Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial.

Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.

Lung Ultrasound Findings in a Patient with Lymphangitic Carcinomatosis.

How to cite this article: Bhattacharjee S, Prasanna M, Maitra S, Ray BR. Lung Ultrasound Findings in a Patient with Lymphangitic Carcinomatosis. Indian J Crit Care Med 2024;28(1):82-83.

Oxygenation Index and Oxygen Saturation Index for Predicting Postoperative Outcome in Patients Undergoing Emergency Surgery: A Prospective Cohort Study.

Background: The OI was originally evaluated as a prognostic tool for acute hypoxemic respiratory failure in children and was an independent predictor for mortality in adult patients with acute respiratory distress syndrome (ARDS). Methods: Oxygenation index and OSI of 201 adult patients undergoing emergency surgery were evaluated at different time points. The primary objective of this study was to find the correlation between OI and OSI. The secondary objectives were to find the prognostic utility of OI and OSI for postoperative mechanical ventilation and mortality. Results: Significant statistical correlation was found between OI and OSI both at the beginning (r 2 = 0.61; p < 0.001) and immediately after surgery (r 2 = 0.47; p < 0.001). Oxygen saturation index at the beginning [area under the receiver operating characteristics curve (AUROC) (95% CI) 0.76 (0.62-0.89); best cutoff 3.9, sensitivity 64% and specificity 45%] and immediately after surgery [AUROC (95% CI) 0.82 (0.72-0.92); best cutoff 3.57, sensitivity 79%, and specificity 62%] were reasonable predictors of the requirement of invasive ventilatory support. Exploratory analysis reported that older age (p = 0.02), higher total leukocyte count (p = 0.002), higher arterial lactate (p = 0.02), and higher driving pressure (p < 0.001) were independently associated with hospital mortality. Conclusion: In adult patients undergoing emergency laparotomy under general anesthesia, OI and OSI were found to be correlated. Both metrics demonstrated reasonable accuracy in predicting the need for invasive ventilatory support beyond 24 hours and hospital mortality. How to cite this article: Thakuria R, Ernest EE, Chowdhury AR, Pangasa N, Kayina CA, Bhattacharjee S, et al. Oxygenation Index and Oxygen Saturation Index for Predicting Postoperative Outcome in Patients Undergoing Emergency Surgery: A Prospective Cohort Study. Indian J Crit Care Med 2024;28(7):645-649.

Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue?

How to cite this article: Sinha S, Bhattacharjee S. Prediction of Delirium in the Critically Ill Obstetric Patients: An Old Friend to the Rescue? Indian J Crit Care Med 2023;27(5):301-302.

Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center.

BACKGROUND AND OBJECTIVE: A large number of studies describing the clinicoepidemiological features of coronavirus disease-2019 (COVID-19) patients are available but very few studies have documented similar features of the deceased. This study was aimed to describe the clinicoepidemiological features and the causes of mortality of COVID-19 deceased patients admitted in a dedicated COVID center in India. METHODOLOGY: This was a retrospective study done in adult deceased patients admitted in COVID ICU from April 4 to July 24, 2020. The clinical features, comorbidities, complications, and causes of mortality in these patients were analyzed. Pediatric deceased were analyzed separately. RESULTS: A total of 654 adult patients were admitted in the ICU during the study period and ICU mortality was 37.7% (247/654). Among the adult deceased, 65.9% were males with a median age of 56 years [interquartile range (IQR), 41.5-65] and 94.74% had one or more comorbidities, most common being hypertension (43.3%), diabetes mellitus (34.8%), and chronic kidney disease (20.6%). The most common presenting features in these deceased were fever (75.7%), cough (68.8%), and shortness of breath (67.6%). The mean initial sequential organ failure assessment score was 9.3 ± 4.7 and 24.2% were already intubated at the time of admission. The median duration of hospital stay was 6 days (IQR, 3-11). The most common cause of death was sepsis with multi-organ failure (55.1%) followed by severe acute respiratory distress syndrome (ARDS) (25.5%). All pediatric deceased had comorbid conditions and the most common cause of death in this group was severe ARDS. CONCLUSION: In this cohort of adult deceased, most were young males with age less than 65 years with one or more comorbidities, hypertension being the most common. Only 5% of the deceased had no comorbidities. Sepsis with multi-organ dysfunction syndrome was the most common cause of death. HOW TO CITE THIS ARTICLE: Aggarwal R, Bhatia R, Kulshrestha K, Soni KD, Viswanath R, Singh AK, et al. Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center. Indian J Crit Care Med 2021; 25(6):622-628.

Epidemiology and clinical characteristics of COVID- 19 patients requiring critical care in a Tertiary care teaching hospital.

BACKGROUND AND AIMS: We describe the epidemiological and clinical characteristics, and 28 day outcome of critically ill COVID-19 patients admitted to a tertiary care centre in India. MATERIAL AND METHODS: We included 60 adult critically ill COVID-19 patients in this prospective observational study, admitted to the intensive care unit (ICU) after obtaining ethics committee approval and informed consent. Demographics, clinical data, and treatment outcome at 28 days were assessed. RESULTS: Demographic characteristics of the COVID-19 patients reveal that compared to the survivors, the non-survivors were significantly older [57.5 vs. 47.5 years], had more comorbid disease [Charlson's comorbidity index 4 vs. 2], higher Apache II scores [19 vs. 8.5], and had significantly higher percentage of smokers. Diabetes mellitus and hypertension were the most common comorbidities. Dyspnea, fever, and cough were the most common presenting symptoms. Total leucocyte count as well as blood lactate level were significantly higher in non-survivors. Around 47% patients had severe ARDS, and 60% patients required invasive mechanical ventilation. 28 day ICU mortality was 50%, with a mortality of 75% in patients receiving invasive mechanical ventilation. Mortality was higher in males than females (57% vs. 33%). Acute kidney injury and septic shock were the most common non-pulmonary complications during ICU stay. Incidence of liver dysfunction, septic shock, and vasopressor use was significantly higher in the non-survivors. CONCLUSION: This study demonstrates a high 28 day mortality in severe COVID-19 patients. Further well designed prospective studies with larger sample size are needed to identify the risk factors associated with poor outcome in such patients.

Carotid Artery Corrected Flow Time and Respiratory Variations of Peak Blood Flow Velocity for Prediction of Hypotension After Induction of General Anesthesia in Adult Patients Undergoing Elective Surgery: A Prospective Observational Study.

OBJECTIVES: Hypotension is common after induction of general anesthesia, and intraoperative hypotension is associated with postoperative end-organ injury such as acute kidney injury and myocardial ischemia. This study was designed to determine the utility of the carotid corrected flow time (cFT) and carotid artery peak blood flow velocity variation (ðVpeak ) for prediction of hypotension after induction of general anesthesia. METHODS: Adult patients (n = 112) undergoing any elective surgery under general anesthesia who fasted for at least 6 to 8 hours were recruited in this prospective observational study. The common carotid artery cFT and ðVpeak were measured with ultrasound 10 minutes before induction of general anesthesia. After that, general anesthesia with propofol was used, and hemodynamic data were collected until 3 minutes after induction of anesthesia. RESULTS: The carotid cFT was significantly correlated with percentages of the fall in the systolic blood pressure at 2 minutes (P < .0001) and 3 minutes (P < .0001) and percentages of the fall in the mean arterial pressure at 1 minute (P = .0006), 2 minutes (P < .0001), and 3 minutes (P < .0001). The cFT was a predictor of hypotension after induction of general anesthesia, with an area under the receiver operating characteristic curve of 0.91. The best cutoff value obtained from this study was 330.2 milliseconds or less, which predicted postinduction hypotension with sensitivity and specificity of 85.7% and 96.8%, respectively. The ðVpeak was an inferior predictor of postinduction hypotension, with an area under the receiver operating characteristic curve of 0.68. The optimum cutoff value was 18.8%, with sensitivity and specificity of 61.9% and 67.4%. CONCLUSIONS: The cFT measured in the common carotid artery is a reasonable predictor of hypotension after induction of general anesthesia in American Society of Anesthesiologists physical status I and II patients. Further studies are required to identify its role in high-risk patients such as older groups and patients with cardiovascular diseases and also to identify interobserver and intraobserver variability of cFT and ðVpeak measurements.

Comparison of colloid and crystalloid using goal-directed fluid therapy protocol in non-cardiac surgery: a meta-analysis of randomized controlled trials.

PURPOSE: A few randomized controlled trials (RCTs) have compared crystalloid-based goal-directed fluid therapy (GDFT) with starch-based GDFT in patients undergoing major surgical procedures with conflicting results. In this meta-analysis, colloid-based GDFT was compared with crystalloid-based GDFT. METHODS: In this meta-analysis, RCTs comparing colloid- and crystalloid-based GDFT in patients undergoing non-cardiac surgery were included. Binary outcomes were reported as risk ratio (RR) and continuous outcomes were reported as mean difference (MD) with 95% confidence interval (95% CI). PubMed, PubMed central, The Cochrane Library database and EMBASE were searched for potentially eligible trials from inception to 28 February 2020. RESULTS: Data of 2392 patients from nine RCTs were included in this meta-analysis. Mortality at the longest available follow-up [RR (95% CI) 1.44 (0.88, 2.34); p = 0.15], postoperative kidney dysfunction [RR (95% CI) 1.07 (0.72, 1.60); p = 0.73], postoperative length of hospital stay [MD (95% CI) - 0.29 ( - 1.25, 0.66) d; p = 0.55], cardiovascular complications [RR (95% CI) 1.20 (0.50, 2.88); p = 0.68], wound complications [RR (95% CI) 1.08 (0.76, 1.54); p = 0.66], pulmonary complications [RR (95% CI) 0.90 (0.71, 1.140); p = 0.40] and bleeding [RR (95% CI) 1.24 (0.77, 1.99); p = 0.37] were similar in both the groups. Postoperative major complications were also similar between patients who received colloid and crystalloid [RR (95% CI) 0.79 (0.48, 1.29); p = 0.34]. CONCLUSION: Colloids in goal-directed fluid therapy protocol does not offer any benefit over crystalloid-based goal-directed fluid therapy protocol in patients undergoing major non-cardiac surgical procedure.

Noninvasive Ventilation and Oxygen Therapy after Extubation in Patients with Acute Respiratory Failure: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Role of noninvasive ventilation (NIV) following extubation in patients with acute respiratory failure is debatable. NIV may provide benefit in post surgical patients, but its role in nonsurgical patients is controversial. MATERIALS AND METHODS: PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) were searched (from 1946 to 20th November 2017) to identify prospective randomized controlled trials, where postextubation NIV has been compared with standard oxygen therapy in adult patients with acute respiratory failure. RESULTS: Data of 1525 patients from 11 randomized trials have been included in this meta-analysis. Two trials used NIV to manage post-extubation respiratory failure. Pooled analysis found that mortality rate at longest available follow-up [OR (95% CI) 0.84 (0.50, 1.42); p = 0.52] and reintubation rate [OR (95% CI) 0.75 (0.51, 1.09); p = 0.13] were similar between NIV and standard oxygen therapy. NIV did not decrease intubation rate when used as preventive modality [OR (95% CI) 0.65 (0.40, 1.06); p = 0.08]. Duration of ICU stay was also similar in the two groups [MD (95% CI) 0.46 (-0.43, 1.36) days; p = 0.3]. CONCLUSION: Post extubation NIV in non- surgical patients with acute respiratory failure does not provide any benefit over conventional oxygen therapy. HOW TO CITE THIS ARTICLE: Maitra S, Bhattacharjee S, Som A. Noninvasive Ventilation and Oxygen Therapy after Extubation in Patients with Acute Respiratory Failure: A Meta-analysis of Randomized Controlled Trials. Indian J Crit Care Med 2019;23(9):414-422.

Goal directed fluid therapy decreases postoperative morbidity but not mortality in major non-cardiac surgery: a meta-analysis and trial sequential analysis of randomized controlled trials.

BACKGROUND AND AIMS: Optimum perioperative fluid administration may improve postoperative outcome after major surgery. This meta-analysis and systematic review has been aimed to determine the effect of dynamic goal directed fluid therapy (GDFT) on postoperative morbidity and mortality in non-cardiac surgical patients. MATERIAL AND METHODS: Meta-analysis of published prospective randomized controlled trials where GDFT based on non-invasive flow based hemodynamic measurement has been compared with a standard care. Data from 41 prospective randomized trials have been included in this study. RESULTS: Use of GDFT in major surgical patients does not decrease postoperative hospital/30-day mortality (OR 0.70, 95 % CI 0.46-1.08, p = 0.11) length of post-operative hospital stay (SMD -0.14; 95 % CI -0.28, 0.00; p = 0.05) and length of ICU stay (SMD -0.12; 95 % CI -0.28, 0.04; p = 0.14). However, number of patients having at least one postoperative complication is significantly lower with use of GDFT (OR 0.57; 95 % CI 0.43, 0.75; p < 0.0001). Abdominal complications (p = 0.008), wound infection (p = 0.002) and postoperative hypotension (p = 0.04) are also decreased with used of GDFT as opposed to a standard care. Though patients who received GDFT were infused more colloid (p < 0.0001), there is no increased risk of heart failure or pulmonary edema and renal failure. CONCLUSION: GDFT in major non- cardiac surgical patients has questionable benefit over a standard care in terms of postoperative mortality, length of hospital stay and length of ICU stay. However, incidence of all complications including wound infection, abdominal complications and postoperative hypotension is reduced.

Combination of 5-HT3 Antagonist and Dexamethasone Is Superior to 5-HT3 Antagonist Alone for PONV Prophylaxis After Laparoscopic Surgeries: A Meta-analysis.

INTRODUCTION: 5-Hydroxytryptamine type 3 (5-HT3) receptor antagonists are the most commonly used drugs for postoperative nausea vomiting (PONV) prophylaxis. Dexamethasone is another antiemetic with proven efficacy in reducing PONV. The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the combination of dexamethasone and 5-HT3 antagonist versus a 5-HT3 antagonist alone as prophylaxis of PONV in laparoscopic surgical patients. METHODS: PubMed, PubMed Central, and CENTRAL databases were searched to identify those randomized trials that compared a 5-HT3 antagonist with the 5-HT3 antagonist and dexamethasone combination for PONV prophylaxis after laparoscopic surgeries. RESULTS: Data from 17 RCTs that evaluated 1402 patients were included. Results from our meta-analysis show that the combination of dexamethasone and a 5-HT3 receptor antagonist is more effective in preventing PONV than the 5-HT3 antagonist alone (odds ratio 0.38, 95% confidence interval [CI] 0.27-0.54; number needed to treat = 6.6), with no statistical heterogeneity (I = 0) among studies. The need for rescue antiemetic is also decreased in patients receiving the combination (odds ratio 0.21, 99% CI 0.10-0.46; number needed to treat = 6), although data are insufficient to detect any significant difference in incidence of adverse effects. In addition, patients in the combination group complained of less pain after 24 hours (Weighted Mean Difference -0.67, 99% CI -1.27 to -0.08). CONCLUSION: Combination of a 5-HT3 receptor antagonist and dexamethasone is significantly more effective than 5-HT3 antagonist alone in preventing PONV after laparoscopic surgeries, with possible improvement in postoperative analgesia.

High-frequency ventilation does not provide mortality benefit in comparison with conventional lung-protective ventilation in acute respiratory distress syndrome: a meta-analysis of the randomized controlled trials.

BACKGROUND: Despite implementation of lung-protective ventilation strategy, acute respiratory distress syndrome is associated with significant mortality, which necessitates the evaluation of ventilatory modes other than conventional lung-protective strategy. This meta-analysis of the randomized controlled trials has been undertaken to know whether high-frequency oscillatory ventilation (HFOV) provides any mortality benefit over conventional ventilation in adult patients with acute respiratory distress syndrome. METHODS: Published randomized controlled trials comparing HFOV with conventional lung-protective ventilation in adult patients with acute respiratory distress syndrome were included in this meta-analysis. RESULTS: A total 1,759 patient data from seven randomized controlled trials have been analyzed here. Primary outcome of the review is in-hospital/30-day mortality and secondary outcomes are duration of intensive care unit stay, duration of mechanical ventilation, requirement of additional treatment, and complications associated with the interventions. HFOV does not offer any in-hospital/30-day mortality benefit (386 of 886 in HFOV vs. 368 of 873 in conventional ventilation; risk ratio, 0.96; 95% CI, 0.77 to 1.19; P = 0.70) over conventional ventilation. It may also prolong the duration of mechanical ventilation (mean difference, 1.18 days; 95% CI, 0.00 to 2.35 days; P = 0.05). Duration of intensive care unit stay (mean difference, 1.24 days; 95% CI, -0.08 to 2.56 days; P = 0.06) and requirement of neuromuscular blocker is similar between two treatment arm. Incidence of refractory hypoxemia is significantly less (risk ratio, 0.60; 95% CI, 0.39 to 0.93; P = 0.02) with the use of HFOV. HFOV is not associated with increased incidence of barotrauma and refractory hypotension. CONCLUSION: HFOV should not be used routinely in all adult patients with acute respiratory distress syndrome as primary ventilation strategy in place of conventional lung-protective ventilation.

Comparison between intrathecal isobaric ropivacaine-fentanyl and bupivacaine-fentanyl in elective infraumbilical orthopedic surgery: A randomized controlled study.

BACKGROUND AND AIMS: We aimed to evaluate and compare the block characteristics and duration of analgesia of intrathecal isobaric ropivacaine-fentanyl and bupivacaine-fentanyl combination in adult patients undergoing lower limb orthopedic surgery. MATERIAL AND METHODS: Seventy-four American Society of Anesthesiologists' I and II adult patients undergoing lower limb orthopedic surgery under subarachnoid block were randomized to receive either 3 ml 0.5% isobaric ropivacaine and 25 mcg fentanyl (Group R) or 3 ml 0.5% isobaric bupivacaine and 25 mcg fentanyl (Group B). The hemodynamic profiles, maximum upper level of sensory block height, time to reach peak block height, two dermatome regression time, and duration of motor block were recorded. RESULTS: There was no statistically significant difference regarding the hemodynamic parameters between the groups. The median (range) peak sensory block height was T7 (T4-T9) in Group R and T7 (T4-T10) in Group B. Time to reach peak block height (13.2 ± 2.3 min in Group R vs. 13.7 ± 2.2 min in Group B; P = 0.385) was similar between the groups. Two dermatome regression time in sensory block (median 120 min vs. 85 min; P < 0.001) and duration of motor block (median 245 min vs. 150 min; P < 0.001) was significantly higher in Group B. The duration of analgesia (median 360 min vs. 245 min; P < 0.001) was significantly higher in the bupivacaine group. CONCLUSION: Intrathecal isobaric bupivacaine-fentanyl combination produces a significantly longer duration of analgesia, sensory block and motor block than isobaric ropivacaine-fentanyl combination. As ropivacaine has a shorter duration of sensory and motor block, it may be preferred in day care surgery.

Evaluation of i-gel(™) airway in children: a meta-analysis.

BACKGROUND: I-gel(™) is a relatively newer addition in the pediatric anesthesia practice. Its comparison with the other laryngeal mask airway repor-ted a wide range of results. Randomized controlled trials where i-gel(™) has been compared with other laryngeal masks (laryngeal mask airway ProSeal(™) and laryngeal mask airway Classic(™) ) in children for airway management device during general anesthesia has been included in this meta-analysis. METHODS: PubMed and Central Register of Clinical Trials of the Cochrane Collaboration for eligible controlled trials using following search words: 'i-gel', 'i-gel laryngeal mask airway', 'i-gel children', 'i-gel paediatric' until February 15, 2014. A total nine prospective randomized controlled trials have been included in this meta-analysis. RESULTS: Pooled analyses have found that i-gel(™) provided significantly higher oropharyngeal leak pressure than laryngeal mask airway ProSeal(™) [496 participants, mean difference 2.07 cm H2 O, 95% CI 0.52-3.62; P = 0.009] and a similar leak in comparison with laryngeal mask airway Classic(™) [355 participants, mean difference 1.73 cm H2 O, 95% CI -0.04, 3.51 cm H2 O; P =0.06]. No difference was found in first insertion success rate and ease of insertion between i-gel(™) , laryngeal mask airway ProSeal(™) , and laryngeal mask airway Classic(™) . Ease of gastric tube insertion is similar between i-gel(™) and laryngeal mask airway ProSeal(™) . Reported complications are infrequent and similar in all three devices. CONCLUSION: We conclude that i-gel(™) is an effective alternative of the commonly used laryngeal mask airway ProSeal(™) and laryngeal mask airway Classic(™) in children for airway management during general anesthesia.