Indian Intensive Care Unit Research Articles

Modification of Initial Empirical Antibiotic Prescription and its Impact on Patient Outcome: Experience of an Indian Intensive Care Unit.

Data on the overall impact of antibiotic modification following initial empiric prescription in both culture-positive and culture-negative critically ill patients are exiguous. In a retrospective analysis of "ANT-CRITIC" study, we classified ICU patients receiving empirical antibiotics who remained in the ICU for >72 hours or till availability of culture results (whichever is longer) into five groups based on culture results and antibiotic modification: negative culture, no change (group I), positive culture, no change (group II), positive culture, de-escalation (group III), positive culture, escalation (group IV) and negative culture, antibiotic modification (group V). Baseline variables and clinical outcomes were compared. Logistic regression analysis was performed to look for independent variables associated with mortality. 276 prescription episodes were analyzed. Group II was associated with worsening organ dysfunction at 72 hours, lower clinical cure rate at day 7, and higher hospital mortality. There was an independent association between group II prescription and hospital mortality [adjusted OR 2.774 (CI 1.178-6.533), p = 0.02]. Group III received longer duration of antibiotic (mean duration = 8.27 ± 4.11 days, median duration = 7 days [IQR 5-11]). Outcomes of critically ill infected patients differ significantly when they are classified based on culture result and antibiotic modification pattern. Ghosh S, Singh A, Lyall A. Modification of Initial Empirical Antibiotic Prescription and its Impact on Patient Outcome: Experience of an Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(8):583-589.

Comparison of admission GCS score to admission GCS-P and FOUR scores for prediction of outcomes among patients with traumatic brain injury in the intensive care unit in India.

This study aimed to determine the predictive power of the Full Outline of Unresponsiveness (FOUR) score and the Glasgow Coma Scale Pupil (GCS-P) score in determining outcomes for traumatic brain injury (TBI) patients. The Glasgow Outcome Scale (GOS) was used to evaluate patients at 1 month and 6 months after the injury. We conducted a 15-month prospective observational study. It included 50 TBI patients admitted to the ICU who met our inclusion criteria. We used Pearson's correlation coefficient to relate coma scales and outcome measures. The predictive value of these scales was determined using the receiver operating characteristic (ROC) curve, calculating the area under the curve with a 99% confidence interval. All hypotheses were two-tailed, and significance was defined as P<0.01. In the present study, the GCS-P and FOUR scores among all patients on admission as well as in the subset of patients who were mechanically ventilated were statistically significant and strongly correlated with patient outcomes. The correlation coefficient of the GCS score compared to GCS-P and FOUR scores was higher and statistically significant. The areas under the ROC curve for the GCS, GCS-P, and FOUR scores and the number of computed tomography abnormalities were 0.912, 0.905, 0.937, and 0.324, respectively. The GCS, GCS-P, and FOUR scores are all excellent predictors with a strong positive linear correlation with final outcome prediction. In particular, the GCS score has the best correlation with final outcome.

Whole-Body Hypothermia, Cerebral Magnetic Resonance Biomarkers, and Outcomes in Neonates With Moderate or Severe Hypoxic-Ischemic Encephalopathy Born at Tertiary Care Centers vs Other Facilities

The association between place of birth and hypothermic neuroprotection after hypoxic-ischemic encephalopathy (HIE) in low- and middle-income countries (LMICs) is unknown. To ascertain the association between place of birth and the efficacy of whole-body hypothermia for protection against brain injury measured by magnetic resonance (MR) biomarkers among neonates born at a tertiary care center (inborn) or other facilities (outborn). This nested cohort study within a randomized clinical trial involved neonates at 7 tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh between August 15, 2015, and February 15, 2019. A total of 408 neonates born at or after 36 weeks' gestation with moderate or severe HIE were randomized to receive whole-body hypothermia (reduction of rectal temperatures to between 33.0 °C and 34.0 °C; hypothermia group) for 72 hours or no whole-body hypothermia (rectal temperatures maintained between 36.0 °C and 37.0 °C; control group) within 6 hours of birth, with follow-up until September 27, 2020. 3T MR imaging, MR spectroscopy, and diffusion tensor imaging. Thalamic N-acetyl aspartate (NAA) mmol/kg wet weight, thalamic lactate to NAA peak area ratios, brain injury scores, and white matter fractional anisotropy at 1 to 2 weeks and death or moderate or severe disability at 18 to 22 months. Among 408 neonates, the mean (SD) gestational age was 38.7 (1.3) weeks; 267 (65.4%) were male. A total of 123 neonates were inborn and 285 were outborn. Inborn neonates were smaller (mean [SD], 2.8 [0.5] kg vs 2.9 [0.4] kg; P = .02), more likely to have instrumental or cesarean deliveries (43.1% vs 24.7%; P = .01), and more likely to be intubated at birth (78.9% vs 29.1%; P = .001) than outborn neonates, although the rate of severe HIE was not different (23.6% vs 17.9%; P = .22). Magnetic resonance data from 267 neonates (80 inborn and 187 outborn) were analyzed. In the hypothermia vs control groups, the mean (SD) thalamic NAA levels were 8.04 (1.98) vs 8.31 (1.13) among inborn neonates (odds ratio [OR], -0.28; 95% CI, -1.62 to 1.07; P = .68) and 8.03 (1.89) vs 7.99 (1.72) among outborn neonates (OR, 0.05; 95% CI, -0.62 to 0.71; P = .89); the median (IQR) thalamic lactate to NAA peak area ratios were 0.13 (0.10-0.20) vs 0.12 (0.09-0.18) among inborn neonates (OR, 1.02; 95% CI, 0.96-1.08; P = .59) and 0.14 (0.11-0.20) vs 0.14 (0.10-0.17) among outborn neonates (OR, 1.03; 95% CI, 0.98-1.09; P = .18). There was no difference in brain injury scores or white matter fractional anisotropy between the hypothermia and control groups among inborn or outborn neonates. Whole-body hypothermia was not associated with reductions in death or disability, either among 123 inborn neonates (hypothermia vs control group: 34 neonates [58.6%] vs 34 [56.7%]; risk ratio, 1.03; 95% CI, 0.76-1.41), or 285 outborn neonates (hypothermia vs control group: 64 neonates [46.7%] vs 60 [43.2%]; risk ratio, 1.08; 95% CI, 0.83-1.41). In this nested cohort study, whole-body hypothermia was not associated with reductions in brain injury after HIE among neonates in South Asia, irrespective of place of birth. These findings do not support the use of whole-body hypothermia for HIE among neonates in LMICs. ClinicalTrials.gov Identifier: NCT02387385.

Use of off-label drugs in the neonatal intensive care unit in India

Background: Off-label use of drugs is widespread in pediatrics and almost all neonates hospitalized in NICU are affected by the use of off-label drugs regardless of gestational age and birth weight. This is because of the lack of regulation for medications in the neonatal population and the delays in updating drug instructions. This is mainly due to the ethical difficulty in the research and difficulties in conducting clinical trials in this vulnerable population. Hence, the study was planned to assess the extent of the use of off-label drugs in the NICU. Methods: An observational study was carried out in the NICU of a tertiary care center from May 2021 to Oct 2022 and case records of neonates admitted to the NICU were evaluated. Results: Among 1745 drug prescriptions in 360 neonates, 1208 (69.22%) were off-label. Anti-infectives were the most commonly used off-label class of drug, Piperacillin+tazobactam was the most commonly used off-label drug and most common reason for off-label prescriptions was indication and administration. It was found that 79.44% of neonates received at least one off-label drug. Conclusions: Off-label use of drugs, specifically anti-infective drugs, is common in NICUs of India as in other countries. So, more research should be done to generate evidence-based guidelines for the rational use of drugs in neonates.

Management of neonatal pulmonary hypertension-a survey of neonatal intensive care units in India

BackgroundPersistent pulmonary hypertension of the newborn (PPHN) is a common neonatal condition associated with significant morbidity and mortality. First-line diagnostic and treatment options such as echocardiography and inhaled nitric oxide (iNO) are not routinely available in resource limited settings and alternative treatment modalities need to be utilized. This study was conducted to assess current diagnostic and management strategies used for PPHN in Indian neonatal intensive care units (NICUs).MethodsA questionnaire in multiple choice question format was sent to practising neonatologists in India via an online survey tool between July to August 2021. Information pertaining to demographic data, diagnostic criteria and management strategies of PPHN was requested. The responses were collated and information processed.ResultsThere were 118 respondent NICUs (response rate 74%). The majority of neonatal units (65%) admitted an average of 1–3 patients of PPHN per month. Targeted neonatal echocardiography (TnECHO) was practised in 80% of the units. Most common management strategies being followed were pulmonary vasodilators (88.1%), inotropes (85.6%), conventional ventilation (68.6%) and high frequency ventilation (59.3%). The most preferred pulmonary vasodilator was sildenafil (79%) and inotropic agent was milrinone (32%). Only 25% of respondents reported use of iNO. None of the participating units used extracorporeal membrane oxygenation.ConclusionWe found wide variability in management practices of PPHN across Indian NICUs. Non-selective pulmonary vasodilators are more widely used than iNO. There is an urgent need for structured TnECHO training programs and evidence based national guidelines for standardized management of PPHN as per availability of resources in India. Additional research on low cost alternative therapies to iNO in Indian settings might be helpful.

Current Trends in Antifungal Prophylaxis for High-Risk Neonates in Neonatal Intensive Care Units in India: A Nationwide Survey.

Background Prophylactic antifungals are often used in high-risk babies in neonatal intensive care units (NICUs) to reduce invasive fungal infections (IFIs). However, existing guidelines regarding prophylactic antifungal usage do not clearly define the high-risk population. This study aimed to assess the practices related to prophylactic antifungal use in NICUs in India. Methods For this cross-sectional study, an online structured questionnaire was completed by neonatologists who worked in level 3 NICUs in 12 states in India during the period June 2022 to August 2022. Results Data from 151 NICUs were analyzed. 71.7% of respondents were from private hospitals, and 28.3% were from government hospitals. Nearly one-fourth of the units (28.5%) used antifungal prophylaxis in all extremely low birth weight (ELBW) babies, while another one-fourth (25.8%) used a case-based approach. The remaining NICUs (45.7%) did not use prophylactic antifungals. Among the users, the preferred antifungal was fluconazole; 3 mg/kg and 6 mg/kg were the dosage regimens used. The commonly used interval for administering fluconazole was 72 hours (69.2% of units). The intravenous route was the preferred route of administration (84.1%). Factors that influenced the non-users were the low incidence of fungal infections in their NICUs and concern about the development of resistance. It was noted that the users felt strongly about the need for further recommendations from pediatric societies and more studies on the efficacy of antifungals. Conclusion There is considerable variation in the use of prophylactic antifungals across NICUs in India. Among the users, uniformity in the choice of antifungal and interval of administration was observed. Further recommendations from pediatric societies, including the definitions of neonates at-risk of fungal infections, are required to ensure consistency in practice and help clinicians decide whether or not to use prophylactic antifungals.

Impact of Appropriate Antibiotics within One Hour and Patients' Outcome: A Study and Review

Background: Rapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock &amp; bacterial meningitis. The initiation of treatment with inappropriate antimicrobial agents (in relation to the subsequently demonstrated sensitivity of the pathogen) as the initial empiric therapy may be the single most common cause of prolonged delays in the introduction of effective therapy. Only in 5% of cases were antibiotics administered within 1 hr of the decision making, in 47% of cases it took 1–2 hrs. Only in 33% of cases antibiotics were prescribed within one hour of decision making. In 95% of cases antibiotics were administered within one hour of prescription. Sepsis is the main cause of death in patients treated in intensive care units (ICU). Current sepsis guidelines recommend administration of antibiotics within one hour of ED triage. However, the quality of supporting evidence is moderate &amp; studied have shown mixed results regarding the association between antibiotics administration timing &amp; outcome in septic shock. Objective:The aim of this study was to assess whether timing of administration of appropriate antibiotics within one hour of admission to the ICU impact patient outcomes. Method: Timing of ICU admission noted from the patient’s ICU nursing chart when the first vital parameters are noted by the nurse. Timing of administration of 1st dose of antibiotic and antibiotic that is administered within the first one hour of admission is noted from ICU nursing chart (in minutes from the timing of ICU admission). Appropriateness of antibiotic is assessed from the microbiology culture and sensitivity result. Outcome measures is noted from the ICU database. Data is then recorded systemically in the data collection form and finally entered in the excel sheet for analysis. All the data is then analysed by statistician by appropriate statistical tests. Result: A total of 53 patients, including 63.2% in the sepsis group and 53.4% in the septic shock group received antibiotics within the first hour. 87.5 % patients who received antibiotic within one hour of admission were discharged compared to 81.0% patients who received first dose of antibiotic beyond one hour of admission. The commonest gram-negative organisms were E. coli and Klebsiella in both groups. The commonest antibiotic administered was Meropenem in both groups. All patients who received appropriate antibiotic were discharged compared with only 69.2% patients discharged whose antibiotic choice was inappropriate. Mortality was 30.8% in the group whose initial antibiotic choice was inappropriate while no patients died in the group where the patient received appropriate empirical therapy. Conclusion: In my study it is demonstrated that gram-negative bacteria remain the major pathogen in sepsis as has been demonstrated in most ICUs in India. When appropriateness as well as timing of administration were compared simultaneously, all patients who received appropriate antibiotic within one hour or more than one hour survived to discharge. However, if antibiotic choice was inappropriate, 25% patients died even if they received the antibiotics within one hour and if the first dose was delayed beyond the first hour, the mortality further increased to 40%. There was no significant difference in the mean of ICU length of stay and mean hospital length of stay of patients based on appropriateness of empirical antibiotic therapy.

Impact of Appropriate Antibiotics within One Hour and Patients' Outcome: A Study and Review

Background: Rapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock &amp; bacterial meningitis. The initiation of treatment with inappropriate antimicrobial agents (in relation to the subsequently demonstrated sensitivity of the pathogen) as the initial empiric therapy may be the single most common cause of prolonged delays in the introduction of effective therapy. Only in 5% of cases were antibiotics administered within 1 hr of the decision making, in 47% of cases it took 1-2 hrs. Only in 33% of cases antibiotics were prescribed within one hour of decision making. In 95% of cases antibiotics were administered within one hour of prescription. Sepsis is the main cause of death in patients treated in intensive care units (ICU). Current sepsis guidelines recommend administration of antibiotics within one hour of ED triage. However, the quality of supporting evidence is moderate &amp; studied have shown mixed results regarding the association between antibiotics administration timing &amp; outcome in septic shock. Objective: The aim of this study was to assess whether timing of administration of appropriate antibiotics within one hour of admission to the ICU impact patient outcomes. Method: Timing of ICU admission noted from the patient’s ICU nursing chart when the first vital parameters are noted by the nurse. Timing of administration of 1st dose of antibiotic and antibiotic that is administered within the first one hour of admission is noted from ICU nursing chart (in minutes from the timing of ICU admission). Appropriateness of antibiotic is assessed from the microbiology culture and sensitivity result. Outcome measures is noted from the ICU database. Data is then recorded systemically in the data collection form and finally entered in the excel sheet for analysis. All the data is then analysed by statistician by appropriate statistical tests. Result: A total of 53 patients, including 63.2% in the sepsis group and 53.4% in the septic shock group received antibiotics within the first hour. 87.5 % patients who received antibiotic within one hour of admission were discharged compared to 81.0% patients who received first dose of antibiotic beyond one hour of admission. The commonest gram-negative organisms were E. coli and Klebsiella in both groups. The commonest antibiotic administered was Meropenem in both groups. All patients who received appropriate antibiotic were discharged compared with only 69.2% patients discharged whose antibiotic choice was inappropriate. Mortality was 30.8% in the group whose initial antibiotic choice was inappropriate while no patients died in the group where the patient received appropriate empirical therapy. Conclusion: In my study it is demonstrated that gram-negative bacteria remain the major pathogen in sepsis as has been demonstrated in most ICUs in India. When appropriateness as well as timing of administration were compared simultaneously, all patients who received appropriate antibiotic within one hour or more than one hour survived to discharge. However, if antibiotic choice was inappropriate, 25% patients died even if they received the antibiotics within one hour and if the first dose was delayed beyond the first hour, the mortality further increased to 40%. There was no significant difference in the mean of ICU length of stay and mean hospital length of stay of patients based on appropriateness of empirical antibiotic therapy.

Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit.

Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium. A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs). Among 1198 adult patients screened during the study period (December 2019-September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group. Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%). Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU. Tiwari AM, Zirpe KG, Khan AZ, Gurav SK, Deshmukh AM, Suryawanshi PB, et al. Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(2):111-118.

Practices During Intubation in COVID-19 Intensive Care Units in India: A Cross-Sectional Questionnaire-Based Survey.

Background Healthcare workers are committed to learning from each other's experience to safely optimize patient management of COVID-19. Acute hypoxemic failure is common in COVID-19 patients, and nearly3.2% may require intubation. Intubation is an aerosol-generating procedure (AGP) that might predispose the performer to COVID-19 infection. This survey was intended to evaluate thepractices during tracheal intubation in COVID-19 intensive care units (ICUs) and analyze them against the recommendations of the All India Difficult Airway Association (AIDAA) for safe practice. Methodology It was a web-based, multicentric cross-sectional survey. The choices in the questions were based on guidelines for airway management in COVID-19. Survey questions were divided into two parts - the first part consisted of demographics and general information, and the second part focused on safe intubation practices. Results A total of 230 responses were obtained from physicians all over India, presuming their active involvement in COVID-19 cases, of which 226 responses were taken into account. Two-thirds of responders did not receive any training before ICU posting. The Indian Council of Medical Research (ICMR) guideline was followed by 89% of responders for personal protective equipment use. Intubation in COVID-19 patients was predominantly conducted by a senior anesthesiologist/intensivist in the teamand a senior resident(37.2%). Rapid sequence intubation (RSI) and modified RSI were preferable among the responder's hospitals (46.5% vs. 33.6%). In most centers, responders used direct laryngoscopefor intubation (62.8%), whereas video laryngoscopewas used by 34%. Most responders confirmed the endotracheal tube (ETT) position by visual inspection (66.3%) over end-tidal carbon dioxide (EtCO2) concentration tracing (53.9%). Conclusions Safe intubation practices were followed in most of the centers across India. However, teaching and training, preoxygenation methods, alternative ventilation strategies, and confirmation of intubation pertinent to COVID-19 airway management need more attention.

Reservoir of Carbapenem-Resistant Acinetobacter baumannii in the Hospital Environment and Colonization Pressure: A Surveillance-Based Study in Indian Intensive Care Unit.

The endemicity of Acinetobacter baumannii in intensive care units (ICUs) is a serious concern. We studied the reservoirs of A. baumannii in the ICU and their effects on colonization pressure and transmission. A prospective surveillance (6 months) was conducted. Screening culture (rectal and axillary) swabs were collected within 48 hours admission and in 120 hours. Surveillance cultures from patients' surroundings, health care workers (HCWs), and hospital sewage were collected. A. baumannii was identified by phenotypic and genotypic methods. Carbapenem resistance and insertion sequence element were detected. Typing was done by repetitive extragenic palindromic-polymerase chain reaction and multilocus sequence typing. Colonization pressure was calculated and compared with environment colonizers. Of the 87 patients, 21.83% (19) were colonized with A. baumannii, 73.68% (14/19) were imported, and 26.31% (5/19) acquired carriers. Axilla was the commonest site. From the environment (15), bed rails 33.33% (5/15) and suction tubes 26.66% (4/15) were the common sites. HCWs showed 7.5% (3/40) carriage. Carbapenem resistance with blaOXA-51, blaOXA-23, and ISAba1 were 91.89% (34/37). Strong correlation between colonization pressures and environmental colonizers was seen (r2 = 0.719, p = 0.032). Carbapenem and polymyxin B were (p ≤ 0.05) significant exposures. Sequence type 623 was the predominant cluster with isolates from carriers, HCWs, and environment. Colonization pressure of carbapenem-resistant A. baumannii depends on their presence in the hospital. Hands of HCWs were an important vehicle for transmission. Infection control measure should consider reducing the environmental reservoir.

New Antibiotic Prescription Pattern in Critically Ill Patients ("Ant-critic"): Prospective Observational Study from an Indian Intensive Care Unit.

This study aimed to address the issue of antibiotic prescription processes in an Indian Intensive care unit (ICUs). In a prospective longitudinal study, all adult patients admitted in the ICU for 24 hours or above between 01 June 2020 and 31 July 2021 were screened for any new antibiotic prescription throughout their ICU stay. All new antibiotic prescriptions were assessed for baseline variables at prescription, any modifications during the course, and the outcome of antibiotic prescription. A total of 1014 patients fulfilled entry criteria; 59.2 and 7.2% of days they were on a therapeutic and prophylactic antibiotic(s). Patients, who were prescribed therapeutic antibiotic(s), had worse ICU outcomes. A total of 49.5% of patients (502 of 1,014) received a total of 552 new antibiotic prescriptions during their ICU stay. About 92.13% of these prescriptions were empirical and blood or other specimens were sent for culture in 78.81 and 60.04% of instances. A total of 31.7% of episodes were microbiologically proven and were more likely to be prescribed by an ICU consultant. A total of 169 modifications were done in 142 prescription episodes; 73 of them after sensitivity results. Thus, the overall rate of de-escalation was 13.95%. Apart from the negative culture result (36.05%), an important reason for a relatively low rate of de-escalation was the absence of sampling (12.32%). Longer ICU stay before antibiotic prescription, underlying chronic liver disease (CLD), worse organ dysfunction, and septic shock were independently associated with unfavorable treatment outcomes. No such independent association was observed between antibiotic appropriateness and patient outcome. Future antibiotic stewardship strategies should address issues of high empirical prescription and poor microbiological sampling hindering the de-escalation process. Ghosh S, Salhotra R, Singh A, Lyall A, Arora G, Kumar N, et al. New Antibiotic Prescription Pattern in Critically Ill Patients ("Ant-critic"): Prospective Observational Study from an Indian Intensive Care Unit. Indian J Crit Care Med 2022;26(12):1275-1284.

Depression and Anxiety among COVID-19 Indian Intensive Care Unit Survivors: A Prospective Observational Study.

Long-lasting physical, cognitive, and mental health sequelae including depression and anxiety are common in intensive care unit (ICU) survivors. This study was aimed to assess the immediate and medium-term mental health sequelae-depression and anxiety among coronavirus disease-2019 (COVID-19) ICU survivors. The COVID-19 ICU survivors of a tertiary level ICU were recruited into this study from 1 July 2020 to 31 October 2020. Willing participants were circulated with an electronic questionnaire. It consisted of demographics and questionnaires related to COVID-19 disease, comorbidities, and a patient health questionnaire (PHQ-9) scale for depression, and generalized anxiety disorder (GAD-7) scale for anxiety. Responses were collected at the time of discharge. Follow-up was done at 2 weeks and 6 months. Among the 133 COVID-19 ICU survivors contacted, 91 survivors submitted the baseline data at the time of discharge. Fourteen and another 11 survivors were lost to follow-up at 2 weeks and at 6 months. The median age was 52.75 and 68.1% (n = 62/91) were male. The median PHQ-9 and GAD-7 scores showed a statistically significant decrease at 2 weeks and a non-significant decrease at 6 months compared to baseline scores. The GAD-7 score was the same or worse between baselines to 2 weeks, but it reduced between baseline to 6 months for all variables and their subgroups. This study revealed a high prevalence of anxiety and depression in the immediate post-discharge period. These findings suggest the need for better mental rehabilitation strategies to deal with the well-being of critically ill survivors in future pandemics. Gunjiganvi M, Rai S, Awale RB, Mishra P, Gurjar M, Gupta D, et al. Depression and Anxiety among COVID-19 Indian Intensive Care Unit Survivors: A Prospective Observational Study. Indian J Crit Care Med 2022;26(12):1267-1274.

Breastfeeding rates at discharge for very low birthweight neonates and their determinants: An observational study from a tertiary care neonatal intensive care unit in India.

Mother's milk is the best milk for neonates. Preterm very low birthweight (VLBW) neonates face many challenges leading to low rates of breastfeeding at discharge. (i) To determine the proportion of <32 weeks preterm VLBW neonates who are exclusively breastfed (EB) at discharge and (ii) determinants of exclusive breastfeeding (EBF) at discharge. An observational study was conducted for a duration of 1 year, from May 2019 to April 2020 in a tertiary care neonatal intensive care unit (NICU) in North India. Consecutive <32 weeks preterm VLBW neonates admitted within 72 h of birth and on full enteral feeds (FEF) within 10 days of birth were included in this study and followed up till discharge. Forty-four of 97 (45.4%) preterm VLBW neonates were exclusively breastfed and 31/97 (32%) received more than 80% mother's own milk (MOM) at discharge. Male sex (P=0.03), those whose first feed had any amount of MOM (P=0.038) or exclusive MOM in their first feed or when initiated on first FEF (P=0.002), and neonates with longer duration of hospital stay (P=0.035) had an increased chance of being exclusively breastfed at discharge. Preterm VLBW neonates who receive any amount of MOM in their first feed or first FEF, male infants and those who stay longer in hospital are more likely to be exclusively breastfed at discharge.

Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study.

BackgroundWe aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010–2011.MethodsAn observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs.ResultsOn the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality.ConclusionsHospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927).How to cite this articleDivatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al. Intensive Care in India in 2018–2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093–1107.

Estimates of Sepsis Prevalence and Outcomes in Adult Patients in the ICU in India: A Cross-sectional Study

Sepsis is a global health problem. Limited data exist on the prevalence of sepsis using current definitions in Intensive Care Units (ICUs) in India. In adult patients admitted to Indian ICUs, what is the prevalence of sepsis using the previous (Sepsis-2) and current (Sepsis-3) definitions? Prospective, observational, multicentre, one-day, cross-sectional study. The primary outcome was the sepsis prevalence using both the Sepsis-2 and Sepsis-3 definitions and their concordance (using Cohen's kappa coefficient (Ƙ)). Additional outcomes included reporting on current microbiological characteristics, anti-microbial use, multi-drug resistant infections, and 30-day discharge and mortality status in sepsis patients. A total of 35 ICUs (85.7% private, 14.3% public) participated enrolling 680 patients (median age 60 (IQR 24) years, 62.1% males). The most common primary diagnosis was renal disease and common comorbidities were diabetes (44.0%) and chronic renal failure (11.6%). The sepsis prevalence on the study day was 382/677 (56.4%). Prevalence by Sepsis-3 and Sepsis-2 definitions were 33.2% and 46.2% respectively with minimal concordance (K = 0.32). In sepsis patients, the most common microorganisms were bacterial (77.9%) followed by fungal infections (14.1%). Approximately 45% of infections were caused by multi-drug resistant organisms. Mortality at 30-days after the study day (27.6% vs 5.3%; P <0.01) and rates of discharge against medical advice (12.8% vs 4.9%; P <0.01) were significantly higher in the sepsis as compared to the non-sepsis cohorts respectively. This multi-centre point prevalence study in Indian ICUs showed a high burden of sepsis using both Sepsis-2 and Sepsis-3 criteria with associated high rates of antimicrobial resistance and mortality. These findings have implications for public health and future research.

Homemade blenderized Ryles tube formula is equally efficient as commercial formula in terms of anthropometric and biochemical measurements in tertiary care neurologic intensive care unit: A single center study

Objectives: In Indian intensive care units (ICUs), malnutrition is a leading cause of death and morbidity. There is a scarcity of information on the state of malnutrition in India and the efficacy of homemade Ryle’s tube formula in neurologic cases as compared to commercial formula feed. The goals of the present study were to evaluate the nutritional status of neurological disorder patients, to prepare a home-based feed using locally available cereal and pulse combinations, and to investigate the impact of two different Ryes tube formulas on nutritional status. Material and Methods: A prospective, randomized comparative study was conducted in the neurological ICU of a tertiary care medical college hospital located in rural Telangana. Group A was given commercial formula, while Group B was given homemade Ryle’s tube formula, which was calorically equivalent to commercial formula. The Harris-Benedict equation was used to determine the patients’ caloric requirements. During hospital stay, both groups received a comparable amount of Ryle’s tube feeding. The impact of two different formulations was evaluated using quantitative indices including weight, body mass index, triceps skinfold thickness, and serum albumin over a period of 2 weeks. The standard deviation and mean were determined. The researchers used a paired t-test with a two-tailed distribution. If the P &lt; 0.05, it was considered significant. For data processing, open-source software open Epi 2007 was used. Results: In both classes, thirty patients were enrolled. On admission, the demographic profiles of both groups were identical, as evidenced by non-significant P-values. According to the sample parameters, there was no substantial difference between the two formulas at the end of the study period. Both formulas were equally efficacious for the nutritional assessment parameters during the study period. Conclusion: On initial admission, malnutrition was uncommon in the neurologic ICU. In terms of study parameters, both formulas were equally efficient. The homemade blenderized formula was 50% less expensive than commercial formula, making it an important nutritional supplementation option for the deprived strata of the population.

Homemade blenderized Ryles tube formula is equally efficient as commercial formula in terms of anthropometric and biochemical measurements in tertiary care neurologic intensive care unit: A single center study

OBJECTIVES:In Indian intensive care units (ICUs), malnutrition is a leading cause of death and morbidity. There is a scarcity of information on the state of malnutrition in India and the efficacy of homemade Ryle’s tube formula in neurologic cases as compared to commercial formula feed. The goals of the present study were to evaluate the nutritional status of neurological disorder patients, to prepare a home-based feed using locally available cereal and pulse combinations, and to investigate the impact of two different Ryes tube formulas on nutritional status.MATERIAL AND METHODS:A prospective, randomized comparative study was conducted in the neurological ICU of a tertiary care medical college hospital located in rural Telangana. Group A was given commercial formula, while Group B was given homemade Ryle’s tube formula, which was calorically equivalent to commercial formula. The Harris-Benedict equation was used to determine the patients’ caloric requirements. During hospital stay, both groups received a comparable amount of Ryle’s tube feeding. The impact of two different formulations was evaluated using quantitative indices including weight, body mass index, triceps skinfold thickness, and serum albumin over a period of 2 weeks. The standard deviation and mean were determined. The researchers used a paired t-test with a two-tailed distribution. If the P &lt; 0.05, it was considered significant. For data processing, open-source software open Epi 2007 was used.RESULTS:In both classes, thirty patients were enrolled. On admission, the demographic profiles of both groups were identical, as evidenced by non-significant P-values. According to the sample parameters, there was no substantial difference between the two formulas at the end of the study period. Both formulas were equally efficacious for the nutritional assessment parameters during the study period.CONCLUSION:On initial admission, malnutrition was uncommon in the neurologic ICU. In terms of study parameters, both formulas were equally efficient. The homemade blenderized formula was 50% less expensive than commercial formula, making it an important nutritional supplementation option for the deprived strata of the population.

Neonatal palliative care practices: an Indian perspective

ABSTRACT Background Neonatal palliative care (NPC) aims to prevent and relieve the suffering of neonates who are not going to recover. Although an integral part of neonatal care, it remains in nascent stages in many parts of the world. Aim To describe neonatologists’ level of knowledge and understanding of NPC, and to describe current practices and barriers to its delivery. Methods The study, a cross-sectional web-based national survey, was undertaken between 2019 and 2020. A structured form of 22 questions about NPC was completed by neonatologists across level III neonatal intensive care units in India. Results Of the 145 questionnaires sent out, 65 responses were returned (44.8%). The participating units were in both public (38.5%) and private/corporate hospitals (61.5%). The concept of NPC was known to 90.8%, and 93.8% could identify conditions necessitating palliation. However, 81.5% of units lacked a palliative team, and few had teams of only neonatologists and neonatal nurses. Only 10.8% of the units had a structured policy, but none addressed all aspects of neonatal palliation. The creation of memories by parents spending time with their neonate (38.9%), photography (75.9%), footprints (13%) or collecting memorabilia was allowed at many centres. Frequently encountered barriers included inadequate knowledge (16.9%), poor infrastructure (21.5%), inadequate human resources (24.6%) and a lack of structured guidelines and legal support (15.4%). Conclusion This is the first study to highlight a large gap in neonatal end-of-life care in India and it reflects an urgent need to facilitate its incorporation into routine care. Abbreviations NICU: neonatal intensive care unit; NPC: neonatal palliative care

Comparison of Clinical Characteristics and Outcome of Critically Ill Patients Admitted to Tertiary Care Intensive Care Units in India during the Peak Months of First and Second Waves of COVID-19 Pandemic: A Retrospective Analysis.

BackgroundCoronavirus disease-2019 (COVID-19) continues to pose serious challenges to healthcare systems globally with the disease progressing over time in crest-trough pattern of waves. We compared the patient characteristics and outcomes of critically ill patients admitted during the first and second waves of COVID-19 pandemic.Materials and MethodsWe did a retrospective analysis of medical records of critically ill patients admitted to intensive care unit (ICU) at the peak period of both waves. The data on demographics, symptoms, treatment received, and outcomes of patients were recorded.ResultsCompared to first wave, significantly more females, younger age group, and those without underlying comorbidities required ICU admission during the second wave. The treatments received during both periods were similar except for preferential use of methylprednisolone over dexamethasone and proclivity of bilevel positive airway pressure (BiPAP) ventilation over high-flow nasal cannula (HFNC). There was no significant difference in the duration of ICU stay and mortality of patients. During the first wave, the factors associated with nonsurvival of patients were advanced age, comorbidities, severe disease, and a lesser number of days on HFNC. All these factors along with higher Sequential Organ Failure Assessment (SOFA) score were observed to be linked with patient nonsurvival during the second wave.ConclusionIn India, the second wave of COVID-19 significantly influenced ICU demographics with a predominance of females and young adults requiring critical care. During both time periods, patients received similar treatment except for the propensity to use methylprednisolone and BiPAP as opposed to dexamethasone and HFNC in second wave. No significant difference in ICU mortality was noted.How to cite this articleKerai S, Singh R, Dutta S, Mahajan A, Agarwal M. Comparison of Clinical Characteristics and Outcome of Critically Ill Patients Admitted to Tertiary Care Intensive Care Units in India during the Peak Months of First and Second Waves of COVID-19 Pandemic: A Retrospective Analysis. Indian J Crit Care Med 2021;25(12):1349–1356.