Author Reply: Lung Ultrasound Score-Does It Really Predict Extubation Failure?

How to cite this article: Rajbanshi LK, Bajracharya A, Devkota D. Author Reply-lung Ultrasound Score-Does It Really Predict Extubation Failure? Indian J Crit Care Med 2023;27(11):857-858.

Molecular biology of carcinoid heart disease: Seeking therapeutic targets in the era of targeted therapy.

Carcinoid tumors (CT) are among the least studied tumors. It is a relatively rare and slow-growing tumor with good survival in its primary form. However, metastatic carcinoid tumor comes up with many different complications contributing to increased morbidity and mortality. Metastatic form of the disease has a wide spectrum of clinical manifestations and multisystem involvement including cardiovascular manifestations, neurological manifestations, and psychiatric manifestations and so on. In this review, we are centered towards the cardiovascular manifestations of the disease, which, by far, is one of the commonest causes of death in these patients. Being a neuroendocrine tumor, cardiovascular manifestations are mainly because of biologically active substances, produced by the tumor cells, remodeling the heart. Development of targeted therapies against carcinoid heart diseases is currently limited by lack of understanding of pathophysiology of the disease processes. In this review, we aim to figure out the spectrum of carcinoid heart diseases, along with the molecular biology of the changes going on, which, in turn, will not only pave a way to the development of targeted therapies but will also extend opportunities for molecular screening of the tumor and diagnosis at an early stage, thereby, reducing the morbidity and mortality.

Can Use of Intravenous Methylene Blue Improve the Hemodynamics and Outcome of the Patients with Refractory Septic Shock? An Observational Study.

Introduction: Refractory shock, which fails to respond to conventional vasopressor therapy, is a common complication of sepsis. Methylene blue has emerged as a potential adjunctive treatment option for reversing refractory shock in sepsis. The aim of this study was to evaluate the impact of intravenous methylene blue infusion on hemodynamic improvement and mortality in patients with refractory shock. Methodology: This was an observational prospective study for the duration of six months conducted at intensive care a medical college and teaching hospital including 76 patients with a diagnosis of septic shock requiring vasopressor therapy. Intravenous (IV) methylene blue was infused as a bolus dose with 2 mg/kg dose in 20 minutes and its response to mean arterial blood pressure, decrease in vasopressor therapy, lactate level, and urine output was recorded in next 2 hours. Patients with improvement in mean arterial pressure (MAP) by 10% or decrease in vasopressor therapy in the next 2 hours were leveled as responder. The length of intensive care unit (ICU) stay, duration of mechanical ventilation, incidence of acute kidney injury (AKI), and mortality were compared between responder and non-responder. Results: A total of 76 patients with refractory shock were included in the study. With the use of IV methylene blue, 41 (53.9%) patients showed significant improvement in MAP within 2 hours (70.17 ± 8.30 vs 64.28 ± 11.84, p = 0.005). Responders were 4.019 times more likely to have vasopressor-free time within 24 hours (18.4% vs 5.3%, p = 0.020, odds ratio 4.019, 95% confidence interval, 1.180-13.682). However, there was no significant difference in terms of mortality, length of ICU stay, ventilator free days, and incidence of AKI. In the responder group, there was a significant increase in the MAP and decrease in vasopressor requirement pre- and post-infusion of methylene blue (p < 0.05). Responder had shorter vasopressor-free days as compared with non-responder (5.34 vs 6.79, p = 0.008) while the mean survival time was longer with responders (21.97 vs 15.93 days, p = 0.024). Conclusion: The use of IV methylene blue in refractory shock as an adjuvant therapy significantly improved the mean arterial blood pressure and decreased the requirement of vasopressor therapy as well as improvement in the survival time. However, there was no change in the mortality, length of ICU stay, ventilator-free days, or incidence of AKI in the patients. How to cite this article: Rajbanshi LK, Bajracharya A, Arjyal B, Devkota D. Can Use of Intravenous Methylene Blue Improve the Hemodynamics and Outcome of the Patients with Refractory Septic Shock? An Observational Study. Indian J Crit Care Med 2023;27(9):669-674.

Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit.

Introduction: Spontaneous breathing trial (SBT) is always successful in mechanically ventilated patients. This study was conducted to assess the prediction of successful SBT and extubation of trachea by bedside lung ultrasound in mechanically ventilated patients. Methodology: This was a prospective observational study for 1 year conducted at a tertiary teaching hospital ICU on 102 patients with age more than 18 years and who were mechanically ventilated for more than 24 hours. Bedside lung ultrasound was used to assess the lung ultrasound score (LUS) and lung profiles in patients who clinically met the criteria for SBT. The LUS at the beginning of SBT and 30 minutes after SBT were used to predict the successful SBT and tracheal extubation. Result: Spontaneous breathing trial and tracheal extubation were successful in 73 (71.6%) and 57 (55.8%) of the patients. The AUC for lung ultrasound in predicting successful SBT at the beginning and 30 minutes of SBT were 0.781 (CI 95% 0.674-0.888, p < 0.001) and 0.841 (CI 95% 0.742-0.941, p < 0.001) with a cut-off value of 17.5 and 19.5, respectively. Similarly, AUC for LUS in relation to tracheal extubation was 0.786 (CI 95% 0.694-0.879, p < 0.001) and 0.841(CI 95% 0.756-0.925, p < 0.001) at 0 and 30 minutes. About 57.5% of the patients with A profiles tolerated successful SBT while 48.3% of the patients having C profile had failed SBT (p < 0.001). COPD, lung ultrasound, higher SOFA score, and longer duration of mechanical ventilation had a statistically significant negative correlation with successful SBT. Conclusion: Lower LUS and A profiles lung ultrasound are associated with more successful weaning and tracheal extubation in mechanically ventilated patients. How to cite this article: Rajbanshi LK, Bajracharya A, Devkota D. Prediction of Successful Spontaneous Breathing Trial and Extubation of Trachea by Lung Ultrasound in Mechanically Ventilated Patients in Intensive Care Unit. Indian J Crit Care Med 2023;27(7):482-487.