Clinical Profiling and Biomarkers for Post-Operative Atrial Fibrillation Prediction in Patients Undergoing Cardiac Surgery.

Post-operative atrial fibrillation (POAF) is the most common arrhythmia in the post-operative period after cardiac surgery. We aim to investigate the main clinical, local, and/or peripheral biochemical and molecular predictors for POAF in patients undergoing coronary and/or valve surgery. Between August 2020 and September 2022, consecutive patients undergoing cardiac surgery without previous history of AF were studied. Clinical variables, plasma, and biological tissues (epicardial and subcutaneous fat) were obtained before surgery. Pre-operative markers associated with inflammation, adiposity, atrial stretch, and fibrosis were analyzed on peripheral and local samples with multiplex assay and real-time PCR. Univariate and multivariate logistic regression analyses were performed in order to identify the main predictors for POAF. Patients were followed-up until hospital discharge. Out of 123 consecutive patients without prior AF, 43 (34.9%) developed POAF during hospitalization. The main predictors were cardiopulmonary bypass time (odds ratio (OR) 1.008 (95% confidence interval (CI), 1.002-1.013), p = 0.005), and plasma pre-operative orosomucoid levels (OR 1.008 (1.206-5.761). After studying differences regarding sex, orosomucoid was the best predictor for POAF in women (OR 2.639 (95% CI, 1.455-4.788), p = 0.027) but not in men. The results support the pre-operative inflammation pathway as a factor involved in the risk of POAF, mainly in women.

Development and validation of a clinical score to estimate progression to severe or critical state in COVID-19 pneumonia hospitalized patients.

The prognosis of a patient with COVID-19 pneumonia is uncertain. Our objective was to establish a predictive model of disease progression to facilitate early decision-making. A retrospective study was performed of patients admitted with COVID-19 pneumonia, classified as severe (admission to the intensive care unit, mechanic invasive ventilation, or death) or non-severe. A predictive model based on clinical, laboratory, and radiological parameters was built. The probability of progression to severe disease was estimated by logistic regression analysis. Calibration and discrimination (receiver operating characteristics curves and AUC) were assessed to determine model performance. During the study period 1152 patients presented with SARS-CoV-2 infection, of whom 229 (19.9%) were admitted for pneumonia. During hospitalization, 51 (22.3%) progressed to severe disease, of whom 26 required ICU care (11.4); 17 (7.4%) underwent invasive mechanical ventilation, and 32 (14%) died of any cause. Five predictors determined within 24 h of admission were identified: Diabetes, Age, Lymphocyte count, SaO2, and pH (DALSH score). The prediction model showed a good clinical performance, including discrimination (AUC 0.87 CI 0.81, 0.92) and calibration (Brier score = 0.11). In total, 0%, 12%, and 50% of patients with severity risk scores ≤ 5%, 6-25%, and > 25% exhibited disease progression, respectively. A risk score based on five factors predicts disease progression and facilitates early decision-making according to prognosis.

Low volume and high concentration of local anesthetic is more efficacious than high volume and low concentration in Labat's sciatic nerve block: a prospective, randomized comparison.

BACKGROUND: Various factors markedly affect the onset time and success rate, of peripheral nerve blockade. This prospective, randomized, double-blind study, compared a dose of mepivacaine 300 mg, in a 20 or 30 mL injection volume for sciatic nerve blockade using Labat's posterior approach. METHODS: A total of 90 patients undergoing foot surgery were randomly allocated to receive sciatic nerve block with 20 mL of 1.5% mepivacaine (n = 45) or 30 mL of 1% mepivacaine (n = 45). All blocks were performed with the use of a nerve stimulator (stimulation frequency 2 Hz; intensity 1.5-0.5 mA). In the two groups, appropriate nerve stimulation was elicited at <0.5 mA and the targeted evoked motor response was plantar flexion of the foot. Time required for onset of sensory and motor block in the distribution of the tibial and common peroneal nerves were recorded. A successful block was defined as a complete loss of pinprick sensation in the sciatic nerve distribution with concomitant inability to perform plantar or dorsal flexion of the foot. RESULTS: A greater success rate was observed with 20 mL of 1.5% mepivacaine (96.6%) than with 30 mL of 1% mepivacaine (68.9%; P < 0.05). Time to onset of complete sensory and motor block was shorter after injection of 20 mL of 1.5% mepivacaine (11 +/- 6 min and 13 +/- 7 min, respectively) than after 30 mL of 1% mepivacaine (17 +/- 8 min and 19 +/- 8 min, respectively, P < 0.05). CONCLUSION: In Labat's sciatic nerve blockade, administering a low volume and a high concentration of local anesthetic (1.5% mepivacaine) is associated with a higher success rate and a shorter onset time than a high volume and a low concentration of solution (1% mepivacaine).

Horner syndrome after unintended subdural block. A report of 2 cases.

Horner syndrome is considered a common finding after epidural analgesia or anesthesia in obstetric patients. Conversely, Horner syndrome is very uncommon in nonobstetric patients. We report 2 cases of Horner syndrome after attempted epidural lumbar anesthesia in 2 patients undergoing peripheral vascular surgery. Spinal fluoroscopy with contrast medium showed subdural catheterization in both cases. Horner syndrome after lumbar epidural anesthesia can be an indicator of inadvertent subdural catheter placement.

Median versus musculocutaneous nerve response with single-injection infraclavicular coracoid block.

BACKGROUND AND OBJECTIVES: Local anesthetic injection after elicitation of a distal motor response with a nerve stimulator is believed to produce a more clinically efficient infraclavicular coracoid block than after elicitation of a proximal motor response. The aim of this study was to investigate whether elicitation of a median or of a musculocutaneous-type nerve response influenced the quality of anesthesia. METHODS: Randomized, prospective, single-blind study. One hundred thirty patients received a coracoid block with 40 mL plain mepivacaine 1.5% after stimulation of median nerve fibers (group 1) or musculocutaneous nerve fibers (group 2). Patients were assessed for sensory and motor block at 5 and 20 minutes. RESULTS: Significantly higher rates of complete anesthesia at 20 minutes were found in the cutaneous distributions of the radial and ulnar nerves in group 1. Significantly higher rates of complete paralysis were found for elbow extension, wrist flexion, and finger and thumb movements in group 1 at 20 minutes. Differences in the extent of anesthesia and paralysis were more remarkable at 5 minutes than at 20 minutes. CONCLUSIONS: Elicitation of a median nerve response improved the efficacy of infraclavicular coracoid block when compared with a musculocutaneous nerve response. Complete paralysis and complete anesthesia of the upper limb were low in both groups.

Lateral approach to the sciatic nerve block in the popliteal fossa: correlation between evoked motor response and sensory block.

BACKGROUND AND OBJECTIVES: The purpose of this study was to identify which of two motor responses of the foot (plantar flexion versus dorsiflexion) best predicts complete sensory blockade of the sciatic nerve when is used for lateral popliteal sciatic nerve block. METHODS: Thirty American Society of Anesthesiologist physical status I or II patients scheduled for foot and ankle surgery under lateral popliteal sciatic nerve block were enrolled in the study. During each block, the needle was placed to evoke one of the following motor responses of the foot: plantar flexion or dorsiflexion. Thirty milliliters of 0.75% ropivacaine was injected after the motor response was elicited at <0.5 mA. The sequence of elicited motor response was randomized. Sensory blockade of the areas of the foot innervated by the deep peroneal, superficial peroneal, posterior tibial, and sural nerves was checked in a blinded manner. Time required for onset of sensory and motor block of the foot was recorded. RESULTS: The 2 groups were similar with regard to demographic variables and type of surgery. The total of nerves blocked (deep and superficial peroneal, posterior tibial, and sural nerves) after elicited plantar flexion was greater (complete sensory block in 58 of 60 nerve distributions) than after elicited dorsiflexion (34 of 60 nerve distributions) (P <.05). Onset of complete sensory and motor blockade of the foot was faster after elicited plantar flexion (16.6 +/- 5.1 minutes, 20.1 +/- 5.1 minutes, respectively) than after elicited dorsiflexion (24.3 +/- 5.1 minutes, 28.1 +/- 5.0 min, P <.05). CONCLUSIONS: After stimulation of the sciatic nerve, plantar flexion better predicts complete sensory blockade of the foot than dorsiflexion when using the lateral approach to the popliteal fossa. The findings of the present study apply to a single injection of 30 mL of ropivacaine 0.75%.