Effect of glycopyrrolate on vasopressor requirements for non-elective cesarean section under spinal anesthesia: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: The study aimed to investigate whether prophylactic use of glycopyrrolate decreases the vasopressor requirements to prevent hypotension following spinal anesthesia during non-elective cesarean section. METHOD: In this double-blind randomized clinical trial, 258 patients undergoing non-elective cesarean section were randomly assigned (1:1) to receive intravenous 0.2 mg glycopyrrolate or normal saline (placebo) before spinal anesthesia. The primary outcome was phenylephrine equivalent needed intraoperatively. Secondary outcomes included incidences of maternal hypotension, reactive hypertension, bradycardia, need for atropine, tachycardia, intraoperative nausea/vomiting, shivering, pruritus, dry mouth, dizziness; neonatal APGAR score at 1 min and 5 min, neonatal resuscitation needed, NICU admission and neonatal death. RESULTS: Three patients withdrew from the study due to failed spinal anesthesia. 128 patients in the glycopyrrolate group and 127 patients in the placebo group were analyzed. The mean phenylephrine equivalent needed was 1108.96 µg in the glycopyrrolate group and 1103.64 µg in the placebo group (mean difference, 5.32 µg [95% CI - 67.97 to 78.62]; P = 0.88). Hypotension occurred in 38 patients (30%) in the glycopyrrolate group as compared with 49 patients (39%) in the placebo group (P = 0.13). Tachycardia was reported in 70% of the participants in the glycopyrrolate group and 57% of those in the placebo group (P = 0.04). No statistically significant difference was noted in hypotensive episodes > 1, reactive hypertension, bradycardia, need for atropine, nausea, vomiting, shivering, and dry mouth between the two groups. Neonatal outcomes were similar in the two groups. CONCLUSION: Prophylactic use of glycopyrrolate does not decrease the requirements of vasopressor to prevent hypotension in non-elective cesarean section under spinal anesthesia. TRIAL REGISTRATION: Registration number: NCT04401345. Date of registration: 26/05/2020. Website: https://clinicaltrials.gov.

Establishing Cardiac Surgery in Eastern Nepal: Early Results.

BACKGROUND: Only few dedicated cardiac centres provide cardiac surgery service in Nepal. We are the only government affiliated centre outside the capital providing this service. In this study, we aim to present our early results of cardiac surgery. METHODS: This retrospective study was conducted at B P Koirala Institute of Health Sciences with objective of analysing the early results of cardiac surgery in the patients operated from July 2016 to March 2017.The data were analysed for patient demographics, type of surgery and cardiac disease, mortality, hospital and intensive care unit stay, valve related complications. RESULTS: Total 51 major cardiac surgeries (42 on pump and nine off pump) were performed. There were 27 (53%) males and 24 (47%) females with median age of 36 years (range: 1 to 70 years).The cardiac diseases consisted of 28 rheumatic heart disease, 12 congenital heart diseases, five coronary artery disease, five chronic constrictive pericarditis and one left atrial myxoma. The mean cardiopulmonary bypass and cross clamp times were 106 ±35 and 80±26 minutes respectively. The mean intensive care unit and hospital stay was 4±2 and 8±3 days respectively. Two (4%) patients required re-exploration for mediastinal bleeding. There was no prosthetic valve thrombosis or infection.Two patients (4%) had superficial wound infections.There were four (7.8%) in hospital mortalities. Remaining 47 patients (91.8%) are in NYHA class I aftermean follow up duration of five months. CONCLUSIONS: Our early result of cardiac surgery is encouraging and has established the safety and feasibility of starting open heart surgery in other parts of Nepal.

Giant pseudoaneurysm of subclavian artery after blunt chest trauma.

Subclavian artery (SCA) pseudoaneurysm after blunt chest trauma is rare and its delayed presentation months after the SCA injury is even rarer. Herein we discuss a case of SCA pseudoaneurysm in a 74-year-old man who presented to us 5 months after blunt chest trauma. He had been managed conservatively for the fracture of first rib and clavicle until presentation to our hospital. He had uncontrolled hypertension and a rapidly increasing large painful swelling (10 by 8 cm) in left clavicular region along with purplish discoloration of the overlying skin. The diagnosis was confirmed after computed tomography angiography and the patient was successfully treated with surgical evacuation of clots, primary repair of the rent in the SCA, and plating of clavicular fracture.