Cuffed versus uncuffed endotracheal tubes in neonates undergoing noncardiac surgeries: A randomized controlled trial.

BACKGROUND: The efficacy and safety of cuffed endotracheal tubes (ETTs) in neonates are still unclear, this study aimed to assess the efficacy of cuffed versus uncuffed ETTs in neonate undergoing noncardiac surgeries. METHODS: Neonates scheduled for noncardiac surgeries were randomized into two groups according to the type of airway device during general anesthesia: cuffed ETT group (n = 60) and the uncuffed ETT group (n = 60). The primary outcome was the incidence of ETT exchange to find the appropriate ETT. Other outcomes included: duration of intubation, lung ultrasound score, and incidence of postoperative complications (croup, wheezes, hypoxia, etc.). RESULTS: The frequency of ETT exchange was lower in the cuffed ETT group compared to the uncuffed one {1 (1.7%) vs. 28 (46.7%), p = .0001; relative risk [95% confidence interval]: 0.54 [0.43-0.69]}. Postoperative adverse events were comparable between both groups except for significantly higher post extubation croup in the uncuffed ETT group compared to the cuffed ETT {10 (16.7%) vs. 3(5%), p value = .04, relative risk (95% confidence interval): 1.14 (1-1.29)}. CONCLUSION: In full term neonates undergoing noncardiac surgeries, the use of cuffed ETT was associated with less need to tracheal tube exchange and less incidence of postoperative croup, without increasing the postoperative respiratory complications compared to uncuffed ETT.

Lung Ultrasound Assisted Comparison of Volume Effects of Fluid Replacement Regimens in Pediatric Patients Undergoing Penile Hypospadias Repair: A Randomized Controlled Trial.

BACKGROUND: Effective perioperative fluid therapy is a great consideration. OBJECTIVES: Using lung ultrasound (LUS), this study evaluated the preference of the conventional and restrictive fluid replacement regimens for their volume impact in pediatric patients undergoing a relatively long procedure with limited volume loss (hypospadias repair). METHODS: Eighty pediatric patients scheduled for hypospadias repair surgery were enrolled for conventional (CG) or restrictive fluid management groups (RG). The CG obtained Ringer's lactate at the conventional calculated doses, while the RG obtained infusion of Ringer's lactate at a rate of 3 mL/kg/h. B-line numbers in the LUS, recovery score, urine output, blood pressure (BP), heart rate HR, and oxygen saturation (SpO2) were recorded. RESULTS: As evidenced by the LUS, RG showed a higher incidence of normal lung morphology with a mean and SD of 1.3 ± 2.2 for B-line numbers, whereas, in CG, they were 3.1 ± 2.2 with a P-value < 0.001. Urine output was 3.2 ± 0.8 and 2.9 ± 0.7 for CG and RG, respectively, with a P-value equal to 0.07. HR, BP, and SpO2 differences between groups were statistically insignificant. The recovery score was higher in RG (5.8 ± 0.4) than in CG (5.1 ± 0.8) at the first postoperative 20 minutes, with a P-value < 0.001. CONCLUSIONS: In lengthy procedures with limited volume loss, using a moderately restrictive regimen is preferred over the conventional intraoperative fluid regimen considering both respiratory dysfunctions and recovery score.

Ischemia-modified Albumin as a Biomarker for Prediction of Poor Outcome in Patients With Traumatic Brain Injury: An Observational Cohort Study.

BACKGROUND: Biomarkers can assist in outcome prediction and therapeutic decision making after traumatic brain injury (TBI). The aim of this study was to evaluate the role of ischemia-modified albumin (IMA) in the prediction of mortality in patients with TBI. METHODS: In this observational study IMA was measured on admission to intensive care unit (D0) and 24 hours later (D1) in a cohort of patients with mixed TBI severity. The primary outcome was the correlation between IMA and 28-day mortality. Secondary outcomes included the incidence of elevated IMA, and the correlation between the severity of TBI and IMA, and between IMA and change in Glasgow coma score (GCS). The area under receiver operating characteristic curve analysis was performed to detect optimal IMA cut-off value for the detection of mortality. RESULTS: Fifty-four patients were included in the study; IMA was elevated in 49 (90.7%) on admission to the intensive care unit. Of the 49 patients with elevated IMA, 22 had a decrease in IMA while 27 had an increase by 24 hours. IMA levels were higher at D0 and D1 (P<0.001 for both) in patients who died compared with those who survived. Twenty-one patients died (mortality rate 38.9%); all had elevated IMA on D0 and D1 and higher IMA levels at D1 compared with D0. Optimal cut-off values for IMA predicted mortality with 76.2% sensitivity and 81.8% specificity at D0 and with 100% sensitivity and specificity at D1. IMA values at D0 and D1 were correlated with D0 and D1 GCS, respectively (both P<0.001). CONCLUSION: IMA levels were elevated in patients following TBI, and can predict mortality with high sensitivity and specificity.

Comparison of two Norepinephrine rescue bolus for Management of Post-spinal Hypotension during Cesarean Delivery: a randomized controlled trial.

BACKGROUND: Data on the best norepinephrine bolus dose for management of hypotension are limited. The aim of this study was to compare the efficacy and safety of two norepinephrine bolus doses in the rescue management of maternal hypotension during cesarean delivery. METHODS: This randomized, controlled trial included mothers scheduled for cesarean delivery with spinal anesthesia with a prophylactic norepinephrine infusion. Following spinal anaesthesia administration, a participant was considered hypotensive if systolic blood pressure was ≤80% compared to the baseline reading. Participants were allocated to receive either 6 mcg or 10 mcg norepinephrine bolus for the management of hypotensive episodes. The hemodynamic response after administration of norepinephrine bolus was recorded. The episode was considered successfully managed if systolic blood pressure returned to within 80% from the baseline reading within 2 min after norepinephrine bolus administration, and did not drop again within 6 min after the norepinephrine bolus. The primary outcome was the incidence of successful management of the first hypotensive episode. Other outcomes included systolic blood pressure, heart rate, incidence of maternal bradycardia, and reactive hypertension. RESULTS: One hundred and ten mothers developed hypotensive episodes and received norepinephrine boluses for management. The number of successfully managed first hypotensive episodes was 50/57 (88%) in the 6 mcg-treated episodes and 45/53 (85%) in the 10 mcg-treated episodes (p = 0.78). Systolic blood pressure was comparable after administration of either bolus dose. Heart rate was lower after administration of 10 mcg bolus compared to 6 mcg bolus, without significant bradycardia requiring atropine administration. The incidence of reactive hypertension was comparable between both groups. CONCLUSION: In mothers undergoing elective cesarean delivery under prophylactic norepinephrine infusion at 0.05 mcg/kg/min, there was no advantage to the use of 10 mcg norepinephrine bolus over 6 mcg norepinephrine bolus for the rescue management of first hypotensive episode. Neither of the 2 bolus doses reached a 100% success rate. The incidences of bradycardia and reactive hypertension were comparable between both norepinephrine doses. TRIAL REGISTRATION: At clinicaltrial.gov registry system on January 4, 2019 Clinical trial identifier: NCT03792906.