Longitudinal Assessment of ROX and HACOR Scores to Predict Non-Invasive Ventilation Failure in Patients with SARS-CoV-2 Pneumonia.

Introduction: NIV (Non-invasive ventilation) and HFNC (High Flow nasal cannula) are being used in patients with acute respiratory failure. HACOR score has been exclusively calculated for patients on NIV, on other hand ROX index is being used for patients on HFNC. This is first study where ROX index has been used in patients on NIV to predict failure. Aim of the study: This study investigates the comparative diagnostic performance of HACOR score and ROX index to predict NIV failure. Methods: We performed a retrospective cohort study of non-invasively ventilated COVID-19 patients admitted between 1st April 2020 to 15th June 2021 to ICU of a tertiary care teaching hospital located in Central India. We assessed factors responsible for NIV failure, and whether these scores HACOR/ROX index have discriminative capacity to predict risk of invasive mechanical ventilation. Results: Of the 441 patients included in the current study, 179 (40.5%) recovered, while remaining 262 (59.4%) had NIV failure. On multivariable analysis, ROX index > 4.47 was found protective for NIV-failure (OR 0.15 (95% CI 0.03-0.23; p<0.001). Age > 60 years and SOFA score were other significant independent predictors of NIV-failure. The AUC for prediction of failure rises from 0.84 to 0.94 from day 1 to day 3 for ROX index and from 0.79 to 0.92 for HACOR score in the same period, hence ROX score was non-inferior to HACOR score in current study. DeLong's test for two correlated ROC curves had insignificant difference expect day-1 (D1: 0.03 to 0.08; p=3.191e-05, D2: -0.002 to 0.02; p = 0.2671, D3: -0.003 to 0.04; p= 0.1065). Conclusion: ROX score of 4.47 at day-3 consists of good discriminatory capacity to predict NIV failure. Considering its non-inferiority to HACOR score, the ROX score can be used in patients with acute respiratory failure who are on NIV.

Predictors of thirty-day mortality among patients with blood stream infection with WHO priority pathogens: single centre exploratory study from a referral teaching hospital in central India.

Background and Objectives: Bloodstream infection (BSI) is defined by the presence of viable microorganisms in the bloodstream. BSI is one of the major causes of sepsis and subsequent adverse clinical outcomes all across the globe. The present study was undertaken to identify clinico-epidemio-microbiological variables associated with 30-day mortality in patients having BSI with WHO priority pathogens. Materials and Methods: The study was conducted at a public sector tertiary care institute in central India from April 2019 to March 2021. Blood samples collected from patients with clinical suspicion of sepsis, were processed by automated bacterial culture system and interpreted as per CLSI guidelines. Calculated sample size was 150. Data was analyzed by R software. Results: Respiratory tract infection was the most common source (43.3%) of BSI, followed by the gastrointestinal (20%) and urinary tract (18.7%). Among the patients, 33% required invasive mechanical ventilation, and 31% required inotropes. Diabetes mellitus (DM) was the most common co-morbidity (34%). The incidence of multi-drug resistant organisms (MDRO) was 59.3%. Escherichia coli was the most commonly (24%) isolated organism, followed by Klebsiella pneumoniae (17.3%) and Acinetobacter baumannii (16%). Conclusion: Higher age, higher qSOFA score / SIRS score / mean SOFA score at presentation had higher mortality. Use of mechanical ventilation and inotropes during treatment and isolation of critical category organisms of WPP and multi drug resistant organisms were independent 30-day mortality predictors.

A multicentre, double-blind, placebo-controlled randomized trial of Mycobacterium w in critically ill patients with COVID-19 (ARMY-2).

BACKGROUND: Mycobacterium w (Mw), an immunomodulator, resulted in better clinical status in severe coronavirus infectious disease 19 (COVID-19) but no survival benefit in a previous study. Herein, we investigate whether Mw could improve clinical outcomes and survival in COVID-19. MATERIALS AND METHODS: In a multicentric, randomized, double-blind, parallel-group, placebo-controlled trial, we randomized hospitalized subjects with severe COVID-19 to receive either 0.3 mL/day of Mw intradermally or a matching placebo for three consecutive days. The primary outcome was 28-day mortality. The co-primary outcome was the distribution of clinical status assessed on a seven-point ordinal scale ranging from discharged (category 1) to death (category 7) on study days 14, 21, and 28. The key secondary outcomes were the change in sequential organ failure assessment (SOFA) score on days 7 and 14 compared to the baseline, treatment-emergent adverse events, and others. RESULTS: We included 273 subjects (136 Mw, 137 placebo). The use of Mw did not improve 28-day survival (Mw vs. placebo, 18 [13.2%] vs. 12 [8.8%], P = 0.259) or the clinical status on days 14 (odds ratio [OR], 1.33; 95% confidence intervals [CI], 0.79-2.3), 21 (OR, 1.49; 95% CI, 0.83-2.7) or 28 (OR, 1.49; 95% CI, 0.79-2.8) between the two study arms. There was no difference in the delta SOFA score or other secondary outcomes between the two groups. We observed higher injection site reactions with Mw. CONCLUSION: Mw did not reduce 28-day mortality or improve clinical status on days 14, 21 and 28 compared to placebo in patients with severe COVID-19. [Trial identifier: CTRI/2020/04/024846].

Postoperative Outcomes After Emergency Surgery in COVID-19 Patients: An Ambispective Matched Cohort Study.

Purpose There is limited data from the Indian subcontinent regarding the surgical outcomes of coronavirus disease (COVID-19) patients. In this observational study, we aimed to evaluate the postoperative outcomes after emergency surgery in COVID-19 patients compared to concurrent age and gender-matched controls. We also sought to analyze the possible predictors of postoperative mortality in COVID-19 patients. Methods This matched cohort study was conducted in a tertiary care teaching hospital in central India, between 1st July 2021 and 30th June 2022. COVID-19-positive patients undergoing emergency surgery under anesthesia were recruited as cases. Age and gender-matched COVID-19-negative patients undergoing a similar nature of surgery in the same period served as concurrent controls. The cases and controls were compared for the 30-day mortality and perioperative complications. Results The COVID-19-positive surgical cohort had a 12.3 times greater 30-day postoperative overall mortality risk as compared to a matched cohort of patients with a negative COVID-19 test. A positive COVID-19 status was associated with more postoperative complications of acute respiratory distress syndrome (ARDS), sepsis, shock, and persistent hyperglycemia. On analysis of predictors of mortality, the presence of preoperative dyspnea, ARDS, American Society of Anesthesiologists Physical Status (ASA-PS) Class IIIE/IVE, increase in sequential organ failure assessment (SOFA) score, Quick SOFA>1, higher creatinine, bilirubin, and lower albumin were observed to be associated with increased mortality. Conclusions Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients undergoing emergency surgery is significantly associated with higher postoperative complications and increased 30-day postoperative mortality.

Comparison of Opioid-Based Versus Opioid-Sparing Anesthesia in Patients Undergoing Glioma Surgery.

Background In the neurosurgical population, opioids may cause respiratory depression, leading to hypercapnia, increased cerebral blood flow (CBF), and ultimately increased intracranial pressure (ICP), which can mask early signs of intracranial complications and delayed emergence. This study was designed to compare perioperative hemodynamic stability, analgesia, and recovery parameters in opioid-based (fentanyl) general anesthesia versus opioid-sparing (dexmedetomidine) general anesthesia in patients undergoing glioma surgeries. Methodology This prospective observational comparative study compared 52 patients in two groups. Twenty-six (50%) patients in group F received Inj. fentanyl IV (intravenous; bolus 2 mcg/kg 10 minutes before induction and then infusion 1 mcg/kg/hour till 30 minutes before skin closure), whereas 26 (50%) patients in group D received Inj. dexmedetomidine IV (0.5 mcg/kg infusion 10 minutes before induction and then maintenance with a 0.5 mcg/kg/hour infusion till 30 minutes before skin closure). Perioperative heart rate (HR), mean arterial pressure (MAP), Numerical Rating Scale for Pain (NRS) assessment and postoperative emergence time, modified Aldrete score, patient satisfaction, and surgeon satisfaction score were estimated and compared in both groups. Results The mean HR was less in group D compared to group F at following time points - 10 minutes after infusion (P = 0.006), laryngoscopy and intubation (P = 0.003), pinning of the skull (P < 0.001), one hour after dura opening (P = 0.007), two hours after dura opening (P = 0.006), five minutes after extubation (P < 0.001), and 30 minutes after extubation (P = 0.011). MAP was lower in group D compared to group F at the following time intervals: 10 minutes after infusion (P = 0.008), five minutes after extubation (P = 0.007), 30 minutes after extubation (P < 0.001), and one hour after extubation (P = 0.023). A significant decrease in emergence time in group D compared to group F (P < 0.001) was noted. NRS was lower in group D at eight hours (P = 0.005) and 12 hours (P < 0.001) post-extubation. Conclusions Dexmedetomidine can be used as an alternative to fentanyl in terms of perioperative hemodynamic stability, perioperative analgesia, smooth early recovery from anesthesia, patient satisfaction, and surgeon satisfaction.

Impact of Vertical and Horizontal Skin Incisions on Outcome Measures in Tracheostomies.

Tracheostomy is a life-saving procedure in which an opening is created in the anterior wall of the trachea. Different skin incision types are administered in tracheostomy procedures, predominantly vertical and horizontal. Various literature on the skin incision types in tracheostomy had contradictory findings, with different studies observing that one skin incision type had better outcomes than its counterpart. Hence the objective of this study was to compare the outcomes associated with vertical and horizontal skin incisions in patients undergoing tracheostomy. Method The present study assessed the outcome measures between the two incision types (vertical and horizontal) in tracheostomy. A prospective longitudinal study was done based on an academic tertiary hospital in Bhopal, Madhya Pradesh. Participants above 18 years who underwent tracheostomy were enrolled in the study and followed up over six months during intraoperative, immediate, within seven days, and long-term periods. Result In intraoperative complications, bleeding was most common (n = 15, 16.7%), followed by passage of tube into false tract (n = 6, 6.7%) and saturation drop (n = 2, 2.2%). Immediate complications comprised T-tube blockage (n = 4, 4.4%) and bleeding (n = 1, 1.1%). Complications within seven days occurred only in the horizontal group in which stomal site ulceration (n = 4, 6.7%) and delayed bleeding (n = 2, 3.3%) was seen, and one participant had unintended decannulation. In the long term, complications observed were stomal granulation (n = 9, 19.1%), dysphagia (n = 7, 14.9%), and unintended decannulation (n = 4, 8.5%). Conclusion In the current study, the most common intraoperative complication was bleeding, the immediate complication was tube dislodgement, and tracheostomy site ulcer was the most common complication within seven days, similar to the literature findings.

Study on Assessing Serum Lactate as an Early Prognostic Determinant in Sepsis Outcome.

BACKGROUND: Apart from being one of the main causes of death, sepsis has recently been considered a chronic critical illness. This has resulted in the implementation of standard treatment recommendations for management, with a focus on the initial phases of treatment. Early detection of sepsis and prognostic grading are now crucial for management. Despite the fact that sequential organ failure assessment score (SOFA), acute physiology, and chronic health evaluation II score (APACHE II) have been widely used in sepsis, there have been shortcomings such as feasibility and many lab parameters involved. As a result, this study was conducted to evaluate the role of serum lactate as an early marker and to compare it to current scoring systems for determining the outcome of sepsis. METHODS AND MATERIAL: This was an observational hospital-based study with 60 individuals recruited over a one-year period from July 2021 to June 2022. Serum lactate, as well as the other laboratory tests required for the computation of SOFA and APACHE II, were performed. The baseline data and the trend of lactate vs standard scores were examined in the first 48 hours, as well as their impact on outcomes in sepsis patients (as measured by mortality rates- patients were followed up for 28 days). The diagnostic accuracy of these scores was calculated using the area under the receiver operating characteristic (ROC) curve (AUROC). RESULTS: The study enrolled 60 people out of a total of 162 people who were screened. The mean age was 48.4 years, with the highest mortality occurring between the ages of 41 and 60 years. Of the total 60 participants, 34 (56.6%) were male, with the respiratory tract being the most common source of infection for sepsis (36.67%). In our study, 46 patients survived while 14 patients died. The mean lactate on admission was 3.1 mmol/L in survivors and 4 mmol/L in non-survivors, whereas APACHE II was 9 and 12.36, and SOFA was 3.63 and 7.79, respectively, in survivors and non-survivors. Serum lactate and prognosis scores were compared in the survivor and non-survivor groups, and the difference in diagnostic accuracy was found to be statistically significant. CONCLUSIONS: Serum lactate can be used as an early recognition marker in patients with a probability of sepsis and serial lactate monitoring has a similar diagnostic accuracy in predicting outcomes as the traditional prognostic scoring systems SOFA and APACHE II.

Anti-SRP-positive necrotising myopathy concurrent with breast malignancy.

Anti-signal recognition particle (anti-SRP)-positive necrotising myopathy causes severe progressive proximal weakness with a propensity to involve pharyngeal, laryngeal and respiratory muscles. It is one of the aggressive inflammatory myopathies. First-line treatment is with high-dose steroids followed by other immunosuppressants, but this conventional therapy is often ineffective. Second-line treatment involves use of either rituximab or intravenous immunonoglobulin (IVIG). Anti-SRP-positive necrotising myopathy is frequently treated as refractory myositis due to its poor responsiveness to steroid monotherapy and conventional immunosuppressive therapies. Therefore, anti-SRP-positive necrotising myopathy differs from immune-mediated myopathy. Although anti-SRP autoantibody is found in only 4-6% of patients with idiopathic inflammatory myopathy, the actual proportion of patients with refractory anti-SRP-positive necrotising myopathy is unknown. We describe a patient with multiple comorbidities who had subacute-onset anti-SRP-positive immune-mediated necrotising myopathy (IMNM). After failing steroids, methotrexate and IVIG therapy, she made a considerable recovery with rituximab. She was later diagnosed to have breast malignancy. Malignancy-associated anti-SRP-positive IMNM is rarely reported.

Adult tetanus is not gone yet, but could be ready to leave: A case-series from central India.

Introduction: Adult tetanus is a neurotoxin mediated infectious disease, that continues to be seen despite availability of a highly efficacious vaccine. In India population-based burden estimates for adult tetanus are not available. Elimination of neonatal and maternal tetanus from India was achieved in 2015 with DPT (diphtheria, pertusis, and tetanus) vaccine during childhood and tetanus toxoid (TT) during antenatal care. Vaccine coverage in adults is uneven. While pregnant women receive the vaccine as part of ante-natal care, booster dose coverage in all other non-pregnant women and men is poor. Case report: We describe four cases of adult tetanus that presented to our tertiary care hospital in central India. Out of four cases, two were homemakers, one was a farmer, another was a student. Three of them were not aware regarding primary tetanus vaccination and none of the four received any booster dosages of tetanus vaccine. Conclusions: These cases highlight complexity of disease management and reinforce the need for adult booster immunization against tetanus.

A prospective study evaluating the effect of a "Diagnostic Stewardship Care-Bundle" for automated blood culture diagnostics.

OBJECTIVES: We prospectively implemented a diagnostic stewardship care-bundle checklist, 'Sepsis-48 DSB', with the aim of reducing intervening duration of key steps of automated blood culture diagnostics (aBCD). METHODS: Sepsis-48 DSB was implemented for automated blood culture bottles (BCBs) received from adult intensive care units (AICUs) during the intervention period (P2; July 2020-June 2021) and intervening durations were compared with those during the retrospective, pre-intervention period (P1; March-June 2020). During both periods, provisional blood culture reports (pBCR) were issued wherein direct microbial identification (dID) was performed in BCBs with Gram-negatives by directly inoculating conventional biochemical tests and direct antimicrobial susceptibility testing (dAST) using EUCAST RAST method. The results were compared with the standard of care (SoC) method (i.e. full incubation followed by identification and AST by VITEKⓇ-2 Compact). RESULTS: During P2, significant reductions in loading time (LT; median: 63.5 vs. 32 minutes, P < 0.001), time to dID+dAST performance (TTD; 186 vs. 115 minutes, P = 0.0018) and an increase in compliance to bundle targets (LT ≤45: 44% vs. 66%, P = 0.006 and TTD ≤120: 34% vs. 51.7%, P = 0.03) were observed. Using dID+dAST method, results were read 694 minutes earlier than SoC method. Of 176 pBCR, 165 (94%) were concordant with SoC in microbial identification of species. Categorical agreement for any drug-bug combination was 92.7% (1079/1164) and corresponding major, very major, and minor error rates were 8.8% (19/216), 4.9% (45/921), and 1.8% (21/1164), respectively. CONCLUSION: The 'diagnostic stewardship care-bundle' strategy was successfully implemented with considerable diagnostic accuracy leading to significant reductions in duration of targeted steps of aBCD.

Accuracy of Sonographic Airway Parameters in Difficult Laryngoscopy Prediction: A Prospective Observational Cohort Study from Central India.

Objective: Though airway ultrasonography (USG) is used to assess difficult laryngoscopy (DL), there is still ambiguity about approach followed and parameters assessed. There is need of a simple, stepwise sonographic assessment with clearly defined parameters for DL prediction. The primary objective of this study was to find diagnostic accuracy of sonographic parameters measured by a stepwise Airway-USG in DL prediction (DLP). Methods: This prospective, observational cohort study was done in 217 elective surgical adult patients administered general anaesthesia with tracheal intubation using conventional laryngoscopy from 1st May 2019 to 31st July 2020, after ethical approval. A sagittal Airway-USG was done using 2-6 Hz transducer in three steps specifying probe placement and head position. Demographic, clinical and Airway-USG measurements were noted. Correlation of the clinical/sonographic parameters was made with Cormack-Lehane score on DL. After receiver operating characteristic curve plotting, the sensitivity, specificity, positive predictive value, negative predictive value (NPV) of DL was calculated for each parameter using open-epi software. Results: DL was observed in 19/217 patients. Airway-USG parameters of skin to epiglottis distance >2.45 cm, hyomental distance with head extension <5.13 cm, head neutral <4.5 cm, their ratio <1.18, maximum tongue thickness >3.93 cm and maximum skin to tongue distance >5.45 cm were statistically significant in predicting DL. DLP score with presence of >3 positive parameters showed 98% specificity, 98% NPV and 96% diagnostic accuracy to predict DL. Conclusion: DLP score derived from Airway-USG may be used as a screening and diagnostic tool for DL.

Melioidosis as a Mystique Infection: A Study From Central India.

INTRODUCTION: Melioidosis is caused by the Gram-negative bacilli Burkholderia pseudomallei, which is found in contaminated water and soil and spreads via inhalation, inoculation, and ingestion. Melioidosis manifests diversely in immunocompetent and immunocompromised patients, ranging from asymptomatic to life-threatening respiratory distress, septic shock, localized tissue infection, necrotizing pneumonia, and soft organ abscesses.  Methods: An 18-month observational study was conducted at a tertiary center in central India among various confirmed melioidosis cases, with data gathered and analyzed. Aerobic culture and sensitivity were performed in all studied cases, either in blood/body fluid/localized collection - using blood agar media for the culture and disc diffusion method on Mueller Hinton agar for sensitivity. Other tests, such as radiological imaging, were conducted according to symptoms and signs of localized infection. RESULTS: The melioidosis cases under study were compared on various clinical/presenting parameters. Melioidosis has a variety of risk factors, but we found that, in India, diabetic patients are at a higher risk of this infection, particularly fatal forms, as all of the patients in our study were diabetic. Melioidosis is known to have joint involvement, either as a source of infection or later in the course of the disease. All cases were successfully treated with antibiotics and surgical procedures, demonstrating the significance of determining disease etiology, early diagnosis, and rapid early management. CONCLUSION:  Melioidosis is a potentially fatal disease, particularly in diabetics, with a wide range of symptoms and complications. Physicians face a variety of challenges, including clinical symptoms resembling other chronic illnesses, such as tuberculosis, delays in laboratory confirmation, underdiagnosis, reduced reporting, and a lack of suspicion. Because there are very little data and it is a seldom reported infection from central India, we are publishing a study on seven melioidosis patients.

A prospective study evaluating the effect of a 'Diagnostic Stewardship Care-Bundle' for automated blood culture diagnostics.

OBJECTIVES: We prospectively implemented a diagnostic stewardship care-bundle checklist, 'Sepsis-48 DSB', with the aim of reducing intervening duration of key steps of automated blood culture diagnostics (aBCD). METHODS: Sepsis-48 DSB was implemented for automated blood culture bottles (BCBs) received from adult intensive care units (AICUs) during the intervention period (P2; July 2020-June 2021) and intervening durations were compared with those during the retrospective, pre-intervention period (P1; March-June 2020). During both periods, provisional blood culture reports (pBCR) were issued wherein direct microbial identification (dID) was performed in BCBs with Gram-negatives by directly inoculating conventional biochemical tests and direct antimicrobial susceptibility testing (dAST) using EUCAST RAST method. The results were compared with the standard of care (SoC) method (i.e. full incubation followed by identification and AST by VITEKⓇ-2 Compact). RESULTS: During P2, significant reductions in loading time (LT) [median: 63.5 vs. 32 minutes, P < 0.001], time to dID+dAST performance (TTD) [186 vs. 115 minutes, P = 0.0018] and an increase in compliance to bundle targets [LT ≤45: 44% vs. 66%, P = 0.006 and TTD ≤120: 34% vs. 51.7%, P = 0.03] were observed. Using dID+dAST method, results were read 694 minutes earlier than SoC method. Of 176 pBCR, 165 (94%) were concordant with SoC in microbial identification of species. Categorical agreement for any drug-bug combination was 92.7% (1079/1164) and corresponding major, very major, and minor error rates were 8.8% (19/216), 4.9% (45/921), and 1.8% (21/1164), respectively. CONCLUSION: The 'diagnostic stewardship care-bundle' strategy was successfully implemented with considerable diagnostic accuracy leading to significant reductions in duration of targeted steps of aBCD.

Antibiotic associated diarrhea due to Clostridioides difficile in a tertiary care teaching hospital, central India.

Background and Objectives: The misuse of antibiotics in recent years has led to an increase in antibiotic associated diarrheas (AAD). Out of several implicated pathogens, Clostridioides difficile is responsible for causing 15-25% of all cases of AAD. However, it has remained under diagnosed for a long time. The current study is planned to explore prevalence of C. difficile amongst AAD patients and to study clinical presentation and associated risk factors. Materials and Methods: Hospital based cross sectional study conducted in patients above 2 years of age. Diagnosis of C. difficile was done by two modalities i.e. glutamate dehydrogenase test followed by toxin detection using enzyme immunoassay and stool culture followed by toxin gene detection. Results: Twelve of 65 patients (18.4%) were positive for C. difficile. Maximum cases were found in younger age group. Abdominal pain and fever were most common complaints. 12 (18.4%) out of 65 study subjects were found to be positive by ELISA. 2/65 (3%) patients were positive for culture with presence of only tcdB gene. Ceftriaxone was the most commonly used antibiotic (25%). Conclusion: C. difficile is significant pathogen implicated in AAD with a prevalence rate of 18.4%. GDH antigen detection followed by Toxin A/B ELISA for C. difficile yielded better detection rate as compared to stool culture.

Aetiologies of Acute Complications in Autoimmune Rheumatologic Diseases: A Hospital-Based Cross-Sectional Study.

BACKGROUND: Autoimmune rheumatic diseases (ARD) present unique challenges in clinical practice. Many of them present in medical emergencies in an unstable state and need immediate evaluation for further plans of action. The clinical conundrum is to distinguish between sepsis, disease flare, or Addisonian crisis (AC) (secondary to steroid withdrawal). This may be further complicated by overlapping clinical features like shock/fever and the coexistence of a combination of the above pathophysiologic mechanisms (e.g. AC with sepsis or AC with disease flare). The known biomarkers may not perform optimally to distinguish them and additional supportive investigations like imaging, cultures, autoimmune serological markers, etc. are needed. Ultimately the boundaries between "the art of medicine" and "the science of medicine" may get blurred, as the established literature evidence falls short and the expert opinion is needed in a time-sensitive manner. In this pragmatic study, researchers have attempted to explore the presentation of rheumatologic emergencies on the above three differentials (sepsis, disease flare, and AC). MATERIALS AND METHODS:  In this hospital-based cross-sectional study, adult patients (age >18 years) with ARD who had unplanned hospital admission due to acute worsening were enrolled. This study was conducted over one year, after getting the Institutional Human Ethics Committee's approval. All relevant hematological, immunological, and hormonal parameters (specifically morning cortisol) were collected and analyzed. The aim was to find the individual and combined prevalence of sepsis, disease flare, or AC in this study group. RESULTS: Forty-one patients were analyzed, with females in the majority (95%) and the dominant age group being 26-49 years (56.1%). A majority had a diagnosis of rheumatoid arthritis (RA) (56.1%) or systemic lupus erythematosus (SLE) (31.7%); the rest were other connective tissue diseases (12.2%). High-risk Quick Sequential Organ Failure Assessment score (qSOFA) score 2-3 was present in 29.3% while the rest had low-risk scores (qSOFA score 0-1). Thirty-two percent had severe disease activity, 46% had mild to moderate disease activity, and 22% of patients had no disease activity. While 78% of patients had low procalcitonin (PCT) values <0.5 microgm/L (low risk of sepsis), 15% had <20 microgm/L, and 7% percentage of patients had serum levels >20 microgm/L (high risk of sepsis). A total of 73.2% of patients had no evidence of infection while 26.8% had either microbiological/radiological evidence of infection. Only 7% of all patients had the presence of an AC. qSOFA scores didn't statistically correlate with a diagnosis of infection or AC but positively correlated with PCT and C-reactive protein (CRP) values. Serum PCT didn't correlate with the presence of infection with statistically significance (p-value 0.217). CONCLUSION: Infections and sepsis are the most important considerations in the emergency presentations of ARDs. Disease flare and AC are also important differentials. Current inflammatory biomarkers like serum CRP and PCT may be less valuable for discriminating between infectious and non-infectious sepsis, especially in chronic inflammatory diseases like ARDs. qSOFA scores may have a prognostic role with less discriminant value. Management of ARD emergencies needs better biomarkers and more research is warranted.

Accuracy of Critical Care Ultrasonography Plus Arterial Blood Gas Analysis Based Algorithm in Diagnosing Aetiology of Acute Respiratory Failure.

Introduction: Lung ultrasound when used in isolation, usually misses out metabolic causes of dyspnoea and differentiating acute exacerbation of COPD from pneumonia and pulmonary embolism is difficult, hence we thought of combining critical care ultrasonography (CCUS) with arterial blood gas analysis (ABG). Aim of the study: The objective of this study was to estimate accuracy of Critical Care Ultrasonography (CCUS) plus Arterial blood gas (ABG) based algorithm in diagnosing aetiology of dyspnoea. Accuracy of traditional Chest X-ray (CxR) based algorithm was also validated in the following setting. Methods: It was a facility based comparative study, where 174 dyspneic patients were subjected to CCUS plus ABG and CxR based algorithms on admission to ICU. The patients were classified into one of five pathophysiological diagnosis 1) Alveolar( Lung-pneumonia)disorder ; 2) Alveolar (Cardiac-pulmonary edema) disorder; 3) Ventilation with Alveolar defect (COPD) disorder ;4) Perfusion disorder; and 5) Metabolic disorder. We calculated diagnostic test properties of CCUS plus ABG and CXR based algorithm in relation to composite diagnosis and correlated these algorithms for each of the defined pathophysiological diagnosis. Results: The sensitivity of CCUS and ABG based algorithm was 0.85 (95% CI-75.03-92.03) for alveolar (lung) ; 0.94 (95% CI-85.15-98.13) for alveolar (cardiac); 0.83 (95% CI-60.78-94.16) for ventilation with alveolar defect; 0.66 (95% CI-30-90.32) for perfusion defect; 0.63 (95% CI-45.25-77.07) for metabolic disorders.Cohn's kappa correlation coefficient of CCUS plus ABG based algorithm in relation to composite diagnosis was 0.7 for alveolar (lung), 0.85 for alveolar (cardiac), 0.78 for ventilation with alveolar defect, 0.79 for perfusion defect and 0.69 for metabolic disorders. Conclusion: CCUS plus ABG algorithm is highly sensitive and it's agreement with composite diagnosis is far superior. It is a first of it's kind study, where authors have attempted combining two point of care tests and creating an algorithmic approach for timely diagnosis and intervention.

Whether Early Steroid dose is Associated with Lower Mortality in COVID-19 Critically Ill Patients-An Exploratory Chart Review.

INTRODUCTION: Steroids have shown its usefulness in critically ill COVID-19 patients. However, the time of starting steroid and dose tailored to severity remain a matter of inquiry due to still emerging evidences and wide-ranging concerns of benefits and harms. We did a retrospective record analysis in an apex teaching hospital ICU setting to explore optimal doses and duration of steroid therapy which can decrease mortality. METHODS: 114 adults with COVID-19-ARDS admitted to ICU between 20th March-15th August 2020 were included in chart review. We did preliminary exploratory analysis (rooted in steroid therapy matrix categorized by dose and duration) to understand the effect of several covariates on survival. This was followed by univariate and multivariate Cox proportion hazard regression analysis and model diagnostics. RESULTS: Exploratory analysis and visualization indicated age, optimal steroid, severity (measured in P/F) of disease and infection status as potential covariates for survival. Univariate cox regression analysis showed significant positive association of age > 60 years {2.6 (1.5-4.7)} and protective effect of optimum steroid {0.38(0.2-0.72)} on death (hazard) in critically ill patients. Multivariate cox regression analysis after adjusting effect of age showed protective effect of optimum steroid on hazard defined as death {0.46(0.23-0.87), LR = 17.04, (p = 2e-04)}. The concordance was 0.70 and model diagnostics fulfilled the assumption criteria for proportional hazard model. CONCLUSION: Optimal dose steroid as per defined 'optimum' (<24 hours and doses tailored to P/F at presentation) criteria can offer protective effect from mortality which persists after adjusting for age. This protective effect was not found to be negatively influenced by the risk of infection.

Role of Thromboelastography and Thromboelastometry in Predicting Risk of Hypercoagulability and Thrombosis in Critically Ill COVID-19 Patients: A Qualitative Systematic Review.

Thromboelastography and rotational thromboelastometry are the viscoelastic point of care devices that use whole blood samples to assess coagulation and fibrinolysis. These devices give information from initiation of the coagulation cascade, activation of clotting factors to fibrin cross-linking, and contribution of fibrinogen and platelet to clot strength and clot lysis. Viscoelastic point of care tests are well established in hypocoaguable states like trauma, cardiac surgery, liver transplantation, and their use in critical care settings with coronavirus disease 2019 (COVID-19) is not so well-known. We performed a systematic review of studies on thromboelastography and rotational thromboelastometry and their modifications to assess their role in critically ill patients with COVID-19. Inclusion criteria were any kind of studies using thromboelastography or rotational thromboelastometry during coronavirus disease critical illness published in English. Ninety-three articles, from December 1, 2019, to August 31, 2020, were identified in the initial search, out of which 12 articles (a total of 380 patients) satisfied the inclusion and exclusion criteria. Thromboelastography and rotational thromboelastometry were observed to detect the hypercoagulable changes and fibrinolysis shutdown associated with COVID-19. Hypercoagulability is associated with an increased risk of venous thrombosis and micro-thrombosis. This review identifies the role of thromboelastography and rotational thromboelastometry in studying the mechanisms contributing to coagulopathy and incidence of thrombosis in COVID-19.

Effect of Remdesivir Administration on Occurrence of Major Adverse Cardiac Events in Critically Ill COVID-19 Pneumonia: A Retrospective Observational Study.

Background and objectives: Major adverse cardiac events (MACE) are frequent in coronavirus disease-2019 (COVID-19). Remdesivir is used worldwide for treatment in COVID-19. In this retrospective observational study, our primary objective was to assess the impact of remdesivir administration on the incidence of MACE and associated 28 day survival in critically ill patients admitted for moderate to severe COVID-19 pneumonia. Patients and methods: We analyzed the data of 437 patients admitted in intensive care unit (ICU) and divided them into two groups: R group (received remdesivir at ICU admission) and NR group (nonremdesivir) or based on the occurrence of MACE in ICU. We followed the data until discharge, death, or 28 days postadmission. Our primary objective was to investigate the log-odds of survival with remdesivir administration and a correlation/regression analysis of MACE with remdesivir administration in all included patients. Results: The incidence of MACE was 72 among 437 patients, with 17 (9.3%) patients in R group vs 55 (21.8%) in NR group (p <0.001). On performing correlation analysis between MACE and remdesivir administration, significant correlation coefficient of -0.168 (p = 0.004) was obtained. On regression analysis, the odds ratio for occurrence of MACE with remdesivir administration was 0.362 (regression coefficient: -1.014, p <0.001). It indicates a 64% decrease in the log-odds of MACE and a 16% increase in the log-odds of survival with remdesivir administration. All 72 patients with MACE had expired, suggesting a high mortality risk with cardiac complications. The odds ratio for mortality due to MACE with remdesivir administration was 0.216 (regression coefficient: -1.530, p -<0.001). It indicates a 79% decrease in the log-odds of death due to MACE with remdesivir administration. Conclusion: Our study showed significant reduction in MACE and mortality benefit in patients who received remdesivir in comparison to standard treatment. How to cite this article: Panda R, Singh P, Jain G, Saigal S, Karna ST, Anand A, et al. Effect of Remdesivir Administration on Occurrence of Major Adverse Cardiac Events in Critically Ill COVID-19 Pneumonia: A Retrospective Observational Study. Indian J Crit Care Med 2022;26(9):993-999.

Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India.

Background: The outcomes in critical illness depend on disease severity, practice protocols, workload, and access to care. This study investigates the factors affecting outcomes in mechanically ventilated coronavirus disease-2019 acute respiratory distress syndrome (COVID-19 ARDS) patients admitted in a tertiary teaching hospital intensive care unit (ICU) in Central India with reference to different time periods in pandemic. This is one of the largest series of mechanically ventilated COVID-19 ARDS patients, globally. Methods: This retrospective cohort study classified the entire data into four time periods (Period 1: April 2020 to June 2020; Period 2: July 2020 to September 2020; Period 3: October 2020 to December 2020; and Period 4: January 2021 to April 2021). We performed a multivariable-adjusted analysis to evaluate predictors of mortality, adjusted for baseline-severity, sequential organ failure assessment (SOFA score) and time period. We applied mixed-effect binomial logistic regression to model fixed-effect variables with incremental complexity. Results: Among the 56 survivors (19.4%) out of 288 mechanically ventilated patients, there was an up-gradient of survival proportion (0, 18.2, 17.4, and 28.6%) in four time periods. Symptom-intubation interval (OR 1.16; 95% CI 1.03-1.31) and driving pressures (DPs) (OR 1.17; 95% CI 1.07-1.28) were significant predictors of mortality in the model having minimal AIC and BIC values. Patients aged above 60 years also had a larger effect, but statistically insignificant effect favoring mortality (OR 1.99; 95% CI 0.92-4.27). The most complex but less parsimonious model (with higher AIC/BIC) indicated the protective odds of high steroid on mortality (OR 0.59; 95% CI 0.59-0.82). Conclusion: The outcomes in mechanically ventilated COVID-19 ARDS patients are heterogeneous across time windows and may be affected by the complex interaction of baseline risk and critical care parameters. How to cite this article: Saigal S, Joshi A, Panda R, Goyal A, Kodamanchili S, Anand A, et al. Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India. Indian J Crit Care Med 2022;26(9):1022-1030.