Therapeutic high-dose vitamin D for vitamin D-deficient severe COVID-19 disease: randomized, double-blind, placebo-controlled study (SHADE-S).

BACKGROUND: efficacy of therapeutic cholecalciferol supplementation for severe COVID-19 is sparingly studied. OBJECTIVE: effect of single high-dose cholecalciferol supplementation on sequential organ failure assessment (SOFA) score in moderate-to-severe COVID-19. METHODS: participants with moderate to severe COVID-19 with PaO2/FiO2 ratio < 200 were randomized to 0.6 million IU cholecalciferol oral (intervention) or placebo. OUTCOMES: primary outcome was change in Day 7 SOFA score and pre-specified secondary outcomes were SOFA and 28-day all-cause mortality. RESULTS: in all, 90 patients (45 each group) were included for intention-to-treat analysis. 25(OH)D3 levels were 12 (10-16) and 13 (12-18) ng/ml (P = 0.06) at baseline; and 60 (55-65) ng/ml and 4 (1-7) ng/ml by Day 7 in vitamin D and placebo groups, respectively. The SOFA score on Day 7 was better in the vitamin D group [3 (95% CI, 2-5) versus 5 (95% CI, 3-7), P = 0.01, intergroup difference - 2 (95% CI, -4 to -0.01); r = 0.4]. A lower all-cause 28-day mortality [24% compared to 44% (P = 0.046)] was observed with vitamin D. CONCLUSIONS: single high-dose oral cholecalciferol supplementation on ICU admission can improve SOFA score at Day 7 and reduce in-hospital mortality in vitamin D-deficient COVID-19. ClinicalTrials.gov  id: NCT04952857 registered dated 7 July 2021. What is already known on this topic-vitamin D has immunomodulatory role. Observational and isolated intervention studies show some benefit in COVID-19. Targeted therapeutic vitamin D supplementation improve outcomes in severe COVID-19 is not studied in RCTs. What this study adds-high-dose vitamin D supplementation (0.6 Million IU) to increase 25(OH)D > 50 ng/ml is safe and reduces sequential organ failure assessment score, in-hospital mortality in moderate to severe COVID-19. How this study might affect research, practice or policy-vitamin D supplementation in vitamin D-deficient patients with severe COVID-19 is useful may be practiced.

Does Arterial Blood Gas (ABG) Provide a Safety Net for Extubation in Surgical Patients?

Background Extubation has always been a critical aspect of anaesthesia. Guidelines and recommendations are in place for achieving successful extubation, but the risk of failure always persists. Through this study, we assess whether arterial blood gas (ABG) values taken intraoperatively help predict extubation success in the operation theatre. Materials and methods This was a prospective observational study for one year of extubated patients whose blood gas values were not within the normal range. The patients of age 18 years and above undergoing high-risk elective and emergency surgeries where at least one intraoperative arterial blood sample was taken for blood gas analysis were included. Apart from parameters of ABG demographic data, urgency and duration of surgery, blood loss, urine output, use of intraoperative fluid(s), and blood product(s) were also observed.  Results Of 578 patients enrolled, 116 patients were extubated based on the predefined extubation criteria. Of these, 24 patients were reintubated within 24 hours. ABG parameters such as partial pressure of arterial oxygen (PaO2) and serum HCO3- levels were significantly lower in the reintubated patients compared to non-reintubated patients (p-values of 0.045 and 0.003, respectively). Conclusion This study showed that the PaO2 <100 mm Hg or ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) of less than 200 and an HCO3- value of less than 18 are plausible ABG parameters to decide extubation in post-surgery patients in OT. PaCO2, base deficit, and lactate were less reliable parameters for planning extubation.

Ultrasound Evaluation to Predict Difficult Laryngoscopy in Children below 2 Years.

OBJECTIVE: To evaluate the feasibility of sonography as a tool to predict difficult airway in children less than 2 y of age. METHODS: Airway ultrasound was performed in 90 children below the age of 2 y to measure airway dimensions preoperatively. Hyomental distance ratio in predicting difficult laryngoscopy was recorded as the primary outcome. Secondary outcomes included tongue thickness/oral cavity thickness ratio and tongue thickness/thyromental distance ratio in predicting difficult laryngoscopy and difficult intubation, time taken for intubation, and any complications. The sensitivity, specificity, positive predictive value, and negative predictive value with 95% CI of all the parameters were recorded. RESULTS: Six out of 90 (6.7%) patients had difficult laryngoscopy. HMDR was significantly different between children with easy and difficult laryngoscopy (1.15 ± 0.11 vs. 1.03 ± 0.016, p = 0.001). The optimal cutoff points for HMDR, TT/OCT, and TT/TMD to predict difficult laryngoscopy (CL grade III, IV) were > 1.055 (sensitivity 100%, specificity 86.9%), 0.755 (sensitivity 100%, specificity 57%), and 0.445 (sensitivity 53.5%, specificity 66.7%), respectively, the AUC being highest for HMDR (0.959). The cutoff value of ≥ 1.055 of HMDR to predict difficult laryngoscopy had the highest AUC of 0.959, p < 0.001. Fifty-two children had IDS = 0, while 38 had IDS between 1 and 4. None of the patients had IDS > 5. CONCLUSIONS: Ultrasound-guided airway assessment is a feasible option in children less than 2 y. Hyomental distance ratio can form a useful tool for predicting difficult airway in this age group. TRIAL REGISTRATION: The trial has been registered in Clinical trial Registry of India (CTRI/2019/05/019014) before enrollment of the first patient.

Patient on Multiple Hormone Replacement Therapy for Hip Arthroplasty: How to Omit Noise and Be Focused?

Total hip arthroplasty (THA) surgery is usually performed in patients with trauma or old-aged osteoarthritis. There has been a recent increase in younger patients presenting with avascular necrosis (AVN) of the hip requiring replacement arthroplasty. Despite being from a younger age group, these patients may present with multiple comorbidities. We describe one such case of Cushing's syndrome with AVN in a young patient with primary adrenal insufficiency, secondary hypothyroidism, and secondary hypogonadism on replacement therapy status post-transsphenoidal pituitary surgery and bilateral adrenalectomy, currently posted for total hip replacement (THR) surgery.