A Prospective Observational Study Comparing Oxygen Saturation/Fraction of Inspired Oxygen Ratio with Partial Pressure of Oxygen in Arterial Blood/Fraction of Inspired Oxygen Ratio among Critically Ill Patients Requiring Different Modes of Oxygen Supplementation in Intensive Care Unit.

Background: Intensive care unit (ICU) patients face a significant rise in mortality rates due to acute hypoxemic respiratory failure (AHRF). The diagnosis of AHRF is based on the PF ratio, but it has limitations in resource-constrained settings. Instead, the Kigali modification suggests using the oxygen saturation/fraction of inspired oxygen (SF) ratio. This study aims to correlate SF ratio and arterial oxygen pressure (PF) ratio in critically ill adults with hypoxemic respiratory failure, who required O2 therapy through different modes of oxygen supplementation. Materials and methods: In an ICU, a prospective observational study included 125 adult AHRF patients receiving oxygen therapy, with data collected on FiO2, PaO2, and SpO2. The SF ratio and PF ratio were calculated, and their correlation was assessed using statistical analysis. The receiver operator characteristics (ROC) curve analysis was conducted to assess the diagnostic precision of the SF ratio in identifying AHRF. Results: Data from a total of 250 samples were collected. The study showed a positive correlation (r = 0.622) between the SF ratio and the PF ratio. The SF threshold values of 252 and 321 were established for PF values of 200 and 300, respectively, featuring a sensitivity of 69% and specificity of 95%. Furthermore, it is worth noting that the PF ratio and SF ratio are interchangeable, regardless of the type of oxygen therapy, as the median values of both the PF ratio and SF ratio displayed statistical significance (p < 0.01) in both acidosis and alkalosis conditions. Conclusion: For patients with AHRF, the noninvasive SF ratio can effectively serve as a substitute for the invasive PF ratio across all oxygen supplementation modes. How to cite this article: Alur TR, Iyer SS, Shah JN, Kulkarni S, Jedge P, Patil V. A Prospective Observational Study Comparing Oxygen Saturation/Fraction of Inspired Oxygen Ratio with Partial Pressure of Oxygen in Arterial Blood/Fraction of Inspired Oxygen Ratio among Critically Ill Patients Requiring Different Modes of Oxygen Supplementation in Intensive Care Unit. Indian J Crit Care Med 2024; 28(3):251-255.

Comparison of admission GCS score to admission GCS-P and FOUR scores for prediction of outcomes among patients with traumatic brain injury in the intensive care unit in India.

BACKGROUND: This study aimed to determine the predictive power of the Full Outline of Unresponsiveness (FOUR) score and the Glasgow Coma Scale Pupil (GCS-P) score in determining outcomes for traumatic brain injury (TBI) patients. The Glasgow Outcome Scale (GOS) was used to evaluate patients at 1 month and 6 months after the injury. METHODS: We conducted a 15-month prospective observational study. It included 50 TBI patients admitted to the ICU who met our inclusion criteria. We used Pearson's correlation coefficient to relate coma scales and outcome measures. The predictive value of these scales was determined using the receiver operating characteristic (ROC) curve, calculating the area under the curve with a 99% confidence interval. All hypotheses were two-tailed, and significance was defined as P<0.01. RESULTS: In the present study, the GCS-P and FOUR scores among all patients on admission as well as in the subset of patients who were mechanically ventilated were statistically significant and strongly correlated with patient outcomes. The correlation coefficient of the GCS score compared to GCS-P and FOUR scores was higher and statistically significant. The areas under the ROC curve for the GCS, GCS-P, and FOUR scores and the number of computed tomography abnormalities were 0.912, 0.905, 0.937, and 0.324, respectively. CONCLUSIONS: The GCS, GCS-P, and FOUR scores are all excellent predictors with a strong positive linear correlation with final outcome prediction. In particular, the GCS score has the best correlation with final outcome.

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

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. How to cite this article: Dharanindra M, Jedge PP, Patil VC, Kulkarni SS, Shah J, Iyer S, et al. Endotracheal Intubation with King Vision Video Laryngoscope vs Macintosh Direct Laryngoscope in ICU: A Comparative Evaluation of Performance and Outcomes. Indian J Crit Care Med 2023;27(2):101-106.

Outcome of Tracheostomy in COVID-19 Patients.

Introduction: Since the start of the COVID-19 pandemic 2019, quite a few patients became critical and needed ICU admission with ventilator assistance. Tracheostomy, which was initially performed late during the course of patient on ventilator, has now been considered a procedure that can be performed relatively early as this leads to early weaning of patients and overcomes the shortage of critical beds. Objective: This study aims to focus on the outcomes of tracheotomised COVID-19 patients in terms of survival and any tracheostomy related morbidity. Methods: A prospective study was performed on COVID-19 patients undergoing tracheostomy at this tertiary care teaching hospital, which also was a dedicated centre for treating COVID-19 patients. The duration of this study was from April 2020 to September 2021. Following tracheostomy, all patients were followed up regularly and clinical changes were recorded. Points that were specifically noted were timing of the tracheostomy, change in ventilator settings, tracheostomy related complications, requirement of oxygen, days needed to wean the patient, decanulation, and, if death, the cause of death. Results: A total of 136 surgical open tracheostomies were performed on COVID-19 patients over the study period. The mean duration of intubation (timing of tracheostomy) was 12 days. A total of 73 out of 136 (53.6%) patients survived. 51 patients (37.5%) got decannulated during the course of the hospital stay. 9 patients were decanulated during the follow up visits and 13 patients were lost to follow up. 63 out of 136 (46.3%) patients died due to COVID pneumonia. Most of the patients who died had gone into multi-organ failure. Air leak syndromes (pneumothorax and pneumomediastinum) were common findings. 10 patients already had surgical emphysema before taking up for tracheostomy and 6 developed 2-3 days after tracheostomy. The most common complication was bleeding, which was seen in 28 out of 136 patients. The Median weaning of period of patients who survived was 5 days. Conclusion: Performing tracheostomy early in COVID-19 patients helps in early weaning of the patient from the ventilator and makes nursing care easier and increases the availability of ICU beds. The mortality rate was 46% amongst the 136 tracheostomies done in COVID-19 patients. Local site bleeding was the most common complication and surgical emphysema was also seen more than routine tracheostomies. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03248-1.

Our Experience of Tracheostomy in COVID-19 Patients.

Tracheostomy in patients with COVID-19 requires significant decision making and procedural planning. Use of tracheostomy can facilitate weaning from ventilation and potentially increase the availability of much needed intensive care unit (ICU) beds, however this being a high aerosol generating procedure it does put the health care worker to risk of transmission. Here we present our experience and protocols for performing tracheostomy in COVID-19 positive patients. Eleven tracheostomies were performed in COIVD-19 patients over a period of 2 months (May-June 2020) at this tertiary care hospital dedicated to manage COVID patients. All patients underwent open surgical tracheostomy, the specific indication, preoperative protocols, surgical steps and precautions taken have been discussed. Tracheostomy was done not before 10 days after initiation of mechanical ventilation. Patient's cardiovascular vitals should show recovery with some spontaneous effort. There should be reduction in need for FiO2 and ventilator requirements. Of total 11 tracheostomies performed only one patient had post procedure bleeding which was controlled conservatively. We have summarized our experience in performing tracheostomies in 11 such patients. Our guidelines and recommendations on tracheostomy during the COVID-19 pandemic are presented in this study. We suggest tracheostomies to be done after 10 days of intubation with precautions and given indications with the idea of early weaning off of patient from ventilator and more availability of ICU beds which is already overwhelmed by patient load.

Direct Medical Cost Analysis of Indian COVID-19 Patients Requiring Critical Care Admission.

INTRODUCTION: Intensive care unit (ICU) admission is required for approximately 25% of patients affected with coronavirus disease-19 (COVID-19) and imposes a high economic burden on patients in resource-limited settings. METHOD: We conducted a retrospective direct medical care cost analysis of COVID-19 patients requiring ICU admission after obtaining the Institutional Ethics Committee approval. Data were obtained from the records of patients admitted to the COVID-19 ICU of a tertiary care trust teaching hospital from June 2020 to December 2020. Direct costs were analyzed and correlated with various demographic variables and clinical outcomes. RESULTS: A total of 176 patients were included (males-76%). The median direct medical cost for a median stay of 13 days was INR 202248.5 ($ 2742.91). Hospital drugs and disposables accounted for 20% of the total cost followed by bed charges (19%), equipment charges (17%), biosafety protective gear (15.5%), pathological and radiological tests (15%), clinical management (7.6%), and biomedical waste management (1.6%). Government schemes accounted for 79% of medical claims followed by directly paying patients (12.5%) and private insurance (8.5%). The cost was significantly higher in patients with diabetes mellitus and sepsis and in those requiring mechanical ventilation (MV) (p <0.05). Shorter lead time to hospital admission and lesser length of hospital stay were associated with significant lower direct cost. CONCLUSION: Direct medical care cost is substantial for COVID-19 patients requiring ICU admission. This cost is significantly associated with increased ICU and hospital stay, longer lead time to admission, diabetes mellitus, sepsis, and those who need high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and MV. HOW TO CITE THIS ARTICLE: Reddy KN, Shah J, Iyer S, Chowdhury M, Yerrapalem N, Pasalkar N, et al. Direct Medical Cost Analysis of Indian COVID-19 Patients Requiring Critical Care Admission. Indian J Crit Care Med 2021;25(10):1120-1125.

Elevated Levels of Neutrophil Activated Proteins, Alpha-Defensins (DEFA1), Calprotectin (S100A8/A9) and Myeloperoxidase (MPO) Are Associated With Disease Severity in COVID-19 Patients.

Understanding of the basis for severity and fatal outcome of SARS-CoV-2 infection is of paramount importance for developing therapeutic options and identification of prognostic markers. So far, accumulation of neutrophils and increased levels of pro-inflammatory cytokines are associated with disease severity in COVID-19 patients. In this study, we aimed to compare circulatory levels of neutrophil secretory proteins, alpha-defensins (DEFA1), calprotectin (S100A8/A9), and myeloperoxidase (MPO) in COVID-19 patients with different clinical presentations. We studied 19 healthy subjects, 63 COVID-19 patients with mild (n=32) and severe (n=31) disease, 23 asymptomatic individuals identified through contact tracing programme and 23 recovering patients (1-4 months post-disease). At the time of disease presentation, serum levels of DEFA1 were significantly higher in patients with mild (mean230 ± 17, p<0.0001) and severe (mean452 ± 46, p<0.0001) disease respectively in comparison to healthy subjects (mean113 ± 11). S100A8/A9 proteins were significantly higher in COVID-19 patients (p<0.0001) irrespective of disease severity. The levels of DEFA1, S100A8/A9 and MPO reduced to normal in recovering patients and comparable to healthy subjects. Surprisingly, DEFA1 levels were higher in severe than mild patients in first week of onset of disease (p=0.004). Odds-ratio analysis showed that DEFA1 could act as potential biomarker in predicting disease severity (OR=11.34). In addition, levels of DEFA1 and S100A8/A9 were significantly higher in patients with fatal outcome (p=0.004 and p=0.03) respectively. The rise in DEFA1 levels was independent of secondary infections. In conclusion, our data suggest that induction of elevated levels of alpha-defensins and S100A8/A9 is associated with poor disease outcome in COVID-19 patients.