“Counting Carbs to Be in Charge”: A Comparison of an Internet-Based Education Module With In-Class Education in Adolescents With Type 1 Diabetes

Carbohydrate counting is an essential component of type 1 diabetes education but can be difficult for adolescents to learn. Because adolescents are avid users of technology, an Internet-based education module was compared with an in-class education session in terms of carbohydrate counting accuracy in adolescents with type 1 diabetes. Adolescent participants displayed increased carbohydrate counting accuracy after attending an in-class education session compared with an Internet-based education module. These results suggest that online education is best reserved as an adjunctive therapy to in-class teaching in this population.

Carbohydrate counting is a recommended daily practice for the self-management of type 1 diabetes, in conjunction with insulin therapy (1). This method allows for more flexibility in the timing and frequency of eating and the amount of carbohydrate consumed during meals and snacks (1). Accuracy in carbohydrate estimation is required to achieve and sustain adequate glycemic control, and differences of ≥20 g from actual carbohydrate amount have been shown to affect postprandial glucose excursions (2,3). Thus, carbohydrate counting is an essential component of conventional diabetes education, a collaborative process whereby patients gain knowledge and skills to successfully self-manage their diabetes and related conditions (4,5).However, evidence suggests that adolescents with type 1 diabetes do not accurately count carbohydrates (6). In a previous study in adolescents with type 1 diabetes, we reported that, despite using carbohydrate counting for managing their diabetes and receiving in-class education with a dietitian, fewer than half of the sample counted carbohydrates accurately (7). Furthermore, a nutrition education intervention focused on carbohydrate counting in adolescents with type 1 diabetes found no improvement in counting accuracy and glycemic control after 3 months (8). These findings suggest a need to develop more intensive education that is cost-effective and readily available and provides the tools to empower individuals in their day-to-day diabetes management (9,10).Multiple factors have a bearing on the delivery of diabetes care for adolescents with type 1 diabetes; these include a shift in responsibility from parents to adolescents, adolescents’ focus on social contexts and peers, developmental inclination toward risk taking, and fatigue from care of a chronic illness (11). Therefore, the approach to diabetes education needs to be engaging, developmentally appropriate, and motivating to encourage appropriate diabetes self-management.Digital technologies are readily used among adolescents, and strategies that incorporate such technologies can potentially help adolescents enhance their skills in diabetes self-management (12,13). These strategies include online educational resources (14), short message service systems (15,16), interactive diabetes management tools (17), video games (18,19), Internet-based communication (20), Internet videoconferencing (21), and mobile device applications (22). Online education for diabetes management may help to reduce the complexity and inaccuracies associated with carbohydrate counting, as well as reduce the barrier of attending face-to-face teaching sessions by being a flexible learning option that can be reviewed at a patient’s convenience.There is no evidence indicating the most effective type of educational platform for training adolescents in carbohydrate counting. Although studies of Internet-based educational tools for diabetes self-management have been conducted in adolescents with type 1 diabetes (23), none have focused exclusively on improving carbohydrate counting skills. Furthermore, the current literature evaluating computer-assisted diabetes education has primarily targeted adults with type 2 diabetes (24,25). Therefore, the objective of this study was to evaluate an Internet-based education module on carbohydrate-counting accuracy in adolescents with type 1 diabetes in comparison with the standard of care (in-class education session). We hypothesized that the Internet-based module would result in improved accuracy compared with the in-class session.     

Role of Prophylactic Noninvasive Ventilation in Patients at High Risk of Extubation Failure

How to cite this article: Singh L. Role of Prophylactic Noninvasive Ventilation in Patients at High Risk of Extubation Failure. Indian J Crit Care Med 2020;24(12):1158–1160.

Prolonged mechanical ventilation (MV) has serious side effects and complications. Thus, one opts for an early extubation after correcting the causes and stabilizing the patient.¹ Extubation is commonly uneventful especially in an odds ratio (OR) but in intensive care unit (ICU) it is often associated with respiratory failure development post post extubation which may very often require reintubation. The rule of thumb about reintubation risk cannot be applied to all patients as the pathophysiology of extubation failure is poorly understood.An average of 15% patients may need reintubation among which 25–30% are at high risk.¹ The high-risk patients of extubation failure include preterm infants, age ≥65 years, any respiratory disease, cardiac disease.² A major cause of weaning failure is acute respiratory failure (ARF) due to respiratory muscle fatigue or increased work of breathing due to decreased pulmonary compliance or increased resistance. Other causes include inadequate cough, airway obstruction, excess secretions, neurologic impairment. An important factor responsible for mortality in ICU patients after extubation is ARF. Noninvasive ventilation (NIV) is used for both management and prevention of post-extubation respiratory failure.After extubation, oxygenation can be improved by three methods available: conventional oxygen therapy, high-flow oxygen therapy, and NIV. Respiratory support is most commonly provided by conventional oxygen therapy. However, in recent years, high-flow oxygen therapy (HFOT) and NIV are being used increasingly. These methods are speculated to prevent extubation failure by promoting alveolar recruitment, preventing alveolar collapse, and reducing the work of breathing. Noninvasive ventilation (NIV) causes an increase in the intrathoracic pressure preventing alveolar collapse, improving oxygenation, and reducing the workload of the heart. It also prevents complications of invasive MV.³ The protocol of using prophylactic NIV can involve the immediate application of NIV within 1 hour of extubation for a duration of 8–24 hours depending upon the improvement in the respiratory parameters, such as, respiratory rate, pH, partial pressures of oxygen, and carbon dioxide. The prophylactic use of NIV has been adopted for reducing the rates of reintubation, duration of MV, and improving the overall prognosis of patients at high risk of post-extubation failure.^1,3–5The International Consensus Conference in intensive care medicine in 2001 suggested that NIV is a promising therapy to prevent respiratory failure after weaning.⁶ It can ameliorate some of the pathophysiologic derangements that occur following extubation. It has been used as an adjunct to weaning or as a part of early extubation approach.Since the need for reintubation has been associated with significantly poor outcomes in terms of prolongation of the ICU stay, hospital stay, use of MV and its associated complications like pneumonia and lung damage, the requirement of tracheotomy, and financial implications, two studies have used different methods for preventing it; among which the prophylactic use of NIV has been found to be is successful.^4,5,7 The successful use of prophylactic NIV has been most pronounced in high-risk patients of extubation failure.⁸ Post-extubation respiratory failure and reintubation prevention by using NIV is supported by weak evidence. NIV can decrease reintubation rates was concluded in two meta-analyses, but these studies had both high risk (only 35%) as well as the general population.^9,10 NIV compared to with conventional oxygen therapy in ICU patients at high risk of reintubation was found to be more effective.⁴ However, a meta-analysis conducted in 2014 with 1,382 patients found that the use of NIV as a preemptive measure after extubation or after respiratory failure which developed post-extubation was not beneficial either in reducing mortality or intubation rate.¹⁰Liu et al.³ found that prophylactic NIV brings about a significant reduction in the atelectasis (OR = 0.43, p = 0.02) and rate of reintubation (OR = 0.33, p = 0.02). The reduction in atelectasis rate is an additional advantage since the development of atelectasis is associated with further complications, such as, pneumonia and atelectrauma.¹¹ One of the previous review studies backed up the improved outcomes of the use of prophylactic NIV in major abdominal surgeries.¹² This was even seen on the patients undergoing cardiothoracic surgeries where prophylactic NIV reduced the rate of reintubation.¹³ In a landmark study by Thille et al.¹ which compared the use of prophylactic NIV in 150 high-risk extubated patients with 83 control extubated patients in an ICU setting, there was a significant reduction in reintubation in the study group (15% vs 28%, p = 0.02). The study is important since it included high-risk patients with cardiac disease and respiratory disease, and found that prophylactic NIV was an independent predictor of extubation success. Their findings were backed up by two studies prior to before it which showed a significant reduction in the reintubation from 24 to 8%, p = 0.027 and from 39 to 5%, p = 0.016, respectively.^4,5In an RCT, Ferrer et al.¹⁴ concluded that early use of NIV averted respiratory failure after extubation and decreased mortality in high-risk patients. Another RCT of 648 patients at high risk of extubation failure concluded that the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation.¹⁵ Nava et al. in a randomized controlled trial studied the use of prophylactic NIV in patients at high risk of extubation failure following at least 48 hours of invasive ventilation and extubation after a successful spontaneous breath trial. They observed that the rate of reintubation was significantly lower in the prophylactic NIV group (8%) compared to with the control group (24%) and NIV was associated with significantly lower ICU mortality and ICU length of stay.⁴ Ferrer et al.¹⁴ applied NIV immediately post-extubation, with age >65 years and APACHE II score >12 at extubation as a factor for high risk of extubation failure and observed that post-extubation respiratory failure was lower in the NIV group (16% vs 33%) but there was no difference in the rate of re-intubation and ICU mortality and 90-days mortality was significantly lower in NIV group. Ferrer et al. in their RCT, used prophylactic NIV in patients with underlying chronic respiratory illness and hypercapnia at extubation. Prophylactic NIV was associated with lower respiratory failure at 48 hours post-extubation and significantly lower 90-day mortality.¹⁶In this issue, Ghosh et al.¹⁷ studied outcomes of prophylactic NIV at extubation after a planned extubation, in patients at a high risk of extubation failure. They observed extubation success in 88.2% of patients at 72 hours. Higher age, longer duration of invasive ventilation, and higher SOFA score at extubation were the factors associated with extubation failure. They also observed organ failure and higher cumulative fluid balance in the first 72 hours post-extubation in the extubation failure group. Ghosh et al.¹⁷ and Upadya et al.¹⁸ observed in their studies that higher cumulative fluid balance at extubation was an independent risk factor for extubation failure in patients after planned extubation.Among the newer modalities, Ali et al.¹⁹ studied the use of nasal high-frequency oscillatory ventilation (NHFOV) as a prophylactic NIV or “rescue mode of NIV” after extubation. The NHFOV is a “noninvasive ventilation mode that applies an oscillatory pressure waveform to the airways using a nasal interface”. The results were promising which showed a decreased requirement of reintubation. It is suggested that NHFOW may be a feasible modality that in is being used as prophylactic NIV following extubation for the prevention of apnea and reintubation. But still, the practical applications need randomized controlled trials to lay down the indications and guidelines for its use in other populations. Prophylactic NIV has emerged as an promising modality and its practical use is welcome. Its efficacy has been seen in diverse age groups ranging from pediatric to adults to elderly.Appropriate patient selection, i.e., those who are at high risk of extubation failure is important, because it is not useful in low-risk patients, but also that its use may be detrimental in some patients.     

Prevalence of Bloodstream Infections and their Etiology in COVID-19 Patients: A Tale of Two Cities

How to cite this article: Tyagi N. Prevalence of Bloodstream Infections and their Etiology in COVID-19 Patients: A Tale of Two Cities. Indian J Crit Care Med 2021;25(4):355–357.

With 114,477,868 people affected worldwide and 2,539,290 deaths till now, coronavirus disease-2019 (COVID-19) is ravaging as the worst pandemic in human history. The unprecedented burden on the healthcare system as well as human resources has proven catastrophic and the world is still grappling with the seemingly relentless surges in cases. The search for effective antiviral therapy has so far been elusive with some steroids remaining the only class of drug that has shown any mortality benefit. Evidence regarding the use of anti-inflammatory drugs like baricitinib and tocilizumab, particularly in critically ill COVID-19 patients who need mechanical ventilation appears chimera for now, and their likely flip side in terms of impending secondary infections presents a clear danger.¹ In almost all severe cases, SARS-CoV-2 infection results in pneumonia and the inflamed fluid-filled alveolar tissue may turn into an ideal habitat for bacterial pathogens. Thus the causative agent resulting in further worsening of severe disease may be a bacteria or fungi rather than virus itself. Patients with COVID-19 are likely to stay on invasive mechanical ventilation for a long time (mean: 9·1 day), thereby increasing the chances of the hospital and ventilator-acquired infections.While rationing of ventilators and ICU beds in overwhelmed health systems could have resulted in unusually high mortalities during the initial phase of COVID-19, what baffled medical community the most was nihilistic mortality figure of almost 100% amongst patients requiring mechanical ventilation, as reported from China. Half of these COVID-19 fatalities were believed to be due to a certain form of secondary infection (pulmonary or other).² The obvious answer to this problem in using early broad-spectrum antibiotics brings forth the risk of multidrug-resistant (MDR) pathogens. During the 2003 SARS-CoV outbreak, analyses of isolates collected from patients in the intensive care unit (ICU) in Prince of Wales Hospital (Hong Kong) showed increased rates of methicillin-resistant Staphylococcus aureus acquisition from 3.53% pre-SARS to 25.30%. This exponential rise despite adequate infection control practices was largely attributed to higher than usual antibiotic usage during the outbreak.³ With almost all patients being treated with more than one antibiotic right from the time of hospital admission, this ongoing battle with COVID-19 is likely to worsen India''s already dire situation regarding high incidence MDR pathogens.The binary choice about not using antibiotics while awaiting etiology of secondary infection and risking increased mortality vs empirically starting them in severely ill COVID-19 gets confounded by lack of data regarding likely bacterial microbiology. Bacterial coinfection has huge geographic variations due to variability in the proportion of patients tested, the microbiology of bacterial infections, and antimicrobial stewardship policies. Langford et al. have tried to address this gap by adopting a concept of “living rapid review and meta-analysis: bacterial co-infection and secondary infection in patients with COVID-19”, which periodically searches literature and updates findings in 3 monthly fashions. Their first published results from 24 studies representing 3,338 patients, identified bacterial co-infection (estimated on presentation) in 3.5% and secondary bacterial infection (during hospitalization) in 14.3% of the patients. Bacterial infection was more common (8.1%) in critically ill patients, this figure now stands grown up at 16.0% (11.6–20.4) (https://www.tarrn.org/covid). They also highlighted that majority of patients with COVID-19 (71.9%) received antibiotics despite most of the guidelines discouraging their use. The biggest shortcoming was specific species of bacterial co-pathogens being reported in 11/24 studies (45.8%), representing less than 14% of patients with reported infections. The most common organisms reported were Mycoplasma species, Haemophilus influenzae, and Pseudomonas aeruginosa.⁴Initial studies from China although initiated by the world regarding outcomes related to secondary infections lacked microbiological details. A multicenter study that included 476 COVID-19 patients, revealed that critically ill ones had the highest percentage of bacterial coinfections (34.5%) compared to patients in the moderately ill and severely ill groups (3.9 and 8.3%, respectively). This higher rate of coinfections in critical patients was observed despite a majority of them (92.9%) receiving antibiotic treatments compared to 59.4 and 83.3% of the patients in the moderately ill and severely ill groups, respectively.⁵ Zhou et al. observed that among 191 COVID-19 patients, bacterial coinfections occurred in 15% of the cases, including 50% of nonsurvivors, even though 95% of patients had received antibiotics; ventilator-associated pneumonia occurred in 31% of patients requiring invasive respiratory support. Even more troubling was the fact that 27/28 COVID-19 patients with coinfections succumbed.² These studies probably confirm the futility of prophylactic antibiotics when it comes to bacterial secondary infections.Li et al. in a retrospective analysis of about 1500 patients, tried to explore etiology and antimicrobial resistance of secondary bacterial infections (SBI) in patients hospitalized with COVID-19.⁶ They confirmed high mortality (49.0%, 50/102) in those with SBI while the overall percentage who acquired SBI was 6.8% (n = 102) only. Among the 159 strains of bacteria isolated from the SBIs, 85.5% were gram-negative bacteria. The top three strains were Acinetobacter baumannii (35.8%), Klebsiella pneumoniae (30.8%), and Stenotrophomonas maltophilia (6.3%). The isolation rates of carbapenem-resistant A. baumannii and K. pneumoniae were 91.2 and 75.5%, respectively. Methicillin resistance was present in 100% of S. aureus and coagulase-negative staphylococci. The high antimicrobial resistance rates of major isolated bacteria highlight that the optimizing choice of antibacterial agents is necessary for SBIs in patients hospitalized with COVID-19. An Italian study analyzed 731 patients and reported that an overall 28-day cumulative incidence of 16.4% bloodstream infections (BSI) was much higher (7.9 vs 3.0%) than presumed lower respiratory tract infections (pLRTI).⁷ Most of the BSIs were due to gram-positive pathogens specifically coagulase-negative staphylococci (69.7%), while among gram-negatives (21.7%) A. baumannii (30.4%) and Escherichia coli (21.7%) predominated. pLRTIs were caused mainly by gram-negative pathogens (53.8%). Eleven patients were diagnosed with putative invasive aspergillosis, again reminding that geographic variations are a rule rather than an exception.In terms of risk factors male gender, older age, heart diseases, hypoproteinemia, corticosteroid and proton-pump inhibitors, early need for ICU, respiratory failure are reported most frequently.Several studies have shown that sustained and substantial reduction of the peripheral lymphocyte counts, especially CD4 T and CD8 T cells, is representative of the immune suppression stage after the cytokine storm activation phase. The dysregulated immune response may be associated with a high risk of developing a secondary bacterial infection.^7,8Current high antibiotic use in COVID-19 patients admitted to intensive care units, renders culture-based microbiological testing less sensitive. Hence, early diagnosis of co-infection is required, preferably using methods capable of detecting potential pathogens and antimicrobial resistance. This brings to centerstage that we still lack good understanding regarding clinical risk factors for concomitant bacterial infections in COVID-19 patients, and India-specific data on how demographics and medical comorbidities influence bacterial infection risk are much needed. One such study from AIIMS, New Delhi, analyzed positive cultures from hospitalized COVID-19 patients. 15% of ICU patients and 12% of non-ICU patients developed secondary infections.⁹ K. pneumoniae (33.3%) was the most common pathogen, followed by A.baumannii (27.1%), E. coli (16.7%), and P.aeruginosa (11.5%). Overall resistance to third-generation cephalosporins and carbapenems was found to be 64–69%. Amongst gram-positive pathogens isolated were MR-CONS and MSCONS which were sensitive to vancomycin, teicoplanin, tigecycline, linezolid, and daptomycin. The AMR genes encoding for carbapenemases-NDM (71%), OXA-48-like (61%), and extended-spectrum beta-lactamases CTX-M (61%) were found highly prevalent in the respiratory samples tested by FilmArray. While it is understandable that neither European nor Chinese microbiota will have many similarities with Indian ones, a study undertaken in a tertiary care center in Jaipur underscores regional variations likely to be encountered within.¹⁰ The low rate of secondary bloodstream infection (9.4%) has prompted authors to raise a red flag against prophylactic use of antibiotics as well as prompt discontinuation in case they were already started. In contrast, they had a much higher incidence of coagulase-negative staphylococci (CoNS) out of which almost 90% were methicillin-resistant, while pseudomonas species were pan drug-sensitive. This wide variation in local microbiology is of utmost significance since the risk factor including age, gender, and severity of illness in both studies are almost mirror images. The USA is the other country that has reported a higher incidence of these otherwise skin commensal CoNS in COVID-19 patients.¹¹ One probable reason could be poor sampling technique and unless a pathological role is confirmed, treating such isolates is another conundrum that clinicians are likely to face. The possibility of antibiotics administered at admission altering the microbiological and clinical milieu is another way of explaining these findings. To diagnose co-infections early in COVID-19, patients should be screened on admission at the intensive care unit and subsequently sampled throughout the disease course.The use of interleukin 6 (IL-6) inhibitors, such as tocilizumab for COVID-19-related cytokine activation syndrome is going to presents a unique challenge by suppressing common signs of sepsis. Acute-phase reactants including white blood cell count and C-reactive protein may also not rise in response to a secondary bacterial infection after tocilizumab use.¹ Duration of this effect likely to last with 1 or 2 doses is also unclear. Procalcitonin may be less affected by IL-6 inhibitors, but the data to identify secondary bacterial infections in this context are in a nascent stage. Lastly, fungal infections including Candida albicans as well as non-albicans and invasive pulmonary aspergillosis are also being reported in patients with COVID-19-associated acute respiratory distress syndrome.¹² This further necessitates discretion when it comes to the use of broad-spectrum antibiotics in COVID-19 patients.Global pandemics from emerging viruses are inevitable in a world with interconnected societies, transcontinental travel, and intuitive tourism. In order to stay well-prepared for the next pandemic, we must be well informed regarding bacterial pathogens commonly observed in secondary infections to avert a healthcare crisis due to antibiotic-resistance.     

Pathogenetic Mechanism of Procalcitonin in COVID-19

How to cite this article: Wiedermann FJ. Pathogenetic Mechanism of Procalcitonin in COVID-19. Indian J Crit Care Med 2021;25(5):594.

Dear Sir,In the Editorial by Savio entitled “Procalcitonin (in COVID-19): The Incessant Quest,” the author wrote that the pathogenetic mechanism for the cause–effect of procalcitonin (PCT) to raise the risk of developing a severe disease remains to be proved.¹The author wants to point to two previously published studies. In the year 2002, the results of an in vitro study revealed that in vitro PCT is a monocyte chemoattractant that deactivates chemotaxis in the presence of additional inflammatory mediators. Nylen et al. demonstrate that increased PCT exacerbates mortality in experimental sepsis, whereas neutralization of PCT increases survival. Thus, PCT, in addition to being an important marker of severity of systemic inflammation and mortality, is an integral part of the inflammatory process and directly affects the outcome.^2,3Our institution has the laboratory possibility to investigate fragments of PCT in a bioassay in order to determine the active part of the peptide PCT. In the future, there is the option to create an agonist and antagonist of PCT. This new molecule should be able to influence the pathogenetic role of PCT in severe sepsis.     

Personal Protective Equipment and Fire

How to cite this article: Paliwal B, Bhatia PK, Kamal M, Purohit A. Personal Protective Equipment and Fire. Indian J Crit Care Med 2021;25(4):473

Personal protective equipment (PPE) is worn by healthcare workers to protect themselves from getting infected from the patients. The component of PPE as well as the nature of the material used for PPE is dictated by the disease and its mode of transmission. Coronavirus disease-2019 (COVID-19) infection being an aerosol-transmitted infection mandates PPE consisting of gowns or coverall, head cover, goggles, mask or face shield, gloves, and rubber boots. The stringent standards mandate that coveralls and gowns should be efficient in protecting from exposure to biologically contaminated solid particles and chemical hazards.¹ The guidelines from the Ministry of Health and Family Welfare, India, in accordance with WHO state that “the fabric that cleared/passed ‘Synthetic Blood Penetration Resistance Test’ (ISO 16603) and the garment that passed ‘Resistance to penetration by biologically contaminated solid particles’ (ISO 22612:2005) may be considered as the benchmark specification to manufacture Coveralls.”^1,2 Hence, coveralls for COVID-19 prevention kit are commonly made from high-density polyethylene formed into a nonwoven fabric that allows heat and sweat to leave the suit while preventing liquids and aerosols from entering it.³ The disposable gowns are typically made of polypropylene, polyester, or polyethylene, whereas the reusable ones carry cotton/polyester blends.³While the material used for PPE ensures protection from viral infections, being inflammable, it does not so from fire. One such fire incident has already been reported in a COVID-19 patient–caring hospital. Media reports claimed the blaze spreads after a staff member''s PPE kit caught fire. The paramedic staff whose PPE had caught fire while saving the patient sustained 21% burns needing hospitalization.⁴ In quick succession, another incident of fire is reported in a COVID-19 center, the details of which are awaited.⁵ The inciting event in these incidences may be preventable, but nevertheless considering the compromised vision and hearing in PPE that affect early detection, communication, and response in incidents of fire; it hints to additional consideration of choosing fire-resistant material for PPE. Nomex or flame-resistant cotton may be used for flame-resistant coveralls or aprons.⁶ By varying the fiber type, bonding process and fabric finish can change the properties of the material; these fire-resistant materials can be made to be liquid and aerosol resistant as well.³To conclude, safety concerns may necessitate the material of PPE in COVID-19 care settings to be fire resistant in addition to being liquid and aerosol resistant.     

Chronic Critical Illness: Are We Just Adding Years to Life?

How to cite this article: Ramakrishnan N. Chronic Critical Illness: Are We Just Adding Years to Life? Indian J Crit Care Med 2020;25(5):482–483.

Chronic critical illness (CCI) patients require prolonged specialized care for months or years and remain a challenge for intensive care professionals and healthcare.¹ It is common in the elderly although the incidence is noted to decline in the very elderly due to an increase in early mortality in that age-group.² Modern life-sustaining technologies allow us to keep patients alive despite ongoing life-threatening illnesses. However, this comes with a price including cognitive and functional restrictions, the burden of decision-making for caregivers, and the impact on the healthcare system at large.³The Pareto principle, also known as the 80–20 rule is relevant in healthcare in many ways. A rather small number of people (20%) utilize the majority (80%) of health-care consultations and hospital admissions.⁴ The majority (80%) of an individual''s healthcare needs and expenses are in the last 20% of their lives. It is also estimated that 80% of the cost of care is spent in the initial 20% of the hospital stay. However, this may not apply to those with CCI as costs may surge during the hospitalization with clinical changes requiring additional interventions and therapies that may be expensive.Intensive care units (ICUs) are traditionally considered to be expensive,⁵ and every attempt is made to transfer patients out to other areas based on the level of care required. The venue of care of CCI may vary based on the facility and the health-care system. In most countries, step-down units, high dependency units, or transitional care units provide a lower cost option to provide monitored multidisciplinary care. In countries such as the United States, where healthcare is predominantly driven by third-party insurance payers, specialized long-term acute care hospitals and skilled nursing facilities provide an alternative venue of care. However, stringent protocols and guidelines on the level of care that they could provide prompt readmission to hospitals when the patient has any significant changes in clinical status. Patients and families continue to exercise their choice in such payment models despite attempts by the treating team to explain the overall prognosis and quality of life measures. Strategies for effective communication should be implemented for shared decision-making in this scenario.⁶ If survival remains the only goal of therapy, we continue to “cheat” life at any cost.⁷ In predominantly socialized health-care systems such as the National Health Service in the United Kingdom, European countries, Canada, and Australia, the cost of continued care is borne by the government and indirectly by the tax payers. Measures are adopted to provide this long-term care in dedicated wards as ICU beds are limited and in high demand. While efforts are made to cover medically necessary services, some of these countries limit coverage for services such as home health or medications.⁷ In countries such as India, where payment for healthcare is largely “out of pocket,” decisions by the family are not uncommonly driven by the ability to pay for continued care. This is changing over the years with initiatives on healthcare coverage provided by government and private payers but still largely inadequate to cover prolonged illnesses. ICU at home is evolving as a more cost-efficient option in this scenario although adding significant physical, mental, and financial burden to the families. In this study, “talk turkey” about their observations in a retrospective cohort from an academic center, the authors observed that patients with hemodynamic instability requiring vasopressors and those with neurological comorbidities were at greatest risk of CCI. Not surprisingly significant number of patients with CCI were tracheostomized. The cost for a patient with CCI was six-fold while mortality was also significantly higher. The authors do not clearly specify if some of the extended care could have been provided in alternative venues in their facility to reduce the ICU length of stay.CCI leads to sleepless nights for the patient and the family. It is indeed appropriate to apply a concept similar to Spielman''s 3P model of chronic insomnia⁸ while managing patients with CCI by evaluating the following aspects:

• Predisposing factors that include the comorbidities (particularly neurological) that lead to hospitalizations but not necessarily always requiring critical care.
• Precipitating factors such as noncompliance or infections leading to acute on chronic organ failure necessitating organ supports such as ventilation, hemodynamic support, and renal replacement therapy.
• Perpetuating factors including malnutrition, dyselectrolytemia, pressure ulcers, nosocomial infections, iatrogenic issues, and physical aspects such as delayed mobility.

I would like to propose that we evaluate larger cohorts of CCI to develop and validate a scoring system based on the above factors to assist with additional 3Ps in the management which should include the following aspects:

• Prevention—which begins from efficient chronic disease management and also promptly addressing precipitating and perpetuating factors
• Prognostication—to assist the family with patient-centered decision
• Palliation—when appropriate

By utilizing this model, we will be in a position to create value-based programs to provide more appropriate care for those with a chronic critical illness.Mortality has been the most studied outcome in critical illness, and we experience a moment of triumph about increased survival with advances in technologies and therapies. But are we only adding years to life without being considerate of the quality of life added to those years?⁹ Are we saving patients or creating victims?^10,11 Are we communicating efficiently to assist with the decision-making? And most importantly, whose life and money is it anyway? Time to ponder.     

Colloids Use in Asian ICU Patients: Do not Mix Oranges with Apples. Consider the Proven Concerns on Hydroxyethyl Starch Use in ICU Patients

How to cite this article: Giordano G, Purgatori A, Bilotta F. Colloids Use in Asian ICU Patients: Do not Mix Oranges with Apples. Consider the Proven Concerns on Hydroxyethyl Starch Use in ICU Patients. Indian J Crit Care Med 2021;25(5):595–596.

Dear Editor,We read with great interest the article by Jacob et al. aimed to evaluate the characteristics of Asian intensive care unit (ICU) patients, “with a focus on fluid and volume therapy.”¹ In this prospective observational study, the authors compared two groups of ICU patients: one receiving crystalloids together with colloids, including hydroxyethyl starch (HES), albumin and gelatin, and the other one receiving only crystalloids. A total of 3,187 patients (India: 18 centers, 2,404 patients; Malaysia: four centers, 394 patients; Taiwan: two centers, 389 patients) were prospectively enrolled in the study and 2,621 were included for multivariate analyses. The primary outcomes were 90-day mortality (n = 2,472), acute kidney injury (AKI) (n = 2,621) and the use of renal replacement therapy (RRT) (n = 2,621). For the 90-day mortality outcome, the authors also compared three subgroups based on the day of the initial colloid dose administration during their ICU stay: day 1, day 2, or day 3. The authors concluded that in critically ill patients the use of colloids, received on day 1 of the ICU stay, was associated with a reduced risk of 90-day mortality and that the initial colloid dose was not associated with an increased risk for AKI or for the use of RRT.After that evidence of higher mortality and AKI in critically ill patients that received HES led to the restrictions by FDA and European Medicines Agency (EMA), the potential for “…intensification of efforts to market HES in low-income and middle-income countries, and that this will mean vulnerable patients […] will bear the highest burden as a consequence” was reported to the Director-General of the World Health Organization in 2018.^2–4 It is therefore not surprising that a group of eminent German scientists that reported no conflict of interest in this trial sponsored by Fresenius Kabi—an HES producing company—coauthored this interesting prospective observational study.A major limitation in interpreting presented data is that the authors pooled evidence collected in patients that received HES—a starch containing colloid—with those of other synthetic and natural colloids. According to the presented data patients treated with HES are consistently a minority: proportions range approximately from one-fifth in the Indian experience to one-tenth in the Malaysian population. How can the authors conclude that “The Rational Fluid Therapy in Asia (RaFTA) registry showed that colloid use was not associated with an increased risk of mortality or AKI but might even be correlated with a survival benefit in the Asian ICU population” when the presented data include mixed evidence from colloids with no reported harm and HES, that is proven to associate with increased mortality and AKI?We wonder which are the current regulatory rules for HES use in the countries where this study was set, and how patients have been informed on the possible and proven risks?⁵     

“I’ve Had an Alarm Set for 3:00 a.m. for Decades”: The Impact of Type 1 Diabetes on Sleep

There is a dearth of research characterizing the impact on a caregiver’s sleep when caring for a minor with type 1 diabetes. This study used focus groups of people with type 1 diabetes and caregivers of minors with type 1 diabetes to explore the experience of how diabetes affects sleep. The occurrence of both unanticipated and planned sleep disruptions led to the majority of participants reporting that their sleep was considerably affected by diabetes. Despite the improvement in blood glucose management that diabetes technology devices can provide, people with type 1 diabetes and their caregivers still report sleep disruption and sleep loss resulting from overnight diabetes management.

The daily self-management behaviors involved in living with type 1 diabetes can be more difficult overnight for people with type 1 diabetes, caregivers, and other household members and can lead to sleep disruptions and emotional experiences such as worrying about severe hypoglycemia occurring during sleep. On average, people with type 1 diabetes experience nocturnal hypoglycemia 25% of the time (1). Emotional experiences can also include fear of hypoglycemia, which refers to extreme worry and anxiety-like symptoms experienced by people living with type 1 diabetes and their caregivers regarding hypoglycemia. Such feelings can result in negative diabetes management behaviors and negatively affect quality of life (2,3). Disturbances caused by diabetes device alarms and fear of hypoglycemia are common barriers to sleep for people with diabetes (4). Research suggests that interventions should be developed to target overnight glycemic management and fear of hypoglycemia to improve sleep quality (5).     

Investigating and Comparing the Effect of Teach-Back and Multimedia Teaching Methods on Self-Care in Patients With Diabetic Foot Ulcers

This study evaluated the effect of teach-back and multimedia teaching methods versus routine care on the self-care of patients with diabetic foot ulcers. Patients receiving either the teach-back or multimedia interventions had greater improvement in self-care scores than those receiving routine care. Both the teach-back and multimedia teaching methods were found to be effective in enhancing the self-care of people with diabetes.

People with diabetes (PWD) account for 7–8% of the total population in Iran (1). PWD are exposed to severe complications such as mental physical problems, including vascular disorders and peripheral neuropathy resulting in diabetic foot ulcers (2–5). Although the number of deaths caused by diabetes complications has decreased in recent years, the number of disabilities caused by diabetes remains high; for example, >70% of amputations are the result of diabetes (6).Diabetic foot ulcers are one of the most important and most common complications of diabetes and the main cause of hospitalization of these patients. Foot ulcers also impose the highest hospital costs on PWD (7). The World Health Organization describes “diabetic foot” as the foot of a person with diabetes who has neurological disorders, some degree of vascular involvement, and susceptibility to infection and ulcer, with or without degradation of deep tissues (8). Diabetic foot ulcers are slow to heal and can disrupt the lifestyle, social activities, health, and quality of life of patients and their caregivers (9). Because of the prevalence of foot ulcers in PWD, we need supportive programs to prevent and control this complication (10).Four risk factors are involved in the development of foot ulcers, including neuropathy, foot deformity, history of previous foot ulcer, and decreased foot circulation. People with these risk factors should receive specific ulcer treatments and implement effective plans to prevent relapse once an ulcer has healed. All PWD—even those without risk factors—need to take good care of their feet because even minor cases can lead to serious problems in these patients (11).Recent studies have shown that several risk factors may be associated with the development of diabetic foot ulcers. Foot ulcers are more common in males, people with longer duration of diabetes (>10 years), older people, those with higher BMIs, and people with other diabetes-associated diseases such as retinopathy, neuropathy, peripheral vascular disease, foot decay, excessive pressure on the soles of the foot (such as from inappropriate shoes and anatomical problems), malnutrition, and infection (12).Diabetes is a chronic disease requiring lifelong adjustment (13). Hence, PWD are expected to carry out rigorous self-care behaviors throughout their life. Evidence has shown that a lack of information and skills needed to manage chronic disease conditions is one of the most important causes of patient noncompliance with treatment and recommendations such as for healthy eating (2).The main goal of diabetes treatment is not only to remove the physical signs and symptoms of the disease, but also to improve the overall quality of life of patients. Self-care is the foundation of health promotion and disease prevention. Thus, providing a self-care educational program helps patients improve their self-care abilities and reduce their fear and dependence, thus enhancing their self-esteem and independence (14). Facilitating the process of self-care can improve the health, economic, and social status of the entire community (15). In addition to reducing hospitalizations, appropriate self-care can prevent many other problems for patients (16). For these reasons, training has a special place in the diabetes treatment process. Having complete information about the overall disease and care is one of the most important rights of patients, and today, patient training is one of the most important care roles and responsibilities of nurses in enhancing patients’ health and ability to adapt to the effects of the disease (17).Training patients via electronic platforms is a new teaching method that allows for the transfer of the concepts and materials in a simpler, more accessible, and more appealing manner. Digital education can involve text, sounds, images, and video elements (18). One form of modern digital teaching is known as the multimedia method (17,19). Multimedia is considered to be an individual teaching method. It is a type of e-learning in which learners learn how to learn (20). Another teaching approach to ensure patient understanding and retention of information is the teach-back method (21). Studies conducted by Oshvandi et al. (22) on heart failure, diabetes, and dialysis patients, respectively, showed that the teach-back teaching increased patients’ self-care behaviors. None of the studies in this area to date have compared the effects of the two teaching methods (teach-back and multimedia) on self-care in PWD.     

Profile of Obstetric Patients in Intensive Care Unit and Untold Stories behind Maternal Deaths and Life-threatening Complications

How to cite this article: Bandyopadhyay, S. Profile of Obstetric Patients in Intensive Care Unit and Untold Stories behind Maternal Deaths and Life-threatening Complications. Indian J Crit Care Med 2021;25(4):362–363.

Obstetric patients who require intensive care unit (ICU) care, take a small share of total ICU admissions. Divatia et al. in their multicenter point prevalence study, which looked into the case-mix of 120 Indian ICUs, reported just 35 obstetric patients out of total 4,209 patients. This makes up to 0.8%. The average APACHE II score of these patients was 13.7 ± 8.5 and there were only one ICU nonsurvivor and one hospital nonsurvivor.¹ This percentage varies across regions and ICUs. It is higher in developing countries than in developed countries. Vasquez et al. in Argentina, when studying obstetric patients in ICU, found as high as 10% of ICU admissions to be obstetric patients. They also had higher mortality.²Obstetric critical care stands out from the other branches of critical care. There remains the question of not only the patient''s outcome but also the fetal outcome. There are diseases specifically due to obstetric complications like antepartum and postpartum hemorrhages and the whole gamut of the diseases related to pregnancy-induced hypertension (PIH). Again there are usual diseases of the ICU, which when occurring in a pregnant patient, are modified due to the different physiologies of pregnancy. One may surmise that the maternal mortality rate, although depending largely on antenatal care and obstetric facilities, also depends on good obstetric critical care. India still has a high maternal mortality rate, although it has steadily improved in the last 5 years.³With this background, the present issue of the Indian Journal of Critical Care Medicine publishes a retrospective case series from the dedicated obstetric ICU in a tertiary care teaching hospital. The patients admitted in the ICU over 18 months were studied. The authors admitted that, as there was also a medical ICU in their hospital, not all obstetric patients, who required ICU care were admitted in their obstetric ICU.⁴There has been studies to this effect from time to time, both prospective and retrospective. They have been from different regions, single-centered and multicentered, from the developed world and the developing world. As one goes through them, one definitely can make out some patterns. The patients in the developed world tend to be older and suffer more from the complications of PIH than from hemorrhage. The reverse is usually true for the patients from the developing world.The present study includes all patients admitted in this ICU during pregnancy and up to 6 weeks after the delivery. The age of the patients were younger compared to western countries and the majority were multigravida. The authors intentionally did not use any disease severity scores in these patients. The effect is that one gets the idea of the diagnoses with which the patients were admitted. But one does not get an idea of the severity of their illness. The authors justify their action, by citing the most of the current severity scores overestimate the mortality in pregnant women. This has been definitely validated by several studies. For example, Rojas-Suarez et al. showed that APACHE II & SAPS II both overestimated mortality in 726 obstetric critical care patients.⁵ However we find that a few Indian as well as western studies do mention such scores, which give us a general idea about the seriousness of the patient''s condition.We note that the major cause of ICU admission remains major obstetric hemorrhages (MOHs) in Asian countries. In the present trial, 47.5% of the admissions were due to obstetric hemorrhages. The second biggest group was that of the patients having complications of PIH, they made up 35.64% of the patients. A similar picture was found in some other studies from India. A study from a tertiary care teaching hospital in Pondicherry reported that 51% admissions in the ICU for the obstetric patients were due to obstetric hemorrhage, and just 18% due to the complications of PIH.⁶ Similarly a 12-year study in a tertiary care hospital from Saudi Arabia showed 32.8% admissions due to obstetric hemorrhage and just 17.2% for PIH.⁷ This contrasts sharply with a study from Argentina where 161 patients of obstetric critical care were studied. PIH and related complications comprised 40% of the patient load and MOH made up just 16%.²Another bane of the ICUs in the developing world, namely, sepsis was quite low in number in this study. Just 5.94% patients had sepsis. Compare this to 28.2% incidence of sepsis in 104 ICU admissions due to obstetric complications in a tertiary care hospital in NOIDA.⁸ Even a nationwide observational study from the Netherlands in 98 obstetric ICUs showed the incidence of sepsis to be higher at 6.6%.⁹Interestingly none of the trials other than the trial from Netherland mentions venous thromboembolisms (VTEs). The Dutch trial mentions fatality, albeit small in number, from VTEs. Do the warmer countries truly have less VTEs or are they missing the diagnoses, remains the question.Although many of the obstetric patients requiring ICU care required mechanical ventilation, some required renal replacement therapy, and a few were in shock, the mortality remained low across the studies. Our present study showed crude mortality of 7.89%, which was lower than the Pondicherry series (13%), Argentina series (11%) but higher than the Dutch series (3.5%). The authors attribute this achievement to their better antenatal care, and the availability of a blood bank in their hospital, which facilitated the management of hemorrhagic complications. In fact they have stated that the mortality was higher among patients who were irregular with their antenatal checkups. Although the numbers were not mentioned.This study along with other similar studies depicts patterns on which one can make conjectures about better handling of critical obstetric patients. The ultimate goal remains to cut down maternal mortality to as low as possible.WHO has said, “There is a story behind every maternal death or life-threatening complications.” We look for such untold stories.     

Quest of Knowledge and Perceived Barriers toward Early Mobilization of Critically Ill Patients in Intensive Care Unit: A Continuing Journey!

How to cite this article: Daptardar AA. Quest of Knowledge and Perceived Barriers toward Early Mobilization of Critically Ill Patients in Intensive Care Unit: A Continuing Journey! Indian J Crit Care Med 2021;25(5):489–490.

Critically ill patients require intensive management before they can recover. Management is even more challenging if they need mechanical ventilation. Early mobilization (EM) in the intensive care unit (ICU) is a physical activity performed as early as the second to fifth day after ICU admission to bring about physiological changes.^1,2EM is defined as mobilization within 72 hours of ICU admission, which is feasible and well-tolerated by most patients once they are stable. It has been difficult to interpret the therapeutic effects of EM due to variations in study populations, interventions, and outcome measures. It has been estimated that up to 46% of ICU patients acquire ICU-acquired weakness, which includes polyneuropathy, myopathy, and/or muscular atrophy during their stay.^3,4 This may have a detrimental effect on the patient''s long-term physical and cognitive functions. Many studies have reported range of motion (ROM) exercises to combat this. The European Society of Intensive Care Medicine has recommended early physical rehabilitation for ICU patients. This has been associated with improved physical function.⁵ Other studies have reported a variety of benefits of EM, which includes reduced mechanical ventilation days, reduced length of ICU stay, reduced hospital length of stay, and improved functional outcomes.^6–8In spite of its potential benefits, EM is not widely performed in the ICU as seen from many international multicenter studies on EM in the ICU, which portrays a low prevalence of out-of-bed mobilization, especially among patients on mechanical ventilation.^9,10 The reason for this may be that mobilizing patients in the ICU is a complex task and is associated with a lot of risks. Equipment and catheters attached to patients can become dislodged causing injury. Critically ill patients who are hemodynamically unstable can also be adversely affected due to mobilization.A growing body of evidence shows the long-term benefits of EM on patient safety, feasibility, functional capacity, strength, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and mortality.^11,12 However, most studies detected considerable barriers to the EM of critically ill adult patients admitted to the ICU which included availability of staff, equipment, oversedation, and lack of education regarding feasibility and safety of EM.In this issue of the journal, a study conducted in the ICU of Tertiary Health Care Academic Institute of Central India, the authors found that majority of members of the multiprofessional team agreed and viewed EM under mechanical ventilation as important and beneficial.¹³ They were knowledgeable about EM and agreed that the benefits of EM outweighed the risks to patients under MV. Similar results were reported in a previous study that analyzed the knowledge and attitudes of multiprofessional healthcare members working in the ICU and delivering care to critically ill patients.¹⁴ The multiprofessional participants in the present study identified several barriers to EM on three levels: (1) Patient-related, such as patient symptoms and conditions, excessive sedation, endotracheal tubes, monitors, and catheters. (2) Provider level barriers, such as limited human and technical resources, limited staffing, and insufficient training. (3) Institutional level barriers related to the ICU culture, lack of proper guidelines, lack of coordination, conflicts of timings of different procedures, and lack of rules for the distribution of tasks and responsibilities.¹³ Similar barriers were also detected in the previous study.¹⁵ In the present study three fourth of the physicians agreed that ROM exercises were sufficient to maintain muscle strength whereas more than half of the physiotherapists and nursing staff disagreed with this. More than half of the physicians were willing to modify the patient level barriers by altering the ventilator settings and reducing sedation to facilitate EM. Although EM was shown to be safe and feasible for patients, there is no information about the staff safety, which was evident by the majority of nursing staff and physiotherapists showing concerns regarding the risk of injuries to the ICU staff during EM. They also reported work stress and long working hours, which might also constitute a considerable barrier to EM in the ICU.¹³The present study confirms that while knowledge continues to advance, practice always remains a step behind, and hence, there is a wide gap between evidence-based knowledge and its application in clinical practice. The study had a small sample size resulting in a selection bias and provided a baseline from one institution only, thus not reflecting the views of other institutions and disciplines. Hence, a multicentre research with a larger sample size or randomized controlled trials is needed to study and evaluate the effects of EM in the ICU using a standardized protocol to determine the optimal timing, intensity, duration, exercise dosage, and progression of mobilization to optimize patient''s physical condition during critical illness.¹⁶     

Focus on the Positive: A Qualitative Study of Positive Experiences Living With Type 1 or Type 2 Diabetes

The purpose of this study was to identify positive experiences associated with diabetes from the perspective of adults diagnosed with type 1 or type 2 diabetes. We conducted in-depth face-to-face and telephone interviews with adults with diabetes. Participants focused on positive and supportive experiences with their peers and community, improved health behaviors, personal growth, and engagement in diabetes advocacy. Communicating positive experiences about diabetes may help clinicians and educators reframe the negative messages commonly shared with people with diabetes.

Diabetes is one of the most significant health problems in the United States and globally. In the United States, an estimated 34.2 million people of all ages—or 10.5% of the population—have diabetes, with the vast majority having type 2 diabetes (1). Diabetes is a group of diseases characterized by high blood glucose levels resulting from the body''s inability to produce or use insulin (2). The two most common forms are type 1 diabetes and type 2 diabetes (2); the former is marked by the body’s inability to produce insulin and the latter by the body’s inability to make enough insulin or to effectively use the insulin it produces (2). Although type 1 diabetes is most commonly diagnosed in childhood or adolescence, it can occur at any age. Likewise, type 2 diabetes is most commonly diagnosed during middle age but can be diagnosed in childhood or adolescence. Recent trends in incidence show increases in both type 1 and type 2 diabetes, especially in children and adolescents (1).Recent data from the Centers for Disease Control and Prevention show that half of U.S. adults with diagnosed diabetes (50.0%) have an A1C value at target (<7.0%) (1). Of these, 19.2% were both nonsmokers and met all three “ABC goals”: A1C <7.0%, blood pressure <140/90 mmHg, and non-HDL cholesterol <130 mg/dL (1). Reaching ABC goals decreases the risk of macrovascular (e.g., cardiovascular disease) and microvascular (e.g., retinopathy, neuropathy, and nephropathy) complications (3–5). Behaviors that promote ABC goal achievement, and in turn reduce the risk for complications, include smoking cessation (6), following a healthy diet (7), losing weight (8), engaging in regular physical activity (9), monitoring blood glucose levels (10), taking medication (11), checking feet (12), and attending clinic appointments (13,14). Active engagement in these behaviors is encouraged in diabetes self-management education and support (DSMES) programs (15,16).DSMES is an important component of care for all people with diabetes (16). DSMES should be person-centered and facilitate learning about diabetes, participating in diabetes decision-making, and acquiring skills for self-care (16). Furthermore, providers who deliver DSMES should incorporate positive, strengths-based language to reduce stigma and feelings of shame and guilt (17,18). Historically, diabetes care and DSMES have focused on behavioral and clinical targets, which may explain their short-term benefits but limited long-term effects on outcomes (19,20). Incorporating personal stories and experiences into diabetes management may help adults with diabetes sustain the benefits they accrue (21–23). However, minimal research has explored positive stories and experiences of living with type 1 or type 2 diabetes. Thus, the purpose of this study was to identify positive experiences with diabetes from the perspective of adults diagnosed with either of these forms of the disease.     

Optic Nerve Sheath Ultrasound: Where do We Go from Here?

How to cite this article: Pichamuthu K. Optic Nerve Sheath Ultrasound: Where do We Go from Here? Indian J Crit Care Med 2021;25(4):360–361.

Raised intracranial pressure (ICP) is a common complication in neurocritical care patients. Identifying raised ICP promptly and monitoring changes in ICP through the course of the patient''s illness are vital to ensuring good clinical outcomes. Various procedures and interventions unrelated to the brain have also been recognized to increase ICP. Clinical signs are woefully inadequate for diagnosing and tracking raised ICP. Traditional imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI) require transport of the patient, may involve radiation, and are not frequently repeatable. They may not be available in secondary hospital setups in our country. Invasive ICP measurement is continuous and accurate but has its drawbacks of invasiveness: procedural skill requirement, infection, and hemorrhage. Ultrasound evaluation of the diameter of the optic nerve sheath visualized behind the globe with a high-frequency ultrasound probe has been recognized to be a good way to detect and track raised ICP.The anatomical basis of this ultrasound imaging is the fact that the meningeal layers of the brain continue around the optic nerve up to the globe of the eye. The dural and arachnoid layers fuse to form the optic nerve sheath. The subarachnoid cerebrospinal fluid (CSF) space around the optic nerve is therefore in continuity with the CSF in the chiasmatic cistern. An increase in CSF pressure leads to distension of the dura-arachnoid sheath and an increase in its diameter. Fibrous trabeculae between the pia and the arachnoid ensure that the sheath is tightly bound to the pia for most of the length of the nerve with only a potential CSF space.^1,2 At the termination of the optic nerve, where it meets the globe, the trabeculae are more elastic so they allow distension of the optic nerve sheath. Thus, the optic nerve sheath distends in response to an elevated CSF pressure only from its attachment to the sclera up to 6–8 mm behind the globe.³ The point of maximum distension is about 3 mm posterior to the globe.Optic nerve sheath ultrasound can be performed in patients who are supine or with the head-end elevated up to 30° with a head neutral position. The optic nerve is insonated through the globe by placing a high-frequency linear probe over the closed eyelid. Images are acquired in axial, parasagittal, and infraorbital coronal planes. The optic nerve is visualized as an anechoic stripe posterior to the sclera. The sheath appears as a hyperechoic layer on either side of the nerve. The optic nerve sheath diameter (ONSD) is measured using calipers from the inner surface of the sheath 3 mm behind the globe. Measurements are taken in different planes and then averaged.Although this ultrasound tool was described in 1987⁴ and expanded on in 1996⁵, it began to be widely used only after studies were published in 2006.⁶ Since then there have been a plethora of publications delving into various aspects of optic nerve ultrasound. Each of these looks into one of three domains in ONSD research. First, there are several articles looking to emphasize the positive correlation between ONSD by ultrasound and raised ICP, detected either by invasive measurements⁷ or by traditional neuroimaging such as CT and MRI.⁸ Meta-analyses of studies done in this domain demonstrate very high sensitivity, specificity, positive and negative predictive values for ONSD in diagnosing of raised ICP. The second domain of focus of ONSD research lies in looking to expand the range of applications of ONSD. The range of applications now includes preeclampsia, high altitude mountain sickness, idiopathic intracranial hypertension, head injury, acute liver failure, and ventriculoperitoneal shunt obstruction.^9,10 The last domain of research focus has been to show how ONSD can change rapidly in response to rapid changes in ICP, thus allowing for real-time tracking of ICP in response to thecal infusions, lumbar puncture, CSF drainage, and procedures such as endotracheal suctioning.¹¹Contributing to this last area of research, Kapoor et al. in the current issue of IJCCM have studied the changes in ONSD that occur during various stages of percutaneous tracheostomy in neurocritical care patients.¹² These authors have shown that the ONSD rises during all stages of percutaneous tracheostomy, though only five patients had a rise significant enough to warrant osmotherapy. It is important to emphasize here that the differences in measured ONSD between various phases of the procedure are insignificant, below the minimum detectable difference (the differences are very small and are smaller than the magnitude of inter and intra-observer variation), with significant overlap of standard deviations. This means that the differences in ONSD during various stages of the percutaneous tracheostomy were insignificant in the majority of the studied patients. There is truly little information on whether optic nerve sheath US can be used to monitor ICP during procedures on neurocritical care patients and the current study attempts to fill the wide gap. An important takeaway from this study is that it is feasible to monitor ONSD at the bedside during procedures in the intensive care unit (ICU).If the evidence so strongly suggests that ultrasound ONSD reliably diagnoses and tracks raised ICP, why is it not being used more widely in day-to-day intensive care practice? One of the most common reasons is the inter- and intraobserver variation that we encounter, making it less reliable and reproducible at the bedside. The second reason is like all other ultrasound modalities, ONSD is time and labor-intensive.I believe that to rid us all of our disillusionment with ONSD and ensure that patients benefit from this revolutionary way of non-invasively monitoring ICP, we need to have a four-pronged approach.The first approach is to standardize the procedure. We know that variations in probe frequency, view, gain, and placement of cursors all have an impact on the measured ONSD.¹³ We need a consensus on the correct procedural technique and that points to the grade the quality of the image. We need to do this at the earliest. This will also reduce the heterogeneity of ONSD research, which impairs applicability.The second step is to stop being obsessed with numbers. A lot of unreliability of ONSD stems from the uncertainty around the correct placement of the cursors to measure the diameter, especially in patients without raised ICP. Moving to a qualitative, pattern recognition-based approach to diagnose raised ICP is reliable and more reproducible.¹³ This qualitative approach with the incorporation of papilledema greatly increases the ease of diagnosing raised ICP by a novice. Quantitative ONSD measurements can be reserved for patients with raised ICP to track changes over time.The last step is to ensure adequate training prior to performing ONSD scans. While the number of scans needed to train an ultrasound expert has been determined to be 10, novices may need 25 scans before independent practice. The training needs to focus on elucidating the anatomical details of the nerve–sheath–globe complex. Particular attention needs to be focused on training in identifying possible artifacts, including lamina cribrosa associated edge artifacts, and using retinal artery Doppler to identify the correct position of the optic nerve.¹⁴Finally, we need more studies that can compare ONSD-based treatment regimens with standard treatment to determine if ONSD ultrasound results in the improvement of meaningful clinical outcomes.Urgent steps along these lines will ensure that this unique window into the brain has its correct and well-deserved place at the bedside of a patient with raised ICP.     

Corona Collateral Damage Syndrome: Perception of the Damage

How to cite this article: Ahmed A. Corona Collateral Damage Syndrome: Perception of the Damage. Indian J Crit Care Med 2021;25(4):358–359.

The world has been reeling under the coronavirus disease-2019 (COVID-19) pandemic, and none have remained unaffected, directly or indirectly, by this novel severe acute respiratory syndrome coronavirus-2. With its high velocity of spread and magnitude, it has had a significant impact on the healthcare delivery system and posed a challenge across the globe. With over 115 million cases around the world and mortality figures of 2.5 million and counting, countries continue to fight this once-in-a-century-time pandemic.¹ The COVID-19 infection has had a direct negative effect on public health, social welfare and economy.The other major concern has been the collateral impact on non-COVID-19 patient care, namely the corona collateral damage syndrome (CCDS), which has been predicted to have a higher mortality than COVID-19 itself, and it is also difficult to measure.² This clinical condition results from delay or avoidance of seeking medical care for non-COVID-19 acute emergency conditions and has been attributed to fear of patients getting infected on coming to the hospital and social stigma attached to it. This was further reinforced by policies like lockdown and directives of staying indoors.However, there is another cause, and it is related to a change in priorities of working, drastic shift in the working pattern, and focus on healthcare institutions, i.e., managing only COVID-19 patients at the cost of non-COVID-19 medical and surgical patients. It was based on the giant surge and wave of patients suffering from COVID-19 infection, who were getting admitted and overwhelming the healthcare services in certain nations. Healthcare systems adopted an overcautious and defensive approach so as not to exhaust the medical services and preserve its resources and manpower from the jaws of COVID-19.³ Fear was also an underlying factor in the minds of all healthcare workers (HCWs), and it was about perceptions of the worst and the unknown.In this current edition, Swagata et al.⁴ have surveyed the perceptions that HCWs carried about the impact of the COVID-19 pandemic on the delivery of acute care services for non-COVID-19 patients and the reason for its change. Set in within 2 months of the lockdown when all HCWs were grappling and gearing up at various fronts, to counter and adapt to this unknown and unanticipated challenge, which came in like a violent storm, this prospective study has made a fair effort to assess how these perceptions were influenced by HCWs and institutional characteristics, at a time when the visibility on future was unclear. The authors have done a remarkable job by doing the electronic survey and received 392 responses (32.1%) with an 84.1% completion rate over a three-week period during the busy peak time. The number of participants is also comparable to other studies done during this period. As per their study, 60.1% of HCWs perceived a reduction in patient visit to the hospital. It shows that the HCWs were quite aware of the possible impact of this pandemic on the various fronts as was evident in the answer to the questions, and this study could measure this awareness with evidence. Studies have highlighted the marked decrease in the number of patients visiting hospitals, and the outpatient department visits have been affected up to 92%.⁵ A 50% reduction in number was seen in patients attending hospital for a cardiac ailment, whereas the cancer-related services were also down by 27%.^6,7 Effect of the pandemic has also been evident on patients with kidney diseases where almost 28.2% of patients missed one or more dialysis services while 4.13% did not turn up at all, further substantiating the CCDS.⁵Regarding the reasons for changes in service provision and utilization, 58% of HCWs in this study attributed it to lockdown and the fear of infection along with the social nuances. This corroborates with the findings of the Society for Cardiovascular Angiography and Interventions consumer survey determining the fears of the people related to the COVID-19 pandemic.⁸ They had reported that 61% of patients feared contracting an infection if they visited the hospital and 57% wanted to avoid urgent medical attention. 52% of people feared COVID-19 more than heart attack and stroke and that was the magnitude of the fear and uncertainty.While most studies during that period looked at the perceptions regarding the behavior and stress of HCWs, the current study, in addition to the above-mentioned studies, included the HCWs perceptions about the impact on acute healthcare services along with the reason for such a change.In this present study, 56.1% of HCWs avoided duty, when it was evaluated in terms of the perception of HCWs’ behavior. These findings were consistent with the observational cross-sectional study by Kumar et al. that was done on 329 HCWs.⁹ They reported that 65% of doctors were reluctant to work during the pandemic in their study. The fear factor was as high as 84.8% as compared to 50.1% seen in the study by Swagata et al. Even the fear for their family and reluctance to work were higher at 94.2% against the 60.2% reported in the current study. Now, these observations were inevitable and have again been highlighted by this study; given the tough and challenging responsibility, the HCWs were shouldering amidst the uncertainties and many unanswered questions. Chatterjee et al.¹⁰ and similar studies have reported that almost 34.9% of HCWs perceived depression while an equal number felt stress and anxiety. Interestingly, lack of protective equipment and high workload were not perceived as contributors to CCDS in the current study contrary to the other published reports.The current study was conducted using a questionnaire-based survey done on a small population that was of mixed variants and in a short period of time. The selection bias and volunteer effect hence cannot be negated completely. Another limitation has been that this study has not touched upon the objective impact of the perceptions of healthcare workers on acute care services related to cardiology, oncology, surgery, and nephrology. It would have been more complete if the respondents had also been asked about the percentage change that was expected, and then the actual impact on the care of patients and effect could have been measured as a follow-up of this study.This once in a century situation has had no parallels. With passing time, there will be better clarity regarding the understanding of the disease process and it''s trend. It will improve the knowledge, attitude and also change the perception which will allay the fear of the unknown. With the successful advent of vaccination and the better gearing up of resources, there is a fresh ray of hope regarding the control of this pandemic.     

Spectrum of Plant Toxin and Deliberate Self-poisoning

How to cite this article: Banerjee T, Datta A. Spectrum of Plant Toxin and Deliberate Self-poisoning. Indian J Crit Care Med 2021;25(4):364–365.

Deliberate self-poisoning (DSP) is a significant global problem and a rising cause of total death worldwide. The incidence of poisoning in India is among the highest in the world with estimated 50,000 deaths per year.¹ Despite the vast number, evidence on prevalence patterns in India is yet limited. Different causes of poisoning include insecticides, household agents, pesticides, industrial chemicals, plants, and animal bites and stings. In India, toxic exposures related to plants account for 6–15%, however, the incidence is much higher in the rural population.² There are more than 4,000 species of medicinal plants, growing as shrubs and herbs, many of them are potentially poisonous and fatal when consumed in high doses.³ They include oleander (cardiotoxin), Oduvanthalai (Cleistanthus collinus) (miscellaneous toxin), strychnine (nux vomica—neurotoxin), Datura (neurotoxin), and others (castor, cactus, henna, etc.). India being a large country, literature data are still limited in relation to common plant poisons consumed, method of ingestion, demographic profile, seasonal variation, socioeconomic data, toxicology pattern, case fatality, and outcome. It is very important to understand the toxicology mechanism and clinical manifestation of different plant poisons consumed as toxicological pattern differs based on culture, availability, and geographic locations across world over.⁴ The current study by Kundavaram Paul Prabhakar Abhilash and others from Christian Medical College, Vellore intends to fill the above mentioned gaps.Oleander (Thevetia peruviana) poisoning is toxic to cardiac muscles and leads to dysfunction of the autonomic nervous system due to the high concentration of cardiac glycosides. Clinical manifestation includes cardiac dysrhythmias, electrolyte imbalance, and cardiac shock being an important cause of death. Gastric lavage with activated charcoal, cardiac monitoring, adequate hydration, and correction of electrolyte abnormalities with probable temporary cardiac pacing is the principles of symptomatic management.⁵ Specific antibodies, such as Digoxin-specific Fab fragment have been successfully used in adult patients, but lack of availability in India restricts their use.⁶ Oduvanthalai (C. collinus) poisoning affects cardiac, renal, metabolic system leading to intractable metabolic acidosis, electrolyte imbalance (hypokalemia), neuromuscular blockade, type 2 respiratory failure leading to death due to toxic constituents cleistanthin and cleistanthin B (glycosides), and diphyllin (arylnaphthalene lignan lactones) found in them. Gastric lavage, correction of electrolyte abnormalities, fluid balance, and cardiac monitoring are the mainstay of management.⁷ Datura (Datura stramonium) poisoning is due to highly toxic anticholinergic properties leading to agitation, tachycardia, delirium, hyperthermia, dilated pupils, and hallucination. Treatment such as gastric lavage and supportive measures are indicated.⁸ Nux vomica (Strychnine nux-vomica) contains highly toxic alkaloids (strychnine and brucine) and has a deleterious effect on the central nervous system. Clinical features include severe metabolic acidosis, opisthotonus, hyperthermia, rhabdomyolysis, renal failure, and respiratory failure leading to death. Treatment is symptomatic with adequate hydration, cardiac, and neurological monitoring.⁹In the current study by Kundavaram Paul Prabhakar Abhilash and others from Christian Medical College, Vellore, 8.2% (150/1821) of DSP cases were with plant poisoning, incidents were higher in the young age group (16–30 years) with female predominance (60%). A seasonal pattern with an increasing trend in the month of April was observed. Those who consumed plant poisons (48%) attributed it to domestic violence. The other factors were unknown (32%), personal issues (0.06%), relationship issues (0.04%), financial issues (0.04%), health (0.02%), and workplace issues (0.02%). A literature search from other studies also showed similar findings with a significant increase of incidences in rural subjects, rural females, and low/middle socioeconomic class.^2,10 Most common ingested poison was oleander (T. peruviana) (59%), Oduvanthalai (C. collinus) (30.7%), nux vomica (S. nux-vomica) (3%), Datura (D. stramonium) (3%), and others (5.3%) included henna (1.3%), cactus (1.3%), and a case each of castor, Gloriosa superba, Adentera pavonina, and Abrus precatorius. The various methods of ingestion were crushed/ground seeds (49%), decoction of leaves (28%), followed by crushed/ground leaves (27%), and chewing and swallowing (9%). There is very limited data available on relative incidence for each of the plants. One study in a tertiary care center in Southern India has detected Oduvanthalai (C. collinus) as the commonest plant poison followed by oleander, strychnine, kalli paal (a poisonous cactus), Datura, papaya, and chrysanthemum in this region.¹¹ Consumption of decoction (OR: 5, 95% CI: 2.27–14.00, p-value: <0.001) and metabolic acidosis (pH <7.35) (OR: 11.48, 95% CI: 4.17–31.57, p-value: <0.001) were more common in Oduvantahlai poisoning as compared to oleander. In-hospital mortality in the study was (9.3%) little higher with other similar studies (6.7%).⁵Time has come for more research-related work in this field at the community level to eliminate selection bias considering the diverse geographic locations, addressing the socioeconomic issues, understanding common plant poisons consumed, toxicology patterns, clinical manifestations so that the emergencies can be dealt more effectively. Few of these plant poisons have any specific antidotes that also need to be addressed. This further emphasizes the need for developing new strategies taking into consideration socioeconomic factors, demographic profile, and medical management options including means to reduce poison absorption which in turn can rapidly reduce deaths resulting from DSP across India.