk of candidaemia, CLAC and its associated mortality. Network level data helps in understanding the true burden of candidaemia and will help in framing infection control policies for the country.

Comparison between dexmedetomidine and lidocaine for attenuation of cough response during tracheal extubation: A systematic review and meta-analysis.

Background and Aims: Tracheal extubation often causes cardiovascular and airway responses, potentially resulting in hazardous consequences. It remains unknown whether dexmedetomidine or lidocaine is more effective for cough suppression. Hence, we conducted a systematic review and meta-analysis of randomised controlled trials to compare the effectiveness and safety of dexmedetomidine and lidocaine in reducing cough response after tracheal extubation in adult patients. Methods: A thorough search of electronic databases, including PubMed, Embase, Cochrane Library, and Web of Science, was conducted to identify relevant studies (from inception to 31 January 2023). Randomised controlled trials comparing intravenous (IV) dexmedetomidine versus IV lidocaine administration during emergence from anaesthesia to prevent tracheal extubation response in adult patients under general anaesthesia were included. The primary outcome was the incidence of post-extubation cough. Secondary outcomes included emergence time, extubation time, residual sedation, and incidences of bradycardia. Statistical analysis was conducted using RevMan software. The Cochrane risk of bias tool was used to evaluate the potential risk for bias. Results: In total, seven studies with 450 participants were included. There was no statistically significant difference in the incidence of cough between dexmedetomidine and lidocaine groups [Risk Ratio = 0.76; 95% Confidence Interval: 0.46, 1.24]. Emergence and extubation times were not significantly different between the two groups. Meta-analysis revealed a higher incidence of bradycardia and residual sedation in dexmedetomidine compared to the lidocaine group. Conclusion: This meta-analysis found no difference in cough, emergence, and extubation time between dexmedetomidine and lidocaine after tracheal extubation. However, residual sedation and bradycardia were more significant in dexmedetomidine than in lidocaine.

Brain Regional Energy Metabolism in Patients with Traumatic Brain Injury: A Cerebral Microdialysis Guided Study.

BACKGROUND: In traumatic brain injuries (TBI), cerebral microdialysis (CMD)-derived parameters, especially the lactate to pyruvate ratio (LP ratio), have been utilized for cerebral perfusion optimization. The objectives were to identify cerebral ischemia as measured by CMD in TBI patients requiring decompressive craniectomy and to observe the correlation between cerebral perfusion pressure (CPP), intracranial pressure (ICP), and CMD variables in these patients. Our secondary aim was to observe the effect of CPP augmentation on ischemia biomarkers. METHODS: After the Institute Ethics Committee approvals, seven adult patients requiring decompressive craniectomy following TBI were enrolled and CMD data were obtained prospectively for 72 h. CPP was augmented by 20% with noradrenaline infusion if LP ratio >40. Correlations were done with bootstrapping (n = 500) to obtain the confidence intervals (CI) due to the small sample size. RESULTS: One patient had cerebral ischemia (median LP ratio of 265.5 and median pyruvate of 38 µmol/L), while another patient had non-ischemic mitochondrial dysfunction (median LP ratio 40.7 and median pyruvate 278.5). The coefficients of correlation between the LP ratio with CPP and ICP were r = -0.05 (CI = -0.14-0.03) and r = 0.09 (CI = -0.03-0.24), respectively. The coefficient of correlation between cerebral and blood glucose was r = 0.38, (CI - 0.35-0.14). Only two patients needed CPP augmentation, however, postaugmentation cerebral biochemistry did not change appreciably. CONCLUSION: CMD can identify cerebral ischemia, however, no correlations were observed between the LP ratio and CPP or ICP. CPP augmentation did not improve cerebral biochemistry. More studies are required to understand and treat cerebral metabolism in TBI.

Evaluation of plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) as an early diagnostic marker of acute kidney injury (AKI) in critically ill trauma patients.

Background and Aims: Acute kidney injury (AKI) is a frequent complication of severe trauma associated with high mortality. The aim of this study was to evaluate the diagnostic ability of plasma and urine neutrophil gelatinase-associated lipocalin (NGAL) as an early marker of AKI assessed by RIFLE criteria as reference in trauma patients in intensive care unit (ICU). Material and Methods: This was a prospective observational study. Four hundred and eighteen patients admitted in the trauma ICU with age ≥18 years without known renal diseases were followed-up (serum creatinine, urine output, and estimated glomerular filtration rate) for 5 consecutive days. As per RIFLE criteria, 70 patients were broadly classified as AKI and rest of the patients (n = 348) as non-AKI. Plasma and urine samples of AKI (n = 70) and non-AKI (n = 70) patients were further assessed for 3 consecutive days following admission. Results: Mean plasma NGAL (pNGAL) was significantly elevated in AKI patients as compared with non-AKI patients; on admission: 204.08 versus 93.74 ng/mL (P = 0.01); at 24 h: 216.73 versus 94.63 ng/mL (P = 0.01); and 48 h: 212.77 versus 86.32 ng/mL (P = 0.01). Mean urine NGAL (uNGAL) at 48 h was also significantly elevated: 15.45 ng/mL in AKI patients as compared with 13.48 ng/mL in non-AKI patients (P = 0.01). Plasma and urine NGAL levels were significantly associated with increased mortality. Conclusion: pNGAL had good predictive value on admission (area under the receiver operative characteristic [AUROC] 0.84), at 24 h (AUROC 0.88) and 48 h (AUROC 0.87), while uNGAL had moderate performance at 24 h (AUROC 0.61) and 48 h (AUROC 0.71). pNGAL can be used as an early and potent diagnostic and predictive marker of AKI and mortality in critically ill trauma patients.

Microbiological Profile and the Resistance Pattern of Pathogens in Neurosurgical Patients from a New Delhi Trauma Center.

BACKGROUND: Neurosurgical patients are considered to be at higher risk for infections including nosocomial infections compared with other critically ill individuals. Empirical antimicrobial therapy is of utmost importance for the survival of infected neurosurgical patients. METHODS: The microbial distribution and antimicrobial resistance patients from January 2012 to December 2021 (10 years) were analyzed retrospectively. Identification was done using VITEK-2 and MALDI-TOF systems. Antimicrobial susceptibility testing was determined by the Kirby Bauer Disk Diffusion Agar method (Clinical and Laboratory Standards Institute) and VITEK-2. RESULTS: A total of 48,474 samples were received, out of which 10,134 (21%) had growth. Respiratory specimens showed the maximum isolation of pathogens (42% n = 4292). The predominant bacterial pathogens were gram negative (n = 8972; 88.5%), whereas gram positives were only 11.5% (n = 1162) of the total organisms. Among the gram positives, the most common was Staphylococcus aureus (64.6%), and among gram negatives, the most common pathogen was Acinetobacter baumanni (38.6%). The weighted average of the drug-resistance profile across all gram positives was >50% for fluoroquinolones (levofloxacin, ciprofloxacin), gentamicin, erythromycin, and ampicillin, and in the case of gram negatives it was >90% for ampicillin-sulbactam, ticarcillin, cefazolin, cefotaxime, and ceftriaxone. Thirty-two patients were found to have candidemia, out of which 6 were C. albicans and the rest were nonalbican. Six neurosurgery patients had infection with C. auris, 4 from blood samples and 2 from urine. CONCLUSIONS: This study will add to the current knowledge and provide a better understanding of pathogen profile and resistance patterns in traumatic brain injury patients.

Measurement of Neutrophil Gelatinase-Associated Lipocalin (Ngal) Following Neuroradiological Procedure/s in Patients with Aneurysmal Subarachnoid Hemorrhage: A Preliminary Study.

Background: Radiocontrast administration during interventional neuroradiology (INR) procedures for aneurysmal subarachnoid haemorrhage (aSAH) can add to renal insult. Serum creatinine (sCr) is a conventional marker of acute kidney injury (AKI). Serum neutrophil gelatinase-associated lipocalin (sNGAL) is a novel marker which is increasingly used to predict renal injury in susceptible patients. Objectives: The primary aim of this study was to evaluate correlation between serum neutrophil gelatinase-associated lipocalin (NGAL) and sCr in aSAH patients undergoing therapeutic or diagnostic INR procedures. The secondary aim was to find the incidence of contrast-induced AKI and hemodynamic complications during the study period. Material and Methods: All consenting aSAH patients (18-60 years, Modified Hunt and Hess grade 1-4) posted for INR procedures during the study time were included. Patients with history of chronic renal disease, recent contrast exposure, or renal insufficiency were excluded. Blood samples for sCr and sNGAL were obtained preprocedure and then at 1, 6, 24, and 48 h after contrast administration. Hourly urine output was noted. AKI was defined by KDIGO guidelines. Statistical Analysis Used: Repeated measurement analysis of variance, Posthoc Bonferroni test and Pearson correlation coefficient test. Results: Fifty patients, mean age 47.34 ± 9.31 years, were enrolled for the study. Majority (48; 96%) were Hunt and Hess (H and H) grade I-III. The mean volume of contrast administered was 123.2 ± 53.08 mL. The mean sNGAL and sCr values at pre-op, 1, 6, 24, and 48 h were 124.99 ± 64.58, 148.40 ± 77.90, 147.33 ± 76.00, 125.49 ± 64.44, and 116.38 ± 61.79 ng/mL and 0.629 ± 0.23, 0.624 ± 0.22, 0.612 ± 0.21, 0.632 ± 0.19, and 0.577 ± 0.22 mg/dL, respectively. There was a correlation in sCr and sNGAL value (P < 0.001) at all study time points. However, no specific pattern was seen. No patient developed any AKI or hemodynamic complications in first 48 h. Conclusions: There is a correlation between serum NGAL and sCr at individual time points. NGAL may represent a sensitive early biomarker of renal impairment after INR Procedures. There was no incidence of AKI after contrast administration in aSAH patients without predisposing renal risk factors.

Comparison of Different Tidal Volumes for Ventilation in Patients with an Acute Traumatic Cervical Spine Injury.

Background: There is scant literature comparing high tidal volume ventilation (HTV) over low tidal volume (LTV) ventilation in acute traumatic cervical spinal cord injury (CSCI). Objective: The aim of this prospective randomized controlled parallel-group, single-blinded study was to compare the effect of two different tidal volumes (12-15 mL/kg and 6-8 mL/kg) in CSCI on days to achieve ventilator-free breathing (VFB), PaO2/FIO2 ratio, the incidence of complications, requirement of vasopressor drugs, total duration of hospital stay, and mortality. Materials and Methods: We enrolled patients with acute high traumatic CSCI admitted to the neurotrauma intensive care unit within 24 h of injury, requiring mechanical ventilation. Participants were randomized to receive either HTV, 12-15 mL/kg (group H) or LTV, 6-8 mL/kg (group L) tidal volume ventilation. Results and Conclusions: A total of 56 patients, 28 in each group were analyzed. Patient demographics and injury severity were comparable between the groups. VFB was achieved in 23 and 19 patients in groups H and L, respectively. The median number of days required to achieve VFB was 3 (2, 56) and 8 (2, 50) days, P = 0.33; PaO2: FIO2 ratio was 364.0 ± 64 and 321.0 ± 67.0, P = 0.01; the incidence of atelectasis was 25% and 46%, P = 0.16, respectively, in group H and group L. The hemodynamic parameters and the vasopressor requirement were comparable in both groups. There was no barotrauma. The duration of hospital stay (P = 0.2) and mortality (P = 0.2) was comparable in both groups. There was no significant difference in days to achieve ventilator-free breathing with HTV (12-15 mL/kg) ventilation compared to LTV (6-8 mL/kg) ventilation in acute CSCI. The PaO2:FiO2 ratio was higher with the use of 12-15 mL/kg. No difference in mortality and duration of hospital stay was seen in either group.

Intraoperative Neuromonitoring for Spinal Surgery in a Pregnant Patient: Case Report and Literature Review.

We report the strategy of anesthesia and intraoperative neurophysiological monitoring (IONM) in a 29-year-old, 22 weeks pregnant patient posted for surgery for aggressive vertebral body hemangioma. We used propofol and fentanyl-based anesthesia for IONM. Motor-evoked potentials (MEP) and somatosensory-evoked potentials (SSEP) were used to monitor the neural tracts during surgery. Fetal heart rate monitoring was done preoperatively and postoperatively. Train of 8, 75 µs duration pulse, 250-500 Hz stimulus was used for MEP and 30 mA, 200-400 µs, 3-5 Hz was used for SSEP. No new motor or somatosensory deficits appeared. Our findings suggest that IONM can be safely done in pregnant women.

Carotid Artery Stenting for a Nonagenarian Presenting as Stuttering Stroke.

Carotid artery stenting (CAS) is performed in patients with minor strokes and transient ischemic attacks (TIAs) to prevent further strokes. However, most operators do not intervene in older adults. We had a 92-year patient with recurrent minor strokes with two possible proximate causes - cardioembolism and significant symptomatic left carotid stenosis. This patient continued to have recurrent ischemic events in the left carotid territory despite optimum management of the cardioembolic source with dual antiplatelets and anticoagulation and was successfully treated with left CAS. The role of carotid revascularization in older patients with high-grade symptomatic carotid stenosis and cardiac comorbidities is discussed.

Correlation Between Invasive and Noninvasive Technique of Intracranial Pressure Measurement in Children With Traumatic Brain Injury: An Observational Study.

BACKGROUND: Direct measurement of intracranial pressure (ICP) is an invasive technique with potential complications, which has prompted the development of alternative, noninvasive, methods of ICP assessment. The aim of this study was to determine the relationship between noninvasive ultrasound-based measurement of optic nerve sheath diameter (ONSD), transcranial Doppler-derived pulsatility index (PI), and invasive ICP measurements in children with traumatic brain injury (TBI). METHODS: Children aged 1 to 18 years undergoing invasive ICP monitoring following TBI were included in the study. Noninvasive ONSD and PI measurements were compared with simultaneous invasive ICP. RESULTS: In all, 406 measurements of ONSD and PI were obtained in 18 patients. ONSD and PI correlated with ICP (r=0.76 and 0.79, respectively), combining ONSD and PI resulted in an even stronger correlation with ICP (r=0.99). Formulas were derived from mixed-effect models that best fitted the data for noninvasive ICP estimation. A combination of ONSD and PI had the highest ability to detect ICP >20 mm Hg (area under the receiver operating characteristic curve=0.99, 95% confidence interval: 0.99-1.00). Optimal cutoff values for the prediction of intracranial hypertension were 5.95 mm for ONSD (sensitivity, 92%; specificity, 76%) and 1.065 for PI (sensitivity, 92%; specificity, 87%). CONCLUSIONS: In children with TBI, a combination of ONSD and PI strongly correlates with invasive ICP and has potential to screen for intracranial hypertension noninvasively. ONSD and PI may be useful tools for assessing ICP where invasive monitoring is unavailable or contraindicated.

One for Everyone: A Study of User Satisfaction Among Health-Care Providers Regarding Extended Use of N95 Masks During the COVID-19 Pandemic.

OBJECTIVE: This study was conducted to assess the feasibility of extended use of N95 masks in our hospital during the coronavirus disease 2019 (COVID-19) pandemic. We also studied the use pattern, user satisfaction, and issues faced during extended use of the mask. METHODS: This cross-sectional study was conducted among health-care providers in a large tertiary care teaching hospital in northern India from April 1 to May 31, 2020. A list was prepared from the institute's register, and participants were chosen by random sampling. The data collected from the physical forms were transferred to excel sheets. RESULTS: A total of 1121 responses were received. The most common problem stated with reuse of N95 masks was loss of fit followed by damage to the slings, highlighted by 44.6% and 44.4% of the participants, respectively. A total of 476 (42.5%) participants responded that they would prefer "cup-shaped N95 mask with respirator". The median scores regarding the satisfaction with the quality of masks and their fit was also 4 each. CONCLUSIONS: It was concluded that the extended use of N95 masks was acceptable, with more than 96% of the participants using these masks.

Antimicrobial consumption in intensive care unit patients at level 1 trauma centre in India.

PURPOSE: Increase in the antimicrobial resistance causes a concern globally. To mitigate the rapidly rising antimicrobial resistance in the health system globally antimicrobial stewardship programs (AMSP) have been advocated. Therefore, we aim to measure aggregate antibiotic consumption by both Defined Daily Dosage (DDD) and Days of Therapy (DOT) methods. METHODS: As a part of Indian Council of Medical Research initiative to develop local AMSP, this prospective study of six months was conducted at a level -1 Trauma Centre of AIIMS, New Delhi. In this, we have included all the patients of polytrauma and neurosurgical Intensive care units between April to October 2019. Consumption of antibiotics data were collected manually daily by infection control practitioners. Data were presented as Days of Therapy (DOT) and Defined Daily Dose (DDD). RESULTS: During the six months of study, antimicrobial consumption of ICU was compared with empirical therapy v/s culture-based therapy. Overall average antimicrobial consumption for the six months for both empirical therapy and culture-based therapy DDD/1000 patient days was 531.8 and 460.7 whereas DOT/1000 patient days 489.9 and 426.04 respectively. CONCLUSIONS: Antimicrobial Stewardship activities aim to ensure judicious consumption of antimicrobials. Such data will be of value in establishing, evaluating and monitoring the function of the AMSP in the healthcare settings.