Background: Coronavirus disease-2019 (COVID-19) pandemic has shown unpredictable course in individual patients. Few patients develop severe disease with progression after admission to a healthcare facility. Multiple parameters have been investigated to identify a marker to predict disease progression. Neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte (PLR) ratio has shown some promise. The current investigation explores the role of NLR and PLR to predict the disease progression. Materials and methods: After obtaining ethics committee approval, 608 patients were screened for inclusion in the prospective observational study, and 201 patients were included in the final analysis. The NLR and PLR were derived from routinely obtained complete blood count analysis. The patients were followed to determine the development of severity of the disease during the course. The NLR and PLR were analyzed in both univariate and multivariable models to assess the association and prediction. Results: In nonsevere (NS) group, the mean age of patients was 50.9 ± 16.3 years, and 66 (61.2%) were male, while in severe group (S), the mean age of patients was 53.7 ± 16.4 years, and 65 (69.89%) were male. NLR at day 1 and day 3 was significantly lower in survivors as compared to nonsurvivors, while the relation of PLR in both the groups was not statistically significant. The NLR is better in predicting the severity of disease as well as mortality than PLR. Conclusion: The NLR calculated at the time of admission has high predictive value for disease deterioration and adverse clinical outcome.

Background: Coronavirus disease 2019 (COVID-19) pandemic has caused a huge burden on healthcare services worldwide, severely affecting the management of non-COVID-19 patients as well. The Government of India has updated guidelines for the clinical management of COVID-19 illness, including severe acute respiratory infections (SARI) definition for triaging suspected COVID-19 cases in an isolated intensive care unit (ICU). The aim of this study was to estimate the adherence of clinicians in triaging COVID-19 suspects as per SARI definition to SARI ICU. This study also observed the impact of such triaging on admission, diagnosis, and treatment process of non-COVID-19 patients admitted to SARI ICU. Patients and methods: This cross-sectional study was conducted in a designated SARI ICU of two tertiary care medical college hospitals involving 78 patients from the month of June to July 2020. Data related to demographics, the severity of illness, advanced life supports, delay in diagnosis, intervention, and treatment of patients in SARI ICU due to suspected COVID-19 status were documented. Results: Adherence to SARI definition for triaging COVID-19-suspect cases was 19.2%. Despite hindrance in diagnosis (17.9%) and treatment (12.8%), mortality among patients in SARI ICU was limited to 14.10%. Results were insignificant when checked for various factors associated with mortality. Conclusion: Nonadherence to SARI definition may lead to undue delay in diagnosis, intervention, and treatment of non-COVID-19 cases. This may result in increased morbidity, mortality, and economic burden on patients and the healthcare system. key message: A rationale and just utilization of healthcare resources are need of the hour in the face of an enormous volume of SARI cases during COVID-19 pandemic. SARI criteria as implemented by the Ministry of Health and Family Welfare (MOHFW), Government of India, are a very important tool in triaging of COVID-19-suspect cases. Adequate measures should be in place in order to mitigate the inadequacies and deficiencies in the treatment of non-COVID-19 cases, which have occurred as a result of COVID-19 pandemic.

Background: Recent changes in the diagnostic criteria and the introduction of newer technologies like prosthetic valve replacement require the need to identify the changing epidemiology of prosthetic valve endocarditis (PVE). Materials and methods: This is a retrospective, cross-sectional, observational study. Patients diagnosed with Candida parapsilosis definite and possible PVE as per modified Duke's criteria for a period of 11 years from January 2010 to December 2020 were included for the analysis. Results: Twelve of the 47 PVE cases (25.5%) were caused by C. parapsilosis. The median age of the patients was 52 years. Males were predominantly affected (58%). Based on the modified Duke's criteria, eight (67%) were definite infective endocarditis (IE) cases. The single valve was affected in 11 cases (92%) with the mitral valve being the commonest (n = 8, 67%). The type of valve commonly involved was mechanical [n = 10, 83%]. The mean size of the vegetation was 13.15 mm. Most cases (n = 7, 58%) were late-onset PVE. The mean C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) levels for C. parapsilosis PVE were 70.2 mg/L, 51.08 mm/hour, and 0.3 ng/mL, respectively. The rates of complications and in-hospital mortality were 75% each. The most common observed complication was embolic events (n = 8, 67%). Statistical significance (p ≤ 0.05) was observed for mean vegetation size, overall complications, embolic events, and mortality for C. parapsilosis PVE when compared with bacterial PVE. Conclusion: C. parapsilosis was the commonest etiological agent causing PVE. Predominant mitral valve involvement, higher rates of late-onset presentation, complications, and mortality were key differential characteristics observed.

Background: The alveolar–arterial oxygen (A–a) gradient measures the difference between the oxygen concentration in alveoli and the arterial system, which has considerable clinical utility. Materials and methods: It was a retrospective, observational cohort study involving the analysis of patients diagnosed with acute COVID pneumonia and required noninvasive mechanical ventilation (NIV) over a period of 3 months. The primary objective was to investigate the utility of the A–a gradient (pre-NIV) as a predictor of 28-day mortality in COVID pneumonia. The secondary objective included the utility of other arterial blood gas (ABG) parameters (pre-NIV) as a predictor of 28-day mortality. The outcome was also compared between survivors and nonsurvivors. The outcome variables were analyzed by receiver-operating characteristic (ROC) curve, Youden index, and regression analysis. Results: The optimal criterion for A–a gradient to predict 28-day mortality was calculated as ≤430.43 at a Youden index of 0.5029, with the highest area under the curve (AUC) of 0.755 (p <0.0001). On regression analysis, the odds ratio for the A–a gradient was 0.99. A significant difference was observed in ABG predictors, including PaO₂, PaCO₂, A–a gradient, AO₂, and arterial–alveolar (a–A) (%) among nonsurvivors vs survivors (p-value <0.001). The vasopressor requirement, need for renal replacement therapy, total parenteral requirement, and blood transfusion were higher among nonsurvivors; however, a significant difference was achieved with the vasopressor need (p <0.001). Conclusion: This study demonstrated that the A–a gradient is a significant predictor of mortality in patients initiated on NIV for worsening respiratory distress in COVID pneumonia. All other ABG parameters also showed a significant AUC for predicting 28-day mortality, although with variable sensitivity and specificity. Key messages: COVID-19 pneumonia shows an initial presentation with type 1 respiratory failure with increased A–a gradient, while a subsequent impending type 2 respiratory failure requires invasive ventilation. A significant difference was observed in ABG predictors, including PaO₂, PaCO₂, A–a gradient, AO₂, and a–A (%) among nonsurvivors vs survivors. (p-value <0.001). The vasopressor requirement, need for renal replacement therapy, total parenteral requirement, and blood transfusion need were higher among nonsurvivors than survivors; however, a significant difference was achieved with the vasopressor need (p <0.001).

Introduction: The utilization of prescription drugs as off-label is common. While this practice can be beneficial to some patients, it can raise a safety concern when scientific evidence is lacking; hence, this study was conducted to evaluate the off-label drug consumption and its adverse drug reactions (ADRs) in the medical intensive care unit (ICU). Materials and methods: In the prospective cohort study conducted for a duration of 6 months, data pertaining to ICU patients’ (age ≥18 years) demography, diagnosis, treatment, and laboratory investigation were collected to assess for off-label use as well as the strength of evidence and the occurrence of ADRs by using MICROMEDEX 2017 version (Healthcare Series Thomson Reuter, Greenwood, CO). Results: Of total 3574 drugs prescribed, 1453 (41%) were off-label indications and 65 (1.81%) were off-label dose. On the evaluation of off-label indication use, 1279 (88%) were evidence-based and 174 (12%) were low/no evidence-based medications (EBMs); 59 (91%) were evidence-based and 6 (9%) were low/no EBMs for off-label dose. Most commonly prescribed evidence-based off-label drug belonged to the gastrointestinal class while low/no evidence drugs were mostly of anti-infective class. A total of 383 ADRs were identified and 139 (36.2%) were implicated due to off-label medications, of which ADRs with evidence off-label medications (87.8%) were higher than low/no evidence off-label medication (12.2%) (P < 0.001). Conclusion: Widespread presence of off-label use was observed in medical ICU. Although incidence of ADRs was similar to the FDA-approved use, ongoing monitoring of such practice is needed.

Background: The responsibility of nurses is early clinical deterioration and taking appropriate action. Knowledge and proficiency in Code Blue protocols come handy, which lacks in most nurses recognizing. Simulation-based learning plays a role in improving performance and confidence in handling such situations. This goal-based method of program evaluation aims to examine Code Blue training programs and compare them with current literature and established professional standards while assessing participants’ experience and change in knowledge to this educational method. Materials and methods: Following ethical approval, a prospective interventional study was conducted in the simulation center of a private medical college in Mangalore on 65 nursing students. A pretest was given to the participants on the day of the session to assess their baseline understanding followed by prebriefing, all previously having received didactic lectures on Code Blue protocol, crash cart, and cardiac arrest algorithms. They were divided into three batches and each batch performed on crash cart and cardiac arrest stations using an electrocardiogram simulator. A simulated drill was enacted by the faculty on managing a Code Blue event and a discussion was followed. Nurses underwent two simulated scenarios, shockable and nonshockable cardiac arrest algorithms, followed by debriefing. Posttest and feedback form was asked to be filled. Results: A significant increase in mean% from pretest to posttest (55.69–77.33%) following simulated drills. Conclusion: The use of simulation to train nurses in Code Blue scenarios records greater satisfaction and improvement in clinical reasoning, knowledge, and skills. Hence, the incorporation of simulation teaching in training of those involved in caring for high-risk patients is the need of the hour.

Introduction: Vancomycin-resistant enterococci (VRE) are emerging as an important multidrug-resistant pathogen causing nosocomial infections, predominantly bacteremia and urinary tract infections. VRE bacteremia has caused a significant increase in the duration of the hospital stay and mortality and had caused high public health threat due to limited treatment options. Materials and methods: Between October 2017 and September 2020, all consecutive patients with culture-proven bloodstream infection with Enterococcus species, isolated for the first time, were included in the study. A total of 427 Enterococcus species were identified, and antimicrobial susceptibility tests were performed and interpreted using Clinical and Laboratory Standard Institute guidelines. Results: Of the total 427 Enterococcus species isolated, 63 (45.6%) were VRE. Among them, 51/63 (81%) were Enterococcus faecium (E. faecium) and 5/63 (8%) were Enterococcus faecalis. There was an increased trend of VRE rate in the bloodstream infections of 6.12% (2018), 13.2% (2019), and 19.2% (2020). The majority of the VRE patients [43/63 (68%)] were admitted to the intensive care units (ICUs). Vancomycin A (VanA) is the most common phenotype isolated from 51/63(81%) patients. Conclusion: This increasing trend of VRE bacteremia is a red alert to the clinicians and the infection control practitioners, so that strict antibiotic policies and proper adherence to the infection control practices can be initiated to reduce the VRE rate.

Background: Very few extensive studies regarding job stressors among doctors and nurses have been conducted in India. It is important to explore the workplace to understand various stressors that adversely affect the well-being of an individual and also affect health care and needs of patients and relatives. Considering this, the present study was planned to determine stress among doctors and nurses from the critical care unit (CCU) and to find the association of stress with selected variables. Materials and methods: This observational cross-sectional study was conducted among all staff (doctors and nurses) from the CCU. Data were collected with a pilot-tested, predesigned, validated questionnaire using the Google survey tool consisting of sociodemographic details and the ICMR work stress questionnaire. Analysis of data was done with SPSS version 25. Results: Of 105 participants, 57 (54.3%) were doctors and 48 (45.7%) were nurses. A total of 48.6% (51) of participants scored 32 of 64, that is, managed stress very well, and 51.4% of participants (54) scored 65 of 95, that is, having a reasonably safe level of stress, but certain areas need improvement. Conclusion: Stress was significantly more among females and those who have sleep problems. No statistically significant difference was found between the level of stress and age, relationship with seniors, exercise, and comorbidities.

The respiratory care (RC) discipline in Yemen emerged 15 years ago. Although there have been significant advancements in the domain, no documented history is available regarding its development and progress over the years. This paper highlights the history and development of the RC field in Yemen and highlights the major events that took place during these times that shaped the development of the RC discipline. A detailed, comprehensive review and assessment were conducted through direct communication, personal interviews, and the review of existing documents in the hospital's archives, academic institutes, Ministry of Public Health and Population, and other relevant resources. The gathered data were evaluated for relevance and grouped on a thematic basis. So far, this is the first paper on the comprehensive history and development of the RC discipline in Yemen.

Background: The aim was to investigate the efficacy of prone positioning (PP) in the management of coronavirus disease-2019 (COVID-19) pneumonia in various setups, with various modes of oxygen therapy and its optimal duration. Materials and methods: A systematic literature search was conducted from inception until May 15, 2021. Patients with a validated diagnosis of COVID-19 and receiving PP were included. Various factors, including intensive care unit (ICU) or non-ICU setup, mode of oxygen therapy, outcome, duration of proning, and limitations, were noted. Results: We retrieved 36 articles with a total of 1,385 patients for qualitative analysis. Out of 36 articles, there were 17 original articles, 09 case series, and 10 case reports. Out of 1,385 participants, 78.9% (n = 1,093) and 21.0% (n = 292) of patients were managed in ICU and non-ICU setup, respectively. Awake PP with high flow nasal cannula (HFNC) was found to be a promising technique; however, the result was inconclusive with helmet continuous positive airway pressure (CPAP). No study has evaluated the optimal duration of awake PP and the associated long-term outcomes. Conclusion: We encourage the use of early awake self-proning in the management of COVID19 disease. However, the evidence in terms of its use in non-ICU setup, the optimal duration of PP, and various oxygenation devices are insufficient, thereby mandating further well-designed multicentric studies to evaluate its efficacy as an adjunct in the management of COVID-19 pneumonia in context to the aforementioned factor.

Objective: Awake proning is an intervention that is being advocated for COVID-19 patients and has been suggested to improve the oxygenation, thereby decreasing oxygen requirements. We performed this systematic review with the aim of appraising the latest published evidence on the clinical effectiveness of awake proning in COVID-19 patients. Data sources: PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Google Scholar, and one trial registry were searched until September 23, 2020, for studies on the use of awake proning for nonintubated COVID-19 patients. Study selection: Published or in-press peer-reviewed randomized control trials, case-control trials, and prospective or retrospective cohort studies in English language only were sought, assessing the effectiveness of awake proning for nonintubated patients diagnosed with COVID-19. Data results: We included 21 published studies (19 single arm and 2 with comparison group). Twenty-three registered clinical trials were identified. No randomized clinical trial has been published so far. Conclusions: Awake proning is probably safe and effective in enhancing oxygenation in nonintubated COVID-19 patients; however, there is insufficient evidence. Further high-quality clinical trials are urgently needed to assess the effectiveness of awake proning on a variety of patient-centered outcomes.

Background: The aim of this study was to determine the anti-factor Xa levels in patients receiving enoxaparin sodium for venous thromboembolism prophylaxis in the intensive care unit (ICU). Patients and methods: Using a cross-sectional study methodology, 73 ICU patients receiving 40 mg enoxaparin sodium daily were enrolled in this study. Anti-factor Xa levels were measured following the second dose. Prophylactic and subprophylactic groups of patients were compared for age, sex, weight, body mass index, total bilirubin, serum albumin, and APACHE II score. Results: Anti-factor Xa levels were prophylactic (0.2–0.6 IU/mL) in 44 (60.3%) patients and subprophylactic (<0.2 IU/mL) in 29 (39.7%) patients. The mean (SD) actual delivered dose of enoxaparin per kilogram body weight was significantly higher, at 0.59 (0.11) mg/kg in the prophylactic group compared to 0.53 (0.13) mg/kg in the subprophylactic group (p = 0.043). The subprophylactic group had significantly lower serum albumin levels compared to the prophylactic group. The total bilirubin levels were not found to be significantly different between the two groups (p = 0.110). Conclusion: A fixed prophylactic 40 mg dose of enoxaparin was associated with a high proportion of subprophylactic anti-factor Xa levels. Weight-based dose and serum albumin level were independent predictors of achieving the prophylactic target range.

Cardiopulmonary resuscitation (CPR) is considered an aerosol-generating procedure. The aim of this study was to identify the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among healthcare providers (HCPs) involved in CPR in coronavirus 2019 (COVID-19) patients. An online and offline anonymous survey with a preformed questionnaire was conducted among the HCPs involved in the care of COVID-19 patients. HCPs who developed reverse transcription-polymerase chain reaction-positive confirmed COVID-19 and/or symptomatic influenza-like illness (ILI) within 14 days of their involvement in CPR of a confirmed COVID-19 patient were identified. Activities performed during CPR, the cumulative number of CPR performed, any breach in personal protective equipment (PPE), type of the mask used, use of any pharmacological prophylaxis, and any psychological impact among HCPs were also identified. A total of 393 HCPs participated in the survey; out of them, 197 HCPs participated in CPR at least once (CPR group) and the rest 196 did not (control group). Ten in the control group and five in the CPR group developed confirmed COVID-19 within the next 2 weeks; however, only one of these five had a breach in PPE during CPR. To conclude, participation in CPR does not increase the risk of SARS-CoV-2 infection in HCPs caring for the COVID-19 patients.

Background: Critically ill Indian children have a higher prevalence of vitamin D deficiency. However, there is not much data available on the subgroup with sepsis. It has been reported that there is an impaired response of parathyroid hormone (PTH) to vitamin D deficiency in critically ill children and adults. Hence, we also sought to analyze the PTH response to vitamin D among the subgroup of critically ill children with sepsis. Patients and methods: Vitamin D and PTH levels of 84 critically ill children with sepsis (cases) and 84 controls were compared between November 2018 and February 2020. Hypovitaminosis D was defined as levels <30 ng/mL. Results: The median (IQR) of vitamin D for cases was 26 (21.30–29.95) ng/mL and that for controls 39.3 (33.65–50.2) ng/mL; p <0.001. Cases had a higher prevalence of hypovitaminosis D as compared to controls (79.7 vs 9.5%; p <0.001). Among the cases, mortality was 24.6% in the 65 children with hypovitaminosis D and 10.5% in those with sufficient vitamin D; the differences were not statistically significant (p = 0.339). There were no significant differences in the duration of pediatric intensive care unit (PICU) stay, serum calcium, PTH, and disease severity among the aforementioned groups. Out of the 65 children with hypovitaminosis D, only 9 (13.8%) were PTH responders. There were no statistically significant differences in mortality, the PICU stay, or disease severity at admission between PTH responders and nonresponders. Conclusions: Hypovitaminosis D was more prevalent among critically ill children with sepsis compared to controls. Parathyroid gland response to hypovitaminosis D was impaired in children with sepsis.

Background: The role of vasoactive medications in septic shock is well-defined, but the appropriate time of initiation of these medications in reference to fluid boluses is not clear. We planned to study prospectively the practices and outcome of initiation of vasoactive infusions with respect to resuscitation fluids boluses in pediatric septic shock. Patients and methods: Children aged 1 month to 18 years diagnosed with septic shock were enrolled to receive fluid resuscitation boluses along with vasoactive drugs. The primary outcome was to look at various practices of the initiation of vasoactive infusions; accordingly, patients were categorized into three groups: N1 received vasoactive infusions after completion of the first bolus (20 mL/kg), N2 after the second (40 mL/kg), and N3 after the third fluid (60 mL/kg) bolus. Secondary outcomes were to compare the time taken, amount of fluid required to achieve hemodynamic stability, total fluid required, and complications in the first 24 hours of treatment and mortality. Results: Hundred children were enrolled and grouped into N1, N2, and N3 with 46, 10, and 44 patients, respectively. The volume of fluid required to achieve the resolution of shock in N1 (40 ± 10 mL/kg) was significantly less than in N2 (70 ± 10 mL/kg) and N3 (70 ± 20 mL/kg); p = 0.02. The time taken to achieve hemodynamic stability was significantly less in N1 (115 ± 45 minutes) than in N2 (196 ± 32 minutes) and N3 (212 ± 44 minutes); p = 0.02. The volume of intravenous fluid required in the first 24 hours (p = 0.02) and complications were lower in the N1 group (p = 0.04). No statistical difference in mortality was seen. Conclusion: Early initiation of vasoactive infusions (after the first bolus) resulted in less total fluid volume, lesser time to achieve hemodynamic stability, less fluid boluses, less length of stay in the pediatric intensive care unit, and lesser complications in the first 24 hours. Highlight: Early initiation of vasoactive infusions—after completion of the first fluid bolus resulted in less need for further fluid boluses, lesser time for shock resolution, lesser fluid overload, and less PICU stay—in pediatric septic shock.

Objectives: To describe the clinical outcomes of hypoxic coronavirus disease 2019 (COVID-19) patients treated with intravenous methylene blue (MB) in a tertiary care hospital. Materials and methods: We conducted a case series of 50 patients with hypoxic COVID-19 treated with intravenous MB admitted to our hospital between June 01 and September 10, 2020. Intravenous MB was administered as rescue therapy in dosage of 1 mg/kg body weight, with a maximum of five doses, to patients with high oxygen requirements (SpO₂/FiO₂ <200) apart from the standard of care after obtaining G6PD levels. Data were abstracted from multiple electronic data sources or patient charts to provide information on patient characteristics, clinical and laboratory variables and outcomes. Results: The median age of the patients was 53.3 (range 25–74 years) and most patients (74%) were men. About 68% of patients had pre-existing comorbidity. Median SpO₂/FiO₂ ratio progressively improved from 132.5 (predose) to 284 before the terminal event (death or discharge), ventilator-free days, and decrease in the proinflammatory biochemical parameter was significantly higher after the second dose of MB. A total of six patients out of 50 required invasive mechanical ventilation (IMV). Thirty patients were discharged with a recovery rate of 60%, while 20 patients succumbed to the illness. There was no major side effect or adverse event reported in any of the patients. Conclusion: MB due to its polypharmacological action against SARS-CoV-2, an inexpensive and widely available drug with minimal side effects, has a significant potential in the treatment of COVID-19.

A 66-year-old Caucasian male with a history of chronic myelomonocytic leukemia (CMML) developed fluid-unresponsive hypotension requiring initiation of four different maximum dosed vasopressors, steroids, and broad-spectrum antibiotics 4 hours following four-vessel coronary artery bypass grafting involving a 150-minute cardiac bypass. Placement of a Swanz-Ganz catheter showed a cardiac output of 7 L/minute with systemic vascular resistance of 571 dynes/sec/cm⁻⁵. Over 24 hours, three doses of tocilizumab (interleukin-6 inhibitor) every 8 hours were initiated, plus 250 mg methylprednisolone per 6 hours increment, and then daily thereafter. After the initial dose of tocilizumab, it was possible to wean vasoconstrictors. We have shown for the first time that therapy with tocilizumab is effective in reversing the hemodynamic instability associated with the significant systemic inflammatory response from the “double hit” of CMML and coronary artery bypass grafting with cardiopulmonary bypass as has previously been shown in cytokine release syndrome.

Cerebral air embolism due to pulmonary tuberculosis is an extremely rare cause of stroke. We report an unusual case of a presentation of cerebral air embolism likely due to pulmonary tuberculosis lesions during a severe cough. We discuss the relationship between the pulmonary tuberculosis and the occurrence of the cerebral air embolism. A 55-year-old man with lung tuberculosis suddenly experienced a nontraumatic loss of consciousness after a severe cough. The magnetic resonance imaging confirmed an ischemic stroke due to cerebral air embolism. The thoracic scan revealed tuberculosis with a parenchymatous cavity. Patients with intrapulmonary tuberculosis cavities should be strongly considered for surgical repair and should be warned about the risk of rupture of the cavity in the situation of increasing thoracic pressure.

Clarithromycin is a commonly used antibiotic. Neuropsychiatric adverse effects are recognized, but the occurrence of seizures and status epilepticus (SE) has been rarely reported. We report the case of an elderly patient who developed generalized tonic-clonic seizures (GTCS) followed by nonconvulsive status epilepticus (NCSE), 2 days after starting clarithromycin. Other causes of seizures were excluded by magnetic resonance imaging (MRI) of the brain, CSF analysis, and routine laboratory studies, thus establishing the causal role of clarithromycin. Clarithromycin was stopped and parenteral antiepileptic drugs started, which controlled the status. In the elderly, symptoms like delirium, drowsiness, confusion, or seizures can occur due to an underlying systemic disease, brain pathology, or adverse effects of medications, all of which must be correctly differentiated. This case illustrates the occurrence of seizures and SE due to clarithromycin. Awareness about this possibility will help physicians recognize and treat such situations promptly.

Oxygen supplementation is required for approximately 14% of the patients diagnosed of having COVID-19 infection. Despite the use of conventional oxygen therapy, 5% among these require treatment in the intensive care unit (ICU). Here, we are describing a situation in which oxygen therapy was delivered to the patients by making an assembly of oxygen tubing, three-way stopcock, and high-flow nasal cannula (HFNC) present in the hospital setting following the malfunction of air blender of HFNC machine (Fig. 1). This assembly might be useful as rescue oxygen therapy during a malfunction of HFNC machine and in resource-limited settings where HFNC machine is not available. The mechanisms of action could be (1) washout of anatomic dead space due to medium oxygen flow, (2) improved gas mixing in large airways, and (3) increased oxygen concentration inside the conducting airway.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the second line of therapy in diabetes mellitus type 2. They are frequently coprescribed with other noninsulin glucose-lowering medications. Diabetic ketoacidosis (DKA) with lower-than-anticipated glucose levels is an important SGLT2i-related adverse effect in postoperative patients. This case highlights the need for increased postoperative surveillance of patients on this group of medications. Ketonuria was managed with short-acting insulin infusion with dextrose-containing intravenous fluid, as a part of the ongoing intensive care treatment to which the patient responded well. Awareness of DKA with lower-than-anticipated glucose levels is an important clinical challenge, an entity that can be confused in the setting of major and complex surgeries. The frequency of this arcane and underreported diagnosis in the perioperative setting is unknown.