Intraoperative kidney replacement therapy in acute liver failure.

Paediatric acute liver failure (PALF) is often characterised by its rapidity of onset and potential for significant morbidity and even mortality. Patients often develop multiorgan dysfunction/failure, including severe acute kidney injury (AKI). Whilst the management of PALF focuses on complications of hepatic dysfunction, the associated kidney impairment can significantly affect patient outcomes. Severe AKI requiring continuous kidney replacement therapy (CKRT) is a common complication of both PALF and liver transplantation. In both scenarios, the need for CKRT is a poor prognostic indicator. In adults, AKI has been shown to complicate ALF in 25-50% of cases. In PALF, the incidence of AKI is often higher compared to other critically ill paediatric ICU populations, with reports of up to 40% in some observational studies. Furthermore, those presenting with AKI regularly have a more severe grade of PALF at presentation. Observational studies in the paediatric population corroborate this, though data are not as robust-mainly reflecting single-centre cohorts. Perioperative benefits of CKRT include helping to clear water-soluble toxins such as ammonia, balancing electrolytes, preventing fluid overload, and managing raised intracranial pressure. As liver transplantation often takes 6-10 h, it is proposed that these benefits could be extended to the intraoperative period, avoiding any hiatus. Intraoperative CKRT (IoCKRT) has been shown to be practicable, safe and may help sicker recipients tolerate the operation with outcomes analogous with less ill patients not requiring IoCKRT. Here, we provide a comprehensive guide describing the rationale, practicalities, and current evidence base surrounding IoCKRT during transplantation in the paediatric population.

Lifestyle Optimization Leads to Superior Liver Regeneration in Live Liver Donors and Decreases Early Allograft Dysfunction in Recipients: A Randomized Control Trial.

INTRODUCTION: The aim of the current randomized control trial was to assess the efficacy of donor lifestyle optimization on liver regeneration and outcome following live donor liver transplantation. METHODS: Live liver donors (LLDs) who were fit with no or minimal steatosis were randomized to receive either a customized low-calorie diet with calorie intake equalling their basal requirement along with exercise for 2 weeks before surgery versus to continue their normal routine lifestyle. Primary objectives were the difference in the day of normalization of serum bilirubin and PT-International normalized ratio and the percentage growth of the liver at postoperative day 7 and 14. Secondary objectives were differences in intraoperative liver biopsy, liver-regeneration markers, blood loss, hospital stay, the complication rate in LLDs, and rates of early graft dysfunction (EGD) in recipients. RESULTS: Sixty-two consecutive LLDs were randomized (28 in intervention vs. 34 in control). Baseline parameters and graft parameters were similar in both groups. LLDs in the intervention arm had significantly decreased calorie intake ( P <0.005), abdominal girth ( P <0.005), BMI ( P =0.05), and weight ( P <0.0005). The mean blood loss ( P =0.038), day of normalization of bilirubin ( P =0.005) and International normalized ratio ( P =0.061), postoperative peak aspartate transaminase ( P =0.003), Alanine transaminase ( P =0.025), and steatosis ( P <0.005) were significantly less in the intervention group. There was significantly higher volume regeneration ( P =0.03) in donors in the intervention arm. The levels of TNF-α, IL-6, and IL-10 levels were significantly higher, while the TGF-ß level was lower in donors in the intervention group. The rate of EGD was significantly higher in recipients in the control group ( P =0.043). CONCLUSION: Lifestyle optimization of LLD is simple to comply with, improves liver regeneration in LLDs, and decreases EGD in recipients, thus can enhance donor safety and outcomes in live donor liver transplantation.

A microwave-assisted intramolecular aminopalladation-triggered domino sequence: an atom economical route to 5,10-dihydroindeno[1,2-b]indoles.

A microwave-assisted, palladium(II)-catalyzed cascade reaction of 2-alkynylanilines tethered with an α,ß-unsaturated carbonyl moiety was established to access 5,10-dihydroindeno[1,2-b]indoles in high yields (up to 84%) in a short reaction time. This operationally simple cascade process shows 100% atom economy and allows the construction of two new five-membered rings and two new (1 C-C and 1 C-N) bonds in a single synthetic attempt. The mechanistic pathway of this reaction is visualized involving intramolecular aminopalladation (5-endo-dig) followed by carbopalladation (olefin insertion) and protonolysis steps. A systematic comparison between microwave irradiation and conventional heating methods was also performed to demonstrate the supremacy of the microwave-assisted approach. This domino reaction requires no protecting groups for the amino group and the palladium catalyst needs no ligands. To the best of our knowledge, this is the first report on microwave-assisted nucleopalladation-initiated cascade transformation.

Role of Nebulized Heparin in Clinical Outcome of COVID-19 Patients with Respiratory Symptoms: A Systematic Review.

Coronavirus disease-2019 (COVID-19) is an extremely contagious illness caused by the SARS-CoV-2 virus and has been declared a pandemic by the World Health Organization (WHO). There are currently no particular treatments, however, nebulized heparin has been offered as a viable therapy. The purpose of this systematic review is to assess the efficacy of nebulized heparin in COVID-19 patients with respiratory symptoms. Methods: Relevant studies were identified through a systematic search of the PubMed, Medline, Embase, Cochrane Library and Web of Science, and Scopus databases. The search terms included "nebulized heparin," "COVID-19," and "SARS-CoV-2." Studies that evaluated the use of nebulized heparin in COVID-19 patients with respiratory symptoms were included. The rest of the studies along with those that were not published in English were excluded. The systematic review was registered under PROSPERO-CRD42023413927. Observations: Five studies have been included in this systematic review. Case reports, case series, observational studies, and randomized controlled trial (RCT) comprised the studies. The patient sample sizes ranged from 2 to 98. The studies assessed the efficacy of nebulized heparin in COVID-19 patients with variable disease severity. The evaluated outcomes included mortality, hospital stay duration, oxygen requirements, and laboratory parameters. Conclusion: Based on the clinical studies included in this systematic review, nebulized heparin may be useful in the management of COVID-19. Oxygen saturation was greater, inflammatory indicators were lower, and hospital stays were shorter in these patients. However, the studies had limitations, including inconsistent sample sizes, varying dosages of nebulized heparin, and no control groups. Nebulized heparin in patients with COVID-19 needs to be studied further to determine its safety and effectiveness. How to cite this article: Gupta B, Ahluwalia P, Gupta N, Gupta A. Role of Nebulized Heparin in Clinical Outcome of COVID-19 Patients with Respiratory Symptoms: A Systematic Review. Indian J Crit Care Med 2023;27(8):572-579.

Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study.

Background: Maintaining homeostasis is an integral part of all physiological processes both in health and disease including critically ill patients and may impact clinical outcomes. The present study was designed to assess prevalence of serum calcium, phosphate, vitamin-D3, FGF-23, and PTH levels abnormalities in AKI. Patients and methods: Single-center, prospective, observational study in a tertiary care hospital. Patients meeting KDIGO criteria for AKI were included. Paired blood samples were drawn from eligible patients-first sample within 24 hours of AKI diagnosis and second after 5 days or at time of hospital discharge, whichever was earlier for measuring serum calcium (albumin corrected), phosphate, PTH, 25(OH)Vit-D, and FGF-23 levels. Clinical outcomes analyzed included survival status, utilization of RRT, and hospital stay. Results: Of the 50 patients with AKI, about three-fourths were males. Mean age of the participants was 57.32 ± 11.47 years. Around half of patients had hypocalcemia and four-fifths had low serum phosphate. Nearly 82% had low 25(OH)Vit-D and 52% cases had high PTH level. Patients who underwent RRT had numerically higher but not significant serum calcium and PTH levels. FGF-23 levels (pg/mL) were significantly higher in patients on RRT (81.70 ± 17.30 vs non-RRT, 72.43 ± 20.27, p = 0.049), nonsurvivors (87.96 ± 18.82 vs survivors 57.11 ± 15.19, p = 0.045), and those hospitalized for time of stay above median (109.67 ± 26.97 vs below median 70.27 ± 20.43, p = 0.046). Among all the bone and mineral parameters analyzed high FGF23 levels were consistently linked with poor clinical outcomes in AKI. Conclusion: The present study found high prevalence of calcium and phosphate disorders in AKI with dysregulated phosphate homeostasis as evidenced from elevated FGF-23 levels linked with morbidity and mortality in AKI. How to cite this article: Singh NP, Panwar V, Aggarwal NP, Chhabra SK, Gupta AK, Ganguli A. Regulation of Calcium Homeostasis in Acute Kidney Injury: A Prospective Observational Study. Indian J Crit Care Med 2022;26(3):302-306.

Mucormycosis in COVID Diabetic Patients: A Horrifying Triad!

Infectious diseases with the coronavirus disease-2019 (COVID-19) can be linked to various microbial and fungal coinfections. Mucormycosis is an invasive opportunistic infection that enters as inhalation of fungal spores through the nose or paranasal sinuses in diabetic and immunocompromised patients. We present our experience of managing seven cases of recent COVID-19 infection with uncontrolled diabetes who developed rhino-orbital mucormycosis. All patients were diagnosed by clinical examination and imaging and managed by emergency surgical debridement and liposomal amphotericin-B. A lethal triad of impaired immunity due to COVID-19 infection, state of hyperglycemia, increased use of steroids, or rampant broad-spectrum antimicrobials works as fertile soil and may assist in the growth or alleviation of a fungal infection. Healthcare professionals must be aware of the potential of secondary invasive fungal infections in diabetic patients with moderate to severe category of COVID-19 infectious disease, especially on steroid therapy. HOW TO CITE THIS ARTICLE: Panwar P, Gupta A, Kumar A, Gupta B, Navriya SC. Mucormycosis in COVID Diabetic Patients: A Horrifying Triad! Indian J Crit Care Med 2021;25(11):1314-1317.

Chronic Kidney Disease of Unknown Origin - What do we know?

The global burden of CKD is considerable and has risen dramatically over the past 20 years. Recently, CKD of unknown origin (CKDu), a form of CKD among rural agricultural communities has been reported worldwide. There is no strong evidence for a single cause of CKDu. Basically, it is a phenotypic environmentally acquired disease with a combination of occupational and social factors. Across all geographical regions, CKDu was most frequently associated with men, middle age, snake bite, infection, and exposure to agrochemicals, heavy metals, herbal drugs, heat stress, and dietary exposures. CKDu has emerged as a challenge in certain regions of the world as there is no acceptable global definition for CKDu. There is an urgent need for health promotion at individual and community levels for early screening of risk factors and timely management. It is also important to strengthen the health service networks for a better quality of life and patient safety as well as adequate financing. Further etiological and interventional research is needed to reduce preventable regional risk factors as well as to develop proactive and comprehensive approaches to prevent and treat the disease.

Stress in ICU Caregivers: Does it Lie in the Eyes of the Beholder?

How to cite this article: Juneja D, Gupta A, Kulkarni AP. Stress in ICU Caregivers: Does it Lie in the Eyes of the Beholder? Indian J Crit Care Med 2019;23(5):203-204.

Pulmonary Hypertension in Patients with End Stage Renal Disease on Maintenance Hemodialysis-A Cross-sectional Study.

BACKGROUND: Pulmonary Hypertension (PH) in End Stage Renal Disease (ESRD) on Maintenance Hemodialysis (HD) portends a poor outcome in patients undergoing dialysis. METHODS: 50 patients with ESRD undergoing regular hemodialysis for at least 3 months were included. Biochemical parameters- hemoglobin, urea, creatinine, albumin, calcium, phosphorus and PTH assessed post dialysis. All patients underwent 2D echocardiography one hour after dialysis to avoid overestimation of pulmonary artery pressures. Measurement of various parameters was carried out including right atrial and ventricular dimensions, tricuspid annular plane systolic excursion, flow across tricuspid and pulmonary valves and tissue doppler imaging of the annular plane. PH was defined as mean right ventricular systolic pressure ≥25 mmHg. Variables were compared between two groups- subjects with PH and Non-PH. RESULTS: Seventeen patients were detected to have PH. All baseline biochemical parameters did not show significant difference between two groups. On ECHO, right atrial and ventricular enlargement and pulmonary vascular resistance were significantly higher in PH group. LA vol index greater than 34ml/m2 was detected in 94.1% patients with PH as opposed to 51.5% in non PH. LVEDP was detected to be significantly higher in PH compared to Non PH (p=0.001; 94.1% vs 39.4%). Mean values of ejection fractions were also significantly different. CONCLUSION: This study suggests that up to one third of ESRD patients on HD develop PH. Echocardiography findings reveal a significant association between raised LVEDP and increased pulmonary artery pressures. Thus, volume overload and diastolic dysfunction (heart failure with preserved ejection fraction) appear to be the main contributors to development of PH.

Clinical Profile, Intensive Care Unit Course, and Outcome of Patients Admitted in Intensive Care Unit with Chikungunya.

OBJECTIVE: Chikungunya is generally a mild disease, rarely requiring Intensive Care Unit (ICU) admission. However, certain populations may develop organ dysfunction necessitating ICU admission. The purpose of the study was to assess the clinical profile and course of chikungunya patients admitted to the ICU, and to ascertain factors linked with poor outcome. METHODS: All patients with chikungunya admitted to ICU were included in the study. Admission Acute Physiology and Chronic Health Evaluation (APACHE) II score and sequential organ failure assessment (SOFA) score were calculated. Primary outcome measured was 28-day mortality and secondary outcomes measured were length of hospital and ICU stay and the need for vasopressor support, renal replacement therapy (RRT), and mechanical ventilation (MV). Logistic regression analysis was performed to identify factors predicting mortality. RESULTS: The most common complaints were fever (96.67%) and altered sensorium (56.67%). Mean admission APACHE II and SOFA scores were 17.28 ± 7.9 and 7.15 ± 4.2, respectively. Fifty-one patients had underlying comorbidities. Vasopressors were required by 46.76%; RRT by 26.67%, and MV by 58.33%, respectively. The 28-day mortality was 36.67%. High APACHE II score (odds ratio: 1.535; 95% confidence interval: 1.053-2.237; P = 0.026) and need for dialysis (odds ratio: 833.221; 95% confidence interval: 1.853-374,664.825; P = 0.031) could independently predict mortality. CONCLUSIONS: Patients with chikungunya fever may require ICU admission for organ failure. They are generally elderly patients with underlying comorbidities. Despite aggressive resuscitation and organ support, these patients are at high risk of death. Admission APACHE II score and need for dialysis may predict patients at higher risk of death.

Bidirectional superior cavopulmonary anastomosis with or without cardiopulmonary bypass: A randomized study.

OBJECTIVES: This study aims to compare the bidirectional superior cavopulmonary anastomosis (BDG) with or without cardiopulmonary bypass (CPB). METHODS: 100 patients undergoing BDG were randomized into two groups: Off-CPB or on-CPB groups. All patients underwent near-infrared spectrophotometry (NIRS) and bispectral index (BIS) monitoring and pre- and postoperative serum 100 beta protein measurements (Sß100) and neuro-cognitive evaluation. Postoperative intensive care unit (ICU) parameters were also studied. RESULTS: The median age of patients in the on-CPB and off-CPB group were 42 and 48 months, respectively (p = 0.11). Median weights in the on-CPB group and off-CPB group were 13.5 (5-50) kg and 15 (7-36) kg, respectively (p = 0.927). There was a significant rise in superior vena cava (SVC) pressure on SVC clamping in the off-CPB group (23.12 ± 6.84 vs 2.98 ± 2.22 mmHg) on-CPB group (p < 0.001). There was a significant fall in NIRS and BIS values from baseline in the off-CPB group during the anastomosis but there was no statistically significant change in serum Sß100from pre-clamp to post-clamp in either group. Inotropic support, duration of ventilation, ICU stay, and hospital stay were significantly less in the off-CPB group (p < 0.001). Assessment of Social Adaptive Functioning revealed no adverse sequelae. There were significant cost savings if surgery was performed off-CPB (p < 0.001). CONCLUSION: Off CPB-BDG is an economical and safe procedure. Duration of inotropic and mechanical ventilatory support, ICU, and hospital stay is significantly less. We did not observe any early adverse neurologic sequelae in patients undergoing off-CPB BDG.

Assessment of Proliferative Potential of Odontogenic Keratocyst and Dentigerous Cyst using Podoplanin: An Immunohistochemical Study.

INTRODUCTION: Odontogenic cysts are commonly encountered lesions among head and neck pathologies. Odontogenic keratocyst (OKC) has unique features of recurrence and local aggressiveness. Podoplanin (PDP) is a lymphatic endothelial marker and is shown to be expressed in a variety of tissues. Hence, we planned to assess the significance of PDP in OKC and dentigerous cyst (DC). MATERIALS AND METHODS: The present study included assessment of immunoexpression of PDP in OKC and DC. Twenty specimens each of OKC and DC were included in the present study and were stained with D2-40 antibody. All the sections were analyzed and were categorized as negative staining, weakly positive staining, and strongly positive staining. All the results were analyzed by Statistical Package for the Social Sciences (SPSS) software. RESULTS: We detected PDP-positive staining in the cell membrane and cytoplasm of the cells of basal cell layer and supra-basal cell layers. In DC cases, we observed positive staining only in cases associated with inflammation. CONCLUSION: Podoplanin does play a significant role in enhancing the local invasive and neoplastic properties of OKC. CLINICAL SIGNIFICANCE: Podoplanin expression in OKC is potentially associated with moderate invasive nature of the neighboring structures.

Choice of valve substitutes.

Infective endocarditis often necessitates surgical intervention, and the choice of valve substitute remains a topic of controversy and highly debatable due to the wide range of available options and recent technical advancements. This manuscript reviews the different valve substitutes in the context of infective endocarditis, including mechanical and bioprosthetic valves, homografts, xenografts, and tissue-engineered valves. The patient's age, sex, demographic location, intellectual quotient, comorbidities, available options, and the experience of the surgeon should all be taken into consideration while choosing the best valve substitute for that individual. While valve repair and reconstruction are preferred whenever feasible, valve replacement may be the only option in certain cases. The choice between mechanical and bioprosthetic valves should be guided by standard criteria such as age, sex, expected lifespan, associated comorbidities, and anticipated adherence to anticoagulation therapy and accessibility of medical facilities for follow-up. For patients with severe chronic illness or a history of intracranial bleeding or associated hematological disorders, the use of mechanical prostheses may be avoided. Homografts and bioprosthetic valves provide an alternative to mechanical valves, thereby decreasing the necessity for lifelong anticoagulation after surgery and diminishing the likelihood of bleeding complications. The manuscript also discusses specific valve substitutes for different heart valves (aortic, mitral, pulmonary, tricuspid positions) and highlights emerging techniques such as the aortic valve neocuspidization (Ozaki procedure) and tissue-engineered valves. Ultimately, the ideal valve substitute in IE should be evidence based on a comprehensive elucidation of clinical condition of the patient and available options.

Incidence and Risk Factors for Postoperative Visual Loss after Cardiac Surgical Procedures: A Systematic Review.

ABSTRACT: Postoperative visual loss (POVL) is an infrequent yet consequential complication that can follow cardiac surgical interventions. This systematic review aims to provide a comprehensive analysis of the incidence of POVL after cardiac surgery and to delineate the associated risk factors. A comprehensive search was conducted in major medical databases for relevant studies published up to September 2022. Eligible studies reporting on the incidence of POVL and identifying risk factors in patients undergoing cardiac surgery were included. Data extraction was performed independently by two reviewers. The pooled incidence rates and the identified risk factors were synthesized qualitatively. POVL after cardiac surgery has an overall incidence of 0.015%, that is, 15 cases per 100,000 cardiac surgical procedures. Risk factors for POVL include patient characteristics (advanced age, diabetes, hypertension, and preexisting ocular conditions), procedural factors (prolonged surgery duration, cardiopulmonary bypass time, and aortic cross-clamping), anesthetic considerations (hypotension, blood pressure fluctuations, and specific techniques), and postoperative complications (stroke, hypotension, and systemic hypoperfusion). Ischemic optic neuropathy (ION) is an uncommon complication, associated with factors like prolonged cardiopulmonary bypass, low hematocrit levels, excessive body weight gain, specific medications, hypothermia, anemia, raised intraocular pressure, and micro-embolization. Diabetic patients with severe postoperative anemia are at increased risk for anterior ischemic optic neuropathy (AION). Posterior ischemic optic neuropathy (PION) can occur with factors like hypertension, postoperative edema, prolonged mechanical ventilation, micro-embolization, inflammation, hemodilution, and hypothermia.While the overall incidence of POVL postcardiac surgery remains modest, its potential impact is substantial, necessitating meticulous consideration of modifiable risk factors. Notably, prolonged surgical duration, intraoperative hypotension, anemia, and reduced hematocrit levels remain salient contributors. Vigilance is indispensable to promptly detect this infrequent yet visually debilitating phenomenon in the context of postcardiac surgical care.

Emergency retrieval of embolised patent ductus arteriosus device from the right pulmonary artery.

Percutaneous closure of patent ductus arteriosus using a duct occluder has become standard of care in its management especially in children more than 6 months of age, weighing more than 6 kg but device embolisation is a potential life-threatening complication and may require immediate open-heart surgery. We describe a case of successful surgical management of a patient in early childhood, in which device has embolised deep into the right pulmonary artery.

An intriguing case report of follicular lymphoid hyperplasia of tongue with the detailed review of literature.

Follicular lymphoid hyperplasia is a rare reactive benign lesion of the oral mucosa. This is also known as pseudolymphoma as the features mimic the malignant counterpart Follicular lymphoma. In present case, a 34 year old male patient came with a nodular swelling in the posterior-lateral left side of tongue. Medical or dental history was non contributory. Swelling was painless, well demarcated, and about peanut sized. The swelling was provisionally diagnosed as either neurilemmoma, mucocele, or traumatic fibroma. Complete excision was performed, and tissue was sent to a private laboratory. Histopathological findings seen were germinal centers having a core of monotonous cells of the same size and demarcated mantle area mimicking the lymphoma. Immunophenotyping revealed diffused positivity for kappa and lambda expressions. CD10 was diffusely positive in germinal centers and BCl 2 was positive in the mantle area while negative in germinal centers. The final diagnosis given was follicular lymphoid hyperplasia. The entity mentioned in the present paper is an unusual variant of the benign lymphoproliferative lesion and very few cases are reported in the tongue area. Thus, it is important to understand the nature of this benign lesion in all aspects to avoid diagnostic dilemmas due to its malignant mirroring characteristics.