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BACKGROUND: Insulin resistance (IR) is one of the independent determinants influencing the length of hospital stay (LOH) and postoperative complications in colorectal procedures. Preoperative oral carbohydrate loading (POCL) has emerged as a prospective countermeasure for IR. This study aimed to investigate the effects of preoperative carbohydrate loading on postoperative IR, inflammatory parameters, and clinical outcomes in patients undergoing elective colorectal surgery. METHODS: This was an open-label, parallel arm, superiority randomized controlled trial conducted over 2 years. Participants were assigned to conventional fasting (CF) and oral carbohydrate loading (OCL) groups. Insulin resistance, insulin sensitivity, Glasgow Prognostic Score (GPS), and IL-6 levels were analyzed on the day of surgery, and the first and third postoperative days. Clinical parameters like thirst, hunger, dry mouth, anxiety, weakness, pain, nausea, and vomiting were compared in the perioperative period. Surgical clinical outcomes such as intestinal recovery, time to independent ambulation, postoperative morbidity, and LOH were also studied. RESULTS: A total of 72 participants were included, with 36 in each group. In the OCL group, there was a statistically significant decrease in postoperative insulin resistance during preop, POD-1 and POD-3 (p=0.0336). Similarly, inflammatory parameters and the Glassgow prognostic scale were found to be significantly lower in the OCL group (p<0.001). Clinical parameters such as thirst, hunger, and dry mouth were significantly lower in the intervention group (p=0.00) with a shortened LOH. CONCLUSION: This study demonstrated that preoperative carbohydrate loading is associated with reduced insulin resistance and inflammatory markers, shortened hospital stays, and improved overall clinical outcomes in elective colorectal surgery.
Subject(s)
Bronchiectasis , Mitral Valve Stenosis , Humans , Mitral Valve Stenosis/surgery , Mitral Valve Stenosis/complications , Mitral Valve Stenosis/diagnostic imaging , Bronchiectasis/surgery , Bronchiectasis/diagnostic imaging , Bronchiectasis/complications , Male , Echocardiography, Transesophageal/methods , Female , Middle AgedABSTRACT
Ureteroscopic nephrolithotripsy is now being preferred over percutaneous nephrolithotomy for removal of kidney stones in children. Here, in this report, we have discussed persistent oxygen desaturation immediately after extubation in a two-year-old child who underwent Ho-YAG (holmium-yttrium-aluminium garnet) laser ureteroscopic nephrolithotripsy. The child developed bilateral pleural effusion after nephrolithotripsy and required continuous oxygen supplementation to maintain oxygen saturation above 95%, followed by ultrasound-guided thoracentesis.
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Primary hypokalaemic periodic paralysis during pregnancy has been rarely reported. Four pregnant women with the acute onset of flaccid paralysis presented between January 2018 and December 2021. Focussed history and physical examination helped an appropriate radiological and laboratory investigation plan to be made. All women recovered within 4-7 days of potassium supplementation. Supplemental potassium continued until delivery. A pain management plan with continuous epidural infusion helped in avoiding stress-induced hypokalaemia. None of the women developed an episode of muscle weakness during the intervening period. In conclusion, a focussed history and targeted laboratory investigation are needed to diagnose primary hypokalaemic periodic paralysis. Early administration of oral or intravenous potassium is crucial in improving fetomaternal outcomes.
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The incidence and magnitude of depression are rarely assessed during preanaesthetic evaluation. The shared physiological mechanisms of depression and anaesthetic drugs are likely to alter the pharmacodynamics of propofol. Therefore, the study aimed to evaluate the burden of presurgical depression and its effect on propofol consumption during anaesthesia. This prospective, observational, cross-sectional, analytical study included adult patients (> 18 years) undergoing surgery. During the preoperative period, depressive symptoms were evaluated by the psychiatrist on 9-point Patient Health Questionnaire-9 (PHQ-9). The propofol requirements were recorded during anaesthesia and compared with those for patients without depression. One hundred and seventy-four patients (87 patients each with and without cancer) underwent presurgical evaluation. The prevalence of depression (>4 Patient Health Questionnaire-9) and moderate to severe depression (>9 PHQ-9) among patients with cancer was 58.6% and 35.6%, respectively. The prevalence of depression (>4 PHQ-9) and moderate to severe depression (>9 PHQ-9) among patients without cancer was 18.4% and 3.4%, respectively. In the cancer group, propofol requirement was significantly lower (114.7 ± 22.9mg vs. 126.4 ± 24.3mg; p = 0.025) in patients with depression than that in those without depression. In conclusion, the burden of depression during the preanaesthetic period among patients with cancer is substantial, and depression reduces propofol requirement during surgery.
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BACKGROUND: Pulmonary vasodilators, including oxygen, have not shown consistent beneficial effects on pulmonary hypertension due to valvular heart disease (PH-VHD). Therefore, the study aimed to assess the effect of 100% fractional inspiration of oxygen (FiO2) on pulmonary and systemic hemodynamics in patients with combined pre- and post-capillary pulmonary hypertension (CpcPH) and isolated post-capillary pulmonary hypertension (IpcPH) due to PH-VHD. METHODS: This prospective study was conducted among patients with PH-VHD undergoing mitral or aortic valve replacement or repair. The study was conducted after induction of anesthesia and pulmonary artery catheterization. Cardiac output was obtained using thermodilution and all direct, and derived hemodynamic variables were obtained at 30% and 100% FiO2. The patients were stratified a priori into responders {(≥10 mmHg fall in mean pulmonary artery pressure (MPAP)} and non-responders. RESULTS: Fifty-seven patients completed the acute vasodilator test. The mean age and body mass index of the study population was 41.8 ± 14.1 years and 21.4 ± 4.6 kg/m2, respectively. There was a significant decrease in MPAP (40.77 ± 12.07 mmHg vs 36.74 ± 13.3 mmHg; P < .001) and pulmonary vascular resistance (PVR) {(median; Interquartile range (IQR); 388; 371 vs 323; 362 dynes sec.cm-5; P < .001) at 100% FiO2. Transpulmonary gradient (TPG) and diastolic pulmonary gradient (DPG) also decreased significantly (P < .001 and P < .001). Cardiac output did not change significantly. The magnitude of decrease in MPAP, PVR, TPG, DPG, and pulmonary artery compliance (PAC) between CpcPH and IpcPH was comparable. Responders did not show a significantly greater fall in MPAP, PVR, TPG, DPG, and PAC after surgery. CONCLUSION: Hyperoxia may lead to reduction in MPAP and PVR in both hemodynamic phenotypes of PH-VHD. A larger sample size is required to support or refute the findings of this study.
Subject(s)
Heart Diseases , Hypertension, Pulmonary , Humans , Vasodilator Agents/pharmacology , Vasodilator Agents/therapeutic use , Oxygen , Prospective Studies , Hemodynamics , Vascular Resistance , Cardiac Catheterization , Retrospective StudiesABSTRACT
BACKGROUND: Modifiable and non-modifiable factors contribute to development and progression of acute kidney injury (AKI) during cardiac surgery. We hypothesized that, the difference between preoperative mean arterial pressure (MAP) and the average mean arterial pressure maintained on cardiopulmonary bypass (CPB) would be strongly predictive of AKI. We also measured plasma Neutrophil gelatinase-associated lipocalin (NGAL), to establish its association with cardiac surgery associated-AKI (CSA-AKI). METHODS: One hundred and twelve high-risk patients undergoing valve, and valve plus coronary artery bypass grafting (CABG) surgery under cardiopulmonary bypass (CPB) were included in this study. Delta mean arterial pressure (MAP) was calculated as the difference between the average of pre-operative and on-bypass MAP, and blood was sampled for NGAL levels, at baseline, and 6-h after CPB. Detailed data collection was done, tabulating most of the factors which might influence development of post-operative cardiac surgery associated-AKI (CSA-AKI). To define CSA-AKI within the first 24-h post-operatively, the Kidney Disease Improving Global Outcomes (KDIGO) classification was used. RESULTS: Out of 112 patients, 44 (39.3%) developed CSA-AKI postoperatively. With an ROC analysis cut-off of delta MAP of more than 25.67 mmHg, 46.4% patients developed post-operative AKI, and the average CPB flows which were 1.8 ± 0.2 were not contributory to the development of early CSA-AKI. In our study, ELISA test for human NGAL was performed on serum samples, and the estimated cut-off value of 1661 ng/mL was found to be significantly associated with early CSA-AKI. CONCLUSIONS: Delta MAP and CPB flows are not related to early post-surgical CSA-AKI in cases with prior high-risk elements. However, baseline serum NGAL, as well as its percent change during the early post-surgical period independently predicted the development of CSA-AKI. This implies that, there may be patients with a higher pre-operative preponderance to develop this complication, which could actually be delineated by the use of serum NGAL estimations at baseline.
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BACKGROUND: Hyperoxygenation has shown promise in improving suspicious fetal heart patterns in women in labor. However, the effect of hyperoxygenation on neonatal outcomes in women in labor with pathologic fetal heart rate tracing has not been studied. OBJECTIVE: This study aimed to evaluate the effect of fractional inspiration of oxygen of 80% compared with fractional inspiration of oxygen of 40% on neonatal outcomes in women with pathologic fetal heart rate tracing. STUDY DESIGN: This randomized, open-label, parallel arm, outcome assessor-blinded clinical trial was conducted in a large tertiary care university hospital. Singleton parturients aged ≥18 years at term gestation in active labor (cervical dilatation of ≥6 cm) with pathologic fetal heart rate tracing were recruited in the study. Pathologic fetal heart rate tracing was defined according to the International Federation of Gynecology and Obstetrics 2015 guidelines. The International Federation of Gynecology and Obstetrics classifies fetal heart rate tracings into 3 categories (normal, suspicious, and pathologic) based on rate, variability, and deceleration. Women in the intervention arm received oxygen at 10 L/min via a nonrebreathing mask, and those in the usual care arm received oxygen at 6 L/min with a simple face mask. Oxygen supplementation was continued until cord clamping. The primary outcome measure was a 5-minute Apgar score. The secondary outcome measures were the proportion of neonatal intensive care unit admission, umbilical cord blood gas variables, level of methyl malondialdehyde in the cord blood, and mode of delivery. RESULTS: Overall, 148 women (74 women in the high fractional inspiration of oxygen arm and 74 in the low fractional inspiration of oxygen arm) with pathologic fetal heart rate tracing were analyzed. The demographic data, obstetrical profiles, and comorbidities were comparable. The median 5-minute Apgar scores were 9 (interquartile range, 8-10) in the hyperoxygenation arm and 9 (interquartile range, 8-10) in the usual care arm (P=.12). Furthermore, the rate of neonatal intensive care unit admission (9.5% vs 12.2%; P=.6) and the requirement of positive pressure ventilation (6.8% vs 8.1%; P=.75) were comparable. Concerning cord blood gas parameters, the hyperoxygenation arm had a significantly higher base deficit in the umbilical vein and lactate level in the umbilical artery. The cesarean delivery rate was significantly lower in women who received hyperoxygenation (4.1% [3/74]) than in women who received normal oxygen supplementation (25.7% [19/74]) (P=.00). In addition, umbilical vein malondialdehyde level in the umbilical vein was lower in the hyperoxygenation group (8.28±4.65 µmol/L) than in the normal oxygen supplementation group (13.44±8.34 µmol/L) (P=.00). CONCLUSION: Hyperoxygenation did not improve the neonatal Apgar score in women with pathologic fetal heart rate tracing. In addition, neonatal intensive care unit admission rate and blood gas parameters remained comparable. Therefore, the results of this trial suggest that a high fractional inspiration of oxygen supplementation confers no benefit on neonatal outcomes in women with pathologic fetal heart rate tracings and normal oxygen saturation.
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Cardiotocography , Labor, Obstetric , Pregnancy , Infant, Newborn , Humans , Female , Adolescent , Adult , Oxygen , Umbilical Arteries , MalondialdehydeABSTRACT
PURPOSE: Pre-conceptual comorbidities, an inherent risk of graft loss, rejection during pregnancy, and the postpartum period in women with thoracic lung transplant may predispose them to increased risk of adverse feto-maternal outcomes. The study aimed to systematically analyze and assess the risk of adverse pregnancy outcomes in women with thoracic organ transplant. METHODS: MEDLINE, EMBASE, and Cochrane library were searched for publication between January 1990 and June 2020. Risk of bias was assessed using Joanna Briggs critical appraisal tool for case series. The primary outcomes included maternal mortality and pregnancy loss. The secondary outcomes were maternal complications, neonatal complications, and adverse birth outcomes. The analysis was performed using the DerSimonian-Laird random effects model. RESULTS: Eleven studies captured data from 275 parturient with thoracic organ transplant describing 400 pregnancies. The primary outcomes included maternal mortality {pooled incidence (95% confidence interval) 4.2 (2.5-7.1) at 1 year and 19.5 (15.3-24.5) during follow-up}. Pooled estimates yielded 10.1% (5.6-17.5) and 21.8% (10.9-38.8) risk of rejection and graft dysfunction during and after pregnancy, respectively. Although 67% (60.2-73.2) of pregnancies resulted in live birth, total pregnancy loss and neonatal death occurred in 33.5% (26.7-40.9) and 2.8% (1.4-5.6), respectively. Prematurity and low birth weight were reported in 45.1% (38.5-51.9) and 42.7% (32.8-53.2), respectively. CONCLUSIONS: Despite pregnancies resulting in nearly 2/3rd of live births, high incidence of pregnancy loss, prematurity and low birth weight remain a cause of concern. Focused pre-conceptual counseling to avoid unplanned pregnancy, especially in women with transplant-related organ dysfunctions and complications, is vital to improve pregnancy outcomes. PROSPERO NUMBER: CRD42020164020.
Subject(s)
Abortion, Spontaneous , Organ Transplantation , Pregnancy Complications , Pregnancy , Infant, Newborn , Female , Humans , Pregnancy Outcome , Infant, Low Birth Weight , Organ Transplantation/adverse effects , Pregnancy Complications/epidemiology , Pregnancy Complications/etiology , Infant, PrematureSubject(s)
Acute Lung Injury , Lung Injury , Humans , Animals , Lung Injury/etiology , Lung , Disease Models, AnimalABSTRACT
Background. The pulse characteristics of arterial circulation might affect radial artery catheterization's success rate. Therefore, we hypothesized that the success rate of radial artery catheterization would be lower in the left-sided severe stenotic valvular lesion group than severe regurgitant valvular lesion group. Methods. This prospective study was conducted among patients with left-sided cardiac valvular lesions undergoing cardiac and non-cardiac surgery. The patients with left-sided severe valvular stenosis and left-sided severe valvular regurgitation were included in the study. Radial artery cannulation was performed using an ultrasound-guided out-of-plane short-axis approach. The outcome measures were success rate, number of attempts, and cannulation time. Result. One hundred fifty-two patients were recruited for the study, and all were eligible for final analysis. The first attempt success rate was non-significantly higher in the stenotic valvular lesion group than the regurgitant group (69.7% vs 56.6%; P = .09). Furthermore, the number of attempts (median; 95% CI) was significantly higher in the regurgitant group (1; 1.2-1.43 vs 1; 1.38-1.67; P = .04). However, it may not be of clinical relevance. Moreover, the cannulation time and the number of redirections of the cannula were comparable. Heart rate was significantly higher in the regurgitant group (91.8 ± 13.9 vs 82.26 ± 15.92 beats/min; P = .00), while the incidence of atrial fibrillation was significantly higher in the stenotic lesion (P = .00). No failure was reported, and the incidence of periarterial hematoma was comparable. Conclusion. The success rate of ultrasound-guided radial arterial catheterization is comparable in left-sided stenotic valvular and regurgitant lesion groups.
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Catheterization, Peripheral , Heart Diseases , Humans , Catheterization, Peripheral/methods , Prospective Studies , Constriction, Pathologic , Ultrasonography, Interventional/methods , Ultrasonography , Radial Artery/diagnostic imaging , Radial Artery/surgeryABSTRACT
Background: Predictors, pregnancy and subsequent pregnancy outcomes in women with peripartum cardiomyopathy (PPCM) are poorly understood in our geographical region. Methods: We retrospectively analysed 58 women with PPCM diagnosed using criteria by the European Society of Cardiology during 2015 to 2019. The main outcome measures were predictors of left ventricular (LV) recovery. LV recovery was defined as return of LV ejection fraction to over 50%. Results: Nearly 80% of women had LV recovery during 6 months follow up. Univariate logistic regression revealed LV end diastolic diameter (adjusted odds ratio (OR); 0.87; 95% CI, 0.78-0.98; p = 0.02), LV end systolic diameter (OR; 0.89; 95% CI, 0.8-0.98; p = 0.02) and inotrope use (OR; 0.2, 95% CI, 0.05-0.7; p = 0.01) as predictors of LV recovery. Relapse was not seen in any of the nine women who had a subsequent pregnancy. Conclusion: LV recovery was higher than those reported in contemporary PPCM cohorts from other parts of the world.
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OBJECTIVES: Literature comparing maternal and perinatal outcomes among women with scarred and primary uterine rupture are limited. Therefore, the study aimed to compare maternal and perinatal outcomes and associated risk factors of uterine rupture among scarred and unscarred uterus. METHODS: This retrospective cohort study was performed at a large tertiary care of India between July 1, 2011 and June 30, 2020. We analysed all the cases of complete uterine rupture beyond the 20th week of gestation. The outcome measures were live birth rate, perinatal mortality, maternal mortality and morbidity. RESULTS: A total of 115 complete uterine ruptures were noted in 148,102 pregnancies. Of those 115 uterine ruptures, 89 (77.3â¯%) uterine ruptures occurred in women with a history of caesarean delivery, and 26 (22.6â¯%) uterine ruptures occurred in primary uterine rupture. The primary uterine rupture group had a significantly higher incidence of lower parity, breech presentation and mean birth weight. The live birth rate (68.18% vs. 42.85â¯%; p=0.04) was significantly higher in the scarred group, and the stillbirth rate (57.14% vs. 31.86â¯%; p=0.009) was significantly higher in the primary uterine rupture group. Hypoxic ischemic encephalopathy, APGAR score, and neonatal intensive care unit admission were comparable. Postpartum haemorrhage, blood transfusion, severe acute maternal morbidity and intensive care unit stay were more frequently reported in the primary uterine rupture group. CONCLUSIONS: The maternal and perinatal outcomes appear less favourable among women with primary uterine rupture than scarred uterine rupture.
Subject(s)
Postpartum Hemorrhage , Uterine Rupture , Pregnancy , Infant, Newborn , Female , Humans , Uterine Rupture/epidemiology , Uterine Rupture/etiology , Retrospective Studies , Uterus/pathology , Cesarean Section/adverse effects , Postpartum Hemorrhage/etiology , Cicatrix/complications , Cicatrix/pathologyABSTRACT
Background and Aims: Retrograde transillumination technique has been found helpful for performing direct and video laryngoscopy by better identification of glottis. The usefulness of this technique during flexible videoscopy by novices has not been evaluated. So, we aimed to compare the retrograde transillumination and conventional technique of flexible videoscopy by novices. The primary outcomes were the time required to visualise the glottis from the point of insertion of the scope into the nostril (T1) and the time needed to see tracheal rings after glottis visualisation (T2). The secondary outcomes were incidence of desaturation with peripheral oxygen saturation (SpO2) <92% and the ease of performance of flexible videoscopy using retrograde transillumination. Methods: A total of 92 surgical patients who are undergoing general anaesthesia with normal airway parameters were randomised into two groups, Group C (Conventional flexible videoscopy- Ambu® aScope™ 3 Broncho Slim) and Group R (Flexible videoscopy aided by retrograde transillumination through the cricothyroid space using an OTICA LED vein finder). Results: The time to visualise glottis from scope insertion into the nose (T1) (median [interquartile range]) in group C and group R was (19.23 [13.6-30.5] versus 22.50 [17.8-25.5] seconds; P value = 0.417) and time to visualise the tracheal rings (T2) was (13.07 [9.1-20.00] versus 12.13 [9.0-19.1] seconds; P value = 0.714) were comparable in both the groups. 61% of residents found the retrograde transillumination to be very helpful. No incidence of desaturation was noted in either group. Conclusion: Retrograde transillumination-aided flexible videoscopy does not shorten the time but facilitates glottis and tracheal rings visualisation among novice anaesthesia residents.