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Context: After the COVID-19 pandemic, multiple reviews have documented the success of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Patients who experience hypoxemia but have normal contractility may be switched to veno-venous-ECMO (VV-ECMO). Purpose: In this review, we present three protocols for anesthesiologists. Firstly, transesophageal echocardiography (TEE) aids in cannulation and weaning off inotropes and fluids. Our main objective is to assist in patient selection for the Avalon Elite single catheter, which is inserted into the right internal jugular vein and terminates in the right atrium. Secondly, we propose appropriate anticoagulant doses. We outline day-to-day monitoring protocols to prevent heparin-induced thrombocytopenia (HIT) or resistance. Once the effects of neuromuscular paralysis subside, sedation should be reduced. Therefore, we describe techniques that may prevent delirium from progressing into permanent cognitive decline. Methods: We conducted a PubMed search using the keywords VV-ECMO, TEE, Avalon Elite (Maquet, Germany), and quetiapine. We combined these findings with interviews conducted with nurses and anesthesiologists from two academic ECMO centers, focusing on anticoagulation and sedation. Results: Our qualitative evidence synthesis reveals how TEE confirms cannulation while avoiding right atrial rupture or low flows. Additionally, we discovered that typically, after initial heparinization, activated partial thromboplastin time (PTT) is drawn every 1 to 2 hours or every 6 to 8 hours once stable. Daily thromboelastograms, along with platelet counts and antithrombin III levels, may detect HIT or resistance, respectively. These side effects can be prevented by discontinuing heparin on day two and initiating argatroban at a dose of 1 µg/kg/min while maintaining PTT between 61 - 80 seconds. The argatroban dose is adjusted by 10 - 20% if PTT is between 40 - 60 or 80 - 90 seconds. Perfusionists assist in establishing protocols following manufacturer guidelines. Lastly, we describe the replacement of narcotics and benzodiazepines with dexmedetomidine at a dose of 0.5 to 1 µg/kg/hour, limited by bradycardia, and the use of quetiapine starting at 25 mg per day and gradually increasing up to 200 mg twice a day, limited by prolonged QT interval. Conclusions: The limitation of this review is that it necessarily covers a broad range of ECMO decisions faced by an anesthesiologist. However, its main advantage lies in the identification of straightforward argatroban protocols through interviews, as well as the discovery, via PubMed, of the usefulness of TEE in determining cannula position and contractility estimates for transitioning from VA-ECMO to VV-ECMO. Additionally, we emphasize the benefits in terms of morbidity and mortality of a seldom-discussed sedation supplement, quetiapine, to dexmedetomidine.
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Background: Nutrition and infectious diseases are 2 influential factors. Mini nutritional assessment (MNA) score is one of the indicators for assessing the nutritional status of the patients. The present study aimed to evaluate the relationship between MNA- short form (SF) and the infectious status of patients admitted to the intensive care unit (ICU) of Hazrat-e-Rasoul hospital in Tehran. Methods: This was a cross-sectional study performed at Hazrat-e-Rasoul hospital in Tehran from 2019 to 2020. Each patient completed the MNA-SF questionnaire. The questionnaire has 6 factors with a score range of 0 to 14, with 12 to 14 indicating "normal nutrition," 8 to 11 indicating "at risk of malnutrition," and 0 to 7 indicating "malnutrition." The patients were monitored for clinical and paraclinical signs and symptoms of infectious disease for the first 14 days after being admitted to the ICU. Then, the relationship between infection level and MNA-SF scores were recorded and the chi-square, independent samples t test, and Pearson correlation test were used. Results: In this study, 119 patients (60 men and 59 women), with a mean age of 53.82 ± 19.76 years were selected, and 71 (59.67%) of the patients had an infection. Women without infection were significantly more than men (p=0.021). In the assessment of the MNA-SF questionnaire, we found that 62 (52.1%) patients had "normal nutrition" status, 30 (25.2%), and 27 (22.7%) had "at risk for malnutrition" and "malnutrition" status, respectively. MNA-SF scores were significantly different in different age groups (p=0.040). There was a significant relationship between weight loss, mobility, and neuropsychological problems with age (p<0.001). Also, there was a meaningful relationship between nutritional status and infection (p=0.032). The results determined that noninfected cases among the patients with "normal nutrition" status were more than those "at risk for malnutrition" (p=0.007). The results of this study showed that clinical outcomes had a significant relationship with nutritional status (p=0.043). Conclusion: Based on the present study, good nutritional status can reduce infection and mortality in patients who are admitted to ICU, and the nutritional status assessed with MNA-SF can play an essential role in patients' susceptibility to infection.
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BACKGROUND: Decreasing side effects and improving the quality of block in caesarean sections by appropriate dosage of local anesthetics and adjuvants could play an important role in the safe management of cesarean section. The present study aimed at comparing the effects of 3 different doses of intrathecal hyperbaric bupivacaine injected with a fixed dose of sufentanil in cesarean sections. METHODS: In a double- blind randomized clinical trial, 105 candidates of elective cesarean section were randomly assigned into 3 groups of 8, 9, and 10 mg of intrathecal bupivacaine plus sufentanil 2.5 µg. The maximum level of sensory block, the intensity of motor block, and vital signs were measured at regular intervals. The incidence of hypotension and bradycardia were also recorded. RESULTS: No significant difference was found between the maximum level of sensory block and the intensity of motor block in 3 groups. The incidences of hypotension and bradycardia as well as administration of atropine and ephedrine were comparable among the 3 groups (P > 0.05). CONCLUSIONS: According to similar effects of different doses of bupivacaine, administration of lower doses of bupivacaine (8mg) is more reasonable for spinal anesthesia for cesarean section.
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BACKGROUND: Malignant gliomas are the most common form of primary intracranial tumors with the highest mortality rates. Various gene alterations are considered as prognostic markers in glioma. But, the relevant molecular mechanisms in this setting are not well-understood. OBJECTIVE: The aim of this study was to assess the association and prognostic value of TLR9 and NFKBIA with clinical significance and also their impact on patient survival in human glioma. METHODS: Expression of TLR9 and NFKBIA mRNA in the tissues was determined by immunohistochemistry and qRT-PCR methods. Kaplan-Meier curves and Cox proportional hazards regression model were used to assess the association of TLR9 and NFKBIA with clinical outcomes of patients. RESULTS: Quantitative real-time PCR analysis showed that TLR9 mRNAs is markedly expressed in glioma tissues than in non-neoplastic tissues (mean±SD: 3.26±0.40 vs. 0.71±0.36, P<0.001). There was also a significant difference between TLR9 mRNAs and high grade glioma (P<0.001).NFKBIA mRNAs was significantly identified in non-neoplastic tissues compared with glioma specimens (mean±SD: 2.76±0.30 vs. 0.94±0.35, P<0.001). Lower levels of NFKBIA mRNA were significantly related to advanced grade of gliomas (P<0.001). Furthermore, Immunoreactivity for high expression of TLR9 was detected in 65% of cases (26/40) that was associated with high grade glioma (P=0.001). No statistically significant correlation was found between TLR9 and other clinical parameters (P>0.05). Immunoreactivity for high expression of NFKBIA was observed in 32.5% (13/40) of cases and NFKBIA expression was decreased in patients with high grad glioma (P=0.014). There was no significant correlation between NFKBIA protein expression and age, sex, and relapse. The Kaplan-Meier analysis indicated that patients with high expression of TLR9 and low expression of NFKBIA are significantly related to poorer OS (P<0.001). In addition, the multivariate Cox regression model revealed that TLR9 and NFKBIA protein expressions (low/high) and tumor grade were potentially an independent predictor of survival in patients (hazard ratio, 2.132, 2.411, 2.13 [95% confidence interval, 1.825-3.782, 1.61-3.231, 1.542-3.92]; P=0.012,P=0.018, P=0.001). CONCLUSION: These data indicate that TLR9 and NFKBIA protein expressions act as independent predictor of survival for the diagnosis of glioma and a prognostic biomarker for those with a tumor at an advanced pathological grade.