Introduction: Extracorporeal membrane oxygenation (ECMO) is a life-support system that provides cardiopulmonary support. With recent advances, the duration of ECMO has increased but data on the outcomes of prolonged V-V ECMO are limited and inconsistent. Materials and methods: It is a retrospective observational study done at a tertiary care center in Kolkata to study the outcome of patients receiving prolonged V-V ECMO defined as >14 days. Observation: A total of 22 patients received prolonged ECMO support. Fifteen patients (68.2%) had severe coronavirus disease-2019 (COVID-19). The mean duration of invasive mechanical ventilation (IMV) before ECMO was 5 days. Baseline PaO₂/FiO₂ (p/f) ratio was 82 and Murray score was 3.5. The mean duration of ECMO support was 27.18 days (SD: 11.59). Five patients (22.7%) had minor bleeding and one patient had oxygenator failure. Survival at hospital discharge was seven patients (31.8%). Conclusion: Duration of ECMO support alone should not represent a basis for decision making to decide futility or continuation of ECMO support. Prolonged ECMO in acute respiratory distress syndrome (ARDS) has minor complications and can lead to recovery in almost one-third of the patients.

Purpose: Monitoring and improving sleep quality may help recovery from major illness. Polysomnography is a gold standard for measuring sleep quality, but routine use is not practical. The goal of this study is to investigate the diagnostic accuracy of an alternative monitor, the Bispectral Index (BIS), for evaluating the quality of sleep-in postoperative patients in the intensive care unit (ICU). Study design: An observational study. Materials and methods: Patients admitted to postoperative ICU after elective major noncardiac surgery were monitored with both BIS and PSG during the first night. The temporally synchronized data from both monitors were obtained for measurement of the association. Clinical outcomes were compared between patients with different postoperative sleep quality. Results: Thirty-three patients were enrolled in this study. For determining the average BIS index associated with good postoperative sleep quality, receiver operating characteristics (ROC) curve was generated. Area under the ROC curve (AUC) was 0.65. The cutoff with best discriminability was 75 with a sensitivity of 68% and a specificity of 56%. Compared with those with good and poor postoperative sleep quality, there were no differences in main postoperative outcomes including duration of mechanical ventilation and ICU stay. Although the quality of sleep after surgery of all subjects with postoperative delirium was poor, the incidence of delirium between the groups did not significantly differ (0% vs 10.3%; p = 0.184). Conclusion: The monitoring of BIS is a viable tool for evaluating sleep quality in mechanically ventilated patients in the postoperative ICU with acceptable precision. Trial registration: www.clinicaltrials.in.th, TCTR20200310005.

Background: Oxygenation index [OI = (MAP × FiO₂ × 100)/PaO₂] assesses the severity of hypoxic respiratory failure. Oxygen saturation index [OSI = (MAP × FiO₂ × 100)/SpO₂] is a noninvasive method to assesses the severity of hypoxic respiratory failure. Conventionally used PaO₂/FiO₂ (P/F) ratio to measure the severity of ARDS requires arterial blood gas (ABG) sampling. It tenders limited prognostic information mandating the need for better markers. Oxygenation index (needs arterial sampling) and OSI (a noninvasive method) are substitutes to provide mortality information in ARDS patients. We evaluated the correlation between P/F, OI, and OSI in invasively ventilated COVID-19 ARDS patients (C-ARDS) and looked at its relationship with mortality. Patients and methods: A retrospective study of invasively ventilated C-ARDS >18 years of age managed in COVID ICU. Ventilator settings (FiO₂, mean airway pressure), pulse oximetry (SpO₂), and ABG values (PaO₂) were simultaneously noted at the time of sample collection. Patient outcomes (alive and deceased) were documented. Differences in parameters between survivors and nonsurvivors were assessed using independent sample t-test. Receiver operating characteristic (ROC) analysis with Youden's index was used to identify cutoff values to determine survival. Results: A total of 1557 measurements for 203 patients were collected over the maximum duration of 21 days after ventilation. About 147 (72.4%) were males and 56 (27.6%) were females. On day one of ventilation, 161 (79.3%) had P/F ratio <200, 28 (13.8%) had P/F ratio between 200 and 300, and 14 (6.9%) had P/F ratio >300. There was a linear relationship between P/F ratio and OSI (r = –0.671), P/F and OI (r = –0.753), and OSI and OI (r = 0.893) (p < 0.001). After natural log transform, the correlation between these factors became stronger [P/F ratio and OSI (r = –0.797), PF and OI (r = –0.949), and OSI and OI (r = 0.902) (p < 0.001)]. About 74 (36.5%) patients survived. Survivors had significantly higher P/F ratio as compared with nonsurvivors (p < 0.05). Oxygen saturation index and OI were significantly lower in survivors as compared with nonsurvivors. Based on day-1 reading, a higher OSI (AUC = 0.719, 95% CI = 0.648–0.790) and OI (AUC = 0.752. 95% CI = 0.684–0.819) significantly can predict mortality. On the other hand, a higher P/F ratio can predict survival (AUC = 0.734, 95% CI = 0.664–0.805). P/F ratio of 160 on day 1 can predict survival. Oxygen saturation index values above 10.4% and OI above 13.5% were the cutoff derived for day 1 values to predict mortality. Conclusion: Noninvasive OSI can be used to assess the severity of hypoxic respiratory failure in C-ARDS without arterial access in resource-limited settings. Oxygen saturation index can noninvasively provide prognostic information in invasively ventilated C-ARDS patients.

Aim: To characterize the impact of adherence to quality metrics of stroke care on the clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) admissions. Methods: Consecutive patients with acute stroke were prospectively followed up for their demographic and clinical characteristics, acute stroke management, and associated clinical outcomes at discharge. Stroke quality metrics [adopted from the American Heart Association (AHA)/American Stroke Association's Get with The Guidelines (GWTG)] with a specific interest in an association between acute reperfusion therapies and functional recovery in stroke patients are analyzed and presented. A composite measure of care was considered “0 (non-adherence) to 1 (adherence).” An all-or-none measure of care was calculated to check whether eligible patients received all the quality-of-care interventions. Multivariate Cox regression models were used to study an association between optimal adherence and clinical outcomes. Results: During the study period, of the total 256 stroke admissions, 200 (78.1%) patients had IS, and the remaining 56 (21.9%) patients had ICH. The median [interquartile range (IQR)] age of total stroke admissions was 57 (36–78) years. Male preponderance was observed (IS: 80% and ICH: 67.9%). The conformity of performance metrics in IS patients was from 69.1% [95% confidence interval (CI), 68.5–69.6] for the use of deep vein thrombosis prophylaxis (DVTp) to 97.8% (95% CI, 96.2–98.6) for the use of statins. In ICH patients, it ranged from 61.7% (95% CI, 60.4–62.5) for the use of DVTp to 89.9% (95% CI, 88.6–89.7) for stroke rehabilitation. The unadjusted odds ratio (OR) of mortality (in-hospital plus the 28th-day postdischarge) was higher in ICH patients vs IS patients (4.42, p = 0.005). Optimal adherence with intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy [hazards ratio (HR) = 0.23], in-hospital acute measures [IS (HR = 0.41) and ICH (HR = 0.63)], and discharge measures [IS (HR = 0.35) and ICH (HR = 0.45)] were associated with reduced hazards of the 28th-day mortality in both cohorts. Compared to ICH, IS patients had significantly improved neurofunctional recovery [modified Rankin score (mRS) ≤ 2, p < 0.01]. Conclusion: Adherence to quality metrics and performance measures was associated with low mortality and favorable clinical outcomes. Also, DVTp as an in-hospital (acute) measure of stroke care needs attention in both cerebrovascular events.

Alcohol use disorders (AUDs) are prevalent in intensive care units (ICUs). Alcohol abuse and/or dependence, leading to alcohol withdrawal syndrome (AWS), is as high as 10% or more. There seem to be wide variations in management strategies used to manage these patients, prompting an evaluation of the knowledge gap as well as finding the barriers. Noting lack of such literature in the Indian setting, a survey is undertaken to evaluate practice patterns surrounding the identification and management of alcohol dependence/abuse and AWS in the Indian critical care scenario. The main respondents of the survey are independent practitioners with anesthesia as their base specialty and overwhelmingly practice in multidisciplinary ICUs. They estimated AUD prevalence to be under 10%. The reason most expressed for lack of AUD documentation is fear of insurance rejection. Very few used risk assessment tool in evaluation of AUDs and AWS. Awareness of ICD 10/DSM-V components of AWS diagnosis was negligible. Chlordiazepoxide and lorazepam were used either in a fixed- or symptom-based therapy. Compared to available literature, haloperidol use is excessive, while barbiturates rarely. The wide variation is seen with the dose and frequency of thiamine in AWS without neurological complications. The impact on mortality and morbidity is poorly understood. In conclusion, the survey reported a lower prevalence compared to international literature. Insurance rejection is one of the main factors in limiting adequate history taking or documenting AUDs. Alcohol withdrawal syndrome risk assessment, monitoring, and management is variable and suboptimal. Variability in all aspects of AUDs is attributable to the knowledge gap. Further studies are needed to bridge the research gap.

Aim: One of the main reasons for the death due to snake bites is the non-availability of antivenoms in the regions where they are needed. The use of medicinal plants and plant-based natural products as an alternative to antivenom will become a milestone in snake bite envenomation. The present study investigates the in vitro antivenom properties of Cyanthillium cinereum root extracts. Materials and methods: The C. cinereum root's aqueous extract was prepared by the Soxhlet extraction method, and phytochemical screening was performed to detect the presence of various bioactive compounds. Thin-layer chromatography (TLC) and gas chromatography–mass spectrometry (GC–MS) analysis were performed for the detection and identification of phytochemical constituents. In this study, an in vitro model is used to assess the antivenom capability of aqueous extract. Venom toxicity and neutralization assays were as follows: An in vitro pharmacological evaluation was performed by direct hemolysis assay, indirect hemolytic assay, proteolytic activity, neutralization of procoagulant activity, and gelatin liquefaction method. Results: Qualitative analysis of phytochemicals by the standard method showed the presence of various phytochemical constituents. Also, GC–MS analysis showed the presence of three major compounds that possess antivenom activity from the obtained 60 bioactive compounds, and their chemical structures were also determined. Venom protein profiling was performed by sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS–PAGE) analysis. The plant extract was able to neutralize the Naja naja (N. naja) and Daboia russelii (D. russelii) venom induced hemolysis and it was reduced below 50 and 40%, respectively and the extract was also able to reduce the hemolytic halo produced by venoms. Procoagulant activity and gelatin liquefaction assay showed that venom-induced clotting was neutralized by increasing the root extract concentration sufficiently. Conclusion: The aqueous extract of the root of C. cinereum showed potent in vitro venom-neutralizing activity, and it can be used as a formidable therapeutic agent against N. naja and D. russelii envenomation.

Aims and objectives: Despite thromboprophylaxis, some severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients develop thrombotic complications with poor prognosis. Our goal is to comprehensively assess the incidence, risk factors, and clinical outcomes associated with thromboembolic events (TE) among adult patients presenting with coronavirus disease-2019 (COVID-19). Materials and methods: The study was conducted as an observational and retrospective study across COVID-19 patients (n = 207) in a tertiary care hospital in the Middle East and North Africa (MENA) region. Electronic health records were collected from the COVID-19 Database from April 2020 to December 2020 which included clinical history and TE. Results: Fifty-six (27.05%) out of 207 patients (age: 54.42 ± 15.01 years) developed TE despite the anticoagulant therapy. The incidence of venous thromboembolism (VTE) was significantly higher for patients aged >50 years compared to <50 years (73.21% vs 26.79%, p < 0.05). There were no differences in the incidence of VTE between genders (p = 0.561). 165 patients (79.71%) received anticoagulant therapy, yet 48 (29%) developed TE. The most commonly used anticoagulant was low-molecular-weight heparin (LMWH, 47.34%). In spite of efficient treatment and medical management, the majority of patients with TE (45 out of 56 patients, 80.35%) experienced mortality. The comorbidities that significantly increase the risk of TE include hypertension (HTN) and ischemic heart disease (IHD). The laboratory parameters that were associated with an increased risk of VTE include ferritin, lactate dehydrogenase (LDH), and creatinine. Conclusion: The COVID-19 patients develop thrombotic complications. Future studies should clarify the underlying mechanisms of TE and optimize the antithrombotic regimens in COVID-19 patients.

Aim and Background: Delirium is highly prevalent in the immediate postoperative period following cardiac surgery and adversely impacts outcomes. Melatonin has been increasingly used in pharmacological prevention of delirium. We aimed to synthesize the available evidence concerning the role of melatonin and melatonin agonists in preventing delirium in patients after cardiac surgery. Materials and methods: PubMed, Google Scholar, and Web of Science databases were searched for relevant randomized and non-randomized trials in adults undergoing cardiac surgery investigating melatonin agonists to prevent delirium. Studies incorporating transplants, preoperative organ support, prophylactic antipsychotics, or children were excluded. Risk-of-bias was assessed using Cochrane ROB 2.0 and ROBINS-I tools. A systematic review and meta-analysis were conducted, calculating pooled odds ratio (OR) for the incidence of postoperative delirium using a random effects model with the Mantel–Haenszel method with restricted maximum-likelihood estimator. Trial sequential analysis was also carried out for the primary outcome. Results: Six randomized trials and one non-randomized trial involving 1,179 patients were included. Incidence of delirium was 16.7 and 29.6% in the intervention and comparator groups respectively, indicating a pooled OR of 0.44 [95% confidence interval (CI) 0.27 – 0.71, p = 0.04] favoring melatonin. Two studies had a high risk of bias, and I² statistics indicated significant heterogeneity. However, publication bias was insignificant, and trial sequential analysis indicated the significance of the attained effect size. Conclusion: Based on available studies, perioperative melatonin use significantly decreases postoperative incidence of delirium after adult cardiac surgery. However, the available quality of evidence is low, and larger trials with standardization of nonpharmacological delirium prevention interventions, in high-risk cohorts, and exploring various dosages and regimens should be carried out.

Background: Continuous positive airway pressure (CPAP) has been used in children with bronchiolitis for a long time. Currently in the low-resource settings, the method of providing oxygen therapy via bubble CPAP (bCPAP) to children with respiratory distress is not standardized and the existing low-flow oxygen therapy has a high mortality rate. Objectives: To study the effectiveness and safety of bCPAP as a respiratory support in children with respiratory distress. Materials and methods: This prospective observational study was conducted in a tertiary care pediatric intensive care unit (PICU) over a period of 3 months. Children with respiratory distress were administered with bCPAP oxygen therapy. Baseline demographic data, such as age, sex, weight, severity of illness was collected. Changes in heart rate, respiratory rate, saturation, respiratory distress score and failure rate after bCPAP therapy were studied. Results: During the study period, 30 children were recruited. Most common cause of respiratory distress requiring bCPAP was pneumonia (66.7%) followed by pleural effusion (20%) and bronchiolitis (13.3%). The median (IQR) CPAP duration and PICU stay in the study was 48 hours (27–48) and 4 days (4–8), respectively. Heart rate and respiratory rate, respiratory distress score improved significantly after CPAP therapy (p < 0.05). CPAP therapy failed in one child and required invasive ventilation. We did not observe any complications due to bCPAP therapy. Conclusion: The use of bCPAP in the treatment of respiratory distress is safe and effective.