Background: Sepsis is a life-threatening organ dysfunction, and acute kidney injury (AKI) is one of the most common complications of sepsis, as well as a cause of high mortality. This study aimed to determine the differences in the incidence of AKI, renal perfusion, clinical course, and outcome of septic patients with preserved or poor ejection admitted to the intensive care unit (ICU) of a tertiary care hospital. Materials and methods: This prospective, observational study included all consecutive patients admitted with septic shock to the ICU from March 2020 to November 2021. Index echocardiography was done within the first 6 hours of admission to the ICU. The vital hemodynamic parameters, dose of vasopressors, serum lactate, urine output, central venous pressure (CVP), and renal resistive index (RRI) were monitored at admission and 1, 6, 12, 24, and 48 hours following the start of vasopressors, with 0 hour being the time for initiation of vasopressors. Serum creatinine and sequential organ failure assessment (SOFA) scores were measured every day for 72 hours. Results: Among 50 adult patients, there were 17 patients with ejection fraction (EF) <40% (group I) and 33 patients with EF ≥40% (group II). The heart rate and CVP were higher in group I at baseline and at the start of vasopressor following fluid resuscitation. There was a significant difference in CVP between the groups at 0 hours, with mean CVP being higher in group I and this difference persisted for a few hours after the start of vasopressors (p = 0.02 at 1 hour and p = 0.2, nonsignificant at 6 hours). The difference in 28-day mortality was not significant between the groups (p = 0.62). The incidence of AKI between the two groups was 47% (eight patients) and 79% (26 patients), respectively, and the difference was statistically significant (p = 0.001). Around 35% of patients in group I had stage 3 AKI (six patients among eight); however, in group II, only 9% (three patients) were in stage 3 AKI. The higher incidence of AKI in group II was mainly contributed to patients in stages 1 and 2 of AKI. However, serum lactate was significantly higher in group II at 0 hours, and this difference persisted for 6 hours. While renal perfusion parameter, RRI, and urine output were comparable between the groups at 0 hours but showed decreasing trends earlier in group I. There was a significant decrease (p = 0.046) in RRI accompanied by an increase in urine output (p = 0.006) in group I patients with septic shock following initiation of dobutamine. Conclusion: Sepsis is associated with high mortality, but AKI in septic patients was not dependent on the cardiac status of the patient. The patients with preserved EF received vasopressors to achieve hemodynamic stability. Hence, we conclude that the early choice and dose of vasopressors might have a beneficial effect on renal perfusion and reduce the incidence of stage III AKI.

Background: The supraclavicular brachial plexus block (SBPB) is a widely used approach in regional anesthesia (RA). The use of ultrasound (USG) guidance significantly reduces the complications of SBPB. Recent advancements suggest that combining lower concentrations of levobupivacaine with dexmedetomidine can maintain efficacy while minimizing adverse reactions. Levobupivacaine 0.5 and 0.25% have been used in combination with dexmedetomidine at doses of 1 µg/kg of body weight; however, the effects of concentrations of levobupivacaine (0.375 and 0.25%) on block parameters and hemodynamics in SBPB, when combined with a fixed dose of dexmedetomidine, for upper limb procedures, remain underexplored. This study investigates the efficacy of 0.375 and 0.25% levobupivacaine, combined with a fixed dose of dexmedetomidine, in USG-guided SBPB. Materials and methods: A prospective, randomized, double-blind trial was conducted on a total of 60 patients scheduled for elective upper limb surgery from June 2021 to May 2022 at our regional medical center. Participants were divided into two groups of 30 each. Group I received 30 mL of 0.375% levobupivacaine with 1 µg/kg dexmedetomidine, and group II received 30 mL of 0.25% levobupivacaine with 1 µg/kg dexmedetomidine. The duration of analgesia was the primary outcome. The onset and duration of sensorimotor blockade, hemodynamic variables, sedation score, and adverse effects were secondary outcomes. Statistical analysis was performed using appropriate tests in Excel for Windows ver. 15, 2013, United States of America. Results: Group I exhibited a significantly faster onset of sensory block (3.93 ± 1.70 minutes) compared to group II (6.07 ± 1.53 minutes). Additionally, group I patients experienced earlier paresthesia and paralysis of the hand and shoulder joints. The duration of analgesia was significantly longer in group I (p < 0.05). Hemodynamic evaluation 2 hours postblock showed no significant differences in mean blood pressure or heart rate between the groups (p > 0.05). Sedation scores, measured using the modified Ramsay Sedation Scale, were comparable between the groups (p > 0.05), with average scores of 2.27 ± 0.45 for group I and 2.23 ± 0.43 for group II. Conclusion: Both concentrations of levobupivacaine, when combined with dexmedetomidine, provided effective surgical anesthesia. However, 0.375% levobupivacaine resulted in a faster onset and prolonged sensory and motor blockade duration compared to 0.25% levobupivacaine. Neither combination resulted in significant side effects or complications, highlighting their safety and efficacy for SBPB.

Environmental stewardship, the greenhouse effect, global warming, and climate change are common phrases that have been increasingly used over the past few decades, promoting change in society. Carbon footprints in healthcare are increasing at an alarming rate, with intensive care wastes contributing a significant percentage. Therefore, it is crucial to implement measures that promote environmental sustainability in these units. A literature search for articles/publications was conducted using keywords such as “green intensive care unit (ICU),” “environmental sustainability in the ICU,” and “carbon footprints of intensive care” in the PubMed database. This review paper discusses opportunities for critical care medicine to reduce its environmental hazards and implement sustainable practices in the intensive care unit.

Biomarkers in critical care have increased manyfold. However, only a few of them are used in clinical practice. Biomarkers are considered as tools that help to make clinical decisions easier. Usage of biomarkers aids clinicians in the diagnosis and treatment of cardiac conditions like myocardial infarction (MI), acute decompensated heart failure (ADHF), and several malignant conditions. In conditions such as sepsis and acute respiratory distress syndrome (ARDS), there are no clear guidelines on the use of biomarkers currently. Hence, biomarkers have been slow to gain relevance in intensive care medical practice. The purpose of this literature review is to discuss few biomarkers currently available that can potentially help for decision-making and management of critically ill patients. Literature search from 2010 to 2023 for articles published in medical databases (PubMed, CrossRef, Google Scholar, Cochrane database) on biomarkers in critical care was performed, and clinically important markers were chosen for review. There is a renewed interest in the field of biomarkers relevant to intensive care unit (ICU). The most studied biomarker is procalcitonin; its usefulness in sepsis and de-escalation of antibiotics is emphasized. Newer biomarkers are aimed to help in assessment and management of critical patients with left and right heart failure, systemic and pulmonary congestion, and renal failure. There are biomarkers that help in ARDS and ventilator management. Several other biomarkers are still in the pipeline. Use of biomarkers in critical care practice is in the uptrend. In future, along with clinical assessment, use of biomarkers will be helpful for managing critically ill patients and is likely to be incorporated into prognostic scoring.

Traumatic internal carotid artery dissection (TICAD) is a rare condition that can be associated with severe neurological disability or even death. We describe a male patient who was admitted to a tertiary care facility after a fall from a two-wheeler. The patient sustained multiple abrasions over the chest and abdomen. Computed tomography (CT) of the brain revealed multiple patchy infarcts in the bilateral cerebral hemispheres. The patient was electively intubated in the intensive care unit (ICU) due to a poor Glasgow Coma Scale (GCS). CT angiography (CTA) of the neck vessels and the brain showed significant focal narrowing (90%) in the distal left internal carotid artery (ICA) just before entering the petrous temporal bone, suggesting a thrombus secondary to dissection. After multidisciplinary team discussions, the patient was treated with aspirin, enoxaparin, and other supportive measures. The patient improved clinically and was discharged home without any neurological deficits.

For patients who have suffered traumatic brain injury (TBI) or are planned for neurosurgical procedures, cerebral perfusion pressure (CPP) monitoring becomes essential for maintaining adequate cerebral blood flow. While measuring intra-arterial blood pressure, the transducer should be zeroed to the level of the tragus. Any erroneous measurement of CPP may lead to the failure of CPP-guided therapies. In neurosurgical patients, the head end of the patient is wholly draped and surrounded by the surgical personnel, which makes identifying the tragus and precise leveling of the transducer to the tragus from the foot end extremely difficult. To overcome this difficulty, we have devised a spirit level that can accurately confirm that the transducer is at the level of the tragus. The described device is easily assembled with the components easily available in the operation room. The device is regularly being used in our daily practice with excellent results.

Tube feeding via enteral access tubes is very commonplace in healthcare and home care settings. However, for various reasons, the majority of the world relies on blenderized kitchen feeds prepared in home kitchens or hospital kitchens. This state-of-the-art review explains in detail the benefits, risks, complications, advantages, and disadvantages of using blenderized tube feeding and commercial feeding formulas and provides suggestions after presenting the evidence in this regard.

Hepatopulmonary syndrome (HPS) is a condition characterized by hypoxemia with partial pressure of oxygen (PaO₂) <80 mm Hg or alveolar–arterial oxygen gradient (A-aO₂) ≥15 mm while breathing room air, pulmonary vascular dilation, and portal hypertension (with or without cirrhosis). The incidence ranges from 5 to 32% in cirrhosis patients. The hypoxia associated with HPS is usually refractory to increasing concentrations of oxygen indicating an underlying right-to-left shunt. An echocardiogram bubble study is used to differentiate between intrapulmonary or intracardiac right-to-left shunt.

A 36-year-old male patient with no known comorbidities was referred from another hospital with a history of fever and skin rash for 10 days. He had been clinically diagnosed with varicella-zoster and empirically started on intravenous acyclovir. He had a progressive worsening of dyspnea for which he was brought to this hospital. Blood gases and high-resolution computed tomography (HRCT) of the chest were suggestive of severe acute respiratory distress syndrome (ARDS). He was intubated and mechanically ventilated in the prone position but had a rapidly deteriorating course, eventually succumbing to multiorgan failure and septic shock. Skin biopsy and bone marrow results were inconclusive. Polymerase chain reaction (PCR) for tropical fever viruses showed positive for varicella-zoster immunoglobulin M (IgM). The present case highlights the possibility of varicella-zoster occurring in immunocompetent individuals and the need to be aware of possible complications such as pneumonia.