Perioperative role of oral gabapentin as an analgesic in paediatric patients: A randomised controlled trial.

Background and Aims: Surgical procedure commonly performed in the advanced pediatric age group includes urogenital surgery, adenotonsillectomy, etc., Aim: The aim of this study is to determine the effect of single-dose gabapentin 15 mg/kg on acute pain in the immediate postoperative period in patients aged 8-14 years undergoing surgeries under general anesthesia. Material and Methods: After the approval from the institutional ethical committee, 60 American Society of Anesthesiologists (ASA) I and II patients aged 8-14 years undergoing urogenital surgeries (orchidopexy/urethroplasty) under general anesthesia were included in this study. The patients were assigned into one of the two treatment groups. Patients in group I received oral gabapentin 15 mg/kg dissolved in 5 mL of honey 2 h before surgery, while patients in group II received 5 mL honey orally 2 h before surgery. Results: A total of 60 patients participated. Patients in group I had lower consumption of fentanyl perioperatively (intraoperatively: 1.36 ± 0.70 mcg/kg; postoperatively: 2.36 ± 0.795 mcg/kg) than group II (intraoperatively: 1.8 ± 0.6 mcg/kg; postoperatively: 2.9 ± 0.47 mcg/kg). The differences in the two groups were significant. The time to first rescue analgesia was greater in group I (3.03 ± 0.60 h) than in group II (2.26 ± 0.57 h). There was an increase in sedation score in the treatment group. Conclusion: Our clinical study demonstrates that a 15 mg/kg single preemptive oral dose of gabapentin might reduce the requirement of analgesics perioperatively in pediatric urogenital surgery but might also be associated with undesirable effects such as increased sedation.

Comparison of the oropharyngeal leak pressure between three second generation supraglottic airway devices during laparoscopic surgery in pediatric patients.

BACKGROUND: Previous studies have shown Proseal LMA and I gel similar to endotracheal intubation in ventilatory ability in pediatric laparoscopic surgeries. AIMS: The primary aim of this study was to assess whether there is a significant difference in the oropharyngeal leak pressure between Ambu Auragrain, I-gel, and Proseal LMA during pediatric laparoscopic surgery. METHODS: In this randomized controlled trial, 90 male patients of American Society of Anesthesiologists physical status I aged between 6 months and 10 years who were scheduled for laparoscopic single-sided inguinal hernia repair were recruited and randomly allocated to three groups in which airway was secured with Ambu Auragain, I gel, or Proseal LMA. The primary outcome was oropharyngeal leak pressure. The secondary outcomes were peak pressures before and after pneumoperitoneum, fiberoptic view, insertion attempts, insertion time, manipulations, perioperative and postoperative anesthesia-related problems. Continuous variables were compared using the one-way analysis of variance or the Kruskal-Wallis test with post hoc Turkey analysis. Categorical and ordinal data were compared using the chi-square test or Fisher's exact test. RESULTS: Oropharyngeal leak pressure before pneumoperitoneum was higher with I gel as compared to Ambu Auragain (27.36 ± 5.72 cm of H2 O vs 23.56 ± 5.72 cm of H2 O) (p = .021) and PLMA (27.36 ± 5.72 cm of H2 O vs 23.24 ± 4.35 cm of H2 O) (p = .011). Oropharyngeal leak pressure after pneumoperitoneum was also higher with I gel as compared to Ambu Auragain (31.58 ± 4.35 cm of H2 O vs 26.83 ± 5.00 cm of H2 O) (p = .001) and Proseal LMA (31.58 ± 4.35 cm of H2 O vs 27.03 ± 3.80 cm of H2 O) (p = .002). Oropharyngeal leak pressures of Ambu Auragain and Proseal LMA were comparable. Postoperative complications were similar in all the supraglottic airway devices. No regurgitation or aspiration-related problem was observed in our study. CONCLUSION: I gel had a higher oropharyngeal leak pressure than the other two supraglottic airway devices and therefore may represent a better choice in situations where higher ventilatory pressures may be necessary, for example, in extremes of weight trendelenburg position, etc. CLINICAL TRIAL IDENTIFIER: Clinical trial registry of India (CTRI/2018/11/016445).

Does Long-term Oxygen Therapy and Noninvasive Ventilation Predispose Rhino-orbital-cerebral Mucormycosis in COVID-19 Patients?

How to cite this article: Kumar A, Kumar A, Kumar N, Kumar A, Sinha C, Singh PK. Does Long-term Oxygen Therapy and Noninvasive Ventilation Predispose Rhino-orbital-cerebral Mucormycosis in COVID-19 Patients? Indian J Crit Care Med 2022;26(9):1063-1064.

Endotracheal tube inflation tubing defect: an unusual cause of intraoperative volume leak.

Loss of endotracheal cuff pressure can lead to airway compromise and loss of volume delivery in mechanical ventilation requiring immediate intervention. A 40 years old male posted for bilateral interpositional arthroplasty was intubated nasally with 7.5 mm flexometallic endotracheal tube. In the intraoperative period airway leak was detected due to loss of cuff pressure even after repeated attempt of cuff inflation. After changing endotracheal tube, leak was detected from the inflation tubing distal to the cuff, which was apparent only when cuff pressure was increased above 30 cm of H2O.

Sympathetic storm or Cytokine storm: A diagnostic dilemma in patient of traumatic brain injury with COVID 19.

PURPOSE: Paroxysmal sympathetic hyperactivity (PSH) occurs in around 15-33% patients of traumatic brain injury. Due to presence of non-specific symptoms, it's always difficult to differentiate between paroxysmal sympathetic storm and cytokine storm syndrome and hence can delay specific treatment. CASE REPORT: We report a clinical case of 19-year-old male tested COVID 19 positive with diffuse axonal injury presented with features of paroxysmal sympathetic storm and cytokine storm syndrome. The patient showed the signs clinical improvement when we treated both these conditions. CONCLUSION: We suggest that clinicians need to have a high degree of suspicion of paroxysmal sympathetic storm in patients of traumatic brain injury and consider its diagnosis. Also, if patient is COVID 19 positive, early identification of signs of developing cytokine storm with monitoring of biomarkers is important for its timely management.

Painful Blisters of Left Hand Following Extravasation of Remdesivir Infusion in COVID-19.

How to cite this article: Kumar N, Kumar A, Pradhan S, Kumar A, Singh K. Painful Blisters of Left Hand Following Extravasation of Remdesivir Infusion in COVID-19. Indian J Crit Care Med 2021;25(2):240-241.

Defecation and Micturition may Cause Syncope in COVID-19 Patients on High Oxygen Requirement.

How to cite this article: Naaz S, Kumar A, Sahay N, Kumar R, Ozair E, Valiaparambath A. Defecation and Micturition may Cause Syncope in COVID-19 Patients on High Oxygen Requirement. Indian J Crit Care Med 2021;25(5):599-600.

Gargling with 7.5% Sodium Bicarbonate Solution for SARS-CoV-2 Viremia Clearance: Our Institutional Clinical Experience.

BACKGROUND: Gargling had been reported to have some roles in the prevention and treatment of respiratory tract infections. The purpose of this study was to assess the ability of regular gargling using 7.5% sodium bicarbonate to eliminate SARS-CoV-2 in the oropharynx and nasopharynx. MATERIALS AND METHODS: This pilot, open-labeled, nonrandomized, parallel single-center study. The effect of 30 seconds, three times per day gargling using 7.5% sodium bicarbonate solution-25 mL on SARS-CoV-2 viral clearance among coronavirus disease-2019 (COVID-19) patients in a dedicated COVID hospital at All India Institute of Medical Sciences, Patna, Bihar, India. We monitored the progress on by days 0, 1, 2, 3, 4, 5, 6, and 7 by observing variables like clinical category, P/F ratio, neutrophil/lymphocyte ratio (NLR) ratio, platelet count, ferritin, lactate dehydrogenase (LDH), CRP, procalcitonin, d-dimer, INR, APTT, and sequential organ function assessment (SOFA) score. We have also done repeat reverse transcription-polymerase chain reaction (RT-PCR) testing on day 5 and day 7. RESULTS: A total of 10 patients (7 males and 3 females) were included in our study after confirmed COVID positivity. The age range was from 30 to 61 years. Based on clinical severity and P/F ratio, 7 patients were included in the milder group as their ratio was more than 200 and the rest 3 patients were included in the moderate group as P/F ratio was less than 200. Two respondents had comorbidities, which were non-Hodgkin's lymphoma and ovarian carcinoma. Viral clearance was achieved at day 7 in 3 of 10 patients. However, the analysis of using 7.5% sodium bicarbonate 25 mL gargle statistically showed nonsignificant p-value for all of our studied variables. However, the PCR results were negative on 24 hours apart, i.e., on day 5 and day 7. CONCLUSIONS: This is only a preliminary study which showed that gargling with 7.5% sodium bicarbonate may not be effective in achieving early SARS-CoV-2 viral clearance among mild COVID-19 patients. However, still larger studies are required to ascertain the benefit of gargling for different stages of COVID-19 patients with keeping in mind the important variables suggestive of viremia clearance. HOW TO CITE THIS ARTICLE: Kumar N, Kumar A, Mahto M, Singh PK. Gargling with 7.5% Sodium Bicarbonate Solution for SARS-CoV-2 Viremia Clearance: Our Institutional Clinical Experience. Indian J Crit Care Med 2021;25(7):791-794.

Acute Peripheral Arterial Thrombosis in COVID-19 Patients on Therapeutic Anticoagulation.

Coronavirus disease-2019 (COVID-19) disease is often complicated by venous thrombosis and embolism. However, arterial thrombosis in a patient already on therapeutic anticoagulation is a rare occurrence. In one patient, we found thrombosis of the radial artery leading to ischemia of the fingers and lateral part of the palm. In another patient, thrombosis was found in the anterior tibial artery, resulting in ischemia of the limb and amputation. Both these patients were on a therapeutic dose of low-molecular-weight heparin. In both cases, heparin infusion was started but with little benefit. It is suggested that intensified anticoagulation should be done in patients at high-risk venous thrombosis, and prompt interventional thrombectomy should be done in cases of failure of pharmacological anticoagulation. HOW TO CITE THIS ARTICLE: Kumar A, Kumar N, Arun SK, Ghosh S, Pattanayak A. Acute Peripheral Arterial Thrombosis in COVID-19 Patients on Therapeutic Anticoagulation. Indian J Crit Care Med 2021;25(4):461-462.

Multiple Peaked Cytokine Storm: Is Multiple Exposures to the COVID-19 Virus a Possible Cause?

Severe acute respiratory syndrome coronavirus 2 is the pathogen that causes coronavirus disease-2019 (COVID-19). Recent studies have shown that the "cytokine storm" (high concentration of proinflammatory cytokines) may contribute to the mortality of COVID-19. Repeated exposure to the virus can lead to a dose-dependent immune response that may be associated with more disease severity and higher mortality. Sudden deterioration/increased oxygen consumption after initial improvement may be due to multiple surges of cytokines storm within a short period, the possible cause may be due to multiple exposures within the incubation period. We hypothesize that multiple surges in cytokines storm in some patients may be due to multiple exposures of the same patient within the incubation period, sepsis, or other inflammatory lesions inside the body. In our cases, sepsis as a cause of cytokine storm was ruled out by doing the procalcitonin test, which was within the normal limit. HOW TO CITE THIS ARTICLE: Kumar A, Kumar A, Kumar A, Kumar N, Sinha C, Singh V. Multiple Peaked Cytokine Storm: Is Multiple Exposures to the COVID-19 Virus a Possible Cause? Indian J Crit Care Med 2021;25(4):463-464.

Second-degree Heart Block Caused by Itolizumab-induced Infusion Reaction in COVID-19.

How to cite this article: Kumar A, Kumar N, Lenin D, Kumar A, Ahmad S. Second-degree Heart Block Caused by Itolizumab-induced Infusion Reaction in COVID-19. Indian J Crit Care Med 2021;25(4):474-475.

Repackaging of Malfunctioning High-flow Nasal Cannula as a Rescue Oxygen Therapy: An Innovation amid COVID-19 Crisis.

Oxygen supplementation is required for approximately 14% of the patients diagnosed of having COVID-19 infection. Despite the use of conventional oxygen therapy, 5% among these require treatment in the intensive care unit (ICU). Here, we are describing a situation in which oxygen therapy was delivered to the patients by making an assembly of oxygen tubing, three-way stopcock, and high-flow nasal cannula (HFNC) present in the hospital setting following the malfunction of air blender of HFNC machine (Fig. 1). This assembly might be useful as rescue oxygen therapy during a malfunction of HFNC machine and in resource-limited settings where HFNC machine is not available. The mechanisms of action could be (1) washout of anatomic dead space due to medium oxygen flow, (2) improved gas mixing in large airways, and (3) increased oxygen concentration inside the conducting airway. How to cite this article: Kumar A, Kumar A, Kumar N, Kumar A, Singh V, Kumar S, et al. Repackaging of Malfunctioning High-flow Nasal Cannula as a Rescue Oxygen Therapy: An Innovation amid COVID-19 Crisis. Indian J Crit Care Med 2021;25(8):948-949.

Acute Exacerbation of Cough as a Precipitating Cause of Hypoxia in COVID-19 Patients.

Kumar A, Kumar A, Kumar A, Sinha C, Kumar N, Singh PK. Acute Exacerbation of Cough as a Precipitating Cause of Hypoxia in COVID-19 Patients. Indian J Crit Care Med 2021;25(11):1324-1325.

The COSEVAST Study Outcome: Evidence of COVID-19 Severity Proportionate to Surge in Arterial Stiffness.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection affects the cardiovascular system at many levels. It initially infects endothelial cells, inducing marked endothelial damage and inflammation. However, there was no empirical evidence of functional compromise of arterial walls. AIMS AND OBJECTIVE: Our primary objective was to study functional arterial damage in coronavirus disease 2019 (COVID-19) and establish the noninvasive measurement of arterial stiffness as an independent marker of disease severity. MATERIALS AND METHODS: We recorded the arterial stiffness of 23 mild, 21 moderate, and 20 severe COVID-19 patients grouped on the latest National Institute of Health (NIH) severity criteria. We observed arterial stiffness of COVID-19 patients with standard parameters like noninvasive estimated carotid-femoral pulse wave velocity (cfPWV), age-normalized increase in cfPWV (ANI_cfPWV), age-normalized increase in aortic augmentation pressure (ANI_AugP), and heart rate-normalized augmentation index (HRN_ AIx). All the parameters were also corrected for statistically significant confounding factors. RESULTS: Moderate and severe COVID-19 patients have extremely significantly elevated arterial stiffness than mild patients. In mild patients, cfPWV (829.1 ± 139.2 cm/second) was significantly lower than both moderate (1067 ± 152.5 cm/second, p <0.0001) and severe (1416 ± 253.9 cm/second, p <0.0001) patients. ANI_cfPWV in moderate and severe patients was significantly higher than mild patients (mild: 101.2 ± 126.1 cm/second; moderate: 279 ± 114.4 cm/second; severe: 580.1 ± 216.4 cm/second; intergroup p <0.0001). The results even after correction for significant confounding factors did not show any considerable change in the increasing trend of arterial stiffness. CONCLUSION: This study establishes the functional deterioration of arteries in proportion to the severity of COVID-19. HOW TO CITE THIS ARTICLE: Kumar N, Kumar S, Kumar A, Bhushan D, Kumar A, Kumar A, et al. The COSEVAST Study Outcome: Evidence of COVID-19 Severity Proportionate to Surge in Arterial Stiffness. Indian J Crit Care Med 2021;25(10):1113-1119.

Modified Negative Airflow Aerosol Prevention Box for COVID-19 Patients.

The importance of this intubation box has come to light recently in view of the coronavirus disease-2019 (COVID-19) pandemic and the fact that intubation is an aerosol-generating procedure (AGP). Risks of the healthcare worker attending to the airway of COVID-19 patients is high and the intubation box aims to minimize that and reduce contamination of the environment. To address this objective of decreasing transmission during AGP, we created a negative airflow aerosol box with a leak-proof airway handling system using readily available and affordable materials. The dimension of this box was 24 × 17.5 × 17.5 cm and it was made of high-quality 4 mm transparent acrylic sheet with two arm holes of 10 cm diameter. The caudal end of the negative airflow aerosol prevention box is wrapped with disposable plastic sheet and the both hand slots are sealed using camera cover and latex hand gloves and it decreases the risk of contamination. How to cite this article: Kumar N, Kumar A, Kumar A, Sinha C. Modified Negative Airflow Aerosol Prevention Box for COVID-19 Patients. Indian J Crit Care Med 2020;24(10):981-982.

Acute Necrotizing Encephalitis as a Probable Association of COVID-19.

BACKGROUND: Meanwhile, over 50 lakh people have now been affected by coronavirus disease-2019 (COVID-19) across the globe. There are various reports on neurological manifestations of COVID-19, which have attracted broad attention. Acute necrotizing encephalopathy (ANE) is a rare complication of influenza and other viral infections and has been related to intracranial cytokine storm, which results in breach in blood-brain barrier leading to encephalitis like presentation. We report an unusual case of acute necrotizing encephalitis as a solitary presentation of COVID-19. CASE DESCRIPTION: We report a case of 35-year-old man from Bihar, presented to our emergency department in unconscious state, with high-grade fever and vomiting since last 5 days. Previous magnetic resonance imaging (MRI) brain showed a left parasellar-middle cranial fossa mass looks most likely like an invasive meningioma. Urgent noncontrast computed tomography scan (NCCT) brain showed that mass as well as hypodensities in both thalami and left caudate nucleus. As per our institutional protocol, clinical management of raised intracranial pressure was initiated. As there is no current evidence from any randomized control trails (RCTs) to recommend any specific treatment for suspected or confirmed patients with COVID-19 with acute necrotizing encephalitis. CONCLUSION: Our case highlights the importance of identifying encephalitis as a presenting sign of COVID-19 based on NCCT findings with normal cerebrospinal fluid (CSF) and normal chest X-ray (CXR) findings. HOW TO CITE THIS ARTICLE: Kumar N, Kumar S, Kumar A, Pati BK, Kumar A, Singh C, et al. Acute Necrotizing Encephalitis as a Probable Association of COVID-19. Indian J Crit Care Med 2020;24(10):991-994.