A bstract Objectives To describe the demographics and evaluate the clinical outcomes of hypoxic coronavirus disease-2019 (COVID-19) patients treated with different immunomodulatory (IM) drugs in a resource-limited setting. Materials and methods We conducted a retrospective cohort study of these patients admitted to our hospital between March 22 and May 31, 2020. Data were abstracted from multiple electronic data sources or patient charts to provide information on patient characteristics, clinical, laboratory variables, and outcomes. Results A total of 134 patients met the inclusion criteria and were followed up till June 7, 2020. The median age of the patients was 55.6 years (range 20–89 years) and 68% were men. At least one comorbidity was seen in 72% of the patients with diabetes (44%) and hypertension (46%) being the most common. At triage, fever (82%), shortness of breath (77%), and cough (61%) were the most common presenting symptoms. A PaO 2 /FiO 2 ratio less than 300 was seen in 60%, and 4.5% required invasive mechanical ventilation within 72 hours of hospital admission. Five immunomodulatory agents (hydroxychloroquine, methylprednisolone, colchicine, etoricoxib, and tocilizumab) were administered in different combinations. Overall, in-hospital mortality was 26.9%, and 32% required mechanical ventilation. Around 69% of patients were discharged home. Five variables (SpO 2 , PaO 2 /FiO 2 ratio, leucocytosis, lymphopenia, and creatinine) on admission were found to be significant in the patients who died. Conclusion Our study provides the characteristics and outcomes of hypoxic COVID-19 patients treated with IM drugs in varied combination. Five independent variables were strong predictors of mortality. How to cite this article Mahale N, Rajhans P, Godavarthy P, Narasimhan VL, Oak G, Marreddy S, et al. A Retrospective Observational Study of Hypoxic COVID-19 Patients Treated with Immunomodulatory Drugs in a Tertiary Care Hospital. Indian J Crit Care Med 2020;24(11):1020–1027.

We present a case of a 32-year-old male doctor, with type I diabetes mellitus on daily insulin therapy, who allegedly consumed large doses of digoxin and propranolol along with simultaneous administration of large dose of insulin with suicidal intent. Initial investigations revealed serum digoxin levels of 7.5 ng/ml, serum insulin 500 μIU/ml, and serum C-peptide 0.43 ng/ml. He was managed with charcoal-based hemoperfusion for digoxin overdose along with injection glucagon for propranolol overdose. His blood sugar levels were maintained with continuous infusion of 20% dextrose till the patient was allowed to take oral diet. Significant clinical improvement was noticed with this therapy which was evident by progressively declining serum digoxin levels, normalization of pulse rate, and adequate blood glucose levels. Finally, with a good hemodynamic profile and a serum digoxin level well within normal limits, he was discharged following consultation with a psychiatrist.

Objectives: To describe the clinical outcomes of hypoxic coronavirus disease 2019 (COVID-19) patients treated with intravenous methylene blue (MB) in a tertiary care hospital. Materials and methods: We conducted a case series of 50 patients with hypoxic COVID-19 treated with intravenous MB admitted to our hospital between June 01 and September 10, 2020. Intravenous MB was administered as rescue therapy in dosage of 1 mg/kg body weight, with a maximum of five doses, to patients with high oxygen requirements (SpO 2 /FiO 2 <200) apart from the standard of care after obtaining G6PD levels. Data were abstracted from multiple electronic data sources or patient charts to provide information on patient characteristics, clinical and laboratory variables and outcomes. Results: The median age of the patients was 53.3 (range 25–74 years) and most patients (74%) were men. About 68% of patients had pre-existing comorbidity. Median SpO 2 /FiO 2 ratio progressively improved from 132.5 (predose) to 284 before the terminal event (death or discharge), ventilator-free days, and decrease in the proinflammatory biochemical parameter was significantly higher after the second dose of MB. A total of six patients out of 50 required invasive mechanical ventilation (IMV). Thirty patients were discharged with a recovery rate of 60%, while 20 patients succumbed to the illness. There was no major side effect or adverse event reported in any of the patients. Conclusion: MB due to its polypharmacological action against SARS‐CoV‐2, an inexpensive and widely available drug with minimal side effects, has a significant potential in the treatment of COVID-19. How to cite this article: Mahale N, Godavarthy P, Marreddy S, Gokhale SD, Funde P, Rajhans PA, et al. Intravenous Methylene Blue as a Rescue Therapy in the Management of Refractory Hypoxia in COVID-19 ARDS Patients: A Case Series. Indian J Crit Care Med 2021;25(8):934–938.

Background: Skin mottling as a clinical perfusion marker in septic shock is correlated well with severity and outcome in white skinned population and its validity as a clinical sign in dark skinned population is not known. Objectives of this study were to evaluate mottling in septic shock in the Indian ethnic population who has different skin colour as compared to white skinned population and compare mottling as an outcome predictor with Capillary Refill Time(CRT) and other biochemical parameters which are the established clinical markers of perfusion in septic shock. Methods: We conducted a prospective observational study of patients with skin colour category 21 to 34 on von Luschan scale or Fitzpatrick type IV and V who had septic shock needing high dose of norepinephrine ≥ 0.2 mcg/kg/min after fluid optimisation. The study was conducted in a mixed medical - surgical ICU over a period of 12 months. Two blinded experts (Dermatologist and a Cosmetic surgeon) independently classified the skin type, validated the occurrence of mottling and scored mottling in our patients. We recorded the demographics, hemodynamic variables, mottling score and observed for the incidence of mottling and its correlation with predictors of severity of septic shock. We also compared CRT, Arterial lactate, central venous oxygen saturation and venoarterial PCO2 gap with mottling as predictor of outcome in septic shock patients. Results: We included 108 patients with age 61±16 years. Mean SOFA and APACHE II scores at enrolment were 10.3 and 21.9 respectively. Incidence of mottling was 20.3 % (22/ 108). CRT > 3 seconds was observed in 50.9% (55/108) Development of mottling significantly correlated with mortality; 20/22(90.9%) patients died in mottling group versus 58/86(65.1%) in non-mottling group (p=0.028). Independent t test of mottling score vs death showed that higher the mottling score, ( score> 3) (p=0.008) more the certainty of death . (p=0.008. CRT > 3 seconds did not corelate with mortality; 40/55(72.7%) patients with CRT > 3 seconds died versus 32/53(74.4%) patients died in CRT≤ 3seconds group. Occurrence of mottling could independently predict mortality ; Positive predictive value of 90.9 % which was comparable to positive predictive value of lactate levels > 4mmol/lit, i.e. 94.1% . CRT > 3 seconds did not corelate with mortality; positive predictive value was 72.7 % Conclusion: Incidence of mottling in septic shock is much less in patients of Indian ethnicity with brown skin colour as compared to that in White skinned population. Occurrence of mottling and not ­­­delayed CRT, is a better predictor of outcome in this setting.

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