Association between a prolonged corrected QT interval and outcomes in patients in a medical Intensive Care Unit

Introduction:

Patients admitted into a medical Intensive Care Unit (ICU) have varying illnesses and risk factors. An electrocardiogram (ECG) is a useful tool to assess the cardiac status. The aim of the study was to determine the prevalence of QT prolongation of the ECG in patients admitted to a medical ICU in a tertiary hospital, to assess outcomes in terms of mortality, cardiovascular events, and duration of ICU stay.

Materials and Methods:

Prospective observational study, 6 months duration, assessing the prevalence of prolonged corrected QT interval (QTc) at admission into a medical ICU. A QTc calculated by Bazett''s formula, of >440 ms for males and >460 ms for females was considered prolonged. Details of illness, clinical and lab parameters were monitored.

Results:

The total number of patients screened was 182. There was a high prevalence of prolonged QTc (30%) on admission to the ICU. This reduced to 19% on day 3 (P = 0.011). In patients with a prolonged QTc the odds ratio of adverse outcome from ICU was 3.17 (confidence interval [CI]: 1.52–6.63) (P = 0.001) and of adverse outcome for hospital stay was 2.27 (CI: 1.11–4.66) (P = 0.014). In the study, 35% of all patients received drugs with QT prolonging action. Of patients with a prolonged QTc at admission 18 (35%) received a QT prolonging drug.

Conclusions:

We found that prolonged QTc is common (30%) in our medical ICU at admission and a large proportion (35%) received drugs capable of prolonging QT interval. These patients with QTc prolongation have a higher odds ratio for adverse outcomes.     

Comparison of acute physiology and chronic health evaluation II and acute physiology and chronic health evaluation IV to predict intensive care unit mortality

Context:

Clinical assessment of severity of illness is an essential component of medical practice to predict the outcome of critically ill-patient. Acute Physiology and Chronic Health Evaluation (APACHE) model is one of the widely used scoring systems.

Aims:

This study was designed to evaluate the Performance of APACHE II and IV scoring systems in our Intensive Care Unit (ICU).

Settings and Design:

A prospective study in 6 bedded ICU, including 76 patients all above 15 years.

Subjects and Methods:

APACHE II and APACHE IV scores were calculated based on the worst values in the first 24 h of admission. All enrolled patients were followed, and outcome was recorded as survivors or nonsurvivors.

Statistical Analysis Used:

SPSS version 17.

Results:

The mean APACHE score was significantly higher among nonsurvivors than survivors (P < 0.005). Discrimination for APACHE II and APACHE IV was fair with area under receiver operating characteristic curve of 0.73 and 0.79 respectively. The cut-off point with best Youden index for APACHE II was 17 and for APACHE IV was 85. Above cut-off point, mortality was higher for both models (P < 0.005). Hosmer–Lemeshow Chi-square coefficient test showed better calibration for APACHE II than APACHE IV. A positive correlation was seen between the models with Spearman''s correlation coefficient of 0.748 (P < 0.01).

Conclusions:

Discrimination was better for APACHE IV than APACHE II model however Calibration was better for APACHE II than APACHE IV model in our study. There was good correlation between the two models observed in our study.     

Hypoalbuminemia in critically sick children

Context:

There is a paucity of data evaluating serum albumin levels and outcome of critically ill-children admitted to intensive care unit (ICU).

Aims:

The aim was to study frequency of hypoalbuminemia and examine association between hypoalbuminemia and outcome in critically ill-children.

Settings and Design:

Retrospective review of medical records of 435 patients admitted to 12 bedded pediatric ICU (PICU).

Materials and Methods:

Patients with hypoalbuminemia on admission or any time during PICU stay were compared with normoalbuminemic patients for demographic and clinical profile. Effect of albumin infusion was also examined. Odds ratio and 95% confidence interval were calculated using SPSS 16.

Results:

Hypoalbuminemia was present on admission in 21% (92 of 435) patients that increased to 34% at the end of 1^st week and to 37% (164 of 435) during rest of the stay in PICU. Hypoalbuminemic patients had higher Pediatric Risk of Mortality scores (12.9 vs. 7.5, P < 0.001) and prolonged PICU stay (13.8 vs. 6.7 days, P < 0.001); higher likelihood of respiratory failure requiring mechanical ventilaton (84.8% vs. 28.8%, P < 0.001), prolonged ventilatory support, progression to multiorgan dysfunction syndrome (87.8% vs. 16.2%) and risk of mortality (25.6% vs. 17.7%). Though, the survivors among recipients of albumin infusion had significantly higher increase in serum albumin level (0.76 g/dL, standard deviation [SD] 0.54) compared with nonsurvivors (0.46 g/dL, SD 0.44; P = 0.016), albumin infusion did not reduce the risk of mortality.

Conclusions:

Hypoalbuminemia is a significant indicator of mortality and morbidity in critically sick children. More studies are needed to define role of albumin infusion in treatment of such patients.     

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

Context:

Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality.

Aims:

To study the risk factors for HAH in settings that practice a preventive protocol.

Settings and Design:

Two tertiary-care hospitals. Prospective observational study design.

Materials and Methods:

Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h.

Statistical Analysis Used:

Risk factors associated with HAH was analysed by multiple logistic regression.

Results:

Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years (P = 0.02), acute kidney injury (AKI) on admission (P = 0.01), mechanical ventilation (P = 0.01), need for ionotropes (P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission (P < 0.001), enteral tube feeds (P = 0.002), negative fluid balance (P = 0.02) and mannitol use (P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients.

Conclusions:

The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.     

Comparison of anxiety, depression, and post-traumatic stress symptoms in relatives of ICU patients in an American and an Indian public hospital

Context:

An intensive care unit (ICU) admission of a patient causes considerable stress among relatives. Whether this impact differs among populations with differing sociocultural factors is unknown.

Aims:

The aim was to compare the psychological impact of an ICU admission on relatives of patients in an American and Indian public hospital.

Settings and Design:

A cross-sectional study was carried out in ICUs of two tertiary care hospitals, one each in major metropolitan cities in the USA and India.

Materials and Methods:

A total of 90 relatives visiting patients were verbally administered a questionnaire between 48 hours and 72 hours of ICU admission that included the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II (BDI-II) and Impact of Events Scale-Revised (IES-R) for post-traumatic stress response.

Statistical Analysis:

Statistical analysis was done using the Mann-Whitney and chi-square tests.

Results:

Relatives in the Indian ICU had more anxiety symptoms (median HADS-A score 11 [inter-quartile range 9-13] vs. 4 [1.5-6] in the American cohort; P<0.0001), more depression symptoms (BDI-II score 14 [8.5-19] vs. 6 [1.5-10.5], P<0.0001) but a comparable post-traumatic stress response (IES-R score>30). 55% of all relatives had an incongruous perception regarding “change in the patient''s condition” compared to the objective change in severity of illness. “Change in worry” was incongruous compared to the perception of improvement of the patient''s condition in 78% of relatives.

Conclusions:

Relatives of patients in the Indian ICU had greater anxiety and depression symptoms compared to those in the American cohort, and had significant differences in factors that may be associated with this psychological impact. Both groups showed substantial discordance between the perceived and objective change in severity of illness.     

Relationship between glycated hemoglobin,Intensive Care Unit admission blood sugar and glucose control with ICU mortality in critically ill patients

Background and Aims:

The association between hyperglycemia and mortality is believed to be influenced by the presence of diabetes mellitus (DM). In this study, we evaluated the effect of preexisting hyperglycemia on the association between acute blood glucose management and mortality in critically ill patients. The primary objective of the study was the relationship between HbA₁c and mortality in critically ill patients. Secondary objectives of the study were relationship between Intensive Care Unit (ICU) admission blood glucose and glucose control during ICU stay with mortality in critically ill patients.

Materials and Methods:

Five hundred patients admitted to two ICUs were enrolled. Blood sugar and hemoglobin A₁c (HbA₁c) concentrations on ICU admission were measured. Age, sex, history of DM, comorbidities, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, hypoglycemic episodes, drug history, mortality, and development of acute kidney injury and liver failure were noted for all patients.

Results:

Without considering the history of diabetes, nonsurvivors had significantly higher HbA₁c values compared to survivors (7.25 ± 1.87 vs. 6.05 ± 1.22, respectively, P < 0.001). Blood glucose levels in ICU admission showed a significant correlation with risk of death (P < 0.006, confidence interval [CI]: 1.004–1.02, relative risk [RR]: 1.01). Logistic regression analysis revealed that HbA₁c increased the risk of death; with each increase in HbA₁c level, the risk of death doubled. However, this relationship was not statistically significant (P: 0.161, CI: 0.933–1.58, RR: 1.2).

Conclusions:

Acute hyperglycemia significantly affects mortality in the critically ill patients; this relation is also influenced by chronic hyperglycemia.     

Could a protocol based on early goal-directed therapy improve outcomes in patients with severe sepsis and septic shock in the Intensive Care Unit setting?

Context:

Sepsis is a disease with high incidence and mortality. Among the interventions of the resuscitation bundle, the early goal-directed therapy (EGDT) is recommended.

Aims:

The aim was to evaluate outcomes in patients with severe sepsis and septic shock using EGDT in real life compared with patients who did not undergo it in the Intensive Care Unit (ICU) setting.

Settings and Design:

retrospective and observational cohort study at tertiary hospital.

Subjects and Methods:

All the patients admitted to ICU were screened for severe sepsis or septic shock and included in a registry and followed. The patients were allocated in two groups according to submission or not to EGDT.

Results:

A total of 268 adult patients with severe sepsis or septic shock were included. EGDT was employed in 97/268 patients. The general mortality was higher in no early goal-directed therapy (no-EGDT) then in EGDT groups (49.7% vs. 37.1% [P = 0.04] in hospital and 40.4% vs. 29.9% [P = 0.08] in the ICU, respectively. The general length of stay [LOS] in the no-EGDT and EGDT groups was 45.0 ± 59.8 vs. 29.1 ± 30.1 days [P = 0.002] in hospital and 17.4 ± 19.4 vs. 9.1 ± 9.8 days [P < 0.001] in the ICU, respectively).

Conclusions:

Our study shows reduced mortality and LOS in patients submitted to EGDT in the ICU setting. A simplified EGDT without central venous oxygen saturation is an important tool for sepsis management.     

Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit

Context:

The role of hand hygiene in preventing health care associated infections (HCAIs) has been clearly established. However, compliance rates remain poor among health care personnel.

Aims:

a) To investigate the health care workers’ hand hygiene compliance rates in the intensive care unit (ICU), b) to assess reasons for non-compliance and c) to study the efficacy of a multimodal intervention strategy at improving compliance.

Settings:

A mixed medical–surgical ICU of a tertiary level hospital.

Design:

A before–after prospective, observational, intervention study.

Materials and Methods:

All health care personnel who came in contact with patients in the ICU were observed for their hand hygiene compliance before and after a multimodal intervention strategy (education, posters, verbal reminders and easy availability of products). A self-report questionnaire was also circulated to assess perceptions regarding compliance. Statistical analysis was done using χ² test or Fisher exact test (Epi info software).

Results:

Hand hygiene compliance among medical personnel working in the ICU was 26% and the most common reason cited for non-compliance was lack of time (37%). The overall compliance improved significantly following the intervention to 57.36% (P<0.000). All health care worker groups showed significant improvements: staff nurses (21.48–61.59%, P<0.0000), nursing students (9.86–33.33%, P<0.0000), resident trainees (21.62–60.71%, P<0.0000), visiting consultants (22–57.14%, P=0.0001), physiotherapists (70–75.95%, P=0.413) and paramedical staff (10.71–55.45%, P< 0.0000).

Conclusions:

Hand hygiene compliance among health care workers in the ICU is poor; however, intervention strategies, such as the one used, can be useful in improving the compliance rates significantly.     

Impact of positive fluid balance on mortality and length of stay in septic shock patients

Background:

Fluid management is important in critically patients. The aim of this study was to determine the relationship between fluid balance and adverse outcomes of septic shock.

Methods:

A retrospective study was conducted in the medical Intensive Care Unit (ICU) of a tertiary university hospital in Thailand, over a 7-year period.

Results:

A total of 1048 patients with an ICU mortality rate of 47% were enrolled. The median cumulative fluid intake at 24, 48, and 72 h from septic shock onset were 4.2, 7.7, and 10.5 L, respectively. Nonsurvivors had a significantly higher median cumulative fluid intake at 24, 48, and 72 h (4.6 vs. 3.9 L, 8.2 vs. 7.1 L, and 11.4 vs. 9.9 L, respectively, P < 0.001 for all). Nonsurvivors also had a significantly higher cumulative and mean fluid balance within 72 h (5.4 vs. 4.4 L and 2.8 vs. 1.6 L, P < 0.001 for both). In multivariate logistic regression analysis, mean fluid balance quartile within 72 h, was independently associated with an increase in ICU and hospital mortality. Quartile 3 and 4 have statistically significant increases in mortality compared with quartile 1 (odds ratio [95% confidence interval] 3.04 [1.9–4.48] and 4.16 [2.49–6.95] for ICU mortality and 2.75 [1.74–4.36] and 3.16 [1.87–5.35] for hospital mortality, respectively, P < 0.001 for all). In addition, the higher amount of mean fluid balance was associated with prolonged ICU stays.

Conclusions:

Positive fluid balance over 3 days is associated with increased ICU and hospital mortality along with prolonged ICU stays in septic shock patients.     

Glycemic variability and outcome in critically ill

Background:

Acute hyperglycemia, hypoglycemia and glycemic variability (GV) have been found to be the three principal domains of glycemic control, which can adversely affect patient outcome. GV may be the confounding factor in tight glycemic control trials in surgical and medical patient.

Objective:

This study was conducted to establish if there was any relationship between GV and intensive care unit (ICU) mortality in the Indian context.

Study Design:

A retrospective review of a large cohort of prospectively collected database.

Setting:

Adult Medical/Surgical/Trauma/Neuro ICU of a tertiary care hospital.

Patient Population:

All patients who had four or more blood glucose measured during the ICU stay.

Outcome:

ICU mortality.

Result:

2208 patients with a total of 11,335 blood glucose values were analyzed. GV measured by the standard deviation (SD) of mean blood glucose and glycemic lability index (GLI), both were significantly (P < 0.001) associated with ICU mortality. This relationship was maintained (odds ratio (OR): 2.023, 95% confidence interval (CI): 1.483-2.758) even after excluding patients with hypoglycemia (<60 mg/dl). Patients with blood glucose values in the euglycemic range but highest SD had higher mortality (54%) compared to mortality (24%) in patients above the euglycemic range. Similarly patients with blood sugar values below the average for study cohort and high GLI, another marker of GV had higher mortality (OR: 5.62, CI: 3.865-8.198) than compared to patients in the hyperglycemic range, reflecting the importance of GV as a prognostic marker in patients with blood sugar in the euglycemic range.

Conclusion:

This study demonstrated that high glucose variability is associated with increased ICU mortality in a large heterogeneous cohort of ICU patients. This effect was particularly evident among patients in the euglycemic range.     

Propofol versus flunitrazepam for inducing and maintaining sleep in postoperative ICU patients

Context:

Sleep deprivation is a common problem on intensive care units (ICUs) influencing not only cognition, but also cellular functions. An appropriate sleep-wake cycle should therefore be maintained to improve patients’ outcome. Multiple disruptive factors on ICUs necessitate the administration of sedating and sleep-promoting drugs for patients who are not analgo-sedated.

Aims:

The objective of the present study was to evaluate sleep quantity and sleep quality in ICU patients receiving either propofol or flunitrazepam.

Settings and Design:

Monocentric, randomized, double-blinded trial.

Materials and Methods:

A total of 66 ICU patients were enrolled in the study (flunitrazepam n = 32, propofol n = 34). Propofol was injected continuously (2 mg/kg/h), flunitrazepam as a bolus dose (0.015 mg/kg). Differences between groups were evaluated using a standardized sleep diary and the bispectral index (BIS).

Statistical Analysis Used:

Group comparisons were performed by Mann-Whitney U-Test. P < 0.05 was considered to be statistically significant.

Results:

Sleep quality and the frequency of awakenings were significantly better in the propofol group (Pg). In the same group lower BIS values were recorded (median BIS propofol 74.05, flunitrazepam 78.7 [P = 0.016]). BIS values had to be classified predominantly to slow-wave sleep under propofol and light sleep after administration of flunitrazepam. Sleep quality improved in the Pg with decreasing frequency of awakenings and in the flunitrazepam group with increasing sleep duration.

Conclusions:

Continuous low-dose injection of propofol for promoting and maintaining night sleep in ICU patients who are not analgo-sedated was superior to flunitrazepam regarding sleep quality and sleep structure.     

Can we predict intensive care relatives at risk for posttraumatic stress disorder?

Aims:

To identify the relatives of the intensive care unit (ICU) patients at risk for developing symptoms of posttraumatic stress disorders.

Setting:

A multidisciplinary hospital ICU.

Design:

Prospective single center observational study.

Material and Methods:

Relatives of patients admitted in the ICU (May06-Nov06) who consented to answer the questionnaire participated in the study. Anxiety was assessed by using the Hospital Anxiety and Depression Scale (HAD) and vulnerability to posttraumatic disorder (PTSD) by using the Impact of Event Scale Revised (IES-R) which was administered on the fifth day of admission and at two months following discharge or death.

Results:

During admission, 48% of the relatives had a HAD score >11 and 72% showed IES-R score >26. There was no association of HAD with gender, patient outcome, working status, age of the patient, or mode of payment of the bills. There was significant association of IES-R >26 with trauma admission, HAD score >11 and mode of payment with the relatives of insured being more stressed as compared to those who settled their bills personally. A total of 35% relatives showed symptoms of posttraumatic stress reaction consistent with a high risk of PTSD after two months. Death in the hospital resulted in elevated HAD and IES-R score during admission and at the two month follow-up. Persistence of stress symptoms was more in school drop outs, working relatives, parents and those with initial anxiety score >11.

Conclusions:

HAD score greater than 11 was the only factor at admission which could statistically predict a higher PTSD score on follow-up. Adequate counseling of this group of relatives may prevent lasting psychological sequelae of an ICU admission in the relatives of critically ill.     

Aluminum phosphide (celphos) poisoning in children: A 5-year experience in a tertiary care hospital from northern India

Background:

Aluminum phosphide (ALP) (celphos) is an agricultural pesticide commonly implicated in poisoning. Literature pertaining to the clinical manifestations and treatment outcome of its poisoning among children is limited.

Materials and Methods:

A retrospective chart review was conducted of the medical records of 30 children aged less than 14 years admitted to pediatric intensive care unit (PICU) of a tertiary care hospital in northern India. Demographic, clinical, and laboratory parameters were recorded. The outcome was categorized into “survivors” and “nonsurvivors.”

Results:

The Mean (SD) age of the enrolled children [19 males (63.3%)] was 8.55 (3.07) years. Among the 30 children, 14 (46.67%) were nonsurvivors and the rest 16 (53.33%) were survivors. Nonsurvivors had ingested significantly higher doses of ALP (P < 0.001), and showed higher time lag to PICU transfer (P 0.031), presence of abnormal radiological findings on chest skiagram (P = 0.007), and a higher Pediatric Risk of Mortality (PRISM) III score (P < 0.001) at admission. Use of magnesium sulfate was associated significantly with survival [odds ratio (OR) (95% CI): 0.11 (0.02-0.66); P 0.016].

Conclusion:

The present study highlights that survival among children with ALP poisoning is predicted by dose of ALP ingestion, time lag to medical attention, and higher PRISM score at admission. Use of magnesium sulfate could be associated with better survival among them.     

Urinary neutrophil gelatinase-associated lipocalin in critically ill surgical cancer patients

Background and Aims:

Neutrophil gelatinase-associated lipocalin (N-GAL) is an early biomarker of acute kidney injury (AKI) due to various etiologies. On the other hand, N-GAL is also elevated in patients with acute inflammatory conditions and in several solid neoplasms. The goal of this study was to assess the efficacy of N-GAL as a predictor of AKI and mortality in oncological surgical patients postoperatively in the intensive care unit (ICU).

Methods:

This was a prospective cohort observation study on adult cancer patients submitted to elective or emergency surgeries and admitted in the ICU. Urinary N-GAL was measured at the first 2 h after admission. AKI incidence and other complications were assessed, including hospital mortality.

Results:

A total of 22 patients were assessed (77% male, age 52.8 years, Acute Physiology and Chronic Health Evaluation II [APACHE II] 17.3) in whom the most frequent site of cancer was the gastrointestinal tract. AKI incidence was 13.6%. Urinary N-GAL was a predictor of AKI (22.0 ng/ml in patients without AKI vs. 239.1 ng/ml in patients with AKI, P < 0.001). Multivariate analysis showed that the main predictors of AKI were age, APACHE II, and N-GAL. N-GAL was also higher, although not statistically significant in patients who died in the hospital.

Conclusions:

In oncological postoperative patients admitted to the ICU, urinary N-GAL was an independent predictor of AKI; moreover, its level was higher in the deceased patients.     

Comparison of post-operative ICU sedation between dexmedetomidine and propofol in Indian population

Context:

Critically ill patients requiring mechanical ventilation frequently need sedatives and analgesics to facilitate their care. Dexmedetomidine, a short-acting alpha-2-agonist, possesses anxiolytic, anesthetic, hypnotic, and analgesic properties.

Aims:

The objective of this study was to evaluate the efficacy and safety of dexmedetomidine in comparison to propofol in the management of sedation for post-operative intensive care unit (ICU) patients, as a sedative agent.

Settings and Design:

Teaching hospital, A phase III, prospective, open, randomized and comparative.

Materials and Methods:

Thirty patients who were ambulatory and who required the post-operative mechanical ventilation or post-operative sedation were enrolled, in which 15 patients received Dexmedetomidine and remaining 15 patients received propofol. All these patients were treated for the period of 8 to 24 h.

Statistical Analysis Used:

Data were analyzed using Student''s t-test and Chi-square test. The value of P < 0.05 was considered as statistically significant.

Results:

Demographic data were comparable. Pulse rate, respiratory rate and blood pressure were comparable. Depth of sedation and extubation time were similar. To maintain analgesia throughout the study period, patients receiving propofol infusions required significantly more analgesics than patients receiving Dexmedetomidine.

Conclusions:

Dexmedetomidine appears to be a safe and acceptable ICU sedative agent when both the clinician''s and patient''s perspectives are considered.     

Carbapenem-resistant Acinetobacter ventilator-associated pneumonia: Clinical characteristics and outcome

Objective:

To study the clinical characteristics and 28-days mortality in patients with ventilator-associated pneumonia (VAP) due to carbapenem-resistant Acinetobacter (CRA).

Design:

Retrospective, observational, cohort study.

Setting:

Intensive care unit (ICU) of a university hospital.

Materials and Methods:

Microbiologically confirmed VAP due to CRA infection.

Intervention:

None.

Results:

Out of 87 patients with VAP due to CRA, 60 (69%) were male; whose median age was 51 years; 73 (84%) patients were medical; 26 (30%) had history of hospitalization in last 3 months; median acute physiology and chronic health evaluation (APACHE) II was 15 and median SOFA 9 at admission; primary reason for ICU admission was respiratory failure (34%); 46 (53%) patients had more than 2 organ failure at ICU admission; median length of ICU stay was 19 days; 66 (76%) patients need vasoactive agents during ICU stay, whereas 55 (63%) patients had renal failure; median duration of mechanical ventilation was 17 days; 22 (25%) patients had acute respiratory distress syndrome (ARDS) during ICU stay; 72 (83%) patients had exposure to carbapenem before inclusion in the study; 33 (38%) patients had same organism at other sites. In the follow-up, 47 (54%) patient survived at 28 days after having VAP; whereas only 40 (46%) patients were discharged from the hospital.

Conclusions:

CRA-VAP has high crude mortality. Advanced age; severity of illness and presence of pneumonia at ICU admission; and presence of shock, ARDS and renal failure have impact on outcome in these patients.     

Glycated hemoglobin A: A predictor of outcome in trauma admissions to intensive care unit

Background and Aim:

Although large studies have demonstrated the association between hyperglycemia and adverse intensive care unit (ICU) outcomes, it is yet unclear which subset of patients benefit from tight sugar control in ICU. Recent evidence suggests that stress induced hyperglycemia (SIH) and co-incidentally detected diabetes mellitus are different phenomena with different prognoses. Differentiating SIH from diabetic hyperglycemia is challenging in ICU settings. We followed a cohort of trauma patients admitted to a surgical intensive care unit (SICU) to evaluate if initial glycated hemoglobin A (HbA₁c) level predicts the outcome of admission.

Materials and Methods:

A cohort of 120 consecutive admissions to SICU following trauma were recruited and admission blood sugar and HbA₁c were measured. Outcomes were prospectively measured by blinded ICU doctors. A logistic regression model was developed to assess if HbA₁c predicts poor outcomes in these settings.

Results:

Nearly 24% of the participants had HbA₁c ≥ 6. Those with HbA₁c ≥ 6 had 3.14 times greater risk of poor outcome at the end of hospital stay when compared to those with HbA₁c < 6 and this risk increased to an odds ratio of 4.57 on adjusting for other significant predictors: Acute Physiology and Chronic Health Evaluation II, injury severity score, admission blood sugar and age at admission.

Conclusions:

Substantial proportion of trauma admissions has underlying diabetes. HbA₁c, a measure of pre admission glycaemic status is an important predictor of ICU outcome in trauma patients.     

A comparative study of complications and long term outcomes of Surgical Tracheostomy and two techniques of Percutaneous Tracheostomy

Context:

The operative technique for surgical tracheostomy has remained unchanged, but different techniques for percutaneous tracheostomy have evolved due to interest in minimally invasive procedures for the critically ill patient.

Aims:

To compare the periprocedural complications and long term outcomes of bedside surgical tracheostomy (ST) with two percutaneous tracheostomy (PCT) techniques, namely serial guide wire dilating forceps (GWDF) and PercuTwist (PT).

Settings and Design:

This prospective observational study was carried out in ICU of a tertiary referral centre over three year period on adult intubated patients needing elective tracheostomy.

Materials and Methods:

Patients with anticipated difficult neck anatomy were assigned for ST based on discretion of intensivist. Patients included for PCT were randomly assigned to the GWDT and PT technique. 90 patients underwent either bedside ST (n = 30), PCT by GWDF technique (n = 30) or PCT with PercuTwist (n = 30) and were followed up with fibreoptic bronchoscopy monthly for 06 months.

Statistical Analysis Used:

Data was analyzed by applying chi square tests for categorical variables.

Results:

Periprocedural complications during PCT included major bleeding (>100ml) in two patients in GWDF group which required conversion to ST. Periprocedural bleeding was also the main complication in ST. Increased incidence of granulation tissue and tracheal narrowing in long term was seen in both ST and PCT groups. All of the P values analysed for the intra operative, post operative complications or long term outcomes were >0.05.

Conclusions:

There was no statistically significant difference in incidence of complications of ST and two techniques of PCT. Proper case selection makes PCT as safe as ST.     

Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India

Background and Aim:

To evaluate the occurrence, indications, course, interventions, and outcome of obstetric patients admitted to the intensive care unit (ICU).

Design:

Retrospective study.

Setting:

ICU of a Medical College Hospital.

Materials and Methods:

The data collected were age, parity, obstetric status, primary diagnosis, interventions, and outcome of obstetric patients admitted to the ICU from Jan 2005 to June 2011.

Results:

Total deliveries were 16,804 in 6.5 years. Obstetric admissions to the ICU were (n = 65) which constitutes 0.39% of deliveries. Majority of the admissions were in the postpartum period (n = 46, 70.8%). The two common indications for admission were obstetric hemorrhage (n = 18, 27.7%) and pregnancy related hypertension with its complications (n = 17, 26.2%). The most common intervention was artificial ventilation (n = 41, 63%). The mortality among obstetric admissions in the ICU was (33.8% (22/65)). The patients appropriate for High Dependency Unit (HDU) care was (32.3% (21/65)). The statistical analysis was done by fractional percentage and Chi-square test.

Conclusions:

Hemorrhage and pregnancy-related hypertension with its complications are the two common indications for ICU admissions. The need for a HDU should be considered.