Effects of Anesthetic Techniques on the Risk of Postoperative Complications Following Lower Extremity Amputation in Diabetes Patients with Coagulation Abnormalities: A Retrospective Cohort Study Using Propensity Score Analysis

Diabetic foot amputation is associated with high morbidity and mortality rates. To prevent cardiovascular complications along with vasculopathy in the course of diabetes mellitus, a high number of patients receive anticoagulant therapy. However, anticoagulants are contraindicated in neuraxial anesthesia limiting available anesthetic modalities. Therefore, in this retrospective study, we aimed to compare between general anesthesia and peripheral nerve block (PNB) with respect to postoperative complications following lower extremity amputation (LEA) in patients with coagulation abnormalities. In total, 320 adult patients who underwent LEA for diabetic foot were divided into two groups according to the anesthetic type (general anesthesia vs. PNB). The inverse probability of treatment weighting was performed to balance the baseline patient characteristics and surgical risk between the two groups. The adjusted analysis showed that compared with the general anesthesia group, the PNB group had lower risks of pneumonia (odds ratio: 0.091, 95% confidence interval [CI]: 0.010–0.850, p = 0.0355), acute kidney injury (odds ratio: 0.078, 95% CI: 0.007–0.871, p = 0.0382), and total major complications (odds ratio: 0.603, 95% CI: 0.400–0.910, p = 0.0161). Additionally, general anesthesia was associated with a higher amount of intraoperative crystalloid administration and a requirement for more frequent vasopressors. In conclusion, PNB appears to be protective against complications following LEA in diabetes patients with coagulopathy.

COVID-19 and Cardiovascular Complications: An Updated Review

COVID-19 has become a global pandemic. Patients with pre-existing comorbidities such as hypertension, diabetes, and cardiovascular disease (CVD) are associated with greater severity and higher mortality. COVID-19 can cause cardiovascular complications, including myocardial injury, myocarditis, heart failure, acute coronary syndrome, and coagulation abnormalities. Possible pathophysiology and molecular pathways driving these disease processes are cytokine release syndrome, RAAS system dysregulation, plaque destabilization and coagulation disorders Myocarditis is one concern among persons who received mRNA-Based COVID-19 vaccines. There are several cardiovascular complications that are possibly caused by COVID-19 treatments, such as QT interval prolongation, arrhythmia, and hypotension. Due to increasingly recognized CVD damage in COVID-19, we need to understand about COVID-19 related to cardiovascular complications and treatment strategies.

Dealing with hypodysfibrinogenemia during pregnancy with a successful outcome

Background: Fibrinogen is a protein playing pleiotropic role in human body. It is engaged in maintaining hemostasis. Congenital fibrinogen disorders comprise quantitative and qualitative fibrinogen anomalies. The symptoms range from bleeding, thrombosis to asymptomatic at all what is the most common case. Hypodysfibrinogenemia with lower level of fibrinogen of reduced activity, is the least common of all congenital fibrinogen disorders. Case report: A 31-year-old woman was reported at the 21 weeks of gestation, suffered from genital tract bleeding and there was a history of stillbirth. Clinical examination with no pathology, however laboratory tests revealed coagulation abnormalities due to prolonged thrombin test, decreased protein S and lower fibrinogen level (70 mg/dl). Autoimmune diseases were excluded and the diagnosis was widened with rotational thromboelastometry and genetic test for hypodysfibrinogenemia. The patient was treated with fibrinogen substitution and prophylactic dose of heparin throughout pregnancy and 2 weeks following labour. At 39 week of gestation Caesarean section was done, with no complications. Results: Genetic test revealed heterozygous mutation in fibrinogen gamma gene confirming hypodysfibrinogenemia. Due to bleeding manifestation in this patient of congenital fibrinogen disorders, fibrinogen substitution was implemented with heparin as a paranticoagulant prophylaxis, what turned out to be successful and enabled the patient to maintain the pregnancy. Conclusions: As hypodysfibrinogenemia symptoms are diverse the management is difficult and each patient’s therapy should be planned separately. Pregnancy may be the first time when congenital fibrinogen disorders reveal and it is especially challenging to prevent from obstetrical complications.

Effect of Fresh Frozen Plasma Transfusion Inpatients with Coagulation Abnormalities

Aim: To study the efficacy of Fresh Frozen Plasma (FFP) transfusion practice in patients with coagulation abnormalities varies in clinical practice. Study Design: A retrospective study. Place and Duration of Study: This study was conducted in Department of Transfusion Medicine, SMCH, Chennai, between the period of 2019-2020. Methodology: The medical records of each patient receiving FFP transfusions that occurred in patients with coagulation abnormalities were reviewed and the data were collected based on pre-and post transfusion PT (>12 sec), APTT (>70sec) and INR (>1.5) and then analysed statistically. Patients with normal coagulation parameters were excluded from study. Results: A total of 1259 units of fresh frozen plasma were transfused to 315 patients between the year 2019-2020. Of the 1259 units transfused 1133 units where transfused to 283 patients with coagulation abnormalities. Apparently 32 patients were excluded from the study as they had normal coagulation profile. Among 251 patients, 37 patients PT were greater than 12 seconds before FFP transfusion out of which the PT was corrected for 14 patients (37.8%) after FFP transfusion. In 228 patients APTT was greater than 70 seconds before FFP transfusion, out of which APTT was corrected in 18 patients (8%) after transfusion. INR values for all 251 patients were greater than1.5 before FFP transfusion, out of which INR was corrected in 84 patients (29%) after transfusion. Conclusion: We conclude that FFP transfusions in patients with coagulation abnormalities maycorrects the defect only in less percentage of patient population, as in our study it corrects only an average of 31% of patient population.

Anaesthetic implications for splenectomy in a child with Gaucher’s disease

Gaucher’s disease, a lysosomal storage disorder, is caused by an inherited deficiency of beta glucocerebrosidase enzyme leading to the accumulation of glucocerebroside in the reticuloendothelial system. Patients with this disease often manifest coagulation abnormalities and multi-organ complications. These factors present a challenge to the anaesthesiologist, in deciding the type as well as the conduct of anaesthesia. We aim to report the anaesthetic management in a 3-years old child with Gaucher’s disease posted for splenectomy.

EFFECT OF KIDNEY DISEASE ON THE MORTALITY OF COVID POSITIVE PATIENTS IN A TERTIARY CARE HOSPITAL, INDIA

INTRODUCTION: CKD and kidney failure are signicant comorbidities associated with unfavourable outcomes in patients with COVID-19. Patients with CKD/kidney failure also have a disproportionate burden of other comorbidities 1 (e.g., coronary artery disease, hypertension, and diabetes mellitus) associated with more severe presentations of COVID-19 . SARS-CoV-2 infection frequently triggers a massive release of proinammatory cytokines and may induce coagulation abnormalities that increase the risk of 2 cardiovascular events and multiorgan dysfunction. MATERIALS & METHODS: It is a retrospective study done in government general hospital Vijayawada from patients admitted with covid positive status having comorbidities, with the help of medical records department, done during 1st April 2020 to 31st March 2021. RESULTS : Out of 150 patients who had a renal abnormality, 40 (27%)had AKI, 110 ( 73%) had CKD, and of these patients, 96( 64%) patients underwent dialysis, 54( 36%) patients did not undergo dialysis, having high mortality mainly in patients having CKD than AKI. Compared to patients with comorbidity without renal abnormality and patients with renal abnormalities, the mortality was high in the later group of patients. CONCLUSION: There is a signicant effect of kidney disease on mortality in covid positive patients. Patients having CKD will have higher mortality compared with AKI. Even though the mortality was seen in patients having comorbidities without renal involvement, mortality was much higher in patients with renal involvement.

Long-term post-discharge coagulation abnormalities in patients with moderate to severe COVID-19

Introduction Coagulopathy plays a significant role in COVID-19 pathogenesis. Benefit from anticoagulation is well established in hospitalized patients. But since there is a lack of data on coagulopathy resolution: there is no consensus in guidelines if extended anticoagulation is required. Purpose The purpose of our work was to analyze coagulation abnormalities at 2 to 5 months after moderate to severe COVID-19. Methods COVID-19 reconvalescents (CR), discharged from our hospital, were called for follow-up at 2–3 (CR1 group, 21 patients) or 5–6 (CR2 group, 26 patients) months after discharge. All CR were not on the anticoagulation therapy by that time. In addition to clinical examination and standard lab tests, we performed an FMD-test to analyze endothelial function, impedance aggregometry to analyze platelet aggregation, and a thrombodynamics test to assess thrombogenesis and fibrinolysis. The control group was recruited before the pandemic started. Results All CR were free from thrombotic complications after discharge from the hospital. Endothelial function was not significantly impaired in CR compared with control, and was still in the normal range (7,07, IQR (3,36; 11,56) vs. 7,87 (5,42; 13,45)). Platelet aggregation was significantly lower in CR1 than in the control group in ADP-induced mode (37, IQR (19; 47) vs. 46, IQR (41; 50), p=0,02) and didn't differ in other groups and other modes (Asa, TRAP-induced). Thrombodynamics tests revealed suppression of the clot formation process in both CR1 and CR2 compared with control. There were decreased clot growth rates (μm/min) (CR1/CR2: 27,1, IQR (26,1; 29,2)/27,6, IQR (26,4; 30,0) vs. 32,2, IQR (30,0; 35,1), both p<0,001); decreased clot size (μm) (CR1/CR2: 1099, IQR (1069; 1194)/1199, IQR (1058; 1221) vs. 1304, IQR (1164; 1380), both p<0,001), and decreased optical density (arb units) (CR1/CR2: 21'607, IQR (20'363; 24'545)/22'741, IQR (21'344; 25'961) vs. 26'556, IQR (24'672; 29'387, p<0,001 and p=0,09 respectively. Fibrinolysis was enhanced in CR groups compared with control (lysis progression was significantly higher for CR2 only, CR1/CR2: 2,9, IQR (2,5; 3,8)/3,8, IQR (2,6; 5,4) vs. 2,5, IQR (1,1; 3,4) %/min, p=0,087 and p=0,007 respectively; expected clot lysis time was shorter in both CR1 and CR2: 36,5, IQR (29,8; 44,2)/31,7, IQR (24,3; 42,7) vs. 65,9. IQR (36,3; 95,5) min, p=0,019 and p=0,016 respectively). There was no statistical difference in clot formation and in fibrinolysis between CR1 and CR2. Conclusion In the deferred period (2–5 months) of COVID-19 the fibrinolysis process remains still active whereas the process of clot formation is mostly suppressed. Endothelial function assessed via the FMD test is within the normal range in the post COVID period. FUNDunding Acknowledgement Type of funding sources: None.

Cardiac diseases following COVID-19 in children and adults: A narrative review on mechanisms and medical implications

Objectives: In December 2019, SARS-CoV2 outbreak from China resulted in Covid-19 worldwide. The involvement of different organs, especially, heart disease can lead to hospitalization and enhance the rate of mortality and morbidity among severe patients. In a narrative review, we aimed to investigate the involvement of heart in adult and children with COVID-19 in critically ill patients. Methods: The clinical and paraclinical manifestation of diseases in adults and children were searched in standard databases, such as PubMed, Google Scholar, Scopus, est. Also, the possible underlying mechanisms were investigated. Results: The CVDs in COVID-19 patients has been characterized by several abnormalities such as myocarditis, acute myocardial injury, acute coronary syndrome, heart failure, arrhythmias, sudden cardiac arrest, coagulation abnormalities, thrombosis, and Kawasaki disease. The most probable mechanisms are attributed to SARS-CoV2 direct and indirect effects. The presence of angiotensin-converting enzyme 2 (ACE2) was confirmed in the cardiac tissue, confirming the direct attack of virus. Moreover, the cytokine storm as a result of enhanced levels of inflammatory mediators and infiltration of inflammatory cells into the cardiac disease, coagulation abnormalities, and endothelial dysfunction contribute to disease. Conclusion: Cardiac diseases are seen in children and adults with COVID-19, related to the different mechanisms, mainly direct attack of virus and cytokine storm. Increasing the knowledge of cardiologists about the cardiac manifestations of COVID-9 in children and adults and underlying mechanisms can improve the consequences and reduce the mortality and morbidity rate among hospitalized patients.