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Background: Epidemiological data on critically ill patients is crucial for understanding resource utilisation, gaps in quality of care and for supporting surveillance of endemic or emerging diseases. We report the epidemiology of critically ill patients from 17 intensive care units (ICUs) in Nepal using an established and standardised ICU registry. Methods: The ICU registry data is collected prospectively and includes data on case mix, severity, organ support and outcomes. We conducted a retrospective observational study with all adult (≥18 years) critically ill patients admitted to 17 ICUs in Nepal between September 2019 and September 2022. We report on case mix, treatment received, severity of illness, standardised mortality rates (SMR), discharge outcomes and ICU service activity. Descriptive statistics were used to report the findings. Results: Of the 18603 unique admissions, 14% were operative, with 35% emergency surgeries. Patients’ median age was 57 (IQR 40-71) and 59% were male. Hypertension and diabetes were common comorbidities and pneumonia accounted for 26% of all admissions. During the ICU stay, 39% of patients received mechanical ventilation, 29% received vasoactive medication and 10% received renal replacement therapy. The median predicted risk of death was 0.1 (IQR 0.1-0.3) using APACHE II and 0.2 (IQR 0.1-0.4) using eTropICS. The median SMR was 0.7 (IQR 0.5-0.8) and 0.8 (IQR 0.6-1.4) using eTropICS and APACHE II, respectively. Median length of stay was 4 days (IQR 2-7). Eighteen percent died in the ICU; of those alive at discharge, 12% went home, 84% went to another department and 3% went to another hospital. COVID-19 was the most common notifiable disease reported (12% of all admissions). Median ICU turnover was 9% (IQR 6-14) with bed capacity ranging from 43-278. Conclusions: These findings should guide forecasting and service planning to ensure ICUs can optimally care for critically ill patients in Nepal.

Failure of ventilation of an anesthetised patient due to problems in mechanical ventilator isnot uncommon. The proper functioning of machine should be ensured before anesthetisinga patient by the automated checking system or manually by the attending anaesthesiologist.However, sudden malfunction of some system of the machine during operation may causethe ventilator to stop risking the patient’s life. About one third of the equipment problemsare due to anesthesia machine and one quarter of the problems are due to human error. Wepresent a case of malfunction of anesthesia ventilator due to an unusual cause of blockage ofanesthesia gas scavenging system.

It is difficult to predict the future course and length of the ongoing COVID-19 pandemic, which has devastated health care systems in low- and middle-income countries. Anesthesiology and critical care services are hard hit because many hospitals have stopped performing elective surgeries, staff and scarce hospital resources have been diverted to manage COVID-19 patients, and several makeshift COVID-19 units had to be set up. Intensive care units are overwhelmed with critically ill patients. In these difficult times, low- and middle-income countries need to improvise, perform indigenous research, adapt international guidelines to suit local needs, and target attainable clinical goals.

Remote site is defined as any location at which an anesthesiologist is required to provide general or regional anesthesia or sedation away from the main operation theater suite and/or anesthesiology department and in which it cannot be guaranteed that the help of another anesthesiologist will be available. Anesthesiologist is frequently involved in anesthetizing children with neurological disorders undergoing therapeutic and diagnostic procedures. These procedures are steadily increasing every year.

The number 2 craniofacial cleft as described by Tessier is an extremely rare cleft of unknown aetiology with distinct soft tissue and bony characteristics. The location of the deformity on the nostril rim is a distinguishing feature of the cleft. It traverses the alveolar arch at the level of the lateral incisor, middle third of the alar rim, the junction between the nasal bone and the frontal process of the maxilla and continues cranially as a number 12 cleft. One such patient with bilateral interruption of the middle third of the alar rim and mild asymmetrical hypertelorism is described.