Non-protocolized fluid administration in critically ill patients, especially those with acute respiratory distress syndrome (ARDS), is associated with poor outcomes. Therefore, fluid administration ...in patients with Coronavirus disease (COVID-19) should be properly guided. Choice of an index to guide fluid management during a pandemic with mass patient admissions carries an additional challenge due to the relatively limited resources. An ideal test for assessment of fluid responsiveness during this pandemic should be accurate in ARDS patients, economic, easy to interpret by junior staff, valid in patients in the prone position and performed with minimal contact with the patient to avoid spread of infection. Patients with COVID-19 ARDS are divided into two phenotypes (L phenotype and H phenotype) according to their lung compliance. Selection of the proper index for fluid responsiveness varies according to the patient phenotype. Heart–lung interaction methods can be used only in patients with L phenotype ARDS. Real-time measures, such a pulse pressure variation, are more appropriate for use during this pandemic compared to ultrasound-derived measures, because contamination of the ultrasound machine can spread infection. Preload challenge tests are suitable for use in all COVID-19 patients. Passive leg raising test is relatively better than mini-fluid challenge test, because it can be repeated without overloading the patient with fluids. Trendelenburg maneuver is a suitable alternative to the passive leg raising test in patients with prone position. If a cardiac output monitor was not available, the response to the passive leg raising test could be traced by measurement of the pulse pressure or the perfusion index. Preload modifying maneuvers, such as tidal volume challenge, can also be used in COVID-19 patients, especially if the patient was in the gray zone of other dynamic tests. However, the preload modifying maneuvers were not extensively evaluated outside the operating room. Selection of the proper test would vary according to the level of healthcare in the country and the load of admissions which might be overwhelming. Evaluation of the volume status should be comprehensive; therefore, the presence of signs of volume overload such as lower limb edema, lung edema, and severe hypoxemia should be considered beside the usual indices for fluid responsiveness.
Tocilizumab (TCZ) is a recombinant anti-interleukin-6 monoclonal antibody which showed uprising evidence as an anti-inflammatory agent which modulates the cytokine storm in patients with COVID-19. ...However, proper use of the drug requires selection of the appropriate patient and timing. The two main factors which might improve patient selection are the degree of respiratory failure and systemic inflammation. TCZ can decrease the mortality and progression to invasive mechanical ventilation in patients with severe COVID-19 who are not yet invasively ventilated. However, its use in invasively ventilated patients did not yet gain the same level of evidence especially when administered after > 1 day from mechanical ventilation. Being an anti-inflammatory and immunomodulatory drug, TCZ was mostly used in patients with COVID-19 who have clear signs of cytokine storm. However, the drug still showed positive response in some studies which did not strictly select patients with elevated markers of systemic inflammation. Thus, it is warranted to investigate and/or re-analyze the role of the drug in patients with severe COVID-19 and with no signs of systemic inflammation. TCZ is used in a dose of 8 mg/kg which can be repeated if there was no clinical improvement. However, there are no clear criteria for judgment of the success of the first dose. Being a drug with a major effect on gross outcomes in a serious pandemic with millions of mortalities, TCZ should be meticulously investigated to reach definitive indications and number of doses to avoid drug overuse, shortage, and side effects.
According to the ARISCAT score, the site of surgery represents the most important determinant of PPCs. Longer duration of surgery is another determinant of PPCs 3. ...almost 21% of the participants ...in the meta-analysis are not considered high-risk patients for developing PPCs. Surprisingly, the results showed significant reduction in the incidence and severity of atelectasis despite the limited number of patients. ...the benefits of low FiO2 could have been more prominent if these outcomes were reported in all patients and might be of greater relevance in high-risk patients and/or high-risk surgery.
...comparison of the two groups might be unfair and should preferably had included multi-variate regression analysis. ...in the GDFT group, the authors stated that they initiated their algorithm ...whenever the cardiac index was less than the target value; however, it is not clear whether they provided any intervention if the mean arterial pressure decreased or not. ...the authors did not mention any details for the hemodynamic management of the patients in the control group.
Background
The hemodynamic effects of relatively low-dose epinephrine and phenylephrine infusions during cesarean delivery under spinal anesthesia were compared.
Methods
This randomized controlled ...trial included full-term pregnant women who underwent elective cesarean delivery. After spinal anesthesia, participants received either epinephrine (0.03 mcg/kg/min) or phenylephrine (0.4 mcg/kg/min) infusion that continued until 5 min after delivery. The primary outcome was a composite outcome of the occurrence of any of hypotension, hypertension, bradycardia, and/or tachycardia. Neonatal outcomes, including umbilical artery blood gas and Apgar scores, were assessed.
Results
In total, 98 patients in each group were analyzed, and the number of patients with the composite outcome was comparable between the epinephrine and phenylephrine groups (30/98 31% vs. 31/98 32%, respectively;
P
= 0.877). However, the incidence of hypotension was likely lower in the epinephrine group than in the phenylephrine group (
P
= 0.066), and the number of hypotensive episodes per patient was lower in the epinephrine group than in the phenylephrine group. On the other hand, the incidence of tachycardia was higher in the epinephrine group than that in the phenylephrine group. The incidence of hypertension was comparable between the two groups and none of the participants developed bradycardia. Neonatal outcomes were comparable between the two groups.
Conclusions
Epinephrine and phenylephrine infusion produced comparable maternal hemodynamics and neonatal outcomes. Epinephrine was associated with a higher incidence of maternal tachycardia and likely lower incidence of maternal hypotension than phenylephrine.
IRB number:
MD-245–2022.
Clinical trial registration:
This study was registered on May 31, 2023 at clinicaltrials.gov registry, NCT05881915, URL:
https://classic.clinicaltrials.gov/ct2/show/NCT05881915term=NCT05881915&draw=2&rank=1
PDF
