Hasil untuk "Anesthesiology"

Andrea Carsetti, Riccardo Antolini, Roberta Domizi et al.

Abstract Background The Venous Excess Ultrasound (VExUS) score integrates inferior vena cava diameter and venous Doppler findings to quantify congestion. Findings are conflicting regarding whether higher VExUS grades reflect worse cardiac function. We conducted a systematic review and meta-analysis to evaluate echocardiographic changes across different VExUS grades and their clinical significance. Methods The systematic review and meta-analysis were performed in accordance with the PRISMA guidelines, including hospitalized patients assessed with the VExUS score and echocardiography. The primary outcome was the association between high VExUS (grades 2–3) and TAPSE. Secondary outcomes explored the association between VExUS and other echocardiographic parameters in different subpopulations. Eligible studies were randomized or observational. The risk of bias was assessed using the ROBINS-I tool. Results Eight studies were included in the primary outcome analysis. Patients with high VExUS scores had significantly lower TAPSE values compared to those with low scores, with a pooled mean difference of −2.35 mm (95% CI −3.27 to −1.42; p < 0.00001). Moderate heterogeneity was observed (I2 = 61%), but the overall effect remained robust. Secondary outcomes showed consistent associations between high VExUS scores and reduced cardiac output, stroke volume, RV S′, and LVOT VTI. However, in a sensitivity analysis excluding studies enrolling patients with heart failure, no significant association was observed between higher VExUS scores and right ventricular dysfunction. Moreover, the pooled mean values of right heart parameters (TAPSE, S′, and RV FAC) in patients with VExUS 2–3 remained within normal physiological ranges, suggesting preserved right ventricular function despite venous congestion. Conclusion This systematic review and meta-analysis demonstrate that patients with venous congestion, as assessed by the VExUS score, may exhibit lower values of echocardiographic parameters of right ventricular function. This association is observed particularly in the subgroup of patients with known cardiac dysfunction and is not present in patients without heart failure. These findings suggest that the VExUS score should be primarily interpreted as a marker of established systemic venous congestion, rather than as an indicator of intrinsic right ventricular systolic impairment.

Metin Kilinc, Enes Çelik, Ibrahim Demir et al.

<i>Background and Objectives</i>: Postoperative femur fracture in elderly patients is associated with high morbidity and mortality, especially in the intensive care unit (ICU). Various factors, including demographic and laboratory parameters, may influence mortality in this population. The aim of this study was to evaluate the association of inflammatory and metabolic markers with mortality in ICU patients with postoperative femur fractures and to identify key predictors to enhance risk stratification and improve patient outcomes. <i>Materials and Methods</i>: In this retrospective single-center study, we analyzed 121 patients aged over 65 years with postoperative femur fractures who were admitted to the ICU between January 2023 and January 2024. Demographic and clinical data, including comorbidities, Charlson Comorbidity Index (CCI), and Acute Physiology and Chronic Health Evaluation (APACHE II) score, were collected. Laboratory parameters such as white blood cell count (WBC), albumin, C-reactive protein (CRP), D-dimer, Pan-Immune-Inflammation Value (PIV), CRP-to-albumin ratio (CAR), neutrophil-to-lymphocyte ratio (NLR), and others were analyzed. Linear regression, logistic regression, and Receiver Operating Characteristic (ROC) analyses were performed to determine the predictive value of these markers for ICU mortality. <i>Results</i>: The mean age of the patients was 76.3 ± 9.6 years, and 52.1% were female. The most common comorbidities were hypertension (67.8%) and diabetes (49.6%). ICU mortality occurred in 24 patients (20%). Significant predictors of mortality included higher CRP (>62.8 mg/L), NLR (>10.0), PIV (>450), and APACHE II scores (>23) (<i>p</i> < 0.001 for all). Lower albumin levels (<2.5 g/dL) were strongly associated with increased mortality (<i>p</i> < 0.001). ROC analysis demonstrated that the APACHE II score had the highest predictive accuracy for mortality (AUC = 0.83), followed by albumin (AUC = 0.79) and PIV (AUC = 0.76). Extended ICU stay (>10 days) was also significantly correlated with increased mortality (<i>p</i> < 0.001). <i>Conclusions</i>: This study successfully demonstrates the utility of combining traditional clinical markers, such as APACHE II score, with novel inflammatory markers, such as PIV, CAR, and NLR, in predicting mortality in ICU patients following femur fracture surgery. The integration of emerging biomarkers with well-established scoring systems offers enhanced predictive accuracy and provides valuable insights into patient management.

Yang H, Yang Y, Huang Y et al.

Huan Yang, Yan Yang, Yihao Huang, Tao Liu, Yiheng Wang Department of Anesthesiology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, People’s Republic of ChinaCorrespondence: Yiheng Wang, Department of Anesthesiology, The First Affiliated Hospital, Hengyang Medical School, University of South China, 69 Chuanshan Road, Shigu District, Hengyang, Hunan, 421001, People’s Republic of China, Tel +867348578511, Email wyheng11@163.comPurpose: The 2,6-disubstituted alkylphenol ciprofol is a novel propofol analog for induction and maintenance of anesthesia. We aimed to compare the effects of ciprofol-based and propofol-based total intravenous anesthesia (TIVA) on postoperative recovery quality following hysteroscopic surgery.Patients and Methods: In this randomized non-inferiority trial, women scheduled for hysteroscopic surgery at a tertiary hospital were randomly assigned to the ciprofol or propofol groups. The patients were administered intravenous injections of ciprofol (0.4 mg/kg) or propofol (2.0 mg/kg) for anesthesia induction before a maintenance infusion at initial rates of 0.8 or 5.0 mg/kg/h, respectively. The primary outcome was the Quality of Recovery-15 scale (QoR-15) score at 24 h post-surgery, and a non-inferiority margin of − 8 was assumed. The secondary outcomes included hemodynamic changes, time to consciousness loss and recovery, incidences of injection pain, body movement, intraoperative respiratory adverse events, and postoperative adverse events.Results: The trial included 120 participants (60 per group). The total QoR-15 score 24 h after surgery in the ciprofol group was comparable to that in the propofol group (median [interquartile range]: 113.5 [111.0, 117.0] vs 112.5 [108.0, 117.0]; median difference [95% confidence interval]: − 1.0 [− 3.0, 2.0]). There were no significant differences in the five QoR-15 dimensions between the groups. The mean arterial pressure and heart rate during anesthesia induction and surgery were significantly higher in the ciprofol group than in the propofol group, whereas the incidence of injection pain was lower. In addition, there were no significant between-group differences in the time to loss of consciousness or awakening, incidences of intraoperative hypoxemia or laryngospasm, or incidences of postoperative nausea, vomiting, headache, dizziness, and drowsiness.Conclusion: Ciprofol is not inferior to propofol in terms of QoR score. Ciprofol administration is suitable for general anesthesia in female patients during hysteroscopic surgery.Keywords: ciprofol, propofol, postoperative recovery quality, hysteroscopic surgery

Karnati Sravani, Balaji Vaithialingam, Dheeraj Masapu et al.

Veronica Simamora, Rr. Sinta Irina, Andriamuri Primaputra Lubis

Pengukuran regional oxygen saturation (rSO2) menggunakan near- infrared spectroscopy (NIRS) berkorelasi dengan saturasi vena sentral. Oksigen serebral sangat dipengaruhi oleh autoregulasi serebri yang dapat mengatur aliran darah ke otak sehingga menyebabkan oksigen dapat bertambah maupun berkurang. Penelitian ini bertujuan melihat perbandingan nilai rSO2 pre dengan pascabedah kraniotomi tumor removal di RSUP Haji Adam Malik Medan. Penelitian ini merupakan jenis penelitian cohort prospective. Penelitian ini dilakukan pada 12 pasien yang menjalani prosedur pembedahan kraniotomi tumor removal selama 14 April–19 Mei 2023 Sampel dipilih menggunakan metode consecutive sampling. Analisis data menggunakan uji t berpasangan. Sebanyak 12 pasien diteliti rSO2 sebelum operasi kraniotomi didapatkan rerata sebesar 64,50±2,98 pada kanan dan kiri didapatkan rerata sebesar 62,58±3,17. Pada rSO2 setelah operasi kraniotomi didapatkan rerata sebesar 71,58±2,31 pada kanan dan kiri didapatkan rerata sebesar 70,25±3,52. Pada rSO2 kanan rerata sebesar 64,50±1,90 dan rSO2 kanan sesudah penelitian ini didapatkan rerata sebesar 71,58±1,71 dengan nilai p<0,05 secara statistik terdapat perbedaan bermakna antara rSO2 kanan sebelum dan sesudah operasi. Simpulan, terdapat perbedaan antara rSO2 sebelum dan sesudah pembedahan kraniotomi tumor removal di RSUP Haji Adam Malik, Medan.

Xu Xiaofeng, Zhan Linsen, Lu Huarong et al.

Background/Aim. Since finding a safe and efficient strategy of multimodal postoperative analgesia and sedation is particularly critical, it is important that dexmedetomidine (DM) combined with opioid anesthetics can enhance that through a synergistic action. The aim of the study was to assess the effect of butorphanol tartrate (BT) combined with DM on postoperative analgesia. Methods. A total of 100 elderly patients undergoing general anesthesia surgery from January 2019 to June 2022 were selected. The patients were divided into two equal groups – research group (RG) and control group (CG), using the random number table method. All patients were given postoperative patient-controlled intravenous analgesia (PCIA) plus background infusion. CG patients were given 10 mg of BT, and RG patients were given 10 mg of BT and 300 μg of DM. The analgesics were diluted in 100 mL of 0.9% normal saline. The doses of rescue analgesic tramadol within 48 hrs after surgery, the number of PCIA boluses 48 hrs after surgery, and postoperative hospitalization time were recorded. The Visual Analog Scale (VAS) score, Ramsay sedation score (RSS), inflammatory and stress responses [interleukin (IL)-6, interferon (IFN)-γ, and angiotensin II (Ang-II)], and anesthesia-related adverse reactions (ARAR) were compared at different time points. Results. The dose of tramadol within 48 hrs after surgery, the number of PCIA boluses 48 hrs after surgery, and the postoperative hospitalization time of RG were lower than those of CG (p < 0.05). VAS scores at rest and during activity and serum IL-6, IFN-γ, and Ang-II levels of both groups increased at 4 and 12 hrs after surgery, then decreased at 24 hrs after surgery. The above indicators of RG were lower than those of CG at each time point (p < 0.05). The RSSs of the two groups increased at 4, 12, and 24 hrs after surgery, then dropped at 48 hrs after surgery. The scores of RG were lower than those of CG at each time point (p < 0.05). The incidence rates of ARAR had no significant difference between RG and CG (p > 0.05). Conclusion. BT combined with DM is effective for analgesia and sedation after general anesthesia surgery in elderly patients, which can reduce inflammatory and stress responses without increasing ARAR.

Shan Meng, Hui Cao, Yichen Huang et al.

Abstract Background Traumatic brain injury (TBI) is a significant worldwide public health concern that necessitates attention. Apoptosis signal-regulating kinase 1 (ASK1), a key player in various central nervous system (CNS) diseases, has garnered interest for its potential neuroprotective effects against ischemic stroke and epilepsy when deleted. Nonetheless, the specific impact of ASK1 on TBI and its underlying mechanisms remain elusive. Notably, mutation of ATP-binding sites, such as lysine residues, can lead to catalytic inactivation of ASK1. To address these knowledge gaps, we generated transgenic mice harboring a site-specific mutant ASK1 Map3k5-e (K716R), enabling us to assess its effects and elucidate potential underlying mechanisms following TBI. Methods We employed the CRIPR/Cas9 system to generate a transgenic mouse model carrying the ASK1-K716R mutation, aming to investigate the functional implications of this specific mutant. The controlled cortical impact method was utilized to induce TBI. Expression and distribution of ASK1 were detected through Western blotting and immunofluorescence staining, respectively. The ASK1 kinase activity after TBI was detected by a specific ASK1 kinase activity kit. Cerebral microvessels were isolated by gradient centrifugation using dextran. Immunofluorescence staining was performed to evaluate blood–brain barrier (BBB) damage. BBB ultrastructure was visualized using transmission electron microscopy, while the expression levels of endothelial tight junction proteins and ASK1 signaling pathway proteins was detected by Western blotting. To investigate TBI-induced neuroinflammation, we conducted immunofluorescence staining, quantitative real-time polymerase chain reaction (qRT-PCR) and flow cytometry analyses. Additionally, immunofluorescence staining and electrophysiological compound action potentials were conducted to evaluate gray and white matter injury. Finally, sensorimotor function and cognitive function were assessed by a battery of behavioral tests. Results The activity of ASK1-K716R was significantly decreased following TBI. Western blotting confirmed that ASK1-K716R effectively inhibited the phosphorylation of ASK1, JNKs, and p38 in response to TBI. Additionally, ASK1-K716R demonstrated a protective function in maintaining BBB integrity by suppressing ASK1/JNKs activity in endothelial cells, thereby reducing the degradation of tight junction proteins following TBI. Besides, ASK1-K716R effectively suppressed the infiltration of peripheral immune cells into the brain parenchyma, decreased the number of proinflammatory-like microglia/macrophages, increased the number of anti-inflammatory-like microglia/macrophages, and downregulated expression of several proinflammatory factors. Furthermore, ASK1-K716R attenuated white matter injury and improved the nerve conduction function of both myelinated and unmyelinated fibers after TBI. Finally, our findings demonstrated that ASK1-K716R exhibited favorable long-term functional and histological outcomes in the aftermath of TBI. Conclusion ASK1-K716R preserves BBB integrity by inhibiting ASK1/JNKs pathway in endothelial cells, consequently reducing the degradation of tight junction proteins. Additionally, it alleviates early neuroinflammation by inhibiting the infiltration of peripheral immune cells into the brain parenchyma and modulating the polarization of microglia/macrophages. These beneficial effects of ASK1-K716R subsequently result in a reduction in white matter injury and promote the long-term recovery of neurological function following TBI.

Denise Battaglini, Denise Battaglini, Lavienraj Premraj et al.

IntroductionNeurological manifestations and complications in coronavirus disease-2019 (COVID-19) patients are frequent. Prior studies suggested a possible association between neurological complications and fatal outcome, as well as the existence of potential modifiable risk factors associated to their occurrence. Therefore, more information is needed regarding the incidence and type of neurological complications, risk factors, and associated outcomes in COVID-19.MethodsThis is a pre-planned secondary analysis of the international multicenter observational study of the COVID-19 Critical Care Consortium (which collected data both retrospectively and prospectively from the beginning of COVID-19 pandemic) with the aim to describe neurological complications in critically ill COVID-19 patients and to assess the associated risk factors, and outcomes. Adult patients with confirmed COVID-19, admitted to Intensive Care Unit (ICU) will be considered for this analysis. Data collected in the COVID-19 Critical Care Consortium study includes patients' pre-admission characteristics, comorbidities, severity status, and type and severity of neurological complications. In-hospital mortality and neurological outcome were collected at discharge from ICU, and at 28-days.Ethics and DisseminationThe COVID-19 Critical Care Consortium main study and its amendments have been approved by the Regional Ethics Committee of participating sites. No further approval is required for this secondary analysis.Trial Registration NumberACTRN12620000421932.

Yves Collin, Tina Hu, André Denault et al.

Background Cerebral oximetry using near-infrared spectroscopy (NIRS) is used for monitoring cerebral oxygen saturation during cardiac surgery and is correlated with clinical outcomes. Our goal was to explore cerebral and somatic NIRS in liver resections as a predictor of post-operative complications. Methods Prospective observational and non-interventional study from a tertiary care university hospital including adult patients undergoing liver resection monitored using NIRS at four sites before and during surgery. Those sites were: frontotemporal left and right zones, right thigh, and right arm. Anesthesiologists and surgeons were blinded to oximetry values. Correlations were assessed between baseline oximetry values and cerebro-somatic desaturation load (threshold of 80% from baseline) values with peri-operative events and complications. Results Ninety patients were distributed equally among gender with a mean age of 59.7 ± 13.1 years. Lower baseline cerebral and/or somatic values were associated with increased risk of delirium, respiratory failure, surgical and renal complications, blood transfusions, and length of stay in the intensive care unit and in the hospital (P < 0.05). The severity of somatic desaturation below 80% was the only parameter associated with blood losses (P = 0.030) and length of hospital stay (P = 0.047). Conclusions Cerebral and somatic desaturation does occur in liver resection and can be used simultaneously during liver surgery. Both baseline cerebral and somatic NIRS values are correlated with complications and outcomes. However, thigh desaturation appears more sensitive than cerebral NIRS values in predicting some of these complications.

Evelien E. Quint, BSc, Donika Zogaj, BSc, Louise B.D. Banning, BSc et al.

Background. Frailty is a multidimensional condition and is the result of the body’s age-associated decline in physical, cognitive, physiological, and immune reserves. The aim of this systematic review is to assess the quality of evidence of the included studies, determine the prevalence of frailty among kidney transplant candidates, and evaluate the relationship between frailty and associated patient characteristics and outcomes after kidney transplantation. Methods. A systematic search was performed for relevant literature on frailty and kidney transplantation. This was followed by a meta-analysis for patient characteristics and outcomes reported by a minimum of 2 studies including mean age, gender, mean body mass index, type of kidney transplantation, dialysis, previous kidney transplantation, comorbidities, hypertension, race, preemptive kidney transplantation, delayed graft function, and length of stay. Results. A total of 18 studies were included in the systematic review and 14 of those studies were suitable for meta-analysis. The overall pooled prevalence of frailty before transplantation was estimated at 17.1% (95% confidence interval [CI], 15.4-18.7). Frailty was significantly associated with higher age (mean difference, 3.6; 95% CI, 1.4-5.9), lower rate of preemptive transplantation (relative risk, 0.60; 95% CI, 0.4-0.9), longer duration of delayed graft function (relative risk, 1.80; 95% CI, 1.1-3.0), and length of stay longer than 2 wk (odds ratio, 1.64; 95% CI, 1.2-2.3). Conclusions. One in 6 kidney transplant recipients is frail before transplantation. The presence of frailty is associated with lower rates of preemptive transplantation, older recipient age, higher rates of delayed graft function, and longer length of stay. Future research is required to explore the association of frailty with other adverse outcomes after kidney transplantation and the effects of intervention programs to improve the different frailty domains.

Zhang Y, Sun H, Li W et al.

Yongfu Zhang,1,&ast; Hengwen Sun,2,&ast; Wengao Li,3 Xian Luo,4 Ting Liu,4 Fan Fang,5 Julan Xiao,5 Samradhvi Garg,6 Yuan Yang,4 Yu Chen5 1Department of Anesthesiology, Guangzhou Women and Children’s Medical Centre, Guangzhou, Guangdong, People’s Republic of China; 2Department of Radiotherapy, Cancer Center, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Guangzhou, Guangdong, People’s Republic of China; 3Department of Psychiatry, 999 Brain Hospital, Guangzhou, Guangdong, People’s Republic of China; 4Department of Psychiatry, Southern Medical University Nanfang Hospital, Guangzhou, Guangdong, People’s Republic of China; 5School of Nursing, Southern Medical University, Guangzhou, Guangdong, People’s Republic of China; 6School of Health in Social Science, University of Edinburgh, Edinburgh, Scotland, UK&ast;These authors contributed equally to this workCorrespondence: Yu Chen Email truelife2010@126.comYuan Yang Email yangyuan_yangyuan@163.comBackground: Depression is a commonly seen mental health concern for mothers and fathers during their transition to parenthood. This study aims to provide new insights into the prevalence of maternal and paternal depression, its demographic and clinical correlates, and its symptom network among Chinese pregnant women and their partners.Methods: In this multicenter, cross-sectional study, 769 pregnant women and their partners were assessed by Edinburgh Postnatal Depression Scale (EPDS) from June 15th to Sep 15th, 2020 in southern China. Convenient sampling method was used. Univariate analyses, multivariate logistic regression, and network analyses were conducted. Networks of maternal and paternal depression were compared.Results: In total, 60 (EPDS total score ≥ 13, 7.80%, 95% CI: 5.90– 9.70%) women and 23 (2.99%, 95% CI: 1.78– 4.20%) of these women’s partners reported depression. Physical comorbidities (OR=2.664, P=0.003) was the only factor that was found to significantly correlate with maternal depression. Network analyses showed that the resulting networks were well connected and that there was significant difference of network structure between maternal and paternal depression (M=0.330, P< 0.001). Centrality plot indicated that “sad or miserable” (strength=1.097) was the most central symptom in the maternal depression network, while “scared or panicky” (strength=1.091) was the most central node in the paternal network. The edge between “things have been getting on top of me” – “able to laugh and see the funny side of things” (difference: 0.153, P=0.020), and “scared or panicky” – “the thought of harming myself” (difference: 0.084, P< 0.001) was significantly stronger in women’s partners than that in pregnant women.Conclusion: Maternal and paternal depression during pregnancy could result in significant negative consequences. Symptoms like “sad or miserable” and “scared or panicky” are critical and might be potential targets for further interventions. Evidence-based treatments, such as pharmacology, psychotherapy, community reinforcement and family training, might be beneficial for parents with depression during and after the pregnancy.Keywords: depression, maternal, network, paternal, pregnancy

Ozkan Gorgulu, Mehmet Nuri Kosar

OBJECTIVE: This study was designed to show that allergic reactions with gamma cyclodextrin-related caused by sugammadex are not anaphylaxis but an anaphylactoid reaction. METHODS: In this retrospective study, 83 morbidly obese patients, who underwent elective laparoscopic sleeve gastrectomy operation, were included. Patient data were obtained from patient files and electronic health records system (SARUS). The patients were divided into two groups as sugammadex (Group S) and neostigmine (Group N). Patient data were recorded, including patient preoperative demographics (age, gender) and preoperative and postoperative (12 hours later) levels of total IgE and ECP (Eosinophil cationic protein) levels. RESULTS: There was not a significant change in the total IgE levels in Group S or Group N (p&gt;0.05); however, the levels of ECP significantly decreased in both groups (p&lt;0.001, p=0.01). In the patients in Group S, the preoperative levels of total IgE were significantly positively, and weakly correlated with the preoperative ECP (p=0.311, p=0.045) and postoperative ECP (p=0.310, p=0.046) levels. CONCLUSION: Allergic reactions that arise from sugammadex related with gamma-cyclodextrin are non-IgE mediated anaphylactoid reactions. Anaphylactoid reaction was not observed after administration of 2 mg kg-1 sugammadex intravenously in patients with morbid obesity.

Gladdy George, A V Varsha, Madhu Andrew Philip et al.

Objectives: del Nido cardioplegia which was traditionally used for myocardial protection in pediatric congenital heart surgery is now being extensively utilized in adult cardiac surgery. The aim of this study was to compare the safety and efficacy of del Nido cardioplegia (DNC) with blood cardioplegia (BC). Materials and Methods: This is a historical cohort study using secondary data. Two hundred and eighty six patients who underwent coronary artery bypass graft (CABG) or valve surgery were included. They were divided into 2 matched cohorts of which 143 patients received BC and 143 patients received DNC. Results: There was no difference in cardiopulmonary bypass time (P = 0.516) and clamp time (P = 0.650) between the groups. The redosing of cardioplegia was significantly less for DNC (1.13 vs. 2.35, P = <0.001). The post bypass hemoglobin was higher for DNC (9.1 vs. 8.7, P = 0.011). The intraoperative and postoperative blood transfusion was comparable (P = 0.344) (P = 0.40). The incidence of clamp release ventricular fibrillation (P = 0.207) was similar. The creatine kinase-MB isotype levels for the CABG patients were comparable on all 3 days (P = 0.104), (P = 0.106), and (P = 0.158). The postoperative left ventricle ejection fraction was lesser but within normal range in the DNC group (53.4 vs. 56.0, P = <0.001). The duration of ventilation (P = 0.186), ICU days (P = 0.931), and postoperative complications (P = 0.354) were comparable. There was no 30-day mortality or postoperative myocardial infarction in both the groups. Conclusion: DNC provides equivalent myocardial protection, efficacy, and surgical workflow and had comparable clinical outcomes to that of BC. This study shows that DNC is a safe alternate to BC in CABG and valve surgeries.

Masato Kobayashi, Masahiko Akatsu, Yoshihisa Fujita et al.

Abstract Background Erythropoietin-producing uterine myoma can cause various complications such as arterial or venous thrombosis and bleeding. Therefore, caution is required in the anesthetic management of affected patients. Case presentation A 57-year-old female was suspected to have an erythropoietin-producing uterine myoma and was scheduled to undergo an abdominal total hysterectomy and bilateral salpingo-oophorectomy. Preoperative levels of hemoglobin and erythropoietin were 21.9 g/dl (normal 11.5–15 g/dl) and 23.2 IU/ml (normal 4.2–23.7 IU/ml), respectively. Preoperative phlebotomy and isovolemic hemodilution were performed to prevent arterial and venous thrombosis, following previous evidence that a hemoglobin level < 16 g/dl reduces the occurrence of polycythemia vera-related complications. Fondaparinux 2.5 mg was subcutaneously injected once daily after the operation, resulting in a good perioperative course without major complications. Conclusion Herein, we have described a successful perioperative management of a patient with erythropoietin-producing uterine myoma. Our findings in this case suggest that this combination of antithrombotic therapies can facilitate anesthetic management of patients with this disease.

Emil Najjar, Ann Hallberg Kristensen, Tonje Thorvaldsen et al.

Abstract Background The use of left ventricular assist devices (LVADs) has increased in the last decade. Major complications have been well described, but there is no data on device alarms and actual or threatening malfunction which impair quality of life and may impair outcomes. This study describes the technical problems related to the use of the HVAD® left ventricular assist device in a single center. Methods We retrospectively reviewed device malfunctions and outcomes in 22 patients with HVAD® left ventricular assist device followed at Karolinska University Hospital between 2011 and 2016. Device malfunction was defined by INTERMACS as a failure of one or more of the components of the LVAD system. The primary outcome was defined as death or hospitalization or unplanned urgent clinic visit due to device alarm of unknown significance or actual or threatening malfunction. Separate secondary outcomes were malfunction resulting in controller exchange and malfunction resulting in battery change. Exploratory outcomes were death, transplantation, or explantation because of recovery. Results Median age was 59 years and 19% were women. Over a mean follow-up time of 1.7 years (37 patient-years), the primary outcome occurred 30 times (0.8 events per patient-year; 0 deaths, 2 hospitalizations and 28 un-planned clinic visits). Secondary outcomes were 41 device malfunctions for 14 patients requiring 45 controller exchanges in 12 patients (1.1 events per patient-year) and 128 battery changes in 12 patients (3.5 events per patient-year). Exploratory outcomes were 8 deaths (36.4%), 7 transplantations (31.8%) and 2 explants due to recovery (9.1%). Conclusion The use of HVAD® was associated with technical problems requiring frequent un-planned clinic visits and changes of controller and/or batteries. There were no deaths due to device malfunction. Further studies are warranted to evaluate the risk of device malfunction and associated reductions in quality of life and cost.

Fu-Shan Xue, Chao Wen, Ya-Yang Liu

Katherine Plewes, Hugh W.F. Kingston, Aniruddha Ghose et al.

Abstract Background Intravascular hemolysis is an intrinsic feature of severe malaria pathophysiology but the pathogenic role of cell-free hemoglobin-mediated oxidative stress in severe malaria associated acute kidney injury (AKI) is unknown. Methods As part of a prospective observational study, enrolment plasma cell-free hemoglobin (CFH), lipid peroxidation markers (F2-isoprostanes (F2-IsoPs) and isofurans (IsoFs)), red cell deformability, and serum creatinine were quantified in Bangladeshi patients with severe falciparum malaria (n = 107), uncomplicated malaria (n = 80) and sepsis (n = 28). The relationships between these indices and kidney function and clinical outcomes were examined. Results AKI was diagnosed at enrolment in 58% (62/107) of consecutive patients with severe malaria, defined by an increase in creatinine ≥1.5 times expected baseline. Severe malaria patients with AKI had significantly higher plasma cell-free hemoglobin (geometric mean CFH: 8.8 μM; 95% CI, 6.2–12.3 μM), F2-isoprostane (56.7 pg/ml; 95% CI, 45.3–71.0 pg/ml) and isofuran (109.2 pg/ml; 95% CI, 85.1–140.1 pg/ml) concentrations on enrolment compared to those without AKI (CFH: 5.1 μM; 95% CI, 4.0–6.6 μM; P = 0.018; F2-IsoPs: 27.8 pg/ml; 95% CI, 23.7–32.7 pg/ml; P < 0.001; IsoFs: 41.7 pg/ml; 95% CI, 30.2–57.6 pg/ml; P < 0.001). Cell-free hemoglobin correlated with markers of hemolysis, parasite burden (P. falciparum histidine rich protein 2 (PfHRP2)), and F2-IsoPs. Plasma F2-IsoPs and IsoFs inversely correlated with pH, positively correlated with creatinine, PfHRP2 and fractional excretion of sodium, and were higher in patients later requiring hemodialysis. Plasma F2-IsoP concentrations also inversely correlated with red cell deformability and were higher in fatal cases. Mixed effects modeling including an interaction term for CFH and time showed that F2-IsoPs, IsoFs, PfHRP2, CFH, and red cell rigidity were independently associated with increasing creatinine over 72 h. Multivariable logistic regression showed that admission F2-IsoPs, IsoFs and red cell deformability were associated with the need for subsequent hemodialysis. Conclusions Cell-free hemoglobin and lipid peroxidation are associated with acute kidney injury and disease severity in falciparum malaria, suggesting a pathophysiological role in renal tubular injury. Evaluation of adjunctive therapies targeting cell-free hemoglobin-mediated oxidative stress is warranted.

Gaurav Chauhan, Pavan Nayar, Chandni Kashyap

Surya Kumar Dube, Sachidanand Jee Bharti, Girija Prasad Rath

Pedersen Torben B, Funder Jonas A, Honge Jesper L et al.

<p>Abstract</p> <p>Background</p> <p>Glutaraldehyde-treated bioprosthetic heart valves are commonly used for replacement of diseased heart valves. However, calcification and wear limit their durability, and the development of new and improved bioprosthetic valve designs is needed and must be evaluated in a reliable animal model. We studied glutaraldehyde-treated valves 6 months after implantation to evaluate bioprosthetic valve complications in the mitral position in juvenile pigs.</p> <p>Materials</p> <p>The study material comprised eight, 5-month old, 60-kg pigs. All pigs received a size 27, glutaraldehyde-treated, stented, Carpentier-Edwards S.A.V. mitral valve prosthesis. After six months, echocardiography was performed, and the valves explanted for gross examination, high resolution X-ray, and histological evaluation.</p> <p>Results</p> <p>Five pigs survived the follow-up period. Preexplant echocardiography revealed a median peak and mean velocity of 1.61 m/s (range: 1.17-2.00) and 1.20 (SD = ±0.25), respectively, and a median peak and mean pressure difference of 10.42 mmHg (range: 5.83-16.55) and 6.51 mmHg (SD = ±2.57), respectively. Gross examination showed minor thrombotic depositions at two commissures in two valves and at all three commissures in three valves. High resolution X-ray imaging revealed different degrees of calcification in all explanted valves, primarily in the commissural and belly areas. In all valves, histological evaluation demonstrated various degrees of fibrous sheath formation, limited immunological infiltration, and no overgrowth of host endothelium.</p> <p>Conclusions</p> <p>Bioprosthetic glutaraldehyde-treated mitral valves can be implanted into the mitral position in pigs and function after 6 months. Echocardiographic data, calcification, and histological examinations were comparable to results obtained in sheep models and human demonstrating the suitability of the porcine model.</p>