Opinion on the (Hemo)dialysate Sodium Prescription: Dialysate Sodium Prescription Should Not Be Considered in Isolation

With advances in hemodialysis technology and the desire to achieve cardiovascular stability during dialysis, prescribed dialysate sodium concentration has gradually increased over the years. Short-term trials suggest low dialysate sodium (<138 mEq/L) is beneficial in reducing interdialytic weight gain, pre- and post-dialysis BP, and predialysis serum sodium; but it increases intradialytic hypotensive episodes. We believe dialysate sodium prescription cannot be considered in isolation. Our approach is to use patient symptoms, meticulous fluid volume management and low temperature dialysate in conjunction with neutral dialysate sodium in managing our dialysis patients. Long-term trials are needed to inform optimum dialysate sodium prescription.

ROCURONIUM VERSUS CISATRACURIUM: INTUBATING CONDITIONS, EFFICACY, AND SAFETY.

Background: Neuromuscular blockers (NMB) are very important adjuvant to general anesthesia,Rocuronium bromide (aminosteroidal NMB) and cisatracurium besylate (benzylisoquinoline NMB) are recently introduced non-depolarizing muscle relaxants.In a prospective randomized study,we had compared both the drugs as regard to the onset of action, intubating conditions,clinical duration,hemodynamic changes,and adverse effects. Method: 80 female patients ASA I&II,18-60 year old underwent elective abdominal surgery under general anesthesia (GA) were randomly assigned into 2 equal groups.ROC group,where 0.9mg/kg rocuronium was given and CIS group, where 0.15mg/kg cisatracurium was given. Standardized GA was given to all patients as follows, fentanyl 1mcg/kg, propofol 2mg/kg,intubation was tried by the same anesthetist who was blind to the given NMB after 60 sec of injection, intubation was done if the intubating condition was acceptable (excellent or good),and it was re-attempted every 30 sec if it was poor or inadequate.Anesthesia was maintained by 60% N2O in O2 and isoflurane to a total MAC 1.5,controlled ventilation was adjusted to normocapnia.Mean arterial blood pressure (MAP),heart rate,and intubating conditions were recorded. Results: Clinically acceptable intubating conditions were achieved after 60 sec more frequently with rocuronium (80%) than with cisatracurium(0%).Rocuronium had advantage of rapid onset of action with good intubating conditions as compared to Cisatracurium and both were found to be potent and safe with excellent cardiovascular stability and also without any apparent histamine release. Conclusion: Rocuronium has a rapid onset of action with good intubating conditions in comparison to cisatracurium both are potent and safe with excellent cardiovascular stability and do not cause apparent histamine release

Anti-Diabetic Drugs in Cardiovascular Disease

Diabetes is one of the important risk factors in cardiovascular disease associated with atherosclerosis, and cardiovascular disease is the leading cause of death in patients with diabetes mellitus. Recent randomized placebo-controlled cardiovascular outcome trials of all new antidiabetic drugs have linked SGLT-2 inhibitors and GLP1-agonists to not only increased cardiovascular stability but significant reduction of cardiovascular disease. These results have led to preferential selection of the most effective and beneficial antidiabetic drugs with the evidence of cardiovascular safety and efficacy. Herein, we address cardiovascular stability and the effectiveness of antidiabetic drugs, focusing on recently developed ones.

Esmolol as an adjunct to general balanced anaesthesia in neurosurgery

Background/Aim: In surgery, and especially in the neurosurgical operations, maintenance of cardiovascular stability during and in the phase of the immediate postoperative recovery is of vital importance. The aim of this study was to investigate the effects of continuous esmolol infusion on the values of cardiovascular parameters and quality of the emergence from anaesthesia in neurosurgical patients. Methods: A total of 40 patients of both sexes scheduled for elective supratentorial surgery were randomly assigned to two groups. Esmolol group received intravenous (iv) infusion of esmolol dissolved in 5 % glucose solution (during the first 5 min at a rate of 0.3 mg/kg/min and thereafter at a rate of 0.1 mg/kg/min), while the ones from the control group received a 5 % glucose solution without esmolol at the same volume and rate. Cardiovascular parameters were registered at critical phases of anaesthesia and operation (induction, intubation, placement of Mayfield frame, craniotomy, skull closure, extubation). Recovery after anaesthesia was assessed based on times of eye opening on command, spontaneous eye opening and regaining of full orientation. Results: Values of systolic blood pressure and heart rate were significantly lower in the esmolol than in the control group of patients. Although the durations of anaesthesia did not differ, patients from the esmolol group required significantly less opioids and isoflurane and recovered after the anaesthesia significantly faster than the patients in the control group. Conclusion: Ultrashort-acting beta-adrenergic receptor antagonist esmolol, administered as a continuous iv infusion, assures better cardiovascular stability and smoother emergence from the balanced inhalation general anaesthesia than the control glucose infusion in elective neurosurgical patients.

The BOAST recommendations for care of the older or frail orthopaedic trauma patient

Safe and effective care for the elderly or physiologically frail patient in cases of trauma requires a multidisciplinary perioperative approach. This article expands upon the British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines for the management of the older or frail orthopaedic trauma patient. Optimisation of the patient is key to a successful surgical outcome, because these patients often have significant comorbidities involving bone health, nutrition, cognitive function and cardiovascular stability. This article discusses the evidence base for tailoring the management of these patients and the importance of doing so in an ageing population. It considers the requisite preoperative procedures and investigations, guidelines for specific cases such as comatose patients or those with complex fractures, and ceiling of care discussions, and then focuses on the postoperative period, including physiotherapy, rehabilitation goals and medical management.

Alternative to General Anesthesia for a Stat Cesarean Delivery in a Patient with a Large Arteriovenous Malformation Involving the Cervicomedullary Junction in Active Labor

A 20-year-old G1P0 patient at 38 weeks and 1 day of gestation was admitted for emergency cesarean delivery. Her past medical history was positive for cervicomedullary arteriovenous malformation (AVM) that ruptured three years before. Spontaneous vaginal delivery was contraindicated by neurosurgery. Aiming for cardiovascular stability and immediate reduction of sympathetic activity, a combined spinal epidural was successfully placed. An uneventful cesarean section was performed. The patient was transferred to the intensive care unit neurologically intact and discharged home after 8 days. This report describes an unusual anesthetic management of a patient with a large AVM in active labor.

Spinal Anesthesia for Removal of Thoraco-Lumbar Pedicle Screw

Background: Spinal anesthesia compared to the general anesthesia has advantages of decreased blood loss, better cardiovascular stability, and postoperative pain control. This study was designed to evaluate pedicle screw removal at the lateral position under spinal anesthesia. Methods: It is a prospective study done in patients with ASA (American Society of Anaesthesiologist) I and II with ages between 17 to 75 years of both sex admitted for pedicle screw removal surgery during the period March 2018 to April 2019 AD in Western Hospital and research center Nepalgunj. All patients were informed about the risk of conversion to general anesthesia in detail. Spinal anesthesia was given to all 83 patients who came for pedicle screw removal. Result: Out of all patients 54% were from Hills and the remaining 46% were from Terai. The commonest cause of injury was fall from a tree which was in 48 (57.8%) out of 83 cases. The commonest level of injury was L1 followed by L2. The operation was completed under spinal anesthesia. None of the patients required conversion to general anesthesia. And 69 (83.1%) patients did not require any additional medications whereas the remaining 14 (16.86%) needed additional medications. Conclusion: Spinal anesthesia is the safe and effective anesthetic technique for short duration spinal surgery eg pedicle screw removal in terms of perioperative events and in prolonged postoperative analgesia, as well as in terms of patient and surgeon’s satisfaction. Keywords: Spinal Anesthesia, Thoracolumbar, Pedicle Screw

PENGARUH POSISI PRONASI PADA BAYI PREMATUR TERHADAP PERUBAHAN HEMODINAMIK

Prematur merupakan bayi yang lahir sebelum usia kehamilan kurang dari 37 minggu. Lebih dari 75% bayi prematur mengalami gangguan pernafasan. Bayi prematur harus mendapat perhatian dan tatalaksana yang baik setelah lahir, untuk menghindari terjadinya masalah pernafasan yang lebih berat. Salah satu tatalaksana yang dapat menyokong terapi oksigen adalah pengaturan posisi pada bayi, yakni posisi pronasi. Posisi pronasi dilakukan untuk mengurangi kompresi abdomen dan memperbaiki fungsi pernapasan dan stabilitas kardiovaskuler. Penelitian ini bertujuan untuk mengetahui pengaruh pemberian posisi pronasi pada bayi prematur terhadap frekuensi nafas, frekuensi denyut jantung dan SpO2. Penelitian ini dilakukan pada bayi prematur yang dirawat di ruang neonatus dengan 32 sampel. Penelitian dilakukan pada bulan Maret – Mei 2018. Penelitian dilakukan dengan penelitian kuantitatif dengan menggunakan metode Quasi-Eksperimental dengan one group Pre-Post Intervensi. Hasil penelitian didapatkan ada pengaruh yang signifikan posisi pronasi pada bayi terhadap peningkatan saturasi oksigen pre-post intervensi 1 dan 2 jam pertama (Pv 0.00), ada pengaruh yang signifikan posisi pronasi pada bayi terhadap HR pre-post intervensi 1 jam pertama (Pv 0.027) dan 2 jam pertama (Pv 0.008). Posisi pronasi dapat diimplementasikan pada bayi premature untuk meningkatkan status hemodinamik yang berdampak pada kualitas hidup bayi. Premature is a baby born before pregnancy is less than 37 weeks. More than 75% of premature babies had respiratory problems. Premature babies must get good attention and management after birth, to avoid more severe respiratory problems. One of the procedures that can support oxygen therapy is the regulation of position in the baby, namely the pronation position. The pronation position is performed to reduce abdominal compression and improve respiratory function and cardiovascular stability. This study aims to determine the effect of giving pronation position in premature infants on the frequency of breath, heart rate and SpO2. The study was conducted in preterm infants who were treated in the neonates room with 32 samples. The study was conducted in March - May 2018. The study was conducted with quantitative research using the Quasi-Experimental method with Independent Test and Pre-Post Intervention. Results: There was a significant effect of pronation position on infants on the increase in oxygen saturation pre-post intervention 1 and the first 2 hours (Pv 0.00), there was a significant influence on pronation position in infants on the first 1 hour HR pre-post intervention (Pv 0.027) and first 2 hours (Pv 0.008). The position of pronation can be implemented on a premature baby to increase haemodynamic status that have an impact on the quality of life of infants.