Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Background: Targeted temperature management (TTM) is a vital element of postresuscitation management after cardiac arrest. Though international guidelines recommend TTM, the supporting evidence is of low certainty. Aims and objectives: To estimate the effect of TTM strategy on mortality and neurological outcomes in postcardiac arrest survivors. Materials and methods: Randomized controlled trials (RCTs) published in English evaluating the use of TTM in adult comatose survivors of cardiac arrest were included. Studies were categorized into two groups, based on hypothermia vs normothermia. The main outcome was death due to any origin. The secondary outcome measures evaluated neurological outcome and complications associated with TTM. Outcomes were analyzed by calculating Odds Ratio (OR) of a worse outcome. ORs with 95% CIs in a forest plot were used to show the results of random-effects meta-analyses. Results: On pooled analysis of 11 RCTs, no difference was observed in death due to any origin rates in the hypothermia compared to the normothermia group (OR; 0.88, 95% CI: 0.39-1.16). Overall, no difference in poor neurological outcome was observed between the two groups (OR; 0.86, 95% CI: 0.66-1.12). Trial sequencing analysis for mortality and poor neurological outcome showed that number to achieve power to predict futility has been achieved in both the parameters. Conclusions: This meta-analysis showed that hypothermia compared to normothermia TTM strategies does not improve survival or neurologic outcomes. How to cite this article: Mishra SB, Patnaik R, Rath A, Samal S, Dash A, Nayak B. Targeted Temperature Management in Unconscious Survivors of Postcardiac Arrest: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022;26(4):506-513.

Polymyxin Monotherapy vs. Combination Therapy for the Treatment of Multidrug-resistant Infections: A Systematic Review and Meta-analysis.

OBJECTIVES: The objective of this review was to compare the effectiveness of Colistin monotherapy and combination therapy for the treatment of multidrug-resistant gram-negative bacterial infections. DATA SOURCES: PubMed, Cochrane Library. STUDY ELIGIBILITY INTERVENTIONS AND EXCLUSIONS: In this systematic review, we included all retrospective and prospective studies and randomized controlled trials (RCTs) that compared intravenous polymyxin monotherapy and combination therapy with any other antibiotic for treating multidrug-resistant infections. Studies using inhaled polymyxins with 5 or less than 5 patients were excluded. The primary outcome was 30-day all-cause mortality and if not reported at day 30 we extracted and documented the closest time point. Both crude outcome rates and adjusted effect estimates were extracted for mortality. STUDY APPRAISAL DATA EXTRACTION AND SYNTHESIS: Search string used was "(Colistin OR polymyxin) AND (Enterobacteriaceae OR Klebsiella OR Acinetobacter OR Escherichia coli OR Pseudomonas) AND (random OR prospective OR retrospective OR cohort OR observational OR blind)." Thirty-nine studies were included in our analysis; out of which 6 RCTs were included and 9 studies used carbapenem as the adjunctive antibiotic. Each study was screened and reviewed for eligibility independently by two authors and data extrapolated on an Excel sheet. RESULTS: The meta-analysis of polymyxin monotherapy vs. combination therapy in multidrug-resistant infections yielded an odds ratio (OR) of 0.81 (95% confidence interval [CI]: 0.65-1.01) with minimal heterogeneity (I 2 = 40%), whereas pooled analysis of this comparison in studies that included carbapenem as combination therapy yielded an OR of 0.64 (CI: 0.40-1.03; I 2 = 62%). Likewise, the pooled analysis of the RCTs yielded an OR of 0.82 (95% CI: 0.58-1.16, I 2 = 22%). All these showed no statistical significance. However, it was seen that polymyxin combination therapy was more effective in multidrug-resistant infections compared to polymyxin monotherapy. The effectiveness was more glaring when carbapenems were used as the combination drug instead of any other antibiotic and more so in many in vitro studies that used polymyxin combination therapy. CONCLUSION: Although statistically insignificant, it would be prudent to use polymyxin combination therapy to treat multidrug-resistant gram-negative bacilli (GNB) infection over monotherapy with preference to use carbapenem as the adjunct alongside polymyxins. HOW TO CITE THIS ARTICLE: Samal S, Mishra SB, Patra SK, Rath A, Dash A, Nayak B, et al. Polymyxin Monotherapy vs. Combination Therapy for the Treatment of Multidrug-resistant Infections: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2021;25(2):199-206.

Study of Antimicrobial Utilization and Cost of Therapy in Medicine Intensive Care Unit of a Tertiary Care Hospital in Eastern India.

INTRODUCTION: High utilization of antimicrobial agent (AMA) and inappropriate usage in an intensive care unit (ICU) intensifies resistant organism, morbidity, mortality, and treatment cost. Prescription audit and active feedback are a proven method to check the irrational prescription. To analyze and compare the utilization of drugs, the World Health Organization (WHO) proposed daily defined dose (DDD)/100 patient days and days of therapy (DOT)/100 patient days to measure utilization of AMAs. Data of AMAs utilization are required for planning an antibiotic policy and for follow-up of intervention strategies. MATERIALS AND METHODS: A prospective observational study was conducted for 1 year from July 2018 to June 2019 and the data obtained from ICU of a tertiary care hospital. The demographic data, the disease data, and the utilization of different classes of AMAs [WHO-Anatomical Therapeutic Chemical (ATC) classification] as well as their cost were recorded. Total number of patient days, DDD, DDD/100 patient days, and DOT/100 patient days were calculated as proposed by the WHO. Statistical analysis was performed using statistical software SPSS version 25.0. The descriptive analysis was performed using summary statistics median [interquartile range (IQR)]. RESULTS: A total 939 patients were included, out of them 332 (35.4%) were female. The median age of the total patients was 58 (45-70). The median length of stay in ICU was 3 days. Mortality rate during our study period was 38.6%. The highly utilized AMAs in our study was ceftriaxone (36.95 DDD/100 patient days) followed by piperacillin/tazobactam (31.57), meropenem (26.4), doxycycline (21.53), and polymyxin B (21.38). The association between APACHE II and SOFA score with use of restricted antibiotics found to be statistical significant (p value 0.018 and 0.000, respectively). The cost of antibiotics per patient and patient days were $449.97 and $93.77, respectively, while median value of total cost was $2,343.26. CONCLUSION: Ceftriaxone was the highest utilized AMA. The risk of receiving restricted antibiotics intensified with increasing prevalence of multidrug resistance bacteria and associated comorbidities. High treatment cost is responsible for higher utilization of restricted antibiotics in ICU. HOW TO CITE THIS ARTICLE: Patra SK, Mishra SB, Rath A, Samal S, Iqbal SN. Study of Antimicrobial Utilization and Cost of Therapy in Medicine Intensive Care Unit of a Tertiary Care Hospital in Eastern India. Indian J Crit Care Med 2020;24(10):938-942.

Short versus long axis ultrasound guided approach for internal jugular vein cannulations: A prospective randomized controlled trial.

OBJECTIVES: Ultrasound-guided internal jugular vein cannulation is a standard procedure performed in ICUs worldwide. According to the guidelines, the short-axis approach is recommended over the long-axis approach for IJV cannulation. Double-operator cannulation is more convenient for the said procedure. However, the guidelines favor single-operator cannulation due to limited trials. We hypothesized that double-operator long-axis cannulation will be faster and have fewer complications than double-operator short-axis cannulation. METHODS: This was a prospective, randomized trial of patients who needed central venous catheterization in the intensive care unit. The eligible patients were randomized into two groups. In one group, the short-axis view by two operators was used for cannulation, and the long-axis view by 2 operators was used in the other group. The time elapsed from skin puncture to guide-wire insertion. RESULTS: The central venous catheter was placed by ultrasound guidance in all 100 patients. No significant differences were observed in the patient characteristics between the two groups. The mean time of insertion was 74.2 ±â€¯110.1 s with the short-axis approach compared with 70.3 ±â€¯97.3 s with the long-axis approach. The frequency of complications was also significantly lower with the long-axis approach. DISCUSSION: The long-axis view for IJV cannulation has similar insertion and procedure timings to the short-axis view. However, the complication rate and number of needle punctures required were less with the long-axis view than with those with the short-axis view.