Background. COVID-19 pandemic has become a global dilemma since December 2019. Are the standard scores, such as acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA) score, accurate for predicting the mortality rate of COVID-19 or the need for new scores? We aimed to evaluate the mortality predictive value of APACHE II and SOFA scores in critically ill COVID-19 patients. Methods. In a cohort study, we enrolled 204 confirmed COVID-19 patients admitted to the intensive care units at the Imam Khomeini hospital complex. APACHE II on the first day and daily SOFA scoring were performed. The primary outcome was the mortality rate in the nonsurvived and survived groups, and the secondary outcome was organ dysfunction. Two groups of survived and nonsurvived patients were compared by the chi-square test for categorical variables and an independent sample t-test for continuous variables. We used logistic regression models to estimate the mortality risk of high APACHE II and SOFA scores. Result. Among 204 severe COVID-19 patients, 114 patients (55.9%) expired and 169 patients (82.8%) had at least one comorbidity that 103 (60.9%) of them did not survive ( ). Invasive mechanical ventilation and its duration were significantly different between survived and nonsurvived groups ( and , respectively). Mean APACHE II and mean SOFA scores were significantly higher in the nonsurvived than in the survived group (14.4 ± 5.7 vs. 9.5 ± 5.1, , 7.3 ± 3.1 vs. 3.1 ± 1.1, , respectively). The area under the curve was 89.5% for SOFA and 73% for the APACHE II score. Respiratory diseases and malignancy were risk factors for the mortality rate ( and , respectively) against diabetes and hypertension. Conclusion. The daily SOFA was a better mortality predictor than the APACHE II in critically ill COVID-19 patients. But they could not predict death with high accuracy. We need new scoring with consideration of the prognostic factors and daily evaluation of changes in clinical conditions.

Objectives: This study will evaluate the main hypothesis that supplementation with vitamins A, B, C, D, and E significantly improves the severity and mortality rate in ICU patients with COVID-19. Trial design: This study is a randomized, single-blinded, two-arm (1:1 ratio) parallel group clinical trial. Participants: We are conducting this study in patients with COVID-19 admitted to intensive care units at the Imam Khomeini Hospital Complex in Tehran, Iran. The inclusion criteria are as follows: (1) aged between 20 and 60 years, (2) both male and female patients with COVID-19, (3) clinical or definitive diagnosis (using polymerase chain reaction (PCR) test), (4) patients have not participated in other clinical trials, and (5) no renal or hepatic abnormalities. The exclusion criteria are as follows: (1) patients with specific and rare viral diseases such as HIV and (2) patients who have been undergoing chemotherapy for the past month. Intervention and comparator: Duration of intervention: 7 days from randomization Intervention in the treatment group: Vitamin A 25,000 IU daily Vitamin D 600,000 IU once during study Vitamin E 300 IU twice daily Vitamin C is taken four times per day B vitamins are taken as a daily Soluvit [which included thiamine nitrate 3.1 mg, sodium riboflavin phosphate 4.9 mg (corresponding to vitamin B₂ 3.6 mg), nicotinamide 40 mg, pyridoxine hydrochloride 4.9 mg (corresponding to vitamin B₆ 4.0 mg), sodium pantothenate 16.5 mg (corresponding to pantothenic acid 15 mg), sodium ascorbate 113 mg (corresponding to vitamin C 100 mg), biotin 60 μg, folic acid 400 μg, and cyanocobalamin 5 μg] The control group will not receive any supplements or placebo. All supplements are made in Iran except for Soluvit (from Fresenius Kabi, New Zealand). Main outcomes: Weight, height, and BMI Severity of pulmonary involvement according to CT scan Respiratory support (invasive or non-invasive) Percentage of oxygen saturation (SpO2 level) Serum levels of WBC, CRP, ESR, IL6, IFN-G, and TNF-α The patient’s body temperature The presence or absence of involvement of organs other than the lungs (e.g., heart, liver, kidneys) Duration of hospitalization Mortality rate Randomization: At baseline, eligible patients were randomly assigned to a 1:1 ratio to one of two groups: intervention and control. Block randomization is used based on the gender of patients. Blinding (masking): Patients are unaware of being placed in the intervention or control groups after signing consent. All treatment staff will be aware of which group each of the patients is in due to the specific conditions of the ICU and the absence of placebo for the control group. Numbers to be randomized (sample size): The researchers plan to include 60 patients in total, with 30 patients in each group. Trial status: This is the first version of the protocol which started on April 2, 2020. Recruitment began April 2, 2020, and is expected to be complete by July 4, 2020. Trial registration: The Iranian Registry of Clinical Trials IRCT20200319046819N1. Registered on April 4, 2020 Full protocol: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol (Fig. 1, Table 1).

Improvement of predictive tools for recognition of airway edema is crucial for safe extubation and patient safety. This study aimed to evaluate the diagnostic accuracy of the Gargle test (GT) as a new test for assessing airway edema and predicting successful extubation in patients admitted to the intensive care unit (ICU). In this prospective observational study, patients underwent head and neck surgeries and admitted to ICU included. All the patients were weaned based on the same protocol.Quantitative Cuff Leak Test (CLT) and qualitative CLTwere first applied followed by GT with normal saline 0.9%. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. One hundred and eighteen (male 67, female 51) participated in this study. The agreement between GT and CLT was low (Kappa: quantitative CLT 0.07, qualitative CLT 0.21). The GT compared to CLT had higher sensitivity (33.3% vs 16.6%), specificity (96.3% vs qualitative CLT 92.8%, quantitative CLT 79.4%), PPV (33.3% vs qualitative CLT 11.11%, quantitative CLT 4.0%), NPV (96.3% vs qualitative CLT 95.4%, quantitative CLT 94.6%), and accuracy (92.92% vs qualitative CLT 88.98%, quantitative CLT 76.27%. The cut-off value for GT was estimated 16.5% (sensitivity 74.1% and specificity 60%). The GT is a simple accurate test and can be used as a new test in the ICU for recognition of airway edema and prediction of safe extubation in patients with head and neck surgeries.

Background. Pain control after operations is essential in decreasing the patient recovery period and potential morbidity. Prescribing opiates is very effective, but significant side effects accompany them. This study aims to examine the effect of local ketamine infiltration in decreasing pain intensity in patients undergoing transabdominal hysterectomy. Methods. In this double-blind, randomized, controlled clinical trial, a total of 92 patients undergoing transabdominal hysterectomy aged 3060years were selected and divided into two intervention and control groups randomly. For the intervention group, ketamine was injected subcutaneously into the incision site at a dose of 0.5mg/kg after the operation. In the control group, 5mg normal saline was used in the same method. Postoperative pain intensity was measured using the visual analog scale (VAS: 010). The pain score and dose of administered opioids were documented at 1, 2, 4, 6, 12, and 24hours and compared between the two groups. Results. Postoperative pain intensity was significantly lower in the intervention group than in the control group, except for hour 24. The mean amounts of administered opioids were significantly lower in the intervention group at hours 6 and 12, as well as the total amount of used opioids, and no significant side effects were documented. Conclusion. Local ketamine subcutaneous injection in the incisional site is effective and is a safe procedure for reducing pain scores in patients who underwent a transabdominal hysterectomy.

Background Improvement of predictive tools for recognition of airway edema is crucial for safe extubation and patient safety. This study aims to evaluate the efficacy of gargle test for assessment of airway edema and prediction of successful extubation in patients undergoing head and neck surgeries. Methods This is a prospective observational study on 118 patients that were undergone head and neck surgeries and been admitted to intensive care units. All the patients were weaned based on the same protocol. Initially, quantitative, and qualitative Cuff Leak Test were done and, the decision for extubation was made by employing them. Subsequently, gargling with purified water was implemented. Exclusion criteria were consisted of the impossibility of extubation due to reasons other than airway edema such as pneumonia. Independent sample t-test was applied to study the difference between quantitative variables between two groups, and Fisher’s exact test was used for categorical variables. P-value < 0.05 was determined as a significant difference between the variables. To investigate the relationship between these two tests, sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. Result One hundred eighteen were enrolled in this study. Sixty-seven patients (56.78%) male and 51 patients (43.22%) were female with a mean age of 54.7 ± 12.2 year. Due to surgical manipulations, and anatomical problems in the hypopharynx and larynx, 5 patients (4.2%) were not able to perform the gargle test. Six patients (5.1%) were facing extubation failure since they experienced respiratory distress and stridor. A measure of agreement (kappa) of gargle test with qualitative and quantitative CLT was low (K = 0.21, k = 0.07, respectively). The gargle test had higher specificity, negative predictive value (NPV), and accuracy compared to quantitative and qualitative CLT. Extubation failure in patients with positive gargle test was significantly lower than patients with negative gargle test (3.7% vs. 33.4 % respectively, P = 0.032). Conclusion The gargle test is simple, cheap, and does not require any equipment, and groups of nerves and muscles which control larynx function are being assessed in the gargle test. It provides better patients safety in difficult extubations.