Cirrhotic cardiomyopathy influences clinical outcomes and enhances performance of conventional risk prediction models in acute-on-chronic liver failure with severe sepsis.

BACKGROUND: Point-of-care echocardiography (POC-Echo) is an essential intensive care hemodynamic monitoring tool. AIMS: To assess POC-Echo parameters [i.e., cardiac index (CI), systemic vascular resistance index (SVRI) and cirrhotic cardiomyopathy (CCM) markers] and serum biomarkers in predicting circulatory failure (need for vasopressors) and mortality in patients with acute-on-chronic liver failure (ACLF) having sepsis-induced hypotension. METHODS: We performed serial POC-Echo within 6 hours (h) of presentation and subsequently at 24, 48 and 72 h in patients with ACLF and sepsis-induced hypotension admitted to our liver intensive care unit. Clinical data, POC-Echo data and serum biomarkers were collected prospectively. RESULTS: We enrolled 120 patients [59% men, aged 49 ± 12 years, 56% alcohol-related disease and median MELDNa of 30 (27-32)], of whom 68 (56.6%) had circulatory failure, with overall mortality of 60%. CCM was present in 52.5%. The predictors of circulatory failure were CI (aHR -1.5; p = 0.021), N-terminal brain natriuretic peptide (aHR -1.1; p = 0.007) and CCM markers; e' septal mitral velocity (aHR -0.5; p = 0.039) and E/e' ratio (aHR -1.2; p = 0.045). Reduction in CI by 20% and SVRI by 15% at 72 h predicted mortality with a sensitivity of 84% and 72%, and specificity 76% and 65%, respectively (p < 0.001). The MELD-CCM model and CLIF-CCM model were computed as MELDNa + 1.815 × E/e' (septal) + 0.402 × e' (septal) and CLIF-C ACLF + 1.815 × E/e' (septal) + 0.402 × e' (septal), respectively, based on multivariable logistic regression. Both scores outperformed MELDNa (z-score = -2.073, p = 0.038) and CLIF-C ACLF score (z score = -2.683, p-value = 0.007), respectively, in predicting 90-day mortality. CONCLUSION: POC-Echo measurements such as CCM markers (E/e' and e' velocity) and change in CI reliably predict circulatory failure and mortality in ACLF with severe sepsis. CCM markers significantly enhanced the CLIF-C ACLF and MELDNa predictive performance.

COVID-19-related dynamic coagulation disturbances and anticoagulation strategies using conventional D-dimer and point-of-care Sonoclot tests: a prospective cohort study.

OBJECTIVES: Coagulation changes associated with COVID-19 suggest the presence of a hypercoagulable state with pulmonary microthrombosis and thromboembolic complications. We assessed the dynamic association of COVID-19-related coagulation abnormalities with respiratory failure and mortality. DESIGN: Single-centre, prospective cohort study with descriptive analysis and logistic regression. SETTING: Tertiary care hospital, North India. PARTICIPANTS: Patients with COVID-19 pneumonia requiring intensive care unit (ICU) admission between August 2020 and November 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: We compared the coagulation abnormalities using standard coagulation tests like prothrombin time, D-dimer, platelet count, etc and point-of-care global coagulation test, Sonoclot (glass beaded(gb) and heparinase-treated(h)). Incidence of thromboembolic or bleeding events and presence of endogenous heparinoids were assessed. Cox proportional Hazards test was used to assess the predictors of 28-day mortality. MEASUREMENT: All patients underwent Sonoclot (glass beaded) test at admission apart from the routine investigations. In patients at risk of thromboembolic or bleeding phenomena, paired tests were performed at day 1 and 3 with Sonoclot. Activated clotting time (ACT) <110 s and peak amplitude >75 units were used as the cut-off for hypercoagulable state. Presence of heparin-like effect (HLE) was defined by a correction of ACT ≥40 s in h-Sonoclot. RESULTS: Of 215 patients admitted to ICU, we included 74 treatment naive subjects. A procoagulant profile was seen in 45.5% (n=5), 32.4% (n=11) and 20.7% (n=6) in low-flow, high-flow and invasive ventilation groups. Paired Sonoclot assays in a subgroup of 33 patients demonstrated the presence of HLE in 17 (51.5%) and 20 (62.5%) at day 1 and 3, respectively. HLE (day 1) was noted in 59% of those who bled during the disease course. Mortality was observed only in the invasive ventilation group (16, 55.2%) with overall mortality of 21.6%. HLE predicted the need for mechanical ventilation (HR 1.2 CI 1.04 to 1.4 p=0.00). On multivariate analysis, the presence of HLE (HR 1.01; CI 1.006 to 1.030; p=0.025), increased C reactive protein (HR 1.040; CI 1.020 to 1.090; p=0.014), decreased platelet function (HR 0.901; CI 0.702 to 1.100 p=0.045) predicted mortality at 28days. CONCLUSION: HLE contributed to hypocoagulable effect and associated with the need for invasive ventilation and mortality in patients with severe COVID-19 pneumonia. TRIAL REGISTRATION: NCT04668404; ClinicalTrials.gov.in. Available from https://clinicaltrials.gov/ct2/show/NCT04668404.

The effect of pulse pressure variation compared with central venous pressure on intraoperative fluid management during kidney transplant surgery: a randomized controlled trial.

BACKGROUND: Traditionally, fluid administration during kidney transplant surgery is guided by central venous pressure (CVP) despite its limited reliability as a parameter for assessing intravascular fluid volume, particularly in patients with cardiovascular diseases. The recommended goals at graft reperfusion are a mean arterial pressure of 90 mm Hg and a CVP of 12-14 mm Hg. This approach may increase the risk of significant adverse effects due to volume overload. Perioperative fluid therapy guided by dynamic indices of fluid responsiveness has been shown to optimize intravascular volume and prevent complications associated with overzealous administration of fluids in major abdominal surgeries. We hypothesized that pulse pressure variation (PPV)-guided fluid administration would result in better optimization of intravascular fluid volume compared with a CVP-guided strategy during kidney transplant surgery. METHODS: In this single-centre randomized double blinded trial, 77 end-stage renal disease patients, who underwent kidney transplant surgery under general anesthesia with epidural analgesia, were randomized to receive either CVP-guided (n = 35) or PPV-guided (n = 35) fluid therapy using predefined hemodynamic endpoints. The primary outcome was the total volume of intraoperative fluids administered. Secondary outcomes were intraoperative hemodynamic changes, serum lactate levels, serum creatinine, need for dialysis within the first week, creatinine elimination ratio, and incidence of immediate and delayed graft dysfunction. RESULTS: Results were analyzed for 70 patients. Eighty percent of the patients underwent living-related donor allograft kidney transplant. Operative variables related to donor characteristics, duration of surgery, graft cold ischemia time, and blood loss were comparable in both groups. The mean (standard deviation) volume of intravenous fluids administered intraoperatively was 1,346 (337) mL in the PPV-guided group vs 1,901 (379) mL in the CVP-guided group (difference in means, 556 mL; 95% confidence interval, 385 to 727; P = 0.001). There were no significant differences in secondary outcomes between the two groups. CONCLUSION: Pulse pressure variation -guided fluid administration significantly decreased the total volume of crystalloids compared with CVP-guided fluid therapy during the intraoperative period in patients who underwent kidney transplant surgery. Nevertheless, our study was underpowered to detect differences in secondary outcomes. TRIAL REGISTRATION: www.ctri.nic.in (CTRI/2018/01/011638); registered 31 January 2018.

RéSUMé: CONTEXTE: Traditionnellement, l'administration liquidienne pendant une chirurgie de transplantation rénale est guidée par la pression veineuse centrale (PVC) et ce, malgré sa fiabilité limitée en tant que paramètre d'évaluation du volume liquidien intravasculaire, en particulier chez les patients atteints de maladies cardiovasculaires. Les objectifs recommandés lors de la reperfusion du greffon sont une tension artérielle moyenne de 90 mmHg et une PVC de 12­14 mmHg. Cette approche pourrait augmenter le risque d'effets indésirables importants dus à une surcharge volémique. Il a été démontré que la thérapie liquidienne périopératoire guidée par des indices dynamiques de réponse au remplissage optimisait le volume intravasculaire et prévenait les complications associées à l'administration liquidienne exagérée lors de chirurgie abdominale majeure. Nous avons émis l'hypothèse qu'une administration liquidienne guidée par la variation de pression différentielle (VPD et delta PP) entraînerait une meilleure optimisation du volume liquidien intravasculaire par rapport à une stratégie guidée par la PVC pendant une chirurgie de transplantation rénale. MéTHODE: Dans cette étude randomisée monocentrique à double insu, 77 patients atteints d'insuffisance rénale terminale, qui ont bénéficié d'une greffe rénale sous anesthésie générale avec analgésie péridurale, ont été randomisés à recevoir une administration liquidienne guidée soit par la PVC (n = 35) ou par la VPD (n = 35) en utilisant des critères hémodynamiques prédéfinis. Le critère d'évaluation principal était le volume total de liquides peropératoires administrés. Les critères secondaires comprenaient les variations hémodynamiques peropératoires, les taux sériques de lactate, la créatininémie, le besoin de dialyse au cours de la première semaine, le taux d'élimination de la créatinine et l'incidence de dysfonctionnement immédiat et retardé du greffon. RéSULTATS: Les résultats ont été analysés pour 70 patients. Quatre-vingts pour cent des patients ont subi une allogreffe de rein provenant d'un donneur vivant apparenté. Les variables opératoires liées aux caractéristiques du donneur, la durée de la chirurgie, le temps d'ischémie froide du greffon et les pertes sanguines étaient comparables dans les deux groupes. Le volume moyen (écart type) de liquides intraveineux administrés en peropératoire était de 1346 (337) mL dans le groupe guidé par VPD vs 1901 (379) mL dans le groupe guidé par PVC (différence de moyennes, 556 mL; intervalle de confiance à 95 %, 385 à 727; P = 0,001). Aucune différence intergroupe significative n'a été observée dans les critères d'évaluation secondaires. CONCLUSION: L'administration liquidienne guidée par la variation de pression différentielle a significativement diminué le volume total de cristalloïdes par rapport à la thérapie liquidienne guidée par la PVC pendant la période peropératoire chez les patients ayant bénéficié d'une greffe de rein. Néanmoins, notre étude ne disposait pas de la puissance suffisante pour détecter les différences dans les critères d'évaluation secondaires. ENREGISTREMENT DE L'éTUDE: www.ctri.nic.in (CTRI/2018/01/011638); enregistré le 31 janvier 2018.

Extended duration pulsed radiofrequency for the management of refractory meralgia paresthetica: a series of five cases.

Meralgia paresthetica (MP) is a sensory mononeuropathy, caused by compression of the lateral femoral cutaneous nerve (LFCN) of thigh. Patients refractory to conservative management are treated with various interventional procedures. We report the first use of extended duration (8 minutes) pulsed radiofrequency of the LFCN in a case series of five patients with refractory MP. Four patients had follow up for 1-2 years, and one had 6 months follow up. All patients reported remarkable and long lasting symptom relief and an increase in daily life activities. Three patients came off medications and two patients required minimal doses of neuropathic medications. No complications were observed.