Delayed inflammatory pulmonary syndrome: A distinct clinical entity in the spectrum of inflammatory syndromes in COVID-19 infection?

BACKGROUND: During the second wave of the coronavirus disease 2019 (COVID-19) pandemic, a subset of critically ill patients developed delayed respiratory deterioration in the absence of new infection, fluid overload or extra-pulmonary organ dysfunction. AIM: To describe the clinical and laboratory characteristics, outcomes, and management of these patients, and to contrast this entity with other post COVID-19 immune dysregulation related inflammatory disorders. METHODS: This was a retrospective observational study of adult patients admitted to the medical intensive care unit of a 2200-bed university affiliated teaching hospital, between May and August 2021, who fulfilled clearly defined inclusion and exclusion criteria. Outcome was assessed by a change in PaO2/FiO2 ratio and levels of inflammatory markers before and after immunomodulation, duration of mechanical ventilation after starting treatment, and survival to discharge. RESULTS: Five patients developed delayed respiratory deterioration in the absence of new infection, fluid overload or extra-pulmonary organ dysfunction at a median interquartile range (IQR) duration of 32 (23-35) d after the onset of symptoms. These patients had elevated inflammatory markers, required mechanical ventilation for 13 (IQR 10-23) d, and responded to glucocorticoids and/or intravenous immunoglobulin. One patient died (20%). CONCLUSION: This delayed respiratory worsening with elevated inflammatory markers and clinical response to immunomodulation appears to contrast the well described Multisystem Inflammatory Syndrome - Adults by the paucity of extrapulmonary organ involvement. The diagnosis can be considered in patients presenting with delayed respiratory worsening, that is not attributable to cardiac dysfunction, fluid overload or ongoing infections, and associated with an increase in systemic inflammatory markers like C-reactive protein, inteleukin-6 and ferritin. A good response to immunomodulation can be expected. This delayed inflammatory pulmonary syndrome may represent a distinct clinical entity in the spectrum of inflammatory syndromes in COVID-19 infection.

Quantification of Organophosphorus Insecticide Removed by Gastric Lavage in Acutely Poisoned Patients: An Observational Study.

Introduction: The effectiveness of gastric lavage in organophosphorus (OP) poisoning has not been established. We assessed the ability of gastric lavage to remove OP insecticides as a preliminary stage in assessing effectiveness. Patients and methods: Organophosphorus poisoning patients presenting within 6 hours were included, irrespective of prior gastric lavage. A nasogastric tube was placed and gastric contents aspirated, followed by at least three cycles of gastric lavage with 200 mL of water. Samples from the initial aspirate and the first three lavage cycles were sent for identification and quantification of the OP compounds. Patients were monitored for complications of gastric lavage. Results: Around 42 patients underwent gastric lavage. Eight (19.0%) patients were excluded from the study because of a lack of analytical standards for ingested compounds. Insecticides were detectable in the lavage samples of 24 of 34 (70.6%) patients. Lipophilic OP compounds were detected in 23 of 24 patients, while no hydrophilic OP compounds could be detected in six patients with reported ingestion of hydrophilic compounds. For chlorpyrifos poisoning (n = 10), only 0.65 mg (SD 1.2) of the estimated ingested amount (n = 5) of 8,600 mg (SD 3,200) was recovered by gastric lavage. The mean proportion of the compound removed by initial gastric aspirate was 79.4% and subsequent three cycles removed 11.5, 6.6, and 2.7%. Conclusion: Lipophilic OP insecticides could be quantified in the stomach contents of OP poisoning patients with the first aspiration or lavage being most effective. The amount removed was very low; hence, routine use of gastric lavage for OP poisoning patients arriving within 6 hours is unlikely to be beneficial. How to cite this article: Mathansingh AJ, Jose A, Fleming JJ, Abhilash KPP, Chandiraseharan VK, Lenin A, et al. Quantification of Organophosphorus Insecticide Removed by Gastric Lavage in Acutely Poisoned Patients: An Observational Study. Indian J Crit Care Med 2023;27(6):397-402.

Comparison between the demographic shift clinical severity and outcome of the first two waves of COVID-19 in pregnancy in a tertiary hospital in India.

OBJECTIVE: To study and compare the maternal and neonatal outcomes of COVID-19 in pregnancy during the two waves of the pandemic in India. METHODS: This observational, retrospective cohort study on pregnant women with SARS-CoV-2 infection was conducted in a 2700-bed tertiary referral center in South India from March 1, 2020 to June 30 2021. The clinical presentation, severity, and maternal and neonatal outcomes of COVID-19 were compared between the two waves. RESULTS: A total of 623 pregnant women tested positive for SARS-CoV-2 infection in our institute; 379 (60.8%) were diagnosed during the first wave and 244 (39.2%) in the second wave. Most of the affected women (81.1%) were in their third trimester. Maternal mortality rate was 823 per 100 000 live births. Composite maternal outcome (increasing requirement for ventilation, pulmonary embolism, disease progression) were more pronounced during the second wave (2.1% vs 6.1%). Between the two waves, both maternal (1 vs 3; P = 0.162) and perinatal (3.2% vs 6.7%; P = 0.065) deaths were higher during the second wave. The cesarean section rate was high during the first wave (48% vs 32.4%; P < 0.001). Preterm births were comparable between the two waves (19.5% vs 22%; P < 0.500). CONCLUSION: The women presented with more severe illness during the second wave of COVID-19. There was higher perinatal mortality, but the maternal mortality was similar between the two waves.

Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever.

Background: Bacterial sepsis is associated with significant morbidity and mortality. However, to date, there is no single test that predicts sepsis with reproducible results. We proposed that using a combination of clinical and laboratory parameters and a novel biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL) may aid in early diagnosis. Method: A prospective cohort study was conducted at a tertiary care center in South India (June 2017 to April 2018) on patients with acute febrile episodes fulfilling the Systemic Inflammatory Response Syndrome (SIRS) criteria. Plasma NGAL and standard clinical and laboratory parameters were collected at the admission. Bacterial sepsis was diagnosed based on blood culture positivity or clinical diagnosis. Clinically relevant plasma NGAL cut-off values were identified using the receive operating characteristic (ROC) curve. Clinically relevant clinical parameters along with plasma NGAL's risk ratios estimated from the multivariable Poisson regression model were rounded and used as weights to create a new scoring tool. Results: Of 100 patients enrolled, 37 had bacterial sepsis. The optimal plasma NGAL cut-off value to predict sepsis was 570 ng/mL [area under the curve (AUC): 0.69]. The NGAL sepsis screening tool consists of the following clinical parameter: diabetes mellitus, the presence of rigors, quick sequential organ failure assessment (qSOFA) >2, a clear focus of infection, and the plasma NGAL >570 ng/mL. A score of <3 ruled out bacterial sepsis and a score >7 were highly suggestive of bacterial sepsis with an interval likelihood ratio (LR) of 7.77. Conclusion: The NGAL sepsis screening tool with a score >7 can be used in the emergency department (ED) to identify bacterial sepsis. How to cite this article: Paul A, Newbigging NS, Lenin A, Gowri M, Varghese JS, Nell AJ, et al. Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever. Indian J Crit Care Med 2023;27(3):176-182.

Central nervous system manifestations of dengue infection: data from a tertiary care Centre in South India.

BACKGROUND: Dengue fever is the second most common mosquito-borne disease affecting human beings and neurological manifestations (NMs) of this arboviral infection are increasingly being reported. METHODS: In this retrospective study, conducted in a tertiary care centre in south India, we sought to describe the spectrum of NMs of dengue fever. The records of all patients admitted in the Department of Internal Medicine over 8 years, with a diagnosis of dengue-based on clinical symptoms and the detection of dengue IgM antibodies or detection of NS1 antigen or nucleic acid by reverse transcriptase-polymerase chain reaction (RT-PCR); with Glasgow coma score (GCS) ≤14, neck stiffness, focal neurological signs, seizures, or visual disturbances-were explored. RESULTS: Of 1121 patients admitted with dengue fever, 341 (30%) had severe dengue and 23 (2%) had NMs. Encephalopathy was seen in 9 patients (39%), encephalitis in 6 (27%), cerebellitis in 4 (17%), acute disseminated encephalomyelitis (ADEM) in 2 (9%), ischaemic stroke in 1 (4%) patient, and neuro-ophthalmological manifestations in 1 (4%) patient. The median duration of hospital stay was 7 days. Nine (39% of) patients required intensive care unit (ICU) admission and 5 (22%) had fatal outcomes. There was no association between thrombocytopenia, metabolic acidosis, transaminitis, hyponatremia, the type of dengue infection, and the various NMs described. CONCLUSIONS: The NMs of dengue infection are varied, and a high index of suspicion is needed to identify them in patients who present with lethargy or altered sensorium on the background of an acute febrile illness suggestive of dengue.

Retrospective study of comparison of clinical severity and outcome of hospitalised COVID-19 patients during the first and second waves of the pandemic in India.

OBJECTIVES: To compare the clinical severity and outcome of hospitalised patients during the two waves of the COVID-19 pandemic in India. SETTING: A tertiary care referral hospital in South India. PARTICIPANTS: Symptomatic SARS CoV-2 reverse transcriptase PCR positive patients presenting to the emergency department during the two waves were recruited. The first wave spanned between April and December 2020 and the second wave between April and May 2021. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome of interest was mortality. Secondary outcomes included illness severity at presentation, need for oxygen therapy, non-invasive ventilation (NIV) and hospital or intensive care unit admission. RESULTS: The mean (SD) age of the 4971 hospitalised patients in the first wave was similar to the 2293 patients in the second wave (52.5±15.4 vs 52.1±15.1 years, p=0.37). When compared with the first wave, during the second wave, a higher proportion of patients presented with critical illness (11% vs 1.1%, p<0.001) and needed supplemental oxygen therapy (n=2092: 42.1% vs n=1459: 63.6%; p<0.001), NIV (n=643; 12.9% vs n=709; 30.9%; p<0.001) or inotropes/vasoactive drugs (n=108; 2.2% vs n=77: 3.4%; p=0.004). Mortality was higher during the second wave (19.2% vs 9.3%; p<0.001). On multivariable regression analysis, age >60 years (risk ratio, RR 2.80; 95% CI 2.12 to 3.70), D-dimer >1000 ng/mL (RR 1.34; 95% CI 1.15 to 1.55), treatment with supplemental oxygen (RR 14.6; 95% CI 8.98 to 23.6) and presentation during the second wave (RR 1.40; 95% CI 1.21 to 1.62) were independently associated with mortality. CONCLUSION: The second wave of the COVID-19 pandemic in India appeared to be associated with more severe presentation and higher mortality when compared with the first wave. Increasing age, elevated D-dimer levels and treatment with supplemental oxygen were independent predictors of mortality.

The Impact of Secondary Hypertension in Pregnancy on Maternal and Fetal Outcomes: A 42-Month Observational Study from South India.

Objectives: To examine the prevalence, etiology, and clinical outcomes of secondary hypertension in pregnancy in a high-risk tertiary care hospital. Study Design: This retrospective study used data from patient records between January 2015 and July 2018. Of 52,293 pregnant women admitted during this period, those with hypertension were included. Patient demographics, diagnosis of secondary hypertension, investigations, suspected etiologies of secondary hypertension, maternal and neonatal outcomes and discharge conditions were included. Main Outcome Measures: The prevalence of secondary hypertension and causes were measured. Univariate followed by multivariate analyses were done to look for associated maternal and neonatal outcomes. Results: Among patients with chronic hypertension in pregnancy, 13.7% had secondary causes, of which renal and cardiac causes were the commonest. The incidence of severe pre-eclampsia (40.5%) among patients with secondary hypertension was higher in patients with systolic blood pressures more than 140 mm of Hg than in those with systolic blood pressures lower than 140 mm of Hg (odds ratio [OR]: 4.92, confidence interval [CI]: 1.7-14.16, p: 0.002) irrespective of etiology. Pre-eclampsia predisposed to maternal acute kidney injury (OR: 1.23, CI: 1.04-1.45, p: 0.003), low birthweight (OR: 4.69, CI: 1.44-11.9, p: 0.006), preterm delivery (OR: 4.69, CI: 1.78-12.34, p: 0.001), and neonatal death (OR: 5.19, CI: 0.97-27.6, p: 0.04). Conclusion: The prevalence of hypertension in pregnancy was 10.3%; among them, the prevalence of secondary hypertension was 1.46%. Uncontrolled secondary hypertension was associated with poor maternal and neonatal outcomes. Strict control of blood pressure in secondary hypertension in pregnancy ensured better outcomes.

Noninvasive Ventilation in the Management of Respiratory Failure Due to COVID-19 Infection: Experience From a Resource-Limited Setting.

OBJECTIVE: To study the role of noninvasive ventilation (NIV) in Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV2) related acute respiratory failure (C-ARF). PATIENTS AND METHODS: Patients with C-ARF managed on NIV were categorized as NIV success or failure (death or intubation). Factors associated with failure were explored using regression analysis and expressed as odds ratio (OR) with 95% CI. RESULTS: Between April 1, 2020, and September 15, 2020, a total of 286 patients with a mean ± SD age of 53.1±11.6 years and Acute Physiology and Chronic Health Evaluation II score of 11.1±5.5 were initiated on NIV. Of the 182 patients (63.6%) successfully managed on NIV alone, 118 had moderate or severe acute respiratory distress syndrome. When compared with NIV success, NIV failure was associated with lower admission PaO2 to fraction of inspired oxygen ratio (P<.001) and higher respiratory rate (P<.001). On penalized logistic regression analysis, NIV failure was associated with higher Acute Physiology and Chronic Health Evaluation II score (OR, 1.12; 95% CI, 1.01 to 1.24), severe acute respiratory distress syndrome (OR, 3.99; 95% CI, 1.24 to 12.9), D-dimer level of 1000 ng/mL DDU (to convert to mg/L, divide by 1000) or greater (OR, 2.60; 95% CI, 1.16 to 5.87), need for inotropes or dialysis (OR, 12.7; 95% CI, 4.3 to 37.7), and nosocomial infections (OR, 13.6; 95% CI, 4.06 to 45.9). Overall mortality was 30.1% (86/286). In patients requiring intubation, time to intubation was longer in nonsurvivors than survivors (median, 5; interquartile range, 3-8 vs 3; interquartile range, 2-3 days; P<.001). CONCLUSION: Noninvasive ventilation can be used successfully in C-ARF. Illness severity and need for non-respiratory organ support predict NIV failure.

Clinical presentation of type 1 and type 2 pyrethroid poisoning in humans.

BACKGROUND: It is unclear if the clinical presentation of poisoning with type 1 and type 2 pyrethroid compounds is different. This study was undertaken to detail the clinical profile and outcome of patients presenting with pyrethroid poisoning and to quantify serum pyrethroid levels. PATIENTS AND METHODS: In this prospective study, patients were categorised as poisoning with type 1 pyrethroids or type 2 pyrethroids. Blood samples were sent for compound identification and quantification. Clinical features and outcomes were compared between the two groups. Factors associated with moderate and severe toxicity were explored using univariate logistic regression analysis and presented as odds ratio (OR) and 95% confidence intervals (CI). RESULTS: Type 1 pyrethroids were implicated in 16 patients and type 2 in 43 patients. The incidence of nausea and vomiting (81.2% vs. 81.3%) and tremor (37.5% vs. 32.6%) were similar in type 1 and type 2 poisoning; paraesthesia (6.2% vs. 32.6%, p = 0.04), hypersalivation (0% vs. 20.9%, p = 0.04), seizures (0% vs. 7%, p = 0.29) and depressed sensorium (0% vs. 18.6%, p = 0.03.) were observed more frequently in type 2 pyrethroid poisoning. Pyrethroids were detected in the serum samples of 24 patients; quantification was possible in 22 patients in whom serum levels ranged from 1.1 to 453 µg/ml. The compounds were undetectable in 35 patients. Two patients (lambda-cyhalothrin poisoning and cypermethrin poisoning) required intubation for low sensorium and respiratory distress. The median (interquartile range) duration of hospitalization was 12 (12-24) hours. All patients survived. Factors associated with moderate and severe toxicity included ingestion of a type 2 pyrethroid, lambda-cyhalothrin (OR 7.81, 95%CI 1.55-39.37, p = 0.01) and volume ingested (OR 1.01, 95%CI 1.00-1.02, p = 0.02). CONCLUSION: Patients with pyrethroid poisoning present predominantly with mild to moderate symptoms. Paraesthesia and hypersalivation are more frequent in type 2 poisoning. A favourable outcome can be expected.

Endovascular management of a patient with massive renal arteriovenous fistula: challenges and tricks.

We describe the endovascular management of a patient with a massive renal arteriovenous fistula and a huge venous aneurysmal sac, who presented with features of cardiac failure and fever. The challenges faced and the outcomes are discussed with relevant literature review.