Mortality Reduction in ICU-Admitted COVID-19 Patients in Suriname after Treatment with Convalescent Plasma Acquired Via Gravity Filtration

Introduction: Although convalescent plasma (CP) treatment is a potential therapeutic option for patients with COVID-19, there is a paucity of data from intensive care unit (ICU) patients with COVID-19 in low-resource settings, such as Suriname. CP was produced by a novel gravity-based filtration method. Methods: In an open-label, multi-center, non-randomized prospective clinical trial, patients with severe or life- threatening COVID-19 symptoms (n=28) with CP treatment were compared with standard treatment alone (n=50). A pre-planned interim analysis is reported. The primary endpoint was a 28-day ICU mortality. Secondary endpoints were changes two days after treatment initiation in pulmonary oxygen exchange capacity (PF ratio) and chest x-ray (CXR) score. Results: Mortality occurred in 18% (CP: 5/28) vs. 36% (Control:18/50). CP treatment of severe COVID-19 resulted in a higher probability of survival, with a hazard ratio (HR) of 0.22 (95% CI, 0.074-0.067), correcting for age, the presence of diabetes and COVID-19 severity. In the severe group, CP resulted in an improved CXR score (P = 0.0013) and increase in PF ratio (P = 0.011) as compared to standard therapy. The gravity-based plasmapheresis method used for CP production was well-tolerated and no adverse events were observed in the donors. Discussion: CP therapy in combination with standard treatment resulted in 78% reduction of 28-day ICU mortality (HR = 0.22) compared to standard treatment alone. Both CXR-score and PF ratio changes represent effective indicators for the treatment effect of CP after two days. The novel CP production method was effective and represents a practical solution for Low- and middle-income countries to produce CP.

Dexmedetomidine as an Anaesthetic Adjunct in Patients Undergoing Elective Off-Pump Coronary Artery Bypass Graft Surgery

Background: The aim of the present study was to study the hemodynamic profile of dexmedetomidine during induction and distal anastomosis of coronary arteries in patients undergoing OPCAB in comparison to the institutional practice of using midazolam. Methods: In Group I, (n=25) patients were anaesthetised using fentanyl, pancuronium bromide, Isoflurane and midazolam. Group II (n=25) patients received a loading dose of dexmedetomidine infusion (1µg/Kg) over 10 minutes followed by an infusion of dexmedetomidine at the rate of 0.6 µg/Kg/hour, along with fentanyl, Pancuronium bromide and isoflurane. Heart rate (HR) mean arterial pressure (MAP), pulmonary artery (PA) catheter derived data and BIS were recorded at baseline, at 1 and 3 minutes after induction, at 1, 3 and 5 minutes after intubation, and at 5 and 30 minutes after protamine administration. MAP and HR were recorded every 10 min during the operation, except during distal anastomosis of the coronary arteries when it was recorded every 5 minutes after application of the Octopus tissue stabilising system. Results: The intubation response by way of increase in HR was much less in group II and stabilized by 5 min after intubation. The accompanying hypotension at 1 minute after induction was more in group II, but it was clinically acceptable (81.68±21.74 mm Hg). During distal graft anastomoses HR was in the range of 68 beats/min to 85 beats/min in group II vs. 85 beats/min to 100 beats/min in Group I. The MAP was lower in this group during the distal anastomosis, but it was within clinically acceptable range (> 65 mm Hg). Conclusion: Dexmedetomidine is a viable option as an anaesthetic adjunct in a loading dose of 1µg/Kg followed by an infusion of 0.6 µg/Kg. Future studies will be necessary to show if this provides any outcome benefits.

The First International Guideline for Oxytocin Safely Decreased Oxytocin Amount During Cesarean Section: A Single-Institution Retrospective Analysis

Purpose: It is routine to administer oxytocin following delivery of the neonate during cesarean section. However, there are many kinds of administration methods. Heesen et al. published an international consensus statement in 2019 on the use of uterotonic agents, including oxytocin during cesarean section [1]. Our institution adapted the guideline-based oxytocin infusion method. We verified the validity of the new approach after one year. Methods: A single-center retrospective study of consecutive patients who underwent cesarean section with a new protocol or the conventional manner from November 2019 to December 2020 was conducted. The primary endpoint was a significant difference in the amount of intraoperative hemorrhage and the total oxytocin amount. Secondary endpoints included differences in the incidence of intraoperative complications. Results: The study included 174 patients: 66 in the new protocol group and 108 in the conventional group. There was a statistically significant difference between the two groups for oxytocin amount (new protocol 4.2 [3.2-5.9] vs. conventional 5.0 [5.0-10] IU, p<0.01) with equivalent intraoperative hemorrhages (new protocol 558 [337-963] vs. conventional 683 [484-1012] g, p=0.08). There was no significant difference in the incidence of nausea. Conclusion: The new guideline-based oxytocin administration safely decreased the intraoperative oxytocin amount in our institution.

The Preschool Child in Acute Dental Care - Sedation and Physical Restraint in Collaboration with Guardians

This article is aimed at dentists who treat children under 6 years of age for acute dental care requiring sedation, and where physical restraint may be necessary. Physical restraint means the occasional holding of the child so that invasive procedures can be performed, with little risk of inflicting physical and/or mental harm. Where circumstances require sedation and physical restraint, emphasis should be placed on the dentist’s preoperative information to the guardian for consent. It is crucial that the guardian decides on an active or passive role regarding support of the child. The recording of this information follows lege artis treatment regulations.

A Review of the Electrophysiological Neuroprognostications after Out of Hospital Cardiac Arrest

This personal opinion review of the potential role for EEG in the multimodal neuroprognostication of comatose cardiac arrest patients, after resuscitation and targeted temperature management, discusses recent findings along with our personal experience from a large single-center cohort of 220 consecutive patients investigated with electrophysiological tests (EEG and SSEP). Although EEG has its limitations, along with all modalities in the multimodal prognostic framework, when timed appropriately and interpreted in a standardized fashion, it can be probabilistic but not deterministic of an individual patient’s neurological prognosis. The EEG phenotype can indicate both good and poor prognoses for a comatose patient on the Intensive Care Unit, which is a distinct advantage of this widely available modality, whilst an SSEP can reliably predict a poor outcome if absent and may also help predict good outcome using amplitude analysis.

Effects of Desflurane Versus Propofol Anesthesia on Regional Cerebral Oxygenation during Spinal Surgery in the Prone Position

Context: Postural change during anaesthesia has a complex effect on systemic and cerebral circulations. Aim: The goal of the study was to evaluate the effects of desflurane and propofol on cerebral oxygenation during spinal surgery in the prone position. Settings and Design: A prospective randomized double-blinded trial. Methods and Materials: Fifty-two patients scheduled for spinal surgery were randomly allocated to propofol (n=25) and desflurane (n=27) groups. Anaesthetic agents were maintained to obtain a bispectral index of 50-55. SAP, DAP, HR, SPO2, ETCO2 and right and left rSO2 were assessed at seven-time points: supine position without oxygen administration (T1), supine position with oxygen administration (T2-baseline), intubation in the supine position (T3), just after prone positioning (T4), 10 minutes after prone positioning (T5), at the end of surgery in the prone position (T6) and at the end of anaesthesia in the supine position (T7). PCO2, PO2 and Hb partial were also recorded at T3 and T7. Results: Demographic data, pre-oxygenation hemodynamic variables and rSO2 were comparable between the groups. There was no significant difference between groups in SAP, DAP, HR, SPO2, and ETCO2 (p=0.095, p=0.061, p=0.357, p=0.088, p=0.328 respectively). PCO2, PO2 and Hb were not significant different between groups (p=0.542, p=0.394, p=0.768 respectively). rSO2 values were not significantly different between groups. In the propofol group, right rSO2 was significantly higher at T3 (p=0.017) and significantly lower at T5 (p=0,019) and at T6 (p=0,028) compared to baseline. Left rSO2 decreased significantly from baseline at T5 (p=0.026) in the propofol group. Left and right rSO2 in the desflurane group decreased significantly from baseline at T5 (p=0.0004 and p=0.0115). Conclusion: In the prone position, desflurane and propofol were associated with a significant decrease in rSO2 without differences between these anaesthetics.

Rapid Sequence Intubation with Remifentanil During COVID-19 Pandemic

We greatly appreciate the interest that De Melo MS, et al. showed on the use of remifentanil in a rapid sequence intubation technique that we recently proposed for patients undergoing surgery during the current SARS-CoV-2 pandemic [1, 2]. The authors also reported the response that Tang and Wang wrote to comment on that paper [3]. Given the interest aroused by our article, we think it would be worth making some clarifications. In brief, in order to limit aerosolization, we proposed to systematically perform rapid induction and intubation in the surgical patient after he had reached a state of deep analgesia with a continuous infusion of high-dose remifentanil (0.2-0.3 g/kg/min) [2]. Although in the title of the article this method is labeled as a rapid sequence induction, in the text, we explain how this technique, far from being standard rapid sequence intubation, was a rather longer technique in which the patient, although in a state of profound analgesia and sedation induced by remifentanil, breathed spontaneously and at last on command, until hypnosis, and muscle paralysis was rapidly induced with a low dose of propofol (<0.5 mg/kg) or midazolam (0.05-0.1 mg/kg) and a full dose of rocuronium (1 mg/kg) [2].