Neeraj Kumar

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. 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. 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. 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. 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.

Minimally invasive cardiac output monitoring (MICOM) devices have revolutionized hemodynamic monitoring in critically ill patients. This chapter reviews the principles and applications of various MICOM devices, including pulse contour analysis (e.g., LiDCO and PiCCO), esophageal Doppler, and bioimpedance cardiography. LiDCO and PiCCO devices use pulse contour analysis to estimate cardiac output, providing valuable insights into hemodynamic function. Their clinical utility spans diverse patient populations, such as those undergoing surgery or experiencing shock. Evidence supporting their use in goal-directed therapy protocols is also examined. However, MICOM devices have limitations, including issues related to accuracy, precision, and clinical interpretation. Understanding these limitations is crucial to harnessing their potential. By providing a comprehensive overview of MICOM devices, this chapter empowers clinicians to make informed decisions about hemodynamic management in critical care settings, ultimately enhancing patient outcomes and driving progress in critical care medicine.

How to cite this article: Kumar N. Point-of-care Ultrasonography for Endotracheal Tube Confirmation: An Essential Adjunct in Airway Management. Indian J Crit Care Med 2026;30(2):92–94.

Introduction: Propofol, a commonly used intravenous anesthetic induction agent, frequently produces pain on injection, with an incidence ranging from 28% to 91%. This study aimed to compare the effect of low-dose ketamine and a pressure vibration mechanical device with placebo in reducing pain during propofol injection in patients undergoing elective surgery. Methods: In this randomized, double-blind, placebo-controlled trial, 300 adults were allocated to pressure vibration (Group V), low-dose ketamine (Group K), or saline placebo (Group P); 275 patients completed the study and were analyzed (92, 91, and 92 patients, respectively). Group P received 5 mL 0.9% saline, Group K ketamine 50 µg/kg diluted in 5 mL saline, and Group V saline with an activated pressure vibration device applied proximal to the intravenous cannula, each administered over 1 min. Propofol 2 mg/kg was infused, with the first 25% delivered at 600 mL/hour, and pain assessed using the McCrirrick and Hunter verbal rating score. The primary outcome was pain on propofol injection. Continuous variables were analyzed using one-way analysis of variance or Kruskal-Wallis tests, categorical variables with χ² tests, with Bonferroni correction applied for multiple primary outcome comparisons. Results: Among 275 analyzed patients, the incidence of no pain was highest in the pressure vibration device group 51.1%; 95% CI 42.4% to 59.8% compared with placebo 30.4%; 95% CI 21.0% to 39.8% and ketamine 33.0%; 95% CI 23.3% to 42.6%; (p=0.001). Severe pain was more frequent in the placebo group (18.5%; 95% CI 10.5% to 26.4%) than in the ketamine (5.5%; 95% CI 0.8% to 10.2%) and vibration groups (4.3%; 95% CI 0.2% to 8.5%; (p=0.001). Recall of injection pain at 1 week was significantly higher with placebo compared with ketamine and vibration device (55.4%, 37.4%, and 26.1%, respectively; p<0.001). Hemodynamic variables and adverse events were comparable across groups. Conclusion: The pressure vibration mechanical device significantly reduced the incidence and severity of propofol injection pain compared with placebo and was at least as effective as low-dose ketamine. Pain recall at 1 week was higher with placebo. This device provides an effective, reusable, non-pharmacological alternative without drug-related adverse effects. Trial registration number: CTRI/2022/12/048300.

Background: Postdural puncture headache (PDPH) following spinal anaesthesia significantly affects postpartum recovery. We evaluated the efficacy of nebulised dexmedetomidine and aminophylline in women with moderate to severe PDPH after caesarean delivery. Methods: In this single-centre, double-blind, randomised controlled trial, 96 postpartum women, with American Society of Anesthesiologists physical status II, Visual Analogue Scale (VAS), with PDPH (VAS>4; Lybecker>2) after subarachnoid block were allocated to receive nebulised dexmedetomidine (1 µg/kg), aminophylline (1.5 mg/kg) or saline placebo. All participants received standardised conservative treatment and remained supine for 72 hours. Nebulisation was administered two times per day for ≤72 hours. The primary endpoint was change in VAS pain score at 24 hours. Secondary endpoints included VAS and Lybecker scores at 48 hours and 72 hours, Patient Global Impression of Change (PGIC) and adverse events. Results: Baseline characteristics were comparable between groups. At 24 hours, median VAS was significantly lower with dexmedetomidine (3 (3–4)) and aminophylline (4 (3–6)) compared with control (6 (5.5–6)) (p<0.001). Pain reduction persisted at 48 hours and 72 hours, with dexmedetomidine producing the fastest resolution. Lybecker scores improved earlier in the treatment groups (p<0.001). PGIC showed ‘very much improved’ in 100% (dexmedetomidine), 53.1% (aminophylline) and 0% (control) (p<0.001). Adverse events were mild and infrequent, with cough and nausea occurring only in the aminophylline group. Conclusions: Nebulised dexmedetomidine and aminophylline provided effective, well-tolerated, non-invasive treatment for PDPH. Dexmedetomidine produced the greatest and earliest improvement. These therapies may represent practical alternatives for PDPH management in postpartum patients; larger multicentre trials allowing early mobilisation are warranted. Trial registration number: Clinical Trials Registry-India (CTRI/2024/01/061322; date of prospective trial registration: 10 January 2024, date of first patient enrolment: 15 January 2024, https://ctri.nic.in/Clinicaltrials/login.php ).

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. 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. 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. 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. 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 registry of India (CTRI/2020/10/028488). 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.

N-methyl-D-aspartate (NMDA) receptor encephalitis is a rare autoimmune encephalitis characterised by high morbidity and mortality, often necessitating intensive care. We report the case of a woman in her early 20s who presented with fever, altered sensorium, dyskinesia, keratoconjunctivitis sicca and xerostomia. A diagnosis of NMDA receptor encephalitis combined with Sjögren’s syndrome (SS) was established based on her history, clinical findings, biochemical analysis and radiological imaging. The condition was successfully managed with immunotherapy and other supportive treatments. This rare combination of NMDA receptor encephalitis and SS presents overlapping central nervous system manifestations, posing a diagnostic challenge.

Cytoreductive surgery and intraoperative, intraperitoneal hyperthermic chemoperfusion (hyperthermic intraperitoneal intraoperative chemotherapy) are commonly used for the management of peritoneal surface metastases. We describe a case of acute embolic infarcts in bilateral cerebellar lobes, cerebral peduncles, thalamus and left parietal lobe cortex in a postmenopausal woman in her 50s diagnosed with bilateral ovarian mucinous adenocarcinoma with peritoneal metastasis under general anaesthesia.