Comparison of lung ultrasound technique versus clinical method to evaluate the accuracy of size and placement of left endobronchial double lumen tube in patients undergoing elective thoracic surgery: a prospective observational study.

Anthropometric measurements like height and gender have been frequently found to be inaccurate in prediction of size of double lumen tube (DLT). A tracheal ultrasonography (TUS) is a technique that can be used to predict the size of DLT and its correct placement for lung isolation. We aim to check the accuracy of ultrasound over clinical methods. This prospective study included 68 patients undergoing elective thoracic surgery requiring one-lung ventilation (OLV) with DLT. The groups were assessed for the size of DLT by either anthropometric measurement using height and gender (Group C) or ultrasound method (Group U). Further, the accuracy of placement of DLT was assessed through, either lung auscultation in group C or various ultrasonographic and ventilatory parameters such as lung isolation in the first attempt (lung sliding and lung pulse sign), oxygenation status and peak airway pressure, in group U. Surgeon satisfaction score was also compared in both the groups. The accuracy of predicted DLT size between Group C and Group U was statistically significant (p=0.044). In Group C, 56% of patients showed a mismatch between the predicted DLT size and the actual size required, while in Group U, the mismatch was only 32.4%. The accuracy of DLT placement through group C was 41% as compared to 79% in Group U. Surgeon satisfaction score was also significantly higher in Group U as compared to Group C (p=0.0028). Thus, our study suggests that tracheal and chest ultrasonography for DLT size selection and placement for lung isolation is superior to clinical methods.

Bygone Ether: Theriac to Obstinate Hiccups-Food for Thought!

How to cite this article: Hirolli D, Panda R, Baidya DK. Bygone Ether: Theriac to Obstinate Hiccups-Food for Thought! Indian J Crit Care Med 2022;26(7):884.

Novel Use of Catheter Mount as an Alternative to T-piece.

Catheter mounts with swivel connectors are used to attach the endotracheal tube to the ventilator circuit, dampening jerks and drags and increasing patient comfort. We suggest a unique application of catheter mount as T-piece for weaning, eliminating the need for a single inventory purchase and repurposing a previously used item for a new use, lowering the financial burden on patients. In our ICU, catheter mounts are being used as an alternative to T-piece for 30-minute weaning trials following successful SBT trials to evaluate patients' response to Zero PEEP (ZEEP) and therefore the probable occurrence of alveolar derecruitment to decrease extubation failure. How to cite this article: Anand A, Panda R, Kodamanchili S, Saigal S, Gowthaman TB, Bhardwaj K. Novel Use of Catheter Mount as an Alternative to T-piece. Indian J Crit Care Med 2022;26(2):246-247.

Communication with Patients on Mechanical Ventilation: A Review of Existing Technologies.

How to cite this article: Anand A, Nair RR, Kodamanchili S, Panda R, Bhardwaj KK, Gowthaman TB. Communication with Patients on Mechanical Ventilation: A Review of Existing Technologies. Indian J Crit Care Med 2022;26(6):756-757.

Trendelenburg Ventilation in Patients of Acute Respiratory Distress Syndrome with Poor Lung Compliance and Diaphragmatic Dysfunction.

Background: Patients with acute respiratory distress syndrome (ARDS) are generally ventilated in either 45° head elevation or prone position as they are associated with decreased incidence of ventilator-associated pneumonia and mortality, respectively.1,2 But in patients with poor lung compliance and super-added diaphragmatic weakness/dysfunction, generating a minimum amount of adequate tidal volume (TV) would be very difficult in propped up/supine/prone position, leading to worsening hypoxia and CO2 retention. We noticed a sustained increase in TV for patients with poor lung compliance (Cs <15 mL/cm H2O) and diaphragmatic dysfunction (bilateral diaphragmatic excursion <1 cm, on spontaneous breaths) when the patients are switched to Trendelenburg position with the same ventilator settings. Patients and methods: A case report with possible explanation for the observed changes has been mentioned. Results: Trendelenburg ventilation delivered more TV than propped up or prone ventilation in patients of ARDS with poor lung compliance and diaphragmatic dysfunction. Conclusion: Trendelenburg ventilation increases static lung compliance and delivers more TV when compared to propped up/supine/prone ventilation in patients of ARDS with poor lung compliance and diaphragmatic dysfunction. Although the exact mechanism behind this is not known till now, we formulated few theories that could explain the possible mechanism. How to cite this article: Kodamanchili S, Saigal S, Anand A, Panda R, Priyanka TN, Balakrishnan GT, et al. Trendelenburg Ventilation in Patients of Acute Respiratory Distress Syndrome with Poor Lung Compliance and Diaphragmatic Dysfunction. Indian J Crit Care Med 2022;26(3):319-321.

Effect of Remdesivir Administration on Occurrence of Major Adverse Cardiac Events in Critically Ill COVID-19 Pneumonia: A Retrospective Observational Study.

Background and objectives: Major adverse cardiac events (MACE) are frequent in coronavirus disease-2019 (COVID-19). Remdesivir is used worldwide for treatment in COVID-19. In this retrospective observational study, our primary objective was to assess the impact of remdesivir administration on the incidence of MACE and associated 28 day survival in critically ill patients admitted for moderate to severe COVID-19 pneumonia. Patients and methods: We analyzed the data of 437 patients admitted in intensive care unit (ICU) and divided them into two groups: R group (received remdesivir at ICU admission) and NR group (nonremdesivir) or based on the occurrence of MACE in ICU. We followed the data until discharge, death, or 28 days postadmission. Our primary objective was to investigate the log-odds of survival with remdesivir administration and a correlation/regression analysis of MACE with remdesivir administration in all included patients. Results: The incidence of MACE was 72 among 437 patients, with 17 (9.3%) patients in R group vs 55 (21.8%) in NR group (p <0.001). On performing correlation analysis between MACE and remdesivir administration, significant correlation coefficient of -0.168 (p = 0.004) was obtained. On regression analysis, the odds ratio for occurrence of MACE with remdesivir administration was 0.362 (regression coefficient: -1.014, p <0.001). It indicates a 64% decrease in the log-odds of MACE and a 16% increase in the log-odds of survival with remdesivir administration. All 72 patients with MACE had expired, suggesting a high mortality risk with cardiac complications. The odds ratio for mortality due to MACE with remdesivir administration was 0.216 (regression coefficient: -1.530, p -<0.001). It indicates a 79% decrease in the log-odds of death due to MACE with remdesivir administration. Conclusion: Our study showed significant reduction in MACE and mortality benefit in patients who received remdesivir in comparison to standard treatment. How to cite this article: Panda R, Singh P, Jain G, Saigal S, Karna ST, Anand A, et al. Effect of Remdesivir Administration on Occurrence of Major Adverse Cardiac Events in Critically Ill COVID-19 Pneumonia: A Retrospective Observational Study. Indian J Crit Care Med 2022;26(9):993-999.

Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India.

Background: The outcomes in critical illness depend on disease severity, practice protocols, workload, and access to care. This study investigates the factors affecting outcomes in mechanically ventilated coronavirus disease-2019 acute respiratory distress syndrome (COVID-19 ARDS) patients admitted in a tertiary teaching hospital intensive care unit (ICU) in Central India with reference to different time periods in pandemic. This is one of the largest series of mechanically ventilated COVID-19 ARDS patients, globally. Methods: This retrospective cohort study classified the entire data into four time periods (Period 1: April 2020 to June 2020; Period 2: July 2020 to September 2020; Period 3: October 2020 to December 2020; and Period 4: January 2021 to April 2021). We performed a multivariable-adjusted analysis to evaluate predictors of mortality, adjusted for baseline-severity, sequential organ failure assessment (SOFA score) and time period. We applied mixed-effect binomial logistic regression to model fixed-effect variables with incremental complexity. Results: Among the 56 survivors (19.4%) out of 288 mechanically ventilated patients, there was an up-gradient of survival proportion (0, 18.2, 17.4, and 28.6%) in four time periods. Symptom-intubation interval (OR 1.16; 95% CI 1.03-1.31) and driving pressures (DPs) (OR 1.17; 95% CI 1.07-1.28) were significant predictors of mortality in the model having minimal AIC and BIC values. Patients aged above 60 years also had a larger effect, but statistically insignificant effect favoring mortality (OR 1.99; 95% CI 0.92-4.27). The most complex but less parsimonious model (with higher AIC/BIC) indicated the protective odds of high steroid on mortality (OR 0.59; 95% CI 0.59-0.82). Conclusion: The outcomes in mechanically ventilated COVID-19 ARDS patients are heterogeneous across time windows and may be affected by the complex interaction of baseline risk and critical care parameters. How to cite this article: Saigal S, Joshi A, Panda R, Goyal A, Kodamanchili S, Anand A, et al. Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India. Indian J Crit Care Med 2022;26(9):1022-1030.

Aftermath of COVID-19 and Critical Care in India.

The coronavirus disease-2019 (COVID-19) pandemic had overwhelmed the healthcare system and forced many patients to be treated at home with oxygen, antibiotics, and steroids, particularly during the second wave. There was increased misuse of antimicrobials in hospitals as well as unguarded self-prescription of these medications among the common people. We are likely to see an increase in the incidence of antimicrobial resistance (AMR), change in the susceptibility pattern of the organisms causing community-acquired infections, and an increase in opportunistic bacterial, tubercular, viral, and fungal infections. How to cite this article: Panda R, Hirolli D, Baidya DK. Aftermath of COVID-19 and Critical Care in India. Indian J Crit Care Med 2021; 25(10):1173-1175.

Point-of-care Glucose Monitoring in COVID-19 Intensive Care Unit: How's It Different?

How to cite this article: Panda R, Hirolli D, Baidya DK. Point-of-care Glucose Monitoring in COVID-19 Intensive Care Unit: How's It Different? Indian J Crit Care Med 2021;25(12):1465-1466.

Reanalyzing the Mortality Analysis of COVID-19 Deaths in a Tertiary Care Center in India.

How to cite this article: Anand A, Panghal R, Kaler P, Saigal S, Panda R, Kodamanchili S, et al. Reanalyzing the Mortality Analysis of COVID-19 Deaths in a Tertiary Care Center in India. Indian J Crit Care Med 2021; 25(10):1211.

Simple Mobile Application for Calculating "Ergotrauma" Made Using an Excel Sheet.

How to cite this article: Anand A, Saigal S, Panda R, Kodamanchili S, Shrivastava P, Das A, et al. Simple Mobile Application for Calculating "Ergotrauma" Made Using an Excel Sheet. Indian J Crit Care Med 2021;25(9):1081.

Accuracy of Critical Care Ultrasonography Plus Arterial Blood Gas Analysis Based Algorithm in Diagnosing Aetiology of Acute Respiratory Failure.

Introduction: Lung ultrasound when used in isolation, usually misses out metabolic causes of dyspnoea and differentiating acute exacerbation of COPD from pneumonia and pulmonary embolism is difficult, hence we thought of combining critical care ultrasonography (CCUS) with arterial blood gas analysis (ABG). Aim of the study: The objective of this study was to estimate accuracy of Critical Care Ultrasonography (CCUS) plus Arterial blood gas (ABG) based algorithm in diagnosing aetiology of dyspnoea. Accuracy of traditional Chest X-ray (CxR) based algorithm was also validated in the following setting. Methods: It was a facility based comparative study, where 174 dyspneic patients were subjected to CCUS plus ABG and CxR based algorithms on admission to ICU. The patients were classified into one of five pathophysiological diagnosis 1) Alveolar( Lung-pneumonia)disorder ; 2) Alveolar (Cardiac-pulmonary edema) disorder; 3) Ventilation with Alveolar defect (COPD) disorder ;4) Perfusion disorder; and 5) Metabolic disorder. We calculated diagnostic test properties of CCUS plus ABG and CXR based algorithm in relation to composite diagnosis and correlated these algorithms for each of the defined pathophysiological diagnosis. Results: The sensitivity of CCUS and ABG based algorithm was 0.85 (95% CI-75.03-92.03) for alveolar (lung) ; 0.94 (95% CI-85.15-98.13) for alveolar (cardiac); 0.83 (95% CI-60.78-94.16) for ventilation with alveolar defect; 0.66 (95% CI-30-90.32) for perfusion defect; 0.63 (95% CI-45.25-77.07) for metabolic disorders.Cohn's kappa correlation coefficient of CCUS plus ABG based algorithm in relation to composite diagnosis was 0.7 for alveolar (lung), 0.85 for alveolar (cardiac), 0.78 for ventilation with alveolar defect, 0.79 for perfusion defect and 0.69 for metabolic disorders. Conclusion: CCUS plus ABG algorithm is highly sensitive and it's agreement with composite diagnosis is far superior. It is a first of it's kind study, where authors have attempted combining two point of care tests and creating an algorithmic approach for timely diagnosis and intervention.

Adult tetanus is not gone yet, but could be ready to leave: A case-series from central India.

Introduction: Adult tetanus is a neurotoxin mediated infectious disease, that continues to be seen despite availability of a highly efficacious vaccine. In India population-based burden estimates for adult tetanus are not available. Elimination of neonatal and maternal tetanus from India was achieved in 2015 with DPT (diphtheria, pertusis, and tetanus) vaccine during childhood and tetanus toxoid (TT) during antenatal care. Vaccine coverage in adults is uneven. While pregnant women receive the vaccine as part of ante-natal care, booster dose coverage in all other non-pregnant women and men is poor. Case report: We describe four cases of adult tetanus that presented to our tertiary care hospital in central India. Out of four cases, two were homemakers, one was a farmer, another was a student. Three of them were not aware regarding primary tetanus vaccination and none of the four received any booster dosages of tetanus vaccine. Conclusions: These cases highlight complexity of disease management and reinforce the need for adult booster immunization against tetanus.

Management of COVID-19-Related Severe Acute Respiratory Distress Syndrome in a Patient With Active Human Immunodeficiency Virus Infection.

Our understanding of the risk of developing severe coronavirus disease 2019 (COVID-19) infection in the population living with HIV is still evolving. In this report, we discuss the successful management of COVID-19-related acute respiratory distress syndrome (ARDS) in an active case of the human immunodeficiency virus (HIV) infection; the patient had an atypical presentation characterized by very rapid progression in the severity of respiratory symptoms needing invasive mechanical ventilation. The way the case was managed broke with the custom that mechanical ventilation in patients with COVID-19-related ARDS should be deferred as much as possible since the chances of survival are minimal, especially in immunocompromised patients. Although patients with HIV infection are immunocompromised and at risk of secondary infection, young age, lack of comorbidities, and early intubation may result in a good prognosis. ARDS ventilation strategy, good infection control practices, and individualized patient care can help to wean patients off mechanical ventilation. Recent evidence does not support the use of antiretroviral drugs for prophylaxis or treatment of COVID-19 infection.

Inadvertent Intravenous Administration of Milk in Postoperative Intensive Care Unit: Sequelae and Management.

Tubing misconnections is an unfortunate and rare occurrence in intensive care units, but the complication is grossly underreported as it is often attributed to human error rather than device failure. This potential underreporting of a complication causes concern because it can be prevented by making an appropriate device design and increase awareness among health care workers. In this case report, we have discussed an enteral feed misconnection to an intravenous cannula has led to respiratory distress and acute kidney injury in a patient admitted to the postoperative intensive care unit. We propose a standard operating protocol for management in such a scenario and the role of ventilation-perfusion (V/Q) scan as an alternative to conventional computed tomography pulmonary angiogram (CTPA) in acute kidney injury patients.

Superior Mesenteric Artery Thrombosis in COVID-19 Pneumonia: an Underestimated Diagnosis-First Case Report in Asia.

The COVID-19 disease caused by novel coronavirus was first reported in Wuhan, China, in December 2019 with 5% patients having severe lung injury. Though this disease primarily presents as a lower respiratory tract infection, multiple digestive manifestations have been reported which are often overlooked. The present case report describes the unusual progression of COVID-19 disease from pneumonia to a procoagulant state leading to superior mesenteric artery thrombosis and subsequent gut ischemia necessitating emergency laparotomy. Coagulopathy in COVID-19 is due to an imbalance in the coagulation homeostasis with increase in prothrombin time, fibrinogen, and D-dimers. Early recognition of abdominal symptoms, diagnosis of pathology, and timely surgical intervention may definitely improve outcome. In the management of any patient with COVID-19 disease, we advocate a comprehensive integrated approach with early recognition of digestive symptoms and their timely intervention which should run parallel to the respiratory management.