Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries. In India, majority of deceased donations happen following brain death (BD). While existing legislation allows for DCDD, there have been only few reports of kidney transplantation following DCDD from India. This document, prepared by a multidisciplinary group of experts, reviews international best practices in DCDD and outlines the path for DCDD in India. Ethical, medical, legal, economic, procedural, and logistic challenges unique to India have been addressed. The practice of withdrawal of life-sustaining treatment (WLST) in India, laid down by the Supreme Court of India, is time-consuming, possible only in patients in a permanent vegetative state, and too cumbersome for day-to-day practice. In patients where continued medical care is futile, the procedure for WLST is described. In controlled DCDD (category-III), decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Families that are inclined toward organ donation are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand-down and return to the intensive care unit (ICU) without donation. In donation following neurologic determination of death (DNDD), if cardiac arrest occurs during the process of BD declaration, the protocol for DCDD category-IV has been described in detail. In DCDD category-V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the ICU. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and techniques, such as normothermic regional perfusion (nRP) and ex vivo machine perfusion, has been provided. The outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for successful execution of DCDD in India are described.

Aim and objective: Mental well-being is one of the most important aspects of health. Life-threatening situations such as diseases affect mental well-being. Mindfulness-based stress reduction (MBSR) program is an effective program for improving well-being. This study aimed to evaluate the effectiveness of MBSR programs on the mental well-being of patients with coronavirus disease-2019 (COVID-19). Materials and methods: This randomized controlled trial study was conducted in 2021. We used simple random sampling for recruiting 60 patients with COVID-19 and assigned them to the intervention and control groups. The intervention comprised eight sessions of the MBSR and was performed for the experimental group. The control group received routine postdischarge care. We used a self-report demographic and Ryff's Psychological Well-being Scale to collect data. To analyze the data, descriptive statistics and inferential statistics including Covariance, MANCOVA, and effect coefficient were used. The Significance level was considered lower than 0. 05. We used SPSS version 21 for data management. Results: The mean score of mental well-being in the intervention group was 56.76 ± 6.88 in the pretest stage and 80.76 ± 7.53 in the posttest stage, and that in the control group was 54.40 ± 10.31 in the pretest stage and 51.23 ± 10.08 in the posttest stage. There was no significant difference between the two groups before the intervention (p >0.05) but there was a significant difference (p <0.05) after the intervention. There was also a significant difference (p <0.05) between the dimensions of mental well-being before and after the intervention. Conclusion: According to our findings, it is recommend to use MBSR program in line with physical treatment for patients with COVID-19.

Background: The genus Providencia, earlier considered a rare pathogen, is now increasingly recognized as a notorious opportunistic pathogen capable of causing serious nosocomial infections, mainly urinary tract infections (UTIs). Treating these infections is an onerous task given the resistance seen in clinical strains to many currently available antimicrobials. The objective of the present study is to provide an overall view into the prevalence of Providencia spp. causing UTIs, their antibiotic susceptibility pattern, and respective clinical outcomes. Materials and methods: This is a retrospective observational study carried out in a tertiary care teaching referral hospital located in Jaipur, India from March 2021 to May 2021. All Providencia spp. strains isolated from urine samples were included in the study. Data were entered in Microsoft Office Excel worksheet. Results are presented in numbers and percentages. Results: Out of 1,261 urine samples processed in the laboratory during the study period, 426 were culture positive and the majority were gram-negative isolates and included Escherichia coli (46.0%) and Klebsiella spp. (28.0%). Providencia spp. was the fourth most common gram-negative pathogen (6.0%). The median age of patients was 65 years. The male:female ratio was 3:2 and maximum patients belonged to the 30–60-year age-group. Diabetes was the commonest associated comorbidity. All patients had an indwelling urinary catheter. Three (20.0%) patients succumbed to infections. Conclusion: Providencia is an opportunistic pathogen that cannot be neglected due to escalating antibiotic resistance. Effective infection control and antibiotic stewardship policies are required to prevent the development of further antibiotic resistance.

Background: Necrotizing soft tissue infections (NSTIs) are life-threatening infections characterized by progressive destruction of muscle, fascia, and overlying subcutaneous tissue. Prospective studies in the field are few, and data from the Indian subcontinent are bleak. Prompt diagnosis and timely treatment are critical for optimal outcomes. The aims of this study are to provide detailed information on the clinical profile of patients with NSTIs and to identify predictors of mortality in order to pick up reversible factors that may improve outcomes. Materials and methods: This study was a prospective cohort study of adult patients with NSTIs in a tertiary center in South India. All patients who were admitted to the surgical intensive care unit (ICU) of the institute with a diagnosis of NSTI were screened and enrolled. All patients were managed according to the local protocol for treatment of NSTIs and intensive care support. Results: In our cohort of patients, simple and multiple logistic regression analysis showed that four factors, namely, AKIN stage 3, shock, need for mechanical ventilation for more than 3 days, and low serum albumin values were found to be significantly associated with higher mortality. Conclusion: The successful management of these patients calls for early diagnosis, resuscitation, surgical debridement, appropriate and timely antibiotics, and early ventilatory weaning before multi-organ failure associated with shock and AKI occurs.

Background: Patients with terminal illnesses hospitalized with acute deteriorations often suffer from unnecessary/inappropriate therapies at the end of their lives. Appropriate advance care planning (ACP) practices aligned to patients’ goals of care may mitigate this. Materials and methods: To explore the rationale for clinical decision-making in hospitalized patients with terminal illnesses and formulate a practice pathway to streamline care. Between May and December 2018, a questionnaire survey with three case vignettes derived from intensive care unit (ICU) patients was emailed to ICU, respiratory and renal doctors, and nurses in two Sydney hospitals. Respondents chose various management options ranging from all active therapies to palliation. The primary outcome was the proportion of responses for each management option. With these and a thematic analysis of responses to identify barriers to ACP practice, a practice pathway was formulated. Results: Of the 310 invited clinicians, 178 responded (57.4%). About 89.2% of respondents reported caring for dying patients frequently. Sixty percent saw patients suffering from prolonged therapies. Most respondents deemed patients in the case vignettes to be terminally ill, warranting ACP discussions. However, many still wanted to treat the acute deterioration with active ICU-level interventions. Most respondents reported being comfortable in having ACP discussions. Conclusion: The survey showed discordance between the stated opinions and the choice of management options for terminally ill patients with acute deteriorations; possibly due to the lack of a considered approach in choosing management options that align with medical consensus and the patient's/family's wishes, a practice pathway is suggested to improve management.

Introduction: Various mortality predictive score models for coronavirus disease-2019 (COVID-19) have been deliberated. We studied how sequential organ failure assessment (SOFA), quick sequential organ failure assessment (qSOFA), acute physiology and chronic health evaluation II (APACHE II), and new early warning signs (NEWS-2) scores estimate mortality in COVID-19 patients. Materials and methods: We conducted a prospective cohort study of 53 patients with moderate-to-severe COVID-19. We calculated qSOFA, SOFA, APACHE II, and NEWS-2 on initial admission and re-evaluated on day 5. We performed logistic regression analysis to differentiate the predictors of qSOFA, SOFA, APACHE II, and NEWS-2 scores on mortality. Result: qSOFA, SOFA, APACHE II, and NEWS-2 scores on day 5 exhibited a difference between survivors and nonsurvivors (p <0.05), also between ICU and non-ICU admission (p <0.05). The initial NEWS-2 revealed a higher AUC value than the qSOFA, APACHE II, and SOFA score in estimating mortality (0.867; 0.83; 0.822; 0.794). In ICU, APACHE II score revealed a higher AUC value than the SOFA, NEWS-2, and qSOFA score (0.853; 0.832; 0.813; 0.809). Concurrently, evaluation on day 5 showed that qSOFA AUC had higher scores than the NEWS-2, APACHE II, and SOFA (0.979; 0.965; 0.939; 0.933) in predicting mortality, while SOFA and APACHE II AUC were higher in ICU admission than NEWS-2 and qSOFA (0.968; 0.964; 0.939; 0.934). According to the cutoff score, APACHE II on day 5 revealed the highest sensitivity and specificity in predicting the mortality (sensitivity 95.7%, specificity 86.7%). Conclusion: All scores signify good predictive values on COVID-19 patients mortality following the evaluation on the day 5. Nonetheless, APACHE-II appears to be the best at predicting mortality and ICU admission rate.

Background: Pain assessment in unconscious patients is a major challenge for healthcare providers. This study aims to compare the diagnostic value of the critical-care pain observation tool (CPOT) and the behavioral pain scale (BPS) for pain assessment among unconscious patients. Materials and methods: This cross-sectional study was conducted in 2019. Forty-five unconscious patients were selected randomly from four general intensive care units (ICUs) in the north of Iran. The discriminant validity of CPOT and BPS were evaluated for pain during a nociceptive and a nonnociceptive procedure. For reliability assessment, interrater agreement was obtained using Lin's concordance correlation coefficient and weighted kappa coefficient. Results: Patients who had been hospitalized in ICU due to surgery or trauma (57.70%) or medical problems (42.30%) were studied. During the nociceptive procedure, the mean scores of CPOT and BPS and all their dimensions, except for the compliance with ventilator dimension, were significantly greater than the nonnociceptive procedure (p <0.05) although the effect size of both instruments was small (0.32 vs 0.18). The Lin's concordance correlation coefficient in nonnociceptive and nociceptive procedures was respectively 0.67 and 0.62 for CPOT and 0.74 and 0.88 for BPS. Conclusion: CPOT and BPS have acceptable discriminant validity in differentiating nonnociceptive and nociceptive procedural pain although the effect size of CPOT is larger than that of BPS. Although both instruments have low reliability, the reliability of BPS is better.

Aim and objective: To examine if sequential organ failure assessment (SOFA) alone or SOFA in combination with pH is a better prognosis and mortality indicator. Materials and methods: We conducted a prospective observational study in a total of sixty patients. The mortality of patients was predicted on the basis of a SOFA score alone or SOFA score in combination with pH, and the prediction by both was compared to the actual outcome. The comparison was based on the “standardized mortality ratio” and the “area under the receiver operating characteristic curve (AUROC).” Result: At the time of admission, both the scores (SOFA and SOFA with pH) were equally effective in predicting mortality. At 48 hours, SOFA with pH proves to be slightly better in mortality prediction than SOFA score alone. The discriminative power of both the scores was assessed by calculating AUROC. AUROC of the SOFA score was better than that of SOFA with pH at admission and at 48 hours, but statistically, both had the same level of discrimination, i.e., excellent. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were the same for both the scores at admission, but all parameters except specificity were better for SOFA with pH at 48 hours. Specificity was the same for both even at 48 hours. Conclusion: At the time of admission, SOFA score and SOFA with pH were equally effective in outcome prediction, but after 48 hours, SOFA with pH proves to be better than the SOFA score alone. The power of discrimination is the same for both the scores at admission and at 48 hours.

Background: In pandemic situations, it is essential that the limited resources are used judiciously to achieve most benefits. Prediction of the disease severity at the earliest will help in better allocation, thus, positively affecting prognosis and treatment. Aim and objective: To investigate patient characteristics and specific biomarkers as possible early predictors of disease severity of SARS-COV-2 infection. Materials and methods: Retrospective single-centric observational study conducted at 70-bedded intensive care unit of tertiary care hospital at Haryana, India. 100 consecutive RT-PCR positive coronavirus disease-2019 (COVID-19) adult patients. Demographics, acute physiology and chronic health evaluation II (Apache-II) score, and Inflammatory markers were compared with respect to oxygenation defect (PaO₂/FiO₂ ratio: <300 or ≥300 mm Hg), need of invasive ventilation, ICU length of stay and 28-day mortality. Findings: Mean age was significantly more in lower PF ratio group (58.01 ± 15.33 vs 50.97 ± 13.78, p = 0.023) whereas sex ratio was comparable among patients in two groups. Significantly, higher APACHE-II score (p ≤0.001) and presence of hypertension (43.54% vs 23.68%; p = 0·045) in low PF ratio group along with higher C-reactive protein (171.78 ± 124.45 vs 101.52 ± 88.70), IL-6 (173.51 vs 53.18) and ferritin (1677.60 ± 2271.13 vs 643.54 ± 718.68) levels. Procalcitonin, lactate dehydrogenase, and creatine phosphokinase (CPK) levels were not significant. Interpretation: Age and APACHE II score and among laboratory parameters CRP, ferritin, and IL-6 levels were significantly higher in low PF ratio group, patients requiring invasive ventilation and in mortality group. Use of this triad (CRP, ferritin, and IL-6 levels) at admission may predict the disease severity early in the course. Addition of APACHE-II may further improve the accuracy of the score.

Aim and objective: The establishment of the potential role of the infected people's ABO blood type in the virus infectivity and aggressivity could clarify the aspects of the various susceptibility to virus and play a key role in assessing its spreading potential in the future. We studied the possible association of risk of coronavirus disease-2019 (COVID-19) infection and severe outcomes of disease with ABO blood groups and Rh factor in the Georgian population. Materials and methods: The effect of blood type on the severity of infection in COVID-19 positive patients admitted to the First University Clinic of Tbilisi State University (Tbilisi, Georgia) from December 2020 to September 2021 was analyzed retrospectively. The odds ratio (OR) criterion was used to determine the influence of the blood group on the risk of COVID-19 infection and of severe course of the disease. Results: The incidence of COVID-19 was 1.65-fold higher in the patients with blood group II(A), and average twice lower in patients with blood groups III(B) and IV(AB), compared with the ABO blood group distribution in healthy donors of the region. The percentage of patients transferring in ICU with I(O) and II(A) blood groups was enough high (42–40%), whereas in patients with III(B) and IV(AB) blood groups very low (12–6%). There were not revealed any statistically significant differences in the distribution of the patients with Rh+ and Rh− blood groups in healthy and COVID-19 infected individuals (including those transferred in the ICU). Conclusion: The link between patients’ ABO blood groups and receptivity to COVID-19 infection, progression and severity of the disease, has been detected. These results are relevant in terms of elucidating the mechanisms and risk factors of infecting and severity course of COVID-19 disease.

Background: The quantium consciousness index (qCON), an electroencephalography (EEG)-based modality, has no studies regarding intensive care unit (ICU) sedation, though very few studies describe its use for assessing depth of anesthesia in the operation theater. In this study, we evaluated qCON for assessing sedation compared with Richmond Agitation Sedation Scale (RASS) in patients on a mechanical ventilator in the ICU. Materials and methods: Eighty-seven mechanically ventilated patients aged between 18 and 60 years were investigated over a 12-hour period. They were given a standardized dosage of sedation comprised of a bolus dose of propofol 0.5 mg/kg and fentanyl 1 µg/kg, and then infusions of propofol 2–5 mg/kg/hour and fentanyl 0.5–2 µg/kg/hour. These drug infusions were adjusted to achieve a RASS score between 0 and -3. Using the qCON monitor, the investigator recorded the qCON values and then assessed the RASS score. Results: A total of 1,218 readings were obtained. After contrasting each qCON value correspondingly with time to each RASS value, we found their correlation to be statistically significant (ρ = 0.288, p <0.0001). With the help of receiver operating characteristic (ROC) curves, we were able to differentiate appropriate from inappropriate levels of sedation. A qCON value of 80 had a sensitivity of 72.67% and a specificity of 67.42% (AUC 0.738 with SE 0.021). Conclusion: qCON can be used for assessing sedation levels in mechanically ventilated critically ill patients. Clinical trial registration: CTRI/2019/07/020064.

Background: Pulse wave transit time is a novel method of estimating continuous cardiac output (esCCO). Since there are not many studies evaluating esCCO, we compared it with arterial pressure based cardiac output (APCO) method (FloTrac). Methods: In this prospective single-center observational study, we included 50 adult patients planned to undergo supramajor oncosurgeries, where major blood loss and extensive fluid shifts were expected. Cardiac output (CO) measurements were obtained by both methods at five distinct time points, giving us 250 paired readings of stroke volume index (SVI) and cardiac index (CI). We analyzed these readings using Pearson's correlation coefficient and Bland–Altman plots, along with other appropriate statistical tests. Results: There was significant correlation between CI and SVI measured by the esCCO and APCO. Bland–Altman plot analysis for CI showed a bias of −0.44 L/minute/m², precision of 0.74, and the limits of agreement of −1.89 and +1.01, while the percentage error was 46.29%. Bland–Altman analysis for SVI showed a bias −5.07 mL with a precision of 9.36, and the limits of agreement to be −23.4 to +13.28. The percentage error was 46.56%. Conclusion: This study demonstrated that esCCO tended to underestimate the CI to a large degree, particularly while estimating the cardiac output in the lower range. We found that the limits of agreement between two methods were wide, which are not likely to be clinically acceptable. Further studies with larger number of data points, obtained in a similar subset of patients, for cardiac output measurement in the perioperative period will certainly help determine if pulse wave transit time (PWTT) is here to stay (CTRI No.: CTRI/2019/08/020543).

Background: Posterior reversible encephalopathy syndrome (PRES) is a reversible condition. The Main pathological feature is vasogenic cerebral edema with predominant involvement of posterior part of the cerebrum. Clinical symptoms range from headache, seizure, and vision loss. We evaluated the clinicoradiological features of patients with PRES and their clinical outcome. Materials and methods: A retrospective study with 30 cases from January 2014 to May 2017. Results: Of thirty patients, 18 were females and twelve patients were male. The Mean age of the patients was 38.6 years. The most common presentation was seizure (66.6%) followed by altered mental status (53.3%) and headache (40%). The Main comorbid illnesses in our study were renal disease (36.7%), hypertension (23.3%), eclampsia, and postpartum sepsis (26.7%). The Most common site was the occipito-parietal region in the magnetic resonance imaging brain (66%). Atypical presentation involved the temporal lobe (16%), basal ganglia (6%), and microhemorrhage (6%). The Outcome was good with 20% mortalities. Conclusion: PRES is a reversible condition and has a good outcome in most patients. In our study, seizure was the most common presentation and renal disease is the most common comorbid illness.

Background: Targeted temperature management (TTM) is a vital element of postresuscitation management after cardiac arrest. Though international guidelines recommend TTM, the supporting evidence is of low certainty. Aims and objectives: To estimate the effect of TTM strategy on mortality and neurological outcomes in postcardiac arrest survivors. Materials and methods: Randomized controlled trials (RCTs) published in English evaluating the use of TTM in adult comatose survivors of cardiac arrest were included. Studies were categorized into two groups, based on hypothermia vs normothermia. The main outcome was death due to any origin. The secondary outcome measures evaluated neurological outcome and complications associated with TTM. Outcomes were analyzed by calculating Odds Ratio (OR) of a worse outcome. ORs with 95% CIs in a forest plot were used to show the results of random-effects meta-analyses. Results: On pooled analysis of 11 RCTs, no difference was observed in death due to any origin rates in the hypothermia compared to the normothermia group (OR; 0.88, 95% CI: 0.39–1.16). Overall, no difference in poor neurological outcome was observed between the two groups (OR; 0.86, 95% CI: 0.66–1.12). Trial sequencing analysis for mortality and poor neurological outcome showed that number to achieve power to predict futility has been achieved in both the parameters. Conclusions: This meta-analysis showed that hypothermia compared to normothermia TTM strategies does not improve survival or neurologic outcomes.

Several vaccines were developed and rolled out at an unprecedented rate in response to the coronavirus disease-2019 (COVID-19) pandemic. Most vaccines approved globally by WHO for emergency use to combat the pandemic were deemed remarkably effective and safe. Despite the safety, rare incidences of vaccine-induced thrombosis and thrombocytopenia (VITT), sometimes known as vaccine-induced prothrombotic thrombocytopenia (VIPIT), have been reported. We report a case of young female with prothrombotic conditions and suspected VITT who developed catastrophic cerebral venous sinus thrombosis (CVST) and progressed to brain death. We highlight hurdles of organ retrieval from a brain-dead patient with suspected SARS-CoV-2 vaccine-induced immune thrombotic thrombocytopenia. There is limited data and lack of substantial evidence regarding transplantation of organs from brain-dead patients with suspected VITT.

A 40-year-old woman known hypertensive presented with progressive ascending paralysis. MRI T2W and FLAIR screening of the brain demonstrated swelling with altered signal in the visual cervical cord, medulla, and another juxtacortical lesion in the right temporal lobe with possibility of a demyelinating etiology. CSF testing did not identify a direct cerebral infection. High-dose steroids followed by a course of IVIG was administered but with no significant response. In these pandemic times, the patients who present with altered mentation and polyfocal neurological deficits and background history of recent COVID-19 infection or recipient of SARS-CoV-2 vaccine the diagnosis of acute disseminated encephalomyelitis (ADEM) should be considered likely.

The substance known as 3,4-methylenedioxymethamphetamine (MDMA) that is commonly named ecstasy is a designer drug used for recreation. The intoxication for MDMA could generate hyperthermia, hepatotoxicity, acute renal failure, cardiovascular toxicity, hyponatremia, serotonin syndrome, coma, and, eventually could lead to, death. There is no antidote available, that is why the treatment is symptomatic and of advanced vital support until the resolution of the case. A case is presented of an adult with multi-organ failure secondary to intoxication for MDMA in whom it was decided to initiate support of oxygenation with extracorporeal membrane oxygenation as a bridge to recovery, with good results.

Stress cardiomyopathy/Takotsubo cardiomyopathy (TC) is a transient and reversible acute heart failure provoked by physical or emotional stress. This case report highlights about a patient who experienced sudden onset chest pain and breathlessness following epidural steroid injection for pain secondary to prolapsed intervertebral disc. Initial clinical features, electrocardiogram, troponin levels, and transthoracic echocardiography showed features suggestive of acute coronary syndrome but the coronary angiogram was normal. The diagnosis of stress cardiomyopathy was made and managed successfully. This case report highlights one of the rare cases of procedure-related early stress cardiomyopathy. Early diagnosis and management reduce morbidity and mortality.

Suicides due to insecticide poisoning represent a major public health concern. Introduction of newer synthetic pesticides like neonicotinoids and fipronil, with novel mechanisms of action, have led to widespread adoption of these in the agriculture industry. They act by altering the neuronal transmission mechanisms in the central nervous system, specifically of the invertebrates, and lead to death of the organism. Though they were perceived to be invertebrate-specific, there have been few case reports of these, leading to notable clinical adverse effects on human exposure. We present a case of acetamiprid and fipronil consumption, who presented to us with central nervous system manifestations and his clinical management. With increasing use of newer pesticides, clinical knowledge regarding the toxic effects of these seems indispensable.

Mycobacterium abscessus is a very unusual cause of infection in immunocompetent patients. It is a rapidly growing microbe that rarely causes disseminated infection or native valve endocarditis. This organism exhibits intrinsic and acquired resistance to multiple antibiotics and hence becomes a major issue in planning treatment regimens. We report a unique case of a young immunocompetent male patient presenting with stroke and persistent fever. After extensive investigations, he was found to have an abscess caused by M. abscessus in the sinus of Valsalva and thrombi in the aorta that was the sequelae following coronary angioplasty. This case report explains the difficulties in the diagnosis and treatment of M. abscessus.