Racemic Epinephrine Research Articles

POST-ESOPHAGOGASTRODUODENOSCOPY NEGATIVE PRESSURE PULMONARY EDEMA

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Negative pressure pulmonary edema (NPPE) is a cause of potentially fatal respiratory failure from exacerbated inspiratory effort against an obstructed airway. Causes of obstruction include anatomical, drug-induced from anesthesia and post-surgical laryngospasm. The incidence of laryngospasm induced pulmonary edema is less known. We present a case of esophagogastroduodenoscopy (EGD) induced laryngospasm with resultant NPPE requiring rapid intubation and management with successful recovery. CASE PRESENTATION: A 49-year-old female with history of hypertension, GERD and obstructive sleep apnea presented to an outpatient gastroenterology center for EGD, which was successfully completed. Post procedure, she became hypoxemic on room air, which resolved temporarily with noninvasive positive pressure ventilation; once this was stopped, the patient desaturated. She was transported via EMS to the ED, where she reported voice change and shortness of breath. Pertinent vitals included respiratory rate 30 and oxygen saturation 91% on CPAP. Exam revealed erythematous hard palate and diffusely decreased breath sounds. There was no tongue enlargement or stridor. Nebulized racemic epinephrine and IV solumedrol were given without improvement. She eventually required intubation during which her vocal cords did not appear to be edematous. Chest x-ray showed pulmonary edema. Patient was supported with volume assist control mechanical ventilation. Repeat chest x-ray after lasix revealed resolution of edema. Patient was extubated successfully. Given history and ruled out causes of cardiogenic pulmonary edema, it was determined that the patient had suffered NPPE from laryngospasm after EGD. DISCUSSION: Differentials for NPPE include myocardial ischemia, cardiogenic pulmonary edema and anaphylaxis. Patient was euvolemic, had a normal EKG and negative troponins. Echo showed normal ventricular function without valvular abnormalities, ruling out cardiogenic pulmonary edema. Lack of exam findings and peripheral eosinophilia ruled out allergic reaction. Literature shows an incidence of NPPE of 12% in patients that develop upper airway obstruction; 50% of all cases are known to be from laryngospasm during or post intubation. NPPE is reported to occur after extubation in 74% and during initial airway management in 26% in patients undergoing anesthesia. Due to lack of familiarity, management of NPPE is controversial. Supportive care, noninvasive positive pressure ventilation and possible intubation remain standard of care. Role of furosemide was studied previously, but showed no benefit. Corticosteroids and bronchodilators have not been studied significantly. CONCLUSIONS: Clinicians need to be aware of NPPE for prompt recognition and management of this possibly fatal condition. With more identified cases, there should be further studies on efficacy of medications and their roles in management. Reference #1: Lemyze M, Mallat J. Understanding negative pressure pulmonary edema. Intensive Care Med. 2014;40(8):1140-3. Reference #2: Bhattacharya, Mallar et al. Negative-Pressure Pulmonary Edema CHEST , 2014;4: 927 - 933. Reference #3: Ghofaily LA, Simmons C, Chen L, Liu R. Negative Pressure Pulmonary Edema after Laryngospasm: A Revisit with a Case Report. J Anesth Clin Res. 2013;3(10):252. DISCLOSURES: No relevant relationships by Nemer Dabage-Forzoli, source=Web Response No relevant relationships by Sana Khan, source=Web Response No relevant relationships by Paul Lange, source=Web Response No relevant relationships by Nick Meyerkord, source=Web Response No relevant relationships by Vijay Srinivasan, source=Web Response No relevant relationships by Shashank Varakantam, source=Web Response

Analysis of endogenous epinephrine and norepinephrine enantiomers in rat plasma and application to a stereoselective pharmacokinetics

Epinephrine and norepinephrine are a class of chiral endogenous catecholamines, which are known as major neurotransmitters. This work described a new LC–MS/MS method coupled with pre-column derivatization, enabling the simultaneous enantiomeric separation of epinephrine and norepinephrine in rat plasma. After protein precipitation procedure, the samples were derivatized with (S)-N-(4-nitrophenoxycarbonyl) phenylalanine methoxyethyl ester, [(S)-NIFE]. The derivatives resolved with good baseline separation on an ACQUITY UPLC BEH C18 column (100 mm × 2.1 mm, 1.7 μm) with mobile phase composed of methanol with 0.2% formic acid in water at a flow rate of 0.2 mL/min. Analysis was performed by multiple reaction monitoring in positive ionization mode. The linear ranges were 1.0–500 ng/mL for epinephrine enantiomers and 1.5–750 ng/mL for norepinephrine enantiomers. The lower limits of quantification for epinephrine and norepinephrine enantiomers were 1.0 and 1.5 ng/mL, respectively. The intra-day and inter-day precision were all less than 10.7% and accuracy ranged from 96.0 to 101.5%. Recoveries for all the analytes were more than 80.3%. The proposed method was successfully applied to simultaneously determine endogenous epinephrine and norepinephrine enantiomers in rat plasma. l-epinephrine and l-norepinephrine were sensitively and accurately quantified while both the d-enantiomers were not detected. Additionally, epinephrine enantiomers were analyzed for stereoselective pharmacokinetics in rats after intravenous administration of racemic epinephrine for the first time. The pharmacokinetic results indicated that the disposition of epinephrine enantiomers was stereoselective and chiral inversion did not occur in rats.

Rate of Airway Intervention for Croup at a Tertiary Children's Hospital 2015-2016.

Croup admission decision making is challenging because the rate of further interventions after stabilization is unclear. We sought to describe rates of inpatient racemic epinephrine (IRE) and additional inpatient airway interventions (IAI) (oxygen or heliox therapy, intubation, or transfer to an intensive care unit) among patients presenting to a tertiary children's hospital with croup. This was a retrospective descriptive study including patients (3months to 8years of age) with an emergency department (ED)/inpatient encounter for croup from January 1, 2015 to December 31, 2016 at a tertiary children's hospital. We excluded intensive care unit direct admissions and patients with bronchiolitis/asthma/pneumonia. We compared 3 groups (a weighted random 5% sample of patients evaluated in ED only, and those admitted with or without IRE/IAI) using Kruskal-Wallis, Pearson χ2, or the Fischer exact test, where appropriate. We used multivariate analysis to compare demographics and preadmission racemic epinephrine (RE) with rates of IRE/IAI in admitted patients. We included 588 patients (194 discharged from the ED, 394 admitted). In admitted patients, 20.8% (82/394) had IRE/IAI, most commonly IRE (20.0%, 79/394). Three admitted patients (0.76%) had IAI. Overall, patients with 2 outside hospital/ED doses of RE had a 12.1% rate of IRE/IAI (23.5% if ≥3 RE doses). Patients with ≥3 preadmission RE doses were more likely to have IRE/IAI compared with 2 RE (adjusted odds ratio=2.08 [95% confidence interval 1.15-3.76]; p=0.02); there were no other significant associations. We found a low rate of IRE/IAI after ED management in patients with croup and no significant associations aside from preadmission RE doses. These findings may be considered in admission decisions.

Inpatient use of racemic epinephrine for children admitted with croup

Pediatric patients with croup are frequently admitted if they require two doses of racemic epinephrine (RE) in the emergency department (ED). We aimed to identify factors associated with the need for additional therapy (> 2 RE doses) among pediatric patients with croup. We performed a single-center retrospective study of consecutive patients admitted from the ED with a diagnosis of croup between January 1, 2011 and December 31, 2015. Primary outcome was need for > 2 doses of RE. Secondary outcomes included time to third RE and 72-hour return visits. We performed logistic regression to identify factors associated with use of > 2 RE doses during hospitalization, and survival analysis to identify time to dosing of 3rd RE from 2nd RE. Of 353 included admissions [250 (70.8%)males, median age 1.48, interquartile range 0.97-2.51years], 106/353 (30.0%) required > 2 RE. In univariate logistic regression, only recent use of steroids within 1day prior to presentation (4.18, 1.48-11.83; P = 0.007) was associated with need for > 2 RE. Survival from third RE was 0.74 (95% CI 0.69-0.78), which was similar to the survival at 12hours (0.70, 95% CI 0.65-0.75). Return visits occurred in 19 (5.4%) patients, of whom 12/19 (63.2%) were given RE. Patients hospitalized for croup with recent use of steroids prior to ED presentation have a greater need for > 2 RE during hospitalization. The majority who require inpatient RE will do so within 8-12hours. These data provide information for risk stratification and duration of monitoring for patients hospitalized with croup.

Comparison of Efficacy of Nebulisation with Salbutamol versus Adrenaline in Acute Bronchiolitis in Children aged Two Months to Two Years

Background: Bronchiolitis is an acute, highly communicable lower respiratory tract infection. A variety of agents ranging from nebulised racemic epinephrine, salbutamol and routinely available levoepinephrine have been tried. The Present study was aimed at comparing the effectiveness of adrenaline and salbutamol in acute bronchiolitis in children aged 2 months to 2 years.
 Materials and Methods: The Present study was conducted at Nobel medical College Teaching Hospital over the period of one year from Feb 2018 to Jan 2019. Two different cohorts were identified in which clinically diagnosed cases and were grouped into Group A and Group B to receive the different drugs as per the study protocol. Respiratory Distress Assessment Instrument (RDAI) Scores was used for clinical assessment.
 Results: The age of the patients ranged from 2 months to 24 months with a median of 8 months. The males constituting about 57.42% of the study population of 155 patients. On comparing the prenebulisation variables with 10 and 30 minutes post nebulisation values, it was found that Both adrenaline and salbutamol caused overall significant improvement in RR (p-value <0.00001 in both groups) except in the age group of 19-24 months. Adrenaline was seen to be superior to salbutamol in decreasing the RR (p<0.0001) except for children in the age group of 19-24months. Adrenaline also caused greater rise in heart rate in comparison to salbutamol in all age groups.
 Conclusion: This study concludes that Adrenaline was seen to be superior to salbutamol in decreasing the RR and RDAI, although it showed variance with age.

Hospital Course of Croup After Emergency Department Management.

To describe inpatient management of patients with croup admitted from the emergency department (ED). In a multicentered, cross-sectional observational study based on retrospective chart review, we identified children 6 months to 5 years of age with a discharge diagnosis of croup. All patients were evaluated in the ED and treated with at least 1 dose of racemic epinephrine (RE) before admission. Children with hypoxia or directly admitted to the PICU were excluded. We identified 628 admissions for croup. Significant interventions, defined as additional RE, helium-oxygen use, or PICU transfer, occurred in 142 patients (22.6%). A total of 137 children received additional RE on the inpatient ward, and 5 received RE and were transferred to the PICU. No patient was treated with helium-oxygen. A total 486 (77.4%) of patients did not receive significant interventions postadmission. Length of stay for children not requiring significant intervention was, on average, <24 hours (18.8 hours [SD 9.3]; range 1.2-111 hours). Children with tachypnea (odds ratio = 2.5; P = .002) on arrival to ED and patients who had ED radiographs (odds ratio = 1.7; P = .018) had increased odds of receiving a significant intervention after admission. Less than one-quarter of children admitted to the general wards for croup received significant interventions after admission. Tachypnea in the ED and use of radiograph were associated with an increased use of significant interventions.

Croup Admissions: Can We Shrink the Elephant in the Room?

This pilot study aims to identify potential predictors of postadmission interventions of hospitalized croup patients and derive a risk model aimed at reducing hospitalizations for croup. Data were collected on all croup hospitalizations for patients aged 1 month to 17 years admitted through a community hospital's emergency department (ED) between 2012 and 2017. Potential predictors were obtained from the electronic medical records including demographics, vital signs, ED length of stay, preintervention and postintervention Westley Croup Score (WCS), number of racemic epinephrine nebulizations administered, time to dexamethasone administration, preexisting conditions, and additional interventions during hospitalization. Statistical analysis used the outcome "patient received racemic epinephrine after hospital admission (yes/no)" to identify characteristics of the child or ED visit associated with that outcome. Preliminary analyses using stepwise logistic regression, tree models, and random forests suggested predictors, interactions among predictors, and the form of their association with the outcome. A final analysis used logistic regression. A total of 116 croup admissions were included, of which 19 (16%) received racemic epinephrine posthospitalization. These characteristics were identified as having some predictive power: sex, preexisting conditions, and preintervention and postintervention WCS, along with the interaction between sex and postintervention WCS. Logistic regression estimated an equation describing the probability of postadmission intervention, permitting the choice among admission thresholds giving different sensitivities and specificities. There appear to be promising predictors in croup patients presenting to the ED, which might help stratify risk for interventions after the ED encounter and thus reduce the number of potentially avoidable admissions.

Identification of children with anaphylaxis at low risk of receiving acute inpatient therapies.

ObjectiveOpportunity exists to reduce unnecessary hospitalizations for children with anaphylaxis given wide variation in admission rates across U.S. emergency departments (EDs). We sought to identify children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies, as these patients may be candidates for ED discharge rather than inpatient hospitalization.MethodsWe conducted a single-center retrospective cohort study of children 1–21 years of age hospitalized with anaphylaxis from 2009 to 2016. Acute inpatient therapies included intramuscular (IM) or racemic epinephrine, bronchodilators, fluid boluses, vasopressors, non-invasive ventilation, or intubation. We derived age-specific (pre-verbal [<36 months] vs. verbal [≥ 36 months]) prediction rules using recursive partitioning to identify children at low risk of receiving acute inpatient therapies.ResultsDuring the study period 665 children were hospitalized for anaphylaxis, of whom 108 (16.2%) received acute inpatient therapies. The prediction rule for patients < 36 months (no wheezing, no cardiac involvement [hypotension or wide pulse pressure]) had a sensitivity of 90.5% (CI 69.6–98.8%) and a negative predictive value of 98.3% (CI 94.1–99.8%) for identifying children at low risk of receipt of acute inpatient therapies during hospitalization. For children ≥ 36 months, the prediction rule (no wheezing, no cardiac involvement, presence of gastrointestinal symptoms) had a sensitivity of 90.8% (CI 82.7–96.0%) and a negative predictive value of 92.4% (CI 85.6–96.7%).ConclusionsWe derived age specific prediction rules for children hospitalized with anaphylaxis at low risk of receiving epinephrine and other acute inpatient therapies. These children may be candidates for ED discharge rather than inpatient hospitalization.

Positive airway pressure ventilation and complications in pediatric tracheocutaneous fistula repair.

Surgical repair of persistent tracheocutaneous fistula in children may be complicated by tracheal air leak with resultant subcutaneous emphysema, pneumomediastinum, and/or pneumothorax. We first sought to identify clinical risk factors for postoperative complications after primary repair of persistent tracheocutaneous fistula in children. Second, the type and frequency of complications in patients administered positive airway pressure ventilation (e.g., bag-valve mask ventilation, continuous positive airway pressure [CPAP], or bilevel positive airway pressure [BiPAP]) postoperatively was determined and compared to a control population. This was a retrospective investigation of all pediatric patients (n = 108) undergoing surgical repair of persistent tracheocutaneous fistula from January 2000 and April 2016 at a tertiary, academic referral center. Type and frequency of postoperative complications were compared among patients who were administered positive airway pressure ventilation postoperatively versus those who were not. Of 108 pediatric patients, complications after tracheocutaneous fistula repair occurred in 22 (20.4%) patients. These included symptoms of respiratory distress requiring intervention (e.g., supplemental O2 , racemic epinephrine, intubation), subcutaneous emphysema, pneumomediastinum and/or pneumothorax, bleeding, wound infection, and readmission. Frequency of all postoperative complications was significantly higher in patients administered positive airway pressure ventilation versus those who were not (50.0% vs. 16.7%, P = 0.015), as were rates of subcutaneous emphysema, pneumomediastinum, and/or pneumothorax (33.3% vs. 4.2%, P = 0.005). Positive airway pressure ventilation after primary repair of persistent tracheocutaneous fistula in children may increase risk of serious respiratory complications. In practice, we advocate for avoidance of bag-valve mask ventilation and caution when utilizing CPAP or BiPAP postoperatively in these patients. 4 Laryngoscope, 130:E30-E34, 2020.

National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals

目的 在芬兰的许多医院，吸入消旋肾上腺素是毛细支气管炎的常规治疗，但2014年芬兰颁布了毛细支气管炎的治疗指南，将其应用限于必要时。本研究探索在2014指南颁布前后用药的变化情况。 方法 本研究统计了2012-2016年间，四所大学附属医院在急诊室、儿科病房及儿科重症监护室使用了多少次0.5 ml的消旋肾上腺素。 结果 在毛细支气管炎治疗指南颁布后，各医院消旋肾上腺素的年使用量均有显著减少，降低了医药费及所耗工时。本研究期间，消旋肾上腺素的总体用量几乎减半，尤其是对于原本用量较大的两所医院，但在原本用量较小的第三家医院则无明显变化。在第四家医院中，开始时为中等用量，在研究期间使用量逐年递减。 结论 目前的毛细支气管炎指南对临床工作有一定影响，消旋肾上腺素的总体用量减半，但在所涉四家医院中其减少程度有显著差异。

Decreasing Racemic Epinephrine for Bronchiolitis in an Academic Children's Hospital.

Bronchiolitis is a leading cause of pediatric hospitalizations in the United States. Although the American Academy of Pediatrics recommends against routine use of bronchodilators in bronchiolitis management, racemic epinephrine was persistently used for this purpose at Le Bonheur Children's Hospital. Our aim was to decrease racemic epinephrine use for bronchiolitis by 50% within 8 months. Our multidisciplinary team used the Institute for Healthcare Improvement's Model for Improvement to develop an aim statement, choose metrics, and perform plan-do-study-act cycles to reduce racemic epinephrine use. We used focused education through in-person and online methods and provided direct feedback to residents, respiratory therapists, and nurses primarily caring for these children. The percentage of all patients admitted for bronchiolitis receiving at least 1 dose of racemic epinephrine was collected from the medical record and recorded on statistical process control charts for distribution to their work areas. Albuterol use and length of stay were collected as balancing measures. We used statistical process control charts to establish special cause variation and identify statistically significant differences in our measures. During our intervention period, the percentage of bronchiolitis patients receiving at least 1 dose of racemic epinephrine to treat bronchiolitis decreased from an average of 26% to 5%, and similarly, albuterol use decreased from an average of 48% to 34%. There was no clinically significant difference in length of stay. Using a multidisciplinary approach and focused education techniques may be an effective way to reduce racemic epinephrine use for children with bronchiolitis.

Use of the pediatric intensive care unit for post-procedural monitoring in young children following microlaryngobronchoscopy: Impact on resource utilization and hospital cost

ObjectiveTo assess the frequency of post-procedural complications, medical interventions, and hospital costs associated with microlaryngobronchoscopy (MLB) in children prophylactically admitted for pediatric intensive care unit (PICU) monitoring for age ≤ 2 years. MethodsWe performed a single-center, retrospective, descriptive study within a 44-bed PICU in a stand-alone, tertiary, pediatric referral center. Inclusion criteria were age ≤2 years and pre-procedural selection of prophylactic PICU monitoring after MLB between January 2010 and December 2015. Children were excluded for existing tracheostomy, if undergoing concurrent non-otolaryngeal procedures, or if intubated at the time of PICU admission. Primary outcomes were the development of major and minor procedural complications and medical rescue interventions. Secondary outcomes were hospital cost and length of stay (LOS). ResultsOne hundred and eight subjects met inclusion criteria with a median age of 5.3 (IQR: 2.6–10.9) months. A majority (86%) underwent therapeutic instrumentation in addition to diagnostic MLB. There were no observed major complications or rescue interventions. Minor complications were noted within 5 h of monitoring and included isolated stridor (24%), desaturation <90% (10%), and nausea/emesis (8%). Minor interventions included supplemental oxygen via regular nasal cannula (39%), single-dose inhaled racemic epinephrine (19%), single-dose systemic corticosteroids (19%), or high flow nasal cannula (HFNC) therapy (4%). Save for two cases of HFNC, interventions were completed or discontinued within 5 h. Median PICU LOS was 1.1 days and median cost was $9650 (IQR: $8235- $14,861) per encounter. Estimated cost of same day observation in our post anesthesia care unit (PACU) following MLB without PICU admission is $1921 per encounter. ConclusionsIn children ≤ 2 years of age prophylactically admitted for PICU observation, we did not observe severe complications or major interventions after MLB. Minor interventions and complications were noted early during post-procedural monitoring. PICU monitoring was substantially more expensive than same-day PACU observation. Young age as the sole criteria for prophylactic PICU monitoring after diagnostic or therapeutic MLB may be unjustified when comparable, cost-conscious care can be achieved in a PACU setting. Prior to pre-procedural selection of PICU monitoring, we recommend a broad contextual risk assessment including a review of comorbidities, operative plan, and intended anesthetic exposure.

Cuffed Versus Uncuffed Endotracheal Tubes in Pediatrics: A Meta-analysis.

BackgroundCuffed and uncuffed endotracheal tubes are commonly used for pediatric patients in surgery and emergency situations. It is still controversial which approach should be adopted. The purpose of the study was to compare the application of cuffed and uncuffed endotracheal tubes in pediatric patients.MethodsWe searched PubMed, Web of Science and Cochrane Library for clinical trials, which compared the two applications in children. The study characteristics and clinical data were summarized by two independent reviewers. Meta-analysis of the data was done using Revman 5.3 software.Results6 studies with 4141 cases were included in this meta-analysis. The pooling analysis showed that more patients need tube changes in uncuffed than cuffed tubes (OR: 0.07, 95% CI: 0.05-0.10, P < 0.00001). However, there were no differences on intubation duration, reintubation occurrence, accidental extubation rate, croup occurrence and racemic epinephrine use during the intubation process. Also we didn’t find any differences on laryngospasm and stridor occurrence after extubation.ConclusionsOur study demonstrated that uncuffed endotracheal tubes increased the need for tube changes. Other incidences or complications between the two groups had no differences. Cuffed tubes may be an optimal option for pediatric patients. But more trials are needed in the future.

Failure of Outpatient Management with Different Observation Times After Racemic Epinephrine for Croup: Smith N, Giordano K, Thompson A, et al. Clin Peds. 2018;57(6):706-710

Failure of Outpatient Management with Different Observation Times After Racemic Epinephrine for Croup: Smith N, Giordano K, Thompson A, et al. Clin Peds. 2018;57(6):706-710

The change in management of bronchiolitis in the intensive care unit between 2000 and 2015.

This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged < 12months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7days (interquartile range 5-12), 5days (4-8) and 8days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p < 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.

A systematic review on the effect of use of impregnated retraction cords on gingiva

Introduction: For teeth requiring crowns or replacement in the form of fixed dental prosthesis, gingival retraction becomes a mandatory procedure which aids in recording the prepared and unprepared surfaces of the abutment tooth. Various methods of retraction known in the past include mechanical (copper band, retraction cord packing, rubber dam placement), chemical and chemo mechanical (retraction cords soaked in racemic epinephrine, dl – aluminium sulfate, aluminium chloride, adrenaline hydrochloride and cordless paste – expasyl and expanding polyvinyl siloxane material) , rotary (gingettage, electro rotary) and laser. Though many new techniques have come up, by far, chemo-mechanical retraction of gingiva is widely preferred. Impregnated gingival retraction cords are known to efficiently perform retraction of the gingiva along with hemostasis. Objective: This systematic review is performed to assess the effects of gingival retraction done by cords impregnated with various chemicals on gingival health. Methods: Search Strategy: The data bases of Pubmed Central and Medline were searched for the related topics. Bibliographies of randomized control trials and reviews, identified in the electronic search, were analyzed for studies published outside the electronically searched journals. Results: The systematic search yielded 4 articles and one article was rejected on the basis of irrelevance of title and abstract. One article was excluded after examination of the core data, 2 articles were handpicked and a total of 4 articles were obtained based on the inclusion criteria. Conclusion: From all the articles considered in this review, we may conclude saying that knitted cords impregnated with aluminium chloride and potassium aluminium sulphate are more preferable than the rest.

Smoke Inhalation Injury: Etiopathogenesis, Diagnosis, and Management.

Smoke inhalation injury is a major determinant of morbidity and mortality in fire victims. It is a complex multifaceted injury affecting initially the airway; however, in short time, it can become a complex life-threatening systemic disease affecting every organ in the body. In this review, we provide a summary of the underlying pathophysiology of organ dysfunction and provide an up-to-date survey of the various critical care modalities that have been found beneficial in caring for these patients. Major pathophysiological change is development of edema in the respiratory tract. The tracheobronchial tree is injured by steam and toxic chemicals, leading to bronchoconstriction. Lung parenchyma is damaged by the release of proteolytic elastases, leading to release of inflammatory mediators, increase in transvascular flux of fluids, and development of pulmonary edema and atelectasis. Decreased levels of surfactant and immunomodulators such as interleukins and tumor-necrosis-factor-α accentuate the injury. A primary survey is conducted at the site of fire, to ensure adequate airway, breathing, and circulation. A good intravenous access is obtained for the administration of resuscitation fluids. Early intubation, preferably with fiberoptic bronchoscope, is prudent before development of airway edema. Bronchial hygiene is maintained, which involves therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. Pharmacological agents such as beta-2 agonists, racemic epinephrine, N-acetyl cysteine, and aerosolized heparin are used for improving oxygenation of lungs. Newer agents being tested are perfluorohexane, porcine pulmonary surfactant, and ClearMate. Early diagnosis and treatment of smoke inhalation injury are the keys for better outcome.

Bronchiolitis Care in the Hospital.

Viral bronchiolitis is a common cause of hospitalization in young children, but despite a variety of therapeutic options, the mainstay of treatment remains supportive care. To examine the most recent evidence for supportive care measures and pharmacologic options in the treatment of bronchiolitis in the hospital setting. MEDLINE search with expert medical librarian for publications on management and therapies for bronchiolitis. Evidence does not support the use of bronchodilators, racemic epinephrine, deep suctioning, systemic corticosteroids, or antibiotics in the absence of a concomitant bacterial infection, as these treatments do not change the course of illness or shorten length of stay (LOS). Nebulized hypertonic saline is not routinely recommended, though it may provide some benefit for patients with anticipated prolonged LOS. Continuous pulse oximetry should not be routinely used in stable patients as it may be associated with longer LOS. Supplemental oxygen should be used to maintain oxyhemoglobin concentrations &#8805;90%, a level lower than what many clinicians may have used previously. Current evidence suggests high-flow nasal cannula may reduce intubation rate, but its effect on LOS is unclear. Intravenous or nasogastric tube hydration should be used when oral hydration is not sufficient. Overall, bronchiolitis remains a self-limited disease whose mainstay of therapy is supportive care.

Case 3: Infant with Stridor

A 3.74-kg term male infant is delivered at an outlying hospital via primary cesarean section because of a maternal history of hip surgery after prolonged rupture of membranes. The mother is a 26-year-old gravida 3, para 0, blood type A positive woman who is rubella equivocal, hepatitis B antibody negative, group B Streptococcus negative, Chlamydia trachomatis and Neisseria gonorrhoeae negative, rapid plasma reagin nonreactive, and human immunodeficiency virus negative. Rupture of membranes is unknown, but occurred at least 1 day before arrival. Significant finding at delivery includes thick, meconium-stained amniotic fluid. The infant’s 1-minute Apgar score is 5. He has stridor and respiratory distress. The DeLee suction is used on the stomach, and continuous positive airway pressure is initiated. His 5-minute Apgar score improves to 7, and he makes a successful transition to oxygen by nasal cannula. Due to the prolonged rupture of membranes, meconium-stained amniotic fluid, and persistence of respiratory distress, a blood culture specimen is obtained and he starts empiric treatment with ampicillin and gentamicin. He is transferred to the special care nursery, where he continues to have stridor at rest. The stridor worsens with agitation. Chest radiography shows pneumomediastinum and pneumothorax. Over the next few days he continues to require intermittent oxygen via nasal cannula to maintain his saturations above 90%. A dose of racemic epinephrine and then albuterol do not improve the stridor. He is able to feed up to 47 mL of breast milk or formula every 3 hours. Blood cultures remain negative, and he …

Failure of Outpatient Management With Different Observation Times After Racemic Epinephrine for Croup.

Observation is necessary following racemic epinephrine (RE) for patients with croup. The ideal length of this observation period is unclear. To compare the rate of failed outpatient management utilizing different observation times after RE administration for croup. We performed a retrospective chart review of children with croup who required RE. Failure of treatment was defined as requiring a second RE treatment and/or returning to the pediatric emergency department for croup symptoms within 24 hours of discharge. The primary analysis considered patients observed between 2.1 and 3 hours compared with those observed for 3.1 to 4 hours. The patients in the 2.1- to 3-hour group had a higher rate of treatment failure (16.7% vs 7.1%, OR = 2.44, P < .01). Patients requiring RE for croup are more likely to have treatment failure if observed for between 2.1 and 3 hours as opposed to 3.1 to 4 hours.