Background: To evaluate the role of ultrasound (US) in the assessment of the airway and to determine whether US has the potential to serve as effective, noninvasive and less time-consuming method for the diagnosis of difficult intubation in ICU patients. Patients and methods: This cross-sectional study was carried in 152 critically ill patients who underwent intubation in the ICU from December 2022 to April 2024. Prior to intubation thyromental height (TMH) and hyomental distance ratio (HMD-R) was measured using a scale and distance from skin to hyoid bone (SHB) and distance from skin to thyrohyoid membrane (STM) was measured using a US. Direct laryngoscopy was performed using a Macintosh blade, and the Cormack–Lehane (CL) grade was noted without external laryngeal manipulation. The laryngoscopy was classified as easy (CL Grade I and II) or difficult (CL Grade III and IV). The number of attempts at intubation, need for alternative difficult intubation approaches or inability to secure the airway was also noted. Results: The incidence of difficult airway was 17.76%. The success rate for first-attempt intubation was 96.7%. Based on the receiver operating characteristic (ROC) curve analysis cut-off value of 1.97 cm [95% confidence interval (CI), 0.949–0.996, area under the curve (AUC), 0.972] for anterior soft tissue thickness from the skin to thyrohyoid membrane distinguished the difficult intubation group from the easy intubation group, with a sensitivity of 96.3% and specificity of 86.4%. For the hyoid bone level, a cut-off value of 0.905 cm (95% CI, 0.706–0.887, AUC, 0.797) had a sensitivity of 74.1% and specificity of 74.4%. Anterior soft tissue thickness from the skin to thyrohyoid membrane was a better predictor of a difficult airway. There was a significant correlation between clinical airway assessments and US airway assessments. Conclusion: Point-of-care US can serve as an independent tool for assessing the airway in intensive care unit (ICU) patients, with anterior soft tissue thickness from skin to thyrohyoid membrane being a superior predictor. Combined models of sonographic and clinical tests could enhance the diagnostic value for identifying difficult intubation cases in ICU patients.

Background: Enhanced recovery is currently considered to be the treatment of various elective major surgeries. Enhanced recovery after surgery (ERAS) includes applying various perioperative measures, strategies, and active participation of patients in the recovery process. Materials and methods: A quasi-experimental study was conducted in the surgical units of a hospital in Karnataka, India. Data were collected from patients undergoing elective abdominal surgery (n = 142). Psychological (anxiety) and physiological outcomes (vital capacity, pulse, respiration, and blood pressure) were assessed in experimental and treatment-as-usual groups on preoperative day 1 (2 days before surgery) and preoperative day 2 (1 day before surgery). Results: The results showed a significant decrease in the state-anxiety scores in the experimental group than in the treatment-as-usual group (p < 0.05). Physiological outcomes such as pain, pulse, respiration, and blood pressure showed a significant decrease in the experimental group than the treatment-as-usual group (p < 0.05). Vital capacity was significantly increased in the experimental group and decreased in the treatment-as-usual group in the postoperative days (p < 0.05). A significant decrease in the length of postoperative stay was seen in the experimental group than in the treatment-as-usual group (p = 0.001). In the experimental group, there were less postoperative complications than in the treatment-as-usual group. Conclusion: Enhanced recovery is considered to be the treatment for various elective major surgeries. It is an essential responsibility of healthcare professionals to improve postoperative outcomes by reducing complications and length of postoperative hospital stay.

Background: Glycemic variability (GV) is the third domain of sepsis-induced dysglycemia, after hyperglycemia and hypoglycemia, potentially leading to adverse outcomes. This study analyzed the association of GV with in-hospital mortality and length of stay (LOS) in non-diabetic sepsis patients. Materials and methods: In this prospective observational study, non-diabetic sepsis patients were followed till day 14 of hospital stay, and blood glucose levels were assessed by finger-prick method (seven times per day) daily; clinico-laboratory and GV parameters [standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic excursion (MAGE)] were assessed on days 1, 3, 5, 7, 10, and 14 of admission. Results: Two hundred thirteen patients were screened and 80 (mean age 45.6 ± 15.37 years; 50% men) were included in the final analysis. Patients with in-hospital mortality had significantly higher GV when compared to patients without in-hospital mortality [SD: 37.57 vs 25.21, adjusted odds ratio (aOR) 1.13, 95% confidence interval (CI) 1.02–1.24, p = 0.013; CV: 24.91 vs 16.88, aOR 1.19, 95% CI: 1.03–1.38, p = 0.016; MAGE: 73.13 vs 48.03, aOR 1.05, 95% CI: 1.01–1.11, p = 0.014], independent of illness severity (APACHE II), mean blood glucose and hypoglycemia on multivariate regression analysis. There was no significant correlation between GV and LOS. Multivariate analysis showed a significant independent association between CV and ventilator requirement (aOR 1.15, 95% CI: 1.03–1.29, p = 0.017) and between SD and need for renal replacement therapy (aOR 1.04, 95% CI: 1–1.09, p = 0.044). Conclusion: This study demonstrated that GV is independently associated with increased in-hospital mortality in non-diabetic sepsis patients. Further studies are required to investigate whether targeting lower GV in septic patients would translate to better outcomes. Clinical significance: Glycemic variability in sepsis is controversial, with discordant results and a paucity of studies on the Indian population in the literature. Despite blood sugar monitoring being routinely done in sepsis patients, GV is rarely measured and the results of our study indicate that it may be worthwhile to estimate GV in sepsis. This may aid in identifying a subset of patients with increased mortality risk, who may benefit from intensive glucose monitoring and modification of insulin regimen.

Background: Carbapenem-resistant Enterobacterales (CRE) infections pose a significant global public health threat. We aimed to assess the risk variables, clinical characteristics, and outcomes of CRE-caused infections in criticalcare patients. Patients and methods: This prospective study enrolled 181 adult patients infected with Enterobacterales in the intensive care unit (ICU). Patients underwent clinical assessment and monitoring throughout their ICU stay. Carbapenem resistance was identified through antibiotic susceptibility testing and multiplex molecular detection of carbapenemase-encoding genes. Results: The mean age of patients was 67.99 ± 12.89 years, with 71.3% being males. Of 181 patients, 111 (61.3%) were found to have CRE infections, including 39 Klebsiella pneumoniae and 31 Escherichia coli isolates. The CRE isolates showed the predominance of the OXA-48 (74.8%), followed by the NewDelhi Metallobetalactamase (NDM) carbapenemase genes (20.7%). The risk factors associated with CRE infection included high sequential organ failure assessment (SOFA) score, prolonged length of stay (LOS) in ICU, prior use of broad-spectrum antimicrobials, hemodialysis, plasma exchange, and prolonged mechanical ventilation. Carbapenem-resistant Enterobacterales infections significantly required longer LOS, more need for mechanical ventilation, and exhibited lower rates of bacterial elimination than carbapenem-susceptible Enterobacterales (CSE) infections. The type of resistance gene did not significantly influence the mortality rate among CRE patients. The successful treatment of OXA-48-positive CRE showed a strong correlation with tigecycline and colistin antibiotics. Conclusion: Carbapenem-resistant Enterobacterales infection in ICU patients was associated with adverse outcomes. Identification of high-risk patients is essential for early diagnosis and appropriate management. Therefore, it is crucial to improve infection control methods and implement antimicrobial stewardship to avoid spreading infections.

Aim and background: To assess the efficacy and safety of Ibutilide infusion for cardioversion of atrial fibrillation (AF) or flutter (AFL) to sinus rhythm. Materials and methods: This open-label, multicenter phase IV study was conducted at six sites across India. The study enrolled 120 patients (108 with AF, 12 with AFL), each receiving up to two, 10-minute intravenous doses of 1.0 mg Ibutilide. The primary endpoints were the proportion of patients achieving cardioversion and the mean time taken to achieve cardioversion. Secondary endpoints included the proportion of patients maintaining sinus rhythm at 24 hours and the incidence of adverse events. Results: The cardioversion rate at 4 hours post-Ibutilide infusion among 120 patients was 65.83% (n = 79), with an average conversion time of 35.12 ± 36.71 minutes. At 24 hours, 85 patients (70.8%) had successful cardioversion, with a mean time of 107.24 minutes. The majority of patients (71.76%) had achieved cardioversion within 30 minutes. Of the 85 patients who achieved successful conversion, 82 (68.3%) maintained sinus rhythm at 24 hours. A total of 66 patients (55%) achieved cardioversion with the first bolus whereas 19 (15.8%) needed a second bolus. Atrial fibrillation patients had a higher conversion rate (75%) compared to AFL patients (33%). A total of 10 adverse events were recorded in eight patients (6.67%), including nausea, headache, palpitations, and bradycardia. Three severe cardiac events, one case of ventricular tachycardia, and two of tachycardia necessitated discontinuation of Ibutilide. No fatalities or serious adverse events (SAE) were reported. Conclusion: Ibutilide was found to be effective and well-tolerated for rapid restoration of sinus rhythm in patients with AF or AFL. Clinical Trial Registry of India: CTRI/2018/01/011248.

Aim and background: Hyperglycemia is a serious condition and associated with an increased risk of complications and mortality in both critically ill and non-critically ill people. Improvement in the glycemic level reduces the length of hospital stay, systemic infections and short- and long-term mortality. The aim was to test the effectiveness of insulin degludec vs insulin glargine and regular insulin in controlling blood sugar in patients with critical hyperglycemia. Materials and methods: Using random control trial, the patients were randomly divided into three equal groups—group R, group G and group D. Each group included 30 patients. Group G was managed using regular insulin together with an insulin glargine. Group D was managed using regular insulin together with an insulin degludec. However, group R was managed using only regular insulin. Results: The incidence of hypoglycemia was statistically more significant in the group of regular insulin than in groups G and group D with a p-value 0.0069. There was no statistically significant difference between the three groups regarding the frequency of hypoglycemia. Conclusion: Ultra-long-acting insulin can effectively control random blood sugar (RBS) with a decrease in the total dose of insulin used. It is recommended that using insulin degludec is a safe and effective alternative to regular insulin for glycemic control in critically ill patients.

Background: Traumatic brain injury (TBI) in children can lead to grave consequences. The mechanism, mode, and management of pediatric neurotrauma are different from adult neurotrauma, and there is a growing demand to study the clinicoepidemiology of pediatric TBI. Objective: To explore the clinicoepidemiological profile and outcome of pediatric neurotrauma. Methods: This single-center retrospective study was conducted at a tertiary referral hospital in the PICU involving children (1 month to 18 years) sustaining TBI (2012–2022). Demographic, clinical, and laboratory details at the onset of admission were collected. Predictors of mortality were compared between survivors and non-survivors. Results: Demographic, clinical, and laboratory data of 316 children with traumatic brain injuries at admission were collected and analyzed. The median (IQR) age was 72 months (36–132 months), with 68% of the cohort being male. The majority of the study population (49.1%) was under the age of 5 years. Injury from a fall was the most frequent mechanism of injury (53.5%), followed by road traffic accidents (5%). More than half of the study population suffered mild-TBI (55%). The overall mortality was 8.9% (28/316), and it was highest in the severe TBI group (31.6%) and under-5 years population (42.9%). Lower pediatric trauma score (PTS) (AOR: 0.52; 95% CI: 0.34–0.82) and polytrauma were significantly associated with mortality (AOR: 4.61; 95% CI: 1.02–20.86). Conclusion: Traumatic brain injury is a significant concern in the pediatric population, particularly those under the age of 5 years. Lower PTS and polytrauma predicted poor outcome.

Aim and background: Fluid resuscitation is the first-line treatment for patients with diabetic ketoacidosis (DKA). However, the optimal choice of resuscitative fluid remains controversial. This study aims to evaluate the impact of balanced electrolyte solution (BES) compared to 0.9% sodium chloride (NS) on various physiological and clinical outcomes in adult DKA patients. Materials and methods: An extensive search of electronic databases, including Embase, PubMed, Cochrane Library, Web of Science, and Google Scholar, was conducted to select studies that directly compared BES and NS in adult DKA patients. This systematic review and meta-analysis included nine studies, comprising both randomized controlled trials and retrospective studies. Combined estimates were expressed as mean differences (MDs) with 95% confidence intervals (CIs). The primary outcomes were time to resolution of DKA and length of hospital stay. The secondary outcomes were post-resuscitation chloride and bicarbonate levels and adverse events. Results: No significant difference was observed between BES and NS in the time to DKA resolution (MD: –1.63; 95% CI: –7.66–4.41; p = 0.60) or length of hospital stay (MD: –0.07; 95% CI: –0.44–0.31; p = 0.73). However, BES resulted in significantly higher post-resuscitation bicarbonate levels (MD: 1.63; 95% CI: 0.86–2.39; p < 0.001) and lower post-resuscitation chloride levels (MD: –2.37; 95% CI: –3.56 to –1.19; p < 0.001). Conclusion: The use of BES is associated with improved post-resuscitation electrolyte balance and preventing hyperchloremic metabolic acidosis in DKA patients. While BES may offer some biochemical advantages, both BES and NS are safe for treating DKA.

Introduction: Delirium is a syndrome commonly seen in intensive care unit (ICU) patients. It is characterized by acute changes in mental status, inattention, disorganized thinking, and altered level of consciousness. Due to its higher prevalence in mechanically ventilated ICU patients, it is crucial to recognize it early and implement standardized evidence-based protocols for preventing it in regular practice. Objectives: To identify the benefits and effectiveness of nonpharmacological interventions for preventing delirium among critically ill patients admitted to the ICU. Methods: The preferred reporting items for systematic reviews and meta-analyses statement guidelines were followed. Two independent authors searched electronic and grey literature for systematic review and meta-analysis in the following databases: PubMed, Scopus, Web of Science, Cochrane Database of Systematic Reviews, and Google Scholar. Results: This umbrella review included 12 studies on delirium prevention interventions, excluding reviews, abstracts, case studies, and pharmacological interventions. Our finding shows that multicomponent strategies are the most promising intervention for preventing delirium. Inclusion of family participation is the most vital part, with flexible visitation to be included in delirium care protocols. Multidisciplinary approaches raise workloads among healthcare professionals through increased coordination, assessments, and documentation. Conclusions: Multicomponent interventions are regarded as the most effective among all nonpharmacological interventions for reducing and preventing delirium. Highlights: Delirium syndrome is preventable among mechanically ventilated patients. The study aims to identify the benefits and effectiveness of nonpharmacological interventions for preventing delirium among critically ill patients admitted to the ICU.