Purpose: To compare norepinephrine and terlipressin vs norepinephrine alone for management of septic shock. Materials and methods: In this prospective, randomized control trial, 50 adult patients with septic shock were randomized into two groups. Group I received a combination of injection terlipressin 0.02 µg/kg/min (fixed dose) infusion and injection norepinephrine 0.01 µg/kg/min infusion and group II received injection norepinephrine 0.01 µg/kg/min infusion alone. Dose of noradrenaline in both the groups was titrated to achieve the target MAP of 65–70 mm Hg. The data collected were the dose of norepinephrine required to maintain an MAP of above 65 mm Hg, urine output, serum lactate, procalcitonin level, C-reactive protein, sequential organ failure assessment (SOFA) score, total duration of vasopressor support, and incidences of the adverse effects. Results: The norepinephrine dose in group I vs group II at 12 hours was found to be 0.141 ± 0.067 vs 0.374 ± 0.096 µg/kg/min (p ≤0.005). The serum lactate was lower, and urine output was higher in group I than group II (p <0.05). Group I had a significantly greater reduction in SOFA score in 12 hours than group II. Group I patient also had a significant decrease in the duration of vasopressor administration than group II patients being discharged from the ICU. However, there was no difference in the mortality between the two groups during their ICU stay. Conclusion: A low-dose continuous infusion of terlipressin and norepinephrine could help attain early resuscitation goals for managing patients with septic shock.

Background: Delirium is frequently observed among critically ill patients in the intensive care unit. Although a preventable and reversible process, it is associated with greater morbidity and mortality. Early recognition and interpreting the predisposing and precipitating risk factors for delirium can improve outcomes among these patients. Objective: A prospective observational study was conducted with the primary objective to evaluate the incidence of delirium in a mixed adult intensive care unit. The secondary objectives were the evaluation of risk factors and outcomes of delirium. Methods: All patients who were more than 18 years of age and with an ICU stay of more than 24 hours were included in the study. Patients with prior history of neurological disorders, psychosis, and who were deaf were excluded. Eligible patients were evaluated by the residents to detect delirium using confusion assessment method for the intensive care unit (CAM-ICU) as a tool. Results: A total of 110 patients were included, and delirium was detected in 41 patients (37.3%). Among the predisposing risk factors, only hypertension was significantly associated with delirium. Among precipitating factors, mechanical ventilation, use of physical restraints and presence of window/natural light exposure, high Acute Physiology and Chronic Health Evaluation II scores, use of opioids, and benzodiazepines were associated with delirium. In multivariate risk regression analysis, presence of window/natural light exposure [odds ratio (OR), 55.52; 95% CI (8.887–346.904)]; (p <0.001) and duration of stay in ICU OR (1.145); 95% CI (1.058–1.238) (p = 0.001) were independent risk factors of delirium. Also, high mortality (53.7%) was observed among the delirious group of patients. Conclusion: Delirium is a common problem in the ICU and is associated with poor outcomes. Various risk factors are linked to ICU environment.

Background: In critically ill patients with low albumin, dose individualization of phenytoin is a challenge. The currently used Sheiner–Tozer equation does not accurately predict the free phenytoin concentration in serum and can result in incorrect dose modifications. The best measure to advocate in these patients is the direct-measurement of free phenytoin concentration. Aims and objectives: Phenytoin exhibits complex pharmacokinetics, requiring careful therapeutic drug monitoring. This study aimed to compare the accuracy of the established Sheiner–Tozer calculation method against the direct-measurement of free phenytoin concentration in serum by high performance liquid chromatography in critically ill patients with low albumin. Materials and methods: Blood specimens for direct-measurement of both total and free phenytoin concentration were obtained from 57 patients with hypoalbuminemia monitored in the intensive care unit. Results: The median [inter-quartile range (IQR)] for Sheiner–Tozer equation calculated total phenytoin concentration and direct-measured total was 17.14 (10.63–24.53) and 9.82 (6.02–13.85) μg mL⁻¹, respectively. Approximately 53 and 5% of patients were found to be subtherapeutic and supratherapeutic for direct-measured total phenytoin concentrations, respectively. In contrast, on applying the Sheiner–Tozer calculation, 23 and 40% had subtherapeutic and supratherapeutic concentrations, respectively, for total phenytoin concentration. The median (IQR) for direct-measured, routine and Sheiner–Tozer equation calculated free phenytoin concentration were 1.92 (1.06–2.76), 0.98 (0.60–1.39), and 1.71 (1.06–2.45) μg mL⁻¹, respectively. Only 45.7% of patients were in agreement with respect to the therapeutic category when direct-measured free was compared against routine calculation free. Conclusion: In patients with low albumin, free phenytoin concentration based on the Sheiner–Tozer corrected equation accurately classified patients based on their therapeutic category of free phenytoin in 73.7% of patients. Hence, for individualization of phenytoin dosage in critically ill patients with low albumin, we recommend direct-measurement of free phenytoin concentration.

Background: Prioritizing the patients requiring intensive care may decrease the fatality of coronavirus disease-2019 (COVID-19). Aims and objectives: To develop, validate, and compare two models based on machine-learning methods for predicting patients with COVID-19 requiring intensive care. Materials and methods: In 2021, 506 suspected COVID-19 patients, with clinical presentations along with radiographic findings, were laboratory confirmed and included in the study. The primary end-point was patients with COVID-19 requiring intensive care, defined as actual admission to the intensive care unit (ICU). The data were randomly partitioned into training and testing sets (70% and 30%, respectively) without overlapping. A decision-tree algorithm and multivariate logistic regression were performed to develop the models for predicting the cases based on their first 24 hours data. The predictive performance of the models was compared based on the area under the receiver operating characteristic curve (AUC), sensitivity, and accuracy of the models. Results: A 10-fold cross-validation decision-tree model predicted cases requiring intensive care with the AUC, accuracy, and sensitivity of 97%, 98%, and 94.74%, respectively. The same values in the machine-learning logistic regression model were 75%, 85.62%, and 55.26%, respectively. Creatinine, smoking, neutrophil/lymphocyte ratio, temperature, respiratory rate, partial thromboplastin time, white blood cell, Glasgow Coma Scale (GCS), dizziness, international normalized ratio, O₂ saturation, C-reactive protein, diastolic blood pressure (DBP), and dry cough were the most important predictors. Conclusion: In an Iranian population, our decision-based machine-learning method offered an advantage over logistic regression for predicting patients requiring intensive care. This method can support clinicians in decision-making, using patients’ early data, particularly in low- and middle-income countries where their resources are as limited as Iran.

Purpose: End-organ damage in coronavirus disease-2019 (COVID-19) is linked to “cytokine storm” and excessive release of inflammatory mediators. Various novel therapies have been used in COVID-19 including urinary trypsin inhibitor therapy. This study explores the efficacy of ulinastatin in COVID-19. Materials and methods: We retrieved the medical records of patients admitted during one month and did a propensity score analysis to create matched treatment and control groups. We analyzed these groups and the outcomes were presented with appropriate statistics. Survival curve was prepared to compare the survival effect of ulinastatin therapy at the end of hospitalization, among both the groups. Results: A total of 736 patients were admitted, and after adjusting the data with propensity score matching, 55 cases were selected by the system. On the final outcome analysis, we found that intensive care unit (ICU) length of stay [median (interquartile range) days 3 (3.5–7.8) vs 2 (0-4); p-value 0.28] in control vs intervention groups, and in hospital mortality (odds ratio: 0.491, CI 95%: 0.099–2.44, p-value 0.435) were not statistically different among the groups. In survival plot analysis also, there was no statistical difference (p-value 0.414) among both the groups.Conclusion: In this retrospective study, we conclude that the final outcome of the ICU length of stay, and overall, in hospital mortality were not different among both the groups. Hence, adequately powered randomized control trials are urgently required to confirm any benefit of ulinastatin therapy in COVID-19 treatment.

Background: Cardiorespiratory arrest is defined as an abrupt halt in the cardiac mechanical activity that is accompanied by the loss of a detectable pulse, the cessation of breathing, and the loss of consciousness. The aim of this study is to create a clinical–epidemiological profile of patients who experienced cardiorespiratory arrest and were admitted to the intensive care unit to evaluate the associated factors and their impact on the prognosis of these patients. Patients and methods: From January to December 2019, the medical records of 135 patients who received cardiopulmonary resuscitation were reviewed for this cross-sectional observational study. The information was collected according to the Utstein model. Results: A low return of spontaneous circulation of 22.2% was observed, with a predominance of females (53.3%) and older patients (68.9%), multiple comorbidities at admission (68.4%), and asystole as the predominant rhythm. Female sex and age >60 years were statistically significant (p = 0.017), as was the association between sex and comorbidities (p = 0.036), with heart disease being the most prevalent in females (p = 0.036). Conclusion: In this study, even though the resuscitation maneuver time (start of resuscitation following arrest) was very short and the defibrillation was performed promptly, there was a high prevalence of cardiac arrest and low survival rates after cardiopulmonary resuscitation.

During the peak of the coronavirus disease-2019 (COVID-19) pandemic, 10 practice-changing decisions were adopted which led to an improved standard of clinical care in the face of overwhelming burden to the healthcare setup. Formation of a control unit with the piggyback team, briefing before donning, replacement of personal protective equipment (PPE) with impermeable surgical gowns, a dedicated prone team and the prone bundle of care, weaning-extubation and tracheostomy protocol, online audiovisual family-patient meet, daily rounds by hospital infection control committee member, each one clean one policy, focused onsite training of healthcare support staff and discharge policy with post-discharge follow-up were the 10 important changes adopted.

Background: Sepsis in children is a conundrum of diagnostic and therapeutic challenges. There is an exigent need for a novel biomarker that can serve as a clear distinguisher of sepsis from other non-septic inflammatory conditions. The role of presepsin as a biomarker of sepsis in children is still a matter of scientific inquiry. Aim and objectives: To evaluate the diagnostic accuracy of presepsin for the prediction of septic shock, in children aged 1 month to 18 years. Materials and methods: This prospective cohort study was conducted in the pediatric emergency, ward, and intensive care unit of a tertiary care hospital. We enrolled all consecutive admissions aged 1 month to 18 years with a diagnosis of sepsis and compared the presepsin, procalcitonin, and C-reactive protein (CRP) levels on admission (day 1) and 72 hours later (day 4) with the clinical outcomes. Results: The mean (±SD) presepsin values in blood culture-proven sepsis patients at admission and 72 hours later were 609.77 ± 417.30 and 839 ± 748.07, respectively. The procalcitonin and presepsin levels at 72 hours in sepsis patients with shock were significantly elevated (38.2 ± 45.55 and 1129.1 ± 1133.80, respectively) as compared to those without shock (10.7 ± 25.42 and 472.5 ± 507.81, respectively), p <0.05. The receiver operating characteristic (ROC) curve analysis of presepsin at 72 hours had an area under curve (AUC) of 0.730, suggesting a fair diagnostic accuracy. Conclusion: Elevated presepsin levels may indicate greater severity of sepsis, particularly in those with shock. However, it lacks diagnostic ability early in the disease and has limited prognostic potential in predicting mortality.

Background: To describe the clinical profile, risk factors, and outcomes that are associated with candida infection among critically ill children. Patients and methods: A retrospective case-control study wherein 109 children admitted to the pediatric intensive care unit (PICU) in the years between 2015 and 2017 with the growth of candida from blood, urine, endotracheal (ET) aspirate, and pus swabs were included and compared to 97 age and sex-matched controls chosen from the same time period. Results: Of the 124 candida isolates from 109 children, 37% were from blood, 24% from urine, and 14% in pus; 40% of the isolates were from ET aspirate. Candida non-albicans types (70%) predominated with Candida tropicalis causing 50% of the infections. Risk factors for candida infection were neutropenia [OR 20.01, 95% CI (0.94–422.32)], mechanical ventilation [OR 5.97, 95% CI (2.44–14.62)], peritoneal dialysis [OR 5.81, 95% CI (1.27–26.50)], institution of amino acids [OR 5.41, 95% CI (0.85–34.13)], presence of central venous catheter [OR 3.83, 95% CI (1.59–9.19)], antibiotic use >5 days [OR 3.58, 95% CI (1.38–9.29)]. Candida Cases (95.4%) had a septic shock with acute kidney injury in 34% and had significantly lower survival than controls [72 (66%) of 109 vs. 74 (80%) of 92] (p = 0.023). Conclusions: The rate of candida infection in our PICU was 4.2% of PICU admissions. The most common species was C. tropicalis. The independent risk factors for candida infection were neutropenia, antibiotic duration >5 days, peritoneal dialysis, amino acid administration, mechanical ventilation, and presence of a central venous catheter (CVC).

The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has discovered a new disease called multisystem inflammatory syndrome in children (MIS-C). In developing nations, pediatricians must be mindful of the similarities between MIS-C and other tropical fevers such as scrub typhus. Not only should such patients be kept on high alert to rule out tropical diseases and receive appropriate treatment, such as steroids or immunomodulatory medications, but this is also concerning because, if rickettsial or bacterial infection is not detected through cultures and serology, steroid, or immunomodulatory treatment alone can be fatal.

Acute intermittent porphyria (AIP) is a rare condition that needs to be kept in mind where its early recognition, conservative management, and removal of the precipitating factor are the key factors in its management. This “little imitator” presented with varied symptoms is often misdiagnosed. The diagnosis requires a strong index of suspicion as choosing an antiepileptic medication in the management of seizure requires a judicial choice to avoid precipitation of the underlying illness.

Sudden onset and de novo Myasthenia gravis (MG) in the presence of systemic lupus erythematosus (SLE) is a rare postpartum phenomenon and can easily misguide the treating physician. A known case of SLE, 4 days after an elective cesarean section, presented to the intensive care unit for weaning-off mechanical ventilation after being put on ventilatory support in the emergency room, following acute-onset partial seizures. She was subsequently diagnosed to have new-onset MG, treated for the condition and later successfully extubated.

Children with malignancies are facing new challenges in post-COVID-19 era. We report an interesting case of a child on treatment for acute lymphoblastic leukemia having a very protracted course of illness with complications not often seen with standard therapy. It intends to make pediatric oncologists and intensive care specialists wary of potential newer complications.

Intra-abdominal infections are known to complicate the course of acute pancreatitis. Invasive fungal infections (Candida spp.) are not the uncommon microorganisms which isolate from intra-abdominal specimen in acute necrotizing pancreatitis. However, we are reporting first case of invasive gastric mucormycosis in a postpartum acute pancreatitis patient.

Postoperative adhesions are commonly seen after most abdominal surgeries. The majority of patients with intra-abdominal adhesions remain asymptomatic; however, some patients may develop symptoms ranging from mild abdominal pain to sometimes life-threatening complications. The most severe complication seen in association with postoperative adhesions is small bowel obstruction (SBO). This complication is rarely seen in the pediatric age-group. Adhesions have the potential to cause bowel obstruction. In addition, they can also affect the normal intestinal motility and transit leading to constipation. Several studies reported in literature show a strong association between constipation and the urinary disorders, such as incontinence and urinary urgency. We herein report a case of a boy who developed adhesive SBO with segmental ileal dilatation leading to constipation, urinary symptoms, and finally presenting to our hospital as acute urinary retention.

Sphingobacterium spiritivorum is a rare cause of human infections worldwide. After reviewing the literature, we could find only eight case reports to date. The majority of cases were of cellulitis and septicemia. Most of these patients were immunocompromised and the recovery rate was lesser. We present a case of a young female diagnosed with scrub typhus complicated by acute respiratory distress syndrome who developed septicemia and septic shock due to S. spiritivorum. She was managed with sensitive antibiotic levofloxacin, clinically improved, and discharged in satisfactory condition.

Background: Human metapneumovirus (hMPV) is a paramyxovirus, well known as a causative agent of respiratory tract infections. Non-respiratory manifestations, including cardiac impairments, remain rare. Only two cases of myocarditis caused by hMPV have been described in adults. Case description: We present the case of a 14-year-old female suffering from Burkitt leukemia and diagnosed with severe myocarditis caused by hMPV, based on results from real-time polymerase chain reaction (RT-PCR) and magnetic resonance imaging (MRI). She was successfully treated by venoarterial extracorporeal membrane oxygenation and intravenous immunoglobulins. She was discharged from pediatric intensive care unit (PICU) 3 weeks later. Conclusion: This is the first pediatric case of hMPV myocarditis requiring venoarterial extracorporeal membrane oxygenation.

Scrub typhus is a known etiology of acute febrile illness in tropical regions such as Asia–Pacific. Several such reports are from the Indian subcontinent with manifestations such as non-specific febrile illness or multiorgan dysfunction [Acute respiratory distress syndrome (ARDS), myocarditis, hepatitis, acute kidney injury, or meningoencephalitis]. We came across a case with a presentation as immune thrombocytopenic purpura complicated by meningitis and acute kidney injury secondary to scrub typhus. This combination of presentation is rare and demands meticulous clinical examination and targeted management toward scrub typhus.

Coronavirus disease-2019 (COVID-19) has stood out as a disease of great medical interest, influencing disease evolution, and severity of diabetes mellitus. The intersection of COVID-19 infection and diabetes mellitus has unmasked inflammation and critical metabolic disturbances. We deliberate the case of a young woman, with type 2 diabetes mellitus, who was hospitalized for COVID-19 infection. Work-up revealed diabetic ketoacidosis (DKA) with lower-than-anticipated glucose levels, and acute metabolic acidosis. Refractoriness of metabolic acidosis to standard treatment required hemodialysis as a salvage therapy.