Coagulopathy and traumatic brain injury (TBI) are complexly intertwined. In isolated TBI, coagulopathy may contribute to hemorrhagic lesion development, progression, or recurrence, as it may lead to ...a particular pattern of coagulopathy called TBI-induced coagulopathy (TBI-IC). We performed a retrospective and descriptive evaluation of 63 patients admitted to the Emergency Clinical Hospital Bucharest with the diagnosis of moderate/severe brain injury. In addition to demographic data, all included patients had a complete paraclinical evaluation that included rotational thromboelastometric (ROTEM) blood-clot analysis. The platelet component (PLTEM) and the endotheliopathy activation and stress index score (EASIX) were calculated. These parameters were presented comparatively according to survival at 30 days and helped define the two study groups: survivors and non-survivors at 30 days. The contribution of platelets to clot strength is derived from maximum clot elasticity (MCE) and maximum clot firmness (MCF). MCE is defined as (MCF × 100)/(100 − MCF), and PLTEM is defined as EXTEM MCE—FIBTEM MCE. EASIX is a novel biomarker recently studied in TBI patients, calculated according to the following formula: lactate dehydrogenase (U/L) × creatinine (mg/dL)/platelets (109 cells/L). Regarding the demographic data, there were no significant differences between the survivors and non-survivors. All ROTEM parameters related to clot amplitude (A5, A10, A20, MCF in EXTEM and FIBTEM channels) were higher in the group of patients who survived. Also, PLTEM was decreased in the group of deceased patients (89.71 ± 22.86 vs. 132.3 ± 16.56 p < 0.0001). The cut-off point determined with the ROC curve is 114.10, with a sensitivity of 94.74% and a specificity of 93.18%, for the detection of the negative prognosis (death at 30 days). The EASIX score was significantly higher in the patients who survived the traumatic event, with a median difference value of 1.15 (p < 0.0001). The ROC analysis of this biomarker highlights a cut-off point of 2.12, with a sensitivity of 88.64% and a specificity of 94.74% (AUC = 0.95, p < 0.0001), for the prediction of mortality. The comparative analysis of the two studied markers was performed using the Cox proportional hazard ratio and highlighted the greater influence that PLTEM has on survival time (b value = −0.05, p < 0.0001) compared to EASIX (b value = 0.49, p = 0.0026). The present retrospective study indicates the potential of the TBI-IC reflecting parameters PLTEM and EASIX as markers of mortality prognosis. Larger prospective studies are needed to confirm their combined prognostic value and use in decision-making and reduction in the burden of disease by adequate allocation of resources in a personalized and timely manner.
Trace elements are essential for several physiological processes. To date, various data have suggested that inadequate levels of trace elements may be involved in the pathogenesis of different ...chronic diseases, including immune-mediated ones, or may develop during their course. Systemic sclerosis (SSc) is a complex autoimmune multisystemic disease, primarily characterized by microvascular dysregulation, the widespread activation of the immune system and tissue fibrosis. According to the latest reports regarding the pathogenesis of SSc, the main pathophysiological processes—inflammation, vasculopathy and fibrosis—may include various trace element derangements. The present literature review aims to update the available data regarding iron, zinc, copper and selenium status in SSc as well as to underline the possible implications of these trace elements in the complexity of the pathogenic process of the disease. We observe that the status of trace elements in SSc plays a crucial role in numerous pathogenic processes, emphasizing the necessity for proper monitoring and supplementation. The reported data are heterogenous and scarce, and future studies are needed in order to draw clearer conclusions about their complete spectrum.
: The management of acute postoperative pain (APP) following major abdominal surgery implies various analgetic strategies. Opioids lie at the core of every analgesia protocol, despite their side ...effect profile. To limit patients' exposure to opioids, considerable effort has been made to define new opioid-sparing anesthesia techniques relying on multimodal analgesia. Our study aims to investigate the role of adjuvant multimodal analgesic agents, such as ketamine, lidocaine, and epidural analgesia in perioperative pain control, the incidence of postoperative cognitive dysfunction (POCD), and the incidence of postoperative nausea and vomiting (PONV) after major abdominal surgery.
: This is a clinical, observational, randomized, monocentric study, in which 80 patients were enrolled and divided into three groups: Standard group, C (
= 32), where patients received perioperative opioids combined with a fixed regimen of metamizole/acetaminophen for pain control; co-analgetic group, Co-A (
= 26), where, in addition to standard therapy, patients received perioperative systemic ketamine and lidocaine; and the epidural group, EA (
= 22), which included patients that received standard perioperative analgetic therapy combined with epidural analgesia. We considered the primary outcome, the postoperative pain intensity, assessed by the visual analogue scale (VAS) at 1 h, 6 h, and 12 h postoperatively. The secondary outcomes were the total intraoperative fentanyl dose, total postoperative morphine dose, maximal intraoperative sevoflurane concentration, confusion assessment method for intensive care units score (CAM-ICU) at 1 h, 6 h, and 12 h postoperatively, and the postoperative dose of ondansetron as a marker for postoperative nausea and vomiting (PONV) severity.
: We observed a significant decrease in VAS score, as the primary outcome, for both multimodal analgesic regimens, as compared to the control. Moreover, the intraoperative fentanyl and postoperative morphine doses were, consequently, reduced. The maximal sevoflurane concentration and POCD were reduced by EA. No differences were observed between groups concerning PONV severity.
: Multimodal analgesia concepts should be individualized based on the patient's needs and consent. Efforts should be made to develop strategies that can aid in the reduction of opioid use in a perioperative setting and improve the standard of care.
Ankylosing spondylitis is one of the top global health burdens and patients affected by it frequently require surgery related to disease progression, such as orthopedic surgery. These patients may ...prove difficult to manage from an anesthetic standpoint, regardless of the anesthetic technique employed, mainly given the potential for difficult airway access and related comorbidities. We present the case of a 52-year-old male posted for urgent cemented total hip arthroplasty with associated bilateral pulmonary fibrosis and an anticipated difficult airway in whom regional anesthesia was performed with satisfactory results, with a favorable intraoperative and postoperative course. The literature review explores the anesthetic techniques employed when a tailored approach is required in managing patients with ankylosing spondylitis.
Background/Objectives: The complexity of trauma-induced coagulopathy (TIC) is a result of the unique interactions between the patient, trauma, and resuscitation-related causes. The main objective of ...trauma resuscitation is to create the optimal milieu for both the development of immediate reparatory mechanisms and the prevention of further secondary injuries. Endotheliopathy represents one of the hallmarks of trauma-induced coagulopathy, and comprises endothelial dysfunction, abnormal coagulation, and inflammation, all of which arise after severe trauma and hemorrhagic shock. Methods: We retrospectively and descriptively evaluated 217 patients admitted to the Bucharest Clinical Emergency Hospital who met the Berlin criteria for the diagnosis of multiple trauma. Patients with high suspicion of auto-heparinization were identified according to the dynamic clinical and para-clinical evolution and subsequently tested using rotational thromboelastometry (ROTEM). The ratio between the clot formation time (CT) was used, obtained on the two channels of interest (INTEM/HEPTEM). Results: Among the 217 patients with a mean age of 43.43 ± 15.45 years and a mean injury severity score (ISS) of 36.98 ± 1.875, 42 patients had a reasonable clinical and para-clinical suspicion of auto-heparinization, which was later confirmed by the INTEM/HEPTEM clotting time ratio in 28 cases (12.9% from the entire study population). A multiple linear regression analysis highlighted that serum lactate (estimated 0.02, p = 0.0098) and noradrenaline requirement (estimated 0.03, p = 0.0053) influenced the CT (INTEM/HEPTEM) ratio. Conclusions: There is a subset of multiple trauma patients in which the CT (INTEM/HEPTEM) ratio was influenced only by serum lactate levels and patients’ need for vasopressor use, reinforcing the relationship between shock, hypoperfusion, and clotting derangements. This emphasizes the unique response that each patient has to trauma.
Endotracheal tube (ETT) is an important risk factor for the development of Ventilator-associated pneumonia (VAP), as it acts as a reservoir for infectious microorganisms and bypasses the host’s ...defenses. One of the preventive measures for VAP is endotracheal tube composition. It has been reported that biofilm formation is reduced by using ETTs coated with pure silver or silver compounds. However, noble metal-alloy ETTs have not been adequately studied.
To evaluate the efficacy of noble metal alloy ETT (coated Bactiguard Infection Protection ETTs) in preventing VAP compared to standard non-coated ETTs in patients requiring ≥ 48 hours of mechanical ventilation and presenting for coma due to drug intoxication.
Randomized controlled study.
Participants were randomized using sealed envelopes with a concealed 1:1 allocation to either the intervention group or the control group. The intervention group used a noble metal–alloy ETT, while the control group received standard ETT. The primary outcomes were the incidence of VAP (per ventilated patients) and the duration of mechanical ventilation.
Initially, a total of 188 patients were assessed for eligibility, and the final allocation group consisted of 180 patients, who were subsequently randomized into the intervention group (n = 97) and control group (n = 83). The incidence of VAP in the intervention and control groups was 27.83% and 43.16% (
= 0.03), and the VAP ratio per 1000 ventilation days was 51.26/1000 and 83.38/1000 (
= 0.01), respectively. The mean durations of mechanical ventilation were 3.2 ± 0.78 in the intervention group and 5.03 ± 1.88 in the control group (
= 0.22). There was no statistically significant difference between groups in terms of mortality and duration of hospital stay.
Noble metal-alloy ETT reduces the incidence of VAP, ventilation days, and ICU stay for patients in mechanical ventilation.
Systemic sclerosis is a chronic autoimmune disorder characterized by multiorgan involvement, most notably of the skin through fibrosis and vasculopathy. One of its most feared complications requiring ...rapid intervention is scleroderma renal crisis, as it can be fatal in the absence of prompt treatment. A 34-year old woman presents with a history of acute renal failure and malignant hypertension occurring one month postpartum and no other scleroderma feature in the following 5 years. Eventually, skin, heart and lung involvement is observed, positive anti-ARN III polymerase antibodies and suggestive capillaroscopic findings. Immunosuppressive therapy with mycophenolate mofetil is initiated and later switched to off-label Rituximab, with significant improvement of disease manifestations. Regular patient monitoring for novel symptom occurrence and appropriate treatment adjustment is essential for optimal management of scleroderma.
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