Role of Prophylactic Noninvasive Ventilation in Patients at High Risk of Extubation Failure

How to cite this article: Singh L. Role of Prophylactic Noninvasive Ventilation in Patients at High Risk of Extubation Failure. Indian J Crit Care Med 2020;24(12):1158–1160.

Prolonged mechanical ventilation (MV) has serious side effects and complications. Thus, one opts for an early extubation after correcting the causes and stabilizing the patient.¹ Extubation is commonly uneventful especially in an odds ratio (OR) but in intensive care unit (ICU) it is often associated with respiratory failure development post post extubation which may very often require reintubation. The rule of thumb about reintubation risk cannot be applied to all patients as the pathophysiology of extubation failure is poorly understood.An average of 15% patients may need reintubation among which 25–30% are at high risk.¹ The high-risk patients of extubation failure include preterm infants, age ≥65 years, any respiratory disease, cardiac disease.² A major cause of weaning failure is acute respiratory failure (ARF) due to respiratory muscle fatigue or increased work of breathing due to decreased pulmonary compliance or increased resistance. Other causes include inadequate cough, airway obstruction, excess secretions, neurologic impairment. An important factor responsible for mortality in ICU patients after extubation is ARF. Noninvasive ventilation (NIV) is used for both management and prevention of post-extubation respiratory failure.After extubation, oxygenation can be improved by three methods available: conventional oxygen therapy, high-flow oxygen therapy, and NIV. Respiratory support is most commonly provided by conventional oxygen therapy. However, in recent years, high-flow oxygen therapy (HFOT) and NIV are being used increasingly. These methods are speculated to prevent extubation failure by promoting alveolar recruitment, preventing alveolar collapse, and reducing the work of breathing. Noninvasive ventilation (NIV) causes an increase in the intrathoracic pressure preventing alveolar collapse, improving oxygenation, and reducing the workload of the heart. It also prevents complications of invasive MV.³ The protocol of using prophylactic NIV can involve the immediate application of NIV within 1 hour of extubation for a duration of 8–24 hours depending upon the improvement in the respiratory parameters, such as, respiratory rate, pH, partial pressures of oxygen, and carbon dioxide. The prophylactic use of NIV has been adopted for reducing the rates of reintubation, duration of MV, and improving the overall prognosis of patients at high risk of post-extubation failure.^1,3–5The International Consensus Conference in intensive care medicine in 2001 suggested that NIV is a promising therapy to prevent respiratory failure after weaning.⁶ It can ameliorate some of the pathophysiologic derangements that occur following extubation. It has been used as an adjunct to weaning or as a part of early extubation approach.Since the need for reintubation has been associated with significantly poor outcomes in terms of prolongation of the ICU stay, hospital stay, use of MV and its associated complications like pneumonia and lung damage, the requirement of tracheotomy, and financial implications, two studies have used different methods for preventing it; among which the prophylactic use of NIV has been found to be is successful.^4,5,7 The successful use of prophylactic NIV has been most pronounced in high-risk patients of extubation failure.⁸ Post-extubation respiratory failure and reintubation prevention by using NIV is supported by weak evidence. NIV can decrease reintubation rates was concluded in two meta-analyses, but these studies had both high risk (only 35%) as well as the general population.^9,10 NIV compared to with conventional oxygen therapy in ICU patients at high risk of reintubation was found to be more effective.⁴ However, a meta-analysis conducted in 2014 with 1,382 patients found that the use of NIV as a preemptive measure after extubation or after respiratory failure which developed post-extubation was not beneficial either in reducing mortality or intubation rate.¹⁰Liu et al.³ found that prophylactic NIV brings about a significant reduction in the atelectasis (OR = 0.43, p = 0.02) and rate of reintubation (OR = 0.33, p = 0.02). The reduction in atelectasis rate is an additional advantage since the development of atelectasis is associated with further complications, such as, pneumonia and atelectrauma.¹¹ One of the previous review studies backed up the improved outcomes of the use of prophylactic NIV in major abdominal surgeries.¹² This was even seen on the patients undergoing cardiothoracic surgeries where prophylactic NIV reduced the rate of reintubation.¹³ In a landmark study by Thille et al.¹ which compared the use of prophylactic NIV in 150 high-risk extubated patients with 83 control extubated patients in an ICU setting, there was a significant reduction in reintubation in the study group (15% vs 28%, p = 0.02). The study is important since it included high-risk patients with cardiac disease and respiratory disease, and found that prophylactic NIV was an independent predictor of extubation success. Their findings were backed up by two studies prior to before it which showed a significant reduction in the reintubation from 24 to 8%, p = 0.027 and from 39 to 5%, p = 0.016, respectively.^4,5In an RCT, Ferrer et al.¹⁴ concluded that early use of NIV averted respiratory failure after extubation and decreased mortality in high-risk patients. Another RCT of 648 patients at high risk of extubation failure concluded that the use of high-flow nasal oxygen with NIV immediately after extubation significantly decreased the risk of reintubation.¹⁵ Nava et al. in a randomized controlled trial studied the use of prophylactic NIV in patients at high risk of extubation failure following at least 48 hours of invasive ventilation and extubation after a successful spontaneous breath trial. They observed that the rate of reintubation was significantly lower in the prophylactic NIV group (8%) compared to with the control group (24%) and NIV was associated with significantly lower ICU mortality and ICU length of stay.⁴ Ferrer et al.¹⁴ applied NIV immediately post-extubation, with age >65 years and APACHE II score >12 at extubation as a factor for high risk of extubation failure and observed that post-extubation respiratory failure was lower in the NIV group (16% vs 33%) but there was no difference in the rate of re-intubation and ICU mortality and 90-days mortality was significantly lower in NIV group. Ferrer et al. in their RCT, used prophylactic NIV in patients with underlying chronic respiratory illness and hypercapnia at extubation. Prophylactic NIV was associated with lower respiratory failure at 48 hours post-extubation and significantly lower 90-day mortality.¹⁶In this issue, Ghosh et al.¹⁷ studied outcomes of prophylactic NIV at extubation after a planned extubation, in patients at a high risk of extubation failure. They observed extubation success in 88.2% of patients at 72 hours. Higher age, longer duration of invasive ventilation, and higher SOFA score at extubation were the factors associated with extubation failure. They also observed organ failure and higher cumulative fluid balance in the first 72 hours post-extubation in the extubation failure group. Ghosh et al.¹⁷ and Upadya et al.¹⁸ observed in their studies that higher cumulative fluid balance at extubation was an independent risk factor for extubation failure in patients after planned extubation.Among the newer modalities, Ali et al.¹⁹ studied the use of nasal high-frequency oscillatory ventilation (NHFOV) as a prophylactic NIV or “rescue mode of NIV” after extubation. The NHFOV is a “noninvasive ventilation mode that applies an oscillatory pressure waveform to the airways using a nasal interface”. The results were promising which showed a decreased requirement of reintubation. It is suggested that NHFOW may be a feasible modality that in is being used as prophylactic NIV following extubation for the prevention of apnea and reintubation. But still, the practical applications need randomized controlled trials to lay down the indications and guidelines for its use in other populations. Prophylactic NIV has emerged as an promising modality and its practical use is welcome. Its efficacy has been seen in diverse age groups ranging from pediatric to adults to elderly.Appropriate patient selection, i.e., those who are at high risk of extubation failure is important, because it is not useful in low-risk patients, but also that its use may be detrimental in some patients.     

Quest of Knowledge and Perceived Barriers toward Early Mobilization of Critically Ill Patients in Intensive Care Unit: A Continuing Journey!

How to cite this article: Daptardar AA. Quest of Knowledge and Perceived Barriers toward Early Mobilization of Critically Ill Patients in Intensive Care Unit: A Continuing Journey! Indian J Crit Care Med 2021;25(5):489–490.

Critically ill patients require intensive management before they can recover. Management is even more challenging if they need mechanical ventilation. Early mobilization (EM) in the intensive care unit (ICU) is a physical activity performed as early as the second to fifth day after ICU admission to bring about physiological changes.^1,2EM is defined as mobilization within 72 hours of ICU admission, which is feasible and well-tolerated by most patients once they are stable. It has been difficult to interpret the therapeutic effects of EM due to variations in study populations, interventions, and outcome measures. It has been estimated that up to 46% of ICU patients acquire ICU-acquired weakness, which includes polyneuropathy, myopathy, and/or muscular atrophy during their stay.^3,4 This may have a detrimental effect on the patient''s long-term physical and cognitive functions. Many studies have reported range of motion (ROM) exercises to combat this. The European Society of Intensive Care Medicine has recommended early physical rehabilitation for ICU patients. This has been associated with improved physical function.⁵ Other studies have reported a variety of benefits of EM, which includes reduced mechanical ventilation days, reduced length of ICU stay, reduced hospital length of stay, and improved functional outcomes.^6–8In spite of its potential benefits, EM is not widely performed in the ICU as seen from many international multicenter studies on EM in the ICU, which portrays a low prevalence of out-of-bed mobilization, especially among patients on mechanical ventilation.^9,10 The reason for this may be that mobilizing patients in the ICU is a complex task and is associated with a lot of risks. Equipment and catheters attached to patients can become dislodged causing injury. Critically ill patients who are hemodynamically unstable can also be adversely affected due to mobilization.A growing body of evidence shows the long-term benefits of EM on patient safety, feasibility, functional capacity, strength, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and mortality.^11,12 However, most studies detected considerable barriers to the EM of critically ill adult patients admitted to the ICU which included availability of staff, equipment, oversedation, and lack of education regarding feasibility and safety of EM.In this issue of the journal, a study conducted in the ICU of Tertiary Health Care Academic Institute of Central India, the authors found that majority of members of the multiprofessional team agreed and viewed EM under mechanical ventilation as important and beneficial.¹³ They were knowledgeable about EM and agreed that the benefits of EM outweighed the risks to patients under MV. Similar results were reported in a previous study that analyzed the knowledge and attitudes of multiprofessional healthcare members working in the ICU and delivering care to critically ill patients.¹⁴ The multiprofessional participants in the present study identified several barriers to EM on three levels: (1) Patient-related, such as patient symptoms and conditions, excessive sedation, endotracheal tubes, monitors, and catheters. (2) Provider level barriers, such as limited human and technical resources, limited staffing, and insufficient training. (3) Institutional level barriers related to the ICU culture, lack of proper guidelines, lack of coordination, conflicts of timings of different procedures, and lack of rules for the distribution of tasks and responsibilities.¹³ Similar barriers were also detected in the previous study.¹⁵ In the present study three fourth of the physicians agreed that ROM exercises were sufficient to maintain muscle strength whereas more than half of the physiotherapists and nursing staff disagreed with this. More than half of the physicians were willing to modify the patient level barriers by altering the ventilator settings and reducing sedation to facilitate EM. Although EM was shown to be safe and feasible for patients, there is no information about the staff safety, which was evident by the majority of nursing staff and physiotherapists showing concerns regarding the risk of injuries to the ICU staff during EM. They also reported work stress and long working hours, which might also constitute a considerable barrier to EM in the ICU.¹³The present study confirms that while knowledge continues to advance, practice always remains a step behind, and hence, there is a wide gap between evidence-based knowledge and its application in clinical practice. The study had a small sample size resulting in a selection bias and provided a baseline from one institution only, thus not reflecting the views of other institutions and disciplines. Hence, a multicentre research with a larger sample size or randomized controlled trials is needed to study and evaluate the effects of EM in the ICU using a standardized protocol to determine the optimal timing, intensity, duration, exercise dosage, and progression of mobilization to optimize patient''s physical condition during critical illness.¹⁶     

Focus on the Positive: A Qualitative Study of Positive Experiences Living With Type 1 or Type 2 Diabetes

The purpose of this study was to identify positive experiences associated with diabetes from the perspective of adults diagnosed with type 1 or type 2 diabetes. We conducted in-depth face-to-face and telephone interviews with adults with diabetes. Participants focused on positive and supportive experiences with their peers and community, improved health behaviors, personal growth, and engagement in diabetes advocacy. Communicating positive experiences about diabetes may help clinicians and educators reframe the negative messages commonly shared with people with diabetes.

Diabetes is one of the most significant health problems in the United States and globally. In the United States, an estimated 34.2 million people of all ages—or 10.5% of the population—have diabetes, with the vast majority having type 2 diabetes (1). Diabetes is a group of diseases characterized by high blood glucose levels resulting from the body''s inability to produce or use insulin (2). The two most common forms are type 1 diabetes and type 2 diabetes (2); the former is marked by the body’s inability to produce insulin and the latter by the body’s inability to make enough insulin or to effectively use the insulin it produces (2). Although type 1 diabetes is most commonly diagnosed in childhood or adolescence, it can occur at any age. Likewise, type 2 diabetes is most commonly diagnosed during middle age but can be diagnosed in childhood or adolescence. Recent trends in incidence show increases in both type 1 and type 2 diabetes, especially in children and adolescents (1).Recent data from the Centers for Disease Control and Prevention show that half of U.S. adults with diagnosed diabetes (50.0%) have an A1C value at target (<7.0%) (1). Of these, 19.2% were both nonsmokers and met all three “ABC goals”: A1C <7.0%, blood pressure <140/90 mmHg, and non-HDL cholesterol <130 mg/dL (1). Reaching ABC goals decreases the risk of macrovascular (e.g., cardiovascular disease) and microvascular (e.g., retinopathy, neuropathy, and nephropathy) complications (3–5). Behaviors that promote ABC goal achievement, and in turn reduce the risk for complications, include smoking cessation (6), following a healthy diet (7), losing weight (8), engaging in regular physical activity (9), monitoring blood glucose levels (10), taking medication (11), checking feet (12), and attending clinic appointments (13,14). Active engagement in these behaviors is encouraged in diabetes self-management education and support (DSMES) programs (15,16).DSMES is an important component of care for all people with diabetes (16). DSMES should be person-centered and facilitate learning about diabetes, participating in diabetes decision-making, and acquiring skills for self-care (16). Furthermore, providers who deliver DSMES should incorporate positive, strengths-based language to reduce stigma and feelings of shame and guilt (17,18). Historically, diabetes care and DSMES have focused on behavioral and clinical targets, which may explain their short-term benefits but limited long-term effects on outcomes (19,20). Incorporating personal stories and experiences into diabetes management may help adults with diabetes sustain the benefits they accrue (21–23). However, minimal research has explored positive stories and experiences of living with type 1 or type 2 diabetes. Thus, the purpose of this study was to identify positive experiences with diabetes from the perspective of adults diagnosed with either of these forms of the disease.     

“Counting Carbs to Be in Charge”: A Comparison of an Internet-Based Education Module With In-Class Education in Adolescents With Type 1 Diabetes

Carbohydrate counting is an essential component of type 1 diabetes education but can be difficult for adolescents to learn. Because adolescents are avid users of technology, an Internet-based education module was compared with an in-class education session in terms of carbohydrate counting accuracy in adolescents with type 1 diabetes. Adolescent participants displayed increased carbohydrate counting accuracy after attending an in-class education session compared with an Internet-based education module. These results suggest that online education is best reserved as an adjunctive therapy to in-class teaching in this population.

Carbohydrate counting is a recommended daily practice for the self-management of type 1 diabetes, in conjunction with insulin therapy (1). This method allows for more flexibility in the timing and frequency of eating and the amount of carbohydrate consumed during meals and snacks (1). Accuracy in carbohydrate estimation is required to achieve and sustain adequate glycemic control, and differences of ≥20 g from actual carbohydrate amount have been shown to affect postprandial glucose excursions (2,3). Thus, carbohydrate counting is an essential component of conventional diabetes education, a collaborative process whereby patients gain knowledge and skills to successfully self-manage their diabetes and related conditions (4,5).However, evidence suggests that adolescents with type 1 diabetes do not accurately count carbohydrates (6). In a previous study in adolescents with type 1 diabetes, we reported that, despite using carbohydrate counting for managing their diabetes and receiving in-class education with a dietitian, fewer than half of the sample counted carbohydrates accurately (7). Furthermore, a nutrition education intervention focused on carbohydrate counting in adolescents with type 1 diabetes found no improvement in counting accuracy and glycemic control after 3 months (8). These findings suggest a need to develop more intensive education that is cost-effective and readily available and provides the tools to empower individuals in their day-to-day diabetes management (9,10).Multiple factors have a bearing on the delivery of diabetes care for adolescents with type 1 diabetes; these include a shift in responsibility from parents to adolescents, adolescents’ focus on social contexts and peers, developmental inclination toward risk taking, and fatigue from care of a chronic illness (11). Therefore, the approach to diabetes education needs to be engaging, developmentally appropriate, and motivating to encourage appropriate diabetes self-management.Digital technologies are readily used among adolescents, and strategies that incorporate such technologies can potentially help adolescents enhance their skills in diabetes self-management (12,13). These strategies include online educational resources (14), short message service systems (15,16), interactive diabetes management tools (17), video games (18,19), Internet-based communication (20), Internet videoconferencing (21), and mobile device applications (22). Online education for diabetes management may help to reduce the complexity and inaccuracies associated with carbohydrate counting, as well as reduce the barrier of attending face-to-face teaching sessions by being a flexible learning option that can be reviewed at a patient’s convenience.There is no evidence indicating the most effective type of educational platform for training adolescents in carbohydrate counting. Although studies of Internet-based educational tools for diabetes self-management have been conducted in adolescents with type 1 diabetes (23), none have focused exclusively on improving carbohydrate counting skills. Furthermore, the current literature evaluating computer-assisted diabetes education has primarily targeted adults with type 2 diabetes (24,25). Therefore, the objective of this study was to evaluate an Internet-based education module on carbohydrate-counting accuracy in adolescents with type 1 diabetes in comparison with the standard of care (in-class education session). We hypothesized that the Internet-based module would result in improved accuracy compared with the in-class session.     

Personal Protective Equipment and Fire

How to cite this article: Paliwal B, Bhatia PK, Kamal M, Purohit A. Personal Protective Equipment and Fire. Indian J Crit Care Med 2021;25(4):473

Personal protective equipment (PPE) is worn by healthcare workers to protect themselves from getting infected from the patients. The component of PPE as well as the nature of the material used for PPE is dictated by the disease and its mode of transmission. Coronavirus disease-2019 (COVID-19) infection being an aerosol-transmitted infection mandates PPE consisting of gowns or coverall, head cover, goggles, mask or face shield, gloves, and rubber boots. The stringent standards mandate that coveralls and gowns should be efficient in protecting from exposure to biologically contaminated solid particles and chemical hazards.¹ The guidelines from the Ministry of Health and Family Welfare, India, in accordance with WHO state that “the fabric that cleared/passed ‘Synthetic Blood Penetration Resistance Test’ (ISO 16603) and the garment that passed ‘Resistance to penetration by biologically contaminated solid particles’ (ISO 22612:2005) may be considered as the benchmark specification to manufacture Coveralls.”^1,2 Hence, coveralls for COVID-19 prevention kit are commonly made from high-density polyethylene formed into a nonwoven fabric that allows heat and sweat to leave the suit while preventing liquids and aerosols from entering it.³ The disposable gowns are typically made of polypropylene, polyester, or polyethylene, whereas the reusable ones carry cotton/polyester blends.³While the material used for PPE ensures protection from viral infections, being inflammable, it does not so from fire. One such fire incident has already been reported in a COVID-19 patient–caring hospital. Media reports claimed the blaze spreads after a staff member''s PPE kit caught fire. The paramedic staff whose PPE had caught fire while saving the patient sustained 21% burns needing hospitalization.⁴ In quick succession, another incident of fire is reported in a COVID-19 center, the details of which are awaited.⁵ The inciting event in these incidences may be preventable, but nevertheless considering the compromised vision and hearing in PPE that affect early detection, communication, and response in incidents of fire; it hints to additional consideration of choosing fire-resistant material for PPE. Nomex or flame-resistant cotton may be used for flame-resistant coveralls or aprons.⁶ By varying the fiber type, bonding process and fabric finish can change the properties of the material; these fire-resistant materials can be made to be liquid and aerosol resistant as well.³To conclude, safety concerns may necessitate the material of PPE in COVID-19 care settings to be fire resistant in addition to being liquid and aerosol resistant.     

Investigating and Comparing the Effect of Teach-Back and Multimedia Teaching Methods on Self-Care in Patients With Diabetic Foot Ulcers

This study evaluated the effect of teach-back and multimedia teaching methods versus routine care on the self-care of patients with diabetic foot ulcers. Patients receiving either the teach-back or multimedia interventions had greater improvement in self-care scores than those receiving routine care. Both the teach-back and multimedia teaching methods were found to be effective in enhancing the self-care of people with diabetes.

People with diabetes (PWD) account for 7–8% of the total population in Iran (1). PWD are exposed to severe complications such as mental physical problems, including vascular disorders and peripheral neuropathy resulting in diabetic foot ulcers (2–5). Although the number of deaths caused by diabetes complications has decreased in recent years, the number of disabilities caused by diabetes remains high; for example, >70% of amputations are the result of diabetes (6).Diabetic foot ulcers are one of the most important and most common complications of diabetes and the main cause of hospitalization of these patients. Foot ulcers also impose the highest hospital costs on PWD (7). The World Health Organization describes “diabetic foot” as the foot of a person with diabetes who has neurological disorders, some degree of vascular involvement, and susceptibility to infection and ulcer, with or without degradation of deep tissues (8). Diabetic foot ulcers are slow to heal and can disrupt the lifestyle, social activities, health, and quality of life of patients and their caregivers (9). Because of the prevalence of foot ulcers in PWD, we need supportive programs to prevent and control this complication (10).Four risk factors are involved in the development of foot ulcers, including neuropathy, foot deformity, history of previous foot ulcer, and decreased foot circulation. People with these risk factors should receive specific ulcer treatments and implement effective plans to prevent relapse once an ulcer has healed. All PWD—even those without risk factors—need to take good care of their feet because even minor cases can lead to serious problems in these patients (11).Recent studies have shown that several risk factors may be associated with the development of diabetic foot ulcers. Foot ulcers are more common in males, people with longer duration of diabetes (>10 years), older people, those with higher BMIs, and people with other diabetes-associated diseases such as retinopathy, neuropathy, peripheral vascular disease, foot decay, excessive pressure on the soles of the foot (such as from inappropriate shoes and anatomical problems), malnutrition, and infection (12).Diabetes is a chronic disease requiring lifelong adjustment (13). Hence, PWD are expected to carry out rigorous self-care behaviors throughout their life. Evidence has shown that a lack of information and skills needed to manage chronic disease conditions is one of the most important causes of patient noncompliance with treatment and recommendations such as for healthy eating (2).The main goal of diabetes treatment is not only to remove the physical signs and symptoms of the disease, but also to improve the overall quality of life of patients. Self-care is the foundation of health promotion and disease prevention. Thus, providing a self-care educational program helps patients improve their self-care abilities and reduce their fear and dependence, thus enhancing their self-esteem and independence (14). Facilitating the process of self-care can improve the health, economic, and social status of the entire community (15). In addition to reducing hospitalizations, appropriate self-care can prevent many other problems for patients (16). For these reasons, training has a special place in the diabetes treatment process. Having complete information about the overall disease and care is one of the most important rights of patients, and today, patient training is one of the most important care roles and responsibilities of nurses in enhancing patients’ health and ability to adapt to the effects of the disease (17).Training patients via electronic platforms is a new teaching method that allows for the transfer of the concepts and materials in a simpler, more accessible, and more appealing manner. Digital education can involve text, sounds, images, and video elements (18). One form of modern digital teaching is known as the multimedia method (17,19). Multimedia is considered to be an individual teaching method. It is a type of e-learning in which learners learn how to learn (20). Another teaching approach to ensure patient understanding and retention of information is the teach-back method (21). Studies conducted by Oshvandi et al. (22) on heart failure, diabetes, and dialysis patients, respectively, showed that the teach-back teaching increased patients’ self-care behaviors. None of the studies in this area to date have compared the effects of the two teaching methods (teach-back and multimedia) on self-care in PWD.     

Leveraging Technology to Improve Diabetes Care in Pregnancy

Pregnant women with diabetes are at higher risk of adverse outcomes. Prevention of such outcomes depends on strict glycemic control, which is difficult to achieve and maintain. A variety of technologies exist to aid in diabetes management for nonpregnant patients. However, adapting such tools to meet the demands of pregnancy presents multiple challenges. This article reviews the key attributes digital technologies must offer to best support diabetes management during pregnancy, as well as some digital tools developed specifically to meet this need. Despite the opportunities digital health tools present to improve the care of people with diabetes, in the absence of robust data and large research studies, the ability to apply such technologies to diabetes in pregnancy will remain imperfect.

Diabetes is a global health problem affecting ∼60 million women of reproductive age (18–44 years of age) (1). Diabetes during pregnancy, whether preexisting or gestational diabetes mellitus (GDM), confers significant risk to women and their offspring. Pregnant women with diabetes have higher rates of iatrogenic preterm birth (2), preeclampsia, gestational hypertension (3,4), and cesarean delivery (5) compared with gravidae without diabetes. In addition, babies born to individuals with diabetes in pregnancy have greater susceptibility for growth abnormalities, neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia, and stillbirth (6).Studies of human pregnancies and research conducted in animal models of diabetes in pregnancy have revealed that hyperglycemia is a causative factor for adverse maternal and neonatal outcomes (7). Maintaining good glucose control (euglycemia) has been shown to mitigate these effects. However, euglycemia is difficult to sustain because pregnancy is characterized by physiological insulin resistance, hyperglycemia, and carbohydrate intolerance as a result of diabetogenic placental hormones (8). In women with normal pancreatic function, insulin production is sufficient to meet this challenge; in women with diabetes, hyperglycemia occurs if treatment is not adjusted appropriately and frequently.Successful pregnancy outcomes in the context of diabetes require reducing A1C, decreasing glycemic variability, and increasing the amount of time spent within a target glycemic range. To attain these clinical goals, women must monitor their blood glucose more frequently, improve their nutrition habits, and enhance their physical activity levels. In addition to comprehensive blood glucose monitoring (BGM), women with diabetes in pregnancy are expected to attend more frequent in-office health care visits than expectant mothers without diabetes. Patients describe significant burdens associated with the testing and reporting of blood glucose values in pregnancy, as well as increased demands of attending in-person health consultations (9,10).For women whose access to high-quality care is limited, diabetes in pregnancy presents an even greater challenge. Minority women and those of lower socioeconomic status are often disproportionately affected by both preexisting diabetes and GDM and have higher rates of diabetes-associated morbidity and mortality (11). Given that women from these vulnerable populations already experience greater rates of preterm birth, stillbirth, and maternal mortality (12,13), observance of the often-stringent BGM, medication modification, and face-to-face mediation regimens essential to reducing diabetes-associated adverse pregnancy outcomes can be difficult to achieve or maintain and, in some cases, may be unattainable.Technological innovations, including smartphone applications (apps) and cellular-enabled blood glucose monitors, present opportunities to improve the delivery of care for all women with diabetes in pregnancy. In addition, artificial intelligence and telemedicine can offer an alternative to in-office visits, extending the reach of diabetes education and support while maintaining standards of care (14). Specifically, apps that aid in managing diabetes in pregnancy have the potential to significantly increase patient engagement. Approximately 92% of reproductive-age women in the United States have smartphones, with usage consistently high (66–95%) across racial/ethnic groups and socioeconomic classes (15). Leveraging the availability and pervasiveness of smartphones has empowered patients to become more proactively engaged in their health care and dramatically changed medical practice and biomedical research (16). In the nonpregnant population, cellular-enabled blood glucose monitors that transmit results in real time to a health care provider (HCP) have improved both glycemic control and patient satisfaction in the self-management of diabetes (17,18). Translating these successes into novel solutions for pregnant women with diabetes could help to achieve the ultimate goals shared by patients and their care: positive maternal and neonatal outcomes.Here, we focus on mobile health (mHealth) apps and their applicability to the management of diabetes in pregnancy. We describe some of the core considerations when evaluating an app for use in patient care, discuss a number of apps developed specifically for diabetes self-management during pregnancy, and summarize key findings from the literature.     

Second-degree Heart Block Caused by Itolizumab-induced Infusion Reaction in COVID-19

How to cite this article: Kumar A, Kumar N, Lenin D, Kumar A, Ahmad S. Second-degree Heart Block Caused by Itolizumab-induced Infusion Reaction in COVID-19. Indian J Crit Care Med 2021;25(4):474–475.

Sir,Itolizumab, an anti-CD6 humanized IgG1 monoclonal antibody, binds to domain-1 of CD-6 that is responsible for priming, activation, and differentiation of T-cells.^[1] It significantly reduces T-cell proliferation along with substantial downregulation of the production of cytokines/chemokines.¹ It was approved for moderate to severe chronic plaque psoriasis in 2013. However, it has recently been approved by the Drug Controller General of India for emergency use in India for the treatment of cytokine release syndrome in moderate to severe acute respiratory distress syndrome patients due to COVID-19.² Here, we report a case of life-threatening infusion-related hypersensitivity reaction of itolizumab.A 65-year-old male COVID-19 patient got admitted to the intensive care unit (ICU) with complaints of shortness of breath and cough without any history of known disease. However, the baseline electrocardiogram (ECG) done in the ICU was suggestive of left bundle branch block (LBBB) (Fig. 1A). The patient was supported through noninvasive ventilation (NIV) and was started on remdesivir, dexamethasone, low-molecular-weight heparin, antibiotics, and other supportive treatment as per our institutional standard protocol. The patient was maintaining on continuous positive airway pressure mode of NIV with a fraction of inspired oxygen (FiO₂) of 0.5 on the third day of ICU admission. Among the laboratory markers, the total leucocyte counts were raised (12,000/μL) with decreased lymphocytes (3.2%) and increased inflammatory markers (CRP, 320 mg/L; D dimer >20 μg/mL; LDH, 1694 U/L; IL6, 329 pg/mL). Serum electrolytes, renal function tests, liver function tests, and arterial blood gases were within acceptable limits. The patient was hemodynamically stable with a respiratory rate of 30 to 35/minute and a PO₂/FiO₂ ratio of 140. After taking informed written consent, inj. itolizumab was planned in this patient because of the increasing severity of the disease along with increased inflammatory markers. Inj. hydrocortisone 100 mg IV and inj. pheniramine 30 mg IV were given 30 minutes before itolizumab infusion. And 100 mg of itolizumab (Alzumab-L, Biocon Biologics) was diluted to 250 mL with normal saline and was started at 25 mL/hour. After about 20 minutes of infusion, the patient started complaining of shivering, sweating, and impending doom. The patient had sudden bronchospasm, and oxygen saturation dropped to 90%. ECG showed second-degree AV nodal block with an increased blood pressure of 180/110 mm Hg (Fig. 1B). The drug was immediately withdrawn and the patient was given a repeat dose of hydrocortisone and pheniramine along with other supportive measures. After sometime patients became alert and their respiratory symptoms were relieved. However, the second-degree heart block in ECG was persistent. ECHO was normal and troponin I was within normal limits while there was a slight increase in CPK-MB. The patient was observed closely and the ECG reverted to its previous state only after 24 hours. The patient was weaned from the ventilator in due course of time and put on face mask on the eighth day of stay.Open in a separate windowFigs 1A and B(A) Baseline ECG showing LBBB; (B) ECG showing second-degree AV nodal block after infusion reactionMost infusion reactions related to monoclonal antibodies are IgE mediated and are mild (grade 1 or 2) in nature.³ The incidence of severe (grade 3 or 4) reactions is generally low. The reported infusion-related reactions to itolizumab are chills/rigors (common), nausea, flushing, urticaria, cough, hypersensitivity, pruritus, rash, wheezing, dyspnea, oxygen desaturation, dizziness, headache, and hypertension. In our case, itolizumab infusion leads to a grade 4 reaction causing a persistent second-degree heart block for about 24 hours. Among the monoclonal antibodies, rituximab is most notorious for causing infusion reactions.⁴ There are only a few reports of cardiac arrhythmias (monomorphic VT, supraventricular tachycardia, trigeminy, and irregular pulse) during therapeutic infusion of rituximab,⁵ and there is no reported case of cardiac arrhythmia during itolizumab infusion. In our case, the patient was having LBBB and was on a QT prolonging drug (remdesivir), which might be a predisposing factor for the occurrence of second-degree heart block during infusion reaction. Premedications (e.g., antipyretics, antihistamines, and steroids) are recommended before the administration of some chemotherapeutic agents and monoclonal antibodies. These drugs should never be given as IV bolus and should always be given slowly in an infusion. Baseline assessments including vital signs and cognition should be documented carefully before the start of treatment and all the emergency equipment and drugs should be kept ready. Grade 3 and 4 reactions should be managed promptly with epinephrine, antihistaminics, and steroids along with other symptomatic supportive measures. As itolizumab is approved for emergency use in COVID-19, risk-benefit ratio should be assessed before prescribing this and should be explained before taking consent for infusion.The patient provided written informed consent for the publication.     

Comparison of Two Electronic Systems for Obtaining Diabetes Care Indicators in Clinical Practice

We compared the completeness of data captured by physicians in a diabetes outpatient clinic using a general electronic health record system versus one that was specifically geared to diabetes. Use of a diabetes-oriented data system was found to allow for greater capture of crucial variables required for diabetes care than a general electronic record and was well accepted by health care providers.

Treatment in patients living with type 2 diabetes requires multicomponent and patient-focused medical care. However, barriers, including costs, inadequate care, lack of access to the health care system, and difficulty obtaining complete medical records, pose challenges in the management of these patients (1,2). Health care technologies offer many potential benefits, including improved efficiency, improved quality of care, reduced costs, and control in terms of expanded treatment options. Furthermore, health technologies can offer patients more access to their own health status and records (3,4).Since the implementation of electronic health record (EHR) systems, multiple studies have evaluated the utility of these electronic tools and their benefits in terms of patients’ health (4). EHR systems have led to care improvements in critical clinical domains and promote adherence to recommendations for optimum diabetes management of diabetes, for which the regular assessment of blood glucose, blood pressure, and lipid levels, as well as provision of appropriate foot and eye care, are essential (5–7). Diabetes care has been found to improve significantly in response to a multicomponent intervention involving a database-linked EHR system; receiving adequate medical care reduced cardiovascular mortality by 30%, blindness by 90%, and end-stage renal disease by 50% (8).Possible factors related to the improvement in diabetes care associated with EHR systems are the implementation of indicators or reminders within these systems that allow clinicians to easily see when biochemical studies should be performed (e.g., A1C, lipid, and microalbuminuria measurements), foot and retinal examinations should be scheduled, and evidence-based goals should be set or reviewed. Also, EHR systems have been found to promote the capture of essential information, with recording up to 84.8% of the total A1C values, 98.5% of systolic blood pressure readings, and 70.6% of LDL cholesterol values (8).EHR systems specifically designed to improve diabetes care are not routinely used in clinical practice, especially in developing countries where the use of traditional health records is common. Implementing such an EHR system could benefit patients, health care professionals (HCPs), and health systems and provide HCPs with information to improve the quality of care they deliver. This study aimed to compare the data captured by the physicians of a diabetes outpatient clinic using a general EHR system versus a diabetes-oriented EHR system called (in Spanish) Sistema de Monitoreo Integral en Diabetes (SMID). Researchers evaluated the percentage of missing data in each system and HCP acceptance of the diabetes-oriented system.     

Prognostic Factors of Fatal and Nonfatal Cardiovascular Events in Patients With Type 2 Diabetes: The Role of Renal Function Biomarkers

In this study, 158 patients with different degrees of renal function were followed for 7 years to assess the prognostic value of various risk factors, including carotid intima-media thickness (cIMT) and biomarkers of renal function, for incident cardiovascular morbidity and mortality in patients with type 2 diabetes. The investigators found that estimated glomerular filtration rate, albuminuria, and history of cardiovascular disease (CVD) can be used for prognosis of CVD, whereas cIMT adds little to the accuracy of this prediction.

Type 2 diabetes, the leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD), is characterized by a heavy cardiovascular (CV) burden. In large population-based epidemiological studies examining mortality and CV events, it has been shown that the risk of these outcomes is higher in patients with a combination of the two conditions (type 2 diabetes and CKD) compared with individuals with CKD but without diabetes and those with diabetes with normal renal function (1,2). Moreover, in the dialysis population, compared with people without diabetes, those with diabetes have a 1.6 times excess risk for CV mortality (3).During the past few decades, novel risk factors have emerged, including factors triggered by the uremic or hyperglycemic environment such as anemia, hypoalbuminemia, albuminuria and reduction of renal function (4), oxidative stress (5), and inflammation (6). Based on the belief that the presence of calcium in any arterial wall of the human body is associated with a nearly fourfold increase in CV morbidity and mortality, it was considered that the presence of atherosclerosis in the carotid artery reflects general atherosclerosis (7). Carotid intima-media thickness (cIMT) has been proposed as a surrogate marker of subclinical atherosclerosis and a strong, independent predictor of CV events in patients with type 2 diabetes or predialysis CKD and those on dialysis (8).Recently, scientific prognostic research has focused on developing risk-predictive models, especially in high-risk populations, such as people with diabetes or CKD. These prognostic models could provide an individualized risk prediction and stratification and thus improve patients’ outcomes and decision-making in clinical practice. An ideal risk model should be simple, quick, easy to assess, and accurate. Herein, we assessed the prognostic value of various risk factors, including cIMT and biomarkers of kidney function, to predict incident fatal and nonfatal CV events in a high-risk population such as patients with documented type 2 diabetes.     

Optic Nerve Sheath Ultrasound: Where do We Go from Here?

How to cite this article: Pichamuthu K. Optic Nerve Sheath Ultrasound: Where do We Go from Here? Indian J Crit Care Med 2021;25(4):360–361.

Raised intracranial pressure (ICP) is a common complication in neurocritical care patients. Identifying raised ICP promptly and monitoring changes in ICP through the course of the patient''s illness are vital to ensuring good clinical outcomes. Various procedures and interventions unrelated to the brain have also been recognized to increase ICP. Clinical signs are woefully inadequate for diagnosing and tracking raised ICP. Traditional imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI) require transport of the patient, may involve radiation, and are not frequently repeatable. They may not be available in secondary hospital setups in our country. Invasive ICP measurement is continuous and accurate but has its drawbacks of invasiveness: procedural skill requirement, infection, and hemorrhage. Ultrasound evaluation of the diameter of the optic nerve sheath visualized behind the globe with a high-frequency ultrasound probe has been recognized to be a good way to detect and track raised ICP.The anatomical basis of this ultrasound imaging is the fact that the meningeal layers of the brain continue around the optic nerve up to the globe of the eye. The dural and arachnoid layers fuse to form the optic nerve sheath. The subarachnoid cerebrospinal fluid (CSF) space around the optic nerve is therefore in continuity with the CSF in the chiasmatic cistern. An increase in CSF pressure leads to distension of the dura-arachnoid sheath and an increase in its diameter. Fibrous trabeculae between the pia and the arachnoid ensure that the sheath is tightly bound to the pia for most of the length of the nerve with only a potential CSF space.^1,2 At the termination of the optic nerve, where it meets the globe, the trabeculae are more elastic so they allow distension of the optic nerve sheath. Thus, the optic nerve sheath distends in response to an elevated CSF pressure only from its attachment to the sclera up to 6–8 mm behind the globe.³ The point of maximum distension is about 3 mm posterior to the globe.Optic nerve sheath ultrasound can be performed in patients who are supine or with the head-end elevated up to 30° with a head neutral position. The optic nerve is insonated through the globe by placing a high-frequency linear probe over the closed eyelid. Images are acquired in axial, parasagittal, and infraorbital coronal planes. The optic nerve is visualized as an anechoic stripe posterior to the sclera. The sheath appears as a hyperechoic layer on either side of the nerve. The optic nerve sheath diameter (ONSD) is measured using calipers from the inner surface of the sheath 3 mm behind the globe. Measurements are taken in different planes and then averaged.Although this ultrasound tool was described in 1987⁴ and expanded on in 1996⁵, it began to be widely used only after studies were published in 2006.⁶ Since then there have been a plethora of publications delving into various aspects of optic nerve ultrasound. Each of these looks into one of three domains in ONSD research. First, there are several articles looking to emphasize the positive correlation between ONSD by ultrasound and raised ICP, detected either by invasive measurements⁷ or by traditional neuroimaging such as CT and MRI.⁸ Meta-analyses of studies done in this domain demonstrate very high sensitivity, specificity, positive and negative predictive values for ONSD in diagnosing of raised ICP. The second domain of focus of ONSD research lies in looking to expand the range of applications of ONSD. The range of applications now includes preeclampsia, high altitude mountain sickness, idiopathic intracranial hypertension, head injury, acute liver failure, and ventriculoperitoneal shunt obstruction.^9,10 The last domain of research focus has been to show how ONSD can change rapidly in response to rapid changes in ICP, thus allowing for real-time tracking of ICP in response to thecal infusions, lumbar puncture, CSF drainage, and procedures such as endotracheal suctioning.¹¹Contributing to this last area of research, Kapoor et al. in the current issue of IJCCM have studied the changes in ONSD that occur during various stages of percutaneous tracheostomy in neurocritical care patients.¹² These authors have shown that the ONSD rises during all stages of percutaneous tracheostomy, though only five patients had a rise significant enough to warrant osmotherapy. It is important to emphasize here that the differences in measured ONSD between various phases of the procedure are insignificant, below the minimum detectable difference (the differences are very small and are smaller than the magnitude of inter and intra-observer variation), with significant overlap of standard deviations. This means that the differences in ONSD during various stages of the percutaneous tracheostomy were insignificant in the majority of the studied patients. There is truly little information on whether optic nerve sheath US can be used to monitor ICP during procedures on neurocritical care patients and the current study attempts to fill the wide gap. An important takeaway from this study is that it is feasible to monitor ONSD at the bedside during procedures in the intensive care unit (ICU).If the evidence so strongly suggests that ultrasound ONSD reliably diagnoses and tracks raised ICP, why is it not being used more widely in day-to-day intensive care practice? One of the most common reasons is the inter- and intraobserver variation that we encounter, making it less reliable and reproducible at the bedside. The second reason is like all other ultrasound modalities, ONSD is time and labor-intensive.I believe that to rid us all of our disillusionment with ONSD and ensure that patients benefit from this revolutionary way of non-invasively monitoring ICP, we need to have a four-pronged approach.The first approach is to standardize the procedure. We know that variations in probe frequency, view, gain, and placement of cursors all have an impact on the measured ONSD.¹³ We need a consensus on the correct procedural technique and that points to the grade the quality of the image. We need to do this at the earliest. This will also reduce the heterogeneity of ONSD research, which impairs applicability.The second step is to stop being obsessed with numbers. A lot of unreliability of ONSD stems from the uncertainty around the correct placement of the cursors to measure the diameter, especially in patients without raised ICP. Moving to a qualitative, pattern recognition-based approach to diagnose raised ICP is reliable and more reproducible.¹³ This qualitative approach with the incorporation of papilledema greatly increases the ease of diagnosing raised ICP by a novice. Quantitative ONSD measurements can be reserved for patients with raised ICP to track changes over time.The last step is to ensure adequate training prior to performing ONSD scans. While the number of scans needed to train an ultrasound expert has been determined to be 10, novices may need 25 scans before independent practice. The training needs to focus on elucidating the anatomical details of the nerve–sheath–globe complex. Particular attention needs to be focused on training in identifying possible artifacts, including lamina cribrosa associated edge artifacts, and using retinal artery Doppler to identify the correct position of the optic nerve.¹⁴Finally, we need more studies that can compare ONSD-based treatment regimens with standard treatment to determine if ONSD ultrasound results in the improvement of meaningful clinical outcomes.Urgent steps along these lines will ensure that this unique window into the brain has its correct and well-deserved place at the bedside of a patient with raised ICP.     

Using Continuous Glucose Monitoring in Clinical Practice

Continuous glucose monitoring is poised to radically change the treatment of diabetes and patient engagement of those afflicted with this disease. This article will provide an overview of CGM and equip health care providers to begin integrating this technology into their clinical practice.

Continuous glucose monitoring (CGM) systems are more than just glucose monitors. Recent CGM systems have moved beyond mere blood glucose monitoring (BGM) by providing both real-time and predictive glycemic data. The robust data garnered from CGM can also be used for detection of trends, identification of asymptomatic events, and review of glycemic variability over a range of time.Increased frequency of glucose monitoring is associated with decreased hypoglycemia and increased glycemic time in range (TIR), which correlates with improved A1C (1). Moreover, glucose patterns captured via CGM data analysis can highlight areas in need of treatment intervention (e.g., to prevent hypoglycemia, improve glycemic control at specific times of day, and increase overall TIR). As is well known, the A1C test provides an indication of average glycemic control over the previous 2–3 months. However, it does not capture glycemic variability; thus, individuals who have the same A1C may have vastly different glucose ranges (2,3). CGM can be a good option for patients with inconsistent or confounding glycemic control, who desire engagement in their own disease management, or whose treatment plan puts them in danger of hypoglycemia.Health care providers (HCPs) can implement two different modalities of CGM. They may prescribe a personal CGM device, which a patient can use either continuously or intermittently, or they may purchase for their practices professional CGM systems that can be sent home with a patient for a brief period of time for diagnostic purposes. The Medtronic iPro2 and the FreeStyle Libre Pro are professional CGM systems for which data are blinded to the patient. The data are uploaded in the HCP’s office for retrospective review with the patient. The Dexcom G6 professional CGM system can be prescribed in blinded and unblinded modes. HCPs may use the unblinded option to help patients increase their awareness of their own glucose levels and make real-time treatment decisions.The data collected by these devices and either downloaded in the clinic or transmitted remotely allow for visualization of a patient’s true glycemic picture and the effects of current interventional treatments. CGM data also give HCPs insight into patients’ behaviors and glycemic patterns and may reveal previously undetected issues such as hypoglycemia (2,3). Retrospective review of CGM data can reveal therapeutic impacts on glucose management, aid in making treatment decisions, and provide opportunities for education.Professional CGM systems have been used clinically to measure the effects of variables over an intermittent or specific time interval, such as 3 days or 2 weeks. More specifically, such CGM has been used to evaluate the effects of various interventions, behaviors, and therapies, including the effects of foods or various types of exercise and medication titration (4–7).The abundance of data gathered via CGM can be reviewed and interpreted through the ambulatory glucose profile (AGP) report, a standardized CGM report that provides a graphical and quantitative display of glycemic activity. The AGP visually displays the dynamics of glycemic activity, including periods of hypoglycemia, glycemic excursions (both high and low), TIR, and recurring glucose patterns, all of which are meaningful metrics for guiding comprehensive diabetes management.From the patient perspective, CGM offers the benefit of real-time glycemic monitoring with glucose trend information indicated by directional arrows. These trend arrows are a visual display of the direction of glycemic activity (i.e., whether the current glucose level is rising, stable, or decreasing) (8). The visual display of CGM data allows patients to view their glycemic activity and monitor the effects of different types of food, timing of meals, activity levels, stress, and illness. This opportunity facilitates increased patient engagement with diabetes management. Having glucose data readily available is also relevant for loved ones and caregivers of people with diabetes, allowing them to better assist in care and offering them peace of mind with regard to hypoglycemia and hyperglycemia.Integrating CGM into clinical practice can be challenging for several reasons. Common issues reported include data overload, increased clinic staff time, and the need for HCP education on data interpretation (9,10). Orienting practice staff to the use of CGM technology and downloading reports to a standalone computer and printer that are separate from restrictive administrative firewalls can streamline analysis of CGM data.Although there can be some barriers to CGM use, there is also strong evidence for its utility in patients with either type 1 or type 2 diabetes and with either personal or professional CGM systems (11). Patient benefits include improvement in A1C, reductions in hypoglycemia and glycemic variability, and greater treatment satisfaction and improved sense of mental well-being (12–15).One solution to overcoming barriers is intermittent use, of personal or professional CGM, from every other week to perhaps every 6 months, followed by office review of the AGP report (16). This option permits an overview of the glycemic picture at important intervals, such as during lifestyle intervention or after medication changes. In addition, reviewing the AGP report with a patient offers an HCP the opportunity for patient education and a means of encouraging communication and shared decision-making.This article is intended to equip HCPs to effectively incorporate CGM into clinical practice by reviewing the overwhelming benefits of this technology and the strategies available to overcome therapeutic inertia with regard to its use. Practical tips and tools for streamlining the use of CGM are provided to maximize patients’ office visits through concise, proficient interpretation of CGM data. Topics include how to efficiently review and share the information displayed on the AGP report, how to interpret and act on that information, and how to bill for CGM use and data interpretation services.     

Chronic Critical Illness: Are We Just Adding Years to Life?

How to cite this article: Ramakrishnan N. Chronic Critical Illness: Are We Just Adding Years to Life? Indian J Crit Care Med 2020;25(5):482–483.

Chronic critical illness (CCI) patients require prolonged specialized care for months or years and remain a challenge for intensive care professionals and healthcare.¹ It is common in the elderly although the incidence is noted to decline in the very elderly due to an increase in early mortality in that age-group.² Modern life-sustaining technologies allow us to keep patients alive despite ongoing life-threatening illnesses. However, this comes with a price including cognitive and functional restrictions, the burden of decision-making for caregivers, and the impact on the healthcare system at large.³The Pareto principle, also known as the 80–20 rule is relevant in healthcare in many ways. A rather small number of people (20%) utilize the majority (80%) of health-care consultations and hospital admissions.⁴ The majority (80%) of an individual''s healthcare needs and expenses are in the last 20% of their lives. It is also estimated that 80% of the cost of care is spent in the initial 20% of the hospital stay. However, this may not apply to those with CCI as costs may surge during the hospitalization with clinical changes requiring additional interventions and therapies that may be expensive.Intensive care units (ICUs) are traditionally considered to be expensive,⁵ and every attempt is made to transfer patients out to other areas based on the level of care required. The venue of care of CCI may vary based on the facility and the health-care system. In most countries, step-down units, high dependency units, or transitional care units provide a lower cost option to provide monitored multidisciplinary care. In countries such as the United States, where healthcare is predominantly driven by third-party insurance payers, specialized long-term acute care hospitals and skilled nursing facilities provide an alternative venue of care. However, stringent protocols and guidelines on the level of care that they could provide prompt readmission to hospitals when the patient has any significant changes in clinical status. Patients and families continue to exercise their choice in such payment models despite attempts by the treating team to explain the overall prognosis and quality of life measures. Strategies for effective communication should be implemented for shared decision-making in this scenario.⁶ If survival remains the only goal of therapy, we continue to “cheat” life at any cost.⁷ In predominantly socialized health-care systems such as the National Health Service in the United Kingdom, European countries, Canada, and Australia, the cost of continued care is borne by the government and indirectly by the tax payers. Measures are adopted to provide this long-term care in dedicated wards as ICU beds are limited and in high demand. While efforts are made to cover medically necessary services, some of these countries limit coverage for services such as home health or medications.⁷ In countries such as India, where payment for healthcare is largely “out of pocket,” decisions by the family are not uncommonly driven by the ability to pay for continued care. This is changing over the years with initiatives on healthcare coverage provided by government and private payers but still largely inadequate to cover prolonged illnesses. ICU at home is evolving as a more cost-efficient option in this scenario although adding significant physical, mental, and financial burden to the families. In this study, “talk turkey” about their observations in a retrospective cohort from an academic center, the authors observed that patients with hemodynamic instability requiring vasopressors and those with neurological comorbidities were at greatest risk of CCI. Not surprisingly significant number of patients with CCI were tracheostomized. The cost for a patient with CCI was six-fold while mortality was also significantly higher. The authors do not clearly specify if some of the extended care could have been provided in alternative venues in their facility to reduce the ICU length of stay.CCI leads to sleepless nights for the patient and the family. It is indeed appropriate to apply a concept similar to Spielman''s 3P model of chronic insomnia⁸ while managing patients with CCI by evaluating the following aspects:

• Predisposing factors that include the comorbidities (particularly neurological) that lead to hospitalizations but not necessarily always requiring critical care.
• Precipitating factors such as noncompliance or infections leading to acute on chronic organ failure necessitating organ supports such as ventilation, hemodynamic support, and renal replacement therapy.
• Perpetuating factors including malnutrition, dyselectrolytemia, pressure ulcers, nosocomial infections, iatrogenic issues, and physical aspects such as delayed mobility.

I would like to propose that we evaluate larger cohorts of CCI to develop and validate a scoring system based on the above factors to assist with additional 3Ps in the management which should include the following aspects:

• Prevention—which begins from efficient chronic disease management and also promptly addressing precipitating and perpetuating factors
• Prognostication—to assist the family with patient-centered decision
• Palliation—when appropriate

By utilizing this model, we will be in a position to create value-based programs to provide more appropriate care for those with a chronic critical illness.Mortality has been the most studied outcome in critical illness, and we experience a moment of triumph about increased survival with advances in technologies and therapies. But are we only adding years to life without being considerate of the quality of life added to those years?⁹ Are we saving patients or creating victims?^10,11 Are we communicating efficiently to assist with the decision-making? And most importantly, whose life and money is it anyway? Time to ponder.