Management of the Traumatized Airway.

There is a lack of evidence-based approach regarding the best practice for airway management in patients with a traumatized airway. General recommendations for the management of the traumatized airway are summarized in table 5. Airway trauma may not be readily apparent, and its evaluation requires a high level of suspicion for airway disruption and compression. For patients with facial trauma, control of the airway may be significantly impacted by edema, bleeding, inability to clear secretions, loss of bony support, and difficulty with face mask ventilation. With the airway compression from neck swelling or hematoma, intubation attempts can further compromise the airway due to expanding hematoma. For patients with airway disruption, the goal is to pass the tube across the injured area without disrupting it or to insert the airway distal to the injury using a surgical approach. If airway injury is extensive, a surgical airway distal to the site of injury may be the best initial approach. Alternatively, if orotracheal intubation is chosen, spontaneous ventilation may be maintained or RSI may be performed. RSI is a common approach. Thus, some of the patients intubated may subsequently require tracheostomy. A stable patient with limited injuries may not require intubation but should be watched carefully for at least several hours. Because of a paucity of evidence-based data, the choice between these approaches and the techniques utilized is a clinical decision depending on the patient's condition, clinical setting, injuries to airway and other organs, and available personnel, expertise, and equipment. Inability to obtain a definitive airway is always an absolute indication for an emergency cricothyroidotomy or surgical tracheostomy.

Pharmaceutical amorphous solid dispersion: A review of manufacturing strategies.

Amorphous solid dispersions (ASDs) are popular for enhancing the solubility and bioavailability of poorly water-soluble drugs. Various approaches have been employed to produce ASDs and novel techniques are emerging. This review provides an updated overview of manufacturing techniques for preparing ASDs. As physical stability is a critical quality attribute for ASD, the impact of formulation, equipment, and process variables, together with the downstream processing on physical stability of ASDs have been discussed. Selection strategies are proposed to identify suitable manufacturing methods, which may aid in the development of ASDs with satisfactory physical stability.

Effect of COVID-19 on the Organs.

The COVID-19 pandemic that first became apparent in Wuhan, China, is now infecting millions all over the world. This is a review of COVID-19's extensive effects on virtually all the organs. It causes inflammation, endotheliitis, vasoconstriction, hypercoagulability, and edema. Lymphocytopenia, elevated D-dimer, elevated fibrin degradation products (FDPs), and disseminated intravascular coagulation (DIC) are observed. Deep vein thrombosis (DVT), venous thromboembolism, pulmonary embolism (PE), systemic and pulmonary arterial thrombosis and embolism, ischemic stroke, and myocardial infarction (MI) are reported. In the heart it can cause acute coronary syndrome, congestive heart failure, myocarditis, and arrhythmias. Kidney injury is usually secondary to systemic abnormalities. Stroke occurs even in young patients. Delirium and seizures are common. Anosmia and impaired sense of taste are reported. Psychological problems are common among patients as well as providers. Stool may contain virus. Lactate dehydrogenase may be elevated. Various skin manifestations including patchy erythematous rash are reported.

Risk of COVID-19 due to Shortage of Personal Protective Equipment.

The supply of personal protective equipment (PPE) is inadequate throughout the United States and the world. This is especially true of N95 respirators. The cost of PPE is high. There are numerous cases of providers working with inadequate PPE and being disciplined on complaining. In the United States, thousands of providers have contracted COVID-19, in part due to inadequate PPE. Extended use and reuse of N95 respirators has been permitted by the Centers for Disease Control and Prevention (CDC). The N95 respirators can be sterilized utilizing vaporized hydrogen peroxide, ultraviolet germicidal irradiation, or dry heat at 70°C-80°C. The risk to providers due to inadequate PPE increases with their age and presence of comorbidities. African-Americans and Latinos are at a greater risk. CDC recommends that in the absence of appropriate PPE, "exclude healthcare personnel at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients." Providing care without appropriate PPE should not be a condition of employment for any provider, especially for the ones in high-risk category.

Increased interleukin-6 after cardiac surgery predicts infection.

Early diagnosis and treatment of infection after cardiac surgery with cardiopulmonary bypass (CPB) improves outcome. Conventional laboratory tests, such as C-reactive protein and white blood cell count can not distinguish patients with early infection from those with systemic inflammatory response syndrome but without infection. After CPB, there is a systemic release of proinflammatory and antiinflammatory cytokines, including tumor necrosis factor-alpha, interleukin (IL)-6, and IL-10. We investigated the predictive ability of these variables for infection after cardiac surgery. Forty-six patients with impaired left ventricular ejection fraction (<60%), scheduled for cardiac surgery, were included. Plasma samples were drawn 1 day before and immediately before surgery, on admission to the intensive care unit, and on days 1, 3, and 7 after surgery. Infection was identified according to the criteria of the Centers for Disease Control and Prevention. After surgery 13 patients developed an infection. In patients with infection, confirmed a median of 4 days after surgery, all measurements of IL-6, and IL-10 on postoperative day 3 were significantly increased. Tumor necrosis factor-alpha, leukocytes, and C-reactive protein were not increased in these patients. Immediately after surgery blood glucose was significantly increased in patients with infection. Increased IL-6 after CPB is predictive of infection after cardiac surgery in patients with impaired left ventricular function.

Small-dose epoprostenol decreases systemic oxygen consumption and splanchnic oxygen extraction during normothermic cardiopulmonary bypass.

Normothermic, nonpulsatile cardiopulmonary bypass (CPB) impairs systemic and splanchnic oxygen transport and increases gastrointestinal permeability. It is an important therapeutic goal to avoid splanchnic dysoxia during CPB. Small-dose prostacyclin therapy improves splanchnic oxygen transport and microcirculation in septic patients. In this study, we sought to determine if during cardiac surgery, the prostacyclin analog epoprostenol improves the balance of systemic and splanchnic oxygen transport. Eighteen patients undergoing cardiac valve replacement were randomized to receive either epoprostenol (3 ng x kg(-1) x min(-1)) or placebo during, and for 1 hour after, surgery. Systemic and splanchnic oxygen delivery, consumption, and extraction and arterial, mixed venous, and hepato-venous lactate concentrations were measured before, during, and after CPB. Gastrointestinal permeability was measured 1 day before and 1 day after surgery using the triple sugar permeability test. During CPB, the epoprostenol group had decreased systemic oxygen consumption and splanchnic oxygen extraction (P = 0.024). These effects were not present 1 hour after the end of epoprostenol infusion. The study was not adequately powered to determine whether epoprostenol altered the trend towards increased lactate metabolism and increased postoperative gastrointestinal permeability, nor could we demonstrate any differences between groups in clinically relevant end-points. In conclusion, these findings suggest that during normothermic CPB, small-dose epoprostenol therapy may reduce systemic oxygen consumption and splanchnic oxygen extraction.

Prodrugs of perzinfotel with improved oral bioavailability.

Previous studies with perzinfotel (1), a potent, selective, competitive NMDA receptor antagonist, showed it to be efficacious in inflammatory and neuropathic pain models. To increase the low oral bioavailability of 1 (3-5%), prodrug derivatives (3a-h) were synthesized and evaluated. The oxymethylene-spaced diphenyl analogue 3a demonstrated good stability at acidic and neutral pH, as well as in simulated gastric fluid. In rat plasma, 3a was rapidly converted to 1 via 2a. Pharmacokinetic studies indicated that the amount of systemic exposure of 1 produced by a 10 mg/kg oral dose of 3a was 2.5-fold greater than that produced by a 30 mg/kg oral dose of 1. Consistent with these results, 3a was significantly more potent and had a longer duration of activity than 1 following oral administration in a rodent model of inflammatory pain. Taken together, these results demonstrate that an oxymethylene-spaced prodrug approach increased the bioavailability of 1.