Optimal Duration of the Apnea Test for Determining Brain Death: Benefit of the Short-Term Apnea Test

Background: The criteria for brain death determination have not been unified globally, and there is no global consensus on the apnea test, which is essential for determining brain death. Since the apnea test is associated with many complications, we aimed to determine an optimal duration of the apnea test.Methods: We analyzed the results of the apnea test performed for brain death determination between August 2013 and February 2021 at a single institution in South Korea. Elevations in the partial pressure of carbon dioxide and mean arterial blood pressure fluctuations over time in the apnea test were recorded.Results: In the 1st and 2nd tests, the mean partial pressure of carbon dioxide increased by more than 20 mmHg at 3 min after the apnea test compared to before the test (P < 0.05). At 4 min in the 1st test and 5 min in the 2nd test, the partial pressure of carbon dioxide exceeded 60 mmHg (P < 0.05). The fluctuation in the mean arterial blood pressure observed for 5 min during the apnea test was not significant. There was no significant fluctuation in the mean arterial blood pressure over time in the apnea test between patients with normal chest radiography findings and those with abnormal chest radiography findings (P = 0.888).Conclusion: Our study proposes that a short-term apnea test protocol is valid for the preservation of organs for donation.

Progesterone Induced Blocking Factor Reduces Hypertension and Placental Mitochondrial Dysfunction with in Response to sFlt-1 during Pregnancy

Preeclampsia (PE) is characterized by new onset hypertension in association with placental ischemia, reduced fetal weight, elevated soluble fms-like tyrosine kinase-1 (sFlt-1), and placental mitochondrial (mt) dysfunction and oxidative stress (ROS). Progesterone induced blocking factor (PIBF) is a product of progesterone signaling that blocks inflammatory processes and we have previously shown PIBF to lower mean arterial blood pressure (MAP) and sFlt-1 in a rat model of PE. Infusion of sFlt-1 causes hypertension and many characteristics of PE in pregnant rodents, however, its role in causing mt dysfunction is unknown. Therefore, we hypothesize that PIBF will improve mt function and MAP in response to elevated sFlt-1 during pregnancy. We tested our hypothesis by infusing sFlt-1 via miniosmotic pumps in normal pregnant (NP) Sprague-Dawley rats (3.7 μg·kg−1·day−1) on gestation days (GD) 13–19 in the presence or absence of PIBF (2.0 µg/mL) injected intraperitoneally on GD 15 and examined mean arterial blood pressure (MAP) and placental mt ROS on GD 19. sFlt-1 increased MAP to 112 + 2 (n = 11) compared to NP rats (98 + 2 mmHg, n = 15, p < 0.05), which was lowered in the presence of sFlt-1 (100 + 1 mmHg, n = 5, p < 0.05). Placental mtATP was reduced in sFlt-1 infused rats versus NP controls, but was improved with PIBF. Placental mtROS was elevated with sFlt-1 compared to NP controls, but was reduced with PIBF. Sera from NP + sFlt-1 increased endothelial cell mtROS, which was attenuated with PIBF. These data demonstrate sFlt-1 induced HTN during pregnancy reduces placental mt function. Importantly, PIBF improved placental mt function and HTN, indicating the efficacy of improved progesterone signaling as potential therapeutics for PE.

The effect of Bispectral index monitoring during induction of anesthesia on the amount of propofol consumtion in patients candidates for surgery

Objectives: This study investigated the effect of Bispectral index (BIS) during induction of anesthesia on the amount of propofol consumed in patient candidates for surgery. Methods: This double-blind clinical trial study was performed on patients undergoing elective surgery under general anesthesia in a hospital. Patients were divided into case and control groups. After being transferred to the operating room, patients were monitored including ECG 3 or 5 leads, non-invasive barometer, and pulse oximetry. Mean arterial blood pressure and heart rate were measured before and after induction, immediately, and 5 minutes after intubation. The dose of propofol was then measured. Data analysis was performed by SPSS software version 20. Results: In the present study, no significant difference was found between the mean age and gender (P> 0.05). The amount of propofol consumed in the case group was significantly lower than the control group (P = 0.039) and the amount of propofol consumed in men and women was not statistically significant (P <0.05). Mean arterial blood pressure before induction was not statistically significant between the two groups (P = 0.83). However, a statistically significant difference was found in the mean arterial blood pressure of the patients during the 4-time points (P = 0.001). There was no statistically significant difference in heart rate between patients before induction (P = 0.48). Statistical analysis of data by ANOVA test did not show a significant interaction between time and group (P = 0.418 and P = 0.74). However, a statistically significant difference was found in patients' heart rate during the 4-time points (F = 7.59 and P = 0.001). Moreover, a significant increase was observed in heart rate after intubation in both groups (P = 0.001). Conclusion: The use of BIS can be effective in reducing the amount of propofol consumed and its side effects. The condition of patients under general anesthesia can be improved by BIS, resulting in the improvement of their subsequent condition.

Methylene blue treatment of pediatric patients in the cardiovascular intensive care unit

Background: In both adults and children, hypotension related to a vasoplegic state has multiple etiologies, including septic shock, burn injury or cardiopulmonary bypass-induced vasoplegic syndrome likely due to an increase in nitric oxide (NO) within the vasculature. Methylene blue is used at times to treat this condition, but its use in pediatric cardiac patients has not been described previously in the literature. Objective: 1) Analyze the mean arterial blood pressures and vasoactive-inotropic scores of pediatric patients whose hypotension was treated with methylene blue compared to hypotensive controls; 2) Describe the dose administered and the pathologies of hypotension cited for methylene blue use; 3) Compare the morbidity and mortality of pediatric patients treated with methylene blue versus controls. Design: A retrospective chart review. Setting: Cardiac ICU in a quaternary care free-standing children’s hospital. Patients: Thirty-two patients with congenital heart disease who received methylene blue as treatment for hypotension, fifty patients with congenital heart disease identified as controls. Interventions: None. Measurements and Main Results: Demographic and vital sign data was collected for all pediatric patients treated with methylene blue during a three-year study period. Mixed effects linear regression models analyzed mean arterial blood pressure trends for twelve hours post methylene blue treatment and vasoactive-inotropic scores for twenty-four hours post treatment. Methylene blue use correlated with an increase in mean arterial blood pressure of 10.8mm Hg over a twelve-hour period (p< 0.001). Mean arterial blood pressure trends of patients older than one year did not differ significantly from controls (p=1.00), but patients less than or equal to one year of age had increasing mean arterial blood pressures that were significantly different from controls (p=0.02). Mixed effects linear regression modeling found a statistically significant decrease in vasoactive-inotropic scores over a twenty-four-hour period in the group treated with methylene blue (p< 0.001). This difference remained significant comparted to controls (p=0.003). Survival estimates did not detect a difference between the two groups (p=0.39). Conclusion: Methylene blue may be associated with a decreased need for vasoactive-inotropic support and may correlate with an increase in mean arterial blood pressure in patients who are less than or equal to one year of age.

The COMPARISON BETWEEN HYPERBARIC BUPIVACAINE PLUS FENTANYL AND HYPERBARIC BUPIVACAINE ALONE IN SPINAL ANESTHESIA FOR CAESAREAN SECTION

Objective: To compare the result of the combination of hyperbaric bupivacaine plus fentanyl with hyperbaric bupivacaine alone in patients undergoing caesarean section in spinal anaesthesia. Study Design: Comparative, cross-sectional study. Place and Duration of Study: Department of Anesthesia, Fauji Foundation Hospital, Rawalpindi Pakistan, from Dec 2017 to Jun 2018. Methodology: After consulting the institutional ethical review committees a total of 60 females between ages 18-40 years were enrolled for caesarean section delivery. They were divided into two groups. The study group (n=30) received a subarachnoid injection of 0.5% hyperbaric bupivacaine (10mg) 2ml with 25ug of fentanyl 0.5ml and control group (n=30) was injected 0.5% hyperbaric bupivacaine 12.5mg (2.5 ml) only. Pain experienced during the procedure was assessed by using 10-point visual analogue scoring method. The mean duration of analgesia, mean arterial blood pressure and heart rate after surgery were compared between two groups. Results: The mean duration of analgesia was 206.5/min ± 6.4 in the study group and it was 163.6min ± 7.2 in the control group (p=0.001). Mean arterial BP after surgery was 92.3mmHg ± 3.8 in the study group and 88.7mmHg ± 4.1 in the control group (p=0.001). The mean heart rate recorded after surgery was 75.2/min ± 5.2 in the study group and it was 70.4/min ± 6.1 in the control group (p=0.001). Conclusions: The mean duration of analgesia was significantly longer in the study group when compared with the control group with better mean arterial blood pressure and heart rate response after Caesarean section.

Is Elevated First Trimester Mean Arterial Blood Pressure Associated With Increased Risk of Placenta Accreta?

Purpose: The present study investigated whether first trimester mean arterial blood pressure (MAP) differed among pregnancies with placenta accreta and healthy pregnancies.Methods: We recruited 176 pregnant females totally from 1 January 2016 to 30 September 2018 in this study, as follows: 65 cases of placenta accreta and 111 cases of BMI and age matched, healthy pregnant controls. First trimester mean arterial blood pressure (MAP) were acquired from laboratory data files. Multiple logistic regression analysis were used to study analyzed the probable risk predictor of placenta accreta. Results: The performance of MAP was lower in healthy pregnancies. The MAP of the placenta accreta group was significantly higher than that of the cont rol group (p=0.001<0.05). Our results also showed that MAP was significantly positively associated with placenta accreta after adjusting for age, BMI, fertilization type, gestational week at time of blood pressure measurement, and previous cesarean section history (odds ratio [β]: 1.11; 95% confidence interval [CI]: 1.04–1.69; p=0.0013<0.05). In addition, smoking during pregnancy (β: 7.57; 95% CI: 1.41–40.72; p=0.018<0.05) and previous cesarean section history (β: 2.57; 95% CI: 1.19–5.54; p=0.016<0.05) were significantly positively associated with placenta accreta.Conclusions: Increased first trimester MAP was significantly positively associated with placenta accreta, suggesting the potential role of MAP in identifying high-risk pregnancies for placenta accreta. Smoking during pregnancy and previous cesarean section history may be risk factors for placenta accreta.

Comparison of perioperative analgesia between intravenous paracetamol and fentanyl for rigid hysteroscopy. A randomised control trial

Objective: To compare efficacy of intravenous paracetamol and fentanyl for intra-operative and post-operative analgesia in patients undergoing for diagnostic and therapeutic rigid hysteroscopy. Methods: Prospective Randomized Clinical Trial was conducted at Aga Khan University Hospital, Karachi, from October 2016 to June 2017. Study instituted after ethical review committee approval and patient has ASA-I, II, aged 18-65 years, consented for hysteroscopy. Anesthesia induction technique was standardized and analgesia in group-P, paracetamol 15 mg/Kg administered 15-30 minutes before surgery and in group-F, fentanyl 2 mcg/kg administered at induction of anesthesia. Intraoperative pain was assessed by changes in heart rate, systolic, diastolic and mean arterial blood pressure and postoperative pain was assessed by visual analogue scale. SPSS 19 was used for data analysis. Results: Sixty patients scheduled for hysteroscopy were allocated into two groups. Patient’s ASA status and demographics were found relatively similar in both groups except for age differences (p< 0.011). In paracetamol group, mean SBP at 10,15, 20, 25 and 30 minutes and mean DBP at 20, 25 minutes & Mean arterial blood pressure at 20 minutes were statistically significant (p<0.05) compared to the fentanyl group. However, the mean heart rate was statistically insignificant among the groups. The postoperative visual analogue pain scores were almost similar at 0, 15, and 30 minutes (p>0.05) among the groups. Although, the rescue analgesia was needed in 3 patients on arrival in recovery room in each group. Conclusion: Intravenous paracetamol offers similar analgesic efficacy to fentanyl for rigid hysteroscopy in ambulatory surgery. However, Continuous...