Indian Journal of Critical Care Medicine最新文献

Objective: Secondary hemophagocytic lymphohistiocytosis (sHLH) is an increasingly recognized complication in patients with scrub typhus, potentially contributing to substantial mortality despite appropriate antibiotic treatment. This study aims to determine the prevalence and prognosis of sHLH and identify diagnostic factors in adult patients with scrub typhus in North India.

Methods: This prospective cohort study was conducted at PGIMER, Chandigarh, from August 2021 to November 2023. sHLH was defined as an HScore of 200 or above. The diagnostic performance of biomarkers such as ferritin, fibrinogen, triglycerides, and C-reactive protein was assessed through receiver operating characteristic curve analysis, evaluating area under the curve (AUC), sensitivity, and specificity.

Results: Out of 150 patients (mean age 39 years, 54% female), 28 (18.7%) were diagnosed with sHLH. Those presenting with high-grade fever, seizures, high pulse rate, hepatomegaly, splenomegaly, cytopenia, and significant hepatic dysfunction were more likely to have sHLH. Ferritin demonstrated the highest diagnostic utility (AUC 0.83), compared to fibrinogen (AUC 0.72), triglyceride (AUC 0.67), and C-reactive protein (AUC 0.69). The optimal cutoff for ferritin was 2000 ng/mL, with a sensitivity of 90% and a specificity of 66%. Higher ferritin thresholds (6000 ng/mL and 10000 ng/mL) increased specificity to 88% and 95%, respectively. Patients with sHLH often presented with multi-organ failure, necessitating mechanical ventilation and vasopressor support. In-hospital mortality was significantly higher in sHLH patients than in those without (21.4% vs 6.6%, p = 0.025).

Conclusion: Early detection of sHLH using the HScore and ferritin significantly influences the management of scrub typhus, underscoring the necessity for tailored therapeutic strategies to improve patient outcomes.

How to cite this article: Selvam S, Tuli A, Yuvasai KP, Saini S, Erla SR, Kaur J, et al. Predicting Secondary Hemophagocytic Lymphohistiocytosis in Adult Patients with Scrub Typhus and Its Prognostic Significance. Indian J Crit Care Med 2024;28(9):823-831.

Background: Regional citrate anticoagulation (RCA) has emerged as a treatment modality that reduces bleeding risk and filter clotting. With initial experience of using RCA with continuous renal replacement therapy (CRRT), we have formulated a working protocol based on published literature.

Objective: The study aimed to evaluate the protocol for routine use of RCA during CRRT requiring anticoagulation and evaluation of filter life.

Methodology: It is a single-center, open-label, prospective, non-randomized, non-interventional, single-arm, observational study conducted at a tertiary care hospital between September 2022 and July 2023. All adult patients with acute kidney injury (AKI) or hyperammonemia requiring CRRT and necessitating the use of anticoagulation were enrolled in the study. The study used Prisma Flex M100 AN 69 dialyzer on Prisma Flex (Baxter) CRRT machines during continuous venovenous hemodiafiltration (CVVHDF). The targeted CRRT dose in all the study patients was 25-30 mL/kg/hour. Based on the published literature, we have developed a working protocol (Appendix 1) for managing patients on CRRT using RCA.

Results: A total of 159 patients were analyzed for the study. The median [interquartile range (IQR)] filter life using RCA was 30 (12-55) hours. Filter clotting was observed in 33.3% of patients. Citrate accumulation was present in 52.25% of patients, but no CRRT was discontinued as citrate accumulation resolved after following the corrective steps in the protocol. None of the patients had citrate toxicity. Chronic liver disease (CLD) (p ≤ 0.001) and those who were post-living donor liver transplant recipients (p = 0.004) had a statistically significant increase in citrate accumulation. Also, patients who had higher lactate at baseline (6 hours post-CRRT initiation), had a higher chance of citrate accumulation.

Conclusion: Our RCA protocol provides a safe approach to regional anticoagulation during CRRT in critically ill patients.

How to cite this article: Pachisia AV, Kumar GP, Harne R, Jagadeesh KN, Patel SJ, Pal D, et al. Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience. Indian J Crit Care Med 2024;28(9):859-865.

How to cite this article: Kumar V. Left Ventricular Diastolic Dysfunction in the Critically Ill: The Rubik's Cube of Echocardiography. Indian J Crit Care Med 2024;28(9):813-815.

The terminology "Financially Palliative" is a pseudonym and refers to a unique challenge faced in countries where public healthcare insurance coverage is not robust and the percentage of out-of-pocket health expenditure continues to be high. Emergency and critical care healthcare expenditures in such circumstances usually pose additional burden as they are unforeseen expenses, disproportionately high, for which most people are unprepared. Such situations may lead into a vicious cycle that initiates with expenditure hesitancy and delay in definitive care, which in turn leads to deterioration in the patient's condition and delay-related complications. This further fuels expenditure hesitancy due to uncertain prognosis and outcomes. The future threats posed by this issue are manifold, which are not only restricted to poor patient outcomes and diminishing physician morale but also hinder progress in science by influencing research outcomes/endpoints in areas where it is highly prevalent. Identifying and defining the problem with terminology is only the first step in working towards solutions. The issue needs to be addressed and mitigated before it spreads its roots deeper into our healthcare system.

How to cite this article: Bhat R, Ramaswami A. "Financially Palliative": The Need to Address a Perplexing Financial Conundrum in Emergency and Critical Care. Indian J Crit Care Med 2024;28(9):820-822.

How to cite this article: Baalaaji M. Pediatric Sepsis - Sailing the Unchartered Waters with Omics. Indian J Crit Care Med 2024;28(9):818-819.

How to cite this article: Vadi SMR, Sanwalka N, Suthar D. Author Response: Oxygenation Indices in Adult COVID ARDS Patients. Indian J Crit Care Med 2024;28(9):889.

Background: Carbamazepine (CBX) is widely used for various medical conditions, but its associated toxicity poses significant clinical concerns. This study aims to provide insights into the clinical presentations, management strategies, and outcomes of CBX toxicity cases in an emergency department (ED) setting.

Methodology: This was a 10-year retrospective cohort chart review study, including all patients with elevated CBX levels. Data on clinical features, CBX levels, laboratory findings, electrocardiograms (ECGs), patient management, and outcomes were analyzed. Cases were categorized as acute or chronic toxicity.

Results: Out of the 1,965 medical charts reviewed, we included 70 patients with CBX levels above the therapeutic range (prevalence: 3.6%). Chronic CBX toxicity cases (55.7%) were predominant, with gastrointestinal (GI) symptoms being the most common. Most patients presented with isolated CBX overdoses (88.6%), while mixed overdoses (11.4%) were less frequent. Patients were categorized based on CBX levels: 44 had mild toxicity (>51 μmol/L), and 26 had moderate toxicity (>85 μmol/L). Within the mild group, 15 patients experienced acute toxicity, compared to 16 patients in the moderate group. Four patients who had mixed overdoses and low sensorium required intubation and mechanical ventilation. Three patients received activated charcoal (AC), and another 3 patients received multiple doses of AC to reduce drug absorption. The majority of patients (65.7%) required hospital admission, underscoring the seriousness of CBX toxicity. There were no fatalities among these 70 patients.

Conclusion: This study emphasizes the importance of a systematic approach to assessing and managing CBX toxicity, considering its diverse clinical presentations and variations in serum CBX levels.

How to cite this article: Hazra D, Ellouze NF, Abri SA. Prevalence and Outcomes of Carbamazepine Toxicity in the Emergency Department: A Single-center Retrospective Study. Indian J Crit Care Med 2024;28(9):866-870.

Background: Reported incidence of acute kidney injury (AKI) is around 5.0-7.5% of all hospitalized patients, and 40% of them are postoperative patients. Major abdominal surgeries account for 3.1-35% of cases of postoperative AKI in various series. The aim of the study was to identify the incidence and risk factors of AKI in peritonitis patients undergoing emergency laparotomy.

Materials and methods: Adult patients aged 18-65 years undergoing emergency laparotomy for perforation peritonitis were included in this prospective observational study. Baseline clinical and laboratory data, intraoperative details and postoperative outcome data (AKI at day 7, length of intensive care unit and hospital stay, and mortality) were recorded. Logistic regression model was constructed to predict AKI at day 7.

Results: N = 140 patients were included in this study and 69 patients (49.3%) developed AKI within day 7. Larger volume of crystalloid [OR (95% CI) 1.00 (1.00-1.00); p = 0.012], intraoperative vasopressor use (OR 7.42 (2.41-22.83); p < 0.001), intraoperative blood loss [OR 1.004(1.00-1.01); p = 0.003] and the presence of chronic liver disease (CLD) [OR 22.44 (1.68-299.26); p = 0.019] were risk factors for the development of AKI. Acute kidney injury patients had increased mortality at day 90 (24.6% vs 1.4%; p < 0.001), length of ICU stay (3 days vs 0 days, p < 0.001), and length of hospital stay (11 days vs 7 days; p < 0.001).

Conclusion: In peritonitis patients undergoing emergency laparotomy, as many as 49% of patients develop AKI within 1 week. The presence of CLD, intraoperative blood loss, and the use of crystalloids and vasopressor increase the odds of developing AKI.

How to cite this article: Priya P, Baidya DK, Anand RK, Ray BR, Khanna P, Krishna A, et al. Epidemiology and Long-term Outcomes of Acute Kidney Injury in Adult Patients with Perforation Peritonitis Undergoing Emergency Laparotomy. Indian J Crit Care Med 2024;28(9):854-858.

Background: Septic shock is associated with high mortality and there is significant heterogeneity in the host response. The aim of this study was to understand the genome-wide expression transcriptomic signatures in children with septic shock and correlate them with outcomes.

Methods: This was a prospective study conducted on children (aged 1 month to 18 years) admitted to the PICU (June-December 2021) with septic shock. Demographic details, clinical details, and administered treatment were collected. Differential gene expression analysis was performed to understand the genes and pathways affecting in different subjects.

Results: Fifteen patients were recruited (Septic shock survivors (n = 5), nonsurvivors (n = 5), and non-sepsis controls (n = 5). The median age of the patients in survivors and nonsurvivors was 15 (13, 24) months and 180 (180, 184) months, respectively. The sepsis-survivors vs nonsepsis possessed 983 upregulated and 624 downregulated genes while comparing sepsis nonsurvivors (SNS) with nonsepsis yielded 1,854 upregulated and 1,761 downregulated genes. Further, the lowest number of deregulated genes (383 upregulated and 486 downregulated) were present in SNS compared to sepsis survivors. The major Reactome pathways, found upregulated in SNSs relative to survivors included CD22 mediated B cell receptor (BCR) regulation, scavenging of heme from plasma, and creation of C4 and C2 activators while T cell receptor (TCR) signaling, the common pathway of fibrin clot formation and generation of second messenger molecules were found to be downregulated.

Conclusion: Mortality-related gene signatures are promising diagnostic biomarkers for pediatric sepsis.

How to cite this article: Lalitha AV, Vasudevan A, Moorthy M, Ramaswamy G. Profiling Molecular Changes of Host Response to Predict Outcome in Children with Septic Shock. Indian J Crit Care Med 2024;28(9):879-886.

Aims and background: Various types of parenteral nutritional products exist, each with specific formulations designed to meet the diverse nutritional needs of patient's post-abdominal surgery. Here, two different parenteral nutrition (PN) solutions BFLUID and NUTRIFLEX PERI are compared in terms of therapeutic efficacy and safety profile.

Materials and methods: A prospective, multi-center, randomized, parallel-group, non-inferiority Phase III clinical trial compared two PN solutions namely BFLUID (N = 78) and NUTRIFLEX PERI (N = 72) in 150 patients undergoing gastrectomy or colectomy. Primary endpoints included length of hospital stay while secondary endpoints included assessment and comparison of length of ICU/HDU stay, assessment of incidents of infections and mortality, change in blood levels of vitamin B1, change in nutritional parameters, thrombophlebitis, pain at the injection site, and recording of adverse events (AEs).

Results: There was no significant difference in terms of length of hospital stay, length of ICU/HDU stay as well as changes in nutritional parameters from baseline and change in blood levels of vitamin B1 from baseline. Both study groups exhibited comparability in terms of AEs, pain at the injection site, and the incidence of phlebitis. There was no significant difference in the number and severity of adverse events reported in both groups. Additionally, no signs of infection were observed in patients from either group.

Conclusion: The trial successfully demonstrated the non-inferiority of BFLUID to NUTRIFLEX PERI. Moreover, the results indicated that PN enriched with high levels of branched-chain amino acids (BCAAs), essential amino acids (EAAs), and thiamine is both safe and efficacious for adult patients undergoing gastrectomy or colectomy.

How to cite this article: Goyal A, Pathak A, BS Madhu, Soni H, Bhatt K, Raju KVVN, et al. Role of Peripheral Parenteral Nutrition Composition on Clinical Outcomes in Patients Undergoing Gastrectomy or Colectomy: A Phase III Indian Clinical Trial. Indian J Crit Care Med 2024;28(9):871-878.