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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 (SpO2/FiO2 <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 SpO2/FiO2 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.

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BACKGROUND: The study evaluated the effect of intra-articular injections of ketamine and 25% dextrose with triamcinolone acetate (TA) and hyaluronic acid (HA) on joint pathology and pain behavior in monosodium iodoacetate (MIA)-induced osteoarthritis (OA) in experimental mice. METHODS: In phase I, the MIA-induced OA model was standardized. In phase II, mice were divided into three groups: disease controls (DC), ketamine 12 mg/kg (K12) and ketamine 24 mg/kg (K24) to select an effective dose of ketamine for phase III. In phase III, the groups were: DC, normal controls (NC), K24, 25% dextrose (D25) - 10 µL, TA 6 mg/kg, and HA - 3.5 mg/kg. The effect of ketamine was compared with the standard drugs - TA and HA. In phases II and III, after 7 days following the induction of OA, animals were subjected to weekly behavioral tests and biweekly drug administration from week 2 to week 4. Subsequently, after 4 weeks knee joint samples were collected and sent for histopathological evaluation to a veterinary pathologist. RESULTS: In phase I, the DC group showed significant OA changes as compared to NC on knee joint histopathology scoring. In phase II, all the behavioral tests and knee joint histopathology results demonstrated a significant improvement with K24 as compared to DC. In phase III, significant differences were found between DC vs. HA, DC vs. D25, DC vs. K24, K24 vs. TA, HA vs. TA for open field test and hot plate test (p<0.001), whereas HA and ketamine showed comparable results for these tests. There was a significant improvement in D25, TA and K24, HA groups as compared to DC in histopathology scores, (p<0.05). CONCLUSIONS: The NMDA antagonist effect of ketamine and the proliferative effect of 25% dextrose showed a reduction in pain and disease activity in the OA model.

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BACKGROUND: The prevalence of diabetes in the population of patients presenting with coronary artery disease continues to rise. The aim of this study was to assess whether high Glycosylated hemoglobin (HbA1c) was associated with adverse outcomes in patients undergoing elective coronary artery bypass grafting. METHODS: A retrospective observational study on prospectively collected data in 4,678 patients undergoing elective, isolated coronary artery bypass graft procedures in a single institution over a 4-year period was conducted. Patients were grouped into those with adequate preoperative control of hyperglycemia (HbA1c <6.5%) and those with suboptimal control (HbA1c ≥6.5%). Multivariable analysis using HbA1c as a binary independent variable was undertaken in the whole group. A subgroup analysis in diabetic patients and in nondiabetic patients was performed. The effect of HbA1c on outcomes at higher levels (HbA1c ≥8.0% and HbA1c ≥9.0%) was also assessed. RESULTS: A total of 4,678 patients (mean age, 58.8; male, 4,254) were included in the study. HbA1c was less than 6.5% in 2,476 (52.93%) patients and 6.5% or higher in 2,202 (47.07%) patients. On multivariate analysis, there was no difference in mortality rates between the groups (odds ratio, 1.36; 95% confidence interval [CI], 0.95 to 1.953; p = 0.08). Overall, an HbA1c of 6.5% or higher was an independent risk factor for respiratory complications (odds ratio, 1.05; 95% CI, 1.008 to 4.631; p = 0.01) and sternal dehiscence (odds ratio, 2.161; 95% CI, 1.008 to 4.63; p = 0.04). An association between HbA1c levels and adverse outcomes was not seen in nondiabetic patients. No additional adverse postoperative complications were seen with increasing HbA1c levels (HbA1c ≥8.0% and HbA1c ≥9.0%). CONCLUSIONS: An HbA1c level of 6.5% or higher in patients presenting for coronary artery bypass grafting was associated with a significant increase in the incidence of deep sternal wound infection and respiratory complications.

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