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.

Physiological effect of prone positioning in mechanically ventilated SARS-CoV-2- infected patients with severe ARDS: An observational study.

Background and Aims: Mechanical ventilation in prone position was associated with a reduction in mortality and increase in arterial oxygenation in acute respiratory distress syndrome (ARDS) patients. However, physiological effects of prone position in COVID ARDS patients are unknown. Material and Methods: In this prospective observational study, data of n = 47 consecutive real time RT- PCR confirmed SARS-CoV-2-infected patients with severe ARDS were included. Respiratory mechanics and oxygenation data of recruited patients were collected before and after prone position. Results: Median (Interquartile range, IQR) age of the recruited patients was 60 (50-67) years and median (IQR) PaO2/FiO2 ratio of 61.2 (54-80) mm Hg with application of median (IQR) positive end expiratory pressure (PEEP) of 12 (10-14) cm H2O before initiation of prone position. Out of those patients, 36 (77%) were prone responders at 16 hours after prone session, evident by increase of PaO2 by at least 20 mm Hg or by 20% as compared to baseline, and 73% patients were sustained responders (after returning to supine position). Plateau airway pressure (p < 0.0001), peak airway pressure (p < 0.0001), and driving pressure (p < 0.0001) were significantly reduced in prone position, and static compliance (p = 0.001), PaO2/FiO2 ratio (p < 0.0001), PaO2 (p = 0.0002), and SpO2 (p = 0.0004) were increased at 4 hours and 16 hours since prone position and also after returning to supine position. Conclusion: In SARS-CoV-2-infected patients, mechanical ventilation in prone position is associated with improvement in lung compliance and oxygenation in almost three-fourth of the patients and persisted in supine position in more than 70% of the patients.

Development of an institutional protocol for percutaneous dilatational tracheostomy in critically ill COVID-19 patients: Initial experience.

Background and Aims: Percutaneous dilatational tracheostomy (PDT) may improve the outcome in critically ill COVID-19 patients on mechanical ventilation. However, the timing of performing tracheostomy may be controversial, and it is an aerosol-generating procedure with a potential risk of viral exposure to healthcare workers. Material and Methods: An operational protocol for performing PDT was made and subsequently followed in a designated COVID-19 ICU. Critically ill adult patients on mechanical ventilators who underwent PDT were included in this retrospective cohort study. Case files were retrospectively reviewed and patient characteristics, clinical outcome, and procedure-related details were noted. Results: Forty-one patients were included in the analysis. The median age was 49 (39-67) years, and 41.5% of patients were females. The median duration of mechanical ventilation before tracheostomy was 10 (8-16) days, and the median (IQR) PaO2/FiO2 ratio on the day of PDT was 155 (125-180) mm Hg. Further, 48.8% of patients had transient desaturation to SpO2 <90%, and 41.5% survived to ICU discharge. None of the health care providers involved in PDT developed any symptoms of COVID 19. Conclusion: This descriptive study demonstrates the feasibility, implementation, and apparent safety of the PDT protocol developed at our institution.

A Proposal for Dedicated "Prone Team" and "Prone Bundle of Care" in COVID-19 ICU.

How to cite this article: Anand RK, Baidya DK, Maitra S, Ray BR. A Proposal for Dedicated "Prone Team" and "Prone Bundle of Care" in COVID-19 ICU. Indian J Crit Care Med 2021;25(3):349-350.

Risk of SARS-CoV-2 Infection among Healthcare Providers Involved in Cardiopulmonary Resuscitation in COVID-19 Patients.

Cardiopulmonary resuscitation (CPR) is considered an aerosol-generating procedure. The aim of this study was to identify the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare providers (HCPs) involved in CPR in coronavirus 2019 (COVID-19) patients. An online and offline anonymous survey with a preformed questionnaire was conducted among the HCPs involved in the care of COVID-19 patients. HCPs who developed reverse transcription-polymerase chain reaction-positive confirmed COVID-19 and/or symptomatic influenza-like illness (ILI) within 14 days of their involvement in CPR of a confirmed COVID-19 patient were identified. Activities performed during CPR, the cumulative number of CPR performed, any breach in personal protective equipment (PPE), type of the mask used, use of any pharmacological prophylaxis, and any psychological impact among HCPs were also identified. A total of 393 HCPs participated in the survey; out of them, 197 HCPs participated in CPR at least once (CPR group) and the rest 196 did not (control group). Ten in the control group and five in the CPR group developed confirmed COVID-19 within the next 2 weeks; however, only one of these five had a breach in PPE during CPR. To conclude, participation in CPR does not increase the risk of SARS-CoV-2 infection in HCPs caring for the COVID-19 patients. Ethics approval and consent to participate: The study was approved by the ethics committee of the All India Institute of Medical Sciences, New Delhi, vide letter number: IEC-676/03.07.2020, dated July 4, 2020. How to cite this article: Soni L, Maitra S, Ray BR, Anand RK, Subramaniam R, Baidya DK. Risk of SARS-CoV-2 Infection among Healthcare Providers Involved in Cardiopulmonary Resuscitation in COVID-19 Patients. Indian J Crit Care Med 2021;25(8):920-922.

Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a type of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 pneumonia has characteristic radiological features. Recent evidence indicates usefulness of chest X-ray and lung ultrasound (LUS) in detecting COVID-19 pneumonia. MATERIALS AND METHODS: In this prospective observational study, chest X-ray and LUS features of 50 adults with COVID-19 pneumonia at the time of presentation were described. RESULTS: Chest X-ray findings were present in 96% of patients, whereas all patients have ultrasound finding. Proportion (95% CI) of patients having bilateral opacities in chest X-ray was 96% (86.5-98.9%), ground glass opacity 74% (60.5-84.1%), and consolidation 50% (36.7-63.4%). In LUS, shred sign and thickened pleura was present in all patients recruited in this study. Air bronchogram was present in at least one area in 80% of all patients and B-lines score of more than 2 was present in at least one lung area in 84% patients. Number of lung areas with "shred sign" were higher in hypoxemic (p = 0.005) and tachypneic (p = 0.006) patients and pleura line abnormalities were present in more lung areas in hypoxemic patients (p = 0.03). CONCLUSION: According to our study, LUS is a useful tool not only in diagnosing, but it also correlates with requirement of respiratory support in COVID-19 patients. HOW TO CITE THIS ARTICLE: Behera S, Maitra S, Anand RK, Baidya DK, Subramaniam R, Kayina CA, et al. Thoracic Radiological Characteristics of COVID-19 Patients at the Time of Presentation: A Cross-sectional Study. Indian J Crit Care Med 2021;25(1):85-87.

SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients.

How to cite this article: Kayina CA, Maitra S, Anand RK, Ray BR, Baidya DK, Subramaniam R. SARS-CoV-2 Infection Presenting with Hyperglycemia and Ketosis: A Case Series of Three Diabetic Patients. Indian J Crit Care Med 2020;24(11):1141-1142.

Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients.

How to cite this article: Nair PR, Maitra S, Ray BR, Anand RK, Baidya DK, Subramaniam R. Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Predictors of the Early Requirement of Mechanical Ventilation in COVID-19 Patients. Indian J Crit Care Med 2020;24(11):1143-1144.

Internal jugular vein cannulation: A comparison of three techniques.

CONTEXT: Ultrasound-guided internal jugular vein (IJV) cannulation is known for increasing success rate and decreasing rate of complications. The ultrasound image can be used as a real time image during cannulation or to prelocate the IJV before attempting cannulation. AIMS: This study compares both the ultrasound-guided technique with the classical anatomical landmark technique (central approach) for right IJV cannulation in terms of success rate, complications, and time for cannulation. SETTINGS AND DESIGN: A prospective, randomized, observational study was conducted at a tertiary care hospital. MATERIAL AND METHODS: One hundred twenty patients requiring IJV cannulation were included in this study and were randomly allocated in three groups. Number of attempts, success rate, venous access time, catheterization time, and complications were observed in each group. STATISTICAL ANALYSIS USED: Statistical analysis was performed using STATA-9 software. Demographic data were compared using one-way analysis of variance (ANOVA). Nonparametric data were compared using the Kruskall-Wallis test, and multiple comparisons were done applying The Mann-Whitney test for individual pairs of groups. Nominal data were compared by applying the Chi-square test and Fisher exact test. RESULTS: Successful cannulation (≤3 attempt) was achieved in 90.83% of patients without any statistical significant difference between the groups. Venous access time and catheterization time was found to be significantly less in both the ultrasound groups than the anatomical land mark group. Number of attempts and success in first attempt was similar between the groups. CONCLUSIONS: Both the ultrasound techniques are found to be better than the anatomical landmark technique. Further, ultrasound-guided prelocation was found to be as effective as ultrasound guided real-time imaging technique for right IJV cannulation.

Comparison of ultrasound guided dorsal radial artery cannulation and conventional radial artery cannulation at the volar aspect of wrist: A pilot randomized controlled trial.

BACKGROUND: Distal radial artery cannulation at the "anatomical snuffbox" carries several theoretical advantages over conventional radial arterial cannulation at the wrist. However, these two techniques have not been evaluated in perioperative settings. METHODS: In this randomized controlled trial, n = 200 patients requiring arterial cannulation for perioperative monitoring were recruited. Patients were randomized to either ultrasound guided distal radial artery cannulation group (group D) or ultrasound guided conventional radial artery cannulation group (group W). Primary outcome of this study was first attempt cannulation success rate. RESULTS: First attempt cannulation success rate was significantly lower in distal radial artery cannulation (57% in group D and 77% in group W; p = 0.003). Use of alternative cannulation site was significantly higher in group D when compared to group W (p = 0.015) and number of attempts for successful cannulation was significantly higher in group D when compared to group W (p = 0.015). None of the patients in any group developed thrombosis and related complications and intraoperative catheter dislodgement. Time to puncture the artery (p < 0.0001), total cannulation time (p < 0.0001), and actual catheter insertion time (p < 0.0001) were significantly higher in group D in comparison to group W. CONCLUSION: Distal radial artery cannulation was associated with lower first attempt cannulation success rate and requires longer time to perform. As distal radial artery is a new technique, further studies are required in different clinical settings.

Comparative evaluation of intraoperative dexmedetomidine versus lidocaine for reducing postoperative cognitive decline in the elderly: a prospective randomized controlled trial.

INTRODUCTION: Neuroinflammation, neuronal cytotoxicity, and apoptosis due to exposure to anaesthetic agents are often implicated in postoperative cognitive dysfunction (POCD). Lidocaine and dexmedetomidine have been shown to suppress the neuron-specific markers of inflammation, and we aimed to compare their neuroprotective efficacy in elderly patients. MATERIAL AND METHODS: This prospective randomized control study compared the incidence of POCD in ASA I/II patients aged 60 to 80 years without any history of substance abuse or any disorder affecting cognition. Dexmedetomidine and lidocaine were administered intraoperatively, and their effects on POCD were correlated with serum levels of IL-1, IL-6, TNF-a, amyloid-ß, and S100 on postoperative day 3. POCD was assessed by the Stroop test, Trail making test-B, Porteus Maze test, Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) on the day before surgery and the third postoperative day, along with blood samples. RESULTS: Demographic parameters, anaesthesia duration, exposure to anaesthetic gases, intraoperative opioid use, and blood transfusion were similar in the lidocaine ( n = 31) and dexmedetomidine ( n = 29) groups. The incidence of POCD was 29.03% in the lidocaine group and 24.1% in the dexmedetomidine group ( P = 0.77). On postoperative day 3, IL-1 levels increased by 449% with lidocaine and 202% with dexmedetomidine ( P = 0.03). TNF-a, IL-6, and S-100ß levels increased similarly in both groups. There was no significant correlation between percentage changes in neuropsychological tests and biomarkers. CONCLUSIONS: There was no significant difference in the incidence of POCD, but dexmedetomidine had a better anti-inflammatory effect in terms of lesser rise of postoperative IL-1 compared to lidocaine.

Association between intraoperative starch use and postoperative kidney dysfunction in patients undergoing major gastro-intestinal surgery: A propensity score-matched analysis.

BACKGROUND: The impact of intraoperative starch-based fluid therapy on postoperative kidney dysfunction in patients undergoing major abdominal surgery is uncertain. Low molecular weight starch is expected to cause less postoperative kidney dysfunction. METHODS: This retrospective study evaluated the impact of intraoperative 6% hydroxyethyl starch on postoperative renal dysfunction. The primary outcome of this study was postoperative acute kidney injury as per KDIGO definition within 72 hours of surgery. RESULTS: This study analysed data from 461 patients with a median (interquartile range) age of 45 (33-58) years, and 48.2% of all patients were female. The proportion (95% confidence interval) of patients who developed acute kidney injury was 0.18 (0.14-0.21); 62.9% of patients had acute kidney injury stage I, 32% had acute kidney injury stage II, and the rest were acute kidney injury stage III. In the propensity score-matched sample, the average treatment effect of intraoperative colloid use on postoperative serum creatinine at day 3 (p = 0.32), duration of postoperative intensive care unit stay (p = 0.97), duration of hospital stay (p = 0.37), postoperative worst international normalised ratio (p = 0.92), and postoperative transfusion requirement (p = 0.40) were not statistically significant. CONCLUSION: Intraoperative use of low molecular weight hydroxyethyl starch use was not associated with postoperative kidney dysfunction and coagulopathy in adult patients undergoing major open abdominal surgery.

Subphenotypes of SARS-CoV-2-Associated ARDS Overlap Each Other: A Retrospective Analysis.

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus-associated pneumonia and acute respiratory distress syndrome (ARDS) were often associated with hyperinflammation and elevation of several serum inflammatory markers but usually less than what is observed in non-coronavirus disease (COVID) ARDS. Elevated inflammatory markers such as C-reactive protein, interleukin (IL)-6, etc., are associated with severe infection. This study identified subphenotypes of COVID-19 ARDS patients by latent profile analysis in a cohort of Indian patients. Methods Data of n = 233 adult Indian patients with laboratory-confirmed SARS-CoV-2 infection admitted to a tertiary care teaching hospital were analyzed in this retrospective study. Only patients with acute respiratory failure (defined by partial pressure of oxygen/fraction of inspired oxygen ratio < 200 mm Hg) and chest X-ray showing bilateral infiltrates were included. Results The patients' mean (standard deviation) age was 53.3 (14.9) years, and 62% were male. A two subphenotypic model was formulated based on the lowest Bayesian information criterion. Neutrophil-to-lymphocyte ratio and serum IL-6 were latent variables in that model (entropy 0.91). The second phenotype (hyperinflammatory) had lower platelet count ( p = 0.02), higher serum creatinine ( p = 0.004), higher C-reactive protein ( p = 0.001), higher ferritin ( p < 0.001), and serum lactate dehydrogenase ( p = 0.009). Age-adjusted hospital mortality ( p = 0.007), duration of hospital stay ( p < 0.001), and duration of intensive care unit stay ( p < 0.001) were significantly higher in the second subphenotype. Conclusion Two distinct but overlapping subphenotypes were identified in SARS-CoV-2-associated respiratory failure. Hyperinflammatory subphenotype was associated with significantly poor short-term outcomes.

Effectiveness of enteral ivabradine for heart rate control in septic shock: A randomised controlled trial.

Persistent tachycardia in patients with septic shock predicts poor outcome. This study sought to investigate the effect of the cardiac pacemaker current inhibitor ivabradine on heart rate and cardio-circulatory function in patients with septic shock. After informed consent, 60 patients with septic shock and persistent tachycardia (heart rate >95 /minute) were prospectively randomly assigned to receive either standard therapy for septic shock (group S) or standard therapy along with enteral ivabradine (group I) for the initial 96 hours after enrolment. Primary outcome was the difference in heart rate between the two groups during the first 96 hours. Secondary outcomes included the effect of ivabradine on haemodynamic, oxygenation, myocardial function and organ function parameters, incidence of adverse events and 30-day overall survival. Heart rate was lower in group I compared to group S (median difference in area under the curve -25.6 (95% confidence intervals -31.4 to -15.9) /minute; P <0.001). Vasopressor requirements, blood lactate levels, Sequential Organ Failure Assessment scores and E/e' ratio were lower in group I compared to group S. Stroke volume index and ejection fraction were higher in group I while cardiac index and oxygen delivery parameters were maintained similar to group S. There was no difference in 30-day mortality or in the incidence of serious adverse events. Enteral ivabradine is effective in reducing heart rate, and improving haemodynamic parameters and cardiac function in patients with septic shock and persistent tachycardia, without increasing the incidence of adverse events.

Effect of driving pressure-guided positive end-expiratory pressure (PEEP) titration on postoperative lung atelectasis in adult patients undergoing elective major abdominal surgery: A randomized controlled trial.

BACKGROUND: As respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions. METHODS: Eighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmH2O was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally. RESULTS: Mean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5-8] vs 4 [2-6] before extubation and 8 [6-9] vs 5 [3-7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%-1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO2 >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups. CONCLUSION: Intraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications.