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Acute Cholecystitis Dr Swapnil Pawar
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Neuromuscular Blockade in Intensive Care – To Be or Not To Be Dr Swapnil Pawar
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Hyperkalemia Dr Swapnil Pawar
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Transfusion Thresholds in Intensive Care Dr Swapnil Pawar
play_arrow Neuromuscular Blockade in Intensive Care – To Be or Not To Be Dr Swapnil Pawar Blog Slides by – Dr Swapnil Pawar Indications for NMB use in ICU – NMB Agents – NMB Monitoring – Evidence – ARDS – Status Asthmaticus – Raised ICP/Severe TBI – Therapeutic hypothermia – Complications associated with the use of NMB in ICU – Supportive Care – Summary –
play_arrow Transfusion Thresholds in Intensive Care Dr Swapnil Pawar Transfusion Thresholds in Intensive Care Blog Written by Dr Jose Chacko Incidence of anemia in the ICU Anemia is all too common among critically ill patients, with 30–50% of patients receiving red cell transfusion. The etiology of anemia in the ICU is multifactorial, contributed by intravenous fluid resuscitation with the resulting hemodilution, repeated blood sampling, low erythropoietin levels induced by inflammatory cytokines, and abnormalities of iron metabolism. A hemoglobin level of 10 gm/dl was proposed by Adam and Lundy among surgical patients in 1942 (1); they averred that “when the concentration […]
play_arrow REALITY Trial – Liberal Vs Restrictive Transfusion in MI Dr Swapnil Pawar REALITY Trial Blog is written by Dr Jose Chacko Setting and design The study conducted in 26 centres in France and 9 centres in Spain Enrolment between March 2016 to September 2019 Patients assigned a 1:1 ratio to the restrictive or a liberal transfusion arm. Web-based, centralized randomization, with blocks of varying size and stratified by centre. MACE assumed to be 11% in the restrictive transfusion group and 15% in the liberal transfusion group. A sample size of 300 patients per group for 80% power to demonstrate […]
play_arrow Tocilizumab Fairytale in COVID-19 Dr Swapnil Pawar Blog Written by – Dr Jose Chacko REMAP-CAP Study population Patients 18 years of age or older, with either clinically suspected or microbiologically confirmed Covid-19, admitted to an intensive care unit (ICU) and receiving respiratory or cardiovascular organ support. Within 24 hours of commencement of organ support Respiratory support Intubation ventilation or NIV High-flow nasal cannulae with flow rates more than 30 liters per minute and the fraction of inspired oxygen more than 0.4 Cardiovascular support Vasopressor or inotrope infusion Excluded Imminent death, limiting of therapy Previously participated in the REMAP-CAP trial […]
play_arrow Oxygen Therapy in ICU- The Circle of Uncertainty Dr Swapnil Pawar Background Clinical practice guidelines give no recommendation for oxygenation targets in adult patients in the ICU owing to sparse evidence. HOT- ICU Trial Setting: 35 ICUs in Denmark, Switzerland, Finland, the Nether- lands, Norway, the United Kingdom, and Iceland Design: Randomized study in permuted blocks. Stratified by center and the presence or otherwise of COPD and hematological malignancy Study population Inclusion Acute respiratory failure, who were receiving at least 10 litres of oxygen per minute in an open system or who had a FiO2 of at least […]
play_arrow COVID-19 Vaccines – Comprehensive Review Dr Swapnil Pawar COVID-19 vaccines: Comprehensive Review Written by – Dr Jose Chacko Several vaccines are being employed against COVID-19 following expedited evaluation and manufacturing processes. Currently, more than 50 potential vaccines are undergoing clinical trials in various phases.1 Effective immunization is considered to be an important strategy in the control of the COVID-19 pandemic. Phases of vaccine development The conventional methodology of vaccine development involves several phases. The first step in the process involves preclinical evaluation. During this phase, the vaccine is administered to experimental animals to evaluate immunogenicity and toxicity. Clinical trials […]
COVID -19 Vaccine Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine Population Inclusion: Healthy adults or those with stable medical conditions including human immunodeficiency virus (HIV), hepatitis B virus, or hepatitis C virus infection were eligible. United States, 130 sites; Argentina, 1; Brazil, 2; South Africa, 4; Germany, 6; and Turkey, 9 Exclusion: Previous history of Covid-19, treatment with immuno-suppressive therapy, or diagnosis with an immunocompromising condition. Design Randomized controlled trial using an interactive Web-based system Intervention 30 μg of BNT162b2 (0.3 ml volume per dose) into the deltoid muscle. Two 30 mcg doses of the vaccine administered 21 […]
Blog Written by – Dr Jose Chacko Lactic acidosis commonly occurs in critically ill patients, especially among those in shock of varying etiology. High lactate levels are uniformly associated with poor clinical outcomes, including mortality.1 However, there is considerable interest and conflict of opinion regarding the clinical value of using lactate levels to guide resuscitation in critically ill patients. Although generally considered to be a marker of tissue hypoxia, the etiology of hyperlactatemia in the critically ill may be multifactorial. Lactate production and metabolism Lactate is generated at the rate of 0.8 mmol/kg/hour (1300 mmol/day) and the normal plasma level […]
RESPIRATORY PHYSIOLOGY Written by – Dr Madhuri Anupindi Describe the anatomy of the trachea and bronchial tree to the level of the segmental bronchi The trachea is a fibrocartilaginous tube which typically has an inner diameter of about 2.5cm and a length of about 10 – 16cm. It begins at the lowest border of the larynx around the level of C6, and ends by bifurcating into the right and left main bronchi around T5-7. The trachea is D shaped in cross section and consists of curved cartilage rings anteriorly and a flat, longitudinal muscle called the trachealis posteriorly. The […]
Effect of Regional Citrate Anticoagulation vs Systemic Heparin Anticoagulation During Continuous Kidney Replacement Therapy on Dialysis Filter Life Span and Mortality Among Critically Ill Patients With Acute Kidney InjuryA Randomized Clinical Trial The blog is written by Dr Jose Chacko Design The study was performed against the background of the KDIGO (2012) guidelines that recommended the use of regional citrate anticoagulation instead of heparin during renal replacement therapy in acute kidney injury in patients who have no impairment of coagulation, no increase in bleeding risk, and not receiving systemic anticoagulation for comorbid conditions. The RICH trial was a randomized, multicenter, […]
Written by – Dr Jose Chacko “Bundled” care in sepsis The 2018 surviving sepsis guidelines combined the previous 3- and 6-h bundles into a single 1-h bundle that included Estimation of lactate levels; repeat if level > 2 mmol/l (weak recommendation; low-quality evidence) Blood culture, followed by broad-spectrum antibiotics (best practice statement) Intravenous crystalloid at 30 ml/kg for hypotension or lactate ≥ 4 mmol/l (strong recommendation; low-quality evidence) Vasopressors if the patient remains hypotensive during or after fluid resuscitation for MAP ≥ 65 mm Hg (strong recommendation; moderate-quality) Bundled vs. physician-judgement based approach Kaukonen et al. showed that mortality with […]
Guidelines and GRADE Methodology Guidelines are recommendations intended to assist providers and recipients of health care and other stakeholders to make informed decisions. Recommendations may relate to clinical interventions, public health activities, or government policies. ( WHO 2003,2007) Before forming guidelines, consider – Who is the target user of the guideline Who it applies to What is covered? – Eg diagnosis and treatment of diabetic retinopathy Develop key questions Key Steps – Group Composition & consultation process Managing conflicts of interests Formulate Question Select Outcomes Rate Importance Create Evidence Profile using GRADE-PRO Rate quality of evidence for each Outcome Downgrade […]
How to Interpret a Meta-Analysis Blog Written by Dr Jose Chacko What is a meta-analysis and why do we need to perform a meta-analysis? We live in the era of evidence-based medicine Some important clinical questions remain unanswered despite several studies e.g., corticosteroids in sepsis; small studies may not be powered; blood sugar control differing conclusions Put together studies systematically, attempt to come to a more definitive conclusion A meta-analysis provides a single, overall measure of the treatment effect, enhancing the clinical interpretation of findings across several studies. You get results as “effect size” How meta-analysis is performed Ask the […]
Physics and Monitoring in ICU – Part 1 Written by – Dr Madhuri Anupindi Describe the physical principles of ultrasound Ultrasound is sound whose frequency is above the range of human hearing. Sound is a mechanical wave produced by vibration of the medium and can be represented by a sinusoidal wave. The wavelength is the distance between two consecutive points of the same phase, the amplitude is the maximal distance covered by each particle during an oscillation and the frequency is the number of cycles occurring in 1 second measured in hertz. Medical ultrasound uses high frequency sound ranging from […]
In this podcast, we discuss the upsurge of the use of technology in Medical education space during COVID-19 pandemic. Dr Eric Gantwerker from Chicago talks about the pros and cons of the different technological solutions emerged during this pandemic. Further reading –
Interpreting an RCT Blog written by – Dr Jose Chacko & Dr Swapnil Pawar 3 Key areas – the validity of the trial methodology; the magnitude and precision of the treatment effect; the applicability of the results to your patient or population. Questions to consider when assessing an RCT Did the study ask a clearly focused question? Was the study an RCT and was it appropriately so? Were participants appropriately allocated to intervention and control groups? Were participants, staff, and study personnel blind to participants’ study groups? Were all the participants who entered the trial accounted for at its conclusion? […]
Steroids in COVID-19 The role of corticosteroids in treating severe infections has been debatable for some time. During the coronavirus disease 2019 (COVID-19) pandemic, rigorous data on the efficacy of corticosteroids have been limited. As of July 24, 2020, 55 studies of corticosteroids for the treatment of COVID-19 have been registered on ClinicalTrials.gov. In early July, The Randomized Evaluation ofCOVID-19 Therapy (RECOVERY) trial reported its findings from 6425 patients randomized to 6mg/d of dexamethasone or usual care. Overall, dexamethasone resulted in an absolute reduction in mortality of 2.8 %( 22.9%vs 25.7%for usual care; age-adjusted rate ratio, 0.83 [95%CI, 0.75- 0.93]). […]
play_arrow Prone Positioning in ARDS Dr Swapnil Pawar Prone Positioning in ARDS Written by – Dr Jose Chacko Edited By – Dr Swapnil Pawar Prone positioning was first proposed in the 1970s as a method to improve gas exchange in ARDS. Subsequent observations of dramatic improvement in oxygenation with simple patient rotation motivated the next several decades of research. During COVID -19 pandemic, the debate on the utility of proning has been resurfaced. Ventilation heterogeneity In ARDS, widespread edema occurs leading to an increase in the weight of the lung. The dependent areas of the lung are compressed by the […]
Understanding of social determinants of health is important not only for budding medical professionals but also for medical educators. In this podcast, Dr Mobola Campbell-Yesufu from Northwestern university talks about the need to include this topic in all medical curricula across the globe. play_arrow Social Determinants of Health in Medical Education Dr Swapnil Pawar This social determinants of health curriculum provide a broad overview of issues of health equity affecting our patients. The curriculum of social determinants of health consists of three modules (social determinants of health, health disparities and social justice). This curriculum teaches residents how to identify […]
Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury The STARRT-AKI Investigators for the Canadian Critical Care Trials Group, the Australian and New Zealand Intensive Care Society Clinical Trials Group, the United Kingdom Critical Care Research Group, the Canadian Nephrology Trials Network, and the Irish Critical Care Trials Group* play_arrow STARRT-AKI Trial Dr Swapnil Pawar Acute kidney injury occurs in up to 50% of critically ill patients and is associated with high morbidity and mortality. Renal replacement therapy (RRT) can rapidly correct life-threatening complications associated with acute kidney injuries, such as severe hyperkalemia, metabolic acidosis, or pulmonary edema due […]
play_arrow Top 10 Practice Changing Trials in Intensive Care Dr Swapnil Pawar Dr Swapnil Pawar & Dr Jose Chacko The ARDS-net low tidal volume (ARMA) study In this multicentric randomized controlled trial (RCT), patients with acute lung injury and acute respiratory distress syndrome (ARDS), (based on pre-Berlin definitions) were enrolled. The study was conducted across 10 university hospitals in the USA for a 3-year period between 1996-99. Patients were ventilated with a tidal volume of 12 ml/kg predicted body weight at a plateau pressure of 50 cm H2O or less, and compared with 6 ml/kg predicted body weight at a […]
Join Dr. Eve Purdy from Canada to learn how to dissect the culture of your working environment through the lens of Anthropology. In this podcast, she describes simulation as a means to create moments of cultural compression and how that can be beneficial to evaluate and thus potentially modify the culture of the place. References – Connecting simulation and quality improvement: how can healthcare simulation really improve patient care? V Brazil, EI Purdy, K Bajaj. BMJ quality & safety 28 (11), 862-865 Identifying and transmitting the culture of emergency medicine through simulation E Purdy, C Alexander, M Caughley, S […]
What really happens in the lung in COVID-19 pneumonia? Although several studies suggest raised levels of inflammatory mediators in COVID-19, it is pertinent to compare levels observed in other types of acute respiratory distress syndrome (ARDS). IL-6 levels may be considerably lower in patients with severe COVID-19 compared with levels that are typically seen in patients with the hyperinflammatory phenotype of ARDS.2 Ackermann et al. evaluated autopsy findings in the lungs from patients who died of COVID-19 and compared it with patients who died of H1N1 pneumonia and those with uninfected lungs. The pulmonary involvement in COVID-19 was characterized […]
Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial The HALTIT trial was an international, multicentric, randomized, double-blind placebo controlled trial. It was carried out in 164 hospitals across 15 countries (UK, Pakistan, Nigeria, Egypt, Malaysia, Georgia, Romania, Nepal, Sudan, Saudi Arabia, Spain, Ireland, Albania, Papua New Guinea, and Australia). Conducted between July 4, 2013, and June 21, 2019. Inclusion Included patients were >16 years and older or aged 18 years or older (depending on the definition of adult in their respective […]
A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19 The only strategies that worked so far in COVID-19 to mitigate transmission are rapid identification of cases, isolation, contact tracing, and self-quarantine of those exposed. To date, no medication has been shown to prevent SARS-CoV-2 transmission. This trial hypothesized that hydroxychloroquine could potentially be used as postexposure prophylaxis, to prevent symptomatic infection after exposure to Covid-19. Setting The study was conducted in Canada and the US. Methods Multicentre Randomised controlled trial. Inclusion Criteria – subjects who were within 3 days of known high-risk exposure (as self-reported) pending formal testing. […]
RECOVERY TRIAL The RECOVERY trial is a randomized clinical trial designed to evaluate several treatment modalities in patients with COVID-19 infection. 11,000 patients from 175 hospitals of the National Health Services. Inclusion Criteria – Hospitalized patients who had clinically suspected or laboratory-confirmed COVID-19 infection Exclusion – if dexamethasone was unavailable at the treating hospital or considered to be definitely indicated or contraindicated by the treating physician. The treating staff was not blinded to the study arm. Intervention – Dexamethasone 6 mg once daily IV or orally for a maximum of 10 days using web-based randomization. Patients were assigned in a […]
Early High-Dose Vitamin D3 for Critically Ill, Vitamin D–Deficient Patients The National Heart, Lung, and Blood Institute PETAL Clinical Trials Network Setting: The study was conducted The National Heart, Lung, and Blood Institute PETAL Clinical Trials Network from April 2017 through July 2018 at 44 U.S. hospitals. Design: 1:1 randomized controlled study, Vit D vs. placebo, using a central electronic system, stratified by site Inclusion: Adults were screened for Vitamin D deficiency by the hospital lab or by a POC test; with a lower cut-off level of 25OH <20 ng/mL. These patients were randomized to one of the study groups. […]
Introduction – Acute respiratory distress syndrome (ARDS) is a life-threatening condition characterized by intense lung inflammation, consolidation, and progressive microatelectasis with refractory acute hypoxemia [1, 2]. Despite advances in technology and sophistication of mechanical ventilators, the mortality of ARDS is still high [3–5]. A multimodal strategy involving non-pharmacologic interventions and pharmacologic interventions is recommended for the management of ARDS. Non-pharmacologic interventions include protective lung ventilation strategies, including low tidal volume and higher positive end-expiratory pressure (PEEP) along with prone positioning. These strategies are accepted because of their beneficial effects on patient outcomes in ARDS [2, 5, 6]. However, the benefit […]
Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomised Clinical Trial Setting: Seven medical centres in China in the Hubei province. Design: February 14, 2020, to April 1, 2020. Patients were randomly assigned via computer-generated random numbering (1:1) to receive standard treatment combined with convalescent plasma transfusion or standard treatment alone. Randomisation was stratified based on whether the infection was “severe” or “life-threatening”. Patients: Included: Patients with COVID-19 diagnosis based on nasopharyngeal polymerase chain reaction (PCR) testing. Patients were randomised within 72 hours of testing positive; pneumonia confirmed by chest […]
Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of Covid-19 — Preliminary Report. New England Journal of Medicine doi:10.1056/NEJMoa2007764 Setting: 73 sites including United States (45), Denmark (8), the United Kingdom (5), Greece (4), Germany (3), Korea (2), Mexico (2), Spain (2), Japan (1), and Singapore (1). Enrollment between February 21, 2020, and April 19, 2020. 844/1059 patients (79.8%) of patients were enrolled at sites in North America. [15.3% in Europe, and 4.9% in Asia). Overall, 53.2% of the patients were white, 20.6% were black, 12.6% were Asian, and 13.6% were designated as other or […]
In this podcast, Professor Dale Needham from John Hopkins hospital shares his insights into ICU rehab experiences during COVID-19 pandemic. He talks about the challenges associated with prolonged ICU length of stay and advises on how to optimise the recovery of COVID-19 patients.
In this podcast, Professor Maurizio Cecconi talks about Italian experiences of the COVID-19 pandemic and outlines the challenges specific to intensive care in the post-pandemic phase. He discusses various issues including prolonged ICU length of stay, slow weaning, and the impact of the pandemic on staff well-being.
COVID -19 has a very unique pattern and it has challenged the dogmatic approach of mechanical ventilation described for ARDS patients. In this podcast, Prof Luciano Gattinoni talks in-depth about the pathophysiology of the disease and how we should ventilate these patients. His key messages are monitor closely, identify the right phenotype, be patient and do not apply blanket protocols for mechanical ventilation. For Full podcast –
Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis Design: Multinational registry analysis including 671 hospitals in North America, South America, Europe, Africa, Asia, and Australia. Subjects: Patients hospitalized between Dec 20, 2019, and April 14, 2020, and tested positive for SARS-CoV-2. Data abstracted from Surgical Outcomes Collaborative (Surgisphere Corporation, Chicago, IL, USA) database. Treatment group: Patients who received either HCQ or CQ either alone or in combination with a macrolide. There were four groups of patients: 1. HCQ, 2. HCQ+macrolide 3. CQ 4. CQ+macrolide Excluded: Patients who received treatment after 48 h […]
Tracheostomy – Tracheotomy in ventilated patients with COVID-19: Guidelines from the COVID-19 Tracheotomy Task Force, a Working Group of the Airway SafetyCommittee of the University of Pennsylvania Health System, published in Annals of Surgery Indication – Tracheotomy may be considered in patients with prolonged periods of intubation, defined as greater than 21 days, who are otherwise without significant comorbidities and would be expected to have a good prognosis if recovery is achieved. Pre-Procedure – Rule out whether the patient is still positive or negative by performing PCR and/or CT chest. Informed consent must be obtained from NOK. LocationThe procedure should […]
Professor Victoria Brazil & Dr Swapnil Pawar What is Translational Simulation? It is a terminology which refers to a subset of simulation activities that are directly focused on a patient or institutional level outcomes and focusing on those outcomes through at least two ways. One is through diagnosing system issues at the individual team or system level and then also seeking to address those issues through simulation. It involves testing new systems or embedding new systems or re-evaluating existing systems. Steroids are a two-edged sword, and we have to think before commencing any patient on steroids carefully. Similarly, translational simulation […]
Remdesivir (also GS-5734) is a monophosphoramidate prodrug of an adenosine analogue that has a broad antiviral spectrum including filoviruses, paramyxoviruses, pneumoviruses, and coronaviruses. In vitro, remdesivir inhibits all human and animal coronaviruses tested to date, including SARS-CoV-2. Intravenous remdesivir was studied for treatment of Ebola virus disease, in which it was adequately tolerated but less effective than several monoclonal antibody therapeutics,and has been used on the basis of individual compassionate use over the past several months in patients with COVID-19 in some countries. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial Strengths – Only RCT on this […]
The literature published from various countries has helped us to understand the disease pattern in COVID-19 pandemic. The New York experience Richardson et al. evaluated a large case series of 5,700 patients admitted to 12 hospitals under Northwell Health, the biggest health care provider in New York (1). They analyzed the clinical characteristics and outcomes of patients hospitalized over a 35-day period between March 1, 2020, and April 4, 2020. All patients tested positive for SARS-CoV-2 by RT-PCR on the nasopharyngeal sample. Patients were followed up until they were discharged alive or dead, or until the study endpoint. On April 4, […]
Remdesivir The nucleotide analog remdesivir has in vitro activity against SARS-CoV-2. It was used on a compassionate basis in 61 patients with COVID-19 who had an oxygen saturation of less than 94% on room air or required supplemental oxygen. Remdesivir was administered intravenously in a dose of 200 mg on day 1, followed by 100 mg per day for 9 days. Clinical outcomes of 53 of the 61 patients were analyzed. At baseline, 30 patients (57%) were invasively ventilated and four patients were on extracorporeal membrane oxygenation (ECMO). The median follow-up period was 18 days. The level of the oxygen […]
Many novel therapies have been proposed in our battle against this deadly pandemic. In this podcast, we summarise the literature available to date and present our views so you can make an informed decision while treating your patients with COVID-19. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) in COVID-19 Do ACE inhibitors and ARBs help or harm? It has been shown that COVID-19 uses the ACE2 receptor to gain access into cells . This has led to the hypothesis ACE inhibitors and ARBs may upregulate ACE2 expression, leading to increased predisposition to COVID-19 infection. However, according to Perico […]
