Deep Machine Learning Might Aid in Combating Intensive Care Unit-Acquired Weakness.

Secondary muscle weakness in critically ill patients like intensive care unit (ICU)-associated weakness is frequently noted in patients with prolonged mechanical ventilation and ICU stay. It can be a result of critical illness, myopathy, or neuropathy. Although ICU-acquired weakness (ICU-AW) has been known for a while, there is still no effective treatment for it. Therefore, prevention of ICU-AW becomes the utmost priority, and knowing the risk factors is crucial. Nevertheless, the pathophysiology and the attributing causes are complex for ICU-AW, and proper delineation and formulation of a preventive strategy from such vast, multifaceted data are challenging. Artificial intelligence has recently helped healthcare professionals understand and analyze such intricate data through deep machine learning. Hence, using such a strategy also helps in knowing the risk factors and their weight as contributors, applying them in formulating a preventive path for ICU-AW worth trials.

Preintubation Machine-Delivered Pressure Support Ventilation With Positive End-Expiratory Pressure Versus Manual Bag-Mask Ventilation for Oxygenation in Overweight and Obese Patients: A Randomized, Pilot Study.

BACKGROUND: Noninvasive positive pressure ventilation (NIPPV) maintains mean airway pressures well, and its usability for preoxygenation is well described. Anesthesia machine-delivered NIPPV-based preoxygenation has recently been evaluated against the traditional manual bag-mask ventilation (BMV). The efficiency of such a technique over the traditional one is yet to be established well. The present study evaluated the feasibility of machine-delivered preoxygenation using pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and compared the effectiveness with BMV. METHODS: Thirty overweight and obese adults belonging to the American Society of Anesthesiologist's physical status I-II were randomized to receive PSV+PEEP or BMV for preintubation preoxygenation targeted to a fraction of expired oxygen (FeO2) of 85% and 90% or for a maximum period of five minutes, whichever came first. Postintubation, the patient was observed for the time taken until 1% desaturation without ventilation. Arterial blood gases, respiratory variables, FeO2 achieved, and different times were collected and compared. RESULTS: The baseline characteristics and arterial blood gases were similar between the two groups. The PSV+PEEP group had consistent and favorable tidal volume and airway pressure delivery. The difference in time to reach a FeO2 of 85% between the two groups was not statistically different. Only two patients achieved a FeO2 of 90% in the PSV+PEEP group versus none in the BMV group. However, partial pressure of oxygen at 1% desaturation (217.42±109.47 versus 138.073±71.319 mmHg, p 0.0259) was higher in the PSV+PEEP group. Similarly, the time until 1% desaturation was significantly prolonged in the PSV+PEEP group (206.6±76.952 versus 140.466±54.245 seconds, p 0.0111). CONCLUSION: The present pilot study findings indicate that preintubation machine-delivered PSV+PEEP-based preoxygenation is feasible and might be more effective than traditional BMV in overweight and obese patients.

Ischemic Stroke as the Presenting Feature for Non-acute Promyelocytic Leukemia Variant of Acute Myeloid Leukemia: A Case Report.

Acute myeloid leukemia (AML) patients encounter complications mainly due to their underlying disease or chemotherapy. Although they are at high risk for both hemorrhagic and thrombotic complications, thrombotic vascular complication as an initial manifestation is less common and rarely reported, especially in non-acute promyelocytic leukemia (non-APML). A 58-year-old female with no co-morbidity presented with fever, decreased appetite, headache, and weakness in her left upper and lower limbs. Laboratory findings showed hyperleukocytosis with 90% blast cells and thrombocytopenia (50,000/dl). While investigated and conservatively managed, she developed a seizure and loss of consciousness on the same day and was admitted to the intensive care unit. Computed tomography showed a massive right infarct in the middle cerebral artery territory with a significant midline shift. Flow cytometry indicated the diagnosis of non-APML; chemotherapy, platelet transfusion, unfractionated heparin, mechanical ventilation, and other supportive treatments were started. While managing this case, we faced challenges in decision-making on thrombolysis, craniotomy, and chemotherapy. The case highlights the salient points and dilemmas in managing such an acutely ill patient in critical care.

Perioperative Management of Emergency Craniotomes in Children With Cyanotic Congenital Heart Disease: A Case Series.

While congenital heart disease is not uncommon, cyanotic congenital heart disease (CCHD) accounts for a minor fraction of them. However, when cyanosis is present, it usually indicates a severe or critical illness. Tetralogy of Fallot (TOF) is one of the common CCHDs, representing 7-10% of all congenital cardiac malformations. Double-outlet right ventricle (DORV) is another CCHD similar to the TOF and associated with decreased pulmonary flow, ventricular septal defect (VSD), and aorta receiving blood from both ventricles. Reduced oxygen arterial saturation and increased viscosity by polycythemia induce focal cerebral ischemia, often in the area supplied by the middle cerebral artery leading to brain abscess. Brain abscesses require craniotomy, which is a major surgery. These patients also often show features of sepsis and increased intracranial pressure. The presence of CCHD further complicates the situation, making perioperative management even more challenging. There are studies in the literature on the management of similar cases, and they report successful management in most of them. However, not all such cases need intensive postoperative management. We present four pediatric cases who had either TOF or DORV and had to undergo craniotomy for brain abscess or ventriculoperitoneal shunt placement. We describe case management and highlight the critical features and cases that require prolonged postoperative critical care management.

Transillumination and Point-of-Care Ultrasonography to Delineate Tracheal Deviation for Challenging Tracheostomy: A Case Report.

Tracheostomy is indicated for varied reasons and is a relatively safe procedure that can be done with both open and percutaneous methods. However, the procedure is often challenging in cases of distorted neck anatomy. Neck swellings often push the trachea laterally or shield it. Even some gross intrathoracic pathology may shift the trachea from the typical trajectory making it challenging to delineate the course of the trachea. A bedside point-of-care technique having a visual aid that can guide the performer thus appears beneficiary. Fiber-optic assistance for correct puncture and confirmation is known, and light-based techniques have been used for tracheostomies. As fiberscopes are not infrequent in tertiary and even secondary care hospitals, transillumination from a flexible bronchoscope can identify the altered course of the trachea, much like a navigation system, and systematically aid the performer in steering away from the obstacles. We present two cases in two scenarios with tracheal deviation who underwent either open or percutaneous tracheostomy with point-of-care ultrasound and transillumination to delineate the course of the trachea and facilitate difficult tracheostomies safely.

Atypical Presentations of Myocardial Infarction: A Systematic Review of Case Reports.

There is a rising incidence of coronary artery diseases and myocardial infarction (MI). Mortality associated with acute MI (AMI) is directly linked to the time to receive treatment and missed diagnoses. Although health professionals are aware of typical AMI presentation, atypical MI is difficult to diagnose, which on the other hand, is likely to have an impact on morbidity and mortality. Therefore, it is prudent to know such atypical presentations, especially for emergency and primary care physicians. We aimed to systematically evaluate the clinical presentations of atypical MI and analyze them to characterize the common clinical presentations of atypical MI. We researched the PubMed database, did citation tracking, and performed Google Scholar advanced search to find the cases reported on the atypical presentation of MI published from January 2000 to September 2022. Articles of all languages were included; Google Translate was used to translate articles published in languages other than English. A total of 496 (56 PubMed articles, 340 citations from included PubMed articles, and 100 articles from Google Scholar advanced search) were screened; 52 case reports were evaluated, and their data were analyzed. Atypical presentations of myocardial infarction are vast; patients may have chest pain without typical characteristics of angina pain or may not have chest pain. No typical characterization could be done. Most patients were in their fifth decade or above of their life and commonly presented with pain and discomfort in the abdomen, head, and neck regions. Prodromal symptoms were consistent findings, and many patients had two to three comorbidities out of four common comorbidities, i.e., diabetes, hypertension, dyslipidemia, and substance abuse. A patient who is 50 years old or more, having comorbidities such as diabetes, hypertension, dyslipidemia, history of tobacco or marijuana usage, presenting with prodromal symptoms like shortness of breath, dizziness, fatigue, syncope, gastrointestinal discomfort or head/neck pain should be suspected for atypical MI.

Practices During Intubation in COVID-19 Intensive Care Units in India: A Cross-Sectional Questionnaire-Based Survey.

Background Healthcare workers are committed to learning from each other's experience to safely optimize patient management of COVID-19. Acute hypoxemic failure is common in COVID-19 patients, and nearly 3.2% may require intubation. Intubation is an aerosol-generating procedure (AGP) that might predispose the performer to COVID-19 infection. This survey was intended to evaluate the practices during tracheal intubation in COVID-19 intensive care units (ICUs) and analyze them against the recommendations of the All India Difficult Airway Association (AIDAA) for safe practice. Methodology It was a web-based, multicentric cross-sectional survey. The choices in the questions were based on guidelines for airway management in COVID-19. Survey questions were divided into two parts - the first part consisted of demographics and general information, and the second part focused on safe intubation practices. Results A total of 230 responses were obtained from physicians all over India, presuming their active involvement in COVID-19 cases, of which 226 responses were taken into account. Two-thirds of responders did not receive any training before ICU posting. The Indian Council of Medical Research (ICMR) guideline was followed by 89% of responders for personal protective equipment use. Intubation in COVID-19 patients was predominantly conducted by a senior anesthesiologist/intensivist in the team and a senior resident (37.2%). Rapid sequence intubation (RSI) and modified RSI were preferable among the responder's hospitals (46.5% vs. 33.6%). In most centers, responders used direct laryngoscope for intubation (62.8%), whereas video laryngoscope was used by 34%. Most responders confirmed the endotracheal tube (ETT) position by visual inspection (66.3%) over end-tidal carbon dioxide (EtCO2) concentration tracing (53.9%). Conclusions Safe intubation practices were followed in most of the centers across India. However, teaching and training, preoxygenation methods, alternative ventilation strategies, and confirmation of intubation pertinent to COVID-19 airway management need more attention.

The Relationship of Respiratory Rate-Oxygenation (ROX) and Modified ROX Index With High-Flow Nasal Cannula Oxygen Therapy in COVID-19 Patients: An Observational Pilot Study.

Background and aim Respiratory Rate-Oxygenation (ROX) and modified ROX (mROX) indexes have been proposed to detect early high-flow nasal cannula (HFNC) therapy failure. We evaluated the utility and relationship of ROX and mROX indexes in COVID-19 patients started on HFNC oxygen therapy. Methods This pilot study collected data from adult COVID-19 patients requiring HFNC oxygenation from 29 Jan - 29 Jun 2021. The patients were divided into two cohorts based on HFNC therapy success. ROX and mROX were compared using statistical diagnostic testing, including receiver operating characteristics and area under the curve (AUC) using online Epitools (https://epitools.ausvet.com.au/) and MedCalc software (MedCalc Software Ltd, Ostend, Belgium, https://www.medcalc.org/); p<0.05 was considered significant. Results Twenty-seven patients fulfilled the inclusion criteria; 48.15% of therapy failed. The cohort's mean ± standard deviation age was 53.93 ± 10.67 years; 74.1% were male. The accuracy of predicting failure for mean ROX versus mROX at baseline and six-hour values was 59.81 versus 70.68 and 67.42 versus 74.88, respectively (all p>0.05). The AUC for ROX and mROX at baseline and at six hours were statistically indifferent. Only an mROX of 4.05 (mean value) and 3.34 (Youden's J cut-off) had a sensitivity plus specificity at 156% and 163%, respectively. Conclusion Both ROX and mROX at baseline and six hours had fair-to-good accuracies and AUC; the differences were insignificant. Both ROX and mROX had better accuracies at six hours. However, only mROX < 4.05 at six hours fulfilled the sensitivity plus specificity criteria to be a clinically valuable screener.

Anaesthetic consideration for neonatal surgical emergencies.

A newborn requires constant vigilance, rapid recognition of the events and swift intervention during anaesthesia. The anaesthetic considerations in neonatal surgical emergencies are based on the physiological immaturity of various body systems, poor tolerance of the anaesthetic drugs, associated congenital disorders and considerations regarding the use of high concentration of oxygen. The main goal is for titration of anaesthetics to desired effects, while carefully monitoring of the cardiorespiratory status. The use of regional anaesthesia has shown to be safe and effective. Advancements in neonatology have resulted in the improvement of the survival of the premature and critically ill newborn babies. Most of the disorders previously considered as neonatal surgical emergencies in the past no longer require immediate surgery due to new technology and new methods of treating sick neonates. This article describes the common neonatal surgical emergencies and focuses on factors that affect the anaesthetic management of patients with these disorders.