Anesthesiological management of Brugada syndrome patients: A systematic review.

Brugada syndrome (BrS) is a major risk factor for sudden cardiac death and ventricular tachyarrhythmias. Several drugs are contraindicated in patients with BrS, including some commonly administered drugs during anesthesia or in the perioperative period; however, there is still a paucity of evidence regarding BrS and common anesthetic pharmaceuticals. We conducted a systematic literature search (PubMed, updated October 10, 2022), including all studies reporting pharmacological management of BrS patients during anesthesia or intensive care, with a specific focus on proarrhythmic effects and possible pharmacological interactions in the context of BrS. The search revealed 44 relevant items, though only three original studies. Two randomized controlled studies were identified, one comparing propofol and etomidate for the induction of general anesthesia and one investigating lidocaine with or without epinephrine for local anesthesia; there was also one prospective study without a control group. The other studies were case series (n = 5, for a total of 19 patients) or case reports (n = 36). Data are reported on a total population of 199 patients who underwent general or local anesthesia. None of the studies evaluated BrS patients in the intensive care unit (ICU). We found the studies focusing on the pharmacological management of BrS patients undergoing general or local anesthesia to be of generally poor quality. However, it appears that propofol can be used safely, without an increase in arrhythmic events. Regional anesthesia is possible, and lidocaine might be preferred over longer-acting local anesthetics. Considering the quality of the included studies and their anecdotal evidence, it seems increasingly important to conduct large multicenter studies or promote international registries with high-quality data on the anesthesiological management of these patients.

Use of ketamine in patients with refractory severe asthma exacerbations: systematic review of prospective studies.

PURPOSE: Asthma is a heterogeneous disease with a wide range of symptoms. Severe asthma exacerbations (SAEs) are characterized by worsening symptoms and bronchospasm requiring emergency department visits. In addition to conventional strategies for SAEs (inhaled ß-agonists, anticholinergics, and systemic corticosteroids), another pharmacological option is represented by ketamine. We performed a systematic review to explore the role of ketamine in refractory SAEs. METHODS: We performed a systematic search on PubMed and EMBASE up to August 12th, 2021. We selected prospective studies only, and outcomes of interest were oxygenation/respiratory parameters, clinical status, need for invasive ventilation and effects on weaning. RESULTS: We included a total of seven studies, five being randomized controlled trials (RCTs, population range 44-92 patients). The two small prospective studies (n = 10 and n = 11) did not have a control group. Four studies focused on adults, and three enrolled a pediatric population. We found a large heterogeneity regarding sample size, age and gender distribution, inclusion criteria (different severity scores, if any) and ketamine dosing (bolus and/or continuous infusion). Of the five RCTs, three compared ketamine to placebo, while one used fentanyl and the other aminophylline. The outcomes evaluated by the included studies were highly variable. Despite paucity of data and large heterogeneity, an overview of the included studies suggests absence of clear benefit produced by ketamine in patients with refractory SAE, and some signals towards side effects. CONCLUSION: Our systematic review does not support the use of ketamine in refractory SAE. A limited number of prospective studies with large heterogeneity was found. Well-designed multicenter RCTs are desirable.

Hemoperfusion and blood purification strategies in patients with COVID-19: A systematic review.

BACKGROUND: Coronavirus disease-19 (COVID-19) ranges from asymptomatic infection to severe cases requiring admission to the intensive care unit. Together with supportive therapies (ventilation in particular), the suppression of the pro-inflammatory state has been a hypothesized target. Pharmacological therapies with corticosteroids and interleukin-6 (IL-6) receptor antagonists have reduced mortality. The use of extracorporeal cytokine removal, also known as hemoperfusion (HP), could be a promising non-pharmacological approach to decrease the pro-inflammatory state in COVID-19. METHODS: We conducted a systematic review of PubMed and EMBASE databases in order to summarize the evidence regarding HP therapy in COVID-19. We included original studies and case series enrolling at least five patients. RESULTS: We included 11 articles and describe the characteristics of the populations studied from both clinical and biological perspectives. The methodological quality of the included studies was generally low. Only two studies had a control group, one of which included 101 patients in total. The remaining studies had a range between 10 and 50 patients included. There was large variability in the HP techniques implemented and in clinical and biological outcomes reported. Most studies described decreasing levels of IL-6 after HP treatment. CONCLUSION: Our review does not support strong conclusions regarding the role of HP in COVID-19. Considering the very low level of clinical evidence detected, starting HP therapies in COVID-19 patients does not seem supported outside of clinical trials. Prospective randomized data are needed.

Distribution of trace elements in the tissues of smooth hound Mustelus mustelus (Linnaeus, 1758) from the southern-eastern waters of Mediterranean Sea (Italy).

Trace element concentrations (Hg, Cd, Pb, Cr, Ni, Cu, Zn) were determined in the muscle, gonads, skin, and brain of smooth hound Mustelus mustelus in order to define the metal distribution patterns. The data indicated that metal accumulation depended on the tissues probably as a consequence of metabolic needs, physiochemical properties, and detoxification processes specific for each element. Metal concentrations were higher in gonads (Hg 0.10-0.70 µg g(-1); Cd 0.02-0.10 µg g(-1); Pb 0.08-0.39 µg g(-1); Cr 0.06-0.36 µg g(-1); Ni 1.37-3.00 µg g(-1); Zn 9.15-16.30 µg g(-1); Cu 1.95-21.62 µg g(-1)) and skin (Hg 0.16-0.66 µg g(-1); Cd 0.01-0.04 µg g(-1); Pb 0.10-0.62 µg g(-1); Cr 0.15-0.68 µg g(-1); Ni 1.60-7.20 µg g(-1); Zn 9.00-16.00 µg g(-1); Cu 0.78-6.80 µg g(-1)) than brain (Hg 0.04-0.34 µg g(-1); Cd 0.01-0.05 µg g(-1); Pb 0.03-0.59 µg g(-1); Cr 0.08-0.48 µg g(-1); Ni 5.59-9.69 µg g(-1); Zn 5.90-7.35 µg g(-1); Cu 0.90-4.02 µg g(-1)), while muscle always exhibited the lowest levels (Hg 1.03-2.58 µg g(-1); Cd 0.01-0.06 µg g(-1); Pb 0.02-0.16 µg g(-1); Cr 0.05-0.28 µg g(-1); Ni 1.13-2.48 µg g(-1); Zn 2.64-5.06 µg g(-1); Cu 0.33-2.23 µg g(-1)). Ni and Hg took exception having the highest concentrations in brain and muscle, respectively. An assessment of the risk for human due to the consumption of these marine organisms was also undertaken. Regarding Cd and Pb intakes, consumption did not guide to any concerns, while it should be extremely moderate when considering Hg intake. The comparative analyses revealed that Mediterranean sharks were exposed to higher Hg levels than biota inhabiting open ocean.

Occurrence of toxic metals (Hg, Cd and Pb) in fresh and canned tuna: public health implications.

Hg, Pb and Cd levels in fresh and canned tuna were determined and assessed by comparing element levels in these samples with maximum permissible limits set by European legislation. The estimated weekly intakes by human consuming both fresh and canned tuna were also evaluated for possible consumer health risks. Among tested metals, Hg had the highest concentrations, followed by Pb and Cd either in fresh tuna or canned tuna. None of the tested samples surpassed the European regulatory limits fixed for Cd and Pb, whereas 8.9% of the tuna cans and 20% of fresh tuna samples exceeded standard for Hg. The size of tuna was a determining factor of Hg burden. A high intake of Hg surpassing the toxicological reference value established by WHO, was associated with consumption of larger size tuna specimens. Also canned tuna consumption with Hg concentrations higher than 1 µg kg(-1), strongly increased the consumer exposure. In contrast, Cd and Pb weekly intakes through consumption either of fresh tuna or canned tuna did not exceed the toxicological reference values established by WHO, and consequently there was no human health risk. A continuous surveillance system of Hg content in these fishery products is crucial for consumer protection.