Mechanical and infectious complications of central venous catheterizations in a tertiary-level intensive care unit in northern India

Background: Central venous catheters (CVC) are associated with mechanical, infectious and thrombotic complications. Aims: To study (a) the incidence of mechanical and infectious complications of CVC insertions and to compare, (b) the rates of these complications between the internal jugular venous (IJV) and the subclavian venous (SCV) accesses. Settings and Design: An adult intensive care unit of a tertiary care hospital. Prospective, observational study. Methods: All landmark-based CVC insertions performed between 1 st October 2008 and 30 th September 2009 were prospectively studied for mechanical and infectious complications. Statistical Analysis: SPSS software for Windows, Version SPSS 16.0, and Epi Info (3.5.1) software. Results: Four hundred and eighty central venous catheterizations were studied (IJV route, 241 and SCV route, 239). Mechanical complications occurred in 86 patients (17.9%, bleeding complications-48, catheter-related complications-27 and pneumothorax-11). The IJV route was associated with a significantly higher incidence of bleeding complications (P=0.009). Forty-seven patients had infectious complications (9.79%), like exit site infections (n=17), catheter tip infections (n=22) and catheter-related bloodstream infections (CRBSIs) (n=8). The risks of infectious complications increased significantly if the CVC was in situ for longer than 7 days (P=0.009), especially with IJV cannulae. The incidence density of CVC tip infections was 7.67 per 1000 catheter days and of CRBSIs was 2.79 per 1000 catheter days. Conclusions: Bleeding complications occurred more frequently with IJV insertions and infectious complications occurred more commonly in cannulae that were left in situ for longer than 7 days

Ventilator-associated pneumonia: A persistent healthcare problem in Indian Intensive Care Units!

Background: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection acquired by patients in the Intensive Care Unit (ICU). However, there are scarce clinical data, particularly from Indian ICUs on the occurrence of this infection. Aims: To collect data on the incidence, microbiological profile, and outcomes of patients with VAP. Settings and Design: Tertiary level, medical-surgical ICU; prospective, observational study. Subjects and Methods: All patients who were mechanically ventilated for >48 h in the ICU during the study were enrolled. VAP was diagnosed according to the Centre for Disease Control (CDC) criteria. Results: A total of 95 (38%) patients developed VAP infections, an incidence of 40.1 VAP infections/1000 mechanical ventilation days. These were predominantly caused by Gram-negative organisms, especially the Acinetobacter species (58 isolates, 53.2%). Many of the VAP-causing isolates (27.3%) demonstrated multidrug resistance. Patients with VAP infections experienced a significantly longer ICU stay (13 days [Interquartile Range (IQ) range = 10-21] vs. 6 days [IQ = 4-8], P 60 years) and those with higher Acute Physiology and Chronic Health Evaluation II scores at admission had significantly greater mortality rates if they acquired a VAP infection (P = 0.010). Conclusions: VAP continues to be a major threat to patients who are admitted for mechanical ventilation into the critical care unit, emphasizing the urgent need for infection control measures

Acinetobacter infections in a tertiary level intensive care unit in northern India: Epidemiology, clinical profiles and outcomes

Summary: Background: Nosocomial Acinetobacter infections are an increasing concern in intensive care units (ICU). Objectives: To study the demographic and clinical characteristics and the outcomes of ICU patients with Acinetobacter infections. Methods: A retrospective, 1-year audit of all Acinetobacter infections diagnosed in ICU patients between January 1 and December 31, 2009. Results: Acinetobacter infection occurred in 94 patients (108 episodes). The most common site of infection was the respiratory tract (83 patients, 76.85%), with medical patients being more susceptible than surgical patients to Acinetobacter lung infections (P = 0.04), particularly late-onset ventilator-associated pneumonia (VAP) (P = 0.04). The majority (63.8%) of infections were acquired in the ICU, and patients with ICU acquired infections were intubated significantly longer than the other patients (P = 0.02). Seventy percent of the infections were caused by multidrug-resistant (MDR) strains, and the overall crude mortality rate was over 70%. The most important factors affecting mortality were the duration of intubation (P = 0.001) and the inappropriate use of antibiotics (P = 0.021) after diagnosis of the infection. Conclusions: Acinetobacter infections are highly prevalent in the ICU, with medical patients being more susceptible to lung infections, particularly late-onset VAP. The early and appropriate selection of antibiotics is the most important determinant of survival among these patients. Keywords: Acinetobacter, Infection, Intensive care uni

Assessment of malnutrition and enteral feeding practices in the critically ill: A single-centre observational study

Background and Aims: Early identification of malnutrition among hospitalised patients is essential to institute appropriate patient-specific nutritional strategies. This study was conducted to evaluate the nutritional status of medical patients at admission to the adult intensive care unit (ICU) and to identify factors which prevent attainment of daily feeding goals in them. Methods: This was a 1 year prospective, observational study on 200 medical adult ICU patients. The study was carried out based on daily documentation. The primary outcome was the nutritional status of medical Patients at admission to the adult ICU. The tests for statistical analysis used were independent t test, Chi-square test, Fisher's exact test and multivariate logistic regression analysis. Results: Out of the 200 patients in our study, 45%, 48.5% and 9% of patients had mild, moderate and severe malnutrition, respectively, corresponding to subjective global assessment (SGA) rating A,B and C, respectively. The most common reasons for non-attainment of daily feeding goals were delayed feed procurement (17.57%), and feeds being held for procedures (16.36%). The overall mean length of ICU stay was 8.63 ± 7.26 days, and the ICU mortality rate was 47.5% (95/200). Patients with SGA rating B and C at admission had higher risk of mortality in the ICU, with an adjusted odds ratio of 3.54 (95% confidence interval [CI]- 1.71–7.33, P = 0.001) and 11.11 (95% CI-2.26–54.66, P = 0.003), respectively. Conclusion: Malnutrition is commonly present at admission among medical ICU patients, and is associated with higher ICU mortality

Modified mallampati score – Does it predict more than a difficult airway? A community-based study assessing the association between modified mallampati score and obstructive sleep apnea

Background and Aim: The suspicion of obstructive sleep apnea (OSA) has serious implications for an anesthesiologist perioperatively. This study examines the association between the modified Mallampati scoring (MMS) and the STOP-BANG score in a community setting. Materials and Methods: This was a community-based cross-sectional survey among 702 adults in a rural area in South India. Airway assessment using MMS and assessment for OSA using STOP-BANG scoring were made by junior doctors trained in the anesthesia department. The association between the Mallampati score and the STOP-BANG score was tested by the Chi-square test using the SPSS version 21. Results: Among the community-dwelling adults, 19.2% had a score of 1, 27.9% had a score of 2, 31.3% had a score of 3, and 21.5% had a score of 4 on the Mallampati scoring system. Using the STOP-BANG score for risk stratification of OSA, 29.2% had an intermediate risk and 5.8% had a high risk for OSA. Higher Mallampati Grades (3 and 4) were a significant risk factor for OSA (61.8% vs. 38.2%, P = 0.001). Conclusion: A higher Mallampati class (3 or 4) is significantly associated with an intermediate-to high risk for OSA as assessed using STOP-BANG score criteria. Therefore, we suggest using the MMS not only as an airway screening tool but also as a predictor of OSA, in view of the rising obesity rates in India