Utilization of NIRS Monitor to Compare the Regional Cerebral Oxygen Saturation Between Dexmedetomidine and Propofol Sedation in Mechanically Ventilated Critically ill Patients with Sepsis- A Prospective Randomized Control Trial.

AIM & BACKGROUND: Delirium frequently occurs in the acute phase of sepsis and is associated with increased ICU and hospital length of stay, duration of mechanical ventilation, and higher mortality rates. We utilized the Near-Infrared Spectroscopy monitor to measure and compare the regional cerebral oxygen saturation in mechanically ventilated patients of sepsis receiving either dexmedetomidine or propofol sedation and assessed the association between delirium and regional cerebral oxygen saturation. METHODS: A single center prospective randomized control trial conducted over a period of two years, 54 patients were included, equally divided between propofol and dexmedetomidine groups. Patients received a blinded study drug, propofol (10 mg/mL) or dexmedetomidine (5 mcg/mL) via infusion pump according to randomization. Infusion rates were adjusted every 10 min based on weight-based titration tables, aiming for target sedation (RASS -2 to 0). Management components included pain monitoring using the CPOT score and delirium assessment using CAM-ICU score. RESULTS: Dexmedetomidine group showed higher mean regional cerebral oxygen saturation as compared to propofol group (P = .036). No significant differences were found in mechanical ventilation or ICU stay durations, delirium-free days, or sedation cessation reasons. Delirium occurred in 36 patients, with lower mean regional cerebral oxygen saturation as compared to non-delirious patients. CONCLUSION: The dexmedetomidine group had higher regional cerebral oxygen saturation compared to the propofol group. Delirious patients showed lower cerebral oxygen saturation than non-delirious patients, suggesting a link between sedation type, cerebral oxygenation, and delirium.CTRI registration: REF/2021/11/048655 N.

Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial.

BACKGROUND: Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY: This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS: Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION: LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.

Comparison of inflammatory markers in low-pressure pneumoperitoneum with deep neuromuscular block versus standard pressure pneumoperitoneum among patients undergoing laparoscopic cholecystectomy for gallstone disease: a randomized control trial.

BACKGROUND: Low-pressure pneumoperitoneum (LPP) is an attempt to improve laparoscopic surgery. Lower pressure causes lesser inflammation and better hemodynamics. There is a lack of literature comparing inflammatory markers in LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB in laparoscopic cholecystectomy. METHODOLOGY: This was a single institutional prospective randomized control trial. Participants included all patients undergoing laparoscopic cholecystectomy for symptomatic gall stone disease. Participants were divided into 2 groups group A and B. Group A-Low-pressure group in which pneumoperitoneum pressure was kept low (8-10 mmHg) with deep Neuromuscular blockade (NMB) and Group B-Normal pressure group (12-14 mmHg) with moderate NMB. A convenience sample size of 80 with 40 in each group was selected. Lab investigations like CBC, LFT, RFT and serum IL-1, IL-6, IL-17, TNF alpha levels were measured at base line and 24 h after surgery and compared using appropriate statistical tests. Other parameters like length of hospital stay, post-operative pain score, conversion rate (low-pressure to standard pressure), and complications were also compared. RESULTS: Eighty participants were analysed with 40 in each group. Baseline characteristics and investigations were statistically similar. Difference (post-operative-pre-operative) of inflammatory markers were compared between both groups. Numerically there was a slightly higher rise in most of the inflammatory markers (TLC, ESR, CRP, IL-6, TNFα) in Group B compared to Group A but not statistically significant. Albumin showed significant fall (p < 0.001) in Group B compared to Group A. Post-operative pain was also significantly less (p < 0.001) in Group A compared to Group B at 6 h and 24 h. There were no differences in length of hospital stay and incidence of complications. There was no conversion from low-pressure to standard pressure. CONCLUSION: Laparoscopic cholecystectomy performed under low-pressure pneumoperitoneum with deep NMB may have lesser inflammation and lesser post-operative pain compared to standard pressure pneumoperitoneum with moderate NMB. Future studies with larger sample size need to be designed to support these findings.

Assessment of Respiratory Muscles, Lung Parenchyma, and Cardiac Function by Ultrasound for Predicting Weaning Failure in Critically Ill Adults: A Prospective Observational Study.

OBJECTIVES: The parasternal intercostal muscle activity, a marker of accessory muscle usage, is found to correlate inversely with the pressure-generating capacity of the diaphragm and level of support of mechanical ventilation. The primary objective of our study was to determine whether the parasternal intercostal muscle thickening fraction (PMTF) measured by ultrasonography can predict weaning. We also evaluated whether addition of lung ultrasound score and echocardiographic assessment can add on to predicting weaning failure. METHODS: This prospective observational study conducted in a mixed medical-surgical intensive care unit, included 60 adult patients who were eligible for a spontaneous breathing trial (SBT) after being invasively mechanically ventilated for more than 48 hours. Ultrasound of respiratory muscles, lung parenchyma, and echocardiographic assessment were performed before and after 120 minutes of SBT. Parasternal intercostal muscles were imaged with a high frequency linear probe on the right second intercostal space 5 cm lateral to the sternal margin. PMTF was calculated as (maximum-minimum thickness)/minimum thickness. RESULTS: Among 60 patients, SBT failure was seen in 11 patients and extubation failed in 8 patients. PMTF (%) was significantly higher in the weaning failure group (13.33 [8.33-19.05]) as compared to patients with successful weaning (6.67 [6.06-11.54]). Diaphragmatic thickening fraction (DTF) correlated inversely to PMTF in patients with weaning failure. A pre-SBT PMTF cut-off of ≥7.7% and post-SBT cut-off of ≥15.38% were good predictors of weaning failure and extubation failure, respectively. CONCLUSIONS: PMTF has good discriminatory power to predict weaning outcomes (area under the receiver operating characteristic curve: 0.74 [0.59-0.88]). Pre-SBT PMTF had similar power as DTF to predict weaning failure.

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

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

Lung Ultrasound Findings in a Patient with Lymphangitic Carcinomatosis.

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

Epidemiology and Long-term Outcomes of Acute Kidney Injury in Adult Patients with Perforation Peritonitis Undergoing Emergency Laparotomy.

Background: Reported incidence of acute kidney injury (AKI) is around 5.0-7.5% of all hospitalized patients, and 40% of them are postoperative patients. Major abdominal surgeries account for 3.1-35% of cases of postoperative AKI in various series. The aim of the study was to identify the incidence and risk factors of AKI in peritonitis patients undergoing emergency laparotomy. Materials and methods: Adult patients aged 18-65 years undergoing emergency laparotomy for perforation peritonitis were included in this prospective observational study. Baseline clinical and laboratory data, intraoperative details and postoperative outcome data (AKI at day 7, length of intensive care unit and hospital stay, and mortality) were recorded. Logistic regression model was constructed to predict AKI at day 7. Results: N = 140 patients were included in this study and 69 patients (49.3%) developed AKI within day 7. Larger volume of crystalloid [OR (95% CI) 1.00 (1.00-1.00); p = 0.012], intraoperative vasopressor use (OR 7.42 (2.41-22.83); p < 0.001), intraoperative blood loss [OR 1.004(1.00-1.01); p = 0.003] and the presence of chronic liver disease (CLD) [OR 22.44 (1.68-299.26); p = 0.019] were risk factors for the development of AKI. Acute kidney injury patients had increased mortality at day 90 (24.6% vs 1.4%; p < 0.001), length of ICU stay (3 days vs 0 days, p < 0.001), and length of hospital stay (11 days vs 7 days; p < 0.001). Conclusion: In peritonitis patients undergoing emergency laparotomy, as many as 49% of patients develop AKI within 1 week. The presence of CLD, intraoperative blood loss, and the use of crystalloids and vasopressor increase the odds of developing AKI. How to cite this article: Priya P, Baidya DK, Anand RK, Ray BR, Khanna P, Krishna A, et al. Epidemiology and Long-term Outcomes of Acute Kidney Injury in Adult Patients with Perforation Peritonitis Undergoing Emergency Laparotomy. Indian J Crit Care Med 2024;28(9):854-858.

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

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

Transfusion trigger in the critically ill with sepsis or septic shock: A prospective study.

Background & objectives: Current practice around transfusion trigger in critically ill sepsis patients is not clear. Moreover, any association of haemoglobin trigger and other transfusion parameters such as age of red blood cells (RBCs) at transfusion and number of units of RBCs transfused with mortality and other adverse outcomes need further assessment. Methods: In this prospective study, patients aged 18-70 yr and admitted to intensive care with a diagnosis of sepsis were included (n=108). Baseline demographic, clinical and laboratory parameters were noted and various transfusion data, i.e., haemoglobin trigger, number of units of RBCs and the age of RBCs were recorded. Following outcome data were collected: 28 and 90 day mortality, duration of mechanical ventilation, vasopressor therapy, intensive care unit (ICU) and hospital stay and requirement of renal replacement therapy. Results: Of the total 108 participants, 78 (72.2%) survived till 28 days and 66 (61.1%) survived till 90 days. Transfusion trigger was 6.9 (6.7-7.1) g/dl [median (interquartile range)]. On multivariable logistic regression analysis, acute physiology and chronic health evaluation (APACHE) II [adjusted odds ratio (aOR) (95% confidence interval {CI}): 0.86 (0.78, 0.96); P=0.005], cumulative fluid balance (CFB) [aOR (95% CI): 0.99 (0.99, 0.99); P=0.005] and admission platelet count [aOR (95% CI): 1.69 (1.01, 2.84); P=0.043] were the predictors of 28 day mortality [model area under the receiver operating characteristics (AUROC) 0.81]. APACHE II [aOR (95% CI): 0.88 (0.81, 0.97); P=0.013], CFB [a OR (95% CI): 0.99977 (0.99962, 0.99993); P=0.044] and transfusion trigger [aOR (95% CI): 3 (1.07, 8.34); P=0.035] were the predictors of 90 day mortality (model AUROC: 0.82). Interpretation & conclusions: In sepsis, patients admitted to the ICU, current practice suggests transfusion trigger is below 7 g/dl and it does not affect any adverse outcome including 28 day mortality.

Functional near-infrared spectroscopy guided mapping of frontal cortex, a novel modality for assessing emergence delirium in children: A prospective observational study.

INTRODUCTION: Despite an 18%-30% prevalence, there is no consensus regarding pathogenesis of emergence delirium after anesthesia in children. Functional near-infrared spectroscopy (fNIRS) is an optical neuroimaging modality that relies on blood oxygen level-dependent response, translating to a mean increase in oxyhemoglobin and a decrease in deoxyhemoglobin. We aimed to correlate the emergence delirium in the postoperative period with the changes in the frontal cortex utilizing fNIRS reading primarily and also with blood glucose, serum electrolytes, and preoperative anxiety scores. METHODS: A total of 145 ASA I and II children aged 2-5 years, undergoing ocular examination under anesthesia, were recruited by recording the modified Yale Preoperative Anxiety Score after acquiring the Institute Ethics Committee approval and written informed parental consent. Induction and maintenance were done with O2, N2O, and Sevoflurane. The emergence delirium was assessed using the PAED score in the postoperative period. The frontal cortex fNIRS recordings were taken throughout anesthesia. RESULTS: A total of 59 children (40.7%) had emergence delirium. The ED+ group had a significant activation left superior frontal cortex (t = 2.26E+00; p = .02) and right middle frontal cortex (t = 2.27E+00; p = .02) during induction, significant depression in the left middle frontal (t = -2.22E+00; p = .02), left superior frontal and bilateral medial (t = -3.01E+00; p = .003), right superior frontal and bilateral medial (t = -2.44E+00; p = .015), bilateral medial and superior (t = -3.03E+00; p = .003), and right middle frontal cortex (t = -2.90E+00; p = .004) during the combined phase of maintenance, and significant activation in cortical activity in the left superior frontal cortex (t = 2.01E+00; p = .0047) during the emergence in comparison with the ED- group. CONCLUSION: There is significant difference in the change in oxyhemoglobin concentration during induction, maintenance, and emergence in specific frontal brain regions between children with and without emergence delirium.

Carotid artery corrected flow time and respiratory variation of blood flow peak velocity for prediction of hypotension after induction of general anesthesia in adult patients undergoing emergency laparotomy for peritonitis: A prospective, observational study.

Background and Aims: Doppler waveform analysis of carotid artery has been found to predict fluid responsiveness in patients undergoing elective surgeries. We evaluated the role of carotid artery corrected flow time (FTc) and respiratory variation of blood flow peak velocity (ðVpeak) in predicting post induction hypotension in patients undergoing emergency laparotomy for peritonitis. Material and Methods: Adult patients (n = 60) with perforation peritonitis undergoing emergency laparotomy under general anesthesia (GA) were recruited in this prospective, observational study. Carotid ultrasonography was performed pre-induction, to determine FTc and ðVpeak. Post-induction hemodynamic parameters were recorded for 5 minutes. Spearman's rank correlation coefficient was used to determine the relationship between hypotension and carotid artery measurements. Results: Post-induction hypotension occurred in 48.3% of patients. The carotid artery FTc was significantly lower (P = 0.008) in patients who developed post-induction hypotension, but ðVpeak was statistically similar (P = 0.62) in both groups. Spearman's rank correlation coefficient revealed a statistically significant correlation between FTc and systolic blood pressure (SBP) change at one-minute post induction (r2 = -0.29, P = 0.03); however statistical significance were not achieved at 2 minutes and 3 minutes (P = 0.05 at both time points). Carotid artery FTc had an area under the receiver operating characteristic (AUROC) curve (95% CI) of 0.70 (0.57-0.84) to predict post-induction hypotension and best cutoff value of 344.8 ms with a sensitivity and specificity of 61% and 79%, respectively. Carotid artery ðVpeak had an AUROC curve (95% CI) of 0.54 (0.39-0.69) to predict post-induction hypotension and best cutoff value of 7.9% with a sensitivity and specificity of 62% and 55%, respectively. Conclusion: Carotid artery FTc and ðVpeak are not reasonable predictors of hypotension in patients undergoing emergency laparotomy for perforation peritonitis.

Comparative evaluation of the analgesic efficacy of ultrasound-guided erector spinae plane block versus intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery: A prospective randomized pilot study.

OBJECTIVES: Existing research on erector spinae plane block and intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery is limited. METHODS: In this prospective, randomized study, 60 patients aged between 18 and 60 years were randomized into two groups (erector spinae plane block and intrathecal morphine). In the erector spinae plane block group, ultrasound-guided erector spinae plane block was performed, following which a mixture of 20 mL of 0.375% ropivacaine and 0.5 mcg/kg of clonidine was injected. In the intrathecal morphine group, 150 mcg preservative-free morphine with 2 mL of normal saline was administered intrathecally. The primary outcome was to evaluate the perioperative opioid consumption in the first 24 h. The secondary outcomes were to evaluate hemodynamic response to surgical stimulus, visual analogue scale score, time to first analgesic requirement, postoperative nausea and vomiting, postoperative opioid consumption, urethral irritation, and incidence of drug-related adverse effects. RESULTS: Total perioperative opioid consumption in the erector spinae plane block group was 355.0 (265.0, 485.0) µg and 240.0 (145.0, 370.0) µg in the intrathecal morphine group (P = 0.09). However, the patients in the erector spinae plane block group had significantly greater postoperative fentanyl consumption (235.0 [120.0, 345.0] µg) compared with those in the intrathecal morphine group (105.0 [30.0, 225.0] µg). There were no statistically significant differences noted for intraoperative opioid consumption, postoperative visual analogue scale score, time to first analgesic request, postoperative nausea and vomiting, and catheter irritation between the two groups. CONCLUSIONS: Although no statistically significant difference in intraoperative opioid consumption was seen between the erector spinae plane block and intrathecal morphine groups, postoperative opioid consumption was significantly higher in the erector spinae plane block group than in the intrathecal morphine group in patients undergoing percutaneous nephrolithotomy surgery.

In Response to: Is the Carotid Artery a Window to the Left Ventricle?

We think correlation of Doppler ultrasound derived CA-VTI and echocardiography derived SV needs further exploration in a larger sample and in various models of hypovolemia and shock under ideal measurement conditions before concluding whether carotid artery can be considered a true window to the left ventricle. How to cite this article: Kundu R, Maitra S, Chowhan G, Baidya DK. In Response to: Is the Carotid Artery a Window to the Left Ventricle? Indian J Crit Care Med 2022;26(3):407.

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.

Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock.

Background: Transthoracic echocardiography is a reliable method to measure a dynamic change in left ventricular outflow tract velocity time integral (LVOTVTI) and stroke volume (SV) in response to passive leg raising (PLR) and can predict fluid responsiveness in critically ill patients. Measuring carotid artery velocity time integral (CAVTI) is easier, does not depend on adequate cardiac window, and requires less skill and expertise than LVOTVTI. The aim of this study is to identify the efficacy of ΔCAVTI and ΔLVOTVTI pre- and post-PLR in predicting fluid responsiveness in critically ill patients with sepsis and septic shock. Methods: After the institutional ethics committee's clearance and informed written consent, 60 critically ill mechanically ventilated patients aged 18-65 years were recruited in this prospective parallel-group study with 20 patients in each group: sepsis (group S), septic shock (group SS), and control (group C). Demographic parameters and baseline acute physiology, age and chronic health evaluation-II and sequential organ failure assessment scores were noted. LVOTVTI, SV, and CAVTI were measured before and after PLR along with other hemodynamic variables. Patients having a change in SV more than 15% following PLR were defined as "responders." Results: Twenty-three patients (38.33%) were responders. Area under receiver-operating characteristic curve for ΔCAVTI could predict responders in control and sepsis patients only. The correlation coefficients between pre- and post-PLR ΔCAVTI and ΔLVOTVTI were 0.530 (p = 0.016), 0.440 (p = 0.052), and 0.044 (p = 0.853) in control, sepsis, and septic shock patients, respectively. Conclusion: Following PLR, ΔCAVTI does not predict fluid responsiveness in septic shock patients and the correlation between ΔCAVTI and ΔLVOTVTI is weak in septic shock patients and only modest in sepsis patients. How to cite this article: Chowhan G, Kundu R, Maitra S, Arora MK, Batra RK, Subramaniam R, et al. Efficacy of Left Ventricular Outflow Tract and Carotid Artery Velocity Time Integral as Predictors of Fluid Responsiveness in Patients with Sepsis and Septic Shock. Indian J Crit Care Med 2021;25(3):310-316. CTRI/Trial Reg No: www.ctri.nic.in, CTRI/2017/11/010434.

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.