Indian Journal of Critical Care Medicine
Volume 25 | Issue S1 | Year 2021


1. Acute Kidney Injury and Hemofiltration

1. Acute Kidney Injury in Severely Preeclamptic Patients Admitted to ICU: Epidemiology and Role of Serum Neutrophil Gelatinase-Associated Lipocalcin. (Conference Abstract ID: 176)

Pooja Yadav, Asha Tyagi, Asha Tyagi, Rashmi Salhotra, Shukla Das, Praveen Singh

UCMS and GTB Hospital, Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.1

Introduction: Critically ill preeclamptic patients may have risk factors for acute kidney injury (AKI). Neutrophil gelatinase-associated lipocalcin (NGAL) is a validated biomarker to predict AKI. We could locate scanty data regarding the epidemiology of AKI and the role of NGAL in preeclamptic patients admitted to ICU.

Materials and methods: Preeclamptic patients admitted to multidisciplinary ICU were included. The occurrence of AKI and its severity for the entire ICU stay using KDIGO criteria, risk factors, and serum NGAL were assessed.

Results: From 52 preeclamptic patients admitted to ICU, majority had eclampsia (75%). The ICU mortality was 15.4%. AKI developed in 25 (48.1%) patients; with stage 1, 2 and 3 in 56%, 36% and 8% respectively. Incidence of sepsis (16% versus 0%), shock (40% versus 7.4%), and anaemia (84% versus 59.3%) was significantly greater in patients with AKI (P < 0.05). ICU mortality (28% versus 3.7%), duration of ICU and hospital stay were significantly higher in preeclamptics with AKI (P < 0.05). Serum NGAL (274 [240-335] ng/ml) showed no association with AKI or mortality (P = 0.725, 0.861); but significant prediction for eclampsia [P = 0.019; AUC = 0.736 (95% CI: 0.569 – 0.904)].

Discussions: The present prospective cohort study aimed to evaluate AKI in a specific subset of critically ill obstetric patients viz., those with preeclampsia. While there is little previous data on AKI in critically ill preeclamptic patients, it has been evaluated among those with the disease but not admitted to ICU.11–13 The incidences herein were reported in a lower percentage than our results viz., 15.3 and 17%.11,12 The much greater incidence noted by us can be attributed to an increased presence of risk factors for AKI encountered in those admitted to the ICU, such as, sepsis and shock.

Conclusion: AKI is common among preeclamptic patients admitted to ICU, but serum NGAL does not predict AKI in these patients.

2. Clinicopathological Spectrum of Kidney Diseases in Patients with Type 2 Diabetes Mellitus: A Record-based Retrospective Study. (Conference Abstract ID: 128)

Vijay Patidar, RK Jha, Sonam Verma

Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.2

Introduction: Non-diabetic kidney diseases (NDKD) have been observed to contribute to a considerably large fraction (one-third)1–4 of kidney diseases among patients with type 2 diabetes mellitus. Through this study, an estimate of the general pattern of diabetic, non-diabetic, and mixed kidney disease will be obtained.

Materials and methods: Study design: Record-based retrospective study.

Study place: SAIMS Medical College Indore.

Inclusion: All type 2 diabetic patients with kidney disease who have undergone biopsy.

Results: A total of 153 patients underwent biopsy. Out of which 110 were men and 43 were women, and the average age being 51.97 ± 10.52. Nephrotic level proteinuria (4+) is significantly high (22.2%) in Group1 patients as compared to the rest. Group 3 predominantly (34.3%) shows insignificant proteinuria which is less than 250 mg/day. 3+ proteinuria is most common.

Discussions: NDKD amounted to 52.87% [out of which NDKD superimposed on diabetic kidney disease (DKD) was 30%, isolated NDKD was 22.87%]. The pro-portion of NDKDs ranged from 21 to 52% in other studies.

Conclusion: NDKDs do occupy a considerable fraction of kidney diseases of type 2 diabetes patients. Their presentation is however different (low degrees of proteinuria, younger patient age).

3. Failing Kidney and a Preserved Heart. (Conference Abstract ID: 92)

C Jayadevi

Govt Villupuram Medical College Hospital, Villupuram, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.3

Introduction: About a half of patients with heart failure have heart failure with preserved ejection fraction (HFpEF), nevertheless HFpEF could be overlooked in the intensive care unit (ICU). The symptoms of HFpEF are similar to those of heart failure with reduced ejection fraction (HFrEF). Acute decompensated HFrEF is a well-known cause of oliguric acute kidney injury (AKI) and it may present as severe AKI requiring extracorporeal ultrafiltration therapy. AKI resulting from acute decompensated heart failure constitutes acute cardiorenal syndrome (CRS) also referred to as type 1 CRS. HFpEF could also lead to AKI but the diagnosis of HFpEF may be overlooked in the setting of AKI since the congestive manifestations of HFpEF are akin to volume overload symptoms resulting from AKI. In such a setting unless thoughtfully considered, the diagnosis of HFpEF might be overlooked and the etiology of AKI may remain elusive. It is crucial to make a prompt diagnosis of HFpEF in the ICU to fix the etiology of AKI in the ICU. We report the case of a 70-year-old woman who presented with oliguric AKI, marked edema, NYHA class IV heart failure, and summarize the diagnostic workup that led to a final diagnosis of HFpEF.

Materials and methods: A 70-year-old woman presented to the emergency room with dyspnea at rest, orthopnea, ankle edema of 1-week duration, and oliguria of 1-day duration. Her urine output was 300 mL in 24 hours. She was a known diabetic and hypertensive. During a routine evaluation 3 months before the current illness, her urine dipstick revealed no overt proteinuria and her serum creatinine was 0.7 mg/dL with an eGFR of 88 mL/min/1.73 m2 by CKD-EPI equation. On admission, she was dyspneic, tachypneic, extremities were warm, she had bilateral pitting ankle edema, jugular venous pressure (JVP) was raised, pulse was 102/minute, regular, BP was 160/90 mm Hg, oxygen saturation while breathing ambient air was 82%, auscultation revealed normal heart sounds and bilateral basal rhales. She had a body mass index (BMI) of 26 kg/m2. Electrocardiogram revealed sinus tachycardia, left ventricular hypertrophy. Chest X-ray revealed cardiomegaly, bilateral pleural effusion, and pulmonary venous congestion. Echocardiogram revealed concentric left ventricular hypertrophy, left ventricular ejection fraction (LVEF) of 52%, the systolic pressure in the pulmonary artery by Doppler was 37 mm Hg indicating pulmonary hypertension, E/e’ by tissue Doppler imaging was 19.1 indicating increased filling pressure, there was no regional wall motion abnormality. The inferior vena cava measured 22 mm. Her central venous pressure was 19 mm Hg. Urine analysis revealed trace protein, spot urine sodium was 4 mol/L. Ultrasonogram revealed normal-sized kidneys with normal cortical echoes. Her serum creatinine was 1.2 mg/dL (eGFR 48 mL/min/1.73 m2) NT-Pro BNP was 17,100 pg/mL (reference < 300 pg/mL) and BNP was 241 pg/mL (reference < 100 pg/mL).

Results: This patient presented with stage 3 AKI (1) with oliguria lasting for 24 hours. Her serum creatinine had increased from 0.7 to 1.2 mg/dL. A low spot urine sodium and a high blood urea/creatinine ratio are suggestive of a renal hypoperfusion state. She had manifestations like resting dyspnea, edema, raised JVP, resting hypoxia and pleural effusion consistent with decompensated heart failure. Given the presentation with marked peripheral and pulmonary congestion that was disproportionate to the fall in GFR one would be inclined to consider differentials like acute glomerulonephritis and acute or type 1 cardiorenal syndrome (CRS).

Discussions: Type 1 CRS becomes the prime diagnostic consideration in this patient. The LVEF by definition is <40% in HFrEF.3 This patient had an ejection fraction of 52% and her clinical presentation with heart failure should arouse suspicion of HFpEF. Although HFpEF accounts for about a half of the patients with heart failure,4 it is often overlooked in clinical practice. Diagnosis of HFpEF4,5 relies on excluding other cardiac and non-cardiac causes of dyspnea in a patient presenting with symptoms and signs consistent with heart failure and preserved left ventricular ejection fraction > 50%. The H2FPEF scoring system6 is a clinical tool that utilizes clinical and echocardiographic parameters to estimate the probability of HFpEF as the cause of dyspnea. This patient had an H2FPEF score of 4 out of 9 (0/2 points for BMI > 30 kg/m2; 1/1 point for hypertension, 0/3 points for atrial fibrillation; 1/1 point for pulmonary artery systolic hypertension; 1/1 point for age > 60; 1/1 point for elevated filling pressure E/e’ > 9). An H2FPEF score of 6 or more is associated with a high probability (>90%) of HFpEF while a score between 2 and 5 is associated with intermediate (40–80%) probability of HFpEF. Our patient had a score of 4. If the H2FPEF score is intermediate then a diagnosis of HFpEF could be established by a raised brain natriuretic peptide (BNP) > 100 pg/mL or N-terminal pro-brain natriuretic peptide (NT-Pro BNP) > 300 pg/mL7 after exclusion of other causes of dyspnea. No other pulmonary or cardiac cause of dyspnea was apparent in this patient. BNP might be elevated in patients with renal failure whether or not they have heart failure.8,9 Elevation of BNP in renal failure might result from volume expansion and left ventricular hypertrophy.9 NT-Pro BNP is cleared by glomerular filtration and hence its plasma level may increase in patients with renal failure. Hence, the diagnostic specificity of NT-Pro BNP for HFpEF is questionable in the presence of renal failure. A study used an NT-Pro BNP cut-off point of 1,200 pg/mL for patients with GFR < 60 mL/min/1.73 m2 and found the sensitivity and specificity to be 89 and 72%.10 The NT-Pro BNP in our patient was 17,100 pg/mL. Old age, hypertension, and diabetes mellitus could have predisposed to HFpEF in our patient.

Conclusion: The congestive clinical manifestations resulting from HFpEF are similar to volume overload resulting from renal failure and hence the diagnosis of HFpEF could be overlooked in the setting of AKI.

4. Pass—A Novel Study to Predict Recovery from AKI in Critically Ill Adult ICU Patients. (Conference Abstract ID: 55)

Dattatray Prabhu, Sonali Dattatray Prabhu, M Chakrapani, Mayoor Vasant Prabhu

Kasturba Medical College Mangalore, Affiliated to Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.4

Introduction: Acute kidney injury and sepsis are highly prevalent in intensive care patients (20–50%) and have a direct effect on mortality and morbidity. Our objective was to evaluate if acute kidney injury (AKI) is going to be persistent or transient in patients admitted with sepsis to intensive care unit (ICU), using variables collected at the time of admission and to develop a formula—persistent AKI scoring system (PASS) to predict recovery.

Materials and methods: The study was conducted over a period of 8 months with a total sample size of 63 participants who were critically ill ICU patients diagnosed with sepsis and AKI. The study was conducted after approval from the ethics and scientific committee and informed consent forms were obtained from the patients/relatives before inclusion. Parameters like serum creatinine (SCr), base excess (BE), plethysmographic variability index (PVI), caval index, R wave variability, mean arterial pressure (MAP), and renal resistivity index (RI) using renal Doppler and need for vasopressors were assessed on admission. Patients were managed with standard protocols with fluid resuscitation and other specific treatments. After 6 hours of fluid resuscitation, the hemodynamic status and volume status of the patient was assessed. Patients were classified as volume responders or non-responders depending on hemodynamic stabilization using parameters like systolic blood pressure and MAP. Reassessment of all the variables was done at 24 and 72 hours after admission including estimation of caval index, amplitude change in R wave, MAP, renal RI, and need for vasopressors. The primary outcome was persistent AKI after 72 hours. The secondary outcome was an initiation of dialysis and death within 15 days of admission.

Results: Thirty-four Thirty-four subjects in this study recovered from AKI. Thirty-two patients showed volume response with respect to hemodynamic parameters and 31 patients were non-responders to fluid resuscitations. Response to fluid, MAP at admission, change in MAP after 6 hours, base excess at admission, requirement of vassopressers (noradrenaline) and PVI at admission did not correlate with recovery of AKI. Renal resistive Index at admission (RI), R wave variability at admission (RVI) and Serum creatinine (S Cr.) at admission correlated well with recovery from AKI which was statistically significant (p value < 0.005). Cut offs for these parameters were derived from the ROC curve analysis. Hence, these 3 parameters were evaluated further to develop the model for predicting recovery from AKI. Multiple logistic regression showed that Creatinine < 2.36 mg%, R wave > 14.45 and Resistive Index < 0.8 at the time of admission were correlated with recovery from AKI with Adjusted Odds ratios of 5.447, 4.032 and 6.208 respectively (Table 1). Based on this, following formula was constructed in which Serum creatinine, R wave variability and renal RI were allotted points:Sensitivity, specificity, predictive value, diagnostic accuracy and Kappa value for S. Creatinine, resistive index at admission and R wave at admission are shown in Table 3. Score >7.8 has sensitivity of 79.4% sensitivity and 72.4% specificity for recovery from AKI. The test has a positive predictive value of 81.8% and negative predictive value of 76.7%. The test and the gold standard agree on 50 out of 63 having a diagnostic accuracy of 79.34%. The Kappa value of 0.586 indicates good agreement with a p value of <0.001. ROC curve analysis showed that PASS Score>7.8 had area under ROC curve of 0.85 (95% confidence interval 0.755 to 0.943; p < 0.001). Table 1: P Adjusted Odds ratio 95% C.I. for Odds Ratio Lower Upper Creatinine > 2.36 0.010 5.447 1.494 19.859 R wave >14.45 0.038 4.032 1.083 15.011 Resistive Index <0.8 0.005 6.208 1.750 22.021. Table 2: Parameter Cutoff Points Creatinine <2.36 5.4 >2.36 0 R wave at admission >14.45 4.0 <14.45 0 Resistive index on admission <0.8 6.2 >0.8 0.Table 3: parameter RI at Admission <0.8 SCr at Admission <2.36 R Wave V @Admission > 14.45 PASS > 7.8 SENSITIVITY 79.30% 72.40% 73.50% 79.40% specificity 58.80% 70.60% 58.60% 79.30% positive predictive value 62.20% 67.70% 67.60% 81.80% negative predictive value 76.90% 75.00% 65.40% 76.70% diagnostic accuracy 68.25% 71.43% 66.67% 79.37% kappa statistics 0.374 0.428 0.324 0.586 p value 0.004 0.001 0.012 <0.001

Fig. 1: Flowchart to guide management

Discussions: Persistent AKI is the commonest cause of morbidity and mortality in sepsis patients. This study helps to predict recovery of AKI in critically ill ICU patients admitted with AKI and sepsis by using noninvasive easily available bedside parameters at the time of admission. We have developed a simple formula “PASS” which helps in predicting recovery from renal angina where we have allotted points for Se creatinine, R wave variability, and renal resistive index. PASS formula stands for persistent AKI scoring system. Formula: [SCr points × 5.4] + [R wave variability points × 4.0] + [RI points × 6.2] = Total score. A total score of more than 7.8 predicted recovery from AKI. We have also prepared a flow chart (Fig. 1) which can help in guiding management and is used as a tool for prediction to identify salvageable renal angina for aggressive patient management and fluid resuscitation.

Conclusion: PASS study can be a simple bedside method to reliably identify potential patients at high risk of persistent AKI and those who can be salvaged by initiating appropriate aggressive fluid resuscitation therapy. Moreover, PASS can be used in rural areas to assess and refer patients at the earliest to higher centers without delay so that appropriate management can be done.

2. Acute Respiratory Failure and Ventilation

1. A Randomized Controlled Trial of Non-Invasive Ventilation with Adaptive Support Ventilation vs Neurally Adjusted Ventilator Assist in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. (Conference Abstract ID: 189)

Inderpaul Singh Sehgal, Bharath Chabbria, Ritesh Agarwal, Kuruswamy Thrai Prasad

Postgraduate Institute of Medical Education and Research, Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.5

Introduction: Background: We have previously demonstrated a reduction in noninvasive ventilation (NIV) failure rates with the use of neurally adjusted ventilator assist (NAVA) during NIV in acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Adaptive support ventilation (ASV) is a closed-loop mode of ventilation, designed to minimize the work of breathing. No previous study has compared NIV-NAVA with NIV-ASV in the management of respiratory failure due to AECOPD.

Hypothesis: We hypothesize that NIV-NAVA will have lower NIV failure rates than ASV in subjects with AECOPD due to better patient-ventilator synchrony.

Objectives: To compare the outcomes between NIV-ASV and NIV-NAVA in patients with AECOPD.

Materials and methods: We included all consecutive subjects with AECOPD who met all the following: (a) an acute (<7 days) sustained worsening of any of the respiratory symptoms (cough, sputum quantity or character, dyspnea) beyond the normal day-to-day variation; (b) arterial blood gas analysis showing a PaCO2 >45 mm Hg with either pH between 7.10 and 7.35 or respiratory rate (RR) >30 breaths/minute; and, (c) exclusion of other causes of acute breathlessness, such as, acute heart failure, pulmonary embolism, pneumonia, and pneumothorax. The primary outcomes were NIV failure rates (intubation). The secondary outcomes were 28- and 90-day mortality, asynchrony index (AI), NIV-related complications, and others.

Results: We enrolled 76 subjects (NIV-NAVA = 36, NIV-ASV = 40; 74% males) with a mean ± SD age of 61.4 ± 8.2 years. Most (49%) subjects were GOLD stage B with a mean Charlson’s comorbidity index of 3.5. 49% of the study subjects had at least one moderate or severe exacerbation in the previous year. There was no difference in the baseline pH or PaCO2 between the two groups. There was no difference in NIV failure rates (NIV-NAVA vs NIV-ASV, 22% (8/36) vs 20% (8/40); p = 0.81). We found no difference in the 28-day (NIV-NAVA vs NIV-ASV, 22% vs 18%) and 90-day (NIV-NAVA vs NIV-ASV, 22% vs 18%) mortality between the NAVA and ASV arms. Notably, we found no difference in the mean asynchrony index between the NIV-NAVA (17) and the NIV-ASV (16%) arm. The proportion of subjects with severe asynchrony was also similar in the two study arms. The use of NIV-ASV (0.6) required significantly (p = 0.03) fewer ventilator manipulations by a physician than NIV-NAVA (1.03) in the initial 24-hours. We found both modes to be safe for delivery of NIV.

Discussions: NIV in AECOPD is associated with improved outcomes. Use of NIV for patients with acute hypercapnic respiratory failure due to AECOPD is associated with a reduction in mortality, intubation rates, length of stay, improvement in clinical parameters, and improvement in arterial blood gas parameters. In the present study, NIV was associated with improvement in respiratory rate, arterial blood gas parameters (pH and PaCO2) with successful hospital outcome in 60 (79%) of subjects irrespective of the mode of ventilation utilized. The intubation rate was 21% which was similar in both groups. A previous study that compared ASV and PSV in patients with subjects with AECOPD at our institute demonstrated an overall NIV failure rate of 28.4% (PSV vs ASV: 34.2 vs 22.2%, p = 0.31) and intubation rate of 16.21% group (ASV vs PSV, 11.1 vs 21.1%; p = 0.138) which was similar between the two groups. In another study, we have demonstrated that NIV-NAVA resulted from better clinical outcomes in those with AECOPD. This is the first trial to have studied noninvasive NAVA and ASV in a randomized controlled setting in patients with AECOPD. Both are closed-loop systems with hypothetical advantages over conventional noninvasive modes. Safety of ASV as a mode of noninvasive ventilation was established in the previous study of AECOPD where complication rates were similar between ASV and PSV and there was a trend toward a reduction in intubation rates with ASV. This trial reiterated the safety of ASV as a mode of noninvasive ventilation.

Conclusion: We found no difference in the NIV failure rates between NIV-NAVA and NIV-ASV. We also did not find any difference in 28- or 90-day mortality and patient-ventilator asynchrony with either mode. However, NIV-ASV required significantly fewer physician manipulations. More studies are required to confirm our findings.

2. Retrospective Observational Analysis of Inflammatory Markers in COVID-19 Patients Admitted to Intensive Care Unit: As Early Predictors of Disease Severity. (Conference Abstract ID: 184)

Divya Gupta, Sandeep Dewan, Munish Chauhan, Apoorv Jain

Fortis Memorial Research Institute, Gurugram, Haryana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.6

Introduction: In pandemic situations, like the one world is facing right now, due to SARS-CoV-2, it becomes absolutely necessary to wisely use the resources to maximize beneficial results. The ability to predict the severity early in the disease course will help in early intervention in sicker patients, thus, positively affecting prognosis as well as treatment cost.

Objectives: To investigate patient characteristics (age, sex, presenting complaints, presence of comorbidities, APACHE-II score) and specific biomarkers [C-reactive protein (CRP), creatinine kinase (CK), procalcitonin, lactate dehydrogenase (LDH), ferritin, interleukin-6 (IL-6)] as possible early predictors of severity of SARS-CoV-2 infection. They were further correlated with the need for mechanical ventilation, length of ICU stay, and 28-day mortality.

Materials and methods: After Ethical committee review, consecutive hundred RT-PCR confirmed adult COVID-19 patients admitted to tertiary care ICU were analyzed retrospectively wherein demographics, Acute Physiological and Chronic Health Evaluation-II (APACHE-II score) and at admission, inflammatory markers (CRP, procalcitonin, S. ferritin, LDH, ESR, IL-6) were compared with respect to oxygenation defect (PaO2/FIO2 < or ≥300), need of mechanical ventilation, length of ICU stay, and 28-day mortality. Data were collected retrospectively from the patient’s electronic medical records and were limited largely to demography, clinical and laboratory parameters at the time of admission along with outcome measures at 28 days of admission. Further, we compared these variables between ventilated and non-ventilated patients. Interventions performed were based on an independent decision of the physician in charge. The statistical software SPSS version 24.0 was used in the analysis. For comparison of mean values between two groups, Student’s unpaired t-test was used. Pearson chi-square test and Pearson correlation tests were used for categorical and scalar data, respectively. Non-parametric tests (chi-square test and Mann–Whitney test) were used where data were not distributed normally. Logistic regression test was performed wherever applicable. A p value <0.05 was considered as significant at a 95% confidence level whereas a p value <0.01 was considered highly significant.

Results: A total of 100 patients’ data including demographic, clinical and laboratory parameters at the time of admission were studied. On comparing the variables between, low PF Ratio (<300) and high PF Ratio (≥300) groups, demographically, mean age was significantly more in lower PF Ratio group (58.01 ± 15.33 vs 50.97 ± 13.78, P = 0.023) whereas sex ratio was comparable among patients in two groups. As compared to low PF Ratio group, in high PF Ratio group, higher APACHE II score (P = <0.001) was found highly significant and presence of hypertension was significant (43.54% vs 23.68%; P = 0.045) whereas presence of Asthma (1.47% vs 2.85%), coronary artery disease (9.67% vs 10.52%), chronic kidney disease (8.06% vs 5.26%), diabetes mellitus (40.32% ys 23.68%), thyroid disease (3.22% vs 7.89%) and cancer (3.22% vs 0%) were found to be insignificant. C- reactive protein (171.78 ± 124.45 vs 101.52±88.70), IL-6(173.51 vs 53.18) and ferritin (1677.60±2271.13 vs 643.54 ± 718.68) levels were found to be significantly higher in patients with PF Ratio<300. All three of them were highly significant in mortality group as well. Levels of procalcitonin, LDH and CPK were not significantly different among the comparison groups. In low PF Ratio subgroup analysis, ventilated patients had shown significantly higher APACHE-II score (P = <0.001), ICU length of stay (p = <0.001); CRP (P = 0.002), Ferritin(P = 0.018) and IL-6(0.003). Overall, ventilator days were correlated highly significantly with longer ICU length of stay (Pearson correlation 0.828; P = <0.001) and higher mortality (Pearson correlation 0.875; P = <0.001).

Discussions: It is imperative to know its presence and effects on the Indian population due to the vividity of the present coronavirus strain. It affects various organ systems causing a blend of signs and symptoms, the respiratory system being the most common target. Involvement of lungs characterized by an intermingling of multiple complex mechanisms like cytokine and chemokine production, and hence, the host immune system dysregulation.1,2 In this study, older age was found to adversely affect the severity in contrast to studies from China which suggested higher severity between 50 and 59 years of age, whereas the Republic of Korea showed a bimodal peak.3 Though our study was consistent with Wang et al. with no gender disparity with respect to the severity of the disease, the results from other studies were inconclusive.4 Thus, larger studies with vivid ethnicity are required before any reasonable conclusion. Furthermore, the presence of hypertensive disorder correlates with severity (27 vs 9%). Review by Yang et al. suggested that hypertension (17 ± 7%, CI 14–22%) and diabetes (8 ± 6%, CI 6–11%) were the most common comorbid findings in COVID-19 patients though, in our study, diabetes was not a significant factor.5 Studies have noticed the negative impact of comorbidities especially in the third and the most serious phase of the disease due to systemic hyperinflammation syndrome.6 Though there is no study to date, as per our data, the APACHE-II score holds good even in coronavirus inflicted patients in determining the severity or prognosis and may be used as an important prognostication tool. Our study had uniform results as depicted in meta-analysis with significantly high CRP values in severely ill patients. Studies, including one meta-analysis, have postulated that serum ferritin, may be used as a biomarker for COVID-19 patients due to its protective role against infection by causing hypoferremia.7,8 This study revealed significantly high admission levels of ferritin in a severe group which was further elevated in ventilated patients and mortality group signifying its role as an early predictor of severity and mortality. Our study had consistent results with studies within ICU cohorts, where there were multiple reports of elevated IL-6 in severe cases as well as in mortality groups.9 Retrospective type study with data attrition and lack of successive values of inflammatory markers at fixed intervals to study the trend are some of its limitations. There is a lot of scope for further research in this direction for a better understanding of the disease course and thus, the better outcome.

Conclusion: This study suggested that along with age and APACHE-II score, the limited triad of CRP, ferritin, and IL-6 levels may predict the disease severity, ventilator requirement, and 28-day mortality early in the course. This may help in early prognostication with better channelization of scarce resources. Larger studies are required to further validate the results.

3. A Quality Improvement Initiative to Improve the Initiation and Acceptability of Non-Invasive Ventilation. (Conference Abstract ID: 182)

Amit Pathania, Jhuma Sankar, Rakesh Lodha, SK Kabra

All India Institute of Medical Sciences, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.7

Introduction: There is increasing interest in the use of noninvasive ventilation (NIV) in critically ill infants and children, as NIV can reduce the intubation rate, improve gas exchange, and decrease the work of breathing. Patient cooperation is crucial for NIV success at all ages. There are quality improvement guidelines in NIV use in adults but there is a paucity of literature in the pediatric age group. With this background, we decided to do this quality improvement study to systematically assess the factors responsible for the failure of initiation and non-acceptance of NIV and to make process changes to improve acceptance of NIV.

Objectives: To evaluate if the use of a quality improvement initiative improves initiation and acceptability of noninvasive ventilation (NIV) in critically ill children with respiratory distress.

Materials and methods: The study was carried out in three phases over a period of 6 months in the pediatric intensive care unit (PICU) of a tertiary care unit in children aged 2 months to 17 years of age. In phase 1, data were collected for 1 month and reasons for noninvasive ventilation failure and intolerance were identified. In phase 2, process changes like adherence to checklist, monitoring, and 1-day orientation program was instituted. The duration of the program was 3 hours with one session per batch of residents/staff posted in ICU. The Plan, Do, Study, Act (PDSA) cycle was carried out in each phase. A washout period of 1 month was given after the training phase. In phase 3, which was for 2 months, the acceptance of noninvasive ventilation was measured again, and results were compared with phase 1.

Results: A total of 37 patients were included,12 in phase1 and 25 in phase 3 of the study respectively. NIV failure was recorded in 5 (42%) patients in phase one and 2 (8%) patients in phase 3 (p = 0.08). The cause of NIV failure was intolerance to the interface in 4 (57%) patients and inability to protect the airway in 3 (43 %) patients. The children in whom NIV was successful, there was marked decrease in the respiratory rate. The median (IQR) respiratory rate was 47/min (40,54) vs. 35/min (30,46) before and after initiation of NIV, respectively in phase 3 (p = 0.0005). Sedation was used in 18 (72%) patients in phase 3 which helped in improved tolerance to the NIV.

Discussions: We observed improvement in NIV acceptance rates from 7/12 to 23/25 after strict adherence to protocol and checklist. Mask intolerance was the most common cause of NIV failure 4 out of 7 (57%). Previous studies have also shown that mask intolerance generated by pain and discomfort may lead to refusal of NIV, prompting its discontinuation and leading to endotracheal intubation.11 Conversely, gas exchange can improve under NIV when an adequate level of anxiolysis and analgesia is obtained, resulting in better synchronization and patient-ventilator interaction; patient-ventilator synchronization further improves patient tolerance.12 In our study, we gave sedation in 18 (72%) in phase 3 which lead to better tolerance to NIV.

Conclusion: The use of a quality improvement initiative in the form of a protocol, checklist, and training of the treating team resulted in improved tolerance to NIV and thereby its success. The use of sedation may help improve tolerance to the interface and contribute to its success.

4. Correlation between Anxiety and Compliance to Non-Invasive Ventilation in Patients Requiring Non-Invasive Ventilation Admitted in COVID ICU. (Conference Abstract ID: 175)

M Keerthivasan, B Gayathri, Arul Saravanan, G Mirunalini

SRM Institute of Science and Technology, Chennai, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.8

Introduction: Patients with severe COVID-19 disease present with respiratory distress requiring ventilator support. Significant psychological concerns are emerging out of this pandemic seen in patients admitted in COVID ICU. BiPAP a form of NIV has proved to be effective in maintaining oxygenation during the phase of distress. We hypothesize that anxiety may reduce the compliance to NIV mask acceptance and translate to higher dyspnea scores.

Objectives: 1. To find a correlation between anxiety contributing to the reduced compliance to NIV mask acceptance and consequently leading to delayed recovery of patients treated in COVID ICU.

Materials and methods: After ethical committee approval, a single-center observational study was conducted from July 2020 to October 2020 in a cohort of patients admitted to COVID ICU. Demographic data and vital signs were recorded. The severity of anxiety was measured using STAI anxiety score on day 0, day 4, day 7, and day 10 of admission. The compliance of patients to NIV mask and the severity of dyspnea was assessed by compliance score and by BORG score, respectively.

Results: A total of 39 patients who needed non-invasive ventilatory support were assessed. Mean age of the patients were 42. 34/39 (87.19%) of the patients were Males and 5/39 (12.82%) patients were Females. Correlation between STAI scoring and compliance to NIV mask acceptance analysed using Pearson correlation was found to be 0.57(p < 0.001). Correlation between STAI anxiety score and dyspnoea severity score analysed using Pearson correlation and was found to be 0.51(P < 0.001). Percentage of patients with severe dyspnoea were found to have low compliance to NIV. (p value<0.05)

Discussions: We found that anxiety scores were very severe in 92% of patients admitted to COVID ICU on day 0. Sharma et al. did a study in the evaluation of patients in critical care and found elevated levels of depression, anxiety, and stress among patients admitted in ICU. Ji Yeon et al. concluded that anxiety score was higher in patients in ICU, so early screening and treatment of psychological symptoms may be an important means to promote rehabilitation and recovery. These two studies correlated with ours. More the anxiety less the patient compliance to keep NIV. On days 4, 7, and 10, considerable reductions in anxiety were noted and patients were more comfortable in keeping NIV, which showed less dyspnea scores. Timothy et al. found delirium to be a significant contributor to morbidity and mortality in the ICU and recommended that all ICU patients be monitored using a validated delirium assessment instrument. To this date, we could not find any publication comparing anxiety scores and its correlation to NIV compliance translating to a better outcome.

Conclusion: Higher the level of anxiety, higher the dyspnea. As days progressed patients were manageable with reassurance. Those who were agitated and required restraint was found to be severely dyspneic ending up in intubation.

5. A Cross-Sectional Study of Baricitinib Outcome in Severe COVID-19 Pneumonia. (Conference Abstract ID: 172)

Ravindra Kumar Patidar, Ravi A Dosi, Shobhit Gupta, RK Jha, PK Joshi, Ankur Agrawal, K Panwar, Piyu Jain

SAIMS, Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.9

Introduction: An inflammatory response to SARS-CoV-2 infection, due to cytokine release syndrome, has been implicated in the pathology of acute respiratory distress syndrome in patients with COVID-19. Baricitinib is a reversible JAK-inhibitor that interrupts the multiple inflammatory cytokines in COVID-19 immunopathology.

Objectives: Our aim to study the overall outcome of baricitinib on critical patients with COVID-19.

Materials and methods: A cross-sectional study of 10 cases, infected with COVID-19 severe pneumonia and were critically ill. The patient’s average ICU stay, CBC, changes in HRCT scans, clinical improvement, cytokine storm markers before and after baricitinib doses were taken into account. Due consent was taken from all patients.

Results: Seventy percent of patients showed a reduction in CRP values. In 70% of patients, D-dimer values either decreased or were kept within normal limits. 90% of patients were shifted from NIV support to NRBM within 7 days of baricitinib. 50% of patients showed a rising trend in platelet counts. 70% patients were shifted to ward from ICU 30% patients were discharged within 7 days of Baricitinib.

Discussions: Baricitinib is the Janus kinase (JAK) inhibitor, which may prevent cytokine storm in patients with SARS-CoV-2 pneumonia.

Conclusion: In our study, baricitinib has shown promising results. It is incumbent on researchers to develop and validate reliable tools to monitor the overall outcome of patients with baricitinib in COVID-19.

6. Lung Characteristics of COVID-19 Patient. (Conference Abstract ID: 170)

Aakas Soni, Sanjith Saseedharan, Vaijayanti Kadam, Ashish Yadav

SL Raheja Hospital, Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.10

Introduction: The high mortality in COVID-19 is related to severe ARDS and the theory is regarding bound one with low compliance and one with high compliance and treatment directed accordingly which included prone ventilation, lung-protective ventilation strategies, however, most of these were based on with western literature with static measurement. None of the literature talk about the actual measurement of recruitability by any method. Our objective is to study lung characteristics to assess recruitability with esophageal manometry, measurement of transpulmonary pressure, end-expiratory lung volume after transpulmonary pressure monitoring guided recruitment.

Objectives: To study the characteristics of COVID-19 lung with esophageal manometry and function residual capacity (FRC).

Materials and methods: Intubation was done when there was effort intolerance with PaO2/FiO2 ratio <150. Inflammatory parameters were sent: ferritin, LDH, D-dimer, WBC count. Esophageal manometry was done, nutrient and end-expiratory lung volume were calculated with GE carescape R860 ventilator using nitrogen washout technique.

Results: Percentage of raised inflammatory markersPercentage of decreased lung compliance in mechanically ventilated patients.78% of the patients out of 25 patients had increased inflammatory markers, 84% of the patients had a poor lung compliance of less 40 mL/cmH2O and 74% of patients were proned. With which 52 % of the patient’s lung out of 25 patients were recruitable.

Discussions: There is significant use of esophageal manometry with measurement of transpulmonary pressure in the patient with poor lung compliance and decreased functional residual capacity (FRC). It has been studied that lung-protective strategies along with transpulmonary pressure measurement are more likely to have better recruitment of the lungs in COVID ARDS.

Conclusion: There is significant use of esophageal manometry with measurement of transpulmonary pressure in the patient with poor lung compliance and decreased functional residual capacity (FRC). It has been studied that lung-protective strategies along with transpulmonary pressure measurement are more likely to have better recruitment of the lungs in COVID ARDS.

7. A Retrospective Observational Study on the Use of Rescue NIV in Severe COVID-19 Patients with HFNC Treatment Failure. (Conference Abstract ID: 167)

Shiraz Assu, Deepak Bhasin, Harpal Singh

Max Super-Speciality Hospital, Mohali, Punjab, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.11

Introduction: As the COVID-19 pandemic is progressing, there are drastic efforts around the world for a magic bullet for its treatment, but what we often forget is the supportive treatment that goes a long way in preventing the disease progression. Of these the most important are the respiratory supportive measures, which include a spectrum ranging from conventional oxygen therapy to invasive mechanical ventilation. As the mortality rates in patients put on mechanical ventilation are very high, it is the noninvasive modes that are proving as the real lifesavers. HFNC and NIV are currently the most preferred modes. The present evidence shows some mortality benefit while using HFNC but not with NIV in acute hypoxic respiratory failure following any kind of pneumonia.1–3

Objectives: The main objective of the study was to find the usefulness of giving rescue NIV trial in severe COVID-19 patients with HFNC failure.

Materials and methods: We conducted a retrospective observational study on severe COVID-19 patients admitted to our COVID ICU, who had received oxygen support via HFNC over a period of 9 months (from March 23 to December 23, 2020). After getting institutional ethics committee clearance, from the hospital’s electronic database details of all the severe COVID-19 patients who were admitted to the COVID ICU during the study period were taken. Out of this, all those who were given HFNC support were observed for the primary and secondary outcome measures. We excluded all the patients <18 years, patients who had taken discharge against medical advice, and patients who were still admitted with us and had not achieved the primary outcome (intubation or mechanical ventilation). As a secondary outcome, we also measured the HFNC failure rate (defined as the need for the application of rescue NIV trial) and mortality rate in the intubated patients. The routine hospital treatment protocol for treating COVID-19 was followed during the study duration, which includes the application of HFNC in all severe disease with type 1 respiratory failure who were not tolerating conventional O2 therapy. Those who had the features of HFNC failure were then given an NIV trial before proceeding with any invasive treatment. If tolerating the same, this was followed by alternate HFNC and NIV application titrated to the patient’s respiratory distress.

Results: Of the total 595 COVID hospital admissions, 265 of the severe COVID-19 patients were admitted to the ICU during the study duration. Out of them, 85 needed HFNC support. The average age of the patients was 56 years (32–80 years) and 80% of them were male. The HFNC failure rate was observed to be 28/85(32.9%). Out of this 10 were successively managed with rescue NIV trial and the remaining 18 had to intubated. Out of the intubated patients 14 died at the hospital, 2 of them were discharged against medical advice and 2 of them were successfully extubated and discharged.

Discussions: The intubation rate (21.2%) in our cohort of patients who were given HFNC support was significantly lower than those observed in other major studies like the FLORALI study (38%), where it was used for managing acute hypoxic respiratory failure (in which 84% of them had one or other kind of pneumonia).3 Even though the HFNC failure rate was 32.9%, by using NIV as a rescue device, intubation was prevented in 11.8% of the patients. The implications of the above finding are vast since the mortality of the intubated COVID-19 patients are very high across the world and a significant decrease in intubation rates means more life’s saved. In our study population also, 14 (77%) of the patients who were intubated following HFNC failure died.

Conclusion: On giving a rescue NIV trail followed by its intermittent application with HFNC, the intubation rates in hypoxic respiratory failure following severe COVID-19 shows a decreasing trend. The above finding needs to be further explored with controlled trials.

8. Impact of High-flow Nasal Oxygen Therapy in COVID-19 Critically Ill Patients with Acute Hypoxemic Respiratory Failure: A Prospective Observational Study. (Conference Abstract ID: 162)

Raman Kumar, Mohd Saif Khan, Sudipto Banerjee, Jay Prakash, Pradeep Kumar Bhattacharya

Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.12

Introduction: About 20 to 30% of COVID-19 patients admitted to ICU develop severe ARDS. Tracheal intubation in such patients carries a high risk of complications and mortality.1,2 High-flow nasal oxygen therapy (HFNOT) is an attractive option as it can reduce the requirement of intubation.

Objectives: This study aimed to determine the impact of HFNOT on the oxygenation level as well as HFNOT failure. The primary objective was to determine the change in PaO2/FiO2 ratio from baseline to at 1 hour, 6 hours, and 7 days of HFNOT initiation in COVID-19 critically ill patients presenting with acute hypoxemic respiratory failure (AHRF). The secondary objective was to determine the HFNOT failure rate [i.e., the requirement of tracheal intubation or noninvasive ventilation (NIV)].

Materials and methods: After approval from the institutional ethics committee and written informed consent, a prospective observational study was performed over a period of 3 months at the COVID intensive care unit of a government institute-hospital in east India. Adult patients (aged >18 years) with confirmed COVID-positive status (SARS-CoV-2 detected in nasopharyngeal swab by real-time reverse transcription-polymerase chain reaction assay), having AHRF (PaO2/FiO2 ratio <300) who are not able to maintain saturation above 90% on standard oxygen therapy were included in this study. On the HFNOT device, the initial flow rate and FiO2 were set at 60 L/minute and 100%, respectively. On case record form (CRF), demographic characteristics, vital signs, laboratory tests, and arterial blood gas tests were recorded. ROX index (ratio of SpO2/FiO2 to respiratory rate) was calculated at 2 hours of HFNOT. Continuous variables were reported as mean or median values when appropriate. The intergroup differences were analyzed using Student’s t-test or Mann–Whitney U test. The intragroup differences between variables at different time points were analyzed using paired Student’s t-test. p ≤ 0.05 was considered statistically significant. Statistical analysis will be performed using SPSS software.

Results: A total of 265 patients were screened out of which 256 patients had AHRF. HFNOT was used as first line therapy in 122 patients in which only 108 found to be eligible for study inclusion. Mean age of the patients was 59.7 ± 15.1 years; male patients accounted for majority (79.6%) of HFNOT cohort. Key comorbidities were diabetes mellitus (48.1%) and hypertension (25.9%). Mean PaO2/FiO2 ratio at baseline was 96.8 ± 30.2) which significantly increased at 1 hour (114.8 ± 32.1, p < 0.001) at 6-hours (130.1± 36.5; p < 0.001) and at 7 days (178.7 ± 41.3; p < 0.001) Mean duration of HFNOT was 10.4 ± 4.9 days. Median (with range) APACHE II and SOFA scores were 22 (12-35) and 8 (4-12) respectively. HFNOT failure rate was 27.8%. NIV was used as ceiling respiratory support in 22.2% of HFNOT cohort. Mean ROX index was significantly higher for the patients who successfully continued on HFNOT compared to those who failed (3.4 ± 0.3 vs 2.8+0.3; p < 0.001). Mean admission glucose level, D dimer and IL-6 values were significantly higher in HFNOT failure group compared to HFNOT success group. Overall, 28-day mortality rate in this cohort was 25.9%. About 50% patients receiving HFNOT developed complications in which epistaxis (18.5%) and air hunger (16.7%) were the most common complications.

Discussions: This study prospectively highlights the significant impact of HFNOT on oxygenation status over time points studied (i.e., at 1 hour, 6 hours, and 7 days). The baseline mean PaO2/FiO2 ratio was <100 (severe ARDS) when HFNOT was initiated. With such a low P/F ratio, HFNOT remarkably outperformed with a success rate of 72.2%. Significant improvement in the P/F ratio may be explained by adequate flow delivery and FiO2 meeting the patients’ demand. The main strengths of the study were its prospective nature and large cohort. The main limitation is that being a single-center study, the results from the study need to be cautiously interpreted before extrapolating to patients in different geographical locations. About 50% of patients developed mild complications, such as, epistaxis, air hunger, and abdominal distension; however, one patient also developed spontaneous tension pneumothorax which required immediate intercostal drain tube placement following which, the patient dramatically improved and survived hospital discharge. We observed admission hyperglycemia, high D-dimer value, and IL-6 levels in patients who failed HFNOT. These findings are consistent with other studies.3–5

Conclusion: HFNOT significantly improves oxygenation level in COVID-19 patients developing acute hypoxemic respiratory failure. The HFNOT failure rate was 27.8%. Admission glucose level, D-dimer, and IL-6 values were significantly higher in patients who failed HFNOT.

9. Ventilator-Associated Events (VAE)—Do They Have Any Utility Beyond Surveillance? (Conference Abstract ID: 160)

Shambhavi Chauhan, Jignesh Shah, Shivakumar Iyer

Bharati Vidyapeeth (DTB) University, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.13

Introduction: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in people receiving mechanical ventilation. VAP rate is widely accepted as an indicator of the quality of care and benchmarking. But due to the lack of any standardized definition and diagnostic criteria for VAP, the Center for Disease Control (CDC) introduced new definitions for ventilator-associated events (VAE) in 2013 for surveillance.

Objectives: This study was done to describe the rates of VAE, characteristics of patients, and risk factors with VAE, and examine the association of VAE on ventilator days, length of stay, and in-hospital mortality.

Materials and methods: This prospective observational study was carried out in the Department of Critical Care Medicine, Bharati Hospital (BVDU) Pune, Maharashtra from March 2019 to March 2020. All the patients on mechanical ventilation (MV) for >3 days were included and were followed till hospital discharge or death whichever was earlier. Baseline demographic data, comorbidities, the severity on admission (APACHE-II and SOFA) was recorded. Daily minimum PEEP and FiO2 (i.e., the minimum set value on the ventilator for that particular calendar day and maintained for >1 hour) were recorded on a standard chart by respiratory therapists. VAE was considered if PEEP or FiO2 increased by 3 cm of water and 20%, respectively, after a period of stability for at least 2 days (The baseline period of stability was defined as the 2 calendar days immediately preceding the first day of increased daily minimum PEEP or FiO2, and must be characterized by ≥ 2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values). Further progression to ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and possible ventilator-associated pneumonia (PVAP) were identified in accordance with CDC 2013 definitions.

Results: Between March 2019 and March 2020, 377 patients required mechanical ventilation in the ICU at our tertiary care teaching hospital. All these patients were screened for eligibility for inclusion in the study. Of these 270 patients were excluded from the study. Of these 270 patients 138 were excluded because of their duration of MV was less than 48 hours,91 patients were admitted with community acquired pneumonia (CAP), 28 patients were excluded because of death within 48 hours, 13 patients were intubated in other hospital and then referred to us. The remaining 107 patients with diagnoses other than CAP, requiring mechanical ventilation for more than 3 days, were included in the study. 14 patients had no period of stabilisation for 2 calender days hence were exculded for VAE consideration. 27 patients had at least one VAE, 2 had only VAC, 6 had only IVAC and 19 patients had only PVAP. Baseline demographic variables were similar in both the groups i.e., Mean age in VAE and Non VAE groups was 46.28 ± 16.5 and 48.35 ± 17.5 respectively. Admission GCS (8.92 ± 3.96 vs 9.63 ± 3.33) and P/F ratios (239.33 ± 67.91 vs 232.09 ± 69.90) were also compared and no significant difference was found in both the groups. Both the groups were comparable in severity also as shown by mean APACHE II score (17.14 ± 6.54 vs 17.21 ± 7.00) and SOFA score (6.14 ± 2.69 vs 6.49 ± 2.80) at admission. Overall VAE rate was 27.95 per 1000 ventilator days and differentially VAC, IVAC and PVAP rates were 2.07, 6.21 and 19.67 respectively. The In-hospital mortality was 55.55% (n = 15) in VAE (n = 27) group and 37.87% (n = 25) in Non-VAE (n = 66) group which was not statistically significant (p = 0.06). But the duration of mechanical ventilation was significantly longer in VAE group i.e., 16.78 ± 10.4 days than Non VAE group i.e., 7.89 ± 3.8 days (p = 0.0001). Also, the duration of ICU and Hospital stay in VAE group was 22.11 ± 13.79 days and 24.18 ± 14.3 days which was significantly more than the Non- VAE group 12.15 ± 8.08 days and 15.41 ± 10.4 days respectively (p = 0.003). Microbiological evaluation displayed, PVAP (n = 19) cases had 53% Acinetobacter baumanii, 21 % Klebsiella, 21% Pseudomonas aeruginosa and 5% Elizabethkingia meningoseptica. 68% of PVAP cases were treated with IV Colistin and 32% were given IV Meropenem.

Discussions: Although the in-hospital mortality was not found to be significantly affected by the occurrence of ventilator-associated events (VAE), VAE are associated with increased morbidity of patients such as longer duration of mechanical ventilation, intensive care, and hospital stay.

Conclusion: CDC definitions though meant for surveillance, may be used as a measure of outcome in critically ill patients with mechanical ventilation.

10. Clinico-Virological Profile, Intensive Care Needs, and Outcome of Infants with Acute Viral Bronchiolitis: A Prospective Observational Study. (Conference Abstract ID: 156)

Lalit Takia, Suresh Kumar Anguranq, Suresh Kumar Angurana, Subhabrata Sarkar, Ishani Bora, Radha Kant Ratho, Jayashree Muralidharan

Post Graduate Institute of Medical Education and Research, Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.14

Introduction: Acute viral bronchiolitis (AVB) is the leading cause of hospitalization among infants in developed and developing countries and associated with significant morbidity. AVB is defined as the first episode of wheezing in a child younger than 12 to 24 months with physical findings of a viral respiratory infection and has no other explanation for the wheezing (pneumonia or atopy). Respiratory syncytial virus (RSV) is the main cause of AVB worldwide and accounts for 30 to 80% of cases. Other viruses implicated are influenza viruses, parainfluenza viruses (PIV 1–3), human metapneumovirus (hMPV), rhinovirus, enterovirus, adenovirus, and bocavirus. The severity of AVB varies from asymptomatic illness or mild respiratory infection to severe lower respiratory tract infection leading to emergency room (ER) visit, pediatric intensive care unit (PICU) admission, and sometimes mortality.

Objectives: To describe clinico-virological profile, treatment details, intensive care needs, and outcome of infants with AVB.

Materials and methods: In this prospective observational study, 173 infants with AVB admitted to the pediatric emergency and pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India from November 2019 to February 2020 were enrolled. The data collection included clinical features, viruses isolated [respiratory syncytial virus (RSV), rhinovirus, influenza A virus, parainfluenza (PIV) 2 and 3, and human metapneumovirus (hMPV)], complications, intensive care needs, treatment, and outcome. Multivariate analysis was performed to determine independent predictors for PICU admission.

Results: The common symptoms were rapid breathing (98.8%), cough (98.3%), and fever (74%); and common examination findings were tachypnea (98.8%), chest retractions (93.6%), respiratory failure (84.4%), wheezing (49.7%), and crepitations (23.1%). RSV and rhinovirus were commonest isolates. Complications were noted in 25% cases as encephalopathy (17.3%), transaminitis (14.3%), shock (13.9%), AKI (7.5%), myocarditis (6.4%), MODS (5.8%), and ARDS (4.6%). More than one-third cases required PICU admission and treatment included nasal cannula oxygen (11%), continuous positive airway pressure (51.4%), high flow nasal canula (14.5%), and mechanical ventilation (23.1%); nebulization (74%); antibiotics (35.9%); and vasoactive drugs (13.9%). The mortality was 8.1%. Underlying comorbidity; chest retractions, respiratory failure, and low oxygen saturation at admission; presence of shock; and need of mechanical ventilation were independent predictors of PICU admission. Isolation of virus or co-infection were not associated with disease severity, intensive care needs, and outcome.

Discussions: AVB had a huge impact on the health of young children and approximately 2 to 3% of infants require hospitalization due to AVB. No available treatment modalities have been shown to shortens the course or hastens the resolution of symptoms of AVB. Therefore, the treatment of AVB is supportive. The American Academy of Pediatrics published clinical practice guidelines based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to standardize the diagnosis and management of AVB. These guidelines emphasized that the diagnosis of AVB should be based on the history and physical examination. Epinephrine, short-acting β2-agonists, systemic glucocorticoids, chest physiotherapy, and antibiotics are not recommended for the treatment of AVB. Nebulization with hypertonic saline may be used as it improves symptoms of mild-to-moderate AVB if the length of stay is >3 days. Since ours is a tertiary care referral hospital, the infants with more severe illness were referred to us which is supportive by the facts that a higher proportion of these infants had a respiratory failure at admission; had higher rates of extrapulmonary complications (25%); more cases required PICU admission (36.4%) and mechanical ventilation (23%), and vasoactive drugs (14%); and had higher mortality (8%). PICU admission is needed in 15 to 25% of children with AVB. Various noninvasive modes of oxygen delivery are being increasingly used including CPAP, HFNC, noninvasive positive pressure ventilation (NPPV), and bilevel positive airway pressure (BiPAP). The common reasons include apnea, severe lower airway disease, or ARDS. The need for mechanical ventilation is usually for a short period (usually <5 days) but may be needed for a longer duration in some children. There is substantial variability in the diagnosis and management of infants with AVB in different PICUs. In the index study, 36.4% of cases needed PICU admission. Underlying comorbidity; the presence of chest retractions, respiratory failure, and lower oxygen saturation at admission; the presence of shock; and the need for mechanical ventilation were independent predictors of PICU admission on multivariate analysis. In AVB, the use of antibiotics is not routinely recommended. Papenburg et al. noted that about 25% of infants with AVB were given antibiotics, 70% of them had no documented bacterial coinfection, and 38% received macrolides. Therefore, efforts are needed to reduce inappropriate and unnecessary use of antibiotics in AVB. With the availability of molecular techniques, it has been possible to identify viruses causing AVB. The most common viruses isolated are RSV (50–80%), rhinovirus (5–25%), PIV (5–25%), hMPV (5–10%), coronavirus (5–10%), adenovirus (5–10%), and influenza virus (1–5%). The proportion of viruses causing AVB differ according to geographical location and time of the year. The clinical features of AVB caused by different viruses are generally indistinguishable. The reported rates of coinfection varied widely among different studies and ranged from 6% to >30%. Few studies noted greater severity of the disease, longer hospital stay, more severe hypoxemia, and greater risk of relapse in children with coinfection, whereas other studies showed no difference in disease severity and outcome in those with coinfection. In the index study, at least one virus was isolated in 74% of cases with RSV and rhinovirus as the commonest isolates. One-fifth of cases had coinfection with >1 virus. However, isolation of virus or coinfection was not associated with any differences in clinical features, complications, treatment, PICU needs, and outcome. The strengths of this study include a prospective study with a large sample size. All the enrolled cases underwent virological testing which is important to determine etiology but did not have much significance in determining disease severity, prognosis, and short-term outcome. The details of treatment, intensive care needs, and the outcome have been described. The predictors of PICU admission were determined. The limitations included a single-center study and a lack of long-term follow-up.

Conclusion: Among infants with AVB, RSV, and rhinovirus were common isolates; >1/3rd required PICU admission; and comorbidity; chest retractions, respiratory failure, low oxygen saturation; shock; and need of mechanical ventilation independently predicted PICU admission.

11. Outcome and Safety of Percutaneous Tracheostomy in COVID-19 Patients: A Single-Center Experience. (Conference Abstract ID: 146)

Nirankar Bhutaka, Mehul Shah

SIR HN Reliance Foundation Hospital And Research Centre, Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.15

Introduction: Background: The role of tracheostomy in corona disease (COVID-19) is unclear with several guidelines advising against this practices.1 However, tracheostomy facilitates weaning from ventilation and potentially increase the availability of much needed intensive care unit beds. Tracheostomy, an aerosol-generating procedure with the risk of infectious transmission for healthcare workers.2 The prior misconception of performing tracheostomy earlier than 21 days was associated with increased risk to healthcare workers and offers no benefit.3 But the global, multidisciplinary guidance on tracheostomy for patients with COVID-19 suggests 10 to 21 days as recommended window for tracheostomy.3

Objectives: We hereby present the outcome and benefits of early tracheostomy done in COVID-19 patients over a period of 9 months at our hospital. We also evaluated the safety and risk of transmission of healthcare workers.

Materials and methods: We performed a retrospective analysis of all COVID-19 positive patients treated at our center who required mechanical ventilation and subsequently underwent tracheostomy. The epidemiological data, indications, timing of tracheostomy in regards to the initiation of mechanical ventilation (MV) and assessment of the severity of COVID pneumonia with APACHE-II score, CT severity index (CTSI), P/F ratio at the time of intubation were all documented. The outcome of the patient in regards to survival, type of procedure and complications, duration of mechanical ventilation post tracheostomy, and length of ICU and hospital stays were recorded. We also monitored healthcare workers directly involved in tracheostomy care acquiring COVID-19, by assessing them clinically for (s/s of fever/breathlessness) and also subjected them to a rapid antigen test every alternate day and RT-PCR every fifth day.

Results: A total of 604 patients were admitted to ICU from March to December 2020, 174 patients required intubation for Acute respiratory distress syndrome (ARDS) of which 16 patients (8–9% ) approximately underwent tracheostomy. Our demographic data suggested a higher average age group of population 73 ± 16yrs treated at our centre and only 18% of these patients undergoing tracheostomy were females. The commonest co-morbidity seen was hypertension (68%)followed by obesity (31%) and then diabetes mellitus (25%) in our cases. We had 13 patient with Apache II score > 17 of which 40% survived. APACHE II Score >23 was associated with the worst outcome. On comparison of their radiology finding with CTSI and CORADS score, all patients undergoing tracheostomy we found patients with average of 16/25 CTSI and a CORADS Score of 5. The predominate indication for tracheostomy was prolonged ventilation and liberation from the ventilatory support. The average time for our patient to undergo tracheostomy was 13.06 days after intubation. 63% of these patients had severe ARDS(P/F <100), while rest had moderate disease. Patients undergoing tracheostomy at our centre had an average P/F ratio of 119 at the time of intubation. Overall outcome was 50% survival of patients’ undergoing tracheostomy. At 30 days we had 66% of survivors of the survivors, patients with moderate ARDS had a 90% survival rate whereas only 1/3rd of the patients suffering from severe ARDS made it. The average length to stay of survivors in the ICU was 34.37 days and hospital stay was nearly 47.37days. The average time of liberation of mechanical ventilation was 10 days. All the tracheostomies were performed percutaneously at the bedside. Only 1 patient out of 16 developed complication in form of bleeding at local site which was managed conservatively. All procedures were performed using personal protective equipment (PPE), FFP3 masks with fluid repellent gowns, gloves, and eye protection. None of our health care workers were infected with Covid 19 infection.

Discussions: During the coronavirus disease 2019 (COVID-19) pandemic, lack of data to guide decisions has been the most evident regarding the timing of tracheostomy. Emerging data concerning infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the course of patients with COVID-19, and clinical experience may alter practice, even preempting publication. For example, Chao et al.4 originally recommended deferring tracheostomy beyond 21 days of intubation and recommended open surgical tracheostomy over percutaneous dilatational tracheostomy; however, updated practices at the authors’ institution reflect outcomes of tracheostomy performed at 10 to 14 days after intubation, with percutaneous technique performed regularly. A total of 100/164 patients underwent tracheostomy safely, with no transmission of COVID-19 infection in healthcare workers involved in their care. Despite similar characteristics and APACHE-II scores, 30-day survival was higher after tracheostomy compared with non-tracheotomized patients. Early tracheostomy in COVID-19 patients appears to be safe and associated with a shorter ICU stay. Prolonged sedation/intubation for patients with COVID-19 delays rehabilitation, can exacerbate resource scarcity, and may increase the risk for thrombotic sequelae (CVA, VTE) or other complications. We found at our center which catered to a higher age of patients, predominantly males having APACHE-II score >17, with moderate to severe ARDS, underwent tracheostomy on an average 13 days postintubation had a better outcome, with 66% surviving beyond 30 days. They were also liberated from mechanical ventilation within 10 days of tracheostomy.

Conclusion: Though we treated a higher age group of patients at our center, 66% of our patients had survived at the end of 30 days. All of the survivors underwent early percutaneous tracheostomy by the twelfth day of intubation facilitating liberation from mechanical ventilation by the tenth day. We conclude even in severe ARDS with a higher age group, higher APACHE-II score, early tracheostomy within 13 days of intubation had better outcomes and less duration of hospital stay. Whether this is true still needs to be proved with more robust data.

12. Extravascular Lung Water and Pulmonary Vascular Permeability Index Measurement in COVID ARDS Gold Standard for ARDS Management. (Conference Abstract ID: 145)

Ziyokov Joshi, Taran Deep

Tagore Heart Care and Hospital, Jalandhar, Punjab, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.16

Introduction: COVID ARDS is the most important cause of mortality in COVID patient to prevent mortality in COVID ARDS we use extravascular lung water index (EVLWI), and pulmonary vascular permeability index (PVPI), and lung-protective ventilation to prevent mortality and weaning from the ventilator.

Objectives: 1. EVLWI measurement, 2. PVPI measurement, 3. Lung protective ventilation.

Materials and methods: In all cases of COVID with SpO2 <94%, we use thermodilution PA catheter and femoral artery line and measurement of EVLWI and PVPI for ventilator weaning.

Results: In our hospital out of 10 ARDS PT, we last two PT with ARDS and septicemia.

Discussions: COVID ARDS is very tough to manage very high mortality; hence, we use EVLWI and PVPI and ABG in all patient any patient IF PaO2/FiO2, <100 we refer a patient to COVID unit in other hospitals for further treatment.

Conclusion: Any patient in which EVLWI and PVPI are high there prognosis is very poor and we should keep this value to normal to prevent mortality with EWLW more than 20 mL/kg mortality in ARDS is 50%.

13. Physiological Effect of Prone Positioning in Mechanically Ventilated Sars-CoV-2 Infected Patients with Severe ARDS: An Observational Study. (Conference Abstract ID: 144)

Srikant Behera, Dalim K Baidya, Souvik Maitra, Bikash R Ray, Rahul K Anand, S Rajeshwari

All India Institute of Medical Sciences, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.17

Introduction: Prone positioning during mechanical ventilation (MV) has been shown to improve oxygenation and decrease mortality in ARDS patients. Prone position reduces lung strain and stress, leads to a more homogenized distribution of lung aeration and recruitment of dorsal alveoli, thus, leading to improvement in oxygenation.1 In mechanically ventilated patients of severe ARDS with PaO2/FiO2 (P/F) ratio < 150, prone position for at least 16 hours a day for consecutive 4 days decreased 28-day mortality by almost 50%.2 To the best of our knowledge, no study has so far assessed the physiological effect of prone position in SARS-CoV-2 infected ARDS patients undergoing invasive MV. Hence, in this observational study, the physiological effect of prone position in SARS-CoV-2 infected severe ARDS patients is being reported.

Objectives: To find out the physiological effect of prone positioning in mechanically ventilated SARS-CoV-2 patients with severe ARDS.

Materials and methods: Permission from the Institute Ethics Committee was obtained before recruitment of patients and consent was obtained from legally acceptable representatives. In this prospective observational study, 20 consecutive laboratories confirmed SARS-CoV-2 patients with severe ARDS (PaO2/FiO2 < 150) on invasive mechanical ventilation were included in the study. As per ICU protocol, in the absence of contraindication, all mechanically ventilated ARDS patients with PaO2/FiO2 < 150 were placed in at least 16 hours/day prone position for consecutive days till the criteria for proning is met. Demographic characteristics, baseline respiratory mechanics, and blood gas data were collected before initiation of the prone position, after 4 and 16 hours of the prone position, and after 4 hours of return of supine position. Prone responders were defined by a 20% increase in PaO2/FiO2 ratio during the prone session and sustained responders were defined by a 20% increase in PaO2/FiO2 ratio 4 hours after return of supine position.

Statistical analysis: All collected data were entered in a Microsoft Excel datasheet. Categorical data were presented as absolute numbers or percentages and non-parametric data were presented as the median and interquartile range (IQR). Unrelated data (between prone responders and non-responders) were compared by Mann–Whitney U test or chi-square test as applicable. Longitudinal variables were compared by Friedman’s test and multiple comparisons were performed by Dunn’s test. A two-sided p value < 0.05 was considered significant. All statistical analyzes were performed using Graph Pad Prism version 8.0.0 for Mac OS (Graph Pad Software, San Diego, California, USA).

Results: The median age in this cohort of 20 severe SARS-CoV-2 infected ARDS was 56 (45.5–67) years. The median P/F ratio was 56 (54- 66) with a median (IQR) PEEP of 12 (12–14) before initiation of prone position. The median (IQR) SOFA score was 7.5 (5.5–9) at the time of inclusion. Seventy-five percentage (95% CI 53.1–88.8) patients were prone responders at 16h prone session and 50 (95% CI 29.9–70.1) % patients were sustained responders after return to supine position. Prone responders had significantly higher baseline respiratory compliance (p = 0.03, Mann Whitney U test) but all other respiratory and blood gas variables were similar between responders and non- responders. There was significant decrease in plateau pressure (p < 0.0001), peak airway pressure (p < 0.0001), and driving pressure (p < 0.0001); and increase in static compliance (p = 0.001), P/F ratio (p < 0.0001), PaO2 (p = 0.0002) and SpO2 (p = 0.0004) at 4h and 16h since initiation of prone session and also after return of supine position. Noradrenalin requirement didn’t change during the prone session (p = 0.20). Percentages of changes in static compliance significantly correlated with P/F ratio after return of supine position (r2=0.62, p = 0.0034) but not at 4h (p = 0.14) and 16h (p = 0.20). Percentages of changes in P/F ratio and driving pressure at 16h (r2=–0.47, p = 0.04) and after return of supine position (r2=–0.59, p = 0.0089) were significantly correlated; but no correlation was found at 4h (p = 0.09). Baseline static compliance was a predictor of prone response with reasonable accuracy [AUROC (95% CI) 0.82 (0.59–1.00)]. Static compliance < 14 predicted no response from prone position with sensitivity (95% CI) and specificity (95% CI) of 80 (37.6–99) % and 73.3 (48.1–89.1) % respectively.

Discussions: We have found that around 75% of the SARS-CoV-2 infected patients with severe ARDS responded with a 16-hour prone position in terms of oxygenation. Overall, there is an improvement in lung mechanics in terms of static compliance, driving pressure, and plateau pressure without any changes in the hemodynamic support. In our series, all the included patients had ‘stiff lung’ as evident by low static compliance. Previous studies reported a variable change in respiratory system compliance in the prone position in ARDS patients,3 whereas we have found a significant decrease in driving pressure and static compliance. Recruitment of the dorsal lung region was the biologically plausible mechanism of improvement in static compliance as both driving pressure and compliance were correlated with change in P/F ratio.4 We have found that these correlations were present even after the return of supine position which indicated sustained lung recruitment in SARS-CoV-2 infected patients. Determination of baseline static compliance is important as it was a predictor of the absence of a response from the prone position and these patients may be subjected to extracorporeal membrane oxygenation early in the course of the disease.

Limitations: In our study, the major limitation was the small sample size, and we could not assess the effect of prone position on the chest wall and lung compliance separately as esophageal manometry was not used.

Conclusion: Prone position in SARS-CoV-2 infected severe ARDS patients is associated with improvement in lung compliance and oxygenation in 75% of the patients and persisted in about 50% of the patients.

14. Role of Biomarkers and Its Trend to Predict the Outcome of COVID Patients: A Retrospective Study. (Conference Abstract ID: 120)

Amarja Ashok Havaldar, M Vinay Kumar, Veronica Lobo, EA Chinny Sushmitha

St John’s Medical College, Bengaluru, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.18

Introduction: Biomarkers have been studied and used in the diagnosis and management of various diseases. The trend in Biomarkers helps in prognosticating and managing critically ill patients. It has been observed that patients with COVID pneumonia have elevated levels of certain biomarkers. The predominantly studied biomarkers are CRP, D-dimer, LDH, ferritin, and IL-6. Various studies have shown that biomarkers can help in assessing the severity of illness and prognostication. In resource-limited settings, the availability and feasibility of using these biomarkers are challenging. Our study aimed to see the trend of biomarkers and to see whether it can predict mortality in COVID-19 patients.

Objectives: Primary objective was to evaluate the trend of biomarkers and its effect on outcome (ICU mortality) in patients admitted with the diagnosis of COVID pneumonia. The secondary objective was the duration of mechanical ventilation and length of ICU stay.

Materials and methods: It was a retrospective study. After IEC approval (IEC no. 267/2020, CTRI/2020/10/028436), patients who were diagnosed with COVID pneumonia by RT-PCR and requiring ICU admission were included in the study. Data were collected from April 2020 till September 2020. Demographic details were collected. Biomarkers which include CRP, D-dimer, ferritin, LDH, procalcitonin, troponin I, neutrophil to lymphocyte ratio, and IL-6 were collected from day 1 to 7 of ICU admission. As per the institutional management protocol, selected biomarkers were sent as per the decision of the treating team. Data were collected from the patient record. The primary outcome was ICU mortality. Secondary outcomes were the length of ICU stay and duration of mechanical ventilation. Statistical analysis was done using STATA 14 software. Continuous data were represented as mean (SD) or median (IQR) as applicable. Categorical data were presented as a percentage. In bivariate analysis, the “t test” was used for parametric data and the “Wilcoxon rank-sum test” was used for non-parametric data. Parameters found to be significant in bivariate were used as a covariate in multivariate analysis.

Results: Total 417 Covid positive patients were admitted in six months. Out of which data of 205 patients was evaluated for interim analysis. Baseline characteristics were similar between two groups. Mortality was 65.85% (Out of 205, 135 died and 70 survived). 142 were male and 63 were female patients and mortality was similar between the groups. APACHE II score and SOFA score were higher in nonsurvivors than survivors and were statistically significant (APACHE II 27.06 vs 19.66 p <0.001, SOFA 10 vs 6.08 p <0.001). In bivariate analysis, Day1 values of Ferritin (p = 0.002, LDH (p = 0.03, Procalcitonin (p = 0.004), Troponin I (p = 0.004) and platelet count (p = 0.018) were found to be significant. Parameters found to be significant in bivariate analysis were used as covariates in logistic regression. In multivariate logistic regression, Ferritin and LDH found to predict the outcome, with ROC = 0.9643 and Hosmer- Lemeshow test for goodness of fit showed p = 0.9742, which is indicative of good predictive model. Using Ferritin alone, ROC was 0.8012. It was observed that cut off >718.2 ng/ml could predict the mortality with sensitivity of 75.68% and specificity of 71.43%. ICU length of stay and duration of mechanical ventilation were similar in two groups.

Discussions: Preliminary results from this study showed biomarkers are useful and can help in predicting the outcome of COVID patients. The biomarkers found to predict ICU mortality were ferritin and LDH on day 1 of ICU admission. The utility of biomarkers in COVID patients has been evaluated and the studies showed different biomarkers to be useful, the predominant one’s being NL ratio, D-dimer till now. The possible reason for seeing varied biomarkers may be due to the stage of the disease and the timing of the sample collection. Future studies on biomarkers should look for the stage of the disease and evaluate for specific biomarkers. There were certain limitations to our study, such as a retrospective design. The serial data of biomarkers were not available hence trend in the biomarkers with respect to the clinical profile of the patient could not be studied. Considering the cost of each test serial data of 7 days was not available and ordering of the blood tests was based on the treating team’s decision.

Conclusion: The present study showed ferritin and LDH, on day 1 of ICU admission can predict the ICU mortality in COVID pneumonia patients. The results of this study need to be validated by a larger observational study.

15. Sequelae of COVID-19 Pneumonia: Our Experience in Intensive Care Unit. (Conference Abstract ID: 112)

Sanjib Kumar Dhar, Binita Panigrahi, Asif Ahmed

Tata Main Hospital, Jamshedpur, Jharkhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.19

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) now a global pandemic and public health problem. Similar to SARS and MERS (Middle East respiratory syndrome) COVID-19 (coronavirus disease 2019) presents as severe and potentially life-threatening acute respiratory Syndromes. But COVID-19 has extensive manifestations as it gains access through the angiotensin-converting enzyme-2 receptor, which is present in every organ system. COVID-19 has high morbidity and mortality affecting many lives and has a huge financial burden on the healthcare system. Apart from active disease COVID-19 has many complications and long-term consequences in different organ system that is yet to quantify.

Objectives: To study complications and sequelae arising post-COVID-19 pneumonia.

Materials and methods: The study period was between August 15 to October 16, 2020.

Inclusion criteria: All adult patients shifted from COVID isolation units and who are critically ill.

Exclusion criteria: Pediatric patients <14 years, patients with negative RT-PCR at the time of admission, COVID-19 negative pneumonia. Out of all admitted patients (n = 85), male population were 53 (62.35%) and female population were 32 patients (37.65%). Patients with age >60 years were 47.05% and age those between 14 and 60 years were 52.95%. The most common comorbidities were hypertension and diabetes accounting for 45.88%, respectively. Other associated co-morbidities were found in 20% of patients involving cardiovascular and renal diseases. While transferring COVID-19 patients from isolation ICU to non-isolation ICU; 22 patients were on invasive mechanical ventilation and 27 patients required noninvasive ventilation or reservoir facemask intermittently (25.88 and 31.76%, respectively). The rest of the patients were either on a simple face mask or nasal prong or were on room air.

Results: Respiratory and neurological sequelae are most commonly observed sequelae in post COVID critically ill patients. Pulmonary fibrosis presented as most common respiratory sequelae in HRCT thorax (6 patients out of 85 patients, 7.05%). 49 patients remain on NIV (non-invasive) or invasive ventilation post COVID. Out of these 3 patients developed pneumothorax along with subcutaneous emphysema and some degree of pneumo-mediastinum. In other words 6.12% patients runderwent mechanical ventilation developed pneumothorax, pneumomediastinum and sub-sutaneousemphysema. This accounts about 3.35% of total critical post COVID patients (n = 85). 2 patients out of 85 critically ill patients (2.35%) who didn’t require mechanical ventilation (invasive or non-invasive) developed spontaneous pneumothorax. Only surgical emphysema noticed in one patients undergoing noninvasive ventilation (1.17%). As far as neurological sequelae concerened delirium was the most common presentation followed by demyelinating neuropathy (flaccid paralysis); Incidence being 7.05% and 2.35% respectively. Bleeding sequelae/ complication observed in 3 patients; one patient each had intracranial haemorrhage, retroperitoneal haematoma and haematuria out of 85 ( incidence 1.17%). Though the main pathophysiology of COVID-19 is hypercoagulation, we observed bleeding complication in 3 patients despite withdrawing anticoagulant or for whom anticoagulant hadn’t been started.

Discussions: Presently, COVID-19 presents as one of the most common causes of respiratory failure. Along with respiratory failure, other organ systems are also affected including cardiovascular, renal, neurological systems. Apart from active disease COVID-19 has many sequelae after the disease process is over. We observed lung fibrosis as the most common sequelae that again lead to pneumothorax and subcutaneous emphysema in critically ill patients (incidence = 7.05%). Similarly, neurological complications and sequelae are not uncommon. The most common presentation being delirium followed by demyelinating polyneuropathy in terms of flaccid palsy. The incidence of bleeding was observed to be 3.54% in our ICU in post-COVID pneumonia patients. Though this is a hypercoagulable state, mandating the use of anticoagulants, one needs to be judicious and vigilant while using anticoagulants.

Conclusion: COVID-19 till now an active disease affecting almost every organ system. So also it has many sequelae involving every organ system which is yet to be quantified. The most common sequelae observed is respiratory sequelae as pulmonary fibrosis. Sequelae of the neurological system are not uncommon; the most common being delirium. The actual incidence of sequelae of other systems is yet to be identified.

16. Clinical Usefulness of Favipiravir in Moderate COVID-19 Patients: Indian Real-World Experience. (Conference Abstract ID: 110)

Sagar Bhagat, Agam Vora, Anil Daxini, Pramod Dadhich, Saiprasad Patil, Hanmant Barkate

Glenmark Pharmaceuticals Ltd, Mumbai, India
Vora Clinic, Mumbai, India
Fortis Hospital, Mumbai, India
Dadhich Clinic, Ajmer, Rajasthan, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.20

Introduction: Favipiravir, a broad-spectrum antiviral agent, acts by inhibiting RNA-dependent RNA polymerase. It is approved in India in the management of mild-moderate COVID-19. It has shown potent in vitro activity against SARS-CoV-2. It has a wide therapeutic safety margin indicated by a wide CC50/EC50 ratio for a high dose. It has shown promising results in clinical studies conducted in China, Russia, Japan, and India. Treatment guidelines from many countries and some states from India have included favipiravir in the treatment protocol. A recently published phase III trial on favipiravir in India has shown early clinical resolution and acceptable safety in mild-moderate COVID-19 infection.

Objectives: The primary objective of the study was to evaluate the effectiveness of favipiravir in moderate COVID-19 patients, while the secondary objective was to determine the safety of favipiravir.

Materials and methods: We retrospectively analyzed medical records of favipiravir-treated COVID-19 cases from 3 centers to capture key details of moderate COVID-19 patients including medical history, symptoms, supportive treatment, and clinical outcome. The protocol of the study was approved by Independent Ethics Committee.

Results: Data from medical records of 193 patients was available for analysis, including 54 patients of moderate severity. The mean age was 59.94 ± 13.18 years. 58.92% of the patients were male. Hypertension (78.57%) and diabetes (55.35%) were the two most prevalent comorbidities. Majority (85.71%) of patients had at least one comorbidity, while 66.07% had ≥2 comorbidities. Mean SpO2 was 92.83 ± 1.88% with a median of 93% (90–98). The most common clinical features were fever (87.5%), cough (80.35%), dyspnoea (57.14%) and myalgia (48.12%). The mean CRP was 65.58 ± 34.74 with a median of 57.85 (1.20 to 151) and the mean d-Dimer was 1082.95 ± 1129.7 with a median of 815 (156–7435). Favipiravir has been used for an average duration of 12.30 ± 3.99 days, with median duration of 14 days (1–14 days). The rate of clinical improvement on days 3, 5, 7 and 10 was 30.35%, 75%, 89.29% and 96.42%. Fever and dyspnoea were fully resolved by day 7 in all enrolled patients, while myalgia was resolved by day 10 in all patients and cough was resolved by day 10 in 97.77% of patients. Corticosteroid was used in 37.5% patients. Oxygen requirements on days 3, 5, 7 and 10 were 28.57%, 14.28%, 8.92% and 7.14% patients respectively. Progression of the disease was seen in 10.71% of cases. Overall favipiravir was well tolerated with few commonly reported adverse events like diarrhoea and nausea, which does not require drug discontinuation. 91.07% patients and physician rated favipiravir as good or very good on global assessment scale.

Discussions: An open-labeled nonrandomized study1 from China compared the effect of favipiravir (day 1: 1,600 mg twice daily; days 2–14: 600 mg twice daily) vs lopinavir/ritonavir (day 1–14: 400/100 twice daily) in the treatment of COVID-19. Compared with the lopinavir/ritonavir arm, however, patients in the favipiravir arm showed a statistically significant shorter median length of time to viral clearance (4 vs 11 days, p < 0.001), improvement in chest CT findings at day 14 after randomization (91.4 vs 62.2%, p = 0.004), and lower incidence of adverse effects (11.43 vs 55.56%, p < 0.001). Chen et al.2 had conducted a prospective, open-label multicentric trial in China to compare two treatment arms in the management of clinically confirmed COVID-19 (maximum duration of symptom onset before randomization: 12 days). Post hoc analysis demonstrated that favipiravir-treated patients showed a trend toward clinical improvement at day 7 among those with moderate COVID-19 (71.43 vs 55.86%, 95% CI: 0.0271 to 0.2843, p = 0.0199) and earlier resolution of fever and cough (p < 0.0001). A Japanese observational study group recorded the details of hospitalized COVID-19 patients in Japan to assess the safety and efficacy of favipiravir. In >90% of cases, favipiravir was administered at a dose of 1,800 mg orally on day 1 followed by 800 mg twice daily on subsequent days. The median duration of therapy was 11 days. Rates of clinical improvement at 7 and 14 days were 73.8 and 87.8%, 66.6 and 84.5%, and 40.1 and 60.3% for mild, moderate, and severe disease, respectively. Thus, the vast majority of patients with mild and moderate disease recovered from the illness.

Conclusion: Approximately 90% clinical resolution rate in moderate COVID-19 patients in real-world settings supports its role in the management of hospitalized patients. Reduction in the oxygen requirement highlights its protective role against disease progression. Overall favipiravir was found to be effective and safe in the management of moderate COVID-19.

17. D-Dimer Levels to Predict in-Hospital Mortality in ICU Patients with COVID-19. (Conference Abstract ID: 96)

Ramesh Hasani, Mohan Nerkar, Prashant Rahate

Sevenstar Hospital, Nagpur, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.21

Introduction: Background: Coronavirus disease 2019 (COVID-19) is a recently described infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing various ICU admissions and deaths. Common laboratory values may provide key insights into patients with COVID-19, the illness caused by the SARS-CoV-2 virus, and may predict the morbidity and outcome.

Objectives: This study aimed to evaluate the effect of elevated D-dimer levels on mortality of patients admitted in ICU with COVID-19.

Materials and methods: All ICU patients with laboratory-confirmed COVID-19 were retrospectively enrolled in Sevenstar Hospital, Nagpur from July 27, 2020, to October 30, 2020. D-dimer levels on admission, on day 3, and day 5 were collected in all ICU patients, and death events were collected. The subjects were divided into two groups discharged and expired. Then, the D-dimer levels between the two groups were compared to assess the predictive value of D-dimer level and mortality in hospitals.

Results: A total of 101 eligible patients were enrolled in the study. 31 deaths occurred during hospitalization. Patients who expired had on admission D-dimer levels of 2729 ± 3243 ng/mL while those discharged had D-dimer value 973 ± 1553 ng/mL (P value < 0.007). D-Dimer of expired patients on Day 3 was 3206.5 ± 3338.8 and of discharged patients was 828.8 ± 1268.8 (P value 0.001). D-dimer of expired patients on Day 5 was 5184. 5 ± 3386.1 vs discharged patients was 588.7 ± 645.5 (P value < 0.0001). Number of Days in ICU for patients who expired was 14.22 ± 6.7 while those survived 7.6 ± 5.9.

Discussions: Here, we report on 101 patients with laboratory-confirmed SARS-CoV-2 infection requiring ICU admission in Sevenstar hospital, Nagpur. Of the 101 patients in this cohort, 31 (30.7%) died. In our study, we demonstrated that in patients diagnosed with COVID-19, D-dimer elevation upon admission and an increasing trend was associated with both increased disease severity and in-hospital mortality. D-dimers are one of the fragments produced when plasmin cleaves fibrin to break down clots. The assays are routinely used as part of a diagnostic algorithm to exclude the diagnosis of thrombosis. However, any pathologic or non-pathologic process that increases fibrin production or breakdown also increases plasma D-dimer levels.

Conclusion: We conclude that SARS-CoV-2 infected patients with an increasing trend of D-dimer (from admission to day 5) have worse clinical outcomes (all-cause mortality) and thus measurement of D-dimers on admission and its trend can guide in clinical decision making.

18. Pneumothorax in COVID-19 Treated with NIV. (Conference Abstract ID: 90)

Sanjay Shridhar Andhare, Mahadev Ashruba Korsale

Sushrut Hospital Barshi, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.22

Introduction: Three case presentation of pneumothorax in COVID-19 patient treated with NIV.

Objectives: Differential diagnosis of clinical deterioration in the patient of COVID-19 positive ARDS on NIV treatable and reversible causes if diagnosed at the earliest.

Materials and methods: We had to monitor patient of COVID-19 admitted to a dedicated hospital on NIV for sudden clinical deterioration.

Results: Besides established causes of sudden clinical deterioration like micro thrombosis, PE, Cytokines Strom. If proper clinical history and examination done, then we can diagnose the the Tension Pneumothorax in Covid 19 positive patient with ARDS on NIV and save the life.

Discussions: Here, we report three cases of tension pneumothorax of COVID-19 positive with ARDS on NIV, out of which two revived one succumbed.

Case 1: A 38-year-old male pt came with c/o sob NYHA gr 3, cough fever since 10/10/2020 RT-PCR positive for COVID-19 with severe COVID, CRP-293, ferritin-886, PCT-normal, D-dimer 732, LDH-776 PT treated outside from 12/10/2020 to 14/10/20 with BiPAP support pt came to our hospital on 14/10/20 with SpO2-54% @RA, pulse 98, BP 130/90 mm Hg RR 32/minute, we put pt on BiPAP support with IPAP-14, EPAP-7 RR-20, ST/T mode with SpO2-94% overnight. On 15/10/20 noon at 1 pm, pt developed sudden chest pain, tachypnea RR-more than 60, tachycardia HR 139, SpO2-50%, BP-100/70, restlessness near arrest situation, on auscultation diffuse crepitations on b/l chest s/o surgical emphysema cxr done which s/o left-sided tension pneumothorax with surgical emphysema extending in neck too emergency Lt sided ICD inserted column movement and air leak seen Pt tachypnea and tachycardia decreased little bit, SpO2-76% on O2 NIV with PS 12/4/100% FiO2 pt little bit stable but on repeat cxr s/o Lt sided ICD in situ, but also. Rt sided pneumothorax so ICD insertion on rt side also done, column movement and air leak seen, now pt become stable SpO2-90% on HFNC with 90% FiO2, RR-22/minute, pulse-86/minute with post ICD insertion cxr s/o b/l lung expansion with b/l ICD in situ. pt continue on HFNC F/B ventury mask than, both ICD removal done 1 day apart from when pt become off O2 pt discharged on 08/11/20 with a stable clinical condition.

Case 2: A 57-year-old female pt k/c/o DMT2, HTN came with c/o fever, dry cough, sob doe nyha gr 2 since 3 days. On examination pulse-90/minute, bp-140/80 mm Hg, RR-26/minute, SpO2-82, cxr s/o of lt lz pneumonia, abg-7.42/40/60/28 with SpO2, 88%, D-dimer 1,500 mg/mL, CRP-59 mg/mL, ferritin-880 ng/mL, PCT-<0.10 ng/mL on 04/07/2020 pt treated as per icmr protocol with O2 10 L/minute with NRBM than pt O2 requirement increased on 06/07/2020 pt put on BiPAP with IPAP-10, EPAP-5 which was titred as per patients wob and SpO2. inj tocilizumab given for cytokine storm on 7/7/20. pt maintaining SpO2 above 94 on BiPAP with IPAP-12, EPAP-7 RR-20 with O2 10 L/minute. ON 15/7/20 pt suddenly get worson restness, had tachypnea with RR-50, tachycardia with HR-140/minute. Air entry to right side absent cxr done which s/o rt sided tension pneumothorax so emergency ICD insertion done uneventfully, thereafter pt treated with HFNC than NIV with minimum PEEP despite all measures pt succumbed on 25/07/20. Case 3: A-40-year-old male pt with no medical illness came with c/o of sob doe nyha gr 4 since 5 days with h/o fever, body ache dry cough since 8 days. Admitted on 10/09/20 on examination pulse-120/minute, BP 130/80, RR = 43/minute, SpO2-49% @ RA, TLC-7200, neutrophils-62, lymphocytes-12, LDH-787 IU/L, lft-wnl, D-dimer 990 mg/mL, CRP-98 mg/L, ferritin-772 ng/mL, PCT-< 0.10 ng/mL Pt treated as per ICMR protocol with NIV ps 12/05/100% FiO2, pt maintaining SpO2 above 94, FiO2 titration done as per SpO2, wob decreased during treatment pt saturation maintaining above 90% on FiO2 60% weaning continue. On 05/10/20 pt SpO2 decreased to 74% on NIV ps 10/5/55% FiO2 with HR-122/minute. BP 130/70 mm Hg RR-46/minute, emergency cxr done s/o of rt sided tension pneumothorax so emergency ICD insertion done un eventfully than pt treated with NIV with minimum pressure support with minimal PEEP of 4, pt ICD removed on 10/10/20. Pt discharged in stable condition on 11/10/20.

Conclusion: Good history taking and clinical examination and very close monitoring help to diagnose COVID-19 patient with ARDS on NIV complicated by tension pneumothorax which is a treatable and reversible cause of sudden clinical deterioration and many times may be missed out. X-ray of all three cases we will present during the virtual conference if the organization allows us.

19. Helmet NIV in Hypoxemic Respiratory Failure Due to Severe COVID-19 Pneumonia: A Descriptive Study. (Conference Abstract ID: 74)

Sunny Kumar, Onkar Jha, Mrinal Sircar

Fortis Hospital, Noida, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.23

Introduction: The utility of HELMET-noninvasive ventilation (NIV) for severe COVID-19 pneumonia-related hypoxemic respiratory failure remains unclear.

Materials and methods: This is an observational descriptive study conducted at a tertiary care hospital in Noida, India. We included adult patients (aged >19 years) with hypoxemic respiratory failure due to severe COVID-19 pneumonia, who were treated with HELMET-NIV. The primary outcome was the proportion of patients who were successfully weaned from HELMET-NIV, while failure comprised of patients who required intubation.

Results: Total of 30 patients were included (mean (±SD) age 57.1±11.9 years). 25 (83.3%) patients were male. Mean baseline PaO2-FiO2 ratio (PFR) was 150.1±57.4 mm of Hg in 30 patients. 19 (63.3%) patients could be successfully weaned from HELMET-NIV. Invasive mechanical ventilation was required in 9 (30%) patients out of which 8 (26.7%) patients died. Total of 22 (73.3%) patients could be discharged home. Receiver operative characteristic (ROC) curve to find optimum cut off PFR at 24 hours (PFR-24) was plotted to predict NIV success: a cut off point that maximized sensitivity and specificity (youdens index) was at PFR 170 with sensitivity and specificity of 71.4% and 88.9% for NIV success, respectively. 7 patients observed complications, of which 5 had mask deflation, 1 complained of noise and 1 patient had barotrauma.

Discussions: The role of NIV in hypoxemic respiratory failure is getting more and more recognition. HELMET interface is a new method of applying NIV. In the setting of the COVID-19 pandemic, the HELMET interface can be an effective method of delivering NIV. It has been described as an aid to decrease virus spread by decreasing aerosol generation. Also, higher pressures can be applied as compared to face mask NIV. In our study, more than 50% of patients could be successfully weaned from NIV. The rate of any major complications was low: only 1 patient had barotrauma (subcutaneous emphysema). However, it is an observational and single-center study. Larger and multicenter studies are needed to support the above findings.

Conclusion: HELMET-NIV for severe COVID-19 pneumonia-related hypoxemic respiratory failure is feasible. The rate of any major complications is low.

20. Ventilator Induced Lung Injury (VILI) in ARDS. (Conference Abstract ID: 73)

Sarang Patil

Maharashtra University of Health Sciences, Nashik, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.24

Introduction: Ventilator-induced lung injury (VILI) has been recognized as a negative prognostic factor in patients with ARDS and is closely related to dynamic lung strain. No guidelines exist that define a safe lung strain limit, however, a recent study has proposed 0.27 as a possible threshold to prevent VILI (Adrián González-López et al.). A recent meta-analysis has suggested that driving pressure (DP) may have important consequences on patient outcomes in ARDS (Amato et al.) which may improve when driving pressure is limited to 15 cm H2O. It remains unclear if limiting the driving pressure reduces the incidence of VILI by decreasing the dynamic lung strain.

Objectives: To assess the prognostic value of dynamic lung strain in ARDS and its correlation with driving pressure.

Materials and methods: Analysis of the patients admitted to the ICU in one year period was done. We estimated patients’ functional residual capacity (FRC) from their reference values and calculated the end-expiratory lung volume (EELV) assuming that patients were in a supine position and had a decrease in volume proportional to their lung compliance. Dynamic lung strain was calculated as ratio TV/EELV. Pearson’s correlation coefficients were used to assess the correlation between strain and driving pressure. Multivariate analysis was used to determine the effects of lung strain on mortality, after adjusting for patients’ characteristics, APACHE and SAPS scores, and Exhauster’s comorbidity index.


Discussions: In patients with ARDS, dynamic lung strain is a strong predictor of mortality, irrespective of patient characteristics, APACHE, and SAPS scores. There is a positive correlation between DP and dynamic lung strain and when DP is limited to 15 cm H2O, the dynamic lung strain is ≤ 0.27, a value that was previously identified as a potential threshold to prevent ventilator-induced lung injury (VILI).

Conclusion: Limiting driving pressure can reduce the lung strain and improve patient outcomes in ARDS.

21. ROX Index a Promising Guide to Mechanical Ventilation. (Conference Abstract ID: 71)

Sarang Patil

Maharashtra University of Health Sciences, Nashik, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.25

Introduction: Early identification of patients at risk of failing noninvasive oxygen therapy has been a challenge but it is of important clinical benefit. The ROX index (Respiratory rate OXygenation index) is defined as the ratio of pulse oximetry by the fraction of inspired oxygen to respiratory rate, has shown to predict HFNC failure and risk for mechanical ventilation in patients with ARDS and pneumonia.


Materials and methods: Sample size: 100 patients admitted to ICU. We perform a retrospective observational cohort study of an adult patient admitted to ICU over two months at a large academic hospital, a clustered logistic regression of daily worst ROX index was performed to estimate the risk of endotracheal intubation and all-cause hospitality mortality.


Discussions: ROX index can accurately identify patients on supplementary oxygen therapy who are at risk for mechanical ventilation (NIV or IMV) and endotracheal intubation. It appears that possible delays in intubation of these patients identified as high-risk patients were associated with increased morbidity and mortality.

Conclusion: ROX index can thus be a good noninvasive modality to identify early patients at risk of mechanical ventilation and ends-tracheal intubation. This is thus a promising index and its use in rescue alert systems can help to significantly reduce morbidity and mortality in high-risk patients.

22. Clinical Profile and Laboratory Parameters in Patients with Moderate-Severe COVID-19 Pneumonia Admitted in Tertiary Care Hospital in South India. (Conference Abstract ID: 61)

Alfiya Sultana, M Mahendra, RS Bhoomika, Abhishek Nuchin, Ankit Pandey, S Shreedhar

Shimoga Institute Of Medical Sciences, Shimoga, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.26

Introduction: Coronavirus pandemic has caused significant morbidity and mortality throughout the world. Due to the novelty of this respiratory virus still, it is unclear regarding the clinical and laboratory profile of patients with COVID-19 pneumonia. So, we took up the study to look for the clinical and laboratory profile of patients with moderate to severe COVID-19 infection.

Materials and methods: A retrospective study was conducted on moderate-severe COVID-19 pneumonia patients admitted to tertiary care hospitals from June to October 2020. Data included demographic details, symptoms, comorbidities, vital parameters were recorded. Laboratory parameters included complete hemogram, neutrophil-lymphocyte ratio, serum ferritin, serum LDH, renal function test, liver function test, and arterial blood gas. Treatments details like the use of remdesivir, use of steroids and anticoagulants, use of a high-flow nasal cannula, noninvasive ventilation, ventilator were collected. Several ICU and hospital stay were recorded.

Results: 4012 confirmed cases of covid-19 were admitted to hospital, of which 560(13.95%) patients who were of moderate-severe severity were included in the study. Mean age of study population was 57.75 ± 13.96 years. Three sixty five (65.17%) were men. Hypertension (41.25%) was most common co-morbidity. Dyspnea (69.46%) was the most common symptom followed by fever (52.5%) and cough (46.78%). Mean duration of symptoms before admission was 4.11 ± 2.09 days. Mean Spo2 at admission was 78.70 ± 18.72. Mean neutrophil to lymphocyte ratio was 8.02 ± 8.66. Mean serum ferritin and serum Lactate dehydrogenase was 539.66 ± 381.78 and 845.73 ± 593.51 respectively. Mean duration of symptoms before hospitalization was 4.11 ± 2.09 days. Remdesivir was given to 298 (53.21%) patients. Mean duration of starting Remdesivir after symptom onset was 5.58 ± 2.78 days. Steroids were given to 454(81%) of patients and anticoagulation was given to 365(65.17%) of patients. High flow nasal cannula was given to 245(43.7%) patients. Ninety one (61.25%) were put on ventilator. Mean duration of hospital stay was 8.71 ± 7.54. A very high mortality 306(54.64%) was observed at our hospital.

Discussions: During the course of this study, we found most of the patients with moderate to severe COVID-19 pneumonia were of an elderly population with male predominance. A north Indian study found the majority of patients below 60 years of age with male predominance. Another North Indian study also found a majority of patients below 60 years. A retrospective study done in Wuhan found male predominance and elderly population affected with COVID-19 pneumonia similar to our study. We found dyspnea to be the most common symptom at presentation. In contrast, fever and cough were the most common symptom in a Chinese study and North Indian study.1–3 We found hypertension and diabetes to be the most common comorbidity similar to a Chinese study. We found a high NLR ratio, high serum ferritin, and serum LDH in our study. A Chinese study done on 110 patients found elevated procalcitonin and D-dimer in severe pneumonia patients. A study was done in New York City also found elevated levels of C-reactive protein and D-dimer in patients with severe COVID-19 pneumonia. We observed a mortality rate of around 54.64% at our hospital. A systematic review done of mortality in patients admitted to ICU found a mortality rate of 37.7% in China, 25.6% in Italy, 23.6% in the US, 29.2% in Spain, 41.2% in Denmark. Another small case series study in western India found a mortality rate of 16.7% in COVID ICU patients.

Conclusion: Patients who are elderly with comorbidities like diabetes and hypertension are more likely to have moderate to severe COVID-19 pneumonia requiring hospitalization. Most patients had elevated serum LDH and serum ferritin which could be a reliable prognostic indicator. Many patients presented late to the hospital with low oxygen saturation which has resulted in high mortality of 54.64%. Early diagnosis and treatment may decrease mortality in COVID-19 patients.

23. Epidemiology and Clinical Characteristics of Suspected COVID-19 Patients with Severe Acute Respiratory Infection (SARI) Admitted to a Tertiary Care Teaching Hospital. (Conference Abstract ID: 56)

Srikant Behera, Dalim K Baidya, Souvik Maitra, Bikash R Ray, Rahul K Anand, S Rajeshwari

All India Institute of Medical Sciences, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.27

Introduction: The COVID-19 pandemic has affected human beings globally. At present, medical science is flooded with literature related to various aspects of COVID-19. But, there is hardly any data found on literature comparing the epidemiology, clinical features, and outcome data of hospitalized COVID-19 SARI patients with non-COVID SARI patients. In this study, we tried to find out the epidemiology, clinical characteristics, and outcome of patients with a severe acute respiratory infection (SARI) admitted as suspected COVID-19 patients in a tertiary care teaching hospital.

Objectives: 1. To know the demographic parameter (age, sex, BMI, comorbidities) and clinical characteristics (presenting symptoms, duration of symptoms, disease severity, etc.) of the SARI patients with suspicion of COVID-19. 2. To know the clinical outcome (duration of hospital stay and survival to hospital discharge) in these patients.

Materials and methods: It was a prospective observational study, conducted at AIIMS, New Delhi. After obtaining permission from the institute ethics committee and written informed consent from their legally acceptable representatives, adult patients (18–75 years) of either sex, fulfilling WHO case definition of severe acute respiratory infection (SARI) with clinical suspicion of COVID-19 infection were included in the study. No formal sample size estimation was performed as no previous study is available in the Indian population when the study was planned and 450 adult patients (n = 450) were included in the study. The only exclusion criterion was the patients or relatives who refused to provide consent for the study. Demographic parameters, systemic comorbidities, and baseline clinical data were collected at the time of admission. Standard intensive care protocol as per current Surviving Sepsis Guidelines and standard management of respiratory failure and acute respiratory distress syndrome were followed in all patients. Protocolized weaning and extubation were followed. Fluid and vasopressor management was guided by hemodynamic variables and point of care ultrasound. Antibiotics therapy was initiated at presentation as per institute protocol and tailored according to the appropriate cultures (blood, urine, abdominal fluid, and tracheal aspirate whenever suitable) and sensitivity report when available. All data were collected in standard case record proforma.

Results: A total of 450 patients with a severe acute respiratory infection (SARI) as per WHO case definition were included in the study. All collected data were entered in a spreadsheet (Microsoft Excel). Normality was tested by Shapiro- Wilk test. Normally distributed data were presented as mean and standard deviation (SD), skewed data as median (Interquartile range) and categorical data were presented as absolute number and percentages. For comparison of related samples, the paired and unpaired t test were used for normally distributed data and the Wilcoxon signed rank test and Mann-Whitney U test were used for skewed data. P value of less than 0.05 was considered as statistically significant. A total of 450 patients with a severe acute respiratory infection (SARI) as per WHO case definition were included in the study. Out of total 450 SARI patients, 291 (64.6%) were positive for SARS-Cov-2 in RT-PCR. The median age of this cohort of SARI patients was 47(34-59) years. All the SARI patients were divided into two subgroups as COVID -19 SARI and non COVID -19 SARI patients. The COVID-19 SARI patients were slightly older in age (48 vs45 years, p = 0.02). The male gender was more common in the whole cohort of SARI patients as well as in both the sub groups. The common presenting symptoms were shortness of breath, malaise, fever, cough, abdominal pain, nausea, nausea / vomiting, chest pain, myalgia, diarrhea, etc. in the cohort of all SARI patients. The incidence fever, cough, and sore throat were higher among COVID-19 SARI patients. There was no significant difference in incidence of shortness of breath, chest pain, nausea and diarrhea runny nose and wheeze between both the groups. But the incidence of myalgia and abdominal pain was significantly higher in non-COVID SARI patients. There was there is no significant difference in duration of fever [4 (2-6) vs 3 (2-3) days, p = 0.17] between the two groups of SARI patients. The common comorbid conditions associated in SARI patients were hypertension, DM, CKD, CAD, malignancy, asthma, CLD, COPD, and obesity. The prevalence of these comorbid conditions was similar in both the SARI groups except for CKD and obesity. CKD was more prevalent non COVID-19 SARI patients and obesity was more prevalent COVID-19 SARI patients. The on admission vital parameters were similar (RR, p = 0.84; HR, P = 0.23; temperature, p = 0.07; SBP, p = 0.05; DBP, p = 0.06) in both group of SARI patients. On comparing the on admission parameters between the two groups of SARI patients, non-COVID SARI patients had significantly low Hb level, low total protein and low albumin level whereas other laboratory parameters (TLC, Platelet, PT/INR, APTT, creatinine, bilirubin) were similar in the both groups. The oxygen saturation/FiO2 ratio was significantly lower in COVID-19 SARI patients. The requirement of ICU admission in this cohort of 450 SARI patients was 33.5%. But, there was no significant difference in requirement of ICU admission between these two groups of SARI patients (32.3% vs. 35.8%, p = 0.44). But, more number of COVID-19 SARI patients required mechanical ventilation (31.6% vs. 22.6%, p = 0.04). The median duration of hospital stay was 9 (5-15) days. The COVID-19 SARI patients had more number of days of hospital stay [11(7-16) vs. 7 (4-12) days, p = 0<000.1]. Among these cohort SARI patients, 34.4% patients died, and there was no significant difference in mortality in these two groups of SARI patients (37.1% vs. 29.5%, P = 0.1)

Discussions: To the best of our knowledge, it is the first study on SARI patients that compared epidemiological, clinical features, and outcome data of hospitalized COVID-19 vs non-COVID SARI patients.

Conclusion: Clinical features like fever, cough, and sore throat were higher in COVID-19 SARI patients. Though, the need for ICU admission was similar in both the groups, patients with COVID-19 SARI required more mechanical ventilation and more days of hospital stay. But, the death rate was similar in both groups.

24. Correlation of Lung Ultrasound Aeration Score with Oxygenation in Ventilator-associated Pneumonia. (Conference Abstract ID: 40)

Sagarika Panda, Ankit Agawal, Gaurav Jain, Praveen Talwar, Udit Chauhan

All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.28

Introduction: Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections, which affect up to 27% of patients in the ICU on mechanical ventilation. It has attributable mortality of 13%, but crude mortality can be higher when there is a delay in diagnosis or delay in initiation of appropriate therapy in the form of appropriate antibiotics or optimization of ventilatory parameters. So, monitoring of its course is primarily important for a favorable outcome. Although lung CT is considered the gold standard for monitoring lung reaeration, the risk of transportation, and radiation exposure limit its repeatability. Lung ultrasonography (LUS) which is a simple bedside noninvasive tool could be an alternative method for monitoring the effectiveness of therapeutic interventions on VAP recovery by assessing the lung aeration score.

Objectives: The primary objective of this study was to identify a correlation between LUS aeration score with lung compliance and oxygenation in patients with ventilator-associated pneumonia. The correlation was calculated for all 5 days (day 1 to day 5) between the LUS aeration score (LUSS) with PaO2/FiO2 ratio and LUSS with static compliance. The secondary objective was to identify a correlation between LUSS (day 1) and 28-day survival in patients of VAP.

Materials and methods: This prospective, outcome assessor-blinded, observational study was conducted in the Department of Anaesthesiology at the All India Institute of Medical Sciences, Rishikesh. Patients who were diagnosed with VAP according to the clinical pulmonary infection score (CPIS) ≥6 of the age group 18 to 60 years were included in the study. Patients with thoracic dressings, subcutaneous emphysema, chronic obstructive pulmonary disease, interstitial lung disease, and morbid obesity (BMI > 40) were excluded from the study. Lung ultrasound was performed with an ultrasonography machine using a 2 to 5 MHz round-tipped probe by an investigator blinded for other outcome variables. It was evaluated at six areas of each hemithorax, superior and inferior areas in anterior, lateral, and posterior fields using parasternal, anterior-axillary, and posterior axillary lines as an anatomic landmark, and outcome parameters were recorded. Lung USG was performed every 24 hourly since the first diagnosis of VAP for consecutive 5 days. The partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2 ratio) and static lung compliance was calculated at the same time for consecutive 5 days. All the patients included in the study were followed for 28 days after ICU admission; if discharged before that, using telephonic conversation.

Results: It was conducted in 23 patients for consecutive 5 days who were diagnosed to have VAP based on the CPIS criteria. There was a significant correlation between LUSS with oxygenation (PaO2/FiO2 ratio) for 5 days. The Day 1 LUSS differ significantly between 28-day survivors and non-survivors. Patients with LUSS(Day1) of ≤ 19 had a sensitivity of 75% and specificity of 73% for predicting 28-day survival. The area under the ROC curve (AUC) was calculated as 0.78. Lung ultrasound aeration score and PaO2/FiO2 ratio changed significantly over time (p = 0.026; p = 0.004 respectively) and maximum change was found in day 5 as compared to day1 (p = 0.036; p = 0.001 respectively). There was a statistically significant difference obtained in the trend of change in LUSS over 5 days between 28 day survivor and nonsurvivor (p = 0.026).

Discussions: There was a significant negative correlations between LUSS with oxygenation (PaO2/FiO2 ratio) in all 5 days (r = −0.66; −0.68; −0.83; −0.85; −0.81 from day 1 to day 5, respectively). A very high correlation was seen from day 3 onward suggesting that clinical improvement became apparent after the first 72 hours of starting antibiotics (1). Our findings are consistent with Li et al., who also found a negative correlation between LUSS and PaO2/FiO2 ratio (r = −0.755, p < 0.001) in ARDS patients (2). Correlation of LUSS with static compliance was not statistically significant on day 1 (r = −0.22; p = 0.324), but from day 2 to day 5 we found significant correlation between them (r = −0.62; −0.73; −0.5; −0.69, respectively). Gattinoni et al. in their study had shown a significant correlation of static lung compliance with the normally aerated tissue (r = 0.77, p < 0.01) but not to the amount of lung injury or poorly aerated tissues (3). On the first day of development of VAP as more non-aerated tissues present in the lung (which can be confirmed from high LUSS on day 1), we could not find a significant correlation between LUSS and static compliance on that day, but as LUSS significantly decreased over time from 19.43 to 17.09 (p = 0.026) and a significant correlation was obtained between LUSS and static compliance afterward. Patients with LUSS (day 1) of ≤19 had a sensitivity of 75% and specificity of 73% for predicting 28-day survival. The area under the ROC curve (AUROC) was calculated as 0.78. This finding is comparable with Li et al. who also found the same cutoff of LUSS for predicting mortality in ARDS patients with high sensitivity and specificity (84 and 89%, respectively).2 The lower sensitivity and specificity in our case can be explained by the lower sample size in our study. Lung ultrasound aeration score and PaO2/FiO2 ratio changed significantly over time (p = 0.026; p = 0.004, respectively). We found a statistically significant difference in the trend of change in LUSS over 5 days between a 28-day survivor and non-survivor (p = 0.026). In 28-day survivors, LUSS decreased over time, but in non-survivors, LUSS did not decrease over time, rather there was a non-significant increase on day 5 as compared to day 1. Xie et al. also observed a significantly higher LUSS for 28-day non-survivor than the survivor at 0, 24, 48, and 72 hours in ARDS patients.4

Conclusion: Serial measurement of LUSS can define the clinical course of VAP resolution, identifying those receiving adequate therapy and good outcome by as early as day 5 and could be of help to define strategies to shorten the duration of therapy. Lung ultrasound score appears to be a valuable tool for evaluating the recovery of VAP as shown by a significant correlation with arterial oxygenation. This study also serves as a step for encouraging future trials with larger sample sizes to validate our results.

25. Study to Evaluate the Accuracy of Ultrasonography in Confirming Endotracheal Tube Placement in Emergency Department. (Conference Abstract ID: 15)

Mit A Nayak, Chirag J Patel, Divyesh B Kalariya

BJ Medical College, Civil Hospital Campus, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.29

Introduction: Securing the airway by endotracheal intubation is a fundamental skill in emergency medicine for definitive airway management. Unrecognized intubation of the esophagus is a significant source of morbidity and mortality. Direct visualization of the endotracheal tube passing through the vocal cord is not always possible due to unfavorable anatomy, trauma, edema, blood, vomitus, and secretions. Studies found that quantitative capnography is the most sensitive tool for confirming tracheal intubation but this method has some limitations, particularly in cardiac arrest patients, such as the need for epinephrine use, low pulmonary flow, and low cardiac output. However, capnography is still not widely available in some emergency departments (EDs) and intensive care units (ICUs). Ultrasound is a common examination tool in many EDs and ICUs. To assist with airway management in critically ill patients, ultrasound is very useful due to its low-cost and portable capability.


Materials and methods: This is a prospective and observational study conducted from July 2019 to July 2020 at Emergency Medicine Department, Civil Hospital and B.J Medical College, Ahmedabad. A total of 250 patients with the emergency presentation were included. As per inclusion and exclusion criteria patients were recruited into the study. Total four persons [Myself (for ultrasonographic confirmation), two resident (one for intubation and direct visualization and second for 5 point auscultation), senior resident or faculty of emergency medicine department (look for a rise in oxygen saturation by pulse oximetry and condensation in the endotracheal tube)] were required for this study and everyone record their findings and time using a stopwatch.

Results: The overall accuracy of ultrasonography method was 98.80% (95% confidence interval (CI) 96.53% to 99.75%). The sensitivity, specificity, positive predictive value and negative predictive value of ultrasonography method for tracheal intubation confirmation were 98.72% (95% CI 96.30% to 99.73%), 100% (95% CI 79.41% to 100%),100 % and 84.21% (95%CI 63.41% to 94.26%) respectively. The likelihood ratio of a positive test was Infinite and the likelihood ratio of a negative test was 0.01(95% CI 0.00 to 0.04).

Discussions: This prospective study aimed to assess the accuracy and timeliness of tracheal ultrasound for determining endotracheal tube placement during emergency intubation. According to the new ACLS guidelines, quantitative waveform capnography is recommended as the most reliable method for confirming endotracheal tube placement. Nevertheless, quantitative capnography is neither widely available nor consistently applied in some EDs. Ultrasound is a common and useful diagnostic tool in many EDs and critical care areas. The use of ultrasound to confirm endotracheal tube placement is attractive due to the following reasons. First, ultrasound is portable, repeatable, and widely available in many EDs, critical care areas, and even outside of the hospital. If ultrasound is as sensitive and specific as the waveform capnography, it can be used instead of waveform capnography is not available. Second, ultrasonographic images are not affected by low pulmonary flow, as compared to capnography. Third, tracheal ultrasound can detect esophageal intubation even before ventilating the patient, which prevents unnecessarily forced ventilation to the stomach and its associated complications.

Conclusion: Ultrasonography detected the tube placement faster and accurately than the other methods. The present study demonstrated that transtracheal sonography has an acceptable degree of sensitivity and specificity for the confirmation of endotracheal intubation. Ultrasonography is a valuable adjunct and should be considered when capnography is unavailable or unreliable.

26. Beside Ultrasonography vs Radiography for Detection of Pulmonary Edema. (Conference Abstract ID: 11)

S Surendhar, Chirag J Patel

BJ Medical College, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.30

Introduction: Pulmonary edema is an abnormal increase in extravascular water secondary to increased hydrostatic pressure in pulmonary circulation due to either congestive heart failure or volume overload. The ability to diagnose, quantify, and monitor pulmonary congestion is important in managing the disease. Point of care lung ultrasonography targeted to the detection of B-lines allows bedside diagnosis of respiratory failure due to impairment of cardiac function, as well as quantification and monitoring of pulmonary interstitial fluid.

Materials and methods: A prospective observational study was carried out at a tertiary care center, Civil hospital, Ahmedabad between February 2019 to 2020. All patients presented to the emergency department with dyspnea evaluated for pulmonary edema. With detailed history, clinical examination, radiological and other investigations, the final diagnosis was made by the respective treating medicine unit. Chest radiography (anteroposterior or posteroanterior) was interpreted by a radiologist and bedside lung ultrasound was done in the emergency department by an emergency physician. We started with a lung ultrasound examination of each patient with a rapid anterior two region scan and lateral two region scan in each side of the lung and then proceeded with another lung examination, consisting of scanning four chest areas on each lung. Lung ultrasound findings are recorded for B-lines for each lung as per region.

Results: A total of 180 patients participated in this study from February 2019 to February 2020. In 180 patients 92 patients diagnosed with pulmonary edema during discharge, out of which 100 patients were positive for pulmonary edema by ultrasonography with sensitivity-96%, specificity-86%, PPV-88%, NPV-90% and 69 patients were positive for pulmonary edema by chest radiography with sensitivity-68%, specificity-93%, PPV-91%, NPV-74%.

Discussions: In our study bedside, US was found to be more sensitive in detecting pulmonary edema than chest radiography while generating a higher negative predictive value. Bedside US could allow the provider to arrive at the correct diagnosis more quickly, thereby expediting effective therapeutic decision making and perhaps decreasing the patient’s length of stay. In 2018, Wootan et al.3 conducted a prospective cohort study of 99 patients who presented to the emergency medicine department with dyspnea. Bedside US showed significantly higher sensitivity (96%) compared to chest radiography (65%; p < 0.001). Of 18 patients with negative radiographic findings and a discharge diagnosis of pulmonary edema, 16 (89%) had positive US findings (p < 0.001).

Conclusion: The findings suggest that LUS is as specific and more sensitive than CXR in the identification of pulmonary edema. Given the potential advantages of its use, LUS should be considered as an adjunct imaging modality in the evaluation of patients with dyspnea.

3. Cardiac Arrest, CPR, Cardiovascular Issues in ICU

1. Significance of “Horizontal ST-Segment with Sharp ST-T Angle” Electrocardiographic Sign in Acute Coronary Syndrome. (Conference Abstract ID: 171)

Mukundkumar V Patel, Dhruvkumar M Patel, Jui R Shah, Maitri M Patel, Harsh D Patel, Jayanti K Gurumukhani

Zydus Medical College and Hospital, Dahod, Dhruv healthcare Multi-speciality Hospital, Ahmedabad, Gujarat, India
SVP hospital, NHLM College, Ahmedabad, Gujarat, India
GCS Medical College, Hospital and Research Center, Ahmedabad, Gujarat, India
Surat Municipal Medical College, Surat, Gujarat, India
Jay Neurocare and Physiotherapy Clinic, Bhavnagar, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.31

Introduction: The electrocardiogram (ECG) is a noninvasive, simple, and routinely available bedside tool and an integral part of clinical examination for the diagnosis and prognostication of chest pain triage in the emergency room. Normal ST-segment is slightly curved and the ST-T angle is obtuse. “Horizontal ST-segment with sharp ST-T angle (HST-STA)” is described as a subtle sign of myocardial ischemia. As per the author’s view, this sign was never studied previously in acute coronary syndrome.

Objectives: The present study aimed to evaluate the significance of ECG sign “HST-STA” in patients with the suspected acute coronary syndrome (ACS).

Materials and methods: This observational prospective study was conducted among consecutive patients aged above 21 years who presented with chest pain suggestive of acute coronary syndrome. The standard 12 lead ECG was recorded on admission and was repeated after 12 hours or during reappearance of symptoms. Patients were classified according to the ECG findings into group I (ST-segment depression), group II (T-wave inversion), and group III (apparently normal ECG). The group III cases were further subclassified according to the presence or absence of HST-STA sign by blinded cardiologists. Serum Troponin-I was measured on admission, after 3 hours and 6 hours. All the cases were referred for a coronary angiogram (CAG) and the test was considered as a gold standard reference test for confirmation of the ACS. Patients with ST-elevation myocardial infarction (STEMI), LBBB, RBBB, ventricular hypertrophy, Brugada syndrome, pacemaker rhythm, and CAG not performed within 4 to 6 weeks of chest pain were excluded. In this study, ACS included only non-STEMI (NSTEMI) and unstable angina (UA) unless specified.

Results: Out of 1221 suspected ACS cases, 354 STEMI, 24 LBBB, 15 RBBB, 16 LVH, 11 RVH and one pacemaker rhythm were excluded. 101 patients either lost from follow up or not subjected for CAG and finally, 699 cases completed the study. Mean age was 48.2 ± 12.5 years and 445 were males. Frequency of ACS was 230, 105 and 364 in Group-1, 2 and 3 respectively. Subsequently, the ACS cases were diagnosed as NSTEMI (151, 70, 221), UA (45, 19, 67) and non-coronary (34, 16, 76) in group 1, 2 and 3 respectively. The sensitivity and specificity, respectively, for detecting ACS were 33.03% and 67.53% by ST-segment depression, 15.96% and 88.31% by T-wave inversion, 48.99% and 55.84% by ST depression plus T inversion, and 29.50% and 84.88% by HST-STA (among ECGs not showing ST-depression or T-wave inversion). The HST-STA sign was more sensitive than T inversion (p = 0.019), and ST depression plus T inversion (p = 0.005), and more specific than ST depression (p = 0.002) and ST depression plus T inversion (p < 0.000) for detecting myocardial ischemia. Multivariate logistic regression analysis showed HST-STA added diagnostic value over other ECG signs (p < 0.001).

Discussions: Until now, it is to the authors’ understanding that the value of HST-STA for detecting CAD in patients with ACS has not yet been addressed in the literature. Although the sign is subtle, it can be easily detected during ECG interpretation by the attending physician aware of it.17,18 Among the patients with chest pain, the prompt and accurate detection of ACS remains an important clinical challenge for ER physicians.3,5,19 ECG is indispensable and extension to clinical examination for ACS management and risk stratification.5,20 Cardiac enzyme markers of cell necrosis are very sensitive but require 3 to 6 hours for detection.21,22 Cardiac imaging and nuclear isotope scans are modern tools having good sensitivity for ACS detection but they require special setups and results are not promptly available.23–26 Studies found that the changes in ECG parameters such as ST-segment depression and T-wave inversion could effectively predict long-term mortality and morbidity of patients with acute coronary syndrome and also those who undergo coronary revascularization.5,27,28 Despite the poor value of ECG to predict ACS, it may be potentially useful for predicting the late outcome of cardiac diseases in comparison with invasive strategies that should be strongly considered.5,29,30 Based on previous studies, each ECG parameter independently could poorly predict CAD with very low sensitivity; however, when the parameters were considered together, the predictive value was significantly increased.30,31 Holubkov et al. also revealed that using at least two ECG signs of myocardial ischemia in any set of contiguous leads causes remarkable higher odds of significant angiographic CAD than those without concomitant ECG abnormalities.32 Hence, the decision about the presence of CAD should be performed on the sum of myocardial ischemia ECG signs instead of a single parameter. Similar to the previous studies,33,34 our study showed low sensitivity as well as partial low specificity of individual ECG sign of ST-segment depression or T-wave inversion. But when these signs considered together sensitivity increased significantly and specificity remain unchanged for predicting CAD. In the current study, the sensitivity of ECG for CAD diagnosis ranged between 15.96 and 48.99% and its specificity ranged from 55.84 to 88.39%, and it matches with the previous studies.30,33,34 Some studies considered several potential strategies for overcoming the poor sensitivity of the ECG.30 In our study, stand-alone HST-STA sign additionally detected 29.5% of ACS cases among apparently normal ECGs in patients with suspected ACS.

Conclusion: The HST-STA is an unexplored subtle ECG sign for the detection of myocardial ischemia in addition to ST depression and T inversion in acute coronary syndrome.

2. To Compare the Change in Lactate Levels with Respect to the Venoarterial Carbon Dioxide Gap During Initial Resuscitation of Patients in Shock. (Conference Abstract ID: 158)

S Col Kiran, Maj Kapil Kulkarni, Brig Rangraj Setlur

Armed Forces Medical College, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.32

Introduction: Current guidelines for hemodynamic management of septic shock recommends the use of markers of tissue hypoxia as resuscitation endpoint. In the initial resuscitation period, targeting either central venous oxygen saturation normalization or lactate clearance, or the combination of both is accepted. However, lactate levels, particularly in the critically ill, maybe in influenced by factors other than global hypoperfusion. PvaCO2 gap, the difference between central venous blood and arterial blood CO2, is dependent on CO2 production and cardiac output. It is a downstream metabolic parameter that has been explored in shock as a marker of resuscitation. A PvaCO2 > 06 mm Hg, is a result of increased oxygen utilization and CO2 production and reflects a low output state with hypoperfusion. Such patients can continue to receive resuscitation despite meeting resuscitation goals of lactates and ScvO2. This study evaluates the correlation of the PvaCO2 gap with lactate clearance during resuscitation in shock.

Objectives: The primary objective of this study is to compare the change in mean lactate levels with respect to the PvaCO2 gap during the first 6 hours of initial resuscitation of patients in shock. The secondary objective was to study the correlation of the PvaCO2 gap with mortality during early resuscitation in patients with shock.

Materials and methods: A prospective observational study conducted over 18 months, included adult patients admitted to a multidisciplinary intensive care unit (ICU) of a tertiary care hospital, in circulatory shock. Sixty-seven patients presenting with circulatory shock from all causes were recruited and blood lactate concentrations, PvaCO2 gap, and hemodynamic variables were obtained at ICU admission (T0) and 06 hours after admission and resuscitation (T6). ICU length of stay, need for mechanical ventilation and its duration, days of vasopressor need, application of renal replacement therapy, and mortality within 28 days were recorded.

Results: Mean PvaCO2 gap levels at T0 and T6 were 7.13 ± 0.813 mmHg and 6.40 ± 0.702 mmHg respectively. Mean serum lactate levels at T0 and T6 were 3.61 ± 0.31 mmol/L and 3.09 ± 0.32 mmol/L respectively. Correlation analysis of PvaCO2 gap with mean lactate levels at T6 showed positive correlation with correlation coefficient (R value) of 0.320 (p < 0.05). Correlation analysis of change in PvaCO2 gap with serum lactate clearance showed significant negative correlation (R value = -0.380) (p value < 0.05). Of 67 cases studied, 57 (83.8%) required vasopressor support for ≤07 days and 11 (16.2%) for > 07 days, 19 (27.9%) required renal replacement therapy, 48 (70.6%) required mechanical ventilation, 43 (63.2%) had duration of ICU stay for ≤ 07 days and 25 (36.8%) had duration of ICU stay for > 07 days and 33 (48.5%) died within 28 days.

Discussions: There was no correlation between the lactate level and the PvaCO2 value at baseline, but results indicate that a persistently high PvaCO2 gap better predicts a lower lactate clearance than a low PvaCO2 gap. A positive correlation is seen between mean lactate levels and the PvaCO2 gap in patients after 06 hours of resuscitation. This indicates that with adequate resuscitation both the mean lactate levels and PvaCO2 gap showed a significant decreasing trend and are covariant. The negative correlation between lactate clearance and the PvaCO2 gap showed that with an increase in lactate clearance at the end of resuscitation there was an associated drop in the PvaCO2 gap. Hence, both are covariant in nature and are good markers of improvement in perfusion. It is also demonstrated that patients who normalize their PvaCO2 gap during the early resuscitation period would have a greater lactate clearance than those who did not normalize their PvaCO2 gap.

Conclusion: Lactate values have a good correlation with the venoarterial carbon dioxide gap when used for assessment of the effectiveness of initial resuscitation of patients presenting to the ICU with circulatory shock. The venoarterial carbon dioxide gap is a good predictor of poor outcomes in circulatory shock.

3. Compliance of Cardiopulmonary Resuscitation During In-hospital Cardiac Arrest in a Teaching Institution. (Conference Abstract ID: 153)

R Arun Kumar, S Chandresh

PSG Institute Of Medical Sciences And Research, Coimbatore, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.33

Introduction: The guidelines for cardiopulmonary resuscitation emphasize the importance of high-quality CPR in determining survival after cardiac arrest, but in clinical practice, the quality and the parameters of CPR is not routinely measured. Measurements of CPR quality during training, actual cardiac arrests, and debriefing to rescuers during arrests may improve CPR quality at subsequent cardiac arrests.

Objectives: The main aim of this audit study is to measure the multiple parameters of in-hospital CPR quality and to determine the compliance with American Heart Association 2020 and international resuscitation guidelines. Primary objective: Compliance with cardiac arrest resuscitation which includes the initial analysis, resuscitation procedures, CPR assessment, and resuscitation outcome.

Secondary objective: Compliance on debriefing and audit outcome.

Materials and methods: This is a retrospective observational analysis done in patients who experienced in-hospital cardiac arrest between January 1, 2019, and December 31, 2019, after obtaining institutional human ethical committee clearance (PSG/IHEC/2020/Project No. 20/139 dated 08.07.2020). The audit was registered in the clinical trial registry of India (CTRI/2020/11/029095).

Inclusion criteria:

Exclusion criteria: The source of our audit study included the cardiac arrest resuscitation form and CPR case sheet audit form maintained in our department and CPR committee. Death is not a predetermined factor to fix the sample size and hence in our study we cannot fix the sample size. It is hence justified that all cardiac arrest victims are given prime importance to seek the cause of death and auditing need to be done in detail to identify the potential cause of death to decrease the mortality and morbidity in near future in a teaching institution. The results of the compliance of cardiopulmonary resuscitation during in-hospital cardiac arrest in a teaching institution are discussed under the following headings based on the CPR audit findings for every month: 1. Protocol deviations; 2. Resource issues; 3. Documentation issues.

Results: Out of 246 cardiac arrest victims, 37.39% (92 out of 246) showed compliance in the protocol deviations, 13% (32 out of 246) with documentation issues, 9.34% (23 out of 246) had resource issues and 40.24% (99 out of 246) showed perfect documentation without any corrections or error in the monitoring of the critical event. Majority of Code blue was noted in the General medicine department (26.01%) followed by cardiology (13.82%), gastro enterology (13.82%), nephrology (12.19%), neurology (12.19%), medical oncology (4.47%), respiratory medicine (6.65%) and other specialities with negligible percentage cause of death according to departmentwise statistics. Majority of deaths were noted in the male gender (161 out of 246) compared to the female (85 out of 246) and the age distribution were predominant in age group between 61 and 70 years of age in both gender.

Discussions: In our institution, CPR is mandatory to perform for at least 30 to 45 minutes following the cardiac arrest. Among the protocol deviations, reversible causes were not addressed in 10.97% of code blue victims and Use of adrenaline was inappropriate with regard to its dosage, timing, and frequency of administration in 15.43% of victims. Prolonged switch role time during high-quality CPR noted in 2.84 and 1.21% had a delay in CPR initiation. 2.43% among arrested victims had difficulty in diagnosing and managing the appropriate cardiac rhythm posing difficulty in managing the coronary event. Documentation of delivery of defibrillation joules was incorrect in 3.25% of cardiac arrest victims. The exact cardiac event at the time of code blue not specified in 5 personnel and 3 cases showed inappropriate documentation of code team members. In few instances, the exact location of code blue was not addressed (1.21%), outcome measures of cardiac arrest missing in a few documentations (0.81%). 1.21% showed inadequacy in high-quality CPR and inadequate airway and ventilation management. The exact time of death was noted in the right place in two profiles among the 246 audit forms. Unavailability of appropriate airway gadgets not available at few instances (1.21%), Improper operating defibrillator in negligible scenarios (1.62%). Unavailable emergency drugs in crash cart very rarely (1.21%) were considered predominant compliance with the resource issues. Improper functioning of laryngoscopes and unavailability of bougie was noted in 1.21%. Debriefing was not done regarding the device issues once. Delay in the arrival of code place was recorded in 0.81%, failure of suctioning device in 0.81%. False code blue calls were omitted in our audit and cardiopulmonary resuscitation was commenced immediately following cardiac arrest in all code blue victims. There were not any issues with lift malfunctioning, availability of AMBU bag, glucometer, or oxygen source in our code blue scenarios. Team leader assigned appropriate roles and responsibilities in the catastrophic event. Debriefing was done in the majority of the cases with found missing in one case among the 246. Based on our clinical audit following recommendations were focussed:

Conclusion: To conclude the auditing was done to improve the quality of healthcare in the resuscitation measures and not to focus on the pitfall of the cardiopulmonary resuscitation. In our audit, we found the issues were more lacking with a performance of resuscitation in an algorithmic approach. Good teamwork and adequate knowledge sharing with live demonstrations and practice in mannequins can help improve the quality of performing CPR.

4. A Descriptive-Analytical Study of the Effect of Thrombolytic Therapy on QT-dispersion in Critically Ill Patients with Acute ST-Elevation Myocardial Infarction. (Conference Abstract ID: 116)

Ankit Laddha, Jain C Subhash

Jhalawar Medical College, Jhalawar, Rajasthan, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.34

Introduction: A descriptive-analytical study of the effect of thrombolytic therapy on QT-dispersion in critically ill patients with acute ST-elevation myocardial infarction.

Objectives: This study aims to assess the effect of thrombolytic therapy on QTd before and 24 hours after thrombolytic therapy in cases with acute ST-elevation myocardial Infarction.

Materials and methods: The critically ill patients with ST-elevation myocardial infarction (STEMI) that underwent thrombolytic therapy were enrolled in this study. Streptokinase was the thrombolytic agent in all the patients. QT dispersion using Standard 12-lead ECG was measured before the beginning of thrombolytic therapy (QTd1) and 24 hours (QTd2) after thrombolytic therapy. ECG intervals were measured using EP Calipers Software. Results were analyzed using SPSS Software version 26.0 and EPIINFO Software. A p value ≤ 0.05 was considered statistically significant.

Results: This study was conducted on 86 patients admitted in Medical ICU with Acute ST elevation Myocardial Infarction. The results revealed significant difference between QTd1 and QTd2 (P-value < 0.05) in cases with Acute Anterior Wall ST elevation Myocardial Infarction. However in cases with Inferior and/or Lateral wall Acute ST elevation Myocardial Infarction the results were not significant (P-value>0.050).

Discussions: Based on the study results, QTd decreased after thrombolytic therapy, thus thrombolytic therapy had significant effects on QTd2 (QTd after 24 hours). Thus, the risk of dysrhythmia decreased after thrombolytic therapy. Similar to our study, Lörincz et al. assessed the effect of Streptokinase on QT dispersion. They reported that QTd increased at early hours after infarction and thrombolytic therapy, but decreased 8 ± 2 hours after thrombolytic therapy (1). Also, Nikiforos et al. studied 60 patients with Acute ST-elevation Myocardial Infarction to assess the effect of Thrombolytic therapy on QTd. They concluded that thrombolysis was associated with a significant decrease in QTd on the standard 12-lead ECG (2).

Conclusion: Thrombolytic therapy had significant effects on QTd in cases with Acute Anterior Wall ST-elevation Myocardial Infarction. Thus, thrombolytic therapy decreases the risk of dysrhythmias in Acute Anterior Wall ST-elevation Myocardial Infarction.

5. Correlation of Common Carotid Artery Blood Flow Parameters With Transthoracic Echocardiography Parameters for Assessing Volume Responsiveness after Passive Leg Raising Test in Critically Ill Patients. (Conference Abstract ID: 105)

Rohit Kumar Patnaik, Bhuvana Krishna

St. Johns Medical College, Bengaluru, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.35

Introduction: The need for fluid resuscitation has been at the forefront of treating patients in shock. To administer the right amount of fluids, we need to know if the patient is volume responsive to a fluid challenge. The passive leg raising (PLR) maneuver is a simple, noninvasive method of knowing volume responsiveness. Correlation between carotid blood flow Doppler parameters with left ventricular outflow tract velocity-time integral (LVOT VTI) to assess the effects of PLR test in predicting volume responsiveness has not been demonstrated in any group of patients. This could provide a viable and much simpler alternative to LVOT VTI in assessing volume responsiveness with the PLR test.

Objectives: Primary:Secondary:

Materials and methods: A prospective observational study was conducted from Jan 2019 to November 2020 in the ICU of a tertiary care hospital. Forty patients were enrolled in the study. All patients were screened within 48 hours of admission. Patients enrolled were evaluated with a 7 to 13 MHz linear transducer probe for carotid flow parameters. Patients were evaluated with a 1 to 5 MHz cardiac probe equipped with Tissue Doppler Imaging (TDI) for LVOT VTI with an apical 5-chamber view. 2 PLR maneuvers (5 minutes apart) were done within 48 hours of ICU admission. Recordings were taken 5 times — Baseline 1, PLR 1, Baseline 2, PLR 2, Baseline 3. The first PLR test was to assess effects on cardiac output using LVOT VTI. The second PLR test was performed to assess effects on carotid blood flow parameters. LVOT VTI parameters and carotid blood flow parameters were recorded for both the PLR maneuvers. Patients were designated as volume responders (VR) if a change in cardiac output using LVOT VTI ≥10 %. All the analyzes were carried out using STATA 13 software.

Results: 40 patients were included in this study. At the time of study, 84% were intubated and mechanically ventilated. 38 % received vasopressor support. A positive PLR test was observed in 33 percent of patients using cardiac output increase of ≥10%. Strong correlation was present between absolute values of cardiac output calculated using LVOT VTI and absolute values of carotid blood flow (using TAPEAK) (r = 0.60, p < 0.05). However, weak correlation was found between simultaneous changes in cardiac output calculated using LVOT VTI and changes in carotid blood flow (using TAPEAK) during PLR (r = 0.05, p < 0.74). A positive PLR response could not be detected by changes in carotid blood flow (area under ROC curve: 0.59 ± 0.09). A multiple logistic regression analysis was run to predict cardiac output using carotid blood flow, carotid peak systolic velocity, systolic blood pressure and heart rate. These variables statistically significantly predicted carotid blood flow, F (4,35) = 8.19, p < 0.0005, R2 = 0.48. Out of the 4 variables, only 2 (carotid blood flow and heart rate) added statistically significantly to the prediction, p < 0.05.

Discussions: We found a strong correlation between cardiac output calculated using LVOT VTI and carotid blood flow at baseline. However, simultaneous changes in cardiac output had a very poor correlation with changes in carotid blood flow, during the PLR test. Considering this, carotid flow parameters cannot be recommended as a means to detect fluid responsiveness with PLR test in critically ill patients. Also, the ability of carotid flow parameters to predict a positive PLR response was not good.

Conclusion: Considering this, carotid flow parameters cannot be recommended as a means to detect fluid responsiveness with PLR test in critically ill patients.

6. Clinical Profile, Risk Factor Profile, and Outcome of ACS in Young Adults. (Conference Abstract ID: 97)

Ritesh Chauhan, RK Jha, Dinesh Sisodiya

Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.36

Introduction: Acute coronary syndrome (ACS) in young patients is a significantly rising problem all over the world. With increasing environmental stress and early onset of diabetes mellitus, hypertension, dyslipidemia in the Asian continent particularly in India.

Materials and methods:

Inclusion criteria: All patients, 30 or younger admitted to SAIMS Medical College-Indore, with a diagnosis of ACS final diagnosis of ACS will be based on two out of three of the following criteria:

Exclusion criteria:



Conclusion: The incidence of acute MI in young patients is increasing day by day which was thought earlier less common among young individuals. This may be because of their lifestyle. Young MI is found to be more common in the male gender.

7. Correlation of Epicardial Fat Thickness with Severity of Coronary Artery Disease. (Conference Abstract ID: 86)

Sameer Pushpad, Rajesh Kumar Jha

Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.37

Introduction: Epicardial fat, the adipose tissue accumulated between the visceral pericardium and the myocardium, is a metabolically active organ with various bioactive molecules, significantly affecting cardiac function. It increases with age, obesity, diabetes, and female gender.

Materials and methods: The study was designed as an observational cross-sectional study. Fifty-one patients of CAD admitted to the Department of Cardiology and Gen. Medicine, SAIMS Medical College, Indore from November 2019 to November 2020 were included in the study. Another 50 non-CAD patients were taken as a control group.

Results: Total 101 cases were taken of which 51 belonged to group 1 (CAD patients) and 50 patients to group 2 (non-CAD patients). In CAD group the mean Age, BMI, smokers, TC, S. urea and LDL were significantly higher than that of the non-CAD group (p = 0.008, p = 0.024, p = 0.02, p = 0.021 and p = 0.008, p = 0.000 respectively).

Discussions: Epicardial fat thickness showed a significant correlation with LDL, BMI, and Gensini score. These results agree with the results obtained from many other similar studies and in Indian studies like Meenakshi et al. and B Verma et al.


8. A Study of Risk Factors and Coronary Angiographic Profile in Young Patients with Acute Coronary Syndrome. (Conference Abstract ID: 82)

Shobhit Gupta, Rajesh Kumar Jha

Sri Aurobindo Medical College and PG Institute Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.38

Introduction: Acute coronary syndrome (ACS) refers to a broad spectrum of clinical conditions compatible with acute myocardial ischemia and/or infarction that are mostly due to abrupt cessation in the blood flow to the coronary circulation. Keeping this in mind, a study was planned to know about the clinical presentation, risk factors, and pattern of coronary artery involvement in young Indian patients (<40 years) with ACS

Materials and methods: Study Design: Hospital-based observational cross-sectional study. Study Period: 18 months. Inclusion Criteria: Diagnosed patients of ACS and needing coronary angiography with age <40 years. Sample Size: The sample size came out to be 68 which was rounded off to 70.


Discussions: In our study, the mean age of subjects was 33.8 years with 66% cases of ACS being STEMI, as compared to the European heart survey where the mean age was 63 years and 42% cases were STEMI; CREATE registry with a mean age of 57 years with 61% patients having STEMI. Thus, most studies show that STEMI is the most frequent presentation of ACS in young. Indian patients are more likely to have early onset of CAD (around a decade earlier than the western population).

Conclusion: Our study is a reflection of the profile of lower and lower-middle, semi-urban population which is the huge population burden of our nation. Indians have a different environmental and genetic makeup that should be kept in mind. This was only a small descriptive study. Large multi-centric similar studies are needed to plan preventive strategies to improve the health status of the huge population of our country.

9. Outcom.es of Trauma Victims with in Hospital Cardiac Arrest Who Survived to Intensive Care Unit Admission in a Level 1 Apex Indian Trauma Center: A Retrospective Cohort Study. (Conference Abstract ID: 79)

Nitin Rai, Richa Aggarwal, Kapil Dev Soni, Anjan Trikha

All India Institute of Medical Sciences, Jai Prakash Narayan Apex Trauma Centre, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.39

Introduction: Patients suffering from trauma-related cardiac arrest (TRCA) are generally reported to have a poor outcome1,2 and arguments for the futility of aggressive support have been made for this patient population.3,4 In our study, we propose to determine the factors related to outcomes for patients following in-hospital cardiac arrest post-trauma and admitted to the intensive care unit (ICU) and to identify characteristics associated with in-hospital mortality. This will help to the optimization of specific post-resuscitation physiologic parameters could similarly improve the outcome for patients resuscitated from TRCA.

Objectives: (1) to determine outcomes of patients following in-hospital cardiac arrest post-trauma and admitted to the intensive care unit (ICU) and (2) to identify characteristics associated with in-hospital mortality.

Materials and methods: This was a retrospective single-centered observational study of the patients admitted to Level 1 Apex Trauma Centre ICU following in-hospital cardiac arrest between January 2017 and July 2018. Details of the patients were retrieved from paper-based registers/ICU registry/hospital medical records section retrospectively. Inclusion criteria were post-cardiac arrest patients following trauma and being admitted to polytrauma ICU following resuscitation. Patients with isolated head injuries and multiple cardiac arrests were excluded. Data were screened and the following factors were recorded — duration of CPR, mechanism of injury, place of cardiac arrest, cause of cardiac arrest and GCS on arrival to ICU, vasopressors/inotropes requirement and duration, severity scoring — APACHE-II and SOFA. Institute Ethics Committee clearance was obtained before the study (Ref. No. IEC-155/05.04.2019).

Results: A total of 37 patients were included in the study. Out of these 31(83.8%) were male and 6 (16.2%) were female. Long bone fracture followed by blunt trauma abdomen (BTA) and blunt trauma chest (BTC) were the most common modes of injury contributing 24.2% and 18.2% each respectively. Mean duration of CPR was 22.7 minutes. The mean duration of vasopressor days was 4.9 days. The mean APACHE 2 and SOFA scores were 25.8 and 12.8 respectively. The average ICU and hospital length of stay were 4.9 and 6.1 days respectively. 35.1% patients survived to hospital discharge. APACHE 2 and SOFA within first 24 hours were associated significantly with in hospital mortality in bivariate analysis. 13 out of 37 (35.1%) patients survived to hospital discharge.

Discussions: This study was an attempt to elucidate the factors associated with the outcomes following in-hospital cardiac arrests. Most of the studies have analyzed out of hospital cardiac arrests or cardiac arrest occurring in the ED.5–7 Thirteen out of 37 (35.1%) patients survived hospital discharge. Traditionally, survival after cardiac arrest is generally considered abysmal. There has been a long-term debate over for futility of aggressive support for this patient population.3,4 Previous observational studies found the survival rate to be between 13.4 and 23% following in and out of hospital cardiac arrest.8,9 Significantly better survival to discharge rate in the present study could be explained by two attributes. First, being a witnessed arrest inside the hospital, there was a timely and quality initiation of resuscitative efforts by medical personnel, unlike an out of hospital cardiac arrest. This was a major contributor to better outcomes. Second, a small sample size could have produced an inflated result. Severity scores — APACHE-II and SOFA within the first 24 hours were significantly associated with in-hospital mortality in bivariate analysis. Whereas age, duration of CPR, and serum lactate levels were not associated with in-hospital mortality.

Conclusion: Resuscitative efforts should be continued despite previous reports of terminating over futility as a survival to discharge rate in one-third of patients is quite significant considering the perspectives of previous data. An investigation into whether optimization of post-resuscitation factors would improve the outcome for these patients may be warranted.

10. Outcome of Out of Hospital Cardiac Arrest Patients Arriving at a Tertiary Care Urban Hospital in India. 2-Year Data Analysis From Online Portal www.aocregistry.com. (Conference Abstract ID: 43)

Anuj Clerk, Krunalkumar Patel, Nikita Desai, Himani Garasia, Nilesh Thumar, Rakesh Mangrolia, Bhargav Umaretiya

Sunshine Global Hospital, Surat, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.40

Introduction: Survival from cardiac arrest remains poor and for meaningful research in India, one needs to first standardize treatment and documentation, before multicentric data can be pooled to create a large database. Arrest Outcome Consortium online Registry (www.aocregistry.com) is an online database created for the same. Initial analysis of single-center data is presented here as a test of its functionality.

Materials and methods: CPR Data of 200 beds, an urban hospital for the year 2018 and 2019 were collected in a standardized format, uploaded, and analyzed on the AOC Registry web portal. Descriptive statistics downloaded from the portal and statistical analysis was done using SPSS software.

Results: Out of 250 cardiac arrests in 2 study years, 62 were OHCA and all received CPR. Average age, equal in both gender was 57 years. Bystander CPR rate among OHCA were 12.9%. Among all OHCA, Asystole was the most common first rhythm [47 (75.8%)], followed by VF-VT [8 (12.9%]) and PEA [7(11.29%)]. Out of 19 who survived on initial CPR,10 were alive on discharge16.12% [10 of 62] and 9 died. At discharge 8.1% [5 of 62] had good [CPC≤2] neurological status. There was no significant difference in survival between male 16.0% [8 Out of 50 survived] and female 16.6% [2 Out of 12 survived]. Best neurological survival was with VF/VT as first rhythm. Multivariate regression analysis showed, First rhythm and admission lactate influence ROSC; but only First rhythm influence survival at discharge.

Discussions: To encourage out-of-hospital bystander CPR, we need research on OHCA. For which large multicentric data are required, for which online portal like AOC registry can help. In this study, single-centered data analysis is displayed as an initial report as an example and the beginning of the process. So, we encourage multiple centers to participate to create a large scale database for more meaningful research.

Conclusion: Survival at discharge was best with VF/pVT as the first rhythm. AOC registry portal could provide descriptive statistics, which can be used for inferential analysis. The large sample size is required for statistical analysis among subgroups, which is possible one multiple center data compiled on the web portal or online CPR registry (www.AOCRegistry.com).

4. Case Report: Poster Only

1. Autonomic Dysfunction with Areflexic Quadriplegia: An Unusual Presentation of Snake Envenomation. (Conference Abstract ID: 199)

Harpreet Singh, Deepak Chaudhary, Navneet Sharma, H Mohan Kumar

GMCH, PGIMER Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.41

Introduction: Rapidly progressing descending areflexic quadriplegia with autonomic dysfunction in the form of hypertension, tachycardia, hypersalivation, sweating, and lacrimation in the absence of proper history from attendants poses a challenge in an emergency area. Neuroparalytic snake envenomation by elapid species has been known to produce autonomic symptoms and even locked-in states. Here, we present a case of a young male with rapidly progressing areflexic quadriplegia with autonomic dysfunction; with no documented history of snakebite who improved after anti-snake venom and ventilatory support.

Objectives: To highlight unusual presentation of neuroparalytic snake bite.

Materials and methods: A 16-year-old young man was admitted to the emergency department with bilateral drooping of eyelids and weakness of all four limbs. On history taking, his attendants disclosed that he had been bitten by their pet dog on the left side of his chest 10 days ago. At a local center, he had been administered one dose of tetanus toxoid and anti-rabies vaccination had been started. On clinical examination, he had a pulse of 125/minute, blood pressure of 150/95 mm Hg, complete ophthalmoplegia, preserved pupillary reflexes, mydriasis, salivation, excessive sweating, bilateral ptosis, areflexic quadriplegia, and hydrophobia and aerophobia could not be elicited. The patient was put on mechanical ventilatory support for respiratory failure and 20 vials (200 mL) of polyvalent anti-snake venom (Bengal Chemicals, Kolkata, India) were administered. All blood investigations were within normal limits. Over the next 48 hours, he continued to have tachycardia in the range of 110 to 130 beats/minute with a systolic blood pressure of 140 to 150 mm Hg and a diastolic pressure of 90 to 95 mm Hg that did not require any antihypertensive therapy. His clinical condition improved after 6 days. He was extubated and discharged after 7 days of admission. A final diagnosis of snake envenomation induced autonomic dysfunction was kept due to improving the muscular weakness, respiratory failure, and dysautonomia after anti-snake venom treatment. The possibility of rabies (encephalitic or neuroparalytic form) was excluded because of a preserved sensorium and the absence of aerophobia and hydrophobia. The pet dog that had bitten him was alive and healthy.

Discussions: Although the World Health Organization states that the annual mortality due to snakebite is approximately 81,000 to 138,000 worldwide, yet, around thrice this number live and are left with residual motor impairment and debilities. A recent study has calculated the snake bite-related deaths in India at around 1.2 million (around 58,000 annually) from 2000 to 2019.1 The main families of venomous snakes in India are: Elapidae, Viperidae, and Hydrophidae (sea snakes). Main Indian elapids are Naja naja (Indian cobra), Bungarus caeruleus (Indian krait), Daboia russalie (Russell viper), and Echis carinatus (saw-scaled viper). Neuroparalytic snake bite is a common medical emergency encountered in tropical countries especially in the rainy seasons and in rural areas. The onset of neuroparalysis may take ½ to 6 hours in cobra bite and 6 to 24 hours for krait bite.2 Neurological symptoms usually appear in the sequential order starting from furrowing of the forehead and progressing to ptosis, diplopia, dysarthria, dysphonia, dyspnea, and dysphagia (involvement of 3rd, 4th, 6th, and lower cranial nerves) and finally involvement of intercostal and skeletal muscles. The limb-girdle muscles are involved before the distal muscles leading onto complete quadriplegia.4 Due to the absence of reflexes and total ophthalmoplegia in severe snake envenomation, it may resemble brain death or a locked-in state.4,5 The neuroparalysis occurs due to the neuromuscular junction blockade by a presynaptic neurotoxin in krait bite and postsynaptic neurotoxin in cobra bite. Dysautonomic features due to elapid envenomation include hypertension/hypotension, rhythm disturbances, tachycardia/bradycardia, pupillary abnormalities, excessive sweating, salivation, lacrimation, chemosis, abdominal pain, vomiting, paralytic ileus, and constipation. In a study from Sri Lanka, hypertension, tachycardia, lacrimation, sweating, and salivation were documented in around 66% of cases of common krait bite (Bungarus caeruleus) and were seen in patients with severe envenomation.6 All patients of Malaysian krait (Bungarus candidus) envenomation in the case series from Thailand had high blood pressure, tachycardia, and mydriasis. The dysautonomia that occurs after snake envenomation has been proposed to result both from presynaptic action of neurotoxin on the parasympathetic ganglia causing blockade and due to inhibition of presynaptic-a2 adrenergic receptors; which inhibits the neurally mediated discharge of norepinephrine resulting in sympathetic hyperactivity. Our patient exhibited tachycardia, excessive salivation, sweating, mild hypertension, and mydriasis simultaneously as a manifestation of neurotoxic snake envenomation induced sympathetic over activity. Dilator pupillary muscle predominantly contains α-1 (sympathomimetic) receptors, whereas the constrictor pupillary muscle has abundant acetylcholine receptors. The sphincter pupillae muscles have a large concentration of acetylcholine and a profuse microvasculature that allows the concentration of venom at this site resulting in an irreversible blockade of acetylcholine receptors causing dilated and non-reacting pupils. Besides the use of mechanical ventilation for respiratory failure in neuroparalytic snake bites, the management of autonomic dysfunction requires intravenous administration of anti-snake venom and general supportive measures. Although our patient did not require antihypertensive medications, yet, studies have used intravenous nitroglycerin for severe hypertension induced by venomous snake bite. A combined α and β blocker like labetalol would be ideal in this situation but this indication for use of labetalol has never been studied.

Conclusion: To conclude a differential diagnosis of elapid snake envenomation should be kept in a patient of rapidly progressive areflexic quadriplegia with autonomic dysfunction in absence of clear history.

2. Myasthenia Gravis—A Rare Cause of Weaning Failure in a Postpartum SLE Patient. (Conference Abstract ID: 196)

Tejasri Ketireddy, Padmaja Durga, Abhiruchi Patki

Nizam’s Institute Of Medical Sciences, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.42

Introduction: SLE and MG are two different clinical syndromes, which can coexist or precede each other but their occurrence in the same patient is rare. The systemic lupus erythematosus (SLE) is a systemic autoimmune disorder affecting predominantly young women characterized by multiorgan dysfunction and the production of multiple autoantibodies. Myasthenia gravis (MG) is an organ-specific autoimmune disease characterized by dysfunction of the neuromuscular junction mediated by autoantibodies resulting in muscle weakness. Both the conditions are known to be aggravated in pregnancy. Myasthenic crisis is a complication of myasthenia gravis characterized by worsening of muscle weakness, resulting in respiratory failure that requires intubation and mechanical ventilation. Weaning in patients with myasthenic crisis (MC) from mechanical ventilation is often difficult. We present a case of weaning failure in a postpartum young woman, presenting to us in intensive care with a history of SLE, incidentally diagnosed to have MG.

Materials and methods: A 29-year-old primi with a history of SLE since 2 years on regular treatment, was shifted to RICU, 4 days post elective LSCS following her first pregnancy, after being mechanically ventilated for a day due to sudden onset respiratory failure and epileptic seizures in the emergency room. Differential diagnosis of flaring of SLE, PRES, eclapmsia was ruled out after investigations. Weaning attempts repeatedly failed despite good GCScore, motor activity, normal chest radiography, and ABG analysis. On the third day of presentation, a left-sided pleural effusion with collapse was noticed and drained. Bronchoscopic removal of the left bronchial mucus plug was carried out, which resolved the collapse. Unsuccessful attempts of weaning followed for a few more days. On the eighth day of presentation, B/L (L>R) ptosis was noted with a QMG score of 14. A diagnosis of MG was made after a positive tension test and the presence of AchR antibodies. Quinolines were omitted in the treatment chart and pyridostigmine 60 mg QID was started. There was a significant improvement in ptosis after 48 hours of starting pyridostigmine. The patient tolerated T-PIECE trails well, weaned off mechanical ventilation after one cycle of plasmapheresis, and was discharged from RICU with stable vitals on room air.

Results: Due to unsuccessful weaning attempts, possibility of Myasthesia Gravis was considered and a QMG score of 14 was observed and a diagnosis of MG was made after a positive tensilon test and presence of AchR antibodies and was started on pyridostigmine 60mg QID. Patient tolerated T-PIECE trails well, weaned off mechanical ventilation after one cycle of plasmapheresis and was discharged from RICU with stable vitals on room air.

Discussions: Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are two autoimmune diseases that have a higher incidence in young females, relapsing-remitting course, and positive antinuclear antibodies. MG is an autoimmune disease of the neuromuscular junction, which results from the presence of postsynaptic acetylcholine receptor antibody (IgG). It is characterized by skeletal muscle weakness and easy fatigability and has a chronic course with remission and exacerbation. Common precipitating factors for MC include respiratory infections (Klebsiella pneumoniae), aspiration, sepsis, surgical procedures (post LSCS), rapid tapering of immune modulation agents, starting corticosteroids treatment (known SLE), exposure to drugs antibiotics (levofloxacin) that may increase myasthenic weakness and pregnancy. MC is one of the important and common complications in the natural history of myasthenia gravis. MC is observed frequently within the first two years following the onset of the disease. As in our case, delayed MG diagnosis may present with MC and respiratory failure may be the first symptom of myasthenia gravis. MG and MC must be considered especially in patients who have unexplained respiratory failure requiring prolonged mechanical ventilation and weaning failure.

Conclusion: Myasthenia gravis is a rare and unusual cause of respiratory distress in the postpartum period. The possibility of exacerbation of SLE had delayed the diagnosis but a keen observation of subtle signs enabled the diagnosis of a rare myasthenia gravis which can present with weaning failure. Thorough preoperative evaluation, optimization, proper intraoperative care, and postoperative intensive care management lead to a favorable outcome which requires a multidisciplinary team approach.

3. Early Tocilizumab Therapy in Severe COVID, Boon or a Bane: A Case Report and Critical Appraisal. (Conference Abstract ID: 183)

Shailendra Shivhare, Ravi A Dosi, Ankur Agrawal, Kamendra S Panwar, Prakash Joshi, Piyu Jain, Gaurav Jain, Pradeep Rajoriya, Jyoti Jaiswal, Manglesh Gupta, Ravindra Kumar Patidar

SAIMS Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.43

Introduction: Pneumonia with severe respiratory failure represents the principal cause of death in COVID-19, where hyper-inflammation plays an important role in lung damage. An effective treatment aiming at reducing the inflammation without preventing virus clearance is thus urgently needed. Tocilizumab, an anti-IL-6 receptor monoclonal antibody, has been proposed for the treatment of patients with COVID-19. Early use of tocilizumab prevents sudden deterioration of patient but after 15 days cavitary lesions are found in HRCT chest which is manageable.

Objectives: To discuss the use of early tocilizumab in severe COVID pneumonia patients.

Materials and methods: A 46-year-old Indian man presented in casualty with the complaint of shortness of breath, cough fever since 5 days admitted in COVID ward after COVID-19 RT-PCR tested positive HRCT chest shows 90% lung involvement. The initial patient was vitally stable with SpO2 98 with 15 L oxygen support NRBM, respiratory rate was 18/minute. ABG shows mild hypoxia. On day 2, the patient started deteriorating, not maintaining saturation on NRNM support taking on NIV support. Worsening of blood marker started. We plan for use of early tocilizumab 400 mg. The next day tocilizumab was given. The patient intubated and took on AC/VC support. After 5 days, the patient successfully extubated. On the seventh day, the patient extubate

Results: Use of early tocilizumab prevents sudden deterioration of patient with 90% lung involvement but after 20 days cavitary lesions found which is manageable.

Discussions: The patient came with severe pneumonia due to COVID. Tocilizumab was given on the third day of admission. The blood marker shows regular improvement. The patient intubated then extubated. Cavitary lesion developed. Oxygen requirement slowly decreases. Bronchoscopy shows normal findings. BAL shows tubercular etiology. ATT started. After 30 days, the patient successfully discharge.

Conclusion: Tocilizumab can be beneficial to the suddenly deteriorating patients due to hyperimmune reaction if the timing of administration is right.

4. Subcutaneous Emphysema and Unexpected Difficult Tracheal Intubation in COVID Patient—An Anesthetic Challenge. (Conference Abstract ID: 181)

Ksheerabdhi, B Gayathri, A Sujina Hermin

SRM Medical College Hospital and Research Centre, Kanchipuram, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.44

Introduction: Subcutaneous emphysema is a rare complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia that should prompt immediate attention to find its cause. Subcutaneous emphysema (SE) occurs when gas or air infiltrates the subcutaneous layer of the skin.

Materials and methods: A case study discussion on a patient admitted in COVID ICU with features of subcutaneous emphysema to evaluate the challenges faced by the anesthesiologists in intubating the patient inside COVID ICU.

Results: A 60 year female patient was admitted in COVID ICU with complaints of breathlessness and tachycardia. Patient was tested positive in RT PCR for covid 19 virus.ON the second day of admission in COVID ICU, patient developed subcutaneous emphysema. Initially saturation was maintaining with facemask on four litres O2. Gradually the oxygen requirement was increasing and the patient was changed to NRBM. Later the Pao2/Fio2 reduced to less than 150 with 15 L of O2 on NRBM so the patient was put on NIV. On day seven of admission into ICU the patient developed desaturation inspite of maximal support with NIV, hence decided to intubate. Suction was kept ready 7″ and 7.5″ cuffed portex tube was kept ready Inj.fentanyl 100 mcg, Inj.propofol 100mg iv and Inj.scoline 100 mg iv given. On putting the laryngoscope only epiglottis was seen, immediately the scope was withdrawn and ambu ventilation was done with 100% O2. second time, intubation was attempted with Mccoy blade, still the vocal cord cannot be made out. on the third attempt VDL was used and result was the same, and the patient started desaturating .4″ classic LMA was inserted and connected to ventilator with 100% Fio2, saturation picked up. surgical team was called and emergency bedside tracheostomy performed.

Discussions: Incidence of subcutaneous emphysema (SE) has been increasingly reported in COVID-19 cases. Sayan et al. published a case series of 11 cases of COVID-19 patients developing SE and spontaneous pneumomediastinum (SPM) without invasive ventilation. Out of these 10 patients had SPM and 9 patients had developed pneumothorax. Patients developed SE on an average of 13.3 days. He noted that patients who were on invasive, noninvasive ventilation, high-flow nasal oxygen HFNO and even on NRBM were developing SE and SPM. The predominant pathology in COVID-19 is interstitial and alveolar inflammation. Focal hemorrhage, alveolar exudates, and pulmonary interstitial fibrosis have also been noted. In many lung specimens on postmortem examination, exfoliation of bronchial epithelial and sudden caliber reduction in the dichotomic tracts were seen. The excessive airway involvement and decreased lung compliance may be the triggering factor making the alveoli more prone for rupture resulting in SE and SPM. In addition, our patient was a known case of bronchial asthma since childhood and probably this could have further increased her chance of development of SE. Although SE is a benign finding the development of spontaneous pneumothorax and SPM should alert the physician to carefully monitor the possible worsening.

Conclusion: Difficult airway in COVID patients can be extremely perplexing. Being honest with our thoughts, reflecting and auditing the experiences and continuous updating can go a long way in managing serious patients.

5. Stroke, Endocarditis with Limited History a Serious Challenge. (Conference Abstract ID: 178)

J Nikhat Sultana, K Subba Reddy, Munshi Intekab Alam

Apollo Hospital Jubilee Hills, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.45

Introduction: A 60-year-old man was brought to the hospital after developing sudden onset of weakness and altered sensorium in a flight. On arrival, the patient was drowsy and no history was available investigations revealed that he had right parietal infarct and was also supposed to have undergone a cardiovascular procedure which was confirmed as aortic valve replacement by transthoracic echocardiography. Blood cultures grew Staphylococcus aureus (MRSA) antibiotics were started based on culture and sensitivity during his stay in hospital there was a progressive growth of vegetation on the aortic valve despite treatment along with persistent arrhythmia and hypernatremia. The patient had a cardiac arrest after arrhythmia and died with endocarditis despite aggressive therapy.

Discussions: Unknown patient with no available history possessed a great challenge in this case despite early recognition and aggressive therapy endocarditis was persistent.

Conclusion: History plays a very important role in the diagnosis of the patient. treatment of prosthetic aortic valve endocarditis is a challenge as therapeutic concentration is not reached. A careful and guided approach is required in such cases.

6. MDI or Nebulization in Moderate to Severe COVID-19 Disease with COPD: Which One is Better? (Conference Abstract ID: 174)

Prakash Gondode, Geetanjali Chilkoti, Spriha Tiwari

All India Institute of Medical Sciences Nagpur, University College Of Medical Sciences, Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.46

Introduction: Aerosol bronchodilator therapy via nebulization, using a nebulizer or metered-dose inhaler (MDI) with a spacer device or dry powder inhaler is the mainstay in the treatment of COPD. We, herein, discuss two such cases with corresponding concerns related to various modes of bronchodilation in moderate to severe COVID-19 patients with COPD. Two COVID-19 patients (60 years/M and 55 years/M) with COPD presented with worsening fever, cough, and shortness of breath for around 10 days. Chest radiographs revealed mid and lower lung zone involvement in both. Both received tazobactam-piperacillin, teicoplanin, ivermectin, hydroxychloroquine, enoxaparin, dexamethasone, salmeterol MDI, multivitamin, and received oxygen via high FiO2 non-rebreathing mask and maintained 92 to 94% oxygen saturation and 24 to 32 breaths/minute. We observed their inability to attain an optimal peak inspiration with MDI and thus increased the dose to @ 4 to 6 puffs. Following no improvement, nebulization was started. With the improvement in peak inspiratory flow rate, the MDIs were reinstituted. The pulmonary symptoms improved and both the patients were discharged subsequently.

Discussions: Bronchodilator delivery by MDI or wet nebulizer is equivalent in the acute treatment of adults with airflow obstruction. 1 A Cochrane review 2 observed no significant difference in FEV1 at 1 hour after dosing between nebulization and MDI; however, an improved FEV1 trend was observed with nebulization.2 In critically ill patients, nebulization is preferred over MDI or DPI as the latter needs an optimal peak inspiratory flow rate (~60 L/minute) which is often compromised in critical illness. During the COVID pandemic, bronchodilation via nebulization has got a serious concern, i.e., the nebulizers produce small- and medium-size aerosol range and can disperse viral particles in exhaled air >0.8 m from the patient and remain airborne for more than 30 minutes.3 Thus, a potential exposure threat to healthcare workers (HCW). It should preferably be provided in isolation within negative pressure rooms with providers donning all personal protective equipment. The expert consensus guidelines recommend replacing nebulization with MDIs in COVID-19 disease; however, no dogmatic guidelines or protocols in this context.4 As far as pathophysiology is concerned, COPD is an obstructive airway pathology characterized by expiratory airflow limitation due to chronic inflammation of the large central airways, peripheral bronchioles, and destruction of lung parenchyma. On the contrary, in COVID-19, Mu et al. observed it to be primarily a restrictive ventilatory defect along with impairment of diffusion capacity as reflected by the pulmonary function tests in 110 discharged survivors with COVID-19.5 Therefore, COVID patients with COPD may present with mixed pattern (obstructive and restrictive) which may affect the performance of the aforementioned modes of bronchodilation.

Conclusion: We emphasize the need for assessing the risk-benefit ratio related to the safety of HCW with the use of MDI plus spacer vs the risk of clinical deterioration by avoiding nebulization in patients with COVID-19 disease with COPD. We also recommend the need for further research and evidence-based concrete guidelines in context to the favorable mode of inhaled bronchodilator in COVID-19 disease.

7. A Rare Case of Esophageal-pleural Fistula Presented Initially as Pleural Effusion with Lung Collapse. (Conference Abstract ID: 173)

Ravindra Kumar Patidar, Ravi A. Dosi, Ankur Agrawal, Kamendra S Panwar, Prakash Joshi, Piyu Jain, Gaurav Jain, Jyoti Jaiswal, Manglesh Gupta, Shailendra Shivhare

SAIMS, Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.47

Introduction: Esophageal pleural fistula is an abnormal connection between the esophagus and pleura. Most cases are due to the postsurgical, post-esophageal endoscopic procedure, esophageal carcinoma, or tuberculosis, chemical injuries, or spontaneous. It is a rare entity with a high degree of morbidity and mortality.

Objectives: Our objective by presenting this case to increase awareness among pulmonologists/physicians for this condition as being a rare entity, mostly initially presented with non-specific symptoms.

Materials and methods: A 35-year-old Indian woman was presented in casualty with a complaint of fever, body ache, and decrease appetite in the last 7 to 8 days associated with difficulty in breathing and swallowing since same time interval. Initially diagnosed as acute febrile illness and routine investigations are done. Chest X-ray was suggestive of left-sided hydropneumothorax with underlying lung collapse. An intercostal chest tube is placed in situ and pale yellow pleural fluid drained and sent for investigations and s/o negative for AFB, malignancy and with sugar 20, total proteins 2.07, albumin 0.96, cell count 38,400, neutrophils 80, lymphocytes 10, RBC 640/cmm, ADA 262, the culture showed growth of Klebsiella pneumoniae, and then the growth of Escherichia coli in repeat culture after 10 days, appropriate sensitive antibiotics are given. Dysphagia was still present and HRCT chest done, showed grade left upper lobe increased attenuation likely suggestive of consolidation patch/? A neoplastic lesion with hydropneumothorax and ground-glass opacities. Contract enhance commuted tomography is done for further evaluation and revealed grade 2nd/3rd hiatus hernia with air channel from the herniated portion into left pleural cavity suggestive of esophageal pleural fistula.

Results: The diagnosis of EPF is difficult as the clinical sign and symptom are nonspecific. The findings on the chest radiograph are nonspecific and include pleural effusion, pneumothorax, or hydropneumothorax. contrast enhanced CT is often required to confirm the diagnosis.

Discussions: We must consider EPF as a possible cause of non-resolving pleural effusion with large and continuous intercostal Drainage. Even in a patient who does not have a history of predisposing factors such as surgery, esophageal instrumentation, etc., spontaneous EPF should be suspected. Early suspicion leads to prompt diagnosis and treatment with in turn decreases morbidity and mortality.

Conclusion: Pleural effusion (accumulation of fluid in the pleural space) can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura or a systemic disorder. While differential diagnosis is made, rare causes should also be kept in mind unless proved otherwise.

8. Multiorgan Infarct Due to Extensive Thrombosis in Numerous Arteries in COVID-19 Patient Even after Adequate Thromboprophylaxis. (Conference Abstract ID: 168)

R Hariprasad, Sadik Mohammed, Makam Shri Harsha, Pradeep Kumar Bhatia

AIIMS, Jodhpur, Rajasthan, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.48


Materials and methods: Case

Results: Treatment given:

Course in ICU: Day 5:Developed severe, constant abdominal pain.

Discussions: Pathophysiology of COVID-19 Induced Hypercoagulopathy:


9. Managing Bilateral Phrenic Nerve Palsy in Neonatal Lupus Erythematosus with Intravenous Immunoglobulin: A Case Report. (Conference Abstract ID: 161)

Choudri Muzafar Paswal, Arun Kumar Baranwal, Navpreet Kaur

PGIMER Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.49

Introduction: Neonatal lupus erythematosus (NLE) is a syndrome characterized by skin lesions and/or cardiac complications and multisystem abnormalities in babies born to mothers with autoantibodies against Ro, La, and, less commonly, U1-ribonucleoprotein (U1-RNP). Neurological abnormalities include hydrocephalus, macrocephaly, aseptic meningitis, myelopathy, and spastic paraparesis, however, phrenic nerve palsy has not been reported in the English language literature.

Materials and methods: A 2-day-old male neonate presented with persistent respiratory distress since day 1 of life. He was born to a hypothyroid mother at term by vaginal delivery. His birth weight was 2.5 kg. Antenatal ultrasound in the 29th week of gestation had shown fetal bradycardia, complete heart block, and hydrops (moderate ascites, pericardial effusion). At 7 hours of postnatal life, he developed respiratory distress which was managed with oxygen by nasal prongs and IV fluids and was referred to us. He was first born to non-consanguineous parents. Family history was not suggestive of autoimmune disease and the mother was asymptomatic. Examination at admission revealed generalized edema, bradycardia (heart rate, 48/minute), tachypnea, abnormal peripheral circulation. His saturation was 88% on room air and improved to 98% on nasal prong oxygen. The abdomen was distended, dilated veins were visible, and the umbilicus was inverted. Liver span was 8 cm. He had cardiomegaly and pulmonary plethora and ECG was suggestive of complete heart block. Echocardiography revealed small ostium Secundum ASD (6 mm) and normal ejection fraction. Ultrasound cranium and fundus examination were normal. The possibility of neonatal lupus was considered. Anti-Ro and Anti-La antibodies of the mother (>100 and 32 IU/mL, respectively) and baby ( >240 and 15 IU/mL, respectively) were suggestive of NLE. Mother was positive for anti-nuclear antibodies (++++). The baby had episodes of anemia and thrombocytopenia during the hospital stay which were supported appropriately. He had conjugated hyperbilirubinemia (total and conjugated bilirubin of 5.26 and 2.54 mg/dL on day 1 which rose to a maximum of 11 and 6.15 mg/dL on day 17 of life, respectively), raised transaminases (aspartate aminotransferase, 380 mg/dL and alanine aminotransferase, 242 mg/dL), and hypothyroidism (TSH = 8.47; T3 = 0.317; T4 = 7.72). Hyperbilirubinemia persisted despite correction of the hypothyroidism. There was no evidence of hemolysis (plasma hemoglobin 125; negative direct Coombs test) and intrauterine infections. At admission, he was started on isoprenaline, continuous positive airway pressure (CPAP) through nasal prongs, and diuretic for bradycardia, respiratory distress, and congestive heart failure, respectively. An epicardial pacemaker (paced with a heart rate of 120/minute) was implanted on day 18 of life. At 48 hours of surgery, he could be weaned from the ventilator and extubated to oxygen with nasal prong CPAP. Improvement in heart rate, aggressive diuresis, and correction of hypoalbuminemia led to resolution of pulmonary and corporeal edema, ascites, and hepatomegaly by day 25 of life. Despite the clinical improvement, he could not be weaned from nasal prong CPAP. Chest radiograph suggested small volume lungs and the elevated diaphragm; bilaterally decreased movements of the diaphragm was detected on fluoroscopic examination. A nerve conduction study done on 29 days of life revealed bilateral phrenic nerve palsy (prolonged latencies and reduced amplitude). The child was given intravenous immunoglobulin (IVIg) (2 g/kg over 2 days) on 31 days of life.

Results: Two weeks later, he could be made off oxygen support and repeat fluoroscopy revealed normal diaphragmatic excursion. Nerve conduction study (at 4 weeks of IVIg) revealed improvement in right phrenic nerve, while left one could not be stimulated. Hemogram and Liver function test improved thereafter. He is gaining weight and acquiring developmental milestones normally.

Discussions: Phrenic nerve palsy with or without peripheral neuropathy is reported in adults and children with SLE. Pathogenesis includes immune complex deposition and vasculitis of vasa nervorum, axonal degeneration, demyelination, and antibody-mediated damage to other components of the neural tissue. Adults present with dyspnea, have elevated dome(s) of the diaphragm on chest radiograph and restrictive pulmonary functions. A persistent requirement of respiratory support, small volume lungs, and elevated diaphragm despite pacemaker implantation, successful treatment of congestive heart failure, and neonatal sepsis led to the suspicion of diaphragm dysfunction, which was confirmed on fluoroscopy and nerve conduction studies. Extensive dissection during cardiothoracic surgery is a common cause of postoperative phrenic nerve palsy and diaphragmatic dysfunction, with the majority having unilateral phrenic nerve palsy. However, it rarely occurs with pacemaker implantation. Bilateral involvement and multisystem dysfunction (cardiac, thyroid, hepatologic, hematologic) suggest maternal autoantibodies to be responsible for it. Though diaphragmatic hypoplasia is described with NLE, phrenic nerve palsy has not been reported with NLE in the English language literature to the best of our knowledge. Complete heart block is permanent, whereas non-cardiac manifestations of NLE usually resolve spontaneously as maternal autoantibodies vanish from neonatal circulation. A persistent requirement for respiratory support and the need for continued hospitalization prompted us to try IVIg as indicated in patients with SLE. It led to prompt clinical response and the baby could be weaned from respiratory support after 2 weeks, and could subsequently be discharged from the hospital. Response to IVIg further supports the bilateral phrenic nerve palsy to be due to NLE in the index case. It remains conjectural whether the nerve dysfunction is demyelinating or axonal in nature.

Conclusion: We reported a baby with NLE presented with complete heart block and had bilateral phrenic nerve palsy. IVIg seems to be curative for consequent diaphragmatic dysfunction.

10. Addisonian Crisis in a Case of Adrenoleukodystrophy Following Magnetic Resonance Imaging Under Total Intravenous Anesthesia. (Conference Abstract ID: 159)

S Kiran, KC Pradip

Armed Forces Medical College, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.50

Introduction: Adrenal crisis, also termed acute adrenal insufficiency is an acute life-threatening condition with a mortality rate of 0.5/100 patients/year.

Materials and methods: The various etiological factors associated with the adrenal crisis are infections, trauma, pregnancy, surgery, emotional stress, strenuous physical activity, thyrotoxicosis, medications, and genetic disorders.

Results: Adrenal crisis is one of the commonest presentations of patients in a critical care setting following various etiology usually secondary to a known case of adrenal insufficiency.

Discussions: Here, we present an atypical presentation of a case of Addisonian crisis in a three and half-year-old child following total intravenous anesthesia for MRI.

Conclusion: A high index of suspicion and clear history taking before MRI is necessary to prevent stressors for the occurrence of Addisonian crisis.

11. “Hyper-Homocysteinemia and Recurrent Pulmonary Embolism without Deep Vein Thrombosis in a Young Alcoholic Patient Presenting as Cavitating Pneumonia”—A Rare Case Report. (Conference Abstract ID: 155)

RS Pal, Ram Babu Sah, Ajay Sagar

ESI-PGIMSR, Basaidarapur, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.51

Introduction: A 32-year-old man, cook by occupation presented to our casualty with a history of (i) Acute onset fever with chills, (ii) Cough with mucopurulent sputum, (iii) Left-sided pleuritic chest pain, (iv) Breathlessness — MMRC grade-4 since 1 week. He also had a history of hemoptysis for 1 day. There was no any comorbidity and significant past history. He was a chronic smoker with a history of regular chronic alcohol intake. His family history was unremarkable. One year before, he was treated for right-sided pneumonia. Delayed resolution of symptoms at that time was further evaluated with computerized pulmonary angiography (CTPA) which showed right pulmonary artery thrombus. But he lost to follow-up. When he presented to us in casualty this time — His vitals were pulse rate 120/minute, respiratory rate-42/minute, BP-94/60 mm Hg, and SpO2-70% on room air. His chest roentgenogram showed left-sided consolidation with para-pneumonic effusion. His routine biochemical investigations were normal, TLC-13,300/μL, N-63, L-24, M-11, E-2. Hb-14.7 g/dL, platelet count-260,000/μL. His HIV-I and II were non-reactive. Sputum for CBNAAT was negative for Mycobacterium tuberculosis. Pleural fluid culture revealed Streptococcus sp. (sensitive to penicillin and ceftriaxone). His D-dimer was raised, but there was no evidence of deep vein thrombosis on venous Doppler of both lower limbs. CECT thorax showed left lower lobe consolidation, thick-walled cavity, and pleural effusion. Further evaluation with CTPA suggested evidence of thrombus in the left pulmonary artery. To ascertain the cause of embolism he was evaluated for a hypercoagulable state which was normal except for low vitamin B12 level-168 pg/mL (normal: 191–663 pg/mL) and raised serum homocysteine level −19.9 mmol/l (protein C, protein S, antithrombin III — normal. Factor IV Leyden mutation — not detected, APLA — normal, Factor VIII — normal). He improved on Inj. ceftriaxone, clindamycin, Inj Fragmin 5,000 IU S/C 12 hourly for 2 weeks and discharged on oral antibiotics for the next 7 days. He was also advised tablets of rivaroxaban, vitamin B12, and folic acid for the next 3 months. He improved clinically, radiologically, and serologically on follow-up.

12. Accidental Guide-wire Retention after Femoral Vein Catheterization: A Case Report. (Conference Abstract ID: 150)

SK Arun, Abhyudhay Kumar

All India Institute Of Medical Sciences, Patna, Bihar, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.52

Introduction: Central venous catheters are often used for various purposes like emergent hemodialysis, in situations where peripheral vein catheterization cannot be achieved, continuous invasive hemodynamic monitoring, and parenteral nutrition. The Seldinger technique is the most commonly used method. It is considered a safe procedure when performed properly under the guidance and of an experienced physician. But it can lead to various complications like arterial puncture, hemothorax, pneumothorax, nerve injury, or air embolism. A rare iatrogenic complication is guide-wire retention, which can be termed as a loss of guide-wire during the procedure.

Objectives: Case resentation: A 70-year-old male patient with COVID positive status with diabetes mellitus was being treated in the COVID ICU. Since the patient was having progressive shortness of breath and he was eventually intubated for the same. Other definitive COVID treatments were going on. But patient developed the features of acute kidney injury and there was a chance to progress onto renal shutdown. So it was decided to go with hemodialysis. Written consent for the procedure was taken. Under all aseptic precautions, the right femoral vein was cannulated using an introducer needle after local infiltration. After confirming it’s a vein, a J-tipped guide-wire was introduced smoothly through the needle. Then, a dilator was advanced over guide-wire to create a track. It was followed by the insertion of the catheter on the guide-wire. During this procedure, the guide-wire was accidentally pushed further ahead into the vein. We soon realized this and removed the catheter but the guide-wire was missing. Urgent X-rays of the kidneys, ureters, bladder region, upper abdomen, and chest were done, in which the guide-wire was clearly visible inside the vein. It was in the right side of the lower abdomen and right thigh region. Ultrasonography (USG) of the abdomen and leg also confirmed the same. Immediately CTVS team was informed about this, and the guide-wire was removed by the same team without any complications. The whole procedure from central venous catheter insertion to guide-wire removal was uneventful and no arrhythmia was recorded in-between.

Discussions: We report an accidental intravascular insertion of a complete guidewire. This is a rare and completely avoidable complication during the procedure. But in this case, it was more difficult due to the unaccustomed environment, where the procedure was being performed by a physician wearing PPE with all its gadgets on. To avoid this simple rules like holding the guidewire at the tip by a non-dominant hand or by the mosquito artery at all times should be followed to prevent its passage into or out of the vessel. If this rule is followed, we can prevent many complications.2 Yet another simple step like at the end of the procedure, a “time out” is practiced during which the operator calls out loudly and clearly that “the guide-wire is out of the patient”, and this is confirmed by the bedside nurse. This finding can then be documented in the patient’s medical records.1 If not they can cause cardiac conduction abnormalities like right bundle branch blocks, new left anterior and posterior fascicular blocks, and rarely asystole. The usual reasons for a guide-wire loss are operator inexperience, not giving proper attention, inadequate supervision during catheterization, and busy and overtired medical staff.

Conclusion: During central venous catheterization, guide-wire related complications are rare and essentially preventable if proper precautions are taken. And since we are in a new era of COVID its always advisable to get adjusted to this new working environment than to suffer complications.

13. An Unusual Case of Severe Pneumocystis Jiroveci Pneumonia (PJP) Presenting as “Recurrent Cytokine Storm” Following COVID-19 Infection. (Conference Abstract ID: 141)

Guttikonda Neeraj, Bharath Cherukuri

NRI Academy of Sciences, Andhra Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.53

Introduction: There is a health emergency going on in the world with the COVID-19 pandemic surging at a great pace leading to a rise in mortality of the aged and vulnerable patients all over the world. The reason for these deaths is suspected to be due to cytokine storm (“Cytokine storm syndrome”). “Cytokine storm” is defined as an activation cascade of auto-amplifying cytokine production due to unregulated host immune response to the viral antigen. Usually, it is noticed in the second week of COVID-19 disease. But the incidence of “Recurrent cytokine storm” presenting weeks after the first episode is not known. In this case report, we wish to highlight such a phenomenon observed in a patient who had survived the first episode of storm weeks before, later diagnosed to be severe PJP pneumonia mimicking cytokine storm.

Materials and methods: This is a case of a 75-year-old man who is known diabetic and hypertensive is diagnosed as having COVID-19 based upon an HRCT scan, which revealed CORADS-4. RT-PCR is negative. He had a cytokine storm in the following week which is addressed with pulse dose steroid and usual standard of care. Two months later, the patient had a similar episode of cytokine storm but was subsequently diagnosed to be severe PJP pneumonia.

Results: This is a case of 75 yr old gentleman who is known diabetic and hypertensive is diagnosed as having COVID-19 based upon HRCT scan,which revealed CORADS-4.RT-PCR is negative.Treated as per COVID 19 protocol. Ten days later, cytokine storm was diagnosed based upon gradual fall in the saturation along with the supporting biochemical and radiological data (figure 1). Pulse dose steroid therapy started with Inj.Methyl prednisolone 500 mg 0D for 4 days along with broad spectrum antibiotic cover. Theuraptic dose of SEPSIVAC vacccine was administered.Later after two weeks of hospital stay including 1 week of ICU stay, patient was discharged on oral anticoagulants, oral steroids and oral antibiotics. Since then he was on tapering dose of steroid. Every week inflammatory panel was being done which was normal. A HRCT scan done as a part of regular followup which revealed 25 – 30% fibrosis along with GGOs (Ground glass opacities) (Figure-2). Within 48–72 hrs of withholding the steroid patient had noticed fall in saturation on exertion, followed by fall in resting saturation levels along with breathlesness. Routine blood investigations done along with inflammatory panel.Urine culture revealed multi drug resistant E. coli and blood culture turned out to be sterile. Treated with broad spectrum antibiotics along with coverage for PJP Pneumonia in view of long term steroid usage. Biochemical markers and clinical status were worsened over the next 48 hours Differential diagnoses at this stage were thought to be : 1) Acute pyelonephritis with ARDS .2) Severe PJP pneumonia in view of long term steriod usage. 3) Community aquired pneumonia. 4) Acute pulmonary thromboembolism. 5) Recurrent Cytokine storm Acute pyelonephritis was ruled out with CT KUB.2D ECHO was normal.But HRCT chest revealed progression of ground glass opacities compared to previous scan. Differential diagnoses at this point being : 1) COVID 19 reinfection. 2) Delayed cytokine storm. 3) Severe PJP pneumonia PCR for COVID 19 and other respiratory viruses was done which is negative.Serum Beta –D-Glucan was sent in suspicion of PJP pneumonia.I nj.Trimethoprim/Sulfamethaxazole 15 mg/kg,Inj.Fluconazole along with broad spectrum antibiotic cover administered.Pulse dose steroid of 500 mg given for 3 days along with regular standard of care.Meanwhile serum Beta –D-Glucan level was obtained which is 678 pg/mL (normal being < 70 pg/mL).False positive possibilities are ruled out. Gradually patient dyspnoea resolved and resting saturation improved from 91% to 96% on room air. In our case,the diagnosis of PJP Pneumonia is based upon the following points, 1) Chronic steroid use of more than 20 mg Prednisone/day for more than 4weeks following COVID 19 infection. 2) Persistence of GGOs on HRCT scan beyond 8 weeks. 3) Serum Beta –D-Glucan level of 678 pg/mL 4) Resting PaO2 on room air being 58 mmHg As the patient recovered, Inj.Trimethoprim/Sulfamethaxazole was changed to oral form and discharged.Ten days later repeat Serum Beta–D-Glucan level is found to be 98 pg/mL. Similar experience has been reported from various authors (1, 2, 3).

Discussions: PJP occurs exclusively in immunodeficient individuals; two-thirds of cases occur in HIV-infected patients4 and the other third in non-HIV patients who have hematological malignancies, solid organ tumors, or are under immunosuppressive therapy.5,6 Among immunosuppressive agents, the role of corticosteroids is the most prominent. There is significant variability in the rate of response to steroid drugs among people.7 Different reasons have been proposed to explain the effect of steroids in increasing the predisposition to P. jirovecii pneumonia, among them the reduction of CD4+ lymphocytes and deficient cell-mediated immune activity are the most important. PJP patients without HIV infection are often admitted because of acute respiratory failure. PCP and COVID-19 share numerous characteristics. Both diseases present with fever, fatigue, dry cough, and dyspnea.2,3 In terms of chest CT findings, bilateral symmetrical ground-glass opacities are frequently seen on chest CT scans in both PCP and COVID-19.4–6 PCP frequently occurs when the CD4 count drops below 200 cells/L, which can manifest as lymphopenia.7 Leukopenia also appears to be the most common presentation in patients with COVID-19, although leukocytosis and lymphopenia have also been reported.8,9 Elevated LDH has also been reported in both COVID-19 and PCP.7,10,11 In both cases, the presence of elevated LDH is an indicator of poorer prognosis.7,11,12 However, PCP generally follows a more subacute course than COVID-19, particularly when considering milder forms of the disease, with 33% of patients having symptoms for at least 2 to 4 weeks before presentation in a case series from early in the HIV epidemic.3 In comparison, the median time to development of dyspnea or pneumonia for symptomatic COVID-19 has been reported to be eight to nine days from illness onset.2,8 Dyspnea is also a more prominent symptom in PCP and was seen in up to 95% of patients in one case series while it is only seen in about 11 to 31% of patients with COVID-19.2–3,9,13 Oral thrush, which has a strong association with PCP, has not been seen in COVID-19.14 COVID-19 and PJP share multiple characteristics, both present with a dry cough, fever, generalized weakness, and dyspnea.8,9 In terms of radiological findings, bilateral symmetrical ground-glass opacities are frequently seen on chest CT scans in COVID-19 and PJP.10 PJP frequently occurs when the CD4 count drops below 200 cells/L, which can manifest as lymphopenia. Leukopenia also appears to be the most common presentation in patients with COVID-19, although leukocytosis and lymphopenia have also been reported.

Conclusion: Patients in whom GGOs are persisting beyond 6 weeks on HRCT scan, a differential diagnosis of PJP pneumonia need to be considered and evaluated to prevent the hazardous consequence.

14. Improvement in Oxygenation and Resolution of RAVO/RVVO on 2D Echo Post Thrombolysis in Suspected Pulmonary Thromboembolism in COVID-19 SARI Patient: A Case Report. (Conference Abstract ID: 139)

Ashish Soneji

DR L H Hiranandani Hospital, Powai, Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.54

Introduction: Pathophysiology of hypoxia in COVID-19 SARI patients can vary in each individual so as the treatment. Pulmonary thromboembolism can be a treatable cause of refractory hypoxia in a given scenario.

Materials and methods: Case summary: We present a case of 74-year-old hypertensive women with COVID-19 SARI. She had severe COVID-19 infection with 60% lung involvement with CTSS 14/25. She was given COVID-19 treatment (remdesivir/solumedrol/LMWH) along with oxygen therapy with a high-flow nasal cannula. Her 2D ECHO done on admission was suggestive of normal LVEF with severe PHT — 66 mm Hg with RAVO/RVVO. She had persistent tachypnea (RR > 40) and a requirement of high-flow oxygen on day 3 of her admission. On evaluation, her D-dimer showed extreme elevation from 3,020 ng/mL (day 0) to 58,061 ng/mL (day 3). In view of the high FiO2 requirement (60 L/minute flow with FiO2 90% on HFNC) and AKI (creat 1.6), it was not feasible to do CTPA. With a high probability of pulmonary thromboembolism based on tachypnea, bedside 2D ECHO, and high biomarkers, the patient was thrombolyzed with 50 mg rTPA. Post thrombolysis, she was continued on heparin in the therapeutic dose and had shown improvement in oxygenation requirement (40 L/minute flow with FiO2 90% on HFNC) with no RAVO/RVVO with mild pulmonary PHT-46 mm Hg on 2D ECHO. CTPA done on day 8 of admission was not suggestive of pulmonary thromboembolism (? resolution) with 60% lung involvement with CTSS 14/25. Further anticoagulation treatment was discontinued due to the development of sepsis and thrombocytopenia during her ICU stay.

Discussions: Thrombolysis in suspected pulmonary thromboembolism in the patient with refractory hypoxia on optimal treatment of severe COVID-19 disease can be offered with high suspicion on 2D ECHO with extremely high D-dimer, where CTPA is not feasible. It shows improvement in oxygenation and resolution of RAVO/RVVO on 2D ECHO. Endotracheal intubation can be avoided which may decrease ICU stay with improved survival.

Conclusion: Thrombolysis in suspected pulmonary thromboembolism in the patient with refractory hypoxia on optimal treatment of severe COVID-19 disease can be offered with high suspicion on 2D ECHO with extremely high D-dimer, where CTPA is not feasible. It shows improvement in oxygenation and resolution of RAVO/RVVO on 2D ECHO. Endotracheal intubation can be avoided which may decrease ICU stay with improved survival.

15. Rare Case Report Severe Pancreatitis with Systemic Inflammatory Response Syndrome with Hypertriglyceridemia in a Patient with Diabetes Mellitus. (Conference Abstract ID: 138)

Nitin Gaikwad, Gajanan Kurundkar

SMT, Kashibai Navale Medical College, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.55

Introduction: The triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis is a rare occurrence. We report a case of an 18-year-old male morbidly obese patient admitted to ICU with a short history of severe abdominal pain, vomiting, and breathlessness. On examination, the patient had tachycardia, severe tachypnea, and severe dehydration. On glucometer BSL was high, ketonuria [4+], and high anion gap [20]. On ABG showed metabolic acidosis with a base excess of −17.3 and bicarbonate of 5. The patient was given all usual supportive care including oxygen therapy, intravenous fluid resuscitation, insulin, and bicarbonate infusion. Emergency abdominal ultrasound was suggestive of the bulky and edematous pancreas. Past medical record suggestive of diabetes mellitus since 3 years, severe hypertriglyceridemia 9,159 mg/dL, and acute pancreatitis. On admission, the SIRS score was 3. Biochemical investigation sr. triglyceride was 545 mg/dL, Sr. lipase 1315 IU/L, and HbA1c 12.9% suggestive of poorly controlled blood sugar level. Later on, abdominal computed tomography confirmed acute pancreatitis. The patient was treated successfully and discharge. Severe hypertriglyceridemia causing pancreatitis in diabetes mellitus is a rare but very serious complication of DKA.

Materials and methods: Case Report.

Results: The patient made a good recovery and was followed in the OPD for management of his blood sugar level and triglyceride management.

Discussions: The triad of DKA, hypertriglyceridemia, and pancreatitis is an unusual presentation of poorly controlled diabetes which occurs in type 1 and type 2 diabetes. In diabetic ketoacidosis, the deficiency of insulin activates lipolysis in adipose tissue releasing increased free fatty acids, which accelerates the formation of VLDL in the liver.1 Reduced activity of lipoprotein lipase in peripheral tissue also decreases the clearance of VLDL from the plasma, resulting in hypertriglyceridemia.2,3 Excess triglycerides are hydrolyzed by pancreatic lipase resulting in the formation of excess free fatty acids. Excess free fatty acids cause acinar cell injury and capillary leakage in pancreatic vascular beds. A possible mechanism of pancreatitis in hypertriglyceridemia patients is the damage of acinar cells and microvascular membrane due to excessive free fatty acid and lecithin formation in pancreatic bed from lipoprotein substrates. Very severe hypertriglyceridemia can either be of genetic or acquired origin resulting from metabolic disorders (e.g., diabetes), diet (including alcohol and obesity), and/or drugs.

Conclusion: The triad of diabetic ketoacidosis, hypertriglyceridemia, and acute pancreatitis is a rare presentation of diabetes. Hypertriglyceridemia is a known but rare cause of acute pancreatitis and the presence of a very high level of triglyceride should prompt clinicians to search for complications like acute pancreatitis and diabetic ketoacidosis.

16. Management of a Patient with Chronic Liver Disease with Aortic Valve Regurgitation by Trans Aortic Valve Repair—A Case Summary. (Conference Abstract ID: 136)

Hemendra Kumar, Imran Gafoor, Vishal Kumar, Rishi Shankar

Ramkrishna Care Hospital, Raipur, Chhattisgarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.56

Introduction: Trans-catheter aortic valve repair is a minimally invasive procedure during which a new valve is inserted without removing the old and damaged valve. A new valve is implanted within a valve. It is a minimally invasive procedure but this procedure has its own complications like bleeding, stroke, contrast-induced kidney injury, valve slipping out of place, and infection. We managed a case of aortic valve regurgitation with chronic liver disease and acute kidney injury by transcatheter aortic valve repair.

Materials and methods: A 59-year-old man who was known case of autoimmune chronic liver disease (CLD), post aortic valve replacement (done in 2012); presented to the hospital with a complaint of abdominal distension, decreased urine output, bilateral pedal edema. He had a history of previous 3 admissions for congestive heart failure and was managed conservatively. On admission, his vitals were stable and he was managed in the ward for his complaints. His initial investigation reports were normal except for deranged renal function tests (serum urea — 115.8 mg/dL, serum creatinine — 3.47 mg/dL). After 3 days patient complained of headache, diarrhea, and vomiting and had cyanosed peripheries and absent radial pulse on examination. He was immediately shifted to ICU and managed with intravenous fluid boluses and inotropes. His repeated investigations reported high total leukocyte counts, worsening renal function tests, and liver function tests. All the cultures were negative including ascitic fluid. 2D ECHO reported aortic valve vegetation which was chronic (as the patient was in regular follow-up). The patient responded to medical management with improved renal and liver functions. The patient was shifted to the ward. After 1 day in the ward, the patient had complained of intermittent fever spikes, vomiting, and non-productive cough along with a decrease in urine output and breathing difficulty. The patient was again shifted to ICU. His renal function tests worsened and his cardiac profile was positive (? congestive heart failure). 2D ECHO had the same findings as before. He responded to medical management and he was shifted back to the ward after stabilization. After 5 days of stay in the ward patient again had complained of difficulty in breathing and decreased urine output with accompanying shock. The patient was again taken into ICU and treatment started with mechanical ventilation and vasopressors. His liver and renal functions deranged. Renal replacement therapy was done; cultures were negative including ascitic fluid. His repeat ECHO reported vegetations in the aortic valve, moderate mitral valve regurgitation, left ventricular hypertrophy with LVEF 50%. The patient improved with treatment but the vasopressor requirement persisted with low doses. He was extubated on NIV, but re-intubated due to type I respiratory failure and worsening shock with peripheral cyanosis. Cardiology and CTVS reference taken. Cardiac CT reported chronic vegetation over the aortic valve. After ruling out infective endocarditis and other causes of pulmonary edema, aortic valve repair was planned. A thorough discussion has done between the cardiology team, cardiothoracic surgery team (CTVS), gastroenterology team, and patient’s relatives, and Transcatheter aortic valve repair (TAVR) was planned in view of comorbidity (CLD and AKI). All advantages and disadvantages and related complications of the procedure with associated comorbidities and cost issues were discussed in detail with the patient’s family. TAVR is done with preparations of all relevant teams (CTVS, interventional radiologist). After the TAVR patient’s vasopressor requirement decreased significantly, the patient improved and later on extubated. During the course, the patient had increased ascites and urosepsis. Treatment optimized and the patient responded to treatment. Blood and blood products transfused as needed and RRT done. Later on patient developed ICU psychosis. The patient was treated, shifted to the ward, and later on discharged after a long hospital stay of almost 3 months.

Results: Patient with history of autoimmune chronic liver disease, acute kidney injury and previous 3 episodes of heart failure with pulmonary edema was optimized and managed with trans-catheter aortic valve repair. There was dilemma for the procedure of valve repair between surgical approach and trans-catheter approach but keeping in mind the comorbidity of patient; we decided for trans-catheter approach with all preparation. Patient responded, improved and was discharged from the hospital. Patient has prolonged hospital stay of almost three months.

Discussions: Aortic valve repair can be done surgical or trans-catheter. In this case, the challenge was to initially manage the patient for pulmonary edema, rule out all other causes of repeated episodes of pulmonary edema and shock, decide for the procedure whether surgical or trans-catheter with consideration of comorbidity (CLD and AKI) and complications; preparation regarding possible complication and management with multiple team approach; repair of the aortic valve and postprocedure monitoring and management.

Conclusion: This case report describes the successful management of a patient with autoimmune chronic liver disease with acute kidney injury and repeated episodes of pulmonary edema with heart failure. As the patient had chronic liver disease there was a risk of bleeding along with surgical complications. The transcatheter approach also has major risks like stroke and contrast-induced kidney injury. we managed all the aspects and transcatheter aortic valve replacement was performed after which the patient improved and was successfully discharged from the hospital.

17. Cerebral Fat Embolism Syndrome after Closed Fracture Tibia—An Unusual Presentation. (Conference Abstract ID: 132)

Ashreen Kaur

Fortis Hospital, Mohali, Punjab, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.57

Introduction: Fat embolism syndrome is a life-threatening condition with a symptom triad of dyspnea, petechiae, and mental confusion.

Materials and methods: It is more common following polytrauma and fractures of long bones but can also occur during or after orthopedic procedures, particularly during intramedullary nailing of long bones or hip or knee replacements.

Results: The clinical spectrum can range from a mild form to a life-threatening condition.

Discussions: Hence, it is essential to make an early diagnosis to timely prevent morbidity and mortality.

Conclusion: We present a case of a healthy young male with early onset of fat embolism syndrome following trauma with an unusual presentation.

18. Vascular Access During Cardiopulmonary Resuscitation. (Conference Abstract ID: 127)

Amit Agrawal, Akshata Amin

Sevenhills Hospital, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.58

Introduction: During a cardiac arrest the focus of clinicians is to provide uninterrupted and high-quality CPR. In cases where peripheral vascular access is difficult, an intra-osseous route is recommended for the administration of drugs over obtaining central venous access.1 Arterial line catheterization during cardiac arrest is again not done commonly and the benefit that it may provide against risks such as infection, needle stick injury, etc., is a topic still to be explored.

Materials and methods: Case report:A 60-year-old man was admitted to emergency with cardiac arrest. After confirming the absence of pulse CPR was started as per guidelines. Peripheral venous access was poor and equipment for intra-osseous access was not available hence the decision was made to insert a central venous catheter into a femoral vein without interrupting CPR. After palpation of femoral pulse, a puncture was made medial to this location using the landmark technique. The catheter was inserted uneventfully in the first attempt. The position was confirmed as appropriate by doing blood gases from the catheter as well as a femoral arterial stab and also by transduced waveform from the catheter. This was used to administer drugs and fluids. Subsequently, using the palpatory method and landmark technique femoral arterial line was also placed and transduced which gave a visual representation of the blood pressure.

Discussions: It is assumed that during cardiac arrest and ongoing CPR; insertion of a central venous catheter and arterial line requires the interruption of CPR and can be technically challenging and associated with complications, but in certain situations, this might turn out to be very helpful. The central venous route has some unique advantages, as compared to the peripheral venous route or the intra-osseous route, higher peak drug concentrations are achieved with the central venous route, that is to say, drug circulation time is shorter.2,3 During CPR palpating for a carotid pulse with the index and middle fingers have been the standard for hundreds of years but even this has some pitfalls. Some patients with a cardiac output do not have a palpable pulse either because their blood pressure is too low; their body habitus makes it difficult to find the pulse, or because the providers’ fingertips are not sensitive enough. Additionally, the presence of gloves can make finger sensation even more dulled. Also, providers may feel a pulse when one is not there. Typically, this occurs when a provider presses down hard over the vessel and confuses their own digital pulse for that of the patients. Finally, each of us has a different quality of sensation at our fingertips. Pierpont et al. observed that in addition to providing continuous pressure monitoring and ready access to arterial blood samples, direct feedback from the intra-arterial pressure waveform frequently led to improved compression technique by the resuscitator performing external cardiac massage.4 For patients who are potential candidates for extracorporeal membrane oxygenation (ECMO) central vascular access obtained during CPR can reduce the time for initiation onto ECMO and these catheters provide a conduit for easy conversion to ECMO cannulae.

Conclusion: Although central vascular access and intra-arterial monitoring is not recommended routinely during CPR; in certain scenarios discussed above, this has a potentially important adjuvant role and can act as a life-saving measure for the patient.

19. Anesthetic Management of a Takayasu Arteritis Patient with Ehler–Danlos Syndrome for Capsulorrhaphy of Temporomandibular Joint. (Conference Abstract ID: 121)

V Sarayu, Shalendra Singh

Armed Forces Medical College, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.59

Introduction: Ehler–Danlos syndrome (EDS) is an inherited connective tissue disorder of six subtypes characterized by joint hypermobility, skin hyperextensibility, vascular fragility, musculoskeletal pain, easy bleeding, severe scoliosis, joint dislocations, atrophic scars, and vessel/viscera rupture. As the disease is rare with the occurrence of one in 5,000 population and, it is often under-diagnosed. We report a 36-year-old male (60 kg) patient with EDS-HT with Takayasu arteritis (TA) and Schizophrenia who underwent capsulorrhaphy of bilateral temporomandibular joint (TMJ) under general anesthesia.

Materials and methods: The patient was premedicated with Inj. glycopyrrolate 0.2 mg IV, Inj midazolam 1 mg IV, and xylometazoline nasal drops to avoid bleeding during nasal intubation. The patient was administered with Inj fentanyl 100 μg IV and anesthesia was induced with Inj propofol 120 mg IV. Care was taken to avoid hyperextension of the neck during mask ventilation, minimal pressure for chin lift and head tilt was used during manual ventilation. Inj Atracurium 30 mg IV given and the airway was secured with gentle laryngoscopy, avoiding excessive mouth opening using 7.0 mm ID nasal flexometallic cuffed endotracheal tube. Anesthesia was maintained with 02/N20 (40:60) and Sevoflurane 1 to 1.5%. Careful positioning of the patient was done with adequate padding of pressure points and avoiding hyperextension of joints including shoulder, hip, and cervical spine under muscle relaxation. Hemodynamics including invasive blood pressure were targeted within the range of 10% of baseline in view of bilateral renal artery stenosis to avoid hypotension, along with meticulous monitoring of urine output of the patient. Neuromuscular blockade was antagonized and the patient was extubated after he was fully awake.

Results: Intra-operatively patient was given 3000 ml of crystalloids and total blood loss was around 400 ml. Postoperative analgesia was provided with IV Paracetamol. No adverse events were reported in post-op period and the patient had no fresh complaints in the follow-up period. He was discharged on 4th postoperative day.

Discussions: Prime concerns were to avoid hyperextension of joints, achieve ventilation with minimal airway pressures and avoid postoperative vomiting and retching. Elective fiberoptic intubation should be considered when difficulties are anticipated. We also used a cotton pad under the blood pressure cuff to prevent hematoma and untreatable diffuse bleeding in EDS subtypes with vascular fragility. Meticulous monitoring of renal perfusion pressure and avoidance of nephrotoxic drugs. Invasive cardiac monitoring to maintain hemodynamics and to monitor blood loss due to vascular fragility. These patients are often less responsive to local anesthetics. No guidelines for neuraxial and general anesthesia exist for these patients.

Conclusion: The Ehlers–Danlos syndrome with chances of vast abnormalities of endocrine, cardiovascular, immune systems, and interactions with anesthetic agents can become challenging to manage for the anesthesiologists. Extra care and effort in all phases of the surgical management of such patients will result in safe recovery from anesthesia and uneventful intra- and postoperative period.

20. Viral Myocarditis and Encephalitis—A Rare Presentation of HHV-6. (Conference Abstract ID: 117)

Ashreen Kaur, RK Jaswal, Amit Shankar Singh

Fortis Hospital, Mohali, Punjab, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.60

Introduction: HHV-6 infects nearly 100% of human beings during childhood and often results in fever, diarrhea, and rash. It has a lifelong latency and can become reactivated later during adulthood in the heart, brain, lungs, and kidney.

Materials and methods: HHV-6 infection has many diagnostic challenges.

Results: HHV-6 reactivation usually occurs in immunosuppressed patients and can lead to complications like pneumonitis, encephalitis, myocarditis, and hepatitis.

Discussions: However, there is limited literature on HHV-6 infection and it remains a diagnostic challenge when encountered in young immunocompetent adults.

Conclusion: We present a case of HHV-6 infection with an atypical presentation in an immunocompetent adult.

21. Predictive Signs of Difficult Intubation. (Conference Abstract ID: 102)

Yash R Joshi, Timsi J Gandhi

Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.61

Introduction: The difficult intubation has been defined as “The clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation, difficulty in trachea intubation or both”. To provide a stepwise approach to identify preoperatively and to manage unanticipated difficulty during tracheal intubation in patients. Maintaining a patient airway is essential for adequate oxygenation and ventilation.

Materials and methods: Given the purpose of the present work, to develop a difficult airway trolley based on the evidence presented in peer-reviewed journals, updated guidelines, and expert consensus. The search was primarily limited to the English language. Since our search strategy was designed to identify all pertinent updated national and international guidelines on difficult airway management.

Results: The following key search variables were applied individually and in combination: airway, guideline(s), intubation, equipment, and management.

Discussions: We can identity difficult intubation preoperatively with the help of history, physical examination, various grading systems, and preoperative assessment of the airway through USG leading to proper planning and preparation, to reduce the risk of complications and avoid unanticipated difficult airway at the time of intubation with the help of difficult airway cart.

Conclusion: Difficult tracheal intubation accounts for 17% of the respiratory-related injuries and results in significant morbidity and mortality. In fact, up to 28 of all anesthesia-related deaths are secondary to the inability to mask ventilate or intubation. An unanticipated difficult airway can lead to a potentially life-threatening clinical situation, and thus every clinician must be able to predict signs in the preoperative period.

22. Anesthetic Management of Patient with Severe Mitral Regurgitation Taken for Lower Segment Cesarean Section Under Epidural Anesthesia. (Conference Abstract ID: 99)

Jignesh Kamaliya, Chandrika Bhut

Sir T Hospital Bhavnagar, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.62

Introduction: Pregnant women with heart disease constitute a unique problem for the anesthetist. In pregnancy mitral regurgitation is most commonly due to mitral valve prolapse, acquired RHD, or rarely due to acute endocarditis. The mortality and morbidity are considerably reduced1 by better perinatal care, where anesthesiologist plays a major role in a multidisciplinary approach. Chronic mitral regurgitation, even if severe, is well tolerated in pregnancy if the patient is asymptomatic and good left ventricular systolic function. Specific intraoperative and postoperative anesthesia management in terms of maintenance of hemodynamic parameters and effective postoperative pain control will minimize postoperative adverse events in patients with mitral regurgitation and these form the goals of anesthetic management in this type of patient. Epidural anesthesia was studied to improve the patient outcome in comparison to spinal or general anesthesia. The study aims to highlight the safety of low dose epidural block, its benefits over spinal and general anesthesia in perioperative management and postoperative pain relief.

Materials and methods: A 23-year-old female patient with a history of 8 months of amenorrhea and previous LSCS comes to sir T hospital with complaints of bilateral pedal edema, abdominal distension, and mild dyspnea. She had no problem in her previous pregnancy. She had a history of pregnancy-induced hypertension for 1 month and regular treatment with T. labetalol (100 mg) BD. She had also a history of convulsion and fascial palsy (which is resolved in 2 days) at 4 months of amenorrhea and managed conservatively. In preoperative assessment, routine investigations are in the normal range except for high creatinine (1.95) and hypoproteinemia with positive ANA (anti-nuclear antibody). ECG shows low voltage changes. 2D ECHO revealed severe mitral regurgitation, small vegetation attached to anterior mitral leaflet with reduced LV compliance and LVEF 55%. According to the cardiologist’s opinion, the patient can be taken for surgery with mild risk of anesthesia from a cardiology point of view. The patient is admitted to obstetric ICU and the physician started T. nifedipine (10 mg) as a patient having high blood pressure (160/100 mm Hg). As the patient having bilateral pedal edema, generalized ascites, altered RFT, hypoproteinemia so nephrologist advised Inj. Albumin, Inj. Torsemide, and Inj. Methylprednisolone (1 g) and finally he advised to terminate the pregnancy.

Results: So, we concluded that pregnant patient with mitral regurgitation makes the anaethetic management challenge. Proper understanding of the pathophysiology of the disorder and careful anaesthesia planning, pre-operative assessment, intra-operative and post-operative management can help in reducing the mortality and morbidity. Low dose epidural anaesthesia provided the advantages over spinal and general anaesthesia in a high risk patient and we successfully managed patient posted for LSCS with severe mitral regurgitation.

Discussions: In general, regurgitant lesions are well tolerated during pregnancy because the reduction in systemic vascular resistance (SVR) reduces the regurgitant flow.3 The prime consideration in managing our case was to maintain hemodynamic stability during surgery and prevention of bradycardia. Factors that exacerbate the regurgitation, such as bradycardia and acute increases in afterload should be avoided. Bradycardia can increase the regurgitant volume by increasing left ventricular end-diastolic volume.4 Precipitation of arterial hypotension and bradycardia due to high sympathetic block remains a common problem associated with conventional spinal anesthesia. General anesthesia is also not very suitable because all anesthetic agents have intrinsic myocardial depressant properties. So, epidural anesthesia can be a suitable alternative to provide intraoperative hemodynamic stability, the patient remains conscious and postoperative absolute pain-free period for at least 48 hours with analgesic administration through an epidural catheter, which reduces the incidence of intraoperative bradycardia and perioperative morbidity.

Conclusion: So, we concluded that pregnant patient with mitral regurgitation makes the anesthetic management challenge. Proper understanding of the pathophysiology of the disorder and careful anesthesia planning, preoperative assessment, intraoperative, and postoperative management can help in reducing mortality and morbidity. Low dose epidural anesthesia provided advantages over spinal and general anesthesia in a high-risk patient and we successfully managed patient posted for LSCS with severe mitral regurgitation.

23. Atypical Presentation of SLE With Secondary ITP in Pregnancy. (Conference Abstract ID: 98)

V Dinesh Kumar Gontla, Srinivas Samavedam, Narmada Aluru, B Rajyalakshmi

Virinchi Hospitals, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.63

Introduction: Systemic lupus erythematosus is an autoimmune disease that classically manifests with fever, arthralgia, and rash, predominantly in women of childbearing age. Although rare de novo SLE can be diagnosed in pregnancy, here we came across a case of SLE with secondary ITP having an atypical presentation during the second trimester.

Discussions: SLE complicates pregnancy in terms of fetal and maternal health. Though it is predominantly diagnosed in women of childbearing age, de novo SLE in pregnancy was reported in very few cases. Having typical presentation of SLE like lupus nephritis, rash, preeclampsia, miscarriages help in the diagnosis of SLE. However, having an atypical presentation of SLE with crisis imposes a challenge both in diagnosis and management of pregnancy with complications. Having a high grade of suspicion of SLE in pregnant women help in earlier diagnosis of SLE.

Conclusion: We hereby present a case of 25-year-old G2A1 who presented with atypical manifestations of SLE in crisis with secondary ITP during the second trimester of pregnancy.

24. Fever of Unknown Origin in a Patient on Adalimumab and Role of FDG-PET/CT. (Conference Abstract ID: 95)

Amrita Shah, Rajvardhan Rangappa, Rajesh Mohan Shetty

Manipal Hospital, Whitefield, Bengaluru, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.64

Introduction: Ankylosing spondylitis is a chronic inflammatory condition affecting the spine, which manifests with back pain and progressive spinal stiffness. Non-steroidal anti-inflammatory drugs (NSAIDs) are used as initial therapy in patients with symptomatic ankylosing spondylitis. In patients with inadequate response to two NSAIDs used for at least 2 to 4 weeks, tumor necrosis factor (TNF)-alpha inhibitors are considered. Screening of these patients for infections and regular follow-up is important. Fever of unknown origin is a febrile illness without an obvious initial etiology. FDG PET/CT can play a vital role when routine fever workup is negative and help in identifying the source.

Materials and methods: A 56-year-old man with ankylosing spondylitis with persisting low backache on NSAIDs was recently initiated on adalimumab. He visited the hospital on an outpatient basis with complaints of fever, pain abdomen, and loss of appetite. Routine laboratory investigations, ultrasound abdomen, done was unremarkable. The patient was admitted to the hospital in view of persisting symptoms and re-evaluated. On day 1, investigations showed transaminitis, thrombocytopenia with raised ESR of 26 and CRP of 51.78 mg/dL (Tables 1 and 2). The patient was empirically started on broad-spectrum antibiotics after sending blood and urine cultures, which did not show any growth. Work up for protein electrophoresis, dengue, malaria, and leptospirosis were reported negative. On day 3, contrast-enhanced CT chest and abdomen was done which showed features suggestive of liver parenchymal disease and splenomegaly with multiple hypodense lesions with normal lung (picture 1). Multiple diverticula were seen in the ascending colon, descending colon, and sigmoid colon. Colonoscopy was done which showed multiple ileocecal ulcers along with diverticulitis. Ulcer biopsy was done and histopathological examination of the same showed non-specific acute chronic ileitis with negative tuberculosis GeneXpert. On day 6, given persisting fever, and most of the workup reported as negative, we decided to do PET CT, which revealed metabolically active lymph nodes above and below the diaphragm. There was a bibasal consolidation of the lung showing increased metabolic activity, ileocecal wall thickening with edema, and increased metabolic activity. Diffuse increased FDG uptake was seen in the enlarged spleen. On day 7, the patient developed hypoxemia and breathlessness requiring oxygen support. Laboratory reports showed worsening liver function test, thrombocytopenia, increased ferritin, LDH. Peripheral smear was reported normal. In view of FDG-PET/CT showing increased uptake in the lung and bone marrow, it was decided to go ahead with bronchoscopy with BAL and bone marrow aspiration. Given background adalimumab, the patient was worked up for tuberculosis, secondary hemophagocytic lymphohistiocytosis (HLH), lymphoma and was empirically initiated on modified anti-Koch’s therapy (AKT) and steroid. The patient showed a dramatic response with the resolution of respiratory distress and fever. Bone marrow picture was not consistent with HLH, hence steroid was stopped. BAL tuberculosis GeneXpert was reported as positive, hence AKT was continued. The patient’s condition gradually improved and was discharged on AKT.

Results: FDG-PET/CT plays an important role in the evaluation in the FUO.

Discussions: Ankylosing spondylitis is a chronic inflammatory condition affecting the spine, which manifests with back pain and progressive spinal stiffness. It is often associated with several articular, periarticular extraspinal, and extra-articular features, including synovitis, enthesitis, and dactylitis. Extraarticular features include uveitis, psoriasis, and inflammatory bowel disease (IBD). Non-steroidal anti-inflammatory drugs (NSAIDs) are used as initial therapy in patients with symptomatic ankylosing spondylitis. It should be tried for at least 2 to 4 weeks before adding the second NSAID. In patients with inadequate response to NSAIDs, TNF-alpha inhibitors are considered. The most widely available TNF-alpha inhibitors are infliximab, etanercept, and adalimumab.1 The choice of TNF-alpha inhibitors is based on patient preferences regarding the route, frequency of administration, physician preference, and experience. TNF-alpha plays an important role in immunity which includes macrophage activation, differentiation of monocytes to macrophages, recruitment of neutrophils, and macrophages with an important role in protection against several pathogens.2–4 All TNF-alpha inhibitors increase the risk of tuberculosis, and the risk is more with infliximab and adalimumab than Etanercept.3 Cases of tuberculosis that are seen soon after the initiation of adalimumab usually represent reactivation of latent tuberculosis. Fever of unknown origin is defined as a prolonged illness for more than 3 weeks with fever and uncertain diagnosis despite thorough history-taking, physical examination, and the available investigations.8 FDG-PET/CT is a sensitive diagnostic modality for the evaluation of FUO by facilitating anatomical localization of focally increased FDG uptake, thereby guiding further diagnostic tests to achieve a final diagnosis. In FDG-PET/CT, FDG accumulates in cells with an increased rate of glycolysis. All activated leukocytes demonstrate increased FDG uptake and it helps us in localizing the sites of infection. A prospective study on the value of FDG-PET/CT performed in patients with FUO identified the underlying etiology in 46% of patients showing its importance.9 FDG-PET/CT should become a routine investigation in the workup of FUO when diagnostic clues are absent. FDG-PET/CT appears to be cost-effective as it avoids unnecessary investigations and reduces the hospital stay. In our case, it helped us in localizing consolidation, which guided us in doing bronchoscopy with lavage and clinches the diagnosis.

Table 1: Complete blood count
Day 1Day 3Day 5Day 9
WBC count (cm3)4500520051005500
RBC count (million/cm3)
Hemoglobin (g/dL)14.414.113.913.6
Hematocrit (%)42.641.541.840.5
Platelet count (cm3)53,00046,00040,00054,900
Table 2: Liver function test
Day 1Day 3Day 7Day 10Day 25
Total bilirubin (mg/dL)1.231.394.265.991.23
Direct bilirubin (mg/dL)0.290.432.093.450.31
Indirect bilirubin (mg/dL)0.942.192.540.92
SGOT (IU/mL)8313623113564
SGPT (IU/mL)3854806731
ALP (IU/mL)356403517458187
Total protein (g/dL)
Serum albumin (g/dL)
Serum globulin (g/dL)

Conclusion: Our patient presented a diagnostic dilemma, given the presenting complaints of fever and abdominal symptoms along with cytopenia and inconclusive initial battery of investigation results. Though we had a high index of suspicion of tuberculosis — negative histopathology, and rapid deterioration made us think otherwise. FDG-PET/CT showed bilateral basal consolidation, therefore going ahead with BAL and bone marrow examination helped us in ruling out differentials and arrive at a diagnosis.

25. An Unusual Case of Non-thrombotic Pulmonary Embolism. (Conference Abstract ID: 94)

Shravani Pabba, Srinivas Samavedam, Narmada Aluru, B Rajyalakshmi, P Ramakrishna Reddy

Virinchi Hospital, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.65

Introduction: Non-thrombotic pulmonary embolism (NTPE) is defined as embolization to the pulmonary circulation of different cell types, bacteria, fungi, parasites, foreign material, or gas. We came across the case of right heart failure secondary to NTPE.

Discussions: NTPE presents a formidable diagnostic challenge, as the condition often presents with very unusual and peculiar signs that are frequently overlooked. They range from the acute presentation as acute respiratory distress syndrome to signs observed late in the disease course as right heart failure. We diagnosed a case of right heart failure due to NTPE secondary bone cement embolization as a rare presentation of NTPE.

Conclusion: Increased awareness of NTPE as an underestimated cause of acute and chronic embolism, which may result in acute and chronic pulmonary hypertension is needed.

26. Cough Syncope Due to Hamartoma: A Rare Clinical Presentation. (Conference Abstract ID: 87)

Sushant Kumar Nanda, Pravati Dutta, Rekha Manjhi

Veer Surendra Sai Institute Of Medical Sciences And Research, Burla, Sambalpur, Odisha, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.66

Introduction: Benign neoplasms account for <1% of lung tumors. Of these, hamartomas are most common with an incidence of 0.025 to 0.32% and occur more commonly in older males (M:F ratio 2–4:1) with a peak incidence in the sixth decade. The majority of cases are peripherally located, asymptomatic, and are incidentally detected on chest radiographs or at autopsy. But rare endobronchial tumors which account for only 1.4% of pulmonary hamartomas can present with obstructive symptoms and pose a diagnostic challenge.

Materials and methods: Case report: A 54-year-old businessman presented with a 1-month history of dry cough associated with 4 to 5 episodes of syncopal attacks and left-sided chest pain. He was a non-smoker and had no history of chronic respiratory, cardiac or neurological disorders. His past history is not suggestive. Examination: Vitals were normal. General examination findings were unremarkable. Respiratory system examination revealed reduced breath sounds over the left mammary and infra-axillary area and no added sounds. Investigations: Blood hemogram and routine biochemistry — within normal limits. Chest X-ray — Patchy consolidation in the left lower zone. Spirometry — mild obstruction with significant reversibility. ECG, 2-D ECHO — normal. USG abdomen and pelvis — normal. Contrast-enhanced CT scan of the thorax-calcified mucus plug with distal atelectatic changes in the anterior basal segment of the left lung. Bronchoscopy findings -smooth endobronchial lesion seen occluding left lower lobe anterior segment completely. Histopathology of endobronchial biopsy — benign bronchial mucosa and peribronchial tissue with focally ossified cartilage; small foci of fibromyxoid stroma admixed with mature adipose tissue; the possibility of hamartoma; Brush cytology — scanty atypical cells highly suspicious of malignancy; BAL fluid cytology — no abnormality detected; PET-CT scan — the obliteration of bronchus of left lower lobe anterior segment by hypodense intraluminal soft tissue with peripheral calcification and low-grade metabolic activity associated with patchy pleural based collapse consolidation. Few subcentimeter mediastinal and bilateral hilar lymphadenopathy showing low-grade metabolic activity probably of inflammatory etiology.

Results: Patient underwent left thoracotomy, left lower lobe anterior and medial segmentectomy with sleeve resection and lymph node dissection. Histopathological study of resected tissue revealed Chondroid hamartoma with maximum tumor size 1.3 cm. Without atypia or malignant changes. Hilar nodes showed reactive lymphadenitis.

Discussions: Though most hamartomas are clinically silent, endobronchial tumors can present with recurrent respiratory tract infections, hemoptysis, and chronic cough. Chances of malignant transformation are very rare and the presence of malignancy should be ruled out in case of large or rapid growing lesions. Radiologically Popcorn calcification and focal fat densities are important diagnostic clues. Preoperative diagnosis is possible only in 15% of cases because of the rarity of the disease and insufficient biopsy sample as tumors are covered by normal bronchial epithelium. Sixty-five percent of tumors are present on the right side. Chondroid variety accounts for only 1% of pulmonary hamartomas. More than 80% of patients are smokers. This case of left-sided endobronchial chondroid hamartoma is of extremely rare occurrence.

Conclusion: The efficacy of bronchoscopic biopsy in the preoperative diagnosis of pulmonary hematomas is limited. Definite diagnosis and treatment can be achieved by surgical resection with minimal morbidity.

27. A Case of Delayed Traumatic Hemopneumothorax. (Conference Abstract ID: 84)

Revant Agarwal, Chirag J Patel

BJ Medical College Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.67

Introduction: Pneumothorax, hemothorax, and hemopneumothorax after trauma are preventable causes of death in the emergency department. The presence of air between visceral pleura and parietal pleura with consecutive retr action of the lung from the chest wall is called pneumothorax. The degree of collapse determines the clinical presentation of pneumothorax. Drainage procedures, such as, chest tube insertion, have been advocated to prevent fatal tension pneumothorax. There are two types of pneumothorax: traumatic and atraumatic. A traumatic pneumothorax can be the result of blunt or penetrating trauma. Pneumothorax can be further classified as simple, tension, or open. A simple pneumothorax does not shift the mediastinal structures, as does a tension pneumothorax which can be life-threatening. Open pneumothorax is an open wound in the chest wall through which air moves in and out. Hemothorax is a frequent sequela of traumatic thoracic injuries, It is a collection of blood in the space between visceral and parietal pleura. It is associated with 25% of pneumothorax and 73% of extrathoracic injuries.

Materials and methods: Case presentation: A 52-year-old male patient presented in ED with A/H/O RTA due to hit by an auto-rickshaw while the patient was crossing the road on November 8, 2020, at around 7.00 pm at Sanand Ahmedabad. Followed by H/O LOC for 15 minutes. The patient was first taken to a private hospital in Sanand where a chest X-ray and NCCT brain were done which were normal. ECG was normal. The patient was discharged from a private hospital after 6 hours of observation. The patient then came to Civil Hospital on November 11 at around 11 am with a complaint of left-sided chest pain and breathing difficulty. The patient was conscious and oriented. On the primary survey, the airway was patent, B/L air entry was present, reduced on the left side, respiratory rate 22/minute, the temperature was normal, pulse rate 98/minute, blood pressure 116/70 mm Hg, and SpO2 91% on room air and a GCS score of 15/15. The patient was immediately started on supportive care of oxygen via venti mask at 4 L/minute, IV access secured and analgesia was given, after which saturation increased to 98%. On Secondary Survey, No long bone injury palpable, 5 × 0.2 cm Sutured wound present on the left scalp.

Results: Investigations Chest Xray showed homogenous soft tissue opacity noted in left lung in lower zone with blunting of CP angle and collapsed lung s/o haemopneumothorax and linear displaced fracture of 7th rib on left side. After taking consent, under local anesthesia a 32 no. Intercostal Drainage Tube was inserted through 5th intercostal space on left side. Eight hundred ml blood came out preceded by gush of air following which breathing improved, RR 20/min spo2 was 98%, BP 110/70mm Hg and Pulse Rate of 90/min

Discussions: Pneumothorax occurs when free air enters the potential space between the visceral and parietal pleura. Primary pneumothorax occurs without clinically apparent lung disease, either spontaneously or from penetration of the intra-pleural space by trauma. Secondary pneumothorax occurs in patients with underlying lung diseases. Pneumothorax can be categorized into two conditions by a time sequence. Once diagnosed, fluid reposition and chest tube insertion must be provided to allow pulmonary re-expansion and stabilize the patient. Ultimately treatment decisions must be individualized based on each patient’s clinical condition. The management of delayed hemothorax primarily requires controlling the bleeding and evacuating the hematoma from the thoracic cavity. A tube thoracostomy should be considered to drain blood from the pleural space, and thoracoscopic surgery or an open thoracotomy should be considered for patients with persistent intrathoracic bleeding.

Conclusion: Chest wall injuries and concomitant hemopneumothoraces are frequent following blunt and penetrating trauma, most commonly after a road traffic accident. Hemopneumothorax and pneumothorax can be missed in initial evaluation after traumatic injury to the chest if a follow-up X-ray is not done after a proper interval in a case of blunt chest trauma. While most thoracic injuries may be managed non-operatively and the mortality rate is low, vigilance is required to detect those injuries that are potentially life-threatening and require urgent intervention.

28. Airway Management of a Case of Cut-Throat Injury. (Conference Abstract ID: 81)

Akshata Amin, Amit Agrawal

Sevenhills Hospital, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.68

Introduction: Penetrating neck injury represents 5 to 10% of all trauma cases.1 Clinicians need to be familiar with management principles as these injuries can often take the clinician by surprise. These injuries can be quite serious as there are a lot of vital structures lying close to each other in the neck and hence the mortality rates in these cases can be as high as 10%.2 Patients with cut-throat injury may present with airway compromise, aspiration, and acute blood loss with hypoxemia because of injury to the airway and major vessels. The best method of achieving definite airway control in the setting of penetrating neck injury will vary according to the clinical circumstances, clinical skill, and hospital resources.3 There have been reports in the literature when the trachea was intubated through the neck wound itself through the transected part of the trachea if transection was present. Some authors have described this approach to be dangerous because it can produce further damage to the larynx or increasing the chances of inhaling vomitus, blood, or secretions.4

Materials and methods: Case report: A 40-year-old man was brought to the Accident and Emergency department with a history of the lacerated wound to the front of the neck as a part of a suicide attempt. On inspection, there was a 3 × 1.5 cut just below the cricoid cartilage along with visible bleeding. On digital exploration, the cut in the trachea could be felt. Considering the risk of aspiration and the fact that the trachea could be easily felt on digital exploration it was decided that Plan A would be to intubate the trachea through the wound using a small size endotracheal tube to secure the airway and prevent ongoing aspiration of blood. Plan B would be to go for Standard Orotracheal intubation. The patient was given 2 mg of Midazolam and 50 μg of Fentanyl intravenously to calm him down and to provide some analgesia. Once the patient was a bit calmer size 5.5 endotracheal tube (ETT) was passed over a pediatric bougie easily into the trachea and position was confirmed by auscultation and end-tidal CO2 monitoring. The tube was secured using tape. Once this was done the patient was sedated further and then subsequently moved to a CT scanner for a preoperative scan to look for the extent of injuries and formulate a plan for surgical repair of the wound.

Discussions: Management of a case of cut-throat injury depends on a lot of factors such as the extent of airway compromise, hemodynamic instability, risk of aspiration, the extent of injuries to other structures, etc. Establishing and maintaining a patent airway is the first priority in severely injured patients. Basic airway maneuvers and simple adjuncts will often enable sufficient oxygenation and ventilation until personnel skilled in tracheal intubation are available. The involvement of a multidisciplinary approach is key to the management, which, should be instituted in good time to prevent complications, such as, chronic airway obstruction, wound infection, scar, persistent voice changes and dysphagia, and need for permanent tracheostomy due to laryngeal stenosis.5

Conclusion: Cut-throat injury presents a challenging scenario for clinicians and often the extent of the injury can be masked and the mortality can be high in such cases. Major risks involved are airway compromise, torrential bleeding, and risk of aspiration. These situations demand quick thinking and a multidisciplinary team involvement with a structured approach to help formulate a management plan and prevent complications.

29. Bilateral ESP Block: Our Savior in Patient with Crouzon Syndrome. (Conference Abstract ID: 69)

Nidhi Arun

Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.69

Introduction: Crouzon syndrome is a rare genetic disorder (incidence 1.6 in 10,0000 patients), characterized by craniofacial dysostosis caused by premature fusion of cranial sutures due to mutation in one of the FCFR genes.1 This affects the growth of the skull and head resulting in abnormal shape and development of the head and face, manifested as brachycephaly, shallow orbits, protruded eyeballs, prominent foreheads, midface hypoplasia, hypoplastic jaw, relative mandibular prognathism, high arched palate with crowded teeth, and sometimes spine abnormalities.2 Here, we are presenting a successfully managed case of Crouzon syndrome, posted for total abdominal hysterectomy (TAH).

Materials and methods: A 45-year-old woman with Crouzon syndrome, with loss of vision and exposure keratitis due to severe proptosis, brachycephaly, limited neck movement, mal-occluded, multiple loose and missing teeth with moderate kyphoscoliosis was posted for TAH for cervical fibroid. On further evaluation, we found that there was associated pulmonary hypertension (pulmonary artery pressure = 38 mm Hg) and hypothyroidism for which she was on medication for 5 years. Her laboratory parameters were normal except for low hemoglobin (7.7 g/dL) despite 2 units of cross-matched packed cell transfusion, most probably due to menorrhagia. Her intelligence and mentation were not affected. Our main concern, in this case, was the difficult airway in view of limited neck movement, abnormalities in the shape of the head, face, and dental anomalies, associated pulmonary hypertension, and moderate kyphoscoliosis imposing procedural difficulty for the central neuraxial block. Administering neuraxial blocks can be technically difficult in patients with Crouzon syndrome due to vertebral fusion and the presence of scoliosis or kyphosis.3 There was also a high probability of eye injury due to severe proptosis while masking ventilation and intubation. Thus, we have decided to go for monitored anesthesia care (MAC) with bilateral ultrasound-guided erector spinae plane (US-ESP) block with dexmedetomidine sedation, after taking informed consent. The patient was educated about ESP block and numeric rating scale (NRS) for pain assessment. In the operation theater, basic monitors were instituted. After positioning the patient in a sitting position, ultrasound-guided bilateral ESP block was given with 20 mL of 0.25% levobupivacaine with, at the level of second lumbar vertebra, and the catheter was secured bilaterally in that myo-facial plane for perioperative continuous infusion of 0.125% levobupivacaine at the rate of 6 mL/hour. Ramsay sedation score of 3 was achieved by dexmedetomidine infusion. Oxygen supplementation was done through a nasal cannula at the rate of 3 mL/minute, avoiding anatomical face mask. Basic noninvasive monitoring like NIBP, SpO2, and ECG was done.

Results: Intraoperative period was uneventful. The patient was followed for 2 postoperative days and was found to be comfortable and stable. NRS was never found to be more than 4.

Discussions: US-ESP block is a myo-facial plane block, described by Forero et al., where drug diffuses in a plane below erector spinae muscle and provides analgesia by blocking dorsal rami, ventral rami as well as rami communicans of spinal nerves.4

Conclusion: We want to convey that the benefits of ESP block like ease to administer, safe, no hemodynamic changes, and extensive analgesia can be used for TAH inpatient with Crouzon syndrome.

30. Pediatric Multisystem Inflammatory Syndrome Temporally Associated with SARS-CoV-2: Case Report From PICU (North India). (Conference Abstract ID: 66)

Sonali Ghosh, Sanjeev Dutta

QRG Health City, Faridabad, Haryana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.70

Introduction: SARS-CoV-2 is a global pandemic. It has affected 57.8 million population and 1.37 million deaths as of November 24, 2020.1 Initially, it was found to be less severe in the pediatric population but now cases have started emerging worldwide in the pediatric age group and they are also requiring critical care management.2,3 It has been termed multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19, also called PIMS-TS (pediatric inflammatory multisystem syndrome temporally associated with COVID-19). It is a hyper-inflammatory syndrome. In India, cases started appearing as early as May 2020. On May 1, 2020, RCPCH published clinical management guidelines for children with presenting symptoms of PIMS-TS.4 WHO and CDC have released criteria for PIMS-TS/atypical Kawasaki disease/Toxic shock syndrome in the second week of May 2020.5 In India, Rauf et al. reported the first case.6 We hereby report two cases from our center, which is a 6-bedded PICU at a tertiary care hospital in North India.

Materials and methods: Case 1: A previously healthy 12-year-old male child presented with a history of fever for 6 days, abdominal pain, headache, non-projectile vomiting, and a rash over the body. On examination in triage, he had tachycardia HR 150/minute and signs of poor peripheral perfusion. He had bilateral non-exudative conjunctivitis, unilateral cervical lymphadenopathy, mucositis, and generalized polymorphous rash. He progressed rapidly to hypotensive shock. Fluid bolus was given, and adrenaline infusion was started. Possibilities considered were KD shock syndrome, PIMS-TS, and septic shock. Laboratory investigations revealed anemia (Hb 9 g%), polymorphic leukocytosis (TLC 15,000 cells/mm3, P80%), hyponatremia (Na 131 mmol/L), CRP 48 mg/L, Trop I 68.96 pg/mL. ECHO revealed mild LV dysfunction and dilated coronaries. He received IVIG 2 g/kg. Also, a pulse dose of methylprednisone (10 mg/kg/dose) was given in view of vasoplegic shock. He became afebrile after 48 hours and other signs also abated by 96 hours. The inflammatory markers showed a declining trend. Hemodynamic parameters gradually improved and vasopressor infusions were tapered and stopped after 96 hours. The SARS-CoV-2 RT-PCR was negative. Work up for other infectious etiology was negative. There was a history of contact with a family member 3 weeks back who was COVID positive. There was no facility for performing COVID antibodies at that time hence it could not be done. Our diagnosis for PIMS-TS was established as per the WHO/CDC case definition. ECHO on follow-up was normal after 7 days. The child was discharged on oral aspirin and steroids (1 mg/kg-tapering).

Results: Case was discharged.

Discussions: Our cases fulfill the criteria of the case definition of MIS-C/PIMS-TS proposed by WHO and CDC as well as they fit the clinical description of KD. The differences from Kawasaki disease being older age group, predominantly gastrointestinal manifestations, circulatory failure, and evidence of increased inflammation. Earlier case reports have supported the role of steroids along with IVIG in such presentations.7 Both the cases received IVIG and steroids and they have shown good improvement. It is proposed that there is an immune-mediated delayed cytokine response to an already cleared SARS-CoV-2 virus from the body. When viral load is high, the genetic response to viral clearance is slow and the interferon response is weak; hence there is an inflammatory response due to cytokine storm.8,9 Our cases highlight the importance of early recognition of signs and timely intervention. It is expected that such cases are expected to rise in the Indian subcontinent with the resurgence of COVID cases.

Conclusion: The above cases highlight that clinicians should be aware of the novel clinical syndrome and early intervention. An early referral to centers with adequate expertise should be considered. There is a need to establish the natural history and epidemiology of such cases in our country.

31. Dyke–Davidoff–Masson Syndrome: A Rare Case Managed in the ICU. (Conference Abstract ID: 62)

Margiben Tusharbhai Bhatt, R Sunil, Rituparna Bordoloi, Shwethapriya Rao

Kasturba Medical College and Hospital, Manipal, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.71

Introduction: Dyke–Davidoff–Masson syndrome (DDMS) is a rare neurological condition.1–3 It is characterized radiologically by atrophy or hypoplasia of one cerebral hemisphere which is secondary to brain insult in the prenatal or early childhood period.4 Typically, it presents with recurrent seizures, facial asymmetry, contralateral hemiplegia, mental retardation, and learning disability.1 Due to its rarity, it may be misdiagnosed by most physicians.

Materials and methods: A 25-year-old woman, with a history of recurrent seizures, low intelligence, right-sided weakness since the age of 5 years came to the hospital with on-going seizures. She was born of a non-consanguineous marriage. Birth history was of full-term normal home delivery. Subsequently, she had episodes of seizure on and off and was advised oral phenytoin regularly. The patient had a history of weakness of the right side of the body since the age of 13 years, nonprogressive in nature. She also had learning difficulties and decreased interaction. At the age of 19 years, she developed an altered sensorium for which she got admitted to hospital for 8 days. MRI brain showed ulegyria in the left parieto-occipital region.

Results: On the day of admission to the hospital, patient had continuous generalised tonic-clonic seizures. She was immediately intubated to protect the airways. Facial asymmetry and prominence of frontal ridge were noted so preparation for difficult intubation was done beforehand. She was started on intravenous antiepileptic medications. EEG was done suggestive of diffuse electrical dysfunction over the left hemisphere associated with epileptiform abnormalities. CT brain was done which showed left cerebrum volume loss, prominence of sulci and dilatation of ipsilateral lateral ventricle, thickening of cranial vault on the left side with dilatation of ipsilateral frontal, mastoid, sinuses. MRI brain consolidated the CT findings characteristic of Dyke-Davidoff-Masson syndrome. She was gradually weaned from the ventilator and extubated. Sensorium was returned to baseline and she was seizure-free with ongoing medications.

Discussions: Dyke, Davidoff, and Masson first reported this rare condition in 1933. They studied plain skull radiographs in 9 patients who presented with seizures, facial asymmetry, hemiparesis, and mental retardation and described the characteristic features.5 CT and MRI brain are the gold standard. Diagnostic features are diffuse cerebral hemiatrophy, prominent cortical sulci, dilated lateral ventricles, calvarial thickening, and ipsilateral osseous hypertrophy with hyper-pneumatization of the frontal sinuses and mastoid air cells.6 The clinical features include contralateral hemiparesis, facial asymmetry, recurrent seizures, and mental retardation along with learning difficulties.7 There are two types of cerebral hemiatrophy; congenital and acquired. Congenital variety results from vascular occlusion involving the middle cerebral artery occurred in the neonatal or gestational period, unilateral cerebral arterial vascular malformations, or any congenital infections. The acquired variant results from prolonged birth asphyxia, recurrent febrile seizures, trauma, tumor, infection, or ischemia.8,9 If such insult has occurred before the age of 3 years then only classical MRI findings are seen.10 Differential diagnosis of this condition is basal ganglia germinoma, Sturge–Weber syndrome, Fishman syndrome, Silver–Russell syndrome, and Rasmussen encephalitis.11 There are many challenges to manage such cases in ICU which are adequate seizure control, difficult airway because of asymmetric facial features, the involvement of multiple systems, and occult myopathies.12 Avoid drugs during intubation which can cause decreased cerebral perfusion. Be aware of occult myopathy while using muscle relaxant. Avoid further insult to the brain by maintaining adequate blood pressure, avoiding hypoxia, avoiding the pressor response during intubation and extubation, and rise in intracranial pressure due to any ICU-related procedures.

Conclusion: DDMS being a rare syndrome is frequently misdiagnosed. A combined clinical and radiological approach makes the diagnosis easy. Management is mainly supportive like antiepileptic medications, physiotherapy, and speech therapy.

32. Hyperkalemia Presenting as Muscle Tremors. (Conference Abstract ID: 59)

Nilesh M Banthia

Neo Clinic and Echo Centre, Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.72

Introduction: A 68-year-old lady, DM and HT, presented with Muscle tremors in the thighs, episodic, and investigations showed hyperkalemia, with K of 9.3 mg%, it was corrected, and the tremors disappeared, ECG only showed tall T waves, which disappeared with treatment and the pt was stable and recovered well.

Objectives: Drugs causing hyperkalemia, with pout renal involvement and the unusual presentation of the pt.

Materials and methods: The pt DM and HT on antidiabetic treatment, with olmesartan for BP and Dytor plus edema feet, after all, evaluation and other supportive treatment, presented with trembling of both the thighs, with weakness, and waddling gait, was investigated, CBc, LFT were normal. Creatinine was 2.0 mg%, and K was 9.3 mg%, rechecked 3 times. Other reports were normal, ECG showed bradycardia with tall t waves, ABG showed metabolic acidosis, with ow Hco3 levels. Despite a high K of 9.3 mg%, the pt came walking into the OPD and was stable.

Results: She was asked to stop olmesartan, and dytor plus, was started on calium gluconate drip for muscle stabilization, and cardiac stability, sodabicarb IV 50 mL rthrice a day, with Dextrose and insulin drip, and athalin nebulisation, and K bind sachets, with duphalac for excretion of K, gradually the K came decreased by 1 mg% per day, and by 4 th day the k was 5.5 meql/Lit, the ECG became normal, and her pulse rate was 88/min, her muscle tremors disappeared, and the pt was stable, graduallyl all her medication for treastment hyperkaleamia was stopped and the pt was discharged home in a stable condition.

Discussions: Reporting a case of hyperkalemia, with levels of K of 9.3 meq/L, with only muscle tremors, and no other cardiac arrhythmias, that is why presenting this case.

Conclusion: An unusual presentation of Hyperkalemia, with only muscle irritability, and no other symptoms, no cardiac arrhythmias, properly manages by stopping the offending drugs, and the pt recovered very well.

33. Early Initiation of Thymosin Alpha 1 for Improved Outcomes in Patients with COVID-19 with Associated Comorbidities—A Single-center Experience. (Conference Abstract ID: 57)

Vimal Ranka

GRMI Hospital, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.73

Introduction: Thymosin Alpha 1 has been recently been available for immunomodulation.

Materials and methods: We utilized this as a repurposed drug for patients with COVID-19.

Results: The first case was a male with morbid obesity aged 62 years presented in ER with complaints of fever and loss of appetite for 7 days. There was a history of sore throat for last 3 days and breathlessness for last 2 days. The patient was a case of type 2 diabetes and known hypertensive controlled on the ongoing medications. At admission, the temperature was 101-degree Fahrenheit, tachypnoeic respiratory rate of 40/ min, tachycardia pulse rate of 120 bpm. He was hypoxic - oxygen saturation (SpO2 on room air) of 85% which necessitated bilevel positive airway pressure (BiPAP) to maintain saturations under intensive care at with 100% fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) of 10 cm H2O. RT PCR was positive, HRCT revealed bilateral mid zone lower zone ground glass opacities suggestive of atypical viral pneumonia. SpO2 was then maintained at 92%. Patient was initiated on IV antibiotics, methylprednisolone, Low Molecular Weight Heparin (LMWH). At day 2 of admission, thymosin alpha 1 was initiated, as 2 vials (each 1.6 mg)/day subcutaneously for consecutive 5 days. BiPAP support was at FiO2 90%, PEEP 8 cm H2O, SpO2 95%, FiO2 60%, PEEP 5 cm H2O, SpO2 97 %; on 2nd and 3rd day, respectively. Day 4, on oxygen mask with 10 litres maintained SpO2 at 97%, respiratory rate 24/min. On day 6, SpO2 was maintained at 97% with 2 litres of oxygen. Subsequently, maintained SpO2 at 98% on room air and was discharged on day 10. CRP reduced from 252 mg/mL to 11 mg/mL at day 9. WBC count increased to 9420 thousand/mm3 at day 7 from 3700 thousand/mm3. IL-6 reduced to 16.2 pg/mL on day 5 from 170 pg/ml. Ferritin improved to 112 ng/mL from 1140 ng/mL. Second case was 74-year-old female, temperature 102-degree Fahrenheit for last 5 days with associated asthenia, diarrhoea, dry cough, and dyspnoea. She was a known T2DM on insulin, IHD on dual anti-platelet therapy, on inhaler therapy for asthma, pulse rate 120 bpm, respiratory rate 38/min, with SpO2 at 78% on room air. HRCT revealed scattered bilateral asymmetrical ground glass opacities. Oxygen was started by High Flow Nasal Cannula (HFNC) with 40 litres of oxygen FiO2 80%. Started on IV methylprednisolone, remdesivir, LMWH, thymosin alpha 1, as 2 vials (each 1.6 mg) / day for consecutive 5 days. Day 5, afebrile, steroids tapered, oxygen requirement tapered to 10 litres on mask. Day 7, oxygen 1 litre per day. Day 8, asymptomatic, discharged on room air with oxygen saturation 98 %. CRP reduced from 178 mg/mL to 6.6 mg/mL at day 9. WBC count increased to 8030 thousand/mm3 at day 10 from 4040 thousand/mm3. D-Dimer reduced to 191 ng/mL on day 7 from baseline of >10,000 ng/mL. IL-6 reduced to 2 pg/mL on day 7 from 111 pg/ml. Ferritin improved to 745 ng/mL from > 2000 ng/mL on day 9.

Discussions: In the first case, tachypnea at presentation dissuaded to initiate remdesivir or tocilizumab. Since corticosteroids were initiated, PEEP and BiPAP support were reduced. In the second case, we found that high-flow nasal cannula oxygen (HFNO) is a reliable and better choice as an early stage oxygen therapy.

Conclusion: In both the cases, with comorbidities, we attribute the biochemical and clinical improvement due to thymosin alpha 1, as the timing of the initiation enabled a positive, clinically meaningful outcome of COVID-19, facilitating the patient to be on room air within 8 days of admission.

34. Tropical Fever Precipitating a Macrovascular Complication (Budd–Chiari Syndrome) and Subsequently Fulminant Hepatic Failure Due to Undetected Polycythemia Vera. (Conference Abstract ID: 47)

Banavathu Kishansing Naik, Sulakshana, Justin Aryabhat Gopaldas

Srmsims Bareilly, Manipal Hospital, Bengaluru, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.74

Introduction: Acute febrile illness in the tropical and sub-tropical region of India is due to a multitude of bacterial and viral pathologies and is labeled as tropical fever until full workup is undertaken. A seasonal change due to vectors is common and usually points to a specific illness (dengue and dengue-like illnesses during monsoon and post-monsoon season). Due to the increased admissions to hospitals for such tropical fevers not just limited to ward but also to ICU, at times management is initiated based initial presentation pattern. A careful review of history and further clinical, microbiological, and biochemical evaluation may be required if a clinical course is complicated.

Objectives: We present a 19-year-old young woman who was admitted to our hospital with a history of fever with rigors and jaundice. A routine workup and initiation of broad-spectrum antimicrobial agents were undertaken. She was required to transfer to the intensive care unit (ICU) in view of altered mental status in the setting of significant biochemical and hematological abnormalities including tests to suggest leptospirosis. Despite optimization of antimicrobial agents, she continued to deteriorate prompting a review of history. Noting sub-acute onset of jaundice, further workup is initiated for rapidly worsening conjugated hyperbilirubinemia. She further underwent evaluation for both intrahepatic and extrahepatic causes including computer tomography (CT) imaging of the abdomen.

Materials and methods: Investigations noted a rapidly worsening conjugated hyperbilirubinemia with altered coagulation and a lack of viral hepatitis as cars of the above. Hematological investigations revealed a hemoconcentration that persisted beyond 24 to 36 hours of ICU stay and aggressive fluid resuscitation. Noting the use of alternative medicine (Ayurvedic medication) for the above, drug toxicity was also considered for the rapid change. Noting lack of extrahepatic causes of cholestasis, a contrast-enhanced CT scan of the abdomen revealed congested large bowel with hepatic vein thrombosis. Noting hydration resistant hemoconcentration and hepatic vein thrombosis, further evaluation into hematological abnormality with a hematologist input confirmed polycythemia vera following flow cytometry analysis with both major criteria being met toward WHO diagnostic criteria.

Results: Despite adequate and aggressive evaluation, antimicrobial therapy, anticoagulant therapy, and supportive care, she progressed rapidly fulminate hepatic failure, and succumbed to Gram-negative sepsis.

Discussions: This case highlights the need for increased awareness among clinicians about patients with leptospirosis when the apparent remission of leptospirosis does not concur with the improvement of liver function. The deterioration of our patient’s clinical condition and the biochemical findings strongly point to an underlying disease that was not obvious at the initial presentation. Since other causes of FHF including viral, toxin, or immunologic disease, Wilsons’ disease were excluded, the diagnosis of Budd–Chiari syndrome underlying leptospirosis appeared more likely. The diagnosis was established based on a contrast CT of the abdomen that showed cirrhosis of the liver with caudate lobe enlargement and obstruction of hepatic veins. Any obstruction of venous vasculature referred to as Budd–Chiari syndrome leads to increased portal and hepatic sinusoid pressures as the blood flow stagnates. Obstruction also causes centrilobular necrosis and peripheral lobule fatty change due to ischemia. Liver biopsy is non-specific but sometimes necessary to differentiate between Budd–Chiari and other causes of hepatomegaly and ascites such as Wilson’s disease, galactosemia, and Reye’s syndrome.

Conclusion: Progressive hepatic dysfunction despite antimicrobial therapy in leptospirosis, should alert the clinician for a prompt search of other contributory factors. Timely detection of cause and appropriate therapy can prevent any catastrophe. Budd–Chiari syndrome should always be suspected in any case of polycythemia with liver dysfunction although any infective pathology may partially explain the hepatic derangements. A careful history in atypical presentation or progress of common illnesses along with targeted investigations is likely to lead to a diagnosis of underlying illnesses and in turn prompt management of both.

35. Hypophosphatemia—A Uncommon Cause of Delirium in Critically Ill Patient. (Conference Abstract ID: 42)

Anuj Clerk, Bhargav Umaretiya, Krunalkumar Patel, Nikita Desai, Himani Garasia, Nilesh Thumar, Rakesh Mangrolia

Sunshine Global Hospital, Surat, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.75

Introduction: Delirium is characterized by impaired cognition with Inattention and disorganized thinking. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Hypophosphatemia can cause altered mentation and delirium but rarely suspected and evaluated for the same. Here, we are presenting a case of hypophosphatemia related delirium.

Materials and methods: Case details: An 83-year-old male pt was admitted with a diagnosis of peripheral vascular disease with thrombotic occlusion of bilateral aorto-femoral graft, right external iliac, common femoral and superficial femoral artery, left common iliac, external iliac arteries which required left lower limb amputation. Along with peri-angioplasty for non-healing amputation stump wound and lumbar sympathetic block for severe pain on the amputation site. The patient had decreased oral intake, required daily dressing and debridement for amputation stump wound along with higher antibiotics for the infection. After revision of amputation, the patient was put on Ryle’s tube feeding as his oral intake remained very low despite the 10th day of admission. The patient became delirious and started on quetiapine. On evaluation for the cause of delirium along with pain, long hospital stay, multiple medications, old age, and COPD, hypokalemia was found. All medications were reviewed, pain control achieved, and corrections for hypokalemia were given. But as the patient had persistent delirium and hypokalemia. Further evaluation for the cause of persistent hypokalemia, phosphorus level checked, which was very low (1.0 mg/dL). Phosphorus was replaced entrally. His delirium improved once his phosphorus and potassium level rectified. With proper Ryle’s tube feeding and daily dressing he gradually improved and was discharged.

Results: Our patient had persistent hypokalemia due to refeeding syndrome-related hypophosphatemia as a cause of delirium.

Discussions: Severe hypophosphatemia can be presented with an altered mental condition. On a high index of suspicion for hypophosphatemia is a must in patients with re-feeding circumstances with persistent hypokalemia, large healing wound, recovering from sepsis causing delirium.

Conclusion: Delirium is multifactorial and hypophosphatemia should be kept as one of the many differentials.

36. Syndrome of Normal Urine UTI (Urinary Tract Infection). (Conference Abstract ID: 41)

Anuj Clerk, Krunalkumar Patel, Nikita Desai, Himani Garasia, Nilesh Thummar, Rakesh Mangrolia, Bhargav Umaretiya

Sunshine Global Hospital, Surat, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.76

Introduction: Urinary tract infection is one of the common sources of infection in patients with sepsis in the intensive care unit. For diagnosis of urinary tract infection, one requires pyuria or bacteriuria (>103 colony count in the catheterized sample) along with symptoms. To contradict the same, we are presenting a case of septic shock due to obstructive urosepsis with a normal urine routine report.

Materials and methods: A 55-year-old man was admitted to some private hospital with complaints of fever, cough, and right leg pain for 2 to 3 days. He had right lower limb cellulitis and he was treated for the same with antibiotics and other supportive care in a prior institute.

Results: In this patient, due to obstructed ureter urine routine micro was normal but the patient had urosepsis.

Discussions: No single investigation should lead to or rule out any diagnosis, so does the normal urine routine and microscopy report. Despite one completely obstructed ureter with infection piled up behind it, the patient can have normal urine from the contralateral non-obstructed ureter, “Normal Urine UTI” is possible. High suspicion along with re-visiting history once more when the septic focus is not obvious. It emphasizes the role of POCUS (Point of Care ultrasound screening) of all critically ill patients by Intensivist to reveal such overt foci of sepsis.

Keywords UTI (urinary tract infection), POCUS [point of Care ultrasound screening].


37. Thymosin Alpha 1 for Managing COVID-19 Cases with Comorbidities Presenting with Mild Symptoms: Distinctive Experience from a Tertiary Care Center. (Conference Abstract ID: 39)

Chinmay Godbole

KJ Somaiya Medical College and Superspeciality Centre, Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.77

Introduction: We present a series of cases with varied clinical spectrum with mild symptoms from a tertiary care center.

Materials and methods: Understand the implications for the clinical utility of thymosin alpha 1 in mild symptoms of COVID-19.

Results: The first case was 37-year-old male, with a history of pulmonary embolism, presented with mild breathlessness, on background therapy of hydroxychloroquine (HCQ) and doxycycline. Thymosin alpha 1 was administrated at admission with 1.6 mg OD s/c with the continuation of the other ongoing therapy. At day 3, SpO2/FiO2 ratio improved to 240 (at presentation was 150), IL-6 reduced to 5 pg/mL from 31 pg/mL, D Dimer reduced from 600 to 587 ng/mL and clinical symptoms improved to just dyspnoea on exertion. The second case was a 33-year-old with mild symptoms, known diabetic on OHA had SpO2/FiO2 ratio 170 at admission, tachycardia (122 bpm), fever (99 F). He was initiated on Thymosin alpha 1–1.6 mg OD. On fourth day of the therapy, SpO2/FiO2 ratio improved to 300, was put off oxygen support, IL-6 reduced to 6 pg/mL from 11 pg/mL and was asymptomatic. The third case was 61-year-old male, with 60 kg body weight, known hypertensive and diabetic on OHA, presented with cough and fever with ongoing therapy of HCQ, azithromycin, ivermectin, doxycycline, enoxaparin. After 5 days of initiation of Thymosin alpha 1–1.6 mg OD, the CT severity score reduced to 4/25 from the initial 5/25, SpO2% on room air improved to 99, with no symptoms. D Dimer reduced from 553 to 300 ng/mL. The fourth case was a 78-year-old 50 kg female, known hypertensive and diabetic with a history of fever was on piperacillin and tazobactam combination, doxycycline, HCQ and steroid. After 5 days of 1.6 mg of thymosin alpha 1, the SpO2/FiO2 ratio improved to 260 from initial 150 and was asymptomatic

Discussions: None of the cases required positive pressure ventilation and none had any preexisting lung disease.

Conclusion: In our experience, it is plausible for the clinical and biochemical improvement to be attributed to the timely utilization of thymosin alpha 1, which could improve the immune regulation and address the dilemma of management of COVID-19.

38. Fatal Spontaneous Clostridium septicum Myonecrosis in an Immunocompetent Host. (Conference Abstract ID: 38)

P Bala, V Deepak, A Rajalakshmi

Kerala Institute of Medical Sciences, Kerala, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.78

Introduction: Clostridial myonecrosis is a life-threatening muscle infection that develops either from an area of trauma or hematogenous from the gastrointestinal tract with muscle seeding. Spontaneous/atraumatic gas gangrene is caused by Clostridium septicum and multiple risk factors have been proposed for the same. We report a case of fatal spontaneous gas gangrene in a previously healthy patient with no comorbidities/risk factors.

Materials and methods: A 62-year-old man, with no previous comorbidities came to the emergency room at 9.30 am with c/o sudden onset pain in the left gluteal region and upper thigh since morning that day. On initial examination, he was hemodynamically stable. There was minimal induration in the affected area. There were no external signs of inflammation during local examination like redness/tenderness/warmth. He had a full range of movements in hip, knee, and ankle joints. Other systems examination was within normal limits. The total leukocyte count was 11,000/µL and hemoglobin was 11.2 g/dL. Urine analysis, serum electrolytes, and creatinine were normal. Radiographic imaging of the hip and spine were normal. The patient’s pain worsened further despite adequate analgesia and so, further imaging was done to rule out perianal/gluteal abscess/aortic dissection. MRI was done and the patient was shifted to critical care ICU for further care. The patient developed tachycardia, tachypnea, and respiratory distress by 5 pm. Skin color changed and mild redness was noted in the upper thigh along with a local rise in temperature. MRI provisionally reported as features of myositis involving left hamstring muscles. His ABG showed severe metabolic acidosis and he developed hypotension after an hour. The patient was intubated and mechanically ventilated. Blood cultures were taken and he was initiated on broad-spectrum antibiotics — piperacillin/tazobactam and doxycycline along with inotropic supports. By 8.30 pm, blebs started to appear in the affected area and by 9.20 pm, the patient developed bradycardia followed by cardiac arrest. Resuscitative measures were taken as per ACLS protocol but the patient could not be revived. Blood culture report came the next day, where 2 out of 4 bottles grew Gram-positive bacilli which were later confirmed as Clostridium septicum.

Discussions: Clostridium septicum is a Gram-positive, anaerobic, spore-forming, highly motile bacteria. The organism shows a strong association with malignancy and immunosuppression. Method of entry of organism is postulated to be due to a defect in the mucosal lining of the bowel caused by conditions like tumor, radiation, chemotherapy. Once disseminated through the hematogenous route, it spreads to a remote site to cause metastatic/distant infection. Virulence is exerted through four main toxins-alpha, beta, delta toxins, and hyaluronidase. Non-specific pain often described as throbbing/heaviness may be the only presenting symptom as in our case. Swelling, the appearance of bullae and blisters, and palpable crepitus usually appear late.1 Association of this disease with malignancy is very strong and so a rigorous search for occult malignancy should be done.2 But in our course, the clinical course was so much rapidly deteriorating that, this could not be done. A study by Chew et al. showed 80% of Clostridium septicum infections were associated with confirmed/occult malignancy.3 A systematic review revealed mortality of 67% in patients with spontaneous gas gangrene caused by this organism.1 The IDSA guidelines recommend high dose insulin 18 to 24 million units/day in divided doses along with intravenous clindamycin.4 Local wound debridement should be done thoroughly and the role of hyperbaric oxygen therapy remains controversial.

Conclusion: Spontaneous gas gangrene is an unusual but fatal disease. We are reporting this case for few reasons. Challenges in making a diagnosis of spontaneous gas gangrene in an immunocompetent patient and the rapid pace at which clinical deterioration occurs, from a near-normal local examination to development of erythema, swelling, and blebs within few hours along with hemodynamic instability and death.

39. A Case of Acquired Methemoglobinemia Managed Successfully in a Patient Admitted in SARI as COVID-19 suspect: A Case Report. (Conference Abstract ID: 35)

Vaishnavi Venkatramana Pandith, Veena Watal, Vaishali Mohod

Grant Government Medical College And Sir Jj Group of Hospitals Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.79

Introduction: A case of acquired methemoglobinemia managed successfully in a patient admitted in SARI as COVID-19 suspect: A case report methemoglobinemia is a rare condition in which the iron in hemoglobin is present in the ferric (Fe3+), not the ferrous (Fe2+) state of normal hemoglobin, which renders red blood cells unable to release oxygen to tissues, produces functional anemia and leads to tissue hypoxia. Patients with coronavirus disease 2019 (COVID-19) often have clinical characteristics, such as chest tightness and dyspnea. Patients with methemoglobinemia can present with breathlessness and refractory hypoxia. In this state of pandemic patients with methemoglobinemia may present with COVID-19 like a picture. So, one must always keep in mind the possibility of other rare differentials. We report a case of refractory hypoxia from acquired methemoglobinemia in a critically ill patient admitted in SARI ICU as a suspect to COVID-19 infection with complaints of breathlessness. A 25-year-old female patient was admitted to SARI ICU as COVID suspect with breathlessness with mild peripheral cyanosis. The patient had no known comorbidities. She gave a history of being treated for malaria and week before the onset of symptoms. She had refractory hypoxia and low SpO2 despite O2 support. Her chest radiograph was normal not showing signs of ARDS or COVID pneumonia. ABG had low SO2 despite high PaO2. Methemoglobinemia was suspected and ABG showed a high percentage of methemoglobin levels. Treatment based on the clinical picture was started with methylene blue her serial ABGs were observed. The patient showed improvement in her clinical condition and saturation on room air. ABGs improved in terms of SO2 and methemoglobin levels.

40. Enigma of Apnea Test for Brain Death on Ecmo—An Ongoing Discussion. (Conference Abstract ID: 30)

Bipin Chalattil, Manoj Kumar Sahu

All India Institute of Medical Sciences, Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.80

Introduction: Coma, absent brain stem reflexes, and apnea are considered the neurological criteria of brain death. As membrane oxygenator does almost the entire gas exchange in patients with severely diseased lungs who are on extracorporeal membrane oxygenation (ECMO), it is not possible to carry out apnea tests in a routine manner. We described the difficulties we faced conducting the apnea test and the other ancillary tests in our patient on venovenous ECMO who suffered a major cerebral insult and reviewed the literature of brain death testing in patients on ECMO. Brain death (BD) as described by the American Academy of Neurology is the irreversible cessation of all functions of the entire brain including the brainstem which requires proof of the absence of brainstem reflexes, cessation of spontaneous breathing (apnea), and irreversible coma of a known cause.1 Extracorporeal membrane oxygenation (ECMO) use has risen in the past decade owing to a wide range of applicability in acute, severe, and reversible cardiac, respiratory, or cardiorespiratory failure.2 However, the issues in legal confirmation of brain death on ECMO patients prevail.3,4 We describe a case in which ECMO was instituted and difficulties for determining BD are highlighted and further description of the literature is discussed.

Case report: A 40-year-old woman weighing 120 kg with pneumonia following H1N1 influenza was transferred to our hospital on mechanical ventilation for worsening respiratory distress. Chest X-ray revealed bilateral diffuse infiltrates. The other parameter

Discussions: ECMO is a form of extracorporeal life support that acts as a rescue in patients with refractory cardiac and respiratory failure. Expanding indications have provided for its increasing use; however, there has been a noted rise in neurological injury in ECMO patients with an incidence of 7.1% of which 23.5% manifest as BD.2,5,6 These sequelae may result from preexisting neurological dysfunction, hypoperfusion due to dysfunctional cerebral autoregulation, reperfusion injury post-resuscitation, rapid blood gas alteration, micro-emboli, thrombosis, and intracranial hemorrhage due to development of coagulopathy or anticoagulant use and differential hypoxia-induced cerebral dysfunction (Harlequin syndrome) in the case of peripheral venoarterial (VA) ECMO.2,4 BD declaration would require demonstration of irreversible unconsciousness, apnea, absent cranial nerve, and brainstem reflexes. To ensure the conduct of AT appropriately, normothermia (core temperature ≥ 36°C) and systolic BP > 100 mm Hg are essential.1 The other prerequisites are the absence of central nervous system-depressant drugs or neuromuscular blocking agents, severe electrolyte, acid-base, or endocrine disturbances. The test is considered positive if there is a rise in PaCO2 ≥ 60 mm Hg or at least 20 mm Hg rise above baseline. AT is considered negative if there is an observed respiratory movement either visualized during the test, detected by a ventilator, or by evidence of thoracoabdominal de-synchrony in consolidated lungs with poor thoracic compliance. It is abandoned in cases of the development of hypoxia or deranged hemodynamics.3,7 Unlike patients on mechanical ventilation alone, gas exchange for patients supported on ECMO occurs mainly through the membrane oxygenator. Carbon dioxide elimination is dependent on the sweep gas flow rate in the circuit. ECMO alters drug pharmacodynamics due to membrane sequestration and interference with decarboxylation, due to which lipophilic drugs may persist for prolonged periods interfering with BD assessment.6,7 Hepatic and renal dysfunction may further delay the drug clearance. Gaseous exchange across the membrane depends on sweep gas flow, the differential movement of carbon dioxide and oxygen, and differential solubility, and hence, the adequate increase in CO2 either does not occur or takes a prolonged period which is complicated by hypoxia or hemodynamic alterations.3,7,8 Hence, on ECMO, the recommended value of PaCO2 rise for a confirmatory AT may not occur even after the stipulated time of AT of 8 to 10 minutes. The reduction of sweep gas flows to a minimum to reduce carbon dioxide elimination also is futile. The respiratory acidosis also may worsen the cardiac output in VA ECMO leading to hypotension. The compromised lung in VV ECMO develops hypoxia before an adequate rise in carbon dioxide is observed.The success of AT in determining BD on ECMO would depend on:Reducing CO2 elimination (to ensure its rise) by decreasing the sweep gas flow on ECMO to a minimum of 0.5 to 1 L/minute (essential for avoiding hypoxia) or by providing a gas mixture known as carbogen (a mixture of CO2 and O2) through the ventilator or addition of CO2 in ECMO circuit.2,5,6,9 In a large meta-analysis, AT could confirm BD in 77% of patients on ECMO.6 In the rest, it failed due to the absence of an appropriate rise in CO2; development of hypoxic, hemodynamic alterations; and neurologist opinion of questionable reliability of AT on ECMO.4,10 The presence of these lacunae with AT has focused our attention on ancillary tests. These tests are of two types, the first are the ones that measure cerebral blood flow, and the second are those which test the bio-electric activity.3 The former includes angiograms either conventional or by CT scan and MRI, TCD, and nuclear studies. The latter include EEG and evoked potentials. The meta-analysis revealed the EEG use in 62% of cases followed by CT angiogram in 22% cases and TCD in 6% cases.6 EEG demonstration of electro-cerebral inactivity defined as the absence of non-artefactual electrical activity of at least 2 μV from baseline over half an hour is supportive of brain death. The CT angiogram should demonstrate the absence of blood flow in internal carotid and vertebral arteries to signify BD. In addition, CT scan may also demonstrate other neurological causes of declining Glasgow coma scale (GCS) such as massive intracranial bleed with raised intracranial pressure and midline shift amenable to urgent neurosurgical intervention. This if left unattended may lead to catastrophic sequelae of herniation culminating in BD. EEG and evoked potentials are affected by potential confounders such as sedative drug use, hypo- or hyperthermia, metabolic abnormalities, and other local electrical interferences. A bispectral index is used in conjunction, with variable success.10 The tests of blood flow detection, although, unaffected by these confounders may provide false-positive results in significant hypotension states or cases of occluded proximal vasculature and they show false-negative with preserved blood flow in BD patients with craniotomy or ventricular drain in situ. Also, these tests are difficult to perform due to concerns with patient shifting to CT or MRI areas and MRI incompatible ECMO circuits. TCD fails to visualize evidence of cerebral circulatory arrest in the majority of adult patients, which however can be used to demonstrate the presence of oscillatory flow with systolic spikes in the pediatric subset.3,5,10 Ancillary tests on their own cannot be used for conclusive BD declaration, so AT is mandatory.2,3,6 In our patient, AT was tried on 2 occasions but could not be completed, so proved inconclusive. The facility for serum levels is not available at our center; however, serum levels of sedative agents should be incorporated in the institutional protocol. The elimination half-lives of midazolam being 1.5 to 2.5 hours and levetiracetam being 6 to 8 hours were taken into consideration before a formal neurological examination. The other commonly used agents in the ICU with their elimination half-lives are mentioned.11 Ancillary tests such as EEG were tried but a lot of interference pattern was seen; TCD could not demonstrate the flow due to local tissue edema owing to long ECMO period. Borderline hemodynamics with inotropic support and risk of decannulation/ECMO circuit disconnections precluded patient transfer to CT facility. Hence, the declaration of BD was done in accordance with the neurologist after 48 hours had elapsed to account for delayed drug clearance. Despite all the shortcomings described in the case about conduction of clinical test including the AT and the ancillary tests (EEG and CT/MRI) for evaluating BD, in the present era, these tests are essential to conclude BD and should be a part of the institutional protocol; however, the logistic issues at our center did not permit us to do so. The subjective nature of opinion by neurologists should also be kept in mind highlighting the need for the ancillary test in cases with failed AT for BD determination. Serum levels of the narcotic agents should be estimated in such cases whenever feasible. This case review focuses the attention on the direct need to modify AT for aiding the conclusive diagnosis of BD in these patients.

Conclusion: The widened implications with a surge in the use of ECMO have necessitated the need for the establishment of guidelines for BD declaration on ECMO. AT is inconclusive in patients on ECMO owing to the altered physiology and underlying pulmonary conditions for which ECMO was instituted. Ancillary tests may play a complementary role, which however would still require AT to confirm BD. Implementation of a standardized approach for AT in this subset would aid in establishing a diagnosis of BD promptly so that organ donation could be facilitated appropriately.

41. Use of “Low Approach” Femoral Central Venous Cannulation During COVID-19 Pandemic. (Conference Abstract ID: 28)

Kunal Singh, Alok Bharti, Prakash K Dubey

All India Institute Of Medical Sciences, Patna, Bihar, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.81

Introduction: Many times critically ill patients who are either suspected cases of COVID-19 or COVID-19 positive coming to intensive care units require central venous access. Wearing personal protective equipment (PPE) for placing a central venous catheter can make the procedure challenging because of poor visibility. Insertion of the central venous catheter becomes even more difficult when the patient is in respiratory distress and is unable to lie flat on the bed. In COVID-19 positive or suspected patients where it is difficult to cannulate internal jugular vein (IJV) or subclavian vein due to anatomical or medical reasons, we suggest ultrasound-guided “low approach” femoral central venous access as an alternative.2 We report a case of acute pulmonary edema secondary to rheumatic heart disease which was managed successfully with ultrasound-guided low approach femoral central venous access.

Materials and methods: A 37-year-old woman with a history of rheumatic heart disease presented in intensive care with acute pulmonary edema. The nasopharyngeal swab was taken for reverse-transcription-polymerase-chain-reaction (RT-PCR) assay to rule out COVID-19. The patient was managed in a line of acute pulmonary edema with an upright position, oxygen support, noninvasive ventilation (NIV), furosemide, and morphine. This patient required urgent central venous access for starting vasopressor and further management. As the patient was unable to lie flat on the bed and multiple attempts for vascular access were already tried in the emergency department, we planned for low approach femoral access. We used ultrasound with a linear probe to scan the femoral vessel at the level of the groin. By keeping the femoral vein in the center of the screen, a needle was inserted from the middle of the linear probe at an angle of 30 to 45°. The position of the guidewire inside the femoral vein was confirmed with ultrasound by using a long axis view before threading the catheter over it. The cannulation was successful in the first attempt.

Discussions: In this case, we successfully inserted an ultrasound-guided femoral central line 5 cm below the inguinal ligament in a view to further reduce catheter induced infection rate. It has been suggested that the risk of infection will be very much reduced if we use full barrier precaution, ultrasound guidance, low approach, tunneling, and medicated catheter. Another advantage of low approach femoral access is that a person doing this procedure is away from the respiratory passage of the patient it may reduce chances of airborne infection during the COVID-19 pandemic. Placing the catheter in the femoral vessel will not interfere with the respiratory care (helmet-based NIV). Proning patients during mechanical ventilation and dressing of the line is also not a problem with low approach femoral venous access. Femoral access should be avoided in patients with peripheral venous and arterial disease and renal transplant.

Conclusion: In this case, we have highlighted that modification of femoral venous access helps to achieve the central access quite fast and also increases the safety of both patient and operator. We suggest that in present times of COVID-19 pandemic, ultrasound-guided low approach femoral central venous access may be used in emergencies and also where other options of central venous cannulation are not suitable.

42. COVID-19 Exacerbating Cryoglobulinemic Vasculitis. (Conference Abstract ID: 25)

Hari Naveen Ashok Kumar, Souvik Chaudhuri

Kasturba Medical College, Manipal, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.82

Introduction: We would like to report a rare case of cryoglobulinemic vasculitis precipitated by COVID-19. Cryoglobulinemic vasculitis is a small vessel vasculitis affecting the skin, joints, peripheral nerves, and kidneys. It is usually associated with hepatitis C virus infection, B-cell lymphoproliferative disorders, and autoimmune disorders.

Materials and methods: Written informed consent obtained from the patient and patients relative to present the details pertaining to the clinical course of illness with pictures and radiological images while maintaining the confidentiality of patient and identification.

Results: 48 year old male patient seropositive for hepatitis C with known end stage kidney disease on maintenance dialysis with history of recent severe covid-19 disease treated with remdesivir, steroids and anticoagulant; presented with shortness of breath, recent onset skin lesions. Purpural lesions on extremities and trunk could not be attributed to any isolated dermatologic disorder. Tzanck smear and gram staining were inconclusive. Covid-19 RTPCR was negative. HRCT chest was done to rule out re-infection. HRCT showed diffuse alveolar haemorrhage. In view of multi system involvement, vasculitis was suspected and diagnosed to have hepatitis C infection associated cryoglobulinaemic vasculitis. Patient underwent dialysis along with plasmapheresis for 3 days and discharged from the intensive care unit.

Discussions: The onset of symptoms and disease progression of cryoglobulinemic vasculitis was probably altered by COVID-19 infection. The patient developed pulmonary complications earlier in the course of illness. To our best of our knowledge, it is the first case of COVID-19 precipitating and hastening disease progression in cryoglobulinemic vasculitis.

Conclusion: In a patient with COVID-19 with hepatitis C infection, the possibility of alveolar hemorrhage due to cryoglobulinemic vasculitis should be kept in mind while ruling out re-infection. Utmost sagacity is required by the treating physician, as the treatment approach is different.

43. Case of Pneumothorax on High-flow Nasal Cannula in COVID-19. (Conference Abstract ID: 23)

Joslita Rebello, Rashmi Mohanan Menon

Father Muller Medical College Mangalore, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.83

Introduction: High-flow nasal cannula (HFNC) is used as alternative respiratory support in hypoxemic respiratory failure. A study on HFNC has shown a linear relationship between flow and airway pressure and delivers PEEP of 3 to 7 cm H2O. This peep effect can lead to barotrauma with high-flow nasal oxygen.

Materials and methods: A 60-year-old man presented with a 1-week history of cough breathlessness and myalgia. No other significant past medical history SARS-CoV-2 positive status confirmed by a reverse transcriptase-polymerase chain reaction. Initial arterial blood gas showed hypoxic respiratory failure. He was put on HFNC on day 2 with oxygen flows at 40 L/minute gradually increased to 50 L/minute.

Results: On day 8 diagnosed with right pneumothorax, a water seal drain was placed. Serial chest radiographs showed resolution of pneumothorax. The water seal drain was removed. The patient was sent to the ward on a face mask.

Discussions: Spontaneous pneumothorax is a rare complication of COVID-19 pneumonia. In the present case, the pneumothorax is due to positive pressure generated by high-flow nasal cannula therapy combined with underlying lung injury caused by SARS-CoV-2 infection. We successfully removed the water seal drain following the resolution of pneumothorax.

Conclusion: This case highlights HFNC therapy with high oxygen flow rates can cause pneumothorax in COVID-19 patients with underlying lung inflammation.

44. Management of Residual Hemothorax—By Using Streptokinase (Through Intercoastal Chest Drain). (Conference Abstract ID: 22)

Tammina Akhila Sai, PV Sai Satyanarayana

Kamineni Institute Of Medical Sciences, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.84

Introduction: Retained hemothorax is a complication of chest trauma that can lead to empyema, entrapped lung, and fibrothorax. Fibrinolytic therapy (intrapleural) appears to have a high rate of success for resolving retained hemothorax when video-assisted thoracoscopy (VATS) is not available.

Objectives: Treatment of residual hemothorax with an intrapleural fibrinolytic agent (streptokinase).

Materials and methods: Streptokinase, 250,000 IU, was diluted in 100 mL of saline solution and administered through a chest tube. The chest tube was clamped for 4 hours, and the patient was asked to rotate in several positions to allow for better distribution of intrapleural streptokinase. After 4 hours, the clamp was removed, and the drained material was measured. The procedure was repeated 3 times till radiographic improvement was achieved.

Results: After fibrinolytic therapy (streptokinase), there was a radiological clearance of hemothorax, and the patient improved clinically.

Discussions: Intrapleural fibrinolysis is useful in the treatment of persistent, loculated hemothorax. A significant increase in the drainage of chest tube with clot lysis with improvement from the clinical, and radiologic parameters suggests that intra-pleural streptokinase is an effective alternative to surgical decortication.

Conclusion: When video-assisted thoracoscopy is not available, streptokinase can be used for the treatment of retained hemothorax. Streptokinase is a cost-effective and effective treatment for the management of retained hemothorax.

45. Running Out of Vascular Access in CKD Patients? A Case Report on Translumbar Dialysis Catheter. (Conference Abstract ID: 10)

Nishant Agrawal, Yadav Waghaji Munde, Jignesh Shah, Prajakta Mane, Sunil Jawale

Bharati Vidyapeeth (DTU) Medical College And Hospital, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.85

Introduction: Vascular access is the key in critically ill patients with an end-stage renal disease requiring hemodialysis. After some years, failure of conventional access is a major cause of morbidity and mortality in patients on chronic hemodialysis. Translumbar tunneled dialysis catheter may be a salvage option, relatively safer, and most practical last choice in such cases for long-term hemodialysis, thereby improving survival and acting as a bridge for renal transplantation. It offers much effective access for dialysis in both adults and children and is considered as a potential choice for those patients with a lack of conventional venous routes. Maintenance of vascular access is very important and challenging in patients undergoing dialysis who have depleted and worn out their traditional vascular access such as arterio-venous fistula, arteriovenous graft, and central venous catheter or have had contraindication for peritoneal dialysis. Herein, we report one such interesting case which had exhausted all the conventional vascular access, thereby necessitating the use of alternative access like translumbar tunneled dialysis catheter insertion.

Discussions: Translumbar catheter is an acceptable alternative for those patients who have been on dialysis for a long period in whom conventional vascular access to make an A-V fistula or to implant a catheter might fail especially those patients with peripheral vascular disease, multiple comorbidities, and multiple previous attempts. Few studies discourage the use of translumbar tunneled dialysis catheter because of its low patency. Catheter patency at 3, 6, and 12 months as per Liu et al. was observed to be 43, 25, and 7% whereas as per Moura et al. was 91, 75, and 45% and a possible reason for better results by Moura et al. was apt catheter positioning during the procedure and scrupulous discernment and correction of kinks and misplacements. The reported Translumbar catheter patency at 12 months ranges from 17 to 73.2%. TLDC is anticipated to have many towering complications, exchanges, including the removals. The most familiar reported complication of TLDC was catheter-related infection and thrombosis. Lund et al. defined translumbar catheter failure as a blood flow rate <200 mL/minute. Low dose (1 mg/mL) one-time alteplase was effective in restoring catheter function in 72 to 82.1% of non-functional catheters. Another most common complication in a patient undergoing hemodialysis is 5- to 10-folds increased risk of bacteremia because of a long-term indwelling catheter. However, TLDC exchange or removal is performed only in case of serious infection or recurrence of infection which is unresponsive to antimicrobial therapy as it is the last resort of vascular access, unlike CVC which is removed if the patient has a fever for more than 48 hours despite antibiotic therapy. Another leading cause of catheter failure in the case of a translumbar catheter is catheter dislodgement because of excess adipose tissue being concentrated in the tunnel area. All these data cumulatively suggest translumbar catheter can be used as a bridge to a new permanent or much effective vascular access in those patients with exhausted access sites for dialysis.

Conclusion: The percutaneous placement of subcutaneous tunneled double lumen hemodialysis catheter directly into IVC is considered to be relatively safe and most practical last choice for vascular access and should be used as a bridge to renal transplantation, especially for those patients who are not on the transplant list due to poor sociocultural condition.

46. An Out of the Ordinary Case Report of Ticagrelor Furthering Rhabdomyolysis Induced by Atorvastatin. (Conference Abstract ID: 9)

Nishant Agrawal, Shivakumar Iyer, Jignesh Shah, Prashant Jedge

Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.86

Introduction: Rhabdomyolysis is evidential aftermath of statin therapy and the contemporaneous use of medications like ticagrelor that inhibit cytochrome P450-3A4 enzyme increases its risk by causing muscle necrosis and release of myoglobin into circulation. We hereby report a case of a 63-year-old male patient who was commenced on ticagrelor, post-transluminal coronary angioplasty on a background of atorvastatin therapy resulting in rhabdomyolysis with acute kidney injury and hyperkalemia. This case highlights, the need for awareness of drug interactions with atorvastatin, as dyslipidemia is commonly encountered these days in most individuals due to sedentary lifestyle practices and invariably most of these individuals are on lipid-lowering agents like atorvastatin but eventually these individuals land up with complications resulting in myocardial infarction or ischemic stroke and hence requiring the addition of antiplatelet drugs and lastly, the importance of early diagnosis and management of rhabdomyolysis to prevent the development of further complications. With the development of newer anti-platelet agents like ticagrelor, it is extremely important to understand the pharmacokinetics, pharmacodynamics, and its related drug interactions to prevent fatal complications like rhabdomyolysis which is commonly overlooked, as reported in our case.

Discussions: The risk of rhabdomyolysis which is characterized by skeletal muscle breakdown leading to release of sarcoplasmic proteins namely, AST and ALT, creatinine kinase (CK), and electrolytes, and thereby causing life-endangering complications like AKI, hyperkalemia, and cardiac arrhythmias are higher when statins are given concurrently with other drugs causing inhibition of cytochrome P450-3A4 enzyme. In our literature search, we found two similar cases of rhabdomyolysis due to the interaction of statin with ticagrelor. In the first case report, the patient was on a higher dose of atorvastatin, 80 mg once daily, and had acute renal failure and higher CK and myoglobin levels. In the other case, the patient was on rosuvastatin, 40 mg once daily. After consuming ticagrelor for a week, the patient had landed up with acute renal failure and elevated CK levels though this drug doesn’t require cytochrome P450-3A4 enzyme for its metabolism. The gamut of statin-induced myopathy varies from myalgia, myositis, and rhabdomyolysis to high up CK levels which might remain asymptomatic, with a mean duration of statin therapy before the onset of symptoms ranges from 1 to 60 days. Hospitalization and intravenous hydration to prevent renal damage remain the mainstay of treatment for patients with clinically notable rhabdomyolysis and once muscle symptoms have resolved, the use of a lower dose of the same statin or replacing other statins in place of the prior one or using other class of lipid-lowering drugs such as bile acid-binding resins and ezetimibe is used for managing dyslipidemia. The superiority of ticagrelor over clopidogrel is that it elevates the serum concentration of statin and hence, provides a shielding effect in patients with coronary artery disease. In this epoch of polypharmacy, it is very important to understand the importance of drug interactions which are frequently overpassed and result in morbidities.

Conclusion: Rhabdomyolysis is an exotic but intimidating complication that can transpire as a result of statin use alone or when used in conjunction with other drugs, that increase the potency of statin and hence we need to be watchful about the same and adjust the dosage of drugs to avoid the pharmacological interactions.

Highlights: An intensivist should be aware of the fact that newer anti-platelet drugs like ticagrelor trigger statin-induced rhabdomyolysis.

5. Critical Care Organization, Quality Management and Outcomes, ICU Information Systems)

1. To Study the Outcome of Mechanically Ventilated Patients in Respiratory ICU. (Conference Abstract ID: 195)

Nida Choudhry, Lalit Singh, Rajeev Tendon

Shri Ram Murti Smarak Institute Of Medical Sciences, Lucknow, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.87

Introduction: Background — The need for ventilatory support is one of the commonest indications for admission into the intensive care unit (ICU). Improving the outcome of mechanically ventilated patients remain a mission we all strive to achieve

Objectives: Aim — To study the outcome of mechanically ventilated Patients in Respiratory ICU — to provide baseline information for epidemiological trends, prognostic factors, and outcome of patients on mechanical ventilation calculated based on the duration of hospital stay, duration of ICU stay, number of days on ventilators, complications, mortality, followed till discharge.

Materials and methods: In this study, 412 patients were admitted to the intensive care unit of Shri Ram Murti Smarak Institute of Medical Sciences (SRMS IMS) at Bareilly Uttar Pradesh between November 2018 and April 2020. Two hundred and fifty patients were enrolled who fulfilled the inclusion and exclusion criteria.

Results: Out of 412 patients admitted to the ICU, 250 patients received mechanical ventilation, either invasive (43%), noninvasive MV (41%) and 16% of the patients showed noninvasive failure and needed invasive ventilation. The commonest indication of MV was acute on chronic respiratory failure (74.8%). Chronic obstructive pulmonary disease was the commonest pre-existing lung disease (50.8%). Highest mortality was observed in renal disease (71%). Invasive mechanical ventilation was associated with high APACHE II score, SOFA score, low Glasgow coma scale, low admission Ph, PO2 and high PCO2 compared to non invasive MV. Duration of hospital stay and length of ICU stay was longer in NIV Failure. The highest risk of mortality, a cutoff point of APACHE II score and SOFA score was >30 and >18 respectively.

Discussions: In the present study, the indication of mechanical ventilation in all studied majority patients (IMV, NIV, NIV failure) was acute on chronic respiratory failure i.e., 33.7, 47.1, and 19.2%, respectively, followed by acute hypoxemic respiratory failure, i.e., 69.8, 22.2, and 8%, respectively, in all groups. In the present study, among survivors, the mean duration of IMV was 7.04 ± 3.02, whereas in NIV failure was 4.57 ± 2.89, which is statistically significant with a p value of 0.0008. Venkatesh Yadav et al.68 demonstrated the mean APACHE-II score and SOFA score of non-survivors was high as compared to non-survivors, the difference was statistically significant that means mortality increases with higher APACHE-II score and SOFA score.

Conclusion: APACHE-II and SOFA scores are a strong predictor of mortality because it helps to assess the severity of illness and base chronic health status of the patients and also provided the prognostic information which was useful for the clinician to assess the outcome of patients admitted to the intensive care unit.

2. Intubation Practices in Trauma Triage: A Prospective Observational Study. (Conference Abstract ID: 194)

Anudeep Jafra, Kajal Jain, Sravani M Venkata, LN Yaddanapudi, SK Gupta

PGIMER, Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.88

Introduction: Hypoxia and obstruction of the airway are the major contributors to death following trauma. Hence, a definitive airway control, which may require endotracheal intubation, is an essential component of trauma resuscitation. Trauma Triage is generally manned by a team comprising of various levels of healthcare professionals. It is not only important whether a patient needs intubation but also when and how to intubate. There is a lack of data pertaining to intubation practices in trauma triage in India.

Objectives: Hence, the present study was conducted to describe the current practice of definitive airway management in the trauma triage of a tertiary hospital catering to northern India. The secondary objectives were to determine the success rate of endotracheal intubation by anesthesia and non-anesthesia residents, to describe the complications during securing the airway and to formulate recommendations based on the results of this observational study.

Materials and methods: This was a prospective observational study conducted at Trauma Triage of level 1 Tertiary Hospital over a period of 1 year. A specifically designed proforma was filled which included the patient’s detailed history of trauma, peri intubation vitals, indications for urgently securing airway, unfavorable conditions, the technique of intubation, medications used, and adverse events following intubation, and a number of attempts taken.

Results: The first attempt success rate of intubation by anesthesia residents was significantly higher than specialty residents (p = 0.0001; 95% CI 9.02–24.66). Airway injuries were most frequent complication (n = 140, 32.8%) followed by hypotension (n = 57, 13.3%). T

Discussions: These prospective observational data come from a tertiary care hospital of a low resource country on intubation practices in trauma victims over a period of 1 year. The first responders are usually non-anesthesia, specialty residents who cater to the immediate needs of the trauma victims. This reflects the different staffing levels and the limited expertise available on arrival to trauma triage. Through this study, it may be noted that although the level of experience met the current standards, there is a need to upgrade the skills of airway management using manikins and mandatory anesthesia rotation. Most of the intubations carried by anesthesia residents were drug-assisted along with the use of muscle relaxants which resulted in less complications and trauma. Literature supports the use of neuromuscular blockers in 62 to 77% of cases, with a strong association being reported between the use of neuromuscular blocking agents, especially depolarizing agents, and fewer adverse effects, as depicted by our results.

Conclusion: We observed that complication rates were more in patients intubated by non-anesthesia residents, use of a high dose of sedative agents like midazolam, and multiple attempts at intubation. Rapid evaluation of these factors and formal training in ATLS can lead to optimal management of the patient and decrease the rate of complications.

3. Respiratory Diseases in Adolescent Patients with Diabetes Mellitus. (Conference Abstract ID: 193)

Pradeep Singh Rajoriya, Ravi A Dosi

Sri Aurobindo Medical College and PGI Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.89

Introduction: Diabetes mellitus is a chronic, progressive, and incompletely implicit metabolic disease. Its associated micro- and macrovascular complications show the result in mortality and morbidity, The microvascular complications are manifested as neuropathy, retinopathy, nephropathy, and macrovascular complications affect the cardiovascular system. It also affects the lungs because of its rich vascularity and plethora in connective tissue (collagen and elastin), in a diabetic patient proliferation of extracellular connective tissue in the lungs, leading to a decline in lung function in a restrictive pattern. WHO has reported that the number of people with DM has risen from 108 million in 1980 to 422 million and 8.5% of the world adult population had DM in 2014. The number of diabetic patients worldwide has been expected to rise to 592 million in 2035 by the International Diabetes Federation. In this manner, I have been summarized and discussed the role of diabetes mellitus involved in the progression of common respiratory diseases in adolescent patients.

Keywords Diabetes mellitus, Respiratory disease.

Objectives: To study respiratory diseases in adolescent patients with diabetes mellitus.

Materials and methods: The present study is a survey study that was conducted in the department of pulmonary medicine of Sri Aurobindo medical college and hospital, Indore. Data will be collected from the attending the OPD and IPD in the department of pulmonary medicine. All the participants were in the age group of 25 to 40 years. Duration of the study — from November 3, 2019, to March 19, 2020.

Results: We investigate 56 patients in the age group between 25 and 40 years. This study shows 31 (55.35%) male and 25 (44.61%) females.

Discussions: Diabetes is identified as an independent risk factor for developing lower respiratory tract infection there appear to be a certain type of respiratory infections that may be more common in diabetics patients. Diabetic patients also appear to be at an increased risk of complications like pneumonia, asthma, etc.

Conclusion: The study shows a high prevalence of infectious diseases such as pulmonary tuberculosis, asthma, and COPD in adolescent patients with DM.

4. Comparison of Early Bispectral Index Guided Postoperative Extubation Verses Extubation in Awake Patients in Neuro Intensive Care Unit. (Conference Abstract ID: 192)

Tushar Kumar, Pradip K Bhattacharya

Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.90

Introduction: Neurosurgical patients have a high risk of neurological complications in the immediate postoperative period increasing both morbidity and mortality. Extubation after uneventful intracranial surgery is tried to be as early as possible to avoid ventilator-associated complications. There are several scales and scoring systems to guide and assist early extubation. However, in neurosurgical patients, these scores may not be sufficient to provide enough data for confidant extubation. The objective of the present study is to compare bispectral index guided postoperative extubation vs extubation in awake patients using various neurological assessment scores in neurointensive ICU after craniotomy and excision of supratentorial space-occupying lesions.

Materials and methods: A total of 16 patients (ASAI-II), aged between 25 and 45 years, who were scheduled to undergo elective neurosurgery operation under general anesthesia and randomly divided into the BIS group (group II) and scoring group (group S), with 8 cases in each group. After satisfactory respiratory recovery patients were extubated. Oxygen saturation by pulse oximeter and HR were recorded before extubation (T0), (T1) at 1 minute, and 5 minutes (T2).

Results: Early extubation using bispectral index found to be significant with p < 0.04. during T1 and T2.

Discussions: Bispectral index assists better to make decisions for extubation than other scoring systems in postoperative neurosurgical patients for supratentorial space-occupying lesions. Kamali et al. showed that BIS reduces extubation time in post-CABG patients.

Conclusion: Using BIS monitoring during and after neurosurgery, it reduces the length of patients’ extubation in ICU.

5. Heart Rate Monitoring of Anesthesiology Residents During the Airway Management of COVID-19 Suspect Patients: An Observational Study. (Conference Abstract ID: 191)

Adabala Vijay Babu, Bhavna Gupta

AIIMS, Rishikesh, Uttarakhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.91

Introduction: Technology has become an integral and central element in modern-day life and affects how we all work and function. Technology has a positive effect for the most part, as it helps us handle and monitor our everyday activities. Nevertheless, new technology has a significant role to play such as solving several other difficulties confronting healthcare services. Anesthesiology by itself is a stressful job. And the stress is quite evident in the residents, which leads to several health-related issues, cardiovascular diseases at an early age, a high number of suicidal attempts by the anesthesia residents.1 With the advancement of technology, smartphone applications for healthcare, e.g., mobile heart disease detection, heart rhythm analysis, remote home care monitoring, eye disease diagnosis, have become highlighted. We conducted a study to monitor the anesthesiology residents’ heart rate variation in the COVID-19 suspect area and compare it to their sleeping HR and baseline HR value. We assume that a significant increase in HR during airway management is an indicator of the stress the resident is undergoing, which usually goes unnoticed.

Materials and methods: In a tertiary care academic center, this was a prospective observational cohort study of anesthesiology residents. All the residents included in the study were of age 20 to 45 years, ASA I-II, and the residents with the experience of managing the airway for six months. Airway management of patients with difficult airways was not included in the study. Informed consent was taken from all the residents who participated in the study. As this sort of research is the first of its kind, 30 residents were included in this study. All participants wore a smartwatch MI band four before going to sleep and installed MI fit application on their smartphones and clicked on continuous sleep and heart rate monitor to detect sleep patterns and sleeping heart rate. From the inbuilt software recordings in the application, participants sleeping duration, sleeping HR, baseline HR was recorded. The next day, HR monitoring of residents during the induction of a general anesthesia in an elective case (COVID SUSPECT area) from 8:40 am to 9 am was recorded in three phases (preinduction, during induction, and postinduction).

Results: Thirty residents were included with a mean and standard deviation of age (26.4 + 1.4, minimum 22 and maximum 29) years, BMI (23.82 + 2.52, minimum 18.68 and maximum 26.56) kg/m2, and having a sleeping pattern of (6.3 + 0.8 minimum 5 and maximum 8) hours.

Discussions: Stress has a detrimental impact on healthcare organizations at multiple levels and, further significantly, is correlated with poor patient safety and quality of treatment, as it can manifest itself through exhaustion and diminished cognitive functioning, eventually affecting the performance of individual work and contributing to a greater risk of errors. Smartwatches, wrist bands, and activity trackers commonly used these days are based on electrocardiography (ECG) or photo-plethysmography (PPG).2 We used Mi band 4 to monitor the heart rate of all residents. We chose this band because it is cheap, comfortable to wear, rather discreet, and lightweight. It is based on the principle of photo-plethysmography (PPG). Our study observed a significant difference in Sleeping HR when we compared the baseline HR and with the induction HR (p < 0.05). This could be due to the activity of the resident and the stressor response of the body. And we found a significant difference between baseline HR and intubating HR.

Conclusion: This sort of continuous information can be used as the feedback option for users to improve their work efficacy. To date, technology has revolutionized healthcare facilities. Working knowledge of these smart devices will help us to balance our stress-free day-to-day activity.

6. Assessment of Best Practices, Knowledge, Attitude, and Perception of Postgraduates Working in Covid ICU—A MultiCenter Study from South India. (Conference Abstract ID: 190)

M Yuvashree, B Gayathri, Pushparani, S Ksheerabdhi

SRM Medical College Hospital And Research Centre, Kanchipuram, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.92

Introduction: Around 30% of patients with severe COVID-19 infection are need admission to an ICU for specialized care. Ninety percent of these patients present with severe acute respiratory distress syndrome corona. Inadequate knowledge and incorrect attitudes among the postgraduates working in ICU can directly influence practices and lead to poor infection control practice, poor management, and spread of disease. This study aimed to assess the knowledge, perception, and attitude of postgraduate students posted toward the COVID-19.

Materials and methods: After ethical committee approval (CTRI REF/2020/11/038549), a descriptive cross-sectional study was done among postgraduate students of different teaching hospitals in South India. Data were collected through the first week off from September 1 to September 8, 2020, during the peak of the pandemic. A convenience sampling technique was used to select participants. The sample size was calculated using EpiCalc-2000 based on the following assumption: the proportion of good knowledge 50%, level of confidence 95% and precision 5%, and apparent prevalence 0.05, to be 74. Then, the sample size increased by 10% to overcome non-response. Confidentiality precautions were ensured during the data collection process. A self-administered questionnaire was used, it was developed by the authors after reviewing previously conducted research, visiting the Ministry of Health and Family Welfare and WHO websites for frequently asked questions. The questionnaire for best practices was selected after studying various review articles, meta-analyzes, and the WHO website. The questionnaire was checked and validated for content and relevance by authors, and one public health and one anesthesia professor. The questionnaire covered the following: (I) Demographic characters: age, sex, years of critical care experience, type of organization in which responders are working, hours of work/day, and whether they were quarantined after the work. (II) The knowledge section: consisted of 20 knowledge questions covering the main general information, mode of transmission, treatment modalities, and ways of disease prevention. Each question was answered by either yes, no, or don’t know. (III) The attitude section; included 10 questions assessing the responder’s attitudes of COVID-19 as a preventable and controllable disease (six items), their attitudes toward regulations taken by the Hospital/Government to overcome the COVID-19 pandemic situation (four items). Response to each item was recorded on the 5-point Likert scale as follows: strongly agree (5-points), agree (4-points), undecided (3-points), disagree (2-points), and strongly disagree. (IV) Risk perception: included assessment of postgraduates’ feelings and perception of fear from catching COVID-19. The response could be either yes or no. As the responders were from various hospitals in south India, we used the online data collection method via Google Forms.

Results: Best practices 20 questions 95.3% of responders commented that there are separate donning and doffing rooms. 40% of hospitals had 2:1 and another 40% 3:1 of patient to staff ratio. It is 43.4% of responders were unaware of how many times per day the floors and surfaces are cleaned. Only 47% of responders committed that the WHO’S five moments of hand hygiene was strictly followed. 17% of places did not use bacterial filters for mechanically ventilated patients and 53% used HME. 71% of responders were aware of the modified ACLS guidelines for COVID suspect patients. 55% of responders agreed that Remedisivir should be started only in moderate to severe cases. 55% of responders preferred Methylprednisolone to treat COVID sequelae. Knowledge: 10 questions The mean knowledge score of participants was 8.5 ± 2.7 ranged from 7 to 10, with the mean correct answer rate of questions was 88.4%. Attitude 10 questions although the majority of our participants considered COVID-19 as a severe disease, they agreed that this disease can be prevented. The vast majority of doctors agreed that infection control standard precaution can protect against COVID-19 (95.6%) after working in COVID ICU. Generally speaking, a positive attitude was more observed among males than females in many attitude items. Perception: 10 questions regarding risk perception, about 83.1% of our participants reported that they were afraid of being infected with COVID-19, and 89.2% stated that they were more susceptible to COVID-19 infection as compared to others. The most common statements accepted by participants as causes of perception of fear of COVID-19 infection were the following: fear of transmission of infection to their families (96.5%), the disease is highly transmissible (91.74%), COVID-I9 new disease with no available vaccine (58.6%) or treatment (77%), the fatality of the disease (62.1%).

Discussions: In the current study, the knowledge level of postgraduates about COVID-19 was high. The mean correct answer rate was 8.5 ± 2.7. This comes in accordance with studies conducted by Abdul, Zhang, and Ghiao, who had reported about 80 to 90% of their respondents had a sufficient level of knowledge. Although many articles were charting out the best practices, we could not find any systematic survey to check whether the practices were followed. WHO’s 5 moments of hand hygiene, refrain from touching eyes, mouth, and nose, and putting surgical face mask were among the preventive measures frequently accepted by our participants. Ng et al. outlined that surgical masks are similarly as effective as N95 respirators if used with hand wash and other infection prevention precautions. Inconsistent with our findings, Kumar et al. and Olum et al. found HCWs’ knowledge regarding the role of face masks in the prevention of the disease to be moderate to poor. It worth mentioning that, and despite their high knowledge score, the vast majority of our respondents were afraid and felt more susceptible to have COVID-19 infection. This parallels studies that found an association between the level of fear and risk perception. Abdel in his Egyptian study reported that two-thirds of HCWs thought they were more susceptible to get infected, which resembles our study.

Conclusion: At the time of writing this manuscript, the national statistics indicate that up to 30% of SARS COVID-19 patients needed ICU admission for ARDS. The majority of them needed different levels of oxygen support from simple masks to NIV to ventilator support. Probably, the timely availability of PPE, the strict infection control measures, and the frequent CME’s and awareness sessions are responsible for making India one among the handful of countries with a very low mortality rate of 10%.

7. Development and Validation of a Low-Cost Electronic Stethoscope: DIY Digital Stethoscope. (Conference Abstract ID: 187)

Agam Jain, Roshan Sahu, Arohi Jain, Thomas Gaumnitz, Rakesh Lodha

All India Institute of Medical Sciences, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.93

Introduction: Among the many challenges COVID-19 presented to us, one of them is difficulty in auscultating patients while wearing coveralls. Although ultrasonography has been advocated as an alternative for the information stethoscope provides, the symmetry of breath sounds in intubated patients and wheeze are important findings with therapeutic implications, which cannot be ascertained through ultrasonography. This study aimed to develop and validate a low cost but effective electronic stethoscope that allows auscultation over the PPE or from a safe distance.

Materials and methods: While developing the DIY stethoscope, we aimed at good quality auscultation sounds while keeping the assembly simple, affordable, and using components that most physicians would already possess. We tried various permutations of sensors, its placement within a stethoscope, and of the entire assembly. After initial testing, we settled on using commonly available commercial microphones, housed either in the ear-tip or within the tubing of a stethoscope. Data were transmitted to a mobile phone, which ran our custom-developed app, which amplified the sound, reduced the noise, and transmitted the data for playback to Bluetooth headphones, which the doctor will be wearing over the PPE. To test our device, we conducted a study in Medicine and Pediatrics wards of a tertiary care hospital of North India in November 2020. Residents posted in these wards, auscultated patients using both the DIY stethoscope and a conventional stethoscope. Which stethoscope would be used first was determined through randomization. After auscultation, each device was rated on a scale of 1 to 10 on the following characteristics: Loudness of sound, Sound clarity, Loudness of noise, Interference caused by noise, Satisfaction, Comfort. Any auscultation findings were also recorded.

Results: Sixteen residents participated in the study and auscultated a total of 100 patients. DIY stethoscope had significantly higher loudness of the auscultation sounds, with a median (IQR) score of 8 (7, 9) for a DIY stethoscope and 8 (7, 8) for a conventional stethoscope.

Discussions: We presented a technique to convert a conventional stethoscope to an electronic one, producing sounds with good clarity and loudness. Although there is more noise in DIY stethoscope as compared to conventional, it does not affect the ability to auscultate patients and identify findings. It also offers louder sounds, ability to record and share auscultation clippings. The app is available free of charge on Google Play Store. As most physicians would already possess most of the components required for assembly of DIY stethoscopes, only the microphone may need to be purchased which drives down the cost of an electronic stethoscope from approximately 500$ to 500₹. Compared to other available attachments for stethoscopes available in the market, not only is it cheaper, but does not require transecting the stethoscope, so it stays unharmed and can be converted back to its original state.

Conclusion: DIY stethoscope offers a frugal and effective solution to challenges in auscultating patients in the COVID care area. Further versions of this device should work on improving noise reduction.

8. Use of Us CTN I for Risk Stratification and Resource Allocation. (Conference Abstract ID: 165)

Sarat Chandra, Ashima Sharma

Nizam’s Institute Of Medical Sciences, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.94

Introduction: COVID-19, having affected millions has caused a global disturbance in healthcare and has overwhelmed hospital resources, much more than any previous disaster of this century. Surveys, especially in middle and low-income countries, have shown partial or complete disruption in the management of non-communicable diseases owing to the pandemic, particularly cardiovascular emergencies. With the given burden of the disease, inadequate healthcare facilities, and personnel, who are also a major risk of contracting the disease, it is prudent to allocate resources judiciously. Cardiac troponins are useful in predicting cardiac insult. High sensitivity troponin assays can detect the levels of these circulating enzymes at levels ten times less than normal assays. This increases the sensitivity of detecting type I MIs but at the cost of specificity. Elevation of these enzymes can occur in conditions other than type I MI like acute heart failure, myocarditis including COVID-19-related viral myocarditis, stress cardiomyopathy, pulmonary embolism, sepsis, critical illness, etc. Studies have shown that the presence of myocardial injury is associated with a greater risk of complications like acute kidney injury and ARDS.

Materials and methods: In our center, Hs cTnI assays were used in patients presenting to ED with suspected cardiac insult within 2 hours of presentation. They were categorized into elevations <10 times and >10 times the upper laboratory limits. Apart from using these values as a tool to detect MIs in non-equivocal ECGs, they have also been used to risk-stratify patients with other clinical conditions as mentioned above. Although actionable measures are not always clear or possible, cTn increases identify patients at higher risk for adverse short and long-term outcomes. The patients were classified into those having (a) chronic myocardial injury, (b) acute non-ischemic myocardial injury, (c) acute MI, or (d) non-cardiac cause. Based on the above classification, patients were allocated specialist consultations or ICU monitoring to ensure adequate resource utilization.

Results: The study was done in 53 patients with various conditions presenting to ED. Levels of Hs cTnI were measured in them as mentioned above. Twenty-two patients had >10 times elevation in their HS cTnI assays and they all had myocardial insult in the form of Acute heart failure, Myocarditis, Sepsis and NSTEMIs..

Discussions: It is shown from the study that HS Trop I levels are elevated in CKD patients and do not give accurate results. Apart from that, patients with elevated HS Trop I required additional care and specialist consultations and had longer hospital stays.

Conclusion: Our observations on the utility of the investigation in the early estimation of major cardiac adverse events will be presented at the conference as a Poster presentation.

9. Comparative Analysis of Various Prevention of Violence against Doctors State Acts in India—A Descriptive Study. (Conference Abstract ID: 163)

Aakash Sethi, Gayatri Laha, Kalpita Shringarpure

Government Medical College, Baroda, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.95

Introduction: Study by the IMA records that about 75 % of the doctors have faced some kind of violence in their professional life.1 Doctors working in critical care wards are more prone to be a victim to violent attacks by patient’s relatives across the globe.2,3 Hospitals in India lack mechanisms in place to avert these incidences like the presence of an emergency team to deal with mob ready to inflict harm on a doctor, prompt police reporting, and knowledge about the acts safeguarding doctors.4 As per the Schedule VII of the Indian Constitution, “Powers to make laws to maintain public order lie exclusively with the states”.5 Therefore, various Prevention of Violence against Doctors Acts (PoVAD) have been enacted by the State governments. These are technically known as “Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) Acts”. India laws a single nationwide act to protect doctors. Multiple state acts might not be without differences between them. After nationwide protests in 2019, the Ministry of Health and Family welfare drafted the National Prevention of Violence against Doctors Bill but it was later stalled by the Indian Home Ministry citing lack of legislative powers of the Parliament to enact such a law.6 Reports suggest that the police aren’t aware of the presence of respective state laws enacted to safeguard doctors.7 Therefore, it could be useful for doctors especially those working in the causality unit to know these acts. We hypothesize that the various State PoVAD laws will differ from each other.

Objectives: Aim — To perform clause by clause analysis of the State PoVAD acts in India and note the variations in them.

Materials and methods: This is a cross-sectional descriptive study conducted over 2 weeks from September 14 to September 30, 2020. The sample consisted of State PoVAD laws which were accessed from www.indiacode.nic.in.Inclusion criteria were State Laws having the following words in their title:The Draft National PoVAD bill was accessed from www.mohfw.gov.in. A purposive sampling method was used. Data were entered and analyzed using MS excel. Quantitative data were expressed as mean ± standard deviation (SD) or median with interquartile range (IQR) depending on the normalcy of data. Qualitative data were expressed using percentage/proportion. Clause by Clause analysis of the acts on the following parameters was done.



Results: A total of 23 states act to protect doctors against violence were found. Mean length of the acts was 3.55 pages (SD = 1.23). The important clause by clause differences are enumerated below. A. The 2nd clause defined various Healthcare (Medicare) institutions, Healthcare personnels that were protected under the act. 16 acts [69.5%] had included more healthcare personnels than the Draft National bill did. For instance in the Gujarat act trained dais were protected as well. 7 state laws [20.5%] had a more inclusive definition of healthcare institutions than National Draft bill. These acts additionally defined ‘Mobile health unit’ under the definition of institutions protected under the act. B. Clause 3 prohibited persons from indulging in acts of violence against doctors or causing loss to their property. C. Clause 4 defined the nature and type of crime a person would committed if they damaged healthcare institutions or attached doctors. All 23 acts made such a crime Non Bailable and Cognizable. D. Clause 5 laid down the provision for punishment awarded to the person guilty under the act. The mean imprisonment of the acts is 3.25 years (SD = 1.54 years). Tamil Nadu state act has the maximum punishment, with imprisonment extending up to 10 years. The Median fine was 50 thousand rupees (IQR 50–50 Lakh) E. Clause 6 talking about compensation for the damage caused to the property was present in all the state acts. In 6 acts [17.6%], this amount will be fixed by the court. In the rest it was mandated at twice the amount of hospital equipment’s damaged by those held guilty. F. In 6 state laws [17.6%] a 7th clause was present. It contained the provision to make rules for carrying out the purposes of this Act. Only the Gujarat Government has made the rules so far.

Discussions: Only 3 and 12 state acts have protected paramedical staff and Allied health workers (midwives) from violence against healthcare personals. The other acts need to recognize attacks on paramedical and allied health workers as being equal to attacks on Allopathic Doctor. Recently, Dr Rajeev Josh, a pediatrician from Mumbai has filed a writ petition in Mumbai High court8 requesting the court to direct the state government to formulate guidelines for the protection of medical professionals and medical institutions from violence and attacks in case of medical accidents. If the petition succeeds, various professional bodies of doctors need to approach the Supreme Court for a direction to the Central government to enact a national act to safeguard doctors.

Conclusion: The Maharashtra and Chhattisgarh acts have an overall wider ambit than the Draft national bill based on all the parameters listed above. There were wide variations among the state acts. A National Act is desirable to have common definitions and imprisonment punishment for perpetrators of violence against doctors. 83.3% of the acts are yet to make rules under the act. In the absence of these rules, the implementation and execution of the act could nearly impossible.

10. Efficacy of Aloe Vera for Prophylaxis against Opioid Induced Constipation: A Pilot Study. (Conference Abstract ID: 152)

Komal Upadhyay, Kanta Bhati

Sardar Patel Medical College, Bikaner, Rajasthan, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.96

Introduction: Morphine and other strong opioids are mainstays of pain management regimens in advanced-stage cancer patients. Opioid-induced constipation (OIC) is the most common side effect and the development of tolerance is rare. Prophylaxis should be started at the same time opioid therapy is started regardless of the drug, route, schedule, or dose. Simple prophylactic measures like fiber, fluids, exercise, and stool softener are generally insufficient. The standard prophylactic regimen includes a stool softener and a stimulant laxative.

Objectives: Various agents like senna, sorbitol, polyethylene glycol, lactulose, and bisacodyl have been used for prophylaxis of opioid-induced constipation with variable success rate. There is a need for a prophylactic agent that has better effectiveness and tolerance. Aloe is unique in this regard as it possesses many other properties that are particularly beneficial for cancer patients. The plant leaves contain numerous vitamins, minerals, enzymes, amino acids, natural sugars, and other bioactive compounds with emollient, purgative, antimicrobial, anti-inflammatory, antioxidant, antifungal, antiseptic properties.

Materials and methods: A pilot study was undertaken to assess the efficacy of aloe vera (A Barbedensis) to be used as a laxative agent for prophylaxis of OIC. After institutional ethics committee clearance, 20 cancer patients were divided into two groups of 10 each. Patients in group “S” received two tablets of senna 11.5 mg twice daily and patients in group “A” received 20 mL of Aloe vera juice twice daily. Bowel Function Index 2 (BFI), need of additional therapy in form of tab bisacodyl and/or peripheral mu receptor antagonist, side effects and complications were noted on weekly basis for 6 weeks.

Results: Both the groups were comparable regarding the demographic profile and total per day morphine consumption. Mean Bowel Function Index (BFI) was the primary end point and was 25 for group S and 27.5 for group A,and the difference between two groups was insignificant (p value >0.05). Additional therapy in form of tab besacodyl ± peripheral mu receptor antagonists was needed in 12% patients in group S and in 19.5% patients in group A. Nausea, abdominal cramps, loose stools and electrolyte imbalance were noted in 10% patients for each in group A while only loose stools were noted in 10% patients in group S.

Discussions: Both the groups were comparable, and with regard to the p value difference between the 2 groups were insignificant.

Conclusion: Aloe vera was effective in the prevention of OIC in >80% of patients with acceptable side effects. However, further detailed studies are needed to evaluate the efficacy, safety, and other beneficial effects of aloe vera in cancer patients.

11. The First Hundred Post COVID-19—The New Normal. (Conference Abstract ID: 147)

Varalakshmi Diwakarla, Bharath Cherukuri, Shaik Saleema

NRI Medical College, Andhra Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.97

Introduction: Our Institution was converted into a State COVID-19 center in June 2020. Since then, approximately 12,000 patients were treated in our hospital including ICU admissions. In late November, we were permitted by the State Government to initiate Non-COVID services. The COVID-19 wards and ICU were and are currently providing services simultaneously although in reduced numbers. ICU admissions started almost immediately. We were faced with a multitude of challenges. These included diagnostic dilemmas, segregation and isolation of suspected COVID-19 cases, ICU admission policy changes, infrastructure challenges, and medical and nursing personnel management to name a few. It took immense administrative and medical planning and adaptation to streamline critical care services.


Materials and methods: This is an observational study on the first 100 admissions to our intensive care unit after restarting Non-COVID-19 services. Data collected will include demographic data, tests to rule out COVID-19, APACHE-II, current diagnosis, length of stay, and ICU outcomes. We will also record the nurse-patient ratio, the modality of communication with family, and family visitation policy. We will study the number of positive cases identified with each diagnostic modality and perform a cost analysis. We will compare ICU admissions during the same months in the previous year and compare patient outcomes. We will also compare outcomes between post-COVID-19 patients and COVID-19 naive patients in the ICU. We will analyze the timeline of various adaptations that were made with respect to ICU structure, admission policy, and diagnostic tools to rule out COVID-19.

Results: The study is in progress.

Discussions: The COVID-19 pandemic has battered healthcare systems worldwide. In resource-limited environments like ours, restarting of non-COVID-19 services has meant an additional burden on the critical care teams. The diagnostic dilemmas in view of common clinical presentations, increase the cost of care with added diagnostics, low nurse to patient ratios, infrastructure reallocation, initial hesitation with family visitation, and limited family interaction created a lot of stress. We had to make changes in admission policy and a plan for the flow of patients to the intensive care unit. This will be a great learning experience for future planning and management.

Conclusion: We hope to throw light on challenges in ICU management in the post COVID era and identify problem areas and potential ways forward.

12. A Study of Clinico-demographic Profile and Seroprevalence of Dengue at a Tertiary Care Hospital of Central India. (Conference Abstract ID: 131)

Rajesh Kumar Rahul, RK Jha, Sonam Verma

Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.98

Introduction: Dengue virus is a flavivirus found largely in areas of tropics and subtropics. Dengue is currently regarded globally as the most important mosquito-borne viral disease presenting with varied symptomatology.1 There are four distinct antigenically related serotypes of dengue virus-DEN1, DEN2, DEN3, and DEN4. Dengue is transmitted, primarily by Aedes aegypti mosquitoes.

Materials and methods: This prospective study was carried out at the department of General Medicine and Microbiology, of Sri Aurobindo Institute of Medical Sciences, Indore, over a period of 1 year (July 2019 to July 2020). Patients presented with febrile illness of 2 to 7 days along with clinical features of the dengue-like illness, i.e., nausea, vomiting, rash, myalgia, and arthralgia were investigated.

Results: During study period total 520 blood samples were tested for dengue infection. Out Of these 80 samples were positive for dengue. Seroprevalence of Dengue was 15.4%. Out of 80 dengue patients, 44 (55%) were male patients and 36 (45%) were female patients. Out of 80 dengue patients, 54 (67.5%) patients were from urban area and 26 (32.5%) from rural area. In our study dengue infection was observed more in the age group 21 to 30 years, followed by 31 to 40 years and 41 to 50 years. The most common symptoms of dengue were fever, body ache, headache, nausea and vomiting. Out of 80 dengue cases, fever with rash was observed in 24 cases.

Discussions: Dengue fever is an acute febrile Arbo-viral disease affecting the tropical and subtropical regions of the world.3 Dengue is endemic to the Indian subcontinent and it is associated with explosive urban epidemics.

Conclusion: Differences in the clinical, biochemical, and hematological profile of dengue virus infection, indicative of a variation in disease severity from dengue fever to dengue hemorrhagic fever.

13. ICU Quality Indicator. (Conference Abstract ID: 108)

Ziyokov Joshi, Sneghdha Mahajan

Tagore Heart Care and Hospital, Jalandhar, Punjab, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.99

Introduction: Rapid response systems have emerged as important resources that focus on the hospitalized patient with unexpected, sudden deterioration in condition from any cause. A rapid response system is a very important system to prevent mortality in every hospital.

Objectives: 1 To establish and test the feasibility of measurement of mortality in hospital. 2 Outcome of the patient after rapid response team treatment after 7 days. 3 To audit and analysis rapid response events in the hospital. 4 To make a hospital mortality prevention protocol.

Materials and methods: We have rapid response system activation criteria 1 Acute physiological criteria A heart rate <40 or. 130/minute B Systolic blood pressure, <90 mm Hg C Urine output <50 mL in last 4 hours D Respiratory rate <8 or >30/minute E SpO2 <90% F Acute change in consciousness 2 organ system-specific criteria A Airway: Respiratory distress, 3 Uncontrolled pain.

Results: In our hospital from January 2018 to August 2019, total admission 18,680 out of this 4% mortality, and out of this 4% I % is surgical mortality.

Discussions: Rapid response system is the most important tool in the hospital to give the best care to a patient in our hospital. We are heaving CODR blue and RRS protocol to prevent and manage all emergencies in the hospital with this our mortality is minimum in India.

Conclusion: Important factor in the successful implementation of a rapid response system in hospital 1 rapid response team 2 activation criteria 3 emergency intervention to stabilized critical patient 4 communication tool SBAR 5 CME for doctor paramedical and workshop to teach them 6 BLS and ACLS teaching to doctor and advance invasive monitor and AED in emergency crash CART in every floor of hospital 7 every 6-month audit 8 CAPA every 6 months.

14. “Prognostic Value of Cycle Threshold” in COVID-19 Confirmed Patients. (Conference Abstract ID: 91)

V Dinesh Kumar Gontla, B Rajyalakshmi, Srinivas Samavedam, Narmada Aluru, P Ramakrishna Reddy

Virinchi Hospitals, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.100

Introduction: RT-PCR test is the standard method for the diagnosis of SARS-CoV-2 infection. This test is based upon the amplification of the fluorescent signal. Number of cycles that fluorescent signal undergoes to reach the threshold called as “Cycle threshold (CT). It is inversely related to the nucleic acid content of the sample.

Objectives: To study the correlation between cycle threshold of RT-PCR test is confirmed COVID-19 patients with severity of the disease.

Materials and methods: This is a single-center retrospective observational study. We have included a total of 192 patients. SARS-CoV-2 infection was confirmed by the RT-PCR test. Entire data have been collected from electronic medical records. The primary outcome was 28-day mortality, secondary outcomes were ICU admission, invasive ventilation, AKI, RRT, shock and CORAD SCORE on HRCT chest, the total length of stay in the hospital, number of ICU days, and ventilator days.

Results: We have concluded mean CT value for all groups and calculated p-value for statistically significance.For total length of stay in hospital,number of ICU days and ventilator days were applied pearson correlation coefficient. P value was statistically significant for mortality, ICU admission and shock groups. Cycle threshold and length of ICU stay were inversely correlated with statistically significant p-value.

Discussions: In our study, it is concluded that low CT is associated with the severity of the disease.

Conclusion: Low CT associated with increased ICU admission, high mortality, shock, and increased length of ICU stay.

15. An Audit of Percutaneous Dilatational Tracheostomy (PCDT) in a Mixed Adult ICU in a Multispeciality Hospital. (Conference Abstract ID: 88)

R Vaidyanathan, Noor Rubina Ahmedi

Cauvery Heart And Multispeciality Hospital, Mysore, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.101

Introduction: Tracheostomy is a common procedure done in ICU patients who either require prolonged ventilation or for airway protection to facilitate weaning from patients’ ventilatory support. The classical surgical technique described by Jackson in 1909 has been performed routinely by either ENT surgeons or other surgeons and has changed little since then. However, the advent of percutaneous tracheostomy, first described by Sheldon In 1955 has revolutionized the procedure and has been modified and improvised several times with the current technique of single graded tracheal dilator over a Selinger type guide wire called the Blue Rhino technique being the most popular one.

Objectives: To do a retrospective analysis of percutaneous dilatational tracheostomy (PCDT) in an adult mixed surgical and medical ICU between December 20011 to November 2020 and to look for any possible immediate, short-term, and long-term complications.

Materials and methods: A retroprospective evaluation after ethical committee approval of all the PCDTs performed between December 2011 and November 2020 was done. All procedures were undertaken by critical care physicians or senior registrars with at least 2 years of working experience in critical care. Ciaglia’s tapered single dilator blue rhino kit (cook) was used for all the patients. A proforma recorded any intraoperative complications and technical difficulties encountered during the procedure. All the patients were followed up for up to 3 months for any delayed complications.

Results: Of the 220 percutaneous tracheostomies performed, the placement of a tracheostomy tube was successful at the first attempt in all but four patients in whom the tube had to be withdrawn and guidewire reinserted and tube placed in proper position.Five patients experienced a complication in the acute phase.There was bilateral pneumothorax in one patient requiring bilateral chest drain insertions who subsequently recovered. One patient proved difficult for the tracheostomy tube to be introduced into the formed stoma and had to be converted to an open procedure in bedside.In three other patients, excessive bleeding occurred during the procedure and a more experienced intensivist was called to complete the tracheostomy. Another patient developed collapse of the left lung post procedure with possible accumulation of pulmonary secretions or mucous plug which required bronchoscopic clearance the next day. There was no incidence of false passage in any of the patients following tracheostomy. Postoperative reactionary bleeding was seen in five patients within six hours of procedure from the surgical site associated with surges of increased in blood pressure which subsided within 24 hours with conservative measures of compressive bandage at the site and blood pressure control. There was no procedure related mortality.Tracheal stenosis was seen in one patient after one month which required bronchoscopic dilatation. Granulomas at the scar site as visualized by fibre optic bronchoscope was seen in two patients resulting in stridor which required bronchoscopic steroid injection. Subsequently all of them recovered without any long term morbidity.

Discussions: PCDT has now almost become the gold standard for tracheostomies in ICU. Bleeding is the most significant early complication. However, most of the cases of bleeding were easily controlled by simple measures like local compression and pressure application. Ultrasound before the procedure to mark the depth of the trachea and avoid any blood vessels along the track may help reduce the bleeding complication. Other significant advantages have been the decreased waiting time and a significant reduction in the cost since it is a bedside procedure. Though comparatively less in incidence delayed complications like granulomas and tracheal stenosis are possible which was seen in <1% of the patients in our series.

Conclusion: PCDT is a safe and effective procedure done at the bedside which has effectively reduced the cost and waiting time with a negligible but finite acute complication in the form of bleeding and a small incidence of delayed complications like tracheal stenosis or granuloma formation.

16. Apollo eACCESS Initiative: Tele-ICU During the COVID Crisis. (Conference Abstract ID: 77)

Sri Ramya Ganti, Sai Praveen Haranath, K Subba

Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.102

Introduction: The practice of Telemedicine is still in its infancy in our country. Lack of awareness, as well as acceptance both on the part of patients and professionals, has been cited as the principal reason behind the delay in its full-fledged development. The Apollo Hospital backed “eACCESS” tele ICU service has been functional since 2013 and has remotely managed over 4,000 ICU patients in the last 3 years in several hospitals in our country. Continuous round the clock monitoring of critically ill patients has been possible with the use of remote technology. The global COVID-19 pandemic has united all nations against a common enemy: the novel coronavirus. In times like these where social distancing is the new norm, the timely release of the Telemedicine Practice Guidelines by the Government of India has enabled healthcare professionals to evaluate, diagnose, and triage remotely. We have currently extended our monitoring services for COVID-19 patients at many remote locations in India like Dadri (UP), Bahr (Bihar), Kaniha (Odisha), Vindhyachal (MP), Korba (Chhattisgarh), and Ramagundam (Telangana).

Materials and methods: Our workflow has evolved with time and we do a minimum of two interactions per remote site every day. Qualified and trained intensive care physicians are monitoring patients in shifts along with specially trained critical care nurses. Standard guidelines issued by The Ministry of Health and Family Welfare for COVID-19 treatment are being followed. Awake proning of conscious patients is also being done at these locations under supervision. We are also providing education to the medical personnel at these remote sites regarding the monitoring of ICU patients, follow-up of investigations, basic medical emergencies, and how to manage them. Interestingly the minimum distance of our remote connection is 100 km and the maximum distance is 1,550 km.

Results: We have monitored over 1700 COVID-19 positive cases since March 2020 at various locations within the Apollo campus in Hyderabad and at remote sites. Majority of the patients admitted for COVID care were males (68.7%). The patient population varied from 8 years to 84 years. We have the capacity to monitor 120 COVID patients at a given point of time. The average length of stay in the hospital is approximately 4.5 days. Triaging and reporting of Electrocardiograms from remote sites is also done from our command center. We have reported 3432 ECGs during this period. We have also provided 409 sub-specialist tele consultations through the eACCESS program since March 2020.

Discussions: Tele-ICUs not only provide 24*7 monitoring of critically ill patients but stand with the bedside team as the first line of care. This modality has helped decrease the frequency and need to physically enter an isolation room. The direct visualization and monitoring of COVID-19 patients have also allowed for the early detection of many emergencies like a drop in oxygen saturation, disconnection from NIV, ventilator circuit issues, etc. Since most of the intensivists are predominantly concentrated in the metro cities, Tele-ICU services have plugged a major gap in the existing healthcare delivery system by providing quality care to smaller rural areas. Patients can have access to remote expertise from the comfort of their homes.

Conclusion: The ongoing COVID-19 pandemic has not only highlighted the shortage of ICUs but also the shortage of trained medical personnel and resources (like personal protective equipment, PPE). Tele-ICU solution can help bridge these barriers by conserving PPE, minimizing exposure, and avoiding infection through constant remote monitoring.

17. An Audit on Dialysis Services in Intensive Care Unit at a Tertiary Care Teaching Hospital. (Conference Abstract ID: 76)

Kiran Vadapalli, Prashanth Jedge, Jignesh Shah, Shivakumar Iyer, Shambhavi Chauhan

Bharati Vidyapeeth Medical College, BVDU, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.103

Introduction: Acute kidney injury is a common presentation in the intensive care unit and the need for dialysis in the care of such patients is essential. The dialysis in the ICU setting differs from that of that done in patients with chronic kidney disease on an outpatient basis in many ways like the need for prolonged dialysis due to hypotension, issues with anticoagulation, and also regarding the complications and their management. This audit is intended to find the incidence of such differences and the possible steps to minimize them.

Materials and methods: The study is done at the Critical Care Department of Bharati Vidyapeeth Medical College, Pune which has a 50 bedded ICU with 2 dialysis machines. This is an observational study. A total of 100 consecutive hemodialysis sessions were analyzed. Patients who presented to the hospital with features of acute kidney injury or developed AKI during the management of their illness and requiring dialysis were studied. The clinical presentation, indication for dialysis, method of vascular access, and process of dialysis and complications both intra-dialysis and immediate post-dialysis and need for supportive care were all studied.

Results: Out of the 100 consecutive dialysis sessions observed, 50 were done in patients who presented with Acute Renal failure on a pre-existing Chronic Kidney disease, 38 presented with acute kidney injury, 4 were for AKI after their hospital admission and 8 dialysis sessions were done for an indication of PLEX for Guillian Barre syndrome and TTP. Major indications for dialysis were fluid overload in 42, severe acidosis in 36, hyperkalemia in 8, and uremic symptoms in 24, and dialysis for PLEX and TTP in 8 ( few had more than one indication). The most common vascular access obtained was through the jugular vein (54), femoral vein (26), permcath (18), and AV Fistula (2). The median time lag from Nephrologists’ advice and initiation of dialysis was 6.5 hours, maximum being 22 hours and mostly occurred for the first dialysis. The main reason was due to the delay in radiological confirmation of access placement and consent and room availability for dialysis. Almost more than 45 were Sustained Low Efficiency Dailly Dialysis (SLEDD) sessions which was the major method of Haemodialysis as many patients were hemodynamically unstable and requiring vasopressors for maintenance of blood pressure during dialysis. The remaining 55 were standard 4-hour hemodialysis. None of the dialysis sessions were CRRT. The most common complication was flow issues during dialysis (30) which lead to either increase in time of dialysis or premature termination. Many had hypoglycemia (32), an increase in vasopressor requirement (18), new-onset hypotension (14), cardiac dysrhythmias (5), and bleeding (2). One patient developed cardiac arrest during the dialysis session.

Discussions: The majority of dialysis sessions were done in patients presenting with acute kidney injury in preexisting chronic kidney disease. Vascular access was obtained through the internal jugular vein in the majority. There was a delay in the initiation of dialysis in many due to time lag in getting consent for the first dialysis and delay in obtaining vascular access and the confirmation of this placement. Many were in shock requiring vasopressors and the requirement increased during a dialysis session. SLEDD was the prime method in their management as there were only 2 machines and SLEDD was able to be performed in the patients without much difficulty.

Conclusion: SLEDD is an efficient method of hemodialysis of critically ill patients. Patients need very vigilant monitoring of vital parameters during dialysis as the need for vasopressors support is high in many critically ill patients and the incidence of hypoglycemia is high which necessitates regular monitoring of blood sugars both during and immediate post-dialysis.

18. Role of Perfusion Index in Assessing the Peripheral Perfusion in Patients Undergoing Major Abdominal Surgeries. (Conference Abstract ID: 67)

Prayag Premnath, Neeta Kavishvar

Government Medical College and New Civil Hospital Surat, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.104

Introduction: Abdominal surgeries are one of the most common surgeries that take place in the operation theater. Major abdominal surgeries are generally associated with extensive fluid loss which can hamper the microcirculation and makes the emphasis on perioperative fluid maintenance. Perioperative hemodynamic instability is associated with postoperative morbidity and mortality. Microcirculation plays a fundamental role in gas and nutrient exchange and it achieves this by controlling the vascular tone. Laparotomies are associated with longer durations as well as excessive fluid and blood loss. Longer durations can lead to heat loss, blood and fluid loss which deranges tissue perfusion and hampers the microcirculation as well. The peripheral perfusion can be detected by making use of the peripheral perfusion index (PPI) obtained from Masimo SET pulse oximetry. A threshold value of 1.4 is taken as cut-off where the PPI below this determines the fact that there is tissue hypoperfusion. With the use of the perfusion index, we can determine the status of the peripheral perfusion as well as the state of tissue perfusion which correlates with the morbidity and mortality of patients undergoing major abdominal surgeries much better than the other noninvasive and invasive parameters much earlier.

Materials and methods: This study was carried out in 31 patients undergoing major abdominal surgeries. The hemodynamic parameters ECG, pulse rate, SBP, DBP, MAP, perfusion index, proximal and distal temperature were recorded before induction and throughout the intraoperative period. Patients were followed till the discharge or death of patients and any postoperative complications were noted. Retrospectively patients were divided into complication and no-complication group to check its association with hemodynamic parameters and PI.

Results: There was no correlation found between perfusion index and DBP, pulse rate and MAP (correlation coefficient = –0.08, –0.025 and 0.04 respectively) and very weak positive correlation with SBP (0.27). There was significant correlation between PI and T1 (0.48, p < 0.01) and negative correlation between PI and temperature difference (–0.37, p = 0.05). There was a weak positive correlation between average fluid given per hour and perfusion index (0.340). The correlation coefficient between PI and requirement of ventilator support was –0.461(p = 0.009 (p < 0.01). There was a very weak negative correlation between perfusion index and death (–0.172)

Discussions: This study was conducted among 31 patients. Of the total 31 patients, 17 (54.8%) were male and 14 (46.2%) were female. The mean age in this study was 33.5 ± 13.6 years. In this study hemodynamic variables like pulse, noninvasive blood pressure, and the difference in forearm-fingertip skin temperature were correlated with perfusion index by Pearson correlation coefficient. There was no correlation between PI and other hemodynamic variables and there was only a weak positive correlation with SBP. The heart, brain, and kidney have their autoregulation, so in critical situations, the body will try to maintain its blood supply by compensating mechanisms. So in this situation, arterial blood pressure correlates poorly with the microcirculatory flow. It also appears from this study that there is no correlation between perfusion index (PI) with conventional hemodynamic parameters like MAP, SBP, DBP, and heart rate. The ultimate goal of management of the patient in the perioperative period is maintaining the tissue perfusion, so PI should be added into the conventional hemodynamic monitoring parameters especially where invasive monitoring like PCWP and SV monitoring is not possible.

Conclusion: PI detects acute hemodynamic responses earlier than conventional parameters and can be used as effective monitoring in improving perioperative outcomes.

19. A Prospective Observational Audit-on the Appropriateness of Initiation, Maintenance, and Complications of DVT Prophylaxis in Critically Ill Patients. (Conference Abstract ID: 53)

S Thangadurai, Jayanthi, L Charan, P Vivekananthan, MN Sivakumar

Royal Care Superspeciality Hospital, Coimbatore, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.105

Introduction: Thromboembolism is a major complication in hospitalized patients. Intensive care unit (ICU) patients have a greater risk of thrombotic events due to additional risk factors such as immobilization, mechanical ventilation, and central catheters. The diagnosis and management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in critically ill patients are challenging and these conditions are associated with high mortality. Medical thromboprophylaxis with low molecular weight heparin (LMWH) as well as unfractionated heparin (UFH) has been shown to reduce the incidence of thromboembolic events in such patients. For patients with a high risk of bleeding, mechanical thromboprophylaxis can be used. According to research, half of the hospitalized patients are at risk of thromboembolism.1 The rate of VTE ranges from 10% to 80% in patients, who are not being given any prophylaxis.2,3 Studies have proven the rate of VTE is greater in hospitalized than in community patients.4 The use of DVT prophylaxis has been almost a standard of care in ICU and by doing this study we intended to audit if initiation of it has been appropriate and whether there is any delay in a certain group of patients, the complications associated and the reason for discontinuation during the ICU stay if any in our ICU for a period of 2 months.

Objectives: To observe whether DVT prophylaxis has been appropriately initiated in all patients getting admitted to ICU, the reason for delays in initiation and discontinuation, the complications for a period of 2 months in the multidisciplinary ICU at a multispecialty hospital in south India.

Materials and methods: We included all adult medical and surgical cases getting admitted to our ICU during the months of September and October of 2020. Data collection included the patient demographics, comorbidities, the reason for ICU admission, DVT risk factors, date of initiation of prophylaxis, whether mechanical or pharmacological or both, if mechanical the reason, if pharmacological the drug used, the reason if any discontinuation during the ICU stays and the complications such as bleeding from any site.

Results: We had total of 105 patients admitted to ICU in the two months of which 74 were medical and 31 were surgical cases. 38 of them had mechanical prophylaxis, 11 had pharmacological and 56 had combined prophylaxis. Average duration for initiation of prophylaxis from admission was 2.19 days for the neurosurgical and trauma patients and as low as 1.2 days for rest of the ICU patients. Total number of missed days were 41 days and the reason for withholding chemoprophylaxis was mostly for some surgical interventions, predominantly for tracheostomy. Complications recorded were predominantly bleeding and was seen in 9 patients. Of them 4 were Endotracheal bleed, one each of hematuria, Malena, gum bleed, central line ooze and minimal nasal bleed.



20. Transport of Critically Ill Patients: Experience from a Tertiary Care Teaching Hospital. (Conference Abstract ID: 37)

Anand Kumar Singh, Banani Poddar, Arvind Baronia

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.106

Introduction: Intrahospital transport of critically ill patients is often necessary for optimal patient care. Adverse effects during and after transport of critically ill patients are frequent. On the other hand, a change in patient management results from about half of the procedures that necessitate transport, indicating good efficiency.


Materials and methods: Design: Prospective observational study. Setting: 20 Bed ICU of the department of critical care medicine, SGPGIMS, Lucknow. Consecutive patients requiring transport to radiological imaging and intervention radiology during the first 28 days of hospital admission were included. Data were collected at the time of transport by the doctor accompanying the patient. Description of the indication, number, duration, organ supports during transport, complications, diagnostic and therapeutic benefits are presented. Data were presented as median (interquartile range) or as number (percentage). Pretransport vital parameters and blood gas were noted and equipment was checked for proper functioning. After confirmation from the radiology department, the patient was shifted with a transport monitor, resuscitation equipment, emergency drugs, and oxygen cylinder. Our team to transport such patients includes one doctor, one staff nurse, and two patient helpers, and the patient is continuously monitored. Any adverse events during the intrahospital transport were noted by the escorting intensivist. Vital signs and oxygen saturation were monitored before and during the transport and post transport, vital signs and arterial blood gases were checked. Patients’ Glasgow coma scale (GCS), Richmond agitation sedation score (RASS), vasopressor inotropic score (VIS), and mechanical ventilator setting will be noted both before and after transport. An adverse event was defined as either a physiological deterioration or equipment related mishap that occurred during transport. Physiological deterioration during transport was defined as significant changes in vital signs, oxygen saturation, or hypotension. A significant change is considered a change in heart rate or blood pressure by 20%, oxygen saturation by 5%, any increase in vasopressor dose or sedation requirement. Statistical analysis: The following were computed using descriptive statistics: demographic data and severity of illness of patients requiring transport, number of transports per patient, duration of transport, and adverse effects. Data were presented as median (interquartile range).

Results: 104 patients of median age 49 years (35–60) were transported from May 2019 to June 2020; 62% were male. The median admission APACHE II score was 24 (IQR 16–28) and median SOFA score of 10 (IQR 7-14). Organ failures at admission were single organ in 19, 2 organ failures in 24 and >2 organ failures in 61. The admission diagnoses of the patients were acute pancreatitis in 28 (26%), cerebrovascular accident in 12 (11%), liver failure in 11(10%), tropical illness in 11(10%) and others in 42 (40%). 104 patients required 152 transports, the commonest being for abdominal CT imaging [57 (38%)]. 47 (31%) patients required multiple transports: 2 in 36 patients, 3 in 11 patients. The SOFA on the day of transport was 14 (10–16). The median day of transport from day of admission was 12 (6–21). The median duration of transport was 35 min (30–45). The organ supports provided during transport included oxygen support in 28 (18%), mechanical ventilation in 110 (71%), vasopressors in 76 (49%). Bolus of sedation was administered in 62 (40%) transports. Physiological worsening was seen in 70 transports; hemodynamic in 39 (25%) and corrected by vasopressor increase in 74 (48%), and respiratory in 34 (22%). Organ supports were provided in 141 (92%) transports; respiratory supports in 140 (92%) and vasopressor supports in 75 (49%) patients and 11 (7%) patients required no organ supports. These transports were beneficial in 150 (98%); all the transports were of diagnostic benefit while therapeutic benefit was obtained in 140 (94%).The procedure was cancelled in 2 due to physiological instability (major adverse event); 5 transports had minor equipment malfunctions.

Discussions: We were able to safely transport critically ill patients with a median SOFA score of 14. All successful transports were of benefit in patient management suggesting good planning and assessment of the risk-benefit ratio. The American College of Critical Care Medicine published guidelines for the safe intrahospital and interhospital transport of critically ill patients. Monitoring during transport is necessary. This includes, at a minimum, continuous electrocardiographic monitoring, continuous pulse oximetry, and periodic measurement of blood pressure, pulse rate, and respiratory rate. In addition, selected patients may benefit from capnography, continuous intra-arterial blood pressure, pulmonary artery pressure, or intracranial pressure monitoring. Each institution should have local guidelines for the transport of critically ill patients which covers key aspects including pretransport communication, personnel, equipment, monitoring, and documentation. They concluded that patient safety is enhanced during transport by organized efficient process supported by appropriate equipment and personnel.

Conclusion: Safe transport was possible in 98% of critically ill patients with high severity of illness. The therapeutic and diagnostic benefit was obtained in 97% of transports.

21. Can POCUS (Point of Care Ultrasound) Replace Conventional Chest X-ray for Confirmation of Above the Diaphragm Central Venous Catheter Placement? A Prospective Observational Study. (Conference Abstract ID: 17)

Anjali B Parmar, Shruti V Sangani, Chirag J Patel

B. J. Medical College, Civil Hospital Campus, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.107

Introduction: Central venous catheterization (CVC) is an important procedure in the emergency department (ED) and it is very useful in patients who require vasoactive medications, hemodynamic monitoring, or sometimes multiple drug infusions. Although CVC is done routinely, sometimes it is associated with complications like catheter tip misplacement (5–9%), pneumothorax (PTX; 0.1–3%), and arterial puncture (3–9%),1–4 despite being made safer through ultrasound (US) guidance.5–8 Traditionally, a chest radiograph (CXR) is performed after postprocedure for CVC confirmation and to rule out pneumothorax. The primary objective of this study was to assess if the point of care ultrasound (POCUS) could more rapidly confirm CVC tip position than standard portable CXR in ED. We hypothesized that POCUS confirmation of CVC placement would be faster than that of CXR confirmation.

Objectives: Rapid vascular access is often required during resuscitation and hence central venous catheter (CVC) placement is a common procedure in the emergency department. Conventional chest radiography is the standard method to confirm CVC placement and exclude complications but is time-consuming thus delaying the use of CVC. So we decided to carry out a study to determine whether POCUS (point of care ultrasound) can be used instead of a chest radiograph (CXR) for confirmation of above the diaphragm CVC placement or not.

Materials and methods: Prospective observational study was done on 100 adult patients who required emergency supradiaphragmatic CVC placement. POCUS was used for placement as well as to see the appearance of turbulent flow in the right atrium when the CVC was flushed with 10 mL agitated saline thus confirming its position. Bilateral thoracic cavities were scanned to rule out any pneumothorax. A portable chest radiograph was advised once CVC was placed. Time is taken for CXR and POCUS, detection of catheter malposition, and associated complications were assessed, charted, and compared using p value.

Results: 100 patients were enrolled and included in the final analysis. POCUS time was 3.17 ± 1.34 (mean ± SD) minutes compared to 35.91 ± 17.23 minutes for CXR performance with a mean difference of 32.7 minutes making it statistically highly significant (P˂0.0001). No catheter malposition or any complication was recorded in our study. Confirmation by both methods was comparable in detection of catheter malposition and complication.

Discussions: Some of the traditional methods to check the endovenous placement of CVC are as follows:11 Aspiration of dark blood in the syringe after puncture of the vessel suggesting venous blood, absence of pulsatile flow from syringe hub giving indirect evidence that a punctured vessel is not an artery, ABG analysis of the aspirated blood, pressure waveform analysis by pressure transducer for invasive monitoring, pressure waveform analysis by simple tube manometry, identification of guidewire in the right atrium by trans-esophageal echocardiography (TEE) and fluoroscopy with simultaneous injection of contrast. All these methods are associated with some of the other advantages and disadvantages ranging from time, cost, accuracy, and availability. In an emergency situation, the most important information regarding a recently placed central venous catheter is proper placement in the venous system and exclusion of pneumothorax. By using POCUS with a saline flush, it is possible to both confirm the venous placement of the catheter and rule out iatrogenic pneumothorax. Mehrdad et al. also described a similar study in which the saline flush method with POCUS was found safe, accurate, and rapid bedside method for CVC confirmation as compared to CXR.

Conclusion: POCUS can confirm CVC placement and also helps in ruling out pneumothorax faster than conventional chest radiograph thus expediting the use of CVC in critically ill patients of the emergency department.

22. Challenge in Reverse Triggering: Matching the Neural Pace (Conferrence Abstract ID: 200)

BG Manjunath, Sateesh Chandra Alavala, Sushmita Jakka, Pawan Kumar Singh, Diksha Tyagi, Dhruva Chaudhry

DOI: https://doi.org/10.5005/jp-journals-10071-23711.108

Objectives: Reverse triggering (RT) is a type of patient-ventilator interaction characterized by mechanical insufflations triggering diaphragm contraction. Identification of RT is important for its clinical consequences including ventilator-induced lung injury (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD). However, the correction of this asynchrony remains unknown. We hypothesized that RT occurs when the set ventilator RR (RRVENT) exceeds the spontaneous rate of the patient and it can be corrected by decreasing RRVENT.

Materials and methods: It was a prospective, observational study conducted in the medical and surgical ICU of a tertiary care hospital between August 2019 and December 2019. Reverse triggering was identified by real-time inspection of pressure and flow waveforms for their characteristic appearance in patients receiving invasive mechanical ventilator support with assist/control mode. Patients were included in the study if their ventilator waveforms showed RT at any point of time during their stay in ICU. Patients receiving neuromuscular blockers were excluded from the study. Demographic, clinical, and ventilator data were recorded in those patients who developed RT. Once the RT was identified, ventilator respiratory rate (RRVENT) gradually decreased without a change in other ventilator settings.

Results: A total of 54 patients were identified with RT during this period. Among these, 38 (76%) patients were receiving sedation when they developed RT. Reverse triggering was associated with double triggering in 37 (69%) patients. Reverse triggering disappeared in all patients when the RRVENT was gradually reduced (to an average of 14 breaths/minute, range 8–20) with no other changes in ventilator settings. When the RT disappeared, all breaths were patient-triggered breaths.

Conclusion: Reverse triggering may occur when the RRVENT exceeds the spontaneous rate. When the clinical situation allows a low RR, decreasing the RRVENT results in the disappearance of RT.

23. To Study the Outcome of Mechanically Ventilated Patients in Respiratory ICU. (Conference Abstract ID: 195)

Nida Choudhry, Lalit Singh, Rajeev Tendon

Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.109

Introduction: Background — The need for ventilatory support is one of the commonest indications for admission into the intensive care unit (ICU). Improving the outcome of mechanically ventilated patients remain a mission we all strive to achieve

Objectives: Aim — To study the outcome of mechanically ventilated Patients in Respiratory ICU — to provide baseline information for epidemiological trends, prognostic factors, and outcome of patients on mechanical ventilation calculated based on the duration of hospital stay, duration of ICU stay, number of days on ventilators, complications, mortality, followed till discharge.

Materials and methods: In this study, 412 patients were admitted to the intensive care unit of Shri Ram Murti Smarak Institute of Medical Sciences (SRMS IMS) at Bareilly Uttar Pradesh between November 2018 and April 2020. Two hundred and fifty patients were enrolled who fulfilled the inclusion and exclusion criteria.

Results: out of 412 patients admitted to the ICU, 250 patients received mechanical ventilation, either invasive (43%), noninvasive MV (41%) and 16% of the patients showed noninvasive failure and needed invasive ventilation. The commonest indication of MV was acute on chronic respiratory failure (74.8%). Chronic obstructive pulmonary disease was the commonest pre-existing lung disease (50.8%). Highest mortality was observed in renal disease (71%). Invasive mechanical ventilation was associated with high APACHE II score, SOFA score, low Glasgow coma scale, low admission Ph, PO2 and high PCO2 compared to non invasive MV. Duration of hospital stay and length of ICU stay was longer in NIV Failure. the highest risk of mortality, a cutoff point of APACHE II score and SOFA score was >30 and >18 respectively.

Discussions: In the present study, the indication of mechanical ventilation in all studied majority patients (IMV, NIV, NIV failure) was acute on chronic respiratory failure i.e., 33.7, 47.1, and 19.2%, respectively, followed by acute hypoxemic respiratory failure, i.e., 69.8, 22.2, and 8%, respectively, in all groups. In the present study, among survivors, the mean duration of IMV was 7.04 ± 3.02, whereas in NIV failure was 4.57 ± 2.89, which is statistically significant with a p value of 0.0008. Venkatesh Yadav et al.68 demonstrated the mean APACHE-II score and SOFA score of non-survivors was high as compared to non-survivors, the difference was statistically significant that means mortality increases with higher APACHE-II score and SOFA score.

Conclusion: APACHE-II and SOFA scores are a strong predictor of mortality because it helps to assess the severity of illness and bas chronic health status of the patients and also provided the prognostic information which was useful for the clinician to assess the outcome of patients admitted to the intensive care unit.

24. Intubation Practices in Trauma Triage: A Prospective Observational Study. (Conference Abstract ID: 194)

Anudeep Jafra, Kajal Jain, Sravani M Venkata, LN Yaddanapudi, SK Gupta

PGIMER, Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.110

Introduction: Hypoxia and obstruction of the airway are the major contributors to death following trauma. Hence, a definitive airway control, which may require endotracheal intubation, is an essential component of trauma resuscitation. Trauma Triage is generally manned by a team comprising of various levels of healthcare professionals. It is not only important whether a patient needs intubation but also when and how to intubate. There is a lack of data pertaining to intubation practices in trauma triage in India.

Objectives: Hence, the present study was conducted to describe the current practice of definitive airway management in the trauma triage of a tertiary hospital catering to northern India. The secondary objectives were to determine the success rate of endotracheal intubation by anesthesia and non-anesthesia residents, to describe the complications during securing the airway and to formulate recommendations based on the results of this observational study.

Materials and methods: This was a prospective observational study conducted at Trauma Triage of level 1 Tertiary Hospital over a period of 1 year. A specifically designed proforma was filled which included the patient’s detailed history of trauma, peri intubation vitals, indications for urgently securing airway, unfavorable conditions, the technique of intubation, medications used, and adverse events following intubation, and a number of attempts taken.

Results: The first attempt success rate of intubation by Anesthesia residents was significantly higher than Speciality residents (p = 0.0001; 95% CI 9.02–24.66). Airway injuries were most frequent complication (n =140, 32.8%) followed by hypotension (n = 57, 13.3%). Total of 99 patients received RSI in trauma triage during intubation by anaesthesia residents, amongst these 77 (77%) patients had no complications, 8% had airway related injuries, 4 (4%) had esophageal intubation, 5 (5%) developed hypoxemia and 3 (3%) had hypotension.

Discussions: These prospective observational data come from a tertiary care hospital of a low resource country on intubation practices in trauma victims over a period of 1 year. The first responders are usually non-anesthesia, specialty residents who cater to the immediate needs of the trauma victims. This reflects the different staffing levels and the limited expertise available on arrival to trauma triage. Through this study, it may be noted that although the level of experience met the current standards, there is a need to upgrade the skills of airway management using manikins and mandatory anesthesia rotation. Most of the intubations carried by anesthesia residents were drug-assisted along with the use of muscle relaxants which resulted in less complications and trauma. Literature supports the use of neuromuscular blockers in 62 to 77% of cases, with a strong association being reported between the use of neuromuscular blocking agents, especially depolarizing agents, and fewer adverse effects, as depicted by our results.

Conclusion: We observed that complication rates were more in patients intubated by non-anesthesia residents, use of a high dose of sedative agents like midazolam, and multiple attempts at intubation. Rapid evaluation of these factors and formal training in ATLS can lead to optimal management of the patient and decrease the rate of complications.

25. Respiratory Diseases in Adolescent Patients with Diabetes Mellitus. (Conference Abstract ID: 193)

Pradeep Singh Rajoriya, Ravi A Dosi

Sri Aurobindo Medical College and PGI Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.111

Introduction: Diabetes mellitus is a chronic, progressive, and incompletely implicit metabolic disease. Its associated micro- and macrovascular complications show the result in mortality and morbidity, The microvascular complications are manifested as neuropathy, retinopathy, nephropathy, and macrovascular complications affect the cardiovascular system. It also affects the lungs because of its rich vascularity and plethora in connective tissue (collagen and elastin), in a diabetic patient proliferation of extracellular connective tissue in the lungs, leading to a decline in lung function in a restrictive pattern. WHO has reported that the number of people with DM has risen from 108 million in 1980 to 422 million and 8.5% of the world adult population had DM in 2014. The number of diabetic patients worldwide has been expected to rise to 592 million in 2035 by the International Diabetes Federation. In this manner, I have been summarized and discussed the role of diabetes mellitus involved in the progression of common respiratory diseases in adolescent patients.

Keywords Diabetes mellitus, Respiratory disease

Objectives: To study respiratory diseases in adolescent patients with diabetes mellitus.

Materials and methods: The present study is a survey study that was conducted in the department of pulmonary medicine of Sri Aurobindo medical college and hospital, Indore. Data will be collected from the attending the OPD and IPD in the department of pulmonary medicine. All the participants were in the age group of 25 to 40 years. Duration of the study — from November 3, 2019, to March 19, 2020.

Results: We investigate 56 patients in the age group between 25 and 40 years. This study shows 31 (55.35%) male and 25 (44.61%) females.

Discussions: Diabetes is identified as an independent risk factor for developing lower respiratory tract infection there appear to be a certain type of respiratory infections that may be more common in diabetics patients. Diabetic patients also appear to be at an increased risk of complications like pneumonia, asthma, etc.

Conclusion: The study shows a high prevalence of infectious diseases such as pulmonary tuberculosis, asthma, and COPD in adolescent patients with DM.

26. Comparison of Early Bispectral Index Guided Postoperative Extubation Verses Extubation in Awake Patients in Neuro Intensive Care Unit. (Conference Abstract ID: 192)

Tushar Kumar, Pradip K Bhattacharya

Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.112

Introduction: Neurosurgical patients have a high risk of neurological complications in the immediate postoperative period increasing both morbidity and mortality. Extubation after uneventful intracranial surgery is tried to be as early as possible to avoid ventilator-associated complications. There are several scales and scoring systems to guide and assist early extubation. However, in neurosurgical patients, these scores may not be sufficient to provide enough data for confidant extubation. The objective of the present study is to compare bispectral index guided postoperative extubation vs extubation in awake patients using various neurological assessment scores in neurointensive ICU after craniotomy and excision of supratentorial space-occupying lesions.

Materials and methods: A total of 16 patients (ASAI-II), aged between 25 and 45 years, who were scheduled to undergo elective neurosurgery operation under general anesthesia and randomly divided into the BIS group (group II) and scoring group (group S), with 8 cases in each group. After satisfactory respiratory recovery patients were extubated. Oxygen saturation by pulse oximeter and HR were recorded before extubation (T0), (T1) at 1 minute, and 5 minutes (T2).

Results: Early extubation using bispectral index found to be significant with p < 0.04. during T1 and T2.

Discussions: Bispectral index assists better to make decisions for extubation than other scoring systems in postoperative neurosurgical patients for supratentorial space-occupying lesions. Kamali et al. showed that BIS reduces extubation time in post-CABG patients.

Conclusion: Using BIS monitoring during and after neurosurgery, it reduces the length of patients’ extubation in ICU.

6. Ethics, Brain Death, Organ Donation, and Transplantation

1. A Cost-benefit Analysis of a Flexible Bronchoscope Vis-À-Vis Life of a Doctor in COVID-19 ERA. (Conference Abstract ID: 52)

Abhishek Joshi, Manish Banjare

MGM Medical College, Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.113

Introduction: We aimed to determine whether single-use flexible bronchoscopes cost-effective when compared to the life of a doctor in this COVID-19 era. In our study, we have tried to study the incidence cross-infection of COVID-19 in doctors of MGM Medical College who used bronchoscope for any procedure.

Objectives: Primary objective: To do a cost-effective analysis of whether it is affordable to use disposable flexible bronchoscope compared to reusable flexible bronchoscope vis-a-vis the life of a doctor in the COVID-19 era.

Materials and methods: Study design: A Retrospective, Observational, Comparative Study. SAMPLE SIZE: Number of COVID-19 positive doctors who used bronchoscope in any procedure (172).

Inclusion Criteria: Doctors (Consultant and Residents) from 3 departments Anaesthesia, General Medicine and Pulmonary Medicine with special attention who contracted COVID-19 infection and Doctors who used Flexible Bronchoscope in COVID-19 patients.

Exclusion criteria: None.

Method: A systematic review of the literature, seeking all reports of cross-contamination or infection following use of reusable FB was done. We designed a simple questionnaire enquiring about basic and details of the doctor who has contracted COVID-19 infection. Then, we progressed in three steps. First, calculate the incidence of COVID-19 infection after reusable FB. Second, micro cost analysis of reusable FB in the clinical setting of our Medical College. Third, the cost of a doctor which nation bears to train a doctor (Rs 3–5 Cr). This produced an accurate estimate of the cost per use of reusable FB. For micro cost analysis, we simulated three scenarios depending upon the usage of a bronchoscope. Analyzing the above data.

Results: Cost of a doctor is difficult to calculate, however, minimum loss to nation is Rs3-5Cr 21% of the staff got infected after handling airways of COVID 19+ patient 1.74% of the staff became infected after doing procedure of bronchoscope (of the total) 14% of the staff who got infected were within 5 days of bronchoscope used 22% of the staff who became infected became seriously ill Cost of Disposable Flexible Bronchoscope is Rs 40000–60000. Whereas, cost of reusable bronchoscope varies with total number of use. High usage: (100 usage): large institutions: Government setup and corporate hospitals: it costs around Rs 24000 which is quite affordable. Medium usage: (50 cases): Midsize hospitals: it costs around Rs 28000 Low usage: (10 cases): small size hospitals: here the per procedure costs increases exorbitantly. It is around Rs 50000 Compared to single use flexible bronchoscope, in low usage (small size hospitals) cost is comparable. In case of large size hospitals, Cost is definitely high but if we take into account life of a doctor and incidence 1.74%. then, total cost of using reusable FB 100 times is 20–30 lacs (Rs 24000 × 100) plus cost of life of a doctor (i.e. Rs 3–5 Crores) which accounts to Rs 3–5 Crores. Whereas, single use bronchoscope if used 100 times will cost Rs 40–60 lacs.

Discussions: It is always up to the financial health of a hospital to choose particular medical equipment. But in our case, it is clearly justifiable to use Disposable FB in COVID-19.

Conclusion: It can be debated in private institutions where usage of the bronchoscope is not that high disposable FB will be more affordable and cost-effective. Cost per usage decreases with an increase in usage (government institutions and large corporate hospitals) but the probability of getting infected also increases. Which in turn increases the chances of doctors getting infected and out of those doctors increases the probability of seriously ill doctor also increases. The cost of using a disposable FB compared to reusable FB is slightly higher. However, seeing the cost that a nation bears in training a doctor and the loss of this doctor is beyond calculation.

7. Imaging in Intensive Care

1. Ultrasound-guided Central Vein Cannulation in COVID Positive Patients in ICU. (Conference Abstract ID: 188)

Roshni Tripathi, Sangita N Parikh

SVP Hospital, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.114

Introduction: Traditionally, central lines are put blindly using anatomical landmarks, which often result in complications, such as, difficulty in access, misplaced lines, pneumothorax, bleeding from inadvertent arterial punctures, etc.

Objectives: To perform a study regarded

Materials and methods: Twenty-five critical care patients at the intensive care units of SVP Hospital, Ahmedabad, who needed central venous cannulation, with informed written consent.

Results: Out of 25 patients, all (100%) cannulated successfully. In only 1 patient, carotid artery was punctured and was cannulated in second attempt.

Discussions: After three or more attempts at insertion, mechanical complications increase by six times compared with a single attempt. In the USG-guided approach, most patients are cannulated in the first attempt compared to a conventional method. In the USG technique, access time required is much less. In most patients where Trendelenburg’s position may be difficult where USG comes like a gift.

Conclusion: We came to the conclusion that the USG approach took less time, required less attempts, and had a lower incidence of complications for cannulation of the internal jugular vein as compared to a conventional method.

2. Comparison of Ultrasound-Guided vs Blind Arterial Cannulations in Critically Ill Patients: A Prospective Randomized Study From a Tertiary Care center. (Conference Abstract ID: 124)

Shreyas Gutte, Afzal Azim, AK Baronia, Banani Poddar, Mohan Gurjar, Prabhakar Mishra

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.115

Introduction: Arterial line cannulation is required in acute care settings for hemodynamic monitoring, frequent arterial blood gas analysis, and repeated blood sampling for laboratory evaluation.1 Point of care ultrasound (USG) is now the preferred technique for all invasive cannulations in intensive care settings. However, there is a paucity of literature to recommend USG-guided arterial cannulations in the intensive care unit (ICU).

Objectives: The primary objective of this study was to compare the first attempt success rate for blind vs USG-guided for radial, femoral, and dorsalis pedis artery cannulations in ICU patients. Secondary outcomes were to assess time for cannulations, number of attempts, complications, comparison of two techniques on patients requiring vasopressor.

Materials and methods: Design: Prospective randomized study from June 2019 to June 2020 conducted in a 20-bedded general-purpose ICU of a tertiary care center. After taking Institutional Ethical Committee approval and CTRI registration, patients were randomized to either blind or USG groups. Inclusion criteria were adult patients (age >18 years) admitted in ICU requiring continuous arterial pressure monitoring. Exclusion criteria included patients admitted with a preexisting arterial catheter, age <18 years, patients cannulated with other than 20 G for radial and dorsalis pedis artery. Randomization was done using a computer-generated table. Cannulations were done by intensivists with experience of >20 arterial USG cannulations and traditional technique cannulation in the radial artery, femoral, and dorsalis pedis artery. All cannulations were done by trainees in intensive care who had done post-graduation in anesthesiology and internal medicine.

Technique of cannulations: Blind method: For radial and dorsalis pedis arterial cannulations, the artery was palpated and punctured at the site of maximal pulsation. Then, a 20 G BD Venflon Pro IV Cannula was advanced over the needle till the flash of blood is seen in the hub of the cannula. For femoral artery cannulation, the artery was palpated and punctured at the site of maximal pulsation, and a 16 G (5 French) ARROW® REF CV-50016 cannula was placed by Seldinger technique. USG technique: For radial and dorsalis pedis artery after preparing the transducer with a sterile cover, the artery was identified using USG with a linear transducer in short-axis view. Approximately 0.5 cm distal to the probe, a 20 G BD Venflon Pro IV Cannula was introduced and advanced at 15 to 300 to skin until the tip of the needle was seen in contact with the anterior wall of the artery. The needle was advanced till blood appears as a flash in the hub. Then, the catheter was advanced over the needle. For femoral artery cannulations, the artery was identified using USG with a linear transducer in short-axis view, 16 G ARROW REF CV-50016 cannula was inserted using Seldinger technique (USG machine — Sonosite Micromaxx ultrasound machine, linear probe). Time calculation: For the traditional blind palpation technique, time taken from palpation of the patient artery to arterial line placement, i.e., when the catheter was successfully placed into the vessel was noted. In the ultrasound group, time taken from the USG machine is turned on and after application of gel on the transducer till the end of arterial line placement into the vessel. The total time taken for an insertion was calculated in seconds. If there was a failure to cannulate on third attempt the clinician was asked to change the site. Additional data collected included demographic profile, attempts for successful cannulations, any complication (hematoma, thrombosis, infection, and vasospasm), number of the cannula used, and vitals before and after cannulations and dose of vasopressor. Statistical analysis included chi-square, Mann–Whitney. A p value < 0.05 was considered statistically significant. Statistical package for social science version 23 (SPSS-23 IBM, USA) was used. The sample size was estimated using a software “Power analysis and sample size version 8 (PASS-2008)”. Group sample sizes of 94 in group 1 (USG-guided) and 94 in group 2 (blind arterial cannulations) achieve 80% power to detect a difference between the group proportions of 0.20 (i.e., 20%).

Results: 201 patients were enrolled into the study with 99 randomized to the Blind group and 102 to the USG group. Demographical characteristics ( Age, Sex, Body Mass Index) in both groups were comparable (p > 0.05). An arterial line was placed on the first attempt in 82(80.4%) in the USG group versus 58(58.6%) in the Blind group (p = 0.02). Time for cannulation (seconds, Mean ± SD) in USG group was significantly reduced compared to blind group in radial, femoral and dorsalis pedis artery [Radial artery: USG 162 ± 6.0, Blind 190.3 ± 7.5, p < 0.001; Femoral artery: USG 184 ± 6.0, Blind 212 ± 3.8, p < 0.001; Dorsalis pedis artery: USG 161.2 ± 1.65, Blind 188.4 ± 3.9, p < 0.001] Complication (subcutaneous hematoma) in both groups was comparable [USG 2(1.9%) vs. Blind 1(1.01%), p ≥ 0.05]. Number of cannula used were significantly reduced in USG group (p = 0.019). Arteries (Radial, Dorsalis pedis, Femoral) cannulated in both groups were also comparable (p = 0.193). Number of patients who were on vasopressor support in both groups were comparable [USG 69(67.6%) vs. Blind: 61(61.6%), p > 0.05]. First pass success rate in patients with vasopressor was also significantly more in USG group [USG 53(76.8%) vs Blind 36(59.1%), p 0.05]. Vitals before cannulation in both groups were comparable (p > 0.05)

Discussions: Studies for USG-guided arterial cannulations are mostly from perioperative and emergency department (ED) settings.1,2 USG-guided arterial cannulations have shown a high first-pass success rate similar to our study.3 This technique has also reduced the time to cannulate.2 To the best knowledge of authors, our study in ICU settings is the first of its kind which has compared USG-guided arterial cannulations with a traditional approach at three different sites in critically ill patients.

Conclusion: USG-guided arterial cannulation has a higher first-pass success rate in critically ill patients including patients with septic shock with less cannulation time as compared to the blind palpation method.

3. Use of Lung and Diaphragmatic Ultrasound in Predicting Successful Weaning Outcomes in Critically Ill Mechanically Ventilated Patients. (Conference Abstract ID: 72)

Kiran Vadapalli, Prashanth Jedge, Jignesh Shah, Shivakumar Iyer, Shambhavi Chauhan, Venkatesh Satri, Nishanth Agarwal

Bharati Vidyapeeth Medical College, BVDU, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.116

Introduction: To study the use of lung and diaphragmatic ultrasound in predicting successful weaning outcomes in critically ill mechanically ventilated patients.

Materials and methods: This is a prospective observational study conducted at the Department of Critical Care Medicine, Bharati Hospital, Pune. The study period was May 2020 to November 2020.

Study population: Patients admitted to the intensive care unit for medical and surgical causes and are mechanically ventilated for >24 hours.

Methods: All the medical and surgical patients admitted in the intensive care unit and ventilated for >24 hours and are deemed to be ready to be weaned are enrolled after getting written informed consent from the next-of-kin. The decision to wean is clinical and not influenced by the study. After the patient is assessed for readiness to wean, the patient undergoes a spontaneous breathing trial for 2 hours with CPAP PSV Mode (PS-8, PEEP-5, and FiO2-40%). If the patient passes the SBT and is planned for weaning, lung USG and diaphragmatic USG are performed on the above ventilator settings. The weaning trial whether successful or failed is assessed and patients are grouped as simple weaning and complicated weaning (difficult/prolonged/failed weaning). The lung ultrasound score and diaphragmatic thickness fraction are correlated with weaning outcome. These measurements were performed by a single intensivist experienced in performing lung and diaphragmatic ultrasound. Lung USG is done with a curvilinear probe. Six regions in each hemithorax — anterior, lateral, and posterior (12 in total) are screened and scored as per international validated score — the lung ultrasound score — 0 to 36. Score 0 — Normal aeration, 1 — >2 well-defined B lines, 2 — Coalescing B lines, 3 — Pulmonary consolidation. The diaphragmatic thickening fraction (%) will be calculated as the difference between inspiratory diaphragmatic thickness (DT i) and expiratory diaphragmatic thickness (DT e) divided by DT e × 100.

Results: 30 patients were enrolled in the study out of which 19 were males and 11 were females. The mean age of the presentation was 48.03 + 13.48 years. Out of the 30, 12 patients were admitted with medical illness (40%) and 18 with surgical illness (60%) at presentation. Major diagnosis at presentation were categorised into Sepsis 8 (27%), Neurological 13 (43%), Cardiovascular 2(7%), Respiratory 3(10%), Gastrointestinal 2(7%) and Gynaecological 2 (7%). The predominant source of sepsis was Respiratory. The predominant indication for mechanical ventilation was respiratory in 11 (37%), CNS in 12 (40%), combination in 4 (13%), and others in 3 (10%). The mean APACHE II score at presentation was 11.70 + 5.38 and the mean SOFA score was 2.77 + 1.83. The mean duration of mechanical ventilation is 6.27 + 5.01 days. Out of 30 patients, final outcome of discharge from the hospital was 25 patients (83.33%) and death in 5 patients (16.7%). Simple weaning occurred in 23 (77%) of patients whereas 7 (23.3%) had complicated weaning. In complicated weaning difficult weaning occurred in 3, prolonged in 1, and failed weaning in 3 patients. Lung ultrasound score with a cut-off of 16 and below was associated with successful weaning from mechanical ventilation with 85% sensitivity and 69 % specificity with an AUC of 0.82 with a p-value of 0.0001. Diaphragmatic thickness fraction has not shown to be correlating significantly with weaning outcome in this study.

Discussions: Lung ultrasound by its direct visualization of aeration can directly visualize the lung pathology. Hence, its score has been shown to correlate well will weaning outcome. Limitations of the study include a single-centered study, done by a single observer and the sample size is small for definitive conclusions.

Conclusion: Lung ultrasound score before weaning could be used as a marker to predict successful weaning.

4. Serial Bedside Ultrasonography for Estimating Urinary Bladder Wall Thickness as a Predictor for Catheter-Associated Urinary Tract Infection in Critically Ill Patients: A Reliable “Cut-Off” Finding Study. (Conference Abstract ID: 70)

Badri Prasad Das, Munesh Gupta, Jayadev Kumar

IMS BHU Varanasi, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.117

Introduction: Indwelling catheters are used routinely in ICUs, which commonly leads to urinary tract infections (CAUTI). Now, diagnosing CAUTI in critically ill patients is a challenge, as most of them are not able to vocalize (suprapubic tenderness), and the diagnostic modalities (C/S) cannot differentiate colonization from CAUTI. It is needless to point, how time is crucial in diagnosing, hence, an unmet need of developing a quick/accurate/objective method of screening/diagnosing CAUTI. Now, we all have a portable USG machine in our ICU, which was never explored for screening or diagnosing CAUTI in ICU. With this background, we have proceeded with an aim to evaluate bladder wall thickness (BWT) with serial bedside ultrasonography in catheterized critically ill patients as a tool to predict CAUTI.

Materials and methods: After ethics committee approval and written informed consent from relatives, a single-centric, prospective, observational cohort study was conducted from March 2019 to February 2020 in ICU, Department of Anesthesia, IMS-BHU, where consecutive adult patients aged 20 to 50 years, admitted with any critical illness, were enrolled into the study and assessed for eligibility (without prior catheterization/UTI, requiring ICU stay for >5 days, requiring urinary catheterization within 2 days of admission, for a period of at least 3 days). All eligible patients were evaluated for bladder wall thickness (BWT), both in the empty bladder (BWTe) and full bladder after 250 mL normal saline instillation (BWTf) as per protocol, with serial bedside ultrasonography (curvilinear probe-3.5 MHz) over a stretch of 21 days or till the patient was in ICU [on day of ICU admission (day 1), then D3, D5, D7, D10, D14, D17, D21, and whenever there was fever (with fluffy sediments in high colored urine)]. Also, urine cultures were sent on those from D3 onward as per protocol or whenever there was fever with suspicion of UTI, the corresponding reports of which were received after 5th to 7th day. Those “BWT values” were allocated into one of the three cohorts based on urine/culture reports [CAUTI group; significant-colony-count (>105) but without CAUTI (CCS group); insignificant-colony-count (CCI group)]. Demographics, SOFA/APACHE, ventilator-days, ICU-LOS, survival rates were noted. Primary outcomes noted were the performance of BWT to predict (screen/diagnose) CAUTI using receiver operating characteristics curve (AUC-ROC) and to find out reliable “cut-off” with highest sensitivity/specificity. Also, correlation of BWT measurements with urine culture reports (CAUTI/colonization/insignificant-colony-counts) and 30-day mortality were noted. Secondary outcomes noted were the incidence of nosocomial UTI (bacterial/fungal). Chi-square/Student’s t-test was used for qualitative/quantitative data with statistical significance at a p value ≤0.05.

Results: Demographic parameters were comparable in the 3 cohorts. There were total of 1242 evaluated “BWT values” obtained on 180 enrolled patients, [476 values in CAUTI group, 362 values in significant colony count but without CAUTI (CCS group), 404 in insignificant colony count (CCI group)]. Mean BWTe in CAUTI group was 5.54 mm ± 1.95 mm vs 4.12 ± 1.62mm in colonization group vs 3.42 ± 1.54 mm in CCI group), p = 0.002. BWT>5.54 mm had a good positive correlation with CAUTI with Spearman’s coefficient of +0.834 with better correlation in empty bladder(BWTe) than in 250 mL filled bladder (BWTf).

Discussions: The reliable cut-off value of BWTe for diagnosing CAUTI was 5.6 mm with highest AUC-ROC (mean 0.887, 95% CI 0.863–0.942) with 91.2% sensitivity and 78% specificity, PPV 88.8% and NPV 85.2%. At the optimum cut-off defined at 3.8 mm, NPV was 100%, PPV was also high (95.2%) with AUC-ROC (mean 0.872, 95% CI 0.822–0.980) with 89.4% sensitivity and 76.2% specificity. Incidence of CAUTI was 38%.

Conclusion: Bladder wall thickness with serial bedside ultrasonography is not only simple, noninvasive, and reproducible but quite a reliable objective method to predict CAUTI in critically ill patients, which may increase diagnostic accuracy for screening outpatients with CAUTI from colonization, with attributes of performance being best in the empty bladder as compared to a full bladder, with cut-off value of 5.6 mm.

5. Use of Handheld Ultrasound Device with Artificial Intelligence for Evaluation of CardioRespiratory System in COVID-19: A Prospective Study. (Conference Abstract ID: 65)

Shivangi Mishra, Harish Mallapura Maheshwarappa, Muralidhar Kanchi

Mazumdar Shaw Medical Center, Narayana Health City, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.118

Introduction: COVID-19 causes various cardiopulmonary manifestations. Bedside point of care ultrasound helps in the rapid diagnosis of these manifestations. Vscan Extend (GE, Wauwatosa, WI, US) is a handheld ultrasound device with a dual probe and an artificial intelligence application to detect ejection fraction. It can help in reducing the time for diagnosis, duration, and number of HCW exposed to COVID-19.

Objectives: This is a prospective observational study comparing the cardiorespiratory parameters assessed by Vscan Extend with the conventional ultrasound machine. This evaluates the safety and accuracy of Vscan Extend and its utility in reducing the time duration for diagnosis.

Materials and methods: Paired observations were made in 96 COVID-19 patients admitted to the intensive care unit by two intensivists. Intensivist A used the Vscan Extend device to assess the cardiac function, lung fields, diaphragm, deep veins, and abdomen. Intensivist B used routine investigation tools like clinical examination, X-ray chest, ECG, and conventional echocardiogram. The agreement between the findings and the time duration required in both the methods was compared.

Results: The median duration of examination using handheld ultrasound was 9 (8.0–11.0) minutes, compared to 20(17–22) minutes with the conventional method (P < 0.001). The Cohen Kappa Coefficient was 1.0 for LV systolic function, most of the lung fields and diaphragmatic movement.

Discussions: The use of handheld ultrasound has significantly decreased the time required for bedside examination of patients than the conventional method. The agreement was perfect between both the methods for systolic function, lung fields, and diaphragmatic movement.

Conclusion: Vscan Extend handheld device helps in the rapid identification and diagnosis of cardiopulmonary manifestations in COVID-19 patients. The agreement between the handheld device and the conventional method proves its efficacy and safety.

6. Experimental Chest X-ray Scoring System for Determining Patient Outcomes in COVID-19 Patients. (Conference Abstract ID: 21)

Nishant Agrawal, Prashant Jedge, Shivakumar Iyer, Jignesh Shah, John Dsouza, Samruddhi Chougale

Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.119

Introduction: Coronavirus disease 2019 (COVID-19), caused by a novel virus — the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a worldwide pandemic now. This new virus is a beta coronavirus that belongs to the Orthocoronavirinae subfamily of the Coronaviridae family.1,2 SARS-CoV-2 was discovered to be the pathogen responsible for a cluster of pneumonia associated with severe respiratory disease.3 Currently, >200 countries, territories, or areas are affected by this novel infectious disease (World Health Organization, 2020) after it first began in Wuhan, China in December 2019. On October 23, 2020, the overall number of confirmed COVID-19 cases was 41,570,883 worldwide, with a confirmed number of 1,134,940 deaths (World Health Organization, 2020).4 Given the recent estimates of mortality rate for COVID-19,5 clinicians should be aware of all the risk factors leading to a fatal outcome. The literature reports that older age and presence of comorbidities (such as hypertension, diabetes, and cardiovascular disease), certain laboratory parameters, and severity of lung abnormalities are associated with an increased risk of mortality in patients with SARS-CoV-2 infection.6 At present, chest computed tomography imaging is considered the most effective method for the detection of lung abnormalities in early-stage disease and for quantitative assessment of severity and progression of COVID-19 infection.3,7 Although chest X-ray (CXR) is not considered sensitive enough for the detection of pulmonary involvement in the early stage of the disease,3,8 Bhorgesi et al.9 believe that, in the current emergency setting, CXR can be a useful diagnostic tool for monitoring the rapid progression of lung abnormalities in infected patients, particularly in intensive care units though the most effective method of detecting lung abnormalities is computed tomography (CT) imaging especially in the early stage of the disease. Although chest radiography has low sensitivity (about 69%) for the diagnosis of COVID-19, the utility of initial CXR on predicting clinical outcomes is an unmet need.10 To improve the risk stratification for infected patients, a chest X-ray (CXR) scoring system has been developed for quantifying and monitoring the severity of lung abnormalities in patients with COVID-19. This CXR scoring system (named the Brixia score) grades lung abnormalities due to COVID-19 on an 18-point severity scale.9 To the best of our knowledge, there are very few studies evaluating the predictive value of a CXR scoring system in patients with COVID-19. Therefore, this study aimed at comparing the novel CXR severity score, scored by an experienced radiologist with mortality, in ICU patients with moderate-severe COVID-19 pneumonia (patients with SpO2 <94%), as CT imaging could not be done for all patients, as our hospital is a large teaching hospital with just one CT machine available and hence becomes difficult to carry out the same on a routine basis.

Objectives: To determine the validity of a CXR scoring system in measuring the outcome for patients infected with COVID-19.

Materials and methods: This is a retrospective study carried out over a period of 4 months from April 1, 2020, to July 31, 2020, at a tertiary care hospital, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, India.

Inclusion criteria: All consecutive COVID positive patients admitted to the intensive care unit and requiring oxygen in the form of HFNC, non-rebreathing mask with 15 L of O2/minute, NIV or invasive ventilation, were selected and their baseline X-ray taken on admission was scored.

Exclusion criteria:

Methods: On admission, the patient’s detailed history was noted and they were examined in the intensive care unit. Their baseline X-rays were scored by a radiologist who was blinded to the patient’s details as well as to the final outcomes and the validity of the scoring done was evaluated against the two outcomes of the patient — discharge or death. The gender of the patient was correlated with his/her outcome. The CXR scoring system used for COVID-19 pneumonia included two steps of imaging analysis.9 The first step was to divide the lungs into six zones on frontal chest projection (anteroposterior projection according to the patient position):The next step was to assign a score (from 0 to 3) to each zone based on the lung abnormalities detected on frontal chest projection as follows:The scores of the six lung zones were then added to obtain an overall “CXR SCORE” ranging from 0 to 18.

Statistical analysis: All statistical analyzes were done by using SPSS software version 25.0. Results of the continuous variables are shown by descriptive statistics and categorical variables are shown by frequency and percentages. Group comparison was done using the chi-square test for categorical variables. An independent t-test was used for continuous variables with a normal distribution. Throughout the results, 5% level of significance was used. All results are shown with 95% of confidence. p value <0.05 was considered as significant.

Results: In our study, out of 143 patients who were assessed for eligibility,13 were excluded making our final sample size 130. Out of 130 patients, 79 patients died whereas 51 patients were discharged. Amongst the patients who had died, the mean age was 57.09 years with a SD of 13.73 and the mean CXR score was calculated to be 12.13 with a SD of 2.50. Amongst the patients who were discharged, the mean age was 53.94 years with a SD of 13.46 and the mean CXR score was calculated to be 11.18 with a SD of 2.30. When the CXR scores were compared with the outcomes, the t value was found to be 2.20 and the p value was calculated as 0.03 which was statistically significant. In our study, 70.8% patients included were males and the rest 29.2% were females. On comparing the gender of the patients with their outcomes using the chi square test, the p value was calculated to be 0.222 which was non- significant.

Discussions: The CXR scoring system has been designed exclusively for semi-quantitative assessment of the severity of pulmonary involvement in patients admitted with COVID-19 pneumonia. It is quite a simple method and can be easily duplicated in other clinical scenarios. The mean age in our study was higher in the death outcome group which is in accordance with various studies like Ruan et al.,11 Wang et al.,12 Yuan et al.,13 and Zhou et al.14 which have shown an association between older age and poor prognosis in patients with COVID-19. The p value for CXR scoring on correlating it with the outcome was found to be significant which implies that this scoring system can be used for the accurate prediction of the outcome for a COVID positive patient. This is in accordance with various studies like Bhorgesi and Malrodi9, Tossie et al.,15 Garg et al.,16 and Lighter et al.17 In our study, the p value for gender correlation with outcomes was found to be non-significant implying that mortality rates were the same in both sexes. This is in contrast with a study done by Bhorgesi et al.,6 which showed mortality to be higher in males compared to females. The major strength of our study is a large sample size. Our study is one of such studies that have assessed the effectiveness of the CXR scoring system for forecasting the final outcome in terms of discharges and deaths in COVID-infected patients, although several studies like Bernheim et al.18 and Pan et al.19 have investigated the role of CT. The observer who was a radiologist in our study was blinded, in turn, decreasing the observer bias. The primary limitation is that only the initial chest radiograph severity score was used as an independent prognostic indicator of the final outcome. The second limitation in our study was the lack of long-term follow-up of the patients who got discharged. Hence, further studies are required to analyze the worsening opacities on the follow-up chest radiographs in relation to the final outcome of the patients.

Conclusion: Our study conferred that a high Brixia score was associated with a high risk of death due to COVID-19 and we contemplate this scoring system to be very apt as it provides very clear and to the point information for clinicians in this prolonged battle against COVID-19.

7. A Prospective Observational Study on E-Point Septal Separation for Assessment of Left Ventricular Ejection Fraction by Emergency Physician. (Conference Abstract ID: 19)

Boopathi M, Chirag J Patel

B.J. Medical College, Civil Hospital, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.120

Introduction: Assessment of LV function by point of care echocardiography is of particular importance in differentiating the causes of dyspnea, hypotension, and chest pain in patients coming to the emergency department. Mitral valve E-point septal separation (EPSS) is one of the methods for estimating left ventricular ejection fraction (LVEF) in the emergency setting. The rapidity of this test to assess left ventricular ejection fraction guide early diagnosis, clinical management, and evaluation of the critically ill patient.

Materials and methods: In our study, a total of 100 patients will be enrolled as per inclusion and exclusion criteria from February 2020 to July 2020 from the Emergency Department, Civil Hospital. A detailed history of the patient will be obtained and vitals will be recorded. The subject will be placed in the supine position. A phased array probe (2.5–5 MHz) will be used. EPSS is measured by direct ultrasound visualization of the heart in parasternal long-axis view. Using M-mode, the marker is placed over the most distal tip of the anterior mitral leaflet during early diastole. The E-point as mentioned represents the point at which mitral valve leaflets travel closest toward the ventricular septum. EPSS is the distance between E point and interventricular septum. EPSS measurement <7 mm indicated as normal LVEF and >7 mm indicated as reduced LVEF.

Results: A total of 100 patients participated in this study from February 2020 to July 2020. In 100 patients, 70 patients were diagnosed as normal LVEF by cardiologist with quantitative measurement. Remaining 30 patients were diagnosed with reduced LVEF. In our study LVEF assessed by using EPSS in emergency department 24 patients were diagnosed with reduced LVEF (EPSS more than 7mm) and 76 patients diagnosed normal LVEF (EPSS less than 7 mm). The sensitivity and specificity of an EPSS measurement of greater than 7 mm for systolic dysfunction were 100% and 80% respectively. PPV-92.1%, NPV-100%.

Discussions: This study demonstrates that EPSS measurements performed by ED physicians are strongly correlated with calculated LVEF assessments obtained by quantitative Simpson’s method. Our study agrees with those from McKaigney et al., which similarly showed a strong correlation between EPSS and LVEF performed on a subset of patients with breathlessness. Comparing the EPSS with the quantitative method better characterizes the relationship between the clinical standard for determining LVEF and those obtained at the point of service among ED patients.

Conclusion: Measurements of EPSS by ED physicians were significantly associated with the quantitative measurements of LVEF by Simpson’s method. An EPSS measurement >7 mm was uniformly sensitive at identifying patients with severely reduced LVEF.

8. Infections and Prevention—Infection Control

1. Respiratory Diseases in Adolescent Patients with Diabetes Mellitus. (Conference Abstract ID: 193)

Pradeep Singh Rajoriya, Ravi A Dosi

Sri Aurobindo Medical College and PGI Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.121

Introduction: Diabetes mellitus is a chronic, progressive, and incompletely implicit metabolic disease. Its associated micro- and macrovascular complications show the result in mortality and morbidity. The microvascular complications are manifested as neuropathy, retinopathy, nephropathy, and macrovascular complications affect the cardiovascular system. It also affects the lungs because of its rich vascularity and plethora in connective tissue (collagen and elastin), in a diabetic patient proliferation of extracellular connective tissue in the lungs, leading to a decline in lung function in a restrictive pattern. WHO has reported that the number of people with DM has risen from 108 million in 1980 to 422 million and 8.5% of the world adult population had DM in 2014. The number of diabetic patients worldwide has been expected to rise to 592 million in 2035 by the International Diabetes Federation. In this manner, I have been summarized and discussed the role of diabetes mellitus involved in the progression of common respiratory diseases in adolescent patients.

Keywords Diabetes mellitus, Respiratory disease.

Objectives: To study respiratory diseases in adolescent patients with diabetes mellitus.

Materials and methods: The present study is a survey study that was conducted in the department of pulmonary medicine of Sri Aurobindo medical college and hospital, Indore. Data will be collected from the attending the OPD and IPD in the department of pulmonary medicine. All the participants were in the age group of 25 to 40 years. Duration of the study — from 3 November 2019 to 19 March 2020.

Results: We investigate 56 patients in the age group between 25 and 40 years. This study shows 31 (55.35%) male and 25 (44.61%) females.

Discussions: Diabetes is identified as an independent risk factor for developing lower respiratory tract infection there appear to be a certain type of respiratory infections that may be more common in diabetic patients. Diabetic patients also appear to be at an increased risk of complications like pneumonia, asthma, etc.

Conclusion: The study shows a high prevalence of infectious diseases such as pulmonary tuberculosis, asthma, and COPD in adolescent patients with DM.

2. VACO Index to Risk Stratify the Geriatric Population with Suspected COVID-19 Infection. (Conference Abstract ID: 164)

Aravind Ranjan, Ashima Sharma

Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.122

Introduction: We have witnessed an unprecedented panic among the public on the non-availability of hospital beds during the first wave of the COVID pandemic. The geriatric population was the major sufferers, as resources were diverted to the younger or working generation. As emergency providers, we faced the challenge of using a screening tool to suspect the severity of disease progression for triaging patients to the correct level of the COVID facility.

Objectives: Risk Stratify Geriatric Population with Suspected COVID-19 Infection based on VACO INDEX.

Materials and methods: Two hundred and two consecutive patients above the age of 65 years were subjected to the calculation of the score using simple parameters like age, sex, history of DM, chronic pulmonary disease, renal disease, peripheral vascular disease, CHF, dementia, cancer, stroke, liver disease, MI, peptic ulcer disease, AIDS, and rheumatological disorder. The results of our study in detail will be discussed at the conference.

Results: We utilized the VACO index to calculate a score and keep the patients well informed. The information helped us to ration beds to them in critical care areas, especially during the times while rationing was limited.

Discussions: A 10% decrease in organ function is known to occur every decade after the age of 65. This means that it is unphysiological to apply the same parameters of qCSI across the whole population. We recommend the VACO index, which uses demographic and preexisting condition data and does not require immediate laboratory investigations.

Conclusion: We recommend the VACO index, which uses demographic and preexisting condition data and does not require immediate laboratory investigations. With constrained resources, a score to identify 30-day mortality with COVID infection at the time of the first contact with a patient helped us immensely to risk stratify our patients.

3. The Efficacy and Safety of Hydroxychloroquine in Treatment of COVID-19—A Systemic Review and Meta-Analysis. (Conference Abstract ID: 149)

Sakshi Duggal, Anirban Hom Choudhuri, Bhuvna Ahuja, Partha S Biswas

GB Pant Institute of Postgraduate Medical Education and Research, Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.123

Introduction: The treatment of SARS-CoV-2 (Severe Acute Respiratory Syndrome coronavirus 2) also known as COVID-19 (coronavirus disease 2019) continues to remain an enigma even after six months of the pandemic. Hydroxychloroquine (HCQ) has been one of the most widely tested drugs for SARS-CoV-2 on account of its antiviral properties. However, the results so far have been far from categorical. The meta-analyzes conducted to date are also lacking in precision and appropriateness. This systematic review and meta-analysis addresses the efficacy and safety of HCQ in SARS-CoV-2 by overcoming the limitations of earlier meta-analysis.

Materials and methods: A total of five prominent medical databases were searched and fourteen studies (n = 12,455) were included in the systematic review and meta-analyzes. The data on survival, alleviation of symptoms, conversion of RT-PCR positivity to negativity, use and efficacy in presence of comorbidities (hypertension, diabetes, and heart disease), and cardiac and gastrointestinal side effects were extracted. Meta-analysis was applied to calculate the pooled estimates. Fixed-effects model results were chosen since I2 was <25%. Meta-analysis was conducted using STATA version 13 (StataCorp LP, College Station, TX, USA).

Results: The pooled estimates showed that HCQ treatment did not significantly affect survival at 14 and 28 days in COVID-19 patients with respect to the control population (RR: 1.003, 95% CI: 0.98–1.02), alleviation of symptoms at day 10 (RR: 1.04, 95% CI: 0.91–1.19), success in presence of co-morbidities (RR: 1.06, 95% CI: 1.04-1.08) and conversion from RT PCR positive to RT PCR negative on day 6 (RR:1.12, 95% CI: 1.04–1.21). There was higher risk for cardiac side effects (RR: 2.01, 95% CI: 1.43–2.83) and gastrointestinal side effects (RR: 1.32, 95% CI: 0.73–2.38) in HCQ recipients.

Discussions: Our study is the most recent update on the safety and efficacy of HCQ in SARS-CoV-2 infection and an in-depth analysis of its survival benefits and alleviation of symptoms. This large systematic review and meta-analysis of 12,455 patients encompassing 14 studies has clearly demonstrated the lack of benefit of HCQ treatment for SARS-CoV-2 infection. It has additionally found higher cardiovascular side effects in the recipients of HCQ. It has assessed the benefits of using HCQ in the presence of heart disease, hypertension, and diabetes which no other meta-analysis has investigated so far. It has found that use of this drug is used more commonly in patients with these diseases but did not improve the outcome as compared to control.

Conclusion: There is no evidence on the safety and efficacy of HCQ either alone or in combination with other drug treatments in SARS-CoV-2 infection.

4. Analysis of Mortality in COVID-19 Patients Admitted to An Intensive Care Unit. (Conference Abstract ID: 148)

Kayanoosh Kadapatti, Jyoti Shendge, Aparna Kulkarni, Jayant Mane, Ranjeet Patil, Sushil Gandhi, Akshay Sonone, Ujjwal Deshmukh, Priyesh Rahulgade

Jehangir Hospital, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.124

Introduction: The COVID-19 pandemic has affected health care infrastructure worldwide. In the city of Pune, we had multiple general and private hospitals admitting COVID positive patients. Protocols and processes were set up as per the ICMR and local corporation guidelines. There were many challenges to manage these patients especially with the newness of the disease, rapidity of spread, the uncertainty of progress of patients with respiratory failure, and lack of physical communication with relatives. Challenges faced by the caregivers were manpower ratios possibly due to attrition and illness. Here, we analyze the mortality of patients with COVID-19 infection admitted to a tertiary care center.

Objectives: Death audit of COVID positive patients who expired in the ICU from April to December 2020 — a 9-month retrospective data analysis.

Materials and methods: A retrospective observational analysis of deaths due to COVID-19 infection from March to December 2020.

Results: 2012 COVID positive patients were admitted to a tertiary care for treatment of which 363 were either directly admitted or transferred into the ICU for moderate to severe/critical disease requiring NIRAD, IPPV or Organ support. 164 patients expired of which 25 died within 24-48hours. The gross hospital mortality from COVID19 disease was 8.17% while net mortality was 6.9%. 107 (65.2%) patients died of severe COVID and 57 (34.75%) perished due to critical disease. More males(76%) expired than females (24%) (n = 125 vs 39 ). Death was highest in age group >60 years with 31% (51) patients aged 61-70 years, 23% (38) patients aged 71-80 years. 21% (35)expired between the age of 51- 60 years. There was a child age 8years died of COVID 19 pneumonia with multisystem inflammatory syndrome of childhood.3 patients died age >90 years and 2 youngsters with IDDM ages 21 and 23 years died <48 hours of being admitted to the ICU. Of the younger patients that perished 7 were between 31-40 years old and 16 (9.75%) aged 41-50 years. Comorbidites that were present in patients who expired were uncontrolled diabetes (HbAIc of >8 ) in 34% of patients (56), hypertension in 39% (64), Ischaemic Heart disease in 19.5% (32), CKD IN 9.7% (16), Stroke old/recent in 6.7% (11). 3 patients had Chronic Liver diease and Parkinsons each, 2 had Alzheimers disease and I each suffered from multiple nyeloma, Carcinoma colon, cervical spine trauma, GBS, Ulcerative colitis. 52 patients (31.7%) expired <5 days, 48 (29.3%) had a stay between 5-10 days in the ICU before they died, 41 (25%) between 10–14 days, 23 (14%) between 14–20 days and 5 (3%) patients died after being in the ICU for >20 days. End of Life care consent was taken in 9 out of 164 patients who died (5.5%). High D dimers values >8 ng/dL at the time of death were seen in 39% (64) patients and a persistent low lymphocyte count <5% was seen in 93.3% of patients who expired.

Discussions: The COVID-19 pandemic has taken its toll on the health of the population, healthcare systems, and economic status of countries worldwide. Due to variations in healthcare systems, demographics of the population and racial considerations different regions need to generate endogenous data. It has been difficult to capture data due to high workloads. Analyzing mortality would help us understand the robustness of the healthcare delivery system, demographic and racial variations, and predisposing risk factors to severe infection leading to death. Ours is a 300-bedded tertiary care center in a smart city of India. We treated 2012 patients infected with the SARS-CoV-2 virus. Three hundred and sixty-three needed intensive care of which 164 expired. The burden on the system increased through the months of July, August, September, and October when the peak of the pandemic was seen. Seventy-five percent of the deaths occurred in these 4 months. Large numbers of patients staying for 10 to 14 days, increased doctor, nurse to patient ratios due to caregiver burnout and illness may have also contributed to untoward outcomes. Males were affected greater than females and mortality was highest in patients aged between 60 and 70 years (31%). Fifty percent of patients died between 60 and 80 years of age which is comparable to western data. Uncontrolled diabetes, hypertension, ischemic heart disease, and chronic kidney disease all of which cause endothelial dysfunction were the predominant risk factors predisposing to death in these patients. End of life care consent was taken in 9 out of 164 patients who died (5.5%). Restriction of visitation and sudden onset of severe illness made it difficult for relatives to consent for end of life care. High D-dimers and persistent low lymphocyte count at the time of death suggest these tests as predictors of mortality possibly due to persistent inflammation and microthrombosis and an inability to clear the virus or due to secondary sepsis as compared to CRP, troponin, LDH, creatinine, and albumin.

Conclusion: The COVID-19 pandemic has tested the health infrastructure in all nations worldwide. In the city of Pune, we had multiple general and private hospitals admitting COVID positive patients. The net mortality rate in our hospital was 6.9% with more males perishing than females. Infection in the elderly and uncontrolled diabetes were important risk factors for mortality as was hypertension. High D-dimers and persistent low lymphocyte count at the time of death suggest these tests as predictors of mortality in our study.

5. Incidence, Molecular Characterization, and Response to Treatment of Multidrug-Resistant and Extended Drug-Resistant Gram Negative Organisms Causing Nosocomial Pneumonia in Intubated COVID-19 Patients in a Tertiary Care Hospital. (Conference Abstract ID: 142)

T Anudeep Kumar, N Pavan Kumar Reddy, Jhansi Vani

Care Hospital, Banjara Hills, Hyderabad, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.125

Introduction: Presently, antimicrobial resistance (AMR) poses a major threat to patient’s treatment as it leads to increased morbidity and mortality, increased hospital stay, and severe economic loss to the patient and nation. The present study was conducted to know the incidence and molecular characteristics of MDR and XDR organisms in intubated COVID-19 patients who are on mechanical ventilation and to find out the most common bacterial strain and resistance pattern observed during the study period and the response to treatment of prescribed antibiotic according to culture sensitivity.

Objectives: Observational study was conducted to detect the incidence and molecular characterization of multidrug-resistant and extended drug-resistant Gram-negative organisms causing nosocomial pneumonia in intubated COVID-19 patients and response to treatment like survival at discharge at tertiary care hospital.

Materials and methods: The respiratory samples like tracheal secretions or BAL specimens were collected where the respiratory infection is suspected. In the department of microbiology, samples were processed and identification of bacteria was done by VITEK (1) machine and its drug resistance was done by BIOFIRE (PCR) (2). The total drug sensitivity was done by VITEK AST.

Results: In a total of 76 culture positive respiratory samples,126 Gram‐negative bacteria were identified as most samples grew multiple organisms, comprising klebsiella pneumoniae [47] and acinetobacter baumannii [29],enterobacter cloacae [16], escherechia coli [15, pseudomonas aeruginosa[16], Serratia marcescens [2], Achromobacter xylosoxidans [1] isolates were detected. Most common resistance pattern observed was CTX-M(96%) followed by NDM(70%),OXA-48(53%),VIM(31%) KPC and AMPC not detected.61 patients recovered were discharged,1 patient went on LAMA,14 patients died

Discussions: COVID-19 pandemic has reinforced the need and importance of good hospital infection control practices, antibiotic stewardship owing to the prolonged ICU stay, increased ventilator days and invasive lines, and use of steroids and other immunomodulators. This study determines the most common Gram-negative isolates in respiratory samples, their resistive patterns, and effectiveness of therapies instituted based on sensitivity testing to better guide initial empirical antibiotics, judicious use of antimicrobials at hand available to intensivists. This study conducted in our Institute showed Klebsiella pneumoniae as the most common organism in respiratory samples and the most common resistance pattern was CTX-M followed by NDM, OXA-48, and VIM (3). The response to treatment was determined by the primary endpoint of discharge out of ICU or death with secondary endpoints like several ventilator days, length of ICU stay, etc. In our study, the primary endpoint of the mortality rate was 20% with the antimicrobial regime based on culture sensitivity. The limitations of the study are single-center observational study.

Conclusion: The study highlights the increased prevalence of multidrug-resistant and extensively drug-resistant strains. Stringent surveillance, proper implementation of hospital infection control practices, and antimicrobial stewardship will help in limiting the emergence and spread of drug-resistant strains.

6. ClinicoDemographic Profile and Outcomes of Severe COVID-19 Infection in Young Adults. (Conference Abstract ID: 119)

Aparna Suresh, GN Srivastava

Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.126

Introduction: COVID-19 is a respiratory and systemic disorder caused by the SARS-CoV-2 virus with a range of severity from mild respiratory symptoms to severe lung injury, multiorgan failure, and death. The main risk factors of the disease are increased age and underlying comorbidity. Newer reports show that younger patients can also suffer from severe COVID pneumonia of which the data are limited. This study intends to uncover the factors that resulted in severe COVID-19 infection in young adults.

Objectives: To study the clinicodemographic profile and outcomes of severe COVID-19 infection in young adults.

Materials and methods: This single-center retrospective study included 163 hospitalized patients in the age group 18 to 35 years diagnosed with severe COVID-19 infection at a tertiary care hospital in Uttar Pradesh from July 2020 to November 2020. Details about patient’s demographics, clinical features, previous comorbidities, laboratory and radiological investigations, and hospital outcomes were obtained from patient records and analyzed.

Results: Out of 163 patients, 60.1% (98) were males and 39.8% (65) were females. The most common comorbidity was diabetes 68.7%, hyperlipidemia 33.1% and obesity 32%. 30.6.% (51) of patients were smokers. Patients presented with shortness of breath (66.9%), cough (65.6%) and fever (60.7%) respectively. Multilobe infiltrates were found in chest xray of (75.4%) patients,.Mean length for ICU stay was 15.5 days (range 3–46). Mechanical ventilation was required in 26.9% of patients. In patients requiring mechanical ventilation, 17 (38%) were discharged and 27(62.8%)died. Of the mechanically ventilated patients 44 had abnormal BMI. Overall mortality was 27% (37patients).

Discussions: There was a male sex predominance with diabetes. Obesity, smoking, and hyperlipidemia were the major risk factors. The major presenting symptoms in these patients were shortness of breath, cough, and fever. Only a quarter of patients required mechanical ventilation, and in those obesity was found to be a major risk factor.

Conclusion: Our study provides insight into presenting characteristics, demographics, and overall outcomes of severe COVID-19 infection in young adults. The preconceived notion of COVID-19 being a disease of the elderly should be changed. In medical emergencies like the COVID pandemic, it is very important to analyze patient demographics to identify the population at risk. Such knowledge not only allows us to produce strategies to help control the spread of disease but also helps us to risk stratify to prevent mortality. It is crucial to learn from an epidemic like this so we can be better prepared for the future.

7. Comparison between Markers of Coagulation Dysfunction and Inflammation in Diabetic and Non-Diabetic COVID-19. (Conference Abstract ID: 106)

Pushpendra S Sengar, RK Jha, Sonam Verma

Sri Aurobindo Medical College and Postgraduate Institute-Indore, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.127

Introduction: COVID-19, the ongoing pandemic has caused thousands of deaths. Diabetes mellitus is frequent comorbidity associated with severe COVID-19 infection and had a worse prognosis. Hypercoagulability and hyperinflammation had been a commonly demonstrated feature among the patients with COVID-19.

Materials and methods: This retrospective cross-sectional study was conducted at SAIMS HOSPITAL, INDORE (M.P.) from July 2020 to September 2020. Patients were categorized into diabetics and non-diabetics based on ADA guidelines and clinical history.

Results: The baseline characteristics of the two groups are comparable as shown in table. The box-plots of peak D-dimer levels in people with diabetes and people without diabetes are shown in figure. The relation between D-dimer levels in COVID-19 in people with diabetes and those without diabetes shows a significant difference t = 1.9715 (p value = 0.02). There is no significant elevation of inflammatory markers (CRP, IL- 6,S.Ferritin) in diabetic COVID-19 when compared to non-diabetics.

Discussions: These results show that the inflammatory and hypercoagulability markers significantly increase in a diabetic group of COVID-19 patients when compared to their non-diabetic counterparts. Various reports suggest that diabetes activate several pathways leading to T-cell differentiation, immune system imbalance, pro- and anti-inflammation imbalance

Conclusion: Diabetes mellitus has been one of the most consistent risk factors for severe disease in patients with COVID-19 and uncontrolled hyperglycemia has been associated with poor outcomes and mortality.

8. Right Atrial Thrombus in a Case of Immunocompromised State with COVID-19. (Conference Abstract ID: 85)

Rajesh Mahadeo Sontakke, Sangeeta Pednekar, Charulata Londhe, Dharmendra Pandey, Niteen Karnik

Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai, Madhya Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.128

Introduction: COVID-19 is a worldwide pandemic. Pieces of evidence are suggesting a strong association between COVID-19 and prothrombotic states. We are reporting a case of critical COVID-19 complicated by a right atrial thrombus. We describe a patient with COVID-19 pneumonia and a clinical hyperinflammatory state. She developed hypoxia and required O2 support. Echocardiography suggestive of right atrial thrombus. She was managed with oxygen therapy and thrombolysis.

Case presentation: A 55-year-old woman came with chief complaints of fever, dyspnea, bilateral pedal edema, and oliguria for 4 days. she was in a known c/o immunocompromised state for 2 years on tenofovir, lamivudine, and efavirenz regimen. She was diagnosed with COVID-19 based on RT-PCR testing which detected SARS-CoV-2. There is no history of i.v. drug abuse.

General examination: Febrile+, pulse = 100/minute, blood pressure-130/90 mm Hg, bilateral pedal edema+, no pallor/icterus/cyanosis/clubbing/lymphadenopathy, jugular venous pressure — raised, tachypneic + SpO2 78% on room air.

Systemic Examination: Respiratory system — bilateral basal crepts.Cardiovascular System — holosystolic murmur of tricuspid regurgitation+.Nervous system—normal.Per abdomen—soft, nontender.

Investigations: HB-13 g% WBC-3,900, platelets 187,000.BUN/creatinine—22/1.3.SGOT/SGPT—149/89.HIV1—Reactive.CD4—259.HbsAg and HCV—Non-reactive.ESR—33.C-reactive protein—9.D-dimer—2,054.63 ng/mL [normal—500 (cut-off)].ECG s/o P—Pulmonale.Chest X-ray (CXR)—s/o cardiomegaly and bilateral peripheral pulmonary infiltrates.SARS-CoV-2 RT-PCR—positive2D ECHO—right ventricle volume overload pattern, dilated right atrium and right ventricle, mild mitral regurgitation, severe tricuspid regurgitation, mild pulmonary regurgitation, mild pulmonary arterial hypertension, aortic valve pressure gradient (AVPG)-7, pulmonary arterial pressure gradient (PASP)-31. Bilateral lower limb Doppler—s/o mild atherosclerotic changes along with bilateral lower limb arterial system biphasic waveform in bilateral anterior tibial artery (ATA), posterior tibial artery (PTA), and dorsalis pedis artery (DPA). CT pulmonary angiography—Moderate cardiomegaly with dilated right atrial, right ventricle, and prominent pulmonary arteries, mild pericardial effusion s/o pulmonary hypertension. Few non-enhancing filling defects in right atrium just distal to opening of superior vena cava anteriorly and along the anterior wall of right Atrium with largest measuring 1.3 × 1 cm distal to opening of superior vena cava s/o thrombosis. Early opacification of inferior vena cava and hepatic veins on arterial phase s/o tricuspid regurgitation.

Course in the ward: Patient was tachypneic on admission with SpO2 of 78% on room air, she was treated with oxygen, antibiotics, inj. Lasix, and inj. heparin. The patient had a long stay of 1 month in the ward, initially, the oxygen requirement was quite high about 15 L/minute by a non-rebreather mask. Oxygen tapered off gradually and shifted to O2 by nasal prongs thereafter weaned off from O2, urine output improved and the patient discharged on oral anticoagulation therapy after patient being asymptomatic and negative COVID swab.

Materials and methods: COVID-19 cases in tertiary care center.

Results: The hypercoagulation state in critically ill COVID-2019 pneumopnia patients should be monitored closely, and anticoagulation therapy should be considered in treatment early in the course of disease Early investigations and treatment with anticoagulants remains the cornerstone of treatment of covid 19 to avoid further complications.

Discussions: Severe COVID-19 infection is associated with hypercoagulable states. It is associated with a high risk for arterial as well as venous thrombosis and pulmonary thromboembolism. Prophylactic anticoagulants are recommended in all patients with severe COVID-19 infection. Full therapeutic dose of anticoagulants is required in patients with proven venous thromboembolism. The dysfunction of endothelial cells induced by infection and hypoxia found in severe COVID-19 can stimulate thrombosis not only by increasing blood viscosity but also through a hypoxia-inducible transcription factor-dependent signaling pathway. A case series of COVID-19 patients with clinically significant coagulopathy, antiphospholipid antibodies, and multiple infarcts in the brain, both digital and pulmonary, has been described. However, these antibodies can also arise transiently in patients with critical illness and various infections. The presence of these antibodies may in rare cases lead to thrombotic events that are difficult to differentiate from other causes of multifocal thrombosis in critically ill patients, such as DIC, heparin-induced thrombocytopenia, and thrombotic microangiopathy. All reported patients had severe hypoxemia and markedly elevated D-dimer levels. Our patient has developed a right atrial thrombus and was having elevated D-dimer level. She was treated with anticoagulation therapy. The international society of thrombosis and hemostasis recommends that all the hospitalized COVID-19 patients should receive a prophylactic dose of LMWH unless they have contraindications (active bleeding and low platelet count). There is a rare occurrence of COVID-19 pneumonia complicated by right atrial thrombus.

Conclusion: The hypercoagulation state in critically ill COVID-19 pneumonia patients should be monitored closely, and anticoagulation therapy should be considered in treatment early in the course of the disease. Early investigations and treatment with anticoagulants remain the cornerstone of treatment of COVID-19 to avoid further complications. We are reporting this case for its rare occurrence.

9. Community and Hospital-Acquired Blood Stream Infections in a Tertiary PICU: A 5-Year Retrospective Study. (Conference Abstract ID: 83)

Mounika V Reddy, AV Lalitha

St. Johns Medical College Hospital, Bengaluru, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.129

Introduction: Severe, invasive infections, both community and hospital-acquired are common, often life-threatening, but differ in their epidemiology, severity spectrum, host factors, pathogen profile, and outcomes.

Objectives: To study and compare the clinical and microbiological profile of the community and hospital-acquired bacterial and fungal infections and their outcomes in a tertiary multidisciplinary PICU.

Materials and methods: Retrospective analysis of all positive blood cultures from a tertiary 12-bedded PICU over 5 years (January 2014 to December 2018). Duplicate cultures and contaminants were eliminated from the analysis. Organisms isolated from the blood within 48 hours of hospital admission were considered as community-acquired infection (CAI) while those isolated after 48 hours as hospital-acquired infection (HAI). Details of host and pathogen characteristics, laboratory investigations, and outcomes (mortality, length of stay) were collected from medical records. Appropriate statistical tests were used for analysis.

Results: Of total 488 positive blood cultures, 166 were excluded due to duplicate cultures and possible contamination. The most common contaminant was Coagulase negative Staphylococcus (CONS), likely reflecting poor technique of sample collection. The median age of cohort was 2 (0–6) years, 55% were males, median PRISM III score was 5 (0–10). The median laboratory parameters on the day of culture were: Hemoglobin 9.1 (7.7–10.5) g/dL, total leukocyte count (TLC) 10,400 (6,205–16,370)/mm3, platelet count 1,19,500 (45,000–2,45,000)/mm3, C-reactive protein (CRP) 4.4 (1.3–13.8) mg/dL, procalcitonin 43 (8.6-111.7) ng/ml, albumin 2.0 (1.4–2.5) g/dL, AST 69 (40–178) U/L, ALT 41 (24-123) U/L, urea 29 (15–57) mg/dl, creatinine 0.5 (0.3-0.9) mg/dl. Of the 322 cultures analyzed, 48% were CAI, rest were HAI. There was significant difference in the spectrum of CAI and HAI (p < 0.001). CAI included gram-positive (50%) [Staphylococcus aureus: 20 (13%), CONS: 30 (19%), Pneumococcus: 16 (10%), hemolytic streptococci: 4 (3%), Enterococcus: 7 (5%)], gram-negative (47%) [Escherichia coli 19 (12%), Pseudomonas 14 (9%), Klebsiella 10 (6%), Salmonella 3 (2%), non-fermenting GNB 19 (12%)], and Candida (5, 3%) infections. HAI included predominantly gram-negative (69%) [Escherichia coli: 21 (13%), Pseudomonas: 6 (4%), Klebsiella: 25 (15%), Acinetobacter: 6 (4%), Enterobacter 10 (6%), NFGNB: 47 (28%)], and less gram-positive (23%) [Staphylococcus aureus: 2 (1%), CONS: 27 (16%), Enterococcus: 10 (6%)] and Candida (13, 8%) infections. There was no difference between CAI and HAI in terms of age, gender, TLC, platelet count, CRP, procalcitonin, AST, ALT, urea, creatinine. CAI had lower PRISM III score (p = 0.03), higher hemoglobin (p = 0.003) and serum albumin (p = 0.02). Survival was similar in CAI and HAI (57% vs 61%, p = 0.42). Mortality varied significantly with type of organism (p = 0.04). However, HAI had longer PICU stay (4 vs 13 days, p < 0.001) and hospital stay (9 vs 23 days, p < 0.001). In the whole cohort, those who survived, as compared to those who did not, did not differ in terms of age, gender, CRP and procalcitonin levels, however, they had significantly lower PRISM III scores (4 vs 7, p = 0.002), higher hemoglobin (9.2 vs 8.7 g/dL, p = 0.006), TLC (11,335 vs 8,635/mm3, p = 0.03), absolute neutrophil count (7,609 vs 5,368/mm3, p = 0.01), platelet count (1,50,000 vs 95,000/mm3, p = 0.01), albumin (2.2 vs 1.7 g/dL, p = 0.004), and lower AST (56 vs 88 U/L, p = 0.006), urea (28 vs 31 mg/dL, p = 0.05), creatinine (0.5 vs 0.63 mg/dL, p = 0.003). Survivors also had longer PICU stay (9 vs 7 days, p = 0.047) and hospital stay (22 vs 9 days, p < 0.001). 91% Staphylococcus aureus isolates were CAI, of which 50% isolates were methicillin resistant (MRSA), all were vancomycin sensitive. All pneumococcal isolates were community acquired and 100% sensitivity to cephalosporins. The number of isolates showed an increasing trend over 5-year period for Staphylococcus aureus and pneumococcus. Enterococcus was both CAI and HAI, 20% isolates were vancomycin resistant (VRE). 47% E.coli, 70% Pseudomonas, 28% Klebsiella isolates were CAI, there was no significant difference in their antibiotic sensitivity as compared to HAI. These gram-negative infections were multidrug-resistant with limited sensitivity to piperacillin-tazobactam (40%), meropenam (60%), aminoglycosides (70%), being 100% sensitive to colistin (100%). The incidence of HAI Acinetobacter infections showed rising trend over 5 years, no colistin resistance was seen.

Discussions: Our study reveals important trends and differences in the community and hospital-acquired bloodstream infections. While both Gram-positive and Gram-negative organisms were common in CAI, the HAI was predominantly caused by Gram-negative bacteria. The incidence of community-acquired MRSA and MDR-Gram-negative infections is on a rising trend. Culture positive sepsis is associated with septic shock and high mortality. Biomarkers like CRP, procalcitonin did not predict mortality.

Conclusion: Severe infections with multidrug-resistant organisms are increasingly becoming common in both community and hospital settings, resulting in significant mortality. Knowledge of the local trends in infection burden, spectrum, and antibiotic susceptibility patterns would help in informing optimal antibiotic choice and infection control interventions to improve outcomes.

10. Effectiveness and Safety of Thymosin Alpha-1 in Patients with Severe COVID-19: A Prospective Open-Label Study. (Conference Abstract ID: 63)

Rahul Pandit

Fortis Hospital, Mulund, Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.130

Introduction: Thymosin alpha 1 has been utilized for immunomodulation in viral infections. There has been a limited clinical evidence for the benefits of COVID-19.

Objectives: To assess the effectiveness and safety of thymosin alpha 1 in patients with severe COVID-19.

Materials and methods: Thymosin alpha 1 was administered, as two injections (each 1.6 mg)/thrice daily subcutaneously for seven consecutive days, along with standard of care (SOC), in 15 consecutive patients diagnosed as COVID-19 positive based on the RT-PCR results. The study duration was from August 27, 2020, till November 2, 2020. The patients were enrolled in the study if any of the following clinical conditions were present; respiratory distress with respiratory rate ≥ 30 breath/minute, SpO2 (oxygen saturation) ≤ 90% on room air, PaO2 (arterial blood oxygen partial pressure)/FiO2 (fraction of inspired oxygen) ≤ 200 mm Hg (1 mm Hg = 0.133 kPa), respiratory failure and the need for mechanical ventilation support. The study is registered with the Clinical Trials Registry of India (Clinical Trial registration number: CTRI/2020/08/027061) and was approved by the institutional ethics committee on August 7, 2020.

Results: The mean duration (days) of the hospitalisation, ICU stay, ventilator support, was 13.2 ± 4.38, 4.4±0.51, 2.87±2.20, respectively. The total lymphocyte count (thousand/mm3), CD4 count (cells/mm3), CD8 count (cells/mm3), increased significantly to 4410 ± 1200 from 2010±680 (p < 0.0001), 558.07±177.55 from 367.20 ± 166.94 (p = 0.0008), 720.07 ± 230.38 from 509.67±199.42 (p = 0.0008), respectively. The CD4/CD8 ratio improved from 0.72 to 0.77. LDH (Lactic Acid Dehydrogenase) levels (units per liter), C reactive protein (CRP) (mg/L), D-dimer levels (mg/L), ferritin (ng/mL), IL-6 (pg/mL) decreased to 329.33 ± 175.62 from 369.00 ± 186.80 (p = 0.0182 NS); 23.66±22.64 from 76.31 ± 78.38 (p = 0.0.105); 0.72 ± 0.37 from 1.42 ± 1.36 (p = 0.0428), 347.09 ± 185.16 from 491.75 ± 230.86 (p = 0.0082), 4.09 ± 1.64 from 18.03±4.91 (p < 0.0001), respectively. The oxygen saturation (SpO2%) increased to 97.60 ±0.74 from 84.93 ±1.79 (p < 0.0001). WHO 8-point ordinal scale decreased (improved) to 3.2 ±0.41 from 5.4 ±0.51 (p < 0.0001). Five patients reported adverse events which were of mild severity, which were unrelated to thymosin alpha 1. There was no mortality reported during the study period.

Discussions: The study demonstrates a statistically significant reduction in cytokines including CRP, D-dimer, ferritin, and IL-6, with a numerically superior reduction in LDH. The significant improvement in the lymphocyte count along with the enhanced CD4 and CD8 count indicates the ability of thymosin alpha 1 to induce a distinctive immunological capacity, to replenish and reverse the phenomenon of exhaustion of the T cells. The improved biochemical parameters are corroborated with the improved SpO2 and the WHO 8-point ordinal scale. The results of our study are corroborative with the earlier clinical evidence which demonstrates the role of thymosin alpha 1 for the clinical improvement by immune reconstitution by inducing thymus output in COVID-19 patients with SARS-CoV-2 infection.

Conclusion: The results of this first prospective study from India indicates that thymosin alpha 1, along with the standard of care approach, appears to be a potential treatment for patients affected by the SARS-CoV-2 infection. Thymosin alpha-1 is a novel therapeutic armamentarium to improvise the clinical outcomes in patients with severe COVID-19.

11. A Telemedicine Approach for Assessment, Identification, Empowerment, and Triage for COVID-19 Patients. (Conference Abstract ID: 58)

Bijay Patni

Diabetes Wellness Care, Kolkata, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.131

Introduction: COVID-19 pandemic has forced the healthcare system to organize healthcare delivery differently.

Materials and methods: We conducted a retrospective analysis of the diabetes wellness care (DWC) database to understand the implications of the new virtual clinic model initiated through telemedicine which was extended to manage COVID-19 patients (n = 218).

Results: Clinical Presentation: 33% (n = 72) were RT-PCR positive, yet, asymptomatic with history of contact. 24.3% (n = 53) had mild symptoms including asthenia and myalgia and temperature < 100.5°F. 42.6 (n = 93) presented with temperature > 100.5° F.

Discussions: Most of the patients were either asymptomatic or had mild upper respiratory symptoms. Moderate with non-life-threatening pneumonia was present in some patients and severe pneumonia and acute respiratory distress syndrome were detected in very few. We were able to judiciously utilize the options of HCQ, doxycycline, and ivermectin in most patients, and a few required favipiravir and azithromycin.

Conclusion: Our telemedicine approach enabled a prompt detection of the varied grade of the symptoms, which enabled an effective triage and led to the isolation of infectious patients. This model was useful to prevent and mitigate unnecessary community exposure.

12. Remdesivir Either Alone or in Combination with Tocilizumab for the Treatment of Severe COVID-19 Infection: A Retrospective Cohort Study. (Conference Abstract ID: 31)

Abhyuday Kumar, Neeraj Kumar, Amarjeet Kumar

All India Institute of Medical Sciences Patna, Bihar, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.132

Introduction: Presently, there is no conclusive data yet for the use of remdesivir or tocilizumab in severe COVID-19 patients. Moreover, there is no study comparing the two drugs in one subset of patients. In some patients, both these drugs are used over a period of time. The present study was designed to evaluate the combined effect of bot these drugs on the clinical condition of the COVID-19 patients.

Objectives: To compare remdesivir alone and in combination with tocilizumab for the treatment of severe COVID-19 patients.

Materials and methods: This retrospective cohort study was designed to analyze the data collected during the routine care of patients. All patients admitted to the ICU over a period of 2 months were included in the study and the data were collected from the patient’s medical records. The primary outcome was clinical improvement defined as an improvement of 2 points on an ordinal scale of the clinical condition of the patient. Secondary outcomes were time to clinical improvement, improvement in PO2/FiO2 ratio, duration of the requirement for supplemental oxygen/noninvasive ventilation/invasive ventilation, and mortality.

Results: Multivariate analysis of these data were done for the identification of variables after the initiation of treatment with Remdesivir or Toclizumab that are potentially predictive of its clinical efficacy. There was no significant difference on clinical improvement of the patient who were treated with Remdesivir alone or in combination with TocilizumabVariables like time to initiation of the therapy, clinical condition at initiation and PO2/ FiO2 ratio were predictive of the clinical efficacy of both drugs.

Discussions: In most of the cases, tocilizumab was initiated in patients who were clinically deteriorating and were having a low PO2/FiO2 ratio at the time of initiation of the therapy. That may be the cause of non-benefit in our subset of patients.

Conclusion: There was no added advantage of tocilizumab when combined with remdesivir on the clinical improvement or mortality of the patient.

13. Awareness of Corona Virus (COVID-19) Infection Among People Accompanying Patients Visiting the Emergency Department of a Medical College. (Conference Abstract ID: 12)

Channamma Inamati, Channamma Inamati, Deepak Segar

East Point Medical College, Bengaluru, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.133

Introduction: COVID‐19 started from one city in China in December 2019, but in a short period, it covered almost all over the world. Nearly 216 countries of the whole world have been affected by this infection. On February 11, 2020, WHO announced this coronavirus disease as COVID-19 and pandemic on March 11, 2020. To prevent the infection socially, the lockdown was imposed globally. In India, the Government also imposed a nationwide lockdown on March 22, 2020, and continued it up to May 30, 2020. But on May 30, 2020, this situation of coronavirus disease outbreak has become worse, as it contains >50 lakhs confirmed cases, nearly 3 lakhs confirmed deaths across 216 countries. WHO has recommended personal hygiene (respiratory hygiene, using face masks, washing hands with water and soap, use of alcohol-based hand sanitizers, avoid touching mouth, eyes and nose), social distancing as an effective preventive measure for this disease. The growing pandemic of COVID-19 requires social distancing and personal hygiene measures. But this message is not clear and well understood among people. This study aimed to determine the awareness and knowledge about COVID-19 among the rural population.

Objectives: This study was designed to assess the knowledge and awareness regarding corona infection among the rural population of Bengaluru district, Karnataka.

Materials and methods: The data were collected over a period of 3 months from March 2020 to May 2020. A total of 75 adults were interviewed who accompanied patients visiting the emergency department of East Point Medical college, Bengaluru Rural district. A questionnaire method was used to gather information, consisting of details on sociodemographic factors, awareness, and knowledge about corona infection.

Results: Among the study population 45 (60%) were male and 30 (40%) female. The majority of the subjects belonged to Hindu family 57 (89.3%). Media was the most common source of information.Majority of them 40 (53.3%) didn’t knew the cause of corona infection.About 56 (74.6%)of participants were aware about transmission of disease.Many of the subjects knew about the preventive measures. Most of them were not aware i.e. 41 (54.6%)regarding treatment and investigation 30(40%) availability for covid infection, but only 21.3% were aware about the vaccine availability for the disease. Quarantine knowledge was present in 84% of the adults.

Discussions: During the past 8 months, the COVID-19 has spread worldwide. Seventy-four cases were found per 1 million people in India in fact, the government has implemented lockdown well before any worst condition appears. After a long period of the lockdown of various commercial activities, we need to understand the extent of public awareness toward the COVID-19 pandemic so that an effective framework for creating awareness among the public should be implemented keeping in view the existing public communication abilities including demographics, literacy levels, language spoken as well as socioeconomic and cultural background. Coronaviruses encompass viruses that can cause illnesses ranging from the common cold to more serious diseases SARS and MERS. The virus that causes COVID-19 disease is a new species of coronavirus. Half of the participants were unaware of this causative agent. About 80% of participants knew the route of transmission. Many of the subjects knew about the preventive measures. The COVID-19 occurs in all age groups. Old-aged persons and those suffering from diseases like high blood pressure, cancer, lung disease, are at higher risk. Around 75% of participants knew the high-risk group population for corona infection. More than 50% of subjects were ignorant about the availability of treatment and investigations for corona infection.

Conclusion: Overall awareness regarding COVID infection was low among rural adults. Strategies are needed to create more awareness about pandemic through continuous education programs regarding the infectious disease.

14. Comparison of Microbial Profile and Resistance Pattern of Early- and Late-Onset Ventilator-Associated Pneumonia in a Tertiary Care ICU of Bangladesh. (Conference Abstract ID: 7)

Uzzwal Kumar Mallick

National Institute of Neurosciences and Hospital, Bangladesh

DOI: https://doi.org/10.5005/jp-journals-10071-23711.134

Introduction: Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs 48 to 72 hours or thereafter following endotracheal intubation.1,2 Early-onset VAP is defined as pneumonia that occurs within 4 days of endotracheal intubation, whereas late-onset VAP is more likely caused by multidrug-resistant (MDR) bacteria and emerges after 4 days of intubation.1–3

Objectives: The objectives of this study were to compare the bacterial profile and resistance pattern of critically ill patients developing early-onset VAP.

Materials and methods: It was a prospective cohort study conducted over a period of 24 months (July 2012 to June 2014) in an ICU of tertiary care hospital and was prospectively analyzed. Subjects were classified by ventilator status: early-onset VAP (<96 hours of mechanical ventilation) or late-onset VAP (>96 hours of mechanical ventilation). Baseline demographics and bacterial etiology were analyzed according to the spectrum of the status of VAP.

Results: The incidence of VAP was 35.73 per 1,000 ventilator days. In our study 52% of the cases were early-onset VAP, while 48% were late-onset VAP. Acinetobacter was the commonest organism isolated from late-onset VAP (p = 0.029) while Pseudomonas was the commonest isolates obtained from early-onset VAP (p = 0.046). Klebsiella, MRSA and E. coli were almost identically distributed between groups (p > 0.05). There is significant difference of sensitivity pattern of Acinetobacter baumannii and pseudomonas aeruginosa in both early and late-onset VAP (p = 0.01). The overall mortality rate in our study was 44%. The mortality was significantly higher in the late-onset VAP (62.5%) than that in the early-onset VAP (26.9%) (p = 0.011).

Discussions: Ventilator-associated pneumonia (VAP) is an important nosocomial infection among ICU patients receiving mechanical ventilation (MV). In this prospective cohort study, we compared patients with early VAP with those with late VAP. Generally, the incidence of VAP varies according to the applied diagnostic criteria and the type of ICU. The incidence of VAP (35.73 per 1,000 ventilator days) in our study was approximately similar to another Indian study.18 The incidence of VAP ranged from 10 to 41.7 per 1,000 ventilator-days in different developing countries.13 But in other Asian countries, the incidence rate is relatively lower, ranging from 9 to 12 per 1,000 ventilator days.19–21 Our study shows that patients in the age group of 40 to 60 years were more prone to develop VAP and this was found in accordance with earlier studies.25 The incidence of VAP was more in males (60%) compared to females (40%) which was similar to studies conducted by Sharma et al.24 Non-fermenters such as Pseudomonas spp. and Acinetobacter spp. were significantly associated with late-onset VAP as it was observed by other workers.14 But in our study even in patients with early-onset VAP, Acinetobacter spp. was the most common pathogen which is similar to an Indian study done by Joseph et al.22 Our study showed that Pseudomonas aeruginosa was the commonest organism in early VAP (42.3%), and in late VAP Acinetobacter baumannii was the commonest organism (66.7%), isolated in tracheal aspirate culture. Dandagi (2006) showed Klebsiella pneumoniae to be the most common organism isolated in the tracheal aspirate culture of the VAP patients.15 Kumar et al.26 showed Pseudomonas to be the most common organisms for both early and late VAP isolated in tracheal aspirate culture. The information on types of pathogens causing VAP in different ICU settings will guide the administration of appropriate empirical antibiotics for the treatment of the infection. I observed that colistin is highly active against Acinetobacter spp., while piperacillin-tazobactam has good activity against Pseudomonas spp. But as we have studied only a small number of isolates, these findings need to be further confirmed by larger clinical trials, as they may have a major impact on the treatment of these VAP pathogens. In our study, late-onset VAP had a poor prognosis in terms of mortality (62.5%) as compared to the early VAP (26.9%), which is statistically significant (p = 0.011). A study done by Gadani et al.16 showed mortality in late VAP (66%) and mortality of early VAP (20%). The higher mortality in the late VAP in our study could be attributed to older age, higher comorbidities like diabetes mellitus, COPD, and CKD.

Conclusion: From the findings, it can be concluded that late VAP had a poor prognosis in terms of mortality (62.5%) as compared to the early type (26.9%). The higher mortality in our study in the late VAP could be attributed to older age, higher comorbidities like diabetes mellitus, COPD, and CKD. In our study, there is a significant difference in sensitivity of Acinetobacter spp. and Pseudomonas spp. between early- and late-onset VAP. Acinetobacter spp. positivity is higher in the late-onset VAP and Pseudomonas spp. are more so in early-onset VAP.

9. Metabolism, Endocrinology, Liver Failure, and Nutrition

1. Glucose Control Study in Our Critical Care Unit. (Conference Abstract ID: 169)

Vaijayanti Nitin Kadam, Sanjith Saseedharan

SL Raheja Hospital, Mumbai, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.135

Introduction: Glucose dysregulation (dysglycemia) is referred to as instability in blood glucose level and this includes hyperglycemia, hypoglycemia, and glucose variability (Boutin and Gauthier, 2014). In the intensive care unit (ICU), the management of hyperglycemia is a crucial factor that determines the outcomes of the treatment. Multiple etiological factors like high glucose production, under-utilization of glucose, reduced insulin secretion, drug treatments, and many more contribute to hyperglycemia. In 80% of critically ill patients, insulin resistance is one of the contributing factors of hyperglycemia.

Objectives: Hyperglycemia is associated with life-threatening complications including damage to the different systems of the body. An earlier study by van den Berghe (2001) on the management of glucose level and better survival outcome in ICU patients increased the interest of researchers and clinicians to discover multiple glucose control protocols and monitoring of glucose control in ICU settings (Preiser et al., 2016). The present study attempted to understand the effectiveness of Saven G protocol intervention in the maintenance of glucose concentration in ICU patients.

Materials and methods: In this observational study, a total of 108 patients (age limit please provide here) admitted in the ICU of RAHEJA HOSPITAL center/hospital were enrolled. Inclusion criteria included all consecutive medical cases getting admitted in ICU, whereas the exclusion criteria were diabetic ketoacidosis, surgery, APACHE II score of <5 and >25, and reported death within 2 days of hospital admission.Saven G protocolThe protocol was approved by the ethical committee of RAHEJA HOSPITAL.Details of the protocol.The measured glucose was expressed as mg/dL and the obtained glucose value were categorized into three-level: <150, 150 to 200, and >200 mg/dL. The main outcome of the study was to evaluate the effectiveness of the proposed insulin protocol in terms of (i) maintenance of various levels of sugar for several hours in a day; (ii) incidences of difference in sugar level in a day; (iii) correlation of sugar level with demographic characteristics and concomitant complications.

Results: The distribution of demographic characteristics and some of the major associated complications in patients in the ICU. Within the demographics, the age and gender of the patients were inquired. The average age of the patients was observed to be 63.96 ±13.14 years. The gender distribution shows more that 68.51% of patients were males, while the rest (31.48%) were females. With respect to complications, 60.1% were affected with hypertension, while 29.63% were impacted with ischemic heart disease. In additions to this, 23.15% of the patients underwent coronary artery bypass graft and only 7.41% were impacted by chronic kidney disease.

Discussions: In this observational study of glucose control in ICU patients, the proposed Saven G protocol was effective to regulate and maintain the glucose level at 150 to 200 mg/dL for 12 hours within a day. Further, this protocol could be widely applied to patients of different ages and both gender, and with existing comorbidities like hypertension.

Conclusion: In this observational study of glucose control in ICU patients, the proposed Saven G protocol was effective to regulate and maintain the glucose level at 150 to 200 mg/dL for 12 hours within a day. Further, this protocol could be widely applied to patients of different ages and both gender, and with existing comorbidities like hypertension.

2. Effect of Various Feeding Regimen on Mortality in Critically Ill Pediatric Patients of a Pediatric Critical Care Unit—A Triple Arm Randomized Control Trial. (Conference Abstract ID: 166)

Gopalakrishnan Ezhumali, Arun Bansal, Jayashree Muralitharan, Suresh Kumar Angurana, Nancy Sahni

Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.136

Introduction: Nutritional support is one of the key management of clinical practice in pediatric intensive care patients. The prevalence of malnutrition in PICU is as high particularly in a country like India. The metabolism and energy need of critically ill children are dynamic, changing from a hypermetabolic state to a hypometabolic state through the PICU stay. Hence, each particular PICU needs to have a set feeding protocol for critically ill children to avoid underfeeding or overfeeding and in turn to improve physiological stability and outcomes. As there is no set feeding protocol in critically ill children for the need of calorie, protein supplementation in critical illness, we planned to study the effects of various feeding regimens on critically ill pediatric patients in a tertiary care pediatric intensive care unit.

Materials and methods: Our study was an open-label triple arm randomized control trial which evaluated the effect of three different enteral nutrition regimen on mortality on critically ill children. We have assessed the effect of a combination of isocaloric, hypocaloric, and hypercaloric feeding along with hyperproteinemic feeding on both septic and non-septic children in a tertiary care PICU. We calculated the resting energy expenditure (REE) with predictive equation (Schofield equation) for all the critically ill children >6 months to 12 years, we had 3 different groups as defined (I — hypocaloric high protein, II — hypercaloric normal protein, III — standard arm-isocaloric normal protein). Hypocaloric was given by 0.5 to 0.8% of REE, hypercaloric was given by 1.2 to 1.5% of REE, high protein was given by 2.5 g/kg/day. Each enrolled participant was given a specified number of calories and protein for the initial 7 days of PICU stay and followed up for the PICU and 28-day mortality. Nutritional and barriers for enteral nutrition data along with disease severity parameters, duration of mechanical ventilation, hospital and PICU length of stay, vasopressor-free days, adverse effects like the incidence of hypo-hyperglycemia, transaminitis, AKI were collected for each participant.

Results: Out of 291 patients screened for eligibility 120 were enrolled in group I, group II had 41 each, and group III had 38 patients. Of the total, 76 (63.4%) were in the septic arm and 44 (36.6%) were in the non-septic arm. Each group had 27, 24 and 25 children with sepsis.

Discussions: Targeting enteral calorie intake was associated with favorable 60-day mortality in a multicentric cohort study by Mehat et al. The authors demonstrated achieving of a target of 66% of calories has significantly less mortality compared to the achieved target of 33% (odds ratio — 0.27) (1). In a systemic review by Bechard et al., patients receiving protein > 1.5 g/kg/day were associated with positive nitrogen balance (2). In our study, PICU mortality and 28-day all-cause mortality were similar in all the three groups and was statistically not significant, probably because we were able to enroll only 20% of the calculated sample size for effect size. The secondary outcomes like the length of PICU stay and hospital stay did not show a significant difference in all three groups comparison.

Conclusion: We found that various combinations of hypo, hyper vs isocaloric feeding with high protein in critically ill children was not associated with mortality benefits and no difference in ventilator-free days, however, it is safe to give adopt permissive underfeeding even in malnourished children.

3. Critical Care Management Issues in a Patient with Eclampsia. (Conference Abstract ID: 114)

Dhriti Chungkrang, Anupama Gill, Aanchal Kakkar, Neerja Banerjee, Mohandeep Kaur, Vikas Arora

ABVIMS, DR RML Hospital, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.137

Introduction: Preeclampsia, eclampsia, and HELLP syndrome are serious and life-threatening, hypertensive conditions encountered by a pregnant woman, and are common causes of ICU admissions among the obstetric population. The diagnostic criteria include systemic BP of ≥140 or diastolic of ≥90 on two occasions at least 4 hours apart. Proteinuria >300 mg/day in women with the gestational age of >20 weeks with previously normal blood pressure. Eclampsia is defined as a convulsive episode or altered level of consciousness in a patient occurring in the setting of preeclampsia provided there is no other cause of the seizure. HELLP syndrome is also associated with preeclampsia — eclampsia characterized by three hallmark features of hemolysis, elevated liver enzymes, and low platelets. Early diagnosis and multidisciplinary approach is mandatory, which if not corrected can lead to sequelae of adverse systemic organ dysfunction which in our patient has led to malignant hypertension, deranged liver function, and PRES syndrome.

Materials and methods: NA.

Discussions: We received a 27-year-old patient in ICU — G3P2L1 with eclampsia, HELLP, and hepatic encephalopathy. The patient had a history of 5 months amenorrhea, IUD spontaneous expulsion with misoprostol was done in labor room wherein she was intubated in view of poor GCS, she also had two episodes of seizure for which she had received two doses of magnesium sulfate outside the hospital and was shifted to anti-epileptic thereon, blood pressure at the time of presentation was 190/110, for which 40 mg i.v. lobate was given B.P after that was 140/90. Our patient was extubated the next day in ICU was vigilantly monitoring. She was managed by a multidisciplinary approach which includes obstetrics, cardiology, nephrology, gastroenterology, and ophthalmology bedside with a clear management plan which includes correction of anemia, target B.P of <160/100 using labetalol 200 mg TDS, along with labetalol infusion, NTG infusion, and other oral antihypertensives like α-2 agonist, CCBs, ARBs, etc. She was carefully monitored in ICU using CVP, arterial line, fluid chart, and lab investigation according to hospital protocol using the coagulation profile, liver and renal function test for any further deterioration. Ophthalmologic findings revealed mild hypertensive retinopathy. NCCT head had normal findings in it. Investigations during ICU stay like CBC and Kft got normal with a gradual rise in liver enzymes and bilirubin levels with no evidence of live rupture or hematoma in ultrasound findings. The patient stayed in our ICU for 10 days with aggressive B.P monitoring along with antihypertensive treatment which after 10 days got settled with a systolic of 160/90. Other investigations also resolved but a mild deterioration of vision remained. The patient after 10 days was transferred to the HDU unit.

Conclusion: In our patient with a history of previous normal vaginal delivery with one live birth, and two successive IUD, we can conclude that proper ANC check-up and evaluation of maternal health at the earliest can help prevent dreaded complication like malignant hypertension leading to PRES syndrome as MRI on day 5th showed mild vasogenic edema in the posterior and parietal lobe and other organopathies.

4. Nutritional Practices Prevalent in Open ICU and Their Impact: A Study in Resource Limited Tertiary Care Hospital. (Conference Abstract ID: 75)

Ashima Mishra, Baladev Prasad Kar, Akhil Unnikrishnan, Bimal Krishna Panda

VIMSAR, Burla, Odisha, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.138

Introduction: Nutrition in critically ill patients has therapeutic importance besides a supportive role. A paucity of studies related to effective nutritional practices in the Indian setup exists. Standardization has not been achieved due to the heterogeneity of availability of facilities and funds in ICUs across different parts of India. This study aimed to assess the efficacy of nutritional practices prevalent in open ICU.

Objectives: The objectives are to study

Materials and methods: This is a prospective observational study initiated in August 2020.

Inclusion criteria: All patients admitted to central ICU including medical and surgical conditions.

Exclusion criteria: Patient who died within 48 hours of admission into ICU or had contraindications of enteral feeding.

Methods: The patients were assessed for nutritional status at the time of entry using SGA score and initiated on standardized blenderized feeds as per calculated calorie and protein requirements based on body weight. The decision of time to initiation of enteral feeding was determined by an individual treating physician. The process of preparing, storing, and handling blenderized feeds was observed and supervised to incorporate the correct amount of calculated nutrients. Outcomes were assessed using parameters like length of ICU stay, mortality, the incidence of feeding intolerance (depending on >500 mL gastric residual volume on aspiration, need for use of prokinetics, development of aspiration pneumonia), serum protein markers, bodyweight. Appropriate statistical methods were applied for result analysis.

Results: A total of 40 patients were observed. The mean age of patients were 45 + 8 years (60.2% males and 40.8% females).18 patients were fed within 24 hrs of their admission and rest after 24 hours. The median time of early initiation of feeding was 12 + 5 hrs and for rest 22 patients the median time of delayed initiation was 47 + 9 hrs. Out of 40, 7 died and for rest the median time of ICU stay was 5.1 + 3.1 days. The median time of ICU stay for patients with early enteral feeding was 4.6 + 2.1 days and for patients with delayed enteral feeding was 5.8 + 1.5. This difference was found to be statistically significant (p = 0.04). The incidence of complications were lower among the patients with appropriate SGA scoring and introduction of blended diet. However, that was not found statistically significant. But between early and delayed introduction of enteral feeding groups, the incidence of complications (sepsis/pneumonia) of patients with early introduction of feeding was 41% and those with delayed feeding, incidence was 49%. This was statistically significant (p < 0.031).

Discussions: Prenutritional assessment and individualization of nutrient requirements of critically ill patients is highly beneficial. Recruitment of ICU Dietician is necessary. Early enteral feeding, if not contraindicated, when initiated as soon as possible leads to better recovery. Complications like aspiration can be prevented by elevation of the head end of beds. More useful markers to assess nutritional status needs to be formulated. Blenderized feeds can be cost-effective substitutes to enteral formulas with near similar efficacy in resource-poor hospitals. Preparation of collective feeds and distribution avoiding prolonged storage can minimize the risks of contamination.

Conclusion: The results showed that there is an improvement of the condition of the patients admitted at ICU with the introduction of SGA scoring and early introduction of blenderized diet in terms of duration of ICU stay and incidence of complications. This needs to be validated by conducting similar studies with larger sample sizes over a longer time period.

5. Comparison of Arterial and Venous Blood Gas Analysis in Patients with Diabetes Keto Acidosis Presenting to Emergency Department. (Conference Abstract ID: 16)

Rahul M Parmar, Jigarkumar B Gosai, Neha V Patel, Chirag J Patel

BJ Medical College, Civil Hospital Campus, Ahmedabad, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.139

Introduction: Diabetic ketoacidosis (DKA) is one of the most serious acute metabolic complications of diabetes. These metabolic derangements result from the combination of absolute or relative insulin deficiency and an increase in counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). It is a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased ketone concentration. Severe hyperglycemia ensues as a result of increased gluconeogenesis, accelerated glycogenolysis, and impaired glucose use by peripheral tissues. The most widely used diagnostic criteria for DKA have been blood glucose >250 mg/dL, serum bicarbonate lower than 15 mEq/L, arterial pH lower than 7.3, an increased anion gap metabolic acidosis, and a moderate degree of ketonemia. The severity of DKA is now classified as mild, moderate, or severe; based primarily on the severity of metabolic acidosis (blood pH, bicarbonate, ketones) and the presence of altered mental status. Arterial blood gas (ABG) analysis is the gold standard method for acquiring this information. But ABG analysis is not without drawbacks.


Materials and methods: With the approval given by the institutional ethics committee, this study was conducted at the Emergency Department, Trauma center, Civil Hospital, Ahmedabad from July 2020 to October 2020. One hundred patients with clinically suspected DKA presenting to the Emergency Department, who match inclusion criteria (before the results of further laboratory tests known) were taken and their arterial and venous blood samples (0.5–1 mL) were taken at the same time.

Results: pH.Bicarbonate:

Average difference between arterial and venous pH values0.037231.3907
Range of difference0 to 0.090 to −2.6
Standard deviation of average0.0180.69
95% limits of agreement0.0018 to 0.07266−2.743 to −0.03742

Discussions: Most textbooks continue to recommend arterial blood gas analysis as the investigation of choice for estimation of pH and bicarbonate in DKA. As mortality in DKA is related among other things to the degree of acidosis, determination of acid-base status has prognostic as well as diagnostic significance. If venous pH gets accepted as an alternative to arterial measurement, this has some potential benefits for patients, hospital staff, and processes. It should be noted that arterial blood gas sampling is more painful to patients and sometimes requires multiple attempts. Arterial puncture is more time consuming and labor-intensive when compared with venipuncture, which must be performed anyway to measure serum electrolytes and glucose levels, as well as to establish intravenous access for fluid resuscitation and insulin administration.

Conclusion: There is reasonable evidence that venous and arterial pH have sufficient agreement as to be clinically interchangeable in DKA patients who are hemodynamically stable without respiratory failure. Unanswered questions include whether this level of the agreement remains true in patients with respiratory compromise or with circulatory instability. This is an area worthy of further study. Venous and arterial bicarbonate also agree closely in DKA but this requires confirmation.

10. Neurointensive Care

1. Epidemiology of TCD Parameters of Cerebral Perfusion in Patients Admitted to a Combined Medical Surgical ICU. (Conference Abstract ID: 197)

Thomas Isiah Sudarsan, Sriram Sampath, Bhuvanna Krishna

St. Johns Medical College Hospital, Bengaluru, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.140

Introduction: Encephalopathy is common in patients being admitted to ICU and could be due to structural or nonstructural causes, with neuroregulatory dysfunction as well as cerebral circulatory disturbances which can be studied invasively and noninvasively. Transcranial Doppler (TCD) provides a noninvasive window to assess the cerebral circulation particularly the Middle cerebral artery flow index and velocities. Although several cross-sectional studies have described abnormalities in the TCD flow parameters they have poorly correlated with invasive measurements of ICP and CPP. A study looking at a trend of TCD parameters (Pulsatility index, velocities, and derived indices—CBFI, ICP) values over time in encephalopathic patients could provide insight into the abnormalities in these patients.

Objectives: Primary: Describe the Pulsatility index (PI), Resistivity index (RI), MCA — Peak systolic velocity (Psv), End diastolic velocity (Edv), Mean flow velocity (Mfv), ICP, and Cerebral Blood flow index (CBFi) as measured by TCD among patients being admitted in ICU.


Materials and methods: A prospective observational study was conducted from January 2019 to December 2020 in the ICU of a tertiary care hospital. All patients admitted to tertiary care ICU were screened within 24 hours of admission and subsequently every 24 hours till discharge from ICU or death. Patients enrolled were evaluated with a 1 to 5 MHz. Phased array echo probe to insonate and acquire MCA flow parameters of Pulsatility index and flow velocities through a transtemporal window. Patients were also evaluated with a 7 to 15 MHz linear vascular probe to measure the optic nerve sheath diameter. Other clinical and laboratory parameters were transcribed from the daily routine investigation being done along with hemodynamic parameters during the TCD analysis. All the analyzes were carried out using SPSS Version 25.

Results: A total of 35 patients were included in the study. Among them 5 patients encephalopathy resolved within 24 hours and were not considered for analysis. The mean age (± S.D) is 45.5 (±22.9) years. Male:Female ratio was 4:1. Among the encephalopathic patients 40% (n = 12) recovered from encephalopathy and 40% (n = 12) had poor outcomes (Death/ DAMA). 26.6% (n = 8) had structural causes of encephalopathy among which acute CVA was most common cause. 73.3% (n = 22) had non structural cause of encephalopathy of which majority had septic/uraemic encephalopathy. PI at the time of admission was high in patients who did not recover from encephalopathy compared to patients who recovered from encephalopathy(1.27 ± 0.39 Vs 1.06 ± 0.3), but it did not attain statistical significance( p = 0.29). Trends in PI were not associated with chances in encephalopathy

Discussions: In previous studies by Dina Zidan et al. (2017) on 106 septic patients, there was a difference in the PI between conscious patients and patients suffering from sepsis-associated encephalopathy and they concluded that PI could be a predictor of sepsis-associated encephalopathy in septic patients. In our study, PI at the time of admission was high in patients who did not recover from encephalopathy compared to patients who recovered from encephalopathy (1.27 ± 0.39 vs 1.06 ± 0.3), but it did not attain statistical significance (p = 0.29). In our study, we also found that the trends in PI were not associated with the progression or resolution of encephalopathy.

Conclusion: We found that TCD flow parameters of pulsatility index varied within a wide range in patients with encephalopathy. Trends in PI were not associated with progression or recovery from encephalopathy.

2. Comparison of Early Bispectral Index-Guided PostOperative Extubation vs Extubation in Awake Patients in Neuro-Intensive Care Unit. (Conference Abstract ID: 192)

Tushar Kumar, Pradip K Bhattacharya

Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.141

Introduction: Neurosurgical patients have a high risk of neurological complications in the immediate postoperative period increasing both morbidity and mortality. Extubation after uneventful intracranial surgery is tried to be as early as possible to avoid ventilator-associated complications. There are several scales and scoring systems to guide and assist early extubation. However, in neurosurgical patients, these scores may not be sufficient to provide enough data for confidant extubation. The objective of the present study is to compare bispectral index-guided postoperative extubation vs extubation in awake patients using various neurological assessment scores in neuro-intensive ICU after craniotomy and excision of supratentorial space-occupying lesions.

Materials and methods: A total of 16 patients (ASAI-II), aged between 25 and 45 years, who were scheduled to undergo elective neurosurgery operation under general anesthesia and randomly divided into the BIS group (group B) and scoring group (group S), with 8 cases in each group. After satisfactory respiratory recovery patients were extubated. Oxygen saturation by pulse oximeter and HR were recorded before extubation (T0), (T1) at 1 minute, and 5 minute (T2).

Results: Early extubation using bispectral index found to be significant with p < 0.04, during T1 and T2.

Discussions: Bispectral index assists better to make decisions for extubation than other scoring systems in postoperative neurosurgical patients for supratentorial space-occupying lesions. Kamali et al. showed that BIS reduces extubation time in post-CABG patients.

Conclusion: Using BIS monitoring during and after neurosurgery, it reduces the length of patients’ extubation in ICU.

3. Temporal Trends in Optic Nerve Sheath Diameter (ONSD) in Neurocritical Illnesses. (Conference Abstract ID: 32)

K Sindhuja, Rishiraj N Verma, Krishna Kumar

Command Hospital (Eastern Command), Kolkata, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.142

Introduction: Optic nerve sheath reflects the same pressure change as the intracranial compartment. Well-known findings of raised ICP like papilledema and pupillary changes appear very late compared to dilatation of the optic nerve sheath.1 Sonographic ONSD measurement provides real-time changes in ICP, can be done bedside and is reproducible, and can be repeated to know the trends in ICP throughout the disease course, thereby averting the risks associated with invasive monitoring or repeated radiation exposure. There is a paucity of data among ICU patients although there are studies that determine disease-specific cut-off for ONSD to detect raised ICP.1–5 This is an observational study to study the temporal trends in ONSD during different clinical scenarios.

Objectives: To investigate the significance of the difference in two measurements of mean binocular ONSD measured after measurement at the first point of contact:Acute change in GCS/FOUR by ≥2 points.

Materials and methods: Subjects of either sex. Age — 18 to 75 years, admitted to the ICU with an established or suspected diagnosis of the following with clinical suspicion of raised ICP:Patients with a history of optic neuritis, arachnoid cyst of the optic nerve, optic nerve trauma metabolic encephalopathy were excluded. Ocular US was performed with a 7.5-MHz linear probe of Mindray DP-8500 in B mode. ONSD was measured at a depth of 3 mm from the distal-most point of the optic nerve in the globe.The pairs of ONSD values were subjected to statistical analysis.

Results: There was a statistically significant difference between ONSD values measured during first point of contact and when measured for the second time due to acute fall in GCS/FOUR by ≥2 (t = –5.906, p < 0.05), when measured for the second time after change in ICH score. (t = –4.9, p < 0.001) and after undergoing decompressive hemicraniectomy in cases of ICH/Malignant Infarct/ TBI. (t-4.189, p = 0.0002) However there was no statistically significant difference between ONSD values measured after undergoing surgery for excision of ICSOL( t=0.155,p>0.05).

Discussions: The difference in ONSD measured at the first point of contact and postoperatively was found to be statistically significant in cases of TBI/Hemorrhagic stroke. (t = −4.189, p = 0.0002). Consistent with these findings seen in our study, in a study done by Rajajee et al. patients had a rapid decrease in mean ONSD to <5 mm following therapeutic intervention with corresponding clinical neurological improvement.1 There was no statistically significant difference between ONSD values measured undergoing surgery for excision of ICSOL. This is consistent with the volume pressure relationship is much more gradual when compressible brain parenchyma is involved.

Conclusion: Difference in mean ONSD measured at the first point of contact and after acute fall in GCS/4 ≥2, after a decompressive craniectomy, after an escalation in ICP management protocol, after an observed pupillary change, after a change from initial ICH score was found to be statistically significant. However, there was no difference in the mean binocular ONSD from the first point of contact and after excision of tumor/ICSOL. Thus, the date and time of performance of ONSD assessment could be recorded and the trend must be analyzed in conjunction with other clinical findings like GCS scores, presence of papilledema, operative status, pupillary change, new-onset seizures, or any other relevant change. It can help decide the further line of management.

4. Comparison of ICU Outcome of Mechanically Ventilated GBS Patients Receiving Intravenous Immunoglobulin or Plasma Exchange in a Tertiary Neurology Referral Hospital. (Conference Abstract ID: 8

Uzzwal Kumar Mallick

National Institute of Neurosciences and Hospital, Bangladesh

DOI: https://doi.org/10.5005/jp-journals-10071-23711.143

Introduction: Guillain–Barré syndrome (GBS) is a demyelinating polyradiculoneuropathy with an acute paralyzing disorder, typically symmetric and ascending and areflexia. Incidence varies between 0.66 and 1.79 cases per 100,000 persons in the general population.1–6 About pathogenesis, the etiologies of GBS remain unclear; however, several findings suggest that causes such as an infection of the respiratory or gastrointestinal tract, vaccinations, surgery, and pregnancy generate an abnormal immune response which leads to a destruction of myelin sheaths and/or axons.7–9 The treatment is based on two mainstays: supportive care and immunomodulatory treatment. Supportive care prevents complications such as deep vein thrombosis, digestive bleeding, and infections especially and physiotherapy. Both plasma exchange (PE) and intravenous immunoglobulins (IVIg) are the two immunomodulatory treatment. Several studies demonstrated that IVIg and PE are an efficacious treatment for GBS.10 Collective data on five trials and 582 patients do not reveal a significant improvement in outcome, either improving faster or more completely with the combination of IVIg and plasmapheresis. The combination exposes the patients to the risks of adverse events from both modalities. There is no evidence to support the use of both IVIg and plasmapheresis therapies.11

Objectives: The study aimed to compare the efficacy of IVIg (intravenous immunoglobulin) vs PE (plasma exchange) in the treatment of mechanically ventilation adults with GBS in the neuro-intensive care unit of Bangladesh.

Materials and methods: This was a prospective, observational cohort study, in a neuro-ICU from 2017 to 2018. We included all patients with GBS who required mechanical ventilation (MV). We defined two groups: group I (group treated by IVIg: 0.4 g/kg/day for 5 days) and group II (group treated by PE: 5 PE during 10 days, every alternate day). We collected clinical and therapeutic aspects and outcome.

Results: Total number of 49 patients (34 in group 1 and 15 in group 2) were enrolled. The mean age was 37.4±9.2 years, with a male predominance (65.3%). on electrophysiological findings, in 4 (32.7%) patients had acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and acute motor axonal neuropathy (AMAN) in 26 (53.1%) patients and acute motor-sensory axonal neuropathy (AMSAN) was 3(6.1%)and NCS was not done in 4 (8.2%) cases. The mean length of ICU stay was 20 ± 19.10 days and 46.60 ± 30.02 days in IVIG and PE group respectively. The ICU stay was significantly shorter (p = 0.001) in the IvIg group than PE group. Patients receiving IvIg were early weaned of MV (p = 0.002) compared to those receiving PE with a statistical significance. Also, duration of M/V (p = 0.002), Need of tracheostomy (p = 0.005) and over all surval rate (p = 0.007) was significantly in favoue of IvIg group than PE group. Out of 49 patients, total 3 patients were died and they all were AMAN variety.

Discussions: In this study, the mean age was 30.94 ± 14.96 years, females were affected more than males and this is against most of the previous reports which mention that GBS demonstrates a slight male predominance, with a male/female ratio of approximately 1.2–1.5:1.12,13 Other researchers in Hong Kong reported a similar predilection between the two sexes.14 Symptoms preceding the onset of GBS were gastrointestinal infections in 36 (79.59%) patients, RTI 13 (26.53%), and 1 (2.04%) chickenpox. It was reported that respiratory infections are the commonest antecedent infection, occurring in about 40 to 70% of cases, while 7 to 20% are gastrointestinal infections.13,15 The findings of this present study have shown that AMAN is the most commonly diagnosed subtype by electrophysiological studies which is 46 (50.0%) patients followed by AIDP (34.78%), AMASN (6.52%), and no MFS. AMAN pattern was the predominant underlying subtype in China, Japan, and Central and South America.13,15 Other studies from North America and Europe as most GBS was AIDP variety.13,15 This different figure supports the large variations in the incidence of different types of GBS which may be related to seasonal or genetic factors with no support studies explaining this difference until now.15 This present study showed a favorable outcome than PE in terms of shorter ICU stay, early starting weaning from MV, shorter duration of MV, fewer complications, and less mortality. It has been found that the mean duration of ICU stay and duration of mechanical ventilation in patients treated with plasmapheresis are significantly lower than in cases treated with IVIg; this reduced the cost of hospitalization and intensive care unit (ICU) care in these patients. The results of the present study are supported by some previous studies that recorded a significant decrease in duration of ICU stay and shorter mechanical ventilation duration which compensate for the cost of plasmapheresis; better secondary outcomes were also achieved.15 However, some studies suggested that patients who received IVIg treatment had more improvement than those with plasmapheresis.16,17 Some other researchers showed no significant difference between the two treatment groups.18,19 However, some other studies suggest that patients who had IVIg treatment had more improvement than those who had PE. Indeed, Koul and Alfutaisi17 and Van der Meché et al.16 showed that the IVIg group had a significantly fast evolution than the PE group. There are some limitations of this study. The small number of cases has also made the comparison statistics not valuable enough as significant results.

Conclusion: Our work reveals a meaningful difference for the MV duration, ICU stay, weaning, and excellent recovery in the IVIg group compared to the PE group in terms of fewer complications.

11. Nursing Care and Physiotherapy

1. Effect of Graded Early Mobilization on Psychomotor Status and Duration of Intensive Care Unit Stay in Mechanically Ventilated Patients. (Conference Abstract ID: 107)

Bijoy Das, Sanchita Saha, Feroz Kabir, Sazzad Hossain

BRB Hospitals Limited, CRP-Mirpur, Jeshore University of Science and Technology, Bangladesh

DOI: https://doi.org/10.5005/jp-journals-10071-23711.144

Introduction: The main purpose of the study was to evaluate the effectiveness of graded early mobilization on psychomotor status and duration of intensive care unit (ICU) stay of patients with mechanical ventilation.

Materials and methods: Design: Considering the availability of participants in the ICU that meet the selection criteria and given time frame by the research ethical committee for data collection Quasi-Experimental design was selected as a research design.

Setting: BRB Hospital limited, Dhaka, Bangladesh. A reputed 500-Bedded General Hospital where there are 30 ICU beds,

Participants: A total of 50 patients were selected as a participant in the study from the hospital. Twenty-five were included in the ICU Treatment group and another 25 were in the intervention group using the purposive sampling method.

Intervention: Graded early mobilization was provided as an intervention to all participants of the intervention group by a professional qualified ICU physiotherapist.

Process of application of intervention: Graded early mobilization was provided as an intervention to all participants of the intervention group by a professional qualified ICU physiotherapist for 10 sessions to each participant. Most of the patients received multiple sessions (2–3 sessions) of intervention within every single day. Another senior physiotherapist was assigned as a data collector for both control and intervention groups to reduce bias and ensure blind. Written consent has been obtained from all patients’ legal guardians initially when patients were in ICU. But patient concerns were also taken and explained all the areas of the study when they are capable to talk.

Scales used: FIM (Functional Independence Measurement) scale and GAD 7 (7 point Generalized Anxiety Depression) scale.

FIM Scale: This scale has 7 points (1–7). Where 1 = Total Assistance or not Testable (Subject <25%) and 7 = Complete Independence. GAD 7 Scale: This scale has 7 points (1–7). Where every individual is given their score. Scores of 5, 10, and 15 are taken as the cut-off points for mild, moderate, and severe anxiety.

Results: In the control group mean FIM score was 17.40 (SD ±4.88) and in the Intervention group mean score was 65.70 (SD ±12.18). The mean difference was statistically significant in the “t” test (p value < 0.001). In the control group, the mean GAD 7 score was 19.50 2.71) and in the intervention group the mean of GAD 7 score was 7.5 (SD ±2.59). In ‘t’ test. p value was = 0.001. The mean of length of ICU stay was in control group 5.60 (SD ±1.07 ) and in intervention group it was 3.10 (SD ±0.56). In ‘t’ test. p value was = 0.001.

Discussions: In this study, we have found that graded early mobilization was highly significant to improve patient functional independence. Most every patient in the control group scored very low in the FIM assessment (mean: 17.40). On the other hand, as all the participants of the intervention group wear treated in ICU with graded mobilization and brought most them out of bed on the second day within ICU, they regained functionally very active within ICU stay. During discharge from ICU their FIM assessment score was very higher (mean: 65.70) compared to the control group and the change was statistically significant. In the current study, we have also found some findings regarding the psychological issues of participants during ICU stay. In the control group, 80% of participants were reported with severe anxiety level in GAD 7 assessment, only 20% were in moderate anxiety level and no one reported normal during ICU stay (GAD 7 mean was: 19.50). But in the intervention group, the scenario was different. All the participants were received graded mobilization in the ICU setting. The professional physiotherapist did plenty of verbal interaction with each and every participant which may be played a vital role in their psychological status as well. The result showed that only 40% of participants were responded to mild anxiety and 10% of participants responded to moderate anxiety in GAD 7 assessment. But 50% of participants were responded with an anxiety-free score in GAD 7 assessment (mean GAD 7 was 5.50). In comparison to the control group, the change was statistically significant (p value was <0.001). In this study, findings were in some features similar and some area better. It was found from the statistical analysis for functional improvement and independence (FIM) of patients, at 18 df the value of “t” at 5% level of significance is 11.635 as found in reference to the “t” table (appendix). Thus, the probability of occurrence (P) of the value obtained (11.635) by chance is much <0.001, the critical or 5% level of significance. “p” comes to <0.001 on referring to the “t” table. It can occur <01 times in 1,000 which means very rarely by chance. So, it showed that graded early mobilization is significantly more effective rather than only ICU treatment for functional improvement and independence of patients. So this experiment establishes the hypothesis and rejects the null hypothesis.

Conclusion: This research showed that graded early mobilization was highly effective to improve mechanically ventilated patients motor and psychological status and reduce the length of ICU stay.

2. Use of Honey vs Standard Care for Hospital-Acquired Pressure Injury in Critically Ill Children—A Multicenter Randomized Controlled Trial. (Conference Abstract ID: 27)

Jhuma Sankar, Jhuma Sankar, AV Lalitha, Ramesh Kumar, Prabudh Goel, M Jeeva Sankar, S K Kabra, Rakesh Lodha

All India Institute of Medical Sciences, New Delhi, India
All ISt Johns’ Hospital, Bengaluru, JIPMER, Puducherry, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.145

Introduction: Pressure injuries cause significant morbidity in critically ill children. Medical grade honey has been well studied in adults in the treatment of acute and chronic skin injuries of various etiologies like pressure injuries, burns, traumatic, and postoperative wounds. While the results have favored honey in most of the studies, its beneficial effects have not yet been explored in the treatment of pressure injuries in critically ill children in a randomized controlled trial.

Objectives: To examine if the use of honey (medicated) for dressing is superior to standard care in terms of time to complete wound healing in stages 1 to 3 pressure injuries (as per the National Pressure Injury Advisory Panel 2016 staging system) in children admitted to the pediatric intensive care unit.

Materials and methods: In this multicenter (3 sites), open-label, parallel-group randomized trial conducted from August 2017 to January 2019, all critically ill children aged 2 months to 17 years of age who developed pressure injury (stages 1–3 inclusive) in the hospital were eligible for inclusion. Those on >2 inotropes, signs of acute wound infection, wounds with >5 cm diameter, or known allergy to honey were excluded. Institutional Ethical Clearance was obtained from all the 3 sites and the trial was registered at ClinicalTrials.gov (NCT03391310). Children were randomized to receive either medicated honey dressing for their pressure injury in the “study group” or “routine wound care” in the “standard care” group. Manuka or active leptospermum honey dressing/gel was used in the “Honey” group. Enrolled children were followed-up till death or discharge from the hospital. We used validated tools such as the Braden Q scale for assessment of risk, prevention, and treatment of pressure injuries and, the Pressure Ulcer Scale for Healing (PUSH) tool for monitoring healing of pressure injuries. The primary outcome was time to complete wound healing (defined as complete healing of the wound without scar or contracture). The sample size calculated was 98 patients and we calculated the relative risk (RR)/mean difference with (95% CI) for all the outcomes using STATA 11.

Results: A total of 99 children were enrolled – 51 in the ‘Honey’ group and 48 in the ‘standard care’ group. Baseline characteristics including nutritional status were comparable between the groups. The most common sites of injury were bony prominences at face mask contact points. The median time to complete healing – was 7 (95% CI 6 to 7) vs. 9 days (7 to 10) in the ‘Honey’ and ‘standard care’ groups, respectively (log rank test p = 0.002). At any random time, children in the ‘Honey’ group were around 1.9-fold more likely to have completely healed their pressure injury than those in the ‘standard care’ group (hazard ratio 1.86; 95% CI 1.21 to 2.87). There were no allergic reactions or secondary wound infection in the ‘Honey group’.

Discussions: Our findings suggest that pressure injury of varying stages from 1 to 3 healed faster by about 2 days when treated with medicated “Honey” as compared to “standard care”. Our results are similar to previously published, small observational studies and case series in children in which “honey” healed wounds faster as compared to routine care. Honey forms a natural biofilm that allows gas exchange, keeps wounds moist and hydrated; has antimicrobial and catalytic properties. The faster healing observed in our study could be attributed to these wound healing properties of medicated honey.

Conclusion: The use of medicated honey dressings decreased the time to wound healing in critically ill children with a pressure injury. There were no allergic reactions or secondary bacterial infections noted in any of the children.

12. Pediatrics

1. A Combination Therapy of Norepinephrine Plus Dobutamine as a First-Line Agent in Fluid Refractory Pediatric Septic Shock—A Randomized Controlled Trial. (Conference Abstract ID: 180)

Kiran Kumar Banothu, Jhuma Sankar, U Vijay Kumar, Priyanka Gupta, Kana Ram Jat, S K Kabra, Rakesh Lodha

All India Institute of Medical Sciences, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.146

Introduction: In critically ill children, septic shock is associated with significant morbidity and mortality. Epinephrine is recommended as the first-line vasoactive agent in fluid refractory cold septic shock in children. Limited data on the use of norepinephrine plus dobutamine in critically ill children

Objectives: To compare the effect of combination therapy of norepinephrine plus dobutamine vs epinephrine as a first-line agent on shock resolution at 1 hour in children with fluid refractory cold septic shock.

Materials and methods: In this open-label randomized controlled study, we randomly assigned children aged 2 months to 18 years with fluid refractory cold septic shock [as defined by American College of Critical Care Medicine (ACCM), 2017] to receive either norepinephrine plus dobutamine (intervention group) or epinephrine (control group). The primary outcome was shock resolution at 1 hour of vasoactive therapy. Shock resolution was defined as the attainment of therapeutic endpoints as per ACCM guidelines. Secondary outcomes were shock resolution at 6 hours, 24 hours, time to attain therapeutic endpoints, time to vasoactive agent withdrawal, and 28-day mortality. Children were managed as per ACCM guidelines, 2017. As this was a pilot study, all eligible patients admitted during the study period (November 2018 to June 2020) were enrolled. Intention to treat analysis was done.

Results: We enrolled 67 children (38 boys): 34 in the norepinephrine plus dobutamine group and 33 in the epinephrine group. The median (IQR) age was 84 (18–120) months and majority were boys (57%). There was no significant difference between the groups in terms of shock resolution at one hour of therapy [17.6% vs. 9%; RR: 2.0; 95% CI: 0.54–7.35; p = 0.25]. At 6 hours, the proportion of children attaining shock resolution was greater in the norepinephrine plus dobutamine group, although it was not significant [76.4% vs 54.5%; RR: 1.69; 95% CI: 0.92–3.13; p = 0.05]. The difference persisted at 24 hours of vasoactive therapy [97% vs. 84.8%; RR: 1.14; 95% CI: 0.97-1.33; p = 0.09]. There was a significant difference in the time to shock resolution – earlier in the norepinephrine plus dobutamine group [3 (2, 6) vs 6 (3, 10) hours; log-rank p = 0.01]. The time to vasoactive agent withdrawal was shorter [53 (28, 185) vs 84 (50, 154) hours; log-rank p = 0.52] and the 28 day mortality was lower in the norepinephrine plus dobutamine group [23.5% vs 39.3%; RR: 0.59; 95% CI: 0.28-1.25; p = 0.16]. The difference however, was not significant. Children in the norepinephrine plus dobutamine group had lower organ dysfunction score (pSOFA) on day 2 of randomisation [Median (IQR): 8 (5,10) vs 9 (8,11); p = 0.04], although subsequently there was no difference between the groups. The mean cardiac index was higher in the norepinephrine plus dobutamine group at 6 hours [Mean (SD): 4 ± 1 vs.3.1 ± 1.2; p = 0.01] and the difference persisted at 24 hours of initiation of vasoactive therapy [4.2 ± 1.1 vs 3.5 ± 1.2; p = 0.05]. There was no difference between the two groups in terms of rhythm abnormality and peripheral ischemic changes.

Discussions: In this randomized controlled trial, we found that shock resolution at 1 hour of therapy was not different between the groups. However, the proportion of children attaining shock resolution was greater at 6 and 24 hours in the norepinephrine plus dobutamine group. Also, children in the norepinephrine plus dobutamine attained shock resolution earlier. There are no published pediatric studies on the use of norepinephrine plus dobutamine. In adults, Annane et al. observed that there was no difference in time to hemodynamic success and time to vasoactive agent withdrawal. Mixed results were observed in adults in terms of rhythm abnormalities with these interventions. Limited evidence showed that the use of norepinephrine does increase cardiac output. Chen et al. and Cheng et al. observed that a combination of vasoactive agents is associated with lower mortality in adults.

Conclusion: In children with fluid refractory cold septic shock, with use of norepinephrine plus dobutamine as a first-line vasoactive agent, although there was no difference in shock resolution at 1 hour of therapy, higher rates of shock resolution at 6 and 24 hours of vasoactive therapy were observed as compared to the use of epinephrine. The time to shock resolution was also earlier in the norepinephrine plus dobutamine group. Our findings need further validation in a larger patient population.

2. Assessment of Serum Vitamin E Levels and Clinical Outcome in Pediatric Intensive Care Unit. (Conference Abstract ID: 177)

Suchetha S Rao, Owais Ahmed Mushtaq, Poornima Manjrekar, Prasanna Mithra

Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.147

Introduction: Vitamin E is an important free radical scavenger that is protective against oxidative injury. Studies evaluating Vitamin E status in a pediatric intensive care unit (PICU) and its role modulating oxidative damages in critical illness are lacking.1 This study was conducted to evaluate the serum levels of Vitamin E in children admitted to PICU and find out the relation of Vitamin E levels with clinical outcomes.

Materials and methods: A hospital-based cross-sectional study was conducted after institutional ethics committee approval and informed consent from parents. Blood samples of 60 children admitted to PICU of tertiary care hospitals attached to Kasturba Medical College, Mangaluru were evaluated to determine serum levels of vitamin E. Clinical outcome was assessed. Relation of serum Vitamin E levels for the need for respiratory support, mechanical ventilation, multiorgan dysfunction, inotropic requirement, length of PICU stay and mortality was assessed. Mann–Whitney U test and chi-square tests were used for analysis. A p value of <0.05 was considered statistically significant.

Results: Sixty children comprising 28 males (47.70%) and 32 females (53.30%) were enrolled. Their average age was 2.95 ± 3.66 years (range: 1 month to 13 years). Out of the 60 children,49 (81.7%) developed organ dysfunction involving one or more organ systems. The most common organ system involved was respiratory (71.6%) followed by neurological (28.3%). The average length of PICU stay was 9.08±6.00 days. Among the study subjects, 2 (3.3%) children expired. The mean value of vitamin E was 3.40 ± 4.67 mcg/ml and vitamin E deficiency was noted in 46 (76.7%) of children. There was a statistically significant association between vitamin E levels with organ dysfunction (p = 0.034) and the need for respiratory support (p = 0.032).

Discussions: Serum levels of micronutrients may be affected by critical illness or inflammation.2 Vitamin E modulates cell-mediated immunity by regulating the generation of lipid peroxidation and prostaglandins. a-tocopherylquinone is the commonest product of oxidative damage which is identified in tissues.3 There have been conflicting reports about vitamin E levels in critical subjects with very few studies evaluating pediatric age groups.1 Vitamin E deficiency was reported by Valla et al. in addition to other micronutrient deficiencies in critically ill patients. There was a significant decreasing trend in levels of micronutrients while oxidative stress intensity increased.4 Our study reported Vitamin E deficiency in the majority of the children which is alarming. Lower levels of Vitamin E were found in patients requiring respiratory support and those with organ dysfunction which may imply the deficiency of Vitamin E leading to oxidative stress and organ damage. However, low plasma levels per se may not indicate low total body stores as critical illness may induce redistribution of antioxidant vitamins.5

Conclusion: The majority of the children were deficient in vitamin E. Lower Vitamin E levels were associated with organ dysfunction and an increased need for respiratory support. It is hence important to emphasize that children requiring intensive care may have micronutrient deficiency which may affect morbidity and mortality.

3. Scope, Safety, and Feasibility of Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: Our Experience. (Conference Abstract ID: 151)

Karthik Kumar Balasubramanian, Priyavarthini Venkatachalapathy, Suchitra Ranjit, Rajeswari Natraj, Vasanth Kumar, Indira Jayakumar, Saravanan Margabandhu

Apollo Children’s Hospital, Chennai, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.148

Introduction: Therapeutic plasma exchange (TPE) is challenging in pediatric patients compared to adults owing to the difficulty in vascular access and other technical considerations. Still, its application in the pediatric intensive care unit (PICU) is increasing with evolving evidence to support its use in select conditions. The American Society For Apheresis (ASFA) regularly updates their evidence-based guidelines on the use of therapeutic apheresis in adults and children, the eighth edition (2019) being the latest. Though there is extensive literature on adults, there is a dearth of studies in children on this subject, especially in the Indian context.

Objectives: To study the demographics, clinical indications, and outcomes of patients who have undergone TPE in a tertiary care PICU.

Materials and methods: This is a retrospective study performed in our tertiary care PICU over 5 years from January 2016 to December 2020 among patients between 1 month and 16 years of age. Demographic details, diagnosis, indication for TPE, procedure details, concurrent extracorporeal therapies, and outcome data were collected from medical records and analyzed. Indications were compared with the latest ASFA categories of recommendations for therapeutic apheresis. The therapeutic response, serious adverse events, PICU length of stay (LOS), and death during hospitalization were studied as outcome variables. Serious adverse events were defined as those occurring during or within 6 hours of completion of the procedure and requiring additional vasoactive agents, mechanical ventilation, cardiopulmonary resuscitation (CPR), or resulting in mortality.

Results: Eighty-eight sessions of TPE were done in 20 patients over 5 years period. Median age of the study population was 10.6 years (Range 7 months–16 years) with male:female ratio of 1.9:1. Median weight was 29.5 kg (Range 6.3 kg–55 kg). Median number of sessions per patient was 5 (Range 1–10). 12 patients had multiorgan dysfunction syndrome (MODS) and equal number of patients required mechanical ventilation during PICU stay. 9 out of 20 patients required concurrent renal replacement therapy (RRT), while none were on extracorporeal membrane oxygenation. All patients underwent 1.5–2 times plasma volume exchange depending upon the diagnosis. The replacement fluid was Fresh Frozen Plasma (FFP) in 12 patients while it was a combination of FFP and 5% albumin in 7 patients. Cryo-poor plasma was used in 1 patient with sepsis/MODS. Median duration of each session was 3 hours (Range 2.5–4 hours). Patients in our study received TPE for 11 different indications falling under various ASFA categories. Thirteen patients underwent TPE for ASFA category I indications (first-line therapy), whereas 3 and 4 patients underwent TPE for categories II(second-line therapy) and III (optimum role not established, decision invidualised) indications respectively. Common indications were thrombotic microangiopathy (TMA) of various causes (7/20) and acute liver failure (6/20). Other indications were vasculitis/connective tissue disorder in 5 patients and fulminant neurological diseases in 2 patients. None of the indication fell under ASFA category IV(TPE ineffective or harmful). Five serious adverse events occurred during total 88 sessions (5.6%). 3 of them occurred during procedure and 2 occurred within 6 hours. There was good therapeutic response in 14 patients (70%). Average PICU LOS was 16 days and there were 3 deaths during hospitalization (15%).

Discussions: TPE in children needs close monitoring because of the potential for hemodynamic instability and other complications during the procedure. So, all TPE procedures in our hospital are done only in PICU. In this retrospective study on TPE in children from our PICU, 20 children underwent 88 sessions of TPE over 5 years. The median age was 10.6 years (range 7 months–16 years) and the median weight was 29.5 kg (range 6.3–55 kg) which were comparable to other similar studies done in children (1–4). Patients in our study had a wide spectrum of diseases involving various organ systems receiving TPE for different indications. TMA and ALF were the common reasons for initiating TPE. Most of our patients had ASFA category 1 indication. This is similar to a study by Haque et al., where 23 out of 28 patients received TPE for ASFA category 1, though indications were predominantly neurological diseases and TTP.4 In contrast to our study results, “Sepsis/MODS” (ASFA category III) was the predominant indication in studies done by Keskin et al., Sik et al., and Duyu et al.3,5,6 Therapeutic response was good in 14 patients (70%). Only a few studies have evaluated the serious adverse events. The incidence of serious adverse events was 5.7% in our study, while it was 3.8% in Haque et al.’s study. Compared to other previously mentioned studies where the mortality rate ranged from 18 to 37.5%, the mortality rate was less in our study population (15%). The results of our study suggest that TPE is effective in diseases involving various organ systems and outcomes are good. It is technically feasible even in infants. However, serious adverse events do occur due to the procedure per se. Hence, it is wise to choose the indications carefully, have predefined goals, anticipate technical difficulties, and be prepared for adversities. Limitations include that it is a single-center study and its retrospective design. The severity of disease and mortality risk at presentation could not be objectively assessed because of a lack of certain data. There has been only one previously published study on TPE in PICU from India. It was from our center, but it included only TPE for non-renal indications.7 To the best of our knowledge, our present study is the first comprehensive data from India on TPE in PICU encompassing various diseases and indications. As more and more diseases with immunological mechanisms are discovered, the scope of TPE in children expands. Most of the currently available literature in children are from retrospective studies done in single centers. Well-constructed, prospective, collaborative clinical trials need to be planned to further explore the scope and limitations of TPE in children.

Conclusion: TPE is a promising tool in PICU to treat a variety of conditions with significant morbidity and mortality. It is technically feasible even in small infants. However, serious adverse events do occur and need to be anticipated for better outcomes.

4. Efficacy and Safety of Levetiracetam vs Phenytoin as Second-line Antiepileptic Agent in Pediatric Convulsive Status Epilepticus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. (Conference Abstract ID: 101)

Renu Suthar, Suresh Kumar Angurana

PGIMER, Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.149

Introduction: Status epilepticus (SE) is the most common neurological emergency in children. Intravenous PHT remained the preferred second-line anti-seizure medication (ASM) for pediatric SE. However, PHT is associated with various life-threatening adverse events. LEV is emerging as an alternative second-line ASM for the management of pediatric SE with efficacy and safety profile.

Objectives: To evaluate the efficacy and safety of levetiracetam (LEV) in comparison to phenytoin (PHT) as second-line antiseizure medication (ASM) for pediatric convulsive status epilepticus (SE).

Materials and methods: Data source: PubMed, Embase, Google scholar/Google, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials. Randomized controlled trials (RCTs) assessing LEV and PHT as a second-line agent for convulsive SE in children <18 years published between January 1, 2000, and November 30, 2020, were selected. Data extraction: The data were pooled regarding the proportion of children achieving seizure cessation within 5 to 60 minutes of completion of study drug infusion (primary outcome); and seizure cessation within 5 minutes, time to achieve seizure cessation, seizure recurrence between 1 and 24 hours, intubation, and cardiovascular instability (secondary outcomes). Data were analyzed using RevMan version 5.4 and quality analysis was done using the Cochrane risk-of-bias tool. The study protocol was registered with PROSPERO.

Results: Twelve RCTs with 2293 children were enrolled. Seizure cessation within 5-60 minutes was similar with both the drugs [82% in LEV vs. 77.5% in PHT, risk ratio (RR) = 1.04, 95% CI 0.97–1.11, p = 0.30]. Seizure recurrences within 1–24 hours was higher with PHT in comparison to LEV (16.6% vs 9.7%, RR = 0.63, 95% CI 0.44–0.90, p = 0.01). Higher proportion of children in PHT group required intubation and mechanical ventilation (21.4% vs. 14.2%, RR = 0.54, 95% CI 0.30–0.98, p = 0.04). Seizure cessation within 5 minutes, time to achieve seizure cessation, and cardiovascular instability were similar with both the drugs. Three studies were at low risk of bias, and nine studies had high risk of bias.

Discussions: In this systemic review and meta-analysis of 12 RCTs involving 2293 children, we demonstrated that the LEV was not superior to PHT as a second-line agent for pediatric convulsive SE. The efficacy of LEV and PHT varied from 50 to 94% and 49 to 80%, respectively. In the pooled analysis, the efficacy of LEV and PHT to control seizures within 5 minutes of study drug infusion (61 vs 65%), 5 minutes to 1 hour of study drug infusion (82 vs 77.5%) were similar, respectively. However, the seizure recurrence rate within 24 hours of study drug infusion was significantly higher in the PHT group as compared to LEV. The rate of intubation or mechanical ventilation was significantly higher in the PHT group whereas the rates of cardiovascular instability were similar with both the groups.

Conclusion: The efficacy of LEV is not superior to PHT as second-line ASM medication for Pediatric convulsive SE. However, the seizure recurrences between 1 and 24 hours and the need for intubation and mechanical ventilation were significantly higher with PHT in comparison to LEV.

5. Deriving a Novel, Cost-Effective Predictor of PICU Mortality in Resource-limited Settings: is “LAG” Index (Serum Lactate X Anion Gap at Admission) the Answer? (Conference Abstract ID: 80)

Suddhasatta Ghosh, Grace Rebekah, Kala Ebenezer, Ebor J Jacob

CMC Vellore, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.150

Introduction: Various illness severity scoring systems have shown conflicting accuracies in predicting mortality in Indian pediatric patients admitted to the PICU. While indices such as PRISM and PIM-scores have been widely validated, their use of multiple variable-based logistic regression models makes it cumbersome for use in a resource-limited setup.

Objectives: To assess the predictive accuracy of the “LAG” index as a novel predictor of mortality in a tertiary care PICU.

Materials and methods: A cross-sectional study was carried out in 500 consecutive children admitted to the PICU at CMC Vellore over a period of a year (July 2017 to July 2018). Demographic data, serum lactate, anion gap, and LAG-index at admission, PIM 2 score (www.sfar.org/scores2/pim22.html) for calculation of predicted mortality rate were assessed. Data were analyzed using Pearson’s correlations and stepwise multiple regression. The sensitivity and specificity of the LAG-index were measured by constructing the receiver operating characteristic curves (ROC). We further utilized two novel statistical tools of net reclassification improvement (NRI) and integrated discrimination improvement (IDI) to assess the incremental predictive impact of new models that integrate a candidate marker (LAG) to preexisting models (PIM2). NRI and IDI values above zero indicate the improved performance of the novel index.

Results: In the study population (n = 500), the median age was 48 months (0-204 months) with a predominance of male patients (62%). Sepsis (21%) was the most common cause of admission followed by cardiac (18%) and neurological (16%) illness. Overall there were 120 deaths (observed mortality 24%) while 380 patients survived (76%). Mean LAG-index score was 58.78(±23.93). The LAG-index amongst patients who died (n = 120) was significantly higher (94.9 vs 45.2, p = 0.001) than the survivors (n = 380). LAG-index correlated significantly with lactate(p = 0.001), anion gap(p = 0.001) and PIM-2 scores(p = 0.001). Amongst the indices, PIM-2 (p = 0.001), LAG-index (p = 0.001) and serum lactate(p = 0.01) correlated well with observed mortality. AUC by ROC-analysis was highest for PIM-2 (AUC = 0.79, 95% CI 0.646–0.920) which was very similar to the LAG-index (AUC-0.76, 95% CI: 0.587–0.84, p = 0.24). LAG-index performed significantly better than serum lactate (AUC – 0.64, CI: 0.503–0.787, p = 0.02) and anion gap (AUC-0.56, CI: 0.425-0.700, p = 0.01) as predictors of mortality. The optimal cut off value for LAG-index in predicting mortality in our population was derived as ≥94.7 using ROC analysis (Sensitivity:89%, Specificity: 78%, PPV: 91.7%, NPV:88.6%, LR: 3.36, Youden’s index: 0.67). The incorporation of LAG to PIM2 gave an NRI of 18.7% (p = 0.001) and IDI of 8.2% (p < 0.001). However, incorporation of serum lactate and anion gap individually into PIM2 failed to show improved prediction of mortality as evidenced by poor NRI and IDI values. On comparing AUCs between pre-existing models and LAG-incorporated models, the model of PIM2 with LAG showed significantly enhanced AUC of PIM2 with LAG (0.832, p = 0.01).

Discussions: Our study is the first to validate the novel LAG-index at admission as a significant predictor of PICU mortality. Given the simplicity of calculation, single-point measurement, and widespread availability, LAG-index can be of immense significance in resource-limited PICU settings like India. A large sample size of 500 PICU patients, use of PIM2 as the standard comparator model, and the use of NRI (Net Reclassification Improvement) and IDI (Integrated Discrimination Improvement) indices are the strengths of our study. Though we have validated LAG-index in a single tertiary care PICU, our findings can encourage further multicenter prospective studies evaluating the utility of the LAG-index as a predictor of mortality in different subsets of PICU patients.

Conclusion: LAG-index can bring about a paradigm shift in predicting mortality in Indian PICU.

6. Can we Predict Outcome of High-flow Nasal Cannula (HFNC) in Children Admitted to PICU with Bronchiolitis: A Novel Index That “ROX”? (Conference Abstract ID: 64)

Suddhasatta Ghosh, S Ranadeep, H Sathya, Benjamin Sagyaraj

Saveetha Medical College, Chennai, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.151

Introduction: A significant concern during high-flow nasal cannula (HFNC) therapy in children admitted to PICU with bronchiolitis is avoiding unnecessary delay in intubation. However, there remains a paucity of indices, especially in resource-limited PICU settings, that can accurately predict the need for mechanical ventilation (MV) in this group of children.

Objectives: To validate the diagnostic accuracy of the novel ROX-index [defined as the ratio of oxygen saturation as measured by pulse oximetry/FiO2 to respiratory rate (RR)] for determining the need for mechanical ventilation in children with bronchiolitis on HFNC therapy.

Materials and methods: This was a 1-year prospective observational cohort study performed in the pediatric intensive care unit (PICU) of a South Indian tertiary care hospital, including children with bronchiolitis who were treated with HFNC. Children needing immediate MV and those electively intubated for diagnostic or therapeutic procedures were excluded. Patients were followed up till death or discharge and failure of HFNC was defined as a subsequent need for MV. Clinical and respiratory variables including arterial blood gas parameters (SpO2, FiO2, RR, flow, PaO2, PaCO2) and ROX-index (SpO2/FiO2 to respiratory rate) were assessed at 0, 2, 6, 12, 18, and 24 hours and subsequently once daily after initiation of HNFC, while the length of ICU stays, HNFC therapy and MV were also recorded. Predictive accuracy of ROX-index and specific cut-offs were derived using area-under-receiver operating characteristic curves (AUROC) analysis while multivariate regression analysis using Cox proportional hazard model was done to elicit association of ROX-index with the highest risk of HNFC failure.

Results: Among the 129 patients treated with HFNC, 37 (29%) required intubation, with age and gender distribution being similar in the HFNC-successful (n = 92) and HFNC-failure (n = 37) groups. The predictive accuracy of the ROX index as evidenced by the AUROC was highest at 2 hrs (0.713, CI: 0.63–0.79, p =0.001), 6 hrs ( 0.766, CI:0.71–0.83, p = 0.002), 12 hrs (0.843, CI:0.76-0.88,p = 0.001),18 hrs (0.811, CI: 0.69–0.84, p =0.002) and 24 hrs (0.792, CI:0.70–0.83, p =0.01) amongst all respiratory variables measured, with cut-offs of ROX-index at 2 hrs, 6 hrs and 12 hrs ( 4.64, 4.95 and 5.34 respectively) demonstrating superior sensitivity, specificity and positive predictive values. Further, children who failed the HNFC (n = 37) showed lesser increase in ROX-index over the first 12 hours than those who were successful on HNFC (n = 92, p < 0.01), thus suggesting the gradual increase in ROX-index as a valuable predictor in the initial 12 hours. Moreover, at the pre-specified cutoffs, regression analysis revealed ROX-index measured at 2hrs (hazard ratio, 0.434; 95% confidence interval, 0.264–0.715;P = 0.001), 6hrs (hazard ratio, 0.304; 95% confidence interval, 0.182–0.509; P < 0.001)and 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161–0.524; P < 0.001) after HFNC initiation to be consistently associated with a lower risk for intubation, after adjustment of multiple covariates. Intubation after 48-hours of HNFC was not associated with increased mortality.

Discussions: Our results indicate that ROX-index can be a valuable tool in a resource-limited PICU setting in determining a need for ventilation in bronchiolitis patients. Not only specific ROX-values at timed intervals but also the rate of increase over the first twelve hours can be useful predictors of HFNC failure in these children. This is the first study to utilize this novel index in a pediatric Indian population.

Conclusion: This is the first study to validate the predictive performance of the novel ROX-index in children admitted to PICU with bronchiolitis and treated initially with HFNC. ROX provides an easy-to-use, low-cost, and effective tool which can have significant therapeutic implications in resource-limited PICU setups to determine the need for ventilation in bronchiolitis patients.

7. Bicarbonate Deficit Correction in Acute Diarrhea Associated Severe Dehydration and Severe Non-Anion Gap Metabolic Acidosis: A Pilot Open-Label Randomized Control Trial. (Conference Abstract ID: 49)

Lalit Takia, Arun Kumar Baranwal, Suresh Kumar, M Jayashree

PGIMER Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.152

Introduction: World Health Organization (WHO) recommendation is silent on the role of bicarbonate therapy in children with acute diarrhea and severe dehydration having severe non-anion gap metabolic acidosis (NAGMA) due to lack of pediatric evidence. We planned to study the efficacy and safety of bicarbonate therapy in addition to dehydration correction in children with acute diarrhea and severe dehydration and severe NAGMA.

Materials and methods: Children (age, ≥1 months to <12 years) with acute diarrhea and severe dehydration presenting with severe NAGMA (pH < 7.2 and/or serum bicarbonate <15 mEq/L) were enrolled in a randomized open-label trial at a tertiary care center. Controls (n = 24) received WHO-recommended dehydration correction with ringer lactate, while an additional bicarbonate deficit correction was given in the intervention group (n = 23) at admission. Time to resolution of metabolic acidosis (pH >7.30 and/or bicarbonate >15 mEq/L) (primary outcome), adverse outcome (composite of PICU transfer and mortality), acute care area free days in 5 days (ACAFD5), hospital stay, and safety (secondary outcomes) were compared.

Results: Both groups were comparable at baseline. Metabolic acidosis resolved significantly faster in the intervention group compared to controls [median (IQR); 8 h (4,28) vs 12 h (4,72); p = 0.013]. At 16 h, more children in intervention group achieved target compared to controls (22/23 vs 16/24, p = 0.031). Among controls, patients with fluid refractory shock (n = 4) needed higher inotropic support compared to intervention group (n = 2) (VIS, 34 vs 10). Five patients in the control group needed PICU transfer (two of whom died), while none in the intervention group (p = 0.049). Intervention group had more ACAFD5 compared to controls [median (IQR); 2 (1,2) vs 1 (1,2); p =0.17].

Discussions: Considering the longer time required for resolution of acidosis and relatively higher incidence of adverse outcome in severe NAGMA patients, we hypothesized that providing bicarbonate, in addition to WHO-recommended dehydration correction with RL, may accelerate the resolution of acidosis and improve the overall outcome. Low serum bicarbonate is the commonest electrolyte abnormality seen in children with diarrhea, and severity of dehydration and other parameters of sickness are found to correlate bicarbonate levels at admission.1–3 In a small controlled trial (n = 30), done more than five decades back, bicarbonate deficit correction in children with metabolic acidosis (pH < 7.34; range, 7.00–7.34) could not show any difference in time taken in the correction of metabolic acidosis.3 There is no information on the number of children with severe metabolic acidosis (pH < 7.20) in the study. In another study, intravenous dehydration correction with bicarbonate-containing fluid was shown to increase the serum bicarbonate and pH significantly compared to non-bicarbonate containing fluid in severely dehydrated infants.4 The persistence of metabolic acidosis for a longer duration seems to be the cause of prolonging the requirement of vasoactive agents, the need for PICU transfer, and mortality in the control group. A better outcome in the intervention group might have been due to the rapid resolution of metabolic acidosis. Sharifuzzaman et al. had also demonstrated higher mortality associated with metabolic acidosis.5 Wathen et al. demonstrated extended hospital stay with lower bicarbonate in patients with dehydration.6 Similarly, children in the intervention group with early resolution of acidosis had less ACA stay and hospital stay. Early resolution of acidosis is likely to lead to less utilization of critical care services and early discharge from hospital, and thus the faster turnover. It is likely to free-up the scarce PICU/hospital beds and healthcare resources for other more deserving critically ill children in LMICs.

Conclusion: Simultaneous bicarbonate therapy during dehydration correction in the sickest lot of diarrhea-dehydration children with severe NAGMA led to faster resolution of metabolic acidosis, less utilization of critical care facilities, and less mortality. No adverse events were associated with bicarbonate therapy. These findings need further validation from larger multicentric trials.

8. Superior Venacaval Oxygen Saturation Monitoring-based Goal-directed Therapy vs Standard Care in Children with Septic Shock: An Open-label Randomized Control Trial. (Conference Abstract ID: 46)

Namita Ravikumar, Arun Baranwal, Muralidharan Jayashree, Ashish Jain, Savita Verma Attri, Pramod Gupta

PGIMER, Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.153

Introduction: Widespread implementation of resuscitation bundle has significantly reduced septic shock mortality in high-income countries questioning the importance of superior venacaval oxygen saturation (ScvO2) monitoring-based early goal-directed therapy (EGDT). However, higher infection burden, suboptimal transport, poor infrastructural facilities, lack of time management, and inability to adhere to the EGDT-based management bundles in lower middle-income countries (LMICs) pose a challenge. We studied the effect of ScvO2 monitoring based GDT until shock reversal vs standard care prevalent in a setting of high pediatric septic shock mortality in terms of feasibility, mortality, and other outcomes.

Materials and methods: Design: Randomized Control Trial.

Setting: Tertiary care teaching hospital.

Study period: 15 months (October 2018 to December 2019).

Participants: Children (6 months–12 years) with fluid refractory septic shock. Inotrope at arrival, chronic illness, healthcare-associated infection, and contraindication for central venous catheter were exclusions.

Interventions: GDT group (n = 46) received fluids, inotropes, and packed red cells targeting ScvO2 of >70% throughout the shock management. Standard therapy (ST; n = 44) group received usual care as per prevalent unit practice.

Outcome: Mortality, shock endpoints, organ dysfunction, and ScvO2 trend.

Results: Baseline characteristics: GDT had lower median age (30 vs 60 months; p =0.09), more severely malnourished children (21.7% vs 6.8%; 0.07), lower pH (7.25 vs 7.315; p = 0.016), had received more fluids (30 vs 20 mL/lg; p = 0.89) and higher vasoactive inotrope score at enrolment (30 vs 20; p =0.66). PRISM-III scores at 12 and 24 hours were comparable. GDT group had lower median hemoglobin (8.8 vs 9.9 g/dL, p = 0.12), platelet count (1.27 vs 1.31 x 106 per mm3) and higher TLC (12.5 vs 10.4 x 103 per mm3). Primary Outcome: Significantly more patients died in GDT [34 (73.9%) vs 21 (47.7%); p = 0.011]. Secondary Outcomes: Lesser GDT patients attained endpoints within 5-day intervention period [24 (52%) vs 29 (66%); p = 0.21], however they attained it earlier (9h vs 12h; p = 0.42) with higher emergency room (ER) mortality [16 (34.7%) vs 10(22.7%); p = 0.2]. Median duration of vasoactive drugs among survivors was longer in GDT group (75h vs 59h; p = 0.62). Median length of ACA stay was higher in GDT group (9 h vs 6.5 h; p = 0.77). More children required mechanical ventilation in GDT group [43 (93.5%) vs 37 (77.3%); p = 0.03].

Discussions: Our study analyzed the outcomes of GDT with interventions targeting ScvO2 >70% until 5 days from enrolment vs the existing standard of care in a setting with a limited number of PICU beds. The existing unit’s current practice includes initial fluid resuscitation, vasoactive infusion through the peripheral line, intubation and hand ventilation if required, early antibiotic therapy, CVC insertion (preferably femoral vein) when VIS > 30 or in situations of difficult peripheral access. We postulated that even if early goal direction, in the strict sense, was difficult, targeting ScvO2 > 70% and sustaining it may improve outcomes. However, we found that the all-cause mortality in GDT (74%) was higher than the ST group (47%).

Conclusion: GDT group had a worse outcome compared to ST, however patients in the former group were sicker on many aspects despite randomization. Children who persistently had ScvO2 < 70% despite resuscitation were likely to have an unfavorable outcome. Adherence to components of SSC guidelines is difficult to achieve in absence of PICU transfer for the level of critical illness we cater to. The endpoints of resuscitation were attained earlier in the GDT group, although it could not get translated into survival.

13. Perioperative Clinical Studies

1. Heart Rate Monitoring of Anesthesiology Residents during the Airway Management of COVID-19 Suspect Patients: An Observational Study. (Conference Abstract ID: 191)

Adabala Vijay Babu, Bhavna Gupta

AIIMS, Rishikesh, Uttarakhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.154

Introduction: Technology has become an integral and central element in modern-day life and affects how we all work and function. Technology has a positive effect for the most part, as it helps us handle and monitor our everyday activities. Nevertheless, new technology has a significant role to play, such as, solving several other difficulties confronting healthcare services. Anesthesiology by itself is a stressful job. And the stress is quite evident in the residents, which leads to several health-related issues, cardiovascular diseases at an early age, a high number of suicidal attempts by the anesthesia residents.1 With the advancement of technology, smartphone applications for healthcare, e.g., mobile heart disease detection, heart rhythm analysis, remote home care monitoring, and eye disease diagnosis, have become highlighted. We conducted a study to monitor the anesthesiology residents’ heart rate variation in the COVID-19 suspect area and compare it to their sleeping HR and baseline HR value. We assume that a significant increase in HR during airway management is an indicator of the stress the resident is undergoing, which usually goes unnoticed.

Materials and methods: In a tertiary care academic center, this was a prospective observational cohort study of anesthesiology residents. All the residents included in the study were of age 20 to 45 years, ASA I–II, and the residents with the experience of managing the airway for 6 months. Airway management of patients with difficult airways was not included in the study. Informed consent was taken from all the residents who participated in the study. As this sort of research is the first of its kind, 30 residents were included in this study. All participants wore a smartwatch MI band four before going to sleep and installed MI fit application on their smartphones and clicked on continuous sleep and heart rate monitor to detect sleep patterns and sleeping heart rate. From the inbuilt software recordings in the application, participants’ sleeping duration, sleeping HR, and baseline HR were recorded. The next day, HR monitoring of residents during the induction of general anesthesia in an elective case (COVID SUSPECT area) from 8:40 am to 9 am was recorded in three phases (pre-induction, during induction, and post-induction).

Results: 30 residents were included with a mean and standard deviation of age (26.4 + 1.4, minimum 22 and maximum 29) years, BMI (23.82 + 2.52, minimum 18.68 and maximum 26.56) KG/M2 and having a sleeping pattern of (6.3 + 0.8 minimum 5 and maximum 8) hours with a predominance of male residents (11:4). Mean heart rate variations at various time points is summarised in table 1 with significant difference seen at time points (T- B vs T-R and T-I vs T-B and T-R with p value 0.001, 0.000 and 0.000 respectively). No significant difference was observed between the baseline HR when compared to pre intubation HR and post-intubation HR, but significant difference was observed when it was compared to resting HR (p value 0.115 and 0.000 respectively). Mean and standard deviation of percentage increase in heart rate at intubation from resting heart rate was 42.79 ± 25.54 percent. (minimum increase 2.79 and maximum increase 98%). Figure 1 reflects the heart rate of participants at various time points. S. No Time points Heart rate pattern Mean + SD P-value P value 1 T-R Sleeping heart rate 69.3 + 13 2 T-B Baseline HR 89.1 + 5.7 T-B vs T-R 0.001 T-B vs T-R 0.000 3 T-pre I Pre Intubation HR 86.0 + 5.3 T-pre I vs T-B 0.523 T-pre I vs T-R 0.553 4 T -I Intubation HR 96.4 + 10.4 T-I vs T-B 0.000 T-I vs T-R 0.000 5 T -post I Post intubation HR 88.6 + 8.2 T-post I vs T-B 0.115 T-post I vs T-R 0.000.

Discussions: Stress has a detrimental impact on healthcare organizations at multiple levels and, further significantly, is correlated with poor patient safety and quality of treatment, as it can manifest itself through exhaustion and diminished cognitive functioning, eventually affecting the performance of individual work and contributing to a greater risk of errors. Smartwatches, wrist bands, and activity trackers commonly used these days are based on electrocardiography (ECG) or photo-plethysmography (PPG).2 We used Mi band 4 to monitor the heart rate of all residents. We chose this band because it is cheap, comfortable to wear, rather discreet and lightweight. It is based on the principle of photo-plethysmography (PPG). Our study observed a significant difference in sleeping HR when we compared the baseline HR and with the induction HR (p < 0.05). This could be due to the activity of the resident and the stressor response of the body. And we found a significant difference between baseline HR and intubating HR.

Conclusion: This sort of continuous information can be used as the feedback option for users to improve their work efficacy. To date, technology has revolutionized healthcare facilities. Working knowledge of these smart devices will help us to balance our stress-free day-to-day activity.

2. To Study the Relation of the Volume of Local Anesthetic and Diaphragm Motility in Ultrasound-guided Supraclavicular Brachial Plexus Block. (Conference Abstract ID: 186)

Deepti Mehta, Gurjeet Khurana, Abhimanyu Pokhriyal

Himalayan Institute of Medical Sciences, Uttarakhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.155

Introduction: Regional anesthesia and peripheral nerve blocks have an important role and have many advantages to be near ideal anesthetic techniques for various surgical procedures. It provides site-specific surgical anesthesia, prolonged postoperative analgesia, minimizes the need for general anesthesia, and facilitates early discharge. Peripheral nerve block technique has an opioid-sparing effect, more comfortable for the patient, eliminating side effects, such as, nausea, vomiting, and reduces patient’s fear, gagging on the endotracheal tube, surgical pain, remembrance, residual weakness, shivering, sore throat, and somnolence. It meets the demand of the surgeon, anesthesiologists, and more comfortable for the patient. A comfortable, symptom-free patient can be discharged from the post-anesthesia care unit in a timely fashion, thus reducing prolonged stay to hospital and cost.1,2

Objectives: To study the incidence of diaphragmatic paresis/paralysis with different volumes of 0.5% ropivacaine in ultrasound-guided supraclavicular brachial plexus block.

Materials and methods: Thirty-six patients undergoing forearm and hand surgery receiving ultrasound-guided supraclavicular brachial plexus block with 0.5% ropivacaine were enrolled. As per Dixon and Massey up and down method,3 the initial volume of 0.5% ropivacaine was 25 mL and we observed for the incidence of diaphragmatic paralysis/paresis in 5 consecutive patients then 0.5% ropivacaine volume for the next patients was determined by the response of the previous patients. The next patient received 2 mL lower volume in case of success and 2 mL higher volume in case of failure of the previous one.

Results: 15 mL of 0.5% ropivacaine produced effective surgical anesthesia with no incidence of diaphragmatic paralysis/paresis with ultrasound-guided supraclavicular brachial plexus block.

Discussions: In our study, we enrolled a total of 36 patients, out of which failure was observed in 1 (2.8%) patient. This lower rate of failure is attributable to the ultrasound-guided technique. This shows the superiority of ultrasound-guided technique over classical and nerve stimulator technique. In-plane approach (needle around the ultrasound probe’s longitudinal axis) lateral to medial was used in our study because by this approach structures were better visualized and needle visualization was clear and possible when needle introduced from the back of the probe. Thus, there was no correlation observed between quality and onset of the motor block with different volumes of 0.5% ropivacaine (25–15 mL). We also observed the meantime of involvement of individual nerves, such as, ulnar nerve (UN) radial nerve (RN), median nerve (MN) in different volumes of 0.5% ropivacaine. Thus, we conclude that while decreasing volume of 0.5% ropivacaine involvement of UN, RN occur late and there was no difference in the involvement of MN. They explained this by the fact that ulnar and medial cutaneous nerves are derived from the inferior trunk of the brachial plexus which is difficult to approach by in-plane technique though they achieved successful block with 30 mL. The volume of LA was a prime consideration in our study. We tried to find out the minimum effective volume of 0.5% ropivacaine required for surgical anesthesia. The minimum effective volume estimated was 15 mL of 0.5% ropivacaine. This 15 mL of 0.5% ropivacaine was found to be sufficient for adequate anesthesia for upper limb surgeries below mid humerus. Saric et al. studied the minimum effective volume of 50:50 mixture of 0.5% levobupivacaine and 2% lidocaine in elderly and middle-aged patients and concluded minimum effective volume in elderly was 16.49 mL and in middle-aged was 44.52 mL.4 Diaphragmatic paralysis was a major concern in our study. This complication is because of the cephalad spread of LA and the involvement of the phrenic nerve. We assessed the diaphragmatic excursion with ultrasound in M mode preoperatively on both sides, after 30 minutes of block performance, postoperative after 6 hours of the block. Percentage of diaphragmatic paralysis decreases by decreasing volume of drug in successive patients. 17 and 15 mL of 0.5% ropivacaine were found to be safer as there was partial loss of diaphragmatic movement after 30 minutes of the block but it was not significant. Renes et al. did a study on ultrasound-guided supraclavicular brachial plexus block, using 20 mL of 0.75% ropivacaine, and found that none of the patients developed hemidiaphragmatic paresis and reduction in lung function (FEV1, FVC, PEFR).5 In our study, we also assessed the diaphragmatic excursion through a portable bedside spirometer. We measured FEV1, FVC, and PEFR preoperatively as a baseline after 30 minutes of the block and 6 hours post block and compared preop values with 30 minutes after block, 30 minutes after block with 6 hours post block within groups. Also, we compared different volumes of 0.5% ropivacaine. Based on our study observations was that with higher volumes there was a decrease in pulmonary function after 30 minutes of the block. The mean difference seen was more in higher volumes than the lower volumes.

Conclusion: We concluded, on decreasing volume of 0.5% ropivacaine, the incidence of diaphragmatic paralysis decreases significantly, and no compromise on the quality of the block.

3. Comparison of the Effect of Dexmedetomidine vs Fentanyl Infusion on Attenuating the Hemodynamic Responses, Bispectral Index (BIS) Changes and Cerebral Perfusion Pressure to Skull Pin Head Holder Application during Craniotomy. (Conference Abstract ID: 185)

Shivangi Saxena, Parul Jindal, Parul Jindal

Himalayan Institute of Medical Sciences, Uttarakhand, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.156

Introduction: Rigid head immobilization before craniotomy is a pivotal element of neurosurgery. As microscopic neurosurgery requires operating with smaller incisions as well as restricted surgical corridors, firm head immobilization is important to maintain the appropriate position of the head and thus, providing stabilization during the complex surgical procedures which are easily achieved by skull pin application.1 Despite the adequate depth of anesthesia, insertion of skull pin for the stability of head during elective craniotomies, along with skin incision and intubation may prove to be a prominent noxious stimulus characterized by an acute sympathetic stimulation, leading to hemodynamic instability.2 These noxious stimuli can lead to a sympathetic response in turn tachycardia and hypertension which may further disrupt cerebral autoregulation.

Objectives: To compare the effect of dexmedetomidine and fentanyl in attenuating the hemodynamic responses, BIS and cerebral perfusion pressure changes to pin placement during elective craniotomies.

Materials and methods: Sixty patients undergoing elective craniotomy with skull pin placement were randomly categorized into two equal groups. Group I received IV dexmedetomidine 1 µg/kg over 10 minutes and group II received IV fentanyl 1 µg/kg over 10 minutes before pin insertion. Outcome variables like heart rate, blood pressure, SpO2, EtCO2, central venous pressure, cerebral perfusion pressure, condition of the brain, and the adverse side effects of the drugs were compared in both the groups at different time intervals pre, post, and during pin insertion, i.e., B0 (baseline value), I0: At the initiation of IV drug infusion of dexmedetomidine or fentanyl. I2, I4, I6, I8, I10: 2, 4, 6, 8, and 10 minutes during IV drug infusion. T0: At the completion of pin insertion. T30, T60, T90, T120, T150, T180, T300, T600, and T900: 30, 60, 90, 120, 150, 180, 300, 600, and 900 seconds, respectively, after pin insertion.

Results: The demographic data was comparable between both the groups. No significant change in heart rate, cerebral persuasion pressure, BIS among both the groups at all the time intervals. Systolic, Diastolic, mean blood pressure and central venous pressure was significantly increased in the fentanyl as compared to the dexmedetomidine group after the pin insertion (p < 0.05). Surgeons reported satisfactory brain condition during surgery in the dexmedetomidine group.

Discussions: The application of skull pin head holder application used in craniotomies for rigid immobilization of the head during the procedure produces a brief, intense hemodynamic response despite an adequate depth of anesthesia, which can be deleterious to the patient as it can even lead to changes in the cerebral perfusion changes and its sequelae, these stress response can be blunted using various pharmacological agents in addition to the local infiltration with local anesthetics.3,4 Based on our results from the study, we can emphasize that even though both the agents have the potential to attenuate this stress response, intravenous dexmedetomidine infusion in a dose of 1 µg/kg over 10 minutes just before the pin application has better hemodynamic stability than intravenous fentanyl 1 µg/kg over 10 minutes. Both the agents lead to comparable changes in the BIS values. Thus, this study serves as a double edge sword-albeit in a good way — by not only substantiating the intraoperative hemodynamic stability for the anesthesiologist but also by aiding in providing a good surgical field for the neurosurgeon.

Conclusion: Based on the results of our study, we suggest IV dexmedetomidine a dose of 1 µg/kg infusion over 10 minutes is a better attenuating agent than IV fentanyl 1 mg/kg over 10 minutes for blunting the deleterious hemodynamic response to the skull pin placement.

4. CMAC Videolaryngoscopy vs Direct Laryngoscopy: Comparing the Mouth-to-Nose Distance between the Patient and Laryngoscopist. (Conference Abstract ID: 179)

Surabhi Gupta, Rajesh S Mane

Jawaharlal Nehru Medical College, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.157

Introduction: Tracheal intubation is a high-risk procedure for the transmission of the virus during this COVID-19 pandemic. These patients may require emergency tracheal intubation and mechanical ventilation to help recovery from illness. These patients may also present for various emergency/elective surgeries that may require administration of general anesthesia and tracheal intubation. Procedures involving securing and manipulation of the airway may put the laryngoscopist at great risk of exposure to the virally contaminated aerosols. Increasing the distance of the laryngoscopists face from the patient and expelled droplets reduces the direct exposure to the mucous membrane. The study aimed to determine the mouth-to-nose distance between the patient and laryngoscopist, the angle formed between the two oral cavities, and the ease of intubation.

Materials and methods: The study was approved by Institutional Ethical Committee. A total of 104 ASA I and II patients undergoing surgery under general anesthesia were enrolled and consent was taken. They were randomly divided into two groups — one group undergoing tracheal intubation with CMAC videolaryngoscope and another group with Macintosh direct laryngoscope. The intubation procedure was filmed and the mouth-to-nose distance formed between the patient and the laryngoscopist was calculated. The angle formed between the two oral cavities were assessed using a mobile phone application. The ease of intubation was determined using a standard scoring system. Descriptive statistics reported using mean, median, and standard deviation for continuous variables and compared using Student’s paired t-test. Categorical variables were reported using numbers and percentages and compared using the Chi-square test.

Results: The mean mouth-to-nose distance using CMAC VL was 45.5673 and using DL was 27.6731. This was statistically significant using a paired t-test (p < 0.05). The mean angle formed by the oral cavities was 49.0577 and 34.0769 with CMAC VL and DL respectively. The ease of intubation was also scored more with CMAC VL compared to DL.

Discussions: The greatest viral load of SARS-CoV-2 is most commonly found in the sputum and upper airway secretions. Droplet spread and direct contact with the respiratory secretions is the leading mode of transmission. The aerosol spread is another mode of transmission and these particles can remain suspended in the air for longer periods. Hence, procedures, such as, endotracheal intubation, connection, and disconnection from a ventilator circuit, extubation, bronchoscopy, tracheal suctioning can cause aerosolization of the viral particles. The process of handling infected patients and performing these procedures can increase the risk of infection to the laryngoscopist. This study showed that the use of a videolaryngoscopy significantly extends the mouth-to-nose distance between the patient to the laryngoscopist compared to direct laryngoscopy and places the laryngoscopist’s face above the direct line of sight to the pharynx, thus minimizing the risk of direct exposure to virally contaminated particles. It may also help reduce the time taken for intubation, thus avoiding a longer exposure to the laryngoscopist.

Conclusion: VL significantly increases the mouth-to-nose distance between the patient and the laryngoscopist compared to DL and increases the angle formed between the laryngoscopist’s face and the patients’ oral cavity. Intubation is easier with VL compared to DL. Hence, this study signifies the use of a videolaryngoscope to minimize the risk of exposure of the infected viral particles to the laryngoscopist.

5. Incidence of Postoperative Cognitive Dysfunction in Patients after Orthopedic Surgeries in a Regional Care Center: A Pilot Study. (Conference Abstract ID: 154)

Komal Upadhyay, Kanta Bhati

Sardar Patel Medical College, Bikaner, Rajasthan, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.158

Introduction: Postoperative cognitive dysfunction is defined as a new cognitive impairment arising after a surgical procedure. The International Society of Postoperative Cognitive Dysfunction considers that POCD is developed when postoperatively deficits are observed in a patient in one or more discrete areas of mental states, such as, attention, concentration, executive function, memory, visuospatial ability, and psychomotor speed. Various factors increase its risk in the postoperative period and are associated with poorer recovery, reduced quality of life, and increased mortality.

Objectives: To assess postoperative cognitive dysfunction in terms of diagnosis, symptoms, and care needs; to analyze relationships between risk factors and its diagnoses in orthopedic patients in a Regional Cancer Centre.

Materials and methods: Its diagnosis requires both pre- and postoperative psychometric testing. An observational pilot study was done on 20 patients admitted over 1 month period in the orthopedic department of a regional care center.

Results: Factors that elevate the risk of POCD include old age, pre-existing cerebral, cardiac, and vascular disease, alcohol abuse, pre – operative anxiety and depression, low educational level, and intra- and postoperative complications. POCD is associated with poorer recovery and increased utilization of social financial assistance. It is also associated with higher mortality. Persistent POCD enters into the differential diagnosis of dementia.

Discussions: POCD is a transient postoperative disturbance and meticulous care should be taken by the surgical and anesthesia teams to prevent intraoperative complications that reduce the risk of POCD. This influences, to various degrees, the patients’ quality of life.

Conclusion: POCD is a transient postoperative disturbance This influences, at various degrees, the patients’ quality of life. Until today, many studies have attempted to investigate POCD; however, the pathophysiology is not completely elucidated and there are many unanswered questions. Further detailed multicenter studies are required to evaluate this further.

6. Comparative Study of Intravenous Tramadol vs Rectal Tramadol for Postoperative Analgesia in Patients Undergoing Cesarean Section under Spinal Anesthesia. (Conference Abstract ID: 143)

Nishkam Verma, Neelam Singh, Dharmendra Kumar Yadav, Vaibhav Singh

Moti Lal Nehru Medical College Prayagraj, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.159

Introduction: Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.1 Postoperative pain is important in causing psychological trauma to the patient. Patients who undergo cesarean section should achieve more postoperative pain relief than surgical patients because of different factors related to the operation.2 For pain relief various groups of drugs, such as, opioids and NSAIDs are used.3 Tramadol has a unique dual action of pain relief, acting both as a central opiate agonist and CNS reuptake inhibitor of norepinephrine and serotonin. Tramadol exists as 2 enantiomers with analgesic properties, both with different mechanisms of action. (+)-Tramadol and its metabolite O-desmethyltramadol (M1) act as mu-receptor agonists altering the release of nociceptive neurotransmitters.4 Tramadol used by different routes, such as, intravenous, intramuscular, rectal or local infiltration, etc., have analgesic efficacy with different duration and variable incidence of side effects.5,6 In this study, we compared intravenous tramadol vs rectal tramadol for postoperative analgesia in the cesarean section under spinal anesthesia.

Objectives: To study postoperative analgesia and duration with intravenous and rectal routes of drug administration. Side effect also noted.

Materials and methods: The study was comparative, randomized, prospective, and hospital-based and conducted on 90 obstetric patients aged from 20 to 40 years, who comes in ASA class I and II undergone for cesarean section after obtaining written consent. Patients having a history of allergy to any drugs, a cardiovascular, renal, respiratory, and neurological disease that comes under ASA> II were excluded from the study. All patients were explained about the procedure and visual analog scale for pain measurement.7 All 90 patients were divided randomly into two groups of 45 each as group I for intravenous and group R for the rectal route of tramadol. After taking the patient on the operation table, multipara monitor was applied and the baseline parameter was noted. Intravenous line secured with 18-gauge intravenous cannula and infusion of ringer lactate started with injection metoclopramide 10 mg and ranitidine 50 mg were given to all patients. Spinal anesthesia is given with a 25-gauge spinal needle in L3–L4 interspaces with 0.5% bupivacaine heavy 12 mg with the desired level of T4 achieved. At the end of the surgery, tramadol 1.5 to 2 mg/kg (max 100 mg) was given intravenously to group I patients and 1.5 to 2 mg/kg (max 100 mg) suppository inserted per rectally in group R patients for postoperative analgesia. This was considered 0 hours. Postoperatively, parameters like PR, MAP, and SPO2 were monitored and VAS and side effect was noted at an interval of 1, 2, 4, 6, 8, 10, and 12 hours. If patient having VAS >4 inj. diclofenac 75 mg given as rescue analgesia.

Table 1: Demographic parameters
Group IGroup Rp value
Mean ± SDMean ± SD
Age26.20 ± 3.2526.91 ± 4.510.393
Wt (kg)61.51 ± 4.2861.42 ± 4.890.927
Table 2: VAS for group I
VAS1 hour2 hours4 hours6 hours8 hours10 hours12 hours
012  9  0  0  0  0  0
13335  0  0  010  0
2  0  1  6  1  1  1  2
3  0  03634192743
≥4  0  0  31025  7  0
Table 3: VAS for group R
VAS1 hour2 hours4 hours6 hours8 hours10 hours12 hours
01416  0  0  0  0  0
13120  2  0  0  0  0
2  0  92517  5  1  0
3  0  01828372831
≥40  0  0  0  31614
Table 4: Rescue analgesia (no. of patients (%))
TimeGroup IGroup R
1 hour  0 (0.0%)  0 (0.0%)
2 hours  0 (0.0%)  0 (0.0%)
4 hours  3 (6.7%)  0 (0.0%)
6 hours10 (22.2%)  0 (0.0%)
8 hours25 (55.6%)  3 (6.7%)
10 hours  7 (15.6%)16 (35.6%)
12 hours  0 (0.0%)14 (31.1%)
Table 5: Duration of analgesia (in minute)
Group IGroup Rp value
Mean ± SD456.00 ± 94.35640.00 ± 77.46<0.001
Table 6: Side effects (no. of patients (%))
Group IGroup R
Nausea  4 (8.9%)2 (4.4%)
Vomiting10 (22.2%)3 (6.7%)

Results: Table 1 shows the demographic data in both groups, which was similar. Tables 2 and 3 show the postoperative VAS score in group I and group R, respectively. Table 4 shows the time and frequency of the rescue analgesic. Table 5 shows the total duration. Table 6 shows the side-effects..

Discussions: This study evaluates the role of tramadol by two different routes in the cesarean section for postoperative pain. We studied VAS scores in both groups and gave rescue analgesia at a score >4. In group I, 100% of patients had been received rescue analgesia by the end of 10 hours while 73.4% of patients in group R needed it by the end of 12 hours and the remaining 26.6% of patients were not needed it. Hence, the duration of analgesia was prolonged in group R compared to group I. Side effects like nausea and vomiting were complained more in group I as compared to group R. Gadani et al.6 found a significantly prolonged duration of analgesia in the rectal group against intravenous tramadol group (504 ± 146.96 vs 426 ± 80.36 minutes). Also, they found a 15% incidence of PONV in the intravenous tramadol group as against 5% in the rectal suppository group. Patel et al.8 found that 45% of the patients needed the first rescue analgesic at 6 hours in the intravenous tramadol group, whereas only 5% of the patients in the rectal tramadol group needed it. By the end of 10 hours, all 100% of patients received rescue analgesic in the intravenous tramadol group and 65% of patients in the suppository group which was a significantly lower proportion. Thus, the duration of analgesia was prolonged in the rectal group with fewer side effect. Padol et al.9 found that the duration of postoperative analgesia was prolonged with the rectal route compared to intravenous administration and noted nausea and vomiting were lower with the rectal route.

Conclusion: Since the duration of analgesia was prolonged with group R which was observed by time for the need of rescue analgesia and percentage of patients who required it in both groups. Hence, we concluded that the rectal route of tramadol is a safe, noninvasive, and better alternative for pain relief in cesarean section with a minimal side effect.

7. Comparison of Efficacy of Ramosetron vs Palonosetron in Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Middle Ear Surgery under General Anesthesia. (Conference Abstract ID: 135)

Pratik Savalia, Neelam Singh, BK Raw, Shobhit Singh

Moti Lal Nehru Medical College, Prayagraj, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.160

Introduction: Postoperative nausea and vomiting (PONV) is one of the most common complaints after anesthesia and surgery and can occur after general, regional, or local anesthesia. PONV has been reported in up to 20 to 30% of all patients undergoing surgery,1 can lead to rare but serious medical complications, such as, aspiration of gastric contents, suture dehiscence, esophageal rupture, subcutaneous emphysema, or pneumothorax, dehydration, electrolyte imbalance.2 The incidence of PONV after middle ear surgery is as high as 80% when no prophylactic antiemetic is given.3 Selective 5-HT3 receptor antagonists have shown efficacy in the prophylaxis and treatment of PONV. Ramosetron and Palonosetron are recent developments in selective 5HT3 receptor antagonists with a longer duration of action.

Objectives: To compare the incidence of postoperative nausea and vomiting during 0 to 6, 6 to 12, 12 to 24, and 24 to 48 hours. To compare VAS score for nausea.

Materials and methods: The present comparative, randomized, prospective, double-blind study includes 70 patients of ASA grade I/II between age 18 and 60 years undergoing middle ear surgery. Patients were randomly allocated into two groups of 35 each; group R: given Inj. ramosetron 0.3 mg i.v. and group P: given Inj. palonosetron 0.075 mg i.v. 30 minutes before the end of surgery. In the procedure, the patient kept nil per oral 8 hours before surgery and given ranitidine, alprazolam one night before the operation, on the day of operation patient premedicated with glycopyrrolate, ondansetron, dexamethasone, the succinylcholine given and patient intubated with ET tube and maintenance are done with vecuronium bromide and inhalational agent isoflurane and before the end of surgery patient given either ramosetron or palonosetron. The incidence of PONV, complete response, VAS score for nausea, the requirement of rescue antiemetics, adverse effects were compared in both groups postoperatively up to 48 hours.

Results: Comparison of Nausea in post-operative period Comparison of Vomiting in post-operative Comparison of Incidence of complete response.

Discussions: In postoperative 0 to 6 hours more patients complained of nausea in group R (17.1%) as compared to group P (11.4%), vomiting although was more in group R (11.4%) vs group P (8.6%). This period (77.1%) has shown complete response (no PONV) as compared to group P (82.9%) and the difference was not significant in all (p > 0.05). In postoperative 6 to 12 hours although more patients complained of nausea in group R (17.1%) as compared to group P (14.3%), and vomiting in group R (14.3%) vs group P (8.6%). In this period (80%), patients in group R shown complete response as compared to group P (82.9%) and the difference was not significant in all (p > 0.05). In 12 to 24 hours period, more patients experienced nausea in group R (31.4%) vs group P (11.4%) and the difference was statistically significant (p < 0.05) while more patients experienced vomiting in this period in group-R (22.9%) as compared to group P (14.3%) but the difference was not statistically significant (p > 0.05). Overall complete response in group R was (62.9%) which was less than group P (80%) not statistically significant (p > 0.05). In the period of 24 to 48 hours in group R (40%), patients experienced nausea as compared to group P (17.1%) which was statistically significant (p < 0.05) while more patient experienced vomiting in group R (40%) as compared to group P (17.1%) and was statistically significant (p < 0.05). Overall complete response during this period was seen more in group P (77.1%) vs group R (54.3%) which was statistically significant (p < 0.05). Patel Vaibhavi et al.4 in comparison of Palonosetron vs Ramosetron in the prevention of PONV in lap surgery no statistical difference was found in severity of nausea and vomiting in 0 to 6 hours (p > 0.05) but the incidence was higher in group R which supports our study. Ahluwalia et al.5 complete response was observed in 92.73 and 80% of the patients during 0 to 2 and 2 to 24 hours, respectively, in group P while in group R it was 90.91 and 70.91% within the same time frame (p > 0.05). It shows that complete responses with Palonosetron and Ramosetron are comparable in 0 to 24 hours which supports our study. Chattopadhyay Suman et al.6 compared the effect of Palonosetron and Ramosetron for the prevention of PONV after cesarean section under spinal anesthesia shows the complete response at 0 to 2 hours 85.5 and 83.3% in group P and group R, respectively (p value > 0.05), while during 2 to 24 hours 70.9 and 53.7% in group P and group R, respectively (p value < 0.05).

Conclusion: In our study, it was observed that Palonosetron was very good in complete response, rescue medication, VAS score for nausea and have long half-life as compared to Ramosetron although the incidence of headache was more in Palonosetron. We conclude that Palonosetron is more effective and better than Ramosetron for the prevention of postoperative nausea and vomiting following middle ear surgeries.

8. Norepinephrine Bolus: A Prophylactic Strategy for Spinal-induced Hypotension. (Conference Abstract ID: 133)

Savita Choudhary, Rakesh Dagar, Sunanda Gupta

Geetanjali Medical College and Hospital, Rajasthan, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.161

Introduction: Spinal-induced hypotension is the most frequently encountered complication of spinal anesthesia despite being the technique of choice for cesarean delivery. Norepinephrine intermittent small dose bolus regime is now emerging as a feasible option for prevention as well as management of spinal-induced hypotension. In resource-limited settings, intermittent boluses have been proven as an effective strategy where limited availability of infusion is a major deterrent for continuous vasopressor infusion. Our study aimed to compare the efficacy of norepinephrine in the prevention of spinal-induced hypotension during cesarean section.

Objectives: Evaluate the norepinephrine 6 µg. To compare the incidence of hypotension rescue vasopressor requirement time of first rescue dose.

Materials and methods: This prospective randomized double-blind study was conducted on 60 patients of ASA-II grade, full-term, singleton pregnancy undergoing elective cesarean sections under spinal anesthesia which were assigned into two groups. Group N6 received norepinephrine 6 µg as an intravenous bolus while group C received normal saline simultaneously with subarachnoid block. Incidence of hypotension, the requirement of rescue doses of norepinephrine, time of first rescue dose, hemodynamic parameters, and incidences of maternal and neonatal complications were assessed, compared, and analyzed in all three groups.

Results: The incidence of post-spinal hypotension was lower in group N6 (63.33%) vs group C (83.33%), p = 0.155. The requirement of rescue dose of norepinephrine (group N6 8.21 ± 2.97 µg) vs group C (11 ± 4.57 µg), p = 0.01. Time to first rescue dose was significantly lower in control group (4[5-2]min as compared to (6[8-4.5] min in group N6, p = 0.004.

Discussions: Norepinephrine owing to its potent α-adrenergic agonist properties with β adrenergic potential results in the less incidence of maternal bradycardia and decreased cardiac output following spinal anesthesia as compared to commonly used drug phenylephrine. The ED90 of an intermittent bolus is 6 µg.

Conclusion: Prophylactic intravenous norepinephrine 6 µg co-administration with spinal anesthesia is effective in the prevention and management of spinal-induced hypotension and it also decreases the total requirement of vasopressor during cesarean section.

9. Comparative Study of Prophylactic Infusions of Phenylephrine and Norepinephrine for the Management of Maternal Hypotension for Cesarean Section under Spinal Anesthesia. (Conference Abstract ID: 100)

CV Soabir Ali

Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.162

Introduction: Hypotension is a frequent intraoperative complication that occurs following spinal anesthesia. To avoid maternal hypotension, the current standard of practice is to administer a continuous phenylephrine infusion. Phenylephrine can have clinically significant side effects, such as, baroreceptor-mediated bradycardia with a consequent decrease in cardiac output (CO). Norepinephrine, therefore, is an effective vasopressor for maintaining blood pressure during spinal anesthesia with less tendency to decrease heart rate and cardiac output.

Objectives: Primary: To compare fall in maternal blood pressure after spinal anesthesia using intravenous infusions of phenylephrine and norepinephrine and to quantify the rescue boluses needed for both the groups. Secondary: To compare fetal acid-base status using umbilical arterial blood gases and to compare the APGAR scores at 1 and 5 minutes in the two groups.

Materials and methods: This study was conducted on 100 normotensive women undergoing CS under SAB. The patients were randomized into two groups of 50 each. Group P received infusions of phenylephrine @ 0.1 µg/kg/minute prophylactically immediately after receiving SAB and group N received a prophylactic infusion of norepinephrine @ 0.05 µg/kg/minute. The changes in heart rate (HR), BP, and side effects were compared till delivery. The neonatal APGAR scores were compared at 1 and 5 minutes and an umbilical artery sample was sent for blood gas analysis.

Results: Ten patients in the phenylephrine group had bradycardia and whereas the norepinephrine group had only 2 patients. SBP showed a fall of >20% from the baseline in 7 patients in the phenylephrine group and we had given rescue boluses of 50 µg phenylephrine and 5 patients in group norepinephrine and rescue boluses were 4 µg norepinephrine. Nausea and vomiting was less in norepinephrine group. There was no difference in APGAR or neonatal acidosis on ABG.

Discussions: In our study, both phenylephrine and norepinephrine infusions had similar efficacy in maintaining maternal SBP within 80% of baseline. Phenylephrine, being a pure α-adrenergic agonist causes reflex bradycardia. In our study, the incidence of bradycardia was higher in the phenylephrine group compared with that in the norepinephrine group and there was no difference in the extent of sensory anesthesia achieved. More patients receiving phenylephrine complained of nausea 4 (8%) and vomiting 2 (4%) compared with no patients who complained of receiving norepinephrine. In the present study, no significant difference in APGAR scores at 1 and 5 minutes between phenylephrine and norepinephrine groups. No neonate had an Apgar score of <7 at any time point. In our study, both the umbilical arterial and venous samples showed an absence of acidosis with pH >7.2. Umbilical arterial and venous blood gases were similar between phenylephrine and norepinephrine groups.

Conclusion: In our study, both phenylephrine and norepinephrine infusions had similar efficacy in maintaining maternal SBP within 80% of baseline. Phenylephrine, being a pure α-adrenergic agonist causes reflex bradycardia. In our study, the incidence of bradycardia was higher in the phenylephrine group compared with that in the norepinephrine group and there was no difference in the extent of sensory anesthesia achieved. More patients receiving phenylephrine complained of nausea 4 (8%) and vomiting 2 (4%) compared with no patients who complained of receiving norepinephrine. In the present study, no significant difference in APGAR scores at 1 and 5 minutes between phenylephrine and norepinephrine groups. No neonate had an Apgar score of <7 at any time point. In our study, both the umbilical arterial and venous samples showed an absence of acidosis with pH >7.2. Umbilical arterial and venous blood gases were similar between phenylephrine and norepinephrine groups.

10. The Earlier, the Better: Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—A Prospective Study. (Conference Abstract ID: 29)

Bipin Chalattil, Manoj Kumar Sahu

All India Institute of Medical Sciences, Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.163

Introduction: Advantages of tracheostomy have been well known. Most of the literature refers to these general intensive care population, excluding cardiac surgery or including only a small number of these patients. On the other hand, there is no clear definition describing the proper time to perform a tracheostomy and defining what are likely benefits of early compared to late tracheostomy. This prospective study aims to assess the probable benefits of early tracheostomy on postoperative outcomes, length of stay, and post-tracheostomy complications within the pediatric cardiac surgical population.

Materials and methods: After obtaining institutional ethics approval, we conducted a prospective study in a single, tertiary care institution, identifying patients who underwent tracheostomy after cardiac surgery from January 2019 to December 2019. Time-to-tracheostomy was defined as “early” if ≤7 days or “late” if > 7 days post-cardiac surgery.

Results: Among Pediatric patients underwent cardiac surgery over the study period; from those, 41 received tracheostomy. 16 (39%) patients underwent early tracheostomy and 25 (61%) late tracheostomy. Incidence of preoperative hospital stay(p = 0.0016), preoperative sepsis(p =0.03), high risk surgery (p = 0.04), postoperative clinical sepsis (p =0.001), c reactive protein levels (p = 0.04), ventilator associated pneumonia (p = 0.002), antibiotic escalation requirement (p =0.006), antifungal therapy requirement (p =0.01), pressure sores(p = 0.01), days of feed interruption (p =0.0017), total days of ventilation(p = 0.0027), tracheostomy tube change requirement (p = 0.02), day of ICU stay (p =0.01), days of hospital stay (p = 0.001), day of decannulation (p = 0.03), day of discharge (p = 0.0089), INR before tracheostomy (p =0.04), PEEP requirement before tracheostomy (p = 0.03) were lower in the early tracheostomy group.

Discussions: The current study identified that ET performed in cardiac surgical patients was associated with reduced incidence of preoperative hospital stay (p = 0.0016), preoperative sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative clinical sepsis (p = 0.001), C-reactive protein levels (p = 0.04), ventilator-associated pneumonia (p = 0.002), antibiotic escalation requirement (p = 0.006), antifungal therapy requirement (p = 0.01), pressure sores (p = 0.01), etc. Furthermore, they had decreased days of feed interruption (p = 0.0017), total days of ventilation (p = 0.0027), tracheostomy tube change requirement (p = 0.02), day of ICU stay (p = 0.01), days of hospital stay (p = 0.001), day of decannulation (p = 0.03), day of discharge (p = 0.0089), INR before tracheostomy (p = 0.04), and PEEP requirement before tracheostomy (p = 0.03). As opposed to the general ICU population, only a few publications are investigating the impact of tracheostomy timing in the pediatric cardiac surgical population. To the best of our knowledge, we could not find any prospective study on early tracheostomy among pediatric cardiac surgical patients.

Conclusion: There are significant benefits in the reduction of postoperative morbidities with overall shorter ICU and hospital stay. These benefits may promote faster patient rehabilitation with reduced healthcare costs.

11. Profile of Obstetric Patients in Intensive Care Unit—A Retrospective Study from a Tertiary Care Center. (Conference Abstract ID: 13)

Heena Gupta

Government Medical College, Jammu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.164

Introduction: Physiological changes of pregnancy along with certain pregnancy-specific diseases may cause a rapid worsening of the health status of the patient necessitating ICU care.

Objectives: To determine the incidence, epidemiological characteristics, morbidity, and mortality of pregnant and postpartum women who required ICU admission.

Materials and methods: It was a cross-sectional, retrospective record analysis of all obstetric admissions in the ICU of a tertiary care center from October 2018 to March 2020. During these 18 months, 30,156 deliveries were conducted. We included all pregnant/postpartum women (within 6 weeks after delivery) admitted to the obstetric ICU over this period. Readmissions within 30 days were counted only once. Research data included patient demographics, obstetric/medical history and diagnosis at admission, ICU course and length of stay, and treatment given and outcome. The clinical indications responsible for ICU admission were categorized as obstetric and non-obstetric. Data were collected from Medical Record Section and entered into a computerized database using MS Office Excel 2007 (Microsoft, Redmond, WA, USA).

Results: There were a total of 30156 obstetric admissions in the hospital over a span of 18 months out of which 127 were admitted in the ICU with 117 survivors and 10 deaths. Majority of patients (79.52%) were admitted due to obstetric reasons. The most common cause of ICU admission was obstetric hemorrhage followed by hypertensive disorders of pregnancy, comprising 37.79% (n = 48/127) and 28.35% (n = 36/127) of all ICU admissions, respectively. Among the non obstetric causes (n = 26/127), ICU admission was most common among those with pre-existing heart diseases (n = 10; 7.87%). Snake bite, organophosphorus poisoning, head injury were the other non obstetric causes. Intrauterine death (IUD) with sepsis (n = 6) was another major reason for maternal admission in our centre.. Four patients of sepsis were in shock and required inotropic support. Forty nine out of 127 patients required mechanical ventilation (38.58%). Mortality was seen in 10 patients who were mechanically ventilated. Mean duration of mechanical ventilation was 1.7 ±1.3 days. Eleven patients who were put on renal replacement therapy had developed complications related to abortion (n = 4), IUD (n = 4), HELLP syndrome (n = 2) and systemic lupus erythematosus (SLE) (n = 1). The mean length of ICU stay was 4 days. There were 10 deaths reported (7.87%) in our study. Intrauterine death leading to sepsis (n = 4) and postpartum hemorrhage leading to acute heart failure (n = 3) were the most common cause of maternal mortality.

Discussions: Changes in hemodynamics during the postpartum period, such as, a 65% increase in cardiac output, acute blood loss during delivery, and decrease in plasma oncotic pressure could be the major factors for a higher incidence of postpartum admissions. The most common primary diagnosis for ICU admission in our study was obstetric hemorrhage (37.47%). Early diagnosis and prompt referral, well-equipped dedicated blood bank facility, the involvement of other multidisciplinary approaches, and intensive care unit have been the major contributing factors for decreasing mortality in young obstetric patients. Uncontrolled hypertension was the second common cause of ICU admission. Eclampsia was the most common indication of assisted ventilation (n = 23), followed by sepsis and PPH.

Limitations: We included patients admitted in obstetric ICU only. As it was a single-center study, so the results are not indicative of the overall antenatal care provided at the peripheral healthcare centers.

Conclusion: Obstetric hemorrhage and hypertensive disorders of pregnancy were the most common indications for admission in obstetric ICU. Sepsis and postpartum hemorrhage were the leading cause of maternal death in our study. A dedicated obstetric ICU in a tertiary care hospital with an interdisciplinary approach is necessary to reduce the high-risk obstetric morbidity and mortality.

14. Poisoning-Toxicology-Pharmacology

1. Serotonin and the Kidney. (Conference Abstract ID: 103)

C Jayadevi

Govt Villupuram Medical College Hospital, Villupuram, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.165

Introduction: Serotonin syndrome is a toxidrome that results from a heightened level of serotonin action in the central and peripheral nervous systems. Some drugs which are commonly used in the intensive care unit or during anesthesia could induce this syndrome. This potentially fatal toxidrome manifests with a constellation of mental changes, autonomic dysfunction, and neuromuscular abnormalities. Prompt recognition of the toxidrome and withdrawal of the offending agent are crucial to prevent catastrophe. We report the case of serotonin syndrome in a 30-year-old man in whom the presentation was profound with convulsions, hyperthermia, clonus, rigidity, altered mental status, and acute kidney injury resulting from rhabdomyolysis.

Materials and methods: A 30-year-old man was rushed to the emergency room after an episode of fall, brief convulsions, and loss of consciousness which befell him at his home. He was apparently healthy before this event and had no morbidities like diabetes mellitus or hypertension. However, he had intermittent headaches and insomnia for which he had taken a combination of tramadol, ondansetron, and metoclopramide during the preceding 7 days. On admission to the hospital, he was irritable, disoriented, and febrile (temperature 100°F). His pulse was 110/minute, BP was 168/108 mm Hg, respiratory rate was 22/minute, and his oxygen saturation with ambient air was 97%. He had spontaneous generalized clonic jerks and the same was also provoked by noise (startle). Pupils were mid position and reacting. There was no focal neurological weakness; however, there was generalized muscular rigidity. Tendon reflexes were exaggerated and he had bilateral ankle clonus. The rest of the clinical examination was unremarkable. A computed tomography scan of the brain was normal. Hemogram revealed a normal blood count. Serum creatine kinase (CK — total) was 33,000 U, serum creatinine was 1.1 mg/dL on the day of admission, serum sodium was 138 mmol/L, potassium was 6.1 mmol/L, and bicarbonate was 17 mmol/L. Urine analysis revealed 1+ protein, microscopy revealed no RBCs but urine tested positive for heme and myoglobin. The liver function test was normal. During the course of his illness, he progressed to oliguric acute kidney injury with serum creatinine increasing to 6 mg/dL which necessitated initiation of hemodialysis. Kidney biopsy revealed myoglobin pigment induced acute tubular injury.

Results: A diagnosis of serotonin syndrome induced by the combination of tramadol, ondansetron, and metoclopramide was made and the patient was managed with the cessation of offending drugs, hydration, benzodiazepine, temporary dialysis, and supportive care with which he made a complete recovery of consciousness and kidney function.

Discussions: Serotonin syndrome results from a heightened serotonin activity in the central and peripheral nervous system predominantly in the 5HT1A and 5HT2A receptors.1 Drugs that interfere with the metabolism and reuptake of serotonin increase the level of serotonin in the nervous system, thereby inducing the toxidrome. The list of drugs that could cause serotonin syndrome is exhaustive; however, common agents of interest to the intensivist include tramadol, meperidine, fentanyl, dextromethorphan, metoclopramide, ondansetron, granisetron, monoamine oxidase inhibitors like linezolid, selegiline, serotonin reuptake inhibitors like fluoxetine, etc.2 Although any one drug on its own could provoke a serotonin syndrome, a combination of two or more drugs has a greater propensity to induce the toxidrome. Our patient had taken a combination of tramadol, metoclopramide, and ondansetron which had acted synergistically to induce serotonin syndrome. Serotonin syndrome is characterized by a constellation2 of mental status changes (like agitation, anxiety, disorientation, excitement, etc.), autonomic dysfunction (like hyperthermia, tachycardia, tachypnea, arrhythmias, etc.), and neuromuscular abnormalities (like tremors, clonus, hyperreflexia, and muscle rigidity). Neuroleptic malignant syndrome and malignant hyperthermia are close differentials for this toxidrome. The diagnosis of serotonin syndrome is made clinically and relies upon the Hunter Serotonin Toxicity Criteria (HSTC).2 The HSTC requires the consumption of a serotoninergic drug with at least one out of the following five requirements being met:This patient had altered mental status, hyperthermia, tachycardia, rigidity, spontaneous, and inducible clonus. Repeated clonus and muscular rigidity culminated in rhabdomyolysis, myoglobinuria, and acute kidney injury.

Conclusion: Serotonin syndrome could present as a life-threatening toxidrome with acute kidney injury in extreme cases. Drugs that are commonly used in the intensive care unit or during anesthesia could induce this syndrome. Prompt recognition and withdrawal of offending drugs are crucial to prevent a catastrophic outcome.

2. A Prospective Study on Clinical Manifestations and Consequences of Paraquat Poisoning in a Tertiary Care Hospital in Kadapa, Andhra Pradesh. (Conference Abstract ID: 89)

V Varun Kumar, M Sureswara Reddy

Government Medical College Kadapa, Andhra Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.166

Introduction: Paraquat (1 dimethyl-4-bipyridylium dichloride) is a contact herbicide widely used in agricultural industries. Acute paraquat poisoning is highly toxic, invariably fatal, and continues to be a major public health concern in many developing countries characterized by acute lung injury, pulmonary fibrosis, renal failure, and multiorgan failure, resulting in a high rate of mortality and morbidity.

Objectives: To study the clinical profile, biochemical profile, complications, management, and outcome in paraquat poisoning.

Materials and methods: All patients admitted to the Intensive Medical Care Unit, GMC Kadapa with a history of paraquat poisoning. Duration of study: 1 and half years November 2018 to May 2020. Type of study: a prospective study. Sample size: 50.

Inclusion criteria: All patients admitted to the IMCU with a history of ingestion of paraquat.

Exclusion criteria: History of multiple poisoning, liver cirrhosis, CKD, and pulmonary disorders. Urine sodium dithionate was used as a paraquat screening test. The following investigations were done to patients — complete blood count, RFT, LFT, ABG, CRP, ECG, chest X-ray, and CT chest. Patients were treated with gastric lavage with activated charcoal, methylprednisolone, cyclophosphamide, N-acetyl cysteine, vitamin C, E, mechanical ventilation, and hemodialysis.

Results: In this study, the paraquat poisoning was most prevalent in the age group 21 – 50 years. Mean age was 31. Female preponderance was noted. Complications like ARDS, lung fibrosis, renal failure,liver injury, multiorgan failure. In our study shows predominantly ARDS(39.5%).Mortality was 96% with maximum deaths were seen between 3 to 7 days(28%)

Discussions: Paraquat exerts its herbicidal activity by inhibiting the reduction of NADP to NADPH during photosynthesis and forming superoxide, singlet oxygen, hydroxyl, and peroxide radicals. These toxic O2 radical species subsequently destroy the lipid cell membranes by polymerization of unsaturated lipid compounds and human tissue toxicity likely results from a similar oxidative mechanism. The lung and kidney are the primary target organs in paraquat toxicity. In the kidney, the principal organ of excretion, paraquat is concentrated during excretion, often leading to acute tubular necrosis, acute kidney injury, which may occur soon after ingestion. Pulmonary fibrosis, cough, dyspnea, tachypnea, edema, pleural effusions, atelectasis, low arterial oxygen tension, increased alveolar oxygen tension gradient, and respiratory failure can occur.

Conclusion: The present study shows that acute pq poisoning can cause leukocytosis, thrombocytopenia. High NLR ratio has an excellent predictor of prognosis in acute pq poisoning. Of all herbicides, paraquat has the highest mortality in all centers despite effective treatment. Because there is no specific antidote, there is an urgent need for the development of preventive approaches and large clinical trials on the effects of different modalities of treatment as the median age of consumption is only 31 years.

3. Blue Patient and Brown Blood—A Case Series. (Conference Abstract ID: 34)

Sulakshana, Banavathu Kishan Sing Naik

SRMS, Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.167

Introduction: With multiple contradictory reports on the efficacy of hydroxychloroquine (HCQ) on COVID-19, the Indian Council of Medical Research (ICMR) recommends its’ use for prophylaxis and treatment of mild cases. Amidst all the controversies, there have been few cases reported of significant methemoglobinemia and hemolysis in COVID-19 cases being treated with HCQ. But, none has been reported from India, possibly because of underestimation in our population. The diagnosis of methemoglobinemia amidst this COVID crisis is really challenging owing to similar clinical manifestations.

Materials and methods: We present a case series where methemoglobinemia was promptly detected and managed efficiently.

Results: Timely detection and management resulted in the uneventful discharge of all three cases.

Discussions: This is to be understood that undiagnosed cases of methemoglobinemia can be potentially fatal due to hypoxic stress on the body. If the condition is not being detected timely, leading to dangerous levels of untreated methemoglobinemia may result in case fatality falsely attributed to COVID-19.

Conclusion: Clinical vigilance is very important while treating critically ill patients.

15. Sedation, Analgesia, and Delirium

1. Sedation and Analgesia in the Mechanically Ventilated Patients: A Comparison between Dexmedetomidine and Midazolam Plus Fentanyl. (Conference Abstract ID: 137)

Jitendra Singh Yadav, Birendra Kumar Raw, Dharmendra Kumar Yadav

Motilal Nehru Medical College, Prayagraj, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.168

Introduction: Sedation and analgesia are now regarded as an integral part of the treatment of patients in the intensive care unit (ICU). Nearly, all patients in the ICU experience pain, whether it is the result of procedures performed on them, the disease process, catheters or tubes inserted into them, or because they are immobile and cannot shift position 1. Analgesia2 is defined as pain control in the form of diminution or elimination of pain. American Society of Anesthesiologists3 defines the level of sedation according to the responsiveness of patients into awake, moderate, or conscious sedation, deep sedation, general anesthesia. A large number of sedative drugs have been used, e.g., benzodiazepines, propofol infusion, and analgesic drugs like opioid analgesics via intravenous, patient-controlled analgesia, intrathecal and epidural routes. NSAID drugs have been used as analgesics. Ideally, a sedative and an analgesic agent used in ICU should have the following criteria like easy administration, rapid onset of action, effective response, predictable duration of action, no adverse effect on vital organs mainly the cardiac and respiratory system. Nowadays light plane of sedation is better preferred for mechanically ventilated patients.

Objectives: The following were the objectives of the present study.

Materials and methods: In the present comparative, randomized, prospective, double-blind study, a total of 60 patients in ICU with a surgical diagnosis who required ICU stay between ages 18 and 60 years of either sex of ASA grade I–II were included. Patients were divided into two groups via the computer-generated random number (30 patients each): Group I: dexmedetomidine — 1 µg/kg loading i.v. over 10 to 20 minutes followed by 0.2 to 0.7 µg/kg/hour and Group II: Midazolam plus fentanyl — loading dose of 1 mg i.v. midazolam and followed by 2 to 3 mg/hour and fentanyl 25 to 50 µg i.v. every 30 minutes to 1 hour followed by 25 to 50 µg/hour till Ramsay Sedation Scale 3.

Results: In our study mean value of RSS at 16 hr in group A was 3.43±.68 as compared to group B was 4 ± 0.74 which was statically significant where as at 24 hr RSS in group A 3.20 ± 0.71 and group B was 3.80±.76 which was statically significant. Ramsay Sedation Score in the group Midazolam plus Fentanyl shows wider range of RSS (2-5) than Dexmedetomidine group (2–4) which was statistically significant at 16 hr (p < 0.007) and 24 hr (p < 0.005). Thus at the end of 24 hr, Midazolam plus Fentanyl infusion provided deep level of sedation. In our study the intergroup comparison of BPS of two group A and B where the mean value of BPS of group A was 7.87±1.20 which gradually decreases and goes to minimum value of BPS 3.53 ± 0.51 at 24 hr while in group B mean value of BPS was 7.6±1.25 at 0 min which also decreases and goes to a minimum value of BPS 3,57 ± 0.50 at 24 hr. No significant difference was found at any time point. Behavioral Pain Scale in both group was comparable which was not statistically significant (p > 0.05).

Discussions: Dexmedetomidine, midazolam, and fentanyl are the drugs that have been used very frequently to achieve adequate sedation and analgesia in mechanically ventilated patients. Dexmedetomidine promotes the decrease in motor activity, mental stability, allowing better care by the physician, nurse, and physical therapist. Its metabolites are inactive and the clearance is urinary and fecal. Analgesia and sedation are related to the binding to central noradrenergic receptors. It can modulate the descending inhibition from the locus coeruleus with noradrenaline release. Dexmedetomidine reduces the incidence of delirium and the duration of mechanical ventilation. It causes little respiratory depression and it is administered at a dose of 1 µg/kg, followed by an infusion of 0.1 to 0.7 µg/kg/hour for analgesia and sedation, with the dose being titrated. With the infusion, hypotension occurs due to the central sympatholytic effect and noradrenaline decrease. The sympatholytic effect can be beneficial as it reduces tachycardia and arterial hypertension, or undesirable, as they cause hypotension and bradycardia. Although both midazolam and fentanyl have a rapid onset and a short clinical duration with a single dose, accumulation and prolonged sedative effects may be observed after continuous administration, which is also indicated by a significantly longer context-sensitive half time of these drugs. We had taken the combination of midazolam and fentanyl despite midazolam alone because it is more effective and safe in a mechanically ventilated patient, without any increased risk for adverse reactions. Bongjin Lee et al.4 studied that fentanyl combined with midazolam is safe and more effective than midazolam alone for sedation therapy in mechanically ventilated children. Lalit Kumar Rajbanshi et al.5 observed that dexmedetomidine provided a comparatively narrower range of sedation level (2–4) than midazolam infusion (2–5) and at the end of 24 hours, the range of the sedation score for the patient in dexmedetomidine infusion was again 2 to 4 while it was 3 to 5 in midazolam group producing deep sedation. Thus, dexmedetomidine provided a uniform pattern of sedation level in comparison to midazolam. Santosh Kumar Sharma, Shahbaz Ahmad, ZulutenaJamir et al.6 observed that dexmedetomidine provided an effective alternative to midazolam in producing and maintaining controlled (RSS 2–3) short-term sedation in mechanically ventilated eclampsia patients and stable hemodynamics. Prasad, Parimala Prasanna Simha, and Jagadeesh7 studied the efficacy of sedation, analgesia, and time required for extubation during dexmedetomidine sedation were compared with that of fentanyl. They observed that dexmedetomidine provides comparable sedation, analgesic, and stable hemodynamic effects as fentanyl. Devangi Parikh, Kolli, Karnik, Lele, and Tendolkar8 compared the satisfaction scores and effectiveness of sedation and analgesia with dexmedetomidine with a combination of midazolam–fentanyl. Dexmedetomidine is a comparable alternative to the combination of midazolam–fentanyl for sedation and analgesia in tympanoplasty surgery under local anesthesia.

Conclusion: Dexmedetomidine provided a lighter plane of sedation that helped to make the patient awake earlier. Patients treated with dexmedetomidine had earlier weaning and removal from mechanical ventilation, shorter ICU stay. So, dexmedetomidine can be preferred over midazolam plus fentanyl in achieving effective sedation and analgesia with a better outcome.

2. A Comparative Study of Bilateral Ilioinguinal and Iliohypogastric Nerve Block vs Wound Infiltration for Postoperative Analgesia in Cesarean Section. (Conference Abstract ID: 109)

Tanu Shree, Joginder Pal Attri, Puneet Kaur Gill

Government Medical College Amritsar, Punjab, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.169

Introduction: Pain forms the inevitable postoperative sequelae of any surgical procedure and the relief of postoperative pain forms a major component of postoperative care of these patients. Despite advances in postoperative pain management, postoperative pain relief and satisfaction are still inadequate in some patients because of individual variability and limitation by the side effects of analgesic drugs or techniques. Postoperative pain is transitory and self-limiting, being most severe during the first postoperative day and diminishing over the next 24 hours and therefore, more amenable to therapy than chronic pain. In the current surgical practice, laparotomy via Pfannenstiel incision is one of the most common operations involving the female abdomen. Cesarean delivery performed via Pfannenstiel incision is a major source for both acute and chronic pain and both systemic (single bolus/patient-controlled) and neuraxial (spinal/epidural) opioids are effective against both visceral and somatic components of pain. Poor treatment of postoperative pain after cesarean delivery is the main reason for patient dissatisfaction. Thus, optimal postoperative analgesia is crucial to facilitate early maternal ambulation, improve infant care, decrease postoperative morbidity and mortality, decrease the length of hospital stay, and improve the patient experience with hospital services.

Objectives: The objectives of the study were to compare the effectiveness of the bilateral ilioinguinal and iliohypogastric nerve block vs wound infiltration for postoperative analgesia in cesarean section done under spinal anesthesia with regards to efficacy, quality, and duration of postoperative analgesia and compare the complications and side effects, hemodynamic variables, and rescue analgesia between two groups.

Materials and methods: Sixty patients of American Society of Anaesthesiologists grade I and II aged 18 to 35 years undergoing cesarean section under spinal anesthesia in our institute were included in our prospective, randomized, interventional, open-label clinical study after obtaining Institutional Ethics Committee approval and written consent of the patients. Patients with contraindication to central neuraxial block, progressive neurological disease, local anesthetic and NSAIDs sensitivity, obese patients, patients with peptic ulcer disease, renal disease, infection at the site of the block were excluded from the study. The patients were divided into two groups of 30 each in a random and unbiased manner using a computer-generated table of random numbers. Group I (n = 30) received wound infiltration, whereas group II (n = 30) received bilateral ilioinguinal and iliohypogastric nerve block with 30 mL of 0.5% ropivacaine plus 30 µg of fentanyl after the effect of spinal anesthesia regressed to T10 level. A standardized anesthetic technique was followed after a preanesthetic check-up. After the attachment of monitors, including ECG leads, noninvasive blood pressure cuff, and pulse oximeter an intravenous line with 18, 20 gauge cannula was established. Baseline vitals were noted. The patient was turned to the left lateral decubitus position. Using aseptic technique, L3-L4 or L2-L3 intervertebral space was located. Skin wheal was raised by a 26-gauge needle with 2% lignocaine then 25G quincke’s spinal needle was introduced into sub-arachnoid space using the mid-line approach. After the free flow of CSF was obtained, 2.2 mL of 0.5% hyperbaric bupivacaine was injected into subarachnoid space. The level of sensory blockade was checked by loss of sensation to pin-prick before surgical incision. Supplemental oxygen was given @5 L/minute via a simple oxygen mask. After the regression of the effect of spinal till T10 level, in group I, 30 mL of 0.5% ropivacaine plus 30 µg of fentanyl was infiltrated along the wound margins after negative aspiration. In group II, bilateral ilioinguinal and iliohypogastric block was performed with 30 mL of 0.5% ropivacaine plus 30 µg of fentanyl using landmark technique. Initially, the anterior superior iliac spine was palpated and a mark was made 2 cm medial and 2 cm superior from it. 15 mL of 0.5% ropivacaine plus 15 µg of fentanyl was injected each side into the planes between external and internal oblique muscles or internal and transverse muscles to block both the nerves. After that, the patient was assessed for postoperative analgesia using a VAS score.

Results: 60 patients were analyzed for post-operative VAS scores and analgesia requirement after IIIH block and wound infiltration. There was no statistically significant difference between the two groups with respect to demographic data like age, height, weight and duration of surgery. VAS score was recorded at 0,2,4,6,8,12 and 24 hours after surgery. We found that mean VAS score at rest was significant (p-value<0.05) at all time intervals except at 24 hours and with movement it was significant at intervals of 2,8,12 and 24 hours. The mean duration of analgesia was prolonged in group II (7.60±1.82 ) hours than group I (3.57±2.28) hours which was nearly double the analgesia achieved with wound infiltration indicating a longer duration of analgesia with IIIH nerve block.

Discussions: Postoperative pain relief is of utmost importance for the physicians managing the postoperative wards, especially after cesarean section to facilitate early ambulation of the mother, infant care, and prevention of postoperative morbidity. Inadequately treated pain after cesarean section is associated with an increased incidence of chronic pain and posttraumatic stress syndrome. IIIH nerve block at the level of the anterior superior iliac spine produces analgesia covering the dermatome supplied by the lumbar nerves in its distal distribution. The Pfannenstiel incision lies within this dermatome. Therefore, it is possible to provide analgesia of the anterior abdominal wall. Peripheral nerve block requires some amount of expertise and commitment but it is possible to improve the comfort of the patient with these simple blocks considerably. In our study, the mean VAS scores were significantly reduced at rest and with movement and the mean duration of analgesia was significantly prolonged in group II.

Conclusion: In the present study, the bilateral IIIH nerve block significantly increased the duration of postoperative analgesia, lowered the VAS scores, and reduced the analgesic consumption as compared to wound infiltration in patients undergoing cesarean section.

3. Incidence of Delirium in Adult Patients Admitted in Intensive Care Unit. (Conference Abstract ID: 104)

Mariappan Junior, Poonam Gupta

VMMC and Safdarjung Hospital, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.170

Introduction: Delirium is an acute impairment of consciousness producing a generalized cognitive impairment. It develops very shortly and has a fluctuating course over the day. The incidence of delirium reported among critically ill patients is 16 to 89%.1 It may be caused by a disease process other than the brain, such as, infection (urinary tract infection, pneumonia) or drug effects, particularly anticholinergic or CNS depressants (benzodiazepines and opioids). Although the rate of prevalence in the ICU is high, delirium often goes unnoticed by the intensivists. Most of the critically ill patients with delirium may either have a hypoactive form or mixed form where they fluctuate between hyperactive and hypoactive forms.2,3 Mechanically ventilated ICU patients are at high risk of developing delirium and its pathogenesis is multifactorial responsible for a longer stay in ICU and higher mortality.4

Objectives: The primary objective was to evaluate the incidence of delirium among adult ICU patients using the confusion assessment method in the intensive care unit (CAM-ICU) and Richmond Agitation–Sedation Scale (RASS). The secondary objective was to evaluate the risk factors accounting for delirium contributing to mortality and morbidity among the delirious patients.

Materials and methods: This prospective and observational study was conducted on all patients aged above 18 years admitted to ICU of a tertiary care hospital for 9 months, after obtaining Institutional Ethical Committee approval and written informed consent from the guardian of all patients admitted in ICU. Family refusal, patients with prior history of psychosis, neurological disorder, unconscious, and deaf patients were excluded from the study. All patient information, comorbidities, medical history, drug history, the reason for ICU admission were recorded at the time of admission in ICU and were assessed twice daily at morning (9 am) and evening (5 pm) by the resident doctors. The endpoint is either positive detection of delirium, discharge from ICU, or death in ICU. The patients were assessed on Acute Physiology and Chronic Health Evaluation II (APACHE-II), Richmond Agitation–Sedation Scale (RAAS), and Confusion assessment method for Intensive care unit (CAM-ICU). Risk factors were classified into predisposing and precipitating factors. Predisposing factors include comorbidities, various medication may be present before the ICU admission and are rarely modifiable, whereas precipitating factors are iatrogenic (mechanical ventilation, sedatives, physical restraints) and related to the severity of illness which are modifiable. Quantitative variables were compared using unpaired t-test/Mann–Whitney test, qualitative variables were compared using Chi-square test/Fisher’s exact test. Univariate and multivariate logistic regression was done to find out significant risk factors of delirium. A p < 0.05 was considered statistically significant. The data were entered in MS Excel spreadsheet and analyzed using Statistical Package for Social Sciences (SPSS) version 21.0.

Results: During the study period, a total of 110 adult patients that fulfilled inclusion and exclusion criteria were admitted in ICU. 41 (37.3%) patients developed delirium during their stay in ICU. Although the median age of patients who developed delirium in their ICU stay was more 35 years, the difference was not significant (p = 0.672) between the two groups. There were no significant gender differences between both groups (p = 0.651). Patients with admissions from medical ward (63.4%) were found significant (p = 0.015) in delirious group, the reason for this was found to be multiple comorbidities among them, also the duration of days on mechanical ventilation among delirious patients from medical wards (23.5±13.3 days(IQR = 17days)). Among the predisposing factors, history of hypertension (31.7%vs14.5%; p = 0.035) was only significant in the development of delirium, while others were not significant. With the regard of precipitating risk factors, high APACHE II scores (15.07 ± 5.99 vs 9.16±7.18; p < 0.001), use of benzodiazepine i.v midazolam 1mg more than once in their stay (29.3%vs13.3%; p = 0.040), opioids i.v morphine 100micrograms/kg / fentanyl 1-2 micrograms/kg (80.5% vs 27.5%; p < 0.001), sepsis (39%vs14.5%; p = 0.004), presence of window/ natural light exposure (12.2% vs.91.3%; p < 0.001), need/use for physical restraints (78%vs4.3%; p < 0.001), mechanical ventilation (97.6% vs 55.1%; p < 0.001), with duration of (20.3±11.6;median 16 days, IQR11vs 6.5±9.4;median 4 days, IQR5), duration of ICU stay (25.00±17.80; median 18 days; IQR15-24 days vs. 6.03±7.76; median 4 days, IQR3-6 days; p <0.001) were found significant in development of delirium. A high mortality noted among delirious patient (53.7%).

Discussions: Using RASS and CAM-ICU tools for evaluation in our study, the incidence of delirium in this study was 41 (37.3%) patients. The incidence of delirium varies from 16 to 60%.1,16,18,19,21,24 This wide range of variations could be due to the type of ICU settings, tools used to assess delirium. The majority (48.7%) of patients were hyperactive, 11 (26.8%) hypoactive and 10 (24.5%) were mixed. Among predisposing risk factors, hypertension (p = 0.035) was associated with delirium. Ouimet et al.1 Dubois et al. too found the same.7 Among precipitating risk factors, higher APACHE II scores (15.07 + 5.99 vs 9.16 + 7.8; p < 0.001) were significant. Ouimet et al. too reported that delirium to be associated with high APACHE II scores (17.9 ± 8.2 vs 14.0 ± 8.0; p < 0.0001) but not with increased age, sex.1 Ely Ew et al.,4 Romapaey et al.,10 and Thomason et al.20 too suggested such association. Among medications, benzodiazepines (midazolam) and opioids (morphine/fentanyl) usages were significantly associated with the development of delirium. Studies from Sharma et al.14 and Lahariya et al.22 concur with our findings. The duration of mechanical ventilation among them was [20.3 ± 11.6 (11) vs 3.95 ± 7.92 (4.5)], which was higher when compared to Lat et al.15 Ely et al.2 have reported that the development of delirium was (32.4%) in mechanically ventilated patients, which was lower than our studies. The mean duration of stay in ICU among delirious patients were (25.00 ± 17.80 days) supports the findings from other studies that delirium was associated with prolonged ICU stay and high mortality 53.7%.10,12,14,20,23 The strength of our study was the daily assessment of delirium twice using CAM-ICU and RASS. Further, the delirious group of patients, who were diagnosed using the tool were treated early which included reorientation and behavioral intervention of patients by the caregivers by making frequent eye contact and instructions to reducing the dose of narcotics even policy of no sedative and antipsychotics (haloperidol/risperidone). This study has limitations, such as, small size, assessment of delirium was not done at a fixed time and we might have missed it as it has a fluctuating course. The present study excluded the patients who had visual and auditory impairments who may are at high risk for the development of delirium. Further, we followed patients until discharge from ICU or death. Factors like doses of sedatives were not evaluated to dose risk relationship. The side effects of antipsychotics were not recorded which is a drawback.

Conclusion: The incidence of delirium was 37.3% among adult patients in the ICU that included both ventilated and non-ventilated patients. Among the predisposing risk factors, hypertension was significant among the delirious group and precipitating factors, sepsis, high APACHE II score, use of sedatives (benzodiazepines and opioids), mechanical ventilation, use of physical restraints, presence of windows/natural light exposure were significant among the delirious patients. Duration of mechanical ventilation and the length of ICU stay were prolonged among the delirious group of patients which increase the morbidity of the patient. High mortality (53.7%) was noted among the delirious group of patients. As the mainstay of management of delirium is not early detection but to modify the precipitating factors but also to reduce the morbidity and mortality among critically ill patients.

16. Sepsis

1. Medical Malpractice Claims in Patients Diagnosed with SepticemiaߞA Descriptive Analysis of Indian National Consumer Court Judgments. (Conference Abstract ID: 122)

Aakash Sethi, Mukesh Yadav, Kalpita Shringarpure

Government Medical College, Baroda, Principal, Govt. Medical College, Banda, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.171

Introduction: Patients in the ICU are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation.1 A patient in India can seek compensation because of injury due to malpractice (negligence) of a doctor by approaching either the District, State, or the National Consumer Court.2 The National Consumer Dispute Redressal Commission (NCDRC) is the highest forum for consumer disputes.2 It can entertain appeals and revisions against the judgment delivered by the state consumer commission.2 It can also entertain petitions which are filled for the first time (known as original case) if the value of the goods or services and the compensation exceeds more than 1 crore rupees.2 Any and all injury to the patient occurring to the patient due to an act or omission of the doctor is not negligence.2 To prove the changes of negligence the patient has to prove four things viz.Therapeutic misadventures and poor outcomes of the surgery are not negligence if the doctor had taken a reasonable degree of care that is expected from a doctor of similar caliber.2 Death of the patient or other postsurgical complications is a common reason for relatives to sue the doctor for damages.3 As the mortality of sepsis cases is high,4 there is a high likelihood of doctors being sued.

Objectives: Aims — To analyze the pattern of medical negligence in patients suffering from septicemia.Objectives; to find out:

Materials and methods: This is a retrospective, descriptive, cross-sectional study of NCDRC judgments pertaining to medical negligence in septicemia. As this was a record review where no human participants were involved, it was exempted from Institutional Human Research Ethics Committee approval. The study was conducted over a period of 4 weeks from October 1 to October 31, 2020. Judgments were accessed from www.scconline.com.Inclusion criteria were the NCDRC judgment having the following words inside the body of the judgment:A purposive sampling method was used. The judgments were analyzed on seven parameters.The quantitative variables include:The qualitative variables include:Data were entered and analyzed using MS Excel. Qualitative data were represented as percentage or proportion and quantitative data as median with interquartile range (IQR). Two groups of qualitative variables were compared using Fisher’s exact probability test. p value <0.05 was considered significant.

Results: On conducting the judgement search, 51 judgements met the inclusion criteria. 17 cases were excluded. Finally 34 judgements were analysed. Oldest judgement was pronounced in 2006 and the latest one in October 2020. In 4 cases [11.7%], the patients had sepsis with organ failure (severe Sepsis). The outcome of the court favored doctor in 8 cases [23.5%] and the rest were in favour of patient. There were 18 Appeal [52.9%], 11 Revision [32.3%] and 5 Original petitions [14.7%]. There were 18 [82.4%] surgeons but only 6 [17.6%] medical specialty doctors against whom negligence cases of sepsis were filled. Premier government hospitals and Multispecialty hospitals who were sued included PGI Chandigarh (3, 8.8%), JIMPER Pondicherry (1, 2.9%), Safdarjung (1, 2.9%), Fortis hospital (5, 14.7%), Apollo hospital (2, 5.8%). The Median compensation awarded was 5.8 lakh [IQR 2.25-10 lakh] while the median compensation asked for by the patient was 20 lakh [IQR 14.6-50 Lakh. On average courts awarded 51.4 % less compensation than was requested by the patient. The outcome of the case (In favour or against doctor) was not influenced by the party (doctor or patient) who filled the case (Fisher exact probability = 0.49). The outcome of the case (in favour or against patient) was not found dependent on the type of case (original, revision, appeal) (Fisher exact probability =0.59) Post-surgical sepsis [11, 32.3%] followed by abdominal infection [5, 14.7%] and crush injury [3, 8.8%] were the most common reason for sepsis. Hysterectomy [2, 5.8%], LSCS [2, 5.8%] and cholecystectomy [1, 2.9%] were the most common operations leading to post-surgical sepsis. Abdominal infection followed by UTI [3, 8.8%], Pneumonia [2, 5.8%] and endophthalmitis [2, 5.8%] were the most common site of dissemination of local infection leading to sepsis.

Discussions: Our study showed that postsurgical damage to intra-abdominal organs leads to most cases of patients suing doctors. Our finding of the most frequently implicated doctor (surgeon) was similar to the study conducted by Yadav et al.5 In the case of PGIMER vs Jasmine, the patient suffering from endophthalmitis, a known case of restrictive cardiomyopathy had systolic BP of 80 mm Hg with raised JVP. The NCDRC told that “OP/hospital and doctors have not clarified as to why the patient was not admitted in ICU or CCU despite knowing that her BP was persistently low” signifying the importance of admitting the patient of sepsis with low BP.

Conclusion: In most cases, where the patient of septicemia sued the doctor, the consumer court found the doctor guilty of negligence. The maximum compensation warded was 40 lakh and the minimum compensation was 1 lakh. As a standard of care, the NCDRC expects doctors to admit the patient when the BP has been persistently low in patients of sepsis. How doctors can protect themselves are a prompt postsurgical diagnosis of injury to intra-abdominal organs, diagnosis of rapidly spreading local infection. Maintaining detailed records including the record for the care taken to prevent any mishap to the patient.

2. Clinical Usefulness of IV Fosfomycin in Critically Ill Patients Admitted in ICU: An Indian Real-Life Experience. (Conference Abstract ID: 113)

Sagar Bhagat, Prachi Sathe, Ajay Bulle, Vasant Nagvekar, Milind Mane, Saiprasad Patil, Hanmant Barkate

Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
Ruby Hall Clinic, Pune, Maharashtra, India
Meditrina Institute of Medical Science, Nagpur, Maharashtra, India
Lilavati Hospital, Mumbai, Maharashtra, India
Noble Hospital Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.172

Introduction: Fosfomycin is a bactericidal, low-molecular-weight, broad-spectrum antibiotic, with putative activity against several bacteria, including multidrug-resistant Gram-negative bacteria, by irreversibly inhibiting an early stage in cell wall synthesis. Evidence suggests that fosfomycin has a synergistic effect when used in combination with other antimicrobial agents. Fosfomycin exhibits advantageous pharmacokinetic properties making it particularly useful for complicated deep-seated, even biofilm-associated infections, such as, respiratory tract, bone, or central nervous system (CNS) infections. Currently, data on the effectiveness of intravenous (IV) fosfomycin in daily clinical practice are still limited.

Objectives: The primary objective of the study was to understand the clinical use of IV fosfomycin in a real-life setting among critically ill patients admitted in ICU, while the secondary objective was to assess the clinical outcome and adverse effects.

Materials and methods: We retrospectively analyzed the clinical utility of fosfomycin in the ICU of four tertiary care centers across India. Medical records were analyzed to capture key details including medical history, culture and sensitivity, treatment details, and clinical outcome. The study was approved by Independent Ethics Committee.

Results: Data from medical record of 60 patients treated with IV fosfomycin was analysed. The mean age of patients was 56.78 years ±16.55 years, while the median age was 58 years (18-99 years). There was male preponderance (78.33%). Nosocomial infection were seen in 41 (68.3%) patients. Common clinical diagnosis were Sepsis (43.3%), bacteraemia (38.3%) and septic shock (38.3%). Enterobacterales were the most common (88.33%) isolates including K.pneumoniae in 45(75%) cases and non-fermenters were few in numbers(10%). Carbapenem-resistant Enterobacteriaceae (CRE) was the commonest (61.66%) resistance profile. Prior β -lactam exposure was limited (10%). 51 (85%) patients required mechanical ventilation, while 14 (23.3%) required CRRT, followed by 6 (10%) who required SLED. The mean dose of fosfomycin was 12.59 ±3.41 g/day, with median of 12 g (8–24 g/day). Fosfomycin therapy was given for a mean duration of 7.65 ± 6.71 days, with a median of 5 days (3 – 39 days). The mean infusion time was 43.09 ±16.09 min, with a median of 30 min (30-90 min). Colistin 15 (25%), Tigecycline 8 (13.33%) and Polymixin B 6 (9.83%) were the commonly used companion drugs with fosfomycin. Clinical cure was observed in 26 (43.3%) patients. Clinical failure and mortality was reported in 13 (21.7%) and 19 (31.7%) patients respectively. No significant association of hypotension (p = 0.079), cardiac arrest (p = 0.067), prior exposure to β-lactam (p = 0.300) and meropenem MIC >8 mg (p = 0.356) was seen with clinical failure/death.

Discussions: Fosfomycin is a novel antibiotic with good in vitro activity against the common pathogens, particularly toward the Enterobacteriaceae. Michalopoulos et al.1 used fosfomycin in 11 patients with nosocomial carbapenemase-producing Klebsiella pneumoniae (CPKP) infections. Intravenous fosfomycin was given as 2 to 4 g/6 hourly in combination with colistin (n = 6), gentamycin (n = 3), piperacillin-tazobactam (n = 1) in 11 patients for 14 ± 5.6 days. A good clinical and microbiological outcome with all-cause mortality of 18% was observed. A prospective study was conducted by Hellenic study group2 finding the outcome of fosfomycin in extensively drug-resistant and pandrug-resistant (PDR) Gram-negative infections. Fifteen intensive care units enrolled in the study. Sixty-five percent of the study population was in severe sepsis or septic shock. The resistance profile of clinical isolates was CPKP (85%), VIM-2 (35%), and PDR (36.6%). The median dose of intravenous fosfomycin was 24 g/day for 14 days and used in combination with colistin (66%), meropenem (25%), tigecycline (39%), and gentamycin (31%). Fifty-four percent of successful clinical outcome at 14 days with 565 bacterial eradication was observed. Case series from India by Mukherjee et al.3 where fosfomycin combination was used in CCRE infections. Four critically ill patients with fosfomycin only sensitive K. pneumoniae infection (colistin MIC ≥4) started on intravenous fosfomycin (2 g 8 hourly) with meropenem (2 g 8 hourly) for an average duration of 10 days. Three out of four patients survived. These evidence suggest the definite place of intravenous fosfomycin in the management of severe Gram-negative infection.

Conclusion: Intravenous use of fosfomycin is seen in serious Gram-negative infections as a combination therapy. Fosfomycin 12 g/day was commonly used in clinical practice with an average treatment duration of 7 days. Colistin is the preferred combination agent. Overall fosfomycin-based treatment in a critically ill patient has shown reasonable efficacy and tolerability in a real-world setting.

3. Role of Serum IL-6 and Ferritin Levels as Marker of Severity and Outcome Predictor in Children with Multiorgan Dysfunction Syndrome. (Conference Abstract ID: 93)

Abhishek Kumar Thakur, Anupama Yerra, Farhan R Shaikh, Parag Dekate, Kapil Sachane, Dinesh Chirla, Ujwala Desai, Karthik Narayanan

Rainbow Children’s Hospital, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.173

Introduction: MODS is the common end result of various insults that predisposes the body to a heightened state of immunological activity with cytokine storm engulfing the majority of organs. Distinct patterns of circulating cytokines and acute phase reactants have proven to some extent for guiding the diagnoses and management of MODS. Serum IL-6 and ferritin could be valuable biomarkers in the giant jigsaw puzzle of cytokine storm in MODS.

Objectives: Primary objective: To assess the role of serum IL-6 and ferritin levels as a marker of severity and outcome — predictor in children with multiorgan dysfunction syndrome.

Materials and methods: Prospective observational study — prospective data of critically ill children presenting with MODS on admission and those children who developed MODS during PICU stay from September 1, 2019, to March 1, 2020, taken. Serum IL-6 and ferritin were measured within 24 hours of the development of MODS. MODS’s clinical diagnosis was based on 2002 Goldstein’s criteria. Severity scores like SOFA score, vasoactive ionotropic score, length of stay, and outcome were noted during the PICU stay.

Results: Total number of admissions was 905 and the total number of children diagnosed with MODS as per Goldstein’s criteria was 253 (28.0%) during the study period. Of these, 94 (37%) were evaluated, concomitant samples for IL-6 and serum ferritin was sent. One hundred sixty-three (n = 163; 64 %) were not included in the study for reasons like parental refusal for participation, death within hours of admission. Mean (± SD) PICU length of stay was 7.6 days ±6.5 AND mean (± SD) total length of stay was 8.7 days ± 7 The mean ± SD SERUM IL-6 was 251.67 ± 577 (n = 94). The mean ferritin was 8462 ± 2060 (n = 94). Mean age of the study population was 56.5 months i:e 4 years and 8 months. Maximum number of children in the study population were infants (n = 36, 38.3%) The largest etiological subgroup was of viral sepsis, dengue fever being the main diagnosis. The most common causes of MODS was Severe Dengue without secondary infection (n = 50, 53.2%), Severe Dengue with Secondary Infection (n = 18, 19.1%, bacterial pneumonia (n = 9, 9.3 %), bacterial pneumonia with ARDS (n = 03, 3.2%), sepsis including culture positive and culture negative cases (n = 06, 6.4%,); Viral encephalitis contributed 4.3% (04), viral myocarditis 2.1% (02) and one patient (1.1% ) each had viral pneumonia. CORRELATION OF SERUM IL 6 with severity score and outcome SOFA score on day 1 has a positive Spearman Correlation Coefficient of 0.466 which was significant (r = 0.466: p = 0.000). Worst SOFA score also had a strong positive, significant correlation (r = 0.483: P value 0.000) with Serum IL6 measures at onset of MODS. The Pearson correlation between SERUM IL-6 and Worst VIS was strong and statistically significant(r = 0.555, p = 0.000). The Receiver Operating Characteristic Curve (ROC) chalked out for the relation between IL-6 and outcome measure of mortality, in the critically ill PICU patients with MODS, assigned a cut off value of SERUM IL-6 at 72.45, shows area under the curve (AUC) to be 0.833 which is excellent correlation with standard error of 0.054 with p value 0.001, which is significant, with sensitivity of 77.8 and specificity of 85.1. This means IL-6 values above the cut-off of 72 is a very potent severity marker for mortality in critically ill children with MODS. The Spearman correlation between Ferritin and VIS Worst is positive, mild at .043 (p = 0.683, not significant) CORRELATION OF SERUM FERRITIN WITH SEVERITY SCORES AND OUTCOME The Spearman correlation between Ferritin and VIS Worst is positive, mild at .043 (p = 0.683, not significant). ROC curve for ferritin versus outcome, the AUC was 15730 ng/ml with a p value of 0.126 with a sensitivity of 37 % and specificity of 86.6 %

Discussions: Sepsis and trauma are the two conditions most commonly associated with multiple organ dysfunction syndromes both in children and adults. IL-6 levels have a positive and moderate to strong Spearman correlation coefficient with SOFA day 1 (0.466) and worst SOFA (0.483), and the correlation was highly significant (p = 0.000). Vasotrope–Inotrope score is associated with important clinically relevant outcomes including ICU length of stay, ventilator days, and mortality. The Pearson correlation between serum IL-6 and worst VIS is 0.555 which is moderate grade and significant (p = 0.000). IL-6 values above the cutoff of 72 pg/mL is a very potent severity marker for mortality with a sensitivity of 77.8% and specificity of 85.1% in critically ill children with MODS in this analysis. Serum ferritin measured at the onset of MODS, had poor specificity and sensitivity with respect to outcome. This study was done before COVID-19 pandemic and none of the study population had COVID illness. Serum biomarkers IL-6 and ferritin were measured only once at the onset of MODS, in comparison to each other, serum IL-6 would be a valuable predictor of the outcome at the onset of MODS.

Conclusion: The epidemiology of MODS in developing countries, especially the Indian subcontinent is very different with viral sepsis predominating the cohort. Serum IL-6 is better correlated to clinical scores like SOFA, VIS, and thus, a better marker of severity. Serum IL-6 in comparison with serum ferritin would be a better biomarker to predict the outcome at the onset of MODS in critically ill children.

4. Comparison of Serum Nucleosomes and Tissue Inhibitor of Metalloproteinase 1 (TIMP1) in Predicting Mortality in Adult Critically Ill Patients in Sepsis: Prospective Observational Study. (Conference Abstract ID: 78)

Nitin Rai, Lokesh Kashyap, Puneet Khanna, Seema Kashyap, Dilip Shende, Rahul Kumar Anand, Shailendra Kumar Yadav, Mithlesh Kumar Singh

All India Institute of Medical Sciences, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.174

Introduction: Sepsis is a life-threatening organ dysfunction due to dysregulated host response to infection. Timely identification is important for risk reduction and better outcomes in critically ill patients. Nucleosomes and TIMP1 are biomarkers whose validity and utility in predicting severity, organ dysfunction, and mortality in sepsis has been proven. However, which biomarker among these two has better predictive value in elucidating disease severity, organ dysfunction, and mortality in sepsis is yet to be answered.

Objectives: The primary outcome was to compare the predictability of nucleosomes and tissue inhibitor of metalloproteinase 1 (TIMP1) in estimating sepsis mortality. The secondary outcome was to evaluate the effects of nucleosomes and tissue inhibitor of metalloproteinase 1 (TIMP1) in assessing disease severity and organ dysfunction.

Materials and methods: After institutional ethics clearance and informed written consent, 80 patients with sepsis/septic shock, aged between 18 and 75 years admitted in ICU were recruited in this single-center, prospective observational study conducted between May 2018 to July 2019. Quantification of serum nucleosomes and TIMP1 was done with enzyme-linked immunosorbent assay (ELISA) using venous blood, within 24 hours of diagnosis of sepsis/septic shock. [Trial registration number: CTRI/REF/CTRI/2018/05/013770].

Results: The optimal cut-off point for TIMP-1 was 149.4 pg/µl with a sensitivity and specificity of 71.4% and 53.3% respectively, while the optimal cut-off point for nucleosomes was 215 pg/μl, providing sensitivity and specificity of 71.4 and 57.7% respectively. DeLong test was used for comparison between the ROC curve for two biomarkers.The AUC-ROC curve for TIMP1 and nucleosomes to discriminate between survivors and non survivors were 0.70 (95% CI 0.58 0.81) and 0.68(0.56-0.80) respectively. Although independently, TIMP1 and nucleosomes have statistically significant capacity to discriminate between survivors and non survivors (p values 0.002 and 0.004 respectively), superiority of one biomarker over other in discriminating between survivors and non survivors was not observed. For TIMP1, correlation was found between TIMP1 value and duration of vasopressor and length of stay. (Spearman’s correlation coefficient r = 0.27, p = 0.03 and r = 0.22, p = 0.04, respectively). For nucleosomes, there was no significant correlation between nucleosomes value and the variables.

Discussions: Sepsis is life-threatening organ dysfunction, characterized by high mortality, more so in septic shock.1 A higher incidence of sepsis-associated mortality of 55 to 65% has been reported from two studies from the Indian subcontinent.2,3 Mortality rates were as high as 7% per hour delay in diagnosis for the first 6 hours.4 The mean values of TIMP1 and nucleosomes were lower in survivors than non-survivors. Similar results have been observed in other studies.5–9 These findings are in line with the current study where we observed significant differences in the concentration of nucleosomes between survivors and non-survivors. TIMP1 and nucleosomes showed moderate to poor ability, with both having approximately similar values (0.70 and 0.68, respectively). The analysis confirmed that although median values of TIMP1 and nucleosomes have a statistically significant capacity between survivors and non-survivors, the superiority of one biomarker over another in discriminating between survivors and non-survivors was not observed (p = 0.69). Bivariate analysis showed a significant correlation between TIMP1 and duration of vasopressor, and length of stay. A similar finding was observed in a study by Bojic, where a significant correlation was found between TIMP1 and the duration of vasopressors.10 Similar to the present study, analyzes performed by Hoffman and Ashoori also did not find a significant association between TIMP1 and other covariates.11,12

Conclusion: The median values of each biomarker showed a statistically significant difference between survivors and non-survivors, the superiority of one biomarker over the other in predicting mortality was not observed. However, this was an observational study with a small sample size; future larger studies are needed to validate the findings of the present study.

5. Evaluation of Ratio of Delta pCO2 to Arterial Venous Oxygen Content Difference (∆pCO2:∆CavO2) as a Perfusion Marker and Prognosticator in Patients with Septic Shock. (Conference Abstract ID: 60)

Ameya Abhay Ghude, Ashwini Jahagirdar

Sahyadri Speciality Hospital, Pune, Maharashtra, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.175

Introduction: Sepsis is the most commonly encountered entity in intensive care practice. Surviving sepsis campaign’s “sepsis bundle” has made the use of lactate and central venous oxygen saturation guided resuscitation widely acceptable. Though very useful, both these markers have their limitations, mainly due to the inherent heterogeneity and sepsis-induced incoherence in the microcirculation. There have been a few studies suggesting that the delta pCO2 to arterial-venous oxygen content difference (∆pCO2:∆CavO2) can be used to predict lactate evolution in patients with septic shock and serve as a marker of global tissue hypoxia. Hence, we decided to conduct this observational study to evaluate (∆pCO2:∆CavO2) as a perfusion marker and prognosticator in patients with septic shock.

Materials and methods: We conducted a prospective observational study of 50 adult septic shock patients admitted to our intensive care units. Septic shock was defined by: 1. SOFA score of 2 or more at the time of admission or change in SOFA score by 2 or more points at the time of transfer to ICU. 2. Needing vasopressor for maintaining MAP of 65 mm Hg. 3. Lactate levels > 2 mmol/L. Pregnant patients, patients with obstructive or interstitial lung disease, patients in Child-Pugh Class C, patients with cardiogenic, neurogenic, obstructive shock, and uncorrected congenital heart disease were excluded from the study. We obtained arterial and central venous blood gases of these patients: 1. at the initiation of resuscitation and 2. Six hours after the start of resuscitation (i.e., after adequate resuscitation). Lactate levels, central venous oxygen saturation were measured. ∆pCO2, ∆pCO2:∆CavO2 were calculated.

Results: Fifty patients were studied. Mortality was thirty-eight percent. Based on mortality patients were divided into survivors and non-survivors. In survivors, initial mean values were - for lactate levels - 3.2 mmol/l (± 2.5), ScvO2 - 64% (± 9%), ∆pCO2 - 6.4 (± 2.1) and ∆pCO2:∆CavO2 - 1.7 (± 0.8). After adequate resuscitation, the respective mean values were 1.8 mmol/L (±1.2), 66% (± 10%), 5.3 (± 0.9), 1.4 (± 0.3). In non-survivors, initial mean values were - for lactate levels - 8.1 mmol/l (± 5.6), ScvO2 - 56% (± 18%), ∆pCO2 - 8.9 (± 2.3) and ∆pCO2:∆CavO2 - 2.5 (± 1.0). After adequate resuscitation, the respective mean values were 5.8 mmol/L (±3.8), 62% (± 11%), 6.5 (± 1.3), 2.1 (± 0.6).

Discussions: In our study, the main result is that the difference in the mean initial values of ∆pCO2:∆CavO2 in survivor and non-survivor groups was highly statistically significant (p < 0.001). ∆pCO2:∆CavO2 is a useful tool to prognosticate patients in septic shock. ∆pCO2:∆CavO2 of 2.0 or more was associated with >75% mortality in patients with septic shock. The difference in mean lactate clearance between the survivor and non-survivor groups was also statistically significant (p < 0.005). Therefore, it can be inferred that high values of ∆pCO2:∆CavO2 ratio predict poor lactate clearance. We also concluded that the ∆pCO2:∆CavO2 ratio cannot be used as a standalone perfusion marker for guiding resuscitation the difference between the decrease in ∆pCO2:∆CavO2 ratio in both the groups was not statistically significant.

Conclusion: ∆pCO2:∆CavO2 may not be useful as a standalone perfusion marker for guiding resuscitation. It is a useful indicator of lactate evolution and a good prognosticator, especially when combined with lactate levels.

6. Observational Study of Culture Positive Sepsis in COVID-19 Critically Ill Patients—Emerging Pattern at a Tertiary ICU Center. (Conference Abstract ID: 54)

A Ganesh, P Vivekananthan, Laxmi Kanth Charan, MN Sivakumar

Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.176

Introduction: Aim:

Materials and methods: We studied a total of 23 critically ill COVID-19 patients admitted over a month retrospectively. We observed that there was no incidence of bloodstream infections in any of the patients during their stay in ICU. The incidence of blood culture testing for BSI was among 43% of the patients. VAP was not observed in any of them either when 21% of the patients underwent culture and sensitivity of their endotracheal aspirate. However, there were six patients with catheter-associated urinary tract infection accounting for nearly 26% of the patients, and the positivity rate was as high as 66% when tested. We observed a very low positivity rate for bloodstream infection and ventilator-associated pneumonia whereas a very high positivity rate for catheter-associated urinary tract infection. All the patients had antiviral drug therapy with remdesivir and steroid therapy during their stay in ICU. Use of procalcitonin to ascertain the presence of infection was also seen in at least 50% of the clinically suspected septic patients.


Discussions: Though the positivity rate was low in tested samples, the clinical decision to cover the episodes of suspected sepsis with antibacterial agents might be substantiated due to the reduced mortality rate observed within our cohort of patients.


7. Effectiveness of Phenylephrine vs Norepinephrine for Initial Hemodynamic Support of Patients with Septic Shock. (Conference Abstract ID: 51)

Swapna Latha Kotagiri, Surendra Gollapudi, Sahithy Mataparthy

Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.177

Introduction: Many studies suggest phenylephrine as a first-line drug for initial inotrope in patients with septic shock. Phenylephrine improves oxygen delivery by improving splanchnic blood flow in septic shock patients. But, there are a limited number of studies to consider for clinical use. In septic shock, norepinephrine has shown compromised blood flow to the mesenteric circulation.

Materials and methods: The study was conducted in KIMS, Narketpally, Telangana, India. The study was carried out in patients with septic shock associated with hemodynamic challenges. On getting approval from the local Institutional Ethics Committee. Informed consent was obtained from all the patients enrolled in the study to give consent by themselves. Patient enrolment has been started from December 2018 to July 2019. All the patients enrolled in the study were patients who have fulfilled the septic shock criteria with a mean arterial pressure.

Results: The study included a total of 30 patients who have been divided into 2 groups based on the drug administered in the patients with phenylephrine and norepinephrine. Each group consisted of 15 patients. Mean age of phenylephrine group was observed to be 65, and norepinephrine group was observed to be 67. The percentage of male patients in each group has been assessed and was recorded as 70 in phenylephrine group and 65 in norepinephrine group. Cause of septic shock was assessed in different aspects like pneumonia which was noted as 4 patients in phenylephrine group and 5 patients in norepinephrine group.

Discussions: Pulmonary artery occlusion pressure (mm Hg) as a baseline in the phenylephrine group was 15 ± 2, and in the norepinephrine group 15 ± 2. After 12 years, it was assessed to be 17 ± 3 in both the groups. Right atrial pressure (mm Hg) was assessed to be 13 ± 3 in the phenylephrine group and 13 ± 3 in the norepinephrine group. After 12 hours, it was assessed to be 14 ± 2 in the phenylephrine and 15 ± 3 in the norepinephrine group.

Conclusion: We conclude from the study that on the administration of phenylephrine as a first-line agent for hemodynamic support in septic shock patients, the MAP was increased without any compromising of hepatosplanchnic and GI perfusion in comparison with norepinephrine.

8. Outcome of Patients Admitted in ICU with MDR Infections. (Conference Abstract ID: 45)

MA Manaf

DOI: https://doi.org/10.5005/jp-journals-10071-23711.178

Introduction: Outcome of MDR Gram-negative infections in ICU.

Objectives: To study the outcome of ICU patients admitted with MDR Gram-negative infections.

Materials and methods: Prospective observational study.

Results: Mortality of patients with MDR Gram-negative infections is around 60%.

Discussions: Multidrug resistance is a global health issue. The mortality of patients acquiring multidrug-resistant Gram-negative infections is high.

Conclusion: The mortality of ICU patients admitted or acquiring Gram-negative multidrug-resistant infections is high.

9. Sepsis in Indian Intensive Care Units: A National Multicenter Point-Prevalence Study. (Conference Abstract ID: 44)

Ashwani Kumar, Parmeet Kaur, Bharath Kumar Tirupakuzhi Vijayaraghavan, Arpita Ghosh, Sarah Grattan, Vivekanand Jha, Bhuvana Krishna, Dilip Mathai, Bala Venkatesh

The George Institute for Global Health and UNSW, Sydney, Australia
Dr Naomi Hammond, Apollo Institute of Medical Sciences and Research, Hyderabad, India
Department of Critical Care Medicine, Apollo Main Hospital, Chennai, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.179

Introduction: The recent Global Burden of Disease (GBD) study reported that in 2017 there were 11 million sepsis cases and approximately 3 million deaths in India. There are only a few studies (largely single center) from India reporting on the sepsis epidemiology in Indian ICUs.

Objectives: The primary objective of this study was to estimate the prevalence of sepsis in patients admitted to Indian intensive care units (ICUs). We also compared prevalence using previous SIRS-criteria (Sepsis-2) and the new Sepsis-3 definitions, examine pathogen profile.

Materials and methods: This was a prospective, observational, multicenter, nation-wide point-prevalence study. Ethics approval or waiver was obtained by all participating sites. An email invitation was sent out to Indian ICUs representing multiple geographical locations and hospital type to participate on one of four study days between May 24 and July 17, 2019. All adult patients (≥18 years) present in the ICU on the study day were included in the study. Data were collected over 24 hours (from 08:00 am to 08:00 am the following day) and at day 30 follow-up. A hospital- and ICU-level questionnaire was completed at each site. Following patient-level data were also collected: demographics, SIRS criteria, Sepsis-3 criteria, infection and antimicrobial details, interventions, and outcome data at 30 days following the study day. De-identified patient data were entered into an electronic case report form via REDCap. The continuous, normally distributed data presented as means with standard deviations, and non-normally distributed data as medians with interquartile ranges while categorical data as numbers and proportions. One-day point prevalence (PPd) was calculated using as follows: Sepsis cases/all cases treated in ICU. Concordance between the two sepsis definitions was assessed using Cohen’s kappa coefficient (K) (values ≥0.80 showing a strong level of agreement).

Results: A total of 35 ICUs participated enrolling 686 patients of which 29 (82.9%) were private hospitals. The participating hospitals were mostly from the southern region (n18; 51.4%) followed by western (n8; 22.9%), northern (n5; 14.3%) eastern (n3; 8.6%) and central (n1; 2.9%). The median age of the study population was 60+24 years with approximately 60% being males. The most common primary diagnosis and comorbidity was kidney disease and diabetes, respectively. The overall prevalence of sepsis on the study day was 55.7%. Prevalence as per Sepsis-3 and Sepsis-2 criteria was 33.2% and 46.2%, respectively. The two sepsis definitions showed poor concordance in (K= 0.32). The most frequently used intervention was mechanical ventilation (41.1%). The proportion of septic shock in Sepsis-3 and Sepsis-2 groups was 15.1% and 10.1%, respectively. In septic shock patients, steroids were administered in 53.1% of with hydrocortisone being the most common steroid and norepinephrine being the most common vasopressor. In sepsis patients, the three most common sites of infection were pulmonary (35.9%), bloodstream (13.7%) and abdomen (11.6%). Most infections were due to gram-negative bacteria and 44.8% of infections were multi-drug resistant. Commonly administered antibiotics were: meropenem (23.4%), piperacillin/tazobactam (10.5%) and teicoplanin (8.0%). Mortality at 30 days after the study day was higher in sepsis patients compared to overall study population (27.6% vs 18.3%; p < 0.001). Most patients were discharged to home (46.2%) and a higher proportion of sepsis patients were discharged against medical advice compared to the overall study population (12.8% vs 9.5%; p < 0.001).

Discussions: This is the largest sepsis cohort study conducted in India.

Conclusion: This national, multicenter point prevalence study showed a high sepsis burden in Indian ICUs with more than half of the patients meeting sepsis criteria on the study days. There was poor agreement between sepsis-3 and sepsis-2 definitions. Gram-negative bacteria were the predominant pathogen. There was a high rate of antimicrobial resistance observed in sepsis patients.

10. To Evaluate the Efficacy of Marik Protocol in Sepsis Patient Causing Circulatory or Respiratory Compromise or Both. (Conference Abstract ID: 36)

Rabinder Singh, Sandeep Bhattacharya

Asian Hospital, Faridabad, Haryana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.180

Introduction: Septic shock is a life-threatening condition that is characterized by a collapse in the ability of the organism to maintain adequate blood pressure and end-organ perfusion secondary to sepsis — a dysregulated inflammatory response triggered by infection.1 Current management strategies for patients with sepsis include early aggressive fluid resuscitation, early appropriate antibiotics, hemodynamic support with vasopressors, and the identification and control of infected sites. Although outcomes have improved with the bundled deployment of these strategies, mortality remains high at 20 to 30% with a global burden of sepsis being an estimated 15 to 19 million cases per year, of which the vast majority of these cases occur in low-income countries, where mortality is reported to be as high as 60%.2 Even among sepsis patients who survive their hospital stay, residual organ dysfunction requiring ongoing treatment after discharge is common. Despite this high level of mortality and morbidity, antibiotics and source control remain the only focused therapies for this condition. The current management of sepsis and septic shock largely focuses on improving oxygen delivery via a combination of intravenous fluid and vasoactive medications while treating the infection with antibiotics and source control. Recently, a study conducted by Marik et al. demonstrated a remarkable decrease in the mortality of septic patients who received a multidrug “cocktail” of intravenous vitamin C, hydrocortisone, and thiamine.3 In this study, we compare the effects of receiving vitamin C, thiamine, and hydrocortisone (along with the standard sepsis care) vs standard sepsis care alone.

Objectives: Primary: To see consecutive days free of a ventilator and vasopressor support (VVFDs) in the 4 days following randomization. Secondary: To see the mortality at 4 days of giving the Marik protocol.

Materials and methods: It was a prospective, single-center, single-blinded, randomized controlled trial. It enrolled a total of 50 patients with sepsis causing respiratory or circulatory compromise or both, who were admitted to the ICU of the Asian Institute of Medical Sciences, Faridabad. Patients were randomly assigned (1:1) to receive i.v. vitamin C (1.5g q6hr for 4 days), i.v. thiamine (200 mg q12hr for 4 days), and i.v. hydrocortisone (50 mg q6hr for 7 days, then tapered down in 3 days) or matching placebos until intensive care unit discharge occurred (whichever was first). Patients randomly assigned to the comparator group were permitted to receive open-label stress-dose steroids at the discretion of the treating clinical team.

Results: Out of a total of 50 patients, 25 were cases. There was no significant difference (P-value = 0.083) in the need for ventilation as only 7 (28%) out of 25 patients among cases required ventilation while 13 (52%) out of 25 patients among controls required ventilation. All the 50 patients (100%), both cases and controls, required vasopressors, but for a variable period of time, leaving no significant difference (P-value = 0.31). The mortality at the end of 4 days was 15 patients (60%) among cases and 9 patients (36%) among controls with no significant difference (P-value = 0.08). *P-value <0.01 considered as significant.

Discussions: Low blood levels of both thiamine and vitamin C are common in sepsis. A large amount of experimental data have shown that vitamin C and corticosteroids decrease the release of inflammatory substances which may lead to organ failure seen in sepsis. There was an equal number of strengths and limitations to our study, making it difficult to reach a solid conclusion.

Conclusion: Our study does not prove to improve the status of the patients in terms of the above-said measures. Additional studies are required to confirm these preliminary findings.

11. Prospective Observational Study on Fluid Balance Status—Identifying Suitable Intervention Points in Care of Critically Ill Patients. (Conference Abstract ID: 33)

Ram G Arun, Vivekanathan, Lakshmikanth Charan, Sivakumar

Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.181

Introduction: To observe the fluid status of critically ill medical and surgical patients in the critical care unit at selected time scales at 24 hours, 3 days, and 7 days of admission to ICU. To identify prognostic severity of illness based on fluid balance status and biochemical values on day 3 of critical illness. To identify and intervene in a certain group of patients wherein the appropriate timing of deresuscitation attempts in fluid management can be instituted.

Materials and methods: Data collection includes all medical and surgical patients with 7 days or more of ICU stay, patient demographics, associated comorbidities, hemodynamic support requirement, the severity of illness score, fluid resuscitation parameters. The primary outcome was to identify the fluid balance state at 24 hours, 72 hours, and at end of 7 days of ICU stay. The secondary outcome includes incidence of ARDS, acute renal failure, anasarca, new-onset cardiac failure.


Discussions: Positive fluid balance is associated with high morbidity and mortality.1 Late conservative fluid management defined as two consecutive days of negative fluid balance during the first week of ICU is an independent predictor of survival in ICU.1 There are suggestions that the transition of systemic inflammatory response syndrome associated with sepsis and septic shock, usually settles by day three, if not indicates the severity of the illness. Patients with sepsis, higher cumulative fluid balance at day 3 but not in the first 24 hours after ICU admission was independently associated with an increase in the hazard of death.2


12. Balanced Crystalloids vs Normal Saline for Initial Fluid Resuscitation in Children with Septic Shock—A Randomized Controlled Trial. (Conference Abstract ID: 26)

Jhuma Sankar, Jayashree Muralidharan, AV Lalitha, Ramesh Kumar, S Mahadevan, Javed Ismail, Vinay Nadkarni, Scott L Weiss, M Jeeva Sankar, SK Kabra, Rakesh Lodha

All India Institute of Medical Sciences, New Delhi, India
PGIMER Chandigarh, St Johns’ Hospital, Bengaluru, Karnataka, India
JIPMER, Puducherry, India
Childrens Hospital of Philadelphia, USA

DOI: https://doi.org/10.5005/jp-journals-10071-23711.182

Introduction: Crystalloids are recommended for initial fluid resuscitation in septic shock and normal saline (NS) is commonly used as it is cheap and readily available. However, increased incidence of hyperchloremic metabolic acidosis and acute kidney injury (AKI) associated with the infusion of NS has been reported in critically ill adults with shock as compared to the use of balanced crystalloids (BC). Unfortunately, there is a paucity of evidence with regard to whether BC is superior to NS in the resuscitation of children with septic shock.

Objectives: To compare the effects of balanced crystalloids with that of normal saline during initial fluid resuscitation on the risk of new-onset acute kidney injury (AKI) and mortality in children with septic shock.

Materials and methods: In this double-blind, randomized trial conducted at four Indian sites from 2017 to 2019, we randomly assigned children <17 years’ age with septic shock (defined as infection with at least two signs of hypoperfusion with or without hypotension) to receive fluid boluses of 20 mL/kg each of either balanced crystalloids (Plasma-Lyte A; BC group) or normal saline (NS group) at the time of detection of shock. The trial was registered at ClinicalTrials.gov (NCT02835157). Children were managed as per the American College of Critical Care Medicine guidelines 2017 and monitored till discharge/death. Renal function tests and serum electrolytes were recorded at admission, 6, 24, 48, 72 hours, and day 7 after initial fluid resuscitation to evaluate the risk of new-onset AKI (any stage of AKI — 1, 2, or 3 as per the 2012 Kidney Disease- Improving Global Outcomes clinical practice guidelines), the requirement of renal replacement therapy (RRT), and hyperchloremia. The primary outcome was the risk of developing new-onset AKI by day 7 after initial fluid resuscitation. The sample size calculated was 708 patients for a power of 90%.

Results: We enrolled 708 (405 boys; median age: 5 years) children: 351 and 357 in the BC and NS groups, respectively. Baseline characteristics including the proportion of children with AKI at admission [5% and 5.6% in the BC and NS groups respectively] were comparable between the two groups. The fluid volumes received in the first 24 hours were similar in both the groups [107 (90, 134) vs. 110 (92, 126) ml/kg in the BC and NS groups respectively. When compared to the NS group, fewer children developed new onset AKI (20% vs. 33% RR 0.62; 95% CI 0.48 to 0.80; p = 0.0001) and required RRT (9% vs. 18% RR 0.50; 0.34 to 0.73; p = 0.0004) in the first 7 days after fluid resuscitation in the BC group. The number (%) of children developing hyperchloremia significantly increased over the first 48 hours in the NS group as compared to the BC group (p = 0.0006). The mortality in both groups was however, similar (33% vs. 34%; RR 0.96; 0.78 to 1.19; p = 0.81). There was no difference in other secondary outcomes including ventilator, inotrope or ICU free days between the groups.

Discussions: We found a significant reduction in the risk of new-onset AKI with the use of BC as compared to NS for fluid resuscitation in children with septic shock. We observed a corresponding increase in the incidence of hyperchloremia at 24, 48, and 72 hours in the NS group as compared to the BC group. Our study findings concur with the in vitro and animal studies that have shown hyperchloremia to be associated with an increase in renal vascular resistance and a decrease in glomerular filtration rate.

Conclusion: The use of balanced crystalloids as compared to normal saline for initial fluid resuscitation was associated with a significant reduction in the risk of new-onset AKI in children with septic shock.

13. Effect of Treatment with Low-Dose Corticosteroids on Mortality in Patients with Severe Sepsis and Septic Shock. (Conference Abstract ID: 24)

Tammina Akhila Sai, PV Sai Satyanarayana, Surendra Gollapudi

Kamineni Institute of Medical Sciences, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.183

Introduction: The benefit and use of low-dose corticosteroids in the reduction of mortality in patients with severe sepsis and septic shock. Septic shock may be associated with relative adrenal insufficiency. Thus, replacement therapy with low-dose steroids has been proposed to treat septic shock. Surviving sepsis guidelines suggest low-dose steroids use for septic shock patients poorly responsive to fluid resuscitation and vasopressor therapy.

Objectives: To assess whether treatment with low dose steroids (hydrocortisone and fludrocortisone) reduce 28-day mortality in patients with severe sepsis and septic shock.

Materials and methods: All the materials required for the study have been collected from the study site on getting approval from the heads of the respective department and on the signing of informed consent by the patients enrolled in the study. Hydrocortisone came in vials containing 100 mg of hydrocortisone powder and 5 mL of sterile water for injection, which was administered intravenously every 6 hours as 50 mg bolus. One tablet containing 50 µg of 9-α-fludrocortisone was administered daily through a nasogastric tube with 20 to 30 mL of water. Placebo was indiscernible from active treatments. The treatment duration was 7 days.

Results: 150 patients were included in analysis (75 in placebo group and 75 in steroid group) 28 day mortality in placebo group was 60.5% and in steroids group was 54.6%. ICU mortality in placebo group was 66.6% and in steroid group was 60%.Hospital mortality in placebo group was 69.3% and in steroid group was 63.5%.

Discussions: A total of 150 patients were randomized. Statistical analysis was by using SAS statistical software. Different parameters are compared among two groups (placebo and steroid group). The mean temperature in the placebo group was 37.7°C and in the placebo group was 37.9°C, both the values are compared by paired t-test, σ was 1.3030, and t value was −0.485. The mean heart rate in the placebo group was 116 bpm and in the steroid group was 117 bpm, both the values are compared by paired t-test, σ was 7.604, and t value was −0.582. Mean MAP (mean arterial pressure) in the placebo group was 52 and steroid group was 51, both the values are compared by paired t-test, σ was 4.028, and t value was 0.785. The mean SOFA score in the placebo group was 16 and in the steroid group was 16, t value was 0. Mean hemoglobin levels in the placebo group were 10.4 g/dL and in the steroid group was 10.24 g/dL, σ was 1.82, and t value was 0.312. The mean leukocyte count in the placebo group was 12,440 cells/cumm and in the steroid group was 11,430 cells/cumm, both the values are compared by paired t-test, σ was 6014, and t value was 0.531. The mean platelet count in the placebo group was 120 × 103/µL and in the steroid group was 122 × 103/µL, both the values are compared by paired t-test, σ was 30.9, and t value is −0.204. Mean arterial lactate levels in the placebo group was 4.26 mmol/L and in the steroid group was 4 mmol/L, both the values are compared by paired t-test, σ was 0.466, and t value was 1.492. A fluid challenge of 20 mL/kg over 20 minutes was given in all patients (both placebo and steroid group). In the placebo group, 11 patients were on dopamine support (mean — 11 µg/kg/minute). In the steroid group, 22 patients were on dopamine support (mean — 10.8 µg/kg/minute). Both the values were compared by Levene’s test for equality of variance, F value was 1.170, and significance of 0.358. If compared by unpaired t-test, if equal variances assumed t value was 0.263 and if equal variance not assumed t value was 0.327. In the placebo group, 22 patients were on dobutamine (mean — 8 µg/kg/minute) and in the steroid group 22 patients were on dobutamine (mean — 8 µg/kg/minute). Both the values were compared by paired t-test and the t value was 0. In the placebo group, six patients were on adrenaline support (mean — 1 µg/kg/minute) and in the steroid group six patients were on adrenaline support (mean — 0.8 µg/kg/minute), both the values were compared by paired t-test and t value was 0.423. In the placebo group, 50 patients were on noradrenaline support (mean — 0.82 µg/kg/minute) and in the placebo group, 50 patients were on noradrenaline support (mean — 0.65 µg/kg/minute), both the values compared by paired t-test, σ was 0.354, and t value was 1.274.

Conclusion: Treatment with low-dose corticosteroids significantly reduced 28 days of mortality in patients with severe sepsis and septic shock.

17. Systemic Diseases

1. Alcohol Septal Injection for Hypertrophic Cardiomyopathy. (Conference Abstract ID: 134)

Ziyokov Joshi, Vishal Bhandari

Tagore Heart Care and Hospital, Jalandhar, Punjab, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.184

Introduction: Alcohol septal injection is a new treatment modality for selective patient those are not fit for surgery like very old age, COPD or CNS disease. For this type of condition alcohol septal injection is safe and minimum invasive treatment with good result.

Objectives: Minimum invasive treatment for high-risk surgery patient. Materials and methods: We have done ECG, X-ray, blood tests. ECHO shows HOCM with peak pressure 90 mm Hg. angiography of coronary arteries is normal. After complete evaluation, we have done Alcohol Septal injection in Cath lab and on ECHO in Cath lab, peak pressure decreased to 30 mm Hg and there is no other complication. Results: Alcohol septal injection is a good treatment for HOCM in high-risk case. Otherwise gold standard for HOCM is surgery. Discussions: Alcohol septal injection is good modality. There are few complications. Those reported are (1) CHB, (2) MI, (3) Cardiac tamponade, (4) LAD dissection, (5) Coronary artery spasm, (6) Cardiogenic shock, (7) Pulmonary embolism, (8) Stroke.

Conclusion: In our case with 1 year follow-up, patient doing well, her pressure is 30 mm Hg with clinically no complaints. We will advise this treatment for high-risk case those not fit for surgery.

2. Clinicopathological Correlation in Fatal COVID-19 Infection Using Postmortem Minimally Invasive Tissue Sampling: The First Case Series from India. (Conference Abstract ID: 115)

Ayush Goel, Animesh Ray, Deepali Jain, Shubham Agarwal, Shekhar Swaroop, Shubham Sahni, Jagbir Nehra, Sanchit Kumar, Manish Soneja, Neeraj Nischal, Naveet Wig, Baidnath Gupta

AIIMS, New Delhi, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.185

Introduction: The COVID-19 pandemic began in China in December 2019. India is the second most affected country, as of November 2020 with more than 8.5 million cases. COVID-19 infection primarily involves the lung with the severity of illness varying from influenza-like illness to acute respiratory distress syndrome. Other organs have also been found to be variably affected. Studies evaluating the histopathological changes of COVID-19 are critical in providing a better understanding of the disease pathophysiology and guiding treatment. Minimally invasive biopsy techniques (MITS/B) provide an easy and suitable alternative to complete autopsies. In this prospective single-center study, we present the histopathological examination of 37 patients who died with complications of COVID-19.

Materials and methods: This was an observational study conducted in the Intensive Care Unit of JPN Trauma Centre AIIMS. A total of 37 patients who died of COVID-19 were enrolled in the study. Postmortem percutaneous biopsies were taken with the help of surface landmarking/ultrasonography guidance from lung, heart, liver, and kidneys; after obtaining ethical consent. The biopsy samples were then stained with hematoxylin and eosin stain. Immunohistochemistry (IHC) was performed using CD61 and CD163 in all lung cores. The SARS-CoV-2 virus was detected using IHC with primary antibodies in selected samples. Details regarding demographics, clinical parameters, hospital course, treatment details, and laboratory investigations were also collected for clinical correlation.

Results: A total of 37 patients underwent post-mortem minimally invasive tissue sampling. Mean age of the patients was 48.7years and 59.5% of them were males. Respiratory failure was the most common complication seen in 97.3%. Lung histopathology showed acute lung injury and diffuse alveolar damage in 78% patients. Associated bronchopneumonia was seen in 37.5% patients and scattered microthrombi were visualised in 21% patients. Immunostaining with CD61 and CD163 highlighted megakaryocytes, and increased macrophages in all samples. Immunopositivity for SARS-CoV-2 was observed in Type II pneumocytes. Acute tubular injury with epithelial vacuolization was seen in 46% of the renal biopsies but none of them showed evidence of microvascular thrombosis. 71% of the liver tissue cores showed evidence of Kupfer cell hyperplasia. 27.5% had evidence of submassive hepatic necrosis and 14% had features of acute on chronic liver failure. All the heart biopsies showed nonspecific features such as hypertrophy with nucleomegaly with no evidence of myocardial necrosis in any of the samples.

Discussions: Minimally invasive autopsies (MIA) or MITS/B are a simplified method of conducting postmortem sampling, originally devised to investigate the causes of death in low-resource settings. Due to the potential risks associated with conducting traditional postmortem examinations in COVID-19 patients, this method has been adopted to study morbid pathological changes in COVID-19 patients. The typical findings described in pulmonary histopathology of COVID-19 patients include epithelial, vascular, fibrotic, and other changes. The epithelial changes described include diffuse alveolar damage with or without hyaline membranes, metaplasia of alveolar epithelium, desquamation/reactive hyperplasia of pneumocytes, viral cytopathic changes, and multinucleated giant cells. Common vascular changes include capillary congestion, thrombosis in microvasculatures, alveolar hemorrhage, capillary changes (proliferation, thickening, fibrin deposition, endothelial detachment), peri- or intravascular inflammatory infiltrates. In our series, the most common histopathological pattern seen on lung samples was DAD (diffuse alveolar damage), with nearly equal numbers of patients showing DAD in the acute exudative phase and organizing phase. The incidence of vascular changes were only 21%, which was less than that reported. Several factors could have contributed to this observation including regular use of anticoagulants in the cohort as a part of national policies, lower thrombotic complications in the population studied due to genetic or climatic factors. Histopathological examination of the liver in COVID-19 patients had typically revealed mild steatosis, focal hepatic necrosis, Kupffer cell hyperplasia, and sinusoidal dilatation as reported in the literature. In our series, the most common features identified include Kupffer cell hypertrophy in 21 (72.41%) patients, acute submassive hepatic necrosis (27.5%) followed by acute on chronic liver failure (13.7%) in a background of chronic liver diseases, features of NCPF (10.3%) and cholestasis (24%). Though in our cohort of liver biopsies, hepatic lobular inflammatory cell infiltrates were not prominent, changes of hepatocyte degeneration as ballooning, acidophil bodies, MDBs (Mallory-Denk bodies), and microvesicular steatosis were prominent. Lack of inflammatory cell infiltrates in the liver has been described in earlier reports on fatal COVID-19 infections. Our findings disagree with the observation of Sonzogni et al. that the liver is not a primary target of COVID-19 infection and only vascular changes in the liver are observed. In this cohort, we identified substantial histological changes of hepatocyte necrosis, degeneration, Kupffer cell hypertrophy, micro, and macrovesicular steatosis, more than the vascular changes. Renal histopathology in COVID-19 is reported to show changes including prominently acute tubular injury (more prominent in the proximal tubules), arteriosclerosis, or glomerulosclerosis (both as features of underlying comorbid conditions like hypertension), focal segmental glomerulosclerosis with a collapsing phenotype, and tubulointerstitial inflammation. Renal vascular changes reported are relatively less common and include fibrin thrombi, thrombotic angiopathy, and lymphocytic endothelitis. In our cohort of patients, the most common finding on renal histopathology was acute tubular injury and preexisting renal conditions were only evident in 18%. None of the cases showed significant vascular changes.

Conclusion: The most common finding in this cohort is the diffuse alveolar damage with a demonstration of SARS-CoV-2 protein in the acute phase of DAD. Microvascular thrombi were rarely identified in the lung, liver, and kidney. Substantial hepatocyte necrosis, hepatocyte degeneration, Kupffer cell hypertrophy, micro, and macrovesicular steatosis unrelated to microvascular thrombi suggests that the liver might be a primary target of COVID-19. This study highlights the importance of MITS/B in better understanding the pathological changes associated with COVID-19.

3. Effectiveness and Usage of Flucytosine in Clinical Practice in India. (Conference Abstract ID: 111)

Sagar Bhagat, Neha Gupta, Hiten Kareliya, Saiprasad Patil, Hanmant Barkate

Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
Medanta Hospital, Gurugram, Haryana, India
Prime Infection Care, Gujarat, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.186

Introduction: A timely and sufficiently high exposure of the appropriate antifungal agent is crucial for the eradication of the fungal pathogens. Very few antifungals penetrate at sanctuary sites such as brain/CSF, eye, bone, synovial fluid, and bladder/urine. Flucytosine (5-FC) achieves good concentration at sanctuary sites hence considered as a treatment option in various conditions. 5-FC with amphotericin B remains the standard of care for cryptococcal meningitis, and the drug continues to have a role in the treatment of Candida infections including C. auris which are life-threatening or in circumstances where drug penetration may be problematic. It has also shown good activity in combination with amphotericin B for the treatment of severe systemic mycoses, such as cryptococcosis, candidosis, chromoblastomycosis, and aspergillosis.

Objectives: The primary objective of the study was to understand the clinical use of 5-FC in a real-life setting in India, while the secondary objective was to determine the clinical outcome and adverse effects.

Materials and methods: We retrospectively analyzed the clinical usage of 5-FC in two centers. Medical records were reviewed to collect crucial data, including medical history, IFI diagnosis, treatment, and clinical outcomes. Information on the administration of flucytosine (dose–duration and adverse effects) were also noted. The protocol of the study was approved by an independent ethics committee.

Results: Medical case records of 23 patients were available for analysis. The average age of patients was 48.25 ± 13.79 years. Male predominance (56.52%) was seen, with male to female ratio of 1.8: 1. The most prevalent comorbidity was diabetes (47.82%). Immunocompromised state was present in 56.52% of patients either HIV/AIDS (17.39%), immunosuppressive therapy (17.39%), corticosteroid (13.04%), chemotherapy (4.34%) or strong organ transplantation (4.34%). 5-FC has been used in the treatment of the candidiasis [candidemia (17.39%), genitourinary candidiasis (13.04%), genitourinary candidiasis with candidemia (4.34%) and candida endocarditis (4.34%)]; cryptococcosis [meningo-encephalitis (21.73 %) and meningitis (8.69 %)]; aspergillosis (21.73%) and mucormycosis (4.3%). Sanctuary sites were involved in 65.21% patients including CSF (39.13%), urine (21.73%) and eye infections (4.34 %). Prior treatment with azoles (56.25%) and polyene antifungals (47.82%) was common. The most frequent isolates were Candida auris and Cryptococcal neoformans, 21.73% each, followed by aspergillus spp. in 17.39%. 5-FC was companion drug to other antifungals [amphotericin-B (69.56%), echinocandins (17.39%)] in majority (91.30%), while in 8.69% it was used as monotherapy. The mean dose used for flucytosine was 4304.34 ± 1528.1 mg/day, with a median dose of 4000 mg/day (range: 1500 to 6500mg). The mean treatment period was 4.13 ± 2.50 weeks, with a median of 3 weeks (range 2-12 weeks). Clinical cure was observed in 78.26%, while in 17.39% of patient’s reported clinical improvement. In 1 patient, clinical failure was reported. No mortality was reported. In most patients, the drug was well tolerated. Fever has been documented in 1 patient on flucytosine therapy.

Discussions: 5-FC exerts its antifungal effects by interfering with both DNA and protein synthesis. It is reported to be most active against Candida and cryptococcal infection and to show synergistic action with amphotericin B in the management of fungal infection. Amphotericin B increases cell permeability, allowing more 5-FC to penetrate the cell. Thus, 5-FC and amphotericin B are synergistic. ACTA trial1 reported 1 week of amphotericin B plus flucytosine was the most effective option for induction therapy for patients with HIV-associated cryptococcal meningitis and all the best-performing regimens contained flucytosine. It also shows good activity against C. auris. It also reported to achieve good urinary concentrations, which is generally 10 to 100 times greater than serum concentrations.2 Indian study highlighted C. albicans showed 100% susceptibility to flucytosine and 84.6% to amphotericin B.3

Conclusion: Flucytosine was found to be effective in the management of Candida, cryptococcal, and mold infections, particularly in the sanctuary sites. It was a frequent companion drug to amphotericin B. Flucytosine, with a better clinical cure and improvement rate, was also reportedly well tolerated.

4. Volume Responsiveness after Passive Leg Raising, Fluid Resuscitation in Patients with Shock. (Conference Abstract ID: 50)

Tammina Akhila Sai, PV Sai Satyanarayana

Kamineni Institute of Medical Sciences, Telangana, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.187

Objectives: Comparison of arterial blood pressure (SBP, DBP, MAP) and etCO2 after fluid resuscitation and passive leg raising:

Patients and methods: Place of study: Department of Emergency Medicine, Kamineni Institute of Medical Sciences, Narketpally. Study duration: October 2018 to September 2020. Sample size: 60 patients. Group I: fluid resuscitation; group II: both PLR and fluid resuscitation. Study type: Prospective Study.

Study material:

Results: Distribution of patients according to age in the present study.

Age (years)Frequency (n = 60)Percentage
20–30  9  15
31–4011  18.33
41–5014  23.33
51–6026  43.33
Table: Comparison between mean arterial pressure and etCO2 at 60 minutes (after resuscitation) and between mean arterial pressure and ScvO2 at 60 minutes and between mean arterial pressure and IVC diameter in group II (fluid resusucitation + passive leg raising).
MAPMeanStandard deviationp value
Table: Comparison between mean arterial pressure and etCO2 at 60 minutes (after resuscitation) and between mean arterial pressure and ScvO2 at 60 minutes and between mean arterial pressure and IVC diameter at 60 minutes in group I (only fluid resuscitation)
MapMeanStandard deviationp value
IVCD  9.537.2183<0.01

Conclusion: The response in hemodynamic parameters in group I [only fluid (crystalloids) resuscitation] is an increase in end-tidal carbon dioxide, increase in systolic blood pressure, increase in diastolic blood pressure, increase in mean arterial pressure. An increase in maximum inferior vena cava diameter and an increase in ScvO2 were statistically significant. The response in hemodynamic parameters in group II (both fluid resuscitation and passive leg raising) is an increase in end-tidal carbon dioxide, increase in systolic blood pressure, increase in diastolic blood pressure, increase in mean arterial pressure, increase in maximum inferior vena cava diameter, and increase in ScvO2 were statistically significant. On comparison of hemodynamic parameters (etCO2, SBP, DBPMAP, IVCD, ScvO2) between group I (only fluid resuscitation) and group II (both fluid resuscitation and passive leg raising), there is statistically no significant difference. After 60 minutes of fluid resuscitation, it was observed that there is clinically and the statistically significant response of etCO2, maximal inferior vena cava diameter, ScvO2 among hypovolemic patients in shock and can be used to guide fluid resuscitation. There was a statistically significant comparison between mean arterial pressure and etCO2 at 60 minutes of resuscitation. Thus, etCO2 can be used in place of mean arterial pressure during the initial 60 minutes of fluid resuscitation in hypovolemic shock patients in the emergency. There was a statistically significant comparison between mean arterial pressure and maximum inferior vena cava diameter at 60 minutes of resuscitation. Thus, maximum inferior vena cava diameter can be used in place of mean arterial pressure during the initial 60 minutes of fluid resuscitation in hypovolemic shock patients in the emergency. There was a statistically significant comparison between mean arterial pressure and ScvO2 at 60 minutes of resuscitation. Thus, ScvO2 can be used in place of mean arterial pressure during the initial 60 minutes of fluid resuscitation in hypovolemic shock patients in the emergency.

5. The COSEVAST Study Outcome: Evidence of COVID-19 Severity Proportionate to Surge in Arterial Stiffness. (Conference Abstract ID: 48)

Neeraj Kumar, Sanjeev Kumar, Abhyuday Kumar, Divendu Bhushan, Amarjeet Kumar, Ajeet Kumar, Veena Singh

AIIMS Patna, Bihar, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.188

Introduction: It has been extensively highlighted that SARS-CoV-2 affects the RAS (renin-angiotensin system) and the angiotensin-converting enzyme-2 receptors play the most important role in the presentation of the COVID-19 disease.2–5 The ACE2 is type I membrane protein expressed on endothelial cells in the kidney, heart, gastrointestinal tract, blood vessels, and, importantly, lung AT2 alveolar epithelial cells, which are particularly prone to SARS-CoV-2 infection. As SARS-CoV-2 is a new coronavirus, and its cardiovascular complications and the underlying pathology is still emerging. However, it is accepted that the virus affects the total vasculature in the human body and this infection becomes a highly accelerated process for the target organ damage. In the case of acute cardiological manifestation, it is termed as Acute COVID-19 Cardiovascular Syndrome (ACovCS) by the American Heart Association’s white paper.6 European Society of Cardiology (ESC) has published a detailed review paper 7 on the involvement of various cardiovascular target organs in COVID-19 disease. This review clearly establishes a close two-way relationship between COVID-19 disease and all cardiovascular diseases (CVD). The prognosis is even worse in patients with preexisting cardiovascular system involvement. Cardiovascular involvement in COVID-19 is seen as a key manifestation. The best way to assess endothelial dysfunction is an assessment of its clinical manifestation, i.e., an increase in arterial stiffness. There have been multiple in vitro and in vivo studies that have shown that the vascular endothelium is an important factor in setting the vascular tone and endothelial dysfunction leads to arterial stiffness.8 Arterial stiffness and enhanced wave reflections are markers of cardiovascular disease and independent predictors of cardiovascular risk.9–12 Stiffening of the large arteries and enhanced wave reflections lead to increased left ventricular (LV) afterload, disturbed coronary perfusion, and mechanical fatigue of the arterial wall.13 The relationship between systemic inflammation and arterial stiffness is well established in the literature.14 The cause-and-effect relationship that acute systemic inflammation leads to deterioration of large-artery stiffness. Findings in study15 on induced inflammation have shown that an acute inflammation caused a temporary increase in central blood pressure and arterial stiffness in terms of pulse wave velocity. This implies the increased risk of cardiovascular events associated with acute systemic inflammation in the COVID-19. COVID-19 disease-related worldwide research and proposed mechanisms pointed to pathophysiological involvement of endothelial dysfunction and arterial wall compromise. However, there was no empirical evidence of the functional compromise of arterial walls. Hence, a study was urgently needed to study an increase in arterial stiffness in COVID-19 patients due to systemic inflammation to stratify the risk and mitigate further cardiovascular damage with guided therapeutic treatment based on the severity of arterial stiffness. This pressing need is justified by a comprehensive review article16 published after the present study was envisaged. We hope that the findings from our study will fulfill the need to a large extent.

Objectives: Primary objective: To study if the measurement of arterial stiffness using pulse wave velocity in mild-moderate and a severe group of COVID-19 patients can stratify cardiovascular risk. Secondary objective: To determine if initial measurements and subsequent changes in arterial stiffness can project the future course of the COVID-19 patient and hence predict the grade of clinical management a confirmed COVID-19 patient would require.

Materials and methods: The present prospective nonrandomized observational study {titled - “To study the relationship of COVID-19 severity with arterial stiffness: A prospective cross-sectional study” (“COSEVAST study”)} was conducted in the COVID-19 ICU, medical ICU, and various wards of dedicated COVID hospital at AIIMS, Patna, Bihar, India. The study protocol, informed consents, and other trial-related documents received the written approval of the Institutional Ethics Committee (IEC No. AIIMS/Pat/IEC/2020/595). The study design was registered with the Clinical Trials Registry of India (CTRI No. CTRI/2020/10/028489). All COVID-19 patients were subject to RT-PCR test and had a confirmed infection of the SARS-CoV-2 virus. Participants, after understanding the study protocol and procedures, gave their written informed consent for the study. The exclusion criteria were known history of any of these diseases — diabetes mellitus (DM), hypertension (HTN), CAD, stroke, neuropathy, PAD, nephropathy, MI, pregnancy, peripheral edema or inflammation, cardiac arrhythmia, and any preexisting cardiovascular disorder.

Patient categorization: The selected patients after fulfilling the inclusion criteria were grouped into three categories — mild, moderate, and severe category based on the latest NIH Guidelines 27 as follows:The range of treatment protocols followed in this study were based on our institutional standard operating procedure (SOP) for the management of COVID-19 patients based on their clinical severity category and it included antivirals (remdesivir), broad-spectrum antibiotics, low-molecular-weight heparin (enoxaparin) immunomodulators (steroids, tocilizumab) and supportive management (oxygen via nasal cannula, face mask, non-rebreathing face mask; noninvasive or invasive mechanical ventilation; awake proning).

Measures of arterial stiffness: Arterial stiffness assessed by PWV (pulse wave velocity) correlates to the number of treated and non-treated cardiovascular risk factors, atherosclerotic events, and cardiovascular risk as predicted by the Framingham risk equations.17 PWV is also positively correlated with carotid intima-media thickness, a marker of atherosclerotic burden in the coronary arteries.18 With the awareness of arterial stiffness during the non-COVID era, clinicians have started adding measurement and treatment of underlying arterial stiffness in their clinical practice.19 International healthcare societies like the European Society of Hypertension (ESH) and European Society of Cardiology (ESC) have included PWV measurement in their 2003 guidelines for the management of hypertension.20,21 Aortic and brachial PWV22 and AIx23 are independently related to the levels of inflammation, suggesting that inflammation plays a role in the regulation of arterial stiffening. In this study, Arterial stiffness is primarily measured in terms of pulse wave velocity, which is a recognized gold standard. Pulse wave velocity, which is a relevant indicator of arterial stiffness, can be measured noninvasively with a variety of devices. However, since COVID-19 is a highly contagious disease, a fully automatic device with minimal contact, less exposure time, and proximity with the patient need to be maintained. It would be always challenging for an observer to conducting the entire test by wearing full personal protection equipment (PPE) kit. So, a test device that avoids close proximity, long exposure, and holding a probe while testing, was needed for the study. We found that the medical device PeriScope (Manufactured by M/s. Genesis Medical Systems Pvt. Ltd., Hyderabad, India) was suitable as it fulfilled all the above requirements. PeriScope is a clinically validated and tested noninvasive medical device used to measure Brachial Ankle PWV (baPWV) and derives the Carotid Femoral PWV (cfPWV), which is equivalent to aortic PWV.24 A population-based study with 3,969 subjects using “PeriScope” has established the role of arterial stiffness in various cardiovascular diseases (CVD).25 Aortic pressure values also have been established as surrogate markers for arterial stiffness. PeriScope estimates the Aortic Pressures and the Systolic Pressure Augmentation (AugP) at the root of the Aorta due to the increased arterial stiffness. The Pressure Augmentation Index (AIx) values found by PeriScope were compared with other internationally accepted noninvasive devices and found to be very accurate and highly comparable.26 All the tests were conducted as per the standard procedure given in the operator’s manual of PeriScope. Electrocardiogram (ECG) electrodes were placed on the ventral surface of both wrists and medial side of ankles, and BP cuffs were wrapped on both upper arm brachial artery and tibial artery above ankles. All the ECG and pressure recordings were done automatically and data were stored in the personal computer for analysis. The built invalidated proprietary algorithm within the PeriScope PC software calculated the following parameters from the waveforms, which were stored in the computer for analysis — systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), heart rate (HR), carotid-femoral pulse wave velocity (cfPWV), Est. Aortic root values of Systolic, Diastolic, Pulse, Mean Arterial Pressures and Systolic Pressure Augmentation (AugP) with Augmentation Index (AIx). Figure 1 shows typical PeriScope COVID-19 arterial risk analysis test report of a Severe Patient

Data analysis: Data are expressed as mean ± SD. Statistical analysis was performed using the GraphPad PRISM software version 5.03 (GraphPad Software Inc., San Diego, California, USA). Differences between all the groups were evaluated by unpaired Student’s “t” test and ANOVA. Linear regression analysis and Pearson’s correlation analysis were performed to evaluate the association between various confounding factors to rule out interdependence. Probability values of p < 0.05 were considered to indicate statistical significance. All p values are two-tailed.

Results: Total 64 patients (42Male and 22 Females) patients were recruited in the study. The patient demographic variables were shown in Table 1. All the patients were under the healthy and normal BMI category. Since the patients did not have any known co-morbidity, Lipid profile or Blood sugar levels were not taken into consideration. The minimum age was 18 years and maximum were 69 years. Although there was a difference between the mean values of age, weight and height; but were statistically not significant between the groups. Figure 2 were showing the graphical representation of overall patient demographics variables as age, weight, height and BMI as (Figs 2A, B, C and D). Although Arterial Blood Gas (ABG) Analysis was carried out for all the patients, it was not possible to find the point-of-time PaO2% value of each patient at the time of arterial stiffness test. For this reason, stat SpO2% reading was taken as the measure of Oxygen saturation for accurate comparison. Also, since it was not possible to check oxygen saturation without external oxygen support in all cases, the best way to quantify the severity was taking ratio of SpO2% and FiO2% as an indication of respiratory distress. Earlier studies and guidelines suggest SpO2% to FiO2% (SF) ratio is a reliable noninvasive surrogate for PaO2% to FiO2% (PF) ratio 28–30 especially in COVID-19 patients. All of the Severe patients were admitted into the COVID-19 ICU whereas all of the Mild patients were admitted into COVID-19 and General wards. Some of the Moderate patients were in the ICU and some were in the General ward with Oxygen support. The statistical analysis of the segregation criteria is as shown in Table 2. The Patient categorization can be clearly visualized by graphical representation (Fig. 3) of the data. The Fig. 3 (A) shows statistical analysis of respiration rate of the three groups, Fig. 3(B) shows FiO2%, Figure 3 (C) shows SpO2% whereas Fig. 3(D) shows the statistical analysis of SF ratio (SpO2/FiO2) respectively. As the ‘normal’ value arterial stiffness is a function of a person’s chronological age 31, (i.e. the normal value of Arterial stiffness goes on increasing with age), the real measure of abnormal increase in Arterial stiffness is the difference of the ‘predicted’ cfPWV value of a ‘normal’ subject of that age and actually measured cfPWV. Hence, Arterial Stiffness was analyzed using the values of Carotid Femoral Pulse Wave velocity (cfPWV), increase in cfPWV from the age dependent normal value, Increase in central Augmentation pressure from age dependent normal value and Augmentation Index (AIx). An earlier study has shown that both Aortic root Systolic Pressure (AoSysP) and Augmentation Index(AIx) values are dependent on Heart Rate.32 To rule out the role of Heart rate in our findings, AIx values were normalized for HR. Also, in our study, the regression analysis between cfPWV and HR showed very low correlation (Multiple r = 0.2180, r2 =0.04754, p = 0.0835). Hence, the effect of HR on cfPWV values is negligible. It can very safely be stated that the findings about arterial stiffness from the study are independent of effect of HR. No other parameters like Heart rate or Pulse Pressure showed consistent increase in their mean values between Mild, Moderate and Severe groups. Heart Rate (Mild: 76.06 ± 14.47 BPM, 95% CI 69.81 to 82.32; Moderate:78.20 ± 17.20 BPM, 95% CI 70.36 to 86.03; Severe: 98.07 ± 18.58 BPM 95% CI 89.37 to 106.8), Brachial Pulse Pressure (Mild: 38.04 ± 7.957 mmHg, 95% CI 34.60 to 41.48; Moderate: 45.95 ± 9.113 mmHg, 95% CI 41.80 to 50.10; Severe: 42.40 ± 12.09 mmHg, 95% CI 36.74 to 48.06) respectively. This can be clearly illustrated as in Fig. 4, were Fig. 4 (A) for Heart Rate and Fig. 4 (B) for Brachial Pulse Pressure in all these three groups. On the other hand, the differences in the measurements of Arterial Stiffness parameters were extremely significant in all three groups. All the Arterial stiffness measurements showed uniformity in trends and almost same rise as per the severity of COVID-19 disease. More importantly, since no confounding factor or dependent parameter was found in the statistical analysis of the data, Arterial Stiffness measures stood out as independent and consistent indicators of severity grade. The analysis of Arterial Stiffness parameters is as given in Table 3. These results can be properly visualized in comparison with the earlier graphs. Figure 5 gives a clear idea about the extremely statistically significant elevation of all Arterial Stiffness measurements across patient groups. The Fig. 5 (A) shows values of cfPWV in all three patient categories. Fig. 5 (B) shows Age Normalized increase in cfPWV, Fig. 5 (C) shows Age normalized increase in Aortic Augmentation Pressure whereas Fig. 5 (D) showed HR Normalized AIx values.

Figs 1A to D: A typical periscope test result

Table 1: Patient arterial stiffness measures as per COVID-19 severity
ParameterMild (1)Moderate (2)Severe (3)p value
Group I—IIGroup II—IIIGroup I—III
cfPWV (cm/second)  829.1 ± 139.21067 ± 152.51416 ± 253.9< 0.0001*< 0.0001*<0.0001*
cfPWV increase# (cm/second)  101.2 ± 126.1   279 ± 114.4580.1 ± 216.4< 0.0001*<0.0001*<0.0001*
AugP increase# (mm Hg)−1.891 ± 2.8173.212 ± 3.1247.246 ± 4.908<0.0001*0.0031*<0.0001*
AIx  4.670 ± 13.0722.16 ± 7.83334.24 ± 8.467< 0.0001*<0.0001*< 0.0001*
HR normalized AIx−13.34 ± 14.185.656 ± 8.61024.80 ± 7.745<0.0001*<0.0001*<0.0001*

Values are expressed as Mean ± SD.

* Significant difference in mean values.

# Age normalized

Discussions: The Lancet article 33 shows clear images with endothelial layer involvement leading to endotheliitis due to COVID-19 infection. Chen et al.34 in their epidemiological studies show that COVID-19 patients admitted to hospital or an intensive care unit (ICU) present frequently with accompanying conditions, such as, advanced age, hypertension, diabetes, and cardiovascular diseases implying compromised endothelial integrity may be playing a major part in COVID-19 mortality. Explaining the potential role of endothelial dysfunction and endothelial layer compromise in COVID-19, the article in cardiovascular research36 shows that chronic endothelial dysfunction may lead to acute vascular inflammation under the attack of the SARS-CoV-2 virus. In our study, the cfPWV which we observed in severe COVID-19 patients was much higher than the cfPWV in patients with long-term chronic diseases like ESRD, CAD, DM, etc. For example, in CAD patients, it was 1,204 ± 301.8 cm/s.24–25 This indicates that COVID-19 damage to the vasculature within <15 days is comparable to the damage caused by CAD in a number of years. Our COSEVAST study had very strict exclusion criteria. All patients with known diabetes, hypertension, obesity, and chronic smokers were excluded. Patients with all other cardiovascular diseases and related surgical intervention/therapy were excluded. This was necessary to eliminate basal deviation of arterial stiffness from the normal vasculature. These exclusions reduced the total number of study subjects but removed any selection bias and amplified the validity of our findings. A similar large-scale, longitudinal, multicentric study (COVID-19 ARTErial Stiffness and vascular AgiNg CARTESIAN Study)37 has been proposed and our study will try to follow harmonization with that study. To the best of our knowledge, this is the first study to independently observe significant functional changes in vasculature due to arterial inflammation in COVID-19 patients in terms of noninvasive measures of arterial stiffness. We wanted to conduct multiple follow-up tests to find any trends in arterial stiffness; however, it proved almost impossible to study patients with COVID-19 disease because of various reasons like changing status of the patient condition, restrictions on research staff movements, and sometimes unfortunate death of the patients during the study. We are also in the process of undertaking a medium-term follow-up study of the patients in the present study after their discharge. These subjects will be observed for changes in Arterial Stiffness and occurrence of cardiovascular disease, if any, over a period of 12 months with the PeriScope device.

Conclusion: The results of this study establish a noninvasive measurement of arterial stiffness as an independent severity marker in COVID-19 patients. It also strongly indicates that regular assessment and regulation of arterial stiffness by titration of therapeutics may reduce acute cardiovascular complications and mortality in COVID-19 patients significantly.

18. Transfusion and Hemostasis Disorders

1. Clinical Profile and Outcome of Patients with Suspected Thrombotic Thrombocytopenic Purpura Treated in Intensive Care in a Tertiary Hospital: A Retrospective Study. (Conference Abstract ID: 198)

N Shiva Kumar, Kiran Kumar Gudivada, Sumitra Sivakoti, Bhuvana Krishna

St Johns Medical College Hospital Bangalore, All India Institute of Medical Sciences (AIIMS), Bibinagar, Hyderabad, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.189

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a hematological emergency with mortality nearing 90% if left untreated. The disease is rare with a prevalence of 10 to 15 per 106 population. There is scant literature, however, which addresses the clinical profile and outcomes of TTP patients admitted to the intensive care unit (ICU).

Objectives: The objective of our study is to determine mortality among patients admitted with suspected TTP to ICU, and evaluate the predictors of survival among TTP patients.

Materials and methods: A retrospective cohort was conducted in a tertiary hospital in south India after obtaining permission from the Institute Ethical Committee. Consecutive patients admitted to the ICU between 2012 and 2020 with a diagnosis of suspected TTP were included. Patients were screened for eligibility with the help of a hospital information system (HIS). Inclusion criteria: age >18 years and patients suspected to have TTP and managed in ICU. The main search terms “schistocytes”, “fragmented cells”, “micro-angiopathic hemolytic anemia” on peripheral smear were used to screen our HIS. Two authors screened records and excluded patients diagnosed with HUS, aHUS, autoimmune causes of hemolysis, snake bite, pregnancy-related causes, accelerated HTN, malignancies, septic shock, DIC, and vasculitis. Demographic parameters, medical history, presenting symptoms, admission APACHE II, daily SOFA score, interventions performed such as plasma exchange (PE), use of steroids, and plasma infusion were extracted from the records. Presenting symptoms were classified as cardiac (myocardial infarction, NSTEMI, Left ventricular dysfunction, arrhythmias), renal (proteinuria, hematuria, oliguria, anuria, fluid overload), neurological (stroke, seizures, coma, focal deficits, headache, visual disturbances), gastrointestinal (vomiting, diarrhea, abdominal pain), and thrombotic symptoms (CNS thrombosis, peripheral vascular, cardiac). Since ADAMTS 13 activity levels were not available, the risk of ADAMSTS 13 deficiency was estimated by PLASMIC score. Laboratory data recorded during ICU stay. Complications during the ICU stay such as nosocomial infections and clinical outcomes such as mortality, length in ICU and hospital stay, and ventilator days were recorded. Patients were categorized into two groups based on mortality and evaluated. Statistical methods — Continues variables are described as mean (standard error) or median with (interquartile range) and categorical variables as numbers with percentage. Non-parametric tests were preferred due to the small sample population. p values < 0.05 were considered significant. Statistical analysis was performed using STATA Version 13.

Results: Among 535 patients that were enrolled (age>18 and hemolysis in peripheral smear), 473 were excluded (direct combs + and those non admitted to ICU). Remaining 96 patient records are thoroughly screened and 33 patient’s diagnosis of suspected TTP were included for final quantitative analysis. Mortality among patients was 42%. There were no statistically significant differences among survivors and non-survivors with respect to sex, BMI, APACHE II score, day 1 SOFA score (p value of 0.08, 0.37, 0.5 and 0.2, respectively). Patients who died were significantly older than the survivors of TTP [42 (±4.2) vs 30.58 (±1.9), p = 0.03]. PLASMIC SCORE was also not statistically different among the survivors and non survivors [5.5 (±0.26) vs 5.7 (±0.28), p = 0.93]. 17(51%) patients had fever, 23(69%) had neurological, 4(12%) had cardiac, 18(54%) had gastrointestinal, 9(27%) had haemorrhagic, 26(78%) had renal and 3(9%) patients had thrombotic manifestations at presentation. There is a trend towards improved survival with early initiation of PE, large cumulative PE volumes, lower platelet transfusions and higher dosage of steroid as adjuvant, however none of these have attained statistical significance. The incidence of CAUTI, CLABSI, VAE and HAP were not different among PE and non-PE recipients.

Conclusion: The mortality of patients admitted to the intensive care unit with the diagnosis of suspected thrombotic thrombocytopenic purpura is comparable to international data. Early initiation of PE with large plasma volume exchanges along with and higher dosage of steroid and cautious use of platelet transfusions may improve survival. The risk of ICU-acquired infections was no significantly higher in plasma exchange.

2. Reperfusion Injury. (Conference Abstract ID: 14)

KS Sayooj

Amala Institute of Medical Sciences, Thrissur, Kerala, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.190

Introduction: In this poster “reperfusion injury”, I am presenting an emergency Fogarty catheter embolectomy in a patient with bilateral iliac artery occlusion. Reperfusion injury is an exacerbation of cellular dysfunction following the restoration of blood flow to the previously ischemic tissues leading to the release of byproducts of cell death and eventually causing multiorgan failure. This event is directly proportional to the duration of ischemia. Through this presentation, I intend to highlight how important is the early diagnosis and intervention of embolisms causing ischemia.

Materials and methods: Fogarty catheter embolectomy was done in Amala Institute of medical sciences and complications occurred in the postsurgical critical care unit.

Results: Early diagnosis and interventions will prevent reperfusion injury.

Discussions: Carcinomas are a hypercoagulable state. If a patient who is a known case of carcinoma presents with paraplegia you have to palpate for peripheral pulses first before ruling out metastasis in the spine. If a pulse is absent do an emergency CT angiography to rule out embolisms. If there is embolism you have to do intervention as early as possible to prevent reperfusion injury. And also during and after embolectomy always expect complications associated with reperfusion injuries like life-threatening arrhythmias and multiorgan failure.

Conclusion: Early diagnosis and intervention could prevent reperfusion injury.

19. Trauma

1. Intubation Practices in Trauma Triage: A Prospective Observational Study. (Conference Abstract ID: 194)

Anudeep Jafra, Kajal Jain, SM Venkata, LN Yaddanapudi, SK Gupta

PGIMER, Chandigarh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.191

Introduction: Hypoxia and obstruction of the airway are the major contributors to death following trauma. Hence, a definitive airway control, which may require endotracheal intubation, is an essential component of trauma resuscitation. Trauma Triage is generally manned by a team comprising of various levels of healthcare professionals. It is not only important whether a patient needs intubation but also when and how to intubate. There is a lack of data pertaining to intubation practices in trauma triage in India.

Objectives: Hence, the present study was conducted to describe the current practice of definitive airway management in the trauma triage of a tertiary hospital catering to northern India. The secondary objectives were to determine the success rate of endotracheal intubation by anesthesia and non-anesthesia residents, to describe the complications during securing the airway, and to formulate recommendations based on the results of this observational study.

Materials and methods: This was a prospective observational study conducted at Trauma Triage of level 1 Tertiary Hospital over a period of 1 year. A specifically designed pro forma was filled which included the patient’s detailed history of trauma, peri intubation vitals, indications for urgently securing airway, unfavorable conditions, a technique of intubation, medications used, and adverse events following intubation, and a number of attempts taken.

Results: The first attempt success rate of intubation by Anesthesia residents was significantly higher than Speciality residents (p = 0.0001; 95% CI 9.02–24.66). Airway injuries were most frequent complication (n =140, 32.8%) followed by hypotension (n =57, 13.3%). Total of 99 patients received RSI in trauma triage during intubation by anaesthesia residents, amongst these 77 (77%) patients had no complications, 8% had airway related injuries, 4 (4%) had esophageal intubation, 5 (5%) developed hypoxemia and 3 (3%) had hypotension.

Discussions: These prospective observational data come from a tertiary care hospital of a low resource country on intubation practices in trauma victims over a period of 1 year. The first responders are usually non-anesthesia, speciality residents who cater to the immediate needs of the trauma victims. This reflects the different staffing levels and the limited expertise available on arrival to trauma triage. Through this study, it may be noted that although the level of experience met the current standards, there is a need to upgrade the skills of airway management using manikins and mandatory anesthesia rotation. Most of the intubations carried by anesthesia residents were drug-assisted along with the use of muscle relaxants which resulted in less complications and trauma. Literature supports the use of neuromuscular blockers in 62 to 77% of cases, with a strong association being reported between the use of neuromuscular blocking agents, especially depolarizing agents, and fewer adverse effects, as depicted by our results.

Conclusion: We observed that complication rates were more in patients intubated by non-anesthesia residents, use of a high dose of sedative agents like midazolam, and multiple attempts at intubation. Rapid evaluation of these factors and formal training in ATLS can lead to optimal management of the patient and decrease the rate of complications.

2. Impact of COVID Virus Infection on the Outcome of Critically Ill Trauma Patients. (Conference Abstract ID: 157)

Manjaree Mishra, Shashi Prakash Mishra, Sumit Sharma, Neelesh Anand, Ghanshyam Yadav

Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.192

Introduction: Surgical practice has undergone extensive changes during the COVID-19 crisis, mostly because of the close contact nature of surgical procedures putting surgeons at higher risk. In the past 3 months, almost 3 million surgeries have been canceled worldwide. Hospitals are being reconfigured in expectation of surges in COVID-19 cases to provide more space for trauma and critically ill patients. All the non-urgent health services were delayed. However, with few changes, trauma and emergency services continue to work according to the existing protocols. Trauma treatment during the pandemic is focused on clinical urgency, patient protection as well as healthcare workers, and resource conservation. In this study, we addressed our understanding of trauma victim triage and treatment during the pandemic, emergency surgery indications, and intensive care.

Objectives: To assess the impact of COVID virus infection on critically ill trauma patients.

Materials and methods: The study included the patients managed in the Intensive Care Unit of Trauma Centre linked with Medical Institution between April and September 2020. The data regarding the protocols followed, perioperative measures taken and management protocol in intensive care unit in accordance with COVID protocol. The demographic data, clinical data, and final outcome were recorded in the study protocol. The final statistical correlation was done.

Results: The standard precautions taken in accordance with COVID protocol have a significant role in the prevention of the spread of the COVID virus. The COVID infection seems to have little impact on the final outcome on patients.

Discussions: The COVID pandemic has made the situation very difficult for hospitals across the globe to ensure patients care and management. There has been an issue related to initial management in an emergency department as well as in the ICU setting. Not only the patient management but also there has been a risk of spread of infection to healthcare workers.

Conclusion: It is therefore recommended that there is a need for strict adherence to the precautions needed to prevent the spread of COVID virus infection. The COVID infection may have an impact on the outcome of patients infected with the COVID virus which must be studied in detail.

3. A Comparison of Glasgow Coma Scale Score with “Full Outline of Unresponsiveness Scale” to Predict Outcome of the Patients with Traumatic Brain Injury Presenting to Emergency Medicine Department. (Conference Abstract ID: 18)

Devanshi Hasmukh Virani, Shruti V Sangani, Chirag J Patel, Dharmistra Dhusa

BJ Medical College, India

DOI: https://doi.org/10.5005/jp-journals-10071-23711.193

Introduction: In patients presenting to emergency department (ED) with traumatic brain injury, it is important to evaluate the neurological status to determine the present clinical status and to predict the outcome of the patient. GCS is the most widely used score, but it has some drawbacks which led to the development of other scores such as the Full Outline of Unresponsiveness (FOUR) score. In our study, we compared the GCS and the FOUR scores in patients presenting with traumatic brain injury.


Materials and methods: We conducted a prospective observational study at a trauma center of B. J. Medical College, Ahmedabad between September 2019 and September 2020 of a total of 200 patients. All patients presenting with a clinical diagnosis of traumatic brain injury (TBI) were evaluated. A primary survey was done initially. Vitals of the patients were taken, and resuscitation started. Simultaneously, a GCS and a FOUR score were recorded by the emergency physician. All patients were evaluated in terms of TBI and relevant investigations were done, and findings were noted. We tabulated all information in Microsoft Excel 2019 and statistical analysis was done with SPSS software.

Results: The mean age of study population was 38.295 ± 15.33 years. Male patients were 79% and 21% were female patients. Road traffic accidents contributed highest percentages of causes of TBI (60%). Patients who were deceased had low GCS score and when GCS 8 was taken as the cut off value, sensitivity of GCS was 87.88% and specificity of GCS was 97.60%. With a positive predictive value of 87.8%; and when FOUR Score of 8 was the cut off value, sensitivity of FOUR score was 100% and Specificity was 97.52%, with a positive predictive value of 89.19%. By comparing the median value of FOUR score with mortality and the median value of GCS score with the mortality by using the Mann-Whitney test showed a p-value of ≥1, which is statistically non-significant.

Discussions: The Glasgow Coma Scale is an objective measurement of clinical status, as it correlates with the outcome, it is a reliable tool for interobserver measurements and is also effective for measuring patient recovery or on-going response to treatment. A minimum score is 3 (deep coma or death) and a maximum score is 15 (no neurological deficit). Three aspects of behavioral response namely eye-opening, verbal, and motor response are examined. All the above responses are tested after the application of a painful stimulus. The drawback of GCS is the failure to incorporate brainstem reflexes. The scale also includes a numerical bias toward the motor response and an important concern of issue is an appropriate application in intubated patients who cannot manifest a verbal response. GCS does not signify subtle changes in the neurological examination. Mayo Clinic, which evaluates four components, developed a new scale: eye, motor responses, brainstem reflexes, and respiration, this is called the Full Outline of Unresponsiveness (FOUR) Score, each rated with a maximum score of four. A higher score indicates a better prognosis. The FOUR score, contrary to the GCS, avoids assessing verbal function.

Conclusion: FOUR score is equally reliable with GCS score. Both have their own significance. FOUR score maintains simplicity and provides far better information, particularly for intubated patients. The FOUR score is a good predictor of the prognosis of critically ill patients.