Base Excess Research Articles

Management strategy for open pelvic fractures: A 11-year single-centre, retrospective observational study

Introduction: Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures. Methods: We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality. ResultsForty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27–57 years) and median ISS was 34 (24–43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907–0.980; p = 0.003). ConclusionA low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings.

Arterial blood gases in newborn infants: Early extraction without prior clamping versus extraction after delayed clamping

ObjectivesTo compare the postpartum arterial blood gas parameters recorded early before cord clamping and after delayed cord clamping (DCC). To explore adverse effects and complications of the cord blood gas collection technique without clamping. DesignRandomised controlled trial. SettingBirthing room of La Ribera University Hospital (Valencia, Spain). Participants122 full-term infants born between February 2020 and January 2021. Two groups were established: the experimental group (early sampling prior to clamping and sampling again after DCC) and the non-experimental group (sampling only after DCC). Measurements and findingsThe comparison of arterial blood gas parameters was made using the Student t-test, while the Fisher's exact test was used to compare the proportion of the adverse effects recorded. The pH and base excess values in the experimental group were significantly greater when the sampling was performed without prior clamping. No statistically significant differences were observed in relation to pCO2 or the appearance of adverse effects between the two groups. No complications were recorded. Key conclusions and implications for practiceThe pH and base excess values were higher when the arterial blood gas measurements were made prior to performing the umbilical cord clamping than when the sampling was performed after the DCC. Arterial blood gas sampling without prior clamping was found to be safe, since no complications or increased adverse effects were observed. The use of this technique is therefore advised in normal births of full-term infants.

Utility of 6% hydroxyethyl starch 130/0.4 in oral cancer surgeries with a duration of over 6 hours: A retrospective case-control study.

To evaluate the utility of 6% hydroxyethyl starch (HES) 130/0.4 in oral cancer surgeries with durations over 6 hours. Using a case-control study design, the investigators enrolled patients who underwent oral cancer surgery involving osteotomy or manipulation near the major blood vessels at the Department of Orofacial Surgery in our hospital between 2017 and 2020. The predictor variable was 6% HES130/0.4. Outcomes included in-out balance and other postoperative parameters pertaining to circulatory maintenance (blood loss, urine volume, infusion volume, blood transfusion volume, albumin dose, hemoglobin levels, blood albumin levels, and doses of vasopressors used to maintain blood pressure), as well as pre- and postoperative renal function, pH, bicarbonate levels, and base excess. Changes in renal function were evaluated by assessing blood urea nitrogen and creatinine levels before surgery and at 1 and 7 days postoperatively. The Mann-Whitney U test was used for between-group comparisons, and Student t test was used for intragroup comparisons. The statistical significance was set at P < .05. A total of 65 patients underwent oral cancer surgery with a duration over 6 hours during the study period. The administration of 6% HES130/0.4 at 22.1 ± 7.5 mL/kg/day did not increase blood loss or the blood transfusion volume. Moreover, patients who were administered 6% HES130/0.4 had a significantly larger mean urine volume and infusion volume than those who were not administered 6% HES130/0.4. The infusion therapy could maintain the urine volume and did not worsen renal function. The results of this study showed that administration of 6% HES130/0.4 at a dose lower than 25 mL/kg in patients undergoing oral cancer surgery over 6 hours was effective for circulation maintenance but did not increase the intraoperative blood loss or transfusion volume. This treatment did not cause any dilutional metabolic acidosis or renal dysfunction.

Hemorrhagic Shock: Blood Marker Sequencing and Pulmonary Gas Exchange

The early identification of internal hemorrhage in critically ill patients may be difficult. Besides circulatory parameters, hemoglobin and lactate concentration, metabolic acidosis and hyperglycemia serve as laboratory markers for bleeding. In this experiment, we examined pulmonary gas exchange in a porcine model of hemorrhagic shock. Moreover, we sought to investigate if a chronological order of appearance regarding hemoglobin, lactatemia, standard base excess/deficit (SBED) and hyperglycemia exists in early severe hemorrhage. In this prospective, laboratory study, twelve anesthetized pigs were randomly allocated to exsanguination or a control group. Animals in the exsanguination group (n = 6) endured a 65% blood loss over 20 min. No intravenous fluids were administered. Measurements were taken before, immediately after, and at 60 min after the completed exsanguination. Measurements included pulmonary and systemic hemodynamic variables, hemoglobin concentration, lactate, base excess (SBED), glucose concentration, arterial blood gases, and a multiple inert gas assessment of pulmonary function. At baseline, variables were comparable. Immediately after exsanguination, lactate and blood glucose were increased (p = 0.001). The arterial partial pressure of oxygen was increased at 60 min after exsanguination (p = 0.04) owing to a decrease in intrapulmonary right-to-left shunt and less ventilation-perfusion inequality. SBED was different to the control only at 60 min post bleeding (p < 0.001). Hemoglobin concentration did not change at any time (p = 0.97 and p = 0.14). In experimental shock, markers of blood loss became positive in chronological order: lactate and blood glucose concentrations were raised immediately after blood loss, while changes in SBED lagged behind and became significant one hour later. Pulmonary gas exchange is improved in shock.

Rate of decline of fetal base excess after neuraxial anesthesia for scheduled cesarean delivery

In scheduled cesarean deliveries, the rate of decrease in the umbilical artery pH is related to the severity of maternal hypotension and the interval from spinal placement to delivery. Base excess values have greater use than umbilical artery pH values to time the duration of fetal acidemia because they demonstrate a linear rather than logarithmic correlation with the degree of acidosis. This study aimed to evaluate the rate of decline in the fetal base excess in scheduled cesarean deliveries that were converted to emergency cesarean delivery owing to fetal bradycardia following spinal anesthesia. All cases of scheduled cesarean deliveries in gestations at >34 weeks' gestation under spinal anesthesia that were converted to emergency cesarean deliveries owing to fetal bradycardia in the period May 2019 to May 2021 were reviewed. Included were those with (1) a preoperative reactive nonstress test and (2) fetal acidemia (umbilical artery pH <7.20). Excluded were those with anesthesia other than spinal and a birthweight below the 10th percentile for gestational age. Time intervals between the completion of spinal anesthesia and delivery were calculated and related to umbilical cord gas analytes. From a cohort of 1064 scheduled cesarean deliveries, 7 fulfilled the study criteria yielding 8 neonates. Mean ± standard error of the mean interval of spinal anesthesia to delivery was 15.0±1.9 minutes, and the decrease in mean blood pressure after spinal anesthesia was 39.1±3.0 mm Hg. Umbilical artery base excess ranged from -5.2 to -16.6 mmol/L (median, -8.0). Based on published normative data of prelabor fetal umbilical artery base excess (-2±0.6 mmol/L), the mean rate of base excess decrease was 0.38±0.25 mmol/minute. The rate of decrease in base excess when scheduled cesarean deliveries are converted to emergency cesarean deliveries owing to fetal bradycardia related to spinal anesthesia (1 mmol/2.6 min) matches the estimated rate of loss of base excess (1 mmol/2-3 minutes) reported in cases of severe bradycardia or sentinel events during labor.

Physico-Chemical Analysis of Groundwater in Noida-Ghaziabad Region

Groundwater quality in Noida and Ghaziabad has been decreasing in recent years as a result of industrial operations and pollution. The primary goal of the present work is to investigate the groundwater quality indicators in the various key locations of Noida and Ghaziabad. Different physico-chemical characteristics of groundwater in these locations were investigated in order to quantify the influence of these parameters on the environment in general and human health in particular. pH, total dissolved solids (TDS), Alkalinity, chemical oxygen demand (COD), biological oxygen demand (BOD), total hardness, carbonates, bicarbonates, turbidity and chlorides were measured. pH, TDS, alkalinity, hardness, and chloride content were found to be 7.35-9.05, 0-30 mg/l, 140-975 mg/l, 170-335 mg/l, and 39.90-939.70 mg/l respectively. The acquired results were compared to the permitted limits set by the Indian water quality standard IS:10500-2012 and recommendations were made to improve the water quality of the study region in order to make the groundwater suitable for consumption.

Analytical Performances of the Novel i-STAT Alinity Point-of-Care Analyzer.

Many Point-of-Care devices have been released over the past decade. However, data regarding their analytical performances in real-world situations remains scarce. Herein, we aimed to assess the analytical performances of the i-STAT Alinity system. We conducted an analytical performances study with the i-STAT Alinity device using cartridges CG4+ (pH, Pco2, Po2, lactate, bicarbonate and base excess); CHEM8+ (Na, K, Cl, ionized Ca, urea, creatinine, glucose, hematocrit and hemoglobin) and PT/INR (prothrombin time and international normalized ratio). We assessed the imprecision and compared the results to those obtained on existing instruments in the central laboratory. We found that the within-lab coefficients of variation (CV) were very low (&lt;2%) or low (2-5%), except for creatinine and PT (CV = 5.2% and CV = 6.3%, respectively). For almost all the parameters, the results were strongly (R2 = 90-95%) or very strongly (R2 &gt; 95%) correlated with those of the existing laboratory instruments, and the biases were very low (&lt;2%) or low (2-5%). However, correlations of the PT and INR measurements with existing instruments were lower (R2 = 86.0% and 89.7%), and biases in the Po2 (7.9%), creatinine (5.4%) and PT (-6.6%) measurements were higher. The i-STAT Alinity appeared as a convenient device for measurements of numerous parameters. However, clinicians should interpret Po2, creatinine and PT results with caution.

Alactic base excess is an independent predictor of death in sepsis: A propensity score analysis

PurposeAlactic base excess (ABE) is a novel biomarker defined as the sum of lactate and standard base excess and estimates the renal capability of handling acid-base disturbances in sepsis. The objective of this study is to see if ABE is an independent predictor of mortality in septic patients with and without renal dysfunction. Materials and methodsWe retrospectively studied 1178 patients with sepsis and septic shock. Patients were divided according to ABE values: 1) negative ABE (<−3 mmol/L); 2) neutral ABE (≥ − 3 and < 4 mmol/L); and 3) positive ABE (≥4 mmol/L). The effect of ABE on mortality was evaluated using Cox regression weight by inverse probability weighting (IPWT) analysis after propensity score assessment. Additionally, we performed a stratified analysis in patients with GFR > 60 mL/min/1.73 m2. ResultsNegative ABE patients had higher mortality than patients with neutral ABE (adjusted HR 1.43; 95%CI 1.02–2.01). Also, in patients with GFR > 60 mL/min/1.73 m2 (n = 493), we observed higher mortality in patients with negative ABE (adjusted HR 2.43; 95%CI 1.07–5.53). ConclusionsNegative ABE is an independent predictor of in-hospital mortality in septic patients with and without renal dysfunction.

Protocol for a multicenter, double-blind, randomized, placebo-controlled phase III trial of the inhaled β2-adrenergic receptor agonist salbutamol for transient tachypnea of the newborn (the REFSAL trial).

Transient tachypnea of the newborn (TTN), which results from inadequate absorption of fetal lung fluid, is the most common cause of neonatal respiratory distress. Stimulation of β-adrenergic receptors enhances alveolar fluid absorption. Therefore, the β2-adrenergic receptor agonist salbutamol has been proposed as a treatment for TTN. This study aims to evaluate the efficacy and safety of salbutamol as supportive pharmacotherapy together with non-invasive nasal continuous positive airway pressure (NIV/nCPAP) for the prevention of persistent pulmonary hypertension of the newborn (PPHN) in infants with TTN. This multicenter, double-blind, phase III trial will include infants with a gestational age between 32 and 42 weeks who are affected by respiratory disorders and treated in eight neonatal intensive care units in Poland. A total of 608 infants within 24 h after birth will be enrolled and randomly assigned (1:1) to receive nebulized salbutamol with NIV or placebo (nebulized 0.9% NaCl) with NIV. The primary outcome is the percentage of infants with TTN who develop PPHN. The secondary outcomes are the severity of respiratory distress (assessed with the modified TTN Silverman score), frequency of need for intubation, duration of NIV and hospitalization, acid-base balance (blood pH, partial pressure of O2 and CO2, and base excess), and blood serum ionogram for Na+, K+, and Ca2+. The Respiratory Failure with Salbutamol (REFSAL) study will be the first clinical trial to evaluate the efficacy and safety of salbutamol in the prevention of persistent pulmonary hypertension in newborns with tachypnea, and will improve short term outcomes. If successful, the study will demonstrate the feasibility of early intervention with NIV/nCPAP together with nebulized salbutamol in the management of TTN. The study protocol was approved by the Bioethics Committee of the Medical University of Warsaw, Warsaw, Poland on November 16, 2020 (decision number KB/190/2020). All procedures will follow the principles of the Declaration of Helsinki. The results of the study will be submitted for knowledge translation in peer-reviewed journals and presented at national and international pediatric society conferences. It is registered at ClinicalTrials.gov NCT05527704, EudraCT 2020-003913-36; Protocol version 5.0 from 04/01/2022.

Clinical characteristics and early prediction of mortality risk in patients with acute organophosphate poisoning-induced shock.

To further get insights of clinical characteristics of acute organophosphate poisoning-induced shock, investigate the relationship between shock and prognosis, and screen risk indicators for prognosis. A total of 73 patients with acute organophosphate poisoning admitted to our hospital between January 2014 and December 2021 were enrolled in this retrospective study. Patients were divided into the shock group and the non-shock group. The pH value of blood, arterial blood carbon dioxide partial pressure (PaCO2), arterial partial pressure of oxygen (PaO2), base excess (BE), lactic acid (Lac), serum albumin (ALB), total bilirubin (TBIL), alanine aminotransferase (ALT), serum creatinine (Cr), serum potassium (K), serum calcium (Ca), serum sodium (Na), blood chloride (Cl), serum troponin I (cTNI), brain natriuretic peptide (BNP), white blood cell count (WBC), hemoglobin (HGB), platelet count (PLT), and other clinical indicators of patients were recorded. Incidence of shock, time of shock onset, and outcomes of patients were also recorded. Cox proportional hazards regression models were performed for analysis. The incidence of organophosphate poisoning-induced shock was 30.1% (22/73), and 72.7% of shock patients developed shock blood pressure within 6 h. The levels of blood lactate, ALT, Cr, cTNI, BNP, and Cl in the shock group were significantly higher than those in the non-shock group, while the level of Ca and pH value was significantly lower than that in the non-shock group (all p < 0.05). Moreover, compared with patients without shock (2.0%), the mortality rate was significantly increased in patients with shock (36.4%), which was supported by the results from adjusted Cox proportional hazards regression model. We found that shock and elevated serum creatinine were associated with increased risk of death in patients with organophosphate poisoning (shock: HR, 10.9; 95% CI 1.2-96.3; elevated serum creatinine: HR, 1.0, 95% CI 1.0-1.0). This study indicated the association between elevated serum creatinine and increased mortality rates in patients with organophosphate poisoning, highlighting the importance of the comprehensive management of shock, especially the control of renal function, in these poisoning patients.

Does Arterial Blood Gas (ABG) Provide a Safety Net for Extubation in Surgical Patients?

Background Extubation has always been a critical aspect of anaesthesia. Guidelines and recommendations are in place for achieving successful extubation, but the risk of failure always persists. Through this study, we assess whether arterial blood gas (ABG) values taken intraoperatively help predict extubation success in the operation theatre. Materials and methods This was a prospective observational study for one year of extubated patients whose blood gas values were not within the normal range. The patients of age 18 years and above undergoing high-risk elective and emergency surgeries where at least one intraoperative arterial blood sample was taken for blood gas analysis were included. Apart from parameters of ABG demographic data, urgency and duration of surgery, blood loss, urine output, use of intraoperative fluid(s), and blood product(s) were also observed. Results Of 578 patients enrolled, 116 patients were extubated based on the predefined extubation criteria. Of these, 24 patients were reintubated within 24 hours. ABG parameters such as partial pressure of arterial oxygen (PaO2) and serum HCO3-levels were significantly lower in the reintubated patients compared to non-reintubated patients (p-values of 0.045 and 0.003, respectively). Conclusion This study showed that the PaO2 <100 mm Hg or ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) of less than 200 and an HCO3- value of less than 18 are plausible ABG parameters to decide extubation in post-surgery patients in OT. PaCO2, base deficit, and lactate were less reliable parameters for planning extubation.

Low Apgar score and need for resuscitation increased the probability of receiving therapeutic hypothermia more strongly than acidosis at birth.

The aim of this study was to investigate how individual markers for birth asphyxia, so-called A criteria, were associated with the probability of receiving therapeutic hypothermia. This population-based cohort study included 1336 live-born singleton term infants with any A criterion in the Stockholm-Gotland Region, Sweden during 2008 to 2014. The Swedish Neonatal Quality Register and National Patient Register were used for data collection. Results were presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). There were 89 infants, 44 boys and 45 girls with mean gestational age 40.5 weeks, who received therapeutic hypothermia. Low Apgar score, aOR 12.44 (95% CI 5.99-25.86), and resuscitation, aOR 9.18 (95% CI 3.77-22.34), were strongly associated with therapeutic hypothermia. A pH <7.0 was less associated with the outcome, aOR 2.02 (95% CI 1.02-4.0). No infant who received therapeutic hypothermia fulfilled the criteria of base deficit ≥16 mmol/L only. A low Apgar score of and/or a need for resuscitation is more relevant for identifying infants eligible for therapeutic hypothermia, compared to other A criteria. This knowledge could be used clinically to identify cases for review and avoid unnecessary monitoring of infants.

破裂性腹部大動脈瘤に対するdamage control surgeryの必要性が示唆された1例(Case of resuscitation from ruptured abdominal aortic aneurysm: necessity of damage control surgery)

要旨症例は87歳の男性。背部痛を主訴に前医へ救急搬送され，腹部大動脈瘤破裂の診断となった。当院への転院搬送中に心停止となったが，心肺蘇生を行い自己心拍再開して当院に到着した。直接手術室へ入室し，手術を開始した。入室時に再度心停止となったが，ステント拡張用のバルーンカテーテルで遮断を試みながら心肺蘇生を継続することで自己心拍再開した。前医で撮影された造影CT解析の結果，ステントグラフト内挿術の解剖学的条件を満たさず，開腹手術の方針とした。人工血管置換術は完遂したが，大量出血および低体温を原因とした凝固能破綻による静脈出血がコントロールできず，damage control surgery（DCS）に準じて早期の手術終了を図る方針としてガーゼパッキング後に閉腹した。術後2日目にガーゼ除去および閉腹術に臨んだが，開腹するとS状結腸から直腸にかけての壊死を認めたため，壊死腸管切除および横行結腸人工肛門造設術を施行した。その後の全身管理には難渋したが，術後294日で退院となった。近年，外傷外科領域ではDCSの考え方が重要視されているが，腹部大動脈瘤破裂を扱う心臓血管外科領域においてはその考え方が浸透しているとは言い難い。腹部大動脈瘤破裂を扱う心臓血管外科医もDCSを念頭においた計画を立てて手術を始めることが，救命率向上のためには重要である。

Comparison of Laboratory Parameters and Outcomes in Perforation Peritonitis Patients before and after Peritoneal Drain Placement: A Prospective Cohort Study

Introduction: Patients with perforation peritonitis present in the Emergency Department with various causes, but bowel perforation is the most frequent cause. These patients often arrive late at tertiary centres, resulting in severe peritoneal contamination and septic shock. Therefore, preoperative peritoneal drain placement provides adequate drainage and better outcomes in such cases. Aim: To compare various clinical and laboratory parameters in patients with perforation peritonitis before and after the placement of a peritoneal drain, prior to any definitive surgical treatment. Materials and Methods: A prospective cohort study was conducted in the Department of General Surgery at Kalpana Chawla Government Medical College in Karnal, Haryana, India, from October 2022 to June 2023. All cases of perforation peritonitis that were critically-ill or in shock upon presentation in the emergency department were planned for intraperitoneal drain placement before definitive surgery. A total of 140 patients were enrolled in the study, and their clinical parameters (temperature, pulse rate, SpO2, and urine output) and laboratory parameters (such as leucocyte count, electrolytes (Na+, K+, Ca++), pH, base excess, bicarbonate values, lactate, Random Blood Sugar (RBS), and haematocrit) were compared before and 24 hours after drain placement. Statistical analysis was performed using paired t-test. Results: The mean age of the patients was 46.03±18.06 years, and 116 (82.85%) of the cases were male. The most common comorbid condition was pulmonary disease {Chronic Obstructive Pulmonary Disese (COPD)/Asthma}, diagnosed in 96 (86.57%) cases. The most common perforation site was duodenal, followed by gastric and ileal, observed in 65 cases (46.42%), 23 (16.34%) cases, and 21 (15%) cases, respectively. There was a significant improvement in clinical parameters such as temperature, pulse rate, Saturation of Peripheral Oxygen (SpO2 ), and urine output after drain placement (p-value &lt;0.001). There was also an improvement in laboratory parameters including leucocyte count, electrolytes (Na+, K+, Ca++), pH, base excess, and bicarbonate values (p-value &lt;0.001). The mortality rate was 20%, with 28 cases resulting in death. Conclusion: Although preoperative intraperitoneal drain placement is not a standard surgical procedure for patients with perforation peritonitis, it resuscitates and stabilises the patient, thereby helping in reducing morbidity and mortality postoperatively.

Cesarean section in Swyer-James-Macleod syndrome: Anesthesia implications.

Dear Editor, Swyer-James-MacLeod Syndrome (SJMS) is a rare, acquired postinfectious condition characterized by bronchiectasis or emphysematous changes.[1,2] These patients have a high risk of perioperative pulmonary complications. A 28-year-old primigravida, at 24 weeks of gestation, came with dyspnea on exertion (grade-3) for the 3 months with no history of recurrent infections. On examination, there was diminished breath sounds on the left side. Chest radiograph (done with abdominal shield) showed left hyperlucent lung with reduced vascular markings and slight mediastinal shift. Rest of the investigations were normal. The patient was referred to chest physician for optimization and a diagnosis of Swyer-James syndrome with left lung bulla/pneumothorax was made. The patient was managed with bronchodilators (Metered-Dose Inhaler levosalbutamol and Tiotropium bromide) and breathing exercises (pursed-lip breathing, diaphragmatic breathing). Spirometry was not done since the patient was in the second trimester of pregnancy. The patient got symptomatically better and an elective cesarean section was planned. Blood gas analysis performed a day before surgery showed PH: 7.441, PCO2:25.6, PO2 = 70.6, Bicarbonate = 17, Base excess = 7.21, Oxygen saturation = 94.4%. High-risk written consent was taken and expected complications were explained. On the day of surgery, the patient was taken in the operation theatre after giving inhalational bronchodilators. Ondansetron 4 mg and ranitidine hydrochloride 50 mg were given intravenously 30 min prior to surgery. A 20-G intravenous cannula was secured, Ringer lactate was started and vital parameters were monitored. Spinal anesthesia with 10 mg of heavy bupivacaine and 25 micrograms of fentanyl in the right lateral position was given. The intraoperative period was uneventful. SJMS was first described in 1953 by Swyer and James, and later explained in detail by MacLeod. A chest radiograph demonstrates lobar or unilateral hyperlucent lung and normal or reduced volume of the affected lung. Patients can present with a multitude of symptoms ranging from asymptomatic with incidental radiographical diagnosis to severe symptoms such as dyspnea and repeated pulmonary infections.[1,2] This syndrome is usually diagnosed in childhood after an evaluation for recurrent respiratory infections, but sometimes they are asymptomatic and may be diagnosed in adulthood.[3,4] In a case series by S. S. Hadice et al.,[3] three out of four patients had no history of airway infection in childhood and were diagnosed in adulthood. The clinical incidence of SJMS in pregnancy is 1:2500.[2] The management focuses on early diagnosis, prevention, and treatment of recurrent pulmonary infections and vaccine administration.[2–4] Severe cases of SJMS may require anesthetic care cautiously tailored to significant obstructive pulmonary physiology.[5] Regional anesthesia should be preferred whenever feasible. Chopra S et al.,[2] reported the successful delivery in a case of SJMS under spinal anesthesia in emergency. Labor epidural anesthesia can also be used in electively scheduled patients and supplemented with low-dose spinal anesthesia before surgery, if required. General anesthesia is associated with risk of bulla rupture, worsening of pneumothorax, and other pulmonary complications. Drugs that can cause histamine release and bronchoconstriction should be avoided. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient and her father have given their consent for his images and other clinical information to be reported in the journal. The patient and father understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The Time-related role of early pH, Base excess and Lactate for the Development in Sepsis in Polytrauma patients. An analysis using the IBM Watson Trauma Pathway Explorer

The Time-related role of early pH, Base excess and Lactate for the Development in Sepsis in Polytrauma patients. An analysis using the IBM Watson Trauma Pathway Explorer

Toxicoepidemiology of Phosphide Poisoning in the Central Part of Iran.

Aluminum phosphide (ALP) and zinc phosphide (ZnP) are toxic agrochemical pesticides, which are commonly used as an agent of self-harm in developing countries. Because of high toxicity of phosphides, we evaluated toxico-epidemiology ALP and ZnP poisoning in with respect to outcome. We performed a cross-sectional study with retrospective chart review including the records for patients admitted due to phosphide poisoning (ALP, ZnP) in a poisoning referral center in Khorshid Hospital, affiliated with Isfahan University of Medial Sciences, Isfahan, Iran. Demographic characteristics, clinical manifestations, outcome (survived or death), and length of hospital stay for the patients were recorded in a data collecting form. Binary backward stepwise logistic regression was used for outcome prediction. Sixty patients were evaluated in the study. The mean age of patients was 27.61. Thirty-nine patients were men. 96.7% of the patients ingested it intentionally. Most of the patients on admission were conscious (66.7%). Abnormality of EKG was noted in 8.3%. The mortality in ALP and ZnP poisoning was 39.2% and 22.2%, respectively. Serum bicarbonate and base excess in the venous blood gas analysis, systolic blood pressure, and serum sodium level were significantly different between patients with ALP and ZnP poisoning on admission time (P < 0.05). On admission, systolic blood pressure was an important predictive factor for mortality (odds ratio 4.87; 95% confidence interval: 1.5-15.45; P = 0.007). The rate of mortality in phosphide poisoning is high. Knowing predictive factors for mortality help physicians for selecting patients in intensive care unit admission and aggressive treatment.

Emergency Department Point-of-Care Tests during Cardiopulmonary Resuscitation to Predict Cardiac Arrest Outcomes.

This study evaluated the role of point-of-care tests (POCT) such as blood lactate, anion gap (AG), base deficit, pH, N-terminal pro B-type natriuretic peptide (NT-proBNP), and troponin as the predictors of cardiac arrest outcomes in the emergency department (ED). We conducted a prospective, observational study in the ED of a tertiary care hospital in India. All the adult patients who received cardiopulmonary resuscitation (CPR) in the ED were included in the study. Blood samples were collected within 10 min of initiation of CPR for assay of POCTs. Outcomes assessed were the return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge (STHD), survival at 7 days, and favorable neurological outcome (FNO) at day 7 of admission. One hundred and fifty-one patients were included in the study (median age: 50 years, 65% males). Out of 151 cases, ROSC, survival at 7 days, STHD, and FNO was observed in 86 patients, six patients, five patients, and two patients, respectively. "No-ROSC" could be significantly predicted by raised lactate (odds ratio [OR]: 1.14, 95% confidence interval: 1.07-1.22) and NT-proBNP (OR: 1.05, 1.01-1.09) values at the time of cardiac arrest. "24-h mortality" could be significantly predicted by the raised lactate (OR: 1.14, 1.01-1.28), low arterial pH (OR: 0.05, 0.01-0.52), raised AG (OR: 1.08, 1.01-1.15), and lower base deficit (<-15) (OR: 1.07, 1.01-1.14). None of the other POCTs was found to be a predictor of other cardiac arrest outcomes. Among various POCTs, raised lactate assayed within 10 min of cardiac arrest can predict poor outcomes like "no-ROSC" and 24-h mortality.

Association between maternal pre-pregnancy BMI category and fetal umbilical artery pH

To evaluate the association between maternal pre-pregnancy body mass index (BMI kg/m2) and fetal umbilical arterial pH at the time of delivery in nulliparous women. We performed a secondary analysis of the nuMoM2b study. Subjects in this study were nulliparous with a singleton pregnancy. Subjects with fetal anomalies or missing fetal umbilical artery pH were excluded. Subjects were categorized based on pre-pregnancy BMI (less than 18.5, 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, and 40 or greater). Our primary outcome was an umbilical artery pH at the time of delivery. We also examined base deficit, the rate of fetal acidosis defined as pH < 7.0, and the need for advanced neonatal resuscitation. Analyses were stratified by the route of delivery. Multivariable linear or logistic regression models were used to calculate adjusted P-values or adjusted odds ratios (95% confidence intervals), controlling for confounders. Of 3,015 subjects, 1,870 (62%) had a vaginal delivery, and 1,145 (38%) had a cesarean delivery. There were significant differences in demographics across the BMI categories in both subjects who had a vaginal delivery and cesarean delivery (age, race, chronic hypertension, gestational diabetes, pregestational diabetes, preeclampsia, and gestational hypertension). Among subjects who had a vaginal delivery, there was no difference in fetal umbilical artery pH (p=0.31) across the BMI categories (Table 1). Base deficit of subjects with BMI < 18.5 and BMI 40 or greater was significantly lower than that of subjects with BMI 18.5-24.9 (adjusted p< 0.05). Among subjects who had a cesarean delivery, the fetal umbilical arterial pH of subjects with BMI 30-34.9 and BMI 40 or greater was significantly lower than that of subjects with BMI 18.5-24.9 (adjusted p< 0.05) (Table 2). In nulliparous subjects with a singleton pregnancy, obesity was associated with decreased fetal umbilical arterial pH at the time of cesarean delivery. However, this finding was not observed in subjects who had a vaginal delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Correlation of umbilical cord blood pH, base deficit, and lactate levels with outcomes of hypoxic newborns: A prospective study

Correlation of umbilical cord blood pH, base deficit, and lactate levels with outcomes of hypoxic newborns: A prospective study