key: cord-0078217-ztgfo98n
authors: nan
title: INTENSIVE CRITICAL CARE
date: 2022-03-03
journal: Lung India
DOI: 10.4103/0970-2113.341098
sha: 8ff53d4620fe79ae2da05614d35b99d49c5b4a5c
doc_id: 78217
cord_uid: ztgfo98n

nan

Background: High-flow nasal oxygen therapy (HFOT) has fueled a growing interest in non-invasive management of acute hypoxemic respiratory failure (AHRF). ROX index, a bedside index can be used to prevent excess mortality associated with delayed intubation. Methods and Objectives: This was a single-center prospective observational cohort study including 55 patients with AHRF treated with HFOT. Identification was through ROC analysis and Kaplan Meier survival estimation of ROX association with HFOT outcome. The most specific cutoff of the ROX index to predict HFOT failure and success was assessed. Results: Among the 55 patients treated with HFOT in the validation cohort, 19 (34.54%) required intubation. Baseline 39 patients were COVID19 positive. The prediction accuracy of the ROX index increased over time (AUC of ROC curve at 2 h, 0.922; 6 h, 0.971; 12 h, 0.980). Sensitivity and specificity of 4.88/4.4 cut off were: 85.7/89.5,73.2/94 at 2 hours, 78.6/84.2, 80.5/97.2 at 6 hours, 78.6/84.2, 78.05/97.2 at 12 hours) ROX greater-than-orequal-to 4.4 was a better cut off than 4.88 on the basis of diagnostic accuracy and was consistently associated with a lower risk for intubation. A ROX less than 4.31, less than 4.61 and less than 4.33 at 2, 6 and 12 hours of HFOT initiation, respectively, were predictors of HFOT failure. ROX ≥ 4.4 at 2 hours had HR of 0.022 with 95% confidence interval of 0.004-0.127 with p value of <0.001. Conclusion: ROX index can help identify low and high risk for intubation in patients of AHRF treated with HFOT.

Background: Ventilator Associated Pneumonia (VAP) is thought to be secondary to bacterial colonization of upper digestive tract and aspiration of contaminated secretions into lower airway. Probiotics are postulated to prevent colonization of these pathogenic bacteria. In this prospective observational study, we aimed to investigate the effects of probiotics on gut microbiota and its relation with clinical outcomes in mechanically ventilated patients. Methods: 20 and 10 patients were recruited in probiotic and control group respectively. Probiotic patients were given six probiotic capsules (VSL#3®:112.5 billion CFU/ cap) in three divided doses for 10 days. Three stool samples were collected, at baseline, between days 3-5 and 7-10. DNA extraction was done using THSTI method, DNA sequencing using 16S-RNA Microbiome Sequencing and analysis using Nanopore Platform. Results: The difference in alpha diversity (shannon's index) at phylum level in 2 nd and 3 rd fecal samples was not statistically significant (probiotic-2.50, control-2.59; p-value: 0.79). There was statistically significant increase in relative abundances of certain pathogenic bacteria in control group (Acinetobacter, Streptococcus, Stenotrephomonas) and increase in certain beneficial bacteria in probiotic group (Dorea, Streptomyces, Coprococcus, Lactobacillus).

Incidence of VAP (probiotic-58%, control-64%; p-value: 0.938) and BSI (probiotic-21%, control-27%; 0.95) were comparable between the groups. The incidence of diarrhea was similar between groups (probiotic-10%, control-9%; p-value: 0.61). The all-cause mortality was seen to be similar between groups (probiotic-58%, control-82%; P-value-0.348). Conclusion: Probiotics lead to favourable alteration in gut microbiome characteristics as shown in our study. Future studies should focus on appropriate dosages and frequency of probiotics which can lead to improved clinical outcomes.

A prospective study on clinical profile, severity, microbiological profile and outcome of patients with ventilator associated infective complications admitted in intensive care unit of a tertiary care hospital

Appolo Multi Speciality Hospital, Kolkata, West Bengal, India. E-mail: bingos.sen@gmail.com Background: Mechanical ventilation epitomizes intensive care medicine. Ventilator-associated infective complications are mainly Ventilator associated respiratory infections (VARI); These are a major cause of concern in the intensive care units (ICUs) worldwide, especially in developing countries. VARI includes patients with ventilator-associated tracheobronchitis (VAT) and ventilator-associated pneumonia (VAP). Establishing microbiological diagnosis for patients with pneumonia is always great challenge. The major thrust in management of pneumonia is based on covering the most likely organisms which is intimately related to different risk factors of pneumonia which again depends on the site of acquisition. Various risk factors have been shown to be associated with the risk of infection with Multidrug resistant (MDR) pathogen Our study is prospective, hospital based study that will be conducted over a period of 12 months in intensive care unit of a tertiary care hospital. Aims and Objective: Data regarding risk factors, severity, microbiological profile and outcome of patients with VAP and VAT is lacking from Eastern India. Our study aims to investigate the above mentioned parameters in a tertiary care hospital in Eastern India. The primary objective of the study will be to study the risk factors, severity scoring, microbiological profile and 28 days outcome of patients admitted in intensive care unit of our hospital. Secondary objective of our study will be to find out any correlation between risk factors, severity scoring, microbiological profile and outcome of patients with VAT and VAP admitted in intensive care unit of our hospital. Methodology: It is a prospective observational study done in the ICU of a tertiary care centre in eastern India. Total 50 patients of clinically, microbiologically and/or radiologically diagnosed case of VAP and VAT was included in the study. A structured data collection proforma was prepared and data collection was done. The clinical parameters studied are age, sex, days on mechanical ventilation, addiction, comorbidities, primary system of involvement, ventilator settings. Microbiological samples include, sputum, endotracheal aspirate, bronchoalveolar lavage. Raw data was tabulated and analysed. Results: In our study 58% of the patients of VARI was VAP and 42% of VAT.66% of our patients were male, Smoking was the commonest addiction (24%), VARI developed early with 17% on Day 3, 72% developed VARI within 5 days of ventilation. 16% had history of recent admission, T2DM and HTN was commonest comorbidities. 58% was VAP, In our study we have studied relationship of SOFA score with severity of VAP and VAT in term of outcome. And SOFA score in all the group was 6 in VAP it was 6.64 in VAT it was 6.68. Outcome was the mean sofa score was 8.19 ± 3.41 in death group and Discharge group was 5.68 ± 1.29, this difference was statistically significant (p=0.004). ET culture is the most commonly analysed sample. Neurological primary cases lead to maximum number of VAT and VAP. In our study in overall group Klebsiella pneumoniae was the predominant organism along with Acinetobacter baumannii both had 40% incidence, Klebsiella penumoniae was the commonest organism causing VAT (42%) while Acinetobacter was commonest to cause VAP (44%) followed by Klebsiella pneumonia (37%). Overall sensitivity pattern that was observed in our study showed that about 80% isolates in overall group were intermediately sensitive to polymyxins. In our Study Klebsiella pneumoniae and Acinetobacter baumannii were the predominant organism. In our study 32% of the overall patients was blood culture positive, 44.8% patiencts of VAP were blood culture positive, in VAT 14.3% blood culture positive. Out of twenty isolates of Acinetobacter baumannii all were intermediately sensitive for polymyxin. 11 were sensitive to Tigecycline, 5 where sensitive 2 to cefoperazone, sulbactum, 4 were sensitive to aminoglycosides, only one was sensitive to carbapenems. 20 Isolates of Klebsiella pneumoniae are there in our study, eighteen isolates were intermediately sensitive to polymyxin. In our study in VAP group Acinetobacter baumanii was associated with 41% mortality and Klebsiella was also associated with 41% mortality. Overall mortality was high in VAP caused by these two organism. Although the mortality in VAT group was low, 50% of it was caused by Klebsiella pneumonia (2 out of 4). The mean SOFA score in VAP patients with Acinetobacter baumanni was 6.73, for Klebsiella pneumoniae it was 6.69. Mortality was 58% for VAP and 19% in VAT. Conclusion: Gram negative bacteria was the predominant cause of VAT and VAP, Acinetobacter and Klebsiella are the commonest organisms. Most Isolates are MDR with intermediate sensitivity to Polymyxins. Rate of blood culture positivity rate in also high in our ICU. But it did not influenced mortality. Median sofa was same in both, Mortality was high in VAP group. Volume control mode was predominant mode of ventilation, Neurological causes was predominant cause that leads to ventilation and subsequent VARI. Department of Respiratory Medicine, KIMS Health, Thiruvananthapuram, Kerala, India. E-mail: sherlocksujith@ gmail.com Background and Objective: The concept of NIV has revolutionized the treatment of acute respiratory failure in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals. Current study was aimed to analyse NIV outcome based on various parameters. Methods: This prospective observational study conducted in KIMS hospital, Thiruvananthapuram between September 2019 to June 2020. All patients with acute respiratory failure aged above 18 years and initiated on NIV except for palliative purposes were included in the study. Relevant data were collected and analysed using relevant statistical methods. Results: Out of the 96 NIV applications, 19 (19.8%) failed NIV application in the form of intubation in 12, in-hospital mortality in 8 (8.3% of the total group). 73. 7% (14/19) had a early failure and 26.3% (5/19) had late failure. The median time for failure after an NIV use in the 19 failure cases was 15 hours. The median length of hospital stay is significantly higher in NIV failure group compared to NIV success group (P<0.001). NIV outcomes like failure rate, in-hospital mortality and length of hospital stay does not have any difference between type 1 and type 2 ARF (p>0.05). NIV failure was found to be higher in patients with pneumonia (p<0.05). Whereas, in-hospital mortality was found to be higher in ILD group undergoing NIV application (p<0.05). Conclusion: NIV is associated with success if used judiciously for proper indications. NIV failure should be anticipated and prevented in order to avoid mortality and morbidity.

Department of Respiratory Medicine, Prathima Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: krishna. ramya1991@gmail.com Background: Among Community-Acquired Pneumonias (CAP), 9.4% of hospitalized patients require Intensive Care Unit (ICU) management. Such subjects have a high mortality of nearly 24%. The present study aimed to look into the factors responsible for ICU admission and evaluating severity scoring systems, microbiological profile and observe the outcomes among the study subjects. Methods: A cross-sectional study was conducted between June 2020 and October 2021 involving a total of 52 subjects with CAP admitted to RICU of age > 12 years.

Avani Rajput, Medha Bargaje Bharati Vidyapeeth, Pune, Maharashtra, Background: A high prevalence of pulmonary thromboembolism has been reported in severe COVID patient in Intensive care unit (ICU). Here in we review incidence and outcome of pulmonary thromboembolism in about 2500 COVID positive patients admitted in our institution. Aim and Objective: To identify the incidence and clinical outcome of pneumothorax in COVID-19 patients. Methods: We performed a retrospective review of COVID-19 cases admitted to our hospital. Patients who were diagnosed with pulmonary thromboembolism were identified to calculate the incidence of this event. Their clinical characteristics were thoroughly documented. Including their clinical outcomes. Results: Two thousand nine hundred ninety-six Covid -19 positive patients were admitted to our institution between January 1 st , 2021 and, December 2021 out of which 1829 patients had moderate to severe disease. 32 cases of severe COVID-19 patients who developed pulmonary embolism during admission were identified. Conclusion: These cases suggest that pulmonary thromboembolism is a complication of COVID 19 early clinical signs of pulmonary embolism should be identified and DVT prophylaxis should be started early in moderate to severe disease.

Sana Ansari Department of Respiratory Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, Background: COPD is a progressive inflammatory airway disorder characterized by persistent airflow limitation due to a mixture of small airway disease, chronic lung inflammation, parenchymal destruction and increased airway responsiveness. The most important cause of COPD remains tobacco smoking. Approximately 20% patients hospitalized for COPD present have hypercapnic respiratory failure, causing increased risk of death. The utility of NIV in such patients is well-established. Studies have demonstrated superior outcomes when treated with NIV compared to management without NIV. It is now a standard component of the management of these patients. In this study we compare the outcome of three different modes of NIV i.e. T, ST and iVAPS mode. Methods: Hundred patients taken in the study after taking informed consent and randomized into three groups. Thirty three patients were kept on T mode, thirty three on ST mode and remaining thirty four patients on iVAPS mode of biPAP and then outcome was decided based on clinical and hematological parameters, invasive ventilation rate and mortality. Result and Conclusion: Results showed the highest success rate with iVAPS mode with least number of invasive ventilation rate and mortality. This concludes the fact that iVAPS mode is superior to all other modes of biPAP in COPD patients with hypercapnic respiratory failure and it is a better alternative to avoid invasive ventilation.

All study subjects were managed according to guidelines. Results: Mean age of subjects was 54.4 ± 17.8 years, 55.75 % were males. Co-morbidities were hypertension (40.3%), diabetes (36.5%), old pulmonary tuberculosis (28.8%) and COPD (25%). 90.3% subjects required oxygen, 50% were kept on NIV and 9.6% subjects required mechanical ventilation. 36.5% patients required hospital stay of more than 5 days. Bacterial cultures were positive in 75%. The most common GNB were Klebsiella pneumoniae (15.3%)