Ulinastatin Add-on to Standard of Care in Critically Ill COVID-19 Patients: A Multicenter, Retrospective Study

Aim: To assess the impact on 30-day mortality with ulinastatin (ULI) used as add-on to standard of care (SOC) compared to SOC alone in coronavirus disease (COVID-19) patients requiring admission to the intensive care unit (ICU). Materials and methods: In this multicentric, retrospective study, we collected data on clinical, laboratory, and outcome parameters in patients with COVID-19. Thirty-day mortality outcome was compared among patients treated with SOC alone and ULI used as add-on to SOC. Odds ratio (OR) and 95% confidence intervals (CI) were determined to identify the predictors of 30-day mortality. Results: Ninety-four patients were identified and enrolled in both groups with comparable baseline parameters. On univariate analysis, 30-day mortality was significantly lower in ULI plus SOC group than SOC alone group (36.2 vs 51.1%, OR 0.54, 95% CI 0.30–0.97, p = 0.040). The effect on mortality was more pronounced in patients who did not require intubation (10.9 vs 34.0%, OR 0.24, 95% CI 0.09–0.66, p = 0.006) and with early administration (within 72 hours of admission) of ULI (30.7 vs 57.9%, OR 0.32, 95% CI 0.11–0.91, p = 0.032). On multivariate analysis, only intubation predicted mortality (adjusted OR 10.13, 95% CI 3.77–27.25, p<0.0001) and the effect of ULI on survival was not significant (adjusted OR 0.58, 95% CI 0.22–1.52, p = 0.270). Conclusion: Given the limited options for COVID-19 patients treated in ICU, early administration of ULI may be helpful, especially in patients not requiring intubation to improve the outcomes. Further, a large, randomized study is warranted to confirm these findings.

Retrospective study on prognostic importance of serum procalcitonin and amino‑terminal pro‑brain natriuretic peptide levels as compared to Acute Physiology and Chronic Health Evaluation IV Score on Intensive Care Unit admission, in a mixed Intensive Care Unit population.

Background: Timely decision making in Intensive Care Unit (ICU) is very essential to improve the outcome of critically sick patients. Conventional scores like Acute Physiology and Chronic Health Evaluation (APACHE IV) are quite cumbersome with calculations and take minimum 24 hours. Procalcitonin has shown to have prognostic value in ICU/Emergency department (ED) in disease states like pneumonia, sepsis etc. NTproBNP has demonstrated excellent diagnostic and prognostic importance in cardiac diseases. It has also been found elevated in non-cardiac diseases. We chose to study the prognostic utility of these markers on ICU admission. Settings and Design: Retrospective observational study. Materials and Methods: A Retrospective analysis of 100 eligible patients was done who had undergone PCT and NTproBNP measurements on ICU admission. Their correlations with all cause mortality, length of hospital stay, need for ventilator support, need for vasopressors were performed. Results: Among 100 randomly selected ICU patients, 28 were non-survivors. NTproBNP values on admission significantly correlated with all cause mortality (P = 0.036, AUC = 0.643) and morbidity (P = 0.000, AUC = 0.763), comparable to that of APACHE-IV score. PCT values on admission did not show significant association with mortality, but correlated well with morbidity and prolonged hospital length of stay (AUC = 0.616, P = 0.045). Conclusion: The current study demonstrated a good predictive value of NTproBNP, in terms of mortality and morbidity comparable to that of APACHE-IV score. Procalcitonin, however, was found to have doubtful prognostic importance. These findings need to be confirmed in a prospective larger study.

Management of refractory hypoxemia.

Mechanical ventilation remains the cornerstone in the management of severe acute respiratory failure. Acute respiratory distress syndrome (ARDS) is the most common cause of respiratory failure. It is associated with substantial mortality, and unmanageable refractory hypoxemia remains the most feared clinical possibility. If hypoxemia persists despite application of lung protective ventilation, additional therapies including inhaled vasodilators, prone positioning, recruitment maneuvers, high‑frequency oscillatory ventilation, neuromuscular blockade (NMB), and extracorporeal membrane oxygenation may be needed. NMB and prone ventilation are modalities that have been clearly linked to reduced mortality in ARDS. Rescue therapies pose a clinical challenge requiring a precarious balance of risks and benefits, as well as, in‑depth knowledge of therapeutic limitations.

Vocal cord dysfunction presenting as refractory asthma.

Vocal cord dysfunction is a rare variety of upper airway obstruction characterized by typical laryngoscopic features and may mimic an acute asthma attack. The case presented in this report pertains to a 15-year-old girl who had repeated acute episodes of dyspnoea and wheezing and remained non-responsive to corticosteroids and inhaled bronchodilators requiring endotracheal intubations for adequate control. Laryngoscopic findings were consistent with vocal cord dysfunction. She was treated with a tracheostomy and psychological support.