Enhancement of central norepinephrinergic neurotransmission contributes to inhibition of seizure-induced respiratory arrest by targeting the beta-1 adrenergic receptor (β1-AR) locating in the cardiomyocytes in the DBA/1 mouse SUDEP model

Sudden unexpected death of epilepsy (SUDEP) is the key cause of of death in patients with epilepsy. Due to the complicated pathogenesis of SUDEP, however, the exact mechanism of SUDEP remains elusive. Currently, although it is recognized that the seizure-induced respiratory arrest (S-IRA) may be a main cause for SUDEP, other factors resulting in SUDEP can not be excluded e.g arrhythmias. Our previous findings indicated that the incidence of seizure-induced respiratory arrest S-IRA and SUDEP evoked by acoustic stimulation or pentetrazol (PTZ) injection was significantly reduced by atomoxetine, a norepinephrine reuptake inhibitor (NRI), suggesting that noradrenergic neurotransmission modulates S-IRA and SUDEP. Given that norepinephrine acts on the central and peripheral target to modulate respiratory and circulation function by targeting adrenergic receptor α and beta (a-AR and β-AR) and the arrhythmias can be contributed to SUDEP. Meanwhile, to further test whether cardiac factors are implicated in S-IRA and SUDEP, we choose esmolol hydrochloride, a selective antagonist of beta-1 adrenergic receptor (β1-AR) to test it in our models. Our findings demonstrated that the lower incidence of S-IRA and SUDEP evoked by acoustic stimulation or PTZ in DBA/1 mice by administration with atomoxetine was significantly reversed by intraperitoneal (IP) of esmolol hydrochloride. Importantly, the data of electrocardiogram (ECG) showed that the cardiac arrhythmia evoked by acoustic stimulation including the ventricular tachycardia, ventricular premature beat and atrioventricular block and administration of atomoxetine significantly reduced theses arrhythmias and the incidence of S-IRA and SUDEP in our models. Thus, the dysfunction of respiratory and circulation may be implicated in the pathogenesis of S-IRA and SUDEP hand in hand and enhancing central norepinephrinergic neurotransmission contributes to inhibition of seizure-induced respiratory arrest by targeting β1-AR locating in the cardiomyocytes. Our findings will show a new light on decoding the pathogenesis of SUDEP. Keywords: sudden unexpected death in epilepsy (SUDEP); seizure-induced respiratory arrest S-IRA); esmolol hydrochloride (Esmolol); Electrocardiogram (ECG); locus coeruleus (LC); cardiac arrhythmia; pentetrazol (PTZ)

Laryngospasm Caused by Removal of Nasogastric Tube after Tracheal Extubation: Case Report

Background: We report a case of laryngospasm during nasogastric tube removal. Laryngospasm is a severe airway complication after surgery and there have been no reports associated with the removal of nasogastric tubes. Case Report: After abdominal surgery, the patient was extubated the tracheal tube, and was removed the nasogastric tube. Thereafter patient went into respiratory arrest. We attempted to ventilate using a face mask, and then through a supraglottic device, but both attempts were unsuccessful. Finally, we re-intubated her and stabilized her vitals. Conclusion: When patients are in emerging from anesthesia, nasogastric tube withdrawal may cause irritation of the vocal cords by gastric acids, and thereby, provoke laryngospasm. This can be avoided by removing it before reversing anesthesia or after the patient is awake.

Disruption of synaptic transmission in the Bed Nucleus of the Stria Terminalis reduces seizure-induced death in DBA/1 mice and alters brainstem E/I balance

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in refractory epilepsy patients. Accumulating evidence from recent human studies and animal models suggests that seizure-related respiratory arrest may be important for initiating cardiorespiratory arrest and death. Prior evidence suggests that apnea onset can coincide with seizure spread to the amygdala and that stimulation of the amygdala can reliably induce apneas in epilepsy patients, potentially implicating amygdalar regions in seizure-related respiratory arrest and subsequent postictal hypoventilation and cardiorespiratory death. This study aimed to determine if an extended amygdalar structure, the dorsal bed nucleus of the stria terminalis (dBNST), is involved in seizure-induced respiratory arrest (S-IRA) and death using DBA/1 mice, a mouse strain which has audiogenic seizures and a high incidence of postictal respiratory arrest and death. The presence of S-IRA significantly increased c-Fos expression in the dBNST of DBA/1 mice. Furthermore, disruption of synaptic output from the dBNST via viral-induced tetanus neurotoxin significantly improved survival following S-IRA in DBA/1 mice without affecting baseline breathing or hypercapnic and hypoxic ventilatory response. This disruption in the dBNST resulted in changes to the balance of excitatory/inhibitory synaptic events in the downstream brainstem regions of the lateral parabrachial nucleus (PBN) and the periaqueductal gray (PAG). These findings suggest that the dBNST is a potential subcortical forebrain site necessary for the mediation of seizure-induced respiratory arrest, potentially through its outputs to brainstem respiratory regions.

Polymyxin B infusion related respiratory arrest: A case report

A 73 years old male, known hypertensive on medication, with the history of SARS-CoV-2 infection nine months ago, presented to us with mucormycosis, he was treated with Liposomal amphotericin B initially. He developed acute kidney injury with recurrent pulmonary oedema requiring ICU admission and Haemodialysis. He later developed catheter related blood stream infection that grew Carbapenem resistant Klebsiella pneumonia and was started on Polymyxin B. However from day 3 of antibiotics he started to develop recurrent respiratory arrest with no apparent cause. He required a brief period of mechanical ventilation and was successfully weaned. He had recurrent such episodes with no apparent cause. After extensive work up and literature search it was diagnosed as Polymyxin B induced respiratory failure. Polymyxins were stopped, patient was discharged in a stable condition after five days of further observation and is currently on follow up with no such episode of dyspnoea.

PELATIHAN BANTUAN HIDUP DASAR/BASIC LIFE SUPPORT BAGI MAHASISWA FAKULTAS ILMU KESEHATAN UNIVERSITAS MUHAMMADIYAH MATARAM

ABSTRAKBantuan Hidup Dasar (BHD) adalah serangkaian usaha awal untuk mengembalikan fungsi pernafasan atau sirkulasi pada seseorang yang mengalami henti nafas dan atau henti jantung (cardiac arrest). Pengetahuan dan keterampilan BHD penting diajarkan terutama tentang teknik dasar penyelamatan korban yang mengalami henti jantung dan henti nafas. Kesiapsiagaan yang tepat berupa pelatihan kepada mahasiswa dalam pemberian BHD sebagai upaya penanggulangan yang cepat dan tepat sehingga dapat meminimalisir kematian akibat henti jantung yang terjadi di lingkungan Fakultas Ilmu Kesehatan Universitas Muhammadiyah Mataram. Saat ini belum ada mahasiswa yang mendapatkan pelatihan mengenai kemampuan melakukan bantuan hidup dasar, maka kegiatan pengabdian ini sangat penting untuk dilakukan untuk mengantisipasi adanya kasus henti jantung dan henti napas. Lokasi pelaksanaan kegiatan pengabdian kepada masyarakat adalah di Fakultas Ilmu Kesehatan, dengan waktu pelaksanaan selama 1 hari. Target dalam pengabdian ini yaitu adanya pemahaman mahasiswa akan perbedaan henti jantung dan serangan jantung dan cara melakukan pertolongan pertama. Luaran dari pengabdian ini adalah adanya peningkatan pengetahuan dan pemahaman mahasiswa dalam memberikan pertolongan pada korban henti nafas dan henti jantung jika ada kejadian henti jantung dan henti nafas yang terjadi di lingkungan Universitas Muhammadiyah Mataram. Kata kunci: bantuan hidup dasar; mahasiswa; fakultas ilmu kesehatan; universitas muhammadiyah mataram. ABSTRACTBasic Life Support (BLS) is a series of initial efforts to restore respiratory or circulatory function in someone who has stopped breathing and/or cardiac arrest. Knowledge and skills of BLS are important to be taught, especially about the basic techniques of saving victims who experience cardiac and respiratory arrest. Appropriate preparedness such as training for students in giving BLS as a quick and appropriate response to minimize deaths from cardiac arrest that occur in the Faculty of Health Sciences, Universitas Muhammadiyah Mataram. Currently, there are no students who have received training on the ability to perform basic life support, so this training is very important to do to anticipate cases of cardiac arrest and respiratory arrest. The location of the implementation of community service activities at the Faculty of Health Sciences, with an implementation time of 1 day. The target in this service is the students' understanding of the difference between cardiac arrest and heart attack and how to perform first aid. The output of training is an increase in students' knowledge and understanding in providing assistance to victims of respiratory arrest and cardiac arrest if cardiac arrest and respiratory arrest occur within the Universitas Muhammadiyah Mataram. Keywords: basic life support; student; faculty of health sciences; universitas muhammadiyah mataram.

COVID-19: A New Horizon in Congenital Heart Diseases

Objective: Previous studies have demonstrated that both children and adult patients with a history of congenital heart disease (CHD) are at high risk for coronavirus disease 2019 (COVID-19) infection. This study investigates the status of COVID-19 infection among children undergoing surgical repair within the past 2 years.Methods: All alive patients operated on in a tertiary referral center between March 2018 and March 2020 were recruited in the present study. Detailed demographics, past medical and surgical history, and physical examination were reviewed for each patient. During the COVID-19 pandemic, data regarding the patient's status were collected by telephone survey from April 15 to April 30, 2020.Results: A total number of 210 patients are analyzed in this study. Participants' median age was 21.59 months [interquartile range (IQR) = 12–54.67], and 125 (59.5%) were female. The median interval between surgery and COVID-19 assessment was 305 days (IQR = 215–400). In addition, 67 (32%) patients used angiotensin receptor blocker (ARB)/angiotensin-converting enzyme (ACE) inhibitor (spironolactone and/or captopril). Sixteen patients (7.6%) were symptomatic and had positive chest CT results and/or RT-PCR compared to the previously reported prevalence of COVID-19 among the pediatric population (2.4% of children with <18 years of age); the prevalence of COVID-19 among the patients operated on due to CHD in the present study was significantly higher (p = 0.00012). Two patients were admitted to the intensive care unit (ICU); one patient was discharged 2 weeks later with acceptable status, and one patient died 2 days after ICU admission due to cardiac and respiratory arrest and myocarditis. The complexity of the underlying cardiac disorders was not different between patients with low risk (p = 0.522), suspicious patients (p = 0.920), and patients positive for COVID-19 (p = 0.234). The ARB/ACE inhibitor consumption was not associated with the COVID-19 infection [p = 0.527, crude odds ratio (OR) = 1.407, 95% CI = 0.489–4.052].Conclusion: Children with a history of previous CHD surgery are more susceptible to infections, especially those infections with pulmonary involvements, as the lung involvement could cause worsening of the patient's condition by aggravating pulmonary hypertension. The results of the current study indicate that these patients are more prone to COVID-19 infection compared to the healthy children population.

Hemifacial spasm is not affected by state of consciousness: a case report

Background Hemifacial spasm (HFS) is a movement disorder caused by mechanical compression of the facial nerve after it has left the brainstem and is characterized by brief or sustained twitching of the muscles innervated by that nerve. Often we observe spasm in an awakening situation. Actually contractions persist during sleep. To our knowledge, there were no reports on how HFS manifests under disturbance of consciousness. Here, we report a case of primary HFS in which the patient's symptoms persisted in a coma. Case presentation A 74-year-old female with right-sided primary HFS for 20 years and had received botulinum toxin injections in our hospital. Unfortunately she was carried to emergency department after traumatic right pneumothorax by accident. During the emergency treatment, she lost consciousness due to simultaneous cardiac arrest and respiratory arrest. She was then admitted to the emergency intensive care unit for further treatment. During her hospitalization, she was in a coma with stable vital signs and persisting symptoms of HFS. Thus, a multidisciplinary consultation was requested to identify whether it was focal cortical seizures involving the right-side facial muscles. Physical examination revealed brief involuntary clonic or tonic contractions accompanied with the ‘Babinski-2 sign’. A combination of relevant data, including her past history, clinical presentation and a negative computed tomography scan of the head, led to a diagnosis of right-sided HFS. As the symptoms of HFS are not life-threatening, the use of anticonvulsants is unnecessary. Conclusions For the layperson, it is crucial to seek a multidisciplinary consultation to obtain a correct diagnosis.