Stable Hemodynamic Conditions Research Articles

Capnography in Pediatric Critical Care Unit and Correlation of End-Tidal and Arterial Carbon Dioxide in Ventilated Children

AbstractRecording of end-tidal carbon dioxide (EtCO2) noninvasively reflects a real-time estimation of arterial carbon dioxide (PaCO2 [partial pressure of CO2]). However, as the EtCO2 is dependent on metabolism, perfusion, and ventilation, predicting PaCO2 from EtCO2 is not linear. The objective of the study was to find out the predictability of PaCO2 from EtCO2 in PICU and to evaluate the factors affecting the correlation of EtCO2 and PaCO2 in critically ill ventilated children. The design involved was prospective observational study. The setting discussed over here is that of pediatric intensive care unit (PICU) of tertiary care hospital. A total of 160 children between 1 month and 14 years received mechanical ventilation. EtCO2, PaCO2, PaO2/FiO2 (PF) ratio, oxygenation index (OI), and ventilation index (VI) are the factors involved in main outcome measures. A total of 535 pairs of EtCO2 and PaCO2 were recorded in 160 ventilated children during the stable hemodynamic state. Mean age and weight (Z-score) of patients were 31.15 ± 40.46 months and −2.10 ± 1.58, respectively. EtCO2 and PaCO2 differences were normal (2–5 mm of Hg) in 393 (73.5%) pairs. High gradient (>5 mm of Hg) was mostly found with children with pneumonia, prolonged ventilation, and pressure mode of ventilation (p < 0.05). EtCO2 had a strong positive correlation with PaCO2 (r = 0.723, 95% confidence interval [CI] = 0.68 and 0.76) and not significantly affected by PF ratio or OI. However, presence of pneumonia and high ventilation index (VI > 20) adversely affected the relationship with poor correlation coefficient (r = 0.449, 95% CI = 0.30, 0.58 and r = 0.227, 95% CI = 0.03, 0.41, respectively). EtCO2 reading showed good validity to predict PaCO2 and not affected by oxygenation parameters. The correlation was affected by the presence of pneumonia and high ventilation index; hence it is recommended to monitor PaCO2 invasively in these patients till a good correlation is established.

Modified Extracorporeal Membrane Oxygenation Offers Stable Hemodynamic Conditions with Less Invasiveness in Coronary Artery Bypass Grafting

Modified Extracorporeal Membrane Oxygenation Offers Stable Hemodynamic Conditions with Less Invasiveness in Coronary Artery Bypass Grafting

Comparison of Oral Clonidine and Gabapentin Premedication for Attenuation of Pressor Response to Laryngoscopy and Endotracheal Intubation.

Background:During the administration of general anesthesia, direct laryngoscopy and endotracheal intubation cause an increase in heart rate, arterial pressure, and dysrhythmias in upto 90% of patients. These changes can be particularly hazardous for patients with cerebral or coronary diseases. Both clonidine and gabapentin have been used for anesthetic effects, but a better drug for controlling hemodynamic parameters is being investigated.Aims:The study was done to evaluate and compare the efficacy of oral clonidine 0.3 mg and oral gabapentin 900 mg as a premedication for attenuation of pressor response to laryngoscopy and endotracheal intubation.Materials and Methods:After obtaining approval from the ethics committee, 75 patients, American Society of Anesthesiologists physical status classes I and II between the ages of 18 and 60 years scheduled to undergo elective noncardiac surgical procedure were enrolled in the study. Patients were randomized into three groups of 25 each who received 0.3 mg clonidine, 900 mg gabapentin, and placebo. The hemodynamic parameters were recorded at various time intervals along with any adverse effects.Statistical Analysis:Quantitative variables were compared using unpaired t-test between the two groups and ANOVA for three groups. Qualitative variables were compared using the Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant.Results:In our study, we found that both clonidine and gabapentin are effective premedicants by oral route 2 h before induction of anesthesia to blunt the hemodynamic response to laryngoscopy and intubation as compared to placebo. Between clonidine and gabapentin, clonidine was found to be more effective with respect to blunting of systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), although found to be statistically significant only at 15 min with respect to SBP and DBP.Conclusion:Using clonidine or gabapentin, one can effectively provide stable hemodynamic conditions during laryngoscopy and endotracheal intubation, but more so with clonidine.

Change in saturation oxygen and hemodynamic responses by adding intrathecal dexmedetomidine vs. sufentanil to bupivacaine in patients undergoing dynamic hip screw operation: a randomized clinical trial.

Sufentanil (SUF) and dexmedetomidine (DEX) are used as bupivacaine in the spinal technique that providing stable hemodynamic conditions with least side effects. This study aimed to compare the change in saturation oxygen and hemodynamic responses after intrathecal DEX and SUF as adjuvants to bupivacaine in patients undergoing dynamic hip screw. This clinical trial was conducted with 80 patients referring to Valiasr Hospital, Arak, Iran, who were randomly assigned to two groups (n = 40): DEX group (8 mg bupivacaine with 5 μg DEX) and SUF group (8 mg bupivacaine with 2.5 μg SUF). The pain severity was lower in DEX group at different hours and the systolic pressure and diastolic blood pressure were lower in DEX group than in SUF group after surgery. Saturation oxygen was generally lower and more stable in DEX group but there was no significant difference between two groups. The incidence of sensory and motor block was lower in DEX group than in SUF group, but the duration of assessment of sensory block was lower in SUF group than in DEX group. DEX relieves pain up to 24 hours postoperatively. Nevertheless, Care should be taken to avoid the DEX induced shivering in patients. The study was approved by Ethical Committee of Arak University of Medical Sciences by IR.ARAKMU.REC.1395.32 code on April 25, 2016 and was registered in Iranian Registry of Clinical Trials by code number: IRCT2017050220258N45 on August 4, 2017.

Low Dose Dabigatran-Induced Severe Pulmonary Hemorrhage and Cardiogenic Shock, Salvaged by Reversal Agent and Extracorporeal Membrane Oxygenation

A 67-year-old man with newly diagnosed posterior mitral leaflet flail and atrial fibrillation was given dabigatran for stroke prevention upon admission. Within 12 hours of taking two doses of 110 mg dabigatran, the patient suffered from severe pulmonary hemorrhage, acute respiratory failure, and cardiogenic shock. He was rescued by a single dose of 5 g idarucizumab in addition to extracorporeal membrane oxygenation (ECMO) support. The patient recovered to stable hemodynamic status then successfully underwent surgical intervention for mitral valve repair. He was discharged 2 weeks after surgery.

A Small Dose of Butorphanol Prevents Sufentanil-induced Cough During General Anesthesia Induction.

This study aimed to evaluate the suppressive effects of a small dose of butorphanol on sufentanil-induced cough during general anesthesia induction. 120 patients who were scheduled for elective maxillofacial surgery of American Society of Anesthesiologists I∼II, aged 18∼65 years were randomly divided into 3 groups (n = 40). Patients received butorphanol 0.1 mg (group I), 1 mg (group II) or an equal volume of 0.9% normal saline (group III) 5 seconds right before sufentanil bolus (0.5ug/kg). Sufentanil was diluted into 5ug/mL and administrated within 5 seconds. The incidence and reflex degree of cough in all groups were evaluated within 2 minutes after the injection of sufentanil during anesthesia induction. Mean arterial pressure (MAP) and heart rate (HR) were recorded at T0 (before the injection of butorphanol or normal saline), T1 (before the injection of sufentanil) and T2 (2 minutes after sufentanil injection). The HR and MAP values were no significant difference among the 3 groups at the same observation point. In group II, the HR decreased significantly at T2 compared with T0 and T1 (P <0.05, T2 VS T0, T1). None of the patients in group I and group II had cough, and 33 patients in group III developed cough, of which 12.5% were mild, 40% were moderate, and 30% were severe. The results of present study suggest that a small dose of butorphanol 0.1 mg can prevent sufentanil-induced cough and ensure a relatively stable hemodynamic state during general anesthesia induction.

Factors predicted with quality of life among hemodialysis patients in private hospital of Thailand

ABSTRACTBackground: The quality of life (QOL) among the end-stage renal disease patients is an essential component for assessing the success of treatment. This study aimed to determine the factors predicted with quality of life among hemodialysis patients in private hospital of Thailand.Method: This cross-sectional study was conducted by interviewing 188 Thai patients with end-stage renal disease (ESRD), who were on hemodialysis (HD) at Sanamchan Hospital Bangkok. Patients with stable hemodynamic status without any history of mental illness were included in this study. However, those who could not properly communicate were excluded. The descriptive statistics and the multiple linear regression were applied to identify the predictive factors of quality of life (QOL) scores in the end-stage renal disease (ESRD) patients on maintenance hemodialysis (HD). The QoL was assessed in three components including kidney disease component score (KDCS) physical component score (PCS) and mental component score (MCS).Findings: More than half of the participants (57%) in this research were male and (44%) were unemployed. The mean average systolic value of the participants was 157 (25.12 SD) mmHg and the diastolic blood pressure was 81 (5.85 SD) mmHg. Average hematocrit (Hct) was 30.95 (4.38 SD), Kt/v was 1.86 (0.96 SD), and average normalized protein catabolic rate (nPCR) was 1.12 (1.09 SD). The age, income, patients with more than three associated diseases, enough expenses for living, frequency of dialysis per week, and duration of treatment was statistically significant with the kidney disease component score (KDCS) (F = 6.28, p < 0.05). Furthermore, the age, income, patients with more than three associated diseases, hematocrit (Hct) and frequency of dialysis per week were the statistically significant with the physical component score (PCS) (F = 4.99, p < 0.05) while patients with more than three associated diseases and enough expenses for living were the statistically significant with the mental component score (MCS) (F = 3.30, p ≤ 0.05).Conclusion: Study concluded that the factors like; age, expenses for living, frequency of dialysis, patients with more than three associated diseases were had a positive impact on the quality of life among the end-stage renal disease patients coming for dialysis in private hospital of Thailand.

High-risk PCI under support of a pulsatile left ventricular assist device – First German experience with the iVAC2L system

BackgroundDuring high-risk percutaneous coronary intervention (PCI) complications may occur, leading to unstable hemodynamic conditions. Circulatory support devices might help to intercept these conditions by supporting cardiac output. We investigated in a prospective trial the performance of the pulsatile iVAC2L system in the setting of high-risk PCI. MethodsCirculatory support by the iVAC2L device was attempted in 20 consecutive patients (three females, mean age 72 ± 9 years, LVEF 44 ± 12%) undergoing high-risk PCI. Aortic pressure data were collected after device placement and immediately after PCI. ResultsSuccessful device placement was achieved in 17 (85%) patients; kinking of iliac artery and device length limited correct device placement in the remaining three patients. PCI success was 100%. With ongoing support (overall support time 122 ± 32min) systolic, diastolic and mean blood pressure increased significantly and kept the higher level until device removal.Critical events occurred in three patients (massive vasospasm, coronary perforation, no-flow in LCA after wire placement), but the iVAC2L device helped to maintain stable hemodynamic conditions with no need for cardiopulmonary resuscitation.Serial controls of hemolysis related parameters in a subgroup of ten patients revealed no significant device related hemolysis after the performance of the iVAC2l system. ConclusionsHigh-risk PCI under hemodynamic support by the iVAC2L device is feasible and safe. Aortic pressure increases with ongoing support. The device helps to stabilize hemodynamic situations if complications occur.

Case Report: Cardiac arrest due to traumatic coronary artery dissection treated by extracorporeal membrane resuscitation

Traumatic coronary artery dissection, which is rare in blunt trauma, has high risk of acute myocardial infarction and cardiac arrest. A 44-year-old man who had a traffic accident was transferred to the emergency department with refractory ventricular fibrillation (VF). After conventional cardiopulmonary resuscitation, we introduced extracorporeal cardiopulmonary resuscitation (ECPR) and obtained return of spontaneous circulation with ST-elevation electrocardiogram at V4-6. Subsequent coronary angiography and intravascular ultrasound supported by extracorporeal membrane oxygenation (ECMO) revealed complete occlusions of left anterior descending and left circumflex artery due to dissections. Drug-eluting stents were placed with restorations of TIMI 2 flows. After ICU admission, his left ventricular function gradually recovered; he was successfully weaned from VA-ECMO on day 9. ECPR may be a valuable option to allow time and stable hemodynamic condition to treat the cause of cardiac arrest.

Pre-surgery urine metabolomics may predict late neurodevelopmental outcome in children with congenital heart disease

BackgroundFrom fetal life until cardiac surgery, complex congenital heart diseases (CHD) exhibit different hemodynamic and oxygenation patterns that can lead to alteration of the metabolic profile. We used a metabolomic approach to identify urine metabolic markers before cardiac surgery, aiming to define the physiology of patients with complex CHD and to contribute to predict their neurodevelopmental outcome. MethodsIn a prospective, observational, single-center study we enrolled 28 patients with complex biventricular and univentricular CHD aged less than 5 years, on stable hemodynamic conditions, and with no genetic anomalies. We analyzed urine samples, collected at the induction of anesthesia, by 1H NMR spectroscopy. Profiles of 1H NMR spectra were submitted to unsupervised (principal component) and supervised (partial least squares-discriminant) multivariate analysis. Neurodevelopment was assessed by neuropsychological and adaptive functioning testing. ResultsPrincipal components analysis divided CHD patients metabolic profiles in two distinct clusters (RED and BLACK). Metabolic profiles belonging to the RED cluster showed higher levels of accumulation of citric acid cycle intermediates and glucose compared to the profiles in the BLACK cluster, indicating a possible switching to anaerobic metabolism. Patients belonging to the RED cluster were significantly more prone to show an adverse neurodevelopment pattern (p = 0.01). ConclusionsThe application of metabolomic analysis to CHD children permitted a deeper insight on their metabolic status that could help to obtain a better understanding of the physiological implications and to predict long-term neurodevelopmental outcome.

A362 Late post operative splenic Bleeding after laparoscopic sleeve gastrectomy: Case report

The risk of postoperative bleeding after laparoscopic sleeve gastrectomy (LSG) has been reported to be between 1% and 6%. Most of them occur in the early post operative period. The bleeding may be intra or extraluminal. Late post operative splenic bleeding is rare and not described in the literature. Here we present a case report with massive late post operative splenic bleeding 10 days post routine LSG. We present a 45 years old morbidly obese female patient with BMI 42 without comormobidities underwent LSG. The operative and post operative course were uneventful with a stable hemodynamic state and CBC. The patient was discharged at POD2 feeling well with a prophylactic anticoagulation. In POD 10 she was admitted emergently to the emergency room (ER) with a clinical presentation of severe abdominal pain with a stable hymodynamic state. The patient underwent CT which revealed a massive active bleeding from the spleen. But after a short time she developed signs of hypovolemic shock and was taken emergently to the operation room. In the operation there was a huge ruptured sub capsular splenic hematoma, a splenectomy was performed. In POD 4 the patient developed pulmonary embolism and was discharged in POD 7. Our review of literature examines this diagnosis is extremely rare.

Uncoupling of cerebral blood flow and brain oxygen saturation under non-pulsatile flow conditions

Introduction Non-pulsatile blood flow has been associated with altered microcirculatory perfusion. Soon after loss of pulsatility a marked heterogenous flow profile in the very small vessels ensues that is coupled with impaired oxygen extraction [1]. We investigated if changes in cerebral blood flow during non-pulsatile perfusion would affect brain tissue oxygenation assessed by near-infrared spectroscopy. Methods After approval by the local ethics committee thirty-two patients were included in this trial. They were studied during general anaesthesia, and stable hemodynamic conditions. Cerebral blood flow velocity in the middle cerebral artery was measured during non-pulsatile flow in the course of cardiac surgery on total extracorporeal bypass and again postoperatively on the intensive care unit during pulsatile flow. We modified cerebral blood flow by changing arterial partial pressures of carbon dioxide between 30, 40 and 50 mmHg. This was conducted either by a change of sweep gas flow at the heart lung machine or by changing respiratory rate at the respirator. In addition to flow measurements patients' regional brain oxygenation was determined. Relative changes in blood flow velocity were plotted against relative changes in regional brain saturation for both flow conditions and compared using Pearson's correlation. A p-value Results Absolute cerebral blood flow velocity was slightly higher during non-pulsatile flow when serum hemoglobin was diluted. Relative changes in cerebral blood flow velocity and regional brain oxygenation were tightly coupled independent of the flow condition. R-values for non-pulsatile and pulsatile blood flow were 0.724 and 0.796, respectively. However, during non-pulsatile flow the slope of the regression line was less steep as compared with pulsatile flow (P Discussion Despite greater cerebral perfusion during hypercapnia and non-pulsatile flow there was no equivalent rise in cerebral oxygenation. Assuming similar cerebral oxygen delivery this finding could be explained by impaired brain oxygen extraction in the high flow range while partial pressure of carbon dioxide was elevated. In contrast, during hypocapnia, when cerebral blood flow was decreased to a greater extent as during pulsatile flow, the concomitant desaturation was less pronounced. Both findings are in line with shunting on the microcirculatory level, whereby hyperperfused vessels coexist with vessels lacking adequate flow. These findings substantiate that loss of pulsatility seems to negatively affect nutritive tissue perfusion. Raised neurological morbidity in patients supported with non-pulsatile extracorporeal cardiac assist devices could potentially be attributable to the observed perfusion deficit [2].

Accurate identification of myocardial viability after myocardial infarction with novel manganese chelate-based MR imaging.

We developed a novel manganese (Mn2+ ) chelate for magnetic resonance imaging (MRI) assessment of myocardial viability in acute and chronic myocardial infarct (MI) models, and compared it with Gadolinium-based delay enhancement MRI (Gd3+ -DEMRI) and histology. MI was induced in 14 rabbits by permanent occlusion of the left circumflex coronary artery. Gd3+ -DEMRI and Mn2+ chelate-based delayed enhancement MRI (Mn2+ chelate-DEMRI) were performed at 7days (acute MI, n=8) or 8weeks (chronic MI, n=6) after surgery with sequential injection of 0.15mmol/kg Gd3+ and Mn2+ chelate. The biodistribution of Mn2+ in tissues and blood was measured at 1.5 and 24h. Blood pressure, heart rate (HR), left ventricular (LV) function, and infarct fraction (IF) were analyzed, and IF was compared with the histology. The Mn2+ chelate group maintained a stable hemodynamic status during experiment. For acute and chronic MI, all rabbits survived without significant differences in HR or LV function before and after injection of Mn2+ chelate or Gd3+ (p>0.05). Mn2+ chelate mainly accumulated in the kidney, liver, spleen, and heart at 1.5h, with low tissue uptake and urine residue at 24h after injection. In the acute MI group, there was no significant difference in IF between Mn2+ chelate-DEMRI and histology (22.92±2.21% vs. 21.79±2.25%, respectively, p=0.87), while Gd3+ -DEMRI overestimated IF, as compared with histology (24.54±1.73%, p=0.04). In the chronic MI group, there was no significant difference in IF between the Mn2+ chelate-DEMRI, Gd3+ -DEMRI, and histology (29.50±11.39%, 29.95±9.40%, and 29.00±10.44%, respectively, p>0.05), and all three were well correlated (r=0.92-0.96, p<0.01). We conclude that the use of Mn2+ chelate-DEMRI is reliable for MI visualization and identifies acute MI more accurately than Gd3+ -DEMRI.

Comparison of efficacy between clonidine and Dexmedetomidine in attenuating the cardiovascular response to laryngoscopy &amp;amp; intubation in laparoscopic cholecystectomy

Laryngoscopy and tracheal intubation are nearly always associated with an increase in the blood pressure and an increase in heart rate due to reflex sympathetic discharge which is caused by epipharyngeal and laryngopharyngeal stimulation. In recent years the laparoscopic surgery which once upon a time were considered to cause least trauma are reported to have hemodynamic instability. Conclusively during general anesthesia, it is desirable to have a stable intraoperative hemodynamic status. Hence in this study, it has been attempted to compare the beneficial effect and also side effect of the two a2-agonist clonidine and Dexmedetomidine in maintaining the perioperative parameters like MAP, heart rate.

Contribution of videothoracoscopy in the management of thoracic wounds with diaphragmatic lesions: A single African center experience

Background and aims The management of thoracic wounds induced by sharp objects outside an extreme emergency remains controversial. The means vary from exploratory thoracotomy to simple monitoring. Between these two extremes, videothoracoscopy as a means of exploration plays an important role and helps to avoid unnecessary thoracotomies, thus making it possible to make early diagnosis of diaphragmatic lesions. The aim of this study was to report our experience in videothoracoscopic management of thoracic wounds by penetrating objects. Material and methods From January 2010 to December 2015, 58 patients with an average age 22.5 years with a thoracic stab wound with a stable hemodynamic condition underwent videothoracoscopy. Results Thoracoscopy revealed a diaphragmatic injury in 17 patients, cardiac or pericardial wounds in four and a haemorrhagic pulmonary injury in 1; all were treated at video-assisted mini-thoracotomy. In the other 36 patients, videothoracoscopic exploration did not demonstrate any intra-thoracic lesion and the procedure consisted of aspiration of a residual hemothorax with the installation of a good view-controlled thoracic drainage. Hospital stay was between 48 and 72 h. Conclusion Videothoracoscopy is a safe and effective way to explore the thoracic cavity in patients with chest wounds with suspected diaphragmatic lesions. It avoids thoracotomy especially in hemodynamically stable patients.

Novel Approach to Assess Intraventricular Pressure Difference in Patients with Left Ventricular Assist Device during Ramp Study

Purpose Blood flow through the left ventricular assist device (LVAD) is dependent on the rotation speed of the impeller, and inversely dependent on the differential pressure across the LVAD (HQ relationship). We developed a novel approach to estimate intraventricular pressure difference (IVPD) in patients with LVAD and assess the change of IVPD according to pump speed during ramp study. Methods We developed in-house code of 1-dimensional incompressible Euler equation written in MATLAB (MathWorks, Natick, MA, USA) which allows us to measure IVPD by analyzing transesophageal echocardiographic images. Color M-mode images in mid-esophageal long axis view were obtained at 3 different pump speeds (low, optimized, high) in 10 patients who had LVAD implant (Figure). The optimal rotation speed was defined by stable hemodynamic conditions and the septal shape on transesophageal imaging. Pairwise comparison between each group was performed using Steel-Dwass analysis. Results Images were successfully obtained in all patients. Median IVPD values were 0.88 mmHg [IQR 0.73 - 1.02] at pre-LVAD implant, 1.86 mmHg [IQR 1.50 - 2.15] at low speed, 2.12 mmHg [IQR 1.72 - 2.71] at optimal speed, 2.09 mmHg [IQR1.72 - 2.31] at high speed, respectively (figure). There was significant difference between pre-implantation and the remaining 3 groups ( p Conclusion These data illustrate a novel approach to estimate IVPD during early diastole in patients with LVAD. Importantly, data suggests that setting of pump speed can be informed by analyzing IVPD during early diastole.

Total Endovascular Repair of Contained Ruptured Thoracoabdominal Aortic Aneurysms

To report perioperative and 1-year results of total endovascular repair of contained ruptured thoracoabdominal aortic aneurysms (TAAAs). Between 2015 and 2017, preoperative, procedural, and postoperative data of patients with radiographic evidence of contained ruptured TAAAs treated by endovascular repair were prospectively collected. Only patients with stable hemodynamic parameters were enclosed. Primary endpoints were 30-day/in-hospital mortality, spinal cord ischemia (SCI), postoperative cardiopulmonary complications, and new onset of hemodialysis. Secondary endpoints were endoleaks, reinterventions, and overall follow-up survival. Twelve patients underwent endovascular repair for contained ruptured TAAAs. According with the Crawford/Safi's classification, 6 type II (50%), 3 type III (25%), 1 type IV (8%), and 2 type V (17%) TAAAs were treated. All patients were symptomatic. Overall, 34 target visceral vessels were planned to be revascularized. The mean time from admission to treatment was 48hours (range 4-96), with 4 patients operated within 24hours. Five patients (42%) were treated by T-branch, 3 (25%) by custom-made fenestrated/branched endografts, 3 (25%) by parallel graft technique, and 1 (8%) by standard thoracic endovascular aortic repair covering a stenotic celiac trunk. The 30-day and in-hospital mortality was 17% and 25%, respectively. Two patients (17%) developed SCI. Cardiac and pulmonary complications were reported in 1 (8%) and 3 (25%) cases, respectively. One patient (8%) needed permanent hemodialysis. Two endoleaks (17%) were detected at the postoperative computed tomography angiography (1 low-flow gutter endoleak and 1 type III endoleak). Four patients (33%) required re-interventions within 30 postoperative days. The mean follow-up was 12months (range 1-22). No late target visceral vessels occlusion, endoleak, or reintervention occurred in this series. Overall, 7/12 (59%) patients were alive, and no cases of TAAA-related mortality occurred during follow-up. According to our results, endovascular repair of contained ruptured TAAAs is feasible by a flexible approach in selected patients with anatomical suitability and stable hemodynamic conditions. Although early mortality and morbidity are significant, with frequent reintervention necessity, subsequent follow-up is free from reinterventions and TAAA-related mortality.

A rare cause of postpartum hemorrhage: the genital thrombus

We report the case of a 30-year old primiparous patient, having given birth to a 3500g boy by cesarean section due to acute fetal distress. Two hours after childbirth, the patient had bilateral painful ecchymotic vulvar swelling suggesting post-partum thrombus of the vulva. Given the clinical stability of the size of this hematoma, the absence of unbearable pain and the stable hemodynamic status, conservative medical treatment (ice bag + NSAIDs). Output was favorable with progressive decrease in the size of the hematoma until disappearance 8 weeks after delivery. Thrombus or genital hematoma is a rare but potentially very serious post-partum haemorrhagic complication. There are four major types of genital hematomas: hematoma of the vulva, vulvo-vaginal hematoma, vaginal hematoma and pelvic-abdominal hematoma. The contributing factors are primiparity, instrumental extractions, toxaemia of pregnancy, twin pregnancies and vulvovaginal varicose veins. It is essential to suspect it in patients with pain and/or internal postpartum hemorrhage, and, if any doubt exists, to perform vulvovaginal inspection. Early treatment is necessary and should be associated with hemodynamic resuscitation, first-line surgery and percutaneous radiologic arterial embolization in case of failure of surgery.

Comparative Evaluation of Dexmedetomidine versus Midazolam as Premedication to Propofol Anesthesia in Endoscopic Retrograde Cholangiopancreatography.

Background:Endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose and treat pancreaticobiliary diseases. It is a potentially uncomfortable procedure that needs to be performed under conscious sedation. Safe and effective sedation protocol is the need of an hour.Aims:This study aims to evaluate the requirement of propofol using midazolam and dexmedetomidine as premedication for ERCP. The degree of comfort experienced by endoscopist and the patients was also assessed.Materials and Methods:A total of sixty patients were enrolled in a randomized, assessor-blinded study in the age group of 40–80 years, American Society of Anesthesiologists physical class II–III undergoing elective ERCP procedures. They were divided into two groups of 30 each. Group D (n = 30): Dexmedetomidine (100 μg/mL + 18 mL saline) loading dose at 1 μg/kg intravenous (IV) over 10 min followed by 0.5 μg/kg/h infusion, and Group M (n = 30): Midazolam at 0.05 mg/kg IV bolus over 10 min followed by normal saline infusion under hemodynamic monitoring. Satisfaction scores, total propofol requirement, and complications such as gagging, restlessness, agitation, postoperative nausea and vomiting were noted and analyzed statistically.Statistical Analysis:Statistical analysis was performed using SSPS 17.0 software (SPSS Inc., 233 South Wacker Drive, Chicago, USA). The Chi-square test was applied for nonparametric data and parametric numerical data, unpaired t-test for intergroup comparison, and repeated measures ANOVA for intragroup comparison. Results were expressed as a mean ± standard deviation. Value of P < 0.05 was considered statistically significant and <0.001 as highly significant.Results:Surgeons and patients were more satisfied and comfortable along with less requirement of propofol in the dexmedetomidine group. The incidence of complications was also less in the dexmedetomidine group as compared to that of midazolam group.Conclusion:Both dexmedetomidine and midazolam can be safely administered as an anesthetic adjuvant to propofol for short procedures like ERCP's. Dexmedetomidine provided intense and better sedation quality along with lesser requirement of propofol doses. Moreover, it provided stable hemodynamic conditions and good recovery characteristics as compared to midazolam group.

An Observational Study of Cerebral Blood Flow Velocity Evaluation in the Prone Position During Posterior Lumbar Surgery.

Prone positioning (PP) is necessary for surgical access during posterior spine procedure. However, physiological changes occur in the PP. Typical findings are a decrease in arterial blood pressure and in cardiac output that could potentially lead to an alteration in cerebral perfusion. Therefore, we decided to study cerebral blood flow velocity (CBFV) with transcranial Doppler ultrasonography to evaluate the effect of the PP on cerebral hemodynamics. Twenty-two patients undergoing spine surgery in the PP were studied. General anesthesia was induced using 250 μg of fentanyl, 2 mg/kg of propofol, and 0.1 mg/kg of vecuronium, and was maintained with 0.25%-0.5% isoflurane, 50% nitrous oxide in oxygen, continuous infusion of 100 μg/kg/min of propofol, 1.5 μg/kg/h of fentanyl, and 0.15 mg/kg/h of ketamine. Continuous invasive arterial blood pressure, heart rate, electrocardiogram, and end-tidal carbon dioxide were monitored. CBFV with transcranial Doppler in the middle cerebral artery was first measured with the patients under general anesthesia in the supine position. Patients were then placed in the PP and remained in this position throughout surgery. CBFV, end-tidal carbon dioxide, heart rate, and blood pressure were measured continuously for 75 minutes after initiation of PP. This coincided with surgical exposure and minimal blood loss. Data were analyzed every 15 minutes for statistical significant change over time. Mean arterial blood pressure decreased 15 minutes after the installation of the PP and onward, but this decrease was not statistically significant. CBFVsyst (the maximal CBFV during the systolic phase of a cardiac cycle) and CBFVmean (the time averaged value of the maximal velocity envelope over 1 cardiac cycle) did not vary at any time points. CBFVdiast (the CBFV just before the acceleration phase [systole] of the next waveform) was lower at T3 (30 minutes after PP) compared to T1 (value derived averaging the first measure in the PP with the ones at 5 and 10 minutes) (P = .01), and the pulsatility index was higher at T5 (60 minutes after PP) compared to T0 (baseline, patient supine under general anesthesia) (P = .04). Data were analyzed at specific time points (T0 and T1). This value was derived by computing an average of the CBFV values collected at the first measure in the PP and at 5 and 10 minutes thereafter: T2, 15 minutes after PP; T3, 30 minutes after PP; T4, 45 minutes after PP; T5, 60 minutes after PP; and T6, 75 minutes after PP. Our data on CBFV during PP for spine surgery demonstrate preservation of cerebral perfusion during stable systemic hemodynamic conditions. The present results do not allow us to determine whether the PP would be similarly tolerated with increasing length of surgery, variations in systemic hemodynamics, and in different patient populations.