Notes

[Atrial fibrillation ablation].
An emergency department (ED) physician should be aware of this tuber toxicity as it presents with airway compromise, which resolves over hours. The symptoms are due to the local effects of calcium oxalate crystals in the tuber. Airway management is the priority and repeated adrenaline nebulization together with supportive care is advised.
Anandhi D, Prakash Raju KNJ, Vivekanandan MP, Kumaresan V. The First Case Series Report of
Tuber Poisoning in Humans. Indian J Crit Care Med 2020;24(7)581-584.
Anandhi D, Prakash Raju KNJ, Vivekanandan MP, Kumaresan V. The First Case Series Report of Typhonium trilobatum Tuber Poisoning in Humans. Indian J Crit Care Med 2020;24(7)581-584.Typical manifestations of coronavirus disease (COVID-19) involve the upper and lower respiratory tract. But as the pandemic surges, we are encountering numerous case reports and series of extrapulmonary presentations of COVID-19 in the outpatient department. Abundant retrospective data have also cited various extrapulmonary complications in the hospitalized COVID-19 patients. This knowledge needs to be condensed and disseminated in order to improve COVID-19 surveillance and to reduce the accidental exposure of healthcare workers. Our review suggests that gastrointestinal tract, cardiovascular system, nervous system, renal system, and manifestations due to hematological abnormalities are common masqueraders to watch out for.
Adukia SA, Ruhatiya RS, Maheshwarappa HM, Manjunath RB, Jain GN. Extrapulmonary Features of COVID-19 A Concise Review. Indian J Crit Care Med 2020;24(7)575-580.
Adukia SA, Ruhatiya RS, Maheshwarappa HM, Manjunath RB, Jain GN. Extrapulmonary Features of COVID-19 A Concise Review. Indian J Crit Care Med 2020;24(7)575-580.In the current COVID-19 pandemic, evidence to justify the use of any specific antiviral drug with proven efficacy is not yet available. Antiviral drug development always remains a challenge to the scientists. Remdesivir has emerged as a promising molecule, based on results of clinical trials and observational studies and has receieved marketing approval for COVID-19 treatment under "emergency use authorization" in countries such as United States. Remdesivir is a newer antiviral drug that acts as an RNA-dependent RNA polymerase (RdRp) inhibitor targeting the viral genome replication process. Therapeutic efficacy was first demonstrated by suppressing viral replication in Ebola-infected rhesus monkeys. #link# It is available for parenteral use with reasonable safety and tolerability profile. Multiple clinical trials are going on in many countries to evaluate its safety, efficacy and tolerability. Positive outcome will make the drug capable of meeting the demand generated by both the current pandemic and future outbreak.
Choudhury S, Chakraborty DS, Lahiry S, Chatterjee S. Past, Present, and Future of Remdesivir An Overview of the Antiviral in Recent Times. Indian J Crit Care Med 2020;24(7)570-574.
Choudhury S, Chakraborty DS, Lahiry S, Chatterjee S. Past, Present, and Future of Remdesivir An Overview of the Antiviral in Recent Times. Indian J Crit Care Med 2020;24(7)570-574.COVID-19 outbreak has caused a pandemonium in modern world. As the virus has spread its tentacles across nations, territories, and continents, the civilized society has been compelled to face an unprecedented situation, never experienced before during peacetime. Metabolism inhibitor are being introduced to an ever-growing new terminologies "social distancing," "lockdown," "stay safe," "key workers," "self-quarantine," "work-from-home," and so on. Many countries across the globe have closed their borders, airlines have been grounded, movement of public transports has come to a grinding halt, and personal vehicular movements have been restricted or barred. In the past couple of months, we have witnessed mayhem in an unprecedented scale social, economic, food security, education, business, travel, and freedom of movements are all casualties of this pandemic. Our experience about this virus and its epidemiology is limited, and mostly the treatment for symptomatic patients is supportive. However, it has been observed that COVID-19 not only attacks the respiratory system; rather it may involve other systems also from the beginning of infection or subsequent to respiratory infection. In this article, we attempt to describe the systemic involvement of COVID-19 based on the currently available experiences. This description is up to date as of now, but as more experiences are pouring from different corners of the world, almost every day, newer knowledge and information will crop up by the time this article is published.
Munjal M, Das S, Chatterjee N, Setra AE, Govil D. Systemic Involvement of Novel Coronavirus (COVID-19) A Review of Literature. Indian J Crit Care Med 2020;24(7)565-569.
Munjal M, Das S, Chatterjee N, Setra AE, Govil D. Systemic Involvement of Novel Coronavirus (COVID-19) A Review of Literature. Indian J Crit Care Med 2020;24(7)565-569.Ultrasound has become an integral part for assessment of critically ill patients. It has helped in diagnosing and treating critically ill patients. link2 The added advantage of ultrasonography is that it is a fantastic diagnostic tool that is easily available at the bedside, repeatable, more objective, and has a steep learning curve. It has become fifth vital assessment along with inspection, palpation, percussion, and auscultation. In the current scenario of COVID-19 pandemic, the disease caused by virus ranges from mild influenza-like illness to severe acute respiratory illness (SARI). Among the patients developing SARI, few require hospitalization and might need intensive care management. As a critical care specialist, we need to keep our antenna up to look for other causes for SARI due to non-COVID etiology as well. This article describes algorithmic approach and vital role of ultrasonography while managing patients with respiratory distress.
Havaldar AA. Vital Role of Ultrasound in the Era of COVID-19 Arriving at the Right Diagnosis Real Time. Indian J Crit Care Med 2020;24(7)563-564.
Havaldar AA. Vital Role of Ultrasound in the Era of COVID-19 Arriving at the Right Diagnosis Real Time. Indian J Crit Care Med 2020;24(7)563-564.Severe hypoxemic respiratory failure is frequently managed with invasive mechanical ventilation with or without prone position (PP). We describe 13 cases of nonhypercapnic acute hypoxemic respiratory failure (AHRF) of varied etiology, who were treated successfully in PP without the need for intubation. Noninvasive ventilation (NIV), high-flow oxygen via nasal cannula, supplementary oxygen with venturi face mask, or nasal cannula were used variedly in these patients. Mechanical ventilatory support is offered to patients with AHRF when other methods, such as NIV and oxygen via high-flow nasal cannula, fail. Invasive mechanical ventilation is fraught with complications which could be immediate, ranging from worsening of hypoxemia, worsening hemodynamics, loss of airway, and even death. Late complications could be ventilator-associated pneumonia, biotrauma, tracheal stenosis, etc. Prone position is known to improve oxygenation and outcome in adult respiratory distress syndrome. We postulated that positioning an uendotracheal intubation and the need for ventilator and therefore better utilization of critical care services.
Rao SV, Udhayachandar R, Rao VB, Raju NA, Nesaraj JJJ, Kandasamy S,
Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients. Indian J Crit Care Med 2020;24(7)557-562.
Rao SV, Udhayachandar R, Rao VB, Raju NA, Nesaraj JJJ, Kandasamy S, et al. Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients. Indian J Crit Care Med 2020;24(7)557-562.
Sepsis syndrome is an emerging healthcare problem, especially in critically ill patients, regardless whether it's community- or hospital-acquired sepsis. link3 This study evaluates the characteristics of these patients, in addition to the type, source, and outcome of sepsis and septic shock, in a university tertiary hospital in Palestine. It also studies the most common organisms encountered in these patients.

This is retrospective observational chart review study of all adult admissions to the intensive care unit over a period of 2 years. The presence of sepsis and septic shock was assessed and documented based on the Third International Consensus Definitions (Sepsis-3). Data regarding demographics, severity, comorbidities, source of infection, microbiology, length of stay, and outcomes (dead/alive at discharge from ICU) were recorded.

A total number of 174 patients were included. The mean age was 57.4 years, with cardiovascular diseases and diabetes being the leading comorbidities encountered in them. Respish Y, Anaya A, et al. Epidemiology of Sepsis Syndrome among Intensive Care Unit Patients at a Tertiary University Hospital in Palestine in 2019. Indian J Crit Care Med 2020;24(7)551-556.
Implementation of evidence-based infection control practices is the need of the hour for every institute to reduce the device-associated infections, which directly reflects the quality of care. As catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection, the study was planned to evaluate the impact of the catheter care bundle in reducing CAUTI incidence.

The prospective interventional study before and after the trial study was carried out in adult intensive care units over a period of 9 months (April-June 2017-pre-implementation phase; July-September 2017-training of healthcare worker and implementation of catheter care bundle; October-December 2017-post-implementation phase). Catheter-associated urinary tract infection rates pre- and post-implementation were expressed as incidence rates with Poisson confidence interval.

Statistically significant reduction was found in the incidence of CAUTI (60%-from 10.7 to 4.5 per 1,000 catheter days). The key factors that contributrthy R, Jeyashree K, Ganesan V, Arunagiri R, Charles J. Impact of Care Bundle Implementation on Incidence of Catheter-associated Urinary Tract Infection A Comparative Study in the Intensive Care Units of a Tertiary Care Teaching Hospital in South India. Indian J Crit Care Med 2020;24(7)544-550.
Soundaram GVG, Sundaramurthy R, Jeyashree K, Ganesan V, Arunagiri R, Charles J. Impact of Care Bundle Implementation on Incidence of Catheter-associated Urinary Tract Infection A Comparative Study in the Intensive Care Units of a Tertiary Care Teaching Hospital in South India. Indian J Crit Care Med 2020;24(7)544-550.
Appropriate early fluid resuscitation is ubiquitous for critically ill patients with metabolic acidosis. Owing to harmful effects of normal saline, commercially prepared balanced salt solutions are being used. However, there is no study comparing use of Ringer's lactate (RL) and commercially available balanced salt solutions in critically ill patients.

A randomized controlled trial was conducted during July 2016 to December 2017. Fifty adult patients admitted to intensive care unit with metabolic acidosis were randomized into group RL or group acetate solution (AC). Respective trial fluid was administered at 20 mL/kg/hour for first hour and 10 mL/kg/hour for second hour. Arterial blood gas analysis samples were taken 15 minutes apart. The fluid resuscitation was continued till pH got corrected to 7.3 or 2 hours, whichever was earlier. The primary aim was to compare time to correct metabolic acidosis in both the groups. The secondary outcomes were the extent of correction of metabolic acidosis, total volume of fluid used, and total cost per patient.
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