What are the recommended practices in intensive care medicine in India for managing critically ill patients?

Intensive Care Medicine Practices in India

Indian ICUs should prioritize implementing rapid response teams with explicit activation criteria, protocol-based sedation and analgesia management, and early goal-directed resuscitation for sepsis, while addressing the unique challenges of resource variability and high rates of terminal discharges that characterize critical care delivery in the country. 1, 2

Core System-Level Recommendations

Rapid Response Systems

• Deploy hospital-wide rapid response teams (RRT) or medical emergency teams (MET) with explicit activation criteria to reduce preventable morbidity and mortality from clinical deterioration outside the ICU 1
• Ensure ward staff acquire complete and accurate vital signs when ordered and escalate significant abnormalities urgently to appropriate clinicians 1
• Implement focused education programs for non-ICU bedside clinicians on recognizing early clinical deterioration, though this should be part of a comprehensive system rather than a standalone intervention 1
• Include patient and family concerns in decisions to obtain additional opinions and activate rapid response 1

Quality Improvement Infrastructure

• Establish quality improvement processes as an integral part of rapid response systems 1
• Use interdisciplinary ICU team approaches with provider education, preprinted or computerized protocols, and quality rounds checklists to facilitate guideline implementation 1
• Regularly evaluate transport practices and patient management during intra-hospital transport (IHT) 1

Patient Management Protocols

Pain, Agitation, and Sedation Management

• Perform routine pain assessment in all ICU patients using validated scales (Behavioral Pain Scale [BPS] or Critical-Care Pain Observation Tool [CPOT] for patients unable to self-report) 1
• Treat pain before considering sedative agents as a fundamental principle 1
• Use an assessment-driven, protocol-based, stepwise approach for pain and sedation management 1
• Maintain light sedation rather than deep sedation in mechanically ventilated adults to reduce duration of mechanical ventilation and ICU length of stay 1
• Administer intravenous opioids as first-line therapy for non-neuropathic pain 1
• Use non-opioid analgesics to reduce opioid-related side effects 1

Sepsis Management

• Initiate early goal-directed resuscitation within the first 6 hours after recognition of severe sepsis 3
• Obtain blood cultures prior to antibiotic therapy 3
• Administer broad-spectrum antibiotics within 1 hour of diagnosing septic shock and severe sepsis 3
• Perform imaging studies promptly to confirm potential infection sources 3
• Use either crystalloids or colloid fluid resuscitation, with preference for balanced crystalloids over isotonic saline in septic patients 3, 4
• Target mean arterial pressure ≥65 mmHg with norepinephrine or dopamine as first-line vasopressors 3

Mechanical Ventilation and Weaning

• Implement therapist-driven weaning protocols and spontaneous breathing trials where physician staffing permits 1
• Use low tidal volume and limitation of inspiratory plateau pressure strategies for acute lung injury/ARDS 3
• Apply at least minimal positive end-expiratory pressure in acute lung injury 3
• Elevate head of bed in mechanically ventilated patients unless contraindicated 3
• Consider respiratory muscle training in patients with respiratory muscle weakness and weaning failure 1
• Use non-invasive ventilation as a weaning strategy in selected hypercapnic patients 1

Intra-Hospital Transport Safety

• Conduct risk-benefit analysis before transporting critically ill patients 1
• Stabilize patients adequately before transport, as patient factors rarely contribute to adverse events when proper stabilization occurs 1
• Ensure competent escort teams with appropriate training in airway management, ventilator settings, and monitoring 1
• Calculate sufficient oxygen reserves for entire transport duration plus 30-minute reserve 1
• Use end-tidal CO2 monitoring during transport of mechanically ventilated patients 1
• Complete pre-transport checklist covering equipment, personnel, destination readiness, and patient preparation 1

India-Specific Considerations

Resource and Organizational Challenges

• Recognize that inadequately equipped ICUs, public hospital settings, and self-paying patient status are independent predictors of mortality in Indian ICUs 2
• Address the high proportion (18.1% ICU mortality with additional terminal discharges) of patients who leave against medical advice or are discharged on request, which has significant implications for outcomes 2
• Implement protocols despite resource constraints, as standardized care pathways can improve outcomes even in variable resource settings 5, 2

Case Mix Patterns

• Anticipate that approximately 46% of ICU patients will have ≥1 organ failure 2
• Expect 28% of patients to develop severe sepsis or septic shock during ICU stay 2
• Plan for 37% of patients requiring mechanical ventilation and 22% requiring vasopressors or inotropes 2
• Note that 12% of patients develop ICU-acquired infections, requiring robust infection prevention protocols 2

Antibiotic Stewardship

• Address the concerning finding that 60.7% of patients without infection receive antibiotics in Indian ICUs 2
• Reassess antibiotic therapy with microbiology and clinical data to narrow coverage when appropriate 3
• Limit antibiotic courses to 7-10 days guided by clinical response 3

Additional Critical Care Interventions

Supportive Care Measures

• Institute glycemic control targeting blood glucose <150 mg/dL after initial stabilization 3
• Provide prophylaxis for deep vein thrombosis 3
• Use stress ulcer prophylaxis with H2 blockers or proton pump inhibitors to prevent upper GI bleeding 3
• Avoid routine use of pulmonary artery catheters in ALI/ARDS 3
• Use conservative fluid strategy for established ALI/ARDS patients not in shock 3

Patient-Centered Care

• Address psychological well-being through relaxation interventions, therapeutic touch, and patient education 1
• Ensure treatment sessions address discomfort and anxiety alongside physiological problems 1
• Include patient education in all treatment sessions 1
• Consider massage as an intervention for anxiety management and sleep promotion 1

Common Pitfalls to Avoid

• Do not delay antibiotic administration in septic patients while awaiting cultures or imaging 3
• Avoid deep sedation as routine practice; light sedation improves outcomes 1
• Do not transport critically ill patients without adequate preparation, competent escorts, and sufficient oxygen reserves 1
• Do not ignore family concerns about patient deterioration; include them in escalation decisions 1
• Avoid treating vital sign abnormalities alone without comprehensive pain and sedation assessment 1