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BACKGROUND: Neuromonitoring in medical intensive care units is challenging as most patients are unfit for invasive intracranial pressure (ICP) modalities or unstable to transport for imaging. Ultrasonography-based optic nerve sheath diameter (ONSD) is an attractive option as it is reliable, repeatable and easily performed at the bedside. It has been sufficiently validated in traumatic brain injury (TBI) to be incorporated into the guidelines. However, currently the data for non-TBI patients is inconsistent for a scientific recommendation to be made. AIM: To compile the existing evidence for understanding the scope of ONSD in measuring ICP in adult non-traumatic neuro-critical patients. METHODS: PubMed, Google Scholar and research citation analysis databases were searched for studies in adult patients with non-traumatic causes of raised ICP. Studies from 2010 to 2024 in English languages were included. RESULTS: We found 37 articles relevant to our search. The cutoff for ONSD in predicting ICP varied from 4.1 to 6.3 mm. Most of the articles used cerebrospinal fluid opening pressure followed by raised ICP on computed tomography/magnetic resonance imaging as the comparator parameter. ONSD was also found to be a reliable outcome measure in cases of acute ischaemic stroke, intracerebral bleeding and intracranial infection. However, ONSD is of doubtful utility in septic metabolic encephalopathy, dysnatremias and aneurysmal subarachnoid haemorrhage. CONCLUSION: ONSD is a useful tool for the diagnosis of raised ICP in non-traumatic neuro-critically ill patients and may also have a role in the prognostication of a subset of patients.

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Point of care ultrasound (POCUS) provides quick bedside assessment for diagnosing and managing life-threatening conditions in critical care medicine. There has been increasing interest in developing infrastructure to archive images, record clinical interpretation, assess quality, and recoup revenue for POCUS. We present a simple workflow by systems integration of electronic medical record, ultrasound machines, picture archiving, and communication system to facilitate POCUS documentation and billing. We recorded a trend on the number of POCUS performed before and after introduction of the structured integration. We observed and recorded a linear increase over time post-intervention. Our innovative and integrated POCUS workflow is an effective way to document and bill POCUS.

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Autoimmune pancreatitis (AIP), otherwise known as non-alcoholic destructive pancreatitis or sclerosing pancreatitis, is a rare form of chronic pancreatitis that is clinically significant due to its potential to mimic pancreatic cancer. In our case, we present a 64-year-old male with a past medical history of type 2 diabetes and epigastric abdominal pain for one year who presented with worsening epigastric abdominal pain, 12-pound weight loss, and vomiting and was found to have a neuroendocrine tumor on a preliminary pathology report, while official pathology later came back stating AIP. Distinguishing between autoimmune pancreatitis (AIP) and pancreatic cancer is vital, given the stark contrast in their treatment and prognosis. In our case, preliminary pathology suggested a neuroendocrine tumor, prompting consultation with oncology. Utilizing invasive testing like EUS-FNA, we obtained an official diagnosis and prevented the patient from undergoing unnecessary treatments and interventions. Our case shows the importance of further testing when a patient presents with a fast-growing obstructive pancreatic mass. While searching the literature, there are no previously documented cases of an AIP mass as large as our patients and as fast-growing.

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Euthyroid sick syndrome (ESS), also referred to as nonthyroidal illness syndrome, is an intriguing condition characterized by dysregulation of thyroid hormones despite normal thyroid gland function. It is diagnosed by low serum triiodothyronine levels, and, in some cases, other thyroid hormones such as thyroxine and thyroid-stimulating hormone may be affected. This condition arises via various physiologic mechanisms and is associated with intensive care unit (ICU) admissions, caloric deprivation, and severe illness. Myxedema coma (MC) is a rare medical emergency with a high mortality rate. It is caused by severe hypothyroidism, resulting in multiorgan failure with features including adrenal insufficiency, thermal dysregulation, and altered mentation. Generally, it is observed in untreated and poorly managed cases of hypothyroidism. However, stress from infections, surgical procedures, and medical comorbidities may precipitate this condition. It is particularly uncommon to see MC arise in the setting of ESS, especially in a patient with no history of thyroid disease, which makes this diagnosis easy to miss. In our case, a 36-year-old female presented with septic shock and was admitted to the ICU, where she subsequently developed ESS and features of MC. This case report aims to explore the risk factors, features, and diagnostic and therapeutic management of these conditions, as well as the diagnostic challenges that arise when these diseases present simultaneously.

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Lance-Adams syndrome (LAS), or chronic post-hypoxic myoclonus, is a myoclonic disorder following acute cerebral hypoxia after successful cardiopulmonary resuscitation (CPR). LAS is distinct from acute post-hypoxic myoclonus (acute PHM), presenting with myoclonic jerks and cerebellar ataxia after regaining consciousness. However, the overlap at the onset complicates differentiation and may lead to the withdrawal of life-sustaining measures, especially in sedated ICU patients. The presented case involves a 77-year-old male diagnosed with LAS post-CPR. Despite the presence of early myoclonic jerks EEG, laboratory testing, and neuroimaging showed no definitive proof of irreversible neurological damage. Once diagnosed, treatment involved sequential antiseizure medications and physical therapy when the patient achieved full consciousness. However, the patient ultimately faced severe disabilities and was unable to recover. This case report emphasizes the importance of limiting sedation, comprehensive clinical examination, and the use of complementary tests when no definitive proof of irreversible neurological damage is present after acute cerebral hypoxia. While LAS has a better vital prognosis than acute PHM, it is associated with poor neurofunctional recovery and chronic disability in most cases. Further research is essential for evidence-based management.

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Non-bacterial thrombotic endocarditis (NBTE) is a very rare condition characterized by sterile thrombi formation on cardiac valves and is often associated with hypercoagulation states, such as malignancy and autoimmune disorders. We present the case of a 74-year-old patient admitted to the intensive care unit with acute respiratory failure, who had a history of COVID-19 infection five months prior to admission, despite having received certified vaccination. The patient developed NBTE involving the mitral valve, alongside acute respiratory distress syndrome (ARDS). In spite of the exclusion of cancer and systemic connective tissue disorders, the patient's condition rapidly deteriorated, leading to treatment-resistant multi-organ failure and demise, despite aggressive management, including anticoagulation therapy, mechanical ventilation, and renal replacement therapy. This case underscores the need for further research into the mechanisms underlying NBTE in the absence of traditional risk factors. Additionally, it highlights the importance of long-term anticoagulant therapy in NBTE management to mitigate the risk of embolic complications. Our case contributes to the growing body of literature identifying a subset of NBTE cancer-free patients with distinct characteristics, including those associated with current or past COVID-19 infection.

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Subcutaneous emphysema, the presence of air in the subcutaneous layer of the skin, is a possible result of surgical, infectious, or spontaneous etiologies. Although usually self-limiting, the development of subcutaneous emphysema in the perioperative period has been associated with delayed extubation and the development of complications such as pneumomediastinum, pneumoperitoneum, and pneumothorax and can worsen clinical outcomes in these patients. Here, we report the case of a 57-year-old male patient who presented to the operating room (OR) for a robotic total colectomy due to Lynch syndrome. The procedure was complicated by the development of diffuse, severe subcutaneous emphysema, which was recognized by palpable crepitus and obscuration of anatomical landmarks during an attempted transversus abdominis plane (TAP) block for pain control prior to patient extubation. The decision was made to leave the patient intubated and managed postoperatively in the ICU, where radiographic and computerized tomography (CT) scans confirmed the severity of subcutaneous emphysema. Hemodynamic and respiratory status were managed in the ICU and on postoperative day 3 the patient passed an endotracheal cuff leak test and was extubated. The patient was transferred to a surgical step-down on postoperative day 7 and following the resolution of ileus and acute kidney injury (AKI), he was discharged from the hospital on postoperative day 17.

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The leukemoid reaction (LR) is reported to be caused by severe stress conditions such as infection, malignancies, intoxication, severe hemorrhage, or acute hemolysis; this condition is attributed to a very severe prognosis. Some reports have suggested that the LR was associated with a systemic stress response. A 36-year-old man who required mechanical circulatory support (MCS), including veno-arterial extracorporeal membrane oxygenation and Impella 5.5 due to severe heart failure, was transferred to our hospital. He showed a markedly elevated WBC count and died of multiple organ failure. The autopsy revealed the possibility that leukocytosis might have been due to an LR; however, the cause of the cardiac failure was unknown. To the best of our knowledge, this study is the first to report a rare case of LR in a patient with severe heart failure requiring MCS.

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Hepatic encephalopathy (HE) is a formidable complication in patients with decompensated cirrhosis, often necessitating the administration of rifaximin (RFX) for effective management. RFX, is a gut-restricted, poorly-absorbable oral rifamycin derived antibiotic that can be used in addition to lactulose for the secondary prophylaxis of HE. It has shown notable reductions in infection, hospital readmission, duration of hospital stay, and mortality. However, limited data exist about the concurrent use of RFX with broad-spectrum antibiotics, because the patients are typically excluded from studies assessing RFX efficacy in HE. A pharmacist-driven quasi-experimental pilot study was done to address this gap. They argue against the necessity of RFX in HE during broad-spectrum antibiotic treatment, particularly in critically ill patients in intensive care unit (ICU). The potential for safe RFX discontinuation without adverse effects is clearly illuminated and valuable insight into the optimization of therapeutic strategies is offered. The findings also indicate that RFX discontinuation during broad-spectrum antibiotic therapy was not associated with higher rates of delirium or coma, and this result remained robust after adjustment in multivariate analysis. Furthermore, rates of other secondary clinical and safety outcomes, including ICU mortality and 48-hour changes in vasopressor requirements, were comparable. However, since the activity of RFX is mainly confined to the modulation of gut microbiota, its potential utility in patients undergoing extensive systemic antibiotic therapy is debatable, given the overlapping antibiotic activity. Further, this suggests that the action of RFX on HE is class-specific (related to its activity on gut microbiota), rather than drug-specific. A recent double-blind randomized controlled (ARiE) trial provided further evidence-based support for RFX withdrawal in critically ill cirrhotic ICU patients receiving broad-spectrum antibiotics. Both studies prompt further discussion about optimal therapeutic strategy for patients facing the dual challenge of HE and systemic infections. Despite these compelling results, both studies have limitations. A prospective, multi-center evaluation of a larger sample, with placebo control, and comprehensive neurologic evaluation of HE is warranted. It should include an exploration of longer-term outcome and the impact of this protocol in non-critically ill liver disease patients.

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Objective Infections leading to severe sepsis and septic shock are among the top five causes requiring admission to the intensive care unit (ICU). Up to 40% of ICU admissions contain a sepsis diagnosis. Without a clear marker to diagnose and manage sepsis, procalcitonin has been extensively studied for its usefulness in the management of bacterial infections. These studies, however, have been focused toward how it can be used to help guide when antibiotics should be initiated and de-escalated. There, however, has not been a study on how this biomarker could be used to predict mortality, and morbidity and help guide a need for antibiotic escalation. Design A retrospective chart review was conducted on patients admitted to the ICU at Northeast Georgia Medical Center between January 1, 2019, to June 30, 2021. Inclusion criteria were all patients above the age of 18 admitted to the ICU with a diagnosis of sepsis and having at least two procalcitonin drawn within 10 days of each other. Exclusion criteria were any patient with a diagnosis of COVID-19. Data Analysis was conducted to identify how delta procalcitonin could identify mortality and morbidity and if there was any change in antibiotics based on the delta procalcitonin.  Conclusion There was a statistically significant association between a delta positive procalcitonin and increased ICU length of stay. There was no statistical significance in expiration based on the antibiotic change in relationship to delta positive change in procalcitonin.

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Patients with thrombocytopenia may report easy bruising, abnormal bleeding, and fatigue. Drug-induced thrombocytopenia has been reported with a variety of medications, most commonly heparin products, sulphonamides, carbamazepine, nonsteroidal anti-inflammatory drugs, anti-epileptic drugs, and chemotherapy. We present the case of a 58-year-old female with severe thrombocytopenia attributed to a calcium channel blocker (CCB) overdose, a very rare cause of thrombocytopenia. We discuss the diagnostic work-up and management in the intensive care unit and perform a literature review.

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Background: Healthcare-associated infections are the leading cause of morbidity and mortality in hospitalized patients. Catheter-associated urinary tract infection (CAUTI) is a leading infection in ICU settings. This study aims to evaluate the patient and catheter-related factors contributing to the urinary tract infection as well as implementing the preventive measures ultimately curbing down the burden of healthcare-associated infections. Material and methods: This is a hospital-based observational study conducted in Department of Microbiology, from October 2020 to September 2021. A total of 150 patients admitted to Medical Intensive Care Unit (MICU) with the indwelling urinary catheter were included. Urine samples were collected with proper aseptic precautions and processed within 2 hours of collection. Identification and antimicrobial susceptibility testing of the isolated pathogens was done as per CLSI guidelines 2019. Results: In this study, the CAUTI rate was 9.4 per 1000 urinary catheter days, while the overall magnitude was 14.67%. It was predominantly reported in 51-70-years age group (34%), and females (63.63%) outnumbered males (36.36%), with Escherichia coli being the commonest pathogen. The highest incidence was reported in the 3rd week of catheterization with diabetes being a predominant risk factor (17.24%). Conclusion: This study provides baseline data on CAUTI rate, pathogens isolated, and risk factors at our institute. The overall goal is to identify, educate, and implement best-practice measures for prevention and curbing down the incidence rates of catheter-associated urinary tract infections. How to cite this article: Parihar S, Sharma R, Kinimi SV, Choudhary S. An Observational Study from Northern India to Evaluate Catheter-associated Urinary Tract Infection in Medical Intensive Care Unit at a Tertiary Care Center. Indian J Crit Care Med 2023;27(9):642-646.

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The combined toxicity of amlodipine and metformin is a rarely reported phenomenon in the literature. The management varies depending on the clinical status of the patient. We present a case that was managed successfully with the early initiation of hemodialysis.

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Patients admitted to the intensive care unit are prone to various complications, one of which is acute kidney injury (AKI). The etiology of acute kidney injury can be multifactorial. Among the various causes, sepsis remains the most prevalent. Cholemic nephropathy (CN) is a rare cause of AKI. Patients with CN usually present with elevated total bilirubin levels of greater than 20 mg/dl. However, CN has been reported in patients with total bilirubin levels of less than 20 mg/dL. These patients were found to have chronic elevations of bilirubin due to chronic liver disease rather than an acute rise in bilirubin levels. In this case series, we present two cases of patients with chronic liver disease who were admitted to the intensive care unit and were found to have AKI with elevated total bilirubin levels over 15 mg/dl.

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Antimicrobial resistance (AMR) continues to present a challenge to international healthcare systems and structures of public health. The focus on optimizing antibiotic prescribing in human populations has challenged healthcare systems charged with making responsible their physician-prescribers. In the United States, physicians in almost every specialty and role use antibiotics as part of their therapeutic armamentariums. In United States hospitals, most patients are administered antibiotics during their stay. Therefore, antibiotic prescribing and utilization is a commonly accepted part of medical practice. In this paper, we utilize social science work on antibiotic prescribing to examine a critical space of care in United States hospital settings. From March to August 2018, we used ethnographic methods to study hospital-based medical intensive care unit physicians at the offices and hospital floors they frequent in two urban United States teaching hospitals. We focused on eliciting the interactions and discussions surrounding antibiotic decision-making that are uniquely influenced by the context of medical intensive care units. We argue that antibiotic use in the medical intensive care units under study was shaped by urgency, hierarchy, and uncertainty representative of the medical intensive care unit's role within the larger hospital system. We conclude that by studying the culture of antibiotic prescribing in medical intensive care units, we can see more clearly both the vulnerability of the looming antimicrobial resistance crisis and by contrast the perceived insignificance of stewarding antibiotic use when considered alongside the fragility of life amidst acute medical concerns regularly experienced in the unit.

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Many bacterial, viral, and fungal co-infections have been reported with COVID-19-associated acute respiratory distress syndrome (ARDS). Invasive Aspergillosis has been described with COVID-19 ARDS. However, it continues to evade diagnosis in critically ill patients admitted to the intensive care unit (ICU). The difficulty is discerning an actual infection from colonization. Unfortunately, a timely diagnosis is crucial since COVID-19-associated pulmonary Aspergillus (CAPA) has high morbidity and mortality. We present three ICU cases of CAPA to illustrate the difficulty in diagnosing and treating the disease. We hope to bring awareness and improve patient outcomes of CAPA.

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AIM: We used genome-based typing data with the aim of identifying the routes of acquisition of Pseudomonas aeruginosa by patients hospitalized in a medical intensive care unit (MICU) over a long period in a non-epidemic context. METHODS: This monocentric prospective study took place over 10 months in 2019 in a 15-bed MICU that applies standard precautions of hygiene. Lockable sink traps installed at all water points of use were bleach disinfected twice a week. We sampled all sink traps weekly to collect 404 P. aeruginosa environmental isolates and collected all P. aeruginosa isolates (N = 115) colonizing or infecting patients (N = 65). All isolates had their phenotypic resistance profile determined and their genome sequenced, from which we identified resistance determinants and assessed the population structure of the collection at the nucleotide level to identify events of P. aeruginosa transmission. FINDINGS: All sink traps were positive for P. aeruginosa, each sink trap being colonized for several months by one or more clones. The combination of genomic and spatiotemporal data identified one potential event of P. aeruginosa transmission from a sink trap to a patient (1/65, 1.5%) and six events of patient cross-transmission, leading to the contamination of five patients (5/65, 7.7%). All transmitted isolates were fully susceptible to ß-lactams and aminoglycosides. CONCLUSIONS: Genome-based typing revealed the contamination of patients by P. aeruginosa originating from sink traps to be infrequent (1.5%) in an MICU with sink trap-bleaching measures, and that only 7.7% of the patients acquired P. aeruginosa originating from another patient.

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Background and objective Despite the adherence to strict infection control measures, vancomycin-resistant enterococcus (VRE) colonization and VRE infections are still important problems nowadays. However, there are only a limited number of studies examining the factors causing the transformation of VRE colonization to VRE infection in the intensive care unit (ICU). The aim of this study is to delineate the prevalence of VRE colonization and its transformation into infection and the risk factors leading to infection. Methods Patients admitted to the third-level mixed-type ICU from 2012 to 2015 for at least 24 hours and acquired VRE colonization and VRE infection, both during and after their admission, were included in the study, and their medical records were examined retrospectively. VRE rectal swabs were taken weekly from each patient on admission and discharge from the ICU. If the VRE-positive patient was detected negative for VRE on the rectal swap taken three times in total as a surveillance culture successively, this patient was accepted as VRE negative. Demographic data, Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores, invasive procedures, treatments (corticosteroid, antibiotic, etc.), nutrition types, laboratory results, and ICU results were recorded. Results Among 1730 patients admitted to ICU, 101 (5.8%) were found to carry VRE colonization. Twelve (11.8%) out of 101 patients colonized with VRE developed VRE infection. About 56.4% had urinary tract infections, 68.3% had pneumonia, 15.8% had surgical site infections, and 24.8% had catheter-associated infections among these infected patients. The most prevalent factor was Enterococcus faecium in patients with VRE colonization (64.3%) and infection (91%). VRE turned negative in 67% of patients with VRE colonization during their stay in ICU. Renal replacement therapy was statistically significant (p < 0.05) in the group with VRE infection (66.7%) compared to the VRE-colonized group (26.1%). Infection development risk among carriers of VRE for more than one week was again found statistically significant (p = 0.025). Demographic data, APACHE-II scores, treatments, nutrition type, previous antibiotic usage and types, invasive procedures, laboratory results, and ICU results were similar among the patients with VRE colonization and infection. Conclusion A longer duration of ICU stay in patients with colonization and previous renal replacement therapy increases the transformation of VRE colonization to VRE infection. Strategies toward decreasing VRE-colonized patients' period of stay in ICU is the main objective to control the rate of VRE infection.

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Background: Digital twins are computerized patient replicas that allow clinical interventions testing in silico to minimize preventable patient harm. Our group has developed a novel application software utilizing a digital twin patient model based on electronic health record (EHR) variables to simulate clinical trajectories during the initial 6 h of critical illness. This study aimed to assess the usability, workload, and acceptance of the digital twin application as an educational tool in critical care. Methods: A mixed methods study was conducted during seven user testing sessions of the digital twin application with thirty-five first-year internal medicine residents. Qualitative data were collected using a think-aloud and semi-structured interview format, while quantitative measurements included the System Usability Scale (SUS), NASA Task Load Index (NASA-TLX), and a short survey. Results: Median SUS scores and NASA-TLX were 70 (IQR 62.5-82.5) and 29.2 (IQR 22.5-34.2), consistent with good software usability and low to moderate workload, respectively. Residents expressed interest in using the digital twin application for ICU rotations and identified five themes for software improvement: clinical fidelity, interface organization, learning experience, serious gaming, and implementation strategies. Conclusion: A digital twin application based on EHR clinical variables showed good usability and high acceptance for critical care education.

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Severe fever with thrombocytopenia syndrome (SFTS) is a fatal infectious disease often transmitted through tick bites and exposure to fluids from infected individuals. Early diagnosis is critical due to the high mortality rates of the disease; however, it might be challenging if a patient's history of tick contact is unclear. We report a detailed diagnosis of SFTS in a 69-year-old man with atypical symptoms but without identifiable tick bites. The diagnosis was made on the basis of massive diarrhea, recurrent shock, and unusual erythema presentation following hospital admission.