Protamine dosing and its impact in cardiac surgery transfusion practice-A retrospective bi-institutional analysis.

BACKGROUND: Bleeding after cardiac surgery is common and continues to require 10-20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective bi-institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)-assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)-low-ratio group (Protamine: UFH ≤ 0.8) and high-ratio group (Protamine: UFH > 0.8). RESULTS: We observed a higher rate of blood transfusion required in high-ratio group (ratio >0.8) compared with low-ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate. CONCLUSION: High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.

The incidence of increased ICP in ICU patients with non-traumatic coma as diagnosed by ONSD and CT: a prospective cohort study.

BACKGROUND: Unexplained coma after critical illness can be multifactorial. We evaluated the diagnostic ability of bedside Optic Nerve Sheath Diameter [ONSD] as a screening test for non-traumatic radiographic cerebral edema. METHODS: In a prospective study, mixed medical-surgical intensive care units [ICU] patients with non-traumatic coma [GCS < 9] underwent bedside ultrasonographic ONSD measurements. Non-traumatic radiographic cerebral edema [NTRCE] was defined as > 5 mm midline shift, cisternal, sulcal effacement, or hydrocephalus on CT. RESULTS: NTRCE was identified in 31 of 102 patients [30.4 %]. The area under the ROC curve for detecting radiographic edema by ONSD was 0.785 [95 % CI 0.695-0.874, p <0.001]. ONSD diameter of 0.57 cm was found to be the best cutoff threshold with a sensitivity 84 % and specificity 71 %, AUC 0.785 [95 % CI 0.695-0.874, p <0.001]. Using ONSD as a bedside test increased the post-test odds ratio [OR] for NTRCE by 2.89 times [positive likelihood ratio], whereas post-test OR for NTRCE decreased markedly given a negative ONSD test [ONSD measurement less than 0.57 cm]; negative likelihood ratio 0.22. CONCLUSIONS: The use of ONSD as a bedside test in patients with non-traumatic coma has diagnostic value in identifying patients with non-traumatic radiographic cerebral edema.

Sodium-glucose cotransporter-2 inhibitors improve cardiovascular outcomes post-acute coronary syndrome complicated by acute heart failure.

Background: Acute coronary syndrome (ACS) remains a risk factor for heart failure (HF). Therefore, we aimed to assess the cardioprotective role of sodium-glucose cotransporter-2 (SGLT2) inhibitors post-ACS in patients with acute HF (AHF) and diabetes. Methods: We conducted a retrospective observational cohort study employing propensity score matching. This study involved patients with diabetes admitted with ACS complicated by AHF, defined as either new clinical HF requiring diuretics during the index admission or having an ejection fraction (EF) of <40%. The study population was divided into two groups; (1) SGLT2 inhibitor users and (2) SGLT2 inhibitor non-users. The Cox proportional hazard regression analysis was used to evaluate the outcomes. Results: A total of 465 patients (93% male; mean age, 55 ± 10 years) were included in this study. Using a 1 : 1 propensity score matching, 78 patients were included per arm with an absolute standardized difference of <0.1 for all baseline characteristics. The use of SGLT2 inhibitors resulted in lower composite outcomes of ACS, HF hospitalization, and all-cause mortality at 1 month and 12 months [1 month: 2.6% vs. 11.5%, HR = 0.20 (0.04-0.94), p = 0.041; 12 months: 14.1% vs. 23.1%, HR = 0.46 (0.22-0.99), p = 0.046]. Conclusion: The findings suggest that SGLT2 inhibitors may confer cardioprotective effects in ACS-induced AHF, thereby widening the spectrum for indications of SGLT2 inhibitors.

Atypical presentation to rocuronium allergy in a 19-year-old female patient.

The danger of anaphylaxis, a rare but life threatening complication of general anesthesia (GA) can be summarized in two: 1. General Anesthesia masks the typical early signs of allergy which can be seen in an awake patient. 2. Anaphylaxis during GA manifests mostly as circulatory/ventilatory failures which can be interpreted as adverse effects of anesthetics or surgery and this can lead to critical delay of effective therapy. A 19-year-old female admitted for posterior spinal fusion and instrumentation (the 5th surgery in patient's life) desaturated seconds after intubation. Cardiopulmonary resuscitation (CPR) was started and the absence of cutaneous signs along with a loud holosystolic murmur were questioned. The patient was promptly resuscitated and allergy to rocuronium was confirmed by intradermal tests 6weeks later. Factors influencing decision making and potential etiology of the newly heard holosystolic murmur during anaphylaxis are discussed.

Repair of Thoracoabdominal Aortic Aneurysm with Thrombosed Infrarenal Component: A Modified Hybrid Technique without Aortic Cross Clamping.

The authors report the successful repair of a Crawford type III thoracoabdominal aortic aneurysm (TAAA) with a thrombosed infrarenal component using a modified hybrid technique without aortic clamping in a high-risk patient. A 64-year-old male with a history of hypertension, diabetes, and severe chronic obstructive pulmonary disease presented with acute on chronic backache and bilateral short distance claudication. A computerized tomography scan demonstrated a large, nonleaking Crawford type III TAAA with thrombosed infrarenal component of the aneurysm. In addition, both common iliac arteries were occluded with the chronic thrombus. A single-stage, modified hybrid procedure involving an aortobifemoral bypass without aortic clamping, debranching of right renal, superior mesenteric, and celiac arteries as well as an endovascular repair of the thoracic aneurysm was performed. Unfortunately, despite a technically sound repair, the patient died postoperatively from a massive pulmonary embolism. TAAA with a thrombosed infrarenal aorta and bilateral common iliac arteries can be repaired using a single-stage modified hybrid procedure without aortic clamping in high-risk patients who cannot tolerate thoracotomy and aortic cross clamping.

Adnexal masses in pregnancy: An updated review.

Adnexal masses in pregnancy are not commonly encountered. The majority of these masses are discovered incidentally during routine follow-up. However, some of these masses become symptomatic due to their size, location, and impingement of adjacent structures. Several diagnostic modalities can be utilized for the detection of adnexal masses with different sensitivity and specificity rates. The differential diagnosis of adnexal masses discovered during pregnancy is broad and includes both benign and malignant lesions. The management of such lesions has been a subject of debate for years with no consensus regarding the best management plan. Tumor size, site, and the trimester of mass detection are all crucial in management. In this account, we review adnexal masses discovered in pregnancy, the diagnostic modalities utilized for detecting these lesions, their differential diagnosis, and management strategies.

Simple Renal Cysts as Markers of Thoracic Aortic Disease.

BACKGROUND: Thoracic aortic aneurysm is usually a clinically silent disease; timely detection is largely dependent upon identification of clinical markers of thoracic aortic disease (TAD); (bicuspid aortic valve, intracranial aortic aneurysm, bovine aortic arch, or positive family history). Recently, an association of simple renal cysts (SRC) with abdominal aortic aneurysm and aortic dissection was established. The aim of our study was to evaluate the prevalence of SRC in patients with TAD in order to assess whether the presence of SRC can be used as a predictor of TAD. METHODS AND RESULTS: We evaluated the prevalence of SRC in 842 patients with TAD (64.0% males) treated at our institution from 2004 to 2013 and compared to a control group of patients (n=543; 56.2% males). Patients were divided into 4 groups: ascending aortic aneurysm (456; 54.2%); descending aortic aneurysm (86; 10.2%); type A aortic dissection (118; 14.0%); and type B aortic dissection (182; 21.6%). SRC were identified by abdominal computed tomography or magnetic resonance imaging of these patients. Prevalence of SRC is 37.5%, 57.0%, 44.1%, and 47.3% for patients with ascending aneurysm, descending aneurysm, type A dissection, and type B dissection, respectively. Prevalence of SRC in the control group was 15.3%. Prevalence of SRC was not significantly different between male and female aortic disease patients, despite reported general male predominance (2:1), which was also observed in our control group (1.7:1). CONCLUSIONS: This study establishes an increased prevalence of SRC in patients with TAD. SRC can potentially be used as a marker for timely detection of patients at risk of TAD.

Current Experience With Acute Type B Aortic Dissection: Validity of the Complication-Specific Approach in the Present Era.

BACKGROUND: Our group proposed in 1992 a "complication-specific approach" for the management of acute aortic dissection type B (TBAD), with uncomplicated cases being treated with medical therapy. In this study, we evaluate the efficacy of this management in in-hospital and postdischarge survival. METHODS: Between 1999 and 2014, 123 consecutive acute TBAD patients were treated at our institution. We compared complicated (rupture/impending rupture, malperfusion, expansion) vs uncomplicated TBAD, as well as TBAD with a dissection flap vs intramural hematoma/penetrating aortic ulcer. RESULTS: A total of 103 patients (84%) were strictly managed according to the complication-specific approach, with 93% in-hospital survival. Twenty deviated from complication-specific approach management (triaged to operation by complication-specific approach, but inoperable for a variety of reasons). Independent risk factors for a complicated course in the dissection flap subgroup (n = 89) were history of coronary artery disease (odds ratio. 3.139; p = 0.04) and maximum aortic diameter exceeding 5 cm (odds ratio, 4.586; p = 0.005). Uncomplicated patients were treated medically with antiimpulse therapy. Among the 103 patients treated with the complication-specific approach, long-term survival was 83%, 78%, 71% and 47% at 1, 3, 5, and 10 years, respectively. Between the uncomplicated and complicated groups, 8-year survival was 55% and 49%, respectively (log-rank p = 0.03). Uncomplicated patients showed comparable 6-year survival (log-rank p = 0.06) to matched normal population controls. CONCLUSIONS: Patients managed with the complication-specific approach showed an overall satisfactory long-term survival over 10 years. No in-hospital deaths occurred in patients with uncomplicated, medically treated acute TBAD, with comparable long-term survival to a matched normal population. These good long-term results provide counterbalancing perspective when considering routine thoracic endovascular aortic repair for all TBAD patients.

Vulvar extrauterine endometrial stromal sarcoma: A case report and literature review.

Endometrial stromal sarcoma (ESS) is an extremely rare neoplasm accounting for only 0.2% of all uterine malignancies and for 15-26% of primary uterine sarcomas. The annual incidence of ESS is 1-2 per million women. Herein, to the best of our knowledge, we present the first reported case of ESS of the vulva in a 50-year-old female presenting with per vaginal spotting over a period of three months. Her past surgical history included a subtotal hysterectomy and left salpingo-oophorectomy for uterine fibroids ten years previously. On examination, a 3.5×3×2 cm cystic mass was found in the right labia majora. The mass was excised and the diagnosis of endometrial stromal sarcoma was made. Subsequent metastatic workup was negative and the patient was started on megestrol acetate. She has remained disease free with no signs or symptoms of recurrent or advanced disease for 28 months.