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Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, Kakkar G, Sapra H, Gupta N, Singhal V, Chaturvedi A. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023; 27:305-314. [PMID: 37214124 PMCID: PMC10196640 DOI: 10.5005/jp-journals-10071-24446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 05/24/2023] Open
Abstract
Background End-of-life (EOL) care is the care of terminally ill patients who are nearing their end. It includes important components like palliative care, supportive care, hospice care, patient's right to choose, and choice of medical intervention, including continuation of routine medical interventions. The aim of this survey was to assess the practices of EOL care in various critical care units in India. Methods The participants included clinicians involved in EOL care of patients with advanced diseases in different hospital across India. We sent blast emails and posted links on social media for inviting participants to take the survey. Study data were collected and managed by using Google Forms. The collected information was automatically entered into a spread sheet and stored in a secure database. Results In total, 91 clinicians took the survey. The years of experience, practice area, and setting had significant effect on the palliative care, terminal strategy, and prognostication in terminally ill patients (p < 0.05). Statistical analysis was done using software STATA. Descriptive statistics were performed, and results were presented as number (percentage). Conclusion The years of work experience, the practice area, and the practice setting have a strong impact on EOL care management of terminally ill patients. There are a lot of gaps in providing EOL care for these patients. Many reforms are needed in the Indian health care system to make EOL care better. How to cite this article Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, et al. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023;27(5):305-314.
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Affiliation(s)
- Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | | | - Swagata Tripathy
- Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Jaya Wanchoo
- Department of Neuroanaesthesia and Neurocritical Care, Medanta The Medicity, Gurgaon, Haryana, India
| | - Gaurav Kakkar
- Department of Neuroanaesthesia and Neurocritical Care, Amrita Hospital, Faridabad, India
| | - Harsh Sapra
- Department of Neuroanaesthesia and Neurocritical Care, Medanta The Medicity, Gurgaon, Haryana, India
| | - Nidhi Gupta
- Department of Neuroanaesthesia, Indraprastha Apollo Hospital, New Delhi, India
| | - Vasudha Singhal
- Department of Neuroanaesthesia and Neurocritical Care, Medanta The Medicity, Gurgaon, Haryana, India
| | - Arvind Chaturvedi
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Prabhakar H, Tripathy S, Gupta N, Singhal V, Mahajan C, Kapoor I, Wanchoo J, Kalaivani M. Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021; 25:126-133. [PMID: 33707888 PMCID: PMC7922463 DOI: 10.5005/jp-journals-10071-23712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Our main objective in developing this consensus is to bring together a set of most agreed-upon statements from a panel of global experts that would act as a guide for clinicians working in neurocritical care units (NCCUs). Background Given the physiological benefits of analgo-sedation in the NCCU, there is little information on their tailoring in the NCCU. This lack of evidence and guidelines on the use of sedation and analgesia in patients with neurological injury leads to a variation in clinical care based on patient requirements and institutional protocols. Review results Thirty-nine international experts agreed to be a member of this consensus panel. A Delphi method based on a Web-based questionnaire developed with Google Forms on a secure institute server was used to seek opinions of experts. Questions were related to sedation and analgesia in the neurocritical care unit. A predefined threshold of agreement was established as 70% to support any recommendation, strong, moderate, or weak. No recommendations were made below this threshold. Responses were collected from all the experts, summated, and expressed as percentage (%). After three rounds, consensus could be reached for 6 statements related to analgesia and 5 statements related to sedation. Consensus could not be reached for 10 statements related to analgesia and 5 statements related to sedation. Conclusion This global consensus statement may help in guiding practitioners in clinical decision-making regarding analgo-sedation in the NCCUs, thereby helping in improving patient recovery profiles. Clinical significance In the lack of high-level evidence, the recommendations may be seen as the current best clinical practice. How to cite this article Prabhakar H, Tripathy S, Gupta N, Singhal V, Mahajan C, Kapoor I, et al. Consensus Statement on Analgo-sedation in Neurocritical Care and Review of Literature. Indian J Crit Care Med 2021;25(2):126–133.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Swagata Tripathy
- Department of Anaesthesia, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Nidhi Gupta
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Vasudha Singhal
- Department of Neuroanaesthesiology and Critical Care, Medanta: The Medicity, Gurugram, Haryana, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Jaya Wanchoo
- Department of Neuroanaesthesiology and Critical Care, Medanta: The Medicity, Gurugram, Haryana, India
| | - Mani Kalaivani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Kapoor I, Wanchoo J, Mahajan C, Singhal V, Roy H, Kumar S, Brahma R, Prasad C, Kalaivani M, Prabhakar H, Chaturvedi A. Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]. Indian J Crit Care Med 2021; 25:382-387. [PMID: 34045803 PMCID: PMC8138650 DOI: 10.5005/jp-journals-10071-23783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Elective percutaneous tracheostomy [PCT] is the widely performed procedure in neurocritically ill patients as an airway management choice in neurocritical care unit [NICU]. Intracranial pressure [ICP] is a vital parameter to be monitored in these patients while undergoing any surgical procedure including PCT. Optic nerve sheath diameter [ONSD], being a surrogate of ICP, can be done bedside and carries less complications than invasive ICP monitoring. The aim of our study was to assess the effect of PCT on ONSD at different stages of PCT. Materials and methods A total of 158 patients with various intracranial pathologies scheduled for PCT in NICU were screened for eligibility in our study. We assessed mean values of ONSD, HR, MBP, and SpO2 for changes over various time points during PCT using generalized estimating equation (GEE). A p value of <0.05 was considered significant. Results A total of 135 patients who underwent PCT were analyzed for the study. The values of ONSD changed significantly at different stages of PCT procedure compared to baseline. The baseline ONSD value was 0.39 ± 0.05 cm. ONSD rose significantly to 0.40 ± 0.06 cm during positioning, 0.41 ± 0.06 cm during skin incision, 0.42 ± 0.07 cm during dilatation of tract, 0.41 ± 0.07 cm during insertion of tracheostomy, and 0.41 ± 0.06 cm at the end of the procedure. Conclusions PCT leads to a significant rise of ONSD values during all stages of PCT. The available evidences point toward detrimental rise in ICP during PCT. ICP can be monitored noninvasively by measuring ONSD using bedside ultrasound. How to cite this article Kapoor I, Wanchoo J, Mahajan C, Singhal V, Roy H, Kumar S, et al. Effect of Percutaneous Tracheostomy on Optic Nerve Sheath Diameter [TONS Trial]. Indian J Crit Care Med 2021;25(4):382-387.
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Affiliation(s)
- Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, AIIMS, New Delhi, India
| | - Jaya Wanchoo
- Department of Neuroanesthesiology and Critical Care, Medanta: The Medicity, Gurgaon, Haryana, India
| | - Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, AIIMS, New Delhi, India
| | - Vasudha Singhal
- Department of Neuroanesthesiology and Critical Care, Medanta: The Medicity, Gurgaon, Haryana, India
| | - Hirok Roy
- Department of Neuroanaesthesiology and Critical Care, AIIMS, New Delhi, India
| | - Subodh Kumar
- Department of Anesthesia and Intensive Care, Government College and hospital, Chandigarh, India
| | - Rupali Brahma
- Department of Anesthesiology, AIIMS, Bilaspur, Chhattisgarh, India
| | - Chandrakant Prasad
- Department of Neuroanaesthesiology and Critical Care, AIIMS, New Delhi, India
| | | | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, AIIMS, New Delhi, India
| | - Arvind Chaturvedi
- Department of Neuroanaesthesiology and Critical Care, AIIMS, New Delhi, India
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Gupta S, Tomar DS, Dixit S, Zirpe K, Choudhry D, Govil D, Mohamed Z, Chakrabortty N, Gurav S, Wanchoo J, Gupta KV. Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT). Indian J Crit Care Med 2020; 24:514-526. [PMID: 32963433 PMCID: PMC7482354 DOI: 10.5005/jp-journals-10071-23441] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Tracheostomy is among the common procedures performed in the intensive care unit (ICU), with percutaneous dilatational tracheostomy (PDT) being the preferred technique. We sought to understand the current practice of tracheostomy in Indian ICUs. Materials and methods A pan-India multicenter prospective observational study, endorsed and peer-reviewed by the Indian Society of Critical Care Medicine (ISCCM), on various aspects of tracheostomy performed in critically ill patients was conducted between September 1, 2019 and December 31, 2019. The SPSS software was used for the statistical analysis. Cross tables were generated and the chi-square test was used for testing of association. The p value < 0.05 was considered statistically significant. Results Out of 67 ICUs that participated, 88.1% were from private sector hospitals. A total of 923 tracheostomies were performed during the study period; out of which, 666 were PDT and 257 were surgical tracheostomy (ST). Coagulopathic patients received more platelet transfusion [p = 0.037 with platelet count (PC) < 50 × 109, p = 0.021 with PC 50–100 × 109] and fresh frozen plasma transfusion in the ST group (p = 0.0001). The performance of PDT vs ST by day 7 of admission was 28.4% vs 21% (p = 0.023). The single dilator technique (60.4%) was the preferred technique for PDT followed by the Grigg's forceps and then the multiple dilator technique. Fiberoptic bronchoscope (FOB) and ultrasonography (USG) were used in 29.3% and 16.8%, respectively, for guidance during tracheostomy. Most of the PDTs were performed by a trained intensivist (74.2%), whereas ST was mostly done by an ENT surgeon (56.8%). Percutaneous dilatational tracheostomy resulted in less hemorrhagic (2.6% vs 7%, p = 0.002) and desaturation complications (2.3% vs 6.6%, p = 0.001) as compared to ST. The duration of procedure was shorter in the PDT group (average shortening by 9.2 minutes) and the ventilator-free days (VFD) were higher in the PDT group. The cost was less in PDT by approximately Rs. 13,104. Conclusion Percutaneous dilatational tracheostomy, especially the single dilator technique, is preferred by clinicians in Indian ICUs. The incidence of minor complications like hemorrhagic episodes is lower with PDT. Percutaneous dilatational tracheostomy was found to be cheaper on cost per patient basis as compared to ST (with or without complications). How to cite this article Gupta S, Tomar DS, Dixit S, Zirpe K, Choudhry D, Govil D, et al. Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT). Indian J Crit Care Med 2020;24(7):514–526.
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Affiliation(s)
- Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India
| | - Deeksha S Tomar
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India
| | - Dhruva Choudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Deepak Govil
- Department of Critical Care, Institute of Critical Care and Anesthesiology, Medanta-The Medicity, Gurugram, Haryana, India
| | - Zubair Mohamed
- Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
| | - Nilanchal Chakrabortty
- Department of Neurointensive Care, Institute of Neurosciences, Kolkata, West Bengal, India
| | - Sushma Gurav
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India
| | - Jaya Wanchoo
- Department of Neuroanesthesia and Critical Care, Institute of Neurosciences, Medanta-The Medicity, Gurugram, Haryana, India
| | - Kanchi Vv Gupta
- Department of Critical Care Medicine, Manipal Hospitals, Bengaluru, Karnataka, India
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Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Zirpe K, Srinivasan S, Mohamed Z, Gupta KV, Wanchoo J, Chakrabortty N, Gurav S. Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020; 24:S31-S42. [PMID: 32205955 PMCID: PMC7085814 DOI: 10.5005/jp-journals-10071-g23184] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs. MATERIALS AND METHODS All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation. RESULTS After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity. CONCLUSION This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients. HOW TO CITE THIS ARTICLE Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31-S42.
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Affiliation(s)
- Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India, , e-mail:
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, , e-mail:
| | - Dhruva Choudhry
- Department of Pulmonary & Critical Care Medicine, University of Health Sciences Rohtak, Haryana, India, , e-mail:
| | - Deepak Govil
- Department of Critical Care, Institute of Critical Care & Anesthesiology, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | | | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India, , e-mail:
| | - Zubair Mohamed
- Department of Organ Transplant Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India, , e-mail:
| | - Kv Venkatesha Gupta
- Department of Critical Care Medicine, Manipal Hospitals, Bengaluru, Karnataka, India, , e-mail:
| | - Jaya Wanchoo
- Department of Neuroanaesthesia and Critical Care, Institute of Neurosciences, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Nilanchal Chakrabortty
- Department of Neurointensive Care, Institute of Neurosciences, Kolkata, West Bengal, India, , e-mail:
| | - Sushma Gurav
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
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Mani GK, Mani M, Sharma PK, Gara A, Aggarwal M, Das AK, Wanchoo J. Merits of performing coronary artery by-pass grafts on the beating heart. J Indian Med Assoc 2001; 99:483-4, 486-8. [PMID: 12018553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
A retrospective study of 1006 patients was undertaken to evaluate the benefit of a change of strategy in performing coronary artery by-pass grafting surgery. Group A consisted of 500 patients who were consecutively operated on cardiopulmonary by-pass and group B consisted of 506 patients who were consecutively operated on using "off pump" techniques. Pre-operative risk profile in both groups were similar as was as in the operating time. There was distinct benefit in amount of homologous transfusion, period of ICU stay, increased usage of radial artery conduit and improvement in transoesophageal echocardiography assessment of ischaemic mitral incompetence immediately after revascularisation in off pump (group B). Though there was a lower mortality in group B ie, 3/506 vis-a-vis 10/500 in group A this is not of statistical significance. Improvement in left ventricular ejection fraction >5.0% occurred more frequently in one month follow-up visits of group B patients. Period of return to active life was also shorter (28 versus 56 days). Based on observations, we conclude that there is a distinct benefit in avoiding cardiopulmonary by-pass while performing coronary artery by-pass grafting.
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Affiliation(s)
- G K Mani
- Indraprastha Apollo Hospitals, New Delhi
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