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Background and Aims: The International Normalised Ratio (INR), which assesses the loss of procoagulant factors in the extrinsic pathway, fails to evaluate the coagulation abnormalities comprehensively after a major liver resection, which often leads to reduced synthesis of procoagulant and anticoagulant-factors. This study was conducted with an aim to study the trend and compare the results of routine coagulation tests and thromboelastography (TEG) during the perioperative period in patients undergoing major liver resections (≥3 segments)., Methods: Twenty-five patients who underwent a major liver resection were enrolled. This prospective, single-arm, interventional study was performed with the primary objective of determining the serial changes in conventional coagulation tests and TEG during the perioperative period in patients undergoing major liver resections, at the preincision period, intraoperative period, postoperatively, at 48 h and on the fifth postoperative day. Transfusion requirements of blood components were also assessed with a TEG-guided replacement strategy. Spearman rank-order correlation was used to study the relationships of coagulation tests (both TEG and conventional tests) at each time point., Results: The prothrombin time (PT)-INR was elevated in 14 patients (56%) at the intraoperative, immediate postoperative and 48-h time points in contrast to the TEG parameters, which remained normal in all patients. Blood component transfusion was avoided in 4, 11 and 10 patients at the intraoperative, immediate postoperative and 48-h time points, respectively., Conclusion: International Normalised Ratio overestimates the coagulopathy in patients undergoing major liver resection, and a thromboelastography-guided transfusion strategy reduces overall transfusion requirements., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Anaesthesia.)

Introduction: Unplanned hospital readmission (UHR) is an important indicator of the quality of the healthcare system in place. It has various implications for the patients and the healthcare system at large. In this article, we have attempted to understand the various factors influencing UHR and the start of adjuvant treatment following cancer surgery., Patients & Methods: In this study adult patients above 18 years of age with upper aerodigestive tract squamous cell carcinoma who underwent surgery at our center between July 2019 to December 2019 were included in the study. Various factors influencing UHR and delay in receiving adjuvant treatment were analyzed., Results: A total of 245 patients satisfied the inclusion criteria. Surgical site infection (SSI) was the factor that had the maximum influence on the UHR (p < 0.002, OR: 5.6, 95% CI: [1.911-16.4]) and delaying the start of adjuvant treatment (p = 0.008, OR: 3.786, 95% CI: [1.421-10.086]) on multivariate analysis. Surgery lasting for >4 h and patients who had received prior treatment tended to develop SSI postoperatively. The presence of SSI also seemed to have had a negative influence on disease-free survival (DFS) as well., Conclusions: SSI is an important postoperative complication having major implications in terms of increased UHR and delays in starting adjuvant treatment which in turn is reflected as a poorer DFS among patients who develop SSI postoperatively., (© 2023 Wiley Periodicals LLC.)

Objective: To identify risk factors for mortality in intensive care units (ICUs) in Asia., Design: Prospective cohort study., Setting: The study included 317 ICUs of 96 hospitals in 44 cities in 9 countries of Asia: China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam., Participants: Patients aged >18 years admitted to ICUs., Results: In total, 157,667 patients were followed during 957,517 patient days, and 8,157 HAIs occurred. In multiple logistic regression, the following variables were associated with an increased mortality risk: central-line-associated bloodstream infection (CLABSI; aOR, 2.36; P < .0001), ventilator-associated event (VAE; aOR, 1.51; P < .0001), catheter-associated urinary tract infection (CAUTI; aOR, 1.04; P < .0001), and female sex (aOR, 1.06; P < .0001). Older age increased mortality risk by 1% per year (aOR, 1.01; P < .0001). Length of stay (LOS) increased mortality risk by 1% per bed day (aOR, 1.01; P < .0001). Central-line days increased mortality risk by 2% per central-line day (aOR, 1.02; P < .0001). Urinary catheter days increased mortality risk by 4% per urinary catheter day (aOR, 1.04; P < .0001). The highest mortality risks were associated with mechanical ventilation utilization ratio (aOR, 12.48; P < .0001), upper middle-income country (aOR, 1.09; P = .033), surgical hospitalization (aOR, 2.17; P < .0001), pediatric oncology ICU (aOR, 9.90; P < .0001), and adult oncology ICU (aOR, 4.52; P < .0001). Patients at university hospitals had the lowest mortality risk (aOR, 0.61; P < .0001)., Conclusions: Some variables associated with an increased mortality risk are unlikely to change, such as age, sex, national economy, hospitalization type, and ICU type. Some other variables can be modified, such as LOS, central-line use, urinary catheter use, and mechanical ventilation as well as and acquisition of CLABSI, VAE, or CAUTI. To reduce mortality risk, we shall focus on strategies to reduce LOS; strategies to reduce central-line, urinary catheter, and mechanical ventilation use; and HAI prevention recommendations.

Background: Ventilator associated pneumonia (VAP) rates in Asia are several times above those of US. The objective of this study is to identify VAP risk factors., Methods: We conducted a prospective cohort study, between March 27, 2004 and November 2, 2022, in 279 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, Vietnam)., Results: 153,717 patients, followed during 892,996 patient-days, acquired 3,369 VAPs. We analyzed 10 independent variables. Using multiple logistic regression we identified following independent VAP RFs= Age, rising VAP risk 1% per year (aOR=1.01; 95%CI=1.00-1.01, P<.0001); male gender (OR=1.17; 95%CI=1.08-1.26, P<.0001); length of stay, rising VAP risk 7% daily (aOR=1.07; 95%CI=1.06-1.07, P<.0001); mechanical ventilation (MV) device utilization (DU) ratio (OR=1.43; 95%CI=1.36-1.51; p<.0001); tracheostomy connected to a MV (OR=11.17; 95%CI=9.55-14.27; p<.0001); public (OR=1.84; 95%CI=1.49-2.26, P<.0001), and private (OR=1.57; 95%CI=1.29-1.91, P<.0001) compared with teaching hospitals; upper-middle income country (OR=1.86; 95%CI=1.63-2.14, P<.0001). Regarding ICUs, Medical-Surgical (OR=4.61; 95%CI=3.43-6.17; P<.0001), Neurologic (OR=3.76; 95%CI=2.43-5.82; P<.0001), Medical (OR=2.78; 95%CI=2.04-3.79; P<.0001), and Neuro-Surgical (OR=2.33; 95%CI=1.61-3.92; P<.0001) showed the highest risk., Conclusions: Some identified VAP RFs are unlikely to change= age, gender, ICU type, facility ownership, country income level. Based on our results, we recommend limit use of tracheostomy, reducing LOS, reducing the MV/DU ratio, and implementing an evidence-based set of VAP prevention recommendations., (Copyright © 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives  The objective is to present the patterns of dual primary malignancies diagnosed at the Pathology Laboratory of Cancer Hospital with the support from hospital-based cancer registry (HBCR), Sangrur, Punjab, India for the years 2018 and 2019. Methods  HBCR abstracts data from electronic medical records. Trained cancer registry staff abstracts cases in standard pro forma. Dual primary was coded as per the International Agency for Research on Cancer rule and was rechecked by the pathologist. Statistical Analysis  Data about multiple primary was entered and documented in an Excel sheet. Time interval was calculated by subtracting the date of diagnosis for second primary and first primary. Results  A total of 6,933 cases were registered, 45 cases are dual primary (26 females, 19 males) of which 64.4% are synchronous and 35.6% metachronous cases. Seventy-nine percent received cancer-directed treatment for synchronous and 87% for metachronous. The most common sites of the primary tumor were breast (33%), head and neck (22.2%), gynecological sites (11%), prostate (9%), esophagus (4%), and remaining other tumors (20.8%). Most common sites for second malignancies were gastrointestinal (GI) tract (31%), gynecological sites (18%), head and neck (16%), hematological malignancies (7%), soft tissue sarcoma (4%), breast (2%), and other sites (22%). Conclusion  More than 70% of cases of primary tumors were in breast, head and neck, gynecological, and prostate. Of these, more than 60% of the second malignancy was found in the GI tract, gynecological, and head and neck sites. Around two-thirds of dual tumors are synchronous. Breast cancer cases have higher incidence of second malignancy. Regular follow-up is necessary to assess the survival of the second primary., Competing Interests: Conflict of Interest None declared., (The Indian Association of Laboratory Physicians. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background and Aims: The analgesic role of gabapentinoids following thoracic surgeries is not clear. In this study, we evaluated the benefits of gabapentinoids for pain management in patients undergoing thoracic onco-surgery in terms of opioids and non-steroidal anti-inflammatory drugs (NSAIDs) sparing effect. We also compared pain scores (PSs), number of days of active surveillance by the acute pain service team, and side effects associated with gabapentinoids., Methods: After ethics-committee approval, data were retrieved retrospectively from clinical sheets, an electronic database, and nurses' charts from a tertiary cancer care hospital. Propensity score matching was performed for six covariates, that is, age, gender, American Society of Anesthesiologists grading, surgical approach, analgesia modality, and worst PS in the first 24 hours performed. A total of 272 patients were grouped into group N (not given gabapentinoids, n = 174) and group Y (given, n = 98)., Results: The median opioid consumption in terms of fentanyl equivalent by group N was 800 µg [inter-quartile range (IQR): 280-900], and the median opioid consumption by group Y was 400 µg (IQR: 100-690) (p = 0.001). The median number of rescue doses of NSAIDs administered to group N was 8 (IQR = 4-10), and the median number of rescue doses to group Y was 3 (IQR = 2-5) (p = 0.001). No difference was found in subsequent PS and for the number of days under acute pain service surveillance for either group. Group Y had an increased incidence of giddiness compared to group N (p = 0.006), with a relative reduction in post-operative nausea and vomiting scores (p = 0.32)., Conclusion: Gabapentinoids used following thoracic onco-surgeries result in a significant reduction in concomitant use of NSAIDs and opioids. There is an increased incidence of dizziness with the use of these drugs., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Anaesthesia.)

Background: The Curing Coma Campaign (CCC) was launched by the Neurocritical Care Society (NCS) in 2019, with the purpose to bring together a diverse group of coma scientists, neurointensivists, and neurorehabilitationists., Methods: The aim of this campaign is to move beyond the limitations imposed by current definitions of coma and identify mechanisms to improve prognostication, identify test therapies, and impact outcomes. At the moment, whole approach of the CCC appears ambitiously challenging., Results: This could be true only for the Western world, such as the North America, Europe, and few developed countries. However, the whole concept of CCC may face potential challenges in the lower-middle income countries. India has several stumbling blocks that need to and can be addressed in the future, for a meaningful outcome, as envisaged in the CCC., Conclusion: India has several potential challenges, which we aim to discuss in this article., How to Cite This Article: Kapoor I, Mahajan C, Zirpe KG, Samavedam S, Sahoo TK, Sapra H, et al . The Curing Coma Campaign®: Concerns in the Indian Subcontinent. Indian J Crit Care Med 2023;27(2):89-92., Competing Interests: Source of support: Nil Conflict of interest: Dr Srinivas Samavedam, Dr Kapil Gangadhar Zirpe and Dr Jigeeshu V Divatia are associated as the Editorial board members of this journal and this manuscript was subjected to this journal's standard review procedures, with this peer review handled independently of these Editorial board members and their research group., (Copyright © 2023; The Author(s).)

Rationale: Directly comparative data on sepsis epidemiology and sepsis bundle implementation in countries of differing national wealth remain sparse. Objectives: To evaluate across countries/regions of differing income status in Asia 1 ) the prevalence, causes, and outcomes of sepsis as a reason for ICU admission and 2 ) sepsis bundle (antibiotic administration, blood culture, and lactate measurement) compliance and its association with hospital mortality. Methods: A prospective point prevalence study was conducted among 386 adult ICUs from 22 Asian countries/regions. Adult ICU participants admitted for sepsis on four separate days (representing the seasons of 2019) were recruited. Measurements and Main Results: The overall prevalence of sepsis in ICUs was 22.4% (20.9%, 24.5%, and 21.3% in low-income countries/regions [LICs]/lower middle-income countries/regions [LMICs], upper middle-income countries/regions, and high-income countries/regions [HICs], respectively; P  < 0.001). Patients were younger and had lower severity of illness in LICs/LMICs. Hospital mortality was 32.6% and marginally significantly higher in LICs/LMICs than HICs on multivariable generalized mixed model analysis (adjusted odds ratio, 1.84; 95% confidence interval, 1.00-3.37; P  = 0.049). Sepsis bundle compliance was 21.5% at 1 hour (26.0%, 22.1%, and 16.2% in LICs/LMICs, upper middle-income countries/regions, and HICs, respectively; P  < 0.001) and 36.6% at 3 hours (39.3%, 32.8%, and 38.5%, respectively; P  = 0.001). Delaying antibiotic administration beyond 3 hours was the only element independently associated with increased mortality (adjusted odds ratio, 2.53; 95% confidence interval, 2.07-3.08; P  < 0.001). Conclusions: Sepsis is a common cause of admission to Asian ICUs. Mortality remains high and is higher in LICs/LMICs after controlling for confounders. Sepsis bundle compliance remains low. Delaying antibiotic administration beyond 3 hours from diagnosis is associated with increased mortality. Clinical trial registered with www.ctri.nic.in (CTRI/2019/01/016898).

Background and Aims: Passage of double-lumen tubes (DLT) can be challenging in patients with limited glottis view. This study aims to determine the usefulness of McGrath® MAC videolaryngoscope (VL) in cases with limited glottis view on direct laryngoscopy with Macintosh blade., Material and Methods: After study approval and registration of trial, consent was sought from all adult patients planned for elective DLT insertion for lung isolation during the course of general anesthesia. Patients not consenting, less than 18 years, with anticipated difficult mask ventilation or need for rapid sequence induction were excluded. Following routine anesthetic induction, laryngoscopy was attempted by an experienced anesthesiologist using Macintosh scope. If the view obtained was Cormack and Lehane (CL) view IIB and above or the attempt at intubation using DLT failed despite a CL I/IIA view, the patient was included in the trial. The laryngoscope was removed and after ensuring adequate oxygenation and depth of anesthesia, intubation was attempted using McGrath® MAC VL. The percentage of glottis opening (POGO) score was noted for both the scopes., Results: DLT insertion was attempted in 76 patients in the study period. Eight patients were included in the trial on account of limited glottis view/failure with Macintosh scope. Insertion of DLT with McGrath MAC was tried only in six patients, in two patients, the VL was not available for use. The mean (standard deviation) POGO score with Macintosh scope was 9 (±20), which significantly improved with the use of VL to 71 (±24), P = 0.01., Conclusion: McGrath MAC is helpful in inserting DLT in patients with limited glottis view with Macintosh scope., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Anaesthesiology Clinical Pharmacology.)

Hemodynamic assessment along with continuous monitoring and appropriate therapy forms an integral part of management of critically ill patients with acute circulatory failure. In India, the infrastructure in ICUs varies from very basic facilities in smaller towns and semi-urban areas, to world-class, cutting-edge technology in corporate hospitals, in metropolitan cities. Surveys and studies from India suggest a wide variation in clinical practices due to possible lack of awareness, expertise, high costs, and lack of availability of advanced hemodynamic monitoring devices. We, therefore, on behalf of the Indian Society of Critical Care Medicine (ISCCM), formulated these evidence-based guidelines for optimal use of various hemodynamic monitoring modalities keeping in mind the resource-limited settings and the specific needs of our patients. When enough evidence was not forthcoming, we have made recommendations after achieving consensus amongst members. Careful integration of clinical assessment and critical information obtained from laboratory data and monitoring devices should help in improving outcomes of our patients., How to Cite This Article: Kulkarni AP, Govil D, Samavedam S, Srinivasan S, Ramasubban S, Venkataraman R, et al . ISCCM Guidelines for Hemodynamic Monitoring in the Critically Ill. Indian J Crit Care Med 2022;26(S2):S66-S76., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.)

Aim: Sedation is essential during invasive mechanical ventilation, and conventionally intravenous analgesic and sedative drugs are used. Sedation with inhaled anesthetics using anesthesia conserving device (ACD) is an alternative. There is no data on the safety and ease of use of AnaConDa™ from India., Materials and Methods: After IEC approval and informed consent, we used AnaConDa™-S for Isoflurane sedation in 50 hemodynamically stable (need for <0.5 µg/kg/min of Noradrenaline infusion), ASA I and II patients aged 18-80 years, undergoing elective mechanical ventilation for up to 24 hours after elective oncosurgeries. Patients with mental obtundation (GCS <14), or if pregnant, were excluded. The primary outcome was time spent between RASS scores of -3 and -4, while secondary outcomes were incidence of delirium, technical problems with AnaConDa™, and adverse systemic effects of isoflurane. Bolus doses of isoflurane 0.2-0.5 mL were given if the Richmond agitation sedation scale (RASS) score was not achieved., Results: Fifty patients received isoflurane infusion for a median of 720 (IQR 630-900) minutes, and all remained in the target sedation range. Median time to awakening [19 (IQR, 5-85) minutes], to follow simple verbal commands [20 (IQR 5-180) minutes], and extubation after stopping the infusion of isoflurane was quick [100 (10-470) minutes]. All patients remained hemodynamically stable. None of the patients had delirium., Conclusion: Target sedation levels were achieved with initial boluses of isoflurane using AnaConDa™-S. Isoflurane sedation delivery using AnaConDa™-S is safe and feasible., How to Cite This Article: Kulkarni AP, Bhosale SJ, Kalvit KR, Sahu TK, Mohanty R, Dhas MM, et al. Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med 2022;26(8):906-912., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.)

Competing Interests: There are no conflicts of interest.

Purpose: We assessed long-term outcomes of dexamethasone 12 mg versus 6 mg given daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia., Methods: We assessed 180-day mortality and health-related quality of life (HRQoL) using EuroQoL (EQ)-5D-5L index values and EQ visual analogue scale (VAS) in the international, stratified, blinded COVID STEROID 2 trial, which randomised 1000 adults with confirmed COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 26 hospitals in Europe and India. In the HRQoL analyses, higher values indicated better outcomes, and deceased patients were given a score of zero., Results: We obtained vital status at 180 days for 963 of 982 patients (98.1%) in the intention-to-treat population, EQ-5D-5L index value data for 922 (93.9%) and EQ VAS data for 924 (94.1%). At 180 days, 164 of 486 patients (33.7%) had died in the 12 mg group versus 184 of 477 (38.6%) in the 6 mg group [adjusted risk difference - 4.3%; 99% confidence interval (CI) - 11.7-3.0; relative risk 0.89; 0.72-1.09; P = 0.13]. The adjusted mean differences between the 12 mg and the 6 mg groups in EQ-5D-5L index values were 0.06 (99% CI - 0.01 to 0.12; P = 0.10) and in EQ VAS scores 4 (- 3 to 10; P = 0.22)., Conclusion: Among patients with COVID-19 and severe hypoxaemia, dexamethasone 12 mg compared with 6 mg did not result in statistically significant improvements in mortality or HRQoL at 180 days, but the results were most compatible with benefit from the higher dose., (© 2022. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: This study examines the impact of the COVID-19 pandemic on health care-associated infection (HAI) incidence in low- and middle-income countries (LMICs)., Methods: Patients from 7 LMICs were followed up during hospital intensive care unit (ICU) stays from January 2019 to May 2020. HAI rates were calculated using the International Nosocomial Infection Control Consortium (INICC) Surveillance Online System applying the Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) criteria. Pre-COVID-19 rates for 2019 were compared with COVID-19 era rates for 2020 for central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), mortality, and length of stay (LOS)., Results: A total of 7,775 patients were followed up for 49,506 bed days. The 2019 to 2020 rate comparisons were 2.54 and 4.73 CLABSIs per 1,000 central line days (risk ratio [RR] = 1.85, p = .0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR = 1.29, p = .10), and 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR = 1.14; p = .69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR = 1.42; p < .0001), respectively. Mean LOS for 2019 and 2020 were 6.02 and 7.54 days (RR = 1.21, p < .0001), respectively., Discussion: This study documents an increase in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Purpose of Review: The physiologically difficult airway is one in which physiologic alterations in the patient increase the risk for cardiorespiratory and other complications during tracheal intubation and transition to positive pressure ventilation. This review will summarize the recent literature around the emerging concept of the physiologically difficult airway, describe its relevance and various patient types in which this entity is observed., Recent Findings: Physiologic derangements during airway management occur due acute illness, pre-existing disease, effects of anesthetic agents, and positive pressure ventilation. These derangements are especially recognized in critically ill patients, but can also occur in otherwise healthy patients including obese, pregnant and pediatric patients who have certain physiological alterations. Critically ill patients may have a physiologically difficult airway due to the presence of acute respiratory failure, hypoxemia, hypotension, severe metabolic acidosis, right ventricular failure, intracranial hypertension, and risk of aspiration of gastric contents during tracheal intubation., Summary: Understanding the physiological alterations and the risks involved in patients with a physiologically difficult airway is necessary to optimize the physiology and adopt strategies to avoid complications during tracheal intubation. Further research will help us better understand the optimal strategies to improve outcomes in these patients., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: There are no conflicts of interest.

Competing Interests: Jigeeshu V Divatia reports lecture fees paid by the Edwards Lifesciences India to his institution.

During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties., Competing Interests: Declaration of interests PN reports honoraria for lectures and other educational events from Tabuk Pharmaceuticals, and is a member of Edward Lifesciences Advisory Board Panel, outside of the submitted work. JVD reports personal fees (paid to institution) from Edwards India, outside the submitted work. MB reports honoraria for lectures and another educational event from Angelini, Bayer, bioMérieux, Cipla, Gilead Sciences, Menarini, Merck Sharp & Dohme (MSD), Pfizer, and Shionogi; grants from Pfizer and MSD, outside of the submitted work; and is on the advisory board of Cidara Therapeutics. JDW reports honoraria (paid to institution) for lectures and other educational events from MSD and Pfizer, outside of the submitted work. BD reports research grants from Ministry of Science and Technology, People's Republic of China (research grant 2020YFC0841300), and Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (2020-I2M-2-005 and 2019-I2M-1-001), outside of the submitted work. LE reports consulting fees (paid to institution) for the National Emerging Special Pathogen Training and Education Centre, outside of the submitted work. SJ reports academic consultation fees from Drager, Fisher-Paykel, Medtronic, Baxter International, and Fresenius–Xenios; and honoraria for lectures and other educational events from Fisher-Paykel and Baxter, outside of the submitted work. MK reports honoraria from Merck and Pfizer for lectures and other educational events, outside of the submitted work. JM reports research grants (paid to institution) from Covidien (Medtronic) and Canadian Institutes of Health Research; personal consultation fees from Janssen Pharmaceuticals and Faron Pharmaceuticals; honoraria from Medtronic for lectures and other educational events; and a consulting agreement signed with Vyaire, outside of the submitted work. MSN reports personal consulting fees from Abbvie, outside of the submitted work. AP reports research grants from Novo Nordisk Foundation, Pfizer, and Fresenius Kabi, outside of the submitted work. MS reports research grants and advisory board fees from NewB; research grants from DSTL, Critical Pressure, and Apollo Therapeutics; speaking fees (paid to institution) from Amormed, advisory board fees from Biotest, GE, Baxter, Roche, and Bayer; and honoria from Shionogi, outside of the submitted work. BV reports research grants and honoraria for the guest lecture and other educational events from Baxter, outside of the submitted work. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: We compared dexamethasone 12 versus 6 mg daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia in the international, randomised, blinded COVID STEROID 2 trial. In the primary, conventional analyses, the predefined statistical significance thresholds were not reached. We conducted a pre-planned Bayesian analysis to facilitate probabilistic interpretation., Methods: We analysed outcome data within 90 days in the intention-to-treat population (data available in 967 to 982 patients) using Bayesian models with various sensitivity analyses. Results are presented as median posterior probabilities with 95% credible intervals (CrIs) and probabilities of different effect sizes with 12 mg dexamethasone., Results: The adjusted mean difference on days alive without life support at day 28 (primary outcome) was 1.3 days (95% CrI -0.3 to 2.9; 94.2% probability of benefit). Adjusted relative risks and probabilities of benefit on serious adverse reactions was 0.85 (0.63 to 1.16; 84.1%) and on mortality 0.87 (0.73 to 1.03; 94.8%) at day 28 and 0.88 (0.75 to 1.02; 95.1%) at day 90. Probabilities of benefit on days alive without life support and days alive out of hospital at day 90 were 85 and 95.7%, respectively. Results were largely consistent across sensitivity analyses, with relatively low probabilities of clinically important harm with 12 mg on all outcomes in all analyses., Conclusion: We found high probabilities of benefit and low probabilities of clinically important harm with dexamethasone 12 mg versus 6 mg daily in patients with COVID-19 and severe hypoxaemia on all outcomes up to 90 days., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Traditional arterial blood gas (ABG) analysis may miss out on some metabolic acid-base disorders. We prospectively compared Stewart's approach in critically ill patients to traditional bicarbonate-anion gap-based methods (with and without correction for albumin) to diagnose acid-base disorders., Patients and Methods: Five hundred ABG samples from medical or surgical patients in the ICU were analyzed with traditional bicarbonate-anion gap-based methodology with and without correction for albumin and Stewart's biochemical approach. The primary outcome identification of additional metabolic disorders diagnosed with Stewart's approach in comparison to bicarbonate system-based approaches. We also looked at the correlation between the strong ion gap (SIG) and the albumin-corrected anion gap (acAnion Gap)., Results: Stewart's approach detected missed metabolic disorders in 58 (11.6%) blood gas results reported as "within normal limits" with the bicarbonate-uncorrected anion gap approach. In 50 (10%) of these ABGs, the acAnion Gap approach was able to diagnose the missed metabolic disorders. Thus, the albumin-corrected anion gap method had a similar diagnostic performance to Stewart's approach, as it missed additional disorders in only eight (1.6%) blood gases., Conclusion: In this study, we found that the acAnion Gap approach was similar in diagnostic performance to Stewart's approach. We feel that the corrected anion gap approach can be safely used if a ready calculator for Stewart's approach is not available., How to Cite This Article: Paliwal R, Pakavakis A, Divatia JV, Kulkarni AP. Utility of Stewart's Approach to Diagnose Missed Complex Acid-Base Disorders as Compared to Bicarbonate-anion Gap-based Methodology in Critically Ill Patients: An Observational Study. Indian J Crit Care Med 2022;26(1):23-32., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; The Author(s).)

Passing the exit Doctor of Medicine/Diplomate of National Board examination is a significant but challenging milestone in the career of any student. A strong knowledge base is the foundation on which a student can build an impactful performance. Knowledge core is tested in the theory part of the examination and its application to patient care during case presentations and viva in the practical examination. Performance during the practicals has one common denominator: convincing the examiner that the patient during anaesthesia would be safe in the student's hands. The way the student answers, the spontaneity and the confidence that the student exudes in answering, the pointed answers to the questions asked, and setting the priorities right when dealing with a multitude of tasks at hand go a long way in ensuring that. This article describes what examiners expect from students and provides tips to postgraduate students preparing for the examination., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Journal of Anaesthesia.)

Multiple studies have reported the increased risk of pulmonary complications and mortality in patients undergoing surgery with perioperative COVID-19 infection. With several reports of long-term sequelae in patients recovered from COVID-19 infection, this survey was conducted to collect the opinions of anesthesiologists regarding modifications to pre-anesthesia checkup (PAC) when COVID-19 survivors are posted for elective surgeries. We designed, validated and distributed a detailed online questionnaire, about various modifications in PAC in different patient populations like asymptomatic patients, patients with mild, moderate or severe hypoxia, significant cardiac complaints during COVID-19 and also geriatric, pediatric and pregnant patients with a history of COVID-19. We received 154 responses. Majority of responders agree that 0-2 weeks from the date of negative for SARS-CoV-2, is the ideal duration for all elective surgeries. Greater than 50% responders agree that a fresh PAC evaluation should be done for such patients which should include documentation of current functional status, fresh chest X-ray, electrocardiogram and coagulation profile. All patients who had hypoxia or cardiac symptoms during COVID-19 infection and even recovered asymptomatic geriatric patients should undergo cardiorespiratory evaluation with investigations such as HRCT chest, ABG, PFT, echocardiography and troponin I levels. Patients' PAC should be individualized, factoring in the severity of COVID-19 infection, post recovery functional status, associated co-morbidities and the urgency as well as the risk of surgical intervention., Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-021-01347-z., Competing Interests: Conflicts of Interest/Competing InterestsThe authors declare that they have no conflict of interest., (© Indian Association of Surgical Oncology 2021.)

Objectives: Critically ill solid organ malignancy patients admitted to intensive care unit (ICU) as unplanned medical admissions behave differently from other subsets of cancer patients (hematolymphoid malignancies and cancer patients admitted for postoperative care). These patients if appropriately selected may benefit from the ICU care. There is paucity of data on critically ill unplanned admissions of solid organ malignancies from South Asia. We analyzed data of patients with solid tumors with unplanned admissions to the ICU to determine the clinical, epidemiological characteristics, and predictors of hospital mortality in an Indian ICU., Materials and Methods: This prospective, observational study was done in our 14-bedded mixed medical-surgical ICU from July 2014 to November 2015. We included all consecutive adult unplanned admissions with solid organ malignancies having ICU stay of >24 hours. Surgical admissions, hematolymphoid malignancies, advanced malignancy with no treatment options, and those cured of cancer >5 years were excluded., Results: Two hundred and thirty-five consecutive patients were included in this cohort. ICU and hospital mortalities were 36.6 and 40%, respectively. On multivariate analysis, cancer status [odds ratio (OR): 3.204; 95% confidence interval (CI): 1.271-8.078], invasive mechanical ventilation (OR: 5.940; 95% CI: 2.632-13.408), and sequential organ failure assessment (SOFA) score on the day of ICU admission (OR: 1.199; 95% CI: 1.042-1.379) were independent predictors of hospital mortality., Conclusion: Acute respiratory failure and septic shock are the common reasons of unplanned ICU admission for patients with solid organ malignancies. With good patient selection, more than half of such patients are likely to be discharged alive from the hospital., How to Cite This Article: Siddiqui SS, Narkhede AM, Chaudhari HK, Ravisankar NP, Dhundi U, Sarode S, et al. Clinico-demographic and Outcome Predictors in Solid Tumor Patients with Unplanned Intensive Care Unit Admissions: An Observational Study. Indian J Crit Care Med 2021;25(12):1421-1426., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Importance: A daily dose with 6 mg of dexamethasone is recommended for up to 10 days in patients with severe and critical COVID-19, but a higher dose may benefit those with more severe disease., Objective: To assess the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia., Design, Setting, and Participants: A multicenter, randomized clinical trial was conducted between August 2020 and May 2021 at 26 hospitals in Europe and India and included 1000 adults with confirmed COVID-19 requiring at least 10 L/min of oxygen or mechanical ventilation. End of 90-day follow-up was on August 19, 2021., Interventions: Patients were randomized 1:1 to 12 mg/d of intravenous dexamethasone (n = 503) or 6 mg/d of intravenous dexamethasone (n = 497) for up to 10 days., Main Outcomes and Measures: The primary outcome was the number of days alive without life support (invasive mechanical ventilation, circulatory support, or kidney replacement therapy) at 28 days and was adjusted for stratification variables. Of the 8 prespecified secondary outcomes, 5 are included in this analysis (the number of days alive without life support at 90 days, the number of days alive out of the hospital at 90 days, mortality at 28 days and at 90 days, and ≥1 serious adverse reactions at 28 days)., Results: Of the 1000 randomized patients, 982 were included (median age, 65 [IQR, 55-73] years; 305 [31%] women) and primary outcome data were available for 971 (491 in the 12 mg of dexamethasone group and 480 in the 6 mg of dexamethasone group). The median number of days alive without life support was 22.0 days (IQR, 6.0-28.0 days) in the 12 mg of dexamethasone group and 20.5 days (IQR, 4.0-28.0 days) in the 6 mg of dexamethasone group (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = .07). Mortality at 28 days was 27.1% in the 12 mg of dexamethasone group vs 32.3% in the 6 mg of dexamethasone group (adjusted relative risk, 0.86 [99% CI, 0.68-1.08]). Mortality at 90 days was 32.0% in the 12 mg of dexamethasone group vs 37.7% in the 6 mg of dexamethasone group (adjusted relative risk, 0.87 [99% CI, 0.70-1.07]). Serious adverse reactions, including septic shock and invasive fungal infections, occurred in 11.3% in the 12 mg of dexamethasone group vs 13.4% in the 6 mg of dexamethasone group (adjusted relative risk, 0.83 [99% CI, 0.54-1.29])., Conclusions and Relevance: Among patients with COVID-19 and severe hypoxemia, 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days. However, the trial may have been underpowered to identify a significant difference., Trial Registration: ClinicalTrials.gov Identifier: NCT04509973 and ctri.nic.in Identifier: CTRI/2020/10/028731.

Background: Asia has more critically ill people than any other part of our planet. The aim of this article is to review the development of critical care as a specialty, critical care societies and education and research, the epidemiology of critical illness as well as epidemics and pandemics, accessibility and cost and quality of critical care, culture and end-of-life care, and future directions for critical care in Asia., Main Body: Although the first Asian intensive care units (ICUs) surfaced in the 1960s and the 1970s and specialisation started in the 1990s, multiple challenges still exist, including the lack of intensivists, critical care nurses, and respiratory therapists in many countries. This is aggravated by the brain drain of skilled ICU staff to high-income countries. Critical care societies have been integral to the development of the discipline and have increasingly contributed to critical care education, although critical care research is only just starting to take off through collaboration across groups. Sepsis, increasingly aggravated by multidrug resistance, contributes to a significant burden of critical illness, while epidemics and pandemics continue to haunt the continent intermittently. In particular, the coronavirus disease 2019 (COVID-19) has highlighted the central role of critical care in pandemic response. Accessibility to critical care is affected by lack of ICU beds and high costs, and quality of critical care is affected by limited capability for investigations and treatment in low- and middle-income countries. Meanwhile, there are clear cultural differences across countries, with considerable variations in end-of-life care. Demand for critical care will rise across the continent due to ageing populations and rising comorbidity burdens. Even as countries respond by increasing critical care capacity, the critical care community must continue to focus on training for ICU healthcare workers, processes anchored on evidence-based medicine, technology guided by feasibility and impact, research applicable to Asian and local settings, and rallying of governments for support for the specialty., Conclusions: Critical care in Asia has progressed through the years, but multiple challenges remain. These challenges should be addressed through a collaborative approach across disciplines, ICUs, hospitals, societies, governments, and countries., (© 2021. The Author(s).)

Objectives: Tracheostomy (TT) and delayed extubation (DE) are two approaches to postoperative airway management in patients after major oral cancer surgery. We planned a study to determine the safety of overnight intubation followed by extubation the next morning (DE) compared to elective TT and to identify factors that were associated with a safe DE (maintenance of a patent airway)., Material and Methods: We conducted a prospective observational study in a tertiary referral cancer care center. We included adult patients undergoing elective major oral cancer surgery under general anesthesia with tracheal intubation. The decision regarding postoperative airway management using either TT or DE was made according to the usual practice at our center., Results: We screened a total of 4477 patients, 720 patients were included. DE was performed in 417 patients (58.4%) and TT in 303 patients (42.4%). On multivariable analysis, T1-T2 tumor stage, absence of extensive resection, primary closure or reconstruction using fasciocutaneous flap, absence of preoperative radiation, no neck dissection or unilateral neck dissection and shorter duration of anesthesia were independent predictors for a safe DE. Overall complications (4.3% versus 22.5%, p = 0.00) and airway complications (1.7% versus 8.7%, p = 0.00) were lower in the DE compared to the TT group respectively. DE was associated with a shorter hospital stay (7.2 ± 3.7 versus 11.5 ± 7.2 days, p = 0.00), time to oral intake and speech compared to TT., Conclusions: A DE strategy after major oral cancer surgery is a safe alternative to TT in a select group of patients., (Copyright © 2021. Published by Elsevier Ltd.)

Background: We aimed to study organizational aspects, case mix, and practices in Indian intensive care units (ICUs) from 2018 to 2019, following the Indian Intensive Care Case Mix and Practice Patterns Study (INDICAPS) of 2010-2011., Methods: An observational, 4-day point prevalence study was performed between 2018 and 2019. ICU, patient characteristics, and interventions were recorded for 24 hours, and ICU outcomes till 30 days after the study day. Adherence to selected compliance measures was determined. Data were analyzed for 4,669 adult patients from 132 ICUs., Results: On the study day, mean age, acute physiology and chronic health evaluation (APACHE II), and sequential organ failure assessment (SOFA) scores were 56.9 ± 17.41 years, 16.7 ± 9.8, and 4.4 ± 3.6, respectively. Moreover, 24% and 22.2% of patients received mechanical ventilation (MV) and vasopressors or inotropes (VIs), respectively. On the study days, 1,195 patients (25.6%) were infected and 1,368 patients (29.3%) had sepsis during their ICU stay. ICU mortality was 1,092 out of 4,669 (23.4%), including 737 deaths and 355 terminal discharges (TDs) from ICU. Compliance for process measures related to MV ranged between 62.7 and 85.3%, 11.2 and 47.4% for monitoring delirium, sedation, and analgesia, and 7.7 and 25.3% for inappropriate transfusion of blood products. Only 34.8% of ICUs routinely used capnography. Large hospitals with ≥500 beds, closed ICUs, the APACHE II and SOFA scores, medical admissions, the presence of cancer or cirrhosis of the liver, the presence of infection on the study day, and the need for MV or VIs were independent predictors of mortality., Conclusions: Hospital size and closed ICUs are independently associated with worse outcomes. The proportion of TDs remains high. There is a scope for improvements in processes of care.Registered at clinicaltrials.gov (NCT03631927)., How to Cite This Article: Divatia JV, Mehta Y, Govil D, Zirpe K, Amin PR, Ramakrishnan N, et al . Intensive Care in India in 2018-2019: The Second Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2021;25(10):1093-1107., Competing Interests: Source of support: This study was funded by the Indian Society of Critical Care Medicine Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Purpose: There are scarce data to aid in prognostication of the outcome of critically ill cancer patients with COVID-19. In this systematic review and meta-analysis, we investigated the mortality of critically ill cancer patients with COVID-19., Methods: We searched online databases and manually searched for studies in English that reported on outcomes of adult cancer patients with COVID-19 admitted to an intensive care unit (ICU) or those with severe COVID-19 between December 2019 and October 2020. Risk of bias was assessed by the Modified Newcastle-Ottawa Scale. The primary outcome was all-cause mortality. We also determined the odds of death for cancer patients versus noncancer patients, as also outcomes by cancer subtypes, presence of recent anticancer therapy, and presence of one or more comorbidities. Random-effects modeling was used., Results: In 28 studies (1,276 patients), pooled mortality in cancer patients with COVID-19 admitted to an ICU was 60.2% (95% CI, 53.6 to 6.7; I 2 = 80.27%), with four studies (7,259 patients) showing higher odds of dying in cancer versus noncancer patients (odds ratio 1.924; 95% CI, 1.596 to 2.320). In four studies (106 patients) of patients with cancer and severe COVID-19, pooled mortality was 59.4% (95% CI, -39.4 to 77.5; I 2 = 72.28%); in one study, presence of hematologic malignancy was associated with significantly higher mortality compared with nonhematologic cancers (odds ratio 1.878; 95% CI, 1.171 to 3.012). Risk of bias was low., Conclusion: Most studies were reported before the results of trials suggesting the benefit of dexamethasone and tocilizumab, potentially overestimating mortality. The observed mortality of 60% in cancer patients with COVID-19 admitted to the ICU is not prohibitively high, and admission to the ICU should be considered for selected patients (registered with PROSPERO, CRD42020207209)., Competing Interests: Sudeep GuptaResearch Funding: Roche, Sanofi, Johnson & Johnson, Amgen, Celltrion, Oncostem Diagnostics, Novartis, AstraZeneca, Intas Jigeeshu V. DivatiaStock and Other Ownership Interests: Cipla, Zydus CadillaOther: Lecture fees from Edwards India, paid to my institution, outside the published workNo other potential conflicts of interest were reported.

Rationale: There are limited data on mechanical discontinuation practices in Asia. Objectives: To document self-reported mechanical discontinuation practices and determine whether there is clinical equipoise regarding protocolized weaning among Asian Intensive Care specialists. Methods: A survey using a validated questionnaire, distributed using a snowball method to Asian Intensive Care specialists. Results: Of the 2,967 invited specialists from 20 territories, 2,074 (69.9%) took part. The majority of respondents (60.5%) were from China. Of the respondents, 42% worked in intensive care units (ICUs) where respiratory therapists were present; 78.9% used a spontaneous breathing trial as the initial weaning step; 44.3% frequently/always used pressure support (PS) alone, 53.4% intermittent spontaneous breathing trials with PS in between, and 19.8% synchronized intermittent mandatory ventilation with PS as a weaning mode. Of the respondents, 56.3% routinely stopped feeds before extubation, 71.5% generally followed a sedation protocol or guideline, and 61.8% worked in an ICU with a weaning protocol. Of these, 78.2% frequently always followed the protocol. A multivariate analysis involving a modified Poisson regression analysis showed that working in an ICU with a weaning protocol and frequently/always following it was positively associated with an upper-middle-income territory, a university-affiliated hospital, or in an ICU that employed respiratory therapists; and negatively with a low-income or lower-middle-income territory or a public hospital. There was no significant association with "in-house" intensivist at night, multidisciplinary ICU, closed ICU, or nurse-patient ratio. There was heterogeneity in agreement/disagreement with the statement, "evidence clearly supports protocolized weaning over nonprotocolized weaning." Conclusions: A substantial minority of Asian Intensive Care specialists do not wean patients in accordance with the best available evidence or current guidelines. There is clinical equipoise regarding the benefit of protocolized weaning.

Objectives: Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC., Methods: An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists., Results: The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated., Conclusions: Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices., Competing Interests: Competing interests: Authors state no conflict of interest., (© 2021 Geetu Bhandoria et al., published by De Gruyter, Berlin/Boston.)

Background and Aims: Regional anaesthesia has been used to reduce acute post-operative pain as well as opioid-related side effects in breast cancer surgery. Erector spinae plane (ESP) block is a relatively new fascial plane block being tried in various surgical procedures. Our study is a double-blind randomised trial, designed to prove the efficacy of this block in breast surgeries., Methods: Seventy female patients scheduled for unilateral breast surgery were enroled in this prospective, randomised, double-blind study. Patients were randomised to group A and group B. All patients received general anaesthesia while group B received additional ultrasound-guided erector spinae block given at thoracic level-T5 with 20ml of 0.25% bupivacaine. Time to first rescue analgesia was the primary outcome. Secondary outcomes were total intraoperative opioid consumption, pain scores over 24 h, post-operative nausea and vomiting and patient satisfaction score at discharge. The Shapiro-Wilk test was used to check the normality of each variable. A comparison was done using Mann-Whitney test and the level of significance was set at 0.05., Results: The median time to first rescue analgesia in group A versus group B was 1 h (1-12h) versus 8 h (1-26h), respectively, with a P value of 0.044. Group B patients had lower pain scores post-operatively and better satisfaction scores at discharge. There was no statistically significant difference in intraoperative fentanyl consumption., Conclusion: Ultrasound-guided ESP block with general anaesthesia offers superior post-operative analgesia compared to general anaesthesia alone in patients undergoing unilateral nonreconstructive breast cancer surgeries., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Indian Journal of Anaesthesia.)

Background: Coronavirus disease 2019 (COVID-19) can lead to severe hypoxic respiratory failure and death. Corticosteroids decrease mortality in severely or critically ill patients with COVID-19. However, the optimal dose remains unresolved. The ongoing randomised COVID STEROID 2 trial investigates the effects of higher vs lower doses of dexamethasone (12 vs 6 mg intravenously daily for up to 10 days) in 1,000 adult patients with COVID-19 and severe hypoxia., Methods: This protocol outlines the rationale and statistical methods for a secondary, pre-planned Bayesian analysis of the primary outcome (days alive without life support at day 28) and all secondary outcomes registered up to day 90. We will use hurdle-negative binomial models to estimate the mean number of days alive without life support in each group and present results as mean differences and incidence rate ratios with 95% credibility intervals (CrIs). Additional count outcomes will be analysed similarly and binary outcomes will be analysed using logistic regression models with results presented as probabilities, relative risks and risk differences with 95% CrIs. We will present probabilities of any benefit/harm, clinically important benefit/harm and probabilities of effects smaller than pre-defined clinically minimally important differences for all outcomes analysed. Analyses will be adjusted for stratification variables and conducted using weakly informative priors supplemented by sensitivity analyses using sceptic priors., Discussion: This secondary, pre-planned Bayesian analysis will supplement the primary, conventional analysis and may help clinicians, researchers and policymakers interpret the results of the COVID STEROID 2 trial while avoiding arbitrarily dichotomised interpretations of the results., Trial Registration: ClinicalTrials.gov: NCT04509973; EudraCT: 2020-003363-25., (© 2021 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Objective: Despite advances in the field of oncology and intensive care, the outcomes of hematolymphoid malignancy (HLM) patients admitted to ICU are poor. This study was carried out to look at the demographic data, clinical features, and predictors of hospital mortality in these patients., Materials and Methods: We prospectively studied 101 adult critically ill patients with HLM admitted to the 14-bedded mixed medical surgical ICU of a tertiary care cancer center. Out of 101 patients, end-of-life care decisions were taken in 7 patients, who were excluded from the outcome analysis. Predictors of in-hospital mortality were evaluated using univariate and multivariate analysis., Results: The ICU and in-hospital mortality recorded in our study were 48.9 and 54.3%, respectively. Neutropenia at ICU admission, Simplified Acute Physiology Score III (SAPS III) score, and mechanical ventilation (MV) within 24 hours of ICU admission were associated with in-hospital mortality on univariate analysis. On multivariate logistic regression analysis, neutropenia at ICU admission (OR 4.621; 95% CI, 1.2-17.357) and MV within 24 hours of ICU admission (OR 2.728; 95% CI, 1.077-6.912) were independent predictors of in-hospital mortality., Conclusion: The HLM patients needing critical care have high acuity of illness, and acute respiratory failure is the commonest reason for ICU admission in these patients. In our study, the ICU survival was more than 50% and more than 45% patients were discharged alive from the hospital. We found a need for MV within 24 hours of ICU admission and presence of neutropenia at ICU admission to be independent predictors of hospital mortality in our study., How to Cite This Article: Siddiqui SS, Prabu NR, Chaudhari HK, Narkhede AM, Sarode SV, Dhundi U, et al. Epidemiology, Clinical Characteristics, and Prognostic Factors in Critically Ill Patients with Hematolymphoid Malignancy. Indian J Crit Care Med 2021;25(1):56-61., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Introduction: Fluid therapy in critically ill patients, especially timing and fluid choice, is controversial. Previous randomized trials produced conflicting results. This observational study evaluated the effect of colloid use on 90-day mortality and acute kidney injury (RIFLE F) within the Rational Fluid Therapy in Asia (RaFTA) registry in intensive care units., Materials and Methods: RaFTA is a prospective, observational study in Asian intensive care unit (ICU) patients focusing on fluid therapy and related outcomes. Logistic regression was performed to identify risk factors for increased 90-day mortality and acute kidney injury (AKI)., Results: Twenty-four study centers joined the RaFTA registry and collected 3,187 patient data sets from November 2011 to September 2012. A follow-up was done 90 days after ICU admission. For 90-day mortality, significant risk factors in the overall population were sepsis at admission (OR 2.185 [1.799; 2.654], p < 0.001), cumulative fluid balance (OR 1.032 [1.018; 1.047], p < 0.001), and the use of vasopressors (OR 3.409 [2.694; 4.312], p < 0.001). The use of colloids was associated with a reduced risk of 90-day mortality (OR 0.655 [0.478; 0.900], p = 0.009). The initial colloid dose was not associated with an increased risk for AKI (OR 1.094 [0.754; 1.588], p = 0.635)., Conclusion: RaFTA adds the important finding that colloid use was not associated with increased 90-day mortality or AKI after adjustment for baseline patient condition., Clinical Significance: Early resuscitation with colloids showed potential mortality benefit in the present analysis. Elucidating these findings may be an approach for future research., How to Cite This Article: Jacob M, Sahu S, Singh YP, Mehta Y, Yang K-Y, Kuo S-W, et al. A Prospective Observational Study of Rational Fluid Therapy in Asian Intensive Care Units: Another Puzzle Piece in Fluid Therapy. Indian J Crit Care Med 2020;24(11):1028-1036., Competing Interests: Source of support: Fresenius Kabi supported data collection with an unrestricted grant. Conflict of interest: None, (Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.)

Background: Health care workers (HCWs) are at risk of getting infected while at work, for example, operating room (OR), hence it is pertinent that they don all the appropriate personal protective equipment (PPE) to minimize the chance of getting infected., Methods: A COVID-19 specific briefing and debriefing form was created and used in the OR along with the World Health Organization surgical safety checklist to reinforce the use of appropriate PPE. An audit was subsequently done to understand the compliance to PPE use, followed by a survey based on the findings of the audit to understand the issues related to noncompliance., Results: The form was used in 183 out of the 238 (77%) surgeries performed during a months' time. The overall compliance for PPE usage was 96.3%. Noncompliance was seen most often for eye protection (45/567) (P = .01). The survey revealed that this was mostly among surgeons mainly due to discomfort, poor visibility, and frequent fogging., Conclusions: Our HCW were adapting well to the new normal of donning appropriate PPE in the OR, except for the eye protection due to discomfort and visibility related issues. This is important to know so that necessary changes could be introduced to better the compliance., (© 2020 Wiley Periodicals LLC.)

Background: Identification of risk factors for perioperative complications helps in the prognostication. We wanted to determine whether Physiological and Operative Severity Score for the enumeration of mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) can be used in patients undergoing head and neck oncosurgery., Methods: We conducted a retrospective analysis of 1265 patients after they had major head and neck oncosurgeries. Demographic, surgical and outcome data was collected. We separately analyzed data for patients who had undergone cancer surgery for oral cavity, pharynx, and larynx. We calculated the POSSUM and P-POSSUM scores., Results: POSSUM scoring system had moderate discrimination (AUC = 0.61) and good calibration (P = .36) for the entire study cohort and in the subgroup. Since there were no deaths in the entire cohort, we were not able to check predictive ability of the scores, for mortality., Conclusions: We found that POSSUM had moderate discrimination and good calibration for morbidity prediction in head and neck cancer surgeries, as well as for the selected subgroup., (© 2020 Wiley Periodicals LLC.)

Background and Aims: The aim of this study was to compare the efficacy of McGRATH series 5 videolaryngoscope (VL) with Macintosh laryngoscope for nasotracheal intubation (NTI) in patients without anticipated difficult airways undergoing head and neck cancer surgeries., Material and Methods: We randomized 60 adult patients for NTI by experienced anesthetists with either Macintosh laryngoscope or McGRATH series 5 VL (VL group). The primary objective was to compare time taken for intubation (TTI). The secondary objectives included success rates, number of attempts, need for optimization maneuvers, Cormack and Lehane (CL) grade, and percentage of difficult intubations., Results: The mean TTI in the VL group was 43 (±10.6) versus 75 (±38.0) s in the Macintosh group (99% CI: 12.5; -51.6 s; P < 0.001). The overall intubation success rate was 100% in both groups. All 29 (100%) patients in the VL group were intubated in the first attempt versus 26 (86%) patients in the Macintosh group (99% CI -5; 33%; P = 0.11). In the Macintosh group, 20 (66%) patients needed optimization maneuver versus none in the VL group (99% CI 40; 91%; P < 0.001). In the VL group, 28 (96%) patients had a CL grade 1 view versus 9 (31%) in Macintosh group (99% CI 38; 92%; P < 0.001). There were no difficult intubations in the VL group versus 3 (10%) in the Macintosh group (99% CI: 7; 28%; P = 0.237). There was no trauma to oropharyngeal structures in either group., Conclusion: The McGRATH series 5 VL has faster TTI, better glottic visualization, and less need for optimization maneuvers than the Macintosh laryngoscope for NTI in patients with unanticipated difficult airways, when performed by experienced anesthetists., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology.)

Competing Interests: There are no conflicts of interest.

Background: Overburdened systems and concerns of adverse outcomes have resulted in deferred cancer surgeries with devastating consequences. In this COVID pandemic, the decision to continue elective cancer surgeries, and their subsequent outcomes, are sparsely reported from hotspots., Methods: A prospective database of the Department of Surgical Oncology was analysed from March 23rd to April 30th, 2020., Findings: Four hundred ninety-four elective surgeries were performed (377 untested and 117 tested for Covid 19 before surgery). Median age was 48 years with 13% (n = 64) above the age of 60 years. Sixty-eight percent patients were American Society of Anaesthesiology (ASA) grade I. As per surgical complexity grading, 71 (14·4%) cases were lower grade (I-III) and 423 (85.6%) were higher grade complex surgeries (IV - VI).Clavien-Dindo ≥ grade III complications were 5.6% (n = 28) and there were no postoperative deaths. Patients >60 years documented 9.3% major complications compared to 5.2% in <60 years (P = 0.169). The median hospital stay was 1 to 9 days across specialties.Postoperatively, 26 patients were tested for COVID 19 and 6 tested positive. They all had higher grade surgeries but none required escalated or intensive care treatment related to COVID infection., Interpretation: A combination of scientific and administrative rationale contributed to favorable outcomes after major elective cancer surgeries. These results support the continuation of elective major cancer surgery in regions with Covid 19 trends similar to India., Competing Interests: The authors report no conflicts of interest.Each author has contributed sufficiently for construction of this manuscript., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: There are no conflicts of interest.