Atrial Fibrillation (AFIB) in the ICU: Incidence, Risk Factors, and Outcomes: The International AFIB-ICU Cohort Study.

OBJECTIVES: To assess the incidence, risk factors, and outcomes of atrial fibrillation (AF) in the ICU and to describe current practice in the management of AF. DESIGN: Multicenter, prospective, inception cohort study. SETTING: Forty-four ICUs in 12 countries in four geographical regions. SUBJECTS: Adult, acutely admitted ICU patients without a history of persistent/permanent AF or recent cardiac surgery were enrolled; inception periods were from October 2020 to June 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 1,423 ICU patients and analyzed 1,415 (99.4%), among whom 221 patients had 539 episodes of AF. Most (59%) episodes were diagnosed with continuous electrocardiogram monitoring. The incidence of AF was 15.6% (95% CI, 13.8-17.6), of which newly developed AF was 13.3% (11.5-15.1). A history of arterial hypertension, paroxysmal AF, sepsis, or high disease severity at ICU admission was associated with AF. Used interventions to manage AF were fluid bolus 19% (95% CI 16-23), magnesium 16% (13-20), potassium 15% (12-19), amiodarone 51% (47-55), beta-1 selective blockers 34% (30-38), calcium channel blockers 4% (2-6), digoxin 16% (12-19), and direct current cardioversion in 4% (2-6). Patients with AF had more ischemic, thromboembolic (13.6% vs 7.9%), and severe bleeding events (5.9% vs 2.1%), and higher mortality (41.2% vs 25.2%) than those without AF. The adjusted cause-specific hazard ratio for 90-day mortality by AF was 1.38 (95% CI, 0.95-1.99). CONCLUSIONS: In ICU patients, AF occurred in one of six and was associated with different conditions. AF was associated with worse outcomes while not statistically significantly associated with 90-day mortality in the adjusted analyses. We observed variations in the diagnostic and management strategies for AF.

The role of ROX index-based intubation in COVID-19 pneumonia: a cross-sectional comparison and retrospective survival analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) patients with acute respiratory failure who experience delayed initiation of invasive mechanical ventilation have poor outcomes. The lack of objective measures to define the timing of intubation is an area of concern. We investigated the effect of timing of intubation based on respiratory rate-oxygenation (ROX) index on the outcomes of COVID-19 pneumonia. METHODS: This was a retrospective cross-sectional study performed in a tertiary care teaching hospital in Kerala, India. Patients with COVID-19 pneumonia who were intubated were grouped into early intubation (within 12 hours of ROX index <4.88) or delayed intubation (12 hours or more hours after ROX <4.88). RESULTS: A total of 58 patients was included in the study after exclusions. Among them, 20 patients were intubated early, and 38 patients were intubated 12 hours after ROX index <4.88. The mean age of the study population was 57±14 years, and 55.0% of the patients were male; diabetes mellitus (48.3%) and hypertension (50.0%) were the most common comorbidities. The early intubation group had 88.2% successful extubation, while only 11.8% of the delayed group had successful extubation (P<0.001). Survival was also significantly more frequent in the early intubation group. CONCLUSIONS: Early intubation within 12 hours of ROX index <4.88 was associated with improved extubation and survival in patients with COVID-19 pneumonia.

Comparison of Efficacy of External Laryngeal Manipulation (ELM) from Right Versus Left Side during Modified Bimanual Laryngoscopy-A Randomised Cross Over Trial.

BACKGROUND: Glottic view differed when assistants provide external laryngeal manipulation (ELM) from right or left side. Objectives were to compare glottic view during direct laryngoscopy with ELM applied by assistant stationed on right side of scopist versus left. Primary outcome was best percentage of glottic opening (POGO) score. Secondary outcome was proportion of patients requiring switch back to initial intervention for best glottic view and intubation. METHODS: With Institutional Review Board and Ethics Committee approval and written informed consent, this randomised cross over trial enrolled participants of American Society of Anesthesiologists (ASA) grade I-II aged 20-70 years for elective surgery under General Anaesthesia (GA). Study interventions were application of ELM during modified bimanual laryngoscopy by trained assistant on right (ELM-R) and left (ELM-L) sides in each participant as per random sequence. RESULTS: Of the 150 participants, 68 were analysed for study interventions using Wilcoxon matched pairs test. Thirty three participants received interventions first from ELM-R and subsequently from ELM-L, while 35 had interventions vice versa. Median POGO score with ELM-R was 40 (IQR: 32.5, 50) and with ELM-L 30 (IQR: 20, 40). There was 10% difference in POGO score between interventions found to be significant (P < .05). Fifty six out of 68 (82.35%) participants had better POGO score when intervention was from right side. Proportion requiring switch back to initially applied intervention was 66.7% (22 out of 33) with ELM-R and 2.9% (one out of 35) with ELM-L. CONCLUSION: For best glottic view, ELM applied by an assistant by right hand standing on right side of scopist is more effective.

Efficacy of Multimodal Intervention Strategies in Improving Perioperative Documentation at a Rural Tertiary Care Centre.

OBJECTIVE: To assess the efficacy of intervention strategies in improving perioperative anaesthetic documentation. METHODS: This interventional study was conducted at our hospital over a period of 5 months, i.e. from October 2016 to February 2017. The subjects were anaesthetic consultants. The perioperative anaesthetic documentation of patients who received general anaesthesia was studied by retrospectively reviewing 100 patient charts before the application of intervention strategies. Intervention measures included lecture sessions, posters and handouts to highlight the important parameters to be documented. Later, another set of 100 patient charts of cases who received general anaesthesia from the same group of anaesthetic consultants were retrospectively reviewed. The recommendations of the Australia and New Zealand College of Anaesthetists were taken as the gold standard. A point-based scoring sheet was used for evaluation. Data were analysed using Microsoft Excel, and the statistical test used was the Mann-Whitney U Test. RESULTS: Documentation standards were significantly improved in the post intervention group compared to the pre intervention group. Furthermore, documentation scores were lower in emergency cases compared to elective cases in both groups. CONCLUSION: Multimodal intervention strategies resulted in higher perioperative documentation scores, and scores were lower in emergency cases than in elective cases in both groups.