Background and Aims:Postoperative pain management in open live donor hepatectomy is vital. This study aimed to compare postoperative analgesia provided by intrathecal morphine (ITM) and epidural in open live donor hepatectomy. Material and Methods:Patients were divided into two groups. In the epidural (EPI) group, a bolus dose of 0.125% levobupivacaine (5-6 mL) with 3 mg of preservative-free morphine (diluted in 5 mL of 0.9% normal saline) was injected. In the postoperative period, infusion of levobupivacaine 0.125% at a rate of 5-8 mL/hour was continued for 3 days. In the intrathecal group (ITM), 0.3 mg morphine with 1.5 mL of 0.5% bupivacaine heavy was injected. General anesthesia was administered. Postoperatively, both groups received intravenous fentanyl patient-controlled analgesia. Numerical rating score (NRS) scores were recorded at 0, 2, 4, 12, 24, 36, 48, and 72 hours postoperatively. Data were analyzed using the Student t-test, Mann-Whitney U test, and Fisher's exact test. P < 0.05 was considered significant. Results:A total of 60 patients were enrolled. The postoperative fentanyl consumption for the first 24 hours was significantly higher in the EPI group compared to the ITM group (162.5 mcg vs. 75 mcg, respectively; P = 0.023). NRS up to 12 hours in the postoperative period at rest, on movement, and for shoulder pain were significantly lower in the ITM group compared to the EPI group (P = 0.000). Conclusions:ITM significantly decreased fentanyl consumption in the first 24 hours when compared to the epidural group in patients undergoing open donor hepatectomy.

BACKGROUND:The biotransformation of inhalational anesthetic agents can result in production of hepatotoxic metabolites, which may potentially impair liver regeneration. Thus, isoflurane and propofol may have differential impacts on liver regeneration after donor hepatectomy. STUDY OBJECTIVE:To compare the regeneration liver volume (RgLV) via computed tomography (CT) volumetry on post-operative day (POD) 14 in isoflurane and propofol groups. DESIGN:Randomized controlled pilot trial. PATIENTS:Sixty donors, who underwent donor hepatectomy. INTERVENTIONS:Patients were randomized into isoflurane and propofol group using computer generated random number tables. In isoflurane group, anesthesia was maintained with isoflurane 1-2 % in air‑oxygen mixture. In propofol group, anesthesia was maintained with the target-controlled infusion (TCI) of propofol using a TCI system (Perfusor® Space- B. Braun) at a plasma target concentration of 3-6 μg.ml-1. BIS was recorded in all patients. MEASUREMENTS:Liver CT volumetry was assessed at POD 14. MAIN RESULTS:RgLV on POD14 was comparable in two groups [449.3(170) & 437.8 (177.8) cm3, [Mean Difference (MD) -11.904 95 % Confidence Interval(CI) -101.83, 78.03 respectively; p = 0.79]. CONCLUSION:Administering propofol or isoflurane may not have differential effect on liver regeneration after donor hepatectomy.

Background and Aims: Three phases (dissection, anhepatic, and neohepatic) exist for propofol pharmacokinetics during liver transplantation (LT), resulting in varying cardiac output, volume of distribution, and drug metabolism. The primary objective was to compare the mean target concentration of propofol required to maintain the bispectral index (BIS) between 40 and 60 during three phases of LT by using a target-controlled infusion of total intravenous anaesthesia (TCI-TIVA). Methods: In this prospective, observational study, 20 adult patients diagnosed with chronic liver disease scheduled for live-donor LT were included. After anaesthesia induction and tracheal intubation, BIS-guided propofol infusion was started using TCI-TIVA with target plasma concentration (TPC) set initially at 2.5 mu g/mL in all patients using the Marsh model. The TPC was decreased or increased by 0.2 mu g/mL whenever the BIS values were persistently below 40 or above 60 for 15 minutes. Data were analysed using ANOVA and repeated measure ANOVA, followed by a post-hoc test. Results: The mean TPC was significantly higher during dissection [2.12 (Standard deviation (SD): 0.63 mu g/mL)] as compared to anhepatic and neohepatic phases [1.29 (SD: 0.65) mu g/mL and 1.35 (SD: 0.54) mu g/mL], respectively (P < 0.001). A significant difference was observed between dissection and anhepatic (mean difference: -0.87 (95% confidence interval (CI): -0.98, -0.75) or dissection and neohepatic phase (mean difference: -0.77 (95% CI: -1.02, -0.53). The propofol dose was significantly higher in dissection compared to the anhepatic and neohepatic phases (P < 0.001). Conclusion: The propofol's mean TPC when using TCI-TIVA decreased in the anhepatic and neohepatic phases to 61% and 63.7% of the dissection phase, respectively.

Background and Aim: Eye surgeries often evoke strong negative emotions in patients, including fear and anxiety. Patient education material plays a crucial role in informing and empowering individuals. Traditional sources of medical information may not effectively address individual patient concerns or cater to varying levels of understanding. This study aims to conduct a comparative analysis of the accuracy, completeness, readability, tone, and understandability of patient education material generated by AI chatbots versus traditional Patient Information Leaflets (PILs), focusing on local anesthesia in eye surgery. Methods: Expert reviewers evaluated responses generated by AI chatbots (ChatGPT and Google Gemini) and a traditional PIL (Royal College of Anaesthetists’ PIL) based on accuracy, completeness, readability, sentiment, and understandability. Statistical analyses, including ANOVA and Tukey HSD tests, were conducted to compare the performance of the sources. Results: Readability analysis showed variations in complexity among the sources, with AI chatbots offering simplified language and PILs maintaining better overall readability and accessibility. Sentiment analysis revealed differences in emotional tone, with Google Gemini exhibiting the most positive sentiment. AI chatbots demonstrated superior understandability and actionability, while PILs excelled in completeness. Overall, ChatGPT showed slightly higher accuracy (scores expressed as mean ± standard deviation) (4.71 ± 0.5 vs 4.61 ± 0.62) and completeness (4.55 ± 0.58 vs 4.47 ± 0.58) compared to Google Gemini, but PILs performed best (4.84 ± 0.37 vs 4.88 ± 0.33) in terms of both accuracy and completeness (p-value for completeness <0.05). Conclusion: AI chatbots show promise as innovative tools for patient education, complementing traditional PILs. By leveraging the strengths of both AI-driven technologies and human expertise, healthcare providers can enhance patient education and empower individuals to make informed decisions about their health and medical care.

ABSTRACT Background: Viscoelastic tests are now routinely used for coagulopathy correction in patients with cirrhosis. Thromboelastography (TEG ® ) and rotational thromboelastometry (RoTEM®) are the most widely studied tests in this population. However, they have not been compared with each other in critically ill patients with liver disease presenting with nonvariceal bleed. Hence, we aimed to compare these tests for coagulopathy correction in patients with liver disease presenting with nonvariceal bleeding. Methods: Sixty adult patients with liver cirrhosis presented to the liver intensive care unit, presenting with a nonvariceal upper gastrointestinal (GI) bleed (diagnosed by doing upper GI endoscopy which revealed bleeding from a nonvariceal source) oral or nasal bleed were enrolled. The patients were allocated to the TEG ® group (Group T) or RoTEM ® group (Group R) depending on the immediate availability of the viscoelastic test. Coagulopathy correction was done in each group as per established protocols and the results were compared. Results: There was a significant difference in the fresh frozen plasma (FFP) transfusion between the groups. The TEG ® group received more FFP when compared to the RoTEM ® group ( P = 0.001). Conclusion: RoTEM ® -based coagulopathy correction leads to lesser use of blood products with similar control of bleeding when compared to TEG, in critically ill patients with cirrhosis.

Background: End -of -life care (EOLC) is a critical aspect of healthcare, yet accessing reliable information remains challenging, particularly in culturally diverse contexts like India. Objective: This study investigates the potential of artificial intelligence (AI) in addressing the informational gap by analyzing patient information leaflets (PILs) generated by AI chatbots on EOLC. Methodology: Using a comparative research design, PILs generated by ChatGPT and Google Gemini were evaluated for readability, sentiment, accuracy, completeness, and suitability. Readability was assessed using established metrics, sentiment analysis determined emotional tone, accuracy, and completeness were rated by subject experts, and suitability was evaluated using the Patient Education Materials Assessment Tool (PEMAT). Results: Google Gemini PILs exhibited superior readability and actionability compared to ChatGPT PILs. Both conveyed positive sentiments and high levels of accuracy and completeness, with Google Gemini PILs showing slightly lower accuracy scores. Conclusion: The findings highlight the promising role of AI in enhancing patient education in EOLC, with implications for improving care outcomes and promoting informed decision -making in diverse cultural settings. Ongoing refinement and innovation in AI -driven patient education strategies are needed to ensure compassionate and culturally sensitive EOLC.

Laparoscopy within the urology field has undergone a note-worthy surge in popularity over the past decade,with particular importance given to renal surgeries such as simple nephrectomy,radical nephrectomy,donor nephrectomy,nephroureterectomy,and partial nephrectomy.1 This shift toward laparoscopic proced-ures among urologists can be attributed to the many benefits of these procedures,including reduced postoperative pain,shorter hospital stays,and faster recovery times.2 However,as with any evolving surgical technique,laparoscopic procedures in renal sur-gery bring forth their own set of distinctive challenges and compli-cations.One infrequent but potentially critical complication is inadvertent diaphragmatic injury during laparoscopic nephrec-tomy.3 In this comprehensive case report,we explored a specific instance of intraoperative diaphragmatic injury,shedding light on its immediate recognition,the intricate technical approach employed for its management,proactive strategies for prevention,and a controlled review of the relevant literature.This report aims to provide a resource for urologists and anaesthesiologists to enhance their understanding of and approach to similar cases in the future.

Background and Aims: Artificial intelligence (AI) chatbots like Conversational Generative Pre-trained Transformer (ChatGPT) have recently created much buzz, especially regarding patient education. Such informed patients understand and adhere to the management and get involved in shared decision making. The accuracy and understandability of the generated educational material are prime concerns. Thus, we compared ChatGPT with traditional patient information leaflets (PILs) about chronic pain medications. Methods: Patients' frequently asked questions were generated from PILs available on the official websites of the British Pain Society (BPS) and the Faculty of Pain Medicine. Eight blinded annexures were prepared for evaluation, consisting of traditional PILs from the BPS and AI-generated patient information materials structured similar to PILs by ChatGPT. The authors performed a comparative analysis to assess materials’ readability, emotional tone, accuracy, actionability, and understandability. Readability was measured using Flesch Reading Ease (FRE), Gunning Fog Index (GFI), and Flesch-Kincaid Grade Level (FKGL). Sentiment analysis determined emotional tone. An expert panel evaluated accuracy and completeness. Actionability and understandability were assessed with the Patient Education Materials Assessment Tool. Results: Traditional PILs generally exhibited higher readability (P values < 0.05), with [mean (standard deviation)] FRE [62.25 (1.6) versus 48 (3.7)], GFI [11.85 (0.9) versus 13.65 (0.7)], and FKGL [8.33 (0.5) versus 10.23 (0.5)] but varied emotional tones, often negative, compared to more positive sentiments in ChatGPT-generated texts. Accuracy and completeness did not significantly differ between the two. Actionability and understandability scores were comparable. Conclusion: While AI chatbots offer efficient information delivery, ensuring accuracy and readability, patient-centeredness remains crucial. It is imperative to balance innovation with evidence-based practice.

Objective This study aimed at studying the challenges and outcomes of live-donor liver transplantation (LDLT) for pediatric acute liver failure (PALF). Study design A total of 315 patients with PALF were treated over a period of 11 years. 42 underwent LT (41 LDLT and one DDLT), constituting 38% (41/110) of all pediatric transplants during this duration. The outcomes of LDLT for PALF were analyzed. Results All the 41 children who underwent LT met the Kings College criteria (KCC). The etiology was indeterminate in 46.3% ( n = 19) children. 75.6% ( n = 31) were on mechanical ventilation for grade 3/4 hepatic encephalopathy. There was presence of cerebral edema on a computed tomography scan of the brain in 50% of the children. One-third of our children required hemodynamic support with vasopressors. Systemic inflammatory response syndrome and sepsis were observed in 46.3% and 41.4% of patients, respectively. Post-LDLT 1- and 5-yr patient and graft survival were 75.6% and 70.9%, respectively. The survival in children satisfying KCC but did not undergo LT was 24% (38/161). Vascular and biliary complication rates were 2.4% and 4.8%, respectively. No graft loss occurred because of acute rejection. In multivariate analysis, pre-LT culture positivity and cerebral edema, persistence of brain edema after transplantation, and resultant pulmonary complications were significantly associated with post-LT death. Thirteen (32%) children who underwent plasmapheresis prior to LT had better post-LT neurological recovery, as evidenced by early extubation. Conclusion LDLT for PALF is lifesaving and provides a unique opportunity to time transplantation. Good long-term survival can be achieved, despite the majority of patients presenting late for transplantation. Early referral and better selection can save more lives through timely transplantation.

Background and Aims: Coagulation dynamics after donor hepatectomy are complex. Having complete knowledge of the actual changes in the coagulation status during donor hepatectomy is important to prevent complications such as pulmonary embolism, deep vein thrombosis, and bleeding. Hence, the present study aimed to study the coagulation dynamics following open donor hepatectomy both by thromboelastography (TEG) and conventional coagulation tests (CCT). Methods: A total of 50 prospective liver donors were included. TEG and CCT [activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalised ratio (INR), fibrinogen, and platelet counts] were performed for each patient before surgery (baseline), on postoperative day (POD) 0, 1, 2, 3, 5, and 10. Results: TEG showed hypercoagulability in 28%, 38%, 30%, 46%, 42%, and 48% patients; in contrast INR showed hypocoagulability in 58%, 63%, 73%, 74%, 20%, and 0% patients on POD 0,1,2,3,5, and 10, respectively. Patients demonstrating hypercoagulability on TEG had significantly decreased reaction time (P = 0.004), significantly increased maximum amplitude (P < 0.001), and alpha angle value (P < 0.001). Postoperatively, INR, PT, and aPTT values increased significantly, while platelets and fibrinogen levels decreased significantly when compared to their baseline values. There was no coagulation-related postoperative complication in any of the patients. Conclusion: Hypercoagulability after donor hepatectomy is common. TEG showed hypercoagulability and did not show any hypocoagulability as suggested by the CCT. In patients undergoing donor hepatectomy, CCT may not reflect the actual changes incoagulation status and tests such as TEG should be performed to know the correct nature of changes in coagulation following donor hepatectomy.

Introduction- Large amount of uid is administered in whipples owing to its long duration of surgery and major resection of pancreas and gastrointestinal structures. Excessive uid may lead to cellular swelling ,disruption of renal architecture and tension in the renal capsule leading to AKI. Thus the primary objective of the study was to study the effect of positive cumulative uid balance on development of postoperative Acute kidney injury (AKI) and length of intensive care stay (ICU). Secondary objective was to nd the effect of positive uid balance on development of sepsis and surgical complications. Methodology- A retrospective analysis was conducted in 106 patients undergoing whipples surgery. Results-Cumulative uid balance in rst 24 hours was 6.5 ± 1.9 litres. Acute kidney injury occurred in 20.6% of patients. On bivariate analysis, older age, longer duration of surgery and the highest lactate were found to be statistically signicantly associated with the development of acute kidney injury. The same factors were also found signicant in the multivariate analysis for development of AKI. Conclusion- Increased positive cumulative uid balance at 24 hours did not increase the development of AKI or increased the length of intensive care stay in patients undergoing whipples surgery .

INTRODUCTION:The duration of perioperative antibiotic prophylaxis following live liver donor hepatectomy (LDH) is not known. METHODS:This is a double-blind equivalence trial. All consecutive LDH were randomized into: group A (three doses) and group B (nine doses) of perioperative antibiotics (piperacillin + tazobactam - 4.5 g intravenous) at fixed 8 hourly intervals. Primary end point was incidence of infective complications as per CDC (Centers for Disease Control and Prevention) criteria. Secondary end points were liver function tests, total leukocyte count, international normalized ratio, hospital stay, morbidity, and cost analysis. RESULTS:One hundred and twenty-six LDHs were enrolled. A total of 19.8% (n = 25) experienced postoperative complications, 11 (17.7%) in group A and 14 (21.9%) in group B (P = .561). Infective complications were seen in 11 donors (8.1%), five in group A and six in group B (P = .79). A total of 8.1% of donors required continuation/up-gradation of antibiotics in group A and 9.4% in group B. Return to soft diet was delayed in group B (P = .039). Median hospital stay and cost were similar. CONCLUSION:Three doses of perioperative antibiotic are equally effective in preventing infective complications.

Introduction: Propofol is the most common drug used for providing sedation due to its short duration of action and early recovery. However, it may be associated with hypotension, desaturations, and bradycardia and does not provide analgesia, due to which various adjuncts are used along with it. Lignocaine decreases the doses of propofol and inhalational agent when used for visceral surgeries. Thus, we conducted a study to compare the dose of propofol along with lignocaine, ketamine, and fentanyl for sedation in endoscopic retrograde cholangiopancreatography (ERCP) procedure. Methods: A total of 105 patients were randomized into three groups. Sedation was provided by intravenous bolus injection of propofol 1 mg/kg in all patients followed by infusion of 0.5 mg/kg/hour. In group K bolus dose of intravenous ketamine was 0.5 mg/kg followed by infusion of 0.3 mg/kg/hour, in group L patients were given intravenous bolus of lignocaine 1.5 mg/kg followed by a infusion of 2 mg/kg/hour, in group F the matched volume of saline and 1 μ/kg fentanyl were administered. Intermittent boluses of propofol were given in all three groups in response to patients’ discomfort evidenced by grimaces, movement, or increase in heart rate or mean arterial pressure by >20% of baseline. The total dose of propofol consumed in the three groups was noted. Results: The total dose of propofol consumed and post-procedure abdominal pain was significantly higher in the fentanyl group but was comparable in lignocaine and ketamine groups. Conclusion: Lignocaine and ketamine were equally effective in deceasing propofol requirement and in preventing post-ERCP abdominal pain.

Background and Aims: Fluid administration during liver transplant (LT) surgery is controversial. Although adverse outcomes following positive intraoperative fluid balance have been reported, studies presenting the influence of cumulative postoperative fluid balance (CFB) on complications following LT are sparse. Patients with chronic liver disease tend to receive more fluid during and after surgery due to their unique physiological disease state. The aim of this study was to evaluate the influence of 48-hour CFB on the development of acute kidney injury (AKI) and pulmonary complications on day 4 after live donor LT. Methods: This retrospective study included 230 patients undergoing live donor LT. The effect of CFB on day 2 on AKI and pulmonary complications was analysed. Chi-square test, Fisher's exact test, samples t-test, Mann-Whitney U-test were used. Results: Bivariate analysis showed a lower graft vs recipient weight ratio (GRWR), sepsis (P < 0.001) and a higher 48-hour CFB after surgery significantly increased the development of AKI. For pulmonary complications, higher Model for End- stage Liver Disease-Na (MELD-Na) score, higher peak arterial lactate, higher 48-hour CFB (P = 0.016) and sepsis (P = 0.003) were found to be statistically significant. Upon multivariate analysis, CFB at 48 hours was significantly higher in patients suffering from pulmonary complications, and GRWR and sepsis were significant for AKI. For every one litre increase in CFB on day 2, the odds of pulmonary complications increased by 37%. Conclusion: A more positive CFB on day 2 increased the development of pulmonary complications and lower GRWR and sepsis increased the development of AKI.

Fever is probably the most frequent symptom observed in neurointensive care by healthcare providers. It is seen in almost 70% of neurocritically ill patients. Fever of central origin was first described in the journal Brain by Erickson in 1939. A significant number of patients develop this fever due to a noninfectious cause, but are often treated as having an infectious fever. Unjustified use of antibiotics adds to the increased cost of treatment and the emergence of resistant strains, contributing to additional morbidity. Since fever has a detrimental impact on the recovery of the acutely injured brain and contributes to an increased stay in the neurointensive care unit (NICU), timely and accurate diagnosis of the cause of fever in the NICU is imperative. Here, we try to understand the underlying mechanism, risk factors, clinical characteristics, diagnosis and management options of the central fever. We also make an attempt to differentiate two noninfectious causes of fever in the NICU: paroxysmal sympathetic hyperactivity and central fever.

Cocoon abdomen is a rare condition in which abdominal structures are surrounded by thick encapsulating peritoneum resulting in dense adhesions. Liver transplant is a high risk surgery with an already increased risk of massive blood loss due to the pre-existing coagulopathy and portal hypertension. Presence of cocoon abdomen with severe dense adhesions can either lead to difficult hepatectomy with massive intra-operative blood loss or failure to proceed with the surgery. This becomes even more important in live donor liver transplantation where it may not be possible to abandon the surgery once the donor liver resection is started. Thus keeping a high suspicion of cocoon abdomen in patients with previous history of kochs abdomen and on long term beta blocker therapy is of utmost importance and this can decrease the morbidity and mortality associated with this condition. A 41 year old male known case of chronic liver disease was posted for live donor liver transplantation. After opening the abdomen thick dense adhesions were found around the intestines and the liver. Due to the dense adhesions surgical team was in dilemma whether to proceed further for the surgery or not. Intra-operatively patient had a blood loss of 12.5 litre. Despite massive transfusion the postoperative course went uneventful and the patient was extubated on 2nd post-operative day. He was shifted out of Intensive care unit on the 6th post-operative day. Cocoon abdomen should be suspected in a chronic liver disease patient with previous history of tuberculosis or on long term beta blocker therapy. Proper preparation before surgery can decrease the morbidity and mortality associated with this major surgery. Our case report clearly shows that such types of patients can be taken up for the live donor liver transplantation surgery with a precaution to start donor hepatectomy only after surgeon has assessed the difficulty status of recipient hepatectomy.

Background: Bronchopleural fistula (BPF) is a connection between the bronchus and pleural spaces resulting into severe ventilation-perfusion mismatch.Patient may deteriorate very rapidly due to difficulty in ventilation in a large fistula.In ICU setting lung separation or blockage of fistula with bronchial blocker is a useful adjunct to save the life.Case report: A 26years old male, was admitted to the ICU following repair of the left diaphragmatic hernia for elective post op mechanical ventilation.In the course of ICU patient get tracheostomy done.He later developed empyema thoracis and iaterogenically developed a large BPF that lead to refractory hypoxemia.Patient was hemodynamically unstable and could not be ventilated leading to fall in saturation and rise in CO2.The condition was managed by blocking the leak through Arndt endobronchial blocker and his life was saved.This endobronchial blocker placement helped as a salvage bridge to stabilize the patient.After the patient was stable, he was taken to operation theatre for a definite management.Discussion: Ventilation is often challenging in a cases of large BPF on mechanical ventilation.Acute decompensation and severe hypoxia can be fatal if not treated in time.There are different methods for lung separation and closure of fistula but in ICU setting in critically ill and tracheostomised patients, very limited options are available.In tracheostomised patients, Arndt endobrochial blocker is a useful adjunct in a desaturating patient to save the life.The use of endobronchial blocker is feasible and can be life saving in critically ill patient.It provides time to optimise the condition before the definite management.Endobronchial blocker can be used as a bridge and salvage therapy.