BACKGROUND AND OBJECTIVES:Transfusion practices in paediatric trauma patients are frequently based on adult protocols, despite notable differences in physiology and injury mechanisms between children and adults. This study was aimed to evaluate the current transfusion practices, among the paediatric trauma population, which will help in guiding management and planning along with research opportunities among paediatric trauma patients MATERIALS AND METHODS: We conducted a prospective observational study over one year, including trauma patients under 18 years who received transfusions. Data collected encompassed demographics, clinical and injury details, transfusion specifics, and outcomes, with descriptive analyses and assessment of associations with clinical and laboratory parameters. RESULTS:Of the paediatric trauma patients, 394 (38.7%) received transfusions. Among these, 388 (98.5%) received PRBC, 159 (40.4%) RDP, 170 (43.2%) FFP, and 3 (0.8%) cryoprecipitate. Median requirements were 21.8 ml/kg PRBC, 5.8 ml/kg RDP, 17.5 ml/kg FFP, and 2.6 ml/kg cryoprecipitate. Early PRBC transfusions were associated with delayed admission, tachycardia, and low baseline haemoglobin. RDP and FFP correlated with higher injury scores, shock index, FAST/eFAST positivity, tachycardia, hypotension, Low Hb, and abnormal PT. Massive transfusion (≥40 ml/kg in 24 h) was required in 102 cases (25.9%), with most blood components administered within the first day. CONCLUSION:A substantial portion of paediatric trauma patients required transfusion, mainly plasma and platelets for severe bleeding. Transfusion need was linked to injury severity and clinical indicators. Early, targeted transfusion may improve outcomes for these vulnerable patients.

Background Sleep is vital for healing, cognitive function, immunity regulation, hormonal balance, and waste clearance. Sleep deprivation is common among intensive care unit (ICU) patients, particularly those receiving mechanical ventilation. Fragmented sleep, pain, noise, and other factors adversely affect recovery and outcomes. Trauma patients often experience increased pain from their injuries. As most sleep studies have been conducted in general and surgical ICUs, but not in trauma patients, a sleep quality assessment study was planned for trauma patients requiring intensive care. The primary objective was to evaluate sleep quality in trauma patients admitted to the ICU. The secondary objectives were to assess sleep quality changes during ICU stay, identify factors affecting sleep, measure environmental noise levels, and determine the incidence of delirium. Methodology A single-center, prospective observational study was conducted at a level I trauma ICU of a tertiary care hospital involving 80 trauma patients from July 2022 to June 2024. Patients were assessed using the Richmond Agitation and Sedation Scale (RASS) to evaluate sedation and agitation levels. Those with a RASS score of -1 to +1 were screened for delirium using the Confusion Assessment Method (CAM-ICU). Delirium-free patients (CAM-ICU score of 0-2) were recruited, and their sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) over three days. Poor sleep was defined as RCSQ <50, and the poor sleep and good sleep groups were analyzed. Data were expressed as mean ± SD or median (IQR) or percentage as appropriate. Sleep groups were compared using Student's t-test for normally distributed continuous variables, Mann-Whitney U test for non-parametric variables, and ANOVA test for repeated measures, while categorical data were compared using Fisher's exact test. Results The mean RCSQ score was 49.87± 5.35 on day one, and the overall mean RCSQ score of the study population was 49.57 ± 4.95, indicating generally poor sleep quality among trauma ICU patients. Poor sleep (RCSQ <50) was found in 52.5% of patients on the first day, 45% on the second day, and 43.75% on the third day. The mean RCSQ score was significantly lower in the poor sleep group (45.87 ± 2.60) compared with the good sleep group (54.29 ± 3.90) (p = 0.001). Overall, the mean age was 41.42 ± 17.04 years and was comparable between the groups, with a male predominance (82.5%, 66). Noise was the most common factor (n = 52), followed by pain (n = 37) and light (n = 18), which kept the patients awake. Mean noise level in the ICU over three days was 48.7 ± 2.04 dB, which was above the WHO recommendations. Delirium cumulative incidence was 20%, and overall mortality was 11.25%. This was not significant between the poor and good sleep groups, though higher mortality was reported in the poor sleep group. Conclusions Trauma patients requiring ICU care reported poor sleep quality, with only minimal improvement during their ICU stay. Noise was identified as the most significant sleep disruptor, followed by light exposure and pain. Noise levels in the ICU exceeded the recommended limits, with significantly higher noise levels reported during the daytime compared with nighttime. Sleep quality did not significantly influence mortality in trauma patients. Better sleep management is required with targeted interventions, though larger trials are needed to confirm its impact on clinical outcomes.

Fat embolism syndrome (FES) often occurs following a long bone fracture and typically manifests within 24–72 h as respiratory distress, petechiae, and neurological signs. Fat embolism associated diffuse alveolar hemorrhage (DAH) is a rare but potentially life-threatening pulmonary complication. Here, we present a case of a 22-year-old male with femur and mandibular fractures following trauma who developed progressive hypoxemia and hemoptysis on day 2 of trauma. Chest X-ray imaging revealed bilateral alveolar infiltrates, and bronchoscopy confirmed alveolar hemorrhage. The patient was placed on mechanical ventilation due to severe alveolar hemorrhage. Treatment was initiated with methylprednisolone, along with nebulization of adrenaline and tranexamic acid to control the bleeding. DAH secondary to FES should be suspected in trauma patients presenting with hemoptysis and hypoxemia. Early diagnosis and prompt administration of corticosteroids and antifibrinolytic therapy can significantly improve patient outcomes.

Background One-lung ventilation (OLV) in acute thoracic trauma presents physiological and technical challenges distinct from elective thoracic anesthesia. Preexisting hypoxemia, hemodynamic instability, and the inflammatory milieu of polytrauma increase susceptibility to ventilator-induced lung injury and postoperative pulmonary complications (PPCs). Data on anesthetic management, technique selection, and outcomes in this population remain limited. We report our experience with OLV in 117 consecutive trauma patients, characterizing clinical practice patterns and identifying predictors of acute respiratory distress syndrome (ARDS). Methods We conducted a retrospective observational cohort study of all trauma patients requiring OLV at the Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, over six years (January 2020 to December 2025). Patient demographics, mechanism of injury, injury patterns, preoperative physiology, OLV technique, intraoperative ventilation parameters, surgical approach, and postoperative outcomes were systematically recorded. Subgroup analyses compared blunt vs penetrating injury, OLV techniques, and video-assisted thoracoscopic surgery (VATS) vs open thoracotomy. Predictors of ARDS were identified through univariate and multivariate binary logistic regression. Results The mean patient age was 35.8 ± 13.1 years; 93.2% were male. Road traffic accidents (52.1%) and blunt chest trauma (70.1%) predominated. Double-lumen tubes were used in 50.4% of cases. Intraoperative hypoxia occurred in 48.3% of patients, and ARDS developed in 23.9%. VATS was associated with a significantly lower ARDS rate (10.3% vs 36.2%; P = 0.001) and reduced intraoperative blood transfusion (13.8% vs 31.0%; P = 0.026) compared with open thoracotomy. On multivariate analysis, the principal independent predictors of ARDS were preoperative mechanical ventilation (adjusted OR (aOR) 5.26; 95% CI 1.21-22.75; P = 0.026), maximum intraoperative fraction of inspired oxygen (FiO₂) (aOR 1.05 per percentage point; 95% CI 1.01-1.09; P = 0.021), and surgical approach, with VATS strongly protective relative to open thoracotomy (aOR 0.13; 95% CI 0.04-0.48; P = 0.002). The model demonstrated good discrimination (area under the receiver operating characteristic curve = 0.850) and calibration (Hosmer-Lemeshow P = 0.905). Conclusions OLV in thoracic trauma is associated with frequent perioperative hypoxia and PPCs, with preoperative mechanical ventilation, higher intraoperative FiO₂ requirements, and open thoracotomy independently associated with increased ARDS risk, whereas VATS was associated with a lower incidence of ARDS.

The Enterobacter cloacae complex (ECC) is increasingly recognized as a major opportunistic pathogen in healthcare-associated infections (HAIs), particularly in intensive care settings. Its clinical relevance has risen in parallel with the global spread of MDR strains, including carbapenemase producers, which complicate management and contribute to excess morbidity, prolonged hospitalization and increased healthcare costs. Outbreaks caused by ECC are often traced to contaminated water systems, medical devices, or the hands of healthcare workers, but reports from low and middle income countries (LMICs) remain scarce. In August–September 2023, a cluster of ECC infections was detected at a Level-1 trauma centre in northern India. An urgent epidemiological and microbiological investigation was undertaken to delineate transmission dynamics, identify reservoirs and guide infection prevention and control (IPC) measures. We conducted a prospective outbreak investigation of all culture-confirmed ECC cases occurring ≥48 h after admission during August–September 2023. Cases were identified in real time and reported in parallel with implementation of control measures. Clinical and epidemiological data included demographics, comorbidities, prior antibiotic exposure, invasive device use and outcomes. Environmental surveillance targeted high-risk areas such as water sources, sinks, taps and hand swabs from healthcare workers. Antimicrobial susceptibility testing (AST) was performed using standard protocols. Infection prevention and control (IPC) interventions included reinforcement of hand hygiene, environmental decontamination, chlorination and treatment of hospital water systems, and central line-associated bloodstream infection (CLABSI) care bundles. WGS was undertaken on 10 representative isolates (5 clinical, 5 environmental) to determine clonal relatedness, sequence types, plasmid profiles and antimicrobial resistance A total of 19 developed ECC infections; 63% were admitted to the ICU. No deaths occurred. Prior antibiotic exposure was reported in 68% and invasive procedures in 74%. Median ICU stay among infected patients was 14 days compared to 8 days in non-ICU cases (P=0.03). Environmental surveillance yielded 52 ECC isolates: 60% from healthcare worker hand swabs and 40% from hospital water samples. All isolates were resistant to cefuroxime. 80% were susceptible to amikacin, meropenem, imipenem, cefepime, tigecycline and cotrimoxazole. WGS showed clonal dissemination of ST97 (60%) and ST171 (40%) with >99.8% identity between clinical and environmental isolates. Plasmids IncX3_1 and IncFII(pECLA)_1_pECLA carried blaNDM, blaACT-5 and blaSHV. Genes oqxA/oqxB (100%) and fosA (68%) were detected. Following IPC interventions, ECC incidence decreased from 15.8 to 6.7 cases per 1000 patient-days (P<0.05). Water contamination fell from 40% to 10%, and hand hygiene compliance improved from 60% to 85%. No additional cases occurred after September 2023. This outbreak was driven by clonal dissemination of ECC, primarily through water systems and healthcare worker hands. WGS provided high resolution evidence linking clinical and environmental isolates, enabling targeted interventions. The multimodal IPC response including reinforced hand hygiene, water decontamination and central line care bundles successfully reduced transmission and contained the outbreak. However, residual water contamination highlights the resilience of ECC in biofilm-associated reservoirs. Our findings underscore the value of integrating genomic epidemiology into outbreak investigations in LMIC settings and the need for sustained environmental monitoring.

Carbapenem-resistant Acinetobacter baumannii (CRAB) is a WHO designated ‘critical priority’ pathogen because of its high capacity for multidrug resistance and association with mortality rates approaching 50% in severe hospital-acquired infections. CRAB is a major driver of ventilator-associated pneumonia (VAP), bloodstream infections and wound infections in critically ill patients, especially in intensive care units. Treatment options are severely limited, with colistin and minocycline often used as last-resort agents despite toxicity concerns. The recently concluded ATTACK trial demonstrated that sulbactam/durlobactam, a novel β-lactam/β-lactamase inhibitor combination, was superior to colistin in terms of efficacy and safety, establishing it as a preferred therapeutic option in global guidelines. Surveillance programmes have consistently reported very high activity, with more than 96% of CRAB isolates worldwide remaining susceptible. However, antimicrobial resistance (AMR) in India is distinct, with carbapenem resistance driven not only by OXA-type carbapenemases but also by endemic metallo-β-lactamases (MBLs) and frequent treatment exposures to broad-spectrum agents. Therefore, regional evaluation of sulbactam/durlobactam is crucial before incorporation into local treatment algorithms. A prospective laboratory-based surveillance was conducted over four months at a tertiary-care teaching hospital. A total of 175 non-duplicate CRAB clinical isolates were collected. The majority originated from respiratory samples (n=140; 80%), reflecting the heavy burden of ventilator-associated and hospital-acquired pneumonia. Additional sources included blood (n=18; 10%), pus/wound swabs (n=7; 4%) and other sterile body fluids (n=10; 6%). All isolates were confirmed as A. baumannii by VITEK MS® (bioMérieux®, France). Antimicrobial susceptibility testing was performed by disc diffusion, and sulbactam/durlobactam activity was assessed using CLSI-M100 2024. A. baumannii SAMN04901667(AR Bank) was included as a quality control strain. Comparative susceptibility to colistin and minocycline was also assessed. Sulbactam/durlobactam exhibited susceptibility in 120 of 175 isolates (68.6%). Non-susceptibility was noted in 31.4% of isolates, substantially higher than resistance rates reported in global surveillance (<2%) or European studies (87.9–96% susceptibility). In contrast, minocycline and colistin demonstrated higher retention of activity, with susceptibility rates of 92.0% (161/175) and 94.0% (164/175), respectively. Respiratory isolates dominated the dataset, accounting for 80% of cases, consistent with India’s disproportionate burden of ventilator-associated pneumonia. No difference in sulbactam/durlobactam susceptibility was observed across specimen types. This study provides the first institutional-level data from India on sulbactam/durlobactam activity against CRAB. Unlike international reports where the agent has emerged as a highly reliable option, our findings reveal considerably reduced susceptibility, with nearly one-third of isolates resistant. This discrepancy likely reflects region-specific resistance mechanisms, such as mutations in penicillin-binding protein 3 (PBP3), the target of sulbactam, or the presence of MBLs that confer cross-resistance. The high prevalence of combination resistance mechanisms in Indian CRAB strains may further compromise efficacy.

Enterococcus faecium drives healthcare-associated bloodstream infections (BSIs) globally, with multidrug resistance and high mortality posing challenges, particularly in trauma settings. Scarce data from Indian trauma centres necessitate analysis to guide management. To assess the epidemiology, clinical characteristics, antimicrobial resistance and outcomes of E. faecium BSIs in a tertiary trauma care facility in India. A retrospective study analysed all E. faecium BSI cases in ICUs of a public-sector tertiary trauma centre. Demographic, clinical, microbiological and antimicrobial susceptibility data were collected. BSIs were classified as primary (central line-associated bloodstream infections [CLABSI] or non-CLABSI) or secondary per CDC definitions. Outcomes were evaluated at 14 days and final follow-up using R software. Of 97 BSI events involving 112 E. faecium isolates, 51.5% occurred in the trauma ICU. Median patient age was 40 years (IQR: 27–55), with 75.3% male. Median time to infection was 8 days (IQR: 5–12) post-admission. CLABSIs, primarily associated with non-tunnelled jugular lines (81.4%), accounted for most cases, followed by non-CLABSI (12.4%) and secondary BSIs (6.2%). Median ICU stay was 21 days (IQR: 14–30). Antimicrobial resistance showed 92.5% of isolates resistant to ampicillin and 37.6% non-susceptible to vancomycin. Linezolid susceptibility was 86.8% and tigecycline susceptibility was 100%. Mortality was 30.9% at 14 days and 48.4% at final follow-up. Early catheter removal occurred in 45.3% of CLABSI cases. The predominance of CLABSIs (81.4%) aligns with global data, where E. faecium is a leading ICU pathogen, driven by catheter use, as seen in European and North American studies. High vancomycin resistance (37.6%) mirrors Indian (up to 81% in high-risk settings) and global (34–81%) VREfm trends, limiting therapeutic options. Linezolid and tigecycline’s efficacy is consistent with international meta-analyses but risks emerging resistance with overuse. Prolonged LOS (21 days) and high mortality (48.4%) reflect VREfm severity, comparable to Chinese (24%) and Italian (27.5–36.6%) studies. Early catheter removal, effective in North American studies, occurred in only 45.3% of CLABSI cases, suggesting underutilization in resource-constrained settings. These findings underscore the need for enhanced catheter care protocols and antimicrobial stewardship to curb MDR E. faecium. Future research should explore molecular resistance mechanisms and cost-effective interventions tailored to Indian trauma settings. E. faecium BSIs in Indian trauma ICUs require urgent infection control and stewardship to address high resistance and mortality.

Catheter-associated urinary tract infections (CAUTIs) are a major healthcare-associated infection (HAI) in trauma care settings, contributing to morbidity, mortality and antimicrobial resistance. In this study we characterize the epidemiology, microbiological profile, antimicrobial resistance patterns, and clinical outcomes of CAUTIs and non-CAUTI urinary tract infections (UTIs) at a Level 1 Trauma Centre in India from 2017 to 2024, using a modified CDC-NHSN definition and digital surveillance. A retrospective analysis of 723 UTI events was conducted using Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC-NHSN) definitions, modified to include Candida spp. at ≥ 105 CFU/mL. Surveillance was performed by dedicated Hospital Infection Control Nurses (HICNs) using a digital system. Microbiological identification and antimicrobial susceptibility testing (AST) were conducted via the conventional manual methods and automated systems. of 723 UTI events, 608 (84.0

Background:Rising antimicrobial resistance (AMR) necessitates innovative metrics, such as days of antibiotic spectrum coverage (DASC), to optimize antibiotic stewardship. This study evaluated antibiotic use in an Indian trauma center using DASC, defined daily doses (DDD), and the World Health Organization (WHO) Access, Watch, Reserve (AWaRe) classification. Methods:This retrospective cohort study analyzed data from 1,812 adult inpatients (mean age: 35 years; 70% male; 80% with polytrauma) admitted to a 250-bed Level-1 Trauma Center at the All India Institute of Medical Sciences (AIIMS), India, from August to October 2022. We measured days of therapy (DOT), DDD, and DASC for 46 antibiotics across 12 pathogens [e.g., methicillin-susceptible Staphylococcus aureus (MSSA), carbapenem-resistant Enterobacteriaceae]. DASC scores were developed through expert consensus and local antibiogram data, and validated using Pearson's correlation with DOT (R = 0.43, p < 0.1) and DDD (R = 0.21). Differences in antibiotic usage between the ICU and ward were analyzed using a t-test in R software. Results:Total antibiotic consumption was 81,064.6 g (3,142 DDD/1,000 patient-days). The Watch group antibiotics dominated usage (37%, 16,018.6 g), resulting in a low Access-to-Watch ratio (0.47). ICU settings showed higher DDD values (326 vs. 193/1,000 patient-days, p < 0.05) and DASC/DOT ratios (mean: 3; 95% CI: 2.73-4.01). Piperacillin-tazobactam accounted for the largest share of the Watch category use (5,952.9 g). DASC values (mean 4401.5, 95% CI: 3592-5211.1) showed a moderate correlation with DOT (R = 0.43, p < 0.1), offering spectrum-specific insights. Conclusions:Excessive use of the Watch group antibiotics contributes significantly to AMR. However, DASC's novel, spectrum-focused approach offers a transformative tool for antibiotic stewardship, supporting targeted de-escalation and improved benchmarking. These findings underscore the urgent need for policy reforms to enforce adherence to the WHO AWaRe classification in Indian centers, potentially reducing AMR-related mortality (30% higher with resistant infections). Integrating DASC into global Antimicrobial stewardship (AMS) programs may redefine antibiotic prescribing practices and help mitigate the AMR crisis.

BackgroundTo investigate the geospatial epidemiology, clinical features, treatment patterns, and antimicrobial resistance (AMR) trends of Stenotrophomonas maltophilia bloodstream infections (BSIs) in Indian intensive care units (ICUs) participating in a standardized healthcare-associated infection (HAI) surveillance program from 2017 to 2024.MethodsThis retrospective, multicentric study analyzed surveillance data from 54 ICUs across India. Standardized HAI definitions and protocols were applied to characterize infection types, clinical outcomes, and antimicrobial susceptibility.ResultsA total of 271 S. maltophilia isolates were identified, with the highest burden in 2023–24 (n = 76, 28.0%). Central line-associated BSIs (CLABSIs) predominated (64.9%), though their proportion decreased over time, with non-CLABSIs rising from 7.4% (2017–18) to 42.1% (2023–24). Mortality was highest in secondary BSIs (60%), followed by CLABSIs (50.3%) and non-CLABSIs (36.4%). The median ICU stay for CLABSI patients was 21 days. No significant associations were observed between infection type and time to infection or length of stay. High resistance was observed to tobramycin (92%), amikacin (80%), and piperacillin-tazobactam (70%), while trimethoprim-sulfamethoxazole (64.7–94.7%), levofloxacin (93%), and minocycline (94.1%) retained activity.ConclusionS. maltophilia represents a significant ICU pathogen in India, underscoring the urgent need for genomic surveillance and resistance-guided therapeutic strategies.

INTRODUCTION:Catheter-associated urinary tract infections (CAUTIs) are one of the most common device-associated infections acquired in a hospital. Trauma patients are highly susceptible to CAUTI, as catheterization is a lifesaving measure often required for their management. This study focuses on the profile of CAUTI, the organism profile with antibiotic susceptibility patterns, and the clinical outcomes in the ICUs of a trauma care center. METHODOLOGY:A retrospective analysis of prospective surveillance data of patients in ICUs was done over a period of ten years (2010-2019) in a level 1 trauma center. A modified NHSN definition of CAUTI was used. Microbiological processing and antibiotic susceptibility profile was done based on standard guidelines. Clinical outcomes were considered for analysis. RESULTS:A total of 10,732 patients were included in the study, accounting for 98,131 patient days and 78,126 urinary catheter days (UCD). Among 546 patients, 577 episodes of CAUTI were recorded, giving a CAUTI rate of 7.4/1,000 catheter days. The average length of stay (LOS) of patients was 19.9 days. There was a significant relationship between UCD and the development of CAUTI. Orthopedic and spinal injuries (91%) accounted for the maximum device utilization ratio, followed by polytrauma (90%), miscellaneous injuries (88%), and head injuries (69%). CAUTI episodes were the highest in head injury patients. Gram-negative organisms (53.4%) dominated the pathogen profile. The crude mortality was 25.1%. CONCLUSIONS:Surveillance of CAUTI with analysis of the organisms and the antibiotic susceptibility trend will help improve infection prevention practices and antibiotic stewardship programs in local hospital settings.

OBJECTIVES:To estimate the profile of non-central line-associated primary bloodstream infections (non-CLABSIs) in intensive care units of Indian hospitals participating in the standardized health-care-associated infection surveillance program. METHODS:This is a multicentric, network-based, prospective surveillance study conducted in 180 individual intensive care units of 47 Indian tertiary care hospitals that were part of the Health-Care-Associated Infection Surveillance Network between May 2017 and April 2024. The non-CLABSIs were defined, monitored, and observed using standardized definitions and surveillance protocols (www.haisindia.com). RESULTS:A total of 7092 laboratory-confirmed non-CLABSI cases and 30,74,954 patient days from 2017 to 2024 were recorded. The overall pooled non-CLABSI rate was 2.3 per 1000 patient days. Gram-negative isolates were the most predominant (5240/7659; 68.4%), including Klebsiella spp. (1766/5240; 33.7%), Acinetobacter baumannii (1613/5240; 30.8%), and Escherichia coli (582/5240; 11.1%). Gram-positive isolates (1728/7659; 22.6%) predominantly included Staphylococcus aureus (953/1728; 55.1%) and Enterococcus spp. (747/1728; 43.2%). Carbapenem resistance was common in Gram-negative infections, particularly in A. baumannii (1253/1554; 80.6%) and Klebsiella spp. (1209/1697; 71.2%). Among Gram-positive, S. aureus exhibited a high level of resistance to methicillin (529/748; 70.7%). CONCLUSIONS:This surveillance study underscores the need to expand infection prevention and control strategies to include non-device-associated risk factors. This will lead to the formulation of comprehensive infection prevention and control programs, mitigating the burden and clinical outcomes of non-CLABSI.

To compare the performance of broth microdilution (BMD), the gold standard method, with the automated Vitek®2 system for colistin susceptibility testing. The analysis focused on genus-specific categorical agreement (CA), very major errors (VME), major errors (ME), MIC distributions (MIC50/MIC90) and evidence of heteroresistance among MDR and XDR Gram-negative isolates. This observational study was conducted from January to December 2024 at a tertiary care hospital. A total of 2717 non-duplicate Gram-negative isolates were included, comprising Acinetobacter baumannii, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Enterobacter cloacae and other less frequently encountered species. Colistin susceptibility was determined using BMD according to CLSI guidelines and Vitek®2 with AST-N281 cards. Comparative analysis assessed CA, VME, ME and correlation of MICs using Spearman’s rank. MIC50/MIC90 values were determined, and heteroresistance was inferred from discrepancies in MIC results between the two methods. By BMD, 93.19% of isolates were classified as intermediate (≤2 μg/mL) and 6.88% as resistant (≥4 μg/mL). Vitek®2 reported 95.25% intermediate and 4.75% resistant. Categorical agreement between the two methods varied by genus, ranging from 85.6% for Enterobacter cloacae to 100% for rare species. Very major error rates were unacceptably high in several clinically significant genera, including Enterobacter cloacae (51.1%), Escherichia coli (75%) and Acinetobacter baumannii (43.3%), while major error rates were consistently low (0–1.03%). MIC50 and MIC90 values showed species-specific variation, reflecting intrinsic differences in susceptibility patterns. Discrepancies between BMD and Vitek®2 suggested heteroresistance, particularly among Enterobacter cloacae and A. baumannii. Correlation of MICs between methods was poor, with Spearman’s coefficients ranging from 0.02 for E. cloacae to 0.48 for E. coli. While Vitek®2 demonstrated overall high categorical agreement with BMD, its reliability was undermined by elevated very major error rates, particularly in Enterobacter cloacae, Escherichia coli and Acinetobacter baumannii. These errors risk misclassifying resistant isolates as susceptible, with potential adverse consequences for patient management. Given the critical importance of colistin in treating MDR/XDR Gram-negative infections, BMD confirmation is strongly recommended for invasive or high-risk cases. Furthermore, evidence of heteroresistance underscores the biological complexity of colistin susceptibility and the limitations of automated testing platforms. In high-AMR settings, reliance on automated methods alone may compromise clinical outcomes, reinforcing the need for stewardship-driven approaches incorporating reference-standard testing.

Background Formal skill-based critical care competency development for non-anaesthetists or non-intensivists is variable in India at the undergraduate and postgraduate levels. This review aims to understand the barriers to the implementation of a simulation-based acute critical care course (ACCC) for clinicians. Methods We reviewed published articles that consist essentially of qualitative data, although some quantitative data is also included. For the stratification of articles, three instruments were used for the critical appraisal of published literature: (i) Guba's four parameters, (ii) ConQual rating and (iii) critical appraisal of the study programme. Results To effect a change in enabling clinicians to manage deteriorating patients safely, it is crucial to equip them with the necessary skills (technical and non-technical). It is important to introduce simulation-based courses, such as ACCC, to enable undergraduate and postgraduate medical and surgical trainees to gain the right balance of competence and confidence in managing complex situations before specialists, who are experts in critical care, take over. Conclusion An executive decision made by those at the helm of medical training and monitoring is necessary in medical education at both the undergraduate and postgraduate levels. The regulatory authorities (National Medical Commission and State Medical Councils) have a responsibility to address a plethora of challenges in the implementation of a scientific approach to simulation-based training. Life-saving skill development, rather than lecture-based education, is the key to equipping all clinicians in managing patients who are at risk of dying.

Renal Doppler ultrasonography may have an important role in the detection of acute kidney injury (AKI) in early stages. This study was aimed to determine whether renal Doppler parameters at day 1 can predict the development of AKI at day 5 in acute circulatory failure (ACF). After ethics committee approval and informed written consent from patients or legally acceptable representatives, we recruited n = 80 critically ill adult patients with ACF in this single-center, prospective observational study. Baseline demographic, clinical, and laboratory parameters were noted. Renal resistive index (RRI), power Doppler ultrasound (PDU) score, and their ratio (RRI/PDU) were measured at baseline and three consecutive days. The primary outcome was the development of AKI at day five, and the secondary outcomes were 28-day mortality, length of ICU stay, duration of ventilation, and vasopressor-free days. Out of 80 patients, n = 32 (40

A 33-year-old man admitted to the emergency department after being involved in road traffic accident. On evaluation and radiological imaging, he sustained closed subtrochanteric fracture in the right femur and a bilateral pelvic. Following primary survey and initial resuscitation, the patient was haemodynamically stable, so the patients shifted to a ward for further management. After 24 hours, the patient exhibited changes in mental status, including drowsiness, confusion, and restlessness with presence of petechial rash (Figure 1A). Additionally, he experienced respiratory distress and hypoxia on arterial blood gas analysis.

PURPOSE:Non-operative management (NOM) has been validated for blunt liver and splenic injuries. Literature on continuous intra-abdominal pressure (IAP) monitoring as a part of NOM remains to be equivocal. The study aimed to find any correlation between clinical parameters and IAP, and their effect on the NOM of patients with blunt liver and splenic injury. METHOD:A prospective cross-sectional study conducted at a level I trauma center from October 2018 to January 2020 including 174 patients who underwent NOM following blunt liver and splenic injuries. Hemodynamically unstable patients or those on ventilators were excluded, as well as patients who suffered significant head, spinal cord, and/or bladder injuries. The study predominantly included males (83.9%) with a mean age of 32.5 years. IAP was monitored continuously and the relation of IAP with various parameters, interventions, and outcomes were measured. Data were summarized as frequency (percentage) or mean ± SD or median (Q1, Q3) as indicated. χ2 or Fisher's exact test was used for categorical variables, while for continuous variables parametric (independent t-test) or nonparametric tests (Wilcoxon rank sum test) were used as appropriate. Clinical and laboratory correlates of IAP < 12 with p < 0.200 in the univariable logistic regression analysis were included in the multivariable analysis. A p < 0.05 was used to indicate statistical significance. RESULTS:Intra-abdominal hypertension (IAH) was seen in 19.0% of the study population. IAH was strongly associated with a high injury severity score (p < 0.001), and other physiological parameters like respiratory rate (p < 0.001), change in abdominal girth (AG) (p < 0.001), and serum creatinine (p < 0.001). IAH along with the number of solid organs involved, respiratory rate, change in AG, and serum creatinine was associated with the intervention, either operative or non-operative (p = 0.001, p = 0.002, p < 0.001, p < 0.001, p = 0.013, respectively). On multivariable analysis, IAP (p = 0.006) and the mean change of AG (p = 0.004) were significantly associated with the need for intervention. CONCLUSION:As a part of NOM, IAP should be monitored as a continuous vital. However, the decision for any intervention, either operative or non-operative cannot be guided by IAP values alone.

BACKGROUND Chest injuries are one of the most common injuries which are admitted in the trauma and emergency departments. It is known that the immune system affects the outcome of patients with significant trauma though the specific role of the components of immune system still remains to be explored. This study aimed to explore the temporal association of immune system with severity and development of complications in patients with blunt chest trauma (BCT). METHODS 75 patients (50 non-intubated and 25 intubated) satisfying the inclusion and exclusion criteria were enrolled in the study and blood samples were collected on Day 0, Day 2, Day 5 and On the day of discharge. Broncho- alveolar lavage fluid was collected once in the intubated patients. The samples were processed to estimate the levels of intracellular cytokines of Neutrophils, T-regulatory cells and T-helper cells. Extracellular levels of IL-9, IFN-γ, TNF-α, IL-4, IL-22, IL-1β, IL-17A, IL-6, IL-10, TGF-β were estimated in the serum as well as in the BAL fluid. 30 healthy volunteers and 10 patients with esophageal cancer undergoing routine bronchoscopy without tracheobronchial involvement were used as controls. The levels of cytokines were compared between 1) the injured and healthy patients 2) patients with Injury severity Score <15 and >15 3) Patients with thoracic trauma severity score <5 and >5 , 4) patients who had uneventful recovery and patients who had uneventful recovery RESULTS Intraneutrophilic levels of IL-6((p<0.001**) ,IL-1β((p<0.001**) , Th22(p=0.0001), Th1(p=0.0012), Intracellular T-reg cytokines levels of IL-10(p=0.0001) and FOX-P3(p<0.001) levels were higher in the patients group as compared to the control group on day-0 of injury. Extracellular cytokines levels of TNF-α (p=0.0433), TGF-β (p=0.0069) were significantly raised in the patient group. In the BAL fluid sample intraneutrophilic levels of IL-6(p<0.001), IL-1β(p<0.0002), Th22(p=0.016) and Th1(0.0049), Intracellular T-reg cytokines levels of TGF-β(p=0.0004) and FOX-P3(p=0.0003) were significantly increased in the patient group as compared to the control group. Extracellular levels of IL-4 (p=0.0271) and IL-1β (p=0.0041) were significantly elevated in the BAL fluid of patients. Patients with overall higher injury severity score (ISS>15) had significantly increased intraneutrophilic cytokines as compared to those with ISS<15. The intracellular T-regulatory cytokines and intracellular T helper cell cytokines did not show such consistent significant results. The extracellular cytokines levels also did not show any statistically significant results in severely injured patients as compared to lesser injured group(ISS>15 vs ISS<15) When compared on the basis of thoracic trauma severity intraneutrophilic cytokines levels did not show any significant results in patients with TTSS>5 vs TTSS<5. Intracellular T-regulatory cytokine levels of IL-10(p=0.0154), TGF-β(p=o.0006), FOX-P3(0.0001) were significantly increased in TTSS>5 group on the day of discharge. The extracellular levels of IL-9, IL-1β, IL-17A, IL-6, IL-10, and TGF-β were significantly elevated in TTSS >5 group even on the day of discharge. Out of 75 patients 22 (29.33%) developed complications. In the complications group the intraneutrophilic cytokines levels of IL-6(p=0.0251) and IL-1β(p=0.0143) were significantly higher on the day of admission as compared to patients who did not develop any complications. The extracellular cytokines levels showed higher values on day 2 of injury of which IFN-γ(p=0.0022), TNF-α(0.0062), IL-4(p=0.0128), IL-1β(p=0.0241), IL-17A(p=0.0035), IL-6(p=0.0279) and IL-10(p=0.023) were raised significantly on day 2 in complications group as compared to patients without complications. CONCLUSIONS The immune system plays a very significant role in final outcome of patients with chest injury in addition to the anatomical injury. The severity of injury activates the immune system in a proportional manner and further exploration of this role can help in development of prognostic indicators and therapeutic immunomodulation.

Visual servoing for the development of autonomous robotic systems capable of administering UltraSound (US) guided regional anesthesia requires real-time segmentation of nerves, needle tip localization and needle trajectory extrapolation. First, we recruited 227 patients to build a large dataset of 41,000 anesthesiologist annotated images from US videos of brachial plexus nerves and developed models to localize nerves in the US images. Generalizability of the best suited model was tested on the datasets constructed from separate US scanners. Using these nerve segmentation predictions, we define automated anesthesia needle targets by fitting an ellipse to the nerve contours. Next, we developed an image analysis tool to guide the needle toward their targets. For the segmentation of the needle, a natural RGB pre-trained neural network was first fine-tuned on a large US dataset for domain transfer and then adapted for the needle using a small dataset. The segmented needle's trajectory angle is calculated using Radon transformation and the trajectory is extrapolated from the needle tip. The intersection of the extrapolated trajectory with the needle target guides the needle navigation for drug delivery. The needle trajectory's average error was within acceptable range of 5 mm as per experienced anesthesiologists. The entire dataset has been released publicly for further study by the research community at https://github.com/Regional-US/