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.
Abstract
Background
Endotracheal intubation requires optimum position of the head and neck. In obese females, the usual ramped position might not provide adequate intubating conditions. We ...hypothesized that a new position, termed modified-ramped position, during induction of anesthesia would facilitate endotracheal intubation through bringing the breasts away from the laryngoscope and would also improve the laryngeal visualization.
Methods
Sixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position (
n =
30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position (
n =
30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view.
Results
Fourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position (
p <
0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position.
Conclusion
Modified-ramped position provided better intubating conditions, improved the laryngeal view, and eliminated the need for repositioning of obese female patients during insertion of the laryngoscope compared to ramped position.
Clinical trial registration
Identifier:
NCT03640442
. Date: August 2018.
...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.
Weaning of patients from the mechanical ventilation remains one of the critical decisions in intensive care unit. This study aimed to evaluate the accuracy of thoracic fluid content (TFC) as a ...predictor of weaning outcome.
An observational cohort study included 64 critically ill surgical patients who were eligible for extubation. Before initiating the spontaneous breathing trial, the TFC was measured using the electrical cardiometry technology. Patients were followed up after extubation and divided into successful weaning group and failed weaning group. Both groups were compared according to respiratory and cardiovascular parameters. Receiver operating characteristic (ROC) curves were constructed to evaluate the ability of TFC to predict weaning outcome.
The number of successfully weaned patients was 41/64 (64%). Twenty (31%) patients had impaired cardiac contractility, and of them, 13/20 (64%) patients were successfully extubated. Both groups, successful weaning group and failed weaning group, were comparable in most of baseline characteristics; however, the TFC was significantly higher in the failed weaning group compared to the successful weaning group. The area under the ROC curves (AUCs) showed moderate predictive ability for the TFC in predicting weaning failure (AUC 95% confidence interval 0.69 0.57-0.8, cutoff value > 50 kΩ
), while the predictive ability of TFC was excellent in the subgroup of patients with ejection fraction < 40% (AUC 95% confidence interval 0.93 0.72-1, cutoff value > 50 kΩ
).
Thoracic fluid content showed moderate ability for predicting weaning outcome in surgical critically ill patients. However, in the subgroup of patients with ejection fraction less than 40%, TFC above 50 kΩ
has an excellent ability to predict weaning failure.
ABSTRACTPerioperative acute myocardial infarction is a life-threatening event. The aim of preoperative evaluation is identifying at-risk patient of developing postoperative complications and to ...undertake risk reduction measures to prevent such complications. We report a case of male patient with good functional capacity and unknown history cardiovascular disease undergoing radical cystectomy who suffered intra-operative cardiac arrest and ST-segment elevation myocardial ischemia. Postoperative urgent coronary revascularization was done and dual antiplatelets therapy was prescribed. Postoperative course was uneventful with no bleeding complication. Major perioperative cardiac events in noncardiac surgery are still probable despite the current guidelines of preoperative evaluation. Early revascularization and antiplatelet administration were feasible and did not produce critical surgical bleeding.
Background
Studies of the accuracy of different airway tests are lacking in elderly. We evaluated and compared the accuracy of thyromental height in predicting difficult intubation in relation to the ...other traditional airway tests in elderly.
Methods
We included 120 patients aged ≥ 65 years scheduled for general anesthesia with tracheal intubation. Thyromental height, modified Mallampati test, thyromental distance and sternomental distance were evaluated. Cormack–Lehane grade > 2 was considered difficult laryngoscopy. Difficult tracheal intubation was considered if successful intubation required more than 2 attempts. The accuracy of different tests in predicting difficult intubation and difficult laryngoscopy were evaluated through area under receiver operating characteristic (AUROC) curves. Univariate and multivariate analyses were conducted to identify risk factors for difficult intubation and difficult laryngoscopy.
Results
Our cohort had a mean age of 71(7) years. We encountered difficult laryngoscopy in 15/120 (12%) patients, difficult intubation in 20/120 (17%) patients, and failed laryngoscopy requiring alternative methods for securing the airway in 3/120 (3%) patients. For predicting difficult intubation, thyromental height and modified Mallampati test showed the highest accuracy AUROC (95% confidence interval): 0.9 (0.83–0.95), cut-off value ≤ 5.9 cm, and AUROC (95% confidence interval): 0.89 (0.82–0.94), cut-off value > 2, respectively. Low thyromental height and high modified Mallampati test were the only independent risk factors for difficult laryngoscopy and difficult intubation.
Conclusion
In elderly scheduled for elective procedure, both thyromental height and modified Mallampati tests showed good accuracy in predicting difficult intubation and difficult laryngoscopy, whilst thyromental distance and sternomental distance were poor predictors.
Data on the best norepinephrine bolus dose for management of hypotension are limited. The aim of this study was to compare the efficacy and safety of two norepinephrine bolus doses in the rescue ...management of maternal hypotension during cesarean delivery.
This randomized, controlled trial included mothers scheduled for cesarean delivery with spinal anesthesia with a prophylactic norepinephrine infusion. Following spinal anaesthesia administration, a participant was considered hypotensive if systolic blood pressure was ≤80% compared to the baseline reading. Participants were allocated to receive either 6 mcg or 10 mcg norepinephrine bolus for the management of hypotensive episodes. The hemodynamic response after administration of norepinephrine bolus was recorded. The episode was considered successfully managed if systolic blood pressure returned to within 80% from the baseline reading within 2 min after norepinephrine bolus administration, and did not drop again within 6 min after the norepinephrine bolus. The primary outcome was the incidence of successful management of the first hypotensive episode. Other outcomes included systolic blood pressure, heart rate, incidence of maternal bradycardia, and reactive hypertension.
One hundred and ten mothers developed hypotensive episodes and received norepinephrine boluses for management. The number of successfully managed first hypotensive episodes was 50/57 (88%) in the 6 mcg-treated episodes and 45/53 (85%) in the 10 mcg-treated episodes (p = 0.78). Systolic blood pressure was comparable after administration of either bolus dose. Heart rate was lower after administration of 10 mcg bolus compared to 6 mcg bolus, without significant bradycardia requiring atropine administration. The incidence of reactive hypertension was comparable between both groups.
In mothers undergoing elective cesarean delivery under prophylactic norepinephrine infusion at 0.05 mcg/kg/min, there was no advantage to the use of 10 mcg norepinephrine bolus over 6 mcg norepinephrine bolus for the rescue management of first hypotensive episode. Neither of the 2 bolus doses reached a 100% success rate. The incidences of bradycardia and reactive hypertension were comparable between both norepinephrine doses.
At clinicaltrial.gov registry system on January 4, 2019 Clinical trial identifier: NCT03792906.
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