Zubair Mohamed - Academia.edu (original) (raw)

Papers by Zubair Mohamed

Southwest Journal of Pulmonary and Critical Care, Oct 2, 2021

Indian Journal of Anaesthesia, 2005

... Dr. Chandola HC1 Dr. Zubair Umer Mohamed2 Dr. Asok Jayaraj Pullani3 ... CHANDOLA, MOHAMED, PU... more ... Dr. Chandola HC1 Dr. Zubair Umer Mohamed2 Dr. Asok Jayaraj Pullani3 ... CHANDOLA, MOHAMED, PULLANI : COMBINED SPINAL-EPIDURAL ANAESTHESIA ... 6. Mumtaz MH, Daz M, Kuz M. Another single space technique for orthopedic surgery [letter] Anaesthesia 1982; 37 ...

Indian Journal of Critical Care Medicine, 2016

Background and Aims: The practice of intensive care includes withholding and withdrawal of care, ... more Background and Aims: The practice of intensive care includes withholding and withdrawal of care, when appropriate, and the goals of care change around this time to comfort and palliation. We decided to survey the attitudes, training, and skills of intensive care residents in relation to end-of-life (EoL) care. All residents at our institute who has worked for at least a month in an adult Intensive Care Unit were invited to participate. Materials and Methods: After Institutional Ethics Committee approval, a Likert-scale questionnaire, divided into five composite measures of EoL skills including training and attitude, was handed over to individual residents and completed data were anonymized. Frequency and descriptive analysis was performed for the demographic variables. Central tendency, variability, and reliability were examined for the five composite measures. Scale internal consistency was checked by Cronbach's coefficient alpha. Multivariate forward conditional regression analysis was conducted to examine the association of demographic data or EoL experience to composite measures. Results: Of the 170 eligible residents, we received 120 (70.5%) responses. Conclusions: Internal medicine residents have more experience in caring for dying patients and conducting EoL discussions. Even though majority of participants reported that they are comfortable with the concept of EoL care, this does not always reflect the actual practice in the hospital. There is a need for further training in skills around EoL care. As this is a self-assessment survey, the specific measures of attitudes and skills in EoL are poorly reflected, indicating a need for further research.

Trends in Anaesthesia and Critical Care, Feb 1, 2012

Summary Fluid therapy is a key component of resuscitation of critically ill patients. However, in... more Summary Fluid therapy is a key component of resuscitation of critically ill patients. However, inadvertent administration of intravenous fluids can have deleterious effects on the patient outcome. Thus, the ability to identify patients who would respond to fluid administration by increasing stroke volume and hence cardiac output is of vital importance. This article attempts to define ‘fluid challenge' and ‘fluid responsiveness‘ and also looks at the advantages and limitations of currently used strategies. The recent increase of research interest in this field reflects the evidence that early fluid optimisation of critically ill patients improves outcome. This concept has subsequently been extended into the peri-operative setting. A brief summary of the latest research in these fields is given.

Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, May 1, 2005

To compare the efficacy of stimulation of P6 acupoint with capsicum plaster in comparison with iv... more To compare the efficacy of stimulation of P6 acupoint with capsicum plaster in comparison with iv ondansetron for the prevention of postoperative nausea and vomiting (PONV). M Me et th ho od ds s: : 120 patients of either sex, ASA I-II, undergoing elective middle ear surgeries under general anesthesia were included in this randomized, prospective, double-blinded and placebo-controlled study. The anesthetic technique was standardized. Patients were divided into three groups. Group I was the control group. Capsicum plaster (1 × 1cm) was affixed at the P6 acupoint on both forearms 30 min before induction of anesthesia in patients of Group II. Patients of Groups I and III received an inactive adhesive plaster at the same site. Ondansetron 4 mg iv was given to patients of Group III at the end of surgery and the rest of the patients received a placebo. The plasters were removed six hours after transferring the patients to the postoperative unit. Criteria were fixed for the administration of rescue antiemetics (ondansetron 4 mg iv). PONV and the requirement for rescue antiemetics were recorded by a blinded observer.

Journal of Diagnostic Medical Sonography, Apr 23, 2022

Objective: Sonography is widely used by clinicians to provide imaging assistance in guiding invas... more Objective: Sonography is widely used by clinicians to provide imaging assistance in guiding invasive procedures. Many sonography users tend to prefer their dominant hand to operate the needle and their nondominant hand on the ultrasound transducer. The aim was this study was to determine whether the dominant hand guiding the needle achieves a faster time to target during ultrasound-guided procedures compared with the nondominant hand. Materials and Methods: Forty novice sonography users, medical students, were randomized to participate in the study. Twenty medical students used a Sonosite® ultrasound equipment system and the other 20 used a Mindray® ultrasound equipment system. Following a video education training session, an informed consent was obtained from each participant. In each equipment group, participants were randomly allocated to either a right-handed needle and a left-handed transducer preference or a left-handed needle and right-handed transducer preference group. A total of ten participants were in each group. A timer was started when the ultrasound transducer came in contact with the phantom model and stopped when the needle reached the target. This simulated task was repeated ten times by the participants. The hand arrangement for the needle and transducer was then switched and the task repeated another ten times by each participant. Results: Handedness was observed over multiple attempts and “time to target” was recorded for groups with both hand preferences and varied ultrasound equipment systems. The most significant finding was that the difference in time was statistically significant between the groups, when comparing the first and fifth procedural attempts. Conclusion: In this novice group of users, despite training for ultrasound-guided procedures using phantom models, irrespective of the ultrasound equipment system, or hand preference, there was no difference in the time to target.

Amrita journal of medicine, 2020

Historical overview Historically, death was believed to occur at the moment that all vital signs ... more Historical overview Historically, death was believed to occur at the moment that all vital signs ceased permanently. For scientists, death in the past coincided with the permanent arrest of all bodily functions. Since the mind is the expression of brain functions, the cessation of its activity was assumed as part of the physical effects of death. For the philosophers and religions, death signifies the departure of the soul and the mind alongside with the cessation of the bodily functions. Death causes the irreversible loss of those essential characteristics which are necessary to the existence of a living human being. Thus, the definition of death should be considered as the irreversible loss of the capacity of consciousness combined with irreversible loss of the capacity to breathe. Death took a different meaning after the mechanical ventilation was invented and patients with catastrophic brain injury were supported in hospitals. This drastic intervention created a new state. In this comatose state, the brain function came to an end, but the rest of the bodily functions were supported by intensive care interventions.

Journal of Surgical Oncology, Sep 22, 2016

Dear Sir/Madam, We read with great interest the article by Grendar and co-workers on the use of N... more Dear Sir/Madam, We read with great interest the article by Grendar and co-workers on the use of N-acetyl cysteine (NAC) in liver resection [1]. It is interesting to note a 9.8% incidence of delirium in the NAC group. In our institute, we commence NAC infusion soon after induction of anesthesia and continue it for 96 hr in donor hepatecotmies. Our incidence of post-operative delirium in these patients is 0.5% (2/400). We note that the dose of NAC used in the study is the one recommended for paracetamol poisoning [2,3]. However, there is no mention of delirium in this population [2-4]. It could be postulated that delirium due to NAC may get interpreted as hepatic encephalopathy in the setting of paracetamol poisoning and acute liver failure. Another explanation could be that delirium may not be a major side effect of NAC in patients with normal liver function, as in live donors. Our protocol for NAC is 150 mg/kg/24 hr, which is the maintenance dose of NAC [2]. In a recent telephonic survey conducted from our institute, we found that around 50% of the institutes in India that perform living donor liver transplantation routinely administer NAC to the donor. Given the potential harm of higher doses of NAC in liver resections [1] and the questionable benefit of any dose after major hepatic surgery [5], it is probably time for a multicentre trial to look into the role, if any, for NAC in donor hepatectomies.

Infection Control & Hospital Epidemiology

Objective: Studies evaluating the incidence, source, and preventability of hospital-onset bactere... more Objective: Studies evaluating the incidence, source, and preventability of hospital-onset bacteremia and fungemia (HOB), defined as any positive blood culture obtained after 3 calendar days of hospital admission, are lacking in low- and middle-income countries (LMICs). Design, setting, and participants: All consecutive blood cultures performed for 6 months during 2020–2021 in 2 hospitals in India were reviewed to assess HOB and National Healthcare Safety Network (NHSN) reportable central-line–associated bloodstream infection (CLABSI) events. Medical records of a convenience sample of 300 consecutive HOB events were retrospectively reviewed to determine source and preventability. Univariate and multivariable logistic regression analyses were performed to identify factors associated with HOB preventability. Results: Among 6,733 blood cultures obtained from 3,558 hospitalized patients, there were 409 and 59 unique HOB and NHSN-reportable CLABSI events, respectively. CLABSIs accounted f...

Open Forum Infectious Diseases

Background The National Healthcare Safety Network (NHSN) central line-associated bloodstream infe... more Background The National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) is a widely accepted quality measure. However, studies from the United States indicate that NHSN reportable CLABSIs account for less than 20% of all hospital-onset bacteremia and fungemia (HOB, i.e., any positive blood culture obtained at least 3 calendar days after hospital admission) events and about 66% of all HOB events are potentially preventable. The incidence and overall preventability of HOB is unknown in low and middle-income countries (LMICs). This study evaluated the epidemiology and preventability of HOB in two hospitals in India. Methods Six months data on all consecutive blood cultures processed in two hospitals (Hospital A- 8.16.2020 to 2.15.2021; Hospital B- 1.1.2021 to 6.30.2021) were collected prospectively to calculate HOB and CLABSI incidence. Correlation between HOB and CLABSI rates was assessed using Spearman’s rank correlation. Medical records of 300...

Medicine

Management of candidemia in developing countries like India encounters laxity in appropriate clin... more Management of candidemia in developing countries like India encounters laxity in appropriate clinical management and challenges in terms of healthcare capacity, despite its association with high morbidity and mortality. Our study aims to evaluate the impact of a comprehensive candidemia care bundle implementation on appropriateness of therapy and major clinical outcomes. The single-center, quasi-experimental study conducted at a south Indian tertiary care center included adult patients diagnosed with candidemia. Following a retrospective review of candidemia patients of the pre-implementation period (January 2013–December 2015), the hospital antifungal stewardship team instituted a clinical pharmacist driven comprehensive candidemia care bundle for candidemia patients during the post-implementation period (October 2017–2019) and its impact on appropriateness of antifungal prescriptions and inpatient mortality was evaluated. The study included 175 patients with candidemia, comprising...

Journal of Pharmacy Practice, 2022

Background: Patients undergoing solid organ transplantation are at a higher risk of multi-drug re... more Background: Patients undergoing solid organ transplantation are at a higher risk of multi-drug resistant (MDR) bacterial infections especially during the immediate post operative period. Objective: To audit the usage, dosage appropriateness and safety of colistin use in abdominal solid organ transplant recipients to treat immediate post-transplant bacterial infections. Methods: After completion of 1000 abdominal solid organ transplants at our institute, data of the transplant recipients who received colistin between October 2010 and December 2019 was extracted from the hospital health information system. Data of all microbiological culture isolates, the minimum inhibitory concentration (MIC) of colistin, appropriateness of colistin dosing and nephrotoxicity associated with colistin use was assessed. Results: Of the 1170 (732 liver and 438 renal) solid organ transplant recipients, 82 (66 liver and 16 renal) received colistin to treat posttransplant MDR bacterial infections. Nearly 60...

Open Forum Infectious Diseases, 2017

Background. Antimicrobial Stewardship is a coordinated effort to improve and measure the appropri... more Background. Antimicrobial Stewardship is a coordinated effort to improve and measure the appropriate use of antimicrobials. Antibiotic resistance is an emerging world health problem and unnecessary prescribing of broad-spectrum antibiotics is a major contributor to this. Skin and soft-tissue infections are a common reason to receive a prescription for antibiotics. Currently there exists a trend for using broad-spectrum intravenous antibiotics for moderate to severe infections when more narrow-spectrum options would be adequate. This study aimed to characterize the choice of antibiotic being prescribed for the management of outpatient cellulitis requiring intravenous antibiotics and evaluate the success of a clinical order set outlining optimal therapy. Methods. This study was a retrospective chart review looking at antibiotic prescribing through the Emergency Department at The Moncton Hospital, in Moncton, New Brunswick. Charts were reviewed before and after the introduction of a clinical order set outlining optimal antibiotic therapy. The goal was to review charts from the pre-and post-intervention group and compare antibiotic usage, treatment failure rates, and adverse events. Results. Of the 54 patients receiving IV antibiotics in the pre-intervention group, 3 received cefazolin, 50 received ceftriaxone, while 1 received levofloxacin. The median duration of IV therapy was four days. After the introduction of the clinical order set there was an absolute increase of 53.8% (n = 35) in the use of cefazolin and absolute decrease of 53.7% (n = 23) in the use of ceftriaxone in the post-intervention group of 59 patients. Both results were statistically significant (P < 0.001). The median duration of IV therapy in this group was 3.5 days. In eligible patients, the clinical order set was utilized 61.1% of the time. There was no significant difference in rates of treatment failure or adverse events between cefazolin and ceftriaxone. Conclusion. The introduction of a clinical order set outlining the preferential use of once-daily cefazolin plus probenecid for the treatment of outpatient cellulitis lead to a statistically significant increase use of cefazolin, and decrease use of ceftriaxone, thus demonstrating a positive stewardship effect at a local level. Disclosures. All authors: No reported disclosures.

Antibiotics, 2021

Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens... more Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens necessitates the implementation of antimicrobial stewardship program (ASP) initiatives to support its rational prescription across healthcare settings. Our study aims to describe the change in the epidemiology of polymyxins and patient outcomes following the implementation of ASP at our institution. The antimicrobial stewardship program initiated in February 2016 at our 1300 bed tertiary care center involved post-prescriptive audits tracking polymyxin consumption and evaluating prescription appropriateness in terms of the right indication, right frequency, right drug, right duration of therapy and administration of the right loading dose (LD) and maintenance dose (MD). Among the 2442 polymyxin prescriptions tracked over the entire study period ranging from February 2016 to January 2020, the number of prescriptions dropped from 772 prescriptions in the pre-implementation period to an ave...

Indian Journal of Critical Care Medicine, 2020

Background: Sepsis remains a leading cause of death worldwide despite advances in management stra... more Background: Sepsis remains a leading cause of death worldwide despite advances in management strategies. Preclinical and observational studies have found mortality benefit with high-dose vitamin C in sepsis. Our study aims to prospectively evaluate the effect of intravenous hydrocortisone, vitamin C [ascorbic acid (AA)], and thiamine (HAT) administration in reducing inpatient all-cause mortality among patients with septic shock. Materials and methods: Our single-center, prospective, open-label, randomized controlled trial recruited patients with admitting diagnosis of septic shock and assigned eligible patients (1:1) into either intervention (HAT) or control group (routine). The HAT group received intravenous combination of vitamin C (1.5 g every 6 hours), thiamine (200 mg every 12 hours), and hydrocortisone (50 mg every 6 hours) within 6 hours of onset of septic shock admission. The treatment was continued for at least 4 days, in addition to the routine standard of care provided to the control group. Thiamine and hydrocortisone use in control arm was not restricted. Vitamin C levels were estimated at baseline and at the end of the 4 days of treatment for both groups. The primary outcome evaluated was mortality during inpatient stay. Results: Among 90 patients enrolled, 88 patients completed the study protocol. The baseline characteristics between the HAT (n = 45) and the routine (n = 43) groups were comparable. The all-cause mortality in the HAT cohort was 57% (26/45) compared to 53% (23/43) in the routine care group (p = 0.4, OR 1.19, 95% CI 0.51-2.76). The time to reversal of septic shock was significantly lower in the HAT (34.58 ± 22.63 hours) in comparison to the routine care (45.42 ± 24.4 hours) (p = 0.03, mean difference −10.84, 95% CI −20.8 to −0.87). No significant difference was observed between the HAT and the routine care with respect to changes in sequential organ failure assessment (SOFA) scores at 72 hours (2.23 ± 2.4 vs 1.38 ± 3.1), the use of mechanical ventilation (48% vs 46%), and mean Vasoactive Inotropic Score (7.77 ± 12.12 vs 8.86 ± 12.5). Conclusion: Intravenous administration of vitamin C, thiamine, and hydrocortisone did not significantly improve the inpatient all-cause mortality among patients with septic shock. Clinical significance: HAT protocol does not reduce hospital mortality but decreases time to shock reversal in septic shock.

Gastroenterology, 2020

Deterioration of patients in hospitals is typically preceded by changes in vital signs. Early war... more Deterioration of patients in hospitals is typically preceded by changes in vital signs. Early warning scores (EWS) are currently used to assess risk, but depend on manual input of data by skilled nurses. A continuous vitals monitoring solution was proposed which can enable the automated recording of 6 key vitals-Heart rate, Blood Oxygen Saturation, Respiratory Rate, 3-lead Electrocardiogram, Non-invasive Blood Pressure and skin temperature. This also provided trends of data captured every 5 minutes and used Modified Early Warning Scores (MEWS) to aid clinical decisions. Clinical efficacy of this system was assessed for vulnerable patients in a non-ICU setting. Methods: An observational study was conducted in a tertiary care hospital (December '18-February '19) which included vulnerable patients admitted to digestive diseases service. Vulnerable patients were defined as: 1) Gastrointestinal bleed patients with normal vitals at admission and 2) Post-operative/post intervention patients including transplant recipients who require monitoring as assessed by the intensivist. Patients were monitored for a minimum of 8 hours in a designated continuous-monitoring ward. The continuous monitoring system (the STASIS Monitoring Solution) provided live wave forms and recorded trends of patient vitals. This was wirelessly transmitted to a central tablet kept with the nurse and was made available on the doctor's mobile app via a cloud service. There were no changes applied to the existing nurse to patient ratio for the study. Decision to shift to the ICU was based on MEWS which was automatically generated from the continuous monitoring solution. The preceding time cohort (September 2018-November 2018) was used as controls to compare the number of 'Code Blue' calls, average length of stay (ALOS), and ICU readmission rates. Results: Thirty eight vulnerable patients were included in the study (Mean age-61±14 years, M: F=6.6:1) and monitored for a total of 2248 hours. Five patients (13%) were found to have abnormal MEWS prompting a shift to the ICU. The number of admissions (10076 vs 9460 patients) and mean Charlson's comorbidity index (2.43 vs 2.17) of patients during the study period were higher as compared to controls. Despite this, there was a 67% reduction in the number of Code blue calls during the study period (3 calls vs 9 calls). [See Table 1] The ALOS and ICU readmission rate during the study period was 44.8% and 44.4% lower as compared to controls. Conclusions: Automated continuous monitoring of vulnerable patients in the non-ICU settings using this system is feasible and clinically beneficial for escalation of care. This can result in efficient utilization of hospital resources and reduce cost of treatment. Larger, controlled trials are required to quantify the clinical and fiscal benefits of universal implementation of such technologies.

Anesthesia: Essays and Researches, 2019

Background: Synthetic colloids, both starches and gelatins, are commonly used as intravascular fl... more Background: Synthetic colloids, both starches and gelatins, are commonly used as intravascular fluid replacements on account of increased vascular persistence. The safety on renal outcomes during perioperative use is poorly understood. Aims: We evaluated renal outcomes of hydroxyethyl starch 6% (HES) and gelatins 4% (G) in patients undergoing elective abdominal surgery. The primary outcome was serum creatinine measurements at baseline, 12 h, 36 h, and 1 week postoperatively (T0, T12, T36, and D7). The secondary outcomes were measurements of prothrombin time (PT), international normalized ratio (INR), fibrinogen, and activated partial thromboplastin time (aPTT) at baseline, 12 h, and 36 h postoperatively. Setting and Design: A prospective randomized study was conducted at a tertiary care institute. Materials and Methods: Seven-five adult patients received either HES (Group H) or gelatin (Group G) at 20-ml/kg body weight or only crystalloids (Group C) during surgery. Statistical tests used were one-way ANOVA, Student's t-test, Pearson correlation method, and Chi-square test. Results: Serum creatinine assessed at T0, T12, T36, and D7 was comparable between the three groups. PT/INR and aPTT showed no significant increase in values of T12 and T36 in comparison to T0. Fibrinogen level was significantly higher in Group C at T12 and T36. Intraoperative vasopressor use, need for product transfusion, length of intensive care unit stay, and return of bowel function were similar between the three groups. Conclusions: Intraoperative use of HES (130/0.4) or gelatin (4%) at 20-ml/kg body weight was not associated with renal dysfunction or altered PT and aPTT in adult patients undergoing elective abdominal major surgeries.

Open Forum Infectious Diseases, 2018

Background. Antimicrobial resistance is a major public health threat internationally but, particu... more Background. Antimicrobial resistance is a major public health threat internationally but, particularly in India. A primary contributing factor to this rise in resistance includes unregulated access to antimicrobials. Implementing antimicrobial stewardship programs (ASPs) in the acute hospital setting will help curb inappropriate antibiotic use in India. Currently, ASPs are rare in India but are gaining momentum. This study describes ASP implementation in a large, academic, private, tertiary care center in India. Methods. An ASP was established in February 2016 consisting of an administrative champion, hospitalist, microbiologist, intensivist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The ASP tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with ASP recommendations. Defined daily dose (DDD) of drugs and cost of antimicrobials were compared between the pre-implementation phase (February 2015-January 2016) and post-implementation phase (February 2016-January 2017). Results. Of 48 555 patients admitted during the post-implementation phase, 1020 received 1326 prescriptions for restricted antibiotics. Antibiotic therapy was appropriate in 56% (742) of the total patient prescriptions. A total of 2776 instances of "inappropriate" antimicrobial prescriptions were intervened upon by the ASP. Duration (806, 29%) was the most common reason for inappropriate therapy. Compliance with ASP recommendations was 54% (318). For all major restricted drugs, the DDD/1000 patient days declined, and there was a significant reduction in mean monthly cost by 14.4% in the post-implementation phase. Conclusions. Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, Indian hospital demonstrated feasibility and economic benefits.

Open Forum Infectious Diseases, 2017

effective standard formulary agents when treating immunocompromised HCT patients at high-risk for... more effective standard formulary agents when treating immunocompromised HCT patients at high-risk for infection. The impact of penicillin allergy de-labeling on Clostridium difficile infection and antibiotic resistance merits evaluation in future studies.

Indian Journal of Transplantation, 2017

Aim: Over the last decade, the number of liver transplantations and centers that provide this ser... more Aim: Over the last decade, the number of liver transplantations and centers that provide this service in India have grown exponentially. However, not all practices relevant to liver transplantation are uniform across the country. We decided to get the opinion from living donor liver transplant (LDLT) centers across the country on four specific aspects relating to LDLT. Methods: We formulated four specific questions that were carefully worded to incorporate aspects of “routine practice” and also answerable in the negative or affirmative, so as to make comparison possible. We collected the data of LDLT centers in India from popular resources such as MOHAN Foundation, from our institutional memory, and also by inquiring with respondents. The following questions were asked: (1) Do you routinely use N-acetyl cysteine for LDLT donors? (2) Do you use routinely use prostaglandin E1 (alprostadil) to facilitate hepatic artery flow in recipients? (3) Do you routinely use antiplatelets to preve...

Southwest Journal of Pulmonary and Critical Care, Oct 2, 2021

Indian Journal of Anaesthesia, 2005

... Dr. Chandola HC1 Dr. Zubair Umer Mohamed2 Dr. Asok Jayaraj Pullani3 ... CHANDOLA, MOHAMED, PU... more ... Dr. Chandola HC1 Dr. Zubair Umer Mohamed2 Dr. Asok Jayaraj Pullani3 ... CHANDOLA, MOHAMED, PULLANI : COMBINED SPINAL-EPIDURAL ANAESTHESIA ... 6. Mumtaz MH, Daz M, Kuz M. Another single space technique for orthopedic surgery [letter] Anaesthesia 1982; 37 ...

Indian Journal of Critical Care Medicine, 2016

Background and Aims: The practice of intensive care includes withholding and withdrawal of care, ... more Background and Aims: The practice of intensive care includes withholding and withdrawal of care, when appropriate, and the goals of care change around this time to comfort and palliation. We decided to survey the attitudes, training, and skills of intensive care residents in relation to end-of-life (EoL) care. All residents at our institute who has worked for at least a month in an adult Intensive Care Unit were invited to participate. Materials and Methods: After Institutional Ethics Committee approval, a Likert-scale questionnaire, divided into five composite measures of EoL skills including training and attitude, was handed over to individual residents and completed data were anonymized. Frequency and descriptive analysis was performed for the demographic variables. Central tendency, variability, and reliability were examined for the five composite measures. Scale internal consistency was checked by Cronbach's coefficient alpha. Multivariate forward conditional regression analysis was conducted to examine the association of demographic data or EoL experience to composite measures. Results: Of the 170 eligible residents, we received 120 (70.5%) responses. Conclusions: Internal medicine residents have more experience in caring for dying patients and conducting EoL discussions. Even though majority of participants reported that they are comfortable with the concept of EoL care, this does not always reflect the actual practice in the hospital. There is a need for further training in skills around EoL care. As this is a self-assessment survey, the specific measures of attitudes and skills in EoL are poorly reflected, indicating a need for further research.

Trends in Anaesthesia and Critical Care, Feb 1, 2012

Summary Fluid therapy is a key component of resuscitation of critically ill patients. However, in... more Summary Fluid therapy is a key component of resuscitation of critically ill patients. However, inadvertent administration of intravenous fluids can have deleterious effects on the patient outcome. Thus, the ability to identify patients who would respond to fluid administration by increasing stroke volume and hence cardiac output is of vital importance. This article attempts to define ‘fluid challenge' and ‘fluid responsiveness‘ and also looks at the advantages and limitations of currently used strategies. The recent increase of research interest in this field reflects the evidence that early fluid optimisation of critically ill patients improves outcome. This concept has subsequently been extended into the peri-operative setting. A brief summary of the latest research in these fields is given.

Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, May 1, 2005

To compare the efficacy of stimulation of P6 acupoint with capsicum plaster in comparison with iv... more To compare the efficacy of stimulation of P6 acupoint with capsicum plaster in comparison with iv ondansetron for the prevention of postoperative nausea and vomiting (PONV). M Me et th ho od ds s: : 120 patients of either sex, ASA I-II, undergoing elective middle ear surgeries under general anesthesia were included in this randomized, prospective, double-blinded and placebo-controlled study. The anesthetic technique was standardized. Patients were divided into three groups. Group I was the control group. Capsicum plaster (1 × 1cm) was affixed at the P6 acupoint on both forearms 30 min before induction of anesthesia in patients of Group II. Patients of Groups I and III received an inactive adhesive plaster at the same site. Ondansetron 4 mg iv was given to patients of Group III at the end of surgery and the rest of the patients received a placebo. The plasters were removed six hours after transferring the patients to the postoperative unit. Criteria were fixed for the administration of rescue antiemetics (ondansetron 4 mg iv). PONV and the requirement for rescue antiemetics were recorded by a blinded observer.

Journal of Diagnostic Medical Sonography, Apr 23, 2022

Objective: Sonography is widely used by clinicians to provide imaging assistance in guiding invas... more Objective: Sonography is widely used by clinicians to provide imaging assistance in guiding invasive procedures. Many sonography users tend to prefer their dominant hand to operate the needle and their nondominant hand on the ultrasound transducer. The aim was this study was to determine whether the dominant hand guiding the needle achieves a faster time to target during ultrasound-guided procedures compared with the nondominant hand. Materials and Methods: Forty novice sonography users, medical students, were randomized to participate in the study. Twenty medical students used a Sonosite® ultrasound equipment system and the other 20 used a Mindray® ultrasound equipment system. Following a video education training session, an informed consent was obtained from each participant. In each equipment group, participants were randomly allocated to either a right-handed needle and a left-handed transducer preference or a left-handed needle and right-handed transducer preference group. A total of ten participants were in each group. A timer was started when the ultrasound transducer came in contact with the phantom model and stopped when the needle reached the target. This simulated task was repeated ten times by the participants. The hand arrangement for the needle and transducer was then switched and the task repeated another ten times by each participant. Results: Handedness was observed over multiple attempts and “time to target” was recorded for groups with both hand preferences and varied ultrasound equipment systems. The most significant finding was that the difference in time was statistically significant between the groups, when comparing the first and fifth procedural attempts. Conclusion: In this novice group of users, despite training for ultrasound-guided procedures using phantom models, irrespective of the ultrasound equipment system, or hand preference, there was no difference in the time to target.

Amrita journal of medicine, 2020

Historical overview Historically, death was believed to occur at the moment that all vital signs ... more Historical overview Historically, death was believed to occur at the moment that all vital signs ceased permanently. For scientists, death in the past coincided with the permanent arrest of all bodily functions. Since the mind is the expression of brain functions, the cessation of its activity was assumed as part of the physical effects of death. For the philosophers and religions, death signifies the departure of the soul and the mind alongside with the cessation of the bodily functions. Death causes the irreversible loss of those essential characteristics which are necessary to the existence of a living human being. Thus, the definition of death should be considered as the irreversible loss of the capacity of consciousness combined with irreversible loss of the capacity to breathe. Death took a different meaning after the mechanical ventilation was invented and patients with catastrophic brain injury were supported in hospitals. This drastic intervention created a new state. In this comatose state, the brain function came to an end, but the rest of the bodily functions were supported by intensive care interventions.

Journal of Surgical Oncology, Sep 22, 2016

Dear Sir/Madam, We read with great interest the article by Grendar and co-workers on the use of N... more Dear Sir/Madam, We read with great interest the article by Grendar and co-workers on the use of N-acetyl cysteine (NAC) in liver resection [1]. It is interesting to note a 9.8% incidence of delirium in the NAC group. In our institute, we commence NAC infusion soon after induction of anesthesia and continue it for 96 hr in donor hepatecotmies. Our incidence of post-operative delirium in these patients is 0.5% (2/400). We note that the dose of NAC used in the study is the one recommended for paracetamol poisoning [2,3]. However, there is no mention of delirium in this population [2-4]. It could be postulated that delirium due to NAC may get interpreted as hepatic encephalopathy in the setting of paracetamol poisoning and acute liver failure. Another explanation could be that delirium may not be a major side effect of NAC in patients with normal liver function, as in live donors. Our protocol for NAC is 150 mg/kg/24 hr, which is the maintenance dose of NAC [2]. In a recent telephonic survey conducted from our institute, we found that around 50% of the institutes in India that perform living donor liver transplantation routinely administer NAC to the donor. Given the potential harm of higher doses of NAC in liver resections [1] and the questionable benefit of any dose after major hepatic surgery [5], it is probably time for a multicentre trial to look into the role, if any, for NAC in donor hepatectomies.

Infection Control & Hospital Epidemiology

Objective: Studies evaluating the incidence, source, and preventability of hospital-onset bactere... more Objective: Studies evaluating the incidence, source, and preventability of hospital-onset bacteremia and fungemia (HOB), defined as any positive blood culture obtained after 3 calendar days of hospital admission, are lacking in low- and middle-income countries (LMICs). Design, setting, and participants: All consecutive blood cultures performed for 6 months during 2020–2021 in 2 hospitals in India were reviewed to assess HOB and National Healthcare Safety Network (NHSN) reportable central-line–associated bloodstream infection (CLABSI) events. Medical records of a convenience sample of 300 consecutive HOB events were retrospectively reviewed to determine source and preventability. Univariate and multivariable logistic regression analyses were performed to identify factors associated with HOB preventability. Results: Among 6,733 blood cultures obtained from 3,558 hospitalized patients, there were 409 and 59 unique HOB and NHSN-reportable CLABSI events, respectively. CLABSIs accounted f...

Open Forum Infectious Diseases

Background The National Healthcare Safety Network (NHSN) central line-associated bloodstream infe... more Background The National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) is a widely accepted quality measure. However, studies from the United States indicate that NHSN reportable CLABSIs account for less than 20% of all hospital-onset bacteremia and fungemia (HOB, i.e., any positive blood culture obtained at least 3 calendar days after hospital admission) events and about 66% of all HOB events are potentially preventable. The incidence and overall preventability of HOB is unknown in low and middle-income countries (LMICs). This study evaluated the epidemiology and preventability of HOB in two hospitals in India. Methods Six months data on all consecutive blood cultures processed in two hospitals (Hospital A- 8.16.2020 to 2.15.2021; Hospital B- 1.1.2021 to 6.30.2021) were collected prospectively to calculate HOB and CLABSI incidence. Correlation between HOB and CLABSI rates was assessed using Spearman’s rank correlation. Medical records of 300...

Medicine

Management of candidemia in developing countries like India encounters laxity in appropriate clin... more Management of candidemia in developing countries like India encounters laxity in appropriate clinical management and challenges in terms of healthcare capacity, despite its association with high morbidity and mortality. Our study aims to evaluate the impact of a comprehensive candidemia care bundle implementation on appropriateness of therapy and major clinical outcomes. The single-center, quasi-experimental study conducted at a south Indian tertiary care center included adult patients diagnosed with candidemia. Following a retrospective review of candidemia patients of the pre-implementation period (January 2013–December 2015), the hospital antifungal stewardship team instituted a clinical pharmacist driven comprehensive candidemia care bundle for candidemia patients during the post-implementation period (October 2017–2019) and its impact on appropriateness of antifungal prescriptions and inpatient mortality was evaluated. The study included 175 patients with candidemia, comprising...

Journal of Pharmacy Practice, 2022

Background: Patients undergoing solid organ transplantation are at a higher risk of multi-drug re... more Background: Patients undergoing solid organ transplantation are at a higher risk of multi-drug resistant (MDR) bacterial infections especially during the immediate post operative period. Objective: To audit the usage, dosage appropriateness and safety of colistin use in abdominal solid organ transplant recipients to treat immediate post-transplant bacterial infections. Methods: After completion of 1000 abdominal solid organ transplants at our institute, data of the transplant recipients who received colistin between October 2010 and December 2019 was extracted from the hospital health information system. Data of all microbiological culture isolates, the minimum inhibitory concentration (MIC) of colistin, appropriateness of colistin dosing and nephrotoxicity associated with colistin use was assessed. Results: Of the 1170 (732 liver and 438 renal) solid organ transplant recipients, 82 (66 liver and 16 renal) received colistin to treat posttransplant MDR bacterial infections. Nearly 60...

Open Forum Infectious Diseases, 2017

Background. Antimicrobial Stewardship is a coordinated effort to improve and measure the appropri... more Background. Antimicrobial Stewardship is a coordinated effort to improve and measure the appropriate use of antimicrobials. Antibiotic resistance is an emerging world health problem and unnecessary prescribing of broad-spectrum antibiotics is a major contributor to this. Skin and soft-tissue infections are a common reason to receive a prescription for antibiotics. Currently there exists a trend for using broad-spectrum intravenous antibiotics for moderate to severe infections when more narrow-spectrum options would be adequate. This study aimed to characterize the choice of antibiotic being prescribed for the management of outpatient cellulitis requiring intravenous antibiotics and evaluate the success of a clinical order set outlining optimal therapy. Methods. This study was a retrospective chart review looking at antibiotic prescribing through the Emergency Department at The Moncton Hospital, in Moncton, New Brunswick. Charts were reviewed before and after the introduction of a clinical order set outlining optimal antibiotic therapy. The goal was to review charts from the pre-and post-intervention group and compare antibiotic usage, treatment failure rates, and adverse events. Results. Of the 54 patients receiving IV antibiotics in the pre-intervention group, 3 received cefazolin, 50 received ceftriaxone, while 1 received levofloxacin. The median duration of IV therapy was four days. After the introduction of the clinical order set there was an absolute increase of 53.8% (n = 35) in the use of cefazolin and absolute decrease of 53.7% (n = 23) in the use of ceftriaxone in the post-intervention group of 59 patients. Both results were statistically significant (P < 0.001). The median duration of IV therapy in this group was 3.5 days. In eligible patients, the clinical order set was utilized 61.1% of the time. There was no significant difference in rates of treatment failure or adverse events between cefazolin and ceftriaxone. Conclusion. The introduction of a clinical order set outlining the preferential use of once-daily cefazolin plus probenecid for the treatment of outpatient cellulitis lead to a statistically significant increase use of cefazolin, and decrease use of ceftriaxone, thus demonstrating a positive stewardship effect at a local level. Disclosures. All authors: No reported disclosures.

Antibiotics, 2021

Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens... more Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens necessitates the implementation of antimicrobial stewardship program (ASP) initiatives to support its rational prescription across healthcare settings. Our study aims to describe the change in the epidemiology of polymyxins and patient outcomes following the implementation of ASP at our institution. The antimicrobial stewardship program initiated in February 2016 at our 1300 bed tertiary care center involved post-prescriptive audits tracking polymyxin consumption and evaluating prescription appropriateness in terms of the right indication, right frequency, right drug, right duration of therapy and administration of the right loading dose (LD) and maintenance dose (MD). Among the 2442 polymyxin prescriptions tracked over the entire study period ranging from February 2016 to January 2020, the number of prescriptions dropped from 772 prescriptions in the pre-implementation period to an ave...

Indian Journal of Critical Care Medicine, 2020

Background: Sepsis remains a leading cause of death worldwide despite advances in management stra... more Background: Sepsis remains a leading cause of death worldwide despite advances in management strategies. Preclinical and observational studies have found mortality benefit with high-dose vitamin C in sepsis. Our study aims to prospectively evaluate the effect of intravenous hydrocortisone, vitamin C [ascorbic acid (AA)], and thiamine (HAT) administration in reducing inpatient all-cause mortality among patients with septic shock. Materials and methods: Our single-center, prospective, open-label, randomized controlled trial recruited patients with admitting diagnosis of septic shock and assigned eligible patients (1:1) into either intervention (HAT) or control group (routine). The HAT group received intravenous combination of vitamin C (1.5 g every 6 hours), thiamine (200 mg every 12 hours), and hydrocortisone (50 mg every 6 hours) within 6 hours of onset of septic shock admission. The treatment was continued for at least 4 days, in addition to the routine standard of care provided to the control group. Thiamine and hydrocortisone use in control arm was not restricted. Vitamin C levels were estimated at baseline and at the end of the 4 days of treatment for both groups. The primary outcome evaluated was mortality during inpatient stay. Results: Among 90 patients enrolled, 88 patients completed the study protocol. The baseline characteristics between the HAT (n = 45) and the routine (n = 43) groups were comparable. The all-cause mortality in the HAT cohort was 57% (26/45) compared to 53% (23/43) in the routine care group (p = 0.4, OR 1.19, 95% CI 0.51-2.76). The time to reversal of septic shock was significantly lower in the HAT (34.58 ± 22.63 hours) in comparison to the routine care (45.42 ± 24.4 hours) (p = 0.03, mean difference −10.84, 95% CI −20.8 to −0.87). No significant difference was observed between the HAT and the routine care with respect to changes in sequential organ failure assessment (SOFA) scores at 72 hours (2.23 ± 2.4 vs 1.38 ± 3.1), the use of mechanical ventilation (48% vs 46%), and mean Vasoactive Inotropic Score (7.77 ± 12.12 vs 8.86 ± 12.5). Conclusion: Intravenous administration of vitamin C, thiamine, and hydrocortisone did not significantly improve the inpatient all-cause mortality among patients with septic shock. Clinical significance: HAT protocol does not reduce hospital mortality but decreases time to shock reversal in septic shock.

Gastroenterology, 2020

Deterioration of patients in hospitals is typically preceded by changes in vital signs. Early war... more Deterioration of patients in hospitals is typically preceded by changes in vital signs. Early warning scores (EWS) are currently used to assess risk, but depend on manual input of data by skilled nurses. A continuous vitals monitoring solution was proposed which can enable the automated recording of 6 key vitals-Heart rate, Blood Oxygen Saturation, Respiratory Rate, 3-lead Electrocardiogram, Non-invasive Blood Pressure and skin temperature. This also provided trends of data captured every 5 minutes and used Modified Early Warning Scores (MEWS) to aid clinical decisions. Clinical efficacy of this system was assessed for vulnerable patients in a non-ICU setting. Methods: An observational study was conducted in a tertiary care hospital (December '18-February '19) which included vulnerable patients admitted to digestive diseases service. Vulnerable patients were defined as: 1) Gastrointestinal bleed patients with normal vitals at admission and 2) Post-operative/post intervention patients including transplant recipients who require monitoring as assessed by the intensivist. Patients were monitored for a minimum of 8 hours in a designated continuous-monitoring ward. The continuous monitoring system (the STASIS Monitoring Solution) provided live wave forms and recorded trends of patient vitals. This was wirelessly transmitted to a central tablet kept with the nurse and was made available on the doctor's mobile app via a cloud service. There were no changes applied to the existing nurse to patient ratio for the study. Decision to shift to the ICU was based on MEWS which was automatically generated from the continuous monitoring solution. The preceding time cohort (September 2018-November 2018) was used as controls to compare the number of 'Code Blue' calls, average length of stay (ALOS), and ICU readmission rates. Results: Thirty eight vulnerable patients were included in the study (Mean age-61±14 years, M: F=6.6:1) and monitored for a total of 2248 hours. Five patients (13%) were found to have abnormal MEWS prompting a shift to the ICU. The number of admissions (10076 vs 9460 patients) and mean Charlson's comorbidity index (2.43 vs 2.17) of patients during the study period were higher as compared to controls. Despite this, there was a 67% reduction in the number of Code blue calls during the study period (3 calls vs 9 calls). [See Table 1] The ALOS and ICU readmission rate during the study period was 44.8% and 44.4% lower as compared to controls. Conclusions: Automated continuous monitoring of vulnerable patients in the non-ICU settings using this system is feasible and clinically beneficial for escalation of care. This can result in efficient utilization of hospital resources and reduce cost of treatment. Larger, controlled trials are required to quantify the clinical and fiscal benefits of universal implementation of such technologies.

Anesthesia: Essays and Researches, 2019

Background: Synthetic colloids, both starches and gelatins, are commonly used as intravascular fl... more Background: Synthetic colloids, both starches and gelatins, are commonly used as intravascular fluid replacements on account of increased vascular persistence. The safety on renal outcomes during perioperative use is poorly understood. Aims: We evaluated renal outcomes of hydroxyethyl starch 6% (HES) and gelatins 4% (G) in patients undergoing elective abdominal surgery. The primary outcome was serum creatinine measurements at baseline, 12 h, 36 h, and 1 week postoperatively (T0, T12, T36, and D7). The secondary outcomes were measurements of prothrombin time (PT), international normalized ratio (INR), fibrinogen, and activated partial thromboplastin time (aPTT) at baseline, 12 h, and 36 h postoperatively. Setting and Design: A prospective randomized study was conducted at a tertiary care institute. Materials and Methods: Seven-five adult patients received either HES (Group H) or gelatin (Group G) at 20-ml/kg body weight or only crystalloids (Group C) during surgery. Statistical tests used were one-way ANOVA, Student's t-test, Pearson correlation method, and Chi-square test. Results: Serum creatinine assessed at T0, T12, T36, and D7 was comparable between the three groups. PT/INR and aPTT showed no significant increase in values of T12 and T36 in comparison to T0. Fibrinogen level was significantly higher in Group C at T12 and T36. Intraoperative vasopressor use, need for product transfusion, length of intensive care unit stay, and return of bowel function were similar between the three groups. Conclusions: Intraoperative use of HES (130/0.4) or gelatin (4%) at 20-ml/kg body weight was not associated with renal dysfunction or altered PT and aPTT in adult patients undergoing elective abdominal major surgeries.

Open Forum Infectious Diseases, 2018

Background. Antimicrobial resistance is a major public health threat internationally but, particu... more Background. Antimicrobial resistance is a major public health threat internationally but, particularly in India. A primary contributing factor to this rise in resistance includes unregulated access to antimicrobials. Implementing antimicrobial stewardship programs (ASPs) in the acute hospital setting will help curb inappropriate antibiotic use in India. Currently, ASPs are rare in India but are gaining momentum. This study describes ASP implementation in a large, academic, private, tertiary care center in India. Methods. An ASP was established in February 2016 consisting of an administrative champion, hospitalist, microbiologist, intensivist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The ASP tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with ASP recommendations. Defined daily dose (DDD) of drugs and cost of antimicrobials were compared between the pre-implementation phase (February 2015-January 2016) and post-implementation phase (February 2016-January 2017). Results. Of 48 555 patients admitted during the post-implementation phase, 1020 received 1326 prescriptions for restricted antibiotics. Antibiotic therapy was appropriate in 56% (742) of the total patient prescriptions. A total of 2776 instances of "inappropriate" antimicrobial prescriptions were intervened upon by the ASP. Duration (806, 29%) was the most common reason for inappropriate therapy. Compliance with ASP recommendations was 54% (318). For all major restricted drugs, the DDD/1000 patient days declined, and there was a significant reduction in mean monthly cost by 14.4% in the post-implementation phase. Conclusions. Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, Indian hospital demonstrated feasibility and economic benefits.

Open Forum Infectious Diseases, 2017

effective standard formulary agents when treating immunocompromised HCT patients at high-risk for... more effective standard formulary agents when treating immunocompromised HCT patients at high-risk for infection. The impact of penicillin allergy de-labeling on Clostridium difficile infection and antibiotic resistance merits evaluation in future studies.

Indian Journal of Transplantation, 2017

Aim: Over the last decade, the number of liver transplantations and centers that provide this ser... more Aim: Over the last decade, the number of liver transplantations and centers that provide this service in India have grown exponentially. However, not all practices relevant to liver transplantation are uniform across the country. We decided to get the opinion from living donor liver transplant (LDLT) centers across the country on four specific aspects relating to LDLT. Methods: We formulated four specific questions that were carefully worded to incorporate aspects of “routine practice” and also answerable in the negative or affirmative, so as to make comparison possible. We collected the data of LDLT centers in India from popular resources such as MOHAN Foundation, from our institutional memory, and also by inquiring with respondents. The following questions were asked: (1) Do you routinely use N-acetyl cysteine for LDLT donors? (2) Do you use routinely use prostaglandin E1 (alprostadil) to facilitate hepatic artery flow in recipients? (3) Do you routinely use antiplatelets to preve...