Effects of mechanical ventilation on the interstitial extracellular matrix in healthy lungs and lungs affected by acute respiratory distress syndrome: a narrative review.

BACKGROUND: Mechanical ventilation, a lifesaving intervention in critical care, can lead to damage in the extracellular matrix (ECM), triggering inflammation and ventilator-induced lung injury (VILI), particularly in conditions such as acute respiratory distress syndrome (ARDS). This review discusses the detailed structure of the ECM in healthy and ARDS-affected lungs under mechanical ventilation, aiming to bridge the gap between experimental insights and clinical practice by offering a thorough understanding of lung ECM organization and the dynamics of its alteration during mechanical ventilation. MAIN TEXT: Focusing on the clinical implications, we explore the potential of precise interventions targeting the ECM and cellular signaling pathways to mitigate lung damage, reduce inflammation, and ultimately improve outcomes for critically ill patients. By analyzing a range of experimental studies and clinical papers, particular attention is paid to the roles of matrix metalloproteinases (MMPs), integrins, and other molecules in ECM damage and VILI. This synthesis not only sheds light on the structural changes induced by mechanical stress but also underscores the importance of cellular responses such as inflammation, fibrosis, and excessive activation of MMPs. CONCLUSIONS: This review emphasizes the significance of mechanical cues transduced by integrins and their impact on cellular behavior during ventilation, offering insights into the complex interactions between mechanical ventilation, ECM damage, and cellular signaling. By understanding these mechanisms, healthcare professionals in critical care can anticipate the consequences of mechanical ventilation and use targeted strategies to prevent or minimize ECM damage, ultimately leading to better patient management and outcomes in critical care settings.

Impact of the American Society of Anesthesiologists (ASA) classification on hip fracture surgery outcomes: insights from a retrospective analysis.

BACKGROUND: The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications. METHODS: A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes. RESULTS: The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51-2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96-1.11). CONCLUSION: The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes.

Unraveling the Complex Web of Fibromyalgia: A Narrative Review.

Fibromyalgia is a complex and often misunderstood chronic pain disorder. It is characterized by widespread musculoskeletal pain, fatigue, and heightened sensitivity, and has evolved in diagnostic criteria and understanding over the years. Initially met with skepticism, fibromyalgia is now recognized as a global health concern affecting millions of people, with a prevalence transcending demographic boundaries. The clinical features and diagnosis of fibromyalgia encompass a range of symptoms beyond pain, including sleep disturbances and cognitive difficulties. This study emphasizes the importance of a comprehensive evaluation for accurate diagnosis, considering the shift from tender point reliance to a more holistic approach. Etiology and pathophysiology involve genetic predisposition, neurotransmitter dysregulation, central sensitization, and immune system involvement. Risk factors such as gender, age, family history, and comorbid conditions contribute to susceptibility. The impact on quality of life is profound, affecting physical and social aspects, often accompanied by mood disorders. Management approaches include pharmacological interventions, non-pharmacological therapies, lifestyle modifications, and alternative treatments. This study also delves into emerging research, exploring advances in neurobiological understanding, brain imaging, genetic markers, glutamate modulation, cannabinoids, gut microbiome, and digital health tools for fibromyalgia management. Overall, this study provides a nuanced and up-to-date overview of the complexities surrounding fibromyalgia, aiming to enhance understanding and support for individuals grappling with this challenging condition.

Personalized medicine using omics approaches in acute respiratory distress syndrome to identify biological phenotypes.

In the last decade, research on acute respiratory distress syndrome (ARDS) has made considerable progress. However, ARDS remains a leading cause of mortality in the intensive care unit. ARDS presents distinct subphenotypes with different clinical and biological features. The pathophysiologic mechanisms of ARDS may contribute to the biological variability and partially explain why some pharmacologic therapies for ARDS have failed to improve patient outcomes. Therefore, identifying ARDS variability and heterogeneity might be a key strategy for finding effective treatments. Research involving studies on biomarkers and genomic, metabolomic, and proteomic technologies is increasing. These new approaches, which are dedicated to the identification and quantitative analysis of components from biological matrixes, may help differentiate between different types of damage and predict clinical outcome and risk. Omics technologies offer a new opportunity for the development of diagnostic tools and personalized therapy in ARDS. This narrative review assesses recent evidence regarding genomics, proteomics, and metabolomics in ARDS research.

A Comparison of the Use of Propofol versus Midazolam for Pediatric Magnetic Resonance Imaging Sedation: Retrospective Cohort Study.

THE AIM OF THE PRESENT STUDY: The aim of the present study was to do a comparison of the recovery profiles and airway-related adverse events of pediatric magnetic resonance imaging (MRI) sedation patients who received propofol alone to those who received midazolam alone. METHODS: This retrospective cohort study was approved by the Mutah University Ethical Approval Committee (No. 2378). A search of the patients' medical records was performed between September 2021 and April 2022 to identify children aged 4 months-11 years who received propofol or midazolam for MRI sedation. The patients were subdivided into two groups: Those who had propofol alone (propofol group) and those who received midazolam (midazolam group) for pediatric MRI sedation. In propofol group, a 1-2 mg/kg of propofol bolus was given to have a deep sedation (Ramsay Sedation Scale score of 5). Patients in midazolam group received 0.05 mg/kg of midazolam. During the maintenance state of sedation, the patient received 150 µg/kg/min of propofol, and the infusion rate was adjusted in 25 µg/kg/min increments up or down at the discretion of the anesthesiologists to maintain a state of deep sedation. The major targets of this study were recovery profiles (time to awake and time to discharge) and airway-related intervention ratios in pediatric MRI sedation patients. Patient demographics, MRI sedation, and recovery data, including propofol induction dose, airway intervention, and sedation-related adverse events from the pediatric sedation recovery unit were also collected. RESULTS: The mean (standard deviation [SD]) propofol induction dose was higher compared to midazolam group (2.4 [0.7] mg vs. 1.3 [0.5] mg; mean difference, 1.1 mg; P < 0.001). The mean (SD) infusion rate was higher in propofol group compared to midazolam group (161.3 [37.6] µg/min/kg vs. 116.2 [25.6] µg/min/kg; mean difference 45.1 µg/min/kg; P < 0.001). The mean (SD) propofol total dose was higher in propofol group compared to midazolam group (236.3 [102.4] mg vs. 180.7 [80.9] mg; mean difference, 155.4 mg; P < 0.001). The mean (SD) time to awake was longer in midazolam group compared to propofol group (21.2 [5.6] min vs. 23.0 [7.1] min; mean difference, 1.8 min; P < 0.001). The mean (SD) time to discharge was longer in midazolam group compared to propofol group (34.5 [6.9] min vs. 38.6 [9.4] min; mean difference, 4.1 min; 95% confidence interval, 3.0-5.1; P < 0.001). CONCLUSION: The administration of midazolam during pediatric MRI sedation can decrease the frequency of airway complications without prolonging the clinically significant recovery profile.

Résumé Objectif de l'étude:L'objectif de la présente étude était de comparer les profils de récupération et les événements indésirables liés aux voies respiratoires chez les patients pédiatriques sous sédation pour une imagerie par résonance magnétique (IRM) ayant reçu du propofol seul à ceux ayant reçu du midazolam seul.Méthodes:Cette étude de cohorte rétrospective a été approuvée par le Comité d'éthique de l'Université de Mutah (No. 2378). Une recherche dans les dossiers médicaux des patients a été réalisée entre septembre 2021 et avril 2022 pour identifier les enfants âgés de 4 mois à 11 ans ayant reçu du propofol ou du midazolam pour une sédation en IRM. Les patients ont été subdivisés en deux groupes : ceux ayant reçu uniquement du propofol (groupe propofol) et ceux ayant reçu du midazolam (groupe midazolam) pour la sédation pédiatrique en IRM. Dans le groupe propofol, un bolus de 1 à 2 mg/kg de propofol a été administré pour atteindre une sédation profonde (score de 5 sur l'échelle de sédation de Ramsay). Les patients du groupe midazolam ont reçu 0,05 mg/kg de midazolam. Pendant la phase de maintien de la sédation, les patients ont reçu 150 µg/kg/min de propofol, et la vitesse de perfusion a été ajustée par paliers de 25 µg/ kg/min, à la discrétion des anesthésistes, pour maintenir un état de sédation profonde. Les principaux objectifs de cette étude étaient les profils de récupération (temps de réveil et temps de sortie) et les taux d'interventions liées aux voies respiratoires chez les patients pédiatriques sous sédation pour IRM. Les données démographiques des patients, les détails de la sédation en IRM et les données de récupération, y compris la dose d'induction de propofol, les interventions liées aux voies respiratoires, et les événements indésirables liés à la sédation dans l'unité de récupération pédiatrique ont également été collectés.Résultats:La dose moyenne (écart-type [ET]) d'induction de propofol était plus élevée par rapport au groupe midazolam (2,4 [0,7] mg contre 1,3 [0,5] mg; différence moyenne, 1,1 mg; P<0,001). Le taux de perfusion moyen (ET) était plus élevé dans le groupe propofol par rapport au groupe midazolam (161,3 [37,6] µg/min/kg contre 116,2 [25,6] µg/min/kg; différence moyenne, 45,1 µg/min/kg; P<0,001). La dose totale moyenne (ET) de propofol était plus élevée dans le groupe propofol par rapport au groupe midazolam (236,3 [102,4] mg contre 180,7 [80,9] mg; différence moyenne, 155,4 mg; P<0,001). Le temps moyen (ET) pour se réveiller était plus long dans le groupe midazolam par rapport au groupe propofol (21,2 [5,6] min contre 23,0 [7,1] min; différence moyenne, 1,8 min; P<0,001). Le temps moyen (ET) de sortie était plus long dans le groupe midazolam par rapport au groupe propofol (34,5 [6,9] min contre 38,6 [9,4] min; différence moyenne, 4,1 min; intervalle de confiance à 95 %, 3,0­5,1; P<0,001).Conclusion:L'administration de midazolam lors de la sédation pédiatrique pour IRM peut diminuer la fréquence des complications des voies respiratoires sans prolonger de manière significative le profil de récupération clinique.

The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients.

Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.

Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases.

The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.

The Delicate Dance of Intraoperative Anesthesia: Addressing Patient and Anesthesiologist Concerns.

Background In the realm of surgical procedures, patients and anesthesiologists have distinct concerns that can have an impact on their relationship. Patients are often riddled with anxiety about the unknowns of anesthesia and the possible risks. Anesthesiologists, too, face their own set of concerns. Despite the importance of this interaction, there has been little research on the specific concerns of both parties. Our study aims to fill this gap by describing and comparing the concerns of patients and anesthesiologists in Jordan. Methodology This cross-sectional study evaluated anesthesia-related problems based on specific questionnaires. The responses to the questionnaires were on a voluntary basis. The consent of the participants was granted after the aims of the study were clarified. Data were collected and analyzed using SPSS version 28 (IBM Corp., Armonk, NY, USA). Results A total of 155 Jordanian anesthesiologists and 1,858 participants from the population who had undergone anesthesia participated in the study. In general anesthesia, over 60% of the anesthesiologists were most worried about ventilation and intubation difficulties during anesthesia induction and death at the end of anesthesia. Regarding regional anesthesia, the primary concerns included toxicity from local anesthesia infiltration (64.5%) and total spinal anesthesia (49.0%). Patients were concerned about various anesthesia-related scenarios, with the highest worries about pain (3.41/4), a sharp drop in vital signs (3.40/4), and an irregular heartbeat (3.39/4). Female patients, those with lower incomes, and those with a bachelor's degree reported higher anesthesia concern levels. Additionally, anesthesiologists' mean concern score was significantly lower than that of patients. Conclusions Patients concentrated on pain, a drop in vital signs, and irregular heartbeats, whereas anesthesiologists were worried about ventilation, intubation, and hypoxia. Patients placed more emphasis on personal experiences and social factors than technical issues. Therefore, patient education about anesthesia and discussion about intra and postoperative expectations are imperative to improve the surgical experience and the relationship between patients and anesthesiologists.

Palliative Care in Amyotrophic Lateral Sclerosis.

Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease of the motor neurons. Given the evolutive characteristics of this disease, palliative care principles should be a foundation of ALS care. A multidisciplinary medical intervention is of paramount importance in the different phases of disease. The involvement of the palliative care team improves quality of life and symptoms, and prognosis. Early initiation is of paramount importance to ensuring patient-centered care, when the patient has still the capability to communicate effectively and participate in his medical care. Advance care planning supports patients and family members in understanding and sharing their preferences according to their personal values and life goals regarding future medical treatment. The principal problems which require intensive supportive care include cognitive disturbances, psychological distress, pain, sialorrhrea, nutrition, and ventilatory support. Communication skills of health-care professionals are mandatory to manage the inevitability of death. Palliative sedation has peculiar aspects in this population, particularly with the decision of withdrawing ventilatory support.

High-Flow Oxygen Therapy in the Perioperative Setting and Procedural Sedation: A Review of Current Evidence.

High-flow oxygen therapy (HFOT) is a respiratory support system, through which high flows of humidified and heated gas are delivered to hypoxemic patients. Several mechanisms explain how HFOT improves arterial blood gases and enhances patients' comfort. Some mechanisms are well understood, but others are still unclear and under investigation. HFOT is an interesting oxygen-delivery modality in perioperative medicine that has many clinical applications in the intensive care unit (ICU) and the operating room (OR). The purpose of this article was to review the literature for a comprehensive understanding of HFOT in the perioperative period, as well as its uses in procedural sedation. This review will focus on the HFOT definition, its physiological benefits, and their mechanisms, its clinical uses in anesthesia, and when it is contraindicated.

Bone Cement and Its Anesthetic Complications: A Narrative Review.

The concept of bone cement implantation syndrome (BCIS) is not yet fully understood. In patients undergoing cemented hip arthroplasty, it is a significant factor in intraoperative mortality and morbidity. It may also manifest in a milder form postoperatively, resulting in hypoxia and confusion. In the older population, hip replacement surgery is becoming more prevalent. The risks of elderly patients suffering BCIS may be increased due to co-existing conditions. In this article, we present a narrative review of BCIS including its definition, incidence, risk factors, etiology, pathophysiology, clinical features, prevention, and management, all from an anesthetic point of view.

Anti-inflammatory therapies for acute respiratory distress syndrome.

INTRODUCTION: Treatments for the acute respiratory distress syndrome (ARDS) are mainly supportive, and ventilatory management represents a key approach in these patients. Despite progress in pharmacotherapy, anti-inflammatory strategies for the treatment of ARDS have shown controversial results. Positive outcomes with pharmacologic and nonpharmacologic treatments have been found in two different biological subphenotypes of ARDS, suggesting that, with a personalized medicine approach, pharmacotherapy for ARDS can be effective. AREAS COVERED: This article reviews the literature concerning anti-inflammatory therapies for ARDS, focusing on pharmacological and stem-cell therapies, including extracellular vesicles. EXPERT OPINION: Despite advances, ARDS treatments remain primarily supportive. Ventilatory and fluid management are important strategies in these patients that have demonstrated significant impacts on outcome. Anti-inflammatory drugs have shown some benefits, primarily in preclinical research and in specific clinical scenarios, but no recommendations are available from guidelines to support their use in patients with ARDS, except in particular settings such as different subphenotypes, specific etiologies, or clinical trials. Personalized medicine seems promising insofar as it may identify specific subgroups of patients with ARDS who may benefit from anti-inflammatory treatment. However, additional efforts are needed to move subphenotype characterization from bench to bedside.

A Rare Case of Scalp Arteriovenous Malformation in an Adolescent Patient.

Scalp arteriovenous malformations (AVMs) are rare lesions that arise due to a pathological fistulous connection between scalp arterial feeders and draining veins without the involvement of capillary beds. Here, we report a case of a 17-year-old male who presented with an enlarging, pulsatile, mass in the scalp of the parietal region with mild headaches and was diagnosed with a scalp AVM that was treated successfully with endovascular trans-arterial embolization. Scalp AVMs are uncommon extracranial vascular abnormalities that neurosurgeons hardly ever see. To precisely define the angiographic architecture of an AVM and to organize further management, digital subtraction angiography is crucial.

Assessment of Basic Life Support Knowledge Among Medical Students in Jordan: Implications for Improving Out-of-Hospital Cardiac Arrest and Road Traffic Accident Survival Rates.

This study aimed to assess the level of basic life support (BLS) knowledge among fifth- and sixth-year medical students in Jordan, identify differences in knowledge levels between male and female students and between different universities, and provide insights into the current status of BLS training in medical education in Jordan. The study had 570 respondents, with females constituting 61.1% of the sample. The total average score for medical students was 12.24/17 (72%), and there was a considerable variation in the response rate between universities. The study found that students whose source of knowledge was previous college courses had the highest mean score, and only 24.9% knew the proper position of both hands while doing chest compressions. The study underscores the importance of adequate BLS training for healthcare providers to improve survival rates and reduce mortality and morbidity associated with out-of-hospital cardiac arrest and road traffic accidents. The findings of this study could inform future interventions aimed at improving BLS knowledge and skills.

Clinical Characteristics of Spinal versus General Anaesthesia in Older Patients Undergoing Hip Fracture Repair Surgery in Jordan: A Multicentre Study.

BACKGROUND: The primary aim of this study was to examine the clinical characteristics and outcomes of older patients who underwent hip fracture repair surgery. The secondary aims were to assess the predictors of the choice of spinal or general anaesthesia and to explore the risk factors for all-cause mortality. METHODS: This three-tertiary centres study was conducted at a tertiary care centre in Jordan. Clinical data include previous fracture history; medication details; comorbidities; surgical approach; and postoperative pain management. RESULTS: Overall, 1084 patients who underwent hip fracture repair were included in this study. The mean age of patients was 78 years, and 55.2% were women. Twenty-four were treated with bisphosphonates before the fracture, whereas 30 were in steroid therapy. Overall, 61.8% of patients underwent spinal anaesthesia, whereas 38.2% underwent general anaesthesia. Spinal anaesthesia group had a lower prevalence of cardiovascular accidents (16.3% vs. 22.3%, p = 0.014) and Alzheimer's (3.4% vs. 1.4%, p = 0.049) than the general anaesthesia group. In the spinal anaesthesia group, postoperative opioid administration (p = 0.025) and postoperative blood transfusion (p = 0.011) occurred more frequently than general anaesthesia group. In hospital, 30-day and all-cause mortality were comparable between both groups. Diabetes mellitus (HR = 2.6; 95%CI = 1.5-4.4; p = 0.001); cemented hip hemiarthroplasty (HR = 2.4; 95%CI = 1.1-5.1; p = 0.025); deep venous thrombosis/pulmonary embolism (HR = 5.0; 95%CI = 1.2-12.9; p = 0.001); and readmission within 1 month from surgery (HR = 3.6; 95%CI = 2.0-6.3; p < 0.001) were all significant predictors of mortality. CONCLUSIONS: This study provides insights into the outcomes and factors associated with different anaesthesia types in hip fracture repair surgery. The anaesthesia type does not affect all-cause mortality in patients undergoing hip fracture repair.

Effect of expiratory flow limitation on ventilation/perfusion mismatch and perioperative lung function during pneumoperitoneum and Trendelenburg position.

BACKGROUND: Laparoscopic surgery and Trendelenburg position may affect the respiratory function and alter the gas exchange. Further the reduction of the lung volumes may contribute to the development of expiratory flow limitation (EFL). The latter is associated with an increased risk of postoperative pulmonary complications. Our aim was to investigate the incidence of EFL and to evaluate its effect on pulmonary function and intraoperative V/Q mismatch. METHODS: This is a prospective study on patients undergoing elective laparoscopic gynecological surgery. We evaluated respiratory mechanics, V/Q mismatch and presence of EFL after anesthesia induction, during pneumoperitoneum and Trendelenburg position and at the end of surgery. Intraoperative gas exchange and hemodynamic were also recorded. Clinical data were collected until seven days after surgery to evaluate the onset of pulmonary postoperative complications (PPCs). RESULTS: Among the 66 patients enrolled, 25/66 (38%) exhibited EFL during surgery, of whom 10/66 (15%) after anesthesia induction, and the remaining 15 patients after pneumoperitoneum and Trendelenburg position. Median PEEP able to reverse flow limitation was 7 [7-10] cmH2O after anesthesia induction and 9 [8-15] cmH2O after pneumoperitoneum and Trendelenburg position. Patients with EFL had significantly higher shunt (17 [2-25] vs. 9 [1-19]; P=0.05), low V̇/Q̇ (27 [20-70] vs. 15 [10-22]; P=0.05) and high V̇/Q̇ (10 [7-14] vs. 6 [4-7]; P=0.024). At the end of surgery, only high V/Q was significantly higher in EFL patients. Further, they exhibited higher incidence of postoperative pulmonary complication (48% (12/25) vs. 15% (6/41), P=0.005), hypoxemia and hypercapnia (80% [20/25] vs. 32% [13/41]; P<0.001). CONCLUSIONS: Expiratory flow limitation is a common phenomenon during gynecological laparoscopic surgery associated with worsen gas exchange, increased V/Q mismatch and altered lung mechanics. Our study showed that patients experiencing EFL during surgery showed a higher risk for PPCs.

Norepinephrine May Exacerbate Septic Acute Kidney Injury: A Narrative Review.

Sepsis, the most serious complication of infection, occurs when a cascade of potentially life-threatening inflammatory responses is triggered. Potentially life-threatening septic shock is a complication of sepsis that occurs when hemodynamic instability occurs. Septic shock may cause organ failure, most commonly involving the kidneys. The pathophysiology and hemodynamic mechanisms of acute kidney injury in the case of sepsis or septic shock remain to be elucidated, but previous studies have suggested multiple possible mechanisms or the interplay of multiple mechanisms. Norepinephrine is used as the first-line vasopressor in the management of septic shock. Studies have reported different hemodynamic effects of norepinephrine on renal circulation, with some suggesting that it could possibly exacerbate acute kidney injury caused by septic shock. This narrative review briefly covers the updates on sepsis and septic shock regarding definitions, statistics, diagnosis, and management, with an explanation of the putative pathophysiological mechanisms and hemodynamic changes, as well as updated evidence. Sepsis-associated acute kidney injury remains a major burden on the healthcare system. This review aims to improve the real-world clinical understanding of the possible adverse outcomes of norepinephrine use in sepsis-associated acute kidney injury.

Role of aspirin, beta-blocker, statins, and heparin therapy in septic patients under mechanical ventilation: a narrative review.

Sepsis is the main cause of death among patients admitted to intensive care units. Management of sepsis includes fluid resuscitation, vasopressors, intravenous antimicrobials, source control, mechanical ventilation, and others. New insights into the potential benefits of non-antimicrobial drugs in sepsis have evolved based on the pathophysiology of the disease and the mechanism of action of some drugs, but the findings are still controversial. In this study, we aimed to evaluate the effect of beta-blockers, aspirin, statins, and heparin as adjunctive treatments in septic patients under mechanical ventilation with non-cardiovascular diseases and their effect on mortality. We searched PubMed with relevant keywords (beta-blockers, aspirin, statins, or heparin, and critically ill or sepsis) for the last 10 years and some personal collection of relevant articles, and then we assessed studies according to prespecified inclusion and exclusion criteria. Our results show that beta-blockers, aspirin, and heparin may have promising feedback on reducing mortality. However, new well-controlled, randomized, multicenter studies are needed to confirm that, and multiple issues regarding their usage need to be addressed. On the other hand, the feedback regarding the effectiveness of statins was not as strong as that of the other drugs studied, and we suggest that further research is needed to confirm these results.

Double neuraxial catheter (Subarachnoid and epidural) in obese patient cancer surgery: A case report.

Introduction: Morbid obesity is one of the major concerns when performing surgeries, due to higher risks of anesthetic complications. Combined spinal and epidural (CSE) anesthesia technique is used effectively in variety of surgical procedures. Case presentation: Our patient is a 58-year old female with a Body Mass Index (BMI) of 44.53 who presented to the emergency department complaining of an abdominal pain of a renal nature. She was found to have an abdominal mass suggestive of anexial mass or a Gastro Intestinal Stromal Tumor (GIST) and was scheduled for surgery. Due to the risks associated with general anesthesia, a double neuraxial catheter (subarachnoid and epidural) was the anesthitic method of choice. Discussion: Overweight and obesity represent a rapidly growing threat to the health of populations in an increasing number of countries. The first report using the double catheter technique described a parturient with a BMI of 76 kg/m2 who had a lumbar Combined Spinal Epidural (CSE) catheter placed for intraoperative anesthesia and postoperative pain management. In the published literature CSE technique use is limited to obstetric procedure of obese females. Conclusion: In our case it is highlighted how an obese patient, with severe comorbidities that can jeopardize the success of the treatments, can be discharged in a few days by performing an "unconventional" but effective anesthetic technique.

Post-COVID-19 syndrome symptoms after mild and moderate SARS-CoV-2 infection.

Background: Post-COVID-19 Syndrome (PCS) is characterized by residual symptoms following the initial recovery from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The prevalence of PCS is known to be the highest among severe and critical forms of the disease. However, the occurrence and risk factors for PCS after mild or moderate SARS-CoV-2 infection has not been extensively investigated. Methods: Online and offline via both paper or mailed questionnaires distributed among Jordan collected between 1st and 21st August 2021, including a total number of 800 respondents, of whom 495 had previous mild to moderate COVID-19 infection. The Newcastle post-COVID syndrome Follow-up Screening Questionnaire was modified, translated, and used as a standard instrument for data collection regarding psychological, medical, and socio-economic symptoms post-infection. The primary outcome was the prevalence of PCS after mild to moderate COVID-19 in Jordan. Secondary outcome was the identification of PCS risk factors. Results: The most common PCS symptom was mood disturbance followed by fatigue, anxiety, and myalgia. Female gender significantly increased the risk for multiple PCS symptoms. Age < 30 years was found to be an independent risk factor for myalgia (p = 0.001). Conclusion: PCS is highly prevalent among COVID-19 survivors in Jordan, especially in females and patients with comorbidities. Planning physical and mental rehabilitation services is recommended for those patients with PCS symptoms after mild to moderate COVID-19 infection.