Higher vs lower doses of dexamethasone in patients with COVID-19 and severe hypoxia (COVID STEROID 2) trial: Protocol and statistical analysis plan

Background

The coronavirus disease 2019 (COVID‐19) pandemic has resulted in millions of deaths and overburdened healthcare systems worldwide. Systemic low‐dose corticosteroids have proven clinical benefit in patients with severe COVID‐19. Higher doses of corticosteroids are used in other inflammatory lung diseases and may offer additional clinical benefits in COVID‐19. At present, the balance between benefits and harms of higher vs. lower doses of corticosteroids for patients with COVID‐19 is unclear.

Methods

The COVID STEROID 2 trial is an investigator‐initiated, international, parallel‐grouped, blinded, centrally randomised and stratified clinical trial assessing higher (12 mg) vs. lower (6 mg) doses of dexamethasone for adults with COVID‐19 and severe hypoxia. We plan to enrol 1,000 patients in Denmark, Sweden, Switzerland and India. The primary outcome is days alive without life support (invasive mechanical ventilation, circulatory support or renal replacement therapy) at day 28. Secondary outcomes include serious adverse reactions at day 28; all‐cause mortality at day 28, 90 and 180; days alive without life support at day 90; days alive and out of hospital at day 90; and health‐related quality of life at day 180. The primary outcome will be analysed using the Kryger Jensen and Lange test adjusted for stratification variables and reported as adjusted mean differences and median differences. The full statistical analysis plan is outlined in this protocol.

Discussion

The COVID STEROID 2 trial will provide evidence on the optimal dosing of systemic corticosteroids for COVID‐19 patients with severe hypoxia with important implications for patients, their relatives and society.

Efficacy of ultrasound-guided erector spinae plane block following breast surgery - A double-blinded randomised, controlled study

Background and Aims:

Regional anaesthesia has been used to reduce acute post-operative pain as well as opioid-related side effects in breast cancer surgery. Erector spinae plane (ESP) block is a relatively new fascial plane block being tried in various surgical procedures. Our study is a double-blind randomised trial, designed to prove the efficacy of this block in breast surgeries.

Methods:

Seventy female patients scheduled for unilateral breast surgery were enroled in this prospective, randomised, double-blind study. Patients were randomised to group A and group B. All patients received general anaesthesia while group B received additional ultrasound-guided erector spinae block given at thoracic level—T5 with 20ml of 0.25% bupivacaine. Time to first rescue analgesia was the primary outcome. Secondary outcomes were total intraoperative opioid consumption, pain scores over 24 h, post-operative nausea and vomiting and patient satisfaction score at discharge. The Shapiro–Wilk test was used to check the normality of each variable. A comparison was done using Mann–Whitney test and the level of significance was set at 0.05.

Results:

The median time to first rescue analgesia in group A versus group B was 1 h (1–12h) versus 8 h (1–26h), respectively, with a P value of 0.044. Group B patients had lower pain scores post-operatively and better satisfaction scores at discharge. There was no statistically significant difference in intraoperative fentanyl consumption.

Conclusion:

Ultrasound-guided ESP block with general anaesthesia offers superior post-operative analgesia compared to general anaesthesia alone in patients undergoing unilateral nonreconstructive breast cancer surgeries.

Indian Resuscitation Council (IRC) suggested guidelines for Comprehensive Cardiopulmonary Life Support (CCLS) for suspected or confirmed coronavirus disease (COVID-19) patient

Management of the recent outbreak of the novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) remains challenging. The challenges are not only limited to its preventive strategies, but also extend to curative treatment, and are amplified during the management of critically ill patients with COVID-19. Older persons with comorbidities like diabetes mellitus, cardiac diseases, hepatic impairment, renal disorders and respiratory pathologies or immune impairing conditions are more vulnerable and have a higher mortality from COVID-19. Earlier, the Indian Resuscitation Council (IRC) had proposed the Comprehensive Cardiopulmonary Life Support (CCLS) for management of cardiac arrest victims in the hospital setting. However, in patients with COVID-19, the guidelines need to be modified,due to various concerns like differing etiology of cardiac arrest, virulence of the virus, risk of its transmission to rescuers, and the need to avoid or minimize aerosolization from the patient due to various interventions. There is limited evidence in these patients, as the SARS-CoV-2 is a novel infection and not much literature is available with high-level evidence related to CPR in patients of COVID-19. These suggested guidelines are a continuum of CCLS guidelines by IRC with an emphasis on the various challenges and concerns being faced during the resuscitative management of COVID-19 patients with cardiopulmonary arrest.

A Prospective Observational Study of Rational Fluid Therapy in Asian Intensive Care Units: Another Puzzle Piece in Fluid Therapy

Introduction

Fluid therapy in critically ill patients, especially timing and fluid choice, is controversial. Previous randomized trials produced conflicting results. This observational study evaluated the effect of colloid use on 90-day mortality and acute kidney injury (RIFLE F) within the Rational Fluid Therapy in Asia (RaFTA) registry in intensive care units.

Materials and methods

RaFTA is a prospective, observational study in Asian intensive care unit (ICU) patients focusing on fluid therapy and related outcomes. Logistic regression was performed to identify risk factors for increased 90-day mortality and acute kidney injury (AKI).

Results

Twenty-four study centers joined the RaFTA registry and collected 3,187 patient data sets from November 2011 to September 2012. A follow-up was done 90 days after ICU admission. For 90-day mortality, significant risk factors in the overall population were sepsis at admission (OR 2.185 [1.799; 2.654], p < 0.001), cumulative fluid balance (OR 1.032 [1.018; 1.047], p < 0.001), and the use of vasopressors (OR 3.409 [2.694; 4.312], p < 0.001). The use of colloids was associated with a reduced risk of 90-day mortality (OR 0.655 [0.478; 0.900], p = 0.009). The initial colloid dose was not associated with an increased risk for AKI (OR 1.094 [0.754; 1.588], p = 0.635).

Conclusion

RaFTA adds the important finding that colloid use was not associated with increased 90-day mortality or AKI after adjustment for baseline patient condition.

Clinical significance

Early resuscitation with colloids showed potential mortality benefit in the present analysis. Elucidating these findings may be an approach for future research.

How to cite this article

Jacob M, Sahu S, Singh YP, Mehta Y, Yang K-Y, Kuo S-W, et al. A Prospective Observational Study of Rational Fluid Therapy in Asian Intensive Care Units: Another Puzzle Piece in Fluid Therapy. Indian J Crit Care Med 2020;24(11):1028–1036.

Novel use of epidural catheter: Air injection for neuroprotection during radiofrequency ablation of spinal osteoid osteoma

Osteoid osteoma (OO) is a benign bone tumor, with a male-female ratio of approximately 2:1 and mainly affecting long bones. Ten percent of the lesions occur in the spine, mostly within the posterior elements. Treatment options for OO include surgical excision and percutaneous imaging-guided radiofrequency ablation (RFA). Lesions within the spine have an inherent risk of thermal damage to the vital structure because of proximity to the neural elements. We report a novel use of the epidural catheter for air injection for the neuroprotection of nerves close to the OO of the spine. A 12-year-old and 30 kg male child with an OO of the L3 vertebra was taken up for RFA. His preoperative examinations were within normal limits. The OO was very close to the L3 nerve root. Under general anesthesia, lumbar epidural catheter was placed in the L3-L4 space under imaging guidance. Ten ml of aliquots of air was injected under imaging guidance to avoid injury to the neural structures due to RFA. The air created a gap between neural elements and the tumor and served as an insulating material thereby protecting the neural elements from damage due to the RFA. Postoperatively, the patient did not develop any neurological deficit.

The Intensive care unit specialist: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine

The role of the critical care specialist has been unequivocally established in the management of severely ill patients throughout the world. Data show that the presence of a critical care specialist in the intensive care unit (ICU) environment has reduced morbidity and mortality, improved patient safety, and reduced length of stay and costs. However, many ICUs across the world function as "open ICUs," in which patients may be admitted under a primary physician who has not been trained in critical care medicine. Although the concept of the ICU has gained widespread acceptance amongst medical professionals, hospital administrators and the general public; recognition and the need for doctors specializing in intensive care medicine has lagged behind. The curriculum to ensure appropriate training around the world is diverse but should ideally meet some minimum standards. The World Federation of Societies of Intensive and Critical Care Medicine has set up a task force to address issues concerning the training, functions, roles, and responsibilities of an ICU specialist.

Central neuraxial blockade for splenectomy in myeloproliferative disease: A word of caution

We describe management of portal vein thrombosis (PVT) in a patient with myeloproliferative disease after splenectomy. This case posed a unique therapeutic challenge in maintaining a fine balance between life-saving thrombolysis and the risk of neuraxial complications due to bleeding. The incidence of PVT after splenectomy in patients with myeloproliferative disorders is high (40%). Anaesthesiologists should be aware of this and avoid central neuraxial blockade in such cases. If post-operative emergency thrombolysis is required in a patient having an epidural catheter in situ, it should be done under close monitoring, weighing the risks and benefits. Fibrinogen levels should be monitored to evaluate the presence of residual thrombolytic effects and to time the catheter removal.

Utilization of operating room time in a cancer hospital

BACKGROUND

Appropriate usage of operating room (OR) time can improve efficiency of utilization of resources and help to decrease surgical waiting lists.

AIMS

This study was conducted to evaluate the pattern of usage of OR time in a tertiary referral cancer hospital.

SETTING AND DESIGN

This was a prospective audit carried out over 2 months in 11 major ORs in a cancer hospital.

MATERIALS AND METHODS

OR anesthesiologists filled a standard form for all patients undergoing elective surgery and documented the following times: entry into OR, start of anesthesia, handover to surgeon, incision, start of reversal, end of anesthesia, and shifting out of patient.

STATISTICAL ANALYSIS

Median time utilized for various OR processes was calculated.

RESULTS

An average of two surgeries were performed per OR session (828 surgeries in 407 OR sessions). Anesthesia and surgery-related processes contributed to 17% and 79%, respectively, of total OR time, with turnover time between cases accounting for the remaining 4%. Fifteen percent (60 out of 407) OR sessions started more than 10 min later than the planned start time, and 17% (70 of 407) of OR sessions ended more than 2 h after the scheduled finish time. An anesthesia procedure room was utilized in only 15% of cases where it could potentially have been used.

CONCLUSION

This audit identified patterns of OR usage in a cancer hospital and helped to detect areas of inefficient utilization. Anesthesia-related processes contributed to 17% of the total OR time.

Severe sepsis bundles

Sepsis is a complex syndrome with its wide spectrum of severity, and is one of the most common causes of death in Critical Care Units. The Surviving Sepsis campaign launched in 2004, is aimed at improving diagnosis, management and survival of patients with sepsis. Care bundles are a group of best evidence based interventions which when instituted together, gives maximum outcome benefit. Care Bundles are simple, uniform and have universal practical applicability. Surviving Sepsis campaign guidelines in 2008 incorporated two sepsis care bundles. The Resuscitation bundle includes seven key interventions to be achieved in 6-h while four interventions have to be completed within 24-h in the Management bundle. Compliance with a bundle implies achieving all the specified goals in that bundle. Limitations to care bundles include the quality of the evidence on which they are based, and that the relative contributions of each element of the bundle are not known. Several observational studies support the hypothesis that sepsis care bundles have an important role in improving outcomes from sepsis. Critical Care Units should develop management strategies to ensure compliance with the sepsis bundles in order to decrease hospital mortality due to severe sepsis.

Efficacy of intravenous ketoprofen for pre-emptive analgesia

AIM

To determine whether intravenous ketoprofen is effective as pre-emptive analgesia for breast surgery.

DESIGN

Randomised, controlled, double blind study.

PATIENTS AND METHODS

50 patients undergoing breast surgery under general anaesthesia randomised to receive either 100 mg intravenous ketoprofen 30 minutes before (Group I), or immediately after surgical incision (Group II). Postoperatively, pain scores (Visual Analogue Scale, VAS) and time to rescue analgesic were recorded by an independent, blinded observer. The study was terminated when rescue analgesic was required (VAS > or =4 or demand for analgesic).

STATISTICAL ANALYSIS

Continuous variables were analysed by the unpaired 't' test, discrete variables with the chi square test, and survival curves by the log-rank test.

RESULTS

Pain scores were significantly lower in Group I till 10 hours after surgery. The number of patients requiring analgesia at 4, 6, 8 and 10 hours was significantly lower in group I (0% vs. 47% [P <0.0001], 0% vs. 44% [P <0.003], 0% vs. 80% [P <0.0001], 0% vs. 100% [P <0.0001] respectively). The mean time for rescue analgesic was 15.47 -/+ 2.87 hours in group I versus 4.22 -/+ 2.55 hours in group II (P <0.0001).

CONCLUSION

Pre-emptive analgesia with Intravenous ketoprofen (100mg) produces better postoperative pain-relief in patients undergoing breast surgery.

Awareness of post-exposure prophylaxis guidelines against occupational exposure to HIV in a Mumbai hospital

BACKGROUND

Exposure to the human immunodeficiency virus (HIV) is a matter of concern for healthcare workers. We conducted a survey to determine the level of awareness amongst operating room personnel regarding post-exposure prophylaxis in case of needlestick injuries from confirmed or suspected cases of HIV.

METHODS

A structured questionnaire was presented to 39 anaesthetists and 31 surgical residents. Questions were related to identification of high risk fluids, risk of transmission, drugs, costs and procedure to be adopted for post-exposure prophylaxis.

RESULTS

Fourteen respondents (20%) were aware of the true risk of transmission. About one-third identified all high risk fluids correctly. Fifty-five respondents (78%) correctly stated that washing the site with soap and water was the initial measure, but less than a third knew whom to contact immediately after a needlestick injury. Though 45 respondents (64%) correctly stated that prophylaxis should be initiated within 1 hour of injury, none knew exactly which drugs were to be used. Thirty respondents (42%) were aware of the use of zidovudine but none were aware of the second or third drugs used for post-exposure prophylaxis. Only 4 respondents (6%) knew the correct duration of post-exposure prophylaxis. Five respondents (7%) knew that the drugs were available in medical stores and 7 knew the approximate cost of therapy.

CONCLUSION

There is surprisingly poor knowledge of post-exposure prophylaxis against HIV. Ongoing awareness and training programmes are necessary to improve the same.

Cardiomediastinal tamponade and shock following three-stage transthoracic oesophagectomy

Massive gastric tube dilatation causing cardiomediastinal tamponade is an unusual cause of obstructive shock after transthoracic oesophagectomy. A 55-year-old female was operated for total transthoracic oesophagectomy. Twelve hours after the surgery, she developed hypotension and raised central venous pressure unresponsive to fluid infusion and ionotropes. X-ray chest showed a massively dilated stomach, which was causing intrathoracic tamponade. Suction applied to the nasogastric tube led to aspiration of 150-200 ml of fluid and a large volume of air, which led to resolution of the haemodynamic instability. A simple manoeuvre like nasogastric suction in postoperative case of oesophagectomy can serve as a diagnostic as well as therapeutic tool. It must be performed before resorting to invasive and expensive examination or intervention.

Failed intubation in the intensive care unit managed with laryngeal mask airway and percutaneous tracheostomy

We report the management of failed intubation in a critically ill, hypoxic and catabolic patient with sepsis and acute lung injury. Insertion of a laryngeal mask airway restored ventilation and corrected hypoxia. As the laryngeal mask provides only a temporary airway, it was essential to secure the airway by percutaneous tracheostomy to initiate mechanical ventilation.

Evaluation of a lactate sensor for rapid repeated measurements of blood lactate concentration

In critically ill patients, serial measurements of blood lactate may indicate adequacy of therapy and predict development of multi-organ failure. We studied the accuracy, precision, and repeatability of the newly developed 800 Series Lactate Sensor (Ciba Corning Diagnostic Corp., Medfield, U.S.A.). Lactate levels determined with the sensor were compared with the standard laboratory method (Abbott TDX) in 75 paired arterial blood samples from 20 patients. Agreement between methods was determined and the mean coefficient of variation calculated for repeated measurements. The bias of the sensor was -0.38 mmol/l (CI -0.23 to -0.53), and the precision +/- 0.67. The coefficient of variation for repeated measurements was 1.95% with the sensor, and 11.5% with the TDX (P = 0.007). The new sensor offers a more reproducible, rapid method of measuring lactate, vital for serial measurements. The relatively wide limits of agreement between the methods reflect the greater variability of the TDX assay.

Omission of nitrous oxide during anesthesia reduces the incidence of postoperative nausea and vomiting. A meta-analysis

BACKGROUND

Postoperative nausea and vomiting are important causes of morbidity after general anesthesia. Nitrous oxide has been implicated as an emetogenic agent in many studies. However, several other trials have failed to sustain this claim. The authors tried to resolve this issue through a meta-analysis of randomized controlled trials comparing the incidence of postoperative nausea and vomiting after anesthesia with or without nitrous oxide.

METHODS

Of 37 published studies retrieved by a search of articles indexed on the MEDLINE database from 1966 to 1994, 24 studies (26 trials) with distinct nitrous-oxide and non-nitrous oxide groups were eligible for the meta-analysis. The pooled odds ratio and relative risk were calculated. Post boc subgroup analysis was also performed to qualify the result.

RESULTS

The pooled odds ratio was 0.63 (0.53 to 0.75). Omission of nitrous oxide reduced the risk for postoperative nausea and vomiting by 28% (18% to 37%). In the subgroup analysis, the maximal effect of omission of nitrous oxide was seen in female patients. In patients undergoing abdominal surgery and general surgical procedures, the effect of omission of nitrous oxide, although in the same direction, was not significant.

CONCLUSION

Omission of nitrous oxide reduced the odds of postoperative nausea and vomiting by 37%, a reduction in risk of 28%.

Tracheal tear during laryngopharyngectomy with gastric transposition

Tracheal rupture occurred in 7 of 174 (4%) patients undergoing laryngopharyngectomy with gastric transposition. Tracheal tears were classified as proximal if they involved the upper two-thirds of the trachea (five patients), or distal if they extended into the lower one-third of the trachea (two patients) and their clinical features and management analyzed. Predisposing factors, including prior radiotherapy (three patients) and preoperative tracheostomy (1 patient) did not influence the site or severity of tracheal injury. Proximal tears were detected incidentally in four patients, but in one patient, manifested postoperatively with subcutaneous emphysema and pneumothorax. Distal tears manifested dramatically with a ventilatory leak. Adequate access for repair of distal tears may necessitate a right thoracotomy while proximal tears may be sutured through the cervical incision. Gastric transposition alone did not prevent air leak in two patients. Postoperative complications included prolapse of the stomach and bilateral pneumothoraces in one patient. Close interaction between the surgeon and the anesthesiologist ensured a successful outcome in six patients. There was one mortality.

Fibreoptic intubation in cicatricial membranes of the pharynx

Two patients presented with almost total obliteration of the pharynx. In one, a membrane developed after corrosive poisoning; in the other, the oropharynx was filled with a dense cicatrix in the sclerosing phase of rhinoscleroma. In both patients, a single opening in the membrane provided access to both the larynx and oesophagus. Fibreoptic intubation allowed both a thorough assessment of the pathology and subsequently the passage of a cuffed tracheal tube to secure the airway. To overcome the problem of respiratory obstruction while the fibrescope passed through the opening in the membrane, either rapid intubation, or a technique using pre-oxygenation and voluntary hyperventilation followed by breath-holding during bronchoscopy, was used. The thin calibre and manoeuvrability of the flexible fibreoptic bronchoscope makes fibreoptic intubation an excellent technique of airway management in cicatricial membranes of the pharynx.