A Comparative Study of Peri-Operative Fluid Therapy With Ringer Lactate and PlasmaLyte in Children Undergoing Intra-Abdominal Surgery: A Randomized Control Trial

Background In this study, we compared Ringer's lactate solution (RL) with PlasmaLyte (PL), a relatively new IV fluid, for perioperative fluid therapy in the pediatric population. Methods This prospective and interventional randomized comparative study was carried out after obtaining clearance from the Institutional Ethics Committee. The study period was from November 2016 to December 2017. Results Hemodynamic parameters such as SpO2, ETCO2, heart rate, blood pressure, temperature, and urine output were stable in both groups throughout the perioperative period without any statistically or clinically significant variations. Children receiving PL (group PL) had better acid-base status, serum electrolytes, and blood lactate profiles compared with children receiving RL (group RL), who had hyponatremia and increased blood lactate levels, which continued to increase in the immediate postoperative period. No significant differences in pH, pCO₂, HCO₃, serum potassium, serum chloride, blood urea, serum creatinine, or blood sugar were observed. Conclusions PL is better than RL for perioperative fluid therapy in children undergoing abdominal surgeries.

Prevalence, severity, and risk factor of breakthrough infection after vaccination with either the Covaxin or the Covishield among healthcare workers: A nationwide cross-sectional study

Background and Aims:

The coronavirus disease-2019 (COVID-19) pandemic has grappled the entire globe since the beginning of 2020. In India, two vaccines were released in January 2021, the Covaxin® and the Covishield™. However, despite vaccination, many breakthrough infections were reported during the second wave in India. The present cross-sectional study aimed to find out prevalence, severity, and associated risk factors of breakthrough infection among healthcare workers (HCWs) vaccinated against COVID-19.

Material and Methods:

After ethical approval and CTRI registration, a validated questionnaire was circulated as Google form-based survey to HCWs across the nation through e-mail over 3 weeks. Biweekly reminders were sent to nonresponders till the desired sample size was attained, after which the survey was closed, and responses were charted. Data obtained from the responses were collated and analyzed.

Results:

A total of 1096 HCWs responded to the survey (54.8% response rate) and 23.36% had breakthrough infection. The severity of infection was more in the 30–50 years age group (P = 0.0170) and doctors belonging to clinical branches (P = 0.0005). The point estimate for effectiveness in preventing infection was significantly better with Covishield™ (78.5% vs. 72.4%) (P = 0.0260). Nearly all those who were infected after vaccination thought that vaccination decreased disease severity.

Conclusion:

Breakthrough COVID-19 infection still occurred after vaccination though the prevalence of severe infection was low. Covishield™ performed significantly better than Covaxin® in terms of preventing the disease. Clinical branches of medicine were found at a higher risk and younger HCWs or those with comorbidities had a higher severity of the disease.

Social Stigma of COVID-19 Experienced by Frontline Healthcare Workers of Department of Anaesthesia and Critical Care of a Tertiary Healthcare Institution in Delhi

Background

Social stigma is associated with Coronavirus Disease-2019 (COVID-19) particularly against people who have contracted the disease or have come in contact with it. There is paucity of studies regarding the prevalence of social stigma against healthcare workers (HCWs) in COVID-19 hospitals in India. The objective of this study was to measure social stigma faced by frontline HCWs of Department of Anaesthesia and Critical Care in a COVID-19 hospital and to assess the relationship between sociodemographic characteristics and social stigma.

Patients and methods

A cross-sectional study using a questionnaire (sociodemographic characteristics along with modified Berger HIV Stigma Scale) was conducted from October 10, 2020 to October 30, 2020, in the Department of Anaesthesia and Critical Care. The survey was distributed among frontline HCWs using Google Forms as well as Bilingual Physical Form. Total stigma and subgroups of stigma scale were measured for different sociodemographic parameters and compared. Data were presented as mean ± standard deviation. p-value <0.05 was taken as significant.

Results

Out of 120 frontline HCWs participated in the study, 68 (56.6%) reported severe level of COVID-19-related stigma. The mean score of COVID-19-related stigma was 41 + 7.69. Mean scores for subgroups of stigma scale, i.e., personalized stigma, disclosure concerns, negative self-image, and concerns with public attitude, were 15.60 + 4.01, 6.68 + 3.21, 5.46 + 3.22, and 13.25 + 2.44, respectively. In the univariate analysis, the overall COVID-19-related stigma scores were associated with age >30 years, male gender, lower designation (technicians and nursing orderly), lesser education, and married HCWs. In logistic regression model, only male gender was significantly associated with severity of COVID-19 stigma.

Conclusion

This study concluded that more than half of frontline HCWs in the Department of Anaesthesia and Critical Care experienced severe social stigma during COVID-19 pandemic, with highest stigma in concerns with public attitude subgroup. Severity of stigma was associated with age, male gender, designation, education, and marital status of HCW.

Highlights

Frontline HCWs of Department Anaesthesia and Critical Care experienced significant stigma related to COVID-19.

How to cite this article

Jain S, Das AK, Talwar V, Kishore J, Heena, Ganapathy U. Social Stigma of COVID-19 Experienced by Frontline Healthcare Workers of Department of Anaesthesia and Critical Care of a Tertiary Healthcare Institution in Delhi. Indian J Crit Care Med 2021;25(11):1241-1246.

Neurological Manifestations of COVID-19: A Series of Seven Cases

There is no dearth of literature on pulmonary involvement in COVID-19 infection. However, extra-pulmonary manifestations are rare and can be easily missed during this pandemic. Our case series hopes to highlight the fact that neurological manifestations of COVID-19 infection are likely to be overlooked. Hence, a low threshold of clinical suspicion and testing for COVID-19 infection is needed in cases presenting with primary neurological symptoms. This will facilitate quicker detection, isolation of cases to prevent further transmission, and provision of early treatment.

Identification of neurological manifestations associated with SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) in patients with no or mild pulmonary infection proves to be a challenge. The incidence of neurological associations of COVID-19 may be small as compared with respiratory disease; however, in the present scenario with an increasing number of cases each day, the overall incidence of patients with neurological manifestations and their health-related socioeconomic impact might be large. Hence it is important to report such cases so that healthcare providers and concerned authorities are aware of and may prepare for the growing burden. The literature on primary neurological manifestations of COVID-19 is limited, and hence our case series is relevant in the current scenario. The most commonly reported neurological complications are cerebrovascular accidents, encephalopathy, encephalitis, meningitis, and Guillain-Barr é syndrome (GBS). We present a series of seven cases with various neurological presentations and possible complications from this novel virus infection.

A Retrospective Evaluation of Combination Therapy of Methylprednisolone and Remdesivir for Severe COVID-19 Patients

Introduction: Severe and threatening complications of Corona Virus Disease-2019 (COVID-19) are caused by direct viral injury as well as excessive and aberrant host immune response induced by the virus. In this context, use of Methylprednisolone (MP) to prevent cytokine storm and Remdesivir to prevent viral replication seems prudent. Aim: To assess the clinical outcome of combination therapy of Remdesivir and MP pulse therapy in patients with severe COVID-19 in Intensive Care Unit (ICU). Materials and Methods: The retrospective study was conducted in the COVID-19 ICU, dealing exclusively with 21 severe illness severe illness cases at Safdurjung Hospital, New Delhi, India from June to July 2020. They were given MP pulse therapy (500 mg/day for three days, followed by 1 mg/kg orally once daily, tapered by 10 or 20 mg/day and finishing with 10 mg) along with intravenous Remdesivir. Pre and post-therapy examination of the patients included clinical features, inflammatory markers (Interleukin-6, ferritin and D-dimer), gas parameters like ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) and changes in chest radiograph. Values of PaO2/ FiO2, inflammatory markers on day 1 and day 3 were expressed as mean±SD and their difference compared using student t-test. Statistical significance was defined as p<0.05. Results: This treatment regimen was associated with significant improvement in PaO2/FiO2 (p<0.001), significant decrease in inflammatory markers (p<0.001) and reversal of radiological changes. Ten patients were discharged within two weeks of treatment while six patients were shifted to high dependency unit for further oxygen requirement. They were all successfully discharged from hospital without oxygen requirement within next two weeks. Five patients developed opportunistic infections and succumbed to death. Side-effects of therapy included hyperglycaemia in nine patients, which was managed by insulin infusion. Conclusion: Combination therapy of MP pulse and Remdesivir in patients with severe COVID-19 resulted in significant clinical improvement. Given the high efficacy, it could be one of the promising approaches to the management of patients with severe COVID-19.

An Update on Initial Epidemiological Profile, Clinical Course, and Outcome of COVID-19 Patients at a Tertiary Care Center in India

Background and Aim

Coronavirus disease 2019 (COVID-19) has become a global pandemic with the spectrum of disease from asymptomatic or mild disease to severe cases requiring intensive care unit (ICU) admission. In India, it started with milder presentation affecting younger population. Later on, an increase in disease severity was observed involving older age group as well. However, there is a paucity of published data regarding patients requiring ICU care in India. This case series describes the initial experience of an ICU in India regarding epidemiological profile, clinical course, and outcome of critically ill COVID-19 patients.

Methods

This case series included 27 consecutive laboratory-confirmed COVID-19 patients who were admitted in a tertiary care ICU over 14 days period, followed up till their discharge from ICU. Demographic and clinical data, including laboratory and radiological findings, were compiled with special attention to co-morbidities of the patients. The management of these patients was done as per the institutional protocol for critically ill COVID-19 patients.

Results

The median age of the patients was 50 years with no difference in gender. Comorbid conditions were seen in 85% of the patients with diabetes (43.7%) and hypertension (37.5%) as the most common conditions. The median duration of symptoms before admission was 6 days with fever as the most common clinical symptom at presentation. Chest roentogram showed bilateral lung infiltrates in 88.8% of the patients. Mild, moderate, and severe hypoxia were observed in 3, 8, and 16 patients, respectively. Ten patients were managed with oxygen therapy. Seventeen patients (62.9%) required ventilatory support. Mortality rate among patients admitted to our ICU was 59.2%.

Conclusions

This case series shows middle-aged patients with comorbid diseases present with severe COVID-19 disease and have poor outcome.

COVID 19: The New Normal in the Clinic: Overcoming Challenges in Palliative Care

Background and Aim:

In the wave of COVID-19 pandemic, the whole world has come to a standstill. This led to a major setback for cancer patients jeopardizing their treatment plans. This study analyzes the coping mechanisms of running outpatient and inpatient palliative care services in these COVID-19 times – the New Normal.

Materials and Methods:

An observational study was conducted in the pain and palliative care unit at a tertiary care hospital, India. The data were collected from March 23, 2020, to May 22, 2020, of all patients coming to the clinic and inpatient referrals. Using manual and electronic records, demographic data was collected along with clinical data. Additional data were compiled with special attention to the patient's pain and its management.

Results:

Despite complete lockdown and initial low patient load, we saw a progressive increase in the number of patients coming to the clinic. A total of 108 patients visited our clinic (65 male and 43 female), of which 78% of the patients were from Delhi. The median age was 43.94 years (range 6 years to 76 years). We had 33 new and 75 old registered cases coming. The main reason was new-onset pain because of noncompliance of drugs; the opioid stock finished with the patient. We saw a very high number of patients requiring strong and weak opioids. Proper personal protection and social distancing helped in preventing crossinfection. None of our staff or patients fell ill during this time. Communication skills were modified to convey feelings and empathize patients. Telemedicine using phone and video calls was used and found to be useful.

Conclusion:

We share our experience and challenges of providing palliative care in our clinic which can be modified as per the individual requirements in other setups.

Physiological Effects of N95 FFP and PPE in Healthcare Workers in COVID Intensive Care Unit: A Prospective Cohort Study

Background

Healthcare workers (HCWs) are at increased risk of exposure to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Personal protective equipment (PPE) is mandated for HCWs. However, the physiological effects on the HCWs while working in the protective gear remains unexplored. This study aimed to assess the physiological effects of the prolonged use of PPE on HCWs.

Materials and methods

Seventy-five HCWs, aged 18–50 years were enrolled in this prospective, observational, cohort study. The physiological variables [heart rate, oxygen saturation, and perfusion index (PI)] were recorded at the start of duty, 4 hours after wearing N95 filtering facepiece respirator (FFR), pre-donning, and post-doffing. The rating of perceived exertion (RPE) score and modified Borg scale for dyspnea was evaluated. The physiological variables were represented as the mean ± standard deviation. Wilcoxon signed-rank test was used to show any difference in RPE and modified Borg scale for dyspnea. A p value of <0.05 was considered significant.

Results

There is a statistically significant difference in the physiological parameters post-doffing compared with baseline: Heart rate (p < 0.001); oxygen saturation (p < 0.001); PI (p < 0.001). RPE score showed increased discomfort with continuous use of N95 FFR. However, exertion increased only marginally. The major adverse effects noted with PPE use were fogging, headache, tiredness, difficulty in breathing, and mask soakage, with a resultant mean duration of donning to be 3.1 hours.

Conclusion

The use of PPE can result in considerable changes in the physiological variables of healthy HCWs. The side effects may lead to excessive exhaustion and increased tiredness after prolonged shifts in the intensive care unit (ICU) while wearing PPE.

How to cite this article

Choudhury A, Singh M, Khurana DK, Mustafi SM, Ganapathy U, Kumar A, et al. Physiological Effects of N95 FFP and PPE in Healthcare Workers in COVID Intensive Care Unit: A Prospective Cohort Study. Indian J Crit Care Med 2020;24(12):1169–1173.

Single-Centre Open-Label Comparative Trial of Video-Assisted Fibreoptic-Bronchoscope-Guided Oral Versus Nasal Intubation in Anaesthetised Spontaneously Breathing Paediatric Patients

Objective

Flexible fibreoptic intubation is challenging in paediatric patients. Very few studies have compared fibreoptic intubation via oral and nasal routes in children. We hypothesised that the total time to a successful fibreoptic-guided tracheal intubation would be faster through the nasal route when compared to the oral route.

Methods

Sixty children aged 6–12 years were randomised to receive fibreoptic tracheal intubation through oral (group FOI) or nasal route (group FNI). We measured the time to glottic view and total time to successful tracheal intubation. The number of attempts needed, first attempt and overall success rate, external manoeuvres needed to obtain an adequate laryngeal view, subjective assessment of ease of intubation and complications, if any, were also recorded.

Results

The time to glottic view (76.26±.7 s vs. 46.33±16.9 s; p=0.001) and total intubation time (4.55±1.07 min vs. 3.05±0.60 min; p<0.0001) were significantly higher in the FOI group as compared to the FNI group. An overall success rate was 100% in the FNI group and 96.6% in the FOI group. The haemodynamic parameters (mean heart rate and blood pressures) changes were comparable in the two groups at all time intervals. The subjective assessment of ease of intubation was comparable in the two groups (p=0.21). Complications were minor and self-limiting.

Conclusion

Intubation guided by a nasal flexible fibreoptic bronchoscope is easier and faster when compared to oral intubation in children aged 6–12 years with normal airway, and it should be preferred for intubation in children requiring fibreoptic intubation.