Comparison of gastric emptying time between breast-fed and formula milk-fed infants less than 6 months old, using gastric ultrasound-An observational study

BACKGROUND

Fasting before elective anesthesia care is a standardized practice worldwide. The aim is to decrease the risk of aspiration leading to pulmonary complications such as aspiration pneumonitis during anesthesia care. There are different guidelines for elective preoperative fasting in children. However, there is insufficient literature measuring gastric emptying time after breast milk or formula milk feeding in infants.

OBJECTIVE

This study used gastric ultrasound to determine the gastric emptying time for breast milk and formula milk in children below 6 months of age. We also compared the calculated gastric volumes among breast-fed and formula milk-fed based on Schmitz's and Spencer's formula.

MATERIALS AND METHODS

This prospective observational study was conducted at a tertiary care center in India between November (2017-2019). A total of 52 infants less than 6 months of age were recruited. The study population was divided into two groups (breast-fed and formula milk-fed) of 26 patients each. Ultrasound was used to measure the antral cross-sectional area of the stomach and to calculate the gastric volume using the two classical formulas (Schmitz and Spencer's). Gastric emptying was reported when the bull's eye appearance of the gastric antrum was seen or when the antral cross-sectional area was less than 3.07 cm2.

RESULTS

The number of breast-fed children whose antral cross-sectional was greater than 3.07 cm2 (cut-off value for aspiration risk) beyond 1 h was 14/26 (53.84%) while none (0) children went beyond 3 h. The number of formula-fed children whose antral cross-sectional was greater than 3.07 cm2 beyond 1 h was 17/26 (65.38%) while one child (3.84%) went beyond 3 h. Using Schmitz's formula, mean (SD) gastric emptying times were 0.35 ± 0.68 h (95% CI 0.35 ± 0.185, range 0.165-0.535) for breast-fed patients and 0.35 ± 0.69 h (95% CI 0.35 ± 0.188, range 0.162-0.538) for formula-fed patients, and were thus neither clinically nor statistically different (p = .73) Using Spencer's formula, the mean gastric emptying times were 0.12 ± 0.33 h (95% CI 0.12 ± 0.09, range 0.03-0.21) for breast-fed patients and 0.04 ± 0.20 h (95% CI 0.04 ± 0.05, range -0.01 to 0.09) for formula-fed patients, and were also neither clinically nor statistically different p = .13.

CONCLUSION

In our series, the gastric emptying times in breast-fed and formula-fed infants less than 6 months old were similar. Our results support the fasting guidelines of the European Society of Anaesthesiology and Intensive Care 2022, that is, 3 h for breastfeeding and 4 h for formula milk feeding. In addition, this shows that the Schmitz's and Spencer's formulae used to calculate the gastric volume based on ultrasound measurement of the antral cross-sectional area are not comparable in infants less than 6 months.

Secondary infections in COVID-19: Antemortem and postmortem culture study

Background

Secondary bacterial infections during COVID-19 hospitalization have been reported in about 6-15% of patients.

Aims

To study the secondary bacterial infections that affected the COVID-19 patients during their hospitalisation and to unearth the bacteriological profile of samples obtained after their demise.

Settings and Design

This prospective study was carried out at a COVID-19 dedicated, apex tertiary care centre in North India from July 2020 to April 2021.

Methods and Materials

Samples of 268 patients were considered for the study. Nasopharyngeal swab specimen, blood, and tissue (lung) were collected from the deceased body as early as possible and processed.

Statistical Analysis

Statistical analyses were performed using STATA version 11.1 (Stata Corp., College Station, TX, USA).

Results

A total of 170 samples were received from patients before their death, which included blood, urine, respiratory samples, pus, and cerebrospinal fluid. Forty-four pathogens were isolated, which consisted of Acinetobacter baumannii (43.1%), Klebsiella pneumoniae (36.3%), Escherichia coli (11.3%), and Pseudomonas aeruginosa (4.5%), Enterococcus faecium (4.5%). Two hundred fifty-eight samples were collected from the deceased bodies wherein the nasopharyngeal sample was highest, followed by tissue and blood. A total of 43 pathogens were isolated among them which included A. baumannii (44.1%), followed by K. pneumoniae (25.5%), E. coli (20.9%), P. aeruginosa (6.97%) and Enterobacter cloacae (2.3%). All these isolates were highly resistant to antimicrobials.

Conclusions

In our study, bacterial profiles in antemortem and postmortem samples were found to be similar, suggesting that resistant pathogens may be the cause of mortality in COVID-19 infected hospitalised patients.

Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials

Introduction

Delirium, being a common disorder among critically ill patients, has a reported incidence ranging 45-83% in the intensive care unit (ICU) population. The prophylactic use of melatonin and melatonergics has been shown to have a positive effect in reducing the incidence of delirium in many clinical trials. Our study was thus proposed to find out the role of melatonin on the incidence and severity of ICU delirium, ICU and hospital length of stay (LOS), requirement, duration of mechanical ventilation, and ICU mortality.

Methodology

A systematic search of various databases was performed to find out the trials which compare melatonin with a placebo or standard therapy for delirium prevention with the results conveyed as mean differences (MDs) or risk ratios. The statistical software, Review Manager (RevMan, version 5.4), was used for data synthesis.

Results

Twelve studies were included in the meta-analysis. Prophylactic administration of melatonin or ramelteon was not associated with a statistically significant reduction in the incidence of delirium (odds ratio [OR] 0.63; confidence interval [CI]: 0.60, 1.32; p = 0.22), the severity of delirium (MD: 0.22; 95% CI: From -1.36 to 1.81; p = 0.78), ICU LOS (MD: 0.05; 95% CI: From -0.65 to 0.75; p = 0.89), hospital LOS (MD: -1.46; 95% CI: From -4.50 to -1.59; p = 0.35), need for mechanical ventilation (OR: 0.74, 95% CI: 0.38-1.44; p = 0.37), and ICU mortality (MD: 0.78; 95% CI: 0.56; 1.11; p = 0.62). However, a significant reduction in the duration of mechanical ventilation (MD: -0.85; 95% CI: From -1.64 to -0.06; p = 0.03) was found.

Conclusion

Our meta-analysis suggests that melatonin when given prophylactically has no significant role in reducing the incidence and severity of delirium, ICU and hospital LOS, need for mechanical ventilation, duration of mechanical ventilation, and ICU mortality. Further studies are warranted.

How to cite this article

Mukundarajan R, Soni KD, Trikha A. Prophylactic Melatonin for Delirium in Intensive Care Unit: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2023;27(9):675-685.

Early Doffing among Frontline Healthcare Workers Working in the COVID Areas in Resource-Limited Settings: Lessons Learned and Interventions Taken

Background

In the fight against the pandemic, personal protective equipment (PPE) has played a vital role. However, working with PPE has its own difficulties and problems. The aim of this study was to find out the reasons of early doffing, that is, in doffing in emergency situations before the shift among healthcare workers (HCWs) working in PPE in the COVID areas in resource-limited settings.

Methods

This cross-sectional, survey-based study was carried out on healthcare workers involved in direct care of patients with COVID-19 in tertiary care COVID center, India. The questionnaire was sent as a Google form through email and social media platforms like WhatsApp and Facebook. The data was reported as the mean ± SD for continuous variables and as the percentage for categorical variables.

Findings

Among 252 healthcare workers who participated in the survey, 145 (57.5%) participants doffed early on 300 occasions. Out of these 145, 50% doffed early only once and rest doffed early multiple times. The most common reason of early doffing was found to be breach in PPE (15.33%) followed by fogging (14%) and headache (12%), and most commonly, breach was in mask or coverall/gown (32.6% each).

Conclusion

Although PPE decreases the risk of infection, it is challenging for HCWs to work in PPE leading to instances of early doffing. The most common reason for early doffing in our study was the breach in PPE and the most common component of breach was found to be mask and coverall/gown. Therefore, we suggest that the proper sizes of the PPE should be made available and proper training in donning should be imparted to HCWs working in PPE.

Virological and cytological changes in tears and conjunctiva of patients with COVID-19

Purpose

To analyze the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in tears/conjunctival epithelium and assess the cytomorphological changes in the conjunctival epithelium of coronavirus disease 2019 (COVID-19) patients.

Methods

In this pilot study, patients with moderate to severe COVID-19 were recruited from the COVID ward/intensive care unit of the institute. Tears and conjunctival swabs were collected from COVID-19 patients and sent to the virology laboratory for reverse transcription polymerase chain reaction (RT-PCR) testing. Conjunctival swabs were used to prepare smears, which underwent cytological evaluation and immunocytochemistry for SARS-CoV-2 nucleocapsid protein.

Results

Forty-two patients were included. The mean age of participants was 48.61 (range: 5-75) years. Seven (16.6%) patients tested positive for SARS-CoV-2 ribonucleic acid in tears samples, four (9.5%) of which were positive on conjunctival swab by RT-PCR in the first test. Cytomorphological changes were observed significantly more in smears from patients with positive RT-PCR on tear samples, including bi-/multi-nucleation (p = 0.01), chromatin clearing (p = 0.02), and intra-nuclear inclusions (p < 0.001). One case (3.2%) showed immunopositivity for SARS-CoV-2; this patient had severe disease and the lowest Ct values for tear and conjunctival samples among all positive cases.

Conclusion

Conjunctival smears from patients with COVID-19 revealed cytomorphological alterations, even in the absence of clinically significant ocular infection. However, viral proteins were demonstrated within epithelial cells only rarely, suggesting that although the conjunctival epithelium may serve as a portal for entry, viral replication is possibly rare or short-lived.

Determination of the optimal length of insertion for central venous catheterization via axillary vein cannulation using preoperative chest X-ray- A prospective feasibility study

Background and Aims

Ensuring safe central venous catheter tip placement is important. Multiple techniques are available to estimate the length of catheter insertion for subclavian and internal jugular approaches. However, the methods to determine the length of insertion for the axillary route have not been validated. The purpose of this feasibility study was to evaluate a simple method for the calculation of catheter length to be inserted and assess whether it accurately predicts the correct tip placement.

Material and Methods

A total of 102 patients requiring preoperative central venous cannulation were evaluated, out of which 60 had successful axillary vein (AxV) cannulation. The length of insertion was calculated using the formula: (2/3* A + B) +Y (A: Clavicular length on chest radiograph [CXR], B: Vertical distance between the sternal head and carina on CXR, Y: Perpendicular distance from the skin to the AxV on ultrasound). A postoperative CXR was used to assess the accurate tip placement (2 cm above the carina to 0.5 cm below it). The primary outcome of the study was the rate of successful placement of the central venous catheter (CVC) in terms of the correct position of the tip of the catheter when the length of the catheter inserted was predicted by the formula described previously.

Results

Optimal placement was observed in 83.33% of the cases. A higher rate of accuracy was seen in the females (P value = 0.03) and shorter patients (P value = 0.01). A Bland-Altman plot depicted a high degree of agreement.

Conclusion

Use of the formula using a CXR and ultrasound allowed P successful placement of the CVC tip at the desired location in 83.33% of the cases.

A Combination of Inflammatory and Hematological Markers is Strongly Associated with the Risk of Death in Both Mild and Severe Initial Disease in Unvaccinated Individuals with COVID-19 Infection

Background

Inflammatory and hematological markers are used extensively for early prognostication and monitoring in COVID-19.We aimed to determine whether routinely prescribed laboratory markers can predict adverse outcome at presentation in COVID-19.

Methods

This retrospective observational study was performed on 401 samples collected between July to December 2020 from COVID-19 positive subjects, admitted at All India Institute of Medical Sciences, Delhi, India. Clinical details and laboratory investigations within 3 days of COVID-19 positivity were obtained. Clinical outcomes were noted from patient medical records, till discharge or death. Laboratory parameters, with individually defined cut-offs, were used, either singly or in combination to distinguish survival and death for those having severe and non-severe disease at initial presentation.

Findings

Total Leukocyte count, Absolute neutrophil count, Neutrophil to Lymphocyte ratio, C-Reactive Protein (CRP), Interleukin-6 (IL-6), Lactate Dehydrogenase, Ferritin and Lymphocyte to CRP ratio (LCR) were significantly altered at presentation in severe COVID-19 as compared to non-severe cases; and, also in those who died due to COVID-19 compared to those who survived. A combination of four markers, CRP (≥3.9mg/dL); IL-6 (≥45.37pg/ml); Ferritin (≥373ng/mL); 1/LCR ≥0.405 was found to strongly predict mortality in cases with non-severe presentation as also in severe cases.

Conclusion and Interpretation

The combination of routinely used markers, CRP, IL-6, Ferritin and 1/LCR can be used to predict adverse outcomes, even in those presenting with mild to moderate disease. This would identify subset of patients who would benefit from closer monitoring than usual for non-severe disease.

A comparison of analgesic efficacy and safety of clonidine and methylprednisolone as additives to 0.25% ropivacaine in stellate ganglion block for the treatment of complex regional pain syndrome: a prospective randomised single blind study

Background

The role of the sympathetic nervous system appears to be central in causing pain in complex regional pain syndrome (CRPS). The stellate ganglion block (SGB) using additives with local anesthetics is an established treatment modality. However, literature is sparse in support of selective benefits of different additives for SGB. Hence, the authors aimed to compare the efficacy and safety of clonidine with methylprednisolone as additives to ropivacaine in the SGB for treatment of CRPS.

Methods

A prospective randomized single blinded study (the investigator blinded to the study groups) was conducted among patients with CRPS-I of the upper limb, aged 18-70 years with American Society of Anaesthesiologists physical status I-III. Clonidine (15 μg) and methylprednisolone (40 mg) were compared as additives to 0.25% ropivacaine (5 mL) for SGB. After medical treatment for two weeks, patients in each of the two groups were given seven ultrasound guided SGBs on alternate days.

Results

There was no significant difference between the two groups with respect to visual analogue scale score, edema, or overall patient satisfaction. After 1.5 months follow-up, however, the group that received methylprednisolone had better improvement in range of motion. No significant side effects were seen with either drug.

Conclusions

The use of additives, both methylprednisolone and clonidine, is safe and effective for the SGB in CRPS. The significantly better improvement in joint mobility with methylprednisolone suggests that it should be considered promising as an additive to local anaesthetics when joint mobility is the concern.

Predictors of Mortality among Patients Hospitalized with COVID-19 during the First Wave in India: A Multisite Case-Control Study

Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) has caused more than 6 million deaths globally. Understanding predictors of mortality will help in prioritizing patient care and preventive approaches. This was a multicentric, unmatched, hospital-based case-control study conducted in nine teaching hospitals in India. Cases were microbiologically confirmed COVID-19 patients who died in the hospital during the period of study and controls were microbiologically confirmed COVID-19 patients who were discharged from the same hospital after recovery. Cases were recruited sequentially from March 2020 until December-March 2021. All information regarding cases and controls was extracted retrospectively from the medical records of patients by trained physicians. Univariable and multivariable logistic regression was done to assess the association between various predictor variables and deaths due to COVID-19. A total of 2,431 patients (1,137 cases and 1,294 controls) were included in the study. The mean age of patients was 52.8 years (SD: 16.5 years), and 32.1% were females. Breathlessness was the most common symptom at the time of admission (53.2%). Increasing age (adjusted odds ratio [aOR]: 46-59 years, 3.4 [95% CI: 1.5-7.7]; 60-74 years, 4.1 [95% CI: 1.7-9.5]; and ≥ 75 years, 11.0 [95% CI: 4.0-30.6]); preexisting diabetes mellitus (aOR: 1.9 [95% CI: 1.2-2.9]); malignancy (aOR: 3.1 [95% CI: 1.3-7.8]); pulmonary tuberculosis (aOR: 3.3 [95% CI: 1.2-8.8]); breathlessness at the time of admission (aOR: 2.2 [95% CI: 1.4-3.5]); high quick Sequential Organ Failure Assessment score at the time of admission (aOR: 5.6 [95% CI: 2.7-11.4]); and oxygen saturation < 94% at the time of admission (aOR: 2.5 [95% CI: 1.6-3.9]) were associated with mortality due to COVID-19. These results can be used to prioritize patients who are at increased risk of death and to rationalize therapy to reduce mortality due to COVID-19.

Risk Factors and Outcomes of Post-traumatic Acute Kidney Injury Requiring Renal Replacement Therapy: A Case-Control Study

Background

Acute kidney injury (AKI) following severe trauma is common. However, the requirement of renal replacement therapy (RRT) in these patients is rare and is associated with high morbidity and mortality. The primary objective of this study was to identify odds of risk factors, in particular, hypotension at presentation, for the requirement of RRT in patients with AKI following trauma.

Methods

We performed a case-control study involving patients who were admitted to the intensive care unit (ICU) at a level I trauma center for at least 24 hours. The primary outcome measure was a study of the odds of risk factors associated with the requirement of RRT in such patients. Univariate comparisons and multiple logistic regression analyses were done to identify other risk factors.

Results

The presence of crush injury, sepsis, and elevated serum creatinine (sCr) on arrival were identified to be independent risk factors for RRT requirement. Hypotension and exposure to radiocontrast or nephrotoxic antimicrobials were not found to be associated with the need for RRT. Acute kidney injury requiring RRT was associated with significantly increased ICU length of stay (15 days vs 5 days; p < 0.001) and higher mortality (83% vs 35%; p < 0.001).

Conclusion

The presence of crush injury, sepsis, and elevated sCr on presentation were identified to be independent risk factors while hypotension association was insignificant for AKI requiring RRT in our investigation.

How to cite this article

Soni KD, Singh A, Tyagi A, Singh Y, Aggarwal R, Trikha A. Risk Factors and Outcomes of Post-traumatic Acute Kidney Injury Requiring Renal Replacement Therapy: A Case-Control Study. Indian J Crit Care Med 2023;27(1):22-25.

"There is No Easy Way to Say This…": Communication Challenges in the COVID-19 Intensive Care Unit

How to cite this article: Venkateswaran V, Soni KD, Trikha A. "There is No Easy Way to Say This…": Communication Challenges in the COVID-19 Intensive Care Unit. Indian J Crit Care Med 2023;27(1):79-81.

A study on the morbid histopathological changes in COVID-19 patients with or without comorbidities using minimally invasive tissue sampling

COVID-19 causes morbid pathological changes in different organs including lungs, kidneys, liver, and so on, especially in those who succumb. Though clinical outcomes in those with comorbidities are known to be different from those without-not much is known about the differences at the histopathological level. To compare the morbid histopathological changes in COVID-19 patients between those who were immunocompromised (Gr 1), had a malignancy (Gr 2), or had cardiometabolic conditions (hypertension, diabetes, or coronary artery disease) (Gr 3), postmortem tissue sampling (minimally invasive tissue sampling [MITS]) was done from the lungs, kidney, heart, and liver using a biopsy gun within 2 hours of death. Routine (hematoxylin and eosin) and special staining (acid fast bacilli, silver methanamine, periodic acid schiff) was done besides immunohistochemistry. A total of 100 patients underwent MITS and data of 92 patients were included (immunocompromised: 27, malignancy: 18, cardiometabolic conditions: 71). In lung histopathology, capillary congestion was more in those with malignancy, while others like diffuse alveolar damage, microthrombi, pneumocyte hyperplasia, and so on, were equally distributed. In liver histopathology, architectural distortion was significantly different in immunocompromised; while steatosis, portal inflammation, Kupffer cell hypertrophy, and confluent necrosis were equally distributed. There was a trend towards higher acute tubular injury in those with cardiometabolic conditions as compared to the other groups. No significant histopathological difference in the heart was discerned. Certain histopathological features were markedly different in different groups (Gr 1, 2, and 3) of COVID-19 patients with fatal outcomes.

SARS-CoV-2 antigen detection in deceased bodies: implications for infection prevention

Background & objectives

High transmissibility of the SARS-CoV-2 has significant implications on healthcare workers' safety, preservation, handling, transportation and disposal of the deceased bodies. The objective of this study was to detect SARS-CoV-2 antigen in nasopharyngeal samples and its implications in handling and care of COVID-19 deceased bodies.

Methods

A study was conducted at a dedicated COVID-19 centre on deceased individuals from April to December 2020. Rapid antigen test (RAT) and reverse transcription (RT)-PCR was compared on all the SARS-CoV-2 positive cadavers recruited in the study.

Results

A total of 115 deceased individuals were included in the study. Of these, 79 (68.7%) were male and 36 (31.3%) were female and majority were in the age group of 51-60 yr [31 (27%)]. SARS-CoV-2 antigen test was positive in 32 (27.8%) and negative in 83 (72.1%) individuals. The mean time interval between deaths to the sample collection was 13.2 h with interquartile range of eight to 20 h. Reverse transcription (RT)-PCR was used as the reference test and 24 (20.9%) cases were true positive; 93.6 per cent [95% confidence interval (CI) 88.8-98.4%] sensitivity, 45.2 per cent (95% CI 35.5-55%) specificity, 60.2 per cent (95% CI 50.6-69.8%) positive predictive value and 88.8 per cent (95% CI 82.7-95%) negative predictive value of antigen test was computed.

Interpretation & conclusions

SARS-CoV-2 antigen test was positive beyond 19 h in COVID-19 deceased individuals. Antigen test was found to be highly sensitive in the deceased. Patients, suspected of having died due to COVID-19, can be screened by this method. As infectiousness of the virus in the deceased bodies cannot be directly concluded from either the antigen or RT-PCR test, yet possible transmission cannot be completely ruled out. Strict infection control measures need to be followed during the handling and clearance of COVID-19 cadavers.

Secondary Bacterial Infections in Mucormycosis-COVID-19 Cases: Experience during the Second COVID-19 Wave in India

In the second wave of COVID-19 in India, there was a new challenge in the form of mucormycosis. Coinfection with mucormycosis was perilous as both conditions required a prolonged hospital stay, thus serving as an ideal platform for secondary infections. Using a retrospective observational study, we studied secondary infections and their impact on the outcome in COVID-19 patients with mucormycosis. The outcome in these patients was evaluated and compared with COVID-19 patients with mucormycosis but without any secondary infection. SPSS V-20 was used for data analysis. Fifty-five patients tested positive for mucormycosis (55/140; 39.28). Twelve out of these 55 (21.8%) developed secondary infections during their hospital stay. Bloodstream infection was the most common (42.86%) secondary infection. The Gram-negative (GN) organisms were more common (11/16; 68.75%) compared with the Gram-positives (GP) (5/16; 31.25%). But the most common isolate was Enterococcus faecium (5/16; 31.25%). A high percentage of microorganisms isolated were multidrug-resistant (15/16; 93.75%). Two out of five (40%) isolates of Enterococcus faecium were vancomycin-resistant (VRE). High resistance to carbapenems was noted in the GN isolates (9/11; 81.81%). The comparison of length of stay in both subgroups was statistically significant (P value <0.001). When compared, the length of stay in people with adverse outcomes was also statistically significant (P value <0.001). Procalcitonin (PCT) had a positive predictive value for the development of secondary bacterial infections (P value <0.001). Antimicrobial stewardship and strict infection control practices are the need of the hour. IMPORTANCE Although our knowledge about COVID-19 and secondary infections in patients is increasing daily, little is known about the secondary infections in COVID-19-mucormycosis patients. Thus, we have intended to share our experience regarding this subgroup. The importance of this study is that it brings to light the type of secondary infections seen in COVID-19-mucormycosis patients. These secondary infections were partially responsible for the mortality and morbidity of the unfortunate ones. We, as health care workers, can learn the lesson and disseminate the knowledge so that in similar situations, health care workers, even in other parts of the world, know what to expect.

Selection of Ideal Reference Genes for Gene Expression Analysis in COVID-19 and Mucormycosis

Selection of reference genes during real-time quantitative PCR (qRT-PCR) is critical to determine accurate and reliable mRNA expression. Nonetheless, not a single study has investigated the expression stability of candidate reference genes to determine their suitability as internal controls in SARS-CoV-2 infection or COVID-19-associated mucormycosis (CAM). Using qRT-PCR, we determined expression stability of the nine most commonly used housekeeping genes, namely, TATA-box binding protein (TBP), cyclophilin (CypA), β-2-microglobulin (B2M), 18S rRNA (18S), peroxisome proliferator-activated receptor gamma (PPARG) coactivator 1 alpha (PGC-1α), glucuronidase beta (GUSB), hypoxanthine phosphoribosyltransferase 1 (HPRT-1), β-ACTIN, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) in patients with COVID-19 of various severities (asymptomatic, mild, moderate, and severe) and those with CAM. We used statistical algorithms (delta-CT [threshold cycle], NormFinder, BestKeeper, GeNorm, and RefFinder) to select the most appropriate reference gene and observed that clinical severity profoundly influences expression stability of reference genes. CypA demonstrated the most consistent expression irrespective of disease severity and emerged as the most suitable reference gene in COVID-19 and CAM. Incidentally, GAPDH, the most commonly used reference gene, showed the maximum variations in expression and emerged as the least suitable. Next, we determined expression of nuclear factor erythroid 2-related factor 2 (NRF2), interleukin-6 (IL-6), and IL-15 using CypA and GAPDH as internal controls and show that CypA-normalized expression matches well with the RNA sequencing-based expression of these genes. Further, IL-6 expression correlated well with the plasma levels of IL-6 and C-reactive protein, a marker of inflammation. In conclusion, GAPDH emerged as the least suitable and CypA as the most suitable reference gene in COVID-19 and CAM. The results highlight the expression variability of housekeeping genes due to disease severity and provide a strong rationale for identification of appropriate reference genes in other chronic conditions as well. IMPORTANCE Gene expression studies are critical to develop new diagnostics, therapeutics, and prognostic modalities. However, accurate determination of expression requires data normalization with a reference gene, whose expression does not vary across different disease stages. Misidentification of a reference gene can produce inaccurate results. Unfortunately, despite the global impact of COVID-19 and an urgent unmet need for better treatment, not a single study has investigated the expression stability of housekeeping genes across the disease spectrum to determine their suitability as internal controls. Our study identifies CypA and then TBP as the two most suitable reference genes for COVID-19 and CAM. Further, GAPDH, the most commonly used reference gene in COVID-19 studies, turned out to be the least suitable. This work fills an important gap in the field and promises to facilitate determination of an accurate expression of genes to catalyze development of novel molecular diagnostics and therapeutics for improved patient care.

Clinical characteristics of COVID-19 patients who underwent tracheostomy and its effect on outcome: A retrospective observational study

BACKGROUND

The exponential rise in Coronavirus disease 2019 (COVID-19) cases has resulted in an increased number of patients requiring prolonged ventilatory support and subsequent tracheostomy. With the limited availability of literature regarding the outcomes of COVID-19 patients with tracheostomy, we attempted to study the clinical characteristics and multiple parameters affecting the outcomes in these patients.

AIM

To determine all-cause mortality following tracheostomy and its association with various risk factors in COVID-19 patients.

METHODS

This retrospective study included 73 adult COVID-19 patients admitted to the ICU between 1 April, 2020 and 30 September, 2021 who underwent tracheostomy as a result of acute respiratory failure due to COVID-19. The data collected included demographics (age, sex), comorbidities, type of oxygen support at admission, severity of COVID-19, complications, and other parameters such as admission to tracheostomy, intubation to tracheostomy, ICU stay, hospital stay, and outcome.

RESULTS

This study included 73 adult patients with an average age of 52 ± 16.67 years, of which 52% were men. The average time for admission to tracheostomy was 18.12 ± 12.98 days while intubation to tracheostomy was 11.97 ± 9 days. The mortality rate was 71.2% and 28.8% of patients were discharged alive. The mean duration of ICU and hospital stay was 25 ± 11 days and 28.21 ± 11.60 days, respectively. Greater age, severe COVID-19, mechanical ventilation, shock and acute kidney injury were associated with poor prognosis; however, early tracheostomy in intubated patients resulted in better outcomes.

CONCLUSION

Patients with severe COVID-19 requiring mechanical ventilation have a poor prognosis but patients with early tracheostomy may benefit with no added risk. We recommend that the timing of tracheostomy be decided on a case-by-case basis and a well-designed randomised controlled trial should be performed to elucidate the potential benefit of early tracheostomy in such patients.

Association between Hypocalcemia and Outcome in COVID-19 Patients: A Retrospective Study

Background Calcium has been shown to play a vital role in the pathophysiology of severe acute respiratory syndrome-coronavirus-2 and middle east respiratory syndrome coronavirus diseases, but less is known about hypocalcemia in coronavirus disease 2019 (COVID-19) patients and its association with the disease severity and the final outcome. Therefore, this study was conducted with an aim to assess clinical features in COVID-19 patients having hypocalcemia and to observe its impact on COVID-19 disease severity and the final outcome.

Methods In this retrospective study, consecutive COVID-19 patients of all age groups were enrolled. Demographical, clinical, and laboratory details were collected and analyzed. On the basis of albumin-corrected calcium levels, patients were classified into normocalcemic (n = 51) and hypocalcemic (n = 110) groups. Death was the primary outcome.

Results The mean age of patients in the hypocalcemic group was significantly lower (p < 0.05). A significantly higher number of hypocalcemic patients had severe COVID-19 infection (92.73%; p < 0.01), had comorbidities (82.73%, p < 0.05), and required ventilator support (39.09%; p < 0.01) compared with normocalcemic patients. The mortality rate was significantly higher in the hypocalcemic patients (33.63%; p < 0.05). Hemoglobin (p < 0.01), hematocrit (p < 0.01), and red cell count (p < 0.01) were significantly lower with higher levels of absolute neutrophil count (ANC; p < 0.05) and neutrophil-to-lymphocyte ratio (NLR; p < 0.01) in the hypocalcemic patients.

Albumin-corrected calcium levels had a significant positive correlation with hemoglobin levels, hematocrit, red cell count, total protein, albumin, and albumin-to-globulin ratio and a significant negative correlation with ANC and NLR.

Conclusion The disease severity, ventilator requirement, and mortality were considerably higher in hypocalcemic COVID-19 patients.

Illness wellness scale: novel grading system for performance status of patients under surgical care

BACKGROUND

Grading the illness using clinical parameters is essential for the daily progress of inpatients. Existing systems do not incorporate these parameters holistically. The study was designed to internally validate the illness wellness scale, based upon clinical assessment of the patients requiring surgical care, for their risk stratification and uniformity of communication between health care providers.

METHODS

Prospective observational study conducted at a tertiary care hospital. An expert panel devised the scale, and it was modified after feedback from 100 health care providers. A total of 210 patients (150 for internal validation and 60 for inter-observer variability) who required care under the department of surgical disciplines were enrolled. This included patients presenting to surgery OPD, admitted to COVID/non-COVID surgical wards and ICUs, aged ≥16 years.

RESULTS

The response rate of the final illness wellness scale was 95% with 86% positive feedback and a mean of 1.7 on the Likert scale for ease of use (one being very easy and five being difficult). It showed excellent consistency and minimal inter-observer variability with the intra-class correlation coefficient (ICC) above 0.9. In the internal validation cohort (n = 150), univariate and multivariable analysis of factors affecting mortality revealed that categorical risk stratification, age ≥ 60 years, presence or absence of co-morbidities especially hypertension and chronic kidney disease significantly affect mortality.

CONCLUSIONS

The Illness wellness scale is an effective tool for uniformly communicating between health care professionals and is also a strong predictor of risk stratification and mortality in patients requiring surgical care.

Ultracellular Imaging of Bronchoalveolar Lavage from Young COVID-19 Patients with Comorbidities Showed Greater SARS-COV-2 Infection but Lesser Ultrastructural Damage Than the Older Patients

In this study, we examined the cellular infectivity and ultrastructural changes due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the various cells of bronchoalveolar fluid (BALF) from intubated patients of different age groups (≥60 years and <60 years) and with common comorbidities such as diabetes, liver and kidney diseases, and malignancies. BALF of 79 patients (38 cases >60 and 41 cases <60 years) were studied by light microscopy, immunofluorescence, scanning, and transmission electron microscopy to evaluate the ultrastructural changes in the ciliated epithelium, type II pneumocytes, macrophages, neutrophils, eosinophils, lymphocytes, and anucleated granulocytes. This study demonstrated relatively a greater infection and better preservation of subcellular structures in these cells from BALF of younger patients (<60 years compared with the older patients (≥60 years). The different cells of BALF from the patients without comorbidities showed higher viral load compared with the patients with comorbidities. Diabetic patients showed maximum ultrastructural damage in BALF cells in the comorbid group. This study highlights the comparative effect of SARS-CoV-2 infection on the different airway and inflammatory cells of BALF at the subcellular levels among older and younger patients and in patients with comorbid conditions.

Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance

Objective

To study the use of serial ultrasound gastric residual volume (GRV) measurements in predicting feed intolerance in critically ill patients.

Patients and methods

This study was conducted in various intensive care units (ICUs) of All India Institute of Medical Sciences, New Delhi. Forty-three critically ill patients aged more than 18 years were studied for a total of 130 enteral feeding days. Gastric residual volume was obtained by calculating the antral cross-sectional area (CSA), which is the product of anteroposterior (AP) and craniocaudal (CC) diameters of gastric antrum obtained using ultrasound in the right lateral decubitus position. A baseline measurement was done before the initiation of the enteral feed and termed GRV0, the ultrasound scanning was repeated every 1 hour for the first 4 hours and termed GRV1, GRV2, GRV3, and GRV4, respectively, and the patients were watched for feed intolerance. The receiver operating characteristic (ROC) curves were constructed to correlate the GRV at each time with feed intolerance.

Results

The data from 43 medical and surgical critically ill patients were analyzed. Out of 130 feeding days, 13 were noted to be feed intolerant. Gastric residual volume at the end of the fourth hour of feed, that is, GRV4 was the best predictor of feed intolerance with 99.3% area under the curve (AUROC), sensitivity of 99%, specificity of 99.3%, and 95% CI, 0.89–0.98 followed by GRV3, with AUROC of 96% and sensitivity and specificity of 92.3 and 96%, respectively, with 95% CI, 0.92–0.99.

How to cite this article

Ankalagi B, Singh PM, Rewari V, Ramachandran R, Aggarwal R, Soni KD, et al. Serial Ultrasonographic-measurement of Gastric Residual Volume in Critically Ill Patients for Prediction of Gastric Tube Feed Intolerance. Indian J Crit Care Med 2022;26(9):987–992.

Clinical profile of ChAdOx1 nCoV-19- and BBV152-vaccinated individuals among hospitalized COVID-19 patients: a pair-matched study

Background:

COVID-19 infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-vaccinated individuals are of clinical concern, especially in those requiring hospitalization. Such real-world data on ChAdOx1 nCoV-19- and BBV152-vaccinated individuals are scarce. Hence, there is an urgent need to understand their clinical profile and outcomes.

Methods:

A 1:1 pair-matched study was performed among vaccinated and unvaccinated COVID-19 patients admitted between March 2021 and June 2021 at a tertiary care centre in New Delhi, India. The vaccinated group (received at least one dose of ChAdOx1 nCoV-19 or BBV152) was prospectively followed till discharge or death and matched [for age (±10 years), sex, baseline disease severity and comorbidities] with a retrospective group of unvaccinated patients admitted during the study period. Paired analysis was done to look for clinical outcomes between the two groups.

Results:

The study included a total of 210 patients, with 105 in each of the vaccinated and unvaccinated groups. In the vaccinated group, 47 (44.8%) and 58 (55.2%) patients had received ChAdOx1 nCoV-19 and BBV152, respectively. However, 73 patients had received one dose and 32 had received two doses of the vaccine. Disease severity was mild in 36.2%, moderate in 31.4% and severe in 32.4%. Two mortalities were reported out of 19 fully vaccinated individuals. All-cause mortality in the vaccinated group was 8.6% (9/105), which was significantly lower than the matched unvaccinated group mortality of 21.9% (23/105), p = 0.007. Vaccination increased the chances of survival (OR = 3.8, 95% CI: 1.42–10.18) compared to the unvaccinated group.

Conclusion:

In the second wave of the pandemic predominated by delta variant of SARS CoV-2, vaccination reduced all-cause mortality among hospitalized patients, although the results are only preliminary.

Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials

Introduction

Vitamin D deficiency is an amendable risk factor linked to increase in mortality in critically ill patients. The aim of this systematic review was to evaluate if vitamin D supplementation reduced the mortality, and length of stay (LOS) in intensive care units (ICU) and hospitals in critically ill adults including coronavirus disease-2019 (COVID-2019) patients.

Materials and methods

We searched the literature using the PubMed, Web of Science, Cochrane and Embase databases until January 13, 2022, for RCTs comparing vitamin D administration to placebo or no treatment in ICUs. The fixed-effect model was used for the primary outcome (all-cause mortality) and the random effect model for secondary objectives (LOS in ICU, hospital, mechanical ventilation). Subgroup analysis included ICU types and high vs low risk of bias. Sensitivity analysis compared severe COVID-19 vs no COVID disease.

Results

Eleven RCTs (2,328 patients) were included in the analysis. Pooled analysis of these RCTs, showed no significant difference in all-cause mortality between the vitamin D and placebo groups [odds ratio (OR) 0.93, p = 0.47]. Inclusion of COVID-positive patients did not change the results (OR 0.91, p = 0.37). No significant difference was observed between the vitamin D and placebo groups in LOS in ICU (p = 0.34); hospital (p = 0.40) and mechanical ventilation duration (p = 0.7). In the subgroup analysis, there was no improvement in mortality in medical ICU (p = 0.36) or surgical ICU (p = 0.03). Neither low risk of bias (p = 0.41) nor high risk of bias (p = 0.39) reduced mortality.

Conclusion

Vitamin D supplementation in the critically ill did not have statistically significant benefits on clinical outcomes in terms of overall mortality, duration of mechanical ventilation, and LOS in ICU and hospital.

How to cite this article

Kaur M, Soni KD, Trikha A. Does Vitamin D Improve All-cause Mortality in Critically Ill Adults? An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2022;26(7):853-862.

Mucormycosis in COVID-19 Patients: A Case-Control Study

(1) Background: During the second wave of COVID-19, India faced a rapid and sudden surge of not only COVID19-delta variant cases but also mucormycosis, making the infection even more fatal. We conducted a study to determine factors associated with the occurrence of mucormycosis in patients with COVID-19. (2) Methods: This case–control study comprised 121 patients; 61 cases (mucormycosis with COVID-19) and 60 controls. Patients were included from April 10, 2021 onwards. Follow-up was conducted after about 90 days and health status was recorded based on the modified Rankin Scale (mRS). (3) Results: Mucormycosis with COVID-19 cases had a median (IQR) age of 49 (43–59) years with 65.6% males and were older (95% CI 1.015–1.075; p = 0.002) than in the control group with median (IQR) 38 (29–55.5) years and 66.6% males. Baseline raised serum creatinine (OR = 4.963; 95% CI 1.456–16.911; p = 0.010) and D-dimer (OR = 1.000; 95% CI 1.000–1.001; p = 0.028) were independently associated with the occurrence of mucormycosis in COVID-19 patients. Additionally, diabetes mellitus (OR = 26.919; 95% CI 1.666–434.892; p = 0.020) was associated with poor outcomes and increased mortality in patients with mucormycosis with COVID-19 as per the multivariable analysis. A total of 30/61 mucormycosis patients had intracranial involvement. (4) Conclusions: The study observed elevated levels of baseline raised creatinine and D-dimer in mucormycosis pa-tients with COVID-19 as compared to the control group. However, future studies may be conducted to establish this cause–effect relationship.

Is it a challenging task to work with personal protective equipment in a COVID-19 ICU: Findings from a hospital-based cross-sectional study from north India

Introduction

Amidst the coronavirus disease 2019 (COVID-19) pandemic, the use of personal protective equipment (PPE) is mandatory for healthcare workers to remain protected against infection. The present study was undertaken to evaluate challenges faced by the healthcare workers while using level 3 PPE.

Methods

This hospital-based study was conducted among resident doctors selected by convenience sampling method using a pretested, semi-structured, self-administered questionnaire after getting informed consent from the participants to collect data on the somatic, psychological, and technical problems faced while working in PPE. Bivariate and multivariable logistic regression was done between outcome variables and other independent variables to check for the association.

Results

Of the total, 252 resident doctors completed the survey, their age ranged from 22 to 36 years with 140 (55.6%) males and 112 (44.4%) females. One-twenty-nine (51.2%) residents were trained to work in ICU, 73 (29%) participants used PPE ≤10 times and the rest 179 (71%) used PPE more than 10 times. The difficulties faced were as follows: visual impairment (n = 244, 96.8%), headache (n = 226, 89.6%), breathing difficulty (n = 216, 85.7%), hearing impairment (n = 201, 79.8%), sweating (n = 242, 96%), and fear of being infected (n = 156,61.9%). Two-thirty-six (93.6%) participants felt that overall work quality reduced due to PPE. Headache, hunger, urge to micturate, anxiety, sleep disturbances, and need to change the timing of medication or diet were higher with increased duration of work with PPE.

Conclusion

A longer duration of work is associated with headache, hunger, anxiety, and sleep disturbances. More research has to be done to improve the PPE to reduce problems like visual impairment, skin irritation, sweating, and breathing difficulty.

Molecular signature of postmortem lung tissue from COVID-19 patients suggests distinct trajectories driving mortality

To elucidate the molecular mechanisms that manifest lung abnormalities during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, we performed whole-transcriptome sequencing of lung autopsies from 31 patients with severe COVID-19 and ten uninfected controls. Using metatranscriptomics, we identified the existence of two distinct molecular signatures of lethal COVID-19. The dominant 'classical' signature (n=23) showed upregulation of the unfolded protein response, steroid biosynthesis and complement activation, supported by massive metabolic reprogramming leading to characteristic lung damage. The rarer signature (n=8) that potentially represents 'cytokine release syndrome' (CRS) showed upregulation of cytokines such as IL1 and CCL19, but absence of complement activation. We found that a majority of patients cleared SARS-CoV-2 infection, but they suffered from acute dysbiosis with characteristic enrichment of opportunistic pathogens such as Staphylococcus cohnii in 'classical' patients and Pasteurella multocida in CRS patients. Our results suggest two distinct models of lung pathology in severe COVID-19 patients, which can be identified through complement activation, presence of specific cytokines and characteristic microbiome. These findings can be used to design personalized therapy using in silico identified drug molecules or in mitigating specific secondary infections.

Alveolar Arterial Gradient and Respiratory Index in Predicting the Outcome of COVID-19 Patients; a Retrospective Cross-Sectional Study

Introduction

Alveolar arterial (A-a) oxygen gradient and respiratory index can be of immense help for the critical care physician in clinical decision making. This study aimed to evaluate the potential application of A-a oxygen gradient and respiratory index in predicting the survival of COVID-19 patients in intensive care unit (ICU).

Method

This is a retrospective cross-sectional study involving 215 adult patients with COVID-19 disease, admitted to the ICU between 1^st April 2020 and 30 June 2021. Details regarding demographic variables, comorbidities, laboratory and arterial blood gas (ABG) findings were recorded. Alveolar-arterial gradient and respiratory index were calculated and tested as predictors of survival.

Result

The mean age of the patients was 51.92 years (65.6 % male). Hypertension was the most common comorbidity and oxygen via non-rebreathing mask was the most common modality used at the time of ICU admission. Mortality was 28.37% and average length of stay was 12.84 days. Patients who died were older (p=0.02), mostly male (p=0.017), had at least one comorbidity (p<0.001), and higher heart rate and respiratory rate (<0.001 and p=0.03, respectively), lower pH on arterial blood gas (ABG) (p=0.002), higher FiO2 requirement (p<0.001), and increased A-a oxygen gradient on admission compared to survivors. According to receiver operating characteristic (ROC) curve analysis, A-a oxygen gradient and respiratory index were not sensitive or specific in predicting mortality in the studied patient subset.

Conclusion

A-a oxygen gradient and respiratory index calculated at time of admission to ICU in patients with COVID-19 were poor predictors of survival.

Outcomes of HFNC Use in COVID-19 Patients in Non-ICU Settings: A Single-center Experience

How to cite this article: Aggarwal A, Arora U, Mittal A, Aggarwal A, Singh K, Ray A, et al.Outcomes of HFNC Use in COVID-19 Patients inNon-ICU Settings: A Single-center Experience. Indian J Crit Care Med 2022;26(4):528–530.

Effect of positive end expiratory pressure on atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia: A lung ultrasonography study

Postoperative pulmonary complications vary in major upper abdominal surgery. The objective of this study was to assess the effect of positive end expiratory pressure on the incidence of atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia using lung ultrasound. The patients were randomised into receiving either no positive end expiratory pressure (Group I) or positive end expiratory pressure of 5cm H₂O (Group II). Lung ultrasound was performed at various time points - baseline, 10 minutes, 2 hours after induction, during closure of skin and 30 minutes post extubation. The lung aeration as assessed by Total Modified Lung Ultrasound Score was worse in the Group I as compared to the Group II at 2 hours post induction. Driving pressure in Group II was significantly reduced compared to Group I. Application of positive end expiratory pressure, as minimal as 5cm H₂O, as a single intervention, helps in significantly reducing the Total Modified Lung Ultrasound Score after a duration of more than 2 hours and also attaining low driving pressures during intraoperative mechanical ventilation.

ACE2 protein expression in lung tissues of severe COVID-19 infection

Angiotensin-converting enzyme 2 (ACE2) is a key host protein by which severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) enters and multiplies within cells. The level of ACE2 expression in the lung is hypothesised to correlate with an increased risk of severe infection and complications in COrona VIrus Disease 2019 (COVID-19). To test this hypothesis, we compared the protein expression status of ACE2 by immunohistochemistry (IHC) in post-mortem lung samples of patients who died of severe COVID-19 and lung samples obtained from non-COVID-19 patients for other indications. IHC for CD61 and CD163 was performed for the assessment of platelet-rich microthrombi and macrophages, respectively. IHC for SARS-CoV-2 viral antigen was also performed. In a total of 55, 44 COVID-19 post-mortem lung samples were tested for ACE2, 36 for CD163, and 26 for CD61, compared to 15 non-covid 19 control lung sections. Quantification of immunostaining, random sampling, and correlation analysis were used to substantiate the morphologic findings. Our results show that ACE2 protein expression was significantly higher in COVID-19 post-mortem lung tissues than in controls, regardless of sample size. Histomorphology in COVID-19 lungs showed diffuse alveolar damage (DAD), acute bronchopneumonia, and acute lung injury with SARS-CoV-2 viral protein detected in a subset of cases. ACE2 expression levels were positively correlated with increased expression levels of CD61 and CD163. In conclusion, our results show significantly higher ACE2 protein expression in severe COVID-19 disease, correlating with increased macrophage infiltration and microthrombi, suggesting a pathobiological role in disease severity.

Risk factors for Coronavirus disease-associated mucormycosis

BACKGROUND

The epidemiology of the Coronavirus-disease associated mucormycosis (CAM) syndemic is poorly elucidated. We aimed to identify risk factors that may explain the burden of cases and help develop preventive strategies.

METHODS

We performed a case-control study comparing cases diagnosed with CAM and taking controls as recovered COVID 19 patients who did not develop mucormycosis. Information on comorbidities, glycemic control, and practices related to COVID-19 prevention and treatment was recorded. Multivariate regression analysis was used to identify independent predictors.

RESULTS

A total of 352 patients (152 cases and 200 controls) diagnosed with COVID-19 during April-May 2021 were included. In the CAM group, symptoms of mucormycosis began a mean of 18.9 (SD 9.1) days after onset of COVID-19, and predominantly rhino-sinus and orbital involvement was present. All, but one, CAM cases had conventional risk factors of diabetes and steroid use. On multivariable regression, increased odds of CAM were associated with the presence of diabetes (adjusted OR 3.5, 95% CI 1.1-11), use of systemic steroids (aOR 7.7, 95% CI 2.4-24.7), prolonged use of cloth and surgical masks (vs. no mask, aOR 6.9, 95%CI 1.5-33.1), and repeated nasopharyngeal swab testing during the COVID-19 illness (aOR 1.6, 95% CI 1.2-2.2). Zinc therapy was found to be protective (aOR 0.05, 95%CI 0.01-0.19). Notably, the requirement of oxygen supplementation or hospitalization did not affect the risk of CAM.

CONCLUSION

Judicious use of steroids and stringent glycemic control are vital to preventing mucormycosis. Use of clean masks, preference for N95 masks if available, and minimizing swab testing after the diagnosis of COVID-19 may further reduce the incidence of CAM.

Simple but Significant Modifications of High-Flow Nasal Cannula

High-flow nasal cannula (HFNC) is one of the most commonly used devices for oxygen therapy during the coronavirus disease 2019 (COVID-19) pandemic in different hospital settings. Multiple alternative options include non-invasive and invasive ventilation. But non-invasive ventilation is very uncomfortable for patients, and weaning from invasive ventilation in a patient with lung pathology is challenging. Hence, HFNC has come up as a safe alternative that averts invasive ventilation. However, its widespread application is difficult in patients with nasal deformities. We discuss two patients, one with caudal dislocation of the nasal septum with a crooked nose and the other patient with septal hypertrophy. In both cases, invasive ventilation was deferred, and target oxygen saturation was achieved after a simple dispositive modification.

SARS-CoV-2 Rapid Antigen Detection in Respiratory and Nonrespiratory Specimens in COVID-19 Patients

Rapid antigen testing for coronavirus disease 2019 (COVID-19) available at present provides immediate results at low cost with less expertise and without any need of sophisticated infrastructure. Most of these test kits available are for nasopharyngeal samples. This is a novel study to detect the presence of COVID antigen in samples other than throat and oropharyngeal. Various samples received from patients admitted in the COVID-19 dedicated center were tested for the presence of antigen. Same procedure was followed as done for the nasopharyngeal sample. A total of 150 samples were tested, which included ascitic fluid, pleural fluid, drain fluid, bile, bronchoalveolar lavage, cerebrospinal fluid, endotracheal tube aspirate, sputum, tissue, and urine. Out of 150, 11 (7.33%) were positive and 138 (92.66%) were negative for the antigen test. The COVID-19 antigen test kit, though designed for nasopharyngeal samples, was able to detect the presence of antigen in other clinical samples.

Establishing communication with relatives of admitted obstetric patients with COVID‐19 infection during COVID‐19 pandemic: A quality improvement initiative

Objectives

Methods

Results

Conclusion

SynopsisThe contents of this page will be used as part of issue TOC only. It will not be published as part of main article.

This quality improvement project establishes that communication with the relatives of isolated COVID‐19‐positive obstetrical patients could be easily streamlined without any additional resources.

Clinical Course and Outcome of Critically Ill Obese Patients with COVID-19 Admitted in Intensive Care Unit of a Single Center: Our Experience and Review

Introduction

Obesity has been considered as one of the independent risk factors for a severe form of coronavirus disease-2019 (COVID-19) and relationship between obesity, critical illness, and infection is still poorly understood. We herein discuss clinical course and outcome of critically ill obese patients with COVID-19 admitted to critical care unit.

Materials and methods

We retrospectively analyzed data of critically ill obese patients hospitalized with COVID-19 over a span of 6 months. Management was guided according to the institutional protocol. Collected data included demographic parameters (age, sex, comorbidities, and body mass index (BMI)), complications, inflammatory markers (interleukin (IL)-6, Ferritin), length of mechanical ventilation, length of intensive care unit (ICU) stay, and inhospital death.

Results

There was no appreciable difference in terms of demographics, inflammatory markers, predictors of mortality scores, and comorbidity indices between the survivors and nonsurvivors. Among outcome analysis, there was a statistically significant difference between ventilator days between survivors and nonsurvivors (p = 0.003^**).

Conclusion

Obesity itself is a significant risk factor for severe COVID-19 infection; however, if efficiently managed and in a protocol-determined manner, it can have a favorable outcome.

How to cite this article

Kaur M, Aggarwal R, Ganesh V, Kumar R, Patel N, Ayub A, et al. Clinical Course and Outcome of Critically Ill Obese Patients with COVID-19 Admitted in Intensive Care Unit of a Single Center: Our Experience and Review. Indian J Crit Care Med 2021;25(12):1382–1386.

Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review

Introduction

Air leak consisting of pneumothorax, pneumomediastinum, and subcutaneous emphysema has been described as one of the complications of coronavirus disease-2019 (COVID-19) infection affecting disease course and outcome. We aimed to conduct a systematic review of published literature to highlight the risk factors, types, and outcomes in COVID-19.

Method

A systematic search of PubMed, Embase, Scopus, and Google Scholar was performed from November 1, 2019, to February 28, 2021. Seventy-one studies fulfilled the inclusion criteria and 136 adult patients were included in the final analysis.

Results

Majority of patients were male (75.2%) with the mean age of 58 years. Hypertension was the most common comorbidity followed by diabetes mellitus. Moreover, 12.5% of patients had a history of smoking while 11.7% had preexisting lung disease. Isolated pneumothorax (48.5%) was the most common and 17.65% had developed spontaneous pneumothorax. Mean onset time was 11.6 days and 67% of patients required an intercostal drainage tube for management. Mortality was 40%, and elderly, female gender, obese and hypertensive were at higher risk.

Conclusion

COVID-19-related air leaks are associated with higher mortality and longer hospital stay and can occur even without positive pressure ventilation. History of smoking and preexisting lung disease has not been shown to increase the incidence of air leak. A well-designed study is required for a better understanding of COVID-19-related air leak.

How to cite this article

Singh A, Singh Y, Pangasa N, Khanna P, Trikha A. Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review. Indian J Crit Care Med 2021;25(12):1434–1445.

Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study

BACKGROUND AND AIMS

The prognosis of patients with cardiac arrest following trauma is poor. Our objectives were: (1) to determine outcomes of patients following in-hospital cardiac arrest posttrauma and admitted to the intensive care unit (ICU) and (2) to identify characteristics associated with in-hospital mortality.

MATERIALS AND METHODS

This was a single-center retrospective analysis of patients admitted to ICU after resuscitation following in-hospital cardiac arrest between January 2017 and July 2018. Patients with isolated head injuries and multiple cardiac arrests were excluded. Bivariate analysis was done to determine a significant association between baseline characteristics and in-hospital mortality.

RESULTS

A total of 37 patients were included. About 35.1% of trauma subjects survived hospital discharge. Bivariate analysis showed positive association between admission Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores with in-hospital mortality. Other characteristics, such as age, duration of cardiopulmonary resuscitation (CPR), and serum lactate levels on admission, were not associated with in-hospital mortality.

CONCLUSION

Despite being at lower survival following a cardiac arrest after trauma, approximately one-third of the patients survived hospital discharge. This implies that aggressive support of this population is not necessarily futile. Optimization of postresuscitation physiological factors and their impacts on outcomes for these patients need further studies.

HOW TO CITE THIS ARTICLE

Soni KD, Rai N, Aggarwal R, Trikha A. Outcomes of Trauma Victims with Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Centre: A Retrospective Cohort Study. Indian J Crit Care Med 2021;25(12):1408-1412.

Temporal Evolution of the PcvCO2-PaCO2/CaO2-CcvO2 Ratio vs Serum Lactate during Resuscitation in Septic Shock

Background

Lactate as a target for resuscitation in patients with septic shock has important limitations. The PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio may be used as an alternative for the same. The primary outcome of the study is to evaluate the correlation between serum lactate and PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio measured at various time points to a maximum of 24 hours in patients with septic shock [mean arterial pressure (MAP) <65 mm Hg]. The secondary outcomes were to study the (1) relationship between the PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio and lactate clearance at 6, 12, and 24 hours as compared to the initial serum lactate, (2) to ascertain whether the PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio and the arterial lactate levels in the first 24 hours are able to predict mortality at day 28 of enrollment, and (3) to determine whether the PcvCO₂–PaCO₂/ CaO₂–CcvO₂ ratio and arterial lactate are useful in discriminating survivors from nonsurvivors.

Materials and methods

Thirty patients with sepsis-induced hypotension who were being actively resuscitated were enrolled. Paired arterial and central venous blood samples were obtained 0.5 hourly till stabilization of MAP and 6 hourly thereafter for the first 24 hours. Patients were followed up to day 28 of enrollment for mortality and organ system failure.

Results

A positive correlation was observed between arterial lactate and PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio at 0, 6, 12, and 18 hours (R = 0.413, p = 0.02; R = 0.567, p = 0.001; R = 0.408, p = 0.025; R = 0.521, p = 0.003, respectively). No correlation was seen between PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio and lactate clearance. The subgroup analysis showed that PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio >1.696 at 24 hours of resuscitation predicted 28-day mortality (sensitivity: 80%, specificity 69.2%, area under the receiver operating characteristic curve 0.82).

Conclusion

The PcvCO₂–PaCO₂/CaO₂–CcvO₂ ratio and lactate are positively correlated during the first 24 hours of active resuscitation from sepsis-induced hypotension, and a threshold of 1.696 mm Hg/mL/dL at 24 hours significantly differentiates survivors from nonsurvivors (CTRI/2017/11/010342).

How to cite this article

Madabhushi S, Trikha A, Anand RK, Ramachandran R, Singh PM, Rewari V. Temporal Evolution of the PcvCO₂–PaCO₂/CaO₂–CcvO₂ Ratio vs Serum Lactate during Resuscitation in Septic Shock. Indian J Crit Care Med 2021; 25(12):1370–1376.

Clinical Features and Outcome of Stroke with COVID-19. COVID-19 Stroke Study Group (CSSG), India

Background and Purpose:

Occurrence of stroke has been reported among patients with COVID-19. The present study compares clinical features and outcomes of stroke patients with and without COVID-19.

Methods:

The COVID-19 Stroke Study Group (CSSG) is a multicentric study in 18 sites across India to observe and compare the clinical characteristics of patients with stroke admitted during the current pandemic period and a similar epoch in 2019. The present study reports patients of stroke with and without COVID-19 (CoVS and non-CoVS, respectively) seen between February 2020 and July 2020. Demographic, clinical, treatment, and outcome details of patients were collected.

Results:

The mean age and gender were comparable between the two groups. CoVS patients had higher stroke severity and extent of cerebral involvement on imaging. In-hospital complications and death were higher among CoVS patients (53.06% vs. 17.51%; P < 0.001) and (42.31% vs. 7.6%; P < 0.001), respectively. At 3 months, higher mortality was observed among CoVS patients (67.65% vs. 13.43%; P < 0.001) and good outcome (modified Rankin score [mRS]: 0–2) was seen more often in non-CoVS patients (68.86% vs. 33.33%; P < 0.001). The presence of COVID-19 and baseline stroke severity were independent predictors of mortality.

Conclusions:

CoVS is associated with higher severity, poor outcome, and increased mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and baseline stroke severity are independent predictors of mortality.

Timing of intraoperative crystalloid infusion may decrease total volume of infusate without affecting early graft function in live related renal transplant surgery: A randomized, surgeon-blinded clinical study

INTRODUCTION

Early graft function is crucial for successful kidney transplantation. Intravascular volume maintenance is paramount in ensuring reperfusion of transplanted kidney. This study was planned to compare whether the timing of fluid infusion can help to decrease amount of fluid given without altering early graft function during renal transplantation.

MATERIALS AND METHODS

The present study included forty recipients, randomized into standard (Group-S) or targeted fluid therapy (Group-T). Group S received fluid according to conventional fasting deficit while Group T received at 1 ml/kg/h from the start of surgery till start of vascular anastomosis after which fluid infusion rate in both group was increased to maintain a central venous pressure of 13-15 mm of Hg till reperfusion. Primary outcome measured was serum creatinine level on first postoperative day while secondary outcomes were IV fluid given, perioperative hemodynamics, onset of diuresis, graft turgidity, urine output, and renal function during first 6 postoperative days.

RESULTS

The study showed Group T postoperatively had early fall in serum creatinine (day 3) than S (day 6) although this difference was not statistically significant. Group T had received significantly less fluid per kg of dry weight (T-42.7 ± 9.7 ml/kg, S-61.1 ± 11.1 ml/kg, P < 0.001), had early diuresis, better graft turgidity and urine output than Group S.

CONCLUSION

Targeted hydration significantly decreases the total amount of fluid infused during the intraoperative period without altering early graft function. Targeted hydration during vascular anastomosis produced stable hemodynamics and early diuresis without any side-effects pertaining to hypo or hyper-volemia.Clinical trial identifier number-CTRI/2016/07/007111.

Characteristics & outcomes of cancer patients with COVID-19: A multicentre retrospective study from India

Background & objectives

High mortality has been observed in the cancer population affected with COVID-19 during this pandemic. We undertook this study to determine the characteristics and outcomes of cancer patients with COVID-19 and assessed the factors predicting outcome.

Methods

Patients of all age groups with a proven history of malignancy and a recent diagnosis of SARS-CoV-2 infection based on nasal/nasopharyngeal reverse transcriptase (RT)-PCR tests were included. Demographic, clinical and laboratory variables were compared between survivors and non-survivors groups, with respect to observed mortality.

Results

Between May 11 and August 10, 2020, 134 patients were included from the three centres and observed mortality was 17.1 per cent. The median age was 53 yr (interquartile range 39-61 yr) and thirty four patients (25%) were asymptomatic. Solid tumours accounted for 69.1 per cent and breast cancer was the most common tumour type (20%). One hundred and five patients (70.5%) had received chemotherapy within the past four weeks and 25 patients (19.3%) had neutropenia at presentation. On multivariate analysis, age [odds ratio (OR) 7.99 (95% confidence interval [CI] 1.18-54.00); P=0.033], haemoglobin [OR 6.28 (95% CI 1.07-37.04); P=0.042] neutrophil-lymphocyte ratio [OR 12.02 (95% CI 2.08-69.51); P=0.005] and baseline serum albumin [OR 18.52 (95% CI 2.80-122.27); P=0.002], were associated with higher mortality. Recent chemotherapy, haematological tumours type and baseline neutropenia did not affect the outcome.

Interpretation & conclusions

Higher mortality in moderate and severe infections was associated with baseline organ dysfunction and elderly age. Significant proportion of patients were asymptomatic and might remain undetected.

Comparison of disease profiles and three-month outcomes of patients with neurological disorders with and without COVID-19: An ambispective cohort study

Objective:

Methods:

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Conclusion: