BACKGROUND:Snakebite is a neglected tropical disease of major public health importance in India, contributing to significant morbidity and mortality. Acute kidney injury (AKI) is among the most serious complications of envenomation, particularly with viperid and some elapid species, and is associated with long-term chronic kidney disease (CKD) risk. OBJECTIVE:This article aims to provide evidence-based recommendations for the recognition, evaluation, and management of snakebite-envenomation-associated AKI (SAKI), integrating global best practices with national treatment protocols and resource realities. MATERIALS AND METHODS:The authors reviewed available literature through PubMed and international recommendations, including the Government of India's Standard Treatment Guidelines (STG), World Health Organization (WHO) guidance, and Kidney Disease Improving Global Outcomes (KDIGO) AKI guidelines. As per the available evidence, the recommendations were formulated through expert panel deliberations. RESULTS:Key recommendations include early recognition of envenomation syndromes, prompt administration of polyvalent antisnake venom (ASV), protocolized monitoring of coagulation and renal parameters, and standardized use of kidney replacement therapy (KRT) according to KDIGO indications. Supportive management of venom-induced consumption coagulopathy (VICC), rhabdomyolysis, and thrombotic microangiopathy (TMA) is emphasized. Special considerations have been outlined for children, pregnant women, patients with preexisting kidney disease, and those bitten by non-"Big Four" snakes. CONCLUSION:SAKI is preventable and treatable with timely intervention, but survivors remain at risk of CKD. With these recommendations, the authors have tried to standardize the diagnostic and therapeutic approach across general medicine, nephrology, and critical care medicine teams in India, aiming to reduce mortality and improve renal outcomes.

We used Delphi methodology to provide guidance on gender equality and equity issues in professional life in intensive care, where information is evolving and no clear standard exists. A 12-member Steering Committee (7 women, 5 men) from 7 countries and 46 international panelists [(23 women, 21 men, 2 preferred not to disclose; median age 52 (33–75) years] from 32 countries (43

Critical care medicine operates in an environment of profound uncertainty, where clinicians must make high-stakes decisions based on incomplete, evolving, and often conflicting information. Despite this, most critical care research is frequentist-based, relying on static thresholds, dichotomous interpretations of evidence, and delayed incorporation of new data. This paradigm may not fully align with the dynamic and probabilistic nature of critical illness. Bayesian approaches offer an alternative framework that explicitly incorporates prior knowledge, continuously updates probabilities as new data emerge, and supports real-time, individualized decision-making. Rather than asking whether an intervention "works" in a binary sense, Bayesian methods estimate the probability of benefit or harm in a given clinical context, thereby aligning more closely with bedside reasoning. Importantly, such approaches are no longer theoretical. Adaptive platform trials have demonstrated the feasibility of Bayesian methodologies at scale, enabling continuous learning, dynamic treatment allocation, and simultaneous evaluation of multiple interventions. In this viewpoint, we explore how Bayesian decision-making could extend beyond research into routine intensive care practice. We discuss its potential to enhance clinical judgment, personalize therapy, and integrate heterogeneous data streams into coherent probabilistic estimates. The question is no longer whether Bayesian methods can be implemented, but how quickly and effectively they can be embedded into everyday critical care practice.

Abstract Background The serial performance of C-reactive protein (CRP), procalcitonin, and emerging biomarker pancreatic stone protein (PSP) was evaluated for the diagnosis of infection and sepsis in patients admitted to the intensive care unit (ICU). Methods All consecutive adult patients with suspected infection or sepsis upon their admission to the ICUs of three multi-speciality hospitals in the UAE were enrolled. CRP, procalcitonin, and PSP levels were measured at admission and repeated within 24–48 h. Patients were categorized into infection vs. non-infection, sepsis vs. non-sepsis groups, and into culture-positive and culture-negative subgroups. Results A total of 272 ICU patients were analyzed. All biomarkers could be used to distinguish infection with CRP (AUROC 0.77; 95% confidence intervals [CI] 0.70–0.83) and procalcitonin (AUROC 0.75; 95% CI 0.68–0.81) showing fair performance. Moreover, serial monitoring at 24–48 h improved performance, especially for procalcitonin (p = 0.04). Among patients with infection, PSP levels were higher in culture-positive compared to culture-negative patients, but the difference did not reach statistical significance (median 229 vs. 142 ng/ml, p = 0.05). However, all three biomarkers failed to discriminate sepsis with an AUROC of 0.56 (95% CI 0.49–0.64) for CRP, 0.54 (95% CI 0.46–0.62) for procalcitonin, and 0.58 (95% CI 0.50–0.66) for PSP, respectively. Combining biomarkers improved specificity (93.85%) but with reduced accuracy. Conclusion Despite a significant rise in all biomarkers, procalcitonin has overall better performance for diagnosing infections. None of the biomarkers could differentiate sepsis at admission.

There is something deeply appealing about the concept of "physiological positive end-expiratory pressure (PEEP)" because it sounds scientific, natural, and evidence-based. The rationale for physiological PEEP is glottic closure at the end of expiration, which helps in preventing alveolar collapse and optimizing gas exchange. However, the translation of physiological PEEP to a minimum preset PEEP in mechanically ventilated patients is standard practice, though it lacks evidence. Moreover, PEEP is not innocuous in positive-pressure ventilation and can cause harm by altering respiratory and cardiovascular mechanics. We present a viewpoint challenging the dogma of the application of "physiological PEEP" during invasive mechanical ventilation. The PEEP, like any other ventilation setting, should be based on pathology and lung mechanics and needs to be individualized. How to cite this article:Manjunatha GK, Schultz MJ, Nasa P. What if the Intensive Care Unit Abandoned the Physiology Myth-The Case of "Physiological PEEP". Indian J Crit Care Med 2026;30(2):95-98.

Airway management is central to the care of critically ill patients, yet it remains one of the most challenging interventions in emergency departments and intensive care units. Patients often present with severe physiological instability, limited cardiopulmonary reserve, and high acuity, while clinicians often work under constraints related to time for preparation, equipment availability, trained workforce, monitoring, and access to advanced rescue techniques. These challenges are particularly pronounced in low- and middle-income countries and other resource-limited or austere environments, where the margin for error is narrow and delays or repeated attempts in airway management may rapidly precipitate hypoxemia, hemodynamic collapse, or cardiac arrest. Although contemporary airway guidelines emphasize structured preparation and rescue pathways, many assume resources that are not consistently available in such settings. This narrative review discusses pragmatic, context-adapted strategies for airway management in constrained environments, with emphasis on physiology-first preparation, appropriate oxygenation and induction techniques, simplified rapid-sequence intubation, and the judicious use of basic airway adjuncts, supraglottic devices, and video laryngoscopy, where available. Adapted difficult airway algorithms, front-of-neck access in the absence of surgical backup, human factors, team training, and ethical considerations are also addressed. This review aims to support safer and effective airway management for critically ill patients in resource-limited emergency and intensive care settings.

Acute Respiratory Distress Syndrome (ARDS) is a heterogeneous clinical syndrome encompassing distinct physiological and biological patterns of lung injury. Despite this heterogeneity, the ratio of arterial oxygen partial pressure to inspired oxygen fraction (PaO2/FiO2) remains the cornerstone of ARDS definitions, severity classification, and clinical decision-making. While its simplicity has facilitated widespread use, the PaO2/FiO2 ratio incompletely reflects the underlying physiological mechanisms of hypoxemia and should not be interpreted as a stand-alone marker of disease severity. The PaO2/FiO2 ratio is highly sensitive to ventilator settings, particularly positive end-expiratory pressure (PEEP), exhibits nonlinear behavior at high inspired oxygen fractions, and provides only a static assessment of gas-exchange. Consequently, it fails to capture key dimensions of ARDS pathophysiology, including lung recruitability, mechanical heterogeneity, and the temporal evolution of injury and response to therapy. These limitations are increasingly relevant in contemporary intensive care, where ventilatory strategies and adjunctive therapies actively modify oxygenation independent of structural lung injury. In this narrative review, we critically re-examine the physiological assumptions underlying the PaO2/FiO2 ratio and evaluate its role in current ARDS practice. We synthesize evidence supporting alternative and complementary oxygenation metrics, such as PEEP-adjusted indices, the oxygenation index, and composite measures including the ROX index (SpO2/FiO2 adjusted for respiratory rate), emphasizing their physiological rationale, clinical interpretability, and practical limitations at the bedside. These metrics are discussed not as replacements, but as tools that may refine the contextual interpretation of hypoxemia. Beyond static oxygenation measures, we explore emerging paradigms that conceptualize ARDS severity as a dynamic, multidimensional construct, integrating longitudinal oxygenation trajectories with respiratory mechanics, imaging-based assessment of lung aeration, and biomarker-informed biological subphenotypes. Repositioning the PaO2/FiO2 ratio within this integrated physiological and biological framework may improve patient stratification, enhance the coherence of therapeutic decision-making, in line with the translational goals of modern intensive care.

PurposeDespite extensive research, it remains unclear which patient-ventilator asynchronies are reliably detectable in clinical practice, most clinically relevant, and how they rank in severity.MethodsMultiple-choice questions and 5-point Likert-scale statements were used in iterative Delphi rounds. Feedback was incorporated until stable consensus or dissensus was reached for all items. First series of rounds focused on identifying and classifying patient-ventilator asynchronies detectable from ventilator waveforms, second series assessed their associations with outcomes in three patient groups, and in the final rounds, asynchronies were ranked by severity within these patient groups and across three scenarios.ResultsIn total, 11 panelists completed nine rounds. Consensus classified ineffective triggering, reverse triggering, double triggering, auto-triggering, insufficient flow, premature cycling, and delayed cycling as clinically relevant patient-ventilator asynchronies. Of these, auto-triggering and delayed cycling were deemed unlikely to be detectable using ventilator waveforms alone. Across all three patient groups, the panelists reached consensus that double triggering and ineffective triggering were the most clinically relevant. In acute respiratory distress syndrome, double triggering, ineffective triggering, and reverse triggering were all judged clinically relevant. In patients without acute respiratory distress syndrome and after cardiac surgery, asynchronies were classified as severe or mild and combined into two composite groups.ConclusionThis Delphi study provides a consensus-based framework for identifying and ranking patient-ventilator asynchronies at the bedside, highlighting those most likely to be clinically relevant and offering a structured approach to support monitoring, intervention, and future research.

Objectives The objectives of this study were to quantify the variability in intensive care unit (ICU) admission decisions, identify influencing factors, and measure the associated stress among different groups of healthcare professionals. Design This was a cross-sectional survey using 10 standardised clinical vignettes. Setting The study was conducted in ICUs in the West Midlands, UK. Participants The study included 84 ICU professionals, categorised as decision-makers ([DMs] consultants and senior registrars, n=47) or non-decision-makers ([NDMs] other clinical staff, n=37). Main outcome measures For each vignette, respondents rated the likelihood of admission, associated stress, and likelihood of admission with unlimited resources on a 10-point Likert scale. The primary reason for non-admission was also selected. Results Admission likelihood was heterogeneous across all vignettes (median 5, IQR 6), with no significant difference between DMs and NDMs. DMs reported significantly lower stress than NDMs (median 4 vs 5, p<0.001). Clinically ambiguous vignettes showed the highest variability and stress. Counterintuitively, admission likelihood was significantly lower under a hypothetical unlimited-resources scenario (median 3 vs 5, p<0.001). "Futility" was the most common reason cited for non-admission. Conclusions Substantial variability and stress are inherent to ICU admission decisions, even among experienced clinicians. Subjective clinician factors shape decisions alongside objective patient data, underscoring the need for decision-support tools in ambiguous cases and strategies to ease the psychological burden on clinical staff.

Delphi methodology plays an important role in consensus development in areas where evidence is limited, ambiguous, or heterogeneous. However, the process remains inherently vulnerable to cognitive and methodological biases involving principal investigators, expert panellists, and other stakeholders. Recognising and proactively addressing these biases is essential to improve the rigour, transparency, and credibility of Delphi-based consensus research. Future efforts should focus on developing structured frameworks for transparent reporting and systematic implementation of bias mitigation strategies throughout the Delphi process.

INTRODUCTION:Postoperative pulmonary complications (PPCs) represent a significant cause of postoperative morbidity and even mortality. However, there is a lack of consensus regarding this composite endpoint, the definition of the individual components, classification and optimal outcome measures. This study aims to refine the PPCs composite framework by evaluating its construct validity, assessing the necessity and risks of a composite measure and exploring the feasibility of differentiating severity categories. METHODS:A Delphi consensus process will be conducted, engaging an international multidisciplinary group of 30-40 panellists, including clinicians, researchers, patients, public representatives and health economists. Through iterative rounds, the study will seek agreement on the individual components of the PPCs composite. Additionally, consensus will establish a framework for a composite outcome measure based on a standardised severity classification, appropriate timeframes and weighted grading of PPCs. ANALYSIS:Consensus, defined by ≥75% concurrence in multiple choice questions or on Likert-scale statements, will be evaluated from round 2 onwards. Delphi rounds will be continued until all statements have reached stability of responses evaluated by χ2 tests or the Kruskal-Wallis test. ETHICS AND DISSEMINATION:The study will be conducted in strict compliance with the principles of the Declaration of Helsinki and will adhere to ACCORD guidance for reporting. Ethics approval has been obtained for this study from the University of Wolverhampton, UK (SOABE/202425/staff/3). Informed consent will be obtained from all panellists before the commencement of the Delphi process. The results of the study will be published in a peer-reviewed journal with the authorship assigned in accordance with ICMJE requirements. TRIAL REGISTRATION NUMBER:NCT06916598 (clinicaltrials.gov).

BACKGROUND:Practice and delivery of critical care in Asia varies according to healthcare structure, income setting, and cultural factors. Identifying research priorities specific to ICU patients and healthcare workers in Asia is needed to guide advancement of critical care in the region. METHODS:This was an international cross-sectional survey study with adapted methods from nominal group techniques. All members of the Asian Critical Care Clinical Trials (ACCCT) Group were invited to submit research question suggestions. Submitted research questions were combined into summarized research questions, grouped into research themes, and individually ranked by number of mentions based on the original question submission (popularity). National and Regional Representatives rated the top 15% most popular summarized research questions by pre-defined importance and feasibility criteria. RESULTS:Between September 20, 2024 and December 10, 2024, 160 of 228 general members of the ACCCT Group (response rate 70.2%) participated in this survey study. The participants were from 112 hospitals across 24 countries and regions within Asia. Participants submitted 408 research questions, which were categorized into 15 themes and combined into 197 summarized research questions. The top three themes, as ranked by the number of mentions, were infection/sepsis, general ICU care, and structure/training/staffing/teamwork/safety. A threshold of 4 mentions was used to identify 26 summarized research questions that represented the top 15% most popular questions. Research questions related to sepsis and acute respiratory distress syndrome were ranked most important and feasible across the region. CONCLUSION:Twenty-six of the most popular research questions in critical care were identified by Asian ICU workers and researchers to drive research agenda in Asia for the next decade.

Although the definition of acute respiratory distress syndrome (ARDS) has undergone numerous revisions aimed at enhancing its diagnostic accuracy and clinical practicality, the usefulness and precision of these definitions remain matters of ongoing discussion. In this Position Paper, we report on a Delphi study to reach a consensus on the conceptual model of ARDS, specifically identifying its defining components within clinical, research, and educational contexts as well as exploring the potential role of subphenotyping. We did a four-round Delphi study, involving experts in ARDS research and management from a diverse range of geoeconomic regions and professional backgrounds. Consensus was achieved for the conceptual model of ARDS; key components to be included for an ARDS definition in the context of research, education, and patient management; and the need for further research in subphenotyping ARDS. Additionally, we highlight knowledge gaps and research priorities that could guide future investigations in this area. Our study builds on previous non-Delphi-based consensus processes (eg, the new global definition of ARDS and recent society-based guidelines) by using a rigorous Delphi method that ensured panellist anonymity and used clear quantitative criteria to mitigate potential peer pressure and group conformity. The findings underscore the need to refine the ARDS definition to better account for the heterogeneity of clinical presentations and underlying pathophysiology, and to improve diagnostic precision, including the use of subphenotyping where appropriate.