Blood Gas Values Research Articles

Early Ventilator Management for Infants With Congenital Diaphragmatic Hernia: Impact of a Standardized Clinical Practice Guideline

BackgroundInfants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality due to pulmonary arterial hypertension and hypoplasia. Mechanical ventilation is a central component of CDH management. Our objective was to evaluate the impact of a standardized clinical practice guideline (implemented in January 2012) on ventilator management for infants with CDH, and associate management changes with short-term outcomes, specifically extracorporeal membrane oxygenation (ECMO) utilization and survival to discharge. MethodsWe conducted a retrospective pre-post study of 103 CDH infants admitted from January 2007–July 2021, divided pre- (n = 40) and post-guideline (n = 63). Clinical outcomes, ventilator settings, and blood gas values in the first 7 days of mechanical ventilation were compared between the pre- and post-guideline cohorts. ResultsPost-guideline, ECMO utilization decreased (11% vs 38%, p = 0.001) and survival to discharge improved (92% vs 68%, p = 0.001). More post-guideline patients remained on conventional mechanical ventilation without need for escalation to high-frequency ventilation or ECMO, and had higher pressures and PaCO2 with lower FiO2 and PaO2 (p < 0.05). ConclusionsStandardized ventilator management optimizing pressures for adequate lung expansion and minimizing oxygen toxicity improves outcomes for infants with CDH. Level of EvidenceIII.

Non-Surgical Respiratory Management in Relation to Feeding and Growth in Patients with Robin Sequence; a Prospective Longitudinal Study.

To reflect upon our non-surgical respiratory management by evaluating clinical outcomes regarding airway, feeding, and growth during the first year of life in patients with Robin Sequence. Prospective study. Sophia Children's Hospital, Rotterdam, the Netherlands. 36 patients with Robin Sequence who were treated between 2011 and 2021. Positional therapy and respiratory support. Data on respiratory outcomes included polysomnography characteristics and capillary blood gas values. Feeding outcomes were based on the requirement of additional tube feeding. Outcomes on growth were expressed as standard-deviation-scores (SDS) for weight-for-age (WFA) and height-for-age (HFA). Twenty patients were treated with positional therapy (PT), whilst the other 16 patients required respiratory support. Twenty-two patients presented with non-isolated Robin Sequence (RS). During the first year of life, obstructive apnea hypopnea index decreased, oxygen levels enhanced, and capillary blood gas values improved. Eighty-six percent (31/36) experienced feeding difficulties, which completely resolved in 71% (22/31) during their first year of life. From start treatment, to stop treatment, to the age of 1 year, the SDS WFA worsened from -0.40 to -0.33 to -1.03, respectively. Non-surgical respiratory treatment resulted in an improvement of respiratory outcomes to near normal during the first year of life in patients with RS. These patients often experience feeding difficulties and endure impaired weight gain up to 1 year of age, despite near normalization of breathing. The high prevalence of feeding difficulties and impaired weight for age indicate the urgency for early recognition and adequate treatment to support optimal growth.

Clinical evaluation of ventilation mode on acute exacerbation of chronic obstructive pulmonary disease with respiratory failure.

At present, understanding of the most effective ventilation methods for treating chronic obstructive pulmonary disease (COPD) patients experiencing acute worsening symptoms and respiratory failure remains relatively limited. This report analyzed the efficiency and side effects of various ventilation techniques used for individuals experiencing an acute COPD exacerbation. To determine whether pressure-controlled ventilation (PCV) can lower peak airway pressures (PAPs) and reduce the incidence of barotrauma compared to volume-controlled ventilation (VCV), without compromising clinical outcomes and oxygenation parameters. We have evaluated 600 patients who were hospitalized due to a severe COPD exacerbation, with 400 receiving mechanical ventilation for the respiratory failure. The participants were divided into two different groups, who were administered either VCV or PCV, along with appropriate management. We thereafter observed patients' attributes, clinical factors, and laboratory, radiographic, and arterial blood gas evaluations at the start and during their stay in the intensive care unit (ICU). We have also employed appropriate statistical methods for the data analysis. Both the VCV and PCV groups experienced significant enhancements in the respiratory rate, tidal volume, and arterial blood gas values during their time in the ICU. However, no significant distinctions were detected between the groups in terms of oxygenation indices (partial pressures of oxygen/raction of inspired oxygen ratio) and partial pressures of carbon dioxide improvements. There was no considerable disparity observed between the VCV and PCV groups in the hospital mortality (32% vs 28%, P = 0.53), the number of days of ICU stay [median interquartile range (IQR): 9 (6-14) d vs 8 (5-13) d, P = 0.41], or the duration of the mechanical ventilation [median (IQR): 6 (4-10) d vs 5 (3-9) d, P = 0.47]. The PCV group displayed lower PAPs compared to the VCV group (P < 0.05) from the beginning of mechanical ventilation until extubation or ICU departure. The occurrence of barotrauma was considerably lower in the PCV group in comparison to the VCV group (6% vs 16%, P = 0.03). Both VCV and PCV were found to be effective in treating patients with acute COPD exacerbation. However, PCV was associated with lower PAPs and a significant decrease in barotrauma, thus indicating that it might be a safer ventilation method for this group of patients. However, further large-scale study is necessary to confirm these findings and to identify the best ventilation approach for patients experiencing an acute COPD exacerbation.

Does the systemic rise in serum lactate levels correlate to free flap failure in head and neck reconstructive surgeries—series of cases

BackgroundHead and neck reconstructive surgeries needs free tissue transfer but it fails sometimes. As most of the flap failure occurs in first 24 h. Local rise in lactate level or glucose lactate ratio provides clear indicator of tissue ischemia and further recovery. The question is about systemic rise in lactate levels with failing flap. Hence, we aimed to use systemic lactate levels to indicate free flap failure. To correlate the systemic rise in serum lactate levels to free flap failure in head and neck reconstructive surgeries. The series of cases were targeted undergoing free fibular graft, posted electively for head and reconstructive surgery operated by same surgeon. Record of blood loss, need of blood transfusion and use of microspan was also done. Monitoring of arterial blood gas values mainly lactate and vitals were done.ResultsOut of 15 patients studied, only 2(13.3%) patients had flap re-exploration (group F). Twelve (80%) patients were of ASA class I. Lactate, pH, blood sugars, base deficits and hemoglobin and vitals studied over 24 h in two groups had no statistically significant difference in the two groups. Lactate rise was noted in all cases for first few hours after starting surgery but elevated values were not observed during hours of flap re-exploration.ConclusionsWe could not establish relation between systemic rise in lactate levels and flap re-exploration or flap failure but continuous acidosis can impact outcome. We need to be vigilant and need to have individualized approach for management.

Comparison of crystalloid and colloid co-load combined with norepinephrine prophylaxis on post-spinal anesthesia hypotension during cesarean delivery: a randomized sequential allocation dose-finding study.

Fluid loading is an essential component of treatment for reducing the incidence of post-spinal anesthesia hypotension and is necessary to maintain intravascular volume, perfuse tissues, and control spinal anesthesia hypotension after sympathetic blockade. We performed a randomized sequential allocation dose-finding study to compare the effects of 10 mL/kg crystalloid and 6% hydroxyethyl starch (130/0.4) co-load on the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery. Eighty patients were randomly allocated to receive either a 10 mL/kg crystalloid (Crystalloid Group, n = 40) or 6% hydroxyethyl starch (130/0.4) (Colloid Group, n = 40) co-load combined with prophylactic norepinephrine infusion during spinal anesthesia for cesarean delivery. The first patient received an initial prophylactic norepinephrine infusion rate of 0.025 μg/kg/min. Subsequent patients received a 0.005 μg/kg/min gradient dose of prophylactic norepinephrine. This dose was administered as a gradient based on its effectiveness for preventing post-spinal anesthesia hypotension (defined as SBP < 80% of baseline value) and determined by the up-and-down sequential allocation methodology. The primary study outcome was the ED90 of prophylactic norepinephrine infusion. Secondary outcomes included the incidence of post-spinal anesthesia hypotension, bradycardia, hypertension, Apgar scores, and umbilical artery blood gas values were also measured. The ED90 values of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery were 0.063 μg (95% CI: 0.050 to 0.064) and 0.062 μg (95% CI: 0.045 to 0.064) using isotonic regression analysis, and 0.068 μg (95% CI: 0.056 to 0.353) and 0.060 μg (95% CI: 0.050 to 3.590) using probit regression analysis in the Crystalloid Group and Colloid Group, respectively. The secondary outcomes were comparable between the two groups. The administration of a 10 mL/kg 6% hydroxyethyl starch (130/0.4) does not provide additional benefits compared to crystalloid co-load in reducing the ED90 of prophylactic norepinephrine infusion for preventing post-spinal anesthesia hypotension during cesarean delivery.

Carbon Monoxide Poisoning: Comparison of Paediatric and Adult Patients

Background: Carbon monoxide (CO) gas is a tasteless, odorless and colorless gas and causes many poisonings every year. In this study, paediatric and adult CO poisoning cases admitted to our emergency department were reviewed retrospectively.&#x0D; Materials and Methods: Paediatric and adult patients who applied to the Emergency Department of Mardin Training and Research Hospital between 01 January 2021 and 31 December 2022 due to CO poisoning due to stove usage were included in the study. Patients were compared according to age, gender, month and time of admission to the emergency department, complaints at admission, laboratory test results and discharge status. &#x0D; Results: 90 patients admitted to the emergency department due to CO poisoning caused by stoves between 2021-2022 were included in the study. While the rate of female patients in the paediatric age group was 53.3%, the rate of female patients in the adult group was 48.9% (p=0.673). When compared according to the complaints of admission to the hospital, the most common complaint in the paediatric age group was nausea-vomiting with 42.2%, while the most common complaint in the adult group was shortness of breath with 26.7%. In both groups, it was determined that the most frequent application was in January with 48.9%. While 15.6% of children were hospitalized, this rate was 4.4% for adults. (p=0.065). While the carboxyhemoglobin (COHb) value at the time of first admission was 18.36±6.60 in the paediatric group, it was 22.03±10.24 in the adult group (p:0.047). In the control blood gas values taken at discharge, COHb level was 2.76±1.83 in children and 5.10±3.02 in adults (p

Effect of preoperative oral rehydration before cesarean section on ultrasound assessment of gastric volume and intraoperative hemodynamic changes: a randomized controlled trial

BackgroundCesarean section often requires an urgent transfusion load due to decreased blood pressure after spinal anesthesia. This prospective randomized study aimed to investigate whether a preoperative oral rehydration solution (ORS) stabilized perioperative circulatory dynamics.MethodsSixty-three parturients scheduled for cesarean section under combined spinal epidural anesthesia (CSEA) were randomly allocated to one of three groups: Group O received 500 mL ORS before bedtime and 500 mL 2 h before CSEA; Group M received mineral water instead of ORS; and Group C had no fluid intake (controls). After entering the operating room, stomach size was measured using ultrasound. Blood samples were obtained, and CSEA was induced. Vasopressors were administered when systolic blood pressure was < 90 mmHg or decreased by > 20%. As a vasopressor, phenylephrine (0.1 mg) was administered at ≥ 60 beats/min heart rate or ephedrine (5 mg) at < 60 beats/min heart rate. The primary outcome was the total number of vasopressor boluses administered. Secondary outcomes were the cross-sectional area of the stomach antrum, maternal plasma glucose levels, serum sodium levels, total intravenous fluid, bleeding volume, urine volume, operative time, and cord blood gas values after delivery.ResultsThe total number of vasopressor boluses was lower in Group O than in Group C (P < 0.05). Group O had lower total dose of phenylephrine than Group C (P < 0.05). There were no significant differences between Group M and other groups. No differences were detected regarding secondary outcomes.ConclusionsIn women scheduled for cesarean section, preoperative ORS stabilized perioperative circulatory dynamics. Neither ORS nor mineral water consumption increased the stomach content volume.Trial RegistrationThis trial is registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000019825: Date of registration 17/11/2015).

XPS™ Jensen lung as a low-cost, high-fidelity training adjunct to ex-vivo lung perfusion.

Ex vivo lung perfusion (EVLP) enables lung resuscitation before transplantation, and training is key, particularly in low-volume settings. To enable technique refinement and continuing education, we sought to demonstrate the value of a low-cost, high-fidelity EVLP simulator that would allow reproducible clinical scenarios. In partnership with our EVLP manufacturer, we utilized the XPS™ Jensen Lung with our clinical system. The Jensen Lung has two simulated lung bladders and an in-line polymethylpentene fiber oxygenator. It allows titration of ventilator support which aids in accurate clinical simulation. For simulations, blood gases (BGs) were obtained and compared with integrated in-line perfusate gas monitors (PGMs). PaO2 , PCO2 , and pH were measured and compared. The PGM and BG values were not significantly different throughout the range of FiO2 and sweep gas flow rates evaluated. The "delta" PaO2 was measured between LA and PA and did not show any change between approaches. The pH measurement between BG and PGM was not significantly different. The XPS™ Jensen Lung simulator allows for a high-fidelity simulator of clinical EVLP. The correlation of the PGM and the BG measurement of the PaO2 and pH allow for a low-cost simulation, as the PGMs are in line in the circuit, and enable real-time tracking of perfusate gas parameters with the PGM. Implementation of a standardized clinical EVLP training program allows the maintenance of technique and enables clinical simulation training without the need for costly animal perfusions and the use of multiple BG measurements.

Umbilical Cord Blood Gas Pairs with Near-Identical Results: Probability of Arterial or Venous Source.

In studies of concomitant arterial-venous umbilical cord blood gases (CAV-UBGs), approximately 10% of technically valid samples have very similar pH and/or pCO2 values and were probably drawn from the same type of blood vessel. Without a way to objectively determine the source in these cases, it has been argued that most of these same-source CAV-UBGs are venous because the vein is larger and more easily sampled than the artery. This study aimed to calculate the probability of an arterial (ProbAS) or venous source (ProbVS) of same-source CAV-UBGs in the clinically and medicolegally important pH range of 6.70 to 7.25 using a statistical predictive model based on the cord blood gas values. Starting with a dataset of 56,703 CAV-UBGs, the ProbAS, ProbVS, and respective 95% confidence intervals (CIs) were calculated for the 241 sample pairs with near-identical pH, pCO2, and pO2 values and a pH of 6.70 to 7.25. Using a previously validated generalized additive model, the source was categorized as: Probable Arterial or Highly Probable Arterial if the ProbAS and CIs were >0.5 or >0.8, respectively; Probable Venous or Highly Probable Venous if the ProbVS and CIs were >0.5 or >0.8, respectively; or Indeterminant if the CIs encompassed ProbAS/VS = 0.5. A total of 39% of the same-source CAV-UBGs were Probable Arterial, 56% were Probable Venous, and 5% were Indeterminant. However, considering samples with a pH ≤7.19, 80% were Probable Arterial and 16% were Probable Venous. Considering the Highly Probable categories, the more acidemic specimens were 9 times more likely to be arterial than venous. Similarly, CAV-UBGs with pCO2 > 8.2 kPa (62 mm Hg) or pO2 ≤ 1.9 kPa (14 mm Hg) were more likely to be in the arterial rather than the venous categories. Same-source CAV-UBGs in the more acidemic, hypercarbic, or hypoxemic ranges are more likely to be arterial than venous. · Umbilical cord arterial/venous gases (CAV-UBGs) with similar values are thought to be mainly venous.. · A validated statistical model was used to predict the probability an arterial or venous source.. · CAV-UBGs with very similar values and pH > 7.19 are likely venous; however, those with pH ≤ 7.19 and/or pCO2 > 8.2 kPa and/or pO2 ≤1.9 kPa are more likely arterial..

Microlithiase alvéolaire pulmonaire : à propos de deux cas familiaux au Maroc

Pulmonary alveolar microlithiasis (PAM) is a rare autosomal recessive disease. The majority of patients are asymptomatic. The disease is often diagnosed on routine radiological examination. We report two familial cases of PAM. A 17-year-old girl with a chest X-ray showing an alveolar syndrome, especially on the right side, a bronchointerstitial syndrome, and diffuse calcifications. The thoracic CT scan showed calcified micro- and macronodules with pleural and pericardial calcifications. Respiratory function tests showed restrictive syndrome and normal blood gas values suggestive if PAM, which was confirmed by the presence of microliths in bronchoalveolar lavage (BAL). Family investigation led to chest radiograph of a 14-year-old sister who was asymptomatic but presented with an aspect of "sandstorm" calcifications. PAM is known to be radio-clinically dissociative. In typical cases, radiology can suggest the diagnosis, which is often confirmed by SLC34A2 mutation or microliths in BAL or sputum. The prognosis is compromised in the long-term. The only effective treatment nowadays is lung transplantation.

Vasopressin and methylprednisolone and hemodynamics after in-hospital cardiac arrest – A post hoc analysis of the VAM-IHCA trial

IntroductionThe Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial demonstrated a significant improvement in return of spontaneous circulation (ROSC) with no clear effect on long-term outcomes. The objective of the current manuscript was to evaluate the hemodynamic effects of intra-cardiac arrest vasopressin and methylprednisolone during the first 24 hours after ROSC. MethodsThe VAM-IHCA trial randomized patients with in-hospital cardiac arrest to a combination of vasopressin and methylprednisolone or placebo during the cardiac arrest. This study is a post hoc analysis focused on the hemodynamic effects of the intervention after ROSC. Post-ROSC data on the administration of glucocorticoids, mean arterial blood pressure, heart rate, blood gases, vasopressor and inotropic therapy, and sedation were collected. Total vasopressor dose between the two groups was calculated based on noradrenaline-equivalent doses for adrenaline, phenylephrine, terlipressin, and vasopressin. ResultsThe present study included all 186 patients who achieved ROSC in the VAM IHCA-trial of which 100 patients received vasopressin and methylprednisolone and 86 received placebo. The number of patients receiving glucocorticoids during the first 24 hours was 22/86 (26%) in the placebo group and 14/100 (14%) in the methylprednisolone group with no difference in the cumulative hydrocortisone-equivalent dose. There was no significant difference between the groups in the mean cumulative noradrenaline-equivalent dose (vasopressin and methylprednisolone: 603 ug/kg [95CI% 227; 979] vs. placebo: 651 ug/kg [95CI% 296; 1007], mean difference −48 ug/kg [95CI% −140; 42.9], p = 0.30), mean arterial blood pressure, or lactate levels. There was no difference between groups in arterial blood gas values and vital signs. ConclusionTreatment with vasopressin and methylprednisolone during cardiac arrest caused no difference in mean arterial blood pressure, vasopressor use, or arterial blood gases within the first 24 hours after ROSC when compared to placebo.

Evaluation of the SIMULRESP: A simulation software of child and teenager cardiorespiratory physiology.

Mathematical models based on the physiology when programmed as a software can be used to teach cardiorespiratory physiology and to forecast the effect of various ventilatory support strategies. We developed a cardiorespiratory simulator for children called "SimulResp."The purpose of this study was to evaluate the quality of SimulResp. SimulResp quality was evaluated on accuracy, robustness, repeatability, and reproducibility. Blood gas values (pH, PaCO2 , PaO2, and SaO2 ) were simulated for several subjects with different characteristics and in different situations and compared to expected values available as reference. The correlation between reference and simulated data was evaluated by the coefficient of determination and Intraclass correlation coefficient. The agreement was evaluated with the Bland & Altman analysis. SimulResp produced healthy child physiological values within normal range (pH 7.40 ± 0.5; PaCO2 40 ± 5 mmHg;PaO2 90 ± 10 mmHg; SaO2 97 ± 3%) starting from a weight of 25-35 kg, regardless of ventilator support. SimulResp failed to simulate accurate values for subjects under 25 kg and/or affected with pulmonary disease and mechanically ventilated. Based on the repeatability was considered as excellent and the reproducibility as mild to good. SimulResp's prediction remains stable within time. The cardiorespiratory simulator SimulResp requires further development before future integration into a clinical decision support system.

Venous Blood Gas and Acid-base Values in Captive Asian Elephants (Elephas maximus)

Background: Blood gas and acid base values are very much essential for health assessment and disease diagnosis of captive elephants especially when clinical signs were nonspecific and other diagnostic techniques may not be available for immediate applications. Region specific normal healthy animal profile is valuable in health care planning for captive elephants. The aim of this study was to assess and evolve the baseline reference values for Blood gas and acid base parameters in captive Asian elephants raised in the Tamil Nadu State of India. Methods: A total of 46 venous blood samples were analyzed for blood gas and acid base values such as partial pressure of oxygen (PvCO2), partial pressure of carbon-dioxide (PvO2), oxygen saturation (SvO2), total carbon dioxide content (TvCO2), Bicarbonate and Base excess (BEecf), bicarbonate (HCO3-) and pH by using i-STAT®1 hand held analyzer. Results: The mean±SE, lower and upper value, 95% and 99% of confidence interval of the pH, PvCo2, PvO2, TvCo2, BEecf, HCO3- , SvO2, Lactate were assessed. As the elephants in this study were apparently healthy, these range of values could well serve as a reference range for captive Asian elephants.

Venovenous Extracorporeal Membrane Oxygenation Initiation for Pediatric Acute Respiratory Distress Syndrome With Cardiovascular Instability is Associated With an Immediate and Sustained Decrease in Vasoactive-Inotropic Scores.

To determine the association of venovenous extracorporeal membrane oxygenation (VV-ECMO) initiation with changes in vasoactive-inotropic scores (VISs) in children with pediatric acute respiratory distress syndrome (PARDS) and cardiovascular instability. Retrospective cohort study. Single academic pediatric ECMO center. Children (1 mo to 18 yr) treated with VV-ECMO (2009-2019) for PARDS with need for vasopressor or inotropic support at ECMO initiation. Arterial blood gas values, VIS, mean airway pressure (mPaw), and oxygen saturation (Sp o2 ) values were recorded hourly relative to the start of ECMO flow for 24 hours pre-VV-ECMO and post-VV-ECMO cannulation. A sharp kink discontinuity regression analysis clustered by patient tested the difference in VISs and regression line slopes immediately surrounding cannulation. Thirty-two patients met inclusion criteria: median age 6.6 years (interquartile range [IQR] 1.5-11.7), 22% immunocompromised, and 75% had pneumonia or sepsis as the cause of PARDS. Pre-ECMO characteristics included: median oxygenation index 45 (IQR 35-58), mPaw 32 cm H 2o (IQR 30-34), 97% on inhaled nitric oxide, and 81% on an advanced mode of ventilation. Median VIS immediately before VV-ECMO cannulation was 13 (IQR 8-25) with an overall increasing VIS trajectory over the hours before cannulation. VISs decreased and the slope of the regression line reversed immediately surrounding the time of cannulation (robust p < 0.0001). There were pre-ECMO to post-ECMO cannulation decreases in mPaw (32 vs 20 cm H 2o , p < 0.001) and arterial P co2 (64.1 vs 50.1 mm Hg, p = 0.007) and increases in arterial pH (7.26 vs 7.38, p = 0.001), arterial base excess (2.5 vs 5.2, p = 0.013), and SpO 2 (91% vs 95%, p = 0.013). Initiation of VV-ECMO was associated with an immediate and sustained reduction in VIS in PARDS patients with cardiovascular instability. This VIS reduction was associated with decreased mPaw and reduced respiratory and/or metabolic acidosis as well as improved oxygenation.

Inhaled nitric oxide as rescue therapy in severe ARDS cases due to COVID-19 pneumonia: a single center experience.

Inhaled NO (iNO) has been recommended as rescue therapy in acute respiratory stress syndrome (ARDS) cases. In this study, we aimed to demonstrate the efficacy of iNO as a rescue therapy in patients with severe ARDS due to COVID-19. This retrospective study included patients with ARDS due to COVID-19 who were treated with iNO between March 2020 and January 2022 in the intensive care unit (ICU) of Inonu University. Patients' files were reviewed retrospectively, and demographic data, APACHE II and Sequential Organ Failure Assessment (SOFA) scores, initiation day of iNO and duration of iNO treatment, length of stay in hospital/ICU, blood biochemistry values, complete blood counts, inflammatory parameters, arterial blood gas values, lactate, PaO2/FiO2 ratios, anti-inflammatory drugs and outcome were recorded. Data from 16 patients were reached. iNO was given at a dose of 20 ppm continuously. The mean duration of treatment with iNO was 3.5 days. All patients took the prone position except a single patient. While all patients received steroid therapy, four patients received anti-cytokine therapy, and five patients received intravenous immunoglobulin therapy. All patients were in severe ARDS with a mean PaO2/FiO2 ratio of 58 before iNO therapy. A significant increase in PaO2/FiO2 values was detected with the use of iNO (p<0.05). While three patients (19%) were discharged from the ICU, thirteen patients died. In our study, it was determined that iNO applied as a rescue treatment in patients with severe ARDS improved oxygenation. Although the effect of iNO on survival was low, it may be interpreted as clinically significant considering the severity of the general clinical condition of the patients.

The accuracy of the Thompson score in predicting early outcome in neonates with hypoxic ischaemic encephalopathy treated with therapeutic cooling in a tertiary hospital.

Hypoxic ischaemic encephalopathy (HIE) is one of the major contributors to neonatal mortality and morbidity in developing countries. Scarcity of resources limits clinicians in optimally caring for these patients. Optimal utilisation of clinical tools such as the Thompson score (TS) can assist in improving care by classifying the severity of HIE followed by appropriate treatment. The primary objective was to study the correlation of the TS and early neonatal outcomes in infants with HIE who received therapeutic hypothermia (TH). Secondary objectives were to investigate the correlation of blood gas values with the TS, need for resuscitation with TS, target organ damage (TOD) with TS and the most common risk factors associated with HIE in Tembisa Provincial Tertiary Hospital (TPTH). This was a retrospective record review of infants admitted with HIE from January 2018 to August 2019 at the TPTH neonatal unit. Infants had to have successfully completed TH. Ninety-three infants met the inclusion criteria, with 32, 48 and 13 being classified into the mild, moderate and severe categories by TS, respectively. The median length of stay (LOS) was noted to rise with a rising TS, recorded to be 7, 8 and 9 days in the mild, moderate and severe groups, respectively. The mortality rate in the study was calculated to be 2.1%, and there was no significant difference across the groups (p=0.231). A need for antiseizure medication (ASM) on discharge was significantly associated with severe HIE (p=0.028). Hypertension was a frequent chronic illness, noted in 11.3% of the mothers. The most frequent perinatal risk factor was meconium aspiration (50.5%), followed by prolonged second stage of labour (PSSL) (17.2%). A higher TS (severe group) was associated with prolonged resuscitation for >10 minutes (p=0.001) and a need for adrenaline (p=0.008). The frequency of cardiac impairment, liver impairment and clinical seizures increased with a higher TS category (p=0.23, p=0.35 and p=0.51, respectively). On blood gas analysis, a low pH and a high base deficit were associated with severe HIE (p=0.027, p=0.061 respectively). The TS is still a useful clinical tool in the era of TH as it is able to predict some early neonatal outcomes such as LOS and a need for ASM at discharge. It is also able to demonstrate increased frequency of duration of resuscitation and a need for adrenaline in severely encephalopathic infants compared with mild. A high TS is also associated with severe metabolic acidosis and increased frequency of TOD. Maternal hypertension, meconium-stained liquor and PSSL are the common risk factors for HIE at TPTH.

Porcine Normothermic Isolated Liver Perfusion.

Porcine models of liver ex situ normothermic machine perfusion (NMP) are increasingly being used in transplant research. Contrary to rodents, porcine livers are anatomically and physiologically close to humans, with similar organ size and bile composition. NMP preserves the liver graft at near-to-physiological conditions by recirculating a warm, oxygenated, and nutrient-enriched red blood cell-based perfusate through the liver vasculature. NMP can be used to study ischemia-reperfusion injury, preserve a liver ex situ before transplantation, assess the liver's function prior to implantation, and provide a platform for organ repair and regeneration. Alternatively, NMP with a whole blood-based perfusate can be used to mimic transplantation. Nevertheless, this model is labor-intensive, technically challenging, and carries a high financial cost. In this porcine NMP model, we use warm ischemic damaged livers (corresponding to donation after circulatory death). First, general anesthesia with mechanical ventilation is initiated, followed by the induction of warm ischemia by clamping the thoracic aorta for 60 min. Cannulas inserted in the abdominal aorta and portal vein allow flush-out of the liver with cold preservation solution. The flushed-out blood is washed with a cell saver to obtain concentrated red blood cells. Following hepatectomy, cannulas are inserted in the portal vein, hepatic artery, and infra-hepatic vena cava and connected to a closed perfusion circuit primed with a plasma expander and red blood cells. A hollow fiber oxygenator is included in the circuit and coupled to a heat exchanger to maintain a pO2 of 70-100 mmHg at 38 °C. NMP is achieved by a continuous flow directly through the artery and via a venous reservoir through the portal vein. Flows, pressures, and blood gas values are continuously monitored. To evaluate the liver injury, perfusate and tissue are sampled at predefined time points; bile is collected via a cannula in the common bile duct.

Effectiveness of PEEP and Recruitment Maneuvers in Improving Oxygenation in Laparoscopic Hysterectomies: A Randomized Controlled Trial

ABSTRACT Rationale: To determine whether positive end-expiratory pressure (PEEP) with lung recruitment will benefit in improving oxygenation and in reduction of post-operative complications in patients undergoing gynecological laparoscopic surgeries in Trendelenburg position. Methods: Seventy-two patients, 36 in each arm, were recruited for single blind randomized controlled trial. Patients in intervention arm received a PEEP of 8 cm H2O and lung recruitment every 45 min and at the end of surgery. Patients in non-intervention arm (group N) received conventional ventilation with no PEEP and recruitment maneuver. Analysis was done on the basis of PaO2, intraoperative hemodynamics, and post-operative complications. Results: Intra-operative pH, pO2, and pCO2 values were 7.41 ± 0.03; 193.8 ± 13.4; and 38.6 ± 2.6 mmHg in group P, and 7.39 ± 0.72; 162.1 ± 5.3; and 38.8 ± 2 mmHg in group N. A significant increase in pO2 level was noted in the PEEP with recruitment group. Post-operative pH, pO2, and pCO2 values in group P were 7.33 ± 0.03; 87.5 ± 4; and 37.2 ± 3.1 mmHg, respectively, in group P and 7.32 ± 0.03, 87.8 ± 2.7; and 38.5 ± 2.6 mmHg in group N. No significant difference in the arterial blood gas (ABG) values was noted in both the groups in the post-operative period. We did not notice any significant hemodynamic variation in the intervention group (group P) checked 1 min, 3 min, and 5 after performing after recruitment maneuver (RM). Conclusion: PEEP with RM can be used to improve oxygenation in patients undergoing laparoscopic surgeries in Trendelenburg position. It has no effect in improving post-operative oxygenation.

Respiratory considerations in patients with neuromuscular disorders.

Patients with neuromuscular disorders (NMDs) develop respiratory impairment as muscles weaken. Ensuing complications include reductions in lung volume, compliance, and cough ability and increased risk for lung infections. Sleep disordered breathing results from weakened upper airway muscles and/or impaired central ventilatory control systems. Evaluation includes measurement of seated and supine vital capacity (VC) and respiratory muscle strength. Assisted cough techniques facilitate airway clearance. The decision to initiate assisted ventilation is multifactorial, and may include consideration of patient symptoms, spirometry, pulmonary pressures, sleep studies or blood gas values. Most patients prefer noninvasive ventilation to enhance mobility and independence. Tracheostomy is indicated when bulbar function is impaired and cough assist measures fail to clear the airway. Technological advances in respiratory support have improved quality of life and longevity. Home care is the best option for most patients but remains a challenge, especially for caregivers with regard to physical, emotional, and financial implications, as well as social, administrative, and insurance concerns.

Elevated methemoglobin levels in patients treated with high-dose hydroxocobalamin.

The aim of this study was to assess the impact of hydroxocobalamin (OHCbl) infusion on arterial blood gas and oximetry values in patients with vasoplegic syndrome. Blood samples collected from 95 patients receiving OHCbl infusion were assayed using the ABL90 FLEX Plus blood gas analyzer for the concentration of methemoglobin (MetHb), total hemoglobin (tHb), carboxyhemoglobin (COHb), arterial oxygen saturation (SaO2), arterial oxygen partial pressure (PaO2), and arterial carbon dioxide partial pressure (PaCO2). Interference of OHCbl on these variables was evaluated using the measured difference between the preinfusion and postinfusion samples. Blood MetHb (%) measured after the infusion of OHCbl (5g) were significantly higher than the baseline levels, with a median of 4.8 (IQR, 3.0-6.5) versus 1.0 (IQR, 1.0-1.2) (P < .001). Blood COHb (%) increased from a median of 1.3 (IQR, 1.0-1.8) to 1.7 (IQR, 1.3-2.2) (P < .001) following the OHCbl infusion. No differences were seen in median levels of tHb, PaO2, PaCO2, and SaO2 between pre- and post-OHCbl treatment. The presence of OHCbl in blood clearly interfered with the oximetry measurements of the hemoglobin component fractions by falsely increasing the levels of MetHb and COHb. Blood levels of MetHb and COHb cannot be reliably determined by the co-oximetry when OHCbl is known or suspected.