Indian Journal of Critical Care Medicine

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2023 | February | Volume 27 | Issue 2

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EDITORIAL

MK Renuka, Baby Sailaja

Blood Lactate in Early Sepsis: A Predictor to “Keep Up” Rather than “Catch Up”

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:2] [Pages No:83 - 84]

Keywords: Biomarker, Blood lactate, Early sepsis, Prognostic scoring models

   DOI: 10.5005/jp-journals-10071-24406  |  Open Access |  How to cite  | 

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EDITORIAL

Anjana Sagar Wajekar

Videolaryngoscopy: Channelizing through Intensive Care Unit Intubations

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:2] [Pages No:85 - 86]

Keywords: Airway management, Capnography, Difficult airway, Intensive care unit, Intratracheal, Intubation, Laryngoscopy, Videolaryngoscopy

   DOI: 10.5005/jp-journals-10071-24409  |  Open Access |  How to cite  | 

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EDITORIAL

Srinivas Samavedam

If Time is Neuron, What Are We Waiting for?

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:2] [Pages No:87 - 88]

Keywords: Acute ischemic stroke, Door-to-needle time, Process improvement, Thrombolysis

   DOI: 10.5005/jp-journals-10071-24412  |  Open Access |  How to cite  | 

551

VIEWPOINT

Srinivas Samavedam, Tapas Kumar Sahoo, Suresh Ramasubban

The Curing Coma Campaign®: Concerns in the Indian Subcontinent

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:4] [Pages No:89 - 92]

Keywords: Campaign, Coma, Curing, Neurocritical care

   DOI: 10.5005/jp-journals-10071-24397  |  Open Access |  How to cite  | 

Abstract

Background: The Curing Coma Campaign (CCC) was launched by the Neurocritical Care Society (NCS) in 2019, with the purpose to bring together a diverse group of coma scientists, neurointensivists, and neurorehabilitationists. Methods: The aim of this campaign is to move beyond the limitations imposed by current definitions of coma and identify mechanisms to improve prognostication, identify test therapies, and impact outcomes. At the moment, whole approach of the CCC appears ambitiously challenging. Results: This could be true only for the Western world, such as the North America, Europe, and few developed countries. However, the whole concept of CCC may face potential challenges in the lower-middle income countries. India has several stumbling blocks that need to and can be addressed in the future, for a meaningful outcome, as envisaged in the CCC. Conclusion: India has several potential challenges, which we aim to discuss in this article.

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Original Article

Nabhat Noparatkailas, Juthamas Inchai, Athavudh Deesomchok

Blood Lactate Level and the Predictor of Death in Non-shock Septic Patients

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:8] [Pages No:93 - 100]

Keywords: Early sepsis, Mortality, Non-shock, Sepsis, Serum lactate

   DOI: 10.5005/jp-journals-10071-24404  |  Open Access |  How to cite  | 

Abstract

Objective: To evaluate the association of initial blood lactate with mortality and subsequent septic shock in non-shock septic patients. Materials and methods: A retrospective cohort study was conducted at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Muang, Chiang Mai, Thailand. Inclusion criteria included septic patients admitted to a non-critical medical ward and had initial serum lactate at the emergency department (ED). Shock and other causes of hyperlactatemia were excluded. Results: A total of 448 admissions were included with median age [interquartile range (IQR)] of 71 (59, 87) years and 200 males (44.6%). Pneumonia was the most common cause of sepsis (47.5%). The median systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) scores were 3 (2, 3) and 1 (1, 2), respectively. The median initial blood lactate was 2.19 (1.45, 3.23) mmol/L. The high blood lactate (≥2 mmol/L) group; N = 248, had higher qSOFA and other predictive scores and had significantly higher 28 days mortality (31.9% vs 10.0%; p < 0.001) and subsequent 3 days septic shock (18.1% vs 5.0%; p < 0.001) than the normal blood lactate group; N = 200. A combination of blood lactate above or equal to 2 mmol/L plus the national early warning score (NEWS) above or equal to 7 showed the highest prediction of 28 days mortality with the area under receiver-operating characteristic curve (AUROC) of 0.70 [95% confidence interval (CI): 0.65–0.75]. Conclusions: An initial blood lactate level above or equal to 2 mmol/L is associated with high mortality and subsequent septic shock among non-shock septic patients. The composite of blood lactate levels and other predictive scores yields better accuracy to predict mortality.

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Original Article

Moturu Dharanindra, Prashant Pandurang Jedge, Vishwanath Chandrashekhar Patil, Jignesh Shah, Shivakumar Iyer, Krishna Shriram Dhanasekaran

Endotracheal Intubation with King Vision Video Laryngoscope vs Macintosh Direct Laryngoscope in ICU: A Comparative Evaluation of Performance and Outcomes

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:6] [Pages No:101 - 106]

Keywords: Airway management, Endotracheal intubation, First-pass success, Glottic view, Mallampati score, Video laryngoscopy

   DOI: 10.5005/jp-journals-10071-24398  |  Open Access |  How to cite  | 

Abstract

Background: Endotracheal intubation to protect airway patency in critically ill patients with the use of videolaryngoscopes has been emerging and their expertise to handle is crucial. Our study focuses on the performance and outcomes of King Vision video laryngoscope (KVVL) in intensive care unit (ICU) compared to Macintosh direct laryngoscope (DL). Materials and methods: This comparative study was conducted by randomizing 143 critically ill patients in ICU into two groups: KVVL and Macintosh DL (n = 73; n = 70). The intubation difficulty was assessed by Mallampati score III or IV, apnea syndrome (obstructive), cervical spine limitation, opening mouth <3 cm, coma, hypoxia, anesthesiologist nontrained (MACOCHA) score. The primary endpoint was the glottic view measured by Cormack–Lehane (CL) grading. The secondary endpoints were a first-pass success, the time required for intubation, airway morbidities, and manipulations required. Results: The KVVL group showed the primary endpoint of significantly improved glottic visualization measured in terms of CL grading compared with the Macintosh DL group (p < 0.001). In the KVVL group, the first pass success rate was higher (95.7%) compared to the Macintosh DL group (81.4%) (p < 0.05). The time required for intubation in the KVVL group (28.77 ± 2.63 seconds) was significantly less compared with Macintosh DL (38.84 ± 2.72 seconds) group (p < 0.001). The airway morbidities observed were similar in both groups (p = 0.5) and the manipulation required for endotracheal intubation was significantly less (p < 0.05) in our KVVL group (16 cases; 23%) compared to the Macintosh DL group (8 cases; 10%). Conclusion: We found that the performance and outcomes of KVVL in intubating critically ill ICU patients were promising when handled by experienced operators who are experts in anesthesiology and airway management.

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Original Article

Aviral Shah, Arundhati Diwan

Stroke Thrombolysis: Beating the Clock

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:4] [Pages No:107 - 110]

Keywords: Acute ischemic stroke, Alteplase, Door-to-imaging, Door-to-needle time, Stroke, Thrombolysis

   DOI: 10.5005/jp-journals-10071-24405  |  Open Access |  How to cite  | 

Abstract

Background: Recombinant tissue plasminogen activator (rtPA) has revolutionized the management of acute ischemic stroke. Shorter door-to-imaging and door-to-needle (DTN) times are crucial for improving the outcomes in thrombolysed patients. Our observational study evaluated the door-to-imaging time (DIT) and DTN times for all thrombolysed patients. Materials and methods: The study was a cross-sectional observational study over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 52 underwent thrombolysis with rtPA. The time intervals between arrival to neuroimaging and initiation of thrombolysis were noted. Result: Of the total patients thrombolysed, only 10 patients underwent neuroimaging [non-contrast computed tomography (NCCT) head with MRI brain screen] within 30 minutes of their arrival in the hospital, 38 patients within 30–60 minutes and 2 each within the 61–90 and 91–120 minute time frames. The DTN time was 30–60 minutes for 3 patients, while 31 patients were thrombolysed within 61–90 minutes, 7 patients within 91–120 minutes, while 5 each took 121–150 and 151–180 minutes for the same. One patient had a DTN between 181 and 210 minutes. Conclusion: Most patients included in the study underwent neuroimaging within 60 minutes and subsequent thrombolysis within 60–90 minutes of their arrival in the hospital. But the time frames did not meet the recommended ideal intervals, and further streamlining of stroke management is needed even at tertiary care centers in India.

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Original Article

Anand M Tiwari, Afroz Ziyaulla Khan, Shrirang Nagorao Bamne, Ria Vishal Malhotra, Santosh M Sontakke, Pankaj B Borade

Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:8] [Pages No:111 - 118]

Keywords: Acute confusional state, Complications, Delirium, Intensive care unit, Mortality, Motor subtypes of delirium, Risk factors

   DOI: 10.5005/jp-journals-10071-24407  |  Open Access |  How to cite  | 

Abstract

Background: Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium. Objective: A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs). Patients and methods: Among 1198 adult patients screened during the study period (December 2019–September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group. Results: Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%). Conclusion: Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU.

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Original Article

Bhupinder Singh, Pavitra Manu Dogra, Vivek Sood, Vishal Singh, Amit Katyal, Manish Dhawan, Shyam Madabhushi, Krishna M Kumar, Bhupendra Singh, Abhishek Sharma

Spectrum, Outcomes, and Mortality Predictors of Acute Kidney Injury among Non-COVID-19 Patients during COVID-19 Pandemic: Data from Four Intensive Care Units

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:8] [Pages No:119 - 126]

Keywords: Acute kidney injury, Dialysis, Non-coronavirus disease-2019, Renal survival

   DOI: 10.5005/jp-journals-10071-24408  |  Open Access |  How to cite  | 

Abstract

Introduction: The data of acute kidney injury (AKI), that is, community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI) among non-COVID patients from intensive care units (ICU) during the coronavirus disease-2019 (COVID-19) pandemic are scarce. We planned to study the change in the profile of such patients compared to the pre-pandemic era. Materials and methods: This prospective observational study was conducted at four ICUs dealing with non-COVID patients at a government hospital in North India, and was aimed at assessing outcomes, and mortality predictors of AKI among non-COVID patients during the COVID-19 pandemic. Renal and patient survival at ICU transfer-out and hospital discharge, ICU and hospital stay duration, mortality predictors, and dialysis requirement at discharge were evaluated. The current or previous COVID-19 infection, previous AKI or chronic kidney disease (CKD), organ donors, and organ transplant patients were excluded. Results: Among the 200 non-COVID-19 AKI patients, diabetes mellitus (DM), primary hypertension, and cardiovascular diseases were the predominant comorbidities in descending order. The commonest cause of AKI was severe sepsis, followed by systemic infections and post-surgery patients. Dialysis requirements at ICU admission during ICU stay and above 30 days were seen in 20.5, 47.5, and 6.5% of patients, respectively. Incidence of CA-AKI and HA-AKI was 1.24:1, whereas dialysis requirement above 30 days was 0.85:1, respectively. The 30-day mortality was 42%. Hepatic dysfunction [hazard ratio (HR): 3.471], septicemia (HR: 3.342), age above 60 years (HR: 4.000), higher sequential organ failure assessment (SOFA) score (HR: 1.107; p = 0.001), anemia (p = 0.003), and low serum iron (p = 0.001) were important mortality predictors in AKI. Conclusion: Compared to the pre-COVID era, CA-AKI was more common than HA-AKI due to restricted elective surgeries during the COVID-19 pandemic. Acute kidney injury with multiorgan involvement and hepatic dysfunction, elderly age with higher SOFA score and sepsis were predictors of adverse renal and patient outcomes.

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Original Article

Anshul Singh, Rashmi Salhotra, Megha Bajaj, Ashok Kumar Saxena, Shiv Kumar Sharma, Deepak Singh, Pragya Yadav

Retention of Knowledge and Efficacy of a Hands-on Training Session in Oxygen Therapy for COVID-19 among Healthcare Workers

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:5] [Pages No:127 - 131]

Keywords: Coronavirus disease-2019, Fight, Healthcare workers, Preparedness

   DOI: 10.5005/jp-journals-10071-24327  |  Open Access |  How to cite  | 

Abstract

Introduction: We conducted basic hands-on training in oxygen therapy and ventilatory management of coronavirus disease-2019 (COVID-19) patients to health care workers (HCWs) at our tertiary care hospital. We designed this study aiming to find out the impact of hands-on training in oxygen therapy for COVID-19 patients on the knowledge and degree of retention of this gained knowledge 6 weeks after the training session among HCWs. Materials and methods: The study was conducted after obtaining approval from the Institutional Ethics Committee. A structured questionnaire consisting of 15 multiple-choice questions was given to the individual HCW. This was followed by a structured 1-hour training session on “Oxygen therapy in COVID-19”, following which the same questionnaire was given to the HCWs with the questions in a different order. After 6 weeks, the same questionnaire with questions in a different format was sent to the participants as a Google form. Results: A total of 256 responses were obtained for the pre-training test and post-training test. The median [IQR] pre-training test scores and post-training test scores were 8 [7–10] and 12 [10–13], respectively. The median retention score was 11 [9–12]. The retention scores were significantly higher than the pre-test scores. Conclusion: About 89% of the HCWs had a significant gain of knowledge. About 76% of the HCWs were able to retain knowledge, which also means the training program was successful. A definitive improvement in baseline knowledge was observed after 6 weeks of training. We propose conducting reinforcement training after 6 weeks of primary training to further augment retention.

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BRIEF RESEARCH COMMUNICATION

Fernando Ariel Sosa, Jeanette Wehit, Pablo Merlo, Agustín Matarrese, Bárbara Tort, Javier Eugenio Roberti, Germán César, Juan Ruiz Martínez, Javier Osatnik, Hatem Soliman-Aboumarie

Transesophageal Echocardiographic Assessment in Patients with Severe Respiratory Distress due to COVID-19 in the Prone Position: A Feasibility Study

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:3] [Pages No:132 - 134]

Keywords: Acute respiratory distress syndrome, Coronavirus disease-2019, Prone position, Transesophageal echocardiographic screening

   DOI: 10.5005/jp-journals-10071-24396  |  Open Access |  How to cite  | 

Abstract

Background and aim: Our aim was to assess the feasibility, safety, and utility of implementing transesophageal echocardiographic screening in patients with coronavirus disease-2019 (COVID-19)-related acute respiratory distress syndrome (ARDS), receiving mechanical ventilation (MV) and in prone position (PP). Methods: Prospective observational study performed in an intensive care unit; patients 18 years, with ARDS, invasive MV, in PP were included. A total of 87 patients were included. Results: There was no need to change ventilator settings, hemodynamic support, or any difficulties with the insertion of the ultrasonographic probe. Mean duration of transesophageal echocardiography (TEE) was 20 minutes. No displacement of the orotracheal tube, vomiting, or gastrointestinal bleeding was observed. Frequent complication was displacement of the nasogastric tube in 41 (47%) patients. Severe right ventricular (RV) dysfunction was detected in 21 (24%) patients and acute cor pulmonale was diagnosed in 36 (41%) patients. Conclusion: Our results show the importance of assessing RV function during the course of severe respiratory distress and the value of TEE for hemodynamic assessment in PP.

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BRIEF RESEARCH COMMUNICATION

Mary Chandrika Anton, B Shanthi, E Vasudevan

Study to Determine a Prognostic Cutoff Values of the Coagulation Analyte D-dimer for ICU Admission among COVID-19 Patients

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:4] [Pages No:135 - 138]

Keywords: Coronavirus disease-2019, D-dimer, Intensive care unit, Prognosis, Prognostic cutoff

   DOI: 10.5005/jp-journals-10071-24395  |  Open Access |  How to cite  | 

Abstract

Introduction: The measured D-dimer levels in coronavirus disease-2019 (COVID-19) patients have no specific cutoff to find the progression of coagulopathy and severity. Aim: This study aimed to determine prognostic cutoff values of D-dimer for intensive care unit (ICU) admission among COVID-19 patients. Materials and methods: This cross-sectional study was conducted in Sree Balaji Medical College and Hospital, Chennai, during a period of 6 months. This study included 460 COVID-19-positive individuals. Results: The mean age was 52.2 ± 12.53 years. Patients with mild illness have D-dimer value 461.8 ± 221, whereas moderate and severe COVID illness patients have D-dimer values of 1915.2 ± 699.9 and 7937.6 ± 2045.2, respectively. D-dimer cutoff value of 1036.9 is shown to be a prognostic cutoff value for COVID-19 patients admitted in the ICU with 99% sensitivity and 17% specificity. The area under curve (AUC) was considered excellent (AUC = 0.827, 95% Cl: 0.78–0.86, p-value < 0.0001) indicative of high sensitivity. Conclusion: The D-dimer value of 1036.9 ng/mL was found to be the optimum cutoff for the patients to predict the severity of the COVID-19-positive patients admitted in the ICU.

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Pediatric Critical Care

Ryan Sohail Kaiser, Mihir Sarkar, Sumantra Kumar Raut, Manas Kumar Mahapatra, Mohammad Asraf Uz Zaman, Oishik Roy, Satyabrata Roy Chowdhoury, Mousumi Nandi

A Study to Compare Ultrasound-guided and Clinically-guided Fluid Management in Children with Septic Shock

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:8] [Pages No:139 - 146]

Keywords: Cumulative fluid balance, Fluid resuscitation, Pediatric, Septic shock, Ultrasound

   DOI: 10.5005/jp-journals-10071-24410  |  Open Access |  How to cite  | 

Abstract

Background: To evaluate the role of ultrasound during initial fluid resuscitation along with clinical guidance in reducing the incidence of fluid overload on day 3 in children with septic shock. Materials and methods: It was a prospective, parallel limb open-labeled randomized controlled superiority trial done in the PICU of a government-aided tertiary care hospital in Eastern India. Patient enrolment took place between June 2021 and March 2022. Fifty-six children aged between 1 month and 12 years, with proven or suspected septic shock, were randomized to receive either ultrasound-guided or clinically guided fluid boluses (1:1 ratio) and subsequently followed up for various outcomes. The primary outcome was frequency of fluid overload on day 3 of admission. The treatment group received ultrasound-guided fluid boluses along with the clinical guidance and the control group received the same but without ultrasound guidance upto 60 mL/kg of fluid boluses. Results: The frequency of fluid overload on day 3 of admission was significantly lower in the ultrasound group (25% vs 62%, p = 0.012) as was the median (IQR) cumulative fluid balance percentage on day 3 [6.5 (3.3–10.3) vs 11.3 (5.4–17.5), p = 0.02]. The amount of fluid bolus administered was also significantly lower by ultrasound [median 40 (30–50) vs 50 (40–80) mL/kg, p = 0.003]. Resuscitation time was shorter in the ultrasound group (13.4 ± 5.6 vs 20.5 ± 8 h, p = 0.002). Conclusion: Ultrasound-guided fluid boluses were found to be significantly better than clinically guided therapy, in preventing fluid overload and its associated complications in children with septic shock. These factors make ultrasound a potentially useful tool for resuscitation of children with septic shock in the PICU.

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CASE REPORT

Jasper J Schouwenburg

Nivolumab-induced Diaphragm Dysfunction: A Case Report

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:2] [Pages No:147 - 148]

Keywords: Diaphragm ultrasound, Myositis, Nivolumab

   DOI: 10.5005/jp-journals-10071-24178  |  Open Access |  How to cite  | 

Abstract

Nivolumab is increasingly used in the treatment of melanoma. However, its use is associated with potentially severe side effects and every organ system can be affected. A case is presented where nivolumab therapy resulted in severe diaphragm dysfunction. With nivolumab's increased use, these types of complications may become more common and every clinician should be alerted to its potential presence when a patient on nivolumab treatment presents with dyspnea. Ultrasound is a readily available method to assess for diaphragm dysfunction.

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LETTER TO THE EDITOR

Kambagiri Pratyusha

Non-invasive Ventilation Failure – Predict and Protect

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:1] [Pages No:149 - 149]

Keywords: Emergency department, HACOR score, Non-invasive mechanical ventilation, Respiratory failure

   DOI: 10.5005/jp-journals-10071-24400  |  Open Access |  How to cite  | 

Abstract

Modified heart rate, acidosis, consciousness, oxygenation and respiratory rate (HACOR) score takes into consideration pneumonia, cardiogenic pulmonary edema, pulmonary acute respiratory distress syndrome (ARDS), immunosuppression, septic shock, and the sequential organ failure assessment (SOFA) score prior to non-invasive mechanical ventilation (NIV) that would impact the success of NIV and are commonly seen in patients presenting to the emergency. Propensity score matching could have been done for similar distribution of baseline characteristics. Specific objective criteria are needed to define respiratory failure requiring intubation.

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LETTER TO THE EDITOR

Abinaya Kannan

Predisposition, Insult, Response, and Organ Dysfunction: A Well-constructed Score!

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:1] [Pages No:150 - 150]

Keywords: Acute physiology and chronic health evaluation IV, Intensive care units, Sequential organ failure assessment

   DOI: 10.5005/jp-journals-10071-24401  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Kambagiri Pratyusha

Paroxysmal Sympathetic Hypertension: An Underdiagnosed Entity or a Diagnostic Difficulty?

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:1] [Pages No:151 - 151]

Keywords: Acute brain injury, Guillain–Barré syndrome, Paroxysmal sympathetic hyperactivity

   DOI: 10.5005/jp-journals-10071-24402  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Time to Place Clostridium difficile Infections in Major Healthcare-associated Infections List

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:2] [Pages No:152 - 153]

Keywords: Clostridium difficile, Clostridium difficile infection, Healthcare-associated Infection

   DOI: 10.5005/jp-journals-10071-24403  |  Open Access |  How to cite  | 

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LETTER TO THE EDITOR

Zohreh Jadali

Neurological Adverse Events Associated with COVID-19 Vaccination

[Year:2023] [Month:February] [Volume:27] [Number:2] [Pages:2] [Pages No:154 - 155]

Keywords: Coronavirus disease 2019, Neurological complication, Pathophysiology, Severe acute respiratory syndrome coronavirus-2, Vaccination

   DOI: 10.5005/jp-journals-10071-24399  |  Open Access |  How to cite  | 

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