Mannitol for prevention of acute kidney injury after liver transplantation: a randomized controlled trial.

BACKGROUND: Acute kidney injury (AKI) is a common complication after liver transplantation, which is associated with increased morbidity and mortality. Therefore, this study investigated mannitol as an oxygen-free radical scavenger and its role in the prevention of early AKI after living donor liver transplantation (LDLT). METHODS: A total of 84 adult patients who underwent LDLT were randomly assigned to two equal groups: the M group, where patients received 1 g/kg mannitol 20%, or the S group, where patients received an equal volume of saline. The primary outcome was the incidence of early AKI, defined as a 0.3 mg/dl increase in the serum creatinine 48 h postoperatively. Laboratory assessments of the graft and creatinine were recorded until 3 months after transplantation besides the post-reperfusion syndrome and the intraoperative hemodynamic measurements. RESULTS: The AKI incidence was comparable between groups (relative risk ratio of 1.285, 95% CI 0.598-2.759, P = 0.518). Moreover, AKI stages and serum creatinine 3 months after transplantation, P = 0.23 and P = 0.25, respectively. The incidence of the post-reperfusion syndrome was comparable in both groups, 29/39 (74.4%) and 31/41 (75.6%) in M and S groups, respectively, P = 0.897. The intraoperative hemodynamic parameters showed no significant difference between groups using the area under the curve. CONCLUSION: The current LDLT recipient sample was insufficient to demonstrate that pre-reperfusion 1 g/kg mannitol infusion would reduce the risk of early AKI or post-reperfusion syndrome. CLINICAL TRIAL REGISTRATION NUMBER: Pan African Clinical Trials Registry (PACTR202203622900599); https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=21511 .

Effect of Anti-Inflammatory and Antimicrobial Cosupplementations on Sepsis Prevention in Critically Ill Trauma Patients at High Risk for Sepsis.

Background: Sepsis development in patients with trauma is associated with bad prognosis. This study investigated the effect of immunomodulatory interventions in major trauma patients at high risk for sepsis. Methods: In a randomized, double-blinded, controlled design, severe trauma patients were stratified by leukocyte anti-sedimentation rate (LAR) test into high risk (HR) and low risk (LR) for sepsis. The HR patients were randomly allocated into intravenous vitamin C plus vitamin B1 (HR-CB), intramuscular vitamin D plus oral Lactobacillus probiotics (HR-DP), or control (HR-C) groups. The clinical trial was registered at clinicaltrials.gov (https://clinicaltrials.gov/show/NCT04216459). Outcomes: The primary outcome was Acute Physiologic Assessment and Chronic Health Evaluation score II (APACHE II) score. Secondary outcomes included sepsis incidence, changes in Sequential Organ Failure Assessment (SOFA) score, and serum monocyte chemoattractant protein-1 (MCP-1) on day 6 from baseline, 28-day mortality, intensive care unit (ICU), and hospital discharge. Results: The HR-DP, HR-CB, and LR groups showed a significantly lower incidence of sepsis development (20%, 20%, and 16%, respectively, versus 60% in the HR-C group, p-value = 0.004). The three groups also showed a significant improvement in APACHE II and SOFA scores. Besides, MCP-1 levels were significantly decreased in HR-DP and HR-CB groups compared to the HR-C group (p-value ≤ 0.05). Significantly decreased mortality (10% and 16% versus 60% in the HR-C group) and increased ICU discharge (95% and 84% versus 45% in the HR-C group) were observed in HR-CB and LR groups (p-value = 0.001). Conclusion: Both combinations of interventions improved APACHE II scores and reduced sepsis incidence in trauma patients. The LAR combined with injury severity score were good sepsis predictors.

Different Analgesic Routes of Magnesium Sulfate: Intravenous versus Pectoralis II Interfascial Plane Block for Breast Cosmetic Surgeries.

PURPOSE: The purpose of the study is to evaluate the most effective analgesic route of magnesium sulfate (MgSO4) either intravenous (i.v.) or pectoralis interfascial plane block. PATIENTS AND METHODS: Fifty adult female patients were divided into two equal groups: i.v. MgSO4 and Pecs II block MgSO4 (Pecs MgSO4) group. After general anesthesia, in i.v. MgSO4 group, the local anesthetic (LA) for Pecs II block was prepared by adding 3 mL saline to 57 mL bupivacaine 0.25% divided equally for each side. A bolus i.v. solution of MgSO4 10% 0.5 mL.kg-1 diluted in saline in a total volume of 100 mL was given over 15 minutes. Then, the solution for continuous i.v. infusion; 30 mL MgSO4 10% and 70 mL saline was infused at the rate of 0.5 mL.kg-1.h-1 intraoperatively. For PecsMgSO4 group, LA formed of 3 mL MgSO4 10% added to 57 mL bupivacaine 0.25%. Whereas, 100 mL saline was given as bolus i.v. followed by continuous infusion of 100 mL normal saline at the rate of 0.5 mL.kg-1.h-1. RESULTS: In the group received MgSO4-bupivacaine Pecs II block, there was a nonsignificant decrease in postoperative morphine consumption compared to i.v. administration of MgSO4. The two groups were comparable in the intensity of pain and sedation scores. CONCLUSION: The use of bupivacaine Pecs II block enhanced with addition of MgSO4 to pectoralis interfascial plane block or intravenously in patients underwent breast cosmetic surgeries under general anesthesia was associated with comparable results of the postoperative morphine requirements, intensity of postoperative pain, and extension of the duration of postoperative analgesia. The intraoperative hemodynamic effects i.v. MgSO4 were superior to the pectoralis interfascial plane route of administration.

Surgically-assisted abdominal wall blocks for analgesia after abdominoplasty: A prospective randomized trial.

BACKGROUND: Abdominoplasty is a common aesthetic procedure. The transversus abdominis plane block (TAPB) and rectus sheath block (RSB) have proven efficacy as analgesic modality for abdominal surgeries. This study demonstrates post-abdominoplasty analgesic duration consequent to the three surgically infiltrated local anesthetic techniques: bilateral TAPB, bilateral RSB, and subcutaneous infiltration (SCI) of 0.25% bupivacaine. METHODS: In this prospective randomized study, 48 adult patients scheduled for abdominoplasty were randomized into three groups: TAPB group (n = 16), RSB group (n = 16), and SCI group (n = 16) utilizing 40 mL of 0.25% bupivacaine for each block. In both TAPB and RSB groups, the block was performed bilaterally after plication of anterior abdominal wall, while in SCI group, the surgical incisional area was infiltrated before skin closure. Main outcome measures included visual analogue scale (VAS), at rest and during movement; the analgesic duration; and the total required doses of morphine in the first postoperative day. RESULTS: A statistically significant longer analgesia was recorded in the TABP group compared with both the RSB and SCI groups. Statistically significant higher VAS scores in the SCI group 4 hours postoperatively was recorded, both at rest and during movement, compared with both TABP and RSB groups. Significant higher morphine consumption in the SCI group was compared with the other two groups. CONCLUSIONS: Among the surgically infiltrated anesthetic techniques for abdominoplasty, bilateral TAPB was associated with longer postoperatively analgesic duration with lower morphine consumption in the first 24 hours compared with RSB and SCI.

Ultrasound-guided multilevel paravertebral block versus local anesthesia for medical thoracoscopy.

BACKGROUND: Local anesthetic infiltration for medical thoracoscopy has an analgesic properties for short duration. Single injection thoracic paravertebral block (PVB) provides limited analgesia. PURPOSE: Comparison between thoracic PVB performed at two or three levels with local infiltration for anesthetic adequacy in adult medical thoracoscopy as a primary outcome and postthoracoscopic analgesia and pulmonary function as secondary outcomes for adult medical thoracoscopy. PATIENTS AND METHODS: Prospective randomized control study included 63 adult patients with exudative pleural effusion randomly divided into three groups of 21 patients: 3-level PVB, 2-level PVB group, and local infiltration group. Patients with contraindications to regional anesthesia or uncontrolled comorbidities were excluded from the study. Pain visual analog scale and spirometry were used for comparison as anesthetic adequacy in adult medical thoracoscopy as a primary outcome besides prolonged analgesia and improved pulmonary function as secondary outcomes. RESULTS: The anesthetic adequacy was 95.3% in 3-level PVB group, 81% in 2-level PVB group, and 71.5% in local infiltration group. The mean sensory level was 1 ± 0.8 and 1 ± 0.6 segment above and 0.8 ± 0.6 and 0.7 ± 0.7 segment below the injected level in 3-level PVB group and 2-level PVB, respectively. VAS was statistically significant higher in local infiltration compared to the other two groups immediately postthoracoscopic and 1 h after. Two-hour postthoracoscopy, significant increase in forced vital capacity values in the three groups compared to their basal values whereas forced expiratory volume at 1 s (FEV1) only in both PVB groups. CONCLUSION: Unilateral 3-level TPVB was superior to 2-level TPVB and LA infiltration for anesthetic adequacy for patients undergoing medical thoracoscopy. Moreover, US-guided TPVB was followed by higher FEV1 values and lower pain scores during the next 12 h postthoracoscopy in comparison to local infiltration, so 3-level TPVB is an effective and relatively safe anesthetic technique for adult patients undergoing medical thoracoscopy which may replace local anesthesia.