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Background and Aims: Intraoperative dexmedetomidine infusion decreases the concurrent anaesthetic and analgesic requirement. However, because of slow onset and offset, it is often used with other drugs. Opioids have a depressant effect on the cardiorespiratory system while ketamine has the opposite pharmacodynamics. Hence, it was hypothesised that ketamine will have a better intraoperative haemodynamic profile compared to fentanyl. This study compared the clinical effects and recovery characteristics of ketamine versus fentanyl when used as an adjuvant along with dexmedetomidine infusion intraoperatively. Methods: A total of 80 patients (18-60 years) undergoing major surgeries were divided into two groups: Group (D + K) received an intraoperative infusion of ketamine 0.5 mg/kg/h, while group (D + F) received fentanyl 0.5 μg/kg/h along with intravenous dexmedetomidine 0.5 μg/kg/h. Intraoperative heart rate (HR), mean blood pressure, and oxygen saturation were recorded at 0 min, 10 min of induction, and thereafter every 30 min throughout the procedure. Ramsay sedation score (RSS) and visual analogue scale (VAS) score were measured at the end of the surgery, at 2 hours, 4 hours, and 6 hours. Results: Reduction in HR and mean blood pressure was more with a tendency of developing hypotension in the fentanyl group compared to the ketamine group. Post-anaesthesia care unit (PACU) stay, need for muscle relaxant and VAS score for pain were also significantly lesser in the ketamine group. Conclusion: Dexmedetomidine with ketamine provided better haemodynamic stability and reduced PACU stay compared to dexmedetomidine with fentanyl.

Byline: Mehershre. Lodhi, Sulakshana. Sulakshana, Anil. Singh, Bikram. Gupta Background and Aims: Intraoperative dexmedetomidine infusion decreases the concurrent anaesthetic and analgesic requirement. However, because of slow onset and offset, it [...]

Aim and background: With a better understanding of the various causes of cardiac arrest (CA) and the development of novel technologies and devices, conventional cardiopulmonary resuscitation (CPR) has undergone several modifications for improved outcomes. Case description: We hereby present a case of a 57-year-old diabetic lady who suffered refractory CA, which was successfully managed with extracorporeal cardiopulmonary resuscitation (e-CPR). The patient was on venoarterial extracorporeal membrane oxygenation for 5 days and was discharged home without any neurological morbidity on day 10 of admission. Conclusion: Indian extracorporeal membrane oxygenation (ECMO) centers are also getting equipped to promptly manage refractory CA cases with extracorporeal technologies. Clinical significance: This is the first case to be reported from Eastern India of successful e-CPR for in-hospital CA. [ABSTRACT FROM AUTHOR]

Background: Initial reports from Wuhan (China) suggested poor outcomes for severe COVID-19 patients treated with Extracorporeal Membrane Oxygenation (ECMO). Extracorporeal Life Support Organization (ELSO) interim 2019 guidelines also recommended using ECMO only when all conventional therapies are exhausted. However, later studies showed that delayed ECMO initiation may lead to longer ECMO runs, offsetting any benefit from resource conservation by delaying the initiation. Hence, this study was intended to analyze the sociodemographic characteristics, type of ECMO, and complications of its outcome in the Indian scenario. Materials and methods: Demographic and patient clinical outcome data of all the patients of severe ARDS due to COVID-19 being treated with ECMO from 1st June 2020 to 31st May 2021 at Medica Super-specialty Hospital (Kolkata, India), were retrospectively compiled and analyzed. Results: Total number of patients treated was 79 with 10% female representation. The mean age was 43 ± 3.2 years and the mean body mass index 37 ± 4.3. Fifty percent of the patient survived. The mean duration of the ECMO run was 17 ± 5.2 days. Sepsis (65%) was the commonest complication observed followed by acute kidney injury (39%). Conclusion: This study provides significant insight into the outcomes of patients of COVID-19 treated by ECMO in the Indian scenario. Mortality rates of COVID-19 patients on ECMO were comparable to the non-COVID-19 patients, although the ECMO run time was relatively longer. Our study concluded that ECMO should be considered as a treatment option in appropriate COVID-19 cases. However, if the capacity diminishes in a pandemic situation, ECMO consideration should be based on more stringent criteria. [ABSTRACT FROM AUTHOR]

Byline: Sulakshana. Sulakshana, Shashi. Prakash Hyponatremia causing seizure is a common cause for admission in the critical care unit. Here, we describe a peculiar case of seizure due to hyponatremia, [...]

Background: It has been more than a year since the whole world is struggling with COVID-19 pandemic and may experience resurgences in the near future. Along with severe pneumonia, this disease is notorious for extensive thromboembolic manifestations. That is why experts advocated aggressive anticoagulation as a part of the therapy since the beginning. However, from May 2020 onwards, cases of heparin-induced thrombocytopenia (HIT) are being reported. HIT in itself is an autoimmune entity leading to life-threatening thrombosis in the setting of thrombocytopenia. Continuation of heparin can have disastrous consequences in case of unrecognized HIT. Hence, timely recognition of HIT is of utmost value to modify the anticoagulation strategy and salvaging lives. We performed a systemic review trying to find all reported cases of HIT in COVID-19. Methods: It involved extensive search of the databases including PubMed, Google Scholar, Scopus, and Embase in an attempt to find all reported literature in the last 1 year (November 1, 2019–December 25, 2020) using keywords in various combinations. Literature search resulted in a total of 27 articles and 12 articles were finally selected based on the study design and their relevance pertaining to the intervention done and the outcome of interest. Results: A total of 35 patients were included (mean age 56.7 ± 12.8 years, male-to-female ratio = 2:1). The most frequent comorbidity was hypertension. Fifty-seven percent of cases were with low-molecular weight heparin and the rest with unfractionated heparin. Confirmatory functional assay was done in 85.7% of cases (67% by serotonin-release assay [SRA] and 33% by heparin-induced platelet aggregation [HIPA]). All cases tested with HIPA were positive, while with SRA, only 30% were positive. The most common alternate anticoagulation used was argatroban infusion. The new arterial thrombotic event was seen in only 5.7% of cases as repeat myocardial infarction, stroke, and splenic infarction, while clinically significant bleeding was seen in 17.1% of cases. Fifty percent of bleeding episodes were seen where conventional doses of argatroban were used, while no mortality was seen with low-dose argatroban infusion. However, only 45.7% of patients were discharged, 31.4% of patients died, while the outcome was pending for 23% of patients. Conclusion: Severe endotheliitis and immune dysregulation giving rise to HIT antibodies and antiphospholipid antibodies have been demonstrated in COVID-19 and modifying our therapy becomes indispensable when it is pathogenic with potentially fatal consequences. In the light of interim results of REMAP-CAP study in severe COVID-19 cases where heparin does not improve the outcome, the present anticoagulation strategy needs re-evaluation. Unrecognized HIT can be catastrophic and close clinical monitoring is required for patients on heparin therapy. [ABSTRACT FROM AUTHOR]

We report a case of fulminant hepatic failure due to the Budd-Chiari syndrome following preservation with a tropical fever. A young lady came with fever, altered mental status, jaundice, and renal failure. Following tropical workup, it was diagnosed as a case of leptospirosis (WHO Faine's criteria) with multi-organ dysfunction. Despite adequate antimicrobial cover, she progressed to hepatic coma (hyperammonemia) and was noted to have worsening conjugated hyperbilirubinemia. Following history review and evaluation for other causes of hepatic failure, hepatic vein thrombosis was detected in addition to the presence of antibodies against Leptospira antigen. Further studies into the causes of thrombosis and persistent hemoconcentration despite aggressive fluid resuscitation led to the diagnosis of polycythemia vera (cytometric analysis). During her stay, she further worsened despite aggressive organ support including dialysis but she succumbed to gram-negative sepsis that occurred during her stay in ICU. This is an interesting and rare case of leptospirosis that unveiled a case of previously asymptomatic polycythemia vera. [ABSTRACT FROM AUTHOR]

Critical illness polyneuromyopathy is a growing concern in intensive care units, but its presentation within 24-48 hours of admission is very unusual. Such presentations should be carefully scrutinized, especially in the presence of severe hypokalemia. [ABSTRACT FROM AUTHOR]