Role of interleukin-6, serum ferritin, and d-dimer in hospitalized COVID-19 patients.

BACKGROUND: Various studies have observed an association between interleukin-6 (IL-6), serum ferritin, d-dimer, and in-hospital mortality in COVID-19 patients. However, multivariate regression analysis was not done in the majority of the studies, Also, the role of interleukin-6 (IL-6), serum ferritin, and d-dimer in hospitalized COVID-19 patients was not adequately studied and reported from our region. METHOD: It was a retrospective cohort study in which the serum IL-6, serum ferritin, and d-dimer of 305 hospitalized COVID-19 patients were analyzed, and their association with mortality was determined. RESULTS: In COVID-19 patients, the levels of IL-6 (P = 0.007), serum ferritin (P = 0.011), and d-dimer (P = 0.004) were significantly elevated in patients with severe SARS-CoV-2 illness (SpO2 < 90 % at admission). IL-6 levels were significantly elevated (186 pg/ml vs. 215 pg/ml, P = 0.003) in non-survivors compared to survivors. However, d-dimer (mg/ml) (P = 0.129) and serum ferritin (mg/ml) (P = 0.051) levels were similar between the two groups. The ROC curve (receiver operating characteristic curve) analysis showed a significant but poor area under the curve (AUC) between elevated IL-6 (>208 pg/ml) and in-hospital mortality (P < 0.008, AUC = 0.61). Kaplan-Meir survival analysis showed poor survival in patients with elevated IL-6 (>208 pg/ml) (Pby log-rank: 0.010) and elevated d-dimer (>1780 mg/ml) (P by log-rank: 0.036). The multivariate cox-regression analysis did not show any association between IL-6, serum ferritin, d-dimer, and in-hospital mortality (P > 0.05). Also, no association was found between serum levels of IL-6, serum ferritin, d-dimer, and the use of a ventilator (P > 0.05) and the severity of SARS-CoV-2 illness (P > 0.05) on multivariate binary logistic regression analysis. CONCLUSION: In this study, the serum levels of IL-6, serum ferritin, and d-dimer were not associated with in-hospital mortality in hospitalized COVID-19 patients on multivariate cox-regression analysis, and were the markers of severe SARS-CoV-2 illness.

Ruptured Aortic Aneurysm in Pregnancy, Anesthetic Management of Endovascular Procedure.

ABSTRACT: Advanced pregnancy is associated with a higher risk of complicated aortopathies owing to the physiologic changes in pregnancy. The diagnosis can be elusive due to its rare incidence. The optimal treatment strategy is chosen based on the clinical condition of the patient, gestational age, and the severity of the aortic disease. A healthy young primigravida presented with acute chest pain in the early second trimester, diagnosed as a thoracic aortic aneurysm that had ruptured causing hemothorax. She underwent emergency endovascular repair under general anesthesia. Aortic disease should always be ruled out early in acute chest pain in pregnancy. Expeditious and strategic management helps improve maternal and fetal outcomes.

Prevalence, Outcomes, and Predictors of Prolonged Corrected QT Interval in Hydroxychloroquine-Naïve Hospitalized COVID-19 Patients.

The studies regarding prevalence, outcomes, and predictors of prolonged corrected QT (QTc) among COVID-19 patients not on QTc-prolonging medication are not available in the literature. In this retrospective cohort study, the QTc of 295 hospital-admitted COVID-19 patients was analyzed and its association with in-hospital mortality was determined. The QTc was prolonged in 14.6% (43/295) of the study population. Prolonged QTc was seen in patients with older age (P = 0.018), coronary artery disease (P = 0.001), congestive heart failure (P = 0.042), elevated N-terminal-pro-B-type natriuretic peptide (NT-ProBNP) (P < 0.0001), and on remdesivir (P = 0.046). No episode of torsades de pointes arrhythmia or any arrhythmic death was observed among patients with prolonged QTc. The mortality was significantly high in patients with prolonged QTc (P = 0.003). The multivariate logistic regression analysis showed coronary artery disease (odds ratio (OR): 4.153, 95% CI 1.37-14.86; P = 0.013), and NT-ProBNP (ng/L) (OR: 1.000, 95% CI 1.000-1.000; P = 0.007) as predictors of prolonged QTc. The prolonged QTc was associated with the worst in-hospital survival (p by log-rank 0.001). A significant independent association was observed between prolonged QTc and in-hospital mortality in multivariate cox-regression analysis (adjusted hazard ratio: 3.861; (95% CI 1.719-6.523), P < 0.0001). QTc was found to be a marker of underlying comorbidities among COVID-19 patients. Prolonged QTc in hospitalized COVID-19 patients was independently associated with in-hospital mortality.

Cardiac troponin in hospitalized COVID-19 patients: Incidence, predictors, and outcomes.

BACKGROUND: The incidence, predictors, and association of cardiac troponin with mortality in hospitalized COVID-19 were not adequately studied in the past and were also not reported from an Indian hospital. METHODS: In this retrospective cohort study, the cardiac troponin of 240 hospitalized COVID-19 patients was measured. The incidence, predictors, and association of elevated cardiac troponin with in-hospital mortality were determined among hospitalized COVID-19 patients. RESULTS: The cardiac troponin was elevated in 12.9% (31/240) of the patients. The troponin was elevated in the patients in the older age group (64 years vs. 55 years, p = .002), severe COVID-19 illness (SpO2 < 90%) (93.5% vs. 60.8%, p < .001), low arterial oxygen saturation (SpO2) (80% vs. 88%, p = .001), and low PaO2/FiO2 ratio (p < .0001). The patients with elevated cardiac troponin had elevated total leukocyte counts (TLC) (p = .001), liver enzyme (p = .025), serum creatinine (p = .011), N-terminal-Pro Brain natriuretic peptide (p < .0001), and d-dimer (p < .0001). The majority of the patients with elevated cardiac troponin were admitted to the intensive care unit (90.3% vs. 51.2%; p < .0001), were on a ventilator (61.3% vs. 21.5%; p < .0001), and had higher mortality (64.5% vs. 19.6%; p < .0001). The Kaplan-Meir survival analysis showed that the patients with elevated troponin had worse survival (p log-rank<.0001). Age, NT-ProBNP, d-dimer, and ventilator were the predictors of elevated troponin in multivariate logistic regression analysis. The Cox-regression analysis showed a significant association between elevated cardiac troponin and in-hospital mortality (adjusted hazard ratio 2.13; 95% confidence interval [CI] 1.145-3.97; p = .017). Two-thirds (65%) of patients with elevated cardiac troponin died during their hospital stay. CONCLUSIONS: COVID-19 patients with elevated cardiac troponin had severe COVID illness, were more commonly admitted to an intensive care unit, were on a ventilator, and had high in-hospital mortality.

Left ventricular outflow tract obstruction following aortic valve replacement: A review of risk factors, mechanism, and management.

The presence of dynamic left ventricular outflow tract obstruction (LVOTO) can complicate the postoperative course of patients undergoing surgical aortic valve replacement (AVR). The phenomenon of LVOTO is a consequence of an interplay of various pathoanatomic mechanisms. The prevailing cardiovascular milieu dictates the hemodynamic significance of the resultant LVOTO in addition to the anatomical risk factors. A thorough understanding of the predisposing factors, mechanism, and hemodynamic sequel of the obstruction is pivotal in managing these cases. A comprehensive echocardiographic examination aids in risk prediction, diagnosis, severity characterization, and follow-up of management efficacy in the setting of postoperative LVOTO. The armamentarium of management modalities includes conservative (medical) and surgical options. A stepwise approach should be formulated based on the physiological and anatomical substrates predisposing to LVOTO. The index phenomenon occurs more frequently than appreciated and should be considered when the post-AVR patients exhibit hemodynamic instability unresponsive to conventional supportive measures. The present article provides an overview of various peculiarities of this under-recognized phenomenon in the context of the perioperative management of patients undergoing AVR.

Transient aphonia, aphagia and facial tingling following intrathecal administration of fentanyl.

Subarachnoid block with local anaesthetic agent and opiod as an adjuvant is a well-known technique with a good record of safety. However, some rare neurological complications like aphonia, dysphagia and tingling sensation have been reported following their administration in pregnant females posted for labour analgesia or caesarean section. We report a case of transient aphonia, aphagia and facial tingling following intrathecal administration of bupivacaine along with fentanyl for lower limb wound debridement in a male patient.

Organ retrieval and banking in brain dead trauma patients: Our experience at level-1 trauma centre and current views.

BACKGROUND: Organ retrieval from brain dead patients is getting an increased attention as the waiting list for organ recipients far exceeds the organ donor pool. In our country, despite a large population the number of brain dead donors undergoing organ donation is very less (2% in our study). AIMS: The present study was undertaken to address issues related to organ donation and share our experience for the same. METHODS: A retrospective case record analysis of over 5 years from September 2007 to August 2012 was performed and the patients fulfilling brain death criterion as per Transplantation of Human Organs and Tissue (Amendment) Act were included. Patient demographics (age, sex), mode of injury, time from injury to the diagnosis of brain death, time from diagnosis of brain death to organ retrieval and complications were analysed. STATISTICS ANALYSIS: Student's t test was used for parametric data and Chi square was used for categorical data. RESULTS: Out of 205 patients who were identified as brain dead, only 10 patients became potential organ donors. CONCLUSION: Aggressive donor management, increasing public awareness about the concept of organ donation, good communication between clinician and the family members and a well-trained team of transplant coordinators can help in improving the number of organ donations.

The comparative evaluation of intravenous with intramuscular clonidine for suppression of hemodynamic changes in laparoscopic cholecystectomy.

BACKGROUND: Clonidine diminishes stress response by reducing circulating catecholamines and hence increases perioperative circulatory stability in patients undergoing laparoscopic surgeries. The aim of this study was to compare intravenous (IV) clonidine (2 µg/kg) with intramuscular (IM) clonidine (2 µg/kg) for attenuation of stress response in laproscopic surgeries. METHODS: Eighty adult patients classified as ASA physical status I or II, aged between 20 and 60 years undergoing elective cholecystectomy under general anesthesia were enrolled for a prospective, randomized, and double-blind controlled trial. They received either IV clonidine (2 µg/kg) 15 min prior to the scheduled surgery (Group I) or IM clonidine (2 µg/kg) 60-90 min prior to the scheduled surgery (Group II). Hemodynamic variables (Heart rate, systolic (SBP), diastolic (DBP), mean arterial pressure (MAP)), SpO2 and EtCO2 were recorded at specific times - baseline, prior to induction, 1 min after intubation, before CO2, insufflation, after CO2 insufflation at 1,5,10,20,30,45,60 min, after release of CO2, at 1 and 10 minutes after extubation. Secondary outcomes included evaluation of adverse effect profile of the two groups. RESULTS: No significant difference was observed in the HR throughout the intraoperative period in between the two groups (P>0.05). There was statistically significant difference in SBP between the two groups starting from 1 minute after induction till 1 min after extubation (P<0.05) but not in DBP except at 1 minute after intubation (P=0.042). Significant difference in MAP was noted at 1 minute after intubation (P=0.004) and then from 5 minutes after CO2 insufflation to 1 minute after extubation (P<0.05). Incidence of adverse effects were higher in group II (P=0.02) especially incidence of hypertension requiring treatment (0.006). CONCLUSION: We conclude that under the conditions of this study, hemodynamic parameters (SBP, DBP and MAP) were better maintained in the IV as compared to the IM route that had significantly higher incidence of hypertension requiring treatment.