LATE ONSET OHSS AND PREGNANCY OUTCOME: A CASE REPORT

Ovulation induction has been an important mode of treatment of infertility.Ovarian stimulation may result in a supraphysiologic response leading to an iatrogenic complication known as the ovarian hyperstimulation syndrome(OHSS) . This syndrome is a potentially lethal condition,the pathophysiologic hallmark of which is the accumulation of massive extravascular exudate combined with profound intravascular volume depletion and hemoconcentration.we report a case of severe OHSS with very large ovaries in a 38yr old case of G2A1 with 4weeks 5days GA ,ICSI conception with TCTA triplets presented to the emergency department with abdominal pain,ascites and respiratory distress . The patient was managed symptomatically with no complications. Although ovarian hyperstimulation is a rare entity ,it is important that the physician recognizes this condition.prompt diagnosis and successful management is likely to avoid serious and rapid development of complications.

Acute pancreatitis and relative polycythaemia: a case series

Relative polycythaemia is an apparent rise in erythrocyte level in the blood. However, the underlying cause is reduced blood plasma. Relative polycythaemia is often caused by loss of body fluids seen in conditions such as burns, dehydration and stress manifesting itself as a raised Haemoglobin or haematocrit. This case series presents a clinical summary of three patients with acute pancreatitis (AP) and relative polycythaemia due to reduction in plasma volume as a result of intravascular volume depletion as demonstrated by increase in haemoglobin and haematocrit. Haem concentration may be considered as a marker for acute severe pancreatitis and correcting the volume depletion by adequate fluid improves the outcome of AP as seen in all our three patients.

Usefulness of non-invasive cardiac output monitoring in elderly patients undergoing monopolar transurethral resection of the prostate: a pilot study

Objective To assess the impact of irrigating fluid on hemodynamic profiles using real-time non-invasive cardiac output monitoring (NICOM) in elderly patients undergoing monopolar transurethral resection of the prostate (TURP). Methods Twenty patients between 65 and 80 years of age who were scheduled for monopolar TURP and received spinal anesthesia up to T10 were enrolled. Irrigating fluid (2.7% sorbitol with 0.5% mannitol solution) was used. Hemodynamic profiles including cardiac index, and stroke volume variation (SVV) using NICOM were obtained. Estimated irrigating fluid absorption was indirectly calculated. Results The median amount of irrigating fluid used was 6000 mL. The median SVV was 11%, which increased to 12% at 10 minutes after initiating surgery. No significant changes in the cardiac index were observed. The estimated absorption of irrigating fluid was almost zero. Conclusions Although the estimated amount of irrigating fluid that was absorbed was negligible, the increase in SVV may indicate intravascular volume depletion with diuresis resulting from mannitol in the irrigating fluid early during irrigation. Therefore, even during short irrigating times, intensive hemodynamic monitoring should be performed to monitor the possibility of intravascular volume depletion as well as volume overload, especially immediately after large amounts of irrigating fluid are used.

PERIOPERATIVE MANAGEMENT OF SICKLE CELL DISEASE: A NARRATIVE REVIEW

An estimated 30 million people worldwide have sickle cell disease (SCD). Emergent and non-emergent surgical procedures in SCD have been associated with relatively increased risks of peri-operative mortality, vaso-occlussive (painful) crisis, acute chest syndrome, post-operative infections, congestive heart failure, cerebrovascular accident and acute kidney injury. Pre-operative assessment must include careful review of the patient’s known crisis triggers, baseline hematologic profile, usual transfusion requirements, pre-existing organ dysfunction and narcotic use. Use of preoperative blood transfusions should be selective and decisions individualized based on the baseline hemoglobin, surgical procedure and anticipated volume of blood loss. Intra- and post-operative management should focus on minimizing hypoxia, hypothermia, acidosis, and intravascular volume depletion. Pre- and post-operative incentive spirometry use should be encouraged.

Pyloric Stenosis

Pyloric stenosis is one of the most common surgical conditions affecting neonates and young infants. Hypertrophy of the pyloric muscular layers results in gradual gastric outlet obstruction. Persistent episodic projectile vomiting and dehydration as well as hypochloremic, hypokalemic metabolic alkalosis are cardinal features. Definitive treatment is surgical pyloromyotomy, but it is not a surgical emergency. Emergency medical intervention is often required to correct intravascular volume depletion and electrolyte disturbances. Morbidity and mortality should be limited due to advancements in surgical and perioperative care. Morbidity can occur due to poor preoperative resuscitation, anesthetic management difficulties, or postoperative complications. The following manuscript is a review of current evidence-based perioperative care of infants with pyloric stenosis. It reviews the pathophysiology that results in metabolic disturbances and intravascular volume depletion. It focuses on preoperative assessment and correction of electrolyte abnormalities and anesthetic technique including airway management and postoperative analgesia.

Cerebral salt wasting following traumatic brain injury

Summary Hyponatraemia is the most commonly encountered electrolyte disturbance in neurological high dependency and intensive care units. Cerebral salt wasting (CSW) is the most elusive and challenging of the causes of hyponatraemia, and it is vital to distinguish it from the more familiar syndrome of inappropriate antidiuretic hormone (SIADH). Managing CSW requires correction of the intravascular volume depletion and hyponatraemia, as well as mitigation of on-going substantial sodium losses. Herein we describe a challenging case of CSW requiring large doses of hypertonic saline and the subsequent substantial benefit with the addition of fludrocortisone. Learning points: The diagnosis of CSW requires a high index of suspicion. Distinguishing it from SIADH is essential to enable prompt treatment in order to prevent severe hyponatraemia. The hallmarks of substantial CSW are hyponatraemia, reduced volume status and inappropriately high renal sodium loss. Substantial volumes of hypertonic saline may be required for a prolonged period of time to correct volume and sodium deficits. Fludrocortisone has a role in the management of CSW. It likely reduces the doses of hypertonic saline required and can maintain serum sodium levels of hypertonic saline.

An unusual case of relative polycythemia with complication of pseudocyst of pancreas

Relative polycythemia is a term used to describe an elevation of the hematocrit level either caused by an acute transient state of hemoconcentration associated with intravascular fluid depletion or a chronic sustained relative polycythemia caused by contraction of the plasma volume. Relative polycythemia can occur when the plasma volume is reduced due to intravascular volume depletion during acute pancreatitis episode, complicating as pseudocyst of pancreas. We report a case of Relative Polycythemia with pseudocyst of Pancreas a secondary complication of pancreatitis.

Abstract W P332: Ratio of Blood Urea Nitrogen to Serum Creatinine Predicts Primary Intracerebral Hemorrhage Volume

Background&Purpose: Dehydration is associated with poor outcomes in stroke patients. A common marker of hydration status is the calculated blood urea nitrogen (BUN) to serum creatinine (SCr) ratio. Few studies in primary ICH patients have focused on intravascular volume depletion and ICH volume. We examined if dehydration (BUN/SCr > 15) predicted admission ICH volume. Subjects&Methods: Consecutive patients (2008 – 2013) who presented with a spontaneous ICH to our academic stroke center in the Southeast US were retrospectively analyzed. Demographics, initial lab values, ICH volumes, and ICH scores were recorded. Patients with INR <= 1.5 were divided into two groups: BUN/SCr <= 15 and > 15. ICH volumes were compared between groups. Statistical significance was determined using linear regression adjusting for admission systolic blood pressure (SBP) and ICH score. Results: We identified 326 patients who met inclusion criteria (mean age 63; SD=15, 43% women, 45% black). Patients with ratio >15 were older (68 vs.60 years, p<0.001). In addition, a higher proportion were white (63% vs.40%, p <0.001) and female (56% vs. 36%, p<0.001). The average SBP on arrival was similar between groups (176 vs.181 mmHg, p=0.159). The average initial ICH volumes for those with BUN/SCr > 15 were higher than patients with BUN/SCr <= 15 (29.6 mL vs. 20.6 mL, p = 0.022). After adjusting for SBP and ICH score, patients with elevated BUN/SCr had an average of 9 mL larger ICH volumes on admission. Conclusions: Elevated BUN/SCr ratio is linked to larger initial ICH volumes even after controlling for ICH score and SBP. This simple ratio is an independent predictor of ICH volume, may reflect poor hydration status, and can potentially be used in the early evaluation and treatment of ICH patients. Future studies to determine if correction impacts functional outcomes are warranted.

Defining the role of albumin infusion in cirrhosis-associated hyponatremia

The presence of negatively charged, impermeant proteins in the plasma space alters the distribution of diffusible ions in the plasma and interstitial fluid (ISF) compartments to preserve electroneutrality and is known as Gibbs-Donnan equilibrium. In patients with hypoalbuminemia due to underlying cirrhosis, the decrease in the plasma water albumin concentration ([Alb−]pw) would be expected to result in a decrease in the plasma water sodium concentration ([Na+]pw) due to an alteration in the distribution of Na+ between the plasma and ISF. In addition, cirrhosis-associated hyponatremia may be due to the renal diluting defect resulting from the intravascular volume depletion due to gastrointestinal losses and overdiuresis and/or decreased effective circulatory volume secondary to splanchnic vasodilatation. Therefore, albumin infusion may result in correction of the hyponatremia in cirrhotic patients either by modulating the Gibbs-Donnan effect due to hypoalbuminemia or by restoring intravascular volume in patients with intravascular volume depletion due to gastrointestinal losses and overdiuresis. However, the differential role of albumin infusion in modulating the [Na+]pw in these patients has not previously been analyzed quantitatively. In the present study, we developed an in vitro assay system to examine for the first time the quantitative effect of changes in albumin concentration on the distribution of Na+ between two compartments separated by a membrane that allows the free diffusion of Na+. Our findings demonstrated that changes in [Alb−]pw are linearly related to changes in [Na+]pw as predicted by Gibbs-Donnan equilibrium. However, based on our findings, we predict that the improvement in cirrhosis-associated hyponatremia due to intravascular volume depletion results predominantly from the restoration of intravascular volume rather than alterations in Gibbs-Donnan equilibrium.