A primigravida at 32 weeks of gestation presented to us with eclampsia and Posterior Reversible Encephalopathy Syndrome (PRES) along with SARS COVID-19 pneumonia. Immediate termination of pregnancy was done under general anaesthesia and patient was electively ventilated in view of increased oxygen requirements. Further therapy using magnesium sulphate, antihypertensives, steroids and convalescent plasma was carried out. The condition of the patient steadily improved leading to her extubation on the 4th postoperative day and subsequent discharge on the 8th day of admission.

Background The Clinical Frailty Scale (CFS) is frequently used to measure frailty in critically ill adults. There is wide variation in the approach to analysing the relationship between the CFS score and mortality after admission to the ICU. This study aimed to evaluate the influence of modelling approach on the association between the CFS score and short-term mortality and quantify the prognostic value of frailty in this context. Methods We analysed data from two multicentre prospective cohort studies which enrolled intensive care unit patients ≥ 80 years old in 26 countries. The primary outcome was mortality within 30-days from admission to the ICU. Logistic regression models for both ICU and 30-day mortality included the CFS score as either a categorical, continuous or dichotomous variable and were adjusted for patient’s age, sex, reason for admission to the ICU, and admission Sequential Organ Failure Assessment score. Results The median age in the sample of 7487 consecutive patients was 84 years (IQR 81–87). The highest fraction of new prognostic information from frailty in the context of 30-day mortality was observed when the CFS score was treated as either a categorical variable using all original levels of frailty or a nonlinear continuous variable and was equal to 9% using these modelling approaches (p < 0.001). The relationship between the CFS score and mortality was nonlinear (p < 0.01). Conclusion Knowledge about a patient’s frailty status adds a substantial amount of new prognostic information at the moment of admission to the ICU. Arbitrary simplification of the CFS score into fewer groups than originally intended leads to a loss of information and should be avoided. Trial registration NCT03134807 (VIP1), NCT03370692 (VIP2)

Background: As the second wave of COVID-19 is gripping the globe, liver transplant centers are increasingly receiving patients with a recent recovery from SARS-CoV-2 infection. Despite full clinical recovery, unexpected, unusual and potentially life-threatening complications in these patients are increasingly being recognized, one such patient is discussed here. By far, this is the first ever reported case of a COVID-19 recovered recipient developing recurrent thrombotic complications, which led us to change our routine anticoagulation protocols.Case presentation: We performed liver transplantation on a 51-year-old gentleman with decompensated liver disease 23-days after recovering from SARS-CoV-2 infection. At the time of surgery, he had no known sequalae of COVID-19. His routine preoperative work-up showed no underlying coagulation disorders. He underwent living related liver transplant (modified right lobe graft) during which, despite massive blood loss and a prolonged anhepatic phase, his thromboelastographic (TEG) parameters persistently revealed hypercoagulability. He received anti-coagulation according to our standard protocol which is based on aPTT ratio and INR. After a brief uneventful early post-operative period, he developed hepatic arterial thrombosis (HAT) on the 14th postoperative day, and again after 4 days, both of which required surgical intervention. He was eventually discharged with normal graft function but was soon readmitted with recurrent HAT and necrosis of anterior sector with cholangiolar abscesses, further leading to graft loss, necessitating re-transplantation, from which he could not recover due to a rejection resistant to all conventional measures.Conclusions: There is emerging evidence that patients following SARS-CoV-2 infection tend to be hypercoagulable. We believe that this hyper coagulability might have played a significant role in the development of hepatic arterial thrombosis and eventual graft loss in this patient. This highlights the importance of revisiting anticoagulation protocols in liver transplant recipients recovered from COVID-19 and base them on TEG rather than routine parameters such as INR and aPTT, which are routinely deranged in such patients.

As the second wave of COVID-19 disease is gripping the globe, liver transplant centers are increasingly receiving patients recovered from SARS-CoV-2 infection in recent few weeks. Unexpected complications in these patients are increasingly being recognized. We performed liver transplantation on a 51-year-old gentleman with decompensated liver disease 23 days after recovering from a mild SARS-CoV-2 infection. Surprisingly, despite massive blood loss and a prolonged anhepatic phase, his thromboelastographic (TEG) parameters persistently revealed hypercoagulability. After a brief uneventful early post-operative period, he developed hepatic arterial thrombosis on the 14th post-operative day, and again after 4 days, both of which required surgical intervention. Following discharge, the artery was thrombosed again which was only picked up when he developed a cholangiolar abscess, leading to graft loss necessitating re-transplantation. There is a lot of evidence suggesting that patients with SARS-CoV-2 infection tend to be hypercoagulable. We believe that this hypercoagulability might have played a significant role in the development of hepatic arterial thrombosis and eventual graft loss in this patient. This highlights the importance of revisiting anticoagulation protocols in liver transplant recipients recovered from COVID-19 and base them on TEG rather than routine parameters such as INR and APTT, which are routinely deranged in such patients.

Background Acute kidney injury (AKI) is commonly associated with increased postoperative morbidity in liver transplant (LT) recipients. The aim of this study was to identify the role of renal resistive index (RRI) in predicting AKI and to study the factors associated with AKI in LT recipients. Patients and methods We performed a single‐center, prospective study, including adult living donor LT recipients at our center between January 2018 and September 2019 with no preoperative renal dysfunction. RRI was calculated on ultrasound doppler once preoperatively, and once daily in the postoperative period through postoperative day (POD) six. Patients were grouped into AKI and non‐AKI groups for comparison. Results Fifty patients were included in the study (mean age, 44 years; 20% females). AKI developed in 25 patients (50%). Both groups were similar in baseline characteristics. RRI of ≥ 0.69 on POD 2 predicted AKI (sensitivity 88%; specificity 92%). RRI on the day before AKI diagnosis (0.71 vs. 0.65) and on the day of diagnosis (0.72 vs. 0.65) were significantly increased relative to preoperative baseline. Conclusions Doppler‐derived RRI is a rapid, non‐invasive, and bedside procedure capable of predicting the occurrence of postoperative AKI in LT recipients.