Toxicoepidemiology of Acute Poisoning: A Classic Tale of Two Indias

How to cite this article: Singh O, Juneja D, Nasa P. Toxicoepidemiology of Acute Poisoning: A Classic Tale of Two Indias. Indian J Crit Care Med 2024;28(4):315-316.

Cytomegalovirus infection in non-immunocompromised critically ill patients: A management perspective

Critically ill patients are a vulnerable group at high risk of developing secondary infections. High disease severity, prolonged intensive care unit (ICU) stay, sepsis, and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections, including cytomegalovirus (CMV). CMV seroconversion has been reported in up to 33% of ICU patients, but its impact on patient outcomes remains a matter of debate. Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/ acquired immuno deficiency syndrome, the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous. Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement. Hence, a better understanding of the symptomatology, diagnostics, and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions.

Dengue induced acute liver failure: A meta summary of case reports

BACKGROUND

Dengue fever is the most common cause of viral hemorrhagic fever, with more than 400 million cases being reported annually, worldwide. Even though hepatic involvement is common, acute liver failure (ALF) is a rare complication of dengue fever.

AIM

To analyze the demographic profile, symptomology, hospital course and outcomes of patients presenting with ALF secondary to dengue infection by reviewing the published case reports.

METHODS

A systematic search was performed from multiple databases including PubMed, Reference Citation Analysis, Science Direct, and Google Scholar. The search terms used were "dengue" OR "severe dengue" OR "dengue shock syndrome" OR "dengue haemorrhagic syndrome" OR "dengue fever" AND "acute liver failure" OR "hepatic failure" OR "liver injury". The inclusion criteria were: (1) Case reports or case series with individual patient details; (2) Reported acute liver failure secondary to dengue infection; and (3) Published in English language and on adult humans. The data were extracted for patient demographics, clinical symptomatology, clinical interventions, hospital and intensive care unit course, need for organ support and clinical outcomes.

RESULTS

Data from 19 case reports fulfilling the predefined inclusion criteria were included. The median age of patients was 38 years (inter quartile range: Q3-Q1 26.5 years) with a female preponderance (52.6%). The median days from diagnosis of dengue to development of ALF was 4.5 d. The increase in aspartate aminotransferase was higher than that in alanine aminotransferase (median 4625 U/L vs 3100 U/L). All the patients had one or more organ failure, with neurological failure present in 73.7% cases. 42.1% patients required vasopressor support and hepatic encephalopathy was the most reported complication in 13 (68.4%) cases. Most of the patients were managed conservatively and 2 patients were taken up for liver transplantation. Only 1 death was reported (5.3%).

CONCLUSION

Dengue infection may rarely lead to ALF. These patients may frequently require intensive care and organ support. Even though most of these patients may improve with supportive care, liver transplantation may be a therapeutic option in refractory cases.

Artificial intelligence: Applications in critical care gastroenterology

Gastrointestinal (GI) complications frequently necessitate intensive care unit (ICU) admission. Additionally, critically ill patients also develop GI complications requiring further diagnostic and therapeutic interventions. However, these patients form a vulnerable group, who are at risk for developing side effects and complications. Every effort must be made to reduce invasiveness and ensure safety of interventions in ICU patients. Artificial intelligence (AI) is a rapidly evolving technology with several potential applications in healthcare settings. ICUs produce a large amount of data, which may be employed for creation of AI algorithms, and provide a lucrative opportunity for application of AI. However, the current role of AI in these patients remains limited due to lack of large-scale trials comparing the efficacy of AI with the accepted standards of care.

Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury: Current Understanding and Therapeutic Options

How to cite this article: Nasa P, Majeed NA, Juneja D. Paroxysmal Sympathetic Hyperactivity after Traumatic Brain Injury: Current Understanding and Therapeutic Options. Indian J Crit Care Med 2024;28(2):97-99.

Nasogastric tube syndrome: A Meta-summary of case reports

BACKGROUND

Since its description in 1790 by Hunter, the nasogastric tube (NGT) is commonly used in any healthcare setting for alleviating gastrointestinal symptoms or enteral feeding. However, the risks associated with its placement are often underestimated. Upper airway obstruction with a NGT is an uncommon but potentially life-threatening complication. NGT syndrome is characterized by the presence of an NGT, throat pain and vocal cord (VC) paralysis, usually bilateral. It is potentially life-threatening, and early diagnosis is the key to the prevention of fatal upper airway obstruction. However, fewer cases may have been reported than might have occurred, primarily due to the clinicians' unawareness. The lack of specific signs and symptoms and the inability to prove temporal relation with NGT insertion has made diagnosing the syndrome quite challenging.

AIM

To review and collate the data from the published case reports and case series to understand the possible risk factors, early warning signs and symptoms for timely detection to prevent the manifestation of the complete syndrome with life-threatening airway obstruction.

METHODS

We conducted a systematic search for this meta-summary from the database of PubMed, EMBASE, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Google scholar, from all the past studies till August 2023. The search terms included major MESH terms "Nasogastric tube", "Intubation, Gastrointestinal", "Vocal Cord Paralysis", and "Syndrome". All the case reports and case series were evaluated, and the data were extracted for patient demographics, clinical symptomatology, diagnostic and therapeutic interventions, clinical course and outcomes. A datasheet for evaluation was further prepared.

RESULTS

Twenty-seven cases, from five case series and 13 case reports, of NGT syndrome were retrieved from our search. There was male predominance (17, 62.96%), and age at presentation ranged from 28 to 86 years. Ten patients had diabetes mellitus (37.04%), and nine were hypertensive (33.33%). Only three (11.11%) patients were reported to be immunocompromised. The median time for developing symptoms after NGT insertion was 14.5 d (interquartile range 6.25-33.75 d). The most commonly reported reason for NGT insertion was acute stroke (10, 37.01%) and the most commonly reported symptoms were stridor or wheezing 17 (62.96%). In 77.78% of cases, bilateral VC were affected. The only treatment instituted in most patients (77.78%) was removing the NG tube. Most patients (62.96%) required tracheostomy for airway protection. But 8 of the 23 survivors recovered within five weeks and could be decannulated. Three patients were reported to have died.

CONCLUSION

NGT syndrome is an uncommon clinical complication of a very common clinical procedure. However, an under-reporting is possible because of misdiagnosis or lack of awareness among clinicians. Patients in early stages and with mild symptoms may be missed. Further, high variability in the presentation timing after NGT insertion makes diagnosis challenging. Early diagnosis and prompt removal of NGT may suffice in most patients, but a significant proportion of patients presenting with respiratory compromise may require tracheostomy for airway protection.

Transient elastography (FibroScan) in critical care: Applications and limitations

FibroScan^® is a non-invasive device that assesses the ‘hardness’ (or stiffness) of the liver via the technique of transient elastography. Because fibrous tissue is harder than normal liver, the degree of hepatic fibrosis can be inferred from the liver hardness. This technique is increasingly being employed to diagnose liver fibrosis, even in critically ill patients. It is now being used not only for diagnosis and staging of liver cirrhosis, but also for outcome prognostication. However, the presence of several confounding factors, especially in critically ill patients, may make interpretation of these results unreliable. Through this review we aim to describe the indications and pitfalls of employing FibroScan in patients admitted to intensive care units.

Clinical course and outcomes of cancer patients admitted in medical ICU with sepsis

Background and aims

Sepsis is not only a leading cause of intensive care unit (ICU) admission but also one of the variables which affect outcomes of cancer patients. We aimed to assess the clinical characteristics, clinical course, mortality and risk factors associated with 30-day mortality in medical oncology patients admitted in a multi-disciplinary medical ICU.

Methods

We conducted a retrospective analysis of 435 consecutive cancer patients admitted in medical ICU over a 28 months period. Patients were divided into two groups based on the presence of sepsis at the time of ICU admission. Data regarding baseline patient characteristics, clinical and laboratory data, need for organ support and 30-day mortality were collected. Sepsis patients were further classified as 30-day survivors and non-survivors and risk factors for mortality in these patients were determined.

Results

Overall 30-day mortality was 57.8%. It was significantly higher in sepsis group patients (73.9%) as compared to non-sepsis patients (46.6%) (p < 0.001). Most common reason for ICU admission in non-sepsis group was respiratory distress (51.4%) followed by altered sensorium (28.4%). Presence of metastasis [odds ratio, OR: 3.89 (95% confidence interval, CI: 1.536-9.901)], high lactate [OR: 1.374 (95% CI: 1.024-1.843)] and need of invasive mechanical ventilator (IMV) support [OR: 7.634 (95% CI: 2.519-23.256)] or vasopressor support [OR: 3.268 (95% CI: 1.179-9.090)] were directly associated with 30-day mortality.

Conclusion

Critically ill cancer patients admitted with sepsis had high mortality. Presence of metastasis, high lactate and need of IMV or vasopressor support was associated with worse prognosis in cancer patients admitted with sepsis in ICU.

Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) play a pivotal role in the pathophysiology of severe acute pancreatitis (SAP) and contribute to new-onset and persistent organ failure. The optimal management of ACS involves a multi-disciplinary approach, from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure (IAP). A targeted literature search from January 1, 2000, to November 30, 2022, revealed 20 studies and data was analyzed on the type and country of the study, patient demographics, IAP, type and timing of surgical procedure performed, post-operative wound management, and outcomes of patients with ACS. There was no randomized controlled trial published on the topic. Decompressive laparotomy is effective in rapidly reducing IAP (standardized mean difference = 2.68, 95% confidence interval: 1.19-1.47, P < 0.001; 4 studies). The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but, potentially lethal ACS. Disease-specific patient selection and the role of less-invasive decompressive measures, like subcutaneous linea alba fasciotomy or component separation techniques, is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS. This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP. However, there is a lack of high-quality evidence on patient selection, timing, and modality of surgical decompression. Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Intrahospital Transport of Critically Ill Patients: Safety First

How to cite this article: Juneja D, Nasa P. Intrahospital Transport of Critically Ill Patients: Safety First. Indian J Crit Care Med 2023;27(9):613-615.

Sodium-glucose Cotransporter-2 Inhibitors induced euglycemic diabetic ketoacidosis: A meta summary of case reports

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are commonly prescribed to manage patients with diabetes mellitus. These agents may rarely lead to the development of euglycemic diabetic ketoacidosis (EDKA), which may complicate the disease course of these patients.

AIM

To analyze the demographic profile, predisposing factors, symptomology, clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series.

METHODS

We performed a systematic search of PubMed, Science Direct, Google Scholar and Reference Citation Analysis databases using the terms "canagliflozin" OR "empagliflozin" OR "dapagliflozin" OR "SGLT2 inhibitors" OR "Sodium-glucose cotransporter-2" AND "euglycemia" OR "euglycemic diabetic ketoacidosis" OR "metabolic acidosis". The inclusion criteria were: (1) Case reports or case series with individual patient details; and (2) Reported EDKA secondary to SGLT2i. Furthermore, the data were filtered from the literature published in the English language and on adults (> 18 years). We excluded: (1) Conference abstracts; and (2) Case reports or series which did not have individual biochemical data. All the case reports and case series were evaluated. The data extracted included patient demographics, clinical symptomatology, clinical interventions, intensive care unit course, need for organ support and outcomes.

RESULTS

Overall, 108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included. The majority of patients were females (54.4%, n = 92), and the commonly reported symptoms were gastrointestinal (nausea/vomiting 65.1%, abdominal pain 37.3%) and respiratory (breathlessness 30.8%). One hundred and forty-nine (88.2%) patients had underlying type II diabetes, and the most commonly involved SGLT-2 inhibitor reported was empagliflozin (46.8%). A triggering factor was reported in most patients (78.7%), the commonest being acute severe infection (37.9%), which included patients with sepsis, coronavirus disease 2019, other viral illnesses, and acute pancreatitis. 61.5% were reported to require intensive unit care, but only a minority of patients required organ support in the form of invasive mechanical ventilation (13%), vasopressors (6.5%) or renal replacement therapy (5.9%). The overall mortality rate was only 2.4%.

CONCLUSION

Patients on SGLT2i may rarely develop EDKA, especially in the presence of certain predisposing factors, including severe acute infections and following major surgery. The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels, which may make the diagnosis challenging. Outcomes of EDKA are good if recognized early and corrective actions are taken. Hence, physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.

Comparison between presepsin, procalcitonin, and CRP as biomarkers to diagnose sepsis in critically ill patients

Background and Aims

Mortality associated with sepsis continues to remain high. Early diagnosis and aggressive management may improve outcomes. Biomarkers may help in early diagnosis, but the search for an ideal biomarker continues. Presepsin has been introduced as a new biomarker, however, it still needs validation before its use becomes routine. In this study, we aimed to compare the efficacy of various biomarkers in patients with suspected sepsis.

Material and Methods

A retrospective analysis of 100 patients with suspected infection, admitted in the medical intensive care unit (ICU) was conducted. Diagnosis of sepsis was made on the basis of the current surviving sepsis guidelines criteria.

Results

Out of 100 patients, 70 were diagnosed to have sepsis, and overall ICU mortality was 22%. Overall, C-reactive protein (CRP) was positive in 98, procalcitonin in 75, and presepsin in 64 patients. For diagnosis of sepsis the sensitivity, specificity, and AUC, respectively, for CRP was 98.6%, 3.3%, and 0.725. For procalcitonin (>0.5 ng/ml) it was 87.1%, 53.3%, and 0.776, and for procalcitonin (>1 ng/ml) 70%, 70%, and 0.816, respectively. For presepsin sensitivity, specificity, and AUC, respectively, for diagnosis of sepsis was 77.1%, 66.7%, and 0.734. For ICU mortality, sensitivity and specificity for CRP was 95.5% and 1.3%, for procalcitonin (>0.5) 72.7% and 24.4.%, for procalcitonin (>1) 59.1% and 42.3%, and for presepsin 61.5% and 27.3%, respectively.

Conclusion

Inflammatory markers may be raised in a large proportion of ICU patients, even in those without sepsis. Procalcitnonin and presepsin had similar efficacy in diagnosing sepsis. However, none of the three biomarkers studied were accurate in predicting ICU mortality.

Liver injury from direct oral anticoagulants

BACKGROUND

Drug-induced liver injury (DILI) can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs. Direct-acting oral anticoagulants (DOACs) are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions. A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs. However, it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.

AIM

To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.

METHODS

A systematic search was conducted on multiple databases including PubMed, Science Direct, Reference Citation Analysis, and Google Scholar. The search terms included “Acute Liver Failure” OR “Acute-On-Chronic Liver Failure” OR “Acute Chemical and Drug Induced Liver Injury” OR “Chronic Chemical and Drug Induced Liver Injury” AND “Factor Xa Inhibitors” OR “Dabigatran” OR “Rivaroxaban” OR “apixaban” OR “betrixaban” OR “edoxaban” OR “Otamixaban”. The results were filtered for literature published in English and on adult patients. Only case reports and case studies reporting cases of DILI secondary to DOACs were included. Data on demographics, comorbidities, medication history, laboratory investigations, imaging, histology, management, and outcomes were extracted.

RESULTS

A total of 15 studies (13 case reports and 2 case series) were included in the analysis, comprising 27 patients who developed DILI secondary to DOACs. Rivaroxaban was the most commonly implicated DOAC (n = 20, 74.1%). The mean time to onset of DILI was 40.6 d. The most common symptoms were jaundice (n = 15, 55.6%), malaise (n = 9, 33.3%), and vomiting (n = 9, 33.3%). Laboratory investigations showed elevated liver enzymes and bilirubin levels. Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury. Most patients had a favourable outcome, and only 1 patient (3.7%) died due to liver failure.

CONCLUSION

DOACs are increasingly used for various clinical conditions, and DILI secondary to DOACs is a rare but potentially serious complication. Prompt identification and cessation of the offending drug are crucial for the management of DILI. Most patients with DILI secondary to DOACs have a favourable outcome, but a small proportion may progress to liver failure and death. Further research, including post-marketing population-based studies, is needed to better understand the incidence and risk factors for DILI secondary to DOACs.

Upper extremity deep vein thrombosis: An intensivist’s perspective

Upper extremity deep vein thrombosis (UEDVT) is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients. Increasing cancer incidence, prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT. It is also associated with high rates of complications like pulmonary embolism, post-thrombotic syndrome and recurrent thrombosis. Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT; hence, a high suspicion index is required for diagnosis. Doppler ultrasound is commonly employed for diagnosis, but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients. Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies. Anticoagulant therapy alone is sufficient in most patients, and thrombolysis and surgical decompression is seldom indicated. The outcome depends on the cause and underlying comorbidities.

Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients: A comparative observational study

BACKGROUND

As per the latest Surviving Sepsis Campaign guidelines, fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization. Nevertheless, raised lactate levels should be interpreted in the clinical context, as there may be other causes of elevated lactate levels. Thus, it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation, and exploring alternative resuscitation targets should be an essential research priority in sepsis.

AIM

To compare the 28-d mortality in two clinical patterns of septic shock: hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context.

METHODS

This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context (Group 1, n = 95) and patients with hyperlactatemia in a non-hypoperfusion context (Group 2, n = 40). Hypoperfusion context was defined by a central venous saturation less than 70%, central venous-arterial PCO₂ gradient [P(cv-a)CO₂] ≥ 6 mmHg, and capillary refilling time (CRT) ≥ 4 s. The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h, 3 h, and 6 h. All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals. Nominal categorical data were compared using the χ² or Fisher’s exact test. Non-normally distributed continuous variables were compared using the Mann-Whitney U test. Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate, CRT, and metabolic perfusion parameters to predict the 28-d all-cause mortality. A P value of < 0.05 was considered significant.

RESULTS

Patient demographics, comorbidities, baseline laboratory, vital parameters, source of infection, baseline lactate levels, and lactate clearance at 3 h and 6 h, Sequential Organ Failure scores, need for invasive mechanical ventilation, days on mechanical ventilation, and renal replacement therapy-free days within 28 d, duration of intensive care unit stay, and hospital stay were comparable between the two groups. The stratification of patients into hypoperfusion and non-hypoperfusion context did not result in a significantly different 28-d mortality (24% vs 15%, respectively; P = 0.234). However, the patients within the hypoperfusion context with high P(cv-a)CO₂ and CRT (P = 0.022) at baseline had significantly higher mortality than Group 2. The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P > 0.05 at all measured intervals. Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion (18.88 ± 9.04 vs 21.08 ± 8.76; P = 0.011). The mean lactate levels and lactate clearance at 3 h and 6 h, CRT, P(cv-a)CO₂ at 0 h, 3 h, and 6 h were found to be associated with 28-d mortality in patients with septic shock, with lactate levels at 6 h having the best predictive value (area under the curve lactate at 6 h: 0.845).

CONCLUSION

Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality, although patients with hypoperfusion displayed a more severe circulatory dysfunction. Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters. Persistently high P(cv-a)CO₂ (> 6 mmHg) or increased CRT (> 4 s) at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients.

What, why and how to monitor blood glucose in critically ill patients

Critically ill patients are prone to high glycemic variations irrespective of their diabetes status. This mandates frequent blood glucose (BG) monitoring and regulation of insulin therapy. Even though the most commonly employed capillary BG monitoring is convenient and rapid, it is inaccurate and prone to high bias, overestimating BG levels in critically ill patients. The targets for BG levels have also varied in the past few years ranging from tight glucose control to a more liberal approach. Each of these has its own fallacies, while tight control increases risk of hypoglycemia, liberal BG targets make the patients prone to hyperglycemia. Moreover, the recent evidence suggests that BG indices, such as glycemic variability and time in target range, may also affect patient outcomes. In this review, we highlight the nuances associated with BG monitoring, including the various indices required to be monitored, BG targets and recent advances in BG monitoring in critically ill patients.

Approach to thromboelastography-based transfusion in cirrhosis: An alternative perspective on coagulation disorders

Viscoelastic tests, specifically thromboelastography and rotational thromboelastometry, are increasingly being used in the management of postoperative bleeding in surgical intensive care units (ICUs). However, life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs, especially those with underlying liver dysfunction. Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications. Compared to conventional coagulation tests, a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices, which may aid physicians in making a rapid diagnosis and instituting early interventions. These tests may help predict bleeding and rationalize the use of blood products in these patients.

Fungal arthritis: A challenging clinical entity

There has been an increasing incidence of fungal infections in recent years. Rarely joints are also affected by fungal infections. Mainly, these infections develop in prosthetic joints, but sometimes native joints are also involved. Candida infections are mostly reported, but patients may also develop infections secondary to non-Candida fungi, especially Aspergillus. Diagnosis and management of these infections is challenging and may involve multiple surgical interventions and prolonged antifungal therapy. Despite this, these infections are associated with high morbidity and mortality. This review described the clinical features, risk factors, and therapeutic interventions required to manage fungal arthritis.

Role of cerebrospinal fluid lactate in diagnosing meningitis in critically ill patients

BACKGROUND

Meningitis is a life-threatening clinical condition associated with high mortality and morbidity. Early diagnosis and specific treatment may improve outcomes. Lack of specific clinical signs or tests make the diagnosis challenging.

AIM

To assess the efficacy of cerebrospinal fluid (CSF) lactate in diagnosing meningitis in critically ill patients.

METHODS

A prospective, observational cohort study was carried out in a neuro-medical intensive care unit (ICU) over a 22 mo period. Adult patients, with suspected meningitis admitted in ICU, were serially recruited. Patients who refused consent, those with peripheral sensorineural deficit, or with any contraindication to lumber puncture were excluded. CSF cytology, bio-chemistry, lactates, culture and polymerase chain reaction based meningo-encephalitis panel were evaluated. Patients were divided in two groups based on clinical diagnosis of meningitis. The efficacy of CSF lactate in diagnosing meningitis was evaluated and compared with other tests.

RESULTS

Seventy-one patients were included and 23 were diagnosed with meningitis. The mean values of CSF total leucocyte count (TLC), proteins and lactates were significantly higher in meningitis group. There was a significant correlation of CSF lactate levels with CSF cultures and meningo-encephalitis panel. CSF lactate (> 2.72 mmol/L) showed good accuracy in diagnosing meningitis with an area under the curve of 0.81 (95% confidence interval: 0.69-0.93), sensitivity of 82.6%, and specificity 72.9%. These values were comparable to those of CSF TLC and protein. Twelve patients with bacterial meningitis had significantly higher CSF lactate (8.9 ± 4.7 mmol/L) than those with non-bacterial meningitis (4.2 ± 3.8 mmol/L), P = 0.006.

CONCLUSION

CSF lactate may be used to aid in our diagnosis of meningitis in ICU patients. CSF lactate (> 2.72 mmol/L) showed good accuracy, sensitivity, and specificity in diagnosing meningitis and may also help to differentiate between bacterial and non-bacterial meningitis.

Bedside ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure in nontraumatic neuro-critically ill patients

BACKGROUND

Delay in treatment of raised intracranial pressure (ICP) leads to poor clinical outcomes. Optic nerve sheath diameter (ONSD) by ultrasonography (US-ONSD) has shown good accuracy in traumatic brain injury and neurosurgical patients to diagnose raised ICP. However, there is a dearth of data in neuro-medical intensive care unit (ICU) where the spectrum of disease is different.

AIM

To validate the diagnostic accuracy of ONSD in non-traumatic neuro-critically ill patients.

METHODS

We prospectively enrolled 114 patients who had clinically suspected raised ICP due to non-traumatic causes admitted in neuro-medical ICU. US-ONSD was performed according to ALARA principles. A cut-off more than 5.7 mm was taken as significantly raised. Raised ONSD was corelated with raised ICP on radiological imaging. Clinical history, general and systemic examination findings, SOFA and APACHE 2 score and patient outcomes were recorded.

RESULTS

There was significant association between raised ONSD and raised ICP on imaging (P < 0.001). The sensitivity, specificity, positive and negative predictive value at this cut-off was 77.55%, 89.06%, 84.44% and 83.82% respectively. The positive and negative likelihood ratio was 7.09 and 0.25. The area under the receiver operating characteristic curves was 0.844. Using Youden’s index the best cut off value for ONSD was 5.75 mm. Raised ONSD was associated with lower age (P = 0.007), poorer Glasgow Coma Scale (P = 0.009) and greater need for surgical intervention (P = 0.006) whereas no statistically significant association was found between raised ONSD and SOFA score, APACHE II score or ICU mortality. Our limitations were that it was a single centre study and we did not perform serial measurements or ONSD pre- and post-treatment or procedures for raised ICP.

CONCLUSION

ONSD can be used as a screening a test to detect raised ICP in a medical ICU and as a trigger to initiate further management of raised ICP. ONSD can be beneficial in ruling out a diagnosis in a low-prevalence population and rule in a diagnosis in a high-prevalence population.

Current role of high dose vitamin C in sepsis management: A concise review

Sepsis and septic shock are common diagnoses for patients requiring intensive care unit admission and associated with high morbidity and mortality. In addition to aggressive fluid resuscitation and antibiotic therapy, several other drugs have been tried as adjuvant therapies to reduce the inflammatory response and improve outcomes. Vitamin C has been shown to have several biological actions, including anti-inflammatory and immunomodulatory effects, which may prove beneficial in sepsis management. Initial trials showed improved patient outcomes when high dose vitamin C was used in combination with thiamine and hydrocortisone. These results, along with relative safety of high-dose (supra-physiological) vitamin C, encouraged physicians across the globe to add vitamin C as an adjuvant therapy in the management of sepsis. However, subsequent large-scale randomised control trials could not replicate these results, leaving the world divided regarding the role of vitamin C in sepsis management. Here, we discuss the rationale, safety profile, and the current clinical evidence for the use of high-dose vitamin C in the management of sepsis and septic shock.

Scoring systems in critically ill: Which one to use in cancer patients?

BACKGROUND

Scoring systems have not been evaluated in oncology patients. We aimed to assess the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, APACHE IV, Simplified Acute Physiology Score (SAPS) II, SAPS III, Mortality Probability Model (MPM) II₀ and Sequential Organ Failure Assessment (SOFA) score in critically ill oncology patients.

AIM

To compare the efficacy of seven commonly employed scoring systems to predict outcomes of critically ill cancer patients.

METHODS

We conducted a retrospective analysis of 400 consecutive cancer patients admitted in the medical intensive care unit over a two-year period. Primary outcome was hospital mortality and the secondary outcome measure was comparison of various scoring systems in predicting hospital mortality.

RESULTS

In our study, the overall intensive care unit and hospital mortality was 43.5% and 57.8%, respectively. All of the seven tested scores underestimated mortality. The mortality as predicted by MPM II₀ predicted death rate (PDR) was nearest to the actual mortality followed by that predicted by APACHE II, with a standardized mortality rate (SMR) of 1.305 and 1.547, respectively. The best calibration was shown by the APACHE III score (χ² = 4.704, P = 0.788). On the other hand, SOFA score (χ² = 15.966, P = 0.025) had the worst calibration, although the difference was not statistically significant. All of the seven scores had acceptable discrimination with good efficacy however, SAPS III PDR and MPM II₀ PDR (AUROC = 0.762), had a better performance as compared to others. The correlation between the different scoring systems was significant (P < 0.001).

CONCLUSION

All the severity scores were tested under-predicted mortality in the present study. As the difference in efficacy and performance was not statistically significant, the choice of scoring system used may depend on the ease of use and local preferences.

Role of high dose vitamin C in management of hospitalised COVID-19 patients: A minireview

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the most dreadful viruses the mankind has witnessed. It has caused world-wide havoc and wrecked human life. In our quest to find therapeutic options to counter this threat, several drugs have been tried, with varying success. Certain agents like corticosteroids, some anti-virals and immunosuppressive drugs have been found useful in improving clinical outcomes. Vitamin C, a water-soluble vitamin with good safety profile, has been tried to reduce progression and im-prove outcomes of patients with coronavirus disease 2019 (COVID-19). Because of its anti-oxidant and immunomodulatory properties, the role of vitamin C has expanded well beyond the management of scurvy and it is increasingly been employed in the treatment of critically ill patients with sepsis, septic shock, acute pancreatitis and even cancer. However, in spite of many case series, observational studies and even randomised control trials, the role of vitamin C remains ambiguous. In this review, we will be discussing the scientific rationale and the current clinical evidence for using high dose vitamin C in the management of COVID-19 patients.

COVID-19 and hemolysis, elevated liver enzymes and thrombocytopenia syndrome in pregnant women - association or causation?

Pregnant women are among the high-risk population for severe coronavirus disease 2019 (COVID-19) with unfavorable peripartum outcomes and increased incidence of preterm births. Hemolysis, the elevation of liver enzymes, and low platelet count (HELLP) syndrome and severe preeclampsia are among the leading causes of maternal mortality. Evidence supports a higher odd of pre-eclampsia in women with COVID-19, given overlapping pathophysiology. Involvement of angiotensin-converting enzyme 2 receptors by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for the entry to the host cells and its downregulation cause dysregulation of the renin-angiotensin-aldosterone system. The overexpression of Angiotensin II mediated via p38 Mitogen-Activated Protein Kinase pathways can cause vasoconstriction and uninhibited platelet aggregation, which may be another common link between COVID-19 and HELLP syndrome. On PubMed search from January 1, 2020, to July 30, 2022, we found 18 studies on of SARS-COV-2 infection with HELLP Syndrome. Most of these studies are case reports or series, did not perform histopathology analysis of the placenta, or measured biomarkers linked to pre-eclampsia/HELLP syndrome. Hence, the relationship between SARS-CoV-2 infection and HELLP syndrome is inconclusive in these studies. We intend to perform a mini-review of the published literature on HELLP syndrome and COVID-19 to test the hypothesis on association vs causation, and gaps in the current evidence and propose an area of future research.

Metformin toxicity: A meta-summary of case reports

BACKGROUND

Metformin is arguably the most commonly prescribed oral hypoglycemic agent for the management of diabetes. Due to the lack of randomized control trials, most of the data pertaining to the clinical course, therapeutic interventions and outcomes of patients with metformin induced toxicity has come from case reports or series.

AIM

To analyse the symptomology, clinical interventions and outcomes of patients presenting with severe metformin toxicity by reviewing the published case reports and series.

METHODS

We performed a systematic search from PubMed, Science Direct, Reference Citation Analysis (https://www.referencecitationanalysis.com/) and Google Scholar databases using the terms “metformin” AND “toxicity” OR “overdose” OR “lactic acidosis” OR “hyperlactatemia”. The inclusion criteria were: (1) Case reports or case series with individual patient details; and (2) Reported toxicity or overdose of metformin in adults, published in the English language. Data regarding baseline demographics, clinical presentation, therapeutic interventions, intensive care unit course and overall outcome were collected.

RESULTS

Two hundred forty-two individual cases were analysed, from 158 case reports and 26 case series, with a cumulative mortality of 19.8%. 214 (88.4%) patients were diabetics on metformin. 57 (23.6%) had acute ingestion, but a great majority (76.4%) were on metformin in therapeutic doses when they developed toxicity. Metformin associated lactic acidosis (MALA) was the most commonly reported adverse effect present in 224 (92.6%) patients. Most of the patients presented with gastrointestinal and neurological symptoms and a significant number of patients had severe metabolic acidosis and hyperlactatemia. The organ support used was renal replacement therapy (RRT) (68.6%), vaso-pressors (58.7%) and invasive mechanical ventilation (52.9%). A majority of patients (68.6%) received RRT for toxin removal, renal dysfunction and correction of MALA. Patients with lowest pH and highest serum lactate and metformin levels also had favourable outcomes with use of RRT.

CONCLUSION

Most of the reported cases were on therapeutic doses of metformin but developed toxicity after an acute deterioration in renal functions. These patients may develop severe lactic acidosis, leading to significant morbidity and need for organ support. Despite severe MALA and the need for multiple organ support, they may have good outcomes, especially when RRT is used. The dose of metformin, serum pH, lactate and metformin levels may indicate the severity of toxicity and the need for aggressive therapeutic measures but may not necessarily indicate poor outcomes.

Air leaks in COVID-19

Coronavirus disease 2019 (COVID-19) continues to create havoc and may present with myriad complications involving many organ systems. However, the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected. There is a high incidence of air leaks in patients with COVID-19, leading to acute worsening of clinical condition. The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and un-derlying lung disease. The exact pathophysiology of air leaks with COVID-19 remains unclear, but multiple factors may play a role in their development. A significant proportion of air leaks may be asymptomatic; hence, a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality. These air leaks may even develop weeks to months after the disease onset, leading to acute deterioration in the post-COVID period. Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.

Ideal scoring system for acute pancreatitis: Quest for the Holy Grail

Clinical scoring systems are required to predict complications, severity, need for intensive care unit admission, and mortality in patients with acute pancreatitis. Over the years, many scores have been developed, tested, and compared for their efficacy and accuracy. An ideal score should be rapid, reliable, and validated in different patient populations and geographical areas and should not lose relevance over time. A combination of scores or serial monitoring of a single score may increase their efficacy.

Capillary leak syndrome: A rare cause of acute respiratory distress syndrome

Capillary leak syndrome (CLS) is a rare clinical syndrome associated with significant morbidity and mortality. Intensive care and supportive therapy constitute the mainstay of the treatment, along with judicious use of crystalloids and colloids such as dextran and starch during the leak phase. The advantages of proning, steroids, and intravenous immunoglobins are worth contemplating in patients with such a presentation. Extracorporeal membrane oxygenation appears to be an excellent strategy to surmount the impediments of the leak and post leak phase of CLS, especially in patients with severe or refractory hypoxemia.

Medication Prescription Errors in Intensive Care Unit: An Avoidable Menace

How to cite this article: Juneja D, Mishra A. Medication Prescription Errors in Intensive Care Unit: An Avoidable Menace. Indian J Crit Care Med 2022;26(5):541–542.

Artificial intelligence in critically ill diabetic patients: current status and future prospects

Recent years have witnessed increasing numbers of artificial intelligence (AI) based applications and devices being tested and approved for medical care. Diabetes is arguably the most common chronic disorder worldwide and AI is now being used for making an early diagnosis, to predict and diagnose early complications, increase adherence to therapy, and even motivate patients to manage diabetes and maintain glycemic control. However, these AI applications have largely been tested in non-critically ill patients and aid in managing chronic problems. Intensive care units (ICUs) have a dynamic environment generating huge data, which AI can extract and organize simultaneously, thus analysing many variables for diagnostic and/or therapeutic purposes in order to predict outcomes of interest. Even non-diabetic ICU patients are at risk of developing hypo or hyperglycemia, complicating their ICU course and affecting outcomes. In addition, to maintain glycemic control frequent blood sampling and insulin dose adjustments are required, increasing nursing workload and chances of error. AI has the potential to improve glycemic control while reducing the nursing workload and errors. Continuous glucose monitoring (CGM) devices, which are Food and Drug Administration (FDA) approved for use in non-critically ill patients, are now being recommended for use in specific ICU populations with increased accuracy. AI based devices including artificial pancreas and CGM regulated insulin infusion system have shown promise as comprehensive glycemic control solutions in critically ill patients. Even though many of these AI applications have shown potential, these devices need to be tested in larger number of ICU patients, have wider availability, show favorable cost-benefit ratio and be amenable for easy integration into the existing healthcare systems, before they become acceptable to ICU physicians for routine use.

Vitamin C-induced Hemolysis: Meta-summary and Review of Literature

Vitamin C is increasingly being used, and even high doses are considered safe. However, complications including hemolysis have been reported. We performed a systematic search from PubMed, Science Direct, and Google Scholar databases from January 1975 till July 31, 2021. Search terms used were "Vitamin C" OR "ascorbic acid" AND "haemolysis" OR "haemolytic anaemia." Data regarding patient's demographics, outcomes and dose, duration, and form of vitamin C were extracted. Fourteen case reports matched the selected criteria, with age ranging from 3 weeks to 75 years with 78.6% being males. About 71.4% were diagnosed to have glucose-6-phosphate dehydrogenase (G6PD) deficiency but previous hemolysis was reported in only two patients, and 57.1% were prescribed vitamin C for nutritional supplementation. The dose ranged from 1 to 200 g/day with 57.1% receiving intravenous formulations. Half of these patients developed other complications including acute kidney injury (AKI), disseminated intravascular coagulation, oxalosis, and methemoglobinemia. About 78.6% developed complications within 3 days of starting vitamin C and only one death was reported. Vitamin C is generally a safe drug but it should be prescribed with caution and only when benefits outweigh the risks. Physicians should be aware of potential complications like severe hemolysis and AKI, especially when using high doses and in G6PD deficiency.

HOW TO CITE THIS ARTICLE

Juneja D, Jain R, Nasa P. Vitamin C-induced Hemolysis: Meta-summary and Review of Literature. Indian J Crit Care Med 2022;26(2):224-227.

Air leak with COVID-19 - A meta-summary

INTRODUCTION

There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the types of air leaks in COVID-19 and their outcomes.

METHODS

The literature search from PubMed, Science Direct, and Google Scholar databases was performed from the start of the pandemic till 31 March 2021. The inclusion criteria were case reports or series on (1) laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, (2) with the individual patient details, and (3) reported diagnosis of one or more air leak syndrome (pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium).

RESULTS

A total of 105 studies with 188 patients were included in the final analysis. The median age was 56.02 (SD 15.53) years, 80% males, 11% had previous respiratory disease, and 8% were smokers. Severe or critical COVID-19 was present in 50.6% of the patients. Pneumothorax (68%) was the most common type of air leak. Most patients (56.7%) required intervention with lower mortality (29.1% vs. 44.1%, p = 0.07) and intercostal drain (95.9%) was the preferred interventional management. More than half of the patients developed air leak on spontaneous breathing. The mortality was significantly higher in patients who developed air leak with positive pressure ventilation (49%, p < 0.001) and required escalation of respiratory support (39%, p = 0.006).

CONCLUSION

Air leak in COVID-19 can occur spontaneously without positive pressure ventilation, higher transpulmonary pressures, and other risk factors like previous respiratory disease or smoking. The mortality is significantly higher if associated with positive pressure ventilation and escalation of respiratory support.

Candida Score: a Predictor of Mortality in Patients with Candidemia

BACKGROUND

Candida score has been developed and used for identifying patients at risk for developing Candida infections. However, its usefulness in predicting outcome of patients with candidemia has not been evaluated. We aimed to determine the risk factors for mortality in patients with candidemia admitted to an Indian medical intensive care unit (ICU).

METHODS

We conducted a retrospective cohort analysis of 56 patients with candidemia presented in 18 months duration. Baseline patient characteristics, ICU course and outcome were noted and Candida score was calculated. We conducted analysis based on the primary outcome measure of ICU mortality.

RESULTS

Out of 3,142 ICU admissions, the incidence of candidemia was 17.8/1,000 admissions. The mean interval between ICU admission and candidemia was 12.9 ± 14.4 days. C. tropicalis was the commonest species isolated from 28.6% isolates, followed by Candida albicans (21.4%) and C. glabrata (12.5%). The mean length of ICU stay was 22.9 ± 28 days and hospital stay was 30.1 ± 30.2 days. Crude ICU mortality was 33.93%. There was no statistically significant difference between mortality of patients with albicans and non-albicans candidemia (p=0.732). On multivariate analysis, only two factors, previous antifungal therapy (p=0.004, OR=101.4, 95% CI=4.52-227.7) and Candida score &gt;3 (p=0.028, OR=13.2, 95% CI=1.3-125) were found to be independently predicting mortality.

CONCLUSION

Candida infection is generally late-onset and is associated with a prolonged ICU and hospital stay, and a high mortality. Candida non-albicans infection was more common but there was no difference in mortality among patients with C. albicans and non-albicans infection. Previous antifungal therapy and Candida score were found to be independently predicting mortality.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19

Introduction

There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids.

Methods

A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round.

Results

Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs.

Conclusion

The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring.

How to cite this article

How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19

INTRODUCTION

There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids.

METHODS

A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round.

RESULTS

Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs.

CONCLUSION

The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring.

HOW TO CITE THIS ARTICLE

How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Delphi methodology in healthcare research: How to decide its appropriateness

The Delphi technique is a systematic process of forecasting using the collective opinion of panel members. The structured method of developing consensus among panel members using Delphi methodology has gained acceptance in diverse fields of medicine. The Delphi methods assumed a pivotal role in the last few decades to develop best practice guidance using collective intelligence where research is limited, ethically/logistically difficult or evidence is conflicting. However, the attempts to assess the quality standard of Delphi studies have reported significant variance, and details of the process followed are usually unclear. We recommend systematic quality tools for evaluation of Delphi methodology; identification of problem area of research, selection of panel, anonymity of panelists, controlled feedback, iterative Delphi rounds, consensus criteria, analysis of consensus, closing criteria, and stability of the results. Based on these nine qualitative evaluation points, we assessed the quality of Delphi studies in the medical field related to coronavirus disease 2019. There was inconsistency in reporting vital elements of Delphi methods such as identification of panel members, defining consensus, closing criteria for rounds, and presenting the results. We propose our evaluation points for researchers, medical journal editorial boards, and reviewers to evaluate the quality of the Delphi methods in healthcare research.

Air leak with COVID-19 - A meta-summary

INTRODUCTION

There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the types of air leaks in COVID-19 and their outcomes.

METHODS

The literature search from PubMed, Science Direct, and Google Scholar databases was performed from the start of the pandemic till 31 March 2021. The inclusion criteria were case reports or series on (1) laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, (2) with the individual patient details, and (3) reported diagnosis of one or more air leak syndrome (pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium).

RESULTS

A total of 105 studies with 188 patients were included in the final analysis. The median age was 56.02 (SD 15.53) years, 80% males, 11% had previous respiratory disease, and 8% were smokers. Severe or critical COVID-19 was present in 50.6% of the patients. Pneumothorax (68%) was the most common type of air leak. Most patients (56.7%) required intervention with lower mortality (29.1% vs. 44.1%, p = 0.07) and intercostal drain (95.9%) was the preferred interventional management. More than half of the patients developed air leak on spontaneous breathing. The mortality was significantly higher in patients who developed air leak with positive pressure ventilation (49%, p < 0.001) and required escalation of respiratory support (39%, p = 0.006).

CONCLUSION

Air leak in COVID-19 can occur spontaneously without positive pressure ventilation, higher transpulmonary pressures, and other risk factors like previous respiratory disease or smoking. The mortality is significantly higher if associated with positive pressure ventilation and escalation of respiratory support.

Practice Pattern of Critical Care Physicians in India for Use of Corticosteroids in COVID-19

INTRODUCTION

Steroids are recommended as the standard of care in managing severe COVID-19. However, several questions remain unanswered regarding the prescription of steroids which led to differing opinions and practice. We surveyed practice patterns of critical care physicians in India for the use of corticosteroids in COVID-19.

METHODS

This was a nationwide, cross-sectional, online, knowledge attitude practice-based survey, among intensivists for corticosteroid use in COVID-19. The survey questionnaire had seven questions for demographic data and 14 questions in the core survey.

RESULTS

384 responses were analyzed from different parts of the country. A majority (81.2%) agreed that steroids improved oxygenation and survival chances. 88.3% agreed that steroids are indicated because of their anti-inflammatory properties, and should be prescribed in patients with moderate (75.8%), severe (59.9%), or critical (41.1%) COVID-19. 68.8% of physicians start steroids on the basis of “need for oxygen therapy” and hyperglycemia (85.2%) was the most commonly reported complication. 59.1% prefer prescribing methylprednisolone followed by Dexamethasone (38.8%). 51.8% preferred to use low dose steroids, and 59.1% have used “pulse steroids’’. Rather than a fixed duration of therapy, 66.9% of the respondents rely on “clinical improvement” before stopping steroids, even if it meant continuing steroids for prolonged periods beyond 14 days (34.1%). 57.8% always taper steroids before stopping.

CONCLUSIONS

We found wide variation in the practice patterns of critical care physicians in India for use of Corticosteroids in COVID-19. The dilemma regarding when to initiate, type of steroid, dose, and duration of therapy still persist emphasizing the need for further research.

Effectiveness of convalescent plasma in Indian patients with COVID-19

BACKGROUND

Convalescent plasma (CP) is being used as a treatment option in hospitalized patients with COVID-19. Till date, there is conflicting evidence on efficacy of CP in reducing COVID-19 related mortality.

OBJECTIVE

To evaluate the effect of CP on 28-day mortality reduction in patients with COVID-19.

METHODS

We did a multi-centre, retrospective case control observational study from 1st May 2020 to 31st August 2020. A total of 1079 adult patients with moderate and severe COVID-19 requiring oxygen, were reviewed. Of these, 694 patients were admitted to ICU. Out of these, 333 were given CP along with best supportive care and remaining 361 received best supportive care only.

RESULTS

In the overall group of 1079 patients, mortality in plasma vs no plasma group was statistically not significant (22.4% vs 18.5%; p = 0.125; OR = 1.27, 95% CI: 0.94--1.72). However, in patients with COVID-19 admitted to ICU, mortality was significantly lower in plasma group (25.5% vs 33.2%; p = 0.026; OR = 0.69, 95%CI: 0.50-0.96). This benefit of reduced mortality was most seen in age group 60 to 74 years (26.7% vs 43.0%; p = 0.004; OR = 0.48, 95% CI: 0.29-0.80), driven mostly by females of this age group (23.1% vs 53.5%; p = 0.013; OR = 0.26, 95% CI: 0.09-0.78). Significant difference in mortality was observed in patients with one comorbidity (22.3% vs 36.5%; p = 0.004; OR = 0.50, 95% CI: 0.31-0.80). Moreover, patients on ventilator had significantly lower mortality in the plasma arm (37.2% vs 49.3%; p = 0.009; OR = 0.61, 95% CI: 0.42-0.89); particularly so for patients on invasive mechanical ventilation (63.9% vs 82.9%; p = 0.014; OR = 0.37, 95% CI: 0.16-0.83).

CONCLUSION

The use of CP was associated with reduced mortality in COVID-19 elderly patients admitted in ICU, above 60 years of age, particularly females, those with comorbidities and especially those who required some form of ventilation.

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice.

METHODS

Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ²) test (p < 0·05 was considered as unstable).

RESULTS

Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment.

CONCLUSION

Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited.

TRIAL REGISTRATION

The study was registered with Clinical trials.gov Identifier: NCT04534569.

Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice.

METHODS

Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ²) test (p < 0·05 was considered as unstable).

RESULTS

Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment.

CONCLUSION

Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited.

TRIAL REGISTRATION

The study was registered with Clinical trials.gov Identifier: NCT04534569.