Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis.

AIMS AND OBJECTIVES: The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. MATERIALS AND METHODS: For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and ClinicalTrials.gov between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. RESULTS: Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31-0.91; I 2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95-1.36; I 2 = 16%). CONCLUSION: The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate. HOW TO CITE THIS ARTICLE: Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(1):108-113.

Severe Acute Respiratory Infection Surveillance during the Initial Phase of the COVID-19 Outbreak in North India: A Comparison of COVID-19 to Other SARI Causes.

INTRODUCTION: World Health Organization proposes severe acute respiratory infection (SARI) case definition for coronavirus disease 2019 (COVID-19) surveillance; however, early differentiation between SARI etiologies remains challenging. We aimed to investigate the spectrum and outcome of SARI and compare COVID-19 to non-COVID-19 causes. PATIENTS AND METHODS: A prospective cohort study was conducted between March 15, 2020, to August 15, 2020, at an adult medical emergency in North India. SARI was diagnosed using a "modified" case definition-febrile respiratory symptoms or radiographic evidence of pneumonia or acute respiratory distress syndrome of ≤14 days duration, along with a need for hospitalization and in the absence of an alternative etiology that fully explains the illness. COVID-19 was diagnosed with reverse transcription-polymerase chain reaction testing. RESULTS: In total, 95/212 (44.8%) cases had COVID-19. Community-acquired pneumonia (n = 57), exacerbation of chronic lung disease (n = 11), heart failure (n = 11), tropical febrile illnesses (n = 10), and influenza A (n = 5) were common non-COVID-19 causes. No between-group differences were apparent in age ≥60 years, comorbidities, oxygenation, leukocytosis, lymphopenia, acute physiology and chronic health evaluation (APACHE)-II score, CURB-65 score, and ventilator requirement at 24-hour. Bilateral lung distribution and middle-lower zones involvement in radiography predicted COVID-19. The median hospital stay was longer with COVID-19 (12 versus 5 days, p = 0.000); however, mortality was similar (31.6% versus 28.2%, p = 0.593). Independent mortality predictors were higher mean APACHE II in COVID-19 and early ventilator requirement in non-COVID-19 cases. CONCLUSIONS: COVID-19 has similar severity and mortality as non-COVID-19 SARI but requires an extended hospital stay. Including radiography in the SARI definition might improve COVID-19 surveillance. HOW TO CITE THIS ARTICLE: Pannu AK, Kumar M, Singh P, Shaji A, Ghosh A, Behera A, et al. Severe Acute Respiratory Infection Surveillance during the Initial Phase of the COVID-19 Outbreak in North India: A Comparison of COVID-19 to Other SARI Causes. Indian J Crit Care Med 2021;25(7):761-767.

Natriuretic Peptides and Need for Reliable Tool to Assess Pulmonary Congestion for Treatment Monitoring in Heart Failure.

Natriuretic peptides (NPs) play a significant role in the pathophysiology of heart failure (HF) and are considered reliable diagnostic and prognostic indicators of congestive HF. Pulmonary congestion in HF patients leads to clinical deterioration and hospitalizations. It remains an important aspect to address the management and treatment tailoring in HF patients. However, the role of NP-guided therapy remains debatable due to contrasting reports in the literature. Current guidelines do not recommend the use of NP-guided therapy in the treatment monitoring of HF. Therefore, there is an urgent need to identify reliable markers for treatment monitoring in congestive HF. For early detection of congestion, a technology-based approach to monitor pulmonary hemodynamics and absolute lung fluid measurement is found to be effective in guiding treatment. Remote dielectric sensing technology is one such non-invasive approach that measures pulmonary fluid levels in the lungs which results in reduced hospitalization and re-admission rate in HF patients. In this review, we summarized the role of natriuretic peptides and the need for a reliable tool to assess pulmonary congestion for treatment monitoring in HF.

Efficacy and safety of the Arctic Sun device for hypoxic-ischemic encephalopathy in adult patients following cardiopulmonary resuscitation: A systematic review and meta-analysis.

AIM: The principal objective of this study was to carry out a comprehensive and thorough analysis to compare the safety and effectiveness of the Arctic Sun, a servo-controlled surface cooling device, with conventional cooling techniques for providing therapeutic hypothermia in adult patients who had experienced hypoxic-ischemic brain injury following cardiopulmonary resuscitation. METHODS: In order to achieve our goal, we conducted an extensive search of multiple databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov up to the date of July 30, 2021. We only included studies that compared the safety and efficacy of the Arctic Sun surface cooling equipment with standard cooling approaches such as cooling blankets, ice packs, and intravenous cold saline for treating comatose adult patients who had recovered after experiencing cardiac arrest. We evaluated various outcomes, including all-cause mortality, good neurological outcome at 1 month, and the occurrence of adverse effects such as infections, shock, and bleeding. We employed a random-effects meta-analysis to estimate the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes. RESULTS: One hundred and fourteen records were identified through our search; however, only three studies met our eligibility criteria, resulting in overall 187 patients incorporated in the meta-analysis. The findings indicated no significant difference in mortality rates among the Arctic Sun device and conventional cooling techniques (OR: 0.64; 95% CI: 0.34-1.19; P = 0.16; I2 = 0%). In addition, we found no significant difference in occurrence of good neurological outcomes (OR: 1.74; 95% CI: 0.94-3.25; P = 0.08; I2 = 0%) between the two cooling methods. However, the application of the Arctic Sun device was associated with increased incidence of infections compared to standard cooling methods (OR: 2.46; 95% CI: 1.18-5.11; P = 0.02; I2 = 0%). While no significant difference occurred in the incidence of shock (OR: 0.29; 95% CI: 0.07-1.18; P = 0.08; I2 = 40%), the use of the Arctic Sun device was linked to significantly fewer bleeding complications compared to standard cooling methods (OR: 0.11; 95% CI: 0.02-0.79; P = 0.03; I2 = 0%). CONCLUSIONS: After analyzing the results of our meta-analysis, we concluded that the use of the Arctic Sun device for targeted temperature management following cardiopulmonary resuscitation did not result in significant differences in mortality rates or improve neurological outcomes when compared to standard cooling techniques.

Comparison of diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis.

BACKGROUND: Intravenous calcium channel blockers or beta-blockers are the preferred rate control medications for hemodynamically stable patients with atrial fibrillation with rapid ventricular rate (AF-RVR) in the emergency department. OBJECTIVES: To compare the efficacy of intravenous diltiazem and metoprolol for rate control and safety with respect to development of hypotension and bradycardia in patients with AF-RVR. METHODS: For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane databases, and the clinicaltrials.gov registry between database inception and 30th May 2021. Articles were included if they compared efficacy and safety of diltiazem versus metoprolol in critically ill adult patients hospitalized with AF-RVR. Outcome measures were achievement of rate control, development of new hypotension, and bradycardia after drug administration. RESULTS: Of 86 records identified, 14 were eligible, all of which had a low to moderate risk of overall bias. The meta-analysis (Mantel-Haenszel, random-effects model) showed that diltiazem use was associated with increased achievement of rate control target compared to metoprolol [14 studies, n = 1732, Odds Ratio (OR): 1.92; 95% Confidence Intervals (CI):1.26 to 2.90; I2 = 61%]. In the pooled analysis, no differences were seen in hypotension using diltiazem vs metoprolol [12 studies, n = 1477, OR: 0.96; 95% CI:0.61 to 1.52; I2 = 35%] or bradycardia [9 studies, n = 1203, OR: 2.44; 95% CI: 0.82 to 7.31; I2 = 48%]. CONCLUSIONS: Intravenous diltiazem is associated with increased achievement of rate control target in patients with AF-RVR compared to metoprolol, while both medications are associated with similar incidence of hypotension and bradycardia.

Etiology of new-onset seizures in adult patients of different age groups presenting to the emergency department in North India and their outcomes.

Introduction: Seizures are one of the most common neurological emergencies encountered in both urban and rural India. There is only limited research work on the etiology of new-onset seizures in adult patients of different age groups presenting to the emergency department, especially from the Indian sub-continent. A new-onset seizure can be the first presentation of stroke, or it may be a symptom of brain infections, metabolic abnormality, brain tumor, systemic disease, or an early phase of epilepsy, which needs scrutiny and appropriate management. A dedicated study of the underlying etiology of new-onset seizures among different age groups and their incidence and prevalence can help in the prognostication and clinical management of these patients. Materials and Methods: This was a prospective observational cross-sectional study conducted in the Emergency Medical Out-patient Department and emergency medical ward of the Post-graduate Institute of medical education and research, Chandigarh. Results: In our research, males out-numbered females. The most common seizure type recorded in our study was generalized tonic-clonic. In the younger age group between 13 and 35 years, infective etiologies were dominant. In the middle age group between 36 and 55 years, cerebrovascular accidents were the dominant etiology, followed by infective causes and metabolic causes. In the older age group above 55 years, the most dominating etiology found was cerebrovascular accident. Almost 72% had abnormal brain imaging. The most common abnormality found was ischemic infarcts. The second most common abnormality detected was a meningeal enhancement. A small percentage of patients had an intra-cranial bleed, and a very small percentage had a subarachnoid hemorrhage. Conclusions: In younger patients, infections such as tubercular and pyogenic meningitis and cerebral malaria are the most common causes of new-onset seizures, followed by malignancy and metabolic causes, in descending order. In the middle age group, stroke is the most common etiology, followed by central nervous system (CNS) infections and metabolic causes, in descending order. In elderly patients, stroke is the leading etiology for new-onset seizures. Physicians working in rural and remote areas routinely face challenges in managing patients with new-onset seizures. Knowledge of different etiologies in different age groups will equip them to make informed decisions regarding investigations and treatment of patients with new-onset seizures. It also encourages them to aggressively search for CNS infections, especially in younger patients.

Direct diagnosis of scrub typhus by full-length 16S ribosomal RNA gene analysis using Oxford Nanopore sequencing.

Scrub typhus (caused by Orientia tsutsugamushi) is a neglected and underdiagnosed disease due to its non-specific clinical presentation and challenging diagnostics. We document the first study of direct diagnosis of scrub typhus from the blood sample of a patient by full-length 16S ribosomal RNA gene amplicon analysis using Oxford Nanopore sequencing.