Is EIT-guided positive end-expiratory pressure titration for optimizing PEEP in ARDS the white elephant in the room? A systematic review with meta-analysis and trial sequential analysis

Electrical Impedance Tomography (EIT) is a novel real-time lung imaging technology for personalized ventilation adjustments, indicating promising results in animals and humans. The present study aimed to assess its clinical utility for improved ventilation and oxygenation compared to traditional protocols. Comprehensive electronic database screening was done until 30th November, 2023. Randomized controlled trials, controlled clinical trials, comparative cohort studies, and assessments of EIT-guided PEEP titration and conventional methods in adult ARDS patients regarding outcome, ventilatory parameters, and P/F ratio were included. Our search retrieved five controlled cohort studies and two RCTs with 515 patients and overall reduced risk of mortality [RR = 0.68; 95% CI: 0.49 to 0.95; I2 = 0%], better dynamic compliance [MD = 3.46; 95% CI: 1.59 to 5.34; I2 = 0%] with no significant difference in PaO2/FiO2 ratio [MD = 6.5; 95%CI -13.86 to 26.76; I2 = 74%]. The required information size except PaO2/FiO2 was achieved for a power of 95% based on the 50% reduction in risk of mortality, 10% improved compliance as the cumulative Z-score of the said outcomes crossed the alpha spending boundary and did not dip below the inner wedge of futility. EIT-guided individualized PEEP titration is a novel modality; further well-designed studies are needed to substantiate its utility.

Intraoperative Regional Cerebral Oxygenation During Pediatric Thoracoscopic Surgery: A Systematic Review

Background: Ventilating a pediatric patient during thoracoscopy is challenging. Few studies have highlighted the impact of capnothorax in children by measuring regional cerebral oxygen saturation (rcSO2) with near infrared spectroscopy. In this systematic review, we aimed to summarize the data from relevant studies and assess whether thoracoscopy in children is associated with intraoperative pathological cerebral desaturation. Methods: The authors systematically searched four databases for relevant studies on the measurement of rcSO2 during pediatric thoracoscopic procedures. The primary outcome was the proportion of patients with pathological desaturation, that is, >20% decline in the intraoperative rcSO2. Risk of bias among the included studies was estimated using the Newcastle-Ottawa scale. Results: The systematic search resulted in 776 articles, of which 7 studies were included in the analysis. In total, 88 patients (99 procedures) with an age ranging from 0 days to 8.1 years were included. Of these, 43 (49%) patients were neonates. The included cohort had esophageal atresia and tracheoesophageal fistula (n = 26), long-gap esophageal atresia (n = 5), congenital diaphragmatic hernia (n = 14), and congenital pulmonary airway malformations and other conditions needing lung resection (n = 43). Of the total 99 procedures, pathological desaturation was noticed in 13 (13.1%, 95% confidence interval 7.2-21.4) of them. Upon quality assessment, most of the studies were weaker in the selection and comparability domains. Conclusion: In this review, pathological cerebral desaturation was noticed in 13.1% of the pediatric thoracoscopic procedures. However, due to limited methodological quality of the included studies, further randomized multicentric studies comparing rcSO2 in open versus thoracoscopic surgeries are needed to derive definitive conclusions.

Coadministration of intravenous calcium along with neostigmine for rapid neuromuscular blockade recovery: A systematic review and meta-analysis

Postoperative residual curarization (PORC) and the impact of the coadministration of intravenous calcium along with an acetylcholinesterase inhibitor on it are not well addressed. Extensive electronic database screening was done until October 7, 2022 after enlisting the protocol of this systematic review in PROSPERO (CRD42021274879). Randomized controlled trials (RCTs) evaluating the impact of intravenous calcium and neostigmine coadministration on neuromuscular recovery were included in this meta-analysis. Our search retrieved four RCTs with a total of 266 patients. The application of calcium shortened the neuromuscular recovery time (SMD = -2.13, 95% confidence interval [CI]: -2.66 to -1.59, I2 = 66%) and reduced the risk of PORC at 5 min (odds ratio [OR] = 0.21, 95% CI: 0.10-0.46, I2 = 0%), with an improved train-of-four (TOF) ratio at 5 min (mean difference [MD] = 9.28, 95% CI: 4-14.57, I2 = 66%). However, neither significant reduction in PORC at 10 min (OR = 0.41, 95% CI: 0.15-1.09, I2 = 0%) nor a better TOF ratio was associated with coadministration of calcium (MD = 0.40, 95% CI: -1.3-2.11). Coadministration of calcium along with neostigmine during the early period of neuromuscular blockade reversal can be used to enhance neuromuscular recovery.

Polygenic Risk Score for Cardiovascular Diseases in Artificial Intelligence Paradigm: A Review

Cardiovascular disease (CVD) related mortality and morbidity heavily strain society. The relationship between external risk factors and our genetics have not been well established. It is widely acknowledged that environmental influence and individual behaviours play a significant role in CVD vulnerability, leading to the development of polygenic risk scores (PRS). We employed the PRISMA search method to locate pertinent research and literature to extensively review artificial intelligence (AI)-based PRS models for CVD risk prediction. Furthermore, we analyzed and compared conventional vs. AI-based solutions for PRS. We summarized the recent advances in our understanding of the use of AI-based PRS for risk prediction of CVD. Our study proposes three hypotheses: i) Multiple genetic variations and risk factors can be incorporated into AI-based PRS to improve the accuracy of CVD risk predicting. ii) AI-based PRS for CVD circumvents the drawbacks of conventional PRS calculators by incorporating a larger variety of genetic and non-genetic components, allowing for more precise and individualised risk estimations. iii) Using AI approaches, it is possible to significantly reduce the dimensionality of huge genomic datasets, resulting in more accurate and effective disease risk prediction models. Our study highlighted that the AI-PRS model outperformed traditional PRS calculators in predicting CVD risk. Furthermore, using AI-based methods to calculate PRS may increase the precision of risk predictions for CVD and have significant ramifications for individualized prevention and treatment plans.

Functional near-infrared spectroscopy guided mapping of frontal cortex, a novel modality for assessing emergence delirium in children: A prospective observational study

INTRODUCTION

Despite an 18%-30% prevalence, there is no consensus regarding pathogenesis of emergence delirium after anesthesia in children. Functional near-infrared spectroscopy (fNIRS) is an optical neuroimaging modality that relies on blood oxygen level-dependent response, translating to a mean increase in oxyhemoglobin and a decrease in deoxyhemoglobin. We aimed to correlate the emergence delirium in the postoperative period with the changes in the frontal cortex utilizing fNIRS reading primarily and also with blood glucose, serum electrolytes, and preoperative anxiety scores.

METHODS

A total of 145 ASA I and II children aged 2-5 years, undergoing ocular examination under anesthesia, were recruited by recording the modified Yale Preoperative Anxiety Score after acquiring the Institute Ethics Committee approval and written informed parental consent. Induction and maintenance were done with O2, N2O, and Sevoflurane. The emergence delirium was assessed using the PAED score in the postoperative period. The frontal cortex fNIRS recordings were taken throughout anesthesia.

RESULTS

A total of 59 children (40.7%) had emergence delirium. The ED+ group had a significant activation left superior frontal cortex (t = 2.26E+00; p = .02) and right middle frontal cortex (t = 2.27E+00; p = .02) during induction, significant depression in the left middle frontal (t = -2.22E+00; p = .02), left superior frontal and bilateral medial (t = -3.01E+00; p = .003), right superior frontal and bilateral medial (t = -2.44E+00; p = .015), bilateral medial and superior (t = -3.03E+00; p = .003), and right middle frontal cortex (t = -2.90E+00; p = .004) during the combined phase of maintenance, and significant activation in cortical activity in the left superior frontal cortex (t = 2.01E+00; p = .0047) during the emergence in comparison with the ED- group.

CONCLUSION

There is significant difference in the change in oxyhemoglobin concentration during induction, maintenance, and emergence in specific frontal brain regions between children with and without emergence delirium.

Feasibility of anterior temporalis muscle ultrasound for assessing muscle wasting in ICU: a prospective cohort study

PURPOSE

Skeletal muscle ultrasound is a valuable tool for assessing muscle wasting in ICU. Previous studies on skeletal muscle ultrasound in ICU have been performed on lower limb muscles. The current study is formulated to assess the feasibility and reliability of anterior temporalis (AT) muscle ultrasound for measuring muscle wasting in ICU.

METHODS

In this prospective cohort study in 48 critically ill patients with sepsis, muscle layer thicknesses (MLTs) and mean grayscale (GS) values of anterior temporalis muscles and quadriceps femoris (Q) were measured at baseline and serially till 7 days. Correlation was made between baseline and change in MLT and GS values of AT and Q muscle and these parameters were compared between ICU survivors and non survivors.

RESULTS

Baseline anterior temporalis MLTs or their longitudinal changes over 7 days did not correlate significantly with the corresponding parameters of quadriceps femoris muscles. The baseline GS values of two muscle groups correlated weakly at baseline, but the change in GS over 7 days showed no correlation. The baseline MLTs of both muscle groups and their longitudinal change over 7 days did not correlate with ICU length of stay. The change in MLT of AT over 7 days was significantly greater in ICU non-survivors compared to survivors.

CONCLUSION

Measurement of ultrasonographic muscle layer thickness and grayscale parameters of anterior temporalis muscle did not show good correlation with that of quadriceps muscle.

Comparative evaluation of isoflurane and desflurane for postoperative cognitive decline in elderly patients: A prospective observational pilot study

BACKGROUND

Approximately 16%-62% of patients undergoing non cardiac surgeries develop postoperative cognitive dysfunction. We compared the incidence of postoperative cognitive dysfunction in older adults aged 60-80 years who underwent open abdominal surgeries under general anaesthesia using isoflurane or desflurane and correlated it with the serum concentration of interleukin 1, interleukin 6, tumour necrosis factor alpha, amyloid β and S100 on postoperative day 3.

METHOD

Forty American Association of Anesthesiologists Physical Classification I or II patients were included after acquiring institutional ethics committee approval, registering in the Clinical Trials Registry - India, and informed written consent. They underwent open abdominal surgery under general anaesthesia and epidurals between 2017 and 2019. Patients with substance abuse or any disorder affecting cognition were excluded. Postoperative cognitive dysfunction was assessed by Stroop test, Wisconsin Card Sorting Test, Trail making test - B, Porteus Maze test, PGI memory scale, mini-mental state examination, and Bender Gestalt test the day before surgery and on the third postoperative day along with blood samples.

RESULTS

Thirty-seven percent of the patients developed postoperative cognitive dysfunction. The risk was similar to isoflurane in comparison with desflurane (risk ratio: 0.65, 95% confidence interval: 0.30, 1.40). A significant percentage increase in reaction time for Porteus Maze test and Trail making test - B was noted with isoflurane (6.69 (4.20-8.94) and 8.01 (2.08-12.5), respectively) in comparison with desflurane group (13.01 (9.09-17.33), p = 0.003 and 11.62 (7.5-17.5), p = 0.017, respectively).

CONCLUSION

Isoflurane and desflurane had a similar impact on the elderly for developing postoperative cognitive dysfunction and no correlation with any of the biomarkers used in the study on postoperative day 3.

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.

Impact of intravenous dexamethasone on the initiation and recovery of atracurium in children: A double-blinded randomized controlled trial

BACKGROUND

Chronic steroid intake has been associated with attenuation of neuromuscular block. Despite some promising animal and adult studies, the effect of a single dose of intravenous dexamethasone on neuromuscular blockers is not well established. Thus, the present study aimed to demonstrate the effect of dexamethasone given at the time of induction for the prevention of PONV on the action of neuromuscular blockers in children undergoing elective surgery.

METHOD

After obtaining approval from the Institute Ethics Committee and written informed parental consent, 100 ASA I and II children aged 4-15 years undergoing elective surgery randomized to receive either: 0.15 mg/kg (maximum of 5 mg) of dexamethasone diluted to a total volume of 2 ml with 0.9% saline (n = 50) or 2 ml of 0.9% saline (n = 50) at the time of induction. The time interval between application of atracurium and maximum T1 depression, 25% twitch height recovery of T1, amid 25% and 75% twitch height recovery of T1, amid the 25% twitch height recovery of T1 and recovery of the neuromuscular block to a TOF ratio of 0.9, and in between the initiation of atracurium injection till the recovery of the neuromuscular block to a TOF ratio of 0.9 was defined as onset time, clinical duration, recovery index, recovery time, and total recovery period, respectively, and recorded.

RESULTS

The onset time and recovery index time were lower (1.96 ± 0.39, 8.04 ± 2.14, respectively) with dexamethasone in comparison with saline (2.01 ± 0.51, 8.9 ± 3.4, respectively) but not statistically significant. The clinical duration, recovery time, and total recovery period were similar.

CONCLUSION

Application of a single bolus dose (0.15 mg/kg) of dexamethasone during induction does not attenuate atracurium-induced neuromuscular blockade in children.

Utility of high-flow nasal oxygen in comparison to conventional oxygen therapy during upper gastrointestinal endoscopic procedures under sedation: A systematic review and meta-analyses

BACKGROUND

Sedation and analgesia are the integral components of modern-day upper gastrointestinal (GI) endoscopic procedures. Irrespective of the sedative agent, hypoxia is the most commonly encountered unwarranted event with sedation. The current study intends to scrutinize whether high-flow nasal oxygen (HFNO) is advantageous for providing respiratory support during upper GI endoscopic procedures over other conventional low-flow oxygen delivery modalities, e.g. nasal cannula, facemask, etc. METHODS: An extensive screening of electronic databases was done till July 31, 2022, after enlisting in International prospective register of systematic reviews (PROSPERO) (CRD42021245409). Randomized controlled trials (RCT), comparative cohort studies, case series, cross-sectional studies and case-control studies evaluating the utility of HFNO during upper GI endoscopy under sedation were included in this meta-analysis.

RESULTS

We retrieved eight randomized control studies and one longitudinal study with 3294 patients. The application of HFNO during endoscopy led to lesser incidence of desaturation spells (odds ratio [OR] = 0.23; 95% CI 0.11-0.48; I² = 71%), reduced procedural interruption (OR = 0.11; 95% CI 0.02-0.60; I² = 88%), better nadir SpO² level during procedure (mean difference [MD] = 3.16; 95% CI 0.54-5.78; I² = 73%), overall lesser incidence of sedation-related adverse events (OR = 0.63; 95% CI 0.42-0.93; I² = 25%), with no significant impact on the duration of endoscopy (MD = 0.15; 95% CI - 0.02 to 0.31, I² = 0%).

CONCLUSION

HFNO is a novel option for upper GI endoscopy under sedation.

CLINICAL TRIAL NUMBER AND REGISTRY URL

CRD42021245409 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021245409 ).

The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review

Background

The utility of instantaneous evaluation of coagulation during primary postpartum haemorrhage (PPH) is paramount in the context of empirical blood product transfusion-related risk of dilutional and consumptive coagulopathy and circulatory overload.

Methods

A profound screening of electronic databases till August 15, 2022 was carried out after being enlisted in PROSPERO (CRD42021275514). Randomized control studies, comparative cohort studies, and cross-sectional studies comparing point-of-care viscoelastic test guided blood product transfusion with empirical transfusion in patients with PPH were included.

Results

We retrieved five studies, with a total of 1914 parturient with PPH. Patients receiving transfusion based upon point of care viscoelastic tests had lesser risk of having emergency hysterectomy (Odds ratio (OR) = 0.55, 95% CI 0.32-0.95, I2 = 7%), transfusion-associated circulatory overload (TACO) (OR = 0.03, 95% CI 0.00-0.50), reduced transfusion of fresh frozen plasma (OR = 0.07, 95% CI 0.04-0.14, I2 = 89%), platelets (OR = 0.51, 95% CI 0.28-0.91, I2 = 89%), packed red blood cell transfusion (OR = 0.70, 95% CI 0.55-0.88, I2 = 89%), and had better cost-effective treatment [Mean difference (MD) = -357.5, 95% CI - 567.75 to -147.25, I2 = 93%] than patient received empirical transfusion. However, there was no significant difference in the requirement of ICU admissions (OR = 0.77, 95% CI = 0.46-1.29, I2 = 82%). No mortality was detected across the studies.

Conclusions

Point of care viscoelastic assessment guided transfusion in PPH confederates with reduced morbidity. Nevertheless, more studies on the triggering values for transfusion, long-term survival, and cost-benefit in patients with PPH are warranted to establish its utility.

Comparative evaluation of intraoperative dexmedetomidine versus lidocaine for reducing postoperative cognitive decline in the elderly: a prospective randomized controlled trial

INTRODUCTION

Neuroinflammation, neuronal cytotoxicity, and apoptosis due to exposure to anaesthetic agents are often implicated in postoperative cognitive dysfunction (POCD). Lidocaine and dexmedetomidine have been shown to suppress the neuron-specific markers of inflammation, and we aimed to compare their neuroprotective efficacy in elderly patients.

MATERIAL AND METHODS

This prospective randomized control study compared the incidence of POCD in ASA I/II patients aged 60 to 80 years without any history of substance abuse or any disorder affecting cognition. Dexmedetomidine and lidocaine were administered intraoperatively, and their effects on POCD were correlated with serum levels of IL-1, IL-6, TNF-a, amyloid-β, and S100 on postoperative day 3. POCD was assessed by the Stroop test, Trail making test-B, Porteus Maze test, Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) on the day before surgery and the third postoperative day, along with blood samples.

RESULTS

Demographic parameters, anaesthesia duration, exposure to anaesthetic gases, intraoperative opioid use, and blood transfusion were similar in the lidocaine ( n = 31) and dexmedetomidine ( n = 29) groups. The incidence of POCD was 29.03% in the lidocaine group and 24.1% in the dexmedetomidine group ( P = 0.77). On postoperative day 3, IL-1 levels increased by 449% with lidocaine and 202% with dexmedetomidine ( P = 0.03). TNF-a, IL-6, and S-100β levels increased similarly in both groups. There was no significant correlation between percentage changes in neuropsychological tests and biomarkers.

CONCLUSIONS

There was no significant difference in the incidence of POCD, but dexmedetomidine had a better anti-inflammatory effect in terms of lesser rise of postoperative IL-1 compared to lidocaine.

Ketamine and dexmedetomidine (Keto-dex) or ketamine and propofol (Keto-fol) for procedural sedation during endoscopic retrograde cholangiopancreatography: Which is safer? A randomized clinical trial

BACKGROUND

Optimum procedural sedation is very essential for conducting non-operating room procedures such as endoscopic retrograde cholangiopancreatography (ERCP). The combination of ketamine and dexmedetomidine (KD) is expected to balance out the undesirable effects of either drug and provide smooth sedation. Together ketamine and propofol (KP) also provide synergistic sedation with stable hemodynamics. This prospective, single-blinded randomized study aimed to compare the effect of both the combinations during ERCP in terms of oxygen desaturation, respiratory depression, hemodynamic parameters, analgesia, recovery time, and ease with which the endoscopist could perform the endoscopy.

METHODS

This prospective, single-blinded randomized study (CTRI/2019/08/020625) was conducted on 84, ASA (American Society of Anesthesiologists) physical status I or II patients, of age 18-65 years presenting for ERCP in a tertiary care center. They were randomized to receive either KD (n=42) or KP (n=42) combination during ERCP. Mean SPO₂ at the end of the procedure was compared between the groups. Apart from these periprocedural hemodynamic and respiratory parameters, pain scores on arrival in the recovery room (t0), 15 minutes (t15), and 30 minutes (t30), recovery time, and endoscopist's satisfaction as per a Likert's scale were recorded.

RESULTS

The mean SpO₂ (SpO₂ recorded every minute during the procedure and averaged over procedure time in minutes) in group KP (97.7 [96.1-98.6]) was significantly lower than group KD (98.5 [98.1-98.8]) (p=0.005). The post-procedure pain scores measured at t0 and t15 were higher in group KP (p<0.001 and p=0.043), and comparable at t30 in both the groups (p=0.711). The time to achieve Modified Aldrete score (MAS) ≥ 9 was significantly more in group KD (p<0.001). The lowest mean arterial pressure and heart rate in group KD were significantly lower than in group KP (p<0.001, p=0.006, respectively). The overall endoscopist satisfaction was better in group KP compared to group KD (p= 0.011).

CONCLUSIONS

The combination of ketamine-dexmedetomidine for procedural sedation during ERCP is a safe alternative to ketamine-propofol with a better respiratory profile.

CLINICAL TRIAL NUMBER AND REGISTRY URL

CTRI/2019/08/020625 ( www.ctri.nic.in ).

Respiratory vaccination

Vaccinations are among the most cost-effective preventive health strategies to reduce healthcare costs and prevent morbidities. Every year, many adults and elderly encounter hospitalization because of infectious respiratory diseases. Among these, viral and bacterial pneumonia, tuberculosis, diphtheria and pertussis infections are some of the diseases that can be prevented and managed with fewer complications, with adequate preventive immunization. This review tries to outline the vaccines available for the prevention of these respiratory ailments along with their schedule and dosages.

The Impact of High-flow Nasal Cannula vs Other Oxygen Delivery Devices during Bronchoscopy under Sedation: A Systematic Review and Meta-analyses

Background

The widespread diagnostic and therapeutic application of bronchoscopy is often associated with complications like desaturation. This systematic review and meta-analysis intend to scrutinize whether the high-flow nasal cannula (HFNC) is advantageous for providing respiratory support during bronchoscopic procedures under sedation, in comparison with other conventional modalities for oxygen therapy.

Materials and methods

A thorough screening of electronic databases was done till 31st December 2021 after obtaining registration in PROSPERO (CRD42021245420). Randomized controlled trials (RCT), evaluating the impact of HFNC and standard/any other oxygen-delivery devices during bronchoscopy were included in this meta-analysis.

Results

We retrieved in nine RCTs, with a total of 1306 patients, the application of HFNC during bronchoscopy led to decreased number of desaturation spells [relative risk (RR) 0.34, 95% confidence interval (CI) 0.27-0.44, I ² = 23%], higher nadir value of SpO₂ [Mean difference (MD) 4.30, 95% CI 2.41-6.19, I ² = 96%], and improved PaO₂ from baseline (MD 21.77, 95% CI 2.8-40.74, I ² = 99%), along with similar PaCO₂ values (MD -0.34, 95% CI -1.82 to 1.13, I ² = 58%) just after the procedure. However, apart from desaturation spell, the findings are significantly heterogeneous. In subgroup analysis, HFNC had significantly lesser desaturation spells and better oxygenation than low-flow devices, but in comparison to noninvasive ventilation (NIV) had a lower nadir value of SpO₂ with no other significant difference.

Conclusion

High-flow nasal cannula led to greater oxygenation and prevented desaturation spells more effectively in comparison with low-flow devices like nasal cannula, venturi mask, etc., and may be considered as an alternative to NIV during bronchoscopy in certain high-risk patients.

How to cite this article

Roy A, Khanna P, Chowdhury SR, Haritha D, Sarkar S. The Impact of High-flow Nasal Cannula vs Other Oxygen Delivery Devices during Bronchoscopy under Sedation: A Systematic Review and Meta-analyses. Indian J Crit Care Med 2022;26(10):1131-1140.

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.

Comparison of Serum Nucleosomes and Tissue Inhibitor of Metalloproteinase1 (TIMP1) in Predicting Mortality in Adult Critically Ill Patients in Sepsis: Prospective Observational Study

Background

Sepsis is a life-threatening organ dysfunction due to dysregulated host response to infection. Timely identification is important for risk reduction and better outcomes in critically ill patients. Nucleosomes and tissue inhibitors of metalloproteinase1 (TIMP1) are the biomarkers whose validity and utility in predicting organ dysfunction and mortality in sepsis have been proven. However, which biomarker among these two has better predictive value in elucidating disease severity, organ dysfunction, and mortality in sepsis is yet to be answered, and further studies are needed.

Methods

Eighty patients with sepsis/septic shock, aged between 18 and 75 years admitted in intensive care unit (ICU) were recruited in this prospective observational trial. Quantification of serum nucleosomes and TIMP1 was done using enzyme linked immunosorbent assay (ELISA) within 24 hours of diagnosis of sepsis/septic shock. The primary outcome was to compare the predictability of nucleosomes and TIMP1 in estimating sepsis mortality.

Results

The area under the receiver operating characteristic curve (AUROC) for TIMP1 and nucleosomes to discriminate between survivors and non-survivors were 0.70 [95% Confidence interval (CI), 0.58-0.81] and 0.68 (0.56-0.80), respectively. Although independent, TIMP1 and nucleosomes have statistically significant capacity to discriminate between survivors and non-survivors (p = 0.002 and p = 0.004, respectively), superiority of one biomarker over the other in discriminating between survivors and non-survivors was not observed.

Conclusion

The median values of each biomarker showed statistically significant differences between survivors and non-survivors, superiority of one biomarker over other in predicting mortality was not observed. However, this was an observational study and larger studies are needed in the future to validate the findings of this study.

How to cite this article

Rai N, Khanna P, Kashyap S, Kashyap L, Anand RK, Kumar S. Comparison of Serum Nucleosomes and Tissue Inhibitor of Metalloproteinase1 (TIMP1) in Predicting Mortality in Adult Critically Ill Patients in Sepsis: Prospective Observational Study. Indian J Crit Care Med 2022;26(7):804-810.

OP0170 PHASE 2A, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY OF THE EFFICACY AND SAFETY OF A TRANSDERMAL ALKALINIZING AND PAIN-RELIEVING TREATMENT FOR REDUCING PAIN ASSOCIATED WITH AN ACUTE GOUT FLARE

Background

Monosodium urate (MSU) deposition is pathognomonic for gouty arthropathy. MSU crystal formation and dissolution is affected by pH and theoretically, alkalinizing agents (eg, sodium bicarbonate, NaHCO₃) that raise the joint microenvironment pH, could facilitate MSU crystal dissolution1 and decrease the pain of an acute gout flare. However, oral NaHCO₃ use is fraught with intolerable gastrointestinal side effects.

Objectives

To determine if NaHCO₃ in a patented transdermal formulation could effectively and safely reduce the pain of an acute gout flare.

Methods

A Phase 2a prospective, double-blind, randomized, placebo-controlled study enrolled 418 subjects across 20 US sites. Patients with a diagnosis of gout using ACR/EULAR criteria (Score ≥ 8), ages 18-75, history of ≥ 2 gout flares in 12 months prior to randomization and on stable doses of urate lowering therapy were included. Exclusion criteria were BMI > 40kg/m2, > 12 gout flares in the year prior to randomization, history of rheumatoid arthritis, psoriatic arthritis, evidence of septic arthritis, acute polyarticular gout (≥ 4 joints), and arthritis of any other cause. Patients were randomized to receive placebo lotion or transdermal NaHCO₃. Upon flare they initiated colchicine (1.2 mg followed by 0.6 mg 1 hour later) and applied study product to the limb of the affected joint. Outcome measures included pain-numeric rating scale (NRS, 0-10), time to resolution of pain (50% reduction), rescue medication use, joint tenderness, and physical function (PROMIS PF-20). Data were collected in patient diaries for the pain and PROMIS measures at several time points from baseline through Day 7, as were adverse events. Statistical analyses utilized ANCOVA (baseline pain as a covariate), Kaplan-Meier curves for homogeneity, and two-proportion z-test, all with α=0.05.

Results

98 patients had a gout flare during the 14-month study period. Those in the active arm (ITT, N=48) had an overall responder rate of 94.5% vs. 79.3% (p=0.01) in the placebo arm (ITT, N=50) over the 7-day follow up. Rescue medication use was lower in the active arm vs. placebo (6.3% vs. 20.0%, p=0.02); and PROMIS PF-20 showed greater improvements over 7 days (22.2 vs. 16.7 points, p=0.05). The most common adverse event was hypertension (14.2%) with no significant difference between arms. Per protocol analyses were conducted to adjust for adherence on Day 1 for time to resolution of pain (Figure 1) and additional 24hr endpoints (Table 1).

Table 1.

Key 24hr Endpoints (Per Protocol, n = 57)

Active (n = 28)Placebo (n = 29)P valueMedian time to resolution, hrs124720.03Change in 24hr PROMIS PF-20 score216.79.40.01Physician-assessed moderate-to-severe joint tenderness 24hr328.0%57.1%0.02

1≥ 50% reduction in pain; K-M Est.; Subjects using rescue medication, discontinuing study drug, or missing pain scores censored

2Consists of 20, 0-5-point questions; higher scores indicate better function

3LIKERT: 0 (no pain), 1 (pain), 2 (wincing), 3 (wincing and withdrawal)

Figure 1.

Time to resolution of pain1 (per protocol population, n = 57)

Conclusion

Transdermal NaHCO₃ reduced the pain intensity and duration of an acute gout flare with higher overall response rates, faster time to resolution, improvements in physical function and a reduction in rescue medication use. The lack of adverse events makes this topical a promising therapeutic choice; especially during debilitating acute gout flares in patients with concomitant comorbidities.

References

[1]Chhana et al, BMC Musculoskelet Disord, 2015

Disclosure of Interests

Puja Khanna Consultant of: Dyve, Horizon, Selecta, Cerecor, Grant/research support from: Dyve, Horizon, Selecta, Cerecor, Ryan Beal Shareholder of: Dyve, Employee of: Dyve

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.

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.

Onset Time of Spinal Anaesthesia in Pregnant Females in Knee-Chest Position: A Randomized Controlled Study

Objective

To assess the efficacy of knee-chest position in shortening the time of spinal induction in pregnant women undergoing elective cesarean section. We also assessed for any untoward adverse events that might limit their usefulness in real-life clinical scenarios.

Methods

Prospective, randomized controlled study was done in maternity operating room of tertiary care institution in 45 ASA II pregnant women undergoing elective cesarean section under spinal anaesthesia. Patients were randomly assigned to groups S (supine) and K (knee-chest position). After performing subarachnoid block (9 mg of 0.5% hyperbaric bupivacaine and 25 µg fentanyl) in the sitting position, women in group K were maintained in the knee-chest position for 60 seconds. Time to attain block height of T6 and maximum sensory blockade, intraoperative hemodynamics, Bromage score, intraoperative fluid, vasopressor requirement, and respiratory parameters were recorded. The newborn was evaluated using Apgar scores at 1 and 5 minutes.

Results:

Data of 45 patients were analyzed. Time to attain T6 block height (group K = 2.1 ± 0.65 minutes, 95% CI: 1.83-2.39; group S = 6.4 ± 0.77 minutes, 95% CI: 6.10-6.78) and time to achieve maximum sensory block height were significantly lower in group K (group K = 3.2 ± 1.35 minutes, 95% CI: 2.61-3.78; group S = 6.6 ± 0.89 min, CI: 6.19-6.98). The degree of motor block was higher in group K than that of group S at 2 minutes (P = .0002), 4 minutes (P < .0001), and 6 minutes (P < .0001), with no difference at 8 minutes. No statistically significant difference was observed in fluids and vasopressors requirement intraoperatively.

Conclusions

This study provides evidence that the onset of adequate surgical anaesthesia for the cesarean section can be hastened by placing the patient in the knee-chest position for a minute after performing the subarachnoid block in the sitting position.

Role of red blood cell distribution width, as a prognostic indicator in COVID-19: A systematic review and meta-analysis

The red blood cell distribution width (RDW), an indicator of anisocytosis has emerged as a potential tool for risk stratification of critically ill patients with sepsis. Prognostic predictors are of paramount interest for prompt intervention and optimal utilization of the healthcare system in this ongoing context of the Coronavirus Disease 2019 (COVID-19) pandemic. The current systematic review and meta-analysis aims to explore the utility of RDW in the prognosis of COVID-19 patients. A comprehensive screening of electronic databases was performed up to 30th April 2021 after enrolling in PROSPERO (CRD42020206685). Observational studies or interventional studies, evaluating the impact of RDW in COVID-19 outcomes (mortality and severity) are included in this meta-analysis.Our search retrieved 25 studies, with a total of 18,392 and 3,446 COVID-19 patients for mortality and disease severity outcomes. Deceased and critically ill patients had higher RDW levels on admission in comparison to survivors and non-severe patients (SMD = 0.46; 95%CI 0.31-0.71; I2  = 88% and SMD = 0.46; 95%CI 0.26-0.67; I2  = 60%, respectively). In a sub-group analysis of 2,980 patients, RDW > 14.5 has been associated with increased risk of mortality (OR = 2.73; 95%CI 1.96-3.82; I2  = 56%). However, the evidences is of low quality. A higher level of RDW on admission in COVID-19 patients is associated with increased morbidity and mortality. However, further studies regarding the cut-off value of RDW are the need of the hour.

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.

Tracheostomy in Patients with Coronavirus Disease 2019: An Overview

As the coronavirus disease 2019 (COVID-19) pandemic is gripping the entire world, many patients are mainly presenting with respiratory problems and subsequently require intubation and mechanical ventilation in severe cases. The need to perform tracheostomy may arise, and the intensivist, anaesthetist, and other surgical specialties may be asked to perform a tracheostomy in known COVID-19 or suspected patients. Surgeons should be prepared for this eventuality while performing the procedures, taking all the measures to keep themselves and their team members safe from the undue risk of infection and exposure. This is a brief review of all the evidence present, till now, for those who will be performing tracheostomy in such patients.

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.

Dura-to-spinal cord distance at different vertebral levels in Indian children: A retrospective computerized tomography scan-based study

Background:

Neuraxial techniques provide good postoperative analgesia for painful procedures in the pediatric population. However, any injury to the spinal cord can lead to irreversible long-term effects.

Aims:

We aimed to evaluate dura-to-cord (DTC) distance from computerized tomography (CT) images of thoracolumbar spine in pediatric age group (1–16 years) at T_8–9, T_9–10, and L_1–2 interspaces to identify the safe space for epidural insertion in Asian children.

Settings and Design:

It was a retrospective study including 141 children aged 1–16 years who underwent routine CT scan of the thoracolumbar region for unrelated diagnostic indications.

Materials and Methods:

Patients with spinal abnormalities were excluded. Sagittal CT images of the thoracolumbar spine were obtained to calculate the DTC at T_8–9, T_9–10, and L_1–2 interspaces. The measurements at all levels were obtained perpendicular to the long axis of the vertebral body.

Statistical Analysis Used:

Continuous data were depicted as mean with standard deviations. The categorical data were presented as counts with percentages.

Results:

The mean DTC distance at T_8–9, T_9–10, and L_1–2 interspaces was 3.51 ± 0.98 mm (95% confidence interval [CI]: 3.35–3.67), 2.73 ± 0.94 mm (95% CI: 2.57–2.89), and 2.83 ± 1.08 mm (95% CI: 2.66–3.02), respectively. A significant difference was found between the genders at T_9–10 (P = 0.02) and L_1–2 levels (P = 0.04). No difference in DTC was found in toddlers, preschool children, school-going children, and adolescents. DTC at T_8–9 showed a significant correlation with age (R² = 0.0479; P = 0.04), weight (R² = 0.038; P = 0.02), and height (R² = 0.037; P = 0.03).

Conclusion:

Thoracic epidural space can be used in children and adolescents for epidural catheter placement. T_8–9 level showed maximum DTC distance and significant correlation with age, height, and weight in CT imaging in the present study.

Anesthesia for Per-oral endoscopic myotomy (POEM) – not so poetic!

Peroral endoscopic myotomy (POEM) is a promising natural orifice transluminal endoscopic procedure for the treatment of esophageal motility disorders, with similar effectiveness as of Heller myotomy. It is performed under general anesthesia in endoscopy suite. Creation of submucosal tunnel in the esophageal wall is a key component. The continuous insufflation of CO₂ inadvertently tracks into surrounding tissues and leads to capno mediastinum, capno thorax, capno peritoneum, and subcutaneous emphysema. Thus, the challenges, for an anesthesiologist are not only providing remote location anesthesia, increased risk of aspiration during induction, but also early detection of these complications and specific emergency management. Though a therapeutic innovation, POEM remains an interdisciplinary challenge with no specific anesthesia care algorithms and evidence-based recommendations. The purpose of this review is to outline the anesthesia and periprocedural practices based on existing evidence.

Posaconazole in the Prevention of COVID-19-associated Mucormycosis: A Concerning Contributor to the Rise in Antifungal Resistance

How to cite this article: Kayarat B, Khanna P. Posaconazole in the Prevention of COVID-19-associated Mucormycosis: A Concerning Contributor to the Rise in Antifungal Resistance. Indian J Crit Care Med 2021;25(10):1209–1210.

Accuracy of predictive equations in guiding tracheal intubation depth in children: A prospective study

BACKGROUND

Accurate insertion depth of endotracheal tube (ETT) in children has been predicted using the demographic variables, such as age, weight, and height. Middle finger length showed good correlation with ETT depth measurement in children aged 4-14 years.

AIMS

The primary objective was to correlate the actual ETT insertion depth with the depth derived from middle finger length, age, weight, and height formulae in children aged 1-4 years. The secondary objective was to find the most accurate formula for prediction of ETT insertion depth.

METHODS

This prospective parallel group study was done in 50 american society of anesthesiologists 1 or 2 children aged 1-4 years undergoing elective surgery under general anesthesia. Children with difficult airway, finger anomalies, or syndromic associations were excluded. Age, weight, height, and middle finger length of all children were measured. Depth of orally inserted uncuffed ETT and tracheal length was measured by fiberoptic bronchoscopy. The actual ETT depth was correlated with the depth calculated from different formulae.

RESULTS

The mean middle finger length was 4.42 ± 0.50 cm, age was 2.64 ± 1.07 years, weight was 12.28 ± 2.84 kg, and height was 82.89 ± 16.23 cm. The mean tracheal length was 6.42 ± 0.96 cm. The mean depth of ETT was actual depth (12.89 ± 1.09 cm), middle finger depth (13.23 ± 1.53cm; p = .001; 95%CI 0.12-0.50), age-based depth 1(3.31 ± 0.53 cm; 95%CI 0.37-1.44; p = .001), weight-based depth (14.14 ± 1.42 cm; 95% CI 0.10-0.51; p = .004), and height-based depth (13.73 ± 0.94 cm; 95% CI 0.15-0.77; p = .004). Middle finger length and age-based formulae showed higher number of accurate placements (58% each). Weight- (74%) and height (64%)-derived formulae gave a higher number of distal ETT placements.

CONCLUSION

Formulas based on the demographic variables and middle finger length showed good correlation with the actual ETT depth in children aged 1-4 years. The percentage of accurate ETT depth placements was higher with middle finger length and age-based formulae.

Comorbidities in Obsessive-Compulsive Disorder Across the Lifespan: A Systematic Review and Meta-Analysis

Comorbidities are seen with obsessive-compulsive disorder (OCD) across the lifespan. Neurodevelopmental comorbidities are common in young children, followed by mood, anxiety, and obsessive-compulsive related disorders (OCRDs) in children, adolescents and adults, and neurological and degenerative disorders in the elderly. Understanding comorbidity prevalence and patterns has clinical and research implications. We conducted a systematic review and meta-analysis on comorbidities in OCD across the lifespan, with the objective to, first, estimate age-wise pattern and prevalence of comorbidities with OCD and, second, to examine associations of demographic (age at assessment, gender distribution) and clinical characteristics (age of onset, illness severity) with comorbidities. Four electronic databases (PubMed, EMBASE, SCOPUS, and PsycINFO) were searched using predefined search terms for articles published between 1979 and 2020. Eligible studies, across age, reported original findings on comorbidities and had an OCD sample size of ≥100. We excluded studies that did not use standardised diagnostic assessments, or that excluded patients on the basis of comorbidity. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review protocol has been registered on the International Prospective Register of Systematic Reviews. A comorbidity rate of 69% was found in a pooled sample of more than 15,000 individuals. Mood disorders (major depressive disorder), anxiety disorders (generalised anxiety disorder), neurodevelopmental disorders (NDDs) and OCRDs were the commonest comorbidities. Anxiety disorders prevailed in children, mood disorders in adults, whereas NDDs were similarly prevalent. Higher comorbidity with any psychiatric illness, NDDs, and severe mental disorders was seen in males, vs. females. Illness severity was inversely associated with rates for panic disorder, tic disorders, OCRDs, obsessive compulsive personality disorder, and anorexia nervosa. This systematic review and meta-analysis provides base rates for comorbidities in OCD across the lifespan. This has implications for comprehensive clinical evaluation and management planning. The high variability in comorbidity rates suggests the need for quality, multi-centric, large studies, using prospective designs. Systematic Review Registration: Unique Identifier: CRD42020215904.

Vitamin C and COVID-19 treatment: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Vitamin C has been used as an anti-oxidant in various diseases including viral illnesses like coronavirus disease (COVID-19).

METHODS

Meta-analysis of randomized controlled trials (RCT) investigating the role of vitamin C supplementation in COVID-19 was carried out.

RESULTS

Total 6 RCTs including n = 572 patients were included. Vitamin C treatment didn't reduce mortality (RR 0.73, 95% CI 0.42 to 1.27; I² = 0%; P = 0.27), ICU length of stay [SMD 0.29, 95% CI -0.05 to 0.63; I² = 0%; P = 0.09), hospital length of stay (SMD -0.23, 95% CI -1.04 to 0.58; I² = 92%; P = 0.57) and need for invasive mechanical ventilation (Risk Ratio 0.93, 95% CI 0.61 to 1.44; I² = 0%; P = 0.76). Further sub-group analysis based on severity of illness (severe vs. non-severe), route of administration (IV vs. oral) and dose (high vs. low) failed to show any observable benefits.

CONCLUSION

No significant benefit noted with vitamin C administration in COVID-19. Well-designed RCTs with standardized control group needed on this aspect.

Convalescent Plasma-A Light at the End of the Tunnel: A Systematic Review and Meta-analysis of Randomized Controlled Trials

In the absence of a definitive therapy during this ongoing unprecedented crisis, coronavirus disease-2019 (COVID-19) pandemic, convalescent plasma transfusion (CPT) has shown some promising results. This review summarizes the existing evidence of the efficacy of CPT in COVID-19 patients based upon scientific publications to date. We have included only the randomized controlled trials (RCTs) through an extensive screening of electronic databases up to July 31, 2021. In 19 RCTs, with a total of 16,476 COVID-19 patients we found low-quality evidence of significant reduction in mortality (odds ratio (OR) = 0.80; 95% confidence interval (CI): 0.66-0.96, I2 = 40%), better clinical outcome when applied <7 days (OR = 2.13, 95% CI 1.28-3.53, I2 = 0%), and improved viral clearance (OR = 2.6, 95% CI: 1.3-5.45, I2 = 74%). Meta-regression analysis found that as a covariate, intubation on admission (p = 0.007) had a significant impact. However, there was any significant reduction neither in duration for clinical improvement (MD = -0.79, 95% CI: -2.76-1.18, I2 = 98%), nor in total period of hospital stay (MD = 0.02, 95% CI: -0.75-0.78, I2 = 81%). Early application of CPT is still relevant in reducing morbidity and mortality in critically ill patients and is too early to write it off as a potential therapeutic modality for COVID-19 patients.

HOW TO CITE THIS ARTICLE

Sarkar S, Khanna P, Singh AK. Convalescent -Plasma-A Light at the End of the Tunnel: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2021;25(11):1292-1300.

The Impact of Neutrophil-Lymphocyte Count Ratio in COVID-19: A Systematic Review and Meta-Analysis

Background: The neutrophil–lymphocyte count ratio (NLR) has emerged as a potential prognostic tool for different diseases. In the current coronavirus disease (COVID-19) pandemic, the NLR may be a useful tool for risk scarification and the optimal utilization of limited healthcare resources. However, there is no consensus regarding the optimal value of NLR, and the association with disease severity and mortality. Thus, this study aims to systematically analyze the current evidence of the utility of baseline NLR as a predictive tool for mortality, disease severity in COVID-19 patients. Methods: A compendious screening of electronic databases up to June 15, 2021, was done after enlisting the protocol in PROSPERO (CRD42020202659). Studies evaluating the utility of baseline NLR in COVID-19 are included for this review as per the PRISMA statement. Results: We retrieved a total of 13112 and 12986 COVID-19 patients for survivability and severity over 90 studies. The expired and critically sick patients had elevated baseline NLR on admission, in comparison to survivors and noncritical patients. (SMD = 3.82; 95% CI: 2.79-4.85; I² = 100% and SMD = 1.42; 95% CI: 1.22-1.63; I² = 95%, respectively). The summary receiver operating curve analysis for mortality (AUC = 0.87; 95% CI: 0.86-0.87; I² = 94.7%), and severity (AUC = 0.82; 95% CI: 0.80-0.84; I² = 79.7%) were also suggestive of its significant predictive value. Conclusions: The elevated NLR on admission in COVID-19 patients is associated with poor outcomes.

Comparative evaluation of ventilator-associated pneumonia in critically ill COVID- 19 and patients infected with other corona viruses: a systematic review and meta-analysis

The Coronavirus disease 19 (COVID-19) pandemic is associated with an unprecedented requirement for intensive care unit (ICU) admission, invasive mechanical ventilation, and thereby significantly increasing the risk of secondary nosocomial pneumonia, Ventilator-Associated Pneumonia (VAP). Our study aims to identify the overall incidence of VAP, common organisms associated with it, and outcome in COVID-19 patients in comparison to the non-SARS-CoV-2 infected critically ill ventilated COVID-19 patients. A comprehensive screening was conducted using major electronic databases), from January 1st 2020 to May 31st 2021, as per the PRISMA statement. In our rapid review, we included a total of 34 studies (involving 8901 cases. Overall VAP was reported in 48.15 % (95% CI 42.3%-54%) mechanically ventilated COVID-19 patients and the mortality rate was 51.4% (95% CI 42.5%-60%). COVID-19 patients had increased risk of VAP and mortality in comparison to other non-SARS-CoV-2 viral pneumonia (OR=2.33; 95%CI 1.75-3.11; I2=15%, and OR=1.46; 95%CI 1.15-1.86; I2=0% respectively). Critically ill COVID-19 patients are prone to develop VAP, which worsens the outcome.

COVID-19-associated subacute invasive pulmonary aspergillosis

BACKGROUND

Though invasive pulmonary aspergillosis is a well known complication of COVID-19 pneumonia, indolent forms of aspergillosis have been rarely described.

METHODS

We prospectively collected the clinico-radio-microbiological data of 10 patients of subacute invasive pulmonary aspergillosis (SAIA), who presented to our hospital with recent history of COVID-19 pneumonia along with cavitary lung disease, positive IgG (against Aspergillus) with or without positive respiratory samples for Aspergillus spp.

RESULT

The mean age of presentation of SAIA was 50.7 ± 11.8 years. All the patients had recently recovered from severe COVID-19 illness with a mean duration of 29.2 ± 12 days from COVID-19 positivity. Cough was the predominant symptom seen in 8/10 (80%) patients followed by haemoptysis. 7/10 (70%) patients were known diabetic. While serum galactomannan was positive in 5/9 patients (55.5%), fungal culture was positive in 2/7 patients (28.5%) and polymerase chain reaction (PCR) for Aspergillus was positive in three patients. Eight (80%) patients presented with a single cavitary lesion; pseudoaneurysm of pulmonary artery was seen in two patients and post-COVID-19 changes were seen in all patients. All patients were treated with voriconazole, out of which four (40%) patients died during the follow-up period.

CONCLUSION

SAIA should be considered in the differential diagnosis of cavitating lung lesions in patients with recent history of COVID-19 in the background of steroid use with or without pre-existing diabetes.

Role of platelet-to-lymphocyte count ratio (PLR), as a prognostic indicator in COVID-19: A systematic review and meta-analysis

Prognostic predictors are of paramount interest for prompt intervention and optimal utilization of the healthcare system in the ongoing context of the COVID-19 pandemic. The platelet-to-lymphocyte count ratio (PLR), has emerged as a potential tool for risk stratification of critically ill patients with sepsis. The current systematic review explores the utility of PLR as a prognostic predictor of COVID-19 patients. We screened the electronic databases until May 15, 2021 after enrolling in PROSPERO (CRD42021220269). Studies evaluating the association between PLR on admission and outcomes in terms of mortality and severity among COVID-19 patients were included. We retrieved 32 studies, with a total of 2768 and 3262 COVID-19 patients for mortality and disease severity outcomes. Deceased and critically ill patients had higher PLR levels on admission in comparison to survivors and non-severe patients (mean differences [MD] = 66.10; 95% confidence interval [CI]: 47.75-84.44; p < 0.00001 and MD = 86.74; 95% CI: 67.7-105.7; p < 0.00001, respectively). A higher level of PLR on admission in COVID-19 patients is associated with increased morbidity and mortality. However, the evidence is of low quality and further studies regarding the cut-off value of PLR are the need of the hour.

"Vitamin D supplementation and COVID-19 treatment: A systematic review and meta-analysis"

BACKGROUND

Vitamin-D is an immune-modulator which might be linked to disease severity by SARS-CoV-2.

METHODS

Meta-analysis of RCTs and quasi-experimental studies, evaluating the role of vitamin-D supplementation in COVID patients was done.

RESULTS

Total 5 studies (3 RCTs and 2 Quasi-experimental) including n = 467 patients were included. Vitamin D didn't reduce mortality (RR 0.55, 95%CI 0.22 to 1.39, p = 0.21), ICU admission rates (RR 0.20, 95% CI 0.01-4.26, p = 0.3) and need for invasive ventilation (RR 0.24, 95% CI 0.01-7.89, p = 0.42).

CONCLUSION

No significant difference with vitamin-D supplementation on major health related outcomes in COVID-19. Well-designed RCTs are required addressing this topic.

Consent in covid: A researcher's dilemma

An informed consent is a vital component of health care and forms an important component of any research study. Informed consent is the process where a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. A proper consent is imperative to ensure safety of the patients. However, obtaining a consent in the hospital settings has become a matter of concern in the times of this coronavirus-19 (COVID-19) pandemic. This brief review describes the additional complexities added to the consent for research and the various modifications needed in view of this pandemic. The current consent proformas need to be modified and individualised to the patient ensuring patient safety during research in the ongoing pandemic. We need to become more familiar with the technology and electronic tools as the acceptable alternative tools of communication in the current scenario. There is a need to incorporate a separate covid consent with due consideration to deferred consent, pre-emptive consent or waiver of a consent.

POS0135 REDUCING IMMUNOGENICITY OF PEGLOTICASE (RECIPE) WITH CONCOMITANT USE OF MYCOPHENOLATE MOFETIL IN PATIENTS WITH REFRACTORY GOUT: A PHASE II RANDOMIZED CONTROLLED TRIAL

Background:

Pegloticase is a recombinant, pegylated uricase, used for treatment of gout patients who fail oral urate lowering therapy (ULT). Its use has been limited due to immunogenicity leading to infusion reactions.1

Objectives:

We evaluated if co-administration of an immunomodulatory agent could prolong the efficacy of pegloticase.

Methods:

Participants were recruited in a Phase II, double-blind, placebo-controlled trial over 18 months and randomized in a 3:1 ratio by site. Inclusion criteria were: a) Age ≥ 18 years who met 2015 ACR/EULAR gout classification criteria and b) chronic refractory gout defined as symptoms inadequately controlled with ULT or contraindications. After a 2-week run-in of mycophenolate mofetil (MMF) 1000 mg twice daily or matching placebo (PBO), they received a combination of pegloticase 8 mg biweekly with MMF or PBO for 12 weeks. Subsequent to this MMF or PBO were discontinued but pegloticase was continued for another 12 weeks. The primary endpoint was proportion of patients who sustained a serum urate (SU) level of ≤ 6 mg/dl at 12 weeks. Secondary endpoints included 24-week durability of SU ≤ 6 mg/dl and rate of adverse events (AEs). Fisher’s exact test and Wilcoxon two-sample test were used for analyses along with Kaplan-Meier estimates and log-rank tests to compare survival curves between groups. Hypothesis tests were two-tailed and p-value (p) < 0.05 indicated statistical significance.

Results:

Of 42 subjects screened, 35 were randomized, and 32 who received at least one dose of pegloticase were included in modified intention to treat analyses. Subjects were predominantly men (88%), mean age of 55.2 years (SD=9.7). Mean duration of gout was 13.4 years (SD=9.0), mean baseline sUA was 9.2 mg/dL (SD=1.6). Tophi were present in 88% and majority were on optimized ULT - 59% on allopurinol and 16% on febuxostat, with 63% reporting > 1 flare in the past year. At baseline both arms (MMF vs. PBO) had similar comorbidities – (82% vs 70%), diabetes mellitus/metabolic syndrome (14% vs 20%), coronary artery disease/peripheral vascular disease (41% vs.70%), BMI>30 (86% vs. 90%) and renal insufficiency (defined as eGFR < 90 mL/min; 73% vs. 70%). At 12 weeks, 19 of 22 (86%) in the MMF arm achieved SU ≤ 6 mg/dl compared to 4 of 10 (40%) in PBO arm (p-value = 0.01). At 24 weeks, the SU was ≤ 6 mg/dl in 68% of MMF arm vs. 30% in PBO (p-value = 0.06), and rates of AEs per month were similar between groups with the PBO arm having more infusion reactions (30% vs. 0%). The MMF arm had higher AEs compared to placebo: musculoskeletal (41% vs. 10%), gastrointestinal (18% vs. 10%), and infections (9% vs. 0%). Figure 1 shows that the percentage of subjects maintaining a sUA < 6 mg/dL at 12 weeks was significantly higher (p=0.02) in the MMF arm, and a significant difference (p=0.03) at 24 weeks indicates sustained benefit from MMF.

Conclusion:

To our knowledge this is the first randomized-controlled proof of concept trial to demonstrate the ability of an immunomodulatory agent in prolonging the efficacy of pegloticase. Short-term concomitant use of MMF therapy with pegloticase was well tolerated and showed a clinically meaningful improvement in the targeted SU ≤6 mg/dL at 12 and 24 weeks. This study suggests an innovative approach to utilize pegloticase therapy in patients with chronic gout.

References:

[1]Sundy et al. Efficacy and tolerability of pegloticase for the treatment of chronic gout in patients refractory to conventional treatment: two randomized controlled trials. JAMA. 2011;306(7):711-20.

Figure 1.

Proportion of subjects maintaining serum urate (SU) ≤ 6 mg/dL over 24 week study period in mycophenolate mofetil + pegloticase vs. placebo + pegloticase

Disclosure of Interests:

Puja Khanna Consultant of: Horizon Pharmaceuticals, Swedish Orphan Biovitrum A, Grant/research support from: Selecta, 2)DYVE, Dinesh Khanna Consultant of: Horizon Pharmaceuticals, Gary Cutter: None declared, Jeff Foster: None declared, Josh Melnick: None declared, Sara Jaafar: None declared, Stephanie Biggers: None declared, Fazlur Rahman: None declared, Hui-Chen Kuo: None declared, Michelle Feese: None declared, Kenneth Saag Consultant of: AbbVie, Inc., Bayer, Daiichi Sankyo Company LTD, Gilead Services, Inc., Horizon Pharma plc, Mallinkrodt, Radius Health, Inc., Roche/Genentech, Shanton Pharma Co., LTD, Teijin, Dyve Bioscience, LG Chem, Regeneron Pharmaceuticals., Swedish Orphan Biovitrum AB, Takeda Pharmaceuticals America, Inc.,

Regional Anesthesia for Spine Surgery

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.