Furosemide Stress Test and Renal Resistive Index for Prediction of Severity of Acute Kidney Injury in Sepsis.

Introduction The furosemide stress test (FST) predicts the severity and the need for renal replacement therapy (RRT) in patients with sepsis-associated acute kidney injury (S-AKI). The renal resistive index (RRI) indicates renal vascular resistance. Objectives The primary objective was to find the correlation between FST and RRI in S-AKI. The secondary objectives were to evaluate the role of FST and RRI on the progression of S-AKI. Methods A total of 154 consenting adult patients with S-AKI were administered FST. Renal echography was performed within the first 12 hours of admission, and RRI was calculated. The patients were grouped either into progressors or non-progressors to AKI-KDIGO stage 3. Results Of the patients who had RRI at Day 1 less than 0.73, 60% recovered, 34.3% needed RRT, and 35.5% died, whereas in those who had RRI at Day 1 greater than 0.73, only 22% recovered, 46.6% required RRT, and 51.6% died. RRI value of 0.73 predicted the need for RRT with a sensitivity of 35.1%, specificity of 80.4% and accuracy of 69.1%. The highest number of patients of KDIGO stage 3 (50%), followed by stage 2 (28.1%) and stage 1 (21.9%), presented technical difficulties in measuring the RRI. Conclusion FST is an economical and easily administered test to assess renal tubular function and can predict the occurrence and progression of S-AKI. RRI is a modest marker for predicting the need for RRT or persistent AKI.

A retrospective analysis of the 5-year trends of antimicrobial resistance in gram-negative bacterial isolates from an intensive care unit at a tertiary care hospital.

Background: Intensive care units (ICUs) in developing countries constitute a high risk for patients acquiring infection by multidrug-resistant organisms (MDROs). The rise in antimicrobial resistance (AMR) threatens the effective prevention and treatment of an increasing range of infections. The present study analyzed the local trends of AMR in Gram-negative isolates of ICU patients from a tertiary care facility in North India. Methods: This retrospective study was conducted over 5 years (January 2018-December 2022). All bacterial isolates from patients admitted to ICU during the study period were included in the study, and their AMR pattern was analyzed. In addition, sensitivity trends of different antimicrobials against the common Gram-negative bacteria were analyzed, and AMR trends were analyzed over the study period. Results: Klebsiella spp. was the most common isolate in samples received from ICU. A rise of carbapenem-resistant microorganisms was observed over the study period. Escherichia coli and Klebsiella spp. showed around 10% and a 17% decrease in susceptibility to carbapenems, respectively. In contrast, a marked 29% decrease in sensitivity to carbapenems was observed in Acinetobacter spp. Conclusion: The inception of integrated stewardship measures has shown a rising trend in susceptibility and is the need of the hour to prevent the spread of MDROs. Surveillance studies help us understand the impact of AMR in hospitals and help plan prevention programs.

Correlation of central venous-to-arterial carbon dioxide difference to arterial-central venous oxygen difference ratio to lactate clearance and prognosis in patients with septic shock: A prospective observational cohort study.

Background: To assess the relationship between the ratio of difference of venoarterial CO2 tension (P (v-a) CO2) and difference of arterio-venous oxygen content (C (a-cv) O2), i.e., ΔPCO2/ΔCaO2 with lactate clearance (LC) at 8 and 24 h, to define a cutoff for the ratio to identify LC >10% and >20% at 8 and 24 h, respectively, and its association with prognosis in septic shock. Methods: Adult patients with septic shock were included in this prospective, observational cohort study. Blood samples for arterial lactate, arterial, and central venous oxygen and carbon dioxide were drawn simultaneously at time zero (T0), 8 h (T8), and 24 h (T24). At T8, patients were divided into Group 8A (LC ≥10%) and Group 8B (LC <10%). At T24, patients were divided into Group 24A (LC ≥20%) and Group 24B (LC <20%). Results: Ninty-eight patients were included. The area under the curve of ΔPCO2/ΔCaO2 at T8 (0.596) and T24 (0.823) was the highest when compared to P(v-a) CO2 and C(a-v) O2. The best cutoff of P(v-a) CO2/C (a-v) O2 as predictor of LC >10% was 1.31 (sensitivity 70.6% and specificity 53.3%) and for LC >20% was 1.37 (sensitivity 100% and specificity 50%). At both T8 and T24, P(v-a) CO2/C (a-v) O2 showed a significant negative correlation with LC. Groups 8A and 24A showed lower intensive care unit mortality than 8B and 24B, respectively. Values of P(v-a) CO2/C (a-v) O2 at T8 were comparable, but at T24, there was a significant difference between the survivors and nonsurvivors (P < 0.001). Conclusion: ΔPCO2/ΔCaO2 predicts lactate clearance, and its 24 h value appears superior to the 8-h value in predicting LC and mortality in septic shock patients.

Comparison of the effects of vitamin C and thiamine on refractory hypotension in patients with sepsis: A randomized controlled trial.

Background: The study aimed to compare the effect of thiamine and ascorbic acid (AA) on mortality, sequential organ failure assessment (SOFA) score, duration and dose of vasopressor support, and need for renal replacement therapy (RRT) in patients with septic shock with refractory hypotension. Methods: Consenting adult patients with septic shock and refractory hypotension were included in this study. Patients were divided into three groups: Group A received 100 ml of balanced salt solution 8 hourly, Group B received 2 mg/kg of thiamine 8 hourly, Group C received 25 mg/kg of AA 8 hourly intravenous (IV) for 72 h. All patients received IV infusion of hydrocortisone 200 mg/day for 72 h. Serum lactate, dose and duration of vasopressor support, SOFA score, need for RRT and hospital mortality were analyzed. Results: The SOFA Score was significantly lower in Group B than in Group A and C at 24, 48, and 72 h. Dosage of norepinephrine was lower in Group B at 66 h and after that, whereas in Groups A and C, it was comparable at all time points. Mortality in Group B was significantly lower but comparable in Groups A and C. The need for RRT was significantly lower in Group B (44%) compared to the control group (88%) but comparable in Group C (76%). Conclusion: In patients with septic shock treated with hydrocortisone, co-treatment with thiamine led to earlier correction of organ dysfunction, reduced need for RRT, and improved mortality compared to patients treated with AA or balanced salt solution. The addition of AA did not yield measurable benefits beyond hydrocortisone alone.

Viewpoint: Weak Scientific Basis for the Recommendation of Executive Summary of Surviving Sepsis Campaign Guidelines 2021.

The Executive summary of Sepsis 2021 was published recently, which for the first time, recommended that in septic shock, the vasopressor infusion should be commenced through a peripherally inserted venous catheter (PiVC) for up to 6 hours. We discuss the scientific basis for such a recommendation regarding the safety of vasopressor infusion through a peripherally inserted vascular catheter or the accepted duration. How to cite this article: Nath SS, Nachimuthu N. Viewpoint: Weak Scientific Basis for the Recommendation of Executive Summary of Surviving Sepsis Campaign Guidelines 2021. Indian J Crit Care Med 2022;26(8):898-899.

Comparison of Conventional Oxygen Therapy With High-Flow Nasal Oxygenation in the Management of Hypercapnic Respiratory Failure.

INTRODUCTION: The effectiveness of high-flow nasal oxygenation (HFNO) in patients with hypercapnic respiratory failure (RF) remains controversial. The current study compared the effectiveness of HFNO in patients with hypercapnic RF with conventional oxygen therapy (COT). OBJECTIVES: The primary objective was to compare changes in the partial pressure of carbon dioxide (PaCO2) between those receiving COT and HFNO. The secondary objectives were to compare changes in the partial pressure of oxygen (PaO2), oxygen saturation (SpO2), respiratory rate (RR), serum bicarbonate level, base excess, lactate level, and incidence of the need for non-invasive ventilation (NIV) and mechanical ventilation (MV). METHODS: We recruited 30 patients with mild to moderate hypercapnic RF in the HFNO group, and data of 30 patients from historical controls, who matched the inclusion criteria, were obtained from medical records for comparison (COT group). The study was terminated after two hours, and patients were managed per the existing protocol after that. Arterial blood gas (ABG) analysis was repeated at the baseline, first, second, and third hours. RESULTS: In the COT group, the mean RR at the baseline, first, second, and third hours was 24.5 ± 2.61, 24.9 ± 3.03, 26.03 ± 3.4, and 22.90 ± 1.86, whereas, in the HFNO group, it was 25.93 ± 3.91, 23.00 ± 3.54, 22.50 ± 3.38, and 21.90 ± 3.57, respectively. The mean PaCO2 in the COT vs. HFNO groups was 54.45 ± 5.83 vs. 62.22 ± 9.15, 57.74 ± 6.05 vs. 58.65 ± 10.43, 60.79 ± 7.48 vs. 60.41 ± 11.24, and 55.23 ± 6.63 vs. 56.95 ± 10.31. The mean SpO2 in the COT group at these points of time was 94.50 ± 1.46, 95.4 ± 1.28, 96.10 ± 1.84, and 97.53 ± 2.05, whereas, in the HFNO group, it was 95.40 ± 2.55, 98.63 ± 1.43, 99.00 ± 1.66, and 99.50 ± 1.31, respectively. The patients who needed NIV after the study period were 50% and 36.67% in the COT and HFNO groups, respectively. CONCLUSIONS: There was no change in PaCO2 levels with HFNO, but there was a significant improvement in SpO2 and PaO2 levels and a decreased RR. Following the termination of the study protocol, more patients in the COT group needed NIV than those in the HFNO group.

Perioperative management of patients with prosthetic heart valves-A narrative review.

Worldwide, about 13% of the 200,000 annual recipients of prosthetic heart valves (PHV) present for various surgical procedures. Also, more and more females are opting for pregnancies after having PHV. All patients with PHV present unique challenges for the anesthesiologists, surgeons and obstetricians (in case of deliveries). They have to deal with the perioperative management of anticoagulation and a host of other issues involved. We reviewed the English language medical literature relevant to the different aspects of perioperative management of patients with PHV, particularly the guidelines of reputed societies that appeared in the last 20 years. Regression of cardiac pathophysiology following valve replacement is variable both in extent and timeline. The extent to which reverse remodeling occurs depends on the perioperative status of the heart. We discussed the perioperative assessment of patients with PHV, including focused history and relevant investigations with the inferences drawn. We examined the need for prophylaxis against infective endocarditis and management of anticoagulation in such patients in the perioperative period and the guidelines of reputed societies. We also reviewed the conduct of anesthesia, including general and regional anesthesia (neuraxial and peripheral nerve/plexus blocks) in such patients. Finally, we discussed the management of delivery in this group of high-risk patients. From the discussion of different aspects of perioperative management of patients with PHV, we hope to guide in formulating the comprehensive plan of management of safe anesthesia in such patients.

Clinical application of viscoelastic point-of-care tests of coagulation-shifting paradigms.

Bleeding during cardiac surgery, liver transplant, trauma and post partum hemorrhage are often multifactorial and these factors are dynamic as new factors crop up during the course of management. Conventional tests of coagulation offer information of a part of the coagulation system and also is time consuming. Viscoelastic point of care tests (VE POCTs) like rotational thromboelastometry, thromboelastogram and Sonoclot, are based on analysis of the viscoelastic properties of clotting blood and provide information for the entire coagulation pathway. In this comprehensive review being presented here, we have examined the pros and cons of VE POCTs including clinical, cost and survival benefits. The recommendations of the various guidelines regarding use of VE POCTs in various scenarios have been discussed. The review also tried to offer suggestions as to their optimal role in management of bleeding during cardiac surgeries, extracorporeal membrane oxygenation, left ventricular assist devices, liver transplant and briefly in trauma and postpartum hemorrhage.

N-Acetylcysteine Supplementation for the Prevention of Postoperative Liver Dysfunction after On-Pump Cardiac Surgery.

INTRODUCTION: Incidence of postoperative liver dysfunction continues to be high (ranging from 10-35%) in those who underwent cardiac surgeries using cardiopulmonary bypass (CPB) and is associated with considerable morbidity and mortality. Prolonged cardiopulmonary bypass time (CPBT) was found to be an independent predictor of postoperative liver dysfunction. So, the aim of the study was to evaluate the effect of prophylactic use of N-acetylcysteine (NAC) in patients undergoing on-pump cardiac surgery with expected prolonged CPBT in prevention of liver dysfunction. METHODS: 60 consenting adult patients undergoing cardiac surgeries using CPB with CPBT more than 120 mins were included in this single-centre, randomized, parallel-group, double blind interventional study. Study group patients received NAC as per protocol. Liver transferases, alkaline phosphatase, serum bilirubin, kidney function tests and coagulation parameters were measured preoperatively, on the day of surgery and for three days postoperatively. RESULTS: Values for serum ALT, AST and ALP were significantly raised in the control group compared to the study group, starting from the day of surgery till 3rd postoperative day. Serum bilirubin level (total and direct) were comparable till first postoperative day and were significantly raised on second and third postoperative days in the control group. Duration of mechanical ventilation, total chest tube drainage, duration of ICU and hospital stay were significantly shorter in study group compared to control group. CONCLUSION: Prophylactic intravenous NAC has a protective role in preventing postoperative hepatic dysfunction in patients undergoing cardiac surgery with cardiopulmonary bypass.

To Compare the Changes in Hemodynamic Parameters and Blood Loss during Percutaneous Nephrolithotomy - General Anesthesia versus Subarachnoid Block.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is done under general anesthesia (GA) in most of the centers. However, associated complications and cost are higher for GA than for regional anesthesia. AIM: The aim of the study was to compare the efficacy of GA versus subarachnoid block (SAB) with regard to intraoperative blood loss and postoperative drop in hemoglobin (Hb) in patients undergoing PCNL. SETTING AND DESIGN: This prospective, randomized, comparative clinical trial was carried out at a tertiary care hospital. After obtaining the institute ethical committee clearance (vide no 57/15), patients were randomly allocated into two groups using table of randomization (n = 30 each), Group A - GA, Group B - SAB. MATERIALS AND METHODS: Intraoperative blood loss was assessed by measuring the Hb of irrigated fluid and postoperative drop in Hb concentration. Other parameters such as intraoperative mean arterial pressure and heart rate were also compared in these groups. STATISTICAL ANALYSIS: The results are presented in frequencies, percentages, and mean ± standard deviation. The Chi-square test was used to compare the categorical variables between the groups. Unpaired t-test was used to compare the continuous variables between the groups. RESULTS: Hemodynamic parameters were similar in both the groups preoperatively. The Hb drop was significant in Group A (1.28 ± 0.35 g.dl-1) as compared to Group B (1.10 ± 0.67 g.dl-1). On calculating Hb in irrigated fluid-blood mixture, it was found to be significantly higher in Group A (1.87 ± 0.44 g.L-1) as compared to Group B (1.25 ± 0.25 g.L-1). CONCLUSIONS: Both GA and SAB are effective and safe in PCNL. However, SAB is associated with less blood loss as estimated by intraoperative blood loss and Hb drop.

Comparison of Superior Vena Cava and Inferior Vena Cava Diameter Changes by Echocardiography in Predicting Fluid Responsiveness in Mechanically Ventilated Patients.

CONTEXT: Resuscitation of critically ill patients requires an accurate assessment of the patient's intravascular volume status. Passive leg raise cause auto transfusion of fluid to the thoracic cavity. AIMS: This study aims to assess and compare the efficacy of superior vena cava (SVC) and inferior vena cava (IVC) diameter changes in response to passive leg raise (PLR) in predicting fluid responsiveness in mechanically ventilated hemodynamically unstable critically ill patients. METHODS: We enrolled 30 patients. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax - Dmin)/Dmax for collapsibility index of SVC (cSVC) and (Dmax - Dmin)/Dmin for distensibility index of IVC (dIVC), where Dmax and Dmin are the maximal and minimal diameters of SVC and IVC. Measurements were performed at baseline and 1 min after PLR. Patients were divided into responders (increase in cardiac index (CI) ≥10%) and nonresponders (NR) (increase in CI <10% or no increase in CI). RESULTS: Among those included, 24 (80%) patients were R and six were NR. There was significant rise in mean arterial pressure, decrease in heart rate, and decrease in mean cSVC from baseline to 1 min after PLR among responders. The best threshold values for discriminating R from NR was 35% for cSVC, with sensitivity and specificity of being 100%, and 25% for dIVC, with 54% sensitivity and 86.7% specificity. The areas under the receiver operating characteristic curves for cSVC and dIVC regarding the assessment of fluid responsiveness were 1.00 and 0.66, respectively. CONCLUSIONS: cSVC had better sensitivity and specificity than dIVC in predicting fluid responsiveness.

Right atrial myxoma: Unusual location; uncommon association.

We are presenting a case of the right atrial myxoma found in a case of rheumatic heart disease. During transthoracic echocardiography for the evaluation of a suspected rheumatic valvular heart disease, a diagnosis of severe mitral stenosis with severe mitral regurgitation with the right atrial thrombus was made. On transesophageal echocardiography, a pedunculated mass in the right atrium was confirmed. In the course of surgery, it was found that there is a tumor originating from the right atrial appendage (RAA) which was confused with clot on echocardiography. Rheumatic heart disease and myxomas have different etiopathogenesis, and this coexistence has not been reported. Further, right atrial myxoma arising out of RAA is also being reported for the first time.

Balanced hydroxyethyl starch solution and hyperglycaemia in non diabetics - a prospective, randomized and controlled study.

BACKGROUND: There are very few studies that have examined the effect of hydroxyethyl starch (HES) solutions on blood glucose level. The study was aimed to compare the effects on blood glucose levels in patients undergoing lower limb surgeries under neuraxial block, receiving HES with those receiving 0.9% saline. PATIENTS AND METHODS: 160 non-diabetic ASA I or II patients, aged between 18-65 years were selected for the trial. Patients were divided into two groups; Group C (n = 80, patients received only 0.9% saline for preloading and maintenance until six hours of the end of preloading) and Group T (n = 80, patients received Tetraspan™ 10 mL kg⁻¹, for preloading and 0.9% saline for maintenance until six hours from the end of preloading). Blood glucose was recorded prior to the start of preloading and repeated at two, four and six hours after the end of HES infusion or the preloading dose of 0.9% saline. RESULTS: The following blood glucose levels were comparable at all times; fasting/baseline (85.3 ± 19.2 mg dL⁻¹ in group C and 95.4 ± 17.3 mg dL⁻¹ in group T); increase in blood glucose concentration at 2 hours (6.44 ± 20.59 mg dL⁻¹ in group C and 10.8 ± 18.1 mg dL⁻¹ in group T); 4 hours (4.1 ± 12.1 mg dL⁻¹ in group C and 3.5 ± 11.8 mg dL⁻¹ in group T); and at 6 hours (2.9 ± 13.4 mg dL⁻¹ in group C and 3.5 ± 10.6 mg dL⁻¹ in group T). CONCLUSION: A balanced HES solution administered intravenously did not cause an increase in blood glucose concentrations compared to those who received 0.9% saline.

Anaesthetic complications in plastic surgery.

Anaesthesia related complications in plastic surgeries are fortunately rare, but potentially catastrophic. Maintaining patient safety in the operating room is a major concern of anaesthesiologists, surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential and pressure to avoid these complications in cosmetic surgery is increasing. Key aspects of patient safety in the operating room are outlined, including patient positioning, airway management and issues related to some specific conditions, essential for minimizing post-operative morbidity. Risks associated with extremes of age in the plastic surgery population, may be minimised by a better understanding of the physiologic changes as well as the pre-operative and post-operative considerations in caring for this special group of patients. An understanding of the anaesthesiologist's concerns during paediatric plastic surgical procedures can facilitate the coordination of efforts between the multiple services involved in the care of these children. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patients' experience and surgical outcome.