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Background and Aims: Many health care staff have been pressed into coronavirus disease-19 patient care with little experience of working in bio-hazard zones because of the overwhelming requirements of manpower. They wear personal protective equipment (PPE) and follow all rules for their safety. However, despite precautions, during doffing, they carry a risk of self-contamination. This randomised cross-over study assessed the risk of self- contamination because of improper doffing of PPEs. Methods: A colourless lotion that glows with a bright-green fluorescent hue under ultraviolet light was applied to simulate germ contamination in various health care workers (HCWs) who volunteered for the study. The primary objective of this study was to know the percentage of HCWs getting self-contaminated. The secondary objectives were to assess which portions of the body get maximally contaminated and infestation of germs on which portions of the PPE carry more risk of self-contaminating after doffing. Results: A total of 152 doffings by 76 participants were analysed, and the volunteers self-contaminated in 43 doffings (28.28%). In 18 of these 43 doffings, self-contamination was noted at more than one location. The most commonly contaminated areas were the arms (33%), clothes on the abdomen (24%), and areas in the lower limb (23%). Germ infestation on the upper parts of a PPE is 2.39 times more likely to cause self-contamination after improper doffing. Conclusion: Faulty doffing resulted in self-contamination in 28.28% of all doffings. Risk is 2.39 times more when germs are nested in the upper body portions of the PPE suit.
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Background The outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 in India has been declared a public health emergency. Many patients with COVID-19 experience cardiac injury. Patients with COVID-19 admitted to the intensive care unit (ICU) with acute myocardial injury showed increased high-sensitivity troponin levels. Abnormal troponin levels may indicate myocardial injury and are commonly associated with COVID-19. Methods We conducted a retrospective observational study of 44 patients with severe COVID-19 in ICU during the second wave. The primary end point of our retrospective study was 28-day mortality, and the time of ICU admission was designated as day 0. We extracted and analyzed cardiac biomarkers, such as creatine kinase (CK), creatine kinase-MB (CK-MB), B-type natriuretic peptide (BNP), and high-sensitivity cardiac troponin I (hs-cTnI), and various inflammatory markers such as C-reactive protein (CRP) level, interleukin 6 (IL-6), d-dimer, ferritin, lactate dehydrogenase, IL-6, and procalcitonin in patients with severe COVID-19 at ICU admission and 72 hours after ICU admission from our electronic medical record system. Results The best cutoff of BNP were 326.8 and 398.5 pg/mL, CK were 195.95 and 180.12 U/L, CK-MB were 112.10 and 108.5 U/L, and hs-cTnI were 0.035 and 0.025 ng/mL, at ICU admission and 72 hours after ICU admission for predicting 28-day mortality among nonsurvivors. Conclusion In patients with severe COVID-19, CK and hs-cTnI may be considered effective and valuable predictive cardiac biomarkers among nonsurvivors and predict poor prognosis.
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Introduction: Slums are the most vulnerable settlements for COVID-19 infection due to overcrowding and unsanitary conditions. Thus, this study was undertaken to determine the level of seroprevalence for SARS-CoV-2 infection among slum dwellers. Material and Methods: A community-based cross-sectional seroepidemiological survey was conducted at several slums of Patna over four weeks, that is, January 20-February 20, 2021. A total of 650 participants were recruited in the study by applying a two-stage random sampling technique. Results: Seroprevalence for SARS-CoV-2-specific IgG antibody was found to be 31.5% (95% Confidence Interval (CI): 27.9-35.1). The seropositivity prevalence was found to be statistically higher among participants belonging to the age group of 18-30 years (41.1%), male gender (67.9%), high-risk occupation (70%), below poverty line (BPL) economic status (62.1%), and residing in a hut (51.2%) and kutcha house (42.4%). Further, 262 participants reported having COVID-like symptoms in the preceding 1 month of the survey, which was found to be significantly associated with the seropositivity status. Conclusion: The finding of the study reflects that a moderate seroprevalence level of COVID-19 infection was acquired in the slum settings of Bihar. Unchecked spread in these informal communities will pose a serious threat to the rest of the bigger sections of urban populations. This indirectly calls for early intervention in the form of preference in the roadmap of COVID-19 vaccination.
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BACKGROUND AND AIMS: The Nutrition Risk in Critically ill (NUTRIC) score is an appropriate nutritional assessment tool in mechanically ventilated patients. We retrospectively observed the applicability of the NUTRIC score for predicting outcomes in coronavirus disease (COVID)-19 acute respiratory distress syndrome (ARDS) patients. METHODS: All adult COVID-19 ARDS patients admitted to the intensive care unit and requiring various forms of oxygen therapy were included in the study. The demographic characteristics and clinical information about the patients were obtained from the hospital's medical records department. The nutritional risk for each patient was assessed using the NUTRIC score at 72 hours of ICU admission. The discriminating power and ability of NUTRIC score, Sequential Organ Failure Assessment (SOFA) score, age and Acute Physiology and Chronic Health Evaluation (APACHE) II to predict the 28-day mortality and need for mechanical ventilation (MV) was calculated using receiver operating characteristic curves and area under this curve. RESULTS: A total of 80 COVID-19 ARDS patients fitted into the inclusion criteria. Among non-survivors, the median Glasgow Coma Score, APACHE II score, NUTRIC score and SOFA score were 10, 16, 6 and 4, respectively. The cut-off values for NUTRIC score, SOFA, and APACHE II to predict 28-day mortality and need for MV was obtained as 3.5, 3.5 and 11.5, respectively. These cut-off values of NUTRIC score, SOFA score, and APACHE II have a sensitivity of 62%, 72.5% and 75.5%, respectively, and specificity of 95%, 72% and 83% for predicting mortality. CONCLUSIONS: Most COVID-19 ARDS patients requiring MV in the ICU are at nutritional risk, and a high NUTRIC score is associated with higher mortality.
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Kumar A, Kumar A, Kumar A, Sinha C, Kumar N, Singh PK. Acute Exacerbation of Cough as a Precipitating Cause of Hypoxia in COVID-19 Patients. Indian J Crit Care Med 2021;25(11):1324-1325.
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BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection affects the cardiovascular system at many levels. It initially infects endothelial cells, inducing marked endothelial damage and inflammation. However, there was no empirical evidence of functional compromise of arterial walls. AIMS AND OBJECTIVE: Our primary objective was to study functional arterial damage in coronavirus disease 2019 (COVID-19) and establish the noninvasive measurement of arterial stiffness as an independent marker of disease severity. MATERIALS AND METHODS: We recorded the arterial stiffness of 23 mild, 21 moderate, and 20 severe COVID-19 patients grouped on the latest National Institute of Health (NIH) severity criteria. We observed arterial stiffness of COVID-19 patients with standard parameters like noninvasive estimated carotid-femoral pulse wave velocity (cfPWV), age-normalized increase in cfPWV (ANI_cfPWV), age-normalized increase in aortic augmentation pressure (ANI_AugP), and heart rate-normalized augmentation index (HRN_ AIx). All the parameters were also corrected for statistically significant confounding factors. RESULTS: Moderate and severe COVID-19 patients have extremely significantly elevated arterial stiffness than mild patients. In mild patients, cfPWV (829.1 ± 139.2 cm/second) was significantly lower than both moderate (1067 ± 152.5 cm/second, p <0.0001) and severe (1416 ± 253.9 cm/second, p <0.0001) patients. ANI_cfPWV in moderate and severe patients was significantly higher than mild patients (mild: 101.2 ± 126.1 cm/second; moderate: 279 ± 114.4 cm/second; severe: 580.1 ± 216.4 cm/second; intergroup p <0.0001). The results even after correction for significant confounding factors did not show any considerable change in the increasing trend of arterial stiffness. CONCLUSION: This study establishes the functional deterioration of arteries in proportion to the severity of COVID-19. HOW TO CITE THIS ARTICLE: Kumar N, Kumar S, Kumar A, Bhushan D, Kumar A, Kumar A, et al. The COSEVAST Study Outcome: Evidence of COVID-19 Severity Proportionate to Surge in Arterial Stiffness. Indian J Crit Care Med 2021;25(10):1113-1119.
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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. How to cite this article: Kumar A, Kumar A, Kumar N, Kumar A, Singh V, Kumar S, et al. Repackaging of Malfunctioning High-flow Nasal Cannula as a Rescue Oxygen Therapy: An Innovation amid COVID-19 Crisis. Indian J Crit Care Med 2021;25(8):948-949.
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BACKGROUND: Gargling had been reported to have some roles in the prevention and treatment of respiratory tract infections. The purpose of this study was to assess the ability of regular gargling using 7.5% sodium bicarbonate to eliminate SARS-CoV-2 in the oropharynx and nasopharynx. MATERIALS AND METHODS: This pilot, open-labeled, nonrandomized, parallel single-center study. The effect of 30 seconds, three times per day gargling using 7.5% sodium bicarbonate solution-25 mL on SARS-CoV-2 viral clearance among coronavirus disease-2019 (COVID-19) patients in a dedicated COVID hospital at All India Institute of Medical Sciences, Patna, Bihar, India. We monitored the progress on by days 0, 1, 2, 3, 4, 5, 6, and 7 by observing variables like clinical category, P/F ratio, neutrophil/lymphocyte ratio (NLR) ratio, platelet count, ferritin, lactate dehydrogenase (LDH), CRP, procalcitonin, d-dimer, INR, APTT, and sequential organ function assessment (SOFA) score. We have also done repeat reverse transcription-polymerase chain reaction (RT-PCR) testing on day 5 and day 7. RESULTS: A total of 10 patients (7 males and 3 females) were included in our study after confirmed COVID positivity. The age range was from 30 to 61 years. Based on clinical severity and P/F ratio, 7 patients were included in the milder group as their ratio was more than 200 and the rest 3 patients were included in the moderate group as P/F ratio was less than 200. Two respondents had comorbidities, which were non-Hodgkin's lymphoma and ovarian carcinoma. Viral clearance was achieved at day 7 in 3 of 10 patients. However, the analysis of using 7.5% sodium bicarbonate 25 mL gargle statistically showed nonsignificant p-value for all of our studied variables. However, the PCR results were negative on 24 hours apart, i.e., on day 5 and day 7. CONCLUSIONS: This is only a preliminary study which showed that gargling with 7.5% sodium bicarbonate may not be effective in achieving early SARS-CoV-2 viral clearance among mild COVID-19 patients. However, still larger studies are required to ascertain the benefit of gargling for different stages of COVID-19 patients with keeping in mind the important variables suggestive of viremia clearance. HOW TO CITE THIS ARTICLE: Kumar N, Kumar A, Mahto M, Singh PK. Gargling with 7.5% Sodium Bicarbonate Solution for SARS-CoV-2 Viremia Clearance: Our Institutional Clinical Experience. Indian J Crit Care Med 2021;25(7):791-794.
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Severe acute respiratory syndrome coronavirus 2 has affected millions of people worldwide. This pandemic requires newer medical management strategies to control the morbidity and mortality associated with the disease. Several approaches, including global targeting of inflammation or neutralizing a single key inflammatory mediator, are being employed to cope with cytokine storms in coronavirus disease-2019 (COVID-19). The role of anti-inflammatory biologics, such as acalabrutinib, tocilizumab, anakinra, and itolizumab can become relevant. Itolizumab is a humanized recombinant immunoglobulin G1 monoclonal antibody. It targets the extracellular, scavenger receptor cysteine-rich (SRCR) distal domain 1 of CD6 and is responsible for priming, activation, and differentiation of T-cells. Itolizumab has been approved by the Drug Controller General of India for the treatment of COVID-19 in India. Here, we shared our clinical experience of 20 patients having moderate acute respiratory distress syndrome (ARDS) due to COVID-19 on treatment with itolizumab. We observed the mortality benefit with single-dose itolizumab (1.6 mg/kg) in patients having moderate COVID-19 ARDS. HOW TO CITE THIS ARTICLE: Kumari P, Kumar A, Sinha C, Kumar A, Singh PK, Arun SK. Off-label Use of Itolizumab in Patients with COVID-19 ARDS: Our Clinical Experience in a Dedicated COVID Center. Indian J Crit Care Med 2021;25(4):467-469.
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Approximately 5-6% of patients diagnosed to have COVID-19 infection present with severe hypoxemia requiring invasive ventilation or non-invasive ventilation (NIV). Additional oxygen to patients on NIV can be given by nasal prong or by connecting oxygen tubing directly to the O2 pick-off port of the NIV mask or by connecting oxygen tubing to the single-limb circuit in between ventilator and patient. Dual oxygen therapy improves oxygenation in COVID-19 patients on NIV. This method may make the patient more comfortable, increase tolerance to NIV, increase the usefulness of NIV for moderate and severe COVID-19 acute respiratory distress syndrome (ARDS). How to cite this article: Kumar A, Kumar A, Sinha C, Kumar N, Singh K, Singh PK. Dual Oxygen Therapy in COVID-19 Patient: A Method to Improve Oxygenation. Indian J Crit Care Med 2021;25(2):231-233.