Comparative evaluation of nebulized versus intravenous dexmedetomidine on intubating conditions during awake fiberoptic nasotracheal intubation.

BACKGROUND: There is a search for an ideal agent to facilitate awake fiberoptic intubation (AFOI). Dexmedetomidine is a selective α2 agonist which can be administered through intravenous, intramuscular, buccal, intranasal & inhalational routes. It provides good intubation conditions without oxygen desaturation but may cause hypotension and bradycardia when administered intravenously. Hence, alternative routes of administering dexmedetomidine which may improve its safety profile are worth exploring. METHODS: In this randomised, controlled, double-blind trial, 46 ASA I/II adult participants scheduled for elective ENT surgery were randomly allocated to Group ND (Nebulised Dexmedetomidine) (n = 23) to receive nebulisation with dexmedetomidine 1µg.kg-1 and Group ID (Intravenous Dexmedetomidine) (n = 23) to receive intravenous dexmedetomidine 1µg.kg-1 before AFOI. All the patients received injection midazolam 1 mg i.v. as premedication before anaesthesia was initiated. The primary outcome was the cough score. The secondary outcomes were the RSS, SAYGO boluses, post-intubation score, hemodynamic parameters, recall of the procedure, patient satisfaction score and any side effects. RESULTS: The cough score was significantly lower in nebulized group (2.43 ± 0.992 vs 3.52 ± 1.082) with p = 0.001. RSS(3.30 ± 0.926 vs 4.22 ± 1.126; p = 0.004), number of SAYGO boluses required (2.74 ± 0.864 vs 3.57 ± 1.161; p = 0.009) & the post intubation score (1.48 ± 0.593 vs 2.17 ± 0.778; p = 0.001) were also significantly lower in nebulized group. CONCLUSIONS: Nebulisation with dexmedetomidine results in desirable degree of sedation and better tolerance of the procedure with adequate attenuation of the haemodynamic responses to intubation.

Audit on Practices of Endotracheal Suctioning in Intensive Care Unit Patients among Health Care Workers (HCWs).

Background: Endotracheal suctioning (ETS) is one of the most frequently performed invasive procedures in intensive care units (ICUs). This audit was aimed at studying current practices and knowledge regarding ETS in the Indian critical care setup, with the background aim of raising awareness regarding correct practices as per current recommendations in critically ill patients. Materials and methods: After registering the trial with the clinical trial registry, India, a structured audit questionnaire containing 20 questions pertaining to ETS was distributed through electronic media among resident doctors working in the ICUs across India. Responses received were statistically analyzed. Results: The questionnaire was sent to 530 clinicians, of which only 200 (37.73%) responded. The audit revealed that only 22% respondents set the maximum negative pressure every time before suctioning, on the suction apparatus and only 32% said they would choose a catheter size of less than half the internal diameter of the endotracheal tube (ETT). About 90% of the respondents did not routinely do any form of documentation of the ETS. Almost 72% of the responders opined that closed suction systems reduce the chances of developing ventilator-associated pneumonia (VAP). Only 46% of respondents thought that no solution should be routinely instilled in ETT during ETS. Conclusion: There is lack of awareness regarding frequency and technique of ETS, infection control and monitoring required during ETS. Institutional protocols should be in place to follow correct guidelines for performing ETS. How to cite this article: Singh R, Bhalotra AR, Sharma S. Audit on Practices of Endotracheal Suctioning in Intensive Care Unit Patients among Health Care Workers (HCWs). Indian J Crit Care Med 2024;28(1):58-65.

A Retrospective Study on Experience of High-flow Nasal Cannula Oxygen in Critically Ill COVID-19 Adult Patients Admitted to Intensive Care Unit.

BACKGROUND: The use of high-flow nasal cannula (HFNC) in coronavirus disease-2019 (COVID-19) patients is debated due to its uncertain benefits and risks of aerosol dispersion. This retrospective study was aimed to assess the outcome of treatment with HFNC therapy in adult COVID-19 patients with acute hypoxemic respiratory failure (AHRF) admitted in intensive care units (ICU) and to assess the factors affecting outcome. MATERIAL AND METHODS: We retrieved electronic medical records of all COVID-19 patients who received HFNC for respiratory support after failure to maintain adequate oxygenation with conventional oxygen devices, between June 1 and August 31, 2020. The data retrieved were statistically analyzed. RESULTS: A total number of 558 COVID-19 patients were admitted to ICUs, out of which 139 patients were identified to be on HFNC and 85 met the inclusion criteria for the study. The success rate of 48.2% with HFNC was observed in these patients. The patients recorded to experience HFNC success were of young age and having higher baseline oxygen saturation compared to those who had its failure. The ROX indices post-initiation were observed to be significantly higher in the success group (p ≤0.001). Awake-prone positioning while receiving HFNC was followed by around more patients in the success group (p <0.001). On multivariate logistic regression analysis, baseline oxygen saturation, awake-prone positioning, and number of days on HFNC were found to be independently affected outcome with HFNC. CONCLUSION: Almost half of the cases of moderate-to-severe COVID-19 pneumonia can be managed successfully with HFNC, without the need of mechanical ventilation. HOW TO CITE THIS ARTICLE: Kerai S, Singh R, Saxena KN, Desai SD, Bhalotra AR. A Retrospective Study on Experience of High-flow Nasal Cannula Oxygen in Critically Ill COVID-19 Adult Patients Admitted to Intensive Care Unit. Indian J Crit Care Med 2022;26(1):62-66.

Assessment of Risk Factors for Coronavirus Disease-2019 in Healthcare Workers: A Case-Control Study.

BACKGROUND AND AIMS: With the rise of coronavirus disease-2019 (COVID-19) cases globally, the infection among frontline healthcare workers (HCWs) escalates many folds. There is, however, limited literature from low middle-income countries regarding risk factors for COVID-19 infection in HCWs. We conducted a case-control study to evaluate the risk factors of COVID-19 infection to HCWs. MATERIALS AND METHODS: This case-control study was conducted in a designated COVID-19 hospital. Eighty-one HCWs involved in direct care of COVID-19 patients, identified as cases, and 266 were recruited as controls. Telephonic interviews with participants were conducted, and information regarding demographic variables, chemoprophylaxis, exposure to infected patients, and adherence to infection prevention and control (IPC) measures was collected. RESULTS: We observed a statistically significant difference in the number of times training session for IPC measures attended by HCWs (p = 0.02), performance of aerosol-generating medical procedures (AGMPs) (p <0.001), practices of donning and doffing of personal protective equipment (PPE) (p <0.001), hand hygiene (p <0.001), and decontamination of highly touched surfaces (p <0.001). Logistic regression analysis revealed if the decontamination of highly touched surfaces is decreased by one unit, the odds of getting COVID-19 infection is multiplied by a factor of 0.41 and AGMPs decrease the risk of being a case by 0.76. CONCLUSION: This study highlighted that inadequate observation of IPC methods increases the risk of COVID-19 infection to frontline HCWs, whereas performance of AGMPs does not enhance the risk. In this study, HCWs undertaking an AGMP, because of concern of acquiring infection, were more diligent during procedures and hence had lesser infection. HOW TO CITE THIS ARTICLE: Kerai S, Singh R, Saxena KN, Desai SD. Assessment of Risk Factors for Coronavirus Disease-2019 in Healthcare Workers: A Case-Control Study. Indian J Crit Care Med 2022;26(1):76-84.

Effect of prone positioning and high flow nasal oxygen on oxygenation and overall outcome in spontaneously breathing awake patient with severe COVID-19 induced acute hypoxemic respiratory failure: A prospective observational study.

Background: Previous studies suggest that prone positioning can increase PaO2/FiO2 and reduce mortality in moderate to severe acute respiratory distress syndrome. Effect of prone positioning and high flow nasal oxygen has been studied individually in COVID-19 patients but their combined effect on patient's outcome is yet to be reported. Methods: In this study 120 severe COVID-19 positive patients were included and placed in awake prone positioning with high flow nasal oxygen. The efficacy in improving oxygenation with prone positioning and high flow nasal oxygen were evaluated by blood gas analysis. The primary outcome was a proportion of patients requiring non-invasive ventilation or invasive ventilation. The secondary outcomes were a comparison of arterial blood gas parameters and biochemical inflammatory parameters pre proning, end of first proning and end of last prone position in these patients. Results: We found only 35 patients (34.3%) required the need for non-invasive or invasive mechanical ventilation support whereas 67 patients (65.7%) were managed successfully on high flow nasal oxygen along with awake prone positioning (p = 0.001). We found there were statistically significant improvements in arterial blood gas parameters and biochemical inflammatory markers after the end of last prone positioning with high flow nasal oxygen. Conclusions: Early application of prone positioning in combination with high flow nasal oxygen may help in avoiding mechanical ventilation by improving oxygenation and biochemical inflammatory markers.

Comparison of Clinical Characteristics and Outcome of Critically Ill Patients Admitted to Tertiary Care Intensive Care Units in India during the Peak Months of First and Second Waves of COVID-19 Pandemic: A Retrospective Analysis.

BACKGROUND: Coronavirus disease-2019 (COVID-19) continues to pose serious challenges to healthcare systems globally with the disease progressing over time in crest-trough pattern of waves. We compared the patient characteristics and outcomes of critically ill patients admitted during the first and second waves of COVID-19 pandemic. MATERIALS AND METHODS: We did a retrospective analysis of medical records of critically ill patients admitted to intensive care unit (ICU) at the peak period of both waves. The data on demographics, symptoms, treatment received, and outcomes of patients were recorded. RESULTS: Compared to first wave, significantly more females, younger age group, and those without underlying comorbidities required ICU admission during the second wave. The treatments received during both periods were similar except for preferential use of methylprednisolone over dexamethasone and proclivity of bilevel positive airway pressure (BiPAP) ventilation over high-flow nasal cannula (HFNC). There was no significant difference in the duration of ICU stay and mortality of patients. During the first wave, the factors associated with nonsurvival of patients were advanced age, comorbidities, severe disease, and a lesser number of days on HFNC. All these factors along with higher Sequential Organ Failure Assessment (SOFA) score were observed to be linked with patient nonsurvival during the second wave. CONCLUSION: In India, the second wave of COVID-19 significantly influenced ICU demographics with a predominance of females and young adults requiring critical care. During both time periods, patients received similar treatment except for the propensity to use methylprednisolone and BiPAP as opposed to dexamethasone and HFNC in second wave. No significant difference in ICU mortality was noted. HOW TO CITE THIS ARTICLE: Kerai S, Singh R, Dutta S, Mahajan A, Agarwal M. Comparison of Clinical Characteristics and Outcome of Critically Ill Patients Admitted to Tertiary Care Intensive Care Units in India during the Peak Months of First and Second Waves of COVID-19 Pandemic: A Retrospective Analysis. Indian J Crit Care Med 2021;25(12):1349-1356.

Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients.

BACKGROUND: This audit was aimed at studying current practices regarding the use of stress ulcer prophylaxis (SUP) in the Indian critical care setup, with the background aim of raising awareness regarding the use and indications of SUP in critically ill patients. MATERIALS AND METHODS: After registering the trial with the clinical trial registry, India, a structured audit questionnaire containing 26 questions pertaining to SUP was distributed through electronic media among clinicians working in the intensive care units (ICUs) across India. Responses obtained were statistically analyzed. RESULTS: The questionnaire was sent to 550 clinicians. Only 197 responded, of whom 91.4% were anesthesiologists, 5.6% were physicians, and 3% were intensivists. The audit revealed that 33% respondents were unaware of the existing SUP guidelines and around 32% did not have protocols for SUP in their ICU. Sixty-nine percent of respondents felt that all ICU patients must receive SUP and 44.7% opined that it should be started on ICU arrival. Almost 94% knew that early enteral feeding is protective against stress ulceration. Only 24.9% responders agreed that there must be clear indications for SUP, and most of them were unaware of all the potential side effects. Once initiated, 43.7% respondents would stop prophylaxis when no indication was left, whereas 69 respondents would stop on ICU discharge. CONCLUSION: There is a lack of awareness regarding initiation, choice of agent, adverse effects as well as termination of SUP in ICU and guidelines for the same. Institutional protocols should be in place and steps need to be taken to prevent unwarranted use. HOW TO CITE THIS ARTICLE: Gupta D, Bhalotra AR, Singh R. Audit on Practices of Stress Ulcer Prophylaxis in Intensive Care Unit Patients. Indian J Crit Care Med 2020;24(3):160-167.

Uterine Rupture: A Seven Year Review at a Tertiary Care Hospital in New Delhi, India.

OBJECTIVE: To identify the obstetric risk factors, incidence, and causes of uterine rupture, management modalities, and the associated maternal and perinatal morbidity and mortality in one of the largest tertiary level women care hospital in Delhi. MATERIALS AND METHODS: A 7-year retrospective analysis of 47 cases of uterine rupture was done. The charts of these patients were analyzed and the data regarding demographic characteristics, clinical presentation, risk factors, management, operative findings, maternal and fetal outcomes, and postoperative complications was studied. RESULTS: The incidence of rupture was one in 1,633 deliveries (0.061%). The vast majority of patients had prior low transverse cesarean section (84.8%). The clinical presentation of the patients with rupture of the unscarred uterus was more dramatic with extensive tears compared to rupture with scarred uterus. The estimated blood loss ranged from 1,200 to 1,500 cc. Hemoperitoneum was identified in 95.7% of the patient and 83% of the patient underwent repair of rent with or without simultaneous tubal ligation. Subtotal hysterectomy was performed in five cases. There were no maternal deaths in our series. However, there were 32 cases of intrauterine fetal demise and five cases of stillbirths. CONCLUSIONS: Uterine rupture is a major contributor to maternal morbidity and neonatal mortality. Four major easily identifiable risk factors including history of prior cesarean section, grand multiparity, obstructed labor, and fetal malpresentations constitute 90% of cases of uterine rupture. Identification of these high risk women, prompt diagnosis, immediate transfer, and optimal management needs to be overemphasized to avoid adverse fetomaternal complications.

Comparative evaluation of gastric pH and volume in morbidly obese and lean patients undergoing elective surgery and effect of aspiration prophylaxis.

INTRODUCTION: The anesthetic management of patients with morbid obesity is challenging. There is no consensus on the routine use of aspiration prophylaxis in morbidly obese patients undergoing elective surgery. AIM: The aim of this study is to assess the risk of pulmonary aspiration and effect of premedication with ranitidine and metoclopramide on gastric pH and volume in morbidly obese and lean patients. METHODS: Gastric volume and pH were measured in 3 groups of 20 patients each: group I (lean, no aspiration prophylaxis), group II (morbidly obese, no aspiration prophylaxis), and group III (morbidly obese; tablet ranitidine, 150 mg; and tablet metoclopramide, 10 mg administered the night before and 2 hours before surgery). Patients with critical gastric volume >25 mL and critical pH <2.5 (Roberts and Shirley criteria) were considered to be at risk for pulmonary aspiration. RESULTS: The percentage of patients with gastric volume >25 mL and pH <2.5 was 5%, 30%, and 0% in groups I, II, and III, respectively. Statistically significant difference existed between groups I and II (P = .04) and groups II and III (P = .006). Premedicated morbidly obese and lean patients were comparable (P = .46). CONCLUSION: Morbidly obese patients undergoing elective surgery are at a higher risk for regurgitation and pulmonary aspiration when compared with lean patients. Preoperative aspiration prophylaxis decreases gastric volume and increases gastric pH and thus should be routinely prescribed.

Comparative evaluation of incidence of emergence agitation and post-operative recovery profile in paediatric patients after isoflurane, sevoflurane and desflurane anaesthesia.

BACKGROUND: Emergence agitation (EA), although well documented in the clinical literature, still has uncertainties and confusion abound on this subject because of the absence of a clear definition and lack of reliable and valid assessment tools. AIM: To compare the incidence and severity of EA and recovery characteristics in paediatric patients under isoflurane, sevoflurane or desflurane anaesthesia and evaluate the effect of age and duration of anaesthesia on the incidence of EA. SETTINGS AND DESIGN: Randomized prospective double-blinded study. METHODS: Seventy-five American Society of Anaesthesiologists I and II patients, aged between 4 months and 7 years, were included in the study. Patients were induced with sevoflurane and oxygen. Anaesthesia was maintained with O(2) + N(2)O and isoflurane, sevoflurane or desflurane according to randomization. Caudal block and paracetamol suppository was administered before the surgical incision. In the Post-Anesthesia Care Unit (PACU), degree of agitation was assessed using the Paediatric Anaesthesia Emergence Delirium Scale. Aldrette score, Face, Legs, Activity, Cry, Consolability score and any adverse events were noted. STATISTICAL ANALYSIS: Chi-square/Fischer exact test was applied for categorical variables; for continuous variables, the analysis of variance/non-parametric Kruskall-Wallis test was applied. Two-sample t-test/non-parametric Wisconsin Mann-Whitney test was applied between the two groups. Statistical significance was determined at P<0.05. RESULTS: Incidence and intensity of EA were comparable in all three groups. Age and duration of anaesthesia do not appear to have any bearing on the incidence of EA. Rapid emergence with sevoflurane and desflurane did not translate into early discharge from PACU. CONCLUSIONS: EA is a multifactorial syndrome. More well-conducted studies using validated scales and standardized protocols should be carried out to better understand this phenomenon.