Physiologic Derangements Research Articles

Viability of Extracorporeal Membrane Oxygenation Circuits during Arterio-venous Shunting: An Observational Study of ECMO Circuits

Introduction Trial off veno-arterial extracorporeal membrane oxygenation is often performed by diversion of circuit flow through an arterio-venous shunt. Separation from the patient presents an augmented risk for microbiological growth and deterioration of the circuit components and blood circulating within it. It is unclear how long mechanical components and blood circulating within the circuit remain intact during arterio-venous shunting. Methods Following decannulation, the arterial and venous lines were connected simulating an arterio-venous shunt. Flow was maintained at 500 ml/min. Observations at 11 intervals were paired with blood culture, blood gases, chemistry and coagulation studies. Heparin was not provided in two circuits, and four circuits received 30 IU/hour. Results Of six circuits studied, five maintained flows of 500 ml/min for 48 hours. One circuit developed extensive clot after two hours and blood flow ceased. Microbial growth was not detected. Glucose, fibrinogen and platelet levels reduced progressively from the outset. Cell breakdown was evident by four hours (increase in plasma potassium and phosphate) and lactate rose above 6.3 mmol/L at four hours in all circuits. Conclusion Arterio-venous shunting longer than four hours carries a risk of blood decomposition and cell energy pathway depletion. Re-establishing extracorporeal membrane oxygenation support post arterio-venous shunting carries a risk of physiological derangement, given the blood composition changes during arterio-venous shunting. Consideration should be given to an alternate method to assess the physiological stability of patients off extracorporeal membrane oxygenation prior to decannulation. Alternately, consider a crystalloid flush of the circuit to remove decomposed blood if the trial-off exceeds four hours.

The definition of predictor and outcome variables in mortality prediction models: a scoping review and quality of reporting study

Mortality prediction models are promising tools for guiding clinical decision-making and resource allocation in intensive care units (ICUs). Clearly specified predictor and outcome variables are necessary to enable external validation and safe clinical application of prediction models. The objective of this study was to identify the predictor and outcome variables used in different mortality prediction models in the ICU and investigate their reporting. For this scoping review, MEDLINE, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Studies developed within a general ICU population reporting on prediction models with mortality as a primary or secondary outcome were eligible. The selection criteria were adopted from a review by Keuning et al. Predictor and outcome variables, variable characteristics (defined as units, definitions, moments of measurement and methods of measurement), and publication details (defined as first author, year of publication and title) were extracted from the included studies. Predictor and outcome variable categories were demographics, chronic disease, care logistics, acute diagnosis, clinical examination and physiological derangement, laboratory assessment, additional diagnostics, support and therapy, risk scores, and (mortality) outcomes. A total of 56 mortality prediction models containing 204 unique predictor and outcome variables were included. The predictor variables most frequently included in the models were age (40 times), admission type (27 times), and mechanical ventilation (21 times). We observed that single variables were measured with different units, according to different definitions, at a different moment, and with a different method of measurement in different studies. The reporting of the unit was mostly complete (98% overall, 95% in the laboratory assessment category), whereas the definition of the variable (74% overall, 63% in the chronic disease category) and method of measurement (70% overall, 34% in the demographics category) were most often lacking. Accurate and transparent reporting of predictor and outcome variables is paramount to enhance reproducibility, model performance in different contexts, and validity. Since unclarity about the required input data may introduce bias and thereby affect model performance, this study advocates that prognostic ICU models can be improved by transparent and clear reporting of predictor and outcome variables and their characteristics.

Rodent Model of Cardiopulmonary Bypass Demonstrates Systemic Inflammation and Neuromarker Changes

IntroductionThe physiologic derangements imposed by cardiopulmonary bypass (CPB) can result in complications such as postoperative delirium. We aim to validate a rodent survival model of CPB demonstrating a systemic inflammatory response and hypothesize that this contributes to post-CPB delirium. MethodsAdult Sprague–Dawley rats were randomized to three groups: 1) Sham peripheral surgical cannulation, 2) CPB followed by acute phase harvest, or 3) CPB followed by 24-h survival. CPB was carried out for 60 min before decannulation and weaning from mechanical ventilation. Physiological and biochemical endpoints were compared between groups. Gene expression analysis of hippocampal tissue was performed using quantitative RT-PCR panels and protein expression levels were confirmed with Western blot. ResultsSixteen animals underwent cannulation and were successfully decannulated without transfusion requirement or inotrope use with one procedure-related mortality. Serum acute phase proinflammatory chemokines cytokine-induced neutrophil chemoattractant 1, cytokine-induced neutrophil chemoattractant 3, fractalkine, and lipopolysaccharide-induced CXC chemokine as well as interleukin (IL)-10 were increased 1 h following CPB compared to sham (P < 0.05). Significant changes in hippocampal expression of biomarkers apolipoprotein 1, vascular epithelial growth factor A, and synapsin 1 were demonstrated following CPB. ConclusionsThis study validated a model of CPB that captures the resultant systemic inflammatory response, and identified differentially expressed proteins that may be associated with brain injury. Modulation of the CPB-induced inflammatory response may be a promising therapeutic target to attenuate post-CPB delirium, and this survival rat model of CPB with low surgical attrition will allow for more comprehensive evaluations of the short- and long-term effects of both CPB and potential therapeutic interventions.

Prevalence of clinical deterioration in the pre-hospital setting.

Improved understanding of the deteriorating patient in the pre-hospital setting may result in earlier recognition and response. Considering the effects of undetected deterioration are profound, it is fundamental to report the prevalence of pre-hospital clinical deterioration to advance our understanding. The present study investigated the prevalence of pre-hospital clinical deterioration and adverse events (AEs) within 3 days of the pre-hospital episode of care. This retrospective cohort study was based on pre-hospital incidents involving adult patients attended by Queensland Ambulance Service between 1 January 2018 and 31 December 2020. Due to lacking a standardised definition of pre-hospital clinical deterioration, established early warning scores (NEWS, MEWS and Q-ADDS) were calculated from pre-hospital vital signs to identify clinical deterioration. Linked hospital data were used to identify the occurrence of an AE. Some degree of physiological derangement was initially observed in over half of the patients, and pre-hospital clinical deterioration was seen in 2.7%-4% of patients. The prevalence of AEs was 3.2%. Patients that experienced an AE were more likely to be male, elderly, suffering from a medical (non-trauma) condition, and had a greater burden of disease. Concerningly, almost 50% of patients that suffered an AE did not meet escalation thresholds of NEWS, MEWS or Q-ADDS. The present study found the prevalence of pre-hospital clinical deterioration and AEs subsequent to pre-hospital episodes of care to be low. Future research should prioritise using standardised criteria to define pre-hospital clinical deterioration and evaluate the performance of early warning scores.

Prognostic Role of Temperature Oxygenation Perfusion Sugar (TOPS) score in Outborn Transported Neonates in a Tertiary Care Center—A Prospective Cohort Study

Background Neonatal outcomes are affected by the acute physiologic derangements of neonatal vitals, such as temperature, blood sugar (GRBS), perfusion, and oxygenation. The aim was to correlate the temperature oxygenation perfusion sugar (TOPS) score of outborn neonates transported with the morbidity and mortality during hospitalization in the neonatal intensive care unit (NICU). Methods Five hundred transported neonates were enrolled in this prospective cohort study by scoring TOPS vitals within an hour of NICU admission, and the outcomes were assessed after 72 hours of hospitalization. Results Among 500 neonates, hypoglycemia, hypoperfusion, hypoxemia, and hypothermia were found in 13%, 32%, 30%, and 37%, respectively. One hundred five (21%) neonates did not survive. Hypoxemia (82%) was the most common parameter, followed by hypoperfusion (78%) among the nonsurvivor neonates. Neonates with a TOPS score of zero survived, whereas neonates with a TOPS score of four had 100% mortality. TOPS SCORE’s overall sensitivity and specificity were reported at 87% and 84%, respectively, with 59% positive and 96% negative predictive values. TOPS score ≥2 had a receiver operating characteristic (ROC) curve at 0.91. Hypoxemia (82%) was the most sensitive parameter to predict mortality, followed by poor perfusion (77%). Conclusion The prognostication of mortality in transported neonates can be assessed by the TOPS score, as mortality notably increases with an increase in the TOPS score. A TOPS score of ≥2 was a good predictor of morbidity and mortality in transported neonates.

6664 A Case of Undistinguished Congenital Adrenal Hyperplasiain a Patient with Hypertensive Emergency and Hypokalemia

Abstract Disclosure: V.L. Del Signore: None. S.T. Kaufman: None. CAH is a group of autosomal recessive disorders resulting in alterations of adrenal steroid biosynthesis. With 95% of CAH cases due to 21-hydroxylase deficiency; other causes are rare. The metabolic, phenotypic, and physiologic derangements are specific to the altered enzymatic pathways, most of which are life threatening. Identifying the enzymatic defect is crucial to treat the patient. We present a case of undifferentiated CAH in an adult resulting in significant systemic illness. A 26-year-old well virilized male presented with chief complaint of shortness of breath, lower extremity swelling, and abdominal distension for 3 weeks. He was found to have acute decompensated heart failure with LVEF 20-25%, NSTEMI, atrial fibrillation, hypertensive emergency with BP of 224/102, and potassium (K+) of 2.7 (3.5-5mmol/L). PMH included hypertension and CAH diagnosed at birth. Patient was unsure of his CAH defect. Pediatric endocrinology prescribed glucocorticoids until age 17 at which point he was told steroids were no longer required. He had been lost to follow up for 9 years. Pediatric records were unattainable. Patient remained hypokalemic and hypertensive despite aggressive K+ repletion and multiple IV antihypertensives. Endocrine work up revealed renin 0.19 (0.25- 5.82ng/mL/hr), aldosterone 4 (&amp;lt; or = 21ng/dL), DHEAs 97 (74-617ug/dL), FSH &amp;lt;0.3 (1.4 - 18.1 m[IU]/mL), LH &amp;lt;0.3 (1.5 - 9.3 m[IU]/mL), total testosterone 306 (250-1,100 ng/dL), SHBG 32 (10-50nmol/L), progesterone 7 (0.2-1.4 ng/mL), ACTH 345 (6-50 pg/mL), AM cortisol 4.4 (5-23 ug/dL), 17 hydroxyprogesterone 311 (32-307 ng/dL), androstenedione 1,926 (50-220 ng/dL), 11-deoxycortisol &amp;gt;10,000 (&amp;lt; or = 119 ng/dL). Cosyntropin stimulation test: 30-minute cortisol 11.1 (&amp;gt;18 ug/dL) and 60-minute cortisol 10.4 (&amp;gt;18 ug/dL). Based on clinical and lab findings a diagnosis of 11-beta hydroxylase deficiency was made. Spironolactone was started to counteract the excessive mineralocorticoid effects of deoxycorticosterone and hydrocortisone to decrease ACTH production. With this treatment, patient’s potassium and blood pressure gradually improved. IV antihypertensives were weaned as he transitioned to oral agents. This case demonstrates the importance of understanding and identifying the underlying pathophysiology of CAH to treat patients appropriately. This patient had a mineralocorticoid excess state, but adequate cortisol precursors to prevent adrenal crisis. He requires glucocorticoid therapy to prevent excessive ACTH from driving their BP and metabolic derangements. With appropriate diagnosis of 11-beta hydroxylase deficiency, patient’s excess risk of morbidity and mortality due to the downstream effects of uncontrolled CAH can be minimized. Presentation: 6/3/2024

The Association of Calcium Derangements With 24-Hour Outcomes in the Deployed Combat Setting.

Calcium derangements remain poorly characterized in the combat trauma population. We describe the incidence of emergency department (ED) calcium derangements, associated physiologic derangements, and 24-hour mortality from the deployed combat setting. We analyzed adult casualties from 2007 to 2023 from the DoD Trauma Registry for U.S. military, U.S. contractor, and coalition casualties that had at least 1 ionized calcium value documented in the ED at a Role 2 or Role 3 military treatment facility. We constructed a series of multivariable logistic regression models to test for the association of hypocalcemia and hypercalcemia with physiological derangements, blood product consumption, and survival. Vital signs and other laboratory studies were based on the concurrent ED encounter. There were 941 casualties that met inclusion for this analysis with 26% (245) having at least 1 calcium derangement. Among those, 22% (211) had at least 1 episode of hypocalcemia and 5% (43) had at least 1 episode of hypercalcemia in the ED. The vast majority (97%, 917) received calcium at least once. Median composite injury severity scores were lower among those with no calcium derangement (8 versus 17, P < .001). Survival was higher during the total hospitalization (98% versus 93%) among those with calcium derangements but similar at 24 hours (99% versus 98%, P = .059). After adjusting for confounder, any hypocalcemic measurement was associated with an elevated international normalized ratio (odds ratio 1.94, 95% CI 1.19-3.16), acidosis (1.66, 1.17-2.37), tachycardia (2.11, 1.42-3.15), hypotension (1.92, 1.09-3.38), depressed Glasgow coma scale (3.20, 2.13-4.81), elevated shock index (2.19, 1.45-3.31), submassive transfusion (3.97, 2.60-6.05), massive transfusion (4.22, 2.66-6.70), supermassive transfusion (3.65, 2.07-6.43), and all hospital stay mortality (2.30, 1.00-5.29). Comparatively, any hypercalcemic measurement was associated with acidosis (2.96, 1.39-6.32), depressed Glasgow coma scale (4.28, 1.81-10.13), submassive transfusion (3.40, 1.37-8.43), massive transfusion (6.25, 2.63-14.83), and supermassive transfusion (13.00, 5.47-30.85). Both hypocalcemia and hypercalcemia in the ED were associated with physiological derangements and blood product use, with a greater extent observed in those with hypocalcemia compared to those with hypercalcemia. Prospective studies are underway to better explain and validate these findings.

Customized Management of Hypothyroidism Through Ayurvedic Intervention

Hypothyroidism is a condition characterized by decreased thyroid hormone production, resulting in diminished metabolic rate, manifesting as a spectrum of symptoms from subclinical hypothyroidism (SCH) to overt hypothyroidism, with associated physiological derangements. In this study Anu taila Nasya was used. A female patient age 22 years weight 58kg was diagnosed with Hypothyroidism from a clinical point of view. There was a dyspnoea, loss of appetite, weakness, weight gain in the last 2 months with irregular menstruation in the past 4 months. Blood report of TSH value shows 6.35µIU/ml. She was treated with Panchakarma Anu taila Nasya followed by Shamana Chikitsa for 6 months follow up. The result of patient was assessed on the basis of subjective and objective criteria. The TSH value after the treatment shows significant result of 4.65µIU/ml. Significant changes were also observed in the clinical features before and after the treatment. So, this study concludes, Anu taila Nasya has Ushna Tikshna dravyas and Vata Kaphahara properties which causes Shodhana and Lekhana of Kapha doshas, along with palliative treatment has shown good and significant result by its Guna-dharma and Shodhana action in hypothyroidism. Hence it can be used as a preferred treatment for hypothyroidism.

Cerebral physiologic insult burden in acute traumatic neural injury: a Canadian High Resolution-TBI (CAHR-TBI) descriptive analysis

BackgroundOver the recent decades, continuous multi-modal monitoring of cerebral physiology has gained increasing interest for its potential to help minimize secondary brain injury following moderate-to-severe acute traumatic neural injury (also termed traumatic brain injury; TBI). Despite this heightened interest, there has yet to be a comprehensive evaluation of the effects of derangements in multimodal cerebral physiology on global cerebral physiologic insult burden. In this study, we offer a multi-center descriptive analysis of the associations between deranged cerebral physiology and cerebral physiologic insult burden.MethodsUsing data from the Canadian High-Resolution TBI (CAHR-TBI) Research Collaborative, a total of 369 complete patient datasets were acquired for the purposes of this study. For various cerebral physiologic metrics, patients were trichotomized into low, intermediate, and high cohorts based on mean values. Jonckheere–Terpstra testing was then used to assess for directional relationships between these cerebral physiologic metrics and various measures of cerebral physiologic insult burden. Contour plots were then created to illustrate the impact of preserved vs impaired cerebrovascular reactivity on these relationships.ResultsIt was found that elevated intracranial pressure (ICP) was associated with more time spent with cerebral perfusion pressure (CPP) < 60 mmHg and more time with impaired cerebrovascular reactivity. Low CPP was associated with more time spent with ICP > 20 or 22 mmHg and more time spent with impaired cerebrovascular reactivity. Elevated cerebrovascular reactivity indices were associated with more time spent with CPP < 60 mmHg as well as ICP > 20 or 22 mmHg. Low brain tissue oxygenation (PbtO2) only demonstrated a significant association with more time spent with CPP < 60 mmHg. Low regional oxygen saturation (rSO2) failed to produce a statistically significant association with any particular measure of cerebral physiologic insult burden.ConclusionsMean ICP, CPP and, cerebrovascular reactivity values demonstrate statistically significant associations with global cerebral physiologic insult burden; however, it is uncertain whether measures of oxygen delivery provide any significant insight into such insult burden.

Hypothermia and the Global War on Terror: 18 Years of Minimal Progress.

The association between hypothermia, coagulopathy, and acidosis in trauma is well described. Hypothermia mitigation starts in the prehospital setting; however, it is often a secondary focus after other life-saving interventions. The deployed environment further compounds the problem due to prolonged evacuation times in rotary wing aircraft, resource limitations, and competing priorities. This analysis evaluates hypothermia in combat casualties and the relationship to resuscitation strategy with blood products. Using the data from the Department of Defense Joint Trauma Registry from 2003 to 2021, a retrospective analysis was conducted on adult trauma patients. Inclusion criteria was arrival at the first military treatment facility (MTF) hypothermic (<95ºF). Study variables included: mortality, year, demographics, battle vs non-battle injury, mechanism, theater of operation, vitals, and labs. Subgroup analysis was performed on severely injured (15 < ISS < 75) hypothermic trauma patients resuscitated with whole blood (WB) vs only component therapy. Of the 69,364 patients included, 908 (1.3%) arrived hypothermic; the vast majority of whom (N = 847, 93.3%) arrived mildly hypothermic (90-94.9°F). Overall mortality rate was 14.8%. Rates of hypothermia varied by year from 0.7% in 2003 to 3.9% in 2014 (P <0.005). On subgroup analysis, mortality rates were similar between patients resuscitated with WB vs only component therapy; though base deficit values were higher in the WB cohort (-10 vs -6, P < 0.001). Despite nearly 20 years of combat operations, hypothermia continues to be a challenge in military trauma and is associated with a high mortality rate. Mortality was similar between hypothermic trauma patients resuscitated with WB vs component therapy, despite greater physiologic derangements on arrival in patients who received WB. As the military has the potential to conduct missions in environments where the risk of hypothermia is high, further research into hypothermia mitigation techniques and resuscitation strategies in the deployed setting is warranted.

Management of Post-cardiotomy Shock.

Patients undergoing cardiac surgery experience significant physiologic derangements that place them at risk for multiple shock phenotypes. Any combination of cardiogenic, obstructive, hemorrhagic, or vasoplegic shock occurs commonly in post-cardiotomy patients. The approach to the diagnosis and management of these shock states has many facets that are distinct compared to non-surgical cardiac intensive care unit patients. Additionally, the approach to and associated outcomes of cardiac arrest in the post-cardiotomy population are uniquely characterized by emergent bedside resternotomy if the circulation is not immediately restored. This review focuses on the unique aspects of the diagnosis and management of post-cardiotomy shock.

Analgesia for emergency laparotomy: a systematic review.

Aims/Background Poorly controlled pain is common after emergency laparotomy. It causes distress, hinders rehabilitation, and predisposes to complications: prolonged hospitalisation, persistent pain, and reduced quality of life. The aim of this systematic review was to compare the relative efficacies of pre-emptive analgesia for emergency laparotomy to inform practice. Methods We performed a search of MEDLINE, MEDLINE In-Process, Embase, PubMed, Web of Science and SCOPUS for comparator studies of preoperative/intraoperative interventions to control/reduce postoperative pain in adults undergoing emergency laparotomy (EL) for general surgical pathologies. Exclusion criteria: surgery including non-abdominal sites; postoperative sedation and/or intubation; non-formal assessment of pain; non-English manuscripts. All manuscripts were screened by two investigators. Results We identified 2389 papers. Following handsearching and removal of duplicates, 1147 were screened. None were eligible for inclusion, with many looking at elective and/or laparoscopic surgeries. Conclusion Our findings indicate there is no evidence base for pre-emptive analgesic strategies in emergency laparotomy. This contrasts substantially with elective cohorts. Potential reasons include variation in practice, management of physiological derangement taking priority, and perceived contraindications to neuraxial techniques. We urge a review of contemporary practice, with analysis of clinical data, to generate expert consensus.

Intensive Management of Post Caesarean Section with Eclampsia: A Case Report

Introduction: Eclampsia, a severe form of pre-eclampsia characterized by high blood pressure and seizures, poses a significant threat to both maternal and fetal health. With a global incidence of 2-8% among pregnancies affected by pre-eclampsia, eklampsia remains a leading cause of maternal mortality, particularly in low-resource settings. Given the potential for serious complications associated with postpartum eklampsia, it is crucial for anesthesia teams to possess a comprehensive understanding of the condition's management and the specific considerations required in the postpartum setting. Case presentation: We report a 19 years old woman post caesarean section with eclampsia. The patient had a recurrent seizure on the first day at the ICU. After had an intensive therapy at the ICU the patient showed a clinically improvement and extubated on the second day. The case highlights the importance of a holistic and comprehensive approach to postpartum care in eklampsia patients. By addressing not only the immediate symptoms but also the underlying physiological and neurological derangements, the ICU team was able to effectively manage the patient's condition and facilitate her recovery. Conclusion: Postpartum care in the intensive care unit needs to be hollistic and comprehensive with the aim of not aggravating the patient's condition and worsening the patient's prognosis.

Transcriptomics and metabolomics reveal hypothalamic metabolic characteristics and key genes after subarachnoid hemorrhage in rats

Subarachnoid hemorrhage (SAH) is a serious hemorrhagic event with high mortality and morbidity. Multiple injurious events produced by SAH can lead to a series of pathophysiologic processes in the hypothalamus that can severely impact patients’ life. These pathophysiologic processes usually result in physiologic derangements and dysfunction of the brain and multiple organs. This dysfunction involved multiple dimensions of the genome and metabolome. In our study, we induced the SAH model in rats to obtain hypothalamic tissue and serum. The samples were subsequently analyzed by transcriptomics and metabolomics. Next, the functional enrichment analysis of the differentially expressed genes and metabolites were performed by GO and KEGG pathway analysis. Through transcriptomic analysis of hypothalamus samples, 263 up-regulated differential genes, and 207 down-regulated differential genes were identified in SAH groups compared to Sham groups. In the KEGG pathway analysis, a large number of differential genes were found to be enriched in IL-17 signaling pathway, PI3K-Akt signaling pathway, and bile secretion. Liquid chromatography-mass spectrometry metabolomics technology was conducted on the serum of SAH rats and identified 11 up-regulated and 26 down-regulated metabolites in positive ion model, and 1 up-regulated and 10 down-regulated metabolites in negative ion model. KEGG pathways analysis showed that differentially expressed metabolites were mainly enriched in pathways of bile secretion and primary bile acid biosynthesis. We systematically depicted the neuro- and metabolism-related biomolecular changes occurring in the hypothalamus after SAH by performing transcriptomics and metabolomics studies. These biomolecular changes may provide new insights into hypothalamus-induced metabolic changes and gene expression after SAH.

Relative Energy Deficiency in Sport (REDs) and knee injuries: current concepts for female athletes

In athletes, a mismatch between caloric intake and energy expended in exercise can eventually lead to Relative Energy Deficiency in Sport (REDs), where the athlete suffers from physiological derangements and decreased sport performance. The prevalence of REDs is higher in females than males. Females are already at a higher risk of knee injuries, which has been attributed to a multitude of factors such as hormonal influences, differences in musculoskeletal anatomy and neuromuscular control compared to males. The literature demonstrates an even higher risk of knee injuries in female athletes with symptoms of REDs. We propose the various factors that influence this risk. A reduction in anabolic hormones can affect muscle development and tendon repair. A relationship between poor neuromuscular control and knee injury has been established, and this can be further worsened in patients with menstrual dysfunction. Chronic deficiency in nutrients such as collagen and vitamin D can result in poorer recovery from microtrauma in tendons and ligaments. All these factors may contribute to increasing the risk of knee injuries, which may include anterior cruciate ligament tears, patella tendinopathy and patellofemoral pain syndrome. This review aims to educate sports clinicians to have a high index of suspicion when treating knee injuries in females; to screen and then manage for REDs if present, for holistic patient care.

High-flow Nasal Oxygen in a Physiologically Difficult Airway for Awake Craniotomy: Optimising the Highs and Lows

Abstract Respiratory failure is a major risk factor for perioperative pulmonary complications, requiring mechanical ventilation following general anaesthesia. Awake craniotomy avoids physiological derangements related to general anaesthesia, while facilitating continuous neurological monitoring of eloquent areas. High-flow nasal oxygen (HFNO) provides effective oxygenation with CPAP of 3–4 cmH2O, along with providing a favourable interface for communication. We present a 53-year-old female with carcinoma breast having brain and lung metastases with malignant pleural effusion and superimposed pulmonary infection, posted for parietal lobe metastasis excision. Due to her pulmonary comorbidities with an oxygen saturation of 88%, she was posted for an awake craniotomy. HFNO was used to maintain her oxygenation intraoperatively. In this patient, HFNO effectively improved the patient’s oxygenation, comfort and compliance without compromising her involvement in neurological testing.

Paediatric Neurosurgical emergency operations:Clinical spectrum, Presentation-Intervention Interval and Early operative outcome in Regional Neurosurgical center, Nigeria

BACKGROUND: Pediatric neurosurgical emergencies are prevalent worldwide, often triggered by acute, life-threatening conditions that necessitate immediate surgery to prevent disability and death. Managing these conditions perioperatively poses significant challenges for neurosurgeons and anesthetists due to potential complications like anemia, seizures, electrolyte imbalances, intracranial hypertension, and vision threats, alongside the primary neurosurgical issues. Proper correction and optimization of these physiological derangements before surgery are crucial for favorable postoperative outcomes. PATIENTS AND METHODS: This retrospective study analyzes emergency neurosurgical operations performed on children aged sixteen and under at a neurosurgical center in Sokoto, Nigeria, from January 2018 to December 2021. The center caters to a population of approximately twenty million people from three north-western and one north-central Nigerian states, as well as neighboring Niger and Benin republics. The area features a mostly arid climate with limited seasonal rainfall and experiences the Sahara’s harmattan winds. RESULTS A total of 131 children underwent emergency neurosurgical procedures during the study period. The majority were males (71%), with an average age of 5.6 years. Hydrocephalus was the most frequent emergency condition, leading to 44.3% of surgeries, primarily through ventriculoperitoneal shunt procedures, which accounted for 42.7% of interventions. Anemia was the most common comorbid condition. The mean time from presentation to intervention was 10 days. Postoperatively, 17.9% of patients suffered from surgical site infections, yet 67.9% had favorable outcomes with a mortality rate of 7.1%. CONCLUSION: This study underscores the importance of timely surgical interventions and highlights the predominance of ventriculoperitoneal shunts in treating pediatric hydrocephalus in the region, with generally positive outcomes despite delays

Endocrine data provide further evidence of physiologic derangement in sea turtles affected by the Deepwater Horizon oil spill

This study was conducted to characterize the adrenocortical and thyroid status of Kemp’s ridley sea turtles Lepidochelys kempii that were affected by the Deepwater Horizon oil spill. A plasma aldosterone assay was validated for L. kempii, and it was used along with previously validated assays for corticosterone and free thyroxine to assess hormone concentrations of 30 L. kempii that were hospitalized due to oil exposure, representing 2 severities of oiling (lightly or heavily oiled). Hormone concentrations were also assessed in relation to 8 clinical biochemical analytes. Analysis of paired samples indicated that oiled turtles had significantly higher initial aldosterone and corticosterone concentrations, which declined during convalescence (average 96 and 90% decrease, respectively). Thyroxine concentrations significantly increased between admission and convalescence (average 65% increase). Initial biochemical data indicated significantly higher plasma potassium, ionized magnesium, and lactate concentrations compared to convalescent values. Aldosterone concentrations were positively correlated with corticosterone, negatively correlated with free thyroxine, and variably correlated with several clinical biochemical analytes. Results of this study indicate that L. kempii had robust adrenocortical activity after oiling, capture, and transport to the hospital, regardless of the degree of oiling, resulting in very high plasma concentrations of aldosterone and corticosterone. This study also confirms that aldosterone can be reliably measured in sea turtle plasma samples, providing another diagnostic tool for the physiologic assessment of this Critically Endangered species.

Pulmonary MRI with hyperpolarized xenon-129 demonstrates novel alterations in gas transfer across the air-blood barrier in asthma.

Individuals with asthma can vary widely in clinical presentation, severity, and pathobiology. Hyperpolarized xenon-129 (Xe129) MRI is a novel imaging method to provide 3-D mapping of both ventilation and gas exchange in the human lung. To evaluate the functional changes in adults with asthma as compared to healthy controls using Xe129 MRI. All subjects (20 controls and 20 asthmatics) underwent lung function measurements and Xe129 MRI on the same day. Outcome measures included the pulmonary ventilation defect and transfer of inspired Xe129 into two soluble compartments: tissue and blood. Ten asthmatics underwent Xe129 MRI before and after bronchodilator to test whether gas transfer measures change with bronchodilator effects. Initial analysis of the results revealed striking differences in gas transfer measures based on age, hence we compared outcomes in younger (n=24, ≤ 35 years) versus older (n=16,>45 years) asthmatics and controls. The younger asthmatics exhibited significantly lower Xe129 gas uptake by lung tissue (Asthmatic: 0.98%±0.24%, Control: 1.17%±0.12%, P=0.035), and higher Xe129 gas transfer from tissue to the blood (Asthmatic: 0.40±0.10, Control: 0.31%±0.03%, P=0.035) than the younger controls. No significant difference in Xe129 gas transfer was observed in the older group between asthmatics and controls (P>0.05). No significant change in Xe129 transfer was observed before and after bronchodilator treatment. By using Xe129 MRI, we discovered heterogeneous alterations of gas transfer that have associations with age. This finding suggests a heretofore unrecognized physiological derangement in the gas/tissue/blood interface in young adults with asthma that deserves further study.

Tenecteplase With Concomitant Anticoagulation for Acute Respiratory Failure in Patients With COVID-19: A Randomized Controlled Trial.

Background Pulmonary thrombosis and thromboembolism play a significant role in the physiologic derangements seen in COVID-19 acute respiratory failure. The effect of thrombolysis with tenecteplase on patient outcomes is unknown. Methods We conducted a randomized, controlled, double-blind, phase II trial comparing tenecteplase versus placebo in patients with COVID-19 acute respiratory failure (NCT04505592). Patients with COVID-19 acute respiratory failure were randomized to tenecteplase 0.25 mg/kg or placebo in a 2:1 proportion. Both groups received therapeutic heparin for at least 72 hours. Results Thirteen patients were included in the trial. Eight patients were randomized to tenecteplase and five were randomized to placebo. At 28 days, 63% (n = 5) of patients assigned to the treatment group were alive and free from respiratory failure compared to 40% (n = 2) in the placebo arm (p = 0.43). Mortality at 28 days was 25% (n = 2) in the treatment arm and 20% (n = 1) in the control arm (p = 1.0). No patients in the treatment arm developed renal failure by 28 days compared to 60% (n = 3) in the placebo arm (p = 0.07). Major bleeding occurred in 25% (n = 2) of the treatment arm and 20% (n = 1) in the placebo arm; however, no patients in either arm experienced intracranial hemorrhage. Conclusions Tenecteplase with concomitant heparin may improve patient outcomes in patients with COVID-19 respiratory failure. As this study was limited by a small sample size, larger confirmatory studies are needed.