Background: Coronavirus disease-2019 (COVID-19) in the last few months has disrupted the healthcare system globally. The objective of this study is to assess the impact of the COVID-19 pandemic on the psychological and emotional well-being of healthcare workers (HCWs). Materials and methods: We conducted an online, cross-sectional, multinational survey, assessing anxiety [using Generalized Anxiety Disorder (GAD) Scale: GAD-2 and GAD-7], depression (using Center for Epidemiologic Studies Depression Scale), and insomnia (using Insomnia Severity Index Scale), among HCWs across India, the Middle East, and North America. We used univariate and bivariate logistic regression to identify risk factors for psychological distress. Results: The prevalence of clinically significant anxiety, depression, and insomnia was 41.4%, 48.0%, and 31.3%, respectively. On bivariate logistic regression, lack of social or emotional support to HCWs was independently associated with anxiety [odds ratio (OR), 3.81 (2.84–3.90)], depression [OR, 6.29 (4.50–8.79)], and insomnia [OR, 3.79 (2.81–5.110]. Female gender and self-COVID-19 were independent risk factors for anxiety [OR, 3.71 (1.53–9.03) and 1.71 (1.23–2.38)] and depression [OR, 1.72 (1.27–2.31) and 1.62 (1.14–2.30)], respectively. Frontliners were independently associated with insomnia [OR, 1.68 (1.23–2.29)]. Conclusion: COVID-19 pandemic has a high prevalence of anxiety, depression, and insomnia among HCWs. Female gender, frontliners, self-COVID-19, and absence of social or emotional support are the independent risk factors for psychological distress.

Background: Severe acute respiratory distress syndrome associated with coronavirus disease-2019 (COVID-19) (CARDS) pneumonitis presents a clinical challenge as regards to the timing of intubation and ambiguity of outcome. There is a lack of clear consensus on when to switch patients from trials of noninvasive therapies to invasive mechanical ventilation. We investigated the effect of the timing of intubation from the time of admission on the clinical outcome of CARDS. Aim and objective: The aim and objective was to analyze the effect of timing of intubation early (within 48 hours of admission to critical care unit) versus delayed (after 48 hours of admission to critical care unit) on mortality in severe CARDS patients. Materials and methods: A retrospective observational study performed in a 28-bedded COVID-19 intensive care unit of a tertiary care hospital in Pune, India. All patients admitted between April 1, 2020, and October 15, 2020, with confirmed COVID-19 (RT-PCR positive) requiring mechanical ventilation were included in the study. Results: The primary outcome was in-hospital mortality. Among 2,230 patients that were admitted to the hospital, 525 required critical care (23.5%), invasive mechanical ventilation was needed in 162 patients and 147 (28%) of critical care admission were included in the study cohort after exclusion. Seventy-five patients (51%) were intubated within 48 hours of critical care admission (early group) and 72 (48.9%) were intubated after 48 hours of critical care admission (delayed group). With regards to the total of 147 included patients; male patients were 74.1% with a median age of 59 years (interquartile range, 51–68 years). Diabetes (44.9%) and hypertension (43.5%) were the most common comorbidities. Higher admission acute physiology and chronic health evaluation II scores and lower absolute lymphocyte count were observed in patients intubated within 48 hours. The early intubated group had a mortality of 60% whereas the same was observed as 77.7% in delayed intubation group, and this difference was statistically significant (p = 0.02). Conclusion: Current study concludes that early intubation is associated with improved survival rates in severe CARDS patients.

Background: Coronavirus disease-2019 (COVID-19) in the last few months has disrupted the healthcare system globally. The objective of this study is to assess the impact of the COVID-19 pandemic on the psychological and emotional well-being of healthcare workers (HCWs). Materials and methods: We conducted an online, cross-sectional, multinational survey, assessing the anxiety (using Generalized Anxiety Disorder [GAD-2] and GAD-7), depression (using Center for Epidemiologic Studies Depression), and insomnia (using Insomnia Severity Index), among HCWs across India, the Middle East, and North America. We used univariate and bivariate logistic regression to identify risk factors for psychological distress. Results: The prevalence of clinically significant anxiety, depression, and insomnia were 41.4, 48.0, and 31.3%, respectively. On bivariate logistic regression, lack of social or emotional support to HCWs was independently associated with anxiety [odds ratio (OR), 3.81 (2.84–3.90)], depression [OR, 6.29 (4.50–8.79)], and insomnia [OR, 3.79 (2.81–5.110)]. Female gender and self-COVID-19 were independent risk factors for anxiety [OR, 3.71 (1.53–9.03) and 1.71 (1.23–2.38)] and depression [OR, 1.72 (1.27–2.31) and 1.62 (1.14–2.30)], respectively. Frontliners were independently associated with insomnia [OR, 1.68 (1.23–2.29)]. Conclusion: COVID-19 pandemic has a high prevalence of anxiety, depression, and insomnia among HCWs. Female gender, frontliners, self-COVID-19, and absence of social or emotional support are the independent risk factors for psychological distress.

Background: Procalcitonin, a biomarker to adjudge the duration of antibiotic therapy in patients with sepsis. Materials and methods: A prospective, randomized, controlled, interventional, single-center study was conducted in a mixed adult intensive care unit (ICU). In a nonblinded study, 90 adult patients admitted to the ICU with sepsis and septic shock were randomized into group P (group procalcitonin) and group C (group control). The duration of antibiotic therapy was decided based on serum procalcitonin levels for patients in group P versus standard treatment protocols in group C. A procalcitonin value of <0.01 ng/mL or a subsequent decline of >80% from the baseline was cutoff and chosen to stop the antibiotic therapy. The primary aim was to compare the duration of antibiotic therapy (in days) in the two groups. The secondary objective was to compare and assess the length of ICU stay, reinfection, secondary infection rate, readmission rate, and mortality among the groups. Results: The mean duration of antibiotic therapy was significantly lesser in patients in group P (4.98 ± 2.56 vs 7.73 ± 3.06 days, p < 0.001). Patients in group C spent more days in ICU (8.80 ± 3.35 vs 5.98 ± 2.73 days, p < 0.001). The secondary infection rate was significantly higher in group C (26.7% vs 4.4%, p = 0.014). Readmission and mortality rates were comparable between the groups. Conclusion: Serum procalcitonin-based algorithm in critically ill patients with sepsis could lead to a reduction in the duration of antibiotic therapy, ICU stay, and associated morbidities like secondary infection rates. It further promotes antibiotic stewardship without any adverse effects on the patient's outcome.

Background: Early mobilization (EM) of critically ill adult patients in intensive care units (ICUs) is a newer concept. It is known to improve overall outcomes, but little is known regarding the attitude and knowledge of healthcare providers (HCPs) and multidisciplinary barriers to its use in the Indian scenario. Aims and objectives: To study the knowledge and attitude of HCPs in ICU about the EM of adult patients who are critically ill and identify perceived barriers to the application of EM. Materials and methods: In a cross-sectional survey conducted in a tertiary care academic institute, the HCPs, namely, physicians, anesthetists, surgeons, nursing staff, and physiotherapists working in ICU were interviewed using a self-structured questionnaire. The data were presented as descriptive statistics. Results: There was 80% response rate. The benefits of EM as shortened length of mechanical ventilation (MV) were acknowledged by 78% respondents and 54% believed that it maintains muscle strength. It was considered crucial by 44% respondents, who opined that it should be started as the patient's cardiorespiratory status stabilizes. The favorable attitudes observed were recognition of benefits for patients under MV exceeded the risks and readiness by physicians to reduce sedation levels and change the parameters of MV. The main barriers identified were the absence of written guidelines or protocols for EM, limited staff to mobilize patients, inadequate training of HCP to facilitate EM, excessive sedation, and medical instability. Conclusion: There exists an awareness of the benefits of EM and favorable attitudes to its application. However, the actual performance of EM was perceived as a challenge due to barriers identified in the study.

Background: An increasing number of patients become chronic critically ill (CCI) and dependent on long-term therapies in the intensive care unit (ICU). Mortality and healthcare costs increase in these patients. In order to deal with this problem, the magnitude and risk factors for CCI must first be determined. Therefore, we aimed at evaluating the incidence cost and risk factors for CCI in our ICU. Materials and methods: This retrospective cohort study was compiled by recruiting patients admitted to our ICU between January 1, 2017, and December 31, 2018. Patients with an ICU stay of more than 21 days were defined as CCI. Patients who did not survive in the first 21 days were excluded from the study because it could be not known whether these patients would progress to CCI. During the study period, 1,166 patients were followed up, and 475 (40%) of them were excluded and 691 patients were included in the final analyses. Results: During the study period, 691 patients were included in the study and 152 of them (22%) were CCI. Age, acute physiology and chronic health evaluation (APACHE)-2 score, length of stay, and daily costs were higher in patients with CCI. The cost for a patient with CCI is sixfold that of a patient without CCI. ICU mortality was 47% in patients without CCI and 54% in the CCI patients (p < 0.001). Conclusion: CCI affects an increasing number of patients and leads to increased mortality rates and cost. Prolonged duration in ICU may cause complications such as secondary infections, sepsis episodes, and acute renal injury. The treatment of these complications may lead to increased mortality and cost.

Background: Coronavirus disease-2019 (COVID-19) causes various cardiopulmonary manifestations. Bedside ultrasound helps in the rapid diagnosis of these manifestations. Vscan Extend™ (GE, Wauwatosa, WI, USA) is a handheld ultrasound device with a dual probe and an artificial intelligence application to detect ejection fraction. It can help in reducing the time for diagnosis, duration, and the number of healthcare workers exposed to COVID-19. This is a prospective observational study comparing the cardiorespiratory parameters and time duration for assessment between Vscan Extend™ and the conventional ultrasound machine. Materials and methods: Paired observations were made in 96 COVID-19 patients admitted to the intensive care unit by two intensivists. Intensivist A used the Vscan Extend™ device to assess the cardiac function, lung fields, diaphragm, deep veins, and abdomen. Intensivist B used clinical examination, X-ray chest, ECG, and conventional echocardiogram for assessment. The agreement between the findings and the time duration required in both the methods was compared. Results: The use of handheld ultrasound has significantly decreased the duration of bedside examination of patients than the conventional method. The median duration of examination using handheld ultrasound was 9 (8.0–11.0) minutes, compared to 20 (17–22) minutes with the conventional method (P < 0.001). The Cohen's kappa coefficient was 1.0 for left ventricular systolic function, most of the lung fields, and diaphragmatic movement. Conclusion: Vscan Extend™ helps in the rapid identification and diagnosis of cardiopulmonary manifestations in COVID-19 patients. The agreement between the handheld device and the conventional method proves its efficacy and safety. CTRI Number: CTRI/2020/07/026701

Introduction: The incidence of complications and mortality in patients undergoing elective surgery in India are unknown. We contributed Indian data to ISOS. Since there were fewer than ten centers, Indian data were not included in the primary analysis. We report postoperative outcomes in the Indian data set of patients following elective surgery. Materials and methods: In this prospective 7-day observational study, after obtaining a waiver of informed consent, data were collected for 30 days from consecutive patients >18 years undergoing elective surgery. The primary outcome was in-hospital postoperative complications. The secondary outcomes were in-hospital all-cause mortality, the relationship between postoperative complications and admission to critical care, and the duration of hospital stay. Complications were graded as mild, moderate, and severe. Failure to rescue was defined as mortality in patients admitted to an intensive care unit (ICU) for the treatment of complications. Results: Complications occurred in 57 (27.5%) patients, who were older (53 vs 47 years, p < 0.001) and had American Society of Anaesthesiologists grades III and IV physical status (p = 0.029). One hundred and thirty-eight (65.7%) patients underwent a major surgical procedure of which 132 (62.8%) procedures were done for malignancy. Postoperative complications were significantly higher (41.5% vs 22.7%) in patients electively admitted to ICU. The overall mortality rate was 2.4%, whereas the mortality rate was 8.8% in those who developed complications. Conclusion: We found that 28% of patients developed postoperative complications. The overall mortality was 2.4% but was higher (8.8%) in those who developed complications. Age and complex surgical procedures independently predicted complications, while lower preoperative hemoglobin appeared to be protective. Study Registration: ISRCTN51817007

Introduction: Coronavirus disease-2019 (COVID-19) pandemic has overloaded the healthcare system beyond its functional capacity. Late referral to higher levels of care may be one of the factors associated with higher mortality. Therefore, we aimed to find simple demographic and laboratory parameters which predict the requirement of admission to a critical care unit. Materials and methods: A case–control study was undertaken in adult age population >18 years, admitted in a dedicated COVID hospital in South India. A total of 50 patients with severe disease (cases) were compared with 143 mild or asymptomatic cases (controls). Those demographic and laboratory parameters that were found to be significant on univariate analysis were used for multiple logistic regression analysis. Results: Univariate analysis of demographic and laboratory data showed higher age, male sex, presence of diabetes mellitus, higher values of C-reactive protein, ferritin, D-dimer, neutrophil–lymphocyte ratio (NLR), and lactate dehydrogenase to be significantly associated with cases. Multivariate logistic regression analysis of these significant variables showed NLR and ferritin to be the independent predictors of the requirement of admission to a critical care unit. The receiver-operating characteristic curve showed an NLR value of 5.2 and a ferritin value of 462 µg/L that were able to predict the requirement of admission in critical care units. Conclusion: High ferritin and NLR were independent predictors of the requirement of admission in critical care units. NLR is a simple tool that can be used in resource-limited settings for triage and early referral to higher levels of care.

Introduction: Intensive care unit (ICU) visitation has traditionally been restrictive, primarily due to septic considerations and staff apprehension towards unrestricted visitation policy. However, ICU admission is stressful for patients and their families and the presence of family relatives at ICU patients’ bedside may help alleviate the same. The present study compares the viewpoints of healthcare workers (HCW) and patients’ family members regarding these two types of visitation policies. Materials and methods: The initial assessment involved a qualitative investigation, based on an inductive grounded theory approach. Participant interviews were audiotaped, transcribed, manually coded, themes analyzed, and aggregate dimensions unfolded. Subsequently, a structured proforma filled by stakeholders and responses were coded as categorical variables (quantitative investigation). Their association with a continuous presence of family members was seen using univariate analysis (Chi-square test) and p <0.05 was considered significant. Satisfaction levels were rated on a Likert scale. Results: Eighty-six stakeholders [group A: HCWs (15 doctors, 29 nurses), group B: patients (n = 18), and their relatives (n = 24)] were interviewed. While group A preferred restricted visitation policy (RVP), group B preferred unrestricted visitation policy (UVP). Quantitative data confirmed that HCWs (92.8% nurses and 85.7% doctors) were more satisfied with RVP and group B (92.3% relatives and 87.5% patients) with UVP. Group A (75.9% nurses and 93.3% doctors) therefore preferred RVP and group B (75% families and 66.6% patients) preferred UVP. Conclusion: The patients and their families were more satisfied with UVP contrary to HCWs who were skeptical towards UVP and preferred RVP.

Background: A clinical risk-scoring algorithm (CRSA) to forecast the scrub typhus severity was developed from two general hospitals in Thailand where patients were classified into three groups—nonsevere, severe, and fatal. In this study, an attempt was made to validate the risk-scoring algorithm for prognostication of scrub typhus severity in India. Materials and methods: This prospective study was conducted at a hospital in South India between November 2017 and March 2019. Patients of scrub typhus were categorized into nonsevere, severe, and fatal according to the CRSA. The patients were also grouped into severe and nonsevere according to the definition of severe scrub typhus which was used as a gold standard. The obtained CRSA score was validated against the classification based on the definition of severe scrub typhus. Receiver operating characteristics (ROC) curve for the scores was plotted and the Youden's index for optimal cutoff was used. Results: A total of 198 confirmed cases of scrub typhus were included in the study. According to the ROC curve, at a severity score ≥7, an optimal combination of sensitivity of 75.9% and specificity of 77.5% was achieved. It correctly predicted 76.77% (152 of 198) of patients as severe, with an underestimation of 10.61% (21 patients) and an overestimation of 12.63% (25 patients). Conclusion: In the present study setting, a cutoff of ≥7 for severity prediction provides an optimum combination of sensitivity and specificity. These findings need to be validated in further studies.

Aim and objective: To reduce the incidence of infiltration and phlebitis by 50% over 2 months among children admitted to the emergency room (ER) of a tertiary care hospital. Materials and methods: The study was conducted in the pediatric ER of a tertiary care hospital in North India. All children aged >28 days, receiving intravenous (IV) medication and/or fluids, were enrolled between June (2017) and September (2017). Existing practices of IV line insertion and maintenance were observed and recorded. The visual infusion phlebitis score and infiltration assessment scale used to grade the extent of the two. The intervention classified as “IV line insertion and maintenance bundle” included the introduction of low-cost mobile sterile compartment trays, audit and feedback, organizational change and introduction of infection control nurse. These interventions were implemented in sequential Plan-Do-Study-Act (PDSA) cycles. Reduction in the “incidence of phlebitis and infiltration” were the outcome measures while “scores on checklist of IV line insertion and IV line maintenance and administration of drugs” were the process measures. Result: The process measures, for IV line insertion, maintenance and administration of drugs through IV line, revealed an increase in scores on the checklist. There was a significant decrease in the incidence of infiltration and phlebitis from 82.9% and 96.1% to 45% and 55%, respectively, after implementation of all PDSA cycles. Conclusion: Multifaceted QI IV line insertion and maintenance bundle reduced the incidence of infiltration and phlebitis. These interventions when integrated into daily work bundles along with continuous education and motivation helped in sustaining the goal and attaining long-term success.

We live in an era of evolving microbial infections and equally evolving drug resistance among microorganisms. In any healthcare facility, intensivists play the most pivotal role with critically ill patients under their direct care. Majority of the critically ill patients already harbor a microorganism at admission or acquire one in the form of healthcare-associated infections during their course of intensive care unit stay. It is therefore rather imperative for intensivists to possess sound knowledge in clinical microbiology. On a negative note, most clinicians have very meager and remote knowledge acquired during their undergraduate years. This knowledge is rather theoretical than applied and wanes over the years becoming nonbeneficial in intensive patient care. We, therefore, intend to explore important concepts in applied microbiology and infection control that intensivists should know and implement in their clinical practice on a day-to-day basis.

Introduction: Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening, allergic reactions affecting the skin and mucous membranes. SJS is considered to be a milder form with less than 10% of body surface area (BSA) involvement. We report successful management of two cases of SJS and TEN. Firstly, a case of a 24-year-old female who presented with rashes over face, chest, and upper limbs after the oral intake of ciprofloxacin and local application of moxifloxacin eye drops. She developed high-grade fever and difficulty in breathing requiring intubation and lung-protective mechanical ventilation and was treated with high-dose methylprednisolone, azithromycin, soframycin skin dressings, and topical ocular antibiotics. Secondly, another case of a 16-year-old female who developed bullous eruptions over the trunk, arms, hands, face, and sole involving 60% of BSA, after oral intake of albendazole. She was diagnosed as TEN and successfully managed with sterile silver nitrate, soframycin dressings, and antibiotics. Key message: Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening, allergic reactions affecting the skin and mucous membranes. Early identification, withdrawal of the suspected drug, and early transfer to a specialized center decrease mortality.

Background: Paroxysmal sympathetic hyperactivity (PSH) is a grave entity affecting patients following traumatic brain injury (TBI). It presents with cyclic and simultaneous fever, posturing, and other symptoms of sympathetic hyperactivity. Lack of diagnostic tests or biochemical markers and its propensity to mimic other common causes of fever in the neurotrauma intensive care unit (ICU) result in clinical dilemmas and management delay. Case descriptions: We present a case series of four patients (two adults and two pediatrics) with TBI who developed PSH during ICU stay. These patients presented with fever along with variable symptoms of sympathetic hyperactivity. However, the value of serum procalcitonin (PCT) was not elevated, and management of PSH was started. Serial monitoring of PCT helped in differentiating fever due to PSH from sepsis and thus the institution of appropriate and timely treatment of PSH and also helped to use antibiotics rationally. Conclusion: The use of serum PCT in differentiating sepsis from systemic inflammatory reaction and its role in the initiation and titration of antibiotics are well described. PSH is a common entity after TBI, causing episodic fever and sympathetic hyperactivity, often confused with infectious pathology. Our report proposes the role of serum PCT in differentiating PSH from infectious etiology and management of two different clinical entities.

Spontaneous air-leak syndromes have emerged as rare but significant complication of Coronavirus disease-2019 (COVID-19) pneumonia in the last few months. This complication has been documented in both spontaneous and mechanically ventilated patients. Although few studies have used computed tomographic scans to confirm the diagnosis, this could be challenging in resource-limited setup. We present a series of 15 cases that highlight the clinical heterogeneity with respect to stage of illness, ventilatory status, and varied clinical scenarios at the time of development of these syndromes. All cases in our series were diagnosed clinically and confirmed by bedside chest X-ray and were managed promptly. Though mortality was not so infrequent in our experience, these air-leak syndromes were not directly attributed as cause of death in these patients. Therefore, high level of clinical suspicion and vigilance is necessary to identify and manage cases of air-leak syndrome.

Background: Blood clot formation is a multifactorial process and has been related many times in intensive care units. Here is presented a multiple thrombosis formation in a rewarming patient. Case description: A 68-year-old patient was admitted to our intensive care unit after lying on the floor for an unknown time. She presented a severe hypothermia at 26° and a severe cardiogenic shock. Because she was confused and was hypoxemic, she had been intubated at her admission. After intravascular warming, we could stop sedative medications. She presented a right hemiparesis and acute left leg ischemia. Computed tomography (CT) scan revealed a constituted left Sylvian stroke and a massive clot along the aorta. She required a surgical embolectomy and fasciotomy. She died after she presented a severe bowel ischemia on the third day after her admission. Conclusion: Relevant hypothesis for blood clot formation in this patient may include prolonged lying position or blood temperature variation. Hypothermia and rewarming responsibilities may explain multiple thrombosis development.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment modality for peritoneal surface malignancies. A variety of metabolic derangements have been reported in the perioperative period in these patients, most of which are a result of the complex interaction of peritoneal denudation, chemotherapy bath, and fluid imbalance. We report three cases of hyperammonemia-related neurological dysfunction seen in HIPEC patients. To the best of our knowledge, this is the first report of this presentation. Timely recognition of this condition needs a high degree of suspicion, and unless aggressively treated, is likely to be associated with poor outcome.

“Clean Hands Save Lives,” we have heard it numerous times. But are our hands really clean? We realized that the most neglected parts of our hands are the most medial part of the little finger and palm and the most lateral part of the index finger and palm. Putting an emphasis on it, we put forward two additional steps in the routine handwashing technique increasing to 9 steps instead of the previous 7.