Clinical Characteristics and Outcome of Patients With Severe COVID-19 Pneumonia at a Public Sector Hospital in Karachi, Pakistan.

INTRODUCTION: In Pakistan, the first case of COVID-19 was reported in February of 2020, cases peaked in June, and by January 2021, approximately 500,000 confirmed cases and over 10,000 deaths have been reported. There is a lack of data in Pakistan of the demographics, clinical characteristics, and outcome of patients with COVID-19 pneumonia, particularly those with severe illness, which we aim to assess. METHODS: This is a single-centered, observational study conducted at the COVID unit of the Shaheed Mohtarma Benazir Bhutto Institute of Trauma in Karachi, Pakistan. A manual medical record review of patients admitted from April 24, 2020 to August 24, 2020 was conducted, and all patients with polymerase chain reaction (PCR) positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) with moderate, severe, and critical COVID-19 pneumonia were included. RESULTS: Of 299 patients, the median age was 60 years (50-65). Males accounted for 221 (73.9%). Most common symptoms were shortness of breath seen in 270 (90.3%) and fever in 225 (75.3%) patients. Diabetes mellitus (51.2%) and hypertension (50.3%) were the predominant co-morbidities. COVID disease was categorized on admission as moderate in 68 (22.7%), severe in 151 (50.5%), and critical in 80 (26.8%) patients. Survival analysis was done in 252 patients, all of whom received steroids, while tocilizumab was administered to 111 (44%) patients. Hundred (39.7%) patients received non-invasive ventilation (NIV), while 57 (22.6%) were placed on mechanical ventilation. Overall, 95 (37.7%) patients died. Factors associated with mortality included older age with those above 60 years more likely to die (odds ratio [OR]: 1.925; 95% CI: 1.148-3.228; pvalue: 0.009), presence of co-morbidities (OR 1.843; 95% CI: 0.983-3.456; p value: 0.070), development of cytokine release syndrome (CRS) (73 [56.2%] vs 57 [43.8%], p value: <0.001), acute kidney injury (31 [81.6%] vs 7 [18.4%], p value: <0.001), cardiac complications (12 [75%] vs 4 [25%], p value: 0.002), and sepsis (29 [87.9%] vs 4 [12.1%], p value: <0.001). Non-survivors were more likely to develop acute respiratory distress syndrome (ARDS), having been placed on NIV and mechanical ventilation. Laboratory parameters at final outcome found that in non-survivors, median total leukocyte count, C-reactive protein (CRP), neutrophil lymphocyte ratio (NLR), and lactate dehydrogenase (LDH) were higher, while absolute lymphocyte count and platelet counts were lower which were found to be statistically significant compared to survivors. CONCLUSION: In this study of patients with severe COVID-19 pneumonia at a public sector hospital in Karachi, Pakistan, most were males, and the average age was 60 years. Mortality was high, and associated factors included older age, presence of comorbid conditions, and the development of ARDS, CRS, and sepsis.

Recovery profile - a comparison of isoflurane and propofol anesthesia for laparoscopic cholecystectomy.

OBJECTIVE: To compare the recovery profile in terms of time of extubation, eye opening, orientation and mobility and frequency of Postoperative Nausea and Vomiting (PONV) between propofol and isoflurane based anesthesia in patients undergoing laparoscopic cholecystectomy with prophylactic antiemetic. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Anesthesia, Civil Hospital and Dow University of Health Sciences, Karachi, from January to April 2007. PATIENTS AND METHODS: After informed consent, a total of 60 ASA I-II patients scheduled for laparoscopic cholecystectomy were divided in two equal groups I and P. Anesthesia in all patients were induced by Nalbuphine 0.15 mg/kg, Midazolam 0.03 mg/kg, Propofol 1.5 mg/kg and Rocuronium 0.6 mg/kg. Anesthesia was maintained with Isoflurane in group I and propofol infusion in group P, while ventilation was maintained with 50% N2O/O2 mixture in both the groups. All patients were given antiemetic prophylaxis. Hemodynamics were recorded throughout anesthesia and recovery period. At the end of surgery, times of extubation, eye opening, orientation (by modified Aldrete score) and mobility (recovery profile) were assessed. PONV was observed and recorded immediately after extubation, during early postoperative period (0-4 hours) and late period (4-24 hours). Antiemetic requirements were also recorded for the same periods in both the groups. RESULTS: Propofol provided faster recovery (extubation and eye opening times) and orientation in immediate postoperative period with statistically significant differences between the groups (p<0.0001). Recovery characteristics were comparably lower in group I. More patients achieved full points (8) on modified Aldrete score at different time until 30 minutes in group P. Postoperative nausea and vomiting in early and late periods were significantly reduced in group P. Moreover, requirement of rescue antiemetic doses were significantly lower in group P in 24 hours (p<0.0001). CONCLUSION: In this series, recovery was much faster with earlier gain of orientation with propofol anesthesia compared to isoflurane in the early recovery periods. Propofol is likely to be a better choice of anesthesia because of its better antiemetic property that persists long into postoperative period and reduces the risk of PONV.

Dexamethasone plus ondansetron for prevention of postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy: a comparison with dexamethasone alone.

OBJECTIVE: To compare the efficacy of combination of dexamethasone plus ondansetron with dexamethasone alone for postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. STUDY DESIGN: Double blinded randomized controlled clinical trial. PLACE AND DURATION OF STUDY: Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Dow University of Health Sciences and Civil Hospital, Karachi, from March 2007 to September 2007. PATIENTS AND METHODS: One hundred patients, both male and female, age 20 to 50 years, ASA Physical status I and II, scheduled for elective laparoscopic cholecystectomy under general anaesthesia were randomly allocated to two groups. Group A received dexamethasone (2 ml) plus ondansetron 4 mg (2 ml) prepared in two different syringes, and group B received dexamethasone 8 mg (2 ml) and normal saline (2 ml), prepared in two separate syringes just before induction of anaesthesia. Anaesthesia was standardized. For the first 24 hours after anaesthesia, the presence or absence of nausea and vomiting (by simply yes or no) was assessed by anaesthetist blinded to randomization. The rescue antiemetic (metoclopromide 10 mg) i.v., was given, if patient remained nauseous for more than 15 minutes, or experience retching or vomiting during study period. RESULTS: In comparison to dexamethasone group, the frequency of nausea and vomiting was clinically and statistically lower in dexamethasone -- ondansetron group (p=0.035). Use of rescue antiemetic was significantly higher in dexamethasone group (p=0.022). Two patients in group A and one patient in group B experienced peri-anal itching at time of giving dexamethasone, none of our patients experienced headache, flushing or other side effects. CONCLUSION: Combination of dexamethasone plus ondansetron is more effective in preventing postoperative nausea and vomiting than dexamethasone alone when used for prophylaxis of PONV before the induction of anaesthesia in patients undergoing laparoscopic cholecystectomy.

Assessment of risk factors for postoperative nausea and vomiting.

OBJECTIVE: To determine the risk factors for postoperative nausea and vomiting. STUDY DESIGN: Quasi-experimental study with prospective data collection. PLACE AND DURATION OF STUDY: The study was conducted at Dow Medical College University and Civil Hospital, Karachi from January to December 2004. PATIENTS AND METHODS: Data on patients' characteristic, anesthesia, surgery and postoperative nausea and vomiting was collected in operating theatre, postanesthesia care unit and wards. RESULTS: During postoperative 24 hours period, 60 out of a total of 200 patients experienced nausea and vomiting. The factors associated with an increased risk of Postoperative Nausea and Vomiting (PONV) were gender (female odds ratio 3), patients with previous history of nausea and vomiting or motion sickness (odds ratio 4), laparoscopic cholecystectomy (odds ratio 3.5) and eye surgery (odds ratio 3.9), all of these were statistically significant (p<0.05). No statistically significant difference was found between the other parameters. CONCLUSION: The incidence of PONV was found significantly higher in female gender, patients with previous history of nausea and vomiting or motion sickness, patient undergoing laparoscopic cholecystectomy and eye surgery.

Single dose caudal tramadol with bupivacaine and bupivacaine alone in pediartic inguinoscrotal surgeries.

OBJECTIVE: To determine the postoperative analgesic effect of Tramadol when given with caudally administered Bupivacaine in children undergoing inguinoscrotal surgeries. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Anaesthesia, Dow University of Health Sciences and Civil Hospital Karachi, from July 2005 to March 2006. PATIENTS AND METHODS: A total of 60 children, undergoing inguinoscrotal surgeries, aged from 1 to 12 years, ASA 1 and 2, were included. The patients were divided into two equal groups. The group given Bupivacaine with Tramadol was called 'group BT' and the group which was given only Bupivacaine was labeled as 'group B'. Group BT was given 0.25%,0.8 ml/kg Bupivacaine and Tramadol 2 mg/kg while the other group B was given 0.25%, 0.8 ml/kg Bupivacaine through caudal route after induction of general anesthesia. No other analgesic was given intraoperatively. The postoperative pain was evaluated by using visual analogue scale/Ocher's face scale/CHEOPS and sedation was assessed by 5 points sedation score at immediate postoperative period 1, 2,3,4,6, 12 and 24 hours. Supplemental analgesia in the form of paracetamol suppositories and syrup Ibuprofen was given accordingly. SaO2, pulse, blood pressure, and motor block were monitored in all the patients. RESULTS: Addition of Tramadol with Bupivacaine resulted in meaningfully increased postoperative analgesic period (16.06 +/- 4.04 hours). No other side effects like respiratory depression, pruritus, urinary retention were found in both the groups except for nausea and vomiting. The demand for supplemental analgesia was more in the patients belonging to B group than BT group. The sedation scores were similar in both the groups. CONCLUSION: The use of Tramadol as an additive with local anesthetics can prolong the postoperative analgesic period when administered caudally. Its use is safe in children.

Intravenous ketamine attenuates injection pain and arterial pressure changes during the induction of anesthesia with propofol: a comparison with lidocaine.

OBJECTIVE: To compare the effects of lidocaine and ketamine pretreatment on injection pain and hypotension due to propofol induction. DESIGN: Double blinded randomized controlled clinical trial. Place and Duration of the Study: Department of Anesthesiology, Surgical Intensive Care Unit and Pain Management, Dow University of Health Sciences and Civil Hospital, Karachi from February 2005 to December 2005. PATIENTS AND METHODS: One hundred patients, age 20-60 years, of either gender, ASA I and II scheduled for elective gynaecological, urological, orthopedic or general surgical procedures under general anesthesia were randomly allocated into two groups i.e. group A to receive ketamine 0.5 mg/kg in volume of 2 ml with venous occlusion and group B to receive 2 ml of 1% lidocaine with venous occlusion as pretreatment before propofol induction. Venous occlusion was performed using rubber tourniquet after elevating the arm for 30 seconds, which was released 60 seconds after giving the pretreatment bolus and anesthesia was induced with propofol (2 mg/ml). Fifteen seconds after injection of 25%, the calculated dose of propofol and severity of injection pain was evaluated. Heart rate (HR) and noninvasive blood pressure were recorded pre-operatively, just before propofol induction, after propofol induction, immediately after intubation and 3 minutes after intubation. RESULTS: Comparing the lidocaine group, the intensity and incidence of pain after propofol injection was lower in ketamine group but remained statistically insignificant. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly higher in ketamine group after induction with propofol. The maximum fall in SBP from baseline in ketamine group was 16% and 29.1% in lidocaine group, while maximum decrease in DBP in ketamine group was found to be12.66% vs. 26.47% in lidocaine group. There was no significant change in heart rate from baseline in either group. CONCLUSION: Ketamine pre-treatment with venous occlusion is an effective method in reducing pain and providing hemodynamic stability after propofol induction.

The role of long-term antibiotics in the prevention of infection in postoperative cardiac surgeries.

OBJECTIVE: To compare the effect of long-term (7 days) versus short-term (2 days) postoperative antibiotics in preventing postoperative infective complications in patients who have undergone open-heart surgeries. DESIGN: Interventional, randomized controlled trial (RCT). PLACE AND DURATION OF STUDY: Department of Cardiac Surgery, Dow University of Health Sciences, from February 2006 to July 2006. PATIENTS AND METHODS: Cardiac patients (n=42), operated for valvular disease (36%), coronary artery bypass grafting (50%), or septal repair (14%), were included in our study. Patients were prospectively randomized into two groups. Group A (n=21) patients received oral antibiotics for 7 days, whereas group B (n=21) patients were given the same for 2 days postoperative. Pre-operative and intra-operative variables were equal in both groups. Total leukocyte count and temperature were monitored daily until the patients were discharged. The chest and leg wounds were inspected daily for any signs of infection. Sputum and urine cultures were sent for selected patients in case of respiratory tract infection or urinary tract infection, respectively. Each patient was followed until the next routine visit in outpatient department. RESULTS: In group A, 3 patients (14%), developed infection postoperatively, whereas in group B, 13 patients (62%) (p =0.001) had to be started on oral or intravenous antibiotics as a result of developing either wound infection, a positive sputum culture, a positive urine culture or a localized infection elsewhere. Mean ward stay in group A was 4.8 +/- 4.5 days and in group B 6.5 +/- 4.1 days (p =0.011). CONCLUSION: In this series, there was a significantly higher frequency of infection and longer hospital stay in patients who received antibiotics for 2 days postoperatively as compared to those who received antibiotics for 7 days.

Intrathecal fentanyl as adjunct to hyperbaric bupivacaine in spinal anesthesia for caesarean section.

OBJECTIVE: To compare the effect of adding fentanyl to intrathecal bupivacaine on the onset, duration and quality of spinal anesthesia and its effect of mother and neonate. DESIGN: Single blind randomized controlled clinical trial. PLACE AND DURATION OF STUDY: Department of Anesthesiology, Surgical Intensive Care Unit and Pain Management, Dow University of Health Sciences and Civil Hospital, Karachi, from January 2003 to June 2004. PATIENTS AND METHODS: Sixty young adult females, ASA physical status I and II, with singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive spinal anesthesia either by using 0.75% hyperbaric bupivacaine 1.5 ml with 0.25 ml normal saline or 0.75% hyperbaric bupivacaine 1.5 ml with 0.25 ml fentanyl (12.5 microg). Blood pressure, heart rate, respiratory rate, oxygen saturation, sensory level, motor block, pain score and side effects were observed every 2 minutes for first 20 minutes, then at-5 minute interval throughout the surgery, thereafter at 30 minutes interval until the patient complained of pain. RESULTS: Comparing the bupivacaine group, time to achieve highest sensory level was significantly shorter in fentanyl group (*p < 0.05), while the duration of complete analgesia (time from injection to first report of pain) lasted significantly more longer in fentanyl group (184+/-20 minutes) than bupivacaine group (126+/-10 minutes). Duration of effective analgesia was also significantly more prolonged in fentanyl group (p < 0.05). There was no significant difference in the incidence of side effects between the two groups. CONCLUSION: Addition of fentanyl to intrathecal bupivacaine results in faster onset with improved peri-operative anesthesia without increasing the side effects.

Comparison of 25-gauge, Quincke and Whitacre needles for postdural puncture headache in obstetric patients.

OBJECTIVE: To compare the frequency of postdural puncture headache (PDPH) and failure rate of spinal anesthesia using 25-gauge Quincke and 25-gauge Whitacre needles in obstetric patients. DESIGN: Single blinded, interventional experimental study. PLACE AND DURATION OF STUDY: This study was conducted at the Department of Anesthesiology, Pain Management and Surgical Intensive Care Unit, Dow University of Health Sciences and Civil Hospital, Karachi from November 1, 2003-April 15, 2004. PATIENTS AND METHODS: One hundred females, aged 18-35 years, ASA physical status I and II, with singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive spinal anesthesia either by using 25-gauge Quincke or 25-gauge Whitacre needles. Patients were followed for 3 days postoperatively. Headache, its relation with posture, onset, duration, severity and response to the treatment were recorded. RESULTS: Compared with the Whitacre group, frequency of postdural puncture headache was significantly higher in Quincke group (*p=0.015), while the overall occurrence of non-postdural puncture headache (NPDPH) did not differ significantly between two groups (p=0.736). Most of PDPH developed on 2nd postoperative day, were mild in nature and resolved within 48 hours of their onset. There was no significant difference in the failure rate of spinal anesthesia in both groups (p=0.149). CONCLUSION: It is suggested that use of 25-gauge Whitacre needle reduces the frequency of PDPH without increasing the failure rate of spinal anesthesia in obstetric patients.