Perception of robotic-assisted surgery (RAS) among medical students: a systematic review and meta-analysis.

INTRODUCTION: Robotic surgery, also known as robotic-assisted surgery (RAS), involves a camera and a small surgical instrument attached to a robotic arm. A trained surgeon operates the robot from a viewing screen while being in the same room. METHODOLOGY: This review was prepared following Cochrane collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. Two authors independently searched and appraised the studies published in PubMed, cumulative index to nursing and allied health literature (CINAHL), Embase, Clinical Key, and Google Scholar. Pooled data analyzed and reported in RevMan software version-5.4. RESULTS: This systematic review and meta-analysis comprised 1400 medical students, from 8 studies. The participants' age ranged from 23 to 49 years. Similarly, the sample size ranged from 25 and 300. The pooled prevalence of the existing studies revealed that 29.8% of medical students, were favorable towards RAS. Effect size (ES), 95% confidence intervals (CI) and heterogeneity (I2) [ES = 29.8, 95% CI 16.4-43.2, I2 = 95.1%, P < 0.00]. About 40% of Australian medical students' positive opinion on RAS [ES = 40.4, 95% CI 25.7-55.2]. Similarly, 34.2% of students from Saudi Arabia [ES = 29.8, 95% CI 22.4-90.8, I2 = 99.3%, P < 0.00], 27.8% students from Canada [ES = 27.8, 95% CI 15.9-39.6], 24.8% from USA [ES = 24.8, 95% CI 6.9-42.7, I2 = 77.3%, P < 0.00] and 24% [ES = 24, 95% CI 18-30] from India favorable towards RAS. DISCUSSION: Medical students from developed nations display favorable attitudes towards RAS. However, implementing of revised curriculum at the beginning of the graduation level sparks medical students' attitude towards robotic surgery.

Routine hematology parameters in COVID-19: A predictor of disease severity and mortality.

Background: Our understanding of the pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is still evolving and is limited for prognostication. The study was performed to predict severity and mortality based on hematology parameters in coronavirus disease (COVID-19). Material and Methods: The study was a single-center retrospective analysis of 240 patients with COVID-19. The hematological parameters were compared between different grades of severity. The receiver operating characteristics (ROC) curve along with the Classification and Regression Trees (CART) methods were used for the analysis. Result: The total leukocyte count, absolute neutrophil count, neutrophil-lymphocyte ratio (NLR), and neutrophil-monocyte ratio (NMR) were increasing along with an increase in severity; while the absolute lymphocyte count and lymphocyte-monocyte ratio (LMR) were decreasing (P < 0.001). For prediction of severity and mortality on admission, the NLR, NMR, and LMR were significant (P < 0.001). The NLR, NMR, and LMR had an area under the receiver operating characteristics curve (AUROC) of 0.86 (95% CI of 0.80-0.91), 0.822 (95% CI of 0.76-0.88), and 0.69 (95% CI of 0.60-0.79), respectively, for severity. While the NLR, NMR, and LMR had an AUROC value of 0.85 (95% CI of 0.79-0.92), 0.83 (95% CI of 0.77-0.89), and 0.67 (95% CI of 0.57-0.78), respectively, for mortality. Conclusion: With the increase in severity there was an increase in the total leukocyte count and absolute neutrophil count while the absolute lymphocyte count decreased. On admission, the cut-off value of NLR >5.2, NMR >12.1, while LMR <2.4 may predict severity and mortality in COVID-19.

Association of hyperglycaemia at-admission & diabetes mellitus with 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection: A retrospective study.

Background & objectives: The association between hyperglycaemia at admission, diabetes mellitus (DM) status and mortality in hospitalized SARS-CoV-2 infected patients is not clear. The purpose of this study was to determine the relationship between DM, at-admission hyperglycaemia and 28 day mortality in patients admitted with moderate-severe SARS-CoV-2 infection requiring intensive care. Methods: All consecutive moderate-to-severe patients with SARS-CoV-2 infection admitted to the intensive care units (ICUs) over six months were enrolled in this single-centre, retrospective study. The predicators for 28 day mortality were analysed from the independent variables including DM status and hyperglycaemia at-admission. Results: Four hundred and fifty two patients with SARS-CoV-2 were admitted to the ICU, with a mean age of 58.5±13.4 yr, 78.5 per cent being male, HbA1c of 7.2 per cent (6.3-8.8) and 63.7 per cent having DM. Overall, 28 day mortality was 48.9 per cent. In univariate analysis, mortality in diabetes patients was comparable with non-diabetes (47.9 vs. 50.6%, P=0.58), while it was significantly higher in hyperglycaemic group (60.4 vs. 35.8%, P<0.001). In multivariate Cox regression analysis, after adjusting for age, sex and comorbidities, hyperglycaemia at-admission was an independent risk factor of mortality [hazard ratio (HR) 1.45, 95% confidence interval (CI) (1.06-1.99), P<0.05]. Interpretation & conclusions: This study showed that the presence of hyperglycaemia at-admission in critically ill SARS-CoV-2 patients was an independent predictor of 28 day mortality. However, the findings may be susceptible to unmeasured confounding, and more research from prospective studies is required.

Pattern of Conventional Coagulation and Thromboelastographic Parameters in Patients with COVID-19 Diseases and Association of COVID-Associated Coagulopathy with Mortality in Intensive Care Unit.

Background: Knowledge of underlying pathophysiology of coagulopathy is evolving and the pattern of coagulation parameters in coronavirus disease 2019 (COVID-19)-associated diseases is still not very clear. Aims: In the present study, we aimed to find out the pattern and distribution of conventional coagulation parameters and thromboelastographic (TEG) parameters in COVID-19-associated coagulopathy (CAC) in survivors and nonsurvivors at 28 days. Setting and Design: The present prospective observational study was conducted at a tertiary care COVID-19 intensive care unit (ICU) facility from March 21, 2020, to July 15, 2021. Materials and Methods: Admission clinical and laboratory data (conventional coagulation, inflammatory and TEG parameters, and disease severity parameters) of 64 COVID-19 patients admitted to the ICU were collected. Patients were divided into two groups, i.e., survivors and nonsurvivors. Statistical Analysis: Data were compared between two groups, i.e., survivors versus no survivors on 28 days using Student's t-test/Mann-Whitney U-test or Chi-square test/Fisher's exact test. Results: Admission mean plasma fibrinogen levels (474.82 ± 167.41 mg.dL-1) and D-dimer were elevated (1.78 [0.66, 3.62] mg.mL-1) in the COVID-19 ICU patients. Overall, COVID-19 patients had mean lower normal platelet count (150 ± 50 × 103 cells.mm-3), with marginally elevated prothrombin time (16.25 ± 3.76 s) and activated partial thromboplastin time (38.22 ± 16.72 s). A 65.6% (42/64) TEG profile analysis showed a normal coagulation profile, and the rest 21.9% (14/64) and 12.5% (8/64) had hypercoagulable and hypocoagulable states, respectively. Plasma D-dimer level was markedly elevated in nonsurvivors compared to survivors (P < 0.05), while no other conventional coagulation parameters and TEG profile demonstrated statistically significant between the two groups. Conclusion: Markedly elevated plasma D-dimer level was observed in nonsurvivors of COVID-19 ICU patients. A large portion of COVID-19 ICU patients had a normal TEG profile. Conventional coagulation parameters and TEG profile were similar between survivors and nonsurvivors.

New insights into development and mortality of COVID-19-associated pulmonary aspergillosis in a homogenous cohort of 1161 intensive care patients.

BACKGROUND: COVID-19-associated pulmonary aspergillosis (CAPA) has been widely reported but homogenous large cohort studies are needed to gain real-world insights about the disease. METHODS: We collected clinical and laboratory data of 1161 patients hospitalised at our Institute from March 2020 to August 2021, defined their CAPA pathology, and analysed the data of CAPA/non-CAPA and deceased/survived CAPA patients using univariable and multivariable models. RESULTS: The overall prevalence and mortality of CAPA in our homogenous cohort of 1161 patients were 6.4% and 47.3%, respectively. The mortality of CAPA was higher than that of non-CAPA patients (hazard ratio: 1.8 [95% confidence interval: 1.1-2.8]). Diabetes (odds ratio [OR] 1.92 [1.15-3.21]); persistent fever (2.54 [1.17-5.53]); hemoptysis (7.91 [4.45-14.06]); and lung lesions of cavitation (8.78 [2.27-34.03]), consolidation (9.06 [2.03-40.39]), and nodules (8.26 [2.39-28.58]) were associated with development of CAPA by multivariable analysis. Acute respiratory distress syndrome (ARDS) (2.68 [1.09-6.55]), a high computed tomography score index (OR 1.18 [1.08-1.29]; p < .001), and pulse glucocorticoid treatment (HR 4.0 [1.3-9.2]) were associated with mortality of the disease. Whereas neutrophilic leukocytosis (development: 1.09 [1.03-1.15] and mortality: 1.17 [1.08-1.28]) and lymphopenia (development: 0.68 [0.51-0.91] and mortality: 0.40 [0.20-0.83]) were associated with the development as well as mortality of CAPA. CONCLUSION: We observed a low but likely underestimated prevalence of CAPA in our study. CAPA is a disease with high mortality and diabetes is a significant factor for its development while ARDS and pulse glucocorticoid treatment are significant factors for its mortality. Cellular immune dysregulation may have a central role in CAPA from its development to mortality.

Role of low-dose tissue plasminogen activator in patients with refractory hypoxia due to presumed microthrombi in pulmonary vasculature in coronavirus disease 2019: A case series and review of the literature.

Severe hypoxia due to coronavirus disease 2019 (COVID-19) is challenging in the intensive care unit (ICU). It is often unresponsive to mechanical ventilation at high positive end-expiratory pressure and the fraction of inspired oxygen combination. The cause of such worsening hypoxia may be microvascular thrombosis in the pulmonary vascular system because of the procoagulant nature of COVID-19 infection. Confirming the diagnosis with computed tomographic pulmonary angiography is not always possible, as the patients are too sick to be shifted. Tissue plasminogen activator (tPA) is recommended for pulmonary thromboembolism with hypotension and worsening hypoxia, as confirmed by computed tomography pulmonary angiography. However, its role in worsening hypoxia because of presumed microthrombi in the pulmonary vasculature in COVID-19 is unclear. We present six cases from our ICU where we used low-dose tPA in COVID-19 refractory hypoxia with presumed microthrombi in the pulmonary vasculature (oligemic lung field, refractory hypoxia, increased D dimer, electrocardiographic features of pulmonary embolism, and right ventricular strain on echocardiography). Oxygenation improved within 6 h and was maintained for up to 48 h in all patients. Therefore, there is a possible role of microthrombi in the mechanism of hypoxia in this setting. An early decision to start low-dose tPA may improve the outcome. However, all patients finally succumbed to sepsis and multiorgan failure later in their course. A systematic review of the literature has also been performed on the mechanism of thrombosis and the use of tPA in hypoxia due to COVID-19.

A questionnaire-based study on quality and adequacy of clinical communication between physician and family members of admitted Covid-19 patients.

OBJECTIVE: To assess adequacy of present means of clinical communication between physicians and (Covid-19) patients' family members, to analyse their perspectives and recommend felicitous practices for virtual conversation during ongoing pandemic. METHODS: Cross-sectional questionnaire-based (20 questions) anonymous online survey was conducted including patient's relatives (Group-1) and treating physicians (Group-2), through Google Forms. RESULTS: Response Rate was 82.5%. Group-1 and Group-2 included 155 and 204 respondents respectively. Group-1 preferred update by resident doctors (39%), twice a day (41.9%), daily case-summaries (80%) and hand-written document/electronic messages (53%,31%) as consent. Whereas Group-2 favored update by senior consultants (63%), daily one appraisal (55.9%) and scanned copies of hand written consent (81%) before high-risk procedures. The groups broadly agreed on the desired duration for a fruitful discussion (5-10 min) and designating one responsible person from the family for daily appraisal. CONCLUSION: Use of modern techniques/technologies of communication (voice/video calls, texts) during the ongoing pandemic is acceptable to majority. PRACTICE IMPLICATIONS: Study proposes a senior physician should communicate to a designated responsible family member at-least once a day for stable and twice a day for critical covid patients (more if patient's health condition changes), either by voice or video calls for 5-10 min.

A novel epidemiological scoring system for the prediction of mortality in COVID-19 patients.

BACKGROUND: Most of the reported risk score models for coronavirus disease 2019 (COVID-19) mortality are based on the levels of inflammatory markers, comorbidities or various treatment modalities, and there is a paucity of risk score models based on clinical symptoms and comorbidities. METHODS: To address this need, age, clinical symptoms and comorbidities were used to develop a COVID-19 scoring system (CSS) for early prediction of mortality in severe COVID-19 patients. The CSS was developed with scores ranging from 0 to 9. A higher score indicates higher risk with good discrimination quality presented by Mann Whitney U test and area under receiver operating characteristic curve (AUROC). RESULTS: Patient age of ≥60 y, cough, breathlessness, diabetes and any other comorbidity (with or without diabetes) are significant and independent risk factors for non-survival among COVID-19 patients. The CSS showed good sensitivity and specificity (i.e. 74.1% and 78.5% at CSS≥5, respectively), with an overall diagnostic accuracy of 82.8%, which was close to the diagnostic accuracy detected in the validation cohort (81.9%). In the validation cohort, high (8-9), medium (5-7) and low (0-4) CSS groups had 54.80%, 28.60% and 6.5% observed mortality, respectively, which was very close to the predicted mortality (62.40%, 27.60% and 5.2%, respectively, by scoring cohort). CONCLUSIONS: The CSS shows a positive relationship between a higher score and proportion of mortality and, as its validation showed, it is useful for the prediction of risk of mortality in COVID-19 patients at an early stage, so that referral for triage and admission can be predetermined even before admission to hospital.

The Impact of COVID-19 on the Clinical Practices, Working Environment, and Social Life of Intensivists in Non-COVID ICU.

Purpose: Enlightening the changes in the usual clinical practices, working environment, and social life of Intensivists working in noncoronavirus disease intensive care units (non-COVID ICU) during the COVID pandemic. Materials and methods: Observational cross-sectional study for Indian intensivists working in non-COVID ICUs conducted between July and September 2021. A 16-question online survey consisting of the work and social profile of the participating intensivists, changes in the usual clinical practices, working environment, and impact on their social life was administered. For the last three sections, intensivists were asked to compare pandemic times to prepandemic times (pre-mid-March 2020). Results: The number of invasive interventions performed by intensivists working in the private sector with lesser clinical experience (<12 years) were significantly less as compared to the government sector (p = 0.07) and clinically experienced (p = 0.07). Intensivists without comorbidities performed significantly lesser number of patient examinations (p = 0.03). The cooperation from healthcare workers (HCWs) decreased significantly with lesser experienced intensivists (p = 0.05). Leaves were significantly reduced in case of private sector intensivists (p = 0.06). Lesser experienced intensivists (p = 0.06) and intensivists working in the private sector (p = 0.06) spent significantly lesser time with family. Conclusion: Coronavirus disease-2019 (COVID-19) affected the non-COVID ICUs as well. Young and private sector intensivists were affected due to less leaves and family time. HCWs need proper training for better cooperation during the pandemic time. How to cite this article: Ghatak T, Singh RK, Kumar A, Patnaik R, Sanjeev OP, Verma A, et al. The Impact of COVID-19 on the Clinical Practices, Working Environment, and Social Life of Intensivists in Non-COVID ICU. Indian J Crit Care Med 2022;26(7):816-824.

Comparison between marked versus unmarked introducer needle in real-time ultrasound-guided central vein cannulation: A prospective randomized study.

INTRODUCTION: Introducer needle tip is not clearly visible during the real-time ultrasound (US)-guided central vein cannulation (CVC). Blind tip leads to mechanical complications. This study was designed to evaluate whether real-time US-guided CVC with a marked introducer needle is superior to the existing unmarked needle. METHODOLOGY: Sixty-two critically ill patients aged 18-60 years of either sex were included in the study. The patients were randomized into two groups based on whether a marked or unmarked introducer needle was used. Both groups underwent real-time US-guided CVC by a single experienced operator. Aseptically, introducer needle was indented with markings spaced 0.5 cm (single marking) and every 1 cm (double marking). This needle was used in the marked group. Approximate depths (centimeter) of the anterior and posterior wall of the internal jugular vein, anterior wall of the internal carotid artery, and lung pleura were appreciated from the midpoint of the probe in short-axis view at the level of the cricoid cartilage. Access time (seconds) was recorded using a stopwatch. A number of attempts and complications such as arterial puncture, hematoma, and pneumothorax of either procedure were compared. RESULTS: Both marked needle and unmarked needle groups were comparable with regard to age, gender, severity scores, platelet counts, prothrombin time, and distance from the midpoint of the probe to the vein, artery, and pleura and skin-to-guide wire insertion access time. However, an average number of attempts (P = 0.03) and complications such as hematoma were significantly lower (P = 0.02) with the marked introducer needle group. Pneumothorax was not reported in any of the groups. CONCLUSION: Our study supports the idea that marked introducer needle can further reduce the iatrogenic complications of US-guided CVC.

Chest ultrasonography in emergency Cesarean delivery in multi-valvular heart disease with pulmonary edema during spinal anesthesia.

Valvular heart disease in a parturient presenting for Cesarean section is challenging. A 25 year old primigravida parturient with severe mitral stenosis, mild mitral regurgitation, mild aortic regurgitation, and mild pulmonary arterial hypertension required Cesarean delivery after developing pulmonary edema. Low-dose spinal with hyperbaric bupivacine 0.5% 1.8 mL plus 25 µg of fentanyl was used for anesthesia. Chest ultrasonography (US) and transthoracic echocardiography (TTE) were used for monitoring purposes. Spinal-induced preload reduction improved the pulmonary edema, as evidenced by chest US. Chest US and TTE helped in fluid management.

Anesthetic management of a patient with Marfan syndrome and severe aortic root dilatation undergoing cholecystectomy and partial hepatic resection.

Due to high mortality associated with aortic dissection, anesthetic management of patients with Marfan syndrome with severe aortic root dilation is a challenging situation. We describe the anesthetic management of a patient with Marfan syndrome with severe aortic root dilation, who required major surgery like cholecystectomy with partial liver resection under general anesthesia. A 47-year-old female presented to pre-anesthetic clinic for cholecystectomy with partial hepatic resection for gall bladder carcinoma. Clinical features, transthoracic echocardiography and computed tomography of thorax supported a diagnosis of Marfan syndrome with severely dilated aortic root. Aortic dissection in patients with Marfan syndrome and severely dilated aortic root can be precipitated by major hemodynamic changes under anesthesia. Careful hemodynamic monitoring and avoidance of hemodynamic swings can prevent this life-threatening event.