The use of personal protection equipment (PPE) is associated with physical and physiological derangements. Healthcare workers are at the forefront of the fight against COVID-19 and are continuously exposed to PPE. This editorial discusses a survey carried out by Jose et al. capturing the physical problems associated with PPE use.

Rapid sequence intubation (RSI) is generally done in the patients requiring intubation in the emergency room. These patients are often full stomach and are at the risk of regurgitation and aspiration leading to aspiration pneumonia. The incidence of aspiration pneumonia during RSI is not known as the term “RSI” is poorly defined and the diagnosis of aspiration pneumonia is often clinical and circumstantial.

Sepsis is the most common cause of mortality in non-cardiac ICUs. The quest for early diagnosis and treatment has led to the discovery of many biomarkers. In this issue, Abdelshafey et al. have evaluated presepsin, a novel biomarker for early detection of sepsis. Presepsin is formed by cleavage of N-terminal of soluble CD14 (sCD14) which is a member of the Toll-like receptors (TLRs). Studies have found a higher level of presepsin in septic patients and values above 946 ng/L correlated well with gram-negative bacterial sepsis.

Arterial blood gas (ABG) is an essential point-of-care test to identify the pH, metabolic, and respiratory status of critically ill patients. In addition, it provides useful information about co-oximetry, lactate, electrolytes, and other parameters. Studies show that it is widely prescribed but the impact of ABG result on clinical care is limited. Protocols addressing effective utilization of ABG can address and help in minimizing cost and complications.

Hemodynamic monitoring and categorization of patients based on fluid responsiveness is the key to decisions prompting the use of fluids and vasoactive agents in septic shock. Distinguishing patients who are going to benefit from fluids from those who will not is of paramount importance as large amounts of fluids used conventionally based on surviving sepsis guidelines may be detrimental. Noninvasive monitoring techniques for the assessment of various cardiovascular parameters are increasingly accepted as the current medical practice. Electrical cardiometry (EC) is one such method for the determination of stroke volume, cardiac output (CO), and other hemodynamic parameters and is based on changes in electrical conductivity within the thorax. It has been validated against gold standard methods such as thermodilution [Malik V, Subramanian A, Chauhan S, et al. World J 2014;4(7):101–108] and is being used more often as a point-of-care noninvasive technique for hemodynamic monitoring. EC is Food and Drug Administration approved and validated for use in neonates, children, and adults. A meta-analysis in 2016, including 20 studies and 624 patients comparing the accuracy of CO measurement by using EC with other noninvasive technologies, demonstrated that EC was the device that offered the most correct measurements. The article in the current issue of IJCCM by Rao et al. (2020) has extended the use of EC to categorize pediatric patients with septic shock into vasodilated and vasoconstricted states based on systemic vascular resistance and correlate the categorization clinically. The authors also studied the changes in hemodynamic parameters after an isotonic fluid bolus of 20 mL/kg was administered. This is a pilot prospective observational study of 30 patients, which has given an insight into physiological rearrangements following fluid administration in patients with septic shock.

Aim and objective: Our main objective in developing this consensus is to bring together a set of most agreed-upon statements from a panel of global experts that would act as a guide for clinicians working in neurocritical care units (NCCUs). Background: Given the physiological benefits of analgo-sedation in the NCCU, there is little information on their tailoring in the NCCU. This lack of evidence and guidelines on the use of sedation and analgesia in patients with neurological injury leads to a variation in clinical care based on patient requirements and institutional protocols. Review results: Thirty-nine international experts agreed to be a member of this consensus panel. A Delphi method based on a Web-based questionnaire developed with Google Forms on a secure institute server was used to seek opinions of experts. Questions were related to sedation and analgesia in the neurocritical care unit. A predefined threshold of agreement was established as 70% to support any recommendation, strong, moderate, or weak. No recommendations were made below this threshold. Responses were collected from all the experts, summated, and expressed as percentage (%). After three rounds, consensus could be reached for 6 statements related to analgesia and 5 statements related to sedation. Consensus could not be reached for 10 statements related to analgesia and 5 statements related to sedation. Conclusion: This global consensus statement may help in guiding practitioners in clinical decision-making regarding analgo-sedation in the NCCUs, thereby helping in improving patient recovery profiles. Clinical significance: In the lack of high-level evidence, the recommendations may be seen as the current best clinical practice.

Background: In the event of coronavirus disease-2019 (COVID-19) spread worldwide, frontline healthcare workers play a key role in the containment of this devastating pandemic, and to prevent the cross-transmission and gain confidence in battle with the pandemic, they are wearing personal protective equipment (PPE). Aim and objective: To explore the adverse health problems and skin reactions caused by the use of PPEs among the frontline nurses in the ICUs of COVID hospital. Materials and methods: A cross-sectional study was conducted using an online-based questionnaire assessing the physical problems, and adverse skin reactions of PPEs were sent among the 150 frontline nurses in ICUs of COVID hospital. The collected data were analyzed using descriptive statistics. Results: We got 137 valid responses from frontline nurses, and the most common adverse health effects expressed by them were headache (73.4%), extreme sweating (59.6%), and difficulty in breathing (36.7%); 91.7% complained about the fogging of the goggle. Majority of frontline nurses expressed nasal bridge scarring (76.64%) and indentation and pain on the back of the ears (66.42%) as the adverse skin reactions after wearing N95 masks. The common skin problems identified due to double gloving of latex gloves were excessive skin soakage with sweat (70.07%) and skin chapping (19%). The protective clothing caused minimal adverse reactions, and excessive sweating (71.53%) was the most reported. Conclusion: The healthcare workers wearing PPE for a prolonged period show significant adverse effects, so appropriate strategies should be taken to prevent the adverse effects by designing effective PPEs and education of preventive measures among healthcare workers.

Background: Securing definitive airway with minimal complications is a challenging task for high-volume emergency departments (ED) that deal with patients with compromised airway. Materials and methods: We conducted a prospective observational study between September 2019 and March 2020. Cohort of adults presenting to the ED requiring rapid sequence induction (RSI) were recruited to determine the prevalence and risk factors for the development of aspiration pneumonia(AP) in patients intubated in the ED. Results: During the study period, a total of 154 patients with a mean age of 44.5 years required RSI in the ED. Male (61%) predominance was noted among the study cohorts. We did not find any association between RSI performed in the ED and the risk of developing AP. The first attempt success rate of RSI was 76.7%, and 33(21.4%) patients had immediate adverse events following RSI. Rescue intubation was required for 11(7.1%) patients. The prevalence of AP following RSI in the ED was 13.4%. Endotracheal tube (ET) aspirate pepsin was positive in 45(29.2%) samples collected. The ET aspirate pepsin assay had low sensitivity (44.44%), specificity (73.53%), positive predictive value (18%), and negative predictive value (91%) in predicting the occurrence of AP. On multivariate logistic regression analysis, male gender (AOR: 7.29, 95%CI: 1.51–35.03, p = 0.013) and diabetes mellitus (AOR: 3.75, 95%CI: 1.23–11.51, p = 0.02) were found to be independent risk factors for developing AP. Conclusion: We identified male gender and diabetes mellitus to be independent predictors of risk of developing AP after RSI in the ED. ET aspirate pepsin levels proved to be neither sensitive nor specific in the diagnosis of AP.

Background and objectives: Aspiration-induced lung injury accounts for a significant proportion of acute pulmonary dysfunction. Few studies were conducted to study the use of early bronchoscopy in mechanically ventilated patients with aspiration pneumonitis. This study aimed at assessing the clinical impact of early bronchoscopy for removal of gastric fluid and solid particles in the first 24 hours of mechanical ventilation (MV) on the progression of aspiration, MV days, intensive care unit (ICU) stay, development of pneumonia, and ICU mortality. Materials and methods: The study was an open-label randomized control trial and included 76 adult subjects mechanically ventilated due to aspiration pneumonitis, half the subjects received early bronchoscopy in the first 24 hours after aspiration for removal of aspirated material and bronchoalveolar lavage sampling, the other half received standard treatment. Results: The intervention group had a significant reduction in the rate of development of pneumonia at 60.5 vs 81.6%, p = 0.043 through the first week of admission, the intervention group has a significantly better hypoxic index (HI), white blood count, clinical pulmonary infection score, lung injury score, and sepsis-related organ failure assessment (SOFA) score compared to the control group. Although there was a reduction in mechanical ventilation days and ICU mortality in the intervention group vs control group that difference did not reach statistical significance. Conclusions: Early bronchoscopy in mechanically ventilated patients with aspiration pneumonitis can be beneficial in improving respiratory functions and decreasing the incidence of development of aspiration pneumonia and may guide the de-escalation of antibiotic therapy.

Background: This study aimed at evaluating the role of presepsin in early identification of sepsis and prediction of mortality in intensive care unit (ICU) patients in comparison to systemic inflammatory response syndrome (SIRS) and quick sequential organ failure assessment (qSOFA) score. Materials and methods: Forty patients were selected randomly after admission to adult ICU. Data from emergency room (ER) triaging, and initial laboratory results were gathered to calculate qSOFA score, SIRS criteria, and SOFA score. Presepsin measurement was performed within 6 hours from ER triaging. The patients were categorized into sepsis and nonsepsis groups depending on the clinical and microbiological criteria and SOFA score changes. Results: Twenty-six patients were diagnosed as septic with an average age of 68.04 ± 18.60 years, while 14 patients were nonseptic with an average age of 51.71 ± 24.88 years. Presepsin with a cutoff value >640 pg/mL (area under the curve [AUC] of 0.848 {p < 0.001}) had a significant diagnostic accuracy of identifying septic cases with sensitivity of 73.08% and specificity of 92.86% as compared to the nonsignificant SIRS (AUC, 0.670; sensitivity, 69.23%; and specificity, 57.14%) or qSOFA (AUC, 0.652; sensitivity, 38.46%; and specificity, 78.57%) criteria. Prespsin with a cutoff value >640 pg/mL also significantly (AUC of 0.920 [p < 0.001]) predicted mortality with sensitivity of 100.0% and specificity of 66.67% compared to the nonsignificant SIRS (AUC, 0.540; sensitivity, 70.0%; and specificity, 43.33%) or qSOFA (AUC, 0.670; sensitivity, 60%; and specificity, 76.67%) criteria. Conclusion: Early presepsin measurement in ICU patients is more accurate in the diagnosis of sepsis and prediction of mortality as compared to SIRS or qSOFA score.

Background: Incontinence-associated dermatitis (IAD) is a potentially serious skin injury that can lead to pressure ulcers (PUs). Many studies have indicated the need for evidence to find the most effective skin care protocol to reduce the incidence and severity of IAD in critically ill patients. Aim and objective: To develop a need-based interventional skin care protocol on IAD after identifying the risk of developing IAD in critically ill patients and by assessing the nurse's knowledge and practice on IAD. Materials and methods: Quantitative research approach with an exploratory research design was adopted in the study. A total of 40 staff nurses and 100 patients were included. To assess the knowledge of staff nurses regarding IAD, a knowledge questionnaire was administered and the IAD prevention practice among staff nurses was assessed with the help of an observation checklist. The risk of IAD among 100 critically ill patients was observed by the investigator, using a perineal risk assessment tool. The obtained data were analyzed by using descriptive and inferential statistics. The protocol was developed by the researcher and it was validated by 5 experts. Results: The results revealed that most of patients (60%) had a high risk for development of IAD. Most of the nurses had poor knowledge (40%) and had poor practice in assessment, perineal area, and prevention of infection area. Hence considering all these aspects, a protocol was developed. Conclusion: The researchers developed a need-based skin care protocol to decrease the development of IAD.

Background: Critically ill patients are under stress, leading to a catabolic response and higher energy expenditure. The associated malnutrition leads to adverse outcomes. Aims and objectives: This study aims to assess the nutritional adequacy (>80% of prescribed calories) in mechanically ventilated (MV) patients and its effects on patients’ outcomes. It also aims to identify the causes of deviation from the nutrition prescription. Materials and methods: This is a prospective observational study involving all adult critically ill patients requiring MV for >48 hours. Patients were prescribed enteral nutrition (EN) targeted to achieve 25 kcal/kg (IBW) of energy and 1.2 g/kg of proteins daily. Standard polymeric formula feeds were initiated as continuous infusion as per the feeding protocol in the intensive care unit (ICU). Data were collected on demography, body mass index (BMI), indication for ICU admission, admission category, and admission APACHE II and SOFA scores, and nutritional risk was captured with mNUTRIC score. Nutritional data on type of feed initiated, amount of calories prescribed/achieved, time taken to initiate feeds, reasons for not starting/delay in the initiation of feeds, time taken to achieve the prescribed calories, and reasons for interruptions of feeds were collected. Primary outcome analyzed was adequacy of nutrition (>80% prescribed dose), and secondary outcomes analyzed were ventilator days and ICU LOS. Results: A total of 622 MV patients were analyzed. 36.1% of patients were at nutritional risk (mNUTRIC ≥5). 89% of patients received EN, and the time taken to start EN in these patients was 10 hours (6–20) (median [IQR]). Only 29.6% of patients achieved nutritional adequacy. Time taken for this was 36 hours (median). On average, patients on MV received 63% (1025 kcal) and 57% (41 g) of their prescribed calories and proteins, respectively. The most common reasons for withholding feeds were airway-related procedures (68.2%) followed by GI intolerance (15%). Frequent interruptions of EN, patients on >1 vasopressors, and surgical admissions were reasons for nutritional inadequacy. Nutritional adequacy had no impact on clinical outcomes. Conclusion: Despite following guidelines and feeding protocols, there exists a wide gap between prescribed nutrition and what is actually delivered in MV patients.

Background: Arterial blood gas (ABG) analysis is a common test ordered in critically ill patients. Often, it is performed very frequently without influencing patient care. Hence, we decided to check the utility of the ABG test in our intensive care unit (ICU). Materials and methods: The data of the previous day ABGs were captured by reviewing the chart in an online pro forma which was filled by the authors. Data relating to patient's details, who ordered ABGs, reason for ordering ABGs, and did the ABG influence patient's management were entered. A total of 985 ABGs were performed in 173 patients for 2 months which was analyzed. Results: Out of 985 ABGs, in 259 instances (26.29%), interventions were done after reviewing an ABG. The major interventions among these ABGs were ventilator settings adjustment in 134 ABGs (13.6%). A total of 790 ABGs were done routinely with no specific indication (80.20%), while doctors ordered one following an event for 195 ABGs (19.80%). Conclusion: Our data suggest that 80% of ABG tests were ordered as part of a routine test.

Background/Objective: Traumatic pneumothorax is an ominous condition necessitating urgent appropriate action. It is typically detected on chest X-rays; however, these may not be able to detect the presence of a subtle pneumothorax, especially in supine position. Lung ultrasound is emerging as a promising modality for detecting pneumothorax in trauma patients. The aim of our study was to compare ultrasound with supine chest radiography for the detection of pneumothorax in trauma patients. Materials and Methods: This was a prospective, single-blinded study carried out on 212 adult thoracoabdominal trauma patients who underwent ultrasound FAST and supine (AP) chest radiography. During the FAST sonography, ultrasound thorax was done to rule out pneumothorax. Only those cases were considered (118) in which the presence or absence of pneumothorax could be confirmed on CT done subsequently or where pneumothorax was confirmed by air escape on chest tube placement, wherever indicated, and the results were compared with sonographic and chest X-ray findings. Observation/Results: There were 48 true positives on CT/chest tube insertion. Among these, ultrasound was able to correctly detect pneumothorax in 43 patients, while supine chest X-rays correctly identified 33 cases. Sensitivity of ultrasound was 89.6 vs. 68.8% of supine chest radiography. Lung ultrasound also had a higher negative predictive value as compared to supine chest X-rays. Conclusions: Lung ultrasound is more sensitive in detecting traumatic pneumothorax than supine chest X-rays, in addition to having numerous other inherent advantages over chest radiography. It should be incorporated in the emergency assessment of thoracic trauma patients to rule out pneumothorax. Clinical significance: Lung sonography is more sensitive in detecting traumatic pneumothorax than supine chest X-rays. No added equipment is required, and the procedure can be carried out at the time of doing ultrasound FAST, thus saving precious time in trauma patients.

Objective: To study if protocolized monitoring of endotracheal tube (ETT) cuff pressure every 6 hours is better than adjusting endotracheal tube cuff inflation by the only bedside clinical assessment. Materials and methods: This was a single-center prospective randomized controlled study done between July 1, 2017 and March 31, 2019. Children between 1 month and 18 years, intubated with cuffed ETT by our trained doctors were included. After obtaining consent, patients were randomized into two groups, standard group (SG) and cuff pressure monitoring group (MG). Sample size was calculated with 80 patients in each group with a power of 80%, significance level (alpha 0.05 and beta 0.2). In the SG, ETT cuff inflation was adjusted by clinical assessment (bedside minimal leak technique and monitoring the percentage of leak displayed on ventilator display) at 6 hours interval. In the MG, cuff pressures were monitored by the device every 6 hours to maintain between 20 and 25 mm Hg. Results: Out of 543 mechanically ventilated children during the study period, 266 were eligible and randomized for study. During the study, 89 patients died and 17 were left against medical advice, leaving 80 patients in each group. Incidence of post-extubation stridor (PES), re-intubation rate, ventilator-associated pneumonia (VAP) rate, ventilator days, and length of pediatric intensive care unit (PICU) stay were analyzed and found no advantage of protocolized monitoring of cuff pressures in the reduction of any of the above variables. Conclusion: Our findings if confirmed by large multicentric studies can bring an end to routine ETT cuff pressure measurements and emphasize more on clinical assessment. Clinical trial registry (CTRI/2019/05/019098).

Aim: To evaluate the utility of noninvasive electrocardiometry (ICON®) for hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock. Materials and methods: Pilot prospective observational study in a 12-bedded tertiary pediatric intensive care unit (PICU) in children aged between 2 months and 16 years with unresolved septic shock after a 20 mL/kg fluid bolus. Those with cardiac index (CI) <3.3 L/min/m² and systemic vascular resistance index (SVRI) >1600 dyn sec/cm⁵/m² were classified as vasoconstrictive shock–electrocardiometry (VCEC) and those with CI >5.5 L/min/m² and SVRI <1000 dyn sec/cm⁵/m² as vasodilated shock–electrocardiometry (VDEC). Fluid responsiveness was defined as a 10% increase in CI with a 20 mL/kg fluid bolus. Sepsis-induced myocardial dysfunction (SMD) was diagnosed on echocardiography. Outcomes studied included clinical shock resolution, length of PICU stay, and mortality. Results: Thirty children were enrolled over 6 months with a median (interquartile range) age and pediatric risk of mortality (PRISM) III score of 87(21,108) months and 6.75(1.5,8.25), respectively; 14(46.6%) were boys and 4(13.3%) died. Clinically, 19(63.3%) children had cold shock and 11(36.7%) had warm shock; however, 16(53.3%) children had VDEC (including five with clinical cold shock) and 14(46.7%) had VCEC using electrocardiometry. Fluid responsiveness was seen in 16(53.3%) children, 10 in the VCEC group and 6 in the VDEC group. In the VCEC group, the responders had a significant rise in CI and a fall in SVRI, while the responders in the VDEC group had a significant rise in CI and SVRI. Fluid responders, compared to nonresponders, had a significantly higher stroke volume variation (SVV) before fluid bolus (24.1 ± 5.2% vs. 18.2 ± 3.5%, p < 0.001) and a higher reduction in SVV after fluid bolus (10.0 ± 2.8% vs. 6.0 ± 4.5%, p = 0.006), higher lactate clearance (p = 0.03) and lower vasoactive-inotropic score (p = 0.04) at 6 hours, higher percentage of clinical shock resolution at 6 (p = 0.01) and 12 hours (p = 0.01), and lesser mortality (p = 0.002). Five (16.6%) children with VCEC had SMD and were less fluid responsive (p = 0.04) with higher mortality (p = 0.01) compared to those without SMD. Conclusions and clinical significance: Continuous, noninvasive hemodynamic monitoring using electrocardiometry permits hemodynamic categorization and assessment of fluid responsiveness in pediatric septic shock. This may provide real-time guidance for optimal interventions, and thus, improve the outcomes.

Stroke ranks the fourth leading disease causing adult mortality and disability. D-dimer (D-D) is the ultimate product of plasmin-mediated degradation of fibrin-rich thrombi. D-D is a simple readily accessible biomarker employed within the diagnostic algorithms for the exclusion of venous thromboembolism. The correlation between D-D infarct size in MRI brain, APACHE II score, and the National Institute of Health Stroke Scale (NIHSS) score in critically ill acute stroke patients has not been fully investigated before. Objective: We aimed to investigate the diagnostic and prognostic value of elevated plasma D-D in critically ill patients admitted with acute cerebrovascular accidents. As far as we know, we are the first to investigate the correlation between plasma D-D levels and the ischemic lesion size in MRI brain and also APACHE II score and NIHSS in critically ill acute ischemic cerebrovascular patients. Setting and participants: A prospective, observational cohort study inside the Critical Care Medicine Department. Thirty patients with AIS were enrolled additionally to 1 healthy age- and sex-matched controls. Interventions: We employed particle-enhanced, immunoturbidimetric assay to detect plasma D-D concentrations. D-D levels D0 and D1 were measured upon admission and 24 hours later, respectively. We reviewed the patient's health records; additionally, demographic, clinical, laboratory, and neuroimaging information was abstracted. Results: D-D concentrations were significantly higher in acute stroke patients compared to healthy controls. ROC curve analysis showed that elevated D-D level more than 310 ng/mL can predict infarct lesion size >1.5 cm in diffusion-weighted MRI brain with sensitivity and specificity (100 and 83%, respectively) and also admission D-D (D0) at cutoff concentration 350 ng/mL and D1 at cutoff value 370 ng/mL are predictors of complicated course with sensitivity and specificity (100 and 84.6%, respectively). There was no significant difference between D0 and D1 D-D levels (p-value >0.05). Conclusion: The plasma D-D biomarker can be a simple readily available test reliable predictor of infarct lesion size >1.5 cm in DW-MRI and outcome in union with the common practice instrumental tests.

Objectives: The objective of this review was to compare the effectiveness of Colistin monotherapy and combination therapy for the treatment of multidrug-resistant gram-negative bacterial infections. Data sources: PubMed, Cochrane Library. Study eligibility, interventions, and exclusions: In this systematic review, we included all retrospective and prospective studies and randomized controlled trials (RCTs) that compared intravenous polymyxin monotherapy and combination therapy with any other antibiotic for treating multidrug-resistant infections. Studies using inhaled polymyxins with 5 or less than 5 patients were excluded. The primary outcome was 30-day all-cause mortality and if not reported at day 30 we extracted and documented the closest time point. Both crude outcome rates and adjusted effect estimates were extracted for mortality. Study appraisal, data extraction and synthesis: Search string used was “(Colistin OR polymyxin) AND (Enterobacteriaceae OR Klebsiella OR Acinetobacter OR Escherichia coli OR Pseudomonas) AND (random OR prospective OR retrospective OR cohort OR observational OR blind).” Thirty-nine studies were included in our analysis; out of which 6 RCTs were included and 9 studies used carbapenem as the adjunctive antibiotic. Each study was screened and reviewed for eligibility independently by two authors and data extrapolated on an Excel sheet. Results: The meta-analysis of polymyxin monotherapy vs. combination therapy in multidrug-resistant infections yielded an odds ratio (OR) of 0.81 (95% confidence interval [CI]: 0.65–1.01) with minimal heterogeneity (I² = 40%), whereas pooled analysis of this comparison in studies that included carbapenem as combination therapy yielded an OR of 0.64 (CI: 0.40–1.03; I² = 62%). Likewise, the pooled analysis of the RCTs yielded an OR of 0.82 (95% CI: 0.58–1.16, I² = 22%). All these showed no statistical significance. However, it was seen that polymyxin combination therapy was more effective in multidrug-resistant infections compared to polymyxin monotherapy. The effectiveness was more glaring when carbapenems were used as the combination drug instead of any other antibiotic and more so in many in vitro studies that used polymyxin combination therapy. Conclusion: Although statistically insignificant, it would be prudent to use polymyxin combination therapy to treat multidrug-resistant gram-negative bacilli (GNB) infection over monotherapy with preference to use carbapenem as the adjunct alongside polymyxins.

Cirrhotic patients with manifestations of the end-stage liver disease have a high risk for developing renal dysfunction even with minor insults. The development of renal dysfunction increases the morbidity and mortality of these patients. Causes of renal dysfunction in cirrhotics can be due to hepatorenal syndrome (HRS) or acute kidney injury (AKI) resulting from prerenal, renal, and postrenal causes. Development of pretransplant renal dysfunction has been shown to affect post-liver transplantation outcomes. Early detection and aggressive strategies for the prevention of further progression of renal dysfunction seem to decrease the morbidity and improve survival in this group of patients. This article aims to outline the pathogenesis of renal dysfunction in cirrhosis, etiological factors, and evaluation of renal dysfunction, strategies for aggressive therapy for renal dysfunction, the indications of renal replacement therapy (RRT) in this group of patients, and the various modalities of RRT with their merits and demerits. A thorough understanding of the pathogenesis, early detection, and aggressive corrective measures for AKI can prevent further progression. In conclusion, a good knowledge of treatment modalities available for renal dysfunction in cirrhosis and institution of timely interventions can significantly improve survival in this group of patients.

Background: Management of hypoxemia in patients with severe COVID-19 respiratory failure is based on the guideline recommendations for specific SpO₂ targets. However, limited data exist on systemic O₂ utilization. The objective of this study was to examine systemic O₂ utilization in a case series of patients with this disease. Patients and methods: Between March 24, and April 9, 2020, 8 patients intubated for severe COVID-19 respiratory failure had near-simultaneous drawing of arterial blood gas (ABG), central venous blood gas (cVBG), and central venous oxygen saturation (ScvO₂) at a mean of 6.1 days into hospitalization. Three patients were managed with indirect cardiac output (CO) monitoring by FloTrac sensor and Vigileo monitor (Edwards Lifesciences, Irvine, CA). The oxygen extraction index (OEI; SaO₂-ScvO₂/SaO₂) and oxygen extraction fraction (OEF; CaO₂-CvO₂/CaO₂ × 100) were calculated. Values for hyperoxia (ScvO₂ ≥ 90%), normoxia (ScvO₂ 71–89%), and hypoxia (ScvO₂ ≤ 70%) were based on the literature. Mean values were calculated. Results: The mean partial pressure of oxygen (PaO₂) was 102 with a mean fraction of inspired O₂ (FiO₂) of 44%. One patient was hyperoxic with a reduced OEI (17%). Five patients were normoxic, but 2 had a reduced OEF (mean 15.9%). Two patients were hypoxic but had increased systemic O₂ utilization based on OEF or OEI. Conclusion: In select patients with severe COVID-19 respiratory failure, O₂ delivery (DO₂) was found to exceed O₂ utilization. SpO₂ targets based on systemic O₂ utilization may help in reducing oxygen toxicity, especially in the absence of anaerobic metabolism. Further data are needed on the prevalence of systemic O₂ utilization in COVID-19.

Identification of neurological manifestations associated with SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) in patients with no or mild pulmonary infection proves to be a challenge. The incidence of neurological associations of COVID-19 may be small as compared with respiratory disease; however, in the present scenario with an increasing number of cases each day, the overall incidence of patients with neurological manifestations and their health-related socioeconomic impact might be large. Hence it is important to report such cases so that healthcare providers and concerned authorities are aware of and may prepare for the growing burden. The literature on primary neurological manifestations of COVID-19 is limited, and hence our case series is relevant in the current scenario. The most commonly reported neurological complications are cerebrovascular accidents, encephalopathy, encephalitis, meningitis, and Guillain-Barré syndrome (GBS). We present a series of seven cases with various neurological presentations and possible complications from this novel virus infection.

High-flow tracheal oxygenation (HFTO), a modification of high-flow nasal cannula (HFNC), has been used in tracheostomized patients but only rarely for weaning. We present two cases on prolonged mechanical ventilation (PMV) where HFTO assisted weaning.

Thiopurines by their glucocorticoid-sparing property help in maintaining remission for patients with inflammatory bowel disease (IBD), when glucocorticoids are reduced and withdrawn. However, due to bone marrow suppression, it cannot be used in various conditions where it is indicated. A 17-year-old patient presented with pancytopenia with neutropenic sepsis and alopecia after 3 weeks of starting azathioprine for her underlying Crohn's disease. Thiopurine S-methyltransferase (TPMT;*2, *3A, *3C) analysis resulted in a wild-type genotype, whereas homozygous Nudix hydrolase 15 (NUDT 15 C415T) variant was positive. Azathioprine was stopped immediately, and she was started on broad-spectrum antibiotics that led to some clinical improvements initially, but later on, the patient developed intestinal obstruction along with postoperative complications leading to death. In this report, we highlight a case of serious hematological toxicity associated with azathioprine use in a patient with Crohn's disease with homozygous NUDT 15 variant, thus favoring the implementation of a pharmacogenomic approach before starting azathioprine, particularly in the Asian population.

Approximately 5–6% of patients diagnosed to have COVID-19 infection present with severe hypoxemia requiring invasive ventilation or non-invasive ventilation (NIV). Additional oxygen to patients on NIV can be given by nasal prong or by connecting oxygen tubing directly to the O₂ pick-off port of the NIV mask or by connecting oxygen tubing to the single-limb circuit in between ventilator and patient. Dual oxygen therapy improves oxygenation in COVID-19 patients on NIV. This method may make the patient more comfortable, increase tolerance to NIV, increase the usefulness of NIV for moderate and severe COVID-19 acute respiratory distress syndrome (ARDS).

Bedside diagnosis of congenital heart disease is sometimes very difficult in patient presenting with respiratory distress in intensive care unit. However, an ECG can provide abundant information regarding its presence and its management. A 25-year-old female presented with sudden onset of respiratory difficulty and shortness of breath, following delivery one day back. Echocardiography could not be done as a poor echo window was obtained and patient could not lie down supine. However, ECG revealed right axis deviation, RBBB, and notching in the apex of the R wave in inferior leads 2,3,aVF (crochetage sign). This is directed to the presence of ASD, which was confirmed with echocardiography after stabilization of patient. We would like to illustrate the importance of simple bedside ECG finding of crochetage sign in the diagnosis of ASD when echocardiography is not possible or available in underdeveloped countries.