Approach to thromboelastography-based transfusion in cirrhosis:An alternative perspective on coagulation disorders

Viscoelastic tests,specifically thromboelastography and rotational thromboelastometry,are increasingly being used in the management of postoperative bleeding in surgical intensive care units(ICUs).However,life-threatening bleeds may complicate the clinical course of many patients admitted to medical ICUs,especially those with underlying liver dysfunction.Patients with cirrhosis have multiple coagulation abnormalities that can lead to bleeding or thrombotic complications.Compared to conventional coagulation tests,a comprehensive depiction of the coagulation process and point-of-care availability are advantages favoring these devices,which may aid physicians in making a rapid diagnosis and instituting early interventions.These tests may help predict bleeding and rationalize the use of blood products in these patients.

Capillary leak syndrome:A rare cause of acute respiratory distress syndrome

Capillary leak syndrome(CLS)is a rare clinical syndrome associated with significant morbidity and mortality.Intensive care and supportive therapy constitute the mainstay of the treatment,along with judicious use of crystalloids and colloids such as dextran and starch during the leak phase.The advantages of proning,steroids,and intravenous immunoglobins are worth contemplating in patients with such a presentation.Extracorporeal membrane oxygenation appears to be an excellent strategy to surmount the impediments of the leak and post leak phase of CLS,especially in patients with severe or refractory hypoxemia.

Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients:A comparative observational study

BACKGROUND As per the latest Surviving Sepsis Campaign guidelines,fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization.Nevertheless,raised lactate levels should be interpreted in the clinical context,as there may be other causes of elevated lactate levels.Thus,it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation,and exploring alternative resuscitation targets should be an essential research priority in sepsis.AIM To compare the 28-d mortality in two clinical patterns of septic shock:hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context.METHODS This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context(Group 1,n=95)and patients with hyperlactatemia in a non-hypoperfusion context(Group 2,n=40).Hypoperfusion context was defined by a central venous saturation less than 70%,central venousarterial PCO_(2)gradient[P(cv-a)CO_(2)]≥6 mmHg,and capillary refilling time(CRT)≥4 s.The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h,3 h,and 6 h.All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals.Nominal categorical data were compared using theχ^(2)or Fisher’s exact test.Nonnormally distributed continuous variables were compared using the Mann-Whitney U test.Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate,CRT,and metabolic perfusion parameters to predict the 28-d all-cause mortality.A P value of<0.05 was considered significant.RESULTS Patient demographics,comorbidities,baseline laboratory,vital parameters,source of infection,baseline lactate levels,and lactate clearance at 3 h and 6 h,Sequential Organ Failure scores,need for invasive mechanical ventilation,days on mechanical ventilation,and renal replacement therapy-free days within 28 d,duration of intensive care unit stay,and hospital stay were comparable between the two groups.The stratification of patients into hypoperfusion and nonhypoperfusion context did not result in a significantly different 28-d mortality(24%vs 15%,respectively;P=0.234).However,the patients within the hypoperfusion context with high P(cva)CO_(2)and CRT(P=0.022)at baseline had significantly higher mortality than Group 2.The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P>0.05 at all measured intervals.Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion(18.88±9.04 vs 21.08±8.76;P=0.011).The mean lactate levels and lactate clearance at 3 h and 6 h,CRT,P(cv-a)CO_(2)at 0 h,3 h,and 6 h were found to be associated with 28-d mortality in patients with septic shock,with lactate levels at 6 h having the best predictive value(area under the curve lactate at 6 h:0.845).CONCLUSION Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality,although patients with hypoperfusion displayed a more severe circulatory dysfunction.Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters.Persistently high P(cv-a)CO_(2)(>6 mmHg)or increased CRT(>4 s)at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients.

Air leaks in COVID-19

Coronavirus disease 2019(COVID-19)continues to create havoc and may present with myriad complications involving many organ systems.However,the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected.There is a high incidence of air leaks in patients with COVID-19,leading to acute worsening of clinical condition.The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and underlying lung disease.The exact pathophysiology of air leaks with COVID-19 remains unclear,but multiple factors may play a role in their development.A significant proportion of air leaks may be asymptomatic;hence,a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality.These air leaks may even develop weeks to months after the disease onset,leading to acute deterioration in the post-COVID period.Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.

Role of cerebrospinal fluid lactate in diagnosing meningitis in critically ill patients

BACKGROUND Meningitis is a life-threatening clinical condition associated with high mortality and morbidity.Early diagnosis and specific treatment may improve outcomes.Lack of specific clinical signs or tests make the diagnosis challenging.AIM To assess the efficacy of cerebrospinal fluid(CSF)lactate in diagnosing meningitis in critically ill patients.METHODS A prospective,observational cohort study was carried out in a neuro-medical intensive care unit(ICU)over a 22 mo period.Adult patients,with suspected meningitis admitted in ICU,were serially recruited.Patients who refused consent,those with peripheral sensorineural deficit,or with any contraindication to lumber puncture were excluded.CSF cytology,bio-chemistry,lactates,culture and polymerase chain reaction based meningo-encephalitis panel were evaluated.Patients were divided in two groups based on clinical diagnosis of meningitis.The efficacy of CSF lactate in diagnosing meningitis was evaluated and compared with other tests.RESULTS Seventy-one patients were included and 23 were diagnosed with meningitis.The mean values of CSF total leucocyte count(TLC),proteins and lactates were significantly higher in meningitis group.There was a significant correlation of CSF lactate levels with CSF cultures and meningo-encephalitis panel.CSF lactate(>2.72 mmol/L)showed good accuracy in diagnosing meningitis with an area under the curve of 0.81(95% confidence interval:0.69-0.93),sensitivity of 82.6%,and specificity 72.9%.These values were comparable to those of CSF TLC and protein.Twelve patients with bacterial meningitis had significantly higher CSF lactate(8.9±4.7 mmol/L)than those with non-bacterial meningitis(4.2±3.8 mmol/L),P=0.006.CONCLUSION CSF lactate may be used to aid in our diagnosis of meningitis in ICU patients.CSF lactate(>2.72 mmol/L)showed good accuracy,sensitivity,and specificity in diagnosing meningitis and may also help to differentiate between bacterial and non-bacterial meningitis.

Transient elastography(FibroScan)in critical care:Applications and limitations

FibroScan®is a non-invasive device that assesses the‘hardness’(or stiffness)of the liver via the technique of transient elastography.Because fibrous tissue is harder than normal liver,the degree of hepatic fibrosis can be inferred from the liver hardness.This technique is increasingly being employed to diagnose liver fibrosis,even in critically ill patients.It is now being used not only for diagnosis and staging of liver cirrhosis,but also for outcome prognostication.However,the presence of several confounding factors,especially in critically ill patients,may make interpretation of these results unreliable.Through this review we aim to describe the indications and pitfalls of employing FibroScan in patients admitted to intensive care units.

Role of high dose vitamin C in management of hospitalised COVID-19 patients:A minireview

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)has emerged as one of the most dreadful viruses the mankind has witnessed.It has caused worldwide havoc and wrecked human life.In our quest to find therapeutic options to counter this threat,several drugs have been tried,with varying success.Certain agents like corticosteroids,some anti-virals and immunosuppressive drugs have been found useful in improving clinical outcomes.Vitamin C,a water-soluble vitamin with good safety profile,has been tried to reduce progression and improve outcomes of patients with coronavirus disease 2019(COVID-19).Because of its anti-oxidant and immunomodulatory properties,the role of vitamin C has expanded well beyond the management of scurvy and it is increasingly been employed in the treatment of critically ill patients with sepsis,septic shock,acute pancreatitis and even cancer.However,in spite of many case series,observational studies and even randomised control trials,the role of vitamin C remains ambiguous.In this review,we will be discussing the scientific rationale and the current clinical evidence for using high dose vitamin C in the management of COVID-19 patients.