ABSTRACT Background: Mycobacterium w ( Mw ), an immunomodulator, resulted in better clinical status in severe coronavirus infectious disease 19 (COVID-19) but no survival benefit in a previous study. Herein, we investigate whether Mw could improve clinical outcomes and survival in COVID-19. Materials and Methods: In a multicentric, randomized, double-blind, parallel-group, placebo-controlled trial, we randomized hospitalized subjects with severe COVID-19 to receive either 0.3 mL/day of Mw intradermally or a matching placebo for three consecutive days. The primary outcome was 28-day mortality. The co-primary outcome was the distribution of clinical status assessed on a seven-point ordinal scale ranging from discharged (category 1) to death (category 7) on study days 14, 21, and 28. The key secondary outcomes were the change in sequential organ failure assessment (SOFA) score on days 7 and 14 compared to the baseline, treatment-emergent adverse events, and others. Results: We included 273 subjects (136 Mw , 137 placebo). The use of Mw did not improve 28-day survival ( Mw vs. placebo, 18 [13.2%] vs. 12 [8.8%], P = 0.259) or the clinical status on days 14 (odds ratio [OR], 1.33; 95% confidence intervals [CI], 0.79-2.3), 21 (OR, 1.49; 95% CI, 0.83-2.7) or 28 (OR, 1.49; 95% CI, 0.79-2.8) between the two study arms. There was no difference in the delta SOFA score or other secondary outcomes between the two groups. We observed higher injection site reactions with Mw . Conclusion: Mw did not reduce 28-day mortality or improve clinical status on days 14, 21 and 28 compared to placebo in patients with severe COVID-19. [Trial identifier: CTRI/2020/04/024846]
Sir, Pituitary apoplexy (PA) is a rare clinical syndrome, which presents with abrupt onset of neurological deterioration due to necrosis and hemorrhage in the pituitary adenoma.[1] We are presenting a case of PA in an acromegaly patient and its Intensive Care Unit (ICU) management. A 24-year-old male was admitted in ICU with respiratory distress and unconsciousness. There was a history of sudden onset with gradual progression of headache and visual disturbances since last 5 days. History revealed untreated polydipsia, polyuria and polyphagia for 2 years. On examination, he had acromegalic built, heart rate 130/min, blood pressure 160/110 mm Hg, respiratory rate 30/min,SpO2 92% with 6L O2 /min. Central nervous system examination revealed Glassgow coma scale (GCS)-E1 V1 M1, normal sized sluggish reactive pupils on both sides. Patient was immediately intubated, and ventilatory support was provided. Blood investigations and imaging studies done [Figure 1 and Table 1]. Arterial blood gas revealed severe metabolic acidosis with hypoxemia. Blood sugar was 596 mg/dl. Regular insulin infusion and 0.9% normal saline were started. Electrocardiogram showed sinus tachycardia. Bedside two-dimensional echocardiogram revealed diastolic heart failure with normal ejection fraction. Injection esmolol infusion was started to decrease the heart rate and blood pressure. Blood hormonal assays were sent. Injection hydrocortisone 200 mg intravenous bolus, followed by 2-4 mg/h infusion was given. Capillary glucose was measured 4 hourly and insulin dosage was titrated to maintain the blood sugar level between 150 and 200 mg/dl. After 12h, blood gas findings were pH 7.28, PaCO2 31.8, PaO2 125.5, HCO3− 14.7 mmol/L, serum lactate-2.5 mmol/L on FiO2 60%. Vitals became stable, and the urine output was adequate. Esmolol infusion was tapered gradually. His blood sugar was controlled with 50U of intermediate acting insulin in three divided doses. Based on the hormonal report [Table 1], infusion of hydrocortisone was stopped on 2nd day, tablet thyroxine 25 μg/day for asymptomatic hypothyroidism and tablet bromocryptine 1.25 mg/day for acromegaly was started through nasogastric tube. GCS improved gradually. After fulfilment of criteria, patient gradually weaned and extubated on the 6 days. He was kept in high dependency unit for 3 days and then shifted to neuromedicine ward.Figure 1: Magnetic resonance imaging brain showed T2-Weighted hypointense and T1-Weightediso-intense mass lesion in sellar, para-sellar, retro-sellar and supra-sellar regionsTable 1: Blood investigations and imaging studiesIn this case, a sudden surge of growth hormone (GH) and insulin like growth factor (IGF-1) resulted in the hyperglycemia precipitate diabetic like condition.[2] The GH/IGF-1 axis has a direct endocrine effect on the myocardium, resulting in hypertrophy, enhancement of contractile performance, and elongation of the action potential of cardiac fibers.[3] This remodelling is further enhanced by the hypertension and glucose intolerance. As hypertrophy becomes more prominent, diastolic dysfunction may develop, leading to the development of heart failure with preserved ejection fraction. Esmolol causes increases in left ventricular end-diastolic volume, left ventricular end-systolic volume and pulmonary artery wedge pressure, as well as a decrease in heart rate and cardiac output.[4] Hence, esmolol was administered to this patient with left ventricular dysfunction. We started hydrocortisone prophylactically for adrenocortical suppression and tapered when serum adrenocorticotrophic hormone found to be normal. In patients with macroadenomas, even in the presence of chiasmatic syndrome, dopamine agonists (bromocriptine) are now proposed as primary treatment.[5] During follow-up, patient had no complaints and his blood sugar was within normal range, and he was doing his physical activity normally. This case report will help in the medical management of PA with the use of esmolol for the anaesthesiologists working in mixed ICUs.
The twelfth rib syndrome appears to be a fairly common and underdiagnosed chronic pain syndrome. The diagnosis of this syndrome is clinical, requires exclusion of specific etiologies, and should only be made when the patient's symptoms can be exactly reproduced by manipulation of the affected rib. Patients with this syndrome can be over investigated and have even undergone surgical procedures when this diagnosis has been overlooked. We present here a case series of 27 women of twelfth rib syndrome over a period span of 18 months, many of whom had come to us after having prolonged and ineffective treatment for lumbar or hypogastric pain. Such patients were successfully managed with infiltration of local anaesthetics and steroid.
Malaria is a worldwide health concern, but a great majority of cases occur in tropical countries like India. With almost 95% of Indian population living in malaria endemic regions, India contributes to most of the global malaria cases and deaths, outside of African countries. Despite significant advances towards malaria control and eradication, mortality associated with severe malaria remains particularly high. Changing epidemiology, vulnerable patient population, overlapping symptomatology, and limited availability of parenteral preparations of artemisinin derivatives pose significant challenges in management of severe malaria. Further, the dearth of large-scale randomized trials from the developing countries makes it difficult to establish evidence-based guidelines pertaining to their situation. Thus, this position paper aims to provide guidance to critical care physicians across the country on managing patients with severe malaria in intensive care units (ICUs).
Xeroderma Pigmentosum (XP) is a rare autosomal recessive disease which causes skin pigmentation with precancerous lesions and neurological abnormalities.These manifestations are due to a cellular hypersensitivity to ultraviolet (UV) radiation leading to a defect in repair of DNA by the process of nucleotide excision repair (NER) mechanism.Here, we are reporting a child with XP scheduled for excision of basal cell carcinoma over the central area of scalp under general anaesthesia.
Sir, Malpositioning is a known complication of central venous catheterization in neonates.[1] We describe a misplacement of the right subclavian vein (SCV) catheter into the contralateral SCV in an infant. Such misplacement not only can impede the venous return but also can distort the central venous pressure measurement[2] that may be significant in a neurosurgical patient. Repositioning also adds to the operating room cost and time. We present a hypothesis involving a possible anatomical factor contributing to the misplacement. A 9-day-old child (body weight 2.5 kg, length 50.5 cm) was posted for decompressive craniotomy of subdural hematoma under general anesthesia. The baby was delivered normally at term. During the last week of her pregnancy, the mother has received electrical shock at home and had landed on her abdomen. The baby had presented with a swelling on the forehead. A computed tomography scan revealed a left temporal intracerebral hemorrhage and a left frontal subdural hematoma. The physical examination was unremarkable, and routine investigations were within normal limits. A 5 Fr triple lumen central venous catheter (Certofix® Trio Paed S 508, B. Braun Melsungen AG, Melsungen, Germany) was planned to be inserted via the right SCV using the anatomic landmark technique by infraclavicular approach, after administering general anesthesia. The J-tip guidewire got twisted during the insertion attempt. Fearing misplacement due to the twisted guidewire, it was decided to use the opposite straight end which is also flexible. The catheter was used uneventfully. A chest X-ray obtained next day showed misplacement in the opposite SCV [Figure 1]. The catheter was repositioned under image guidance using a Seldinger guidewire.Figure 1: Chest X-ray showing the misplaced catheter (left) and a diagrammatic representation of the supracardial venous system in infants (right)It has been found by cadaveric dissection that the central venous anatomy in infants is slightly different as compared to that of children aged more than 1 year, which is similar to that of adults.[3] It is clear from the central venous anatomy in infants [Figure 1] that the SCV arch superiorly on both sides of its course, more on the right side than the left. In older children and adults, they become more horizontal. During central venous access, the direction of the J-tip of the Seldinger wire influences the path taken by the guidewire and the consequently that of the catheter.[4] It appears from the anatomical relations that it is extremely difficult for the straight end of a right SCV guidewire to enter the opposite SCV as the left innominate vein joins the right at almost right angle. This makes the path very tortuous for such a placement. One possible explanation is that the anatomical position of these veins changed with the phases of respiration. We speculate that at the height of inspiration, both SCVs assumed a more horizontal position bringing them in alignment. Under the influence of neuromuscular blocking agents, a compliant chest wall and an inflated lung due to positive pressure ventilation had contributed to this change in anatomy. After needle puncture, the guidewire must have been negotiated into the vein at the height of inspiration. This misplacement did not produce any clinical problem due to the high rate of flow in the vein.[3] Twisting of the guidewire during insertion is a known factor in contributing to misplacements.[5] That is why we decided to use the opposite straight end of the guidewire which is also flexible. Difference in anatomical relationship of thoracic veins in infants as compared to older children should be kept in mind during central venous catheterization. We recommend ceasing of ventilation at end expiration for a few seconds during insertion of a straight guidewire in infants as this may influence the direction of the path taken by the guidewire during right SCV cannulation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest
Sir, A 40-year-old male weighing 63 kg presented to Emergency Department with alleged history of road traffic accident 2 days ago with altered sensorium and seizures, referred from a rural hospital. He had a Guedel's orophayrngeal airway size 4 (11 cm) (Romsons Scientific and Surgical Industries Pvt. Ltd., Agra, India) in situ firmly fixed with an elastic adhesive bandage. On initial assessment in the emergency scenario, the patient had a Glasgow Coma Score (GCS) of E3 V2 M5 with stable haemodynamics. A noncontrast computed tomography scan brain showed a left fronto-temporo-parietal subdural haematoma with underlying contusion with no mass effect and no evidence of any associated injuries. The patient was immediately shifted to our trauma Intensive Care Unit (ICU) for further management and monitoring. By the time patient reached the ICU, GCS deteriorated to E2 V1 M5 following a brief episode of seizure which lasted for 60 s. Hence, the decision was taken to perform rapid sequence induction using intravenous propofol (2 mg/kg) and injection rocuronium (1.2 mg/kg). On pulling out Guedel's airway to perform oral suctioning before intubation, it was noticed that the mucosa of the palatal region had undergone blackish discolouration apparently due to the sustained pressure of the Guedel's airway. However, the trachea was easily intubated with the appropriate size of the tracheal tube. In rural set ups such as ours, Guedel's airway is commonly available and used as a bite guard as well as for maintaining an open airway and it is made up of elastomeric or plastic material. However, the lack of awareness among primary health care providers can lead to fatal complications during airway management, especially during emergencies. Ideally, an appropriate size airway should relieve/prevent obstruction of the airway by preventing the tongue from falling back. Pressure necrosis of lower lip due to incorrect placement of Guedel's airway has also been reported.[1] The best criterion for proper size and position of the airway is an unobstructed gas passage. A method to ascertain the appropriate size of the airway by measuring the distance between the angle of mouth and mandible has been described.[2] Many primary care providers may not be aware of this. We also recommend that the manufacturers provide a diagrammatic depiction showing how to select proper size and insertion technique of airway on the package back cover to prevent such complications. In our case, palatal pressure necrosis may have occurred due to inappropriate size selection, prolonged placement and firm fixation of Guedel's airway with a tight elastic adhesive bandage. There is need to emphasize the importance of using proper size of airway devices and teaching the healthcare workers of correct usage of the devices available to them. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
In the article that appeared on page 481-484 of the Indian Journal of Anaesthesia, Vol. 58, No. 4, July-August, 2014 issue there was an error in author's name and sequence. The author's name should have appeared as Bikram Kumar Gupta instead of Bikram Kumar Sharma. Now the authors’ names and affiliations should be read as follows:
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