A bstract Background Severe acute respiratory distress syndrome associated with coronavirus disease-2019 (COVID-19) (CARDS) pneumonitis presents a clinical challenge as regards to the timing of intubation and ambiguity of outcome. There is a lack of clear consensus on when to switch patients from trials of noninvasive therapies to invasive mechanical ventilation. We investigated the effect of the timing of intubation from the time of admission on the clinical outcome of CARDS. Aim and objective The aim and objective was to analyze the effect of timing of intubation early (within 48 hours of admission to critical care unit) versus delayed (after 48 hours of admission to critical care unit) on mortality in severe CARDS patients. Materials and methods A retrospective observational study performed in a 28-bedded COVID-19 intensive care unit of a tertiary care hospital in Pune, India. All patients admitted between April 1, 2020, and October 15, 2020, with confirmed COVID-19 (RT-PCR positive) requiring mechanical ventilation were included in the study. Results The primary outcome was in-hospital mortality. Among 2,230 patients that were admitted to the hospital, 525 required critical care (23.5%), invasive mechanical ventilation was needed in 162 patients and 147 (28%) of critical care admission were included in the study cohort after exclusion. Seventy-five patients (51%) were intubated within 48 hours of critical care admission (early group) and 72 (48.9%) were intubated after 48 hours of critical care admission (delayed group). With regards to the total of 147 included patients; male patients were 74.1% with a median age of 59 years (interquartile range, 51–68 years). Diabetes (44.9%) and hypertension (43.5%) were the most common comorbidities. Higher admission acute physiology and chronic health evaluation II scores and lower absolute lymphocyte count were observed in patients intubated within 48 hours. The early intubated group had a mortality of 60% whereas the same was observed as 77.7% in delayed intubation group, and this difference was statistically significant ( p = 0.02). C onclusion Current study concludes that early intubation is associated with improved survival rates in severe CARDS patients. How to cite this article Zirpe KG, Tiwari AM, Gurav SK, Deshmukh AM, Suryawanshi PB, Wankhede PP, et al. Timing of Invasive Mechanical Ventilation and Mortality among Patients with Severe COVID-19-associated Acute Respiratory Distress Syndrome. Indian J Crit Care Med 2021;25(5):493–498.

INTRODUCTIONSurgical stress and pain elicits a consistent and well defined metabolic response, involving release of neuroendocrine hormones and cytokines that leads to myriad of detrimental effects. Regional anesthesia effectively produces mitigation of nociception as it diminishes the intensity of afferent impulses reaching the spinal cord. Brachial plexus block by axillary approach is one the most popular and reliable technique to provide anesthesia for forearm and hand surgeries. Furthermore, central neural blockade and pneumothorax are avoided as it may occur with other approaches of brachial plexus blockade. ABSTRACTBackground: Brachial plexus block by axillary approach achieves good motor sensory and sympathetic blockade below elbow joint. Addition of opioid compounds to local anesthetics improves the block properties and reduces central opioid related side effects. We compared combination of local anaesthetic bupivacaine with fentanyl and butorphanol in axillary block for upper limb surgeries. Aims and objectives were to compare the block quality, duration of sensory and motor block, post-operative analgesia, safety and side effects in two groups. Methods: 60 patients posted for elective or emergency forearm and hand surgeries were randomly divided into 2 groups of 30 each. group B (n=30) received 40ml of 0.25% bupivacaine with butorphanol (25mcg/kg) and group F (n=30) received 40ml of 0.25% bupicaine with fentanyl (1mcg/kg). Onset and duration of sensory block (pinprick) and motor block (Lovett's rating scale), hemodynamic parameters, postoperative analgesia and side effects were noted in each group. Results: The mean time of onset of sensory block was earlier in group B (2.29±0.62 min) as compared to group F (7.53±2.24 min) in group B. The mean time of onset of motor block was also rapid in group B (4.13±0.78 minutes) than in group F (9.98±2.94 minutes). The mean duration of motor block was longer in group F (9.73±2.48) hours as compared to group B (7.15±2.20) hours in group A. Post-operatively at the end of 10 hours patients in group F were having discomforting pain (65%) as compared to group B who were having distressing and horrible pain (50%) as evaluated by Mc Gill pain questionnaire. Both the groups were hemodynamically stable, no side effects were noted. Conclusions: Onset of sensory and motor blockade was rapid in group B, however group F showed longer lasting motor block and postoperative analgesia. Both groups were hemodynamically stable and without any side effects.

A bstract Background Delirium is a common, under-recognized, and often fatal condition in critically ill patients, characterized by acute disorder of attention and cognition. The global prevalence varies with a negative impact on outcomes. A paucity of Indian studies exists that have systematically assessed delirium. Objective A prospective observational study designed to determine the incidence, subtypes, risk factors, complications, and outcome of delirium in Indian intensive care units (ICUs). Patients and methods Among 1198 adult patients screened during the study period (December 2019–September 2021), 936 patients were included. The confusion assessment method score (CAM-ICU) and Richmond agitation sedation scale (RASS) were used, with additional confirmation of delirium by the psychiatrist/neurophysician. Risk factors and related complications were compared with a control group. Results Delirium occurred in 22.11% of critically ill patients. The hypoactive subtype was the most common (44.9%). The risk factors recognized were higher age, increased acute physiology and chronic health evaluation (APACHE-II) score, hyperuricemia, raised creatinine, hypoalbuminemia, hyperbilirubinemia, alcoholism, and smoking. Precipitating factors included patients admitted on noncubicle beds, proximity to the nursing station, requiring ventilation, as well as the use of sedatives, steroids, anticonvulsants, and vasopressors. Complications observed in the delirium group were unintentional removal of catheters (35.7%), aspiration (19.8%), need for reintubation (10.6%), decubitus ulcer formation (18.4%), and high mortality (21.3% vs 5%). Conclusion Delirium is common in Indian ICUs with a potential effect on length of stay and mortality. Identification of incidence, subtype, and risk factors is the first step toward prevention of this important cognitive dysfunction in the ICU. How to cite this article Tiwari AM, Zirpe KG, Khan AZ, Gurav SK, Deshmukh AM, Suryawanshi PB, et al . Incidence, Subtypes, Risk factors, and Outcome of Delirium: A Prospective Observational Study from Indian Intensive Care Unit. Indian J Crit Care Med 2023;27(2):111–118.