Evaluation of Early Tocilizumab Effect on Multiorgan Dysfunction in Critically Ill Patients With COVID-19: A Propensity Score-Matched Study.

Background: Tocilizumab (TCZ) has been proposed as potential rescue therapy for severe COVID-19. No previous study has primarily assessed the role of TCZ in preventing severe COVID-19-related multiorgan dysfunction. Hence, this multicenter cohort study aimed to evaluate the effectiveness of TCZ early use versus standard of care in preventing severe COVID-19-related multiorgan dysfunction in COVID-19 critically ill patients during intensive care unit (ICU) stay. Methods: A multicenter, retrospective cohort study includes critically ill adult patients with COVID-19 admitted to the ICUs. Patients were categorized into two groups, the treatment group includes patients who received early TCZ therapy within 24 hours of ICU admission and the control group includes patients who received standard of care. The primary outcome was the multiorgan dysfunction on day three of the ICU admission. The secondary outcomes were 30-day, and in-hospital mortality, ventilator-free days, hospital length of stay (LOS), ICU LOS, and ICU-related complications. Results: After propensity score matching, 300 patients were included in the analysis based on predefined criteria with a ratio of 1:2. Patients who received TCZ had lower multiorgan dysfunction score on day three of ICU admission compared to the control group (beta coefficient: -0.13, 95% CI: -0.26, -0.01, P-value = 0.04). Moreover, respiratory failure requiring MV was statistically significantly lower in patients who received early TCZ compared to the control group (OR 0.52; 95% CI 0.31, 0.91, P-value = 0.02). The 30-day and in-hospital mortality were significantly lower in patients who received TCZ than those who did not (HR 0.56; 95% CI 0.37, 0.85, P-value = 0 .006 and HR 0.54; 95% CI 0.36, 0.82, P-value = 0.003, respectively). Conclusion: In addition to the mortality benefits associated with early TCZ use within 24 hours of ICU admission, the use of TCZ was associated with a significantly lower multiorgan dysfunction score on day three of ICU admission in critically ill patients with COVID-19.

Multiorgan Dysfunction Syndrome in Abusive and Accidental Pediatric Traumatic Brain Injury.

BACKGROUND: Abusive head trauma (AHT) is a mechanism of pediatric traumatic brain injury (TBI) with high morbidity and mortality. Multiorgan dysfunction syndrome (MODS), defined as organ dysfunction in two or more organ systems, is also associated with morbidity and mortality in critically ill children. Our objective was to compare the frequency of MODS and evaluate its association with outcome between AHT and accidental TBI (aTBI). METHODS: This was a single center, retrospective cohort study including children under 3 years old admitted to the pediatric intensive care unit with nonpenetrating TBI between 2014 and 2021. Presence or absence of MODS on days 1, 3, and 7 using the Pediatric Logistic Organ Dysfunction-2 score and new impairment status (Functional Status Scale score change > 1 compared with preinjury) at hospital discharge (HD), short-term timepoint, and long-term timepoint were abstracted from the electronic health record. Multiple logistic regression was performed to examine the association between MODS and TBI mechanism with new impairment status. RESULTS: Among 576 children, 215 (37%) had AHT and 361 (63%) had aTBI. More children with AHT had MODS on days 1 (34% vs. 23%, p = 0.003), 3 (28% vs. 6%, p < 0.001), and 7 (17% vs. 3%, p < 0.001) compared with those with aTBI. The most common organ failures were cardiovascular ([AHT] 66% vs. [aTBI] 66%, p = 0.997), neurologic (33% vs. 16%, p < 0.001), and respiratory (34% vs. 15%, p < 0.001). MODS was associated with new impairment in multivariable logistic regression at HD (odds ratio 19.1 [95% confidence interval 9.8-38.6, p < 0.001]), short-term discharge (7.4 [3.7-15.2, p < 0.001]), and long-term discharge (4.3 [2.0-9.4, p < 0.001])]. AHT was also associated with new impairment at HD (3.4 [1.6-7.3, p = 0.001]), short-term discharge (2.5 [1.3-4.7, p = 0.005]), and long-term discharge (2.1 [1.1-4.1, p = 0.036]). CONCLUSIONS: Abusive head trauma as a mechanism was associated with MODS following TBI. Both AHT mechanism and MODS were associated with new impairment at all time points.

Serial Evaluation of Sequential Organ Failure Assessment Score (SOFA) as a Predictor of Outcome in Children Admitted in Pediatric Intensive Care Unit (PICU) at Tertiary Care Hospital.

Background: Sequential organ failure assessment score (SOFA) is a score to quantify organ system dysfunction. This study was done to evaluate SOFA as a predictor of outcomes in children in pediatric intensive care unit (PICU). Objective: (A) To determine whether initial SOFA, Delta SOFA, and SOFA score at 72 hours are better predictors of outcome in terms of sensitivity and specificity. (B) To compare the initial SOFA, Delta SOFA, and SOFA score at 72 hours. Materials and methods: A prospective observational study was conducted on 160 patients aged from 29 days to 12 years admitted in PICU of a Tertiary Care Hospital in a metropolitan city in India for a period of 1 year. Then, the initial SOFA score, 72-hour SOFA, and Delta SOFA (T0 SOFA - T72 SOFA) were calculated and patients were followed up till discharge from PICU or deceased. Results: The best threshold to differentiate between discharged and deceased corresponds to as initial SOFA of 7.50 with a sensitivity of 64.71%, and specificity of 89.51%. The similar threshold for 72 hours SOFA is 10.50 which correspond to a sensitivity of 76.47% and specificity of 96.50%. The study showed strong evidence (p-value < 0.05) that, patients whose Delta SOFA values increased from the previous value (-1.5), had a greater chance to succumb to illness. Delta SOFA had the best sensitivity (82.35%) and 72-hour SOFA had the best specificity (96.50%) in predicting the outcome of PICU patients. Conclusion: This study emphasizes the use of SOFA score as a prognostic indicator in critically ill children, as variables measured are easily available. How to cite this article: Lois A, Save S. Serial Evaluation of Sequential Organ Failure Assessment Score (SOFA) as a Predictor of Outcome in Children Admitted in Pediatric Intensive Care Unit (PICU) at Tertiary Care Hospital. Indian J Crit Care Med 2023;27(8):590-595.

Amniotic fluid embolism causing multiorgan embolisms and reinforces the need for point-of-care ultrasound.

INTRODUCTION: Pregnant patients are at risk of several possible complications during the peripartum period. Amniotic fluid embolism (AFE) is a peripartum complication with high mortality and morbidity. The sudden entry of amniotic fluid into the maternal circulation causes a rapid and dramatic sequence of clinical events called AFE. The reported incidence of AFE after a cesarean section is around 19%, and after a normal delivery, it is 11%. AFE causing multiple embolisms is not reported in the literature, nor is the use of point-of-care ultrasound (POCUS) in the diagnosis of AFE. We report a case of AFE causing pulmonary and ovarian embolisms. CASE: A 34-year-old pregnant lady had an elective lower section cesarean section (LSCS) for transverse lying and placenta previa under combined spinal and epidural anesthesia. She was gravida 3 para 2 and had regular antenatal check-ups, and she presented for her LSCS at 36 weeks of gestation. Immediately after delivery of the fetus, the patient had convulsions, cardiac arrest, and disseminated intravascular coagulopathy (DIC). Immediately, cardiopulmonary resuscitation started, and the team achieved a return of spontaneous circulation (ROSC) in 3 minutes. DIC was corrected with blood and blood products during this maneuver, and POCUS of the inferior vena cava and heart showed multiple small particles floating, thus confirming the diagnosis of AFE in this patient. The patient was transferred to the intensive care unit (ICU), intubated, and ventilated, necessitating a vasopressor infusion. Computed tomographic pulmonary angiography (CTPA) showed pulmonary embolism and ovarian vein embolism, which were managed with heparin infusion. She was hemodynamically stable and weaned from vasopressors, and the ventilator was then extubated on day 13 of ICU admission. She remained awake and in stable condition. The patient was transferred to the ward and subsequently discharged to go home on the 20th-day post-delivery. CONCLUSION: AFE can be quickly diagnosed using clinical manifestations and POCUS, and it can be managed early for better patient outcomes. POCUS will show multiple smaller and a few larger amniotic fluid emboli in the heart and vena cava. These larger AFE emboli can migrate and cause multiple embolisms, requiring systemic anticoagulation.

Influence of extracorporeal cytokine adsorption on hemodynamics in severe acute pancreatitis: Results of the matched cohort pancreatitis cytosorbents inflammatory cytokine removal (PACIFIC) study.

BACKGROUND: Outcome of severe acute pancreatitis (SAP) highly depends on the degree of systemic inflammation and organ failure. Although treatment approaches targeting the inflammatory cascade have failed in pancreatitis, recent studies suggest that extracorporeal cytokine adsorption effectively reduces concentrations of pro-inflammatory cytokines and potentially improves the outcome of sepsis. METHODS: Sixteen patients with SAP, presenting within 7 days upon onset of pain, an APACHE-II score of ≥10 and ≥1 marker of poor prognosis, received 2 consecutive 24-h treatments with CytoSorb® extracorporeal cytokine adsorption (intervention group). Hemodynamics, organ failure, and mortality were compared with an APACHE-II score-matched retrospective control group of 32 patients. RESULTS: The primary objective (20% decrease in the vasopressor dependency index or 20% increase in the cardiac index) was reached in 68.8% of the intervention and 28.1% of the control patients (p = 0.007), respectively. The cytokine adsorption significantly reduced IL-6 (-1998 pg/ml, p = 0.005) serum levels and resulted in stable CRP (p = 0.101) and decreased PCT (p = 0.003) levels in contrast to increased CRP (p = 0.014) and stable PCT levels (p = 0.695) in the control group. While mortality and improvement of respiratory failure were similar in both groups, renal failure significantly improved (change of KDIGO classification 72 h postcytokine adsorption [-1 vs. 0, p = 0.005]) and the SOFA score significantly decreased (day 5: -1.8 ± 2.0 vs. 1 ± 3.8, p = 0.013) in the intervention group. CONCLUSION: Cytokine adsorption might be an effective treatment option to stabilize hemodynamics in SAP. It decreases levels of the pro-inflammatory marker IL-6 and stabilizes organ function according to serial SOFA score assessments.

Acute gastrointestinal injury in critically ill children: Impact on clinical outcome.

AIM: To estimate acute gastrointestinal injury (AGI) in critically ill children and association of its severity with mortality. METHODS: In a prospective cohort study, critically ill children (1 month-18 years) were enrolled. Gastrointestinal symptoms over the first week of admission were classified into AGI grades 1 through 4, using a paediatric adaptation of European Society of Intensive Care Medicine AGI definitions. Performance of AGI grades in predicting 28-day mortality was evaluated. RESULTS: Of 151 children enrolled, 71 (47%, 95% confidence interval (CI): 38.9-55.3%) developed AGI, with AGI grades 1, 2, 3 and 4 in 22.5%, 15.9%, 6.6% and 2%, respectively. The 28-day mortality progressively increased with AGI grade 0 (15%), 1 (35%), 2 (50%), 3 (70%), through 4 (100%), P < 0.001. Association of AGI grades with 28-day mortality was significant even after adjustment for disease severity, age and nutritional status (odds ratio (OR) = 2.152, 95% CI: 1.455, 3.184). Among AGI grades, and paediatric logistic organ dysfunction-2 score components, cardiovascular (OR = 1.525, 95% CI: 1.142, 2.037) and haematological (OR = 1.719, 95% CI: 1.067, 2.772) components of paediatric logistic organ dysfunction-2 score and AGI grades (OR = 1.565, 95% CI: 1.001, 2.449) showed significant association with 28-day mortality. CONCLUSIONS: Nearly half of the critically ill children developed AGI. AGI grades were independently associated with increased mortality, and mortality progressively increased with AGI grade.

Non-Thyroidal Illness Syndrome-Associated Multiorgan Dysfunction After Surgical Repair of Type A Aortic Dissection.

OBJECTIVE: The purpose of this cohort study was to investigate the relationship between non-thyroidal illness syndrome (NTIS) and severe multiorgan dysfunction, measured by Sequential Organ Failure Assessment score ≥11, after surgical repair of type A aortic dissection (TAAD). SETTING: An observational study. PARTICIPANTS: The present study included 310 patients with TAAD surgically repaired between January 2019 and December 2020 in Beijing Anzhen Hospital. INTERVENTIONS: Patients after surgical repair after TAAD. MEASUREMENTS AND MAIN RESULTS: Among a total of 310 patients with TAAD undergoing surgical repair included in this study, 132 (42.6%) experienced surgery-associated NTIS. Severe multiorgan dysfunction was experienced more often in patients with NTIS (27.3% v 11.2%, p < 0.0001). Multivariate analysis demonstrated NTIS was associated closely with an increased risk of severe multiorgan dysfunction (odds ratio [OR] = 2.54, 95% CI = 1.39-4.64 p = 0.002), which predicted an in-hospital death rate of 95%. Non-thyroidal illness syndrome also was related with in-hospital major adverse cardiovascular and cerebral events (OR = 2.12, 95% CI = 1.30-3.46 p = 0.003), acute kidney injury (OR = 3.17, 95% CI = 1.17-8.47 p = 0.023), and postoperative pulmonary complications (OR = 2.32, 95% CI = 1.34-4.03 p = 0.003). However, hepatic inadequacy was comparable in the NTIS and control groups. CONCLUSIONS: Non-thyroidal illness syndrome was associated closely with multiorgan dysfunction after surgical repair of TAAD, which may be correlated further with an increased incidence of in-hospital mortality and complications.

[Cardiogenic shock following yew needle poisoning : Digoxin immune fab, va-ECMO and albumin dialysis for the treatment of a suicidal yew leaf poisoning]. / Kardiogener Schock nach Eibennadelintoxikation : Digitalisantidot, va-ECMO und Albumindialyse in der Therapie der suizidalen Eibennadelintoxikation.

We present the case of a 46-year-old male who developed refractory bradycardia with cardiogenic shock after attempting suicide by ingestion of yew leaves. Due to delayed availability of the Digoxin immune fab, a va-ECMO was established to maintain sufficient circulation. Administration of the digoxin fab resulted in recovery of spontaneous circulation. Continuous venovenous hemodiafiltration with hemoadsorption and albumin dialysis were initiated with the intention to remove immune fab-toxin complexes and as organ support in acute kidney and liver failure. Within 5 days the patient was successfully weaned from ECMO, liver support and renal replacement and discharged without physical sequelae.

[Short version of the 2nd edition of the German-Austrian S3 guidelines "Cardiogenic shock complicating myocardial infarction-Diagnosis, monitoring and treatment"]. / Kurzversion der 2. Auflage der deutsch-österreichischen S3-Leitlinie "Infarkt-bedingter Kardiogener Schock ­ Diagnose, Monitoring und Therapie".

BACKGROUND: The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects. METHODS: Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions. RESULTS: A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.

Pathophysiology of Advanced Heart Failure: What Knowledge Is Needed for Clinical Management?

Understanding of heart failure (HF) has evolved from a simple hemodynamic problem through a neurohormonally and proinflammatory-driven syndrome to a complex multiorgan dysfunction accompanied by inadequate energy handling. This article discusses the most important clinical aspects of advanced HF pathophysiology. It presents the concept of neurohormonal activation and its deleterious effect on cardiovascular system and reflex control. The current theories regarding the role of inflammation, cytokine activation, and myocardial remodeling in HF progression are presented. Advanced HF is a multiorgan syndrome with interplay between cardiovascular system and other organs. The role of iron deficiency is also discussed.

Vaccine-Associated Thrombocytopenia and Thrombosis: Venous Endotheliopathy Leading to Venous Combined Micro-Macrothrombosis.

Serious vaccine-associated side effects are very rare. Major complications of vaccines are thrombocytopenia and thrombosis in which pathogenetic mechanism is consistent with endotheliopathy characterized by "attenuated" sepsis-like syndrome, leading to the activation of inflammatory and microthrombotic pathway. In the COVID-19 pandemic, acute respiratory distress syndrome caused by microthrombosis has been the major clinical phenotype from the viral sepsis in association with endotheliopathy-associated vascular microthrombotic disease (EA-VMTD), sometimes presenting with thrombotic thrombocytopenic purpura (TTP)-like syndrome. Often, venous thromboembolism has coexisted due to additional vascular injury. In contrast, clinical phenotypes of vaccine complication have included "silent" immune thrombocytopenic purpura (ITP-like syndrome), multiorgan inflammatory syndrome, and deep venous thrombosis (DVT), cerebral venous sinus thrombosis (CVST) in particular. These findings are consistent with venous (v) EA-VMTD. In vEA-VMTD promoted by activated complement system following vaccination, "consumptive" thrombocytopenia develops as ITP-like syndrome due to activated unusually large von Willebrand factor (ULVWF) path of hemostasis via microthrombogenesis. Thus, the pathologic phenotype of ITP-like syndrome is venous microthrombosis. Myocarditis/pericarditis and other rare cases of inflammatory organ syndrome are promoted by inflammatory cytokines released from activated inflammatory pathway, leading to various organ endotheliitis. Vaccine-associated CVST is a form of venous combined "micro-macrothrombosis" composed of binary components of "microthrombi strings" from vEA-VMTD and "fibrin meshes" from vaccine-unrelated incidental vascular injury perhaps such as unreported head trauma. This mechanism is identified based on "two-path unifying theory" of in vivo hemostasis. Venous combined micro-macrothrombosis due to vaccine is much more serious thrombosis than isolated distal DVT made of macrothrombus. This paradigm changing novel concept of combined micro-macrothrombosis implies the need of combined therapy of a complement inhibitor and anticoagulant for CVST and other complex forms of DVT.

DNA-bound elastase of neutrophil extracellular traps degrades plasminogen, reduces plasmin formation, and decreases fibrinolysis: proof of concept in septic shock plasma.

Activation of platelets and neutrophils in septic shock results in the formation of microvascular clots containing an intricate scaffold of fibrin with neutrophil extracellular traps (NETs) DNA. NETs contain multiple components that might impact endogenous fibrinolysis, resulting in failure to lyse clots in the microcirculation and residual systemic microthrombosis. We propose herein that the reservoir of human neutrophil elastase (HNE) on NETs may directly interfere with the fibrinolytic mechanism via a plasminogen proteolytic pathway. To investigate this mechanism, we constructed fibrin-NETs matrices by seeding and activating neutrophils onto a fibrin surface and monitored plasminogen activation or degradation. We demonstrate that the elastase activity of HNE-DNA complexes is protected from inhibition by plasma antiproteases and sustains its ability to degrade plasminogen. Using mass spectrometry proteomic analysis, we identified plasminogen fragments composed of kringle (K) domains (K1+2+3, k1+2+3+4) and the serine protease (SP) region (K5-SP). We further demonstrate that patients with septic shock with disseminated intravascular coagulation have circulating HNE-DNA complexes, HNE-derived plasminogen fragments, a low plasminogen concentration, and a reduced capacity to generate plasmin onto fibrin. In conclusion, we show that NETs bearing active HNE-DNA complexes reduce plasminogen into fragments, thus impairing fibrinolysis by decreasing the local plasminogen concentration, plasminogen binding to fibrin, and localized plasmin formation.-Barbosa da Cruz, D., Helms, J., Aquino, L. R., Stiel, L., Cougourdan, L., Broussard, C., Chafey, P., Riès-Kautt, M., Meziani, F., Toti, F., Gaussem, P., Anglés-Cano, E. DNA-bound elastase of neutrophil extracellular traps degrades plasminogen, reduces plasmin formation, and decreases fibrinolysis: proof of concept in septic shock plasma.

Blood purification therapy with a hemodiafilter featuring enhanced adsorptive properties for cytokine removal in patients presenting COVID-19: a pilot study.

BACKGROUND: Systemic inflammation in COVID-19 often leads to multiple organ failure, including acute kidney injury (AKI). Renal replacement therapy (RRT) in combination with sequential extracorporeal blood purification therapies (EBP) might support renal function, attenuate systemic inflammation, and prevent or mitigate multiple organ dysfunctions in COVID-19. AIM: Describe overtime variations of clinical and biochemical features of critically ill patients with COVID-19 treated with EBP with a hemodiafilter characterized by enhanced cytokine adsorption properties. METHODS: An observational prospective study assessing the outcome of patients with COVID-19 admitted to the ICU (February to April 2020) treated with EBP according to local practice. Main endpoints included overtime variation of IL-6 and multiorgan function-scores, mortality, and occurrence of technical complications or adverse events. RESULTS: The study evaluated 37 patients. Median baseline IL-6 was 1230 pg/ml (IQR 895) and decreased overtime (p < 0.001 Kruskal-Wallis test) during the first 72 h of the treatment, with the most significant decrease in the first 24 h (p = 0.001). The reduction in serum IL-6 concentrations correlated with the improvement in organ function, as measured in the decrease of SOFA score (rho = 0.48, p = 0.0003). Median baseline SOFA was 13 (IQR 6) and decreased significantly overtime (p < 0.001 at Kruskal-Wallis test) during the first 72 h of the treatment, with the most significant decrease in the first 48 h (median 8 IQR 5, p = 0.001). Compared to the expected mortality rates, as calculated by APACHE IV, the mean observed rates were 8.3% lower after treatment. The best improvement in mortality rate was observed in patients receiving EBP early on during the ICU stay. Premature clotting (running < 24 h) occurred in patients (18.9% of total) which featured higher effluent dose (median 33.6 ml/kg/h, IQR 9) and higher filtration fraction (median 31%, IQR 7.4). No electrolyte disorders, catheter displacement, circuit disconnection, unexpected bleeding, air, or thromboembolisms due to venous cannulation of EBP were recorded during the treatment. In one case, infection of vascular access occurred during RRT, requiring replacement. CONCLUSIONS: EBP with heparin-coated hemodiafilter featuring cytokine adsorption properties administered to patients with COVID-19 showed to be feasible and with no adverse events. During the treatment, patients experienced serum IL-6 level reduction, attenuation of systemic inflammation, multiorgan dysfunction improvement, and reduction in expected ICU mortality rate.

The successful use of extra-corporeal membrane oxygenation as rescue therapy for unilateral pulmonary edema following minimally invasive mitral valve surgery.

Unilateral right pulmonary edema has been reported as a potential life-threatening complication after minimally invasive mitral valve surgery. Nearly 2% of these cases in the immediate postoperative period have been reported to require extra-corporeal membrane oxygenation support as a rescue therapy for severe hypoxia. The exact pathophysiology of this condition remains unclear, but has been assumed to be related to ischemia-reperfusion injury and re-expansion pulmonary edema. We present in this report the successful use of extra-corporeal membrane oxygenation to manage two cases of severe hypoxia and multiorgan dysfunction secondary to unilateral right pulmonary edema.

Severe thrombotic microangiopathy accompanied by liver rupture and multiorgan failure at week 26 of pregnancy.

OBJECTIVE: Case of a primigravid woman who suffered from severe PTMS (postpartum thrombotic microangiopathy syndrome) in the 26th week of pregnancy. DESIGN: Case report. SETTING: Department of Gynecology and Obstetrics, Hospital Nový Jičín; Department of Gynecology and Obstetrics, University Hospital Ostrava; Department of Hematooncology, University Hospital Ostrava; Department of Anaesthesiology and Resuscitation, University Hospital Ostrava. RESULTS: A thirty-one-year old primigravid woman was admitted to a secondary level institution due to epigastric pain and spontaneous rupture of membranes at 26th week of pregnancy. On admission her blood pressure was 140/90 mm Hg and an intrauterine fetal death was confirmed. The patients condition deteriorated quickly, resulting in a hypertensive crisis (220/120 mm Hg), which did not respond to medication over a two hour period. Emergency caesarean section was performed, but the patients condition progressed to HELLP syndrome class I, DIC and MOF. She was transferred to the intensive care unit (ICU) of the district referral hospital 38 hours postpartum. On admission to ICU, liver rupture was diagnosed which was managed conservatively. Therapeutic plasma exchange (TPEX) was initiated on day 2 postpartum in response to falling platelets and continued for 6 days. Due to acute kidney injury (AKI), the patient required dialysis for 21 days. The patients condition improved gradually and at 28 days after admission to ICU she was transferred back to the referring hospital. The consensus reached by the treating teams was that PTMS was the most likely diagnosis. CONCLUSION: This case demonstrates that PTMS improves (usually rapidly) after TPEX is initiated. It also emphasises the importance of maintaining a high index of suspicion for PTMS so that life-saving TPEX can be initiated, because it does not respond to classical treat-ment used in the management of HELLP syndrome. Other research suggests patients may also require a terminal complement blockade with the anti-C5 monoclonal antibody (eculizumab). Further research could focus on diagnostic tests to distinguish PTMS from HELLP to identify which patients would most benefit from these treatments.

A Rare Case of Podophyllin Poisoning: Early Intervention is Lifesaving.

Accidental poisoning in children is very common, making up 10.9% of all unintentional injuries worldwide. Africa has the highest incidence of fatal poisonings worldwide, at 4 per 100,000. Poisoning with podophyllin is rare, with most cases documented around the 1970s to 1980s. Podophyllin is a resin mixture obtained from the dried Rhizome and roots of Podophyllin peltatum (North America) and Podopyllin emodi (India). Podophyllotoxin is the most toxic chemical present in the podophyllin, which is lipid soluble; so crosses the cell membrane easily and inhibits mitotic spindle formation. Both topical application and oral consumption can cause podophyllin poisoning. Neurotoxicity is the most serious effect along with bone marrow depression, gastrointestinal irritation, and hepatic and renal dysfunction. Management of podophyllin toxicity is mainly symptomatic, and no specific antidote exists. We report a case of a 2-year-old-year girl with accidental podophyllin poisoning, who presented with neurotoxicity followed by multiorgan dysfunction and then succumbed. Education of parents and healthcare workers on home safety still remains the mainstay of prevention. How to cite this article: Jain MK, Patnaik S, Rup AR, Gaurav A. A Rare Case of Podophyllin Poisoning: Early Intervention is Lifesaving. Indian J Crit Care Med 2020;24(6):477-479.

A Rare Case of Rhinocerebral Mucormycosis Presenting as Garcin Syndrome and Acute Ischemic Stroke.

BACKGROUND: Mucormycosis is a rare fungal infection affecting immunocompromised patients, with the rhinocerebral variant as the most common presentation.1 Garcin syndrome is the progressive involvement of the cranial nerves resulting in total unilateral paralysis of cranial nerves, absence of sensory or motor deficits, and not associated with features of raised intracranial pressure.2 We report a case of invasive rhinocerebral mucormycosis presenting as Garcin syndrome and acute ischemic stroke. HOW TO CITE THIS ARTICLE: Nagendra V, Thakkar KD, Prasad Hrishi A, Prathapadas U. A Rare Case of Rhinocerebral Mucormycosis Presenting as Garcin Syndrome and Acute Ischemic Stroke. Indian J Crit Care Med 2020;24(11):1137-1138.

Acute kidney injury in the pediatric intensive care unit at a tertiary care hospital of the Armed Forces: a cross-sectional observational study.

BACKGROUND: Acute kidney injury (AKI) is shown to be the commonest complication in critically ill children admitted to the pediatric intensive care unit (PICU). Kidney Disease: Improving Global Outcomes (KDIGO) classification and definition are now used universally. We undertook prospective observational study to study the etiology and maximum stage of AKI as defined by KDIGO and its complications and outcomes. METHODS: All children admitted to the PICU were included in the study. The diagnosis of sepsis and multiorgan dysfunction syndrome (MODS) was made according to the standard international guidelines. The patients were followed up till discharge/death. All children were screened for AKI at admission and subsequently using serum creatinine measured by modified Jaffe's method and urine output measurement. RESULTS: A total of 197 children were admitted to the PICU. 38 (19.28%) developed AKI, and 6 (15.78%) developed stage III AKI. Malignancies, serious neurological and renal disorders, and postsurgery complications accounted for most of the cases with AKI. Six were admitted with primary renal condition. Sepsis with or without MODS was seen in 12 patients with AKI and in 8 without AKI. Twenty-one children with AKI and 3 children without AKI were exposed to nephrotoxic drugs. Twenty-three children with AKI required inotropic support. The average length of stay (ALOS) of children with AKI in the PICU was 9.86 days, whereas ALOS of children without AKI was 6.23 days. Eighteen children with AKI (47.36%) and 36 (21.38%) with no AKI died. CONCLUSIONS: AKI in children in the PICUs of referral hospitals in the armed forces have varied etiologies and presentations. These children require early identification and management with close monitoring to prevent long-term renal morbidity and mortality.

Acute Intestinal Failure.

Acute intestinal failure (AIF), "reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, requiring parenteral nutrition", is common, but very often neglected part of multiorgan dysfunction syndrome (MODS) in the critically ill patients. It is now increasingly being recognized as a cause of prolonged ICU and hospital stay and poor outcome. Multidisciplinary team approach, systematic approach to management with treatment of sepsis, early mobilization and enteral feeding with prokinetics if required, control of intra-abdominal pressure and surgical intervention, when mandated, can help treat AIF and improve patient outcomes. How to cite this article: Chandankhede SR, Kulkarni AP. Acute Intestinal Failure. Indian J Crit Care Med 2020;24(Suppl 4):S168-S174.

Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum.

Multiorgan dysfunction syndrome (MODS) remains a major complication and challenge to treat patients with critical illness in different intensive care unit settings. The exact mechanism and pathophysiology of MODS is complex and remains unexplored. We reviewed the literature from January 2011 to August 2019 to analyze the underlying mechanisms, prognostic factors, MODS scoring systems, organ systems dysfunctions, and the management of MODS. We used the search engines PubMed, MEDLINE, Scopus, and Google Scholar with the keywords "multiple organ dysfunction syndrome," "intensive care units," "multiorgan failure," "MODS scoring system," and "MODS management." The initial search yielded 3550 abstracts, of which 91 articles were relevant to the scope of the present article. A better understanding of a disease course will help differentiate the signs of an intense inflammatory response from the early onset of sepsis and minimize the inappropriate use of medications. This, in turn, will promote organtargeted therapy and prevent occurrence and progression of MODS.