Objective:Only two devices [air-Q® intubating laryngeal airway (ILA) and AmbuAura-i] have been studied previously for blind endotracheal intubation (ETI) in paediatric patients. The aim of the study was to compare the success rate of blind ETI through BlockbusterTM laryngeal mask (LM) and air-Q® ILA in paediatric patients. Methods:Eighty patients with the American Society of Anesthesiologists' physical status I and II, aged between six months and 10 years, were enrolled in this randomised controlled trial. The patients were intubated through either of the supraglottic airway devices (SADs) by visualised, blind intubation. The primary outcome was the first- attempt success rate of ETI. Secondary outcomes were the overall success rate of ETI, the oropharyngeal leak pressure, the fiberoptic glottic view, the time to intubation, and the complication rate. Results:BlockbusterTM LM was having significantly higher first attempt success rate without any manipulation as compared to air-Q® ILA (55% vs. 32.5%; P value =0.042). Overall success rate was also significantly higher in BlockbusterTM LM (77.5% vs. 55%; P value =0.03). In subgroup analyses, BlockbusterTM LM demonstrated significantly higher first-attempt and overall intubation success rates in children aged 6 months to 5 years, while success rates were comparable between devices among children older than 5 years. Conclusion:BlockbusterTM LM, having more than 50% success rate of first-attempt blind intubation through SAD, can be a helpful device in crises during airway management of children and, thus, an ideal SAD for difficult airway carts.

Background and aims:Acute kidney injury (AKI) is a common and serious complication among critically ill COVID-19 patients. Early identification of patients at risk is challenging because serum creatinine rises late in the course of renal injury. Unlike prior COVID-19 AKI studies that measured serum neutrophil gelatinase-associated lipocalin (sNGAL) or Cystatin-C at a single time point, this study evaluates their serial trajectories and quantifies biomarker-creatinine lead-time in a critically ill intensive care unit (ICU) cohort. Patients and methods:This prospective observational study involved 65 adults with moderate to severe COVID-19 in the ICU. Serum biomarkers [NGAL, cystatin-C, interleukin (IL)-6, kidney injury molecule (KIM)-1, tissue inhibitor of metalloproteinases (TIMP)-2, creatinine] and urinary Klotho (uKlotho) were measured on days 0, 1, 2, 3, 5, 7, and 10. Acute kidney injury was defined per kidney disease: Improving global outcomes (KDIGO) criteria. Receiver operating characteristic (ROC) analysis and lead-time estimation evaluated predictive performance. Results:Acute kidney injury occurred in 47/65 (72.3%) patients; of them, 36/47 (76.6%) progressed to KDIGO stages 2-3, and 5 (10.6%) required renal replacement therapy (RRT). Among the biomarkers studied, sNGAL demonstrated the highest discrimination for KDIGO-defined AKI [area under curve (AUC): 0.71-0.79] and increased approximately 1 day before creatinine-based AKI diagnosis. Serum cystatin-C (sCystatin-C) showed moderate predictive value (AUC: 0.63-0.70) with a median lead time of approximately 1-2 days. Serum KIM-1 (sKIM-1) demonstrated only borderline variation across severity groups, while uKlotho did not show significant discriminatory performance. Although TIMP-2 and IL-6 were significantly elevated with increasing disease severity, their overall discriminative performance for AKI was lower compared with NGAL and cystatin-C. Conclusion:In critically ill COVID-19 patients, serial sNGAL and sCystatin-C demonstrated modest but consistent discrimination for KDIGO-defined AKI and showed a tendency to rise 1-2 days prior to creatinine-based diagnosis. In contrast, sKIM-1, serum TIMP-2, uKlotho, and serum IL-6 exhibited limited discriminatory performance for early AKI detection. How to cite this article:Kumar N, Mahto M, Kumar A, Kumar A, Kumar A. Renal Biomarkers of Injury as Early Predictors of COVID-19 Associated Acute Kidney Injury: A Prospective Observational Trial (BRICOAKI Study). Indian J Crit Care Med 2026;30(4):298-304.

Background & aims: Thoracic epidural analgesia is regarded as the gold-standard analgesic method for upper abdominal surgery. The retrolaminar block is a relatively newer block used for abdominal surgeries. This study aimed to compare the postoperative analgesic efficacy of continuous retrolaminar block with thoracic epidural in patients undergoing abdominal surgery by subcostal incision. Methods: Sixty American Society of Anesthesiologists (ASAI/II) patients scheduled for abdominal surgery under subcostal incision were randomly allocated to have a continuous catheter placed for retrolaminar block (RLB group) or a catheter for thoracic epidural (TEA group) after general anaesthesia. The primary outcome of this study was 24-h postoperative morphine consumption. The secondary outcomes included intraoperative fentanyl requirement, number of patients requiring rescue analgesia, postoperative pain score (NRS), and procedurerelated complications. Results: The mean postoperative 24-h morphine consumption was 7.32 f 2.07 mg in the RLB group and 6.29 f 2.29 mg in the TEA group. The difference between two groups was statistically insignificant (P = 0.06). Postoperative rescue analgesia was required in 13 patients of the RLB group and 8 patients in the TEA group. The mean total fentanyl requirement intraoperatively was 30 f 13.99 mu g in the RLB group and 20 f 10.14 mu g in the TEA group (P = 0.15). We also did not find any significant differences in postoperative pain scores between the two groups at any time points. Conclusion: Continuous retrolaminar block was non-inferior to thoracic epidural in providing postoperative analgesia for upper abdominal surgery via subcostal incision with a comparable duration of analgesic effect and reduction of opioid consumption. Clinical trial registry: India (CTRI) CTRI/2023/03/050171.

How to cite this article: Kumar A, Kumar A, Singh K, et al. Nebulization with Hypertonic Saline and Adrenaline Mixture to Improve Oxygenation in COVID-19 Patients with Centrally Distributed Lung Opacity: Pathophysiology and Clinical Experience. Indian J Respir Care 2025;14(2):140–142.

Background:NETosis is a unique form of cell death leading to the formation of neutrophil extracellular traps (NETs), which may be responsible for many of the serious complications of COVID-19, such as acute respiratory distress syndrome (ARDS), cytokine storm, thromboembolic complications, acute organ dysfunction, and multiorgan failure. Aims:The aim was to assess the relationship between markers of NETosis [citrullinated histones (Cit-H3), myeloperoxidase (MPO), and elastase] and COVID-19, as well as its severity. Patients and methods:Ninety-nine hospitalized adult patients aged 18 years or older with COVID-19 and 30 controls were prospectively enrolled. Serum levels of Cit-H3, MPO, and elastase were measured at the time of admission, and their levels were compared between the clinical categories of COVID-19 (non-severe, severe, and critical). The correlation between markers of NETosis and the PO2/FiO2 ratio was also determined. Results:Among the NETs markers, Cit-H3 and elastase levels significantly increased in the COVID-19 patients compared to the control. In the comparison of COVID-19 categories, only Cit-H3 significantly increased in severe categories compared to the non-severe group. Citrullinated histones showed fair diagnostic ability for the prediction of the severity, with a sensitivity and specificity of approximately 74 and 64%, respectively, at a cut-off of 34 ng/mL. Elastase was found to have a weak negative correlation, while Cit-H3 had a moderate negative correlation with the PO2/FiO2 ratio. Conclusions:Citrullinated histones, along with C-reactive protein (CRP), are independently associated with COVID-19 severity. These findings support the relevance of NETosis-related biomarkers in disease progression and may inform future research on targeted monitoring strategies. Clinical trial registration no:Clinical trial registry of India (CTRI/2020/10/028488). How to cite this article:Kumar A, Kumar N, Banerjee A, Kumar A, Kumar A, Sinha C. Relationship of Circulatory Markers of NETosis with COVID-19 Severity: A Prospective Cohort Study. Indian J Crit Care Med 2025;29(12):1032-1039.

Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India Address for correspondence: Dr. Chandni Sinha, Room No 502, B-Block, OT Complex, All India Institute of Medical Sciences, Patna - 801 507, Bihar, India. E-mail: [email protected]

Pulmonary manifestation in dengue is due to the involvement of both the upper and lower airways. Severe forms of dengue infection (pleural effusion, dengue hemorrhagic shock syndrome, and acute respiratory distress syndrome [ARDS]) are mainly due to the involvement of the lower respiratory tract. ARDS is a well-known respiratory complication following dengue infection. Patients with chronic kidney disease (CKD) diagnosed with dengue had a higher risk of unfavorable outcomes. Pulmonary involvement is one of the life-threatening complications in patients having CKD that contributes to increasing the mortality rate. Dysregulation of cytokines and apoptotic signaling pathway is a nonclassical mechanism of the kidney–lung crosstalk that results in the development of acute kidney injury in patients having ARDS. Severe worsening of renal function is common in CKD patients with dengue. Here, we discuss fluid management strategy in a patient having CKD who developed ARDS following dengue infection. The difficulty in the therapeutic dilemma is attributable to ambiguity in liberal versus conservative fluid therapy, contributing to a high risk of mortality. The narrow window of fluid tolerance in CKD patients further complicates the resuscitation strategy in patients with dengue ARDS.

REPORTbladder decreases due to sepsis, reduced renal blood flow, and reduced cardiac output. 5It is feasible to monitor (PuO 2 ) either in the bladder or by using a polarographic electrode after its placement into the urinary catheter. 6Silverton et al. 7 monitored continuous PuO 2 data using a noninvasive

How to cite this article: Kumar A, Kumar A, Kumar N, Kumar A, Sinha C, Singh PK. Does Long-term Oxygen Therapy and Noninvasive Ventilation Predispose Rhino-orbital-cerebral Mucormycosis in COVID-19 Patients? Indian J Crit Care Med 2022;26(9):1063-1064.

Rationale: The gastrointestinal manifestations of COVID-19 include anorexia, nausea, vomiting, abdominal pain, and diarrhea. However, pancreatitis as the presentation of COVID-19 is rarely reported. Patient’s Concern: A 63-year-old COVID-19 patient presented with complaints of abdominal pain and difficulty breathing for 5 d. Diagnosis: Contrast-enhanced computed tomography of the abdomen suggested acute interstitial pancreatitis without any biliary tract obstruction. Interventions: The patient was resuscitated with intravenous fluids based on dynamic parameters of fluid responsiveness. The patient was started on enteral feeding, analgesics, antibiotics, dexamethasone, low molecular weight heparin, and supportive therapy. Outcomes: The patient developed severe acute respiratory distress syndrome and died 6 days after admission. Lessons: Management of COVID-19 in the presence of pancreatitis is challenging. Adequate early fluid resuscitation is an important aspect of medical management for COVID-19 patients with pancreatitis and restrictive strategies must be followed. Increased liver enzymes and renal dysfunction in acute pancreatitis can also limit the use of specific therapies like remdesivir. Dexamethasone, even though it has shown a beneficial effect in treating COVID-19, can have an additive effect in causing hyperglycemia in these cases. Clinicians should be aware of this atypical presentation of COVID-19 with pancreatitis and adjust their management strategies, keeping in mind the considerations for both diseases.

Diverticular pouch in the esophagus poses unique anesthetic challenges. Presence of a diverticular pouch in the pharynx poses high risk of aspiration, despite adequate hours of fasting. Herein, we describe a case of a child with proximal esophageal diverticulum in which the anesthesia team faced the challenge of aspiration prevention during the perioperative period. Proper preoperative history, preparation, and intraoperative and postoperative management are imperative to prevent aspiration. Manual compression of the pouch by the caregiver might be exercised in the pediatric age group during and after feeds.

1. The Lancet. Palliative care and the COVID‐19 pandemic. Lancet 2020;395:1168. 2. Doolittle GC, Allen A. Practising oncology via telemedicine. J Telemed Telecare 1997;3:63‐70. 3. Dhiliwal SR, Salins N. Smartphone applications in palliative homecare. Indian J Palliat Care 2015;21:88‐91. 4. Coyle N, Khojainova N, Francavilla JM, Gonzales GR. Audio‐visual communication and its use in palliative care. J Pain Symptom Manage 2002;23:171‐5. 5. Peate I. COVID‐19 and palliative care. Br J Nurs 2020;29:455. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‐NonCommercial‐ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‐commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Submitted: 24‐May‐20 Revised: 26‐May‐20 Accepted: 09‐Jun‐20 Published: 30‐Jun‐20

Background: Arterial stiffness has been established as an independent and specific marker of various chronic cardiovascular diseases. Based on the detailed review of available research and case studies reported in reputed international journals, it can be concluded that Endothelial Damage (Endotheliitis) both in small and large arteries may be an important factor of morbidity and mortality in COVID-19 patients. Despite the pathological evidence of structural damage due to Endotheliitis in COVID-19 patients, the functional deterioration of the vasculature was not yet studied.Hyper activated inflammation of the arteries may lead to sudden rise in arterial stiffness, the functional indicator of severity of cardiovascular impairment, which develops into Multiple Organ Dysfunction Syndrome (MODS) in COVID-19. Supervising and controlling the arterial Stiffness may be a way to mitigate the morbidities and mortalities caused due to COVID-19. Objective: Our primary objective was to study functional arterial damage in COVID-19 disease and establish the non-invasive measurement of Arterial Stiffness as an independent marker of disease severity.Methods: We recorded the Arterial Stiffness of 23 Mild, 21 Moderate and 20 Severe COVID-19 patients grouped on latest NIH severity criteria. Patients with pre-existing Diabetes and Hypertension were excluded. We observed Arterial Stiffness of COVID-19 patients with standard parameters like non-invasive Carotid-Femoral Pulse Wave velocity (cfPWV), Age-Normalized increase in cfPWV (ANI_cfPWV), Age-Normalized increase in Aortic Augmentation Pressure (ANI_AugP) and Heart rate-normalized Augmentation Index (HRN_ AIx).Results: Moderate and Severe COVID-19 patients have extremely significantly elevated arterial stiffness than Mild patients. In Mild patients, cfPWV (829.1 ± 139.2 cm/s) was significantly lower than both Moderate (1067 ± 152.5 cm/s, P < 0.0001)and Severe (1416 ± 253.9 cm/s, P < 0.0001) patients. ANI_cfPWV in Moderate and Severe patients was significantly higher than Mild patients. (Mild: 101.2 ± 126.1 cm/s;Moderate: 279 ± 114.4 cm/s;Severe: 580.1 ± 216.4 cm/s;intergroup P <0.0001).Similarly, ANI_AugP also showed a significant difference in all three groups. (Mild: -1.891 ±2.817 mmHg;Moderate: 3.212 ± 3.124 mmHg;Severe: 7.246 ± 4.908 mmHg;with P <0.0001, P =0.0031, P <0.0001 respectively). HRN_ AIx also showed a significant increase in Moderate and Severe groups in comparison with the Mild Group. (Mild: 13.34 ±14.18;Moderate: 5.656±8.610;Severe: 24.80± 7.745;intergroup P <0.0001).Conclusion: This is the first study establishing the functional deterioration of vasculature in terms of abnormal increase in arterial stiffness in proportion with severity of COVID-19 disease. Our findings strongly suggest that arterial stiffness can be an independent and accurate marker for objective risk stratification and therapeutic alleviation of the acute cardiovascular complications like MODS in COVID-19.Trial Registration: The study design was registered with the Clinical Trials Registry of India (CTRI No. CTRI/2020/10/028489).Funding Statement: No external funding.Declaration of Interests: Authors declare no conflict of interest.Ethics Approval Statement: The study protocol, informed consents and other trial-related documents received the written approval of Institutional Ethics Committee (IEC No. AIIMS/Pat/IEC/2020/595).

Capnography or end-tidal carbon dioxide (ETCO2) is a useful adjunct in assessing ventilation and can serve as an objective tool for assessing sedation/analgesia in pediatric intensive care and procedural sedation. The ability to continuously measure exhaled carbon dioxide can provide vital information about airway, breathing, and circulation in critically ill pediatric patients. It is recommended that carbon dioxide (CO2) monitoring should be immediately available for children undergoing sedation. [1] Sedation should be used with caution in any COVID-19 pediatric patients as they may have co-existing respiratory compromise from COVID-19 pneumonia and close monitoring of oxygenation and ventilation is warranted. Whereas in the past it may have been acceptable to connect a CO2 sampling line directly to a patient's facemask, in the effort of avoiding contamination with COVID positive patients, the following assembly was created. We made a very simple and light weight assembly of Capnography monitoring by inserting a 7 cm cut part of 3.0 mm ID uncuffed ETT (Endotracheal tube) to one of the exhalation port of the pediatrics face mask. The distal end of the uncuffed 3.0 mm ID ETT very snugly fits into one of the hole of the exhalation port. We can keep the distal end of the ETT up to the radiopaque marker inside the face mask to avoid any resistance. A 15 mm ET Tube connector is attached to other end of the ETT which was then connected to a high-efficiency particulate air (HEPA) heat and moisture exchanging (HME) filter. The CO2 sampling line is then connected to the HEPA HME so that sampled gas is filtered. (Figure 1). The CO2 tracing can be obtained to monitor respiratory rate but this can be also monitored by clinical observation and assessment by electrocardiogram systems that use impedance plethysmography. We are successfully using this assembly in suspected cases of COVID-19 pediatric patients after completion of elective or emergency operative surgeries or cases of procedural sedation requiring CO2 sampling. However, it is not a tested method and there is no safety data available with any study at present. This assembly can be made easily from readily available materials and has the advantage of appropriate CO2 monitoring without risking contamination of equipment and potential harm to future patients. Authors declare no conflict of interest.