Irreversible Shock Research Articles

Identify of Preoperative and Postoperative Complication of Planned Management and Emergency Management of Patients with PAS Disorder

Background: Placenta accreta spectrum (PAS) often results in significant blood loss and peripartum hysterectomy; the mother may not survive. In many cases, timely prenatal diagnosis allows for careful birth planning in a specialized facility with a highly qualified multidisciplinary team. This has been shown to reduce maternal morbidity. Scheduled deliveries are associated with lower rates of bleeding and emergency procedures when compared to emergency deliveries. Objective: The aim of this study is to identify the preoperative and postoperative complication of planned management and emergency management of patients with PAS disorder. Methods: The cross-sectional comparative study was conducted in the Department of Obstetrics & Gynaecology, Dhaka Medical College Hospital, Dhaka from 18th January 2020 to 17th July 2020. A total of 84 patients diagnosed as a case of PAS disorder (antenatally and peroperative diagnosed) and scheduled for planned management or emergency management of PAS were included according to inclusion and exclusion criteria. 42 planned management of PAS disorder patients as Group A and 42 emergency management of PAS disorder patients as Group B. The questionnaire was pretested, corrected and finalized. Data were collected by face-to-face interview and analyzed by appropriate computer based programmed software Statistical Package for the Social Sciences (SPSS), version 24. Results: In this study, mean ± SD of age was calculated 26.3 ± 4.3 years for Group – A and 28.1 ± 3.2 years for Group – B. Urban population were predominant in group-A. About 30 (70.0%)) patients in group-A and 10 (23.8%) patients in group-B came from urban. Large number of respondents 22 (52.4%) and 10 (50.0%) were housewife in both groups. Among the patients, the lower class 18 (42.9%) and 23 (54.8%) comprised the major percentage of the patients in both groups. More participants in Group-A 29 (69.00%) received ANC regularly than Group B 10 (23.80%), the difference was statistically significant (p<0.05). In group-A maximum patients presented with only USG findings of PAS disorders and with APH or without APH 26 (61.8%). In group-B, PPH and internal haemorrhage 10 (23.8) was noted predominantly. The mild anemia was more in 23 (54.8%) patients in group A and 16 (38.1%) patients in group B which was statistically significant (p < 0.001). More participants in Group-B 26 (61.9%) required early termination, whereas majority of group A 35 (83.3%) was terminated at 35-36 weeks. There was a statistically significant difference between groups. Maximum patients were managed by peripartum hysterectomy 35 (82.0%) and 31 (73.8%) in group A & B respectively. Presence of multidisciplinary team was arranged in 38 (90.4%) in group A and 18 (42.9%) in group B. General anesthesia and CV line was given in 36 (85.7%) patients in group-A and 27 (64.3%) patients in group-B. Massive blood transfusion was needed in 23 (54.8%) patients in Group B & only 3 (7.1%) patients in Group A. Placenta acreta was present 11 (26.2%) patients in group A and 7 (16.7%) patients in group B. Placenta percreta with bladder invasion and peroperative bladder injury was higher in group-B patients. More than 3 L blood was transfused 3 (7.1%) patients in group A and 23 (54.8%) patients in group B. PPH, Sepsis, Re-exploration, DIC and ICU admission were the significant complication in Group-B patients, reported 41 (95.0), 4 (9.5%), 8 (19.0%), 9 (21.4%) and 21 (50.0%) of women and in less complication in Group A 13 (31.0), 0%, 0%, 1 (2.3) and 4 (9.5). In this study mortality rate was 2 (4.8%) in group-B (due to irreversible shock &DIC). Poor outcomes were significantly higher in group-B. NICU admission for prematurity was required in 9 (21.4%) of the babies in group-A and 23 (54.8%) babies of group-B. Birth asphyxia was observed in 4 (9.5%) of the babies in group-A and 13 (31.0%) in Group-B. Conclusion: Prenatal diagnosis and placenta preservation may be linked to lower rates of morbidity in mothers. For morbidly adherent placenta linked with placenta previa, we advise hysterectomy as the preferred course of therapy following extremely thorough prenatal counseling. Maternal problems and fetal outcomes may be improved by early risk factor identification and proactive management.

Perspectives on the surgical intervention of venous injuries: In-depth analysis

Background. The surgical treatment of venous injuries is examined in this work, with particular attention to the brachial vein and its prevalence, methods, and results. Purposes. It assesses surgical techniques, issues that arise after surgery, and the significance of developments in venous repair. In these complicated instances, the research aids in better decision-making and patient care. Methods. A study at the Advanced Vascular Institute and Al-Hashed military hospitals between 2017 and 2018 involved 150 patients with acute venous injuries, predominantly males aged 3-65 years. The study observed a change in the causes of venous injury, with a rise in cases of blunt trauma, particularly in metropolitan areas, but penetrating trauma remains the most common cause. Diagnosis is mainly reached clinically by looking for signs and symptoms, and surgical plans can be made without the Doppler study, which is now available in all casualty wards. Results. To treat hypovolemia and shock, two bilateral wide-bore cannulas with rapid cross-matched blood (rapid method) and ringers or normal saline fluid. The most common injury was to the brachial vein, which was repaired primarily by ligation and, after that, by various techniques, including venography. Follow-ups were difficult for those from other governments, especially our soldier's surgery done at Al-Hashed hospitals, where we advised them to consult vascular surgeons near their residences. Ten individuals had their venous ligation and fasciotomy complications—often accompanied by concomitant artery trauma—required an amputation. Conclusions. The use of fasciotomies varied and did not significantly correlate with the kind of operation. Doppler study checked the patency of the repaired veins, and the follow-up revealed no signs of thrombotic problems. Four patients, all in critical hemodynamic conditions with significant arterial and venous injuries, died during surgery from irreversible shock, accounting for the study's 2.7% fatality rate.

Parametric Influence on Rotating Detonation Combustion: Insights from Fast Reactive Euler Simulations

A two-dimensional unsteady reactive Euler solver is employed to model rotating detonation combustion (RDC). A baseline case is chosen, and several combustor geometric and design parameters are varied individually in order to assess their effect on flowfield structure, exhaust flow properties, and performance. The parameters of interest are the perimeter and axial lengths of the combustor annulus, mass flux, outlet throat area, air injector throat area, and equivalence ratio. Quantification of the isentropically available work (IAW) in the exhaust flow is employed as a performance criterion. IAW is primarily affected by mass flux and outlet throat area through the effects of one-dimensional flow and, to a lesser degree, by perimeter and axial length through changes in the fraction of the flow that experiences irreversible shock processing. For all cases in the present study, this fraction appears to be solely determined by the ratio of detonation height to axial length. This ratio is also highly correlated to the angle of the oblique shock and the strength of the flow fluctuations. The predicted wave speed is between 90 and 95% of the Chapman–Jouguet velocity for a range of equivalence ratios between 0.6 and 1.4.

SAT475 Levothyroxine and Liothyronine Treated Myxedema Coma with Irreversible Cardiopulmonary Failure: A Rare Phenomenon

Abstract Disclosure: T. Menon: None. Y. Xie: None. A. Wang: None. Introduction: We describe a case of myxedema coma associated with irreversible cardiogenic shock and the challenges in optimal management. Case Presentation: A previously healthy 23-year-old man with a history of untreated hypothyroidism (TSH 100 uIU/mL six months prior) presented to the hospital for abdominal pain, shortness of breath, and cough. He soon had two cardiac arrests with successful resuscitation and was stabilized via mechanical ventilation and vasopressors. Physical exam showed peripheral and facial edema with mild jaundice. Laboratory results showed elevated creatinine 1.73 (0.5-1.30 mg/dL), AST 440 (10-40 U/L), ALT 353 (10-45 U/L), and total bilirubin 3.6 (0.2-1.2 mg/dL). Thyroid function tests showed TSH 857 (0.27-4.20 uIU/mL), FT4 <0.1 (0.9-1.8 ng/dL), and TT3 < 20 (80-200 ng/dL), and negative thyroglobulin and TPO antibodies. A thyroid ultrasound showed a small thyroid gland. Echocardiogram revealed severe bi-ventricular failure, with an ejection fraction of 10-15%, dilated chambers, pulmonary hypertension, and moderate pericardial effusion. The patient was initiated on VA-ECMO and treated medically for cardiogenic shock. Myxedema coma treatment was started with IV levothyroxine (LT4) 400 mcg, IV Liothyronine (LT3) 10 mcg, and IV hydrocortisone 100 mg every eight hours. The patient subsequently received IV LT4 100 mcg daily and IV LT3 10-30 mcg daily based on levels of daily FT4 and TT3. Hydrocortisone was tapered down as free cortisol levels prior to steroid administration were elevated at 4.6 (0.2-1.8 ug/dL). Despite significant improvements in TSH values (from 857 to 67 uIU/L), FT4 (from <0.1 to 1.2 ng/dL), and TT3 (from < 20 to 60 ng/dL), the patient’s cardiac function did not improve and he underwent successful orthotopic heart transplantation two weeks after initial presentation. A cardiac biopsy demonstrated cardiomegaly with left ventricular hypertrophy, subendocardial fibrosis, and patent arteries, without other etiologies of heart failure. The patient recovered and was discharged on oral LT4 137 mcg daily, LT3 5 mcg twice daily, and prednisone per cardiac transplantation protocol. Discussion: Several cases describe myxedema coma with reversible heart failure in 4 to 5 days with appropriate hypothyroidism treatment. This case, however, describes irreversible cardiomyopathy despite optimal medical therapy, eventually requiring heart transplantation. Because the cardiac myocyte is dependent on plasma T3 due to lack of intracellular deiodinase, T3 administration may improve cardiac function in myxedema coma induced heart failure. Consensus regarding the use, optimal dose, and duration of LT3 in these situations requires further investigation. Conclusion: We report an unusual case of irreversible cardiomyopathy due to myxedema coma in a young, healthy patient, highlighting the need for rapid correction of hypothyroidism with both IV LT4 and LT3. Presentation Date: Saturday, June 17, 2023

Proposal of a double ejector-two flash tank absorption refrigeration cycle: Energy, exergy and thermoeconomic evaluation

This research presents the proposal of a double ejector-two flash tank absorption refrigeration cycle, in which vapor and liquid ejectors are implemented simultaneously before the condensers and absorbers components. For the vapor ejector simulation, the shock circle approach is used. The internal environment of the vapor ejector, including the chocking phenomenon and the irreversible shock process, is also thoroughly examined. It is proposed that ejectors and flash tanks can improve the system performance. It is possible to improve the ejector entrainment ratio by incorporating a flash tank between the evaporator and condenser, which would also increase the evaporator cooling effect. Moreover, a second flash tank is installed between the generator and the absorber, which allows the generator to operate at a lower temperature and thus reduces the generator heat load. Consequently, the system's COP (coefficient of performance) increases. Furthermore, the unit cost of the final product in a wide range of operational conditions is calculated. The findings revealed up to 56.8% increase in the COP. The improvement of the maximum exergetic efficiency in the new cycle compared to the basic cycle also reaches 22.5%. Moreover, the thermoeconomic investigation show up to 34.6%. reduction in product cost.

A case of hemorrhagic shock due to massive upper gastrointestinal bleeding: from the differential diagnosis to the correct management

Upper Gastro-Intestinal Bleeding (UGIB) spans from minor bleeding to life-threatening events. Identification of early signs of shock, proper management of hemodynamically unstable patients, and correct risk stratification are essential for an appropriate diagnostic workup and therapy. This case reports a young man admitted to the emergency department with haematemesis. His medical history was unremarkable, without any risk factors for gastrointestinal bleeding. A few hours after admission, further episodes of haematemesis occurred, and the patient's condition rapidly deteriorated to irreversible shock. A contrast-enhanced computed tomography (CECT) revealed morphological features of chronic liver disease and oesophagal varices. The patient underwent upper gastrointestinal endoscopy, confirming oesophagal varices with massive bleeding. Although promptly applied, endoscopic hemostasis was ineffective, and the patient died twenty-four hours after admission. Based on this case, we reviewed the diagnostic and therapeutic approaches for patients with massive UGIB and provided a practical approach to this life-threatening emergency.

Clinical and Immunologic Correlates of Vasodilatory Shock Among Ebola Virus-Infected Nonhuman Primates in a Critical Care Model.

Existing models of Ebola virus infection have not fully characterized the pathophysiology of shock in connection with daily virologic, clinical, and immunologic parameters. We implemented a nonhuman primate critical care model to investigate these associations. Two rhesus macaques received a target dose of 1000 plaque-forming units of Ebola virus intramuscularly with supportive care initiated on day 3. High-dimensional spectral cytometry was used to phenotype neutrophils and peripheral blood mononuclear cells daily. We observed progressive vasodilatory shock with preserved cardiac function following viremia onset on day 5. Multiorgan dysfunction began on day 6 coincident with the nadir of circulating neutrophils. Consumptive coagulopathy and anemia occurred on days 7 to 8 along with irreversible shock, followed by death. The monocyte repertoire began shifting on day 4 with a decline in classical and expansion of double-negative monocytes. A selective loss of CXCR3-positive B and T cells, expansion of naive B cells, and activation of natural killer cells followed viremia onset. Our model allows for high-fidelity characterization of the pathophysiology of acute Ebola virus infection with host innate and adaptive immune responses, which may advance host-targeted therapy design and evaluation for use after the onset of multiorgan failure.

Broad-Spectrum Clearance of Lipopolysaccharides from Blood Based on a Hemocompatible Dihistidine Polymer.

Blood infection can release toxic bacterial lipopolysaccharides (LPSs) into bloodstream, trigger a series of inflammatory reactions, and eventually lead to multiple organ dysfunction, irreversible shock, and even death, which seriously threatens human life and health. Herein, a functional block copolymer with excellent hemocompatibility is proposed to enable broad-spectrum clearance of LPSs from whole blood blindly before pathogen identification, facilitating timely rescue from sepsis. A dipeptide ligand of histidine-histidine (HH) was designed as the LPS binding unit, and poly[(trimethylamine N-oxide)-co-(histidine-histidine)], a functional block copolymer combining the LPS ligand of HH and a zwitterionic antifouling unit of trimethylamine N-oxide (TMAO), was then designed by reversible addition-fragmentation chain transfer (RAFT) polymerization. The functional polymer achieved effective clearance of LPSs from solutions and whole blood in a broad-spectrum manner and had good antifouling and anti-interference properties and hemocompatibility. The proposed functional dihistidine polymer provides a novel strategy for achieving broad-spectrum clearance of LPSs, with potential applications in clinical blood purification.

Management of unexpected placenta accreta spectrum cases in resource-poor settings

On a global scale, cases of placenta accreta spectrum are often just identified during cesarean delivery because they are missed during antenatal care screening. Routine operating teams not trained in the management of placenta accreta spectrum are faced with difficult surgical situations and have to make decisions that may define the clinical outcomes. Although there are general recommendations for the intraoperative management of placenta accreta spectrum, no studies have described the clinical reality of unexpected placenta accreta spectrum cases in resource-poor settings. This study aimed to describe the maternal outcomes of previously undiagnosed placenta accreta spectrum managed in resource-poor settings in Colombia and Indonesia. This was a retrospective case series of women with histologically confirmed placenta accreta spectrum treated in 2 placenta accreta spectrum centers after referral from remote resource-poor hospitals. Clinical outcomes were analyzed according to the initial type of management: (1) no cesarean delivery; (2) placenta left in situ after cesarean delivery; (3) partial removal of the placenta after cesarean delivery; and (4) post-cesarean hysterectomy. In addition, we evaluated the use of telemedicine by comparing the outcomes of women in hospitals that used the support of the placenta accreta spectrum center during the initial surgery. A total of 29 women who were initially managed in Colombia (n=2) and Indonesia (n=27) were included. The lowest volume of blood loss and the lowest frequency of complications were in women who underwent deferred cesarean delivery (n=5; 17.2%) and in those who had a delayed placental delivery (n=5; 20.7%). Five maternal deaths (14%) occurred in the group that did not receive telehelp, and 4 women died of irreversible shock because of uncontrolled bleeding. Previously undiagnosed placenta accreta spectrum in resource-poor hospitals was associated with a high risk of maternal mortality. Open-close abdominal surgery or leaving the placenta in situ seem to be the best choices for unexpected placenta accreta spectrum management in resource-poor settings. Telemedicine with a placenta accreta spectrum center may improve prognosis.

Insidious, deadly, common - polytrauma with pelvic fracture

Polytrauma patients with pelvic injuries have a high mortality rate, particularly in those who are haemodynamically unstable, reaching up to 42%. This case study involves a 66-year-old cyclist struck by a tram in Gdańsk, Poland in October 2022. Upon arrival at the Emergency Department of the Medical University of Gdańsk, the patient exhibited stability but later entered the initial shock phase. Comprehensive imaging unveiled flail chest, bilateral pneumothorax, spinal fractures, and an unstable pelvis. Despite a negative point-of-care ultrasound, the planned orthopaedic pelvic stabilization surgery transitioned to endovascular intervention due to deteriorating shock and suspected retroperitoneal bleeding. Despite a successful procedure, the patient succumbed to irreversible shock and multiple organ failure the next day in the intensive care unit. The significance of rapid identification of internal bleeding followed by timely endovascular intervention and retroperitoneal pelvic packing is underscored, as it has demonstrated decreased mortality in similar cases.

Native-valve endocarditis detected by point-of-care echocardiography

BackgroundInfective endocarditis carries a high morbidity and mortality; therefore, a rapid diagnosis and timely treatment is crucial to improve outcomes. Diagnosis of infective endocarditis is supported on echocardiogram findings.Case presentationAn adult male with history of long-term hemodialysis, presented with embolic manifestations (cerebral, skin) and fever. A large vegetation in the mitral valve and other in the tricuspid valve were detected by point-of-care transthoracic echocardiogram, while blood cultures subsequently resulted positive for methicillin-resistant Staphylococcus aureus. Despite therapeutic efforts, the patient developed into an irreversible shock and died.ConclusionsPoint-of-care echocardiogram has a pivotal role in diagnosis and decision-making of infective endocarditis.

Primary PPH What Worsen Maternal Outcome?

Objective: The aim of the study was to explore factors that worsen maternal outcome (maternal morbidity and mortality) in cases developed Primary Postpartum Hemorrhage (PPH). Methodology: Cross sectional observational study carried out during the period from July 2016 till June 2017, 387 cases were recruited in the study from those who developed 1ry PPH. All data concerning cases were recorded including personal, obstetric, medical history, details of medical services received, complications and maternal mortality. Analysis of data recorded was done to determine factors associated with worse maternal outcome (morbidity and mortality). Results: 387 cases developed 1ry PPH (either managed in or referred) to hospitals of Minia Governorate (two secondary hospitals and one tertiary hospital) during the period of the study. 87 cases were excluded due to incomplete records. 1y PPH was common in MG 53% , residents’ rural areas 63.7%, patients not booked for ANC 59.7% and anemic patients 67.9%. Bivariate correlation of factors that worsen maternal outcome showed positive correlation between maternal complications and maternal age, parity, residence (rural areas), distance between residence and hospital (far), positive history of medical problems (anemia), blood transfusion and number of blood units. Maternal complications developed in 13.3%, coagulopathy was the most common 37.5%. 9 cases developed maternal mortality (3%) most common cause of death was irreversible shock 44.4%. Conclusion: Factors that worsen the maternal outcome in patients who developed primary PPH are residence in rural areas, decrease awareness of ANC importance, high parity, advanced maternal age, prevalence of anemia and decrease number of well qualified hospitals.

Evaluation of Retained Placenta: A Study in a District Hospital

Introduction: The placenta is an organ that is attached to the uterine wall and connects the fetus with the mother through the umbilical cord. The placenta is said to be retained when it is not expelled out even half an hour after the birth of the baby. The study aimed to evaluate the retention of the placenta. Methods: This was a cross-sectional study was conducted at the Department of Obstetrics & Gynecology , Faridpur Medical College Hospital, Faridpur from June 2016 to November 2016. The sample was taken purposively and the sample size was 110. Patients were diagnosed with a case of 'retained placenta' through proper history, and clinical examination. Written informed consent was taken from every patient or their relatives. The information was collected in a preformed data collection sheet. Observation and results of the study and statistical analysis were presented in tables. Data were analyzed by using the computer-based program Statistical Package for Social Science (SPSS) software for windows. Result: Out of 110 study subjects about 58.18% were found in the age group of 21-30 years and 20% were found in the age group of 20 years. The age of the patients ranges from 18 to 40 years. Among 110 study subjects, 64.55% were from lower socioeconomic status, 27.27% were from middle socioeconomic status and only 8.18% belonged to affluent socioeconomic status. The majority (74.54%) of cases were delivered at home and 25.46% of cases were delivered at different levels of hospitals (among them 1.82% of cases occurred in the institute where the study was done). Among them 20% were para- 1, 54.54% were para-2-4 and 25.46% of respondents were para ≥ 5. The majority (60%) of study subjects were admitted between 3 to 8 hours after developing retained placenta, followed by 18.19% who came within 2 hours. Regarding the clinical presentation, 69.09% of study subjects presented with anemia of varying degrees, 24.53% presented with shock, 5.45% presented with sepsis, and only 0.93% (one patient) presented with acute renal failure. Concerning predisposing factors of retained placenta, 25.46% of study subjects were grand multipara, 11.82% had H/O MR or D & C, 10.90% with prolonged labor, 10.90% respondents had IUD, 10% with past H/O retained placenta, 8.20% had preterm labor, 2.72% had H/O LUCS/ other uterine surgery and 20% were without any predisposing factors. Among the respondents, 27.27% of study subjects presented with genital tract trauma, 5.45% with sepsis, 5.45% with acute renal failure, 0.91% with DIC, 0.91% with uterine prolapse 64.55% with no associated conditions/complications. Among the total study population, 58.18% of retained placenta cases required manual removal under G/A, and 41.82% were managed by manual removal of the placenta under deep sedation. Out of 110 respondents, 21.82% of cases of retained placenta did not require any blood transfusion, 58.18% received 1-2 units and 20% received 3 or more units of blood transfusion. During management, 13.63% of study subjects developed uterine atony, 0.91% developed uterine inversion, 2.73% were complicated by uterine perforation, 0.91% were complicated by anesthetic hazard; 81.82% had no complication during management. Out of 110, 18.18% of study subjects experienced various complications. Among them 9.10% were managed by intrauterine balloon tamponade,2.73% required hysterectomy, and 6.37% were managed by other measures. 70% of respondents stayed in the hospital for 1-3 days, 26.36% for 4 to 7 days, and 3.64% stayed more than 7 days before discharge. Regarding the outcome of retained placenta among study subjects, 80.91% improved and discharged, 10% had severe anemia and required subsequent blood transfusion, 6.36% developed an infection, 0.91% developed acute renal failure and 2 patients died (one due to DIC and another patient due to irreversible shock). Conclusion: The retained placenta is an obstetric emergency. Rapid recognition and treatments are essential because heavy blood loss with coagulation problems remains the lethal factor in this disease. Rapid control of hemorrhage should be the first initiative. Active management of the third stage of labor lowers the danger by a significant percentage.

The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review

PurposeHaemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking. Materials and methodsWe performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009–2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1–4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes. ResultsHaemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH. ConclusionThis study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1–4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.

Ruptured uterus: Frequency, risk factors and feto-maternal outcome: Current scenario in a low-resource setup.

IntroductionPakistan is among the countries with the highest maternal death rates. Obstetric hemorrhage accounts for 41% of these deaths. Uterine rupture is a grave obstetric emergency with high maternal and neonatal morbidity and mortality. It is important to identify its frequency and associated risk factors to formulate programs for its prevention and management. This study aimed to assess the frequency, associated risk factors, fetomaternal outcomes, and management of women with the ruptured uterus at our hospital.Material and methodsIt was a retrospective study of 206 women to review data collected from cases of uterine rupture managed at the WCTH Bannu, Pakistan from October 2016 to October 2018. A structured proforma was designed and used to extract data from operating theatre registers and the hospital medical records. In our hospital, there is a strong system of maintaining all information of the patients related to demographics, obstetric information, operative notes, and postoperative course during their hospital stay in the patient’s charts. Detailed information on operative procedures is further maintained in the operation theater register and all these registers are checked in the weekly statistical meetings to ensure proper documentation. Data was entered and analyzed in SPSS package version 21 (IBM Corp.; Armonk, NY, USA). Frequency and percentages were calculated for the categorical variables. For inferential statistics, chi-square or Fischer exact tests were used. A p-value of < 0.05 was considered statistically significant.ResultsThe overall incidence of the ruptured uterus was 1.71%. The important etiological factors were grand multiparity 62 (35.2%), obstructed/neglected labour 58 (32.9%), injudicious use of Oxytocin 56 (31.8%) and prostaglandins 26 (14.7%), previous cesarean section 35 (19.8%) and previous pelvic surgery (0.5%). Hysterectomy was done in 80.6% of cases, 34 (19.2%) patients underwent uterine repair and 4.5% had bladder repair. The mortality rate was 21%, mainly due to irreversible shock or disseminated intravascular coagulation. Perinatal mortality was 91.4%. Duration of surgery more than two hours and presentation to the hospital at night time was significantly associated with poor maternal outcome (p = 0.00).ConclusionUterine rupture is a preventable obstetric emergency associated with high fetomaternal morbidity and mortality. The main causes were grand multigravidity, obstructed labour, previous C-sections and injudicious use of oxytocin and prostaglandins. Women with prolonged surgery and admission at night time had a poor maternal outcome.

Sepsis: Evidence-based pathogenesis and treatment.

Sepsis can develop during the body’s response to a critical illness leading to multiple organ failure, irreversible shock, and death. Sepsis has been vexing health care providers for centuries due to its insidious onset, generalized metabolic dysfunction, and lack of specific therapy. A common factor underlying sepsis is the characteristic hypermetabolic response as the body ramps up every physiological system in its fight against the underlying critical illness. A hypermetabolic response requires supraphysiological amounts of energy, which is mostly supplied via oxidative phosphorylation generated ATP. A by-product of oxidative phosphorylation is hydrogen peroxide (H2O2), a toxic, membrane-permeable oxidizing agent that is produced in far greater amounts during a hypermetabolic state. Continued production of mitochondrial H2O2 can overwhelm cellular reductive (antioxidant) capacity leading to a build-up within cells and eventual diffusion into the bloodstream. H2O2 is a metabolic poison that can inhibit enzyme systems leading to organ failure, microangiopathic dysfunction, and irreversible septic shock. The toxic effects of H2O2 mirror the clinical and laboratory abnormalities observed in sepsis, and toxic levels of blood H2O2 have been reported in patients with septic shock. This review provides evidence to support a causal role for H2O2 in the pathogenesis of sepsis, and an evidence-based therapeutic intervention to reduce H2O2 levels in the body and restore redox homeostasis, which is necessary for normal organ function and vascular responsiveness.

Selective Prehospital Advanced Resuscitative Care - Developing a Strategy to Prevent Prehospital Deaths From Noncompressible Torso Hemorrhage.

Hemorrhage, and particularly noncompressible torso hemorrhage remains a leading cause of potentially preventable prehospital death from trauma in the United States and globally. A subset of severely injured patients either die in the field or develop irreversible hemorrhagic shock before they can receive hospital definitive care, resulting in poor outcomes. The focus of this opinion paper is to delineate (a) the need for existing trauma systems to adapt so that potentially life-saving advanced resuscitation and truncal hemorrhage control interventions can be delivered closer to the point-of-injury in select patients, and (b) a possible mechanism through which some trauma systems can train and incorporate select prehospital advanced resuscitative care teams to deliver those interventions.

SOFA Score, Hemodynamics and Body Temperature Allow Early Discrimination between Porcine Peritonitis-Induced Sepsis and Peritonitis-Induced Septic Shock.

Porcine model of peritonitis-induced sepsis is a well-established clinically relevant model of human disease. Interindividual variability of the response often complicates the interpretation of findings. To better understand the biological basis of the disease variability, the progression of the disease was compared between animals with sepsis and septic shock. Peritonitis was induced by inoculation of autologous feces in fifteen anesthetized, mechanically ventilated and surgically instrumented pigs and continued for 24 h. Cardiovascular and biochemical parameters were collected at baseline (just before peritonitis induction), 12 h, 18 h and 24 h (end of the experiment) after induction of peritonitis. Analysis of multiple parameters revealed the earliest significant differences between sepsis and septic shock groups in the sequential organ failure assessment (SOFA) score, systemic vascular resistance, partial pressure of oxygen in mixed venous blood and body temperature. Other significant functional differences developed later in the course of the disease. The data indicate that SOFA score, hemodynamical parameters and body temperature discriminate early between sepsis and septic shock in a clinically relevant porcine model. Early pronounced alterations of these parameters may herald a progression of the disease toward irreversible septic shock.

Refractory Shock. Casuistics

Shock Syndrome is an acute progressive circulatory insufficiency where the Heart is unable to circulate the blood in time unit, for supplying with O2 to the cells and to take out from them CO2 and other final and intermediate toxic metabolites. Shock is acute inadequate organ perfusion to meet the tissue’s oxygenation demand. Shock means: an Acute suffering of cells and organ`s tissues of organism. The term refractory shock is applied when, in spite of apparently adequate therapy, the shock state continues. There are three types of refractory shock: Refractory (or Irreversible) shock, Refractory (Septic) shock, Refractory (Cardiogenic) shock (RCS). Diagnosis Evaluation should focus on the identification of the primary cause and reversible secondary contributors, such as hypovolemia, pump failure, or obstruction that is causing shock. Differential diagnosis must be done with: septic shock, vasodilatory shock and cardiogenic shock. Treatment Coronary PP &gt; 50 mm Hg, Improve myocardial function, C.I. &lt; 3.5 is a risk factor, 2.5 may be sufficient. Fluids first, then cautious pressors. Remember aortic DIASTOLIC pressures drives coronary perfusion (DBP-PAOP = Coronary Perfusion Pressure) .If inotropes and vasopressors fail, intra-aortic balloon pump Temporary circulatory support with extracorporeal membrane oxygenation (ECMO). Sol. natrium bicarbonat 8.4% (PH ≤7.2). Recomandation Refractory shock which is mainly caused by cardiogenic shock and Septic shock are severe conditions that cause increased mortality in patients with such conditions. Advances in the treatment of these serious conditions have enabled the healing of these patients and the relative reduction of Mortality.

Design and performance evaluation of a double ejector boosted multi-pressure level absorption cycle for refrigeration

In this work, a multi-pressure double ejector boosted absorption refrigeration system (DEBARS) is designed and analyzed; two vapor and liquid ejectors are implemented simultaneously before the condenser and absorber components and both of the solution and refrigerant heat exchangers are included in the cycle. Vapor and liquid ejectors are simulated and analyzed in details and the shock circle method is used for the vapor ejector simulation. The characteristics inside the vapor ejector involving the chocking phenomenon and the irreversible shock process are also considered comprehensively. The proposed system is compared with the basic and three-pressure level absorption refrigeration cycles. The results show that the multi-pressure level cycle has the superior performance to both of the previous cycles; The maximum Coefficient of performance (COP) and second law efficiency (ηII) in the new cycle is improved up to 108.35/33.11 and 31.61/46.62 percent in comparison with the basic and three-pressure level cycles, respectively. The generator activation temperature of the DEBARS is in the range of basic cycle and 36–55 °C lower than the three-pressure level cycle; Also, the evaporator start-up temperature in the DEBARS is considerably lower than both of the basic and three-pressure level cycles.