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Background: We 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. Methods: An 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. Results: On 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. Conclusions: Hospital 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. [ABSTRACT FROM AUTHOR]

Background: This study presents a real-world scenario for prescription pattern, efficacy, and safety data on the current clinical use of intravenous fosfomycin in critically ill patients in Indian settings. Patients and methods: This was a retrospective cohort study conducted for a period of 10 months among critically ill patients admitted to hospital's critical care unit. The primary objective of the study was to analyze the prescription pattern of intravenous fosfomycin, and the secondary objective was to evaluate the safety profile and patient outcomes. Results: A total of 309 patients were enrolled, and they were diagnosed with bacteremia (45.3%), pneumonia (15.85%), septic shock (14.24%), and urinary tract infections (UTI) (13.91%). The average dose of fosfomycin given was 11.7 ± 4.06 gm/day. The average duration of the therapy was 4.85 ± 3.59 days with a median duration of 4 days. Fosfomycin was given at 8 hourly dosing frequency to maximum (45.6%) cases. Hypokalemia was the most observed adverse event. The overall survival was seen in 55% of patients. Conclusion: Our data suggest that UTI, infection caused by Escherichia coli, and a daily dose of >12 g were associated with better clinical outcomes. The overall survival of critically ill patients receiving fosfomycin was 55%. [ABSTRACT FROM AUTHOR]

The global pandemic involving severe acute respiratory syndrome--coronavirus-2 (SARS-COV-2) has stretched the limits of science. Ever since it emerged from the Wuhan province in China, it has spread across the world and has been fatal to about 4% of the victims. This position statement of the Indian Society of Critical Care Medicine represents the collective opinion of the experts chosen by the society. [ABSTRACT FROM AUTHOR]

Aim: The aim of this review article is not only to analyze the clinical burden of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care unit (ICU) setting of India, along with the patterns of prevalence and its prevention measures, but also to focus on the new anti-MRSA research molecules which are in late stage of clinical development. Background: Methicillin resistance is reported to be present in 13-47% of Staphylococcus aureus infections in India. Therapeutic options to combat MRSA are becoming less, because of emerging resistance to multiple classes of antibiotics. Intensive care units are the harbinger of multidrug-resistant organisms including MRSA and are responsible for its spread within the hospital. The emergence of MRSA in ICUs is associated with poor clinical outcomes, high morbidity, mortality, and escalating treatment costs. There is an urgency to bolster the antibiotic pipeline targeting MRSA. The research efforts for antibiotic development need to match with the pace of emergence of resistance, and new antibiotics are needed to control the impending threat of untreatable MRSA infections. Review results: Fortunately, several potential antibiotic agents are in the pipeline and the future of MRSA management appears reassuring. Clinical significance: The authors believe that this knowledge may help form the basis for strategic allocation of current healthcare resources and the future needs. [ABSTRACT FROM AUTHOR]

Background and Aim: Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Advisory board meetings were arranged to develop the practice guidelines specific to Indian context, for the use of EN in critically ill patients and to overcome challenges in this field. Methods: Various existing guidelines, meta-analyses, randomized controlled trials, controlled trials, and review articles were reviewed for their contextual relevance and strength. A systematic grading of practice guidelines by advisory board was done based on strength of the supporting evidence. Wherever Indian studies were not available, references were taken from the international guidelines. Results: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding EN versus parenteral nutrition; nutrition screening and assessment; nutrition in hemodynamically unstable; route of nutrition; tube feeding and challenges; tolerance; optimum calorie-protein requirements; selection of appropriate enteral feeding formula; micronutrients and immune-nutrients; standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices. Conclusion: This paper summarizes the optimum nutrition practices for critically ill patients. The possible solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance in critical care settings regarding appropriate critical-care nutrition practices and to set up Intensive Care Unit nutrition protocols. [ABSTRACT FROM AUTHOR]

Background and Aims: Deep venous thrombosis (DVT) prophylaxis is underutilized, and there is a paucity of data reflecting the incidence of DVT in Indian Intensive Care Unit (ICU) population. We sought to evaluate the incidence and risk factors for DVT in medical and surgical ICU patients with DVT prophylaxis. Material and Methods: The ICU patients more than 18 years old, expected to be in the ICU for more than 48 h were enrolled and DVT prophylaxis were given as per risk and were observed for clinical signs of DVT along with duplex ultrasound until in ICU. The patients receiving anticoagulant for some other reasons were excluded along with those with pregnancy, congenital coagulation disorders and terminal illness. Results: The incidence of DVT was 0.8% (95% confidence interval: 0.78-0.81) in mixed populations (1.6% in medical and 0.5% in surgical). The higher DVT score (DVT (+) 10.75 ± 2.06/DVT (-) 8.75 ± 1.7 P = 0. 0264), Acute physiology and chronic health evaluation (APACHE) IV score (DVT positive patient - DVT (+) 59.25 ± 15.06/DVT negative patients - DVT (-) 44.01 ± 13.74) P = 0. 0292), length of ICU stay ([DVT (+) 26.75 ± 12.87 days/DVT (-) 5.19 ± 6.18] P < 0.010), and inotropes (DVT (+) 50%/DVT (-) 12.3% P = 0. 023) were associated with DVT. Conclusion: The incidence of DVT was 0.8% with prophylaxis. High DVT and APACHE IV score were associated with DVT. Prolonged ICU stay and vasopressors were the risk factors. [ABSTRACT FROM AUTHOR]

Background: Timely decision making in Intensive Care Unit (ICU) is very essential to improve the outcome of critically sick patients. Conventional scores like Acute Physiology and Chronic Health Evaluation (APACHE IV) are quite cumbersome with calculations and take minimum 24 hours. Procalcitonin has shown to have prognostic value in ICU/Emergency department (ED) in disease states like pneumonia, sepsis etc. NTproBNP has demonstrated excellent diagnostic and prognostic importance in cardiac diseases. It has also been found elevated in non-cardiac diseases. We chose to study the prognostic utility of these markers on ICU admission.Settings and Design: Retrospective observational study.Materials and Methods: A Retrospective analysis of 100 eligible patients was done who had undergone PCT and NTproBNP measurements on ICU admission. Their correlations with all cause mortality, length of hospital stay, need for ventilator support, need for vasopressors were performed.Results: Among 100 randomly selected ICU patients, 28 were non-survivors. NTproBNP values on admission significantly correlated with all cause mortality (P = 0.036, AUC = 0.643) and morbidity (P = 0.000, AUC = 0.763), comparable to that of APACHE-IV score. PCT values on admission did not show significant association with mortality, but correlated well with morbidity and prolonged hospital length of stay (AUC = 0.616, P = 0.045).Conclusion: The current study demonstrated a good predictive value of NTproBNP, in terms of mortality and morbidity comparable to that of APACHE-IV score. Procalcitonin, however, was found to have doubtful prognostic importance. These findings need to be confirmed in a prospective larger study. [ABSTRACT FROM AUTHOR]

Introduction: Fluid therapy in critically ill patients, especially timing and fluid choice, is controversial. Previous randomized trials produced conflicting results. This observational study evaluated the effect of colloid use on 90-day mortality and acute kidney injury (RIFLE F) within the Rational Fluid Therapy in Asia (RaFTA) registry in intensive care units. Materials and methods: RaFTA is a prospective, observational study in Asian intensive care unit (ICU) patients focusing on fluid therapy and related outcomes. Logistic regression was performed to identify risk factors for increased 90-day mortality and acute kidney injury (AKI). Results: Twenty-four study centers joined the RaFTA registry and collected 3,187 patient data sets from November 2011 to September 2012. A follow-up was done 90 days after ICU admission. For 90-day mortality, significant risk factors in the overall population were sepsis at admission (OR 2.185 [1.799; 2.654], p < 0.001), cumulative fluid balance (OR 1.032 [1.018; 1.047], p < 0.001), and the use of vasopressors (OR 3.409 [2.694; 4.312], p < 0.001). The use of colloids was associated with a reduced risk of 90-day mortality (OR 0.655 [0.478; 0.900], p = 0.009). The initial colloid dose was not associated with an increased risk for AKI (OR 1.094 [0.754; 1.588], p = 0.635). Conclusion: RaFTA adds the important finding that colloid use was not associated with increased 90-day mortality or AKI after adjustment for baseline patient condition. Clinical significance: Early resuscitation with colloids showed potential mortality benefit in the present analysis. Elucidating these findings may be an approach for future research. [ABSTRACT FROM AUTHOR]

Background Infections with carbapenem-resistant organisms (CRO) are increasing worldwide and are associated with high mortality. Patients transferred from outside hospitals have been reported to be at increased risk of CRO colonization and infection. The rate of subsequent CRO infection in patients colonized with CRO is unclear in a high CRO burden setting Methods Medanta Hospital in Gurgaon, India instituted CRO colonization screening for patients transferred from outside hospitals for infection control purposes. From April 2018 to May 2018, patients transferred from other hospitals to the intensive care unit at Medanta were subjected to CRO colonization screening using Xpert Carba R (Cepheid) performed on the day of transfer. Subsequent recovery of CRO in cultures of blood, bronchoalveolar lavage fluid, urine in specimens with pyuria obtained from patients without urinary catheters, pus, and tissue were considered to be indicative of CRO infection. The association of CRO colonization with subsequent CRO infection was assessed with a Fisher exact test Results Among 457 patients screened, 205 patients (45%) were found to be colonized with CRO at admission. Genes for New Delhi Metallo-β-lactamase (NDM) were detected in 184 (40%) patients, OXA-48 in 97 (21%) patients, VIM in 18 (4%) patients, KPC in 5 (1%) patients, and IMP1 in 5 (1%) patients; >1 carbapenemase gene was detected in 95 (21%) patients. CRO infections were observed in 25 (5%) patients including 12 with bacteremia, 7 with pneumonia, 4 with urinary tract infection, and 2 with soft-tissue infection. Among patients with CRO colonization, 17 (8%) patients developed CRO infection during the course of hospitalization; among patients without admission CRO colonization, subsequent CRO infection was found in 8 (3%) patients. CRO admission colonization was associated with subsequent clinical infection with CRO (odds ratio = 2.8, P = 0.02) Conclusion CRO colonization was found in almost half of patients transferred from outside hospitals to a large tertiary care hospital in India and was associated with subsequent CRO infection. Further work is necessary to understand the role of CRO colonization screening in infection control and antimicrobial stewardship in a setting with high CRO burden Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Background: Indian Society of Critical Care Medicine (ISCCM) guidelines on Planning and Designing Intensive care (ICU) were first developed in 2001 and later updated in 2007. These guidelines were adopted in India, many developing Nations and major Institutions including NABH. Various international professional bodies in critical care have their own position papers and guidelines on planning and designing of ICUs; being the professional body of intensivists in India ISCCM therefore addresses the subject in contemporary context relevant to our clinical practice, its variability according to specialty and subspecialty, quality, resource limitation, size and location of the institution. Aim: To have a consensus document reflecting the philosophy of ISCCM to deliver safe & quality Critical Care in India, taking into consideration the requirement of regulatory agencies (national & international) and need of people at large, including promotion of training, education and skill upgradation. It also aiming to promote leadership and development and managerial skill among the critical care team. Material and Methods: Extensive review of literature including search of databases in English language, resources of regulatory bodies, guidelines and recommendations of international critical care societies. National Survey of ISCCM members and experts to understand their viewpoints on respective issues. Visiting of different types and levels of ICUs by team members to understand prevailing practices, aspiration and Challenges. Several face to face meetings of the expert committee members in big and small groups with extensive discussions, presentations, brain storming and development of initial consensus draft. Discussion on draft through video conferencing, phone calls, Emails circulations, one to one discussion Result: Based upon extensive review, survey and input of experts' ICUs were categorized in to three levels suitable in Indian setting. Level III ICUs further divided into sub category A and B. Recommendations were grouped in to structure, equipment and services of ICU with consideration of variation in level of ICU of different category of hospitals. Conclusion: This paper summarizes consensus statement of various aspect of ICU planning and design. Defined mandatory and desirable standards of all level of ICUs and made recommendations regarding structure and layout of ICUs. Definition of intensive care and intensivist, planning for strength of ICU and requirement of manpower were also described. [ABSTRACT FROM AUTHOR]

A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH <7.25 & PaCO2 ≥ 45) before initiating invasive mechanical ventilation (IMV) except in patients requiring immediate intubation. (2A). Lower the pH higher the chance of failure of NIV. (2B) NIV should not to be used routinely in normo- or mildly hyper-capneic patients with acute exacerbation of COPD, without acidosis (pH > 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/ Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent air-borne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C. APPLICATION OF NIV: Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D. MANAGEMENT OF PATIENT ON NIV: D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E. EQUIPMENT: Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non--invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F. WEANING: Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B) [ABSTRACT FROM AUTHOR]

Background and Aims: We aim to study the significance of intraoperative hyperlactatemia in reconstructive oncoplastic surgery. Material and Methods: A retrospective observational study was conducted on a cohort of patients who underwent reconstructive oncoplastic surgery with free flap for oral cancer over a 6-month period. The study population was divided into two groups based on peak lactate levels. Group N with peak lactate level less than 2 mmol/L and Group H peak lactate level more than 2 mmol/L. The various parameter studied were patient's comorbidities; intraoperative events (vasopressor requirement, blood transfusion, and duration of surgery); postoperative parameters including the need for re- exploration and duration of stay in hospital and intensive care unit. Results: The study demonstrates that intraoperative rise of lactate was not influenced by comorbidities. None of the intraoperative parameters studied influenced the lactate levels. Baseline lactate level was found to correlate with peak lactate level intraoperatively. But it was observed that there was normalization of lactate level within 24 hours postoperatively in both the groups. There was no difference in outcome parameters in the two groups. Conclusion: Intraoperative hyperlactatemia is not a significant prognostic factor for outcome in oncoplastic reconstructive surgery. [ABSTRACT FROM AUTHOR]

We report a case of 27-year-old female diagnosed with hemophagocytic lymphohistiocytosis (HLH) following a recent Epstein--Barr virus (EBV) infection. A known case of relapsing remitting multiple sclerosis on corticosteroids for last 6 months presented to the critical care unit with fever, maculopapular rash and difficulty in breathing. A rapid and correct diagnosis with the precise treatment led to complete recovery of this patient. The HLH is a rare complication of primary EBV infection. [ABSTRACT FROM AUTHOR]

Importance: Infection is frequent among patients in the intensive care unit (ICU). Contemporary information about the types of infections, causative pathogens, and outcomes can aid the development of policies for prevention, diagnosis, treatment, and resource allocation and may assist in the design of interventional studies.Objective: To provide information about the prevalence and outcomes of infection and the available resources in ICUs worldwide.Design, Setting, and Participants: Observational 24-hour point prevalence study with longitudinal follow-up at 1150 centers in 88 countries. All adult patients (aged ≥18 years) treated at a participating ICU during a 24-hour period commencing at 08:00 on September 13, 2017, were included. The final follow-up date was November 13, 2017.Exposures: Infection diagnosis and receipt of antibiotics.Main Outcomes and Measures: Prevalence of infection and antibiotic exposure (cross-sectional design) and all-cause in-hospital mortality (longitudinal design).Results: Among 15 202 included patients (mean age, 61.1 years [SD, 17.3 years]; 9181 were men [60.4%]), infection data were available for 15 165 (99.8%); 8135 (54%) had suspected or proven infection, including 1760 (22%) with ICU-acquired infection. A total of 10 640 patients (70%) received at least 1 antibiotic. The proportion of patients with suspected or proven infection ranged from 43% (141/328) in Australasia to 60% (1892/3150) in Asia and the Middle East. Among the 8135 patients with suspected or proven infection, 5259 (65%) had at least 1 positive microbiological culture; gram-negative microorganisms were identified in 67% of these patients (n = 3540), gram-positive microorganisms in 37% (n = 1946), and fungal microorganisms in 16% (n = 864). The in-hospital mortality rate was 30% (2404/7936) in patients with suspected or proven infection. In a multilevel analysis, ICU-acquired infection was independently associated with higher risk of mortality compared with community-acquired infection (odds ratio [OR], 1.32 [95% CI, 1.10-1.60]; P = .003). Among antibiotic-resistant microorganisms, infection with vancomycin-resistant Enterococcus (OR, 2.41 [95% CI, 1.43-4.06]; P = .001), Klebsiella resistant to β-lactam antibiotics, including third-generation cephalosporins and carbapenems (OR, 1.29 [95% CI, 1.02-1.63]; P = .03), or carbapenem-resistant Acinetobacter species (OR, 1.40 [95% CI, 1.08-1.81]; P = .01) was independently associated with a higher risk of death vs infection with another microorganism.Conclusions and Relevance: In a worldwide sample of patients admitted to ICUs in September 2017, the prevalence of suspected or proven infection was high, with a substantial risk of in-hospital mortality. [ABSTRACT FROM AUTHOR]