Comparison between two ocular cleansing modalities in a population of newborns admitted to Neonatal Intensive Care Unit with clinical signs of conjunctivitis: a randomized controlled trial.

BACKGROUND: Neonatal conjunctivitis is frequent and could benefit from daily cleansing with saline. Anyway super infections can occur and therefore antibiotics are frequently needed. Recently alternative therapies (e.g. Echinacea angustifolia) are used for neonatal conjunctivitis to try to reduce antibiotics therapy. The aim of the study was to verify if the use of gauze containing Echinacea angustifolia compared to standard sodium-chloride at the onset of conjunctivitis symptoms is effective in reducing the clinical symptoms and the risk for superinfections. METHODS: The study was randomized and controlled. Neonates admitted in a tertiary level Neonatal Intensive Care Unit (NICU), with clinical signs of conjunctivitis during hospital stay, were randomized in two groups: group A (3 times daily ocular cleansing for 48 h with sterile gauze; group B (3 times daily ocular cleansing for 48 h with Iridium® baby gauze (Neoox) containing Echinacea angustifolia and pineapple sativus). An eye swab for cultural analysis was taken at time of presentation (T0) prior to treatment and at the end of ocular cleansing (T1). RESULTS: Sixty-three neonates were enrolled (GrA=30 and GrB=33). At T0, eye specimen positivity was found in 16/30 (48%) in group A and in 18/33 (55%) in group B (P=0.9). No statistical differences among groups at T0 regarding culture positivity. After 48 h, babies in Gr A have significantly fewer positive swabs compared to group B (group A: 18/29, group B: 10/32; P=0.009). Neonates in group B who had negative swab at T0 had a significantly reduced risk to have positive culture at T1 (OR 0.28, CI: 0.10-0,80, P=0.01), also considering confounding factors (birth weight, gestational age, mode of delivery) (adjusted OR 0.15, CI: 0.03-0.52, P<0.01). No differences in regard to antibiotic needs (P=0.95) during the course of conjunctivitis between groups. CONCLUSIONS: Our data suggest that these gauzes containing Echinacea angustifolia might help in avoiding super-infections, contaminations and in reducing ocular bacterial load.

Correction of neurological deficiency in patients with acute ischemic stroke by application of different qualitative composition of infusion solutions.

OBJECTIVE: Introduction: Infusion therapy is an important component in the treatment of patients with acute ischemic stroke (AIS). The aim: Compare the dynamics of changes neurological deficiency in the application of solutions: 0.9% NaCl, HES 130, HAES-LX-5% and mannitol 15% in patients with AIS. PATIENTS AND METHODS: Materials and methods: The study included 100 patients with AIS. As the investigated solutions were used: isosmolar 0.9% NaCl, hyperosmolar mannitol 15%, colloid-isoosmolar HES 130, colloid-hyperosmolar HAES-LX-5%. The control group received only 0.9% NaCl compared: 0.9% NaCl+HES 130, 0.9% NaCl+HAES-LX-5%, 0.9% NaCl+mannitol 15%. The evaluation of treatment efficacy (magnitude of neurological deficiency) was performed daily for 7 days using the Glasgow Coma Scale (GCS), Full Outline of UnResponsiveness (FOUR) Score, National Institutes of Health Stroke Scale (NIHSS) and BIS-index. RESULTS: Results: The conducted research showed that the application of 0.9% NaCl and mannitol did not have a significant effect on the dynamics of neurological deficits according to the GCS, FOUR and NIHSS scales for 7 days of observation (p>0.05). The use of HES 130 contributed to a statistically significant improvement in the parameters of the GCS (p<0,05), which is confirmed by significant changes in the BIS-index (p<0,05) during a seven-day infusion therapy. The most significant positive changes were observed in the group with HAES-LX-5%, which was marked by an improvement in the neurological state during 7 days treatment acoording to the GCS, FOUR and BIS index (p<0.05). CONCLUSION: Conclusions: The intergroup analysis of the neurological deficiency confirmed the worst result of treatment in the group with mannitol (p<0,05) and the best result with HAES-LX-5% (p<0,05).

The effectiveness of a saline mouth rinse regimen and education programme on radiation-induced oral mucositis and quality of life in oral cavity cancer patients: A randomised controlled trial.

Radiation therapy (RT) and concurrent chemotherapy RT (CCRT) generate radiation-induced oral mucositis (OM) and lower quality of life (QOL). This study assessed the impact of a saline mouth rinse regimen and education programme on radiation-induced OM symptoms, and QOL in oral cavity cancer (OCC) patients receiving RT or CCRT. Ninety-one OCC patients were randomly divided into a group that received saline mouth rinses and an education programme and a control group that received standard care. OM symptoms and QOL were assessed with the WHO Oral Toxicity Scale, MSS-moo and UW-QOL. Data were collected at the first postoperative visit to the radiation department (T0) and at 4 weeks and 8 weeks after beginning RT or CCRT. Patients in both groups had significantly higher levels of physical and social-emotional QOL at 8 weeks after beginning RT or CCRT compared to the first visit. Patients in the saline rinse group had significantly better physical and social-emotional QOL as compared to the standard care group at 8 weeks. Radiation-induced OM symptoms and overall QOL were not different between the groups. We thus conclude the saline rinse and education programme promote better physical and social-emotional QOL in OCC patients receiving RT/CCRT.

[Mesotherapy as a treatment of pain and disability in patients affected by neck pain in spondylartrosis]. / La mesoterapia come trattamento del dolore e della disabilità in pazienti affetti da cervicalgia in spondilartrosi.

Mesotherapy is a technique that treats locoregional pain with intradermal injection of a drug in the affected area. Its short-term efficacy was observed in patients with low back pain using both normal saline solution, if there were contraindications to drugs' use, or a cocktail of drugs (normal saline solution, lidocaine hydrochloride, and lysine acetylsalicylate), whereas only the latter provided benefit for up to three months after treatment. The aim of this study was to measure the effects of mesotherapy in patients affected by neck pain in spondylarthrosis, a common pathology in rehabilitation, associated with significant disability and increased health expenditure. One hundred patients participated in the study, of whom 50 (mean age 66.9 years) were treated with mesotherapy with a cocktail of drugs and 50 (mean age 64.7 years) with normal saline solution. Pain and disability were measured at different times (i.e. before treatment, at the end of five weeks of treatment, four weeks and 12 weeks after treatment), by using different pain scales, including a visual analogue scale, the short-form McGill pain questionnaire, the Present Pain Intensity scale and the Neck Disability Index. Mesotherapy with either normal saline solution or with a cocktail of drugs were both found to be effective in the short term in reducing pain and disability. However, only patients treated with a cocktail of drugs showed improvement at three months following treatment.

Effects of replacing saline solution during surgery for colon cancer in Korea.

BACKGROUND: Surgical site infections are often linked to contamination of saline solution by the patient's organs, doctors' and nurses' hands, or surgical instruments. Scrub nurses also use the saline solution to soften sutures or moisturize gauze. Therefore, we performed a randomized study of Korean clean-contaminated surgeries for colon cancer to evaluate whether replacing saline solution affected the level of contamination. MATERIALS AND METHODS: In the control group (n = 26), normal saline was not replaced during surgery. In the experimental group (n = 26), normal saline and bowl were replaced after colon lesions were removed. RESULTS: We found that replacing the saline solution during surgery significantly lowered the number of colony-forming units in the solution (t = -5.18, P < 0.001). CONCLUSIONS: Therefore, we suggest that nurses replace the saline solution after removing the contaminated organs and that this replace be performed in clinical settings in Korea.

Contemporary Approaches to Perioperative IV Fluid Therapy.

BACKGROUND: Intravenous fluid therapy is required for most surgical patients, but inappropriate regimens are commonly prescribed. The aim of this narrative review was to provide evidence-based guidance on appropriate perioperative fluid management. METHOD: We did a systematic literature search of the literature to identify relevant studies and meta-analyses to develop recommendations. RESULTS: Of 275 retrieved articles, we identified 25 articles to inform this review. "Normal" saline (0.9% sodium chloride) is not physiological and can result in sodium overload and hyperchloremic acidosis. Starch colloid solutions are not recommended in surgical patients at-risk of sepsis or renal failure. Most surgical patients can have clear fluids and/or administration of carbohydrate-rich drinks up to 2 h before surgery. An intraoperative goal-directed fluid strategy may reduce postoperative complications and reduce hospital length of stay. Regular postoperative assessment of the patient's fluid status and requirements should include looking for physical signs of dehydration or hypovolemia, or fluid overload. Both hypovolemia and salt and water overload lead to adverse events, complications and prolonged hospital stay. Urine output can be an unreliable indicator of hydration status in the postoperative surgical patient. Excess fluid administration has been linked to acute kidney injury, gastrointestinal dysfunction, and cardiac and pulmonary complications. CONCLUSION: There is good evidence supporting the avoidance of unnecessary fasting and the value of an individualized perioperative IV fluid regimen, with transition to oral fluids as soon as possible, to help patients recover from major surgery.

POstLAparoscopic Reduction of pain By combining intraperitoneal normal salinE And the pulmonary Recruitment maneuver (POLAR BEAR trial). RCT to estimate reduction in pain after laparoscopic surgery when using a combination therapy of intraperitoneal normal saline and the pulmonary recruitment maneuver.

BACKGROUND: Shoulder pain and pain in the upper abdomen are common complaints after laparoscopy, sometimes surpassing the pain at incision sites. The incidence of shoulder pain ranges from 35 to 80%. Post-laparoscopic pain is caused by retention of carbon dioxide in the abdomen, which irritates the phrenic nerve and diaphragm, causing referred pain in the shoulder and in the upper abdomen. A promising strategy to reduce this post-laparoscopic pain is the pulmonary recruitment maneuver, which indirectly increases intraperitoneal pressure and thereby facilitates removal of residual carbon dioxide. An alternative strategy is the infusion of intraperitoneal normal saline. With normal saline infusion, carbon dioxide rises and escapes through the port sites. In addition, normal saline offers a physiologic buffer system to dissolve excess carbon dioxide. METHODS/DESIGN: This multicenter randomized controlled trial is conducted in two teaching hospitals in the Netherlands. Women between 18 and 65 years of age, with an ASA classification of I-II who are scheduled to undergo an elective laparoscopic procedure with benign gynecologic indication can participate. Following informed consent, participants are randomly allocated into two groups at the end of the surgical procedure. In the intervention group, the upper abdomen is filled with normal saline infusion with the patient in the Trendelenburg position. Then the anesthesiologist performs a standardized pulmonary recruitment maneuver with a pressure of 40 cm H2O. The trocar sleeve valves will be left open, so carbon dioxide can escape the abdominal cavity. With the patient in a neutral position the instruments are removed from the abdomen. In the control group, carbon dioxide is removed from the abdominal cavity at the end of surgery, with gentle abdominal pressure and passive exsufflation through the port sites, with open sleeve valves. The primary outcomes are the incidence and intensity of post-laparoscopic pain in the shoulder, upper abdomen and at the operation sites, at 8, 24 and 48 h after surgery. Secondary outcomes are postoperative use of analgesics, nausea, vomiting and pulmonary complications. DISCUSSION: This study may reduce post-laparoscopic pain in women undergoing laparoscopy. TRIAL REGISTRATION: Dutch trial register, number NTR4812 .

Tumescent TAPP: laparoscopic inguinal hernia repair after the preperitoneal tumescent injection of diluted lidocaine and epinephrine saline solution and carbon dioxide gas.

PURPOSE: Laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) is technically difficult and not infrequently followed by postoperative complications and pain, especially when performed by inexperienced surgeons. To simplify TAPP and reduce postoperative pain, we devised a novel procedure whereby TAPP is carried out after the inguinal preperitoneal infiltration of diluted lidocaine and epinephrine saline solution and carbon dioxide gas (tumescent TAPP). This report introduces the concept of tumescent TAPP and summarizes its operative results. METHODS: About 120 ml of diluted lidocaine and epinephrine solution and 60 ml of CO2 gas were infiltrated into the inguinal preperitoneal space through a transabdominal needle before TAPP. Tumescent TAPP was performed for 400 patients (355 men, 45 women; mean age, 63.2 years). RESULTS: Using tumescent TAPP, we found it easier to confirm the inguinal anatomy and dissect the preperitoneal layer and inguinal floor, with less bleeding. The mean operation time was 101.9 min and there were few perioperative complications and minimal pain. CONCLUSIONS: Tumescent TAPP makes conventional TAPP easier and safer; however, this procedure should be verified by a comparative study with conventional TAPP.

Complications and management of hyponatremia.

PURPOSE OF REVIEW: Hyponatremia causes significant morbidity, mortality, and disability. This review considers the literature of the past 18 months to improve understanding of these complications and to identify therapeutic strategies to prevent them. RECENT FINDINGS: Acute hyponatremia causes serious brain swelling that can lead to permanent disability or death. A 4-6 mEq/l increase in serum sodium is sufficient to reverse impending herniation. Brain swelling is minimal in chronic hyponatremia, and to avoid osmotic demyelination, correction should not exceed 8 mEq/l/day. In high-risk patients, correction should not exceed 4-6 mEq/l/day. Inadvertent overcorrection of hyponatremia is common and preventable by controlling unwanted urinary water losses with desmopressin. Even mild chronic hyponatremia is associated with increased mortality, attention deficit, gait instability, osteoporosis, and fractures, but it is not known if the correction of mild hyponatremia improves outcomes. SUMMARY: Controlled trials are needed to identify affordable treatments for hyponatremia that reduce the need for hospitalization, decrease hospital length of stay, and decrease morbidity. Such trials could also help answer the question of whether hyponatremia causes excess mortality or whether it is simply a marker for severe, lethal, underlying disease.

Percutaneous discal cyst rupture in a professional football player using sublaminar epidural injection for thecal sac displacement.

A case of percutaneous discal cyst rupture in a 25-year-old professional American football player is reported. The patient presented with a 3-day history of severe left-sided back pain. Magnetic resonance imaging examination demonstrated a discal cyst effacing the left L4-L5 lateral recess, with interposed thecal sac. A sublaminar epidural injection was performed displacing the thecal sac, exposing the discal cyst, and allowing for percutaneous perforation. The patient had complete resolution of symptoms after discal cyst rupture and was able to compete in a professional football game 3 days later. Computed tomography-guided percutaneous rupture is a therapeutic modality that may be considered for treatment of a symptomatic discal cyst.

Role of warm saline mouth rinse in prevention of alveolar osteitis: a randomized controlled trial.

BACKGROUND: The present study was aimed at determining the role warm saline rinse in the prevention of alveolar osteitis following dental extractions. MATERIALS AND METHODS: Apparently patients aged 16 and above who were referred to the Oral Surgery Clinic of our institution, with an indication for non-surgical extraction of pathologic teeth were prospectively and uniformly randomized into warm saline group and control. The experimental group (n = 80) were instructed to gargle 6 times daily with warm saline and no such instructions were given to the second group (n = 80) to serve as controls. Information on demographic, indications for extraction, and development of alveolar osteitis were obtained and analyzed. Comparative statistics were done using Pearson's chi square or Fisher's exact test as appropriate. A p value of less than 0.05 was considered significant. RESULTS: The demographic and other baseline parameters such as indications for extractions were comparable among the study groups (p > 0.05). The overall prevalence of alveolar osteitis was 13.7%. There was a statistical significant difference between the study groups with respect to development of alveolar osteitis (X2 = 15.00, df = 1, p = 0.001).The risk of development of alveolar osteitis was 4 times higher in the control group (OR = 4.33, P = 0.001). CONCLUSION: Warm saline mouth rinse instruction is beneficial in the prevention of development of alveolar osteitis after dental extractions.

[Theoretical basis and clinical benefits of dry salt inhalation therapy]. / A szárazsó-belégzéssel történo kezelés elméleti alapjai és gyakorlati haszna.

Dry salt inhalation (halotherapy) reproduces the microclimate of salt caves, with beneficial effect on health. Sodium chloride crystals are disrupted into very small particles (with a diameter less than 3 µm), and this powder is artificially exhaled into the air of a comfortable room (its temperature is between 20-22 °C, and the relative humidity is low). The end-concentration of the salt in the air of the room will be between 10-30 mg/m(3). The sick (or healthy) persons spend 30-60 minutes in this room, usually 10-20 times. Due to the greater osmotic pressure the inhaled salt diminishes the oedema of the bronchial mucosa, decreases its inflammation, dissolves the mucus, and makes expectoration easier and faster (expectoration of air pollution and allergens will be faster, too). It inhibits the growth of bacteria and, in some case, kills them. Phagocyte activity is also increased. It has beneficial effect on the well being of the patients, and a relaxation effect on the central nervous system. It can prevent, or at least decrease the frequency of the respiratory tract inflammations. It produces better lung function parameters, diminishes bronchial hyperreactivity, which is the sign of decreasing inflammation. Its beneficial effect is true not only in inflammation of the lower respiratory tract, but also in acute or chronic upper airways inflammations. According to the international literature it has beneficial effect for some chronic dermatological disease, too, such as psoriasis, pyoderma and atopic dermatitis. This treatment (called as Indisó) is available under medical control in Hungary, too.

Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury?: con.

The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury.

The effects of an epithelial barrier protective cationic aerosol on allergen-induced airway inflammation in asthma: a randomized, placebo-controlled clinical trial.

Inhaled cationic airway lining modulator (iCALM) is a cationic aerosol therapy comprised of 1.29% calcium chloride dissolved in 0.9% isotonic saline that enhances the biophysical barrier function of the airway lining fluid and primes the host defense response. It's ability to attenuate bronchitis caused by inhaled particles was investigated using an allergen-inhalation model in a proof-of-concept study. In a randomized, double-blind, placebo-controlled cross-over trial of 6 mild atopic steroid-naïve asthmatic subjects, 3 doses of iCALM were well tolerated and they attenuated allergen-induced increase in sputum eosinophils, and levels of IL-5, MCP-1 and eotaxin. This study provides an opportunity to investigate the role of enhancing epithelial barrier to decrease airway inflammation provoked by inhaled particles in a variety of airway diseases.

Postprocedural pain in shoulder arthrography: differences between using preservative-free normal saline and normal saline with benzyl alcohol as an intraarticular contrast diluent.

OBJECTIVE: The purpose of this study was to prospectively evaluate the effect of benzyl alcohol, a common preservative in normal saline, on postprocedural pain after intraarticular injection for direct shoulder MR arthrography. SUBJECTS AND METHODS: From April 2011 through January 2013, 138 patients underwent direct shoulder MR arthrography. Using the Wong-Baker Faces Pain Scale, patients were asked to report their shoulder pain level immediately before and immediately after the procedure and then were contacted by telephone 6, 24, and 48 hours after the procedure. Fourteen patients did not receive the prescribed amount of contrast agent for diagnostic reasons or did not complete follow-up. Sixty-two patients received an intraarticular solution including preservative-free normal saline (control group) and 62 patients received an intraarticular solution including normal saline with 0.9% benzyl alcohol as a contrast diluent (test group). Patients were randomized as to which intraarticular diluent they received. Fluoroscopic and MR images were reviewed for extracapsular contrast agent administration or extravasation, full-thickness rotator cuff tears, and adhesive capsulitis. The effect of preservative versus control on pain level was estimated with multiple regression, which included time after procedure as the covariate and accounted for repeated measures over patients. RESULTS: Pain scale scores were significantly (p = 0.0382) higher (0.79 units; 95% CI, 0.034-1.154) with benzyl alcohol preservative compared with control (saline). In both study arms, the pain scale scores decreased slightly after the procedure, increased by roughly 1 unit over baseline for the test group and 0.3 unit over baseline for the control group by 6 hours after the procedure, were 0.50 unit over baseline for the test group and 0.12 unit over baseline for the control group at 24 hours, then fell to be slightly greater than baseline at 48 hours with benzyl alcohol and slightly less than baseline without benzyl alcohol. These trends over time were highly significant (p < 0.0001). CONCLUSION: Shoulder arthrography is often associated with postprocedural discomfort that begins immediately after the procedure and resolves by 48 hours. There is significantly increased patient discomfort at 6 and 48 hours when using normal saline preserved with benzyl alcohol as a diluent compared with using normal saline without preservative as a diluent.

A novel balanced isotonic sodium solution vs normal saline during major surgery in children up to 36 months: a multicenter RCT.

BACKGROUND: The use of isotonic electrolytic solutions for the intraoperative fluid management in children is largely recognized, but the exact composition still needs to be defined. OBJECTIVES: The primary objective of this randomized controlled open trial was to compare the changes in chloride plasma concentration using two intraoperative isotonic fluid regimens (Sterofundin vs. normal saline, both added with 1% of glucose) in children undergoing major surgery. Secondary objectives were to compare changes in other electrolytes, renal function, and the occurrence of hypoglycemia. METHODS: Children aged between 1 and 36 months, scheduled for major surgery, were randomized to receive Sterofundin or saline during the intraoperative time. Children with preoperative electrolyte abnormalities, hemodynamic instability, and severe renal or hepatic dysfunction were excluded. The primary outcome was the Δ of Cl(-) (Δ = change in plasma concentration between post- and pre-infusion), and secondary outcomes included Δ of other electrolytes and intraoperative hypoglycemia. RESULTS: A total of 240 patients were included in the two study sites and randomized to receive Sterofundin plus 1% glucose or normal saline plus 1% glucose, in a open fashion (229 were finally analyzed). Δ of Cl- and Mg++ was statistically less relevant in patients who received intraoperative Sterofundin, and Δ of the other electrolytes was comparable between the two study groups. Relative risk of hyperchloremia was significantly higher when large volumes were infused (over than 46.7 ml·kg(-1) ), regardless of type of crystalloid infused. Hypoglycemia occurred in two of 229 patients. CONCLUSIONS: Sterofundin is safer than normal saline in protecting young children undergoing major surgery against the risk of increasing plasma chlorides and the subsequent metabolic acidosis.

Subacromial triamcinolone acetonide, hyaluronic acid and saline injections for shoulder pain an RCT investigating the effectiveness in the first days.

BACKGROUND: Subacromial impingement is a common cause of shoulder complaints in general practice. When the initial treatment with acetaminophen and low dose Non Steroidal Anti Inflammatory Drugs fails, triamcinolone acetonide injections are commonly used. Triamcinolone acetonide injections are effective at four to six weeks. Little is known about the pain relief effect of triamcinolone acetonide injections in the first days after injection and the effect of repeated injection. In this study we investigate the effect of triamcinolone acetonide injections compared to hyaluronic acid and NaCl injections using a pain diary. METHODS: 159 Patients recruited for an RCT comparing the effect of subacromial injections of triamcinolone acetonide, hyaluronic acid and sodium chloride (NaCl) were used in this study. They were blinded for their treatment and could receive up to three injections. Primary outcome consisted of the patient perceived pain on a VAS score recorded on a daily basis during 21 days following injection. Secondary outcome consisted of the amount of taken escape medication following injection and adverse effects. RESULTS: All patients received the first injection. 150 patients also received the second and third injections. 97% Of the paper and pencil pain diaries were returned for data analysis.The triamcinolone acetonide group showed the largest decrease in pain on the VAS scores after injection compared to the hyaluronic acid and NaCl group in the first week after injection. The reduction in pain was best achieved after the first injection, the second triamcinolone acetonide injection showed a further reduction in pain. The third triamcinolone acetonide injection only showed a slight improvement in pain reduction. CONCLUSIONS: In this study we could show a booster effect in pain reduction after repeated triamcinolone acetonide injection. The triamcinolone acetonide group showed a faster reduction in pain after injection compared to the hyaluronic acid and NaCl group. The effect was best seen after the first and second triamcinolone acetonide injection, it is therefore questionable whether it is necessary to repeat triamcinolone acetonide injections more than two times. TRIAL REGISTRATION: ISRCTN51511455. Registered 20 December 2005.

Comparing efficacy of three methods of tranexamic acid administration in reducing hemoglobin drop following total knee arthroplasty.

The ideal method of providing tranexamic acid (TXA) for decreasing hemoglobin drop after TKA is still controversial. In this clinical trial, 200 patients were randomly allocated to four groups. In group 1,500 mg TXA was administered intravenously. In group 2, the joint irrigated with 3 g of TXA in 100 cc of saline. In group 3, 1.5 g of TXA was injected through the drain. Group 4 did not take TXA. Albeit all methods had a statistical effect on hemoglobin drop, drainage and number of transfused units when compared to controls, but intravenous injection of TXA seems to be much more effective in terms of reducing hemoglobin drop and transfused units; and what's more TXA injection by drain is more effective regarding to reducing postoperative drainage.

Effect of phenylephrine on the haemodynamic state and cerebral oxygen saturation during anaesthesia in the upright position.

BACKGROUND: The upright sitting or beachchair position is associated with hypotension, risk of cerebral hypoperfusion, and cerebral injury. We hypothesized that by increasing arterial pressure with phenylephrine administration, cerebral perfusion, and postoperative recovery would be improved. METHODS: Thirty-four patients undergoing elective shoulder surgery were randomized to receive either saline or phenylephrine infusion (PE) 5 min before being placed in the upright position. Simultaneous measurements of mean arterial pressure, cerebral oxygen saturation, middle cerebral artery velocity, and cardiac function using transthoracic echocardiography were made. Postoperative neurocognitive function was assessed. RESULTS: At the commencement of PE, mean (SD) cerebral oxygen saturation significantly decreased from 77 (10) to 67 (13)% (P=0.02), and further to 59 (11) % on upright positioning. The level of cerebral saturation upright was not significantly different to patients receiving saline (P=0.07), with values remaining at room-air levels. Middle cerebral artery blood velocity increased by 20% (P=0.04). Phenylephrine prevented hypotension in the upright position primarily by maintaining preload and increasing systemic vascular resistance (P=0.01), and was associated with a decrease in cardiac output. No postoperative neurocognitive dysfunction was identified. CONCLUSIONS: Despite maintaining arterial pressure with phenylephrine, cerebral desaturation occurred with upright positioning. Cerebral oxygen saturation can provide a valuable endpoint when evaluating the effect of vasopressor therapy on cerebral perfusion.

N-acethyl-cysteine reduces the occurrence of contrast-induced acute kidney injury in patients with renal dysfunction: a single-center randomized controlled trial.

BACKGROUND: The occurrence of contrast-induced acute kidney injury (CIAKI) has paralleled the increased number of diagnostic interventions requiring radiographic contrast media (CM). Several strategies aimed at preventing renal injury following iodine have been carried out over the last several years. The aim of this study was to evaluate the impact of three different strategies aimed at preventing CIAKI in patients with renal dysfunction (serum creatinine >1.25 mg/dl or estimated creatinine clearance <45 ml/min) receiving low osmolar CM for diagnostic-therapeutic procedures. METHODS: Candidates received 154 mmol NaHCO3 solution (B0) at a rate of 3 ml/kg/h from at least 2 h before the procedure and at 1 ml/kg/h during and for the next 6-12 h; the same schedule plus N-acethyl-cysteine (NAC) 600 mg twice daily the day before and the day of the procedure (BN) or NAC as above plus 154 mmol NaCl solution at a rate of 3 ml/kg/h from at least 2 h before the procedure and at 1 ml/kg/h during and for the next 6-12 h (SN). Serum creatinine (SCr) was measured at baseline and on days 2 or occasionally 3 after CM. The main outcome measure was the occurrence of CIAKI, defined as a ≥25% increase in SCr within 2-3 days of CM. RESULTS: The three groups were similar with regard to age, gender distribution, weight, baseline serum levels of creatinine, sodium, potassium, urate and estimated creatinine clearance. A larger proportion of individuals received ACEIs/ARAs in the BN group (p < 0.05), but in the SN group, more patients declared a past history of acute myocardial infarction or had high blood pressure, and few displayed mild-moderate left ventricular dysfunction (p < 0.05). CIAKI occurred in 24/123 (19.5%) assessable patients (15/42 in the B0 group, 3/43 in the BN group and 6/38 in the SN group; p < 0.01). Thus, 15/42 patients who did not receive NAC developed CIAKI in contrast to 9/81 who did (p < 0.01). Multivariate logistic regression models showed that the use of NAC was the unique factor associated with a statistically significant influence for the occurrence of CIAKI (OR: 0.18; 95% CI: 0.04-0.72; p = 0.016). CONCLUSIONS: The results from this study show that: (1) the occurrence of CIAKI after low-osmolar CM administration is similar to that reported worldwide. (2) NAC-based renoprotective measures are superior for the prevention of CIAKI in patients with previous renal dysfunction. (3) They also demonstrate that bicarbonate expansion alone has limited value in preventing CIAKI. For those individuals at risk, combination prophylaxis including volume expansion plus NAC should be recommended to reduce the chance of overt kidney injury following CM administration.