A Simple Adaptation for the Convenient Application of Incentive Spirometry in Tracheostomized Critically Ill Patients.

How to cite this article: Arasu M, Singh AK, LaguduvaH A. A Simple Adaptation for the Convenient Application of Incentive Spirometry in Tracheostomized Critically Ill Patients. Indian J Crit Care Med 2024;28(5):520-521.

Role of red blood cell distribution width, as a prognostic indicator in COVID-19: A systematic review and meta-analysis.

The red blood cell distribution width (RDW), an indicator of anisocytosis has emerged as a potential tool for risk stratification of critically ill patients with sepsis. Prognostic predictors are of paramount interest for prompt intervention and optimal utilization of the healthcare system in this ongoing context of the Coronavirus Disease 2019 (COVID-19) pandemic. The current systematic review and meta-analysis aims to explore the utility of RDW in the prognosis of COVID-19 patients. A comprehensive screening of electronic databases was performed up to 30th April 2021 after enrolling in PROSPERO (CRD42020206685). Observational studies or interventional studies, evaluating the impact of RDW in COVID-19 outcomes (mortality and severity) are included in this meta-analysis.Our search retrieved 25 studies, with a total of 18,392 and 3,446 COVID-19 patients for mortality and disease severity outcomes. Deceased and critically ill patients had higher RDW levels on admission in comparison to survivors and non-severe patients (SMD = 0.46; 95%CI 0.31-0.71; I2  = 88% and SMD = 0.46; 95%CI 0.26-0.67; I2  = 60%, respectively). In a sub-group analysis of 2,980 patients, RDW > 14.5 has been associated with increased risk of mortality (OR = 2.73; 95%CI 1.96-3.82; I2  = 56%). However, the evidences is of low quality. A higher level of RDW on admission in COVID-19 patients is associated with increased morbidity and mortality. However, further studies regarding the cut-off value of RDW are the need of the hour.

Impact of intravenous dexamethasone on the initiation and recovery of atracurium in children: A double-blinded randomized controlled trial.

BACKGROUND: Chronic steroid intake has been associated with attenuation of neuromuscular block. Despite some promising animal and adult studies, the effect of a single dose of intravenous dexamethasone on neuromuscular blockers is not well established. Thus, the present study aimed to demonstrate the effect of dexamethasone given at the time of induction for the prevention of PONV on the action of neuromuscular blockers in children undergoing elective surgery. METHOD: After obtaining approval from the Institute Ethics Committee and written informed parental consent, 100 ASA I and II children aged 4-15 years undergoing elective surgery randomized to receive either: 0.15 mg/kg (maximum of 5 mg) of dexamethasone diluted to a total volume of 2 ml with 0.9% saline (n = 50) or 2 ml of 0.9% saline (n = 50) at the time of induction. The time interval between application of atracurium and maximum T1 depression, 25% twitch height recovery of T1, amid 25% and 75% twitch height recovery of T1, amid the 25% twitch height recovery of T1 and recovery of the neuromuscular block to a TOF ratio of 0.9, and in between the initiation of atracurium injection till the recovery of the neuromuscular block to a TOF ratio of 0.9 was defined as onset time, clinical duration, recovery index, recovery time, and total recovery period, respectively, and recorded. RESULTS: The onset time and recovery index time were lower (1.96 ± 0.39, 8.04 ± 2.14, respectively) with dexamethasone in comparison with saline (2.01 ± 0.51, 8.9 ± 3.4, respectively) but not statistically significant. The clinical duration, recovery time, and total recovery period were similar. CONCLUSION: Application of a single bolus dose (0.15 mg/kg) of dexamethasone during induction does not attenuate atracurium-induced neuromuscular blockade in children.

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.

Role of platelet-to-lymphocyte count ratio (PLR), as a prognostic indicator in COVID-19: A systematic review and meta-analysis.

Prognostic predictors are of paramount interest for prompt intervention and optimal utilization of the healthcare system in the ongoing context of the COVID-19 pandemic. The platelet-to-lymphocyte count ratio (PLR), has emerged as a potential tool for risk stratification of critically ill patients with sepsis. The current systematic review explores the utility of PLR as a prognostic predictor of COVID-19 patients. We screened the electronic databases until May 15, 2021 after enrolling in PROSPERO (CRD42021220269). Studies evaluating the association between PLR on admission and outcomes in terms of mortality and severity among COVID-19 patients were included. We retrieved 32 studies, with a total of 2768 and 3262 COVID-19 patients for mortality and disease severity outcomes. Deceased and critically ill patients had higher PLR levels on admission in comparison to survivors and non-severe patients (mean differences [MD] = 66.10; 95% confidence interval [CI]: 47.75-84.44; p < 0.00001 and MD = 86.74; 95% CI: 67.7-105.7; p < 0.00001, respectively). A higher level of PLR on admission in COVID-19 patients is associated with increased morbidity and mortality. However, the evidence is of low quality and further studies regarding the cut-off value of PLR are the need of the hour.

The Impact of Neutrophil-Lymphocyte Count Ratio in COVID-19: A Systematic Review and Meta-Analysis.

Background: The neutrophil-lymphocyte count ratio (NLR) has emerged as a potential prognostic tool for different diseases. In the current coronavirus disease (COVID-19) pandemic, the NLR may be a useful tool for risk scarification and the optimal utilization of limited healthcare resources. However, there is no consensus regarding the optimal value of NLR, and the association with disease severity and mortality. Thus, this study aims to systematically analyze the current evidence of the utility of baseline NLR as a predictive tool for mortality, disease severity in COVID-19 patients. Methods: A compendious screening of electronic databases up to June 15, 2021, was done after enlisting the protocol in PROSPERO (CRD42020202659). Studies evaluating the utility of baseline NLR in COVID-19 are included for this review as per the PRISMA statement. Results: We retrieved a total of 13112 and 12986 COVID-19 patients for survivability and severity over 90 studies. The expired and critically sick patients had elevated baseline NLR on admission, in comparison to survivors and noncritical patients. (SMD = 3.82; 95% CI: 2.79-4.85; I2 = 100% and SMD = 1.42; 95% CI: 1.22-1.63; I2 = 95%, respectively). The summary receiver operating curve analysis for mortality (AUC = 0.87; 95% CI: 0.86-0.87; I2 = 94.7%), and severity (AUC = 0.82; 95% CI: 0.80-0.84; I2 = 79.7%) were also suggestive of its significant predictive value. Conclusions: The elevated NLR on admission in COVID-19 patients is associated with poor outcomes.

COVID-19 infection in patients with haematological disease - A tertiary centre experience from north India.

This retrospective study was aimed to understand the clinical, laboratory, radiological parameters and the outcome of COVID-19 patients with underlying haematological disease. All patients with known haematological disease admitted with COVID-19-positive status from April to August 2020 in the COVID-19 facility of a tertiary care centre in north India, were included. Their medical records were analyzed for outcome and mortality risk factors. Fifty four patients, 37 males, were included in the study. Of these, 36 patients had haematological malignancy and 18 had benign disorder. Fever (95.5%), cough (59.2%) and dyspnoea (31.4%) were the most common symptoms. Nine patients had severe disease at diagnosis, mostly malignant disorders. Overall mortality rate was 37.0 per cent, with high mortality seen in patients with aplastic anaemia (50.0%), acute myeloid (46.7%) and lymphoblastic leukaemia (40.0%). On univariate analysis, Eastern Cooperative Oncology Group performance status >2 [odd ratio (OR) 11.6], COVID-19 severity (OR 8.2), dyspnoea (OR 5.7) and blood product transfusion (OR 6.4) were the predictors of mortality. However, the presence of moderate or severe COVID-19 (OR 16.6, confidence interval 3.8-72.8) was found significant on multivariate analysis. The results showed that patients with haematological malignancies and aplastic anaemia might be at increased risk of getting severe COVID-19 infection and mortality as compared to the general population.

Impact of COVID-19 in patients with concurrent co-infections: A systematic review and meta-analyses.

The burden and impact of secondary superadded infections in critically ill coronavirus disease 2019 (COVID-19) patients is widely acknowledged. However, there is a dearth of information regarding the impact of COVID-19 in patients with tuberculosis, HIV, chronic hepatitis, and other concurrent infections. This review was conducted to evaluate the consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in patients with concurrent co-infections based on the publications reported to date. An extensive comprehensive screening was conducted using electronic databases up to 3rd September 2020 after obtaining registration with PROSPERO (CRD420202064800). The observational studies or interventional studies in English, evaluating the impact of SARS-CoV-2 in patients with concurrent infections are included for the meta-analyses. Our search retrieved 20 studies, with a total of 205,702 patients. Patients with tuberculosis (RR = 2.10; 95% CI, 1.75-2.51; I2 = 0%), influenza (RR = 2.04; 95% CI, 0.15-28.25, I2 = 99%) have an increased risk of mortality during a co-infection with SARS-CoV-2. No significant impact is found in people living with HIV (RR = 0.99; 95% CI, 0.82-1.19; I2 = 30%), Chronic hepatitis (RR = 1.15; 95% CI, 0.73-1.81; I2 = 10%). Several countries (Brazil, Paraguay, Argentina, Peru, Colombia, and Singapore) are on the verge of a dengue co epidemic (cumulative 878,496 and 5,028,380 cases of dengue and COVID-19 respectively). The impact of COVID-19 in patients of concurrent infections with either tuberculosis or influenza is detrimental. The clinical outcomes of COVID-19 in HIV or chronic hepatitis patients are comparable to COVID-19 patients without these concurrent infections.

Rapid chromatographic immunoassay-based evaluation of COVID-19: A cross-sectional, diagnostic test accuracy study & its implications for COVID-19 management in India.

Background & objectives: Coronavirus disease 2019 (COVID-19) has so far affected over 41 million people globally. The limited supply of real-time reverse transcription-polymerase chain reaction (rRT-PCR) kits and reagents has made meeting the rising demand for increased testing incompetent, worldwide. A highly sensitive and specific antigen-based rapid diagnostic test (RDT) is the need of the hour. The objective of this study was to evaluate the performance of a rapid chromatographic immunoassay-based test (index test) compared with a clinical reference standard (rRT-PCR). Methods: A cross-sectional, single-blinded study was conducted at a tertiary care teaching hospital in north India. Paired samples were taken for RDT and rRT-PCR (reference standard) from consecutive participants screened for COVID-19 to calculate the sensitivity and specificity of the RDT. Further subgroup analysis was done based on the duration of illness and cycle threshold values. Cohen's kappa coefficient was used to measure the level of agreement between the two tests. Results: Of the 330 participants, 77 were rRT-PCR positive for SARS-CoV-2. Sixty four of these patients also tested positive for SARS-CoV-2 by RDT. The overall sensitivity and specificity were 81.8 and 99.6 per cent, respectively. The sensitivity of RDT was higher (85.9%) in participants with a duration of illness ≤5 days. Interpretation & conclusions: With an excellent specificity and moderate sensitivity, this RDT may be used to rule in COVID-19 in patients with a duration of illness ≤5 days. Large-scale testing based on this RDT across the country would result in quick detection, isolation and treatment of COVID-19 patients.

Intensive care management of patients with COVID-19.

The COVID-19 pandemic originated in China in December 2019 and has since then, swept across the world. The last Influenza pandemic of 1918 happened before the advent of modern medicine. We have come a long way since then. But the pandemic has still caught us unprepared in many quarters. The review focuses on the management of critically ill COVID-19 patients and the various challenges faced by intensivists.

Medial versus lateral approach in ultrasound-guided costoclavicular brachial plexus block for upper limb surgery: a randomized control trial.

INTRODUCTION: Costoclavicular brachial plexus block has become a procedure of choice for surgical anaesthesia or analgesia in upper limb surgery. The technique is not standardised yet, and two approaches are currently employed: the medial and lateral approach. Our study aims to compare the two approaches in terms of performance time and patient-specific clinical outcomes. MATERIAL AND METHODS: The primary outcome assessed was performance time. The secondary outcomes were imaging time, needling time, block onset time, total anaesthesia time, anaesthesia success, and performer difficulty score. RESULTS: Of 59 patients, 30 patients were randomized to Group M and 29 patients were randomized to Group L. We conducted statistical analysis using a modified intention-to-treat approach. The mean ± SD for performance time (in minutes) was 11.9 ± 3.8 in Group M and 9.4 ± 4.1 in Group L with a difference between means (95% CI) of 2.4 (0.3 to 4.5) ( P < 0.05). The median (interquartile range) needling time of Group M was 9.5 minutes (5-16) vs. 7 (4-19) in Group L ( P = 0.035). Among patients, 40%, 26.67%, 33.3% in Group M had grade 3, 2, 1 performer difficulty whereas 10.3%, 37.9%, 51.7% in Group L had grade 3, 2, 1 performer difficulty, respectively ( P = 0.032). The mean performance time was 9.95 minutes in patients with body mass index (BMI) 25 ( P = 0.0243). CONCLUSIONS: Our study revealed that the medial approach has no significant advantage over the lateral approach with regards to performance time, imaging time, needling time, and performer difficulty. Both performance time and performer difficulty increase with BMI and depth of the cords, with a larger difference in the medial approach.

Effect of preprocedure anxiety and oestrogen levels on Postoperative Nausea and Vomiting in patients undergoing diagnostic laparoscopy and hysteroscopy for infertility: A prospective observational pilot study.

BACKGROUND: Females undergoing laparoscopic gynaecological surgeries have a high incidence of postoperative nausea and vomiting. Apart from the established risk factors, hormonal, psychological, genetic and ethnic factors may also contribute to postoperative nausea and vomiting. This study aimed to evaluate the relationship between preoperative anxiety and serum oestrogen level with postoperative nausea and vomiting in patients undergoing diagnostic laparoscopy - hysteroscopy for infertility. METHODS: In total, 100 female patients, between the ages of 20-40 years, undergoing diagnostic laparoscopy - hysteroscopy for infertility were recruited for this study. Preoperative anxiety level was assessed using Depression, Anxiety and Stress Scale-21 (DASS-21) Questionnaire. Serum oestrogen samples were taken before anaesthesia. Postoperative nausea and vomiting grading was rated with 0-3 Likert-type scale. An association of anxiety and oestrogen levels to postoperative nausea and vomiting was done. RESULTS: The analysis between median DASS 21 scores to postoperative nausea and vomiting grading showed no association between DASS 21 scores and postoperative nausea and vomiting grades. Comparing the mean oestrogen levels in patients among each grade of postoperative nausea and vomiting showed no significant difference in the mean oestrogen levels. CONCLUSION: Our study did not find evidence of a significant association between serum oestrogen levels, preoperative anxiety, and postoperative nausea and vomiting.

Comparative evaluation of isoflurane and desflurane for postoperative cognitive decline in elderly patients: A prospective observational pilot study.

BACKGROUND: Approximately 16%-62% of patients undergoing non cardiac surgeries develop postoperative cognitive dysfunction. We compared the incidence of postoperative cognitive dysfunction in older adults aged 60-80 years who underwent open abdominal surgeries under general anaesthesia using isoflurane or desflurane and correlated it with the serum concentration of interleukin 1, interleukin 6, tumour necrosis factor alpha, amyloid ß and S100 on postoperative day 3. METHOD: Forty American Association of Anesthesiologists Physical Classification I or II patients were included after acquiring institutional ethics committee approval, registering in the Clinical Trials Registry - India, and informed written consent. They underwent open abdominal surgery under general anaesthesia and epidurals between 2017 and 2019. Patients with substance abuse or any disorder affecting cognition were excluded. Postoperative cognitive dysfunction was assessed by Stroop test, Wisconsin Card Sorting Test, Trail making test - B, Porteus Maze test, PGI memory scale, mini-mental state examination, and Bender Gestalt test the day before surgery and on the third postoperative day along with blood samples. RESULTS: Thirty-seven percent of the patients developed postoperative cognitive dysfunction. The risk was similar to isoflurane in comparison with desflurane (risk ratio: 0.65, 95% confidence interval: 0.30, 1.40). A significant percentage increase in reaction time for Porteus Maze test and Trail making test - B was noted with isoflurane (6.69 (4.20-8.94) and 8.01 (2.08-12.5), respectively) in comparison with desflurane group (13.01 (9.09-17.33), p = 0.003 and 11.62 (7.5-17.5), p = 0.017, respectively). CONCLUSION: Isoflurane and desflurane had a similar impact on the elderly for developing postoperative cognitive dysfunction and no correlation with any of the biomarkers used in the study on postoperative day 3.

Effectiveness of electroconvulsive therapy in acute management of delirious mania in COVID-19 positive woman in second trimester pregnancy.

Delirious mania has been described as a state of acute excitement, fluctuating sensorium, affective and catatonic symptoms. Electroconvulsive therapy (ECT) despite being an effective treatment modality in such cases, has been under-utilised during pregnancy, mainly due to safety concerns. Here, we report the effectiveness of ECT in acute management of delirious mania in a 24 weeks pregnant woman who also tested COVID-19 positive during hospitalisation. Patient presented with three weeks history of acute manic excitement with period of altered sensorium and catatonic symptoms with no response to trials of two antipsychotic agents. After organic causes ruled out, patient was planned for ECT while ongoing antipsychotic was continued. After the first ECT session, patient tested positive for COVID-19, though asymptomatic and had to be shifted to COVID-19 isolation facility. Complete resolution of psychiatric symptoms occurred after fifth ECT. All five ECT sessions, including those in COVID-19 isolation facility were carried out under supervision of a multidisciplinary team. None of the ECT sessions had any major adverse event. Symptom remission sustained even following ECT discontinuation. No neonatal or maternal adverse effects observed after an uneventful delivery at 35 weeks. Both mother and child continued to maintain well in follow-up period of one year on oral olanzapine. In this unusual concurrent presentation of mania, delirium and catatonic symptoms during second trimester pregnancy, we highlighted the effectiveness and safety of ECT as a viable treatment modality. Additionally, management challenges posed by patient testing COVID-19 positive and then, administering ECT in COVID-19 isolation facility using personal protective equipment by multidisciplinary team has been highlighted.

Is it a challenging task to work with personal protective equipment in a COVID-19 ICU: Findings from a hospital-based cross-sectional study from north India.

Introduction: Amidst the coronavirus disease 2019 (COVID-19) pandemic, the use of personal protective equipment (PPE) is mandatory for healthcare workers to remain protected against infection. The present study was undertaken to evaluate challenges faced by the healthcare workers while using level 3 PPE. Methods: This hospital-based study was conducted among resident doctors selected by convenience sampling method using a pretested, semi-structured, self-administered questionnaire after getting informed consent from the participants to collect data on the somatic, psychological, and technical problems faced while working in PPE. Bivariate and multivariable logistic regression was done between outcome variables and other independent variables to check for the association. Results: Of the total, 252 resident doctors completed the survey, their age ranged from 22 to 36 years with 140 (55.6%) males and 112 (44.4%) females. One-twenty-nine (51.2%) residents were trained to work in ICU, 73 (29%) participants used PPE ≤10 times and the rest 179 (71%) used PPE more than 10 times. The difficulties faced were as follows: visual impairment (n = 244, 96.8%), headache (n = 226, 89.6%), breathing difficulty (n = 216, 85.7%), hearing impairment (n = 201, 79.8%), sweating (n = 242, 96%), and fear of being infected (n = 156,61.9%). Two-thirty-six (93.6%) participants felt that overall work quality reduced due to PPE. Headache, hunger, urge to micturate, anxiety, sleep disturbances, and need to change the timing of medication or diet were higher with increased duration of work with PPE. Conclusion: A longer duration of work is associated with headache, hunger, anxiety, and sleep disturbances. More research has to be done to improve the PPE to reduce problems like visual impairment, skin irritation, sweating, and breathing difficulty.

Clinical profile of ChAdOx1 nCoV-19- and BBV152-vaccinated individuals among hospitalized COVID-19 patients: a pair-matched study.

Background: COVID-19 infections among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-vaccinated individuals are of clinical concern, especially in those requiring hospitalization. Such real-world data on ChAdOx1 nCoV-19- and BBV152-vaccinated individuals are scarce. Hence, there is an urgent need to understand their clinical profile and outcomes. Methods: A 1:1 pair-matched study was performed among vaccinated and unvaccinated COVID-19 patients admitted between March 2021 and June 2021 at a tertiary care centre in New Delhi, India. The vaccinated group (received at least one dose of ChAdOx1 nCoV-19 or BBV152) was prospectively followed till discharge or death and matched [for age (±10 years), sex, baseline disease severity and comorbidities] with a retrospective group of unvaccinated patients admitted during the study period. Paired analysis was done to look for clinical outcomes between the two groups. Results: The study included a total of 210 patients, with 105 in each of the vaccinated and unvaccinated groups. In the vaccinated group, 47 (44.8%) and 58 (55.2%) patients had received ChAdOx1 nCoV-19 and BBV152, respectively. However, 73 patients had received one dose and 32 had received two doses of the vaccine. Disease severity was mild in 36.2%, moderate in 31.4% and severe in 32.4%. Two mortalities were reported out of 19 fully vaccinated individuals. All-cause mortality in the vaccinated group was 8.6% (9/105), which was significantly lower than the matched unvaccinated group mortality of 21.9% (23/105), p = 0.007. Vaccination increased the chances of survival (OR = 3.8, 95% CI: 1.42-10.18) compared to the unvaccinated group. Conclusion: In the second wave of the pandemic predominated by delta variant of SARS CoV-2, vaccination reduced all-cause mortality among hospitalized patients, although the results are only preliminary.

Epidural Fever: Hiding in the Shadows.

Recent research has focused on inflammation and oxidative stress that is seen in women developing intrapartum fever. The interleukin-6 (IL-6) levels have been found to be elevated in women who receive epidural analgesia and become febrile. This suggests that the epidural itself induces an inflammatory response and it is not a physiologic process of labour. Similar findings with additional proinflammatory mediators and reactive oxygen species seem to support this theory. Epidural analgesia also affects the body's thermoregulatory mechanisms. It causes an increase in shivering and appears to be associated with a decrease in heat dissipation via sweating and hyperventilation, most likely because of blockade of the sympathetic stimulation. Considering these factors, it is probable that epidurals do contribute to the development of the associated fever. There remains the possibility that subclinical chorioamnionitis might be the underlying cause of a subset of maternal intrapartum fevers. In summary, histologic chorioamnionitis and epidural analgesia appear to be the independent contributors to intrapartum fever.

Poor outcomes in patients with cirrhosis and Corona Virus Disease-19.

BACKGROUND AND AIM: There is a paucity of data on the clinical presentations and outcomes of Corona Virus Disease-19 (COVID-19) in patients with underlying liver disease. We aimed to summarize the presentations and outcomes of COVID-19-positive patients and compare with historical controls. METHODS: Patients with known chronic liver disease who presented with superimposed COVID-19 (n = 28) between 22 April 2020 and 22 June 2020 were studied. Seventy-eight cirrhotic patients without COVID-19 were included as historical controls for comparison. RESULTS: A total of 28 COVID-19 patients (two without cirrhosis, one with compensated cirrhosis, sixteen with acute decompensation [AD], and nine with acute-on-chronic liver failure [ACLF]) were included. The etiology of cirrhosis was alcohol (n = 9), non-alcoholic fatty liver disease (n = 2), viral (n = 5), autoimmune hepatitis (n = 4), and cryptogenic cirrhosis (n = 6). The clinical presentations included complications of cirrhosis in 12 (46.2%), respiratory symptoms in 3 (11.5%), and combined complications of cirrhosis and respiratory symptoms in 11 (42.3%) patients. The median hospital stay was 8 (7-12) days. The mortality rate in COVID-19 patients was 42.3% (11/26), as compared with 23.1% (18/78) in the historical controls (p = 0.077). All COVID-19 patients with ACLF (9/9) died compared with 53.3% (16/30) in ACLF of historical controls (p = 0.015). Mortality rate was higher in COVID-19 patients with compensated cirrhosis and AD as compared with historical controls 2/17 (11.8%) vs. 2/48 (4.2%), though not statistically significant (p = 0.278). Requirement of mechanical ventilation independently predicted mortality (hazard ratio 13.68). Both non-cirrhotic patients presented with respiratory symptoms and recovered uneventfully. CONCLUSION: COVID-19 is associated with poor outcomes in patients with cirrhosis, with worst survival rates in ACLF. Mechanical ventilation is associated with a poor outcome.

Avoiding ICU Admission by Using a Fast-Track Protocol Is Safe in Selected Adult-to-Adult Live Donor Liver Transplant Recipients.

BACKGROUND: We evaluated patient characteristics of live donor liver transplant (LDLT) recipients undergoing a fast-track protocol without intensive care unit (ICU) admission versus LDLT patients receiving posttransplant ICU care. METHODS: Of the 153 LDLT recipients, 46 patients were included in our fast-track protocol without ICU admission. Both, fast-tracked patients and ICU-admitted patients were compared regarding donor and patient characteristics, perioperative characteristics, and postoperative outcomes and complications. In a subgroup analysis, we compared fast-tracked patients with patients who were admitted in the ICU for less than 24 hours. RESULTS: Fast-tracked versus ICU patients had a lower model for end-stage liver disease score (13 ± 4 vs 18 ± 7; P < 0.0001), lower preoperative bilirubin levels (51 ± 50 µmol/L vs 119.4 ± 137.3 µmol/L; P < 0.001), required fewer units of packed red blood cells (1.7 ± 1.78 vs 4.4 ± 4; P < 0.0001), and less fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 5; P < 0.0001) during transplantation. Regarding postoperative outcomes, fast-tracked patients presented fewer bacterial infections within 30 days (6.5% [3] vs 29% [28]; P = 0.002), no episodes of pneumonia (0% vs 11.3% [11]; P = 0.02), and less biliary complications within the first year (6% [3] vs 26% [25]; P = 0.001). Also, fast-tracked patients had a shorter posttransplant hospital stay (10.8 ± 5 vs 21.3 ± 29; P = 0.002). In the subgroup analysis, fast-tracked vs ICU patients admitted for less than 24 hours had lower requirements of packed red blood cells (1.7 ± 1.78 vs 3.9 ± 4; P = 0.001) and fresh-frozen plasma (2.7 ± 2 vs 5.8 ± 4.5; P = 0.0001). CONCLUSIONS: Fast-track of selected patients after LDLT is safe and feasible. An objective score to perioperatively select LDLT recipients amenable to fast track is yet to be determined.