Acute Liver Research Articles

S2617 LCHAD-Negative Acute Fatty Liver of Pregnancy: A Rare, Catastrophic Disorder with Unknown Risk of Recurrence

S2617 LCHAD-Negative Acute Fatty Liver of Pregnancy: A Rare, Catastrophic Disorder with Unknown Risk of Recurrence

Current conception about the pathogenesis and intensive care of severe COVID-19 (review)

The aim of the research. The aim of this work was to summarize the scientific literature data on the pathogenesis and intensive care of the severe course of coronavirus infection.
 Materials and methods. Databases such as PubMed, Google Scholar, Scopus and Web Of Science 2020-2021 were used for literary searches.
 Results. An intense inflammatory response against the SARS-CoV-2 virus in COVID-19 patients causes a cytokine storm and hypercoagulability with the development of acute respiratory distress syndrome (ARDS) and multiple organ failure. Approximately 17 % to 35 % of hospitalized patients with COVID-19 are treated in the intensive care unit, most often due to hypoxemic respiratory failure and the development of ARDS, and between 29 % and 91 % of patients in intensive care units require invasive ventilation.
 In addition to acute respiratory failure, hospitalized patients may have acute renal failure (9 %), liver dysfunction (19 %), coagulation disorders (10 %–25 %), and septic shock (6 %).
 More than 75 % of hospitalized patients require additional oxygen therapy. Respiratory support could vary from the need for oxygen supplementation through a nasal catheter to invasive ventilation or extracorporeal membrane oxygenation in patients with the most severe ARDS.
 The uncontrolled inflammation and coagulation seen in COVID-19 patients is similar to multifactorial ARDS, where a plethora of evidence has demonstrated the ability of long-term corticosteroid therapy (CST) to reduce inflammation-coagulation-fibroproliferation and accelerate recovery.
 With regard to the assessment of the benefits of therapeutic anticoagulation in patients with elevated D-dimer, the question has not yet been finally resolved, and research devoted to this is still ongoing.
 Conclusions. The approaches to respiratory, anticoagulant, anti-inflammatory therapy in critically ill patients with COVID-19 require further research to determine the optimal treatment tactics

Лабораторная диагностика патологии печени у беременных

В статье представлены данные об особенностях течения гепатитов А, В, С, D, Е у беременных женщин, методы скрининговой верификации патологии печени, клинико-лабораторные признаки внепеченочных проявлений хронических вирусных гепатитов В и С. В представленной работе определены диагностически значимые лабораторные показатели гемохроматоза, аутоиммунного гепатита, внутрипеченочного холестаза беременных, неудержимой рвоты беременных, острой жировой дистрофии печени, HELLP-синдрома. В статье представлены современные методы проведения лабораторной безпункционной биопсии печени для оценки фиброза, активности гепатита и стеатоза печени. Лекция предназначена для врачей-инфекционистов, акушеров-гинекологов, гастроэнтерологов, семейных врачей.

COVID-19 and thrombosis

The first case of novel corona virus disease (COVID-19) was reported in China and undoubtedly today this disease has rapidly crossed borders, infecting people throughout the world. There are heaps of complications related to COVID-19 namely acute respiratory failure, acute liver and kidney injury, bacterial and fungal infections, and septic shock. Vascular thrombosis is another burden that COVID-19 is pilling on to the load of its complications. Venous thromboembolism namely deep vein thrombosis and pulmonary thromboembolism; pulmonary microvasculature thrombosis and systemic arterial thromboembolic events like limb ischemia, myocardial ischemia/infarction and cerebrovascular thrombosis are being increasingly reported in COVID-19 patients.

The Differences of T-Regulator Cells, Alanine Aminotransferase Serum and Aspartate Aminotranspherase Between Hepatitis B Chronic Patients with and without Liver Fibrosis

Background: Hepatitis B is acute or chronic liver inflammation caused by hepatitis B viral and can progress to hepatic chirrosis or liver cancer. Chronic hepatitis B has a high risk for liver fibrosis. Chronic inflammation and liver fibrosis are interrelated processes. This study aimed to determine the differences in T-regulator cells, Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) between chronic hepatitis B patients with and without liver fibrosis.Method: This study used a cross-sectional method for patients diagnosed with chronic hepatitis B in the Inpatient and Outpatient Department of the Internal Medicine Department DR. M. Djamil Padang and other hospitals in Padang city for 6 months. Samples were selected by consecutive sampling according to inclusion and exclusion criteria. Liver fibrosis is identified by fibroscan. Data were analyzed by SPSS 21.0.Results: thirty-two patients were diagnosed with chronic hepatitis B and 50% had liver fibrosis. The levels of T-regulator cells in chronic hepatitis B patients without liver fibrosis were 2.08% and liver fibrosis 2.25%, but this difference was not statistically significant (p 0.05). Mean ALT levels in the group without fibrosis were 19 IU/L (7IU/L-71IU/L) and liver fibrosis 61 IU / L (13IU/L-625IU/L). The mean AST level in the group without fibrosis were 15.5 IU/L (10IU/L-32IU/L) and liver fibrosis 35.5 IU/L (10IU/L-476IU/L). The difference between ALT and AST in the two groups was significant (p 0.05). Hepatitis B patients with liver fibrosis had higher ALT and AST levels than without fibrosis.Conclusion: There were differences levels of T-regulator cells in the two groups, but it was not statistically significant. ALT and AST levels were higher in the liver fibrosis group and statistically significant.

Liver transplantation in pediatric patients under 15 kg; duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses

Back ground. Liver transplantation is an effective treatment for acute or chronic liver failure and metabolic liver disease, which is associated with good quality of life in over 80 percent of recipients. We aimed to evaluate outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in pediatric liver transplant recipients below 15-kg.Methods. In this single-center retrospective study, all children less than 15 kg that have undergone liver transplantation at Nemazee Hospital Organ Transplant Center affiliated with Shiraz University of Medical Sciences from 2009 till 2019, were enrolled. Over a 10-yr period, 181 liver transplants were performed in patients with two techniques including duct-to-duct (Group 1) vs. Roux-en-Y hepaticojejunostomy biliary anastomoses (Group 2). All data was collected from patients’ medical records, operative notes, and post-transplant follow up notes. Data was analyzed by SPSS software V21.Results. Overall, 94 patients had duct to duct anastomosis (group 1) and 87 cases had Roux-en-Y hepaticojejunostomy (group 2). The mean age of the patients was 2.46 ± 1.5. The most common underlying diseases was biliary atresia (32%). The most prevalent complication after the surgery was infection in both groups. cardiopulmonary problems were significantly higher in group 2 (24.1% vs 4.3%) (p < 0.001). The rate of infection was significantly higher in group 2, as well.Conclusion. Our study showed a relatively high rate of post-operative infection which was the most among patients who had undergone Roux-en-Y hepaticojejunostomy. Except from biliary complications which were mostly observed in DD group, other complications were more common among Roux-en-Y group.

Analysis of clinical characteristics and genetic testing in patients with acute fatty liver of pregnancy: a retrospective study

BackgroundAcute fatty liver of pregnancy (AFLP) is an acute, rare and potentially lethal disease typically occurring in the third trimester of pregnancy. So far, there is no effective means of prevention. Therefore, in this study, we retrospectively analyzed the clinical features of AFLP patients for a better understanding. Meanwhile, for the first time, the genetic background associated with the onset of AFLP was discussed by high-throughput sequencing, hoping to provide evidence for genetic counseling and prenatal diagnosis of AFLP.MethodsThirteen AFLP patients admitted to our hospital and other hospital from March 2012 to February 2020 were selected. Clinical data about general condition, laboratory test, liver biopsy and the prognosis of mother and fetus were collected for retrospective analysis. In addition, the peripheral blood of five patients with AFLP and one newborn infant of his mother with AFLP was sequenced with whole-exome sequencing and gene mutation was analyzed by bioinformatics methods.ResultsThe initial symptoms of AFLP varied differently, with jaundice (9/13, 69%), fatigue (8/13, 62%) and nausea and vomiting (6/13, 46%) being the most common. Moreover, the main maternal complications were coagulopathy (13/13, 100%), followed by acute renal dysfunction (10/13, 77%). Raised serum bilirubin, transaminases and uric acid were found in all patients (100%), hypoglycemia was found in six patients (46%) and fatty liver on ultrasound was seen in five patients (5/12, 42%). One (7%) maternal death occurred and all neonates survived delivery. In addition, to our surprise, whole-exome sequencing showed that no gene mutation in related enzymes involved in fatty acid metabolism was noted in the pregnant women and children receiving genetic testing.ConclusionsEarly visit, early detection, early termination of pregnancy and multidisciplinary comprehensive treatment are the key factors to improve the prognosis of AFLP patients and their newborn infants. Furthermore, although limited size of study, to our knowledge, this report is the first to present the lack of common mutation involved in fatty acid oxidation in Chinese patients with AFLP via whole-exome sequencing. Thus, further studies are needed with larger and more varied samples to validate the conclusion.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review.

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

Care of the Patient With Abnormal Liver Test Results.

Liver tests are commonly performed in primary care and may signal the presence of acute or chronic liver disease. Abnormal results are defined by standardized rather than individual laboratory thresholds and must be interpreted in the context of a patient's history and examination. The pattern and severity of liver injury may provide clues about the cause of disease and should guide diagnostic evaluation with serologic testing and liver imaging. A systematic, stepwise approach to the evaluation and management of abnormal liver test results is recommended to optimize high-value care.

A Case Series of Fatal Fulminant Hepatic Failure in Postpartum Females Secondary to Acute Fatty Liver of Pregnancy

A Case Series of Fatal Fulminant Hepatic Failure in Postpartum Females Secondary to Acute Fatty Liver of Pregnancy

Moving Forward to New Trends in Liver Transplantation

Liver transplantation (LT) is the only recognized effective treatment for end-stage liver disease (ESLD) and acute fulminant liver failure [...]

Disseminated intravascular coagulation associated organ failure in obstetric patients admitted to intensive care units: a multicenter study in China

We aimed to determine disseminated intravascular coagulation (DIC)-associated organ failure and underlying diseases based on data from three ICU wards in tertiary hospitals in China from 2008 to 2016. The diagnosis of DIC was confirmed by an International Society of Thrombosis and Hemostasis score greater than or equal to 5. The maternal outcomes included the changes in organ function 24 h after ICU admission. The durations of hospital stay and ICU stay were recorded as secondary outcomes. Among 297 ICU admissions (median Sequential Organ Failure Assessment score, 4) for obstetric diseases, there were 87 DIC cases, with an estimated DIC incidence of 87 per 87,580 deliveries. Postpartum hemorrhage was the leading disease associated with DIC (71, 81.6%), followed by hypertensive disorders (27, 31.0%), sepsis (15, 17.2%), acute fatty liver of pregnancy (11, 12.6%) and amniotic fluid embolism (10, 11.5%). Compared with patients without DIC, those with DIC had higher rates of multiple organ dysfunction syndrome/death (27.6% vs 4.8%, p = 0.000), organ failure (36.8% vs 24.3%, p = 0.029), among which organ failure included acute renal failure (32.2% vs 10.0%, p = 0.000), respiratory failure (16.1% vs 8.6%, p = 0.057), disturbance of consciousness (12.6% vs 2.4%, p = 0.000) and DIC group also had higher rates of massive transfusion (52.9% vs 21.9%, p = 0.000), hysterectomy (32.2% vs 15.7%, p = 0.001), longer ICU (4 days vs 2 days, p = 0.000) and hospital stays (14 days vs 11 days, p = 0.005). DIC and amniotic fluid embolism were independent risk factors for organ failure in patients admitted to the ICU. Postpartum hemorrhage was the leading cause of DIC associated organ failure in obstetrics admitted to the ICU. The control of obstetric bleeding in a timely manner may improve obstetric prognoses.

Acute Fatty Liver of Pregnancy.

Hepatology Department, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France Guidelines for Letters. Letters posing a question or challenge to an article appearing in Obstetrics & Gynecology should be submitted within 8 weeks of the article’s publication online. Letters received after 8 weeks will rarely be considered. Letters should not exceed 350 words, including signatures and 5 references. Letters will be published at the discretion of the Editor. The Editor may send the letter to the authors of the original paper so their comments may be published simultaneously. The Editor reserves the right to edit and shorten letters. Letters should be submitted using the Obstetrics & Gynecology online submission and review system, Editorial Manager (http://ong.edmgr.com). Financial Disclosure The authors did not report any potential conflicts of interest.

Bioactivity of naringin and related mechanisms.

Naringin is a flavonoid compound, which can be used to treat or prevent various diseases, such as obesity, heart disease, diabetes, and metabolic syndrome. The medicinal value of naringin is mainly reflected in its antioxidant and anti-inflammatory functions, and it has a protective effect on pathophysiology. Furthermore, naringin has shown potential to become an alternative as traditional anti-inflammatory drug, because it exerts less side effects than chemically synthesized compounds. In this paper, we are reviewing the specific molecular mechanisms of anti-inflammatory and antioxidant properties of naringin. We analyze and discuss the primary role of naringin in the treatment of diseases such as acute and chronic liver injury, lung injury, bowel disease, and neurodegenerative diseases. Besides, the bactericidal effect of naringin is also reviewed.

Cardiac manifestations of the coronavirus disease-19: a review of pathogenesis, clinical manifestations, diagnosis, and treatment.

The coronavirus disease-19 (COVID-19), first appearing in Wuhan, China, and later declared as a pandemic, has caused serious morbidity and mortality worldwide. Severe cases usually present with acute respiratory distress syndrome (ARDS), pneumonia, acute kidney injury (AKI), liver damage, or septic shock. However, with recent advances in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) research, the virus´s effect on cardiac tissues has become evident. Reportedly, an increased number of COVID-19 patients manifested serious cardiac complications such as heart failure, increased troponin, and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), cardiomyopathies, and myocarditis. These cardiac complications initially present as chest tightness, chest pain, and heart palpitations. Diagnostic investigations such as telemetry, electrocardiogram (ECG), cardiac biomarkers (troponin, NT-proBNP), and inflammatory markers (D-dimer, fibrinogen, PT, PTT), must be performed according to the patient´s condition. The best available options for treatment are the provision of supportive care, anti-viral therapy, hemodynamic monitoring, IL-6 blockers, statins, thrombolytic, and anti-hypertensive drugs. Cardiovascular disease (CVD) healthcare workers should be well-informed about the evolving research regarding COVID-19 and approach as a multi-disciplinary team to devise effective strategies for challenging situations to reduce cardiac complications.

A Case Report on Mephentermine Induced Psychosis with Acute Liver & Kidney Injury

Background: Mephentermine is a sympathomimetic agent derived from methamphetamine. It is a commonly used drug for the treatment of hypotension during anaesthesia. Its abuse has markedly increased especially in the young population due to its stimulant properties and ability to boost performance in competitive sports or bodybuilding. Very few cases of Mephentermine dependence with or without psychosis have been reported from India and worldwide. Case Description: A 24-year-old male presented with a sudden onset of behavioural abnormalities a few hours following the use of Mephentermine. He was very agitated and restless. On physical examination, tachycardia, elevated BP and bilaterally dilated pupils were found. His symptoms remitted within a few hours of using Injection Haloperidol 10 mg with Lorazepam 4 mg once. He was found to have grossly deranged liver and kidney function tests. There was no past and family history of any psychiatric illness. No past history of any physical illness. Conclusion: No previous report of mephentermine induced psychosis with acute kidney and liver injury has been reported in the literature. Cases such as this may be common among the general public. Long term follow-up is required to know the course and outcome in such unusual cases.

MULTI ORGAN DYSFUNCTION IN A POST-COVID PATIENT - A CASE REPORT

The typical presentation of SARS-CoV-2 VIRUS infection is pulmonary involvement causing COVID 19 pneumonia. Although in recent times cases are being reported from different hospital that shows multi organ involvement due to COVID-19 virus. Acute pancreatitis is one of the main presentations .here is a case report that shows not only acute pancreatitis but elevated liver enzymes causing non alcoholic liver disease along with gallbladder involvement in a patient who was presented as COVID 19 negative.

Liver Complications after Allogeneic Hematopoietic Stem Cell Transplantation: Descriptive Longitudinal Study Using Liver Parameters Monitoring and Their Impact on Transplantation Outcomes Using a Prediction Score

The indications and use of allogeneic hematopoietic cell transplantation (allo-HCT) have rapidly grown and become a standard procedure for many patients with hematological malignancies. Although the overall outcomes have significantly improved over the past two decades, liver-related complications are often encountered after transplantation and are a large component of the associated overall morbidity and mortality and account for up to 15% of transplantation-related mortality (TRM). The differential diagnosis include drug toxicity, infectious complications, graft versus host disease (GVHD), sinusoidal obstruction syndrome (SOS), metabolic conditions, and development of neoplastic conditions. The principal aim of our study was to evaluate in a longitudinal analysis, the variation of different liver biological parameters, their correlation with liver complications and their impact on transplantation outcomes. Our secondary objective was to establish a score that allows the prediction of liver complications in order to avoid severe evolution.We included in this study 417 patients who underwent allo-HCT between years 2009 and 2015. There were 245 (59%) males and 172 (41%) females, with a median age at allo-HCT of 49 years (18-69). The major diagnoses were acute leukemias (N=210, 50%), myelodysplastic syndromes (N=64, 15%) and lymphomas (N=60, 14%). Before transplantation, 256 (61%) patients were in complete remission or in “chronic” phase. HC donors were identical siblings in 35% of cases, matched unrelated in 28%, mismatched unrelated in 33% and haploidentical in 4%. Cells source was peripheral blood in 47%, bone marrow in 39% and cord blood in 14% of patients. Conditioning regimens were of reduced intensity in 52% and myeloablative in 48% of transplantations.A liver screening including bilirubin, alkaline phosphatase, transaminases (ASAT, ALAT) and GGT, was performed twice a week during the first 4 weeks after transplantation, once a week during the second and third months and once a month until the end of the first year, then, once every 3 months during the second year. In case of abnormalities, further analyses were performed including ultrasound and liver biopsy when needed.Acute GVHD grade ≥II was observed in 160 patients [81 grade II: 19 gut, 61 skin and 1 Liver; 79 grade III-IV: 14 gut grade III & 21 grade IV, 33 skin grade III & 4 grade IV, 3 liver grade III & 4 grade IV]. The cumulative incidence of acute GVHD grade II-IV and grade III-IV at 3 months were 26% [22-31] and 14% [11-18] respectively. Chronic GVHD developed in 133 patients (75 limited & 53 extensive) with a cumulative incidence of 15% (12-19) and 31% (26-35) at 1 & 2 years respectively.Liver complications observed until 3 months after allo-HCT included 10 GVHD (2 grade I, 1 grade II, 3 grade III and 4 grade IV), 14 SOS, 158 EBV reactivations, 158 CMV reactivations and 101 HHV6 reactivations. The median time of SOS occurrence was 15 days [11-25] with cumulative incidence of 3.12% at 3 months. The median time of EBV, CMV and HHV6 reactivations was 49 days, 43 days and 41 days respectively with a cumulative incidence of 37%, 33% and 20% respectively at 3 months. Over 60 000 results for biological parameters were analyzed and allowed the establishment of a scoring system for each parameter able to predict the occurrence of liver complications notably SOS and acute GVHD. The score took into consideration a parameter value over the normal, its percentage compared to normal value and the way of its evolution over time or its kinetics. The analysis showed significant impact of bilirubin score on SOS (HR=3.9 [2.3-6.4], p<0.001); bilirubin and GGT scores on acute gut GVHD (HR= 11.5 [4.1-32.4], p<0.001 & HR= 2.4 [1.03-5.8], p=0.042 respectively); bilirubin, ASAT and ALAT scores on acute liver GVHD.After a median follow-up of 14 months, 215 (52%) patients are alive and 202 (48%) died with 110 (26%) from TRM causes and 92 (22%) from relapse. Median survival was 30 [23-37] months with a survival probability at 3 years of 46% [41-52]. The median PFS was 14 [11-20] months with a PFS probability 3 years of 38% [33-43]. In multivariate analysis, ASAT and bilirubin high scores have significantly worsened OS.In conclusion, we showed a very interesting scoring system that can predict liver complications by monitoring the biological parameters which could prevent morbidity and consequent mortality and leads to optimal allo-HCT outcomes. DisclosuresNicolini:BMS: Consultancy, Honoraria, Speakers Bureau; Incyte Biosciences: Honoraria, Speakers Bureau; ARIAD: Honoraria, Speakers Bureau; Novartis: Consultancy, Honoraria, Research Funding, Speakers Bureau.

MORPHOLOGICAL SUBSTANTIATION OF DIFFERENTIAL DIAGNOSIS OF JAUNDICE SYNDROME IN PATIENTS WITH ACUTE CHOLECYSTITIS

Summary. Objective. To improve the results of treatment of patients with jaundice syndrome by improving the diagnosis quality of obstructive jaundice and improving methods of surgical treatment.&#x0D; Materials and methods. The results of diagnosis and treatment of 272 patients with benign jaundice syndrome admitted to the clinic on an urgent basis from 2010 to 2020 were analyzed. Differential diagnosis of the nature of jaundice and its cause was carried out according to ultrasound and ERCP.&#x0D; Results. Based on the revealed differences in the data of histostructures of the gallbladder wall in patients with acute cholecystitis, hepatitis, and liver cirrhosis, we determined ultrasound criteria for the differential diagnosis of mechanical and parenchymal jaundice. Ultrasound made it possible in a short time to determine the obstructive or parenchymal nature of jaundice by the nature of changes in the liver and the wall of the gallbladder. (Patent № 134089 dated April 25, 2019).In cases of mechanical origin of jaundice, ultrasound data helped to establish its cause and determine the tactics of treatment.&#x0D; Conclusion. 1. Morphological changes in the wall of the gallbladder in patients with acute cholecystitis, hepatitis and liver cirrhosis are qualitatively different from each other. 2. The combination of changes in the liver and the wall of the gallbladder revealed by ultrasound examination makes it possible to differentiate parenchymal and obstructive jaundice with a high degree of reliability.

Hypoglycemia in a Surgical Intensive Care Unit.

Glycemic control is an important aspect of critical care because derangements are associated with morbidity and mortality. Patients at highest risk for hypoglycemia in the surgical intensive care unit (SICU) are incompletely described by existing literature. Our objective was to delineate this high-risk patient population in our SICU. In this single-center, retrospective, observational study, SICU patients admitted from June 1, 2019 to July 31, 2020 with ≥1 episode of hypoglycemia (blood glucose <60mg/dL) were included. There were 41 hypoglycemic events in 27 patients, comprising an incidence of 1.5% among SICU patients. The most common admission diagnoses were cirrhosis (n = 13, 48%), polytrauma (n = 12, 44%), multisystem organ failure (n = 11, 41%), diabetes mellitus (n = 9, 33%), and soft tissue infection (n = 8, 30%). Four high-risk populations were identified: patients in multisystem organ failure (MSOF) (n = 11, 41%); those who were nil per os (NPO) (n = 10, 37%); patients receiving long acting subcutaneous insulin, for example, Lantus (n = 3, 11%); and those on continuous intravenous insulin infusions (n = 3, 11%). After multi-disciplinary peer review, most hypoglycemic events (n = 16, 59%) were deemed iatrogenic. Hypoglycemia is rare in surgical critical care. When it does occur, patients are typically in MSOF, NPO, on long acting subcutaneous insulin or continuous insulin infusions, have soft tissue infections, or have acute or chronic liver failure. Increased vigilance with frequent blood glucose monitoring in these high-risk patients may reduce the risk of hypoglycemia in the SICU.