Early Aggressive Resuscitation Research Articles

Different but Equal: Outcomes of Prolonged Postanesthesia Care Unit Stay After Trauma Laparotomy

IntroductionHospital overcrowding is common and can lead to delays in intensive care unit (ICU) admission, resulting in increased morbidity and mortality in medical and surgical patients. Data on delayed ICU admission are limited in the postsurgical trauma cohort. Damage control laparotomy with temporary abdominal closure (DCL-TAC) for severely injured patients is often followed by an aggressive early resuscitation phase, usually occurring in the ICU. We hypothesized that patients who underwent DCL-TAC with initial postanesthesia care unit (PACU) stay would have worse outcomes than those directly admitted to ICU. MethodsA retrospective chart review identified all trauma patients who underwent DCL-TAC at a level 1 trauma center over a 5 y period. Demographics, injuries, and resuscitation markers at 12 and 24 h were collected. Patients were stratified by location after index laparotomy (PACU versus ICU) and compared. Outcomes included composite morbidity and mortality. Multivariable logistic regression was performed. ResultsOf the 561 patients undergoing DCL-TAC, 134 (24%) patients required PACU stay due to ICU bed shortage, and 427 (76%) patients were admitted directly to ICU. There was no difference in demographics, injury severity score, time to resuscitation, complications, or mortality between PACU and ICU groups. Only 46% of patients were resuscitated at 24 h; 76% underwent eventual primary fascial closure. Under-resuscitation at 24 h (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.31-0.95, P = 0.03), increased age (AOR 1.04; 95% CI 1.02-10.55, P < 0.0001), and increased injury severity score (AOR 1.04; 95% CI 1.02-1.07, P < 0.0001) were associated with mortality on multivariable logistic regression. The median time in PACU was 3 h. ConclusionsPACU hold is not associated with worse outcomes in patients undergoing DCL-TAC. While ICU was designed for the resuscitation of critically ill patients, PACU is an appropriate alternative when an ICU bed is unavailable.

EGS P07 Upper GI Injury trends, rates, and mortality in major trauma centre

Abstract Background Trauma is one of the leading causes of death in UK. Moderate and severe trauma presents with multi-organ / multi cavity involvement. Robust resuscitation, methodical approach, prompt diagnosis and early surgical intervention have an impact on mortality. Injury severity score (ISS) is widely used across trauma centres to estimate severity. It is found to be linked with mortality and outcome. An ISS of 9-15 classes as moderate and an ISS of &amp;gt; 15 is considered severe trauma. In this study we aimed to evaluate the mortality associated with upper GI injuries I.e., oesophagus, stomach, duodenum, liver, pancreas, spleen and diaphragm. Methods Retrospective analysis was carried out on prospectively maintained trauma data base in an urban major trauma centre (MTC) with tertiary upper GI surgical cover. All patients presenting with moderate or severe trauma based on ISS between 1st of January 2012 to 31st of Dec 2022 were included in this study. Proportion of upper GI injuries in reference to overall major trauma cases were analysed. All cause index-admission mortality associated with upper GI injuries was calculated. Results A total of 8984 patients presented in this centre with moderate - severe trauma (ISS&amp;gt;9) during study period. Overall mortality was found to be 8.6% (n=780). Liver injuries were seen in 228 (2.5%), splenic injuries in 226 (2.5%), diaphragmatic rupture in 26 (0.29%), oesophago-gastric (OG) trauma in 16 (0.2%) and duodenum and pancreatic injuries in 15 (0.17%) patients. Highest mortality was found in OG trauma with 31.2%, followed by diaphragmatic injures with 19%, liver injuries with 12.7%, splenic injuries with 9.3%. Upper GI injuries are associated with high median ISS of 28.5 and present as polytrauma spectrum. Conclusions Although oesophago-gastric injuries are rare but, have relatively high mortality. Early aggressive resuscitation, involvement of oesophago-gastric or HPB surgeons, and multidisciplinary approach is required to deal with such complex injuries to get the best outcome. Robust national collaborative mechanisms across MTCs should be encouraged to share experiences, learn lessons and promote research.

Fulminans Purpura due to Morganella morganii.

Purpura fulminans is a dermatological manifestation of an underlying life-threatening condition, and is characterized by disseminated intravascular coagulation and skin necrosis.It is a morbid and potentially fatal condition that can be a cutaneous manifestation of Morganella morganii bacteraemia.Early identification and accurate diagnosis of the underlying cause can help minimize morbidity and mortality; management should be tailored to the individual, with the use of intravenous antibiotics, necrotic skin excision and aggressive early resuscitation.

Characteristics and Outcomes of Traumatic Cardiac Arrests in the Pan-Asian Resuscitation Outcomes Study*

Objective Little is known about survival outcomes after traumatic cardiac arrest in Asia, or the association of Utstein factors with survival after traumatic cardiac arrests. This study aimed to describe the epidemiology and outcomes of traumatic cardiac arrests in Asia, and analyze Utstein factors associated with survival. Methods Traumatic cardiac arrest patients from 13 countries in the Pan-Asian Resuscitation Outcomes Study registry from 2009 to 2018 were analyzed. Multilevel logistic regression was performed to identify factors associated with the primary outcomes of survival to hospital discharge and favorable neurological outcome (Cerebral Performance Category (CPC) 1-2), and the secondary outcome of return of spontaneous circulation (ROSC). Results There were 207,455 out-of-hospital cardiac arrest cases, of which 13,631 (6.6%) were trauma patients aged 18 years and above with resuscitation attempted and who had survival outcomes reported. The median age was 57 years (interquartile range 39–73), 23.0% received bystander cardiopulmonary resuscitation (CPR), 1750 (12.8%) had ROSC, 461 (3.4%) survived to discharge, and 131 (1.0%) had CPC 1-2. Factors associated with higher rates of survival to discharge and favorable neurological outcome were arrests witnessed by emergency medical services or private ambulances (survival to discharge adjusted odds ratio (aOR) = 2.95, 95% confidence interval (CI) = 1.99–4.38; CPC 1-2 aOR = 2.57, 95% CI = 1.25–5.27), bystander CPR (survival to discharge aOR = 2.16; 95% CI 1.71–2.72; CPC 1-2 aOR = 4.98, 95% CI = 3.27–7.57), and initial shockable rhythm (survival to discharge aOR = 12.00; 95% CI = 6.80–21.17; CPC 1-2 aOR = 33.28, 95% CI = 11.39–97.23) or initial pulseless electrical activity (survival to discharge aOR = 3.98; 95% CI = 2.99–5.30; CPC 1-2 aOR = 5.67, 95% CI = 3.05–10.53) relative to asystole. Conclusions In traumatic cardiac arrest, early aggressive resuscitation may not be futile and bystander CPR may improve outcomes.

Effect of the "Time to Surgery" on Civil Cranial Gunshot Injuries: Syria War.

Studies on cranial gunshot injuries in the Syrian war are present in the literature. However, the effect of surgical timing on the clinical outcomes of patients undergoing surgical treatment has not been discussed extensively. In this study, the time from injury to surgery is called "time to surgery." Kilis, a city close to Aleppo, Afrin, and Azez, where the conflicts in Syria are intense, is one of the cities where the first emergency treatments were administered. This study aimed to evaluate patients who underwent surgery in Kilis State Hospital due to cranial gunshot injury in the Syrian war and to investigate the effect of surgical timing on mortality and Glasgow Outcome Score.Surgical treatment was applied to 42 (32.8%) patients in the first 4 hours, 64 (50%) patients within 4 to 24 hours, and 22 (17.2%) patients between 24 hours and 3 days. As the time to surgery decreased, the good Glasgow Outcome Score (GOS) (4-5) outcome rates increased. The differences in surgical timing and GOS results of patients with Glasgow Coma Score (GCS) <8 and >8 were found to be significant for good GOS results. As the time to surgery decreased for patients with a GCS <8 and >8, mortality rates decreased equally. This result was statistically significant.Our study showed that surgical timing is as important as early intubation, aggressive resuscitation, and admission GCS for both survey and GOS.

OUR SURGICAL EXPERIENCE IN ACUTE MESENTERIC ISCHEMIA- VARIOUS PATHOPHYSIOLGICAL TYPES – A CASE SERIES

BACKGROUND: Mesenteric ischemia is a frequently lethal condition resulting from critically reduced perfusion to the gastrointestinal tract. It accounts for 1-2% of hospital admissions for abdominal pain. Mortality due to mesenteric ischemia ranges from 24% to 96% with an average of 69%. AIM: The aim of this case series is to outline the clinical presentation and challenges in diagnosis of acute mesenteric ischemia and emphasize the importance of early diagnosis and intervention in reducing the mortality and morbidity. This article presents a series of 4 cases of the 3 major types of acute mesenteric ischemia – 2 cases of Acute Mesenteric Arterial Thrombosis(AMAT), one case of Acute Mesenteric Arterial Embolism(AMAE) and one case of Mesenteric Venous Thrombosis(MVT). MATERIALS AND METHODS: A total number of 4 patients who had undergone emergency laparotomy for acute mesenteric ischemia during the month of December 2020 in the Department of General Surgery, Government Kilpauk Medical College were studied. All 4 cases have been analysed during this study period of one month and followed up until discharge from the hospital. RESULTS: This case series consisted of 4 cases. Out of 4 cases, 3 were cases of Superior Mesenteric Arterial Occlusion due to thrombus and emboli and 1 was a case of Superior Mesenteric Vein Occlusion by thrombus. All 4 were male patients. All 4 patients presented with sudden onset of abdominal pain with or without vomiting. Abdominal distension, constipation and clinical features suggestive of bowel gangrene was not seen in all cases. Out of 4 cases, 2 cases were diagnosed early and taken up for immediate surgery and had a better outcome postoperatively with shorter hospital stay. Denitive diagnosis could not be made at time of admission for one case and was taken up for surgery late after the general condition of the patient deteriorated and extensive gangrene of the small bowel was seen during surgery. One case succumbed to septic shock after surgery following delayed presentation. This case series attempts to highlight that the key to successful management in acute mesenteric ischemia is a high index of suspicion leading to early diagnosis, aggressive resuscitation and early mesenteric revascularization. CONCLUSION: Despite the remarkable advances in in vascular surgical technique, vascular imaging, percutaneous intervention and surgical critical care, mesenteric ischemia remains a complex and often disheartening disease. Acute mesenteric ischemia is a life threatening vascular emergency that requires a high degree of clinical suspicion and early intervention to avoid a poor outcome. As Acute Mesenteric Ischemia often affects elderly patients, we have to consider the possibility of acute mesenteric ischemia in all elderly patients presenting with abdominal pain that is out of proportion to the ndings on physical examination

Spontaneous Spleen Rupture and Apixaban

Novel oral anticoagulants (NOACs) are now widely used. Spontaneous splenic rupture (SLR) is a rare condition. It is life-threatening, especially if not immediately recognized. Previous studies have shown an association between NOAC use and SLR. We report a case of a 53-year-old female patient who responded to cardiopulmonary resuscitation (CPR) after SLR. The patient, who had an external cardiac device for heart failure 13 months ago was admitted to our emergency department. She was unconscious, pale, hypotensive and had tachycardia. Free fluid was detected in the peritoneum by bedside ultrasonography. The patient was resuscitated for 20 minutes after arrest during the follow-up period. She was stabilized and computed tomography showed a large subcapsular splenic hematoma with active extravasation around the spleen, but persistent low urine output developed with hypotension despite resuscitation. She was taken to the operating room for splenectomy and abdominal washing. She was then recovered and discharged 17 days later. We wanted to draw attention to a patient with SLR due to NOACs. Rapid diagnosis and aggressive early resuscitation are critical in the management of NOAC associated SLR.

S1909 Black Esophagus: A Syndrome of Acute Esophageal Necrosis

INTRODUCTION: Black esophagus, also known as acute esophageal necrosis (AEN) syndrome is a rare entity characterized by patchy or diffuse circumferential black pigmentation of esophageal mucosa from ischemic necrosis and may present with life threatening upper gastrointestinal hemorrhage (UGIH) resulting in high mortality in immunocompromised patients. CASE DESCRIPTION/METHODS: A 56-year-old female with diabetes mellitus (DM), gastroesophageal reflux disease (GERD), and alcohol abuse (8–10 drinks daily) presented with multiple episodes of coffee ground emesis and epigastric abdominal pain for two days. The pain was sharp epigastric, 10/10 in severity, non-radiating, precipitated with ingestion of oral intake, without alleviating factors. On examination, she was tachycardic (120/minute) and hypotensive (80/50 mm of Hg), had oropharyngeal erythema with white spots on its posterior wall, and significant ptyalism. She had epigastric tenderness and unremarkable digital rectal examination. Laboratory workup revealed lactic acidosis (>15 mmol/L), acute kidney injury with creatinine 2.21 mg/dL, leukocytosis (18 k/dL), and transaminitis. A computed tomography (CT) of abdomen and pelvis without contrast was unremarkable. The hospital course was complicated by hematemesis, dysphagia, and melena. After initial resuscitation, esophagogastroduodenoscopy (EGD) was performed which revealed inflammation of the epiglottis, arytenoid cartilages, and dark mucosal pigmentation of distal 2/3 of the esophagus with associated hiatus hernia (Figure 1). A biopsy of esophageal mucosa demonstrated fragments of fibrinopurulent exudate and necrotic tissue with pigment deposition (Figure 2). Evidence of helicobacter pylori, cytomegalovirus, herpes simplex virus, candida albicans infections, and malignancy was not found on further testing. She was managed with strict NPO, total parenteral nutrition, proton pump inhibitors, and analgesics. Serial EGDs showed complete resolution of the lesion in 4 weeks and was transitioned to an oral diet. DISCUSSION: In this case, vascularity of the distal esophagus was compromised due to uncontrolled DM, GERD, and binge alcohol drinking, complicated with acute UGIH due to mucosal tears from persistent vomiting. Acute UGIH is alarming for AEN in patients with multiple co-morbidities and a high index of clinical suspicion is required for pursuing EGD for early diagnosis. Early recognition and aggressive resuscitation are the fundamental principles for the management of AEN and better outcome of the disease.Figure 1.: Distal two-thirds of the esophagus showing black pigmentation of mucosa due to ischemic necrosis.Figure 2.: A biopsy of esophageal mucosa demonstrating fragments of fibrinopurulent exudate and necrotic tissue with pigment deposition (arrow).

Profile and Outcome of Near-hanging Patients Presenting to Emergency Department in a Tertiary Care Hospital in South India - A Retrospective Descriptive Study.

Background:Hanging is one of the common modes of deliberate self-harm presenting to emergency departments (EDs) across the world. Early intervention and aggressive resuscitation can decrease the morbidity and mortality associated with near-hanging. Our aim was to study the profile of patients presenting with near-hanging and their outcome to our adult ED.Materials and Methods:Medical records of patients with age more than 15 years presenting with near-hanging to the ED was reviewed retrospectively. The following profile data such as age, gender, marital status, material used for hanging, and type of hanging were collected. The information regarding the outcome of the patients from the hospital also analyzed. The data were analyzed to express the mean (±standard deviation) for the quantitative variables and frequency for the qualitative variables (±percent) using SPSS statistical software.Results:The analysis of 2 years data from August 2014 to July 2016 revealed 77 patients reached the ED with near-Hanging. The mean age of the patients − 31.1 years. Approximately, 43% were complete hanging, while rest were partial hanging. Majority of the patients used dressing materials for hanging themselves. Out of 77 patients, 64 were discharged alive while 2 patients died in the hospital and 11 were left against medical advice.Conclusions:Hanging is still a major mode of deliberate self-harm in South India both among men and women. The outcome of near-hanging is positively influenced by early admission and active treatment.

Nutritional status of children with Wilms' tumour on admission to a South African hospital and its influence on outcome.

In developing countries up to 77% of children with cancer have been shown to be malnourished on admission. High rates of malnutrition occur due to factors such as poverty and advanced disease. Weight can be an inaccurate parameter for nutritional assessment of children with solid tumours as it is influenced by tumour mass. This study aimed to assess the prevalence of malnutrition amongst children with Wilms tumour (WT), the level of nutritional support received on admission and the influence of nutritional status on outcome. Seventy-six children diagnosed with WT and admitted to Inkosi Albert Luthuli Central Hospital between 2004 and 2012 were studied prospectively. Nutritional assessment was conducted using weight, height, mid-upper arm circumference (MUAC) and triceps skinfold thickness (TSFT) prior to initiating treatment. Outcome was determined 2 years after admission. Time until commencement of nutritional resuscitation and nature, thereof, were recorded. Stunting and wasting was evident in 12% and 15% of patients, respectively. The prevalence of malnutrition was 66% when MUAC, TSFT and albumin were used. Malnutrition was not a predictor of poor outcome and did not predict advanced disease. The majority of patients (84%) received nutritional resuscitation within 2 weeks of admission. When classifying nutritional status in children with WT, the utilisation of weight and height in isolation can lead to an underestimation of the prevalence of malnutrition. Nutritional assessment of children with WT should also include MUAC and TSFT. Early aggressive nutritional resuscitation is recommended.

Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients.

Early aggressive hemodynamic resuscitation using elevated plasma lactate as a marker is an essential component of managing critically ill patients. Therefore, measurement of blood lactate is recommended to stratify patients based on the need for fluid resuscitation and the risks of multiple organ dysfunction syndrome and death. Hyperlactatemia is common among critically ill patients, and lactate levels and their trend may be reliable markers of illness severity and mortality. Although hyperlactatemia has been widely recognized as a marker of tissue hypoxia/hypoperfusion, it can also result from increased or accelerated aerobic glycolysis during the stress response. Additionally, lactate may represent an important energy source for patients in critical condition. Despite its inherent complexity, the current simplified view of hyperlactatemia is that it reflects the presence of global tissue hypoxia/hypoperfusion with anaerobic glycolysis. This review of hyperlactatemia in critically ill patients focuses on its pathophysiological aspects and recent clinical approaches. Hyperlactatemia in critically ill patients must be considered to be related to tissue hypoxia/hypoperfusion. Therefore, appropriate hemodynamic resuscitation is required to correct the pathological condition immediately. However, hyperlactatemia can also result from aerobic glycolysis, unrelated to tissue dysoxia, which is unlikely to respond to increases in systemic oxygen delivery. Because hyperlactatemia may be simultaneously related to, and unrelated to, tissue hypoxia, physicians should recognize that resuscitation to normalize plasma lactate levels could be over-resuscitation and may worsen the physiological status. Lactate is a reliable indicator of sepsis severity and a marker of resuscitation; however, it is an unreliable marker of tissue hypoxia/hypoperfusion.

Evidence-based fluid management in the ICU.

Evidence-based fluid therapy is complicated by blurred boundaries toward other fields of therapy and the majority of trials not focusing on patient-relevant outcomes. Additionally, recent trials unsettled the faith in traditional concepts on fluid therapy. The article reviews the evidence on diagnosis and treatment of hypovolemia and discusses the use of balanced solutions and early goal-directed therapy (EGDT) in septic shock resuscitation. Hypovolemia should be diagnosed and its treatment guided by a multifaceted approach, including medical history, physical examination, volume responsiveness, and technical parameters - dynamic indicators, volumetric indicators, sonography, and metabolic indicators. Central venous pressure and pulmonary artery occlusion pressure should be avoided. In ICU patients, balanced crystalloids should primarily be used, because unbalanced infusions (especially saline) cause hyperchloremic acidosis which is associated with renal impairment and infections. Colloids are beneficial to restore blood volume rapidly. Hydroxyethyl starch may be harmful although the validity of the respective recent studies is limited by methodological flaws. Early aggressive fluid therapy is still beneficial in septic shock resuscitation, despite recent trials challenging the EGDT concept. Today, 10 years after Rivers, 'usual care' includes aggressive fluid resuscitation that is as effective as formal EGDT. Evidence-based fluid therapy includes a multifaceted diagnostic approach, the primary use of balanced crystalloids and early aggressive (septic) shock resuscitation.

Practical management of burns and inhalation injury

Burn injuries are often associated with profound physiologic derangements due to the nature of the underlying injuries and the overwhelming inflammatory response that ensues. In recent decades, a number of advancements have been made in the management of thermal burns. Inhalation injury frequently occurs in patients with thermal burns and can be a significant source of morbidity and mortality. Due to the intense inflammatory response that occurs after a burn injury, early aggressive volume resuscitation is necessary to minimize the risk of developing multiorgan dysfunction. Adequate sedation and analgesia, early enteral nutrition, physical rehabilitation, excision and grafting, and other supportive measures are also critically important to promoting healing and improving long-term outcomes. This review outlines a general approach to the management of patients with burn and inhalation injuries and highlights some of the recent advances in the care of these patients.

Fat Emboli Syndrome in a Child with Duchenne Muscular Dystrophy After Minor Trauma

BackgroundFat embolism syndrome is the result of systemic manifestations of fat emboli in the microcirculation. Duchenne muscular dystrophy is a condition that increases the risk of fracture resulting in fat emboli. Case ReportWe describe a patient with Duchenne muscular dystrophy who exhibited cardiopulmonary, neurologic, and ophthalmologic sequelae consistent with fat emboli syndrome after minor trauma. Why Should an Emergency Physician Be Aware of This?Fat embolism syndrome is a rare but important consideration with significant morbidity and risk of mortality in patients with Duchenne muscular dystrophy after even minor trauma. Early recognition and aggressive resuscitation are crucial to positive clinical outcomes.

Plesiomonas shigelloides Septic Shock Leading to Death of Postsplenectomy Patient with Pyruvate Kinase Deficiency and Hemochromatosis.

Although Plesiomonas shigelloides, a water-borne bacterium of the Enterobacteriaceae family, usually causes self-limiting gastroenteritis with diarrhea, several cases of sepsis have been reported. We report the case of a 43-year-old male patient with hemochromatosis, pyruvate kinase deficiency, and asplenia via splenectomy who developed septic shock caused by P. shigelloides complicated by respiratory failure, renal failure, liver failure, and disseminated intravascular coagulation. Early aggressive antimicrobial therapy and resuscitation measures were unsuccessful and the patient passed away. We kindly suggest clinicians to implement early diagnosis of septic shock, empirical coverage with antibiotics, and prompt volume resuscitation based on the high mortality rate of P. shigelloides bacteremia.

Impact of age on the clinical outcomes of major trauma.

In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing.We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients. Review of the literature. Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality. The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

Fluid management in patients with trauma: Restrictive versus liberal approach.

Trauma is a leading cause of death worldwide, and almost 30% of trauma deaths are due to blood loss. A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. Some recent studies have shown that early volume restoration in certain types of trauma before definite hemostasis may result in accelerated blood loss, hypothermia, and dilutional coagulopathy. This review discusses the advances and changes in protocols in fluid resuscitation and blood transfusion for treatment of traumatic hemorrhage shock. The concept of low volume fluid resuscitation also known as permissive hypotension avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that although lower than normal, is adequate for short periods. Permissive hypotension is part of the damage control resuscitation strategy, which targets the conditions that exacerbate hemorrhage. The elements of this strategy are permissive hypotension, minimization of crystalloid resuscitation, control of hypothermia, prevention of acidosis, and early use of blood products to minimize coagulopathy.

Impact of aggressive surgical intervention in fournier's gangrene and its correlation to the outcome in patients at a rural hospital

Background: Fournier’s gangrene is rare and rapidly spreading aggressive and progressive infection of the perineum in which fascial necrosis is more extensive than the visible gangrene. Early surgical debridement prompt antibiotic administration, are essential for a better prognosis. Delay in diagnosis or treatment increase the mortality rate. This could be because of the multi factorial and poly microbial association of the disease. Aim: We attempt to describe the importance of early radical debridement and its effect on the outcome of the disease. Methodology: We conducted an analytical study on 26 patients of Fournier gangrene admitted in the rural hospital from July 2011 to July 2014. On admission, their Fournier gangrene severity index was calculated. The broad spectrum antibiotics were started and radical debridement was done in all patients on the same day within 6 hours of admission. Daily dressing was done till the wound showed healthy granulation tissue. The scrotal skin was mobilized and suturing was done. Result: In our studies there was no mortality. This indicates that early aggressive resuscitation to correct the dehydration and early radical debridement improves the outcome in this rare and fatal disease.

Ebola virus disease: an update for anesthesiologists and intensivists.

PurposeEbola virus disease (EVD) is a viral hemorrhagic fever that is highly transmissible and all too often rapidly fatal. Recent outbreaks in West Africa reveal that this infection has the potential to be transmitted worldwide. Anesthesiologists and intensivists, due to their training in the management of the critically ill, may be called upon to assist in the management of these patients. The focus of this brief review is on the epidemiology, pathogenesis, and management of patients with EVD.SourceReview of the current literature.Principal findingsEbola virus disease causes severe diarrhea, electrolyte disturbances and other major end-organ dysfunction. Early aggressive resuscitation may reduce the mortality of this disease. There is presently no available vaccine nor cure, with experimental therapies having yielded limited success. Personal protective equipment (PPE) is necessary for all patient contact, and enhanced PPE is required for all aerosol-generating medical procedures.ConclusionAnesthesiologists and intensivists may be called upon to manage patients with EVD. It is important that these clinicians have an appreciation for the epidemiology and pathogenesis of this disease and for the proper utilization of PPE when treating these patients.

Neonatal cardiovascular emergencies after hospital discharge

Neonates with out-of-hospital cardiovascular emergencies get to Emergency Department or Neonatal Intensive Care Unit in a state of shock, which is a complex clinical syndrome characterized by an acute failure of the circulatory system with inadequate tissue and organ perfusion. It has been demonstrated that early recognition and time-sensitive aggressive resuscitation of neonatal shock significantly reduce mortality and improve outcomes [1]. The update algorithm for goal-directed treatment of neonatal shock emphasizes early use of therapies directed to restore threshold heart rates, normalize blood pressure and capillary refill ≤2 seconds and subsequent intensive hemodynamic support aimed to goals of central venous oxygen saturation (ScvO2) >70% and cardiac index (CI) >3.3 L/min/m2[ 2]. Rapid attainment of a vascular access is pivotal for fluid resuscitation and inotrope therapy and an intraosseous needle must be early inserted especially in the case of cardiac arrest or decompensated shock [3]. Rapid crystalloid boluses of 10-20 ml/kg (over 5-10 minutes) up to 60 ml/kg in the first hour must be administered paying attention to signs of fluid overload because overaggressive therapy can be detrimental in case of cardiogenic shock. An echocardiographic analysis can help clinicians to assess the inferior vena cava diameter or collapsibility as an index of preload status [4] and to evaluate the ventricular size and contractility to identify a cardiogenic shock [5]. Prostaglandin infusion is recommended until a ductal-dependent lesion is ruled out by trained echocardiographists. Empiric antibiotics should be administered within one hour if a sepsis is suspected [6]. Neonates with fluid refractory shock need to start and titrate a peripheral inotropic support and progressively to be added vasopressors according to the hemodynamic state. Many methods are available for the hemodynamic monitoring after the first hour of stabilization of the neonate. A safer ultrasound-guided central venous access can easily be obtained [7] and ScvO2 be measured. The radial arterial pressure monitoring is recommended and the arterial waveform can be used to derive additional hemodynamic information. The monitoring of CI is feasible in neonates only by non-invasive methods such as doppler echocardiography or impedance cardiography [8]. Many aspects of the intensive hemodynamic support of neonatal shock resemble those of paediatric critical care medicine (PCCM) usually provided by anaesthesiologists. We believe that neonatologists need a specific PCCM training before dealing with critically ill neonates and for this purpose our team has devised some courses (Figure ​(Figure1)1) to meet these particular educational and procedural skill needs. Figure 1 Simulation-based training of an ultrasound-guided central venous catheterization. The figure illustrates the ultrasound-guided vessel puncture technique by using phantoms. The trainee visualizes the simulated vessel in transverse scans (short axis) and ...