Aviptadil: A multifaceted approach to mitigating hypoxemia in acute respiratory distress syndrome.

Acute Respiratory Distress Syndrome (ARDS) is a severe and potentially life-threatening lung condition that often leads to Intensive Care Unit (ICU) admissions. Treating ARDS in the ICU involves providing essential support for proper oxygenation and ventilation, often requiring mechanical ventilation using high positive end-expiratory pressure (PEEP) to recruit alveoli. Strategies like prone positioning and extracorporeal membrane oxygenation (ECMO) may be necessary for stubbornly low oxygen levels. Addressing the underlying cause, if known, and employing additional therapies to prevent complications are also integral parts of the management. Despite advances in critical care, ARDS remains a formidable challenge with considerable risks of mortality and complications. Early recognition, immediate intervention, and comprehensive ICU care are pivotal in enhancing outcomes for ARDS patients. Ongoing research and clinical trials continue to explore innovative treatments and strategies to improve the prognosis of individuals with ARDS. In this series, we share our experience regarding the safe utilization of Aviptadil for treating ARDS arising from causes other than COVID-19.

Ulinastatin Add-on to Standard of Care in Critically Ill COVID-19 Patients: A Multicenter, Retrospective Study.

AIM: To assess the impact on 30-day mortality with ulinastatin (ULI) used as add-on to standard of care (SOC) compared to SOC alone in coronavirus disease (COVID-19) patients requiring admission to the intensive care unit (ICU). MATERIALS AND METHODS: In this multicentric, retrospective study, we collected data on clinical, laboratory, and outcome parameters in patients with COVID-19. Thirty-day mortality outcome was compared among patients treated with SOC alone and ULI used as add-on to SOC. Odds ratio (OR) and 95% confidence intervals (CI) were determined to identify the predictors of 30-day mortality. RESULTS: Ninety-four patients were identified and enrolled in both groups with comparable baseline parameters. On univariate analysis, 30-day mortality was significantly lower in ULI plus SOC group than SOC alone group (36.2 vs 51.1%, OR 0.54, 95% CI 0.30-0.97, p = 0.040). The effect on mortality was more pronounced in patients who did not require intubation (10.9 vs 34.0%, OR 0.24, 95% CI 0.09-0.66, p = 0.006) and with early administration (within 72 hours of admission) of ULI (30.7 vs 57.9%, OR 0.32, 95% CI 0.11-0.91, p = 0.032). On multivariate analysis, only intubation predicted mortality (adjusted OR 10.13, 95% CI 3.77-27.25, p<0.0001) and the effect of ULI on survival was not significant (adjusted OR 0.58, 95% CI 0.22-1.52, p = 0.270). CONCLUSION: Given the limited options for COVID-19 patients treated in ICU, early administration of ULI may be helpful, especially in patients not requiring intubation to improve the outcomes. Further, a large, randomized study is warranted to confirm these findings.

Noninvasive Respiratory Devices in COVID-19.

How to cite this article: Mehta C, Mehta Y. Noninvasive Respiratory Devices in COVID-19. Indian J Crit Care Med 2022;26(7):770-772.

Use of CytoSorb therapy to treat critically ill coronavirus disease 2019 patients: a case series.

BACKGROUND: Acute respiratory distress syndrome is an important clinical presentation of respiratory complications caused by severe acute respiratory syndrome coronavirus 2, a novel coronavirus responsible for the ongoing pandemic. The disease is poorly understood, and immunopathogenesis is constantly evolving. Cytokine release syndrome remains central to pathology of coronavirus disease 2019. Antivirals, anticytokine treatment, and other pharmacological approaches have failed to treat it. CytoSorb, an extracorporeal cytokine adsorber that reduces the cytokine storm and other inflammatory mediators in the blood, seems promising in treating severely ill patients with coronavirus disease 2019. CASE PRESENTATION: This article presents three cases of Asian ethnicity of severely ill adult patients with coronavirus disease 2019 admitted to intensive care unit who were treated with CytoSorb therapy. All patients used single CytoSorb device. During their clinical course, all patients were prescribed tocilizumab (an interleukin-6 receptor blocker), antivirals, hydroxychloroquine, azithromycin, and other antibiotics and general antipyretic drugs. No vasopressor treatment was required. The patients' average duration of stay in intensive care unit was 30 days; the average duration of stay in hospital was 31 days. All three patients showed significant improvement in biochemical parameters and clinical outcomes post CytoSorb therapy. C-reactive protein levels decreased by 91.5%, 97.4%, and 55.75 %, and mean arterial pressure improved by 18%, 23%, and 17 % in patient 1, 2, and 3, respectively, on day 7 post-therapy. CONCLUSIONS: All three patients improved clinically and survived.

Experience with hemoadsorption (CytoSorb®) in the management of septic shock patients.

BACKGROUND: Cytokines and inflammatory mediators are the hallmarks of sepsis. Extracorporeal cytokine hemoadsorption devices are the newer clinical support system to overcome the cytokine storm during sepsis. AIM: To retrospectively evaluate the clinical outcomes of patients admitted in intensive care unit with septic shock with different etiologies. METHODS: The laboratory parameters including biomarkers such as procalcitonin, serum lactate and C-reactive protein; and the hemodynamic parameters; mean arterial pressure, vasopressor doses, sepsis scores, cytokine levels and other vital parameters were evaluated. We evaluated these outcomes among survivors and non-survivors. RESULTS: Of 100 patients evaluated, 40 patients survived. Post treatment, the vasopressors dosage remarkably decreased though it was not statistically different; 34.15% (P = 0.0816) for epinephrine, 20.5 % for norepinephrine (P = 0.3099) and 51% (P = 0.0678) for vasopressin. In the survivor group, a remarkable reduction of biomarkers levels; procalcitonin (65%, P = 0.5859), C-reactive protein (27%, P = 0.659), serum lactate (27%, P = 0.0159) and bilirubin (43.11%; P = 0.0565) were observed from baseline after CytoSorb® therapy. A significant reduction in inflammatory markers; interleukin 6 and interleukin 10; (87% and 92%, P < 0.0001) and in tumour necrosis factor (24%, P = 0.0003) was also seen. Overall, 28 (28%) patients who were given CytoSorb® therapy less than 48 h after onset of septic shock survived and the maximum duration of stay for 70% of these patients in intensive care unit was less than 15 d. CONCLUSION: CytoSorb® is a safe and well tolerated rescue therapy option in patients with septic shock. However, early (preferably within < 48 h after onset of septic shock) initiation could result in better clinical outcomes. Further randomized trials are needed to define the potential benefits of this new treatment modality.

MDRPU -an uncommonly recognized common problem in ICU: A point prevalence study.

BACKGROUND: Pressure ulcers (PU) usually occur over bony prominences in hospitalized patients. But they may occur due to medical devices referred also as Medical device related pressure ulcers (MDRPU). The United States National advisory panel (NPUAP) recognizes it as an important entity. MDRPU is one of the key quality indicators of hospital care, so far no data is available on MDRPU from the Indian Sub-continent. AIM: The primary objective of the study was to examine prevalence and Risk factors of MDRPU in critically sick patients. DESIGN: A Cross-sectional point prevalence study. METHODS: All patients above 18 years of age admitted in Intensive care units (ICU) on the date of the survey were included in the study. It was conducted in medical, cardiothoracic and neurosurgical ICUs. Demographic and MDRPU data were recorded. MDRPU was staged as per National Pressure ulcer advisory panel staging system. Ethics Committee approval was obtained prior to the start of the study. RESULTS: One hundred and forty-six patients were included. The prevalence of PU was 26.0%. The prevalence of MDRPU was found to be 19.2%. MDRPUs most commonly occurred with non-invasive ventilation mask (NIV) and nasogastric tube (NGT) (20% and 12.3% respectively). MDRPUs were associated with a longer ICU Stay. CONCLUSIONS: MDRPUs pose a significant burden on healthcare. Our study showed significant prevalence rate of MDRPU which is comparable to those seen internationally. There is a compelling need to have continuous audits and structured training programs among healthcare professionals to prevent MDRPUs in critically sick patients.

Percutaneous tracheostomy.

Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically sick patients. It can be safely performed bedside by intensivists.This has resulted in decline in the use of surgical tracheostomy in intensive care unit (ICU) except in few selected cases. Most common indication of tracheostomy in ICU is need for prolonged ventilation. About 10% of patients requiring at least 3 days of mechanical ventilator support get tracheostomised during ICU stay. The ideal timing of PDT remains undecided at present. Contraindications and complications become fewer with increase in experience. Various methods of performing PDT have been discovered in last two decades. Preoperative work up, patient selection and post tracheostomy care form key components of a successful PDT. Bronchoscopy and ultrasound have been found to be useful procedural adjuncts, especially in presence of unfavorable anatomy. This article gives a brief overview about the use of PDT in ICU.

Retrospective study on prognostic importance of serum procalcitonin and amino-terminal pro-brain natriuretic peptide levels as compared to Acute Physiology and Chronic Health Evaluation IV Score on Intensive Care Unit admission, in a mixed Intensive Care Unit population.

BACKGROUND: Timely decision making in Intensive Care Unit (ICU) is very essential to improve the outcome of critically sick patients. Conventional scores like Acute Physiology and Chronic Health Evaluation (APACHE IV) are quite cumbersome with calculations and take minimum 24 hours. Procalcitonin has shown to have prognostic value in ICU/Emergency department (ED) in disease states like pneumonia, sepsis etc. NTproBNP has demonstrated excellent diagnostic and prognostic importance in cardiac diseases. It has also been found elevated in non-cardiac diseases. We chose to study the prognostic utility of these markers on ICU admission. SETTINGS AND DESIGN: Retrospective observational study. MATERIALS AND METHODS: A Retrospective analysis of 100 eligible patients was done who had undergone PCT and NTproBNP measurements on ICU admission. Their correlations with all cause mortality, length of hospital stay, need for ventilator support, need for vasopressors were performed. RESULTS: Among 100 randomly selected ICU patients, 28 were non-survivors. NTproBNP values on admission significantly correlated with all cause mortality (P = 0.036, AUC = 0.643) and morbidity (P = 0.000, AUC = 0.763), comparable to that of APACHE-IV score. PCT values on admission did not show significant association with mortality, but correlated well with morbidity and prolonged hospital length of stay (AUC = 0.616, P = 0.045). CONCLUSION: The current study demonstrated a good predictive value of NTproBNP, in terms of mortality and morbidity comparable to that of APACHE-IV score. Procalcitonin, however, was found to have doubtful prognostic importance. These findings need to be confirmed in a prospective larger study.

Management of refractory hypoxemia.

Mechanical ventilation remains the cornerstone in the management of severe acute respiratory failure. Acute respiratory distress syndrome (ARDS) is the most common cause of respiratory failure. It is associated with substantial mortality, and unmanageable refractory hypoxemia remains the most feared clinical possibility. If hypoxemia persists despite application of lung protective ventilation, additional therapies including inhaled vasodilators, prone positioning, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade (NMB), and extracorporeal membrane oxygenation may be needed. NMB and prone ventilation are modalities that have been clearly linked to reduced mortality in ARDS. Rescue therapies pose a clinical challenge requiring a precarious balance of risks and benefits, as well as, in-depth knowledge of therapeutic limitations.

Epstein-Barr virus infection-Related hemophagocytic lymphohistiocytosis.

We report a case of 27-year-old female diagnosed with hemophagocytic lymphohistiocytosis (HLH) following a recent Epstein-Barr virus (EBV) infection. A known case of relapsing remitting multiple sclerosis on corticosteroids for last 6 months presented to the critical care unit with fever, maculopapular rash and difficulty in breathing. A rapid and correct diagnosis with the precise treatment led to complete recovery of this patient. The HLH is a rare complication of primary EBV infection.

Pressure ulcer and patient characteristics--A point prevalence study in a tertiary hospital of India based on the European Pressure Ulcer Advisory Panel minimum data set.

BACKGROUND: Pressure ulcers is a frequent problem in hospitalized patients. Several prevalence studies have been conducted across the globe. Little information is available regarding prevalence of pressure ulcers in India. PURPOSE: The aim was to identify the prevalence of pressure ulcers in one of the tertiary hospital in northern India and the factors associated with its development. DESIGN: A cross sectional point prevalence study. INSTRUMENTS: European Pressure Ulcer Advisory Panel (EPUAP) data collection form. METHODS: Ethics approval was obtained prior to start of the study. Total of 358 patients were enrolled in the study. All patients above 18 years of age admitted in intensive care units and wards were included in the study. Patients admitted in emergency, day care, coronary care unit were excluded because of their short duration of hospital stay (varies from 24 to 72 h usually). All patients admitted before midnight on the predetermined day were included. The Braden scale was used to identify the risk of developing pressure ulcers. European Pressure ulcer advisory panel (EPUAP) minimum data set was used to collect prevalence data. RESULTS: The overall prevalence rate was 7.8%.The sacrum and heel were more commonly affected. Grade III pressure ulcers were the most common (42.8%). CONCLUSION: The pressure ulcer prevalence rate in our hospital was lower than that published in international studies. Severe forms of pressure ulcers were commonly encountered This data provides background information that may help us in developing protocols for applying effective practices for prevention of pressure ulcers.

Vocal cord dysfunction presenting as refractory asthma.

Vocal cord dysfunction is a rare variety of upper airway obstruction characterized by typical laryngoscopic features and may mimic an acute asthma attack. The case presented in this report pertains to a 15-year-old girl who had repeated acute episodes of dyspnoea and wheezing and remained non-responsive to corticosteroids and inhaled bronchodilators requiring endotracheal intubations for adequate control. Laryngoscopic findings were consistent with vocal cord dysfunction. She was treated with a tracheostomy and psychological support.