Rational Use of Oxygen in COVID-19 Pandemic - Are We Doing Enough?

During the episodes of large case surge of COVID-19, the health care system of many nations have struggled, more so in nations with resource limitations. Recently, Nepal and the neighboring nation India are being hit hard by the pandemic. Management of patients with moderate and severe COVID-19 remains largely supportive, with oxygen therapy being the cornerstone of the management. Procurement, maintenance of oxygen supply system, coupled with avoiding misuse and wastage of oxygen is of paramount importance to better utilize the scarce resources amidst the peaks of a pandemic. Nepal needs to adopt policies to make best use of its stores and supplies with a collective effort from all stakeholders to save additional lives.

Steroid Stewardship in COVID-19.

Corticosteroids have transformed clinical practice in COVID-19 following the publication of the results of the RECOVERY trial. Despite available evidence, there is considerable disparity among physicians in the dose and duration of steroids they prescribe. Steroids have a fragile affiliation in clinical practice with the benefits frequently accompanied by distressing adverse effects. An institutional steroid stewardship program can help all physicians take advantage of what is the only proven therapy of benefit in this global crisis while avoiding its overuse and the numerous adverse effects associated with it. Keywords: COVID-19; corticosteroids; RECOVERY trial; steroid stewardship.

The story of critical care in Asia: a narrative review.

BACKGROUND: Asia has more critically ill people than any other part of our planet. The aim of this article is to review the development of critical care as a specialty, critical care societies and education and research, the epidemiology of critical illness as well as epidemics and pandemics, accessibility and cost and quality of critical care, culture and end-of-life care, and future directions for critical care in Asia. MAIN BODY: Although the first Asian intensive care units (ICUs) surfaced in the 1960s and the 1970s and specialisation started in the 1990s, multiple challenges still exist, including the lack of intensivists, critical care nurses, and respiratory therapists in many countries. This is aggravated by the brain drain of skilled ICU staff to high-income countries. Critical care societies have been integral to the development of the discipline and have increasingly contributed to critical care education, although critical care research is only just starting to take off through collaboration across groups. Sepsis, increasingly aggravated by multidrug resistance, contributes to a significant burden of critical illness, while epidemics and pandemics continue to haunt the continent intermittently. In particular, the coronavirus disease 2019 (COVID-19) has highlighted the central role of critical care in pandemic response. Accessibility to critical care is affected by lack of ICU beds and high costs, and quality of critical care is affected by limited capability for investigations and treatment in low- and middle-income countries. Meanwhile, there are clear cultural differences across countries, with considerable variations in end-of-life care. Demand for critical care will rise across the continent due to ageing populations and rising comorbidity burdens. Even as countries respond by increasing critical care capacity, the critical care community must continue to focus on training for ICU healthcare workers, processes anchored on evidence-based medicine, technology guided by feasibility and impact, research applicable to Asian and local settings, and rallying of governments for support for the specialty. CONCLUSIONS: Critical care in Asia has progressed through the years, but multiple challenges remain. These challenges should be addressed through a collaborative approach across disciplines, ICUs, hospitals, societies, governments, and countries.

Characteristics and Outcome of Patients with COVID-19 Undergoing Invasive Mechanical Ventilation for Respiratory Failure in a Tertiary Level Hospital in Nepal.

BACKGROUND: Corona virus disease 2019 has become a global health issue. The goal of this study was to investigate the characteristics and outcomes of patients with corona virus disease 2019 undergoing invasive mechanical ventilation and identify factors associated with mortality. METHODS: Ninety four consecutive critically ill patients with confirmed corona virus disease 2019 undergoing invasive mechanical ventilation were included in this retrospective, single-center, observational study. The outcome variable was mortality of patients undergoing invasive mechanical ventilation and factors associated with it during intensive care unit stay. RESULTS: Seventy nine (84%) out of 94 patients with confirmed corona virus disease 2019 who underwent invasive mechanical ventilation didn't survive. Ninety four percent of patients who had Type 2 Diabetes Mellitus did not survive in comparison to 72 percent of patients who didn't have Type 2 Diabetes Mellitus. Similarly, 48 (94.1%) out of 51 patients with a positive C-reactive protein value didn't survive in comparison to 31 (72%) out of 43 patients with a negative C-reactive protein. CONCLUSIONS: The presence of Type 2 Diabetes Mellitus and a positive C-reactive protein value were strongly associated with mortality. Patients with a Sequential organ failure assessment score of more than eight at intensive care unit admission and peak D-dimer level of more than or equal to two during intensive care unit stay didn't show significant association with mortality. These findings need further exploration through larger prospective studies.

Mucormycosis: An unanticipated progeny of COVID-19.

The rapid surge of COVID-19 cases in the second wave of the pandemic has crippled the healthcare delivery system in Nepal and neighboring countries. Unlike in the first wave of the pandemic, several cases of mucormycosis have been reported in patients with COVID-19 from Nepal and India. In this report, we briefly describe the clinical presentation, diagnosis, and risk factors for mucormycosis and explore why patients with COVID-19 are at an increased risk for developing the infection. As treatment of mucormycosis is challenging and consumes a lot of resources, prevention of mucormycosis is pivotal in low-income countries like Nepal. We also highlight some basic steps that are easy to perform and important to reduce the risk of infection.

Tofacitinib as an Adjunct Immunomodulator for Treatment of a Patient with Severe COVID-19: A Case Report.

Severe coronavirus disease 2019 can be associated with progressive respiratory failure. In addition to respiratory support and other supportive care, use of corticosteroids has shown to improve outcome. Despite the use of steroids, a significant proportion of patients progressively worsen. Adjunct immunomodulators have been studied in addition to steroids in these patients. Here we present a successful use of tofacitinib, a Janus Kinase inhibitor, in conjunction with dexamethasone for a patient with rapid worsening of respiratory status and with high level of serum inflammatory biomarkers.

Neurological Manifestations of COVID-19 Associated Multi-system Inflammatory Syndrome in Children: A Systematic Review and Meta-analysis.

BACKGROUND: Children comprise only 1-5% of COVID-19 cases. Recent studies have shown that COVID-19 associated multisystem inflammatory syndrome in children (MIS-C) can present with neurological signs and symptoms. In this systematic review and meta-analysis, we have reviewed neurological involvement in these patients. METHODS: A comprehensive electronic literature search was done on PubMed, Google Scholar, Embase, Cochrane database, and SCOPUS for the published English language articles from December 1, 2019, to February 28, 2021. A meta-analysis of the proportion was expressed as a pooled proportion with a 95% confidence interval (CI). Representative forest plots showing individual studies and the combined effect size were generated to provide an overview of the results. RESULTS: This systematic review and meta-analysis analyzed 15 published MIS-C studies with a total of 785 patients. Neurological manifestations in patients with MIS-C was found in 27.1%. We found that 27% developed headaches, 17.1% developed meningism/meningitis and 7.6 % developed encephalopathy. Other uncommon neurological manifestations of MIS-C includes anosmia, seizures, cerebellar ataxia, global proximal muscle weakness and bulbar palsy. In MIS-C patients with neurological feature, neuroimaging showed signal changes in the splenium of the corpus callosum. Electroencephalography showed slow wave pattern and nerve conduction studies and electromyography showed mild myopathic and neuropathic changes. CONCLUSIONS: Our study revealed that neurological manifestations are not uncommon in patients with MIS-C. Further large prospective studies are needed to better explore the disease spectrum and to unravel the underlying pathophysiology.

Management of Stroke During COVID-19 Pandemic: The Challenges in Nepal.

The COVID-19 pandemic has significantly affected health care delivery globally. COVID-19 is associated with varied neurological manifestations including acute ischemic stroke. In densely populated South Asian nations like Nepal that have suboptimal baseline health care systems, we foresee unique challenges during this pandemic to ensure effective stroke management as well as the safety of health care workers involved in the management of stroke patients. Keywords: COVID-19; health care workers; safety; stroke management.

COVID-19: Current Understanding of Pathophysiology.

Coronavirus disease 2019 has emerged as a global pandemic, affecting millions of people across the globe. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters the human cell after binding to the Angiotensin-Converting Enzyme 2 receptors, that are present in various organs. The involvement of the respiratory system is common and may progress to acute respiratory distress syndrome. Besides the involvement of respiratory system other systems like cardiovascular, renal, gastrointestinal and central nervous are not uncommon. In-depth understanding of the pathophysiological basis of organs and systems involvement and disease progression aids in the safe and effective management of the COVID-19 patients. It also helps to guide future well-designed clinical trials, which is the need of time. This review aims to explore the current understanding of pathophysiological basis of various organ system involvement in patients with COVID-19, that can have relevance for patient management and future research. We reviewed the articles in various databases to assemble the current evidences. Keywords: Coronavirus disease 2019; COVID-19; pathophysiology; severe acute respiratory syndrome coronavirus 2.

Anaesthetic Management of Patients with COVID-19: A Single Center Initial Experience from Nepal.

Anaesthetic management of patients with Corona Virus Disease (COVID-19) posses multiple challenges. In the low-income nation like Nepal, factors like suboptimal infrastructure and resource limitations may add on to the existing challenges. Proper planning and preparedness can help to overcome the challenges and enhance safety of both the patients undergoing surgery and of the health care workers involved in patient management. Keywords: Anaesthetic management; COVID-19; Nepal.

Neurological manifestations of COVID-19: a systematic review.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the global spread of coronavirus disease (COVID-19). Our understanding of the impact this virus has on the nervous system is limited. Our review aims to inform and improve decision-making among the physicians treating COVID-19 by presenting a systematic analysis of the neurological manifestations experienced within these patients. METHODS: Any study, released prior to May 20, 2020, that reported neurological manifestations in patients infected by SARS-CoV-2 was systematically reviewed using the PRISMA (Preferred Reporting Items for Systemic review and Meta-Analysis) statement. RESULTS: Our systematic review included data from 37 articles: twelve retrospective studies, two prospective studies, and the rest case reports/series. The most commonly reported neurological manifestations of COVID-19 were myalgia, headache, altered sensorium, hyposmia, and hypogeusia. Uncommonly, COVID-19 can also present with central nervous system manifestations such as ischemic stroke, intracerebral hemorrhage, encephalo-myelitis, and acute myelitis, peripheral nervous manifestations such as Guillain-Barré syndrome and Bell's palsy, and skeletal muscle manifestations such as rhabdomyolysis. CONCLUSION: While COVID-19 typically presents as a self-limiting respiratory disease, it has been reported in up to 20% of patients to progress to severe illness with multi-organ involvement. The neurological manifestations of COVID-19 are not uncommon, but our study found most resolve with treatment of the underlying infection. Although the timeliness of this review engages current challenges posed by the COVID-19 pandemic, readers must not ignore the limitations and biases intrinsic to an early investigation.

COVID-19 Pandemic: Shortage of Personal Protective Equipment, Use of Improvised Surrogates, and the Safety of Health Care Workers.

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