Hypotensive Shock Research Articles

Severe drug eruption after antibiotic administration in patients receiving immune checkpoint inhibitors: A monocentric case series

AbstractImmune checkpoint inhibitor (ICI) therapy is often associated with cutaneous immune‐related adverse events (irAEs). Drug eruptions stemming from concomitantly or consecutively administered medications are also frequent and tend to be severe. We herein present three cases of severe drug eruption in patients receiving antibiotics during ICI therapy in which hypotensive shock occurring during antibiotic administration was followed by generalized erythema and prolonged organ damage. Three patients received tazobactam/piperacillin (TAZ/PIPC) for an infection during ICI treatment. A high fever developed in all the patients after a switch was made to other antibiotics (Figures 2–4). Since no skin rash was observed at fever onset, a flare‐up of the infection was suspected, and TAZ/PIPC administration was resumed. Thereafter, the patients suddenly experienced hypotensive shock and respiratory failure requiring ICU management for generalized erythema and organ damage. Since anaphylaxis caused by TAZ/PIPC is rare, the patients’ clinical findings might be a manifestation of synergistic, complementary, immunomodulatory effects of ICI. In patients receiving ICI therapy, a fever occurring during antibiotic administration may indicate the onset of an immune hypersensitivity reaction to the drug. Resumption of antibiotic administration, especially TAZ/PIPC, during such a period may trigger an excessive inflammatory response, leading to an anaphylaxis‐like reaction and organ damage.

Adverse reactions to antiarrhythmic drugs

There are various types of adverse reactions to antiarrhythmic drugs (AADs). Proarrhythmia, which refers to an exacerbation of the preexisting arrhythmia or occurrence of a new arrhythmia, may occur under the therapeutic concentration of an AAD. Bradyarrhythmia is the most common type of proarrhythmia due to AADs, and prior myocardial infarction and old age are known risk factors. Atrial flutter with 1:1 atrioventricular conduction usually occurs during rhythm control of atrial fibrillation with class IC AADs. QT prolongation due to AADs, mainly class III AADs, elevates the risk of torsade de pointes by triggered activity due to early afterdepolarization. The addition of clinical factors that promote QT prolongation, such as hypokalemia, hypomagnesemia, female sex, and bradycardia, increases the risk of developing torsade de pointes. Proarrhythmic monomorphic ventricular tachycardia usually occurs as a result of slow conduction and disparity of refractoriness due to class IC AADs. In patients with preexisting left ventricular systolic dysfunction or structural heart disease, the risk of hypotension or cardiogenic shock caused by negative inotropic effects due to AADs should be considered. To prevent these major adverse reactions to AADs, we need to understand the electrophysiologic properties of AADs in detail. Furthermore, the risk of proarrhythmia could be heightened by interplay with clinical factors, such as electrolyte unbalances, heart rate, and hepatic/renal or myocardial dysfunction. Sufficient awareness about drug-drug interactions, which may affect the metabolism of AADs, will improve patient safety during the management of arrhythmia.

Evaluation of Multisystem Inflammatory Syndrome in Children (MIS-C) Cases: Clinical Features and Cardiologic Findings

Multisystem inflammatory syndrome in children (MIS-C) is a disease characterized by hyperinflammation with multiple organ involvement that develops after COVID-19 infection. In this study, we aimed to assess the clinical characteristics, cardiologic findings, and cardiac magnetic resonance imaging (MRI) results of MIS-C cases. Thirty-one patients diagnosed with MIS-C and followed up at Eskişehir Osmangazi University Faculty of Medicine between November 2020 and June 2022 were included in the study. The clinical and epidemiological characteristics and cardiological findings of the patients were evaluated retrospectively. Fifty-five percent of the thirty-one MIS-C cases were male and the mean age was 102 (2-204) months. The most common presenting symptoms were fever, rash, conjunctivitis, and abdominal pain. The most common cardiac findings were left ventricular dysfunction, myocarditis, and coronary artery dilatation. Cardiac MRI was performed in 4 of 8 patients with severe cardiac findings, and no pathologic findings were noted. Patients who had hypotension and cardiogenic shock at the time of admission, who had high ferritin, D-dimer, and IL -6 levels on laboratory tests, and who had left ventricular dysfunction and myocarditis on echocardiography had a high rate of ICU admission. The degree of cardiovascular involvement is important in following up on the disease and determining the treatment regimen. All patients should be monitored by echocardiography and cardiac MRI for possible permanent cardiac damage. Although MIS-C can lead to serious, life-threatening cardiac manifestations, early diagnosis and appropriate treatment can prevent the risk of serious cardiac morbidity and mortality in the future.

A Curious Case of Hypervitaminosis D-related Hypercalcemia

Abstract Hypercalcemia can manifest with various symptoms and poses diagnostic challenges due to its multifactorial etiology. This case highlights a 74-year-old patient with hypercalcemia of complex origin. The patient had a history of chronic liver disease, chronic kidney disease, and a previous episode of hypercalcemia associated with excessive oral Vitamin D intake. On admission, the patient presented with disorientation and increased drowsiness. Further evaluation revealed persistently high serum calcium levels, low parathyroid hormone levels, and elevated levels of Vitamin D. Investigations identified a duodenal nodule with multiple lymph node enlargement, suggesting a malignancy as the underlying cause. Other potential factors contributing to hypercalcemia, such as a granulomatous disease, prolonged immobilization, and a deactivating mutation of the 24-hydroxylase gene (CYP24A1), were also considered. Despite interventions, including hemodialysis and denosumab administration, the patient’s condition deteriorated due to sepsis and hypotensive shock, ultimately resulting in death. This case emphasizes the importance of considering multiple etiologies in cases of hypercalcemia in the elderly and the challenges involved in managing severe symptomatic hypercalcemia. Medical professionals must employ sound clinical reasoning and comprehensive diagnostic approaches to accurately identify and address the underlying cause. Hemodialysis may be necessary in refractory cases to achieve serum calcium normalization.

“Mephentermine Abuse” an Age-old Concern with New Challenges: Review of Literature with Case Series

Abstract Mephentermine, a stimulant drug, is used as vasoconstrictor to maintain blood pressure in hypotensive states and shock, but due to its stimulant effects on the central nervous system, it has also been used for performance enhancement by athletes. Here, we discuss three cases where the patients had used mephentermine to enhance their work performance. Case 1: A male in his 30’s, presented with palpitation, headache, and hypertension after 1 year of use of mephentermine which he had started using with the purpose of increasing his work performance. Case 2: A 22-year-old male presented with depressive symptoms following a 3-year history of use of mephentermine after being suggested by peers to enhance performance at gym. Case 3: A 22-year-old male with 2-year history of mephentermine, presented with withdrawal symptoms, after being introduced to mephentermine by his peers to improve physical performance and difficulty stopping its use on his own. It was found that the purpose of mephentermine abuse in all three discussed cases was to enhance performance, either at sports or workplace, which gradually lead to physical or mental complications or withdrawal symptoms. It thus seems imperative to create awareness about the harmful and addictive effects of mephentermine to masses, and simultaneously limiting its easy availability.

A case study of hypotensive shock induced by metoprolol combined with propafenone hydrochloride

A case study of hypotensive shock induced by metoprolol combined with propafenone hydrochloride

Snake bite-induced leukoencephalopathy

A 15-year-old girl was brought to the casualty with an alleged history of snake bite on the ring finger of her right hand (A), which showed digital ischemia. The patient was unresponsive with severe respiratory distress. Patient management was done through elective intubation, cardiopulmonary Resuscitation with lifesaving emergency medications were given followed by anti snake venom. Finger reconstructive plastic surgery was performed after the patient became stable. On MR Imaging of the brain, the T2 and FLAIR sequences (B) showed symmetrical hyperintensities in the bilateral caudate nucleus and lentiform nucleus. Diffusion-weighted imaging (C) shows the cortical rim of restriction in bilateral subcortical white matter and corpus callosum and with corresponding low signal intensity on A.D.C. There was no associated haemorrhage. Neurological signs and symptoms after a venomous snake bite are most often related to venom´s toxic effects, which are anticoagulant/procoagulant activity or neurotoxicity. Some patients develop neurological complications related to cerebral hypoxia, which are related to hypotensive shock that may accompany some snake bite envenomation. Neuromuscular disorders, that is, damage to the peripheral nervous system, occur most often after the bite of elapids but may also occur following a viper bite. The effect of neurotoxins may start from minutes to a few hours after the inoculation of venom, causing weakness related to a blockage of synaptic transmission at either presynaptic or postsynaptic levels.

Gastric ultrasound-assisted diagnosis of undifferentiated shock

Rationale: Peptic ulcer disease and variceal bleeding are two of the most common causes of gastrointestinal (GI) bleeding. GI bleeding can present with symptoms of hemodynamic instability such as tachycardia and shock. Patient’s Concern: A 33-year-old man with confusion and hypotension (blood pressure: 70/40 mmHg and pulse rate: 140/min) was brought by emergency medical services from home to the emergency department without any companion. The patient was in undifferentiated shock. His hypotension was assessed with inferior vena cava (IVC) size and collapsibility, and rapid ultrasound in shock and hypotension (RUSH) protocol was used to investigate the cause of his shock. Following the RUSH protocol when scanning the IVC, parts of the stomach were seen in its vicinity and suspended heterogeneous particles were observed in the fluid. After seeing these particles, we suspected GI bleeding. Diagnosis: Endoscopy confirmed GI bleeding. Interventions: After placing an orogastric tube and suction, about 2 L of coffee-ground fluid with clots was removed. We started intravenous proton-pump inhibitors 80 mg bolus, followed by a continuous infusion of 8 mg/h. The patient received about 2 L of normal saline and 2 units of packed red blood cells to correct his hypotension. Outcomes: After being admitted to the GI ward and treated for three days, the patient was discharged from the hospital with a hemoglobin level of 11 g/dL and continued to have an outpatient follow-up at the clinic. Lessons: The use of gastric ultrasound in conjunction with the RUSH protocol can help to diagnose undifferentiated hypotensive shock. The components of the RUSH exam are the heart (H), IVC (I), Morrison’s/FAST abdominal views with the aorta (MA), and pulmonary and pipes scanning (P), and can be memorized with the mnemonic: HI-MAP. We would like to introduce a new mnemonic: Hi-MAPS, adding stomach (S) to the RUSH protocol in undifferentiated hypotension and shock to evaluate upper GI bleeding.

Abstract 12100: Catastrophic Large Post-Stemi Inferoseptum Ventricular Septal Rupture With Left-to-Right Shunt and an Inferoseptum Pulsatile Pseudoaneurysm

Case Presentation: 49-year-old male without known cardiovascular history presented with three days of atypical chest discomfort. 12-lead EKG revealed ST-segment elevations in II-III-aVF and depression in V1 suggestive of an acute infero-posterior MI (A), Troponin T at 6.85 ng/mL. Following administration of DAPT and heparinization, emergent coronary angiography proved a dominant RCA with proximal 60% and middle 100% occlusion (B), 80% focal stenosis at mid-LAD and 70% focal stenosis at prox-LCx (C). PCI with intra-aortic balloon pump support was performed, with two DES deployed in the RCA, use of a trans-venous pacemaker was required for complete AV block, and two defibrillations required for ventricular fibrillation. Following further hemodynamic compromise unexplained by his hemodynamic parameters, TEE was performed, demonstrating a large mid/distal infero-septum ventricular septal defect with left to right shunt (D, E and F), as well as a basal/mid infero-septum large pseudo-aneurysm (PSA) cavity (contained rupture) (G: low velocity Doppler flow from LV to PSA cavity, H and I show intact septum). The patient continued to decompensate requiring escalation to temporary mechanical circulatory support with VA-ECMO. Heart transplantation was initially considered, family decided to withdraw care due to multi-organ failure and poor prognosis Discussion: Due to widespread availability of primary percutaneous coronary intervention with early reperfusion, mechanical complications post MI are less common in current days. Following transmural MI, persistent hypotension and cardiogenic shock should alert for complications such as VSD or PSA. While VSD may be amenable to percutaneous or surgical closure, PSA is associated with very high mortality even if surgery is attempted. Given the presence of both a VSD and PSA, mechanical support with VA-ECMO allowed us to support the patient for several days as a bridge to decision regarding heart transplantation

Analysis of child with pyruvate carboxylase deficiency type A due to compound heterozygous variants of the PC gene

To analyze the clinical features and genetic basis for a child with pyruvate carboxylase deficiency type A (PCD-A). Clinical data of the child was retrospectively analyzed. The child and his parents were subjected to trio-whole exome sequencing, and candidate variants were verified by bioinformatics analysis. The child was admitted due to fever with vomiting and disturbance of consciousness. His clinical manifestations included severe decompensated acidosis, hypotension and intractable shock. Cranial MRI showed abnormal signal in the brain, and chest X-ray revealed acute pulmonary edema. DNA sequencing revealed that he has harbored compound heterozygous variants of the PC gene, namely c.182T>C (p.I61T) and c.2581G>A (p.V861M), which were respectively inherited from his father and mother. Neither variant was retrievable in the ClinVar and HGMD databases. Through prediction of protein structure, both variants may affect the functional stability of the protein product. The compound heterozygous variants of the PC gene probably underlay the PCD-A in this child. Combined with the clinical features, the child was ultimately diagnosed as PCD-A. Above finding has enriched the spectrum of PC gene variation underlying PCD-A.

Markers of endothelial glycocalyx dysfunction in Clarkson disease

BackgroundClarkson disease (monoclonal gammopathy-associated idiopathic systemic capillary leak syndrome, ISCLS) is a rare idiopathic condition marked by transient, relapsing-remitting episodes of systemic microvascular hyper-permeability, which liberates plasma fluid and macromolecules into the peripheral tissues. This pathology manifests clinically as the abrupt onset of hypotensive shock, hemoconcentration, and hypoalbuminemia.MethodsWe analysed endothelial glycocalyx (eGCX)-related markers in plasma from patients with ISCLS during acute disease flares and convalescence by ELISA and comprehensive proteomic profiling. We evaluated eGCX-related components and gene expression in cultured endothelial cells using RNA-sequencing, real-time PCR, and fluorescence staining.ResultsSerum levels of eGCX-related core components including hyaluronic acid (HA) and the core proteoglycan soluble syndecan-1 (sCD138) were elevated at baseline and during acute ISCLS flares. Serial measurements demonstrated that sCD138 levels peaked during the recovery (post-leak) phase of the illness. Proteomic analysis of matched acute and convalescent ISCLS plasma revealed increased abundance of eGCX-related proteins, including glypicans, thrombospondin-1 (TSP-1), and eGCX-degrading enzymes in acute compared to remission plasma. Abundance of endothelial cell damage markers did not differ in acute and baseline plasma. Expression of several eGCX-related genes and surface carbohydrate content in endothelial cells from patients with ISCLS did not differ significantly from that observed in healthy control cells.ConclusionseGCX dysfunction, but not endothelial injury, may contribute to clinical symptoms of acute ISCLS.Serum levels of of eGCX components including sCD138 may be measured during acute episodes of ISCLS to monitor clinical status and therapeutic responses.

Management of Acute Episodes of Clarkson Disease (Monoclonal Gammopathy-Associated Systemic Capillary Leak Syndrome) With Intravenous Immunoglobulins.

Monoclonal gammopathy-associated idiopathic systemic capillary leak syndrome (ISCLS, Clarkson disease) is a rare disorder defined by transient but recurrent bouts of hypotensive shock and anasarca resulting from plasma extravasation. Although prophylactic treatment with high-dose intravenous immunoglobulins (IVIG, 1–2 g/kg/mo) prevents most disease flares, its utility for acute episodes of ISCLS is unclear. Here, we report the results of a retrospective study of subjects with acute ISCLS treated at or near the onset of symptoms with IVIG. We found that administration of IVIG with minimal additional intravenous fluids was safe and associated with rapid clinical improvement. IVIG given close to the onset of ISCLS-related symptoms is associated with a favorable outcome.

Pediatric Emergency Department Sepsis Screening Tool Accuracy During the COVID-19 Pandemic.

Automated sepsis alerts in pediatric emergency departments (EDs) can identify patients at risk for sepsis, allowing for earlier intervention with appropriate therapies. The impact of the COVID-19 pandemic on the performance of pediatric sepsis alerts is unknown. We performed a retrospective cohort study of 59 335 ED visits before the pandemic and 51 990 ED visits during the pandemic in an ED with an automated sepsis alert based on systemic inflammatory response syndrome criteria. The sensitivity, specificity, negative predictive value, and positive predictive value of the sepsis algorithm were compared between the prepandemic and pandemic phases and between COVID-19-negative and COVID-19-positive patients during the pandemic phase. The proportion of ED visits triggering a sepsis alert was 7.0% (n = 4180) before and 6.1% (n = 3199) during the pandemic. The number of sepsis alerts triggered per diagnosed case of hypotensive septic shock was 24 in both periods. There was no difference in the sensitivity (74.1% vs 72.5%), specificity (93.2% vs 94.0%), positive predictive value (4.1% vs 4.1%), or negative predictive value (99.9% vs 99.9%) of the sepsis alerts between these periods. The alerts had a lower sensitivity (60% vs 73.3%) and specificity (87.3% vs 94.2%) for COVID-19-positive versus COVID-19-negative patients. The sepsis alert algorithm evaluated in this study did not result in excess notifications and maintained adequate performance during the COVID-19 pandemic in the pediatric ED setting.

Pathological role of the calcium-sensing receptor in sepsis-induced hypotensive shock: Therapeutic possibilities and unanswered questions.

Sepsis is a life-threatening disease involving multiorgan dysfunction, prompted by an unregulated host response to infection. Shock is a complication of sepsis in which the circulatory and cellular metabolism anomalies are significant enough to raise the risk of death. Calcium dyshomeostasis occurs during sepsis condition due to imbalance between calcium uptake and excessive release induced by inflammatory cytokines. This calcium imbalance can cause activation of calcium-sensing receptors (CaSRs) located on the surface of T cells and thereby promote release of reactive oxygen species (ROS). The elevated ROS and inflammatory cytokines during sepsis condition have been reported to directly damage the endothelial cells, disrupt the barrier functions that might result in leakage of fluids, and inflammatory cells in tissues Moreover, several evidence have revealed that the calcium mediated activation of CaSR could produce systemic vasodilatory response by stimulating the nitric oxide production and opening of calcium-activated potassium channels, while infusion of its antagonist elevated the blood pressure. These evidence indicate that activation of CaSR during sepsis conditions results in release of ROS and inflammatory cytokines, which could produce an endothelial barrier damage, cardiomyocyte apoptosis. These pathological events could produce loss of fluid in tissues and cardiac dysfunction. Further the direct vasodilatory effects of CaSR activation might add to the shock-like condition. Thus, we hereby propose that inhibition of CaSR could suppress the release of ROS, inflammatory mediators, and thereby prevent the endothelial damage, cardiac dysfunction, and maintain systemic vascular tone.

Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock

To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock. This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure. Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.) CONCLUSION: In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

Preparation and characterization of polymyxin B- and histidine-coupled magnetic nanoparticles for purification of biologics from acquired endotoxin contamination

BackgroundEndotoxin is a major process-related impurity that can act as a strong immunostimulant leading to fever and hypotensive shock. Thus, the US FDA and international quality standards strictly direct the biologics manufacturers to control the endotoxin contamination during the purification process. In this work, a developed method for biologics purification from acquired endotoxin contamination is introduced. This is accomplished by the preparation of dextran-coated magnetic nanoparticles using a facile rapid co-precipitation method.ResultsThe resulting magnetic nanoparticles (MNPs) are characterized by dynamic light scattering, transmission electron microscope, Fourier transform infrared spectroscopy, X-ray diffraction, and vibrating sample magnetometry. The dextran-coated magnetic nanoparticles are further coupled to either polymyxin B or histidine to provide a positively charged ligand which enhances the affinity to the negatively charged endotoxin. Both ligands-coupled MNPs are tested for purification efficiency using the chromogenic kinetic assay. The method conditions are optimized using a two-level factorial design to achieve best purification conditions of the contaminated biologics and indicated endotoxin removal percentage 85.12% and maximum adsorption capacity of 38.5 mg/g, for histidine-coupled MNPs.ConclusionsThis developed method is introduced to serve biologics manufacturers to improve their manufacturing processes through providing a simple purifying tool for biologics from acquired endotoxin contamination.Graphical

Long-term sexual dysfunction and hypotensive shock in a patient with a pheochromocytoma

Long-term sexual dysfunction and hypotensive shock in a patient with a pheochromocytoma

A practical guide to the American Society of Anesthesiologists-physical status classification (ASA-PS).

Sir, We read the brief communication, “Reliability of American Society of Anaesthesiologists physical status classification” by Nicola Parenti in the Indian Journal of Anaesthesia with great interest.[1] This systematic review on the reliability of the American Society of Anesthesiologists physical status (ASA-PS) classification showed a wide inter-rated agreement range and suggested a reliability test for the users before using it for general communication. We are of the opinion that the training on ASA-PS classification system should be uniform, up to date and standardised for the results of reliability tests to be commendable. The ASA-PS classification was amended on December 13, 2020 (original approval: October 15, 2014) and it includes the paediatric and obstetric examples.[2] We intend to highlight the salient features of this amendment to improve the understanding and ultimately narrow the gap in the variability of its use. The purpose of the ASA-PS classification is pre-operative assessment and communication of the patients’ medical condition.[2] In combination with other factors like type of surgery and frailty, it can imply perioperative risks and complications, though stand-alone it does not predict perioperative risks.[23] Currently, there is tremendous emphasis on improving the perioperative assessment and ultimately patient outcomes using the ever-advancing healthcare information technology.[45] The definitions and examples of the ASA-PS classification serve as guidelines for the clinicians to follow. The clinicians may develop their institution-specific ASA classification allocation examples incorporated into their health care information technology system. ASA-PS assessment is done during each preanesthetic visit. The final assessment is done after the evaluation of the patient on the day of anaesthesia care by the anaesthesiologist in-charge. The status of the patient at the time of operation is important e.g., presence of rhonchi in a previously well-controlled chronic mild lung disease patient at the time of operation. There are mainly five points to consider for assigning ASA-PS classification. i) presence of co-morbidities like diabetes, hypertension, asthma, and other systemic diseases with or without functional limitations, ii) social habits like smoking, alcohol use iii) whether the patient is pregnant or not, iv) body mass index (BMI) of the patient, and v) whether the operation belongs to the elective or emergency category. For instance, a 21-year-old man who is an active smoker and posted for emergency acute appendicectomy, would be assigned ASA-PS II E in view of being an ‘active smoker’ and emergency nature of the operation. Similarly, a 50-year-old lady who is posted for elective mesh hernioplasty and has well controlled diabetes mellitus on regular medication with no functional limitations, would be assigned ASA-PS II in view of the well-controlled diabetes. Likewise, a 21-year-old primigravida, with a BMI of 50, posted for emergency lower segment caesarean section for cord prolapse with no known medical illness, would be ASA-PS III E, in view of a BMI of 50. Though pregnancy is ASA-PS II, a BMI >39 is ASA-PS III, and thus, a higher class is assigned. Furthermore, a 19-year-old boy with polytrauma with massive intraabdominal bleeding in hypotensive shock, posted for emergency exploratory laparotomy, would be ASA-PS V E because he is not expected to survive without operation. Also, a 50-year-old man who is a known case of chronic obstructive airway disease on regular medication, posted for knee arthroscopy and is currently having rhonchi on examination, would be ASA-PS III in view of the active rhonchi. The ASA-PS classification does not consider the age of the patient, the risk of difficult airway, Mendelson syndrome, intraoperative bleeding, and complexity of the operation. These factors can significantly increase the perioperative morbidity and mortality. There is considerable variation in ASA-PS classification allocation due to the inconsistent understanding of the definitions.[6] Nevertheless, despite its limitations, the ASA-PS classification is widely used in anaesthesia practice. This insight is worth an evaluation for simplified training and teaching of ASA-PS classification. The uniform and standardised teaching can prompt reduction in inter-user variance and improve reliability. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Case Report: Severe Rhabdomyolysis and Multiorgan Failure After ChAdOx1 nCoV-19 Vaccination

BackgroundSevere skeletal muscle damage has been recently reported in patients with SARS-CoV-2 infection and as a rare vaccination complication.Case summaryOn Apr 28, 2021 a 68-year-old man who was previously healthy presented with an extremely severe rhabdomyolysis that occurred nine days following the first dose of SARS-CoV-2 ChAdOx1 nCov-19 vaccination. He had no risk factors, and denied any further assumption of drugs except for fermented red rice, and berberine supplement. The clinical scenario was complicated by a multi organ failure involving bone marrow, liver, lung, and kidney. For the rapid increase of the inflammatory markers, a cytokine storm was suspected and multi-target biologic immunosuppressive therapy was started, consisting of steroids, anakinra, and eculizumab, which was initially successful resulting in close to normal values of creatine phosphokinase after 17 days of treatment. Unfortunately, 48 days after the vaccination an accelerated phase of deterioration, characterized by severe multi-lineage cytopenia, untreatable hypotensive shock, hypoglycemia, and dramatic increase of procalcitonin (PCT), led to patient death.ConclusionPhysicians should be aware that severe and fatal rhabdomyolysis may occur after SARS-CoV2 vaccine administration.

POS-180 OUTCOMES OF CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) INITIATED DURING CRITICAL PHASE OF SEVERE DENGUE IN CHILDREN - SINGLE TERTIARY CARE CENTRE EXPERIENCE FROM SOUTH INDIA

Children with severe dengue experience excessive capillary leak during the critical phase of illness, whereas adults are more prone to severe bleeding. Fluid overload (F.O) is an undesirable event occurring in children with hypotensive shock, requiring large volumes of fluids for shock reversal. Existing literature on critically ill children suggests an F.O cut-off of >10% for intervention. As fluid overload is a major outcome determinant for critically ill children with severe dengue, early initiation of ultrafiltration combined with a target of negative fluid balance in the initial hours of CRRT may improve clinical outcomes.