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Levonadifloxacin (intravenous) and its oral prodrug alalevonadifloxacin are broad-spectrum antibacterial agents developed for the treatment of difficult-to-treat infections caused by multidrug-resistant Gram-positive bacteria, especially methicillin-resistant Staphylococcus aureus, atypical bacteria, anaerobic bacteria, and biodefence pathogens as well as Gram-negative bacteria. Levonadifloxacin has a well-defined mechanism of action involving a strong affinity for DNA gyrase as well as topoisomerase IV. Alalevonadifloxacin with widely differing solubility and oral bioavailability has pharmacokinetic profile identical to levonadifloxacin. Unlike existing MRSA drugs such as vancomycin and linezolid, which cause unfavorable side effects like nephrotoxicity, bone-marrow toxicity, and muscle toxicity, levonadifloxacin/alalevonadifloxacin has demonstrated superior safety and tolerability features with no serious adverse events. Levonadifloxacin/alalevonadifloxacin could be a useful weapon in the battle against infections caused by resistant microorganisms and could be a preferred antibiotic of choice for empirical therapy in the future. [ABSTRACT FROM AUTHOR]

Levonadifloxacin (intravenous) and its oral prodrug alalevonadifloxacin are broad-spectrum antibacterial agents developed for the treatment of difficult-to-treat infections caused by multidrug-resistant Gram-positive bacteria, especially methicillin-resistant Staphylococcus aureus, atypical bacteria, anaerobic bacteria, and biodefence pathogens as well as Gram-negative bacteria. Levonadifloxacin has a well-defined mechanism of action involving a strong affinity for DNA gyrase as well as topoisomerase IV. Alalevonadifloxacin with widely differing solubility and oral bioavailability has pharmacokinetic profile identical to levonadifloxacin. Unlike existing MRSA drugs such as vancomycin and linezolid, which cause unfavorable side effects like nephrotoxicity, bone-marrow toxicity, and muscle toxicity, levonadifloxacin/alalevonadifloxacin has demonstrated superior safety and tolerability features with no serious adverse events. Levonadifloxacin/alalevonadifloxacin could be a useful weapon in the battle against infections caused by resistant microorganisms and could be a preferred antibiotic of choice for empirical therapy in the future. [ABSTRACT FROM AUTHOR]

Sepsis is a life-threatening condition that causes a global health burden associated with high mortality and morbidity. Often life-threatening, sepsis can be caused by bacteria, viruses, parasites or fungi. Sepsis management primarily focuses on source control and early broad-spectrum antibiotics, plus organ function support. Comprehensive changes in the way we manage sepsis patients include early identification, infective focus identification and immediate treatment with antimicrobial therapy, appropriate supportive care and hemodynamic optimization. Despite all efforts of clinical and experimental research over thirty years, the capacity to positively influence the outcome of the disease remains limited. This can be due to limited studies available on sepsis in developing countries, especially in Southeast Asia. This review summarizes the progress made in the diagnosis and time associated with sepsis, colistin resistance and chloramphenicol boon, antibiotic abuse, resource constraints and association of sepsis with COVID-19 in Southeast Asia. A personalized approach and innovative therapeutic alternatives such as CytoSorb® are highlighted as potential options for the treatment of patients with sepsis in Southeast Asia. [ABSTRACT FROM AUTHOR]

Background: Levonadifloxacin is a novel broad-spectrum antibiotic belonging to the benzoquinolizine subclass of quinolones. It is available in intravenous as well as oral formulation for the treatment of infections caused by common Gram-positive bacterial pathogens including methicillin-resistant Staphylococcus aureus (MRSA). Patients and Methods: This study retrospectively assessed the real-world safety and efficacy of levonadifloxacin (oral and/or IV) in the treatment of 1229 patients across various clinical conditions. Study outcomes were clinical and microbiological success at the end of therapy. Results: The mean duration of levonadifloxacin therapy was 7.2 days, with a time to clinical improvement averaging at 4 days. Three hundred and three patients received oral therapy, 875 received IV, and 51 received a combination of IV followed by oral therapy. Patients were prescribed levonadifloxacin for skin and soft-tissue infections, diabetic foot infections, septicemia, catheter-related bloodstream infections, bone and joint infections, febrile neutropenia, and respiratory infections including COVID-19 pneumonia. High clinical success rates of 98.3%, 93.7%, and 96.1% with oral, IV, and IV followed by oral levonadifloxacin, respectively, were obtained. Only 11 mild adverse events were reported in 9 patients which included constipation, diarrhea, hyperglycemia, nausea, fatigue, and vomiting. Overall, 96.3% and 97.3% of investigators rated the efficacy and safety of levonadifloxacin as "good to excellent." Conclusions: An excellent safety and efficacy profile of levonadifloxacin was observed in this study making it a suitable treatment option for management of various bacterial infections, including those caused by resistant Gram-positive pathogens such as MRSA and quinolone-resistant S. aureus. [ABSTRACT FROM AUTHOR]

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: Acute respiratory distress syndrome is an important clinical presentation of respiratory complications caused by severe acute respiratory syndrome coronavirus 2, a novel coronavirus responsible for the ongoing pandemic. The disease is poorly understood, and immunopathogenesis is constantly evolving. Cytokine release syndrome remains central to pathology of coronavirus disease 2019. Antivirals, anticytokine treatment, and other pharmacological approaches have failed to treat it. CytoSorb, an extracorporeal cytokine adsorber that reduces the cytokine storm and other inflammatory mediators in the blood, seems promising in treating severely ill patients with coronavirus disease 2019.Case Presentation: This article presents three cases of Asian ethnicity of severely ill adult patients with coronavirus disease 2019 admitted to intensive care unit who were treated with CytoSorb therapy. All patients used single CytoSorb device. During their clinical course, all patients were prescribed tocilizumab (an interleukin-6 receptor blocker), antivirals, hydroxychloroquine, azithromycin, and other antibiotics and general antipyretic drugs. No vasopressor treatment was required. The patients' average duration of stay in intensive care unit was 30 days; the average duration of stay in hospital was 31 days. All three patients showed significant improvement in biochemical parameters and clinical outcomes post CytoSorb therapy. C-reactive protein levels decreased by 91.5%, 97.4%, and 55.75 %, and mean arterial pressure improved by 18%, 23%, and 17 % in patient 1, 2, and 3, respectively, on day 7 post-therapy.Conclusions: All three patients improved clinically and survived. [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 management of coronavirus disease-2019 (COVID-19) is witnessing a change as we learn more about the pathophysiology and the severity of the disease. Several randomized controlled trials (RCTs) and meta-analysis have been published over the last few months. Several interventions and therapies which showed promise in the initial days of the pandemic have subsequently failed to show benefit in well-designed trials. Understanding of the methods of oxygen delivery and ventilation have also evolved over the past few months. The Indian Society of Critical Care Medicine (ISCCM) has reviewed the evidence that has emerged since the publication of its position statement in May and has put together an addendum of updated evidence. [ABSTRACT FROM AUTHOR]

Aim/objective/introduction: Cytokine storm or cytokine release syndrome (CRS) is inevitable in severe and critically ill patients with novel coronavirus disease-2019 (COVID-19). This review aimed to discuss current therapeutic options for the management of CRS in COVID-19. Background: Cytokine storm is caused by the colossal release of proinflammatory cytokines [e.g., IL (interleukin)-2, IL-6, IL-8 TNF (tumor necrosis factor)-α, etc.] causing dysregulated, hyperimmune response. This immunopathogenesis leads to acute lung injury and acute respiratory distress syndrome (ARDS). Targeting cytokine storm with the therapies that are already available in India with the support of published guidelines and consensus can assist in achieving a better outcome in COVID-19. Review results: We predominantly included published guidelines or consensus recommendations about the management of cytokine storm in COVID-19. From the existing literature evidence, it is observed that among the currently available agents, low-dose corticosteroids and heparin can be beneficial in managing cytokine storm. The use of serine protease inhibitors such as ulinastatin has been advised by some experts. Though therapies such as high-dose vitamin C and interleukin-6 inhibitors (e.g., tocilizumab) have been advised, the evidence regarding their use for cytokine storm in COVID-19 is limited. Therapies such as Janus kinase inhibitors (JAK) inhibitors and Neurokinin-1 receptor (NK-1) antagonists are still in research. Besides, pharmaceutical treatments, use of blood purification strategies, and convalescent plasma may be life-saving options in some of the critically ill COVID-19 patients. For these therapies, there is a need to generate further evidence to substantiate their use in CRS management. Conclusion: Current management of COVID-19 is preventive and supportive. Different therapies can be used to prevent and treat the cytokine storm. More research is needed for further supporting the use of these treatments in COVID-19. [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 differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field. Materials and methods: Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences. 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 prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered. Conclusion: This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical 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 for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol. [ABSTRACT FROM AUTHOR]

All patients who proceed for surgery must be considered as COVID-19 cases till a test result becomes available. Initially called pneumonia of unknown cause, coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) now has a global foot-print. [Extracted from the article]

Heart failure (HF) is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. American College of Cardiology Foundation / American Heart Association 2013 guidelines have classified HF into two categories: (i) HF with reduced (≤40%) ejection fraction (HFrEF) or systolic HF, and (ii) HF with preserved (≥50%) ejection fraction (HFpEF) or diastolic HF. Risk factors for HFpEF include age more than 70 years, female gender, hypertension, wide pulse pressure, diabetes mellitus, chronic renal insufficiency, left ventricular hypertrophy, atrial fibrillation, smoking, recent weight gain, and exercise intolerance. Cardiac catheterization and echocardiography are used for the confirmation of diagnosis of HFpEF. Intraoperatively, the hemodynamic goals in patients with HFpEF are avoidance of tachycardia, maintenance of sinus rhythm, and maintenance of higher than usual filling pressure. No specific treatment for HFpEF is established, and therapeutic options include an intravenous diuretic, a beta blocker or calcium channel blocker, a venodilator, and management of co-morbidities. [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]

Objective: Management of emergency care Background: Patients with COVID-19 undergoing emergency or complex surgical procedures are at increased risk of developing perioperative complications. CytoSorb is a blood purification therapy used to remove circulating cytokines in conditions of hyperinflammation. This report is of a patient with COVID-19 requiring redo replacement of the aortic valve and aorta due to aortic aneurysm of the ascending aorta (Bentall procedure) associated with Marfan syndrome. The patient was successfully treated with extracorporeal cytokine hemoadsorption. Case Report: A 34-year-old man with Marfan syndrome, who had undergone a Bentall procedure in 2018, was admitted with symptoms of worsening dyspnea, tachycardia, fever, and confirmed COVID-19. Further diagnostic workup revealed dehiscence of the aortic root as well as moderate aortic regurgitation, in the context of a hyperinflammatory state. Anti-infective treatment was initiated. Given the severity of symptoms, COVID-19, echocardiography findings, and risk of aortic rupture, urgent Bentall surgery was performed. Additionally, a CytoSorb hemoadsorber was integrated into the cardiopulmonary bypass circuit to attenuate the anticipated systemic hyperinflammation. Intraoperatively, several blood products were administered due to excessive bleeding from the friable tissues and the pre-existing anemia and thrombocytopenia. Treatment was associated with marked improvements in vital parameters and inflammatory markers, and weaning from the ventilator and inotropes was possible after 48 hours. The remaining time in hospital was uneventful. Conclusions: This report supports the findings from recent studies and reports that extracorporeal cytokine hemoadsorption has a role to play in reducing the systemic effects of cytokine storm associated with complex surgery involving cardiopulmonary bypass alongside severe infections, including COVID-19. [ABSTRACT FROM AUTHOR]

Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. Unstable alpha thalassemia hemoglobin chains may precipitate after prolonged exposure to relatively low temperatures which can be prevented by a short duration of bypass under normothermia or mild hypothermia (32-35 degrees).[[6]] Thalassemic patients need to be worked up thoroughly. To the editor, A 67-year female, known case of beta thalassemia intermedia and rheumatoid arthritis (RA) (since 50 years) was diagnosed to have severe calcific aortic stenosis, valve area of 0.7 cm2, gradient 90/60 mm Hg, hypertrophic normal left ventricle without regional wall abnormality. [Extracted from the article]

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]

Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically sick patients. It can be safely performed bedside by intensivists.This has resulted in decline in the use of surgical tracheostomy in intensive care unit (ICU) except in few selected cases. Most common indication of tracheostomy in ICU is need for prolonged ventilation. About 10% of patients requiring at least 3 days of mechanical ventilator support get tracheostomised during ICU stay. The ideal timing of PDT remains undecided at present. Contraindications and complications become fewer with increase in experience. Various methods of performing PDT have been discovered in last two decades. Preoperative work up, patient selection and post tracheostomy care form key components of a successful PDT. Bronchoscopy and ultrasound have been found to be useful procedural adjuncts, especially in presence of unfavorable anatomy. This article gives a brief overview about the use of PDT in ICU. [ABSTRACT FROM AUTHOR]

Free-floating right heart thrombi are uncommon and need emergency treatment in view of their tendency to dislodge and cause pulmonary embolism. We report a successful surgical management of a patient who had large mobile right atrial thrombus, bilateral pulmonary thrombi, coronary artery disease, and postmyocardial infarction ventricular septal rupture (VSR). The patient underwent coronary angiography, inferior vena cava filter placement, removal of thrombi from the right atrium and pulmonary arteries, repair of VSR, and coronary artery bypass graft surgery in a hybrid operating room. [ABSTRACT FROM AUTHOR]

An editorial is presented in which the editor discusses the recent trends in hemodynamic monitoring with respect to cardiac surgery. The concept of hemodynamic monitoring is explained. The article also discusses the need for an effective monitoring tool for hemodynamic instability during cardiac surgeries. Common modalities for measurement such as the pulmonary artery catheter (PAC) and the noninvasive pulse contour analysis devices, aimed towards preventing tissue hypoxia, are mentioned

Background and Aims: Long distance air travel for medical needs is on the increase worldwide. The condition of some patients necessitates specially modified aircraft, and monitoring and interventions during transport by trained medical personnel. This article presents our experience in domestic and international interhospital air medical transportation from January 2010 to January 2014. Material and Methods: Hospital records of all air medical transportation undertaken to the institute during the period were analyzed for demographics, primary etiology, and events during transport. Results: 586 patients, 453 (77.3%) males and 133 (22.6%) females of ages 46.7 ± 12.6 years and 53.4 ± 9.7 years were transported by us to the institute. It took 3030 flying hours with an average of 474 ± 72 min for each mission. The most common indication for transport was cardiovascular diseases in 210 (35.8%) and central nervous system disease in 120 (20.4%) cases. The overall complication rate was 5.3% There was no transport related mortality. Conclusion: Cardiac and central nervous system ailments are the most common indication for air medical transportation. These patients may need attention and interventions as any critical patient in the hospital but in a difficult environment lacking space and help. Air medical transport carries no more risk than ground transportation. [ABSTRACT FROM AUTHOR]

Objective: Acute kidney injury (AKI) is a commonly encountered postoperative complication after cardiac surgery especially in high risk patients. AKI though seen more commonly after conventional on pump coronary artery bypass surgery (CCABG), is not uncommon after off pump coronary bypass surgery (OPCAB). Various biomarkers have shown promise over last one decade as an early marker for predicting AKI postoperatively. NGAL is one such biomarker whose concentration is increased in urine after any nephrotoxic and ischemic insult. The objective of this study was to assess the role of urine NGAL in predicting AKI after OPCAB in patients with increased risk of developing AKI. Design: A prospective cohort study. Setting: A clinical study in a multi specialty hospital. Participants: Eighty patients. Materials and Methods: study was approved by the hospital research ethics committee. 80 patients posted for OPCAB with an increased risk of developing AKI defined as having a Cleveland Clinic Foundation Acute renal failure scoring System score of ≥6 were included in the study. Patients with coronary angiography (CAG) within 48 hrs prior to surgery, pre-existing AKI, preoperative renal replacement therapy (RRT) and CKD stage 5 were excluded. Urine NGAL level before the start of surgery baseline and at 4 hrs post surgery were done. Renal function tests were assessed on the day of surgery (4 hrs post surgery) and on the next three days. Result: Seven patients developed AKI as defined by acute kidney infection network (AKIN) and risk injury failure loss end stage (RIFLE) criteria for AKI. NGAL value at 4 hrs in patients who developed AKI was significantly higher than in those patients who did not develop AKI (P < 0.05). Conclusion: urine NGAL is an early biomarker of acute kidney injury in patients undergoing OPCAB surgeries. However, large multicentre studies may be needed to confirm it. [ABSTRACT FROM AUTHOR]

Mechanical ventilation remains the cornerstone in the management of severe acute respiratory failure. Acute respiratory distress syndrome (ARDS) is the most common cause of respiratory failure. It is associated with substantial mortality, and unmanageable refractory hypoxemia remains the most feared clinical possibility. If hypoxemia persists despite application of lung protective ventilation, additional therapies including inhaled vasodilators, prone positioning, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade (NMB), and extracorporeal membrane oxygenation may be needed. NMB and prone ventilation are modalities that have been clearly linked to reduced mortality in ARDS. Rescue therapies pose a clinical challenge requiring a precarious balance of risks and benefits, as well as, in-depth knowledge of therapeutic limitations. [ABSTRACT FROM AUTHOR]

Intraoperative aortic dissection is a rare but fatal complication of open heart surgery. By recognizing the population at risk and by using a gentle operative technique in such patients, the surgeon can usually avoid iatrogenic injury to the aorta. Intraoperative transesophageal echocardiography and epiaortic scanning are invaluable for prompt diagnosis and determination of the extent of the injury. Prevention lies in the strict control of blood pressure during cannulation/decannulation, construction of proximal anastomosis, or in avoiding manipulation of the aorta in high-risk patients. Immediate repair using interposition graft or Dacron patch graft is warranted to reduce the high mortality associated with this complication. [ABSTRACT FROM AUTHOR]

Objective: Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha(TNF ά), interleukin-6 and leucocyte count. Design: A prospective randomised non blind study. Setting: A clinical study in a multi specialty hospital. Participants: Eighty six patients. Material and Methods/intervention: The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: - 6, TNF ά, cortisol, Troponin - I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis. Primary Outcomes: Postoperative complications, total intensive care unit stay and hospital stay. Secondary Outcome: Stress response. Result: Study group showed decreased Interlukin - 6 at day 2, TNF ά at day 2 and 5,troponin I at day 5, and decreased total hospital stay (p < 0.05). Conclusion: Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it. [ABSTRACT FROM AUTHOR]

The article discusses the role of cardiac anesthesiologists in intensive care medicine. Topics discussed include the areas covered by critical care medicine, cardiac anaesthesiology as a sub-speciality of anesthesiology focusing on patients undergoing cardiothoracic surgery and related procedures and characteristics of cardiac surgery patients that make the delivery of high quality critical care medicine important for the success of cardiac surgery.

The article examines the role of simulation in hemodynamic monitoring in cardiac surgery. Noted are the benefits of medical simulation including the practice virtual hemodynamic stabilization of a patient in surgical and intensive care unit, the options it can provide among the three shock case scenarios cardiogenic shock, hypovolemic shock, and septic shock. Other topics mentioned include chest drain, fluid balance sheet, and poor urine output.

These guidelines, written for clinicians, contains evidence-based recommendations for the prevention of hospital acquired infections Hospital acquired infections are a major cause of mortality and morbidity and provide challenge to clinicians. Measures of infection control include identifying patients at risk of nosocomial infections, observing hand hygiene, following standard precautions to reduce transmission and strategies to reduce VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be emphasized upon. Infection prevention in special subsets of patients - burns patients, include identifying sources of organism, identification of organisms, isolation if required, antibiotic prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus, early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher risk of opportunistic infections. The post tranplant timetable is divided into three time periods for determining risk of infections. Room ventilation, cleaning and decontamination, protective clothing with care regarding food requires special consideration. Monitoring and Surveillance are prioritized depending upon the needs. Designated infection control teams should supervise the process and help in collection and compilation of data. Antibiotic Stewardship Recommendations include constituting a team, close coordination between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of information technology among other measure. The recommendations in these guidelines are intended to support, and not replace, good clinical judgment. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments. [ABSTRACT FROM AUTHOR]

Background: Delirium is a commonly seen complication of cardiac surgery. Dexmedetomidine, by its anti-inflammatory properties and other effects, can attenuate postoperative delirium.Aims: The aim of this work was to study the incidence of delirium after coronary artery bypass graft surgery, and to compare the effects of dexmedetomidine and propofol on the incidence of postoperative delirium in coronary artery bypass graft surgery patients.Materials and Methods: A prospective, observational study was conducted on 180 consecutive patients undergoing off-pump or on-pump coronary artery bypass graft surgery. The patients were administered either intravenous dexmedetomidine (n = 90) or propofol (n = 90) after hemostasis was achieved, till they were ready for weaning from the ventilator. The Confusion Assessment Method was used to assess the incidence of postoperative delirium.Measurements and Main Results: A total of 25 (13.8%) patients developed delirium after coronary artery bypass graft surgery. Sedation with dexmedetomidine was associated with a significantly reduced incidence of postoperative delirium (8.9% v 18.9% propofol, P = 0.049). Subgroup analyses showed reduced incidence of postoperative delirium in off-pump patients compared to on-pump coronary artery bypass graft patients (3.3% vs. 20%, P = 0.009 dexmedetomidine group and 11.6% vs. 33.3%, P = 0.047 propofol group respectively). The mean age of the patients who had delirium was significantly more (64.9 ± 8.1 years vs. 52.5 ± 5.8 years, P = 0.046) compared to those who did not have delirium.Conclusion: Administration of dexmedetomidine-based sedation resulted in the reduced incidence of postoperative delirium compared to propofol-based sedation in patients after coronary artery bypass graft surgery. [ABSTRACT FROM AUTHOR]

Both short and long term cognitive changes occur after cardiac surgery but the pathophysiology of these neurobehavioral changes remain incompletely understood. The cause of cognitive decline is most likely multifactorial and probably represents a complex interaction between cerebral microemboli, global cerebral hypoperfusion, inflammation, and genetic susceptibility. The problem of cognitive decline after cardiac surgery continues to increase as the surgical population becomes older and has more prevalent comorbid diseases. A better understanding of the etiology is essential to finding new preventive strategies as no definitive therapy exists for cognitive dysfunction. [ABSTRACT FROM AUTHOR]

The authors look at the challenges associated with the establishment of a new cardiac surgical unit. One of the issues to be addressed in designing the facility is determining the size of the facility. Among the processes and protocols to be considered are staffing norms and training. They recommend including recording of the outcomes and putting a trend analysis to ensure continuous quality improvement in the whole process.

The benefits of thoracic epidural analgesia in patients undergoing coronary artery bypass grafting are well documented. However, the literature available on the role of high thoracic epidural analgesia (HTEA) in patients with chronic obstructive pulmonary disease undergoing off-pump coronary artery bypass graft (OPCAB) surgery is scarce. We conducted a randomized clinical trial to establish whether HTEA is beneficial in patients with chronic obstructive pulmonary disease undergoing elective OPCAB surgery. After institutional ethics board approval and informed consent, 62 chronic obstructive pulmonary disease patients undergoing elective OPCAB were randomly grouped into two (n = 31 each). Both groups received general anesthesia (GA), but in the HTEA group patients, TEA was also administered. Standardized surgical and anesthetic techniques were used for both the groups. Pulmonary function tests were performed pre-operatively, 6 h and 24 h post-extubation and on days 2, 3, 4 and 5 along with arterial blood gas analysis (ABG) analysis. Time for extubation (h) and time for oxygen withdrawal (h) were recorded. Pain score was assessed by the 10-cm visual analogue scale. All hemodynamic/oxygenation parameters were noted. Any complications related to the TEA were also recorded. Patients in the HTEA group were extubated earlier (10.8 h vs. 13.5 h, P < 0.01) and their oxygen withdrawal time was also significantly lower (26.26 h vs. 29.87 h, P < 0.01). The VAS score, both at rest and on coughing, was significantly lower in the HTEA group at all times, post-operatively (P < 0.01). The forced vital capacity improved significantly at 6 h post-operatively in the HTEA group (P = 0.026) and remained significantly higher thereafter. A similar trend was observed in forced expiratory volume in the first second on day 2 in the HTEA group (P = 0.024). We did not observe any significant side-effects/mortality in either group. In chronic obstructive pulmonary disease patients undergoing elective OPCAB surgery, HTEA is a good adjunct to GA for early extubation, faster recovery of pulmonary function and better analgesia. [ABSTRACT FROM AUTHOR]

Perioperative Thoracic epidural analgesia (TEA) is an important part of a multimodal approach to improve analgesia and patient outcome after cardiac and thoracic surgery. This is particularly important for obese patients undergoing off pump coronary artery bypass surgery (OPCAB). We conducted a randomized clinical trial at tertiary care cardiac institute to compare the effect of TEA and conventional opioid based analgesia on perioperative lung functions and pain scores in obese patients undergoing OPCAB. Sixty obese patients with body mass index >30 kg/m² for elective OPCAB were randomized into two groups (n=30 each). Patients in both the groups received general anesthesia but in group 1, TEA was also administered. We performed spirometry as preoperative assessment and at six hours, 24 hours, second, third, fourth and fifth day after extubation, along with arterial blood gases analysis. Visual analogue scale at rest and on coughing was recorded to assess the degree of analgesia. The other parameters observed were: time to endotracheal extubation, oxygen withdrawal time and intensive care unit length of stay. On statistical analysis there was a significant difference in Vital Capacity at six hours, 24 hours, second and third day postextubation. Forced vital capacity and forced expiratory volume in one second followed the same pattern for first four postoperative days and peak expiratory flow rate remained statistically high till second postoperative day. ABG values and PaO2 /FiO2 ratio were statistically higher in the study group up to five days. Visual analogue scale at rest and on coughing was significantly lower till fourth and third postoperative day respectively. Tracheal extubation time, oxygen withdrawal time and ICU stay were significantly less in group 1. The use of TEA resulted in better analgesia, early tracheal extubation and shorter ICU stay and should be considered for obese patients undergoing OPCAB. [ABSTRACT FROM AUTHOR]

Antiphospholipid antibody syndrome (APLAS) characterises a clinical condition of arterial and venous thrombosis associated with phospholipids directed antibodies. APLAS occurs in 2% of the general population. However, one study demonstrated that 7.1% of hospitalised patients were tested positive for at least one of the three anticardiolipin antibody idiotype. Antiphospholipid antibodies often inhibit phospholipids dependent coagulation in vitro and interfere with laboratory testing of hemostasis. Therefore, the management of anticoagulation during cardiopulmonary bypass can be quite challenging in these patients. Here, we present a case of right atrial mass removal and pulmonary thrombectomy in a patient of APLAS. [ABSTRACT FROM AUTHOR]

Trans-esophageal echocardiography (TEE) is routinely used in valvular surgery in most institutions. The popularity of TEE stems from the fact that it can supplement or confirm information gained from other methods of evaluation or make completely independent diagnoses. Quantitative and qualitative assessment permits informed decisions regarding surgical intervention, type of intervention, correction of inadequate surgical repair and re-operation for complications. This review summarizes the various methods for quantification of aortic regurgitation and stenosis on TEE. The application of Doppler echo (pulsed wave, continuous wave and color) with two-dimensional echo allows the complete evaluation of AV lesions. [ABSTRACT FROM AUTHOR]

Minimally invasive surgery with robotic assistance should elicit minimal pain. Regional analgesic techniques have shown excellent analgesia after thoracotomy. Thus the aim of this study was to compare thoracic epidural analgesia (TEA) technique with paravertebral block (PVB) technique in these patients with regard to quality of analgesia, complications, and haemodynamic and respiratory parameters. This was a prospective randomised study involving 36 patients undergoing elective robotic-assisted coronary artery bypass grafting (CABG). TEA or PVB were administered in these patients. The results revealed no significant differences with regard to demographics, haemodynamics, and arterial blood gases. Pulmonary functions were better maintained in PVB group postoperatively; however, this was statistically insignificant. The quality of analgesia was also comparable in both the groups. We conclude that PVB is a safe and effective technique for postoperative analgesia after robotic-assisted CABG and is comparable to TEA with regard to quality of analgesia. [ABSTRACT FROM AUTHOR]

Background: Diaphragm is the most important part of the respiratory system. Diaphragmatic palsy following cardiac surgery is not uncommon and can cause deterioration of pulmonary functions and attendant pulmonary complications. Objectives: Aim of this study was to observe the incidence of diaphragmatic palsy after off pump coronary artery bypass grafting (OPCAB) as compared to conventional CABG and to assess the efficacy of chest physiotherapy on diaphragmatic palsy in post cardiac surgical patients. Design and Setting: An observational prospective interventional study done at a tertiary care cardiac centre. Patients: 2280 consecutive adult patients who underwent cardiac surgery from February 2005 to august 2005. Results: 30 patients out of 2280 (1.31%) developed diaphragmatic palsy. Patients were divided based on the presence or absence of symptoms viz. breathlessness at rest or exertion or with the change of posture along with hypoxemia and / or hypercapnia. Group I included 14 patients who were symptomatic (CABG n=13, post valve surgery n=1), While Group II included 16 asymptomatic patients (CABG n=12, post valve surgery n=4), 9 patients (64%) from Group I (n=14) and 4 patients (25%) from group II showed complete recovery from diaphragmatic palsy as demonstrated ultrasonographically. Conclusion: The incidence of diaphragmatic palsy was remarkably less in our adult cardiac surgical patients because most of the cardiac surgeries were performed off pump and intensive chest physiotherapy beginning shortly after extubation helped in complete or near complete recovery of diaphragmatic palsy. Chest Physiotherapy led to marked improvement in functional outcome following post cardiac surgery diaphragmatic palsy. We also conclude that ultrasonography is a simple valuable bed-side tool for rapid diagnosis of diaphragmatic palsy. [ABSTRACT FROM AUTHOR]

The objective of this study was to compare the risk factors and outcome of patients with preexisting resistant gram-negative bacilli (GNB) with those who develop sensitive GNB in the cardiac intensive care unit (ICU). Of the 3161 patients (n = 3,161) admitted to the ICU during the study period, 130 (4.11%) developed health care-associated infections (HAIs) with GNB and were included in the cohort study. Pseudomonas aeruginosa (37.8%) was the most common organism isolated followed by Klebsiella species (24.2%), E. coli (22.0%), Enterobacter species (6.1%), Stenotrophomonas maltophilia (5.7%), Acinetobacter species (1.3%), Serratia marcescens (0.8%), Weeksella virosa (0.4%) and Burkholderia cepacia (0.4%). Univariate analysis revealed that the following variables were significantly associated with the antibiotic-resistant GNB: females (P = 0.018), re-exploration (P = 0.004), valve surgery (P = 0.003), duration of central venous catheter (P < 0.001), duration of mechanical ventilation (P < 0.001), duration of intra-aortic balloon counter-pulsation (P = 0.018), duration of urinary catheter (P < 0.001), total number of antibiotic exposures prior to the development of resistance (P < 0.001), duration of antibiotic use prior to the development of resistance (P = 0.014), acute physiology and age chronic health evaluation score (APACHE II), receipt of anti-pseudomonal penicillins (piperacillin-tazobactam) (P = 0.002) and carbapenems (P < 0.001). On multivariate analysis, valve surgery (adjusted OR = 2.033; 95% CI = 1.052-3.928; P = 0.035), duration of mechanical ventilation (adjusted OR = 1.265; 95% CI = 1.055-1.517; P = 0.011) and total number of antibiotic exposure prior to the development of resistance (adjusted OR = 1.381; 95% CI = 1.030-1.853; P = 0.031) were identified as independent risk factors for HAIs in resistant GNB. The mortality rate in patients with resistant GNB was significantly higher than those with sensitive GNB (13.9% vs. 1.8%; P = 0.03). HAI with resistant GNB, in ICU following cardiac surgery, are independently associated with the following variables: valve surgeries, duration of mechanical ventilation and prior exposure to antibiotics. The mortality rate is significantly higher among patients with resistant GNB. [ABSTRACT FROM AUTHOR]

Abstract: Background: Elevated troponin I in the absence of angiographically visible coronary lesions is seen in up to 10–15% of those undergoing angiography for suspected coronary artery disease. This study aims to elucidate the etiology of elevated cardiac troponin I in patients with normal coronary arteries on angiography. Methods: We identified 1551 (8.6%) patients with normal coronary arteries from our catheterization database of 17,950 patients from Jan 2000 to Jun 2004. Elevated troponin I levels were found in 217 (14%) of 1551 patients with normal coronary arteries. Of these 217 patients, 73 surgical patients were excluded, and the remaining 144 patients formed the study population. The study population was compared with age and gender matched patients with myocardial infarction and coronary artery disease (Group II). Results: The patients with elevated cardiac troponin I (cTnI) with normal coronary arteries had significantly lower prevalence of atherosclerotic risk factors and significantly higher left ventricular ejection fractions. The cTnI in patients with normal coronary arteries was elevated due to a number of causes including tachycardia, myocarditis, pericarditis, severe aortic stenosis, gastrointestinal bleeding, sepsis, left ventricular hypertrophy, severe congestive heart failure, cerebrovascular accident, electrical trauma, myocardial contusion, hypertensive emergency, myocardial bridging, pulmonary embolism, diabetic ketoacidosis, chronic obstructive pulmonary disease exacerbation and coronary spasm. Conclusions: Cardiac troponin I could be elevated in a number of conditions, apart from acute myocardial infarction, and could reflect myonecrosis. Acute myocardial infarction is a clinical diagnosis as the laboratory is an aide to, not a replacement for, informed decision making. [Copyright &y& Elsevier]

Background: An ideal CO monitor should be noninvasive, cost effective, reproducible, reliable during various physiological states. Limited literature is available regarding the noninvasive CO monitoring in open chest surgeries.Aim: The aim of this study was to compare the CO measurement by Regional Impedance Cardiography (RIC) and Thermodilution (TD) method in patients undergoing off pump coronary artery bypass graft surgery (OPCAB).Settings and Design: We conducted a prospective observational comparative study of CO measurement by the noninvasive RIC method using the NICaS Hemodynamic Navigator system and the gold standard TD method using pulmonary artery catheter in patients undergoing OPCAB. A total of 150 data pair from the two CO monitoring techniques were taken from 15 patients between 40-70 years at various predefined time intervals of the surgery.Patients and Methods: We have tried to find out the accuracy, precision and cost effectiveness of the newer RIC technique. Mean CO, bias and precision were compared for each pair i.e.TD-CO and RIC-CO as recommended by Bland and Altman. The Sensitivity and specificity of cutoff value to predict change in TD-CO was used to create a Receiver operating characteristic or ROC curve.Results: Mean TD-CO values were around 4.52 ± 1.09 L/min, while mean RIC- CO values were around 4.77± 1.84 L/min. The difference in CO change was found to be statistically not significant (p value 0.667). The bias was small (-0.25). The Bland Altman plot revealed a mean difference of -0.25 litres. The RIC method had a sensitivity of 55.56 % and specificity of 33.33 % in predicting 15% change in CO of TD method and the total diagnostic accuracy was 46.67%.Conclusion: A fair correlation was found between the two techniques. The RIC method may be considered as a promising noninvasive, potentially low cost alternative to the TD technique of hemodynamic measurement. [ABSTRACT FROM AUTHOR]

Thirty seven year old asymptomatic male underwent routine medical examination which revealed an abnormal mass in the right atrium. Family history was not suggestive of any cardiac or malignant disease. Detailed investigation detected deficiency of protein S, which is a vitamin K dependent protein and a cofactor for activated protein C mediated cleavage of factor Va and VIIIa. The deficiency of protein S predisposes to venous thrombosis. Further investigation revealed that it was an organized calcified thrombus in right atrium occupying almost whole of the cavity. Various approaches including surgical excision, thrombolysis and anticoagulation has been used to manage such thrombosis. However therapeutic approach is still a question of debate. Atriotomy and excision of mass was done using cardiopulmonary bypass. [ABSTRACT FROM AUTHOR]

A seventy eight year old male patient was admitted in our hospital with headache, vomiting, irritability and confusion. Initially he was diagnosed as a case of pyogenic encephalitis. Further investigations revealed that patient had cerebrospinal fluid rhinorrhea and coronary artery disease. He successfully underwent coronary artery bypass grafting and cerebrospinal fluid leak repair. [ABSTRACT FROM AUTHOR]

Despite advances in various modalities of management, subarachnoid hemorrhage (SAH) continues to be associated with high mortality, which is further increased by associated comorbidities. Aortic stenosis (AS) is one such disease which can further complicate the course of SAH. We recently managed a known patient of severe AS, who presented with aneurysmal SAH. Patient was planned for neurovascular intervention. With proper assessment and planning, patient was managed with favorable outcome despite the restrictions faced in the neurovascular intervention laboratory. [ABSTRACT FROM AUTHOR]