Background: The red cell distribution width (RDW) has been investigated as a predictive factor for complications and mortality in several critical illnesses, including cardiovascular diseases. Objective: The current study aimed to assess the relationship of RDW with severity and in-hospital mortality in patients with ST-elevation myocardial infarction (STEMI). Materials and methods: A prospective hospital-based observational study was conducted at a tertiary care institute of Northern India. Fifty patients of STEMI who underwent coronary angiography/primary coronary intervention were enrolled as cases and equal number of age- and sex-matched individuals not suffering from any cardiac disease were taken as controls. The RDW admission values of the cases were compared with that of controls. Red cell distribution width values were also compared across the outcome groups among cases. Results: The mean RDW-SD of the cases was 49.0 ± 4.6 fL whereas it was 44.7 ± 3.5 fL for controls, the difference being statistically significant (p < 0.001). Among the total patients, 4 (8.0%) expired during hospital stay and the rest 46 (92.0%) were discharged alive. The mean RDW-SD of expired patients was significantly higher than that of patients who remained alive (p = 0.002). There was a significant positive correlation between RDW and global registry of acute coronary events (GRACE) score (p = 0.02) and a significant negative correlation between RDW and left ventricular ejection fraction (LVEF) (p = 0.04). Area under the receiver operating characteristics (ROC) curve for RDW was higher than that of LVEF, showing superiority of RDW to LVEF in predicting mortality among the STEMI patients. Conclusion: Red cell distribution width may serve as a promising prognostic biomarker and tool for risk stratification in patients with STEMI.

Introduction and aims: Urine output (UO) in response to furosemide stress test (FST) can predict the progression of acute kidney injury (AKI). This study aimed to assess if changes in UO, urine spot sodium (USS), urine spot sodium creatinine ratio (USSCR) and changes in these parameters over 6 hours could differentiate between progressive and non-progressive AKI. Materials and methods: Fifty critically ill adults with AKI in acute kidney injury network (AKIN) stages I and II with volume overload were included in this prospective study. The FST was performed with 1 mg/kg intravenous bolus. Hourly UO, USS, USSCR, maximum USS difference (USSDMAX), and maximum USSCR difference (USSCRDMAX) were documented. Any progression of AKI was noted till day 3. Results: A total of 50 patients were recruited and n = 10 had progressive AKI (PAKI) and n = 40 had non-progressive AKI (NPAKI). Urine output at 1 and 2 h were significantly less in PAKI group. USS0, USS2, USS6, and USSDMAX were comparable between the groups. USSCR0 and USSCR6 were comparable between the groups whereas USSCR2 and USSCRDMAX were significantly less in PAKI group. USSDMAX did not correlate with UO1 (correlation coefficient 0.2, p = 0.16). However, USSCRDMAX showed a poor but significant correlation with UO1 (correlation coefficient 0.3, p = 0.03). Conclusion: To conclude, hourly UO in the first two hours and maximum change in USSCR within 6 hours following the FST may have an important role in early differentiation of progressive AKI in critically ill patients.

Aims and background: Competency-based medical education has been widely accepted across the globe and it has been adopted in the undergraduate curriculum in India from 2019. One introduction to this curriculum is the Electives postings. Electives are chosen by the students. The objectives of this project were to document the implementation of electives in emergency medicine for the medical undergraduates and to assess its effectiveness in terms of improving the knowledge and changing in perceptions of students. Materials and methods: The Analysis, Design, Development, Implementation, and Evaluation (ADDIE) instructional design approach was followed to prepare this electives module. The cross-sectional study was conducted on eight students who chose the emergency medicine elective for two consecutive years. The students were engaged in teaching learning activities and assessments for a duration of 15 days. They completed a pre- and post-course survey forms, pre- and post-tests and were given feedback on daily activities conducted. Results: All students gave positive response in terms of course conduct, satisfaction, gain in knowledge, and core skills of emergency medicine procedures. There was significant difference in student perception regarding the role of an emergency physician, triaging patients, taking history, examination, and management of life-threatening emergencies following the posting. All students showed noteworthy improvement in post-test scores compared with pre-course test. Conclusion: A structured 2-week elective posting in emergency medicine has a positive impression on student's perception regarding the specialty and has a remarkable advancement in knowledge and core skills of emergency medicine competencies.

The synthetic antimicrobial agent Linezolid effectively penetrates many tissues and exhibits effectiveness against drug-resistant Gram-positive bacteria. This agent's pharmacokinetic qualities cast doubt on the need for intravenous treatment in cases of serious illness. For its time-dependent action to have an impact, serum levels must stay above the minimum inhibitory concentration throughout the dosage interval. According to our research, Linezolid infusions have been proposed to be given as continuous infusions to maintain adequate tissue and serum levels without trough concentration fluctuations. This will optimize the drug's effects and protect against toxicity and drug resistance. In critically ill individuals experiencing septic shock in the ICU, this study sought to validate the safety and efficacy of continuous Linezolid infusion in comparison to the conventional regimen. A prospective, randomized, controlled research involving 140 individuals suffering from septic shock who were older than 18 was carried out. Two groups of patients were randomly assigned. With an average treatment duration of 9.83 ± 2.537 in the intermittent infusion group and 7.39 ± 1.653 in the continuous infusion group, the first group obtained IV linezolid 600 mg twice daily as an intermittent infusion (II) over 60 minutes, whereas the second group obtained 300 mg IV as a loading dosage, and then continuous infusion of 900 mg/day in the first day and 1,200 mg/day in the subsequent days. There was a significantly high clinical cure and less ICU and hospital stay in the continuous infusion group (p < 0.001). Moreover, there was a lower incidence of developing thrombocytopenia in patients with renal impairment who got continuous infusion. Continuous infusion modality showed an advantage in terms of enhancing clinical efficacy in seriously ill cases with septic shock secondary to Gram-positive bacterial infection, especially in cases with renal impairment.

Background: This study aims to assess the knowledge of Palestinian critical care nurses regarding the prevention of ventilator-associated pneumonia (VAP), an acquired infection that affects critically ill patients on ventilators in hospitals. Nurses caring for these patients may not always be aware of the most effective methods to prevent VAP. Materials and methods: A descriptive cross-sectional study was conducted in five government hospitals in Gaza Strip, Palestine over 3 months. A convenience sample technique (72) of critical care nurses was selected. Data were collected through a self-administered questionnaire divided into; demographic characteristics and knowledge about critical care nurses of preventive interventions for VAP. Statistical analysis was performed using SPSS version 25. Results: More than half of the critical care nurses (67%) were male and the majority of critical care nurses (63%) were aged between 20 and 29 years. Furthermore, 32% of critical care nurses were from Alshifa Medical Complex. The overall mean knowledge among critical care nurses to prevent VAP was 72%, indicating correct answers to knowledge-related queries. Conclusion: Our study indicated that the knowledge of critical care nurses about VAP prevention was inadequate. Age, marital status, and years of experience were significantly associated with a good level of knowledge about the prevention of VAP (p < 0.05). However, there was no significant association between knowledge about VAP prevention of VAP and gender, qualification level, and type of intensive care unit (ICU).

Background: Prediction of prognosis in sepsis is an essential research area aiming to improve disease outcomes. In this study, we investigated the role of the C-reactive protein (CRP)/procalcitonin (PCT) ratio as a prognostic tool in sepsis patients. Materials and methods: This prospective observational study was conducted at the intensive care unit (ICU) of Alexandria Main University Hospital in the period from January to June 2024. One hundred and seventy patients with a diagnosis of sepsis were enrolled. Sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHEII) score and CRP/PCT ratio were calculated on admission (day 1), and as a follow-up on day 3. Patients were subsequently divided into survivor and non-survivor groups, and the data were compared. Results: The CRP/PCT ratio was significantly lower, on admission and on follow-up, in non-survivor patients than in survivor patients. The ratio median (minimum–maximum) in non-survivors was 4.82 (1.51–23.28) vs 11.23 (1.85–136.7) in survivors on admission, and it was 7.37 (2.27–26.36) in non-survivors vs 11.37 (2.78–110.9) in survivors on day 3. The ratio was significantly lower in patients with septic shock than in non-septic shock patients. The ratio had a significant negative correlation with both SOFA and APACHEII scores. The receiver operating characteristic (ROC) curve showed high accuracy of the day 1 CRP/PCT ratio to predict mortality [area under curve (AUC = 0.835)], which is comparable to the day 1 SOFA score (AUC = 0.878) and higher than the day 1 PCT and day 1 APACHE scores. Conclusion: Our results suggest a potential role for the CRP/PCT ratio, on admission and on follow-up, as a marker for predicting prognosis in sepsis patients, where low ratio values can predict poor disease outcome.

Background: Development of ventilator-associated pneumonia (VAP) is attributed to the microaspiration of pooled secretions around the cuff of airway devices. Despite the emphasis on the use of endotracheal tubes (ET) with subglottic secretion (SS) drainage ports to prevent VAP, the quality of the evidence for this recommendation remains moderate. This prospective observational study analyzed microbiological concordance between SS and endotracheal aspirate (ETA) cultures to generate further evidence in this regard. Materials and methods: Paired samples (SS and ETA) of 100 consenting patients admitted to intensive care unit (ICU) were sent on day 1, 4, and 7 to the microbiology laboratory where they were transcultured and species identification was performed. The SS and ETA were considered concordant or discordant based on isolated organisms and antibiotic sensitivity profile. Clinical surveillance for VAP was done according to CDC criteria during the first week of ventilation. Results: For a total of 197 paired samples, the overall concordance of SS and ETA cultures was 71.5%, with day-wise concordances of 68, 76.2, and 73.5% for D1, D4, and D7, respectively. Gram-negatives bacteria were the most frequently isolated, with 125 (31.7%) samples reporting A. baumannii. Amongst 18 patients clinically diagnosed with VAP during the first week of MV, the concordance between SS and ETA was 73.5%, and day-wise concordance was 77.2, 72.2, and 76.9% on D1, D4, and D7, respectively. Conclusion: A fairly high microbiological concordance was observed in SS and ETA samples obtained from patients with invasive airway devices, and similar concordance was found in patients developing VAP during the first week of ventilation.

Aims and background: Glucocorticoids, vitamin C and thiamine have important biological effects in patients with sepsis and septic shock. Multiple studies have demonstrated the beneficial role of a combination therapy of vitamin C, hydrocortisone and thiamine in patients with sepsis and septic shock in terms of mortality reduction, and increase in the number of days free of ventilators and vasopressors. Materials and methods: Patients who had septic shock were assessed for eligibility after intensive care unit (ICU) admission. After randomization, the treatment group received a combination of vitamin C, thiamine and hydrocortisone for a duration of 96 hours (16 doses) and the control group received hydrocortisone for a duration till the patient was on vasopressors. The primary outcome assessed was ICU mortality, and the key secondary outcome was the duration free of vasopressor administration at the end of 7 days. Results: A total of 86 patients were included in the study. Seventy percent of patients in the control group and 58 percent in the intervention group died during ICU stay. None of the primary and secondary outcomes were statistically significant. Conclusion: The use of a combination of vitamin C, hydrocortisone and thiamine has no added benefits over the use of hydrocortisone alone in patients with septic shock. Clinical significance: The results of this clinical trial shows that the use of a combination of vitamin C, hydrocortisone and thiamine in patients with septic shock is not useful and should not be a routine practice in critically ill septic patients.

Introduction: Transferring patients between hospitals is an important aspect and is often the weak link in the health system. Robust real-time communication before transfer may be a valuable tool to improve the emergency care of children. Our study was aimed at developing evidence for the effectiveness of efficient communication networks between a tertiary care hospital and the referring hospitals in improving patient outcomes. Materials and methods: We carried out a prospective observational study conducted in two phases. After the collection of baseline data in phase I, a communication network was established between our hospital and referring hospitals as the part of intervention. The effectiveness of the intervention was ascertained in the second phase. Results: A total of 3,460 pediatric patients sought care from the emergency department of our hospital during the study period, 1,658 during phase I and 1,802 in phase II. Of the total patients admitted in pediatric emergency, 1,436 (86.61%) survived in the pre-establishment phase (phase I), and 1,762 (97.62%) survived in the post-intervention phase (phase II). The duration of stay during phase II was lower than in phase I, the difference being statistically significant. Propensity score matching analysis and interrupted time series analysis using a control chart also suggested improved survival of children during phase II after the intervention. Conclusions: Our study showed that the establishment of a communication network improved the outcome of children attending our pediatric emergency. Further research is needed to assess if the usefulness of the intervention was not due to secular trends or the difference in patient profiles between the two phases.

Purpose: This systematic review aimed to assess the accuracy of ultrasound in diagnosing shock types among intensive care patients. Materials and methods: A comprehensive search of PubMed, Embase, Scopus, Cochrane Central Register, and Google Scholar was conducted for controlled trials published up to June 2023. Two intensivists independently screened articles for full-text reviews and abstracts, evaluating study quality using the QUADAS-2 tool. Prospective studies assessing ultrasound for diagnosing shock types in critically ill patients with undifferentiated shock were included. Results: Among 7287 articles identified, four met the inclusion criteria for meta-analysis. Pooled positive likelihood ratios were 8.8 (95% CI: 2.4–32.37) for distributive shock and 137.56 (95% CI: 27.76–681.64) for obstructive shock. Summary receiver operating characteristic (SROC) curves showed an area under the curve (AUC) of 0.99 for cardiogenic and obstructive shock, 0.5 for hypovolemic and mixed shock, and 0.76 for distributive shock. Pooled negative likelihood ratios ranged from 0.05 (95% CI: 0.010 to 0.24) for cardiogenic shock to 0.22 (95% CI: 0.127–0.38) for mixed-etiology shock. Conclusion: Ultrasound demonstrates high accuracy in diagnosing obstructive and cardiogenic shock among intensive care patients with undifferentiated shock. However, its utility for other shock types appears limited.

Objectives: Heart rate control using beta-blockers in sepsis has traditionally been avoided because of concerns with worsening cardiac index and organ perfusion. Recent studies has explored the possible beneficial effects of targeted heart rate control in patients with septic shock who have tachycardia despite initial resuscitation. We performed a systematic review and meta-analysis to explore the effects of heart rate control in septic shock patients. Methods: A systematic review and meta-analysis was conducted searching for studies from PubMed, Cochrane Central, and Embase registers for randomized controlled trials (RCTs) that compared the mortality of patients with sepsis and septic shock treated with targeted rate control. The literature search was done to include studies from January 2013 to December 2023. Two independent researchers independently assessed the studies and included RCTS in which adult patients (>18 years of age) with septic shock were treated with targeted heart rate control vs placebo after initial resuscitation due to persistent tachycardia. The study data was extracted by two independent researchers. A random effects model was used to present the results. A trial sequential analysis (TSA) was performed for the primary outcome of 28-day mortality. Results: A total of 9 studies with a pooled sample size of 807 participants were included in the analysis. Eight of the included studies with a pooled sample size of 766 reported 28-day mortality. Targeted heart rate control was associated with a trend toward lower 28-day mortality [risk ratio (RR): 0.78; 95% CI: 0.62–0.99; p = 0.04; I² = 48%]. Trial sequential analysis showed the cumulative effect lying within the zone of uncertainty, with diversity-adjusted required information size of 1,756 and pooled effect size of the pooled RR 0.78 (alpha-spending adjusted 95% CI: 0.53–1.15). There was a statistically significant lower heart rate associated with rate control (MD: –16.66; 95% CI: –23.89 to –9.42; p-value < 0.001) but no difference in mean arterial pressure. cardiac index, lactate levels, norepinephrine (NE) requirements, and ICU length of stay (LOS) in between the groups. Conclusion: Targeted heart rate control in patients with septic shock may be tolerated from a hemodynamic standpoint. However, the beneficial effect on mortality is less certain than was reported in the initial studies.