Traumatic Aortic Injury in a 3-Year-Old Child - A Case Report and Literature Review

This case report describes a case of aortic injury with pseudo-aneurysm in a 3-year-old Saudi boy following a motor vehicle accident. The diagnosis was suspected on computed tomography scan, and emergency surgery was performed. A Dacron graft was inserted to repair the injured aorta. Postoperatively, absent femoral, and distal pulses were noted, and thromboembolectomy was performed with good outcome. We believe that our study makes a significant contribution to the literature because it raises awareness of aortic injury and rupture in pediatric patients with multi-organ trauma following motor vehicle accidents. A high index of suspicion and early intervention are essential in improving outcomes.

Intranasal Premedication Combined with Erector Spinae Plane Block during Spinal Surgery for a Paediatric Patient: A Case Report

Posterior spinal fusion surgery for congenital scoliosis may cause substantial surgical trauma. Erector Spinae Plane Block (ESPB) can alleviate pain in adults who undergo spinal surgery; however, reports regarding its use in paediatric patients are limited. Here, we report the case of a 2-year-old girl who underwent posterior spinal fusion for congenital scoliosis. The patient initially experienced severe sadness upon separation from her parents; however, after performing various interactive activities, premedication using intranasal dexmedetomidine and midazolam was administered to sedate the patient. Ultrasound-guided bilateral ESPB was applied for perioperative analgesia. The anaesthesiologist identified mild-to-moderate pain during the first 6 days after surgery using the visual analogue scale for pain and Face, Legs, Activity, Cry, and Consolability scale. Therefore, ESPB may provide a satisfactory analgesic effect and help reduce postoperative opioid consumption in children who require spinal fusion surgery.

Histone Deacetylase Inhibitors as Potential COVID-19 Virus RNA-Dependent RNA Polymerase Inhibitors: A Molecular Docking and Dynamics Study

The novel coronavirus disease that initially appeared in 2019, commonly identified as COVID-19 is an acute infectious disease precipitated by the SARSCoV- 2 and has become a severe pandemic health crisis. People stricken with a severe case of COVID-19 are subject to a relatively higher mortality rate, which is brought about predominantly by the difficulty of having potent and specific antiviral drugs for its treatment. In this context, the viral RNA-dependent RNA polymerase (RdRp) is an attractive target for antiviral inhibitors, mainly because of its essential role in processing the polyproteins translated from viral RNA. Moreover, histone deacetylases inhibitors represent one of the most promising antiviral agents. Therefore, in this contribution, the in silico structure-based drug design approach was employed to identify novel structural characteristics for the potential repurposed activity of HDACIs as antivirals against COVID-19. Herein, 12 HDAC inhibitors were screened to explore their potential anti-viral activity against RNA-dependent RNA polymerase (RdRp) (6NUR). Results revealed that large number of the screened HDAC inhibitors are strongly bound into the active binding site of crystallographic structure of RNA-dependent RNA polymerase (RdRp) (6NUR) with lowest CDOCKER energy and CDOCKER interaction energy are very close to those of the control drug remdesivir. Importantly, the virtually screened HDAC inhibitors, particularly, Givinostat, Pracinostat, Panobinostat, Romidepsin (FK228) and its active metabolite (RedF) could be promising candidates for COVID-19 RNA-dependent RNA polymerase (RdRp) inhibitors. Significantly, these inhibitors should be evaluated on their effectivity when treating COVID-19, specifically using the drugs that have been approved for clinical trials with limited toxicity.

Cytokine Release Syndrome after Tisagenlecleucel Infusion in Pediatric Patients with Refractory/Relapsed B-Lineage Acute Lymphoblastic Leukemia: Is there a Role for Diclofenac?

Background: Cytokine Release Syndrome (CRS) is a major complication after Chimeric-Antigen Receptor (CAR) T cell treatment, characterized by an uncontrolled sistemic inflammatory reaction. The potential role of diclofenac in the management of CRS has been investigated in five pediatric patients treated for relapsed/refractory B-lineage acute lymphoblastic leukemia. Procedure: in case of persistent fever with fever-free intervals shorter than 3 hours, diclofenac continuous infusion was initiated, at the starting dose of 0.5 mg/Kg/day, the lowest effective pediatric dose, in our experience, possibly escalated up to 1 mg/Kg/day, as per institutional guidelines. Vital signs, O2 requirement, SpO2/FiO2 ratio and dosage of diclofenac and vasopressors until CRS resolution were recorded. Results: CRS occurred at a median of 20 hours (range 8-27) after tisagenlecleucel infusion. Diclofenac was started at a median of 20 hours (range 13-33) after fever onset. A mean of 3,07 febrile peaks without diclofenac and 0,95 with diclofenac were reported (p-value 0.02). A clinical benefit was achieved by hampering the progression of tachypnea and, mainly, tachycardia. Despite fever control, CRS progressed in four of the five patients and hypotension requiring vasopressors, fluid retention, besides hypoxia, occurred. Vasopressors were followed by 1-2 doses of tocilizumab (one in patient 2 and two in patients 3, 4, and 5), plus steroids in patients 4 and 5. Conclusion: based on a limited number of patients, diclofenac leads to a better fever control, which translates into symptom relief and improvement of tachycardia, but could not prevent the progression of CRS.

Current Nutritional Support in Critical Ill Covid-19 Patients: A Brief Review

Covid-19 is a high prevalence of pneumonia of pathless cause in that started in 2019 in Wuhan, Hubei Province, China. Five to 10% of the coronavirus SARSCoV- 2-infected patients, i.e., with new coronavirus disease 2019 (COVID-19), are presenting with an Acute Respiratory Distress Syndrome (ARDS) requiring urgent respiratory and hemodynamic support in the Intensive Care Unit (ICU). However, nutrition is an important element of care. The nutritional assessment and the early nutritional care management of COVID-19 patients must be integrated into the overall therapeutic strategy. Absence of treatment for this new virus, finding alternative methods to prevent and control the disease is important. Having a well-functioning immune system is essential for the host’s defense against pathogenic organisms. Malnutrition can lead to an impaired immune system during life. Even though the immune system response to infection is itself a factor that could lead to nutritional status impairment. Deficiency of some nutrients can lead to disorders of immune system. Adequate intake of vitamins (A, D, Bs, C and E), minerals (selenium, zinc and iron) and omega-3 fatty acids are among the essential factors in proper immune system function and the international recommendations on nutrition in the ICU should be followed. Some specific issues about the nutrition of the COVID-19 patients in the ICU should be emphasized. We propose a flow chart and ten key issues for optimizing the nutrition management of COVID-19 patients in the ICU.

The Use Extracorporeal Membrane Oxygenation Therapy in a Severe Blunt Chest Trauma with a Main Tracheal Injury

Major tracheobronchial trauma by blunt chest trauma is high mortality rates worldwide. The use conventional mechanical ventilation in a tension pneumothorax patient by major tracheobronchial trauma has been ineffective with barotrauma. However, the application of Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for recovery. Neither ECMO-associated bleeding nor clotting of the extracorporeal circuit is an upmost for trauma patients. We report a case of previously healthy 16-year-old man with left main bronchial rupture after vehicular accident, who had progressive dyspnea and left tension pneumothorax. After the chest tube drainage, double-lumen endotracheal intubation and mechanical ventilation initiation, severe respiratory distress kept on deterioration. On VV-ECMO transfer to our hospital, we performed emergency thoracotomy and identified the rupture of the left main bronchus. After operation, the patient’s condition improved. VV-ECMO and mechanical ventilation were stopped on days 8 and 9, respectively. He was discharged without complications from the ICU on day 20.