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

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World Journal of Gastroenterology 2023年第9期29卷 1460-1474页

作者： Sahil Kataria Deven Juneja omender singh Institute of Critical Care Medicine Max Super Speciality HospitalNew Delhi 110017India

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.

关键词： Bleeding Chronic liver disease Cirrhosis Thromboelastography Viscoelastic tests

Sodium-glucose Cotransporter-2 Inhibitors induced euglycemic diabetic ketoacidosis:A meta summary of case reports

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World Journal of Diabetes 2023年第8期14卷 1314-1322页

作者： Deven Juneja Prashant Nasa Ravi Jain omender singh Institute of Critical Care Medicine Max Super Speciality HospitalSaketNew Delhi 110017India Department of Critical Care Medicine NMC Specialty HospitalDubai 7832United Arab Emirates Department of Internal Medicine College of Medicine and Health SciencesAl Ain 15551Abu DhabiUnited Arab Emirates Department of Critical Care Medicine Mahatma Gandhi Medical College and HospitalJaipur 302022RajasthanIndia

BACKGROUND Sodium-glucose cotransporter-2 inhibitors(SGLT2i)are commonly prescribed to manage patients with diabetes mellitus.These agents may rarely lead to the development of euglycemic diabetic ketoacidosis(EDKA),which may complicate the disease course of these patients.AIM To analyze the demographic profile,predisposing factors,symptomology,clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series.METHODS We performed a systematic search of PubMed,Science Direct,Google Scholar and Reference Citation Analysis databases using the terms“canagliflozin”OR“empagliflozin”OR“dapagliflozin”OR“SGLT2 inhibitors”OR“Sodium-glucose cotransporter-2”AND“euglycemia”OR“euglycemic diabetic ketoacidosis”OR“metabolic acidosis”.The inclusion criteria were:(1)Case reports or case series with individual patient details;and(2)Reported EDKA secondary to SGLT2i.Furthermore,the data were filtered from the literature published in the English language and on adults(>18 years).We excluded:(1)Conference abstracts;and(2)Case reports or series which did not have individual biochemical data.All the case reports and case series were evaluated.The data extracted included patient demographics,clinical symptomatology,clinical interventions,intensive care unit course,need for organ support and outcomes.RESULTS Overall,108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included.The majority of patients were females(54.4%,n=92),and the commonly reported symptoms were gastrointestinal(nausea/vomiting 65.1%,abdominal pain 37.3%)and respiratory(breathlessness 30.8%).One hundred and forty-nine(88.2%)patients had underlying type II diabetes,and the most commonly involved SGLT-2 inhibitor reported was empagliflozin(46.8%).A triggering factor was reported in most patients(78.7%),the commonest being acute severe infection(37.9%),which included patients with sepsis,coronavirus disease 2019,other viral illnesses,and acute pa

关键词： Canagliflozin Empagliflozin Euglycemia Diabetes mellitus Diabetic ketoacidosis Sodium-glucose cotransporter-2 inhibitors Sodium-glucose cotransporter-2

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

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World Journal of Clinical Cases 2023年第16期11卷 3765-3779页

作者： Sahil Kataria omender singh Deven Juneja Amit Goel Madhura Bhide Devraj Yadav Institute of Critical Care Medicine Max Super Speciality HospitalSaketNew Delhi 110017India

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

关键词： Capillary refill time Central venous saturation Hypoperfusion Lactate Mortality PCO_(2)gap Septic shock

Upper extremity deep vein thrombosis:An intensivist’s perspective

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World Journal of Critical Care Medicine 2023年第3期12卷 130-138页

作者： omender singh Deven Juneja Institute of Critical Care Medicine Max Super Speciality HospitalSaketNew Delhi 110017India

Upper extremity deep vein thrombosis(UEDVT)is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients.Increasing cancer incidence,prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT.It is also associated with high rates of complications like pulmonary embolism,post-thrombotic syndrome and recurrent thrombosis.Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT;hence,a high suspicion index is required for diagnosis.Doppler ultrasound is commonly employed for diagnosis,but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients.Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies.Anticoagulant therapy alone is sufficient in most patients,and thrombolysis and surgical decompression is seldom indicated.The outcome depends on the cause and underlying comorbidities.

关键词： Catheter associated deep vein thrombosis Pacemaker associated deep vein thrombosis Paget-von Schröetter syndrome Thoracic outlet syndrome Upper extremity deep vein thrombosis

Air leaks in COVID-19

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World Journal of Virology 2022年第4期11卷 176-185页

作者： Deven Juneja Sahil Kataria omender singh Institute of Critical Care Medicine Max Super Speciality HospitalSaketNew Delhi 110017India

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.

关键词： Air leak COVID-19 Pneumothorax Pneumomediastinum SARS-CoV-2 Subcutaneous emphysema

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

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World Journal of Virology 2022年第5期11卷 300-309页

作者： Deven Juneja Anish Gupta Sahil Kataria omender singh Institute of Critical Care Medicine Max Super Speciality HospitalSaketNew Delhi 110017India

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.

关键词： Ascorbic acid COVID-19 SARS-CoV-2 Vitamin C

Bedside ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure in nontraumatic neurocritically ill patients

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World Journal of Critical Care Medicine 2023年第1期12卷 10-17页

作者： Madhura Bhide omender singh Deven Juneja Amit Goel Institute of Critical Care Medicine Max Super Speciality HospitalSaketNew Delhi 110017India

BACKGROUND Delay in treatment of raised intracranial pressure(ICP)leads to poor clinical outcomes.Optic nerve sheath diameter(ONSD)by ultrasonography(US-ONSD)has shown good accuracy in traumatic brain injury and neurosurgical patients to diagnose raised ICP.However,there is a dearth of data in neuro-medical intensive care unit(ICU)where the spectrum of disease is different.AIM To validate the diagnostic accuracy of ONSD in non-traumatic neuro-critically ill patients.METHODS We prospectively enrolled 114 patients who had clinically suspected raised ICP due to non-traumatic causes admitted in neuro-medical ICU.US-ONSD was performed according to ALARA principles.A cut-off more than 5.7 mm was taken as significantly raised.Raised ONSD was corelated with raised ICP on radiological imaging.Clinical history,general and systemic examination findings,SOFA and APACHE 2 score and patient outcomes were recorded.RESULTS There was significant association between raised ONSD and raised ICP on imaging(P<0.001).The sensitivity,specificity,positive and negative predictive value at this cut-off was 77.55%,89.06%,84.44% and 83.82% respectively.The positive and negative likelihood ratio was 7.09 and 0.25.The area under the receiver operating characteristic curves was 0.844.Using Youden’s index the best cut off value for ONSD was 5.75 mm.Raised ONSD was associated with lower age(P=0.007),poorer Glasgow Coma Scale(P=0.009)and greater need for surgical intervention(P=0.006)whereas no statistically significant association was found between raised ONSD and SOFA score,APACHE II score or ICU mortality.Our limitations were that it was a single centre study and we did not perform serial measurements or ONSD pre-and post-treatment or procedures for raised ICP.CONCLUSION ONSD can be used as a screening a test to detect raised ICP in a medical ICU and as a trigger to initiate further management of raised ICP.ONSD can be beneficial in ruling out a diagnosis in a low-prevalence population and rule in a diagnosis in a high-prevalence population.

关键词： Intracranial pressure Intensive care unit Neuro-critical care Optic nerve sheath diameter Ultrasonography

Scoring systems in critically ill: Which one to use in cancer patients?

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World Journal of Critical Care Medicine 2022年第6期11卷 364-374页

作者： Anisha Beniwal Deven Juneja omender singh Amit Goel Akhilesh singh Hemant Kumar Beniwal Institute of Critical Care Medicine Max Super Speciality HospitalSaketNew Delhi 110017India Department of Neurosurgery Dr SNMC HospitalJodhpur 342001India

BACKGROUND Scoring systems have not been evaluated in oncology patients.We aimed to assess the performance of Acute Physiology and Chronic Health Evaluation(APACHE)II,APACHE III,APACHE IV,Simplified Acute Physiology Score(SAPS)II,SAPS III,Mortality Probability Model(MPM)II0 and Sequential Organ Failure Assessment(SOFA)score in critically ill oncology patients.AIM To compare the efficacy of seven commonly employed scoring systems to predict outcomes of critically ill cancer patients.METHODS We conducted a retrospective analysis of 400 consecutive cancer patients admitted in the medical intensive care unit over a two-year period.Primary outcome was hospital mortality and the secondary outcome measure was comparison of various scoring systems in predicting hospital mortality.RESULTS In our study,the overall intensive care unit and hospital mortality was 43.5%and 57.8%,respectively.All of the seven tested scores underestimated mortality.The mortality as predicted by MPM II0 predicted death rate(PDR)was nearest to the actual mortality followed by that predicted by APACHE II,with a standardized mortality rate(SMR)of 1.305 and 1.547,respectively.The best calibration was shown by the APACHE III score(χ^(2)=4.704,P=0.788).On the other hand,SOFA score(χ^(2)=15.966,P=0.025)had the worst calibration,although the difference was not statistically significant.All of the seven scores had acceptable discrimination with good efficacy however,SAPS III PDR and MPM II0 PDR(AUROC=0.762),had a better performance as compared to others.The correlation between the different scoring systems was significant(P<0.001).CONCLUSION All the severity scores were tested under-predicted mortality in the present study.As the difference in efficacy and performance was not statistically significant,the choice of scoring system used may depend on the ease of use and local preferences.

关键词： APACHE score Intensive care unit Medical oncology SOFA score Scoring systems Severity of illness index

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

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World Journal of Meta-Analysis 2023年第7期11卷 340-350页

作者： Sahil Kataria Deven Juneja omender singh Department of Critical Care Medicine Holy Family HospitalNew Delhi 110025India Department of Critical Care Medicine Max Super Speciality HospitalNew Delhi 110017India

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.

关键词： FibroScan Intensive care unit Liver dysfunction Liver stiffness Transient elastography