Background: Delayed transfer to the intensive care unit (ICU) contributes to increased mortality. Clinical tools, developed to shorten this delay, are especially useful in hospitals where the ideal healthcare provider-to-patient ratio is not met. This study aimed to validate and compare the accuracy of the well-accepted modified early warning score (MEWS) and the newer cardiac arrest risk triage (CART) score in the Philippine setting. Patients and methods: This case–control study involved 82 adult patients admitted to the Philippine Heart Center. Patients who had cardiopulmonary (CP) arrest at the wards and those transferred to the ICU were included. Vital signs and alert-verbal-pain-unresponsive (AVPU) scales were recorded from recruitment until 48 hours prior to CP arrest or ICU transfer. The MEWS and CART scores were computed at specific time points and compared using measures of validity. Results: The highest accuracy was obtained by the CART score with a cut-off of ≥12 at 8 hours prior to CP arrest or ICU transfer, with a specificity of 80.43% and sensitivity of 66.67%. At this time point, the MEWS with a cut-off of ≥3 had a specificity of 78.26% but a lower sensitivity of 58.33%. The area under the curve (AUC) analysis revealed that these differences were not statistically significant. Conclusion: We recommend an MEWS threshold of 3 and a CART score threshold of 12 to help identify patients at risk for clinical deterioration. The CART score had comparable accuracy to the MEWS, but the latter's computation may be easier.

Introduction: Cardiac troponin-I (cTnI) elevation release during hypertensive emergencies (HEs) is a frequent epiphenomenon that may tangle management of individuals being treated for HEs. The primary objective of this study was to determine the prevalence, determinants, and clinical significance of cTnI elevation and secondary objective was to find out the prognostic significance of cTnI elevation in patients admitted for HE in the emergency department (ED) of a tertiary care hospital. Methodology: The investigator has employed the quantitative research approach with a prospective observational descriptive design. The population of this study comprised of 205 adults, which included both males and females, who were more than or 18 years of age. The subjects were selected by non-probability purposive sampling technique. The study was conducted from August 2015 to December 2016 (16 months). Ethical permission was obtained from the Institutional Ethics Committee (IEC), Max Super Speciality Hospital, Saket, New Delhi and well-informed written consents were taken from the subjects. The analysis of data was done with the help of SPSS, version 17.0. Results: Out of 205 patients in the study, cTnI elevation was found in 102 patients (49.8%). Moreover, there was increased duration of stay in the hospital in patient with elevated cTnI level with mean duration stay 1.55 ± 0.82 (p <0.001). In addition, cTnI elevation was associated with increased mortality, 11 out of 102 in an elevated cTnI group (10.8%) with p <0.002. Conclusion: It was found that cTnI elevation in individuals affected by various clinical factors. The authors highlighted a high frequency of mortality among the individuals presented with HE with elevated cTnI level, whereas the presence of cTnI was associated with greater odds of death.

Objective: To determine whether high-flow nasal oxygen (HFNO) or noninvasive ventilator (NIV) can avoid invasive mechanical ventilation (IMV) in COVID-19-related acute respiratory distress syndrome (ADRS), and the outcome predictors of these modalities. Design: Multicenter retrospective study conducted in 12 ICUs in Pune, India. Patients: Patients with COVID-19 pneumonia who had PaO₂/FiO₂ ratio <150 and were treated with HFNO and/or NIV. Intervention: HFNO and/or NIV. Measurements: The primary outcome was to assess the need of IMV. Secondary outcomes were death at Day 28 and mortality rates in different treatment groups. Main results: Among 1,201 patients who met the inclusion criteria, 35.9% (431/1,201) were treated successfully with HFNO and/or NIV and did not require IMV. About 59.5% (714/1,201) patients needed IMV for the failure of HFNO and/or NIV. About 48.3, 61.6, and 63.6% of patients who were treated with HFNO, NIV, or both, respectively, needed IMV. The need of IMV was significantly lower in the HFNO group (p <0.001). The 28-day mortality was 44.9, 59.9, and 59.6% in the patients treated with HFNO, NIV, or both, respectively (p <0.001). On multivariate regression analysis, presence of any comorbidity, SpO₂ <90%, and presence of nonrespiratory organ dysfunction were independent and significant determinants of mortality (p <0.05). Conclusions: During COVID-19 pandemic surge, HFNO and/or NIV could successfully avoid IMV in 35.5% individuals with PO₂/FiO₂ ratio <150. Those who needed IMV due to failure of HFNO or NIV had high (87.5%) mortality.

Introduction: Sepsis leads to left and/or right ventricular systolic and/or diastolic dysfunction resulting in adverse outcomes. Myocardial dysfunction can be diagnosed by echocardiography (ECHO) and early intervention can be planned. There are lacunae in Indian literature regarding the true incidence of septic cardiomyopathy and its influence on the outcome of patients admitted to intensive care unit (ICU). Materials and methods: This prospective observational study was conducted on patients consecutively admitted with sepsis to the ICU of a tertiary care hospital in North India. In these patients, ECHO was performed after 48–72 hours to establish left ventricular (LV) dysfunction, in whom the ICU outcome was analyzed. Result: The incidence of LV dysfunction was 14%. About 42.86% of patients had isolated systolic dysfunction, 7.14% of patients had isolated diastolic dysfunction, and 50.00% of patients had combined LV systolic and diastolic dysfunctions. The average days of mechanical ventilation in patients without LV dysfunction group (group I) was 2.41 ± 3.82 days as compared to 4.43 ± 4.27 days in patients with LV dysfunction (group II) (p = 0.034). Incidence of all-cause ICU mortality was 11 (12.79%) in group I and 3 (21.43%) in group II (p = 0.409). The mean duration of stay in ICU was 8.26 ± 4.41 days in group I as compared to 13.21 ± 6.83 days in group II. Conclusion: We concluded that sepsis-induced cardiomyopathy (SICM) in ICU is quite prevalent and clinically significant. All-cause ICU mortality and length of ICU stay are prolonged in patients with SICM.

Background: Sepsis is a life-threatening organ dysfunction due to dysregulated host response to infection. Timely identification is important for risk reduction and better outcomes in critically ill patients. Nucleosomes and tissue inhibitors of metalloproteinase1 (TIMP1) are the biomarkers whose validity and utility in predicting organ dysfunction and mortality in sepsis have been proven. However, which biomarker among these two has better predictive value in elucidating disease severity, organ dysfunction, and mortality in sepsis is yet to be answered, and further studies are needed. Methods: Eighty patients with sepsis/septic shock, aged between 18 and 75 years admitted in intensive care unit (ICU) were recruited in this prospective observational trial. Quantification of serum nucleosomes and TIMP1 was done using enzyme linked immunosorbent assay (ELISA) within 24 hours of diagnosis of sepsis/septic shock. The primary outcome was to compare the predictability of nucleosomes and TIMP1 in estimating sepsis mortality. Results: The area under the receiver operating characteristic curve (AUROC) for TIMP1 and nucleosomes to discriminate between survivors and non-survivors were 0.70 [95% Confidence interval (CI), 0.58–0.81] and 0.68 (0.56–0.80), respectively. Although independent, TIMP1 and nucleosomes have statistically significant capacity to discriminate between survivors and non-survivors (p = 0.002 and p = 0.004, respectively), superiority of one biomarker over the other in discriminating between survivors and non-survivors was not observed. Conclusion: The median values of each biomarker showed statistically significant differences between survivors and non-survivors, superiority of one biomarker over other in predicting mortality was not observed. However, this was an observational study and larger studies are needed in the future to validate the findings of this study.

Background: Septic shock is commonly treated in the emergency department (ED) with vasopressors. Prior data have shown that vasopressor administration through a peripheral intravenous line (PIV) is feasible. Objectives: To characterize vasopressor administration for patients presenting to an academic ED in septic shock. Materials and methods: Retrospective observational cohort study evaluating initial vasopressor administration for septic shock. ED patients from June 2018 to May 2019 were screened. Exclusion criteria included other shock states, hospital transfers, or heart failure history. Patient demographics, vasopressor data, and length of stay (LOS) were collected. Cases were grouped by initiation site: PIV, ED placed central line (ED-CVL), or tunneled port/indwelling central line (Prior-CVL). Results: Of the 136 patients identified, 69 were included. Vasopressors were initiated via PIV in 49%, ED-CVL in 25%, and prior-CVL in 26%. The time to initiation was 214.8 minutes in PIV and 294.7 minutes in ED-CVL (p = 0.240). Norepinephrine predominated all groups. No extravasation or ischemic complications were identified with PIV vasopressor administration. Twenty-eight-day mortality was 20.6% for PIV, 17.6% for ED-CVL, and 61.1% for prior-CVL. Of 28-day survivors, ICU LOS was 4.44 for PIV and 4.86 for ED-CVL (p = 0.687), while vasopressor days were 2.26 for PIV and 3.14 for ED-CVL (p = 0.050). Conclusion: Vasopressors are being administered via PIVs for ED septic shock patients. Norepinephrine comprised the majority of initial PIV vasopressor administration. There were no documented episodes of extravasation or ischemia. Further studies should look at the duration of PIV administration with potential avoidance of central venous cannulation altogether in appropriate patients.

Purpose: Enlightening the changes in the usual clinical practices, working environment, and social life of Intensivists working in noncoronavirus disease intensive care units (non-COVID ICU) during the COVID pandemic. Materials and methods: Observational cross-sectional study for Indian intensivists working in non-COVID ICUs conducted between July and September 2021. A 16-question online survey consisting of the work and social profile of the participating intensivists, changes in the usual clinical practices, working environment, and impact on their social life was administered. For the last three sections, intensivists were asked to compare pandemic times to prepandemic times (pre-mid-March 2020). Results: The number of invasive interventions performed by intensivists working in the private sector with lesser clinical experience (<12 years) were significantly less as compared to the government sector (p = 0.07) and clinically experienced (p = 0.07). Intensivists without comorbidities performed significantly lesser number of patient examinations (p = 0.03). The cooperation from healthcare workers (HCWs) decreased significantly with lesser experienced intensivists (p = 0.05). Leaves were significantly reduced in case of private sector intensivists (p = 0.06). Lesser experienced intensivists (p = 0.06) and intensivists working in the private sector (p = 0.06) spent significantly lesser time with family. Conclusion: Coronavirus disease-2019 (COVID-19) affected the non-COVID ICUs as well. Young and private sector intensivists were affected due to less leaves and family time. HCWs need proper training for better cooperation during the pandemic time.

Background: Coronavirus disease-2019 (COVID-19) pandemic has been a cause of significant mental health disturbances in medical health personnel. However, 18 months into the pandemic, healthcare workers (HCWs) have become accustomed to the heightened stress and anxiety that comes with caring for COVID patients. Through this study, we aim to measure depression, anxiety, stress, and insomnia in doctors with the help of validated scales. Materials and methods: This was a cross-sectional study with an online survey design conducted among doctors from major hospitals in New Delhi. The questionnaire included participant demographics, including designation, specialty, marital status, and living arrangements. This was followed by questions from the validated depression, anxiety, stress scale (DASS-21), and insomnia severity index (ISI). Depression, anxiety, stress, and insomnia scores were calculated for each participant, and the data were analyzed statistically. Results: The mean scores of the whole study population showed no depression, moderate anxiety, mild stress, and subthreshold insomnia. Female doctors exhibited more psychological issues (mild depression and stress, moderate anxiety, but only subthreshold insomnia) as compared to males (mild anxiety, but no depression, stress, and insomnia). Junior doctors also had higher depression, anxiety, and stress scores than senior doctors. Similarly, single doctors, those living alone, and those not having kids had higher DASS and insomnia scores. Discussion: HCWs have been under tremendous mental stress during this pandemic which is influenced by multiple factors. Female sex, junior doctors, working on the frontline, not being in a relationship, and living alone may be some of the factors recognized in our study and corroborated by many authors, which may increase the chances of depression, anxiety, and stress in them. HCWs need regular counseling, time off for rejuvenation, and social support to overcome this hurdle.

Background: The major brunt of coronavirus disease-2019 (COVID-2019) is borne by the lungs. The major cause of morbidity and mortality in COVID-19 patients is a compromise of the respiratory system. Pneumothorax is noted as an insignificant proportion of patients suffering from COVID-19, but it jeopardizes the clinical recovery significantly. We, in the case series of 10 patients, will be summarizing the epidemiological, demographic, and clinical characteristics of COVID-19 patients who also developed pneumothorax. Patients and methods: All the confirmed cases of COVID-19 pneumonia diagnosed between May 1, 2020 and August 30, 2020, admitted at our center meeting the inclusion criteria and whose clinical course was complicated by pneumothorax were made part of our study. Their clinical records were studied, and epidemiological, demographic, and clinical data of these patients were collected and compiled in this case series. Results: All the patients in our study required ICU care, and 60% received non-invasive mechanical ventilation, while 40% of the patients progressed to intubation and invasive mechanical ventilation. A total of 70% of the patients in our study had a successful outcome, while 30% succumbed to the disease and expired. Conclusion: Epidemiological, demographic, and clinical characteristics of COVID-19 patients complicated with pneumothorax were evaluated. Our study showed that pneumothorax also developed in some patients who had not received mechanical ventilation, indicating that pneumothorax could be a secondary complication of SARS-CoV-2 infection. Our study also emphasizes the fact that even the majority of patients whose clinical course was complicated by pneumothorax had a successful outcome emphasizing the need for timely and adequate intervention in such cases.

Background: Deliberate self-harm (DSH) in developing nations has a significant impact on health and economic conditions of patients and families. Materials and methods: This retrospective study aims to study the cost of hospitalization and the factors affecting the cost of medical care. Adult patients with a diagnosis of DSH were included. Results: A total of 107 patients were included with the most common type of poison consumed being pesticides (35.5%) followed by a tablet overdose (31.8%). There was a male preponderance with a mean (SD) age of 30.04 (9.03) years. The median cost of admission was ₹13,690 (USD 195.57); DSH with pesticide increased the cost of care by 67% as compared to non-pesticides. Other factors which increased the cost were need for intensive care, ventilation, use of vasopressors, and development of ventilator-associated pneumonia (VAP). Conclusions: Pesticide-based poisoning is the most frequent cause of DSH. Among different types of DSH, pesticide poisoning is associated with a higher direct cost of hospitalization.

Introduction: Ventilator-associated events (VAEs) are one of the main sources of concern in critically ill patients due to the high frequency and mortality. We conducted this analysis to compare the effects of open endotracheal suctioning system with closed one on the incidences of VAEs in adult patients receiving mechanical ventilation (MV). Materials and methods: A comprehensive literature search was performed in PubMed, Scopus, Cochrane Library, and hand searching bibliographies of retrieved articles. The search was confined to randomized controlled trials with human adults comparing closed tracheal suction systems (CTSS) vs open tracheal suction systems (OTSS) in prevention of ventilator-associated pneumonia (VAP). Full-text articles were used in order to extract the data. Data extraction was only started after completing the quality assessment. Results: The search resulted in 59 publications. Among them, 10 were identified as eligible for meta-analysis. There was a significant increase in incidence of VAP when using OTSS compared to CTSS, so that OCSS increased the incidence of VAP by 57% (OR 1.57, 95% CI 1.063–2.32, p = 0.02). Discussion: Our results showed that using CTSS can significantly decrease VAP development compared to OTSS. This conclusion does not yet mean the routine use of CTSS as a standard VAP prevention measure for all patients since individual patient's disease and cost are other factors that should be in mind when determining the choice of the suctioning system. High-quality trials with a larger sample size are highly recommended.

Objectives: The objective of this study is to synthesize the current literature about the relationship between the occurrence of diabetes insipidus (DI), its diagnosis criteria, and management after withdrawal of vasopressin (VP) in critically ill. Data sources: This scoping review followed the recommendations of Preferred Reporting Items for Systematic Review and Meta-Analyses for Scoping Review (PRISMA-ScR). The search literature was conducted in MEDLINE and EMBASE databases, until March 2022. A manual search was also conducted in order to include articles that were not identified in the initial search performed in the databases. Study selection and data extraction: The selection of studies and extraction of data were carried out in a paired and independent manner. There was no restriction regarding the language of publication of the included manuscripts. Data synthesis: The analysis included 17 studies (16 case reports and one retrospective cohort). All studies used VP, with a median time of drug infusion of 48 hours (IQR: 16–72) and DI incidence of 1.53%. The diagnosis of DI was based on diuresis output and concomitant hypernatremia or changes in serum sodium concentration, with median time to symptoms onset after discontinuation of VP of 5 hours (IQR: 3–10). The treatment of DI consisted mainly of fluid management and the use of desmopressin. Conclusions: DI after VP withdrawal was present in 51 patients described in 17 studies, but diagnosis and management varied among each report. Using the available data, we propose a diagnosis suggestion and a flowchart for managing patients with DI after withdrawal of VP in the Intensive Care Unit. Multicentric collaborative research is urgently needed to obtain more quality data on this topic.

Introduction: Vitamin D deficiency is an amendable risk factor linked to increase in mortality in critically ill patients. The aim of this systematic review was to evaluate if vitamin D supplementation reduced the mortality, and length of stay (LOS) in intensive care units (ICU) and hospitals in critically ill adults including coronavirus disease-2019 (COVID-2019) patients. Materials and methods: We searched the literature using the PubMed, Web of Science, Cochrane and Embase databases until January 13, 2022, for RCTs comparing vitamin D administration to placebo or no treatment in ICUs. The fixed-effect model was used for the primary outcome (all-cause mortality) and the random effect model for secondary objectives (LOS in ICU, hospital, mechanical ventilation). Subgroup analysis included ICU types and high vs low risk of bias. Sensitivity analysis compared severe COVID-19 vs no COVID disease. Results: Eleven RCTs (2,328 patients) were included in the analysis. Pooled analysis of these RCTs, showed no significant difference in all-cause mortality between the vitamin D and placebo groups [odds ratio (OR) 0.93, p = 0.47]. Inclusion of COVID-positive patients did not change the results (OR 0.91, p = 0.37). No significant difference was observed between the vitamin D and placebo groups in LOS in ICU (p = 0.34); hospital (p = 0.40) and mechanical ventilation duration (p = 0.7). In the subgroup analysis, there was no improvement in mortality in medical ICU (p = 0.36) or surgical ICU (p = 0.03). Neither low risk of bias (p = 0.41) nor high risk of bias (p = 0.39) reduced mortality. Conclusion: Vitamin D supplementation in the critically ill did not have statistically significant benefits on clinical outcomes in terms of overall mortality, duration of mechanical ventilation, and LOS in ICU and hospital.

Objective: Persistent shock (PS) or recurrent shock (RS) after initial fluids and vasoactives can be secondary to myriad complex mechanisms, and these patients can have a high mortality. We developed a noninvasive tiered hemodynamic monitoring approach which included, in addition to basic echocardiography, cardiac output monitoring and advanced Doppler studies to determine the etiology and provide targeted therapy of PS/RS. Design: Prospective observational study. Setting: Tertiary Care Pediatric Intensive Care Unit, India. Methods: A pilot conceptual report describing the clinical presentation of 10 children with PS/RS using advanced ultrasound and noninvasive cardiac output monitoring. Children with PS/RS after initial fluids and vasoactive agents despite basic echocardiography underwent BESTFIT + T3 (Basic Echocardiography in Shock Therapy for Fluid and Inotrope Titration) with lung ultrasound and advanced 3-tiered monitoring (T1-3). Results: Among 10/53 children with septic shock and PS/RS over a 24-month study period, BESTFIT + T3 revealed combinations of right ventricular dysfunction, diastolic dysfunction (DD), altered vascular tone, and venous congestion (VC). By integrating information obtained by BESTFIT + T1-3 and the clinical context, we were able to modify the therapeutic regimen and successfully reverse shock in 8/10 patients. Conclusion: We present our pilot results with BESTFIT + T3, a novel approach that can noninvasively interrogate major cardiac, arterial, and venous systems that may be particularly useful in regions where expensive rescue therapies are out of reach. We suggest that, with practice, intensivists already experienced in bedside POCUS can use the information obtained by BESTFIT + T3 to direct time-sensitive precision cardiovascular therapy in persistent/recurrent pediatric septic shock.

True bilateral spontaneous chylothorax without any etiology has been reported rarely in the pediatric literature. A 3-year-old male child was detected to have incidental moderate chylothorax on USG thorax done for scrotal swelling. Investigations for infectious, malignant, cardiac, and congenital etiology were unremarkable. Effusion was drained by securing bilateral intercostal drains (ICD) and confirmed to be chyle on biochemical evaluation. The child was discharged with ICD in situ, but there was non-resolution of bilateral pleural effusion. Because of the failure of conservative treatment, video-assisted thoracoscopy (VATS) with pleurodesis was done. Thereafter, the child improved symptomatically and was discharged. On follow-up, there is no recurrence of pleural effusion, and the child has been growing well, albeit the etiology remains elusive. Chylothorax should not be missed in children presenting with scrotal swelling. In children with spontaneous chylothorax, VATS should be done after a fair trial of conservative medical management (thoracic drainage) along with continued nutritional management.

Pyogenic ventriculitis is defined as the inflammation of the ependymal lining of the cerebral ventricular system. It is characterized by the presence of suppurative fluid in the ventricles. It mostly affects neonates and children but rarely can be seen in adult population. In adults, it usually affects the elderly population. It is usually healthcare associated and occurs secondary to ventriculoperitoneal shunt, external ventricular drain, intrathecal drug delivery, brain stimulation devices, and neurosurgical intervention. Primary pyogenic ventriculitis though rare should be considered as one of the differential diagnoses in patients who do not improve despite an appropriate antibiotic regimen in bacterial meningitis. Our case report on primary pyogenic ventriculitis secondary to community-acquired bacterial meningitis in an elderly diabetic male patient illustrates the importance of utilization of multiplex polymerase chain reaction (PCR), repeated neuroimaging, and prolonged course of antibiotics for the successful management and outcome.

Background: Organophosphorus (OP) pesticides are extensively used both in developed and developing countries. Organophosphorus poisoning primarily occurs through occupational, accidental, and suicidal exposures. Toxicity through parenteral injections is seldom reported and there are only very few case reports till date. Case presentation: We report a case of parenteral injection of 10 mL of OP compound (Dichlorvos 76%) into a swelling over the left leg. The compound was injected by the patient himself as adjuvant therapy for swelling. Initial manifestations included vomiting, abdomen pain, and excessive secretions followed by neuromuscular weakness. The patient was subsequently intubated and treated with atropine and pralidoxime. The patient did not improve with antidotes for OP poisoning, attributed to the depot the OP compound had formed. The swelling was excised and the patient immediately showed response to the treatment. Biopsy of the swelling showed granuloma and fungal hyphae. The patient developed intermediate syndrome during the ICU stay and was discharged after 20 days of hospital stay.

A tracheobronchial avulsion is a very rare and serious condition that occurs mostly due to blunt trauma chest caused by high-speed traffic accidents. In this article, we present a challenging case of a 20-year-old male who had a right tracheobronchial transection with carinal tear which was repaired on cardiopulmonary bypass (CPB) through right thoracotomy. Challenges faced and a review of literature will be discussed.

Percutaneous dilatational tracheostomy (PDT) is a routinely performed procedure in the intensive care unit (ICU). Bronchoscopy guidance is recommended which requires expertise to use it, and also it is not readily available in all ICUs. Moreover, it can lead to carbondioxide (CO₂) retention and hypoxia during the procedure. To overcome these issues, we are using a waterproof 4 mm borescope examination camera in place of a bronchoscope which allows continuous ventilation, and real-time images of the tracheal lumen can be viewed on a smartphone or a tablet during the procedure. These real-time images can be transmitted wirelessly to a control room where experts can monitor and guide the junior staff performing the procedure. We are reporting successful use of the borescope camera during PDT.