Antimicrobial resistance heterogeneity among multidrug-resistant Gram-negative pathogens: Phenotypic, genotypic, and proteomic analysis.

Microbes evolve rapidly by modifying their genomes through mutations or through the horizontal acquisition of mobile genetic elements (MGEs) linked with fitness traits such as antimicrobial resistance (AMR), virulence, and metabolic functions. We conducted a multicentric study in India and collected different clinical samples for decoding the genome sequences of bacterial pathogens associated with sepsis, urinary tract infections, and respiratory infections to understand the functional potency associated with AMR and its dynamics. Genomic analysis identified several acquired AMR genes (ARGs) that have a pathogen-specific signature. We observed that blaCTX-M-15, blaCMY-42, blaNDM-5, and aadA(2) were prevalent in Escherichia coli, and blaTEM-1B, blaOXA-232, blaNDM-1, rmtB, and rmtC were dominant in Klebsiella pneumoniae. In contrast, Pseudomonas aeruginosa and Acinetobacter baumannii harbored blaVEB, blaVIM-2, aph(3'), strA/B, blaOXA-23, aph(3') variants, and amrA, respectively. Regardless of the type of ARG, the MGEs linked with ARGs were also pathogen-specific. The sequence type of these pathogens was identified as high-risk international clones, with only a few lineages being predominant and region-specific. Whole-cell proteome analysis of extensively drug-resistant K. pneumoniae, A. baumannii, E. coli, and P. aeruginosa strains revealed differential abundances of resistance-associated proteins in the presence and absence of different classes of antibiotics. The pathogen-specific resistance signatures and differential abundance of AMR-associated proteins identified in this study should add value to AMR diagnostics and the choice of appropriate drug combinations for successful antimicrobial therapy.

Incidence of Interstitial Alveolar Syndrome on Point-of-Care Lung Ultrasonography in Pre-eclamptic Women With Severe Features: A Prospective Observational Study.

BACKGROUND: Lung interstitial edema is a clinically silent pathology that develops before overt pulmonary edema among pre-eclamptic women with severe features. Point-of-care lung ultrasonography (LUS) has been suggested as an accessible bedside tool that may identify lung interstitial edema before developing clinical signs and symptoms. Thus, we planned to use bedside LUS as a diagnostic tool in admitted pre-eclamptic women with severe features, with the aim of identifying alveolar-interstitial fluid, seen as B-lines. Our primary objective was to assess the incidence of interstitial alveolar syndrome on lung ultrasonography. METHODS: We conducted a prospective, single-center, observational study on parturients with pre-eclampsia with severe features over a period of 15 months. LUS in 4 intercostal spaces (ICS) was performed on all eligible patients. The number of single or confluent B-lines in each space was recorded by an independent observer. A scoring system was used to grade the lung fluid content based on the number of single and confluent B-lines per ICS, with scores ranging from 0 to 32 (low, 0-10; moderate, 11-20; and high, 21+). The incidence of B-lines at admission and before and after delivery was calculated. In addition, bedside 2D echocardiography was performed to assess left ventricular systolic and diastolic function. Any correlation between presence of B-lines on LUS and blood pressure, clinical symptoms, or echocardiography findings was assessed. RESULTS: Seventy patients were enrolled in the study. On LUS, B-lines were seen in 64.3% patients at admission (45/70 vs 25/70 without B-lines; P = .02), 65.7% patients before delivery (46/70 vs 24/70 without B-lines; P = .01), and 58.6% patients 24 hours postpartum (41/70 versus 29/70 without B-lines; P = .15). Nearly all patients (94.3%) exhibited low to moderate severity of pulmonary fluid burden at admission. Echocardiography revealed diastolic dysfunction in 47.1% (n = 33/70) patients with associated B-lines in the majority (n = 32/33). The total B-line score and E/e' ratio among patients with diastolic dysfunction was found to be strongly correlated (r = 0.848; P < .001). All pre-eclamptic women with presence of breathlessness (11/11; 100%) and facial puffiness (16/16; 100%) on admission had B-lines on LUS. CONCLUSIONS: We conclude that ultrasonographic pulmonary interstitial syndrome is present in more than half of the women with pre-eclampsia with severe features and correlates with diastolic dysfunction, high blood pressure records, and acute-onset breathlessness.

A Prospective, Randomized Comparison of the Classical Altemir's Method With the Newer Seldinger's Technique of Submental Intubation.

BACKGROUND: Submental intubation performed using the classical Altemir's technique is a well-accepted, safe technique for providing optimal operating field to the maxillofacial surgeon, in cases where either nasotracheal or orotracheal intubation is impossible. We propose a new, percutaneous Seldinger's technique of submental intubation as an interesting alternative to the classical Altemir's technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract, instead of bluntly dissecting it. We hypothesized that Seldinger's technique would be associated with reduced procedure time and minimal scar formation in patients with maxillofacial fractures. METHODS: We enrolled 60 patients scheduled to undergo maxillofacial injury fixation under general anesthesia. After consent, the cohort was randomly allocated to undergo submental intubation by either the classical Altemir's technique or Seldinger's technique. As our primary objective, we noted the time taken to complete the procedure of submental intubation. Our secondary objectives were the components of primary outcome, such as disconnection/apnea time, bleeding, and technical difficulties during the procedure. We also observed for complications such as presence of salivary fistula/infection at hospital discharge and scar characteristics at 1- and 3-month follow-up. RESULTS: The median time for performing submental intubation in the Seldinger group was significantly lower than that in the Altemir group (170.5 [136.5-256.0] seconds vs 220.0 [205.5-289.0] seconds; P value, .040). The median disconnection time was also significantly lower in the Seldinger group (12.0 [10.8-20.0] seconds vs 19.0 [15.0-23.0] seconds; P value, .036). Furthermore, significant bleeding was absent in nearly 53.8% of the study participants in the Seldinger group as compared to 25.9% in the Altemir group. At follow-up, there was no evidence of differences in scar characteristics between the 2 groups. CONCLUSIONS: Seldinger's technique is associated with shorter procedure time and reduced apnea time due to easier and better tract formation, thus minimizing the effort required to exteriorize the endotracheal tube. Furthermore, as dilation reduces tissue damage, Seldinger's technique is associated with significantly less procedural bleeding. Thus, Seldinger's technique can be safe, easy, and faster to perform compared with the classical Altemir's technique of submental intubation in patients with maxillofacial trauma.

Peri-Intubation Hypoxia After Delayed Versus Rapid Sequence Intubation in Critically Injured Patients on Arrival to Trauma Triage: A Randomized Controlled Trial.

BACKGROUND: Critically injured patients who are agitated and delirious on arrival do not allow optimal preoxygenation in the emergency area. We investigated whether the administration of intravenous (IV) ketamine 3 minutes before administration of a muscle relaxant is associated with better oxygen saturation levels while intubating these patients. METHODS: Two hundred critically injured patients who required definitive airway management on arrival were recruited. The subjects were randomized as delayed sequence intubation (group DSI) or rapid sequence intubation (group RSI). In group DSI, patients received a dissociative dose of ketamine followed by 3 minutes of preoxygenation and paralysis using IV succinylcholine for intubation. In group RSI, a 3-minute preoxygenation was performed before induction and paralysis using the same drugs, as described conventionally. The primary outcome was incidence of peri-intubation hypoxia. Secondary outcomes were first-attempt success rate, use of adjuncts, airway injuries, and hemodynamic parameters. RESULTS: Peri-intubation hypoxia was significantly lower in group DSI (8 [8%]) compared to group RSI (35 [35%]; P = .001). First-attempt success rate was higher in group DSI (83% vs 69%; P = .02). A significant improvement in mean oxygen saturation levels from baseline values was seen in group DSI only. There was no incidence of hemodynamic instability. There was no statistically significant difference in airway-related adverse events. CONCLUSIONS: DSI appears promising in critically injured trauma patients who do not allow adequate preoxygenation due to agitation and delirium and require definitive airway on arrival.

Neonatal outcomes following prophylactic administration of phenylephrine or noradrenaline in women undergoing scheduled caesarean delivery: A randomised clinical trial.

BACKGROUND: There is limited evidence to support the use of noradrenaline over phenylephrine during elective caesarean section with regards to its impact on foetal acidosis. Concerns regarding a deleterious effect of noradrenaline on foetal blood gas analysis because of its ß-mimetic activity cannot currently be ruled out by data from randomised controlled trials. OBJECTIVE: We hypothesised that noradrenaline would be associated with higher umbilical artery base excess values and less foetal acidosis compared with phenylephrine. This study aimed to observe the effect of prophylactic infusions of phenylephrine or noradrenaline in low-risk elective caesarean delivery on umbilical artery blood gas analysis. DESIGN: A prospective, randomised, double-blind trial. SETTING: Labour room operating theatre of tertiary care hospital in Northern India from April 2020 to November 2020. PATIENTS: Full-term, nonlabouring pregnant women, scheduled for elective caesarean delivery under spinal anaesthesia. INTERVENTION: Equipotent prophylactic infusions of either phenylephrine 100 µg min-1 or noradrenaline 5 µg min-1 were administered to maintain maternal SBP between 90 and 110% of baseline using a predefined algorithm. MAIN OUTCOME MEASURE: The primary outcome was umbilical artery base excess in noradrenaline versus the phenylephrine group. The incidence of foetal acidosis defined as umbilical artery base excess less than -6 mmol l-1 was also assessed for noradrenaline versus phenylephrine. RESULTS: Median [IQR] umbilical artery base excess was significantly higher in the noradrenaline group: -5.4 [-6.6 to -4.03] versus -6.95 [-9.02 to -4.53] in the phenylephrine group (P = 0.014). No significant difference in the incidence of foetal acidosis was observed between noradrenaline and phenylephrine groups: 36 versus 54% (P 0.07); difference 18% (95% CI, -1.4 to 35.6%). CONCLUSION: Prophylactic noradrenaline 5 µg min-1 infusion resulted in higher base excess values compared with phenylephrine 100 µg min-1 infusion. A comparable incidence of foetal acidosis was observed in women receiving either noradrenaline or phenylephrine. Maternal bradycardia was more pronounced with phenylephrine while targeting blood pressure goals. CTRI: CTRI/2020/03/023986.

Socio-behavioural determinants of maternal near miss: a prospective case control study from a tertiary care centre of India.

Near miss occurs in far greater numbers than maternal deaths and allows a more robust quantification on risk factors and determinants of life-threatening complications. A 'Three delay model' has been proposed in identification of causes of near miss and maternal deaths. There may be delay in seeking and obtaining health care: delay in recognising danger signs and deciding to reach source of care, delay in reaching appropriate source of care and delay in obtaining appropriate and adequate treatments. We compared various delays between near miss cases (n = 100) and controls (n = 200). Women who fulfilled criteria of near miss were taken as cases. Women who had obstetrical complications like near miss but were managed successfully and did not reach near miss state were labelled as controls. Near miss were then compared with maternal death. For normally distributed measurable data, outcome was compared using Student's t-test, for non-normally distributed/ordinal data, outcome was compared using Mann-Whitney's test. For categorical/classified data, association with outcome was analysed using Chi-Square test/Fisher's exact test.Delay in all three levels was seen among the groups. Lack of knowledge, non-availability of decision maker, and concern of cost of transport were main contributors of these delays.Impact StatementWhat is already known on this subject? Nonavailability of healthcare and low socio-economic status strongly correlate with maternal morbidity and mortality.What do the results of this study add? Lack of knowledge, non-availability of the decision maker, and concern of cost of transport were the main contributors of delay in seeking medical care. Majority of the cases of near miss were attributed to poor utilisation of health resources, ignorance and lack of emergency obstetric care at the primary level.What are the implications of these findings for clinical practice and/or further research? Patient and attendant education to ensure follow-up visits, recognise danger signs and report without undue delay, compliance to dietary modifications, medications given needs to be addressed at every visit to reduce the impact of socio-behavioural determinants on maternal near miss and mortality which are preventable in majority of cases.

Ventilator-associated Events Surveillance in a Trauma Intensive Care Unit: A Prospective Study of Incidence, Predictive Values, Sensitivity, Specificity, Accuracy, and Concordance with Ventilator-associated Pneumonia.

Introduction: The Centres for Disease Control and Prevention (CDC) introduced a new definition of ventilator-associated events (VAEs) in 2013 in place of longstanding ventilator-associated pneumonia (VAP) definition. Three entities under VAE, ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP), were introduced. Objectives: To assess the incidence of all VAEs in a tertiary care trauma ICU and to find the predictive value of VAE and sensitivity of VAE definitions for VAP. Design: Cohort prospective study at trauma intensive care unit (ICU) of PGIMER, Chandigarh, from July 2018 till June 2019. Materials and methods: Patients admitted in trauma ICU were checked for VAP and VAE criteria defined by CDC. Results: Four hundred and sixty five patients were observed. Around 378 patients were included in the study with 4046 patient days and 3031 mechanical ventilation (MV) days. Incidence rate of PVAP, IVAC, VAC, and VAP was 2.97, 6.60, 10.23, and 9.24 per 1000 ventilator days, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of diagnosing VAP were 0.61, 0.97, 0.68, and 0.97 for VAC; 0.80, 0.97, 0.57, and 0.99 for IVAC; and 0.78, 0.94, 0.25, and 0.9 for PVAP, respectively. Kendall's W test showed that there was very poor concordance between VAP and VAE. How to cite this article: Kaur K, Jain K, Biswal M, Dayal SK. Ventilator-associated Events Surveillance in a Trauma Intensive Care Unit: A Prospective Study of Incidence, Predictive Values, Sensitivity, Specificity, Accuracy, and Concordance with Ventilator-associated Pneumonia. Indian J Crit Care Med 2022;26(5):584-590.

Massive transfusion protocol: Need of the hour - A tertiary care centre experience.

Background and Aims: Massive transfusion (MT) in critically ill patients during major volume losses can lead to serious adverse outcomes. Studies have reported that rampant red cell infusion for maintaining perfusion support has had detrimental effects on patients' short- and long-term survival rates. Evidence-based studies quote the importance of maintaining blood product ratio during massive hemorrhage and ensuring good outcomes with the least morbidity and mortality. Material and Methods: It is an observational study to compare the ratio of usage of blood products and their role in the outcome of MT cases. Results: A total of 70 patients (29 females and 41 males) who received MT were included in the study. There was no fixed ratio of packed red blood cells (PRBC) to blood components for patients with massive hemorrhage. The average ratio of PRBC: fresh frozen plasma (FFP):platelet concentrate (PC) was 1:0.9:0.6. However, blood component therapy with PRBC: FFP ratio between 1 and 2 was associated with a significant rise in post-acute phase hemoglobin value (P value = 0.018). Conclusion: Appropriate blood component therapy during the acute bleeding phase in massively transfused patients can further decrease the transfusion demand and transfusion-related complications. There is a need to adhere to the MT protocol for the clinical areas requiring MT in the developing world too.

Sonographic Optic Nerve Sheath Diameter Following Seizure Prophylaxis in Pre-Eclamptic Parturients With Severe Features: A Prospective, Observational Study.

OBJECTIVES: Neurological manifestations, including raised intracranial pressures, are a hallmark of worsening pre-eclampsia. Invasive methods for measuring intracranial pressure, though a gold standard, are not always a viable option. Maternal ocular sonography is a promising bedside tool, which serves as a noninvasive, cost-effective means for measuring optic nerve sheath diameter (ONSD), a surrogate marker of raised intracranial pressures. We studied the ultrasonographically measured ONSD in severely pre-eclamptic women, and the effect of magnesium sulfate therapy on its values. METHODS: Thirty severely pre-eclamptic women at ≥28 weeks gestation were included. We recorded baseline ONSD values, serum magnesium levels, neurological symptoms, vitals, and repeated them at 4 and 12 hours following magnesium sulfate therapy, and then at 24 hours postpartum. An ONSD value >5.8 mm was suggestive of raised intracranial pressure. Primary outcome measure was to evaluate changes in ultrasonographically measured ONSD following seizure prophylaxis with magnesium sulfate. RESULTS: Women, 73.3%, had baseline ONSD >5.8 mm, with mean diameter being significantly high (6.02 ± 0.77 mm). There was a statistically nonsignificant decline in mean ONSD values at 4 and 12 hours, as well as at 24 hours postpartum. Patients with neurological symptoms declined significantly (from 70 to 10%; p value <.001) following magnesium sulfate therapy. CONCLUSIONS: Majority of severely pre-eclamptic parturients had high ONSD value suggestive of raised intracranial pressures, which persisted in the postpartum period and was unaffected by magnesium sulfate therapy. Ultrasound can thus serve as a point-of-care, cost-effective, easily available bedside tool for indirectly measuring intracranial pressures in this high-risk population.

The collateral fallout of COVID19 lockdown on patients with head injury from north-west India.

BACKGROUND: The COVID19 lockdown has altered the dynamics of living. Its collateral fallout on head injury care has not been studied in detail, especially from low- and middle-income countries, possibly overwhelmed more than developed nations. Here, we analyze the effects of COVID19 restrictions on head injury patients in a high-volume Indian referral trauma center. METHODS: From the prospective trauma registry, clinico-epidemiological and radiological parameters of patients managed during 190 days before and 190 days during COVID19 phases were studied. As an indicator of care, the inpatient mortality of patients with severe HI was also compared with appropriate statistical analyses. RESULTS: Of the total 3372 patients, there were 83 head injury admissions per week before COVID19 restrictions, which decreased to 33 every week (60% drop) during the lock phases and stabilized at 46 per week during the unlock phases. COVID19 restrictions caused a significant increase in the proportion of patients arriving directly without resuscitation at peripheral centers and later than 6 h of injury. Though the most common mechanism was vehicular, a relative increase in the proportion of assaults was noted during COVID19. There was no change in the distribution of mild, moderate, and severe injuries. Despite a decrease in the percentage of patients with systemic illnesses, severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02). CONCLUSIONS: COVID19 restrictions have amplified the already delayed admission among patients of head injury from north-west India. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.

Head injury care in a low- and middle-income country tertiary trauma center: epidemiology, systemic lacunae, and possible leads.

BACKGROUND: Although head injury (HI) from low- and middle-income countries (LMIC) heavily contributes to the global disease burden, studies are disproportionately less from this part of the world. Knowing the different epidemiological characteristics from high-income nations can target appropriate prevention strategies. This study aims to provide a comprehensive overview of the clinico-epidemiological data of HI patients, focusing on the existing challenges with possible solutions from a developing nation's perspective. METHODS: This is a prospective, registry-based, observational study of HI in an Indian tertiary trauma-care center over 4 years. Various clinico-epidemiological parameters, risk factors, and imaging spectrum were analyzed in a multivariate model to identify the challenges faced by LMIC and discuss pragmatic solutions. RESULTS: The study included a large-volume cohort of 14,888 patients. Notably, half of these patients belonged to mild HI, despite most were referred (90.3%) cases. Only one-third (30.8%) had severe HI. Less than a third reached us within 6 h of injury. Road traffic accidents (RTA) accounted for most injuries (61.1%), especially in the young (70.9%). Higher age, males, RTA, helmet non-usage, drunken driving, systemic injuries, and specific imaging features had an independent association with injury severity. CONCLUSIONS: The study represents the much-needed, large-volume, epidemiological profile of HI from an LMIC, highlighting the suboptimal utilization of peripheral healthcare systems. Strengthening and integrating these facilities with the tertiary centers in a hub and enhanced spoke model, task sharing design, and efficient back-referrals promise effective neurotrauma care while avoiding overburden in the tertiary centers. Better implementation of road safety laws also has the potential to reduce the burden of HI.

Safety and Efficacy of IV Dexmedetomidine as an Adjunct to Propofol to Sedate Anxious and Uncooperative Pediatric Dental Patients: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the safety and efficacy of dexmedetomidine (dex) as an adjunct to propofol sedation in pediatric dental patients. STUDY DESIGN: This RCT enrolled 30 anxious ASA-I 2-5 year olds. Allocated into 2 groups either receiving IV propofol (1 mg/kg)(Gp-P) or [IV dex (1ug/kg) with propofol(1 mg/kg)] (Gp-D) after oral midazolam premedication (0.5 mg/kg). Sedation maintained with propofol infusion at 50-75ug/kg/min. Additional bolus/es of propofol (1mg/kg) was/were administered in case of inadequate sedation. Primary outcome was to compare requirement of propofol in two groups. Secondary outcomes were to compare vital signs, depth of sedation, induction, treatment and recovery time, intra & post-operative complications and analgesic requirement post-operatively. RESULTS: Total propofol (in mgs) used and number of additional boluses were significantly higher in group P (p<0.05). Although within normal limits, heart rate was significantly lower in group D. Respiratory rate, oxygen saturation, NIBP were comparable. Depth of sedation achieved was comparable at all steps (p>0.05). Induction time (mins) was significantly lower in Group P (p<0.05), however treatment and recovery time were similar (p>0.05). Desaturation was observed in 3/15(group P) & 0/15(group D). Analgesic requirement post-operatively was significantly higher in group P (p<0.05). CONCLUSION: Dexmedetomidine is a safe and effective adjunct to propofol.

Sepsis in the Parturient.

Sepsis is a leading cause of maternal morbidity with a high case fatality rate and leads to significant perinatal loss. Early identification and appropriate time management can significantly improve maternal and perinatal outcomes. The physiological changes of pregnancy and puerperium make pregnant women more susceptible to sepsis and also pose a challenge for early diagnosis because of overlap of clinical features and laboratory values. The validation of scoring/warning systems for sepsis in parturient needs further research. Infections during puerperium are commonly polymicrobial in nature and warrant broad-spectrum antibiotics. Maternal resuscitation in antepartum period has to be tailored to ensure fetal well-being and adequate placental perfusion. For the management of sepsis in pregnancy, the guidelines from surviving sepsis campaign (SSC) for general adult population are extrapolated with modifications related to physiological alterations in pregnancy and puerperium. Timing of delivery is based on the obstetric indications unless the source of sepsis is intrauterine. How to cite this article: Jain V, Arora A, Jain K. Sepsis in the Parturient. Indian J Crit Care Med 2021;25(Suppl 3):S267-S272.

Containment of varicella outbreak in intensive care unit of a tertiary level hospital.

BACKGROUND: Varicella-Zoster virus (VZV) infection in healthcare organizations, especially in intensive care units (ICU), having admitted immunocompromised patients, is of serious concern as well as poses threat to healthcare workers working in such critical areas. The present report defines the transmission and infection control measures initiated to curtail VZV infection spread in the trauma ICU of a tertiary care hospital of North India. OUTBREAK REPORT: At the infection outset, there were 12 patients admitted in ICU and 54 healthcare workers were posted to manage these critical patients. After confirmation of VZV infection, all susceptible patients as well as healthcare workers were quarantined and fresh intake of patients was restricted. Out of the total healthcare workers, 14 (25.92%) were found susceptible (as per protective VZV IgG titers) and were vaccinated. Of the 12 patients admitted in the ICU, six patients were discharged and sent home directly, four patients expired due to their critical disease state, one patient left against medical advice, and one patient remained admitted in ICU till the incubation period was over. Epidemiologically, line listing for index case reporting was done. The efficacy of control measures was re-evaluated to strengthen existing infection control practices and general measures viz. strict hand washing, adherence to aseptic protocols and intensification of environmental cleaning. CONCLUSIONS: Established varicella surveillance measures ensure VZV outbreaks are identified in a timely manner and control measures implemented to prevent further transmission. Also, vaccination policy among HCWs is the utmost requirement despite having huge financial implications.

Trauma care and COVID-19 pandemic.

The Coronavirus SARS- CoV-2 (COVID-19) pandemic has overwhelmed the ability of health care systems all over the world. With the spread of the disease, countries have adopted different models to reorganize infrastructure and reallocate the resources to deal with the pandemic. All the nonurgent hospital services have been postponed. But, trauma and emergency services continue to function according to the established protocols with few modifications. During the pandemic, trauma care is based on clinical urgency, safety of the patient as well as health care workers (HCWs) and conservation of resources. The strategies include non-operative management if possible, restricting the number of personnel and utilization of remote consultation or telemedicine. In the present article, we discuss the triage and management of trauma victim during the pandemic, indications for emergency surgery and psychological impact of the pandemic. We also discuss the future challenges during the post-COVID-19 phase.

Management of pregnant laboring women during COVID-19 pandemic.

Since its first outbreak in December 2019 in Wuhan, China, coronavirus disease 2019 (COVID-19) has become a global public health threat. In the midst of this rapidly evolving pandemic condition, the unique needs of pregnant women should be kept in mind while making treatment policies and preparing response plans. Management of COVID-19 parturients requires a multidisciplinary approach consisting of a team of anesthesiologists, obstetricians, neonatologists, nursing staff, critical care experts, infectious disease, and infection control experts. Labor rooms as well as operating rooms should be in a separate wing isolated from the main wing of the hospital. In the operating room, dedicated equipment and drugs for both neuraxial labor analgesia and cesarean delivery, as well as personal protective equipment, should be readily available. The entire staff must be specifically trained in the procedures of donning, doffing, and in the standard latest guidelines for disposal of biomedical waste of such areas. All protocols for the management of both COVID-19 suspects as well as confirmed patients should be in place. Further, simulation-based rehearsal of the procedures commonly carried out in the labor room and the operation theaters should be ensured.

Maternal hyperuricemia as a marker of post-spinal hypotension and uterine tone during cesarean delivery: a prospective observational study.

PURPOSE: Raised serum uric acid, a marker of oxidative stress, is known to increase vascular tone and depress myometrial contractility. A rise in serum uric acid levels has also been reported during labor, warranting its correlation with post-spinal hypotension and uterine tone. METHODS: Serum UA sample was drawn from enrolled healthy, laboring parturients. Of these, 100 women who required emergency cesarean delivery were re-sampled prior to surgery. Following spinal anesthesia we recorded episodes of hypotension (MAP < 80% of baseline), use of vasopressors and supplemental uterotonics. The primary outcome was maternal hyperuricemia (1SD > appropriate for gestation age) and its correlation with post-spinal hypotension. Secondary outcomes were total vasopressors used, duration of labor and its effect on uric acid levels, uterine tone and neonatal outcome. RESULTS: Hyperuricemia was observed in 33% of parturients. On comparing with women showing normal uric acid levels, hyperuricemic parturients experienced significantly lower incidence of post-spinal hypotension (45.5% vs. 67.2%; p value = 0.04) and lower vasopressor usage (p value = 0.06). Clinically, an increased use of supplemental uterotonics in these parturients was noted (p = 0.20). The duration of labor had no impact on uric acid levels. Neonatal outcome was unaffected. CONCLUSIONS: In healthy, normotensive parturients undergoing emergency cesarean delivery, maternal hyperuricemia is associated with lower incidence of post-spinal hypotension and reduced need of vasopressors. Elevated serum uric acid levels may also be associated with decreased uterine tone, necessitating greater requirement of supplemental uterotonics. However, further prospective trials are needed to strongly establish this association.

Applicability of WHO Maternal Severity Score (MSS) and Maternal Severity Index (MSI) Model to predict the maternal outcome in near miss obstetric patients: a prospective observational study.

OBJECTIVE: To assess the applicability of WHO Maternal Severity Score (MSS) and Maternal Severity Index (MSI) Model in near miss (NM) obstetric patients METHODS: It was a prospective observational study conducted at a tertiary health care center from July 2015 to Feb 2016. All patients fulfilling one or more WHO NM criteria were included. MSS and MSI were calculated for all NM patients on admission. They were then followed up till the final outcome (NM or death). Each NM parameter, system-wise MSS, total MSS and MSI were then associated with the final outcome. RESULTS: Of 4822 patients, 1739 had potentially life-threatening conditions of which 174 were identified as NM. The average MSS and MSI of patients who remained NM was 4.41 and 11.67%, respectively, and those who died was 9.47 and 58.16%, respectively. Both were found to be significantly associated with the outcome (p < 0.001). MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC - 0.838 [95% CI 0.766-0.910]). However, of 25 NM criteria, only 17 NM criteria and 3 system dysfunctions (cardiovascular, respiratory and neurological) were found to associate significantly with the outcome. CONCLUSION: MSS and MSI act as good prognostic tools to assess the severity of maternal complications and estimate the probability of death in NM patients. As all NM parameters are not equally predictive of severity of maternal morbidity, different scores per NM parameter and system should be assigned while calculating MSS for better prognostication.

Lung Ultrasound as a Bedside Tool for Assessment of Extravascular Lung Water in Critically Ill Head Injured Patients: An Observational Study.

INTRODUCTION: Extra vascular lung water (EVLW) is defined as the amount of fluid in the interstitial and alveolar spaces. Primary aim of this study was to assess EVLW using lung USG (B lines >3 per lung field) in critically ill head injured patients. MATERIALS AND METHODS: Intubated adult patients admitted in Trauma ICU with head injury (GCS 4-15) were assessed by daily chest X-ray and lung ultrasonography. Lung water content was graded based on the number of B lines per ICS with score ranging from 0-32 and categorized as low pulmonary fluid burden (0-10), moderate fluid burden (11-20) and high fluid burden (21-32). RESULTS: 140 critically ill head injured patients were assessed for eligibility and 20 excluded. Incidence of increased EVLW using lung USG was 61.66% (74/120) and the incidence reported using chest x ray was 40.83%(49/120) and the difference was statistically significant (p value <0.001). Increased EVLW significantly increased the duration of weaning, mechanical ventilation and ICU stay (p value <0.05). Significant association was observed between APACHE II, SAPS II and GCS at admission to ICU with presence of EVLW (p value ≤0.001). Mean delay in identification of EVLW by chest X-ray (CXR) compared to lung ultrasound was 1.42±0.76 days. CONCLUSION: Lung ultrasound is better than CXR for early detection of increased EVLW in critically ill head injured patients and has prognostic relevance as increased EVLW prolongs duration of mechanical ventilation and ICU stay. HOW TO CITE THIS ARTICLE: Gattupalli V, Jain K, et al. Lung Ultrasound as a Bedside Tool for Assessment of Extravascular Lung Water in Critically Ill Head Injured Patients: An Observational Study. Indian J Crit Care Med 2019;23(3):131-134.