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   Table of Contents - Current issue
July-September 2022
Volume 12 | Issue 3
Page Nos. 119-179

Online since Tuesday, September 20, 2022

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What's new in critical illness and injury science? Resource allocation and very short intensive care unit stays p. 119
Andrew C Miller
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Evaluation of time to death after admission to an intensive care unit and factors associated with mortality: A retrospective longitudinal study p. 121
Ana Luiza Mezzaroba, Alexandre S Larangeira, Fernanda K Morakami, Jair Jesus Junior, Amanda A Vieira, Marina M Costa, Fernanda M Kaneshima, Giovana Chiquetti, Ulisses E Colonheze, Giovanna C. S. Brunello, Lucienne T. Q. Cardoso, Tiemi Matsuo, Cintia M. C. Grion
Background: Among nonsurvivors admitted to the intensive care unit (ICU), some present early mortality while other patients, despite having a favorable evolution regarding the initial disease, die later due to complications related to hospitalization. This study aims to identify factors associated with the time until death after admission to an ICU of a university hospital. Methods: Retrospective longitudinal study that included adult patients admitted to the ICU between January 1, 2008, and December 31, 2017. Nonsurviving patients were divided into groups according to the length of time from admission to the ICU until death: Early (0–5 days), intermediate (6–28 days), and late (>28 days). Patients were considered septic if they had this diagnosis on admission to the ICU. Simple linear regression analysis was performed to evaluate the association between time to death over the years of the study. Multivariate cox regression was used to assess risk factors for the outcome in the ICU. Results: In total, 6596 patients were analyzed. Mortality rate was 32.9% in the ICU. Most deaths occurred in the early (42.8%) and intermediate periods (47.9%). Patients with three or more dysfunctions on admission were more likely to die early (P < 0.001). The diagnosis of sepsis was associated with a higher mortality rate. The multivariate analysis identified age >60 years (hazard ratio [HR] 1.009), male (HR 1.192), mechanical ventilation (HR 1.476), dialysis (HR 2.297), and sequential organ failure assessment >6 (HR 1.319) as risk factors for mortality. Conclusion: We found a higher proportion of early and intermediate deaths in the study period. The presence of three or more organ dysfunctions at ICU admission was associated with early death. The diagnosis of sepsis evident on ICU admission was associated with higher mortality.
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A retrospective cohort study of short-stay admissions to the medical intensive care unit: Defining patient characteristics and critical care resource utilization p. 127
Pooja N Pandit, Mark Mallozzi, Rahed Mohammed, Gregory McDonough, Taylor Treacy, Nathaniel Zahustecher, Erika J Yoo
Background: Little is known about the mortality and utilization outcomes of short-stay intensive care unit (ICU) patients who require <24 h of critical care. We aimed to define characteristics and outcomes of short-stay ICU patients whose need for ICU level-of-care is ≤24 h compared to nonshort-stay patients. Methods: Single-center retrospective cohort study of patients admitted to the medical ICU at an academic tertiary care center in 2019. Fisher's exact test or Chi-square for descriptive categorical variables, t-test for continuous variables, and Mann–Whitney two-sample test for length of stay (LOS) outcomes. Results: Of 819 patients, 206 (25.2%) were short-stay compared to 613 (74.8%) nonshort-stay. The severity of illness as measured by the Mortality Probability Model-III was significantly lower among short-stay compared to nonshort-stay patients (P = 0.0001). Most short-stay patients were admitted for hemodynamic monitoring not requiring vasoactive medications (77, 37.4%). Thirty-six (17.5%) of the short-stay cohort met Society of Critical Care Medicine's guidelines for ICU admission. Nonfull-ICU LOS, or time spent waiting for transfer out to a non-ICU bed, was similar between the two groups. Hospital mortality was lower among short-stay patients compared to nonshort-stay patients (P = 0.01). Conclusions: Despite their lower illness severity and fewer ICU-level care needs, short-stay patients spend an equally substantial amount of time occupying an ICU bed while waiting for a floor bed as nonshort-stay patients. Further investigation into the factors influencing ICU triage of these subacute patients and contributors to system inefficiencies prohibiting their timely transfer may improve ICU resource allocation, hospital throughput, and patient outcomes.
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Utility of National Early Warning Score 2 to risk-stratify coronavirus disease of 2019 patients in the emergency department: A retrospective cohort study p. 133
Sweta Khuraijam, Alok Gangurde, Vridhi Shetty
Background: The application of a risk stratification pathway is necessary for the emergency department (ED) to assess the severity of the disease and the need for escalation of therapy. We aimed to implement the National Early Warning Score 2 (NEWS2) pathway at triage to differentiate patients who are stable or critically ill with no invasive investigations at the time of admission during the coronavirus disease of 2019 (COVID-19) era in comparison to other clinical risk scores. Methods: One hundred and four patients were collected from April 1, 2021, to June 1, 2021, during the second wave of the COVID-19 pandemic at an academic medical center in India. The NEWS2 scoring system and the quick sepsis-related organ failure assessment (qSOFA) score were introduced as part of the initial assessment in the triage area of the ED. Data were assessed using the area under the receiving operating characteristic (AUROC) curve for NEWS2 and qSOFA scores, respectively. Results: In the study, NEWS2 classification indicated that 25% of patients required continuous monitoring, of which 12.7% subsequently deteriorated within 24 h of admission and 7% died. Both, NEWS2 (threshold 0; 1, AUROC 0.883; 95%; confidence interval [CI] 0.8–0.966) and qSOFA (threshold 0; 1, AUROC 0.851; 95% CI 0.766–29 0.936) effectively identified COVID-19 patients in the ED at risk for clinical deterioration. There was no significant difference in the diagnostic performance of qSOFA and NEWS2 (DeLong's test P = 0.312). Conclusion: Both NEWS2 and qSOFA effectively-identified COVID-19 patients in the ED at risk for clinical deterioration with no significant statistical difference. However, a triage level risk stratification score can be developed with the inclusion of blood parameters on admission to further validate the practice.
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Comparison of the effects of vitamin C and thiamine on refractory hypotension in patients with sepsis: A randomized controlled trial p. 138
N Nandhini, Deepak Malviya, Samiksha Parashar, Chandrakant Pandey, Soumya Sankar Nath, Manoj Tripathi
Background: The study aimed to compare the effect of thiamine and ascorbic acid (AA) on mortality, sequential organ failure assessment (SOFA) score, duration and dose of vasopressor support, and need for renal replacement therapy (RRT) in patients with septic shock with refractory hypotension. Methods: Consenting adult patients with septic shock and refractory hypotension were included in this study. Patients were divided into three groups: Group A received 100 ml of balanced salt solution 8 hourly, Group B received 2 mg/kg of thiamine 8 hourly, Group C received 25 mg/kg of AA 8 hourly intravenous (IV) for 72 h. All patients received IV infusion of hydrocortisone 200 mg/day for 72 h. Serum lactate, dose and duration of vasopressor support, SOFA score, need for RRT and hospital mortality were analyzed. Results: The SOFA Score was significantly lower in Group B than in Group A and C at 24, 48, and 72 h. Dosage of norepinephrine was lower in Group B at 66 h and after that, whereas in Groups A and C, it was comparable at all time points. Mortality in Group B was significantly lower but comparable in Groups A and C. The need for RRT was significantly lower in Group B (44%) compared to the control group (88%) but comparable in Group C (76%). Conclusion: In patients with septic shock treated with hydrocortisone, co-treatment with thiamine led to earlier correction of organ dysfunction, reduced need for RRT, and improved mortality compared to patients treated with AA or balanced salt solution. The addition of AA did not yield measurable benefits beyond hydrocortisone alone.
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Correlation of central venous-to-arterial carbon dioxide difference to arterial-central venous oxygen difference ratio to lactate clearance and prognosis in patients with septic shock: A prospective observational cohort study p. 146
Kavya Sindhu, Deepak Malviya, Samiksha Parashar, Chandrakant Pandey, Soumya Sankar Nath, Shilpi Misra
Background: To assess the relationship between the ratio of difference of venoarterial CO2 tension (P (v-a) CO2) and difference of arterio-venous oxygen content (C (a-cv) O2), i.e., ΔPCO2/ΔCaO2 with lactate clearance (LC) at 8 and 24 h, to define a cutoff for the ratio to identify LC >10% and >20% at 8 and 24 h, respectively, and its association with prognosis in septic shock. Methods: Adult patients with septic shock were included in this prospective, observational cohort study. Blood samples for arterial lactate, arterial, and central venous oxygen and carbon dioxide were drawn simultaneously at time zero (T0), 8 h (T8), and 24 h (T24). At T8, patients were divided into Group 8A (LC ≥10%) and Group 8B (LC <10%). At T24, patients were divided into Group 24A (LC ≥20%) and Group 24B (LC <20%). Results: Ninty-eight patients were included. The area under the curve of ΔPCO2/ΔCaO2 at T8 (0.596) and T24 (0.823) was the highest when compared to P(v-a) CO2 and C(a-v) O2. The best cutoff of P(v-a) CO2/C (a-v) O2 as predictor of LC >10% was 1.31 (sensitivity 70.6% and specificity 53.3%) and for LC >20% was 1.37 (sensitivity 100% and specificity 50%). At both T8 and T24, P(v-a) CO2/C (a-v) O2 showed a significant negative correlation with LC. Groups 8A and 24A showed lower intensive care unit mortality than 8B and 24B, respectively. Values of P(v-a) CO2/C (a-v) O2 at T8 were comparable, but at T24, there was a significant difference between the survivors and nonsurvivors (P < 0.001). Conclusion: ΔPCO2/ΔCaO2 predicts lactate clearance, and its 24 h value appears superior to the 8-h value in predicting LC and mortality in septic shock patients.
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The potential effect of iopamidol contrast on renal function in patients infected with SARS-CoV-2 virus: A retrospective cohort study p. 155
Sarven Tersakyan, Monica Chappidi, Ankit Patel, Kenneth Hainsworth, Abdalhai Alshoubi
Background: Many types of computed tomography (CT) scans require the use of contrast. Acute kidney injury (AKI) is a known adverse effect of intravenous contrast administration. To our knowledge, the effects of low-osmolar contrast agents such as iopamidol on renal function in patients infected with the SARS-CoV-2 virus have never been studied. This study investigates the incidence of AKI following iopamidol contrast administration in patients infected with the SARS-CoV-2 virus. Methods: This retrospective cohort study included two groups: patients who received CT pulmonary angiography who were infected with SARS-CoV-2 virus and those who tested negative for SARS-CoV-2. Data were collected from the electronic medical record of a single hospital from January 1, 2020, to September 15, 2020. AKI was defined using the Kidney Disease: Improving Global Outcomes definition: increase in serum creatinine by ≥0.3 mg/dL (≥26.5 mcmol/L) within 48 h, or increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within the prior 7 days, or urine volume <0.5 mL/kg/h for 6 h. Results: AKI occurred in 13.51% of patients in the SARS-CoV-2 positive group and 16.92% of patients in the negative group. Using a two-sample test to compare the equality of proportions (with continuity correction factor), we found there is no significant difference in the two proportions (P = 0.3735). Conclusion: There was no significant difference in the incidence of AKI between SARS-CoV-2 positive and negative groups. Given the limitations of this study, further work must be done on this topic.
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Point-of-care versus central laboratory measurements of electrolytes and hemoglobin: A prospective observational study in critically ill patients in a tertiary care hospital p. 160
Sangeeta Sahoo, Jyotiranjan Sahoo, Neha Singh, Upendra Hansda, Satyabrata Guru, Nitish Topno
Background: A blood gas analyzer is a point-of-care (POC) testing device used in the Emergency Department (ED) to manage critically ill patients. However, there were differences in results found from blood gas analyzers for hemoglobin (Hgb) and electrolytes parameters. We conducted a comparative validity study in ED in patients who had requirements of venous gas analysis, complete blood count, and electrolytes. The objective was to find the correlation of Hgb, sodium (Na+), and potassium (K+) values between the blood gas analyzer and laboratory autoanalyzer. Methods: A total of 206 paired samples were tested for Hgb, Na+, and K+. Total 4.6 ml of venous blood was collected from each participant, 0.6 ml was used for blood gas analysis as POC testing and 4 ml was sent to the central laboratory for electrolyte and Hgb estimation. Results: The mean difference between POC and laboratory method was 0.608 ± 1.41 (95% confidence interval [CI], 0.41–0.80; P < 0.001) for Hgb, 0.92 ± 3.5 (95% CI, 0.44–1.40) for Na+, and 0.238 ± 0.62 (95% CI, −0.32–0.15; P < 0.001) for K+. POC testing and laboratory method showed a strong positive correlation with Pearson correlation coefficient (r) of 0.873, 0.928, and 0.793 for Hgb, Na+, and K+, respectively (P < 0.001). Conclusion: Although there was a statistical difference found between the two methods, it was under the United States Clinical Laboratory Improvement Amendment range. Hence, starting the therapy according to the blood gas analyzer results may be beneficial to the patient and improve the outcome.
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The risk factors of the functional status, quality of life, and family psychological status in children with postintensive care syndrome: A cohort study p. 165
Saptadi Yuliarto, Kurniawan Taufik Kadafi, Sri Fauziah, Takhta Khalasha, William Prayogo Susanto
Background: Intensive care treatment has a side effect of several impairments after hospital discharge, known as postintensive care syndrome (PICS). PICS in children must be well evaluated because PICS can affect their global development and quality of life. Our specific aims are to determine the impact of intensive care treatment and the risk factors which contribute to PICS. Methods: In this observational cohort study, we identified critically ill children treated in intensive care units (ICUs) for more than 24 h and survived. We evaluated the internal and external risk factors of the patients in the intensive care. We interviewed their parents to define the functional status and quality of life of the patients in 7 days before ICU admission and the psychological status of the family at the time of intensive care admission. The interview was repeated in 3 months after the intensive care discharge. Results: There was a significant decrease in functional status and quality of life after intensive care treatment (P < 0.001). However, none of the internal risk factors were significantly associated with PICS. Neurologic involvement in the disease was associated with the significantly reduced functional status of patients, while the severity of the disease was significantly associated with both functional status and quality of life. Our study also showed a significant psychological disorder of the family in the intensive care. Conclusion: The occurrence of PICS in children was associated with the severity of the disease, decreased the functional status and quality of life, and contributed to psychological disorders for the family.
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Gastrointestinal histopathology of acute colchicine toxicity after lower dose treatment of pericarditis: A case report p. 174
Lisa Liu, Steven Tessier, Rodrigo Duarte-Chavez, Daniel Marino, Anish Kaza, Santo Longo, Sudip Nanda
Colchicine is an anti-inflammatory alkaloid drug with anti-microtubule activity. Colchicine toxicity is a serious and potentially fatal complication associated with hallmark histopathological features most conspicuous in proliferative tissues such as the gastrointestinal tract. These features have only been reported in patients treated with high doses. We report a patient who experienced acute colchicine toxicity with gastrointestinal histologic changes after treatment with the lowest dose of colchicine. Knowledge of drug–drug interactions and the organs involved in colchicine metabolism is imperative when using colchicine, even when administered at its lowest dose.
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Heister mouth gag aided endotracheal intubation in patients with maxillofacial trauma: A case report p. 177
Karan Singla, Tanvir Samra, Kajal Jain
Securing the airway in patients with maxillofacial trauma is challenging for the anesthesiologist. Pain and facial deformities limit mouth opening and hence direct laryngoscopy. Fractured bone segments, blood, oral secretions, and tissue edema preclude the use of fiber-optic bronchoscopes for intubation of the trachea. We report a successful attempt of orotracheal intubation with a Macintosh blade in a 25-year-old patient with restricted mouth opening with the use of a Heister mouth gag.
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