TM A BI-MONTHLY NEWSLETTER OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE www.isccm.org COMMUNICATIONS Critical Care EDITORIAL OFFICE Dr. Yatin Mehta 272 Espace, Nirvana Country, Gurgaon 122001 Mobile : +91 9971698149 • emails : [email protected]Published By : INDIAN SOCIETY OF CRITICAL CARE MEDICINE For Free Circulation Amongst Medical Professionals Unit 6, First Floor, Hind Service Industries Premises Co-operative Society, Near Chaitya Bhoomi, Off Veer Savarkar Marg, Dadar, Mumbai – 400028 Tel. 022-24444737 • Telefax :022-24460348 • email : [email protected]We request our esteemed readers to send their valued feedback, suggestions & views at [email protected]Contents ISCCM NEWS HEADLINES 1 ISCCM News Headlines 2 Editorial 2 Editorial Board 2017-2018 3 President's Desk 3 Nurses Training Program - ISCCM Jodhpur 4 General Secretary's Desk 4 ISCCM Examination – Prometric 5 Guidelines / Practice Corner - Guidelines for the Early Management of Patients with Acute Ischemic Stroke 6 1 st National Conference on Critical Care and Infections in Liver Diseases 7 ISCCM Academic Activity CME Conducted 2017 - Visakhapatnam Branch 7 Jaipur Haemodynamic Monitoring Workshop 2017 8 Glimpse of CRITICARE 2017 Kochi 9 ISCCM Delhi NCR Report 9 Nutrition Workshop Report of ISCCM Raipur Branch 10 Quiz Fifth Edition 10 Answers for Fourth Episode 10 Essentials of Trauma Anesthesia and Intensive Care 1st/2016 11 Best of Brussels 2017 11 Image Section 11 Critical Care Update 2017 12 Journal Scan 14 South Zone Critical Care 2017 15 CRITICARE 2018 Criticare 2017 an academic extravaganza Multiple regional conferences across the country First thematic conference on critical care and infections in liver disease ISCCM Examinations - Prometric Journal Scan 'Battle of the Brains' - Quiz VOLUME 12.1 MARCH-APRIL 2017 Block Your Dates CRITICARE 2018 7-11 March, 2018 • Varanasi
Transcript
TM
A B I - M O N T H LY N E W S L E T T E R O F I N D I A N S O C I E T Y O F C R I T I C A L C A R E M E D I C I N E
www.isccm.org
C O M M U N I C A T I O N SCritical Care
Editorial officE
dr. Yatin Mehta272 Espace, Nirvana Country, Gurgaon 122001Mobile : +91 9971698149 • emails : [email protected]
Published By :
IndIan SocIety of crItIcal care MedIcIneFor Free Circulation Amongst Medical ProfessionalsUnit 6, First Floor, Hind Service Industries Premises Co-operative Society, Near Chaitya Bhoomi, Off Veer Savarkar Marg, Dadar, Mumbai – 400028 Tel. 022-24444737 • Telefax :022-24460348 • email : [email protected]
We request our esteemed readers to send their valued feedback,
ANurses Training Program on Oral Care and VAP prevention was conducted by ISCCM Jodhpur City Branch in co-ordination with Department of Anaesthesiology & Critical Care, AIIMS Jodhpur on 10th
February 2017. Total sixty-nine (69) ICU staff nurse participated from all over Jodhpur and discussion on following topics was done:1. Oral Care for Mechanically Ventilated Patients: Dr.Nikhil Kothari, AIIMS
Jodhpur.2. Suction Protocols in an Intubated Patient: Dr.Shilpa Goyal, AIIMS Jodhpur.3. Ventilator Associated Pneumonia (VAP) Definition & Prevention: Dr. Sadik
Mohammed, AIIMS Jodhpur.
dr. nikhil, SecretaryiSCCM City Branch, Jodhpur
The lectures were followed by hands-on workstations, in which practical tips and guidelines regarding Oral Care, Endotracheal suctioning and on protocols for VAP prevention were discussed.
The CriTiCal Care CommuniCaTions a Bi-monThly newsleTTer of indian soCieTy of CriTiCal Care mediCine4
dr. Subhal dixitgeneral Secretary, iSCCM
Dear all
Thanks for bestowing your faith in me and giving me my second term as general secretary with additional charge
of secretary examination.
Over the last few years ISCCM has grown with a rapid pace in all aspects including membership, educational activities across the length and breath of India and at an international level with mutual agreements with SCCM, ESICM.
ISCCM ensures to keep up with its educational programs throughout the year via meetings and webinars in order to reach and spread knowledge to one and all.
The college is very active in all aspects and has introduced the new online exam pattern which has been implemented from this year.
General Secretary's Desk
I am happy to inform that more and more hospitals and teachers are been inducted and approved for the training of young doctors in critical care.
ISCCM is also reaching out to all its members and students accross various branches via the ISCCM app and student and branch management system which has been introduced from this year .
I request all my friends of ISCCM to feel free to get in touch with me anytime to plan and discuss any issues and also encourage their friends to become our members.
I assure you all that with the help of all my colleagues in the Executive committee under the dynamic leadership of Dr Kapil Zirpe we shall take ISCCM to greater heights
Best wishes
ISCCm examination – Prometric
ISCCM is proud to announce the introduction of its first online exam for IDCCM /POST MBBS courses. The first examination was conducted on 12th March 2017. This is the brain child of
Dr Deepak Govil who has put in many hours of hard work. This has helped raise the bar for exit examinations even higher.
Prometric is the world’s leading provider of technology-enabled testing solutions. As a pioneer in computer-based testing, Prometric offer a history in testing that dates back 68 years as a pioneering enterprise in educational research and assessment. Together, Prometric and its parent company ETS® represent the “Gold Standard” against which other providers of test development and delivery services seek to operate.
Prometric is a trusted test development and delivery provider to more than 350 organizations worldwide. Exam sponsors trust Prometric to meet their certification and employment objectives by providing reliable, targeted, and innovative services that achieve their desired results and geographic reach. Prometric is an experienced leader in the field of healthcare catering to more than 60 clients ranging from allied health to medical specialties. Some of the key healthcare clients includes: National Board of Examinations
(NBE), National Board of Medical Examiners (NBME), Association of American Medical Colleges (AAMC), Saudi Council of Health Specialties (SCHS), Medical Council of Canada (MCC), American Board of Pediatrics (ABP), American Board of Orthopedic Surgery and Irish Medical Council amongst others.
Beginning 2017, Prometric partnered with Indian Society of Critical Care Medicine (ISCCM) to deliver two of their prestigious exams namely Indian Diploma in Critical Care Medicine (IDCCM) and Post MBBS Certificate Course (CTCCM) in their own test centres at 8 locations across India. The first computerized administration of IDCCM was held on 12 March 2017. All exams were delivered in state of the art testing facilities providing best-in-class testing experience to candidates. Security and quality is of paramount importance to Prometric that aims to provide a professional testing experience to meritorious and honest test takers. For ISCCM, all candidates had to undergo enhanced security check along with image capture. All exams were proctored and were conducted under DVR surveillance. Candidate's identification and admit cards were thoroughly checked and verified before they were seated in the lab for testing.
dr. Subhal dixit dr. deepak Govil dr. Kapil Zirpe dr. Yatin MethaCONTROLLER EXAMS VICE CHANCELLOR PRESIDENT /CHANCELLOR PRESIDENT ELECT
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Guidelines for the Early Management of Patients with Acute Ischemic Stroke
Stroke 2013; 44: 870-947
GuIDelINeS / PRACTICe CoRNeR
GUIDELINES / PRACTICE CORNER
GUIDELINES FOR THE EARLY MANAGEMENT OF PATIENTS WITH ACUTE ISCHEMIC STROKE
Stroke 2013;44:870-947
1. The use of a stroke rating scale, preferably the NIHSS, is recommended (I B)
2. Only the assessment of blood glucose must precede the initiation of intravenous rtPA (I B).
3. Either NECT or MRI is recommended before intravenous rtPA administration to exclude ICH (I A)
• A sign of cerebral ischemia within the first few hours after symptom onset on NECT is loss of gray-white differentiation
• blending of the densities of the cortex and underlying white matter in the insula (insular ribbon sign)
• increased densities within the occluded artery (MCA sign)
• Clot within a branch of the MCA (MCA dot sign)
• Diffusion-weighted imaging (DWI) has emerged as the most sensitive and specific imaging technique for acute infarct, far better than NECT or any other MRI sequence
• The artery susceptibility sign is the magnetic resonance (MR) correlate of the hyperdense MCA seen on NECT
5. NoninvasiveimagingofthecervicalvesselsshouldbeperformedroutinelyaspartoftheevaluationofpatientswithsuspectedTIAs (I A)
6. Frank hypodensity on NECT may increase the risk ofhemorrhage with fibrinolysis and should be considered intreatment decisions (III A)
7. Patients with elevated blood pressure and are otherwise eligible for treatment with intravenous rtPA should have their blood pressure lowered to systolic blood pressure is <185 mm Hg and diastolic blood pressure is <110 mm Hg (I B) before fibrinolytic therapy is initiated.
• Higher blood pressures during the initial 24 hours were associated with greater risk of sICH in a linear fashion
• Intravenous Labetolol or Nicardipine can be used to decrease BP
8. Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness (I C)
• Common causes of hypoxia include partial airway obstruction, hypoventilation, aspiration, atelectasis, and pneumonia
• Central periodic breathing (Cheyne-Stokes respirations)is a frequent complication of stroke and is associated with decreases in oxygen saturation
9. Supplemental oxygen should be provided to maintain oxygen saturation >94% (I C)
• Recent AHA guidelines for emergency cardiovascular care for stroke and resuscitated cardiac arrest patients recommend
administration of oxygen to hypoxemic patients to maintain oxygen saturation >94%
10. Sources of hyperthermia (temperature >38°C) should be identified and treated (I C)
• In acute ischemic stroke, hyperthermia is associated with poor neurological outcome, secondary to increased metabolic demands, enhanced release of neurotransmitters, and increased free radical production
• Hyperthermia may be secondary to a cause of stroke, such as infective endocarditis, or may represent a complication, such as pneumonia, urinary tract infection (UTI), or sepsis
11. Hypovolemia should be corrected with intravenous normal saline (I C)
• Hypovolemia may predispose to hypoperfusion and exacerbate the ischemic brain injury, cause renal impairment, and potentiate thrombosis
• Isotonic solutions such as 0.9% saline are more evenly distributed into the extracellular spaces (interstitial and intravascular) and may be better for patients with acute ischemic stroke.
12.Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) isrecommendedforselectedpatientswhomaybetreatedwithin3 hours of onset of ischemic stroke (I A)
• The US FDA approved the use of intravenous rtPA on the basis of the results of the 2-part NINDS rtPA Stroke Trial where there was an increase in the odds of a favorable outcome
• Spontaneous ICH remains the main risk
13. The door-to-needle time (time of bolus administration) should bewithin60minutesfromhospitalarrival(IA)
• The contraindications for intravenous fibrinolytic therapy are
Significant head trauma or prior stroke in previous 3 months
Symptoms suggest subarachnoid hemorrhage
Arterial puncture at noncompressible site in previous 7 days
History of previous intracranial hemorrhage
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Recent intracranial or intraspinal surgery
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to
Platelet count <100 000/mm³
Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
Current use of anticoagulant with INR >1.7 or PT >15 seconds
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Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests
14. Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset (I B)
• As per ECASS III trial, the additional exclusion criteria were people >80 years old, those with a baseline NIHSS score >25, those taking oral anticoagulants (even if their INR was <1.7), and those who had the combination of a previous stroke and diabetes mellitus
15. Intra-arterial fibrinolysis is beneficial for treatment of carefully selected patients with major ischemic strokes of <6 hours’ duration caused by occlusions of the MCA who are not otherwise candidates for intravenous rtPA (I B)
• Intra-arterial fibrinolysis is more efficacious for recanalization of proximal arterial occlusions
• Severe neurological deficits (NIHSS score ≥10) that suggest a proximal arterial occlusion, radiographic evidence of occlusion of a major intracranial vessel and recent history of a major surgery which poses the risk for systemic bleeding with intravenous rTPA are considered potential indications for the use of intra-arterial therapy.
16.Whenmechanical thrombectomy is pursued, stent retrieverssuchasSolitaireFRandTrevoaregenerallypreferredtocoilretrievers such as Merci (I A)
17. The Merci, Penumbra System, Solitaire FR, and Trevo thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis in carefully selected patients (IIa B)
• The Merci Retriever uses a memory-shaped nitinol wire with helical loops of decreasing diameter at its distal end to engage the clot. It is advanced through the microcatheter in its compressed form distal to the occlusion. Subsequent withdrawal of the microcatheter deploys the device in its preimposed helical shape
• Urgent angioplasty with adjunctive stent deployment
is being used to restore antegrade flow, with or without fibrinolysis or clot extraction
• Solitaire FR and Trevo devices, the stent retrievers are deployed within symptomatic intracranial thrombi to reperfuse tissue immediately and then used to engage and retrieve the clot
18. At present, the usefulness of argatroban or other thrombin inhibitors for treatment of patients with acute ischemic stroke is not well established (IIb B), only to be used in clinical trials
19.Urgent anticoagulation, with the goal of preventing earlyrecurrentstroke,haltingneurologicalworsening,orimprovingoutcomesafteracuteischemicstroke,isnotrecommendedfortreatmentofpatientswithacuteischemicstroke(IIIA)
20. Initiation of anticoagulant therapy within 24 hours of treatment with intravenous rtPA is not recommended (III B).
21.Oraladministrationofaspirin(initialdoseis325mg)within24 to 48 hours after stroke onset is recommended (I A)
22. The usefulness of clopidogrel for the treatment of acute ischemic stroke is not well established (IIb C)
23. Aspirin and other antiplatelet agents that inhibit glycoprotein IIb/IIIa receptor are not recommended as a substitute for other acute interventions for treatment of stroke (III B)
24. The administration of high-dose albumin, use of devices to augment cerebral blood flow and the usefulness of drug-induced hypertension in patients with acute ischemic stroke is not well established (IIb B)
25.Hemodilution by volume expansion and use of vasodilatorydrugslikepentoxyphyllinearenotrecommended(IIIA)
26. Patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable (IIa B)
27. The utility of induced hypothermia, transcranial near-infrared laser therapy is not well established for the treatment of acute ischemic stroke (IIb B)
1st National Conference on Critical Care and Infections in liver Diseases
The Institute of Liver and Biliary Sciences (ILBS) established by the Government of the National Capital Territory (NCT) of Delhi as an Autonomous Super-speciality Institute,
a Deemed-to-be-University status by the University Grants Commission (UGC) is a ‘de-novo institute with a promise for
excellence’ in Hepatobiliary Medicine, Surgery and Research and is a unique institute that is dedicated to patient management, teaching and research. This institute conducted it’s 1st National Conference on Critical Care and Infections in Liver Diseases India under the aegis of Asian Pacific Association for the Study of the Liver (APASL), International Club of Ascites and Indian Society of Critical Care Medicine (ISCCM)- Delhi NCR on 25-26th January 2017 with 6 parallel pre conference workshops on the 24th January 2017. The attendance in the workshops was 320 delegates and for the main scientific program was 500 delegates. The entire conference was divided into systems and challenges in each organ system was discussed based on a case based scenario with participation from eminent Hepatologists, Intensivists, Gastroenterologists, pulmonologist and anesthetists from across the country. Prof SK Sarin the director who has a keen interest in liver critical care conceptualized it and was jointly organized by Dr. Rakhi Maiwall Asso Prof Hepatology and Dr. Lalita Gouri Mitra Asso Prof Critical Care and Dr Yash Javeri –SCCM Delhi NCR.
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ISCCm Academic Activity
Cme Conducted 2017 -
Visakhapatnam Branch
JAN-2017 23rd January, 2017 Ethical and Legal issues in End of Life care in ICU Dr. Subhash Kumar Todi – Kolkata
FEB-2017 28th February, 2017 ICU Updates - 2017 Dr. Atchyuth, Dr. Kavitha & Dr. Hari Prasad - Vizag
ACE(Academy for Critical Care Education)
in association with
ISCCM, Jaipur(Indian Society of Critical Care Medicine)
Present
Jaipur HaemodynamicMonitoring Workshop 201727th May, 2017 Saturday & 28th May, 2017 Sunday
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Glimpse of CRITICARE 2017
Kochi
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ISCCm Delhi NCR Report1st National Conference on Critical Care and Infections in Liver Diseases
HISI Antimicrobial Stewardship Meeting 24th January 2017, Delhi Organised by Dr. Raman Sardana and Dr. V. Khillan
5th Annual Critical Care Refresher Course
The 5th Annual Critical Care Refresher Course held on 15th to 18th February 2017 under the aegis of Delhi NCR chapter of ISCCM was conducted by the Gastro and Liver Transplant
Critical Care Team of Medanta The Medicity. The course was conducted over a period of four days and covered various aspects of the subject in more than 70 lectures designed specifically for the exam going students. The Course Director, Dr Sachin Gupta, alongwith Dr. Mozammil Shafi, Course Co-ordinator ensured the course was made student friendly. Dr. Yatin Mehta, Chairman of Critical Care Institute at Medanta The Medicity and President Elect of ISCCM inaugurated the event along with the ever encouraging
and excellent teacher, Dr. Deepak Govil, Director Critical Care at Medanta The Medicity and Vice Chancellor, Indian College of Critical Care. The students had the opportunity to interact with varied imminent International (Australia, London, Oman) and National faculty based at Delhi NCR. The participation touched more than 200 candidates from all parts of the country and appearing in various National and International Critical Care exams and was appreciated thoroughly. The candidates were handed over the relevant study material and all the presentations in the form of audio visual clips in a pen drive and also as a Google drive link.
Monthly Meeting
January Monthly Meeting Date was organised on 21st Jan 2017 at Willow Hall, India Habitat Centre. New Delhi
Organized by Dr Yash Javeri/Dr Munish Chauhan
Chairpersons: Dr Tariq Ali and Dr Prashant Saxena
Agenda
1. Interesting Skin Lesions in ICU - Dr Munish K Chauhan, Venkateshwar Hospital, Delhi
2. Interesting Case presentation -Dr Tarun Jhamb, Columbia Asia Hospital, Gurgaon
3. Journal Club - Dr. Prashant Kumar, Medanta Hospital, Gurgaon
Executive Committee Meeting
SCCM Delhi NCR held on 14th January at CSOI, New Delhi.
IDCC Preparatory Course
IDCC Preparatory Course conducted by Dr Prakash Shastri held on 26th February 2017 at Hotel Metropolitan, New Delhi
Nutrition Workshop Report of
ISCCM Raipur Branch
organised by
dr. Surya Prakash SahuSecretary, iSCCM, raipur chapter
Society of critical care medicine, Raipur chapter organised a workshop on Nutrition on 12 Feb 2017 that was a grand success. Many of the city's nephrologist, gastroenterologist, nutritionist and intensivist were present here.
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Quiz Fifth Edition
Essentials of Trauma Anesthesia and Intensive Care 1st/2016
Q1. All of the following are causes of Antithrombin (AT) deficiency except?
A. Liver cirrhosis
B. Nephrotic syndromes
C. Extracorporeal membrane oxygenation (ECMO)
D. Hemodialysis
E. Normal pregnancy
Q2. All of the follow are risk factors for Transfusion Related Acute Lung Injury (TRALI) except?
A. Liver transplantation
B. Alcohol abuse
C. High peak airway pressure on mechanical ventilator
D. High interleukin (IL)-8 levels
E. Negative fluid balance
Q3. Our ISCCM
"The Indian Journal of Critical Care Medicine" was started in which year
Q4. 54 year old male is admitted to ICU with chills, fever and new onset of murmur. Patient is diagnosed with 'Streptococcus Bovis' endocardititis after 4 bottles reported positive for blood culture and vegetation on mitral valve found on Echo. What should be your next concern?
Q5. Which electrolyte imbalance is common in Ecstasy (MDMA) intoxication?
Q6. Who AM I ?
Q7. Expansion -SCET
Q8. SSC 2016 - We suggest using albumin in addition to crystalloids for initial resuscitation and subsequent intravascular volume replacement in patients with sepsis and septic shock when patients require substantial amounts of crystalloids.
What recommendation and quality of evidence?
Q9. Spot On
Q10. Which tool is best for screening a patient for blunt cardiac injury?
Answers to Fourth Episode1. Dr Archie Brain: The Laryngeal Mask
In 1981, Dr Archie Brain completed his first prototype of the Laryngeal Mask at his home in London. Safer, more reliable and easier to use than any other equipment available at that time, this device is designed to keep the airway clear and to seal the larynx, thus protecting the lungs. Though it was originally turned down by several companies, since its development in the 1980s, the laryngeal airway has been used over 350 million times worldwide.
2. Lazarus sign is a reflex movement in brain dead patients, which causes them to briefly raise their arms and drop them.
3. DIANA. DetermInants of Antimicrobial use aNd de-escalAtion in critical care
4. ELICIT -- End of Life Care in India Task Force
5. Fires involving ordinary combustible materials such as cloth, wood, paper rubber and many plastics.
6. 3 to 7 days
7. MARS. Molecular adsorbent Recirculating System
Mixed antagonist response syndrome
8. Methotrexate and Methanol
9. Device for stool dis-impaction
10. 10/8/2010
dr. yatin Mehta and dr. yash JaveriPlease mail the answers at the earliest to [email protected] answers with the name of first two correct entries will be
published in next issue
Winners of Critiquiz 2016-2017 “Bat tle of the Brains”
Episode 4
dr. Yusuf BhambhaniPorbandar
It is my pleasure to introduce the book ‘Essentials of Trauma Anesthesia and Intensive Care’ and the chief author Dr Babita Gupta to the readers. This book extensively
discusses the anesthetic and critical care management in trauma practice. It covers the recent guidelines in the management of a severely injured patient in the operating room and intensive care unit. All the chapters concisely present the core concepts in trauma anesthesia and critical care.. This book has been prepared by renowned faculty members in the field of Anesthesia and critical care. It is a comprehensive book written in a lucid style, and directed not only to
all anesthesiologists and intensivists, but also emergency physicians, surgeons and orthopedic surgeons managing trauma patients. The book should prove to be useful to postgraduates, senior residents and consultants.
About The Author : Babita Gupta
Dr. Babita Gupta ia an additional professor in department of anesthesiology, pain medicine and critical care at Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi. She is a passionate teacher and has been actively organizing various workshops pertaining to trauma anesthesia and critical care.
She has a number of national and international publications to her credit.
The highlights of the book are:
• Burden of trauma
• Role of anesthesiologist in acute trauma care
• Initial approach to trauma patients
• Anesthetic and critical care management in specific trauma situations such as, traumatic brain injury, thoracic trauma, cardiac trauma, spine trauma, musculoskeletal trauma and abdominal trauma
• Principles of damage control surgery and damage control resuscitation
• Massive transfusion protocols
• Regional anesthesia with special emphasis on ultrasound-guided nerve blocks
• Brain death and organ donation
ISBN: 9788184451931
http://www.readwhere.com/read/917513
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Image Section
(Answer in the next issue)
The Forgotten Films
A 70-year-old woman with end-stage liver disease from hepatitis C was admitted to the hospital for confusion. A few days after admission, abdominal pain with marked abdominal distention developed. Abdominal Radiograph revealed.
To order your copy, please send the following order slip with cheque/DD payable at Mumbai favouring INDIAN SOCIETY OF CRITICAL CARE MEDICINE to ISCCM Secretariat office, Mumbai
ORDER SLIP
CRITICAL CARE UPDATE 2017 BOOK
Indian Society of Critical Care MedicineUnit 6, First Floor, Hind Service Industries Premises Co.operative Society,Near Chaitya Bhoomi, Off Veer Savarkar Marg, Dadar, Mumbai – 400028Tel:022-24444737/24460348
(ii) Cheque/DD payable at Mumbai should be drawn in favour of Indian Society of Critical Care Medicine
(iii) Order slip and Cheque/DD to be sent at following ISCCM Secretariat, Mumbai office address- :-
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JOUR
NAL SCAN
Hyperoxia and hypertonic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trialProf Pierre asfar, Md, frédérique Schortgen, Md, Julie Boisramé-helms, Md, Julien Charpentier, Md, Emmanuel guérot, Md, Prof Bruno Megarbane, Md, david grimaldi, Md, fabien grelon, Md, nadia anguel, Md, Prof Sigismond lasocki, Md, Matthieu henry-lagarrigue, Md, frederick gonzalez, Md, françois legay, Md, Christophe guitton, Md, Maleka Schenck, Md, Jean Marc doise, Md, Jérôme devaquet, Md, Prof thierry Van der linden, Md, delphine Chatellier, Md, Jean Philippe rigaud, Md, Prof Jean dellamonica, Md, Prof fabienne tamion, Md, Prof ferhat Meziani, Md, Prof alain Mercat, Md, Prof didier dreyfuss, Valérie Seegers, Md, Prof Peter radermacher, Md
Background: There is insufficient research into the use of mechanical ventilation with increased inspiratory oxygen concentration (fio2) and fluid resuscitation with hypertonic saline solution in patients with septic shock. We tested whether these interventions are associated with reduced mortality.
Methods: this two-by-two factorial, multicentre, randomised, clinical trial (hyPErS2S) recruited patients aged 18 years and older with septic shock who were on mechanical ventilation from 22 centres in france. Patients were randomly assigned 1:1:1:1 to four groups by a computer generated randomisation list stratified by site and presence or absence of acute respiratory distress syndrome by use of permuted blocks of random sizes. Patients received, in an open-labelled manner, mechanical ventilation either with fio2 at 1·0 (hyperoxia) or fio2 set to target an arterial haemoglobin oxygen saturation of 88–95% (normoxia) during the first 24 h; patients also received, in a double-blind manner, either 280 ml boluses of 3·0% (hypertonic) saline or 0·9% (isotonic) saline for fluid resuscitation during the first 72 h. the primary endpoint was mortality at day 28 after randomisation in the intention-to-treat population. this study was registered with ClinicalTrials.gov, number NCT01722422.
Findings: Between Nov 3, 2012, and June 13, 2014, 442 patients were recruited and assigned to a treatment group (normoxia [n=223] or hyperoxia [n=219]; isotonic [n=224] or hypertonic [n=218]). The trial was stopped prematurely for safety reasons. 28 day mortality was recorded for 434 patients; 93 (43%) of 217 patients had died in the hyperoxia group versus 77 (35%) of 217 patients in the normoxia group (hazard ratio [HR] 1·27, 95% CI 0·94–1·72; p=0·12). 89 (42%) of 214 patients had died in the hypertonic group versus 81 (37%) of 220 patients in the isotonic group (HR 1·19, 0·88–1·61; p=0·25). We found a significant difference in the overall incidence of serious adverse events between the hyperoxia (185 [85%]) and normoxia groups (165 [76%]; p=0·02), with a clinically relevant doubling in the hyperoxia group of the number of patients with intensive care unit-acquired weakness (24 [11%] vs 13 [6%]; p=0·06) and atelectasis (26 [12%] vs 13 [6%]; p=0·04) compared with the normoxia group. We found no statistical difference for serious adverse events between the two saline groups (p=0·23).
Interpretation: in patients with septic shock, setting fio2 to 1·0 to induce arterial hyperoxia might increase the risk of mortality. hypertonic (3%) saline did not improve survival. (the lancet respiratory Medicine 2017/ doi: http://dx.doi.org/10.1016/S2213-2600(17)30046-2)
Our View: this is very common among practitioners to maximize fio2 to 1.0 in shock states without due attention to resulting hyperoxia. Caution may be exercised in this approach. the concept of trying to resuscitate with hypertonic saline is surprising. random allocation of patients is also a point to be noted, especially since different phenotypes of ARDS have been identified.
Early administration of selenium in patients with acute traumatic brain injury: A randomized double-blinded controlled trial omid Moradi Moghaddam, Mohammad niakan lahiji, Valiollah hassani, Shakiba Mozari
Aim: the present study was carried out to examine this hypothesis that administration of selenium can prevent the development of injuries by brain trauma and thus can modulate patients’ functional recovery and also improve posttraumatic outcome.
Materials and Methods: this double-blinded controlled trial was carried out on 113 patients who were hospitalized following traumatic brain injury (TBI) with Glasgow Coma Scale score of 4–12 that were randomly assigned to receive selenium within 8 h after injury plus standard treatment group or routine standard treatment alone as the control. the primary endpoint was to assess patients’ functional recovery at 2 months after the injury based on extended glasgow outcome Scale score (goS-E). Secondary outcomes included the changes in full outline of unresponsiveness score (four) score, Sequential organ failure assessment (Sofa) score, and acute physiology and chronic health evaluation (aPaChE) iii score, side effects of selenium, length of intensive Care unit (iCu) stay, and length of hospital stay.
Results: there was no difference in the length of iCu and hospital stay, the trend of the change in four and Sofa scores within 15 days of first interventions, and the mean APACHE III score on the 1st and 15th days between the two groups. Mortality was 15.8% in selenium group and 19.6% in control group with no between-group difference. no difference was revealed between the two groups in appropriate outcome according to goS-E score at 60 ± 10 days and also 30 ± 5 days according to the severity of tBi.
Conclusion: This human trial study could not demonstrate beneficial effects of intravenous infusion of selenium in the improvement of outcomes in patients with acute tBi. (indian Journal of Critical Care Medicine 2017; 21: 75-79/ DOI: 10.4103/ijccm.IJCCM_391_16)
Our View: There are agreed beneficial effects of selenium in balancing oxidants and antioxidants but probably the short duration and low
doses could not mark a difference. further long term studies with varying doses are warranted.
Thiamine as a Renal Protective Agent in Septic Shock: A Secondary Analysis of a Randomized, Double-Blind, Placebo-Controlled Trial ari Moskowitz, lars W andersen, Michael n Cocchi, Mathias Karlsson, Parth V Patel, Michael W donnino
Rationale: acute kidney injury (aKi) is common in patients with sepsis and has been associated with high mortality rates. the provision of thiamine to septic patients may reduce the incidence and severity of sepsis-related aKi and thereby prevent renal failure requiring renal replacement therapy (rrt).
Objectives: to test the hypothesis that thiamine supplementation mitigates kidney injury in septic shock.
Methods: this was a secondary analysis of a single-center, randomized, double-blind trial comparing thiamine to placebo in patients with septic shock. renal function, need for rrt, timing of hemodialysis catheter placement, and timing of rrt initiation were abstracted. the baseline creatinine and worst creatinine values between 3-24 hours, 24-48 hours, and 48-72 hours were likewise abstracted. Results: There were 70 patients eligible for analysis after excluding 10 patients in whom hemodialysis was initiated before study drug administration. Baseline serum creatinine in the thiamine group was 1.2mg/dl [iQr 0.8,2.5] as compared to 1.8mg/dl [iQr 1.3,2.7] in the placebo group (p=0.3). after initiation of the study drug, more patients in the placebo group as compared to the thiamine group were started on rrt (8 [21%] vs. 1 [3%], p = 0.04). In the repeated measures analysis adjusting for the baseline creatinine level, the worst creatinine levels were higher in the placebo group as compared to the thiamine group (p = 0.05).
Conclusions: in this post-hoc analysis of a randomized controlled trial, septic shock patients randomized to receive thiamine had lower serum creatinine levels and a lower rate of progression to rrt than patients randomized to placebo. These findings should be considered hypothesis generating and can be used as a foundation for further, prospective investigation in this area. (annals of the american thoracic Society/2017 doi: http://dx.doi.org/10.1513/annalsatS.201608-656BC)
Our view: thiamine is only marginally stored in our body and excessive amounts are easily excreted in the urine. there is no known toxicity of thiamine. its role as renal protective agent may encourages us to consider. Also consider supplements when deficiency is likely. Thiamine deficiency is more likely to be widespread due to prevalent malnutrition in our patients. Supplements might be considered since measuring the levels is not feasible in many centres.
AMOBES (Active Mobility Very Early After Stroke) A Randomized Controlled Trialalain P. yelnik, Victorine Quintaine, Cedric andriantsifanetra, Marie Wannepain, Peggy reiner, hélène Marnef, Mathilde Evrard, Elena Meseguer, Jean Pascal devailly, Monica lozano, Catherine lamy, florence Colle, Eric Vicaut, on behalf of the aMoBES group
Background and Purpose: intensive physical therapy (Pt) facilitates motor recovery when provided during a subacute stage after stroke. The efficiency of very early intensive PT has been less investigated. We aimed to investigate whether intensive PT conducted within the first 2 weeks could aid recovery of motor control.
Methods: this multicentre randomized controlled trial compared soft Pt (20-min/d apart from respiratory needs) and intensive Pt (idem+45 minutes of intensive exercises/day) initiated within the first 72 hours after a first hemispheric stroke. The primary outcome was change in motor control between day (d) 90 and d0 assessed by the fugl–Meyer score. Main secondary outcomes were number of days to walking 10 m unassisted, balance, autonomy, quality of life, and unexpected medical events. all analyses were by intent to treat.
Results: We could analyze data for 103 of the 104 included patients (51 control and 52 experimental group; 64 males; median age overall 67 [interquartile range 59–77], 67 right hemispheric lesions, 80 ischemic lesions, National Institutes of Health Stroke Scale score ≥8 for 82%). Fugl–Meyer score increased over time (P<0.0001), with no significant effect of treatment (P=0.29) or interaction between treatment and time (P=0.40). The median change in score between D90 and D0 was 27.5 (12–40) and 22.0 (12–56) for control and experimental groups (P=0.69). Similar results were found for the secondary criteria.
Conclusions:Very early after stroke, intensive exercises may not be efficient in improving motor control. this conclusion may apply to mainly severe stroke. (Stroke 2016/ doi https://doi.org/10.1161/STROKEAHA.116.014803)
Our View: Based on the results of present study Physical therapy may be considered beneficial in subacute phase instead of early acute phase in stroke.
Effectiveness and safety of procalcitonin evaluation for reducing mortality in adults with sepsis, severe sepsis or septic shockBrenda ng andriolo, regis B andriolo, reinaldo Salomão, Álvaro n atallah
Background: Serum procalcitonin (PCt) evaluation has been proposed for early diagnosis and accurate staging and to guide decisions regarding patients with sepsis, severe sepsis and septic shock, with possible reduction in mortality.
Objectives:to assess the effectiveness and safety of serum PCt evaluation for reducing mortality and duration of antimicrobial therapy in adults with sepsis, severe sepsis or septic shock.
Search methods: We searched the Central register of Controlled Trials (CENTRAL; 2015, Issue 7); MEDLINE (1950 to July 2015); Embase (Ovid SP, 1980 to July 2015); Latin American Caribbean Health
Sciences Literature (LILACS via BIREME, 1982 to July 2015); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCo host, 1982 to July 2015), and trial registers (iSrCtn registry, Clinicaltrials.gov and CenterWatch, to July 2015). We reran the search in october 2016. We added three studies of interest to a list of ‘Studies awaiting classification’ and will incorporate these into formal review findings during the review update.
Selection criteria: We included only randomized controlled trials (rCts) testing PCt-guided decisions in at least one of the comparison arms for adults (≥ 18 years old) with sepsis, severe sepsis or septic shock, according to international definitions and irrespective of the setting.
Data collection and analysis: two review authors extracted study data and assessed the methodological quality of included studies. We conducted meta-analysis with random-effects models for the following primary outcomes: mortality and time spent receiving antimicrobial therapy in hospital and in the intensive care unit (iCu), as well as time spent on mechanical ventilation and change in antimicrobial regimen from a broad to a narrower spectrum.
Main results: We included 10 trials with 1215 participants. low-quality evidence showed no significant differences in mortality at longest follow-up (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.01; I2 = 10%; 10 trials; N = 1156), at 28 days (RR 0.89, 95% CI 0.61 to 1.31; I2 = 0%; four trials; N = 316), at ICU discharge (RR 1.03, 95% CI 0.50 to 2.11; I2 = 49%; three trials; N = 506) and at hospital discharge (RR 0.98, 95% CI 0.75 to 1.27; I2 = 0%; seven trials; N = 805; moderate-quality evidence). However, mean time receiving antimicrobial therapy in the intervention groups was -1.28 days (95% CI to -1.95 to -0.61; I2 = 86%; four trials; N = 313; very low-quality evidence). no primary study has analysed the change in antimicrobial regimen from a broad to a narrower spectrum. (Cochrane reviews 2017/ DOI: 10.1002/14651858.CD010959.pub2)
Authors’ conclusions: up-to-date evidence of very low to moderate quality, with insufficient sample power per outcome, does not clearly support the use of procalcitonin-guided antimicrobial therapy to minimize mortality, mechanical ventilation, clinical severity, reinfection or duration of antimicrobial therapy of patients with septic conditions.
Our View: other biomarkers also have limitations in diagnosing infections. in the present armamentarium, procalcitonin can cautiously be used as a composite biomarker. other clinical information can definitely improve the overall interpretation.
Initiation time of renal replacement therapy on patients with acute kidney injury: A systematic review and meta-analysis of 8179 participantsCaixia Wang, lin-Sheng lv, hui huang, Jianqiang guan, zengchun ye, Shaomin li, yanni Wang, tanqi lou, Xun liu
the early initiation of renal replacement therapy has been recommended for patients with acute renal failure by some studies, but its effects on mortality and renal recovery are unknown. We conducted an updated meta-analysis to provide quantitative evaluations of the association between the early initiation of renal replacement therapy and mortality for patients with acute kidney injury. after applying inclusion/exclusion criteria, 51 studies, including 10 randomized controlled trials, with a total of 8179 patients were analyzed. analysis of the included trials showed that patients receiving early renal replacement therapy had a 25% reduction in all-cause mortality compared to those receiving late renal replacement therapy (risk ratio [rr] 0.75, 95% Ci [0.69, 0.82]). We also noted a 30% increase in renal recovery (rr 1.30, 95% Ci [1.07, 1.56]), a reduction in hospitalization of 5.84 days (mean difference [MD], 95% CI [–10.27, –1.41]) and a reduction in the duration of mechanical ventilation of 2.33 days (MD, 95% CI [–3.40, –1.26]) in patients assigned to early renal replacement therapy. the early initiation of renal replacement therapy was associated with a decreased risk of all-cause mortality compared with the late initiation of rrt in patients with acute kidney injury. These findings should be interpreted with caution given the heterogeneity between studies. further studies are needed to identify the causes of mortality and to assess whether mortality differs by dialysis dose. (nephrology 2017 22(1): 7-18/ doi: 10.1111/nep.12890)
Our View: Probably a paradigm shift is taking place in managing AKI in the critical illness. While earlier few identifier indications were considered to initiate renal replacement therapy, now more evidences are building up to handle them early to avoid complications and improve outcomes. recommendations for rrt in iCu seem to be shifting towards a fluid balance and acid base targeted strategy.
Coexistence and Impact of Limb Muscle and Diaphragm Weakness at Time of Liberation from Mechanical Ventilation in Medical Intensive Care Unit Patients Martin dres , Bruno-Pierre dubé , Julien Mayaux , Julie delemazure , danielle reuter , laurent Brochard, thomas Similowski, and alexandre demoule
AbstractRationale: intensive care unit (iCu)- and mechanical ventilation (MV)-acquired limb muscle and diaphragm dysfunction may both be associated with longer length of stay and worse outcome. Whether they are two aspects of the same entity or have a different prevalence and prognostic impact remains unclear.
Objectives: to quantify the prevalence and coexistence of these two forms of iCu-acquired weakness and their impact on outcome.
Methods: In patients undergoing a first spontaneous breathing trial after at least 24 hours of MV, diaphragm dysfunction was evaluated using twitch tracheal pressure in response to bilateral anterior magnetic phrenic nerve stimulation (a pressure <11 cm h2O defined dysfunction) and ultrasonography (thickening fraction [tfdi] and excursion). Limb muscle weakness was defined as a Medical Research Council (MRC) score less than 48.
Measurements and Main Results: Seventy-six patients were assessed at their first spontaneous breathing trial: 63% had diaphragm
dr. Prashant KumarMd, idCCM, fnB (Critical Care), EdiC, PgdPha, doaEditor 'Critical Care Waarticles'Senior Consultant Critical Care, Medanta the Medicity, global health Private ltd., Sector - 38, gurgaon - 122001, haryana, indiaMobile: +919899302959 e-mail: [email protected]
dr. Srinivas SamavedamMd, dnB, frCP, fnB, EdiC, fiCCMdiploma in health Care Quality Management, diploma in Medical law and Ethics, head, Critical Care unit, Virinchi hospitals, hyderabadMobile: +919866343632e-mail: [email protected]
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dysfunction, 34% had limb muscle weakness, and 21% had both. There was a significant but weak correlation between MRC score and twitch pressure (ρ = 0.26; P = 0.03) and TFdi (ρ = 0.28; P = 0.01), respectively. Low twitch pressure (odds ratio, 0.60; 95% confidence interval, 0.45–0.79; P < 0.001) and TFdi (odds ratio, 0.84; 95% confidence interval, 0.76–0.92; P < 0.001) were independently associated with weaning failure, but the MrC score was not. diaphragm dysfunction was associated with higher iCu and hospital mortality, and limb muscle weakness was associated with longer duration of MV and hospital stay.
Conclusions: diaphragm dysfunction is twice as frequent as limb muscle weakness and has a direct negative impact on weaning outcome. the two types of muscle weakness have only limited overlap.(American Journal of Respiratory and Critical Care Medicine 2017; 195(1):/ DOI: http://dx.doi.org/10.1164/rccm.201602-0367OC)
Our View: Both muscle power in limbs and the respiratory muscle should be separately assessed and has prognostic significance. Maximal inspiratory and expiratory mouth pressures sustained for 1 s is good assessment tools but has limitations in ventilated patients.
Clinical outcomes of extended versus intermittent administration of piperacillin/tazobactam for the treatment of hospital-acquired pneumonia: a randomized controlled trialh. Bao, y. lv, d. Wang, J. Xue, z. yan
the purpose of this study was to assess the pharmacokinetic (PK) characteristics, clinical efficiency, and pharmacoeconomic parameters of piperacillin/tazobactam administered by extended infusion (Ei) or intermittent infusion (ii) in the treatment of hospital-acquired pneumonia (haP) in critically ill patients with low illness severity in China. fifty patients completed the study, with 25 patients receiving 4/0.5 g piperacillin/tazobactam over 30 min as the II group and 25 patients receiving 4/0.5 g piperacillin/tazobactam over 3 h every 6 h as the Ei group. drug assay was performed using high-performance liquid chromatography (hPlC). the percentage of the dosing interval for which the free piperacillin concentration (%ft) exceeds the minimum inhibitory concentration (MiC) was calculated. the patients’ therapy cost, clinical efficiency, and adverse effects were also recorded. %fT>MIC was about 100, 98.73, and 93.04 % in the EI arm versus 81.48, 53.29, and 42.15 % in the II arm, respectively, when the microorganism responsible for HAP had an MIC of 4, 8, and 16 mg/L. The therapy cost in the Ei group was lower than that of the ii group ($1351.72 ± 120.39 vs. $1782.04 ± 164.51, p = 0.001). However, the clinical success rate, clinical failure rate, and drug-related adverse events did not significantly differ between groups. EI treatment with piperacillin/tazobactam was a cost-effective approach to the management of haP, being equally clinically effective to conventional ii. (Eur J Clin Microbiol Infect Dis (2017) 36:459–466 DOI 10.1007/s10096-016-2819-1)
Our view: Ei was more likely to enable better achievement of %ft>MiC. it might be utilized therapeutic options in high illness severity with limited options. a paradigm change needs to happen to improve the efficacy of the limited armamentarium of antibiotics.
The impact of early tracheostomy in neurotrauma patients: A retrospective studyKapil g zirpe, deepali Vishnu tambe, abhijit M deshmukh, Sushma K gurav
Background: although majority of neurotrauma patients require long term ventilatory support but the timing of tracheostomy in such patients is controversial.
Method: this retrospective study was conducted at a tertiary Care hospital, Pune, india. Patients >18 years of age, who underwent percutaneous tracheostomy (PCT) from June 2010 to November 2014 at neurotrauma unit (ntu) of hospital, were included. Patients were divided in two groups according to the timing of tracheostomy, early tracheostomy (ET) group (≤5 days; N=100) and late tracheostomy (LT) group (>5 days; N=64). The nonparametric Mann-Whitney test and Chi-square tests were used to compare these groups.
Result: There were no significant differences between the groups in terms of age, sex, aPaChE ii and gCS Score. Patients in the Et group had a significantly shorter stay in the NTU compared to patients in the lt group (mean, 18 vs. 21.2 days, p=0.005), fewer mechanical ventilation days (mean, 8.1 vs. 11.7 days, P=0.000) and shorter length of stay in hospital (mean, 28.8 vs. 34.37 days, P=0.019). There was no difference between Et and lt groups in post PCt ventilator free days (mean, 8.2 vs. 9.4 days; P=0.094). Mortality rates in ET vs. LT groups were also comparable (35% vs. 29.7%; P=0.480).
Conclusion: results suggest that Et in neurotrauma patients might be associated with shorter length of stay in ntu and hospital, and shorter duration of mechanical ventilation however there was no mortality difference. (Indian Journal of Critical Care Medicine 2017; 21(1): 6-10 DOI: 10.4103/0972-5229.198309)
Our view: Et can avoid a variety of adverse effects of use of sedatives and paralysing agents. We have also observed shorter stay and reduced period on mechanical ventilation in such patients.
Antipyretic Therapy in Critically Ill Septic Patients: A Systematic Review and Meta-Analysis.Anne M Drewry; Enyo A Ablordeppey; Ellen T Murray; Carolyn R T Stoll; Sonya R Izadi; Catherine M Dalton; Angela C Hardi; Susan A Fowler; Brian M Fuller; Graham A Colditz
Objective: this meta-analysis aimed to examine the impact of antipyretic therapy on mortality in critically ill septic adults.
Data sources: literature searches were implemented in ovid Medline, Embase, Scopus, Cumulative index of nursing and allied health literature, Cochrane Central register of Controlled trials, nhS Economic Evaluation database, and Clinicaltrials.gov through february 2016.
Study selection: inclusion criteria were observational or randomized studies of septic patients, evaluation of antipyretic treatment, mortality reported, and English-language version available. Studies were excluded if they enrolled pediatric patients, patients with neurologic injury, or healthy volunteers. Criteria were applied by two independent reviewers.
Data extraction: two reviewers independently extracted data and evaluated methodologic quality. outcomes included mortality, frequency of shock reversal, acquisition of nosocomial infections, and changes in body temperature, heart rate, and minute ventilation. randomized and observational studies were analyzed separately.
Data synthesis: Eight randomized studies (1,507 patients) and eight observational studies (17,432 patients) were analyzed. Antipyretic therapy did not reduce 28-day/hospital mortality in the randomized studies (relative risk, 0.93; 95% CI, 0.77-1.13; I = 0.0%) or observational
studies (odds ratio, 0.90; 95% CI, 0.54-1.51; I = 76.1%). Shock reversal (relative risk, 1.13; 95% CI, 0.68-1.90; I = 51.6%) and acquisition of nosocomial infections (relative risk, 1.13; 95% CI, 0.61-2.09; I = 61.0%) were also unchanged. antipyretic therapy decreased body temperature (mean difference, -0.38°C; 95% CI, -0.63 to -0.13; I = 84.0%), but not heart rate or minute ventilation.
Conclusions: Antipyretic treatment does not significantly improve 28-day/hospital mortality in adult patients with sepsis. this is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-nC-nd), where it is permissible to download and share the work provided it is properly cited. the work cannot be changed in any way or used commercially without permission from the journal.( Critical care medicine 2017 doi: 10.1097/CCM.0000000000002285)
Our view: i think this need more emphasis among the practicing intensivists. More often than not we are tempted to correct fever by antipyretics. it’s a big blow on use of antipyretics to correct numbers alone if the findings of this and similar other studies are believed and accepted.
Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trialEstelle C nijssen, MSc, roger J rennenberg, Md, Patty J nelemans, Md, Brigitte a Essers, Phd, Marga M Janssen, MSc, Marja a Vermeeren, Phd, Vincent van ommen, Md, Joachim E Wildberger, Md
Background: intravenous saline is recommended in clinical practice guidelines as the cornerstone for preventing contrast-induced nephropathy in patients with compromised renal function. however, clinical-effectiveness and cost-effectiveness of this prophylactic hydration treatment in protecting renal function has not been adequately studied in the population targeted by the guidelines, against a group receiving no prophylaxis. this was the aim of the aMaCing trial.
Methods: aMaCing is a prospective, randomised, phase 3, parallel-group, open-label, non-inferiority trial of patients at risk of contrast-induced nephropathy according to current guidelines. high-risk patients (with an estimated glomerular filtration rate [eGFR] of 30–59 ml per min/1·73 m2) aged 18 years and older, undergoing an elective procedure requiring iodinated contrast material administration at Maastricht university Medical Centre, the netherlands, were randomly assigned (1:1) to receive intravenous 0·9% naCl or no prophylaxis. We excluded patients with egfr lower than 30 ml per min/1·73 m2, previous dialysis, or no referral for intravenous hydration. Randomisation was stratified by predefined risk factors. The primary outcome was incidence of contrast-induced nephropathy, defined as an increase in serum creatinine from baseline of more than 25% or 44 μmol/l within 2–6 days of contrast exposure, and cost-effectiveness of no prophylaxis compared with intravenous hydration in the prevention of contrast-induced nephropathy. We measured serum creatinine immediately before, 2–6 days, and 26–35 days after contrast-material exposure. laboratory personnel were masked to treatment allocation. adverse events and use of resources were systematically recorded. the non-inferiority margin was set at 2·1%. Both intention-to-treat and per-protocol analyses were done. this trial is registered with ClinicalTrials.gov, number NCT02106234.
Findings: Between June 17, 2014, and July 17, 2016, 660 consecutive patients were randomly assigned to receive no prophylaxis (n=332) or intravenous hydration (n=328). 2–6 day serum creatinine was available for 307 (92%) of 332 patients in the no prophylaxis group and 296 (90%) of 328 patients in the intravenous hydration group. Contrast-induced nephropathy was recorded in eight (2·6%) of 307 non-hydrated patients and in eight (2·7%) of 296 hydrated patients. the absolute difference (no hydration vs hydration) was-0·10% (one-sided 95% CI-2·25 to 2·06; one-tailed p=0·4710). No hydration was cost-saving relative to hydration. no haemodialysis or related deaths occurred within 35 days. 18 (5·5%) of 328 patients had complications associated with intravenous hydration.
Interpretation: We found no prophylaxis to be non-inferior and cost-saving in preventing contrast-induced nephropathy compared with intravenous hydration according to current clinical practice guidelines. (The Lancet 2017 DOI: http://dx.doi.org/10.1016/S0140-6736(17)30057-0)
Our View: the results of this study are so valuable particularly to the cardiac patients who may be at risk of fluid overload. For other patients who may not benefit from hydration but are given boluses are at risk of fluid overload (fo) which is independently associated with poor outcome in hospitalized patients.
The effect of early goal-directed therapy for treatment of severe sepsis or septic shock: A systemic review and meta-analysisSun-Kyung Park, Md, Su rin Shin, Md, Min hur, Md, Won ho Kim, Md, Phd, Eun-ah oh, Md, Soo hee lee, Md
Purpose: to assess the effects of early goal-directed therapy (Egdt) on reducing mortality compared with conventional management of severe sepsis or septic shock.
Materials and methods: We included a systemic review, using the Medline and EMBaSE. Seventeen randomized trials with 5765 patients comparing Egdt with usual care were included.
Results: There were no significant differences in mortality between EGDT and control groups (relative risk [RR], 0.89; 95% confidence interval [Ci], 0.79-1.00), with moderate heterogeneity (i2 = 56%). the Egdt was associated with lower mortality rates when the mortality rate of the usual care group was greater than 30% (12 trials; RR, 0.83; 95% Ci, 0.72-0.96), but not when the mortality rate in the usual care group was less than 30% (5 trials; RR, 1.03; 95% CI, 0.92-1.16). The mortality benefit was seen only in subgroup of population analyzed between publication of the 2004 and 2012 Surviving Sepsis Campaign guidelines, but not before and after these publications.
Conclusion: This meta-analysis was heavily influenced by the recent addition of the trio of trials published after 2014. The results of the recent trio of trials may be biased due to methodological issues. this includes lack of blinding by incorporating similar diagnostic and therapeutic interventions as the original Egdt trial. (Journal of Critical Care 2017 doi: http://dx.doi.org/10.1016/j.jcrc.2016.10.019)
Our View: Egdt is established principle in resuscitation of severe sepsis and septic shock.
Randomized clinical trial of preoperative skin antisepsis with chlorhexidine gluconate or povidone–iodineh. M. Park, S.S. han, E. C. lee, S. d. lee, h. M. yoon, B. W. Eom, S. h. Kim, K. W. ryu, S.J. Park, y. W. Kim, B. Park
Background: Skin antiseptic agents are used to prevent surgical-site infection (SSI); few trials have reported the superiority of any specific agent in clean-contaminated abdominal surgery. This RCT was designed to compare the effectiveness of chlorhexidine gluconate and povidone–iodine.
Methods: Consecutive patients who underwent clean-contaminated upper gastrointestinal or hepatobiliary–pancreatic open surgery between 2011 and 2014 were assigned randomly to either chlorhexidine gluconate or povidone–iodine. the primary endpoint was the occurrence of SSi within 30 days of surgery. Secondary endpoints included causative organisms and risk factors for SSi.
Results: A total of 534 patients were randomized; 31 (5.8 per cent) developed an SSi. there was no difference in the overall SSi rate in the chlorhexidine gluconate and povidone–iodine groups: 15 of 267 (5.6 per cent) and 16 of 267 (6.0 per cent) respectively (P = 0.853). the most common causative organism
was Enterococcus faecalis. in subgroup analysis, biliary–pancreatic surgery had a higher SSi rate (26 of 127, 20.5 per cent) than upper gastrointestinal (2 of 204, 1.0 per cent) and hepatic (3 of 203, 1.5 per cent) resection. Both age (60 years and over) and type of incision were associated with the risk of SSi.
Conclusion: no difference was detected between chlorhexidine gluconate and povidone–iodine antiseptics for prevention of SSi. Registration number: NCT01495117 (http://www.clinicaltrials.gov).( BJS 2017; 104: e145–e150 DOI: 10.1002/bjs.10395)
Our view: Very relevant in day to day practice but we prefer chlorhexidine gluconate due to coloring effect of povidone–iodine.
Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Systematic Review and Meta-Analysis nathan Evaniew, Emilie P. Belley-Côté, nader fallah, Vanessa K. noonan,Carly S. rivers, Marcel f. dvorak
Previous meta-analyses of methylprednisolone (MPS) for patients with acute traumatic spinal cord injuries (tSCis) have not addressed confidence in the quality of evidence used for pooled effect estimates, and new primary studies have been recently published. We aimed to determine whether MPS improves motor recovery and is associated with increased risks for adverse events. We searched MEdlinE, EMBaSE, and the Cochrane library, and two reviewers independently screened articles, extracted data, and evaluated risk of bias. We pooled outcomes from randomized, controlled trials (rCts) and controlled observational studies separately and used the grades of recommendation, assessment, development, and Evaluation approach to evaluate confidence. We included four RCTs and 17 observational studies. MPS was not associated with an increase in long-term motor score recovery (two RCTs: 335 participants; mean difference [MD], -1.11; 95% confidence interval [CI], -4.75 to 2.53; p = 0.55, low confidence; two observational studies: 528 participants; MD, 1.37; 95% CI, -3.08 to 5.83; p = 0.55, very low confidence) or improvement by at least one motor grade (three observational studies: 383 participants; risk ratio [RR], 0.84; 95% CI, 0.53–1.33; p = 0.46, very low confidence). Evidence from two rCts demonstrated superior short-term motor score improvement if MPS was administered within 8 h of injury (two RCTs: 250 participants; MD, 4.46; 95% CI, 0.97–7.94; p = 0.01, low confidence), but risk of bias and imprecision limit confidence in these findings. Observational studies demonstrated a significantly increased risk for gastrointestinal bleeding (nine studies: 2857 participants; RR, 2.18; 95% CI, 1.13–4.19; p = 0.02, very low confidence), but RCTs did not. Pooled evidence does not demonstrate a significant long-term benefit for MPS in patients with acute TSCIs and suggests it may be associated with increased gastrointestinal bleeding. these findings support current guidelines against routine use, but strong recommendations are not warranted because confidence in the effect estimates is limited. (Journal of neurotrauma 2016 doi:10.1089/neu.2015.4192.)
Our view: different centres still have MPS in use for the acute Spinal Cord injury (aSCi) based on post hoc analysis of outdated naSCiS 2 trials showing improvement in motor function who were started treatment within 8 hours of injury. others believe common practice, and medicolegal concerns. We think we should not routinely use it. the selected few cases where edema may be the likely underlying cause of loss of function, MPS use may prove a bet.
Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillatorrobert J. russo, M.d., Ph.d., heather S. Costa, Ph.d., Patricia d. Silva, M.S., Jeffrey l. anderson, M.d., aysha arshad, M.d., robert W.W. Biederman, M.d., noel g. Boyle, M.d., Ph.d., Jennifer V. frabizzio, M.d., ulrika Birgersdotter-green, M.d., Steven l. higgins, M.d., rachel lampert, M.d., Christian E. Machado, M.d., Edward t. Martin, M.d., andrew l. rivard, M.d., Jason C. rubenstein, M.d., raymond h.M. Schaerf, M.d., Jennifer d. Schwartz, M.d., dipan J. Shah, M.d., gery f. tomassoni, M.d., gail t. tominaga, M.d., allison E. tonkin, M.d., Seth uretsky, M.d., and Steven d. Wolff, M.d., Ph.d.
Background: the presence of a cardiovascular implantable electronic device has long been a contraindication for the performance of magnetic resonance imaging (Mri). We established a prospective registry to determine the risks associated with MRI at a magnetic field strength of 1.5 tesla for patients who had a pacemaker or implantable cardioverter-defibrillator (ICD) that was “non–MRI-conditional” (i.e., not approved by the food and drug administration for Mri scanning).
Methods: Patients in the registry were referred for clinically indicated nonthoracic MRI at field strength of 1.5 tesla. Devices were interrogated before and after Mri with the use of a standardized protocol and were appropriately reprogrammed before the scanning. the primary end points were death, generator or lead failure, induced arrhythmia, loss of capture, or electrical reset during the scanning. the secondary end points were changes in device settings.
Results: Mri was performed in 1000 cases in which patients had a pacemaker and in 500 cases in which patients had an iCd. no deaths, lead failures, losses of capture, or ventricular arrhythmias occurred during Mri. one iCd generator could not be interrogated after MRI and required immediate replacement; the device had not been appropriately programmed per protocol before the Mri. We observed six cases of self-terminating atrial fibrillation or flutter and six cases of partial electrical reset. Changes in lead impedance, pacing threshold, battery voltage, and P-wave and r-wave amplitude exceeded
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prespecified thresholds in a small number of cases. Repeat MRI was not associated with an increase in adverse events.
Conclusions: in this study, device or lead failure did not occur in any patient with a non–Mri-conditional pacemaker or iCd who underwent clinically indicated nonthoracic Mri at 1.5 tesla, was appropriately screened, and had the device reprogrammed in accordance with the prespecified protocol. (NEJM 2017 DOI: 10.1056/NEJMoa1603265)
Our View: Mri can particularly not be attempted for those having pacing dependence. Pacemaker should be turned off as a test under control environments with the programmer readily at hand for the desired period of Mri scan. if the patient is unable to tolerate short periods, then Mri scans should not be attempted with Mri non compatible devices. Also the benefits of the diagnostic information must be well weighed against the possible harm.
Gender Parity in Critical Care MedicineMehta S, Burns KE, Machado fr, fox-robichaud aE, Cook dJ, Calfee CS, Ware lB, Burnham El, Kissoon n, Marshall JC, Mancebo J, finfer S, hartog C, reinhart K, Maitland K, Stapleton rd, Kwizera a, amin P, abroug f, Smith o, laake Jh, Shrestha gS, herridge MS
AbstractClinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. These documents inform and shape patient care around the world. in this perspective we discuss the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities and government. We propose five strategies to ensure
gender parity within critical care medicine. (am J respir Crit Care Med. 2017 DOI:10.1164/rccm.201701-0076CP)
Our View: Such must happen in a uniform manner and with larger acceptance in the coming future. the imagined effects are great for a wholesome society at large.
Coimbatore, Tamil Nadu
Organized by ISCCM Coimbatore ChapterIn Association with ISCCM Tamil Nadu ChaptersChennai | Trichy | Puducherry
SOUTH ZONE CRITICAL CARE - 20173rd ANNUAL SOUTH ZONE CONFERENCE OF ISCCM
Thematic Conference on Neuro Critical Care
September 14th & 15th - Workshop | 16th & 17th - Main ConferenceConference Highlights
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CRITICARE 2018 7-11 March, 2018 • Varanasi
SWaGatHaM!
Friends,
I am honoured and privileged to assume the role of Chairperson of the 24th Annual Congress at Varanasi.
Situated on the bank of River Ganga. Varanasi is the oldest living city & considered as the holiest and most sacred place on this planet. Mark Twain once said, "Varanasi is older than history, older than tradition, older even than legend & looks twice as old as all of them put together." It is also an important industrial center, famous for its carpet, silk fabrics, perfumes, ivory works & sculptures.
Banaras Hindu University is an internationally reputed temple of learning. It was founded by the great nationalist leader, Pt. Madan Mohan Malviya, in 1916. It played a stellar role in the independence
dr. Kapil Zirpenational PrESidEnt, iSCCM &
ChairMan SCiEntifiC CoMMittEE
movement & has developed into one of the greatest center of learning. It has produced many a great freedom fighters, renowned scholars, artists, scientists & technologist all contributing immensely towards the
progress of modern India. We also proud to be associated with six Bharat Ratna Award.
I am confident that we will be steadfast in addressing the pressing challenges. On behalf of all of us, I am most pleased to welcome Prof. D K Singh who is organizing secretary of 24 TH Annual Congress of ISCCM. Over his years of service in BHU, he has distinguished himself as a person with dedication, integrity, and professionalism. We are confident that he and his team will continue to make outstanding contributions to ISCCM.
Thus, on the behalf of Organizing Committee, Varanasi City Branch & BHU, I invite you all to join this excellent scientific feast at Varanasi in 2018. The city is eager to greet with you with spiritual music to enlighten your soul with learning & knowledge.
Dr. Michael S Niederman Dr. Michale Oleary Dr. Rupert Pearse Dr. Vito Marco Ranieri Dr. Claudio Ronco
Prof. Alain Combes Prof. Dr. Med. Tobias Welte Prof. Giuseppe Citerio Prof. Jean-Louis Teboul Prof. Paul Wischmeyer
INTERNATIONAL FACULTY
Editorial officEdr. Yatin Mehta
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