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Introduction There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the types of air leaks in COVID-19 and their outcomes. Methods The literature search from PubMed, Science Direct, and Google Scholar databases was performed from the start of the pandemic till 31 March 2021. The inclusion criteria were case reports or series on (1) laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, (2) with the individual patient details, and (3) reported diagnosis of one or more air leak syndrome (pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium). Results A total of 105 studies with 188 patients were included in the final analysis. The median age was 56.02 (SD 15.53) years, 80% males, 11% had previous respiratory disease, and 8% were smokers. Severe or critical COVID-19 was present in 50.6% of the patients. Pneumothorax (68%) was the most common type of air leak. Most patients (56.7%) required intervention with lower mortality (29.1% vs. 44.1%, p = 0.07) and intercostal drain (95.9%) was the preferred interventional management. More than half of the patients developed air leak on spontaneous breathing. The mortality was significantly higher in patients who developed air leak with positive pressure ventilation (49%, p Conclusion Air leak in COVID-19 can occur spontaneously without positive pressure ventilation, higher transpulmonary pressures, and other risk factors like previous respiratory disease or smoking. The mortality is significantly higher if associated with positive pressure ventilation and escalation of respiratory support.

Chylothorax is a rare complication after total thyroidectomy with radical neck dissection, and isolated right side chylothorax is even rarer. Treatment may be conservative or surgical. Besides being helpful in making a diagnosis, thoracic duct lymphangiography (TDL) may be therapeutic in some cases. However, its application in high output chylous leak is not fully explored. Here, we present a rare case of right-sided high output chylothorax, secondary to total thyroidectomy, successfully treated with TDL.

Background Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. Methods Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p Results Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16–24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. Conclusion Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. Trial registration: The study was registered with Clinical trials.gov Identifier: NCT04534569.

Background and purpose Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines. Methods This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared. Results This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level. Conclusion In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time. Abbreviations list ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization. How to cite this article Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6-S30.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an x-linked recessive genetic disorder with mutation in the G6PD gene. Defect in the enzyme G6PD causes red blood cells (RBCs) to breakdown prematurely causing hemolytic anemia. Hemolytic anemia is also a known hematological complication associated with viral hepatitis. In such patients, hemolysis may be more severe if there is any secondary injury to RBC in the form of membrane defect, oxidative stress, or enzyme deficiency like in G6PD deficiency. Here, we present a case of an adult, not previously diagnosed with G6PD deficiency, who presented with viral hepatitis, severe hemolysis, and multiorgan failure.

Pulmonary tuberculosis can have a wide variety of presentations including hematological manifestations. We report a case of a young male patient who presented with complaints of generalized petechiae, gum bleeding, systemic lymphadenopathy, and severe thrombocytopenia. His bone marrow revealed normal megakaryocytes, and in the absence of hepatosplenomegaly, a diagnosis of immune thrombocytopenic purpura (ITP) was made. The thrombocytopenia responded to course of intravenous immune globulin. The smear made from fine-needle aspiration of cervical lymph nodes showed acid-fast bacilli. This case highlights the rare association of extrapulmonary tuberculosis with ITP.

Background: Convalescent plasma (CP) is being used as a treatment option in hospitalized patients with COVID-19. Till date, there is conflicting evidence on efficacy of CP in reducing COVID-19 related mortality.Objective: to evaluate the effect of CP on 28-day mortality reduction in patients with COVID-19. Methods: We did a multi-center, retrospective case control observational study from 1st May 2020 to 31st August 2020. A total of 1079 adult patients with moderate and severe COVID-19 requiring oxygen, were reviewed. Of these, 694 patients were admitted to ICU. Out of these, 333 were given CP along with best supportive care and remaining 361 received best supportive care only. Results: In the overall group of 1079 patients, mortality in plasma vs no plasma group was statistically not significant (22.4% vs 18.5%; p = 0.125). However, in patients with COVID-19 admitted to ICU, mortality was significantly lower in plasma group (25.5% vs 33.2%; p = 0.026). This benefit of reduced mortality was most seen in age group 60 to 74 years (26.7% vs 43.0%; p = 0.004), driven mostly by females of this age group (23.1% vs 53.5%; p = 0.013). Significant difference in mortality was observed in patients with one comorbidity (22.3% vs 36.5%; p = 0.004). Moreover, patients on ventilator had significantly lower mortality in the plasma arm (37.2% vs 49.3%; p = 0.009); particularly so for patients on invasive mechanical ventilation (63.9% vs 82.9%; p = 0.014). Conclusion: The use of CP reduced mortality in COVID-19 elderly patients admitted in ICU, above 60 years of age, particularly females, those with comorbidities and especially those who required some form of ventilation. Funding Statement: None to declare. Declaration of Interests: None to declare. Ethics Approval Statement: The manuscript has ethical clearance and approval from the ethics committee of the institute . A copy of the approval letter is attached. (Reference number is RS/MSSH/GMRCHS/IEC/IM/20-16).

Background Convalescent plasma (CP) is being used as a treatment option in hospitalized patients with COVID-19. Till date, there is conflicting evidence on efficacy of CP in reducing COVID-19 related mortality. Objective To evaluate the effect of CP on 28-day mortality reduction in patients with COVID-19. Methods We did a multi-centre, retrospective case control observational study from 1st May 2020 to 31st August 2020. A total of 1079 adult patients with moderate and severe COVID-19 requiring oxygen, were reviewed. Of these, 694 patients were admitted to ICU. Out of these, 333 were given CP along with best supportive care and remaining 361 received best supportive care only. Results In the overall group of 1079 patients, mortality in plasma vs no plasma group was statistically not significant (22.4% vs 18.5%; p = 0.125; OR = 1.27, 95% CI: 0.94‐–1.72). However, in patients with COVID-19 admitted to ICU, mortality was significantly lower in plasma group (25.5% vs 33.2%; p = 0.026; OR = 0.69, 95%CI: 0.50–0.96). This benefit of reduced mortality was most seen in age group 60 to 74 years (26.7% vs 43.0%; p = 0.004; OR = 0.48, 95% CI: 0.29–0.80), driven mostly by females of this age group (23.1% vs 53.5%; p = 0.013; OR = 0.26, 95% CI: 0.09–0.78). Significant difference in mortality was observed in patients with one comorbidity (22.3% vs 36.5%; p = 0.004; OR = 0.50, 95% CI: 0.31–0.80). Moreover, patients on ventilator had significantly lower mortality in the plasma arm (37.2% vs 49.3%; p = 0.009; OR = 0.61, 95% CI: 0.42–0.89); particularly so for patients on invasive mechanical ventilation (63.9% vs 82.9%; p = 0.014; OR = 0.37, 95% CI: 0.16–0.83). Conclusion The use of CP was associated with reduced mortality in COVID-19 elderly patients admitted in ICU, above 60 years of age, particularly females, those with comorbidities and especially those who required some form of ventilation.

A 57-year-old male presented with hemoptysis of 4 years duration and a gradually increasing pleural mass on chest X-ray. The mass was causing pressure effects on the liver and the lungs. To rule out malignancy, thoracotomy was performed, which revealed large, thick-walled hematoma. Complete excision of mass was performed. Post-operative course was complicated by massive pleural bleeding requiring massive blood transfusions and re-exploratory thoracotomy. Subsequent tests revealed factor IX deficiency and, hence, he was managed with recombinant factor IX concentrate. This case stresses upon the fact that hereditary bleeding disorders may be diagnosed even in late adulthood with atypical presentations such as pseudotumor in pleural space. Moreover, hemophilia B may present with normal APTT levels making the diagnosis even more difficult.

Hypertriglyceridemia can cause severe diseases such as acute pancreatitis (AP) and coronary artery disease. The routine management of hypertriglyceridemia is dietary restriction of fat and lipid-lowering medications to manage the secondary or precipitating causes of hypertriglyceridemia. However, in cases of AP with severe hypertriglyceridemia (SHTG) (triglycerides [TG] >1000 mg/dl) rapid reduction of TG levels to well below 1000 mg/dl can improve outcome and prevent further episodes of pancreatitis. Plasmapheresis is a therapeutic option in such medical emergencies. We discussed 2 cases of severe AP with SHTG where we used early plsmapheresis along with other supportive management.

Purpose: The purpose of the study was to assess the clinical profile and course of dengue patients admitted to the intensive care unit (ICU) and to identify factors related to poor outcome. Methods: All patients with dengue admitted to ICU over 2.5 years were included prospectively. Severity of illness was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and organ failure was determined by the Sequential Organ Failure Assessment score. Primary outcome measure was 28-day mortality. Logistic regression analysis was performed to identify factors predicting mortality. Results: Data from 198 patients were analyzed. Mean age was 39.56 ± 17.1 years, and 61.1% were male. The commonest complaints were fever (96%) and rash (37.9%). Mean admission APACHE II and Sequential Organ Failure Assessment scores were 7.52 ± 7.8 and 4.52 ± 3.4, respectively. The commonest organ failure was coagulation (43.4%) followed by respiratory failure (13.1%). Vasopressors were required by 11.6%; and dialysis and mechanical ventilation were required by 7.6% and 9.1%, respectively. Mortality was 12 (6.1%); and on multivariate analysis, APACHE II score (odds ratio, 1.781; 95% confidence interval, 0.967-3.281; P = .048) could independently predict mortality. Conclusions: Patients with dengue fever may require ICU admission for organ failure. Outcome is good if appropriate aggressive care and organ support are instituted. Admission APACHE II score may predict patients at higher risk of death.

Objective: Few studies have addressed the outcome of patients with cirrhosis requiring mechanical ventilation (MV). We aimed to investigate the short-term outcome of such patients. Methods: Retrospective review of data of 73 consecutive patients with cirrhosis requiring MV over a 2-year period (2006-2008). Data on patient’s characteristics, reason for MV, the presence of other organ failure, and first day Acute Physiology Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), Child-Pugh (CP), and Model for End-Stage Liver Disease (MELD) scores were collected, with 30-day mortality being the primary outcome measure. Results: Observed mortality in ICU and at 30 days was 75.3% and 87.7%, respectively. Area under curve was 0.77 (95% CI, 0.65-0.86) for APACHE II, 0.94 (95% CI, 0.85-0.98) for SOFA, 0.83 (95% CI, 0.7-0.96) for CP, and 0.93 (95% CI, 0.85-0.98) for MELD ( P = .096) in predicting 30-day mortality. By univariate analysis, indication for intubation ( P = .001), need for vasopressor support ( P = .002), the presence of renal failure ( P < .03), and duration of MV ( P < .001) were significantly associated with mortality. On multivariate analysis, only duration of MV (adjusted odds ratio 0.63, 95% CI: 0.42-0.95, P = .03) was the independent predictor of mortality with a majority of patients, 51/64 (79.7%), dying in the first 48 hours of intubation. Conclusions: Patients with cirrhosis requiring MV have a dismal prognosis. Such patients and their families should be informed about the overall outcome to assist their decisions about life support and intensive care, outside the transplant setting. Prognostic scores, especially SOFA and MELD, may aid in determining which patients may benefit from aggressive therapy.

Context: Intermittent subglottic drainage (ISD) of secretions is recommended for prevention of ventilator-associated pneumonia (VAP) as it reduces microaspiration from the area around the cuff. Poor suction techniques can contribute to VAP, hence closed suction system (CSS) may have theoretical benefit in VAP prevention. Combination of these two techniques may provide added advantage. Aims: To study the influence of ISD with/without CSS on the incidence of VAP. Materials and Methods: Data from 311 patients requiring mechanical ventilation (MV) for more than 72 hours were collected retrospectively. They were divided into four groups as follows: group A, no intervention; group B, only CSS; group C, only ISD; and group D, ISD with CSS. These groups were compared with respect to incidence of VAP, duration of MV, length of ICU and hospital stay and ICU mortality. Results: Patients in the four groups were comparable with respect to age, sex ratio and admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores. Incidence of VAP per 1000 ventilator days in groups A, B, C, and D were 25, 23.9, 15.7 and 14.3, respectively ( P =0.04). There was no significant difference in the duration of MV ( P =0.33), length of ICU ( P =0.55) and hospital stay ( P =0.36) and ICU mortality ( P =0.9) among the four groups. Conclusions: ISD of secretions reduces the incidence of VAP. CSS alone or in combination with ISD has no significant effect on VAP incidence. Hence, ISD may be recommended for VAP prevention, but indications other than VAP prevention should determine the type of the suction system.

Results of the PROWESS trial suggested that heparin may reduce the efficacy of recombinant human activated protein C (rhAPC) and the XPRESS study also showed increased bleeding complications in patients receiving heparin with rhAPC. Although it has been shown that heparin prophylaxis may be used along with rhAPC, no study has shown the interaction between continuous heparin infusion and rhAPC. Here, we report a case of severe sepsis with pulmonary embolism who was concurrently administered heparin and rhAPC infusions, with positive results and no bleeding complications.

Severe dengue fever (SDF) is a potentially fatal disorder with bleeding being a common cause of mortality. Bleeding is generally secondary to thrombocytopenia, which is a common finding in patients with SDF. Intravenous anti-D is an approved therapeutic option in improving platelet counts in the management of idiopathic thrombocytopenic purpura (ITP). It has also been tried in patients with SDF for improving thrombocytopenia. Here we report a series of eight patients with SDF who showed remarkable improvement after administration of anti-D.

Purpose Noninvasive ventilation (NIV) is used as an initial ventilatory support in acute respiratory distress syndrome (ARDS), but its utility is unclear, and persistence in those who do not improve may delay intubation and lead to adverse outcomes. Hence, it becomes imperative to have a clear understanding of selecting patients who will benefit from this modality. Methods In this prospective observational study, we included all consecutive adults, over a 3-year period, who fulfilled criteria for ARDS by the Berlin definition. Basic demographics, ventilatory support, intensive care unit course, and outcome were recorded. Results Of 170 patients, 96 (56.47%) were initially managed with NIV. Noninvasive ventilation failure was seen in 42 (43.75%) of 96, and low baseline Pa o 2 /F io 2 , shock, and ARDS severity were associated with NIV failure. Overall intensive care unit mortality was 63 (37.1%) of 170, and high Acute Physiology and Chronic Health Evaluation II score, low Pa o 2 /F io 2 , shock, and ARDS severity were associated with increased mortality. Noninvasive ventilation failure and mortality were significantly higher in moderate and severe ARDS. Conclusions Noninvasive ventilation maybe useful in selected patients with mild ARDS but should be used with great caution in moderate and severe ARDS, as failure risk is high. In addition, low Pa o 2 /F io 2 and shock are associated with NIV failure. Acute Physiology and Chronic Health Evaluation II score, shock, low Pa o 2 /F io 2 , and ARDS severity are associated with increased mortality.

Inability to intubate and/or ventilate either due to distorted neck anatomy or restricted mouth opening is uncommon but potentially hazardous clinical scenario in head and neck cancer patients. Emergency cricothyroidotomy in such patients may provide a means of oxygenating the patient, but in practice has limitations and does not establish a definitive airway. We report 2 cases who had distorted face and neck anatomy in which percutaneous tracheostomy was done as an emergency life-saving procedure when other measures to obtain a definitive airway failed.

Owing to its wide and easy availability, digoxin has got a significant abuse potential and may be used for suicidal purposes. Digoxin-specific antibody (Fab) fragments have become the mainstay of therapy for severe digoxin toxicity and have significantly helped in reducing mortality. However, due to its high cost and limited availability alternative measures may need to be used to manage severe intoxications especially in countries like India, where Fab fragments are unavailable. Here, we present a case of a young female who presented to our casualty with alleged history of consumption of 17.5 mg of digoxin tablets. After admission to ICU, she developed atrioventricular blocks with hemodynamic instability which had to be managed with temporary pacemaker. Her serum digoxin levels were high (12.63 ng/ml) and in the absence of Fab fragments, resin hemoperfusion was done which drastically reduced the serum digoxin levels and reverted the symptoms.

Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units (ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a "turf" war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffing may be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.

The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units (ICUs). The elderly are predisposed to sepsis due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge.

Implementation of evidence-based guidelines to prevent and manage ventilator-associated pneumonia (VAP) in the clinical setting may not be adequate. We aimed to assess the implementation of selected VAP prevention strategies, and to learn how VAP is managed by the intensivists practicing in the Indian Subcontinent. Three hundred 10-point questionnaires were distributed during an International Critical Care Conferenceheld at New Delhi in 2009. A total of 126 (42%) questionnaires distributed among delegates from India, Nepal and Sri Lanka were analyzed. Majority (96.8%) reported using VAP bundles with a high proportion including head elevation (98.4%), chlorhexidine mouthcare (83.3%), stress ulcer prophylaxis (96.8%), heat and moisture exchangers (HME, 92.9%), early weaning (94.4%), and hand washing (97.6%) as part of their VAP bundle. Use of subglottic secretion drainage (SSD, 45.2%) and closed suction systems (CSS, 74.6%) was also reported by many intensivists, whereas use of selective gut decontamination was reported by only 22.2%. Commonest method for sampling was endotracheal suction by 68.3%. Gram negative organisms were reported to be the most commonly isolated. Majority (39.7%) reported using proton pump inhibitors for stress ulcer prophylaxis and 84.1% believed that VAP contributed to increased mortality. De-escalating therapy was considered in patients responding to treatment by 57.9% and 65.9% considered adding empirical methicillin resistant Staphylococcus aureus (MRSA)coverage, while 63.5% considered adding nebulized antibiotics in certain high-risk patients. There was good concordance regarding VAP prophylaxis among the intensivists with a majority adhering to evidence-based guidelines. We could identify certain issues like the choice of agent for stress ulcer prophylaxis, use of HME filters, SSD and CSS, where there still exists some practice variability and opportunities for improvement.

Disease-severity scoring systems have been developed for stratification of ICU patients. These systems have been tested and validated in various general medical and surgical ICU patients. However, the validity and efficacy of these systems, especially the newer generation, has not been assessed in patients with sepsis, which is the commonest indication for admission to a medical ICU. Hence, we conducted this study to assess the performance of various ICU scoring systems - Acute Physiology and Chronic Health Evaluation (APACHE) II, III, IV; Simplified Acute Physiology Score (SAPS) II, III; Mortality Prediction Model (MPM) II0, III0; and Sequential Organ Failure Assessment (SOFA) scores - in septic patients admitted to a medical ICU.

While cancer patients are known to be at higher risk for infection and subsequent complications, there is a scarcity of data regarding incidence and outcome of septic cancer patients admitted to ICUs. Hence, we aimed to assess the incidence of cancer patients admitted with sepsis to an onco-medical ICU and study their ICU course and outcome.

A 57-year-old diabetic and hypertensive man presented with a short history of fever, dry cough and right side chest pain. A chest radiograph showed right pleural based homogenous shadow in middle and lower zones with obliteration of right costo-phrenic angle suggestive of right side effusion. Aspiration of pleural fluid revealed frank pus for which inter-costal tube drainage was performed. Due to persistence of empyema, the patient was subjected to thoracoscopy. Thoracoscopy showed multiloculated empyema. Thoracoscopic pleural biopsy and fluid showed septate fungal hyphae. Thoracotomy and parietal pleurectomy, with resection of part of right lower lobe, was carried out. Pleural fluid, pleural and lung tissue culture grew Aspergillus fumigatus. The patient showed good recovery with voriconazole after thoracotomy.

Context: Use of steroids in septic shock is an issue of contention, more so with two major trials reporting conflicting results. Aims: To assess the current knowledge, attitudes and practices (KAP) related to the role of steroids in septic shock among intensivists practising in Hyderabad. Setting, Design, Materials and Methods: Questionnaires containing 10 questions pertaining to the role of steroids in septic shock, were distributed to 76 intensivists during the monthly critical care meeting. Results: A great majority of intensivists (82%) agreed that the role of steroids is restricted to septic shock not responding to vasopressors. There was no clear consensus regarding the role of corticotropin stimulation test or the timing of total cortisol level testing, if it has to be performed. Hydrocortisone was clearly the choice of steroid for most intensivists and intravenous bolus injection being the preferred route of administration. There was no agreement regarding the dose of steroids, the role of fludrocortisone and whether steroids should be tapered. Most of the respondents did not extend the steroid therapy beyond seven days and the most common side effect reported was hyperglycemia. Conclusion: There is a lot of ambiguity in the knowledge, attitudes or practices regarding role of steroids in septic shock among intensivists in Hyderabad. Uniform policies and protocols need to be devised at institutional level, with multispecialty inputs, and doctors need to be familiarized accordingly.

Purpose The aim of the study was to assess and compare the efficacy of various scoring systems in predicting the severity and outcome of patients with acute pancreatitis (AP) admitted in intensive care unit (ICU). Methods Prospective, single institution review of 55 consecutive AP patients admitted in ICU during a 2-year period. Disease severity scores and mortality predictions were calculated using the collected data in the first 48 hours of ICU admission for Ranson and Glasgow scores and in the first 24 hours for other scores. Results Forty-two patients (76.4%) developed severe pancreatitis. Intensive care unit and 30-day mortality was 18.2% and 27.3%, respectively. Use of mechanical ventilation (MV) was an independent predictor of outcome on multivariate analysis with lack of MV being protective (adjusted odds ratio, 0.003; 95% confidence interval [CI], 0.00001-0.67; P = .04). All scoring systems had comparable accuracy in predicting severity and 30-day mortality, but sequential organ failure assessment (SOFA) score had greater efficacy with its area under curve for predicting severity and 30-day mortality being 0.81 (95% CI, 0.69-0.92) and 0.93 (95% CI, 0.85-0.99), respectively. Sensitivity and specificity (SOFA score, >4) was 76.2% and 69.2%, respectively, for predicting severity, and sensitivity and specificity (SOFA score, >8) was 86.7% and 90%, respectively, for predicting 30-day mortality. Conclusions Use of MV is an independent predictor of outcome in AP patients admitted to ICU. Although all scoring systems had reliable accuracy in predicting severity and outcome, SOFA score performed better with additional advantages of easy applicability and timely assessment.

Purpose: The study aimed to describe the clinical outcome of patients with liver cirrhosis admitted to intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) in predicting mortality. Methods: In this prospective study of patients with cirrhosis admitted to the ICU, demographic data, APACHE II score, SOFA score, presence of acute renal failure (ARF), need for organ support, and mortality were collected. Results: The observed mortality in ICU and at 30 days among 104 patients was 42.3% (95% confidence interval [CI], 32.7%-52.0%) and 56.7% (95% CI, 47.0%-66.4%), respectively. Area under the receiver operating characteristic curve for first-day APACHE II in predicting 30-day mortality was 0.90 (95% CI, 0.83-0.96) and 0.93 (95% CI, 0.88-0.98) for SOFA score (P = .24). On multivariate analysis, ARF (adjusted odds ratio, 7.7; 95% CI, 1.09-54.64) and mechanical ventilation (adjusted odds ratio, 277.6; 95% CI, 12.83-6004.94) were significantly associated with mortality. Conclusions: Presence of ARF and need for mechanical ventilation are associated with high mortality in patients with liver cirrhosis admitted to the ICU. Acute Physiology and Chronic Health Evaluation II and SOFA are good prognostic models in predicting 30-day mortality and do not differ in performance.

Certain colloids like albumin and plasma protein fraction (PPF) have been derived from human plasma and they are used as plasma expanders to treat patients with shock. PPF, which more closely resembles plasma in its constituents, contains albumin plus α and β globulins. We conducted this study to assess the effect of PPF on need for vasopressors, organ support and ICU mortality in patients with septic shock.

Background and Aim: There is scarcity of data from the Indian subcontinent regarding the profile and outcome of patients presenting with acute poisoning admitted to intensive care units (ICU). We undertook this retrospective analysis to assess the course and outcome of such patients admitted in an ICU of a tertiary care private hospital. Methods: We analyzed data from 138 patients admitted to ICU with acute poisoning between July 2006 and March 2009. Data regarding type of poisoning, time of presentation, reason for ICU admission, ICU course and outcome were obtained. Results: Seventy (50.7%) patients were males and majority (47.8%) of admissions were from age group 21 to 30 years. The most common agents were benzodiazepines, 41/138 (29.7%), followed by alcohol, 34/138 (24.63%) and opioids, 10/138 (7.2%). Thirty-two (23%) consumed two or more agents. Commonest mode of toxicity was suicidal (78.3%) and the route of exposure was mainly oral (97.8%). The highest incidence of toxicity was due to drugs (46.3%) followed by household agents (13%). Organ failure was present in 67 patients (48.5%). During their ICU course, dialysis was required in four, inotropic support in 14 and ventilator support in 13 patients. ICU mortality was 3/138 (2.8%). All deaths were due to aluminium phosphide poisoning. Conclusions: The present data give an insight into epidemiology of poisoning and represents a trend in urban India. The spectrum differs as we cater to urban middle and upper class. There is an increasing variety and complexity of toxins, with substance abuse attributing to significant number of cases.

Context: Blood culture is routinely taken at the time of admission to the intensive care unit (ICU) for patients suspected to have infection. We undertook this study to determine the incidence of bacteremia at the time of ICU admission and to assess its impact on the outcome. Methods: Retrospective cohort study from all the admissions in ICU, in whom blood cultures sent at the time of admission were analyzed. Data regarding patient demographics, probable source of infection, previous antibiotic use and ICU course was recorded. Severity of illness on admission was assessed by acute physiology and chronic health evaluation II score. Statistical Analysis: Qualitative data were analyzed using Chi-square or Fisher Exact test and quantitative data were analyzed using Student's t -test. Primary outcome measure was ICU mortality. Results: Of 567 patients, 42% patients were on antibiotics. Sixty-four percent of the patients were direct ICU admission from casualty, 10.76% were from wards and 6.17% from other ICUs, and 19.05% were transfers from other hospitals. Blood cultures were positive in 10.6% patients. Mortality was significantly higher in patients with positive blood cultures (45% vs. 13.6%; P =0.000). On univariate analysis, only previous antibiotic use was statistically associated with higher mortality ( P =0.011). Bacteremic patients who were already on antibiotics had a significantly higher mortality (OR 12.9, 95% CI: 1.6-100). Conclusions: Blood cultures may be positive in only minority of the patients with suspected infection admitted to ICU. Nevertheless, the prognosis of those patients with positive blood culture is worse, especially if culture is positive in spite of the patient being on antibiotics.

Blood culture is routinely taken at the time of admission to the ICU for all patients suspected to have any infection, even though it may be positive only in a few patients. Moreover, the impact of a positive blood culture in such a patient population is not clear.