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BackgroundGlobal pandemic of COVID 19 has affected many countries. The initial epicenter was in China with gradual spread to various countries including India.For a developing country like India with limited resources and high population, it is worthwhile to know how these patients requiring intensive care admission were managed and the outcome of these patients. To address these issues, a prospective observational study was planned.Methods A multicenter study was conducted from June 2020 to December 2020 including 4 centers across India. Patients > 18 years of age admitted in the intensive care unit (ICU), with the diagnosis of COVID 19 pneumonia confirmed by reverse transcriptase –polymerase chain reaction (RT-PCR) or rapid antigen test (RAT) as applicable were included. Factors associated with ICU mortality were examined using multivariable logistic regression analysis and Cox proportional hazard model. ResultsOf 667 patients were included in the study. ICU mortality was 60 %. In multivariable analysis, history of cerebral vascular accident (CVA), day 1 acute physiology and chronic health evaluation (APACHE II) score, need for invasive ventilator support, minimum PO2, fluid balance and complications such as pneumothorax and arrhythmia during ICU admission were associated with mortality. Among these parameters, day 1 need for invasive ventilator support (odds ratio OR: 3.01(1.81, 5.00) and development of arrhythmia (OR 3.85 [1.56, 8.06]) had higher odds of mortality. Cox proportional hazard analysis showed, history of ischemic heart disease (IHD) (Hazard Ratio, HR 1.64, 95% CI:1.13, 2.38), day1 APACHE II (HR 1.03, 95% CI:1.00, 1.07), arterial blood gas (ABG) pH (HR 0.14, 95% CI:0.03, 0.56) and use of therapeutic anticoagulation (HR 0.42,95% CI:0.29, 0.61) as a predictor of 7 days ICU mortality. Daywise trend of ventilator parameters showed dynamic compliance was higher on day3 and 4 in survivors.ConclusionIn this cohort of ICU patients, ICU mortality was 60%. The reason for higher mortality could be the severity of illness as suggested by the day 1 PF ratio (109.31 [77.79-187.26]).Trial Registration-(IEC131/2020, CTRI/2020/06/025858).

Coronavirus disease (COVID)-19 has spread across the globe. For a country like India with limited resources and a high population, it is worth knowing how these patients were managed. This prospective study was aimed to evaluate the patient characteristics and risk factors associated with mortality.The study was conducted from 15 June 2020 to 31 December 2020 in four centres across India. Patients above 18 years of age admitted in the intensive care unit (ICU) with severe COVID-19 pneumonia were included. Details of oxygen therapy and ventilator characteristics were collected for seven days.Of 667 patients included in the study, the average age was 57 (standard deviation (SD) = 15) years and 70.46% were male. The ICU mortality was 60%. Acute physiology, age and chronic health evaluation (APACHE II) score was 29.8 (SD = 6.1). Among various significant risk factors, the need for invasive ventilator support on day 1 [odds ratio (OR): 3.11, 95% confidence interval (CI) (1.91-5.08)] and the development of arrhythmia [OR 3.85 CI (1.69,8.77) confidence interval (CI) (1.69, 8.77)] had higher odds of mortality. PF ratio [partial pressure of arterial oxygen/fraction of inspired oxygen] was 109.31 (77.79-187.26), maximum positive end-expiratory pressure was 10.29 (3.5) cmHIn this cohort of patients, ICU mortality was 60%. The reason for higher mortality could be the severity of illness as suggested by day 1 PF ratio and APACHE II score.

Aspergillus is described as mould characterised by septate hyphae about 2-4μ in diameter, it is ubiquitous in nature and spreads by inhalation of spores. It causes opportunistic infections in almost six forms namely Allergic bronchopulmonary aspergillosis, Aspergillus sinusitis, Cutaneous aspergillosis, Aspergilloma, Chronic pulmonary aspergillosis, Invasive aspergillosis. Invasive aspergillosis of mediastinum in an immunocompetent patient has rarely been reported. We present a case of a young male who had presented with chest pain, cough and breathleness was later diagnosed as fulminant mediastinal aspergillosis. Incisional biopsy with histology report and endotracheal cultures helped in diagnosing mediastinal aspergillosis. Despite initiation of the right antifungal therapy and best supportive measures, patient died of septic shock and multiorgan dysfunction. This case report highlights the need for higher suspicion in such cases of mediastinal masses and early tissue biopsy which can help in reducing mortality.

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease. We present a 61-year-old uncorrected TOF patient who presented with sepsis and acute respiratory failure. At presentation, the patient had tachypnea, tachycardia, and oxygen saturation (SpO2) 64%. Chest X-ray (CXR) showed bilateral basal opacities. 2D echo revealed left ventricular dysfunction, infundibulum stenosis, pulmonary atresia, overriding of the aorta, and ventricular septal defect. A provisional diagnosis of community-acquired pneumonia with septic shock with uncorrected TOF was made. He received empirical antibiotics, ventilatory support, and supportive care. Ventilator weaning was done accepting an arbitrary baseline SpO2 of 70–75% and lactate-guided volume resuscitation led to a successful outcome. Coronary angiogram showed collaterals. This case report illustrates the dilemmas faced in treating a critically ill uncorrected TOF. To the best of our knowledge, this case could be the oldest surviving uncorrected TOF patient in the Indian population. How to cite this article Prakash SY, Kartik M, Rao M, Harde YR. Challenges Faced in Managing an Adult Uncorrected Tetralogy of Fallot Patient with Pneumonia and Septic Shock in the Intensive Care Unit. Indian J Crit Care Med 2020;24(11):1135–1136.

Context: The quality of health care and outcomes of Intensive Care Unit (ICU) have been a major subject of discussion in the past decade. Quality indicators in ICUs maintain an order of uniformity and standard care of delivery across ICUs. Aims: In this study, we tried to analyze the percentage compliance of quality indicators in ICU across our country. Methods: Four hundred complete questionnaire forms were collected in two stages by means of conducting a survey and through email responses to the survey questionnaire. Data were tabulated and evaluated in percentage responses. Results: Monitoring of infection control measures such as hand hygiene (77%), monitoring of ICU-acquired infections (>75%), and quality and policy measures (>70%) were promising. Improvements are required in following end-of-life pathways (52%) and staffing patterns in ICU. ICU discharge timings (41%), standardized mortality ratio monitoring (39%), and multidisciplinary rounds (58%) in ICUs are few areas we need to develop further. Conclusion: The future of critical care looks promising with growing number of trained intensivists and hospitals functioning with an average ICU bed strength of 30–40. Such surveys need to be performed regularly to improve the patient care and safety across ICUs.

INTRODUCTION: Centipedes are multisegmeted arthropods with a single pair of legs per segment and one pair of antennae .Centipede stings occur in the warmer climates throughout the world. The species of medical importance is Scolopendra Sp which has been described as the longest and the most aggressive tropical centipede. Centipede stings often occur as the victim is putting on clothes or while in bed.CASE PRESENTATION: A 19 yr old female arrived in our tertiary care emergency room at 5:30am after being treated at a local hospital for an unknown insect bite on her right arm 6 hrs prior while asleep.She had complaints of vomiting,dyspnea and local pain.She received antihistamines,steroids,epinephrine and analgesics for anaphylactic shock and pain prior to arrival.Her presenting vitals were a heart rate of 145 beats per minute, BP 60/40 mmHg ,respiratory rate of 35/min and oxygen saturation of 85% on room air. She had bilateral crackles and her hemoglobin,WBC count,electrolytes and PT,INR were normal. EKG revealed ST depression in V3,V4,V5,V6 leads (>2mm).Chest radiograph showed pulmonary edema and echocardiogram showed global hypokinesia of the left ventricle with EF of 40%,while troponin-t(2.98)was slightly elevated . Treatment was initiated with digoxin,carnitine and dobutamine infusion to support her cardiac output and furosemide was given for pulmonary edema along with non-invasive ventilation.She improved with therapy and a repeat echocardiogram two days later showed EF of 62% with normal LV function.Subsequent history and bystander observation confirmed the visual appearance of the insect to be a centipede.DISCUSSION: Gomes et al (1)used animal models to demonstrate significant cardiovascular effects of Scolopendra venom, mediated by histamine and a cardiodepressant factor designated as Toxin-S. Most authorities recognize the cardiodepressant Toxin-S to be the lethal factor (predatory), and the histamine/serotonin components to be pain mediators (defensive)(2). Systemic symptoms due to centipede bite may include anxiety, fever, dizziness, palpitations, and nausea. Extensive myonecrosis with subsequent compartment syndrome, rhabdomyolysis, and acute renal failure has been seen after a centipede bite.Japanese Scolopendra species have been reported to cause psychological disturbances and Korsakoff syndrome. A recent study suggests possible myocardial ischemia after a nonfatal centipede sting as a mechanism that could lead to death(3)CONCLUSIONS: There have been only a few cases of centipede envenomation causing myocardial ischaemia reported. Our case was notable due to the acute presentation of pulmonary edema with cardiac injury with raised cardiac enzyme levels. This complication should be considered when treating such patients, and appropriate diagnostic studies should be obtained.1) Gomes A, Datta A, Sarangi B, Kar PK, Lahiri SC. Occurrence of histamine and histamine release by centipede venom. Indian J Med Res. 1982;76:888.2) Stankiewicz M, Hamon A, Benkhalifa R, et al. Effects of a centipede venom fraction on insect nervous system, a native Xenopus oocyte receptor and on an expressed Drosophila muscarinic receptor. Toxicon.1999;37:1431-1445.3) Ozsarac M, Karcioglu O, Ayrik C, Somuncu F, Gumrukcu S. Acute coronary ischemia following centipede envenomation: Case report and review of the literature. Wilderness Environ Med. 2004;15:109-12DISCLOSURE: The following authors have nothing to disclose: Munta Kartik, Sai Praveen Haranath, Rahul Amte, Palepu GopalNo Product/Research Disclosure InformationApollo Hospitals, Department of Critical Care Medicine, Jubilee Hills, Hyderabad, India. Language: en