Background: End-of-life (EOL) care is the care of terminally ill patients who are nearing their end. It includes important components like palliative care, supportive care, hospice care, patient's right to choose, and choice of medical intervention, including continuation of routine medical interventions. The aim of this survey was to assess the practices of EOL care in various critical care units in India. Methods: The participants included clinicians involved in EOL care of patients with advanced diseases in different hospital across India. We sent blast emails and posted links on social media for inviting participants to take the survey. Study data were collected and managed by using Google Forms. The collected information was automatically entered into a spread sheet and stored in a secure database. Results: In total, 91 clinicians took the survey. The years of experience, practice area, and setting had significant effect on the palliative care, terminal strategy, and prognostication in terminally ill patients (p < 0.05). Statistical analysis was done using software STATA. Descriptive statistics were performed, and results were presented as number (percentage). Conclusion: The years of work experience, the practice area, and the practice setting have a strong impact on EOL care management of terminally ill patients. There are a lot of gaps in providing EOL care for these patients. Many reforms are needed in the Indian health care system to make EOL care better.

Background: Delirium is a neuropsychiatric illness. It affects critically ill patients on ventilator and increases mortality. The aim of this study was to evaluate the association of C-reactive protein (CRP) level with delirium in critically obstetrics women and its role in prediction of delirium. Materials and methods: Arospective observational study was conducted in the intensive care unit (ICU), and the duration of study was one year. Total 145 subjects were recruited, 33 patients were excluded, and 112 subjects were studied. For study, group A (n = 36) includes critically ill obstetric women who had delirium on admission; group B (n = 37) includes critically ill obstetric women who developed delirium within 7 days; and group C (n = 39) that includes critically ill obstetric women who did not develop delirium after follow-up of 7 days was served as control. Disease severity was assessed by using acute physiologic assessment and chronic health evaluation (APACHE) II score, and Richmond Agitation-Sedation Scale (RASS) was used to assess awakeness. In awake patients (RASS of ≥3), delirium was assessed by the use of confusion assessment method for ICU tools. C-reactive protein measured by particle enhanced turbidimetric immunoassay—two point kinetic method. Results: The mean ages of group A, B, and C were 26.44 ± 4.72, 27.46 ± 4.97, and 28.26 ± 5.67 years, respectively. C-reactive protein levels on the day of delirium development (group B) were found to be significantly higher than day 1 CRP levels of groups A and C. The mean Global Attentiveness Rating (GAR) was significantly lower in groups A and B as compared to that in group C (p < 0.001). On evaluating the correlation of CRP with GAR, it was found to be inverse and mild in strength for the correlation between CRP and GAR (r = −0.403, p < 0.001). At a cut-off value of >181 mg/L, CRP had sensitivity of 93.2% and specificity of 69.2%. The positive predictive value was 85% and the negative predictive value was 84.4% that differentiate delirium from non-delirium. Conclusion: C-reactive protein is a useful tool for screening and prediction of delirium in critically ill obstetric patients.

Aim and background: To publish data with outcome statistics from our online cardiac arrest (CA) outcome consortium (AOC) online registry. Materials and methods: Data on cardiac arrest (CA) from tertiary care hospitals were collected on the AOC registry online portal from January 2017 to May 2022. Survival endpoints from cardiac arrest events like ROSC, and survival at hospital discharge with neurological status at discharge were analyzed and presented. Studies of demographics, the association of outcome with age, gender, bystander CPR, low and no flow times, and admission lactate were also done along with suitable statistical analysis. Results: Out of 2,235 CA, 2,121 received CPR (1,998 IHCA, 123 Out of hospital Cardiac Arrest (OHCA)) as 114 were DNR. The males-female ratio was 70:30. Average age at arrest was 58.7 years. 26% OHCA received bystander CPR but survival advantage was not significant. (with 16%, without 14% p = 0.78). Asystole (67.7%), Pulseless Electrical Activity (PEA) (25.6%), and VF/pVT (6.7%) as first rhythm significantly influence survival (4.9, 8.6 and 39.4%: p < 0.001) ROSC was achieved in 355 (16.7%), with 173 (8.2%) alive and 141 (6.6%) having good (CPC ≤ 2) neurological state at discharge. At discharge, survival as well as CPC ≤ 2 outcomes were significantly better in females. On multivariate regression analysis, first rhythm and low flow time influence survival at discharge. Admission lactate (available only in 102 OHCA) was lower in survivors than non-survivors 10.3 vs 11.5 mmol/L but the difference was not statistically significant (p = 0.397]. Conclusion: Data from our AOC registry shows poor overall survival from CA. The Female gender had a higher survival rate. Ventricular Fibrillation/Pulseless Ventricular Tachycardia (VF/pVT) as first rhythm and low flow time influence the survival to discharge (CTRI/2022/11/047140).

Rationale: Nurses working in the intensive care unit (ICU) are constantly bombarded with stressful events and traumatic situations that may have deleterious effects on their health. The implications and the outcomes of exposure to these constant stressors by this workforce, on their mental health, are largely unknown. Objective: To determine and measure if critical care nurses are having more work-related mental disturbances compared to their counterparts who are working in less stressful environments such as wards. Materials and methods: We collected data from three large tertiary care hospitals in south India spanning over two states (n = 383 and 220 respectively) using various validated tools. Relevant data and results: In both cohorts of nurses, we determined the prevalence of symptoms of post-traumatic stress disorder (PTSD), depression, and anxiety using various validated tools such as PTSS-10 and hospital anxiety and depression scale (HADS). About 29% (CI 95%,18–37) of the ICU nurses were found to have symptoms PTSD, in comparison to 15% (95% CI,10–21) of the ward nurses (p = 0.04). The stress levels apart from the workplace reported by both groups were statistically similar. In the sub-domains of depression and anxiety, both groups faired equal probabilities. Conclusion: From this multicenter study, we have found that the staff nurses working in critical care areas of the hospital suffering from PTSD to a greater extent compared to their counterparts working in calmer ward conditions. This study will shower vital information to hospital administration and nursing leadership in improving the workplace mental health and satisfaction at jobs of ICU nurses working in tedious working conditions.

Introduction: Frailty describes a state or syndrome of reduced physical, physiologic, and cognitive reserve that increases vulnerability to acute illness. To study the prevalence of frailty in critically ill patients and find its association with resource utilization and short-term intensive care unit (ICU) outcomes. Material and methods: This was a prospective observational study. All adult patients ≥50 years admitted to the ICU were included and frailty was assessed by the clinical frailty score (CFS). Data were collected on demography, coexisting illness, CFS, Acute Physiology and Chronic Health Evaluation II (APACHE-II), and Sequential Organ Failure Assessment Score (SOFA) scores. Patients were followed for 30 days. Outcome data were collected on organ supports provided, duration of ICU and hospital length of stay (LOS), and ICU and 30-day mortality. Results: 137 patients were enrolled in the study. The prevalence of frailty was 38.6%. Frail patients were older and had a more comorbid illness. APACHE-II and SOFA scores were 22.1 ± 7.0 and 7.2 ± 3.29, significantly higher in frail patients, respectively. There was a trend towards higher requirement for organ supports in frail patients. Median ICU and hospital LOS were 8 vs 6 and 20 vs 12 (frail vs nonfrail) days, respectively (p < 0.05). Intensive care unit mortality in frail and nonfrail patients was 28.3% and 23.8%, respectively (p = 0.56). Thirty-day mortality in frail patients was 49%, significantly higher compared with nonfrail patients (28.5%). Conclusion: The prevalence of frailty in ICU patients was high. Frail patients were quite ill on ICU admission, and they had a prolonged ICU and hospital LOS. Increasing frailty score was associated with higher mortality at 30 days.

Background: We studied the incidence of magnesium (Mg) disturbances in patients admitted to a multidisciplinary intensive care unit (ICU) and correlated serum magnesium levels with clinical outcomes. Materials and methods: The study was conducted on 280 critically ill patients aged above 18 years and admitted to the ICU. Serum magnesium levels at admission were correlated with mortality, need for and duration of mechanical ventilation, duration of ICU stay, presence of comorbid conditions, and electrolyte disturbances. Result: There was a high incidence of Mg disturbances at admission among patients admitted to the ICU. The incidence of hypomagnesemia and hypermagnesemia was 40.9 and 13.9% respectively. The mean Mg level among patients who expired was 1.55 ± 0.68 mg/dL, and the association with outcome was found to be statistically significant (p = 0.001). Hypomagnesemia (HypoMg) was associated with significantly higher mortality (51.3%) as compared to normomagnesemia (NormoMg) (29.3%) and hypermagnesemia (HyperMg) (23.1%) (HypoMg vs NormoMg, HypoMg vs HyperMg, p = 0.001, 0.002 respectively). The need for mechanical ventilation was significantly higher in hypomagnesemic as compared to hypermagnesemia patients (p = 0.012). The association of baseline APACHE II and SOFA scores with serum Mg levels was statistically significant (p = 0.001 and 0.002 respectively). The incidence of gastrointestinal disorders was significantly higher among hypomagnesemia patients (HypoMg vs NormoMg, p = 0.023), while chronic kidney disease was significantly higher in hypermagnesemic patients (HypoMg vs HyperMg, p = 0.0009, NormoMg vs HyperMg, p = 0.0004). On comparing the incidence of electrolyte disorders between HypoMg, NormoMg, and HyperMg groups, it was found that hypokalemia and hypocalcemia (p = 0.0003 and 0.039 respectively) were associated with hypomagnesemia and hyperkalemia and hypercalcemia (p = 0.001 and 0.005 respectively) were associated with hypermagnesemia. Conclusion: Our study highlights the role of Mg monitoring in critically ill patients admitted to the ICU and its value for a favorable outcome. We found that hypomagnesemia was significantly associated with adverse outcomes and higher mortality in critically ill patients. Intensivists should maintain a high index of suspicion for Mg disturbances and evaluate patients appropriately.

Background: Sepsis is a dysregulated host response to infection that leads to acute organ dysfunction. The Sequential Organ Failure Assessment (SOFA) score is one of the gold standard tests in assessing the patient's status during ICU stay and also to predict the clinical outcomes of the patients. Procalcitonin (PCT) is a more specific marker for bacterial infection. In this study, we compared PCT and SOFA scores in predicting morbidity and mortality outcomes in sepsis. Materials and methods: A prospective cohort study was conducted on 80 patients with suspected sepsis. Patients who were >18 years of age with suspected sepsis presenting to the emergency room within 24–36 hours of illness are included in the study. SOFA score was calculated, and blood was drawn for PCT at the time of admission. Results: The average SOFA score in survivors was 6.1 ± 1.93, whereas, in nonsurvivors, it was 8.3 ± 2.13. The average PCT level in survivors was 3.7 ± 1.5, whereas, in nonsurvivors, was 6.4 ± 3.13. Area under the curve (AUC) for serum procalcitonin was found to be 0.77 (p value = 0.001) with average procalcitonin level of 4.15 ng/mL with sensitivity of 70% and specificity of 60%. AUC of SOFA score was found to be 0.78 (p value = 0.001) with an average score of 8, having a sensitivity of 73% and specificity of 74%. Conclusion: Serum PCT and SOFA scores are significantly elevated in patients with sepsis and septic shock, indicating their utility in predicting the severity and also their ability to assess end-organ damage.

Background: The monocyte distribution width (MDW), a novel inflammatory biomarker reflecting morphological changes in response to inflammation, has been shown to be useful in identifying COVID-19 infection or predicting death. However, data on the association with predicting the need for respiratory support are still limited. The aim of this study was to determine the association of MDW with the need for respiratory support in patients with SARS-CoV-2 infection. Patients and methods: This is a single-center retrospective cohort study. Consecutive hospitalized COVID-19 adult patients who presented at the outpatient department (OPD) or emergency department (ED) between May and August 2021 were enrolled. Respiratory support was defined as any one of the following: conventional oxygen therapy, high-flow oxygen nasal cannula, noninvasive, or invasive mechanical ventilation. The performance of MDW was measured using the area under the receiver operating characteristic (AuROC) curve. Results: Of the 250 enrolled patients, 122 (48.8%) patients received respiratory support. The mean MDW was significantly higher in the respiratory support group: 27.2 ± 4.6 vs 23.6 ± 4.1 (p < 0.001). The MDW ≥ 25 had the best AuROC characteristics of 0.70 (95% CI: 0.65–0.76). Conclusions: The MDW is a potential biomarker that may aid in identifying individuals at risk of requiring oxygen support in COVID-19 and can be easily implemented in clinical practice.

Objective: To study the utility of flexible fiberoptic bronchoscopy (FFB), and its effects on oxygenation and hemodynamics in children while on respiratory assist devices. Materials and methods: The data of non-ventilated patients who underwent FFB during their stay in the PICU from January 2012 to December 2019 was retrieved from medical, nurses, and bronchoscopy records. The study parameters, demography, diagnosis, indication, and findings of FFB and interventions done after FFB, were noted, and also the oxygenation and hemodynamic parameters before, during and 3 hours after FFB. Results: Data from the first FFB of 155 patients were analyzed retrospectively. About 54/155 (34.8%) children underwent FFB while on HFNC. About 75 (48.4%) patients were on conventional oxygen therapy (COT) before FFB. There were 51 (33%) patients who had received mechanical ventilation and were extubated successfully. The 98 (63.2%) children had primary respiratory diseases. Stridor and lung atelectasis were indications for FFB in 75 (48.4%) cases and the commonest bronchoscopic finding was retained secretions in the airways. Based on the FFB findings, 50 medical and 22 surgical interventions were done. The commonest medical and surgical interventions were changes in antibiotics (25/50) and tracheostomy (16/22) respectively. There was a significant fall in SpO₂ and a rise in hemodynamic parameters during FFB. All these changes were reversed after the procedure with no consequences. Conclusion: Flexible fiberoptic bronchoscopy is a useful tool to diagnose and guide interventions in non-ventilated pediatric intensive care unit (PICU). There were significant but transient changes in oxygenation and hemodynamics with no serious consequences.

The spectrum of neuro-COVID is broader than anticipated. Neurological disease in COVID-19 may be due to a direct attack of the virus, due to the immune response against the virus, secondary due to affection of the heart or arteries, or due to side effects from the treatment applied against COVID-19.

Recent amendments to the onerous legal procedure laid down in the Landmark Supreme Court Judgment Common Cause vs The Union of India have aroused widespread interest. The new procedural guidelines of January 2023 appear workable and should ease ethical decision-making toward the end-of-life in India. This commentary provides the backdrop to the evolution of legal provisions for advance directives, withdrawal, and withholding decisions in terminal care.