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1. Acute Kidney Injury and Hemofiltration being 51.97 ± 10.52. Nephrotic level proteinuria (4+) is significantly high (22.2%) in Group1 patients as compared to the rest. Group 3 predominantly (34.3%) shows insignificant proteinuria which is less 1. Acute Kidney Injury in Severely Preeclamptic Patients Admitted than 250 mg/day. 3+ proteinuria is most common. Discussions: to ICU: Epidemiology and Role of Serum Neutrophil Gelatinase- NDKD amounted to 52.87% [out of which NDKD superimposed on Associated Lipocalcin. (Conference Abstract ID: 176) diabetic kidney disease (DKD) was 30%, isolated NDKD was 22.87%]. Pooja Yadav, Asha Tyagi, Asha Tyagi, Rashmi Salhotra, Shukla The pro-portion of NDKDs ranged from 21 to 52% in other studies. Das, Praveen Singh Conclusion: NDKDs do occupy a considerable fraction of kidney UCMS and GTB Hospital, Delhi, India diseases of type 2 diabetes patients. Their presentation is however DOI: 10.5005/jp-journals-10071-23711.1 different (low degrees of proteinuria, younger patient age). Introduction: Critically ill preeclamptic patients may have risk factors for acute kidney injury (AKI). Neutrophil gelatinase- 3. Failing Kidney and a Preserved Heart. (Conference Abstract associated lipocalcin (NGAL) is a validated biomarker to predict ID: 92) AKI. We could locate scanty data regarding the epidemiology of C Jayadevi AKI and the role of NGAL in preeclamptic patients admitted to Govt Villupuram Medical College Hospital, Villupuram, Tamil Nadu, ICU. Materials and methods: Preeclamptic patients admitted to India multidisciplinary ICU were included. The occurrence of AKI and its DOI: 10.5005/jp-journals-10071-23711.3 severity for the entire ICU stay using KDIGO criteria, risk factors, and serum NGAL were assessed. Results: From 52 preeclamptic patients Introduction: About a half of patients with heart failure have heart admitted to ICU, majority had eclampsia (75%). The ICU mortality failure with preserved ejection fraction (HFpEF), nevertheless HFpEF was 15.4%. AKI developed in 25 (48.1%) patients; with stage 1, 2 could be overlooked in the intensive care unit (ICU). The symptoms and 3 in 56%, 36% and 8% respectively. Incidence of sepsis (16% of HFpEF are similar to those of heart failure with reduced ejection versus 0%), shock (40% versus 7.4%), and anaemia (84% versus fraction (HFrEF). Acute decompensated HFrEF is a well-known cause 59.3%) was significantly greater in patients with AKI (P < 0.05). ICU of oliguric acute kidney injury (AKI) and it may present as severe AKI mortality (28% versus 3.7%), duration of ICU and hospital stay were requiring extracorporeal ultrafiltration therapy. AKI resulting from significantly higher in preeclamptics with AKI (P < 0.05). Serum acute decompensated heart failure constitutes acute cardiorenal NGAL (274 [240-335] ng/ml) showed no association with AKI or syndrome (CRS) also referred to as type 1 CRS. HFpEF could also mortality (P = 0.725, 0.861); but significant prediction for eclampsia lead to AKI but the diagnosis of HFpEF may be overlooked in the [P = 0.019; AUC = 0.736 (95% CI: 0.569 – 0.904)]. Discussions: The setting of AKI since the congestive manifestations of HFpEF are present prospective cohort study aimed to evaluate AKI in a specific akin to volume overload symptoms resulting from AKI. In such a subset of critically ill obstetric patients viz., those with preeclampsia. setting unless thoughtfully considered, the diagnosis of HFpEF While there is little previous data on AKI in critically ill preeclamptic might be overlooked and the etiology of AKI may remain elusive. patients, it has been evaluated among those with the disease but It is crucial to make a prompt diagnosis of HFpEF in the ICU to fix not admitted to ICU.11–13 The incidences herein were reported in a the etiology of AKI in the ICU. We report the case of a 70-year-old lower percentage than our results viz., 15.3 and 17%.11,12 The much woman who presented with oliguric AKI, marked edema, NYHA greater incidence noted by us can be attributed to an increased class IV heart failure, and summarize the diagnostic workup that presence of risk factors for AKI encountered in those admitted to the led to a final diagnosis of HFpEF. Materials and methods: A 70-year- ICU, such as, sepsis and shock. Conclusion: AKI is common among old woman presented to the emergency room with dyspnea at preeclamptic patients admitted to ICU, but serum NGAL does not rest, orthopnea, ankle edema of 1-week duration, and oliguria of predict AKI in these patients. 1-day duration. Her urine output was 300 mL in 24 hours. She was a known diabetic and hypertensive. During a routine evaluation 3 months before the current illness, her urine dipstick revealed no 2. Clinicopathological Spectrum of Kidney Diseases in Patients overt proteinuria and her serum creatinine was 0.7 mg/dL with an with Type 2 Diabetes Mellitus: A Record-based Retrospective eGFR of 88 mL/min/1.73 m2 by CKD-EPI equation. On admission, she Study. (Conference Abstract ID: 128) was dyspneic, tachypneic, extremities were warm, she had bilateral Vijay Patidar, RK Jha, Sonam Verma pitting ankle edema, jugular venous pressure (JVP) was raised, Sri Aurobindo Medical College and Postgraduate Institute, Indore, pulse was 102/minute, regular, BP was 160/90 mm Hg, oxygen Madhya Pradesh, India saturation while breathing ambient air was 82%, auscultation DOI: 10.5005/jp-journals-10071-23711.2 revealed normal heart sounds and bilateral basal rhales. She had Introduction: Non-diabetic kidney diseases (NDKD) have been a body mass index (BMI) of 26 kg/m2. Electrocardiogram revealed observed to contribute to a considerably large fraction (one- sinus tachycardia, left ventricular hypertrophy. Chest X-ray revealed third)1–4 of kidney diseases among patients with type 2 diabetes cardiomegaly, bilateral pleural effusion, and pulmonary venous mellitus. Through this study, an estimate of the general pattern of congestion. Echocardiogram revealed concentric left ventricular diabetic, non-diabetic, and mixed kidney disease will be obtained. hypertrophy, left ventricular ejection fraction (LVEF) of 52%, the Materials and methods: Study design: Record-based retrospective systolic pressure in the pulmonary artery by Doppler was 37 mm study. Study place: SAIMS Medical College Indore. Inclusion: All Hg indicating pulmonary hypertension, E/e’ by tissue Doppler type 2 diabetic patients with kidney disease who have undergone imaging was 19.1 indicating increased filling pressure, there biopsy. Results: A total of 153 patients underwent biopsy. Out of was no regional wall motion abnormality. The inferior vena cava which 110 were men and 43 were women, and the average age measured 22 mm. Her central venous pressure was 19 mm Hg.

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Urine analysis revealed trace protein, spot urine sodium was 4 Academy of Higher Education (MAHE), Manipal, Karnataka, India mol/L. Ultrasonogram revealed normal-sized kidneys with normal DOI: 10.5005/jp-journals-10071-23711.4 cortical echoes. Her serum creatinine was 1.2 mg/dL (eGFR 48 mL/ 2 Introduction: Acute kidney injury and sepsis are highly prevalent min/1.73 m ) NT-Pro BNP was 17,100 pg/mL (reference < 300 pg/ in intensive care patients (20–50%) and have a direct effect on mL) and BNP was 241 pg/mL (reference < 100 pg/mL). Results: This mortality and morbidity. Our objective was to evaluate if acute patient presented with stage 3 AKI (1) with oliguria lasting for 24 kidney injury (AKI) is going to be persistent or transient in patients hours. Her serum creatinine had increased from 0.7 to 1.2 mg/dL. admitted with sepsis to intensive care unit (ICU), using variables A low spot urine sodium and a high blood urea/creatinine ratio are collected at the time of admission and to develop a formula— suggestive of a renal hypoperfusion state. She had manifestations persistent AKI scoring system (PASS) to predict recovery. Materials like resting dyspnea, edema, raised JVP, resting hypoxia and and methods: The study was conducted over a period of 8 months pleural effusion consistent with decompensated heart failure. with a total sample size of 63 participants who were critically ill ICU Given the presentation with marked peripheral and pulmonary patients diagnosed with sepsis and AKI. The study was conducted congestion that was disproportionate to the fall in GFR one would after approval from the ethics and scientific committee and be inclined to consider differentials like acute glomerulonephritis informed consent forms were obtained from the patients/relatives and acute or type 1 cardiorenal syndrome (CRS). Discussions: before inclusion. Parameters like serum creatinine (SCr), base excess Type 1 CRS becomes the prime diagnostic consideration in this 3 (BE), plethysmographic variability index (PVI), caval index, R wave patient. The LVEF by definition is <40% in HFrEF. This patient variability, mean arterial pressure (MAP), and renal resistivity index had an ejection fraction of 52% and her clinical presentation with (RI) using renal Doppler and need for vasopressors were assessed heart failure should arouse suspicion of HFpEF. Although HFpEF on admission. Patients were managed with standard protocols with accounts for about a half of the patients with heart failure,4 it is 4,5 fluid resuscitation and other specific treatments. After 6 hours of often overlooked in clinical practice. Diagnosis of HFpEF relies fluid resuscitation, the hemodynamic status and volume status on excluding other cardiac and non-cardiac causes of dyspnea in a of the patient was assessed. Patients were classified as volume patient presenting with symptoms and signs consistent with heart responders or non-responders depending on hemodynamic failure and preserved left ventricular ejection fraction > 50%. The 6 stabilization using parameters like systolic blood pressure and H2FPEF scoring system is a clinical tool that utilizes clinical and MAP. Reassessment of all the variables was done at 24 and 72 hours echocardiographic parameters to estimate the probability of HFpEF after admission including estimation of caval index, amplitude as the cause of dyspnea. This patient had an H2FPEF score of 4 out change in R wave, MAP, renal RI, and need for vasopressors. The 2 of 9 (0/2 points for BMI > 30 kg/m ; 1/1 point for hypertension, 0/3 primary outcome was persistent AKI after 72 hours. The secondary points for atrial fibrillation; 1/1 point for pulmonary artery systolic outcome was an initiation of dialysis and death within 15 days of hypertension; 1/1 point for age > 60; 1/1 point for elevated filling admission. Results: Thirty-four Thirty-four subjects in this study pressure E/e’ > 9). An H2FPEF score of 6 or more is associated with recovered from AKI. Thirty-two patients showed volume response a high probability (>90%) of HFpEF while a score between 2 and 5 with respect to hemodynamic parameters and 31 patients were is associated with intermediate (40–80%) probability of HFpEF. Our non-responders to fluid resuscitations. Response to fluid, MAP at patient had a score of 4. If the H2FPEF score is intermediate then a admission, change in MAP after 6 hours, base excess at admission, diagnosis of HFpEF could be established by a raised brain natriuretic requirement of vassopressers (noradrenaline) and PVI at admission peptide (BNP) > 100 pg/mL or N-terminal pro-brain natriuretic did not correlate with recovery of AKI. Renal resistive Index at 7 peptide (NT-Pro BNP) > 300 pg/mL after exclusion of other causes admission (RI), R wave variability at admission (RVI) and Serum of dyspnea. No other pulmonary or cardiac cause of dyspnea was apparent in this patient. BNP might be elevated in patients with renal failure whether or not they have heart failure.8,9 Elevation of BNP in renal failure might result from volume expansion and left ventricular hypertrophy.9 NT-Pro BNP is cleared by glomerular filtration and hence its plasma level may increase in patients with renal failure. Hence, the diagnostic specificity of NT-Pro BNP for HFpEF is questionable in the presence of renal failure. A study used an NT-Pro BNP cut-off point of 1,200 pg/mL for patients with GFR < 60 mL/min/1.73 m2 and found the sensitivity and specificity to be 89 and 72%.10 The NT-Pro BNP in our patient was 17,100 pg/mL. Old age, hypertension, and diabetes mellitus could have predisposed to HFpEF in our patient. Conclusion: The congestive clinical manifestations resulting from HFpEF are similar to volume overload resulting from renal failure and hence the diagnosis of HFpEF could be overlooked in the setting of AKI.

4. Pass—A Novel Study to Predict Recovery from AKI in Critically Ill Adult ICU Patients. (Conference Abstract ID: 55) Dattatray Prabhu, Sonali Dattatray Prabhu, M Chakrapani, Mayoor Vasant Prabhu Kasturba Medical College Mangalore, Affiliated to Manipal Fig. 1: Flowchart to guide management

S2 Indian Journal of Critical Care Medicine: ABSTRACTS CRITICARE – IJCCM2021 ABSTRACTS CRITICARE – IJCCM2021 creatinine (S Cr.) at admission correlated well with recovery from 2. Acute Respiratory Failure and Ventilation AKI which was statistically significant (p value < 0.005). Cut offs for these parameters were derived from the ROC curve analysis. Hence, 1. A Randomized Controlled Trial of Non-Invasive Ventilation with these 3 parameters were evaluated further to develop the model for Adaptive Support Ventilation vs Neurally Adjusted Ventilator predicting recovery from AKI. Multiple logistic regression showed Assist in Patients with Acute Exacerbation of Chronic Obstructive that Creatinine < 2.36 mg%, R wave > 14.45 and Resistive Index < 0.8 Pulmonary Disease. (Conference Abstract ID: 189) at the time of admission were correlated with recovery from AKI with Inderpaul Singh Sehgal, Bharath Chabbria, Ritesh Agarwal, Adjusted Odds ratios of 5.447, 4.032 and 6.208 respectively (Table 1). Kuruswamy Thrai Prasad Based on this, following formula was constructed in which Serum Postgraduate Institute of Medical Education and Research, creatinine, R wave variability and renal RI were allotted points: Chandigarh, India • SCr <2.36 is allotted 1 point and values >2.36 is allotted 0 points; DOI: 10.5005/jp-journals-10071-23711.5 • R wave variability > 14.45 is alloted 1 point and values <14.45 Introduction: Background: We have previously demonstrated a are allotted 0 points and reduction in noninvasive ventilation (NIV) failure rates with the • RI <0.8 is allotted 1 point and RI > 0.8 is allotted 0 points. use of neurally adjusted ventilator assist (NAVA) during NIV in FORMULA (Table 2): [SCr points × 5.4] + [R wave variability points acute exacerbation of chronic obstructive pulmonary disease × 4.0] + [RI points × 6.2] = Total score. Total score more than 7.8 (AECOPD). Adaptive support ventilation (ASV) is a closed-loop predicted recovery from AKI. mode of ventilation, designed to minimize the work of breathing. Sensitivity, specificity, predictive value, diagnostic accuracy and No previous study has compared NIV-NAVA with NIV-ASV in the Kappa value for S. Creatinine, resistive index at admission and R management of respiratory failure due to AECOPD. Hypothesis: wave at admission are shown in Table 3. Score >7.8 has sensitivity We hypothesize that NIV-NAVA will have lower NIV failure rates of 79.4% sensitivity and 72.4% specificity for recovery from AKI. The than ASV in subjects with AECOPD due to better patient-ventilator test has a positive predictive value of 81.8% and negative predictive synchrony. Objectives: To compare the outcomes between NIV-ASV value of 76.7%. The test and the gold standard agree on 50 out of and NIV-NAVA in patients with AECOPD. Materials and methods: 63 having a diagnostic accuracy of 79.34%. The Kappa value of We included all consecutive subjects with AECOPD who met all 0.586 indicates good agreement with a p value of <0.001. ROC the following: (a) an acute (<7 days) sustained worsening of any of curve analysis showed that PASS Score>7.8 had area under ROC the respiratory symptoms (cough, sputum quantity or character, curve of 0.85 (95% confidence interval 0.755 to 0.943; p < 0.001). dyspnea) beyond the normal day-to-day variation; (b) arterial Table 1: P Adjusted Odds ratio 95% C.I. for Odds Ratio Lower Upper blood gas analysis showing a PaCO2 >45 mm Hg with either Creatinine > 2.36 0.010 5.447 1.494 19.859 R wave >14.45 0.038 pH between 7.10 and 7.35 or respiratory rate (RR) >30 breaths/ 4.032 1.083 15.011 Resistive Index <0.8 0.005 6.208 1.750 22.021. minute; and, (c) exclusion of other causes of acute breathlessness, Table 2: Parameter Cutoff Points Creatinine <2.36 5.4 >2.36 0 R wave such as, acute heart failure, pulmonary embolism, pneumonia, at admission >14.45 4.0 <14.45 0 Resistive index on admission <0.8 and pneumothorax. The primary outcomes were NIV failure 6.2 >0.8 0 .Table 3: parameter RI at Admission <0.8 SCr at Admission rates (intubation). The secondary outcomes were 28- and 90-day <2.36 R Wave V @Admission > 14.45 PASS > 7.8 SENSITIVITY 79.30% mortality, asynchrony index (AI), NIV-related complications, and 72.40% 73.50% 79.40% specificity 58.80% 70.60% 58.60% 79.30% others. Results: We enrolled 76 subjects (NIV-NAVA = 36, NIV-ASV = positive predictive value 62.20% 67.70% 67.60% 81.80% negative 40; 74% males) with a mean ± SD age of 61.4 ± 8.2 years. Most (49%) predictive value 76.90% 75.00% 65.40% 76.70% diagnostic accuracy subjects were GOLD stage B with a mean Charlson’s comorbidity 68.25% 71.43% 66.67% 79.37% kappa statistics 0.374 0.428 0.324 index of 3.5. 49% of the study subjects had at least one moderate 0.586 p value 0.004 0.001 0.012 <0.001 or severe exacerbation in the previous year. There was no difference Discussions: Persistent AKI is the commonest cause of morbidity in the baseline pH or PaCO2 between the two groups. There was no and mortality in sepsis patients. This study helps to predict recovery difference in NIV failure rates (NIV-NAVA vs NIV-ASV, 22% (8/36) vs of AKI in critically ill ICU patients admitted with AKI and sepsis by 20% (8/40); p = 0.81). We found no difference in the 28-day (NIV- using noninvasive easily available bedside parameters at the time of NAVA vs NIV-ASV, 22% vs 18%) and 90-day (NIV-NAVA vs NIV-ASV, admission. We have developed a simple formula “PASS” which helps 22% vs 18%) mortality between the NAVA and ASV arms. Notably, in predicting recovery from renal angina where we have allotted we found no difference in the mean asynchrony index between points for Se creatinine, R wave variability, and renal resistive index. the NIV-NAVA (17) and the NIV-ASV (16%) arm. The proportion of PASS formula stands for persistent AKI scoring system. Formula: [SCr subjects with severe asynchrony was also similar in the two study points × 5.4] + [R wave variability points × 4.0] + [RI points × 6.2] = arms. The use of NIV-ASV (0.6) required significantly (p = 0.03) fewer Total score. A total score of more than 7.8 predicted recovery from ventilator manipulations by a physician than NIV-NAVA (1.03) in the AKI. We have also prepared a flow chart (Fig. 1) which can help in initial 24-hours. We found both modes to be safe for delivery of NIV. guiding management and is used as a tool for prediction to identify Discussions: NIV in AECOPD is associated with improved outcomes. salvageable renal angina for aggressive patient management Use of NIV for patients with acute hypercapnic respiratory failure and fluid resuscitation. Conclusion: PASS study can be a simple due to AECOPD is associated with a reduction in mortality, bedside method to reliably identify potential patients at high intubation rates, length of stay, improvement in clinical parameters, risk of persistent AKI and those who can be salvaged by initiating and improvement in arterial blood gas parameters. In the present appropriate aggressive fluid resuscitation therapy. Moreover, PASS study, NIV was associated with improvement in respiratory rate, can be used in rural areas to assess and refer patients at the earliest arterial blood gas parameters (pH and PaCO2) with successful to higher centers without delay so that appropriate management hospital outcome in 60 (79%) of subjects irrespective of the mode of can be done. ventilation utilized. The intubation rate was 21% which was similar

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in both groups. A previous study that compared ASV and PSV in data were not distributed normally. Logistic regression test was patients with subjects with AECOPD at our institute demonstrated performed wherever applicable. A p value <0.05 was considered an overall NIV failure rate of 28.4% (PSV vs ASV: 34.2 vs 22.2%, p = as significant at a 95% confidence level whereas a p value <0.01 0.31) and intubation rate of 16.21% group (ASV vs PSV, 11.1 vs 21.1%; was considered highly significant. Results: A total of 100 patients’ p = 0.138) which was similar between the two groups. In another data including demographic, clinical and laboratory parameters at study, we have demonstrated that NIV-NAVA resulted from better the time of admission were studied. On comparing the variables clinical outcomes in those with AECOPD. This is the first trial to have between, low PF Ratio (<300) and high PF Ratio (≥300) groups, studied noninvasive NAVA and ASV in a randomized controlled demographically, mean age was significantly more in lower PF setting in patients with AECOPD. Both are closed-loop systems with Ratio group (58.01 ± 15.33 vs 50.97 ± 13.78, P = 0.023) whereas sex hypothetical advantages over conventional noninvasive modes. ratio was comparable among patients in two groups. As compared Safety of ASV as a mode of noninvasive ventilation was established to low PF Ratio group, in high PF Ratio group, higher APACHE in the previous study of AECOPD where complication rates were II score (P = <0.001) was found highly significant and presence similar between ASV and PSV and there was a trend toward a of hypertension was significant (43.54% vs 23.68%; P = 0.045) reduction in intubation rates with ASV. This trial reiterated the safety whereas presence of Asthma (1.47% vs 2.85%), coronary artery of ASV as a mode of noninvasive ventilation. Conclusion: We found disease (9.67% vs 10.52%), chronic kidney disease (8.06% vs 5.26%), no difference in the NIV failure rates between NIV-NAVA and NIV- diabetes mellitus (40.32% ys 23.68%), thyroid disease (3.22% vs ASV. We also did not find any difference in 28- or 90-day mortality 7.89%) and cancer (3.22% vs 0%) were found to be insignificant. and patient-ventilator asynchrony with either mode. However, C- reactive protein (171.78 ± 124.45 vs 101.52±88.70), IL-6(173.51 NIV-ASV required significantly fewer physician manipulations. More vs 53.18) and ferritin (1677.60±2271.13 vs 643.54 ± 718.68) levels studies are required to confirm our findings. were found to be significantly higher in patients with PF Ratio<300. All three of them were highly significant in mortality group as 2. Retrospective Observational Analysis of Inflammatory Markers well. Levels of procalcitonin, LDH and CPK were not significantly in COVID-19 Patients Admitted to Intensive Care Unit: As Early different among the comparison groups. In low PF Ratio subgroup Predictors of Disease Severity. (Conference Abstract ID: 184) analysis, ventilated patients had shown significantly higher Divya Gupta, Sandeep Dewan, Munish Chauhan, Apoorv Jain APACHE-II score (P = <0.001), ICU length of stay (P = <0.001); CRP Fortis Memorial Research Institute, Gurugram, Haryana, India (P = 0.002), Ferritin(P = 0.018) and IL-6(0.003). Overall, ventilator DOI: 10.5005/jp-journals-10071-23711.6 days were correlated highly significantly with longer ICU length of Introduction: In pandemic situations, like the one world is facing stay (Pearson correlation 0.828; P = <0.001) and higher mortality right now, due to SARS-CoV-2, it becomes absolutely necessary (Pearson correlation 0.875; P = <0.001). Discussions: It is imperative to wisely use the resources to maximize beneficial results. The to know its presence and effects on the Indian population due ability to predict the severity early in the disease course will help to the vividity of the present coronavirus strain. It affects various in early intervention in sicker patients, thus, positively affecting organ systems causing a blend of signs and symptoms, the prognosis as well as treatment cost. Objectives: To investigate respiratory system being the most common target. Involvement patient characteristics (age, sex, presenting complaints, presence of of lungs characterized by an intermingling of multiple complex comorbidities, APACHE-II score) and specific biomarkers [C-reactive mechanisms like cytokine and chemokine production, and hence, 1,2 protein (CRP), creatinine kinase (CK), procalcitonin, lactate the host immune system dysregulation. In this study, older age dehydrogenase (LDH), ferritin, interleukin-6 (IL-6)] as possible early was found to adversely affect the severity in contrast to studies predictors of severity of SARS-CoV-2 infection. They were further from China which suggested higher severity between 50 and 59 correlated with the need for mechanical ventilation, length of ICU years of age, whereas the Republic of Korea showed a bimodal 3 stay, and 28-day mortality. Materials and methods: After Ethical peak. Though our study was consistent with Wang et al. with no committee review, consecutive hundred RT-PCR confirmed adult gender disparity with respect to the severity of the disease, the 4 COVID-19 patients admitted to tertiary care ICU were analyzed results from other studies were inconclusive. Thus, larger studies retrospectively wherein demographics, Acute Physiological and with vivid ethnicity are required before any reasonable conclusion. Chronic Health Evaluation-II (APACHE-II score) and at admission, Furthermore, the presence of hypertensive disorder correlates inflammatory markers (CRP, procalcitonin, S. ferritin, LDH, ESR, with severity (27 vs 9%). Review by Yang et al. suggested that hypertension (17 ± 7%, CI 14–22%) and diabetes (8 ± 6%, CI 6–11%) IL-6) were compared with respect to oxygenation defect (PaO2/ FIO2 < or ≥300), need of mechanical ventilation, length of ICU stay, were the most common comorbid findings in COVID-19 patients and 28-day mortality. Data were collected retrospectively from though, in our study, diabetes was not a significant factor.5 Studies the patient’s electronic medical records and were limited largely have noticed the negative impact of comorbidities especially in the to demography, clinical and laboratory parameters at the time of third and the most serious phase of the disease due to systemic admission along with outcome measures at 28 days of admission. hyperinflammation syndrome.6 Though there is no study to date, Further, we compared these variables between ventilated and as per our data, the APACHE-II score holds good even in coronavirus non-ventilated patients. Interventions performed were based on inflicted patients in determining the severity or prognosis and an independent decision of the physician in charge. The statistical may be used as an important prognostication tool. Our study had software SPSS version 24.0 was used in the analysis. For comparison uniform results as depicted in meta-analysis with significantly of mean values between two groups, Student’s unpaired t-test was high CRP values in severely ill patients. Studies, including one used. Pearson chi-square test and Pearson correlation tests were meta-analysis, have postulated that serum ferritin, may be used used for categorical and scalar data, respectively. Non-parametric as a biomarker for COVID-19 patients due to its protective role tests (chi-square test and Mann–Whitney test) were used where against infection by causing hypoferremia.7,8 This study revealed

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significantly high admission levels of ferritin in a severe group which protocol and checklist. Mask intolerance was the most common was further elevated in ventilated patients and mortality group cause of NIV failure 4 out of 7 (57%). Previous studies have also signifying its role as an early predictor of severity and mortality. shown that mask intolerance generated by pain and discomfort Our study had consistent results with studies within ICU cohorts, may lead to refusal of NIV, prompting its discontinuation and where there were multiple reports of elevated IL-6 in severe cases leading to endotracheal intubation.11 Conversely, gas exchange as well as in mortality groups.9 Retrospective type study with data can improve under NIV when an adequate level of anxiolysis and attrition and lack of successive values of inflammatory markers analgesia is obtained, resulting in better synchronization and at fixed intervals to study the trend are some of its limitations. patient-ventilator interaction; patient-ventilator synchronization There is a lot of scope for further research in this direction for a further improves patient tolerance.12 In our study, we gave better understanding of the disease course and thus, the better sedation in 18 (72%) in phase 3 which lead to better tolerance to outcome. Conclusion: This study suggested that along with age NIV. Conclusion: The use of a quality improvement initiative in and APACHE-II score, the limited triad of CRP, ferritin, and IL-6 levels the form of a protocol, checklist, and training of the treating team may predict the disease severity, ventilator requirement, and 28-day resulted in improved tolerance to NIV and thereby its success. The mortality early in the course. This may help in early prognostication use of sedation may help improve tolerance to the interface and with better channelization of scarce resources. Larger studies are contribute to its success. required to further validate the results. 4. Correlation between Anxiety and Compliance to Non-Invasive 3. A Quality Improvement Initiative to Improve the Initiation and Ventilation in Patients Requiring Non-Invasive Ventilation Acceptability of Non-Invasive Ventilation. (Conference Abstract Admitted in COVID ICU. (Conference Abstract ID: 175) ID: 182) M Keerthivasan, B Gayathri, Arul Saravanan, G Mirunalini Amit Pathania, Jhuma Sankar, Rakesh Lodha, SK Kabra SRM Institute of Science and Technology, Chennai, Tamil Nadu, All India Institute of Medical Sciences, New Delhi, India India DOI: 10.5005/jp-journals-10071-23711.7 DOI: 10.5005/jp-journals-10071-23711.8 Introduction: There is increasing interest in the use of noninvasive Introduction: Patients with severe COVID-19 disease present ventilation (NIV) in critically ill infants and children, as NIV can with respiratory distress requiring ventilator support. Significant reduce the intubation rate, improve gas exchange, and decrease psychological concerns are emerging out of this pandemic seen in the work of breathing. Patient cooperation is crucial for NIV success patients admitted in COVID ICU. BiPAP a form of NIV has proved to at all ages. There are quality improvement guidelines in NIV use in be effective in maintaining oxygenation during the phase of distress. adults but there is a paucity of literature in the pediatric age group. We hypothesize that anxiety may reduce the compliance to NIV mask With this background, we decided to do this quality improvement acceptance and translate to higher dyspnea scores. Objectives: 1. study to systematically assess the factors responsible for the failure To find a correlation between anxiety contributing to the reduced of initiation and non-acceptance of NIV and to make process compliance to NIV mask acceptance and consequently leading changes to improve acceptance of NIV. Objectives: To evaluate to delayed recovery of patients treated in COVID ICU. Materials if the use of a quality improvement initiative improves initiation and methods: After ethical committee approval, a single-center and acceptability of noninvasive ventilation (NIV) in critically ill observational study was conducted from July 2020 to October 2020 children with respiratory distress. Materials and methods: The in a cohort of patients admitted to COVID ICU. Demographic data and study was carried out in three phases over a period of 6 months vital signs were recorded. The severity of anxiety was measured using in the pediatric intensive care unit (PICU) of a tertiary care unit in STAI anxiety score on day 0, day 4, day 7, and day 10 of admission. children aged 2 months to 17 years of age. In phase 1, data were The compliance of patients to NIV mask and the severity of dyspnea collected for 1 month and reasons for noninvasive ventilation was assessed by compliance score and by BORG score, respectively. failure and intolerance were identified. In phase 2, process changes Results: A total of 39 patients who needed non-invasive ventilatory like adherence to checklist, monitoring, and 1-day orientation support were assessed. Mean age of the patients were 42. 34/39 program was instituted. The duration of the program was 3 hours (87.19%) of the patients were Males and 5/39 (12.82%) patients with one session per batch of residents/staff posted in ICU. The were Females. Correlation between STAI scoring and compliance Plan, Do, Study, Act (PDSA) cycle was carried out in each phase. A to NIV mask acceptance analysed using Pearson correlation was washout period of 1 month was given after the training phase. In found to be 0.57(p < 0.001). Correlation between STAI anxiety score phase 3, which was for 2 months, the acceptance of noninvasive and dyspnoea severity score analysed using Pearson correlation and ventilation was measured again, and results were compared was found to be 0.51(P < 0.001). Percentage of patients with severe with phase 1. Results: A total of 37 patients were included,12 in dyspnoea were found to have low compliance to NIV. (p value<0.05) phase1 and 25 in phase 3 of the study respectively. NIV failure was Discussions: We found that anxiety scores were very severe in 92% recorded in 5 (42%) patients in phase one and 2 (8%) patients in of patients admitted to COVID ICU on day 0. Sharma et al. did a study phase 3 (p = 0.08). The cause of NIV failure was intolerance to the in the evaluation of patients in critical care and found elevated levels interface in 4 (57%) patients and inability to protect the airway in of depression, anxiety, and stress among patients admitted in ICU. Ji 3 (43 %) patients. The children in whom NIV was successful, there Yeon et al. concluded that anxiety score was higher in patients in ICU, was marked decrease in the respiratory rate. The median (IQR) so early screening and treatment of psychological symptoms may be respiratory rate was 47/min (40,54) vs. 35/min (30,46) before and an important means to promote rehabilitation and recovery. These after initiation of NIV, respectively in phase 3 (p = 0.0005). Sedation two studies correlated with ours. More the anxiety less the patient was used in 18 (72%) patients in phase 3 which helped in improved compliance to keep NIV. On days 4, 7, and 10, considerable reductions tolerance to the NIV. Discussions: We observed improvement in in anxiety were noted and patients were more comfortable in keeping NIV acceptance rates from 7/12 to 23/25 after strict adherence to NIV, which showed less dyspnea scores. Timothy et al. found delirium

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to be a significant contributor to morbidity and mortality in the was done when there was effort intolerance with PaO2/FiO2 ratio ICU and recommended that all ICU patients be monitored using a <150. Inflammatory parameters were sent: ferritin, LDH, D-dimer, validated delirium assessment instrument. To this date, we could not WBC count. Esophageal manometry was done, nutrient and end- find any publication comparing anxiety scores and its correlation to expiratory lung volume were calculated with GE carescape R860 NIV compliance translating to a better outcome. Conclusion: Higher ventilator using nitrogen washout technique. Results: Percentage the level of anxiety, higher the dyspnea. As days progressed patients of raised inflammatory markers were manageable with reassurance. Those who were agitated and • Ferritin—88% required restraint was found to be severely dyspneic ending up in • LDH—68% intubation. • D-dimer—76% • WBC—80% 5. A Cross-Sectional Study of Baricitinib Outcome in Severe Percentage of decreased lung compliance in mechanically COVID-19 Pneumonia. (Conference Abstract ID: 172) ventilated patients. Ravindra Kumar Patidar, Ravi A Dosi, Shobhit Gupta, RK Jha, PK • Compliance—84% Joshi, Ankur Agrawal, K Panwar, Piyu Jain 78% of the patients out of 25 patients had increased inflammatory SAIMS, Indore, Madhya Pradesh, India markers, 84% of the patients had a poor lung compliance of less DOI: 10.5005/jp-journals-10071-23711.9 40 mL/cmH2O and 74% of patients were proned. With which Introduction: An inflammatory response to SARS-CoV-2 infection, 52 % of the patient’s lung out of 25 patients were recruitable. due to cytokine release syndrome, has been implicated in the Discussions: There is significant use of esophageal manometry pathology of acute respiratory distress syndrome in patients with with measurement of transpulmonary pressure in the patient with COVID-19. Baricitinib is a reversible JAK-inhibitor that interrupts the poor lung compliance and decreased functional residual capacity multiple inflammatory cytokines in COVID-19 immunopathology. (FRC). It has been studied that lung-protective strategies along with Objectives: Our aim to study the overall outcome of baricitinib transpulmonary pressure measurement are more likely to have on critical patients with COVID-19. Materials and methods: A better recruitment of the lungs in COVID ARDS. Conclusion: There cross-sectional study of 10 cases, infected with COVID-19 severe is significant use of esophageal manometry with measurement of pneumonia and were critically ill. The patient’s average ICU stay, transpulmonary pressure in the patient with poor lung compliance CBC, changes in HRCT scans, clinical improvement, cytokine storm and decreased functional residual capacity (FRC). It has been markers before and after baricitinib doses were taken into account. studied that lung-protective strategies along with transpulmonary Due consent was taken from all patients. Results: Seventy percent pressure measurement are more likely to have better recruitment of patients showed a reduction in CRP values. In 70% of patients, of the lungs in COVID ARDS. D-dimer values either decreased or were kept within normal limits. 90% of patients were shifted from NIV support to NRBM within 7 7. A Retrospective Observational Study on the Use of Rescue days of baricitinib. 50% of patients showed a rising trend in platelet NIV in Severe COVID-19 Patients with HFNC Treatment Failure. counts. 70% patients were shifted to ward from ICU 30% patients (Conference Abstract ID: 167) were discharged within 7 days of Baricitinib. Discussions: Baricitinib Shiraz Assu, Deepak Bhasin, Harpal Singh is the Janus kinase (JAK) inhibitor, which may prevent cytokine Max Super-Speciality Hospital, Mohali, Punjab, India storm in patients with SARS-CoV-2 pneumonia. Conclusion: In our DOI: 10.5005/jp-journals-10071-23711.11 study, baricitinib has shown promising results. It is incumbent on Introduction: As the COVID-19 pandemic is progressing, there are researchers to develop and validate reliable tools to monitor the drastic efforts around the world for a magic bullet for its treatment, overall outcome of patients with baricitinib in COVID-19. but what we often forget is the supportive treatment that goes a long way in preventing the disease progression. Of these the 6. Lung Characteristics of COVID-19 Patient. (Conference Abstract most important are the respiratory supportive measures, which ID: 170) include a spectrum ranging from conventional oxygen therapy to Aakas Soni, Sanjith Saseedharan, Vaijayanti Kadam, Ashish invasive mechanical ventilation. As the mortality rates in patients Yadav put on mechanical ventilation are very high, it is the noninvasive SL Raheja Hospital, Mumbai, Maharashtra, India modes that are proving as the real lifesavers. HFNC and NIV are DOI: 10.5005/jp-journals-10071-23711.10 currently the most preferred modes. The present evidence shows Introduction: The high mortality in COVID-19 is related to severe some mortality benefit while using HFNC but not with NIV in acute ARDS and the theory is regarding bound one with low compliance hypoxic respiratory failure following any kind of pneumonia.1–3 and one with high compliance and treatment directed accordingly Objectives: The main objective of the study was to find the which included prone ventilation, lung-protective ventilation usefulness of giving rescue NIV trial in severe COVID-19 patients strategies, however, most of these were based on with western with HFNC failure. Materials and methods: We conducted a literature with static measurement. None of the literature talk retrospective observational study on severe COVID-19 patients about the actual measurement of recruitability by any method. admitted to our COVID ICU, who had received oxygen support via Our objective is to study lung characteristics to assess recruitability HFNC over a period of 9 months (from March 23 to December 23, with esophageal manometry, measurement of transpulmonary 2020). After getting institutional ethics committee clearance, from pressure, end-expiratory lung volume after transpulmonary the hospital’s electronic database details of all the severe COVID- pressure monitoring guided recruitment. Objectives: To study the 19 patients who were admitted to the COVID ICU during the study characteristics of COVID-19 lung with esophageal manometry and period were taken. Out of this, all those who were given HFNC function residual capacity (FRC). Materials and methods: Intubation support were observed for the primary and secondary outcome

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measures. We excluded all the patients <18 years, patients who and written informed consent, a prospective observational study had taken discharge against medical advice, and patients who was performed over a period of 3 months at the COVID intensive were still admitted with us and had not achieved the primary care unit of a government institute-hospital in east India. Adult outcome (intubation or mechanical ventilation). As a secondary patients (aged >18 years) with confirmed COVID-positive status outcome, we also measured the HFNC failure rate (defined as the (SARS-CoV-2 detected in nasopharyngeal swab by real-time reverse need for the application of rescue NIV trial) and mortality rate in transcription-polymerase chain reaction assay), having AHRF (PaO2/ the intubated patients. The routine hospital treatment protocol FiO2 ratio <300) who are not able to maintain saturation above 90% for treating COVID-19 was followed during the study duration, on standard oxygen therapy were included in this study. On the which includes the application of HFNC in all severe disease with HFNOT device, the initial flow rate and FiO2 were set at 60 L/minute type 1 respiratory failure who were not tolerating conventional and 100%, respectively. On case record form (CRF), demographic O2 therapy. Those who had the features of HFNC failure were then characteristics, vital signs, laboratory tests, and arterial blood gas given an NIV trial before proceeding with any invasive treatment. tests were recorded. ROX index (ratio of SpO2/FiO2 to respiratory If tolerating the same, this was followed by alternate HFNC and NIV rate) was calculated at 2 hours of HFNOT. Continuous variables application titrated to the patient’s respiratory distress. Results: Of were reported as mean or median values when appropriate. The the total 595 COVID hospital admissions, 265 of the severe COVID- intergroup differences were analyzed using Student’s t-test or 19 patients were admitted to the ICU during the study duration. Mann–Whitney U test. The intragroup differences between variables Out of them, 85 needed HFNC support. The average age of the at different time points were analyzed using paired Student’s patients was 56 years (32–80 years) and 80% of them were male. t-test. p ≤ 0.05 was considered statistically significant. Statistical The HFNC failure rate was observed to be 28/85(32.9%). Out of analysis will be performed using SPSS software. Results: A total of this 10 were successively managed with rescue NIV trial and the 265 patients were screened out of which 256 patients had AHRF. remaining 18 had to intubated. Out of the intubated patients 14 HFNOT was used as first line therapy in 122 patients in which only died at the hospital, 2 of them were discharged against medical 108 found to be eligible for study inclusion. Mean age of the patients advice and 2 of them were successfully extubated and discharged. was 59.7 ± 15.1 years; male patients accounted for majority (79.6%) Discussions: The intubation rate (21.2%) in our cohort of patients of HFNOT cohort. Key comorbidities were diabetes mellitus (48.1%) who were given HFNC support was significantly lower than those and hypertension (25.9%). Mean PaO2/FiO2 ratio at baseline was observed in other major studies like the FLORALI study (38%), 96.8 ± 30.2) which significantly increased at 1 hour (114.8 ± 32.1, where it was used for managing acute hypoxic respiratory failure p < 0.001) at 6-hours (130.1± 36.5; p < 0.001) and at 7 days (178.7 (in which 84% of them had one or other kind of pneumonia).3 Even ± 41.3; p < 0.001) Mean duration of HFNOT was 10.4 ± 4.9 days. though the HFNC failure rate was 32.9%, by using NIV as a rescue Median (with range) APACHE II and SOFA scores were 22 (12-35) device, intubation was prevented in 11.8% of the patients. The and 8 (4-12) respectively. HFNOT failure rate was 27.8%. NIV was implications of the above finding are vast since the mortality of the used as ceiling respiratory support in 22.2% of HFNOT cohort. intubated COVID-19 patients are very high across the world and a Mean ROX index was significantly higher for the patients who significant decrease in intubation rates means more life’s saved. successfully continued on HFNOT compared to those who failed In our study population also, 14 (77%) of the patients who were (3.4 ± 0.3 vs 2.8+0.3; p < 0.001). Mean admission glucose level, D intubated following HFNC failure died. Conclusion: On giving a dimer and IL-6 values were significantly higher in HFNOT failure rescue NIV trail followed by its intermittent application with HFNC, group compared to HFNOT success group. Overall, 28-day mortality the intubation rates in hypoxic respiratory failure following severe rate in this cohort was 25.9%. About 50% patients receiving HFNOT COVID-19 shows a decreasing trend. The above finding needs to developed complications in which epistaxis (18.5%) and air hunger be further explored with controlled trials. (16.7%) were the most common complications. Discussions: This study prospectively highlights the significant impact of HFNOT 8. Impact of High-flow Nasal Oxygen Therapy in COVID-19 on oxygenation status over time points studied (i.e., at 1 hour, 6 Critically Ill Patients with Acute Hypoxemic Respiratory Failure: hours, and 7 days). The baseline mean PaO2/FiO2 ratio was <100 A Prospective Observational Study. (Conference Abstract ID: 162) (severe ARDS) when HFNOT was initiated. With such a low P/F Raman Kumar, Mohd Saif Khan, Sudipto Banerjee, Jay Prakash, ratio, HFNOT remarkably outperformed with a success rate of Pradeep Kumar Bhattacharya 72.2%. Significant improvement in the P/F ratio may be explained Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India by adequate flow delivery and FiO2 meeting the patients’ demand. DOI: 10.5005/jp-journals-10071-23711.12 The main strengths of the study were its prospective nature and Introduction: About 20 to 30% of COVID-19 patients admitted large cohort. The main limitation is that being a single-center study, to ICU develop severe ARDS. Tracheal intubation in such patients the results from the study need to be cautiously interpreted before carries a high risk of complications and mortality.1,2 High-flow nasal extrapolating to patients in different geographical locations. About oxygen therapy (HFNOT) is an attractive option as it can reduce 50% of patients developed mild complications, such as, epistaxis, the requirement of intubation. Objectives: This study aimed to air hunger, and abdominal distension; however, one patient also determine the impact of HFNOT on the oxygenation level as well as developed spontaneous tension pneumothorax which required HFNOT failure. The primary objective was to determine the change immediate intercostal drain tube placement following which, the patient dramatically improved and survived hospital discharge. in PaO2/FiO2 ratio from baseline to at 1 hour, 6 hours, and 7 days of HFNOT initiation in COVID-19 critically ill patients presenting with We observed admission hyperglycemia, high D-dimer value, acute hypoxemic respiratory failure (AHRF). The secondary objective and IL-6 levels in patients who failed HFNOT. These findings are 3–5 was to determine the HFNOT failure rate [i.e., the requirement of consistent with other studies. Conclusion: HFNOT significantly tracheal intubation or noninvasive ventilation (NIV)]. Materials and improves oxygenation level in COVID-19 patients developing acute methods: After approval from the institutional ethics committee hypoxemic respiratory failure. The HFNOT failure rate was 27.8%.

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Admission glucose level, D-dimer, and IL-6 values were significantly PVAP rates were 2.07, 6.21 and 19.67 respectively. The In-hospital higher in patients who failed HFNOT. mortality was 55.55% (n = 15) in VAE (n = 27) group and 37.87% (n = 25) in Non-VAE (n = 66) group which was not statistically significant 9. Ventilator-Associated Events (VAE)—Do They Have Any Utility (p = 0.06). But the duration of mechanical ventilation was significantly Beyond Surveillance? (Conference Abstract ID: 160) longer in VAE group i.e., 16.78 ± 10.4 days than Non VAE group i.e., Shambhavi Chauhan, Jignesh Shah, Shivakumar Iyer 7.89 ± 3.8 days (p = 0.0001). Also, the duration of ICU and Hospital Bharati Vidyapeeth (DTB) University, Pune, Maharashtra, India stay in VAE group was 22.11 ± 13.79 days and 24.18 ± 14.3 days DOI: 10.5005/jp-journals-10071-23711.13 which was significantly more than the Non- VAE group 12.15 ± 8.08 Introduction: Ventilator-associated pneumonia (VAP) is the most days and 15.41 ± 10.4 days respectively (p = 0.003). Microbiological common nosocomial infection in people receiving mechanical evaluation displayed, PVAP (n = 19) cases had 53% Acinetobacter ventilation. VAP rate is widely accepted as an indicator of the quality baumanii, 21 % Klebsiella, 21% Pseudomonas aeruginosa and 5% of care and benchmarking. But due to the lack of any standardized Elizabethkingia meningoseptica. 68% of PVAP cases were treated definition and diagnostic criteria for VAP, the Center for Disease with IV Colistin and 32% were given IV Meropenem. Discussions: Control (CDC) introduced new definitions for ventilator-associated Although the in-hospital mortality was not found to be significantly events (VAE) in 2013 for surveillance. Objectives: This study was affected by the occurrence of ventilator-associated events (VAE), VAE done to describe the rates of VAE, characteristics of patients, are associated with increased morbidity of patients such as longer and risk factors with VAE, and examine the association of VAE on duration of mechanical ventilation, intensive care, and hospital ventilator days, length of stay, and in-hospital mortality. Materials stay. Conclusion: CDC definitions though meant for surveillance, and methods: This prospective observational study was carried may be used as a measure of outcome in critically ill patients with out in the Department of Critical Care Medicine, Bharati Hospital mechanical ventilation. (BVDU) Pune, Maharashtra from March 2019 to March 2020. All the patients on mechanical ventilation (MV) for >3 days were included 10. Clinico-Virological Profile, Intensive Care Needs, and and were followed till hospital discharge or death whichever was Outcome of Infants with Acute Viral Bronchiolitis: A Prospective earlier. Baseline demographic data, comorbidities, the severity on Observational Study. (Conference Abstract ID: 156) admission (APACHE-II and SOFA) was recorded. Daily minimum Lalit Takia, Suresh Kumar Anguranq, Suresh Kumar Angurana, PEEP and FiO2 (i.e., the minimum set value on the ventilator for that Subhabrata Sarkar, Ishani Bora, Radha Kant Ratho, Jayashree particular calendar day and maintained for >1 hour) were recorded Muralidharan on a standard chart by respiratory therapists. VAE was considered Post Graduate Institute of Medical Education and Research, if PEEP or FiO2 increased by 3 cm of water and 20%, respectively, Chandigarh, India after a period of stability for at least 2 days (The baseline period of DOI: 10.5005/jp-journals-10071-23711.14 stability was defined as the 2 calendar days immediately preceding Introduction: Acute viral bronchiolitis (AVB) is the leading cause of the first day of increased daily minimum PEEP or FiO , and must 2 hospitalization among infants in developed and developing countries be characterized by ≥ 2 calendar days of stable or decreasing daily and associated with significant morbidity. AVB is defined as the first minimum FiO or PEEP values). Further progression to ventilator- 2 episode of wheezing in a child younger than 12 to 24 months with associated condition (VAC), infection-related ventilator-associated physical findings of a viral respiratory infection and has no other complication (IVAC), and possible ventilator-associated pneumonia explanation for the wheezing (pneumonia or atopy). Respiratory (PVAP) were identified in accordance with CDC 2013 definitions. syncytial virus (RSV) is the main cause of AVB worldwide and accounts Results: Between March 2019 and March 2020, 377 patients required for 30 to 80% of cases. Other viruses implicated are influenza viruses, mechanical ventilation in the ICU at our tertiary care teaching parainfluenza viruses (PIV 1–3), human metapneumovirus (hMPV), hospital. All these patients were screened for eligibility for inclusion in the study. Of these 270 patients were excluded from the study. Of rhinovirus, enterovirus, adenovirus, and bocavirus. The severity of AVB these 270 patients 138 were excluded because of their duration of MV varies from asymptomatic illness or mild respiratory infection to severe was less than 48 hours,91 patients were admitted with community lower respiratory tract infection leading to emergency room (ER) acquired pneumonia (CAP), 28 patients were excluded because of visit, pediatric intensive care unit (PICU) admission, and sometimes death within 48 hours, 13 patients were intubated in other hospital mortality. Objectives: To describe clinico-virological profile, treatment and then referred to us. The remaining 107 patients with diagnoses details, intensive care needs, and outcome of infants with AVB. other than CAP, requiring mechanical ventilation for more than 3 days, Materials and methods: In this prospective observational study, 173 were included in the study. 14 patients had no period of stabilisation infants with AVB admitted to the pediatric emergency and pediatric for 2 calender days hence were exculded for VAE consideration. 27 intensive care unit (PICU) of a tertiary care teaching hospital in North patients had at least one VAE, 2 had only VAC, 6 had only IVAC and 19 India from November 2019 to February 2020 were enrolled. The data patients had only PVAP. Baseline demographic variables were similar collection included clinical features, viruses isolated [respiratory in both the groups i.e., Mean age in VAE and Non VAE groups was syncytial virus (RSV), rhinovirus, influenza A virus, parainfluenza 46.28 ± 16.5 and 48.35 ± 17.5 respectively. Admission GCS (8.92 ± (PIV) 2 and 3, and human metapneumovirus (hMPV)], complications, 3.96 vs 9.63 ± 3.33) and P/F ratios (239.33 ± 67.91 vs 232.09 ± 69.90) intensive care needs, treatment, and outcome. Multivariate analysis were also compared and no significant difference was found in both was performed to determine independent predictors for PICU the groups. Both the groups were comparable in severity also as admission. Results: The common symptoms were rapid breathing shown by mean APACHE II score (17.14 ± 6.54 vs 17.21 ± 7.00) and (98.8%), cough (98.3%), and fever (74%); and common examination SOFA score (6.14 ± 2.69 vs 6.49 ± 2.80) at admission. Overall VAE rate findings were tachypnea (98.8%), chest retractions (93.6%), respiratory was 27.95 per 1000 ventilator days and differentially VAC, IVAC and failure (84.4%), wheezing (49.7%), and crepitations (23.1%). RSV and rhinovirus were commonest isolates. Complications were noted in

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25% cases as encephalopathy (17.3%), transaminitis (14.3%), shock whereas other studies showed no difference in disease severity and (13.9%), AKI (7.5%), myocarditis (6.4%), MODS (5.8%), and ARDS (4.6%). outcome in those with coinfection. In the index study, at least one More than one-third cases required PICU admission and treatment virus was isolated in 74% of cases with RSV and rhinovirus as the included nasal cannula oxygen (11%), continuous positive airway commonest isolates. One-fifth of cases had coinfection with >1 virus. pressure (51.4%), high flow nasal canula (14.5%), and mechanical However, isolation of virus or coinfection was not associated with any ventilation (23.1%); nebulization (74%); antibiotics (35.9%); and differences in clinical features, complications, treatment, PICU needs, vasoactive drugs (13.9%). The mortality was 8.1%. Underlying and outcome. The strengths of this study include a prospective study comorbidity; chest retractions, respiratory failure, and low oxygen with a large sample size. All the enrolled cases underwent virological saturation at admission; presence of shock; and need of mechanical testing which is important to determine etiology but did not have ventilation were independent predictors of PICU admission. Isolation much significance in determining disease severity, prognosis, and of virus or co-infection were not associated with disease severity, short-term outcome. The details of treatment, intensive care needs, intensive care needs, and outcome. Discussions: AVB had a huge and the outcome have been described. The predictors of PICU impact on the health of young children and approximately 2 to 3% admission were determined. The limitations included a single-center of infants require hospitalization due to AVB. No available treatment study and a lack of long-term follow-up. Conclusion: Among infants modalities have been shown to shortens the course or hastens the with AVB, RSV, and rhinovirus were common isolates; >1/3rd required resolution of symptoms of AVB. Therefore, the treatment of AVB is PICU admission; and comorbidity; chest retractions, respiratory failure, supportive. The American Academy of Pediatrics published clinical low oxygen saturation; shock; and need of mechanical ventilation practice guidelines based on the Grading of Recommendations, independently predicted PICU admission. Assessment, Development and Evaluation (GRADE) system to standardize the diagnosis and management of AVB. These guidelines 11. Outcome and Safety of Percutaneous Tracheostomy in emphasized that the diagnosis of AVB should be based on the history COVID-19 Patients: A Single-Center Experience. (Conference and physical examination. Epinephrine, short-acting β2-agonists, Abstract ID: 146) systemic glucocorticoids, chest physiotherapy, and antibiotics are not recommended for the treatment of AVB. Nebulization with Nirankar Bhutaka, Mehul Shah hypertonic saline may be used as it improves symptoms of mild-to- SIR HN Reliance Foundation Hospital And Research Centre, Mumbai, Maharashtra, India moderate AVB if the length of stay is >3 days. Since ours is a tertiary care referral hospital, the infants with more severe illness were referred DOI: 10.5005/jp-journals-10071-23711.15 to us which is supportive by the facts that a higher proportion of Introduction: these infants had a respiratory failure at admission; had higher rates Background: The role of tracheostomy in corona disease (COVID-19) of extrapulmonary complications (25%); more cases required PICU is unclear with several guidelines advising against this practices.1 admission (36.4%) and mechanical ventilation (23%), and vasoactive However, tracheostomy facilitates weaning from ventilation and drugs (14%); and had higher mortality (8%). PICU admission is needed potentially increase the availability of much needed intensive care in 15 to 25% of children with AVB. Various noninvasive modes of unit beds. Tracheostomy, an aerosol-generating procedure with oxygen delivery are being increasingly used including CPAP, HFNC, the risk of infectious transmission for healthcare workers.2 The noninvasive positive pressure ventilation (NPPV), and bilevel positive prior misconception of performing tracheostomy earlier than 21 airway pressure (BiPAP). The common reasons include apnea, severe days was associated with increased risk to healthcare workers and lower airway disease, or ARDS. The need for mechanical ventilation offers no benefit.3 But the global, multidisciplinary guidance on is usually for a short period (usually <5 days) but may be needed for tracheostomy for patients with COVID-19 suggests 10 to 21 days as a longer duration in some children. There is substantial variability recommended window for tracheostomy.3 Objectives: We hereby in the diagnosis and management of infants with AVB in different present the outcome and benefits of early tracheostomy done in PICUs. In the index study, 36.4% of cases needed PICU admission. COVID-19 patients over a period of 9 months at our hospital. We Underlying comorbidity; the presence of chest retractions, respiratory also evaluated the safety and risk of transmission of healthcare failure, and lower oxygen saturation at admission; the presence of workers. Materials and methods: We performed a retrospective shock; and the need for mechanical ventilation were independent analysis of all COVID-19 positive patients treated at our center predictors of PICU admission on multivariate analysis. In AVB, the use who required mechanical ventilation and subsequently underwent of antibiotics is not routinely recommended. Papenburg et al. noted tracheostomy. The epidemiological data, indications, timing of that about 25% of infants with AVB were given antibiotics, 70% of tracheostomy in regards to the initiation of mechanical ventilation them had no documented bacterial coinfection, and 38% received (MV) and assessment of the severity of COVID pneumonia with macrolides. Therefore, efforts are needed to reduce inappropriate APACHE-II score, CT severity index (CTSI), P/F ratio at the time of and unnecessary use of antibiotics in AVB. With the availability of intubation were all documented. The outcome of the patient in molecular techniques, it has been possible to identify viruses causing regards to survival, type of procedure and complications, duration AVB. The most common viruses isolated are RSV (50–80%), rhinovirus of mechanical ventilation post tracheostomy, and length of ICU (5–25%), PIV (5–25%), hMPV (5–10%), coronavirus (5–10%), adenovirus and hospital stays were recorded. We also monitored healthcare (5–10%), and influenza virus (1–5%). The proportion of viruses causing workers directly involved in tracheostomy care acquiring COVID- AVB differ according to geographical location and time of the year. 19, by assessing them clinically for (s/s of fever/breathlessness) The clinical features of AVB caused by different viruses are generally and also subjected them to a rapid antigen test every alternate indistinguishable. The reported rates of coinfection varied widely day and RT-PCR every fifth day. Results: A total of 604 patients among different studies and ranged from 6% to >30%. Few studies were admitted to ICU from March to December 2020, 174 patients noted greater severity of the disease, longer hospital stay, more severe required intubation for Acute respiratory distress syndrome hypoxemia, and greater risk of relapse in children with coinfection, (ARDS) of which 16 patients (8–9% ) approximately underwent

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tracheostomy. Our demographic data suggested a higher average We conclude even in severe ARDS with a higher age group, higher age group of population 73 ± 16yrs treated at our centre and only APACHE-II score, early tracheostomy within 13 days of intubation 18% of these patients undergoing tracheostomy were females. The had better outcomes and less duration of hospital stay. Whether commonest co-morbidity seen was hypertension (68%)followed this is true still needs to be proved with more robust data. by obesity (31%) and then diabetes mellitus (25%) in our cases. We had 13 patient with Apache II score > 17 of which 40% survived. 12. Extravascular Lung Water and Pulmonary Vascular APACHE II Score >23 was associated with the worst outcome. On Permeability Index Measurement in COVID ARDS Gold Standard comparison of their radiology finding with CTSI and CORADS score, for ARDS Management. (Conference Abstract ID: 145) all patients undergoing tracheostomy we found patients with Ziyokov Joshi, Taran Deep average of 16/25 CTSI and a CORADS Score of 5. The predominate Tagore Heart Care and Hospital, Jalandhar, Punjab, India indication for tracheostomy was prolonged ventilation and DOI: 10.5005/jp-journals-10071-23711.16 liberation from the ventilatory support. The average time for our Introduction: COVID ARDS is the most important cause of mortality patient to undergo tracheostomy was 13.06 days after intubation. in COVID patient to prevent mortality in COVID ARDS we use 63% of these patients had severe ARDS(P/F <100), while rest had extravascular lung water index (EVLWI), and pulmonary vascular moderate disease. Patients undergoing tracheostomy at our centre permeability index (PVPI), and lung-protective ventilation to had an average P/F ratio of 119 at the time of intubation. Overall prevent mortality and weaning from the ventilator. Objectives: outcome was 50% survival of patients’ undergoing tracheostomy. 1. EVLWI measurement, 2. PVPI measurement, 3. Lung protective At 30 days we had 66% of survivors of the survivors, patients with ventilation. Materials and methods: In all cases of COVID with moderate ARDS had a 90% survival rate whereas only 1/3rd of SpO <94%, we use thermodilution PA catheter and femoral artery the patients suffering from severe ARDS made it. The average 2 line and measurement of EVLWI and PVPI for ventilator weaning. length to stay of survivors in the ICU was 34.37 days and hospital Results: In our hospital out of 10 ARDS PT, we last two PT with stay was nearly 47.37days. The average time of liberation of ARDS and septicemia. Discussions: COVID ARDS is very tough to mechanical ventilation was 10 days. All the tracheostomies were manage very high mortality; hence, we use EVLWI and PVPI and performed percutaneously at the bedside. Only 1 patient out of ABG in all patient any patient IF PaO /FiO , <100 we refer a patient 16 developed complication in form of bleeding at local site which 2 2 to COVID unit in other hospitals for further treatment. Conclusion: was managed conservatively. All procedures were performed Any patient in which EVLWI and PVPI are high there prognosis is very using personal protective equipment (PPE), FFP3 masks with fluid poor and we should keep this value to normal to prevent mortality repellent gowns, gloves, and eye protection. None of our health with EWLW more than 20 mL/kg mortality in ARDS is 50%. care workers were infected with Covid 19 infection. Discussions: During the coronavirus disease 2019 (COVID-19) pandemic, lack 13. Physiological Effect of Prone Positioning in Mechanically of data to guide decisions has been the most evident regarding Ventilated Sars-CoV-2 Infected Patients with Severe ARDS: An the timing of tracheostomy. Emerging data concerning infectivity Observational Study. (Conference Abstract ID: 144) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the course of patients with COVID-19, and clinical experience Srikant Behera, Dalim K Baidya, Souvik Maitra, Bikash R Ray, may alter practice, even preempting publication. For example, Rahul K Anand, S Rajeshwari Chao et al.4 originally recommended deferring tracheostomy All India Institute of Medical Sciences, New Delhi, India beyond 21 days of intubation and recommended open surgical DOI: 10.5005/jp-journals-10071-23711.17 tracheostomy over percutaneous dilatational tracheostomy; Introduction: Prone positioning during mechanical ventilation however, updated practices at the authors’ institution reflect (MV) has been shown to improve oxygenation and decrease outcomes of tracheostomy performed at 10 to 14 days after mortality in ARDS patients. Prone position reduces lung strain and intubation, with percutaneous technique performed regularly. A stress, leads to a more homogenized distribution of lung aeration total of 100/164 patients underwent tracheostomy safely, with no and recruitment of dorsal alveoli, thus, leading to improvement in transmission of COVID-19 infection in healthcare workers involved oxygenation.1 In mechanically ventilated patients of severe ARDS in their care. Despite similar characteristics and APACHE-II scores, with PaO2/FiO2 (P/F) ratio < 150, prone position for at least 16 hours 30-day survival was higher after tracheostomy compared with a day for consecutive 4 days decreased 28-day mortality by almost non-tracheotomized patients. Early tracheostomy in COVID-19 50%.2 To the best of our knowledge, no study has so far assessed the patients appears to be safe and associated with a shorter ICU stay. physiological effect of prone position in SARS-CoV-2 infected ARDS Prolonged sedation/intubation for patients with COVID-19 delays patients undergoing invasive MV. Hence, in this observational study, rehabilitation, can exacerbate resource scarcity, and may increase the physiological effect of prone position in SARS-CoV-2 infected the risk for thrombotic sequelae (CVA, VTE) or other complications. severe ARDS patients is being reported. Objectives: To find out the We found at our center which catered to a higher age of patients, physiological effect of prone positioning in mechanically ventilated predominantly males having APACHE-II score >17, with moderate SARS-CoV-2 patients with severe ARDS. Materials and methods: to severe ARDS, underwent tracheostomy on an average 13 days Permission from the Institute Ethics Committee was obtained before postintubation had a better outcome, with 66% surviving beyond recruitment of patients and consent was obtained from legally 30 days. They were also liberated from mechanical ventilation acceptable representatives. In this prospective observational study, within 10 days of tracheostomy. Conclusion: Though we treated 20 consecutive laboratories confirmed SARS-CoV-2 patients with a higher age group of patients at our center, 66% of our patients severe ARDS (PaO2/FiO2 < 150) on invasive mechanical ventilation had survived at the end of 30 days. All of the survivors underwent were included in the study. As per ICU protocol, in the absence of early percutaneous tracheostomy by the twelfth day of intubation contraindication, all mechanically ventilated ARDS patients with facilitating liberation from mechanical ventilation by the tenth day. PaO2/FiO2 < 150 were placed in at least 16 hours/day prone position

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for consecutive days till the criteria for proning is met. Demographic recruitment in SARS-CoV-2 infected patients. Determination of characteristics, baseline respiratory mechanics, and blood gas data baseline static compliance is important as it was a predictor of the were collected before initiation of the prone position, after 4 and 16 absence of a response from the prone position and these patients hours of the prone position, and after 4 hours of return of supine may be subjected to extracorporeal membrane oxygenation early position. Prone responders were defined by a 20% increase in in the course of the disease. Limitations: In our study, the major PaO2/FiO2 ratio during the prone session and sustained responders limitation was the small sample size, and we could not assess the were defined by a 20% increase in PaO2/FiO2 ratio 4 hours after effect of prone position on the chest wall and lung compliance return of supine position. Statistical analysis: All collected data separately as esophageal manometry was not used. Conclusion: were entered in a Microsoft Excel datasheet. Categorical data were Prone position in SARS-CoV-2 infected severe ARDS patients is presented as absolute numbers or percentages and non-parametric associated with improvement in lung compliance and oxygenation data were presented as the median and interquartile range (IQR). in 75% of the patients and persisted in about 50% of the patients. Unrelated data (between prone responders and non-responders) were compared by Mann–Whitney U test or chi-square test as 14. Role of Biomarkers and Its Trend to Predict the Outcome of applicable. Longitudinal variables were compared by Friedman’s COVID Patients: A Retrospective Study. (Conference Abstract test and multiple comparisons were performed by Dunn’s test. A ID: 120) two-sided p value < 0.05 was considered significant. All statistical Amarja Ashok Havaldar, M Vinay Kumar, Veronica Lobo, EA analyzes were performed using Graph Pad Prism version 8.0.0 for Chinny Sushmitha Mac OS (Graph Pad Software, San Diego, California, USA). Results: St John’s Medical College, Bengaluru, Karnataka, India The median age in this cohort of 20 severe SARS-CoV-2 infected DOI: 10.5005/jp-journals-10071-23711.18 ARDS was 56 (45.5–67) years. The median P/F ratio was 56 (54- Introduction: Biomarkers have been studied and used in the 66) with a median (IQR) PEEP of 12 (12–14) before initiation of diagnosis and management of various diseases. The trend in prone position. The median (IQR) SOFA score was 7.5 (5.5–9) at Biomarkers helps in prognosticating and managing critically ill the time of inclusion. Seventy-five percentage (95% CI 53.1–88.8) patients. It has been observed that patients with COVID pneumonia patients were prone responders at 16h prone session and 50 (95% have elevated levels of certain biomarkers. The predominantly CI 29.9–70.1) % patients were sustained responders after return studied biomarkers are CRP, D-dimer, LDH, ferritin, and IL-6. to supine position. Prone responders had significantly higher Various studies have shown that biomarkers can help in assessing baseline respiratory compliance (p = 0.03, Mann Whitney U test) the severity of illness and prognostication. In resource-limited but all other respiratory and blood gas variables were similar settings, the availability and feasibility of using these biomarkers between responders and non- responders. There was significant are challenging. Our study aimed to see the trend of biomarkers decrease in plateau pressure (p < 0.0001), peak airway pressure (p and to see whether it can predict mortality in COVID-19 patients. < 0.0001), and driving pressure (p < 0.0001); and increase in static Objectives: Primary objective was to evaluate the trend of compliance (p = 0.001), P/F ratio (p < 0.0001), PaO2 (p = 0.0002) and biomarkers and its effect on outcome (ICU mortality) in patients SpO2 (p = 0.0004) at 4h and 16h since initiation of prone session admitted with the diagnosis of COVID pneumonia. The secondary and also after return of supine position. Noradrenalin requirement objective was the duration of mechanical ventilation and length didn’t change during the prone session (p = 0.20). Percentages of of ICU stay. Materials and methods: It was a retrospective study. changes in static compliance significantly correlated with P/F ratio After IEC approval (IEC no. 267/2020, CTRI/2020/10/028436), after return of supine position (r2=0.62, p = 0.0034) but not at 4h patients who were diagnosed with COVID pneumonia by RT-PCR (p = 0.14) and 16h (p = 0.20). Percentages of changes in P/F ratio and requiring ICU admission were included in the study. Data were and driving pressure at 16h (r2=–0.47, p = 0.04) and after return of collected from April 2020 till September 2020. Demographic details supine position (r2=–0.59, p = 0.0089) were significantly correlated; were collected. Biomarkers which include CRP, D-dimer, ferritin, but no correlation was found at 4h (p = 0.09). Baseline static LDH, procalcitonin, troponin I, neutrophil to lymphocyte ratio, compliance was a predictor of prone response with reasonable and IL-6 were collected from day 1 to 7 of ICU admission. As per accuracy [AUROC (95% CI) 0.82 (0.59–1.00)]. Static compliance < 14 the institutional management protocol, selected biomarkers were predicted no response from prone position with sensitivity (95% sent as per the decision of the treating team. Data were collected CI) and specificity (95% CI) of 80 (37.6–99) % and 73.3 (48.1–89.1) from the patient record. The primary outcome was ICU mortality. % respectively. Discussions: We have found that around 75% of the Secondary outcomes were the length of ICU stay and duration of SARS-CoV-2 infected patients with severe ARDS responded with a mechanical ventilation. Statistical analysis was done using STATA 16-hour prone position in terms of oxygenation. Overall, there is 14 software. Continuous data were represented as mean (SD) or an improvement in lung mechanics in terms of static compliance, median (IQR) as applicable. Categorical data were presented as a driving pressure, and plateau pressure without any changes in the percentage. In bivariate analysis, the “t test” was used for parametric hemodynamic support. In our series, all the included patients had data and the “Wilcoxon rank-sum test” was used for non-parametric ‘stiff lung’ as evident by low static compliance. Previous studies data. Parameters found to be significant in bivariate were used as a reported a variable change in respiratory system compliance in covariate in multivariate analysis. Results: Total 417 Covid positive the prone position in ARDS patients,3 whereas we have found a patients were admitted in six months. Out of which data of 205 significant decrease in driving pressure and static compliance. patients was evaluated for interim analysis. Baseline characteristics Recruitment of the dorsal lung region was the biologically plausible were similar between two groups. Mortality was 65.85% (Out of mechanism of improvement in static compliance as both driving 205, 135 died and 70 survived). 142 were male and 63 were female pressure and compliance were correlated with change in P/F patients and mortality was similar between the groups. APACHE II ratio.4 We have found that these correlations were present even score and SOFA score were higher in nonsurvivors than survivors after the return of supine position which indicated sustained lung and were statistically significant (APACHE II 27.06 vs 19.66 p <0.001,

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SOFA 10 vs 6.08 p <0.001). In bivariate analysis, Day1 values of cardiovascular and renal diseases. While transferring COVID-19 Ferritin (p = 0.002, LDH (p = 0.03, Procalcitonin (p = 0.004), Troponin patients from isolation ICU to non-isolation ICU; 22 patients were on I (p = 0.004) and platelet count (p = 0.018) were found to be invasive mechanical ventilation and 27 patients required noninvasive significant. Parameters found to be significant in bivariate analysis ventilation or reservoir facemask intermittently (25.88 and 31.76%, were used as covariates in logistic regression. In multivariate logistic respectively). The rest of the patients were either on a simple face regression, Ferritin and LDH found to predict the outcome, with ROC mask or nasal prong or were on room air. Results: Respiratory and = 0.9643 and Hosmer- Lemeshow test for goodness of fit showed neurological sequelae are most commonly observed sequelae in p = 0.9742, which is indicative of good predictive model. Using post COVID critically ill patients. Pulmonary fibrosis presented as Ferritin alone, ROC was 0.8012. It was observed that cut off >718.2 most common respiratory sequelae in HRCT thorax (6 patients out ng/ml could predict the mortality with sensitivity of 75.68% and of 85 patients, 7.05%). 49 patients remain on NIV (non-invasive) or specificity of 71.43%. ICU length of stay and duration of mechanical invasive ventilation post COVID. Out of these 3 patients developed ventilation were similar in two groups. Discussions: Preliminary pneumothorax along with subcutaneous emphysema and some results from this study showed biomarkers are useful and can degree of pneumo-mediastinum. In other words 6.12% patients help in predicting the outcome of COVID patients. The biomarkers runderwent mechanical ventilation developed pneumothorax, found to predict ICU mortality were ferritin and LDH on day 1 of pneumomediastinum and sub-sutaneousemphysema. This accounts ICU admission. The utility of biomarkers in COVID patients has been about 3.35% of total critical post COVID patients (n = 85). 2 patients evaluated and the studies showed different biomarkers to be useful, out of 85 critically ill patients (2.35%) who didn’t require mechanical the predominant one’s being NL ratio, D-dimer till now. The possible ventilation (invasive or non-invasive) developed spontaneous reason for seeing varied biomarkers may be due to the stage of the pneumothorax. Only surgical emphysema noticed in one patients disease and the timing of the sample collection. Future studies on undergoing noninvasive ventilation (1.17%). As far as neurological biomarkers should look for the stage of the disease and evaluate sequelae concerened delirium was the most common presentation for specific biomarkers. There were certain limitations to our study, followed by demyelinating neuropathy (flaccid paralysis); such as a retrospective design. The serial data of biomarkers were Incidence being 7.05% and 2.35% respectively. Bleeding sequelae/ not available hence trend in the biomarkers with respect to the complication observed in 3 patients; one patient each had intracranial clinical profile of the patient could not be studied. Considering haemorrhage, retroperitoneal haematoma and haematuria out of 85 the cost of each test serial data of 7 days was not available and ( incidence 1.17%). Though the main pathophysiology of COVID-19 is ordering of the blood tests was based on the treating team’s hypercoagulation, we observed bleeding complication in 3 patients decision. Conclusion: The present study showed ferritin and LDH, despite withdrawing anticoagulant or for whom anticoagulant on day 1 of ICU admission can predict the ICU mortality in COVID hadn’t been started. Discussions: Presently, COVID-19 presents as pneumonia patients. The results of this study need to be validated one of the most common causes of respiratory failure. Along with by a larger observational study. respiratory failure, other organ systems are also affected including cardiovascular, renal, neurological systems. Apart from active disease 15. Sequelae of COVID-19 Pneumonia: Our Experience in COVID-19 has many sequelae after the disease process is over. We Intensive Care Unit. (Conference Abstract ID: 112) observed lung fibrosis as the most common sequelae that again Sanjib Kumar Dhar, Binita Panigrahi, Asif Ahmed lead to pneumothorax and subcutaneous emphysema in critically Tata Main Hospital, Jamshedpur, Jharkhand, India ill patients (incidence = 7.05%). Similarly, neurological complications DOI: 10.5005/jp-journals-10071-23711.19 and sequelae are not uncommon. The most common presentation Introduction: Severe acute respiratory syndrome coronavirus 2 being delirium followed by demyelinating polyneuropathy in terms (SARS-CoV-2) now a global pandemic and public health problem. of flaccid palsy. The incidence of bleeding was observed to be Similar to SARS and MERS (Middle East respiratory syndrome) COVID- 3.54% in our ICU in post-COVID pneumonia patients. Though this 19 (coronavirus disease 2019) presents as severe and potentially is a hypercoagulable state, mandating the use of anticoagulants, life-threatening acute respiratory Syndromes. But COVID-19 has one needs to be judicious and vigilant while using anticoagulants. extensive manifestations as it gains access through the angiotensin- Conclusion: COVID-19 till now an active disease affecting almost converting enzyme-2 receptor, which is present in every organ every organ system. So also it has many sequelae involving every system. COVID-19 has high morbidity and mortality affecting many organ system which is yet to be quantified. The most common lives and has a huge financial burden on the healthcare system. sequelae observed is respiratory sequelae as pulmonary fibrosis. Apart from active disease COVID-19 has many complications and Sequelae of the neurological system are not uncommon; the most long-term consequences in different organ system that is yet to common being delirium. The actual incidence of sequelae of other quantify. Objectives: To study complications and sequelae arising systems is yet to be identified. post-COVID-19 pneumonia. Materials and methods: The study period was between August 15 to October 16, 2020. Inclusion 16. Clinical Usefulness of Favipiravir in Moderate COVID-19 criteria: All adult patients shifted from COVID isolation units & who are Patients: Indian Real-World Experience. (Conference Abstract critically ill. Exclusion criteria: Pediatric patients <14 years, patients ID: 110) with negative RT-PCR at the time of admission, COVID-19 negative pneumonia. Out of all admitted patients (n = 85), male population Sagar Bhagat, Agam Vora, Anil Daxini, Pramod Dadhich, were 53 (62.35%) and female population were 32 patients (37.65%). Saiprasad Patil, Hanmant Barkate Patients with age >60 years were 47.05% and age those between 14 Glenmark Pharmaceuticals Ltd, Mumbai, India; Vora Clinic, Mumbai, India; Fortis Hospital, Mumbai, India; Dadhich Clinic, and 60 years were 52.95%. The most common comorbidities were Ajmer, Rajasthan, India hypertension and diabetes accounting for 45.88%, respectively. Other associated co-morbidities were found in 20% of patients involving DOI: 10.5005/jp-journals-10071-23711.20

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Introduction: Favipiravir, a broad-spectrum antiviral agent, acts study group recorded the details of hospitalized COVID-19 patients by inhibiting RNA-dependent RNA polymerase. It is approved in in Japan to assess the safety and efficacy of favipiravir. In >90% of India in the management of mild-moderate COVID-19. It has shown cases, favipiravir was administered at a dose of 1,800 mg orally on day potent in vitro activity against SARS-CoV-2. It has a wide therapeutic 1 followed by 800 mg twice daily on subsequent days. The median safety margin indicated by a wide CC50/EC50 ratio for a high dose. duration of therapy was 11 days. Rates of clinical improvement at It has shown promising results in clinical studies conducted in 7 and 14 days were 73.8 and 87.8%, 66.6 and 84.5%, and 40.1 and China, Russia, Japan, and India. Treatment guidelines from many 60.3% for mild, moderate, and severe disease, respectively. Thus, the countries and some states from India have included favipiravir in the vast majority of patients with mild and moderate disease recovered treatment protocol. A recently published phase III trial on favipiravir from the illness. Conclusion: Approximately 90% clinical resolution in India has shown early clinical resolution and acceptable safety rate in moderate COVID-19 patients in real-world settings supports in mild-moderate COVID-19 infection. Objectives: The primary its role in the management of hospitalized patients. Reduction in the objective of the study was to evaluate the effectiveness of favipiravir oxygen requirement highlights its protective role against disease in moderate COVID-19 patients, while the secondary objective progression. Overall favipiravir was found to be effective and safe in was to determine the safety of favipiravir. Materials and methods: the management of moderate COVID-19. We retrospectively analyzed medical records of favipiravir-treated COVID-19 cases from 3 centers to capture key details of moderate 17. D-Dimer Levels to Predict in-Hospital Mortality in ICU Patients COVID-19 patients including medical history, symptoms, supportive with COVID-19. (Conference Abstract ID: 96) treatment, and clinical outcome. The protocol of the study was approved by Independent Ethics Committee. Results: Data from Ramesh Hasani, Mohan Nerkar, Prashant Rahate medical records of 193 patients was available for analysis, including Sevenstar Hospital, Nagpur, Maharashtra, India 54 patients of moderate severity. The mean age was 59.94 ± 13.18 DOI: 10.5005/jp-journals-10071-23711.21 years. 58.92% of the patients were male. Hypertension (78.57%) Introduction: and diabetes (55.35%) were the two most prevalent comorbidities. Background: Coronavirus disease 2019 (COVID-19) is a recently Majority (85.71%) of patients had at least one comorbidity, while described infectious disease caused by severe acute respiratory 66.07% had ≥2 comorbidities. Mean SpO2 was 92.83 ± 1.88% with syndrome coronavirus 2 (SARS-CoV-2) causing various ICU a median of 93% (90–98). The most common clinical features were admissions and deaths. Common laboratory values may provide fever (87.5%), cough (80.35%), dyspnoea (57.14%) and myalgia key insights into patients with COVID-19, the illness caused (48.12%). The mean CRP was 65.58 ± 34.74 with a median of 57.85 by the SARS-CoV-2 virus, and may predict the morbidity and (1.20 to 151) and the mean d-Dimer was 1082.95 ± 1129.7 with a outcome. Objectives: This study aimed to evaluate the effect of median of 815 (156–7435). Favipiravir has been used for an average elevated D-dimer levels on mortality of patients admitted in ICU duration of 12.30 ± 3.99 days, with median duration of 14 days with COVID-19. Materials and methods: All ICU patients with (1–14 days). The rate of clinical improvement on days 3, 5, 7 and 10 laboratory-confirmed COVID-19 were retrospectively enrolled was 30.35%, 75%, 89.29% and 96.42%. Fever and dyspnoea were in Sevenstar Hospital, Nagpur from July 27, 2020, to October fully resolved by day 7 in all enrolled patients, while myalgia was 30, 2020. D-dimer levels on admission, on day 3, and day 5 were resolved by day 10 in all patients and cough was resolved by day collected in all ICU patients, and death events were collected. The 10 in 97.77% of patients. Corticosteroid was used in 37.5% patients. subjects were divided into two groups discharged and expired. Oxygen requirements on days 3, 5, 7 and 10 were 28.57%, 14.28%, Then, the D-dimer levels between the two groups were compared 8.92% and 7.14% patients respectively. Progression of the disease was to assess the predictive value of D-dimer level and mortality in seen in 10.71% of cases. Overall favipiravir was well tolerated with hospitals. Results: A total of 101 eligible patients were enrolled few commonly reported adverse events like diarrhoea and nausea, in the study. 31 deaths occurred during hospitalization. Patients which does not require drug discontinuation. 91.07% patients and who expired had on admission D-dimer levels of 2729 ± 3243 ng/ physician rated favipiravir as good or very good on global assessment mL while those discharged had D-dimer value 973 ± 1553 ng/ scale. Discussions: An open-labeled nonrandomized study1 from mL (P value < 0.007). D-Dimer of expired patients on Day 3 was China compared the effect of favipiravir (day 1: 1,600 mg twice 3206.5 ± 3338.8 and of discharged patients was 828.8 ± 1268.8 daily; days 2–14: 600 mg twice daily) vs lopinavir/ritonavir (day 1–14: (P value 0.001). D-dimer of expired patients on Day 5 was 5184. 400/100 twice daily) in the treatment of COVID-19. Compared with 5 ± 3386.1 vs discharged patients was 588.7 ± 645.5 (P value < the lopinavir/ritonavir arm, however, patients in the favipiravir arm 0.0001). Number of Days in ICU for patients who expired was showed a statistically significant shorter median length of time to 14.22 ± 6.7 while those survived 7.6 ± 5.9. Discussions: Here, we viral clearance (4 vs 11 days, p < 0.001), improvement in chest CT report on 101 patients with laboratory-confirmed SARS-CoV-2 findings at day 14 after randomization (91.4 vs 62.2%, p = 0.004), infection requiring ICU admission in Sevenstar hospital, Nagpur. and lower incidence of adverse effects (11.43 vs 55.56%, p < 0.001). Of the 101 patients in this cohort, 31 (30.7%) died. In our study, Chen et al.2 had conducted a prospective, open-label multicentric we demonstrated that in patients diagnosed with COVID-19, trial in China to compare two treatment arms in the management D-dimer elevation upon admission and an increasing trend was of clinically confirmed COVID-19 (maximum duration of symptom associated with both increased disease severity and in-hospital onset before randomization: 12 days). Post hoc analysis demonstrated mortality. D-dimers are one of the fragments produced when that favipiravir-treated patients showed a trend toward clinical plasmin cleaves fibrin to break down clots. The assays are routinely improvement at day 7 among those with moderate COVID-19 used as part of a diagnostic algorithm to exclude the diagnosis of (71.43 vs 55.86%, 95% CI: 0.0271 to 0.2843, p = 0.0199) and earlier thrombosis. However, any pathologic or non-pathologic process resolution of fever and cough (p < 0.0001). A Japanese observational that increases fibrin production or breakdown also increases

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plasma D-dimer levels. Conclusion: We conclude that SARS- s/o rt sided tension pneumothorax so emergency ICD insertion CoV-2 infected patients with an increasing trend of D-dimer done uneventfully, thereafter pt treated with HFNC than NIV with (from admission to day 5) have worse clinical outcomes (all-cause minimum PEEP despite all measures pt succumbed on 25/07/20. mortality) and thus measurement of D-dimers on admission and Case 3: A-40-year-old male pt with no medical illness came with its trend can guide in clinical decision making. c/o of sob doe nyha gr 4 since 5 days with h/o fever, body ache dry cough since 8 days. Admitted on 10/09/20 on examination pulse- 18. Pneumothorax in COVID-19 Treated with NIV. (Conference 120/minute, BP 130/80, RR = 43/minute, SpO2-49% @ RA, TLC-7200, Abstract ID: 90) neutrophils-62, lymphocytes-12, LDH-787 IU/L, lft-wnl, D-dimer Sanjay Shridhar Andhare, Mahadev Ashruba Korsale 990 mg/mL, CRP-98 mg/L, ferritin-772 ng/mL, PCT-< 0.10 ng/mL Sushrut Hospital Barshi, Maharashtra, India Pt treated as per ICMR protocol with NIV ps 12/05/100% FiO2, pt maintaining SpO above 94, FiO titration done as per SpO , wob DOI: 10.5005/jp-journals-10071-23711.22 2 2 2 decreased during treatment pt saturation maintaining above 90% Introduction: Three case presentation of pneumothorax in COVID- on FiO 60% weaning continue. On 05/10/20 pt SpO decreased 19 patient treated with NIV. Objectives: Differential diagnosis of 2 2 to 74% on NIV ps 10/5/55% FiO2 with HR-122/minute. BP 130/70 clinical deterioration in the patient of COVID-19 positive ARDS on mm Hg RR-46/minute, emergency cxr done s/o of rt sided tension NIV treatable and reversible causes if diagnosed at the earliest. pneumothorax so emergency ICD insertion done un eventfully Materials and methods: We had to monitor patient of COVID- than pt treated with NIV with minimum pressure support with 19 admitted to a dedicated hospital on NIV for sudden clinical minimal PEEP of 4, pt ICD removed on 10/10/20. Pt discharged in deterioration. Results: Besides established causes of sudden clinical stable condition on 11/10/20. Conclusion: Good history taking and deterioration like micro thrombosis, PE, Cytokines Strom. If proper clinical examination and very close monitoring help to diagnose clinical history and examination done, then we can diagnose the COVID-19 patient with ARDS on NIV complicated by tension the Tension Pneumothorax in Covid 19 positive patient with ARDS pneumothorax which is a treatable and reversible cause of sudden on NIV and save the life. Discussions: Here, we report three cases clinical deterioration and many times may be missed out. X-ray of of tension pneumothorax of COVID-19 positive with ARDS on NIV, all three cases we will present during the virtual conference if the out of which two revived one succumbed. Case 1: A 38-year-old organization allows us. male pt came with c/o sob NYHA gr 3, cough fever since 10/10/2020 RT-PCR positive for COVID-19 with severe COVID, CRP-293, 19. Helmet NIV in Hypoxemic Respiratory Failure Due to Severe ferritin-886, PCT-normal, D-dimer 732, LDH-776 PT treated outside COVID-19 Pneumonia: A Descriptive Study. (Conference Abstract from 12/10/2020 to 14/10/20 with BiPAP support pt came to our ID: 74) hospital on 14/10/20 with SpO2-54% @RA, pulse 98, BP 130/90 mm Hg RR 32/minute, we put pt on BiPAP support with IPAP-14, EPAP-7 Sunny Kumar, Onkar Jha, Mrinal Sircar Fortis Hospital, Noida, Uttar Pradesh, India RR-20, ST/T mode with SpO2-94% overnight. On 15/10/20 noon at 1 pm, pt developed sudden chest pain, tachypnea RR-more than DOI: 10.5005/jp-journals-10071-23711.23 60, tachycardia HR 139, SpO2-50%, BP-100/70, restlessness near Introduction: The utility of HELMET-noninvasive ventilation (NIV) for arrest situation, on auscultation diffuse crepitations on b/l chest severe COVID-19 pneumonia-related hypoxemic respiratory failure s/o surgical emphysema cxr done which s/o left-sided tension remains unclear. Materials and methods: This is an observational pneumothorax with surgical emphysema extending in neck too descriptive study conducted at a tertiary care hospital in Noida, emergency Lt sided ICD inserted column movement and air leak India. We included adult patients (aged >19 years) with hypoxemic seen Pt tachypnea and tachycardia decreased little bit, SpO2-76% respiratory failure due to severe COVID-19 pneumonia, who were on O2 NIV with PS 12/4/100% FiO2 pt little bit stable but on repeat treated with HELMET-NIV. The primary outcome was the proportion cxr s/o Lt sided ICD in situ, but also. Rt sided pneumothorax so of patients who were successfully weaned from HELMET-NIV, while ICD insertion on rt side also done, column movement and air failure comprised of patients who required intubation. Results: leak seen, now pt become stable SpO2-90% on HFNC with 90% Total of 30 patients were included (mean (±SD) age 57.1±11.9 FiO2, RR-22/minute, pulse-86/minute with post ICD insertion cxr years). 25 (83.3%) patients were male. Mean baseline PaO2-FiO2 s/o b/l lung expansion with b/l ICD in situ. pt continue on HFNC ratio (PFR) was 150.1±57.4 mm of Hg in 30 patients. 19 (63.3%) F/B ventury mask than, both ICD removal done 1 day apart from patients could be successfully weaned from HELMET-NIV. Invasive when pt become off 2O pt discharged on 08/11/20 with a stable mechanical ventilation was required in 9 (30%) patients out of clinical condition. Case 2: A 57-year-old female pt k/c/o DMT2, HTN which 8 (26.7%) patients died. Total of 22 (73.3%) patients could came with c/o fever, dry cough, sob doe nyha gr 2 since 3 days. On be discharged home. Receiver operative characteristic (ROC) curve examination pulse-90/minute, bp-140/80 mm Hg, RR-26/minute, to find optimum cut off PFR at 24 hours (PFR-24) was plotted to SpO2-82, cxr s/o of lt lz pneumonia, abg-7.42/40/60/28 with SpO2, predict NIV success: a cut off point that maximized sensitivity 88%, D-dimer 1,500 mg/mL, CRP-59 mg/mL, ferritin-880 ng/mL, and specificity (youdens index) was at PFR 170 with sensitivity PCT-<0.10 ng/mL on 04/07/2020 pt treated as per icmr protocol with and specificity of 71.4% and 88.9% for NIV success, respectively. 7 O2 10 L/minute with NRBM than pt O2 requirement increased on patients observed complications, of which 5 had mask deflation, 1 06/07/2020 pt put on BiPAP with IPAP-10, EPAP-5 which was titred complained of noise and 1 patient had barotrauma. Discussions: as per patients wob and SpO2. inj tocilizumab given for cytokine The role of NIV in hypoxemic respiratory failure is getting more and storm on 7/7/20. pt maintaining SpO2 above 94 on BiPAP with more recognition. HELMET interface is a new method of applying IPAP-12, EPAP-7 RR-20 with O2 10 L/minute. ON 15/7/20 pt suddenly NIV. In the setting of the COVID-19 pandemic, the HELMET interface get worson restness, had tachypnea with RR-50, tachycardia with can be an effective method of delivering NIV. It has been described HR-140/minute. Air entry to right side absent cxr done which as an aid to decrease virus spread by decreasing aerosol generation.

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Also, higher pressures can be applied as compared to face mask as a potential threshold to prevent ventilator-induced lung injury NIV. In our study, more than 50% of patients could be successfully (VILI). Conclusion: Limiting driving pressure can reduce the lung weaned from NIV. The rate of any major complications was low: only strain and improve patient outcomes in ARDS. 1 patient had barotrauma (subcutaneous emphysema). However, it is an observational and single-center study. Larger and multicenter 21. ROX Index a Promising Guide to Mechanical Ventilation. studies are needed to support the above findings. Conclusion: (Conference Abstract ID: 71) HELMET-NIV for severe COVID-19 pneumonia-related hypoxemic Sarang Patil respiratory failure is feasible. The rate of any major complications Maharashtra University of Health Sciences, Nashik, Maharashtra, is low. India DOI: 10.5005/jp-journals-10071-23711.25 20. Ventilator Induced Lung Injury (VILI) in ARDS. (Conference Abstract ID: 73) Introduction: Early identification of patients at risk of failing noninvasive oxygen therapy has been a challenge but it is of Sarang Patil important clinical benefit. The ROX index (Respiratory rate Maharashtra University of Health Sciences, Nashik, Maharashtra, OXygenation index) is defined as the ratio of pulse oximetry by India the fraction of inspired oxygen to respiratory rate, has shown to DOI: 10.5005/jp-journals-10071-23711.24 predict HFNC failure and risk for mechanical ventilation in patients Introduction: Ventilator-induced lung injury (VILI) has been with ARDS and pneumonia. recognized as a negative prognostic factor in patients with ARDS Objectives: and is closely related to dynamic lung strain. No guidelines exist • To validate the ROX index in all patients admitted to ICU and that define a safe lung strain limit, however, a recent study has on supplemental oxygen modalities. proposed 0.27 as a possible threshold to prevent VILI (Adrián • To utilize the ROX index in the rescue alert system. González-López et al.). A recent meta-analysis has suggested that Materials and methods: Sample size: 100 patients admitted to driving pressure (DP) may have important consequences on patient ICU. We perform a retrospective observational cohort study of an outcomes in ARDS (Amato et al.) which may improve when driving adult patient admitted to ICU over two months at a large academic pressure is limited to 15 cm H2O. It remains unclear if limiting the hospital, a clustered logistic regression of daily worst ROX index driving pressure reduces the incidence of VILI by decreasing the was performed to estimate the risk of endotracheal intubation and dynamic lung strain. Objectives: To assess the prognostic value all-cause hospitality mortality. of dynamic lung strain in ARDS and its correlation with driving Results: pressure. Materials and methods: Analysis of the patients admitted • A total of 100 adult patients were included, of which 39 were to the ICU in one year period was done. We estimated patients’ intubations. functional residual capacity (FRC) from their reference values and • Odds of intubation were 18 times higher when the ROX index calculated the end-expiratory lung volume (EELV) assuming that was <4.6 (OR 7.95, 95% CI, 4.91–12.86, p < 0.001). patients were in a supine position and had a decrease in volume • The ROX index threshold of 4.6 resulted in a 99.5% specificity proportional to their lung compliance. Dynamic lung strain was and 3.0% sensitivity, with a likelihood ratio for intubation of 6.4. calculated as ratio TV/EELV. Pearson’s correlation coefficients were • There was a dose-response of the number of daily ROX ≤4.6 used to assess the correlation between strain and driving pressure. events and mortality. Multivariate analysis was used to determine the effects of lung strain • The mortality of patients with ROX > 4.6 was 1.5% compared on mortality, after adjusting for patients’ characteristics, APACHE to 22% and 27%, in patients who had one and four instances and SAPS scores, and Exhauster’s comorbidity index. of ROX < 4.6 respectively. Results: · For each additional daily ROX ≤ 4.6 event, the odds of mortality • There were 300 patients admitted to the ICU for ARDS requiring increased incrementally by 2.65 (OR), 95% CI 1.84 to 3.85), p < 0.001. invasive mechanical ventilation. Discussions: ROX index can accurately identify patients on • Mean age was 60 years. supplementary oxygen therapy who are at risk for mechanical • 39.32% were female. ventilation (NIV or IMV) and endotracheal intubation. It appears • Mortality was 57.95%. • The mean driving pressure was 13.01 cm H2O, mean lung strain that possible delays in intubation of these patients identified as was 0.29 and mean compliance was 41.82 mL/cm H2O. high-risk patients were associated with increased morbidity and • On multivariate analysis we found that lung strain was an mortality. Conclusion: ROX index can thus be a good noninvasive independent predictor of mortality (OR 3.89 [1.50–10.13], p = modality to identify early patients at risk of mechanical ventilation 0.005) and ends-tracheal intubation. This is thus a promising index and • In patients with driving pressure (DP)<15 cm H2O, the mean its use in rescue alert systems can help to significantly reduce lung strain was 0.272 [0.269–0.275] whereas when DP ≥ 15 cm morbidity and mortality in high-risk patients. H2O the mean strain was 0.346 [0.341–0.350, p < 0.001] • There was a positive correlation between DP and dynamic lung 22. Clinical Profile and Laboratory Parameters in Patients with strain (R = 0.5732, p < 0.001). Moderate-Severe COVID-19 Pneumonia Admitted in Tertiary Care Discussions: In patients with ARDS, dynamic lung strain is a strong Hospital in South India. (Conference Abstract ID: 61) predictor of mortality, irrespective of patient characteristics, Alfiya Sultana, M Mahendra, RS Bhoomika, Abhishek Nuchin, APACHE, and SAPS scores. There is a positive correlation between DP Ankit Pandey, S Shreedhar and dynamic lung strain and when DP is limited to 15 cm H2O, the Shimoga Institute Of Medical Sciences, Shimoga, Karnataka, India dynamic lung strain is ≤ 0.27, a value that was previously identified DOI: 10.5005/jp-journals-10071-23711.26

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Introduction: Coronavirus pandemic has caused significant patients had elevated serum LDH and serum ferritin which could morbidity and mortality throughout the world. Due to the novelty be a reliable prognostic indicator. Many patients presented late to of this respiratory virus still, it is unclear regarding the clinical the hospital with low oxygen saturation which has resulted in high and laboratory profile of patients with COVID-19 pneumonia. mortality of 54.64%. Early diagnosis and treatment may decrease So, we took up the study to look for the clinical and laboratory mortality in COVID-19 patients. profile of patients with moderate to severe COVID-19 infection. Materials and methods: A retrospective study was conducted 23. Epidemiology and Clinical Characteristics of Suspected on moderate-severe COVID-19 pneumonia patients admitted to COVID-19 Patients with Severe Acute Respiratory Infection tertiary care hospitals from June to October 2020. Data included (SARI) Admitted to a Tertiary Care Teaching Hospital. (Conference demographic details, symptoms, comorbidities, vital parameters Abstract ID: 56) were recorded. Laboratory parameters included complete Srikant Behera, Dalim K Baidya, Souvik Maitra, Bikash R Ray, hemogram, neutrophil-lymphocyte ratio, serum ferritin, serum Rahul K Anand, S Rajeshwari LDH, renal function test, liver function test, and arterial blood All India Institute of Medical Sciences, New Delhi, India gas. Treatments details like the use of remdesivir, use of steroids DOI: 10.5005/jp-journals-10071-23711.27 and anticoagulants, use of a high-flow nasal cannula, noninvasive ventilation, ventilator were collected. Several ICU and hospital stay Introduction: The COVID-19 pandemic has affected human beings were recorded. Results: 4012 confirmed cases of covid-19 were globally. At present, medical science is flooded with literature admitted to hospital, of which 560(13.95%) patients who were of related to various aspects of COVID-19. But, there is hardly any data moderate-severe severity were included in the study. Mean age of found on literature comparing the epidemiology, clinical features, study population was 57.75 ± 13.96 years. Three sixty five (65.17%) and outcome data of hospitalized COVID-19 SARI patients with were men. Hypertension (41.25%) was most common co-morbidity. non-COVID SARI patients. In this study, we tried to find out the Dyspnea (69.46%) was the most common symptom followed by epidemiology, clinical characteristics, and outcome of patients with fever (52.5%) and cough (46.78%). Mean duration of symptoms a severe acute respiratory infection (SARI) admitted as suspected before admission was 4.11 ± 2.09 days. Mean Spo2 at admission COVID-19 patients in a tertiary care teaching hospital. Objectives: 1. was 78.70 ± 18.72. Mean neutrophil to lymphocyte ratio was 8.02 To know the demographic parameter (age, sex, BMI, comorbidities) ± 8.66. Mean serum ferritin and serum Lactate dehydrogenase and clinical characteristics (presenting symptoms, duration of was 539.66 ± 381.78 and 845.73 ± 593.51 respectively. Mean symptoms, disease severity, etc.) of the SARI patients with suspicion duration of symptoms before hospitalization was 4.11 ± 2.09 days. of COVID-19. 2. To know the clinical outcome (duration of hospital Remdesivir was given to 298 (53.21%) patients. Mean duration of stay and survival to hospital discharge) in these patients. Materials starting Remdesivir after symptom onset was 5.58 ± 2.78 days. and methods: It was a prospective observational study, conducted Steroids were given to 454(81%) of patients and anticoagulation at AIIMS, New Delhi. After obtaining permission from the institute was given to 365(65.17%) of patients. High flow nasal cannula ethics committee and written informed consent from their legally was given to 245(43.7%) patients. Ninety one (61.25%) were put acceptable representatives, adult patients (18–75 years) of either on ventilator. Mean duration of hospital stay was 8.71 ± 7.54. A sex, fulfilling WHO case definition of severe acute respiratory very high mortality 306(54.64%) was observed at our hospital. infection (SARI) with clinical suspicion of COVID-19 infection Discussions: During the course of this study, we found most of the were included in the study. No formal sample size estimation patients with moderate to severe COVID-19 pneumonia were of an was performed as no previous study is available in the Indian elderly population with male predominance. A north Indian study population when the study was planned and 450 adult patients found the majority of patients below 60 years of age with male (n = 450) were included in the study. The only exclusion criterion predominance. Another North Indian study also found a majority was the patients or relatives who refused to provide consent for of patients below 60 years. A retrospective study done in Wuhan the study. Demographic parameters, systemic comorbidities, and found male predominance and elderly population affected with baseline clinical data were collected at the time of admission. COVID-19 pneumonia similar to our study. We found dyspnea to Standard intensive care protocol as per current Surviving Sepsis be the most common symptom at presentation. In contrast, fever Guidelines and standard management of respiratory failure and and cough were the most common symptom in a Chinese study acute respiratory distress syndrome were followed in all patients. and North Indian study.1–3 We found hypertension and diabetes Protocolized weaning and extubation were followed. Fluid and to be the most common comorbidity similar to a Chinese study. vasopressor management was guided by hemodynamic variables We found a high NLR ratio, high serum ferritin, and serum LDH in and point of care ultrasound. Antibiotics therapy was initiated at our study. A Chinese study done on 110 patients found elevated presentation as per institute protocol and tailored according to the procalcitonin and D-dimer in severe pneumonia patients. A study appropriate cultures (blood, urine, abdominal fluid, and tracheal was done in New York City also found elevated levels of C-reactive aspirate whenever suitable) and sensitivity report when available. protein and D-dimer in patients with severe COVID-19 pneumonia. All data were collected in standard case record proforma. Results: We observed a mortality rate of around 54.64% at our hospital. A A total of 450 patients with a severe acute respiratory infection systematic review done of mortality in patients admitted to ICU (SARI) as per WHO case definition were included in the study. All found a mortality rate of 37.7% in China, 25.6% in Italy, 23.6% in the collected data were entered in a spreadsheet (Microsoft Excel). US, 29.2% in Spain, 41.2% in Denmark. Another small case series Normality was tested by Shapiro- Wilk test. Normally distributed study in western India found a mortality rate of 16.7% in COVID ICU data were presented as mean and standard deviation (SD), skewed patients. Conclusion: Patients who are elderly with comorbidities data as median (Interquartile range) and categorical data were like diabetes and hypertension are more likely to have moderate presented as absolute number and percentages. For comparison to severe COVID-19 pneumonia requiring hospitalization. Most of related samples, the paired and unpaired t test were used for

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normally distributed data and the Wilcoxon signed rank test and All India Institute of Medical Sciences, Rishikesh, Uttarakhand, Mann-Whitney U test were used for skewed data. P value of less India than 0.05 was considered as statistically significant. A total of 450 DOI: 10.5005/jp-journals-10071-23711.28 patients with a severe acute respiratory infection (SARI) as per WHO Introduction: Ventilator-associated pneumonia (VAP) is one of the case definition were included in the study. Out of total 450 SARI most frequent hospital-acquired infections, which affect up to 27% patients, 291 (64.6%) were positive for SARS-Cov-2 in RT-PCR. The of patients in the ICU on mechanical ventilation. It has attributable median age of this cohort of SARI patients was 47(34-59) years. All mortality of 13%, but crude mortality can be higher when there is the SARI patients were divided into two subgroups as COVID -19 a delay in diagnosis or delay in initiation of appropriate therapy in SARI and non COVID -19 SARI patients. The COVID-19 SARI patients the form of appropriate antibiotics or optimization of ventilatory were slightly older in age (48 vs45 years, p = 0.02). The male gender parameters. So, monitoring of its course is primarily important for was more common in the whole cohort of SARI patients as well a favorable outcome. Although lung CT is considered the gold as in both the sub groups. The common presenting symptoms standard for monitoring lung reaeration, the risk of transportation, were shortness of breath, malaise, fever, cough, abdominal pain, and radiation exposure limit its repeatability. Lung ultrasonography nausea, nausea / vomiting, chest pain, myalgia, diarrhea, etc. in the (LUS) which is a simple bedside noninvasive tool could be an cohort of all SARI patients. The incidence fever, cough, and sore alternative method for monitoring the effectiveness of therapeutic throat were higher among COVID-19 SARI patients. There was no interventions on VAP recovery by assessing the lung aeration score. significant difference in incidence of shortness of breath, chest Objectives: The primary objective of this study was to identify a pain, nausea and diarrhea runny nose and wheeze between both correlation between LUS aeration score with lung compliance and the groups. But the incidence of myalgia and abdominal pain was oxygenation in patients with ventilator-associated pneumonia. The significantly higher in non-COVID SARI patients. There was there is correlation was calculated for all 5 days (day 1 to day 5) between no significant difference in duration of fever [4 (2-6) vs 3 (2-3) days, the LUS aeration score (LUSS) with PaO2/FiO2 ratio and LUSS with p = 0.17] between the two groups of SARI patients. The common static compliance. The secondary objective was to identify a comorbid conditions associated in SARI patients were hypertension, correlation between LUSS (day 1) and 28-day survival in patients of DM, CKD, CAD, malignancy, asthma, CLD, COPD, and obesity. The VAP. Materials and methods: This prospective, outcome assessor- prevalence of these comorbid conditions was similar in both the blinded, observational study was conducted in the Department SARI groups except for CKD and obesity. CKD was more prevalent of Anaesthesiology at the All India Institute of Medical Sciences, non COVID-19 SARI patients and obesity was more prevalent COVID- Rishikesh. Patients who were diagnosed with VAP according to the 19 SARI patients. The on admission vital parameters were similar clinical pulmonary infection score (CPIS) ≥6 of the age group 18 to (RR, p = 0.84; HR, P = 0.23; temperature, p = 0.07; SBP, p = 0.05; DBP, 60 years were included in the study. Patients with thoracic dressings, p = 0.06) in both group of SARI patients. On comparing the on subcutaneous emphysema, chronic obstructive pulmonary disease, admission parameters between the two groups of SARI patients, interstitial lung disease, and morbid obesity (BMI > 40) were non-COVID SARI patients had significantly low Hb level, low total excluded from the study. Lung ultrasound was performed with an protein and low albumin level whereas other laboratory parameters ultrasonography machine using a 2 to 5 MHz round-tipped probe (TLC, Platelet, PT/INR, APTT, creatinine, bilirubin) were similar in the by an investigator blinded for other outcome variables. It was both groups. The oxygen saturation/FiO2 ratio was significantly evaluated at six areas of each hemithorax, superior and inferior areas lower in COVID-19 SARI patients. The requirement of ICU admission in anterior, lateral, and posterior fields using parasternal, anterior- in this cohort of 450 SARI patients was 33.5%. But, there was no axillary, and posterior axillary lines as an anatomic landmark, and significant difference in requirement of ICU admission between outcome parameters were recorded. Lung USG was performed these two groups of SARI patients (32.3% vs. 35.8%, p = 0.44). But, every 24 hourly since the first diagnosis of VAP for consecutive 5 more number of COVID-19 SARI patients required mechanical days. The partial pressure of arterial oxygen to fraction of inspired ventilation (31.6% vs. 22.6%, p = 0.04). The median duration of oxygen ratio (PaO2/FiO2 ratio) and static lung compliance was hospital stay was 9 (5-15) days. The COVID-19 SARI patients had calculated at the same time for consecutive 5 days. All the patients more number of days of hospital stay [11(7-16) vs. 7 (4-12) days, included in the study were followed for 28 days after ICU admission; p = 0<000.1]. Among these cohort SARI patients, 34.4% patients if discharged before that, using telephonic conversation. Results: died, and there was no significant difference in mortality in these It was conducted in 23 patients for consecutive 5 days who were two groups of SARI patients (37.1% vs. 29.5%, P = 0.1) Discussions: diagnosed to have VAP based on the CPIS criteria. There was a To the best of our knowledge, it is the first study on SARI patients significant correlation between LUSS with oxygenation (PaO2/FiO2 that compared epidemiological, clinical features, and outcome data ratio) for 5 days. The Day 1 LUSS differ significantly between 28-day of hospitalized COVID-19 vs non-COVID SARI patients. Conclusion: survivors and non-survivors. Patients with LUSS(Day1) of ≤ 19 had Clinical features like fever, cough, and sore throat were higher in a sensitivity of 75% and specificity of 73% for predicting 28-day COVID-19 SARI patients. Though, the need for ICU admission was survival. The area under the ROC curve (AUC) was calculated as similar in both the groups, patients with COVID-19 SARI required 0.78. Lung ultrasound aeration score and PaO2/FiO2 ratio changed more mechanical ventilation and more days of hospital stay. But, significantly over time (p = 0.026; p = 0.004 respectively) and the death rate was similar in both groups. maximum change was found in day 5 as compared to day1 (p = 24. Correlation of Lung Ultrasound Aeration Score with 0.036; p = 0.001 respectively). There was a statistically significant Oxygenation in Ventilator-associated Pneumonia. (Conference difference obtained in the trend of change in LUSS over 5 days Abstract ID: 40) between 28 day survivor and nonsurvivor (p = 0.026). Discussions: There was a significant negative correlations between LUSS Sagarika Panda, Ankit Agawal, Gaurav Jain, Praveen Talwar, Udit with oxygenation (PaO /FiO ratio) in all 5 days (r = −0.66; −0.68; Chauhan 2 2

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−0.83; −0.85; −0.81 from day 1 to day 5, respectively). A very high cardiac arrest patients, such as the need for epinephrine use, low correlation was seen from day 3 onward suggesting that clinical pulmonary flow, and low cardiac output. However, capnography is improvement became apparent after the first 72 hours of starting still not widely available in some emergency departments (EDs) and antibiotics (1). Our findings are consistent with Li et al., who also intensive care units (ICUs). Ultrasound is a common examination found a negative correlation between LUSS and PaO2/FiO2 ratio (r tool in many EDs and ICUs. To assist with airway management in = −0.755, p < 0.001) in ARDS patients (2). Correlation of LUSS with critically ill patients, ultrasound is very useful due to its low-cost static compliance was not statistically significant on day 1 (r = −0.22; and portable capability. p = 0.324), but from day 2 to day 5 we found significant correlation Objectives: between them (r = −0.62; −0.73; −0.5; −0.69, respectively). Gattinoni • To assess the diagnostic accuracy of using tracheal ultrasound et al. in their study had shown a significant correlation of static lung to examine endotracheal tube placement during emergency compliance with the normally aerated tissue (r = 0.77, p < 0.01) but intubation. not to the amount of lung injury or poorly aerated tissues (3). On the • To assess sensitivity and specificity of airway ultrasounds in first day of development of VAP as more non-aerated tissues present confirming endotracheal tube placement against traditional in the lung (which can be confirmed from high LUSS on day 1), we clinical methods. could not find a significant correlation between LUSS and static • To assess the time taken for each method to confirm tube compliance on that day, but as LUSS significantly decreased over placement in an emergency setting. time from 19.43 to 17.09 (p = 0.026) and a significant correlation was Materials and methods: This is a prospective and observational obtained between LUSS and static compliance afterward. Patients study conducted from July 2019 to July 2020 at Emergency with LUSS (day 1) of ≤19 had a sensitivity of 75% and specificity of Medicine Department, Civil Hospital and B.J Medical College, 73% for predicting 28-day survival. The area under the ROC curve Ahmedabad. A total of 250 patients with the emergency (AUROC) was calculated as 0.78. This finding is comparable with presentation were included. As per inclusion and exclusion criteria Li et al. who also found the same cutoff of LUSS for predicting patients were recruited into the study. Total four persons [Myself (for mortality in ARDS patients with high sensitivity and specificity (84 ultrasonographic confirmation), two resident (one for intubation and 89%, respectively).2 The lower sensitivity and specificity in our and direct visualization and second for 5 point auscultation), senior case can be explained by the lower sample size in our study. Lung resident or faculty of emergency medicine department (look for a ultrasound aeration score and PaO2/FiO2 ratio changed significantly rise in oxygen saturation by pulse oximetry and condensation in over time (p = 0.026; p = 0.004, respectively). We found a statistically the endotracheal tube)] were required for this study and everyone significant difference in the trend of change in LUSS over 5 days record their findings and time using a stopwatch. Results: The overall between a 28-day survivor and non-survivor (p = 0.026). In 28-day accuracy of ultrasonography method was 98.80% (95% confidence survivors, LUSS decreased over time, but in non-survivors, LUSS did interval (CI) 96.53% to 99.75%). The sensitivity, specificity, positive not decrease over time, rather there was a non-significant increase predictive value and negative predictive value of ultrasonography on day 5 as compared to day 1. Xie et al. also observed a significantly method for tracheal intubation confirmation were 98.72% (95% higher LUSS for 28-day non-survivor than the survivor at 0, 24, 48, CI 96.30% to 99.73%), 100% (95% CI 79.41% to 100%),100 % and and 72 hours in ARDS patients.4 Conclusion: Serial measurement 84.21% (95%CI 63.41% to 94.26%) respectively. The likelihood ratio of LUSS can define the clinical course of VAP resolution, identifying of a positive test was Infinite and the likelihood ratio of a negative those receiving adequate therapy and good outcome by as early test was 0.01(95% CI 0.00 to 0.04). Discussions: This prospective as day 5 and could be of help to define strategies to shorten the study aimed to assess the accuracy and timeliness of tracheal duration of therapy. Lung ultrasound score appears to be a valuable ultrasound for determining endotracheal tube placement during tool for evaluating the recovery of VAP as shown by a significant emergency intubation. According to the new ACLS guidelines, correlation with arterial oxygenation. This study also serves as quantitative waveform capnography is recommended as the most a step for encouraging future trials with larger sample sizes to reliable method for confirming endotracheal tube placement. validate our results. Nevertheless, quantitative capnography is neither widely available nor consistently applied in some EDs. Ultrasound is a common 25. Study to Evaluate the Accuracy of Ultrasonography in and useful diagnostic tool in many EDs and critical care areas. Confirming Endotracheal Tube Placement in Emergency The use of ultrasound to confirm endotracheal tube placement is Department. (Conference Abstract ID: 15) attractive due to the following reasons. First, ultrasound is portable, Mit A Nayak, Chirag J Patel, Divyesh B Kalariya repeatable, and widely available in many EDs, critical care areas, BJ Medical College, Civil Hospital Campus, Ahmedabad, Gujarat, and even outside of the hospital. If ultrasound is as sensitive and India specific as the waveform capnography, it can be used instead of DOI: 10.5005/jp-journals-10071-23711.29 waveform capnography is not available. Second, ultrasonographic images are not affected by low pulmonary flow, as compared to Introduction: Securing the airway by endotracheal intubation is capnography. Third, tracheal ultrasound can detect esophageal a fundamental skill in emergency medicine for definitive airway intubation even before ventilating the patient, which prevents management. Unrecognized intubation of the esophagus is a unnecessarily forced ventilation to the stomach and its associated significant source of morbidity and mortality. Direct visualization complications. Conclusion: Ultrasonography detected the tube of the endotracheal tube passing through the vocal cord is not placement faster and accurately than the other methods. The always possible due to unfavorable anatomy, trauma, edema, present study demonstrated that transtracheal sonography has an blood, vomitus, and secretions. Studies found that quantitative acceptable degree of sensitivity and specificity for the confirmation capnography is the most sensitive tool for confirming tracheal of endotracheal intubation. Ultrasonography is a valuable adjunct intubation but this method has some limitations, particularly in

S18 Indian Journal of Critical Care Medicine: ABSTRACTS CRITICARE – IJCCM2021 ABSTRACTS CRITICARE – IJCCM2021 and should be considered when capnography is unavailable or 3. Cardiac Arrest, CPR, Cardiovascular Issues in ICU unreliable. 1. Significance of “Horizontal ST-Segment with Sharp ST-T 26. Beside Ultrasonography vs Radiography for Detection of Angle” Electrocardiographic Sign in Acute Coronary Syndrome. Pulmonary Edema. (Conference Abstract ID: 11) (Conference Abstract ID: 171) S Surendhar, Chirag J Patel Mukundkumar V Patel, Dhruvkumar M Patel, Jui R Shah, Maitri M BJ Medical College, Ahmedabad, Gujarat, India Patel, Harsh D Patel, Jayanti K Gurumukhani DOI: 10.5005/jp-journals-10071-23711.30 Zydus Medical College and Hospital, Dahod, Dhruv healthcare Introduction: Pulmonary edema is an abnormal increase in Multi-speciality Hospital, Ahmedabad, Gujarat, India; SVP hospital, NHLM College, Ahmedabad, Gujarat, India; GCS Medical College, extravascular water secondary to increased hydrostatic pressure Hospital and Research Center, Ahmedabad, Gujarat, India; Surat in pulmonary circulation due to either congestive heart failure or Municipal Medical College, Surat, Gujarat, India; Jay Neurocare volume overload. The ability to diagnose, quantify, and monitor and Physiotherapy Clinic, Bhavnagar, Gujarat, India pulmonary congestion is important in managing the disease. DOI: 10.5005/jp-journals-10071-23711.31 Point of care lung ultrasonography targeted to the detection of B-lines allows bedside diagnosis of respiratory failure due to Introduction: The electrocardiogram (ECG) is a noninvasive, simple, impairment of cardiac function, as well as quantification and and routinely available bedside tool and an integral part of clinical monitoring of pulmonary interstitial fluid. Materials and methods: examination for the diagnosis and prognostication of chest pain A prospective observational study was carried out at a tertiary triage in the emergency room. Normal ST-segment is slightly curved care center, Civil hospital, Ahmedabad between February 2019 to and the ST-T angle is obtuse. “Horizontal ST-segment with sharp 2020. All patients presented to the emergency department with ST-T angle (HST-STA)” is described as a subtle sign of myocardial dyspnea evaluated for pulmonary edema. With detailed history, ischemia. As per the author’s view, this sign was never studied clinical examination, radiological and other investigations, the previously in acute coronary syndrome. Objectives: The present final diagnosis was made by the respective treating medicine study aimed to evaluate the significance of ECG sign “HST-STA” unit. Chest radiography (anteroposterior or posteroanterior) was in patients with the suspected acute coronary syndrome (ACS). interpreted by a radiologist and bedside lung ultrasound was Materials and methods: This observational prospective study was done in the emergency department by an emergency physician. conducted among consecutive patients aged above 21 years who We started with a lung ultrasound examination of each patient presented with chest pain suggestive of acute coronary syndrome. with a rapid anterior two region scan and lateral two region scan The standard 12 lead ECG was recorded on admission and was in each side of the lung and then proceeded with another lung repeated after 12 hours or during reappearance of symptoms. examination, consisting of scanning four chest areas on each Patients were classified according to the ECG findings into group lung. Lung ultrasound findings are recorded for B-lines for each I (ST-segment depression), group II (T-wave inversion), and group lung as per region. Results: A total of 180 patients participated in III (apparently normal ECG). The group III cases were further this study from February 2019 to February 2020. In 180 patients subclassified according to the presence or absence of HST-STA 92 patients diagnosed with pulmonary edema during discharge, sign by blinded cardiologists. Serum Troponin-I was measured on out of which 100 patients were positive for pulmonary edema by admission, after 3 hours and 6 hours. All the cases were referred ultrasonography with sensitivity-96%, specificity-86%, PPV-88%, for a coronary angiogram (CAG) and the test was considered as a NPV-90% and 69 patients were positive for pulmonary edema gold standard reference test for confirmation of the ACS. Patients by chest radiography with sensitivity-68%, specificity-93%, with ST-elevation myocardial infarction (STEMI), LBBB, RBBB, PPV-91%, NPV-74%. Discussions: In our study bedside, US was ventricular hypertrophy, Brugada syndrome, pacemaker rhythm, found to be more sensitive in detecting pulmonary edema than and CAG not performed within 4 to 6 weeks of chest pain were chest radiography while generating a higher negative predictive excluded. In this study, ACS included only non-STEMI (NSTEMI) value. Bedside US could allow the provider to arrive at the correct and unstable angina (UA) unless specified. Results: Out of 1221 diagnosis more quickly, thereby expediting effective therapeutic suspected ACS cases, 354 STEMI, 24 LBBB, 15 RBBB, 16 LVH, 11 RVH decision making and perhaps decreasing the patient’s length and one pacemaker rhythm were excluded. 101 patients either of stay. In 2018, Wootan et al.3 conducted a prospective cohort lost from follow up or not subjected for CAG and finally, 699 cases study of 99 patients who presented to the emergency medicine completed the study. Mean age was 48.2 ± 12.5 years and 445 department with dyspnea. Bedside US showed significantly higher were males. Frequency of ACS was 230, 105 and 364 in Group-1, 2 sensitivity (96%) compared to chest radiography (65%; p < 0.001). and 3 respectively. Subsequently, the ACS cases were diagnosed Of 18 patients with negative radiographic findings and a discharge as NSTEMI (151, 70, 221), UA (45, 19, 67) and non-coronary (34, 16, diagnosis of pulmonary edema, 16 (89%) had positive US findings 76) in group 1, 2 and 3 respectively. The sensitivity and specificity, (p < 0.001). Conclusion: The findings suggest that LUS is as specific respectively, for detecting ACS were 33.03% and 67.53% by and more sensitive than CXR in the identification of pulmonary ST-segment depression, 15.96% and 88.31% by T-wave inversion, edema. Given the potential advantages of its use, LUS should be 48.99% and 55.84% by ST depression plus T inversion, and 29.50% considered as an adjunct imaging modality in the evaluation of and 84.88% by HST-STA (among ECGs not showing ST-depression patients with dyspnea. or T-wave inversion). The HST-STA sign was more sensitive than T inversion (p = 0.019), and ST depression plus T inversion (p = 0.005),

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and more specific than ST depression (p = 0.002) and ST depression However, lactate levels, particularly in the critically ill, maybe in plus T inversion (p < 0.000) for detecting myocardial ischemia. influenced by factors other than global hypoperfusion. PvaCO2 Multivariate logistic regression analysis showed HST-STA added gap, the difference between central venous blood and arterial diagnostic value over other ECG signs (p < 0.001). Discussions: blood CO2, is dependent on CO2 production and cardiac output. It Until now, it is to the authors’ understanding that the value of is a downstream metabolic parameter that has been explored in HST-STA for detecting CAD in patients with ACS has not yet been shock as a marker of resuscitation. A PvaCO2 > 06 mm Hg, is a result addressed in the literature. Although the sign is subtle, it can of increased oxygen utilization and CO2 production and reflects a be easily detected during ECG interpretation by the attending low output state with hypoperfusion. Such patients can continue to 17,18 physician aware of it. Among the patients with chest pain, receive resuscitation despite meeting resuscitation goals of lactates the prompt and accurate detection of ACS remains an important and ScvO . This study evaluates the correlation of the PvaCO gap 3,5,19 2 2 clinical challenge for ER physicians. ECG is indispensable and with lactate clearance during resuscitation in shock. Objectives: extension to clinical examination for ACS management and risk The primary objective of this study is to compare the change in stratification.5,20 Cardiac enzyme markers of cell necrosis are very 21,22 mean lactate levels with respect to the PvaCO2 gap during the first sensitive but require 3 to 6 hours for detection. Cardiac imaging 6 hours of initial resuscitation of patients in shock. The secondary and nuclear isotope scans are modern tools having good sensitivity objective was to study the correlation of the PvaCO gap with for ACS detection but they require special setups and results are 2 mortality during early resuscitation in patients with shock. Materials not promptly available.23–26 Studies found that the changes in ECG and methods: A prospective observational study conducted over parameters such as ST-segment depression and T-wave inversion 18 months, included adult patients admitted to a multidisciplinary could effectively predict long-term mortality and morbidity of intensive care unit (ICU) of a tertiary care hospital, in circulatory patients with acute coronary syndrome and also those who undergo shock. Sixty-seven patients presenting with circulatory shock from coronary revascularization.5,27,28 Despite the poor value of ECG to all causes were recruited and blood lactate concentrations, PvaCO predict ACS, it may be potentially useful for predicting the late 2 outcome of cardiac diseases in comparison with invasive strategies gap, and hemodynamic variables were obtained at ICU admission that should be strongly considered.5,29,30 Based on previous (T0) and 06 hours after admission and resuscitation (T6). ICU length studies, each ECG parameter independently could poorly predict of stay, need for mechanical ventilation and its duration, days of CAD with very low sensitivity; however, when the parameters vasopressor need, application of renal replacement therapy, and were considered together, the predictive value was significantly mortality within 28 days were recorded. Results: Mean PvaCO2 increased.30,31 Holubkov et al. also revealed that using at least two gap levels at T0 and T6 were 7.13 ± 0.813 mmHg and 6.40 ± 0.702 ECG signs of myocardial ischemia in any set of contiguous leads mmHg respectively. Mean serum lactate levels at T0 and T6 were causes remarkable higher odds of significant angiographic CAD 3.61 ± 0.31 mmol/L and 3.09 ± 0.32 mmol/L respectively. Correlation 32 than those without concomitant ECG abnormalities. Hence, the analysis of PvaCO2 gap with mean lactate levels at T6 showed decision about the presence of CAD should be performed on the positive correlation with correlation coefficient (R value) of 0.320 sum of myocardial ischemia ECG signs instead of a single parameter. (p < 0.05). Correlation analysis of change in PvaCO2 gap with serum Similar to the previous studies,33,34 our study showed low sensitivity lactate clearance showed significant negative correlation (R value as well as partial low specificity of individual ECG sign of ST-segment = -0.380) (p value < 0.05). Of 67 cases studied, 57 (83.8%) required depression or T-wave inversion. But when these signs considered vasopressor support for ≤07 days and 11 (16.2%) for > 07 days, 19 together sensitivity increased significantly and specificity remain (27.9%) required renal replacement therapy, 48 (70.6%) required unchanged for predicting CAD. In the current study, the sensitivity mechanical ventilation, 43 (63.2%) had duration of ICU stay for ≤ 07 of ECG for CAD diagnosis ranged between 15.96 and 48.99% and days and 25 (36.8%) had duration of ICU stay for > 07 days and 33 its specificity ranged from 55.84 to 88.39%, and it matches with the (48.5%) died within 28 days. Discussions: There was no correlation 30,33,34 previous studies. Some studies considered several potential between the lactate level and the PvaCO2 value at baseline, but strategies for overcoming the poor sensitivity of the ECG.30 In our results indicate that a persistently high PvaCO2 gap better predicts a study, stand-alone HST-STA sign additionally detected 29.5% of ACS lower lactate clearance than a low PvaCO2 gap. A positive correlation cases among apparently normal ECGs in patients with suspected is seen between mean lactate levels and the PvaCO2 gap in patients ACS. Conclusion: The HST-STA is an unexplored subtle ECG sign for after 06 hours of resuscitation. This indicates that with adequate the detection of myocardial ischemia in addition to ST depression resuscitation both the mean lactate levels and PvaCO2 gap showed and T inversion in acute coronary syndrome. a significant decreasing trend and are covariant. The negative

correlation between lactate clearance and the PvaCO2 gap showed 2. To Compare the Change in Lactate Levels with Respect to the that with an increase in lactate clearance at the end of resuscitation Venoarterial Carbon Dioxide Gap During Initial Resuscitation of there was an associated drop in the PvaCO2 gap. Hence, both Patients in Shock. (Conference Abstract ID: 158) are covariant in nature and are good markers of improvement in S Col Kiran, Maj Kapil Kulkarni, Brig Rangraj Setlur perfusion. It is also demonstrated that patients who normalize Armed Forces Medical College, Pune, Maharashtra, India their PvaCO2 gap during the early resuscitation period would have DOI: 10.5005/jp-journals-10071-23711.32 a greater lactate clearance than those who did not normalize their

Introduction: Current guidelines for hemodynamic management PvaCO2 gap. Conclusion: Lactate values have a good correlation of septic shock recommends the use of markers of tissue hypoxia with the venoarterial carbon dioxide gap when used for assessment as resuscitation endpoint. In the initial resuscitation period, of the effectiveness of initial resuscitation of patients presenting to targeting either central venous oxygen saturation normalization the ICU with circulatory shock. The venoarterial carbon dioxide gap or lactate clearance, or the combination of both is accepted. is a good predictor of poor outcomes in circulatory shock.

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3. Compliance of Cardiopulmonary Resuscitation During In- the male gender (161 out of 246) compared to the female (85 out hospital Cardiac Arrest in a Teaching Institution. (Conference of 246) and the age distribution were predominant in age group Abstract ID: 153) between 61 and 70 years of age in both gender. Discussions: R Arun Kumar, S Chandresh In our institution, CPR is mandatory to perform for at least 30 PSG Institute Of Medical Sciences And Research, Coimbatore, Tamil to 45 minutes following the cardiac arrest. Among the protocol Nadu, India deviations, reversible causes were not addressed in 10.97% of DOI: 10.5005/jp-journals-10071-23711.33 code blue victims and Use of adrenaline was inappropriate with Introduction: The guidelines for cardiopulmonary resuscitation regard to its dosage, timing, and frequency of administration in emphasize the importance of high-quality CPR in determining 15.43% of victims. Prolonged switch role time during high-quality survival after cardiac arrest, but in clinical practice, the quality and CPR noted in 2.84 and 1.21% had a delay in CPR initiation. 2.43% the parameters of CPR is not routinely measured. Measurements of among arrested victims had difficulty in diagnosing and managing CPR quality during training, actual cardiac arrests, and debriefing the appropriate cardiac rhythm posing difficulty in managing to rescuers during arrests may improve CPR quality at subsequent the coronary event. Documentation of delivery of defibrillation cardiac arrests. Objectives: The main aim of this audit study is to joules was incorrect in 3.25% of cardiac arrest victims. The exact measure the multiple parameters of in-hospital CPR quality and cardiac event at the time of code blue not specified in 5 personnel to determine the compliance with American Heart Association and 3 cases showed inappropriate documentation of code team 2020 and international resuscitation guidelines. Primary objective: members. In few instances, the exact location of code blue was not Compliance with cardiac arrest resuscitation which includes the initial analysis, resuscitation procedures, CPR assessment, addressed (1.21%), outcome measures of cardiac arrest missing in and resuscitation outcome. Secondary objective: Compliance a few documentations (0.81%). 1.21% showed inadequacy in high- on debriefing and audit outcome. Materials and methods: This quality CPR and inadequate airway and ventilation management. is a retrospective observational analysis done in patients who The exact time of death was noted in the right place in two experienced in-hospital cardiac arrest between January 1, 2019, profiles among the 246 audit forms. Unavailability of appropriate and December 31, 2019, after obtaining institutional human ethical airway gadgets not available at few instances (1.21%), Improper committee clearance (PSG/IHEC/2020/Project No. 20/139 dated operating defibrillator in negligible scenarios (1.62%). Unavailable 08.07.2020). The audit was registered in the clinical trial registry of emergency drugs in crash cart very rarely (1.21%) were considered India (CTRI/2020/11/029095). predominant compliance with the resource issues. Improper Inclusion criteria: functioning of laryngoscopes and unavailability of bougie was • All code blue victims. noted in 1.21%. Debriefing was not done regarding the device • Code Blue victims aged between 20 and 80 years. issues once. Delay in the arrival of code place was recorded in Exclusion criteria: 0.81%, failure of suctioning device in 0.81%. False code blue calls • Audit is not done in a pediatric population. were omitted in our audit and cardiopulmonary resuscitation • The victims with impending cardiac arrest where there are signs was commenced immediately following cardiac arrest in all code of spontaneous circulation. The source of our audit study included the cardiac arrest blue victims. There were not any issues with lift malfunctioning, resuscitation form and CPR case sheet audit form maintained in availability of AMBU bag, glucometer, or oxygen source in our our department and CPR committee. Death is not a predetermined code blue scenarios. Team leader assigned appropriate roles and factor to fix the sample size and hence in our study we cannot responsibilities in the catastrophic event. Debriefing was done in fix the sample size. It is hence justified that all cardiac arrest the majority of the cases with found missing in one case among victims are given prime importance to seek the cause of death the 246. Based on our clinical audit following recommendations and auditing need to be done in detail to identify the potential were focussed: cause of death to decrease the mortality and morbidity in near • Good dynamic teamwork for successful resuscitation. future in a teaching institution. The results of the compliance of • To document all cardiac events appropriately. cardiopulmonary resuscitation during in-hospital cardiac arrest in • Manage the cardiac arrest in an algorithmic approach. a teaching institution are discussed under the following headings • Checking the availability of resources at all places. based on the CPR audit findings for every month: 1. Protocol • Debriefing help to decrease the incidence of cardiac arrest deviations; 2. Resource issues; 3. Documentation issues. Results: event and a potential cause can be diagnosed at the right time. Out of 246 cardiac arrest victims, 37.39% (92 out of 246) showed • Frequent basic life support learning sessions to upgrade all compliance in the protocol deviations, 13% (32 out of 246) with medical and paramedical knowledge and effective performance documentation issues, 9.34% (23 out of 246) had resource issues and 40.24% (99 out of 246) showed perfect documentation of CPR. without any corrections or error in the monitoring of the critical Conclusion: To conclude the auditing was done to improve the event. Majority of Code blue was noted in the General medicine quality of healthcare in the resuscitation measures and not to department (26.01%) followed by cardiology (13.82%), gastro focus on the pitfall of the cardiopulmonary resuscitation. In our enterology (13.82%), nephrology (12.19%), neurology (12.19%), audit, we found the issues were more lacking with a performance medical oncology (4.47%), respiratory medicine (6.65%) and other of resuscitation in an algorithmic approach. Good teamwork and specialities with negligible percentage cause of death according adequate knowledge sharing with live demonstrations and practice to departmentwise statistics. Majority of deaths were noted in in mannequins can help improve the quality of performing CPR.

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4. A Descriptive-Analytical Study of the Effect of Thrombolytic parameters with left ventricular outflow tract velocity-time integral Therapy on QT-dispersion in Critically Ill Patients with Acute ST- (LVOT VTI) to assess the effects of PLR test in predicting volume Elevation Myocardial Infarction. (Conference Abstract ID: 116) responsiveness has not been demonstrated in any group of patients. Ankit Laddha, Jain C Subhash This could provide a viable and much simpler alternative to LVOT Jhalawar Medical College, Jhalawar, Rajasthan, India VTI in assessing volume responsiveness with the PLR test. DOI: 10.5005/jp-journals-10071-23711.34 Objectives: Primary: Introduction: A descriptive-analytical study of the effect of • To determine the correlation between carotid blood flow thrombolytic therapy on QT-dispersion in critically ill patients parameters and LVOT VTI in determining volume responsiveness with acute ST-elevation myocardial infarction. Objectives: This with PLR Test. study aims to assess the effect of thrombolytic therapy on QTd Secondary: before and 24 hours after thrombolytic therapy in cases with acute • To determine whether changes in carotid blood flow parameters ST-elevation myocardial Infarction. Materials and methods: The can detect a positive PLR test. critically ill patients with ST-elevation myocardial infarction (STEMI) Materials and methods: A prospective observational study was that underwent thrombolytic therapy were enrolled in this study. conducted from Jan 2019 to November 2020 in the ICU of a tertiary Streptokinase was the thrombolytic agent in all the patients. QT care hospital. Forty patients were enrolled in the study. All patients dispersion using Standard 12-lead ECG was measured before the were screened within 48 hours of admission. Patients enrolled beginning of thrombolytic therapy (QTd1) and 24 hours (QTd2) were evaluated with a 7 to 13 MHz linear transducer probe for after thrombolytic therapy. ECG intervals were measured using carotid flow parameters. Patients were evaluated with a 1 to 5 MHz EP Calipers Software. Results were analyzed using SPSS Software cardiac probe equipped with Tissue Doppler Imaging (TDI) for LVOT version 26.0 and EPIINFO Software. A p value ≤ 0.05 was considered VTI with an apical 5-chamber view. 2 PLR maneuvers (5 minutes statistically significant. Results: This study was conducted on 86 apart) were done within 48 hours of ICU admission. Recordings patients admitted in Medical ICU with Acute ST elevation Myocardial were taken 5 times — Baseline 1, PLR 1, Baseline 2, PLR 2, Baseline Infarction. The results revealed significant difference between 3. The first PLR test was to assess effects on cardiac output using QTd1 and QTd2 (P-value < 0.05) in cases with Acute Anterior Wall LVOT VTI. The second PLR test was performed to assess effects on ST elevation Myocardial Infarction. However in cases with Inferior carotid blood flow parameters. LVOT VTI parameters and carotid and/or Lateral wall Acute ST elevation Myocardial Infarction the blood flow parameters were recorded for both the PLR maneuvers. results were not significant (P-value>0.050). Discussions: Based Patients were designated as volume responders (VR) if a change on the study results, QTd decreased after thrombolytic therapy, in cardiac output using LVOT VTI ≥10 %. All the analyzes were thus thrombolytic therapy had significant effects on QTd2 (QTd carried out using STATA 13 software. Results: 40 patients were after 24 hours). Thus, the risk of dysrhythmia decreased after included in this study. At the time of study, 84% were intubated thrombolytic therapy. Similar to our study, Lörincz et al. assessed and mechanically ventilated. 38 % received vasopressor support. the effect of Streptokinase on QT dispersion. They reported that A positive PLR test was observed in 33 percent of patients using QTd increased at early hours after infarction and thrombolytic cardiac output increase of ≥10%. Strong correlation was present therapy, but decreased 8 ± 2 hours after thrombolytic therapy (1). between absolute values of cardiac output calculated using LVOT Also, Nikiforos et al. studied 60 patients with Acute ST-elevation VTI and absolute values of carotid blood flow (using TAPEAK) Myocardial Infarction to assess the effect of Thrombolytic therapy (r = 0.60, p < 0.05). However, weak correlation was found between on QTd. They concluded that thrombolysis was associated with simultaneous changes in cardiac output calculated using LVOT VTI a significant decrease in QTd on the standard 12-lead ECG (2). and changes in carotid blood flow (using TAPEAK) during PLR (r = Conclusion: Thrombolytic therapy had significant effects on QTd in 0.05, p < 0.74). A positive PLR response could not be detected by cases with Acute Anterior Wall ST-elevation Myocardial Infarction. changes in carotid blood flow (area under ROC curve: 0.59 ± 0.09). Thus, thrombolytic therapy decreases the risk of dysrhythmias in A multiple logistic regression analysis was run to predict cardiac Acute Anterior Wall ST-elevation Myocardial Infarction. output using carotid blood flow, carotid peak systolic velocity, 5. Correlation of Common Carotid Artery Blood Flow Parameters systolic blood pressure and heart rate. These variables statistically With Transthoracic Echocardiography Parameters for Assessing significantly predicted carotid blood flow, F (4,35) = 8.19, p < 0.0005, Volume Responsiveness after Passive Leg Raising Test in Critically R2 = 0.48. Out of the 4 variables, only 2 (carotid blood flow and Ill Patients. (Conference Abstract ID: 105) heart rate) added statistically significantly to the prediction, p < 0.05. Discussions: We found a strong correlation between cardiac Rohit Kumar Patnaik, Bhuvana Krishna output calculated using LVOT VTI and carotid blood flow at baseline. St. Johns Medical College, Bengaluru, Karnataka, India However, simultaneous changes in cardiac output had a very poor DOI: 10.5005/jp-journals-10071-23711.35 correlation with changes in carotid blood flow, during the PLR test. Introduction: The need for fluid resuscitation has been at the Considering this, carotid flow parameters cannot be recommended forefront of treating patients in shock. To administer the right as a means to detect fluid responsiveness with PLR test in critically amount of fluids, we need to know if the patient is volume ill patients. Also, the ability of carotid flow parameters to predict responsive to a fluid challenge. The passive leg raising (PLR) a positive PLR response was not good. Conclusion: Considering maneuver is a simple, noninvasive method of knowing volume this, carotid flow parameters cannot be recommended as a means responsiveness. Correlation between carotid blood flow Doppler to detect fluid responsiveness with PLR test in critically ill patients.

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6. Clinical Profile, Risk Factor Profile, and Outcome of ACS in Young patients of CAD admitted to the Department of Cardiology and Gen. Adults. (Conference Abstract ID: 97) Medicine, SAIMS Medical College, Indore from November 2019 to Ritesh Chauhan, RK Jha, Dinesh Sisodiya November 2020 were included in the study. Another 50 non-CAD Sri Aurobindo Medical College and Postgraduate Institute, Indore, patients were taken as a control group. Results: Total 101 cases Madhya Pradesh, India were taken of which 51 belonged to group 1 (CAD patients) and DOI: 10.5005/jp-journals-10071-23711.36 50 patients to group 2 (non-CAD patients). In CAD group the mean Age, BMI, smokers, TC, S. urea and LDL were significantly higher Introduction: Acute coronary syndrome (ACS) in young patients than that of the non-CAD group (p = 0.008, p = 0.024, p = 0.02, p = is a significantly rising problem all over the world. With increasing 0.021 and p = 0.008, p = 0.000 respectively). Discussions: Epicardial environmental stress and early onset of diabetes mellitus, fat thickness showed a significant correlation with LDL, BMI, and hypertension, dyslipidemia in the Asian continent particularly in Gensini score. These results agree with the results obtained from India. many other similar studies and in Indian studies like Meenakshi et Materials and methods: al. and B Verma et al. • Prospective observational study. Conclusion: Inclusion criteria: All patients, 30 or younger admitted to SAIMS • Increased amount of epicardial fat thickness is associated with Medical College-Indore, with a diagnosis of ACS final diagnosis the increased severity of CAD. of ACS will be based on two out of three of the following criteria: • The 2D echocardiography evaluation of epicardial fat thickness • Ischemic chest pain for at least 30 minutes. can be an easy, noninvasive and inexpensive test to screen the • Electrocardiogram (ECG) evidence of ACS. patient for coronary artery disease. • Rise/fall of the cardiac biomarker troponin I. Exclusion criteria: • Stable angina 8. A Study of Risk Factors and Coronary Angiographic Profile • Age younger than 18 years. in Young Patients with Acute Coronary Syndrome. (Conference • Patients who are unwilling for the study. Abstract ID: 82) Results: Shobhit Gupta, Rajesh Kumar Jha • Out of 39 young MI patients, 37 patients were male and 02 Sri Aurobindo Medical College and PG Institute Indore, Madhya patients were female. Pradesh, India • The mean age of the patients with acute MI was 28.33 years, DOI: 10.5005/jp-journals-10071-23711.38 with a maximum number of patients belonging to the age of Introduction: Acute coronary syndrome (ACS) refers to a broad 25–30 years. spectrum of clinical conditions compatible with acute myocardial • In this study, the chest pain (28, 76.92%) was the most common ischemia and/or infarction that are mostly due to abrupt cessation presenting symptom found in patients with ACS, which is in the blood flow to the coronary circulation. Keeping this in mind, followed by sweating in most cases. A similar finding was a study was planned to know about the clinical presentation, risk reported in earlier studies. factors, and pattern of coronary artery involvement in young Indian Discussions: patients (<40 years) with ACS Materials and methods: Study • Female’s age group is significantly different from males. Design: Hospital-based observational cross-sectional study. Study • Body mass index (BMI) is not significantly different in males and Period: 18 months. Inclusion Criteria: Diagnosed patients of ACS female participants. and needing coronary angiography with age <40 years. Sample • Most common MI observed was STEMI overall. NSTEMI Size: The sample size came out to be 68 which was rounded off to 70. incidence is significantly higher in females (p < 0.001). UA Results: incidence is significantly higher in females (p < 0.001). While a • Majority of patients (47%) belonged to the age group of 36 to significantly higher incidence rate of STEMI ACS was observed 40 years with a male: female ratio of approximately 2:1. in males (p < 0.001). • All the patients were symptomatic with chest pain being the Conclusion: The incidence of acute MI in young patients is most common symptom (96%). increasing day by day which was thought earlier less common • Living in urban areas (67%) & sedentary lifestyle (66%) were among young individuals. This may be because of their lifestyle. common social predisposing factors. Significant association was Young MI is found to be more common in the male gender. seen in the distribution of hypertension, diabetes, obesity and overall number of risk factors with severity of findings in CAG. 7. Correlation of Epicardial Fat Thickness with Severity of Discussions: In our study, the mean age of subjects was 33.8 years Coronary Artery Disease. (Conference Abstract ID: 86) with 66% cases of ACS being STEMI, as compared to the European Sameer Pushpad, Rajesh Kumar Jha heart survey where the mean age was 63 years and 42% cases Sri Aurobindo Medical College and PG Institute, Indore, Madhya were STEMI; CREATE registry with a mean age of 57 years with 61% Pradesh, India patients having STEMI. Thus, most studies show that STEMI is the DOI: 10.5005/jp-journals-10071-23711.37 most frequent presentation of ACS in young. Indian patients are Introduction: Epicardial fat, the adipose tissue accumulated more likely to have early onset of CAD (around a decade earlier than between the visceral pericardium and the myocardium, is a the western population). Conclusion: Our study is a reflection of the metabolically active organ with various bioactive molecules, profile of lower and lower-middle, semi-urban population which is significantly affecting cardiac function. It increases with age, obesity, the huge population burden of our nation. Indians have a different diabetes, and female gender. Materials and methods: The study environmental and genetic makeup that should be kept in mind. was designed as an observational cross-sectional study. Fifty-one This was only a small descriptive study. Large multi-centric similar

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studies are needed to plan preventive strategies to improve the rate to be between 13.4 and 23% following in and out of hospital health status of the huge population of our country. cardiac arrest.8,9 Significantly better survival to discharge rate in the present study could be explained by two attributes. First, being a 9. Outcom.es of Trauma Victims with in Hospital Cardiac Arrest witnessed arrest inside the hospital, there was a timely and quality Who Survived to Intensive Care Unit Admission in a Level 1 Apex initiation of resuscitative efforts by medical personnel, unlike an Indian Trauma Center: A Retrospective Cohort Study. (Conference out of hospital cardiac arrest. This was a major contributor to better Abstract ID: 79) outcomes. Second, a small sample size could have produced an inflated result. Severity scores — APACHE-II and SOFA within the first Nitin Rai, Richa Aggarwal, Kapil Dev Soni, Anjan Trikha All India Institute of Medical Sciences, Jai Prakash Narayan Apex 24 hours were significantly associated with in-hospital mortality in Trauma Centre, New Delhi, India bivariate analysis. Whereas age, duration of CPR, and serum lactate levels were not associated with in-hospital mortality. Conclusion: DOI: 10.5005/jp-journals-10071-23711.39 Resuscitative efforts should be continued despite previous reports Introduction: Patients suffering from trauma-related cardiac 1,2 of terminating over futility as a survival to discharge rate in one- arrest (TRCA) are generally reported to have a poor outcome third of patients is quite significant considering the perspectives and arguments for the futility of aggressive support have been 3,4 of previous data. An investigation into whether optimization of made for this patient population. In our study, we propose to post-resuscitation factors would improve the outcome for these determine the factors related to outcomes for patients following patients may be warranted. in-hospital cardiac arrest post-trauma and admitted to the intensive care unit (ICU) and to identify characteristics associated with 10. Outcome of Out of Hospital Cardiac Arrest Patients Arriving at in-hospital mortality. This will help to the optimization of specific a Tertiary Care Urban Hospital in India. 2-Year Data Analysis From post-resuscitation physiologic parameters could similarly improve Online Portal www.aocregistry.com. (Conference Abstract ID: 43) the outcome for patients resuscitated from TRCA. Objectives: (1) to determine outcomes of patients following in-hospital cardiac Anuj Clerk, Krunalkumar Patel, Nikita Desai, Himani Garasia, arrest post-trauma and admitted to the intensive care unit (ICU) and Nilesh Thumar, Rakesh Mangrolia, Bhargav Umaretiya Sunshine Global Hospital, Surat, Gujarat, India (2) to identify characteristics associated with in-hospital mortality. Materials and methods: This was a retrospective single-centered DOI: 10.5005/jp-journals-10071-23711.40 observational study of the patients admitted to Level 1 Apex Introduction: Survival from cardiac arrest remains poor and Trauma Centre ICU following in-hospital cardiac arrest between for meaningful research in India, one needs to first standardize January 2017 and July 2018. Details of the patients were retrieved treatment and documentation, before multicentric data can be from paper-based registers/ICU registry/hospital medical records pooled to create a large database. Arrest Outcome Consortium section retrospectively. Inclusion criteria were post-cardiac arrest online Registry (www.aocregistry.com) is an online database created patients following trauma and being admitted to polytrauma for the same. Initial analysis of single-center data is presented here ICU following resuscitation. Patients with isolated head injuries as a test of its functionality. Materials and methods: CPR Data of 200 and multiple cardiac arrests were excluded. Data were screened beds, an urban hospital for the year 2018 and 2019 were collected and the following factors were recorded — duration of CPR, in a standardized format, uploaded, and analyzed on the AOC mechanism of injury, place of cardiac arrest, cause of cardiac arrest Registry web portal. Descriptive statistics downloaded from the and GCS on arrival to ICU, vasopressors/inotropes requirement and portal and statistical analysis was done using SPSS software. Results: duration, severity scoring — APACHE-II and SOFA. Institute Ethics Out of 250 cardiac arrests in 2 study years, 62 were OHCA and all Committee clearance was obtained before the study (Ref. No. IEC- received CPR. Average age, equal in both gender was 57 years. 155/05.04.2019). Results: A total of 37 patients were included in the Bystander CPR rate among OHCA were 12.9%. Among all OHCA, study. Out of these 31(83.8%) were male and 6 (16.2%) were female. Asystole was the most common first rhythm [47 (75.8%)], followed Long bone fracture followed by blunt trauma abdomen (BTA) and by VF-VT [8 (12.9%]) and PEA [7(11.29%)]. Out of 19 who survived blunt trauma chest (BTC) were the most common modes of injury on initial CPR,10 were alive on discharge16.12% [10 of 62] and 9 contributing 24.2% and 18.2% each respectively. Mean duration died. At discharge 8.1% [5 of 62] had good [CPC≤2] neurological of CPR was 22.7 minutes. The mean duration of vasopressor days status. There was no significant difference in survival between was 4.9 days. The mean APACHE 2 and SOFA scores were 25.8 and male 16.0% [8 Out of 50 survived] and female 16.6% [2 Out of 12 12.8 respectively. The average ICU and hospital length of stay were survived]. Best neurological survival was with VF/VT as first rhythm. 4.9 and 6.1 days respectively. 35.1% patients survived to hospital Multivariate regression analysis showed, First rhythm and admission discharge. APACHE 2 and SOFA within first 24 hours were associated lactate influence ROSC; but only First rhythm influence survival at significantly with in hospital mortality in bivariate analysis. 13 out discharge. Discussions: To encourage out-of-hospital bystander of 37 (35.1%) patients survived to hospital discharge. Discussions: CPR, we need research on OHCA. For which large multicentric data This study was an attempt to elucidate the factors associated with are required, for which online portal like AOC registry can help. In the outcomes following in-hospital cardiac arrests. Most of the this study, single-centered data analysis is displayed as an initial studies have analyzed out of hospital cardiac arrests or cardiac report as an example and the beginning of the process. So, we arrest occurring in the ED.5–7 Thirteen out of 37 (35.1%) patients encourage multiple centers to participate to create a large scale survived hospital discharge. Traditionally, survival after cardiac database for more meaningful research. Conclusion: Survival at arrest is generally considered abysmal. There has been a long- discharge was best with VF/pVT as the first rhythm. AOC registry term debate over for futility of aggressive support for this patient portal could provide descriptive statistics, which can be used for population.3,4 Previous observational studies found the survival inferential analysis. The large sample size is required for statistical

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analysis among subgroups, which is possible one multiple center caeruleus (Indian krait), Daboia russalie (Russell viper), and Echis data compiled on the web portal or online CPR registry (www. carinatus (saw-scaled viper). Neuroparalytic snake bite is a common AOCRegistry.com). medical emergency encountered in tropical countries especially in the rainy seasons and in rural areas. The onset of neuroparalysis 4. Case Report: Poster Only may take ½ to 6 hours in cobra bite and 6 to 24 hours for krait bite.2 Neurological symptoms usually appear in the sequential order starting from furrowing of the forehead and progressing to 1. Autonomic Dysfunction with Areflexic Quadriplegia: An ptosis, diplopia, dysarthria, dysphonia, dyspnea, and dysphagia Unusual Presentation of Snake Envenomation. (Conference (involvement of 3rd, 4th, 6th, and lower cranial nerves) and finally Abstract ID: 199) involvement of intercostal and skeletal muscles. The limb-girdle Harpreet Singh, Deepak Chaudhary, Navneet Sharma, H Mohan muscles are involved before the distal muscles leading onto Kumar complete quadriplegia.4 Due to the absence of reflexes and total GMCH, PGIMER Chandigarh, India ophthalmoplegia in severe snake envenomation, it may resemble DOI: 10.5005/jp-journals-10071-23711.41 brain death or a locked-in state.4,5 The neuroparalysis occurs Introduction: Rapidly progressing descending areflexic quadriplegia due to the neuromuscular junction blockade by a presynaptic with autonomic dysfunction in the form of hypertension, neurotoxin in krait bite and postsynaptic neurotoxin in cobra tachycardia, hypersalivation, sweating, and lacrimation in the bite. Dysautonomic features due to elapid envenomation include absence of proper history from attendants poses a challenge in an hypertension/hypotension, rhythm disturbances, tachycardia/ emergency area. Neuroparalytic snake envenomation by elapid bradycardia, pupillary abnormalities, excessive sweating, salivation, species has been known to produce autonomic symptoms and even lacrimation, chemosis, abdominal pain, vomiting, paralytic ileus, and locked-in states. Here, we present a case of a young male with rapidly constipation. In a study from Sri Lanka, hypertension, tachycardia, progressing areflexic quadriplegia with autonomic dysfunction; lacrimation, sweating, and salivation were documented in around with no documented history of snakebite who improved after 66% of cases of common krait bite (Bungarus caeruleus) and 6 anti-snake venom and ventilatory support. Objectives: To highlight were seen in patients with severe envenomation. All patients unusual presentation of neuroparalytic snake bite. Materials and of Malaysian krait (Bungarus candidus) envenomation in the case methods: A 16-year-old young man was admitted to the emergency series from Thailand had high blood pressure, tachycardia, and department with bilateral drooping of eyelids and weakness of mydriasis. The dysautonomia that occurs after snake envenomation all four limbs. On history taking, his attendants disclosed that he has been proposed to result both from presynaptic action of had been bitten by their pet dog on the left side of his chest 10 neurotoxin on the parasympathetic ganglia causing blockade days ago. At a local center, he had been administered one dose of and due to inhibition of presynaptic-a2 adrenergic receptors; tetanus toxoid and anti-rabies vaccination had been started. On which inhibits the neurally mediated discharge of norepinephrine clinical examination, he had a pulse of 125/minute, blood pressure resulting in sympathetic hyperactivity. Our patient exhibited of 150/95 mm Hg, complete ophthalmoplegia, preserved pupillary tachycardia, excessive salivation, sweating, mild hypertension, reflexes, mydriasis, salivation, excessive sweating, bilateral ptosis, and mydriasis simultaneously as a manifestation of neurotoxic areflexic quadriplegia, and hydrophobia and aerophobia could not snake envenomation induced sympathetic over activity. Dilator be elicited. The patient was put on mechanical ventilatory support pupillary muscle predominantly contains α-1 (sympathomimetic) for respiratory failure and 20 vials (200 mL) of polyvalent anti-snake receptors, whereas the constrictor pupillary muscle has abundant venom (Bengal Chemicals, Kolkata, India) were administered. All acetylcholine receptors. The sphincter pupillae muscles have a large blood investigations were within normal limits. Over the next 48 concentration of acetylcholine and a profuse microvasculature hours, he continued to have tachycardia in the range of 110 to 130 that allows the concentration of venom at this site resulting in an beats/minute with a systolic blood pressure of 140 to 150 mm Hg irreversible blockade of acetylcholine receptors causing dilated and and a diastolic pressure of 90 to 95 mm Hg that did not require any non-reacting pupils. Besides the use of mechanical ventilation for antihypertensive therapy. His clinical condition improved after 6 respiratory failure in neuroparalytic snake bites, the management days. He was extubated and discharged after 7 days of admission. of autonomic dysfunction requires intravenous administration of A final diagnosis of snake envenomation induced autonomic anti-snake venom and general supportive measures. Although our dysfunction was kept due to improving the muscular weakness, patient did not require antihypertensive medications, yet, studies respiratory failure, and dysautonomia after anti-snake venom have used intravenous nitroglycerin for severe hypertension treatment. The possibility of rabies (encephalitic or neuroparalytic induced by venomous snake bite. A combined α and β blocker form) was excluded because of a preserved sensorium and the like labetalol would be ideal in this situation but this indication for absence of aerophobia and hydrophobia. The pet dog that had use of labetalol has never been studied. Conclusion: To conclude bitten him was alive and healthy. Discussions: Although the a differential diagnosis of elapid snake envenomation should be World Health Organization states that the annual mortality due kept in a patient of rapidly progressive areflexic quadriplegia with to snakebite is approximately 81,000 to 138,000 worldwide, yet, autonomic dysfunction in absence of clear history. around thrice this number live and are left with residual motor impairment and debilities. A recent study has calculated the snake 2. Myasthenia Gravis—A Rare Cause of Weaning Failure in a bite-related deaths in India at around 1.2 million (around 58,000 Postpartum SLE Patient. (Conference Abstract ID: 196) annually) from 2000 to 2019.1 The main families of venomous Tejasri Ketireddy, Padmaja Durga, Abhiruchi Patki snakes in India are: Elapidae, Viperidae, and Hydrophidae (sea Nizam’s Institute Of Medical Sciences, Hyderabad, Telangana, India snakes). Main Indian elapids are Naja naja (Indian cobra), Bungarus DOI: 10.5005/jp-journals-10071-23711.42

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Introduction: SLE and MG are two different clinical syndromes, and common complications in the natural history of myasthenia which can coexist or precede each other but their occurrence gravis. MC is observed frequently within the first two years following in the same patient is rare. The systemic lupus erythematosus the onset of the disease. As in our case, delayed MG diagnosis may (SLE) is a systemic autoimmune disorder affecting predominantly present with MC and respiratory failure may be the first symptom young women characterized by multiorgan dysfunction and of myasthenia gravis. MG and MC must be considered especially the production of multiple autoantibodies. Myasthenia gravis in patients who have unexplained respiratory failure requiring (MG) is an organ-specific autoimmune disease characterized prolonged mechanical ventilation and weaning failure. Conclusion: by dysfunction of the neuromuscular junction mediated by Myasthenia gravis is a rare and unusual cause of respiratory distress autoantibodies resulting in muscle weakness. Both the conditions in the postpartum period. The possibility of exacerbation of SLE are known to be aggravated in pregnancy. Myasthenic crisis is a had delayed the diagnosis but a keen observation of subtle signs complication of myasthenia gravis characterized by worsening enabled the diagnosis of a rare myasthenia gravis which can of muscle weakness, resulting in respiratory failure that requires present with weaning failure. Thorough preoperative evaluation, intubation and mechanical ventilation. Weaning in patients optimization, proper intraoperative care, and postoperative with myasthenic crisis (MC) from mechanical ventilation is often intensive care management lead to a favorable outcome which difficult. We present a case of weaning failure in a postpartum requires a multidisciplinary team approach. young woman, presenting to us in intensive care with a history of SLE, incidentally diagnosed to have MG. Materials and methods: 3. Early Tocilizumab Therapy in Severe COVID, Boon or a Bane: A A 29-year-old primi with a history of SLE since 2 years on regular Case Report and Critical Appraisal. (Conference Abstract ID: 183) treatment, was shifted to RICU, 4 days post elective LSCS following her first pregnancy, after being mechanically ventilated for a day Shailendra Shivhare, Ravi A Dosi, Ankur Agrawal, Kamendra S due to sudden onset respiratory failure and epileptic seizures Panwar, Prakash Joshi, Piyu Jain, Gaurav Jain, Pradeep Rajoriya, in the emergency room. Differential diagnosis of flaring of SLE, Jyoti Jaiswal, Manglesh Gupta, Ravindra Kumar Patidar SAIMS Indore, Madhya Pradesh, India PRES, eclapmsia was ruled out after investigations. Weaning attempts repeatedly failed despite good GCScore, motor activity, DOI: 10.5005/jp-journals-10071-23711.43 normal chest radiography, and ABG analysis. On the third day of Introduction: Pneumonia with severe respiratory failure presentation, a left-sided pleural effusion with collapse was noticed represents the principal cause of death in COVID-19, where and drained. Bronchoscopic removal of the left bronchial mucus hyper-inflammation plays an important role in lung damage. An plug was carried out, which resolved the collapse. Unsuccessful effective treatment aiming at reducing the inflammation without attempts of weaning followed for a few more days. On the eighth preventing virus clearance is thus urgently needed. Tocilizumab, day of presentation, B/L (L>R) ptosis was noted with a QMG score an anti-IL-6 receptor monoclonal antibody, has been proposed for of 14. A diagnosis of MG was made after a positive tension test and the treatment of patients with COVID-19. Early use of tocilizumab the presence of AchR antibodies. Quinolines were omitted in the prevents sudden deterioration of patient but after 15 days cavitary treatment chart and pyridostigmine 60 mg QID was started. There lesions are found in HRCT chest which is manageable. Objectives: was a significant improvement in ptosis after 48 hours of starting To discuss the use of early tocilizumab in severe COVID pneumonia pyridostigmine. The patient tolerated T-PIECE trails well, weaned patients. Materials and methods: A 46-year-old Indian man off mechanical ventilation after one cycle of plasmapheresis, and presented in casualty with the complaint of shortness of breath, was discharged from RICU with stable vitals on room air. Results: cough fever since 5 days admitted in COVID ward after COVID-19 Due to unsuccessful weaning attempts, possibility of Myasthesia RT-PCR tested positive HRCT chest shows 90% lung involvement. Gravis was considered and a QMG score of 14 was observed and The initial patient was vitally stable with SpO2 98 with 15 L oxygen a diagnosis of MG was made after a positive tensilon test and support NRBM, respiratory rate was 18/minute. ABG shows mild presence of AchR antibodies and was started on pyridostigmine hypoxia. On day 2, the patient started deteriorating, not maintaining 60mg QID. Patient tolerated T-PIECE trails well, weaned off saturation on NRNM support taking on NIV support. Worsening mechanical ventilation after one cycle of plasmapheresis and was of blood marker started. We plan for use of early tocilizumab 400 discharged from RICU with stable vitals on room air. Discussions: mg. The next day tocilizumab was given. The patient intubated Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) and took on AC/VC support. After 5 days, the patient successfully are two autoimmune diseases that have a higher incidence in extubated. On the seventh day, the patient extubate Results: Use young females, relapsing-remitting course, and positive antinuclear of early tocilizumab prevents sudden deterioration of patient with antibodies. MG is an autoimmune disease of the neuromuscular 90% lung involvement but after 20 days cavitary lesions found junction, which results from the presence of postsynaptic which is manageable. Discussions: The patient came with severe acetylcholine receptor antibody (IgG). It is characterized by skeletal pneumonia due to COVID. Tocilizumab was given on the third muscle weakness and easy fatigability and has a chronic course with day of admission. The blood marker shows regular improvement. remission and exacerbation. Common precipitating factors for MC The patient intubated then extubated. Cavitary lesion developed. include respiratory infections (Klebsiella pneumoniae), aspiration, Oxygen requirement slowly decreases. Bronchoscopy shows normal sepsis, surgical procedures (post LSCS), rapid tapering of immune findings. BAL shows tubercular etiology. ATT started. After 30 modulation agents, starting corticosteroids treatment (known days, the patient successfully discharge. Conclusion: Tocilizumab SLE), exposure to drugs antibiotics (levofloxacin) that may increase can be beneficial to the suddenly deteriorating patients due to myasthenic weakness and pregnancy. MC is one of the important hyperimmune reaction if the timing of administration is right.

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4. Subcutaneous Emphysema and Unexpected Difficult Tracheal the experiences and continuous updating can go a long way in Intubation in COVID Patient—An Anesthetic Challenge. managing serious patients. (Conference Abstract ID: 181) Ksheerabdhi, B Gayathri, A Sujina Hermin 5. Stroke, Endocarditis with Limited History a Serious Challenge. SRM Medical College Hospital and Research Centre, Kanchipuram, (Conference Abstract ID: 178) Tamil Nadu, India J Nikhat Sultana, K Subba Reddy, Munshi Intekab Alam DOI: 10.5005/jp-journals-10071-23711.44 Apollo Hospital Jubilee Hills, Hyderabad, Telangana, India Introduction: Subcutaneous emphysema is a rare complication DOI: 10.5005/jp-journals-10071-23711.45 of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Introduction: A 60-year-old man was brought to the hospital pneumonia that should prompt immediate attention to find after developing sudden onset of weakness and altered its cause. Subcutaneous emphysema (SE) occurs when gas or sensorium in a flight. On arrival, the patient was drowsy and no air infiltrates the subcutaneous layer of the skin. Materials and history was available investigations revealed that he had right methods: A case study discussion on a patient admitted in COVID parietal infarct and was also supposed to have undergone a ICU with features of subcutaneous emphysema to evaluate the cardiovascular procedure which was confirmed as aortic valve challenges faced by the anesthesiologists in intubating the patient replacement by transthoracic echocardiography. Blood cultures inside COVID ICU. Results: A 60 year female patient was admitted grew Staphylococcus aureus (MRSA) antibiotics were started based in COVID ICU with complaints of breathlessness and tachycardia. on culture and sensitivity during his stay in hospital there was Patient was tested positive in RT PCR for covid 19 virus.ON the second a progressive growth of vegetation on the aortic valve despite day of admission in COVID ICU, patient developed subcutaneous treatment along with persistent arrhythmia and hypernatremia. emphysema. Initially saturation was maintaining with facemask The patient had a cardiac arrest after arrhythmia and died with on four litres O2. Gradually the oxygen requirement was increasing endocarditis despite aggressive therapy. Discussions: Unknown and the patient was changed to NRBM .Later the Pao2/Fio2 reduced patient with no available history possessed a great challenge in this to less than 150 with 15 L of O2 on NRBM so the patient was put case despite early recognition and aggressive therapy endocarditis on NIV. On day seven of admission into ICU the patient developed was persistent. Conclusion: History plays a very important role in desaturation inspite of maximal support with NIV, hence decided the diagnosis of the patient. treatment of prosthetic aortic valve to intubate. Suction was kept ready 7" and 7.5" cuffed portex tube endocarditis is a challenge as therapeutic concentration is not was kept ready Inj.fentanyl 100 mcg, Inj.propofol 100mg iv and Inj. reached. A careful and guided approach is required in such cases. scoline 100 mg iv given .On putting the laryngoscope only epiglottis was seen, immediately the scope was withdrawn and ambu 6. MDI or Nebulization in Moderate to Severe COVID-19 Disease ventilation was done with 100% O2. second time, intubation was attempted with Mccoy blade ,still the vocal cord cannot be made with COPD: Which One is Better? (Conference Abstract ID: 174) out. on the third attempt VDL was used and result was the same, Prakash Gondode, Geetanjali Chilkoti, Spriha Tiwari and the patient started desaturating .4" classic LMA was inserted All India Institute of Medical Sciences Nagpur, University College Of Medical Sciences, Delhi, India and connected to ventilator with 100% Fio2, saturation picked up. surgical team was called and emergency bedside tracheostomy DOI: 10.5005/jp-journals-10071-23711.46 performed. Discussions: Incidence of subcutaneous emphysema Introduction: Aerosol bronchodilator therapy via nebulization, (SE) has been increasingly reported in COVID-19 cases. Sayan et al. using a nebulizer or metered-dose inhaler (MDI) with a spacer published a case series of 11 cases of COVID-19 patients developing device or dry powder inhaler is the mainstay in the treatment SE and spontaneous pneumomediastinum (SPM) without invasive of COPD. We, herein, discuss two such cases with corresponding ventilation. Out of these 10 patients had SPM and 9 patients had concerns related to various modes of bronchodilation in moderate developed pneumothorax. Patients developed SE on an average of to severe COVID-19 patients with COPD. Two COVID-19 patients 13.3 days. He noted that patients who were on invasive, noninvasive (60 years/M and 55 years/M) with COPD presented with worsening ventilation, high-flow nasal oxygen HFNO and even on NRBM were fever, cough, and shortness of breath for around 10 days. Chest developing SE and SPM. The predominant pathology in COVID- radiographs revealed mid and lower lung zone involvement 19 is interstitial and alveolar inflammation. Focal hemorrhage, in both. Both received tazobactam-piperacillin, teicoplanin, alveolar exudates, and pulmonary interstitial fibrosis have also ivermectin, hydroxychloroquine, enoxaparin, dexamethasone, been noted. In many lung specimens on postmortem examination, salmeterol MDI, multivitamin, and received oxygen via high FiO2 exfoliation of bronchial epithelial and sudden caliber reduction in non-rebreathing mask and maintained 92 to 94% oxygen saturation the dichotomic tracts were seen. The excessive airway involvement and 24 to 32 breaths/minute. We observed their inability to attain and decreased lung compliance may be the triggering factor an optimal peak inspiration with MDI and thus increased the dose making the alveoli more prone for rupture resulting in SE and SPM. to @ 4 to 6 puffs. Following no improvement, nebulization was In addition, our patient was a known case of bronchial asthma started. With the improvement in peak inspiratory flow rate, the since childhood and probably this could have further increased MDIs were reinstituted. The pulmonary symptoms improved and her chance of development of SE. Although SE is a benign finding both the patients were discharged subsequently. Discussions: the development of spontaneous pneumothorax and SPM should Bronchodilator delivery by MDI or wet nebulizer is equivalent alert the physician to carefully monitor the possible worsening. in the acute treatment of adults with airflow obstruction. 1 A Conclusion: Difficult airway in COVID patients can be extremely Cochrane review 2 observed no significant difference in FEV1 at perplexing. Being honest with our thoughts, reflecting and auditing 1 hour after dosing between nebulization and MDI; however, an

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improved FEV1 trend was observed with nebulization.2 In critically days, appropriate sensitive antibiotics are given. Dysphagia was ill patients, nebulization is preferred over MDI or DPI as the latter still present and HRCT chest done, showed grade left upper lobe needs an optimal peak inspiratory flow rate (~60 L/minute) which is increased attenuation likely suggestive of consolidation patch/? often compromised in critical illness. During the COVID pandemic, A neoplastic lesion with hydropneumothorax and ground-glass bronchodilation via nebulization has got a serious concern, i.e., opacities. Contract enhance commuted tomography is done for the nebulizers produce small- and medium-size aerosol range and further evaluation and revealed grade 2nd/3rd hiatus hernia can disperse viral particles in exhaled air >0.8 m from the patient with air channel from the herniated portion into left pleural and remain airborne for more than 30 minutes.3 Thus, a potential cavity suggestive of esophageal pleural fistula. Results: The exposure threat to healthcare workers (HCW). It should preferably diagnosis of EPF is difficult as the clinical sign and symptom be provided in isolation within negative pressure rooms with are nonspecific. The findings on the chest radiograph are providers donning all personal protective equipment. The expert nonspecific and include pleural effusion, pneumothorax, or consensus guidelines recommend replacing nebulization with MDIs hydropneumothorax. contrast enhanced CT is often required to in COVID-19 disease; however, no dogmatic guidelines or protocols confirm the diagnosis. Discussions: We must consider EPF as a in this context.4 As far as pathophysiology is concerned, COPD is an possible cause of non-resolving pleural effusion with large and obstructive airway pathology characterized by expiratory airflow continuous intercostal Drainage. Even in a patient who does not limitation due to chronic inflammation of the large central airways, have a history of predisposing factors such as surgery, esophageal peripheral bronchioles, and destruction of lung parenchyma. On instrumentation, etc., spontaneous EPF should be suspected. the contrary, in COVID-19, Mu et al. observed it to be primarily a Early suspicion leads to prompt diagnosis and treatment with restrictive ventilatory defect along with impairment of diffusion in turn decreases morbidity and mortality. Conclusion: Pleural capacity as reflected by the pulmonary function tests in 110 effusion (accumulation of fluid in the pleural space) can pose a discharged survivors with COVID-19.5 Therefore, COVID patients with diagnostic dilemma to the treating physician because it may be COPD may present with mixed pattern (obstructive and restrictive) related to disorders of the lung or pleura or a systemic disorder. which may affect the performance of the aforementioned modes of While differential diagnosis is made, rare causes should also be bronchodilation. Conclusion: We emphasize the need for assessing kept in mind unless proved otherwise. the risk-benefit ratio related to the safety of HCW with the use of MDI plus spacer vs the risk of clinical deterioration by avoiding 8. Multiorgan Infarct Due to Extensive Thrombosis in nebulization in patients with COVID-19 disease with COPD. We Numerous Arteries in COVID-19 Patient Even after Adequate also recommend the need for further research and evidence-based Thromboprophylaxis. (Conference Abstract ID: 168) concrete guidelines in context to the favorable mode of inhaled R Hariprasad, Sadik Mohammed, Makam Shri Harsha, Pradeep bronchodilator in COVID-19 disease. Kumar Bhatia AIIMS, Jodhpur, Rajasthan, India 7. A Rare Case of Esophageal-pleural Fistula Presented Initially as DOI: 10.5005/jp-journals-10071-23711.48 Pleural Effusion with Lung Collapse. (Conference Abstract ID: 173) Introduction: Ravindra Kumar Patidar, Ravi A. Dosi, Ankur Agrawal, Kamendra • COVID-19 is a thrombotic state (hypercoagulable) S Panwar, Prakash Joshi, Piyu Jain, Gaurav Jain, Jyoti Jaiswal, • Incidence of thromboembolic complications: Manglesh Gupta, Shailendra Shivhare • DVT: 25%. SAIMS, Indore, Madhya Pradesh, India • Combined DVT, PE, and arterial thrombosis: 31%. DOI: 10.5005/jp-journals-10071-23711.47 • Anticoagulation therapy is recommended to prevent Introduction: Esophageal pleural fistula is an abnormal thrombotic complications. connection between the esophagus and pleura. Most cases are • Rare case of extensive thrombosis of abdominal arteries — due to the postsurgical, post-esophageal endoscopic procedure, multiorgan infarct being reported first time even after giving esophageal carcinoma, or tuberculosis, chemical injuries, or anticoagulation prophylaxis. spontaneous. It is a rare entity with a high degree of morbidity Materials and methods: Case and mortality. Objectives: Our objective by presenting this case • A 60-year-old male, k/c/o hypertension on medication, to increase awareness among pulmonologists/physicians for this diagnosed to have COVID-19 pneumonia, with SpO2 of 85% on condition as being a rare entity, mostly initially presented with 15 L/minute O2 through a face mask. non-specific symptoms. Materials and methods: A 35-year-old • Fully conscious, with normal vitals admitted in ICU. Indian woman was presented in casualty with a complaint of Results: Treatment given: fever, body ache, and decrease appetite in the last 7 to 8 days • Azithromycin 500 mg od associated with difficulty in breathing and swallowing since • Dexamethasone 6 mg IV od same time interval. Initially diagnosed as acute febrile illness • Remdesivir 100 mg IV od and routine investigations are done. Chest X-ray was suggestive • LMWH 0.4 mL SC bd COURSE IN ICU: DAY 5: Developed severe, of left-sided hydropneumothorax with underlying lung collapse. constant abdominal pain. An intercostal chest tube is placed in situ and pale yellow pleural • P/A: Soft, tender in umbilical, hypogastric area fluid drained and sent for investigations and s/o negative for AFB, • CECT Abdomen: Superior mesentric artery (SMA) thrombus, malignancy and with sugar 20, total proteins 2.07, albumin 0.96, edematous wall bowel loops, caecum, colon. cell count 38,400, neutrophils 80, lymphocytes 10, RBC 640/cmm, • Thrombolysis with streptokinase done, Heparin therapeutic ADA 262, the culture showed growth of Klebsiella pneumoniae, bolus dose followed by infusion given, aPTT targeted for 3 times and then the growth of Escherichia coli in repeat culture after 10 normal. DAY 6,7 : Abdominal pain improved, passed stools.

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Oral liquid started DAY and: Pain increased, whole abdomen was distended, dilated veins were visible, and the umbilicus tender, gaurding. Emergency laparotomy done and bowels was inverted. Liver span was 8 cm. He had cardiomegaly and excised. CECT Abdomen: Massive infarct in spleen, Multiple pulmonary plethora and ECG was suggestive of complete heart Massive infarct in both kidneys, ischaemic bowel loops. Celieac block. Echocardiography revealed small ostium Secundum ASD artery, bilateral renal artery, splenic artery occluded Emergency (6 mm) and normal ejection fraction. Ultrasound cranium and Laparotomy and ischaemic bowel loops excised. POD1: He fundus examination were normal. The possibility of neonatal lupus developed refractory hypoxemia, shock and cardiac arrest and was considered. Anti-Ro and Anti-La antibodies of the mother died on POD 1. (>100 and 32 IU/mL, respectively) and baby ( >240 and 15 IU/mL, Course in ICU: respectively) were suggestive of NLE. Mother was positive for anti- Day 5: Developed severe, constant abdominal pain. nuclear antibodies (++++). The baby had episodes of anemia and • P/A: Soft, tender in umbilical, hypogastric area. thrombocytopenia during the hospital stay which were supported • CECT Abdomen: appropriately. He had conjugated hyperbilirubinemia (total and Discussions: Pathophysiology of COVID-19 Induced conjugated bilirubin of 5.26 and 2.54 mg/dL on day 1 which rose Hypercoagulopathy: to a maximum of 11 and 6.15 mg/dL on day 17 of life, respectively), • Multifactorial. raised transaminases (aspartate aminotransferase, 380 mg/dL • Acute inflammatory response: cytokine stromeà activation of and alanine aminotransferase, 242 mg/dL), and hypothyroidism platelet, endothelial cells, tissue factor, changes in levels of (TSH = 8.47; T3 = 0.317; T4 = 7.72). Hyperbilirubinemia persisted thrombomodulin, proteins C and S. despite correction of the hypothyroidism. There was no evidence • Binding of SARS-CoV-2 to angiotensin-converting enzyme à of hemolysis (plasma hemoglobin 125; negative direct Coombs endothelial activation. test) and intrauterine infections. At admission, he was started on • Bedridden. isoprenaline, continuous positive airway pressure (CPAP) through • Presence of large vascular catheters. nasal prongs, and diuretic for bradycardia, respiratory distress, and Conclusion: congestive heart failure, respectively. An epicardial pacemaker • COVID-19 patients can develop thromboembolism even after (paced with a heart rate of 120/minute) was implanted on day 18 of adequate thromboprophylaxis. life. At 48 hours of surgery, he could be weaned from the ventilator • Thromboprophylaxis to be started either with LMWH, heparin. and extubated to oxygen with nasal prong CPAP. Improvement in • Point of care ultrasound (POCUS) screening should be done for heart rate, aggressive diuresis, and correction of hypoalbuminemia early diagnosis of any thrombotic complication. led to resolution of pulmonary and corporeal edema, ascites, and • PT/INR, aPTT, D-dimer to be monitored every 48 hours. hepatomegaly by day 25 of life. Despite the clinical improvement, he could not be weaned from nasal prong CPAP. Chest radiograph 9. Managing Bilateral Phrenic Nerve Palsy in Neonatal Lupus suggested small volume lungs and the elevated diaphragm; Erythematosus with Intravenous Immunoglobulin: A Case Report. bilaterally decreased movements of the diaphragm was detected (Conference Abstract ID: 161) on fluoroscopic examination. A nerve conduction study done on 29 days of life revealed bilateral phrenic nerve palsy (prolonged Choudri Muzafar Paswal, Arun Kumar Baranwal, Navpreet Kaur latencies and reduced amplitude). The child was given intravenous PGIMER Chandigarh, India immunoglobulin (IVIg) (2 g/kg over 2 days) on 31 days of life. DOI: 10.5005/jp-journals-10071-23711.49 Results: Two weeks later, he could be made off oxygen support and Introduction: Neonatal lupus erythematosus (NLE) is a syndrome repeat fluoroscopy revealed normal diaphragmatic excursion. Nerve characterized by skin lesions and/or cardiac complications conduction study (at 4 weeks of IVIg) revealed improvement in right and multisystem abnormalities in babies born to mothers phrenic nerve, while left one could not be stimulated. Hemogram with autoantibodies against Ro, La, and, less commonly, and Liver function test improved thereafter. He is gaining weight U1-ribonucleoprotein (U1-RNP). Neurological abnormalities and acquiring developmental milestones normally. Discussions: include hydrocephalus, macrocephaly, aseptic meningitis, Phrenic nerve palsy with or without peripheral neuropathy is myelopathy, and spastic paraparesis, however, phrenic nerve reported in adults and children with SLE. Pathogenesis includes palsy has not been reported in the English language literature. immune complex deposition and vasculitis of vasa nervorum, Materials and methods: A 2-day-old male neonate presented axonal degeneration, demyelination, and antibody-mediated with persistent respiratory distress since day 1 of life. He was damage to other components of the neural tissue. Adults present born to a hypothyroid mother at term by vaginal delivery. His with dyspnea, have elevated dome(s) of the diaphragm on chest birth weight was 2.5 kg. Antenatal ultrasound in the 29th week radiograph and restrictive pulmonary functions. A persistent of gestation had shown fetal bradycardia, complete heart block, requirement of respiratory support, small volume lungs, and and hydrops (moderate ascites, pericardial effusion). At 7 hours elevated diaphragm despite pacemaker implantation, successful of postnatal life, he developed respiratory distress which was treatment of congestive heart failure, and neonatal sepsis led to managed with oxygen by nasal prongs and IV fluids and was the suspicion of diaphragm dysfunction, which was confirmed on referred to us. He was first born to non-consanguineous parents. fluoroscopy and nerve conduction studies. Extensive dissection Family history was not suggestive of autoimmune disease and the during cardiothoracic surgery is a common cause of postoperative mother was asymptomatic. Examination at admission revealed phrenic nerve palsy and diaphragmatic dysfunction, with the generalized edema, bradycardia (heart rate, 48/minute), tachypnea, majority having unilateral phrenic nerve palsy. However, it rarely abnormal peripheral circulation. His saturation was 88% on room occurs with pacemaker implantation. Bilateral involvement air and improved to 98% on nasal prong oxygen. The abdomen and multisystem dysfunction (cardiac, thyroid, hepatologic,

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hematologic) suggest maternal autoantibodies to be responsible rate 120/minute, respiratory rate-42/minute, BP-94/60 mm Hg, for it. Though diaphragmatic hypoplasia is described with NLE, and SpO2-70% on room air. His chest roentgenogram showed phrenic nerve palsy has not been reported with NLE in the English left-sided consolidation with para-pneumonic effusion. His language literature to the best of our knowledge. Complete heart routine biochemical investigations were normal, TLC-13,300/ block is permanent, whereas non-cardiac manifestations of NLE μL, N-63, L-24, M-11, E-2. Hb-14.7 g/dL, platelet count-260,000/ usually resolve spontaneously as maternal autoantibodies vanish μL. His HIV-I and II were non-reactive. Sputum for CBNAAT was from neonatal circulation. A persistent requirement for respiratory negative for Mycobacterium tuberculosis. Pleural fluid culture support and the need for continued hospitalization prompted us revealed Streptococcus sp. (sensitive to penicillin and ceftriaxone). to try IVIg as indicated in patients with SLE. It led to prompt clinical His D-dimer was raised, but there was no evidence of deep vein response and the baby could be weaned from respiratory support thrombosis on venous Doppler of both lower limbs. CECT thorax after 2 weeks, and could subsequently be discharged from the showed left lower lobe consolidation, thick-walled cavity, and hospital. Response to IVIg further supports the bilateral phrenic pleural effusion. Further evaluation with CTPA suggested evidence nerve palsy to be due to NLE in the index case. It remains conjectural of thrombus in the left pulmonary artery. To ascertain the cause whether the nerve dysfunction is demyelinating or axonal in nature. of embolism he was evaluated for a hypercoagulable state which Conclusion: We reported a baby with NLE presented with complete was normal except for low vitamin B12 level-168 pg/mL (normal: heart block and had bilateral phrenic nerve palsy. IVIg seems to be 191–663 pg/mL) and raised serum homocysteine level −19.9 mmol/l curative for consequent diaphragmatic dysfunction. (protein C, protein S, antithrombin III — normal. Factor IV Leyden mutation — not detected, APLA — normal, Factor VIII — normal). 10. Addisonian Crisis in a Case of Adrenoleukodystrophy He improved on Inj. ceftriaxone, clindamycin, Inj Fragmin 5,000 IU Following Magnetic Resonance Imaging Under Total Intravenous S/C 12 hourly for 2 weeks and discharged on oral antibiotics for the Anesthesia. (Conference Abstract ID: 159) next 7 days. He was also advised tablets of rivaroxaban, vitamin B12, and folic acid for the next 3 months. He improved clinically, S Kiran, KC Pradip radiologically, and serologically on follow-up. Armed Forces Medical College, Pune, Maharashtra, India DOI: 10.5005/jp-journals-10071-23711.50 12. Accidental Guide-wire Retention after Femoral Vein Introduction: Adrenal crisis, also termed acute adrenal insufficiency Catheterization: A Case Report. (Conference Abstract ID: 150) is an acute life-threatening condition with a mortality rate of 0.5/100 SK Arun, Abhyudhay Kumar patients/year. Materials and methods: The various etiological All India Institute Of Medical Sciences, Patna, Bihar, India factors associated with the adrenal crisis are infections, trauma, DOI: 10.5005/jp-journals-10071-23711.52 pregnancy, surgery, emotional stress, strenuous physical activity, thyrotoxicosis, medications, and genetic disorders. Results: Adrenal Introduction: Central venous catheters are often used for various crisis is one of the commonest presentations of patients in a critical purposes like emergent hemodialysis, in situations where peripheral care setting following various etiology usually secondary to a known vein catheterization cannot be achieved, continuous invasive case of adrenal insufficiency. Discussions: Here, we present an hemodynamic monitoring, and parenteral nutrition. The Seldinger atypical presentation of a case of Addisonian crisis in a three and technique is the most commonly used method. It is considered a half-year-old child following total intravenous anesthesia for MRI. safe procedure when performed properly under the guidance and Conclusion: A high index of suspicion and clear history taking of an experienced physician. But it can lead to various complications before MRI is necessary to prevent stressors for the occurrence of like arterial puncture, hemothorax, pneumothorax, nerve injury, Addisonian crisis. or air embolism. A rare iatrogenic complication is guide-wire retention, which can be termed as a loss of guide-wire during the procedure. Objectives: Case resentation: A 70-year-old male 11. “Hyper-Homocysteinemia and Recurrent Pulmonary patient with COVID positive status with diabetes mellitus was being Embolism without Deep Vein Thrombosis in a Young Alcoholic treated in the COVID ICU. Since the patient was having progressive Patient Presenting as Cavitating Pneumonia”—A Rare Case shortness of breath and he was eventually intubated for the same. Report. (Conference Abstract ID: 155) Other definitive COVID treatments were going on. But patient RS Pal, Ram Babu Sah, Ajay Sagar developed the features of acute kidney injury and there was a ESI-PGIMSR, Basaidarapur, New Delhi, India chance to progress onto renal shutdown. So it was decided to go DOI: 10.5005/jp-journals-10071-23711.51 with hemodialysis. Written consent for the procedure was taken. Introduction: A 32-year-old man, cook by occupation presented Under all aseptic precautions, the right femoral vein was cannulated to our casualty with a history of (i) Acute onset fever with chills, (ii) using an introducer needle after local infiltration. After confirming Cough with mucopurulent sputum, (iii) Left-sided pleuritic chest it’s a vein, a J-tipped guide-wire was introduced smoothly through pain, (iv) Breathlessness — MMRC grade-4 since 1 week. He also had the needle. Then, a dilator was advanced over guide-wire to create a history of hemoptysis for 1 day. There was no any comorbidity and a track. It was followed by the insertion of the catheter on the significant past history. He was a chronic smoker with a history of guide-wire. During this procedure, the guide-wire was accidentally regular chronic alcohol intake. His family history was unremarkable. pushed further ahead into the vein. We soon realized this and One year before, he was treated for right-sided pneumonia. Delayed removed the catheter but the guide-wire was missing. Urgent resolution of symptoms at that time was further evaluated with X-rays of the kidneys, ureters, bladder region, upper abdomen, and computerized pulmonary angiography (CTPA) which showed chest were done, in which the guide-wire was clearly visible inside right pulmonary artery thrombus. But he lost to follow-up. When the vein. It was in the right side of the lower abdomen and right he presented to us in casualty this time — His vitals were pulse thigh region. Ultrasonography (USG) of the abdomen and leg also

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confirmed the same. Immediately CTVS team was informed about COVID 19 protocol. Ten days later,cytokine storm was diagnosed this, and the guide-wire was removed by the same team without based upon gradual fall in the saturation along with the supporting any complications. The whole procedure from central venous biochemical and radiological data (figure 1). Pulse dose steroid catheter insertion to guide-wire removal was uneventful and no therapy started with Inj.Methyl prednisolone 500 mg 0D for 4 arrhythmia was recorded in-between. Discussions: We report an days along with broad spectrum antibiotic cover. Theuraptic dose accidental intravascular insertion of a complete guidewire. This is a of SEPSIVAC vacccine was administered.Later after two weeks of rare and completely avoidable complication during the procedure. hospital stay including 1 week of ICU stay, patient was discharged But in this case, it was more difficult due to the unaccustomed on oral anticoagulants, oral steroids and oral antibiotics. Since then environment, where the procedure was being performed by a he was on tapering dose of steroid. Every week inflammatory panel physician wearing PPE with all its gadgets on. To avoid this simple was being done which was normal. A HRCT scan done as a part of rules like holding the guidewire at the tip by a non-dominant regular followup which revealed 25 – 30% fibrosis along with GGOs hand or by the mosquito artery at all times should be followed to (Ground glass opacities) (Figure-2). Within 48–72 hrs of withholding prevent its passage into or out of the vessel. If this rule is followed, the steroid patient had noticed fall in saturation on exertion, we can prevent many complications.2 Yet another simple step like followed by fall in resting saturation levels along with breathlesness. at the end of the procedure, a “time out” is practiced during which Routine blood investigations done along with inflammatory panel. the operator calls out loudly and clearly that “the guide-wire is out Urine culture revealed multi drug resistant E. coli and blood culture of the patient”, and this is confirmed by the bedside nurse. This turned out to be sterile. Treated with broad spectrum antibiotics finding can then be documented in the patient’s medical records.1 along with coverage for PJP Pneumonia in view of long term steroid If not they can cause cardiac conduction abnormalities like right usage. Biochemical markers and clinical status were worsened bundle branch blocks, new left anterior and posterior fascicular over the next 48 hours Differential diagnoses at this stage were blocks, and rarely asystole. The usual reasons for a guide-wire loss thought to be : 1) Acute pyelonephritis with ARDS .2) Severe PJP are operator inexperience, not giving proper attention, inadequate pneumonia in view of long term steriod usage. 3) Community supervision during catheterization, and busy and overtired medical aquired pneumonia. 4) Acute pulmonary thromboembolism. staff.Conclusion: During central venous catheterization, guide-wire 5) Recurrent Cytokine storm Acute pyelonephritis was ruled related complications are rare and essentially preventable if proper out with CT KUB.2D ECHO was normal.But HRCT chest revealed precautions are taken. And since we are in a new era of COVID its progression of ground glass opacities compared to previous scan. always advisable to get adjusted to this new working environment Differential diagnoses at this point being : 1) COVID 19 reinfection. than to suffer complications. 2) Delayed cytokine storm. 3) Severe PJP pneumonia PCR for COVID 19 and other respiratory viruses was done which is negative. 13. An Unusual Case of Severe Pneumocystis Jiroveci Pneumonia Serum Beta –D-Glucan was sent in suspicion of PJP pneumonia.I (PJP) Presenting as “Recurrent Cytokine Storm” Following nj.Trimethoprim/Sulfamethaxazole 15 mg/kg,Inj.Fluconazole along COVID-19 Infection. (Conference Abstract ID: 141) with broad spectrum antibiotic cover administered.Pulse dose steroid of 500 mg given for 3 days along with regular standard of Guttikonda Neeraj, Bharath Cherukuri care.Meanwhile serum Beta –D-Glucan level was obtained which NRI Academy of Sciences, Andhra Pradesh, India is 678 pg/mL (normal being < 70 pg/mL).False positive possibilities DOI: 10.5005/jp-journals-10071-23711.53 are ruled out .Gradually patient dyspnoea resolved and resting Introduction: There is a health emergency going on in the world saturation improved from 91% to 96% on room air. In our case,the with the COVID-19 pandemic surging at a great pace leading to diagnosis of PJP Pneumonia is based upon the following points, a rise in mortality of the aged and vulnerable patients all over 1) Chronic steroid use of more than 20 mg Prednisone/day for the world. The reason for these deaths is suspected to be due to more than 4weeks following COVID 19 infection. 2) Persistence of cytokine storm (“Cytokine storm syndrome”). “Cytokine storm” GGOs on HRCT scan beyond 8 weeks. 3) Serum Beta –D-Glucan is defined as an activation cascade of auto-amplifying cytokine level of 678 pg/mL 4) Resting PaO2 on room air being 58 mmHg production due to unregulated host immune response to the As the patient recovered, Inj.Trimethoprim/Sulfamethaxazole was viral antigen. Usually, it is noticed in the second week of COVID-19 changed to oral form and discharged.Ten days later repeat Serum disease. But the incidence of “Recurrent cytokine storm” presenting Beta–D-Glucan level is found to be 98 pg/mL. Similar experience weeks after the first episode is not known. In this case report, has been reported from various authors (1, 2, 3). Discussions: PJP we wish to highlight such a phenomenon observed in a patient occurs exclusively in immunodeficient individuals; two-thirds who had survived the first episode of storm weeks before, later of cases occur in HIV-infected patients4 and the other third in diagnosed to be severe PJP pneumonia mimicking cytokine storm. non-HIV patients who have hematological malignancies, solid Materials and methods: This is a case of a 75-year-old man who is organ tumors, or are under immunosuppressive therapy.5,6 known diabetic and hypertensive is diagnosed as having COVID-19 Among immunosuppressive agents, the role of corticosteroids is based upon an HRCT scan, which revealed CORADS-4. RT-PCR is the most prominent. There is significant variability in the rate of negative. He had a cytokine storm in the following week which is response to steroid drugs among people.7 Different reasons have addressed with pulse dose steroid and usual standard of care. Two been proposed to explain the effect of steroids in increasing the months later, the patient had a similar episode of cytokine storm but predisposition to P. jirovecii pneumonia, among them the reduction was subsequently diagnosed to be severe PJP pneumonia. Results: of CD4+ lymphocytes and deficient cell-mediated immune activity This is a case of 75 yr old gentleman who is known diabetic and are the most important. PJP patients without HIV infection are often hypertensive is diagnosed as having COVID-19 based upon HRCT admitted because of acute respiratory failure. PCP and COVID-19 scan,which revealed CORADS-4.RT-PCR is negative.Treated as per share numerous characteristics. Both diseases present with fever,

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2,3 fatigue, dry cough, and dyspnea. In terms of chest CT findings, requirement (40 L/minute flow with FiO2 90% on HFNC) with no bilateral symmetrical ground-glass opacities are frequently seen RAVO/RVVO with mild pulmonary PHT-46 mm Hg on 2D ECHO. on chest CT scans in both PCP and COVID-19.4–6 PCP frequently CTPA done on day 8 of admission was not suggestive of pulmonary occurs when the CD4 count drops below 200 cells/L, which can thromboembolism (? resolution) with 60% lung involvement with manifest as lymphopenia.7 Leukopenia also appears to be the CTSS 14/25. Further anticoagulation treatment was discontinued most common presentation in patients with COVID-19, although due to the development of sepsis and thrombocytopenia during leukocytosis and lymphopenia have also been reported.8,9 Elevated her ICU stay. Discussions: Thrombolysis in suspected pulmonary LDH has also been reported in both COVID-19 and PCP.7,10,11 In thromboembolism in the patient with refractory hypoxia on optimal both cases, the presence of elevated LDH is an indicator of poorer treatment of severe COVID-19 disease can be offered with high prognosis.7,11,12 However, PCP generally follows a more subacute suspicion on 2D ECHO with extremely high D-dimer, where CTPA is course than COVID-19, particularly when considering milder forms not feasible. It shows improvement in oxygenation and resolution of of the disease, with 33% of patients having symptoms for at least RAVO/RVVO on 2D ECHO. Endotracheal intubation can be avoided 2 to 4 weeks before presentation in a case series from early in the which may decrease ICU stay with improved survival. Conclusion: HIV epidemic.3 In comparison, the median time to development Thrombolysis in suspected pulmonary thromboembolism in the of dyspnea or pneumonia for symptomatic COVID-19 has been patient with refractory hypoxia on optimal treatment of severe reported to be eight to nine days from illness onset.2,8 Dyspnea is COVID-19 disease can be offered with high suspicion on 2D ECHO also a more prominent symptom in PCP and was seen in up to 95% with extremely high D-dimer, where CTPA is not feasible. It shows of patients in one case series while it is only seen in about 11 to 31% improvement in oxygenation and resolution of RAVO/RVVO on 2D of patients with COVID-19.2–3,9,13 Oral thrush, which has a strong ECHO. Endotracheal intubation can be avoided which may decrease association with PCP, has not been seen in COVID-19.14 COVID-19 ICU stay with improved survival. and PJP share multiple characteristics, both present with a dry cough, fever, generalized weakness, and dyspnea.8,9 In terms of 15. Rare Case Report Severe Pancreatitis with Systemic radiological findings, bilateral symmetrical ground-glass opacities Inflammatory Response Syndrome with Hypertriglyceridemia are frequently seen on chest CT scans in COVID-19 and PJP.10 PJP in a Patient with Diabetes Mellitus. (Conference Abstract ID: 138) frequently occurs when the CD4 count drops below 200 cells/L, Nitin Gaikwad, Gajanan Kurundkar which can manifest as lymphopenia. Leukopenia also appears SMT, Kashibai Navale Medical College, Pune, Maharashtra, India to be the most common presentation in patients with COVID-19, DOI: 10.5005/jp-journals-10071-23711.55 although leukocytosis and lymphopenia have also been reported. Conclusion: Patients in whom GGOs are persisting beyond 6 weeks Introduction: The triad of diabetic ketoacidosis, hypertriglyceridemia, on HRCT scan, a differential diagnosis of PJP pneumonia need to be and acute pancreatitis is a rare occurrence. We report a case of considered and evaluated to prevent the hazardous consequence. an 18-year-old male morbidly obese patient admitted to ICU with a short history of severe abdominal pain, vomiting, and breathlessness. On examination, the patient had tachycardia, 14. Improvement in Oxygenation and Resolution of RAVO/ severe tachypnea, and severe dehydration. On glucometer BSL RVVO on 2D Echo Post Thrombolysis in Suspected Pulmonary was high, ketonuria [4+], and high anion gap [20]. On ABG showed Thromboembolism in COVID-19 SARI Patient: A Case Report. metabolic acidosis with a base excess of −17.3 and bicarbonate of (Conference Abstract ID: 139) 5. The patient was given all usual supportive care including oxygen Ashish Soneji therapy, intravenous fluid resuscitation, insulin, and bicarbonate DR L H Hiranandani Hospital, Powai, Mumbai, Maharashtra, India infusion. Emergency abdominal ultrasound was suggestive of the DOI: 10.5005/jp-journals-10071-23711.54 bulky and edematous pancreas. Past medical record suggestive of Introduction: Pathophysiology of hypoxia in COVID-19 SARI diabetes mellitus since 3 years, severe hypertriglyceridemia 9,159 patients can vary in each individual so as the treatment. Pulmonary mg/dL, and acute pancreatitis. On admission, the SIRS score was thromboembolism can be a treatable cause of refractory hypoxia 3. Biochemical investigation sr. triglyceride was 545 mg/dL, Sr. in a given scenario. Materials and methods: Case summary: We lipase 1315 IU/L, and HbA1c 12.9% suggestive of poorly controlled present a case of 74-year-old hypertensive women with COVID-19 blood sugar level. Later on, abdominal computed tomography SARI. She had severe COVID-19 infection with 60% lung involvement confirmed acute pancreatitis. The patient was treated successfully with CTSS 14/25. She was given COVID-19 treatment (remdesivir/ and discharge. Severe hypertriglyceridemia causing pancreatitis solumedrol/LMWH) along with oxygen therapy with a high-flow in diabetes mellitus is a rare but very serious complication of DKA. nasal cannula. Her 2D ECHO done on admission was suggestive Materials and methods: Case Report. Results: The patient made a of normal LVEF with severe PHT — 66 mm Hg with RAVO/RVVO. good recovery and was followed in the OPD for management of his She had persistent tachypnea (RR > 40) and a requirement of blood sugar level and triglyceride management. Discussions: The high-flow oxygen on day 3 of her admission. On evaluation, her triad of DKA, hypertriglyceridemia, and pancreatitis is an unusual D-dimer showed extreme elevation from 3,020 ng/mL (day 0) to presentation of poorly controlled diabetes which occurs in type

58,061 ng/mL (day 3). In view of the high FiO2 requirement (60 1 and type 2 diabetes. In diabetic ketoacidosis, the deficiency of L/minute flow with FiO2 90% on HFNC) and AKI (creat 1.6), it was insulin activates lipolysis in adipose tissue releasing increased not feasible to do CTPA. With a high probability of pulmonary free fatty acids, which accelerates the formation of VLDL in the thromboembolism based on tachypnea, bedside 2D ECHO, and liver.1 Reduced activity of lipoprotein lipase in peripheral tissue high biomarkers, the patient was thrombolyzed with 50 mg also decreases the clearance of VLDL from the plasma, resulting rTPA. Post thrombolysis, she was continued on heparin in the in hypertriglyceridemia.2,3 Excess triglycerides are hydrolyzed by therapeutic dose and had shown improvement in oxygenation pancreatic lipase resulting in the formation of excess free fatty acids.

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Excess free fatty acids cause acinar cell injury and capillary leakage Renal replacement therapy was done; cultures were negative in pancreatic vascular beds. A possible mechanism of pancreatitis including ascitic fluid. His repeat ECHO reported vegetations in the in hypertriglyceridemia patients is the damage of acinar cells and aortic valve, moderate mitral valve regurgitation, left ventricular microvascular membrane due to excessive free fatty acid and hypertrophy with LVEF 50%. The patient improved with treatment lecithin formation in pancreatic bed from lipoprotein substrates. but the vasopressor requirement persisted with low doses. He Very severe hypertriglyceridemia can either be of genetic or was extubated on NIV, but re-intubated due to type I respiratory acquired origin resulting from metabolic disorders (e.g., diabetes), failure and worsening shock with peripheral cyanosis. Cardiology diet (including alcohol and obesity), and/or drugs. Conclusion: and CTVS reference taken. Cardiac CT reported chronic vegetation The triad of diabetic ketoacidosis, hypertriglyceridemia, and acute over the aortic valve. After ruling out infective endocarditis and pancreatitis is a rare presentation of diabetes. Hypertriglyceridemia other causes of pulmonary edema, aortic valve repair was planned. is a known but rare cause of acute pancreatitis and the presence of A thorough discussion has done between the cardiology team, a very high level of triglyceride should prompt clinicians to search cardiothoracic surgery team (CTVS), gastroenterology team, and for complications like acute pancreatitis and diabetic ketoacidosis. patient’s relatives, and Transcatheter aortic valve repair (TAVR) was planned in view of comorbidity (CLD and AKI). All advantages 16. Management of a Patient with Chronic Liver Disease with and disadvantages and related complications of the procedure Aortic Valve Regurgitation by Trans Aortic Valve Repair—A Case with associated comorbidities and cost issues were discussed in Summary. (Conference Abstract ID: 136) detail with the patient’s family. TAVR is done with preparations of Hemendra Kumar, Imran Gafoor, Vishal Kumar, Rishi Shankar all relevant teams (CTVS, interventional radiologist). After the TAVR Ramkrishna Care Hospital, Raipur, Chhattisgarh, India patient’s vasopressor requirement decreased significantly, the patient improved and later on extubated. During the course, the DOI: 10.5005/jp-journals-10071-23711.56 patient had increased ascites and urosepsis. Treatment optimized Introduction: Trans-catheter aortic valve repair is a minimally and the patient responded to treatment. Blood and blood products invasive procedure during which a new valve is inserted without transfused as needed and RRT done. Later on patient developed removing the old and damaged valve. A new valve is implanted ICU psychosis. The patient was treated, shifted to the ward, and within a valve. It is a minimally invasive procedure but this later on discharged after a long hospital stay of almost 3 months. procedure has its own complications like bleeding, stroke, Results: Patient with history of autoimmune chronic liver disease, contrast-induced kidney injury, valve slipping out of place, and acute kidney injury and previous 3 episodes of heart failure with infection. We managed a case of aortic valve regurgitation with pulmonary edema was optimized and managed with trans-catheter chronic liver disease and acute kidney injury by transcatheter aortic valve repair. There was dilemma for the procedure of valve aortic valve repair. Materials and methods: A 59-year-old man repair between surgical approach and trans-catheter approach who was known case of autoimmune chronic liver disease (CLD), but keeping in mind the comorbidity of patient; we decided for post aortic valve replacement (done in 2012); presented to the trans-catheter approach with all preparation. Patient responded, hospital with a complaint of abdominal distension, decreased improved and was discharged from the hospital. Patient has urine output, bilateral pedal edema. He had a history of previous prolonged hospital stay of almost three months. Discussions: Aortic 3 admissions for congestive heart failure and was managed valve repair can be done surgical or trans-catheter. In this case, conservatively. On admission, his vitals were stable and he was the challenge was to initially manage the patient for pulmonary managed in the ward for his complaints. His initial investigation edema, rule out all other causes of repeated episodes of pulmonary reports were normal except for deranged renal function tests (serum edema and shock, decide for the procedure whether surgical or urea — 115.8 mg/dL, serum creatinine — 3.47 mg/dL). After 3 days trans-catheter with consideration of comorbidity (CLD and AKI) patient complained of headache, diarrhea, and vomiting and had and complications; preparation regarding possible complication cyanosed peripheries and absent radial pulse on examination. He and management with multiple team approach; repair of the was immediately shifted to ICU and managed with intravenous aortic valve and postprocedure monitoring and management. fluid boluses and inotropes. His repeated investigations reported Conclusion: This case report describes the successful management high total leukocyte counts, worsening renal function tests, and of a patient with autoimmune chronic liver disease with acute liver function tests. All the cultures were negative including ascitic kidney injury and repeated episodes of pulmonary edema with fluid. 2D ECHO reported aortic valve vegetation which was chronic heart failure. As the patient had chronic liver disease there was a (as the patient was in regular follow-up). The patient responded risk of bleeding along with surgical complications. The transcatheter to medical management with improved renal and liver functions. approach also has major risks like stroke and contrast-induced The patient was shifted to the ward. After 1 day in the ward, the kidney injury. we managed all the aspects and transcatheter aortic patient had complained of intermittent fever spikes, vomiting, valve replacement was performed after which the patient improved and non-productive cough along with a decrease in urine output and was successfully discharged from the hospital. and breathing difficulty. The patient was again shifted to ICU. His renal function tests worsened and his cardiac profile was positive 17. Cerebral Fat Embolism Syndrome after Closed Fracture (? congestive heart failure). 2D ECHO had the same findings as Tibia—An Unusual Presentation. (Conference Abstract ID: 132) before. He responded to medical management and he was shifted back to the ward after stabilization. After 5 days of stay in the Ashreen Kaur ward patient again had complained of difficulty in breathing and Fortis Hospital, Mohali, Punjab, India decreased urine output with accompanying shock. The patient DOI: 10.5005/jp-journals-10071-23711.57 was again taken into ICU and treatment started with mechanical Introduction: Fat embolism syndrome is a life-threatening condition ventilation and vasopressors. His liver and renal functions deranged. with a symptom triad of dyspnea, petechiae, and mental confusion.

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Materials and methods: It is more common following polytrauma the intra-arterial pressure waveform frequently led to improved and fractures of long bones but can also occur during or after compression technique by the resuscitator performing external orthopedic procedures, particularly during intramedullary nailing cardiac massage.4 For patients who are potential candidates for of long bones or hip or knee replacements. Results: The clinical extracorporeal membrane oxygenation (ECMO) central vascular spectrum can range from a mild form to a life-threatening condition. access obtained during CPR can reduce the time for initiation onto Discussions: Hence, it is essential to make an early diagnosis to ECMO and these catheters provide a conduit for easy conversion timely prevent morbidity and mortality. Conclusion: We present to ECMO cannulae. Conclusion: Although central vascular access a case of a healthy young male with early onset of fat embolism and intra-arterial monitoring is not recommended routinely during syndrome following trauma with an unusual presentation. CPR; in certain scenarios discussed above, this has a potentially important adjuvant role and can act as a life-saving measure for 18. Vascular Access During Cardiopulmonary Resuscitation. the patient. (Conference Abstract ID: 127) Amit Agrawal, Akshata Amin 19. Anesthetic Management of a Takayasu Arteritis Patient Sevenhills Hospital, India with Ehler–Danlos Syndrome for Capsulorrhaphy of DOI: 10.5005/jp-journals-10071-23711.58 Temporomandibular Joint. (Conference Abstract ID: 121) Introduction: During a cardiac arrest the focus of clinicians is Sarayu V, Shalendra Singh to provide uninterrupted and high-quality CPR. In cases where Armed Forces Medical College, Pune, Maharashtra, India peripheral vascular access is difficult, an intra-osseous route is DOI: 10.5005/jp-journals-10071-23711.59 recommended for the administration of drugs over obtaining Introduction: Ehler–Danlos syndrome (EDS) is an inherited central venous access.1 Arterial line catheterization during cardiac connective tissue disorder of six subtypes characterized by arrest is again not done commonly and the benefit that it may joint hypermobility, skin hyperextensibility, vascular fragility, provide against risks such as infection, needle stick injury, etc., is a musculoskeletal pain, easy bleeding, severe scoliosis, joint topic still to be explored. Materials and methods: Case report:A dislocations, atrophic scars, and vessel/viscera rupture. As the 60-year-old man was admitted to emergency with cardiac arrest. disease is rare with the occurrence of one in 5,000 population and, After confirming the absence of pulse CPR was started as per it is often under-diagnosed. We report a 36-year-old male (60 kg) guidelines. Peripheral venous access was poor and equipment patient with EDS-HT with Takayasu arteritis (TA) and Schizophrenia for intra-osseous access was not available hence the decision was who underwent capsulorrhaphy of bilateral temporomandibular made to insert a central venous catheter into a femoral vein without joint (TMJ) under general anesthesia. Materials and methods: interrupting CPR. After palpation of femoral pulse, a puncture The patient was premedicated with Inj. glycopyrrolate 0.2 mg IV, was made medial to this location using the landmark technique. Inj midazolam 1 mg IV, and xylometazoline nasal drops to avoid The catheter was inserted uneventfully in the first attempt. The bleeding during nasal intubation. The patient was administered position was confirmed as appropriate by doing blood gases with Inj fentanyl 100 μg IV and anesthesia was induced with Inj from the catheter as well as a femoral arterial stab and also by propofol 120 mg IV. Care was taken to avoid hyperextension of the transduced waveform from the catheter. This was used to administer neck during mask ventilation, minimal pressure for chin lift and drugs and fluids. Subsequently, using the palpatory method head tilt was used during manual ventilation. Inj Atracurium 30 and landmark technique femoral arterial line was also placed mg IV given and the airway was secured with gentle laryngoscopy, and transduced which gave a visual representation of the blood avoiding excessive mouth opening using 7.0 mm ID nasal pressure. Discussions: It is assumed that during cardiac arrest and flexometallic cuffed endotracheal tube. Anesthesia was maintained ongoing CPR; insertion of a central venous catheter and arterial line with 02/N20 (40:60) and Sevoflurane 1 to 1.5%. Careful positioning requires the interruption of CPR and can be technically challenging of the patient was done with adequate padding of pressure and associated with complications, but in certain situations, this points and avoiding hyperextension of joints including shoulder, might turn out to be very helpful. The central venous route has hip, and cervical spine under muscle relaxation. Hemodynamics some unique advantages, as compared to the peripheral venous including invasive blood pressure were targeted within the range route or the intra-osseous route, higher peak drug concentrations of 10% of baseline in view of bilateral renal artery stenosis to are achieved with the central venous route, that is to say, drug avoid hypotension, along with meticulous monitoring of urine circulation time is shorter.2,3 During CPR palpating for a carotid output of the patient. Neuromuscular blockade was antagonized pulse with the index and middle fingers have been the standard and the patient was extubated after he was fully awake. Results: for hundreds of years but even this has some pitfalls. Some Intra-operatively patient was given 3000 ml of crystalloids and patients with a cardiac output do not have a palpable pulse either total blood loss was around 400 ml. Postoperative analgesia was because their blood pressure is too low; their body habitus makes provided with IV Paracetamol. No adverse events were reported it difficult to find the pulse, or because the providers’ fingertips in post-op period and the patient had no fresh complaints in are not sensitive enough. Additionally, the presence of gloves can the follow-up period. He was discharged on 4th postoperative make finger sensation even more dulled. Also, providers may feel a day. Discussions: Prime concerns were to avoid hyperextension pulse when one is not there. Typically, this occurs when a provider of joints, achieve ventilation with minimal airway pressures and presses down hard over the vessel and confuses their own digital avoid postoperative vomiting and retching. Elective fiberoptic pulse for that of the patients. Finally, each of us has a different intubation should be considered when difficulties are anticipated. quality of sensation at our fingertips. Pierpont et al. observed We also used a cotton pad under the blood pressure cuff to prevent that in addition to providing continuous pressure monitoring hematoma and untreatable diffuse bleeding in EDS subtypes with and ready access to arterial blood samples, direct feedback from vascular fragility. Meticulous monitoring of renal perfusion pressure

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and avoidance of nephrotoxic drugs. Invasive cardiac monitoring anesthesia-related deaths are secondary to the inability to mask to maintain hemodynamics and to monitor blood loss due to ventilate or intubation. An unanticipated difficult airway can lead vascular fragility. These patients are often less responsive to local to a potentially life-threatening clinical situation, and thus every anesthetics. No guidelines for neuraxial and general anesthesia clinician must be able to predict signs in the preoperative period. exist for these patients. Conclusion: The Ehlers–Danlos syndrome with chances of vast abnormalities of endocrine, cardiovascular, 22. Anesthetic Management of Patient with Severe Mitral immune systems, and interactions with anesthetic agents can Regurgitation Taken for Lower Segment Cesarean Section Under become challenging to manage for the anesthesiologists. Extra Epidural Anesthesia. (Conference Abstract ID: 99) care and effort in all phases of the surgical management of such Jignesh Kamaliya, Chandrika Bhut patients will result in safe recovery from anesthesia and uneventful Sir T Hospital Bhavnagar, Gujarat, India intra- and postoperative period. DOI: 10.5005/jp-journals-10071-23711.62 Introduction: Pregnant women with heart disease constitute 20. Viral Myocarditis and Encephalitis—A Rare Presentation of a unique problem for the anesthetist. In pregnancy mitral HHV-6. (Conference Abstract ID: 117) regurgitation is most commonly due to mitral valve prolapse, Ashreen Kaur, RK Jaswal, Amit Shankar Singh acquired RHD, or rarely due to acute endocarditis. The mortality and Fortis Hospital, Mohali, Punjab, India morbidity are considerably reduced1 by better perinatal care, where DOI: 10.5005/jp-journals-10071-23711.60 anesthesiologist plays a major role in a multidisciplinary approach. Introduction: HHV-6 infects nearly 100% of human beings during Chronic mitral regurgitation, even if severe, is well tolerated in childhood and often results in fever, diarrhea, and rash. It has a pregnancy if the patient is asymptomatic and good left ventricular lifelong latency and can become reactivated later during adulthood systolic function. Specific intraoperative and postoperative in the heart, brain, lungs, and kidney. Materials and methods: anesthesia management in terms of maintenance of hemodynamic HHV-6 infection has many diagnostic challenges. Results: HHV-6 parameters and effective postoperative pain control will minimize reactivation usually occurs in immunosuppressed patients and can postoperative adverse events in patients with mitral regurgitation lead to complications like pneumonitis, encephalitis, myocarditis, and these form the goals of anesthetic management in this type and hepatitis. Discussions: However, there is limited literature of patient. Epidural anesthesia was studied to improve the patient on HHV-6 infection and it remains a diagnostic challenge when outcome in comparison to spinal or general anesthesia. The study encountered in young immunocompetent adults. Conclusion: We aims to highlight the safety of low dose epidural block, its benefits present a case of HHV-6 infection with an atypical presentation in over spinal and general anesthesia in perioperative management an immunocompetent adult. and postoperative pain relief. Materials and methods: A 23-year- old female patient with a history of 8 months of amenorrhea and 21. Predictive Signs of Difficult Intubation. (Conference Abstract previous LSCS comes to sir T hospital with complaints of bilateral ID: 102) pedal edema, abdominal distension, and mild dyspnea. She had no problem in her previous pregnancy. She had a history of pregnancy- Yash R Joshi, Timsi J Gandhi induced hypertension for 1 month and regular treatment with T. Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India labetalol (100 mg) BD. She had also a history of convulsion and DOI: 10.5005/jp-journals-10071-23711.61 fascial palsy (which is resolved in 2 days) at 4 months of amenorrhea Introduction: The difficult intubation has been defined as “The and managed conservatively. In preoperative assessment, routine clinical situation in which a conventionally trained anesthesiologist investigations are in the normal range except for high creatinine experiences difficulty with face mask ventilation, difficulty in (1.95) and hypoproteinemia with positive ANA (anti-nuclear trachea intubation or both”. To provide a stepwise approach to antibody). ECG shows low voltage changes. 2D ECHO revealed identify preoperatively and to manage unanticipated difficulty severe mitral regurgitation, small vegetation attached to anterior during tracheal intubation in patients. Maintaining a patient mitral leaflet with reduced LV compliance and LVEF 55%. According airway is essential for adequate oxygenation and ventilation. to the cardiologist’s opinion, the patient can be taken for surgery Materials and methods: Given the purpose of the present with mild risk of anesthesia from a cardiology point of view. The work, to develop a difficult airway trolley based on the evidence patient is admitted to obstetric ICU and the physician started T. presented in peer-reviewed journals, updated guidelines, and nifedipine (10 mg) as a patient having high blood pressure (160/100 expert consensus. The search was primarily limited to the English mm Hg). As the patient having bilateral pedal edema, generalized language. Since our search strategy was designed to identify all ascites, altered RFT, hypoproteinemia so nephrologist advised Inj. pertinent updated national and international guidelines on difficult Albumin, Inj. Torsemide, and Inj. Methylprednisolone (1 g) and airway management. Results: The following key search variables finally he advised to terminate the pregnancy. Results: So, we were applied individually and in combination: airway, guideline(s), concluded that pregnant patient with mitral regurgitation makes intubation, equipment, and management. Discussions: We can the anaethetic management challenge. Proper understanding identity difficult intubation preoperatively with the help of history, of the pathophysiology of the disorder and careful anaesthesia physical examination, various grading systems, and preoperative planning, pre-operative assessment, intra-operative and post- assessment of the airway through USG leading to proper planning operative management can help in reducing the mortality and and preparation, to reduce the risk of complications and avoid morbidity. Low dose epidural anaesthesia provided the advantages unanticipated difficult airway at the time of intubation with over spinal and general anaesthesia in a high risk patient and we the help of difficult airway cart. Conclusion: Difficult tracheal successfully managed patient posted for LSCS with severe mitral intubation accounts for 17% of the respiratory-related injuries and regurgitation. Discussions: In general, regurgitant lesions are well results in significant morbidity and mortality. In fact, up to 28 of all tolerated during pregnancy because the reduction in systemic

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vascular resistance (SVR) reduces the regurgitant flow.3 The prime ankylosing spondylitis. In patients with inadequate response to consideration in managing our case was to maintain hemodynamic two NSAIDs used for at least 2 to 4 weeks, tumor necrosis factor stability during surgery and prevention of bradycardia. Factors (TNF)-alpha inhibitors are considered. Screening of these patients that exacerbate the regurgitation, such as bradycardia and acute for infections and regular follow-up is important. Fever of unknown increases in afterload should be avoided. Bradycardia can increase origin is a febrile illness without an obvious initial etiology. FDG the regurgitant volume by increasing left ventricular end-diastolic PET/CT can play a vital role when routine fever workup is negative volume.4 Precipitation of arterial hypotension and bradycardia due and help in identifying the source. Materials and methods: A to high sympathetic block remains a common problem associated 56-year-old man with ankylosing spondylitis with persisting low with conventional spinal anesthesia. General anesthesia is also not backache on NSAIDs was recently initiated on adalimumab. He very suitable because all anesthetic agents have intrinsic myocardial visited the hospital on an outpatient basis with complaints of depressant properties. So, epidural anesthesia can be a suitable fever, pain abdomen, and loss of appetite. Routine laboratory alternative to provide intraoperative hemodynamic stability, the investigations, ultrasound abdomen, done was unremarkable. The patient remains conscious and postoperative absolute pain-free patient was admitted to the hospital in view of persisting symptoms period for at least 48 hours with analgesic administration through and re-evaluated. On day 1, investigations showed transaminitis, an epidural catheter, which reduces the incidence of intraoperative thrombocytopenia with raised ESR of 26 and CRP of 51.78 mg/ bradycardia and perioperative morbidity. Conclusion: So, we dL (Tables 1 and 2). The patient was empirically started on broad- concluded that pregnant patient with mitral regurgitation makes spectrum antibiotics after sending blood and urine cultures, which the anesthetic management challenge. Proper understanding of the did not show any growth. Work up for protein electrophoresis, pathophysiology of the disorder and careful anesthesia planning, dengue, malaria, and leptospirosis were reported negative. On preoperative assessment, intraoperative, and postoperative day 3, contrast-enhanced CT chest and abdomen was done which management can help in reducing mortality and morbidity. Low showed features suggestive of liver parenchymal disease and dose epidural anesthesia provided advantages over spinal and splenomegaly with multiple hypodense lesions with normal lung general anesthesia in a high-risk patient and we successfully (picture 1). Multiple diverticula were seen in the ascending colon, managed patient posted for LSCS with severe mitral regurgitation. descending colon, and sigmoid colon. Colonoscopy was done which showed multiple ileocecal ulcers along with diverticulitis. Ulcer 23. Atypical Presentation of SLE With Secondary ITP in Pregnancy. biopsy was done and histopathological examination of the same (Conference Abstract ID: 98) showed non-specific acute chronic ileitis with negative tuberculosis V Dinesh Kumar Gontla, Srinivas Samavedam, Narmada Aluru, B GeneXpert. On day 6, given persisting fever, and most of the workup Rajyalakshmi reported as negative, we decided to do PET CT, which revealed Virinchi Hospitals, Hyderabad, Telangana, India metabolically active lymph nodes above and below the diaphragm. There was a bibasal consolidation of the lung showing increased DOI: 10.5005/jp-journals-10071-23711.63 metabolic activity, ileocecal wall thickening with edema, and Introduction: Systemic lupus erythematosus is an autoimmune increased metabolic activity. Diffuse increased FDG uptake was seen disease that classically manifests with fever, arthralgia, and rash, in the enlarged spleen. On day 7, the patient developed hypoxemia predominantly in women of childbearing age. Although rare de and breathlessness requiring oxygen support. Laboratory reports novo SLE can be diagnosed in pregnancy, here we came across showed worsening liver function test, thrombocytopenia, increased a case of SLE with secondary ITP having an atypical presentation ferritin, LDH. Peripheral smear was reported normal. In view of during the second trimester. Discussions: SLE complicates FDG-PET/CT showing increased uptake in the lung and bone pregnancy in terms of fetal and maternal health. Though it is marrow, it was decided to go ahead with bronchoscopy with BAL predominantly diagnosed in women of childbearing age, de novo and bone marrow aspiration. Given background adalimumab, the SLE in pregnancy was reported in very few cases. Having typical patient was worked up for tuberculosis, secondary hemophagocytic presentation of SLE like lupus nephritis, rash, preeclampsia, lymphohistiocytosis (HLH), lymphoma and was empirically initiated miscarriages help in the diagnosis of SLE. However, having an on modified anti-Koch’s therapy (AKT) and steroid. The patient atypical presentation of SLE with crisis imposes a challenge both showed a dramatic response with the resolution of respiratory in diagnosis and management of pregnancy with complications. distress and fever. Bone marrow picture was not consistent with Having a high grade of suspicion of SLE in pregnant women help HLH, hence steroid was stopped. BAL tuberculosis GeneXpert in earlier diagnosis of SLE. Conclusion: We hereby present a case was reported as positive, hence AKT was continued. The patient’s of 25-year-old G2A1 who presented with atypical manifestations condition gradually improved and was discharged on AKT. Results: of SLE in crisis with secondary ITP during the second trimester of FDG-PET/CT plays an important role in the evaluation in the FUO. pregnancy. Discussions: Ankylosing spondylitis is a chronic inflammatory 24. Fever of Unknown Origin in a Patient on Adalimumab and condition affecting the spine, which manifests with back pain Role of FDG-PET/CT. (Conference Abstract ID: 95) and progressive spinal stiffness. It is often associated with several articular, periarticular extraspinal, and extra-articular features, Amrita Shah, Rajvardhan Rangappa, Rajesh Mohan Shetty including synovitis, enthesitis, and dactylitis. Extraarticular features Manipal Hospital, Whitefield, Bengaluru, Karnataka, India include uveitis, psoriasis, and inflammatory bowel disease (IBD). DOI: 10.5005/jp-journals-10071-23711.64 Non-steroidal anti-inflammatory drugs (NSAIDs) are used as initial Introduction: Ankylosing spondylitis is a chronic inflammatory therapy in patients with symptomatic ankylosing spondylitis. It condition affecting the spine, which manifests with back pain and should be tried for at least 2 to 4 weeks before adding the second progressive spinal stiffness. Non-steroidal anti-inflammatory drugs NSAID. In patients with inadequate response to NSAIDs, TNF-alpha (NSAIDs) are used as initial therapy in patients with symptomatic inhibitors are considered. The most widely available TNF-alpha

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Table 1: Complete blood count Day 1 Day 3 Day 5 Day 9 WBC count (cm3) 4500 5200 5100 5500 RBC count (million/cm3) 5.11 5.03 5.06 4.92 Hemoglobin (g/dL) 14.4 14.1 13.9 13.6 Hematocrit (%) 42.6 41.5 41.8 40.5 Platelet count (cm3) 53,000 46,000 40,000 54,900

Table 2: Liver function test Day 1 Day 3 Day 7 Day 10 Day 25 Total bilirubin (mg/dL) 1.23 1.39 4.26 5.99 1.23 Direct bilirubin (mg/dL) 0.29 0.43 2.09 3.45 0.31 Indirect bilirubin (mg/dL) 0.94 2.19 2.54 0.92 SGOT (IU/mL) 83 136 231 135 64 SGPT (IU/mL) 38 54 80 67 31 ALP (IU/mL) 356 403 517 458 187 Total protein (g/dL) 7.8 6.6 5.6 5.0 6.4 Serum albumin (g/dL) 4.0 3.6 2.8 2.1 3.5 Serum globulin (g/dL) 3.8 3.0 2.8 2.9 2.9 inhibitors are infliximab, etanercept, and adalimumab.1 The choice 25. An Unusual Case of Non-thrombotic Pulmonary Embolism. of TNF-alpha inhibitors is based on patient preferences regarding (Conference Abstract ID: 94) the route, frequency of administration, physician preference, and Shravani Pabba, Srinivas Samavedam, Narmada Aluru, B experience. TNF-alpha plays an important role in immunity which Rajyalakshmi, P Ramakrishna Reddy includes macrophage activation, differentiation of monocytes to Virinchi Hospital, Hyderabad, Telangana, India macrophages, recruitment of neutrophils, and macrophages with DOI: 10.5005/jp-journals-10071-23711.65 an important role in protection against several pathogens.2–4 All Introduction: Non-thrombotic pulmonary embolism (NTPE) is TNF-alpha inhibitors increase the risk of tuberculosis, and the defined as embolization to the pulmonary circulation of different risk is more with infliximab and adalimumab than Etanercept.3 cell types, bacteria, fungi, parasites, foreign material, or gas. We Cases of tuberculosis that are seen soon after the initiation of came across the case of right heart failure secondary to NTPE. adalimumab usually represent reactivation of latent tuberculosis. Discussions: NTPE presents a formidable diagnostic challenge, Fever of unknown origin is defined as a prolonged illness for as the condition often presents with very unusual and peculiar more than 3 weeks with fever and uncertain diagnosis despite signs that are frequently overlooked. They range from the acute thorough history-taking, physical examination, and the available presentation as acute respiratory distress syndrome to signs investigations.8 FDG-PET/CT is a sensitive diagnostic modality for observed late in the disease course as right heart failure. We the evaluation of FUO by facilitating anatomical localization of diagnosed a case of right heart failure due to NTPE secondary bone focally increased FDG uptake, thereby guiding further diagnostic cement embolization as a rare presentation of NTPE. Conclusion: tests to achieve a final diagnosis. In FDG-PET/CT, FDG accumulates Increased awareness of NTPE as an underestimated cause of acute in cells with an increased rate of glycolysis. All activated leukocytes and chronic embolism, which may result in acute and chronic demonstrate increased FDG uptake and it helps us in localizing the pulmonary hypertension is needed. sites of infection. A prospective study on the value of FDG-PET/ CT performed in patients with FUO identified the underlying 26. Cough Syncope Due to Hamartoma: A Rare Clinical etiology in 46% of patients showing its importance.9 FDG-PET/ Presentation. (Conference Abstract ID: 87) CT should become a routine investigation in the workup of FUO when diagnostic clues are absent. FDG-PET/CT appears to be cost- Sushant Kumar Nanda, Pravati Dutta, Rekha Manjhi effective as it avoids unnecessary investigations and reduces the Veer Surendra Sai Institute Of Medical Sciences And Research, hospital stay. In our case, it helped us in localizing consolidation, Burla, Sambalpur, Odisha, India which guided us in doing bronchoscopy with lavage and clinches DOI: 10.5005/jp-journals-10071-23711.66 the diagnosis. Conclusion: Our patient presented a diagnostic Introduction: Benign neoplasms account for <1% of lung tumors. dilemma, given the presenting complaints of fever and abdominal Of these, hamartomas are most common with an incidence of 0.025 symptoms along with cytopenia and inconclusive initial battery of to 0.32% and occur more commonly in older males (M:F ratio 2–4:1) investigation results. Though we had a high index of suspicion of with a peak incidence in the sixth decade. The majority of cases are tuberculosis — negative histopathology, and rapid deterioration peripherally located, asymptomatic, and are incidentally detected made us think otherwise. FDG-PET/CT showed bilateral basal on chest radiographs or at autopsy. But rare endobronchial tumors consolidation, therefore going ahead with BAL and bone marrow which account for only 1.4% of pulmonary hamartomas can present examination helped us in ruling out differentials and arrive at a with obstructive symptoms and pose a diagnostic challenge. diagnosis. Materials and methods: Case report: A 54-year-old businessman

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presented with a 1-month history of dry cough associated with is called pneumothorax. The degree of collapse determines the 4 to 5 episodes of syncopal attacks and left-sided chest pain. clinical presentation of pneumothorax. Drainage procedures, such He was a non-smoker and had no history of chronic respiratory, as, chest tube insertion, have been advocated to prevent fatal cardiac or neurological disorders. His past history is not suggestive. tension pneumothorax. There are two types of pneumothorax: Examination: Vitals were normal. General examination findings traumatic and atraumatic. A traumatic pneumothorax can be the were unremarkable. Respiratory system examination revealed result of blunt or penetrating trauma. Pneumothorax can be further reduced breath sounds over the left mammary and infra-axillary classified as simple, tension, or open. A simple pneumothorax area and no added sounds. Investigations: Blood hemogram does not shift the mediastinal structures, as does a tension and routine biochemistry — within normal limits. Chest X-ray — pneumothorax which can be life-threatening. Open pneumothorax Patchy consolidation in the left lower zone. Spirometry — mild is an open wound in the chest wall through which air moves in and obstruction with significant reversibility. ECG, 2-D ECHO — normal. out. Hemothorax is a frequent sequela of traumatic thoracic injuries, USG abdomen and pelvis — normal. Contrast-enhanced CT scan of It is a collection of blood in the space between visceral and parietal the thorax-calcified mucus plug with distal atelectatic changes in pleura. It is associated with 25% of pneumothorax and 73% of the anterior basal segment of the left lung. Bronchoscopy findings extrathoracic injuries. Materials and methods: Case presentation: -smooth endobronchial lesion seen occluding left lower lobe A 52-year-old male patient presented in ED with A/H/O RTA due anterior segment completely. Histopathology of endobronchial to hit by an auto-rickshaw while the patient was crossing the road biopsy — benign bronchial mucosa and peribronchial tissue with on November 8, 2020, at around 7.00 pm at Sanand Ahmedabad. focally ossified cartilage; small foci of fibromyxoid stroma admixed Followed by H/O LOC for 15 minutes. The patient was first taken to with mature adipose tissue; the possibility of hamartoma; Brush a private hospital in Sanand where a chest X-ray and NCCT brain cytology — scanty atypical cells highly suspicious of malignancy; were done which were normal. ECG was normal. The patient was BAL fluid cytology — no abnormality detected; PET-CT scan — the discharged from a private hospital after 6 hours of observation. obliteration of bronchus of left lower lobe anterior segment by The patient then came to Civil Hospital on November 11 at around hypodense intraluminal soft tissue with peripheral calcification and 11 am with a complaint of left-sided chest pain and breathing low-grade metabolic activity associated with patchy pleural based difficulty. The patient was conscious and oriented. On the primary collapse consolidation. Few subcentimeter mediastinal and bilateral survey, the airway was patent, B/L air entry was present, reduced hilar lymphadenopathy showing low-grade metabolic activity on the left side, respiratory rate 22/minute, the temperature was probably of inflammatory etiology. Results: Patient underwent left normal, pulse rate 98/minute, blood pressure 116/70 mm Hg, and thoracotomy, left lower lobe anterior and medial segmentectomy SpO2 91% on room air and a GCS score of 15/15. The patient was with sleeve resection and lymph node dissection. Histopathological immediately started on supportive care of oxygen via venti mask at study of resected tissue revealed Chondroid hamartoma with 4 L/minute, IV access secured and analgesia was given, after which maximum tumor size 1.3 cm. Without atypia or malignant changes. saturation increased to 98%. On Secondary Survey, No long bone Hilar nodes showed reactive lymphadenitis. Discussions: Though injury palpable, 5 × 0.2 cm Sutured wound present on the left scalp. most hamartomas are clinically silent, endobronchial tumors can Results: Investigations Chest Xray showed homogenous soft tissue present with recurrent respiratory tract infections, hemoptysis, opacity noted in left lung in lower zone with blunting of CP angle and chronic cough. Chances of malignant transformation are very and collapsed lung s/o haemopneumothorax and linear displaced rare and the presence of malignancy should be ruled out in case of fracture of 7th rib on left side. After taking consent, under local large or rapid growing lesions. Radiologically Popcorn calcification anesthesia a 32 no. Intercostal Drainage Tube was inserted through and focal fat densities are important diagnostic clues. Preoperative 5th intercostal space on left side. Eight hundred ml blood came diagnosis is possible only in 15% of cases because of the rarity of out preceded by gush of air following which breathing improved, the disease and insufficient biopsy sample as tumors are covered RR 20/min spo2 was 98%, BP 110/70mm Hg and Pulse Rate of 90/ by normal bronchial epithelium. Sixty-five percent of tumors are min Discussions: Pneumothorax occurs when free air enters the present on the right side. Chondroid variety accounts for only 1% potential space between the visceral and parietal pleura. Primary of pulmonary hamartomas. More than 80% of patients are smokers. pneumothorax occurs without clinically apparent lung disease, This case of left-sided endobronchial chondroid hamartoma either spontaneously or from penetration of the intra-pleural is of extremely rare occurrence. Conclusion: The efficacy of space by trauma. Secondary pneumothorax occurs in patients bronchoscopic biopsy in the preoperative diagnosis of pulmonary with underlying lung diseases. Pneumothorax can be categorized hematomas is limited. Definite diagnosis and treatment can be into two conditions by a time sequence. Once diagnosed, fluid achieved by surgical resection with minimal morbidity. reposition and chest tube insertion must be provided to allow pulmonary re-expansion and stabilize the patient. Ultimately 27. A Case of Delayed Traumatic Hemopneumothorax. treatment decisions must be individualized based on each patient’s (Conference Abstract ID: 84) clinical condition. The management of delayed hemothorax primarily requires controlling the bleeding and evacuating the Revant Agarwal, Chirag J Patel hematoma from the thoracic cavity. A tube thoracostomy should be BJ Medical College Ahmedabad, Gujarat, India considered to drain blood from the pleural space, and thoracoscopic DOI: 10.5005/jp-journals-10071-23711.67 surgery or an open thoracotomy should be considered for patients Introduction: Pneumothorax, hemothorax, and hemopneumothorax with persistent intrathoracic bleeding. Conclusion: Chest wall after trauma are preventable causes of death in the emergency injuries and concomitant hemopneumothoraces are frequent department. The presence of air between visceral pleura and parietal following blunt and penetrating trauma, most commonly after a pleura with consecutive retr action of the lung from the chest wall road traffic accident. Hemopneumothorax and pneumothorax can

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be missed in initial evaluation after traumatic injury to the chest changes and dysphagia, and need for permanent tracheostomy if a follow-up X-ray is not done after a proper interval in a case of due to laryngeal stenosis.5 Conclusion: Cut-throat injury presents blunt chest trauma. While most thoracic injuries may be managed a challenging scenario for clinicians and often the extent of the non-operatively and the mortality rate is low, vigilance is required injury can be masked and the mortality can be high in such cases. to detect those injuries that are potentially life-threatening and Major risks involved are airway compromise, torrential bleeding, require urgent intervention. and risk of aspiration. These situations demand quick thinking and a multidisciplinary team involvement with a structured approach 28. Airway Management of a Case of Cut-Throat Injury. to help formulate a management plan and prevent complications. (Conference Abstract ID: 81) Akshata Amin, Amit Agrawal 29. Bilateral ESP Block: Our Savior in Patient with Crouzon Sevenhills Hospital, India Syndrome. (Conference Abstract ID: 69) DOI: 10.5005/jp-journals-10071-23711.68 Nidhi Arun Introduction: Penetrating neck injury represents 5 to 10% of all Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India trauma cases.1 Clinicians need to be familiar with management DOI: 10.5005/jp-journals-10071-23711.69 principles as these injuries can often take the clinician by surprise. Introduction: Crouzon syndrome is a rare genetic disorder These injuries can be quite serious as there are a lot of vital (incidence 1.6 in 10,0000 patients), characterized by craniofacial structures lying close to each other in the neck and hence the dysostosis caused by premature fusion of cranial sutures due to mortality rates in these cases can be as high as 10%.2 Patients with mutation in one of the FCFR genes.1 This affects the growth of the cut-throat injury may present with airway compromise, aspiration, skull and head resulting in abnormal shape and development of and acute blood loss with hypoxemia because of injury to the the head and face, manifested as brachycephaly, shallow orbits, airway and major vessels. The best method of achieving definite protruded eyeballs, prominent foreheads, midface hypoplasia, airway control in the setting of penetrating neck injury will vary hypoplastic jaw, relative mandibular prognathism, high arched according to the clinical circumstances, clinical skill, and hospital palate with crowded teeth, and sometimes spine abnormalities.2 resources.3 There have been reports in the literature when the Here, we are presenting a successfully managed case of Crouzon trachea was intubated through the neck wound itself through the syndrome, posted for total abdominal hysterectomy (TAH). transected part of the trachea if transection was present. Some Materials and methods: A 45-year-old woman with Crouzon authors have described this approach to be dangerous because syndrome, with loss of vision and exposure keratitis due to severe it can produce further damage to the larynx or increasing the proptosis, brachycephaly, limited neck movement, mal-occluded, chances of inhaling vomitus, blood, or secretions.4 Materials and multiple loose and missing teeth with moderate kyphoscoliosis was methods: Case report: A 40-year-old man was brought to the posted for TAH for cervical fibroid. On further evaluation, we found Accident and Emergency department with a history of the lacerated that there was associated pulmonary hypertension (pulmonary wound to the front of the neck as a part of a suicide attempt. On artery pressure = 38 mm Hg) and hypothyroidism for which she inspection, there was a 3 × 1.5 cut just below the cricoid cartilage was on medication for 5 years. Her laboratory parameters were along with visible bleeding. On digital exploration, the cut in the normal except for low hemoglobin (7.7 g/dL) despite 2 units of trachea could be felt. Considering the risk of aspiration and the fact cross-matched packed cell transfusion, most probably due to that the trachea could be easily felt on digital exploration it was menorrhagia. Her intelligence and mentation were not affected. decided that Plan A would be to intubate the trachea through the Our main concern, in this case, was the difficult airway in view of wound using a small size endotracheal tube to secure the airway limited neck movement, abnormalities in the shape of the head, and prevent ongoing aspiration of blood. Plan B would be to go face, and dental anomalies, associated pulmonary hypertension, for Standard Orotracheal intubation. The patient was given 2 mg and moderate kyphoscoliosis imposing procedural difficulty for of Midazolam and 50 μg of Fentanyl intravenously to calm him the central neuraxial block. Administering neuraxial blocks can down and to provide some analgesia. Once the patient was a bit be technically difficult in patients with Crouzon syndrome due calmer size 5.5 endotracheal tube (ETT) was passed over a pediatric to vertebral fusion and the presence of scoliosis or kyphosis.3 bougie easily into the trachea and position was confirmed by There was also a high probability of eye injury due to severe auscultation and end-tidal CO2 monitoring. The tube was secured proptosis while masking ventilation and intubation. Thus, we have using tape. Once this was done the patient was sedated further decided to go for monitored anesthesia care (MAC) with bilateral and then subsequently moved to a CT scanner for a preoperative ultrasound-guided erector spinae plane (US-ESP) block with scan to look for the extent of injuries and formulate a plan for dexmedetomidine sedation, after taking informed consent. The surgical repair of the wound. Discussions: Management of a case patient was educated about ESP block and numeric rating scale of cut-throat injury depends on a lot of factors such as the extent (NRS) for pain assessment. In the operation theater, basic monitors of airway compromise, hemodynamic instability, risk of aspiration, were instituted. After positioning the patient in a sitting position, the extent of injuries to other structures, etc. Establishing and ultrasound-guided bilateral ESP block was given with 20 mL of maintaining a patent airway is the first priority in severely injured 0.25% levobupivacaine with, at the level of second lumbar vertebra, patients. Basic airway maneuvers and simple adjuncts will often and the catheter was secured bilaterally in that myo-facial plane enable sufficient oxygenation and ventilation until personnel for perioperative continuous infusion of 0.125% levobupivacaine skilled in tracheal intubation are available. The involvement of at the rate of 6 mL/hour. Ramsay sedation score of 3 was achieved a multidisciplinary approach is key to the management, which, by dexmedetomidine infusion. Oxygen supplementation was should be instituted in good time to prevent complications, such as, done through a nasal cannula at the rate of 3 mL/minute, avoiding chronic airway obstruction, wound infection, scar, persistent voice anatomical face mask. Basic noninvasive monitoring like NIBP, SpO2,

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and ECG was done. Results: Intraoperative period was uneventful. discharged on oral aspirin and steroids (1 mg/kg-tapering). Results: The patient was followed for 2 postoperative days and was found Case was discharged. Discussions: Our cases fulfill the criteria of to be comfortable and stable. NRS was never found to be more the case definition of MIS-C/PIMS-TS proposed by WHO and CDC than 4. Discussions: US-ESP block is a myo-facial plane block, as well as they fit the clinical description of KD. The differences described by Forero et al., where drug diffuses in a plane below from Kawasaki disease being older age group, predominantly erector spinae muscle and provides analgesia by blocking dorsal gastrointestinal manifestations, circulatory failure, and evidence rami, ventral rami as well as rami communicans of spinal nerves.4 of increased inflammation. Earlier case reports have supported Conclusion: We want to convey that the benefits of ESP block like the role of steroids along with IVIG in such presentations.7 Both ease to administer, safe, no hemodynamic changes, and extensive the cases received IVIG and steroids and they have shown good analgesia can be used for TAH inpatient with Crouzon syndrome. improvement. It is proposed that there is an immune-mediated delayed cytokine response to an already cleared SARS-CoV-2 virus 30. Pediatric Multisystem Inflammatory Syndrome Temporally from the body. When viral load is high, the genetic response to Associated with SARS-CoV-2: Case Report From PICU (North viral clearance is slow and the interferon response is weak; hence India). (Conference Abstract ID: 66) there is an inflammatory response due to cytokine storm.8,9 Our Sonali Ghosh, Sanjeev Dutta cases highlight the importance of early recognition of signs and QRG Health City, Faridabad, Haryana, India timely intervention. It is expected that such cases are expected to rise in the Indian subcontinent with the resurgence of COVID cases. DOI: 10.5005/jp-journals-10071-23711.70 Conclusion: The above cases highlight that clinicians should be Introduction: SARS-CoV-2 is a global pandemic. It has affected aware of the novel clinical syndrome and early intervention. An early 57.8 million population and 1.37 million deaths as of November 1 referral to centers with adequate expertise should be considered. 24, 2020. Initially, it was found to be less severe in the pediatric There is a need to establish the natural history and epidemiology population but now cases have started emerging worldwide in of such cases in our country. the pediatric age group and they are also requiring critical care management.2,3 It has been termed multisystem inflammatory 31. Dyke–Davidoff–Masson Syndrome: A Rare Case Managed in syndrome in children (MIS-C) associated with COVID-19, also called the ICU. (Conference Abstract ID: 62) PIMS-TS (pediatric inflammatory multisystem syndrome temporally associated with COVID-19). It is a hyper-inflammatory syndrome. Margiben Tusharbhai Bhatt, R Sunil, Rituparna Bordoloi, In India, cases started appearing as early as May 2020. On May Shwethapriya Rao 1, 2020, RCPCH published clinical management guidelines for Kasturba Medical College and Hospital, Manipal, Karnataka, India children with presenting symptoms of PIMS-TS.4 WHO and CDC have DOI: 10.5005/jp-journals-10071-23711.71 released criteria for PIMS-TS/atypical Kawasaki disease/Toxic shock Introduction: Dyke–Davidoff–Masson syndrome (DDMS) is a syndrome in the second week of May 2020.5 In India, Rauf et al. rare neurological condition.1–3 It is characterized radiologically reported the first case.6 We hereby report two cases from our center, by atrophy or hypoplasia of one cerebral hemisphere which is which is a 6-bedded PICU at a tertiary care hospital in North India. secondary to brain insult in the prenatal or early childhood period.4 Materials and methods: Case 1: A previously healthy 12-year-old Typically, it presents with recurrent seizures, facial asymmetry, male child presented with a history of fever for 6 days, abdominal contralateral hemiplegia, mental retardation, and learning pain, headache, non-projectile vomiting, and a rash over the body. disability.1 Due to its rarity, it may be misdiagnosed by most On examination in triage, he had tachycardia HR 150/minute and physicians. Materials and methods: A 25-year-old woman, with a signs of poor peripheral perfusion. He had bilateral non-exudative history of recurrent seizures, low intelligence, right-sided weakness conjunctivitis, unilateral cervical lymphadenopathy, mucositis, since the age of 5 years came to the hospital with on-going seizures. and generalized polymorphous rash. He progressed rapidly to She was born of a non-consanguineous marriage. Birth history hypotensive shock. Fluid bolus was given, and adrenaline infusion was of full-term normal home delivery. Subsequently, she had was started. Possibilities considered were KD shock syndrome, episodes of seizure on and off and was advised oral phenytoin PIMS-TS, and septic shock. Laboratory investigations revealed regularly. The patient had a history of weakness of the right side anemia (Hb 9 g%), polymorphic leukocytosis (TLC 15,000 cells/mm3, of the body since the age of 13 years, nonprogressive in nature. P80%), hyponatremia (Na 131 mmol/L), CRP 48 mg/L, Trop I 68.96 She also had learning difficulties and decreased interaction. At the pg/mL. ECHO revealed mild LV dysfunction and dilated coronaries. age of 19 years, she developed an altered sensorium for which she He received IVIG 2 g/kg. Also, a pulse dose of methylprednisone (10 got admitted to hospital for 8 days. MRI brain showed ulegyria in mg/kg/dose) was given in view of vasoplegic shock. He became the left parieto-occipital region. Results: On the day of admission afebrile after 48 hours and other signs also abated by 96 hours. The to the hospital, patient had continuous generalised tonic-clonic inflammatory markers showed a declining trend. Hemodynamic seizures. She was immediately intubated to protect the airways. parameters gradually improved and vasopressor infusions were Facial asymmetry and prominence of frontal ridge were noted so tapered and stopped after 96 hours. The SARS-CoV-2 RT-PCR was preparation for difficult intubation was done beforehand. She was negative. Work up for other infectious etiology was negative. started on intravenous antiepileptic medications. EEG was done There was a history of contact with a family member 3 weeks back suggestive of diffuse electrical dysfunction over the left hemisphere who was COVID positive. There was no facility for performing associated with epileptiform abnormalities. CT brain was done COVID antibodies at that time hence it could not be done. Our which showed left cerebrum volume loss, prominence of sulci diagnosis for PIMS-TS was established as per the WHO/CDC case and dilatation of ipsilateral lateral ventricle, thickening of cranial definition. ECHO on follow-up was normal after 7 days. The child was vault on the left side with dilatation of ipsilateral frontal, mastoid,

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sinuses. MRI brain consolidated the CT findings characteristic of with tall t waves, ABG showed metabolic acidosis, with ow Hco3 Dyke-Davidoff-Masson syndrome. She was gradually weaned levels. Despite a high K of 9.3 mg%, the pt came walking into the from the ventilator and extubated. Sensorium was returned to OPD and was stable. Results: She was asked to stop olmesartan, baseline and she was seizure-free with ongoing medications. and dytor plus, was started on calium gluconate drip for muscle Discussions: Dyke, Davidoff, and Masson first reported this rare stabilization, and cardiac stability, sodabicarb IV 50 mL rthrice a condition in 1933. They studied plain skull radiographs in 9 patients day, with Dextrose and insulin drip, and athalin nebulisation, and who presented with seizures, facial asymmetry, hemiparesis, and K bind sachets, with duphalac for excretion of K, gradually the K mental retardation and described the characteristic features.5 CT came decreased by 1 mg% per day, and by 4 th day the k was 5.5 and MRI brain are the gold standard. Diagnostic features are diffuse meql/Lit, the ECG became normal, and her pulse rate was 88/min, cerebral hemiatrophy, prominent cortical sulci, dilated lateral her muscle tremors disappeared, and the pt was stable, graduallyl ventricles, calvarial thickening, and ipsilateral osseous hypertrophy all her medication for treastment hyperkaleamia was stopped and with hyper-pneumatization of the frontal sinuses and mastoid air the pt was discharged home in a stable condition. Discussions: cells.6 The clinical features include contralateral hemiparesis, facial Reporting a case of hyperkalemia, with levels of K of 9.3 meq/L, asymmetry, recurrent seizures, and mental retardation along with with only muscle tremors, and no other cardiac arrhythmias, that learning difficulties.7 There are two types of cerebral hemiatrophy; is why presenting this case. Conclusion: An unusual presentation congenital and acquired. Congenital variety results from vascular of Hyperkalemia, with only muscle irritability, and no other occlusion involving the middle cerebral artery occurred in the symptoms, no cardiac arrhythmias, properly manages by stopping neonatal or gestational period, unilateral cerebral arterial vascular the offending drugs, and the pt recovered very well. malformations, or any congenital infections. The acquired variant results from prolonged birth asphyxia, recurrent febrile seizures, 33. Early Initiation of Thymosin Alpha 1 for Improved Outcomes trauma, tumor, infection, or ischemia.8,9 If such insult has occurred in Patients with COVID-19 with Associated Comorbidities—A before the age of 3 years then only classical MRI findings are Single-center Experience. (Conference Abstract ID: 57) 10 seen. Differential diagnosis of this condition is basal ganglia Vimal Ranka germinoma, Sturge–Weber syndrome, Fishman syndrome, Silver– GRMI Hospital, Ahmedabad, Gujarat, India Russell syndrome, and Rasmussen encephalitis.11 There are many DOI: 10.5005/jp-journals-10071-23711.73 challenges to manage such cases in ICU which are adequate seizure control, difficult airway because of asymmetric facial features, the Introduction: Thymosin Alpha 1 has been recently been available involvement of multiple systems, and occult myopathies.12 Avoid for immunomodulation. Materials and methods: We utilized this drugs during intubation which can cause decreased cerebral as a repurposed drug for patients with COVID-19. Results: The first perfusion. Be aware of occult myopathy while using muscle relaxant. case was a male with morbid obesity aged 62 years presented in Avoid further insult to the brain by maintaining adequate blood ER with complaints of fever and loss of appetite for 7 days. There pressure, avoiding hypoxia, avoiding the pressor response during was a history of sore throat for last 3 days and breathlessness for intubation and extubation, and rise in intracranial pressure due last 2 days. The patient was a case of type 2 diabetes and known to any ICU-related procedures. Conclusion: DDMS being a rare hypertensive controlled on the ongoing medications. At admission, syndrome is frequently misdiagnosed. A combined clinical and the temperature was 101-degree Fahrenheit, tachypnoeic radiological approach makes the diagnosis easy. Management is respiratory rate of 40/ min, tachycardia pulse rate of 120 bpm. He mainly supportive like antiepileptic medications, physiotherapy, was hypoxic - oxygen saturation (SpO2 on room air) of 85% which and speech therapy. necessitated bilevel positive airway pressure (BiPAP) to maintain saturations under intensive care at with 100% fraction of inspired 32. Hyperkalemia Presenting as Muscle Tremors. (Conference oxygen (FiO2) and positive end-expiratory pressure (PEEP) of 10 cm Abstract ID: 59) H2O. RT PCR was positive, HRCT revealed bilateral mid zone lower zone ground glass opacities suggestive of atypical viral pneumonia. Nilesh M Banthia SpO2 was then maintained at 92%. Patient was initiated on IV Neo Clinic and Echo Centre, Mumbai, Maharashtra, India antibiotics, methylprednisolone, Low Molecular Weight Heparin DOI: 10.5005/jp-journals-10071-23711.72 (LMWH). At day 2 of admission, thymosin alpha 1 was initiated, as Introduction: A 68-year-old lady, DM and HT, presented with 2 vials (each 1.6 mg)/day subcutaneously for consecutive 5 days. Muscle tremors in the thighs, episodic, and investigations showed BiPAP support was at FiO2 90%, PEEP 8 cm H2O, SpO2 95%, FiO2 hyperkalemia, with K of 9.3 mg%, it was corrected, and the tremors 60%, PEEP 5 cm H2O, SpO2 97 %; on 2nd and 3rd day, respectively. disappeared, ECG only showed tall T waves, which disappeared with Day 4, on oxygen mask with 10 litres maintained SpO2 at 97%, treatment and the pt was stable and recovered well. Objectives: respiratory rate 24/min. On day 6, SpO2 was maintained at 97% Drugs causing hyperkalemia, with pout renal involvement and the with 2 litres of oxygen. Subsequently, maintained SpO2 at 98% on unusual presentation of the pt. Materials and methods: The pt room air and was discharged on day 10. CRP reduced from 252 mg/ DM and HT on antidiabetic treatment, with olmesartan for BP and mL to 11 mg/mL at day 9. WBC count increased to 9420 thousand/ Dytor plus edema feet, after all, evaluation and other supportive mm3 at day 7 from 3700 thousand/mm3. IL-6 reduced to 16.2 pg/ treatment, presented with trembling of both the thighs, with mL on day 5 from 170 pg/ml. Ferritin improved to 112 ng/mL from weakness, and waddling gait, was investigated, CBc, LFT were 1140 ng/mL. Second case was 74-year-old female, temperature normal. Creatinine was 2.0 mg%, and K was 9.3 mg%, rechecked 102-degree Fahrenheit for last 5 days with associated asthenia, 3 times. Other reports were normal, ECG showed bradycardia diarrhoea, dry cough, and dyspnoea. She was a known T2DM on

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insulin, IHD on dual anti-platelet therapy, on inhaler therapy for a hemoconcentration that persisted beyond 24 to 36 hours of ICU asthma, pulse rate 120 bpm, respiratory rate 38/min, with SpO2 at stay and aggressive fluid resuscitation. Noting the use of alternative 78% on room air. HRCT revealed scattered bilateral asymmetrical medicine (Ayurvedic medication) for the above, drug toxicity was ground glass opacities. Oxygen was started by High Flow Nasal also considered for the rapid change. Noting lack of extrahepatic Cannula (HFNC) with 40 litres of oxygen FiO2 80%. Started on IV causes of cholestasis, a contrast-enhanced CT scan of the abdomen methylprednisolone, remdesivir, LMWH, thymosin alpha 1, as 2 vials revealed congested large bowel with hepatic vein thrombosis. (each 1.6 mg) / day for consecutive 5 days. Day 5, afebrile, steroids Noting hydration resistant hemoconcentration and hepatic vein tapered, oxygen requirement tapered to 10 litres on mask. Day 7, thrombosis, further evaluation into hematological abnormality oxygen 1 litre per day. Day 8, asymptomatic, discharged on room with a hematologist input confirmed polycythemia vera following air with oxygen saturation 98 %. CRP reduced from 178 mg/mL to flow cytometry analysis with both major criteria being met toward 6.6 mg/mL at day 9. WBC count increased to 8030 thousand/mm3 at WHO diagnostic criteria. Results: Despite adequate and aggressive day 10 from 4040 thousand/mm3. D-Dimer reduced to 191 ng/mL evaluation, antimicrobial therapy, anticoagulant therapy, and on day 7 from baseline of >10,000 ng/mL. IL-6 reduced to 2 pg/ supportive care, she progressed rapidly fulminate hepatic failure, mL on day 7 from 111 pg/ml. Ferritin improved to 745 ng/mL from and succumbed to Gram-negative sepsis. Discussions: This case > 2000 ng/mL on day 9. Discussions: In the first case, tachypnea highlights the need for increased awareness among clinicians at presentation dissuaded to initiate remdesivir or tocilizumab. about patients with leptospirosis when the apparent remission Since corticosteroids were initiated, PEEP and BiPAP support were of leptospirosis does not concur with the improvement of liver reduced. In the second case, we found that high-flow nasal cannula function. The deterioration of our patient’s clinical condition and oxygen (HFNO) is a reliable and better choice as an early stage the biochemical findings strongly point to an underlying disease oxygen therapy. Conclusion: In both the cases, with comorbidities, that was not obvious at the initial presentation. Since other causes we attribute the biochemical and clinical improvement due to of FHF including viral, toxin, or immunologic disease, Wilsons’ thymosin alpha 1, as the timing of the initiation enabled a positive, disease were excluded, the diagnosis of Budd–Chiari syndrome clinically meaningful outcome of COVID-19, facilitating the patient underlying leptospirosis appeared more likely. The diagnosis was to be on room air within 8 days of admission. established based on a contrast CT of the abdomen that showed cirrhosis of the liver with caudate lobe enlargement and obstruction 34. Tropical Fever Precipitating a Macrovascular Complication of hepatic veins. Any obstruction of venous vasculature referred (Budd–Chiari Syndrome) and Subsequently Fulminant Hepatic to as Budd–Chiari syndrome leads to increased portal and hepatic Failure Due to Undetected Polycythemia Vera. (Conference sinusoid pressures as the blood flow stagnates. Obstruction also Abstract ID: 47) causes centrilobular necrosis and peripheral lobule fatty change Banavathu Kishansing Naik, Sulakshana, Justin Aryabhat due to ischemia. Liver biopsy is non-specific but sometimes Gopaldas necessary to differentiate between Budd–Chiari and other Srmsims Bareilly, Manipal Hospital, Bengaluru, Karnataka, India causes of hepatomegaly and ascites such as Wilson’s disease, galactosemia, and Reye’s syndrome. Conclusion: Progressive DOI: 10.5005/jp-journals-10071-23711.74 hepatic dysfunction despite antimicrobial therapy in leptospirosis, Introduction: Acute febrile illness in the tropical and sub- should alert the clinician for a prompt search of other contributory tropical region of India is due to a multitude of bacterial and factors. Timely detection of cause and appropriate therapy can viral pathologies and is labeled as tropical fever until full workup prevent any catastrophe. Budd–Chiari syndrome should always is undertaken. A seasonal change due to vectors is common be suspected in any case of polycythemia with liver dysfunction and usually points to a specific illness (dengue and dengue-like although any infective pathology may partially explain the hepatic illnesses during monsoon and post-monsoon season). Due to the derangements. A careful history in atypical presentation or progress increased admissions to hospitals for such tropical fevers not just of common illnesses along with targeted investigations is likely limited to ward but also to ICU, at times management is initiated to lead to a diagnosis of underlying illnesses and in turn prompt based initial presentation pattern. A careful review of history and management of both. further clinical, microbiological, and biochemical evaluation may be required if a clinical course is complicated. Objectives: We 35. Hypophosphatemia—A Uncommon Cause of Delirium in present a 19-year-old young woman who was admitted to our Critically Ill Patient. (Conference Abstract ID: 42) hospital with a history of fever with rigors and jaundice. A routine workup and initiation of broad-spectrum antimicrobial agents were Anuj Clerk, Bhargav Umaretiya, Krunalkumar Patel, Nikita Desai, undertaken. She was required to transfer to the intensive care unit Himani Garasia, Nilesh Thumar, Rakesh Mangrolia (ICU) in view of altered mental status in the setting of significant Sunshine Global Hospital, Surat, Gujarat, India biochemical and hematological abnormalities including tests to DOI: 10.5005/jp-journals-10071-23711.75 suggest leptospirosis. Despite optimization of antimicrobial agents, Introduction: Delirium is characterized by impaired cognition with she continued to deteriorate prompting a review of history. Noting Inattention and disorganized thinking. In critically ill patients, it sub-acute onset of jaundice, further workup is initiated for rapidly may develop secondary to multiple precipitating or predisposing worsening conjugated hyperbilirubinemia. She further underwent causes. Hypophosphatemia can cause altered mentation and evaluation for both intrahepatic and extrahepatic causes including delirium but rarely suspected and evaluated for the same. Here, computer tomography (CT) imaging of the abdomen. Materials we are presenting a case of hypophosphatemia related delirium. and methods: Investigations noted a rapidly worsening conjugated Materials and methods: Case details: An 83-year-old male pt hyperbilirubinemia with altered coagulation and a lack of viral was admitted with a diagnosis of peripheral vascular disease hepatitis as cars of the above. Hematological investigations revealed with thrombotic occlusion of bilateral aorto-femoral graft, right

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external iliac, common femoral and superficial femoral artery, Conclusion: left common iliac, external iliac arteries which required left lower • POCUS (point of Care ultrasound screening) is highly desirable limb amputation. Along with peri-angioplasty for non-healing for diagnosis of the source of sepsis in a patient of septic shock. amputation stump wound and lumbar sympathetic block for • Urosepsis should not be ruled out in a patient with a normal severe pain on the amputation site. The patient had decreased oral urine routine. intake, required daily dressing and debridement for amputation stump wound along with higher antibiotics for the infection. 37. Thymosin Alpha 1 for Managing COVID-19 Cases with After revision of amputation, the patient was put on Ryle’s tube Comorbidities Presenting with Mild Symptoms: Distinctive feeding as his oral intake remained very low despite the 10th Experience from a Tertiary Care Center. (Conference Abstract day of admission. The patient became delirious and started on ID: 39) quetiapine. On evaluation for the cause of delirium along with Chinmay Godbole pain, long hospital stay, multiple medications, old age, and COPD, KJ Somaiya Medical College and Superspeciality Centre, Mumbai, hypokalemia was found. All medications were reviewed, pain Maharashtra, India control achieved, and corrections for hypokalemia were given. But DOI: 10.5005/jp-journals-10071-23711.77 as the patient had persistent delirium and hypokalemia. Further Introduction: We present a series of cases with varied clinical evaluation for the cause of persistent hypokalemia, phosphorus spectrum with mild symptoms from a tertiary care center. Materials level checked, which was very low (1.0 mg/dL). Phosphorus was and methods: Understand the implications for the clinical utility replaced entrally. His delirium improved once his phosphorus of thymosin alpha 1 in mild symptoms of COVID-19. Results: and potassium level rectified. With proper Ryle’s tube feeding The first case was 37-year-old male, with a history of pulmonary and daily dressing he gradually improved and was discharged. embolism, presented with mild breathlessness, on background Results: Our patient had persistent hypokalemia due to refeeding therapy of hydroxychloroquine (HCQ) and doxycycline. Thymosin syndrome-related hypophosphatemia as a cause of delirium. alpha 1 was administrated at admission with 1.6 mg OD s/c with Discussions: Severe hypophosphatemia can be presented the continuation of the other ongoing therapy. At day 3, SpO2/ with an altered mental condition. On a high index of suspicion FiO2 ratio improved to 240 (at presentation was 150), IL-6 reduced for hypophosphatemia is a must in patients with re-feeding to 5 pg/mL from 31 pg/mL, D Dimer reduced from 600 to 587 ng/ circumstances with persistent hypokalemia, large healing wound, mL and clinical symptoms improved to just dyspnoea on exertion. recovering from sepsis causing delirium. Conclusion: Delirium is The second case was a 33-year-old with mild symptoms, known multifactorial and hypophosphatemia should be kept as one of diabetic on OHA had SpO2/FiO2 ratio 170 at admission, tachycardia the many differentials. (122 bpm), fever (99 F). He was initiated on Thymosin alpha 1–1.6 mg OD. On fourth day of the therapy, SpO2/FiO2 ratio improved 36. Syndrome of Normal Urine UTI (Urinary Tract Infection). to 300, was put off oxygen support, IL-6 reduced to 6 pg/mL from (Conference Abstract ID: 41) 11 pg/mL and was asymptomatic. The third case was 61-year-old Anuj Clerk, Krunalkumar Patel, Nikita Desai, Himani Garasia, male, with 60 kg body weight, known hypertensive and diabetic Nilesh Thummar, Rakesh Mangrolia, Bhargav Umaretiya on OHA, presented with cough and fever with ongoing therapy of Sunshine Global Hospital, Surat, Gujarat, India HCQ, azithromycin, ivermectin, doxycycline, enoxaparin. After 5 DOI: 10.5005/jp-journals-10071-23711.76 days of initiation of Thymosin alpha 1–1.6 mg OD, the CT severity score reduced to 4/25 from the initial 5/25, SpO2% on room air Introduction: Urinary tract infection is one of the common improved to 99, with no symptoms. D Dimer reduced from 553 to sources of infection in patients with sepsis in the intensive care 300 ng/mL. The fourth case was a 78-year-old 50 kg female, known unit. For diagnosis of urinary tract infection, one requires pyuria hypertensive and diabetic with a history of fever was on piperacillin or bacteriuria (>103 colony count in the catheterized sample) and tazobactam combination, doxycycline, HCQ and steroid. After along with symptoms. To contradict the same, we are presenting 5 days of 1.6 mg of thymosin alpha 1, the SpO2/FiO2 ratio improved a case of septic shock due to obstructive urosepsis with a normal to 260 from initial 150 and was asymptomatic Discussions: None urine routine report. Materials and methods: A 55-year-old man of the cases required positive pressure ventilation and none had was admitted to some private hospital with complaints of fever, any preexisting lung disease. Conclusion: In our experience, it cough, and right leg pain for 2 to 3 days. He had right lower limb is plausible for the clinical and biochemical improvement to be cellulitis and he was treated for the same with antibiotics and attributed to the timely utilization of thymosin alpha 1, which other supportive care in a prior institute. Results: In this patient, could improve the immune regulation and address the dilemma due to obstructed ureter urine routine micro was normal but the of management of COVID-19. patient had urosepsis. Discussions: No single investigation should lead to or rule out any diagnosis, so does the normal urine routine 38. Fatal Spontaneous Clostridium septicum Myonecrosis in an and microscopy report. Despite one completely obstructed ureter Immunocompetent Host. (Conference Abstract ID: 38) with infection piled up behind it, the patient can have normal urine from the contralateral non-obstructed ureter, “Normal Urine P Bala, V Deepak, A Rajalakshmi UTI” is possible. High suspicion along with re-visiting history Kerala Institute of Medical Sciences, Kerala, India once more when the septic focus is not obvious. It emphasizes DOI: 10.5005/jp-journals-10071-23711.78 the role of POCUS (Point of Care ultrasound screening) of all Introduction: Clostridial myonecrosis is a life-threatening critically ill patients by Intensivist to reveal such overt foci of muscle infection that develops either from an area of trauma or sepsis. Keywords: UTI (urinary tract infection), POCUS [point of hematogenous from the gastrointestinal tract with muscle seeding. Care ultrasound screening]. Spontaneous/atraumatic gas gangrene is caused by Clostridium

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septicum and multiple risk factors have been proposed for the same. swelling, and blebs within few hours along with hemodynamic We report a case of fatal spontaneous gas gangrene in a previously instability and death. healthy patient with no comorbidities/risk factors. Materials and methods: A 62-year-old man, with no previous comorbidities came 39. A Case of Acquired Methemoglobinemia Managed to the emergency room at 9.30 am with c/o sudden onset pain in Successfully in a Patient Admitted in SARI as COVID-19 suspect: the left gluteal region and upper thigh since morning that day. On A Case Report. (Conference Abstract ID: 35) initial examination, he was hemodynamically stable. There was Vaishnavi Venkatramana Pandith, Veena Watal, Vaishali Mohod minimal induration in the affected area. There were no external Grant Government Medical College And Sir Jj Group of Hospitals signs of inflammation during local examination like redness/ Mumbai, Maharashtra, India tenderness/warmth. He had a full range of movements in hip, knee, DOI: 10.5005/jp-journals-10071-23711.79 and ankle joints. Other systems examination was within normal limits. The total leukocyte count was 11,000/µL and hemoglobin Introduction: A case of acquired methemoglobinemia managed was 11.2 g/dL. Urine analysis, serum electrolytes, and creatinine successfully in a patient admitted in SARI as COVID-19 suspect: A were normal. Radiographic imaging of the hip and spine were case report methemoglobinemia is a rare condition in which the normal. The patient’s pain worsened further despite adequate iron in hemoglobin is present in the ferric (Fe3+), not the ferrous analgesia and so, further imaging was done to rule out perianal/ (Fe2+) state of normal hemoglobin, which renders red blood cells gluteal abscess/aortic dissection. MRI was done and the patient was unable to release oxygen to tissues, produces functional anemia shifted to critical care ICU for further care. The patient developed and leads to tissue hypoxia. Patients with coronavirus disease tachycardia, tachypnea, and respiratory distress by 5 pm. Skin color 2019 (COVID-19) often have clinical characteristics, such as chest changed and mild redness was noted in the upper thigh along with tightness and dyspnea. Patients with methemoglobinemia can a local rise in temperature. MRI provisionally reported as features present with breathlessness and refractory hypoxia. In this state of myositis involving left hamstring muscles. His ABG showed of pandemic patients with methemoglobinemia may present with severe metabolic acidosis and he developed hypotension after COVID-19 like a picture. So, one must always keep in mind the an hour. The patient was intubated and mechanically ventilated. possibility of other rare differentials. We report a case of refractory Blood cultures were taken and he was initiated on broad-spectrum hypoxia from acquired methemoglobinemia in a critically ill patient antibiotics — piperacillin/tazobactam and doxycycline along with admitted in SARI ICU as a suspect to COVID-19 infection with inotropic supports. By 8.30 pm, blebs started to appear in the complaints of breathlessness. A 25-year-old female patient was affected area and by 9.20 pm, the patient developed bradycardia admitted to SARI ICU as COVID suspect with breathlessness with followed by cardiac arrest. Resuscitative measures were taken as per mild peripheral cyanosis. The patient had no known comorbidities. ACLS protocol but the patient could not be revived. Blood culture She gave a history of being treated for malaria and week before report came the next day, where 2 out of 4 bottles grew Gram- the onset of symptoms. She had refractory hypoxia and low SpO2 positive bacilli which were later confirmed as Clostridium septicum. despite O2 support. Her chest radiograph was normal not showing Discussions: Clostridium septicum is a Gram-positive, anaerobic, signs of ARDS or COVID pneumonia. ABG had low SO2 despite spore-forming, highly motile bacteria. The organism shows a strong high PaO2. Methemoglobinemia was suspected and ABG showed association with malignancy and immunosuppression. Method of a high percentage of methemoglobin levels. Treatment based on entry of organism is postulated to be due to a defect in the mucosal the clinical picture was started with methylene blue her serial ABGs lining of the bowel caused by conditions like tumor, radiation, were observed. The patient showed improvement in her clinical chemotherapy. Once disseminated through the hematogenous condition and saturation on room air. ABGs improved in terms of route, it spreads to a remote site to cause metastatic/distant SO2 and methemoglobin levels. infection. Virulence is exerted through four main toxins-alpha, beta, delta toxins, and hyaluronidase. Non-specific pain often 40. Enigma of Apnea Test for Brain Death on Ecmo—An Ongoing described as throbbing/heaviness may be the only presenting Discussion. (Conference Abstract ID: 30) symptom as in our case. Swelling, the appearance of bullae and blisters, and palpable crepitus usually appear late.1 Association of Bipin Chalattil, Manoj Kumar Sahu All India Institute of Medical Sciences, Delhi, India this disease with malignancy is very strong and so a rigorous search for occult malignancy should be done.2 But in our course, the clinical DOI: 10.5005/jp-journals-10071-23711.80 course was so much rapidly deteriorating that, this could not be Introduction: Coma, absent brain stem reflexes, and apnea are done. A study by Chew et al. showed 80% of Clostridium septicum considered the neurological criteria of brain death. As membrane infections were associated with confirmed/occult malignancy.3 oxygenator does almost the entire gas exchange in patients with A systematic review revealed mortality of 67% in patients with severely diseased lungs who are on extracorporeal membrane spontaneous gas gangrene caused by this organism.1 The IDSA oxygenation (ECMO), it is not possible to carry out apnea tests guidelines recommend high dose insulin 18 to 24 million units/ in a routine manner. We described the difficulties we faced day in divided doses along with intravenous clindamycin.4 Local conducting the apnea test and the other ancillary tests in our wound debridement should be done thoroughly and the role of patient on venovenous ECMO who suffered a major cerebral insult hyperbaric oxygen therapy remains controversial. Conclusion: and reviewed the literature of brain death testing in patients on Spontaneous gas gangrene is an unusual but fatal disease. We ECMO. Brain death (BD) as described by the American Academy of are reporting this case for few reasons. Challenges in making a Neurology is the irreversible cessation of all functions of the entire diagnosis of spontaneous gas gangrene in an immunocompetent brain including the brainstem which requires proof of the absence patient and the rapid pace at which clinical deterioration occurs, of brainstem reflexes, cessation of spontaneous breathing (apnea), from a near-normal local examination to development of erythema, and irreversible coma of a known cause.1 Extracorporeal membrane

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oxygenation (ECMO) use has risen in the past decade owing to a continuous positive airway pressure (CPAP) support for alveolar wide range of applicability in acute, severe, and reversible cardiac, recruitment in atelectasis. 2 respiratory, or cardiorespiratory failure. However, the issues in Reducing CO2 elimination (to ensure its rise) by decreasing the legal confirmation of brain death on ECMO patients prevail.3,4 We sweep gas flow on ECMO to a minimum of 0.5 to 1 L/minute describe a case in which ECMO was instituted and difficulties for (essential for avoiding hypoxia) or by providing a gas mixture known determining BD are highlighted and further description of the as carbogen (a mixture of CO2 and O2) through the ventilator or 2,5,6,9 literature is discussed. Case report: A 40-year-old woman weighing addition of CO2 in ECMO circuit. In a large meta-analysis, AT 120 kg with pneumonia following H1N1 influenza was transferred could confirm BD in 77% of patients on ECMO.6 In the rest, it failed to our hospital on mechanical ventilation for worsening respiratory due to the absence of an appropriate rise in CO2; development of distress. Chest X-ray revealed bilateral diffuse infiltrates. The other hypoxic, hemodynamic alterations; and neurologist opinion of parameter Discussions: ECMO is a form of extracorporeal life support questionable reliability of AT on ECMO.4,10 The presence of these that acts as a rescue in patients with refractory cardiac and respiratory lacunae with AT has focused our attention on ancillary tests. These failure. Expanding indications have provided for its increasing use; tests are of two types, the first are the ones that measure cerebral however, there has been a noted rise in neurological injury in ECMO blood flow, and the second are those which test the bio-electric patients with an incidence of 7.1% of which 23.5% manifest as BD.2,5,6 activity.3 The former includes angiograms either conventional or by These sequelae may result from preexisting neurological dysfunction, CT scan and MRI, TCD, and nuclear studies. The latter include EEG hypoperfusion due to dysfunctional cerebral autoregulation, and evoked potentials. The meta-analysis revealed the EEG use in reperfusion injury post-resuscitation, rapid blood gas alteration, 62% of cases followed by CT angiogram in 22% cases and TCD in micro-emboli, thrombosis, and intracranial hemorrhage due to 6% cases.6 EEG demonstration of electro-cerebral inactivity defined development of coagulopathy or anticoagulant use and differential as the absence of non-artefactual electrical activity of at least 2 μV hypoxia-induced cerebral dysfunction (Harlequin syndrome) in the from baseline over half an hour is supportive of brain death. The case of peripheral venoarterial (VA) ECMO.2,4 BD declaration would CT angiogram should demonstrate the absence of blood flow in require demonstration of irreversible unconsciousness, apnea, internal carotid and vertebral arteries to signify BD. In addition, CT absent cranial nerve, and brainstem reflexes. To ensure the conduct scan may also demonstrate other neurological causes of declining of AT appropriately, normothermia (core temperature ≥ 36°C) and Glasgow coma scale (GCS) such as massive intracranial bleed with systolic BP > 100 mm Hg are essential.1 The other prerequisites raised intracranial pressure and midline shift amenable to urgent are the absence of central nervous system-depressant drugs or neurosurgical intervention. This if left unattended may lead to neuromuscular blocking agents, severe electrolyte, acid-base, or catastrophic sequelae of herniation culminating in BD. EEG and endocrine disturbances. The test is considered positive if there is a evoked potentials are affected by potential confounders such as rise in PaCO2 ≥ 60 mm Hg or at least 20 mm Hg rise above baseline. sedative drug use, hypo- or hyperthermia, metabolic abnormalities, AT is considered negative if there is an observed respiratory and other local electrical interferences. A bispectral index is used movement either visualized during the test, detected by a ventilator, in conjunction, with variable success.10 The tests of blood flow or by evidence of thoracoabdominal de-synchrony in consolidated detection, although, unaffected by these confounders may provide lungs with poor thoracic compliance. It is abandoned in cases false-positive results in significant hypotension states or cases of of the development of hypoxia or deranged hemodynamics.3,7 occluded proximal vasculature and they show false-negative with Unlike patients on mechanical ventilation alone, gas exchange for preserved blood flow in BD patients with craniotomy or ventricular patients supported on ECMO occurs mainly through the membrane drain in situ. Also, these tests are difficult to perform due to concerns oxygenator. Carbon dioxide elimination is dependent on the sweep with patient shifting to CT or MRI areas and MRI incompatible ECMO gas flow rate in the circuit. ECMO alters drug pharmacodynamics due circuits. TCD fails to visualize evidence of cerebral circulatory arrest to membrane sequestration and interference with decarboxylation, in the majority of adult patients, which however can be used to due to which lipophilic drugs may persist for prolonged periods demonstrate the presence of oscillatory flow with systolic spikes interfering with BD assessment.6,7 Hepatic and renal dysfunction in the pediatric subset.3,5,10 Ancillary tests on their own cannot be may further delay the drug clearance. Gaseous exchange across the used for conclusive BD declaration, so AT is mandatory.2,3,6 In our membrane depends on sweep gas flow, the differential movement patient, AT was tried on 2 occasions but could not be completed, of carbon dioxide and oxygen, and differential solubility, and hence, so proved inconclusive. The facility for serum levels is not available the adequate increase in CO2 either does not occur or takes a at our center; however, serum levels of sedative agents should be prolonged period which is complicated by hypoxia or hemodynamic incorporated in the institutional protocol. The elimination half-lives 3,7,8 alterations. Hence, on ECMO, the recommended value of PaCO2 of midazolam being 1.5 to 2.5 hours and levetiracetam being 6 to 8 rise for a confirmatory AT may not occur even after the stipulated hours were taken into consideration before a formal neurological time of AT of 8 to 10 minutes. The reduction of sweep gas flows to examination. The other commonly used agents in the ICU with their a minimum to reduce carbon dioxide elimination also is futile. The elimination half-lives are mentioned.11 Ancillary tests such as EEG respiratory acidosis also may worsen the cardiac output in VA ECMO were tried but a lot of interference pattern was seen; TCD could leading to hypotension. The compromised lung in VV ECMO develops not demonstrate the flow due to local tissue edema owing to long hypoxia before an adequate rise in carbon dioxide is observed. ECMO period. Borderline hemodynamics with inotropic support The success of AT in determining BD on ECMO would depend on: and risk of decannulation/ECMO circuit disconnections precluded • Maintenance of stable hemodynamics. patient transfer to CT facility. Hence, the declaration of BD was done • Adequate preoxygenation. in accordance with the neurologist after 48 hours had elapsed to • Prevention of hypoxia in different ways like tracheal insufflation account for delayed drug clearance. Despite all the shortcomings of oxygen through a catheter, T-piece use, adjusting ventilator described in the case about conduction of clinical test including the settings to 100% oxygen on pressure-assist mode, or use of AT and the ancillary tests (EEG and CT/MRI) for evaluating BD, in the

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present era, these tests are essential to conclude BD and should be a approach, tunneling, and medicated catheter. Another advantage of part of the institutional protocol; however, the logistic issues at our low approach femoral access is that a person doing this procedure center did not permit us to do so. The subjective nature of opinion is away from the respiratory passage of the patient it may reduce by neurologists should also be kept in mind highlighting the need chances of airborne infection during the COVID-19 pandemic. for the ancillary test in cases with failed AT for BD determination. Placing the catheter in the femoral vessel will not interfere with Serum levels of the narcotic agents should be estimated in such the respiratory care (helmet-based NIV). Proning patients during cases whenever feasible. This case review focuses the attention on mechanical ventilation and dressing of the line is also not a problem the direct need to modify AT for aiding the conclusive diagnosis with low approach femoral venous access. Femoral access should be of BD in these patients. Conclusion: The widened implications avoided in patients with peripheral venous and arterial disease and with a surge in the use of ECMO have necessitated the need for renal transplant. Conclusion: In this case, we have highlighted that the establishment of guidelines for BD declaration on ECMO. AT is modification of femoral venous access helps to achieve the central inconclusive in patients on ECMO owing to the altered physiology access quite fast and also increases the safety of both patient and and underlying pulmonary conditions for which ECMO was operator. We suggest that in present times of COVID-19 pandemic, instituted. Ancillary tests may play a complementary role, which ultrasound-guided low approach femoral central venous access however would still require AT to confirm BD. Implementation may be used in emergencies and also where other options of central of a standardized approach for AT in this subset would aid in venous cannulation are not suitable. establishing a diagnosis of BD promptly so that organ donation could be facilitated appropriately. 42. COVID-19 Exacerbating Cryoglobulinemic Vasculitis. (Conference Abstract ID: 25) 41. Use of “Low Approach” Femoral Central Venous Cannulation Hari Naveen Ashok Kumar, Souvik Chaudhuri During COVID-19 Pandemic. (Conference Abstract ID: 28) Kasturba Medical College, Manipal, Karnataka, India Kunal Singh, Alok Bharti, Prakash K Dubey DOI: 10.5005/jp-journals-10071-23711.82 All India Institute Of Medical Sciences, Patna, Bihar, India Introduction: We would like to report a rare case of cryoglobulinemic DOI: 10.5005/jp-journals-10071-23711.81 vasculitis precipitated by COVID-19. Cryoglobulinemic vasculitis is Introduction: Many times critically ill patients who are either a small vessel vasculitis affecting the skin, joints, peripheral nerves, suspected cases of COVID-19 or COVID-19 positive coming to and kidneys. It is usually associated with hepatitis C virus infection, intensive care units require central venous access. Wearing personal B-cell lymphoproliferative disorders, and autoimmune disorders. protective equipment (PPE) for placing a central venous catheter can Materials and methods: Written informed consent obtained from make the procedure challenging because of poor visibility. Insertion the patient and patients relative to present the details pertaining to of the central venous catheter becomes even more difficult when the clinical course of illness with pictures and radiological images the patient is in respiratory distress and is unable to lie flat on the while maintaining the confidentiality of patient and identification. bed. In COVID-19 positive or suspected patients where it is difficult Results: 48 year old male patient seropositive for hepatitis C with to cannulate internal jugular vein (IJV) or subclavian vein due to known end stage kidney disease on maintenance dialysis with anatomical or medical reasons, we suggest ultrasound-guided history of recent severe covid-19 disease treated with remdesivir, “low approach” femoral central venous access as an alternative.2 We steroids and anticoagulant; presented with shortness of breath, report a case of acute pulmonary edema secondary to rheumatic recent onset skin lesions. Purpural lesions on extremities and trunk heart disease which was managed successfully with ultrasound- could not be attributed to any isolated dermatologic disorder. guided low approach femoral central venous access. Materials and Tzanck smear and gram staining were inconclusive. Covid-19 RTPCR methods: A 37-year-old woman with a history of rheumatic heart was negative. HRCT chest was done to rule out re-infection. HRCT disease presented in intensive care with acute pulmonary edema. showed diffuse alveolar haemorrhage. In view of multi system The nasopharyngeal swab was taken for reverse-transcription- involvement, vasculitis was suspected and diagnosed to have polymerase-chain-reaction (RT-PCR) assay to rule out COVID-19. hepatitis C infection associated cryoglobulinaemic vasculitis. The patient was managed in a line of acute pulmonary edema with Patient underwent dialysis along with plasmapheresis for 3 days and an upright position, oxygen support, noninvasive ventilation (NIV), discharged from the intensive care unit. Discussions: The onset of furosemide, and morphine. This patient required urgent central symptoms and disease progression of cryoglobulinemic vasculitis venous access for starting vasopressor and further management. As was probably altered by COVID-19 infection. The patient developed the patient was unable to lie flat on the bed and multiple attempts pulmonary complications earlier in the course of illness. To our for vascular access were already tried in the emergency department, best of our knowledge, it is the first case of COVID-19 precipitating we planned for low approach femoral access. We used ultrasound and hastening disease progression in cryoglobulinemic vasculitis. with a linear probe to scan the femoral vessel at the level of the Conclusion: In a patient with COVID-19 with hepatitis C infection, groin. By keeping the femoral vein in the center of the screen, a the possibility of alveolar hemorrhage due to cryoglobulinemic needle was inserted from the middle of the linear probe at an angle vasculitis should be kept in mind while ruling out re-infection. of 30 to 45°. The position of the guidewire inside the femoral vein Utmost sagacity is required by the treating physician, as the was confirmed with ultrasound by using a long axis view before treatment approach is different. threading the catheter over it. The cannulation was successful in 43. Case of Pneumothorax on High-flow Nasal Cannula in the first attempt. Discussions: In this case, we successfully inserted COVID-19. (Conference Abstract ID: 23) an ultrasound-guided femoral central line 5 cm below the inguinal ligament in a view to further reduce catheter induced infection rate. Joslita Rebello, Rashmi Mohanan Menon It has been suggested that the risk of infection will be very much Father Muller Medical College Mangalore, Karnataka, India reduced if we use full barrier precaution, ultrasound guidance, low DOI: 10.5005/jp-journals-10071-23711.83

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Introduction: High-flow nasal cannula (HFNC) is used as alternative Bharati Vidyapeeth (DTU) Medical College And Hospital, Pune, respiratory support in hypoxemic respiratory failure. A study on Maharashtra, India HFNC has shown a linear relationship between flow and airway DOI: 10.5005/jp-journals-10071-23711.85 pressure and delivers PEEP of 3 to 7 cm H2O. This peep effect can Introduction: Vascular access is the key in critically ill patients lead to barotrauma with high-flow nasal oxygen. Materials and with an end-stage renal disease requiring hemodialysis. After methods: A 60-year-old man presented with a 1-week history some years, failure of conventional access is a major cause of of cough breathlessness and myalgia. No other significant past morbidity and mortality in patients on chronic hemodialysis. medical history SARS-CoV-2 positive status confirmed by a reverse Translumbar tunneled dialysis catheter may be a salvage option, transcriptase-polymerase chain reaction. Initial arterial blood gas relatively safer, and most practical last choice in such cases for showed hypoxic respiratory failure. He was put on HFNC on day long-term hemodialysis, thereby improving survival and acting as 2 with oxygen flows at 40 L/minute gradually increased to 50 L/ a bridge for renal transplantation. It offers much effective access minute. Results: On day 8 diagnosed with right pneumothorax, for dialysis in both adults and children and is considered as a a water seal drain was placed. Serial chest radiographs showed potential choice for those patients with a lack of conventional resolution of pneumothorax. The water seal drain was removed. venous routes. Maintenance of vascular access is very important The patient was sent to the ward on a face mask. Discussions: and challenging in patients undergoing dialysis who have Spontaneous pneumothorax is a rare complication of COVID-19 depleted and worn out their traditional vascular access such as pneumonia. In the present case, the pneumothorax is due to arterio-venous fistula, arteriovenous graft, and central venous positive pressure generated by high-flow nasal cannula therapy catheter or have had contraindication for peritoneal dialysis. combined with underlying lung injury caused by SARS-CoV-2 Herein, we report one such interesting case which had exhausted infection. We successfully removed the water seal drain following all the conventional vascular access, thereby necessitating the use the resolution of pneumothorax. Conclusion: This case highlights of alternative access like translumbar tunneled dialysis catheter HFNC therapy with high oxygen flow rates can cause pneumothorax insertion. Discussions: Translumbar catheter is an acceptable in COVID-19 patients with underlying lung inflammation. alternative for those patients who have been on dialysis for a long period in whom conventional vascular access to make an 44. Management of Residual Hemothorax—By Using A-V fistula or to implant a catheter might fail especially those Streptokinase (Through Intercoastal Chest Drain). (Conference patients with peripheral vascular disease, multiple comorbidities, Abstract ID: 22) and multiple previous attempts. Few studies discourage the use Tammina Akhila Sai, PV Sai Satyanarayana of translumbar tunneled dialysis catheter because of its low Kamineni Institute Of Medical Sciences, Telangana, India patency. Catheter patency at 3, 6, and 12 months as per Liu et al. DOI: 10.5005/jp-journals-10071-23711.84 was observed to be 43, 25, and 7% whereas as per Moura et al. Introduction: Retained hemothorax is a complication of chest was 91, 75, and 45% and a possible reason for better results by trauma that can lead to empyema, entrapped lung, and fibrothorax. Moura et al. was apt catheter positioning during the procedure Fibrinolytic therapy (intrapleural) appears to have a high rate of and scrupulous discernment and correction of kinks and success for resolving retained hemothorax when video-assisted misplacements. The reported Translumbar catheter patency at thoracoscopy (VATS) is not available. Objectives: Treatment 12 months ranges from 17 to 73.2%. TLDC is anticipated to have of residual hemothorax with an intrapleural fibrinolytic agent many towering complications, exchanges, including the removals. (streptokinase). Materials and methods: Streptokinase, 250,000 The most familiar reported complication of TLDC was catheter- IU, was diluted in 100 mL of saline solution and administered related infection and thrombosis. Lund et al. defined translumbar through a chest tube. The chest tube was clamped for 4 hours, catheter failure as a blood flow rate <200 mL/minute. Low dose and the patient was asked to rotate in several positions to allow (1 mg/mL) one-time alteplase was effective in restoring catheter for better distribution of intrapleural streptokinase. After 4 hours, function in 72 to 82.1% of non-functional catheters. Another most the clamp was removed, and the drained material was measured. common complication in a patient undergoing hemodialysis is The procedure was repeated 3 times till radiographic improvement 5- to 10-folds increased risk of bacteremia because of a long- was achieved. Results: After fibrinolytic therapy (streptokinase), term indwelling catheter. However, TLDC exchange or removal there was a radiological clearance of hemothorax, and the is performed only in case of serious infection or recurrence of patient improved clinically. Discussions: Intrapleural fibrinolysis infection which is unresponsive to antimicrobial therapy as it is is useful in the treatment of persistent, loculated hemothorax. A the last resort of vascular access, unlike CVC which is removed if significant increase in the drainage of chest tube with clot lysis with the patient has a fever for more than 48 hours despite antibiotic improvement from the clinical, and radiologic parameters suggests therapy. Another leading cause of catheter failure in the case of a that intra-pleural streptokinase is an effective alternative to surgical translumbar catheter is catheter dislodgement because of excess decortication. Conclusion: When video-assisted thoracoscopy adipose tissue being concentrated in the tunnel area. All these is not available, streptokinase can be used for the treatment of data cumulatively suggest translumbar catheter can be used as a retained hemothorax. Streptokinase is a cost-effective and effective bridge to a new permanent or much effective vascular access in treatment for the management of retained hemothorax. those patients with exhausted access sites for dialysis. Conclusion: The percutaneous placement of subcutaneous tunneled double lumen hemodialysis catheter directly into IVC is considered to be 45. Running Out of Vascular Access in CKD Patients? A Case Report relatively safe and most practical last choice for vascular access on Translumbar Dialysis Catheter. (Conference Abstract ID: 10) and should be used as a bridge to renal transplantation, especially Nishant Agrawal, Yadav Waghaji Munde, Jignesh Shah, Prajakta for those patients who are not on the transplant list due to poor Mane, Sunil Jawale sociocultural condition.

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46. An Out of the Ordinary Case Report of Ticagrelor Furthering but intimidating complication that can transpire as a result of Rhabdomyolysis Induced by Atorvastatin. (Conference Abstract statin use alone or when used in conjunction with other drugs, ID: 9) that increase the potency of statin and hence we need to be Nishant Agrawal, Shivakumar Iyer, Jignesh Shah, Prashant Jedge watchful about the same and adjust the dosage of drugs to avoid Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, the pharmacological interactions. Highlights: An intensivist should Maharashtra, India be aware of the fact that newer anti-platelet drugs like ticagrelor DOI: 10.5005/jp-journals-10071-23711.86 trigger statin-induced rhabdomyolysis. Introduction: Rhabdomyolysis is evidential aftermath of statin therapy and the contemporaneous use of medications like 5. Critical Care Organization, Quality Management ticagrelor that inhibit cytochrome P450-3A4 enzyme increases and Outcomes, ICU Information Systems) its risk by causing muscle necrosis and release of myoglobin into circulation. We hereby report a case of a 63-year-old male patient 1. To Study the Outcome of Mechanically Ventilated Patients in who was commenced on ticagrelor, post-transluminal coronary Respiratory ICU. (Conference Abstract ID: 195) angioplasty on a background of atorvastatin therapy resulting in Nida Choudhry, Lalit Singh, Rajeev Tendon rhabdomyolysis with acute kidney injury and hyperkalemia. This Shri Ram Murti Smarak Institute Of Medical Sciences, Lucknow, case highlights, the need for awareness of drug interactions with Uttar Pradesh, India atorvastatin, as dyslipidemia is commonly encountered these DOI: 10.5005/jp-journals-10071-23711.87 days in most individuals due to sedentary lifestyle practices and Introduction: Background — The need for ventilatory support invariably most of these individuals are on lipid-lowering agents is one of the commonest indications for admission into the like atorvastatin but eventually these individuals land up with intensive care unit (ICU). Improving the outcome of mechanically complications resulting in myocardial infarction or ischemic stroke ventilated patients remain a mission we all strive to achieve and hence requiring the addition of antiplatelet drugs and lastly, the Objectives: Aim — To study the outcome of mechanically ventilated importance of early diagnosis and management of rhabdomyolysis Patients in Respiratory ICU — to provide baseline information for to prevent the development of further complications. With the epidemiological trends, prognostic factors, and outcome of patients development of newer anti-platelet agents like ticagrelor, it on mechanical ventilation calculated based on the duration of is extremely important to understand the pharmacokinetics, hospital stay, duration of ICU stay, number of days on ventilators, pharmacodynamics, and its related drug interactions to prevent fatal complications, mortality, followed till discharge. Materials and complications like rhabdomyolysis which is commonly overlooked, methods: In this study, 412 patients were admitted to the intensive as reported in our case. Discussions: The risk of rhabdomyolysis care unit of Shri Ram Murti Smarak Institute of Medical Sciences which is characterized by skeletal muscle breakdown leading to (SRMS IMS) at Bareilly Uttar Pradesh between November 2018 release of sarcoplasmic proteins namely, AST and ALT, creatinine and April 2020. Two hundred and fifty patients were enrolled who kinase (CK), and electrolytes, and thereby causing life-endangering fulfilled the inclusion and exclusion criteria. Results: Out of 412 complications like AKI, hyperkalemia, and cardiac arrhythmias patients admitted to the ICU, 250 patients received mechanical are higher when statins are given concurrently with other drugs ventilation, either invasive (43%), noninvasive MV (41%) and 16% causing inhibition of cytochrome P450-3A4 enzyme. In our of the patients showed noninvasive failure and needed invasive literature search, we found two similar cases of rhabdomyolysis ventilation. The commonest indication of MV was acute on chronic due to the interaction of statin with ticagrelor. In the first case respiratory failure (74.8%). Chronic obstructive pulmonary disease report, the patient was on a higher dose of atorvastatin, 80 mg once was the commonest pre-existing lung disease (50.8%). Highest daily, and had acute renal failure and higher CK and myoglobin mortality was observed in renal disease (71%). Invasive mechanical levels. In the other case, the patient was on rosuvastatin, 40 mg ventilation was associated with high APACHE II score, SOFA score, once daily. After consuming ticagrelor for a week, the patient low Glasgow coma scale, low admission Ph, PO2 and high PCO2 had landed up with acute renal failure and elevated CK levels compared to non invasive MV. Duration of hospital stay and length though this drug doesn’t require cytochrome P450-3A4 enzyme of ICU stay was longer in NIV Failure. The highest risk of mortality, for its metabolism. The gamut of statin-induced myopathy varies a cutoff point of APACHE II score and SOFA score was >30 and >18 from myalgia, myositis, and rhabdomyolysis to high up CK levels respectively. Discussions: In the present study, the indication of which might remain asymptomatic, with a mean duration of statin mechanical ventilation in all studied majority patients (IMV, NIV, therapy before the onset of symptoms ranges from 1 to 60 days. NIV failure) was acute on chronic respiratory failure i.e., 33.7, 47.1, Hospitalization and intravenous hydration to prevent renal damage and 19.2%, respectively, followed by acute hypoxemic respiratory remain the mainstay of treatment for patients with clinically notable failure, i.e., 69.8, 22.2, and 8%, respectively, in all groups. In the rhabdomyolysis and once muscle symptoms have resolved, the present study, among survivors, the mean duration of IMV was 7.04 use of a lower dose of the same statin or replacing other statins in ± 3.02, whereas in NIV failure was 4.57 ± 2.89, which is statistically place of the prior one or using other class of lipid-lowering drugs significant with a p value of 0.0008. Venkatesh Yadav et al.68 such as bile acid-binding resins and ezetimibe is used for managing demonstrated the mean APACHE-II score and SOFA score of non- dyslipidemia. The superiority of ticagrelor over clopidogrel is that survivors was high as compared to non-survivors, the difference it elevates the serum concentration of statin and hence, provides was statistically significant that means mortality increases with a shielding effect in patients with coronary artery disease. In this higher APACHE-II score and SOFA score. Conclusion: APACHE-II and epoch of polypharmacy, it is very important to understand the SOFA scores are a strong predictor of mortality because it helps to importance of drug interactions which are frequently overpassed assess the severity of illness and base chronic health status of the and result in morbidities. Conclusion: Rhabdomyolysis is an exotic patients and also provided the prognostic information which was

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useful for the clinician to assess the outcome of patients admitted 3. Respiratory Diseases in Adolescent Patients with Diabetes to the intensive care unit. Mellitus. (Conference Abstract ID: 193) Pradeep Singh Rajoriya, Ravi A Dosi 2. Intubation Practices in Trauma Triage: A Prospective Sri Aurobindo Medical College and PGI Indore, Madhya Pradesh, Observational Study. (Conference Abstract ID: 194) India Anudeep Jafra, Kajal Jain, Sravani M Venkata, LN Yaddanapudi, DOI: 10.5005/jp-journals-10071-23711.89 SK Gupta Introduction: Diabetes mellitus is a chronic, progressive, and PGIMER, Chandigarh, India incompletely implicit metabolic disease. Its associated micro- DOI: 10.5005/jp-journals-10071-23711.88 and macrovascular complications show the result in mortality and morbidity, The microvascular complications are manifested Introduction: Hypoxia and obstruction of the airway are the as neuropathy, retinopathy, nephropathy, and macrovascular major contributors to death following trauma. Hence, a definitive complications affect the cardiovascular system. It also affects the airway control, which may require endotracheal intubation, is lungs because of its rich vascularity and plethora in connective an essential component of trauma resuscitation. Trauma Triage tissue (collagen and elastin), in a diabetic patient proliferation of is generally manned by a team comprising of various levels of extracellular connective tissue in the lungs, leading to a decline healthcare professionals. It is not only important whether a patient in lung function in a restrictive pattern. WHO has reported that needs intubation but also when and how to intubate. There is a the number of people with DM has risen from 108 million in lack of data pertaining to intubation practices in trauma triage 1980 to 422 million and 8.5% of the world adult population had in India. Objectives: Hence, the present study was conducted to DM in 2014. The number of diabetic patients worldwide has describe the current practice of definitive airway management been expected to rise to 592 million in 2035 by the International in the trauma triage of a tertiary hospital catering to northern Diabetes Federation. In this manner, I have been summarized and India. The secondary objectives were to determine the success discussed the role of diabetes mellitus involved in the progression rate of endotracheal intubation by anesthesia and non-anesthesia of common respiratory diseases in adolescent patients. Keywords: residents, to describe the complications during securing the Diabetes mellitus, Respiratory disease. Objectives: To study airway and to formulate recommendations based on the results respiratory diseases in adolescent patients with diabetes mellitus. of this observational study. Materials and methods: This was Materials and methods: The present study is a survey study that a prospective observational study conducted at Trauma Triage was conducted in the department of pulmonary medicine of Sri of level 1 Tertiary Hospital over a period of 1 year. A specifically Aurobindo medical college and hospital, Indore. Data will be designed proforma was filled which included the patient’s collected from the attending the OPD and IPD in the department detailed history of trauma, peri intubation vitals, indications for of pulmonary medicine. All the participants were in the age urgently securing airway, unfavorable conditions, the technique group of 25 to 40 years. Duration of the study — from November of intubation, medications used, and adverse events following 3, 2019, to March 19, 2020. Results: We investigate 56 patients intubation, and a number of attempts taken. Results: The first in the age group between 25 and 40 years. This study shows 31 attempt success rate of intubation by anesthesia residents was (55.35%) male and 25 (44.61%) females. Discussions: Diabetes significantly higher than specialty residents (p = 0.0001; 95% CI is identified as an independent risk factor for developing lower 9.02–24.66). Airway injuries were most frequent complication (n = respiratory tract infection there appear to be a certain type of 140, 32.8%) followed by hypotension (n = 57, 13.3%). T Discussions: respiratory infections that may be more common in diabetics These prospective observational data come from a tertiary care patients. Diabetic patients also appear to be at an increased risk of hospital of a low resource country on intubation practices in complications like pneumonia, asthma, etc. Conclusion: The study trauma victims over a period of 1 year. The first responders are shows a high prevalence of infectious diseases such as pulmonary usually non-anesthesia, specialty residents who cater to the tuberculosis, asthma, and COPD in adolescent patients with DM. immediate needs of the trauma victims. This reflects the different staffing levels and the limited expertise available on arrival to trauma triage. Through this study, it may be noted that although 4. Comparison of Early Bispectral Index Guided Postoperative the level of experience met the current standards, there is a need Extubation Verses Extubation in Awake Patients in Neuro to upgrade the skills of airway management using manikins and Intensive Care Unit. (Conference Abstract ID: 192) mandatory anesthesia rotation. Most of the intubations carried Tushar Kumar, Pradip K Bhattacharya by anesthesia residents were drug-assisted along with the use Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India of muscle relaxants which resulted in less complications and DOI: 10.5005/jp-journals-10071-23711.90 trauma. Literature supports the use of neuromuscular blockers Introduction: Neurosurgical patients have a high risk of in 62 to 77% of cases, with a strong association being reported neurological complications in the immediate postoperative between the use of neuromuscular blocking agents, especially period increasing both morbidity and mortality. Extubation after depolarizing agents, and fewer adverse effects, as depicted by uneventful intracranial surgery is tried to be as early as possible our results. Conclusion: We observed that complication rates to avoid ventilator-associated complications. There are several were more in patients intubated by non-anesthesia residents, use scales and scoring systems to guide and assist early extubation. of a high dose of sedative agents like midazolam, and multiple However, in neurosurgical patients, these scores may not be attempts at intubation. Rapid evaluation of these factors and sufficient to provide enough data for confidant extubation. The formal training in ATLS can lead to optimal management of the objective of the present study is to compare bispectral index patient and decrease the rate of complications. guided postoperative extubation vs extubation in awake patients

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using various neurological assessment scores in neurointensive ICU (preinduction, during induction, and postinduction). Results: Thirty after craniotomy and excision of supratentorial space-occupying residents were included with a mean and standard deviation of lesions. Materials and methods: A total of 16 patients (ASAI-II), aged age (26.4 + 1.4, minimum 22 and maximum 29) years, BMI (23.82 between 25 and 45 years, who were scheduled to undergo elective + 2.52, minimum 18.68 and maximum 26.56) kg/m2, and having neurosurgery operation under general anesthesia and randomly a sleeping pattern of (6.3 + 0.8 minimum 5 and maximum 8) divided into the BIS group (group II) and scoring group (group S), hours. Discussions: Stress has a detrimental impact on healthcare with 8 cases in each group. After satisfactory respiratory recovery organizations at multiple levels and, further significantly, is patients were extubated. Oxygen saturation by pulse oximeter and correlated with poor patient safety and quality of treatment, as it HR were recorded before extubation (T0), (T1) at 1 minute, and can manifest itself through exhaustion and diminished cognitive 5 minutes (T2). Results: Early extubation using bispectral index functioning, eventually affecting the performance of individual found to be significant with p < 0.04. during T1 and T2. Discussions: work and contributing to a greater risk of errors. Smartwatches, Bispectral index assists better to make decisions for extubation than wrist bands, and activity trackers commonly used these days are other scoring systems in postoperative neurosurgical patients for based on electrocardiography (ECG) or photo-plethysmography supratentorial space-occupying lesions. Kamali et al. showed that (PPG).2 We used Mi band 4 to monitor the heart rate of all residents. BIS reduces extubation time in post-CABG patients. Conclusion: We chose this band because it is cheap, comfortable to wear, Using BIS monitoring during and after neurosurgery, it reduces the rather discreet, and lightweight. It is based on the principle of length of patients’ extubation in ICU. photo-plethysmography (PPG). Our study observed a significant difference in Sleeping HR when we compared the baseline HR and 5. Heart Rate Monitoring of Anesthesiology Residents During with the induction HR (p < 0.05). This could be due to the activity of the Airway Management of COVID-19 Suspect Patients: An the resident and the stressor response of the body. And we found Observational Study. (Conference Abstract ID: 191) a significant difference between baseline HR and intubating HR. Adabala Vijay Babu, Bhavna Gupta Conclusion: This sort of continuous information can be used as AIIMS, Rishikesh, Uttarakhand, India the feedback option for users to improve their work efficacy. To date, technology has revolutionized healthcare facilities. Working DOI: 10.5005/jp-journals-10071-23711.91 knowledge of these smart devices will help us to balance our stress- Introduction: Technology has become an integral and central free day-to-day activity. element in modern-day life and affects how we all work and function. Technology has a positive effect for the most part, as it 6. Assessment of Best Practices, Knowledge, Attitude, and helps us handle and monitor our everyday activities. Nevertheless, Perception of Postgraduates Working in Covid ICU—A MultiCenter new technology has a significant role to play such as solving several Study from South India. (Conference Abstract ID: 190) other difficulties confronting healthcare services. Anesthesiology by itself is a stressful job. And the stress is quite evident in the residents, M Yuvashree, B Gayathri, Pushparani, S Ksheerabdhi which leads to several health-related issues, cardiovascular SRM Medical College Hospital And Research Centre, Kanchipuram, Tamil Nadu, India diseases at an early age, a high number of suicidal attempts by the anesthesia residents.1 With the advancement of technology, DOI: 10.5005/jp-journals-10071-23711.92 smartphone applications for healthcare, e.g., mobile heart disease Introduction: Around 30% of patients with severe COVID-19 detection, heart rhythm analysis, remote home care monitoring, infection are need admission to an ICU for specialized care. Ninety eye disease diagnosis, have become highlighted. We conducted a percent of these patients present with severe acute respiratory study to monitor the anesthesiology residents’ heart rate variation distress syndrome corona. Inadequate knowledge and incorrect in the COVID-19 suspect area and compare it to their sleeping HR attitudes among the postgraduates working in ICU can directly and baseline HR value. We assume that a significant increase in HR influence practices and lead to poor infection control practice, during airway management is an indicator of the stress the resident poor management, and spread of disease. This study aimed to is undergoing, which usually goes unnoticed. Materials and assess the knowledge, perception, and attitude of postgraduate methods: In a tertiary care academic center, this was a prospective students posted toward the COVID-19. Materials and methods: observational cohort study of anesthesiology residents. All the After ethical committee approval (CTRI REF/2020/11/038549), a residents included in the study were of age 20 to 45 years, ASA I-II, descriptive cross-sectional study was done among postgraduate and the residents with the experience of managing the airway for students of different teaching hospitals in South India. Data six months. Airway management of patients with difficult airways were collected through the first week off from September 1 to was not included in the study. Informed consent was taken from all September 8, 2020, during the peak of the pandemic. A convenience the residents who participated in the study. As this sort of research sampling technique was used to select participants. The sample is the first of its kind, 30 residents were included in this study. All size was calculated using EpiCalc-2000 based on the following participants wore a smartwatch MI band four before going to sleep assumption: the proportion of good knowledge 50%, level of and installed MI fit application on their smartphones and clicked on confidence 95% and precision 5%, and apparent prevalence 0.05, continuous sleep and heart rate monitor to detect sleep patterns to be 74. Then, the sample size increased by 10% to overcome and sleeping heart rate. From the inbuilt software recordings in the non-response. Confidentiality precautions were ensured during application, participants sleeping duration, sleeping HR, baseline the data collection process. A self-administered questionnaire was HR was recorded. The next day, HR monitoring of residents during used, it was developed by the authors after reviewing previously the induction of a general anesthesia in an elective case (COVID conducted research, visiting the Ministry of Health and Family SUSPECT area) from 8:40 am to 9 am was recorded in three phases Welfare and WHO websites for frequently asked questions. The

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questionnaire for best practices was selected after studying nose, and putting surgical face mask were among the preventive various review articles, meta-analyzes, and the WHO website. The measures frequently accepted by our participants. Ng et al. outlined questionnaire was checked and validated for content and relevance that surgical masks are similarly as effective as N95 respirators if by authors, and one public health and one anesthesia professor. The used with hand wash and other infection prevention precautions. questionnaire covered the following: (I) Demographic characters: Inconsistent with our findings, Kumar et al. and Olum et al. found age, sex, years of critical care experience, type of organization in HCWs’ knowledge regarding the role of face masks in the prevention which responders are working, hours of work/day, and whether of the disease to be moderate to poor. It worth mentioning that, they were quarantined after the work. (II) The knowledge section: and despite their high knowledge score, the vast majority of consisted of 20 knowledge questions covering the main general our respondents were afraid and felt more susceptible to have information, mode of transmission, treatment modalities, and COVID-19 infection. This parallels studies that found an association ways of disease prevention. Each question was answered by between the level of fear and risk perception. Abdel in his Egyptian either yes, no, or don’t know. (III) The attitude section; included study reported that two-thirds of HCWs thought they were more 10 questions assessing the responder’s attitudes of COVID-19 as susceptible to get infected, which resembles our study. Conclusion: a preventable and controllable disease (six items), their attitudes At the time of writing this manuscript, the national statistics indicate toward regulations taken by the Hospital/Government to overcome that up to 30% of SARS COVID-19 patients needed ICU admission the COVID-19 pandemic situation (four items). Response to each for ARDS. The majority of them needed different levels of oxygen item was recorded on the 5-point Likert scale as follows: strongly support from simple masks to NIV to ventilator support. Probably, agree (5-points), agree (4-points), undecided (3-points), disagree the timely availability of PPE, the strict infection control measures, (2-points), and strongly disagree. (IV) Risk perception: included and the frequent CME’s and awareness sessions are responsible for assessment of postgraduates’ feelings and perception of fear from making India one among the handful of countries with a very low catching COVID-19. The response could be either yes or no. As the mortality rate of 10%. responders were from various hospitals in south India, we used the online data collection method via Google Forms. Results: Best 7. Development and Validation of a Low-Cost Electronic practices 20 questions 95.3% of responders commented that there Stethoscope: DIY Digital Stethoscope. (Conference Abstract ID: are separate donning and doffing rooms. 40% of hospitals had 2:1 187) and another 40% 3:1 of patient to staff ratio. It is 43.4% of responders were unaware of how many times per day the floors and surfaces Agam Jain, Roshan Sahu, Arohi Jain, Thomas Gaumnitz, Rakesh are cleaned. Only 47% of responders committed that the WHO’S Lodha five moments of hand hygiene was strictly followed. 17% of places All India Institute of Medical Sciences, New Delhi, India did not use bacterial filters for mechanically ventilated patients and DOI: 10.5005/jp-journals-10071-23711.93 53% used HME. 71% of responders were aware of the modified ACLS Introduction: Among the many challenges COVID-19 presented guidelines for COVID suspect patients. 55% of responders agreed to us, one of them is difficulty in auscultating patients while that Remedisivir should be started only in moderate to severe cases. wearing coveralls. Although ultrasonography has been advocated 55% of responders preferred Methylprednisolone to treat COVID as an alternative for the information stethoscope provides, the sequelae. Knowledge: 10 questions The mean knowledge score symmetry of breath sounds in intubated patients and wheeze of participants was 8.5 ± 2.7 ranged from 7 to 10, with the mean are important findings with therapeutic implications, which correct answer rate of questions was 88.4%. Attitude 10 questions cannot be ascertained through ultrasonography. This study although the majority of our participants considered COVID-19 as aimed to develop and validate a low cost but effective electronic a severe disease, they agreed that this disease can be prevented. stethoscope that allows auscultation over the PPE or from a safe The vast majority of doctors agreed that infection control standard distance. Materials and methods: While developing the DIY precaution can protect against COVID-19 (95.6%) after working stethoscope, we aimed at good quality auscultation sounds while in COVID ICU. Generally speaking, a positive attitude was more keeping the assembly simple, affordable, and using components observed among males than females in many attitude items. that most physicians would already possess. We tried various Perception: 10 questions regarding risk perception, about 83.1% permutations of sensors, its placement within a stethoscope, of our participants reported that they were afraid of being infected and of the entire assembly. After initial testing, we settled on with COVID-19, and 89.2% stated that they were more susceptible using commonly available commercial microphones, housed to COVID-19 infection as compared to others. The most common either in the ear-tip or within the tubing of a stethoscope. Data statements accepted by participants as causes of perception of fear were transmitted to a mobile phone, which ran our custom- of COVID-19 infection were the following: fear of transmission of developed app, which amplified the sound, reduced the noise, infection to their families (96.5%), the disease is highly transmissible and transmitted the data for playback to Bluetooth headphones, (91.74%), COVID-I9 new disease with no available vaccine (58.6%) which the doctor will be wearing over the PPE. To test our device, or treatment (77%), the fatality of the disease (62.1%). Discussions: we conducted a study in Medicine and Pediatrics wards of a In the current study, the knowledge level of postgraduates about tertiary care hospital of North India in November 2020. Residents COVID-19 was high. The mean correct answer rate was 8.5 ± 2.7. posted in these wards, auscultated patients using both the DIY This comes in accordance with studies conducted by Abdul, Zhang, stethoscope and a conventional stethoscope. Which stethoscope and Ghiao, who had reported about 80 to 90% of their respondents would be used first was determined through randomization. had a sufficient level of knowledge. Although many articles were After auscultation, each device was rated on a scale of 1 to 10 on charting out the best practices, we could not find any systematic the following characteristics: Loudness of sound, Sound clarity, survey to check whether the practices were followed. WHO’s 5 Loudness of noise, Interference caused by noise, Satisfaction, moments of hand hygiene, refrain from touching eyes, mouth, and Comfort. Any auscultation findings were also recorded.Results:

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Sixteen residents participated in the study and auscultated a on the above classification, patients were allocated specialist total of 100 patients. DIY stethoscope had significantly higher consultations or ICU monitoring to ensure adequate resource loudness of the auscultation sounds, with a median (IQR) score utilization. Results: The study was done in 53 patients with various of 8 (7, 9) for a DIY stethoscope and 8 (7, 8) for a conventional conditions presenting to ED. Levels of Hs cTnI were measured in stethoscope. Discussions: We presented a technique to convert a them as mentioned above. Twenty-two patients had >10 times conventional stethoscope to an electronic one, producing sounds elevation in their HS cTnI assays and they all had myocardial insult with good clarity and loudness. Although there is more noise in in the form of Acute heart failure, Myocarditis, Sepsis and NSTEMIs.. DIY stethoscope as compared to conventional, it does not affect Discussions: It is shown from the study that HS Trop I levels are the ability to auscultate patients and identify findings. It also elevated in CKD patients and do not give accurate results. Apart offers louder sounds, ability to record and share auscultation from that, patients with elevated HS Trop I required additional clippings. The app is available free of charge on Google Play care and specialist consultations and had longer hospital stays. Store. As most physicians would already possess most of the Conclusion: Our observations on the utility of the investigation components required for assembly of DIY stethoscopes, only the in the early estimation of major cardiac adverse events will be microphone may need to be purchased which drives down the presented at the conference as a Poster presentation. cost of an electronic stethoscope from approximately 500$ to 500₹. Compared to other available attachments for stethoscopes 9. Comparative Analysis of Various Prevention of Violence against available in the market, not only is it cheaper, but does not require Doctors State Acts in India—A Descriptive Study. (Conference transecting the stethoscope, so it stays unharmed and can be Abstract ID: 163) converted back to its original state. Conclusion: DIY stethoscope Aakash Sethi, Gayatri Laha, Kalpita Shringarpure offers a frugal and effective solution to challenges in auscultating Government Medical College, Baroda, Gujarat, India patients in the COVID care area. Further versions of this device DOI: 10.5005/jp-journals-10071-23711.95 should work on improving noise reduction. Introduction: Study by the IMA records that about 75 % of the doctors have faced some kind of violence in their professional 8. Use of Us CTN I for Risk Stratification and Resource Allocation. life.1 Doctors working in critical care wards are more prone to (Conference Abstract ID: 165) be a victim to violent attacks by patient’s relatives across the Sarat Chandra, Ashima Sharma globe.2,3 Hospitals in India lack mechanisms in place to avert these Nizam’s Institute Of Medical Sciences, Hyderabad, Telangana, India incidences like the presence of an emergency team to deal with DOI: 10.5005/jp-journals-10071-23711.94 mob ready to inflict harm on a doctor, prompt police reporting, Introduction: COVID-19, having affected millions has caused a and knowledge about the acts safeguarding doctors.4 As per the global disturbance in healthcare and has overwhelmed hospital Schedule VII of the Indian Constitution, “Powers to make laws to resources, much more than any previous disaster of this century. maintain public order lie exclusively with the states”.5 Therefore, Surveys, especially in middle and low-income countries, have various Prevention of Violence against Doctors Acts (PoVAD) have shown partial or complete disruption in the management of been enacted by the State governments. These are technically non-communicable diseases owing to the pandemic, particularly known as “Medicare Service Persons and Medicare Service cardiovascular emergencies. With the given burden of the disease, Institutions (Prevention of Violence and Damage to Property) inadequate healthcare facilities, and personnel, who are also a Acts”. India laws a single nationwide act to protect doctors. major risk of contracting the disease, it is prudent to allocate Multiple state acts might not be without differences between resources judiciously. Cardiac troponins are useful in predicting them. After nationwide protests in 2019, the Ministry of Health cardiac insult. High sensitivity troponin assays can detect the and Family welfare drafted the National Prevention of Violence levels of these circulating enzymes at levels ten times less than against Doctors Bill but it was later stalled by the Indian Home normal assays. This increases the sensitivity of detecting type I Ministry citing lack of legislative powers of the Parliament to enact MIs but at the cost of specificity. Elevation of these enzymes can such a law.6 Reports suggest that the police aren’t aware of the occur in conditions other than type I MI like acute heart failure, presence of respective state laws enacted to safeguard doctors.7 myocarditis including COVID-19-related viral myocarditis, stress Therefore, it could be useful for doctors especially those working cardiomyopathy, pulmonary embolism, sepsis, critical illness, in the causality unit to know these acts. We hypothesize that the etc. Studies have shown that the presence of myocardial injury various State PoVAD laws will differ from each other.Objectives: is associated with a greater risk of complications like acute Aim — To perform clause by clause analysis of the State PoVAD kidney injury and ARDS. Materials and methods: In our center, acts in India and note the variations in them. Hs cTnI assays were used in patients presenting to ED with • To compile the State PoVAD laws. suspected cardiac insult within 2 hours of presentation. They • To compare and contrast different state laws with the draft were categorized into elevations <10 times and >10 times the National PoVAD bill. upper laboratory limits. Apart from using these values as a tool • To compare and contrast various state acts with each other. to detect MIs in non-equivocal ECGs, they have also been used to Materials and methods: This is a cross-sectional descriptive study risk-stratify patients with other clinical conditions as mentioned conducted over 2 weeks from September 14 to September 30, 2020. above. Although actionable measures are not always clear or The sample consisted of State PoVAD laws which were accessed possible, cTn increases identify patients at higher risk for adverse from www.indiacode.nic.in. short and long-term outcomes. The patients were classified into Inclusion criteria were State Laws having the following words in those having (a) chronic myocardial injury, (b) acute non-ischemic their title: myocardial injury, (c) acute MI, or (d) non-cardiac cause. Based • Prevention of violence.

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• Doctors. succeeds, various professional bodies of doctors need to approach • Medicare Service. the Supreme Court for a direction to the Central government to enact The Draft National PoVAD bill was accessed from www.mohfw.gov. a national act to safeguard doctors. Conclusion: The Maharashtra in. A purposive sampling method was used. Data were entered and Chhattisgarh acts have an overall wider ambit than the Draft and analyzed using MS excel. Quantitative data were expressed as national bill based on all the parameters listed above. There were wide mean ± standard deviation (SD) or median with interquartile range variations among the state acts. A National Act is desirable to have (IQR) depending on the normalcy of data. Qualitative data were common definitions and imprisonment punishment for perpetrators expressed using percentage/proportion. Clause by Clause analysis of violence against doctors. 83.3% of the acts are yet to make rules of the acts on the following parameters was done. under the act. In the absence of these rules, the implementation and Quantitative execution of the act could nearly impossible. • Length of an act in pages. • Maximum length of imprisonment in years. 10. Efficacy of Aloe Vera for Prophylaxis against Opioid Induced • Maximum amount of fine in rupees. Constipation: A Pilot Study. (Conference Abstract ID: 152) • Number of clauses present. Qualitative Komal Upadhyay, Kanta Bhati Sardar Patel Medical College, Bikaner, Rajasthan, India • Definitions of Medicare service persons and institutions. • Ambit of the acts done by the person which amount to crime DOI: 10.5005/jp-journals-10071-23711.96 — commission, attempt, abetment, incitement, or all. Introduction: Morphine and other strong opioids are mainstays • If both fine and a prison sentence are mandatory. of pain management regimens in advanced-stage cancer patients. • Type of crime — cognizable/non-cognizable, bailable/non- Opioid-induced constipation (OIC) is the most common side effect bailable. and the development of tolerance is rare. Prophylaxis should be • Power to make rules and if the rules have been made. started at the same time opioid therapy is started regardless of the • Provision for compounding of offense. drug, route, schedule, or dose. Simple prophylactic measures like • Provision for compensation for a doctor in addition to fine. fiber, fluids, exercise, and stool softener are generally insufficient. Results: A total of 23 states act to protect doctors against violence The standard prophylactic regimen includes a stool softener were found. Mean length of the acts was 3.55 pages (SD = 1.23). The and a stimulant laxative. Objectives: Various agents like senna, important clause by clause differences are enumerated below. A. sorbitol, polyethylene glycol, lactulose, and bisacodyl have The 2nd clause defined various Healthcare (Medicare) institutions, been used for prophylaxis of opioid-induced constipation with Healthcare personnels that were protected under the act. 16 variable success rate. There is a need for a prophylactic agent acts [69.5%] had included more healthcare personnels than the that has better effectiveness and tolerance. Aloe is unique in this Draft National bill did. For instance in the Gujarat act trained dais regard as it possesses many other properties that are particularly were protected as well. 7 state laws [20.5%] had a more inclusive beneficial for cancer patients. The plant leaves contain numerous definition of healthcare institutions than National Draft bill. These vitamins, minerals, enzymes, amino acids, natural sugars, and other acts additionally defined ‘Mobile health unit’ under the definition of bioactive compounds with emollient, purgative, antimicrobial, institutions protected under the act. B. Clause 3 prohibited persons anti-inflammatory, antioxidant, antifungal, antiseptic properties. from indulging in acts of violence against doctors or causing loss to Materials and methods: A pilot study was undertaken to assess their property. C. Clause 4 defined the nature and type of crime a the efficacy of aloe vera (A Barbedensis) to be used as a laxative person would committed if they damaged healthcare institutions agent for prophylaxis of OIC. After institutional ethics committee or attached doctors. All 23 acts made such a crime Non Bailable and clearance, 20 cancer patients were divided into two groups of 10 Cognizable. D. Clause 5 laid down the provision for punishment each. Patients in group “S” received two tablets of senna 11.5 mg awarded to the person guilty under the act. The mean imprisonment twice daily and patients in group “A” received 20 mL of Aloe vera of the acts is 3.25 years (SD = 1.54 years). Tamil Nadu state act has juice twice daily. Bowel Function Index 2 (BFI), need of additional the maximum punishment, with imprisonment extending up to 10 therapy in form of tab bisacodyl and/or peripheral mu receptor years. The Median fine was 50 thousand rupees (IQR 50–50 Lakh) antagonist, side effects and complications were noted on weekly E. Clause 6 talking about compensation for the damage caused to basis for 6 weeks. Results: Both the groups were comparable the property was present in all the state acts. In 6 acts [17.6%], this regarding the demographic profile and total per day morphine amount will be fixed by the court. In the rest it was mandated at consumption. Mean Bowel Function Index (BFI) was the primary twice the amount of hospital equipment’s damaged by those held end point and was 25 for group S and 27.5 for group A,and the guilty. F. In 6 state laws [17.6%] a 7th clause was present. It contained difference between two groups was insignificant (p value >0.05). the provision to make rules for carrying out the purposes of this Act. Additional therapy in form of tab besacodyl ± peripheral mu Only the Gujarat Government has made the rules so far. receptor antagonists was needed in 12% patients in group S and Discussions: Only 3 and 12 state acts have protected paramedical in 19.5% patients in group A. Nausea, abdominal cramps, loose staff and Allied health workers (midwives) from violence against stools and electrolyte imbalance were noted in 10% patients for healthcare personals. The other acts need to recognize attacks on each in group A while only loose stools were noted in 10% patients paramedical and allied health workers as being equal to attacks in group S. Discussions: Both the groups were comparable, and on Allopathic Doctor. Recently, Dr Rajeev Josh, a pediatrician from with regard to the p value difference between the 2 groups were Mumbai has filed a writ petition in Mumbai High court8 requesting insignificant.Conclusion: Aloe vera was effective in the prevention the court to direct the state government to formulate guidelines of OIC in >80% of patients with acceptable side effects. However, for the protection of medical professionals and medical institutions further detailed studies are needed to evaluate the efficacy, safety, from violence and attacks in case of medical accidents. If the petition and other beneficial effects of aloe vera in cancer patients.

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11. The First Hundred Post COVID-19—The New Normal. Sri Aurobindo Medical College and Postgraduate Institute, Indore, (Conference Abstract ID: 147) Madhya Pradesh, India Varalakshmi Diwakarla, Bharath Cherukuri, Shaik Saleema DOI: 10.5005/jp-journals-10071-23711.98 NRI Medical College, Andhra Pradesh, India Introduction: Dengue virus is a flavivirus found largely in areas DOI: 10.5005/jp-journals-10071-23711.97 of tropics and subtropics. Dengue is currently regarded globally Introduction: Our Institution was converted into a State COVID-19 as the most important mosquito-borne viral disease presenting 1 center in June 2020. Since then, approximately 12,000 patients were with varied symptomatology. There are four distinct antigenically treated in our hospital including ICU admissions. In late November, related serotypes of dengue virus-DEN1, DEN2, DEN3, and DEN4. we were permitted by the State Government to initiate Non-COVID Dengue is transmitted, primarily by Aedes aegypti mosquitoes. services. The COVID-19 wards and ICU were and are currently Materials and methods: This prospective study was carried out providing services simultaneously although in reduced numbers. at the department of General Medicine and Microbiology, of Sri ICU admissions started almost immediately. We were faced with Aurobindo Institute of Medical Sciences, Indore, over a period a multitude of challenges. These included diagnostic dilemmas, of 1 year (July 2019 to July 2020). Patients presented with febrile segregation and isolation of suspected COVID-19 cases, ICU illness of 2 to 7 days along with clinical features of the dengue-like admission policy changes, infrastructure challenges, and medical illness, i.e., nausea, vomiting, rash, myalgia, and arthralgia were and nursing personnel management to name a few. It took immense investigated. Results: During study period total 520 blood samples administrative and medical planning and adaptation to streamline were tested for dengue infection. Out Of these 80 samples were critical care services. positive for dengue. Seroprevalence of Dengue was 15.4%. Out Objectives: of 80 dengue patients, 44 (55%) were male patients and 36 (45%) • Study and analyze challenges in a Non-COVID ICU in the were female patients. Out of 80 dengue patients, 54 (67.5%) patients COVID-19 era. were from urban area and 26 (32.5%) from rural area. In our study • Analyze diagnostic modalities used to rule out COVID-19 and dengue infection was observed more in the age group 21 to 30 the cost implications thereby. years, followed by 31 to 40 years and 41 to 50 years. The most • Analyze the outcomes in post-COVID-19 patients vs NON-COVID common symptoms of dengue were fever, body ache, headache, patients. nausea and vomiting. Out of 80 dengue cases, fever with rash was • Bring into focus the real-time adaptive changes made to observed in 24 cases. Discussions: Dengue fever is an acute febrile improve the quality of care. Arbo-viral disease affecting the tropical and subtropical regions of 3 Materials and methods: This is an observational study on the the world. Dengue is endemic to the Indian subcontinent and it is first 100 admissions to our intensive care unit after restarting associated with explosive urban epidemics. Conclusion: Differences Non-COVID-19 services. Data collected will include demographic in the clinical, biochemical, and hematological profile of dengue data, tests to rule out COVID-19, APACHE-II, current diagnosis, virus infection, indicative of a variation in disease severity from length of stay, and ICU outcomes. We will also record the nurse- dengue fever to dengue hemorrhagic fever. patient ratio, the modality of communication with family, and family visitation policy. We will study the number of positive 13. ICU Quality Indicator. (Conference Abstract ID: 108) cases identified with each diagnostic modality and perform a Ziyokov Joshi, Sneghdha Mahajan cost analysis. We will compare ICU admissions during the same Tagore Heart Care and Hospital, Jalandhar, Punjab, India months in the previous year and compare patient outcomes. We DOI: 10.5005/jp-journals-10071-23711.99 will also compare outcomes between post-COVID-19 patients and Introduction: Rapid response systems have emerged as important COVID-19 naive patients in the ICU. We will analyze the timeline of resources that focus on the hospitalized patient with unexpected, various adaptations that were made with respect to ICU structure, sudden deterioration in condition from any cause. A rapid response admission policy, and diagnostic tools to rule out COVID-19. Results: system is a very important system to prevent mortality in every The study is in progress. Discussions: The COVID-19 pandemic hospital. Objectives: 1 To establish and test the feasibility of has battered healthcare systems worldwide. In resource-limited measurement of mortality in hospital. 2 Outcome of the patient environments like ours, restarting of non-COVID-19 services after rapid response team treatment after 7 days. 3 To audit and has meant an additional burden on the critical care teams. The analysis rapid response events in the hospital. 4 To make a hospital diagnostic dilemmas in view of common clinical presentations, mortality prevention protocol. Materials and methods: We have increase the cost of care with added diagnostics, low nurse to rapid response system activation criteria 1 Acute physiological patient ratios, infrastructure reallocation, initial hesitation with criteria A heart rate <40 or. 130/minute B Systolic blood pressure, family visitation, and limited family interaction created a lot of stress. <90 mm Hg C Urine output <50 mL in last 4 hours D Respiratory rate We had to make changes in admission policy and a plan for the flow <8 or >30/minute E SpO2 <90% F Acute change in consciousness of patients to the intensive care unit. This will be a great learning 2 organ system-specific criteria A Airway: Respiratory distress, 3 experience for future planning and management. Conclusion: We Uncontrolled pain. Results: In our hospital from January 2018 to hope to throw light on challenges in ICU management in the post August 2019, total admission 18,680 out of this 4% mortality, and COVID era and identify problem areas and potential ways forward. out of this 4% I % is surgical mortality. Discussions: Rapid response system is the most important tool in the hospital to give the best 12. A Study of Clinico-demographic Profile and Seroprevalence of care to a patient in our hospital. We are heaving CODR blue and RRS Dengue at a Tertiary Care Hospital of Central India. (Conference protocol to prevent and manage all emergencies in the hospital Abstract ID: 131) with this our mortality is minimum in India. Conclusion: Important Rajesh Kumar Rahul, RK Jha, Sonam Verma factor in the successful implementation of a rapid response system

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in hospital 1 rapid response team 2 activation criteria 3 emergency long-term complications. Materials and methods: A retroprospective intervention to stabilized critical patient 4 communication tool evaluation after ethical committee approval of all the PCDTs SBAR 5 CME for doctor paramedical and workshop to teach them performed between December 2011 and November 2020 was done. 6 BLS and ACLS teaching to doctor and advance invasive monitor All procedures were undertaken by critical care physicians or senior and AED in emergency crash CART in every floor of hospital 7 every registrars with at least 2 years of working experience in critical care. 6-month audit 8 CAPA every 6 months. Ciaglia’s tapered single dilator blue rhino kit (cook) was used for all the patients. A proforma recorded any intraoperative complications 14. “Prognostic Value of Cycle Threshold” in COVID-19 Confirmed and technical difficulties encountered during the procedure. All Patients. (Conference Abstract ID: 91) the patients were followed up for up to 3 months for any delayed V Dinesh Kumar Gontla, B Rajyalakshmi, Srinivas Samavedam, complications. Results: Of the 220 percutaneous tracheostomies Narmada Aluru, P Ramakrishna Reddy performed, the placement of a tracheostomy tube was successful Virinchi Hospitals, Hyderabad, Telangana, India at the first attempt in all but four patients in whom the tube had to DOI: 10.5005/jp-journals-10071-23711.100 be withdrawn and guidewire reinserted and tube placed in proper Introduction: RT-PCR test is the standard method for the diagnosis position.Five patients experienced a complication in the acute phase. of SARS-CoV-2 infection. This test is based upon the amplification There was bilateral pneumothorax in one patient requiring bilateral of the fluorescent signal. Number of cycles that fluorescent signal chest drain insertions who subsequently recovered. One patient undergoes to reach the threshold called as “Cycle threshold (CT). proved difficult for the tracheostomy tube to be introduced into It is inversely related to the nucleic acid content of the sample. the formed stoma and had to be converted to an open procedure in Objectives: To study the correlation between cycle threshold of bedside.In three other patients, excessive bleeding occurred during RT-PCR test is confirmed COVID-19 patients with severity of the the procedure and a more experienced intensivist was called to disease. Materials and methods: This is a single-center retrospective complete the tracheostomy. Another patient developed collapse observational study. We have included a total of 192 patients. SARS- of the left lung post procedure with possible accumulation of CoV-2 infection was confirmed by the RT-PCR test. Entire data have pulmonary secretions or mucous plug which required bronchoscopic been collected from electronic medical records. The primary outcome clearance the next day. There was no incidence of false passage in was 28-day mortality, secondary outcomes were ICU admission, any of the patients following tracheostomy. Postoperative reactionary invasive ventilation, AKI, RRT, shock and CORAD SCORE on HRCT bleeding was seen in five patients within six hours of procedure chest, the total length of stay in the hospital, number of ICU days, from the surgical site associated with surges of increased in blood and ventilator days. Results: We have concluded mean CT value for pressure which subsided within 24 hours with conservative measures all groups and calculated p-value for statistically significance.For of compressive bandage at the site and blood pressure control. total length of stay in hospital,number of ICU days and ventilator There was no procedure related mortality.Tracheal stenosis was days were applied pearson correlation coefficient. P value was seen in one patient after one month which required bronchoscopic statistically significant for mortality, ICU admission and shock groups. dilatation. Granulomas at the scar site as visualized by fibre optic Cycle threshold and length of ICU stay were inversely correlated bronchoscope was seen in two patients resulting in stridor which with statistically significant p-value. Discussions: In our study, it is required bronchoscopic steroid injection. Subsequently all of them concluded that low CT is associated with the severity of the disease. recovered without any long term morbidity. Discussions: PCDT has Conclusion: Low CT associated with increased ICU admission, high now almost become the gold standard for tracheostomies in ICU. mortality, shock, and increased length of ICU stay. Bleeding is the most significant early complication. However, most of the cases of bleeding were easily controlled by simple measures 15. An Audit of Percutaneous Dilatational Tracheostomy (PCDT) like local compression and pressure application. Ultrasound before in a Mixed Adult ICU in a Multispeciality Hospital. (Conference the procedure to mark the depth of the trachea and avoid any blood Abstract ID: 88) vessels along the track may help reduce the bleeding complication. R Vaidyanathan, Noor Rubina Ahmedi Other significant advantages have been the decreased waiting time Cauvery Heart And Multispeciality Hospital, Mysore, Karnataka, and a significant reduction in the cost since it is a bedside procedure. India Though comparatively less in incidence delayed complications like DOI: 10.5005/jp-journals-10071-23711.101 granulomas and tracheal stenosis are possible which was seen in <1% of the patients in our series. Conclusion: PCDT is a safe and effective Introduction: Tracheostomy is a common procedure done in ICU procedure done at the bedside which has effectively reduced the cost patients who either require prolonged ventilation or for airway and waiting time with a negligible but finite acute complication in protection to facilitate weaning from patients’ ventilatory support. the form of bleeding and a small incidence of delayed complications The classical surgical technique described by Jackson in 1909 has been like tracheal stenosis or granuloma formation. performed routinely by either ENT surgeons or other surgeons and has changed little since then. However, the advent of percutaneous 16. Apollo eACCESS Initiative: Tele-ICU During the COVID Crisis. tracheostomy, first described by Sheldon In 1955 has revolutionized (Conference Abstract ID: 77) the procedure and has been modified and improvised several times with the current technique of single graded tracheal dilator over Sri Ramya Ganti, Sai Praveen Haranath, K Subba a Selinger type guide wire called the Blue Rhino technique being Apollo Hospitals, Jubilee Hills, Hyderabad, Telangana, India the most popular one. Objectives: To do a retrospective analysis of DOI: 10.5005/jp-journals-10071-23711.102 percutaneous dilatational tracheostomy (PCDT) in an adult mixed Introduction: The practice of Telemedicine is still in its infancy in surgical and medical ICU between December 20011 to November our country. Lack of awareness, as well as acceptance both on the 2020 and to look for any possible immediate, short-term, and part of patients and professionals, has been cited as the principal

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reason behind the delay in its full-fledged development. The Apollo Bharati Vidyapeeth Medical College, BVDU, Pune, Maharashtra, Hospital backed “eACCESS” tele ICU service has been functional India since 2013 and has remotely managed over 4,000 ICU patients DOI: 10.5005/jp-journals-10071-23711.103 in the last 3 years in several hospitals in our country. Continuous Introduction: Acute kidney injury is a common presentation in round the clock monitoring of critically ill patients has been the intensive care unit and the need for dialysis in the care of such possible with the use of remote technology. The global COVID-19 patients is essential. The dialysis in the ICU setting differs from pandemic has united all nations against a common enemy: the that of that done in patients with chronic kidney disease on an novel coronavirus. In times like these where social distancing is outpatient basis in many ways like the need for prolonged dialysis the new norm, the timely release of the Telemedicine Practice due to hypotension, issues with anticoagulation, and also regarding Guidelines by the Government of India has enabled healthcare the complications and their management. This audit is intended professionals to evaluate, diagnose, and triage remotely. We have to find the incidence of such differences and the possible steps to currently extended our monitoring services for COVID-19 patients minimize them. Materials and methods: The study is done at the at many remote locations in India like Dadri (UP), Bahr (Bihar), Critical Care Department of Bharati Vidyapeeth Medical College, Kaniha (Odisha), Vindhyachal (MP), Korba (Chhattisgarh), and Pune which has a 50 bedded ICU with 2 dialysis machines. This is Ramagundam (Telangana). Materials and methods: Our workflow an observational study. A total of 100 consecutive hemodialysis has evolved with time and we do a minimum of two interactions sessions were analyzed. Patients who presented to the hospital per remote site every day. Qualified and trained intensive care with features of acute kidney injury or developed AKI during the physicians are monitoring patients in shifts along with specially management of their illness and requiring dialysis were studied. trained critical care nurses. Standard guidelines issued by The The clinical presentation, indication for dialysis, method of vascular Ministry of Health and Family Welfare for COVID-19 treatment are access, and process of dialysis and complications both intra-dialysis being followed. Awake proning of conscious patients is also being and immediate post-dialysis and need for supportive care were done at these locations under supervision. We are also providing all studied. Results: Out of the 100 consecutive dialysis sessions education to the medical personnel at these remote sites regarding observed, 50 were done in patients who presented with Acute Renal the monitoring of ICU patients, follow-up of investigations, basic failure on a pre-existing Chronic Kidney disease, 38 presented with medical emergencies, and how to manage them. Interestingly acute kidney injury, 4 were for AKI after their hospital admission and the minimum distance of our remote connection is 100 km and 8 dialysis sessions were done for an indication of PLEX for Guillian the maximum distance is 1,550 km. Results: We have monitored Barre syndrome and TTP. Major indications for dialysis were fluid over 1700 COVID-19 positive cases since March 2020 at various overload in 42, severe acidosis in 36, hyperkalemia in 8, and uremic locations within the Apollo campus in Hyderabad and at remote symptoms in 24, and dialysis for PLEX and TTP in 8 ( few had more sites. Majority of the patients admitted for COVID care were males than one indication). The most common vascular access obtained (68.7%). The patient population varied from 8 years to 84 years. We was through the jugular vein (54), femoral vein (26), permcath (18), have the capacity to monitor 120 COVID patients at a given point and AV Fistula (2). The median time lag from Nephrologists’ advice of time. The average length of stay in the hospital is approximately and initiation of dialysis was 6.5 hours, maximum being 22 hours 4.5 days. Triaging and reporting of Electrocardiograms from remote and mostly occurred for the first dialysis. The main reason was sites is also done from our command center. We have reported 3432 due to the delay in radiological confirmation of access placement ECGs during this period. We have also provided 409 sub-specialist and consent and room availability for dialysis. Almost more than tele consultations through the eACCESS program since March 45 were Sustained Low Efficiency Dailly Dialysis (SLEDD) sessions 2020. Discussions: Tele-ICUs not only provide 24*7 monitoring of which was the major method of Haemodialysis as many patients critically ill patients but stand with the bedside team as the first line were hemodynamically unstable and requiring vasopressors for of care. This modality has helped decrease the frequency and need maintenance of blood pressure during dialysis. The remaining 55 to physically enter an isolation room. The direct visualization and were standard 4-hour hemodialysis. None of the dialysis sessions monitoring of COVID-19 patients have also allowed for the early were CRRT. The most common complication was flow issues during detection of many emergencies like a drop in oxygen saturation, dialysis (30) which lead to either increase in time of dialysis or disconnection from NIV, ventilator circuit issues, etc. Since most premature termination. Many had hypoglycemia (32), an increase of the intensivists are predominantly concentrated in the metro in vasopressor requirement (18), new-onset hypotension (14), cities, Tele-ICU services have plugged a major gap in the existing cardiac dysrhythmias (5), and bleeding (2). One patient developed healthcare delivery system by providing quality care to smaller rural cardiac arrest during the dialysis session. Discussions: The majority areas. Patients can have access to remote expertise from the comfort of dialysis sessions were done in patients presenting with acute of their homes. Conclusion: The ongoing COVID-19 pandemic has kidney injury in preexisting chronic kidney disease. Vascular access not only highlighted the shortage of ICUs but also the shortage of was obtained through the internal jugular vein in the majority. trained medical personnel and resources (like personal protective There was a delay in the initiation of dialysis in many due to time equipment, PPE). Tele-ICU solution can help bridge these barriers lag in getting consent for the first dialysis and delay in obtaining by conserving PPE, minimizing exposure, and avoiding infection vascular access and the confirmation of this placement. Many were through constant remote monitoring. in shock requiring vasopressors and the requirement increased during a dialysis session. SLEDD was the prime method in their 17. An Audit on Dialysis Services in Intensive Care Unit at a management as there were only 2 machines and SLEDD was able to Tertiary Care Teaching Hospital. (Conference Abstract ID: 76) be performed in the patients without much difficulty. Conclusion: Kiran Vadapalli, Prashanth Jedge, Jignesh Shah, Shivakumar Iyer, SLEDD is an efficient method of hemodialysis of critically ill patients. Shambhavi Chauhan Patients need very vigilant monitoring of vital parameters during

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dialysis as the need for vasopressors support is high in many there was only a weak positive correlation with SBP. The heart, critically ill patients and the incidence of hypoglycemia is high which brain, and kidney have their autoregulation, so in critical situations, necessitates regular monitoring of blood sugars both during and the body will try to maintain its blood supply by compensating immediate post-dialysis. mechanisms. So in this situation, arterial blood pressure correlates poorly with the microcirculatory flow. It also appears from this 18. Role of Perfusion Index in Assessing the Peripheral Perfusion study that there is no correlation between perfusion index (PI) in Patients Undergoing Major Abdominal Surgeries. (Conference with conventional hemodynamic parameters like MAP, SBP, DBP, Abstract ID: 67) and heart rate. The ultimate goal of management of the patient in Prayag Premnath, Neeta Kavishvar the perioperative period is maintaining the tissue perfusion, so PI Government Medical College and New Civil Hospital Surat, should be added into the conventional hemodynamic monitoring Gujarat, India parameters especially where invasive monitoring like PCWP and SV monitoring is not possible. Conclusion: PI detects acute DOI: 10.5005/jp-journals-10071-23711.104 hemodynamic responses earlier than conventional parameters Introduction: Abdominal surgeries are one of the most common and can be used as effective monitoring in improving perioperative surgeries that take place in the operation theater. Major abdominal outcomes. surgeries are generally associated with extensive fluid loss which can hamper the microcirculation and makes the emphasis on 19. A Prospective Observational Audit-on the Appropriateness of perioperative fluid maintenance. Perioperative hemodynamic Initiation, Maintenance, and Complications of DVT Prophylaxis instability is associated with postoperative morbidity and mortality. in Critically Ill Patients. (Conference Abstract ID: 53) Microcirculation plays a fundamental role in gas and nutrient S Thangadurai, Jayanthi, L Charan, P Vivekananthan, MN exchange and it achieves this by controlling the vascular tone. Sivakumar Laparotomies are associated with longer durations as well as Royal Care Superspeciality Hospital, Coimbatore, Tamil Nadu, India excessive fluid and blood loss. Longer durations can lead to heat loss, blood and fluid loss which deranges tissue perfusion and DOI: 10.5005/jp-journals-10071-23711.105 hampers the microcirculation as well. The peripheral perfusion Introduction: Thromboembolism is a major complication in can be detected by making use of the peripheral perfusion index hospitalized patients. Intensive care unit (ICU) patients have a (PPI) obtained from Masimo SET pulse oximetry. A threshold value greater risk of thrombotic events due to additional risk factors such of 1.4 is taken as cut-off where the PPI below this determines the as immobilization, mechanical ventilation, and central catheters. fact that there is tissue hypoperfusion. With the use of the perfusion The diagnosis and management of deep vein thrombosis (DVT) and index, we can determine the status of the peripheral perfusion pulmonary embolism (PE) in critically ill patients are challenging as well as the state of tissue perfusion which correlates with the and these conditions are associated with high mortality. Medical morbidity and mortality of patients undergoing major abdominal thromboprophylaxis with low molecular weight heparin (LMWH) as surgeries much better than the other noninvasive and invasive well as unfractionated heparin (UFH) has been shown to reduce the parameters much earlier. Materials and methods: This study was incidence of thromboembolic events in such patients. For patients carried out in 31 patients undergoing major abdominal surgeries. with a high risk of bleeding, mechanical thromboprophylaxis can be The hemodynamic parameters ECG, pulse rate, SBP, DBP, MAP, used. According to research, half of the hospitalized patients are at 1 perfusion index, proximal and distal temperature were recorded risk of thromboembolism. The rate of VTE ranges from 10% to 80% 2,3 before induction and throughout the intraoperative period. in patients, who are not being given any prophylaxis. Studies have Patients were followed till the discharge or death of patients and proven the rate of VTE is greater in hospitalized than in community 4 any postoperative complications were noted. Retrospectively patients. The use of DVT prophylaxis has been almost a standard of patients were divided into complication and no-complication group care in ICU and by doing this study we intended to audit if initiation to check its association with hemodynamic parameters and PI. of it has been appropriate and whether there is any delay in a certain Results: There was no correlation found between perfusion index group of patients, the complications associated and the reason for and DBP, pulse rate and MAP (correlation coefficient = –0.08, –0.025 discontinuation during the ICU stay if any in our ICU for a period and 0.04 respectively) and very weak positive correlation with SBP of 2 months. Objectives: To observe whether DVT prophylaxis (0.27). There was significant correlation between PI and T1 (0.48, has been appropriately initiated in all patients getting admitted p < 0.01) and negative correlation between PI and temperature to ICU, the reason for delays in initiation and discontinuation, the difference (–0.37, p = 0.05). There was a weak positive correlation complications for a period of 2 months in the multidisciplinary ICU between average fluid given per hour and perfusion index (0.340). at a multispecialty hospital in south India. Materials and methods: The correlation coefficient between PI and requirement of ventilator We included all adult medical and surgical cases getting admitted support was –0.461(p = 0.009 (p < 0.01). There was a very weak to our ICU during the months of September and October of 2020. negative correlation between perfusion index and death (–0.172) Data collection included the patient demographics, comorbidities, Discussions: This study was conducted among 31 patients. Of the the reason for ICU admission, DVT risk factors, date of initiation of total 31 patients, 17 (54.8%) were male and 14 (46.2%) were female. prophylaxis, whether mechanical or pharmacological or both, if The mean age in this study was 33.5 ± 13.6 years. In this study mechanical the reason, if pharmacological the drug used, the reason hemodynamic variables like pulse, noninvasive blood pressure, and if any discontinuation during the ICU stays and the complications the difference in forearm-fingertip skin temperature were correlated such as bleeding from any site. Results: We had total of 105 patients with perfusion index by Pearson correlation coefficient. There was admitted to ICU in the two months of which 74 were medical and no correlation between PI and other hemodynamic variables and 31 were surgical cases. 38 of them had mechanical prophylaxis,

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11 had pharmacological and 56 had combined prophylaxis. Average Description of the indication, number, duration, organ supports duration for initiation of prophylaxis from admission was 2.19 days during transport, complications, diagnostic and therapeutic benefits for the neurosurgical and trauma patients and as low as 1.2 days are presented. Data were presented as median (interquartile range) for rest of the ICU patients. Total number of missed days were 41 or as number (percentage). Pretransport vital parameters and days and the reason for withholding chemoprophylaxis was mostly blood gas were noted and equipment was checked for proper for some surgical interventions, predominantly for tracheostomy. functioning. After confirmation from the radiology department, Complications recorded were predominantly bleeding and was the patient was shifted with a transport monitor, resuscitation seen in 9 patients. Of them 4 were Endotracheal bleed, one each equipment, emergency drugs, and oxygen cylinder. Our team to of hematuria, Malena, gum bleed, central line ooze and minimal transport such patients includes one doctor, one staff nurse, and nasal bleed. two patient helpers, and the patient is continuously monitored. Discussions: Any adverse events during the intrahospital transport were noted • Initiation of DVT prophylaxis was indeed appropriate in our by the escorting intensivist. Vital signs and oxygen saturation were ICU patients with a slight delay in neurosurgical and trauma monitored before and during the transport and post transport, vital patients which is obvious. signs and arterial blood gases were checked. Patients’ Glasgow • The complications are not very high and transient discontinuation coma scale (GCS), Richmond agitation sedation score (RASS), was done during those episodes which might be acceptable. vasopressor inotropic score (VIS), and mechanical ventilator setting • Combined thromboprophylaxis and mechanical prophylaxis will be noted both before and after transport. An adverse event was is undertaken in the majority of the patients and the efficacy defined as either a physiological deterioration or equipment related of such practice and cost-effectiveness needs to be reviewed. mishap that occurred during transport. Physiological deterioration • Withholding DVT thromboprophylaxis for minor bleeding during transport was defined as significant changes in vital episodes can be avoided with senior input. signs, oxygen saturation, or hypotension. A significant change is Conclusion: considered a change in heart rate or blood pressure by 20%, oxygen • Initiation of DVT prophylaxis was indeed appropriate in our saturation by 5%, any increase in vasopressor dose or sedation ICU patients with a slight delay in neurosurgical and trauma requirement. Statistical analysis: The following were computed patients which is obvious. using descriptive statistics: demographic data and severity of illness • The complications are not very high and transient discontinuation of patients requiring transport, number of transports per patient, was done during those episodes which might be acceptable. duration of transport, and adverse effects. Data were presented as • Combined thromboprophylaxis and mechanical prophylaxis median (interquartile range). Results: 104 patients of median age is undertaken in the majority of the patients and the efficacy 49 years (35–60) were transported from May 2019 to June 2020; of such practice and cost-effectiveness needs to be reviewed. 62% were male. The median admission APACHE II score was 24 (IQR • Withholding DVT thromboprophylaxis for minor bleeding 16–28) and median SOFA score of 10 (IQR 7-14). Organ failures at episodes can be avoided with senior input. admission were single organ in 19, 2 organ failures in 24 and >2 organ failures in 61. The admission diagnoses of the patients were 20. Transport of Critically Ill Patients: Experience from a Tertiary acute pancreatitis in 28 (26%), cerebrovascular accident in 12 (11%), Care Teaching Hospital. (Conference Abstract ID: 37) liver failure in 11(10%), tropical illness in 11(10%) and others in Anand Kumar Singh, Banani Poddar, Arvind Baronia 42 (40%). 104 patients required 152 transports, the commonest Sanjay Gandhi Postgraduate Institute of Medical Sciences, being for abdominal CT imaging [57 (38%)]. 47 (31%) patients Lucknow, Uttar Pradesh, India required multiple transports: 2 in 36 patients, 3 in 11 patients. The DOI: 10.5005/jp-journals-10071-23711.106 SOFA on the day of transport was 14 (10–16). The median day of Introduction: Intrahospital transport of critically ill patients is often transport from day of admission was 12 (6–21). The median duration necessary for optimal patient care. Adverse effects during and after of transport was 35 min (30–45). The organ supports provided transport of critically ill patients are frequent. On the other hand, during transport included oxygen support in 28 (18%), mechanical a change in patient management results from about half of the ventilation in 110 (71%), vasopressors in 76 (49%). Bolus of sedation procedures that necessitate transport, indicating good efficiency. was administered in 62 (40%) transports. Physiological worsening Objectives: was seen in 70 transports; hemodynamic in 39 (25%) and corrected • To describe the demographics of transport of critically ill by vasopressor increase in 74 (48%), and respiratory in 34 (22%). patients: diseases requiring transport, number of transports Organ supports were provided in 141 (92%) transports; respiratory for each patient, and the duration of transport. supports in 140 (92%) and vasopressor supports in 75 (49%) patients • To study the number and types of adverse events occurring and 11 (7%) patients required no organ supports. These transports during intrahospital transport of critically ill adults, and the were beneficial in 150 (98%); all the transports were of diagnostic interventions provided for these adverse events. benefit while therapeutic benefit was obtained in 140 (94%).The • To study the outcome of transports in terms of change/benefit procedure was cancelled in 2 due to physiological instability (major in patient management. adverse event); 5 transports had minor equipment malfunctions. Materials and methods: Design: Prospective observational study. Discussions: We were able to safely transport critically ill patients Setting: 20 Bed ICU of the department of critical care medicine, with a median SOFA score of 14. All successful transports were of SGPGIMS, Lucknow. Consecutive patients requiring transport to benefit in patient management suggesting good planning and radiological imaging and intervention radiology during the first assessment of the risk-benefit ratio. The American College of Critical 28 days of hospital admission were included. Data were collected Care Medicine published guidelines for the safe intrahospital and at the time of transport by the doctor accompanying the patient. interhospital transport of critically ill patients. Monitoring during

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transport is necessary. This includes, at a minimum, continuous any complication was recorded in our study. Confirmation by both electrocardiographic monitoring, continuous pulse oximetry, and methods was comparable in detection of catheter malposition and periodic measurement of blood pressure, pulse rate, and respiratory complication. Discussions: Some of the traditional methods to rate. In addition, selected patients may benefit from capnography, check the endovenous placement of CVC are as follows:11 Aspiration continuous intra-arterial blood pressure, pulmonary artery pressure, of dark blood in the syringe after puncture of the vessel suggesting or intracranial pressure monitoring. Each institution should have venous blood, absence of pulsatile flow from syringe hub giving local guidelines for the transport of critically ill patients which covers indirect evidence that a punctured vessel is not an artery, ABG key aspects including pretransport communication, personnel, analysis of the aspirated blood, pressure waveform analysis by equipment, monitoring, and documentation. They concluded that pressure transducer for invasive monitoring, pressure waveform patient safety is enhanced during transport by organized efficient analysis by simple tube manometry, identification of guidewire process supported by appropriate equipment and personnel. in the right atrium by trans-esophageal echocardiography (TEE) Conclusion: Safe transport was possible in 98% of critically ill and fluoroscopy with simultaneous injection of contrast. All these patients with high severity of illness. The therapeutic and diagnostic methods are associated with some of the other advantages and benefit was obtained in 97% of transports. disadvantages ranging from time, cost, accuracy, and availability. In an emergency situation, the most important information regarding 21. Can POCUS (Point of Care Ultrasound) Replace Conventional a recently placed central venous catheter is proper placement Chest X-ray for Confirmation of Above the Diaphragm Central in the venous system and exclusion of pneumothorax. By using Venous Catheter Placement? A Prospective Observational Study. POCUS with a saline flush, it is possible to both confirm the venous (Conference Abstract ID: 17) placement of the catheter and rule out iatrogenic pneumothorax. Anjali B Parmar, Shruti V Sangani, Chirag J Patel Mehrdad et al. also described a similar study in which the saline flush B. J. Medical College, Civil Hospital Campus, Ahmedabad, Gujarat, method with POCUS was found safe, accurate, and rapid bedside India method for CVC confirmation as compared to CXR. Conclusion: DOI: 10.5005/jp-journals-10071-23711.107 POCUS can confirm CVC placement and also helps in ruling out pneumothorax faster than conventional chest radiograph thus Introduction: Central venous catheterization (CVC) is an important expediting the use of CVC in critically ill patients of the emergency procedure in the emergency department (ED) and it is very useful department. in patients who require vasoactive medications, hemodynamic monitoring, or sometimes multiple drug infusions. Although CVC 22. Challenge in Reverse Triggering: Matching the Neural Pace is done routinely, sometimes it is associated with complications like (Conferrence Abstract ID: 200) catheter tip misplacement (5–9%), pneumothorax (PTX; 0.1–3%), and arterial puncture (3–9%),1–4 despite being made safer through BG Manjunath, Sateesh Chandra Alavala, Sushmita Jakka, ultrasound (US) guidance.5–8 Traditionally, a chest radiograph (CXR) Pawan Kumar Singh, Diksha Tyagi, Dhruva Chaudhry is performed after postprocedure for CVC confirmation and to rule DOI: 10.5005/jp-journals-10071-23711.108 out pneumothorax. The primary objective of this study was to assess Objectives: Reverse triggering (RT) is a type of patient-ventilator if the point of care ultrasound (POCUS) could more rapidly confirm interaction characterized by mechanical insufflations triggering CVC tip position than standard portable CXR in ED. We hypothesized diaphragm contraction. Identification of RT is important for its that POCUS confirmation of CVC placement would be faster than clinical consequences including ventilator-induced lung injury that of CXR confirmation. Objectives: Rapid vascular access is (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD). often required during resuscitation and hence central venous However, the correction of this asynchrony remains unknown. catheter (CVC) placement is a common procedure in the emergency We hypothesized that RT occurs when the set ventilator RR department. Conventional chest radiography is the standard (RRVENT) exceeds the spontaneous rate of the patient and it can method to confirm CVC placement and exclude complications but be corrected by decreasing RRVENT. Materials and methods: It is time-consuming thus delaying the use of CVC. So we decided was a prospective, observational study conducted in the medical to carry out a study to determine whether POCUS (point of care and surgical ICU of a tertiary care hospital between August 2019 ultrasound) can be used instead of a chest radiograph (CXR) for and December 2019. Reverse triggering was identified by real-time confirmation of above the diaphragm CVC placement or not. inspection of pressure and flow waveforms for their characteristic Materials and methods: Prospective observational study was done appearance in patients receiving invasive mechanical ventilator on 100 adult patients who required emergency supradiaphragmatic support with assist/control mode. Patients were included in the CVC placement. POCUS was used for placement as well as to see study if their ventilator waveforms showed RT at any point of time the appearance of turbulent flow in the right atrium when the during their stay in ICU. Patients receiving neuromuscular blockers CVC was flushed with 10 mL agitated saline thus confirming its were excluded from the study. Demographic, clinical, and ventilator position. Bilateral thoracic cavities were scanned to rule out any data were recorded in those patients who developed RT. Once the pneumothorax. A portable chest radiograph was advised once RT was identified, ventilator respiratory rate (RRVENT) gradually CVC was placed. Time is taken for CXR and POCUS, detection of decreased without a change in other ventilator settings. Results: catheter malposition, and associated complications were assessed, A total of 54 patients were identified with RT during this period. charted, and compared using p value. Results: 100 patients were Among these, 38 (76%) patients were receiving sedation when enrolled and included in the final analysis. POCUS time was 3.17 ± they developed RT. Reverse triggering was associated with double 1.34 (mean ± SD) minutes compared to 35.91 ± 17.23 minutes for triggering in 37 (69%) patients. Reverse triggering disappeared CXR performance with a mean difference of 32.7 minutes making it in all patients when the RRVENT was gradually reduced (to an statistically highly significant (P˂0.0001). No catheter malposition or average of 14 breaths/minute, range 8–20) with no other changes

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in ventilator settings. When the RT disappeared, all breaths were 24. Intubation Practices in Trauma Triage: A Prospective patient-triggered breaths. Conclusion: Reverse triggering may Observational Study. (Conference Abstract ID: 194) occur when the RRVENT exceeds the spontaneous rate. When the Anudeep Jafra, Kajal Jain, Sravani M Venkata, LN Yaddanapudi, clinical situation allows a low RR, decreasing the RRVENT results in SK Gupta the disappearance of RT. PGIMER, Chandigarh, India DOI: 10.5005/jp-journals-10071-23711.110 23. To Study the Outcome of Mechanically Ventilated Patients in Introduction: Hypoxia and obstruction of the airway are the Respiratory ICU. (Conference Abstract ID: 195) major contributors to death following trauma. Hence, a definitive Nida Choudhry, Lalit Singh, Rajeev Tendon airway control, which may require endotracheal intubation, is Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar an essential component of trauma resuscitation. Trauma Triage Pradesh, India is generally manned by a team comprising of various levels of DOI: 10.5005/jp-journals-10071-23711.109 healthcare professionals. It is not only important whether a patient Introduction: Background — The need for ventilatory support is needs intubation but also when and how to intubate. There is a one of the commonest indications for admission into the intensive lack of data pertaining to intubation practices in trauma triage care unit (ICU). Improving the outcome of mechanically ventilated in India. Objectives: Hence, the present study was conducted to patients remain a mission we all strive to achieve Objectives: describe the current practice of definitive airway management Aim — To study the outcome of mechanically ventilated in the trauma triage of a tertiary hospital catering to northern Patients in Respiratory ICU — to provide baseline information India. The secondary objectives were to determine the success for epidemiological trends, prognostic factors, and outcome rate of endotracheal intubation by anesthesia and non-anesthesia of patients on mechanical ventilation calculated based on the residents, to describe the complications during securing the duration of hospital stay, duration of ICU stay, number of days airway and to formulate recommendations based on the results on ventilators, complications, mortality, followed till discharge. of this observational study. Materials and methods: This was Materials and methods: In this study, 412 patients were admitted a prospective observational study conducted at Trauma Triage to the intensive care unit of Shri Ram Murti Smarak Institute of of level 1 Tertiary Hospital over a period of 1 year. A specifically Medical Sciences (SRMS IMS) at Bareilly Uttar Pradesh between designed proforma was filled which included the patient’s November 2018 and April 2020. Two hundred and fifty patients detailed history of trauma, peri intubation vitals, indications for were enrolled who fulfilled the inclusion and exclusion criteria. urgently securing airway, unfavorable conditions, the technique Results: out of 412 patients admitted to the ICU, 250 patients of intubation, medications used, and adverse events following received mechanical ventilation, either invasive (43%), noninvasive intubation, and a number of attempts taken. Results: The first MV (41%) and 16% of the patients showed noninvasive failure and attempt success rate of intubation by Anesthesia residents was needed invasive ventilation. The commonest indication of MV was significantly higher than Speciality residents (p = 0.0001; 95% CI acute on chronic respiratory failure (74.8%). Chronic obstructive 9.02–24.66). Airway injuries were most frequent complication pulmonary disease was the commonest pre-existing lung disease (n =140, 32.8%) followed by hypotension (n = 57, 13.3%). Total (50.8%). Highest mortality was observed in renal disease (71%). of 99 patients received RSI in trauma triage during intubation Invasive mechanical ventilation was associated with high APACHE by anaesthesia residents, amongst these 77 (77%) patients had II score, SOFA score ,low Glasgow coma scale, low admission Ph, no complications, 8% had airway related injuries, 4 (4%) had

PO2 and high PCO2 compared to non invasive MV. Duration of esophageal intubation, 5 (5%) developed hypoxemia and 3 (3%) hospital stay and length of ICU stay was longer in NIV Failure. had hypotension. Discussions: These prospective observational the highest risk of mortality, a cutoff point of APACHE II score data come from a tertiary care hospital of a low resource country and SOFA score was >30 and >18 respectively. Discussions: In on intubation practices in trauma victims over a period of 1 the present study, the indication of mechanical ventilation in year. The first responders are usually non-anesthesia, specialty all studied majority patients (IMV, NIV, NIV failure) was acute on residents who cater to the immediate needs of the trauma chronic respiratory failure i.e., 33.7, 47.1, and 19.2%, respectively, victims. This reflects the different staffing levels and the limited followed by acute hypoxemic respiratory failure, i.e., 69.8, 22.2, expertise available on arrival to trauma triage. Through this and 8%, respectively, in all groups. In the present study, among study, it may be noted that although the level of experience met survivors, the mean duration of IMV was 7.04 ± 3.02, whereas in the current standards, there is a need to upgrade the skills of NIV failure was 4.57 ± 2.89, which is statistically significant with airway management using manikins and mandatory anesthesia a p value of 0.0008. Venkatesh Yadav et al.68 demonstrated the rotation. Most of the intubations carried by anesthesia residents mean APACHE-II score and SOFA score of non-survivors was high were drug-assisted along with the use of muscle relaxants which as compared to non-survivors, the difference was statistically resulted in less complications and trauma. Literature supports the significant that means mortality increases with higher APACHE-II use of neuromuscular blockers in 62 to 77% of cases, with a strong score and SOFA score. Conclusion: APACHE-II and SOFA scores association being reported between the use of neuromuscular are a strong predictor of mortality because it helps to assess the blocking agents, especially depolarizing agents, and fewer adverse severity of illness and bas chronic health status of the patients effects, as depicted by our results.Conclusion: We observed and also provided the prognostic information which was useful that complication rates were more in patients intubated by for the clinician to assess the outcome of patients admitted to non-anesthesia residents, use of a high dose of sedative agents the intensive care unit. like midazolam, and multiple attempts at intubation. Rapid

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evaluation of these factors and formal training in ATLS can lead However, in neurosurgical patients, these scores may not be to optimal management of the patient and decrease the rate of sufficient to provide enough data for confidant extubation. The complications. objective of the present study is to compare bispectral index guided postoperative extubation vs extubation in awake patients 25. Respiratory Diseases in Adolescent Patients with Diabetes using various neurological assessment scores in neurointensive ICU Mellitus. (Conference Abstract ID: 193) after craniotomy and excision of supratentorial space-occupying lesions. Materials and methods: A total of 16 patients (ASAI-II), aged Pradeep Singh Rajoriya, Ravi A Dosi between 25 and 45 years, who were scheduled to undergo elective Sri Aurobindo Medical College and PGI Indore, Madhya Pradesh, neurosurgery operation under general anesthesia and randomly India divided into the BIS group (group II) and scoring group (group S), DOI: 10.5005/jp-journals-10071-23711.111 with 8 cases in each group. After satisfactory respiratory recovery Introduction: Diabetes mellitus is a chronic, progressive, and patients were extubated. Oxygen saturation by pulse oximeter and incompletely implicit metabolic disease. Its associated micro- HR were recorded before extubation (T0), (T1) at 1 minute, and and macrovascular complications show the result in mortality 5 minutes (T2). Results: Early extubation using bispectral index and morbidity, The microvascular complications are manifested found to be significant with p < 0.04. during T1 and T2. Discussions: as neuropathy, retinopathy, nephropathy, and macrovascular Bispectral index assists better to make decisions for extubation than complications affect the cardiovascular system. It also affects the other scoring systems in postoperative neurosurgical patients for lungs because of its rich vascularity and plethora in connective supratentorial space-occupying lesions. Kamali et al. showed that tissue (collagen and elastin), in a diabetic patient proliferation of BIS reduces extubation time in post-CABG patients.Conclusion: extracellular connective tissue in the lungs, leading to a decline in Using BIS monitoring during and after neurosurgery, it reduces the lung function in a restrictive pattern. WHO has reported that the length of patients’ extubation in ICU. number of people with DM has risen from 108 million in 1980 to 422 million and 8.5% of the world adult population had DM in 2014. The number of diabetic patients worldwide has been expected to rise to 6. Ethics, Brain Death, Organ Donation, and 592 million in 2035 by the International Diabetes Federation. In this Transplantation manner, I have been summarized and discussed the role of diabetes mellitus involved in the progression of common respiratory diseases 1. A Cost-benefit Analysis of a Flexible Bronchoscope Vis-À-Vis in adolescent patients. Keywords: Diabetes mellitus, Respiratory Life of a Doctor in COVID-19 ERA. (Conference Abstract ID: 52) disease Objectives: To study respiratory diseases in adolescent Abhishek Joshi, Manish Banjare patients with diabetes mellitus. Materials and methods: The present MGM Medical College, Indore, Madhya Pradesh, India study is a survey study that was conducted in the department of DOI: 10.5005/jp-journals-10071-23711.113 pulmonary medicine of Sri Aurobindo medical college and hospital, Introduction: We aimed to determine whether single-use flexible Indore. Data will be collected from the attending the OPD and IPD bronchoscopes cost-effective when compared to the life of a in the department of pulmonary medicine. All the participants were doctor in this COVID-19 era. In our study, we have tried to study the in the age group of 25 to 40 years. Duration of the study — from incidence cross-infection of COVID-19 in doctors of MGM Medical November 3, 2019, to March 19, 2020. Results: We investigate 56 College who used bronchoscope for any procedure. Objectives: patients in the age group between 25 and 40 years. This study Primary objective: To do a cost-effective analysis of whether it shows 31 (55.35%) male and 25 (44.61%) females. Discussions: is affordable to use disposable flexible bronchoscope compared Diabetes is identified as an independent risk factor for developing to reusable flexible bronchoscope vis-a-vis the life of a doctor lower respiratory tract infection there appear to be a certain type in the COVID-19 era. Materials and methods: Study design: A of respiratory infections that may be more common in diabetics Retrospective, Observational, Comparative Study. SAMPLE SIZE: patients. Diabetic patients also appear to be at an increased risk of Number of COVID-19 positive doctors who used bronchoscope in complications like pneumonia, asthma, etc. Conclusion: The study any procedure (172). Inclusion Criteria: Doctors (Consultant and shows a high prevalence of infectious diseases such as pulmonary Residents) from 3 departments Anaesthesia, General Medicine tuberculosis, asthma, and COPD in adolescent patients with DM. and Pulmonary Medicine with special attention who contracted COVID-19 infection and Doctors who used Flexible Bronchoscope in 26. Comparison of Early Bispectral Index Guided Postoperative COVID-19 patients. Exclusion criteria: None. Method: A systematic Extubation Verses Extubation in Awake Patients in Neuro review of the literature, seeking all reports of cross-contamination Intensive Care Unit. (Conference Abstract ID: 192) or infection following use of reusable FB was done. We designed a simple questionnaire enquiring about basic and details of Tushar Kumar, Pradip K Bhattacharya the doctor who has contracted COVID-19 infection. Then, we Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India progressed in three steps. First, calculate the incidence of COVID-19 DOI: 10.5005/jp-journals-10071-23711.112 infection after reusable FB. Second, micro cost analysis of reusable Introduction: Neurosurgical patients have a high risk of FB in the clinical setting of our Medical College. Third, the cost neurological complications in the immediate postoperative of a doctor which nation bears to train a doctor (Rs 3–5 Cr). This period increasing both morbidity and mortality. Extubation after produced an accurate estimate of the cost per use of reusable FB. uneventful intracranial surgery is tried to be as early as possible For micro cost analysis, we simulated three scenarios depending to avoid ventilator-associated complications. There are several upon the usage of a bronchoscope. Analyzing the above data. scales and scoring systems to guide and assist early extubation. Results: Cost of a doctor is difficult to calculate, however, minimum

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loss to nation is Rs3-5Cr 21% of the staff got infected after handling Discussions: After three or more attempts at insertion, mechanical airways of COVID 19+ patient 1.74% of the staff became infected complications increase by six times compared with a single attempt. after doing procedure of bronchoscope (of the total) 14% of the In the USG-guided approach, most patients are cannulated in the staff who got infected were within 5 days of bronchoscope used first attempt compared to a conventional method. In the USG 22% of the staff who became infected became seriously ill Cost of technique, access time required is much less. In most patients Disposable Flexible Bronchoscope is Rs 40000–60000. Whereas, where Trendelenburg’s position may be difficult where USG comes cost of reusable bronchoscope varies with total number of use. like a gift. Conclusion:: We came to the conclusion that the USG High usage: (100 usage): large institutions: Government setup approach took less time, required less attempts, and had a lower and corporate hospitals: it costs around Rs 24000 which is quite incidence of complications for cannulation of the internal jugular affordable. Medium usage: (50 cases): Midsize hospitals: it costs vein as compared to a conventional method. around Rs 28000 Low usage: (10 cases): small size hospitals: here the per procedure costs increases exorbitantly. It is around Rs 50000 2. Comparison of Ultrasound-Guided vs Blind Arterial Compared to single use flexible bronchoscope, in low usage (small Cannulations in Critically Ill Patients: A Prospective Randomized size hospitals) cost is comparable. In case of large size hospitals, Study From a Tertiary Care center. (Conference Abstract ID: 124) Cost is definitely high but if we take into account life of a doctor and incidence 1.74%. then, total cost of using reusable FB 100 times Shreyas Gutte, Afzal Azim, AK Baronia, Banani Poddar, Mohan is 20–30 lacs (Rs 24000 × 100) plus cost of life of a doctor (i.e. Rs Gurjar, Prabhakar Mishra Sanjay Gandhi Postgraduate Institute of Medical Sciences, 3–5 Crores) which accounts to Rs 3–5 Crores. Whereas, single use Lucknow, Uttar Pradesh, India bronchoscope if used 100 times will cost Rs 40–60 lacs. Discussions: It is always up to the financial health of a hospital to choose DOI: 10.5005/jp-journals-10071-23711.115 particular medical equipment. But in our case, it is clearly justifiable Introduction: Arterial line cannulation is required in acute care to use Disposable FB in COVID-19. Conclusion: It can be debated settings for hemodynamic monitoring, frequent arterial blood gas in private institutions where usage of the bronchoscope is not analysis, and repeated blood sampling for laboratory evaluation.1 that high disposable FB will be more affordable and cost-effective. Point of care ultrasound (USG) is now the preferred technique Cost per usage decreases with an increase in usage (government for all invasive cannulations in intensive care settings. However, institutions and large corporate hospitals) but the probability of there is a paucity of literature to recommend USG-guided arterial getting infected also increases. Which in turn increases the chances cannulations in the intensive care unit (ICU). Objectives: The of doctors getting infected and out of those doctors increases the primary objective of this study was to compare the first attempt probability of seriously ill doctor also increases. The cost of using a success rate for blind vs USG-guided for radial, femoral, and dorsalis disposable FB compared to reusable FB is slightly higher. However, pedis artery cannulations in ICU patients. Secondary outcomes were seeing the cost that a nation bears in training a doctor and the loss to assess time for cannulations, number of attempts, complications, of this doctor is beyond calculation. comparison of two techniques on patients requiring vasopressor. Materials and methods: Design: Prospective randomized study from June 2019 to June 2020 conducted in a 20-bedded general- 7. Imaging in Intensive Care purpose ICU of a tertiary care center. After taking Institutional Ethical Committee approval and CTRI registration, patients were 1. Ultrasound-guided Central Vein Cannulation in COVID Positive randomized to either blind or USG groups. Inclusion criteria were Patients in ICU. (Conference Abstract ID: 188) adult patients (age >18 years) admitted in ICU requiring continuous Roshni Tripathi, Sangita N Parikh arterial pressure monitoring. Exclusion criteria included patients SVP Hospital, Ahmedabad, Gujarat, India admitted with a preexisting arterial catheter, age <18 years, patients DOI: 10.5005/jp-journals-10071-23711.114 cannulated with other than 20 G for radial and dorsalis pedis artery. Introduction: Traditionally, central lines are put blindly using Randomization was done using a computer-generated table. anatomical landmarks, which often result in complications, such Cannulations were done by intensivists with experience of >20 as, difficulty in access, misplaced lines, pneumothorax, bleeding arterial USG cannulations and traditional technique cannulation in from inadvertent arterial punctures, etc. the radial artery, femoral, and dorsalis pedis artery. All cannulations • Ultrasonography provides “real-time” imaging, i.e., the needle were done by trainees in intensive care who had done post- can be visualized entering the vein that may result in a less graduation in anesthesiology and internal medicine. Technique of associated complication. cannulations: Blind method: For radial and dorsalis pedis arterial Objectives: To perform a study regarded cannulations, the artery was palpated and punctured at the site • Ease of cannulation. of maximal pulsation. Then, a 20 G BD Venflon Pro IV Cannula • Time consumed. was advanced over the needle till the flash of blood is seen in the Materials and methods: Twenty-five critical care patients at the hub of the cannula. For femoral artery cannulation, the artery was intensive care units of SVP Hospital, Ahmedabad, who needed palpated and punctured at the site of maximal pulsation, and a central venous cannulation, with informed written consent. 16 G (5 French) ARROW® REF CV-50016 cannula was placed by Results: Out of 25 patients, all (100%) cannulated successfully. In Seldinger technique. USG technique: For radial and dorsalis pedis only 1 patient, carotid artery was punctured and was cannulated artery after preparing the transducer with a sterile cover, the artery in second attempt. was identified using USG with a linear transducer in short-axis view. • 96% of patients are cannulated in the first attempt. Approximately 0.5 cm distal to the probe, a 20 G BD Venflon Pro • Complication rate is 4%. IV Cannula was introduced and advanced at 15 to 300 to skin until

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the tip of the needle was seen in contact with the anterior wall of 3. Use of Lung and Diaphragmatic Ultrasound in Predicting the artery. The needle was advanced till blood appears as a flash Successful Weaning Outcomes in Critically Ill Mechanically in the hub. Then, the catheter was advanced over the needle. Ventilated Patients. (Conference Abstract ID: 72) For femoral artery cannulations, the artery was identified using Kiran Vadapalli, Prashanth Jedge, Jignesh Shah, Shivakumar USG with a linear transducer in short-axis view, 16 G ARROW REF Iyer, Shambhavi Chauhan, Venkatesh Satri, Nishanth Agarwal CV-50016 cannula was inserted using Seldinger technique (USG Bharati Vidyapeeth Medical College, BVDU, Pune, Maharashtra, machine — Sonosite Micromaxx ultrasound machine, linear probe). India Time calculation: For the traditional blind palpation technique, time DOI: 10.5005/jp-journals-10071-23711.116 taken from palpation of the patient artery to arterial line placement, Introduction: To study the use of lung and diaphragmatic i.e., when the catheter was successfully placed into the vessel was ultrasound in predicting successful weaning outcomes in critically noted. In the ultrasound group, time taken from the USG machine ill mechanically ventilated patients. Materials and methods: This is is turned on and after application of gel on the transducer till the a prospective observational study conducted at the Department of end of arterial line placement into the vessel. The total time taken Critical Care Medicine, Bharati Hospital, Pune. The study period was for an insertion was calculated in seconds. If there was a failure May 2020 to November 2020. Study population: Patients admitted to cannulate on third attempt the clinician was asked to change to the intensive care unit for medical and surgical causes and are the site. Additional data collected included demographic profile, mechanically ventilated for >24 hours. Methods: All the medical and attempts for successful cannulations, any complication (hematoma, surgical patients admitted in the intensive care unit and ventilated thrombosis, infection, and vasospasm), number of the cannula used, for >24 hours and are deemed to be ready to be weaned are enrolled and vitals before and after cannulations and dose of vasopressor. after getting written informed consent from the next-of-kin. The Statistical analysis included chi-square, Mann–Whitney. A p value < decision to wean is clinical and not influenced by the study. After the 0.05 was considered statistically significant. Statistical package for patient is assessed for readiness to wean, the patient undergoes a social science version 23 (SPSS-23 IBM, USA) was used. The sample spontaneous breathing trial for 2 hours with CPAP PSV Mode (PS-8, size was estimated using a software “Power analysis and sample PEEP-5, and FiO -40%). If the patient passes the SBT and is planned size version 8 (PASS-2008)”. Group sample sizes of 94 in group 1 2 for weaning, lung USG and diaphragmatic USG are performed on (USG-guided) and 94 in group 2 (blind arterial cannulations) achieve the above ventilator settings. The weaning trial whether successful 80% power to detect a difference between the group proportions or failed is assessed and patients are grouped as simple weaning of 0.20 (i.e., 20%). Results: 201 patients were enrolled into the study and complicated weaning (difficult/prolonged/failed weaning). with 99 randomized to the Blind group and 102 to the USG group. The lung ultrasound score and diaphragmatic thickness fraction Demographical characteristics ( Age, Sex, Body Mass Index) in both are correlated with weaning outcome. These measurements were groups were comparable (p > 0.05). An arterial line was placed on performed by a single intensivist experienced in performing lung the first attempt in 82(80.4%) in the USG group versus 58(58.6%) and diaphragmatic ultrasound. Lung USG is done with a curvilinear in the Blind group (p = 0.02). Time for cannulation (seconds, Mean probe. Six regions in each hemithorax — anterior, lateral, and ± SD) in USG group was significantly reduced compared to blind posterior (12 in total) are screened and scored as per international group in radial, femoral and dorsalis pedis artery [Radial artery: validated score — the lung ultrasound score — 0 to 36. Score 0 — USG 162 ± 6.0, Blind 190.3 ± 7.5, p < 0.001; Femoral artery: USG 184 Normal aeration, 1 — >2 well-defined B lines, 2 — Coalescing B ± 6.0, Blind 212 ± 3.8, p < 0.001; Dorsalis pedis artery: USG 161.2 lines, 3 — Pulmonary consolidation. The diaphragmatic thickening ± 1.65, Blind 188.4 ± 3.9, p < 0.001] Complication (subcutaneous fraction (%) will be calculated as the difference between inspiratory hematoma) in both groups was comparable [USG 2(1.9%) vs. Blind diaphragmatic thickness (DT i) and expiratory diaphragmatic 1(1.01%), p ≥ 0.05]. Number of cannula used were significantly thickness (DT e) divided by DT e × 100. Results: 30 patients were reduced in USG group (p = 0.019). Arteries (Radial, Dorsalis pedis, enrolled in the study out of which 19 were males and 11 were Femoral) cannulated in both groups were also comparable (p = females. The mean age of the presentation was 48.03 + 13.48 0.193). Number of patients who were on vasopressor support in years. Out of the 30, 12 patients were admitted with medical illness both groups were comparable [USG 69(67.6%) vs. Blind: 61(61.6%), p (40%) and 18 with surgical illness (60%) at presentation. Major > 0.05]. First pass success rate in patients with vasopressor was also diagnosis at presentation were categorised into Sepsis 8 (27%), significantly more in USG group [USG 53(76.8%) vs Blind 36(59.1%), Neurological 13 (43%), Cardiovascular 2(7%), Respiratory 3(10%), p 0.05]. Vitals before cannulation in both groups were comparable Gastrointestinal 2(7%) and Gynaecological 2 (7%). The predominant (p > 0.05) Discussions: Studies for USG-guided arterial cannulations source of sepsis was Respiratory. The predominant indication for are mostly from perioperative and emergency department (ED) mechanical ventilation was respiratory in 11 (37%), CNS in 12 (40%), settings.1,2 USG-guided arterial cannulations have shown a high combination in 4 (13%), and others in 3 (10%). The mean APACHE first-pass success rate similar to our study.3 This technique has also II score at presentation was 11.70 + 5.38 and the mean SOFA score reduced the time to cannulate.2 To the best knowledge of authors, was 2.77 + 1.83. The mean duration of mechanical ventilation is our study in ICU settings is the first of its kind which has compared 6.27 + 5.01 days. Out of 30 patients, final outcome of discharge USG-guided arterial cannulations with a traditional approach at from the hospital was 25 patients (83.33%) and death in 5 patients three different sites in critically ill patients. Conclusion: USG-guided (16.7%). Simple weaning occurred in 23 (77%) of patients whereas 7 arterial cannulation has a higher first-pass success rate in critically ill (23.3%) had complicated weaning. In complicated weaning difficult patients including patients with septic shock with less cannulation weaning occurred in 3, prolonged in 1, and failed weaning in 3 time as compared to the blind palpation method. patients. Lung ultrasound score with a cut-off of 16 and below was

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associated with successful weaning from mechanical ventilation colonization/insignificant-colony-counts) and 30-day mortality with 85% sensitivity and 69 % specificity with an AUC of 0.82 with a were noted. Secondary outcomes noted were the incidence of p-value of 0.0001. Diaphragmatic thickness fraction has not shown nosocomial UTI (bacterial/fungal). Chi-square/Student’s t-test was to be correlating significantly with weaning outcome in this study. used for qualitative/quantitative data with statistical significance at Discussions: Lung ultrasound by its direct visualization of aeration a p value ≤0.05. Results: Demographic parameters were comparable can directly visualize the lung pathology. Hence, its score has been in the 3 cohorts. There were total of 1242 evaluated “BWT values” shown to correlate well will weaning outcome. Limitations of the obtained on 180 enrolled patients, [476 values in CAUTI group, 362 study include a single-centered study, done by a single observer values in significant colony count but without CAUTI (CCS group), and the sample size is small for definitive conclusions. Conclusion: 404 in insignificant colony count (CCI group)]. Mean BWTe in CAUTI Lung ultrasound score before weaning could be used as a marker group was 5.54 mm ± 1.95 mm vs 4.12 ± 1.62mm in colonization to predict successful weaning. group vs 3.42 ± 1.54 mm in CCI group), p = 0.002. BWT>5.54 mm had a good positive correlation with CAUTI with Spearman’s coefficient 4. Serial Bedside Ultrasonography for Estimating Urinary Bladder of +0.834 with better correlation in empty bladder(BWTe) than in Wall Thickness as a Predictor for Catheter-Associated Urinary 250 mL filled bladder (BWTf).Discussions: The reliable cut-off value Tract Infection in Critically Ill Patients: A Reliable “Cut-Off” Finding of BWTe for diagnosing CAUTI was 5.6 mm with highest AUC-ROC Study. (Conference Abstract ID: 70) (mean 0.887, 95% CI 0.863–0.942) with 91.2% sensitivity and 78% Badri Prasad Das, Munesh Gupta, Jayadev Kumar specificity, PPV 88.8% and NPV 85.2%. At the optimum cut-off IMS BHU Varanasi, Uttar Pradesh, India defined at 3.8 mm, NPV was 100%, PPV was also high (95.2%) with AUC-ROC (mean 0.872, 95% CI 0.822–0.980) with 89.4% sensitivity DOI: 10.5005/jp-journals-10071-23711.117 and 76.2% specificity. Incidence of CAUTI was 38%. Conclusion: Introduction: Indwelling catheters are used routinely in ICUs, Bladder wall thickness with serial bedside ultrasonography is not which commonly leads to urinary tract infections (CAUTI). Now, only simple, noninvasive, and reproducible but quite a reliable diagnosing CAUTI in critically ill patients is a challenge, as most objective method to predict CAUTI in critically ill patients, which of them are not able to vocalize (suprapubic tenderness), and the may increase diagnostic accuracy for screening outpatients with diagnostic modalities (C/S) cannot differentiate colonization from CAUTI from colonization, with attributes of performance being best CAUTI. It is needless to point, how time is crucial in diagnosing, in the empty bladder as compared to a full bladder, with cut-off hence, an unmet need of developing a quick/accurate/objective value of 5.6 mm. method of screening/diagnosing CAUTI. Now, we all have a portable USG machine in our ICU, which was never explored for 5. Use of Handheld Ultrasound Device with Artificial Intelligence screening or diagnosing CAUTI in ICU. With this background, we for Evaluation of CardioRespiratory System in COVID-19: A have proceeded with an aim to evaluate bladder wall thickness Prospective Study. (Conference Abstract ID: 65) (BWT) with serial bedside ultrasonography in catheterized critically ill patients as a tool to predict CAUTI. Materials and methods: Shivangi Mishra, Harish Mallapura Maheshwarappa, Muralidhar After ethics committee approval and written informed consent Kanchi from relatives, a single-centric, prospective, observational cohort Mazumdar Shaw Medical Center, Narayana Health City, Karnataka, India study was conducted from March 2019 to February 2020 in ICU, Department of Anesthesia, IMS-BHU, where consecutive adult DOI: 10.5005/jp-journals-10071-23711.118 patients aged 20 to 50 years, admitted with any critical illness, Introduction: COVID-19 causes various cardiopulmonary were enrolled into the study and assessed for eligibility (without manifestations. Bedside point of care ultrasound helps in the rapid prior catheterization/UTI, requiring ICU stay for >5 days, requiring diagnosis of these manifestations. Vscan Extend (GE, Wauwatosa, urinary catheterization within 2 days of admission, for a period of WI, US) is a handheld ultrasound device with a dual probe and an at least 3 days). All eligible patients were evaluated for bladder wall artificial intelligence application to detect ejection fraction. It can thickness (BWT), both in the empty bladder (BWTe) and full bladder help in reducing the time for diagnosis, duration, and number after 250 mL normal saline instillation (BWTf) as per protocol, of HCW exposed to COVID-19. Objectives: This is a prospective with serial bedside ultrasonography (curvilinear probe-3.5 MHz) observational study comparing the cardiorespiratory parameters over a stretch of 21 days or till the patient was in ICU [on day of assessed by Vscan Extend with the conventional ultrasound ICU admission (day 1), then D3, D5, D7, D10, D14, D17, D21, and machine. This evaluates the safety and accuracy of Vscan Extend and whenever there was fever (with fluffy sediments in high colored its utility in reducing the time duration for diagnosis. Materials and urine)]. Also, urine cultures were sent on those from D3 onward as methods: Paired observations were made in 96 COVID-19 patients per protocol or whenever there was fever with suspicion of UTI, the admitted to the intensive care unit by two intensivists. Intensivist A corresponding reports of which were received after 5th to 7th day. used the Vscan Extend device to assess the cardiac function, lung Those “BWT values” were allocated into one of the three cohorts fields, diaphragm, deep veins, and abdomen. Intensivist B used based on urine/culture reports [CAUTI group; significant-colony- routine investigation tools like clinical examination, X-ray chest, count (>105) but without CAUTI (CCS group); insignificant-colony- ECG, and conventional echocardiogram. The agreement between count (CCI group)]. Demographics, SOFA/APACHE, ventilator-days, the findings and the time duration required in both the methods ICU-LOS, survival rates were noted. Primary outcomes noted were was compared. Results: The median duration of examination the performance of BWT to predict (screen/diagnose) CAUTI using handheld ultrasound was 9 (8.0–11.0) minutes, compared to using receiver operating characteristics curve (AUC-ROC) and to 20(17–22) minutes with the conventional method (P < 0.001). The find out reliable “cut-off” with highest sensitivity/specificity. Also, Cohen Kappa Coefficient was 1.0 for LV systolic function, most of the correlation of BWT measurements with urine culture reports (CAUTI/ lung fields and diaphragmatic movement. Discussions: The use of

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handheld ultrasound has significantly decreased the time required as CT imaging could not be done for all patients, as our hospital is for bedside examination of patients than the conventional method. a large teaching hospital with just one CT machine available and The agreement was perfect between both the methods for systolic hence becomes difficult to carry out the same on a routine basis. function, lung fields, and diaphragmatic movement.Conclusion: Objectives: To determine the validity of a CXR scoring system Vscan Extend handheld device helps in the rapid identification and in measuring the outcome for patients infected with COVID-19. diagnosis of cardiopulmonary manifestations in COVID-19 patients. Materials and methods: This is a retrospective study carried out The agreement between the handheld device and the conventional over a period of 4 months from April 1, 2020, to July 31, 2020, at method proves its efficacy and safety. a tertiary care hospital, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, India. Inclusion criteria: All consecutive COVID 6. Experimental Chest X-ray Scoring System for Determining positive patients admitted to the intensive care unit and requiring Patient Outcomes in COVID-19 Patients. (Conference Abstract oxygen in the form of HFNC, non-rebreathing mask with 15 L of O2/ ID: 21) minute, NIV or invasive ventilation, were selected and their baseline X-ray taken on admission was scored. Nishant Agrawal, Prashant Jedge, Shivakumar Iyer, Jignesh Shah, Exclusion criteria: John Dsouza, Samruddhi Chougale • Patients with chronic organic failure (chronic liver disease, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune, chronic kidney failure, chronic respiratory failure, and cardiac Maharashtra, India arrest). DOI: 10.5005/jp-journals-10071-23711.119 • Patients with chronic neurological illness. Introduction: Coronavirus disease 2019 (COVID-19), caused by a Methods: On admission, the patient’s detailed history was noted novel virus — the severe acute respiratory syndrome coronavirus and they were examined in the intensive care unit. Their baseline 2 (SARS-CoV-2), is a worldwide pandemic now. This new virus is a X-rays were scored by a radiologist who was blinded to the patient’s beta coronavirus that belongs to the Orthocoronavirinae subfamily details as well as to the final outcomes and the validity of the scoring 1,2 of the Coronaviridae family. SARS-CoV-2 was discovered to be the done was evaluated against the two outcomes of the patient pathogen responsible for a cluster of pneumonia associated with — discharge or death. The gender of the patient was correlated severe respiratory disease.3 Currently, >200 countries, territories, with his/her outcome. The CXR scoring system used for COVID-19 or areas are affected by this novel infectious disease (World Health pneumonia included two steps of imaging analysis.9 The first step Organization, 2020) after it first began in Wuhan, China in December was to divide the lungs into six zones on frontal chest projection 2019. On October 23, 2020, the overall number of confirmed COVID- (anteroposterior projection according to the patient position): 19 cases was 41,570,883 worldwide, with a confirmed number of • Upper zones (A and D): above the inferior wall of the aortic arch. 4 1,134,940 deaths (World Health Organization, 2020). Given the • Middle zones (B and E): below the inferior wall of the aortic arch 5 recent estimates of mortality rate for COVID-19, clinicians should and above the inferior wall of the right inferior pulmonary vein be aware of all the risk factors leading to a fatal outcome. The (i.e., the hilar structures). literature reports that older age and presence of comorbidities • Lower zones (C and F): below the inferior wall of the right inferior (such as hypertension, diabetes, and cardiovascular disease), certain pulmonary vein (i.e., the lung bases). laboratory parameters, and severity of lung abnormalities are • For technical reasons, for bedside CXR in some critically ill associated with an increased risk of mortality in patients with SARS- patients, it was difficult to identify some anatomical landmarks, 6 CoV-2 infection. At present, chest computed tomography imaging and hence in these cases, each lung was divided into three is considered the most effective method for the detection of lung equal zones. abnormalities in early-stage disease and for quantitative assessment The next step was to assign a score (from 0 to 3) to each zone based of severity and progression of COVID-19 infection.3,7 Although chest on the lung abnormalities detected on frontal chest projection as X-ray (CXR) is not considered sensitive enough for the detection of follows: pulmonary involvement in the early stage of the disease,3,8 Bhorgesi • Score 0: no lung abnormalities. et al.9 believe that, in the current emergency setting, CXR can be a • Score 1: interstitial infiltrates. useful diagnostic tool for monitoring the rapid progression of lung • Score 2: interstitial and alveolar infiltrates (interstitial abnormalities in infected patients, particularly in intensive care units predominance). though the most effective method of detecting lung abnormalities • Score 3: interstitial and alveolar infiltrates (alveolar is computed tomography (CT) imaging especially in the early stage predominance). of the disease. Although chest radiography has low sensitivity The scores of the six lung zones were then added to obtain an (about 69%) for the diagnosis of COVID-19, the utility of initial CXR overall “CXR SCORE” ranging from 0 to 18. on predicting clinical outcomes is an unmet need.10 To improve the Statistical analysis: All statistical analyzes were done by using risk stratification for infected patients, a chest X-ray (CXR) scoring SPSS software version 25.0. Results of the continuous variables system has been developed for quantifying and monitoring the are shown by descriptive statistics and categorical variables are severity of lung abnormalities in patients with COVID-19. This CXR shown by frequency and percentages. Group comparison was done scoring system (named the Brixia score) grades lung abnormalities using the chi-square test for categorical variables. An independent due to COVID-19 on an 18-point severity scale.9 To the best of our t-test was used for continuous variables with a normal distribution. knowledge, there are very few studies evaluating the predictive Throughout the results, 5% level of significance was used. All results value of a CXR scoring system in patients with COVID-19. Therefore, are shown with 95% of confidence. p value <0.05 was considered this study aimed at comparing the novel CXR severity score, scored as significant. Results: In our study, out of 143 patients who were by an experienced radiologist with mortality, in ICU patients with assessed for eligibility,13 were excluded making our final sample moderate-severe COVID-19 pneumonia (patients with SpO2 <94%), size 130. Out of 130 patients, 79 patients died whereas 51 patients

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were discharged. Amongst the patients who had died, the mean rapidity of this test to assess left ventricular ejection fraction guide age was 57.09 years with a SD of 13.73 and the mean CXR score early diagnosis, clinical management, and evaluation of the critically was calculated to be 12.13 with a SD of 2.50. Amongst the patients ill patient. Materials and methods: In our study, a total of 100 who were discharged, the mean age was 53.94 years with a SD of patients will be enrolled as per inclusion and exclusion criteria from 13.46 and the mean CXR score was calculated to be 11.18 with a SD February 2020 to July 2020 from the Emergency Department, Civil of 2.30. When the CXR scores were compared with the outcomes, Hospital. A detailed history of the patient will be obtained and vitals the t value was found to be 2.20 and the p value was calculated will be recorded. The subject will be placed in the supine position. as 0.03 which was statistically significant. In our study, 70.8% A phased array probe (2.5–5 MHz) will be used. EPSS is measured patients included were males and the rest 29.2% were females. by direct ultrasound visualization of the heart in parasternal long- On comparing the gender of the patients with their outcomes axis view. Using M-mode, the marker is placed over the most distal using the chi square test, the p value was calculated to be 0.222 tip of the anterior mitral leaflet during early diastole. The E-point which was non- significant. Discussions: The CXR scoring system as mentioned represents the point at which mitral valve leaflets has been designed exclusively for semi-quantitative assessment of travel closest toward the ventricular septum. EPSS is the distance the severity of pulmonary involvement in patients admitted with between E point and interventricular septum. EPSS measurement COVID-19 pneumonia. It is quite a simple method and can be easily <7 mm indicated as normal LVEF and >7 mm indicated as reduced duplicated in other clinical scenarios. The mean age in our study LVEF. Results: A total of 100 patients participated in this study was higher in the death outcome group which is in accordance from February 2020 to July 2020. In 100 patients, 70 patients with various studies like Ruan et al.,11 Wang et al.,12 Yuan et al.,13 were diagnosed as normal LVEF by cardiologist with quantitative and Zhou et al.14 which have shown an association between older measurement. Remaining 30 patients were diagnosed with reduced age and poor prognosis in patients with COVID-19. The p value LVEF. In our study LVEF assessed by using EPSS in emergency for CXR scoring on correlating it with the outcome was found to department 24 patients were diagnosed with reduced LVEF (EPSS be significant which implies that this scoring system can be used more than 7mm) and 76 patients diagnosed normal LVEF (EPSS less for the accurate prediction of the outcome for a COVID positive than 7 mm). The sensitivity and specificity of an EPSS measurement patient. This is in accordance with various studies like Bhorgesi and of greater than 7 mm for systolic dysfunction were 100% and Malrodi9, Tossie et al.,15 Garg et al.,16 and Lighter et al.17 In our study, 80% respectively. PPV-92.1%, NPV-100%. Discussions: This study the p value for gender correlation with outcomes was found to be demonstrates that EPSS measurements performed by ED physicians non-significant implying that mortality rates were the same in both are strongly correlated with calculated LVEF assessments obtained sexes. This is in contrast with a study done by Bhorgesi et al.,6 which by quantitative Simpson’s method. Our study agrees with those showed mortality to be higher in males compared to females. The from McKaigney et al., which similarly showed a strong correlation major strength of our study is a large sample size. Our study is one of between EPSS and LVEF performed on a subset of patients with such studies that have assessed the effectiveness of the CXR scoring breathlessness. Comparing the EPSS with the quantitative method system for forecasting the final outcome in terms of discharges and better characterizes the relationship between the clinical standard deaths in COVID-infected patients, although several studies like for determining LVEF and those obtained at the point of service Bernheim et al.18 and Pan et al.19 have investigated the role of CT. among ED patients. Conclusion: Measurements of EPSS by ED The observer who was a radiologist in our study was blinded, in turn, physicians were significantly associated with the quantitative decreasing the observer bias. The primary limitation is that only the measurements of LVEF by Simpson’s method. An EPSS measurement initial chest radiograph severity score was used as an independent >7 mm was uniformly sensitive at identifying patients with severely prognostic indicator of the final outcome. The second limitation reduced LVEF. in our study was the lack of long-term follow-up of the patients who got discharged. Hence, further studies are required to analyze 8. Infections and Prevention—Infection Control the worsening opacities on the follow-up chest radiographs in relation to the final outcome of the patients. Conclusion: Our study 1. Respiratory Diseases in Adolescent Patients with Diabetes conferred that a high Brixia score was associated with a high risk of Mellitus. (Conference Abstract ID: 193) death due to COVID-19 and we contemplate this scoring system to be very apt as it provides very clear and to the point information for Pradeep Singh Rajoriya, Ravi A Dosi clinicians in this prolonged battle against COVID-19. Sri Aurobindo Medical College and PGI Indore, Madhya Pradesh, India 7. A Prospective Observational Study on E-Point Septal DOI: 10.5005/jp-journals-10071-23711.121 Separation for Assessment of Left Ventricular Ejection Fraction Introduction: Diabetes mellitus is a chronic, progressive, and by Emergency Physician. (Conference Abstract ID: 19) incompletely implicit metabolic disease. Its associated micro- Boopathi M, Chirag J Patel and macrovascular complications show the result in mortality B.J. Medical College, Civil Hospital, Ahmedabad, Gujarat, India and morbidity. The microvascular complications are manifested DOI: 10.5005/jp-journals-10071-23711.120 as neuropathy, retinopathy, nephropathy, and macrovascular Introduction: Assessment of LV function by point of care complications affect the cardiovascular system. It also affects the echocardiography is of particular importance in differentiating lungs because of its rich vascularity and plethora in connective the causes of dyspnea, hypotension, and chest pain in patients tissue (collagen and elastin), in a diabetic patient proliferation of coming to the emergency department. Mitral valve E-point extracellular connective tissue in the lungs, leading to a decline in septal separation (EPSS) is one of the methods for estimating left lung function in a restrictive pattern. WHO has reported that the ventricular ejection fraction (LVEF) in the emergency setting. The number of people with DM has risen from 108 million in 1980 to 422

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million and 8.5% of the world adult population had DM in 2014. The 3. The Efficacy and Safety of Hydroxychloroquine in Treatment of number of diabetic patients worldwide has been expected to rise to COVID-19—A Systemic Review and Meta-Analysis. (Conference 592 million in 2035 by the International Diabetes Federation. In this Abstract ID: 149) manner, I have been summarized and discussed the role of diabetes Sakshi Duggal, Anirban Hom Choudhuri, Bhuvna Ahuja, Partha mellitus involved in the progression of common respiratory diseases S Biswas in adolescent patients. Keywords: Diabetes mellitus, Respiratory GB Pant Institute of Postgraduate Medical Education and Research, disease. Objectives: To study respiratory diseases in adolescent Delhi, India patients with diabetes mellitus. Materials and methods: The present DOI: 10.5005/jp-journals-10071-23711.123 study is a survey study that was conducted in the department of Introduction: The treatment of SARS-CoV-2 (Severe Acute pulmonary medicine of Sri Aurobindo medical college and hospital, Respiratory Syndrome coronavirus 2) also known as COVID-19 Indore. Data will be collected from the attending the OPD and IPD (coronavirus disease 2019) continues to remain an enigma even in the department of pulmonary medicine. All the participants after six months of the pandemic. Hydroxychloroquine (HCQ) were in the age group of 25 to 40 years. Duration of the study — has been one of the most widely tested drugs for SARS-CoV-2 from 3 November 2019 to 19 March 2020. Results: We investigate on account of its antiviral properties. However, the results so far 56 patients in the age group between 25 and 40 years. This study have been far from categorical. The meta-analyzes conducted shows 31 (55.35%) male and 25 (44.61%) females. Discussions: to date are also lacking in precision and appropriateness. This Diabetes is identified as an independent risk factor for developing systematic review and meta-analysis addresses the efficacy and lower respiratory tract infection there appear to be a certain type safety of HCQ in SARS-CoV-2 by overcoming the limitations of of respiratory infections that may be more common in diabetic earlier meta-analysis. Materials and methods: A total of five patients. Diabetic patients also appear to be at an increased risk of prominent medical databases were searched and fourteen studies complications like pneumonia, asthma, etc. Conclusion: The study (n = 12,455) were included in the systematic review and meta- shows a high prevalence of infectious diseases such as pulmonary analyzes. The data on survival, alleviation of symptoms, conversion tuberculosis, asthma, and COPD in adolescent patients with DM. of RT-PCR positivity to negativity, use and efficacy in presence of comorbidities (hypertension, diabetes, and heart disease), and cardiac and gastrointestinal side effects were extracted. Meta- 2. VACO Index to Risk Stratify the Geriatric Population with analysis was applied to calculate the pooled estimates. Fixed-effects Suspected COVID-19 Infection. (Conference Abstract ID: 164) model results were chosen since I2 was <25%. Meta-analysis was Aravind Ranjan, Ashima Sharma conducted using STATA version 13 (StataCorp LP, College Station, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India TX, USA). Results: The pooled estimates showed that HCQ treatment DOI: 10.5005/jp-journals-10071-23711.122 did not significantly affect survival at 14 and 28 days in COVID-19 Introduction: We have witnessed an unprecedented panic among patients with respect to the control population (RR: 1.003, 95% the public on the non-availability of hospital beds during the CI: 0.98–1.02), alleviation of symptoms at day 10 (RR: 1.04, 95% CI: first wave of the COVID pandemic. The geriatric population was 0.91–1.19), success in presence of co-morbidities (RR: 1.06, 95% CI: the major sufferers, as resources were diverted to the younger 1.04-1.08) and conversion from RT PCR positive to RT PCR negative or working generation. As emergency providers, we faced the on day 6 (RR:1.12, 95% CI: 1.04–1.21). There was higher risk for challenge of using a screening tool to suspect the severity of cardiac side effects (RR: 2.01, 95% CI: 1.43–2.83) and gastrointestinal disease progression for triaging patients to the correct level of the side effects (RR: 1.32, 95% CI: 0.73–2.38) in HCQ recipients. COVID facility. Objectives: Risk Stratify Geriatric Population with Discussions: Our study is the most recent update on the safety Suspected COVID-19 Infection based on VACO INDEX. Materials and efficacy of HCQ in SARS-CoV-2 infection and an in-depth and methods: Two hundred and two consecutive patients above analysis of its survival benefits and alleviation of symptoms. This the age of 65 years were subjected to the calculation of the score large systematic review and meta-analysis of 12,455 patients using simple parameters like age, sex, history of DM, chronic encompassing 14 studies has clearly demonstrated the lack pulmonary disease, renal disease, peripheral vascular disease, CHF, of benefit of HCQ treatment for SARS-CoV-2 infection. It has dementia, cancer, stroke, liver disease, MI, peptic ulcer disease, additionally found higher cardiovascular side effects in the AIDS, and rheumatological disorder. The results of our study in recipients of HCQ. It has assessed the benefits of using HCQ in detail will be discussed at the conference. Results: We utilized the presence of heart disease, hypertension, and diabetes which the VACO index to calculate a score and keep the patients well no other meta-analysis has investigated so far. It has found that informed. The information helped us to ration beds to them in use of this drug is used more commonly in patients with these critical care areas, especially during the times while rationing was diseases but did not improve the outcome as compared to control. limited. Discussions: A 10% decrease in organ function is known Conclusion: There is no evidence on the safety and efficacy of to occur every decade after the age of 65. This means that it is HCQ either alone or in combination with other drug treatments in unphysiological to apply the same parameters of qCSI across the SARS-CoV-2 infection. whole population. We recommend the VACO index, which uses 4. Analysis of Mortality in COVID-19 Patients Admitted to An demographic and preexisting condition data and does not require Intensive Care Unit. (Conference Abstract ID: 148) immediate laboratory investigations. Conclusion: We recommend the VACO index, which uses demographic and preexisting condition Kayanoosh Kadapatti, Jyoti Shendge, Aparna Kulkarni, Jayant data and does not require immediate laboratory investigations. Mane, Ranjeet Patil, Sushil Gandhi, Akshay Sonone, Ujjwal With constrained resources, a score to identify 30-day mortality Deshmukh, Priyesh Rahulgade with COVID infection at the time of the first contact with a patient Jehangir Hospital, Pune, Maharashtra, India helped us immensely to risk stratify our patients. DOI: 10.5005/jp-journals-10071-23711.124

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Introduction: The COVID-19 pandemic has affected health care of patients staying for 10 to 14 days, increased doctor, nurse to infrastructure worldwide. In the city of Pune, we had multiple patient ratios due to caregiver burnout and illness may have also general and private hospitals admitting COVID positive patients. contributed to untoward outcomes. Males were affected greater Protocols and processes were set up as per the ICMR and local than females and mortality was highest in patients aged between corporation guidelines. There were many challenges to manage 60 and 70 years (31%). Fifty percent of patients died between these patients especially with the newness of the disease, rapidity 60 and 80 years of age which is comparable to western data. of spread, the uncertainty of progress of patients with respiratory Uncontrolled diabetes, hypertension, ischemic heart disease, and failure, and lack of physical communication with relatives. chronic kidney disease all of which cause endothelial dysfunction Challenges faced by the caregivers were manpower ratios possibly were the predominant risk factors predisposing to death in these due to attrition and illness. Here, we analyze the mortality of patients. End of life care consent was taken in 9 out of 164 patients patients with COVID-19 infection admitted to a tertiary care center. who died (5.5%). Restriction of visitation and sudden onset of severe Objectives: Death audit of COVID positive patients who expired in illness made it difficult for relatives to consent for end of life care. the ICU from April to December 2020 — a 9-month retrospective High D-dimers and persistent low lymphocyte count at the time of data analysis. Materials and methods: A retrospective observational death suggest these tests as predictors of mortality possibly due analysis of deaths due to COVID-19 infection from March to to persistent inflammation and microthrombosis and an inability December 2020. Results: to clear the virus or due to secondary sepsis as compared to CRP, 2012 COVID positive patients were admitted to a tertiary care for troponin, LDH, creatinine, and albumin. Conclusion: The COVID- treatment of which 363 were either directly admitted or transferred 19 pandemic has tested the health infrastructure in all nations into the ICU for moderate to severe/critical disease requiring NIRAD, worldwide. In the city of Pune, we had multiple general and private IPPV or Organ support. 164 patients expired of which 25 died within hospitals admitting COVID positive patients. The net mortality rate 24-48hours. The gross hospital mortality from COVID19 disease in our hospital was 6.9% with more males perishing than females. was 8.17% while net mortality was 6.9%. 107 (65.2%) patients died Infection in the elderly and uncontrolled diabetes were important of severe COVID and 57 (34.75%) perished due to critical disease. risk factors for mortality as was hypertension. High D-dimers and More males(76%) expired than females (24%) (n = 125 vs 39 ). Death persistent low lymphocyte count at the time of death suggest these was highest in age group >60 years with 31% (51) patients aged tests as predictors of mortality in our study. 61-70 years, 23% (38) patients aged 71-80 years. 21% (35)expired between the age of 51- 60 years. There was a child age 8years died 5. Incidence, Molecular Characterization, and Response to of COVID 19 pneumonia with multisystem inflammatory syndrome Treatment of Multidrug-Resistant and Extended Drug-Resistant of childhood.3 patients died age >90 years and 2 youngsters with Gram Negative Organisms Causing Nosocomial Pneumonia IDDM ages 21 and 23 years died <48 hours of being admitted to the in Intubated COVID-19 Patients in a Tertiary Care Hospital. ICU. Of the younger patients that perished 7 were between 31-40 (Conference Abstract ID: 142) years old and 16 (9.75%) aged 41-50 years. Comorbidites that were T Anudeep Kumar, N Pavan Kumar Reddy, Jhansi Vani present in patients who expired were uncontrolled diabetes (HbAIc Care Hospital, Banjara Hills, Hyderabad, Telangana, India of >8 ) in 34% of patients (56), hypertension in 39% (64), Ischaemic DOI: 10.5005/jp-journals-10071-23711.125 Heart disease in 19.5% (32), CKD IN 9.7% (16), Stroke old/recent in 6.7% (11). 3 patients had Chronic Liver diease and Parkinsons each, 2 Introduction: Presently, antimicrobial resistance (AMR) poses a had Alzheimers disease and I each suffered from multiple nyeloma, major threat to patient’s treatment as it leads to increased morbidity Carcinoma colon, cervical spine trauma, GBS, Ulcerative colitis. 52 and mortality, increased hospital stay, and severe economic loss patients (31.7%) expired <5 days, 48 (29.3%) had a stay between to the patient and nation. The present study was conducted to 5-10 days in the ICU before they died, 41 (25%) between 10–14 days, know the incidence and molecular characteristics of MDR and XDR 23 (14%) between 14–20 days and 5 (3%) patients died after being organisms in intubated COVID-19 patients who are on mechanical in the ICU for >20 days. End of Life care consent was taken in 9 out ventilation and to find out the most common bacterial strain of 164 patients who died (5.5%). High D dimers values >8 ng/dL at and resistance pattern observed during the study period and the time of death were seen in 39% (64) patients and a persistent the response to treatment of prescribed antibiotic according to low lymphocyte count <5% was seen in 93.3% of patients who culture sensitivity. Objectives: Observational study was conducted expired. Discussions: The COVID-19 pandemic has taken its toll on to detect the incidence and molecular characterization of the health of the population, healthcare systems, and economic multidrug-resistant and extended drug-resistant Gram-negative status of countries worldwide. Due to variations in healthcare organisms causing nosocomial pneumonia in intubated COVID- systems, demographics of the population and racial considerations 19 patients and response to treatment like survival at discharge different regions need to generate endogenous data. It has been at tertiary care hospital. Materials and methods: The respiratory difficult to capture data due to high workloads. Analyzing mortality samples like tracheal secretions or BAL specimens were collected would help us understand the robustness of the healthcare delivery where the respiratory infection is suspected. In the department system, demographic and racial variations, and predisposing risk of microbiology, samples were processed and identification of factors to severe infection leading to death. Ours is a 300-bedded bacteria was done by VITEK (1) machine and its drug resistance tertiary care center in a smart city of India. We treated 2012 patients was done by BIOFIRE (PCR) (2). The total drug sensitivity was infected with the SARS-CoV-2 virus. Three hundred and sixty-three done by VITEK AST. Results: In a total of 76 culture positive needed intensive care of which 164 expired. The burden on the respiratory samples,126 Gram‐negative bacteria were identified system increased through the months of July, August, September, as most samples grew multiple organisms, comprising klebsiella and October when the peak of the pandemic was seen. Seventy-five pneumoniae [47] and acinetobacter baumannii [29],enterobacter percent of the deaths occurred in these 4 months. Large numbers cloacae [16], escherechia coli [15, pseudomonas aeruginosa[16],

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Serratia marcescens [2], Achromobacter xylosoxidans [1] isolates died. Of the mechanically ventilated patients 44 had abnormal BMI. were detected. Most common resistance pattern observed was Overall mortality was 27% (37patients). Discussions: There was CTX-M(96%) followed by NDM(70%),OXA-48(53%),VIM(31%) KPC a male sex predominance with diabetes. Obesity, smoking, and and AMPC not detected.61 patients recovered were discharged,1 hyperlipidemia were the major risk factors. The major presenting patient went on LAMA,14 patients died Discussions: COVID-19 symptoms in these patients were shortness of breath, cough, and pandemic has reinforced the need and importance of good fever. Only a quarter of patients required mechanical ventilation, hospital infection control practices, antibiotic stewardship owing and in those obesity was found to be a major risk factor. Conclusion: to the prolonged ICU stay, increased ventilator days and invasive Our study provides insight into presenting characteristics, lines, and use of steroids and other immunomodulators. This demographics, and overall outcomes of severe COVID-19 infection study determines the most common Gram-negative isolates in in young adults. The preconceived notion of COVID-19 being a respiratory samples, their resistive patterns, and effectiveness of disease of the elderly should be changed. In medical emergencies therapies instituted based on sensitivity testing to better guide like the COVID pandemic, it is very important to analyze patient initial empirical antibiotics, judicious use of antimicrobials at hand demographics to identify the population at risk. Such knowledge available to intensivists. This study conducted in our Institute not only allows us to produce strategies to help control the spread showed Klebsiella pneumoniae as the most common organism in of disease but also helps us to risk stratify to prevent mortality. It respiratory samples and the most common resistance pattern was is crucial to learn from an epidemic like this so we can be better CTX-M followed by NDM, OXA-48, and VIM (3). The response to prepared for the future. treatment was determined by the primary endpoint of discharge out of ICU or death with secondary endpoints like several ventilator 7. Comparison between Markers of Coagulation Dysfunction days, length of ICU stay, etc. In our study, the primary endpoint of and Inflammation in Diabetic and Non-Diabetic COVID-19. the mortality rate was 20% with the antimicrobial regime based (Conference Abstract ID: 106) on culture sensitivity. The limitations of the study are single-center Pushpendra S Sengar, RK Jha, Sonam Verma observational study. Conclusion: The study highlights the increased Sri Aurobindo Medical College and Postgraduate Institute-Indore, prevalence of multidrug-resistant and extensively drug-resistant Madhya Pradesh, India strains. Stringent surveillance, proper implementation of hospital DOI: 10.5005/jp-journals-10071-23711.127 infection control practices, and antimicrobial stewardship will help Introduction: COVID-19, the ongoing pandemic has caused in limiting the emergence and spread of drug-resistant strains. thousands of deaths. Diabetes mellitus is frequent comorbidity associated with severe COVID-19 infection and had a worse 6. ClinicoDemographic Profile and Outcomes of Severe COVID-19 prognosis. Hypercoagulability and hyperinflammation had been a Infection in Young Adults. (Conference Abstract ID: 119) commonly demonstrated feature among the patients with COVID- Aparna Suresh, GN Srivastava 19. Materials and methods: This retrospective cross-sectional study Institute of Medical Sciences, Banaras Hindu University, Varanasi, was conducted at SAIMS HOSPITAL, INDORE (M.P.) from July 2020 Uttar Pradesh, India to September 2020. Patients were categorized into diabetics and DOI: 10.5005/jp-journals-10071-23711.126 non-diabetics based on ADA guidelines and clinical history. Results: The baseline characteristics of the two groups are comparable as Introduction: COVID-19 is a respiratory and systemic disorder shown in table. The box-plots of peak D-dimer levels in people caused by the SARS-CoV-2 virus with a range of severity from mild with diabetes and people without diabetes are shown in figure. respiratory symptoms to severe lung injury, multiorgan failure, The relation between D-dimer levels in COVID-19 in people with and death. The main risk factors of the disease are increased age diabetes and those without diabetes shows a significant difference and underlying comorbidity. Newer reports show that younger t = 1.9715 (p value = 0.02). There is no significant elevation of patients can also suffer from severe COVID pneumonia of which inflammatory markers (CRP, IL- 6,S.Ferritin) in diabetic COVID-19 the data are limited. This study intends to uncover the factors that when compared to non-diabetics. Discussions: These results show resulted in severe COVID-19 infection in young adults. Objectives: that the inflammatory and hypercoagulability markers significantly To study the clinicodemographic profile and outcomes of severe increase in a diabetic group of COVID-19 patients when compared COVID-19 infection in young adults. Materials and methods: This to their non-diabetic counterparts. Various reports suggest that single-center retrospective study included 163 hospitalized patients diabetes activate several pathways leading to T-cell differentiation, in the age group 18 to 35 years diagnosed with severe COVID-19 immune system imbalance, pro- and anti-inflammation imbalance infection at a tertiary care hospital in Uttar Pradesh from July 2020 Conclusion: Diabetes mellitus has been one of the most consistent to November 2020. Details about patient’s demographics, clinical risk factors for severe disease in patients with COVID-19 and features, previous comorbidities, laboratory and radiological uncontrolled hyperglycemia has been associated with poor investigations, and hospital outcomes were obtained from patient outcomes and mortality. records and analyzed. Results: Out of 163 patients, 60.1% (98) were males and 39.8% (65) were females. The most common comorbidity was diabetes 68.7%, hyperlipidemia 33.1% and obesity 32%. 30.6.% 8. Right Atrial Thrombus in a Case of Immunocompromised State (51) of patients were smokers. Patients presented with shortness with COVID-19. (Conference Abstract ID: 85) of breath (66.9%), cough (65.6%) and fever (60.7%) respectively. Rajesh Mahadeo Sontakke, Sangeeta Pednekar, Charulata Multilobe infiltrates were found in chest xray of (75.4%) patients,. Londhe, Dharmendra Pandey, Niteen Karnik Mean length for ICU stay was 15.5 days (range 3–46). Mechanical Lokmanya Tilak Municipal Medical College and Sion Hospital, ventilation was required in 26.9% of patients .In patients requiring Mumbai, Madhya Pradesh, India mechanical ventilation, 17 (38%) were discharged and 27(62.8%) DOI: 10.5005/jp-journals-10071-23711.128

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Introduction: COVID-19 is a worldwide pandemic. Pieces of hypercoagulation state in critically ill COVID-2019 pneumopnia evidence are suggesting a strong association between COVID-19 patients should be monitored closely, and anticoagulation therapy and prothrombotic states. We are reporting a case of critical COVID- should be considered in treatment early in the course of disease 19 complicated by a right atrial thrombus. We describe a patient Early investigations and treatment with anticoagulants remains the with COVID-19 pneumonia and a clinical hyperinflammatory state. cornerstone of treatment of covid 19 to avoid further complications. She developed hypoxia and required O2 support. Echocardiography Discussions: Severe COVID-19 infection is associated with suggestive of right atrial thrombus. She was managed with oxygen hypercoagulable states. It is associated with a high risk for arterial therapy and thrombolysis. Case presentation: A 55-year-old as well as venous thrombosis and pulmonary thromboembolism. woman came with chief complaints of fever, dyspnea, bilateral Prophylactic anticoagulants are recommended in all patients with pedal edema, and oliguria for 4 days. she was in a known c/o severe COVID-19 infection. Full therapeutic dose of anticoagulants immunocompromised state for 2 years on tenofovir, lamivudine, is required in patients with proven venous thromboembolism. The and efavirenz regimen. She was diagnosed with COVID-19 based dysfunction of endothelial cells induced by infection and hypoxia on RT-PCR testing which detected SARS-CoV-2. There is no history found in severe COVID-19 can stimulate thrombosis not only by of i.v. drug abuse. General examination: Febrile+, pulse = 100/ increasing blood viscosity but also through a hypoxia-inducible minute, blood pressure-130/90 mm Hg, bilateral pedal edema+, transcription factor-dependent signaling pathway. A case series no pallor/icterus/cyanosis/clubbing/lymphadenopathy, jugular of COVID-19 patients with clinically significant coagulopathy, venous pressure — raised, tachypneic + SpO2 78% on room air. antiphospholipid antibodies, and multiple infarcts in the brain, Systemic Examination: Respiratory system — bilateral basal crepts. both digital and pulmonary, has been described. However, these Cardiovascular System — holosystolic murmur of tricuspid antibodies can also arise transiently in patients with critical illness regurgitation+. and various infections. The presence of these antibodies may in rare Nervous system—normal. cases lead to thrombotic events that are difficult to differentiate Per abdomen—soft, nontender. from other causes of multifocal thrombosis in critically ill patients, Investigations: HB-13 g% WBC-3,900, platelets 187,000. such as DIC, heparin-induced thrombocytopenia, and thrombotic BUN/creatinine—22/1.3. microangiopathy. All reported patients had severe hypoxemia SGOT/SGPT—149/89. and markedly elevated D-dimer levels. Our patient has developed HIV1—Reactive. a right atrial thrombus and was having elevated D-dimer level. CD4—259. She was treated with anticoagulation therapy. The international HbsAg and HCV—Non-reactive.ESR—33. society of thrombosis and hemostasis recommends that all the C-reactive protein—9. hospitalized COVID-19 patients should receive a prophylactic D-dimer—2,054.63 ng/mL [normal—500 (cut-off)]. dose of LMWH unless they have contraindications (active bleeding ECG s/o P—Pulmonale. and low platelet count). There is a rare occurrence of COVID-19 Chest X-ray (CXR)—s/o cardiomegaly and bilateral peripheral pneumonia complicated by right atrial thrombus. Conclusion: pulmonary infiltrates. The hypercoagulation state in critically ill COVID-19 pneumonia SARS-CoV-2 RT-PCR—positive patients should be monitored closely, and anticoagulation therapy 2D ECHO—right ventricle volume overload pattern, dilated right should be considered in treatment early in the course of the atrium and right ventricle, mild mitral regurgitation, severe tricuspid disease. Early investigations and treatment with anticoagulants regurgitation, mild pulmonary regurgitation, mild pulmonary remain the cornerstone of treatment of COVID-19 to avoid further arterial hypertension, aortic valve pressure gradient (AVPG)-7, complications. We are reporting this case for its rare occurrence. pulmonary arterial pressure gradient (PASP)-31. Bilateral lower limb Doppler—s/o mild atherosclerotic changes along with bilateral 9. Community and Hospital-Acquired Blood Stream Infections lower limb arterial system biphasic waveform in bilateral anterior in a Tertiary PICU: A 5-Year Retrospective Study. (Conference tibial artery (ATA), posterior tibial artery (PTA), and dorsalis pedis Abstract ID: 83) artery (DPA). CT pulmonary angiography—Moderate cardiomegaly Mounika V Reddy, AV Lalitha with dilated right atrial, right ventricle, and prominent pulmonary St. Johns Medical College Hospital, Bengaluru, Karnataka, India arteries, mild pericardial effusion s/o pulmonary hypertension. DOI: 10.5005/jp-journals-10071-23711.129 Few non-enhancing filling defects in right atrium just distal to opening of superior vena cava anteriorly and along the anterior Introduction: Severe, invasive infections, both community and wall of right Atrium with largest measuring 1.3 × 1 cm distal to hospital-acquired are common, often life-threatening, but differ opening of superior vena cava s/o thrombosis. Early opacification of in their epidemiology, severity spectrum, host factors, pathogen inferior vena cava and hepatic veins on arterial phase s/o tricuspid profile, and outcomes. Objectives: To study and compare the clinical regurgitation. Course in the ward: Patient was tachypneic on and microbiological profile of the community and hospital-acquired bacterial and fungal infections and their outcomes in a tertiary admission with SpO2 of 78% on room air, she was treated with oxygen, antibiotics, inj. Lasix, and inj. heparin. The patient had a multidisciplinary PICU. Materials and methods: Retrospective long stay of 1 month in the ward, initially, the oxygen requirement analysis of all positive blood cultures from a tertiary 12-bedded PICU was quite high about 15 L/minute by a non-rebreather mask. over 5 years (January 2014 to December 2018). Duplicate cultures Oxygen tapered off gradually and shifted to O by nasal prongs and contaminants were eliminated from the analysis. Organisms 2 isolated from the blood within 48 hours of hospital admission were thereafter weaned off from 2O , urine output improved and the patient discharged on oral anticoagulation therapy after patient considered as community-acquired infection (CAI) while those being asymptomatic and negative COVID swab. Materials and isolated after 48 hours as hospital-acquired infection (HAI). Details methods: COVID-19 cases in tertiary care center. Results: The of host and pathogen characteristics, laboratory investigations,

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and outcomes (mortality, length of stay) were collected from common in CAI, the HAI was predominantly caused by Gram- medical records. Appropriate statistical tests were used for analysis. negative bacteria. The incidence of community-acquired MRSA and Results: Of total 488 positive blood cultures, 166 were excluded MDR-Gram-negative infections is on a rising trend. Culture positive due to duplicate cultures and possible contamination. The most sepsis is associated with septic shock and high mortality. Biomarkers common contaminant was Coagulase negative Staphylococcus like CRP, procalcitonin did not predict mortality. Conclusion: Severe (CONS), likely reflecting poor technique of sample collection. The infections with multidrug-resistant organisms are increasingly median age of cohort was 2 (0–6) years, 55% were males, median becoming common in both community and hospital settings, PRISM III score was 5 (0–10). The median laboratory parameters resulting in significant mortality. Knowledge of the local trends in on the day of culture were: Hemoglobin 9.1 (7.7–10.5) g/dL, total infection burden, spectrum, and antibiotic susceptibility patterns leukocyte count (TLC) 10,400 (6,205–16,370)/mm3, platelet count would help in informing optimal antibiotic choice and infection 1,19,500 (45,000–2,45,000)/mm3, C-reactive protein (CRP) 4.4 control interventions to improve outcomes. (1.3–13.8) mg/dL, procalcitonin 43 (8.6-111.7) ng/ml, albumin 2.0 (1.4–2.5) g/dL, AST 69 (40–178) U/L, ALT 41 (24-123) U/L, urea 29 10. Effectiveness and Safety of Thymosin Alpha-1 in Patients with (15–57) mg/dl, creatinine 0.5 (0.3-0.9) mg/dl. Of the 322 cultures Severe COVID-19: A Prospective Open-Label Study. (Conference analyzed, 48% were CAI, rest were HAI. There was significant Abstract ID: 63) difference in the spectrum of CAI and HAI (p < 0.001). CAI included Rahul Pandit gram-positive (50%) [Staphylococcus aureus: 20 (13%), CONS: 30 Fortis Hospital, Mulund, Mumbai, Maharashtra, India (19%), Pneumococcus: 16 (10%), hemolytic streptococci: 4 (3%), DOI: 10.5005/jp-journals-10071-23711.130 Enterococcus: 7 (5%)], gram-negative (47%) [Escherichia coli 19 Introduction: Thymosin alpha 1 has been utilized for (12%), Pseudomonas 14 (9%), Klebsiella 10 (6%), Salmonella 3 (2%), immunomodulation in viral infections. There has been a limited non-fermenting GNB 19 (12%)], and Candida (5, 3%) infections. HAI clinical evidence for the benefits of COVID-19. Objectives: To included predominantly gram-negative (69%) [Escherichia coli: 21 assess the effectiveness and safety of thymosin alpha 1 in patients (13%), Pseudomonas: 6 (4%), Klebsiella: 25 (15%), Acinetobacter: with severe COVID-19. Materials and methods: Thymosin alpha 6 (4%), Enterobacter 10 (6%), NFGNB: 47 (28%)], and less gram- 1 was administered, as two injections (each 1.6 mg)/thrice daily positive (23%) [Staphylococcus aureus: 2 (1%), CONS: 27 (16%), subcutaneously for seven consecutive days, along with standard Enterococcus: 10 (6%)] and Candida (13, 8%) infections. There was of care (SOC), in 15 consecutive patients diagnosed as COVID-19 no difference between CAI and HAI in terms of age, gender, TLC, positive based on the RT-PCR results. The study duration was from platelet count, CRP, procalcitonin, AST, ALT, urea, creatinine. CAI had August 27, 2020, till November 2, 2020. The patients were enrolled lower PRISM III score (p = 0.03), higher hemoglobin (p = 0.003) and in the study if any of the following clinical conditions were present; serum albumin (p = 0.02). Survival was similar in CAI and HAI (57% vs respiratory distress with respiratory rate ≥ 30 breath/minute, 61%, p = 0.42). Mortality varied significantly with type of organism (p SpO (oxygen saturation) ≤ 90% on room air, PaO (arterial blood = 0.04). However, HAI had longer PICU stay (4 vs 13 days, p < 0.001) 2 2 oxygen partial pressure)/FiO2 (fraction of inspired oxygen) ≤ 200 and hospital stay (9 vs 23 days, p < 0.001). In the whole cohort, those mm Hg (1 mm Hg = 0.133 kPa), respiratory failure and the need for who survived, as compared to those who did not, did not differ in mechanical ventilation support. The study is registered with the terms of age, gender, CRP and procalcitonin levels, however, they Clinical Trials Registry of India (Clinical Trial registration number: had significantly lower PRISM III scores (4 vs 7, p = 0.002), higher CTRI/2020/08/027061) and was approved by the institutional hemoglobin (9.2 vs 8.7 g/dL, p = 0.006), TLC (11,335 vs 8,635/mm3, ethics committee on August 7, 2020. Results: The mean duration p = 0.03), absolute neutrophil count (7,609 vs 5,368/mm3, p = 0.01), (days) of the hospitalisation, ICU stay, ventilator support, was 13.2 platelet count (1,50,000 vs 95,000/mm3, p = 0.01), albumin (2.2 vs ± 4.38, 4.4±0.51, 2.87±2.20, respectively. The total lymphocyte 1.7 g/dL, p = 0.004), and lower AST (56 vs 88 U/L, p = 0.006), urea count (thousand/mm3), CD4 count (cells/mm3), CD8 count (cells/ (28 vs 31 mg/dL, p = 0.05), creatinine (0.5 vs 0.63 mg/dL, p = 0.003). mm3), increased significantly to 4410 ± 1200 from 2010±680 (p < Survivors also had longer PICU stay (9 vs 7 days, p = 0.047) and 0.0001), 558.07±177.55 from 367.20 ± 166.94 (p = 0.0008), 720.07 ± hospital stay (22 vs 9 days, p < 0.001). 91% Staphylococcus aureus 230.38 from 509.67±199.42 (p = 0.0008), respectively. The CD4/CD8 isolates were CAI, of which 50% isolates were methicillin resistant ratio improved from 0.72 to 0.77. LDH (Lactic Acid Dehydrogenase) (MRSA), all were vancomycin sensitive. All pneumococcal isolates levels (units per liter), C reactive protein (CRP) (mg/L), D-dimer were community acquired and 100% sensitivity to cephalosporins. levels (mg/L), ferritin (ng/mL), IL-6 (pg/mL) decreased to 329.33 The number of isolates showed an increasing trend over 5-year ± 175.62 from 369.00 ± 186.80 (p = 0.0182 NS); 23.66±22.64 from period for Staphylococcus aureus and pneumococcus. Enterococcus 76.31 ± 78.38 (p = 0.0.105); 0.72 ± 0.37 from 1.42 ± 1.36 (p = 0.0428), was both CAI and HAI, 20% isolates were vancomycin resistant (VRE). 347.09 ± 185.16 from 491.75 ± 230.86 (p = 0.0082), 4.09 ± 1.64 47% E.coli, 70% Pseudomonas, 28% Klebsiella isolates were CAI, from 18.03±4.91 (p < 0.0001), respectively. The oxygen saturation there was no significant difference in their antibiotic sensitivity as (SpO2%) increased to 97.60 ±0.74 from 84.93 ±1.79 (p < 0.0001). compared to HAI. These gram-negative infections were multidrug- WHO 8-point ordinal scale decreased (improved) to 3.2 ±0.41 resistant with limited sensitivity to piperacillin-tazobactam (40%), from 5.4 ±0.51 (p < 0.0001). Five patients reported adverse events meropenam (60%), aminoglycosides (70%), being 100% sensitive which were of mild severity, which were unrelated to thymosin to colistin (100%). The incidence of HAI Acinetobacter infections alpha 1. There was no mortality reported during the study period. showed rising trend over 5 years, no colistin resistance was seen. Discussions: The study demonstrates a statistically significant Discussions: Our study reveals important trends and differences reduction in cytokines including CRP, D-dimer, ferritin, and IL-6, in the community and hospital-acquired bloodstream infections. with a numerically superior reduction in LDH. The significant While both Gram-positive and Gram-negative organisms were improvement in the lymphocyte count along with the enhanced

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CD4 and CD8 count indicates the ability of thymosin alpha 1 to cohort study was designed to analyze the data collected during induce a distinctive immunological capacity, to replenish and the routine care of patients. All patients admitted to the ICU over reverse the phenomenon of exhaustion of the T cells. The improved a period of 2 months were included in the study and the data were biochemical parameters are corroborated with the improved SpO2 collected from the patient’s medical records. The primary outcome and the WHO 8-point ordinal scale. The results of our study are was clinical improvement defined as an improvement of 2 points on corroborative with the earlier clinical evidence which demonstrates an ordinal scale of the clinical condition of the patient. Secondary the role of thymosin alpha 1 for the clinical improvement by outcomes were time to clinical improvement, improvement in PO2/ immune reconstitution by inducing thymus output in COVID-19 FiO2 ratio, duration of the requirement for supplemental oxygen/ patients with SARS-CoV-2 infection. Conclusion: The results of noninvasive ventilation/invasive ventilation, and mortality. Results: this first prospective study from India indicates that thymosin Multivariate analysis of these data were done for the identification alpha 1, along with the standard of care approach, appears to of variables after the initiation of treatment with Remdesivir or be a potential treatment for patients affected by the SARS-CoV-2 Toclizumab that are potentially predictive of its clinical efficacy. infection. Thymosin alpha-1 is a novel therapeutic armamentarium There was no significant difference on clinical improvement of the to improvise the clinical outcomes in patients with severe COVID-19. patient who were treated with Remdesivir alone or in combination with TocilizumabVariables like time to initiation of the therapy, 11. A Telemedicine Approach for Assessment, Identification, clinical condition at initiation and PO2/ FiO2 ratio were predictive Empowerment, and Triage for COVID-19 Patients. (Conference of the clinical efficacy of both drugs. Discussions: In most of the Abstract ID: 58) cases, tocilizumab was initiated in patients who were clinically Bijay Patni deteriorating and were having a low PO2/FiO2 ratio at the time of Diabetes Wellness Care, Kolkata, India initiation of the therapy. That may be the cause of non-benefit in DOI: 10.5005/jp-journals-10071-23711.131 our subset of patients. Conclusion: There was no added advantage Introduction: COVID-19 pandemic has forced the healthcare of tocilizumab when combined with remdesivir on the clinical system to organize healthcare delivery differently. Materials and improvement or mortality of the patient. methods: We conducted a retrospective analysis of the diabetes wellness care (DWC) database to understand the implications of the 13. Awareness of Corona Virus (COVID-19) Infection Among new virtual clinic model initiated through telemedicine which was People Accompanying Patients Visiting the Emergency extended to manage COVID-19 patients (n = 218). Results: Clinical Department of a Medical College. (Conference Abstract ID: 12) Presentation: 33% (n = 72) were RT-PCR positive, yet, asymptomatic Channamma Inamati, Channamma Inamati, Deepak Segar with history of contact. 24.3% (n = 53) had mild symptoms including East Point Medical College, Bengaluru, Karnataka, India asthenia and myalgia and temperature < 100.5°F. 42.6 (n = 93) DOI: 10.5005/jp-journals-10071-23711.133 presented with temperature > 100.5° F. Discussions: Most of the Introduction: COVID‐19 started from one city in China in December patients were either asymptomatic or had mild upper respiratory 2019, but in a short period, it covered almost all over the world. symptoms. Moderate with non-life-threatening pneumonia Nearly 216 countries of the whole world have been affected by this was present in some patients and severe pneumonia and acute infection. On February 11, 2020, WHO announced this coronavirus respiratory distress syndrome were detected in very few. We were disease as COVID-19 and pandemic on March 11, 2020. To prevent able to judiciously utilize the options of HCQ, doxycycline, and the infection socially, the lockdown was imposed globally. In India, ivermectin in most patients, and a few required favipiravir and the Government also imposed a nationwide lockdown on March 22, azithromycin. Conclusion: Our telemedicine approach enabled 2020, and continued it up to May 30, 2020. But on May 30, 2020, this a prompt detection of the varied grade of the symptoms, which situation of coronavirus disease outbreak has become worse, as it enabled an effective triage and led to the isolation of infectious contains >50 lakhs confirmed cases, nearly 3 lakhs confirmed deaths patients. This model was useful to prevent and mitigate unnecessary across 216 countries. WHO has recommended personal hygiene community exposure. (respiratory hygiene, using face masks, washing hands with water and soap, use of alcohol-based hand sanitizers, avoid touching 12. Remdesivir Either Alone or in Combination with Tocilizumab mouth, eyes and nose), social distancing as an effective preventive for the Treatment of Severe COVID-19 Infection: A Retrospective measure for this disease. The growing pandemic of COVID-19 Cohort Study. (Conference Abstract ID: 31) requires social distancing and personal hygiene measures. But this Abhyuday Kumar, Neeraj Kumar, Amarjeet Kumar message is not clear and well understood among people. This study All India Institute of Medical Sciences Patna, Bihar, India aimed to determine the awareness and knowledge about COVID-19 DOI: 10.5005/jp-journals-10071-23711.132 among the rural population. Objectives: This study was designed Introduction: Presently, there is no conclusive data yet for the to assess the knowledge and awareness regarding corona infection use of remdesivir or tocilizumab in severe COVID-19 patients. among the rural population of Bengaluru district, Karnataka. Moreover, there is no study comparing the two drugs in one subset Materials and methods: The data were collected over a period of of patients. In some patients, both these drugs are used over a 3 months from March 2020 to May 2020. A total of 75 adults were period of time. The present study was designed to evaluate the interviewed who accompanied patients visiting the emergency combined effect of bot these drugs on the clinical condition of department of East Point Medical college, Bengaluru Rural district. the COVID-19 patients. Objectives: To compare remdesivir alone A questionnaire method was used to gather information, consisting and in combination with tocilizumab for the treatment of severe of details on sociodemographic factors, awareness, and knowledge COVID-19 patients. Materials and methods: This retrospective about corona infection. Results: Among the study population 45

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(60%) were male and 30 (40%) female. The majority of the subjects were late-onset VAP. Acinetobacter was the commonest organism belonged to Hindu family 57 (89.3%). Media was the most common isolated from late-onset VAP (p = 0.029) while Pseudomonas was source of information.Majority of them 40 (53.3%) didn’t knew the the commonest isolates obtained from early-onset VAP (p = 0.046). cause of corona infection.About 56 (74.6%)of participants were Klebsiella, MRSA and E. coli were almost identically distributed aware about transmission of disease.Many of the subjects knew between groups (p > 0.05). There is significant difference of about the preventive measures. Most of them were not aware i.e. 41 sensitivity pattern of Acinetobacter baumannii and pseudomonas (54.6%)regarding treatment and investigation 30(40%) availability aeruginosa in both early and late-onset VAP (p = 0.01). The overall for covid infection, but only 21.3% were aware about the vaccine mortality rate in our study was 44%. The mortality was significantly availability for the disease. Quarantine knowledge was present higher in the late-onset VAP (62.5%) than that in the early-onset VAP in 84% of the adults. Discussions: During the past 8 months, the (26.9%) (p = 0.011). Discussions: Ventilator-associated pneumonia COVID-19 has spread worldwide. Seventy-four cases were found per (VAP) is an important nosocomial infection among ICU patients 1 million people in India in fact, the government has implemented receiving mechanical ventilation (MV). In this prospective cohort lockdown well before any worst condition appears. After a long study, we compared patients with early VAP with those with late period of the lockdown of various commercial activities, we need VAP. Generally, the incidence of VAP varies according to the applied to understand the extent of public awareness toward the COVID-19 diagnostic criteria and the type of ICU. The incidence of VAP (35.73 pandemic so that an effective framework for creating awareness per 1,000 ventilator days) in our study was approximately similar among the public should be implemented keeping in view the to another Indian study.18 The incidence of VAP ranged from 10 to existing public communication abilities including demographics, 41.7 per 1,000 ventilator-days in different developing countries.13 literacy levels, language spoken as well as socioeconomic and But in other Asian countries, the incidence rate is relatively lower, cultural background. Coronaviruses encompass viruses that can ranging from 9 to 12 per 1,000 ventilator days.19–21 Our study shows cause illnesses ranging from the common cold to more serious that patients in the age group of 40 to 60 years were more prone to diseases SARS and MERS. The virus that causes COVID-19 disease is develop VAP and this was found in accordance with earlier studies.25 a new species of coronavirus. Half of the participants were unaware The incidence of VAP was more in males (60%) compared to females of this causative agent. About 80% of participants knew the route (40%) which was similar to studies conducted by Sharma et al.24 of transmission. Many of the subjects knew about the preventive Non-fermenters such as Pseudomonas spp. and Acinetobacter spp. measures. The COVID-19 occurs in all age groups. Old-aged persons were significantly associated with late-onset VAP as it was observed and those suffering from diseases like high blood pressure, cancer, by other workers.14 But in our study even in patients with early-onset lung disease, are at higher risk. Around 75% of participants knew VAP, Acinetobacter spp. was the most common pathogen which is the high-risk group population for corona infection. More than 50% similar to an Indian study done by Joseph et al.22 Our study showed of subjects were ignorant about the availability of treatment and that Pseudomonas aeruginosa was the commonest organism in investigations for corona infection. Conclusion: Overall awareness early VAP (42.3%), and in late VAP Acinetobacter baumannii was regarding COVID infection was low among rural adults. Strategies the commonest organism (66.7%), isolated in tracheal aspirate are needed to create more awareness about pandemic through culture. Dandagi (2006) showed Klebsiella pneumoniae to be the continuous education programs regarding the infectious disease. most common organism isolated in the tracheal aspirate culture of the VAP patients.15 Kumar et al.26 showed Pseudomonas to be 14. Comparison of Microbial Profile and Resistance Pattern of the most common organisms for both early and late VAP isolated Early- and Late-Onset Ventilator-Associated Pneumonia in a in tracheal aspirate culture. The information on types of pathogens Tertiary Care ICU of Bangladesh. (Conference Abstract ID: 7) causing VAP in different ICU settings will guide the administration of appropriate empirical antibiotics for the treatment of the infection. Uzzwal Kumar Mallick I observed that colistin is highly active against Acinetobacter National Institute of Neurosciences and Hospital, Bangladesh spp., while piperacillin-tazobactam has good activity against DOI: 10.5005/jp-journals-10071-23711.134 Pseudomonas spp. But as we have studied only a small number Introduction: Ventilator-associated pneumonia (VAP) is defined of isolates, these findings need to be further confirmed by larger as pneumonia that occurs 48 to 72 hours or thereafter following clinical trials, as they may have a major impact on the treatment 1,2 endotracheal intubation. Early-onset VAP is defined as pneumonia of these VAP pathogens. In our study, late-onset VAP had a poor that occurs within 4 days of endotracheal intubation, whereas prognosis in terms of mortality (62.5%) as compared to the early late-onset VAP is more likely caused by multidrug-resistant (MDR) VAP (26.9%), which is statistically significant (p = 0.011). A study 1–3 bacteria and emerges after 4 days of intubation. Objectives: The done by Gadani et al.16 showed mortality in late VAP (66%) and objectives of this study were to compare the bacterial profile and mortality of early VAP (20%). The higher mortality in the late VAP in resistance pattern of critically ill patients developing early-onset our study could be attributed to older age, higher comorbidities like VAP. Materials and methods: It was a prospective cohort study diabetes mellitus, COPD, and CKD. Conclusion: From the findings, conducted over a period of 24 months (July 2012 to June 2014) it can be concluded that late VAP had a poor prognosis in terms in an ICU of tertiary care hospital and was prospectively analyzed. of mortality (62.5%) as compared to the early type (26.9%). The Subjects were classified by ventilator status: early-onset VAP (<96 higher mortality in our study in the late VAP could be attributed to hours of mechanical ventilation) or late-onset VAP (>96 hours of older age, higher comorbidities like diabetes mellitus, COPD, and mechanical ventilation). Baseline demographics and bacterial CKD. In our study, there is a significant difference in sensitivity of etiology were analyzed according to the spectrum of the status of Acinetobacter spp. and Pseudomonas spp. between early- and late- VAP. Results: The incidence of VAP was 35.73 per 1,000 ventilator onset VAP. Acinetobacter spp. positivity is higher in the late-onset days. In our study 52% of the cases were early-onset VAP, while 48% VAP and Pseudomonas spp. are more so in early-onset VAP.

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9. Metabolism, Endocrinology, Liver Failure, and widely applied to patients of different ages and both gender, and Nutrition with existing comorbidities like hypertension. Conclusion: In this observational study of glucose control in ICU patients, the proposed Saven G protocol was effective to regulate and maintain the glucose 1. Glucose Control Study in Our Critical Care Unit. (Conference level at 150 to 200 mg/dL for 12 hours within a day. Further, this Abstract ID: 169) protocol could be widely applied to patients of different ages and Vaijayanti Nitin Kadam, Sanjith Saseedharan both gender, and with existing comorbidities like hypertension. SL Raheja Hospital, Mumbai, Maharashtra, India DOI: 10.5005/jp-journals-10071-23711.135 2. Effect of Various Feeding Regimen on Mortality in Critically Ill Introduction: Glucose dysregulation (dysglycemia) is referred to as Pediatric Patients of a Pediatric Critical Care Unit—A Triple Arm instability in blood glucose level and this includes hyperglycemia, Randomized Control Trial. (Conference Abstract ID: 166) hypoglycemia, and glucose variability (Boutin and Gauthier, 2014). Gopalakrishnan Ezhumali, Arun Bansal, Jayashree Muralitharan, In the intensive care unit (ICU), the management of hyperglycemia Suresh Kumar Angurana, Nancy Sahni is a crucial factor that determines the outcomes of the treatment. Postgraduate Institute of Medical Education and Research Multiple etiological factors like high glucose production, under- (PGIMER), Chandigarh, India utilization of glucose, reduced insulin secretion, drug treatments, and many more contribute to hyperglycemia. In 80% of critically DOI: 10.5005/jp-journals-10071-23711.136 ill patients, insulin resistance is one of the contributing factors Introduction:: Nutritional support is one of the key management of of hyperglycemia. Objectives: Hyperglycemia is associated with clinical practice in pediatric intensive care patients. The prevalence life-threatening complications including damage to the different of malnutrition in PICU is as high particularly in a country like systems of the body. An earlier study by van den Berghe (2001) on India. The metabolism and energy need of critically ill children are the management of glucose level and better survival outcome in dynamic, changing from a hypermetabolic state to a hypometabolic ICU patients increased the interest of researchers and clinicians state through the PICU stay. Hence, each particular PICU needs to discover multiple glucose control protocols and monitoring of to have a set feeding protocol for critically ill children to avoid glucose control in ICU settings (Preiser et al., 2016). The present underfeeding or overfeeding and in turn to improve physiological study attempted to understand the effectiveness of Saven G stability and outcomes. As there is no set feeding protocol in protocol intervention in the maintenance of glucose concentration critically ill children for the need of calorie, protein supplementation in ICU patients. Materials and methods: In this observational study, in critical illness, we planned to study the effects of various feeding a total of 108 patients (age limit please provide here) admitted in the regimens on critically ill pediatric patients in a tertiary care pediatric ICU of RAHEJA HOSPITAL center/hospital were enrolled. Inclusion intensive care unit. Materials and methods: Our study was an criteria included all consecutive medical cases getting admitted open-label triple arm randomized control trial which evaluated the in ICU, whereas the exclusion criteria were diabetic ketoacidosis, effect of three different enteral nutrition regimen on mortality on surgery, APACHE II score of <5 and >25, and reported death within critically ill children. We have assessed the effect of a combination 2 days of hospital admission. of isocaloric, hypocaloric, and hypercaloric feeding along with Saven G protocol hyperproteinemic feeding on both septic and non-septic children The protocol was approved by the ethical committee of RAHEJA in a tertiary care PICU. We calculated the resting energy expenditure HOSPITAL. (REE) with predictive equation (Schofield equation) for all the Details of the protocol. critically ill children >6 months to 12 years, we had 3 different groups The measured glucose was expressed as mg/dL and the obtained as defined (I — hypocaloric high protein, II — hypercaloric normal glucose value were categorized into three-level: <150, 150 to 200, protein, III — standard arm-isocaloric normal protein). Hypocaloric and >200 mg/dL. The main outcome of the study was to evaluate was given by 0.5 to 0.8% of REE, hypercaloric was given by 1.2 to the effectiveness of the proposed insulin protocol in terms of (i) 1.5% of REE, high protein was given by 2.5 g/kg/day. Each enrolled maintenance of various levels of sugar for several hours in a day; participant was given a specified number of calories and protein (ii) incidences of difference in sugar level in a day; (iii) correlation for the initial 7 days of PICU stay and followed up for the PICU and of sugar level with demographic characteristics and concomitant 28-day mortality. Nutritional and barriers for enteral nutrition data complications. Results: The distribution of demographic along with disease severity parameters, duration of mechanical characteristics and some of the major associated complications in ventilation, hospital and PICU length of stay, vasopressor-free patients in the ICU. Within the demographics, the age and gender days, adverse effects like the incidence of hypo-hyperglycemia, of the patients were inquired. The average age of the patients was transaminitis, AKI were collected for each participant. Results: observed to be 63.96 ±13.14 years. The gender distribution shows Out of 291 patients screened for eligibility 120 were enrolled in more that 68.51% of patients were males, while the rest (31.48%) group I, group II had 41 each, and group III had 38 patients. Of the were females. With respect to complications, 60.1% were affected total, 76 (63.4%) were in the septic arm and 44 (36.6%) were in the with hypertension, while 29.63% were impacted with ischemic non-septic arm. Each group had 27, 24 and 25 children with sepsis. heart disease. In additions to this, 23.15% of the patients underwent Discussions: Targeting enteral calorie intake was associated with coronary artery bypass graft and only 7.41% were impacted by favorable 60-day mortality in a multicentric cohort study by Mehat chronic kidney disease. Discussions: In this observational study et al. The authors demonstrated achieving of a target of 66% of of glucose control in ICU patients, the proposed Saven G protocol calories has significantly less mortality compared to the achieved was effective to regulate and maintain the glucose level at 150 to target of 33% (odds ratio — 0.27) (1). In a systemic review by Bechard 200 mg/dL for 12 hours within a day. Further, this protocol could be et al., patients receiving protein > 1.5 g/kg/day were associated

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with positive nitrogen balance (2). In our study, PICU mortality and ultrasound findings. The patient stayed in our ICU for 10 days with 28-day all-cause mortality were similar in all the three groups and aggressive B.P monitoring along with antihypertensive treatment was statistically not significant, probably because we were able to which after 10 days got settled with a systolic of 160/90. Other enroll only 20% of the calculated sample size for effect size. The investigations also resolved but a mild deterioration of vision secondary outcomes like the length of PICU stay and hospital stay remained. The patient after 10 days was transferred to the HDU did not show a significant difference in all three groups comparison. unit. Conclusion: In our patient with a history of previous normal Conclusion: We found that various combinations of hypo, hyper vs vaginal delivery with one live birth, and two successive IUD, we can isocaloric feeding with high protein in critically ill children was not conclude that proper ANC check-up and evaluation of maternal associated with mortality benefits and no difference in ventilator- health at the earliest can help prevent dreaded complication like free days, however, it is safe to give adopt permissive underfeeding malignant hypertension leading to PRES syndrome as MRI on day even in malnourished children. 5th showed mild vasogenic edema in the posterior and parietal lobe and other organopathies. 3. Critical Care Management Issues in a Patient with Eclampsia. (Conference Abstract ID: 114) 4. Nutritional Practices Prevalent in Open ICU and Their Impact: Dhriti Chungkrang, Anupama Gill, Aanchal Kakkar, Neerja A Study in Resource Limited Tertiary Care Hospital. (Conference Banerjee, Mohandeep Kaur, Vikas Arora Abstract ID: 75) ABVIMS, DR RML Hospital, New Delhi, India Ashima Mishra, Baladev Prasad Kar, Akhil Unnikrishnan, Bimal DOI: 10.5005/jp-journals-10071-23711.137 Krishna Panda Introduction: Preeclampsia, eclampsia, and HELLP syndrome VIMSAR, Burla, Odisha, India are serious and life-threatening, hypertensive conditions DOI: 10.5005/jp-journals-10071-23711.138 encountered by a pregnant woman, and are common causes of Introduction: Nutrition in critically ill patients has therapeutic ICU admissions among the obstetric population. The diagnostic importance besides a supportive role. A paucity of studies criteria include systemic BP of ≥140 or diastolic of ≥90 on two related to effective nutritional practices in the Indian setup exists. occasions at least 4 hours apart. Proteinuria >300 mg/day in Standardization has not been achieved due to the heterogeneity women with the gestational age of >20 weeks with previously of availability of facilities and funds in ICUs across different parts of normal blood pressure. Eclampsia is defined as a convulsive India. This study aimed to assess the efficacy of nutritional practices episode or altered level of consciousness in a patient occurring prevalent in open ICU. in the setting of preeclampsia provided there is no other Objectives: The objectives are to study cause of the seizure. HELLP syndrome is also associated with • the benefits of nutritional assessment using Subjective Global preeclampsia — eclampsia characterized by three hallmark Assessment (SGA) scoring system and individualization of features of hemolysis, elevated liver enzymes, and low platelets. nutritional needs of critically ill patients. Early diagnosis and multidisciplinary approach is mandatory, • the effect of time of initiation of nutrition on the prognosis of which if not corrected can lead to sequelae of adverse systemic patients. organ dysfunction which in our patient has led to malignant • the efficiency of blenderized feeding formulas in fulfilling hypertension, deranged liver function, and PRES syndrome. the nutritional requirements and its impact on outcomes of Materials and methods: NA. Discussions: We received a critically ill patients. 27-year-old patient in ICU — G3P2L1 with eclampsia, HELLP, and Materials and methods: This is a prospective observational hepatic encephalopathy. The patient had a history of 5 months study initiated in August 2020. Inclusion criteria: All patients amenorrhea, IUD spontaneous expulsion with misoprostol was admitted to central ICU including medical and surgical conditions. done in labor room wherein she was intubated in view of poor Exclusion criteria: Patient who died within 48 hours of admission GCS, she also had two episodes of seizure for which she had into ICU or had contraindications of enteral feeding. Methods: received two doses of magnesium sulfate outside the hospital The patients were assessed for nutritional status at the time of and was shifted to anti-epileptic thereon, blood pressure at the entry using SGA score and initiated on standardized blenderized time of presentation was 190/110, for which 40 mg i.v. lobate was feeds as per calculated calorie and protein requirements based given B.P after that was 140/90. Our patient was extubated the on body weight. The decision of time to initiation of enteral next day in ICU was vigilantly monitoring. She was managed by a feeding was determined by an individual treating physician. multidisciplinary approach which includes obstetrics, cardiology, The process of preparing, storing, and handling blenderized nephrology, gastroenterology, and ophthalmology bedside with feeds was observed and supervised to incorporate the correct a clear management plan which includes correction of anemia, amount of calculated nutrients. Outcomes were assessed using target B.P of <160/100 using labetalol 200 mg TDS, along with parameters like length of ICU stay, mortality, the incidence of labetalol infusion, NTG infusion, and other oral antihypertensives feeding intolerance (depending on >500 mL gastric residual like α-2 agonist, CCBs, ARBs, etc. She was carefully monitored in ICU volume on aspiration, need for use of prokinetics, development using CVP, arterial line, fluid chart, and lab investigation according of aspiration pneumonia), serum protein markers, bodyweight. to hospital protocol using the coagulation profile, liver and renal Appropriate statistical methods were applied for result analysis. function test for any further deterioration. Ophthalmologic Results: A total of 40 patients were observed. The mean age of findings revealed mild hypertensive retinopathy. NCCT head patients were 45 + 8 years (60.2% males and 40.8% females).18 had normal findings in it. Investigations during ICU stay like patients were fed within 24 hrs of their admission and rest after 24 CBC and Kft got normal with a gradual rise in liver enzymes and hours. The median time of early initiation of feeding was 12 + 5 hrs bilirubin levels with no evidence of live rupture or hematoma in and for rest 22 patients the median time of delayed initiation was

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47 + 9 hrs. Out of 40, 7 died and for rest the median time of ICU • To determine whether venous blood gas values can replace stay was 5.1 + 3.1 days. The median time of ICU stay for patients arterial gas values in the initial emergency department with early enteral feeding was 4.6 + 2.1 days and for patients evaluation of patients with suspected diabetic ketoacidosis. with delayed enteral feeding was 5.8 + 1.5. This difference was Materials and methods: With the approval given by the institutional found to be statistically significant (p = 0.04). The incidence of ethics committee, this study was conducted at the Emergency complications were lower among the patients with appropriate Department, Trauma center, Civil Hospital, Ahmedabad from SGA scoring and introduction of blended diet. However, that July 2020 to October 2020. One hundred patients with clinically was not found statistically significant. But between early and suspected DKA presenting to the Emergency Department, who delayed introduction of enteral feeding groups, the incidence match inclusion criteria (before the results of further laboratory tests of complications (sepsis/pneumonia) of patients with early known) were taken and their arterial and venous blood samples introduction of feeding was 41% and those with delayed feeding, (0.5–1 mL) were taken at the same time. Results: pH. incidence was 49%. This was statistically significant (p < 0.031). Bicarbonate: Discussions: Prenutritional assessment and individualization of Average difference between arterial and 0.03723 1.3907 nutrient requirements of critically ill patients is highly beneficial. venous pH values Recruitment of ICU Dietician is necessary. Early enteral feeding, if Range of difference 0 to 0.09 0 to −2.6 not contraindicated, when initiated as soon as possible leads to Standard deviation of average 0.018 0.69 better recovery. Complications like aspiration can be prevented by elevation of the head end of beds. More useful markers to assess 95% limits of agreement 0.0018 to −2.743 to 0.07266 −0.03742 nutritional status needs to be formulated. Blenderized feeds can Discussions: Most textbooks continue to recommend arterial blood be cost-effective substitutes to enteral formulas with near similar gas analysis as the investigation of choice for estimation of pH and efficacy in resource-poor hospitals. Preparation of collective feeds bicarbonate in DKA. As mortality in DKA is related among other and distribution avoiding prolonged storage can minimize the things to the degree of acidosis, determination of acid-base status risks of contamination. Conclusion: The results showed that there has prognostic as well as diagnostic significance. If venous pH gets is an improvement of the condition of the patients admitted at accepted as an alternative to arterial measurement, this has some ICU with the introduction of SGA scoring and early introduction potential benefits for patients, hospital staff, and processes. It should of blenderized diet in terms of duration of ICU stay and incidence be noted that arterial blood gas sampling is more painful to patients of complications. This needs to be validated by conducting similar and sometimes requires multiple attempts. Arterial puncture is studies with larger sample sizes over a longer time period. more time consuming and labor-intensive when compared with venipuncture, which must be performed anyway to measure serum 5. Comparison of Arterial and Venous Blood Gas Analysis in electrolytes and glucose levels, as well as to establish intravenous Patients with Diabetes Keto Acidosis Presenting to Emergency access for fluid resuscitation and insulin administration.Conclusion: Department. (Conference Abstract ID: 16) There is reasonable evidence that venous and arterial pH have Rahul M Parmar, Jigarkumar B Gosai, Neha V Patel, Chirag J Patel sufficient agreement as to be clinically interchangeable in DKA BJ Medical College, Civil Hospital Campus, Ahmedabad, Gujarat, patients who are hemodynamically stable without respiratory India failure. Unanswered questions include whether this level of the DOI: 10.5005/jp-journals-10071-23711.139 agreement remains true in patients with respiratory compromise Introduction: Diabetic ketoacidosis (DKA) is one of the most or with circulatory instability. This is an area worthy of further study. serious acute metabolic complications of diabetes. These metabolic Venous and arterial bicarbonate also agree closely in DKA but this derangements result from the combination of absolute or relative requires confirmation. insulin deficiency and an increase in counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). It is 10. Neurointensive Care a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased ketone concentration. Severe hyperglycemia ensues as 1. Epidemiology of TCD Parameters of Cerebral Perfusion a result of increased gluconeogenesis, accelerated glycogenolysis, in Patients Admitted to a Combined Medical Surgical ICU. and impaired glucose use by peripheral tissues. The most widely (Conference Abstract ID: 197) used diagnostic criteria for DKA have been blood glucose >250 mg/ Thomas Isiah Sudarsan, Sriram Sampath, Bhuvanna Krishna dL, serum bicarbonate lower than 15 mEq/L, arterial pH lower than St. Johns Medical College Hospital, Bengaluru, Karnataka, India 7.3, an increased anion gap metabolic acidosis, and a moderate DOI: 10.5005/jp-journals-10071-23711.140 degree of ketonemia. The severity of DKA is now classified as mild, moderate, or severe; based primarily on the severity of metabolic Introduction: Encephalopathy is common in patients being acidosis (blood pH, bicarbonate, ketones) and the presence of admitted to ICU and could be due to structural or nonstructural altered mental status. Arterial blood gas (ABG) analysis is the gold causes, with neuroregulatory dysfunction as well as cerebral standard method for acquiring this information. But ABG analysis circulatory disturbances which can be studied invasively and is not without drawbacks. noninvasively. Transcranial Doppler (TCD) provides a noninvasive Objectives: window to assess the cerebral circulation particularly the Middle • To study and analyze correlations and mean differences cerebral artery flow index and velocities. Although several between simultaneous arterial and peripheral venous blood gas cross-sectional studies have described abnormalities in the values in emergency department (ED) patients with suspected TCD flow parameters they have poorly correlated with invasive diabetic ketoacidosis. measurements of ICP and CPP. A study looking at a trend of TCD

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parameters (Pulsatility index, velocities, and derived indices—CBFI, 2. Comparison of Early Bispectral Index-Guided PostOperative ICP) values over time in encephalopathic patients could provide Extubation vs Extubation in Awake Patients in Neuro-Intensive insight into the abnormalities in these patients. Objectives: Care Unit. (Conference Abstract ID: 192) Primary: Describe the Pulsatility index (PI), Resistivity index (RI), Tushar Kumar, Pradip K Bhattacharya MCA — Peak systolic velocity (Psv), End diastolic velocity (Edv), Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India Mean flow velocity (Mfv), ICP, and Cerebral Blood flow index DOI: 10.5005/jp-journals-10071-23711.141 (CBFi) as measured by TCD among patients being admitted Introduction: Neurosurgical patients have a high risk of in ICU. neurological complications in the immediate postoperative Secondary: period increasing both morbidity and mortality. Extubation after • To determine if TCD parameters [PI, RI, ICP (Derived) and CBfi] uneventful intracranial surgery is tried to be as early as possible abnormalities and trends were associated with outcomes of to avoid ventilator-associated complications. There are several encephalopathic patients in ICU. scales and scoring systems to guide and assist early extubation. • To determine whether the pattern and the distribution of However, in neurosurgical patients, these scores may not be these parameters will help differentiate the pathophysiology sufficient to provide enough data for confidant extubation. The of encephalopathy in these patients. objective of the present study is to compare bispectral index-guided Materials and methods: A prospective observational study was postoperative extubation vs extubation in awake patients using conducted from January 2019 to December 2020 in the ICU of a various neurological assessment scores in neuro-intensive ICU tertiary care hospital. All patients admitted to tertiary care ICU were after craniotomy and excision of supratentorial space-occupying screened within 24 hours of admission and subsequently every lesions. Materials and methods: A total of 16 patients (ASAI-II), aged 24 hours till discharge from ICU or death. Patients enrolled were between 25 and 45 years, who were scheduled to undergo elective evaluated with a 1 to 5 MHz. Phased array echo probe to insonate neurosurgery operation under general anesthesia and randomly and acquire MCA flow parameters of Pulsatility index and flow divided into the BIS group (group B) and scoring group (group S), velocities through a transtemporal window. Patients were also with 8 cases in each group. After satisfactory respiratory recovery evaluated with a 7 to 15 MHz linear vascular probe to measure patients were extubated. Oxygen saturation by pulse oximeter the optic nerve sheath diameter. Other clinical and laboratory and HR were recorded before extubation (T0), (T1) at 1 minute, parameters were transcribed from the daily routine investigation and 5 minute (T2). Results: Early extubation using bispectral index being done along with hemodynamic parameters during the TCD found to be significant with p < 0.04, during T1 and T2. Discussions: analysis. All the analyzes were carried out using SPSS Version 25. Bispectral index assists better to make decisions for extubation than Results: A total of 35 patients were included in the study. Among other scoring systems in postoperative neurosurgical patients for them 5 patients encephalopathy resolved within 24 hours and were supratentorial space-occupying lesions. Kamali et al. showed that not considered for analysis. The mean age (± S.D) is 45.5 (±22.9) BIS reduces extubation time in post-CABG patients. Conclusion: years. Male:Female ratio was 4:1. Among the encephalopathic Using BIS monitoring during and after neurosurgery, it reduces the patients 40% (n = 12) recovered from encephalopathy and 40% length of patients’ extubation in ICU. (n = 12) had poor outcomes (Death/ DAMA). 26.6% (n = 8) had structural causes of encephalopathy among which acute CVA was most common cause. 73.3% (n = 22) had non structural 3. Temporal Trends in Optic Nerve Sheath Diameter (ONSD) in cause of encephalopathy of which majority had septic/uraemic Neurocritical Illnesses. (Conference Abstract ID: 32) encephalopathy. PI at the time of admission was high in patients K Sindhuja, Rishiraj N Verma, Krishna Kumar who did not recover from encephalopathy compared to patients Command Hospital (Eastern Command), Kolkata, India who recovered from encephalopathy(1.27 ± 0.39 Vs 1.06 ± 0.3), but DOI: 10.5005/jp-journals-10071-23711.142 it did not attain statistical significance( p = 0.29). Trends in PI were Introduction: Optic nerve sheath reflects the same pressure not associated with chances in encephalopathy Discussions: In change as the intracranial compartment. Well-known findings of previous studies by Dina Zidan et al. (2017) on 106 septic patients, raised ICP like papilledema and pupillary changes appear very late there was a difference in the PI between conscious patients and compared to dilatation of the optic nerve sheath.1 Sonographic patients suffering from sepsis-associated encephalopathy and ONSD measurement provides real-time changes in ICP, can be they concluded that PI could be a predictor of sepsis-associated done bedside and is reproducible, and can be repeated to know encephalopathy in septic patients. In our study, PI at the time the trends in ICP throughout the disease course, thereby averting of admission was high in patients who did not recover from the risks associated with invasive monitoring or repeated radiation encephalopathy compared to patients who recovered from exposure. There is a paucity of data among ICU patients although encephalopathy (1.27 ± 0.39 vs 1.06 ± 0.3), but it did not attain there are studies that determine disease-specific cut-off for ONSD statistical significance (p = 0.29). In our study, we also found that the to detect raised ICP.1–5 This is an observational study to study trends in PI were not associated with the progression or resolution the temporal trends in ONSD during different clinical scenarios. of encephalopathy. Conclusion: We found that TCD flow parameters Objectives: To investigate the significance of the difference in of pulsatility index varied within a wide range in patients with two measurements of mean binocular ONSD measured after encephalopathy. Trends in PI were not associated with progression measurement at the first point of contact:Acute change in GCS/ or recovery from encephalopathy. FOUR by ≥2 points.

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• Post decompressive surgery (TBI/Hemorrhagic stroke/ 4. Comparison of ICU Outcome of Mechanically Ventilated GBS malignant infarct). Patients Receiving Intravenous Immunoglobulin or Plasma • Post tumor de-bulking (Intra-cranial space-occupying lesion). Exchange in a Tertiary Neurology Referral Hospital. (Conference • Change in intracerebral hemorrhage scores (hemorrhagic Abstract ID: 8 stroke). Uzzwal Kumar Mallick Materials and methods: Subjects of either sex. Age — 18 to National Institute of Neurosciences and Hospital, Bangladesh 75 years, admitted to the ICU with an established or suspected DOI: 10.5005/jp-journals-10071-23711.143 diagnosis of the following with clinical suspicion of raised ICP: Introduction: Guillain–Barré syndrome (GBS) is a demyelinating • Hemorrhagic stroke (any ICH score on admission into ICU). polyradiculoneuropathy with an acute paralyzing disorder, typically • Traumatic brain injury (<48 hours of injury). symmetric and ascending and areflexia. Incidence varies between • Intra-cranial space-occupying lesion was included. 0.66 and 1.79 cases per 100,000 persons in the general population.1–6 Patients with a history of optic neuritis, arachnoid cyst of the About pathogenesis, the etiologies of GBS remain unclear; however, optic nerve, optic nerve trauma metabolic encephalopathy were several findings suggest that causes such as an infection of the excluded. Ocular US was performed with a 7.5-MHz linear probe respiratory or gastrointestinal tract, vaccinations, surgery, and of Mindray DP-8500 in B mode. ONSD was measured at a depth of pregnancy generate an abnormal immune response which leads 3 mm from the distal-most point of the optic nerve in the globe. to a destruction of myelin sheaths and/or axons.7–9 The treatment is • ONSD was re-assessed when based on two mainstays: supportive care and immunomodulatory • Acute fall in GCS/4 of 2 or more points. treatment. Supportive care prevents complications such as deep • Change from initial ICH score. vein thrombosis, digestive bleeding, and infections especially • Post decompressive hemicraniectomy in cases of ICH/ and physiotherapy. Both plasma exchange (PE) and intravenous malignant infarct/TBI. immunoglobulins (IVIg) are the two immunomodulatory treatment. • Post tumor excision for ICSOL. Several studies demonstrated that IVIg and PE are an efficacious The pairs of ONSD values were subjected to statistical analysis. treatment for GBS.10 Collective data on five trials and 582 patients Results: There was a statistically significant difference between do not reveal a significant improvement in outcome, either ONSD values measured during first point of contact and when improving faster or more completely with the combination of measured for the second time due to acute fall in GCS/FOUR by IVIg and plasmapheresis. The combination exposes the patients ≥2 (t = –5.906, p < 0.05), when measured for the second time after to the risks of adverse events from both modalities. There is no change in ICH score. (t = –4.9, p < 0.001) and after undergoing evidence to support the use of both IVIg and plasmapheresis decompressive hemicraniectomy in cases of ICH/Malignant Infarct/ therapies.11 Objectives: The study aimed to compare the efficacy TBI. (t-4.189, p = 0.0002) However there was no statistically significant of IVIg (intravenous immunoglobulin) vs PE (plasma exchange) in difference between ONSD values measured after undergoing the treatment of mechanically ventilation adults with GBS in the surgery for excision of ICSOL( t=0.155,p>0.05). Discussions: The neuro-intensive care unit of Bangladesh. Materials and methods: difference in ONSD measured at the first point of contact and This was a prospective, observational cohort study, in a neuro-ICU postoperatively was found to be statistically significant in cases of from 2017 to 2018. We included all patients with GBS who required TBI/Hemorrhagic stroke. (t = −4.189, p = 0.0002). Consistent with mechanical ventilation (MV). We defined two groups: group I (group these findings seen in our study, in a study done by Rajajee et al. treated by IVIg: 0.4 g/kg/day for 5 days) and group II (group treated patients had a rapid decrease in mean ONSD to <5 mm following by PE: 5 PE during 10 days, every alternate day). We collected clinical therapeutic intervention with corresponding clinical neurological and therapeutic aspects and outcome. Results: Total number of improvement.1 There was no statistically significant difference 49 patients (34 in group 1 and 15 in group 2) were enrolled. The between ONSD values measured undergoing surgery for excision mean age was 37.4±9.2 years, with a male predominance (65.3%). of ICSOL. This is consistent with the volume pressure relationship on electrophysiological findings, in 4 (32.7%) patients had acute is much more gradual when compressible brain parenchyma is inflammatory demyelinating polyradiculoneuropathy (AIDP) and involved. Conclusion: Difference in mean ONSD measured at acute motor axonal neuropathy (AMAN) in 26 (53.1%) patients and the first point of contact and after acute fall in GCS/4 ≥2, after a acute motor-sensory axonal neuropathy (AMSAN) was 3(6.1%)and decompressive craniectomy, after an escalation in ICP management NCS was not done in 4 (8.2%) cases. The mean length of ICU stay protocol, after an observed pupillary change, after a change from was 20 ± 19.10 days and 46.60 ± 30.02 days in IVIG and PE group initial ICH score was found to be statistically significant. However, respectively. The ICU stay was significantly shorter (p = 0.001) in there was no difference in the mean binocular ONSD from the first the IvIg group than PE group. Patients receiving IvIg were early point of contact and after excision of tumor/ICSOL. Thus, the date weaned of MV (p = 0.002) compared to those receiving PE with and time of performance of ONSD assessment could be recorded a statistical significance. Also, duration of M/V (P = 0.002), Need and the trend must be analyzed in conjunction with other clinical of tracheostomy (p = 0.005) and over all surval rate (p = 0.007) findings like GCS scores, presence of papilledema, operative status, was significantly in favoue of IvIg group than PE group. Out of pupillary change, new-onset seizures, or any other relevant change. 49 patients, total 3 patients were died and they all were AMAN It can help decide the further line of management. variety. Discussions: In this study, the mean age was 30.94 ±

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14.96 years, females were affected more than males and this is committee for data collection Quasi-Experimental design was against most of the previous reports which mention that GBS selected as a research design. Setting: BRB Hospital limited, Dhaka, demonstrates a slight male predominance, with a male/female ratio Bangladesh. A reputed 500-Bedded General Hospital where there of approximately 1.2–1.5:1.12,13 Other researchers in Hong Kong are 30 ICU beds, Participants: A total of 50 patients were selected reported a similar predilection between the two sexes.14 Symptoms as a participant in the study from the hospital. Twenty-five were preceding the onset of GBS were gastrointestinal infections in 36 included in the ICU Treatment group and another 25 were in (79.59%) patients, RTI 13 (26.53%), and 1 (2.04%) chickenpox. It was the intervention group using the purposive sampling method. reported that respiratory infections are the commonest antecedent Intervention: Graded early mobilization was provided as an infection, occurring in about 40 to 70% of cases, while 7 to 20% intervention to all participants of the intervention group by a are gastrointestinal infections.13,15 The findings of this present professional qualified ICU physiotherapist. Process of application study have shown that AMAN is the most commonly diagnosed of intervention: Graded early mobilization was provided as an subtype by electrophysiological studies which is 46 (50.0%) patients intervention to all participants of the intervention group by a followed by AIDP (34.78%), AMASN (6.52%), and no MFS. AMAN professional qualified ICU physiotherapist for 10 sessions to each pattern was the predominant underlying subtype in China, Japan, participant. Most of the patients received multiple sessions (2–3 and Central and South America.13,15 Other studies from North sessions) of intervention within every single day. Another senior America and Europe as most GBS was AIDP variety.13,15 This different physiotherapist was assigned as a data collector for both control figure supports the large variations in the incidence of different and intervention groups to reduce bias and ensure blind. Written types of GBS which may be related to seasonal or genetic factors consent has been obtained from all patients’ legal guardians initially with no support studies explaining this difference until now.15 This when patients were in ICU. But patient concerns were also taken present study showed a favorable outcome than PE in terms of and explained all the areas of the study when they are capable to shorter ICU stay, early starting weaning from MV, shorter duration talk. Scales used: FIM (Functional Independence Measurement) of MV, fewer complications, and less mortality. It has been found scale and GAD 7 (7 point Generalized Anxiety Depression) scale. that the mean duration of ICU stay and duration of mechanical FIM Scale: This scale has 7 points (1–7). Where 1 = Total Assistance ventilation in patients treated with plasmapheresis are significantly or not Testable (Subject <25%) and 7 = Complete Independence. lower than in cases treated with IVIg; this reduced the cost of GAD 7 Scale: This scale has 7 points (1–7). Where every individual hospitalization and intensive care unit (ICU) care in these patients. is given their score. Scores of 5, 10, and 15 are taken as the cut-off The results of the present study are supported by some previous points for mild, moderate, and severe anxiety. Results: In the control studies that recorded a significant decrease in duration of ICU stay group mean FIM score was 17.40 (SD ±4.88) and in the Intervention and shorter mechanical ventilation duration which compensate for group mean score was 65.70 (SD ±12.18). The mean difference the cost of plasmapheresis; better secondary outcomes were also was statistically significant in the “t” test (p value < 0.001). In the achieved.15 However, some studies suggested that patients who control group, the mean GAD 7 score was 19.50 2.71) and in the received IVIg treatment had more improvement than those with intervention group the mean of GAD 7 score was 7.5 (SD ±2.59). In plasmapheresis.16,17 Some other researchers showed no significant ‘t’ test. p value was = 0.001. The mean of length of ICU stay was in difference between the two treatment groups.18,19 However, some control group 5.60 (SD ±1.07 ) and in intervention group it was 3.10 other studies suggest that patients who had IVIg treatment had (SD ±0.56). In ‘t’ test. p value was =0.001. Discussions: In this study, more improvement than those who had PE. Indeed, Koul and we have found that graded early mobilization was highly significant Alfutaisi17 and Van der Meché et al.16 showed that the IVIg group to improve patient functional independence. Most every patient had a significantly fast evolution than the PE group. There are some in the control group scored very low in the FIM assessment (mean: limitations of this study. The small number of cases has also made 17.40). On the other hand, as all the participants of the intervention the comparison statistics not valuable enough as significant results. group wear treated in ICU with graded mobilization and brought Conclusion: Our work reveals a meaningful difference for the MV most them out of bed on the second day within ICU, they regained duration, ICU stay, weaning, and excellent recovery in the IVIg functionally very active within ICU stay. During discharge from ICU group compared to the PE group in terms of fewer complications. their FIM assessment score was very higher (mean: 65.70) compared to the control group and the change was statistically significant. In 11. Nursing Care and Physiotherapy the current study, we have also found some findings regarding the psychological issues of participants during ICU stay. In the control 1. Effect of Graded Early Mobilization on Psychomotor Status and group, 80% of participants were reported with severe anxiety level Duration of Intensive Care Unit Stay in Mechanically Ventilated in GAD 7 assessment, only 20% were in moderate anxiety level and Patients. (Conference Abstract ID: 107) no one reported normal during ICU stay (GAD 7 mean was: 19.50). Bijoy Das, Sanchita Saha, Feroz Kabir, Sazzad Hossain But in the intervention group, the scenario was different. All the BRB Hospitals Limited, CRP-Mirpur, Jeshore University of Science participants were received graded mobilization in the ICU setting. and Technology, Bangladesh The professional physiotherapist did plenty of verbal interaction DOI: 10.5005/jp-journals-10071-23711.144 with each and every participant which may be played a vital role Introduction: The main purpose of the study was to evaluate in their psychological status as well. The result showed that only the effectiveness of graded early mobilization on psychomotor 40% of participants were responded to mild anxiety and 10% of status and duration of intensive care unit (ICU) stay of patients participants responded to moderate anxiety in GAD 7 assessment. with mechanical ventilation. Materials and methods: Design: But 50% of participants were responded with an anxiety-free score Considering the availability of participants in the ICU that meet in GAD 7 assessment (mean GAD 7 was 5.50). In comparison to the selection criteria and given time frame by the research ethical the control group, the change was statistically significant (p value

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was <0.001). In this study, findings were in some features similar in the ‘Honey’ group and 48 in the ‘standard care’ group. Baseline and some area better. It was found from the statistical analysis for characteristics including nutritional status were comparable functional improvement and independence (FIM) of patients, at between the groups. The most common sites of injury were bony 18 df the value of “t” at 5% level of significance is 11.635 as found prominences at face mask contact points. The median time to in reference to the “t” table (appendix). Thus, the probability of complete healing – was 7 (95% CI 6 to 7) vs. 9 days (7 to 10) in the occurrence (P) of the value obtained (11.635) by chance is much ‘Honey’ and ‘standard care’ groups, respectively (log rank test p = <0.001, the critical or 5% level of significance. “p” comes to <0.001 0.002). At any random time, children in the ‘Honey’ group were on referring to the “t” table. It can occur <01 times in 1,000 which around 1.9-fold more likely to have completely healed their pressure means very rarely by chance. So, it showed that graded early injury than those in the ‘standard care’ group (hazard ratio 1.86; 95% mobilization is significantly more effective rather than only ICU CI 1.21 to 2.87). There were no allergic reactions or secondary wound treatment for functional improvement and independence of infection in the ‘Honey group’. Discussions: Our findings suggest patients. So this experiment establishes the hypothesis and rejects that pressure injury of varying stages from 1 to 3 healed faster by the null hypothesis. Conclusion: This research showed that graded about 2 days when treated with medicated “Honey” as compared early mobilization was highly effective to improve mechanically to “standard care”. Our results are similar to previously published, ventilated patients motor and psychological status and reduce small observational studies and case series in children in which the length of ICU stay. “honey” healed wounds faster as compared to routine care. Honey forms a natural biofilm that allows gas exchange, keeps wounds moist and hydrated; has antimicrobial and catalytic properties. The 2. Use of Honey vs Standard Care for Hospital-Acquired Pressure faster healing observed in our study could be attributed to these Injury in Critically Ill Children—A Multicenter Randomized wound healing properties of medicated honey. Conclusion: The Controlled Trial. (Conference Abstract ID: 27) use of medicated honey dressings decreased the time to wound Jhuma Sankar, Jhuma Sankar, AV Lalitha, Ramesh Kumar, healing in critically ill children with a pressure injury. There were Prabudh Goel, M Jeeva Sankar, S K Kabra, Rakesh Lodha no allergic reactions or secondary bacterial infections noted in any All India Institute of Medical Sciences, New Delhi, India; All ISt of the children. Johns’ Hospital, Bengaluru, JIPMER, Puducherry, India DOI: 10.5005/jp-journals-10071-23711.145 12. Pediatrics Introduction: Pressure injuries cause significant morbidity in critically ill children. Medical grade honey has been well studied 1. A Combination Therapy of Norepinephrine Plus Dobutamine as in adults in the treatment of acute and chronic skin injuries of a First-Line Agent in Fluid Refractory Pediatric Septic Shock—A various etiologies like pressure injuries, burns, traumatic, and Randomized Controlled Trial. (Conference Abstract ID: 180) postoperative wounds. While the results have favored honey in most of the studies, its beneficial effects have not yet been explored Kiran Kumar Banothu, Jhuma Sankar, U Vijay Kumar, Priyanka in the treatment of pressure injuries in critically ill children in a Gupta, Kana Ram Jat, S K Kabra, Rakesh Lodha All India Institute of Medical Sciences, New Delhi, India randomized controlled trial. Objectives: To examine if the use of honey (medicated) for dressing is superior to standard care in terms DOI: 10.5005/jp-journals-10071-23711.146 of time to complete wound healing in stages 1 to 3 pressure injuries Introduction: In critically ill children, septic shock is associated with (as per the National Pressure Injury Advisory Panel 2016 staging significant morbidity and mortality. Epinephrine is recommended system) in children admitted to the pediatric intensive care unit. as the first-line vasoactive agent in fluid refractory cold septic Materials and methods: In this multicenter (3 sites), open-label, shock in children. Limited data on the use of norepinephrine plus parallel-group randomized trial conducted from August 2017 to dobutamine in critically ill children Objectives: To compare the January 2019, all critically ill children aged 2 months to 17 years effect of combination therapy of norepinephrine plus dobutamine of age who developed pressure injury (stages 1–3 inclusive) in the vs epinephrine as a first-line agent on shock resolution at 1 hour hospital were eligible for inclusion. Those on >2 inotropes, signs in children with fluid refractory cold septic shock. Materials of acute wound infection, wounds with >5 cm diameter, or known and methods: In this open-label randomized controlled study, allergy to honey were excluded. Institutional Ethical Clearance we randomly assigned children aged 2 months to 18 years was obtained from all the 3 sites and the trial was registered at with fluid refractory cold septic shock [as defined by American ClinicalTrials.gov (NCT03391310). Children were randomized to College of Critical Care Medicine (ACCM), 2017] to receive receive either medicated honey dressing for their pressure injury either norepinephrine plus dobutamine (intervention group) or in the “study group” or “routine wound care” in the “standard care” epinephrine (control group). The primary outcome was shock group. Manuka or active leptospermum honey dressing/gel was resolution at 1 hour of vasoactive therapy. Shock resolution was used in the “Honey” group. Enrolled children were followed-up defined as the attainment of therapeutic endpoints as per ACCM till death or discharge from the hospital. We used validated tools guidelines. Secondary outcomes were shock resolution at 6 hours, such as the Braden Q scale for assessment of risk, prevention, and 24 hours, time to attain therapeutic endpoints, time to vasoactive treatment of pressure injuries and, the Pressure Ulcer Scale for agent withdrawal, and 28-day mortality. Children were managed Healing (PUSH) tool for monitoring healing of pressure injuries. The as per ACCM guidelines, 2017. As this was a pilot study, all eligible primary outcome was time to complete wound healing (defined patients admitted during the study period (November 2018 to June as complete healing of the wound without scar or contracture). 2020) were enrolled. Intention to treat analysis was done. Results: The sample size calculated was 98 patients and we calculated the We enrolled 67 children (38 boys): 34 in the norepinephrine plus relative risk (RR)/mean difference with (95% CI) for all the outcomes dobutamine group and 33 in the epinephrine group. The median using STATA 11. Results: A total of 99 children were enrolled – 51 (IQR) age was 84 (18–120) months and majority were boys (57%).

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There was no significant difference between the groups in terms study was conducted to evaluate the serum levels of Vitamin E in of shock resolution at one hour of therapy [17.6% vs. 9%; RR: 2.0; children admitted to PICU and find out the relation of Vitamin E 95% CI: 0.54–7.35; p = 0.25]. At 6 hours, the proportion of children levels with clinical outcomes. Materials and methods: A hospital- attaining shock resolution was greater in the norepinephrine based cross-sectional study was conducted after institutional ethics plus dobutamine group, although it was not significant [76.4% committee approval and informed consent from parents. Blood vs 54.5%; RR: 1.69; 95% CI: 0.92–3.13; p = 0.05]. The difference samples of 60 children admitted to PICU of tertiary care hospitals persisted at 24 hours of vasoactive therapy [97% vs. 84.8%; RR: attached to Kasturba Medical College, Mangaluru were evaluated to 1.14; 95% CI: 0.97-1.33; p = 0.09]. There was a significant difference determine serum levels of vitamin E. Clinical outcome was assessed. in the time to shock resolution – earlier in the norepinephrine plus Relation of serum Vitamin E levels for the need for respiratory dobutamine group [3 (2, 6) vs 6 (3, 10) hours; log-rank p = 0.01]. support, mechanical ventilation, multiorgan dysfunction, inotropic The time to vasoactive agent withdrawal was shorter [53 (28, 185) requirement, length of PICU stay and mortality was assessed. vs 84 (50, 154) hours; log-rank p = 0.52] and the 28 day mortality Mann–Whitney U test and chi-square tests were used for analysis. was lower in the norepinephrine plus dobutamine group [23.5% A p value of <0.05 was considered statistically significant.Results: vs 39.3%; RR: 0.59; 95% CI: 0.28-1.25; p = 0.16]. The difference Sixty children comprising 28 males (47.70%) and 32 females however, was not significant. Children in the norepinephrine plus (53.30%) were enrolled. Their average age was 2.95 ± 3.66 years dobutamine group had lower organ dysfunction score (pSOFA) (range: 1 month to 13 years). Out of the 60 children,49 (81.7%) on day 2 of randomisation [Median (IQR): 8 (5,10) vs 9 (8,11); p = developed organ dysfunction involving one or more organ systems. 0.04], although subsequently there was no difference between the The most common organ system involved was respiratory (71.6%) groups. The mean cardiac index was higher in the norepinephrine followed by neurological (28.3%). The average length of PICU stay plus dobutamine group at 6 hours [Mean (SD): 4 ± 1 vs.3.1 ± 1.2; was 9.08±6.00 days. Among the study subjects, 2 (3.3%) children p = 0.01] and the difference persisted at 24 hours of initiation of expired. The mean value of vitamin E was 3.40 ± 4.67 mcg/ml and vasoactive therapy [4.2 ± 1.1 vs 3.5 ± 1.2; p = 0.05]. There was no vitamin E deficiency was noted in 46 (76.7%) of children. There difference between the two groups in terms of rhythm abnormality was a statistically significant association between vitamin E levels and peripheral ischemic changes. Discussions: In this randomized with organ dysfunction (p = 0.034) and the need for respiratory controlled trial, we found that shock resolution at 1 hour of support (p = 0.032). Discussions: Serum levels of micronutrients therapy was not different between the groups. However, the may be affected by critical illness or inflammation.2 Vitamin E proportion of children attaining shock resolution was greater at 6 modulates cell-mediated immunity by regulating the generation and 24 hours in the norepinephrine plus dobutamine group. Also, of lipid peroxidation and prostaglandins. a-tocopherylquinone is children in the norepinephrine plus dobutamine attained shock the commonest product of oxidative damage which is identified in resolution earlier. There are no published pediatric studies on the tissues.3 There have been conflicting reports about vitamin E levels use of norepinephrine plus dobutamine. In adults, Annane et al. in critical subjects with very few studies evaluating pediatric age observed that there was no difference in time to hemodynamic groups.1 Vitamin E deficiency was reported by Valla et al. in addition success and time to vasoactive agent withdrawal. Mixed results to other micronutrient deficiencies in critically ill patients. There were observed in adults in terms of rhythm abnormalities with was a significant decreasing trend in levels of micronutrients while these interventions. Limited evidence showed that the use of oxidative stress intensity increased.4 Our study reported Vitamin E norepinephrine does increase cardiac output. Chen et al. and deficiency in the majority of the children which is alarming. Lower Cheng et al. observed that a combination of vasoactive agents is levels of Vitamin E were found in patients requiring respiratory associated with lower mortality in adults. Conclusion: In children support and those with organ dysfunction which may imply the with fluid refractory cold septic shock, with use of norepinephrine deficiency of Vitamin E leading to oxidative stress and organ plus dobutamine as a first-line vasoactive agent, although there damage. However, low plasma levels per se may not indicate low was no difference in shock resolution at 1 hour of therapy, higher total body stores as critical illness may induce redistribution of rates of shock resolution at 6 and 24 hours of vasoactive therapy antioxidant vitamins.5 Conclusion: The majority of the children were were observed as compared to the use of epinephrine. The time deficient in vitamin E. Lower Vitamin E levels were associated with to shock resolution was also earlier in the norepinephrine plus organ dysfunction and an increased need for respiratory support. It dobutamine group. Our findings need further validation in a is hence important to emphasize that children requiring intensive larger patient population. care may have micronutrient deficiency which may affect morbidity and mortality.

2. Assessment of Serum Vitamin E Levels and Clinical Outcome 3. Scope, Safety, and Feasibility of Therapeutic Plasma Exchange in Pediatric Intensive Care Unit. (Conference Abstract ID: 177) in Pediatric Intensive Care Unit: Our Experience. (Conference Suchetha S Rao, Owais Ahmed Mushtaq, Poornima Manjrekar, Abstract ID: 151) Prasanna Mithra Karthik Kumar Balasubramanian, Priyavarthini Kasturba Medical College Mangalore, Manipal Academy of Higher Venkatachalapathy, Suchitra Ranjit, Rajeswari Natraj, Vasanth Education, Manipal, Karnataka, India Kumar, Indira Jayakumar, Saravanan Margabandhu DOI: 10.5005/jp-journals-10071-23711.147 Apollo Children’s Hospital, Chennai, India Introduction: Vitamin E is an important free radical scavenger DOI: 10.5005/jp-journals-10071-23711.148 that is protective against oxidative injury. Studies evaluating Introduction: Therapeutic plasma exchange (TPE) is challenging Vitamin E status in a pediatric intensive care unit (PICU) and its role in pediatric patients compared to adults owing to the difficulty 1 modulating oxidative damages in critical illness are lacking. This in vascular access and other technical considerations. Still, its

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application in the pediatric intensive care unit (PICU) is increasing various organ systems receiving TPE for different indications. TMA with evolving evidence to support its use in select conditions. The and ALF were the common reasons for initiating TPE. Most of our American Society For Apheresis (ASFA) regularly updates their patients had ASFA category 1 indication. This is similar to a study evidence-based guidelines on the use of therapeutic apheresis by Haque et al., where 23 out of 28 patients received TPE for ASFA in adults and children, the eighth edition (2019) being the latest. category 1, though indications were predominantly neurological Though there is extensive literature on adults, there is a dearth of diseases and TTP.4 In contrast to our study results, “Sepsis/MODS” studies in children on this subject, especially in the Indian context. (ASFA category III) was the predominant indication in studies done Objectives: To study the demographics, clinical indications, and by Keskin et al., Sik et al., and Duyu et al.3,5,6 Therapeutic response outcomes of patients who have undergone TPE in a tertiary was good in 14 patients (70%). Only a few studies have evaluated care PICU. Materials and methods: This is a retrospective study the serious adverse events. The incidence of serious adverse performed in our tertiary care PICU over 5 years from January 2016 events was 5.7% in our study, while it was 3.8% in Haque et al.’s to December 2020 among patients between 1 month and 16 years study. Compared to other previously mentioned studies where of age. Demographic details, diagnosis, indication for TPE, procedure the mortality rate ranged from 18 to 37.5%, the mortality rate was details, concurrent extracorporeal therapies, and outcome data less in our study population (15%). The results of our study suggest were collected from medical records and analyzed. Indications were that TPE is effective in diseases involving various organ systems compared with the latest ASFA categories of recommendations for and outcomes are good. It is technically feasible even in infants. therapeutic apheresis. The therapeutic response, serious adverse However, serious adverse events do occur due to the procedure events, PICU length of stay (LOS), and death during hospitalization per se. Hence, it is wise to choose the indications carefully, have were studied as outcome variables. Serious adverse events were predefined goals, anticipate technical difficulties, and be prepared defined as those occurring during or within 6 hours of completion for adversities. Limitations include that it is a single-center study and of the procedure and requiring additional vasoactive agents, its retrospective design. The severity of disease and mortality risk at mechanical ventilation, cardiopulmonary resuscitation (CPR), presentation could not be objectively assessed because of a lack of or resulting in mortality. Results: Eighty-eight sessions of TPE certain data. There has been only one previously published study on were done in 20 patients over 5 years period. Median age of the TPE in PICU from India. It was from our center, but it included only study population was 10.6 years (Range 7 months–16 years) with TPE for non-renal indications.7 To the best of our knowledge, our male:female ratio of 1.9:1. Median weight was 29.5 kg (Range 6.3 present study is the first comprehensive data from India on TPE in kg–55 kg). Median number of sessions per patient was 5 (Range PICU encompassing various diseases and indications. As more and 1–10). 12 patients had multiorgan dysfunction syndrome (MODS) more diseases with immunological mechanisms are discovered, the and equal number of patients required mechanical ventilation scope of TPE in children expands. Most of the currently available during PICU stay. 9 out of 20 patients required concurrent renal literature in children are from retrospective studies done in single replacement therapy (RRT), while none were on extracorporeal centers. Well-constructed, prospective, collaborative clinical trials membrane oxygenation. All patients underwent 1.5–2 times plasma need to be planned to further explore the scope and limitations of volume exchange depending upon the diagnosis. The replacement TPE in children. Conclusion: TPE is a promising tool in PICU to treat fluid was Fresh Frozen Plasma (FFP) in 12 patients while it was a a variety of conditions with significant morbidity and mortality. It is combination of FFP and 5% albumin in 7 patients. Cryo-poor plasma technically feasible even in small infants. However, serious adverse was used in 1 patient with sepsis/MODS. Median duration of each events do occur and need to be anticipated for better outcomes. session was 3 hours (Range 2.5–4 hours). Patients in our study received TPE for 11 different indications falling under various ASFA 4. Efficacy and Safety of Levetiracetam vs Phenytoin as Second- categories. Thirteen patients underwent TPE for ASFA category I line Antiepileptic Agent in Pediatric Convulsive Status Epilepticus: indications (first-line therapy), whereas 3 and 4 patients underwent A Systematic Review and Meta-Analysis of Randomized TPE for categories II(second-line therapy) and III (optimum role Controlled Trials. (Conference Abstract ID: 101) not established, decision invidualised) indications respectively. Renu Suthar, Suresh Kumar Angurana Common indications were thrombotic microangiopathy (TMA) of PGIMER, Chandigarh, India various causes (7/20) and acute liver failure (6/20). Other indications DOI: 10.5005/jp-journals-10071-23711.149 were vasculitis/connective tissue disorder in 5 patients and fulminant neurological diseases in 2 patients. None of the indication Introduction: Status epilepticus (SE) is the most common fell under ASFA category IV(TPE ineffective or harmful). Five serious neurological emergency in children. Intravenous PHT remained the adverse events occurred during total 88 sessions (5.6%). 3 of them preferred second-line anti-seizure medication (ASM) for pediatric occurred during procedure and 2 occurred within 6 hours. There SE. However, PHT is associated with various life-threatening adverse was good therapeutic response in 14 patients (70%). Average PICU events. LEV is emerging as an alternative second-line ASM for LOS was 16 days and there were 3 deaths during hospitalization the management of pediatric SE with efficacy and safety profile. (15%). Discussions: TPE in children needs close monitoring Objectives: To evaluate the efficacy and safety of levetiracetam because of the potential for hemodynamic instability and other (LEV) in comparison to phenytoin (PHT) as second-line antiseizure complications during the procedure. So, all TPE procedures in our medication (ASM) for pediatric convulsive status epilepticus (SE). hospital are done only in PICU. In this retrospective study on TPE in Materials and methods: Data source: PubMed, Embase, Google children from our PICU, 20 children underwent 88 sessions of TPE scholar/Google, Scopus, Cumulative Index to Nursing and Allied over 5 years. The median age was 10.6 years (range 7 months–16 Health Literature (CINAHL), Cochrane Database of Systematic years) and the median weight was 29.5 kg (range 6.3–55 kg) which Reviews, and Cochrane Central Register of Controlled Trials. were comparable to other similar studies done in children (1–4). Randomized controlled trials (RCTs) assessing LEV and PHT as a Patients in our study had a wide spectrum of diseases involving second-line agent for convulsive SE in children <18 years published

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between January 1, 2000, and November 30, 2020, were selected. novel statistical tools of net reclassification improvement (NRI) Data extraction: The data were pooled regarding the proportion and integrated discrimination improvement (IDI) to assess the of children achieving seizure cessation within 5 to 60 minutes of incremental predictive impact of new models that integrate a completion of study drug infusion (primary outcome); and seizure candidate marker (LAG) to preexisting models (PIM2). NRI and cessation within 5 minutes, time to achieve seizure cessation, seizure IDI values above zero indicate the improved performance of recurrence between 1 and 24 hours, intubation, and cardiovascular the novel index. Results: In the study population (n = 500), the instability (secondary outcomes). Data were analyzed using RevMan median age was 48 months (0-204 months) with a predominance version 5.4 and quality analysis was done using the Cochrane risk- of male patients (62%). Sepsis (21%) was the most common of-bias tool. The study protocol was registered with PROSPERO. cause of admission followed by cardiac (18%) and neurological Results: Twelve RCTs with 2293 children were enrolled. Seizure (16%) illness. Overall there were 120 deaths (observed mortality cessation within 5-60 minutes was similar with both the drugs [82% 24%) while 380 patients survived (76%). Mean LAG-index score in LEV vs. 77.5% in PHT, risk ratio (RR) = 1.04, 95% CI 0.97–1.11, p = was 58.78(±23.93). The LAG-index amongst patients who died 0.30]. Seizure recurrences within 1–24 hours was higher with PHT (n = 120) was significantly higher (94.9 vs 45.2,p = 0.001) than in comparison to LEV (16.6% vs 9.7%, RR = 0.63, 95% CI 0.44–0.90, the survivors (n = 380). LAG-index correlated significantly with p = 0.01). Higher proportion of children in PHT group required lactate(p = 0.001), anion gap(p = 0.001) and PIM-2 scores(p = intubation and mechanical ventilation (21.4% vs. 14.2%, RR = 0.54, 0.001). Amongst the indices, PIM-2 (p = 0.001), LAG-index (p = 95% CI 0.30–0.98, p = 0.04). Seizure cessation within 5 minutes, time 0.001) and serum lactate(p = 0.01) correlated well with observed to achieve seizure cessation, and cardiovascular instability were mortality. AUC by ROC-analysis was highest for PIM-2 (AUC = 0.79, similar with both the drugs. Three studies were at low risk of bias, 95% CI 0.646–0.920) which was very similar to the LAG-index and nine studies had high risk of bias. Discussions: In this systemic (AUC-0.76, 95% CI: 0.587–0.84, p = 0.24). LAG-index performed review and meta-analysis of 12 RCTs involving 2293 children, we significantly better than serum lactate (AUC – 0.64, CI: 0.503–0.787, demonstrated that the LEV was not superior to PHT as a second-line p = 0.02) and anion gap (AUC-0.56, CI: 0.425-0.700, p = 0.01) as agent for pediatric convulsive SE. The efficacy of LEV and PHT varied predictors of mortality. The optimal cut off value for LAG-index from 50 to 94% and 49 to 80%, respectively. In the pooled analysis, in predicting mortality in our population was derived as ≥94.7 the efficacy of LEV and PHT to control seizures within 5 minutes using ROC analysis (Sensitivity:89%, Specificity: 78%, PPV: 91.7%, of study drug infusion (61 vs 65%), 5 minutes to 1 hour of study NPV:88.6%, LR: 3.36, Youden’s index: 0.67). The incorporation of drug infusion (82 vs 77.5%) were similar, respectively. However, the LAG to PIM2 gave an NRI of 18.7% (p = 0.001) and IDI of 8.2% seizure recurrence rate within 24 hours of study drug infusion was (p < 0.001). However, incorporation of serum lactate and anion significantly higher in the PHT group as compared to LEV. The rate gap individually into PIM2 failed to show improved prediction of of intubation or mechanical ventilation was significantly higher in mortality as evidenced by poor NRI and IDI values. On comparing the PHT group whereas the rates of cardiovascular instability were AUCs between pre-existing models and LAG-incorporated models, similar with both the groups. Conclusion: The efficacy of LEV is the model of PIM2 with LAG showed significantly enhanced AUC not superior to PHT as second-line ASM medication for Pediatric of PIM2 with LAG (0.832, p = 0.01). Discussions: Our study is the convulsive SE. However, the seizure recurrences between 1 and 24 first to validate the novel LAG-index at admission as a significant hours and the need for intubation and mechanical ventilation were predictor of PICU mortality. Given the simplicity of calculation, significantly higher with PHT in comparison to LEV. single-point measurement, and widespread availability, LAG- index can be of immense significance in resource-limited PICU 5. Deriving a Novel, Cost-Effective Predictor of PICU Mortality in settings like India. A large sample size of 500 PICU patients, use of Resource-limited Settings: is “LAG” Index (Serum Lactate X Anion PIM2 as the standard comparator model, and the use of NRI (Net Gap at Admission) the Answer? (Conference Abstract ID: 80) Reclassification Improvement) and IDI (Integrated Discrimination Suddhasatta Ghosh, Grace Rebekah, Kala Ebenezer, Ebor J Jacob Improvement) indices are the strengths of our study. Though CMC Vellore, Tamil Nadu, India we have validated LAG-index in a single tertiary care PICU, our findings can encourage further multicenter prospective studies DOI: 10.5005/jp-journals-10071-23711.150 evaluating the utility of the LAG-index as a predictor of mortality Introduction: Various illness severity scoring systems have shown in different subsets of PICU patients. Conclusion: LAG-index can conflicting accuracies in predicting mortality in Indian pediatric bring about a paradigm shift in predicting mortality in Indian PICU. patients admitted to the PICU. While indices such as PRISM and PIM-scores have been widely validated, their use of multiple 6. Can we Predict Outcome of High-flow Nasal Cannula (HFNC) variable-based logistic regression models makes it cumbersome in Children Admitted to PICU with Bronchiolitis: A Novel Index for use in a resource-limited setup. Objectives: To assess the That “ROX”? (Conference Abstract ID: 64) predictive accuracy of the “LAG” index as a novel predictor of mortality in a tertiary care PICU. Materials and methods: A Suddhasatta Ghosh, S Ranadeep, H Sathya, Benjamin Sagyaraj cross-sectional study was carried out in 500 consecutive children Saveetha Medical College, Chennai, Tamil Nadu, India admitted to the PICU at CMC Vellore over a period of a year (July DOI: 10.5005/jp-journals-10071-23711.151 2017 to July 2018). Demographic data, serum lactate, anion Introduction: A significant concern during high-flow nasal cannula gap, and LAG-index at admission, PIM 2 score (www.sfar.org/ (HFNC) therapy in children admitted to PICU with bronchiolitis is scores2/pim22.html) for calculation of predicted mortality rate avoiding unnecessary delay in intubation. However, there remains a were assessed. Data were analyzed using Pearson’s correlations paucity of indices, especially in resource-limited PICU settings, that and stepwise multiple regression. The sensitivity and specificity can accurately predict the need for mechanical ventilation (MV) of the LAG-index were measured by constructing the receiver in this group of children. Objectives: To validate the diagnostic operating characteristic curves (ROC). We further utilized two accuracy of the novel ROX-index [defined as the ratio of oxygen

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saturation as measured by pulse oximetry/FiO2 to respiratory rate 7. Bicarbonate Deficit Correction in Acute Diarrhea Associated (RR)] for determining the need for mechanical ventilation in children Severe Dehydration and Severe Non-Anion Gap Metabolic with bronchiolitis on HFNC therapy. Materials and methods: This Acidosis: A Pilot Open-Label Randomized Control Trial. was a 1-year prospective observational cohort study performed in (Conference Abstract ID: 49) the pediatric intensive care unit (PICU) of a South Indian tertiary Lalit Takia, Arun Kumar Baranwal, Suresh Kumar, M Jayashree care hospital, including children with bronchiolitis who were treated PGIMER Chandigarh, India with HFNC. Children needing immediate MV and those electively DOI: 10.5005/jp-journals-10071-23711.152 intubated for diagnostic or therapeutic procedures were excluded. Introduction: World Health Organization (WHO) recommendation Patients were followed up till death or discharge and failure of HFNC is silent on the role of bicarbonate therapy in children with acute was defined as a subsequent need for MV. Clinical and respiratory diarrhea and severe dehydration having severe non-anion gap variables including arterial blood gas parameters (SpO2, FiO2, RR, metabolic acidosis (NAGMA) due to lack of pediatric evidence. We flow, PaO2, PaCO2) and ROX-index (SpO2/FiO2 to respiratory rate) planned to study the efficacy and safety of bicarbonate therapy were assessed at 0, 2, 6, 12, 18, and 24 hours and subsequently once in addition to dehydration correction in children with acute daily after initiation of HNFC, while the length of ICU stays, HNFC diarrhea and severe dehydration and severe NAGMA. Materials therapy and MV were also recorded. Predictive accuracy of ROX- and methods: Children (age, ≥1 months to <12 years) with acute index and specific cut-offs were derived using area-under-receiver diarrhea and severe dehydration presenting with severe NAGMA operating characteristic curves (AUROC) analysis while multivariate (pH < 7.2 and/or serum bicarbonate <15 mEq/L) were enrolled in regression analysis using Cox proportional hazard model was done a randomized open-label trial at a tertiary care center. Controls (n to elicit association of ROX-index with the highest risk of HNFC = 24) received WHO-recommended dehydration correction with failure. Results: Among the 129 patients treated with HFNC, 37 ringer lactate, while an additional bicarbonate deficit correction was given in the intervention group (n = 23) at admission. Time (29%) required intubation, with age and gender distribution being to resolution of metabolic acidosis (pH >7.30 and/or bicarbonate similar in the HFNC-successful (n = 92) and HFNC-failure (n = 37) >15 mEq/L) (primary outcome), adverse outcome (composite of groups. The predictive accuracy of the ROX index as evidenced by PICU transfer and mortality), acute care area free days in 5 days the AUROC was highest at 2 hrs (0.713, CI: 0.63–0.79, p =0.001), 6 (ACAFD5), hospital stay, and safety (secondary outcomes) were hrs ( 0.766, CI:0.71–0.83, p = 0.002), 12 hrs (0.843, CI:0.76-0.88,p compared. Results: Both groups were comparable at baseline. = 0.001),18 hrs (0.811, CI: 0.69–0.84, p =0.002) and 24 hrs (0.792 Metabolic acidosis resolved significantly faster in the intervention ,CI:0.70–0.83, p =0.01) amongst all respiratory variables measured, group compared to controls [median (IQR); 8 h (4,28) vs 12 h (4,72); with cut-offs of ROX-index at 2 hrs, 6 hrs and 12 hrs ( 4.64, 4.95 and p = 0.013]. At 16 h, more children in intervention group achieved 5.34 respectively) demonstrating superior sensitivity, specificity target compared to controls (22/23 vs 16/24, p = 0.031). Among and positive predictive values. Further, children who failed the controls, patients with fluid refractory shock (n = 4) needed higher HNFC (n = 37) showed lesser increase in ROX-index over the first 12 inotropic support compared to intervention group (n = 2) (VIS, hours than those who were successful on HNFC (n = 92, p < 0.01), 34 vs 10). Five patients in the control group needed PICU transfer thus suggesting the gradual increase in ROX-index as a valuable (two of whom died), while none in the intervention group (p = predictor in the initial 12 hours. Moreover, at the pre-specified 0.049). Intervention group had more ACAFD5 compared to controls cutoffs, regression analysis revealed ROX-index measured at 2hrs [median (IQR); 2 (1,2) vs 1 (1,2); p =0.17]. Discussions: Considering (hazard ratio, 0.434; 95% confidence interval, 0.264–0.715; P = 0.001), the longer time required for resolution of acidosis and relatively 6hrs (hazard ratio, 0.304; 95% confidence interval, 0.182–0.509; higher incidence of adverse outcome in severe NAGMA patients, P < 0.001)and 12 hours (hazard ratio, 0.291; 95% confidence interval, we hypothesized that providing bicarbonate, in addition to WHO- 0.161–0.524; P < 0.001) after HFNC initiation to be consistently recommended dehydration correction with RL, may accelerate associated with a lower risk for intubation, after adjustment of the resolution of acidosis and improve the overall outcome. Low multiple covariates. Intubation after 48-hours of HNFC was not serum bicarbonate is the commonest electrolyte abnormality seen in children with diarrhea, and severity of dehydration and associated with increased mortality. Discussions: Our results other parameters of sickness are found to correlate bicarbonate indicate that ROX-index can be a valuable tool in a resource-limited levels at admission.1–3 In a small controlled trial (n = 30), done PICU setting in determining a need for ventilation in bronchiolitis more than five decades back, bicarbonate deficit correction in patients. Not only specific ROX-values at timed intervals but also the children with metabolic acidosis (pH < 7.34; range, 7.00–7.34) rate of increase over the first twelve hours can be useful predictors could not show any difference in time taken in the correction of HFNC failure in these children. This is the first study to utilize this of metabolic acidosis.3 There is no information on the number novel index in a pediatric Indian population. Conclusion: This is the of children with severe metabolic acidosis (pH < 7.20) in the first study to validate the predictive performance of the novel ROX- study. In another study, intravenous dehydration correction with index in children admitted to PICU with bronchiolitis and treated bicarbonate-containing fluid was shown to increase the serum initially with HFNC. ROX provides an easy-to-use, low-cost, and bicarbonate and pH significantly compared to non-bicarbonate effective tool which can have significant therapeutic implications in containing fluid in severely dehydrated infants.4 The persistence resource-limited PICU setups to determine the need for ventilation of metabolic acidosis for a longer duration seems to be the cause in bronchiolitis patients. of prolonging the requirement of vasoactive agents, the need

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for PICU transfer, and mortality in the control group. A better 21 (47.7%); p = 0.011]. Secondary Outcomes: Lesser GDT patients outcome in the intervention group might have been due to the attained endpoints within 5-day intervention period [24 (52%) vs rapid resolution of metabolic acidosis. Sharifuzzaman et al. had 29 (66%); p = 0.21], however they attained it earlier (9h vs 12h; p also demonstrated higher mortality associated with metabolic = 0.42) with higher emergency room (ER) mortality [16 (34.7%) vs acidosis.5 Wathen et al. demonstrated extended hospital stay with 10(22.7%); p = 0.2]. Median duration of vasoactive drugs among lower bicarbonate in patients with dehydration.6 Similarly, children survivors was longer in GDT group (75h vs 59h; p = 0.62). Median in the intervention group with early resolution of acidosis had less length of ACA stay was higher in GDT group (9 h vs 6.5 h; p = 0.77). ACA stay and hospital stay. Early resolution of acidosis is likely to More children required mechanical ventilation in GDT group [43 lead to less utilization of critical care services and early discharge (93.5%) vs 37 (77.3%); p = 0.03]. Discussions: Our study analyzed from hospital, and thus the faster turnover. It is likely to free-up the the outcomes of GDT with interventions targeting ScvO2 >70% until scarce PICU/hospital beds and healthcare resources for other more 5 days from enrolment vs the existing standard of care in a setting deserving critically ill children in LMICs. Conclusion: Simultaneous with a limited number of PICU beds. The existing unit’s current bicarbonate therapy during dehydration correction in the sickest practice includes initial fluid resuscitation, vasoactive infusion lot of diarrhea-dehydration children with severe NAGMA led to through the peripheral line, intubation and hand ventilation if faster resolution of metabolic acidosis, less utilization of critical care required, early antibiotic therapy, CVC insertion (preferably femoral facilities, and less mortality. No adverse events were associated with vein) when VIS > 30 or in situations of difficult peripheral access. bicarbonate therapy. These findings need further validation from We postulated that even if early goal direction, in the strict sense, larger multicentric trials. was difficult, targeting ScvO2 > 70% and sustaining it may improve outcomes. However, we found that the all-cause mortality in GDT 8. Superior Venacaval Oxygen Saturation Monitoring-based (74%) was higher than the ST group (47%). Conclusion: GDT group Goal-directed Therapy vs Standard Care in Children with Septic had a worse outcome compared to ST, however patients in the Shock: An Open-label Randomized Control Trial. (Conference former group were sicker on many aspects despite randomization. Abstract ID: 46) Children who persistently had ScvO2 < 70% despite resuscitation Namita Ravikumar, Arun Baranwal, Muralidharan Jayashree, were likely to have an unfavorable outcome. Adherence to Ashish Jain, Savita Verma Attri, Pramod Gupta components of SSC guidelines is difficult to achieve in absence of PGIMER, Chandigarh, India PICU transfer for the level of critical illness we cater to. The endpoints DOI: 10.5005/jp-journals-10071-23711.153 of resuscitation were attained earlier in the GDT group, although it Introduction: Widespread implementation of resuscitation bundle could not get translated into survival. has significantly reduced septic shock mortality in high-income 13. Perioperative Clinical Studies countries questioning the importance of superior venacaval oxygen saturation (ScvO2) monitoring-based early goal-directed therapy 1. Heart Rate Monitoring of Anesthesiology Residents during (EGDT). However, higher infection burden, suboptimal transport, the Airway Management of COVID-19 Suspect Patients: An poor infrastructural facilities, lack of time management, and inability Observational Study. (Conference Abstract ID: 191) to adhere to the EGDT-based management bundles in lower middle- Adabala Vijay Babu, Bhavna Gupta income countries (LMICs) pose a challenge. We studied the effect AIIMS, Rishikesh, Uttarakhand, India of ScvO2 monitoring based GDT until shock reversal vs standard care prevalent in a setting of high pediatric septic shock mortality DOI: 10.5005/jp-journals-10071-23711.154 in terms of feasibility, mortality, and other outcomes. Materials Introduction: Technology has become an integral and central and methods: Design: Randomized Control Trial. Setting: Tertiary element in modern-day life and affects how we all work and care teaching hospital. Study period: 15 months (October 2018 to function. Technology has a positive effect for the most part, as it December 2019). Participants: Children (6 months–12 years) with helps us handle and monitor our everyday activities. Nevertheless, fluid refractory septic shock. Inotrope at arrival, chronic illness, new technology has a significant role to play, such as, solving several healthcare-associated infection, and contraindication for central other difficulties confronting healthcare services. Anesthesiology by venous catheter were exclusions. Interventions: GDT group (n = 46) itself is a stressful job. And the stress is quite evident in the residents, received fluids, inotropes, and packed red cells targeting ScvO2 of which leads to several health-related issues, cardiovascular >70% throughout the shock management. Standard therapy (ST; diseases at an early age, a high number of suicidal attempts by n = 44) group received usual care as per prevalent unit practice. the anesthesia residents.1 With the advancement of technology, Outcome: Mortality, shock endpoints, organ dysfunction, and ScvO2 smartphone applications for healthcare, e.g., mobile heart disease trend. Results: Baseline characteristics: GDT had lower median age detection, heart rhythm analysis, remote home care monitoring, (30 vs 60 months; p =0.09), more severely malnourished children and eye disease diagnosis, have become highlighted. We conducted (21.7% vs 6.8%; 0.07), lower pH (7.25 vs 7.315; p = 0.016), had a study to monitor the anesthesiology residents’ heart rate received more fluids (30 vs 20 mL/lg; p = 0.89) and higher vasoactive variation in the COVID-19 suspect area and compare it to their inotrope score at enrolment (30 vs 20; p =0.66). PRISM-III scores at sleeping HR and baseline HR value. We assume that a significant 12 and 24 hours were comparable. GDT group had lower median increase in HR during airway management is an indicator of the hemoglobin (8.8 vs 9.9 g/dL, p = 0.12), platelet count (1.27 vs 1.31 x stress the resident is undergoing, which usually goes unnoticed. 106 per mm3) and higher TLC (12.5 vs 10.4 x 103 per mm3). Primary Materials and methods: In a tertiary care academic center, this Outcome: Significantly more patients died in GDT [34 (73.9%) vs was a prospective observational cohort study of anesthesiology

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residents. All the residents included in the study were of age 20 2. To Study the Relation of the Volume of Local Anesthetic to 45 years, ASA I–II, and the residents with the experience of and Diaphragm Motility in Ultrasound-guided Supraclavicular managing the airway for 6 months. Airway management of patients Brachial Plexus Block. (Conference Abstract ID: 186) with difficult airways was not included in the study. Informed Deepti Mehta, Gurjeet Khurana, Abhimanyu Pokhriyal consent was taken from all the residents who participated in the Himalayan Institute of Medical Sciences, Uttarakhand, India study. As this sort of research is the first of its kind, 30 residents DOI: 10.5005/jp-journals-10071-23711.155 were included in this study. All participants wore a smartwatch MI Introduction: Regional anesthesia and peripheral nerve blocks band four before going to sleep and installed MI fit application on have an important role and have many advantages to be near ideal their smartphones and clicked on continuous sleep and heart rate anesthetic techniques for various surgical procedures. It provides monitor to detect sleep patterns and sleeping heart rate. From the site-specific surgical anesthesia, prolonged postoperative analgesia, inbuilt software recordings in the application, participants’ sleeping minimizes the need for general anesthesia, and facilitates early duration, sleeping HR, and baseline HR were recorded. The next discharge. Peripheral nerve block technique has an opioid-sparing day, HR monitoring of residents during the induction of general effect, more comfortable for the patient, eliminating side effects, anesthesia in an elective case (COVID SUSPECT area) from 8:40 such as, nausea, vomiting, and reduces patient’s fear, gagging am to 9 am was recorded in three phases (pre-induction, during on the endotracheal tube, surgical pain, remembrance, residual induction, and post-induction). Results: 30 residents were included weakness, shivering, sore throat, and somnolence. It meets the with a mean and standard deviation of age (26.4 + 1.4, minimum demand of the surgeon, anesthesiologists, and more comfortable 22 and maximum 29) years, BMI (23.82 + 2.52, minimum 18.68 and for the patient. A comfortable, symptom-free patient can be maximum 26.56) KG/M2 and having a sleeping pattern of (6.3 + 0.8 discharged from the post-anesthesia care unit in a timely fashion, minimum 5 and maximum 8) hours with a predominance of male thus reducing prolonged stay to hospital and cost.1,2 Objectives: residents (11:4). Mean heart rate variations at various time points To study the incidence of diaphragmatic paresis/paralysis with is summarised in table 1 with significant difference seen at time different volumes of 0.5% ropivacaine in ultrasound-guided points (T- B vs T-R and T-I vs T-B and T-R with p value 0.001, 0.000 supraclavicular brachial plexus block. Materials and methods: and 0.000 respectively). No significant difference was observed Thirty-six patients undergoing forearm and hand surgery receiving between the baseline HR when compared to pre intubation HR and ultrasound-guided supraclavicular brachial plexus block with 0.5% post-intubation HR, but significant difference was observed when it ropivacaine were enrolled. As per Dixon and Massey up and down was compared to resting HR (p value 0.115 and 0.000 respectively). method,3 the initial volume of 0.5% ropivacaine was 25 mL and Mean and standard deviation of percentage increase in heart rate we observed for the incidence of diaphragmatic paralysis/paresis at intubation from resting heart rate was 42.79 ± 25.54 percent. in 5 consecutive patients then 0.5% ropivacaine volume for the (minimum increase 2.79 and maximum increase 98%). Figure 1 next patients was determined by the response of the previous reflects the heart rate of participants at various time points. S. No patients. The next patient received 2 mL lower volume in case of Time points Heart rate pattern Mean + SD P-value P value 1 T-R success and 2 mL higher volume in case of failure of the previous Sleeping heart rate 69.3 + 13 2 T-B Baseline HR 89.1 + 5.7 T-B vs T-R one. Results: 15 mL of 0.5% ropivacaine produced effective 0.001 T-B vs T-R 0.000 3 T-pre I Pre Intubation HR 86.0 + 5.3 T-pre I surgical anesthesia with no incidence of diaphragmatic paralysis/ vs T-B 0.523 T-pre I vs T-R 0.553 4 T -I Intubation HR 96.4 + 10.4 T-I paresis with ultrasound-guided supraclavicular brachial plexus vs T-B 0.000 T-I vs T-R 0.000 5 T -post I Post intubation HR 88.6 + 8.2 block. Discussions: In our study, we enrolled a total of 36 patients, T-post I vs T-B 0.115 T-post I vs T-R 0.000. Discussions: Stress has a out of which failure was observed in 1 (2.8%) patient. This lower detrimental impact on healthcare organizations at multiple levels rate of failure is attributable to the ultrasound-guided technique. and, further significantly, is correlated with poor patient safety and This shows the superiority of ultrasound-guided technique over quality of treatment, as it can manifest itself through exhaustion classical and nerve stimulator technique. In-plane approach (needle and diminished cognitive functioning, eventually affecting the around the ultrasound probe’s longitudinal axis) lateral to medial performance of individual work and contributing to a greater was used in our study because by this approach structures were risk of errors. Smartwatches, wrist bands, and activity trackers better visualized and needle visualization was clear and possible commonly used these days are based on electrocardiography (ECG) when needle introduced from the back of the probe. Thus, there or photo-plethysmography (PPG).2 We used Mi band 4 to monitor was no correlation observed between quality and onset of the the heart rate of all residents. We chose this band because it is motor block with different volumes of 0.5% ropivacaine (25–15 cheap, comfortable to wear, rather discreet and lightweight. It is mL). We also observed the meantime of involvement of individual based on the principle of photo-plethysmography (PPG). Our study nerves, such as, ulnar nerve (UN) radial nerve (RN), median nerve observed a significant difference in sleeping HR when we compared (MN) in different volumes of 0.5% ropivacaine. Thus, we conclude the baseline HR and with the induction HR (p < 0.05). This could be that while decreasing volume of 0.5% ropivacaine involvement of due to the activity of the resident and the stressor response of the UN, RN occur late and there was no difference in the involvement body. And we found a significant difference between baseline HR of MN. They explained this by the fact that ulnar and medial and intubating HR. Conclusion: This sort of continuous information cutaneous nerves are derived from the inferior trunk of the can be used as the feedback option for users to improve their work brachial plexus which is difficult to approach by in-plane technique efficacy. To date, technology has revolutionized healthcare facilities. though they achieved successful block with 30 mL. The volume Working knowledge of these smart devices will help us to balance of LA was a prime consideration in our study. We tried to find out our stress-free day-to-day activity.

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the minimum effective volume of 0.5% ropivacaine required for fentanyl in attenuating the hemodynamic responses, BIS and surgical anesthesia. The minimum effective volume estimated cerebral perfusion pressure changes to pin placement during was 15 mL of 0.5% ropivacaine. This 15 mL of 0.5% ropivacaine elective craniotomies. Materials and methods: Sixty patients was found to be sufficient for adequate anesthesia for upper limb undergoing elective craniotomy with skull pin placement were surgeries below mid humerus. Saric et al. studied the minimum randomly categorized into two equal groups. Group I received IV effective volume of 50:50 mixture of 0.5% levobupivacaine and dexmedetomidine 1 µg/kg over 10 minutes and group II received 2% lidocaine in elderly and middle-aged patients and concluded IV fentanyl 1 µg/kg over 10 minutes before pin insertion. Outcome minimum effective volume in elderly was 16.49 mL and in middle- variables like heart rate, blood pressure, SpO2, EtCO2, central aged was 44.52 mL.4 Diaphragmatic paralysis was a major concern venous pressure, cerebral perfusion pressure, condition of the in our study. This complication is because of the cephalad spread brain, and the adverse side effects of the drugs were compared in of LA and the involvement of the phrenic nerve. We assessed the both the groups at different time intervals pre, post, and during diaphragmatic excursion with ultrasound in M mode preoperatively pin insertion, i.e., B0 (baseline value), I0: At the initiation of IV drug on both sides, after 30 minutes of block performance, postoperative infusion of dexmedetomidine or fentanyl. I2, I4, I6, I8, I10: 2, 4, 6, after 6 hours of the block. Percentage of diaphragmatic paralysis 8, and 10 minutes during IV drug infusion. T0: At the completion decreases by decreasing volume of drug in successive patients. of pin insertion. T30, T60, T90, T120, T150, T180, T300, T600, 17 and 15 mL of 0.5% ropivacaine were found to be safer as there and T900: 30, 60, 90, 120, 150, 180, 300, 600, and 900 seconds, was partial loss of diaphragmatic movement after 30 minutes of respectively, after pin insertion. Results: The demographic data the block but it was not significant. Renes et al. did a study on was comparable between both the groups. No significant change ultrasound-guided supraclavicular brachial plexus block, using in heart rate, cerebral persuasion pressure, BIS among both the 20 mL of 0.75% ropivacaine, and found that none of the patients groups at all the time intervals. Systolic, Diastolic, mean blood developed hemidiaphragmatic paresis and reduction in lung pressure and central venous pressure was significantly increased function (FEV1, FVC, PEFR).5 In our study, we also assessed the in the fentanyl as compared to the dexmedetomidine group diaphragmatic excursion through a portable bedside spirometer. after the pin insertion (p < 0.05). Surgeons reported satisfactory We measured FEV1, FVC, and PEFR preoperatively as a baseline brain condition during surgery in the dexmedetomidine group. after 30 minutes of the block and 6 hours post block and compared Discussions: The application of skull pin head holder application preop values with 30 minutes after block, 30 minutes after block used in craniotomies for rigid immobilization of the head during with 6 hours post block within groups. Also, we compared different the procedure produces a brief, intense hemodynamic response volumes of 0.5% ropivacaine. Based on our study observations despite an adequate depth of anesthesia, which can be deleterious was that with higher volumes there was a decrease in pulmonary to the patient as it can even lead to changes in the cerebral function after 30 minutes of the block. The mean difference seen perfusion changes and its sequelae, these stress response can be was more in higher volumes than the lower volumes. Conclusion: blunted using various pharmacological agents in addition to the We concluded, on decreasing volume of 0.5% ropivacaine, the local infiltration with local anesthetics.3,4 Based on our results from incidence of diaphragmatic paralysis decreases significantly, and the study, we can emphasize that even though both the agents no compromise on the quality of the block. have the potential to attenuate this stress response, intravenous dexmedetomidine infusion in a dose of 1 µg/kg over 10 minutes 3. Comparison of the Effect of Dexmedetomidine vs Fentanyl just before the pin application has better hemodynamic stability Infusion on Attenuating the Hemodynamic Responses, Bispectral than intravenous fentanyl 1 µg/kg over 10 minutes. Both the Index (BIS) Changes and Cerebral Perfusion Pressure to Skull agents lead to comparable changes in the BIS values. Thus, this Pin Head Holder Application during Craniotomy. (Conference study serves as a double edge sword-albeit in a good way — by Abstract ID: 185) not only substantiating the intraoperative hemodynamic stability Shivangi Saxena, Parul Jindal, Parul Jindal for the anesthesiologist but also by aiding in providing a good Himalayan Institute of Medical Sciences, Uttarakhand, India surgical field for the neurosurgeon. Conclusion: Based on the results of our study, we suggest IV dexmedetomidine a dose of 1 DOI: 10.5005/jp-journals-10071-23711.156 µg/kg infusion over 10 minutes is a better attenuating agent than Introduction: Rigid head immobilization before craniotomy is a IV fentanyl 1 mg/kg over 10 minutes for blunting the deleterious pivotal element of neurosurgery. As microscopic neurosurgery hemodynamic response to the skull pin placement. requires operating with smaller incisions as well as restricted surgical corridors, firm head immobilization is important 4. CMAC Videolaryngoscopy vs Direct Laryngoscopy: Comparing to maintain the appropriate position of the head and thus, the Mouth-to-Nose Distance between the Patient and providing stabilization during the complex surgical procedures Laryngoscopist. (Conference Abstract ID: 179) which are easily achieved by skull pin application.1 Despite the adequate depth of anesthesia, insertion of skull pin for the Surabhi Gupta, Rajesh S Mane stability of head during elective craniotomies, along with skin Jawaharlal Nehru Medical College, India incision and intubation may prove to be a prominent noxious DOI: 10.5005/jp-journals-10071-23711.157 stimulus characterized by an acute sympathetic stimulation, Introduction: Tracheal intubation is a high-risk procedure for leading to hemodynamic instability.2 These noxious stimuli the transmission of the virus during this COVID-19 pandemic. can lead to a sympathetic response in turn tachycardia and These patients may require emergency tracheal intubation and hypertension which may further disrupt cerebral autoregulation. mechanical ventilation to help recovery from illness. These patients Objectives: To compare the effect of dexmedetomidine and may also present for various emergency/elective surgeries that

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may require administration of general anesthesia and tracheal Introduction: Postoperative cognitive dysfunction is defined as intubation. Procedures involving securing and manipulation of a new cognitive impairment arising after a surgical procedure. the airway may put the laryngoscopist at great risk of exposure to The International Society of Postoperative Cognitive Dysfunction the virally contaminated aerosols. Increasing the distance of the considers that POCD is developed when postoperatively deficits are laryngoscopists face from the patient and expelled droplets reduces observed in a patient in one or more discrete areas of mental states, the direct exposure to the mucous membrane. The study aimed to such as, attention, concentration, executive function, memory, determine the mouth-to-nose distance between the patient and visuospatial ability, and psychomotor speed. Various factors laryngoscopist, the angle formed between the two oral cavities, increase its risk in the postoperative period and are associated with and the ease of intubation. Materials and methods: The study was poorer recovery, reduced quality of life, and increased mortality. approved by Institutional Ethical Committee. A total of 104 ASA I Objectives: To assess postoperative cognitive dysfunction in terms and II patients undergoing surgery under general anesthesia were of diagnosis, symptoms, and care needs; to analyze relationships enrolled and consent was taken. They were randomly divided into between risk factors and its diagnoses in orthopedic patients in two groups — one group undergoing tracheal intubation with a Regional Cancer Centre. Materials and methods: Its diagnosis CMAC videolaryngoscope and another group with Macintosh requires both pre- and postoperative psychometric testing. An direct laryngoscope. The intubation procedure was filmed and observational pilot study was done on 20 patients admitted over the mouth-to-nose distance formed between the patient and the 1 month period in the orthopedic department of a regional care laryngoscopist was calculated. The angle formed between the two center. Results: Factors that elevate the risk of POCD include old oral cavities were assessed using a mobile phone application. The age, pre-existing cerebral, cardiac, and vascular disease, alcohol ease of intubation was determined using a standard scoring system. abuse, pre – operative anxiety and depression, low educational Descriptive statistics reported using mean, median, and standard level, and intra- and postoperative complications. POCD is deviation for continuous variables and compared using Student’s associated with poorer recovery and increased utilization of social paired t-test. Categorical variables were reported using numbers financial assistance. It is also associated with higher mortality. and percentages and compared using the Chi-square test. Results: Persistent POCD enters into the differential diagnosis of dementia. The mean mouth-to-nose distance using CMAC VL was 45.5673 Discussions: POCD is a transient postoperative disturbance and and using DL was 27.6731. This was statistically significant using a meticulous care should be taken by the surgical and anesthesia paired t-test (p < 0.05). The mean angle formed by the oral cavities teams to prevent intraoperative complications that reduce the risk was 49.0577 and 34.0769 with CMAC VL and DL respectively. The of POCD. This influences, to various degrees, the patients’ quality ease of intubation was also scored more with CMAC VL compared of life. Conclusion: POCD is a transient postoperative disturbance to DL. Discussions: The greatest viral load of SARS-CoV-2 is most This influences, at various degrees, the patients’ quality of life. Until commonly found in the sputum and upper airway secretions. today, many studies have attempted to investigate POCD; however, Droplet spread and direct contact with the respiratory secretions the pathophysiology is not completely elucidated and there are is the leading mode of transmission. The aerosol spread is another many unanswered questions. Further detailed multicenter studies mode of transmission and these particles can remain suspended in are required to evaluate this further. the air for longer periods. Hence, procedures, such as, endotracheal intubation, connection, and disconnection from a ventilator 6. Comparative Study of Intravenous Tramadol vs Rectal Tramadol circuit, extubation, bronchoscopy, tracheal suctioning can cause for Postoperative Analgesia in Patients Undergoing Cesarean aerosolization of the viral particles. The process of handling infected Section under Spinal Anesthesia. (Conference Abstract ID: 143) patients and performing these procedures can increase the risk Nishkam Verma, Neelam Singh, Dharmendra Kumar Yadav, of infection to the laryngoscopist. This study showed that the use Vaibhav Singh of a videolaryngoscopy significantly extends the mouth-to-nose Moti Lal Nehru Medical College Prayagraj, Uttar Pradesh, India distance between the patient to the laryngoscopist compared to direct laryngoscopy and places the laryngoscopist’s face above the DOI: 10.5005/jp-journals-10071-23711.159 direct line of sight to the pharynx, thus minimizing the risk of direct Introduction: Pain is defined as an unpleasant sensory and emotional 1 exposure to virally contaminated particles. It may also help reduce experience associated with actual or potential tissue damage. the time taken for intubation, thus avoiding a longer exposure to the Postoperative pain is important in causing psychological trauma to laryngoscopist. Conclusion: VL significantly increases the mouth- the patient. Patients who undergo cesarean section should achieve to-nose distance between the patient and the laryngoscopist more postoperative pain relief than surgical patients because of 2 compared to DL and increases the angle formed between the different factors related to the operation. For pain relief various 3 laryngoscopist’s face and the patients’ oral cavity. Intubation is groups of drugs, such as, opioids and NSAIDs are used. Tramadol easier with VL compared to DL. Hence, this study signifies the use has a unique dual action of pain relief, acting both as a central opiate of a videolaryngoscope to minimize the risk of exposure of the agonist and CNS reuptake inhibitor of norepinephrine and serotonin. infected viral particles to the laryngoscopist. Tramadol exists as 2 enantiomers with analgesic properties, both with different mechanisms of action. (+)-Tramadol and its metabolite 5. Incidence of Postoperative Cognitive Dysfunction in Patients O-desmethyltramadol (M1) act as mu-receptor agonists altering 4 after Orthopedic Surgeries in a Regional Care Center: A Pilot the release of nociceptive neurotransmitters. Tramadol used by Study. (Conference Abstract ID: 154) different routes, such as, intravenous, intramuscular, rectal or local infiltration, etc., have analgesic efficacy with different duration and Komal Upadhyay, Kanta Bhati variable incidence of side effects.5,6 In this study, we compared Sardar Patel Medical College, Bikaner, Rajasthan, India intravenous tramadol vs rectal tramadol for postoperative analgesia DOI: 10.5005/jp-journals-10071-23711.158 in the cesarean section under spinal anesthesia. Objectives: To study

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postoperative analgesia and duration with intravenous and rectal MAP, and SPO2 were monitored and VAS and side effect was noted at routes of drug administration. Side effect also noted. Materials and an interval of 1, 2, 4, 6, 8, 10, and 12 hours. If patient having VAS >4 inj. methods: The study was comparative, randomized, prospective, diclofenac 75 mg given as rescue analgesia. Results: Table 1 shows and hospital-based and conducted on 90 obstetric patients aged the demographic data in both groups, which was similar. Tables 2 from 20 to 40 years, who comes in ASA class I and II undergone for and 3 show the postoperative VAS score in group I and group R, cesarean section after obtaining written consent. Patients having a respectively. Table 4 shows the time and frequency of the rescue history of allergy to any drugs, a cardiovascular, renal, respiratory, analgesic. Table 5 shows the total duration. Table 6 shows the side- and neurological disease that comes under ASA> II were excluded effects.. Discussions: This study evaluates the role of tramadol by from the study. All patients were explained about the procedure two different routes in the cesarean section for postoperative pain. and visual analog scale for pain measurement.7 All 90 patients We studied VAS scores in both groups and gave rescue analgesia at were divided randomly into two groups of 45 each as group I for a score >4. In group I, 100% of patients had been received rescue intravenous and group R for the rectal route of tramadol. After taking analgesia by the end of 10 hours while 73.4% of patients in group the patient on the operation table, multipara monitor was applied R needed it by the end of 12 hours and the remaining 26.6% of and the baseline parameter was noted. Intravenous line secured patients were not needed it. Hence, the duration of analgesia was with 18-gauge intravenous cannula and infusion of ringer lactate prolonged in group R compared to group I. Side effects like nausea started with injection metoclopramide 10 mg and ranitidine 50 mg and vomiting were complained more in group I as compared to were given to all patients. Spinal anesthesia is given with a 25-gauge group R. Gadani et al.6 found a significantly prolonged duration of spinal needle in L3–L4 interspaces with 0.5% bupivacaine heavy 12 analgesia in the rectal group against intravenous tramadol group mg with the desired level of T4 achieved. At the end of the surgery, (504 ± 146.96 vs 426 ± 80.36 minutes). Also, they found a 15% tramadol 1.5 to 2 mg/kg (max 100 mg) was given intravenously incidence of PONV in the intravenous tramadol group as against to group I patients and 1.5 to 2 mg/kg (max 100 mg) suppository 5% in the rectal suppository group. Patel et al.8 found that 45% inserted per rectally in group R patients for postoperative analgesia. of the patients needed the first rescue analgesic at 6 hours in the This was considered 0 hours. Postoperatively, parameters like PR, intravenous tramadol group, whereas only 5% of the patients in the rectal tramadol group needed it. By the end of 10 hours, all 100% Table 1: Demographic parameters of patients received rescue analgesic in the intravenous tramadol Group I Group R group and 65% of patients in the suppository group which was a Mean ± SD Mean ± SD p value significantly lower proportion. Thus, the duration of analgesia was prolonged in the rectal group with fewer side effect. Padol et al.9 Age 26.20 ± 3.25 26.91 ± 4.51 0.393 found that the duration of postoperative analgesia was prolonged Wt (kg) 61.51 ± 4.28 61.42 ± 4.89 0.927 with the rectal route compared to intravenous administration

Table 2: VAS for group I VAS 1 hour 2 hours 4 hours 6 hours 8 hours 10 hours 12 hours 0 12 9 0 0 0 0 0 1 33 35 0 0 0 10 0 2 0 1 6 1 1 1 2 3 0 0 36 34 19 27 43 ≥4 0 0 3 10 25 7 0

Table 3: VAS for group R VAS 1 hour 2 hours 4 hours 6 hours 8 hours 10 hours 12 hours 0 14 16 0 0 0 0 0 1 31 20 2 0 0 0 0 2 0 9 25 17 5 1 0 3 0 0 18 28 37 28 31 ≥4 0 0 0 0 3 16 14

Table 4: Rescue analgesia (no. of patients (%)) Table 5: Duration of analgesia (in minute) Time Group I Group R Group I Group R p value 1 hour 0 (0.0%) 0 (0.0%) Mean ± SD 456.00 ± 94.35 640.00 ± 77.46 <0.001 2 hours 0 (0.0%) 0 (0.0%) 4 hours 3 (6.7%) 0 (0.0%) Table 6: Side effects (no. of patients (%)) 6 hours 10 (22.2%) 0 (0.0%) 8 hours 25 (55.6%) 3 (6.7%) Group I Group R 10 hours 7 (15.6%) 16 (35.6%) Nausea 4 (8.9%) 2 (4.4%) 12 hours 0 (0.0%) 14 (31.1%) Vomiting 10 (22.2%) 3 (6.7%)

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and noted nausea and vomiting were lower with the rectal route. • During 12-24 hrs postoperatively, the incidence of nausea was Conclusion: Since the duration of analgesia was prolonged with inGroup-P (11.43%) Vs Group-R (31.43%), which was statistically group R which was observed by time for the need of rescue analgesia significant (p < 0.05). and percentage of patients who required it in both groups. Hence, • During 12-24hrs postoperatiely,the incidence of vomiting in we concluded that the rectal route of tramadol is a safe, noninvasive, Group-P was (14.3%) Vs Group-R (22.9%) (p>0.05) and complete and better alternative for pain relief in cesarean section with a response in Group-P was (80%) Vs Group-R was (62.9%) which minimal side effect. was not statistically significant (p>0.05). • During 12-24 hrs postoperatively VAS score in Group-P 7. Comparison of Efficacy of Ramosetron vs Palonosetron in was 0.34±0.90 Vs in Group-R 1±1.49 and the difference was Prevention of Postoperative Nausea and Vomiting in Patients statistically significant (p < 0.05). Undergoing Middle Ear Surgery under General Anesthesia. • During period of 24-48hrs postoperatively incidence of nausea (Conference Abstract ID: 135) in group-P (17.14%) Vs Group-R (40%), (p < 0.05). Pratik Savalia, Neelam Singh, BK Raw, Shobhit Singh • During 24-48 hrs postoperatively vomiting in group-P was Moti Lal Nehru Medical College, Prayagraj, Uttar Pradesh, India (17.14%) Vs group-R (40%) (p < 0.05) whereas complete response DOI: 10.5005/jp-journals-10071-23711.160 was more in Group-P (77.1%) Vs Group-R(54.3%) which was Introduction: Postoperative nausea and vomiting (PONV) is one of statistically significant (p < 0.05). the most common complaints after anesthesia and surgery and can • During 24-48hrs postoperatively VAS score for nausea in occur after general, regional, or local anesthesia. PONV has been Group-P was 1.28±1.63 and in Group-R was 0.51±1.17 which reported in up to 20 to 30% of all patients undergoing surgery,1 can was statistically significant (p < 0.05). lead to rare but serious medical complications, such as, aspiration • Need for Rescue Anti-emetics in group-P (8.57%) compared of gastric contents, suture dehiscence, esophageal rupture, to group-R (22.86%), and the difference was not statistically subcutaneous emphysema, or pneumothorax, dehydration, significant (p-value>0.05). electrolyte imbalance.2 The incidence of PONV after middle ear • Complications like headache, dizziness, drowsiness, constipation surgery is as high as 80% when no prophylactic antiemetic is given.3 were comparable in both groups with no statistically significant Selective 5-HT3 receptor antagonists have shown efficacy in the difference (p value>0.05). prophylaxis and treatment of PONV. Ramosetron and Palonosetron Discussions: In postoperative 0 to 6 hours more patients complained are recent developments in selective 5HT3 receptor antagonists of nausea in group R (17.1%) as compared to group P (11.4%), with a longer duration of action. Objectives: To compare the vomiting although was more in group R (11.4%) vs group P (8.6%). incidence of postoperative nausea and vomiting during 0 to This period (77.1%) has shown complete response (no PONV) as 6, 6 to 12, 12 to 24, and 24 to 48 hours. To compare VAS score compared to group P (82.9%) and the difference was not significant for nausea. Materials and methods: The present comparative, in all (p > 0.05). In postoperative 6 to 12 hours although more randomized, prospective, double-blind study includes 70 patients patients complained of nausea in group R (17.1%) as compared of ASA grade I/II between age 18 and 60 years undergoing middle to group P (14.3%), and vomiting in group R (14.3%) vs group P ear surgery. Patients were randomly allocated into two groups of (8.6%). In this period (80%), patients in group R shown complete 35 each; group R: given Inj. ramosetron 0.3 mg i.v. and group P: response as compared to group P (82.9%) and the difference was not given Inj. palonosetron 0.075 mg i.v. 30 minutes before the end significant in all (p > 0.05). In 12 to 24 hours period, more patients of surgery. In the procedure, the patient kept nil per oral 8 hours experienced nausea in group R (31.4%) vs group P (11.4%) and the before surgery and given ranitidine, alprazolam one night before difference was statistically significant (p < 0.05) while more patients the operation, on the day of operation patient premedicated with experienced vomiting in this period in group-R (22.9%) as compared glycopyrrolate, ondansetron, dexamethasone, the succinylcholine to group P (14.3%) but the difference was not statistically significant given and patient intubated with ET tube and maintenance are (p > 0.05). Overall complete response in group R was (62.9%) done with vecuronium bromide and inhalational agent isoflurane which was less than group P (80%) not statistically significant (p and before the end of surgery patient given either ramosetron or > 0.05). In the period of 24 to 48 hours in group R (40%), patients palonosetron. The incidence of PONV, complete response, VAS experienced nausea as compared to group P (17.1%) which was score for nausea, the requirement of rescue antiemetics, adverse statistically significant (p < 0.05) while more patient experienced effects were compared in both groups postoperatively up to 48 vomiting in group R (40%) as compared to group P (17.1%) and was hours. Results: Comparison of Nausea in post-operative period statistically significant (p < 0.05). Overall complete response during Comparison of Vomiting in post-operative Comparison of Incidence this period was seen more in group P (77.1%) vs group R (54.3%) 4 of complete response. which was statistically significant (p < 0.05). Patel Vaibhavi et al. • Demographic data and clinical characteristics were comparable in comparison of Palonosetron vs Ramosetron in the prevention of between both the groups in respect of age, sex, weight, ASA PONV in lap surgery no statistical difference was found in severity status, risk factors for PONV, vital parameters and duration of of nausea and vomiting in 0 to 6 hours (p > 0.05) but the incidence 5 anaesthesia with no significant difference (p > 0.05) was higher in group R which supports our study. Ahluwalia et al. • During 0-6hrs and 6-12hrs postoperative period no significant complete response was observed in 92.73 and 80% of the patients difference found between two groups in the incidence of PONV during 0 to 2 and 2 to 24 hours, respectively, in group P while and complete response (p > 0.05). in group R it was 90.91 and 70.91% within the same time frame • During 0-6hrs and 6-12hrs postoperative period difference (p > 0.05). It shows that complete responses with Palonosetron in mean VAS score for Nausea was not statistically significant and Ramosetron are comparable in 0 to 24 hours which supports 6 (p>0.05). our study. Chattopadhyay Suman et al. compared the effect of

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Palonosetron and Ramosetron for the prevention of PONV after 9. Comparative Study of Prophylactic Infusions of Phenylephrine cesarean section under spinal anesthesia shows the complete and Norepinephrine for the Management of Maternal response at 0 to 2 hours 85.5 and 83.3% in group P and group Hypotension for Cesarean Section under Spinal Anesthesia. R, respectively (p value > 0.05), while during 2 to 24 hours 70.9 (Conference Abstract ID: 100) and 53.7% in group P and group R, respectively (p value < 0.05). CV Soabir Ali Conclusion: In our study, it was observed that Palonosetron was Vardhman Mahavir Medical College and Safdarjung Hospital, New very good in complete response, rescue medication, VAS score for Delhi, India nausea and have long half-life as compared to Ramosetron although DOI: 10.5005/jp-journals-10071-23711.162 the incidence of headache was more in Palonosetron. We conclude Introduction: Hypotension is a frequent intraoperative complication that Palonosetron is more effective and better than Ramosetron for that occurs following spinal anesthesia. To avoid maternal the prevention of postoperative nausea and vomiting following hypotension, the current standard of practice is to administer middle ear surgeries. a continuous phenylephrine infusion. Phenylephrine can have 8. Norepinephrine Bolus: A Prophylactic Strategy for Spinal- clinically significant side effects, such as, baroreceptor-mediated induced Hypotension. (Conference Abstract ID: 133) bradycardia with a consequent decrease in cardiac output (CO). Norepinephrine, therefore, is an effective vasopressor for Savita Choudhary, Rakesh Dagar, Sunanda Gupta maintaining blood pressure during spinal anesthesia with less Geetanjali Medical College and Hospital, Rajasthan, India tendency to decrease heart rate and cardiac output. Objectives: DOI: 10.5005/jp-journals-10071-23711.161 Primary: To compare fall in maternal blood pressure after spinal Introduction: Spinal-induced hypotension is the most frequently anesthesia using intravenous infusions of phenylephrine and encountered complication of spinal anesthesia despite being norepinephrine and to quantify the rescue boluses needed for both the technique of choice for cesarean delivery. Norepinephrine the groups. Secondary: To compare fetal acid-base status using intermittent small dose bolus regime is now emerging as a umbilical arterial blood gases and to compare the APGAR scores feasible option for prevention as well as management of spinal- at 1 and 5 minutes in the two groups. Materials and methods: This induced hypotension. In resource-limited settings, intermittent study was conducted on 100 normotensive women undergoing CS boluses have been proven as an effective strategy where limited under SAB. The patients were randomized into two groups of 50 availability of infusion is a major deterrent for continuous each. Group P received infusions of phenylephrine @ 0.1 µg/kg/ vasopressor infusion. Our study aimed to compare the efficacy of minute prophylactically immediately after receiving SAB and group norepinephrine in the prevention of spinal-induced hypotension N received a prophylactic infusion of norepinephrine @ 0.05 µg/kg/ during cesarean section. Objectives: Evaluate the norepinephrine minute. The changes in heart rate (HR), BP, and side effects were 6 µg. To compare the incidence of hypotension rescue vasopressor compared till delivery. The neonatal APGAR scores were compared requirement time of first rescue dose. Materials and methods: This at 1 and 5 minutes and an umbilical artery sample was sent for blood prospective randomized double-blind study was conducted on 60 gas analysis. Results: Ten patients in the phenylephrine group had patients of ASA-II grade, full-term, singleton pregnancy undergoing bradycardia and whereas the norepinephrine group had only 2 elective cesarean sections under spinal anesthesia which were patients. SBP showed a fall of >20% from the baseline in 7 patients assigned into two groups. Group N6 received norepinephrine 6 in the phenylephrine group and we had given rescue boluses of µg as an intravenous bolus while group C received normal saline 50 µg phenylephrine and 5 patients in group norepinephrine and simultaneously with subarachnoid block. Incidence of hypotension, rescue boluses were 4 µg norepinephrine. Nausea and vomiting the requirement of rescue doses of norepinephrine, time of first was less in norepinephrine group. There was no difference in rescue dose, hemodynamic parameters, and incidences of maternal APGAR or neonatal acidosis on ABG. Discussions: In our study, both and neonatal complications were assessed, compared, and phenylephrine and norepinephrine infusions had similar efficacy in analyzed in all three groups. Results: The incidence of post-spinal maintaining maternal SBP within 80% of baseline. Phenylephrine, hypotension was lower in group N6 (63.33%) vs group C (83.33%), p being a pure α-adrenergic agonist causes reflex bradycardia. In our = 0.155. The requirement of rescue dose of norepinephrine (group study, the incidence of bradycardia was higher in the phenylephrine N6 8.21 ± 2.97 µg) vs group C (11 ± 4.57 µg), p = 0.01. Time to first group compared with that in the norepinephrine group and there rescue dose was significantly lower in control group (4[5-2]min was no difference in the extent of sensory anesthesia achieved. as compared to (6[8-4.5] min in group N6, p = 0.004. Discussions: More patients receiving phenylephrine complained of nausea Norepinephrine owing to its potent α-adrenergic agonist properties 4 (8%) and vomiting 2 (4%) compared with no patients who with β adrenergic potential results in the less incidence of maternal complained of receiving norepinephrine. In the present study, no bradycardia and decreased cardiac output following spinal significant difference in APGAR scores at 1 and 5 minutes between anesthesia as compared to commonly used drug phenylephrine. phenylephrine and norepinephrine groups. No neonate had an The ED90 of an intermittent bolus is 6 µg. Conclusion: Prophylactic Apgar score of <7 at any time point. In our study, both the umbilical intravenous norepinephrine 6 µg co-administration with spinal arterial and venous samples showed an absence of acidosis with anesthesia is effective in the prevention and management of spinal- pH >7.2. Umbilical arterial and venous blood gases were similar induced hypotension and it also decreases the total requirement between phenylephrine and norepinephrine groups. Conclusion: of vasopressor during cesarean section. In our study, both phenylephrine and norepinephrine infusions had

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similar efficacy in maintaining maternal SBP within 80% of baseline. requirement (p = 0.02), day of ICU stay (p = 0.01), days of hospital Phenylephrine, being a pure α-adrenergic agonist causes reflex stay (p = 0.001), day of decannulation (p = 0.03), day of discharge (p bradycardia. In our study, the incidence of bradycardia was higher in = 0.0089), INR before tracheostomy (p = 0.04), and PEEP requirement the phenylephrine group compared with that in the norepinephrine before tracheostomy (p = 0.03). As opposed to the general ICU group and there was no difference in the extent of sensory population, only a few publications are investigating the impact of anesthesia achieved. More patients receiving phenylephrine tracheostomy timing in the pediatric cardiac surgical population. complained of nausea 4 (8%) and vomiting 2 (4%) compared with To the best of our knowledge, we could not find any prospective no patients who complained of receiving norepinephrine. In the study on early tracheostomy among pediatric cardiac surgical present study, no significant difference in APGAR scores at 1 and 5 patients. Conclusion: There are significant benefits in the reduction minutes between phenylephrine and norepinephrine groups. No of postoperative morbidities with overall shorter ICU and hospital neonate had an Apgar score of <7 at any time point. In our study, stay. These benefits may promote faster patient rehabilitation with both the umbilical arterial and venous samples showed an absence reduced healthcare costs. of acidosis with pH >7.2. Umbilical arterial and venous blood gases were similar between phenylephrine and norepinephrine groups. 11. Profile of Obstetric Patients in Intensive Care Unit—A Retrospective Study from a Tertiary Care Center. (Conference 10. The Earlier, the Better: Tracheostomy in Postoperative Abstract ID: 13) Pediatric Cardiac Surgical Patients—A Prospective Study. Heena Gupta (Conference Abstract ID: 29) Government Medical College, Jammu, India Bipin Chalattil, Manoj Kumar Sahu DOI: 10.5005/jp-journals-10071-23711.164 All India Institute of Medical Sciences, Delhi, India Introduction: Physiological changes of pregnancy along with DOI: 10.5005/jp-journals-10071-23711.163 certain pregnancy-specific diseases may cause a rapid worsening of Introduction: Advantages of tracheostomy have been well the health status of the patient necessitating ICU care. Objectives: known. Most of the literature refers to these general intensive care To determine the incidence, epidemiological characteristics, population, excluding cardiac surgery or including only a small morbidity, and mortality of pregnant and postpartum women number of these patients. On the other hand, there is no clear who required ICU admission. Materials and methods: It was definition describing the proper time to perform a tracheostomy a cross-sectional, retrospective record analysis of all obstetric and defining what are likely benefits of early compared to late admissions in the ICU of a tertiary care center from October 2018 tracheostomy. This prospective study aims to assess the probable to March 2020. During these 18 months, 30,156 deliveries were benefits of early tracheostomy on postoperative outcomes, conducted. We included all pregnant/postpartum women (within length of stay, and post-tracheostomy complications within the 6 weeks after delivery) admitted to the obstetric ICU over this pediatric cardiac surgical population. Materials and methods: After period. Readmissions within 30 days were counted only once. obtaining institutional ethics approval, we conducted a prospective Research data included patient demographics, obstetric/medical study in a single, tertiary care institution, identifying patients who history and diagnosis at admission, ICU course and length of underwent tracheostomy after cardiac surgery from January 2019 stay, and treatment given and outcome. The clinical indications to December 2019. Time-to-tracheostomy was defined as “early” if responsible for ICU admission were categorized as obstetric and ≤7 days or “late” if > 7 days post-cardiac surgery. Results: Among non-obstetric. Data were collected from Medical Record Section Pediatric patients underwent cardiac surgery over the study period; and entered into a computerized database using MS Office Excel from those, 41 received tracheostomy. 16 (39%) patients underwent 2007 (Microsoft, Redmond, WA, USA). Results: There were a total of early tracheostomy and 25 (61%) late tracheostomy. Incidence of 30156 obstetric admissions in the hospital over a span of 18 months preoperative hospital stay(p = 0.0016), preoperative sepsis(p =0.03), out of which 127 were admitted in the ICU with 117 survivors high risk surgery (p = 0.04), postoperative clinical sepsis (p =0.001), and 10 deaths. Majority of patients (79.52%) were admitted due c reactive protein levels (p = 0.04), ventilator associated pneumonia to obstetric reasons. The most common cause of ICU admission (p = 0.002), antibiotic escalation requirement (p =0.006), antifungal was obstetric hemorrhage followed by hypertensive disorders therapy requirement (p =0.01), pressure sores(p = 0.01), days of of pregnancy, comprising 37.79% (n = 48/127) and 28.35% (n = feed interruption (p =0.0017), total days of ventilation(p = 0.0027), 36/127) of all ICU admissions, respectively. Among the non obstetric tracheostomy tube change requirement (p = 0.02), day of icu stay (p causes (n = 26/127), ICU admission was most common among =0.01), days of hospital stay (p = 0.001), day of decannulation (p those with pre-existing heart diseases (n = 10; 7.87%). Snake bite, = 0.03), day of discharge (p = 0.0089), INR before tracheostomy organophosphorus poisoning, head injury were the other non (p =0.04), PEEP requirement before tracheostomy (p = 0.03) were obstetric causes. Intrauterine death (IUD) with sepsis (n = 6) was lower in the early tracheostomy group. Discussions: The current another major reason for maternal admission in our centre.. Four study identified that ET performed in cardiac surgical patients was patients of sepsis were in shock and required inotropic support. associated with reduced incidence of preoperative hospital stay Forty nine out of 127 patients required mechanical ventilation (p = 0.0016), preoperative sepsis (p = 0.03), high risk surgery (p = (38.58%). Mortality was seen in 10 patients who were mechanically 0.04), postoperative clinical sepsis (p = 0.001), C-reactive protein ventilated. Mean duration of mechanical ventilation was 1.7 ±1.3 levels (p = 0.04), ventilator-associated pneumonia (p = 0.002), days. Eleven patients who were put on renal replacement therapy antibiotic escalation requirement (p = 0.006), antifungal therapy had developed complications related to abortion (n = 4), IUD (n requirement (p = 0.01), pressure sores (p = 0.01), etc. Furthermore, = 4), HELLP syndrome (n = 2) and systemic lupus erythematosus they had decreased days of feed interruption (p = 0.0017), total (SLE) (n = 1). The mean length of ICU stay was 4 days. There were 10 days of ventilation (p = 0.0027), tracheostomy tube change deaths reported (7.87%) in our study. Intrauterine death leading to

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sepsis (n = 4) and postpartum hemorrhage leading to acute heart exaggerated and he had bilateral ankle clonus. The rest of the failure (n = 3) were the most common cause of maternal mortality. clinical examination was unremarkable. A computed tomography Discussions: Changes in hemodynamics during the postpartum scan of the brain was normal. Hemogram revealed a normal blood period, such as, a 65% increase in cardiac output, acute blood loss count. Serum creatine kinase (CK — total) was 33,000 U, serum during delivery, and decrease in plasma oncotic pressure could be creatinine was 1.1 mg/dL on the day of admission, serum sodium the major factors for a higher incidence of postpartum admissions. was 138 mmol/L, potassium was 6.1 mmol/L, and bicarbonate was The most common primary diagnosis for ICU admission in our 17 mmol/L. Urine analysis revealed 1+ protein, microscopy revealed study was obstetric hemorrhage (37.47%). Early diagnosis and no RBCs but urine tested positive for heme and myoglobin. The prompt referral, well-equipped dedicated blood bank facility, the liver function test was normal. During the course of his illness, he involvement of other multidisciplinary approaches, and intensive progressed to oliguric acute kidney injury with serum creatinine care unit have been the major contributing factors for decreasing increasing to 6 mg/dL which necessitated initiation of hemodialysis. mortality in young obstetric patients. Uncontrolled hypertension Kidney biopsy revealed myoglobin pigment induced acute tubular was the second common cause of ICU admission. Eclampsia was the injury. Results: A diagnosis of serotonin syndrome induced by most common indication of assisted ventilation (n = 23), followed the combination of tramadol, ondansetron, and metoclopramide by sepsis and PPH. Limitations: We included patients admitted in was made and the patient was managed with the cessation of obstetric ICU only. As it was a single-center study, so the results offending drugs, hydration, benzodiazepine, temporary dialysis, are not indicative of the overall antenatal care provided at the and supportive care with which he made a complete recovery peripheral healthcare centers. Conclusion: Obstetric hemorrhage of consciousness and kidney function. Discussions: Serotonin and hypertensive disorders of pregnancy were the most common syndrome results from a heightened serotonin activity in the central indications for admission in obstetric ICU. Sepsis and postpartum and peripheral nervous system predominantly in the 5HT1A and hemorrhage were the leading cause of maternal death in our 5HT2A receptors.1 Drugs that interfere with the metabolism and study. A dedicated obstetric ICU in a tertiary care hospital with reuptake of serotonin increase the level of serotonin in the nervous an interdisciplinary approach is necessary to reduce the high-risk system, thereby inducing the toxidrome. The list of drugs that could obstetric morbidity and mortality. cause serotonin syndrome is exhaustive; however, common agents of interest to the intensivist include tramadol, meperidine, fentanyl, 14. Poisoning-Toxicology-Pharmacology dextromethorphan, metoclopramide, ondansetron, granisetron, monoamine oxidase inhibitors like linezolid, selegiline, serotonin 1. Serotonin and the Kidney. (Conference Abstract ID: 103) reuptake inhibitors like fluoxetine, etc.2 Although any one drug on C Jayadevi its own could provoke a serotonin syndrome, a combination of two Govt Villupuram Medical College Hospital, Villupuram, Tamil Nadu, or more drugs has a greater propensity to induce the toxidrome. India Our patient had taken a combination of tramadol, metoclopramide, DOI: 10.5005/jp-journals-10071-23711.165 and ondansetron which had acted synergistically to induce Introduction: Serotonin syndrome is a toxidrome that results from serotonin syndrome. Serotonin syndrome is characterized by a 2 a heightened level of serotonin action in the central and peripheral constellation of mental status changes (like agitation, anxiety, nervous systems. Some drugs which are commonly used in the disorientation, excitement, etc.), autonomic dysfunction (like intensive care unit or during anesthesia could induce this syndrome. hyperthermia, tachycardia, tachypnea, arrhythmias, etc.), and This potentially fatal toxidrome manifests with a constellation neuromuscular abnormalities (like tremors, clonus, hyperreflexia, of mental changes, autonomic dysfunction, and neuromuscular and muscle rigidity). Neuroleptic malignant syndrome and abnormalities. Prompt recognition of the toxidrome and withdrawal malignant hyperthermia are close differentials for this toxidrome. of the offending agent are crucial to prevent catastrophe. We report The diagnosis of serotonin syndrome is made clinically and relies 2 the case of serotonin syndrome in a 30-year-old man in whom the upon the Hunter Serotonin Toxicity Criteria (HSTC). The HSTC presentation was profound with convulsions, hyperthermia, clonus, requires the consumption of a serotoninergic drug with at least rigidity, altered mental status, and acute kidney injury resulting one out of the following five requirements being met: from rhabdomyolysis. Materials and methods: A 30-year-old man • Spontaneous clonus. was rushed to the emergency room after an episode of fall, brief • Inducible clonus with agitation or diaphoresis. convulsions, and loss of consciousness which befell him at his • Ocular clonus with agitation or diaphoresis. home. He was apparently healthy before this event and had no • Tremor and hyperreflexia. morbidities like diabetes mellitus or hypertension. However, he • Hypertonia, temperature >100.4°F, and ocular or inducible had intermittent headaches and insomnia for which he had taken clonus. a combination of tramadol, ondansetron, and metoclopramide This patient had altered mental status, hyperthermia, tachycardia, during the preceding 7 days. On admission to the hospital, he rigidity, spontaneous, and inducible clonus. Repeated clonus and was irritable, disoriented, and febrile (temperature 100°F). His muscular rigidity culminated in rhabdomyolysis, myoglobinuria, pulse was 110/minute, BP was 168/108 mm Hg, respiratory rate and acute kidney injury. Conclusion: Serotonin syndrome could was 22/minute, and his oxygen saturation with ambient air was present as a life-threatening toxidrome with acute kidney injury 97%. He had spontaneous generalized clonic jerks and the same in extreme cases. Drugs that are commonly used in the intensive was also provoked by noise (startle). Pupils were mid position and care unit or during anesthesia could induce this syndrome. Prompt reacting. There was no focal neurological weakness; however, recognition and withdrawal of offending drugs are crucial to there was generalized muscular rigidity. Tendon reflexes were prevent a catastrophic outcome.

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2. A Prospective Study on Clinical Manifestations and Introduction: With multiple contradictory reports on the efficacy Consequences of Paraquat Poisoning in a Tertiary Care Hospital of hydroxychloroquine (HCQ) on COVID-19, the Indian Council of in Kadapa, Andhra Pradesh. (Conference Abstract ID: 89) Medical Research (ICMR) recommends its’ use for prophylaxis and V Varun Kumar, M Sureswara Reddy treatment of mild cases. Amidst all the controversies, there have Government Medical College Kadapa, Andhra Pradesh, India been few cases reported of significant methemoglobinemia and DOI: 10.5005/jp-journals-10071-23711.166 hemolysis in COVID-19 cases being treated with HCQ. But, none has been reported from India, possibly because of underestimation Introduction: Paraquat (1 dimethyl-4-bipyridylium dichloride) is in our population. The diagnosis of methemoglobinemia amidst a contact herbicide widely used in agricultural industries. Acute this COVID crisis is really challenging owing to similar clinical paraquat poisoning is highly toxic, invariably fatal, and continues manifestations. Materials and methods: We present a case series to be a major public health concern in many developing countries where methemoglobinemia was promptly detected and managed characterized by acute lung injury, pulmonary fibrosis, renal failure, efficiently.Results: Timely detection and management resulted in and multiorgan failure, resulting in a high rate of mortality and the uneventful discharge of all three cases. Discussions: This is to be morbidity. Objectives: To study the clinical profile, biochemical understood that undiagnosed cases of methemoglobinemia can be profile, complications, management, and outcome in paraquat potentially fatal due to hypoxic stress on the body. If the condition is poisoning. Materials and methods: All patients admitted to not being detected timely, leading to dangerous levels of untreated the Intensive Medical Care Unit, GMC Kadapa with a history of methemoglobinemia may result in case fatality falsely attributed paraquat poisoning. Duration of study: 1 and half years November to COVID-19. Conclusion: Clinical vigilance is very important while 2018 to May 2020. Type of study: a prospective study. Sample treating critically ill patients. size: 50. Inclusion criteria: All patients admitted to the IMCU with a history of ingestion of paraquat. Exclusion criteria: History of 15. Sedation, Analgesia, and Delirium multiple poisoning, liver cirrhosis, CKD, and pulmonary disorders. Urine sodium dithionate was used as a paraquat screening test. 1. Sedation and Analgesia in the Mechanically Ventilated Patients: The following investigations were done to patients — complete A Comparison between Dexmedetomidine and Midazolam Plus blood count, RFT, LFT, ABG, CRP, ECG, chest X-ray, and CT chest. Fentanyl. (Conference Abstract ID: 137) Patients were treated with gastric lavage with activated charcoal, methylprednisolone, cyclophosphamide, N-acetyl cysteine, vitamin Jitendra Singh Yadav, Birendra Kumar Raw, Dharmendra Kumar C, E, mechanical ventilation, and hemodialysis. Results: In this study, Yadav the paraquat poisoning was most prevalent in the age group 21 Motilal Nehru Medical College, Prayagraj, Uttar Pradesh, India – 50 years. Mean age was 31. Female preponderance was noted. DOI: 10.5005/jp-journals-10071-23711.168 Complications like ARDS, lung fibrosis, renal failure,liver injury, Introduction: Sedation and analgesia are now regarded as an multiorgan failure. In our study shows predominantly ARDS(39.5%). integral part of the treatment of patients in the intensive care unit Mortality was 96% with maximum deaths were seen between 3 to (ICU). Nearly, all patients in the ICU experience pain, whether it is 7 days(28%) Discussions: Paraquat exerts its herbicidal activity by the result of procedures performed on them, the disease process, inhibiting the reduction of NADP to NADPH during photosynthesis catheters or tubes inserted into them, or because they are immobile and forming superoxide, singlet oxygen, hydroxyl, and peroxide and cannot shift position 1. Analgesia2 is defined as pain control in radicals. These toxic O2 radical species subsequently destroy the lipid the form of diminution or elimination of pain. American Society of cell membranes by polymerization of unsaturated lipid compounds Anesthesiologists3 defines the level of sedation according to the and human tissue toxicity likely results from a similar oxidative responsiveness of patients into awake, moderate, or conscious mechanism. The lung and kidney are the primary target organs in sedation, deep sedation, general anesthesia. A large number of paraquat toxicity. In the kidney, the principal organ of excretion, sedative drugs have been used, e.g., benzodiazepines, propofol paraquat is concentrated during excretion, often leading to acute infusion, and analgesic drugs like opioid analgesics via intravenous, tubular necrosis, acute kidney injury, which may occur soon after patient-controlled analgesia, intrathecal and epidural routes. ingestion. Pulmonary fibrosis, cough, dyspnea, tachypnea, edema, NSAID drugs have been used as analgesics. Ideally, a sedative and pleural effusions, atelectasis, low arterial oxygen tension, increased an analgesic agent used in ICU should have the following criteria alveolar oxygen tension gradient, and respiratory failure can occur. like easy administration, rapid onset of action, effective response, Conclusion: The present study shows that acute pq poisoning predictable duration of action, no adverse effect on vital organs can cause leukocytosis, thrombocytopenia. High NLR ratio has mainly the cardiac and respiratory system. Nowadays light plane an excellent predictor of prognosis in acute pq poisoning. Of all of sedation is better preferred for mechanically ventilated patients. herbicides, paraquat has the highest mortality in all centers despite Objectives: The following were the objectives of the present study. effective treatment. Because there is no specific antidote, there is • To assess and compare sedation levels. an urgent need for the development of preventive approaches and • To assess and compare analgesia levels. large clinical trials on the effects of different modalities of treatment Materials and methods: In the present comparative, randomized, as the median age of consumption is only 31 years. prospective, double-blind study, a total of 60 patients in ICU with a surgical diagnosis who required ICU stay between ages 18 and 3. Blue Patient and Brown Blood—A Case Series. (Conference 60 years of either sex of ASA grade I–II were included. Patients Abstract ID: 34) were divided into two groups via the computer-generated random Sulakshana, Banavathu Kishan Sing Naik number (30 patients each): Group I: dexmedetomidine — 1 µg/kg SRMS, Institute of Medical Sciences, Bareilly, Uttar Pradesh, India loading i.v. over 10 to 20 minutes followed by 0.2 to 0.7 µg/kg/hour and Group II: Midazolam plus fentanyl — loading dose of 1 mg i.v. DOI: 10.5005/jp-journals-10071-23711.167

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midazolam and followed by 2 to 3 mg/hour and fentanyl 25 to 50 dexmedetomidine sedation were compared with that of fentanyl. µg i.v. every 30 minutes to 1 hour followed by 25 to 50 µg/hour They observed that dexmedetomidine provides comparable till Ramsay Sedation Scale 3. Results: In our study mean value of sedation, analgesic, and stable hemodynamic effects as fentanyl. RSS at 16 hr in group A was 3.43±.68 as compared to group B was Devangi Parikh, Kolli, Karnik, Lele, and Tendolkar8 compared the 4 ± 0.74 which was statically significant where as at 24 hr RSS in satisfaction scores and effectiveness of sedation and analgesia with group A 3.20 ± 0.71 and group B was 3.80±.76 which was statically dexmedetomidine with a combination of midazolam–fentanyl. significant. Ramsay Sedation Score in the group Midazolam plus Dexmedetomidine is a comparable alternative to the combination Fentanyl shows wider range of RSS (2-5) than Dexmedetomidine of midazolam–fentanyl for sedation and analgesia in tympanoplasty group (2–4) which was statistically significant at 16 hr (p < 0.007) surgery under local anesthesia. Conclusion: Dexmedetomidine and 24 hr (p < 0.005). Thus at the end of 24 hr, Midazolam plus provided a lighter plane of sedation that helped to make the Fentanyl infusion provided deep level of sedation. In our study patient awake earlier. Patients treated with dexmedetomidine had the intergroup comparison of BPS of two group A and B where earlier weaning and removal from mechanical ventilation, shorter the mean value of BPS of group A was 7.87±1.20 which gradually ICU stay. So, dexmedetomidine can be preferred over midazolam decreases and goes to minimum value of BPS 3.53 ± 0.51 at 24 hr plus fentanyl in achieving effective sedation and analgesia with a while in group B mean value of BPS was 7.6±1.25 at 0 min which also better outcome. decreases and goes to a minimum value of BPS 3,57 ± 0.50 at 24 hr. No significant difference was found at any time point. Behavioral 2. A Comparative Study of Bilateral Ilioinguinal and Iliohypogastric Pain Scale in both group was comparable which was not statistically Nerve Block vs Wound Infiltration for Postoperative Analgesia in significant (p > 0.05). Discussions: Dexmedetomidine, midazolam, Cesarean Section. (Conference Abstract ID: 109) and fentanyl are the drugs that have been used very frequently to Tanu Shree, Joginder Pal Attri, Puneet Kaur Gill achieve adequate sedation and analgesia in mechanically ventilated Government Medical College Amritsar, Punjab, India patients. Dexmedetomidine promotes the decrease in motor DOI: 10.5005/jp-journals-10071-23711.169 activity, mental stability, allowing better care by the physician, Introduction: Pain forms the inevitable postoperative sequelae of nurse, and physical therapist. Its metabolites are inactive and the any surgical procedure and the relief of postoperative pain forms a clearance is urinary and fecal. Analgesia and sedation are related to major component of postoperative care of these patients. Despite the binding to central noradrenergic receptors. It can modulate the advances in postoperative pain management, postoperative descending inhibition from the locus coeruleus with noradrenaline pain relief and satisfaction are still inadequate in some patients release. Dexmedetomidine reduces the incidence of delirium and because of individual variability and limitation by the side effects the duration of mechanical ventilation. It causes little respiratory of analgesic drugs or techniques. Postoperative pain is transitory depression and it is administered at a dose of 1 µg/kg, followed by and self-limiting, being most severe during the first postoperative an infusion of 0.1 to 0.7 µg/kg/hour for analgesia and sedation, with day and diminishing over the next 24 hours and therefore, more the dose being titrated. With the infusion, hypotension occurs due amenable to therapy than chronic pain. In the current surgical to the central sympatholytic effect and noradrenaline decrease. The practice, laparotomy via Pfannenstiel incision is one of the most sympatholytic effect can be beneficial as it reduces tachycardia and common operations involving the female abdomen. Cesarean arterial hypertension, or undesirable, as they cause hypotension and delivery performed via Pfannenstiel incision is a major source bradycardia. Although both midazolam and fentanyl have a rapid for both acute and chronic pain and both systemic (single bolus/ onset and a short clinical duration with a single dose, accumulation patient-controlled) and neuraxial (spinal/epidural) opioids are and prolonged sedative effects may be observed after continuous effective against both visceral and somatic components of pain. administration, which is also indicated by a significantly longer Poor treatment of postoperative pain after cesarean delivery is the context-sensitive half time of these drugs. We had taken the main reason for patient dissatisfaction. Thus, optimal postoperative combination of midazolam and fentanyl despite midazolam alone analgesia is crucial to facilitate early maternal ambulation, improve because it is more effective and safe in a mechanically ventilated infant care, decrease postoperative morbidity and mortality, patient, without any increased risk for adverse reactions. Bongjin decrease the length of hospital stay, and improve the patient Lee et al.4 studied that fentanyl combined with midazolam is safe experience with hospital services. Objectives: The objectives and more effective than midazolam alone for sedation therapy of the study were to compare the effectiveness of the bilateral in mechanically ventilated children. Lalit Kumar Rajbanshi et ilioinguinal and iliohypogastric nerve block vs wound infiltration al.5 observed that dexmedetomidine provided a comparatively for postoperative analgesia in cesarean section done under narrower range of sedation level (2–4) than midazolam infusion spinal anesthesia with regards to efficacy, quality, and duration of (2–5) and at the end of 24 hours, the range of the sedation score postoperative analgesia and compare the complications and side for the patient in dexmedetomidine infusion was again 2 to 4 while effects, hemodynamic variables, and rescue analgesia between two it was 3 to 5 in midazolam group producing deep sedation. Thus, groups. Materials and methods: Sixty patients of American Society dexmedetomidine provided a uniform pattern of sedation level in of Anaesthesiologists grade I and II aged 18 to 35 years undergoing comparison to midazolam. Santosh Kumar Sharma, Shahbaz Ahmad, cesarean section under spinal anesthesia in our institute were ZulutenaJamir et al.6 observed that dexmedetomidine provided an included in our prospective, randomized, interventional, open- effective alternative to midazolam in producing and maintaining label clinical study after obtaining Institutional Ethics Committee controlled (RSS 2–3) short-term sedation in mechanically approval and written consent of the patients. Patients with ventilated eclampsia patients and stable hemodynamics. Prasad, contraindication to central neuraxial block, progressive neurological Parimala Prasanna Simha, and Jagadeesh7 studied the efficacy disease, local anesthetic and NSAIDs sensitivity, obese patients, of sedation, analgesia, and time required for extubation during patients with peptic ulcer disease, renal disease, infection at the

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site of the block were excluded from the study. The patients were the bilateral IIIH nerve block significantly increased the duration divided into two groups of 30 each in a random and unbiased of postoperative analgesia, lowered the VAS scores, and reduced manner using a computer-generated table of random numbers. the analgesic consumption as compared to wound infiltration in Group I (n = 30) received wound infiltration, whereas group II (n = patients undergoing cesarean section. 30) received bilateral ilioinguinal and iliohypogastric nerve block with 30 mL of 0.5% ropivacaine plus 30 µg of fentanyl after the effect of spinal anesthesia regressed to T10 level. A standardized 3. Incidence of Delirium in Adult Patients Admitted in Intensive anesthetic technique was followed after a preanesthetic check-up. Care Unit. (Conference Abstract ID: 104) After the attachment of monitors, including ECG leads, noninvasive Mariappan Junior, Poonam Gupta blood pressure cuff, and pulse oximeter an intravenous line with VMMC and Safdarjung Hospital, New Delhi, India 18, 20 gauge cannula was established. Baseline vitals were noted. DOI: 10.5005/jp-journals-10071-23711.170 The patient was turned to the left lateral decubitus position. Using Introduction: Delirium is an acute impairment of consciousness aseptic technique, L3-L4 or L2-L3 intervertebral space was located. producing a generalized cognitive impairment. It develops very Skin wheal was raised by a 26-gauge needle with 2% lignocaine shortly and has a fluctuating course over the day. The incidence of then 25G quincke’s spinal needle was introduced into sub-arachnoid delirium reported among critically ill patients is 16 to 89%.1 It may space using the mid-line approach. After the free flow of CSF was be caused by a disease process other than the brain, such as, obtained, 2.2 mL of 0.5% hyperbaric bupivacaine was injected into infection (urinary tract infection, pneumonia) or drug effects, subarachnoid space. The level of sensory blockade was checked by particularly anticholinergic or CNS depressants (benzodiazepines loss of sensation to pin-prick before surgical incision. Supplemental and opioids). Although the rate of prevalence in the ICU is high, oxygen was given @5 L/minute via a simple oxygen mask. After delirium often goes unnoticed by the intensivists. Most of the the regression of the effect of spinal till T10 level, in group I, 30 mL critically ill patients with delirium may either have a hypoactive of 0.5% ropivacaine plus 30 µg of fentanyl was infiltrated along form or mixed form where they fluctuate between hyperactive and the wound margins after negative aspiration. In group II, bilateral hypoactive forms.2,3 Mechanically ventilated ICU patients are at ilioinguinal and iliohypogastric block was performed with 30 mL of high risk of developing delirium and its pathogenesis is 0.5% ropivacaine plus 30 µg of fentanyl using landmark technique. multifactorial responsible for a longer stay in ICU and higher Initially, the anterior superior iliac spine was palpated and a mark mortality.4 Objectives: The primary objective was to evaluate the was made 2 cm medial and 2 cm superior from it. 15 mL of 0.5% incidence of delirium among adult ICU patients using the confusion ropivacaine plus 15 µg of fentanyl was injected each side into the assessment method in the intensive care unit (CAM-ICU) and planes between external and internal oblique muscles or internal Richmond Agitation–Sedation Scale (RASS). The secondary and transverse muscles to block both the nerves. After that, the objective was to evaluate the risk factors accounting for delirium patient was assessed for postoperative analgesia using a VAS score. contributing to mortality and morbidity among the delirious Results: 60 patients were analyzed for post-operative VAS scores patients. Materials and methods: This prospective and observational and analgesia requirement after IIIH block and wound infiltration. study was conducted on all patients aged above 18 years admitted There was no statistically significant difference between the two to ICU of a tertiary care hospital for 9 months, after obtaining groups with respect to demographic data like age, height, weight Institutional Ethical Committee approval and written informed and duration of surgery. VAS score was recorded at 0,2,4,6,8,12 consent from the guardian of all patients admitted in ICU. Family and 24 hours after surgery. We found that mean VAS score at rest refusal, patients with prior history of psychosis, neurological was significant (p-value<0.05) at all time intervals except at 24 disorder, unconscious, and deaf patients were excluded from the hours and with movement it was significant at intervals of 2,8,12 study. All patient information, comorbidities, medical history, drug and 24 hours. The mean duration of analgesia was prolonged in history, the reason for ICU admission were recorded at the time of group II (7.60±1.82 ) hours than group I (3.57±2.28) hours which admission in ICU and were assessed twice daily at morning (9 am) was nearly double the analgesia achieved with wound infiltration and evening (5 pm) by the resident doctors. The endpoint is either indicating a longer duration of analgesia with IIIH nerve block. positive detection of delirium, discharge from ICU, or death in ICU. Discussions: Postoperative pain relief is of utmost importance for The patients were assessed on Acute Physiology and Chronic Health the physicians managing the postoperative wards, especially after Evaluation II (APACHE-II), Richmond Agitation–Sedation Scale cesarean section to facilitate early ambulation of the mother, infant (RAAS), and Confusion assessment method for Intensive care unit care, and prevention of postoperative morbidity. Inadequately (CAM-ICU). Risk factors were classified into predisposing and treated pain after cesarean section is associated with an increased precipitating factors. Predisposing factors include comorbidities, incidence of chronic pain and posttraumatic stress syndrome. IIIH various medication may be present before the ICU admission and nerve block at the level of the anterior superior iliac spine produces are rarely modifiable, whereas precipitating factors are iatrogenic analgesia covering the dermatome supplied by the lumbar nerves (mechanical ventilation, sedatives, physical restraints) and related in its distal distribution. The Pfannenstiel incision lies within this to the severity of illness which are modifiable. Quantitative variables dermatome. Therefore, it is possible to provide analgesia of the were compared using unpaired t-test/Mann–Whitney test, anterior abdominal wall. Peripheral nerve block requires some qualitative variables were compared using Chi-square test/Fisher’s amount of expertise and commitment but it is possible to improve exact test. Univariate and multivariate logistic regression was done the comfort of the patient with these simple blocks considerably. to find out significant risk factors of delirium. A p < 0.05 was In our study, the mean VAS scores were significantly reduced at considered statistically significant. The data were entered in MS rest and with movement and the mean duration of analgesia was Excel spreadsheet and analyzed using Statistical Package for Social significantly prolonged in group II. Conclusion: In the present study, Sciences (SPSS) version 21.0. Results: During the study period, a

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total of 110 adult patients that fulfilled inclusion and exclusion risperidone). This study has limitations, such as, small size, criteria were admitted in ICU. 41 (37.3%) patients developed assessment of delirium was not done at a fixed time and we might delirium during their stay in ICU. Although the median age of have missed it as it has a fluctuating course. The present study patients who developed delirium in their ICU stay was more 35 excluded the patients who had visual and auditory impairments years, the difference was not significant (p = 0.672) between the who may are at high risk for the development of delirium. Further, two groups. There were no significant gender differences between we followed patients until discharge from ICU or death. Factors like both groups (p = 0.651). Patients with admissions from medical doses of sedatives were not evaluated to dose risk relationship. The ward (63.4%) were found significant (p = 0.015) in delirious group, side effects of antipsychotics were not recorded which is a the reason for this was found to be multiple comorbidities among drawback. Conclusion: The incidence of delirium was 37.3% among them, also the duration of days on mechanical ventilation among adult patients in the ICU that included both ventilated and non- delirious patients from medical wards (23.5±13.3 days(IQR = ventilated patients. Among the predisposing risk factors, 17days)). Among the predisposing factors, history of hypertension hypertension was significant among the delirious group and (31.7%vs14.5%; p = 0.035) was only significant in the development precipitating factors, sepsis, high APACHE II score, use of sedatives of delirium, while others were not significant. With the regard of (benzodiazepines and opioids), mechanical ventilation, use of precipitating risk factors, high APACHE II scores (15.07 ± 5.99 vs physical restraints, presence of windows/natural light exposure 9.16±7.18; p < 0.001), use of benzodiazepine i.v midazolam 1mg were significant among the delirious patients. Duration of more than once in their stay (29.3%vs13.3%; p = 0.040), opioids i.v mechanical ventilation and the length of ICU stay were prolonged morphine 100micrograms/kg / fentanyl 1-2 micrograms/kg (80.5% among the delirious group of patients which increase the morbidity vs 27.5%; p < 0.001), sepsis (39%vs14.5%; p = 0.004), presence of of the patient. High mortality (53.7%) was noted among the window/ natural light exposure (12.2% vs.91.3%; p < 0.001), need/ delirious group of patients. As the mainstay of management of use for physical restraints (78%vs4.3%; p < 0.001), mechanical delirium is not early detection but to modify the precipitating ventilation (97.6% vs 55.1%; p < 0.001), with duration of factors but also to reduce the morbidity and mortality among (20.3±11.6;median 16 days, IQR11vs 6.5±9.4;median 4 days, IQR5), critically ill patients. duration of ICU stay (25.00±17.80; median 18 days; IQR15-24 days vs. 6.03±7.76; median 4 days, IQR3-6 days; p <0.001) were found 16. Sepsis significant in development of delirium. A high mortality noted 1. Medical Malpractice Claims in Patients Diagnosed with among delirious patient (53.7%). Discussions: Using RASS and Septicemia—A Descriptive Analysis of Indian National Consumer CAM-ICU tools for evaluation in our study, the incidence of delirium Court Judgments. (Conference Abstract ID: 122) in this study was 41 (37.3%) patients. The incidence of delirium varies from 16 to 60%.1,16,18,19,21,24 This wide range of variations Aakash Sethi, Mukesh Yadav, Kalpita Shringarpure could be due to the type of ICU settings, tools used to assess Government Medical College, Baroda, Principal, Govt. Medical delirium. The majority (48.7%) of patients were hyperactive, 11 College, Banda, Uttar Pradesh, India (26.8%) hypoactive and 10 (24.5%) were mixed. Among predisposing DOI: 10.5005/jp-journals-10071-23711.171 risk factors, hypertension (p = 0.035) was associated with delirium. Introduction: Patients in the ICU are more likely than other Ouimet et al.1 Dubois et al. too found the same.7 Among hospitalized patients to experience medical errors, due to the precipitating risk factors, higher APACHE II scores (15.07 + 5.99 vs complexity of their conditions, need for urgent interventions, and 9.16 + 7.8; p < 0.001) were significant. Ouimet et al. too reported considerable workload fluctuation.1 A patient in India can seek that delirium to be associated with high APACHE II scores (17.9 ± compensation because of injury due to malpractice (negligence) 8.2 vs 14.0 ± 8.0; p < 0.0001) but not with increased age, sex.1 Ely of a doctor by approaching either the District, State, or the National Ew et al.,4 Romapaey et al.,10 and Thomason et al.20 too suggested Consumer Court.2 The National Consumer Dispute Redressal such association. Among medications, benzodiazepines Commission (NCDRC) is the highest forum for consumer disputes.2 It (midazolam) and opioids (morphine/fentanyl) usages were can entertain appeals and revisions against the judgment delivered significantly associated with the development of delirium. Studies by the state consumer commission.2 It can also entertain petitions from Sharma et al.14 and Lahariya et al.22 concur with our findings. which are filled for the first time (known as original case) if the value The duration of mechanical ventilation among them was [20.3 ± of the goods or services and the compensation exceeds more than 11.6 (11) vs 3.95 ± 7.92 (4.5)], which was higher when compared to 1 crore rupees.2 Any and all injury to the patient occurring to the Lat et al.15 Ely et al.2 have reported that the development of delirium patient due to an act or omission of the doctor is not negligence.2 was (32.4%) in mechanically ventilated patients, which was lower To prove the changes of negligence the patient has to prove four than our studies. The mean duration of stay in ICU among delirious things viz. patients were (25.00 ± 17.80 days) supports the findings from other • Doctor owed a duty to care to a patient. studies that delirium was associated with prolonged ICU stay and • There was a breach of that duty. high mortality 53.7%.10,12,14,20,23 The strength of our study was the • Consequential damages due to the act/omission. daily assessment of delirium twice using CAM-ICU and RASS. • Direct causation of the injury to doctor’s act.2 Further, the delirious group of patients, who were diagnosed using Therapeutic misadventures and poor outcomes of the surgery the tool were treated early which included reorientation and are not negligence if the doctor had taken a reasonable degree of behavioral intervention of patients by the caregivers by making care that is expected from a doctor of similar caliber.2 Death of the frequent eye contact and instructions to reducing the dose of patient or other postsurgical complications is a common reason for narcotics even policy of no sedative and antipsychotics (haloperidol/ relatives to sue the doctor for damages.3 As the mortality of sepsis

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cases is high,4 there is a high likelihood of doctors being sued. patient) was not found dependent on the type of case (original, Objectives: Aims — To analyze the pattern of medical negligence revision, appeal) (Fisher exact probability =0.59) Post-surgical in patients suffering from septicemia. sepsis [11, 32.3%] followed by abdominal infection [5, 14.7%] and Objectives; to find out: crush injury [3, 8.8%] were the most common reason for sepsis. • Outcome/verdict of the court. Hysterectomy [2, 5.8%], LSCS [2, 5.8%] and cholecystectomy [1, • Pattern of compensation. 2.9%] were the most common operations leading to post-surgical • Standard of accepted care. sepsis. Abdominal infection followed by UTI [3, 8.8%], Pneumonia • Ways in which doctors can protect themselves from negligence [2, 5.8%] and endophthalmitis [2, 5.8%] were the most common site claims. of dissemination of local infection leading to sepsis. Discussions: Materials and methods: This is a retrospective, descriptive, Our study showed that postsurgical damage to intra-abdominal cross-sectional study of NCDRC judgments pertaining to medical organs leads to most cases of patients suing doctors. Our finding negligence in septicemia. As this was a record review where of the most frequently implicated doctor (surgeon) was similar no human participants were involved, it was exempted from to the study conducted by Yadav et al.5 In the case of PGIMER vs Institutional Human Research Ethics Committee approval. The study Jasmine, the patient suffering from endophthalmitis, a known was conducted over a period of 4 weeks from October 1 to October case of restrictive cardiomyopathy had systolic BP of 80 mm Hg 31, 2020. Judgments were accessed from www.scconline.com. with raised JVP. The NCDRC told that “OP/hospital and doctors Inclusion criteria were the NCDRC judgment having the following have not clarified as to why the patient was not admitted in ICU or words inside the body of the judgment: CCU despite knowing that her BP was persistently low” signifying • Medical. the importance of admitting the patient of sepsis with low BP. • Negligence. Conclusion: In most cases, where the patient of septicemia sued the • Sepsis or septicemia or septic shock. doctor, the consumer court found the doctor guilty of negligence. • The patient had sepsis as determined from either medical The maximum compensation warded was 40 lakh and the minimum records, postmortem report, or independent expert opinion compensation was 1 lakh. As a standard of care, the NCDRC expects mentioned within the judgment. doctors to admit the patient when the BP has been persistently A purposive sampling method was used. The judgments were low in patients of sepsis. How doctors can protect themselves analyzed on seven parameters. are a prompt postsurgical diagnosis of injury to intra-abdominal The quantitative variables include: organs, diagnosis of rapidly spreading local infection. Maintaining • Amount of compensation claimed by the patient. detailed records including the record for the care taken to prevent • Amount of compensation awarded by the court. any mishap to the patient. The qualitative variables include: • Type of case — appeal, revision, original. • Verdict of the court — negligence or no negligence. 2. Clinical Usefulness of IV Fosfomycin in Critically Ill Patients • Doctor’s specialty. Admitted in ICU: An Indian Real-Life Experience. (Conference • Cause of sepsis and site of infection. Abstract ID: 113) • Presence or absence of organ dysfunction. Sagar Bhagat, Prachi Sathe, Ajay Bulle, Vasant Nagvekar, Milind Data were entered and analyzed using MS Excel. Qualitative data Mane, Saiprasad Patil, Hanmant Barkate were represented as percentage or proportion and quantitative data Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India; Ruby as median with interquartile range (IQR). Two groups of qualitative Hall Clinic, Pune, Maharashtra, India; Meditrina Institute of Medical variables were compared using Fisher’s exact probability test. p Science, Nagpur, Maharashtra, India; Lilavati Hospital, Mumbai, value <0.05 was considered significant. Results: On conducting Maharashtra, India; Noble Hospital Pune, Maharashtra, India the judgement search, 51 judgements met the inclusion criteria. 17 DOI: 10.5005/jp-journals-10071-23711.172 cases were excluded. Finally 34 judgements were analysed. Oldest Introduction: Fosfomycin is a bactericidal, low-molecular-weight, judgement was pronounced in 2006 and the latest one in October broad-spectrum antibiotic, with putative activity against several 2020. In 4 cases [11.7%], the patients had sepsis with organ failure bacteria, including multidrug-resistant Gram-negative bacteria, by (severe Sepsis). The outcome of the court favored doctor in 8 cases irreversibly inhibiting an early stage in cell wall synthesis. Evidence [23.5%] and the rest were in favour of patient. There were 18 Appeal suggests that fosfomycin has a synergistic effect when used in [52.9%], 11 Revision [32.3%] and 5 Original petitions [14.7%]. There combination with other antimicrobial agents. Fosfomycin exhibits were 18 [82.4%] surgeons but only 6 [17.6%] medical specialty advantageous pharmacokinetic properties making it particularly doctors against whom negligence cases of sepsis were filled. useful for complicated deep-seated, even biofilm-associated Premier government hospitals and Multispecialty hospitals who infections, such as, respiratory tract, bone, or central nervous system were sued included PGI Chandigarh (3, 8.8%), JIMPER Pondicherry (CNS) infections. Currently, data on the effectiveness of intravenous (1, 2.9%), Safdarjung (1, 2.9%), Fortis hospital (5, 14.7%), Apollo (IV) fosfomycin in daily clinical practice are still limited. Objectives: hospital (2, 5.8%). The Median compensation awarded was 5.8 lakh The primary objective of the study was to understand the clinical [IQR 2.25-10 lakh] while the median compensation asked for by the use of IV fosfomycin in a real-life setting among critically ill patients patient was 20 lakh [IQR 14.6-50 Lakh. On average courts awarded admitted in ICU, while the secondary objective was to assess the 51.4 % less compensation than was requested by the patient. The clinical outcome and adverse effects. Materials and methods: We outcome of the case (In favour or against doctor) was not influenced retrospectively analyzed the clinical utility of fosfomycin in the by the party (doctor or patient) who filled the case (Fisher exact ICU of four tertiary care centers across India. Medical records were probability = 0.49). The outcome of the case (in favour or against analyzed to capture key details including medical history, culture

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and sensitivity, treatment details, and clinical outcome. The study Colistin is the preferred combination agent. Overall fosfomycin- was approved by Independent Ethics Committee. Results: Data based treatment in a critically ill patient has shown reasonable from medical record of 60 patients treated with IV fosfomycin efficacy and tolerability in a real-world setting. was analysed. The mean age of patients was 56.78 years ±16.55 years, while the median age was 58 years (18-99 years). There 3. Role of Serum IL-6 and Ferritin Levels as Marker of Severity was male preponderance (78.33%). Nosocomial infection were and Outcome Predictor in Children with Multiorgan Dysfunction seen in 41 (68.3%) patients. Common clinical diagnosis were Syndrome. (Conference Abstract ID: 93) Sepsis (43.3%), bacteraemia (38.3%) and septic shock (38.3%). Abhishek Kumar Thakur, Anupama Yerra, Farhan R Shaikh, Parag Enterobacterales were the most common (88.33%) isolates Dekate, Kapil Sachane, Dinesh Chirla, Ujwala Desai, Karthik including K.pneumoniae in 45(75%) cases and non-fermenters were Narayanan few in numbers(10%). Carbapenem-resistant Enterobacteriaceae Rainbow Children’s Hospital, India (CRE) was the commonest (61.66%) resistance profile. Prior β DOI: 10.5005/jp-journals-10071-23711.173 -lactam exposure was limited (10%). 51 (85%) patients required mechanical ventilation, while 14 (23.3%) required CRRT, followed Introduction: MODS is the common end result of various insults by 6 (10%) who required SLED. The mean dose of fosfomycin was that predisposes the body to a heightened state of immunological 12.59 ±3.41 g/day, with median of 12 g (8–24 g/day). Fosfomycin activity with cytokine storm engulfing the majority of organs. therapy was given for a mean duration of 7.65 ± 6.71 days, with a Distinct patterns of circulating cytokines and acute phase reactants median of 5 days (3 – 39 days). The mean infusion time was 43.09 have proven to some extent for guiding the diagnoses and ±16.09 min, with a median of 30 min (30-90 min). Colistin 15 management of MODS. Serum IL-6 and ferritin could be valuable (25%), Tigecycline 8 (13.33%) and Polymixin B 6 (9.83%) were the biomarkers in the giant jigsaw puzzle of cytokine storm in MODS. commonly used companion drugs with fosfomycin. Clinical cure Objectives: Primary objective: To assess the role of serum IL-6 and was observed in 26 (43.3%) patients. Clinical failure and mortality ferritin levels as a marker of severity and outcome — predictor in was reported in 13 (21.7%) and 19 (31.7%) patients respectively. children with multiorgan dysfunction syndrome. Materials and No significant association of hypotension (p = 0.079), cardiac methods: Prospective observational study — prospective data of arrest (p = 0.067), prior exposure to β-lactam (p = 0.300) and critically ill children presenting with MODS on admission and those meropenem MIC >8 mg (p = 0.356) was seen with clinical failure/ children who developed MODS during PICU stay from September 1, death. Discussions: Fosfomycin is a novel antibiotic with good in 2019, to March 1, 2020, taken. Serum IL-6 and ferritin were measured vitro activity against the common pathogens, particularly toward within 24 hours of the development of MODS. MODS’s clinical the Enterobacteriaceae. Michalopoulos et al.1 used fosfomycin in diagnosis was based on 2002 Goldstein’s criteria. Severity scores 11 patients with nosocomial carbapenemase-producing Klebsiella like SOFA score, vasoactive ionotropic score, length of stay, and pneumoniae (CPKP) infections. Intravenous fosfomycin was given outcome were noted during the PICU stay. Results: Total number as 2 to 4 g/6 hourly in combination with colistin (n = 6), gentamycin of admissions was 905 and the total number of children diagnosed (n = 3), piperacillin-tazobactam (n = 1) in 11 patients for 14 ± 5.6 with MODS as per Goldstein’s criteria was 253 (28.0%) during the days. A good clinical and microbiological outcome with all-cause study period. Of these, 94 (37%) were evaluated, concomitant mortality of 18% was observed. A prospective study was conducted samples for IL-6 and serum ferritin was sent. One hundred sixty- by Hellenic study group2 finding the outcome of fosfomycin in three (n = 163; 64 %) were not included in the study for reasons like extensively drug-resistant and pandrug-resistant (PDR) Gram- parental refusal for participation, death within hours of admission. negative infections. Fifteen intensive care units enrolled in the Mean (± SD) PICU length of stay was 7.6 days ±6.5 AND mean (± SD) study. Sixty-five percent of the study population was in severe total length of stay was 8.7 days ± 7 The mean ± SD SERUM IL-6 was sepsis or septic shock. The resistance profile of clinical isolates 251.67 ± 577 (n = 94). The mean ferritin was 8462 ± 2060 (n = 94). was CPKP (85%), VIM-2 (35%), and PDR (36.6%). The median dose Mean age of the study population was 56.5 months i:e 4 years and 8 of intravenous fosfomycin was 24 g/day for 14 days and used in months. Maximum number of children in the study population were combination with colistin (66%), meropenem (25%), tigecycline infants (n = 36, 38.3%) The largest etiological subgroup was of viral (39%), and gentamycin (31%). Fifty-four percent of successful sepsis, dengue fever being the main diagnosis. The most common clinical outcome at 14 days with 565 bacterial eradication was causes of MODS was Severe Dengue without secondary infection observed. Case series from India by Mukherjee et al.3 where (n = 50, 53.2%), Severe Dengue with Secondary Infection (n = 18, fosfomycin combination was used in CCRE infections. Four critically 19.1%, bacterial pneumonia (n = 9, 9.3 %), bacterial pneumonia ill patients with fosfomycin only sensitive K. pneumoniae infection with ARDS (n = 03, 3.2%), sepsis including culture positive and (colistin MIC ≥4) started on intravenous fosfomycin (2 g 8 hourly) culture negative cases (n = 06, 6.4%,); Viral encephalitis contributed with meropenem (2 g 8 hourly) for an average duration of 10 4.3% (04), viral myocarditis 2.1% (02) and one patient (1.1% ) each days. Three out of four patients survived. These evidence suggest had viral pneumonia. CORRELATION OF SERUM IL 6 with severity the definite place of intravenous fosfomycin in the management score and outcome SOFA score on day 1 has a positive Spearman of severe Gram-negative infection. Conclusion: Intravenous use Correlation Coefficient of 0.466 which was significant (r = 0.466: p of fosfomycin is seen in serious Gram-negative infections as a = 0.000). Worst SOFA score also had a strong positive, significant combination therapy. Fosfomycin 12 g/day was commonly used correlation (r = 0.483: P value 0.000) with Serum IL6 measures at in clinical practice with an average treatment duration of 7 days. onset of MODS. The Pearson correlation between SERUM IL-6 and

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Worst VIS was strong and statistically significant(r = 0.555, p = 0.000). in sepsis has been proven. However, which biomarker among these The Receiver Operating Characteristic Curve (ROC) chalked out for two has better predictive value in elucidating disease severity, the relation between IL-6 and outcome measure of mortality, in organ dysfunction, and mortality in sepsis is yet to be answered. the critically ill PICU patients with MODS, assigned a cut off value Objectives: The primary outcome was to compare the predictability of SERUM IL-6 at 72.45, shows area under the curve (AUC) to be of nucleosomes and tissue inhibitor of metalloproteinase 1 0.833 which is excellent correlation with standard error of 0.054 (TIMP1) in estimating sepsis mortality. The secondary outcome with p value 0.001, which is significant, with sensitivity of 77.8 and was to evaluate the effects of nucleosomes and tissue inhibitor specificity of 85.1. This means IL-6 values above the cut-off of 72 is a of metalloproteinase 1 (TIMP1) in assessing disease severity and very potent severity marker for mortality in critically ill children with organ dysfunction. Materials and methods: After institutional MODS. The Spearman correlation between Ferritin and VIS Worst ethics clearance and informed written consent, 80 patients with is positive, mild at .043 (p = 0.683, not significant) CORRELATION sepsis/septic shock, aged between 18 and 75 years admitted in OF SERUM FERRITIN WITH SEVERITY SCORES AND OUTCOME The ICU were recruited in this single-center, prospective observational Spearman correlation between Ferritin and VIS Worst is positive, study conducted between May 2018 to July 2019. Quantification mild at .043 (p = 0.683, not significant) .ROC curve for ferritin versus of serum nucleosomes and TIMP1 was done with enzyme-linked outcome, the AUC was 15730 ng/ml with a p value of 0.126 with immunosorbent assay (ELISA) using venous blood, within 24 hours a sensitivity of 37 % and specificity of 86.6 % Discussions: Sepsis of diagnosis of sepsis/septic shock. [Trial registration number: CTRI/ and trauma are the two conditions most commonly associated REF/CTRI/2018/05/013770]. Results: The optimal cut-off point with multiple organ dysfunction syndromes both in children and for TIMP-1 was 149.4 pg/µl with a sensitivity and specificity of adults. IL-6 levels have a positive and moderate to strong Spearman 71.4% and 53.3% respectively, while the optimal cut-off point for correlation coefficient with SOFA day 1 (0.466) and worst SOFA nucleosomes was 215 pg/μl, providing sensitivity and specificity of (0.483), and the correlation was highly significant p( = 0.000). 71.4 and 57.7% respectively. DeLong test was used for comparison Vasotrope–Inotrope score is associated with important clinically between the ROC curve for two biomarkers.The AUC-ROC curve relevant outcomes including ICU length of stay, ventilator days, and for TIMP1 and nucleosomes to discriminate between survivors mortality. The Pearson correlation between serum IL-6 and worst and non survivors were 0.70 (95% CI 0.58 0.81) and 0.68(0.56-0.80) VIS is 0.555 which is moderate grade and significant (p = 0.000). respectively. Although independently, TIMP1 and nucleosomes IL-6 values above the cutoff of 72 pg/mL is a very potent severity have statistically significant capacity to discriminate between marker for mortality with a sensitivity of 77.8% and specificity of survivors and non survivors (p values 0.002 and 0.004 respectively), 85.1% in critically ill children with MODS in this analysis. Serum superiority of one biomarker over other in discriminating between ferritin measured at the onset of MODS, had poor specificity and survivors and non survivors was not observed. For TIMP1, correlation sensitivity with respect to outcome. This study was done before was found between TIMP1 value and duration of vasopressor and COVID-19 pandemic and none of the study population had COVID length of stay. (Spearman’s correlation coefficient r = 0.27, p = 0.03 illness. Serum biomarkers IL-6 and ferritin were measured only and r = 0.22, p = 0.04, respectively). For nucleosomes, there was once at the onset of MODS, in comparison to each other, serum IL-6 no significant correlation between nucleosomes value and the would be a valuable predictor of the outcome at the onset of MODS. variables. Discussions: Sepsis is life-threatening organ dysfunction, Conclusion: The epidemiology of MODS in developing countries, characterized by high mortality, more so in septic shock.1 A especially the Indian subcontinent is very different with viral sepsis higher incidence of sepsis-associated mortality of 55 to 65% has predominating the cohort. Serum IL-6 is better correlated to clinical been reported from two studies from the Indian subcontinent.2,3 scores like SOFA, VIS, and thus, a better marker of severity. Serum Mortality rates were as high as 7% per hour delay in diagnosis for IL-6 in comparison with serum ferritin would be a better biomarker the first 6 hours.4 The mean values of TIMP1 and nucleosomes to predict the outcome at the onset of MODS in critically ill children. were lower in survivors than non-survivors. Similar results have been observed in other studies.5–9 These findings are in line with 4. Comparison of Serum Nucleosomes and Tissue Inhibitor of the current study where we observed significant differences in Metalloproteinase 1 (TIMP1) in Predicting Mortality in Adult the concentration of nucleosomes between survivors and non- Critically Ill Patients in Sepsis: Prospective Observational Study. survivors. TIMP1 and nucleosomes showed moderate to poor (Conference Abstract ID: 78) ability, with both having approximately similar values (0.70 and 0.68, respectively). The analysis confirmed that although median Nitin Rai, Lokesh Kashyap, Puneet Khanna, Seema Kashyap, Dilip values of TIMP1 and nucleosomes have a statistically significant Shende, Rahul Kumar Anand, Shailendra Kumar Yadav, Mithlesh capacity between survivors and non-survivors, the superiority of Kumar Singh one biomarker over another in discriminating between survivors All India Institute of Medical Sciences, New Delhi, India and non-survivors was not observed (p = 0.69). Bivariate analysis DOI: 10.5005/jp-journals-10071-23711.174 showed a significant correlation between TIMP1 and duration of Introduction: Sepsis is a life-threatening organ dysfunction due vasopressor, and length of stay. A similar finding was observed to dysregulated host response to infection. Timely identification in a study by Bojic, where a significant correlation was found is important for risk reduction and better outcomes in critically ill between TIMP1 and the duration of vasopressors.10 Similar to the patients. Nucleosomes and TIMP1 are biomarkers whose validity present study, analyzes performed by Hoffman and Ashoori also and utility in predicting severity, organ dysfunction, and mortality did not find a significant association between TIMP1 and other

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covariates.11,12 Conclusion: The median values of each biomarker ratio predict poor lactate clearance. We also concluded that the showed a statistically significant difference between survivors and ∆pCO2:∆CavO2 ratio cannot be used as a standalone perfusion non-survivors, the superiority of one biomarker over the other marker for guiding resuscitation the difference between the in predicting mortality was not observed. However, this was an decrease in ∆pCO2:∆CavO2 ratio in both the groups was not observational study with a small sample size; future larger studies statistically significant. Conclusion: ∆pCO2:∆CavO2 may not be are needed to validate the findings of the present study. useful as a standalone perfusion marker for guiding resuscitation. It is a useful indicator of lactate evolution and a good prognosticator, 5. Evaluation of Ratio of Delta pCO2 to Arterial Venous Oxygen especially when combined with lactate levels. Content Difference (∆pCO2:∆CavO2) as a Perfusion Marker and Prognosticator in Patients with Septic Shock. (Conference 6. Observational Study of Culture Positive Sepsis in COVID-19 Abstract ID: 60) Critically Ill Patients—Emerging Pattern at a Tertiary ICU Center. Ameya Abhay Ghude, Ashwini Jahagirdar (Conference Abstract ID: 54) Sahyadri Speciality Hospital, Pune, Maharashtra, India A Ganesh, P Vivekananthan, Laxmi Kanth Charan, MN Sivakumar DOI: 10.5005/jp-journals-10071-23711.175 Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India Introduction: Sepsis is the most commonly encountered entity in intensive care practice. Surviving sepsis campaign’s “sepsis DOI: 10.5005/jp-journals-10071-23711.176 bundle” has made the use of lactate and central venous oxygen Introduction: Aim: saturation guided resuscitation widely acceptable. Though very • To identify the incidence of culture-positive sepsis in critically useful, both these markers have their limitations, mainly due to ill COVID-19 patients at our tertiary intensive care unit. the inherent heterogeneity and sepsis-induced incoherence in • To categorize patients based on their comorbidities, the the microcirculation. There have been a few studies suggesting severity of illness and treatments underwent to see if there that the delta pCO2 to arterial-venous oxygen content difference is any correlation toward their predisposition toward culture- (∆pCO2:∆CavO2) can be used to predict lactate evolution in patients positive sepsis. with septic shock and serve as a marker of global tissue hypoxia. Materials and methods: We studied a total of 23 critically ill COVID- Hence, we decided to conduct this observational study to evaluate 19 patients admitted over a month retrospectively. We observed (∆pCO2:∆CavO2) as a perfusion marker and prognosticator in that there was no incidence of bloodstream infections in any patients with septic shock. Materials and methods: We conducted of the patients during their stay in ICU. The incidence of blood a prospective observational study of 50 adult septic shock culture testing for BSI was among 43% of the patients. VAP was not patients admitted to our intensive care units. Septic shock was observed in any of them either when 21% of the patients underwent defined by: 1. SOFA score of 2 or more at the time of admission or culture and sensitivity of their endotracheal aspirate. However, there change in SOFA score by 2 or more points at the time of transfer were six patients with catheter-associated urinary tract infection to ICU. 2. Needing vasopressor for maintaining MAP of 65 mm accounting for nearly 26% of the patients, and the positivity rate Hg. 3. Lactate levels > 2 mmol/L. Pregnant patients, patients with was as high as 66% when tested. We observed a very low positivity obstructive or interstitial lung disease, patients in Child-Pugh Class rate for bloodstream infection and ventilator-associated pneumonia C, patients with cardiogenic, neurogenic, obstructive shock, and whereas a very high positivity rate for catheter-associated urinary uncorrected congenital heart disease were excluded from the tract infection. All the patients had antiviral drug therapy with study. We obtained arterial and central venous blood gases of these remdesivir and steroid therapy during their stay in ICU. Use of patients: 1. at the initiation of resuscitation and 2. Six hours after procalcitonin to ascertain the presence of infection was also seen the start of resuscitation (i.e., after adequate resuscitation). Lactate in at least 50% of the clinically suspected septic patients. levels, central venous oxygen saturation were measured. ∆pCO2, Results: ∆pCO2:∆CavO2 were calculated. Results: Fifty patients were studied. • In our cohort of critically ill COVID19 patients’ the incidence of Mortality was thirty-eight percent. Based on mortality patients catheter associated urinary tract infection was very high were divided into survivors and non-survivors. In survivors, initial • We also observed that there was surprisingly very low positivity mean values were - for lactate levels - 3.2 mmol/l (± 2.5), ScvO2 - rate for ventilator associated pneumonia and blood stream 64% (± 9%), ∆pCO2 - 6.4 (± 2.1) and ∆pCO2:∆CavO2 - 1.7 (± 0.8). associated infections when cultures were undertaken After adequate resuscitation, the respective mean values were 1.8 • Though the positivity rate was low in tested samples, clinical mmol/L (±1.2), 66% (± 10%), 5.3 (± 0.9), 1.4 (± 0.3). In non-survivors, decision to cover the episodes of suspected sepsis with initial mean values were - for lactate levels - 8.1 mmol/l (± 5.6), ScvO2 antibacterial agents might be substantiated due to reduced - 56% (± 18%), ∆pCO2 - 8.9 (± 2.3) and ∆pCO2:∆CavO2 - 2.5 (± 1.0). mortality rate observed within our cohort of patients After adequate resuscitation, the respective mean values were 5.8 Discussions: Though the positivity rate was low in tested samples, mmol/L (±3.8), 62% (± 11%), 6.5 (± 1.3), 2.1 (± 0.6).Discussions: In our the clinical decision to cover the episodes of suspected sepsis with study, the main result is that the difference in the mean initial values antibacterial agents might be substantiated due to the reduced of ∆pCO2:∆CavO2 in survivor and non-survivor groups was highly mortality rate observed within our cohort of patients. statistically significant (p < 0.001). ∆pCO2:∆CavO2 is a useful tool to Conclusion: prognosticate patients in septic shock. ∆pCO2:∆CavO2 of 2.0 or more • In our cohort of critically ill COVID-19 patients, the incidence was associated with >75% mortality in patients with septic shock. of catheter-associated urinary tract infection was very high. The difference in mean lactate clearance between the survivor and • We also observed that there was a surprisingly very low positivity non-survivor groups was also statistically significant (p < 0.005). rate for ventilator-associated pneumonia and bloodstream Therefore, it can be inferred that high values of ∆pCO2:∆CavO2 associated infections when cultures were undertaken.

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• Though the positivity rate was low in tested samples, the patients acquiring multidrug-resistant Gram-negative infections clinical decision to cover the episodes of suspected sepsis with is high. Conclusion: The mortality of ICU patients admitted or antibacterial agents might be substantiated due to the reduced acquiring Gram-negative multidrug-resistant infections is high. mortality rate observed within our cohort of patients. 9. Sepsis in Indian Intensive Care Units: A National Multicenter 7. Effectiveness of Phenylephrine vs Norepinephrine for Point-Prevalence Study. (Conference Abstract ID: 44) Initial Hemodynamic Support of Patients with Septic Shock. Ashwani Kumar, Parmeet Kaur, Bharath Kumar Tirupakuzhi (Conference Abstract ID: 51) Vijayaraghavan, Arpita Ghosh, Sarah Grattan, Vivekanand Jha, Swapna Latha Kotagiri, Surendra Gollapudi, Sahithy Mataparthy Bhuvana Krishna, Dilip Mathai, Bala Venkatesh Kamineni Institute of Medical Sciences, Narketpally, Nalgonda, The George Institute for Global Health and UNSW, Sydney, Telangana, India Australia, Dr Naomi Hammond, Apollo Institute of Medical DOI: 10.5005/jp-journals-10071-23711.177 Sciences and Research, Hyderabad, India, Department of Critical Care Medicine, Apollo Main Hospital, Chennai, Tamil Nadu, India Introduction: Many studies suggest phenylephrine as a first-line drug for initial inotrope in patients with septic shock. Phenylephrine DOI: 10.5005/jp-journals-10071-23711.179 improves oxygen delivery by improving splanchnic blood flow in Introduction: The recent Global Burden of Disease (GBD) study septic shock patients. But, there are a limited number of studies to reported that in 2017 there were 11 million sepsis cases and consider for clinical use. In septic shock, norepinephrine has shown approximately 3 million deaths in India. There are only a few compromised blood flow to the mesenteric circulation. Materials studies (largely single center) from India reporting on the sepsis and methods: The study was conducted in KIMS, Narketpally, epidemiology in Indian ICUs. Objectives: The primary objective Telangana, India. The study was carried out in patients with septic of this study was to estimate the prevalence of sepsis in patients shock associated with hemodynamic challenges. On getting approval admitted to Indian intensive care units (ICUs). We also compared from the local Institutional Ethics Committee. Informed consent was prevalence using previous SIRS-criteria (Sepsis-2) and the new obtained from all the patients enrolled in the study to give consent by Sepsis-3 definitions, examine pathogen profile.Materials and themselves. Patient enrolment has been started from December 2018 methods: This was a prospective, observational, multicenter, to July 2019. All the patients enrolled in the study were patients who nation-wide point-prevalence study. Ethics approval or waiver was have fulfilled the septic shock criteria with a mean arterial pressure. obtained by all participating sites. An email invitation was sent out Results: The study included a total of 30 patients who have been to Indian ICUs representing multiple geographical locations and divided into 2 groups based on the drug administered in the patients hospital type to participate on one of four study days between with phenylephrine and norepinephrine. Each group consisted of 15 May 24 and July 17, 2019. All adult patients (≥18 years) present patients. Mean age of phenylephrine group was observed to be 65, in the ICU on the study day were included in the study. Data and norepinephrine group was observed to be 67. The percentage were collected over 24 hours (from 08:00 am to 08:00 am the of male patients in each group has been assessed and was recorded following day) and at day 30 follow-up. A hospital- and ICU-level as 70 in phenylephrine group and 65 in norepinephrine group. Cause questionnaire was completed at each site. Following patient-level of septic shock was assessed in different aspects like pneumonia data were also collected: demographics, SIRS criteria, Sepsis-3 which was noted as 4 patients in phenylephrine group and 5 patients criteria, infection and antimicrobial details, interventions, and in norepinephrine group. Discussions: Pulmonary artery occlusion outcome data at 30 days following the study day. De-identified pressure (mm Hg) as a baseline in the phenylephrine group was 15 patient data were entered into an electronic case report form via ± 2, and in the norepinephrine group 15 ± 2. After 12 years, it was REDCap. The continuous, normally distributed data presented as assessed to be 17 ± 3 in both the groups. Right atrial pressure (mm means with standard deviations, and non-normally distributed Hg) was assessed to be 13 ± 3 in the phenylephrine group and 13 ± data as medians with interquartile ranges while categorical data 3 in the norepinephrine group. After 12 hours, it was assessed to be as numbers and proportions. One-day point prevalence (PPd) was 14 ± 2 in the phenylephrine and 15 ± 3 in the norepinephrine group. calculated using as follows: Sepsis cases/all cases treated in ICU. Conclusion: We conclude from the study that on the administration Concordance between the two sepsis definitions was assessed of phenylephrine as a first-line agent for hemodynamic support using Cohen’s kappa coefficient (K) (values ≥0.80 showing a in septic shock patients, the MAP was increased without any strong level of agreement). Results: A total of 35 ICUs participated compromising of hepatosplanchnic and GI perfusion in comparison enrolling 686 patients of which 29 (82.9%) were private hospitals. with norepinephrine. The participating hospitals were mostly from the southern region (n18; 51.4%) followed by western (n8; 22.9%), northern (n5; 14.3%) eastern (n3; 8.6%) and central (n1; 2.9%). The median age of the 8. Outcome of Patients Admitted in ICU with MDR Infections. study population was 60+24 years with approximately 60% being (Conference Abstract ID: 45) males. The most common primary diagnosis and comorbidity was MA Manaf kidney disease and diabetes, respectively. The overall prevalence DOI: 10.5005/jp-journals-10071-23711.178 of sepsis on the study day was 55.7%. Prevalence as per Sepsis-3 Introduction: Outcome of MDR Gram-negative infections in and Sepsis-2 criteria was 33.2% and 46.2%, respectively. The two ICU. Objectives: To study the outcome of ICU patients admitted sepsis definitions showed poor concordance in (K= 0.32). The with MDR Gram-negative infections. Materials and methods: most frequently used intervention was mechanical ventilation Prospective observational study. Results: Mortality of patients (41.1%). The proportion of septic shock in Sepsis-3 and Sepsis-2 with MDR Gram-negative infections is around 60%. Discussions: groups was 15.1% and 10.1%, respectively. In septic shock patients, Multidrug resistance is a global health issue. The mortality of steroids were administered in 53.1% of with hydrocortisone

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being the most common steroid and norepinephrine being the controlled trial. It enrolled a total of 50 patients with sepsis causing most common vasopressor. In sepsis patients, the three most respiratory or circulatory compromise or both, who were admitted common sites of infection were pulmonary (35.9%), bloodstream to the ICU of the Asian Institute of Medical Sciences, Faridabad. (13.7%) and abdomen (11.6%). Most infections were due to Patients were randomly assigned (1:1) to receive i.v. vitamin C gram-negative bacteria and 44.8% of infections were multi-drug (1.5g q6hr for 4 days), i.v. thiamine (200 mg q12hr for 4 days), and resistant. Commonly administered antibiotics were: meropenem i.v. hydrocortisone (50 mg q6hr for 7 days, then tapered down in (23.4%), piperacillin/tazobactam (10.5%) and teicoplanin (8.0%). 3 days) or matching placebos until intensive care unit discharge Mortality at 30 days after the study day was higher in sepsis occurred (whichever was first). Patients randomly assigned to patients compared to overall study population (27.6% vs 18.3%; the comparator group were permitted to receive open-label p < 0.001). Most patients were discharged to home (46.2%) and stress-dose steroids at the discretion of the treating clinical team. a higher proportion of sepsis patients were discharged against Results: Out of a total of 50 patients, 25 were cases. There was no medical advice compared to the overall study population (12.8% significant difference (P-value = 0.083) in the need for ventilation vs 9.5%; p < 0.001). Discussions: This is the largest sepsis cohort as only 7 (28%) out of 25 patients among cases required ventilation study conducted in India. Conclusion: This national, multicenter while 13 (52%) out of 25 patients among controls required point prevalence study showed a high sepsis burden in Indian ventilation. All the 50 patients (100%), both cases and controls, ICUs with more than half of the patients meeting sepsis criteria required vasopressors, but for a variable period of time, leaving on the study days. There was poor agreement between sepsis-3 no significant difference (P-value = 0.31). The mortality at the end and sepsis-2 definitions. Gram-negative bacteria were the of 4 days was 15 patients (60%) among cases and 9 patients (36%) predominant pathogen. There was a high rate of antimicrobial among controls with no significant difference (P-value = 0.08). resistance observed in sepsis patients. *P-value <0.01 considered as significant.Discussions: Low blood levels of both thiamine and vitamin C are common in sepsis. A 10. To Evaluate the Efficacy of Marik Protocol in Sepsis Patient large amount of experimental data have shown that vitamin C and Causing Circulatory or Respiratory Compromise or Both. corticosteroids decrease the release of inflammatory substances (Conference Abstract ID: 36) which may lead to organ failure seen in sepsis. There was an Rabinder Singh, Sandeep Bhattacharya equal number of strengths and limitations to our study, making Asian Hospital, Faridabad, Haryana, India it difficult to reach a solid conclusion. Conclusion: Our study does not prove to improve the status of the patients in terms of the DOI: 10.5005/jp-journals-10071-23711.180 above-said measures. Additional studies are required to confirm Introduction: Septic shock is a life-threatening condition that these preliminary findings. is characterized by a collapse in the ability of the organism to maintain adequate blood pressure and end-organ perfusion 11. Prospective Observational Study on Fluid Balance Status— secondary to sepsis — a dysregulated inflammatory response Identifying Suitable Intervention Points in Care of Critically Ill triggered by infection.1 Current management strategies for Patients. (Conference Abstract ID: 33) patients with sepsis include early aggressive fluid resuscitation, early appropriate antibiotics, hemodynamic support with Ram G Arun, Vivekanathan, Lakshmikanth Charan, Sivakumar vasopressors, and the identification and control of infected sites. Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India Although outcomes have improved with the bundled deployment of these strategies, mortality remains high at 20 to 30% with DOI: 10.5005/jp-journals-10071-23711.181 a global burden of sepsis being an estimated 15 to 19 million Introduction: To observe the fluid status of critically ill medical cases per year, of which the vast majority of these cases occur in and surgical patients in the critical care unit at selected time scales low-income countries, where mortality is reported to be as high at 24 hours, 3 days, and 7 days of admission to ICU. To identify as 60%.2 Even among sepsis patients who survive their hospital prognostic severity of illness based on fluid balance status and stay, residual organ dysfunction requiring ongoing treatment biochemical values on day 3 of critical illness. To identify and after discharge is common. Despite this high level of mortality intervene in a certain group of patients wherein the appropriate and morbidity, antibiotics and source control remain the only timing of deresuscitation attempts in fluid management can be focused therapies for this condition. The current management instituted. Materials and methods: Data collection includes all of sepsis and septic shock largely focuses on improving oxygen medical and surgical patients with 7 days or more of ICU stay, delivery via a combination of intravenous fluid and vasoactive patient demographics, associated comorbidities, hemodynamic medications while treating the infection with antibiotics and support requirement, the severity of illness score, fluid resuscitation source control. Recently, a study conducted by Marik et al. parameters. The primary outcome was to identify the fluid balance demonstrated a remarkable decrease in the mortality of septic state at 24 hours, 72 hours, and at end of 7 days of ICU stay. The patients who received a multidrug “cocktail” of intravenous secondary outcome includes incidence of ARDS, acute renal failure, vitamin C, hydrocortisone, and thiamine.3 In this study, we anasarca, new-onset cardiac failure. compare the effects of receiving vitamin C, thiamine, and Results: hydrocortisone (along with the standard sepsis care) vs standard • The ongoing prospective observational study aims to quantify sepsis care alone. Objectives: Primary: To see consecutive days the fluid status at different time scales of ICU stay with a view free of a ventilator and vasopressor support (VVFDs) in the 4 days to see if interventions at 72 hours can prevent further increase following randomization. Secondary: To see the mortality at 4 in positive balance days of giving the Marik protocol. Materials and methods: It • Positive fluid balance incidence within our intensive care unit was a prospective, single-center, single-blinded, randomized will help us to implement steps to implement deresuscitation

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attempts after 72 hours of ICU stay with a view to observe (RRT), and hyperchloremia. The primary outcome was the risk of secondary outcome improvements, especially in patients with developing new-onset AKI by day 7 after initial fluid resuscitation. sepsis. The sample size calculated was 708 patients for a power of 90%. Discussions: Positive fluid balance is associated with high morbidity Results: We enrolled 708 (405 boys; median age: 5 years) children: and mortality.1 Late conservative fluid management defined as two 351 and 357 in the BC and NS groups, respectively. Baseline consecutive days of negative fluid balance during the first week characteristics including the proportion of children with AKI at of ICU is an independent predictor of survival in ICU.1 There are admission [5% and 5.6% in the BC and NS groups respectively] were suggestions that the transition of systemic inflammatory response comparable between the two groups. The fluid volumes received syndrome associated with sepsis and septic shock, usually settles in the first 24 hours were similar in both the groups [107 (90, 134) by day three, if not indicates the severity of the illness. Patients with vs. 110 (92, 126) ml/kg in the BC and NS groups respectively. When sepsis, higher cumulative fluid balance at day 3 but not in the first compared to the NS group, fewer children developed new onset AKI 24 hours after ICU admission was independently associated with (20% vs. 33% RR 0.62; 95% CI 0.48 to 0.80; p = 0.0001) and required an increase in the hazard of death.2 RRT (9% vs. 18% RR 0.50; 0.34 to 0.73; p = 0.0004) in the first 7 days Conclusion: after fluid resuscitation in the BC group. The number (%) of children • The ongoing prospective observational study aims to quantify developing hyperchloremia significantly increased over the first 48 the fluid status at different time scales of ICU stay to see if hours in the NS group as compared to the BC group (p = 0.0006). interventions at 72 hours can prevent further increase in The mortality in both groups was however, similar (33% vs. 34%; positive balance. RR 0.96; 0.78 to 1.19; p = 0.81). There was no difference in other • Positive fluid balance incidence within our intensive care unit secondary outcomes including ventilator, inotrope or ICU free days will help us to implement steps to implement deresuscitation between the groups. Discussions: We found a significant reduction attempts after 72 hours of ICU stay to observe secondary in the risk of new-onset AKI with the use of BC as compared to NS outcome improvements, especially in patients with sepsis. for fluid resuscitation in children with septic shock. We observed a corresponding increase in the incidence of hyperchloremia at 24, 12. Balanced Crystalloids vs Normal Saline for Initial Fluid 48, and 72 hours in the NS group as compared to the BC group. Resuscitation in Children with Septic Shock—A Randomized Our study findings concur with the in vitro and animal studies that Controlled Trial. (Conference Abstract ID: 26) have shown hyperchloremia to be associated with an increase in renal vascular resistance and a decrease in glomerular filtration rate. Jhuma Sankar, Jayashree Muralidharan, AV Lalitha, Ramesh Conclusion: The use of balanced crystalloids as compared to normal Kumar, S Mahadevan, Javed Ismail, Vinay Nadkarni, Scott L saline for initial fluid resuscitation was associated with a significant Weiss, M Jeeva Sankar, SK Kabra, Rakesh Lodha reduction in the risk of new-onset AKI in children with septic shock. All India Institute of Medical Sciences, New Delhi, India; PGIMER Chandigarh, St Johns’ Hospital, Bengaluru, Karnataka, India; JIPMER, Puducherry, India; Childrens Hospital of Philadelphia, USA 13. Effect of Treatment with Low-Dose Corticosteroids on Mortality in Patients with Severe Sepsis and Septic Shock. DOI: 10.5005/jp-journals-10071-23711.182 (Conference Abstract ID: 24) Introduction: Crystalloids are recommended for initial fluid Tammina Akhila Sai, PV Sai Satyanarayana, Surendra Gollapudi resuscitation in septic shock and normal saline (NS) is commonly Kamineni Institute of Medical Sciences, Telangana, India used as it is cheap and readily available. However, increased incidence of hyperchloremic metabolic acidosis and acute kidney DOI: 10.5005/jp-journals-10071-23711.183 injury (AKI) associated with the infusion of NS has been reported in Introduction: The benefit and use of low-dose corticosteroids critically ill adults with shock as compared to the use of balanced in the reduction of mortality in patients with severe sepsis crystalloids (BC). Unfortunately, there is a paucity of evidence and septic shock. Septic shock may be associated with relative with regard to whether BC is superior to NS in the resuscitation of adrenal insufficiency. Thus, replacement therapy with low-dose children with septic shock. Objectives: To compare the effects of steroids has been proposed to treat septic shock. Surviving sepsis balanced crystalloids with that of normal saline during initial fluid guidelines suggest low-dose steroids use for septic shock patients resuscitation on the risk of new-onset acute kidney injury (AKI) and poorly responsive to fluid resuscitation and vasopressor therapy. mortality in children with septic shock. Materials and methods: In Objectives: To assess whether treatment with low dose steroids this double-blind, randomized trial conducted at four Indian sites (hydrocortisone and fludrocortisone) reduce 28-day mortality from 2017 to 2019, we randomly assigned children <17 years’ age in patients with severe sepsis and septic shock. Materials and with septic shock (defined as infection with at least two signs of methods: All the materials required for the study have been hypoperfusion with or without hypotension) to receive fluid boluses collected from the study site on getting approval from the heads of of 20 mL/kg each of either balanced crystalloids (Plasma-Lyte A; the respective department and on the signing of informed consent BC group) or normal saline (NS group) at the time of detection of by the patients enrolled in the study. Hydrocortisone came in shock. The trial was registered at ClinicalTrials.gov (NCT02835157). vials containing 100 mg of hydrocortisone powder and 5 mL of Children were managed as per the American College of Critical Care sterile water for injection, which was administered intravenously Medicine guidelines 2017 and monitored till discharge/death. Renal every 6 hours as 50 mg bolus. One tablet containing 50 µg of function tests and serum electrolytes were recorded at admission, 9-α-fludrocortisone was administered daily through a nasogastric 6, 24, 48, 72 hours, and day 7 after initial fluid resuscitation to tube with 20 to 30 mL of water. Placebo was indiscernible from evaluate the risk of new-onset AKI (any stage of AKI — 1, 2, or 3 as active treatments. The treatment duration was 7 days. Results: per the 2012 Kidney Disease- Improving Global Outcomes clinical 150 patients were included in analysis (75 in placebo group practice guidelines), the requirement of renal replacement therapy and 75 in steroid group) 28 day mortality in placebo group

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was 60.5% and in steroids group was 54.6%. ICU mortality in Introduction: Alcohol septal injection is a new treatment modality placebo group was 66.6% and in steroid group was 60%.Hospital for selective patient those are not fit for surgery like very old mortality in placebo group was 69.3% and in steroid group was age, COPD or CNS disease. For this type of condition alcohol 63.5%. Discussions: A total of 150 patients were randomized. septal injection is safe and minimum invasive treatment with Statistical analysis was by using SAS statistical software. Different good result. Objectives: Minimum invasive treatment for high- parameters are compared among two groups (placebo and risk surgery patient. Materials and methods: We have done ECG, steroid group). The mean temperature in the placebo group was X-ray, blood tests. ECHO shows HOCM with peak pressure 90 mm 37.7°C and in the placebo group was 37.9°C, both the values are Hg. angiography of coronary arteries is normal. After complete compared by paired t-test, σ was 1.3030, and t value was −0.485. evaluation, we have done Alcohol Septal injection in Cath lab and on The mean heart rate in the placebo group was 116 bpm and in ECHO in Cath lab, peak pressure decreased to 30 mm Hg and there the steroid group was 117 bpm, both the values are compared is no other complication. Results: Alcohol septal injection is a good by paired t-test, σ was 7.604, and t value was −0.582. Mean MAP treatment for HOCM in high-risk case. Otherwise gold standard (mean arterial pressure) in the placebo group was 52 and steroid for HOCM is surgery. Discussions: Alcohol septal injection is good group was 51, both the values are compared by paired t-test, σ modality. There are few complications. Those reported are (1) CHB, was 4.028, and t value was 0.785. The mean SOFA score in the (2) MI, (3) Cardiac tamponade, (4) LAD dissection, (5) Coronary artery placebo group was 16 and in the steroid group was 16, t value spasm, (6) Cardiogenic shock, (7) Pulmonary embolism, (8) Stroke. was 0. Mean hemoglobin levels in the placebo group were 10.4 Conclusion: In our case with 1 year follow-up, patient doing well, g/dL and in the steroid group was 10.24 g/dL, σ was 1.82, and t her pressure is 30 mm Hg with clinically no complaints. We will value was 0.312. The mean leukocyte count in the placebo group advise this treatment for high-risk case those not fit for surgery. was 12,440 cells/cumm and in the steroid group was 11,430 cells/ cumm, both the values are compared by paired t-test, σ was 6014, 2. Clinicopathological Correlation in Fatal COVID-19 Infection and t value was 0.531. The mean platelet count in the placebo 3 3 Using Postmortem Minimally Invasive Tissue Sampling: The First group was 120 × 10 /µL and in the steroid group was 122 × 10 / Case Series from India. (Conference Abstract ID: 115) µL, both the values are compared by paired t-test, σ was 30.9, and t value is −0.204. Mean arterial lactate levels in the placebo Ayush Goel, Animesh Ray, Deepali Jain, Shubham Agarwal, group was 4.26 mmol/L and in the steroid group was 4 mmol/L, Shekhar Swaroop, Shubham Sahni, Jagbir Nehra, Sanchit Kumar, both the values are compared by paired t-test, σ was 0.466, and Manish Soneja, Neeraj Nischal, Naveet Wig, Baidnath Gupta AIIMS, New Delhi, India t value was 1.492. A fluid challenge of 20 mL/kg over 20 minutes was given in all patients (both placebo and steroid group). In the DOI: 10.5005/jp-journals-10071-23711.185 placebo group, 11 patients were on dopamine support (mean Introduction: The COVID-19 pandemic began in China in December — 11 µg/kg/minute). In the steroid group, 22 patients were on 2019. India is the second most affected country, as of November dopamine support (mean — 10.8 µg/kg/minute). Both the values 2020 with more than 8.5 million cases. COVID-19 infection were compared by Levene’s test for equality of variance, F value primarily involves the lung with the severity of illness varying was 1.170, and significance of 0.358. If compared by unpaired from influenza-like illness to acute respiratory distress syndrome. t-test, if equal variances assumed t value was 0.263 and if equal Other organs have also been found to be variably affected. Studies variance not assumed t value was 0.327. In the placebo group, 22 evaluating the histopathological changes of COVID-19 are critical in patients were on dobutamine (mean — 8 µg/kg/minute) and in providing a better understanding of the disease pathophysiology the steroid group 22 patients were on dobutamine (mean — 8 and guiding treatment. Minimally invasive biopsy techniques µg/kg/minute). Both the values were compared by paired t-test (MITS/B) provide an easy and suitable alternative to complete and the t value was 0. In the placebo group, six patients were on autopsies. In this prospective single-center study, we present adrenaline support (mean — 1 µg/kg/minute) and in the steroid the histopathological examination of 37 patients who died with group six patients were on adrenaline support (mean — 0.8 µg/ complications of COVID-19. Materials and methods: This was an kg/minute), both the values were compared by paired t-test and observational study conducted in the Intensive Care Unit of JPN t value was 0.423. In the placebo group, 50 patients were on Trauma Centre AIIMS. A total of 37 patients who died of COVID-19 noradrenaline support (mean — 0.82 µg/kg/minute) and in the were enrolled in the study. Postmortem percutaneous biopsies placebo group, 50 patients were on noradrenaline support (mean were taken with the help of surface landmarking/ultrasonography — 0.65 µg/kg/minute), both the values compared by paired t-test, guidance from lung, heart, liver, and kidneys; after obtaining ethical σ was 0.354, and t value was 1.274. Conclusion: Treatment with consent. The biopsy samples were then stained with hematoxylin low-dose corticosteroids significantly reduced 28 days of mortality and eosin stain. Immunohistochemistry (IHC) was performed in patients with severe sepsis and septic shock. using CD61 and CD163 in all lung cores. The SARS-CoV-2 virus was detected using IHC with primary antibodies in selected samples. 17. Systemic Diseases Details regarding demographics, clinical parameters, hospital course, treatment details, and laboratory investigations were also 1. Alcohol Septal Injection for Hypertrophic Cardiomyopathy. collected for clinical correlation. Results: A total of 37 patients (Conference Abstract ID: 134) underwent post-mortem minimally invasive tissue sampling. Mean age of the patients was 48.7years and 59.5% of them were males. Ziyokov Joshi, Vishal Bhandari Respiratory failure was the most common complication seen in Tagore Heart Care and Hospital, Jalandhar, Punjab, India 97.3%. Lung histopathology showed acute lung injury and diffuse DOI: 10.5005/jp-journals-10071-23711.184 alveolar damage in 78% patients. Associated bronchopneumonia

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was seen in 37.5% patients and scattered microthrombi were segmental glomerulosclerosis with a collapsing phenotype, and visualised in 21% patients. Immunostaining with CD61 and CD163 tubulointerstitial inflammation. Renal vascular changes reported highlighted megakaryocytes, and increased macrophages in all are relatively less common and include fibrin thrombi, thrombotic samples. Immunopositivity for SARS-CoV-2 was observed in Type angiopathy, and lymphocytic endothelitis. In our cohort of patients, II pneumocytes. Acute tubular injury with epithelial vacuolization the most common finding on renal histopathology was acute was seen in 46% of the renal biopsies but none of them showed tubular injury and preexisting renal conditions were only evident evidence of microvascular thrombosis. 71% of the liver tissue cores in 18%. None of the cases showed significant vascular changes. showed evidence of Kupfer cell hyperplasia. 27.5% had evidence Conclusion: The most common finding in this cohort is the diffuse of submassive hepatic necrosis and 14% had features of acute on alveolar damage with a demonstration of SARS-CoV-2 protein chronic liver failure. All the heart biopsies showed nonspecific in the acute phase of DAD. Microvascular thrombi were rarely features such as hypertrophy with nucleomegaly with no evidence identified in the lung, liver, and kidney. Substantial hepatocyte of myocardial necrosis in any of the samples. Discussions: necrosis, hepatocyte degeneration, Kupffer cell hypertrophy, micro, Minimally invasive autopsies (MIA) or MITS/B are a simplified and macrovesicular steatosis unrelated to microvascular thrombi method of conducting postmortem sampling, originally devised to suggests that the liver might be a primary target of COVID-19. This investigate the causes of death in low-resource settings. Due to the study highlights the importance of MITS/B in better understanding potential risks associated with conducting traditional postmortem the pathological changes associated with COVID-19. examinations in COVID-19 patients, this method has been adopted to study morbid pathological changes in COVID-19 patients. The typical findings described in pulmonary histopathology 3. Effectiveness and Usage of Flucytosine in Clinical Practice in of COVID-19 patients include epithelial, vascular, fibrotic, and India. (Conference Abstract ID: 111) other changes. The epithelial changes described include diffuse Sagar Bhagat, Neha Gupta, Hiten Kareliya, Saiprasad Patil, alveolar damage with or without hyaline membranes, metaplasia Hanmant Barkate of alveolar epithelium, desquamation/reactive hyperplasia of Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India; pneumocytes, viral cytopathic changes, and multinucleated giant Medanta Hospital, Gurugram, Haryana, India, Prime Infection Care, cells. Common vascular changes include capillary congestion, Gujarat, India thrombosis in microvasculatures, alveolar hemorrhage, capillary DOI: 10.5005/jp-journals-10071-23711.186 changes (proliferation, thickening, fibrin deposition, endothelial Introduction: A timely and sufficiently high exposure of the detachment), peri- or intravascular inflammatory infiltrates. In appropriate antifungal agent is crucial for the eradication of the our series, the most common histopathological pattern seen on fungal pathogens. Very few antifungals penetrate at sanctuary lung samples was DAD (diffuse alveolar damage), with nearly sites such as brain/CSF, eye, bone, synovial fluid, and bladder/urine. equal numbers of patients showing DAD in the acute exudative Flucytosine (5-FC) achieves good concentration at sanctuary sites phase and organizing phase. The incidence of vascular changes hence considered as a treatment option in various conditions. 5-FC were only 21%, which was less than that reported. Several factors with amphotericin B remains the standard of care for cryptococcal could have contributed to this observation including regular use meningitis, and the drug continues to have a role in the treatment of anticoagulants in the cohort as a part of national policies, lower of Candida infections including C. auris which are life-threatening or thrombotic complications in the population studied due to genetic in circumstances where drug penetration may be problematic. It has or climatic factors. Histopathological examination of the liver in also shown good activity in combination with amphotericin B for COVID-19 patients had typically revealed mild steatosis, focal the treatment of severe systemic mycoses, such as cryptococcosis, hepatic necrosis, Kupffer cell hyperplasia, and sinusoidal dilatation candidosis, chromoblastomycosis, and aspergillosis. Objectives: The as reported in the literature. In our series, the most common features primary objective of the study was to understand the clinical use of identified include Kupffer cell hypertrophy in 21 (72.41%) patients, 5-FC in a real-life setting in India, while the secondary objective was acute submassive hepatic necrosis (27.5%) followed by acute to determine the clinical outcome and adverse effects. Materials on chronic liver failure (13.7%) in a background of chronic liver and methods: We retrospectively analyzed the clinical usage of diseases, features of NCPF (10.3%) and cholestasis (24%). Though 5-FC in two centers. Medical records were reviewed to collect crucial in our cohort of liver biopsies, hepatic lobular inflammatory cell data, including medical history, IFI diagnosis, treatment, and clinical infiltrates were not prominent, changes of hepatocyte degeneration outcomes. Information on the administration of flucytosine (dose– as ballooning, acidophil bodies, MDBs (Mallory-Denk bodies), and duration and adverse effects) were also noted. The protocol of the microvesicular steatosis were prominent. Lack of inflammatory cell study was approved by an independent ethics committee. Results: infiltrates in the liver has been described in earlier reports on fatal Medical case records of 23 patients were available for analysis. COVID-19 infections. Our findings disagree with the observation The average age of patients was 48.25 ± 13.79 years. Male of Sonzogni et al. that the liver is not a primary target of COVID- predominance (56.52%) was seen, with male to female ratio of 19 infection and only vascular changes in the liver are observed. 1.8: 1. The most prevalent comorbidity was diabetes (47.82%). In this cohort, we identified substantial histological changes of Immunocompromised state was present in 56.52% of patients hepatocyte necrosis, degeneration, Kupffer cell hypertrophy, micro, either HIV/AIDS (17.39%), immunosuppressive therapy (17.39%), and macrovesicular steatosis, more than the vascular changes. corticosteroid (13.04%), chemotherapy (4.34%) or strong Renal histopathology in COVID-19 is reported to show changes organ transplantation (4.34%). 5-FC has been used in the including prominently acute tubular injury (more prominent in the treatment of the candidiasis [candidemia (17.39%), genitourinary proximal tubules), arteriosclerosis, or glomerulosclerosis (both as candidiasis (13.04%), genitourinary candidiasis with candidemia features of underlying comorbid conditions like hypertension), focal (4.34%) and candida endocarditis (4.34%)]; cryptococcosis

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[meningo-encephalitis (21.73 %) and meningitis (8.69 %)]; 2018 to September 2020. Sample size: 60 patients. Group I: fluid aspergillosis (21.73%) and mucormycosis (4.3%). Sanctuary sites resuscitation; group II: both PLR and fluid resuscitation. Study type: were involved in 65.21% patients including CSF (39.13%), urine Prospective Study. (21.73%) and eye infections (4.34 %). Prior treatment with azoles Study material: (56.25%) and polyene antifungals (47.82%) was common. The most • Mid ray multichannel cardiac monitor for continuous etCO2 frequent isolates were Candida auris and Cryptococcal neoformans, monitoring with etCO2 probe (side stream technology). 21.73% each, followed by aspergillus spp. in 17.39%. 5-FC was • Arterial line (radial). companion drug to other antifungals [amphotericin-B (69.56%), • Mid ray multichannel cardiac monitor for monitoring systolic, echinocandins (17.39%)] in majority (91.30%), while in 8.69% it diastolic, and mean arterial pressure, with a pressure transducer was used as monotherapy. The mean dose used for flucytosine (invasive monitoring). was 4304.34 ± 1528.1 mg/day, with a median dose of 4000 mg/day • Sonosite ultrasound for measurement of maximal IVC diameter. (range: 1500 to 6500mg). The mean treatment period was 4.13 ± • Central venous catheter (single/double/triple lumen) for ScvO2 2.50 weeks, with a median of 3 weeks (range 2-12 weeks). Clinical sampling. cure was observed in 78.26%, while in 17.39% of patient’s reported Results: Distribution of patients according to age in the present clinical improvement. In 1 patient, clinical failure was reported. study. No mortality was reported. In most patients, the drug was well tolerated. Fever has been documented in 1 patient on flucytosine Age (years) Frequency (n = 60) Percentage therapy. Discussions: 5-FC exerts its antifungal effects by interfering 20–30 9 15 with both DNA and protein synthesis. It is reported to be most 31–40 11 18.33 active against Candida and cryptococcal infection and to show 41–50 14 23.33 synergistic action with amphotericin B in the management of fungal 51–60 26 43.33 infection. Amphotericin B increases cell permeability, allowing Total 60 100 more 5-FC to penetrate the cell. Thus, 5-FC and amphotericin B are synergistic. ACTA trial1 reported 1 week of amphotericin B plus Table: Comparison between mean arterial pressure and etCO2 at 60 flucytosine was the most effective option for induction therapy minutes (after resuscitation) and between mean arterial pressure and for patients with HIV-associated cryptococcal meningitis and ScvO2 at 60 minutes and between mean arterial pressure and IVC all the best-performing regimens contained flucytosine. It also diameter in group II (fluid resusucitation + passive leg raising). shows good activity against C. auris. It also reported to achieve MAP Mean Standard deviation p value good urinary concentrations, which is generally 10 to 100 times EtCO 35.3 13.6461 <0.01 greater than serum concentrations.2 Indian study highlighted C. 2 albicans showed 100% susceptibility to flucytosine and 84.6% to IVCD 8.70 13.7488 <0.01 amphotericin B.3 Conclusion: Flucytosine was found to be effective ScvO2 55.80 13.3055 <106 in the management of Candida, cryptococcal, and mold infections, particularly in the sanctuary sites. It was a frequent companion Table: Comparison between mean arterial pressure and etCO2 drug to amphotericin B. Flucytosine, with a better clinical cure and at 60 minutes (after resuscitation) and between mean arterial improvement rate, was also reportedly well tolerated. pressure and ScvO2 at 60 minutes and between mean arterial pressure and IVC diameter at 60 minutes in group I (only fluid 4. Volume Responsiveness after Passive Leg Raising, Fluid resuscitation) Resuscitation in Patients with Shock. (Conference Abstract Map Mean Standard deviation p value ID: 50) EtCO2 33.1 6.3158 <0.01 Tammina Akhila Sai, PV Sai Satyanarayana IVCD 9.53 7.2183 <0.01 Kamineni Institute of Medical Sciences, Telangana, India ScvO 55.67 5.6046 <0.01 DOI: 10.5005/jp-journals-10071-23711.187 2 Objectives: Comparison of arterial blood pressure (SBP, DBP, MAP) Conclusion: The response in hemodynamic parameters in group and etCO2 after fluid resuscitation and passive leg raising: I [only fluid (crystalloids) resuscitation] is an increase in end-tidal • To assess the fluid responsiveness after passive leg raising and carbon dioxide, increase in systolic blood pressure, increase in fluid resuscitation. diastolic blood pressure, increase in mean arterial pressure. An • To assess the volume status and responsiveness with a change increase in maximum inferior vena cava diameter and an increase in IVC diameter. in ScvO2 were statistically significant. The response in hemodynamic • Changes in ScvO2 related to PLR and fluid resuscitation. parameters in group II (both fluid resuscitation and passive leg • To compare between mean arterial pressure and etCO2 at 60 raising) is an increase in end-tidal carbon dioxide, increase in systolic minutes of resuscitation. blood pressure, increase in diastolic blood pressure, increase in • To compare between mean arterial pressure and IVCD at 60 mean arterial pressure, increase in maximum inferior vena cava minutes of resuscitation. diameter, and increase in ScvO2 were statistically significant. On • To compare between mean arterial pressure and ScvO2 at 60 comparison of hemodynamic parameters (etCO2, SBP, DBPMAP, minutes of resuscitation. IVCD, ScvO2) between group I (only fluid resuscitation) and Patients and methods: group II (both fluid resuscitation and passive leg raising), there Place of study: Department of Emergency Medicine, Kamineni is statistically no significant difference. After 60 minutes of fluid Institute of Medical Sciences, Narketpally. Study duration: October resuscitation, it was observed that there is clinically and the

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14 statistically significant response of etCO2, maximal inferior vena literature. The cause-and-effect relationship that acute systemic cava diameter, ScvO2 among hypovolemic patients in shock and inflammation leads to deterioration of large-artery stiffness. can be used to guide fluid resuscitation. There was a statistically Findings in study15 on induced inflammation have shown that an significant comparison between mean arterial pressure and etCO2 acute inflammation caused a temporary increase in central blood at 60 minutes of resuscitation. Thus, etCO2 can be used in place pressure and arterial stiffness in terms of pulse wave velocity. This of mean arterial pressure during the initial 60 minutes of fluid implies the increased risk of cardiovascular events associated with resuscitation in hypovolemic shock patients in the emergency. acute systemic inflammation in the COVID-19. COVID-19 disease- There was a statistically significant comparison between mean related worldwide research and proposed mechanisms pointed arterial pressure and maximum inferior vena cava diameter at to pathophysiological involvement of endothelial dysfunction 60 minutes of resuscitation. Thus, maximum inferior vena cava and arterial wall compromise. However, there was no empirical diameter can be used in place of mean arterial pressure during evidence of the functional compromise of arterial walls. Hence, a the initial 60 minutes of fluid resuscitation in hypovolemic shock study was urgently needed to study an increase in arterial stiffness patients in the emergency. There was a statistically significant in COVID-19 patients due to systemic inflammation to stratify comparison between mean arterial pressure and ScvO2 at 60 the risk and mitigate further cardiovascular damage with guided minutes of resuscitation. Thus, ScvO2 can be used in place of mean therapeutic treatment based on the severity of arterial stiffness. arterial pressure during the initial 60 minutes of fluid resuscitation This pressing need is justified by a comprehensive review article16 in hypovolemic shock patients in the emergency. published after the present study was envisaged. We hope that the findings from our study will fulfill the need to a large extent. 5. The COSEVAST Study Outcome: Evidence of COVID-19 Severity Objectives: Primary objective: To study if the measurement of Proportionate to Surge in Arterial Stiffness. (Conference Abstract arterial stiffness using pulse wave velocity in mild-moderate and ID: 48) a severe group of COVID-19 patients can stratify cardiovascular risk. Secondary objective: To determine if initial measurements Neeraj Kumar, Sanjeev Kumar, Abhyuday Kumar, Divendu and subsequent changes in arterial stiffness can project the future Bhushan, Amarjeet Kumar, Ajeet Kumar, Veena Singh course of the COVID-19 patient and hence predict the grade of AIIMS Patna, Bihar, India clinical management a confirmed COVID-19 patient would require. DOI: 10.5005/jp-journals-10071-23711.188 Materials and methods: The present prospective nonrandomized Introduction: It has been extensively highlighted that SARS-CoV-2 observational study {titled - “To study the relationship of COVID-19 affects the RAS (renin-angiotensin system) and the angiotensin- severity with arterial stiffness: A prospective cross-sectional study” converting enzyme-2 receptors play the most important role in (“COSEVAST study”)} was conducted in the COVID-19 ICU, medical 2–5 the presentation of the COVID-19 disease. The ACE2 is type I ICU, and various wards of dedicated COVID hospital at AIIMS, membrane protein expressed on endothelial cells in the kidney, Patna, Bihar, India. The study protocol, informed consents, and heart, gastrointestinal tract, blood vessels, and, importantly, other trial-related documents received the written approval of the lung AT2 alveolar epithelial cells, which are particularly prone to Institutional Ethics Committee (IEC No. AIIMS/Pat/IEC/2020/595). SARS-CoV-2 infection. As SARS-CoV-2 is a new coronavirus, and The study design was registered with the Clinical Trials Registry its cardiovascular complications and the underlying pathology of India (CTRI No. CTRI/2020/10/028489). All COVID-19 patients is still emerging. However, it is accepted that the virus affects the were subject to RT-PCR test and had a confirmed infection of the total vasculature in the human body and this infection becomes SARS-CoV-2 virus. Participants, after understanding the study a highly accelerated process for the target organ damage. In the protocol and procedures, gave their written informed consent case of acute cardiological manifestation, it is termed as Acute for the study. The exclusion criteria were known history of any of COVID-19 Cardiovascular Syndrome (ACovCS) by the American these diseases — diabetes mellitus (DM), hypertension (HTN), CAD, Heart Association’s white paper.6 European Society of Cardiology stroke, neuropathy, PAD, nephropathy, MI, pregnancy, peripheral (ESC) has published a detailed review paper 7 on the involvement edema or inflammation, cardiac arrhythmia, and any preexisting of various cardiovascular target organs in COVID-19 disease. This cardiovascular disorder. Patient categorization: The selected review clearly establishes a close two-way relationship between patients after fulfilling the inclusion criteria were grouped into COVID-19 disease and all cardiovascular diseases (CVD). The three categories — mild, moderate, and severe category based on prognosis is even worse in patients with preexisting cardiovascular the latest NIH Guidelines 27 as follows: system involvement. Cardiovascular involvement in COVID-19 is • Mild category: Individuals with mild signs and symptoms like seen as a key manifestation. The best way to assess endothelial fever, cough, sore throat, malaise, headache, muscle pain, dysfunction is an assessment of its clinical manifestation, i.e., an nausea, vomiting, diarrhea, loss of taste and smell but who increase in arterial stiffness. There have been multiple in vitro and do not have shortness of breath, dyspnea, or abnormal chest in vivo studies that have shown that the vascular endothelium is imaging. an important factor in setting the vascular tone and endothelial • Moderate category: Individuals who show evidence of lower dysfunction leads to arterial stiffness.8 Arterial stiffness and respiratory disease during clinical assessment or imaging and enhanced wave reflections are markers of cardiovascular disease who have a saturation of oxygen (SpO2) ≥ 94% on room air at and independent predictors of cardiovascular risk.9–12 Stiffening of sea level. the large arteries and enhanced wave reflections lead to increased • Severe category: Individuals who have a saturation of oxygen left ventricular (LV) afterload, disturbed coronary perfusion, and (SpO2) < 94% on room air at sea level, a respiratory rate of >30 13 mechanical fatigue of the arterial wall. The relationship between breaths/minute, PaO2/FiO2 <300 mm Hg, or lung infiltrates systemic inflammation and arterial stiffness is well established in the >50%.

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The range of treatment protocols followed in this study were mean arterial pressure (MAP), pulse pressure (PP), heart rate (HR), based on our institutional standard operating procedure (SOP) carotid-femoral pulse wave velocity (cfPWV), Est. Aortic root values for the management of COVID-19 patients based on their of Systolic, Diastolic, Pulse, Mean Arterial Pressures and Systolic clinical severity category and it included antivirals (remdesivir), Pressure Augmentation (AugP) with Augmentation Index (AIx). broad-spectrum antibiotics, low-molecular-weight heparin Figure 1 shows typical PeriScope COVID-19 arterial risk analysis (enoxaparin) immunomodulators (steroids, tocilizumab) and test report of a Severe Patient Data analysis: Data are expressed as supportive management (oxygen via nasal cannula, face mask, mean ± SD. Statistical analysis was performed using the GraphPad non-rebreathing face mask; noninvasive or invasive mechanical PRISM software version 5.03 (GraphPad Software Inc., San Diego, ventilation; awake proning). Measures of arterial stiffness: Arterial California, USA). Differences between all the groups were evaluated stiffness assessed by PWV (pulse wave velocity) correlates to the by unpaired Student’s “t” test and ANOVA. Linear regression analysis number of treated and non-treated cardiovascular risk factors, and Pearson’s correlation analysis were performed to evaluate atherosclerotic events, and cardiovascular risk as predicted by the the association between various confounding factors to rule out Framingham risk equations.17 PWV is also positively correlated interdependence. Probability values of p < 0.05 were considered to with carotid intima-media thickness, a marker of atherosclerotic indicate statistical significance. All p values are two-tailed. Results: burden in the coronary arteries.18 With the awareness of arterial Total 64 patients (42Male and 22 Females) patients were recruited stiffness during the non-COVID era, clinicians have started adding in the study. The patient demographic variables were shown in measurement and treatment of underlying arterial stiffness in Table 1. All the patients were under the healthy and normal BMI their clinical practice.19 International healthcare societies like the category. Since the patients did not have any known co-morbidity, European Society of Hypertension (ESH) and European Society of Lipid profile or Blood sugar levels were not taken into consideration. Cardiology (ESC) have included PWV measurement in their 2003 The minimum age was 18 years and maximum were 69 years. guidelines for the management of hypertension.20,21 Aortic and Although there was a difference between the mean values of age, brachial PWV22 and AIx23 are independently related to the levels weight and height; but were statistically not significant between of inflammation, suggesting that inflammation plays a role in the the groups. Figure 2 were showing the graphical representation regulation of arterial stiffening. In this study, Arterial stiffness is of overall patient demographics variables as age, weight, height primarily measured in terms of pulse wave velocity, which is a and BMI as (Figs 2A, B, C and D). Although Arterial Blood Gas (ABG) recognized gold standard. Pulse wave velocity, which is a relevant Analysis was carried out for all the patients, it was not possible to indicator of arterial stiffness, can be measured noninvasively with a find the point-of-time PaO2% value of each patient at the time of variety of devices. However, since COVID-19 is a highly contagious arterial stiffness test. For this reason, stat SpO2% reading was taken disease, a fully automatic device with minimal contact, less exposure as the measure of Oxygen saturation for accurate comparison. time, and proximity with the patient need to be maintained. It Also, since it was not possible to check oxygen saturation without would be always challenging for an observer to conducting the external oxygen support in all cases, the best way to quantify the entire test by wearing full personal protection equipment (PPE) severity was taking ratio of SpO2% and FiO2% as an indication of kit. So, a test device that avoids close proximity, long exposure, respiratory distress. Earlier studies and guidelines suggest SpO2% and holding a probe while testing, was needed for the study. We to FiO2% (SF) ratio is a reliable noninvasive surrogate for PaO2% found that the medical device PeriScope (Manufactured by M/s. to FiO2% (PF) ratio 28–30 especially in COVID-19 patients. All of the Genesis Medical Systems Pvt. Ltd., Hyderabad, India) was suitable Severe patients were admitted into the COVID-19 ICU whereas all of as it fulfilled all the above requirements. PeriScope is a clinically the Mild patients were admitted into COVID-19 and General wards. validated and tested noninvasive medical device used to measure Some of the Moderate patients were in the ICU and some were in Brachial Ankle PWV (baPWV) and derives the Carotid Femoral PWV the General ward with Oxygen support. The statistical analysis of the (cfPWV), which is equivalent to aortic PWV.24 A population-based segregation criteria is as shown in Table 2. The Patient categorization study with 3,969 subjects using “PeriScope” has established the role can be clearly visualized by graphical representation (Fig. 3) of of arterial stiffness in various cardiovascular diseases (CVD).25 Aortic the data. The Fig. 3 (A) shows statistical analysis of respiration pressure values also have been established as surrogate markers rate of the three groups, Fig. 3(B) shows FiO2%, Figure 3 (C) shows for arterial stiffness. PeriScope estimates the Aortic Pressures and SpO2% whereas Fig. 3(D) shows the statistical analysis of SF ratio the Systolic Pressure Augmentation (AugP) at the root of the Aorta (SpO2/FiO2) respectively. As the ‘normal’ value arterial stiffness is a due to the increased arterial stiffness. The Pressure Augmentation function of a person’s chronological age 31, (i.e. the normal value Index (AIx) values found by PeriScope were compared with other of Arterial stiffness goes on increasing with age), the real measure internationally accepted noninvasive devices and found to be very of abnormal increase in Arterial stiffness is the difference of the accurate and highly comparable.26 All the tests were conducted ‘predicted’ cfPWV value of a ‘normal’ subject of that age and actually as per the standard procedure given in the operator’s manual of measured cfPWV. Hence, Arterial Stiffness was analyzed using the PeriScope. Electrocardiogram (ECG) electrodes were placed on the values of Carotid Femoral Pulse Wave velocity (cfPWV), increase in ventral surface of both wrists and medial side of ankles, and BP cfPWV from the age dependent normal value, Increase in central cuffs were wrapped on both upper arm brachial artery and tibial Augmentation pressure from age dependent normal value and artery above ankles. All the ECG and pressure recordings were done Augmentation Index (AIx). An earlier study has shown that both automatically and data were stored in the personal computer for Aortic root Systolic Pressure (AoSysP) and Augmentation Index(AIx) analysis. The built invalidated proprietary algorithm within the values are dependent on Heart Rate.32 To rule out the role of Heart PeriScope PC software calculated the following parameters from rate in our findings, AIx values were normalized for HR. Also, in the waveforms, which were stored in the computer for analysis our study, the regression analysis between cfPWV and HR showed — systolic blood pressure (SBP), diastolic blood pressure (DBP), very low correlation (Multiple r = 0.2180, r2 =0.04754, p = 0.0835).

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Hence, the effect of HR on cfPWV values is negligible. It can very 95% CI 89.37 to 106.8), Brachial Pulse Pressure (Mild: 38.04 ± 7.957 safely be stated that the findings about arterial stiffness from the mmHg, 95% CI 34.60 to 41.48; Moderate: 45.95 ± 9.113 mmHg, 95% study are independent of effect of HR. No other parameters like CI 41.80 to 50.10; Severe: 42.40 ± 12.09 mmHg, 95% CI 36.74 to Heart rate or Pulse Pressure showed consistent increase in their 48.06) respectively. This can be clearly illustrated as in Fig. 4, were mean values between Mild, Moderate and Severe groups. Heart Fig. 4 (A) for Heart Rate and Fig. 4 (B) for Brachial Pulse Pressure in Rate (Mild: 76.06 ± 14.47 BPM, 95% CI 69.81 to 82.32; Moderate:78.20 all these three groups. On the other hand, the differences in the ± 17.20 BPM, 95% CI 70.36 to 86.03; Severe: 98.07 ± 18.58 BPM measurements of Arterial Stiffness parameters were extremely

Figs 1A to D: A typical periscope test result

Table 1: Patient arterial stiffness measures as per COVID-19 severity Parameter Mild (1) Moderate (2) Severe (3) p value Group I—II Group II—III Group I—III cfPWV (cm/second) 829.1 ± 139.2 1067 ± 152.5 1416 ± 253.9 < 0.0001* < 0.0001* <0.0001* cfPWV increase# (cm/second) 101.2 ± 126.1 279 ± 114.4 580.1 ± 216.4 < 0.0001* <0.0001* <0.0001* AugP increase# (mm Hg) −1.891 ± 2.817 3.212 ± 3.124 7.246 ± 4.908 <0.0001* 0.0031* <0.0001* AIx 4.670 ± 13.07 22.16 ± 7.833 34.24 ± 8.467 < 0.0001* <0.0001* < 0.0001* HR normalized AIx −13.34 ± 14.18 5.656 ± 8.610 24.80 ± 7.745 <0.0001* <0.0001* <0.0001* Values are expressed as Mean ± SD. *Significant difference in mean values. #Age normalized

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significant in all three groups. All the Arterial stiffness measurements therapeutics may reduce acute cardiovascular complications and showed uniformity in trends and almost same rise as per the severity mortality in COVID-19 patients significantly. of COVID-19 disease. More importantly, since no confounding factor or dependent parameter was found in the statistical analysis 18. Transfusion and Hemostasis Disorders of the data, Arterial Stiffness measures stood out as independent and consistent indicators of severity grade. The analysis of Arterial 1. Clinical Profile and Outcome of Patients with Suspected Stiffness parameters is as given in Table 3. These results can be Thrombotic Thrombocytopenic Purpura Treated in Intensive properly visualized in comparison with the earlier graphs. Figure Care in a Tertiary Hospital: A Retrospective Study. (Conference 5 gives a clear idea about the extremely statistically significant Abstract ID: 198) elevation of all Arterial Stiffness measurements across patient groups. The Fig. 5 (A) shows values of cfPWV in all three patient N Shiva Kumar, Kiran Kumar Gudivada, Sumitra Sivakoti, categories. Fig. 5 (B) shows Age Normalized increase in cfPWV, Fig. 5 Bhuvana Krishna (C) shows Age normalized increase in Aortic Augmentation Pressure St Johns Medical College Hospital Bangalore, All India Institute of whereas Fig. 5 (D) showed HR Normalized AIx values. Discussions: Medical Sciences (AIIMS), Bibinagar, Hyderabad, India The Lancet article 33 shows clear images with endothelial layer DOI: 10.5005/jp-journals-10071-23711.189 involvement leading to endotheliitis due to COVID-19 infection. Introduction: Thrombotic thrombocytopenic purpura (TTP) is Chen et al.34 in their epidemiological studies show that COVID-19 a hematological emergency with mortality nearing 90% if left patients admitted to hospital or an intensive care unit (ICU) present untreated. The disease is rare with a prevalence of 10 to 15 per 106 frequently with accompanying conditions, such as, advanced age, population. There is scant literature, however, which addresses hypertension, diabetes, and cardiovascular diseases implying the clinical profile and outcomes of TTP patients admitted to the compromised endothelial integrity may be playing a major part intensive care unit (ICU). Objectives: The objective of our study is to in COVID-19 mortality. Explaining the potential role of endothelial determine mortality among patients admitted with suspected TTP dysfunction and endothelial layer compromise in COVID-19, the to ICU, and evaluate the predictors of survival among TTP patients. article in cardiovascular research36 shows that chronic endothelial Materials and methods: A retrospective cohort was conducted in dysfunction may lead to acute vascular inflammation under the a tertiary hospital in south India after obtaining permission from attack of the SARS-CoV-2 virus. In our study, the cfPWV which we the Institute Ethical Committee. Consecutive patients admitted observed in severe COVID-19 patients was much higher than the to the ICU between 2012 and 2020 with a diagnosis of suspected cfPWV in patients with long-term chronic diseases like ESRD, CAD, TTP were included. Patients were screened for eligibility with the DM, etc. For example, in CAD patients, it was 1,204 ± 301.8 cm/s.24–25 help of a hospital information system (HIS). Inclusion criteria: age This indicates that COVID-19 damage to the vasculature within <15 >18 years and patients suspected to have TTP and managed in ICU. days is comparable to the damage caused by CAD in a number of The main search terms “schistocytes”, “fragmented cells”, “micro- years. Our COSEVAST study had very strict exclusion criteria. All angiopathic hemolytic anemia” on peripheral smear were used to patients with known diabetes, hypertension, obesity, and chronic screen our HIS. Two authors screened records and excluded patients smokers were excluded. Patients with all other cardiovascular diagnosed with HUS, aHUS, autoimmune causes of hemolysis, snake diseases and related surgical intervention/therapy were excluded. bite, pregnancy-related causes, accelerated HTN, malignancies, This was necessary to eliminate basal deviation of arterial stiffness septic shock, DIC, and vasculitis. Demographic parameters, medical from the normal vasculature. These exclusions reduced the history, presenting symptoms, admission APACHE II, daily SOFA total number of study subjects but removed any selection bias score, interventions performed such as plasma exchange (PE), use and amplified the validity of our findings. A similar large-scale, of steroids, and plasma infusion were extracted from the records. longitudinal, multicentric study (COVID-19 ARTErial Stiffness Presenting symptoms were classified as cardiac (myocardial and vascular AgiNg CARTESIAN Study)37 has been proposed and infarction, NSTEMI, Left ventricular dysfunction, arrhythmias), our study will try to follow harmonization with that study. To the renal (proteinuria, hematuria, oliguria, anuria, fluid overload), best of our knowledge, this is the first study to independently neurological (stroke, seizures, coma, focal deficits, headache, visual observe significant functional changes in vasculature due to disturbances), gastrointestinal (vomiting, diarrhea, abdominal pain), arterial inflammation in COVID-19 patients in terms of noninvasive and thrombotic symptoms (CNS thrombosis, peripheral vascular, measures of arterial stiffness. We wanted to conduct multiple cardiac). Since ADAMTS 13 activity levels were not available, the follow-up tests to find any trends in arterial stiffness; however, it risk of ADAMSTS 13 deficiency was estimated by PLASMIC score. proved almost impossible to study patients with COVID-19 disease Laboratory data recorded during ICU stay. Complications during Table 1: Patient arterial stiffness measures as per COVID-19 severity because of various reasons like changing status of the patient the ICU stay such as nosocomial infections and clinical outcomes Parameter Mild (1) Moderate (2) Severe (3) p value condition, restrictions on research staff movements, and sometimes such as mortality, length in ICU and hospital stay, and ventilator unfortunate death of the patients during the study. We are also in days were recorded. Patients were categorized into two groups Group I—II Group II—III Group I—III the process of undertaking a medium-term follow-up study of the based on mortality and evaluated. Statistical methods — Continues cfPWV (cm/second) 829.1 ± 139.2 1067 ± 152.5 1416 ± 253.9 < 0.0001* < 0.0001* <0.0001* patients in the present study after their discharge. These subjects variables are described as mean (standard error) or median with # cfPWV increase (cm/second) 101.2 ± 126.1 279 ± 114.4 580.1 ± 216.4 < 0.0001* <0.0001* <0.0001* will be observed for changes in Arterial Stiffness and occurrence of (interquartile range) and categorical variables as numbers with AugP increase# (mm Hg) −1.891 ± 2.817 3.212 ± 3.124 7.246 ± 4.908 <0.0001* 0.0031* <0.0001* cardiovascular disease, if any, over a period of 12 months with the percentage. Non-parametric tests were preferred due to the small AIx 4.670 ± 13.07 22.16 ± 7.833 34.24 ± 8.467 < 0.0001* <0.0001* < 0.0001* PeriScope device. Conclusion: The results of this study establish a sample population. p values < 0.05 were considered significant. HR normalized AIx −13.34 ± 14.18 5.656 ± 8.610 24.80 ± 7.745 <0.0001* <0.0001* <0.0001* noninvasive measurement of arterial stiffness as an independent Statistical analysis was performed using STATA Version 13. Results: Among 535 patients that were enrolled (age>18 and hemolysis in Values are expressed as Mean ± SD. severity marker in COVID-19 patients. It also strongly indicates that *Significant difference in mean values. regular assessment and regulation of arterial stiffness by titration of peripheral smear), 473 were excluded (direct combs + and those #Age normalized

Indian Journal of Critical Care Medicine: ABSTRACTS CRITICARE – IJCCM2021 S111 ABSTRACTS CRITICARE – IJCCM2021 non admitted to ICU). Remaining 96 patient records are thoroughly 19. Trauma screened and 33 patient’s diagnosis of suspected TTP were included for final quantitative analysis. Mortality among patients was 42%. 1. Intubation Practices in Trauma Triage: A Prospective There were no statistically significant differences among survivors Observational Study. (Conference Abstract ID: 194) and non-survivors with respect to sex, BMI, APACHE II score, day 1 SOFA score (p value of 0.08, 0.37, 0.5 and 0.2, respectively). Anudeep Jafra, Kajal Jain, SM Venkata, LN Yaddanapudi, SK Patients who died were significantly older than the survivors of Gupta TTP [42 (±4.2) vs 30.58 (±1.9), p = 0.03]. PLASMIC SCORE was also PGIMER, Chandigarh, India not statistically different among the survivors and non survivors DOI: 10.5005/jp-journals-10071-23711.191 [5.5 (±0.26) vs 5.7 (±0.28), p = 0.93]. 17(51%) patients had fever, Introduction: Hypoxia and obstruction of the airway are the 23(69%) had neurological, 4(12%) had cardiac, 18(54%) had major contributors to death following trauma. Hence, a definitive gastrointestinal, 9(27%) had haemorrhagic, 26(78%) had renal and airway control, which may require endotracheal intubation, is 3(9%) patients had thrombotic manifestations at presentation. an essential component of trauma resuscitation. Trauma Triage There is a trend towards improved survival with early initiation of is generally manned by a team comprising of various levels of PE, large cumulative PE volumes, lower platelet transfusions and healthcare professionals. It is not only important whether a patient higher dosage of steroid as adjuvant, however none of these have needs intubation but also when and how to intubate. There is a attained statistical significance. The incidence of CAUTI, CLABSI, lack of data pertaining to intubation practices in trauma triage VAE and HAP were not different among PE and non-PE recipients. in India. Objectives: Hence, the present study was conducted to Conclusion: The mortality of patients admitted to the intensive care describe the current practice of definitive airway management unit with the diagnosis of suspected thrombotic thrombocytopenic in the trauma triage of a tertiary hospital catering to northern purpura is comparable to international data. Early initiation of PE India. The secondary objectives were to determine the success with large plasma volume exchanges along with and higher dosage rate of endotracheal intubation by anesthesia and non-anesthesia of steroid and cautious use of platelet transfusions may improve residents, to describe the complications during securing the survival. The risk of ICU-acquired infections was no significantly airway, and to formulate recommendations based on the results higher in plasma exchange. of this observational study. Materials and methods: This was a prospective observational study conducted at Trauma Triage 2. Reperfusion Injury. (Conference Abstract ID: 14) of level 1 Tertiary Hospital over a period of 1 year. A specifically KS Sayooj designed pro forma was filled which included the patient’s detailed Amala Institute of Medical Sciences, Thrissur, Kerala, India history of trauma, peri intubation vitals, indications for urgently securing airway, unfavorable conditions, a technique of intubation, DOI: 10.5005/jp-journals-10071-23711.190 medications used, and adverse events following intubation, and Introduction: In this poster “reperfusion injury”, I am presenting a number of attempts taken. Results: The first attempt success an emergency Fogarty catheter embolectomy in a patient with rate of intubation by Anesthesia residents was significantly higher bilateral iliac artery occlusion. Reperfusion injury is an exacerbation than Speciality residents (p = 0.0001; 95% CI 9.02–24.66). Airway of cellular dysfunction following the restoration of blood flow to injuries were most frequent complication (n =140, 32.8%) followed the previously ischemic tissues leading to the release of byproducts by hypotension (n =57, 13.3%). Total of 99 patients received RSI of cell death and eventually causing multiorgan failure. This event in trauma triage during intubation by anaesthesia residents, is directly proportional to the duration of ischemia. Through this amongst these 77 (77%) patients had no complications, 8% had presentation, I intend to highlight how important is the early airway related injuries, 4 (4%) had esophageal intubation, 5 (5%) diagnosis and intervention of embolisms causing ischemia. developed hypoxemia and 3 (3%) had hypotension. Discussions: Materials and methods: Fogarty catheter embolectomy was done These prospective observational data come from a tertiary care in Amala Institute of medical sciences and complications occurred hospital of a low resource country on intubation practices in in the postsurgical critical care unit. Results: Early diagnosis trauma victims over a period of 1 year. The first responders are and interventions will prevent reperfusion injury. Discussions: usually non-anesthesia, speciality residents who cater to the Carcinomas are a hypercoagulable state. If a patient who is a known immediate needs of the trauma victims. This reflects the different case of carcinoma presents with paraplegia you have to palpate staffing levels and the limited expertise available on arrival to for peripheral pulses first before ruling out metastasis in the spine. trauma triage. Through this study, it may be noted that although If a pulse is absent do an emergency CT angiography to rule out the level of experience met the current standards, there is a need embolisms. If there is embolism you have to do intervention as to upgrade the skills of airway management using manikins and early as possible to prevent reperfusion injury. And also during mandatory anesthesia rotation. Most of the intubations carried and after embolectomy always expect complications associated by anesthesia residents were drug-assisted along with the use with reperfusion injuries like life-threatening arrhythmias and of muscle relaxants which resulted in less complications and multiorgan failure. Conclusion: Early diagnosis and intervention trauma. Literature supports the use of neuromuscular blockers could prevent reperfusion injury. in 62 to 77% of cases, with a strong association being reported

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between the use of neuromuscular blocking agents, especially 3. A Comparison of Glasgow Coma Scale Score with “Full Outline depolarizing agents, and fewer adverse effects, as depicted by of Unresponsiveness Scale” to Predict Outcome of the Patients our results. Conclusion: We observed that complication rates with Traumatic Brain Injury Presenting to Emergency Medicine were more in patients intubated by non-anesthesia residents, use Department. (Conference Abstract ID: 18) of a high dose of sedative agents like midazolam, and multiple Devanshi Hasmukh Virani, Shruti V Sangani, Chirag J Patel, attempts at intubation. Rapid evaluation of these factors and Dharmistra Dhusa formal training in ATLS can lead to optimal management of the BJ Medical College, India patient and decrease the rate of complications. DOI: 10.5005/jp-journals-10071-23711.193 Introduction: In patients presenting to emergency department 2. Impact of COVID Virus Infection on the Outcome of Critically (ED) with traumatic brain injury, it is important to evaluate the Ill Trauma Patients. (Conference Abstract ID: 157) neurological status to determine the present clinical status and to Manjaree Mishra, Shashi Prakash Mishra, Sumit Sharma, Neelesh predict the outcome of the patient. GCS is the most widely used Anand, Ghanshyam Yadav score, but it has some drawbacks which led to the development of Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India other scores such as the Full Outline of Unresponsiveness (FOUR) DOI: 10.5005/jp-journals-10071-23711.192 score. In our study, we compared the GCS and the FOUR scores in Introduction: Surgical practice has undergone extensive patients presenting with traumatic brain injury. changes during the COVID-19 crisis, mostly because of the Objectives: close contact nature of surgical procedures putting surgeons at • To compare the FOUR score with the GCS score in traumatic higher risk. In the past 3 months, almost 3 million surgeries have brain injury (TBI) patients. been canceled worldwide. Hospitals are being reconfigured in • To understand the effectiveness of the FOUR score as an expectation of surges in COVID-19 cases to provide more space assessment tool. for trauma and critically ill patients. All the non-urgent health • To assess whether the FOUR score is an alternative tool in TBI services were delayed. However, with few changes, trauma and patients or could be complimentary. emergency services continue to work according to the existing Materials and methods: We conducted a prospective observational protocols. Trauma treatment during the pandemic is focused study at a trauma center of B. J. Medical College, Ahmedabad on clinical urgency, patient protection as well as healthcare between September 2019 and September 2020 of a total of workers, and resource conservation. In this study, we addressed 200 patients. All patients presenting with a clinical diagnosis of our understanding of trauma victim triage and treatment during traumatic brain injury (TBI) were evaluated. A primary survey was the pandemic, emergency surgery indications, and intensive done initially. Vitals of the patients were taken, and resuscitation care. Objectives: To assess the impact of COVID virus infection started. Simultaneously, a GCS and a FOUR score were recorded on critically ill trauma patients. Materials and methods: The by the emergency physician. All patients were evaluated in terms study included the patients managed in the Intensive Care Unit of TBI and relevant investigations were done, and findings were of Trauma Centre linked with Medical Institution between April noted. We tabulated all information in Microsoft Excel 2019 and and September 2020. The data regarding the protocols followed, statistical analysis was done with SPSS software. Results: The mean perioperative measures taken and management protocol in age of study population was 38.295 ± 15.33 years. Male patients intensive care unit in accordance with COVID protocol. The were 79% and 21% were female patients. Road traffic accidents demographic data, clinical data, and final outcome were recorded contributed highest percentages of causes of TBI (60%). Patients in the study protocol. The final statistical correlation was done. who were deceased had low GCS score and when GCS 8 was taken Results: The standard precautions taken in accordance with as the cut off value, sensitivity of GCS was 87.88% and specificity COVID protocol have a significant role in the prevention of the of GCS was 97.60%. With a positive predictive value of 87.8%; spread of the COVID virus. The COVID infection seems to have and when FOUR Score of 8 was the cut off value, sensitivity of little impact on the final outcome on patients. Discussions: The FOUR score was 100% and Specificity was 97.52%, with a positive COVID pandemic has made the situation very difficult for hospitals predictive value of 89.19%. By comparing the median value of across the globe to ensure patients care and management. There FOUR score with mortality and the median value of GCS score with has been an issue related to initial management in an emergency the mortality by using the Mann-Whitney test showed a p-value of department as well as in the ICU setting. Not only the patient ≥1, which is statistically non-significant. Discussions: The Glasgow management but also there has been a risk of spread of infection Coma Scale is an objective measurement of clinical status, as it to healthcare workers. Conclusion: It is therefore recommended correlates with the outcome, it is a reliable tool for interobserver that there is a need for strict adherence to the precautions needed measurements and is also effective for measuring patient recovery to prevent the spread of COVID virus infection. The COVID infection or on-going response to treatment. A minimum score is 3 (deep may have an impact on the outcome of patients infected with the coma or death) and a maximum score is 15 (no neurological COVID virus which must be studied in detail. deficit). Three aspects of behavioral response namely eye-opening,

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verbal, and motor response are examined. All the above responses this is called the Full Outline of Unresponsiveness (FOUR) Score, are tested after the application of a painful stimulus. The drawback each rated with a maximum score of four. A higher score indicates of GCS is the failure to incorporate brainstem reflexes. The scale a better prognosis. The FOUR score, contrary to the GCS, avoids also includes a numerical bias toward the motor response and assessing verbal function. Conclusion: FOUR score is equally an important concern of issue is an appropriate application in reliable with GCS score. Both have their own significance. FOUR intubated patients who cannot manifest a verbal response. GCS does not signify subtle changes in the neurological examination. score maintains simplicity and provides far better information, Mayo Clinic, which evaluates four components, developed a new particularly for intubated patients. The FOUR score is a good scale: eye, motor responses, brainstem reflexes, and respiration, predictor of the prognosis of critically ill patients.

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