Marching Ahead through the Pandemic: Continuing Anesthesia Services in COVID Era—Our Experience from a Tertiary Care Cancer Centre

Introduction This paper aims to provide an overview of the administrative and clinical preparations done in a tertiary care cancer hospital in continuing operation theatre (OT) services through the COVID pandemic.

Methods Retrospective data collection, data for the past 1.5 years (COVID period) March 2020 to August 2021 were compared to surgical output for a similar duration of time before the COVID era (September 2018–February 2020).

Results A total of 1,022 surgeries were done under anesthesia in the COVID period as against 1,710 surgeries done in a similar time frame in the pre-COVID era. Overall, we saw a 40%drop in the total number of cases. Thorax, abdominal, and miscellaneous surgeries (soft tissue sarcomas, urology, and gyneconcology) saw a maximum fall in numbers; however, head and neck cases saw an increase in numbers during the pandemic. Surgical morbidity and mortality were similar in the COVID and pre-COVID era. No cases of severe COVID infection were reported among the healthcare staff working in OT.

Discussion We could successfully continue our anesthesia services with minimal risk to healthcare staff throughout the pandemic by adopting major guidelines in a pragmatic and practical approach with minor changes to suit our setup.

DFV890: a new oral NLRP3 inhibitor—tested in an early phase 2a randomised clinical trial in patients with COVID-19 pneumonia and impaired respiratory function

Background

Coronavirus-associated acute respiratory distress syndrome (CARDS) has limited effective therapy to date. NLRP3 inflammasome activation induced by SARS-CoV-2 in COVID-19 contributes to cytokine storm.

Methods

This randomised, multinational study enrolled hospitalised patients (18–80 years) with COVID-19-associated pneumonia and impaired respiratory function. Eligible patients were randomised (1:1) via Interactive Response Technology to DFV890 + standard-of-care (SoC) or SoC alone for 14 days. Primary endpoint was APACHE II score at Day 14 or on day-of-discharge (whichever-came-first) with worst-case imputation for death. Other key assessments included clinical status, CRP levels, SARS-CoV-2 detection, other inflammatory markers, in-hospital outcomes, and safety.

Findings

Between May 27, 2020 and December 24, 2020, 143 patients (31 clinical sites, 12 countries) were randomly assigned to DFV890 + SoC (n = 71) or SoC alone (n = 72). Primary endpoint to establish clinical efficacy of DFV890 vs. SoC, based on combined APACHE II score, was not met; LSM (SE), 8·7 (1.06) vs. 8·6 (1.05); p = 0.467. More patients treated with DFV890 vs. SoC showed ≥ 1-level improvement in clinical status (84.3% vs. 73.6% at Day 14), earlier clearance of SARS-CoV-2 (76.4% vs. 57.4% at Day 7), and mechanical ventilation-free survival (85.7% vs. 80.6% through Day 28), and there were fewer fatal events in DFV890 group (8.6% vs. 11.1% through Day 28). DFV890 was well tolerated with no unexpected safety signals.

Interpretation

DFV890 did not meet statistical significance for superiority vs. SoC in primary endpoint of combined APACHE II score at Day 14. However, early SARS-CoV-2 clearance, improved clinical status and in-hospital outcomes, and fewer fatal events occurred with DFV890 vs. SoC, and it may be considered as a protective therapy for CARDS.

Trial registration

ClinicalTrials.gov, NCT04382053.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01904-w.

Perioperative anaesthetic management in cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC): a retrospective analysis in a single tertiary care cancer centre

Objectives

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with increased morbidity and mortality. We retrospectively analysed the perioperative anesthetic management in patients undergoing HIPEC surgery.

Methods

After ethics approval, we reviewed the records of patients who underwent CRS/HIPEC from 2015 until 2020. We noted the peritoneal carcinomatosis index (PCI), blood loss, anastomoses done, total amount of fluid given, delta temperature and duration of surgery. These were correlated with the need for postoperative ventilation, length of ICU stay, Clavien–Dindo score and 30 day mortality.

Results

Of the 180 patients reviewed, the majority were women (85%) with a mean age of 48 years who had ovarian tumors (n=114). The total amount of fluid given was associated with an increased length of ICU stay (p=0.008). Prolonged surgery resulted in increased length of ICU stay (p<0.001), need for postoperative ventilation (p=0.006) and a poor Clavien–Dindo score (p=0.039). A high PCI score correlated with increased ICU stay, 30 day mortality (p<0.001), and the need for postoperative ventilation (0.005).

Conclusions

PCI, duration of surgery and blood loss were major predictors of postoperative morbidity. Additionally, the amount of fluid given and delta temperature affected patient outcome and should be individualized to the patient’s needs.

Single-dose oral ivermectin in mild and moderate COVID-19 (RIVET-COV): A single-centre randomized, placebo-controlled trial

INTRODUCTION

Ivermectin is an antiparasitic drug which has in-vitro efficacy in reducing severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) viral load. Hence, Ivermectin is under investigation as a repurposed agent for treating COVID-19.

METHODS

In this pilot, double blind, randomized controlled trial, hospitalized patients with mild-to-moderate COVID-19 were assigned to a single oral administration of an elixir formulation of Ivermectin at either 24 mg or 12 mg dose, or placebo in a 1:1:1 ratio. The co-primary outcomes were conversion of RT-PCR to negative result and the decline of viral load at day 5 of enrolment. Safety outcomes included total and serious adverse events. The primary outcomes were assessed in patients who had positive RT-PCR at enrolment (modified intention-to-treat population). Safety outcomes were assessed in all patients who received the intervention (intention-to-treat population).

RESULTS

Among the 157 patients randomized, 125 were included in modified intention-to-treat analysis. 40 patients each were assigned to Ivermectin 24 mg and 12 mg, and 45 patients to placebo. The RT-PCR negativity at day 5 was higher in the two Ivermectin arms but failed to attain statistical significance (Ivermectin 24 mg, 47.5%; 12 mg arm, 35.0%; and placebo arm, 31.1%; p-value = 0.30). The decline of viral load at day 5 was similar in each arm. No serious adverse events occurred.

CONCLUSIONS

In patients with mild and moderate COVID-19, a single oral administration of Ivermectin did not significantly increase either the negativity of RT-PCR or decline in viral load at day 5 of enrolment compared with placebo.

Effect of proning in patients with COVID-19 acute hypoxemic respiratory failure receiving noninvasive oxygen therapy

Background:

Novel coronavirus (SARS-CoV-2) infection is associated with hypoxemic respiratory failure. Mechanical ventilation (MV) is reported to have high mortality in SARS-CoV-2 acute respiratory distress syndrome. We aimed to investigate whether awake prone positioning (PP) can improve oxygenation and prevent intubation when employed early.

Methods:

This prospective interventional study included proven coronavirus disease 2019 (COVID-19) patients with room air saturation 93% or less. The primary outcome was the rate of intubation between the two groups. The secondary outcomes included ROX index (SpO₂/FiO₂%/respiratory rate, breaths/min) at 30 min following the intervention, ROX index at 12 h, time to recovery of hypoxemia, and mortality.

Results:

A total of 45 subjects were included (30 cases and 15 controls) with a mean (standard deviation [SD]) age of 53.1 (11.0) years. The age, comorbidities, and baseline ROX index were similar between the two groups. The median duration of PP achieved was 7.5 h on the 1^st day. The need for MV was higher in the control group (5/15; 33.3%) versus prone group (2/30; 6.7%). At 30 min, there was a statistically significant improvement in the mean (SD) ROX index of cases compared with that of the controls (10.7 [3.8] vs. 6.7 [2.6], P < 0.001). No significant adverse effects related to intervention were noted.

Conclusion:

Awake PP is associated with significant improvement in oxygenation and may reduce the need for MV in subjects with COVID-19.

A Child with Acute Lymphoblastic Leukemia in Institutional Isolation during the COVID Pandemic: A Multifaceted Responsibility

The occurrence of the COVID-19 pandemic has caused big challenges in medical communities due to its unpredictable and uncertain nature. It leads to a great deal of physical and psychological concerns. It is more prone to patients with comorbidities such as hypertension and diabetes mellitus and also to immune-compromised patients such as cancer patients. Children are no exception. Acute lymphoblastic leukemia (ALL) is the most common malignancy in the pediatric age group. In this case, we discuss the concerns and reflect the issues of a 10-year-old boy of ALL who was tested COVID positive during the evaluation and treatment of his disease and was admitted in a COVID isolation center along with his mother who was COVID negative.

Challenging Concerns of Transgender Community Amidst COVID-19

A 30-year-old transgender woman was admitted to the dedicated COVID hospital. She presented with mild symptoms and had various psychosocial insecurities, which remained unattended on reaching our health-care facility. From being left alone by her peers, lack of proper deliverance of information, and the stigma attached to the gender issues made her anxious and fearful. Although there are studies showing the prevalence of psychosocial burden in transgender people, a comprehensive approach led by a palliative care physician is yet to be initiated.

Clinico-demographic profile & hospital outcomes of COVID-19 patients admitted at a tertiary care centre in north India

BACKGROUND & OBJECTIVES

In December 2019, a novel coronavirus (SARS-CoV-2) emerged in China and rapidly spread globally including India. The characteristic clinical observations and outcomes of this disease (COVID-19) have been reported from different countries. The present study was aimed to describe the clinico-demographic characteristics and in-hospital outcomes of a group of COVID-19 patients in north India.

METHODS

This was a prospective, single-centre collection of data regarding epidemiological, demographic, clinical and laboratory parameters, management and outcome of COVID-19 patients admitted in a tertiary care facility in north India. Patient outcomes were recorded as death, discharge and still admitted.

RESULTS

Data of 144 patients with COVID-19 were recorded and analyzed. The mean age of the patients was 40.1±13.1 yr, with 93.1 per cent males, and included 10 (6.9%) foreign nationals. Domestic travel to or from affected States (77.1%) and close contact with COVID-19 patients in congregations (82.6%) constituted the most commonly documented exposure. Nine (6.3%) patients were smokers, with a median smoking index of 200. Comorbidities were present in 23 (15.9%) patients, of which diabetes mellitus (n=16; 11.1%) was the most common. A significant proportion of patients had no symptoms (n=64; 44.4%); among the symptomatic, cough (34.7%) was the most common symptom followed by fever (17.4%) and nasal symptoms (2.15%). Majority of the patients were managed with supportive treatment with hydroxychloroquine and azithromycin given on a case-to-case basis. Only five (3.5%) patients required oxygen supplementation, four (2.8%) patients had severe disease requiring intensive care, one required mechanical ventilation and mortality occurred in two (1.4%) patients. The time to reverse transcription-polymerase chain reaction (RT-PCR) negativity was 16-18 days.

INTERPRETATION & CONCLUSIONS

In this single-centre study of 144 hospitalized patients with confirmed COVID-19 in north India, the characteristic findings included younger age, high proportion of asymptomatic patients, long time to PCR negativity and low need for intensive care unit care.

Concerns of Health-care Professionals Managing COVID Patients under Institutional Isolation during COVID-19 Pandemic in India: A Descriptive Cross-sectional Study

Objective

Health-care professionals (HCPs) are the frontline warriors in the time of this uncertain and unpredictable crisis of COVID. They face many challenges while caring for these patients, yet they are expected to cope with it and deliver their duties for the betterment of humankind. Our primary aim was to identify and assess the concerns of HCPs working in COVID area in a tertiary institutional isolation center.

Methodology

An online Google-based questionnaire survey was distributed through various social media platforms after approval of the institutional review board to a total of 100 HCPs who were treating and managing COVID-positive patients.

Results

Of 100 responses, 72% were concerned about the risk of infection to self and family, while 46% reported disruption of their daily activities at a personal level. At the institutional level, 17% were concerned about inadequate personal protective equipment-related challenges. 20% had inadequate knowledge and training about COVID. 16% of participants were anxious all the time, 11% feared all the time, and 12% had stress all the time while treating COVID patients. Connectedness and communication with family and friends, word of appreciation, music, and TV were few strategies to cope up with these challenges.

Conclusion

There is a need to identify and address the concerns and challenges faced by HCPs and to develop a comprehensive strategy and guideline to provide a holistic care and to ensure their security in the workplace.

Assessment of the Prevalence of Symptoms in Patients Under Institutional Isolation in COVID-19 Pandemic in India

OBJECTIVE

To understand the trend of prevalence of symptoms of coronavirus disease 2019 (COVID-19) pandemic, some studies have been conducted outside India, but for Indian patients, there is no such study available. Therefore, this study was designed to analyze the trends of symptoms in Indian patients during COVID-19 pandemic.

METHODS

A retrospective study was conducted on 100 patients (73 males, 24 females, and 3 transgenders) admitted under institutional isolation at a tertiary care center in India using a self-designed survey-based questionnaire. A descriptive analysis of results done based on age and sex.

RESULTS

COVID incidence recorded is high in male (73%) as compared to female (24%), yet female patients have a higher prevalence of symptoms as compared to male patients.

CONCLUSION

Male patients are more as far as COVID incidence is concerned, while female patients show high prevalence of symptoms as compared to male patients. Patients presenting with COVID-positive report suffer a significant burden of symptoms, and timely recognition of symptoms and their management can significantly reduce morbidity and mortality due to COVID-19.

Dystonic reaction to a phenothiazine presenting as Bell's palsy

An 11-year-old boy presented to the pediatric ED with signs and symptoms of Bell's palsy, which was believed to be a result of otitis media. He subsequently began to list to the left and could not walk erect. Because of a history of prochlorperazine use for vomiting, a diagnosis of a dystonic reaction to a phenothiazine was made, and the patient was treated with intravenous diphenhydramine. All symptoms resolved, including seventh nerve palsy, within 5 minutes of treatment. Medications are often prescribed by physicians for vomiting without caretakers being aware of the side-effects. Dystonic reactions can be severe and present with myriad neurologic signs and symptoms.