Resuscitative Measures Research Articles

Anesthetic considerations in supravalvular aortic stenosis: A case series

Supravalvular aortic stenosis (SVAS), characterized by elastin arteriopathy, presents either as a localized narrowing at the sinotubular junction or as a diffuse form with additional involvement of the ascending aorta, aortic arch, and its branches. Associated lesions of the aortic valve, coronary artery narrowing, and pulmonary artery stenosis can further complicate the disease process. These patients are inherently at risk for developing myocardial ischemia, particularly in the setting of anesthesia or sedation. The left ventricular hypertrophy, secondary to the obstruction, results in increased left ventricular wall tension and myocardial oxygen consumption. Associated anatomic factors in the coronary arteries can further impair coronary blood flow. Any anesthetic drug that further increases oxygen consumption or decreases the coronary blood flow will result in an imbalance and increase the risk of cardiac arrest. We present a series of three patients with SVAS who were operated at our institute and subsequently discharged with good outcomes. The hemodynamic goal during the perioperative should aim to balance the myocardial oxygen supply-demand ratio. Extreme vigilance and aggressive resuscitative measures are needed to prevent any adverse myocardial event that can happen immediately after anesthetic induction or during periods of intense sympathetic stimulation such as laryngoscopy, sternotomy, aortic cannulation, or during emergence from anesthesia.

Em Busca da Melhor Metodologia para Avaliação Cardíaca Pré-competitiva do Atleta Jovem

The aim of this text is to highlight the aspects of the study recently published in the European Heart Journal (Value of screening for the risk of sudden cardiac death in young competitive athletes) and the two comments and one editorial that followed it, which, due to their relevance and uniqueness, could drive future processes to optimise athlete screening methodologies, improving their efficiency, and reducing costs. This will require further studies with follow-up, the refinement of normality criteria and the implementation of immediate and effective resuscitation measures with automatic external defibrillation in all sports venues and gyms.

Role of Fluid Resuscitation and Supportive Management of Diarrhea

The pediatric population is sensitive in every aspect. There are several parts of their bodies that need extreme levels of care and support until these children have reached a mature age. Similarly, there are several aspects of health that require immediate and urgent intervention, particularly in the pediatric population for better care and management. The reason behind this is the delicate and sensitive nature of the children’s health. Compromising any aspect of pediatric care might lead to severe consequences, which could be life-threatening too. Therefore, it is in the best interest of both the parents of the children and the physicians to be vigilant about the affected children’s symptoms just so they do not miss out on any important signs that could be transient or short-lived. Diarrhea is among the pediatric conditions that can very easily take a turn for the worse if it is not managed appropriately. Diarrhea can lead to severe consequences, including death in children, especially the malnourished ones. Diarrhea results in the excessive excretion of water, and electrolytes including sodium, potassium, bicarbonate, and zinc through watery stools. Dehydration ensues when these losses are not sufficiently replenished, leading to deficits in both water and electrolytes. The extent of dehydration is categorized based on symptoms and signs that mirror the quantity of fluid expelled. Depending upon these extents and degrees of dehydration, performing immediate resuscitation measures might be necessary. Among these measures, oral rehydration therapy is considered to be one of the most useful ones. It helps replenish the electrolytes rapidly and without causing any life-threatening consequences, especially when done within the specified time. On the brighter side, these fluid resuscitative measures might be the only interventions required to stop the child's progression further towards a severe form of the disease. This review is based on this fact only, and it revolves around the importance of performing fluid resuscitation and other elementary-level supportive measures that might be the only shot at saving the life of the child if done at an early stage. Thai review will help take action under the right circumstances if such a case arises in the clinical setting.

ABOUT THE PATHOGENETIC BASIS, FEATURES OF THE CLINICAL COURSE AND THE SELECTIVE APPROACH TO THE SELECTION OF INTERVENTION DEPENDING ON THE PHASES OF THE CLINICAL COURSE OF PERSISTENT TRAUMATIC SUBDURAL HYDROMAS

The work is based on an analysis of surgical treatment of 57 victims with a persistent form of traumatic subdural hydromas. The pathogenetic basis and features of the clinical course of persistent hydromas and their neurological symptoms were clarified. The often observed phasic nature of the clinical course of persistent subdural hydromas has been noted; describes neurological symptoms characteristic of the transition from the pure, uncomplicated phase of subdural hydromas to the complicated, persistent clinical phase. Using the method of in-depth analysis of intraoperative surgical findings and clinical observations of neurological signs, the dependence of the pathoanatomical states of the brain on the prolonged compressive influence of volumetrically accumulating fluid in the subdural cavity was established. It is clarified that the persistent clinical form more often occurs with inertial injuries and with the valve mechanism of hydroma formation. It has been established that pure, uncomplicated traumatic subdural hydromas occur in 4-5% of cases among various clinical and anatomical forms of severe traumatic brain injury. Among them, in 31.5% of cases, pure, uncomplicated subdural hydromas take on a protracted clinical course - they become severe, persistent phase (in 57 cases among 181 of our observations) with frequent death - in 24 (42.1%) cases among 57 cases of complicated, persistent forms of traumatic subdural hydromas. Based on significant clinical material (57 observations), it was established that in the persistent clinical phase, the only indication is osteoplastic craniotomy with intraoperative straightening of the collapsed brain by injection into the lateral ventricle, through the inferior horn, up to 10-15 ml. distilled solution or 20-25 cc. air with the creation at the end of the intervention of additional, subapponeurotic reserve spaces, by detaching the apponeurotic skin flap from the periosteum of the skull around the burr hole, to a depth of 10-15 cm, for the “waste” of the cerebrospinal fluid collecting in the subdural cavity, in order to prevent conditions for mass the effect of compression and dislocation of the brain. Along with the indicated innovative surgical method, it is recommended that, in order to improve volumetric cerebral blood flow and enhance brain perfusion, resuscitation measures include means that enhance the left ventricular volumetric output of blood. In the case of a complicated, persistent form of subdural hydromas, repeated intervention should be strongly preferred to the microcraniotomy method, expectant management and prolonged resuscitation measures, including forced dehydration therapy.

Emergency Medicine Perspectives: The Importance of Bystanders and Their Impact on On-Site Resuscitation Measures and Immediate Outcomes of Out-of-Hospital Cardiac Arrest.

Out-of-hospital cardiac arrests (OHCAs) represent critical medical emergencies in which timely interventions can make a significant difference in patient outcomes. Despite their importance, the role of on-scene witnesses during such events remains relatively unexplored. This research seeks to shed light on the influence of witnesses, especially family members, during OHCAs and the effect of their interventions, or the absence thereof, on outcomes. Drawing from existing literature, our working hypothesis suggests that the presence of a witness, particularly one who is knowledgeable about CPR, can increase the likelihood of obtaining the return of spontaneous circulation (ROSC), potentially enhancing overall survival rates. Using a retrospective analytical method, we thoroughly reviewed medical records from the Lublin Voivodeship between 2014-2017. Out of 5111 events identified using ICD-10 diagnosis codes and ICD-9 medical procedure codes, 4361 cases specifically related to sudden cardiac arrest were chosen. Concurrently, 750 events were excluded based on predefined criteria. Both basic and advanced EMS teams showed higher rates of CPR initiation and an increased likelihood of obtaining ROSC. Notably, the presence of a trained EMS professional as a witness significantly increased the chances of CPR initiation. The presenting rhythms most often detected were ventricular tachycardia (VT) and ventricular fibrillation (VF). Different urgency codes were directly linked to varying ROSC outcomes. When witnesses, especially family members, began chest compressions, the use of amiodarone was notably higher. A significant finding was that 46.85% of OHCA patients died without witnesses, while family members were present in 23.87% of cases. Actions taken by witnesses, especially chest compressions, generally extended the overall duration of patient care. The crucial influence of witnesses, particularly family members, on OHCA outcomes is evident. Therefore, it is essential to increase public awareness of CPR techniques and rapid intervention strategies to improve outcomes in emergency situations.

Differential Diagnosis of Cardiac Amyloidosis and Hypertrophic Cardiomyopathy

Diagnosis and differential diagnosis of cardiac amyloidosis and hypertrophic cardiomyopathy is difficult in some cases, which is confirmed by the presented clinical observation. The patient A., 67 years old, from the age of 59 for 7 years suffered from arterial hypertension with a maximum blood pressure of 170/100 mmHg, received hypotensive therapy. Myocardial infarction, a history of stroke denies. Since January 2018, at the age of 65, against the background of spontaneous stabilization of blood pressure figures, shortness of breath when climbing to the 2nd floor, lifting weights, suffocation at night, swelling of the shins, feet, in connection with which I turned to a doctor. When examined on an electrocardiogram, a low voltage of QRS complexes in the leads from the extremities was noted, there was no increase in the amplitude of the r wave in V1–3. Echocardiography revealed a thickening of the interventricular septum and the posterior wall of the left ventricle up to 1.9 cm without obstruction of the outlet of the left ventricle, restrictive type of diastolic dysfunction, dilation of the left and right atria, moderate pulmonary hypertension, moderate amount of fluid in the pericardial cavity. Magnetic resonance imaging of the heart revealed a pattern typical of cardiac amyloidosis: diffuse subendocardial contrast of the myocardium of both ventricles in the absence of local contractility disorders, increased myocardial thickness in all segments, hydropericardium. Biopsy of the skin and subcutaneous fat with Congo red staining and polarization microscopy revealed no amyloid deposits. No mutations in the transthyretin gene responsible for transthyretin amyloidosis (ATTR–amyloidosis) were detected during the genetic study. Sequencing of 10 genes encoding myocardial sarcomeric proteins in the MYBPC3 gene revealed a mutation c.3197C >G (p.Pro1066Arg) in a heterozygous state, previously described in patients with hypertrophic cardiomyopathy of Slavic origin. Cascade family screening for the mutation was not carried out due to the fact that the patient did not know the father, the mother died at the age of 75 from heart failure, the only son died from an accident six months before the patient’s treatment. On 15.02.2019, the patient suffered a circulatory arrest with successful resuscitation measures. For the purpose of secondary prevention of sudden cardiac death, a single–chamber cardioverter-defibrillator was implanted on 22.02.2019. Despite the ongoing therapy, the patient died in March 2019. from progressive heart failure. Thus, a clinical case is presented where magnetic resonance imaging suspected amyloid cardiomyopathy, which did not receive morphological confirmation in biopsies of extra–cardiac localization. Hypertrophic cardiomyopathy caused by mutation c.3197C >G (p.Pro1066Arg) in the MYBPC3 gene was confirmed on the basis of clinical and instrumental and molecular genetic methods. The pattern characteristic of cardiac amyloidosis described in this patient with instrumental examination methods may be due to a violation of autophagy processes previously described with a number of mutations in the MYBPC3 gene, which may lead to the accumulation of amyloid-like inclusions in cardiomyocytes. For differential diagnosis of cardiomyopathies in complex cases, endomyocardial biopsy may be required. The possibility of coexistence of genetically determined hypertrophic cardiomyopathy and amyloid heart disease is not excluded.

Protein-S-100-beta is increased in patients with decompensated cirrhosis admitted to ICU

BackgroundHepatic encephalopathy (HE) is highly prevalent in patients with liver diseases. The pathophysiology of HE is centered on the synergic role of hyperammonemia and systemic inflammation. However, some data suggest altered functioning of the blood–brain barrier (BBB). Assessing BBB function is challenging in clinical practice and at the bedside. Protein-S-100 Beta (PS100-Beta) could be a useful peripheral marker of BBB permeability in HE. This study aimed to assess plasmatic PS100-Beta levels in a prospective cohort of patients admitted to the intensive care unit (ICU) with decompensated cirrhosis with and without overt HE. MethodsWe retrospectively evaluated a prospective cohort of cirrhotic patients admitted to the ICU from October 2013 to September 2015 that had an available plasmatic PS100-Beta measurement. Patients with previous neurological impairment or limitation of intensive or resuscitative measures were excluded. Overt HE was defined as West-Haven grades 2 to 4. The patients were compared to a control cohort of outpatient clinic cirrhotic and non-cirrhotic patients explored for isolated elevation of liver enzymes. After ICU discharge, the patients were followed for at least 3 months for the occurrence of overt HE. Adverse outcomes (liver transplantation or death) were collected. The ability of PS100-Beta – in combination with other factors – to predict overt HE was evaluated in a multivariate analysis using logistic regression. Likelihood ratios were used to determine the effects and calculate odds ratios (OR). Survival analysis was performed by using the Kaplan–Meier method and survival between groups was compared using a Log-rank test. ResultsA total of 194 ICU patients and 207 outpatients were included in the study. Increased levels of plasmatic PS100-Beta were detected in the ICU decompensated cirrhotic patients compared with the outpatients ([0.15±0.01] mg/L vs. [0.08±0] mg/L, P <0.001). ICU patients with overt HE had higher levels of PS100-Beta ([0.19±0.03] mg/L) compared with the ICU patients without overt HE ([0.13±0.01] mg/L) (P=0.003). PS100-Beta levels did not differ in outpatients with F 0–3 compared to F 4 fibrosis (P=0.670). PS100-Beta values were correlated with Child-Pugh score (P <0.001), Model for End-Stage Liver Disease (MELD) score (P=0.004), C-reactive protein (P <0.001), ammonemia (P <0.001), and chronic liver failure consortium (CLIF-C) organ failure (P <0.001) and CLIF-C acute-on-chronic (P=0.038) scores, but not with leukocytes (P=0.053), procalcitonin (PCT) (P=0.107), or the lymphocyte-to-neutrophil ratio in ICU patients (P=0.522). In a multivariate model including age, ammonemia, PS100-Beta, PCT, MELD, presence of transjugular portosystemic shunt, and sodium level, the diagnostic performance was 0.765 for the diagnosis of overt HE. Patients with a PS100-Beta level <0.12 mg/L had a better overall survival (P=0.019) and a better survival without liver transplantation (P=0.013). ConclusionsSerum levels of PS100-Beta are elevated in ICU patients with decompensated cirrhosis, and even more so in those displaying overt HE, and the levels are correlated with outcome. This suggests an increase in the permeability of the BBB in these patients.

Methylmalonic acidemia (MMA) with homocystinuria cblD &amp; cblF types - A rare disorder of vitamin Bmetabolism in the western region of India

Methylmalonic acidemia (MMA) with homocystinuria cblD &amp; cblF type, a very rare disorder of vitamin B12 metabolism, can result in severe neurological complications in a child. The incidence of combined MMA with homocystinuria cblD &amp; cblF type is estimated as less than 1: 100,000. Mutation analysis by next-generation sequencing (NGS) and validation of the NGS variant by Sanger sequencing, is not only the gold standard in diagnosis of MMA but also, can help in the choice of treatment strategy as B12 responsive or unresponsive. We report a male child initially presented at 10 months of age with poor feeding, delayed growth and no head control (milestone, normally present at 3-4 months). The child on evaluation was diagnosed as a case of MMA with homocystinuria type cblD &amp; cblF, based on investigations such as liquid chromatography-mass spectrometry (LC-MS) and mutation analysis done by next-generation sequencing (NGS) validation with Sanger sequencing. He was treated with vitamin B12 supplements and other supportive conservative therapy. Subsequently, he developed global developmental delay and severe neurological complications, within two years. The child was admitted to the pediatric ICU and he underwent percutaneous endoscopic gastrostomy (PEG) and placed on mechanical ventilation via tracheostomy in situ. Unfortunately, the child did not respond to treatment and succumbed to death, despite all resuscitative measures. The aim of this case report is to create awareness about a clinical presentation associated with a very rare metabolic disorder, MMA with homocystinuria cblD &amp; cblF types and the need for early diagnosis, also, to establish an outline for the treatment in these patients.

Peculiarities of Clinical Symptoms, Somatic Complications, Approaches to Therapy and Outcomes of Delirium Induced by Exposure to Synthetic Cannabinoids: Systematic Review

INTRODUCTION: The use of synthetic cannabinoids (SCs) is an urgent healthcare problem, due to, among other things, a high number of complications.&#x0D; AIM: To systematize the peculiarities of clinical presentation, somatic complications, effectiveness of empirical approaches to therapy, and probable outcomes of delirium induced by exposure to SCs.&#x0D; MATERIALS AND METHODS: The analysis of scientific publications selected by the keywords in eLibrary, СNKI, PubMed databases, was conducted. According to PRISMA recommendations, 20 articles were taken for analysis.&#x0D; RESULTS: Today, it is impossible to predict the period when SC-induced delirium may occur. It can start after one-time intake of even small dose, and can occur both due to intoxication and with the underlying withdrawal state on the 2nd4th days after the last use. Besides classic symptoms, the clinical picture of delirium is characterized by many symptoms of schizophrenic psychoses: hallucinations of threatening or drug-addicted content; secondary paranoid delusion, less expressed than hallucinations; aggressiveness and agitated behavior; some formal thinking disorders; rarely, KandinskiClerambault and oneiroid syndromes. There are reported cases of severe somatic complications in the form of depression of consciousness, rhabdomyolysis, acute renal failure, cardiomyopathy, myocardial infarction, epilepsy, infectious complications with the underlying weakened immunity. Therapy of SC-induced delirium includes detoxification and metabolic therapy, administration of antipsychotics and tranquilizers; use of resuscitation measures in case of depression of consciousness and development of life-threatening conditions. SC-induced delirium lasts from several hours to several days. In most cases, it terminates with complete recovery with amnesia of the period of confusion and asthenia, but in some cases fatal outcomes are reported caused not only by accidents such as road accidents or suicide, but also by somatic complications (most often of infectious character, or multi-organ failure).&#x0D; CONCLUSION: SСs remain relevant due to high frequency of their use and continuous emergence of new analogs to substances of this group. They have multidirectional effect, and so far it is difficult to predict at what period the delirium induced by them may occur.

INFLUENCE OF OBESITY ON DIFFICULTY OF RUNNING CORONAVIRUS DISEASE (COVID-19) (clinical case)

Aim: To conduct a retrospective analysis of the influence of obesity on the severity of the course of COVID-19 based on the analysis of the chart of an inpatient who was treated in the infectious department of the Chernivtsi Regional Clinical Hospital.&#x0D; Materials and methods. "Medical card of an inpatient" of a patient who was undergoing inpatient treatment in the infectious department of the Chernivtsi Regional Clinical Hospital.&#x0D; Results. A 42-year-old obese patient (BMI 40.0 kg/m2) was admitted to the inpatient ward of the infectious disease department of the Chernivtsi Regional Clinical Hospital on the 5th day of her illness. In hospital conditions, oxygen therapy was immediately started (flow 3 l/min), antibiotic therapy (cefepime - 1 g 3 r/day), hormone therapy (dexamethasone - 8 mg 1 r/day) was prescribed. On the 26th day of intensive treatment, the patient's condition significantly worsened. The state of consciousness was disturbed to the level of sopor, and then came a coma. Hemodynamic instability was noted, which required medical support (dopamine). The patient underwent endotracheal intubation and mechanical ventilation. Despite all the measures applied, cardiac arrest occurred. The resuscitation measures that were carried out did not have the desired effect, and the death of the patient was confirmed.&#x0D; Conclusion. In patients with obesity (BMI &gt; 40), the course of COVID-19 is much more severe, compared to patients whose body weight is within acceptable norms. Also, excess body weight significantly increases the risk of complications in patients with COVID-19 caused by Sars-Cov2, and more often leads to a fatal outcome.

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Simulation Training in Teaching Nurses of Maternity Hospitals the Skills of Taking an Electrocardiogram and Providing Emergency Care

Circulatory arrest is a common cause of death in the world. Resuscitation measures are practical skills aimed at preserving human life. Training in ECG and basic cardiopulmonary resuscitation is a key element in the training of specialists capable of providing quality care in critical situations. The scenario method of training allowed us to work out the acquired skills in real conditions. The simulation training program contributes to improving the quality of medical care and can be recommended for widespread use in medical institutions.

Extracorporeal cardiopulmonary resuscitation-When the heart no longer functions

Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for restoring blood circulation in patients with refractory circulatory failure. While conventional resuscitation measures are being continued, venoarterial extracorporeal membrane oxygenation (VA ECMO) is established in patients with cardiac arrest. This bypass can compensate for the functions of the heart and lungs until recovery of organ function. The benefit of ECPR compared to conventional resuscitation appears to be evident, especially after aprolonged resuscitation period; however, in three prospective randomized controlled studies an advantage has not yet been conclusively proven for widespread use in clinical routine. ECPR systems are complex and resource-intensive and should therefore be limited to specialized centers where sufficient numbers of patients are treated to ensure ahigh level of expertise in the teams.

A two-point strategy to clarify prognosis in >80 year olds experiencing out of hospital cardiac arrest

BackgroundThe global population is aging, with the number of ≥80-year-olds projected to triple over the next 30 years. Rates of out-of-hospital cardiac arrest (OHCA) are also increasing within this age group. MethodsThe Victorian Ambulance Cardiac Arrest Registry was utilised to identify OHCAs in patients aged ≥80 years between 2002–2021. Predictors of survival to discharge were defined and a prognostic score derived from this cohort. Results77,628 patients experienced OHCA of whom 25,269 (32.6%) were ≥80 years (80–90 years = 18,956; 90–100 years = 6,148; >100 years = 209). The number of patients ≥80 years increased over time both absolutely (p = 0.002) and proportionally (p = 0.028). 619 (2.4%) patients survived to discharge without change over time. Older ages had no difference in witnessed OHCA status but were less likely to have shockable rhythm (OR 0.50 (95% CI 0.44–0.57) for 90–100-year-olds, OR 0.28 (95% CI 0.12–0.63) for 90–100-year-olds). If OHCA was witnessed and there was a shockable rhythm then survival was 14%; if one factor was present survival was 5–6% and if neither factor was present, survival was 0.09%. These survival rates enabled derivation of a simplified prognostic assessment score – the ‘15/5/0’ score - highly comparable to a previously-published American cohort. ConclusionsElderly OHCA rates have increased to one-third of caseload. The most important factors predicting survival were whether the OHCA was witnessed and there was a shockable rhythm. We present a simple two-point ‘15/5/0’ prognostic score defining which patients will gain most from advanced resuscitative measures.

Anesthetic drug concentrations and placental transfer rate in fetus between term and preterm infants, twins, and singletons.

Objective: This study aims to determine the drug concentration of etomidate, remifentanil, and rocuronium bromide for general anesthesia in fetus as well as the placental transport rate between term and preterm delivery, twins, and singleton. Study design: Sixty parturients with 72 fetuses undergoing cesarean section under general anesthesia were included. According to whether the fetus was a twin or premature, parturients were divided into Group I (term singleton), Group II (premature singleton), Group III (term twins), and Group IV (premature twins). The preoperative demographic characteristics and laboratory examination of parturients, hemodynamic indicators, the Apgar score of neonates at 1, 5, and 10min after delivery and at specific assigned values, umbilical artery blood gas analysis results, neonatal weight, and resuscitative measures were recorded. Anesthetic drug concentrations in maternal arterial (MA), umbilical arterial (UA), and umbilical venous (UV) blood were detected by Ultra Performance Liquid Chromatography Tandem Mass Spectrometry (UPLC-MS/MS). Result: No significant differences were observed in the concentrations of etomidate, remifentanil, and rocuronium bromide in MA, UV, and UA blood, or in the UV/MA and UA/UV ratios between term and preterm infants, twins, and singletons. Moreover, there was no variation in the anesthetic drug concentration among each pair of twins. Additionally, no correlation was found between the neonatal weight and the plasma concentrations of anesthetic drugs in UV and UA blood, except for remifentanil in UA blood. Conclusion: Preterm or twin deliveries do not affect the neonatal concentration of etomidate, remifentanil, and rocuronium bromide used in general anesthesia for cesarean sections. Clinical Trial Registration: www.chictr.org.cn, identifier ChiCTR2100046547.

Comparative Study between Restrictive versus Liberal Intravenous Fluid Administration in Severe Sepsis and Septic Shock; A Randomized Clinical Trial

Abstract Background Sepsis is an inflammatory response to severe infection characterized by hypovolemia and vasodilation and treated with early antibiotics and fluid resuscitation. In-hospital mortality rates have decreased from 80% in the early years of intensive care to 20-30% in the modern era through improved surveillance, early treatment of underlying infection, and advances in support for failing organs. Despite the central role intravenous (IV) fluid administration has played in sepsis management for the last 15 years, fundamental questions regarding “which fluid” and “in what amount” remain unanswered. Objective To compare between the outcomes of fluid administration strategies in the form of restricted or usual fluid administration in patient with severe sepsis and septic shock, and to detect the optimal strategy of fluid administration which decreases morbidity and mortality. Patients and Methods This was a Prospective controlled; randomized, comparative study was conducted in the intensive care units at Ain-Shams University Hospitals and Gamal Abdelnaser Hospital. This study was conducted on 80 adult patients divided into two groups: Group A: 40 adult patients taking the Usual Care, and Group B: 40 adult patients taking the Restrictive Care. Results The restrictive fluid group received significantly less resuscitative IV fluid than the usual care group prior to randomization, over 24 hours, over 48 hours, over 72 hours and total, Moreover; the restrictive fluid group also received a lower fraction of non-resuscitative IV fluid than the usual care group. In addition, the restrictive fluid group also received less amount of total forms IV fluid than the usual care group. There were no statistically significant differences between the two groups in adjunct resuscitative measures administered including albumin, blood transfusion, or stress dose steroids. By day 30, 9 participants (22.5%) in the restrictive fluid group and 7 participants (17.5%) in the usual care had died with no statistical significant difference between the both groups (p = 0.29). Conclusion A restrictive resuscitation strategy that significantly limited the amount of IV fluid administered to patients with severe sepsis and septic shock show slight improvement as regard mean arterial blood pressure, urine output and lactate level. at the same time did not appear to increase mortality, organ dysfunction, or adverse events. Our data contribute to the current state of clinical equipoise surrounding the use of IV fluids in sepsis, support a larger multicenter trial addressing this topic, and inform future study design. This study demonstrates that a restrictive resuscitation strategy can successfully reduce the amount of IV fluid administered to patients with severe sepsis and septic shock compared with usual care. Although limited by the sample size, we observed no increase in mortality, organ failure, or adverse events.

Effects of dual job practices on professionalism amongst doctors - A critical literature review

Abstract&#x0D; Background&#x0D; Professionalism in medicine is a trust based social contract between professionals and public wherein professionals are expected to subordinate all their interests to the larger interests of patients and public. Recent commercialization trends have eroded ethical as well as scientific underpinnings of this sacred profession. This situation calls for immediate and planned resuscitative measures to reverse it. Healthcare professionals particularly dual jobs holding doctors themselves are the key persons in this regards.&#x0D; Objective&#x0D; To systematically examine literature on perceptions of doctors about dual jobs and its effects on professionalism in resource limited settings.&#x0D; Methods&#x0D; Through systematic searches of Medline, Ovid, ERIC and Science Direct combined with grey search from Google Scholar and hand search from reference lists and selected journals, eighteen articles were found appropriate to be included in this review.&#x0D; Results: Six themes were identified: dual job and motives behind private practice; monetary gains and non-professional behavior; threats to professionals and professionalism; role of medical education in building up professionalism; economic principles, law &amp; medical professionalism and finally the governance in healthcare development. The results suggest paucity of qualitative studies on perspectives of doctors with dual jobs about the practices of professionalism in both public and private sectors and their views about remedial measures in low income settings.&#x0D; Conclusions: The review highlighted the need to explore the perceptions of the key elements i.e. doctors; particularly those with dual jobs about the practices of professionalism in public and private sectors along with their proposals about remedial measures in resource limited settings.&#x0D;

Isolation of &lt;i&gt;Globicatella sanguinis&lt;/i&gt; from a neonate with sepsis using BacT/Alert and VITEK-2 compact system at Federal Teaching Hospital, Katsina, northwest Nigeria: A case report

Neonatal sepsis is a significant cause of neonatal morbidity and mortality, predominantly in developing countries. The bacterial causes of neonatal sepsis and their antimicrobial susceptibility patterns are however dynamic. Globicatella sanguinis is a streptococcus-like bacterial agent capable of causing serious infection in humans that has been rarely isolated from clinical samples, and is an uncommon pathogen that is difficult to identify. Identification based on phenotypic methods alone can misidentify many bacteria, and this may affect precise antibiotic treatment. We report the isolation of a rare bacterial pathogen, G. sanguinis from a three-hour-old preterm female neonate (28 weeker, extremely low birth weight) with sepsis and respiratory distress syndrome (RDS) at Federal Teaching Hospital Katsina, Nigeria, and to the best of our knowledge, one of the very few reported cases all over the world. Blood sample was aseptically collected from the neonate and cultured on BacT/Alert automated system (BioMérieux, Mercy-Etoile, France). A rare bacterium was identified from a positive culture, and in vitro susceptibility test using VITEK-2 compact system showed the isolate to be sensitive to gentamicin, cefuroxime, ceftriaxone, and ceftazidime. Despite antibiotic treatment and other standards of care, on day 9 of admission, the baby developed apnea and all resuscitative measures proved abortive. In a developing country like Nigeria where child mortality due to infection is high, the inclusion of advanced technologies such as improved VITEK-2 compact system, PCR, MALDI-TOF MS, and next-generation sequencing, could play a significant role in its reduction.

Effect of Novel Placental Transfusion Technique—Gravity-Aided Cord Blood Transfusion at Birth on Hemoglobin Levels in Preterm Infants Born Less than 30 Weeks: A Randomized Controlled Trial

Introduction Delayed cord clamping (DCC) is considered standard of practice in very preterm deliveries but could not be practiced in more than 50%, as they need resuscitation measures. We studied the effect of a novel technique of placental transfusion, gravity aided cord blood transfusion (GCT) in comparison to standard care in preterm &lt;30 weeks of gestation on hemoglobin levels at 24 hours of life. Methods This randomized noninferiority trial was conducted in a tertiary care unit from September 2020 to June 2021 in South India. Preterm infants with gestational age (GA) &lt;30 weeks were randomized to either GCT or standard care. GCT was performed by clamping the cord with maximal length immediately after birth, shifting the baby to radiant warmer and holding the whole length of the umbilical cord attached to the baby vertically upwards, allowing blood to drain by gravity while the steps of resuscitation were being performed simultaneously. Standard care was either DCC in vigorous babies and immediate cord clamping (ICC) in nonvigorous babies. Primary outcome was hemoglobin levels at 24 hours of birth. The study was terminated in view of slow recruitment due to covid pandemic. Results Twenty two babies were included. Nine babies were in the GCT group. The median (IQR) hemoglobin at 24 hours of life was 16.9 (16.3-18.9) in the GCT group and 16.4 (14.8-17.8) in standard care; the difference was not statistically significant ( P = .4). Higher hemoglobin at 24 hours of life was observed in GCT group with median (IQR) of 16.9 (16.3-18.9) compared to the ICC group with median (IQR) of 15.55 (14.5-17.1), though not statistically significant ( P = .095). Conclusion The novel placental transfusion strategy, namely GCT, is feasible in preterm neonates. Hemoglobin level at 24 hours was not significantly different between GCT and standard care groups. There is a need for large RCT to assess the effect of GCT on other important clinical outcomes in preterm neonates.

Acute myocardial infarction complicated by sudden out-of-hospital cardiac arrest: a clinical case

Justification. One of the serious complications of acute myocardial infarction (AMI) is out-of-hospital cardiac arrest, which is associated with electrical instability of the myocardium, ventricular arrhythmias. The development of a complication in the presence of an emergency medical team requires immediate resuscitation measures, including basic resuscitation measures and defibrillation.Aim: To present a clinical case of a patient with AMI with ST segment elevation complicated by recurrent ventricular fibrillation, hospitalized in an emergency hospital with the possibility of performing invasive interventions.Methodology and methods of research. The analysis of anamnesis, electrocardiographic data of the patient, the results of coronary angiography and stenting of the coronary artery, echocardiography examination, Holter monitoring, laboratory studies was carried out.Results. Patient P., female, 81 years old, was taken to the emergency hospital 2 hours and 15 minutes after the start of the clinic. At the prehospital stage, recurrent ventricular fibrillation, stopped by repeated three defibrillations. Non-contact, twice bouts of motor arousal. The council decided to conduct coronary angiography with possible stenting of the coronary arteries immediately. It was performed by femoral access on the right in 30 minutes after hospitalization. Complete occlusion of the anterior interventricular artery was revealed. Conductor recanalization and stenting of permanent residence was performed using a drug-coated stent. In the intensive care unit, drip administration of dopamine, noninvasive ventilation of the lungs, heparin administration were continued; double antiplatelet therapy, atorvastatin, amiodarone were prescribed. Since the fourth day, a beta-blocker has been added to therapy. Physical and psychological rehabilitation was carried out. She was discharged on the 15th day in a satisfactory condition.Conclusion. Out-of-hospital cardiac death requires urgent resuscitation measures, among which defibrillation occupies a special place, as well as immediate hospitalization to a cardiology center with the possibility of performing invasive interventions. Early rehabilitation plays an important role in the treatment of patients.