A Retrospective Observational Study to Analyze Recruitment Paradigms in the Treatment of Hypoxemic COVID-19 Patients Admitted in the Intensive Care Unit of a Tertiary Care Institute in India

Introduction: This retrospective study attempted to assess the recruitability of the lungs that were affected by acute respiratory distress syndrome (ARDS) due to COVID-19. This was done with the combined use of transpulmonary pressure monitoring (to limit the stress), measurement of end-expiratory lung volume (EELV) (to measure the actual volume gain and be within limits of strain), electrical impedance tomography (EIT), and compliance (to diagnose overdistension). Recruitment was judged clinically by an increase in the SpO2 values. Methods: Retrospective data from the charts and progress sheets were collected from 27 patients admitted to the intensive care unit (between February 2021 and June 2021) with a ratio of arterial Partial pressure of oxygen (PaO2 in mmHg) to fractional inspired oxygen (FiO2) < 150 (i.e., PaO2/FiO2 < 150) with a diagnosis of ARDS. The esophageal pressure was monitored using the polyfunctional nasogastric tube (Nutrivent (TM)). The end-expiratory volume was measured using the Carescape R860 (GE Healthcare) by the nitrogen multiple breath wash-out/wash-in (EELV) at a positive end-expiratory pressure of 5. EIT measurements were performed using the Pulmo Vista 500. We performed a recruitment maneuver using the "staircase maneuver. " Results: As per the results of our study, we found that almost 2/3rd (66.7%) of the patients affected with COVID lungs affected with ARDS were recruitable. Conclusion: The results of our study again make us believe that majority of COVID-19 lungs affected with ARDS may be recruitable in the earlier stage of the illness (within the 1st week of ARDS). Thus, in such patients, safe, monitored lung recruitment should be attempted to improve oxygenation rather than directly proning the patient, which is fraught with its own set of complications.

Comparison of Nutritional Pattern and Use Between Covid and Non-Covid ICU Patients

Introduction: Nutrition plays an important role in ICU patients, more so in hypercatabolic COVID-19 illness. Among other lifethreatening problems, nutrition seemed to have taken a backseat in many hospitals due to logistics, reduction of manpower, isolation practices, etc. Objectives: To study the pattern and use of nutrition in our tertiary care COVID ICU in comparison to the non-COVID ICU. Materials and methods: An observational study was performed of 941 consecutive patients from March 2020 to June 2021 by collecting data from the iNUTRIMON software.1 In view of the various challenges faced in the delivery of appropriate nutrition and the hypermetabolic nature of the disease a COVID-specific nutrition protocol was formulated at the start of the pandemic.2 It involved the use of enteral scientific feeding formula for all COVID patients tolerating an oral diet. The protocol can be accessed at https://www.opensciencepublications.com/fulltextarticles/IJN- 2395-2326-7-216.html. The energy was prescribed using simple predictive equations (i.e., 25 kcal/kg). In case of mechanically ventilated patients, indirect calorimetry-derived measures were used. All patients were prescribed 1.8 g/kg proteins. The protocol for nutrition patients remained the same with the exception that in non-COVID patients oral supplements were added only if 50% of the kitchen diet was not taken within 3 days. The use of TPN for both groups remained as per the protocol. The software iNutrimon calculated the scientific feeding formulae (product) based on the prescription of energy, proteins, and volumes, taking into account the viscosity and precise water requirement per scoop of formula feed. Results: The mean length of ICU stay of COVID patients was 9.31 days as compared to 6.8 days in non-COVID patients. 8.8% of the patients required TPN as compared to 1.4% of the non-COVID population. Only 0.6% of the total enteral feeding in the COVID ICU was with kitchen diet alone compared to 7.8% in the non-COVID ICU. The incidence of use of supplemental nutrition was 97% per patient as compared to 57.6% per non-COVID patient. Among the scientific feeding formulae, the use of peptamen (85%) was highest in COVID patients as compared to 25% in non-COVID patients. The per-day cost of nutrition for COVID patients admitted to the ICU was found to be comparable to non-COVID patients when a cost analysis was done. Conclusion: There was a 168% increase in the use of scientific feeding formula and a 60% increase in the use of TPN in COVID patients as compared to non-COVID patients. This is also reflected as an increase in the cost of feeding. The use of TPN seems to suggest the increased intolerance to enteral nutrition. The increased use of scientific feeding formulae may indicate the adherence to protocol and also seems to suggest that COVID patients needed to be supplemented as kitchen feeds were unable to meet the requirements.

Are We Feeding Our Critically Ill Covid Patients, Right?

Objective: Primary objective: To study the energy expenditure in a significant number of mechanically ventilated COVID-19 patients in ARDS. Secondary objective: 1. To compare the deviations seen with predictive equations based on actual and ideal body weight. 2. To compare the EE derived versus the VCO2 based estimation. Materials and methods: The Resting Energy expenditure (REE) of 60 patients was measured with the help of the ESCOVYX-module for indirect calorimetry using the GE CARESCAPE R860 ventilator. The steady-state was validated by ensuring a respiratory quotient of 0.7-0.8 and variation of 5% for VCO2 and VO2 for at least 30 minutes. It was ensured that for 60 minutes the patient was not disturbed by endotracheal tube suction, no ventilatory changes were performed, and no vasopressors alteration was done. The absence of a leak was ascertained on the ventilator. The calculation was done from day 2 onwards after mechanical ventilation and subsequently every 2nd day till the patient was on ventilator. The resting energy expenditure was also calculated by the simple predictive equations as per ESPEN COVID-19 guidelines, i.e., 25-30 kcal/kg of which the mean of 27 kcal/kg was chosen. Bodyweight was estimated by height equation 50 kg for 5 ft plus 2.3 kg for each inch >5 feet. The quantitative measures were studied by Bland and Altman plot to describe an agreement between the two by constructing a line of agreement. The limits were calculated by using the mean and standard deviation of the difference between the two measurements. Statistics: The EE derived from the two methods is compared by Bland and Altman plots. Reliability and adequacy between the methods are tested using ROC curves with kappa coefficient (reliability coefficient). For the coefficient of variation, ANOVA is used when applicable. IBM SPSS Statistics for Windows, version 24.0 (IBM Corporation, Chicago, USA) was used to perform analyses. MedCalc version 19 (MedCalc bv, Ostend, Belgium) was used to create BlandeAltman plots. Results: No 1: The estimated mean energy expenditure derived from weight-based calculations was 2576 ± 469 kcal/24 hours, which was significantly higher when compared with an estimation of EE from indirect calorimetry of 1507 ± 499 kcal/24 hours (15-20 kcal/kg/day). This correlation is significant but not useful for prediction (R = 0.345). No 2: The estimated mean EEVCO2 was 1388 ± 467 kcal/24 hours compared with an estimation of EE from indirect calorimetry of 1507 ± 499 kcal/24 hours. The Bias and precision, as visualized by the limits of agreement, are shown in the Bland-Altman plot where there was a significant bias of only 118 kcal/day (95% CI (-187 to 422 kcal);p < 0.001. The regression analysis reveals that for every one unit change in EEVCO2 value, there is one unit change in EE by IC. This correlation is significant (R = 0.951). Similarly, the Bland-Altman plot was tested between the estimated mean EEVCO2 and EE derived from weight-based calculations. The difference was wide with significant bias of 1187 kcal/day (95% CI (-2256 to (-118) kcal);p < 0.001). Conclusion: The ESPEN guidelines (30 kcal/kg through the disease state) for energy estimation may not be right in COVID-19 patients and the study calls for more personalisation of energy estimation by the correct use of indirect calorimetry.

Abdominal Wall Fungal Co-infection-Mucormycosis Associated with COVID-19: A Case Report

Aim and objective: To present a rare case of abdominal wall fungal coinfection with Mucormycosis in a patient of COVID-19. Materials and methods: A 33-year-old female operated case of laparoscopic ectopic pregnancy removal with salpingectomy and tubectomy, at postoperative day 5 had redness and pus discharge from the operative site and was diagnosed with abdominal wall cellulitis. She underwent local exploration and wound wash. On postoperative day 21, the patient came to the emergency room with cellulitis, and pain at the port insertion site. On examination, we highlight BP 90/50 mm Hg and blood test analysis with HB-8.3, leucocyte count 29.91 × 109/L, CRP 333 mg/L. Results: CT scan revealed necrotizing fasciitis. She underwent wide local excision and debridement. Post debridement the next day during dressing, the wound showed a cotton fluffy appearance at the edges and part of the base with black necrotic areas. A wound swab was sent for fungal culture, KOH mount, pus culture, and tissue for histopathology. In the meantime, she was started on empirical antifungal amphotericin B, meropenem, and minocycline antibiotics. On history, the patient remarked that she did have fever, sore throat, and cough for 5 days, 4 weeks before laparoscopic ectopic pregnancy removal. Also one of her family members had tested positive for COVID-19. COVID antibodies test was done which were reactive: 1.96. Tissue histopathology revealed mucormycosis. MRI abdomen findings showed a 15 cm large defect involving the entire thickness of subcutaneous fat. A high degree of suspicion and promptness in starting antifungal treatment prevented the fatal outcome. Conclusion: COVID-19 is associated with immune dysregulation and consequently life-threatening infections. The prolonged and indiscriminate use of steroids for the treatment of COVID-19 could contribute to this problem of fungal superinfection of mucormycosis. It seems prudent to have a very high suspicion supplemented with thorough clinical examination and low threshold for imaging in order to diagnose secondary fungal infections, such as mucormycosis. Early so that the treatment can be instituted as soon as possible.

Effect of Lateral Positioning on Oxygen Levels in An Obese Critically Hypoxic COVID-19 Patient: A Case Report ABS0174)

Aim and objective: To demonstrate the effectiveness of lateral positioning as a salvage for deteriorating PaO2/FiO2 ratio through a case report of a morbidly obese individual managed with lateral positioning. To demonstrate that the improvement of oxygenation was due to the recruitment of previously non-ventilated lung areas as demonstrated by Electrical impedance tomography. The study noted the evolution in SpO2, variations in regional distribution of ventilation (TV), and changes in end-expiratory lung volume/ FRC. Materials and methods: The patient was ventilated using the Carescape R860 GE ventilator. As per protocol, the transpulmonary pressure was monitored using an esophageal manometer using the Nutrivent. End expiratory lung volume (EELV) or the functional residual capacity (FRC) was measured using the nitrogen washout method. The patient was ventilated with a pressurecontrolled mode at a FiO2 of 80% of ventilated with the driving pressure (pressure control-peep) maintained at 15. The PEEP was progressively increased in steps of 5 (staircase maneuver). The staircase recruitment was continued to reach an inspiratory transpulmonary pressure of 25 or a peep of 40 (whichever reached earlier). At each step of the staircase manoeuvre, the end expiratory lung volume, compliance, and the electrical impedance tomography values were noted to avoid overdistension. Lateral (both left and right, ∼ 40° with pillows) and supine positions were performed (∼ 2 h for each position). At each position, an FRC calculation (average of three) was done and an EIT measurement was done. The strain was a calculation by the formula tidal volume/functional residual capacity and found to be <0.25 at all times. Results: The positional alteration (right and left lateral) consistently showed an improvement in the end-expiratory lung volume/FRC along with a clear demonstration of improvement of air redistribution in the lung maps by electrical impedance tomography. The findings of the case suggest recruitment of previously non-ventilated/ poorly ventilated lung areas. Conclusion: The case study results provide evidence of the effectiveness of a lateral positioning in the improvement of oxygenation in COVID ARDS. This case report would encourage the use of lateral positioning in those hypoxic patients who cannot be proned or in those units who have no expertise in proning.

Are COVID-19 Lungs Recruitable-yes!!! If Done the Right Way

Aim and objective: To find out whether the COVID-19 affected ARDS lungs are recruitable with the combined use of 1. Transpulmonary pressure monitoring (to limit the stress);2. End expiratory lung volume measurement (to limit strain);3. Electrical impedance tomography;4. Compliance (to diagnose overdistension) and the increase in the SpO2 as a marker of clinical recruitment. Materials and methods: Retrospective data from charts and progress sheets were collected from 27 patients admitted to the ICU (between February 2021 and June 2021) with PaO2/FiO2 ratio <150 with a diagnosis of acute respiratory distress syndrome. Data acquisition: As a protocol, the esophageal pressure was monitored using the polyfunctional nasogastric tube (Nutrivent). The end-expiratory volume was measured using the Carescape R860 (Carescape R860;GE Healthcare) by the nitrogen multiple breath wash-out/ wash-in (EELV) at a PEEP of 5. Electrical impedance tomography measurements were performed using the PulmoVista 500. We performed a recruitment maneuver using the staircase maneuver. Statistics: Categorical variables are presented as frequency and percentage (%) and continuous variables are presented as mean and standard deviation. Comparison between pre- and post-recruitable was tested using t-test, while repeated-measures ANOVA was used to test follow-ups like 2 hours and 4 hours. Statistical significance is assumed at a value of p < 0.05. Results: As per the results of our study we found that almost 2/3rd (66.7%) of the COVID ARDS lungs were recruitable safely. The average plateau pressure (cm of H2O), mean compliance, FRC, and SPO2 were noted before the attempt at recruitment and after recruitment. After conducting the staircase manoeuvre, the plateau pressure remained at 25.56 with a standard deviation of 3.641. However, the mean compliance rose to 31.926 with a standard deviation of 10.099. Post recruitment there was a marked rise of FRC to 1581.778 with a standard deviation of 311.049 mL. Pre recruitment means SPO2 was 83.6% with a standard deviation of 3.9%. Post recruitment at 2 hours the SPO2 had reached 91.1% with a standard deviation of 5.4% and remained the same at 91.9% with a standard deviation of 7.5%. Among the 27 patients' clinical recruitment was seen in 18 patients (66.7%). As per the results of our study, we found that almost 2/3rd (66.7% or 18/27 pts) of the COVID ARDS lungs were recruitable safely (rise in SPO2 maintained at 2 and 4 hours along with the absence of overdistension as seen on EIT with an increase in FRC and compliance). Conclusion: As per the results of our study almost 2/3rd of COVID-19 patients were recruitable. This is the first Indian study to comprehensively study recruitment in COVID-19. ARDS pts with the best available techniques. This study shows that majority of COVID-19 lungs may be recruitable in the earlier stage of the illness (within the first week of ARDS) and thus warrant a trial of a safe monitored recruitment strategy.

Lung characteristics of COVID-19 patient

Introduction: The high mortality in COVID-19 is related to severe ARDS and the theory is regarding bound one with low compliance and one with high compliance and treatment directed accordingly which included prone ventilation, lung-protective ventilation strategies, however, most of these were based on with western literature with static measurement. None of the literature talk about the actual measurement of recruitability by any method. Our objective is to study lung characteristics to assess recruitability with esophageal manometry, measurement of transpulmonary pressure, end-expiratory lung volume after transpulmonary pressure monitoring guided recruitment. Objectives: To study the characteristics of COVID-19 lung with esophageal manometry and function residual capacity (FRC). Materials and methods: Intubation was done when there was effort intolerance with PaO2/FiO2 ratio <150. Inflammatory parameters were sent: ferritin, LDH, D-dimer, WBC count. Esophageal manometry was done, nutrient and endexpiratory lung volume were calculated with GE carescape R860 ventilator using nitrogen washout technique. Results: Percentage of raised inflammatory markers •Ferritin-88% •LDH-68% •D-dimer-76% •WBC-80% Percentage of decreased lung compliance in mechanically ventilated patients. •Compliance-84% 78% of the patients out of 25 patients had increased inflammatory markers, 84% of the patients had a poor lung compliance of less 40 mL/cmH2O and 74% of patients were proned. With which 52 % of the patient's lung out of 25 patients were recruitable. Discussions: There is significant use of esophageal manometry with measurement of transpulmonary pressure in the patient with poor lung compliance and decreased functional residual capacity (FRC). It has been studied that lung-protective strategies along with transpulmonary pressure measurement are more likely to have better recruitment of the lungs in COVID ARDS. Conclusion: There is significant use of esophageal manometry with measurement of transpulmonary pressure in the patient with poor lung compliance and decreased functional residual capacity (FRC). It has been studied that lung-protective strategies along with transpulmonary pressure measurement are more likely to have better recruitment of the lungs in COVID ARDS.