Intermittent Intravenous Bolus Research Articles

Neonate with Respiratory Distress, Bilateral Microtia, Hypocalcemia, and Lymphopenia.

Neonate with Respiratory Distress, Bilateral Microtia, Hypocalcemia, and Lymphopenia.

Safety and effectiveness of intravenous procainamide in patients with frequent ventricular ectopics during cardiac magnetic resonance scanning: a way to ensure high quality imaging

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac magnetic resonance (CMR) imaging in patients with frequent ventricular arrhythmias provides significant diagnostic and prognostic information but is challenging due to artefacts. In patients with occasional ventricular premature contractions (VPCs), arrhythmia rejection algorithms can be used to acquire good quality cine images at the expense of longer breath-hold times. However, arrhythmia sorting in not practical in cases of frequent VPCs; other options include triggered data acquisition which compromises image quality or use of low temporal and spatial resolution ‘real-time’ imaging. Purpose The aim of our study was to examine the safety and effectiveness of the class Ia antiarrhythmic medication procainamide for suppressing ventricular ectopy and acquiring high quality CMR images. Methods 50 consecutive patients (mean age 48 ± 16 years; 52% female) with a high burden of VPCs during CMR scanning were included in the study. Procainamide was administered on the scanner table prior to CMR scanning at intermittent intravenous bolus doses of 50 mg every minute, until suppression of VPCs was achieved or a maximum dose of 10 mg/kg was reached. Blood pressure was measured every minute and there was continuous monitoring of heart rate and ECG trace. CMR studies were performed on a 1,5T Magnetom Avanto scanner using a standard cardiac protocol. Results The average dose of procainamide administered was 567 ± 197 mg (range 200-1000 mg). Procainamide successfully suppressed VPCs in 82% of patients (20 patients with complete suppression and 21 with significant reduction); 7 patients had minimal suppression of VPCs, while there was no effect of procainamide in only 2 patients. Baseline blood pressure (BP) was mildly reduced (mean change systolic BP -12 ± 9 mmHg; diastolic BP -4 ± 9 mmHg) but none of the patients developed symptomatic hypotension. Baseline heart rate (HR) was relatively unchanged (baseline 75 ± 11 beats per minute (bpm) – peak procainamide HR 74 ± 12 bpm (mean HR change -1 ± 6 bpm). None of the patients developed pathological ECG changes. CMR scan had normal findings in 42% of the patients, 26% had non-ischemic cardiomyopathy, in 16% the most likely diagnosis was VPC-related cardiomyopathy, 14% had previous myocarditis, and 1 patient had dual pathology (dilated cardiomyopathy with previous myocardial infarction). Mean left ventricular ejection fraction was 55% ± 9%. Conclusion We propose the bolus intravenous administration of procainamide prior to CMR scanning as a safe and effective alternative approach for suppressing VPCs and acquiring high quality images in patients with frequent ventricular arrhythmias and normal or only mildly impaired left ventricular function. Further studies are needed to assess its safety and effectiveness in larger patient cohorts, including also patients with ventricular systolic impairment.

Bolus Intravenous Procainamide in Patients with Frequent Ventricular Ectopics during Cardiac Magnetic Resonance Scanning: A Way to Ensure High Quality Imaging.

Acquiring high-quality cardiac magnetic resonance (CMR) images in patients with frequent ventricular arrhythmias remains a challenge. We examined the safety and efficacy of procainamide when administered on the scanner table prior to CMR scanning to suppress ventricular ectopy and acquire high-quality images. Fifty consecutive patients (age 53.0 [42.0–58.0]; 52% female, left ventricular ejection fraction 55 ± 9%) were scanned in a 1.5 T scanner using a standard cardiac protocol. Procainamide was administered at intermittent intravenous bolus doses of 50 mg every minute until suppression of the ectopics or a maximum dose of 10 mg/kg. The average dose of procainamide was 567 ± 197 mg. Procainamide successfully suppressed premature ventricular contractions (PVCs) in 82% of patients, resulting in high-quality images. The baseline blood pressure (BP) was mildly reduced (mean change systolic BP −12 ± 9 mmHg; diastolic BP −4 ± 9 mmHg), while the baseline heart rate (HR) remained relatively unchanged (mean HR change −1 ± 6 bpm). None of the patients developed proarrhythmic changes. Bolus intravenous administration of procainamide prior to CMR scanning is a safe and effective alternative approach for suppressing PVCs and acquiring high-quality images in patients with frequent PVCs and normal or only mildly reduced systolic function.

Comparison of two techniques (intermittent intravenous bolus morphine vs. morphine infusion) for analgesic titration in patients who had advanced cancer with severe pain: a prospective randomised study

ObjectiveTo compare the analgesic efficacy of two techniques of morphine titration (intermittent intravenous bolus vs infusion) by calculating rescue dosage in a day at 1 week after analgesic titration.MethodsOne hundred...

Continuous intravenous versus intermittent bolus midazolam with remifentanil during arteriovenous fistula placement with monitored anesthesia care in chronic renal failure patients: a randomized controlled trial.

ABSTRACTBACKGROUND: There is limited data on the use of intravenous continuous infusion (CI) versus intravenous intermittent bolus (IB) doses of midazolam for conscious sedation in patients with chronic renal failure. Unexpected adverse events can occur in chronic renal failure patients undergoing short procedures.OBJECTIVE: Investigate and compare the sedoanalgesic and adverse effects of intravenous continuous infusion (CI) use of midazolam with intravenous intermittent bolus (IB) doses of midazolam while using intravenous remifentanil as a rescue medication, and assess patient and surgeon satisfaction.DESIGN: Prospective, randomized, single-blind controlled study.SETTINGS: Two tertiary care hospitals.PATIENTS AND METHODS: Study included patients aged 43-81 years with a diagnosis of chronic renal failure who were referred for an arteriovenous fistula procedure with modified anesthesia care between August 2012 and April 2016. The patients were randomized to intravenous CI or IB doses of midazolam. IB doses of remifentanil were used as a rescue medication.MAIN OUTCOME MEASURES: Primary outcomes were amounts of midazolam and remifentanil medications during the operation, the amount of remifentanil as a rescue medication, and the satisfaction of patient and surgeon.SAMPLE SIZE: 116 assessed for eligibility; 99 randomized to CI (n=50) or IB doses (n=49 of midazolam).RESULTS: The total dose of midazolam by CI was greater than with midazolam by IB (P=.002). The total dose of remifentanil was higher with IB doses of midazolam in comparison to CI of midazolam (P=.001). The groups were similar in sedation and pain control, duration of procedure, recovery time, patient satisfaction and adverse events; surgeon satisfaction was greater with CI versus IB (P=.035).CONCLUSION: Intravenous CI midazolam during MAC provides better surgeon satisfaction then IB midazolam and can be used safely for arteriovenous fistula procedures.LIMITATIONS: Two different surgeon groups.CONFLICT OF INTEREST: None.

Intravenous norepinephrine and mephentermine for maintenance of blood pressure during spinal anaesthesia for caesarean section: An interventional double-blinded randomised trial.

Background and Aims:Spinal anaesthesia induced hypotension (SAIH) and bradycardia may prove deleterious to both parturient and baby, hence vasopressors play a vital role in their management. Recent studies on norepinephrine as rescue vasopressor during subarachnoid block (SAB) enlighten its role for SAIH. This randomised double-blind trial was conducted to compare the effect of intermittent intravenous boluses of norepinephrine and frequently used mephentermine for management of SAIH in caesarean section (CS) to prove whether norepinephrine produces comparable effects or superior to mephentermine.Methods:After approval from Institutional Ethics Committee and registration in Clinical Trials Registry India (CTRI/2019/06/019652), 256 parturients posted for elective CS under SAB were randomly allocated into Group-N and Group-M (n = 84) using chit system, who received boluses of intravenous norepinephrine 8μg and mephentermine 6mg for SAIH, respectively. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), Response%, Apgar score and maternal complications were analysed.Results:The changes in SBP and DBP were comparable in both the groups. It was significantly low after SAB compared to baseline and significantly high compared to 1st hypotensive value in both the groups throughout the study period (<0.0001). HR was comparable for initial 10 min, thereafter it was significantly high in Group-M (<0.0001) till 40 min. Response% after the first bolus was significantly high in Group-N (59.30n ± 29.21 vs 39.78 ± 25.6; P = <0.0001).Conclusion:Intravenous norepinephrine is better than mephentermine with respect to high response% and stable maternal HR although both are equally effective in maintaining blood pressure following SAIH during elective CS.

Safety of inhalational anesthesia in patients with multiple drug allergies presenting for major surgeries under general anesthesia

The prevalence of perioperative anaphylaxis is 1 in 1250–20,000 anesthetics. Inhalational anesthesia is considered safe in patients with multiple drug allergies, as there have been no reports of anaphylaxis to volatile inhalational agents. Anesthetic management of six patients with documented allergy to all commonly used anesthetic drugs who underwent major surgeries under general anesthesia is described as a case series. The plan of anesthesia in these patients was an anesthetic gas-based general anesthesia without using muscle relaxants but with the use of intravenous fentanyl if patient was not allergic to it. Sevoflurane 8% in oxygen was used for induction. Following cessation of breathing and on attaining an end-tidal concentration of >4% sevoflurane, direct laryngoscopy and intubation were performed. Anesthesia was maintained with sevoflurane in nitrous oxide and oxygen mixture maintaining a lower end-tidal carbon dioxide. Hypotension and/or bradycardia were managed with intermittent intravenous boluses of adrenaline 20 μg. At the end of surgery, all anesthetic gases were cutoff, and patients were extubated when awake. No muscle relaxant was used in any of the cases. Two patients received fentanyl before induction, whereas others were given oral paracetamol 2 h before induction. Postoperative analgesia was provided with oral paracetamol which was given 2–4 h after surgery. Intraoperative period was uneventful for these patients. In patients with multiple drug allergies, inhalational agent-based general anesthesia can be considered as a safe alternative to regular anesthetic practice involving polypharmacy, with a reduced risk of perioperative adverse events.

Effect of bilateral thoracic paravertebral block combined with general anesthesia on early recovery after Nuss procedure in patients with pectus excavatum

Objective To evaluate the effect of bilateral thoracic paravertebral block(TPVB)combined with general anesthesia on early recovery after Nuss procedure in patients with pectus excavatum. Methods Sixty patients of both sexes with pectus excavatum, aged 8-18 yr, with body mass index<18.5-32.0 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective Nuss procedure, were divided into 2 groups by using a random number table method: general anesthesia group(group GA, n=30)and bilateral TPVB combined with general anesthesia group(group TPVB+ GA, n=30). Bilateral TPVB was performed at the level of T5 under ultrasound guidance at 30 min before operation in group TPVB+ GA.Anesthesia was induced by intravenous injection of fentanyl, propofol and rocuronium and maintained by inhalation of sevoflurane, intravenous infusion of remifentanil 0.1-0.5 μg·kg-1·min-1, and intermittent intravenous boluses of rocuronium.Patients received patient-controlled intravenous analgesia after operation.Tramadol 1-2 mg/kg or dizocin 0.1 mg/kg was intravenously injected as rescue analgesic, maintaining visual analogue scale score ≤3 within 2 days after operation.The intraoperative consumption of remifentanil, postoperative consumption of sufentanil, requirement for rescue analgesia and development of nausea and retching/vomiting were recorded.Quality of recovery was assessed using the Quality of Recovery-15 at 1 and 2 days after operation. Results Compared with group GA, the intraoperative consumption of remifentanil, postoperative consumption of sufentanil, rate of rescue analgesia and incidence of nausea and vomiting were significantly decreased, and Quality of Recovery-15 scores were increased at 1 and 2 days after operation in group TPVB+ GA(P<0.05). Conclusion Bilateral TPVB combined with general anesthesia can reduce the perioperative consumption of opioids and is beneficial for the early recovery after Nuss procedure in patients with pectus excavatum. Key words: Nerve block; Thoracic vertebrae; Anesthesia, general; Rehabilitation; Funnel chest

Modifiying efficacy of pectoral nerve block combined with general anesthesia in patients undergoing radical mastectomy

Objective To evaluate the modifiying efficacy of pectoral nerve (Pecs) block combined with general anesthesia in patients undergoing radical mastectomy. Methods A total of 60 American Society of Anesthesiologists physical status Ⅰ or Ⅱ female patients, aged 40-64 yr, weighing 50-70 kg, scheduled for elective radical mastectomy, were divided into 2 groups (n= 30 each) using a random number table method: general anesthesia group (group GA) and Pecs block combined with general anesthesia group (group PB+ GA). The patients in group PB+ GA received Pecs block guided by ultrasound.After the needle was advanced to the pleura plane between the pectoralis major and minor, 0.33% ropivacaine 15 ml was injected, and 0.33% ropivacaine 30 ml was injected into the surface of the serratus anterior muscle at the level of the third rib.Anesthesia was induced by intravenous injection of midazolam, propofol, sufentanil and cisatracurium and maintained by target-controlled infusion of propofol and intermittent intravenous boluses of sufentanil and cisatracurium.Bispectral index value was maintained at 40-60.Patient-controlled intravenous analgesia was performed with sufentanil at the end of surgery.Immediately after anesthesia induction, at 30 min and 2 h after skin incision, and at 2, 6 and 24 h after operation, peripheral venous blood samples were collected for determination of the concentrations of plasma epinephrine by radioimmunoassay, and the blood samples were collected from the end of the finger at the same time for determination of blood glucose concentrations.The consumption of intraoperative sufentanil, emergence time, pressing times of patient-controlled analgesia (PCA) and development of nausea and vomiting within 24 h after operation were recorded. Results Compared with group GA, blood glucose and plasma epinephrine concentrations were significantly decreased, the intraoperative sufentanil consumption was reduced, the emergence time was shortened, the pressing times of PCA were decreased at 2, 6 and 24 h after operation(P 0.05). Conclusion When Pecs block combined with general anesthesia is used in the patients undergoing radical mastectomy, it is helpful in reducing the opioid consumption and more helpful in inhibiting postoperative stress responses and pain responses than general anesthesia alone. Key words: Nerve block; Thoracic nerves; Anesthesia, general; Breast neoplasms

Constant rate infusion vs. intermittent bolus administration of IV furosemide in 100 pets with acute left-sided congestive heart failure: A retrospective study

The aim of this study was to determine whether the addition of constant rate infusion (CRI) to intermittent intravenous bolus (IVB) administration of furosemide resulted in an improvement in medical outcomes in dogs and cats with acute left-sided congestive heart failure (L-CHF). A total of 76 client-owned dogs and 24 client-owned cats admitted with acute L-CHF were retrospectively divided between an IVB group (43 dogs and 16 cats) and a CRI group (33 dogs and 8 cats). The median furosemide dose used in dogs in the CRI group (median 0.99mg/kg/h; range 0.025–3.73mg/kg/h) was lower than the dose used in dogs in the IVB group (median 1.19mg/kg/h; range 0.027–7.14mg/kg/h; P=0.008). Respiratory rates were lower in the IVB group (P=0.005) and the CRI group (P=0.039) compared to pre-treatment values. The overall short-term mortality was 15%. A trend of longer hospitalisation in the IVB group relative to the CRI group (P=0.07) was shown. Creatinine and total plasma protein concentrations increased more in the CRI group than in the IVB group, suggestive of a higher risk of dehydration and azotaemia. There may be safety profile differences between CRI and IVB, warranting a prospective study using a larger sample size.

Intermittent Intravenous Nitroglycerin Boluses for Acute Pulmonary Edema

Intermittent Intravenous Nitroglycerin Boluses for Acute Pulmonary Edema

Norepinephrine Intermittent Intravenous Boluses to Prevent Hypotension During Spinal Anesthesia for Cesarean Delivery: A Sequential Allocation Dose-Finding Study

(Anesth Analg. 2017;125(1):212–218) Phenylephrine, which is easy to titrate, is the current first-choice vasopressor for prevention and treatment of maternal hypotension during spinal anesthesia for cesarean delivery (CD). However, it has a propensity to increase afterload and reduce maternal heart rate and cardiac output. Norepinephrine has been suggested as an alternative, with a proposed potency ratio for norepinephrine to phenylephrine of 16:1, although its administration as a bolus during CD has not been established. The authors of the present study thus determined the effective norepinephrine dose (ED90), when given as intermittent intravenous boluses, to prevent post-spinal hypotension in women undergoing elective CD.

Assessing Propylene Glycol Toxicity in Alcohol Withdrawal Patients Receiving Intravenous Benzodiazepines: A One-Compartment Pharmacokinetic Model.

While some case reports indicate that high doses of propylene glycol (PG) may result in metabolic acidosis, there has been no large-scale study that evaluatedthe risk of metabolic acidosis in patients receiving PG-containing benzodiazepines for acute alcohol withdrawal. This study was undertaken to evaluate the potential toxicity of PG in patients with acute alcohol withdrawal treated with intermittent intravenous bolus doses of diazepam and/or lorazepam. This is a retrospective case study using data collected from 18 randomly selected patients receiving one or both of these medications per a modified Clinical Institute Withdrawal Assessment for Alcohol (CIWA) Class 3 protocol. Plasma levels of PG were estimated using a one-compartment pharmacokinetic model. Only two patients had an elevated anion gap compared to their baseline value with one also experiencing a significant increase in serum creatinine. No increases in serum osmolarity were noted. Analysis showed that the benzodiazepine dose received was a good predictor of the estimated PG concentration (r=0.6), but was poorly correlated with the anion gap. No significant correlation was found with the creatinine clearance or serum creatinine. Patients receiving several daily doses were at higher risk of developing an anion gap (r=0.33), but the estimated maximum PG concentration did not correlate with the anion gap or serum concentration. It does not appear that intermittent bolus administration of intravenous benzodiazepines for alcohol withdrawal influenced renal function or anion gap regardless of number of administered doses, amount of PG received, or the estimated PG concentration.

Norepinephrine Intermittent Intravenous Boluses to Prevent Hypotension During Spinal Anesthesia for Cesarean Delivery: A Sequential Allocation Dose-Finding Study.

The use of phenylephrine as the first-line agent for prevention and treatment of maternal hypotension during cesarean delivery (CD) may reduce cardiac output, posing a theoretical risk to mother and fetus. Norepinephrine has been suggested as a potential alternative, because its β-adrenergic effects might result in greater heart rate and cardiac output than phenylephrine. The use of norepinephrine to prevent and treat hypotension during CD is new, and its use as a bolus has not been fully determined in this context. The purpose of this study was to determine the effective norepinephrine dose, when given as intermittent intravenous (IV) boluses, to prevent postspinal hypotension in 90% of women undergoing elective CD (ED90). This was a prospective, double-blind sequential allocation dose-finding study, using the biased coin up-and-down design. Forty-term pregnant women undergoing elective CD under spinal anesthesia received a set intermittent norepinephrine bolus of either 3, 4, 5, 6, 7, or 8 µg every time their systolic blood pressure (SBP) fell to below 100% of baseline. The primary outcome was the success of the norepinephrine regimen to maintain SBP at or above 80% of baseline, from induction of spinal anesthesia to delivery of the fetus. Secondary outcomes included nausea, vomiting, hypertension (SBP > 120% of baseline), bradycardia (<50 bpm), upper sensory level of anesthesia to ice cold and umbilical artery and vein blood gases. The ED90 and 95% confidence intervals (CIs) were estimated using both truncated Dixon and Mood and isotonic regression methods. The estimated ED90 of norepinephrine was 5.49 µg (95% CI, 5.15-5.83) using the truncated Dixon and Mood method and 5.80 µg (95% CI, 5.01-6.59) using the isotonic regression method. The use of intermittent IV norepinephrine boluses to prevent spinal-induced hypotension in elective CD seems feasible and was not observed to be associated with adverse outcomes. Practically, we suggest an ED90 dose of 6 µg. Further work is warranted to elucidate the comparative effects of intermittent IV bolus doses of phenylephrine and norepinephrine, in terms of efficacy and safety.

Steady-state pharmacokinetic simulation of intermittent vs. continuous infusion valproic acid therapy in non-critically ill and critically ill patients

Objectives: Valproic acid (VPA) is a broad-spectrum antiepileptic drug used for a variety of neurologic disorders. The relatively short half-life seen with intermittent intravenous bolus doing may lead to serum concentration variability. Continuous infusion VPA therapy is an approach to mitigate these effects. The objective of this study is to characterize the pharmacokinetics of continuous infusion of VPA in acutely ill patients and to determine dosing regimens that most frequently obtain goal steady-state serum concentrations.Methods: This is a retrospective pharmacokinetics study in adult patients receiving continuous infusion VPA per institutional protocol for seizure or status migrainosus. Pharmacokinetic parameters were reviewed for 234 patients (25 critically ill) and compared between the two groups (non-critically ill vs. critically ill). Intermittent and continuous infusion dosing strategies were modeled utilizing Monte Carlo simulations for both cohorts. Frequencies of serum concentration attainment were reported.Results: The percent target attainment for the non-critically ill group and critically ill group were 69.4 and 58.3% (p = 0.282) post-loading dose and 69.7 and 37.5% (p = 0.004) steady state, respectively. The volume of distribution was significantly different between the two groups (0.35 vs. 0.68 L/kg, p = < 0.0001). Highest frequency of target attainment (50–100 mcg/ml) occurred in the continuous infusion 2 mg/kg/h simulation for both critically ill (45.19%) and acutely ill (48.16%) groups.Discussion: Critically ill patients have an increased volume of distribution. Increasing the volume of distribution requires higher loading doses of VPA to obtain desired therapeutic concentrations. Continuous infusion VPA provides more consistent serum steady-state concentrations while mitigating pharmacokinetic variability.

Prophylactic low dose continuous calcium infusion during peripheral blood stem cell (PBSC) collections to reduce citrate related toxicity

BackgroundCitrate toxicity is one of the most frequent complications of apheresis procedures. It is caused by the infusion of the acid citrate dextrose (ACD), which chelates the calcium ions. AimsThe aim of this study is to assess the effectiveness of prophylactic continuous infusion of calcium gluconate over intermittent bolus infusion to reduce citrate toxicity during large volume peripheral blood stem cell collection. Materials and MethodsWe retrospectively analysed the records of PBSC collection procedures performed from March 2010 to December 2013. Donors were selected as per the set guidelines. Machine used to perform the procedures was Cobe spectra. The study population was divided into 2 groups. One composed of intermittent intravenous bolus infusion at the onset of hypocalcaemic symptoms, the other composed of calcium gluconate administration as continuous infusion throughout the procedure. ResultThe most common reported hypocalcaemic symptoms were mild perioral paresthesia followed by digital numbness. Of the 50 individuals who were injected with bolus calcium 40 (80%) individuals suffered from symptoms of hypocalcaemia, whereas 23 of 66 individuals (34.8%) suffered from hypocalcaemia in the continuous infusion group. This difference was significant (P < 0.001). Both groups were compared with respect to age, gender ratio, weight of the individuals, total blood volume processed, ACD used, calcium gluconate dose used, time taken for the procedure, the product volume. Significant difference was noticed only with respect to the product volume. This implies that the groups were comparable with respect to parameters such as age, gender ratio, weight of the individuals, total blood volume processed, ACD used, calcium gluconate dose used, and the time taken for the procedure. Also that significantly more products (244 v/s 204 ml) was collected in the continuous infusion group. ConclusionsOur results show that prophylactic continuous IV administration of low dose calcium-gluconate throughout the PBSC harvesting procedure reduced the incidence as well as the severity of citrate related toxicity. This increases his/her tolerance to withstand longer durations of the procedure and collect more volume of the product, hence may reduce the number of sittings of the procedure.

Pharmacokinetics of Morphine and Its Metabolites in Infants and Young Children After Congenital Heart Surgery.

The objective of this study was to characterize morphine glucuronidation in infants and children following cardiac surgery for possible treatment individualization in this population. Twenty children aged 3days to 6years, admitted to the cardiovascular intensive care unit after congenital heart surgery, received an intravenous (IV) loading dose of morphine (0.15mg/kg) followed by subsequent intermittent IV bolus doses based on a validated pain scale. Plasma samples were collected over 6h after the loading dose and randomly after follow-up doses to measure morphine and its major metabolite concentrations. A population pharmacokinetic model was developed with the non-linear mixed effects software NONMEM. Parent disposition was adequately described by a linear two-compartment model. Effect of growth (size and maturation) on morphine parameters was accounted for by allometric body weight-based models. An intermediate compartment with Emax model best characterized glucuronide concentrations. Glomerular filtration rate was identified as a significant predictor of glucuronide formation time delay and maximum concentrations. Clearance of morphine in children with congenital heart disease is comparable to that reported in children without cardiac abnormalities of similar age. Children 1-6months of age need higher morphine doses per kilogram to achieve an area under concentration-time curve comparable to that in older children. Pediatric patients with renal failure receiving morphine therapy are at increased risk of developing opioid toxicity due to accumulation of morphine metabolites.

Refractory Edema with Congestive Heart Failure Stepwise Approaches Nephrology Perspectives

Generalized edema occurs secondary to many clinical disorders; the usual management of edema is the using of diuretics. Diuretic resistance means failure to decrease the extracellular fluid volume despite the using of diuretics. Many factors are involved in the development of refractory edema, and the decreased response to the usual diuretic regimen, during management of diuretic resistance all these factors must be in consideration. Some pre-diuresis precautions, lab and imaging procedures are mandatory to ensure good effect of management. To use intermittent Intravenous Bolus versus Continuous IV Infusion Diuretic Therapy, which is better, which is safest? What is Single IV Effective Dose of Loop Diuretics What is Maximum IV Effective Dose of Loop Diuretics? If IV Furosemide is Ineffective, Can I Switch to Equivalent IV Dose of Bumetanide or Torsemide? When to Add Thiazide Diuretic? When to Add Spironolactone? IV High-Dose Furosemide and Hypertonic Saline Solutions, The new ERA. How to Monitor Response and Side Effects of IV Diuretic Therapy? All these questions are answered in the review article.

Deleterious impact of propofol on in vitro fertilization. a prospective randomized trial

Propofol is widely used for anesthesia in oocyte transvaginal aspiration. In vitro studies on animal models have shown that propofol could be deleterious for fertilization and embryo development in a dose- and time-dependent manner. The purpose of this study was to analyse the potential negative effects of propofol on human in vitro fertilization outcomes. Prospective-double blind, randomized trial. 144 patients with more than four metaphase II oocytes retrieved were enrolled in this study and randomly separated. Two protocols of anesthesia were used. Group A: (GA, n=74) received intravenous (IV) propofol 2 mg/kg, midazolam 0.015 mg/kg and fentanyl 1 μg/kg. Group B: (GB, n=74) IV propofol 1.5 mg/kg, midazolam 0.05 mg/kg and fentanyl 1.5 μg/kg. Maintenance of anesthesia was achieved by intermittent IV bolus when required. Quantity of propofol, duration and quality of anesthesia, number of oocytes, embryo quality and pregnancy rate were evaluated. Mean doses of propofol were GA: 0.277 ± 0.080 mg/kg.min and GB: 0.195 ± 0.055 mg/kg.min (p< .01). No significant differences were found among anesthetics parameters, patient age, number of oocytes retrieved, fertilization rate and embryo quality in both groups. A significative difference was found in clinical pregnancy rate between groups (GA: 27.0% vs GB: 43.3%, p < .05). Our findings suggest that the administration of high doses of propofol produces a negative late effect on human embryo development. The use of lower doses of propofol and the consistent lower exposure of the oocytes to the drug, show an improvement in clinical pregnancy rate, maintaining quality of anesthesia and optimal postoperative recovery. According to our results, we postulate that the reduction of propofol could improve the results of in vitro fertilization treatments.

Bilateral subclavian artery stenosis found by inter-arm blood pressure difference during distal pancreatectomy

Bilateral subclavian artery stenosis found by inter-arm blood pressure difference during distal pancreatectomy