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The aim of this review was to update evidence for benefit of convalescent plasma transfusion (CPT) in patients with coronavirus disease 2019 (COVID-19). Databases were searched for randomized controlled trials (RCT) comparing CPT plus standard treatment versus standard treatment only in adults with COVID-19. Primary outcome measures were mortality and need for invasive mechanical ventilation (IMV). Twenty-Six RCT involving 19,816 patients were included in meta-analysis for mortality. Quantitative synthesis showed no statistically significant benefit of adding CPT to standard treatment (RR = 0.97, 95% CI = 0.92 to 1.02) with unimportant heterogeneity (Q(25) = 26.48, p = .38, I 2  = 0.00%). Trim-and-fill-adjusted effect size was unimportantly changed and level of evidence was graded as high. Trial sequential analysis (TSA) indicated information size was adequate and CPT was futile. Seventeen trials involving 16,083 patients were included in meta-analysis for need of IMV. There was no statistically significant effect of CPT (RR = 1.02, 95% CI = 0.95 to 1.10) with unimportant heterogeneity (Q(16) = 9.43, p = .89, I 2  = 3.30%). Trim-and-fill-adjusted effect size was trivially changed and level of evidence was graded as high. TSA showed information size was adequate and indicated futility of CPT. It is concluded with high level of certainty that CPT added to standard treatment of COVID-19 is not associated with reduced mortality or need of IMV compared with standard treatment alone. In view of these findings, further trials on efficacy of CPT in COVID-19 patients are probably not needed., (© 2023. The Author(s).)

Background and Aims: Cerebral oedema and increased intracranial pressure are associated with poor neurological outcomes in traumatic brain injury (TBI). This study aimed to examine the correlation between transcranial doppler (TCD) derived indices and computed tomography assessed cerebral oedema score in patients with TBI., Methods: This prospective observational study was conducted between April 2021 and December 2021 after approval from the University Research Ethics Committee (R75/2021) and registration with the clinicaltrials.gov (NCT04834453). Cerebral oedema on computed tomography (CT) imaging of the brain was scored as (0 = no cerebral oedema, 1 = mild cerebral oedema, 2 = moderate cerebral oedema, and 3 = severe cerebral oedema). The daily neurological assessment was performed using Glasgow coma scale score. TCD-based parameters, mean flow velocity (MFV), and pulsatility index (PI) in middle cerebral arteries were simultaneously obtained., Results: There was a significant negative correlation between MFV and cerebral oedema score (r = - 0.840, P <.001) and a significant positive correlation between PI and cerebral oedema score (r = 0.825, P <.001) on the seventh day of assessment. Significant differences were noted in MFV [53.17 ± 7.52 cm/s vs. 34.55 ± 3.35 cm/s] and PI [1.02 ± 0.16 vs. 1.46 ± 0.07] in patients with improvement and no improvement in cerebral oedema after seven days of TBI management., Conclusion: Bedside assessments of TCD-based parameters of MFV and PI correlate well with CT-based assessment of cerebral oedema in patients with TBI., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Anaesthesia.)

Background and Aims: Starting antibiotic therapy at the proper time is the cornerstone of the management of ventilator-associated pneumonia (VAP). However, using antibiotics for a long duration of therapy in intensive care leads to increased bacterial resistance, financial burden and adverse drug reactions. We hypothesised that lung ultrasound may have a role in guiding antibiotic discontinuation in patients with VAP that will help to reduce the antibiotic duration and decrease the resistance., Methods: This was a prospective blinded cohort study from October 2020 to September 2021 in which 62 VAP patients were recruited. Antibiotics were started, procalcitonin (PCT) level and clinical pulmonary infection score were estimated and lung ultrasound (US) was performed on day 1 and repeated on day 7. On day 7, discontinuation of antibiotics was recommended if the PCT level was <0.25 μg/L. A lung reaeration score was recorded., Results: Based on the PCT levels, antibiotics were discontinued in 40 patients. The computed tomography findings of VAP had improved in all. The ultrasound reaeration score showed a highly significant negative correlation with the PCT on day 7 (-0.718, P < 0.001). A cut-off of 5 for the US score showed a sensitivity of 92.5%, specificity of 95.5%, positive predictive value of 97.4% and negative predictive value of 87.5% in detecting a low PCT score on day 7., Conclusion: Lung US is a non-invasive and safe method that can be used to guide antibiotic therapy in VAP., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Journal of Anaesthesia.)

Introduction: The aim of this systematic review and meta-analysis was to determine the reliability of transcranial sonography as an alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients., Evidence Aquisition: The PubMed, EMBASE, Cochrane Library, Scopus and Web of Science databases were searched. Original studies evaluating brain midline shift in adult neurocritical patients using both transcranial sonography and computed tomography were eligible. Primary outcome measure was concordance between both methods as quantified in terms of concordance correlation coefficient. Secondary outcome measure was limits of agreement, defined as mean difference between sonography and computed tomography plus and minus 1.96 standard deviations., Evidence Synthesis: Twelve studies (574 patients, 689 examinations) were eligible. Ten studies (416 patients, 492 examinations) provided adequate data for evaluation of concordance. Pooling of effect sizes showed strong concordance between both methods (concordance correlation coefficient, 0.91; 95% CI, 0.87 to 0.94). Two missing studies were imputed and effect size was adjusted to 0.88 (95% CI, 0.81 to 0.93). Nine studies (442 patients, 571 examinations) provided adequate data for estimation of limits of agreement. Pooling of effect sizes showed a bias of -0.53 mm (95% limits of agreement, -1.22 to 0.16 mm). Four missing studies were imputed and bias was adjusted to -0.68 mm (95% limits of agreement, -1.31 to -0.04 mm)., Conclusions: Transcranial sonography may serve as reliable alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. Both methods have strong concordance with acceptably narrow limits of agreement.

Background and Aims: The proportion of patients undergoing living donor liver transplantation is high especially in countries without or with limited cadaver organ sharing programs. The aim of this study was to evaluate the post-hepatectomy effect of using N-Acetylcysteine (NAC) infusion in living donors undergoing donor hepatectomy., Methods: In a prospective randomised non-blinded study, 50 healthy donors were enrolled; following hepatectomy patients were randomised into 2 groups: Group NC receiving NAC 150 mg/kg diluted in 100 ml glucose 5% over 40 minutes, followed by NAC 12.5 mg/kg in 500 ml glucose 5% over 4 hours. This was followed by NAC 6.25 mg/kg for 2 post-operative days, Group C (Control group) received ringer acetate infusion at same rate for 2 days. The primary outcome was serum lactate levels. Secondary outcomes were liver function tests, serum creatinine and urine output on intensive care unit (ICU) admission (0 hr.), after 24 hours and 48 hours, length of ICU stay., Results: Our study revealed significant reduction in serum lactate in Group NC at 0, 24 and 48 hours compared to C group ( P = 0.017, 0.002, 0.014). INR values showed significant reduction after 48 hours in Group NC compared to Group C ( P = 0.049). Total Bilirubin, ALT, and Creatinine, urine output and ICU stay showed no statistical difference between the 2 groups., Conclusion: The NAC protocol is a safe, cost-effective tool for improvement of post hepatectomy liver function and early stabilisation of the metabolic profile., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Anaesthesia.)

Introduction: The aim of this review was to determine current evidence for the effect of therapeutic hypothermia (TH) on survival and neurological outcome in adults suffering cardiac arrest (CA)., Evidence Aquisition: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and NLM databases from 2000 to 2017 using the following terms: hypothermia, cooling, therapeutic, cardiac arrest, resuscitation, cardiopulmonary, CPR. Studies were eligible if they compared TH versus normothermic management in adult humans sustaining CA. Randomized controlled trials (RCT), pilot studies and observational trials were included., Evidence Synthesis: Ten studies involving 3259 patients were included in meta-analysis. Pooling all eligible studies showed a favorable effect for TH on survival and neurological recovery. However, sensitivity analysis for RCTs showed no benefit on either outcome, while observational trials showed benefit for neurological recovery with just marginally significant benefit regarding survival. Studies including patients with shockable rhythms demonstrated benefit for both outcome measures, while those including patients with any rhythms demonstrated benefit for neurological recovery but not for survival. TH did not benefit patients with non-shockable rhythms. Trials using external cooling favored TH regarding survival and neurological outcome but those using systemic cooling with or without external cooling did not show such benefit. When the overall incidence of complications was pooled, there was a statistically significant shift in odds ratio favoring normothermic management over TH., Conclusions: Evidence from RCTs suggests TH does not improve survival or neurological outcome, while observational trials favor TH over normothermia. TH may be attended with higher risk for complications.