Background and aims:Recent sepsis guidelines recognize myocardial dysfunction as a major contributor to the pathophysiology of septic shock. Sepsis-induced cardiomyopathy (SIC) is typically characterized by acute onset and potential reversibility. The present study aimed to determine the incidence, spectrum, and prognostic significance of myocardial dysfunction in patients with septic shock. Patients and methods:We included patients aged 18 years or older diagnosed with septic shock. We excluded those having an improper window for transthoracic echocardiography, known cardiac diseases, pregnancy, or postcardiac arrest status. Eligible patients underwent transthoracic echocardiography within the first 24 hours of intensive care unit (ICU) admission. Echocardiography was used to assess systolic and diastolic function of both ventricles based on the criteria recommended by the American Society of Echocardiography (ASE). For patients with abnormal findings, a follow-up echocardiogram was conducted on day 7 to assess the reversibility of myocardial dysfunction. Results:Myocardial dysfunction was identified in 39 of 71 patients, yielding an incidence of 54.9% (95% CI: 42.6-66.7). Mortality was significantly higher among patients with SIC, with 29 out of 39 succumbing to the condition. Sepsis-induced cardiomyopathy was characterized by various patterns, including left ventricular (LV) systolic dysfunction, LV diastolic dysfunction, and right ventricular (RV) dysfunction, with LV diastolic dysfunction being the most prevalent. Multivariable regression analysis, adjusting for potential confounders, demonstrated that the presence of SIC was an independent predictor of mortality. Conclusion:Sepsis-induced cardiomyopathy was present in over half of the patients with septic shock, with diastolic dysfunction being the predominant subtype. Sepsis-induced cardiomyopathy was associated with increased mortality. How to cite this article:Nadaf ZM, Ravikumar RH, Anand RK, Ramachandran R, Trikha A, Wig N, et al. Incidence and Prognostic Impact of Myocardial Dysfunction in Septic Shock: An Observational Cohort Study. Indian J Crit Care Med 2026;30(1):56-61.

Pregnancy can trigger thrombotic microangiopathy (TMA), a condition associated with high morbidity and mortality if treatment is delayed. Timely diagnosis remains challenging, particularly in resource-limited settings due to limited access to specialised assays. We present three cases of maternal TMA admitted to our tertiary care unit located in a developing country. One patient was a known case of hereditary thrombocytopenic purpura. Two other cases presented with TMA post-caesarean section complicated by sepsis and postpartum haemorrhage, respectively, and were diagnosed as pregnancy-associated TMA (likely complement-mediated haemolytic uraemic syndrome). Management decisions were largely based on clinical assessment and a resource-adapted pragmatic approach due to unavailability of specialised assays and eculizumab. All patients were treated with urgent therapeutic plasma exchange. This report emphasises the importance of recognising pregnancy-associated TMAs and tailoring the diagnosing and managing strategies to available resources.

Background and Aims:Sepsis is a common cause of mortality and morbidity in patients admitted to the intensive care unit (ICU), requiring reliable scoring systems to predict outcomes and guide management. Existing traditional scoring systems inadequately capture sepsis complexity. This study developed the Organ Failure Assessment by Ratio (OFAR) score to improve ICU mortality prediction in sepsis patients. Methods:This retrospective observational study was conducted in the ICUs of a tertiary care centre between January 2021 to December 2023 and included adult patients meeting Sepsis-3 criteria. Demographic data, ICU mortality, and six composite variables were collected: bilirubin-to-albumin ratio, pulse oximetric saturation to fraction of inspired oxygen ratio (SpO2/FiO2 ratio), shock index, lactate-to-bicarbonate ratio, urea-to-estimated glomerular filtration rate ratio, and cumulative lung ultrasound score-to-platelet ratio. These variables were evaluated to develop and assess the predictive accuracy of OFAR score for ICU mortality. Results:The OFAR score showed greater discriminatory power with an area under the curve (AUC) of 0.78 than quick Sequential Organ Failure Assessment score (qSOFA) (AUC: 0.70) and Acute Physiology and Chronic Health Evaluation score II (APACHE II) (AUC: 0.73) and was comparable to Sequential Organ Failure Assessment score (SOFA) (AUC: 0.76). With a cut-off score of 51.6, OFAR score demonstrated a sensitivity of 73.7% and a specificity of 72.1%. Conclusion:The OFAR score provides higher predictive power for ICU mortality than qSOFA and APACHE II in our study population, raising its potential as an alternative risk stratification scoring system in sepsis patients. Additional external validation is required to confirm its generalisability across diverse populations.

Time-limited trials (TLTs) have been proposed as an approach for addressing prognostic uncertainty in critical care, helping to determine whether continuation of life-sustaining therapy will achieve patient goals. Implementation of TLTs has been variable, in part because of uncertainty in their definition and application, but also because of differences across ICUs in culture, system structure, resources, and patient population served. In September 2023, the American Thoracic Society (ATS) published an official workshop report establishing a consensus definition of TLTs in critical care. This report provided much-needed clarity on the key components of TLTs and future directions for research; however, numerous other factors may continue to influence the implementation of TLTs in ICUs around the world. We asked intensivists caring for adult and pediatric patients across medical, surgical, neurological, and oncological ICUs in Kenya, Hong Kong, Colombia, India, the United States, Argentina, Saudi Arabia, and France to provide perspectives on how TLTs are applied in their ICUs and how the ATS report has shaped their practice.

This study developed and validated a machine learning model to predict refractory septic shock in patients with sepsis admitted to a tertiary care center in India. Using an ambispective design, data from 1,008 adult intensive care unit patients were used for model development and 102 for prospective validation. Demographic, clinical, laboratory, and imaging variables were analyzed through a structured three-tiered feature selection process, and Random Forest classifiers were trained on optimized feature sets. The best-performing model, incorporating 27 clinical and laboratory features, achieved an area under the receiver operating characteristics curve of 0.877 in the training cohort and 0.839 in prospective validation, demonstrating high accuracy, precision, and recall. Early identification of high-risk patients using this model can facilitate timely interventions and improve outcomes. The validated machine learning model shows strong predictive ability and interpretability for refractory septic shock, though multicenter studies are required to confirm its generalizability before widespread clinical implementation.

Implementation of Enhanced Recovery After Surgery (ERAS) protocols in paediatric surgery remains limited, despite proven benefits in adults. The barriers to implementation and protocol modifications requires comprehensive detailing in paediatrics. We aimed to determine the practicality and safety of ERAS in paediatric laparoscopies at a tertiary-care center, addressing the context-specific barriers. This was a prospective, single-arm, preliminary study. One hundred thirty-six children, aged 2–14 years, undergoing laparoscopy were enrolled. ERAS elements were implemented perioperatively. The outcomes analysed included protocol compliance, length of hospital stay (LOS), 30-day complications, readmission and mortality rates. The challenges to implementation were noted. Overall protocol compliance was 82.5 ± 12.4

Abernethy malformation is a rare congenital portosystemic shunt. A type 2 Abernethy malformation is characterised by a side-to-side shunt between the extrahepatic portal vein and the inferior vena cava. Unmetabolised toxins that bypass hepatic circulation lead to intrapulmonary vascular dilatation. Approximately 3%-12% of portosystemic shunts present with features of hepatopulmonary syndrome, often presenting with progressive hypoxaemia and cyanosis.While endovascular device closure represents the preferred therapeutic approach for most cases, rarely, large or anatomically unfavourable shunts may necessitate surgical ligation that is met with unique anaesthetic challenges surrounding maintenance of adequate oxygenation and haemodynamic stability. We report the noteworthy anaesthetic concerns faced during successful surgical closure of Abernethy shunt in a boy in mid childhood.

Trans-thoracic echocardiography (TTE) improves the diagnostic skills of anesthesia trainees during the perioperative period. We compared performance between two educational intervention, simulation-based hands-on training and video-based training as measured by a novel TTE Competency Score (TCS). Fifty novice anesthesia residents were randomized into an intervention group-I (received simulation-based training) and a control group-C (received video-based training). Both groups underwent evaluations of their knowledge and skills on live volunteers or ICU patients using TCS right after the training and again six months thereafter. An independent sample t-test was employed to compare TCS between the groups, while a paired t-test was used to assess intragroup TCS at the baseline, after training, and six months post-training. The two groups had no significant difference in the pre-test assessment scores. Immediately following the training session, Group I exhibited a significantly higher TCS compared to Group C (25.2 ± 2.7 and 22.4 ± 2.5, p = 0.01). Compared to the I-group, the C-group made more attempts to achieve competence. Group I exhibited higher confidence levels both immediately and six months later. After a six-month follow-up, the TCS scores in both groups were lower than the scores recorded immediately. This study demonstrates that a structured, problem-based simulator course improved immediate TCS and 6-month confidence compared with video-based training. However, a decline in TCS in both groups over time highlights the need for periodic refreshers within six months to improve retention. CTRI [CTRI/2021/07/034684].

Background: A rise in biomarkers of lung injury with intraoperative mechanical ventilation in patients with healthy lungs may herald postoperative pulmonary complications (POPC). However, perioperative cytokine responses to mechanical ventilation in patients with previous SARS-CoV-2 associated pulmonary involvement are unknown. Objectives: To monitor proinflammatory cytokine responses to intraoperative mechanical ventilation in Corona virus disease-19 (COVID-19) survivors with COVID-associated pulmonary involvement and determine utility of these biomarkers in predicting POPC. Design: A prospective cohort study. Setting: Operating room, postoperative recovery area. Methods: Twenty-four patients with previous COVID-related lung involvement (group 1) and 20 patients with no/presumably no COVID-19 infection (group 2) undergoing various surgeries under general anaesthesia were recruited. General anaesthesia and ventilation were managed similarly in two groups. Bronchoalveolar lavage fluid (BALF) samples were collected at onset of ventilation and at end of surgery. Serum samples were collected at same timepoints and 1-hour postoperatively. Main outcome measures: Concentrations of interleukin-8 (IL-8) and tumour necrosis factor α (TNFα) were measured using Enzyme-linked immunosorbent assay, interleukin-6 (IL-6) by Chemiluminescence immunoassay and C-Reactive protein (CRP) by immunoturbidimetry on automated analyzers. Results: Patient demographics were comparable in both groups except age and American society of Anaesthesiologists classification. Rise of BALF IL-6 and IL-8 was more significant in group 1 (P < 0.001), compared to group 2 (P < 0.05 for IL-6 and P < 0.01 for IL-8). A significant increase in serum IL-6 correlated well with serum CRP at several timepoints in group 1. In both groups, BALF and serum TNF α was below detection limit. Only one patient in group 1 developed POPC. Conclusions: Despite a significant perioperative elevation of IL-6 and IL-8 in BALF, when mechanically ventilated, incidence of POPC did not increase in COVID survivors with prior COVID-associated pulmonary involvement. However, this needs to be validated on a larger sample size.

The two approaches described for ultrasound-guided supraclavicular brachial plexus block are single injection (SI) at corner pocket technique and drug injection in two or more aliquots. A prospective, randomized, controlled study was conducted to compare the SI at the corner pocket with the double-injection (DI) ultrasound-guided supraclavicular brachial plexus block. Our study hypothesis was that the DI technique results in a faster onset time of the block and a lower failure rate as compared to the SI, corner pocket technique. The primary objective of the study was to compare the anesthesia onset time in SI versus DI technique in ultrasound-guided supraclavicular brachial plexus block for orthopedic surgeries of the upper limb. Fifty adult patients of the American Society of Anesthesiologists physical status I and II scheduled for hand, wrist, forearm, and elbow orthopedic surgeries were randomized into two groups, SI at corner pocket (n = 25) and DI (n = 25). The drug used in both groups was 20 mL of 0.5% bupivacaine with 1 mcg/kg clonidine solution. The performance time, anesthesia onset time, surgical anesthesia, failed block, and any complications were noted by a blinded observer. The mean anesthesia onset time was longer in SI (17.7 min [Standard deviation (SD) = 4.55 min]) as compared to DI (12.8 min [SD = 3.93 min]). The DI group had a quicker onset of sensory anesthesia as well as motor blockade of all 4 nerves, i.e., musculocutaneous, radial, and median nerves at 15 min and ulnar nerve at 20 min. The time to first rescue analgesic dose was earlier in the SI group (11.18 h [SD = 1.56]) than in the DI group (12.89 h [SD = 1.87]). Prolonged duration of anesthesia (12.79 [SD = 1.7] vs. 9.76 [SD = 3.96] h, P < 0.001) was observed in the DI group as compared to the SI group. DI ultrasound-guided supraclavicular block had a faster onset time, provided prolonged postoperative analgesia, and thus, a delayed demand for rescue analgesics than SI technique.

Background and Aims: Both dexmedetomidine and midazolam-ketamine are known for their minimal respiratory depressant effects. While many studies have documented the use of dexmedetomidine in providing conscious sedation during awake fiberoptic-guided nasal intubation (AFNI), the use of midazolam-ketamine combination for this procedure has not been reported. The aim of this study was to compare the efficacy of dexmedetomidine with midazolam-ketamine combination for AFNI in patients with difficult airways undergoing oromaxillofacial surgery. Material and Methods: This study involved 60 patients undergoing oromaxillofacial surgery. They were randomized to receive either dexmedetomidine (1 μg/kg) (group D) or a combination of midazolam (0.02 mg/kg) and ketamine (0.5 mg/kg) (group MK) for sedation during awake fiberoptic nasotracheal intubation. Both groups received topical local anesthesia during the procedure using the spray-as-you-go technique. The primary outcome measured was cough score during intubation. Secondary outcomes included overall intubation, post-intubation, and sedation scores. Incidences of side effects such as hypoxemia and bradycardia were also measured. Results: The cough score (group D: 1.33 ± 0.61, group MK: 1.3 ± 0.53; P = 0.822), overall intubation score, and post-intubation score were comparable between the two groups. Patients receiving dexmedetomidine were significantly more sedated than patients receiving midazolam-ketamine. Patients receiving dexmedetomidine had significantly lower heart rates and blood pressure than patients receiving midazolam-ketamine. Four patients in group D had hypoxemia, while no patient in group MK developed hypoxemia. Conclusions: Both dexmedetomidine and midazolam-ketamine combinations were equally effective for sedation during AFNI in patients with difficult airways scheduled for orofacial maxillary surgery. Patients receiving dexmedetomidine were more sedated, but the incidence of side effects was similar in both groups.

Background and Aims: Sepsis-associated acute kidney injury (SA-AKI) significantly contributes to morbidity and mortality. Current biomarkers have limitations, necessitating the exploration of alternative indicators. This study aims to evaluate various urinary electrolyte parameters to predict SA-AKI. Methods: A prospective observational study included 111 sepsis patients within 24 h of admission. Urinary electrolyte samples were collected, and indices were calculated. Patients were monitored for 7 days to assess for acute kidney injury (AKI) according to Kidney Disease Improving Global Outcomes (KDIGO) definition criteria, mortality rates, and the need for renal replacement therapy. Mann-Whitney U test and Chi-squared test were used to analyse continuous and categorical variables, respectively. Receiver-operating characteristic (ROC) curves were constructed to determine to discriminatory ability of various parameters in predicting AKI. Results: Of 111 patients, 42.3% developed AKI, with a mortality rate of 59.5%. When evaluating urinary parameters, the product of urine sodium and urine creatinine exhibited the maximum full form [area under the receiver operating characteristic (AUROC): 0.66; 95%CI: 0.56, 0.77)], and the parameter of fractional excretion of potassium (FeK) exhibited an AUROC of 0.62 (95%CI: 0.51, 0.72). Furthermore, 2-hour excretion of potassium revealed a statistically significant correlation with 2-hour creatinine clearance (r = 0.62, P < 0.001). Logistic regression models, incorporating Sequential Organ Failure Assessment (SOFA) score, FeK, and urine sodium concentration as variables (P = 0.020, 0.044, and 0.033, respectively), achieved an AUROC of 0.751 in predicting AKI. Conclusion: Urine sodium levels and fractional potassium excretion moderately effectively predict AKI in sepsis patients. Urine potassium excretion correlates with glomerular filtration rate.

PURPOSE:Evaluation of the effect of supraglottoplasty on co-existing tracheomalacia in pediatric patients with congenital laryngotracheomalacia to establish the venturi effect in vivo. METHODS:A prospective interventional study was conducted in a tertiary care hospital from 2020 to 2024. All consecutive pediatric patients undergoing supraglottoplasty for congenital laryngomalacia, with co-existing tracheomalacia on pre-operative bronchoscopic assessment were included and were assessed for change in severity of tracheomalacia by bronchoscopy and clinical parameters post-surgery as a comparison to the preoperative period. RESULTS:Twenty-eight patients including sixteen boys and twelve girls aged 1-30 months underwent supraglottoplasty. Statistically significant reduction in tracheal collapse was noted in all twenty-eight patients post-surgery on bronchoscopic evaluation (mean reduction by 41.45 ± 9.72 %). Clinically significant improvement was seen in terms of severity of stridor, frequency of hospitalization, apparent life-threatening events, z score for weight for age and parental perception of resolution of symptoms of their ward. CONCLUSION:Supraglottoplasty for correction of laryngomalacia results in significant improvement in co-existing tracheomalacia. Associated medical comorbidities were not found to affect the positive outcome. Supraglottoplasty being a simple surgery with insignificant complication rate and very high success rate may be considered as the first line of surgical intervention in severely symptomatic pediatric patients with laryngotracheomalacia.

BACKGROUND:The impact of intraoperative starch-based fluid therapy on postoperative kidney dysfunction in patients undergoing major abdominal surgery is uncertain. Low molecular weight starch is expected to cause less postoperative kidney dysfunction. METHODS:This retrospective study evaluated the impact of intraoperative 6% hydroxyethyl starch on postoperative renal dysfunction. The primary outcome of this study was postoperative acute kidney injury as per KDIGO definition within 72 hours of surgery. RESULTS:This study analysed data from 461 patients with a median (interquartile range) age of 45 (33-58) years, and 48.2% of all patients were female. The proportion (95% confidence interval) of patients who developed acute kidney injury was 0.18 (0.14-0.21); 62.9% of patients had acute kidney injury stage I, 32% had acute kidney injury stage II, and the rest were acute kidney injury stage III. In the propensity score-matched sample, the average treatment effect of intraoperative colloid use on postoperative serum creatinine at day 3 (p = 0.32), duration of postoperative intensive care unit stay (p = 0.97), duration of hospital stay (p = 0.37), postoperative worst international normalised ratio (p = 0.92), and postoperative transfusion requirement (p = 0.40) were not statistically significant. CONCLUSION:Intraoperative use of low molecular weight hydroxyethyl starch use was not associated with postoperative kidney dysfunction and coagulopathy in adult patients undergoing major open abdominal surgery.

Background and Aims: Simulation-based teaching (SBT) has become integral to healthcare education, offering a dynamic and immersive learning experience for bridging theoretical knowledge with real-world clinical practice. Faculty members play a crucial role in shaping the effectiveness of simulation-based education, necessitating the implementation of comprehensive faculty development programmes. This scoping review explores existing literature on training programmes for simulation-based teaching, focusing on strategies employed and the overall impact on educators and the quality of simulation-based education.Methods: The scoping review comprised five sequential steps: identifying the research question; identifying relevant studies; study selection; charting the data; and collating, summarising, and reporting the results. The research questions focused on existing practices and approaches in faculty development for simulation-based teaching, challenges or barriers reported, and the effectiveness of utilised methods and strategies.Results: A systematic search of databases yielded 13 studies meeting inclusion criteria out of 1570 initially screened papers. These studies provided insights into various aspects of faculty development programmes, including their nature, duration, and participant profiles. Despite the diversity in approaches, detailed, specialty-specific programmes were scarce, especially in anaesthesiology. Challenges, while implicit, lacked explicit exploration. Most studies reported positive outcomes, emphasising achievement of learning objectives, appreciable course content, and relevance to teaching practices.Conclusion: This scoping review describes the existing literature regarding the faculty training or development programmes related to SBT. The programmes target various health professionals and have a wide range of durations. The need for such a programme targeting anaesthesiologists is emphasised.

Postoperative pulmonary complications (PPC) after major abdominal surgery are common and incidence may reach up to 30%. PPCs contributes to increased morbidity, cost of care and length of hospital stay. In this secondary analysis of a randomized controlled trial, we identified whether a postoperative lung ultrasound aeration score can predict PPCs after elective major abdominal surgery.Patients and methodsThis is study is a secondary analysis of a previously published randomized controlled trial [1] where n = 82 adult patients of American Society of Anesthesiologists physical status I or II, undergoing elective major open abdominal surgery under general anaesthesia were recruited. In group T patients, PEEP was titrated incrementally till lowest driving pressure is achieved and the same procedure was repeated in every 2 h. In group F patients, a PEEP of 5 cm H2O was used throughout the surgery. Lung USG aeration score was evaluated before and after induction of general anaesthesia and at the end of surgery (before and after extubation). Patients were followed till postoperative day 3 for PPC and oxygen requirement.ResultsPostoperative lung USG score (before extubation) was able to predict PPC [AUROC (95% CI) 0.65 (0.51–0.79)] and postoperative oxygen requirement [AUROC (95% CI) 0.70 (0.59–0.83)]. Postoperative lung USG score (after extubation) was able to predict PPC [AUROC (95% CI) 0.63 (0.49–0.78)] and postoperative oxygen requirement [AUROC (95% CI) 0.70 (0.58–0.83)]. After adjustment of age (p = 0.06), body mass index (p = 0.01), serum albumin (p = 0.02), duration of anaesthesia (p = 0.29), smoking status and type of surgery; lung USG score after extubation was an independent predictor of postoperative oxygen requirement [adjusted OR (95% CI) 1.28 (1.05–1.55)].ConclusionLung USG aeration score at the end of surgery (before and after extubation) was able to predict postoperative oxygen requirement with some degree of accuracy.References1. Mini G, Ray BR, Anand RK, Muthiah T, Baidya DK, Rewari V, Sahni P, Maitra S. Effect of driving pressure-guided positive end-expiratory pressure (PEEP) titration on postoperative lung atelectasis in adult patients undergoing elective major abdominal surgery: A randomized controlled trial. Surgery. 2021 Jul;170(1):277–283.

Background: This prospective, double-blinded, randomized study aimed to compare the efficacy of dexmedetomidine and fentanyl infusions in maintaining hemodynamics during head and neck free flap surgery, as well as their impact on the relative amount of blood loss. Methods: Twenty patients with American Society of Anesthesiologists physical status I and II scheduled for elective head and neck free flap surgery were enrolled. The patients were randomly assigned to receive either dexmedetomidine (1 µg/kg over 10 min at anesthesia induction, followed by 0.2 to 0.75 µg/kg per hour infusion during maintenance) or fentanyl (1 to 2 µg/kg per hour infusion during maintenance). Intraoperative hemodynamic parameters, blood loss, blood transfusion requirements, surgeon satisfaction, adverse drug effects, and free flap survival up to 7 days were recorded. Results: The dexmedetomidine group achieved a mean arterial pressure (MAP) value between 60 and 70 mmHg at multiple time points (15 min, 3rd, 4th, 5th, and 6th hours), while the fentanyl group did not reach this range at any time point. The intergroup statistical analysis revealed a significant difference only at the 5th hour with (95