Single Intravenous Bolus versus Continuous Infusion of Tranexamic Acid to Reduce Blood Loss in Transurethral Resection of Prostate: a Prospective Randomized Double-Blind Study

Background and aim Intraoperative use of a single bolus dose of tranexamic acid may not be sufficient to prevent bleeding in the early postoperative period. The present study was carried out to compare the effect of two dose regimens of tranexamic acid in reducing perioperative blood loss and the amount of allogeneic blood transfusion in transurethral resection of prostate. Design prospective, double-blinded and controlled study. Setting Ain Shams University Hospital, Patients and Methods 50 patients electively posted for transurethral resection of prostate were randomly assigned to receive a single bolus dose of tranexamic acid (10 mg/kg) (Group A), a bolus dose of tranexamic acid (10 mg/kg) followed by infusion (1 mg/kg/h) till 4 h postoperatively (Group B). Measurements Total intraoperative blood loss, amount of allogeneic blood transfusion, postoperative drain collections, and hemoglobin and hematocrit levels were recorded at different time intervals. Data obtained after comparing two groups were analyzed using the statistical package for social sciences. Results There was no statistically significant difference among patients in both groups regarding intraoperative blood loss and postoperative blood loss at 6 hrs and 48 hrs postoperatively. However the post-operative blood loss at 24 hrs was significantly higher among patients in group A than patients in group B (P-value= 0.014) . Conclusion Tranexamic acid causes more effective reduction in post-operative blood loss when used as a bolus followed by an infusion continued in the postoperative period in comparison to its use as a single intravenous bolus in transurethral resection of prostate.

A neuroanatomical mechanism linking perinatal TCDD exposure to lower urinary tract dysfunction in adulthood

Benign Prostatic Hyperplasia / Lower Urinary Tract Dysfunction (BPH/LUTD) is a classic disease of aging which affects nearly all men. Symptoms typically present in the fifth or sixth decade and progressively worsen over the remainder of life. Here, we identify a surprising origin of this disease that traces back to the intrauterine environment of the developing male, challenging existing paradigms about when this disease process begins. We delivered a single bolus dose of a widespread environmental contaminant, present in the serum of most Americans (2,3,7,8 tetrachlorodibenzo-p-dioxin, TCDD, 1 µg/kg), and representative of a broader class of environmental contaminants, to pregnant mice and observed an increase in the abundance of a neurotrophic factor, artemin, in the developing mouse prostate. Artemin is required for noradrenergic axon recruitment across multiple tissues and TCDD rapidly increases prostatic noradrenergic axon density in the male fetus. The hyperinnervation does not resolve, but rather persists into adulthood, when it is coupled to autonomic hyperactivity of prostatic smooth muscle and abnormal urinary function, including increased urinary frequency, a bothersome symptom in men. We offer new evidence that prostate neuroanatomical development is malleable and that intrauterine chemical exposures can permanently reprogram prostate neuromuscular function to cause male LUTD in adulthood.

Evaluation of the Effect of Single Bolus Dose of Intravenous Dexmedetomidine in Spinal Anaesthesia for Lower Limb Surgeries

Introduction: The use of intrathecal adjuvants in spinal anaesthesia in enhancing and prolonging it’s action has been well established and is widely used for surgery below the umbilicus. Dexmedetomidine, a selective α2A receptor agonist is a suitable adjuvant due to its selective activity. Objectives: To evaluate the effect of a single bolus dose of intravenous dexmedetomidine as an adjuvant in cases undergoing lower limb surgeries under spinal anaesthesia. Methodology: One hundred patients posted for lower limb surgery under spinal anaesthesia with hyperbaric bupivacaine, were equally divided into two groups. In group D, in addition to spinal, intravenous dexmedetomidine 0.5mcg/kg over 10 min was given whereas group C patients received spinal and intravenous normal saline . Results: The onset of sensory and motor block was faster in group D (2.09 ± 0.71 min, 3.18 ± 1min)compared to group C (3.5 ± 0.82 min, 6.19 ± 1.87 min) which was statistically significant . The duration of sensory and motor block was also significantly prolonged in Group D (174.5 ± 14.04 min, 133.4 ± 10.42 min) as compared to Group C(138.2 ± 11.51 min, 120.4 ± 8.8 min).The duration of analgesia in Group D (225.3 ±20.11 min)was prolonged when compared to Group C (168.3 ± 15.11). Conclusion: Intravenous dexmedetomidine as a single bolus dose before spinal anaesthesia can fasten the onset of sensory and motor block, prolongs the duration of sensory and motor block and also increased the duration of analgesia.

Index of Microcirculatory Resistance Measured during Intracoronary Adenosine-Induced Hyperemia

Background. The index of microcirculatory resistance is an invasive measure of coronary microvascular function that has to be calculated during maximal hyperemia, classically achieved with intravenous adenosine (IV). The aim of this study was to evaluate the use of intracoronary (IC) adenosine for the calculation of IMR. Methods and Results. 31 patients with stable coronary artery disease were included in the study. Coronary pressure and thermodilution measurements were obtained at rest and during maximal hyperemia using a pressure-temperature sensor-tipped coronary guidewire. Duplicate measurements were performed using first IC and then IV adenosine. Dispersion of transit times was comparable for IC and IV adenosine. IMR values based on IC vs IV adenosine showed a high level of agreement and an intraclass correlation coefficient of 0.90. Applying an upper normal limit of 25, misclassification of IMR using IC adenosine was seen in just one patient in whom IC adenosine resulted in a lower value. A simplified procedure based on a single bolus dose of saline did not change the level of agreement or the rate of misclassification. Conclusions. We found an excellent agreement between IMR values measured during hyperemia induced by IC as compared to IV adenosine. The use of IC adenosine may facilitate invasive assessment of microvascular function and is potentially time- and cost-saving with less patient discomfort as compared to IV infusion. The trail is registered with NCT03369184.

Comprehensive assessment of the pharmacokinetic properties of a single bolus dose of colecalciferol in terms of efficacy and safety

Background: The lack of a unified approach to the treatment of deficiency and vitamin D deficiency stimulated a detailed study of the dynamics of indicators of phosphorus-calcium metabolism, parathyroid hormone, 25(OH)D (calcidiol). Aim: To evaluate the pharmacokinetic properties of colecalciferol at a dosage of 150 000 IU, from the standpoint of its efficacy and safety in clinical practice. Materials and methods: Observational, single-center, prospective, selective, uncontrolled study of a comprehensive assessment of the pharmacokinetic properties of a single saturating dose of 150 000 IU of colecalciferol. To assess the pharmacokinetic properties of colecalciferol at a dosage of 150 000 IU, we set efficacy and safety criteria. The criterion for the effectiveness of treatment was to achieve an adequate level of vitamin D (more than 30 ng / ml at the initial insufficient level and more than 20 ng / ml for patients with vitamin D deficiency). The safety criteria for the correction of vitamin D deficiency or deficiency were the absence of patient complaints, adverse events and / or serious adverse events, as well as the preservation of the main laboratory parameters of phosphorus-calcium metabolism within the reference values. Results: When studying the efficacy of a dose of 150 000 IU in patients with vitamin D deficiency and insufficiency, it was found that the level of calcidiol was significantly higher in the group after treatment with colecalciferol compared with the group before treatment (p 0.05). The peak of the maximum value for patients with deficiency was established on the 14 day from the moment of administration of colecalciferol and was 37.1 6.28 ng / ml, and for patients with initial vitamin D deficiency 40.1 3.71 ng / ml. In the study of the safety of colecalciferol in a bolus dose of 150 000 IU, there were no statistically significant differences in the laboratory parameters of calcium-phosphorus metabolism, both in the group before treatment and after correction of deficiency and vitamin D insufficiency in both groups. Conclusion: Colecalciferol in the form of a single bolus dose of 150 000 IU demonstrated its efficacy and safety in real clinical practice.

Incidence of Hemidiaphragmatic Paralysis with Patient Controlled Infusion of Low Volume of Ropivacaine after Ultrasound Guided Low Dose Interscalene Brachial Plexus Block, A Prospective Observational Study

BACKGROUND Hemidiaphragmatic paralysis is a complication of single shot and continuous interscalene brachial plexus block that can be minimised by ultrasound guided extrafascial catheter placements and by limiting the amount of local anaesthetic administered. We hypothesized that patient controlled infusion of low volume of ropivacaine for a period of 24 hours would not cause hemidiaphragmatic paralysis and would provide adequate analgesia.METHODS 54 patients aged 18-65 years undergoing surgery for shoulder dislocation or proximal humerus fracture were recruited and allocated into two groups of 27 each, patient controlled interscalene analgesia (PCIA) and multimodal analgesia (MA). Interscalene catheter was inserted at end of surgery and 10 ml of 0.5% ropivacaine was administered as single bolus dose. PCIA was initiated after four hours to deliver background infusion of 2 ml/hr, bolus of 5ml (0.2% of ropivacaine) with lockout interval of 30 minutes for a total duration of 24 hours. Incidence of hemidiaphragmatic paralysis using M-mode ultrasonography was recorded at extubation,4,6,12 and 24hrs. Numerical rating scale (NRS) for pain, patient satisfaction score and complications were also recorded. Acetaminophen (1 gm) and diclofenac 75 gm were used in MA group.RESULT No diaphragmatic paresis was reported in patients administered the background infusion or single bolus doses of ropivacaine and scanned at 4, 6,12 and 24 hrs. Partial paresis was noted in all patients in which two bolus doses/hour were administered 30 minutes after the second bolus. All patients with paresis had diaphragmatic excursion normalized in the next recording made at 4 hours and no complication was reported in any patient. NRS was below 3 at all time points in PCIA and the cumulative fentanyl and tramadol consumption was significantly higher in MA group. The incidence of complete and partial paresis of diaphragm was 85%and 3.7% after single shot bolus dose respectively and had resolved before start of infusion after 4 hours.CONCLUSION Patient controlled low volume continous infusion of ropivacaine (2 ml/hr of 0.2% of ropivacaine) with administration of a single bolus dose of 5ml in an hour does not cause unilateral phrenic paresis. Partial paresis is reported with two bolus doses/hour.Clinical trial number NCT03081728 (clinicaltrials.gov;)