Weaning Off Research Articles

Extended and Safe Support with the CentriMag® Temporary Ventricular Assist Device Implanted with Skirted-Cannula Technique.

CentriMag® (Abbott, Pleasanton, CA, USA) is indicated for temporary circulatory support for up to 30 days. Extended support is not uncommon, and the results vary considerably. Herein, we review our experience on extended support. We retrospectively analyzed 19 patients supported with CentriMag as a bridge to recovery, long-term ventricular assist device or transplantation from September 2011 to October 2021. Nineteen patients (16 men and 3 women; mean age 51.7 ± 9.2 years) had CentriMag left ventricular assist device (LVAD) implantation with the skirted-cannula technique. Twelve (63.2%), 6 (31.6%), and 1 (5.3%) patient were in INTERMACS 1, 2, and 3, respectively. The aims of support were bridge-to-decision in 3 patients (15.8%), and bridge-to-transplantation in 16 patients (84.2%). Fourteen patients were supported for longer than 30 days, while 5 patients had their CentriMag removed before 30 days. Of the 5 patients supported for less than 30 days, 3 died early after implantation due to complications of prolonged shock. The other 2 patients were successfully transplanted. Among the 14 patients supported for longer than 30 days, 1 patient died after transplantation and 13 patients survived either after transplantation or weaning off CentriMag. The overall 1-year survival rate was 73.7%. The duration of support for all patients ranged from 6 to 191 days (64 ± 61 days; median 41 days). The skirted cannula technique for apical cannulation in implantation of CentriMag LVAD is an easy, safe and durable technique. Immediate post-operative and long-term complications are not common. Its use over 30 days is associated with acceptable survival.

Anesthesia Management of Severe Hypoxemia During Total Arch Replacement for Acute Aortic Dissection: A Case Report

Background: Acute aortic dissection poses a life-threatening condition that typically necessitates immediate surgical intervention, such as total arch replacement. However, hypoxemia is a severe complication in such surgeries, potentially resulting in organ dysfunction, prolonged hospital stays, and even mortality. Hypoxemia presents significant challenges to anesthesiologists. Through this case, we can enhance our comprehension of anesthetic management for total arch replacement. Case presentation: A 43-year-old man with acute type A aortic dissection underwent total arch replacement. After a smooth surgery, severe hypoxemia occurred during weaning off cardiopulmonary bypass. Initial interventions, including airway suction and recruitment maneuvers, failed to improve oxygenation. Further investigations found left lung atelectasis and pleural effusion on transesophageal echocardiography, with minimal improvement after drainage. Fiberoptic bronchoscopy revealed extensive tenacious secretions occluding the airways. Conventional suctioning was ineffective due to high sputum viscosity. Ultimately, techniques including pulmonary lavage, bronchoscopic suctioning, and repeated lung recruitment controlled the refractory hypoxemia. The patient recovered after treatment in the intensive care unit. Conclusions: It is worth noting that our case highlights the challenges posed by severe hypoxemia during total arch replacement surgery. The successful management of this complication underscores the importance of a multidisciplinary approach and close monitoring during the perioperative period. Individualized anesthetic management plays a critical role in addressing severe hypoxemia during total arch replacement surgery.

BENEFICIAL EFFECTS OF A NOVEL INTRAOPERATIVE SURGICAL IRRIGANT ON POST-OPERATIVE KNEE SWELLING AND LIMB FUNCTION IN PRIMARY TOTAL KNEE ARTHROPLASTY

Total knee arthroplasty (TKA) is one of the most common elective orthopedic procedures performed in inpatient and outpatient settings. Swelling, stiffness and pain are common complications that occur after TKA resulting in functional impairment of the joint. Reducing post-operative (PO) inflammation, which consequently helps mitigate edema, swelling and pain, is critical to functional recovery after surgery. This pilot study was designed to evaluate the effects of the intraoperative application of a novel surgical irrigant called XPERIENCE® Advanced Surgical Irrigation (XP), on post TKA lower extremity swelling, joint function, and pain, as part of an all-encompassing swelling reduction regimen. Intraoperative povidone-iodine (PI) application was used as the control. Swelling; an indicator of inflammation, was measured by single frequency-bioimpedance assessment (SF-BIA). Range of motion (ROM) and reliance on ambulatory assistive devices (AAD) were evaluated as indicators of functional recovery. Narcotic consumption for pain management and numerical pain scoring were evaluated as surrogate, limited indicators of quality of life. These parameters were assessed over a period of 6 weeks post index TKA and compared between the control cohort treated intraoperatively with PI and the intervention cohort treated intraoperatively with XP. Intraoperative irrigation with XP resulted in statistically significant improvements in PO swelling at days 7 (p<0.05) and 14 (p<0.01) post index surgery compared to the PI treated control cohort. Statistically significant improvements in ROM at day 7 (p=0.043) and AAD usage at day 21 (p=0.049) were noted in the XP cohort compared to the PI cohort. The XP cohort exhibited a quicker “weaning off opioids” timeline evidenced by the PI cohort reaching half of the maximum percentage of subjects using opioids 8 days later than the XP cohort. There was no statistically significant difference noted in numerical pain scores between the two cohorts. This pilot study signifies the utility of XP as a multifunctional, intraoperative surgical irrigation solution which has demonstrable benefits of reducing PO swelling with the potential to impact functional recovery after TKA.

Behavior of calves reared with half-day contact with their dams

Dam-calf contact has been suggested to improve animal welfare in dairy calves, but practical and economical concerns have led to interest in half-day contact between cows and their calves. However, little is known about the behavioral effects of half-day contact compared with whole-day contact. The present study investigated the behavior of 45 dairy calves housed with their dams in either a whole-day system (cows only away twice daily for milking) or a half-day system (cows away from afternoon milking until after morning milking the next day). Data were video recorded during 24 h when calves were on average 3, 5, and 7 wk old. Half-day calves spent less time suckling and received less grooming compared with whole-day calves, indicating that they received less maternal care. Half-day calves were quicker to reunite with their dam when the cows returned from morning milking compared with whole-day calves. Half-day calves also suckled alien cows more often, although mainly shortly after the cows returned to the pen in the morning. This may indicate that they were hungrier than whole-day calves at this time of day. Half-day calves spent more time eating solid feeds, which may prepare them better for separation from the dam and weaning off milk. In conclusion, half-day dam-calf contact may affect calf welfare both positively and negatively, and further research focusing more directly on assessing affective states is encouraged.

2007 RE-OPENING OF MALAWI'S DIPLOMATIC MISSION IN NEW DELHI UNDER PRESIDENT BINGU WA- MUTHALIKA: DISCUSSING THE CRITICAL JUNCTURES

Malawi and India improved their bilateral ties during the presidency of Bingu wa Muthalika that run from 2004 to 2012. Thus in 2007 Malawi opened its resident mission in New Delhi, followed by the re-opening of Indias diplomatic mission in Lilongwe in 2012. Several critical junctures pushed Bingu wa Muthalika, president of Malawi then, to resurrect diplomatic engagement with India. The notable critical junctures being the lust for accelerated economic growth and the weaning off of trust by the western traditional donors due to registered human rights violations that engulfed his regime. Bingu chose India for the enhanced relations because India had allowing principles of foreign policy that included policy of non-intrusion and policy of solidarity with the third world countries, which looked welcoming to Bingus interests and desires. Needless to say, Bingus strategic interest with India was that of aid to finance flagship developmental projects for his political survival and legacy, the same way the first president of Malawi, Kamuzu Banda manoeuvred by benefiting economically from the apartheid South Africa and Israel. The study used library research, employing secondary data sources in form of journal articles, books, newspapers and You Tube videos to collect content for analysis. Individual level of analysis in International Relations was favoured to adequately examine the character of Bingu wa Muthalika. KEY WORDS: Aid, Critical Juncture, Principles of Foreign Policy, Path Dependency, Strategic Interests

Abstract 19163: A Rare Case of Pericarditis as an Initial Manifestation of Rheumatoid Arthritis

Case Presentation: A 69-year-old male with a history of chronic recurrent pericarditis presented with a 3-week episode of chest pain. Despite treatment with ibuprofen, colchicine, prednisone, and anakinra, he experienced multiple flares upon attempting to wean off anakinra. His current workup revealed an elevated C-reactive protein and an echocardiogram showing a small pericardial effusion. Cardiac magnetic resonance imaging showed mild pericardial late gadolinium enhancement and increased pericardial signal on T2 STIR imaging, confirming a flare of recurrent pericarditis. The patient was started on rilonacept while being weaned off anakinra. During a follow-up after 3 months, the patient reported new onset polyarthralgia, prompting a referral to rheumatology. Rheumatoid factor was negative, but anti-citrullinated protein antibodies were positive, leading to a diagnosis of rheumatoid arthritis (RA). Azathioprine was added to the treatment regimen alongside rilonacept. Discussion: The patient's recurrent pericarditis was initially considered idiopathic but, with the subsequent RA diagnosis, it was suspected that RA may have been the underlying cause. While pericarditis is a known cardiac complication of RA, it is uncommon for pericarditis to be the initial manifestation of RA. Anakinra and rilonacept are both interleukin-1 (IL-1) inhibitors, with anakinra being FDA-approved for RA treatment. However, rilonacept has not been extensively studied in patients with RA. The case suggests that the use of certain medications may have masked RA symptoms, and as those medications were tapered, the RA symptoms became more evident. This case highlights the possibility of idiopathic pericarditis evolving into an autoimmune etiology, such as RA, over time. The combination of rilonacept and azathioprine for treating RA has limited evidence, emphasizing the need for further research in this area.

Weaning Habits and Nutritional Status Determinants among under-5 Children in Nigeria

Introduction: High household income may not guarantee a satisfactory nutritional outcome of the children if households are lacking of care, dietary quality and health care access. Malnutrition will persist despite rapid income growth if more effective approach to combat the problem is absent. This study was carried out to determine the influence of correct feeding habits on the nutritional status among under-fives in an urban city in southwestern Nigeria.
 Methodology: This was a community based, cross-sectional, descriptive study, investigations such as dietary survey, anthropometry and clinical examination were done. A multistage sampling technique was used in the study. Data were collected via pretested, close ended, interviewer administered questionnaire. The questionnaires obtained from the study were analyzed using statistical package for social sciences (SPSS version 20) software program.
 Results: A total of 407 participants with the mean age of 26.58 ± 10.10 months were recruited into the study. Exclusive breastfeeding was practiced by 39.8 % of the mothers. About 56.5% of the mothers reported having given their babies the first milk (colostrum). The mean age of weaning off breast was 7.4 ±1.5 months. Immunization coverage among the respondents were BCG- 82.1%, Oral polio= 81.3%, Pentavalent [DPT 3] = 87.2% and Measles=88.7%. The mid upper arm circumference revealed 30(55.6%) of male were at greater risk of malnutrition than female 24(44.4%), while 45(56.1%) of males had severe malnutrition. Mean head circumference for age Z-score test between boys and girls in age group 13 to 24 months [p=0.009, C.I= -0.27-0.19] and 25 to 36 months were significant statistically (p =0.003, - 0.35-0.22). The value for age group 37-48 months was p=0.53, C.I= 0.015-0.59 and p=0.57, C.I= 2.59-1.70 for 49-60 months was not statistically significant.
 Conclusion: This study has shown that the mean age of weaning was 7.4 ±1.5 months. It also reported the mean values of head circumference to be significantly lower among girls than boys below 36 months and this may have developmental and nutritional implications in Nigeria and other African countries.

NLR and PLR as an indicator of outcomes following uneventful cardiac surgery

Background: Patients with coronary artery disease and valvular heart diease continue to be referred for cardiac surgery after medical management fails or in cases where it isn’t feasible. These patients are susceptible to infection and inflammation due to previous MI, cardiopulmonary bypass and the stress associated with surgery itself. Most of these patients also have associated co-morbidities that further increases the risk of post-operative complication. Neutrophil/lymphocyte ratio (NLR) and Platelet/lymphocyte ratio (PLR) is a gaining popularity as a marker of inflammation. Hence we conducted this study to see if NLR and PLR can be used as indicators of outcomes following uneventful cardiac surgery. Methods: A retrospective study was performed on patients undergoing off-pump CABG, on-pump CABG and valve surgeries. Demographic details was noted of all the patients. Postoperative outcomes such as ST-T changes, other arrhythmias, acute kidney/liver injury, wound infection or LRTI within 7 days of surgery was noted and documented. Surgery related factors- cross clamp time, bleeding, challenges in weaning off bypass and operative time were also recorded. Preoperative, day 1, and day 2 NLR and PLR was recorded. Results: Two hundred and six patients in the study. Elevated Pre-op and post-op NLR and reduced PLR values was significantly associated with post-operative ST-T changes and LRTI, with a weak positive correlation between NLR and wound discharge. Additionally, we found that NLR and PLR showed a weak negative correlation with type II diabetes mellitus, pump time/ surgery time > 120 minutes and patients with history of recent MI. Higher preoperative NLR and reduced PLR was significantly associated with postoperative acute liver injury. Conclusions: Higher preoperative and postoperative NLR and reduced PLR is associated with higher rates of complications post-cardiac surgery.

COVID-19 versus Other Disease Etiologies as the Cause of ARDS in Patients Necessitating Venovenous Extracorporeal Membrane Oxygenation—A Comparison of Patients’ Data during the Three Years of the COVID-19 Pandemic

Considering the characteristics of coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS), we compared the clinical course and outcomes of patients with ARDS who received venovenous extracorporeal membrane oxygenation (VV ECMO) based on the etiology of ARDS. This retrospective single-center study included adult patients with severe ARDS necessitating VV ECMO during the COVID-19 pandemic. Among 45 patients who received VV ECMO, 21 presented with COVID-19. COVID-19 patients exhibited lower sequential organ failure assessment scores (9 [8–12.75] versus 8 [4–11.5], p = 0.033) but longer duration of VV ECMO support (10.5 days [3.25–29.25] versus 28 days [10.5–70.5] p = 0.018), which was accompanied by an weaning off rate from VV ECMO in 12/24 (50%) versus 12/21 (57.1%) and 28-day mortality in 9/24 [37.5%] versus 2/21 [9.5%] in non-COVID-19 and COVID-19 patients (p = 0.767, p = 0.040), respectively. Finally, in the adjusted Cox regression model for hospital mortality, the hazard ratio of COVID-19 was not significant (hazard ratio 0.350, 95% confidence interval 0.110–1.115, p = 0.076). Although the VV ECMO period was longer, COVID-19 did not significantly impact ECMO weaning off and mortality rates. Nonetheless, judicious patient selections based on risk factors should be followed.

Prognostic Relevance of the Lung Ultrasound Score: A Multioutcome Study in Infants with Respiratory Distress Syndrome.

There is growing evidence for the usefulness of the lung ultrasound score (LUS) in neonatal intensive care. We evaluated whether the LUS is predictive of outcomes in infants with respiratory distress syndrome (RDS). Neonates less than 34 weeks of gestational age were eligible for this prospective, multicenter cohort study. The outcomes of interest were the need for mechanical ventilation (MV) at <72 hours of life, the need for surfactant (SF), successful weaning from continuous positive airway pressure (CPAP), extubation readiness, and bronchopulmonary dysplasia. Lung scans were taken at 0 to 6 hours of life (Day 1), on Days 2, 3, and 7, and before CPAP withdrawal or extubation. Sonograms were scored (range 0-16) by a blinded expert sonographer. The area under the receiver operating characteristic curve (AUC) was used to estimate the prediction accuracy of the LUS. A total of 647 scans were obtained from 155 newborns with a median gestational age of 32 weeks. On Day 1, a cutoff LUS of 6 had a sensitivity (Se) of 88% and a specificity (Sp) of 79% to predict the need for SF (AUC = 0.86), while a cutoff LUS of 7 predicted the need for MV at <72 hours of life (Se = 89%, Sp = 65%, AUC = 0.80). LUS acquired prior to weaning off CPAP was an excellent predictor of successful CPAP withdrawal, with a cutoff level of 1 (Se = 67%, Sp = 100%, AUC = 0.86). The LUS has significant predictive ability for important outcomes in neonatal RDS. · Lung ultrasound has significant prognostic abilities in neonatal RDS.. · Early sonograms (0-6 h of life) accurately predict the requirement for SF and ventilation.. · Weaning off CPAP is effective when the LUS (range 0-16) is less than or equal to 1..

Unusual severe hypoxemia due to unilateral pulmonary edema after conventional cardiopulmonary bypass salvaged by veno-venous extracorporeal membrane oxygenation: a case report

BackgroundWe report a case in which veno-venous extracorporeal membrane oxygenation (V-V ECMO) saved the life of a patient who developed severe hypoxemia due to unusual unilateral pulmonary edema (UPE) after cardiopulmonary bypass (CPB).Case presentationA 69-year-old man underwent aortic valve replacement and coronary artery bypass grafting. Following uneventful weaning off CPB, he developed severe hypoxemia. The ratio of arterial oxygen tension to inspired oxygen fraction (PaO2/FiO2) decreased from 301 mmHg 5 min after CPB to 42 mmHg 90 min after CPB. A chest X-ray revealed right-sided UPE. Immediately established V-V ECMO increased PaO2/FiO2 to 170 mmHg. Re-expansion pulmonary edema (REPE) was likely, as the right lung remained collapsed during CPB following the accidental opening of the right chest cavity during graft harvesting.ConclusionsV-V ECMO was effective in improving oxygenation and saving the life of a patient who had fallen into unilateral REPE unusually developing after conventional CPB.

Tracheostomy in COVID-19 Pandemic; did we achieve our aims? A developing country's experience.

Objective: To evaluate the effect of tracheostomy on COVID positive patients and the risk included in the procedure for the patient and health care workers. Study Design: Retrospective Observational Study. Setting: Shifa International Hospital Islamabad, Pakistan. Period: 30th May 2020 to 15th February 2022. Material &amp; Methods: The tracheostomies were performed in COVID ICU at bed side by ENT team. This is a study of 22 patients mostly with multiple comorbidities who presented to the hospital with symptoms of SARS-COVID-19. The changes in their ventilation were recorded before and after the tracheostomy. The health care workers included in the study were also kept under observation for any possible cross infection. Results: Eight out of twenty two patients were weaned off from ventilator. There was decrease in partial pressure of oxygen after the procedure but the mortality rate was high. None of the members of operating team, ICU team, anaesthesia team was infected with the virus. Conclusion: Our study shows that although tracheostomy helps in weaning off from ventilator, it has no role in weaning off COVID patients. There is no benefit of tracheostomy for a COVID positive patients. Furthermore, if adequate personal protective equipment’s are used, there is no risk of spread of infection from patient during the procedure of tracheostomy.

Lung ultrasound score for monitoring the withdrawal of extracorporeal membrane oxygenation on neonatal acute respiratory distress syndrome

BackgroundExtracorporeal membrane oxygenation (ECMO) is considered an efficient and life-saving treatment for neonatal severe acute respiratory distress syndrome (ARDS). Bedside lung ultrasound (LUS) is an attractive and feasible method for evaluating neonatal ARDS. ObjectiveTo evaluate the value of LUS score at veno-arterial (V-A) ECMO withdrawal in neonatal patients with severe acute ARDS. MethodsA retrospective preliminary study was conducted in our cardiac intensive care unit from June 2021 to June 2022. Eight severe ARDS neonates who received V-A ECMO were enroled in this study. LUS was measured daily during ECMO and when weaning off ECMO. The relationships between the LUS score and ECMO parameters (blood flow and the sweep gas of FiO2) were assessed. Results(1) There was a significant improvement in LUS score by ECMO treatment. And, various diagnostic signs of lung ultrasound were detected during ECMO, including pulmonary edema (7 neonates) and lung consolidation (4 neonates), followed by pleural effusion (1 neonate) and bilateral white lung (1 neonate). (2) A total of 12 trials for weaning off ECMO were carried out, of which four failed, but all eight neonates finally succeeded in passing the weaning trial. LUS score of 21 or less was defined as a cut-off value for predicting ECMO weaning success. During ECMO treatment, LUS score was positively correlated with ECMO blood flow (r = 0.866, P < 0.05). ConclusionsLUS can be used to evaluate the various lung diagnostic signs in ARDS neonatal patients during ECMO treatment, and the LUS score under ECMO treatment decreases over time. The reduction in LUS score is associated with lower ECMO blood flow. LUS score is regarded as a predictor of ECMO weaning success.

Association between diaphragmatic dysfunction after adult cardiovascular surgery and prognosis of mechanical ventilation: a retrospective cohort study

BackgroundDiaphragmatic dysfunction often occurs after adult cardiovascular surgery. The prognostic effect of diaphragmatic dysfunction on ventilatory management in patients after cardiovascular surgery is unknown. This study aimed to investigate the association between diaphragmatic dysfunction and prognosis of ventilatory management in adult postoperative cardiovascular surgery patients.MethodsThis study was a single-center retrospective cohort study conducted at a tertiary care university hospital. This study included adult patients admitted to the intensive care unit under tracheal intubation after cardiovascular surgery. Spontaneous breathing trial was performed, and bilateral diaphragmatic motion was assessed using ultrasonography; diaphragmatic dysfunction was classified as normal, incomplete dysfunction, or complete dysfunction. The primary outcome was weaning off in mechanical ventilation. The duration of mechanical ventilation was defined as duration from the date of ICU admission to the date of weaning off in mechanical ventilation. The secondary outcomes were reintubation, death from all causes, improvement of diaphragm position assessed by chest radiographs. The subdistribution hazard ratio or hazard ratio (HR) with 95% confidence of intervals (CIs) were estimated by Fine-Gray models or Cox proportional hazard models adjusted for potential confounders.ResultsOf 153 patients analyzed, 49 patients (32.0%) had diaphragmatic dysfunction. Diaphragmatic dysfunction consisted of incomplete dysfunction in 38 patients and complete dysfunction in 11 patients. Diaphragmatic dysfunction groups had longer duration of mechanical ventilation (68 h [interquartile range (IQR) 39–114] vs 23 h [15–67], adjusted subdistribution HR 0.63, 95% CIs 0.43–0.92). There was a higher rate of reintubation (12.2% vs 2.9%, univariate logistic regression analysis p = 0.034, unadjusted odds ratio = 4.70, 95% CIs 1.12–19.65), and a tendency to have higher death from all causes in the diaphragmatic dysfunction group during follow-up period (maximum 6.5 years) (18.4% vs 9.6%, adjusted HR 1.64, 95% CIs 0.59–4.53). The time to improvement of diaphragm position on chest radiograph was significantly longer in the diaphragmatic dysfunction group (14 days [IQR 6–29] vs 5 days [IQR 2–10], adjusted subdistribution HR 0.54, 95% CIs 0.38–0.77).ConclusionsDiaphragmatic dysfunction after adult cardiovascular surgery was significantly associated with longer duration of mechanical ventilation and higher reintubation.

Nutritional Approach of Neonatal with High Output Stoma Due to Long Segment Hirschsprung Disease: A Case Report

Background: High Output Stoma (HOS) continues to be one of the most challenging problems for pediatrician especially in neonates. One of the most common causes in neonatal HOS is post resection long segment Hirschsprung disease.&#x0D; Case: We reported a case of three-day-old baby boy diagnosed as Hirschsprung diseases with peritonitis possibility and did laparotomy with ileal resection, double barrel ileostomy and biopsy. Nutritional management is a major subject on taking care of this type of neonatal patient. We share our experience in limited facilities with all the patient uniqueness&#x0D; Discussion: Loss of a significant length of the small bowel results in interrelated physiologic events as a result of decreased small intestinal mucosal absorptive cell. This leads to a lesser fraction of ingested food and intestinal secretion thus causing an excessive volume loss. The introduction of early enteral feeds promotes intestinal adaptation, with subsequent weaning off parenteral nutrition. Most off patient with high output stoma will require parenteral nutrition which is associated with acute and long-term complications. In our case, we did early nutritional intervention using parenteral and enteral nutrition, counting ongoing fluid loss trough stoma and adjust it to total daily fluid requirement. We found weight loss during hospitalized due to HOS, and we do catch up at the end. We found difficulties to adjust comparation between enteral and parenteral intake to maintain the weight gain.&#x0D; Conclusion: Although parenteral nutrition is often necessary, at least initially, the therapeutic goal should be to enhance intestinal adaptation and enteral nutrient assimilation, and thereby reduce parenteral nutrition requirements. Daily monitoring for ongoing fluid loss very crucial for adjusting nutrition.

Dexmedetomidine Versus Midazolam: Does Choice of Sedatives Effect the Duration of Mechanical Ventilation

Objective: To evaluate Dexmedetomidine and Midazolam in mechanical ventilation regarding the extubation time.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Department of Anaesthesia, Combined Military Hospital, Kharian, from May to Dec 2019.&#x0D; Methodology: A total of 88 patients on mechanical ventilator support in ICU were included. In Group-D (Dexmedetomidine), a loading dose of 1 μg/kg Dexmedetomidine over ten minutes was given, and sedation was maintained by continuous infusion at the rate of 0.2–0.6 μg/kg/hr. In Group-M (Midazolam), an intravenous 0.5–1 mg bolus of Midazolam was given over two minutes and maintained by continuous infusion at 10-50 μg /kg/hr; doses were increased incrementally 1–2 mg/hour until desired sedation level was achieved. The Richmond Agitation and Sedation Score assessed the sedation level. The total duration of mechanical ventilation and time from weaning off trial to extubation was recorded.&#x0D; Results: In this study, the mean duration of mechanical ventilation was 63.07±32.07 hours in Group-D versus 86.14±38.96 hours in Group-M (p-value=0.003). The mean extubation time was 25.09±7.33 hours in Group-D versus 30.31±8.37 hours in Group-M (p-value =0.002).&#x0D; Conclusion: This study concluded that Dexmedetomidine is superior Midazolam in providing sedation to mechanically ventilated patients. It reduces the duration of mechanical ventilation and time of extubation.Keywords: Dexmedetomidine, Extubation, Mechanical ventilation, Midazolam, Sedation.

Perspectives of and Experience toward the Abuse of Antidiarrheal Drug (Loperamide) among Community Pharmacists: A Cross-Sectional Study.

A cross-sectional study was conducted in Jordan, using a self-administered online questionnaire. The questionnaire consisted of three main parts: demographics, the experience of pharmacists with abusers' behavior, as well as their perspectives toward loperamide abuse. A total of 250 community pharmacists completed the survey, 54% (135) of which were female. Almost one-third (33.2%; 83) of the participants reported exposure to suspected cases of loperamide abuse during the last six months. Pharmacists declared that most of the suspected loperamide abusers were male (60.2%), of middle-low socioeconomic status (69.9%), and between 20 and 30 years of age (57.8%). The largest quantity (packs) of loperamide requested by a single patient was around 33.2 ± 14.9 at once. As reported by pharmacists, the suspected reasons behind loperamide abuse included 50% seeking euphoria, 17% relieving anxiety, and 33% controlling addiction (weaning off other opioids). The multivariate logistic regression analysis demonstrated a significant correlation between the male sex (OR = 1.2, 95% CI 0.12-1.59), pharmacy location in the center of Jordan (OR = 21.2, 95% CI 2.45-183.59), late-night working shift (Shift C, OR = 1.29, 95% CI 0.12-2.08), and abuse to loperamide during the last six months. This study sheds light on loperamide abuse potentials, which could be influenced by different sociodemographic characteristics. Accordingly, close monitoring and thorough tackling of the abuse practices are mandated through an increase in educational and awareness campaigns about proper medication use.

Veno-venous Extracorporeal Membrane Oxygenation: Anesthetic Considerations in Clinical Practice.

After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO). In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline. We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation. Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 μg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 μg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval. The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.

Information seeking behavior of medical students in Sri Lanka

Information seeking behavior involves identifying needs, searching approaches and the use of information. This study aims to explore the information seeking behavior of medical students in Sri Lanka. A qualitative study, using focus group discussions, was conducted with 85 final year medical students of four universities in Sri Lanka. 47 of the participants were males and their average age was 26 years. All focus group discussions were audio-recorded and the records were transcribed verbatim. A thematic analysis of content was carried out. The themes identified varied from conceptualization of information seeking behaviour to needs, strategies, barriers, and facilitators. Students use limited sources of information in classroom-based learning and they confine mainly to material provided by teachers, i.e., teacher-directed behavior. This was primarily driven by exam orientation and the belief about in learning. They seek information from external sources, e.g., internet, while they learn in the clinical environment, i.e., self-directed behaviour, as they face more uncertainty in such settings. Web sources used ranged from informal, e.g., Wikipedia, to standard, e.g., PubMed, sources. Although the participants were millennials some tend to prefer printed material which gives them a higher sense of ‘confidence’. The role of a traditional library seems to be of weaning off with smartphones and tablets gaining popularity . The primary orientation of information seeking is academic needs. Learning environment and its level of intellectual challenge sophisticates the process; teachers and teaching play a vital role in widening the scope of information seeking.

Clinical characteristics and long-term outcomes following pancreatic injury – An international multicenter cohort study

BackgroundTrauma to the pancreas is rare but associated with significant morbidity. Currently available management guidelines are based on low-quality evidence and data on long-term outcomes is lacking. This study aimed to evaluate clinical characteristics and patient-reported long-term outcomes for pancreatic injury. MethodsA retrospective cohort study evaluating treatment for pancreatic injury in 11 centers across 5 European nations over >10 years was performed. Data relating to pancreatic injury and treatment were collected from hospital records. Patients reported quality of life (QoL), changes to employment and new or ongoing therapy due to index injury. ResultsIn all, 165 patients were included. The majority were male (70.9%), median age was 27 years (range: 6–93) and mechanism of injury predominantly blunt (87.9%). A quarter of cases were treated conservatively; higher injury severity score (ISS) and American Association for the Surgery of Trauma (AAST) pancreatic injury scores increased the likelihood for surgical, endoscopic and/or radiologic intervention. Isolated, blunt pancreatic injury was associated with younger age and pancreatic duct involvement; this cohort appeared to benefit from non-operative management. In the long term (median follow-up 93; range 8–214 months), exocrine and endocrine pancreatic insufficiency were reported by 9.3% of respondents. Long-term analgesic use also affected 9.3% of respondents, with many reported quality of life problems (QoL) potentially attributable to side-effects of opiate therapy. Overall, impaired QoL correlated with higher ISS scores, surgical therapy and opioid analgesia on discharge. ConclusionsPancreatic trauma is rare but can lead to substantial short- and long-term morbidity. Near complete recovery of QoL indicators and pancreatic function can occur despite significant injury, especially in isolated, blunt pancreatic injury managed conservatively and when early weaning off opiate analgesia is achieved.