Venoarterial extracorporeal membrane oxygenation for vasoplegic shock after treprostinil refill of an implanted intravenous pump: a case report.

Introduction: Venoarterial extracorporeal membrane oxygenation (ECMO) is a rescue therapy that can stabilize patients with hemodynamic compromise. Indications continue to evolve, including drug overdose. However, the indication merely for vasoplegic shock following drug overdose is controversial. Case summary: We report a case of a 57-year-old male with high-risk idiopathic pulmonary arterial hypertension treated with upfront triple combination therapy (sildenafil, bosentan, and intravenous treprostinil infusion via subcutaneous abdominal implantable pump). In one of the refills of the drug reservoir, accidental administration of 1 months's supply of treprostinil (200 mg) into the subcutaneous tissue occurred, causing refractory vasoplegic shock. He required urgent VA-ECMO for 96 h, surviving to discharge 28 days later. Discussion: Treprostinil poisoning is rare due to its less frequent use but is life-threatening. ECMO may be considered in vasoplegic shock due to overdose of vasodilatory medication. It allows organ perfusion to be maintained, with the knowledge that recovery is as rapid as drug elimination.

Effect of Preoperative Anxiety on Postoperative Pain after Craniotomy.

Pain following craniotomy is challenging. Preoperative anxiety can be one of the controllable factors for prevention of post-craniotomy pain. The main objective of this prospective observational study is to determine this relationship in patients undergoing scheduled craniotomy from February to June 2021. After excluding patients with Mini-Mental State Examination (MMSE) ≤ 24 points, we administered a preoperative State Trait Anxiety Inventory (STAI) questionnaire. We recorded the patient's analgesic assessment using the Numerical Rating Score (NRS) at 1, 8, 24, and 48 h after surgery. A total of 73 patients were included in the study. Twelve others were excluded due to a MMSE ≤ 24 points. The main predictors for NRS postoperatively at 1, 8, 24, and 48 h were STAI A/E score, male gender, youth, and depression. We identified a cut-off point of 24.5 in STAI A/E for predicting a NRS > 3 (sensitivity 82% and specificity 65%) at 24 h postoperative and a cut-off of 31.5 in STAI A/R (sensitivity 64% and specificity 77%). In conclusion, preoperative STAI scores could be a useful tool for predicting which patient will experience at least moderate pain after craniotomy. The identification of these patients may allow us to highlight psychological preparation and adjuvant analgesia.

Effect of prewarming on body temperature in short-term bladder or prostatic transurethral resection under general anesthesia: A randomized, double-blind, controlled trial.

Perioperative hypothermia causes postoperative complications. Prewarming reduces body temperature decrease in long-term surgeries. We aimed to assess the effect of different time-periods of prewarming on perioperative temperature in short-term transurethral resection under general anesthesia. Randomized, double-blind, controlled trial in patients scheduled for bladder or prostatic transurethral resection under general anesthesia. Eligible patients were randomly assigned to receive no-prewarming or prewarming during 15, 30, or 45 min using a forced-air blanket in the pre-anesthesia period. Tympanic temperature was used prior to induction of anesthesia and esophageal temperature intraoperatively. Primary outcome was the difference in core temperature among groups from the induction of general anesthesia until the end of surgery. Repeated measures multivariate analysis of covariance modeled the temperature response at each observation time according to prewarming. We examined modeled contrasts between temperature variables in subjects according to prophylaxis. We enrolled 297 patients and randomly assigned 76 patients to control group, 74 patients to 15-min group, 73 patients to 30-min group, and 74 patients to the 45-min group. Temperature in the control group before induction was 36.5 ± 0.5 °C. After prewarming, core temperature was significantly higher in 15- and 30-min groups (36.8 ± 0.5 °C, p = 0.004; 36.7 ± 0.5 °C, p = 0.041, respectively). Body temperature at the end of surgery was significantly lower in the control group (35.8 ± 0.6 °C) than in the three prewarmed groups (36.3 ± 0.6 °C in 15-min, 36.3 ± 0.5 °C in 30-min, and 36.3 ± 0.6 °C in 45-min group) (p < 0.001). Prewarming prior to short-term transurethral resection under general anesthesia reduced the body temperature drop during the perioperative period. These time-periods of prewarming also reduced the rate of postoperative complications.Study Registration Registered at ClinicalTrials.gov (Identifier: NCT03630887).

Short-Periods of Pre-Warming in Laparoscopic Surgery. A Non-Randomized Clinical Trial Evaluating Current Clinical Practice.

BACKGROUND: Pre-warming prevents perioperative hypothermia. We evaluated the current clinical practice of pre-warming and its effects on temperature drop and postoperative complications; Methods: This prospective, observational pilot study examines clinical practice in a tertiary hospital on 99 patients undergoing laparoscopic urological surgery. Pre-warming was performed in the pre-anesthesia room. Patients were classified into three groups: P 0 (non-prewarmed), P 5-15 (pre-warming 5-15 min) and P > 15 (pre-warming 15-30 min). Tympanic temperature was recorded in the pre-anesthesia room, prior to anesthesia induction, and in the PACU. Esophageal temperature was recorded intraoperatively. The occurrence of shivering, pain intensity, length of stay in PACU, and postoperative complications during hospital stay were also recorded; Results: After pre-warming, between-group difference in body temperature was higher in P > 15 than in P 0 (0.4 °C, 95% CI 0.14-0.69, p = 0.004). Between P 5-15 and P 0 difference was 0.2 °C (95% CI 0.04-0.55, p = 0.093). Temperature at the end of surgery was higher in pre-warmed groups [mean between-group difference 0.5 °C (95% CI 0.13-0.81, p = 0.007) for P 5-15; 0.9 °C (95% CI 0.55-1.19, p < 0.001) for P > 15]. Pain and shivering was less common in pre-warmed groups. Postoperative transfusions and surgical site infections were lower in P > 15; Conclusion: Short-term pre-warming prior to laparoscopic urological surgery decreased temperature perioperative drop and postoperative complications.

Prospective observational study of the effectiveness of prewarming on perioperative hypothermia in surgical patients submitted to spinal anesthesia.

Prewarming has been shown to prevent intraoperative inadvertent hypothermia. Nevertheless, data about optimal prewarming-time from published clinical trials report contradictory results. We conducted this pilot study to evaluate routine clinical practice regarding prewarming and its effect on the prevalence of perioperative hypothermia in patients undergoing transurethral resection (TUR) under spinal anesthesia. This was a prospective, observational, pilot study to examine clinical practice in a tertiary hospital regarding prewarming in 140 consecutive patients. When prewarming (pw) was performed, forced-air warming was provided in the pre-anesthesia room for 15 (pw15), 30 (pw30), or 45 (pw45) min. Tympanic temperature was recorded upon entering the pre-anesthesia room, at the time of initiating surgery, and every 15 min intra-operatively. We also recorded duration of the surgical procedure and length of stay in the Post-Anesthesia Care Unit (PACU). Pw15 was performed in 34 patients, pw30 in 29 patients, and pw45 in 21 patients. Fifty-six patients did not receive pw and 96% of them developed hypothermia at the end of the surgical procedure, compared to 73% of patients in pw15 (p = 0.002), 75% in pw30 (p = 0.006) and 90% in pw45 (p = 0.3). Length of stay in the PACU was markedly shorter in pw15 (131 ± 69 min) and pw30 (123 ± 60 min) than in the non-pw group (197 ± 105 min) (p = 0.015 and p = 0.011, respectively). This difference was not significant in pw45 (129 ± 56 min) compared to non-pw patients. In conclusion, prewarming for 15 or 30 min before TUR under spinal anesthesia prevents development of hypothermia at the end of the surgical procedure.

Looking for the reason of hemodynamic instability: a case report of the role of intraoperative ultrasound / Buscando o motivo da instabilidade hemodinâmica: relato de caso sobre o papel do ultrassom intraoperatório

Abstract Background and objectives: A prompt and effective management of trauma patient is necessary. The aim of this case report is to highlight the importance of intraoperative echocardiography as a useful tool in patients suffering from refractory hemodynamic instability no otherwise explained. Case report: A 41 year-old woman suffered a car accident. At the emergency department, no abnormalities were found in ECG or chest X-ray. Abdominal ultrasound revealed the presence of abdominal free liquid and the patient was submitted to urgent exploratory laparotomy. Nevertheless, she persisted suffering arterial hypotension and metabolic acidosis. Looking for the reason of her hemodynamic instability, intraoperative transthoracic echocardiography was performed, finding out the presence of pericardial effusion. Once the cardiac surgeon extracted pericardial clots, patient's situation improved clinically and analytically. Conclusion: Every anesthesiologist should be able to use the intraoperative echocardiography as an effective tool in order to establish the appropriate measures to promote the survival of patients suffering severe trauma.

Resumo Justificativa e objetivos: O atendimento rápido e eficaz do paciente de trauma é necessário. O objetivo deste relato de caso foi destacar a importância do ecocardiograma intraoperatório como uma ferramenta útil em pacientes que sofrem de instabilidade hemodinâmica refratária sem explicação aparente. Relato de caso: Uma mulher de 41 anos sofreu um acidente de automóvel. No departamento de emergência, nenhuma anormalidade foi encontrada no ECG ou na radiografia de tórax. Uma ultrassonografia abdominal revelou a presença de líquido livre no abdome, e a paciente foi submetida à laparotomia exploradora de urgência. No entanto, a paciente continuou apresentando hipotensão arterial e acidose metabólica. Na busca pelo motivo de sua instabilidade hemodinâmica, um ecocardiograma transtorácico foi realizado no período intraoperatório e constatou a presenc¸a de derrame pericárdico. Após a remoção dos coágulos pericárdicos pelo cirurgião cardíaco, a condição da paciente melhorou clínica e analiticamente. Conclusão: Todo anestesiologista deve saber utilizar o ecocardiograma intraoperatório como ferramenta eficaz para estabelecer as medidas adequadas para promover a sobrevida de pacientes com traumatismos graves.

Polymyxin B for Gram Negative Multidrug Resistant Bacteria in a Hispanic Population.

OBJECTIVE: This study intends to determine the prevalence of multidrug resistant (MDR) infections by A. baumannii, K. pneumoniae and P. aeruginosa in a tertiary care teaching hospital intensive care unit (ICU) in San Juan, PR, estimate the mortality rate and compare the morbidity and mortality differences among those treated with and without polymyxin B. METHODS: We selected adults patients admitted to the ICU who had positive cultures from January 2012 to June 2013. Sample consisted of 25 patients with age ranges from 27-78 years, 13 women and 12 men. RESULTS: The median age at death was 60 years. Polymyxin B nephrotoxicity was identified on 15% of the patients. Variables related to higher survival were younger age, female sex, use of polymyxin B, and the use of daptomycin. The use of vancomycin and vasopressors were associated with worse outcome. Mortality associated to single MDR bacteria was 88% for A. baumannii, 84% for K. pneumoniae and 67% for P. aeruginosa. All patients with more than one MDR infection died in the ICU. CONCLUSION: The use of polymyxin B was associated with an ICU mortality reduction. Unexpectedly we found a significantly improved survival in patients who received polymyxin B in combination with daptomycin, which awaits prospective confirmation.

[Looking for the reason of hemodynamic instability: a case report of the role of intraoperative ultrasound]. / Buscando o motivo da instabilidade hemodinâmica: relato de caso sobre o papel do ultrassom intraoperatório.

BACKGROUND AND OBJECTIVES: A prompt and effective management of trauma patient is necessary. The aim of this case report is to highlight the importance of intraoperative echocardiography as a useful tool in patients suffering from refractory hemodynamic instability no otherwise explained. CASE REPORT: A 41 year-old woman suffered a car accident. At the emergency department, no abnormalities were found in ECG or chest X-ray. Abdominal ultrasound revealed the presence of abdominal free liquid and the patient was submitted to urgent exploratory laparotomy. Nevertheless, she persisted suffering arterial hypotension and metabolic acidosis. Looking for the reason of her hemodynamic instability, intraoperative transthoracic echocardiography was performed, finding out the presence of pericardial effusion. Once the cardiac surgeon extracted pericardial clots, patient's situation improved clinically and analytically. CONCLUSION: Every anesthesiologist should be able to use the intraoperative echocardiography as an effective tool in order to establish the appropriate measures to promote the survival of patients suffering severe trauma.

Echocardiography and passive leg raising in the postoperative period: A prospective observational study.

BACKGROUND: Signs of hypovolaemia are frequent in the postoperative period, but not all patients need or respond to fluid administration. An increase in cardiac output (CO) after passive leg raising (PLR) has been demonstrated to be useful as a volume response predictor in non-surgical, spontaneously breathing patients. OBJECTIVE: The objective of this study was to evaluate the accuracy of transthoracic echocardiography after PLR to predict fluid responsiveness in post-surgical patients. DESIGN: A prospective observational study. SETTING: A tertiary hospital between January and July 2015. PATIENTS: Fifty-one spontaneously breathing postoperative patients with suspected hypovolaemia (arterial hypotension, oliguria, tachycardia or delayed capillary refill) were considered for the study. INTERVENTION: Demographic and personal data were collected, as well as heart rate variations, mean arterial pressure during PLR and after administering 500 ml of Ringer's lactate solution. CO was measured by transthoracic echocardiography. MAIN OUTCOME MEASURES: The primary outcome was measurement of CO before and after PLR and Ringer's lactate administration. RESULTS: Forty-one patients were included in the study (six patients were excluded because of a poor echocardiographic window and four because of misalignment of the Doppler and outflow tract of the left ventricle). Twenty-two patients (54%) were considered responders to fluid therapy, with an increase of stroke volume greater than or equal to 15% after 500 ml lactated Ringer's infusion. The highest area under the curve was found for an increase in CO (0.91 ±â€Š0.05; 95% confidence interval 0.78 to 0.97). An increase in CO greater than 11% after the PLR manoeuvre predicts a volume response with 68% sensitivity and 100% specificity. CONCLUSION: This is the first study showing that measurement of CO after PLR can predict volume response in spontaneously breathing postoperative patients.

Fundamentos teórico metodológicos para el proceso de formación ambiental en la carrera de tecnología de la salud / Methodological theoretical grounds for the environmental training process in the health technology career

El presente trabajo, se sustenta en las Bases Metodológicas de las Ciencias de la Educación, fundamentalmente la Didáctica y la Gestión de los Procesos Educativos y Ambientales, cuyo método general es el Materialismo Dialéctico, a partir de los paradigmas socio críticos y el enfoque histórico cultural de Vigotsky se pretende: determinar los fundamentos teórico metodológicos del proceso de Formación Ambiental para la carrera de Tecnología de la Salud, a partir de la implementación en la práctica de una Estrategia Metodológica de dicho proceso de Formación Ambiental para los estudiantes de la carrera, ya que actualmente existen limitaciones en dicho proceso, dado por lo atomizado, descontextualizado y asistémico del proceso formativo. Consideramos que para lograr un proceso de Formación Ambiental de carácter sistémico y eficiente, se necesita una estrategia metodológica que atraviese el Currículo como eje transversal, mediante la asignatura integradora que potencie un proceso de enseñanza aprendizaje más eficiente, pertinente y desarrollador, con enfoques interdisciplinarios, que se sustenten en principios, categorías y leyes de la Didáctica, la Sociología y la Gestión Ambiental, con el objetivo de lograr un egresado competente, capaz de transformar las realidades que enfrenta el mundo de hoy, en materia de formación ambiental, con modelos sostenibles y nuevos saberes, que promuevan la salud humana con su carácter de sistema, y además la salud del ambiente, basado en los 7 saberes de la educación de Edgar Morín y los paradigmas de la UNESCO. Este proceso es sin dudas interdisciplinario, transdisciplinario, por lo que abarca el proceso formativo escolar y no escolarizado, potenciando grupos de promotores culturales para fomentar la cultura ambiental dirigida al Desarrollo Sostenible.

The present work is based on the methodological grounds of Sciences of Education, mainly Didactics and the Management of the Educative and Environmental Processes which general method is the Dialectic Materialism,from the social and critical paradigms and from the Vigosquy´s Cultural Historic Approach and it is intended to determine the methodological theoretical grounds of the environmental training process for the Health Technology Major from the practice of a methodological strategy of this environmental training process for the students of this major, because nowadays there are limitations in this process, given by the atomized ,out of context and asystemic training process. It is considered that for obtaining a systemic and efficient environmental training process a methodological strategy is necessary for crossing the Curriculum as a transversal axis through the integrating subject which support a more efficient ,pertinent and developing teaching -learning process with inter discipline approaches which are supported by principles, categories and laws of Didactics, Sociology and Environmental Training Subjects in order to obtain a competent graduate, able to change the facts that the current world have to face according to the environmental training with sustained models and new knowledge based on the Edgar Morín"7 knowledge of Education and the paradigms of UNESCO. This process is inter discipline, trans-discipline, embracing the school and non-school training process supporting the culture promoters in order to promote the environmental culture directed to a sustained development.

Fundamentos teórico-metodológicos para el proceso de formación ambiental en la carrera de Tecnología de la Salud / Methodological theoretical grounds for the environmental training process in the health technology career

El presente trabajo, se sustenta en las Bases Metodológicas de las Ciencias de la Educación, fundamentalmente la Didáctica y la Gestión de los Procesos Educativos y Ambientales, cuyo método general es el Materialismo Dialéctico, a partir de los paradigmas sociocríticos y el enfoque histórico cultural de Vigotsky se pretende: determinar los fundamentos teórico metodológicos del proceso de Formación Ambiental para la carrera de Tecnología de la Salud, a partir de la implementación en la práctica de una Estrategia Metodológica de dicho proceso de Formación Ambiental para los estudiantes de la carrera, ya que actualmente existen limitaciones en dicho proceso, dado por lo atomizado, dexcontextualizado y asistémico del proceso formativo. Consideramos que para lograr un proceso de Formación Ambiental de carácter sistémico y eficiente, se necesita una estrategia metodológica que atraviese el Currículo como eje transversal, mediante la asignatura integradora que potencie un proceso de enseñanza aprendizaje más eficiente, pertinente y desarrollador, con enfoques interdisciplinarios, que se sustenten en principios, categorías y leyes de la Didáctica, la Sociología y la Gestión Ambiental, con el objetivo de lograr un egresado competente, capaz de transformar las realidades que enfrenta el mundo de hoy, en materia de formación ambiental, con modelos sostenibles y nuevos saberes, que promuevan la salud humana con su carácter de sistema, y además la salud del ambiente, basado en los 7 saberes de la educación de Edgar Morín y los paradigmas de la UNESCO. Este proceso es sin dudas interdisciplinario, transdisciplinario, por lo que abarca el proceso formativo escolar y no escolarizado, potenciando grupos de promotores culturales para fomentar la cultura ambiental dirigida al Desarrollo Sostenible (AU)

The present work is based on the methodological grounds of Sciences of Education, mainly Didactics and the Management of the Educative and Environmental Processes which general method is the Dialectic Materialism,from the social and critical paradigms and from the Vigosquy´s Cultural Historic Approach and it is intended to determine the methodological theoretical grounds of the environmental training process for the Health Technology Major from the practice of a methodological strategy of this environmental training process for the students of this major, because nowadays there are limitations in this process, given by the atomized ,out of context and asystemic training process. It is considered that for obtaining a systemic and efficient environmental training process a methodological strategy is necessary for crossing the Curriculum as a transversal axis through the integrating subject which support a more efficient ,pertinent and developing teaching -learning process with inter discipline approaches which are supported by principles, categories and laws of Didactics, Sociology and Environmental Training Subjects in order to obtain a competent graduate, able to change the facts that the current world have to face according to the environmental training with sustained models and new knowledge based on the Edgar Morín”7 knowledge of Education and the paradigms of UNESCO. This process is inter discipline, trans-discipline, embracing the school and non-school training process supporting the culture promoters in order to promote the environmental culture directed to a sustained development

Diseño de un sistema de vigilancia epidemiológica para los XVII Juegos Deportivos Centroamericanos y del Caribe, Puerto Rico, 1993 / Development of a system for epidemiologic surveillance for the XVII Central American and Caribbean Sport Games, Puerto Rico, 1993

The probability of recording infectious diseases and injuries to the musculoskeletal system during sports events with a large number of participants is very high. From an historical perspective the distribution and trends of diseases that have an impact on public health have been evaluated by means of epidemiological surveillance systems. However, the application of these epidemiological methods to sports medicine is relatively recent. The utilization of an epidemiological surveillance system during sports events with a large number of participating athletes and countries has been reported in a limited number of competitions. In this article we describe the design of a system for epidemiological surveillance utilized during the XVII Central American and Caribbean Sports Games held in Puerto Rico in 1993, as an example of a surveillance system that could be regularly established in this type of event

Descripción de la morbilidad reportada en el sistema de vigilancia epidemiológica de los XVII Juegos Deportivos Centroamericanos y del Caribe, Puerto Rico, 1993 / Description of morbidity notified in the epidemiologic surveillance system of XVII Central American and Caribbean Sport Games, Puerto Rico, 1993

The objective of the epidemiological surveillance system for the XVII Central American and Caribbean Sports Games in 1993 in Puerto Rico was to estimate the morbidity related to infectious diseases and sports injuries during the competitions. In the village hospital a total of 794 medical consultations were reported; 57.7 per cent of the patients were athletes. Among athletes, the rate of consultation was 10.4 for every 100 participants. The consultations were more frequent in males (535, 67.4 per cent ). The analysis by country of origin revealed that the athletes from Guatemala (42, 9.2 per cent ) and Jamaica (35, 7.6 per cent ) used the services more frequently. The incidence of consultations by sport was higher in field hockey (47, 10.3 per cent ), followed by athletics (46, 10 per cent ), and softball (36, 7.9 per cent ). The most frequent diagnoses were injuries--302, 38.04 per cent ; of these 229 (75.8 per cent ) were athletes--,conditions of the respiratory system (180, 22.67 per cent ), problems of the skin and mucous membranes (85, 10.71 per cent ), and problems of the gastrointestinal tract (56, 7.05 per cent ). The severity of the majority of the conditions was mild and required primary care health professionals