Background: Although constipation occurs frequently in patients admitted in the ICU, its impact on their outcome has not been extensively studied. The aim of this study is to investigate the occurrence of constipation and its implications in patients admitted with a diagnosis of sepsis. Materials and methods: This is a prospective observational study of adult patients admitted with sepsis to a tertiary care, referral ICU, over the period of 3 months between January and March 2019, and who stayed for three or more days. Patients with gastrointestinal bleed/disorders and those who undergone major gastrointestinal surgery and failure to start feed within 72 hours of ICU admission were excluded. Results: Among the 61 septic patients, constipation occurred in 16 (26.2%) of the patients. Constipated and nonconstipated patients were equally matched in terms of gender (p = 0.082) or comorbidities. Acute Physiology and Chronic Health Evaluation II (APACHE II) score (p = 0.001), duration of mechanical ventilation (p = 0.053), and ICU mortality (p = 0.011) were higher in the constipation group. Conclusion: Monitoring the frequency of bowel movements in critically ill patients admitted with sepsis and the avoidance of constipation can decrease duration of mechanical ventilation and mortality rate in ICU.

Background: The standard practice for catheterization of needle-based interventions such as cannulation of the internal jugular vein (IJV) is performed by using the guidance of ultrasound (US) for vascular access during anesthetic care. Catheterization of IJV is the most common site for central venous access due to lower mechanical complications rates during insertion of a central venous catheter (CVC) compared to other routes such as subclavian vein. The purpose of this study was to determine the influence of respiration and position of the patient in awake and anesthetized conditions on the size of IJV. Materials and methods: This study was a prospective cohort study conducted on cardiac surgical patients. The dimensions of the right IJV (RIJV) were measured during two phases of respiration (inspiration and expiration) using 2-dimensional (2D) US with the patient in supine and Trendelenburg positions in both awake and anesthetized mechanically ventilated states. Results: It was found that the Trendelenburg position during spontaneous breathing was the most favorable state for IJV puncture as the anteroposterior (AP) as well as lateral diameters both increased significantly during inspiration, and the lateral diameter increased significantly during expiration. The Trendelenburg in a mechanically ventilated state resulted in an increase in the AP and lateral diameters during inspiration, but there was no change during expiration. There were no complications during the study. Conclusion: The Trendelenburg position in awake spontaneously breathing patients is the most favorable state for performing IJV puncture.

Critical care medicine (CCM) is a universally recognized branch of specialized medicine that is ubiquitous, spreading from large metropolitan cities to 2-tier cities, to district headquarters hospitals. Training in CCM is necessary to manage patients who need intensive care management. CCM warrants having high-quality training that imparts sound theoretical and practical knowledge. Additionally, the training must be uniform throughout the nation. Uniformity of training assures a standard form of care anywhere in the country and enhances the chance of employability of the candidates irrespective of place of training. Toward this effort, we propose the implementation of a “modular training program” in Intensive Care Medicine. This aims to maintain uniformity of syllabus, uniformity of training regarding practical skills, incorporate access to national-level training, through structured training and educational programmes that include online/offline classes, standardized internal assessment/evaluation as well as external examination and certification. This training encompasses incorporates impetus for research activity, during the training period.

Fluid therapy is one of the interventions in a day-to-day practice. It is predominantly used for resuscitating a patient with acute circulatory failure. Fluid therapy aims to improve macrocirculation and thereby oxygen delivery at the tissue level. Various fluids are available for resuscitating patients, classified into crystalloids or colloids. Still, we lack the ideal fluid for resuscitation. Colloids once promised to be the ideal fluid for resuscitation, their effectiveness has been questioned by the recent evidence and also indicated the possible harm associated with its use. Is there any truth in the matter?

Angiotensin receptor blockers are commonly used to treat hypertension. However, the toxicity of this medication can be life-threatening and can cause severe hypotension and refractory shock. There are no case reports or published guidelines for its management. We hereby present a case of a young female with telmisartan overdose who was managed with multiple vasopressors and rescue therapies like methylene blue, high-dose glucose-insulin infusion, ascorbic acid, thiamine, steroids, and other agents. Early detection and intensive management of refractory shock are necessary to prevent mortality.

Panhypopituitarism and adrenal crisis may mimic a case of septic shock, to begin with, and diagnosis is sometimes difficult. A definitive diagnosis is crucial for a successful outcome. Generalized weakness associated with symptoms such as drowsiness, altered sensorium, and easy fatigability are the common presentations in patients presenting to the emergency department. The symptoms may be related to the nervous system (central as well as peripheral), metabolic disorders, electrolytes, endocrinopathy, infectious diseases, toxins, trauma, etc. Early recognition with prompt management helps in preventing life-threatening complications. We describe a case of a 50-year-old female who presented with drowsiness and generalized weakness which initially appeared as a septic shock but on detailed workup was found to be suffering from hypopituitarism. In the laboratory, the workup patient was found to be having decreased levels of pituitary hormones which were suggestive of hypopituitarism. In this case, presented here, the magnetic resonance imaging (MRI) of the brain was suggestive of “empty sella.” It is a rare disorder and patients with empty sella may be asymptomatic or present with one or more pituitary hormone deficiencies. The patient was treated with hormone replacement therapy to which the patient responded well and progressively improved.

Awake extracorporeal membrane oxygenation (ECMO) is a new concept that is evolving in the current day scenario of intensive care practice worldwide. It is indeed a phenomenal initiative towards early mobilization of patients, despite being on cardiopulmonary/pulmonary assist devices attached to the patients. This has prevented many complications associated with long stays in hospitals as well as cost-saving practices. Although awake ECMO has its own pros and cons and poses lot many challenges to the intensivists, nevertheless it has been shown to benefit patients and reduce morbidity. In this submission, we are describing two representative cases of awake ECMO: the first one is a patient with COVID-19- induced acute respiratory distress syndrome with venovenous ECMO and the other patient is a post-pulmonary endarterectomy patient on venoarterial ECMO for refractory ventricular tachycardia. These two cases illustrate not only the feasibility but also the successful outcome of awake ECMO.

Polysubstance abuse is an established rampant problem in the current young generation with advent of easy availability and uncontrolled use of emerging supplements for bodybuilding. Our case report depicts a rapidly progressive multi-organ dysfunction with acute presentation due to polysubstance abuse. This brawny physique young male was admitted to the intensive care unit (ICU) with unusual complaints of shooting pain, paresthesia, and weakness of both lower limbs but massively altered blood parameters. On careful and detailed history taking he was found to be known to consume cannabidiol oil, anabolic steroids, amino acid supplements, cocaine, and alcohol. The key to this case was to keep an eye on suspicious ways of presentation, detailed history, and careful examination. Emphasis on questions the surrounding substance abuse should be an integral part of the history taking process. His organ failures resolved with appropriate treatment during ICU stay to be stepped down toward and later discharged home.

Introduction: The Mount Fuji sign is a common sign of tension pneumocephalus, usually occurring after surgical evacuation of subdural hematomas (SDHs). It may be suspected when such postsurgical patients present with headache or vomiting or other neurological signs and is diagnosed by computed tomography (CT) scan of the brain. It usually occurs within the immediate postoperative period but may rarely be seen even months after the surgery. Case report: We present the case of a 69-year-old male who developed a subdural collection of air, following surgery to evacuate a subdural hematoma. Conclusion: The patient was successfully treated with conservative measures including administering 100% oxygen, adequate analgesia and Fowler's position. However, severe neurological symptoms such as seizure or obtundation warrants emergency decompression.

With several contradictory reports on the efficacy of hydroxychloroquine (HCQ) on COVID-19, the Indian Council of Medical Research (ICMR) recommended its use for prophylaxis and treatment of mild cases during the first wave of the pandemic. Amidst all the controversies, there have been a few cases reported of significant methemoglobinemia and hemolysis in COVID-19 cases being treated with HCQ. The diagnosis of methemoglobinemia amidst this COVID-19 crisis is really challenging owing to similar clinical manifestations. We present a case series where methemoglobinemia was promptly detected and managed efficiently, resulting in the uneventful discharge of all three cases. This is to be understood that undiagnosed cases of methemoglobinemia can be potentially fatal due to hypoxic stress on the body. If the condition is not being detected timely, leading to dangerous levels of untreated methemoglobinemia may cause a case of fatality falsely attributed to COVID-19. However, when the HCQ is not being used for COVID-19 presently, still clinicians must know different drugs that can cause methemoglobinemia and should promptly intervene to avoid any catastrophe.

Introduction: Myoclonus is an involuntary, jerky body movement that is a sign of encephalopathy due to various underlying pathologies, one of which is dengue encephalopathy. Often, these movements are subtle and suppressed by the frequent use of sedatives and paralytic agents. Case report: A 67-year-old male diagnosed with dengue encephalopathy presented with involuntary jerky movements of his face, which were confirmed as orofacial multifocal myoclonus by electroencephalogram (EEG) studies. Conclusion: It is important to recognize myoclonic movements and look for an underlying cause.