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Background and Aim: Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU. Materials and Methods: A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods. Results: Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay's Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation. Conclusion: The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.

Diabetic ketoacidosis (DKA) is a known complication of acute pancreatitis (AP). On the other hand, ketosis can induce AP. Ketoacidosis along with AP induces an inflammatory cascade by oxidative stress and dehydration. Both of these factors lead to stasis of blood and endothelial damage which makes these patients prothrombotic. We report a case of DKA precipitated by AP. This patient developed watershed infarct in brain during her course of disease which was possibly attributed to hypercoagulability, stasis and endothelial injury triggered by ketosis.

Development of autoantibodies against coagulation factor VIII (FVIII) leads to a rare condition defined as acquired hemophilia (AH). If not diagnosed and treated early, AH may be associated with high mortality and morbidity. A 65-year-old woman presented with history of macrohematuria, acute renal failure, cardiogenic shock, and acute respiratory failure. Blood investigation revealed azotemia, prolonged activated partial thromboplastin time (aPTT), coagulation FVIII level of

Fat embolism and fat embolism syndrome (FES) are well-known complications of long bone fracture and surgery involving manipulation of skeletal elements. Many non-traumatic causes of FES have been suggested but they constitute only a small portion. FES presents with classical symptoms of petechiae, hypoxemia, central nervous system symptoms along with other features such as tachycardia and pyrexia. Diagnosis of FES relies on clinical judgment rather than objective findings such as emboli present in the retinal vessels on fundoscopy, fat globules present in urine and sputum, a sudden inexplicable drop in hematocrit or platelet values, increasing erythrocyte sedimentation rate.

Urea cycle disorders (UCD) are common during neonatal period, and it is rarely reported in adults. We are reporting a patient presenting with post-partum neuropsychiatric symptoms rapidly progressing to coma. Markedly raised serum ammonia level on presentation with an initial normal magnetic resonance imaging (MRI) of brain and normal liver function tests led to the suspicion of UCD, which was confirmed on the basis of urine orotic acid and elevated serum amino acid levels. We had to resort to hemodialysis to correct the hyperammonemic coma, which was unresponsive to conventional anti-ammonia measures. She exhibited remarkable improvement with a progressive decline in serum ammonia with repeated hemodialysis and made a full recovery. Timely diagnosis and early institution of hemodialysis in the setting of a poor neurological status maybe considered a suitable treatment option.

Idiopathic pulmonary hypertension (PH) is a diagnosis of exclusion for any patient presenting with pulmonary hypertension (PH). Patient with PH may present with thrombocytopenia along with other signs of PH. We report a case of PH who presented with thrombocytopenia and breathlessness. The possible causes of thrombocytopenia were evaluated and excluded prior to concluding that her thrombocytopenia is due to PH. Various pathogenic mechanisms have been described for thrombocytopenia associated with PH.

Raised intra-abdominal pressure and abdominal compartment syndrome are commonly noticed in critically ill patients. In the recent past, their presence in a variety of medical and surgical conditions other than trauma has been emphasized. Early detection, prevention, and treatment reduce the morbidity and mortality in these critically ill patients.

Electrical shock therapies are capable of terminating arrhythmias due to reentry. Reentry is the predominant mechanism of majorities of arrhythmias in ICUs.

Partial exchange transfusion during cardiopulmonary bypass, while conducting cardiac surgery may be a useful technique in patients with high level of sickle hemoglobin. Along with this preoperative use of hydroxyurea and alternative analgesic modalities such as transcutaneous electrical nerve stimulation in postoperative period may be beneficial, in our opinion. A 16-year-old female of Turner's syndrome having sickle cell anemia scheduled for closure of arterial septal defect on cardiopulmonary bypass was managed with partial exchange transfusion and warm cardioplegia.

Gastrothorax is characterized by herniation of the stomach and other abdominal contents into the thoracic cavity either through the oesophageal hiatus or ruptured diaphragm. When gastrothorax causes pulmonary and hemodynamic compromise, due to compression of lungs and mediastinal structures, it is named as tension gastrothorax. Diagnosis of tension gastrothorax is often complicated during late pregnancy, because of unusual presentation, altered physiology, absence of trauma, hesitation about radiation exposure, and rarity of the condition. We report a case of a patient, in her 32nd week of pregnancy, who presented with left tension gastrothorax. Lower segment caesarean section was planned after steroid therapy, with all the preparations for thoracotomy. Intra-operatively, stomach, spleen, and colon were found herniated in the left hemithorax, through a ruptured left hemidiaphragm. Thoracotomy was done immediately after caesarean section, with reduction of herniated contents and repair of the defect in the diaphragm. The patient and her baby were discharged in stable condition 2 weeks after thoracotomy.