Sheila Nainan Myatra

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.

Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC).

We report on the effect of the International Nosocomial Infection Control Consortiums (INICC) multidimensional approach for the reduction of ventilator-associated pneumonia (VAP) in adult patients hospitalized in 21 intensive-care units (ICUs), from 14 hospitals in 10 Indian cities. A quasi-experimental study was conducted, which was divided into baseline and intervention periods. During baseline, prospective surveillance of VAP was performed applying the Centers for Disease Control and Prevention/National Healthcare Safety Network definitions and INICC methods. During intervention, our approach in each ICU included a bundle of interventions, education, outcome and process surveillance, and feedback of VAP rates and performance. Crude stratified rates were calculated, and by using random-effects Poisson regression to allow for clustering by ICU, the incidence rate ratio for each time period compared with the 3-month baseline was determined. The VAP rate was 17.43/1000 mechanical ventilator days during baseline, and 10.81 for intervention, showing a 38% VAP rate reduction (relative risk 0.62, 95% confidence interval 0.5-0.78, P = 0.0001).

Neurolytic celiac plexus block: a better alternative to opioid treatment in upper abdominal malignancies: an Indian experience.

The majority of patients with advanced upper abdominal malignancies suffer from moderate to severe pain due to unavailability of morphine in developing world. This study was undertaken to evaluate the role of neurolytic celiac plexus block on pain and quality of life in this patient subpopulation. One hundred consecutive patients receiving opioids for their pain relief were divided in two groups. Group I (control) patients received oral morphine and NSAIDs and group II (study) patients underwent neurolytic celiac plexus block (NCPB) to compare their effects on pain relief, morphine consumption, quality of life (QOL), Karnofsky and performance scores up to one month. NCPB provided statistically significant better pain relief and reduced morphine consumption at one month (P = 0.000). Superior Karnofsky and performance scores also favored NCPB group (P = 0.000); however the difference in overall QOL was not statistically significant (P = 0.24). Patients in oral morphine group had more side effects (94% vs. 58%) as compared to NCPB (P = 0.000). NCPB is an effective tool to reduce opioid requirement and the drug-related adverse effects. It is a rewarding technique, especially when morphine availability and its easy accessibility to the deserving patient is poor.

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.

Device-Associated Infection Rates in 20 Cities of India, Data Summary for 2004-2013: Findings of the International Nosocomial Infection Control Consortium.

OBJECTIVE To report the International Nosocomial Infection Control Consortium surveillance data from 40 hospitals (20 cities) in India 2004-2013. METHODS Surveillance using US National Healthcare Safety Networks criteria and definitions, and International Nosocomial Infection Control Consortium methodology. RESULTS We collected data from 236,700 ICU patients for 970,713 bed-days Pooled device-associated healthcare-associated infection rates for adult and pediatric ICUs were 5.1 central line-associated bloodstream infections (CLABSIs)/1,000 central line-days, 9.4 cases of ventilator-associated pneumonia (VAPs)/1,000 mechanical ventilator-days, and 2.1 catheter-associated urinary tract infections/1,000 urinary catheter-days In neonatal ICUs (NICUs) pooled rates were 36.2 CLABSIs/1,000 central line-days and 1.9 VAPs/1,000 mechanical ventilator-days Extra length of stay in adult and pediatric ICUs was 9.5 for CLABSI, 9.1 for VAP, and 10.0 for catheter-associated urinary tract infections. Extra length of stay in NICUs was 14.7 for CLABSI and 38.7 for VAP Crude extra mortality was 16.3% for CLABSI, 22.7% for VAP, and 6.6% for catheter-associated urinary tract infections in adult and pediatric ICUs, and 1.2% for CLABSI and 8.3% for VAP in NICUs Pooled device use ratios were 0.21 for mechanical ventilator, 0.39 for central line, and 0.53 for urinary catheter in adult and pediatric ICUs; and 0.07 for mechanical ventilator and 0.06 for central line in NICUs. CONCLUSIONS Despite a lower device use ratio in our ICUs, our device-associated healthcare-associated infection rates are higher than National Healthcare Safety Network, but lower than International Nosocomial Infection Control Consortium Report.

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.

Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine

Background and Aim: Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU. Materials and Methods: A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods. Results: Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsays Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation. Conclusion: The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.

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.

Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle.

Objectives: To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines. Design: Worldwide online survey. Setting: Intensive care. Intervention: A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle. Measurement and Main Results: There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was “prescribed” by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits. Conclusions: The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.

Erratum to: Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions

Purpose To compare the attitudes of physicians towards withholding and withdrawing life-sustaining treatments in intensive care units (ICUs) in low-middle-income Asian countries and regions with those in high-income ones, and to explore differences in the role of families and surrogates, legal risks, and financial considerations between these countries and regions.