Author Response.

How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. Author Response. Indian J Crit Care Med 2024;28(5):515.

Author Response.

How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. Author Response. Indian J Crit Care Med 2024;28(5):512.

The Comparative Efficacy of Ceftazidime-Avibactam with or without Aztreonam vs Polymyxins for Carbapenem-resistant Enterobacteriaceae Infections: A Prospective Observational Cohort Study.

Background: Carbapenem-resistant enterobacteriaceae (CRE) is associated with high mortality in critically ill patients, with limited treatment options. This study aims to compare clinical response, microbiological response, and mortality in patients treated with ceftazidime-avibactam with or without aztreonam (CAZ-AVI + AZT) and colistin or polymyxin B (polymyxins) in CRE infections. Materials and methods: This single-center prospective observational study included adult patients with CRE infections treated with CAZ-AVI+AZT or polymyxins between January 2022 and December 2022 at a Tertiary Care Medical Center in India. The clinical response, microbiological response, and mortality were compared between the two groups using a Cox multivariate regression model adjusted for the baseline SOFA score and comorbidities. Results: A total of 89 patients were enrolled, with 59 (66%) patients receiving CAZ-AVI + AZT and 30 receiving polymyxins. Baseline demographics and clinical characteristics were similar between the two groups. The Cox multivariate regression analysis showed a statistically significant difference in clinical failure on day 14 with the CAZ-AVI + AZT group vs polymyxins (HR = 0.78, 95% CI 0.63-0.95, p = 0.018). There was no difference in microbiological failure (HR = 1.08, 95% CI 0.66-1.77, p = 0.76), microbiological relapse (HR = 0.75, 95% CI 0.36-3.02, p = 0.62), and hospital mortality (HR = 1.04, 95% CI 0.75-1.43, p = 0.796) between the two groups. Conclusion: Treatment with ceftazidime-avibactam with or without aztreonam for CRE infections associated with a better clinical response compared with polymyxins monotherapy but without any difference in microbiological response or mortality. How to cite this article: Vijayakumar M, Selvam V, Renuka MK, Rajagopalan RE. The Comparative Efficacy of Ceftazidime-Avibactam with or without Aztreonam vs Polymyxins for Carbapenem-resistant Enterobacteriaceae Infections: A Prospective Observational Cohort Study. Indian J Crit Care Med 2023;27(12):923-929.

Predictors of Clinically Significant Bleeding in Thrombocytopenic Dengue Patients Admitted to Intensive Care Unit: A Retrospective Study.

Background: Recognition of clinically significant bleeding (CSB) is vital for effective management of dengue patients. The primary objective was to identify the predictors of CSB among dengue patients and to formulate a simple scoring system. The secondary objective was to compare the grades of bleeding and severity of thrombocytopenia. Materials and methods: We conducted a retrospective study of adults aged above 18 years with dengue, admitted to the intensive care unit (ICU) of a tertiary care hospital in South India from 2015 to 2021. Demographic, clinical, and laboratory variables on admission were collected. The association of clinically significant bleeding with the above parameters was assessed by univariate and multivariate analysis. Results: A total of 9,817 dengue cases were hospitalized during the study period. A total of 120 patients with thrombocytopenia (<100000 cells/mm3) were admitted to the ICU and of them 38 (31.6%) had CSB. On univariate analysis fever, sequential organ function assessment (SOFA) score, elevated activated partial thromboplastin time (aPTT), and altered sensorium were significantly associated with CSB. The multivariate model identified SOFA score [adjusted odds ratio (aOR): 1.52; 95% confidence interval (CI): 1.11-2.08], temperature >38.3°C (aOR: 2.71; 95% CI: 1.1-6.47) and elevated aPTT > 40 seconds (aOR: 4.66; 95% CI: 1.42-15.3) as independent risk factors. A clinical predictive score was developed incorporating these three parameters. The performance of the score identified by the receiver operating characteristic (ROC) curve [area under the curve (AUC): 0.81; 95% CI: 0.73-0.91] demonstrated a sensitivity of 81% and specificity of 77%. Conclusion: This study revealed that temperature above 38.3°C, elevated aPTT, and an increase in SOFA score were identified as independent risk factors for CSB. A clinical predictive score derived from these variables can identify patients likely to develop CSB. How to cite this article: Logia P, Selvam V, Parasuraman V, Renuka MK, Rajagopalan RE. Predictors of Clinically Significant Bleeding in Thrombocytopenic Dengue Patients Admitted to Intensive Care Unit: A Retrospective Study. Indian J Crit Care Med 2023;27(12):888-894.

Blood Lactate in Early Sepsis: A Predictor to "Keep Up" Rather than "Catch Up".

How to cite this article: Renuka MK, Sailaja B. Blood Lactate in Early Sepsis: A Predictor to "Keep Up" Rather than "Catch Up". Indian J Crit Care Med 2023;27(2):83-84.

Nutritional Adequacy in Mechanically Ventilated Patient: Are We Doing Enough?

BACKGROUND: Critically ill patients are under stress, leading to a catabolic response and higher energy expenditure. The associated malnutrition leads to adverse outcomes. AIMS AND OBJECTIVES: This study aims to assess the nutritional adequacy (>80% of prescribed calories) in mechanically ventilated (MV) patients and its effects on patients' outcomes. It also aims to identify the causes of deviation from the nutrition prescription. MATERIALS AND METHODS: This is a prospective observational study involving all adult critically ill patients requiring MV for >48 hours. Patients were prescribed enteral nutrition (EN) targeted to achieve 25 kcal/kg (IBW) of energy and 1.2 g/kg of proteins daily. Standard polymeric formula feeds were initiated as continuous infusion as per the feeding protocol in the intensive care unit (ICU). Data were collected on demography, body mass index (BMI), indication for ICU admission, admission category, and admission APACHE II and SOFA scores, and nutritional risk was captured with mNUTRIC score. Nutritional data on type of feed initiated, amount of calories prescribed/achieved, time taken to initiate feeds, reasons for not starting/delay in the initiation of feeds, time taken to achieve the prescribed calories, and reasons for interruptions of feeds were collected. Primary outcome analyzed was adequacy of nutrition (>80% prescribed dose), and secondary outcomes analyzed were ventilator days and ICU LOS. RESULTS: A total of 622 MV patients were analyzed. 36.1% of patients were at nutritional risk (mNUTRIC χ5). 89% of patients received EN, and the time taken to start EN in these patients was 10 hours (6-20) (median [IQR]). Only 29.6% of patients achieved nutritional adequacy. Time taken for this was 36 hours (median). On average, patients on MV received 63% (1025 kcal) and 57% (41 g) of their prescribed calories and proteins, respectively. The most common reasons for withholding feeds were airway-related procedures (68.2%) followed by GI intolerance (15%). Frequent interruptions of EN, patients on >1 vasopressors, and surgical admissions were reasons for nutritional inadequacy. Nutritional adequacy had no impact on clinical outcomes. CONCLUSION: Despite following guidelines and feeding protocols, there exists a wide gap between prescribed nutrition and what is actually delivered in MV patients. HOW TO CITE THIS ARTICLE: Kalaiselvan MS, Arunkumar AS, Renuka MK, Sivakumar RL. Nutritional Adequacy in Mechanically Ventilated Patient: Are We Doing Enough? Indian J Crit Care Med 2021;25(2):166-171.

Comparison of acute physiology and chronic health evaluation II (APACHE II) and acute physiology and chronic health evaluation IV (APACHE IV) severity of illness scoring systems, in a multidisciplinary ICU.

BACKGROUND AND AIMS: Outcome prediction of critically ill patients is an integral part of care in an Intensive Care Unit (ICU). Acute Physiology and Chronic Health Evaluation (APACHE) scoring systems provide an objective means of mortality prediction in ICU. The aim of this study was to compare the performance of APACHE II and IV scoring system in our ICU. MATERIAL AND METHODS: All patients admitted to the ICU between January and June 2014 and who met the inclusion criteria were evaluated. APACHE II and IV score were calculated during the first 24 h of ICU stay based on the worst values. All patients were followed up till discharge from the hospital or death. Statistical analysis was performed using SPSS version 19.0. Discrimination of the model for mortality was assessed using receiver operating characteristic curve and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. RESULTS: Of a total 1268, 1003 patients were included in this study. The mean (±standard deviation) admission APACHE II score was 19.4 ± 8.9, and APACHE IV score was 59.1 ± 27.2. The APACHE scores were significantly higher among nonsurvivors than survivors (P < 0.001). The overall crude hospital mortality rate was 17.6%. APACHE IV had better discriminative power area under the ROC curve ([AUC] -0.82) than APACHE II (AUC-0.75). Both APACHE II and APACHE IV had poor calibration. CONCLUSIONS: APACHE IV showed better discrimination compared to APACHE II in our ICU population. Both APACHE II and APACHE IV had poor calibration. However, APACHE II calibrated better compared to APACHE IV.

An analysis of the predictors of mortality and morbidity in patients admitted after suicidal hanging to an Indian multidisciplinary Intensive Care Unit.

BACKGROUND AND AIMS: Hanging is a frequently used method to attempt suicide in India. There is a lack of data in the Indian population regarding clinical features and outcomes of suicidal hanging. The purpose of this study was to evaluate the factors affecting mortality and morbidity in patients admitted with suicidal hanging to the Intensive Care Unit (ICU). METHODS: A 6-year retrospective study of adult patients admitted to the ICU with suicidal hanging was analysed for demographics, mode of hanging, lead time to emergency room (ER) admission, clinical presentation, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, admission Glasgow coma scale (GCS) and neurological outcomes. The primary outcome was in-hospital mortality rate. Secondary outcomes were hospital length of stay (LOS), ICU-LOS, time for neurological recovery, organ support and duration of mechanical ventilation. Statistical analysis was performed using the Student's t-test for continuous variables and Chi-square test for categorical variables. RESULTS: We analysed data of 106 patients. The median age was 27 years [Interquartile Range (IQR) (22-34)]. The median lead time to ER admission was 1 h [IQR (0.5-1.4)] with median ICU stay of 3 days [IQR (2-4)]. Vasopressors were administered to 27.4% patients. GCS was ≤7 in 65% patients, and 84.9% patients received mechanical ventilation. Mortality rate was 10.3%. Survivors recovered with normal organ function. CONCLUSION: Suicidal hanging is associated with significant mortality. Admission GCS, APACHE II and 48 h SOFA score were predictors of poor outcome.

Clinical Features and Outcomes of Patients with Posterior Reversible Encephalopathy Syndrome.

AIMS: The aim of this study was to study the clinical features and outcomes of patients with posterior reversible encephalopathy syndrome (PRES) admitted to the Intensive Care Unit (ICU). SUBJECTS AND METHODS: All adult patients admitted to our ICU with acute onset neurologic symptoms with focal vasogenic edema on magnetic resonance imaging (MRI) were included in the study. Data were collected on demography, coexisting illness, admission severity of illness, neurological symptoms, blood pressure, treatment initiated, and MRI findings. Outcome data collected included mortality, ICU average length of stay (ALOS), number of ventilator days, and neurological disability at discharge assessed by modified Rankin scale (MRS). RESULTS: Fourteen patients were admitted with PRES. Thirteen patients were female, and their mean age was 31.5 ± 8.3 years. Etiology of PRES included eclampsia (64.2%), lupus nephritis (21.4%), CKD (7.1%), and hypertension (n = 1 [7.1%]). The most common presenting symptom was seizure (92.8%), followed by visual disturbance (42.8%), headache (42.8%), encephalopathy (14.2%), and status epilepticus (14.2%). The Glasgow coma scale on admission was 12.3 ± 2.9. High blood pressure was seen in 12 patients 85.7%; their mean systolic and diastolic pressures were 173 ± 10.2 and 110 ± 8.6 mmHg, respectively. MRI showed that parieto-occipital region was most commonly involved (92.8%), followed by frontal lobe (42.8%). ICU ALOS was 4.35 ± 2.4 days and mean ventilator days was 1.7 ± 2.0 days. One patient (1/14 [7.4%]) died of multiorgan failure and 13 patients were discharged with no residual neurological deficit (MRS, 0). CONCLUSIONS: PRES is a potentially reversible disorder with prompt recognition and control of blood pressure.

Use of Nutrition Risk in Critically ill (NUTRIC) Score to Assess Nutritional Risk in Mechanically Ventilated Patients: A Prospective Observational Study.

CONTEXT: Nutritional risk assessment must be done on all critically ill patients. Malnutrition in intensive care unit (ICU) patients is associated with adverse clinical outcomes. Traditional scoring systems cannot be used for screening in mechanically ventilated (MV) patients because these patients are unable to provide information on their history of food intake and weight loss. The Nutrition Risk in Critically ill (NUTRIC) score is the appropriate nutritional assessment tool in MV patients. AIMS: This prospective observational study was conducted to identify the nutritional risk in MV patients using modified NUTRIC (mNUTRIC) score (with the exception of interleukin-6). PATIENTS AND METHODS: All adult patients admitted to the ICU and required MV for more than 48 h were included in the study. Data were collected on variables required to calculate mNUTRIC score. Patients with mNUTRIC score ≥5 are considered at nutritional risk. Outcome data were collected on ICU length of stay, ventilator-free days, and mortality. RESULTS: A total of 678 MV patients fit into the inclusion criteria. Majority of the patients were male (67%). Mean age of the patients was 55 years. About 288 (42.5%) patients were at high nutritional risk (mNUTRIC score ≥5). Patients with high mNUTRIC score ≥5 had longer mean ICU average length of stay of 9.0 (±4.2) versus 7.8 (±5.8) mean (± standard deviation) days (P < 0.01) and higher mortality 41.4% versus 26.1% (P < 0.0) compared to patients with low NUTRIC score (≤4). High mNUTRIC score (≥5) predicted mortality with area under the curve of 0.582 (95% confidence interval 0.535-0.628). CONCLUSIONS: Nearly 42.5% of MV patients admitted to ICU were at nutritional risk, and high mNUTRIC score was associated with increased ICU length of stay and higher mortality.

Outcome of Noncardiac Surgical Patients Admitted to a Multidisciplinary Intensive Care Unit.

CONTEXT: Surgical procedures carry significant morbidity and mortality depending on the type of surgery and patients. There is a dearth of evidence from India on the outcome of surgical patients admitted to an Intensive Care Unit (ICU). AIMS: We aimed to describe the incidence and risk factors of postoperative complications and mortality in noncardiac surgical patients admitted to the ICU. SETTINGS AND DESIGN: This was a prospective observational study on all perioperative patients admitted to a multidisciplinary ICU for 18 months. SUBJECTS AND METHODS: Data on demography, admission Acute Physiology and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA) scores, perioperative course, type and duration of surgery, reason for ICU admission, ICU interventions, and perioperative complications were recorded. The primary outcomes analyzed were perioperative complications and mortality. RESULTS: The study included 762 patients with a mean age of (mean ± standard deviation [SD]) 50.5 ± 18 years and a male (58.4%) preponderance. The mean (±SD) admission APACHE-II and SOFA scores were 15 (±5.0) and 4.26 (±2.6), respectively. The most common reason for ICU admission was elective mechanical ventilation 50%, followed by prolonged surgery 26.2% and hemodynamic instability 21.2%. Most (51.1%) patients belonged to American Society of Anaesthesiologists physical Status III or IV and Lee's surgical risk Category I and II (66.8%). The most common surgical procedures performed were gastro-intestinal (28.5%) followed by interventional Neuro-radiology (14.0%) and orthopedic (13.9%). Overall perioperative complications were observed in 51.4% (n = 392). Common complications observed were hemodynamic instability 24%, hypothermia 17.2%, sepsis 17.3%, poor glycemic control 11.2%, perioperative myocardial infarction 7.1%, cardiac arrest 0.13%, and acute kidney injury (AKI) 10.1%. The overall hospital mortality was 7.9%. Multivariate logistic regression analysis showed that admission APACHE-II score, sepsis, AKI, and ICU length of stay were independent predictors for mortality. CONCLUSIONS: High risk perioperative patients after noncardiac surgery have significant mortality and morbidity.

Clinical profile and outcome of patients with severe sepsis treated in an intensive care unit in India

Introduction: Sepsis is the leading cause of intensive care unit (ICU) admissions and is associated with high mortality. Objectives: To identify the incidence, risk factors and outcome of patients with severe sepsis and septic shock. Methods: A prospective observational study was done in a multidisciplinary ICU over a period of 18 months. We included all adult patients admitted to ICU with features of severe sepsis and septic shock as per SCCM/ACCP guidelines. Data related to demography, co-existing illnesses, parameters to assess Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores, other relevant laboratory data, source of infection, organ failures and supportive measures given were recorded. Primary outcome data on mortality was collected and secondary outcome data on ventilator days, ICU length of stay (ALOS) and ventilator free days were recorded. Results: A total of 1162 patients were screened and 356 patients had severe sepsis. Incidence of severe sepsis was 30.6% and mortality rate was 51.6%. APACHEII (23.37 ± 9.47) and SOFA (7.58 ± 4.05) scores at admission were high. Most common source of infection was from the respiratory tract (37.2%) followed by urinary tract (10.3%) and intra-abdominal (9.5%) infections. About 63% of patients required ventilator support, 25.5% of patients required vasopressor support despite adequate fluid resuscitation and one third of patients required renal replacement therapy (35.7%). Haematocrit, total leucocyte count, serum bilirubin and SOFA scores were significantly higher among non-survivors. Conclusions: Incidence of severe sepsis was high and was associated with a poor patient outcome in an ICU in India.

A retrospective study of clinical profile and outcomes of critically ill patients with heat-related illness.

BACKGROUND AND AIMS: Heat-related illness (HRI) due to high ambient temperatures is a common feature during the Indian summer. HRI often results in Intensive Care Unit (ICU) admissions and are associated with significant morbidity and mortality. However, published report on the effects of HRI among the Indian population is lacking. This study was undertaken to identify the profile of patients admitted to ICU with clinical features of HRI and study their clinical outcomes. METHODS: This was a retrospective case series of patients admitted with features of HRI during the summer of 2012 in our multidisciplinary ICU. Data on demographics, co-morbid illness, admission severity of illness (Acute Physiology and Chronic Health Evaluation II [APACHE II]), organ failure scores (Sequential Organ Failure Assessment [SOFA]) and neuroimaging studies were collected. Outcome data studied included mortality, ICU length of stay (LOS), ventilator days and hospital LOS. Statistical analysis was performed using Student's t-test, Chi-square test and multivariate analysis. RESULTS: Twenty-six patients met the diagnostic criteria for HRI. Fifteen were males. The mean age was 53.12 ± 18.6 years. Mean APACHE II score was 19.6 ± 7.7 and mean SOFA score was 7.5 ± 2.6. The common presenting symptoms were fever with neurological impairment (100%) and gastrointestinal symptoms (30%). Major organ systems involvement include neurological (100%), renal (57%), hepatic (34%) and coagulation abnormalities (26%). Most common metabolic abnormality noted was hyponatraemia (73%). Magnetic resonance imaging findings suggestive of heat stroke were seen in 5 of 26 patients. Mortality rate was 34%. 8 of 17 survivors had residual neurological impairment. CONCLUSION: HRI carries a high mortality and significant neurological morbidity.