Context:Traditionally, intensive care unit (ICU) discharge has followed a tiered approach of managing cases, i.e., patients are transferred to a general or parent surgical ward or high-dependency unit before being discharged to home. This practice assumes that some additional time is mandatory to observe patients who are recovering from the illness. With latest improvisations in postdischarge services for direct discharge to home (DDH), the balance is shifting in favor of DDH. Aims:To compare the clinical outcomes and safety of ICU patients discharged directly to home with those transferred to hospital wards before being discharged. Settings and Design:Prospective cohort study done at a tertiary care hospital. Methods:According to patient's discharge or transfer to ward (TTW), they were grouped in either of the two: Group D: Direct discharge to home (DDH), Group W: TTW (minimum stay in ward 24 h). All patients were followed up to 3 months of discharge/transfer. Statistical Analysis Used:Continuous data of two independent groups were compared by independent Student's t-test, whereas categorical data by Chi-square (χ2) test were used. A two-tailed (α =2) P < 0.05 was considered statistically significant. Results:The results showed that ICU patient discharged directly to home had better post-ICU recovery for 90 days' follow-up. Conclusions:ICU patients discharged directly to home have significantly better clinical outcomes and safety, when applied to carefully selected ICU patients compared to those transferred to hospital wards before being discharged.
Background:Upper gastrointestinal bleeding (UGIB) remains a common medical emergency associated with significant morbidity and mortality. Early risk stratification is essential to identify patients who require urgent intervention. The Glasgow-Blatchford Score (GBS) is widely used to assess UGIB severity at presentation; however, data regarding its performance in the Indian population are limited. This study aimed to evaluate the ability of the GBS to predict the need for blood transfusion and early endoscopy among patients presenting with UGIB. Methods:A retrospective observational study was conducted at a tertiary care hospital in South India over a period of 2.5 years. Medical records of adult patients (18-80 years) presenting to the emergency department with clinical features of UGIB were reviewed. Demographic, clinical, and laboratory parameters required for calculating the GBS were collected. Statistical analysis included independent t-tests and Chi-square tests to evaluate associations between GBS and clinical outcomes. Receiver operating characteristic (ROC) curve analysis was performed to determine optimal cutoff values for predicting blood transfusion and early endoscopy. Results:A total of 100 patients were included, with a mean age of 59 ± 12 years, and 78% were male. Chronic liver disease was present in 61% of the cohort. Patients requiring blood transfusion had significantly higher GBS values compared with those who did not (P = 0.006). ROC analysis showed moderate predictive ability for blood transfusion (area under the curve [AUC] 67.8%) with an optimal cutoff score of 8 (sensitivity 86% and specificity 46%). For early endoscopy, the AUC was 71.8%, with a cutoff score of 9 (sensitivity: 80.6% and specificity: 54%). Conclusion:The GBS demonstrated significant predictive value for identifying patients with UGIB who are likely to require blood transfusion and early endoscopic evaluation. Incorporation of GBS into emergency department triage protocols may facilitate timely risk stratification and support evidence-based management of UGIB.
Background:Generative artificial intelligence (AI) tools are increasingly used by healthcare professionals, yet empirical data on adoption among Latin American emergency medicine clinicians remain limited. Methods:A voluntary, anonymous, cross-sectional online survey was administered to emergency medicine professionals across Latin America (April-October 2025). The Spanish-language instrument, pilot-tested before deployment, assessed AI familiarity, use patterns, perceived value, risks, governance, and training needs. Descriptive statistics and Chi-square tests were used for analysis. Results:A total of 123 respondents from 16 countries were analyzed. Most practiced in public or mixed healthcare settings (71.3%) and had over 10 years of experience (61.3%). Familiarity with generative AI was moderate to high (76.9%), and professional use was common (78.3%), with ChatGPT the dominant platform (81.0%). Adoption patterns were homogeneous across countries, with no significant associations between country of origin and familiarity, frequency of use, or platform preference. Primary applications included research and literature review (66.1%), medical education (59.1%), and clinical documentation (40.9%). Nearly half reported high perceived utility (49.6%), and 51.7% noted improvements in productivity. Major concerns included misinformation, erosion of clinical judgment (56.2% each), algorithmic bias (53.7%), and legal liability (46.3%). Institutional AI governance was nearly absent, with only 7.4% reporting existing policies. Despite this, 88.4% expressed interest in formal AI training and 65.6% supported integration into clinical guidelines. Conclusions:Latin American emergency clinicians are rapidly adopting generative AI with perceived benefits across multiple domains, but almost entirely without governance frameworks or structured training, highlighting an urgent need for regional policy and education infrastructure.
Background:Prognostication in sepsis remains challenging as conventional scores and biomarkers, including procalcitonin (PCT) and lactate, show limited predictive strength when used alone. This study evaluated the ability of mid-regional proadrenomedullin (MR-proADM) to predict 14-day mortality in patients with sepsis, intending to improve early risk stratification. Methods:A prospective observational study was conducted at a tertiary hospital in North India over 18 months. One hundred and twenty patients admitted to the intensive care unit (ICU) and ward with sepsis were enrolled. On admission, serum MR-proADM, PCT, and lactate were measured, and Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated. Prognostic accuracy was determined using the receiver operating characteristic (ROC) analysis. Results:The mean age of the participants was 45.9 ± 16.1 years, with 54.2% male. Nonsurvivors (n = 56) required ICU care more frequently (69.6%) and ventilator support (55.4%). MR-proADM levels were significantly higher in nonsurvivors (2.48 ± 1.93 nmol/L) than survivors (1.43 ± 0.78 nmol/L, P < 0.001). MR-proADM achieved an area under ROC of 0.767, which was comparable to SOFA (0.712), lower than lactate (0.807), and superior to PCT (0.693) and APACHE II (0.699). MR-proADM >5.75 nmol/L was uniformly associated with mortality. Conclusion:MR-proADM is a reliable adjunctive prognostic biomarker for sepsis and may enhance early risk stratification when used alongside established scores and biomarkers.
Background:Plasma lactate >2 mmol/L has been associated with increased mortality in acute pulmonary embolism (PE), even among hemodynamically stable patients. Despite strong evidence, lactate remains underutilized in risk stratification tools such as the simplified PE Severity Index (sPESI). To assess the incremental prognostic value of plasma lactate when integrated into a Bayesian probability model for Pulmonary Embolism. Methods:Pretest probabilities were defined by SI and sPESI. Sensitivity and specificity for plasma lactate >2 mmol/L were derived from prior meta-analyses and validated multicenter datasets. Likelihood ratios were applied within a Bayesian nomogram to estimate posttest probabilities. Diagnostic efficiency was evaluated using Bayesian Diagnostic Gain (BDG) and Bayesian Number Needed to Diagnose (BNND). Results:Thirty-day mortality for SI >1 was 24.1% versus 10.7% for low-risk SI and 10.7% versus 1.5% for sPESI. Lactate >2 mmol/L yielded 82.4% sensitivity (95% confidence interval [CI]: 56.8-95.3) and 73.5% specificity (95% CI: 71.8-74.4). Integrating lactate into the SI model produced an Absolute Diagnostic Gain (ADG) of 25.9% (BNND = 4), outperforming the sPESI model (ADG: 16.3%, BNND = 6). Conclusions:Bayesian integration of plasma lactate with the SI enhances prognostic accuracy and produces superior diagnostic gains compared with sPESI-based models. This supports a probabilistic, physiology-driven approach to PE risk stratification.
Background:Thiamine is a vitamin that plays a role in lactate clearance. Patients with sepsis may present with elevated lactate, and also in cirrhosis, as lactate is hepatically metabolized. Prior studies showed mixed results regarding the role of thiamine for lactate clearance with limited inclusion of cirrhosis patients. The purpose of this study was to determine the association of high-dose intravenous thiamine on time to lactate clearance among patients with cirrhosis and sepsis. Methods:We performed a single-center retrospective cohort study of critically ill patients with cirrhosis with a diagnosis of sepsis with lactate >4 mmol/L between January 1, 2020, and December 31, 2024. Patients who received ≥400 mg were classified as receiving high-dose thiamine. Fine-Gray competing risks models adjusted for demographic, comorbidity, and illness severity variables estimated the association of receiving high-dose thiamine with time to lactate clearance, defined as a lactate <3 mmol/L. Additional secondary outcomes included intensive care unit and in-hospital mortality. Results:A total of 136 patients were identified and included in the analysis. Median age was 58.4, and 54% were male. Thirty-three patients received high-dose thiamine. Patients had similar baseline characteristics, including on indicators of illness severity, cirrhosis severity, and use of vasopressors. In both unadjusted and adjusted models, the receipt of high-dose thiamine was not associated with differences in time to lactate clearance or mortality. Conclusions:Thiamine use in patients with cirrhosis who experienced sepsis did not result in improved lactate clearance compared to those who did not receive high-dose thiamine. These data do not support empiric high-dose thiamine to aid lactate clearance in this population.
Background:Acute myocardial infarction (AMI) and related cardiac conditions are leading global causes of mortality. Timely diagnosis and intervention in AMI are vital; however, existing biochemical markers such as myoglobin, creatine kinase-MB (CK-MB), and troponins have limitations in early detection. Heart-type fatty acid-binding protein (H-FABP), abundant in cardiac tissue, has emerged as a potential early biomarker for AMI. This study evaluates the diagnostic efficacy of H-FABP compared to troponin-T (Trop-T) and CK-MB, aiming to establish H-FABP as a reliable biomarker for early acute coronary syndrome (ACS) diagnosis. Methods:This prospective comparative cross-sectional study was conducted at KLES Dr. Prabhakar Kore Hospital from January to December 2023, enrolling 50 patients presenting with chest pain suggestive of ACS. Laboratory assessments were executed for cardiac Trop-T, CK-MB, and H-FABP. Trop-T and CK-MB levels were measured upon presentation and again 6-12 h postadmission, while H-FABP was qualitatively assessed at presentation only. Data on symptoms and medical history were recorded. Laboratory analyses utilized electrochemiluminescence immunoassay for Trop-T and CK-MB and rapid chromatographic immunoassay for H-FABP. The primary outcome was sensitivity for diagnosing ACS within the initial 3-h window, with secondary outcomes including specificity, positive predictive value, and negative predictive value. Results:The mean age was 52.68 ± 12 years, with a significant male predominance (74.4% in AMI). Typical chest pain was reported by 80% of patients. H-FABP showed 76.92% sensitivity, 100% specificity, and a highly significant P < 0.0001 within the 3-h window, while Trop-T's sensitivity improved over time from 35.90% at presentation to 84.60% at 6-12 h. CK-MB exhibited moderate sensitivity (43.59% at presentation and 66.70% at 6-12 h) and significant specificity (100%). Conclusion:This study highlights clinical and diagnostic differences between AMI and UA. H-FABP demonstrated high diagnostic accuracy during the early hours of presentation, suggesting its potential as a valuable early biomarker for ACS diagnosis. However, larger multicentric studies are necessary to validate these findings before routine clinical adoption.
Background:Acute pancreatitis (AP) is frequently complicated by acute kidney injury (AKI), contributing to increased morbidity and mortality. Thoracic epidural analgesia (TEA) may improve splanchnic perfusion, attenuate inflammation, and reduce renal dysfunction. Methods:In this prospective randomized controlled trial, 88 adults with AP were enrolled; 8 were lost to follow-up. Eighty patients were analyzed and randomized to a TEA group (n = 40) or a control group (n = 40). The TEA group received epidural analgesia in addition to standard care. Renal and metabolic parameters, including urine output, serum urea, creatinine, electrolytes, lactate, bicarbonate, and base excess, were monitored. AKI was defined and staged using KDIGO criteria. Statistical analysis was performed using independent t-tests and Chi-square tests, with P < 0.05 considered significant. Results:Baseline characteristics were comparable between groups. Transient hypotension occurred in nine TEA patients and was managed conservatively; no major complications were observed. Postintervention urine output was significantly higher (P = 0.034) and serum urea significantly lower (P = 0.016) in the TEA group. Lactate levels were lower (P = 0.011), bicarbonate levels higher (P = 0.026), and base excess less negative (P = 0.033), indicating improved perfusion and metabolic status. AKI occurred in 7/40 patients in the TEA group and 12/40 in controls, a nonsignificant difference (P = 0.14). However, AKI severity was lower in the TEA group. Conclusion:TEA was associated with improved renal and metabolic parameters and a trend toward reduced AKI incidence and severity in AP, without major adverse effects. Larger multicenter studies are needed for confirmation.
Background:Early identification of high-risk sepsis patients remains a clinical priority. Hematological ratios such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) have emerged as potential prognostic biomarkers reflecting systemic inflammation and immune dysregulation in sepsis. To evaluate the prognostic significance of NLR, PLR, and MLR in predicting clinical outcomes in patients with sepsis, including mortality, hospital stay duration, and need for mechanical ventilation. Methods:This prospective cross-sectional observational study included 200 adult patients (>18 years) with clinically diagnosed sepsis admitted to a tertiary care hospital from January 2023 to March 2025. Complete blood counts were used to calculate NLR, PLR, and MLR. The Sequential Organ Failure Assessment score was used to assess organ dysfunction. Statistical comparisons were performed using t-tests, ANOVA, Chi-square tests, and receiver operating characteristic (ROC) curve analysis. Correlation analyses were also conducted. Results:Higher NLR and MLR values were significantly associated with prolonged hospital stay (P = 0.0031 and P = 0.0027, respectively) and need for mechanical ventilation (P = 0.0018 and P = 0.0012, respectively). ROC analysis revealed that NLR (area under the curve [AUC] =0.797) and PLR (AUC = 0.707) had good predictive accuracy for mortality. No significant difference was observed in inflammatory ratios between death and discharge groups. Conclusion:NLR and MLR serve as reliable prognostic indicators in sepsis and correlate significantly with disease severity and outcomes. Their inclusion in the initial sepsis workup may support early risk stratification and clinical decision-making.
Introduction:Ventilator-associated pneumonia (VAP) is a microbial infection that develops in the lungs when a patient has been intubated for mechanical ventilation for more than 48 h. Diagnosis of VAP remains a challenge despite clinical advances. NMR-based metabolomics might play a pivotal role in overcoming the diagnostic complexity of VAP by investigating biomarkers. Materials and Methods:This case-control study was conducted in 2024-2025 at Sir Sunder Lal Hospital, Varanasi. The participated patients had an intubation period of more than 48 h; a total of 44 patients were recruited, of which 20 patients developed VAP and 24 were non-VAP patients. NMR spectra of serum were recorded, and statistical analysis was done. Results:The 2D scatter plot of PC1 versus PC2 scores clearly shows a distinction between the groups, with the principal component analysis explaining 18.9% of the variance. Partial least-squares discriminant analysis demonstrated R 2 and Q 2 values of 0.328 and 0.0552, respectively, indicating a probability to model fit. A total of 27 distinct metabolites were identified. Univariate receiver operating characteristic curve analysis identified phenylalanine (area under the curve [AUC] = 0.720), acetoacetate (AUC = 0.706), and glutamate (AUC = 0.690) as significant metabolites. With AUC values within the fair accuracy range, these three metabolites are considered acceptable biomarkers for the diagnosis of VAP. Conclusion:The elevated metabolites indicate lung injury and perturbed inflammatory pathways, which may result from invasive mechanical ventilation. We conclude that the levels of phenylalanine, acetoacetate, and glutamate may serve as biomarkers and aid in the diagnosis of VAP, disease monitoring, and therapeutic stratification.
Background:Effective and timely weaning is essential for improving the outcome of intensive care unit (ICU) patients. This study was conducted to determine whether diaphragmatic thickness fraction measured by ultrasound provides any additional benefit when combined with clinical parameters for successful weaning. Methods:This prospective observational study was conducted on 100 mechanically ventilated patients in the ICU. When the criteria for weaning were satisfactorily fulfilled, a spontaneous breathing trial was administered. Rapid Shallow Breathing Index (RSBI) and bedside ultrasound to measure diaphragmatic thickness fraction (DTF) were recorded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RSBI and DTF were calculated utilizing a cutoff value of RSBI <82 and a DTF cutoff of >37%. The predictability of weaning success was evaluated by the area under the receiver operating characteristic curve (AUROC). Results:Of the 100 patients observed, 68 patients had weaning success while 32 patients experienced weaning failure. The sensitivity, specificity, PPV, and NPV of RSBI were greater compared to DTF (88.23%, 96.87%, 98.36%, and 79.48% vs. 88.23%, 84.37%, 92.30%, and 77.14% respectively). The AUROC values for RSBI, DTF, and their combination were 0.86, 0.78, and 0.90, respectively. The Pearson correlation coefficient of RSBI with DTF was found to be -0.475. Conclusion:RSBI proved to be a highly reliable predictor of successful weaning, demonstrating superior diagnostic accuracy. The combination of RSBI and DTF improved the diagnostic validity profile, suggesting that integration of diaphragmatic ultrasound with conventional clinical indices enhances the reliability of weaning assessment.
Background:Endotracheal intubation (ETI) is a commonly performed emergency procedure used to secure the airways in critically ill patients. Despite its importance, ETI presents significant risks to patients with difficult airways. The availability of different types of laryngoscopes, most notably video laryngoscopes and direct laryngoscopes (DLs), has contributed to improved intubation success rates and reduced complications. While numerous studies have compared video laryngoscopes and DLs, there remains a limited synthesis of evidence evaluating the full range of all laryngoscopes across different patient population and clinical settings. Methods:A narrative synthesis approach was employed in this review. Relevant articles were obtained from multiple databases, including PubMed (MEDLINE), CINAHL, and PsycINFO. Articles published up to June 23, 2025, were considered for inclusion. The methodological rigor and reporting quality of each article were appraised. The screening and exclusion process were documented using the PRISMA flow diagram. Titles, abstracts, full texts, and reference lists of all retrieved articles were thoroughly reviewed to identify potentially relevant publications. Results:Video laryngoscopes, particularly the McGrath, GlideScope, and C-MAC D-Blade, demonstrated superior performance compared to laryngoscopes. There was better first-pass success, better view of the larynx, less need for external adjusting maneuvers, and shorter time to intubation. Other devices such as Airtraq and Bonfils fiberscope have good results in some clinical settings, but are useful only where there is high operator dependence and have a more difficult learning curve. Conclusion:Video laryngoscopes have proven to be better than DLs in managing adult patients with difficult airways due to the advantages of the success rate, visualization of the glottis, and efficiency of the procedure. However, methodological heterogeneity and an absence of consistently high quality in clinical trial data lead to inadequate evidence for recommending one specific laryngoscope as being better for all difficult airway scenarios. Further well-designed high-quality clinical studies are required to determine the most effective laryngoscope for intubating adults with difficult airways across diverse clinical settings.
Background:Lumbar spine surgeries are associated with severe postoperative pain due to the extensive handling of tissue and bone. Multimodal analgesia is the preferred choice but is associated with systemic side effects. Atomized drugs at the local surgical site may be a more attractive option than the intravenous route. In this study, we compare the atomized form of ketamine and dexmedetomidine at the surgical site for postoperative pain relief in lumbar spine surgeries. Methods:After approval from institutional ethics committee and the Clinical Trial Registry - India, 45 patients of age group between 18 and 60 years, scheduled for lumbar spine surgery under general anesthesia were divided into three equal groups: Group D: Received dexmedetomidine 1 µ/kg, Group K: Received Ketamine 1 mg/kg and Group N: Received 20 ml of normal saline. Drugs were diluted in 20 mL of normal saline and applied over the surgical site at the end of the surgery, before closure, in the form of fine droplets using an atomizer device. Our primary outcome was the postoperative analgesia measured by the Visual Analog Scale. Results:Duration of postoperative analgesia was significantly higher in the ketamine group, 240 min (interquartile range [IQR]: 120-360) than the dexmedetomidine group, 120 min (IQR: 120-240) determined by the Kruskal-Wallis test (P < 0.001). Conclusion:Atomized ketamine and dexmedetomidine at the surgical site during closure in lumbar spine fixation surgery is an attractive choice for postoperative pain relief without any systemic side effects.
Background:Extracorporeal treatment (ECTR) have been employed for poison elimination dating back to as early as the 1960s, but during the current day and time, the indications for ECTR are mostly arbitrary and are considered when other treatments of poison elimination or reduction below toxic levels are not available. It is invaluable, especially when the toxins or poison are amendable to removal by ECTR, especially in a setting of clinical deterioration, the unavailability of specific antidotes, or when other treatment modalities are cost prohibitive in a tertiary setting with ECTR facilities. Objective:To reiterate the efficacy of extracorporeal therapy techniques in poisoning focusing on the indications, available modalities, and outcomes. Methods:Three clinical cases of acute poisoning with phenobarbitone, copper sulfate, and snake envenomation, effectively managed by ECTR, in detail were reviewed. A literature review on ECTR in poisoning was also conducted to summarize the principles. Results:All three patients were managed with appropriate ECTR modalities. Therapeutic plasma exchange was used to treat snakebite-induced thrombotic microangiopathy, hemodialysis was used to treat phenobarbital toxicity, and plasma exchange was used effectively for copper sulfate poisoning. ECTR was initiated early, which resulted in clinical improvement and recovery in all cases. Conclusion:HD remains a pivotal treatment option for the management of severe poisonings. Nevertheless, given the rare possibility of an encounter with cases necessitating treatment with extracorporeal therapies and the lack of recommendations and guidelines to standardize the practice, the evidence supporting the application of ECTR still remains limited and needs to be studied further for high-quality evidence.
