Accuracy of Sonographic Airway Parameters in Difficult Laryngoscopy Prediction: A Prospective Observational Cohort Study from Central India.

Objective: Though airway ultrasonography (USG) is used to assess difficult laryngoscopy (DL), there is still ambiguity about approach followed and parameters assessed. There is need of a simple, stepwise sonographic assessment with clearly defined parameters for DL prediction. The primary objective of this study was to find diagnostic accuracy of sonographic parameters measured by a stepwise Airway-USG in DL prediction (DLP). Methods: This prospective, observational cohort study was done in 217 elective surgical adult patients administered general anaesthesia with tracheal intubation using conventional laryngoscopy from 1st May 2019 to 31st July 2020, after ethical approval. A sagittal Airway-USG was done using 2-6 Hz transducer in three steps specifying probe placement and head position. Demographic, clinical and Airway-USG measurements were noted. Correlation of the clinical/sonographic parameters was made with Cormack-Lehane score on DL. After receiver operating characteristic curve plotting, the sensitivity, specificity, positive predictive value, negative predictive value (NPV) of DL was calculated for each parameter using open-epi software. Results: DL was observed in 19/217 patients. Airway-USG parameters of skin to epiglottis distance >2.45 cm, hyomental distance with head extension <5.13 cm, head neutral <4.5 cm, their ratio <1.18, maximum tongue thickness >3.93 cm and maximum skin to tongue distance >5.45 cm were statistically significant in predicting DL. DLP score with presence of >3 positive parameters showed 98% specificity, 98% NPV and 96% diagnostic accuracy to predict DL. Conclusion: DLP score derived from Airway-USG may be used as a screening and diagnostic tool for DL.

Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India.

Background: The outcomes in critical illness depend on disease severity, practice protocols, workload, and access to care. This study investigates the factors affecting outcomes in mechanically ventilated coronavirus disease-2019 acute respiratory distress syndrome (COVID-19 ARDS) patients admitted in a tertiary teaching hospital intensive care unit (ICU) in Central India with reference to different time periods in pandemic. This is one of the largest series of mechanically ventilated COVID-19 ARDS patients, globally. Methods: This retrospective cohort study classified the entire data into four time periods (Period 1: April 2020 to June 2020; Period 2: July 2020 to September 2020; Period 3: October 2020 to December 2020; and Period 4: January 2021 to April 2021). We performed a multivariable-adjusted analysis to evaluate predictors of mortality, adjusted for baseline-severity, sequential organ failure assessment (SOFA score) and time period. We applied mixed-effect binomial logistic regression to model fixed-effect variables with incremental complexity. Results: Among the 56 survivors (19.4%) out of 288 mechanically ventilated patients, there was an up-gradient of survival proportion (0, 18.2, 17.4, and 28.6%) in four time periods. Symptom-intubation interval (OR 1.16; 95% CI 1.03-1.31) and driving pressures (DPs) (OR 1.17; 95% CI 1.07-1.28) were significant predictors of mortality in the model having minimal AIC and BIC values. Patients aged above 60 years also had a larger effect, but statistically insignificant effect favoring mortality (OR 1.99; 95% CI 0.92-4.27). The most complex but less parsimonious model (with higher AIC/BIC) indicated the protective odds of high steroid on mortality (OR 0.59; 95% CI 0.59-0.82). Conclusion: The outcomes in mechanically ventilated COVID-19 ARDS patients are heterogeneous across time windows and may be affected by the complex interaction of baseline risk and critical care parameters. How to cite this article: Saigal S, Joshi A, Panda R, Goyal A, Kodamanchili S, Anand A, et al. Changing Critical Care Patterns and Associated Outcomes in Mechanically Ventilated Severe COVID-19 Patients in Different Time Periods: An Explanatory Study from Central India. Indian J Crit Care Med 2022;26(9):1022-1030.

Six-Week Hospital-Based Pulmonary Rehabilitation in Covid Pneumonia ICU Survivors: Experience from a Tertiary Care Center in Central India.

OBJECTIVE: There is very limited data on the usefulness of pulmonary rehabilitation in patients with coronavirus pneumonia who have survived intensive care unit care. The primary aim was to explore the feasibility of conducting a pulmonary rehabilitation program in patients with coronavirus disease-19 pneumonia surviving intensive care. The secondary aim was to study the impact of a hospital-based 6-week pulmonary rehabilitation program on exercise capacity, quality of life, and psychological parameters in these patients. This study was conducted at the Center for Pulmonary Rehabilitation, Department of Pulmonary Medicine of the institute. MATERIAL AND METHODS: A total of 27 patients were enrolled. Among them, 14 patients who completed the desired 12 sessions over 6 weeks constituted the pulmonary rehabilitation group and 13 patients who either did not consent or defaulted within the first 2 weeks were considered as controls. Both groups had assessments at 0 and 6 weeks that included a 6-Minute Walk Test, Incremental Shuttle Walk Test, mMRC Dyspnea Scale, Baseline Dyspnea Index, and Transitional Dyspnea Index, Saint George's Respiratory Questionnaire score, and Depression, Anxiety, Stress Scale-21 score. RESULTS: Significant improvement in dyspnea by mMRC (P = .01) and exercise capacity as measured by 6-Minute Walk Test (P <.001) and Incremental Shuttle Walk Test (P = .025) was seen in the pulmonary rehabilitation group as compared to the control group. There was no significant improvement in quality of life and psychological parameters (Depression, Anxiety, Stress Scale 21 score) after 6 weeks of pulmonary rehabilitation program as measured in our study. CONCLUSION: Pulmonary rehabilitation is feasible and appears promising in coronavirus disease acute respiratory distress syndrome survivors. However, data from other centers and a larger number of patients are required to imbibe conclusive results.

Undiagnosed laryngocele: an airway emergency.

Laryngoceles are rare dilated laryngeal saccules that can present as acute airway obstruction and lead to airway emergencies. A man, presented to the emergency room, with difficulty in breathing and change in voice. An unevaluated pulsatile swelling was present on the left side of neck. Since, the patient was in stridor, an awake fiberoptic bronchoscopy (FOB)-guided intubation was planned with readiness for emergency tracheostomy, if needed. On FOB, an edematous supraglottic area with a narrowed glottic opening was observed. The procedure was abandoned and a surgical tracheostomy was performed to secure the airway. Postoperative contrast-enhanced CT neck revealed a huge laryngocele in left cervical region. We recommend that a high index of suspicion for presence of laryngocele should be kept in mind when a patient presents with stridor with pulsatile neck swelling. Timely aspiration of laryngocele may help in amelioration of the respiratory distress avoiding emergency tracheostomy.

Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study.

BACKGROUND: Tracheostomy is integral in long-term intensive care of coronavirus disease-2019 (COVID-19) patients. There is a paucity of studies on weaning outcomes and mortality after tracheostomy in COVID-19 in Indian scenario. MATERIALS AND METHODS: We conducted a retrospective, single-center, observational study of severe COVID-19 patients who underwent elective tracheostomy (n = 65) during critical care in a tertiary care institute in Central India from May 1, 2020, to April 30, 2021. Data were collected from Medical records, ICU charts, and follow-up visits by patient. A primary objective was to study the clinical characteristics, tracheostomy complications, weaning outcomes, and mortality at 28 and 60 days of ICU admission. We categorized the cohort into two groups (deceased and survivor) and studied association of clinical parameters with 28-day mortality. Cox Proportional regression analysis was applied to calculate the hazard ratio among the predictors of mortality with p value <0.05 as significant. RESULTS: Elective tracheostomy was done in 69 of 436 (15.8%) patients on invasive mechanical ventilation, of which 65 were included. Tracheostomy was percutaneous in 45/65 (69%) and surgical in 20/65 (31%) with timing from intubation as early in 41/65 and late in 24/65 with most common indication as weaning failure followed by anticipated prolonged ventilation. Tracheostomy complications were present in 29/65 (45%) patients with no difference in complication rates between timing and type of tracheostomy. Downsizing, decannulation, and weaning were successful in 22%, 32 (49%), and 35/65 (54%) patients after tracheostomy. The 28-day mortality was 30/65 (46%). The fractional inspired oxygen concentration (FiO2) requirement in survivors was lower (0.4-0.6, p = 0.015) with a higher PaO2/FiO2 ratio (118-200, p = 0.033). Early tracheostomy within 7 days of intubation was not associated with weaning or survival benefit. CONCLUSIONS: We suggest that tracheostomy should be delayed to after 7 days of intubation, especially till FiO2 reduces to 0.5 with improvement in PaO2/FiO2 for better outcomes and avoiding a wasted procedure (CTRI/2021/07/034768). STUDY HIGHLIGHTS: Tracheostomy is integral in care of COVID-19 patients needing prolonged ventilation. There is no difference in complications in early/late or percutaneous dilatational/surgical technique. We observed successful weaning post-tracheostomy in 54% patients. Mortality at 28 days was 46%. Early tracheostomy within 7 days of intubation did not improve weaning or survival. HOW TO CITE THIS ARTICLE: Karna ST, Trivedi S, Singh P, Khurana A, Gouroumourty R, Dodda B, et al. Weaning Outcomes and 28-day Mortality after Tracheostomy in COVID-19 Patients in Central India: A Retrospective Observational Cohort Study. Indian J Crit Care Med 2022;26(1):85-93.

Analysis of dynamic changes in optic nerve sheath diameter (ONSD) with ultrasound in post-craniotomy patients: Trends and correlation with computed tomography ONSD and Glasgow coma scale in post-operative period.

Objectives: Intracranial pressure (ICP) monitoring in patients with intracranial tumors undergoing craniotomy is usually done in perioperative period in intensive care unit. Invasive measurement of ICP, though considered as the gold standard, has its own limitations such as availability of expertise, equipment, and associated complications. Period of raised ICP in post-operative period may impact patient outcomes. Post-craniotomy computed tomography (CT) assessment is done routinely and may need to be repeated if indicated during post-operative stay. Utility of sonographic serial optic nerve sheath diameter (ONSD) assessment in post-operative monitoring of patients who have undergone elective craniotomy was explored in this study. The primary objective of the study was to measure the dynamic change in ONSD as compared to baseline pre-operative measurement in the first 3 postoperative days after elective craniotomy. The secondary objective of the study was to evaluate correlation between ONSD value with Glasgow Coma Scale (GCS) and post-operative CT findings. Materials and Methods: In this prospective, observational, and cohort study, we studied adult patients undergoing craniotomy for intracranial tumors. GCS assessment and sonographic measurement of ONSD were done preoperatively, immediate post-operative period, and 12, 24, and 48 h after surgery. CT scan to detect raised ICP was done at 24 h post-operative. Correlation of ONSD with GCS at respective period and correlation of CT scan finding with respective ONSD assessment were evaluated. Results: A total of 57 patients underwent elective craniotomy for intracranial tumors. Significant difference was observed in ONSD value depending on time of measurement perioperatively (χ2 = 78.9, P = 0.00). There was initial increase in the first 12 h followed by decrease in ONSD in the next 48 h. Negative correlation was observed between baseline ONSD and 12 h GCS (ρ = -0.345, P = 0.013). There was significant change in GCS scores based on the status of ONSD (raised or normal) at 12 h after surgery (P = 0.014). Significant correlation between USG ONSD and CT ONSD was observed (ρ = 0.928, P = 0.000). Optimal cutoff value of ONSD to detect raised ICP with reference to CT signs was 4.8 mm with 80% sensitivity and 95% specificity. Conclusion: ONSD undergoes dynamic changes, correlates with CT scan, and has good diagnostic accuracy to detect raised ICP post-craniotomy for intracranial tumors. It may serve as a useful tool in monitoring in resource-limited setup.

Frequency and Impact of Preadmission Digestive Symptoms on Outcome in Severe COVID-19: A Prospective Observational Cohort Study.

BACKGROUND: Coronavirus disease-2019 (COVID-19) commonly presents with respiratory symptoms. However, symptoms involving the digestive system may be present, significance of which is not well studied in the Indian scenario. METHODS: This prospective observational cohort study included consecutive patients with severe COVID-19 admitted to intensive care unit of our tertiary care hospital from September 9, 2020, to March 14, 2021. We evaluated the frequency of preadmission digestive symptoms and compared the demographic, clinical, laboratory parameters, and organ failure at admission and during intensive care along with mortality between those with and without digestive symptoms. In the digestive group, we sought to find predictors of mortality. RESULTS: Digestive symptoms were present in 76/234 (32.4%) with severe COVID-19 infection. In comparison to nondigestive group, digestive patients had higher need for noninvasive ventilation (p 0.028), invasive lines (68%, p 0.003), vasopressors (64%, p 0.01), blood product transfusion (21.1%, p <0.001), and heart failure (55.4%, p 0.041). Confounding factors of alcohol abuse, smoking, sedentary lifestyle as a causative agent for heart failure could not be ruled out. Proportional mortality rate is higher in the digestive group (65.8%, p = 0.015). Mortality is multifactorial with preadmission abdominal pathologies (HR 4.3) or central nervous system (CNS)-related comorbidities (HR 2.829), presentation with multiple digestive symptoms (HR 6.9), higher sequential organ failure assessment score (SOFA) score at admission (HR 1.258) and discharge (HR 1.162), and presence of acute kidney injury (AKI) Grade 3 (HR 2.95) as predictors of mortality. After adjusting for all confounders, need for vasopressor was observed to be associated with 11.58 times higher risk of mortality. CONCLUSION: Preadmission digestive symptoms may be associated with a turbulent illness with invasive interventions, heart failure, and greater proportional mortality in severe COVID-19. AKI Grade 3 is identified as a preventable risk factor predicting mortality. CTRI/2021/03/032325. HOW TO CITE THIS ARTICLE: Karna ST, Singh P, Revadi G, Khurana A, Shivhare A, Saigal S, et al. Frequency and Impact of Preadmission Digestive Symptoms on Outcome in Severe COVID-19: A Prospective Observational Cohort Study. Indian J Crit Care Med 2021;25(11):1247-1257.

The Effect of Normal Saline and Plasmalyte on Acid-Base Status in Patients Undergoing Head-and-Neck Surgery with Free Flap Reconstruction: A Prospective, Observational Cohort Study.

Background: Intraoperative fluid strategy may affect the graft viability in head-and-neck surgeries with free flap reconstruction (HNS-FFR). Studies to guide regarding association of intraoperative fluid with metabolic parameters during such surgeries are infrequent. Aim: This study aimed to compare plasmalyte (PL) and normal saline (NS) (0.9%) in terms of acid-base balance and electrolytes in the peri-operative period along with graft viability during above-mentioned surgeries. Settings and Design: Prospective, observational cohort study was conducted in patients, 18-65 years, undergoing HNS-FFR at a tertiary care center. Materials and Methods: The cohort was categorized into two groups based on the intraoperative fluid used, i.e., PL (Group A) and NS (Group B) group. The primary objective was to compare arterial blood gas parameters at seven time points till the 3rd postoperative day. We studied the effect on graft viability and length of hospital stay. Statistical Analysis Used: The independent t-tests, Chi-square, or Fisher's exact test were used to evaluate the categorical variables with a repeated measures analysis of variance for inter-group comparison with P < 0.05 as significant. Results: Seventy-one (36 in Group A and 35 in Group B) patients were included in the study with comparable baseline characteristics. Group A had a better acid-base status, especially after the conclusion of vascular anastomosis (pH 7.37 ± 0.06 vs. 7.33 ± 0.04, P = 0.014) and in the postoperative period (pH 7.35 ± 0.07 vs. 7.31 ± 0.05, P = 0.013). No statistically significant difference was observed in outcome parameters between the groups. Conclusions: PL may be preferred over NS due to better metabolic milieu during HNS-FFR surgery.

Superior Mesenteric Artery Thrombosis in COVID-19 Pneumonia: an Underestimated Diagnosis-First Case Report in Asia.

The COVID-19 disease caused by novel coronavirus was first reported in Wuhan, China, in December 2019 with 5% patients having severe lung injury. Though this disease primarily presents as a lower respiratory tract infection, multiple digestive manifestations have been reported which are often overlooked. The present case report describes the unusual progression of COVID-19 disease from pneumonia to a procoagulant state leading to superior mesenteric artery thrombosis and subsequent gut ischemia necessitating emergency laparotomy. Coagulopathy in COVID-19 is due to an imbalance in the coagulation homeostasis with increase in prothrombin time, fibrinogen, and D-dimers. Early recognition of abdominal symptoms, diagnosis of pathology, and timely surgical intervention may definitely improve outcome. In the management of any patient with COVID-19 disease, we advocate a comprehensive integrated approach with early recognition of digestive symptoms and their timely intervention which should run parallel to the respiratory management.

Surgical Retrieval of Embolized Patent Ductus Arteriosus Occluder Device in an Adult after 12 Years of Initial Deployment: A Case Report with Perioperative Considerations and Decision-Making in Resource-Limited Settings.

Transcatheter closure of patent ductus arteriosus (PDA) is a well-established technique worldwide, with minimal incidence of associated major and minor complications. Surgical closure of PDA is equally effective with negligible mortality risk. We describe a case of an adult with unexpected diagnosis of PDA occluder device embolization in main pulmonary artery, presenting after 12 years of initial device deployment during childhood. Due to persistent duct flow, patient developed severe pulmonary hypertension and congestive heart failure. In this report, we are focusing on perioperative management of surgical retrieval of the embolized device along with the need of intermediate and sometimes long term follow up of patients planned for percutaneous closure, in order to avoid procedure-related complications and associated morbidity and mortality risk. At the same time, the socio-economic aspects of the patient should also be considered in decision-making in terms of choice of transcatheter versus surgical closure of the shunt.

Detection of Coagulopathy in Chronic Renal Disease using Thromboelastography and its comparison with Conventional Tests.

PURPOSE OF THE STUDY: Thromboelastography provides a holistic picture of blood coagulation including fibrin formation, cross, linking and fibrinolysis. Coagulaopathy in end stage renal disease (ESRD) is multifactorial. The present evaluated the thromboelastographic profile of ESRD patients and compared it to conventional tests of coagulation. STUDY DESIGN: In this observational case control study, fifty ESRD patients and 50 controls were recruited. Venous samples were withdrawn and platelet count, International Normalization Ratio and fibrinogen levels were measure. Simultaneously a thromboelastography (TEG) was performed. All samples were drawn prior to initiation of dialysis. RESULTS: The fibrinogen concentration was higher in the ESRD group compared to control (455.51±83.39 vs. 233.84±71.71 mg/dl, P<0.05). The maximum amplitude in ESRD group was 76.94 ± 15.11 mm, which was significantly higher than control group 65.10±10.31 mm (P<0.05).Out of 50 ESRD patients,39 had maximum amplitude (MA) >73mm, 3 had MA <55 mm while 8 patients had normal MA. Further, it was seen that in four out if the five patients whose INR was greater than 1.5. TEG was hypercoaguable. Also, three patients whose platelet count was less than x105/dl had normal thromboelastographs. Two patients with normal platelet count, fibrinogen and INR had hypercoaguable thromboelastographs. Thromboelastography could detect fibrinolysis in 5 patients of end stage renal disease. CONCLUSION: The present study demonstrated that INR, platelet count and fibrinogen levels do not reflect the actual coagulation status in patients of ESRD. Thromboelastography is a better tool to detect coagulopathy in this group of patients.

Use of ultrasound-guided preoperative diaphragmatic thickness as a predictor of postoperative weaning failure in recipients and donors scheduled for living donor liver transplant surgery.

BACKGROUND AND OBJECTIVES: The present study was designed to explore the utility of ultrasound-guided diaphragmatic thickness in the preoperative period in healthy controls scheduled for live-related donor hepatectomy and patients suffering from chronic liver disease scheduled for liver transplantation (LT) and its use as a predictor of postoperative weaning failure. MATERIALS AND METHODS: This prospective observational study was conducted in a tertiary health care center and 65 adult (18-70 years) participants (30 healthy liver donors and 35 liver transplant recipients) were enrolled for this study. Right diaphragmatic thickness of both donors and recipients was measured by B-mode ultrasound using a 10 MHz linear array transducer in the supine position in the operation theater just before induction of anesthesia. For subgroup analysis of the recipients, we further divided them into two groups - Group 1 (diaphragmatic thickness < 2 mm) and Group 2 (diaphragmatic thickness > 2 mm), and comparison was done for duration of mechanical ventilation. Intergroup comparison was made for duration of mechanical ventilation and various other parameters. RESULTS: The sonographic measurement of diaphragm revealed that its thickness is decreased in patients with chronic liver disease patients (2.12 ± 0.54 mm) as compared to healthy donors (3.70 ± 0. 58 mm). On multiple logistic regression, higher duration of mechanical ventilation was associated with diaphragmatic thickness < 2 mm (Group 1 of recipients) (adjusted odds ratio 0.86; 95% confidence interval: 0.75-0.99; P = 0.013) after adjusting for age, gender, and body mass index. CONCLUSIONS: Diaphragmatic thickness is decreased in patients with chronic liver disease as compared to healthy liver donors. Preoperative measurement of ultrasound-guided right hemidiaphragm thickness can be used to predict weaning failure in patients undergoing LT. Other studies are needed to confirm these finding on different group of patients.

Multimodal temperature management during donor hepatectomy under combined general anaesthesia and neuraxial analgesia: Retrospective analysis.

BACKGROUND AND AIMS: Unintended hypothermia (UIH) during surgery under general anaesthesia has adverse implications. A retrospective analysis of the perioperative temperature records of healthy voluntary liver donors was done to evaluate the efficacy of a multimodal protocol for temperature management. METHODS: Records of 50 American Society of Anesthesiologists physical status Class 1 patients operated for Donor Hepatectomy lasting >2 h under combined general and epidural anaesthesia were analysed. Ambient temperature was maintained 24°C-27°C before induction of GA and during insertion of epidural catheter. Active warming was done using warming mattress set to temperature 38°C, hot air blanket with temperature set to 38°C and fluid warming device (Hotline™) with preset temperature of 41°C. Nasopharyngeal temperature was continuously monitored. After induction of GA and draping of the patient, ambient temperature was decreased and maintained at 21°C-24°C and was again increased to 24°C-27°C at the conclusion of surgery. During surgery, for every 0.1°C above 37°C, one heating device was switched off such that at 37.3°C all the 3 devices were switched off. Irrigation fluid was pre-warmed to 39°C. RESULTS: Baseline temperature was 35.9°C ± 0.4°C. Minimum temperature recorded was 35.7°C ± 0.4°C. Mean decrease in temperature below the baseline temperature was 0.2°C ± 0.2°C. Temperature at the end of surgery was 37.4°C ± 0.5°C. CONCLUSION: Protocol-based temperature management with simultaneous use of resistive heating mattress, forced-air warming blanket, and fluid warmer along with ambient temperature management is an effective method to prevent unintended perioperative variation in body temperature.

Diagnostic and therapeutic challenge of heart failure after liver transplant: Case series.

Heart failure (HF) following liver transplant (LT) surgery is a distinct clinical entity with high mortality. It is known to occur in absence of obvious risk factors. No preoperative workup including electrocardiogram, echocardiography at rest and on stress, reasonably prognosticates the risk. In patients of chronic liver disease, cirrhotic cardiomyopathy, alcoholic cardiomyopathy, and stress induced cardiomyopathy have each been implicated as a cause for HF after LT. However distinguishing one etiology from another not only is difficult, several etiologies may possibly coexist in a given patient. Diagnostic dilemma is further compounded by the fact that presentation and management of HF irrespective of the possible underlying cause, remains the same. In this case series, 6 cases are presented and in the light of existing literature modification in the preoperative workup are suggested.

Post-operative hypertension, a surrogate marker of the graft function and predictor of survival in living donor liver transplant recipients: A retrospective study.

BACKGROUND AND AIMS: De novo hypertension (HTN) in liver transplantation recipients is a known entity. We investigated haemodynamic behaviour after a liver transplant to see if it can predict survival to discharge from the hospital. METHODS: electronic records of Haemodynamic parameters and laboratory investigations of 95 patients of living donor liver transplant (LDLT) were retrospectively analysed. RESULTS: Twenty-three patients were operated for acute liver failure (ALF) and 72 patients for chronic liver disease (CLD). Eight patients of CLD and four of ALF did not survive. CLD patients had statistically significant rise in systolic blood pressure from the post-operative day (POD) 1 to POD 4 and diastolic blood pressure (DBP) from POD 3 to POD 6. Heart rate (HR) significantly decreased from POD 3 to POD 5. Haemodynamic parameters returned to baseline values within 20 days. Diastolic HTN had a positive predictive value of 100% for survival with 100% sensitivity and specificity. Systolic HTN had a positive predictive value of 100% for survival (sensitivity-89%, specificity-100%). ALF patients had a significant decrease in HR from POD 2 to POD 10. Bradycardia (HR ≤60/min) had a positive predictive value of 100% for survival with a sensitivity of 45% and 58% in CLD and ALF, respectively, with a specificity of 100% in both the groups. Non-survivors had no significant change in haemodynamics. In CLD group, International Normalised Ratio had statistically significant, strong negative correlation with DBP. CONCLUSION: Haemodynamic pattern of recovery may be used for predicting survival to discharge after LDLT.

Intraoperative blood loss in orthotopic liver transplantation: The predictive factors.

Liver transplantation has been associated with massive blood loss and considerable transfusion requirements. Bleeding in orthotopic liver transplantation is multifactorial. Technical difficulties inherent to this complex surgical procedure and pre operative derangements of the primary and secondary coagulation system are thought to be the principal causes of perioperative hemorrhage. Intraoperative practices such as massive fluid resuscitation and resulting hypothermia and hypocalcemia secondary to citrate toxicity further aggravate the preexisting coagulopathy and worsen the perioperative bleeding. Excessive blood loss and transfusion during orthotopic liver transplant are correlated with diminished graft survival and increased septic episodes and prolonged ICU stay. With improvements in surgical skills, anesthetic technique, graft preservation, use of intraoperative cell savers and overall perioperative management, orthotopic liver transplant is now associated with decreased intra operative blood losses. The purpose of this review is to discuss the risk factors predictive of increased intra operative bleeding in patients undergoing orthotopic liver transplant.