Cardiac Function in Brain Death, Usage of Advanced Hemodynamic Monitoring

Background: This study used advanced hemodynamic monitoring along with simultaneous echocardiography to assess donated heart function of brain death patients using advanced hemodynamic monitoring and its efficacy in organ donation. Methods: Forty-eight brain death patients who were candidates of heart donation on the basis of primary standard investigations were selected with purposive and convenient sampling methods. They were investigated with advanced hemodynamic monitoring after echocardiography and primary assessments and the gleaned data were recorded. Results: Echocardiography showed that LVS (left ventricle size) and LVF (left ventricle function) were normal in %100 and %87.5 of patients, respectively. LVEF (left ventricle ejection fraction) was <%50 in %12.5 and >%50 in %87.5 of patients. SVR was smaller than 1200 at the beginning of the study that reached %54.4 at the end of the study. CI (cardiac index) was < 2.4 in %16.7 of the patients at the onset of the study that reached %25 at the end. Reduction of CI and SVR in patients with EF <%50 was significantly higher than that in patients with EF>%50. Conclusion: Given the extensive pathological changes in the cardiovascular system exerted by brain death, advanced hemodynamic monitoring, if performed continually, can greatly aid in managing inotropic drugs in these patients, decision-making for managing intravascular volume, creating hemodynamic stability, and finally, preventing deterioration of function of the donated heart and loss of a donated organ.

Effect of single-dose intravenous dexamethasone on postoperative pain and postoperative nausea and vomiting in patients undergoing lower segment cesarean section under spinal anesthesia

Background: Lower segment caesarean sections (LSCS) are commonly done under spinal anaesthesia. Although spinal anaesthetic techniques are relatively safe and associated with quick and uneventful recovery, post-operative pain is a major concern after effect of spinal anaesthesia weans off. Other than pain postoperative nausea and vomiting (PONV) is one of the important side effects of spinal anaesthesia. Steroids by virtue of their anti-inflammatory effect is expected to reduce pain consequent upon inflammation and many studies have shown their efficacy in reducing pain as well as PONV in post-operative patients. Aims and Objectives: Primary objective of the study was to evaluate efficacy of single-dose dexamethasone in reducing post-operative pain. The secondary objectives were to analyse effect of single-dose dexamethasone on hemodynamic stability as well as incidence of nausea and vomiting in patients undergoing LSCS under spinal anesthesia. Materials and Methods: This was a double-blind comparative study in which 60 patients undergoing LSCS under spinal anaesthesia were included on the basis of a predefined inclusion and exclusion criteria. Written informed consent was obtained from all patients. The patients were divided into two groups: Group D: 30 patients who received IV dexamethasone 8 mg (2 ml) intravenously just before giving spinal anesthesia. Group N: 30 patients who received Normal saline (2 ml) immediately before spinal anesthesia. In both groups, hemodynamic parameters, respiratory rate, severity of post-operative pain, and incidence of PONV was compared. P value less than 0.05 was taken as statistically significant. Results: Patients in Group D had significantly less severe post-operative pain (as assessed by the Visual analog scale) and incidence of PONV (P<0.05). Significantly less post-operative rescue analgesia was required in patients who received single dose of intravenous dexamethasone (P<0.05). In terms of hemodynamic stability, both groups were found to be comparable with no statistically significant difference. Conclusion: Single-dose dexamethasone is effective in reducing post-operative pain as well as incidence of PONV in patients undergoing LSCS under spinal anesthesia.

Evaluation of the effect of preoperative anxiety on intraoperative hemodynamic stability and drug consumption in patients who underwent BIS-guided total intravenous anesthesia (TIVA) for neurophysiological monitoring in spine surgery

In our study, the aim was to evaluate the effects of preoperative anxiety measured by Spielberger’s State-Trait Anxiety Inventory-State (STAI-S) and State-Trait Inventory-Trait (STAI-T) scores on intraoperative hemodynamic stability, drug consumption and recovery in patients who underwent spinal surgery with neurophysiological monitoring and total intravenous anesthesia with bispectral index (BIS) monitoring, without the use of muscle relaxants. Eighty patients with planned spinal surgery and neurophysiological monitoring were included in this prospective observational study. Anxiety scores were recorded by applying Spielberger’s STAI-T and STAI-S scoring questionnaires to all patients included in the study 1 hour before the operation. Age, gender and American Society of Anesthesiologists (ASA) scores of the patients who were taken to the operating table without premedication were recorded. Before anesthesia induction, standard monitoring including electrocardiography (ECG), noninvasive blood pressure, peripheral oxygen saturation (SpO2), BIS was applied. The correlation between STAI-T and STAI-S scores with demographic characteristics of patients, preoperative, post-induction, 5th minute, 10th minute, 30th minute, 50th minute, 70th minute, 90th minute heart rate (HR), mean arterial pressure (MAP), SpO2, operation time, recovery time, and total amount of propofol and remifentanil used during the operation were evaluated statistically. A significant negative correlation was observed between STAI-S anxiety scoring and age (p < 0.05). A significant positive correlation was found between the total amount of remifentanil and propofol used with the STAI-S score (p < 0.05). Significant positive correlations were observed between the STAI-S score and the HR value preoperatively, and in the 5th, 30th, 50th, 70th, and 90th minutes (p < 0.05). Our study showed that preoperative anxiety increases intraoperative drug consumption and heart rate. It is of great importance to keep the amount of intraoperative medication at optimal levels, to measure preoperative anxiety, and to eliminate it with multimodal treatments, especially for the accurate detection of neurological damage in patients with neurophysiological monitoring.

Continuous Renal Replacement Therapy: A Review

Kidney is an important organ to maintain hemodynamic stability inside the human body. In patient with acute kidney injury (AKI) there was a decreased kidney function that could interfere hemodynamic stability which can lead to multi organ failure even death. Around 5-10% patients with AKI required renal replacement therapy (RRT) to support their decreased renal function. Continuous renal replacement therapy (CRRT) is one of RRT modality that commonly used for patients with AKI who are hemodynamically unstable or in critically ill conditions.CRRT could divided into 4 mode, slow continuous ultrafiltration (SCUF), continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis (CVVHD) and continuous veno-venous hemodialfiltration (CVVHDF). CRRT used based on renal and nonrenal indication. Several studies are still trying to prove nonrenal indication of RRT, to ascertain whether CRRT could be used as therapy effectively. Therefore the indication, the mechanism and the comparison of renal replacement therapy are very important to be understood.

Abnormal Uterine Bleeding in Adolescent

Abnormal uterine bleeding (AUB) is defined as the abnormal bleeding from the uterine corpus in term of duration, volume, frequency and/or regularity. This condition occurs in 37% of adolescents and may affect the quality of life and increased hospitalization. Etiology is divided into structural and non-structural causes, known as PALM-COEIN. The most common etiology in adolescents is anovulatory menstruation due to immature hypothalamus-hypophysis axis. Diagnostic evaluation should include investigation in the etiology of AUB, anemia signs, and hemodynamic status. Treatment of AUB consists of hormonal and non-hormonal therapy. Therapy in adolescent is given based on the severity of bleeding, grading of anemia, and hemodynamic stability. Follow-up is required after therapy. Understanding AUB in adolescents can help clinicians deliver appropriate and comprehensive treatment. This review was aimed to explain about definition, epidemiology, etiology, pathophysiology, diagnosis, and treatment of abnormal uterine bleeding in adolescent.

Early application of extracorporeal membrane oxygenation for myocarditis with shock: a case report

The current therapy for myocarditis is immunosuppressive therapy. However, in rare cases in which patients do not respond to intervention, their condition can rapidly deteriorate to myocarditis with shock, which is characterized by extensive and diffuse lymphocyte infiltration in the myocardium. Most cases of myocarditis are caused by virus-mediated damage of cardiomyocytes, and its clinical manifestations are ventricular arrhythmia and hemodynamic disturbances. Extracorporeal membrane oxygenation is an effective intervention, which regulates hemodynamic stability and avoids systemic hypoperfusion. This intervention has been used to sustain hemodynamic stability in patients with myocarditis and shock. We report here early application of extracorporeal membrane oxygenation for successful treatment of a patient with myocarditis and shock.

Ventricular septal intramyocardial dissection after cardiac fibrosarcoma excision

Intramyocardial dissection following cardiac tumor excision is uncommon. The evidence available is limited to few case reports. Herein,we report an infant with large cardiac fibrosarcoma arising from the interventricular septum and underwent surgical excision.One month after surgery echocardiography revealed a cystic dissection located in the interventricular septum with residual shunts within the ventricular chambers. we performed conservative strategy due to the high surgical risk, difficulty of interventional therapy and hemodynamic stability.

Delayed splenic rupture and conservative management: case series

Splenic injury is frequent in patients with abdominal trauma and delayed splenic rupture yields a poorer prognosis. Patients with hemodynamic stability, despite the grade of splenic anatomical injury, can be safely treated by conservative management (observation or angiography/angioembolization), if no other intra-abdominal injuries are found and a multidisciplinary team (surgeons, interventional radiologists) is available. The conservative approach is an alternative to surgery and its possible complications. In this case series, the authors present three trauma cases very commonly seen in emergency rooms, in whom delayed splenic rupture was diagnosed. All three patients were submitted to conservative management, with no need for surgery or complications. This case series presents some common clinical signs and diagnostic steps, also showing the safety and efficacy of clinical observation in this setting.

Provocative mesenteric angiography for localizing ambiguous gastrointestinal hemorrhage

Objectives: Five percent of patients with recurrent gastrointestinal (GI) hemorrhage have indeterminate origin by radiological and endoscopic examinations. To improve diagnostic accuracy and therapeutic embolization, the technique of provocative mesenteric angiography (PMA) has been developed. It involves the addition of pharmacologic agents to standard angiographic protocols to induce bleeding. Material and Methods: This is an institutional review board-approved, retrospective study of 20 patients who underwent PMA between 2014 and 2019. All patients had clinical evidence of GI hemorrhage without a definite source. PMA consisted of anticoagulation with 5000 units of heparin and selective transcatheter injection of up to 600 μg of nitroglycerine, followed by slow infusion of up to 24 mg of tissue plasminogen activator into the arterial distribution of the highest suspicion mesenteric artery. Results: Among the 20 patients who underwent PMA, 11/20 (55%) resulted in angiographically visible extravasation. Of these 11 patients, nine patients underwent successful embolization with coil or glue and were discharged upon achieving hemodynamic stability. Two patients spontaneously stopped bleeding. In our series, PMA resulted in the successful treatment of 9/20 (45%) patients with recurrent hemorrhage. No procedure-associated complications were reported with these 20 patients during the procedure and their course of hospitalization. Conclusion: In our experience, PMA is an effective and safe approach in localizing and treating the source of GI bleeding in about half of patients with an otherwise unidentifiable source.

Comparative Study Between Dexmedetomidine and Fentanyl as Sedatives in Awake Fiberoptic Intubation in Cervical Spine Surgeries

Background Various drugs are used for providing favorable intubation conditions during awake fiberoptic intubation (AFOI). However, most of them have various side effects. Aim The aim of this study was to compare the effects of dexmedetomedine and fentanyl as regards sedative effects, hemodynamic stability, intubation time and intubation attempts success during awake fiberoptic intubation. Material and Methods A randomized double-blind prospective study was conducted on a total of 40 patients scheduled for elective cervical spine surgeries who were randomly allocated into two equal groups (n 20): (group A) patients received a bolus dose of dexmedetomidine of 1 mcg/kg over 10 min followed by a continuous infusion of dexmedetomidine at 0.5 mcg/kg/h. and fentanyl group (group B) received dose of 1 μg/kg over 10 min followed by 0.5 μg/kg/hr. Sedation score (Ramsy sedation score), hemodynamic variables, oxygen saturation, intubation time and intubation attempts were noted and compared between the two groups. Results Ramsy Sedation Score was significantly favorable (P &lt; 0.001) in group A in comparison to group B, moreover better hemodynamic stability during intubation (P &lt; 0.05) and less intubation attempts were observed in group A in comparison to group B. Conclusion The results of our study showed that dexmedetomidine provides optimum sedation without compromising airway or hemodynamic stability and with favorable intubation time and less intubation attempts during AFOI in comparison to fentanyl.