The recently formulated guidelines by Khilnani GC et al. for the prescription of antibiotics for critically ill patients present an extensive compilation of evidence and recommendations. Despite their comprehensive nature, several inconsistencies need addressing. In this commentary, we delve into some of these discrepancies in the order in which they appeared in the guidelines, starting with the misrepresentation of “nonbronchoscopic bronchoalveolar lavage (BAL)” and “mini BAL” as different techniques when they are, in fact, identical. Secondly, the Centers for Disease Control and Prevention (CDC) in the year 2013 replaced the older, unreliable ventilator-associated pneumonia (VAP) definition with ventilator-associated events (VAE). This new VAE definition eliminates subjectivity in pneumonia diagnosis by focusing on objective criteria for ventilator support changes, avoiding dependence on potentially inaccurate chest X-rays and inconsistent medical record keeping. Thus, using the term VAP in the Indian guidelines seems regressive. Furthermore, the recommendation for routine anaerobic coverage in aspiration pneumonia is outdated and unsupported by current evidence. Lastly, while endorsing multiplex polymerase chain reaction (PCR) for pathogen identification, the guidelines fail to adequately address its limitations and the risk of overdiagnosis.

Background: It was initially believed that coronavirus disease-2019 (COVID-19) increased the risk of complications as well as mortality in obstetric patients. This study was done to analyze any difference in-patient admissions, indications and outcomes in the obstetric ICU before and during the COVID-19 pandemic. Materials and methods: A retrospective study of obstetric cases admitted to the intensive care unit over a period of 6 years was done. The 6-year period was divided into 2 groups, pre-COVID-19 era (1st March 2017–1st March 2020) and the COVID-19 pandemic (2nd March 2020–2nd March 2023). The causes of admission, clinical characteristics, interventions required and outcomes of these patients were compared to see if there was any difference between the two periods and whether COVID-19 out obstetric patients at any additional risk as compared to patients admitted during the pre-COVID-19 period. Results: It was found that there was no significant difference in the number of admissions, associated problems, interventions required and outcomes of patients between the two groups. The data seemed to suggest that the number of abortions have increased post COVID-19, but further studies would be required for that. Conclusion: Obstetric patients did not seem to be at an increased risk for ICU admission due to SARS-CoV-2. Furthermore, no additional increase in morbidity or mortality was observed in those patients in comparison to those admitted before the pandemic.

Background: The classification of Berlin definition is based on the PaO_2/FiO₂ ratio, which has been found to have a poor association with mortality. Airway pressures reflect lung compliance and the settings of mechanical ventilators. In this study, we aimed to investigate the change in the severity of COVID-19-associated acute respiratory distress syndrome (ARDS) classification using [PaO₂/FiO₂ × PEEP] (P/FP) ratio compared to the traditional P/F ratio, and whether the P/FP ratio improves the predictive validity of in-hospital mortality. Methods: Our study sample included patients from the OXIVA-CARDS study. In this secondary analysis, we examined the oxygenation index and oxygen saturation index in relation to the P/FP ratio, as well as the risk of P/FP in mortality. We used Pearson's correlation to assess the relationships between various parameters. Receiver operating characteristic analysis with Youden's index was used to compare the prognostic value of the oxygenation index (OI), oxygen saturation index (OSI), P/F ratio, P/FP ratio, and SaO₂/FiO₂ ratio for predicting overall mortality. Multiple logistic regression was also performed to determine the impact of mean airway pressure (Pmean), S/F ratio, OI, and P/FP ratio on mortality. Results: A total of 201 patients (with 1543 measurements) were included in the analysis. Overall, 522 (34%) were reclassified into either more or less severe categories. Patients who were classified as having severe ARDS based on the P/FP ratio had significantly lower P/FP ratio, oxygenation index, and A-a O2 gradient as compared to those classified as having severe ARDS based on the P/F ratio (p < 0.05) at all levels of ARDS severity. On multivariate regression analysis, only the OI significantly impacted mortality (p < 0.05). Conclusion: We observed that the oxygen index and oxygen saturation index were more sensitive than the PaO_2/FiO₂ ratio and P/FP ratio. Additionally, only the oxygenation index had a significant impact on mortality. By including airway pressures in the calculation of the OI, its predictive ability is enhanced compared to using the S/F ratio, P/F ratio, or P/FP ratio. Highlights: The sensitivity of mortality by including Pmean is higher as compared to when only PEEP is taken into consideration. P/FP is a weak predictor of mortality as compared to OI and OSI.

In the intensive care unit (ICU), relentless demands of immediate action, reliance on high-tech equipment, and weight of an overwhelming workload can obscure the patient's humanity. The impact of this dehumanization and humanization may be significant, hence the study aimed to understand experiences of ICU patients and their families and seek to understand the outcomes of such encounters during the course of ICU care. The study was based on inductive-grounded theory approach. After taking informed consent, the investigators invited the participants for the interview, in the vernacular language that was audio recorded and field notes were taken. Under the two main dimensions of humanization and dehumanization, the data yielded four main themes and eight sub-themes. The themes were communication, infrastructure, experience of care and patient autonomy. The dehumanizing behaviors contributed to patients feeling disregarded and undermined their sense of dignity and worth. To our understanding, this is the foremost barrier to a heathy patient–physician relationship. However, by prioritizing humanization in the ICU, healthcare professionals can create a more compassionate and supportive environment. Hence, it is essential to implement strategies that improve patient and family support in the ICU, such as providing regular updates on the patient's condition, offering emotional support through counseling services, and involving families in the care decision-making process. These measures can help alleviate the vulnerability experienced by patients and their families during such challenging times.

Objectives: To study the efficacy of polymyxin B hemoperfusion in addition to standard care for sepsis treatment. Materials and methods: Fifty sepsis patients (mean age 54.26 ± 14.64 years; 68% males) were randomized to either the case group (n = 25; receiving Polymyxin B hemoperfusion in addition to standard ICU care) or the control group (n = 25; receiving standard ICU care only). The patients were followed up at frequent intervals of 6, 12, 24, 48, and 72 hours. A last follow-up on day 7 was done. The duration of the ICU stay and survival until day 7 were recorded. Changes in clinical and biochemical parameters were also noted and compared. Results: Mean sequential organ failure assessment (SOFA) scores at admission were 3.44 ± 1.00 and 2.80 ± 0.82, respectively, in cases and controls. Cases as compared to controls showed faster, and sustainable improvement. No significant difference between the two groups was seen for mortality at day 7. Conclusion: Polymyxin B hemoperfusion tends to show a faster recovery and a non-significant trend towards reduced mortality in ICU-admitted sepsis patients.

Background: Sepsis, a life-threatening condition characterized by a dysregulated immune response to infection, remains a significant clinical challenge globally. This study aims to enhance the predictive accuracy of existing sepsis severity scores by developing augmented versions of the SOFA and SAPS-III models, termed Pro-SOFA and Pro-SAPS, through the integration of biomarkers procalcitonin (PCT), neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP). Methods: This prospective observational study was conducted in the medical ICU of a tertiary care hospital in southern India from August 2022 to December 2023. A total of 301 adult patients suspected or confirmed to have sepsis were assessed for eligibility, with 171 patients completing the study. Demographic and clinical data were collected; SOFA and SAPS-III scores were calculated and augmented with PCT, NLR, and CRP to develop Pro-SOFA and Pro-SAPS models. The performance of these models was evaluated using Brier scores, AUC, and net reclassification index (NRI). Results: The augmented Pro-SOFA and Pro-SAPS models demonstrated superior predictive accuracy compared to their original counterparts. The Brier scores for Pro-SOFA and Pro-SAPS were 0.181 and 0.165, respectively, indicating better calibration than the original scores. The Pro-SAPS showed significant improvement over the original SAPS-III score (NRI = 0.50, SE = 0.14, p < 0.01). Similarly, Pro-SOFA outperformed the original SOFA (NRI = 0.49, SE = 0.13, p < 0.01). Conclusion and clinical significance: Integrating PCT, CRP, and NLR with SOFA and SAPS-III scores to develop Pro-SOFA and Pro-SAPS significantly improves the predictive accuracy for sepsis mortality and can thus potentially improve sepsis outcomes.

Background: This study examines the trends of procalcitonin (PCT), neutrophil-to-lymphocyte ratio (NLR), and sequential organ failure assessment (SOFA) scores in intensive care unit (ICU) sepsis patients from different infection sources. Elevations in PCT and NLR reflect infection severity and predict sepsis prognosis. Combining them may enhance diagnostic accuracy and prognostic capabilities, despite variations in cut-off values. The study emphasizes the significance of these biomarkers in improving sepsis management and patient outcomes. Materials and methods: This was a prospective observation study of ICU sepsis patients from different infection sources. Procalcitonin and NLR levels were measured on days 0, 2, and 4 of admission. Sequential organ failure assessment scores on these days were also analyzed. The cut-off values were obtained for predicting the prognosis of sepsis ICU patients. Results: The study included 100 sepsis patients with an equal distribution of males and females and a mean age of 72 years. Procalcitonin showed a significant decrease over time, while NLR initially increased before decreasing on day 4, and SOFA scores showed no significant changes. Deceased patients had significantly higher PCT and SOFA scores on days 2 and 4. Receiver operating characteristic curve analysis showed promising predictive results for PCT on day 4 and SOFA scores on days 2 and 4. Conclusion: Understanding the trends of PCT and NLR concerning the infection source can provide deeper insights into their diagnostic and prognostic capabilities. This comparative analysis of PCT, NLR, and SOFA score trends contributes to the improvement of patient outcomes through accurate assessment of sepsis severity and progression, early diagnosis, and timely intervention.

Background and objectives: Several respiratory complications have been described after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Materials and methods: Patients admitted to intensive care unit (ICU) after CRS and HIPEC during 10 years. Data recorded were: Demographic characteristics; severity of illness; complete blood sample; chest radiographs; type of cancer and extension; HIPEC drug and temperature; ICU and hospital stay; and mortality. Results: Of the 124 patients included, 67 patients (54.0%) presented respiratory complications: 56 (83.6%) acute respiratory failure, 25 (37.3%) pleural effusion, 13 (19.4%) atelectasis, and 3 (4.5%) other; only 1 (3.0%) developed pneumonia. They had higher severity scores at ICU admission. 1 patient required initiation of invasive mechanical ventilation during ICU admission due to pneumonia, and 1 patient needed placement of a pleural chest tube due to symptomatic pleural effusion. Only the need for a high fluid balance during surgery was correlated to the development of respiratory complications on multivariate analysis. Median ICU stay was 5 (4.0–5.0) days. ICU mortality was 0.8.0%. Conclusion: In our study, 54% of patients treated with CRS and HIPEC developed respiratory complications during the postoperative period. However, the majority of these complications were not severe and did not significantly impact mortality rates or hospital stays.

Background: The confusion assessment method for the intensive care unit (CAM-ICU) is a bedside tool to diagnose delirium in critically ill patients. This study aims to determine the reliability and validity of the Hindi version of CAM-ICU against the Diagnostic and Statistical Manual (DSM), fourth edition text revision (DSM-IV-TR), and DSM, fifth edition (DSM-5) criteria for diagnosis of delirium. Methods: Seventy-five Hindi-speaking consenting patients ≥18-year-old with Richmond Agitation Sedation Scale ≥−3 and an anticipated ICU stay > 48 hours were included. Patients with known severe mental illnesses, visual/hearing loss, neurological injury, burns, drug overdose, and Glasgow Coma Scale <9 at the time of screening were excluded. After 48 hours of ICU stay and ensuring at least 2 hours of sedative interruption, within a 4-hour period, two examiners independently assessed delirium using the Hindi version of the scale and an experienced psychiatrist assessed the patients independently and applied the DSM-IV-TR and DSM-5 criteria for diagnosing delirium. Time taken for CAM-ICU assessment, inter-observer reliability, sensitivity, specificity, and positive and negative predictive values were calculated. Results: The Cohen's κ value was 0.944 (p < 0.001). The Cronbach's α for observer 1 and observer 2 was 0.961 and 0.968, respectively. The sensitivity and negative predictive value of the tool was 100% with both DSM-IV-TR and DSM-5. The specificity was 90.2% and 92% and the positive predictive value was 82.8 and 86.2% with DSM-IV-TR and DSM-5, respectively. Conclusions: The Hindi version of CAM-ICU is a reliable and valid tool for the diagnosis of delirium in an ICU setting. Trial registration: The study was registered with the Clinical Trials Registry, India (CTRI) as per the research guidelines laid down by the Indian Council of Medical Research before enrolling the participants. (CTRI number- CTRI/2021/01/030471). The registration date was 14th January 2021. URL of registry is http://ctri.nic.in. Highlights: Delirium in the ICU is often undiagnosed due to unfamiliarity, lack of understanding of symptoms, non-availability of psychiatric consultation, and validated diagnostic tools in the native language of the patient. This study aims to find the reliability and validity of the Hindi version of CAM-ICU.

Background: The present study examined the duration of bronchodilation induced by nebulized glycopyrronium bromide (GB) and compared its effectiveness and incidence of any side effects with the combination of salbutamol and ipratropium bromide (SI) in critically ill mechanically ventilated chronic obstructive pulmonary disease (COPD) patients. Patients and methods: This prospective, observational study was conducted in mechanically ventilated adult patients of COPD (18–75 years). Data of two groups of patients were collected for 12 hours each for three consecutive days after the nebulization – Group I: those who received 25 µg of GB, and Group II: those who received 1.25 mg of levo-salbutamol and 500 µg of ipratropium by nebulization. Results: A significantly higher number of patients in group II had copious secretions. The mean static compliance was comparable at all time intervals, whereas the mean airway pressure was significantly lower in group II from 15 minutes to 4 hours post-nebulization. In group I, the onset of bronchodilation was 30 minutes on days 1 and 3, and 60 minutes on day 2, whereas, in group II, it was 60 minutes on days 1 and 2 and 30 minutes on day 3. In group I, bronchodilation was 10 hours on day 1 and 12 hours each on days 2 and 3, whereas in group II, bronchodilation was 4 hours on day 1 and 6 hours each on day 2 and 3. Conclusion: Compared with SI, GB nebulization resulted in lesser respiratory secretions, a longer duration of action in terms of lowered airway resistance, and no adverse effects like hypertension, tachycardia, or desiccation of respiratory secretions.

Background: Acute kidney injury (AKI) is a hidden complication among children within pediatric intensive care units (PICU). Aim: To evaluate the early predictive and diagnostic value of Urinary [TIMP-2]•[IGFBP7] to detect AKI in PICU patients. Methods: A case-control study was conducted on 112 children (72 admitted to PICU and 40 healthy controls) Urinary [TIMP-2]•[IGFBP7] was measured within 24 hours of PICU admission. Results: Acute kidney injury developed in 52 (72.2%) out of 72 critically ill patients. The AKI group had significantly higher serum creatinine, CRP, and pediatric sequential organ failure assessment score (pSOFA) score (p = 0.001, 0.01, and 0.001, respectively) and significantly lower estimated creatinine clearance (eCCl) (p = 0.001). Urinary [TIMP-2]•[IGFBP7] was significantly higher in the AKI group as compared with the non-AKI group (p = 0.007). The duration of the PICU stay was 1.8-fold higher in the AKI group (p = 0.004). At the time of study enrollment, 7 (13.5%) patients had normal initial eCCl. 26 patients (50.0%) fulfilled the “Risk,” 18 patients (34.6%) the “Injury,” 1 patient (1.9%) the “Failure” and 0 patient (0%) the “Loss” criteria. Nine (17%) patients progressed to the next higher pediatrics risk, injury, failure, loss, end-stage renal disease (pRIFLE) stage. Urinary [TIMP-2]•[IGFBP7] was significantly higher in the “Failure” stage followed by “Injury,” stage then the “Risk,” stage (p = 0.001). Hypovolemia/dehydration had the highest [TIMP-2]•[IGFBP7] values followed by sepsis. Urinary [TIMP-2]•[IGFBP7] was significantly increased in mechanically ventilated and patients who received inotropic medications. Conclusions: [TIMP-2]·[IGFBP7] was higher in AKI patients compared with non-AKI ones especially cases with hypovolemia and sepsis. It may predict severe morbidity and mortality because its higher levels in mechanically ventilated children and those on positive inotropic support.

Introduction: The care of critically ill patients involves communication and shared decision-making with families and determination of goals of care. Analyzing these aspects through electronic health records (EHRs) can support research in ICUs, associating them with outcomes. This review aims to explore studies that examine these topics. Methods: A scoping review was conducted through a systematic literature search of articles in PubMed, Web of Science, and Embase databases using MESH terms up to 2024, conducted in ICU settings, focusing on communication with families, shared decision-making, goals, and end-of-life care. Results: A total of 10 articles were included, divided into themes: Records and family, and records in quality improvement projects. Variables based on records with common characteristics were identified. Outcome analysis was performed through questionnaires to family members, healthcare professionals or by analyzing care processes. The studies revealed associations between family members’ perceptions and mental health symptoms and documented elements such as communication, therapeutic limitations, social and spiritual support. Studies evaluating quality communication improvement projects did not show significant impact on documented care, except for those that assessed improvements based on palliative care. Conclusion: The analysis of documented care for critically ill patients can be conducted from various perspectives. Processes amenable to improvement, such as communication with family members, definition of goals of care, limitations, shared decision-making, evaluated through EHRs, are associated with mental health symptoms and perceptions of families of critically ill patients. Documentation-based studies can contribute to improvements in patient- and family-centered care in the ICU.