Jigeeshu V Divatia

Omission of nitrous oxide during anesthesia reduces the incidence of postoperative nausea and vomiting - A meta-analysis

Background Postoperative nausea and vomiting are important causes of morbidity after general anesthesia. Nitrous oxide has been implicated as an emetogenic agent in many studies. However, several other trials have failed to sustain this claim. The authors tried to resolve this issue through a meta-analysis of randomized controlled trials comparing the incidence of postoperative nausea and vomiting after anesthesia with or without nitrous oxide. Methods Of 37 published studies retrieved by a search of articles indexed on the MEDLINE database from 1966 to 1994, 24 studies (26 trials) with distinct nitrous-oxide and non-nitrous oxide groups were eligible for the meta-analysis. The pooled odds ratio and relative risk were calculated. Post hoc subgroup analysis was also performed to qualify the result. Results The pooled odds ratio was 0.63 (0.53 to 0.75). Omission of nitrous oxide reduced the risk for postoperative nausea and vomiting by 28% (18% to 37%). In the subgroup analysis, the maximal effect of omission of nitrous oxide was seen in female patients. In patients undergoing abdominal surgery and general surgical procedures, the effect of omission of nitrous oxide, although in the same direction, was not significant. Conclusion Omission of nitrous oxide reduced the odds of postoperative nausea and vomiting by 37%, a reduction in risk of 28%.

Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study.

Objectives To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign’s resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance. Design Prospective cohort study. Setting 150 intensive care units in 16 Asian countries. Participants 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients’ baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded. Main outcome measure Compliance with the Surviving Sepsis Campaign’s resuscitation (six hours) and management (24 hours) bundles. Results Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870; 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle. Conclusions While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures, antibiotics, and central venous pressure was independently associated with improved survival.

Determinants of Procedural Pain Intensity in the Intensive Care Unit. The Europain® Study

RATIONALE Intensive care unit (ICU) patients undergo several diagnostic and therapeutic procedures every day. The prevalence, intensity, and risk factors of pain related to these procedures are not well known. OBJECTIVES To assess self-reported procedural pain intensity versus baseline pain, examine pain intensity differences across procedures, and identify risk factors for procedural pain intensity. METHODS Prospective, cross-sectional, multicenter, multinational study of pain intensity associated with 12 procedures. Data were obtained from 3,851 patients who underwent 4,812 procedures in 192 ICUs in 28 countries. MEASUREMENTS AND MAIN RESULTS Pain intensity on a 0-10 numeric rating scale increased significantly from baseline pain during all procedures (P < 0.001). Chest tube removal, wound drain removal, and arterial line insertion were the three most painful procedures, with median pain scores of 5 (3-7), 4.5 (2-7), and 4 (2-6), respectively. By multivariate analysis, risk factors independently associated with greater procedural pain intensity were the specific procedure; opioid administration specifically for the procedure; preprocedural pain intensity; preprocedural pain distress; intensity of the worst pain on the same day, before the procedure; and procedure not performed by a nurse. A significant ICU effect was observed, with no visible effect of country because of its absorption by the ICU effect. Some of the risk factors became nonsignificant when each procedure was examined separately. CONCLUSIONS Knowledge of risk factors for greater procedural pain intensity identified in this study may help clinicians select interventions that are needed to minimize procedural pain. Clinical trial registered with www.clinicaltrials.gov (NCT 01070082).

Severe sepsis bundles.

Sepsis is a complex syndrome with its wide spectrum of severity, and is one of the most common causes of death in Critical Care Units. The Surviving Sepsis campaign launched in 2004, is aimed at improving diagnosis, management and survival of patients with sepsis. Care bundles are a group of best evidence based interventions which when instituted together, gives maximum outcome benefit. Care Bundles are simple, uniform and have universal practical applicability. Surviving Sepsis campaign guidelines in 2008 incorporated two sepsis care bundles. The Resuscitation bundle includes seven key interventions to be achieved in 6-h while four interventions have to be completed within 24-h in the Management bundle. Compliance with a bundle implies achieving all the specified goals in that bundle. Limitations to care bundles include the quality of the evidence on which they are based, and that the relative contributions of each element of the bundle are not known. Several observational studies support the hypothesis that sepsis care bundles have an important role in improving outcomes from sepsis. Critical Care Units should develop management strategies to ensure compliance with the sepsis bundles in order to decrease hospital mortality due to severe sepsis.

The Changes in Pulse Pressure Variation or Stroke Volume Variation After a “tidal Volume Challenge” Reliably Predict Fluid Responsiveness During Low Tidal Volume Ventilation*

Objectives: Stroke volume variation and pulse pressure variation do not reliably predict fluid responsiveness during low tidal volume ventilation. We hypothesized that with transient increase in tidal volume from 6 to 8 mL/kg predicted body weight, that is, “tidal volume challenge,” the changes in pulse pressure variation and stroke volume variation will predict fluid responsiveness. Design: Prospective, single-arm study. Setting: Medical-surgical ICU in a university hospital. Patients: Adult patients with acute circulatory failure, having continuous cardiac output monitoring, and receiving controlled low tidal volume ventilation. Interventions: The pulse pressure variation, stroke volume variation, and cardiac index were recorded at tidal volume 6 mL/kg predicted body weight and 1 minute after the “tidal volume challenge.” The tidal volume was reduced back to 6 mL/kg predicted body weight, and a fluid bolus was given to identify fluid responders (increase in cardiac index > 15%). The end-expiratory occlusion test was performed at tidal volumes 6 and 8 mL/kg predicted body weight and after reducing tidal volume back to 6 mL/kg predicted body weight. Results: Thirty measurements were obtained in 20 patients. The absolute change in pulse pressure variation and stroke volume variation after increasing tidal volume from 6 to 8 mL/kg predicted body weight predicted fluid responsiveness with areas under the receiver operating characteristic curves (with 95% CIs) being 0.99 (0.98–1.00) and 0.97 (0.92–1.00), respectively. The best cutoff values of the absolute change in pulse pressure variation and stroke volume variation after increasing tidal volume from 6 to 8 mL/kg predicted body weight were 3.5% and 2.5%, respectively. The pulse pressure variation, stroke volume variation, central venous pressure, and end-expiratory occlusion test obtained during tidal volume 6 mL/kg predicted body weight did not predict fluid responsiveness. Conclusions: The changes in pulse pressure variation or stroke volume variation obtained by transiently increasing tidal volume (tidal volume challenge) are superior to pulse pressure variation and stroke volume variation in predicting fluid responsiveness during low tidal volume ventilation.

End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC).

Purpose: The purpose was to develop an end-of-life care (EOLC) policy for patients who are dying with an advanced life limiting illness and to develop practical procedural guidelines for limiting inappropriate therapeutic medical interventions and improve the quality of care of the dying within an ethical framework and through a professional and family/patient consensus process. Evidence: The Indian Society of Critical Care Medicine (ISCCM) published its first guidelines on EOLC in 2005 [1] which was later revised in 2012.[2] Since these publications, there has been an exponential increase in empirical information and discussion on the subject. The literature reviewed observational studies, surveys, randomized controlled studies, as well as guidelines and recommendations, for education and quality improvement published across the world. The search terms were: EOLC; do not resuscitate directives; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care; EOLC in India; cultural variations. Indian Association of Palliative Care (IAPC) also recently published its consensus position statement on EOLC policy for the dying.[3] Method: An expert committee of members of the ISCCM and IAPC was formed to make a joint EOLC policy for the dying patients. Proposals from the chair were discussed, debated, and recommendations were formulated through a consensus process. The members extensively reviewed national and international established ethical principles and current procedural practices. This joint EOLC policy has incorporated the sociocultural, ethical, and legal perspectives, while taking into account the needs and situation unique to India.

The impact of the International Nosocomial Infection Control Consortium (INICC) multicenter, multidimensional hand hygiene approach in two cities of India

The fundamental tool for preventing and controlling healthcare-acquired infections is hand hygiene (HH). Nonetheless, adherence to HH guidelines is often low. Our goal was to assess the effect of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach (IMHHA) in three intensive care units of three INICC member hospitals in two cities of India and to analyze the predictors of compliance with HH. From August 2004 to July 2011, we carried out an observational, prospective, interventional study to evaluate the implementation of the IMHHA, which included the following elements: (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance and (6) performance feedback. The practices of health care workers were monitored during randomly selected 30-min periods. We observed 3612 opportunities for HH. Overall adherence to HH increased from 36.9% to 82% (95% CI 79.3-84.5; P=0.0001). Multivariate analysis indicated that certain variables were significantly associated with poor HH adherence: nurses vs. physicians (70.5% vs. 74%; 95% CI 0.62-0.96; P=0.018), ancillary staff vs. physicians (43.6% vs. 74.0%; 95% CI 0.48-0.72; P<0.001), ancillary staff vs. nurses (43.6% vs. 70.5%; 95% CI 0.51-0.75; P<0.001) and private vs. academic hospitals (74.2% vs. 66.3%; 95% CI 0.83-0.97; P<0.001). It is worth noticing that in India, the HH compliance of physicians is higher than in nurses. Adherence to HH was significantly increased by implementing the IMHHA. Programs targeted at improving HH are warranted to identify predictors of poor compliance.

WhatsApp: What an App!

Sir, Telemedicine, defined as “The use of electronic information and communications technologies to provide and support health care when distance separates the providers of care from their patients.”[1] Telemedicine introduced into specific settings such as rural healthcare system, improved outcomes.[2] For communication between the members of any division in the field of medicine is perhaps a verbal report via telephones. Telephone communication can be rapid but not objective and precise. To add more accurate information to verbal report, clinical photographs taken by digital cameras were transmitted in the late 1990s.[3] WhatsApp (WA) was introduced mainly to text, exchange photos, videos and voice note, and is popular among smart phone users.[4] However, it can also serve as a medium for doctors to rescue ailing people during the times of emergency, as this case illustrates. A 45-year-old gentleman operated case of Lt Bite composite resection + PMMC (a case of Left Ca Buccal Mucosa), with no comorbid medical history, other than electrocardiogram (ECG) findings of right bundle branch block with left anterior hemiblock, was admitted to intensive care unit (ICU) on postoperative day 7 postgeneralized tonic-clonic convulsions with bradycardia (38 bpm). The registrar on-call called up the consultant on-call to inform him about the patient condition. In order to confirm the diagnosis, it was decided to send the ECG changes via WA to the consultant for a diagnosis. Complete heart block diagnosis is made based on the pictures. The consultant was 40 km away from the center where the patient was located. It was decided to do transcutaneous pacing to tide out the crisis. The images were sent again to the consultant by WA. Transvenous pacing wires were put by the consultant and the patient rhythm stabilized. The images were sent by WA to the senior consultant and intensivist who opined regarding proper placement. We decided to shift the patient to another center, where there were advanced facilities for further management. Changes in ECG patterns were noted on the cardioscope while transferring the patient in an ambulance to referral center [Figure 1]. We immediately sent the images of cardioscope by WA to senior consultant, who advised to withdraw the wire of pacemaker till it senses. The pacing wire was withdrawn till we could see pacing, the images of which were again sent to a senior consultant who concurred with proper placements [Figure 2]. Figure 1 WhatsApp image showing monitor with transvenous pacing with ECG changes Figure 2 WhatsApp image showing transvenous pacing Due to the availability of such a wonderful app and smartphone we could manage the catastrophe and could save the life of the patient. We would like to mention here, since there is an availability of telemedicine and electronic ICU,[5] at centers world over, in situations like transporting the patient to higher center, such technology is not available. Availability of an application where we can transfer images and videos, during the transportation of patients, plays a crucial role in avoiding mishaps, provided there is an active network of the mobile service provider. We conclude that, smartphones running applications such as WA play a vital role in transmitting medical information and images in resource-limited situations.

Tracheal intubation in the ICU: Life saving or life threatening?

Tracheal intubation (TI) is a routine procedure in the intensive care unit (ICU), and is often life saving. However, life-threatening complications occur in a significant proportion of procedures, making TI perhaps one the most common but underappreciated airway emergencies in the ICU. In contrast to the controlled conditions in the operating room (OR), the unstable physiologic state of critically ill patients along with underevaluation of the airways and suboptimal response to pre-oxygenation are the major factors for the high incidence of life-threatening complications like severe hypoxaemia and cardiovascular collapse in the ICU. Studies have shown that strategies planned for TI in the OR can be adapted and extrapolated for use in the ICU. Non-invasive positive-pressure ventilation for pre-oxygenation provides adequate oxygen stores during TI for patients with precarious respiratory pathology. The intubation procedure should include not only airway management but also haemodynamic, gas exchange and neurologic care, which are often crucial in critically ill patients. Hence, there is a necessity for the implementation of an Intubation Bundle during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study

Aims: To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). Patients and Methods: An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. Results: On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. Conclusions: The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.