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Introduction Air leak consisting of pneumothorax, pneumomediastinum, and subcutaneous emphysema has been described as one of the complications of coronavirus disease-2019 (COVID-19) infection affecting disease course and outcome. We aimed to conduct a systematic review of published literature to highlight the risk factors, types, and outcomes in COVID-19. Method A systematic search of PubMed, Embase, Scopus, and Google Scholar was performed from November 1, 2019, to February 28, 2021. Seventy-one studies fulfilled the inclusion criteria and 136 adult patients were included in the final analysis. Results Majority of patients were male (75.2%) with the mean age of 58 years. Hypertension was the most common comorbidity followed by diabetes mellitus. Moreover, 12.5% of patients had a history of smoking while 11.7% had preexisting lung disease. Isolated pneumothorax (48.5%) was the most common and 17.65% had developed spontaneous pneumothorax. Mean onset time was 11.6 days and 67% of patients required an intercostal drainage tube for management. Mortality was 40%, and elderly, female gender, obese and hypertensive were at higher risk. Conclusion COVID-19-related air leaks are associated with higher mortality and longer hospital stay and can occur even without positive pressure ventilation. History of smoking and preexisting lung disease has not been shown to increase the incidence of air leak. A well-designed study is required for a better understanding of COVID-19-related air leak. How to cite this article Singh A, Singh Y, Pangasa N, Khanna P, Trikha A. Risk Factors, Clinical Characteristics, and Outcome of Air Leak Syndrome in COVID-19: A Systematic Review. Indian J Crit Care Med 2021;25(12):1434–1445.

As the coronavirus disease 2019 (COVID-19) pandemic is gripping the entire world, many patients are mainly presenting with respiratory problems and subsequently require intubation and mechanical ventilation in severe cases. The need to perform tracheostomy may arise, and the intensivist, anaesthetist, and other surgical specialties may be asked to perform a tracheostomy in known COVID-19 or suspected patients. Surgeons should be prepared for this eventuality while performing the procedures, taking all the measures to keep themselves and their team members safe from the undue risk of infection and exposure. This is a brief review of all the evidence present, till now, for those who will be performing tracheostomy in such patients. [ABSTRACT FROM AUTHOR] Copyright of Turkish Journal of Anesthesia & Reanimation is the property of Turkish Society of Anaesthesiology & Reanimation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Children with cystic fibrosis (CF) constitute a high-risk group for COVID-19 with underlying chronic lung disease. COVID-19 severity varying from mild infection to need of intensive care has been described in children with CF. Two children with significant underlying pulmonary morbidity are described here, who developed severe disease following SARS-CoV-2 infection. Case 1 (a 9-y-old boy) had pneumonia with respiratory failure requiring noninvasive ventilation support. He had delayed clearance of SARS-CoV-2, with recurrence of symptomatic disease with short asymptomatic period in between. He was also diagnosed with CF-related diabetes and allergic bronchopulmonary aspergillosis during the second episode. Case 2 (an 18-mo-old boy) had two episodes of SARS-CoV-2–related severe lower respiratory infection within a period of 2 mo, requiring high-flow nasal oxygen support. Both children had 3rd pulmonary exacerbation but SARS-CoV-2 was not detected in respiratory secretions. To conclude, children with CF with underlying pulmonary morbidity, can develop severe COVID-19 and prolonged SARS-CoV-2 shedding. Supplementary Information The online version contains supplementary material available at 10.1007/s12098-021-04057-0.

The exponential rise in Coronavirus disease 2019 (COVID-19) cases has resulted in an increased number of patients requiring prolonged ventilatory support and subsequent tracheostomy. With the limited availability of literature regarding the outcomes of COVID-19 patients with tracheostomy, we attempted to study the clinical characteristics and multiple parameters affecting the outcomes in these patients.To determine all-cause mortality following tracheostomy and its association with various risk factors in COVID-19 patients.This retrospective study included 73 adult COVID-19 patients admitted to the ICU between 1 April, 2020 and 30 September, 2021 who underwent tracheostomy as a result of acute respiratory failure due to COVID-19. The data collected included demographics (age, sex), comorbidities, type of oxygen support at admission, severity of COVID-19, complications, and other parameters such as admission to tracheostomy, intubation to tracheostomy, ICU stay, hospital stay, and outcome.This study included 73 adult patients with an average age of 52 ± 16.67 years, of which 52% were men. The average time for admission to tracheostomy was 18.12 ± 12.98 days while intubation to tracheostomy was 11.97 ± 9 days. The mortality rate was 71.2% and 28.8% of patients were discharged alive. The mean duration of ICU and hospital stay was 25 ± 11 days and 28.21 ± 11.60 days, respectively. Greater age, severe COVID-19, mechanical ventilation, shock and acute kidney injury were associated with poor prognosis; however, early tracheostomy in intubated patients resulted in better outcomes.Patients with severe COVID-19 requiring mechanical ventilation have a poor prognosis but patients with early tracheostomy may benefit with no added risk. We recommend that the timing of tracheostomy be decided on a case-by-case basis and a well-designed randomised controlled trial should be performed to elucidate the potential benefit of early tracheostomy in such patients.

Background: Coronavirus disease-2019 (COVID-19) pandemic has shown unpredictable course in individual patients. Few patients develop severe disease with progression after admission to a healthcare facility. Multiple parameters have been investigated to identify a marker to predict disease progression. Neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte (PLR) ratio has shown some promise. The current investigation explores the role of NLR and PLR to predict the disease progression. Materials and methods: After obtaining ethics committee approval, 608 patients were screened for inclusion in the prospective observational study, and 201 patients were included in the final analysis. The NLR and PLR were derived from routinely obtained complete blood count analysis. The patients were followed to determine the development of severity of the disease during the course. The NLR and PLR were analyzed in both univariate and multivariable models to assess the association and prediction. Results: In nonsevere (NS) group, the mean age of patients was 50.9 ± 16.3 years, and 66 (61.2%) were male, while in severe group (S), the mean age of patients was 53.7 ± 16.4 years, and 65 (69.89%) were male. NLR at day 1 and day 3 was significantly lower in survivors as compared to nonsurvivors, while the relation of PLR in both the groups was not statistically significant. The NLR is better in predicting the severity of disease as well as mortality than PLR. Conclusion: The NLR calculated at the time of admission has high predictive value for disease deterioration and adverse clinical outcome. How to cite this article: Singh Y, Singh A, Rudravaram S, Soni KD, Aggarwal R, Patel N, et al. Neutrophil-to-lymphocyte Ratio and Platelet-to-lymphocyte Ratio as Markers for Predicting the Severity in COVID-19 Patients: A Prospective Observational Study. Indian J Crit Care Med 2021;25(8):847–852.

Background and objective A large number of studies describing the clinicoepidemiological features of coronavirus disease-2019 (COVID-19) patients are available but very few studies have documented similar features of the deceased. This study was aimed to describe the clinicoepidemiological features and the causes of mortality of COVID-19 deceased patients admitted in a dedicated COVID center in India. Methodology This was a retrospective study done in adult deceased patients admitted in COVID ICU from April 4 to July 24, 2020. The clinical features, comorbidities, complications, and causes of mortality in these patients were analyzed. Pediatric deceased were analyzed separately. Results A total of 654 adult patients were admitted in the ICU during the study period and ICU mortality was 37.7% (247/654). Among the adult deceased, 65.9% were males with a median age of 56 years [interquartile range (IQR), 41.5-65] and 94.74% had one or more comorbidities, most common being hypertension (43.3%), diabetes mellitus (34.8%), and chronic kidney disease (20.6%). The most common presenting features in these deceased were fever (75.7%), cough (68.8%), and shortness of breath (67.6%). The mean initial sequential organ failure assessment score was 9.3 ± 4.7 and 24.2% were already intubated at the time of admission. The median duration of hospital stay was 6 days (IQR, 3-11). The most common cause of death was sepsis with multi-organ failure (55.1%) followed by severe acute respiratory distress syndrome (ARDS) (25.5%). All pediatric deceased had comorbid conditions and the most common cause of death in this group was severe ARDS. Conclusion In this cohort of adult deceased, most were young males with age less than 65 years with one or more comorbidities, hypertension being the most common. Only 5% of the deceased had no comorbidities. Sepsis with multi-organ dysfunction syndrome was the most common cause of death. How to cite this article Aggarwal R, Bhatia R, Kulshrestha K, Soni KD, Viswanath R, Singh AK, et al. Clinicoepidemiological Features and Mortality Analysis of Deceased Patients with COVID-19 in a Tertiary Care Center. Indian J Crit Care Med 2021; 25(6):622-628.

The crisis caused by Coronavirus disease-2019 (COVID-19) pandemic has led us to safeguard ourselves and our colleagues against transmission of this highly contagious infection, while aiming for the same goals of care. In spite of the stringent measures adopted by affected countries, rising number of healthcare workers (HCWs) are getting infected, dwindling the scarce manpower at our disposal. In the pre-COVID-19 times, cardiopulmonary resuscitation (CPR) was offered unhesitantly to all patients, who had even a slim chance of achieving return of spontaneous circulation. In COVID-19 era, CPR, due to some components being high aerosol-generating procedures (AGPs), has become high-risk procedure for the HCWs. Instead of “Primum non nocere” (first do no harm), we are forced to change to “Primum non nocere ad te” (first do no harm to yourself). The challenge is therefore to provide best possible chance of survival to deserving patients, whose COVID-19 status might be unknown, without causing harm to the HCWs. In this review, we discuss the current data regarding infected HCWs, outcomes of inhospital and out-of-hospital cardiac arrests, components of CPR which are high-risk AGPs, how to safeguard the HCWs while offering CPR, and the ethical considerations when CPR is considered, in this COVID-19 era. We wish to emphasize here that there is NO EMERGENCY in a pandemic, and time must be made for donning appropriate PPE. We feel that clear policies need to be developed by the institutions to deliver CPR to correct population, in this challenging period. How to cite this article: Kulkarni AP, Singh Y, Garg H, Jha S. Cardiopulmonary Resuscitation during COVID-19 Pandemic: Outcomes, Risks, and Protective Strategies for the Healthcare Workers and Ethical Considerations. Indian J Crit Care Med 2020;24(9):868–872.

Background Coronavirus disease (COVID-19) remains a health concern with new challenges emerging as the pandemic progresses. The recent rise of opportunistic infections especially mucormycosis in COVID-19 patients is further complicating their outcomes. Mucormycosis is well known to infect patients with diabetes mellitus, malignancy, chemotherapy, and other immunocompromised conditions. The treatment of COVID-19 largely remains systemic steroids and other immunomodulators that add to the risk of invasive fungal infection. Methodology Here, we present a retrospective case series of 13 patients with individual clinical characteristics along with the demography and treatment details. The data were collected retrospectively in a single center that caters to a large population of COVID-19 patients with varying severity. Results Thirteen patients were presented with COVID-19 associated mucormycosis (CAM). The median age was higher in non-survivors (49.5 years), with a higher odds of death (23.8) in those with severe COVID, having overall mortality of 64.3%. Moreover, diabetes mellitus was present in 61.5% of patients with a mortality of 75%. About 11 (84.6%) patients had received prior steroids for COVID-19. The incidence of hyperglycemia at admission was equal among both survivors and non-survivors. Conclusion The prevalence of mucormycosis seems to be increasing among COVID-19 patients which may be associated with increased use of steroids, the possible immunocompromised state imposed by SARS-CoV-2, or co-existing conditions such as diabetes mellitus. The mortality of CAM is remarkably high and apart from preventive practices and rational use of immunomodulators, a high index of suspicion with early diagnosis would be key to survival.

The corona virus disease 2019 (COVID-19) pandemic sweeping across the world has severely strained health care resources (equipment and personnel) forcing us to rethink strategies to provide obstetric care while judiciously using resources. We describe the anaesthetic management of a mildly symptomatic, COVID-19 positive, 28-year-old second gravida with term pregnancy who was taken up for an elective caesarean section under subarachnoid block in a standalone maternity facility. Challenges encountered and modifications of standard procedures so as to optimize patient care and minimize exposure of health care professionals are also discussed.

Introduction: Hyperbaric preparation of local anaesthetics have been used in subarachnoid block till now. Levobupivacaine and Ropivacaine, newly introduced S-enantiomer related to bupivacaine, have low cardio-neurotoxicity profile. In this study isobaric form of Levobupivacaine and Ropivacaine with Fentanyl were evaluated in terms of clinical efficacy as well as block characteristics. Materials and Methods: In this prospective, single blind study, sixty patients of ASA grade I or II, 20-65yrs of age, of either sex, posted for lower abdominal or lower extremity surgery, were randomly administered either 3 ml Levobupivacaine (0.5%) or Ropivacaine (0.75%) with Fentanyl (25µg). Intra and postoperative block characteristic, hemodynamic parameters as well as side effects were recorded. Results: Time to reach T10 sensory level and bromage 1 was earlier in group LF compared to group RF (p value =0.001). Peak sensory level was T6-T8 in group LF and T8-T10 in group RF. Significantly longer duration of sensory and motor block was produced in group LF (271.5 ± 5.06 and 252.16 ± 4.69 min) compared to group RF (228 ± 4.16 and 195.33 ± 3.54 min). The time to first rescue analgesia was also significantly prolonged in group LF (292.83 ± 5.28 min) compared to group RF (258 ± 4.32 min) (p value =0.001). Conclusion: Equipotent doses of isobaric Levobupivacaine and Ropivacaine with Fentanyl (25µg) offered satisfactory anaesthesia with minimal haemodynamic variability. Levobupivacaine produced rapid onset and prolonged anaesthesia while Ropivacaine provided rapid recovery of sensory and motor block and early mobility, suitable for day care surgery. Keywords: Isobaric, Levobupivacaine, Ropivacaine, Bupivacaine, Fentanyl.

Sickle cell disorder (SCD) is a genetic disorder of haemoglobin with a wide spectrum of severity and manifestations. It is a significant global public health problem and is mainly widespread among many tribal populations. Sickle cell disease (SCD) in pregnancy poses a unique challenge due to the physiological changes in pregnancy, the multitude of various organs involved, and its complications. The databases of PubMed, MedLine ResearchGate, EMbase, Scopus and Google Scholar were searched for literature about SCDs published up to 2021. Search terms and phrases used were 'sickle cell disease', 'sickle cell disease and pregnancy', 'anaesthesia and analgesia in sickle cell disease' and 'transfusion in sickle cell disease'. Original articles, guidelines, review articles, case reports, letters to editor and abstracts were reviewed with particular focus on pathophysiology and anaesthetic implications of sickle cell anaemia with pregnancy. While ample literature is available on SCDs, there is a paucity of literature on SCDs with pregnancy. In this review, we have attempted to present the relevant literature in a comprehensible manner.

Background and Aims: The coronavirus disease 2019 (COVID-19) pandemic has resulted in a large number of healthcare workers (HCW) getting infected, making it difficult to sustain uninterrupted and quality healthcare services. Using a mask is the minimum standard of care to prevent the spread of infection. Recently, the World Health Organization (WHO) has added airborne spread as an important mode of spread of COVID-19. The aim of this survey study was to assess the awareness about the use and reuse of masks for infection control practices among HCWs during the ongoing pandemic. Materials and Methods: A questionnaire-based survey on the awareness, knowledge, and practices related to the use of masks in COVID-19 infection in the healthcare setting was circulated through E-mail to medical and paramedical staff. A convenient sampling method was used for data collection, and the distribution of responses was presented as frequencies and percentages. Descriptive statistics were performed for all groups and subgroups based on the responses. Results: The survey sent to 1000 HCWs but only 394 responses (response rate 39.4%) were obtained. N95 was used by 282 (71.57%) personnel, surgical mask in 99 (25.12%) workers, cloth mask 11 (2.79%), and no mask in 2 (0.05%) HCW. Two hundred and eighty (71.07%) HCWs were reusing the mask. However, only 150 out of 280 subjects (53.57%) were correctly reusing the mask. Conclusion: Although universal masking was present in our study population, the awareness about the correct practice of reuse was limited. Since the pandemic is not going to settle any time soon and we might get short on existing supplies, it is vital that the HCWs need to be trained for the correct reuse and more efficient ways of reuse need to be explored.

Laryngocoele is a rare, benign laryngeal disease causing a variety of symptoms. However, this condition can lead to upper airway obstruction, thus posing problems in airway management and ventilation. Therefore, prior planning of anaesthetic and airway management of such patients is desirable, wherein awake intubation techniques are safer methods of securing a definite airway. Awake videolaryngoscopy-guided intubation can be safely used as an alternative to awake fibreoptic bronchoscopy-guided intubation.

Background: Postspinal anesthesia hypotension (PSH) in pregnant women is common and may lead to poor maternal and fetal outcome. Fluid loading in pregnant women before spinal anesthesia to prevent hypotension is of limited ability. We hypothesized that those women who are hypovolemic before spinal anesthesia may be at risk of PSH and inferior vena cava collapsibility index (IVCCI) will be able to identify hypovolemic parturients. Methods: In this prospective observational study, n = 45 women undergoing elective lower segment cesarean section with singleton pregnancy were recruited and IVCCI in left lateral tilt (with wedge) and supine position (without wedge) were noted by M-mode ultrasound (USG) before spinal anesthesia. After spinal anesthesia, changes in blood pressure were noted till 15 min after spinal anesthesia. Results: USG measurements were obtained in 40 patients and 23 of 40 patients (57.5%) had at least one episode of hypotension. Area under the ROC curve of IVCCI with wedge to predict PSH was 0.46 (95% CI 0.27, 0.64) and best cut-of value was 25.64 with a sensitivity and specificity of 60.9% and 35.5%, respectively. Area under the ROC curve of IVCCI without wedge to predict PSH was 0.38 (95% CI 0.19, 0.56) and best cut-of value was 20.4 with a sensitivity and specificity of 69.6% and 23.5%, respectively. Conclusion: We conclude that IVCCI is not a predictor of PSH in pregnant women undergoing elective cesarean section.