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Hepatopancreaticobiliary (HPB) surgery is major upper abdominal surgery with considerable risk of pulmonary complications related to postoperative pain. While epidural analgesia remains an effective analgesic technique for upper abdominal surgery, HPB surgery poses challenges to its use due to coagulopathy. Erector spinae plane (ESP) blocks are a promising alternative to epidurals. Injection of local anesthetic deep to the erector spinae muscle plane and placement of a catheter for prolonged effect provide both somatic and visceral analgesia for both thoracic and abdominal surgery. We describe a series of 3 cases that illustrate the efficacy of ESP blocks after major HPB surgery.

Background:The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of conditions characterized by proximal muscle weakness. Autoantibodies are identified in more than 80% of patients with polymyositis (PM) or dermatomyositis (DM). Some are also found in other connective tissue diseases (CTD), while others are more specific to IIM. Thus, they are classified into two categories named myositis associated antibodies (MAA) and myositis specific antibodies (MSA). MSA have been reported as being 90% specific for IIM while MAA are found in up to 50% of myositis patients. 1Objectives:The aim of the study was to evaluate the myositis antibody prevalence and to assess the associations of these antibodies with clinical manifestations, final diagnosis, medication received and outcomes.Methods:A retrospective chart review study was conducted at St. James’s Hospital from 2015-2020. All positive myositis panels were obtained. The MAA evaluated were PMScl (100/75), U1snRNP, Ku and Ro52, while MSA were Mi2a, Mi2b, TIF1, MDA5, NXP2, SAE1, Jo-1, SRP, PL-7, PL-12, EJ and OJ.Results:We identified 52 patients who were positive for one or more MSA/MAAs. The mean age was 58.9 years, the majority were female (65.3%).The most prevalent MAA was anti-Ro52 (29/52) followed by anti-PMScl 100/75 (7/52), anti-Ku and anti-U1RNP were seen in (3/52) each. The prevalence of MSA were (4/52) for anti-PL12 and (3/52) for anti-SAE1 followed by (2/52) for each of anti-Mi2b, anti-NXP2, anti-Jo, anti-SRP, anti-PL7, anti-EJ and anti-OJ while only (1/52) for anti-MDA5. The most common observed clinical phenotypes in our cohort were arthralgia (20/52), ILD (18/52) and cutaneous manifestations (15/52). Less than a quarter of the studied population had arthritis (8/52), myositis (7/52), raynauds (7/52) and malignancy (4/52). Various diagnosis were allocated for these patients, while only eight cases were diagnosed with dermatomyositis. Medication received and the final outcome for those with strong positive MSA were summarized in table1.Conclusion:IIM was the final diagnosis in only 15% of positive myositis panels and the presence of antisynthetase antibodies didn’t necessarily indicate the presence of antisynthetase syndrome thus signifying low specificity in our cohort.References:[1]Ghirardello A, Borella E, Beggio M, Franceschini F, Fredi M, Doria A. Myositis autoantibodies and clinical phenotypes. Auto Immun Highlights. 2014;5(3):69-75. Published 2014 Aug 23.IIMMAAMSAILDArthritisArthralgiaMyositisRaynaudsCutanousMalignancyFinal diagnosisTreatment OutcomeNXP2++DermatomyositisMyasthenia gravisPrednisolone + IVIG Remission/stable+Azathioprine +pyridostigmineMDA5++Amyopathic dermatomyositisPrednisolone + MTX Remission/stableSAE1++DermatomyositisPrednisolone + MTX Remission/stableILDPL12+IPFNo medication Remission/stableRo52PL12+IPFPrednisolone DiedSAE1/OJ+IPFNo medication Lost follow-upEJ+IPFNo medication Remission/stablePL12+Interstitial pneumonia with autoimmune feature (IPAF)Under evaluation Remission/stableRo52PL7+++++Anti-synthetase syndromePrednisolone +cyclophosphamide Remission/stablethen azathioprinePL7++Anti-synthetase syndromePrednisolone + Remission/stableRituximabJO-1++Anti-synthetase syndromeNo medication Remission/stableRo52JO-1+Anti-synthetase syndromePrednisolone + MMF Remission/stablethen rituximabCTDSAE1/SRP++Progressive pulmonary fibrosis (post COVID, ARDS and recurrent aspiration)Esophageal Ca T1N2M0 s/p esophagectomyAntibiotics +supportive care Remission/stableSRP++Limited cutaneous sclerodermaNifedipine Remission/stableRo52EJ+SjogrenHCQ Remission/stableOthersU1snRNP/ Ro52OJ++++MCTDAutoimmune hepatitisPrednisolone+ Remission/stableAzathioprine+HCQNXP2+Polymyalgia rheumaticaPrednisolone Remission/stablekuMi2b+large vessel vasculitisPrednisolone+ Remission/stableTocilizumabPL12+++PsAMTX Remission/stableMi2bPBCUrsodeoxycholic acid Remission/stableDisclosure of Interests:None declared

Patient: Male, 43 Final Diagnosis: Hepatopulmonary syndrome Symptoms: Dyspnea Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Unusual clinical course Background: Hepatopulmonary syndrome (HPS) is a pulmonary complication of advanced liver disease with dyspnea as the predominant presenting symptom. The diagnosis of HPS can often be missed due to its nonspecific presentation and the presence of other comorbidities. Case Report: We present an interesting case of an obese 43-year-old man who presented with progressive, unexplained hypoxemia and shortness of breath in the absence of any symptoms or signs of chronic liver disease. After extensive cardiopulmonary investigations, he was diagnosed with severe HPS as a result of non-alcoholic steatohepatitis (NASH) leading to cirrhosis. He subsequently underwent successful hepatic transplantation and continues to improve at 12-month follow-up. Conclusions: HPS needs to be considered in the differential diagnosis of unexplained hypoxemia. Given its poor prognosis, early diagnosis is warranted and treatment with liver transplantation is the preferred choice.

Background. The presence of patent foramen ovale (PFO) has been linked to many illness, including cryptogenic stroke, transient ischemic attack, migraine, platypnea-orthodeoxia syndrome and decompression sickness in scuba divers. Transesophageal echocardiography is the gold standard technique for the visualization of atrial septal anatomy, but it is a secondary level exam, not always available, with additional associated costs and not completely free from procedural risks. Standard transthoracic echocardiography (TTE) has a too low sensitivity for PFO screening. Purpose. The aim of the study was to assess the role of TTE associated with agitated saline contrast injection (contrast-TTE) as a gatekeeper for the identification of PFO in a large cohort of patients undergoing selection for percutaneous closure. Methods. A total of 200 patients undergoing a diagnostic work-up for the identification of PFO was imaged by contrast-TTE at rest and after provocative maneuvers (PM: Valsalva in all cases). Contrast TTE was graded from 0 to 4 on the bases of bubbles counting (0: no bubbles; 1: 30 bubbles; 4: complete LV opacification). PFO closure was performed after a consensual clinical decision by the cardiologist and the neurologist taking into account comprehensive imaging, clinical evaluation and thrombophilia screening. PFO closure was always monitored by intracardiac echocardiography. Results. At baseline contrast TTE was positive (≥2) in 34 patients (17%) while contrast TTE with PM was positive in 94 cases (47%). 27 out of 200 patients (14%) had an interatrial septal aneurysms. PFO closure was performed in 34 cases (17%). All of these had severe right-to-left shunting (≥3) at contrast TTE and 9 cases had also an interatrial septal aneurysms. The procedure was aborted in only 1 patient due to a complex defect anatomy. Conclusion. Contrast TTE with PM may be not only considered an accurate tool for the detection of PFO but may be also inserted in the diagnostic work- up as a primary gatekeeper for percutaneous closure. Severe shunting at contrast TTE influences final decision making in a large cohort of cases undergoing screening for PFO closure.

Near-infrared spectrophotometry assesses cerebral oxygen saturation (ScO2) based on the absorption spectra of oxygenated and deoxygenated hemoglobin, and the translucency of biological tissue, in the near-infrared band. There is increasing evidence that optimising cerebral oxygenation, guided by ScO2, is associated with improved outcomes in a variety of high risk surgical settings. However, in patients with liver disease, bilirubin can potentially render cerebral oximetry inaccurate. As a result, measurement of cerebral oxygen saturation is rarely undertaken in patients undergoing hepatobiliary surgery. We prospectively measured baseline and intraoperative cerebral oxygen saturation in patients undergoing major pancreatic surgery. Indices including bilirubin, sodium, platelets and maximum amplitude on thromboelastography were associated with low baseline ScO2. However, those patients with low ScO2 (≤51%) maintained a similar trend in cerebral oximetry values both at induction and intraoperatively to those with a normal ScO2. We conclude that the pattern of cerebral oximetry is similar in patients undergoing major pancreatic surgery regardless of their underlying liver dysfunction. Therefore, cerebral oximetry may have a role in monitoring neurological function in this high risk group of patients.

Objective Open abdominal aortic aneurysm (AAA) repair is associated with a high risk of renal injury with few known strategies demonstrating a reduction in this risk. Remote ischemic preconditioning (RIPC) has been identified as having the potential to minimize organ injury following major vascular surgery. This trial investigated the potential for RIPC to attenuate renal and myocardial injury in patients undergoing elective open AAA repair. Design Prospective, randomized double-blinded control trial. Setting Tertiary referral hospital. Participants Sixty-two patients undergoing elective open AAA repair. Intervention RIPC was achieved via three 5-minute cycles of upper limb ischemia using a blood pressure cuff or control (sham cuff). Measurements Primary outcome was the occurrence of renal injury, as measured by an increase in creatinine during the first 4 postoperative days. Secondary outcomes included urinary neutrophil-gelatinase-associated lipocalin (NGAL), occurrence of acute kidney injury (AKI), occurrence of myocardial injury as defined by troponin rise, incidence of postoperative complications, and mortality. There was no difference in postoperative creatinine levels, NGAL levels, or the occurrence of AKI between the groups at any postoperative time point. Similarly, there was no difference in the occurrence of myocardial injury or mortality. Of note, 6 patients in the RIPC group, while no patient in the control group, experienced postoperative complications that required repeat surgical laparotomy, potentially masking any renoprotective effects of RIPC. Conclusion RIPC did not reduce the risk of postoperative renal failure or myocardial injury in patients undergoing open AAA repair. The authors’ results do not support the introduction of this technique to routine clinical practice.

Background Intensive care unit (ICU) re-admission identifies a high-risk group in terms of hospital mortality, length of stay, and resource utilization. Only hospital and ICU mortality are well described in the literature on critically ill patients needing re-admission. Methods With ethical committee approval, from a prospectively collected database of all admissions to a combined medical and surgical ICU from January 1 to December 31, 2004, we identified all ICU re-admissions from within the hospital and analysed the factors associated with increased incidence of re-admission. At 2–3 yr after discharge, we evaluated the functional outcome of the surviving re-admitted patients as Glasgow Outcome Score (GOS) and Karnofsky index and identified determinants of both mortality and good functional outcome. Results Seventy-three (7.4%) of the 1061 patients who survived their first ICU stay were re-admitted during the study period. Of the 73 re-admitted patients, 14 died in ICU, 17 died later in the same hospital stay, and 10 died in the interim. Thus, 32 (43.8%) were alive 2–3 yr after discharge. The median [IQR] GOS of the survivors was 4 (see Mackle and colleagues in One year outcome of intensive care patients with decompensated alcoholic liver disease. Br J Anaesth 2006; 97: 496–8 and Jennett and Bond in Assessment of outcome after severe brain damage. A practical scale. Lancet 1975; 1: 480–4) and their median Karnofsky index was 70 [70–90] at follow-up. The only independent predictors of favourable functional outcome at follow-up were lower Apache 2 scores on both first ICU admission and on re-admission. Conclusions Although the ICU, hospital, and subsequent mortalities are high in patients after ICU re-admission, most survivors at 2–3 yr had by then made a good functional recovery and were independent.

Background Any landmark-based regional anaesthetic technique raises two important issues. The first is the accuracy of placement of the needle and thus the local anaesthetic in a ‘blind' technique and the second is the potential for damage to adjacent structures. We designed a prospective, blinded study in an adult general surgical population to evaluate with ultrasound the placement of the needle tip and local anaesthetic during transversus abdominis plane (TAP) blocks using the landmark-based ‘double-pop' technique. Methods After induction of general anaesthesia, 36 adult patients had a TAP block performed bilaterally using the standard landmark-based technique. Ultrasonography was then used to record the actual needle position and local anaesthetic spread. The anaesthetist performing the block was blinded to the ultrasound images. Results Thirty-six adult patients were included in the study, which was terminated early due to what was considered an unacceptably high level of peritoneal needle placements. The needle tip and local anaesthetic spread were in the correct plane in only 17 (23.6%) of the injections. In the remaining 55 (76.4%), the needle was in the subcutaneous tissue 1 (1.38%), external oblique muscle 1 (1.38%), plane between the external and internal oblique muscles 5 (6.94%), internal oblique muscle 26 (36.1%), transversus abdominis muscle 9 (12.5%), and peritoneum 13 (18%). Conclusions We conclude that the needle and local anaesthetic placement using the standard landmark-based approach to the TAP block is inaccurate, and the incidence of peritoneal placement is unacceptably high.

Background An increasing number of patients with alcoholic liver disease (ALD) are being referred for critical care support, but limited information is available on their short- and medium-term outcomes. This study aimed to determine mortality rates, identify optimal predictors of prognosis, and determine the appropriate time to apply these predictors in patients with ALD admitted to intensive care unit (ICU). Methods In this retrospective study, patients admitted to ICU between 2009 and 2012 with a primary diagnosis of ALD were included. Survival was calculated using the Kaplan-Meier method, risk factors for death determined by logistic regression analysis, and discriminative capacity of models using receiver operating characteristic curves. Results Of 170 patients admitted with liver disease, 62 met the inclusion criteria. Survival rates in the ICU, in hospital, and at 6 months were 40.3% (95% confidence interval [CI], 30.7%-49.9%), 35.5% (95% CI, 25.35%-45.65%), and 29% (95% CI, 19.4%-38.6%), respectively. Multiple linear regression analysis of day 1 variables produced an equation with Sequential Organ Failure Assessment score and lactate as significant predictors of mortality; this model had an area under the receiver operating characteristic curve of 0.93. A score greater than 12 in this model correlated with a mortality of more than 80% at all time points and was more accurate than any other score examined. Conclusion Patients admitted to ICU with ALD have a very high inhospital mortality. A combination of the established Sequential Organ Failure Assessment score and lactate provided the most accurate predictor of outcome on day of admission and at all subsequent time points.

A simple test that could guide successful cessation of continuous renal replacement therapy (CRRT) in critically ill patients would be clinically useful. This study aimed to investigate whether a 2-hour creatinine clearance (2h-CrCl) measurement could more accurately predict successful cessation of CRRT than serum creatinine or urine output alone.This retrospective study identified all patients admitted to a university teaching hospital intensive care unit who received CRRT and had a 2h-CrCl measurement performed in the 12 hours preceding CRRT cessation. The ability of 2h-CrCl to predict successful discontinuation of CRRT was compared to other renal indices.Of 85 patients who had 2h-CrCl performed prior to CRRT cessation 53 (62.4%)(success group) remained dialysis free 7 days after CRRT cessation. 2h-CrCl was a better predictor of remaining CRRT free at day 7 (OR, 1.108 [1.05-1.17] per 1 mL/min increase in 2 hours CrCl, P.001) than urine output, serum creatinine or age. A 2h-CrCl value of 23 mL/min had a sensitivity, specificity and positive predictive value for remaining CRRT free at day 7 of 75.5%, 84.4%, and 88.8%, respectively.2h-CrCl may be a useful measurement to help guide discontinuation from CRRT.

Acute kidney injury (AKI) is a common problem in critically ill patients, with a reported incidence of 1 to 25% and a poor prognosis. Although optimal dosing of renal replacement therapy (RRT) is relatively well understood, appropriate timing of commencing and ceasing RRT in patients with AKI has been under debate for a long time. From the viewpoint of an early renal support strategy, the goal of early RRT is to maintain solute clearance and fluid balance to prevent subsequent multiorgan damage, while waiting for the recovery of renal function. It has previously been noted that 2-hourly creatinine clearance accurately reflects the more cumbersome 24-hour value [1]. The aim of the present study was to evaluate whether routine measurement of creatinine clearance (CrCl) could help to predict when to cease dialysis, and determine what value for CrCl best predicted remaining dialysis-free in critically ill patients receiving CRRT.

Rates of readmission to the ICU are often cited as controversial indices of quality of intensive care, adequacy of follow-up and as guides to resource allocation. Nonetheless there are few data on the long-term functional outcome of ICU recidivists: we set out to study this.