Circulatory Compromise Research Articles

A vasoactive inotropic score predicts the severity of compromised systemic circulation and mortality in preterm infants

To validate the vasoactive inotropic score as a predictor of the severity of compromised systemic circulation and mortality in preterm infants. A retrospective study was conducted on preterm infants with Compromised systemic circulation [hypotension±lactic acidosis±oliguria] who received a cardiovascular support, we calculated the vasoactive inotropic score (VIS) and cumulative exposure to cardiovascular medications over time (VISct). Receiver operator curve was constructed to predict the primary outcome which was death & refractory hypotension. VIS had an area under the curve of 0.73 (95% CI 0.85-0.98, p < 0.001). A VIS cut off of 25 has sensitivity and specificity of 66% and 92%, and positive and negative predictive values of 78.5% and 83%, respectively. High VIS predicts the severity of Compromised systemic circulation and mortality rate in preterm infants.

Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study.

Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant. We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups. Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35). This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.

Cohen’s Comprehensive Thoracic Anesthesia

Cohen’s Comprehensive Thoracic Anesthesia

Giant umbilical cord with impending heart failure—Prognostic significance of prenatal ultrasound

Detection of giant umbilical cord prenatally should lead to vigilant monitoring particularly at term as fetal demise is a possibility, as noted in the present case because of altered hemodynamics and related vascular complications such as compromised fetal circulation. A case of prenatally diagnosed, giant umbilical cord with fetoplacental insufficiency and impending heart failure is reported. An 18-year-old primigravida, presented at 34 weeks of gestational age with complaints of acute onset abdominal pain. Fetal umbilical artery obstetric Doppler examination demonstrated reversal of diastolic flow. 2D echocardiography demonstrated dilated all 4 chambers of the heart with reduced contractility suggesting impending heart failure. Subsequently, fetal demise was noted after 2 days, and labour was induced followed by vaginal delivery of the dead fetus. A giant umbilical cord was seen at delivery with absent knots or strictures. This case report deserves a special mention as there were no earlier reported cases of giant umbilical cord in literature presenting with impending heart failure and fetal demise. We have presented the detailed clinical course of the fetus with giant umbilical cord along with a review of the related literature.

Alien Limb Phenomenon After Diffuse Corpus Callosum Ischemic Stroke.

The alien limb is a phenomenon characterized by a cluster of clinical features wherein the limb behaves autonomously and as separated from a person's identity. We herein report a 36-year-old Indian female with multiple comorbidities who presented with recurrent episodes of limb-shaking transient ischemic attacks for 1year, followed by left-sided hemiplegia. During recovering, the patient noticed a feeling that as if her left hand did not belong to herself and acted autonomously (alien limb phenomenon) along with visuospatial deficits. Magnetic resonance imaging of the brain revealed ischemic stroke diffusely involving corpus callosum. Magnetic resonance angiography was suggestive of compromised right-sided anterior circulation. This was corroborated by digital subtraction angiography that revealed reduced flow in right internal carotid artery. Diffuse infarction of the corpus callosum requires involvement of both the anterior and the posterior circulation. Due to the lack of clinical features suggestive of chronic internal carotid artery dissection, occlusive atherosclerotic disease of the anterior cerebral circulation associated with possible steal phenomenon from the posterior circulation was the most probable underlying mechanism for the callosal stroke. Steal phenomenon has been proposed as a compensatory mechanism in hemodynamically compromised ischemic parenchyma and it can explain the co-existence of anterior and posterior circulation strokes. This case also highlights how both anterior and posterior types of the alien limb phenomenon can co-exist in a background of vascular insult, resulting from intra-cranial atherosclerotic disease.

Refractory electrical storm in coronary artery disease patient, challenges of dying heart

Electrical storm most often occurs in patients with coronary artery disease and left ventricular dysfunction. We report a case of recurrent ventricular Tachycardia (VT) in a 49-year-old male patient previously known to have an inferior myocardial infarction and hypertension, presented with ischemic chest pain accompanied by dizziness, hypotension, and tachycardia. An electrocardiogram showed monomorphic VT. A prompt synchronized electrical cardioversion under sedation has reverted the rhythm to the sinus. An echocardiogram showed left ventricular segmental wall motion abnormalities and ejection fraction of 37%. Then the condition complicated by recurrent VT necessitates multiple electrical cardioversions and defibrillation given for recurrent ventricular Fibrillation (VF) and short cardiopulmonary resuscitations that revived the patient from cardiac arrests. The patient had received a total of 103 electrical shocks over 15 days during which, he developed circulatory and respiratory compromise that required mechanical ventilation on twice occasions. Meticulous care including central monitoring and inotrope for hypotensive episodes was provided. A coronary angiogram showed normal left anterior descending and circumflex coronary arteries and a totally occluded right coronary artery which was failed to be revascularized in an attempt of angioplasty. The patient was successfully weaned off the ventilator and run a quiet course afterward. An implantable cardioverter-defibrillator was placed while maintained on oral amiodarone, mexiletine, metoprolol, and omega-3-acid ethyl esters, then discharged asymptomatic without recorded dysrhythmias. This case report underscores the challenges encountered throughout the management of such particular life-threatening ventricular arrhythmias and their impact on patient safety.

A Postoperative Free Flap Monitoring System: Circulatory Compromise Detection Based on Visible-Light Image

Microvascular free flap surgery has been a reliable reconstruction method, but some flaps may have circulatory compromise within five to seven days of surgery. Besides, many auxiliary devices are expensive and complex to operate. Therefore, most of the medical personnel still use the manual observation. To decrease heavy workload on medical personnel, the monitoring system was developed to analyze the color variation of free flap by a visible-light camera with advantages such as fast operation, low cost, noninvasive behavior, and contactless and nonradiative operation would be also needed for patients. The proposed system was mainly comprised of a longitudinal image registration without markers and a circulatory compromise detection, which were aiming to reduce the deformation from patients’ motion and eliminate the influence of illumination variation from the surrounding, respectively. In the clinical trial, the performance assessment of image registration reveals that the average and the standard variation of dice similarity coefficient (DSC) can reach 0.959 and 0.011, respectively. The relationship among the situation of blood perfusion and the results of circulatory compromise detection at flap was summarized and shown that the detection system not only determined the moment of vascular occlusion but also the type of occlusion. In addition, vascular congestion was even detected much earlier than manual observation. Therefore, our monitoring system is expected to relieve the workload on medical personnel and could be a reliable tool for the surgeon to hold onto the chance of repairing the free flap with vascular obstruction.

O uso da câmera termográfica no diagnóstico auxiliar do aspecto celulítico

Aesthetic cellulite is a disorder characterized by the skin with an “orange peel” appearance and has negatively affected the self-esteem and social life of more than 80% of post-pubertal women. The content in question covers the scarcity of evaluative studies in the area of aesthetics and favors the standardization of a technique for evaluating this dysfunction. The present study aimed to verify the use of thermography as an auxiliary method in the diagnosis of possible circulatory alterations in the gluteal region, as in cases of cellulite appearance, and to investigate the possibility of preventing its worsening. This is an observational study, carried out with eighteen female volunteers aged between 18 and 35 years old, with striae alba in the gluteal region, without drug treatment with photosensitive substances, or using isotretinoin, or still applying any specific topical treatment on the buttocks. The participants were divided into 2 groups, which were group 1 (non-uniform thermographic images) and group 2 (uniform thermographic images). Assessments of the cellulite’s appearance were performed through conventional photographs, thermography, and by 3 specialists in the field of dermatofunctional physiotherapy. The results showed that the severity of cellulite cannot be classified only through a visual assessment or questionnaires, since the participants who do not have the physical characteristic of cellulite, demonstrated through the thermography, a circulatory compromise, which suggests a possible risk in developing cellulite. Therefore, this study concluded that a previous diagnosis through a thermographic camera can help in the prevention of this dysfunction.

Lymphocintilographic evaluation of lymphatic circulation in victims of circuferential degloving injuries of the lower limbs.

secondary forms of lymphedema may occur as consequence of tumors, surgeries, radiotherapy, trauma and infections. Degloving injuries are severe and infrequent forms of trauma, with avulsion at the level of muscular fascia, and consequent injury of the lymphatic system. to evaluate the alterations in lymphatic circulation in patients being victims of circumferential degloving injuries in the lower limbs, using lymphoscintigraphic. retrospective analysis of the cases treated in the period from 2010 to 2016. Segmental, circumferential and unilateral injuries with involvement of the lower limbs were included. Lymphoscintigraphy was performed after a minimum interval of 12 months after the end of treatment. The non-injured lower limb was used as control. The Kleinhans Semiquantitative Index (KSI) was used for the semiquantitative evaluation of the lymphoscintigraphic findings. eighteen patients were evaluated, six of whom were female and 12 were male. The mean age was 28.11 years. The average vertical extension of the circumferential traumatized segment was 29.33cm. The injured area presented variations of 5 to 15% of the body surface, with an average of 8.95%. Lymphoscintigraphy was performed after an average interval of 22.55 months. Alterations were observed on the traumatized limb (TL) in 13 patients. All control limbs (CL) were normal. The mean KSI observed in TL was 8.32, while in CL, the average value was 0.58 (p<0.001). patients with circumferential degloving injuries in the lower limbs present compromised lymphatic circulation and high probability to develop lymphedema.

Utilizing Mask RCNN for Monitoring Postoperative Free Flap: Circulatory Compromise Detection Based on Visible-Light and Infrared Images

The new postoperative free flap monitoring system combines visible-light and infrared techniques to overcome the limitations of our previous study, such as resistance to illumination change, patients with large movements, and the infrared images being too blurry to identify the boundary. In the visible-light system, the Mask region-based convolutional neural networks (RCNN) was adopted to segment the region of the free flap, and these time-course visible images were aligned using our proposed image registration method. Then, the registered visible images were projected onto the infrared image by the coordinate transformation. The analysis method adopted the residual factor analysis to extract the more unvarnished specific factors. The experiments were divided into two parts. In image processing, the accuracy of the coordinate transformation has a mean error of 1.78 pixels and a standard deviation of 0.98 pixels. The segmentation results showed excellent performance in the most severe case with apparent motion and rotation, covered by gauze and the ventilator, as well as illumination variation. The dice coefficient is 0.9551 ± 0.0158, and the Hausdorff distance is 2.3943 ± 0.3921 pixels. The image registration results also reveal that the Canny edge of the deformed image was superimposed onto the reference image well. In circulatory compromise detection, the vascular congestion was detected much earlier than manual observation, and the classified type of occlusion was the same as the clinical reports. Therefore, the dual-camera monitoring system provides a reliable tool for the surgeon to hold onto the chance of repairing the free flap with vascular obstruction.

Appendix-preserving elective herniorrhaphy for de Garengeot hernia: two case reports

BackgroundEmergency appendectomy is often performed for de Garengeot hernia. However, in some cases, there may be a chance to perform an appendix-preserving elective surgery.Case descriptionA 76-year-old woman presented to our hospital with complaints of a right inguinal swelling, which we diagnosed as a de Garengeot hernia using computed tomography (CT). B-mode ultrasonography (US) of the mass showed an appendix 4–6 mm in diameter with a clear wall structure; color Doppler US showed pulsatile blood flow signal in the appendiceal wall. Twenty-eight days later, herniorrhaphy with transabdominal preperitoneal repair (TAPP) was performed without appendectomy. Another 70-year-old woman presented to our hospital with complaints of a painful bulge in the right inguinal region. The diagnosis of de Garengeot hernia was made using CT. B-mode US showed an appendix 5 mm in diameter with a clear wall structure. Color Doppler US showed a pulsatile blood signal in the appendiceal wall. Seven days later, herniorrhaphy with TAPP was performed without appendectomy.ConclusionDe Garengeot hernia is often associated with appendicitis; however, an appendix-preserving elective herniorrhaphy can be performed if US and intraoperative findings do not suggest appendicitis or circulatory compromise in the appendix.

Endovascular Therapy for Venous Thromboembolic Diseases.

Thrombolytic therapy plays an important role in treating venous thromboembolic events in patients with unstable hemodynamics or compromised limb circulation. Standard catheter-directed thrombolysis requires a lower dosage of thrombolytic agents than systemic thrombolysis, thus lowering the risk of bleeding. Pharmacomechanical catheter- directed thrombolysis further decreases the dose of thrombolytic agents and duration of infusion. Percutaneous mechanical thrombolysis may potentially become an alternative for patients not suitable for thrombolytic agents. With an increasing number of devices and ongoing trials, endovascular therapy is a promising development that may improve both safety and efficacy in treating venous thromboembolic diseases.

Maternal plasma soluble neuropilin-1 is downregulated in fetal growth restriction complicated by abnormal umbilical artery Doppler: a pilot study.

ABSTRACTObjectivesPlacental expression of neuropilin‐1 (NRP1), a proangiogenic member of the vascular endothelial growth factor receptor family involved in sprouting angiogenesis, was recently discovered to be downregulated in pregnancies with fetal growth restriction (FGR) and abnormal umbilical artery (UA) Doppler. Soluble NRP1 (sNRP1) is an antagonist to NRP1; however, little is known about its role in normal and FGR pregnancies. This study tested the hypotheses that, first, sNRP1 would be detectable in maternal circulation and, second, its concentration would be upregulated in FGR pregnancies compared to those with normal fetal growth and this would correlate with the severity of the disease as assessed by UA Doppler.MethodsThis was a prospective case–control pilot study of 40 singleton pregnancies (20 FGR cases and 20 uncomplicated controls) between 24 + 0 and 40 + 0 weeks' gestation followed in an academic perinatal center from January 2015 to May 2017. FGR was defined as an ultrasound‐estimated fetal weight < 10th percentile for gestational age. The control group was matched to the FGR group for maternal age and gestational age at assessment. Fetal ultrasound biometry and UA Doppler were performed using standard protocols. Maternal plasma sNRP1 measurements were performed using a commercially available ELISA.ResultsContrary to the study hypothesis, maternal plasma sNRP1 levels were significantly decreased in FGR pregnancies as compared to those with normal fetal growth (137.4 ± 44.8 pg/mL vs 166.7 ± 36.9 pg/mL; P = 0.03). However, there was no significant difference in sNRP1 concentration between the control group and FGR pregnancies that had normal UA Doppler. Plasma sNRP1 was downregulated in FGR pregnancies with elevated UA systolic/diastolic ratio (P = 0.023) and those with UA absent or reversed end‐diastolic flow (P = 0.005) in comparison to FGR pregnancies with normal UA Doppler. This suggests that biometrically small fetuses without hemodynamic compromise are small‐for‐gestational age rather than FGR.ConclusionsThis study demonstrated a significant decrease in maternal plasma sNRP1 concentration in growth‐restricted pregnancies with fetoplacental circulatory compromise. These findings suggest a possible role of sNRP1 in modulating fetal growth and its potential as a biomarker for FGR. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

DEBILITATING SUBCUTANEOUS EMPHYSEMA IN THE SETTING OF RESOLVING SECONDARY PNEUMOTHORAX

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Subcutaneous emphysema (SE) is defined as the presence of air under subcutaneous tissues manifesting as swelling and crepitus. This typically benign self-limiting condition can rapidly deteriorate if left unchecked. We present a case of debilitating SE in the setting of pneumothorax management. CASE PRESENTATION: A 72-year-old man with severe chronic obstructive pulmonary disease presented with an iatrogenic small right-sided pneumothorax immediately after CT-guided biopsy of a pulmonary nodule. He improved after right thoracostomy tube insertion. Twenty-four hours after removal of the tube, he experienced dyspnea and chest pain. Physical exam was pertinent for absent breath sounds on the right hemithorax. A new moderately sized right sided lateral pneumothorax was noted on emergent chest x-ray. Due to worsening respiratory failure, he underwent intubation prior to being transferred to the intensive care unit. Upon chest tube placement, he was noted to have extensive crepitus on the bilateral neck, right hemithorax, abdomen, and pelvis. He was successfully extubated and repeat imaging confirmed resolution of pneumothorax with complete lung re-expansion, thus the chest tube was shifted from suction to water seal. Five minutes after, the subcutaneous emphysema rapidly progressed to involve the entire face as evidenced by worsening bilateral periorbital edema, closure of palpebral fissures, and high patient distress. Infraclavicular blowhole incisions were then placed and the chest tube was placed back on 20 mmHg suction. He was continued on suction for three more days until eventual resolution of the subcutaneous emphysema. DISCUSSION: SE is defined as de novo infiltration of air in the subcutaneous layers of the skin. Potential causes include surgeries, trauma, infections, and idiopathic etiology, with an incidence of 0.43% to 2.34%. Complications of extensive SE include dysphagia and compression of the airway, barotrauma, expanding pneumothorax, reduced cardiac preload, skin necrosis, amongst others. Debilitating features include anxiety, dysphagia, dysphonia, and significant respiratory or circulatory compromise. Our patient had a higher risk for SE due to the timing of the thoracotomy tube insertion while the patient was exposed to positive pressure. Worsening of the SE was due to premature discontinuation of chest tube suction. Although the pneumothorax has already resolved, it is prudent to delay transitioning the suction to water seal until the SE has stabilized. Infraclavicular blow-hole incisions, subcutaneous drains, fenestrated angiocatheters, vacuum assisted dressings and increasing suction on a pre-existing chest tube have also been described to expedite the time to recovery from debilitating SE CONCLUSIONS: Early identification and management are essential to decrease SE-related complications and mortality. More studies are needed to explore ideal management options. REFERENCE #1: Aghajanzadeh M, Dehnadi A, Ebrahimi H, Fallah Karkan M, Khajeh Jahromi S, Amir Maafi A, Aghajanzadeh G. Classification and Management of Subcutaneous Emphysema: a 10-Year Experience. Indian J Surg. 2015 Dec;77(Suppl 2):673-7 REFERENCE #2: Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med. 1984 Jul;144(7):1447-53 REFERENCE #3: Jones P, Hewer R, Wolfenden Het al. Subcutaneous emphysema associated with chest tube drainage. Respirology 2001; 6(2): 87–89 DISCLOSURES: No relevant relationships by Gustavo Avila, source=Web Response No relevant relationships by Jessica Baek, source=Web Response No relevant relationships by Renuka Reddy, source=Web Response No relevant relationships by Jodi Renner, source=Web Response No relevant relationships by Larnelle Simms, source=Web Response No relevant relationships by Laura Suzanne Suarez, source=Web Response No relevant relationships by Claudia Tejera Quesada, source=Web Response

Left ventricular ejection fraction is associated with intraoperative circulatory collapse during transcatheter aortic valve implantation.

BackgroundIntraoperative hemodynamic collapse during transcatheter aortic valve implantation (TAVI) is a devastating complication that requires mechanical support. In this study, we sought to analyze our early experience in using cardiopulmonary bypass (CPB) support to circumvent circulatory compromise during TAVI.MethodsBetween January 2018 and December 2020, 102 consecutive patients (54 males; mean age, 71.2±8.9 years) received TAVI at Tianjin Chest Hospital, and an emergency CPB device was used in 6 of these patients (5.9%). The clinical data of the CPB and no-CPB groups were analyzed to identify the factors associated with intraoperative hemodynamic collapse requiring CPB.ResultsAll 6 patients who needed emergency CPB support were successfully weaned from the device. This group had a higher Society of Thoracic Surgeons Score [4.09 (2.02, 6.85) vs. 7.47 (5.07, 23.46); P=0.030], more patients with a left ventricular ejection fraction (LVEF) ≤30% [4 (66.7%) vs. 2 (2.1%); P=0.000], a larger right ventricle anteroposterior diameter [20.50 (19.75, 21.25) vs.19.00 (17.00, 20.00); P=0.016], and a higher degree of aortic regurgitation [4.50 (2.75, 5.00) vs. 2.00 (1.00, 4.00); P=0.018] compared to the no-CPB group. The CPB group also had a higher in-hospital mortality rate than did the no-CPB group (16.7% vs. 4.7%; P=0.026). Multivariable analysis determined that the presence of lower pre-TAVI LVEF was associated with intraoperative hemodynamic collapse.ConclusionsOur results indicate that LVEF is an independent risk factor for requiring emergency CPB during the TAVI procedure. The need for emergency CPB support was associated with higher in-hospital mortality.

Risks of Laparoscopic Harvest of Free Intestinal Flaps for Esophageal Reconstruction.

Performing ablative surgery using an laparoscope is a common practice. However, its use in the harvest of a segment of intestine for reconstruction has 2 major challenges: risk of damage to the vascular pedicle of the flap as well as to the vessels of other parts of the intestine that remain in the peritoneal cavity and risk of damage to the intestinal flap while pulling it out through a small opening in the abdominal wall. The aim of this study was to report advantages and disadvantages of harvesting free intestinal flaps using the laparoscopic method, explaining the challenges faced and lessons learned from this experience. Free intestinal flaps were harvested by laparoscopy in 12 patients aged 28 to 63 years. There were 9 free jejunal flaps for the reconstruction of the cervical esophagus and 3 ileocolic flaps for the reconstruction of both the cervical esophagus and voice reconstruction. In 1 patient, laparoscopy was converted to laparotomy due to previous colectomy, which resulted in compromised circulation to the rest of the colon. One jejunal flap had leakage at its pharyngeal end; therefore, a pectoralis major myocutaneous flap was used for closure. In addition, 1 ileocolic flap had partial loss of its anterior wall, and a free anterolateral flap was used as a patch for closure. Furthermore, it was very difficult to harvest 1 free jejunal flap due to the thick and fat mesentery. Prolonged operative times, unexpected leakage at the anastomosis sites, partial loss of flaps, possible risk of vascular pedicle damage or venous compromise, demanding pedicle dissection in obese patients, and requirement of conversion to laparotomy are the major drawbacks of harvesting free intestinal flaps by laparoscopy.

Cardiopulmonary effects of phosphine poisoning: A preliminary evaluation of milrinone

Exposure to phosphine (PH3) presents with a host of diverse, non-specific symptoms that span multiple organ systems and is characterized by a high mortality rate. While a comprehensive mechanism for PH3 poisoning remains inconclusive, prior studies have implicated cardiac failure and circulatory compromise as potential pathways central to PH3-induced mortality. In this study, milrinone (MLR), a phosphodiesterase-3 inhibitor used to treat cardiac failure, was investigated as a potential countermeasure for PH3 poisoning. Lethality, physiological responses, and behavioral changes were evaluated in telemetrized female rats pretreated with water (sham) or one of three doses of MLR (40, 200, or 600 μg/kg) and exposed to PH3 (660 ppm for 25–40 min; 16,500–26,400 ppm × min). Animals receiving prophylactic administration of 600 μg/kg of MLR had nominally improved survivability compared to sham animals, although median lethal concentration-time and time of death did not differ substantially between treatment groups. Changes in respiration and behavior induced by PH3 appeared largely unaffected by MLR pretreatment, regardless of dose. Conversely, MLR pretreatment alleviated some aspects of PH3-induced cardiac function impairment, with slight dose-dependent effects observed for cardiac contractility, mean arterial pressure, and QRS duration. Together, these results illustrate the importance of circulatory compromise in PH3 poisoning and highlight the potential viability of MLR as a potential countermeasure option or part of a countermeasure regimen when administered prophylactically at 600 μg/kg.

A Review of 1073 Cases of Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) in Finger and Hand Surgeries in an Urban Hospital in Malaysia.

BackgroundThe Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) technique achieves an almost bloodless field for clear visualization during surgeries. WALANT utilizes lidocaine and epinephrine for anesthesia and hemostasis, respectively, without the usage of sedation and tourniquet. This avoids the potential side effects of tourniquet-related pain and sedation-related complications. However, acceptance is still low due to concerns regarding the safety of epinephrine injection in the finger. There is a persistent belief that epinephrine can cause digital ischemia.PurposeTo evaluate retrospectively possible complications of hand surgeries performed using the WALANT technique.MethodsAll finger and hand procedures performed under the WALANT technique from June 2016 to May 2021 in an urban tertiary hospital were studied retrospectively.ResultsThere were a total of 1073 cases, of which 694 were females and 379 were males. The mean age was 55 years. Finger surgeries (e.g., trigger finger release, excision of finger lesions, removal of implants) consisted of 707 cases; and the rest (366 cases) were hand surgeries (e.g., carpal tunnel release, excision of hand lesions, removal of implants). In all cases reviewed, there were no instances of circulatory compromise. There were also no circumstances where usage of reversal with phentolamine is recorded.ConclusionWe believe that performing finger and hand surgeries using the WALANT technique is safe and beneficial. The usage of WALANT in hand surgeries avoids tourniquet pain. However, WALANT should be used with caution in those with vascular insufficiency or disease.

Clinical observations of COVID-19 infection in patients with chronic thromboembolic pulmonary hypertension.

Aim To present clinical observations of the novel coronavirus infection (COVID-19) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) after a surgical intervention in the form of thromobendarterectomy from pulmonary artery branches.Material and methods The Acad. E.N. Meshalkin National Medical Research Center performed 127 open surgical interventions for CTEPH in the form of thromobendarterectomy from 2016 through 2020. The present study enrolled 113 patients included into the follow-up care group and into the Center Registry who were followed up for more than 6 months after the surgery. Clinical and functional features of COVID-19 were evaluated in the studied group.Results In the follow-up care group, 5 (4.4%) postoperative CTEPH patients had COVID-19. One patient had asymptomatic disease, and others had typical clinical symptoms and bilateral polysegmental pneumonia. There were no cases requiring artificial ventilation and no lethal outcomes. All patients with COVID-19 received anticoagulants as a basis therapy for CTEPH, and two patients who had residual pulmonary arterial hypertension (PAH) additionally received a PAH-specific therapy. During the treatment of COVID-19, no adjustment of the anticoagulant or PAH-specific therapy was required.Conclusion The group of patients with CTEPH is a unique pathophysiological model for studying the effect of COVID-19 under the conditions of compromised pulmonary circulation. In the studied follow-up care group, the COVID-19 morbidity was 4.4 % without fatal outcomes. Evaluation of the role of chronic anticoagulant and PAH-specific therapy in COVID-19 postoperative patients as well as evaluation of the role of COVID-19 in CTEPH progression merit further investigation.

ZOR DURUMLARDA ALICI DAMAR OLARAK SERBEST FLEP KİMERİZASYONUNU İÇEREN FARKLI MODALİTELERLE BİRLİKTE TORAKOAKROMİAL ARTERYEL GÖVDE VE SEFALİK VEN SİSTEMİNİN KULLANIMI

Objective&#x0D; We aimed to remind surgeons of the presence of the&#x0D; thoracoacromial arterial trunk and cephalic vein (TATCV)&#x0D; for a comfortable and reliable free flap transfer&#x0D; to the head, arm, and trunk, in case the mainstream recipient vessels of these regions pose some inconveniences&#x0D; due to previous surgery, radiotherapy, or&#x0D; trauma.&#x0D; Material and Methods&#x0D; Eight cases of trauma or tumor involving the head and&#x0D; neck or upper extremity, treated with free tissue transfer&#x0D; in which this vascular system was used with different&#x0D; modalities, were reviewed retrospectively.&#x0D; Results&#x0D; This vascular system proved to be reliable in all cases.&#x0D; It enabled chimerization with the pectoral flap. It was&#x0D; used in six patients for head and neck reconstructions&#x0D; and in two upper extremity restrorations. Switching&#x0D; the anastomoses to TAT-CV site and cephalic vein&#x0D; transposition were found to be rapid and reliable methods&#x0D; to rescue a flap with compromised circulation.&#x0D; Discussion&#x0D; Although anatomically well known by many reconstructive&#x0D; surgeons, its ease of dissection, consistency,&#x0D; supply of branches of differing caliber, and strategic&#x0D; location is not adequately appreciated. Moreover, in&#x0D; cases of pectoralis major flap transfer in which additional&#x0D; tissue is required, this vascular system is already&#x0D; there to receive it.