Background and purpose: Intrahospital transport (IHT) of critically ill patients is essential for diagnostic and therapeutic indications, requiring thorough assessment and careful preparation of patients, staff, and equipment throughout the process. Variability in practices among hospitals can affect patient safety and may result in adverse events (AEs). This position statement is designed to provide guidance to multidisciplinary critical care teams in the adoption of evidence-based recommendations aimed at mitigating risks and improving safety during patient transport. Method: This position statement has been drafted by an expert committee on IHT constituted by the Indian Society of Critical Care Medicine. The process involved thorough review of literature from electronic database using PubMed services. Recommendations made are tailored with considerations for Indian setting; the units may further modify these as per local needs and equipment and staffing available. The final manuscript was written after achieving consensus among members, and final draft was accepted by all the committee members. Results: This position statement offers a compilation of 38 strategic recommendations, which are comprehensive and deal with all aspects of IHT of the critically ill. Recommendations provided in this document are, therefore, applicable for routine use during the IHT. They cover all phases of transport and answer questions pertaining to pre-, intra-, and post-transport considerations. It will help to achieve uniformity, minimize AEs, and enhance safety. Conclusions: This is a standard set of 38 evidence-based recommendations to ensure safety for IHT, tailored for implementation in various criticalcare settings across India. Science is ever-changing, and periodic review will be needed to keep it up to date with emerging evidence and standards.

Background: Advanced care planning (ACP) and advance medical directives (AMDs) are vital for aligning medical decisions with patient preferences, particularly for end-of-life care. The 2018 Supreme Court judgment in India established the legality of AMDs, enabling patients to exercise their autonomy. Recent amendments in 2023 simplified procedural requirements, replacing judicial magistrate approval with a streamlined two-tier medical board system. This article proposes a culturally sensitive and practical 12-step framework for implementing ACP and AMDs in India. Materials and methods: A structured and consensus-driven process was undertaken by experts in palliative medicine, neurology, critical care, and geriatrics, supported by key medical organizations. The development process included multiple iterations, public consultations, and feedback from legal and medical stakeholders. The framework integrates legal, ethical, and cultural considerations to address procedural and systemic challenges in ACP implementation. Results: The proposed 12-step pathway focuses on three phases: creating living wills, periodic reviews and updates, and executing AMDs. Key components include initiating discussions, identification and appointment of surrogate decision-makers, ensuring legal compliance through simplified procedures, and providing guidance for withholding or withdrawing life-sustaining treatments. Implementation strategies emphasize public awareness, provider training, and institutional policies to normalize ACP. Simplified legal requirements introduced in 2023 facilitate broader adoption and reduce procedural barriers. Conclusion: This framework provides a practical, culturally relevant model for ACP in India, ensuring patient-centered, ethical, and transparent end-of-life care. By integrating simplified legal procedures and addressing misconceptions through education and policy initiatives, the proposed approach empowers individuals, families, and healthcare providers to make informed decisions, fostering dignity and autonomy in medical care.

Background: Ventilator-associated pneumonia (VAP) remains a major challenge while managing ventilated critically ill patients in neurocritical care units (NCUs). Materials and methods: This was a prospective, single-center, observational study. All adult patients admitted to our NCU requiring mechanical ventilation (MV) for >48 hours were screened for VAP as per clinical pulmonary infectious score (CPIS) criteria. The primary outcome was the incidence of VAP in the ICU. Secondary outcomes were risk factors, microbiology, percentage of MDR/XDR organisms, mortality, and length of stay (LOS) of VAP. Results: A total of 24.94% (114 of 457) patients developed VAP. The incidence of VAP was 39.43/1000 ventilator days. Multivariate analysis of the risk factors identified, male gender, low Glasgow coma scale (GCS) of 3–8, prolonged ventilation, and diabetes mellitus as significant risk factors for the development of VAP (p < 0.05). Acinetobacter baumannii (31.58%), Klebsiella pneumoniae (28.95%), and Pseudomonas aeruginosa (13.16%) were the most common organisms responsible for VAP. Most of these isolates were multidrug resistant (MDR) (81.58%), and extensively drug-resistant (XDR) organisms (12.28%). Although VAP patients had longer ICU-LOS (26.2 ± 24.2 vs 11.8 ± 6.9 days, p < 0.0001), it did not affect the mortality (18.4% for VAP vs 14.3% for non-VAP, p = 0.5). Conclusion: Ventilator-associated pneumonia has a high incidence of 39.43 per 1,000 ventilator days in the Indian neurocritical care setting.

Aim/background: Fiberoptic bronchoscopy (FOB) is the gold standard for assessing airway involvement in burn patients but is invasive. Ultrasound (USG) has not been previously used to evaluate the airway in burn patients. Our study evaluated the feasibility of using USG to assess airway involvement in inhalational burn injury and correlated its efficacy with FOB. Materials and methods: This prospective observational study was conducted in the burns intensive care unit (ICU) of a tertiary care hospital. Bedside airway USG was performed to evaluate vocal cord (VC) width for edema and other airway parameters, including tongue thickness, pre-epiglottis space depth, inter-arytenoid distance, epiglottis-to-midpoint of VC, distance between the true VCs, distance between the false VCs, tracheal wall thickness, and tracheal air column width. Fiberoptic bronchoscopy was then performed to assess airway involvement, and findings were correlated with USG at the VC level. Results: About 51 patients were included. Airway USG assessment was able to predict the VC edema, correlating with FOB findings in 30 patients. Ultrasound showed a sensitivity and specificity of 85.2 and 81.3%, respectively, with a positive and negative predictive value of 90.9 and 72.2%, respectively, for assessing airway edema at the level of VC. The mean right and left VC widths were 21.15 ± 9.52 mm and 22.03 ± 9.52 mm, respectively, in patients with VC edema. The pre-epiglottis space in patients with (n = 33) vs without VC edema (n = 18) was found to be statistically significant (14.5± 5.64 mm vs 10.87 ± 4.36 mm; p = 0.02). Conclusion: Ultrasound can be used as a reliable, non-invasive bedside predictor of airway involvement in patients with suspected inhalational injury.

Background: Advanced age is a known marker of vulnerability, but frailty is an independent predictor of poor outcomes in critically ill patients. The clinical frailty score (CFS) facilitates rapid assessment, aiding prognostication, care improvement, and resource allocation, particularly in resource-limited intensive care units (ICUs). Materials and methods: A prospective observational cohort study was conducted from April to September 2023 at a tertiary care ICU. The study included 166 patients aged ≥50 years with ICU stays longer than 48 hours, excluding those with contraindications for care escalation. Data were collected on demographics, Clinical parameters, and scoring systems including acute physiological and chronic health evaluation II (APACHE-II), sequential organ failure assessment (SOFA), Charlson comorbidity index (CCI), and CFS. Predictive analyses were performed using receiver operating curve (ROC) curves, cut-offs, and logistic regression. Results: The median age of patients was 65 years, with an APACHE-II score of 18 and a CFS of 4. In-hospital mortality was 46.4%. The CFS outperformed other scoring systems in predicting both in-hospital mortality [Area under the receiver operating characteristic curve (AUC-ROC) 0.73] and net negative outcomes (AUC ROC 0.75). Frailty (CFS ≥6) was present in 39.75% of patients, with each unit increase in CFS associated with a 41.8% higher odds of mortality and a 50.7% higher odds of net negative outcomes. The optimal CFS cut-offs were 4 for 80% sensitivity and 6 for 80% specificity. Conclusion: The CFS is a practical and reliable tool for predicting ICU outcomes, outperforming traditional scoring systems. It supports improved decision-making and resource allocation. Further multicenter studies are necessary to validate its broader use in critical care practice.

Introduction: High quality and effective ventilation system operation plays a major role in maintaining indoor air quality in critical care unit (CCU). Aim of this study was to detect the role of antimicrobial-air-purifier in reducing the colony counts of microbes in air and high surface. Methods: This prospective study was conducted in CCU over a period of 18 months from November 2022 to May 2024 after approval from Hospital Ethics Committee. Microbial load was tested in CCU in the presence of and absence of purifier and air/high touch surface sampling was done by using settle-plate method on consecutive days in two phases (with/without purifier). Microorganism culture and identification was done using VITEK-2, and colony counting was performed using Omeliansky formula. Results: The comparison of microbial load in the CCUs between two phases revealed significant difference in the air and surface on days 1, 7, 14, 30, and 60 (p < 0.0001). Among gram-positive cocci (GPC), the most common isolate identified was coagulase-negative Staphylococcus species [35 (92.10%)], followed by Micrococcus luteus [5 (13.15%)] and Staphylococcus aureus [1 (2.63%)]. All GPC were resistant to methicillin and erythromycin while 1 (5%) strain was resistant to vancomycin, teicoplanin, and linezolid. Among gram-negative bacilli (GNB), the most common isolate was Acinetobacter species [8/23 (34.78%)], followed by P. species [5 (21.74%)]. About 19−23 (85−100%) GNB strains were resistant to third-generation cephalosporins and beta-lactam and beta-lactamase inhibitors. About 9−15 (42.3−67.64%) were resistant to tigecycline and carbapenems. Decreased bloodstream infections/catheter-associated urinary tract infections (CAUTI) rate of 3.49−2.92/3.97−1.95/1,000 patient-days was observed in CCU, while the device utilization ratio was same. Conclusion: Antimicrobial air purifier showed an effective role in decreasing the central line-associated blood stream infections and CAUTI rates in CCU.

Background and objective: Certain serum biomarkers have been reported to predict the severity and mortality of community-acquired pneumonia (CAP). There is a dearth of studies on this subject in the Indian population in patients with CAP. The present prospective observational study was conducted to find the utility of the blood urea nitrogen (BUN)/serum albumin (B/A) ratio as a biomarker to predict the severity and mortality in patients with CAP. Materials and methods: All 90 patients aged ≥ 18 years of either sex, with a new radiographic infiltrate, were included. Various biochemical parameters such as BUN, serum albumin, and procalcitonin were tested. The serum B/A ratio was calculated. A chest radiograph was obtained. Patients were followed up for the duration of their stay in hospital till discharge or death. Results: The sensitivity and specificity of the B/A ratio at the optimum cut-off value of 10.66 to predict the severity of CAP was about 79.0%, whereas the sensitivity and specificity of the procalcitonin at the optimum cut-off value of 1.50 ng/dL to predict the severity of CAP were 71.15 and 84.21%, respectively. The sensitivity and specificity of the B/A ratio at the optimum cut-off value of 19.8 to predict the mortality of CAP was about 99.0%, whereas the sensitivity and specificity of the procalcitonin at the optimum cut-off value of 5.55 ng/dL to predict the mortality of CAP was about 92.0%. Conclusion: The B/A ratio and procalcitonin are simple but independent predictors of mortality and severity of CAP.

Introduction: Catheter-associated urinary tract infections (CAUTIs) account for 80% of nosocomial UTIs and 40% of hospital-acquired infections, making them the most common healthcare-associated infections globally. Despite the rise of quinolone-resistant Escherichia coli and extended-spectrum β-lactamase-producing gram-negative bacteria, fluoroquinolones remain a common empirical treatment. Understanding antimicrobial resistance (AMR) associated with CAUTIs is critical. Methods: A prospective observational study was conducted from November 2023 to July 2024 at Deenanath Mangeshkar Hospital, Maharashtra, India. The study included catheterized patients in the intensive care unit (ICU) with a duration of over 48 hours showing UTI symptoms, including fever, suprapubic discomfort, urgency, or dysuria. Among 80 patients (mean age 56.75 ± 23.65 years; 53% male), bacterial isolates, resistance patterns, and risk factors were analyzed. Results: Catheter-associated UTIs developed in 59 patients (73.75% prevalence; 83.1 per 1,000 catheter days). Patients aged over 60, hospitalized for more than 10 days, or with comorbidities like diabetes (51.3%), hypertension (HTN) (37.5%), or chronic kidney disease (10%) were at higher risk. Escherichia coli and Klebsiella pneumoniae were the most common pathogens (34.14%), with gram-negative bacilli constituting 84.74% of isolates. Candida species, particularly C. tropicalis (34.78%) and C. auris (26%), were also significant. Conclusion: This study identifies E. coli, K. pneumoniae, and Candida species as major CAUTI pathogens, with substantial multidrug resistance among gram-negative bacteria. Regular AMR surveillance and targeted infection control strategies are essential to combat CAUTI-related challenges and improve clinical outcomes.

Introduction: Amongst the non-fermenting gram-negative bacteria (NFGNB), Pseudomonas (P.) and Acinetobacter species predominate the landscape. However, less common NFGNB such as Burkholderia, Stenotrophomonas, Achromobacter, Ralstonia and Elizabethkingia species, amongst others, are assuming increasing importance. We describe a single-center experience of bacteremia caused by rare NFGNBs in an Indian intensive care unit (ICU). Materials and methods: A retrospective study of adult patients with bacteremia caused by rare NFGNB in the ICU. Results: Of the total 205 cases, Burkholderia (B.) species (43.4%, n = 89) were the commonest, followed by Stenotrophomonas species (20.4%, n = 42). The bacteremia was related to an indwelling catheter in 42.9 % of the patients. The median duration of hospitalization preceding the bacteremia was 16 days. Except for B. Achromobacter and Aeromonas species, meropenem showed high rates of resistance. Overall, cotrimoxazole, levofloxacin and minocycline were the most effective antibiotics active in vitro; with some differences noted specific to different organisms. The overall day 28 mortality was 34.1%. On multivariate analysis, the presence of shock (p = 0.008, CI: 1.188–5.052) and receipt of steroids (p = 0.015, CI: 1.032–3.891) were significantly associated with mortality. Conclusions: This is one of the largest studies from India, describing the landscape of NFGNB causing bacteremia in the ICU. Our study shows that these infections are acquired late during the course of hospitalization, have limited therapeutic options, and can be associated with significant mortality. Implementation of stringent infection control practices is needed to reduce this threat.

Aim and background: Antimicrobial sensitivity (AMS) reports are often available after 72 hours of identification of gram-negative (GN) hospital-acquired infection (HAI). Prediction of carbapenem-resistant infection (CRI) among GN strains is important even before AMS reports are available, for judicious use of empirical antibiotics. We aimed to study the predictors of CRI in patients with HAI. Materials and methods: We conducted a single-center prospective observational study between April 2023 and September 2024 on patients of GN sepsis with HAI. The use of empirical carbapenem antibiotics, organ dysfunction scores, the modified nutritional risk in critically ill (mNUTRIC) score, blood-count-derived inflammation indices, type of HAI, AMS reports, and in-hospital mortality were noted. Results: A total of 935 sepsis patients with HAI were screened, and there were 195 patients with GN infection. Among the 195 patients, 145 (74.4%) had CRI and 50 (25.6%) had non-CRI. Multivariable logistic regression revealed that the length of intensive care unit (ICU) stay before the day of HAI (p = 0.009, adjusted odds ratio (OR) 1.155, 95% confidence interval (CI) 1.037−1.286), presence of ventilator-associated pneumonia (VAP) (p-value < 0.001, adjusted OR 4.170, 95% CI: 1.858–9.361), empirical carbapenem antibiotics before the day of HAI (p-value = 0.004, adjusted OR 3.164, 95% CI: 1.439–6.957), and septic shock on the day of HAI (p-value 0.012, adjusted OR 4.162, 95% CI: 1.366–12.677) were the independent risk factors of CRI. Conclusion: In GN sepsis patients with HAI, respiratory infection (VAP), length of ICU stay prior to HAI, septic shock, and empirical carbapenem antibiotic administration are risk factors of CRI.

Background: The potential benefits of safe physiotherapy are immense, which may mitigate the devastating functional impairments caused by critical illness. However, there is sparse data on its safety with respect to hemodynamic changes, including the level of vasopressor therapy at which physiotherapy is deemed safe. Materials and methods: The hemodynamic parameters were recorded before, after, and every 5 minutes during physiotherapy in a total of 107 patients. Cardiac output was measured by Doppler ultrasound. Based on the type of physiotherapy, the study participants were grouped into active and passive groups. The frequencies of predefined adverse events were captured. Results: Of the 107 study participants, 65 received active physiotherapy (Group I) and 42 passive physiotherapy (Group II), with 29% on noradrenaline infusion. There was an increasing trend in each of the hemodynamic parameters after physiotherapy, as compared to rest. The mean changes in parameters before and after physiotherapy were heart rate 6.04/min; respiratory rate 3.9/min; systolic blood pressure 5 mm Hg; diastolic blood pressure 3.3 mm Hg; mean arterial pressure 3.4 mm Hg, cardiac output 0.752 L/min; and SpO₂ 0.44%. Despite being statistically significant, the small changes after physiotherapy lack clinical significance. Subgroup analysis between the active and passive physiotherapy groups was also done. The incidence of adverse events was 10.2%. Conclusion: Physiotherapy may be well tolerated in critically ill patients, even when there is a requirement for vasopressor support. Transient hemodynamic changes likely reflect physiological compensation for increased oxygen demand during physiotherapy, with low adverse event rates highlighting its safety in the intensive care unit (ICU). (CRTI Registration number: CTRI/2022/09/045766)

Aim and background: Hypervirulent Klebsiella pneumoniae (HvKp) is a virulent strain associated with invasive infections. While initially community-acquired, hospital-acquired HvKp (HA-HvKp) and carbapenem-resistant HvKp (CR-HvKp) are increasingly reported. This meta-analysis evaluates the prevalence, risk factors, and clinical outcomes associated with HvKp, including CR-HvKp and HA-HvKp, among Kp infections. Methodology: A systematic search of PubMed, Scopus, Embase, and Cochrane Library was conducted until December 2024. Observational studies comparing HvKp vs classical Kp (cKp), CR-HvKp vs carbapenem-sensitive HvKp (CS-HvKp), and HA-HvKp vs community-acquired HvKp (CA-HvKp) were included. Quality was assessed using the Joanna Briggs Critical Appraisal Tool, and pooled prevalence and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results: Fifty studies with 6,663 participants were included. The HvKp prevalence was 33.0%, with most studies from Asia, predominantly China. Temporal analysis revealed an increase in HvKp prevalence (27.7% in 2006–2018 to 38.5% in 2019–2024). The CR-HvKp prevalence rose from 9.5% to 16.5% (2016–2024). The HA-HvKp prevalence increased from 25.9 to 47.1%. Key risk factors included diabetes mellitus (OR = 1.56), CA-Kp (OR = 2.59), and hypermucoviscous (HM)-phenotype (OR = 29.79). Complications included liver abscess (OR = 6.35), metastatic spread (OR = 4.74), meningitis (OR = 11.14), and septic shock (OR = 1.30). Mortality was higher in HvKp infections but not statistically significant (p = 0.219). HA-HvKp and immunosuppression were significant CR-HvKp risk factors, with CR-HvKp showing higher mortality. Conclusions: Diabetes mellitus, CA-Kp infections, and HM-phenotype are significant risk factors for HvKp. The rising prevalence of CR-HvKp and HA-HvKp highlights the need for early detection, infection control, and targeted treatment strategies.