Dexmedetomidine as an effective alternative tool for heart rate control in atrial fibrillation during general anesthesia-A case report.

Atrial fibrillation (AF) is a common arrhythmia requiring effective heart rate (HR) management. Conventional therapies may not always achieve the desired HR control during intraoperative conditions. We present two cases of AF patients in whom dexmedetomidine, an alpha-2 receptor agonist, was utilized during surgery when conventional treatments proved ineffective. In Case 1, a 65-year-old male with multiple comorbidities underwent surgery. Despite receiving intraoperative medications for AF, his HR remained uncontrolled. Dexmedetomidine successfully stabilized his HR without complications. In Case 2, a 75-year-old male with heart disease experienced a sudden HR surge during surgery, which remained uncontrolled despite conventional treatment. Dexmedetomidine effectively managed his HR, ensuring a safer surgical course. While the primary indication of dexmedetomidine is not arrhythmia management, this case report suggests its potential in challenging cases. Further research is needed to explore its therapeutic role in tachyarrhythmia management and establish appropriate dosing strategies.

A complex case of posterior reversible encephalopathy syndrome after combined spinal epidural of preeclampsia parturient: A case report.

Posterior reversible encephalopathy syndrome (PRES) is a disorder characterized by vasogenic edema affecting the posterior brain region. We report a case of PRES in a 36-year-old woman with preeclampsia who underwent an emergency cesarean section with spinal anesthesia. After surgery, she developed right leg weakness, headache, and seizures. Imaging showed white matter edema consistent with PRES. The exact cause of PRES is unclear, but elevated blood pressure and endothelial dysfunction are implicated. Tight blood pressure control in PRES is crucial for management, and prompt recognition and treatment are essential for favorable outcomes.

Factors Associated With People's Accessibility to Mental Healthcare Services in Ukraine: Focusing on Household Head Vulnerability.

Objectives: This study examines the factors associated with access to mental healthcare services among people living in the government-controlled areas (GCAs) of Donetsk and Luhansk oblasts in Ukraine. Methods: The 2020 Ukraine Multi-Sector Needs Assessment conducted by REACH was subjected to frequency analysis, percentage analysis, and binary logistic regression to confirm the factors associated with accessibility to mental healthcare services among Ukrainian household heads. Results: Older household heads, heads with high accessibility to healthcare facilities, and those with low health expenditures were highly likely to have low access to mental healthcare services. Household heads' awareness of household members' medical assistance eligibility was significantly and positively associated with the former's mental healthcare accessibility. Conclusion: This study revealed the mental health vulnerability of people living in GCAs in Ukraine, in which the situation progresses from conflict to war. The need for mental healthcare, which is adversely affected by armed conflict, is expected to increase. Accordingly, further studies should clarify the demand for and methods to enhance mental healthcare services to ensure the timely provision of these services in the future.

Severe pulmonary edema occurred during endobronchial ultrasound under monitored anesthesia care - A case report.

BACKGROUND: Endobronchial ultrasound (EBUS) is widely used to diagnose lung cancer. Monitored anesthesia care (MAC) can enhance patient comfort and procedural conditions during EBUS. EBUS under MAC is usually safe but can lead to various complications. CASE: A 34-year-old male who had increased sputum for two months showed an enlarged paratracheal lymph node and planned for lymph node biopsy by EBUS. During EBUS under MAC, an unexpected oxygen saturation decline required intervention. After intubation, copious frothy fluid was suctioned from the bronchi, and oxygenation was recovered. A narrowed trachea and the EBUS bronchoscope might have resulted in upper airway obstruction, and suction performed under these conditions might have caused pulmonary edema. The patient received non-invasive ventilation and high-flow nasal cannula and recovered without complications. CONCLUSIONS: When there is an expected risk of upper airway obstruction during EBUS, careful preoperative evaluation and preparation are essential to prevent negative pressure pulmonary edema.

Participation and Influencing Factors in the Decision-Making of Life-Sustaining Treatment: A Focus on Deceased Patients with Hematologic Neoplasms.

Purpose: This study aimed to investigate the involvement of patients who died from hematologic neoplasms in the decision-making process surrounding the withdrawal of life-sustaining treatment (LST). Methods: A total of 255 patients diagnosed with hematologic neoplasms who ultimately died following decisions related to LST during their end-of-life period at a university hospital were included in the study. Data were retrospectively obtained from electronic medical records and analyzed utilizing the chi-square test, independent t-test, and logistic regression. Results: In total, 42.0% of patients participated in the decision-making process regarding LST for their hematologic neoplasms, while 58.0% of decisions were made with family involvement. Among these patients, 65.1% died in general wards and 34.9% in intensive care units (ICUs) as a result of decisions such as the suspension of LST. The period from the LST decision to death was longer when the decision was made by the patient (average, 27.15 days) than when it was made by the family (average, 7.48 days). Most decisions were made by doctors and family members in the ICU, where only 20.6% of patients exercised their right to make decisions regarding LST, a rate considerably lower than 79.4% observed in general wards. Decisions to withhold or withdraw LST were more commonly made by patients themselves than by their families. Conclusion: The key to discussing the decision to suspend hospice care and LST is respecting the patient's self-determination. If a patient is lucid prior to admission to the ICU, considerations about suspending LST should involve the patient input.

Anesthetic management of an elderly COVID-19 patient with pulmonary thromboembolism for hip surgery - A case report.

BACKGROUND: COVID-19 and delayed hip surgery are well-known risk factors for thromboembolism in elderly patients. CASE: We report the case of an 88-year-old female patient with COVID-19 and pulmonary thromboembolism (PTE) who underwent delayed hip surgery 21 days after the injury. Heparinization and inferior vena cava filters were used to treat and prevent PTE. Transesophageal echocardiography and extracorporeal membrane oxygenation (ECMO) sheaths were inserted as a precaution in case of emergencies during surgery; the procedure was performed without any specific event. CONCLUSIONS: COVID-19-infected patients suffering from a hip fracture have a high risk of thromboembolism, and therefore, require utmost attention for appropriate evaluation and prevention.

Catatonia associated with prolonged stupor after general anesthesia in a patient with multiple neuropsychiatric disorders -a case report.

BACKGROUND: Delayed emergence after general anesthesia may significantly affect a patient's condition. We present the case of a patient who experienced prolonged delayed recovery of consciousness, language, and motor response due to catatonia after eight hours of total elbow arthroplasty under general anesthesia. CASE: A 68-year-old woman with neuropsychiatric disorders and Parkinson's disease did not respond adequately during recovery after more than eight hours of general anesthesia. Following the operation, the patient was semi-comatose and appeared to have nonconvulsive status epilepticus upon awakening from anesthesia. However, subsequent examinations did not reveal any organic causes. The patient was subsequently diagnosed with catatonia, treated, and discharged following gradual improvement. CONCLUSIONS: Although rare, patients taking psychiatric drugs for an extended period may experience delayed emergence after prolonged general anesthesia without identifiable causes. Catatonia should be considered in the differential diagnoses of these patients.

Evaluation of Salivary Biomarkers of Periodontal Disease Based on Smoking Status: A Systematic Review.

Saliva is a useful biomarker for diagnosing oral health conditions, including periodontal disease (PD). Smoking is a risk factor for PD. The aim of this systematic review was to summarize the salivary biomarkers associated with PD based on smoking status. A comprehensive search of the MEDLINE (via PubMed), EMBASE, Cochrane, SCOPUS, and Web of Sciences databases was conducted up to 1 January 2021 using key terms relevant to the topic of our research and Cochrane methodology and improved with searching a gray literature resource. The methodological quality of all included studies was assessed with the revised Quality Assessment of Diagnostic Accuracy Studies-2. Seven studies were included. Smokers had increased levels of malondialdehyde, sialic acid, salivary cortisol, salivary interleukin 1ß, albumin, tissue inhibitor of matrix metalloproteinase (TIMP), and the pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (ICTP), as well as decreased levels of superoxide dismutase, activity of lactate dehydrogenase, activity of enzyme activity of ß-glucuronidase, uric acid, matrix metalloproteinase-8 (MMP-8)/TIMP-1 ratio, and combinations of MMP-8 and ICTP. However, mixed results were observed some studies in detecting glutathione peroxidase, MMP-8, and MMP-14. The results were interpreted with caution because of limitations in the number of included studies and the study design. Some salivary biomarkers are potentially useful in combination or alone for diagnosing PD. Methodological and systematic studies are needed to develop more effective biomarkers.

Non-Communicable Diseases and Transitioning Health System in the Democratic People's Republic of Korea during COVID-19 Lockdown.

While there are increasing concerns on COVID-19 situation in Democratic People's Republic of Korea (DPRK, or North Korea), little is known about North Korea's health system function for Non-Communicable Diseases. Given the scarcity of available evidence, a scoping review was conducted in peer review articles from MEDLINE, SCOPUS, and Web of Science, and policy literatures from Rodongshinmun, state-run media in North Korea to analyze the North Korea health system and COVID-19 pandemic. The transition to a market economy is expected to deepen the gap between the rich and the poor over access to health care, causing a new type of health inequality in North Korea. COVID-19 lockdown intensified the DPRK's economic predicament exacerbating shortage of health financing on non-communicable diseases. The case study of mixed evidence from scoping review indicates that NCDs prevention and management are not functional in the transitioning health system under chronic economic crisis and isolation. This study indicates that NCDs prevention and management are not functional in the transitioning health system under chronic economic crisis and isolation. The destabilized markets under COVID-19 lockdown intensified the DPRK's economic predicament and exacerbated the chronic shortage of health financing especially to NCDs.

Association between the Human Development Index and Confirmed COVID-19 Cases by Country.

It is important to understand the ultimate control of COVID-19 in all countries around the world in relation to the characteristics of developed countries, LDCs, and the variety of transmission characteristics of COVID-19. Therefore, this study aimed to identify factors associated with confirmed cases of COVID-19 with a focus on the Human Development Index (HDI). The units of analysis used for the current study were countries, and dataset were aggregated from multiple sources. This study used COVID-19 data from Our World in Data, the Global Health Security Index, and the WORLD BANK. A total of 171 countries were included in the analysis. A multi-variable linear regression with a hierarchical framework was employed to investigate whether the HDI is associated with confirmed COVID-19 cases after controlling for the demographic and healthcare system characteristics of the study countries. For Model 2, which controlled for demographic and healthcare system characteristics, HDI (ß = 0.46, p < 0.001, 95% CI = 2.64−10.87) and the number of physicians per 1000 people (ß = 0.34, p < 0.01, 95% CI = 0.21−0.75) had significant associations with the total number of confirmed COVID-19 cases per million people. Countries with a high HDI level are able to conduct higher per capita testing, resulting in higher numbers of confirmed cases than in countries with lower HDI levels. This study has shown evidence that could be used by governments and international organizations to identify national characteristics and provide the international cooperation necessary to develop effective prevention and intervention methods to deal with the global pandemic.

Prophylactic use of donut-shaped cushion to reduce sacral pressure injuries during open heart surgery.

Background: Pressure injuries are likely to develop in the operating room due to the high temperature and humidity underneath the patients. This study was designed to reduce sacral pressure injuries using donut-shaped cushions on patients undergoing open heart surgery in a supine position for more than three hours. Materials and Methods: Patients undergoing open heart surgery for more than three hours were randomly allocated. Depending on the allocation, either the donut-shaped cushion (donut group) or hydrophilic foam dressing (control group) was applied before draping. Patients were evaluated for the development of pressure injuries, National Pressure Ulcer Advisory Panel (NPUAP) stage, and injury size immediately after surgery, 48 hours, and seven days after surgery. Results: Forty-five patients were enrolled in this study. Twenty-two were assigned to the donut group and 23 were assigned to the control group. Three patients developed pressure injuries of NPUAP stage I or higher. All injuries occurred in the control group, but there was no statistically significant difference (P = 0.083). Conclusions: Patients who underwent cardiac surgery for more than three hours and used a donut-shaped cushion did not develop pressure injuries, although no statistical difference was noted. Specific preventative measures in the operating room may play a crucial role in preventing pressure injuries, and further research should be pursued.

Two cases of late-onset cardiovascular toxicities after a single injection of local anesthetics during supraclavicular brachial plexus block - A report of two cases.

BACKGROUND: Local anesthetics systemic toxicity (LAST) is a grave complication of regional anesthesia that usually occurs immediately after local anesthetics injection. Here, we report on rare late-onset toxicity cases after supraclavicular brachial plexus blocks. CASE: Two patients underwent surgery for radius fractures. We used lidocaine 100 mg and ropivacaine 150 mg for blocking and infused dexmedetomidine for intraoperative sedation. The 63-year-old male patient's blood pressure dropped to 87/60 mmHg after 3 h 15 min after blocking. Ventricular fibrillation occurred 10 min later. After five defibrillations, electrocardiography showed ventricular tachycardia that was normalized through one cardioversion. The 54-year-old female patient's heart rate decreased to 35 beats/min 2 h 30 min after blocking. Her vital signs returned to normal after administering atropine, ephedrine, epinephrine, and lipid emulsion. CONCLUSIONS: Physicians should remember that LAST may occur long after local anesthetic injection and be aware of factors that may adversely affect the course of LAST.

Epidural analgesia versus intravenous analgesia after minimally invasive repair of pectus excavatum in pediatric patients: a systematic review and meta-analysis.

BACKGROUND: Postoperative pain control after the minimally invasive repair of pectus excavatum (MIRPE) is essential, but there is a controversy about a better analgesic method between epidural and intravenous (IV) analgesia. This systematic review and meta-analysis aimed to compare the effect of epidural versus IV analgesia following MIRPE. METHODS: We searched PubMed, MEDLINE, EMBASE, Cochrane Central Register, and ClinicalTrials.gov for randomized controlled trials (RCTs) dated up to 31st May 2021. The primary outcome was the area under the curve (AUC) of the weighted mean visual analog scale (VAS) after MIRPE. The secondary outcomes were postoperative nausea, operation time, total operating room time, and postoperative length of hospital stay. RESULTS: Four RCTs involving 243 patients were finally included in this meta-analysis. The AUC of the weighted mean VAS was 343.62 in the epidural group and 375.24 in the IV group. The epidural group showed lower VAS than the IV group at 12 to 48 h after the surgery. Postoperative nausea, operation time and length of hospital stay was not different between two groups. The epidural group had a significantly longer total operating room time due to epidural catheter insertion time. CONCLUSIONS: Epidural analgesia after the MIRPE had a better analgesic effect than IV analgesia. However, IV analgesia may also be a viable option, and physicians should wisely choose analgesic modalities after MIRPE.

Successful anesthetic management of a giant lower lip hemangioma patient using high flow nasal cannula -a case report.

BACKGROUND: Giant lip hemangioma is a rare disease that may cause difficulty in preoxygenation and ventilation when using face masks and intubation during general anesthesia induction. CASE: A laparoscopic cholecystectomy was planned for a 77-year-old woman. The patient had a giant lower lip hemangioma that was 12 x 5 x 5 cm, which made preoxygenation and ventilation through a face mask impossible and put her at risk of hemangioma rupture. We preoxygenated her through a high-flow nasal cannula (HFNC). Following propofol and succinylcholine administration, we intubated the patient with a video laryngoscope without desaturation, hemangioma rupture, or CO2 retention. CONCLUSIONS: HFNC is a useful tool when difficult intubation is expected in patients who have problems using conventional face masks.

Venovenous ECMO treatment, outcomes, and complications in adults according to large case series: A systematic review.

BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV ECMO) has gained popularity for the treatment of refractory respiratory failure during and after the 2009 influenza pandemic, and still represents a precious therapeutic resource for severe novel coronavirus 2019 infection. However, most of the published studies are small case series, and only two randomized trials exist in literature. AIM: Aim of this systematic review is to describe trends in VV ECMO treatment outcomes according to large studies only. METHODS: We searched and included studies with more than 100 VV ECMO cases dated up to August 1st, 2019. RESULTS: Thirty-three studies published in the period 2011-2019 met inclusion criteria, for a total of 12,860 patients (age 46.3 ± 17.4 years). ARDS was mainly by pneumonia, in 3126 (37%) cases; further 401(7%) patients had H1N1 Influenza A infection. Cannulation-related complications occurred in 502 (7%) cases. Weighted mean (95% confidence interval) of VV ECMO duration was 8.9 (8.7-9.1) days, and ICU stay was 23.6 (22.4-24.8) days. Mortality at the longest follow up available was 40%. Data collection in 70% of the studies had a duration of >5 years. CONCLUSION: This study reveals the characteristics of large case VV ECMO studies.

Fibrin Clot Mistook as a Worm in the Intravenous Line.

There have been several reports of foreign bodies being discovered in the intravenous set. In this case, the patient complained that he found a worm in his intravenous line. It was later confirmed as a long, white fibrin deposit by pathologic examination. This happened even though there was a non-return valve in the intravenous line. Also, since there were few red blood cells in the deposit, it did not look like a blood clot. In cases like this, we suggest that physicians keep this possibility in mind to reassure their patients.

Blood clot formation in reinfusion bag with CATSmart: Two case reports.

Autologous blood cell salvage reduces the need for postoperative allogeneic blood transfusion and alleviates immunologic reactions, so the technique is commonly used in cardiac surgery. The continuous autotransfusion system is a type of blood cell salvage device. Although the processing program of continuous autotransfusion system includes filtering of several materials from suctioned blood, such as clots, leukocytes, cytokines, and complement, we identified some unexpected blood clots in the reinfusion bag. Pathologic examination revealed that the clots were composed of fibrin, red blood cell aggregates, and histiocytes. We report two cases of these abnormal findings during the use of CATSmart in cardiac surgery.

Anticholinergic premedication-induced fever in paediatric ambulatory ketamine anaesthesia.

OBJECTIVE: A randomized, double-blind, prospective study to evaluate the effect of anticholinergic drugs on thermoregulation in paediatric patients undergoing ambulatory anaesthesia with ketamine. METHODS: Patients were randomized to receive either 0.005 mg/kg glycopyrrolate or the equivalent volume of normal saline (placebo) at 30 min before ketamine anaesthesia. Body temperature was measured tympanically at baseline and at 0, 30, 60 and 90 min postoperatively. The quantity of saliva prodiced during surgery and incidence of fever were recorded. RESULTS: Body temperature was significantly higher in the glycopyrrolate group (n = 42) than the placebo group (n = 42) at 30, 60 and 90 min after surgery, and higher than baseline at 0, 30, 60 and 90 min after surgery. In the placebo group, body temperature was significantly higher than baseline at 0 and 30 min after surgery. Saliva secretion was significantly lower in the glycopyrrolate group than the placebo group. CONCLUSION: Routine premedication with adjunctive anticholinergics should not be considered in paediatric patients receiving ketamine sedation due to the increased risk of fever.Trial registration number, Clinicaltrials.gov: NCT02430272.