The aim of the study is to estimate the prevalence of atelectasis assessed with computer tomography (CT) in SARS-CoV-2 pneumonia and the relationship between the amount of atelectasis with ...oxygenation impairment, Intensive Care Unit admission rate and the length of in-hospital stay.
Two-hundred thirty-seven patients admitted to the hospital with SARS-CoV-2 pneumonia diagnosed by clinical, radiology and molecular tests in the nasopharyngeal swab who underwent a chest computed tomography because of a respiratory worsening from Apr 1 to Apr 30, 2020 were included in the study. Patients were divided into three groups depending on the presence and amount of atelectasis at the computed tomography: no atelectasis, small atelectasis (< 5% of the estimated lung volume) or large atelectasis (> 5% of the estimated lung volume). In all patients, clinical severity, oxygen-therapy need, Intensive Care Unit admission rate, the length of in-hospital stay and in-hospital mortality data were collected.
Thirty patients (19%) showed small atelectasis while eight patients (5%) showed large atelectasis. One hundred and seventeen patients (76%) did not show atelectasis. Patients with large atelectasis compared to patients with small atelectasis had lower SatO
/FiO
(182 vs 411 respectively, p = 0.01), needed more days of oxygen therapy (20 vs 5 days respectively, p = 0,02), more frequently Intensive Care Unit admission (75% vs 7% respectively, p < 0.01) and a longer period of hospitalization (40 vs 14 days respectively p < 0.01).
In patients with SARS-CoV-2 pneumonia, atelectasis might appear in up to 24% of patients and the presence of larger amount of atelectasis is associated with worse oxygenation and clinical outcome.
Hemophilia C management in obstetric anesthesia Guadalix-Sanchez, Cristina; Albajar-Bobes, Andrea; Barbero-Mielgo, Macarena ...
Saudi journal of anaesthesia,
2022 Jan-Mar, 2022-00-00, 20220101, 2022-01-01, Letnik:
16, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Coagulation alterations might represent a problem in obstetric anesthesia considering that they may contraindicate neuraxial techniques and worsen a case of uterine atony with more severe bleeding if ...they are not correctly recognized and treated. We report the case of a parturient diagnosed with severe factor XI deficiency during the delivery progress. In this case, non-steroidal anti-inflammatory drugs and neuraxial techniques were avoided and intravenous patient-controlled analgesia with boluses of remifentanil was used for pain management. Treatment with tranexamic acid and fresh frozen plasma was initiated and the absence of urgent factor XI availability was notified. Due to no progression of labor, cesarean section was required and a general anesthesia was performed. During the procedure, uterine atony occurred. Uterine massage and several uterotonic drugs were needed to control it. The patient remained stable and the delivery was accomplished without further incidents. The objective of this report is to present the pain, coagulation and bleeding management of a patient with hemophilia C in our obstetric department and to alert for the need of multidisciplinary work to successfully approach this type of patient.
INTRODUCTION:Spontaneous hepatic rupture has been describe before in association with some conditions but there is only few cases in which a spontaneuos liver rupture during transplantation has been ...reported(1).We present one of these case, requiring total hepatectomy and portocaval shunt, followed by retransplatation. CASE REPORT:A 65 year-old man HVC positive with chronic hepatopathy,was admitted for a liver transplantation.The donor had a history of Chagas disease with normal liver function tests.After completing the caval and portal anastomosis, the liver was revascularized.Within minutes it developed multiple large subcapsular haematomas that spontaneously ruptured leading to an uncontrollable hemorrage.Despite all the efforts to stop the bleeding the liver continue to rupture, forcing the surgeons to perform an hepatectomy of the implanted liver and a portocaval anastomosis.The patient was taken to the ICU and was retransplanted 14 hours later. DISCUSSION:Spontaneous hepatic rupture is rare.The exact aetiology is not well understood(1).Because of this rare condition,no single institution has acumulated enough experience to make recommendations about treatment(2).In an unstable patient with rupture of the liver,operation is neccesary.Sometimes perihepatic packing, segmentectomy or hemihepatectomy are enough.In others the only treatment is total hepatectomy followed by trasplantation.Over the last years, the technique of venovenous bypass is become more selective. However it has been use in most of the cases during the anaepathic phase if the trasplantation was carried out in two phases(3).Our patient was not placed in bypass.The most common complications that could occur with this technique are those related with venous hypertension. REFERENCES: 1.Mistry,B.Spontaneous rupture of the liver upon revascularization during transplantation.Transplantation 2000;69:2214-2218.2.Mascarenhas,R.Spontaneuos hepatic rupture: a report of five cases.HPB 2002;4(4):167-170. 3.Sanabria,R.Total hepatectomy and liver transplantation as a two-stage procedure for fulminant hepatic failure:A safe procedure in exceptional circumstances.World J Hepatol. 2016,8(4):226-230.LEARNING POINT:Selection of a suitable donor is one of the most important factors for a succesful outcome after trasplantation.Eventhough in our case a venovenous bypass was not used,it could be useful in order to decompress the systemic and portal venous systems and,reduce this way, the possible complications
NON-CARDIAC SURGERY IN PATIENTS WITH VENTRICULAR ASSIST DEVICES:OUR EXPERIENCE IN PUERTA DE HIERRO UNIVERSITY HOSPITAL, MADRID. Albajar, A; Gonzu00e1lez, A; u00c1lvarez J.M; Forteza, A; ...Gu00f3mez-Bueno, M; Garcu00eda, J. Anaesthesiology and Reanimation.Puerta de Hierro University Hospital, Madrid; Spain. BACKGROUND: Heart failure constitutes a high incident and prevalent syndrome. Its prevalence in devoloped countries is 10000 cases per million habitants. The calculated risk of developing a heart failure is around 20% in the American population above 40 years old. It affects at 1-2% of the global population and above 75 years old its prevalence raises up to 10-20% (1), representing around 2% of the total health expenditure. It takes around 10% of the hospital beds and the surviving expectations of the patients with an advance disease is less than the surviving expectations of some kinds of cancer. Eventhough the surviving rates are being modified , currently is about 50% to five years from the diagnose date. At present, we can realize the higher use of ventricular assist devices (VAD) for patients with congestive heart failure refractory to medical treatment (divided in four groups: shock after myocardial acute infraction, myocardial disfunction after cardiac surgery, heart failure after myocarditis and chronic descompesated heart failure (2)) and for patients as a bridge to cardiac trasplant due to the low number of appropiate heart donations (3). We present two cases of patients with ventricular assist devices (berlin heart R) undergoing urgent surgery. CASE REPORT: CASE 1: Male, with a left ventricle assist device (Berlin heart) implanted in early december 2009 because of a dilated cardiomyopathy (FEVI 30%; tricuspid and mitral insufficiency and severe pulmonary hypertension). No allergies. No other personal background. Regular medication: alopurinol, dipiridamol 100mg c/8h, acetylsalicylic acid 300mg c/24h., carvedilol, captopril, sildenafil, enoxaparine 80mg c/12. Hospitalized requiring emergency laparotomy for an open appendicectomy and drainage of an appendicular abscess. 3L of ascitis are aspirated during the surgery and a left pleural drainage is placed with a debit of 1L of serohematic pleural liquid. Haemodynamically stable during introperatory not requiring vasoactive support. Not important intraoperatory bleeding, Transfusion of 1 platelet pool. Enoxaparin suspended during hospitalization befote surgery. Fluids: 500mL colloids and 1000mL crystalloidsAfter the surgery is transfer to the ICU intubated. Blood test after admission in ICU: lactate: 1.1; troponin: 0,13; GOT: 26; GGT 122; platelets: 783.000; INR 2,34; APTT: 47,7 sec; Hb: 10,2 g/dL; Htco: 32%; Urea: 60; Creatinine: 0,9. Leucocytes: 24,920. Extubated after 4 hours in ICU (Sat above 97% pO2: 163 pCo2: 37,5 with nasal prongs at 2lpm. Antibiotherapy with Vancomycin and Meropenem is continuated (iniciated before surgery because of febricula and leukocytosis). The day after surgery the patient remains hemodynamically stable and starts oral tolerance without problems, the acetylsalicylic acid (100mg/d), dipiridamol (100mg c/8h) and Infussion of 1000Ui of sodic heparin are initiated. Not active bleeding nor anemization not required transfusion during the postoperatory. Discharge from ICU 3 days after surgery. CASE2: Male, 50 years old with a biventricular assist device (berlin heart) implanted in April 2015 because of a hipertrofic cardiomyopathy in dilated phase (FEVI 25%). Regular medication: Acenocumarol (removed 3 days before surgery), clopidogrel (changed to acetylsalycilic acid 100mg a week before surgery), bisoprolol, furosemide, omeprazol. In July 2015 is hospitalized for an elective laparoscopic cholecystectomy. Tendency to hypotension during the surgery requiring vasoactive support i(norepinephrine in a low dose (0,022 mcg/kg/min) and volumen. Altough the patient was not taking the acenocumarol 3 days before surgery we could observe a coagulopathy with INR of 2 so we proceded to the administration of 1200Ui of prothrombinic complex. Not important intraoperatory bleeding, Not transfussion. Profilactic antibiotherapy with cefazoline 2gr. Intraoperative fluids administration: 2000mL crystalloids. Admission in ICU after surgery: haemodinamically stable and extubated. O2 saturation around 99% pO2: 100 pCo2: 34,1 pH: 7,4 HCO3-: 22 with nasal prongs at 4lpm. Blood test at arriving: Lactate 0,7; platelets:262,000; INR 1,4; APTT:48,60 sec; Hb:7,60 g/dL; Htco:23,70 ; Urea: 46,00 Creatinine: 0,85. Leucocytes: 12,000. Hb of 7,6 after surgery with no acute bleeding, requiring transfusion of red cells during the postoperatory. The day after the surgery, the Infussion of 400Ui/h of sodic heparin is initiated. Good subsequent oral tolerance.Discharge from ICU 24hs after surgery. No signs of infection. Good appearance of the surgical wound. Reinsertion of Sintrom with INR control between 2,5-3,5 48h after surgical procedure. Control of surgical pain with paracetamol and metamizol avoiding other NSAIDs for risk of cardiac descompensation. DISCUSSION: Nowadays, is becoming more common to deal with patients carriying an assist device serving as a brigde to a cardiac transplant as we have seen in these two patients. Eventhough every day we know more about the performance of these devices and its indications (4), there is not a lot of information published about the intraoperatory management of the patients carriers of VAD that require urgent or scheduled surgery . The presence of these sets,added to the usual comorbidities of these patients, enhance the posibillity of intraoperatory and postoperatory complications. Altough we only have the experience with a low number of patients , we can see the importance of understanding several aspects: the safe and proper operation of each device, underlying the importance of the correct placement of the VAD cannulas during the intervention avoiding this way their kincking so the cardiac output is the adecuate for the patient during the whole procedure; In second place, the accurate managment of the medication, including anticoagulants and antiplatelet, for their correct suspension or the correct reversion of their action to prevent a profuse intraoperatory bleeding (1); In addition qe should know the physiological cardiaopulmonary changes due to the implation of VAD knowing thet large volumen infussions during the surgery are necessary due to its dependance of high preload to its correct function. To sum up, we have to be able to determine the correct implementation of antibiotherapy ,profilact or therapeutic, in this patients because of their higher risk of infections. REFERENCES: 1. Kristensen, S; Knutti, J; Saraste A; Anker,S; Botker, H E; DeHert, S; Ford, I; Gonzu00e1les-Juanatey, JR; Gorenek, B; Roberts, G; Hoeft, A; Huber, K; Lung, B; Kjeldsen, K; Longrois, D; Luscher, TF; Pierard, L; Pocock, S; Price, S; Roffi, M; Sirnes, PA; Sousa-Uva, M; Voudris, V; Funck-Brentano, C.. 2014 ESC/ESA guidelines on non cardiac surgery: cardiovascular assessment and Management. European Heart Journal (2014) 35; 2383-2431. 2. Delgado M; Bernabeo, G; Hernu00e1n Delgado, D; Avances en asistencias circulatorias mecu00e1nicas. Division of cardiology and trasplantation. University Health Network. Toronto. Ontario. Canada.3. Gu00f3mez Bueno, M; Segovia Cuber, J; Alonso-Pulpu00f3n Rivera, L. Asistencia mecu00e1nica circulatoria y trasplante cardiaco. Indicaciones y situaciu00f3n en Espau00f1a. Unidad de insuficiencia cardiaca y trasplantre. Servicio cardiologu00eda. Hospital universitario Puerta de Hierro. Madrid. Espau00f1a. 4. Feldman, D; Pamboukinan, SV; Teuteberg JJ, et al. The 2013 International society for heart and lung transplantation guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant 2013; 32: 157.LEARNING POINT: In brief, we should create protocols for the corecct anaesthetic management of patients with VAD. There are not a lot of cases per year in our hospital or others with the same characteristics so it is important to be prepared in advance and study the managment of this patients in other centres. There are not a lot of intraoperatory modifications but we have to understand perfectly the managment of these devices so if a complication shows up we know how to deal with it inmediatly. The two most relevant points during the intraoperatory are the manteinance of a good preload and the correct colocation of the cannulas, in order to avoid their kinking, so we can ensure the correct cardiac flow corresponding to the CMI (coporal mass index) of the patient. We also have to know the antibiotic and the anticoagulation management before and after the surgery and have a close perioperatively monitoring.
Some cCD cases can present nonspecific symptoms, if any, as seen in other intrauterine or perinatal infections (like Toxoplasma gondii, Treponema pallidum, rubella virus, cytomegalovirus, HIV, herpes ...simplex virus, and parvovirus infections). ...detection of T. cruzi congenital infection should rely on easy-to-use and point-of-care diagnostic tools 17. ...more sensitive and automated tests are needed for early detection of very low levels of T. cruzi, particularly when transmission occurs in the last period of pregnancy, close to or even at birth. Thereby, the following factors should be taken into account: the best timing of blood sampling (1 to 3 months after birth rather than at birth, unless in presence of a clinically ill newborn), the number of samples to be taken, the sample collection process (EDTA, guanidine EDTA, filter paper, blood clot), the DNA extraction procedure, the DNA target (satellite DNA and/or kinetoplast DNA), the type of method (standard PCR or real-time PCR, requiring slightly more complex equipment and higher cost), the quality control, and the biological standards 28–34. ...currently, molecular tests can be considered as uptaking tests in order to prevent losing the patient during the follow-up, when parasitological techniques are not available/reliable for logistical/organizational constraints or lack of skilled personnel. First external quality assurance program for bloodstream Real-Time PCR monitoring of treatment response in clinical trials of Chagas disease.
Chagas disease (CD) is a highly prevalent parasitic disease in immigrants from Mexico, as well as all of Central and South America. The total number of infected people is estimated between eight and ...ten million 1, 2, of whom 30%-40% either have, or will, develop cardiopathy, gastrointestinal disease, or both 1. Cardiac involvement is the main cause of death from this infection through arrhythmias and cardiomyopathy. Nifurtimox and benznidazole are the only available medicines with proven efficacy against Trypanosoma cruzi infection in acute, congenital infection and early chronic infection. Until recently the treatment of chronic disease, particularly of adult patients with indeterminate form, was controversial; but during the past decade there has been a trend to offer treatment to adult patients and those with early cardiomyopathy.
Chagas is a complex, multidimensional phenomenon in which political, economic, environmental, biomedical, epidemiological, psychological, and sociocultural factors intersect. Nonetheless, the ...hegemonic conceptualisation has long envisioned Chagas as primarily a biomedical question, while ignoring or downplaying the other dimensions, and this limited view has reinforced the disease's long neglect. Integrating the multiple dimensions of the problem into a coherent approach adapted to field realities and needs represents an immense challenge, but the payoff is more effective and sustainable experiences, with higher social awareness, increased case detection and follow-up, improved adherence to care, and integrated participation of various actors from multiple action levels. Information, Education, and Communication (IEC) initiatives have great potential for impact in the implementation of multidimensional programs of prevention and control successfully customised to the diverse and complex contexts where Chagas disease persists.
Abstract
With the objective of providing an insightful analysis of Chagas disease in the world, the authors share their collective reflections about the current situation of this public health ...problem in: rural environments of Latin America; urban environments of endemic and non-endemic areas everywhere; and, at a global level. A perspective based on the ‘Democracy and Health Promotion’ axis allowed the development of an innovative update about Chagas disease as a model of a complex socio-environmental health problem, with a key set of elements that goes beyond biomedical aspects. The authors created a dialogue between the fundamental elements of the Curitiba Statement on Health Promotion and Equity and crucial aspects of a reflection on the reality of Chagas disease today that at the same time challenges the different actors involved. With that reference, the call to promote a ‘critical analysis of viabilities and opportunities for action, considering the potentialities and barriers imposed by the complexity of social movements in the present context of recedes and the loss of rights’ was emphasized repeatedly. Finally, on the occasion of the recent creation of the Technical Group on Information, Education and Communication to control Chagas disease, WHO Department of Control of Neglected Tropical Diseases, the authors share reflections to propose an inclusive and transformative approach of health promotion—what we hope is a new horizon for people affected, directly and indirectly, by Chagas disease.
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