Vimi Rewari

Background and Aims: Anaesthetic drugs may modulate immunological responses and neutrophil functions. Neutrophil extracellular traps (NETs) are web-like chromatin structures released by activated neutrophils, comprising cell-free deoxyribonucleic acid (cfDNA), histones, and myeloperoxidase (MPO), and contribute to perioperative inflammation. Methods: Seventy patients aged 18–60 years, American Society of Anesthesiologists physical status I–II, undergoing isolated pelvic-acetabular or femoral shaft fracture surgery were randomised to general anaesthesia (GA, n = 35) or regional anaesthesia (RA) (subarachnoid block + epidural; n = 35). Blood samples were collected pre-operatively (T1), intra-operatively (T2), immediately postoperatively (T3), and 24 hours postoperatively (T4). NETs, MPO, and cfDNA were quantified by flow cytometry; histone H3 was quantified by enzyme-linked immunosorbent assay. Patients were followed for 5 days for the development of systemic inflammatory response syndrome (SIRS). Results: NET formation, measured as MPO-cfDNA co-localisation events, was significantly lower in the RA group at T3 and T4 compared with GA [median (interquartile range): 1.72 (1.12–4.1) vs 3.75 (2.8–7.1), P = 0.01; and 1.6 (0.91–4.3) vs 4.24 (3.02–7.8), P = 0.01, respectively]. MPO and histone H3 were also significantly lower in RA at T3 and T4 ( P = 0.01). cfDNA was lower in RA at all time points but without statistical significance. SIRS incidence was significantly lower with RA than GA [7 (20%) vs 16 (45.71%), P = 0.02]. Conclusion: NET formation was significantly lower in the RA group at T3 and T4. A statistically significant correlation was observed between NETs and their key components (MPO and histone H3). A lower incidence of SIRS was observed in the RA group.

Abernethy malformation is a rare congenital portosystemic shunt. A type 2 Abernethy malformation is characterised by a side-to-side shunt between the extrahepatic portal vein and the inferior vena cava. Unmetabolised toxins that bypass hepatic circulation lead to intrapulmonary vascular dilatation. Approximately 3%–12% of portosystemic shunts present with features of hepatopulmonary syndrome, often presenting with progressive hypoxaemia and cyanosis. While endovascular device closure represents the preferred therapeutic approach for most cases, rarely, large or anatomically unfavourable shunts may necessitate surgical ligation that is met with unique anaesthetic challenges surrounding maintenance of adequate oxygenation and haemodynamic stability. We report the noteworthy anaesthetic concerns faced during successful surgical closure of Abernethy shunt in a boy in mid childhood.

Pregnancy can trigger thrombotic microangiopathy (TMA), a condition associated with high morbidity and mortality if treatment is delayed. Timely diagnosis remains challenging, particularly in resource-limited settings due to limited access to specialised assays. We present three cases of maternal TMA admitted to our tertiary care unit located in a developing country. One patient was a known case of hereditary thrombocytopenic purpura. Two other cases presented with TMA post-caesarean section complicated by sepsis and postpartum haemorrhage, respectively, and were diagnosed as pregnancy-associated TMA (likely complement-mediated haemolytic uraemic syndrome). Management decisions were largely based on clinical assessment and a resource-adapted pragmatic approach due to unavailability of specialised assays and eculizumab. All patients were treated with urgent therapeutic plasma exchange. This report emphasises the importance of recognising pregnancy-associated TMAs and tailoring the diagnosing and managing strategies to available resources.

Background and Aims: Sepsis is a common cause of mortality and morbidity in patients admitted to the intensive care unit (ICU), requiring reliable scoring systems to predict outcomes and guide management. Existing traditional scoring systems inadequately capture sepsis complexity. This study developed the Organ Failure Assessment by Ratio (OFAR) score to improve ICU mortality prediction in sepsis patients. Methods: This retrospective observational study was conducted in the ICUs of a tertiary care centre between January 2021 to December 2023 and included adult patients meeting Sepsis-3 criteria. Demographic data, ICU mortality, and six composite variables were collected: bilirubin-to-albumin ratio, pulse oximetric saturation to fraction of inspired oxygen ratio (SpO ₂ /FiO ₂ ratio), shock index, lactate-to-bicarbonate ratio, urea-to-estimated glomerular filtration rate ratio, and cumulative lung ultrasound score-to-platelet ratio. These variables were evaluated to develop and assess the predictive accuracy of OFAR score for ICU mortality. Results: The OFAR score showed greater discriminatory power with an area under the curve (AUC) of 0.78 than quick Sequential Organ Failure Assessment score (qSOFA) (AUC: 0.70) and Acute Physiology and Chronic Health Evaluation score II (APACHE II) (AUC: 0.73) and was comparable to Sequential Organ Failure Assessment score (SOFA) (AUC: 0.76). With a cut-off score of 51.6, OFAR score demonstrated a sensitivity of 73.7% and a specificity of 72.1%. Conclusion: The OFAR score provides higher predictive power for ICU mortality than qSOFA and APACHE II in our study population, raising its potential as an alternative risk stratification scoring system in sepsis patients. Additional external validation is required to confirm its generalisability across diverse populations.

Recent sepsis guidelines recognize myocardial dysfunction as a major contributor to the pathophysiology of septic shock. Sepsis-induced cardiomyopathy (SIC) is typically characterized by acute onset and potential reversibility. The present study aimed to determine the incidence, spectrum, and prognostic significance of myocardial dysfunction in patients with septic shock. We included patients aged 18 years or older diagnosed with septic shock. We excluded those having an improper window for transthoracic echocardiography, known cardiac diseases, pregnancy, or postcardiac arrest status. Eligible patients underwent transthoracic echocardiography within the first 24 hours of intensive care unit (ICU) admission. Echocardiography was used to assess systolic and diastolic function of both ventricles based on the criteria recommended by the American Society of Echocardiography (ASE). For patients with abnormal findings, a follow-up echocardiogram was conducted on day 7 to assess the reversibility of myocardial dysfunction. Myocardial dysfunction was identified in 39 of 71 patients, yielding an incidence of 54.9% (95% CI: 42.6–66.7). Mortality was significantly higher among patients with SIC, with 29 out of 39 succumbing to the condition. Sepsis-induced cardiomyopathy was characterized by various patterns, including left ventricular (LV) systolic dysfunction, LV diastolic dysfunction, and right ventricular (RV) dysfunction, with LV diastolic dysfunction being the most prevalent. Multivariable regression analysis, adjusting for potential confounders, demonstrated that the presence of SIC was an independent predictor of mortality. Sepsis-induced cardiomyopathy was present in over half of the patients with septic shock, with diastolic dysfunction being the predominant subtype. Sepsis-induced cardiomyopathy was associated with increased mortality. Nadaf ZM, Ravikumar RH, Anand RK, Ramachandran R, Trikha A, Wig N, et al. Incidence and Prognostic Impact of Myocardial Dysfunction in Septic Shock: An Observational Cohort Study. Indian J Crit Care Med 2026;30(1):56–61.

Background and Aims: Sepsis-associated acute kidney injury (SA-AKI) significantly contributes to morbidity and mortality. Current biomarkers have limitations, necessitating the exploration of alternative indicators. This study aims to evaluate various urinary electrolyte parameters to predict SA-AKI. Methods: A prospective observational study included 111 sepsis patients within 24 h of admission. Urinary electrolyte samples were collected, and indices were calculated. Patients were monitored for 7 days to assess for acute kidney injury (AKI) according to Kidney Disease Improving Global Outcomes (KDIGO) definition criteria, mortality rates, and the need for renal replacement therapy. Mann-Whitney U test and Chi-squared test were used to analyse continuous and categorical variables, respectively. Receiver-operating characteristic (ROC) curves were constructed to determine to discriminatory ability of various parameters in predicting AKI. Results: Of 111 patients, 42.3% developed AKI, with a mortality rate of 59.5%. When evaluating urinary parameters, the product of urine sodium and urine creatinine exhibited the maximum full form [area under the receiver operating characteristic (AUROC): 0.66; 95%CI: 0.56, 0.77)], and the parameter of fractional excretion of potassium (FeK) exhibited an AUROC of 0.62 (95%CI: 0.51, 0.72). Furthermore, 2-hour excretion of potassium revealed a statistically significant correlation with 2-hour creatinine clearance (r = 0.62, P < 0.001). Logistic regression models, incorporating Sequential Organ Failure Assessment (SOFA) score, FeK, and urine sodium concentration as variables (P = 0.020, 0.044, and 0.033, respectively), achieved an AUROC of 0.751 in predicting AKI. Conclusion: Urine sodium levels and fractional potassium excretion moderately effectively predict AKI in sepsis patients. Urine potassium excretion correlates with glomerular filtration rate.