BACKGROUND Since its description in 1790 by Hunter,the nasogastric tube(NGT)is commonly used in any healthcare setting for alleviating gastrointestinal symptoms or enteral feeding.However,the risks associated with its...BACKGROUND Since its description in 1790 by Hunter,the nasogastric tube(NGT)is commonly used in any healthcare setting for alleviating gastrointestinal symptoms or enteral feeding.However,the risks associated with its placement are often underes-timated.Upper airway obstruction with a NGT is an uncommon but potentially life-threatening complication.NGT syndrome is characterized by the presence of an NGT,throat pain and vocal cord(VC)paralysis,usually bilateral.It is poten-tially life–threatening,and early diagnosis is the key to the prevention of fatal upper airway obstruction.However,fewer cases may have been reported than might have occurred,primarily due to the clinicians'unawareness.The lack of specific signs and symptoms and the inability to prove temporal relation with NGT insertion has made diagnosing the syndrome quite challenging.AIM To review and collate the data from the published case reports and case series to understand the possible risk factors,early warning signs and symptoms for timely detection to prevent the manifestation of the complete syndrome with life-threatening airway obstruction.METHODS We conducted a systematic search for this meta-summary from the database of PubMed,EMBASE,Reference Citation Analysis(https://www.referencecitation-analysis.com/)and Google scholar,from all the past studies till August 2023.The search terms included major MESH terms"Nasogastric tube","Intubation,Gastrointestinal","Vocal Cord Paralysis",and“Syndrome”.All the case reports and case series were evaluated,and the data were extracted for patient demographics,clinical symptomatology,diagnostic and therapeutic interventions,clinical course and outcomes.A datasheet for evaluation was further prepared.RESULTS Twenty-seven cases,from five case series and 13 case reports,of NGT syndrome were retrieved from our search.There was male predominance(17,62.96%),and age at presentation ranged from 28 to 86 years.Ten patients had diabetes mellitus(37.04%),and nine were hypertensive(33.33%).Only three(11.11%)patients were reported to be immunocompromised.The median time for developing symptoms after NGT insertion was 14.5 d(interquartile range 6.25-33.75 d).The most commonly reported reason for NGT insertion was acute stroke(10,37.01%)and the most commonly reported symptoms were stridor or wheezing 17(62.96%).In 77.78%of cases,bilateral VC were affected.The only treatment instituted in most patients(77.78%)was removing the NG tube.Most patients(62.96%)required tracheostomy for airway protection.But 8 of the 23 survivors recovered within five weeks and could be decannulated.Three patients were reported to have died.CONCLUSION NGT syndrome is an uncommon clinical complication of a very common clinical procedure.However,an under-reporting is possible because of misdiagnosis or lack of awareness among clinicians.Patients in early stages and with mild symptoms may be missed.Further,high variability in the presentation timing after NGT insertion makes diagnosis challenging.Early diagnosis and prompt removal of NGT may suffice in most patients,but a significant proportion of patients presenting with respiratory compromise may require tracheostomy for airway protection.展开更多
BACKGROUND Dengue fever is the most common cause of viral hemorrhagic fever,with more than 400 million cases being reported annually,worldwide.Even though hepatic involvement is common,acute liver failure(ALF)is a rar...BACKGROUND Dengue fever is the most common cause of viral hemorrhagic fever,with more than 400 million cases being reported annually,worldwide.Even though hepatic involvement is common,acute liver failure(ALF)is a rare complication of dengue fever.AIM To analyze the demographic profile,symptomology,hospital course and outcomes of patients presenting with ALF secondary to dengue infection by reviewing the published case reports.METHODS A systematic search was performed from multiple databases including PubMed,Reference Citation Analysis,Science Direct,and Google Scholar.The search terms used were"dengue"OR"severe dengue"OR"dengue shock syndrome"OR"dengue haemorrhagic syndrome"OR"dengue fever"AND"acute liver failure"OR"hepatic failure"OR"liver injury".The inclusion criteria were:(1)Case reports or case series with individual patient details;(2)Reported acute liver failure secondary to dengue infection;and(3)Published in English language and on adult humans.The data were extracted for patient demographics,clinical sympto-matology,clinical interventions,hospital and intensive care unit course,need for organ support and clinical outcomes.RESULTS Data from 19 case reports fulfilling the predefined inclusion criteria were included.The median age of patients was 38 years(inter quartile range:Q3-Q126.5 years)with a female preponderance(52.6%).The median days from diagnosis of dengue to development of ALF was 4.5 d.The increase in aspartate aminotransferase was higher than that in alanine aminotransferase(median 4625 U/L vs 3100 U/L).All the patients had one or more organ failure,with neurological failure present in 73.7%cases.42.1%patients required vasopressor support and hepatic enceph-alopathy was the most reported complication in 13(68.4%)cases.Most of the patients were managed conser-vatively and 2 patients were taken up for liver transplantation.Only 1 death was reported(5.3%).CONCLUSION Dengue infection may rarely lead to ALF.These patients may frequently require intensive care and organ support.Even though most of these patients may improve with supportive care,liver transplantation may be a therapeutic option in refractory cases.展开更多
Critically ill patients are a vulnerable group at high risk of developing secondary infections.High disease severity,prolonged intensive care unit(ICU)stay,sepsis,and multiple drugs with immunosuppressive activity mak...Critically ill patients are a vulnerable group at high risk of developing secondary infections.High disease severity,prolonged intensive care unit(ICU)stay,sepsis,and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections,including cytomegalovirus(CMV).CMV seroconversion has been reported in up to 33%of ICU patients,but its impact on patient outcomes remains a matter of debate.Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/acquired immuno deficiency syndrome,the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous.Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement.Hence,a better understanding of the symptomatology,diagnostics,and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions.展开更多
Intra-abdominal hypertension(IAH)and abdominal compartment syndrome(ACS)play a pivotal role in the pathophysiology of severe acute pancreatitis(SAP)and contribute to new-onset and persistent organ failure.The optimal ...Intra-abdominal hypertension(IAH)and abdominal compartment syndrome(ACS)play a pivotal role in the pathophysiology of severe acute pancreatitis(SAP)and contribute to new-onset and persistent organ failure.The optimal management of ACS involves a multi-disciplinary approach,from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure(IAP).A targeted literature search from January 1,2000,to November 30,2022,revealed 20 studies and data was analyzed on the type and country of the study,patient demographics,IAP,type and timing of surgical procedure performed,post-operative wound management,and outcomes of patients with ACS.There was no randomized controlled trial published on the topic.Decom-pressive laparotomy is effective in rapidly reducing IAP(standardized mean difference=2.68,95%confidence interval:1.19-1.47,P<0.001;4 studies).The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but,potentially lethal ACS.Disease-specific patient selection and the role of less-invasive decompressive measures,like subcutaneous linea alba fasciotomy or component separation techniques,is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS.This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP.However,there is a lack of high-quality evidence on patient selection,timing,and modality of surgical decompression.Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.展开更多
BACKGROUND Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are commonly prescribed to manage patients with diabetes mellitus.These agents may rarely lead to the development of euglycemic diabetic ketoacidosis(EDKA),w...BACKGROUND Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are commonly prescribed to manage patients with diabetes mellitus.These agents may rarely lead to the development of euglycemic diabetic ketoacidosis(EDKA),which may complicate the disease course of these patients.AIM To analyze the demographic profile,predisposing factors,symptomology,clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series.METHODS We performed a systematic search of PubMed,Science Direct,Google Scholar and Reference Citation Analysis databases using the terms“canagliflozin”OR“empagliflozin”OR“dapagliflozin”OR“SGLT2 inhibitors”OR“Sodium-glucose cotransporter-2”AND“euglycemia”OR“euglycemic diabetic ketoacidosis”OR“metabolic acidosis”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported EDKA secondary to SGLT2i.Furthermore,the data were filtered from the literature published in the English language and on adults(>18 years).We excluded:(1)Conference abstracts;and(2)Case reports or series which did not have individual biochemical data.All the case reports and case series were evaluated.The data extracted included patient demographics,clinical symptomatology,clinical interventions,intensive care unit course,need for organ support and outcomes.RESULTS Overall,108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included.The majority of patients were females(54.4%,n=92),and the commonly reported symptoms were gastrointestinal(nausea/vomiting 65.1%,abdominal pain 37.3%)and respiratory(breathlessness 30.8%).One hundred and forty-nine(88.2%)patients had underlying type II diabetes,and the most commonly involved SGLT-2 inhibitor reported was empagliflozin(46.8%).A triggering factor was reported in most patients(78.7%),the commonest being acute severe infection(37.9%),which included patients with sepsis,coronavirus disease 2019,other viral illnesses,and acute pancreatitis.61.5%were reported to require intensive unit care,but only a minority of patients required organ support in the form of invasive mechanical ventilation(13%),vasopressors(6.5%)or renal replacement therapy(5.9%).The overall mortality rate was only 2.4%.CONCLUSION Patients on SGLT2i may rarely develop EDKA,especially in the presence of certain predisposing factors,including severe acute infections and following major surgery.The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels,which may make the diagnosis challenging.Outcomes of EDKA are good if recognized early and corrective actions are taken.Hence,physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.展开更多
Critically ill patients are prone to high glycemic variations irrespective of their diabetes status.This mandates frequent blood glucose(BG)monitoring and regulation of insulin therapy.Even though the most commonly em...Critically ill patients are prone to high glycemic variations irrespective of their diabetes status.This mandates frequent blood glucose(BG)monitoring and regulation of insulin therapy.Even though the most commonly employed capillary BG monitoring is convenient and rapid,it is inaccurate and prone to high bias,overestimating BG levels in critically ill patients.The targets for BG levels have also varied in the past few years ranging from tight glucose control to a more liberal approach.Each of these has its own fallacies,while tight control increases risk of hypoglycemia,liberal BG targets make the patients prone to hyperglycemia.Moreover,the recent evidence suggests that BG indices,such as glycemic variability and time in target range,may also affect patient outcomes.In this review,we highlight the nuances associated with BG monitoring,including the various indices required to be monitored,BG targets and recent advances in BG monitoring in critically ill patients.展开更多
BACKGROUND Drug-induced liver injury(DILI)can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs.Direct-acting oral anticoagulants(DOACs)are non-vitamin K-based ant...BACKGROUND Drug-induced liver injury(DILI)can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs.Direct-acting oral anticoagulants(DOACs)are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions.A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs.However,it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.AIM To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.METHODS A systematic search was conducted on multiple databases including PubMed,Science Direct,Reference Citation Analysis,and Google Scholar.The search terms included“Acute Liver Failure”OR“Acute-On-Chronic Liver Failure”OR“Acute Chemical and Drug Induced Liver Injury”OR“Chronic Chemical and Drug Induced Liver Injury”AND“Factor Xa Inhibitors”OR“Dabigatran”OR“Rivaroxaban”OR“apixaban”OR“betrixaban”OR“edoxaban”OR“Otamixaban”.The results were filtered for literature published in English and on adult patients.Only case reports and case studies reporting cases of DILI secondary to DOACs were included.Data on demographics,comorbidities,medication history,laboratory investigations,imaging,histology,management,and outcomes were extracted.RESULTS A total of 15 studies(13 case reports and 2 case series)were included in the analysis,comprising 27 patients who developed DILI secondary to DOACs.Rivaroxaban was the most commonly implicated DOAC(n=20,74.1%).The mean time to onset of DILI was 40.6 d.The most common symptoms were jaundice(n=15,55.6%),malaise(n=9,33.3%),and vomiting(n=9,33.3%).Laboratory investigations showed elevated liver enzymes and bilirubin levels.Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury.Most patients had a favourable outcome,and only 1 patient(3.7%)died due to liver failure.CONCLUSION DOACs are increasingly used for various clinical conditions,and DILI secondary to DOACs is a rare but potentially serious complication.Prompt identification and cessation of the offending drug are crucial for the management of DILI.Most patients with DILI secondary to DOACs have a favourable outcome,but a small proportion may progress to liver failure and death.Further research,including post-marketing population-based studies,is needed to better understand the incidence and risk factors for DILI secondary to DOACs.展开更多
BACKGROUND The proficiency of nursing professionals in the infection prevention and control(IPC)practices is a core component of the strategy to mitigate the challenge of healthcare associated infections.AIM To test k...BACKGROUND The proficiency of nursing professionals in the infection prevention and control(IPC)practices is a core component of the strategy to mitigate the challenge of healthcare associated infections.AIM To test knowledge of nurses working in intensive care units(ICU)in South Asia and Middle East countries on IPC practices.METHODS An online self-assessment questionnaire based on various aspects of IPC practices was conducted among nurses over three weeks.RESULTS A total of 1333 nurses from 13 countries completed the survey.The average score was 72.8%and 36%of nurses were proficient(mean score>80%).43%and 68.3%of respondents were from government and teaching hospitals,respectively.79.2%of respondents worked in<25 bedded ICUs and 46.5%in closed ICUs.Statistically,a significant association was found between the knowledge and expertise of nurses,the country’s per-capita income,type of hospitals,accreditation and teaching status of hospitals and type of ICUs.Working in high-and upper-middleincome countries(β=4.89,95%CI:3.55 to 6.22)was positively associated,and the teaching status of the hospital(β=-4.58,95%CI:-6.81 to-2.36)was negatively associated with the knowledge score among respondents.CONCLUSION There is considerable variation in knowledge among nurses working in ICU.Factors like income status of countries,public vs private and teaching status of hospitals and experience are independently associated with nurses’knowledge of IPC practices.展开更多
BACKGROUND Understanding the transmission dynamics of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection among healthcare workers(HCWs)and their social contacts is crucial to plan appropriate risk-re...BACKGROUND Understanding the transmission dynamics of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection among healthcare workers(HCWs)and their social contacts is crucial to plan appropriate risk-reduction measures.AIM To analyze the socio-demographic risk factors and transmission of SARS-CoV-2 infection among HCWs in two tertiary care hospitals in Dubai,United Arab Emirates.METHODS The demographic and clinical characteristics were available for all HCWs in both facilities from the human resources department.A cross-sectional survey was conducted from January-April 2022 among HCWs who tested positive through Reverse Transcriptase Polymerase Chain Reaction of the nasopharyngeal swab for SARS-CoV-2 between March 2020 and August 2021 in two tertiary-level hospitals.The survey included questions on demographics,work profile,characteristics of coronavirus disease 2019(COVID-19),and infection among their household or co-workers.The survey also checked the knowledge and perception of participants on the infection prevention measures related to SARS-CoV-2.RESULTS Out of a total of 346 HCWs infected with SARS-CoV-2,286(82.7%)HCWs consented to participate in this study.From the sample population,150(52.5%)of participants were female,and a majority(230,80.4%)were frontline HCWs,including 121 nurses(121,42.4%).Only 48(16.8%)participants were fully vaccinated at the time of infection.Most infected HCWs(85%)were unaware of any unprotected exposure and were symptomatic at the time of testing(225,78.7%).Nearly half of the participants(140,49%)had co-infection among household,and nearly one-third(29.5%)had coinfection among three or more household.Another 108(37.8%)participants reported crossinfection among co-workers.The frontline HCWs were significantly more infected(25.1%vs 8.6%,P<0.001)compared to non-frontline HCWs.Another significant risk factor for a high infection rate was male sex(P<0.001).Among the infected frontline HCWs,a significantly higher proportion were male and shared accommodation with family(P<0.001).COVID-19 vaccination significantly reduced the infection rate(83.2%vs 16.8,P<0.001)among HCWs.Most participants(99.3%)were aware about importance of appropriate use of personal protective equipment.However,only 70%agreed with the efficacy of the COVID-19 vaccination in preventing an infection and severe disease.CONCLUSION The risk profiling of the HCWs infected with SARS-CoV-2 found that working at frontline and being male increase the rate of infection.COVID-19 vaccination can effectively reduce the rate of transmission of SARS-CoV-2 among HCWs.展开更多
Euglycemic diabetic ketoacidosis(DKA)is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose(less than 11 mmol/L).The absence of hyperglycemia is a conundrum f...Euglycemic diabetic ketoacidosis(DKA)is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose(less than 11 mmol/L).The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units;it may delay diagnosis and treatment causing worse outcomes.Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus.With the addition of sodium/glucose cotransporter-2 inhibitors in diabetes mellitus management,euglycemic DKA incidence has increased.The other causes of euglycemic DKA include pregnancy,fasting,bariatric surgery,gastroparesis,insulin pump failure,cocaine intoxication,chronic liver disease and glycogen storage disease.The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit,milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio.Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones.The diagnostic workup includes arterial blood gas for metabolic acidosis,serum ketones and exclusion of other causes of high anion gap metabolic acidosis.Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration,electrolytes deficit and insulin replacement.The dextrosecontaining fluids should accompany intravenous insulin to correct metabolic acidosis,ketonemia and to avoid hypoglycemia.展开更多
The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units(ICUs). The elderly are predisposed to sepsis due to co-existing comorbi...The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units(ICUs). The elderly are predisposed to sepsis due to co-existing comorbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge.展开更多
The coronavirus disease 2019(COVID-19)pandemic has caused unprecedented pressure on public health and healthcare.The pandemic surge and resultant lockdown have affected the standard-of-care of many medical conditions ...The coronavirus disease 2019(COVID-19)pandemic has caused unprecedented pressure on public health and healthcare.The pandemic surge and resultant lockdown have affected the standard-of-care of many medical conditions and diseases.The initial uncertainty and fear of cross transmission of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)have changed the routine management of patients with pre-existing liver diseases,hepatocellular carcinoma,and patients either listed for or received a liver transplant.COVID-19 is best described as a multisystem disease caused by SARS-CoV-2,and it can cause acute liver injury or decompensation of the pre-existing liver disease.There has been considerable research on the pathophysiology,infection transmission,and treatment of COVID-19 in the last few months.The pathogenesis of liver involvement in COVID-19 includes viral cytotoxicity,the secondary effect of immune dysregulation,hypoxia resulting from respiratory failure,ischemic damage caused by vascular endotheliitis,congestion because of right heart failure,or drug-induced liver injury.Patients with chronic liver diseases,cirrhosis,and hepatocellular carcinoma are at high risk for severe COVID-19 and mortality.The phase Ⅲ trials of recently approved vaccines for SARS-CoV-2 did not include enough patients with pre-existing liver diseases and excluded immunocompromised patients or those on immunomodulators.This article reviews the currently published research on the effect of COVID-19 on the liver and the management of patients with pre-existing liver disease,including SARS-CoV-2 vaccines.展开更多
The Delphi technique is a systematic process of forecasting using the collective opinion of panel members.The structured method of developing consensus among panel members using Delphi methodology has gained acceptanc...The Delphi technique is a systematic process of forecasting using the collective opinion of panel members.The structured method of developing consensus among panel members using Delphi methodology has gained acceptance in diverse fields of medicine.The Delphi methods assumed a pivotal role in the last few decades to develop best practice guidance using collective intelligence where research is limited,ethically/logistically difficult or evidence is conflicting.However,the attempts to assess the quality standard of Delphi studies have reported significant variance,and details of the process followed are usually unclear.We recommend systematic quality tools for evaluation of Delphi methodology;identification of problem area of research,selection of panel,anonymity of panelists,controlled feedback,iterative Delphi rounds,consensus criteria,analysis of consensus,closing criteria,and stability of the results.Based on these nine qualitative evaluation points,we assessed the quality of Delphi studies in the medical field related to coronavirus disease 2019.There was inconsistency in reporting vital elements of Delphi methods such as identification of panel members,defining consensus,closing criteria for rounds,and presenting the results.We propose our evaluation points for researchers,medical journal editorial boards,and reviewers to evaluate the quality of the Delphi methods in healthcare research.展开更多
Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units(ICUs) and provide focused, high quality care ...Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units(ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a "turf" war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffingmay be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.展开更多
Sepsis and septic shock are common diagnoses for patients requiring intensive care unit admission and associated with high morbidity and mortality.In addition to aggressive fluid resuscitation and antibiotic therapy,s...Sepsis and septic shock are common diagnoses for patients requiring intensive care unit admission and associated with high morbidity and mortality.In addition to aggressive fluid resuscitation and antibiotic therapy,several other drugs have been tried as adjuvant therapies to reduce the inflammatory response and improve outcomes.Vitamin C has been shown to have several biological actions,including anti-inflammatory and immunomodulatory effects,which may prove beneficial in sepsis management.Initial trials showed improved patient outcomes when high dose vitamin C was used in combination with thiamine and hydrocortisone.These results,along with relative safety of high-dose(supra-physiological)vitamin C,encouraged physicians across the globe to add vitamin C as an adjuvant therapy in the management of sepsis.However,subsequent largescale randomised control trials could not replicate these results,leaving the world divided regarding the role of vitamin C in sepsis management.Here,we discuss the rationale,safety profile,and the current clinical evidence for the use of highdose vitamin C in the management of sepsis and septic shock.展开更多
BACKGROUND Metformin is arguably the most commonly prescribed oral hypoglycemic agent for the management of diabetes.Due to the lack of randomized control trials,most of the data pertaining to the clinical course,ther...BACKGROUND Metformin is arguably the most commonly prescribed oral hypoglycemic agent for the management of diabetes.Due to the lack of randomized control trials,most of the data pertaining to the clinical course,therapeutic interventions and outcomes of patients with metformin induced toxicity has come from case reports or series.AIM To analyse the symptomology,clinical interventions and outcomes of patients presenting with severe metformin toxicity by reviewing the published case reports and series.METHODS We performed a systematic search from PubMed,Science Direct,Reference Citation Analysis(https://www.referencecitationanalysis.com/)and Google Scholar databases using the terms“metformin”AND“toxicity”OR“overdose”OR“lactic acidosis”OR“hyperlactatemia”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported toxicity or overdose of metformin in adults,published in the English language.Data regarding baseline demographics,clinical presentation,therapeutic interventions,intensive care unit course and overall outcome were collected.RESULTS Two hundred forty-two individual cases were analysed,from 158 case reports and 26 case series,with a cumulative mortality of 19.8%.214(88.4%)patients were diabetics on metformin.57(23.6%)had acute ingestion,but a great majority(76.4%)were on metformin in therapeutic doses when they developed toxicity.Metformin associated lactic acidosis(MALA)was the most commonly reported adverse effect present in 224(92.6%)patients.Most of the patients presented with gastrointestinal and neurological symptoms and a significant number of patients had severe metabolic acidosis and hyperlactatemia.The organ support used was renal replacement therapy(RRT)(68.6%),vasopressors(58.7%)and invasive mechanical ventilation(52.9%).A majority of patients(68.6%)received RRT for toxin removal,renal dysfunction and correction of MALA.Patients with lowest pH and highest serum lactate and metformin levels also had favourable outcomes with use of RRT.CONCLUSION Most of the reported cases were on therapeutic doses of metformin but developed toxicity after an acute deterioration in renal functions.These patients may develop severe lactic acidosis,leading to significant morbidity and need for organ support.Despite severe MALA and the need for multiple organ support,they may have good outcomes,especially when RRT is used.The dose of metformin,serum pH,lactate and metformin levels may indicate the severity of toxicity and the need for aggressive therapeutic measures but may not necessarily indicate poor outcomes.展开更多
Pregnant women are among the high-risk population for severe coronavirus disease 2019(COVID-19)with unfavorable peripartum outcomes and increased incidence of preterm births.Hemolysis,the elevation of liver enzymes,an...Pregnant women are among the high-risk population for severe coronavirus disease 2019(COVID-19)with unfavorable peripartum outcomes and increased incidence of preterm births.Hemolysis,the elevation of liver enzymes,and low platelet count(HELLP)syndrome and severe preeclampsia are among the leading causes of maternal mortality.Evidence supports a higher odd of pre-eclampsia in women with COVID-19,given overlapping pathophysiology.Involvement of angiotensin-converting enzyme 2 receptors by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)for the entry to the host cells and its downregulation cause dysregulation of the renin-angiotensin-aldosterone system.The overexpression of Angiotensin II mediated via p38 Mitogen-Activated Protein Kinase pathways can cause vasoconstriction and uninhibited platelet aggregation,which may be another common link between COVID-19 and HELLP syndrome.On PubMed search from January 1,2020,to July 30,2022,we found 18 studies on of SARS-COV-2 infection with HELLP Syndrome.Most of these studies are case reports or series,did not perform histopathology analysis of the placenta,or measured biomarkers linked to pre-eclampsia/HELLP syndrome.Hence,the relationship between SARS-CoV-2 infection and HELLP syndrome is inconclusive in these studies.We intend to perform a mini-review of the published literature on HELLP syndrome and COVID-19 to test the hypothesis on association vs causation,and gaps in the current evidence and propose an area of future research.展开更多
The Coronavirus disease-2019(COVID-19)pandemic has inundated critical care services globally.The intensive care units(ICUs)and critical care providers have been forefront of this pandemic,evolving continuously from ex...The Coronavirus disease-2019(COVID-19)pandemic has inundated critical care services globally.The intensive care units(ICUs)and critical care providers have been forefront of this pandemic,evolving continuously from experiences and emerging evidence.In this review,we discuss the key lessons from the ongoing wave of COVID-19 pandemic and preparations for a future surge or second wave.The model of sustainable critical care services should be based on 1)infrastructure development,2)preparation and training of manpower,3)implementing standard of care and infection control,4)sustained supply-chain and finally,and 5)surge planning.展开更多
Background:We did a retrospective analysis of critical coronavirus disease 2019(COVID-19)patients admitted to our intensive care unit(ICU).The objective was to evaluate the outcome,risk factors and effect of prone pos...Background:We did a retrospective analysis of critical coronavirus disease 2019(COVID-19)patients admitted to our intensive care unit(ICU).The objective was to evaluate the outcome,risk factors and effect of prone position in critically ill patients requiring invasive mechanical ventilation(IMV).Patients and methods:The data were collected regarding demographics,comorbidities,laboratory parameters and treatment.Logistic regression was used for analysis of the association of risk factors to the outcome.Results:From 15 March to 30 May 2020,35(59.3%)out of 59 critical COVID-19 requiring IMV were admitted to a tertiary care hospital in Dubai.The day-28 ICU mortality was 28.8% and 48.6% in patients requiring IMV.Prone position(PP)was used in 17(48.6%)patients for median duration of 19(5-20)hours with significant PaO_(2)/FiO_(2) improvement.Acute kidney injury was common(30.5%),and half of the patients required renal replacement therapy(RRT)with higher mortality(77.8%).Lactate dehydrogenase(LDH)odd ratio(OR)-1.006[95%CI-1.00-1.01],D-dimer(OR-1.003[1.000-1.000]),low total leucocyte count(OR-1.135[1.01-1.28]),and lymphopenia(OR-0.909[0.84-0.98])were independently associated with increased risk of IMV.Conclusions:IMV requirement in patients with COVID-19 is associated with higher mortality.Inflammatory markers like LDH,D-dimer,and lymphopenia can be used to predict the prognosis.The patients with COVID-19 on IMV respond significantly with prone position,and it should be considered early with a longer duration.展开更多
文摘BACKGROUND Since its description in 1790 by Hunter,the nasogastric tube(NGT)is commonly used in any healthcare setting for alleviating gastrointestinal symptoms or enteral feeding.However,the risks associated with its placement are often underes-timated.Upper airway obstruction with a NGT is an uncommon but potentially life-threatening complication.NGT syndrome is characterized by the presence of an NGT,throat pain and vocal cord(VC)paralysis,usually bilateral.It is poten-tially life–threatening,and early diagnosis is the key to the prevention of fatal upper airway obstruction.However,fewer cases may have been reported than might have occurred,primarily due to the clinicians'unawareness.The lack of specific signs and symptoms and the inability to prove temporal relation with NGT insertion has made diagnosing the syndrome quite challenging.AIM To review and collate the data from the published case reports and case series to understand the possible risk factors,early warning signs and symptoms for timely detection to prevent the manifestation of the complete syndrome with life-threatening airway obstruction.METHODS We conducted a systematic search for this meta-summary from the database of PubMed,EMBASE,Reference Citation Analysis(https://www.referencecitation-analysis.com/)and Google scholar,from all the past studies till August 2023.The search terms included major MESH terms"Nasogastric tube","Intubation,Gastrointestinal","Vocal Cord Paralysis",and“Syndrome”.All the case reports and case series were evaluated,and the data were extracted for patient demographics,clinical symptomatology,diagnostic and therapeutic interventions,clinical course and outcomes.A datasheet for evaluation was further prepared.RESULTS Twenty-seven cases,from five case series and 13 case reports,of NGT syndrome were retrieved from our search.There was male predominance(17,62.96%),and age at presentation ranged from 28 to 86 years.Ten patients had diabetes mellitus(37.04%),and nine were hypertensive(33.33%).Only three(11.11%)patients were reported to be immunocompromised.The median time for developing symptoms after NGT insertion was 14.5 d(interquartile range 6.25-33.75 d).The most commonly reported reason for NGT insertion was acute stroke(10,37.01%)and the most commonly reported symptoms were stridor or wheezing 17(62.96%).In 77.78%of cases,bilateral VC were affected.The only treatment instituted in most patients(77.78%)was removing the NG tube.Most patients(62.96%)required tracheostomy for airway protection.But 8 of the 23 survivors recovered within five weeks and could be decannulated.Three patients were reported to have died.CONCLUSION NGT syndrome is an uncommon clinical complication of a very common clinical procedure.However,an under-reporting is possible because of misdiagnosis or lack of awareness among clinicians.Patients in early stages and with mild symptoms may be missed.Further,high variability in the presentation timing after NGT insertion makes diagnosis challenging.Early diagnosis and prompt removal of NGT may suffice in most patients,but a significant proportion of patients presenting with respiratory compromise may require tracheostomy for airway protection.
文摘BACKGROUND Dengue fever is the most common cause of viral hemorrhagic fever,with more than 400 million cases being reported annually,worldwide.Even though hepatic involvement is common,acute liver failure(ALF)is a rare complication of dengue fever.AIM To analyze the demographic profile,symptomology,hospital course and outcomes of patients presenting with ALF secondary to dengue infection by reviewing the published case reports.METHODS A systematic search was performed from multiple databases including PubMed,Reference Citation Analysis,Science Direct,and Google Scholar.The search terms used were"dengue"OR"severe dengue"OR"dengue shock syndrome"OR"dengue haemorrhagic syndrome"OR"dengue fever"AND"acute liver failure"OR"hepatic failure"OR"liver injury".The inclusion criteria were:(1)Case reports or case series with individual patient details;(2)Reported acute liver failure secondary to dengue infection;and(3)Published in English language and on adult humans.The data were extracted for patient demographics,clinical sympto-matology,clinical interventions,hospital and intensive care unit course,need for organ support and clinical outcomes.RESULTS Data from 19 case reports fulfilling the predefined inclusion criteria were included.The median age of patients was 38 years(inter quartile range:Q3-Q126.5 years)with a female preponderance(52.6%).The median days from diagnosis of dengue to development of ALF was 4.5 d.The increase in aspartate aminotransferase was higher than that in alanine aminotransferase(median 4625 U/L vs 3100 U/L).All the patients had one or more organ failure,with neurological failure present in 73.7%cases.42.1%patients required vasopressor support and hepatic enceph-alopathy was the most reported complication in 13(68.4%)cases.Most of the patients were managed conser-vatively and 2 patients were taken up for liver transplantation.Only 1 death was reported(5.3%).CONCLUSION Dengue infection may rarely lead to ALF.These patients may frequently require intensive care and organ support.Even though most of these patients may improve with supportive care,liver transplantation may be a therapeutic option in refractory cases.
文摘Critically ill patients are a vulnerable group at high risk of developing secondary infections.High disease severity,prolonged intensive care unit(ICU)stay,sepsis,and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections,including cytomegalovirus(CMV).CMV seroconversion has been reported in up to 33%of ICU patients,but its impact on patient outcomes remains a matter of debate.Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/acquired immuno deficiency syndrome,the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous.Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement.Hence,a better understanding of the symptomatology,diagnostics,and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions.
文摘Intra-abdominal hypertension(IAH)and abdominal compartment syndrome(ACS)play a pivotal role in the pathophysiology of severe acute pancreatitis(SAP)and contribute to new-onset and persistent organ failure.The optimal management of ACS involves a multi-disciplinary approach,from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure(IAP).A targeted literature search from January 1,2000,to November 30,2022,revealed 20 studies and data was analyzed on the type and country of the study,patient demographics,IAP,type and timing of surgical procedure performed,post-operative wound management,and outcomes of patients with ACS.There was no randomized controlled trial published on the topic.Decom-pressive laparotomy is effective in rapidly reducing IAP(standardized mean difference=2.68,95%confidence interval:1.19-1.47,P<0.001;4 studies).The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but,potentially lethal ACS.Disease-specific patient selection and the role of less-invasive decompressive measures,like subcutaneous linea alba fasciotomy or component separation techniques,is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS.This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP.However,there is a lack of high-quality evidence on patient selection,timing,and modality of surgical decompression.Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.
文摘BACKGROUND Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are commonly prescribed to manage patients with diabetes mellitus.These agents may rarely lead to the development of euglycemic diabetic ketoacidosis(EDKA),which may complicate the disease course of these patients.AIM To analyze the demographic profile,predisposing factors,symptomology,clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series.METHODS We performed a systematic search of PubMed,Science Direct,Google Scholar and Reference Citation Analysis databases using the terms“canagliflozin”OR“empagliflozin”OR“dapagliflozin”OR“SGLT2 inhibitors”OR“Sodium-glucose cotransporter-2”AND“euglycemia”OR“euglycemic diabetic ketoacidosis”OR“metabolic acidosis”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported EDKA secondary to SGLT2i.Furthermore,the data were filtered from the literature published in the English language and on adults(>18 years).We excluded:(1)Conference abstracts;and(2)Case reports or series which did not have individual biochemical data.All the case reports and case series were evaluated.The data extracted included patient demographics,clinical symptomatology,clinical interventions,intensive care unit course,need for organ support and outcomes.RESULTS Overall,108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included.The majority of patients were females(54.4%,n=92),and the commonly reported symptoms were gastrointestinal(nausea/vomiting 65.1%,abdominal pain 37.3%)and respiratory(breathlessness 30.8%).One hundred and forty-nine(88.2%)patients had underlying type II diabetes,and the most commonly involved SGLT-2 inhibitor reported was empagliflozin(46.8%).A triggering factor was reported in most patients(78.7%),the commonest being acute severe infection(37.9%),which included patients with sepsis,coronavirus disease 2019,other viral illnesses,and acute pancreatitis.61.5%were reported to require intensive unit care,but only a minority of patients required organ support in the form of invasive mechanical ventilation(13%),vasopressors(6.5%)or renal replacement therapy(5.9%).The overall mortality rate was only 2.4%.CONCLUSION Patients on SGLT2i may rarely develop EDKA,especially in the presence of certain predisposing factors,including severe acute infections and following major surgery.The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels,which may make the diagnosis challenging.Outcomes of EDKA are good if recognized early and corrective actions are taken.Hence,physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.
文摘Critically ill patients are prone to high glycemic variations irrespective of their diabetes status.This mandates frequent blood glucose(BG)monitoring and regulation of insulin therapy.Even though the most commonly employed capillary BG monitoring is convenient and rapid,it is inaccurate and prone to high bias,overestimating BG levels in critically ill patients.The targets for BG levels have also varied in the past few years ranging from tight glucose control to a more liberal approach.Each of these has its own fallacies,while tight control increases risk of hypoglycemia,liberal BG targets make the patients prone to hyperglycemia.Moreover,the recent evidence suggests that BG indices,such as glycemic variability and time in target range,may also affect patient outcomes.In this review,we highlight the nuances associated with BG monitoring,including the various indices required to be monitored,BG targets and recent advances in BG monitoring in critically ill patients.
文摘BACKGROUND Drug-induced liver injury(DILI)can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs.Direct-acting oral anticoagulants(DOACs)are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions.A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs.However,it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.AIM To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.METHODS A systematic search was conducted on multiple databases including PubMed,Science Direct,Reference Citation Analysis,and Google Scholar.The search terms included“Acute Liver Failure”OR“Acute-On-Chronic Liver Failure”OR“Acute Chemical and Drug Induced Liver Injury”OR“Chronic Chemical and Drug Induced Liver Injury”AND“Factor Xa Inhibitors”OR“Dabigatran”OR“Rivaroxaban”OR“apixaban”OR“betrixaban”OR“edoxaban”OR“Otamixaban”.The results were filtered for literature published in English and on adult patients.Only case reports and case studies reporting cases of DILI secondary to DOACs were included.Data on demographics,comorbidities,medication history,laboratory investigations,imaging,histology,management,and outcomes were extracted.RESULTS A total of 15 studies(13 case reports and 2 case series)were included in the analysis,comprising 27 patients who developed DILI secondary to DOACs.Rivaroxaban was the most commonly implicated DOAC(n=20,74.1%).The mean time to onset of DILI was 40.6 d.The most common symptoms were jaundice(n=15,55.6%),malaise(n=9,33.3%),and vomiting(n=9,33.3%).Laboratory investigations showed elevated liver enzymes and bilirubin levels.Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury.Most patients had a favourable outcome,and only 1 patient(3.7%)died due to liver failure.CONCLUSION DOACs are increasingly used for various clinical conditions,and DILI secondary to DOACs is a rare but potentially serious complication.Prompt identification and cessation of the offending drug are crucial for the management of DILI.Most patients with DILI secondary to DOACs have a favourable outcome,but a small proportion may progress to liver failure and death.Further research,including post-marketing population-based studies,is needed to better understand the incidence and risk factors for DILI secondary to DOACs.
文摘BACKGROUND The proficiency of nursing professionals in the infection prevention and control(IPC)practices is a core component of the strategy to mitigate the challenge of healthcare associated infections.AIM To test knowledge of nurses working in intensive care units(ICU)in South Asia and Middle East countries on IPC practices.METHODS An online self-assessment questionnaire based on various aspects of IPC practices was conducted among nurses over three weeks.RESULTS A total of 1333 nurses from 13 countries completed the survey.The average score was 72.8%and 36%of nurses were proficient(mean score>80%).43%and 68.3%of respondents were from government and teaching hospitals,respectively.79.2%of respondents worked in<25 bedded ICUs and 46.5%in closed ICUs.Statistically,a significant association was found between the knowledge and expertise of nurses,the country’s per-capita income,type of hospitals,accreditation and teaching status of hospitals and type of ICUs.Working in high-and upper-middleincome countries(β=4.89,95%CI:3.55 to 6.22)was positively associated,and the teaching status of the hospital(β=-4.58,95%CI:-6.81 to-2.36)was negatively associated with the knowledge score among respondents.CONCLUSION There is considerable variation in knowledge among nurses working in ICU.Factors like income status of countries,public vs private and teaching status of hospitals and experience are independently associated with nurses’knowledge of IPC practices.
文摘BACKGROUND Understanding the transmission dynamics of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection among healthcare workers(HCWs)and their social contacts is crucial to plan appropriate risk-reduction measures.AIM To analyze the socio-demographic risk factors and transmission of SARS-CoV-2 infection among HCWs in two tertiary care hospitals in Dubai,United Arab Emirates.METHODS The demographic and clinical characteristics were available for all HCWs in both facilities from the human resources department.A cross-sectional survey was conducted from January-April 2022 among HCWs who tested positive through Reverse Transcriptase Polymerase Chain Reaction of the nasopharyngeal swab for SARS-CoV-2 between March 2020 and August 2021 in two tertiary-level hospitals.The survey included questions on demographics,work profile,characteristics of coronavirus disease 2019(COVID-19),and infection among their household or co-workers.The survey also checked the knowledge and perception of participants on the infection prevention measures related to SARS-CoV-2.RESULTS Out of a total of 346 HCWs infected with SARS-CoV-2,286(82.7%)HCWs consented to participate in this study.From the sample population,150(52.5%)of participants were female,and a majority(230,80.4%)were frontline HCWs,including 121 nurses(121,42.4%).Only 48(16.8%)participants were fully vaccinated at the time of infection.Most infected HCWs(85%)were unaware of any unprotected exposure and were symptomatic at the time of testing(225,78.7%).Nearly half of the participants(140,49%)had co-infection among household,and nearly one-third(29.5%)had coinfection among three or more household.Another 108(37.8%)participants reported crossinfection among co-workers.The frontline HCWs were significantly more infected(25.1%vs 8.6%,P<0.001)compared to non-frontline HCWs.Another significant risk factor for a high infection rate was male sex(P<0.001).Among the infected frontline HCWs,a significantly higher proportion were male and shared accommodation with family(P<0.001).COVID-19 vaccination significantly reduced the infection rate(83.2%vs 16.8,P<0.001)among HCWs.Most participants(99.3%)were aware about importance of appropriate use of personal protective equipment.However,only 70%agreed with the efficacy of the COVID-19 vaccination in preventing an infection and severe disease.CONCLUSION The risk profiling of the HCWs infected with SARS-CoV-2 found that working at frontline and being male increase the rate of infection.COVID-19 vaccination can effectively reduce the rate of transmission of SARS-CoV-2 among HCWs.
文摘Euglycemic diabetic ketoacidosis(DKA)is an acute life-threatening metabolic emergency characterized by ketoacidosis and relatively lower blood glucose(less than 11 mmol/L).The absence of hyperglycemia is a conundrum for physicians in the emergency department and intensive care units;it may delay diagnosis and treatment causing worse outcomes.Euglycemic DKA is an uncommon diagnosis but can occur in patients with type 1 or type 2 diabetes mellitus.With the addition of sodium/glucose cotransporter-2 inhibitors in diabetes mellitus management,euglycemic DKA incidence has increased.The other causes of euglycemic DKA include pregnancy,fasting,bariatric surgery,gastroparesis,insulin pump failure,cocaine intoxication,chronic liver disease and glycogen storage disease.The pathophysiology of euglycemic DKA involves a relative or absolute carbohydrate deficit,milder degree of insulin deficiency or resistance and increased glucagon/insulin ratio.Euglycemic DKA is a diagnosis of exclusion and should be considered in the differential diagnosis of a sick patient with a history of diabetes mellitus despite lower blood glucose or absent urine ketones.The diagnostic workup includes arterial blood gas for metabolic acidosis,serum ketones and exclusion of other causes of high anion gap metabolic acidosis.Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration,electrolytes deficit and insulin replacement.The dextrosecontaining fluids should accompany intravenous insulin to correct metabolic acidosis,ketonemia and to avoid hypoglycemia.
文摘The incidence of severe sepsis and septic shock is increasing in the older population leading to increased admissions to the intensive care units(ICUs). The elderly are predisposed to sepsis due to co-existing comorbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations and above all due to the effects of aging itself. A lower threshold and a higher index of suspicion is required to diagnose sepsis in this patient population because the initial clinical picture may be ambiguous, and aging increases the risk of a sudden deterioration in sepsis to severe sepsis and septic shock. Management is largely based on standard international guidelines with a few modifications. Age itself is an independent risk factor for death in patients with severe sepsis, however, many patients respond well to timely and appropriate interventions. The treatment should not be limited or deferred in elderly patients with severe sepsis only on the grounds of physician prejudice, but patient and family preferences should also be taken into account as the outcomes are not dismal. Future investigations in the management of sepsis should not only target good functional recovery but also ensure social independence and quality of life after ICU discharge.
文摘The coronavirus disease 2019(COVID-19)pandemic has caused unprecedented pressure on public health and healthcare.The pandemic surge and resultant lockdown have affected the standard-of-care of many medical conditions and diseases.The initial uncertainty and fear of cross transmission of severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)have changed the routine management of patients with pre-existing liver diseases,hepatocellular carcinoma,and patients either listed for or received a liver transplant.COVID-19 is best described as a multisystem disease caused by SARS-CoV-2,and it can cause acute liver injury or decompensation of the pre-existing liver disease.There has been considerable research on the pathophysiology,infection transmission,and treatment of COVID-19 in the last few months.The pathogenesis of liver involvement in COVID-19 includes viral cytotoxicity,the secondary effect of immune dysregulation,hypoxia resulting from respiratory failure,ischemic damage caused by vascular endotheliitis,congestion because of right heart failure,or drug-induced liver injury.Patients with chronic liver diseases,cirrhosis,and hepatocellular carcinoma are at high risk for severe COVID-19 and mortality.The phase Ⅲ trials of recently approved vaccines for SARS-CoV-2 did not include enough patients with pre-existing liver diseases and excluded immunocompromised patients or those on immunomodulators.This article reviews the currently published research on the effect of COVID-19 on the liver and the management of patients with pre-existing liver disease,including SARS-CoV-2 vaccines.
文摘The Delphi technique is a systematic process of forecasting using the collective opinion of panel members.The structured method of developing consensus among panel members using Delphi methodology has gained acceptance in diverse fields of medicine.The Delphi methods assumed a pivotal role in the last few decades to develop best practice guidance using collective intelligence where research is limited,ethically/logistically difficult or evidence is conflicting.However,the attempts to assess the quality standard of Delphi studies have reported significant variance,and details of the process followed are usually unclear.We recommend systematic quality tools for evaluation of Delphi methodology;identification of problem area of research,selection of panel,anonymity of panelists,controlled feedback,iterative Delphi rounds,consensus criteria,analysis of consensus,closing criteria,and stability of the results.Based on these nine qualitative evaluation points,we assessed the quality of Delphi studies in the medical field related to coronavirus disease 2019.There was inconsistency in reporting vital elements of Delphi methods such as identification of panel members,defining consensus,closing criteria for rounds,and presenting the results.We propose our evaluation points for researchers,medical journal editorial boards,and reviewers to evaluate the quality of the Delphi methods in healthcare research.
文摘Intensive care is slowly being recognized as a separate medical specialization. Physicians, called intensivists, are being specially trained to manage intensive care units(ICUs) and provide focused, high quality care to critically ill patients. However, these ICUs were traditionally managed by primary physicians who used to admit patients in ICUs under their own care. The presence of specially trained intensivists in these ICUs has started a "turf" war. In spite of the availability of overwhelming evidence that intensivists-based ICUs can provide better patient care leading to improved outcome, there is hesitancy among hospital administrators and other policy makers towards adopting such a model. Major critical care societies and workgroups have recommended intensivists-based ICU models to care for critically ill patients, but even in developed countries, on-site intensivist coverage is lacking in a great majority of hospitals. Lack of funds and unavailability of skilled intensivists are commonly cited as the main reasons for not implementing intensivist-led ICU care in most of the ICUs. To provide optimal, comprehensive and skilled care to this severely ill patient population, it is imperative that a multi-disciplinary team approach must be adopted with intensivists as in-charge. Even though ICU organization and staffingmay be determined by hospital policies and other local factors, all efforts must be made to attain the goal of having round-the-clock onsite intensivist coverage to ensure continuity of specialized care for all critically ill patients.
文摘Sepsis and septic shock are common diagnoses for patients requiring intensive care unit admission and associated with high morbidity and mortality.In addition to aggressive fluid resuscitation and antibiotic therapy,several other drugs have been tried as adjuvant therapies to reduce the inflammatory response and improve outcomes.Vitamin C has been shown to have several biological actions,including anti-inflammatory and immunomodulatory effects,which may prove beneficial in sepsis management.Initial trials showed improved patient outcomes when high dose vitamin C was used in combination with thiamine and hydrocortisone.These results,along with relative safety of high-dose(supra-physiological)vitamin C,encouraged physicians across the globe to add vitamin C as an adjuvant therapy in the management of sepsis.However,subsequent largescale randomised control trials could not replicate these results,leaving the world divided regarding the role of vitamin C in sepsis management.Here,we discuss the rationale,safety profile,and the current clinical evidence for the use of highdose vitamin C in the management of sepsis and septic shock.
文摘BACKGROUND Metformin is arguably the most commonly prescribed oral hypoglycemic agent for the management of diabetes.Due to the lack of randomized control trials,most of the data pertaining to the clinical course,therapeutic interventions and outcomes of patients with metformin induced toxicity has come from case reports or series.AIM To analyse the symptomology,clinical interventions and outcomes of patients presenting with severe metformin toxicity by reviewing the published case reports and series.METHODS We performed a systematic search from PubMed,Science Direct,Reference Citation Analysis(https://www.referencecitationanalysis.com/)and Google Scholar databases using the terms“metformin”AND“toxicity”OR“overdose”OR“lactic acidosis”OR“hyperlactatemia”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported toxicity or overdose of metformin in adults,published in the English language.Data regarding baseline demographics,clinical presentation,therapeutic interventions,intensive care unit course and overall outcome were collected.RESULTS Two hundred forty-two individual cases were analysed,from 158 case reports and 26 case series,with a cumulative mortality of 19.8%.214(88.4%)patients were diabetics on metformin.57(23.6%)had acute ingestion,but a great majority(76.4%)were on metformin in therapeutic doses when they developed toxicity.Metformin associated lactic acidosis(MALA)was the most commonly reported adverse effect present in 224(92.6%)patients.Most of the patients presented with gastrointestinal and neurological symptoms and a significant number of patients had severe metabolic acidosis and hyperlactatemia.The organ support used was renal replacement therapy(RRT)(68.6%),vasopressors(58.7%)and invasive mechanical ventilation(52.9%).A majority of patients(68.6%)received RRT for toxin removal,renal dysfunction and correction of MALA.Patients with lowest pH and highest serum lactate and metformin levels also had favourable outcomes with use of RRT.CONCLUSION Most of the reported cases were on therapeutic doses of metformin but developed toxicity after an acute deterioration in renal functions.These patients may develop severe lactic acidosis,leading to significant morbidity and need for organ support.Despite severe MALA and the need for multiple organ support,they may have good outcomes,especially when RRT is used.The dose of metformin,serum pH,lactate and metformin levels may indicate the severity of toxicity and the need for aggressive therapeutic measures but may not necessarily indicate poor outcomes.
文摘Pregnant women are among the high-risk population for severe coronavirus disease 2019(COVID-19)with unfavorable peripartum outcomes and increased incidence of preterm births.Hemolysis,the elevation of liver enzymes,and low platelet count(HELLP)syndrome and severe preeclampsia are among the leading causes of maternal mortality.Evidence supports a higher odd of pre-eclampsia in women with COVID-19,given overlapping pathophysiology.Involvement of angiotensin-converting enzyme 2 receptors by severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)for the entry to the host cells and its downregulation cause dysregulation of the renin-angiotensin-aldosterone system.The overexpression of Angiotensin II mediated via p38 Mitogen-Activated Protein Kinase pathways can cause vasoconstriction and uninhibited platelet aggregation,which may be another common link between COVID-19 and HELLP syndrome.On PubMed search from January 1,2020,to July 30,2022,we found 18 studies on of SARS-COV-2 infection with HELLP Syndrome.Most of these studies are case reports or series,did not perform histopathology analysis of the placenta,or measured biomarkers linked to pre-eclampsia/HELLP syndrome.Hence,the relationship between SARS-CoV-2 infection and HELLP syndrome is inconclusive in these studies.We intend to perform a mini-review of the published literature on HELLP syndrome and COVID-19 to test the hypothesis on association vs causation,and gaps in the current evidence and propose an area of future research.
文摘The Coronavirus disease-2019(COVID-19)pandemic has inundated critical care services globally.The intensive care units(ICUs)and critical care providers have been forefront of this pandemic,evolving continuously from experiences and emerging evidence.In this review,we discuss the key lessons from the ongoing wave of COVID-19 pandemic and preparations for a future surge or second wave.The model of sustainable critical care services should be based on 1)infrastructure development,2)preparation and training of manpower,3)implementing standard of care and infection control,4)sustained supply-chain and finally,and 5)surge planning.
文摘Background:We did a retrospective analysis of critical coronavirus disease 2019(COVID-19)patients admitted to our intensive care unit(ICU).The objective was to evaluate the outcome,risk factors and effect of prone position in critically ill patients requiring invasive mechanical ventilation(IMV).Patients and methods:The data were collected regarding demographics,comorbidities,laboratory parameters and treatment.Logistic regression was used for analysis of the association of risk factors to the outcome.Results:From 15 March to 30 May 2020,35(59.3%)out of 59 critical COVID-19 requiring IMV were admitted to a tertiary care hospital in Dubai.The day-28 ICU mortality was 28.8% and 48.6% in patients requiring IMV.Prone position(PP)was used in 17(48.6%)patients for median duration of 19(5-20)hours with significant PaO_(2)/FiO_(2) improvement.Acute kidney injury was common(30.5%),and half of the patients required renal replacement therapy(RRT)with higher mortality(77.8%).Lactate dehydrogenase(LDH)odd ratio(OR)-1.006[95%CI-1.00-1.01],D-dimer(OR-1.003[1.000-1.000]),low total leucocyte count(OR-1.135[1.01-1.28]),and lymphopenia(OR-0.909[0.84-0.98])were independently associated with increased risk of IMV.Conclusions:IMV requirement in patients with COVID-19 is associated with higher mortality.Inflammatory markers like LDH,D-dimer,and lymphopenia can be used to predict the prognosis.The patients with COVID-19 on IMV respond significantly with prone position,and it should be considered early with a longer duration.
