Red Blood Cell Transfusion Thresholds in Critically Ill Patients.

Anemia of multifactorial etiology is common among critically ill patients and several arbitrary transfusion thresholds have been proposed. Transfusion of red blood cells has been well established to increase morbidity and even mortality among critically ill patients. Several randomized controlled studies have evaluated the use of a restrictive compared to a more liberal transfusion strategy in the critically ill. A transfusion threshold of 7 g/dL appears to be generally safe, especially in the younger age group without significant comorbidities. Besides, a restrictive transfusion strategy reduces the incidence of transfusion-related complications. However, the decision to transfuse needs to be individualized depending on the clinical situation, balancing putative benefits against possible complications. HOW TO CITE THIS ARTICLE: Chacko J, Brar G. Red Blood Cell Transfusion Thresholds in Critically Ill Patients. Indian J Crit Care Med 2019;23(Suppl 3):S181-S184.

Papillary Muscle Dysfunction Due to Coronary Slow-Flow Phenomenon Presenting with Acute Mitral Regurgitation and Unilateral Pulmonary Edema.

Cardiogenic pulmonary edema usually presents with characteristic clinical features and bilateral infiltrates on the chest radiograph. Rarely, pulmonary edema may manifest unilaterally, leading to a mistaken diagnosis of a primary lung pathology. We present a 30-year-old man who developed acute coronary syndrome following an overdose of alprazolam. He developed breathlessness with unilateral infiltrates on the chest radiograph. Echocardiography revealed regional wall motion abnormalities related to underlying ischemia and acute mitral regurgitation with an eccentric jet. Besides, he had significant impairment of left ventricular systolic function. His coronary angiogram revealed a slow-flow phenomenon in the right coronary and left anterior descending artery territories. Ischemia-related dysfunction of the posterolateral papillary muscle probably led to a floppy posterior mitral leaflet and an eccentrically directed regurgitant jet, leading to unilateral pulmonary edema. He was commenced on dual antiplatelet therapy, heparin infusion, atorvastatin, frusemide, and ramipril, following which he showed gradual clinical improvement along with resolution of the radiological infiltrates. His left ventricular function improved, and the mitral valve function normalized on echocardiography within a week.

Bilateral Lower Cranial Nerve Palsy after Closed Head Injury: A Case Report and Review of Literature.

Paralysis of the lower cranial nerves is uncommon after closed head injuries. Most cases reported are unilateral and associated with base of skull fractures, usually involving the occipital condyles. Bilateral lower cranial nerve palsy is even less common, with only a handful of cases reported in literature. A 17-year-old girl presented to us after she was involved in a side-on collision with a car while driving a scooter. She sustained traumatic brain injury requiring mechanical ventilation. Detailed neurological evaluation revealed bilateral paralysis of the IXth, Xth, and XIIth cranial nerves with no evidence of a fracture of the base of skull or brain stem injury. A traction type of injury to the nerves arising from a whiplash mechanism may have led to paralysis of the lower cranial nerves in our patient. An exhaustive review of literature revealed 11 reports of bilateral lower cranial nerve palsy associated with closed head injuries; there were only four cases without underlying fracture of the occipital condyles. Our patient made a complete recovery over a period of 4 months. A traction type of injury to the lower cranial nerves may occur due to a whiplash mechanism. This type of injury may be associated with a favorable outcome.

Bedside ultrasonography-Applications in critical care: Part II.

Point of care ultrasonography, performed by acute care physicians, has developed into an invaluable bedside tool providing important clinical information with a major impact on patient care. In Part II of this narrative review, we describe ultrasound guided central venous cannulation, which has become standard of care with internal jugular vein cannulation. Besides improving success rates, real-time guidance also significantly reduces the incidence of complications. We also discuss compression ultrasonography - a quick and effective bedside screening tool for deep vein thrombosis of the lower extremity. Abdominal ultrasound offers vital clues in the emergency setting; in the unstable trauma victim, a focused examination may provide immediate answers and has largely superseded diagnostic peritoneal lavage in diagnosing intraperitoneal bleed. From estimation of intracranial pressure to transcranial Doppler studies, ultrasound is becoming increasingly relevant to neurocritical care. Ultrasound may also help with airway management in several situations, including percutaneous tracheostomy. Clearly, bedside ultrasonography has become an indispensable part of intensive care practice - in the rapid assessment of critically ill-patients as well as in enhancing the safety of invasive procedures.

Bedside ultrasonography: Applications in critical care: Part I.

There is increasing interest in the use of ultrasound to assess and guide the management of critically ill patients. The ability to carry out quick examinations by the bedside to answer specific clinical queries as well as repeatability are clear advantages in an acute care setting. In addition, delays associated with transfer of patients out of the Intensive Care Unit (ICU) and exposure to ionizing radiation may also be avoided. Ultrasonographic imaging looks set to evolve and complement clinical examination of acutely ill patients, offering quick answers by the bedside. In this two-part narrative review, we describe the applications of ultrasonography with a special focus on the management of the critically ill. Part I explores the utility of echocardiography in the ICU, with emphasis on its usefulness in the management of hemodynamically unstable patients. We also discuss lung ultrasonography - a vastly underutilized technology for several years, until intensivists began to realize its usefulness, and obvious advantages over chest radiography. Ultrasonography is rapidly emerging as an important tool in the hands of intensive care physicians.

Dynamic α-Fetoprotein Response and Outcomes After Liver Transplant for Hepatocellular Carcinoma.

Importance: Accurate preoperative prediction of hepatocellular carcinoma (HCC) recurrence after liver transplant is the mainstay of selection tools used by transplant-governing bodies to discern candidacy for patients with HCC. Although progress has been made, few tools incorporate objective measures of tumor biological characteristics, resulting in inclusion of patients with high recurrence rates and exclusion of others who could otherwise be cured. Objective: To externally validate the New York/California (NYCA) score, a recently published multi-institutional US HCC selection tool that was the first model incorporating a dynamic α-fetoprotein response (AFP-R) and compare the validated score with currently accepted HCC selection tools, namely, the Milan Criteria (MC), the French-AFP (F-AFP), and Metroticket 2.0 models. Design, Setting, and Participants: A retrospective, multicenter prognostic analysis of prospectively collected databases of 2236 adults undergoing liver transplant for HCC was conducted at 3 US, 1 Canadian, and 4 European centers from January 1, 2001, to December 31, 2013. The AFP-R was measured as the difference between maximum and final pre-liver transplant AFP level. Cox proportional hazards regression and competing risk regression analyses examined recurrence-free and overall survival. Receiver operating characteristic analyses and net reclassification index were used to compare NYCA with MC, F-AFP, and Metroticket 2.0. Data analysis was performed from June 2019 to April 2020. Main Outcomes and Measures: The primary study outcome was 5-year recurrence-free survival; overall survival was the secondary outcome. Results: Of 2236 patients, 1808 (80.9%) were men; mean (SD) age was 58.3 (7.96) years. A total of 545 patients (24.4%) did not meet the MC. The NYCA score proved valid on competing risk regression analysis, accurately predicting recurrence-free and overall survival (5-year cumulative incidence of recurrence risk in NYCA risk categories was 9.5% for low-, 20.5%, for acceptable-, and 40.5% for high-risk categories; P < .001 for all). The NYCA also predicted recurrence-free survival on a center-specific level: 453 of 545 patients (83.1%) who did not meet MC, 213 of 308 (69.2%) who did not meet the French-AFP, 292 of 384 (76.1%) who did not meet Metroticket 2.0 would be recategorized into NYCA low- and acceptable-risk groups (>75% 5-year recurrence-free survival). The Harrell C statistic for the validated NYCA score was 0.66 compared with 0.59 for the MC and 0.57 for the F-AFP models (P < .001). The net reclassification index for NYCA was 8.1 vs MC, 12.9 vs F-AFP, and 10.1 vs Metroticket 2.0. Conclusions and Relevance: This study appears to externally validate the importance of AFP-R in the selection of patients with HCC for liver transplant. The AFP-R represents one of the truly objective measures of biological characteristics available before transplantation. Incorporation of AFP-R into selection criteria allows safe expansion of MC and other models, offering liver transplant to patients with acceptable tumor biological characteristics who would otherwise be denied potential cure.

Isolated inhalational injury: Clinical course and outcomes in a multidisciplinary intensive care unit.

BACKGROUND AND AIMS: Although smoke inhalation is well known to cause acute lung injury, there are few reports in literature that study the evolution, clinical course and outcomes of isolated inhalational lung injury in a modern intensive care setting. A major fire disaster provided us the opportunity to study victims of isolated inhalational injury admitted to our Multidisciplinary Intensive Care Unit (MICU). MATERIALS AND METHODS: We studied the clinical course, ICU and hospital outcomes of 13 victims of a fire disaster who required mechanical ventilation for isolated inhalational lung injury. All patients were followed up at regular intervals, and their functional status was assessed at 8 months after hospital discharge. RESULTS: The Lung Injury Scores (LIS) worsened to reach a nadir on Day 3 of injury. There was a significant correlation between the LIS on Day 3 and duration of mechanical ventilation (r = 0.8; P = 0.003), ICU (r = 0.8; P = 0.002) and hospital (r = 0.6; P = 0.02) days. Late-onset airway complications were encountered in four patients. Three of them required long-term artificial airways - two with a tracheostomy while the third patient required surgical insertion of a "T" tube. Persistent problems with phonation occurred in two patients. At 8 months postdischarge, all patients were independent with activities of daily living; all were back to work, except for two who continued to need artificial airways. CONCLUSIONS: Inhalational lung injury progresses over the first few days and is worst after 72 h. Late-onset airway complications may manifest after several weeks and require repeated intervention.

Apical ballooning syndrome after attempted suicidal hanging.

We report a case of "Apical Ballooning Syndrome" following attempted suicidal hanging. Our patient developed retrosternal chest pain and ischemic changes on electrocardiography (ECG), a day after the suicidal attempt. She underwent an angiogram considering the possibility of acute coronary syndrome. However, her coronary arteries were normal; the left ventricle showed the typical ballooning pattern characterized by hypokinesia of the distal septum and apex. On follow-up a week later, she remained asymptomatic; her ECG changes had reversed and the left ventricular contractility was normal on echocardiography.