Feasibility of USG-Guided Objective Initial Assessment of Pupillary Size and Pupillary Reflexes Versus Clinical Examination in Patients With Altered Mental Status: A Cross-Sectional Study.

BACKGROUND: Pupillary assessment is an important part of the neurological assessment which provides vital information in critically ill patients. However, clinical pupillary assessment is subjective. The ultrasound-guided pupillary examination is objective. There are limited pieces of literature regarding its use in assessing patients with altered mental status. So, we studied the extent of agreement of B-mode ultrasound with clinical examination for assessment of the pupillary size and reflex in patients with altered mental status. OBJECTIVES: The primary objective was to determine the extent of agreement between clinical examination and ultrasound-based examination for assessing pupillary reflex and size in patients with altered mental status in two settings (trauma and non-trauma patients). METHODS: Exactly 200 subjects (158 males, mean [range] age 43.56 [18-92 years]) with no history of partial globe rupture or dementia were included in this cross-sectional study from March 2019 to March 2020. B-mode ultrasound was performed with the subject's eyes closed using a 7-12 MHz linear probe and a standardized light stimulus. ICC score, paired t-test, kappa, Wilcoxon signed-rank test, and Bland-Altman plots were used for statistical analysis. RESULTS: The clinical-USG agreement for pupillary light reflex examination (Pupillary Diameter [PD] at rest, after direct light stimulation [Dstim ] and consensual light stimulation [Cstim ]) was excellent (ICC, 0.93-0.96). The Kappa coefficient (0.74 ± 0.07) showed an agreement of 87.36% between clinical and USG examination for pupillary reflex (reactive or non-reactive). CONCLUSION: USG-guided pupillary examination proves to be a better adjunct to neurological assessment in patients with altered mental status.

High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial.

OBJECTIVES: Sympathetic crashing acute pulmonary edema (SCAPE) is a subset of heart failure with a dramatic presentation. The unique physiology of this condition requires a different management strategy from the conventional practice. The trial objective was to compare the efficacy of high-dose and low-dose GTN in patients with SCAPE. METHODS: This was an open-label randomised control trial conducted in a tertiary care teaching hospital in India from 11 November 2021 to 30 November 2022. Consenting participants were randomised to high-dose GTN or conventional low-dose GTN. The primary outcome was symptom resolution at 6 hours and 12 hours. Secondary outcomes included intubation rates, admission rates, length of hospital stay, and any short-term adverse effects of GTN and major adverse cardiac events (MACE) at 30 days. RESULTS: Fifty-four participants were included (26 high-dose GTN, 26 low-dose GTN). At 6 hours, symptom resolution was seen in 17 patients (65.4%) in the 'high-dose' group, compared with 3 (11.5%) in the 'low-dose' group (p<0.001). At 12 hours, 88.5% of patients had a clinical resolution in the 'high-dose' arm versus 19.5% in 'low-dose' arm . The low-dose group had longer median hospital stay (12 hours vs 72 hours), more frequent MACE (3.8% vs 26.9%, p=0.02) and a higher intubation rate (3.8% vs 19.2%, p=0.08). The only short-term adverse effect seen was a headache in both the groups. CONCLUSION: In SCAPE, patients receiving high-dose GTN (>100 mcg/min) had earlier symptom resolution compared with the conventional 'low dose' GTN without any significant adverse effects. TRIAL REGISTRATION: Clinical trial registry of India (CTRI/2021/11/037902).

Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study.

Background: The main objective is to detect clinically significant conditions by transcranial ultrasound (TCS) in post-decompressive craniectomy (DC) patients who come to the emergency department. Materials and methods: This was a cross-sectional observational study. We studied 40 post-DC patients. After primary stabilization, TCS was done. Computer tomography of head was done within 2 hours of performing TCS. The correlation between both modalities were assessed by the measurement of lateral ventricle (LV) (Bland-Altman plot), Midline shift and mass lesion. Additionally, normal cerebral anatomy, 3rd and 4th ventricles and external ventricular drainage (EVD) catheter visualization were also done. Results: About 14/40 patients came with non-neurosurgical complaints and 26/40 patients came with neurosurgical complaints. Patients with non-neurosurgical complaints (4/14) had mass lesions and 1/14 had MLS. Patients with neurosurgical complaints (11/26) had mass lesions and about 5 patients had MLS. A good correlation was found between TCS and CT of head in measuring LV right (CT head = 17.4 ± 13.8 mm and TCS = 17.1 ± 14.8 mm. The mean difference (95% CI) = [0.28 (-1.9 to 1.33), ICC 0.93 (0.88-0.96)], Left [CT head = 17.8 ± 14.4 mm and TCS = 17.1 ± 14.2 mm, the mean difference (95% CI) 0.63 (-1.8 to 0.61), ICC 0.96 (0.93-0.98)], MLS [CT head = 6.16 ± 3.59 (n = 7) and TCS = 7.883 ± 4.17 (n = 6)] and mass lesions (kappa 0.84 [0.72-0.89] [95% CI] p-value < 0.001). The agreement between both modalities for detecting mass lesions is 93.75%. Conclusion: Point of care ultrasound (POCUS) is a bedside, easily operable, non-radiation hazard and dynamic imaging tool that can be used for TCS as a supplement to CT head in post-DC patients in emergency as well as in ICU. However, assessment of the ventricular system (pre/post-EVD insertion), monitoring of regression/progression of mass lesion, etc. can be done with TCS. Repeated scans are possible in less time which can decrease the frequency of CT head. How to cite this article: Chouhan R, Sinha TP, Bhoi S, Kumar A, Agrawal D, Nayer J, et al. Correlation between Transcranial Ultrasound and CT Head to Detect Clinically Significant Conditions in Post-craniectomy Patients Performed by Emergency Physician: A Pilot Study. Indian J Crit Care Med 2024;28(3):299-306.

Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial.

OBJECTIVE: To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN: Parallel-group, blinded multicenter trial. SETTING: PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS: Children up to 15 years of age with septic shock. METHODS: Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS: MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS: The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS: Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.

The Role of Triple Rule-out CT in an Indian Emergency Setting.

Background: Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way. Materials and methods: Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings. Results: Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89-25.95 mSv). Conclusion: Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases. How to cite this article: Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P. et al. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023;27(3):190-194.

Variants of concern responsible for SARS-CoV-2 vaccine breakthrough infections from India.

Emerging reports of SARS-CoV-2 breakthrough infections entail methodical genomic surveillance for determining the efficacy of vaccines. This study elaborates genomic analysis of isolates from breakthrough infections following vaccination with AZD1222/Covishield and BBV152/Covaxin. Variants of concern B.1.617.2 and B.1.1.7 responsible for cases surge in April-May 2021 in Delhi, were the predominant lineages among breakthrough infections.

Sensitivity and specificity of waterbath ultrasound technique in comparison to the conventional methods in diagnosing extremity fractures.

INTRODUCTION: Point of care ultrasound (POCUS) has variable diagnostic accuracy in diagnosing fractures. Waterbath technique is a modification of the conventional ultrasound technique which may improve diagnostic accuracy by enhancing image quality. Authors studied the diagnostic accuracy of waterbath technique compared to the final diagnosis based on clinical examination and radiology in the identification of fractures of hand and foot. METHODS: Patients of >18 yrs. age with suspected distal hand and foot fractures presenting to the emergency department of a level 1 trauma center were recruited after informed consent. Unconscious and hemodynamically unstable patients, injuries >72 h old, open fractures, obvious deformities, and old fractures at the affected site were excluded. Cases were subjected to waterbath technique performed by an academic emergency medicine resident and relevant radiographs were ordered and interpreted by an orthopedic specialist. CT/MRI, if done in case of discrepancy, was interpreted by radiologist. The findings of both waterbath technique and radiology were blinded to each other and compared to the final diagnosis made by a cumulative assessment of clinical examination, radiographs, and CT/MRI of the discrepant cases. RESULTS: Waterbath technique identified fractures of hand and foot with sensitivity of 97% (95% CI 90%-100%), specificity 94% (95%CI 81%-99%), PPV 98% (95%CI 91%-99%), NPV 94% (95%CI 79%-98%), LR+ 17.5(95% CI 4.5-67.2), LR- 0.03(95% CI 0.01-0.12) and diagnostic accuracy 96% (95%CI 91%-99%). CONCLUSION: This pilot study has demonstrated the utility of Waterbath technique in the diagnosis of fractures of hand and foot in adults in the ED setting. Future well designed studies are required to explore the potential of this novel technique in both adult and pediatric population.

Assessing the serum chymase level as an early predictor of dengue severity.

We conducted a prospective, observational study to assess the serum chymase level, a mast cell derived protease, as a predictor of dengue severity. NS1-positive non-severe dengue patients of age ≥14 years with duration of fever ≤4 days were included in the study. At the time of admission, the serum sample was taken for chymase estimation. Patients were followed up to four days after they became afebrile to find out the final diagnosis. Total of 338 non-severe dengue patients were recruited (mean age: 29.15 years; male: 66%). On follow-up, 26 patients (7.8%) developed severe dengue. Only chymase level (adjusted odds ratio [aOR]: 1.787; 95% confidence interval [CI]: 1.309-2.440) and platelet count at admission (aOR: 0.981; 95% CI: 0.968-0.993) were able to predict the severity after adjustment for all variables. But, for prediction of severe dengue, the area under receiver's operating curve of chymase was 0.835 (95% CI: 0.765-0.905), which was significantly higher than that of the platelet count at admission (0.760, 95% CI: 0.650-0.870) (p < .001). Patients who developed severe dengue in due course of illness had significantly higher serum chymase level at admission as compared with the rest of the patients. Similar findings were noted across all age-groups. At an optimum cut-off value of 1.35 ng/ml, chymase had a positive likelihood ratio (LR) of 3.5 and a negative LR of 0.15, for predicting severe dengue. This study demonstrated the potential ability of serum chymase levels at admission, as a biomarker for prediction of severe dengue in due course of illness.

Impact of personal protective equipment on the effectiveness of chest compression - A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: To assess the impact of personal protective equipment (PPE) on different aspects of chest compression (CC) during cardiopulmonary resuscitation, we conducted this study. METHODS: This systematic review was performed according to the PRISMA. We searched PubMed, EMBASE and Web of Science from inception to June-6, 2020, limiting to the studies that reported the comparison of the effectiveness of CC in terms of CC rate, CC depth, the proportion of adequate CC rate, the proportion of adequate CC depth or proportion of adequate recoil; in study arms with or without PPE. Risk of bias was assessed by the ROB-2 and ROBINS-I tool. Quantitative data synthesis was done using the generic inverse variance method and the fixed-effects model. RESULTS: Five simulation-based studies were finally included. A Significant decrease in CC rate (SMD: -0.28, 95%CI: -0.47 to -0.10) and CC depth (SMD: -0.26, 95%CI: -0.44 to -0.07) were observed in the PPE arm as compared to the no-PPE arm. The difference in CC rate was more prominently seen in adult CPR than in paediatric CPR. Without PPE, the proportion of adequate CC rate delivered was 0.74, which reduced significantly to 0.60 after use of PPE (p - 0.035). Similarly, the proportion of adequate CC depth was significantly lesser (p - 0.001) in PPE arm (0.55), as compared to that of the no-PPE arm (0.78). CONCLUSION: The use of PPE compromises the quality of CC during CPR significantly, and newer ways to deliver chest compression has to be investigated. This study was prospectively registered in PROSPERO (CRD42020192031).

Mobile phone ingestion requiring endoscopic retrieval.

A 24-year-old male was brought to our emergency with complaints of abdominal pain for two days. There was a history of foreign body ingestion five days earlier, details of which he refused to reveal. After investigation with abdominal X ray and ultrasound, the foreign body was detected to be a mobile phone containing a battery. Clinical evaluation revealed no signs of lithium toxicity due to battery leak. The patient underwent endoscopy for removal of the mobile phone. The case shows the importance of thorough investigation and prompt attempt at endoscopic removal in the event of ingestion of foreign bodies containing batteries.

Lung sonographic findings in COVID-19 patients.

OBJECTIVE: The objective of this study was to describe the lung sonographic findings of COVID-19 patients prospectively and investigate its association with disease severity. METHODS: This study was conducted in an emergency department and included consecutively enrolled laboratory confirmed COVID-19 patients. Lung sonography findings were described in all the included patients and analysed with respect to the clinical severity of the patients. RESULTS: 106 patients were included in the study. Common sonographic findings in COVID-19 patients were pleural line irregularity or shredding (70% of patients), followed by B - profile (59%), pleural line thickening (33%), occasional B - lines (26%), sub-pleural consolidations (35%), deep consolidations (6%), spared areas (13%), confluent B - lines or waterfall sign (14%) and pleural effusion (9%). These findings tended to be present more bilaterally and in lower lung zones. Sonographic characteristics like bilateral lung involvement, B - profile, spared areas and confluent B - lines or waterfall sign were significantly associated (p < 0.01) with clinical severity (more frequent with increasing disease severity). CONCLUSION: The lung sonographic findings of COVID-19 were found more bilaterally and in lower lung zones, and specific findings like B - profile, pleural thickening, spared areas and confluent B - lines or waterfall sign were associated with severe COVID-19.

High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study.

BACKGROUND: Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute heart failure with a dramatic presentation. Rapid identification and management in the emergency department (ED) is key to saving these patients and preventing morbidity associated with endotracheal intubation and intensive care treatment. Use of high-dose nitroglycerin (NTG) and noninvasive ventilation (NIV) has been advocated in management of such patients. OBJECTIVE: To study the feasibility and safety of high-dose NTG combined with NIV in SCAPE. METHODS: This was a prospective observational pilot study done in the ED of a tertiary care hospital. All patients were treated with high-dose NTG and NIV. The primary objective was to study the feasibility and safety of the SCAPE management protocol in terms of the outcome of the patient. Resolution of symptoms in 6 h and need for intubation were recorded as endpoints. Any complications associated with high-dose NTG were also recorded. RESULTS: A total of 25 patients were recruited. The mean bolus dose of NTG given was 872 µg, and mean cumulative dose, 35 mg. There was no incidence of hypotension after the bolus dose of nitroglycerin. Eleven patients had resolution of symptoms at 3 h of therapy. Twenty-four patients were discharged from the ED itself after a brief period of observation, and one patient was intubated and shifted to the intensive care unit. CONCLUSION: Use of our specific SCAPE treatment algorithm, which included high-dose NTG and NIV, was safe and provided rapid resolution of symptoms.

Utility of HEART Pathway in Identifying Low-Risk Chest Pain in Emergency Department.

BACKGROUND: Chest pain is a common presenting symptom in the emergency department (ED). The HEART (history, electroencephalogram [ECG], age, risk factors, and troponin I) score, with addition of troponin at 3 h, helps to determine appropriate risk stratification of the patients. OBJECTIVE: This study evaluated the utility of the HEART pathway as a decision aid designed for risk stratification of patients with acute-onset chest pain for early and safe disposition. METHODS: This was a prospective observational study done in a tertiary care center. Focused history, 12-lead ECG, and baseline troponin I level on arrival and at hour 3 were recorded. Subjects were classified as low risk (HEART score 0-3) or high risk (HEART score ≥ 4). Patients with a HEART score of 0-3 with negative troponin I at 3 h were discharged and were followed up for major adverse cardiac events (MACEs) within 30 days of ED presentation. RESULTS: A total of 250 patients were screened for the study, of which 151 were included for the final analysis. One hundred and two patients (68%) were male and 54% of patients were younger than 45 years. HEART scores of 0 (n = 16), 1 (n = 43), 2 (n = 44), and 3 (n = 48) were observed. There was only 1 MACE (0.7%) in 30 days after ED discharge in the study population. The mean length of ED stay in the low-risk group was 4.5 h. CONCLUSIONS: Low-risk patients, as per the HEART pathway, can be discharged safely from the ED, which reduces ED stay and health care resource use.

Prognostic Value of Serum Procalcitonin Levels in Patients With Febrile Neutropenia Presenting to the Emergency Department.

BACKGROUND: Various risk-stratification scores have been developed to identify low-risk febrile neutropenia (FN). The Multinational Association of Supportive Care in Cancer (MASCC) score is a commonly used validated scoring system, although its performance varies due to its subjectivity. Biomarkers like procalcitonin (PCT) are being used in patients with FN to detect bacteremia and additional complications. OBJECTIVE: Our objective was to compare the performance of MASCC score with PCT in predicting adverse outcomes in patients with FN. METHODS: This was a prospective observational study that included chemotherapy-induced FN in hematologic or solid malignancy. The MASCC score, PCT levels, and blood cultures were taken at the first point of contact, and patient treatment was managed according to routine institutional protocol. The primary outcome was mortality at 30 days. RESULTS: A total of 100 patients were recruited, of which 92 had hematologic malignancy and 8 had solid malignancy. Forty-six patients were classified as low risk by MASCC score (≥21). The PCT threshold, 1.42 ng/mL, was taken as a cutoff value, with area under the receiver operating characteristic curve (AUROC) of 0.664 (95% confidence interval [CI] -0.55 to 0.77) for predicting mortality. AUROC for MASCC was 0.586 (95% CI 0.462 to 0.711). CONCLUSIONS: PCT is a useful marker with better prognostic efficacy than MASCC score in patients with FN and can be used as an adjunct to the score in risk-stratifying patients with FN.

Effect of Early Administration of Vitamin D on Clinical Outcome in Critically Ill Sepsis Patients: A Randomized Placebo-controlled Trial.

BACKGROUND: Administration of vitamin D to unselected heterogeneous critically ill patients did not demonstrate outcome benefit. The current study was undertaken to identify if early administration of vitamin D can reduce intensive care unit (ICU) length of stay and improve clinical outcomes in critically ill patients with sepsis. METHODS: This single-center randomized double-blind placebo-controlled trial was done in the ICU and emergency inpatient ward of a tertiary care teaching institute in New Delhi, India. A total of 126 adult patients aged 18 to 80 years of either sex diagnosed to have sepsis were included within 24 hours of admission to the hospital and randomized into vitamin D or placebo groups. The patients in the intervention group received vitamin D3 540,000 units dissolved in 45 mL of milk. The placebo group received 45 mL of milk. RESULTS: The median length of ICU stay (8 vs 9 days; p = 0.32), median length of hospital stay (12 vs 12 days; p = 0.33), median duration of vasopressors requirement (4 vs 3 days; p = 0.84), median duration of mechanical ventilation (5 vs 7 days; p = 0.23), requirement of tracheostomy (34 vs 39%; p = 0.71), and 90-day mortality [35 vs 46%; p = 0.29; HR 0.72 (0.42-1.24)] were similar in vitamin D and placebo arm.A subgroup analysis in patients with severe vitamin D deficiency (vitamin D <12 ng/mL) revealed a significantly decreased incidence of tracheostomy (28 vs 57%; p = 0.04), a trend toward decreased 90-day mortality [34 vs 66%; p = 0.08; HR 0.44 (0.19-1.01)], and duration of mechanical ventilation (6 vs 11 days; p = 0.05) in patients receiving vitamin D. CONCLUSION: Administration of large-dose vitamin D within 24 hours of admission does not reduce the length of ICU stay in critically ill sepsis patients. HOW TO CITE THIS ARTICLE: Bhattacharyya A, Subramaniam R, Baidya DK, Aggarwal P, Wig N. Effect of Early Administration of Vitamin D on Clinical Outcome in Critically Ill Sepsis Patients: A Randomized Placebo-controlled Trial. Indian J Crit Care Med 2021;25(10):1147-1154.

CISNE versus MASCC: Identifying low risk febrile neutropenic patients.

OBJECTIVE: Febrile neutropenia though a dreaded complication of chemotherapy, not all patients need inpatient treatment. Risk score indices like MASCC and CISNE have been developed to identify low risk patients eligible for outpatient management. We undertook this study to compare the performances of MASCC and CISNE. METHODS: This was a prospective observational study conducted in a tertiary care centre from August 2017 to April 2019 where patients with chemotherapy induced febrile neutropenia were included. Basic demographic data and primary site of cancer were collected with characteristics required to calculate both MASCC and CISNE scores. The primary outcome measure was 30-day mortality. Apart from the 3 group risk stratification of CISNE, apriori it was decided that two-tier CISNE score will be calculated with 0 or 1 score as low risk and ≥2 as high risk. Descriptive statistics are reported and predictive performance of each score was analysed. RESULTS: Total of 129 patients were recruited. The performance of three-tier CISNE score was more specific (90.6%, 95% CI 76.9-96.9) but sensitivity (25.1%, 95% CI 17.0-36.3) was low compared to that of MASCC score (sensitivity 58.1%, 95% CI 47.0-68.5; specificity 65.1, 95% CI 49.0-78.5%). However, analysis with two-tier CISNE score demonstrated a better sensitivity (56.9%, 95%CI 45.8-67.4). Kappa for agreement between the two scores was 0.520 (95% CI 0.373-0.667, p < 0.001). CONCLUSION: CISNE and MASCC have fair discriminatory power in identifying low risk febrile neutropenia cases. Two group stratification on CISNE scoring will help in better decision making in emergency department.

COVID-19 in health care workers - A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: It is essential to know the proportion of health care workers (HCW) who are COVID 19 positive, as well as the severity and mortality among them. METHODS: This systematic review was performed according to the Preferred Reporting Items for Systematic review and meta-analysis. Databases including PubMed, EMBASE and Web of Science were searched from December-31, 2019 to April-23, 2020. The search was limited to the studies that reported the data on the number of COVID-19 positive healthcare workers, among the COVID-19 positive patients. Case reports, duplicate publications, reviews, and family-based studies were excluded. The methodological quality of studies was assessed by the Appraisal tool for Cross-Sectional Studies (AXIS) tool. RESULTS: In this systematic review and meta-analysis, we pooled eleven studies to investigate the above factors. The overall proportion of HCW who were SARS-CoV-2 positive among all COVID-19 patients was 10.1% (95%CI: 5.3-14.9). This proportion varied according to the country of study i.e. China (7 studies) - 4.2%, 95%CI:2.4-6.0; United States (3 studies) - 17.8%, 95%CI:7.5-28.0; and Italy (1 study) - 9.0%, 95%CI:8.6-9.4. The incidence of severe or critical disease in HCW (9.9%, 95%CI:0.8-18.9) was significantly lower (p < 0.001) than the incidence of severe or critical disease in all COVID-19 positive patients (29.4%, 95%CI:18.6-40.2). Similarly, the mortality among HCW (0.3%, 95%CI:0.2-0.4) was also significantly lower (p < 0.001) as compared to that of all patients (2.3%, 95%CI:2.2-2.4). CONCLUSION: Health care workers who are COVID-19 positive constituted a significant proportion of all COVID-19 patients; but the severity and mortality were lower among them.

Endotracheal Tube Placement Confirmation by Ultrasonography: A Systematic Review and Meta-Analysis of more than 2500 Patients.

BACKGROUND: The integration of point-of-care ultrasound in endotracheal tube placement confirmation has been focus of many recent studies. OBJECTIVES: We sought to determine the diagnostic accuracy of ultrasonography in confirmation of endotracheal intubation compared with standard confirmatory methods. METHODS: We completed an extensive search of PubMed, EMBASE, Cochrane Central, Web of Science, and bibliographies of the selected articles from inception to October 2019. The search was limited to prospective studies conducted in human adults that compared the accuracy of ultrasonography in confirming the endotracheal tube position with a reference standard. The methodologic quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate random-effects model summarized diagnostic accuracy statistics. Subgroup analyses by ultrasonographic signs, study location, the operator's specialty, types of transducer, the technique of ultrasound confirmation, and clinical setting (cardiac arrest vs. non-cardiac arrest) were performed. RESULTS: Thirty studies involving 2534 patients were selected for this meta-analysis. The estimated pooled sensitivity and specificity for ultrasonography were 0.982 (95% confidence interval [CI] 0.971-0.988) and 0.957 (95% CI 0.901-0.982), respectively. Subgroup analyses did not reveal significant difference by ultrasonographic sign used, location, the sonographer's specialty, transducer type, or ultrasound technique used. Ultrasound was also found to be a useful adjunct in confirming endotracheal tube position in the subgroup of patients with cardiac arrest, with sensitivity of 0.99 (95% CI 0.98-1.00) and specificity of 0.84 (95% CI 0.67-1.00), respectively. CONCLUSIONS: Ultrasonography is a valuable and reliable adjunct for endotracheal tube confirmation, including during cardiac arrest resuscitation.

Serum Angiopoietin-1 and -2 and VEGF are associated with severe disease in vivax malaria.

BACKGROUND & OBJECTIVES: Malaria continues to be a significant public health problem in tropical countries including India; however, there are limited tools to predict occurrence of severe disease due to malaria. This study was designed to evaluate the role of Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Vascular endothelial growth factor (VEGF) and Asymmetric Dimethylarginine (ADMA)as disease biomarkers in uncomplicated malaria (UM) and severe malaria (SM). METHODS: This is a prospective observational study carried out at All India Institute of Medical Sciences (AIIMS), tertiary referral hospital in New Delhi, India. The study population included patients diagnosed with malaria (Plasmodium falciparum or Plasmodium vivax) either by rapid diagnostic kit test or positive peripheral smear and age more than 12 years. Forty-nine patients (25 with SM, 24 with UM) and 22 controls were recruited. In addition to routine investigations, serum concentrations of Ang-1, Ang-2, VEGF and ADMA were measured using ELISA technique. RESULTS: We observed Ang-1 serum levels to be significantly lower in patients with severe malaria (7775 pg/ml) compared to uncomplicated malaria (17629 pg/ml) and healthy controls (43472 pg/ml) [p <0.001]. Ang-2 levels were significantly higher in severe malaria (11100 pg/ml) compared to uncomplicated malaria (7315 pg/ml) and healthy controls (3679 pg/ml) (p <0.001). The ratio of Ang-2/Ang-1 was significantly higher in patients with severe malaria. VEGF serum levels was significantly lower in severe malaria (130.36 pg/ml) compared to uncomplicated malaria (317.3 pg/ml). The Ang-1, Ang-2 and VEGF levels were able to differentiate severe malaria from uncomplicated malaria caused by P. vivax but not with P. falciparum. INTERPRETATION & CONCLUSION: We conclude that Ang-1, Ang-2 and VEGF are markers of disease severity in vivax malaria.

"Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation.

As per current guidelines, whenever an advanced airway is in place during cardiopulmonary resuscitation, positive pressure ventilation should be provided without pausing for chest compression. Positive pressure ventilation can be provided through bag-valve resuscitator (BV) or mechanical ventilator (MV), which was found to be equally efficacious. In a busy emergency department, with less trained personnel use of MV is advantageous over BV in terms of reducing human errors and relieving the airway manager to focus on other resuscitation tasks. Currently, there are no guidelines specific to MV settings in cardiac arrest. We present a concept of "six-dial ventilator strategy during CPR" that encompasses the evidence-based settings appropriate during chest compression. We suggest use of volume control ventilation with the following settings: (1) positive end-expiratory pressure of 0 cm of water (to allow venous return), (2) tidal volume of 8 mL/kg with fraction of inspired oxygen at 100% (for adequate oxygenation), (3) respiratory rate of 10 per minute (for adequate ventilation), (4) maximum peak inspiratory pressure or P max alarm of 60 cm of water (to allow tidal volume delivery during chest compression), (5) switching OFF trigger (to avoid trigger by chest recoil), and (6) inspiratory to expiratory time ratio of 1:5 (to provide adequate inspiratory time of 1 second). How to cite this article: Sahu AK, Timilsina G, Mathew R, Jamshed N, Aggarwal P. "Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation. Indian J Crit Care Med 2020;24(6):487-489.