Impact of Establishing a Pain Clinic in a Rural Cancer Centre Based on the Knowledge and Experience of the Pain of Cancer Patients - A Prospective, Questionnaire-Based Study.

Objectives: Unrelieved pain significantly affects the quality of life of cancer patients. In rural settings, cancer patients do not have information or knowledge about how to control their pain because of a lack of resources or awareness. We conducted an interventional, questionnaire-based prospective study in a rural tertiary care oncological centre to look for the impact of establishing a pain clinic based on the knowledge and experience of cancer patients regarding their cancer pain. Material and Methods: The patient pain questionnaire was filled by 380 random non-surgical patients complaining of pain who visited our centre for the treatment of cancer. The information generated was used for setting up a pain clinic covering all aspects of cancer pain. After 3 months of starting the pain clinic services, all these patients who visited the pain clinic at least once were again surveyed similarly. Out of 380 patients, we could only follow up with 348 patients and other patients were lost to follow-up. Results: After visiting the pain clinic the mean value of the response for most of the questions decreased suggesting that the responses became more favourable as the knowledge improved and the experience of the pain became less distressing for the patients. The mean value of the responses to all the questions related to the overall knowledge of cancer pain before visiting a pain clinic was 4.22 ± 1.58 and after visiting a pain clinic was 3.83 ± 0.95 which was statistically significant (P = 0.000). The mean value of the responses to the questions related to the overall experience of the pain before visiting the pain clinic was 3.81 ± 1.42 and after visiting the pain clinic was 2.14 ± 1.05 which was highly significant (P = 0.000). We found out that the patients who had a higher mean value of the responses (8-10) suggesting the most unfavourable responses benefitted the most and the number of patients having the most unfavourable responses decreased after visiting the pain clinic. Conclusion: In a rural tertiary healthcare cancer centre, the establishment of a pain clinic increased the general understanding and experience of cancer patients regarding their pain and pain management.

Administration of magnesium sulphate does not prevent post-reperfusion syndrome but is necessary during living donor liver transplantation.

Severe hemodynamic instability is observed during portal vein de-clamping in the form of post-reperfusion syndrome in liver transplantation. The protective effect of magnesium on inflammation and ischemia-reperfusion injuries of various organs is evident, but its role in the prevention of post-reperfusion syndrome in liver transplantation is not clear. We investigated the effect of magnesium sulphate on the incidence of post-reperfusion syndrome during living donor liver transplantation. The secondary outcomes were the requirement of vasopressor boluses and levels of serum magnesium, lactate and serum C-reactive protein. Seventy living donor liver transplant recipients were randomized into a magnesium (M) group (n = 35) or normal saline (N) group (n = 35). The patients in group M received 35 mg/kg of magnesium sulphate, 30 minutes after the beginning of the anhepatic phase, and patients in group N received normal saline. The incidence of post-reperfusion syndrome in group M and group N was 34.29% and 40%, respectively, with no significant difference. The requirement for rescue vasopressor boluses and levels of C-reactive protein and lactate were also comparable between the two groups. However, the incidence of hypomagnesemia at the end of surgery was significantly higher in group N (37.1% vs. 14.28%, p = 0.027). Magnesium does not appear to prevent post-reperfusion syndrome. However, hypomagnesemia is more frequently seen during liver transplantation. Hence, serum magnesium should be routinely monitored and administered during liver transplantation.

Evaluation of the Integrative Weaning Index for Predicting the Outcome of Spontaneous Breathing Trial in Patients with Cirrhosis on Mechanical Ventilation: A Pilot Study.

OBJECTIVE: Studies on mechanical ventilation in patients with cirrhosis have focused mainly on survival, as the disease is considered to carry a poor prognosis. The process of weaning in these patients has never been studied. With improving survival, it would be ideal to study the weaning indices that could add experience in clinical management. The integrative weaning index is known to predict weaning failure, even in those who tolerate the spontaneous breathing trial. However, it has been evaluated mainly in patients with chronic obstructive pulmonary disease. Our aim is to study the integrative weaning index in predicting the outcome of the spontaneous breathing trial in patients with cirrhosis undergoing mechanical ventilation. METHODS: Adult cirrhotic patients requiring mechanical ventilation for the first time were enrolled. Twenty-seven patients were found eligible for weaning. After the decision to wean, the patients were put on pressure support mode of ventilator followed by spontaneous breathing trial using T-piece for 2 hours. RESULTS: The study population was divided into two groups: successful spontaneous breathing trial group (Group S) and unsuccessful spontaneous breathing trial group (Group U) based on the outcome of the breathing trial. The mean respiratory rate was significantly lower in Group S as compared to Group U. The compliance of the respiratory system and integrative weaning index were found to be significantly higher in Group S. An integrative weaning index of 28 mL/cmH2O breaths/min/L was found to be a good predictor of weaning success. CONCLUSIONS: Our results demonstrate that weaning from mechanical ventilation is possible in critically ill patients with cirrhosis. An integrative weaning index of 28 mL/cmH2O breaths/min/L could be a successful predictor of weaning from mechanical ventilation.

A randomized-controlled trial comparing 20% albumin to plasmalyte in patients with cirrhosis and sepsis-induced hypotension [ALPS trial].

BACKGROUND & AIMS: The choice of resuscitation fluid in patients with cirrhosis and sepsis-induced hypotension is unclear. 5% albumin was superior to normal saline in the FRISC study. We compared the efficacy and safety of 20% albumin, which has greater oncotic properties, to plasmalyte in reversing sepsis-induced hypotension. METHODS: Critically ill patients with cirrhosis underwent open-label randomization to receive either 20% albumin (0.5-1.0 g/kg over 3 hours; n = 50) or plasmalyte (30 ml/kg over 3 hours, n = 50). The primary endpoint of the study was the attainment of mean arterial pressure (MAP) above 65 mmHg at 3 hours. RESULTS: Baseline characteristics were comparable in albumin and plasmalyte groups; arterial lactate (6.16±3.18 mmol/L vs. 6.38±4.77 mmol/L; p = 0.78), MAP (51.4±6.52 mmHg vs. 49.9±4.45 mmHg; p = 0.17) and SOFA score (10.8±2.96 vs. 11.1±4.2; p = 0.68), respectively. Most patients were alcoholics (39%) and had pneumonia (40%). In the intention-to-treat analysis, albumin was superior to plasmalyte in achieving the primary endpoint (62% vs. 22%; p <0.001). A faster decline in arterial lactate (p = 0.03), a reduced need for dialysis (48% vs. 62%; p = 0.16), and a longer time to initiation of dialysis (in hours) (68.13±47.79 vs. 99.7± 63.4; p = 0.06) were seen with albumin. However, the 28-day mortality rate was not different (58% vs. 62%, p = 0.57) and treatment had to be discontinued in 11 (22%) patients in the albumin group due to adverse effects compared to no discontinuations in the plasmalyte group. CONCLUSION: In patients with cirrhosis and sepsis-induced hypotension, 20% albumin leads to a faster improvement in hemodynamics and lactate clearance than plasmalyte, while 28-day survival was similar. However, patients on 20% albumin need to be closely monitored as it was more often associated with pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT02721238. LAY SUMMARY: The current randomized-controlled trial performed in critically ill patients with cirrhosis and sepsis-induced hypotension highlights that 20% albumin restores arterial pressure more quickly but causes more pulmonary complications than plasmalyte. The impact on renal functions was also modest. These effects did not result in improvement in survival at 28 days. Plasmalyte is safer and well-tolerated and can be considered for volume resuscitation in patients with cirrhosis and sepsis-induced hypotension.

Great Expectations: Care Bundles can only be as Effective as the Component Elements!

How to cite this article: Mitra LG, Kulkarni AP. Great Expectations: Care Bundles can only be as Effective as the Component Elements! Indian J Crit Care Med 2022;26(10):1074-1075.

EEG abnormality as a prognostic factor in cirrhotic patients with Grade III-IV hepatic encephalopathy requiring mechanical ventilation: A retrospective analysis.

BACKGROUND AND AIM: Hepatic encephalopathy is a serious complication that entails liver cirrhosis with a high mortality rate. The Child- Turcotte-Pugh class (CTP class) and model for end-stage liver disease (MELD) score are two important prognostic indicators for cirrhosis, while sequential organ failure assessment (SOFA) is a dynamic score for the assessment of critically ill patients. Patients with liver disease with advanced CTP class and higher MELD scores have poor prognosis. The aim of this study was to evaluate the role of electroencephalography (EEG) in cirrhotic patients requiring ventilator support for hepatic encephalopathy Grade III-IV. METHODS: A retrospective study was conducted on patients admitted to the liver intensive care unit (ICU) of a tertiary teaching institute. EEG records of 92 patients with Grade III-IV hepatic encephalopathy who were admitted between April 2015 and May 2017 to the liver ICU were analyzed. The correlation between EEG findings and 28-day mortality, ICU length of stay, and the number of days on mechanical ventilation was determined. RESULTS: Seventy-eight of 92 patients (85%) exhibited bilateral slowing EEG pattern, suggestive of encephalopathy. A triphasic pattern was the most common EEG abnormality in 40% (31 of 78) of the patients. Patients with abnormal EEG had a significantly higher MELD score compared to those with a normal EEG (P=0.02). There were no significant differences in length of mechanical ventilation between both groups, but an increasing trend was observed in those with abnormal EEG (P=0.09). CONCLUSION: EEG findings correlate well with severity of disease in critically ill patients with liver disease. RELEVANCE FOR PATIENTS: EEG has a role in monitoring and prognostication of hepatic encephalopathy in critically ill patients with liver disease.

Comparison of 5% human albumin and normal saline for fluid resuscitation in sepsis induced hypotension among patients with cirrhosis (FRISC study): a randomized controlled trial.

AIMS: Sepsis and septic shock are common causes of hospitalization and mortality in patients with cirrhosis. There is no data on the choice of fluid and resuscitation protocols in sepsis-induced hypotension in cirrhosis. METHODS: In this open-label trial conducted at a single center, we enrolled 308 cirrhotics with sepsis-induced hypotension and randomized them to receive either 5% albumin or normal saline. The primary endpoint was a reversal of hypotension [mean arterial pressure, MAP, ≥ 65 mmHg] at 3 h. Secondary endpoints included serial effects on heart rate, arterial lactate and urine output. RESULTS: 154 patients each received 5% albumin (males, 79.8%, mean MAP 52.9 ± 7.0 mm Hg) or 0.9% saline (85.1%, 53.4 ± 6.3 mm Hg) with comparable baseline parameters and liver disease severity. Reversal of hypotension was higher in patients receiving 5% albumin than saline at the end of one hour [25.3% and 11.7%, p = 0.03, Odds ratio (95% CI)-1.9 (1.08-3.42)] and at the end of three hours [11.7% and 3.2%, p = 0.008, 3.9 (1.42-10.9)]. Sustained reduction in heart rate and hyperlactatemia (p < 0.001) was better in the albumin group. At one week, the proportion of patients surviving was higher in the albumin group than those receiving saline (43.5% vs 38.3%, p = 0.03). Female gender and SOFA ≥ 11 were predictors of non-response to fluid. CONCLUSIONS: 5% human albumin is safe and beneficial in reversing sepsis-induced hypotension compared to normal saline in patients with cirrhosis improving clinically assessable parameters of systemic hemodynamics, tissue perfusion and in-hospital short-term survival of cirrhosis patients with sepsis.

Co-orchestration of acute kidney injury and non-kidney organ failures in critically ill patients with cirrhosis.

BACKGROUND & AIMS: Little is known on the course of acute kidney injury (AKI) and its relation to non-kidney organ failures and mortality in critically ill patients with cirrhosis (CICs). METHODS: We conducted a large prospective, single-centre, observational study in which CICs were followed up daily, during the first 7 days of intensive care, collecting prespecified criteria for AKI, extrarenal extrahepatic organ failures (ERH-OFs) and systemic inflammatory response syndrome (SIRS). RESULTS: A total of 291 patients admitted to ICU were enrolled; 231 (79.4%) had at least one ERH-OFs, 168 (58%) had AKI at presentation, and 145 (49.8%) died by 28 days. At day seven relative to baseline, 151 (51.8%) patients had progressive or persistent AKI, while the rest remained free of AKI or had AKI improvement. The 28-day mortality rate was higher among patients with progressive/persistent AKI (74.2% vs 23.5%; P < .001) or maximum stage 3 of AKI in the first week. Two-level mixed logistic regression modelling identified independent baseline risk factors for progressive/persistent AKI, including 3 to 4 SIRS criteria, infections due to multidrug-resistant bacteria (MDR), elevated serum bilirubin, and number of ERH-OFs. Follow-up risk factors included increases in bilirubin and chloride levels, and new development of 2 or 3 ERH-OFs. CONCLUSIONS: Our results show that among CICs admitted to the ICU, the stage and course of AKI in the first week determines outcomes. Strategies combating MDR infections, multiorgan failure, liver failure and intense systemic inflammation could prevent AKI progression or persistence in CICs.

Open Abdomen in a Critically Ill Patient.

One of the damage control strategies used to avoid or treat abdominal compartment syndrome is "open abdomen (OA)," where the facial edges and the skin is left open, exposing the abdominal viscera. Although it reduces the mortality both in trauma and non-trauma abdominal complications, it does create a significant challenge in an intensive care setting, as it has physiological consequences that need early recognition and prompt treatment both in the intensive care unit and in the operating room. The article aims to review literature on "open abdomen," describe the challenges in such cases, and proposes a guideline for the intensivist in managing a patient with an OA. How to cite this article: Mitra LG, Saluja V, Dhingra U. Open Abdomen in a Critically Ill Patient. Indian J Crit Care Med 2020;24(Suppl 4):S193-S200.

Tracheostomy in critically ill liver disease patients with coagulopathy: A retrospective study at a tertiary center.

INTRODUCTION: Critically ill patients with liver disease commonly present to the intensive care unit (ICU) with need for prolonged ventilation, difficult weaning, and refractory coagulopathy. These patients experience both bleeding and thrombotic complications with a precariously balanced state of coagulopathy. The purpose of this study was to assess the bleeding complications of tracheostomy in critically ill patients with liver disease. METHODS: A retrospective study was conducted in liver ICU of a tertiary teaching institute. Medical records were analyzed to assess postprocedure complication rate among 73 critically ill liver disease patients who had undergone tracheostomy during the period of October 2017 to September 2018. RESULTS: Ten out of 73 patients (13%) required transfusion of blood products after 12 h of procedure, despite thromboelastography (TEG)-based correction prior to procedure. Of these, 7 patients (9%) underwent surgical tracheostomy (ST) and three patients (4%) underwent percutaneous tracheostomy. Statistically no significant difference in bleeding was seen among the two groups, but a rising trend was seen with the ST group (P = 0.52). None of the patients experienced procedure-related pneumothorax and subcutaneous emphysema, as observed in the chest X-ray. CONCLUSION: We conclude that coagulopathy should not be deterrence for the performance of tracheostomy in critically ill patients with liver disease. Adequate clotting support guided by the global tests of coagulation, such as TEG, ensures lesser incidence of bleeding.