Risk factors of acute kidney injury in very low birth weight infants in a tertiary neonatal intensive care unit

Abstract Objective Acute kidney injury (AKI) in the neonatal period is associated with worst outcomes as increased mortality and increased length of hospital stay. Very low birth weight (VLBW) newborns are at higher risk for developing several other conditions that are associated with worst outcomes. Understanding the risk factors for AKI may help to prevent this condition and improve neonatal care for this population. Methods This retrospective cohort study included 155 very low birth weight newborns admitted between 2015 and 2017. The authors compared the newborns who developed neonatal AKI with the non-AKI group and analyzed the main risk factors for developing AKI in the population. The authors also performed an analysis of the main outcomes defined as the duration of mechanical ventilation, length of stay, and death. Results From the cohort, a total of 61 (39.4%) patients had AKI. The main risk factors associated with Neonatal AKI were necrotizing enterocolitis (aOR 7.61 [1.69 - 34.37]; p = 0.008), neonatal sepsis (aOR 2.91 [1.17 - 7.24], p = 0.021), and hemodynamic instability (aOR 2.99 [1.35 - 6.64]; p = 0.007). Neonatal AKI was also associated with an increase in the duration of mechanical ventilation in 9.4 days (p = 0.026) and in an increase in mortality 4 times (p = 0.009), after adjusting for the other variables. Conclusion The present results highlight the importance of minimizing sepsis and necrotizing enterocolitis, as well as the importance of identifying hemodynamic instability, to prevent AKI and diminish the burden of morbimortality in VLBW newborns.

Lesiones traumáticas de pelvis / Traumatic Pelvic Injuries

Introducción: El tratamiento del traumatismo pélvico es uno de los más complejos en la atención al trauma. La tasa de mortalidad es alta. Objetivo: Examinar los criterios actuales acerca de las lesiones traumáticas de pelvis y las posibles estrategias existentes para su tratamiento. Métodos: Se realizó una búsqueda de artículos publicados en la base de datos PubMed entre los años 2011-2020. Se excluyeron trabajos porque estaban duplicados o los datos de origen eran insuficientes. Resultados: Se analizaron los mecanismos de las lesiones, su fisiopatología, principios y pilares de la atención médica y recomendaciones para el uso de herramientas de diagnóstico en el trauma, entre otras. Las complicaciones se presentan en pacientes con trauma pélvico abierto que pueden tener secuelas crónicas como incontinencia fecal y urinaria, impotencia, dispareunia, discapacidad residual en las funciones físicas, absceso perineal y pélvico, dolor crónico y complicaciones vasculares como embolia o trombosis. La mayoría de las muertes (44,7 por ciento) ocurren el día del trauma. Un enfoque multidisciplinario en la atención a las lesiones traumáticas de pelvis, contribuye a una mejora en el rendimiento y en los resultados de los pacientes. Conclusiones: Las lesiones traumáticas del anillo pélvico son consecuencia de accidentes de alta energía y constituyen una de las lesiones de mayor gravedad a las que está expuesto el ser humano. La posibilidad de inestabilidad mecánica asociada a alteraciones hemodinámicas obliga a la adopción de protocolos de actuación inmediata, para evitar la elevada mortalidad que se asocia a estas lesiones(AU)

Introduction: The treatment of pelvic trauma is one of the most complex in trauma care. Mortality rate is high. Objective: To examine the current criteria about traumatic pelvic injuries and the possible existing strategies for their treatment. Methods: A search was carried out for articles published in PubMed database from 2011 to 2020. Works that were duplicated or had insufficient source data were excluded. Results: We analyzed injury mechanisms, pathophysiology, classifications, principles and pillars of medical care, and recommendations for the use of diagnostic tools in pelvic trauma, among others. Complications with functional limitations occur in patients with open pelvic trauma who may have chronic sequelae such as fecal and urinary incontinence, impotence, dyspareunia, residual disability in physical functions, perineal and pelvic abscess, chronic pain, and vascular complications such as embolism or thrombosis. Most deaths (44.7 percent) occur on the day of the trauma. A multidisciplinary approach to treating traumatic pelvic injuries contributes to improved performance and patient outcomes. Conclusions: Traumatic injuries to the pelvic ring are the consequence of high-energy accidents and constitute one of the most serious injuries to which humans are exposed. The possibility of mechanical instability associated with hemodynamic alterations requires the adoption of protocols for immediate action, to avoid the high mortality associated with these injuries(AU)

Risk factors of hemodynamic instability after carotid artery stenting in elderly patients / 国际外科学杂志

Objective:To investigate the risk factors related to the hemodynamic instability occurring after carotid artery stenting(CAS) in elderly patients with carotid artery stenosis.Methods:The clinical data of 80 patients with carotid artery stenosis, who were treated with CAS at Xuanwu Hospital, Capital Medical University during the period from January 2018 to Decmber 2018, were retrospectively analyzed. Record demographic characteristics (age, gender, height, weight), history of underlying diseases (hypertension, diabetes, kidney disease, heart failure, etc.), history of medications, etc. Observe the clinical parameters such as creatinine, blood urea nitrogen (BUN), urine volume, input and output, albumin, hemoglobin, location of stenosis, and degree of stenosis. Measurement data conforming to the normal distribution were expressed as the mean ± standard deviation ( Mean± SD), and the t-test was used for comparison between groups; the measurement data that does not conform to the normal distribution were expressed as the median (interquartile range) [ M( P25, P75)] indicates that the rank sum test was used for comparison between groups; the Chi-square test was used for comparison of count data between groups. Relevant variables were subjected to single factor analysis, and statistically significant indicators were selected according to the results of single factor analysis to be included in the multivariate Logistic regression analysis. Results:After CAS, a total of 37 patients among the 80 patients developed hemodynamic instability, the incidence rate was 46.25%. Univariate analysis indicated that the factors associated with the occurrence of postoperative hemodynamic instability included height , platelet count, ulceration plaque and the fluid intake in the first 24 hours after surgery; Multivariate regression analysis revealed that the presence of ulceration plaque ( OR=11.559, 95% CI: 1.232-108.495) and the fluid intake in the first 24 hours after surgery( OR=1.001, 95% CI: 1.000-1.001) were the independent risk factors related to the hemodynamic instability after CAS. Conclusion:Elderly patients with the presence of ulceration plaque before surgery are more likely to develop hemodynamic instability after CAS, and within 24 hours after surgery is a high-risk time period for hemodynamic instability.

Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient / La Tomografía Computarizada Corporal Total es una herramienta segura, efectiva y eficiente en el paciente politraumatizado con inestabilidad hemodinámica

Abstract Trauma is a complex pathology that requires an experienced multidisciplinary team with an inherent quick decision-making capacity, given that a few minutes could represent a matter of life or death. These management decisions not only need to be quick but also accurate to be able to prioritize and to efficiently control the injuries that may be causing impending hemodynamic collapse. In essence, this is the cornerstone of the concept of damage control trauma care. With current technological advances, physicians have at their disposition multiple diagnostic imaging tools that can aid in this prompt decision-making algorithm. This manuscript aims to perform a literature review on this subject and to share the experience on the use of whole body computed tomography as a potentially safe, effective and efficient diagnostic tool in cases of severely injured trauma patients regardless of their hemodynamic status. Our general recommendation is that, when feasible, perform a whole body computed tomography without interrupting ongoing hemostatic resuscitation in cases of severely injured trauma patients with or without signs of hemodynamic instability. The use of this technology will aid in the decision-making of the best surgical approach for these patients without incurring any delay in definitive management and/or increasing significantly their radiation exposure.

Resumen El trauma es una compleja patología que requiere un equipo experimentado y multidisciplinario con una capacidad para la toma de decisiones Oportuna ya que en unos pocos minutos pueden representar la diferencia entre la vida y la muerte. Estas decisiones deben ser precisas para ser capaces de priorizar y controlar eficientemente las lesiones que puedan estar causando el compromiso hemodinámico. En esencia, este es el punto clave del concepto de control de daños en la atención del trauma. Con los nuevos avances tecnológicos, el equipo médico tiene a disposición múltiples herramientas imagenológicas de diagnóstico. Este artículo presenta una revisión de la literatura y descripción de la experiencia local con el uso de la tomografía corporal total como una herramienta diagnostica potencialmente segura, efectiva y eficiente en casos de pacientes con trauma severo sin importar su estado hemodinámico. La recomendación general, cuando sea posible, es que se debe realizar una tomografía corporal total sin interrumpir las maniobras de resucitación hemostática en casos de pacientes severamente traumatizados con o sin signos de inestabilidad hemodinámica. El uso de esta tecnología tiene como objetivo tomar decisiones pertinentes y definir el mejor abordaje quirúrgico para el paciente sin incurrir en tardanzas en el manejo definitivo o incrementar el tiempo de exposición a la radiación.

Study of pattern and management strategies of solid visceral injuries in blunt trauma abdomen in tertiary care centre

Background: Blunt trauma abdomen is a leading cause of morbidity and mortality among all age groups. In spite of the best techniques and advances in diagnostic and supportive care, the morbidity and mortality still remain large. The aim was to evaluate pattern and management strategies of solid visceral injuries in blunt trauma abdomen patients.Methods: This was a prospective study on 100 consecutive patients admitted in Department of General Surgery at a tertiary care center with an antecedent history of blunt abdominal injury. All patients proven to have penetrating injury and hollow viscus injury were excluded. The pattern of injury, presentation and parameters associated with management strategies were evaluated.Results: In the present study, solid viscera injury in blunt trauma abdomen is more common in age group 21-30 years (43%) with male predominance (92%). RTA (75%) were the most common mode of injury followed by fall. Most common clinical presentation was abdominal pain (86%) followed by tachycardia (34%) and hypotension (6%). Most common viscera injured is liver (48.2%) followed by spleen (36.7%), kidney (12.3%) and pancreas (2.8%). Majority of patients were managed conservatively (84%).Conclusions: It was concluded from the study that irrespective of the solid organ injury in blunt trauma abdomen, patients can be managed conservatively due to aggressive resuscitation with supplement drug therapy, use of analgesia or sedation in ICU setup and close monitoring. Patients are grossly hemodynamically unstable at presentation do require intervention either immediate or in due course of time.

Focused cardiac ultrasound in anesthetic practice: technique and indications / Ultrassom cardíaco focado na prática anestésica: técnica e indicações

Abstract The use of ultrasonography is well established in several anesthesia sub-specialties. Recently, there has been a major expansion of the POC (Point-Of-Care) ultrasound technique in intensive care, surgery, and emergency medicine, corroborating that USPOC in perioperative medicine has a much more comprehensive capability for both providing improved hemodynamic monitoring and early diagnosis of complications. The objective of the present article was to describe the use of a USPOC modality (focused cardiac US) that can be used for bedside assessment of unstable patients. Within a specific list of diagnoses, clinical treatment for a given situation can be tailored according to ultrasound findings, and by using binary and simple questions. Perioperative focused cardiac US use by the anesthesiologist has been related to lower rates of complications and mortality in high-risk patients.

Resumo O uso da ultrassonografia na prática anestésica já é bem estabelecido com a sua utilização em diversas subespecialidades. Recentemente, houve uma grande disseminação da técnica de ultrassonografia POC (point-of-care) nas áreas de medicina intensiva, cirurgia e medicina de urgência, confirmando que o seu uso em medicina perioperatória tem um potencial muito mais abrangente tanto para melhor monitorização hemodinâmica, como também para diagnóstico precoce de complicações. O objetivo deste artigo é descrever a utilização de uma modalidade de USPOC (ultrassom cardíaco focado) que pode ser utilizado à beira do leito com o objetivo de avaliar o paciente instável e, dentro de uma lista específica de diagnósticos, individualizar o tratamento clínico para determinada situação com base nos achados ultrassonográficos utilizando-se de questões de caráter binário e simples, sendo que o seu uso pelo anestesiologista no período perioperatório está relacionado a menores taxas de complicações e mortalidade em pacientes de alto risco.

Implementation of a new Single-Pass Whole-Body Computed Tomography Protocol: Is it safe, effective and efficient in patients with severe trauma? / Implementación de un nuevo protocolo de Tomografía Computarizada Corporal Total de un solo pase: ¿Es seguro, efectivo y eficiente en pacientes con trauma severo?

Abstract Purpose: The objective of this study was to evaluate the implementation of a new single-pass whole-body computed tomography Protocol in the management of patients with severe trauma. Methods: This was a descriptive evaluation of polytrauma patients who underwent whole-body computed tomography. Patients were divided into three groups: 1. Blunt trauma hemodynamically stable 2. Blunt trauma hemodynamically unstable and 3. Penetrating trauma. Demographics, whole-body computed tomography parameters and outcome variables were evaluated. Results: Were included 263 patients. Median injury severity score was 22 (IQR: 16-22). Time between arrival to the emergency department and completing the whole-body computed tomography was under 30 minutes in most patients [Group 1: 28 minutes (IQR: 14-55), Group 2: 29 minutes (IQR: 16-57), and Group 3: 31 minutes (IQR: 13-50; p= 0.96)]. 172 patients (65.4%) underwent non-operative management. The calculated and the real survival rates did not vary among the groups either [Group 1: TRISS 86.4% vs. real survival rate 85% (p= 0.69); Group 2: TRISS 69% vs. real survival rate 74% (p= 0.25); Group 3: TRISS 93% vs. real survival rate 87% (p= 0.07)]. Conclusion: This new single-pass whole-body computed tomography protocol was safe, effective and efficient to decide whether the patient with severe trauma requires a surgical intervention independently of the mechanism of injury or the hemodynamic stability of the patient. Its use could also potentially reduce the rate of unnecessary surgical interventions of patients with severe trauma including those with penetrating trauma.

Resumen Introducción: El objetivo de este estudio fue evaluar la implementación de un nuevo protocolo de tomografía computarizada corporal total para el manejo de pacientes con trauma severo. Métodos: Este estudio es una evaluación descriptiva de pacientes que recibieron tomografía computarizada corporal total. Los pacientes fueron divididos en 3 grupos: 1. Trauma cerrado hemodinámicamente estables, 2. Trauma cerrado hemodinámicamente inestables y 3. Trauma penetrante. Se evaluaron las características demográficas, parámetros relacionados con la técnica y los desenlaces de los pacientes. Resultados: Se incluyeron 263 pacientes. La mediana del puntaje de severidad de la lesión fue 22 (RIQ: 16-22). El tiempo entre el ingreso a urgencias y completar la tomografía corporal total fue menor a 30 minutos en la mayoría de pacientes [Grupo 1: 28 minutos (RIQ: 14-55), Grupo 2: 29 minutos (RIQ: 16-57), y Grupo 3: 31 minutos (RIQ: 13-50; p= 0.96). 172 pacientes (65.4%) recibieron manejo no operatorio. Las tasas de supervivencia calculadas y reales no difirieron entre ninguno de los grupos [Grupo 1: TRISS 86.4% vs. Tasa real de supervivencia 85% (p= 0.69); Grupo 2: TRISS 69% vs. Tasa real de supervivencia 74% (p= 0.25); Grupo 3: TRISS 93% vs. Tasa real de supervivencia 87% (p= 0.07)]. Conclusión: Este nuevo protocolo de tomografía corporal total de un solo pase fue seguro, efectivo y eficiente para definir si los pacientes con trauma severo requieren o no una intervención quirúrgica. Su uso podría reducir la tasa de intervenciones quirúrgicas innecesarias en estos pacientes incluyendo los que se presentan con trauma penetrante.

Utilidad de la ecocardiografía transtorácica focalizada en emergencias hemodinámicas intraoperatorias / Usefulness of Focalized transthoracic ecocardiography in intraoperative hemodynamic emergencys

INTRODUCTION: Echocardiography represents one of the most important advances in the monitoring of critical patients. Initially available only in cardiovascular surgery, currently, there is transesophageal echocardiography (TEE) and transthoracic echocardiography (ETT) in non-cardiac surgery, for anesthesiologists. The advantages of ETT is a non-invasive tool, of lower cost than the transesophageal transducer and therefore more feasible to be overcrowded and available in the pavilion. OBJECTIVE: To evaluate the usefulness of TTE in patients with hemodynamic compromise during non-cardiac surgery. NATERIAL AND METHODS: In a prospective manner between April 2016 and September 2018, patients were studied who during their intraoperative period presented a compromise of their hemodynamic state, defined as an average blood pressure under 55 mm Hg, for more than 3 minutes and without response to the usual therapy based on vasopressors and volume. Each of these patients had a prospective protocol for focused ETT looking for the cause of this disorder, by a duly trained operator. RESULTS: 124 patients, with an average age of 67 years (range 42 to 93 years) were evaluated. In all cases, at least one echocardiographic window was obtained that allowed a diagnosis to be made and/or to guide the therapy. The main causes of hemodynamic compromise were hypovolemia (52%), poor left ventricular function (21%) and other causes such as pericardial effusion, suspected pulmonary thromboembolism, pulmonary pathology and suspected myocardial ischemia. DISCUSSION: The ETT could be a feasible tool to use in acute hemodynamic events, since it offers good quality windows that allow new decisions based on the diagnosis and also allows to guide the selected therapies. In addition, it has been shown to positively impact clinical behaviors in the perioperative period. ETT is a non-invasive monitor, reasonably easy to learn to use; In addition to directly visualizing cardiac structures, it allows differential diagnoses of the causes of intraoperative hypotension. The therapies can also be decided according to the echocardiographic images and control how they generate changes in the cardiac cavities and in the hemodynamic state of the patient.

INTRODUCCIÓN: La ecocardiografía representa uno de los más importantes avances en la monitorización de pacientes críticos. Inicialmente disponible sólo en cirugía cardiovascular, en la actualidad, se cuenta con ecocardiografía transesofágica (ETE) y ecocardiografía transtorácica (ETT) en cirugía no cardíaca, para los anestesiólogos. Las ventajas del ETT están en ser una herramienta no invasiva, de menor costo que el transductor transesofágico y, por lo tanto, más factible de ser masificada y estar disponible en pabellón. OBJETIVO: Evaluar la utilidad de ETT en pacientes con compromiso hemodinámico durante cirugía no cardiaca. MATERIAL Y MÉTODOS: En forma prospectiva entre abril de 2016 y septiembre del 2018, se estudiaron enfermos que durante su intraoperatorio presentaron compromiso de su estado hemodinámico, definido como una presión arterial media bajo 55 mm Hg, por más de 3 minutos y sin respuesta a la terapia habitual basada en vasopresores y volumen. A cada uno de estos enfermos se le realizó un protocolo prospectivo de ETT focalizado buscando la causa de esta alteración, por un operador debidamente entrenado. RESULTADOS: 124 pacientes, con edad promedio de 67 años (rango 42 a 93 años) fueron evaluados. En todos los casos se obtuvo al menos una ventana ecocardiográfica que permitió realizar un diagnóstico y/o guiar la terapia. Las principales causas de compromiso hemodinámico fueron hipovolemia (52%), mala función del ventrículo izquierdo (21%) y otras causas como derrame pericárdico, sospecha de tromboembolismo pulmonar, patología pulmonar y sospecha de isquemia miocárdica. La ETT podría ser una herramienta factible de utilizar en eventos hemodinámicos agudos, ya que ofrece ventanas de buena calidad que permiten tomar decisiones nuevas basadas en el diagnóstico y, además, permite guiar las terapias seleccionadas. Además, ha mostrado impactar de forma positiva las conductas clínicas en el perioperatorio. DISCUSIÓN: La ETT es un monitor no invasivo, razonablemente fácil de aprender a utilizar que además de visualizar de manera directa las estructuras cardíacas, permite realizar diagnósticos diferenciales de las causas de hipotensión intraoperatoria. Además, se puede decidir las terapias de acuerdo a las imágenes ecocardiográficas y controlar cómo éstas generan cambios en las cavidades cardíacas y en el estado hemodinámico del paciente.

Traumatismo cardíaco penetrante en pediatría: presentación de caso, Hospital Infantil Dr. Robert Reid Cabral (HIRRC), República Dominicana / Penetrating Cardiac Trauma in Children: Case Presentation, Hospital Infantil Dr. Robert Reid Cabral, Dominican Republic.

Introducción: el traumatismo cardíaco es una condición poco frecuente en edad pediátrica, ocurriendo en menos del 5 % de traumatismos torácicos. Afecta más frecuentemente los ventrículos que las aurículas. Según el mecanismo de injuria puede ser: cerrado (como las contusiones torácicas) o penetrante (como las heridas por arma blanca o armas de fuego). El siguiente documento tiene la intención de describir la presentación clínica y el manejo de un paciente pediátrico con traumatismo cardíaco penetrante; se pretendió realizar una revisión de literatura sobre otros casos de traumatismo cardíaco penetrante. Presentación del caso: se expone el caso clínico de un paciente masculino de 14 años de edad, quien es referido al centro por historia de herida de arma blanca en región precordial izquierda. Se recibe con inestabilidad hemodinámica y hemitórax izquierdo hipodinámico; luego de realizar estudios de imagen y laboratorio se decide realizar toracocentesis. Ante evidente deterioro clínico, se decide realizar exploración quirúrgica, donde se halla laceración del ventrículo izquierdo y hematoma pericárdico, y se procede a drenar hematoma y cardiorrafia de ventrículo izquierdo. Conclusión: luego de describir la presentación y manejo de nuestro paciente, llegamos a la conclusión de que la sospecha clínica y el diagnóstico y manejo precoz son imprescindibles para mejorar el pronóstico de estos traumatismos. Asimismo, entendemos pertinente la exploración quirúrgica temprana ante los casos de inestabilidad hemodinámica, evitando el retraso de un tratamiento oportuno

Introduction: Cardiac trauma is a rare condition in pediatrics, occurring in less than 5 % of thoracic trauma. It affects the ventricles more often than the atria. Depending on the mechanism of injury, it may be classified as closed (such as blunt chest traumas) or penetrating (such as wounds with a knife or guns). The following document has the intention to describe the clinical presentation and management of a pediatric patient with a penetrating cardiac trauma, and it was intended to conduct a literature review on other cases of penetrating cardiac trauma. Case presentation: We present the clinical case of a 14-year-old male, who is referred to the center with history of a knife wound in the left precordial region. He is received with hemodynamic instability and hypodynamic left hemithorax, and, after performing imaging and laboratory studies, it was decided to perform thoracentesis. In the presence of evident clinical deterioration, it was decided to perform surgical exploration, where laceration of the left ventricle and pericardial hematoma is evidenced, for which drainage of hematoma and left ventricle cardiorrhaphy were performed. Conclusion: After describing the presentation and management of our patient, we conclude that clinical suspicion and early diagnosis and management are essential to improve the prognosis of these injuries. Likewise, we recognize the pertinence of early surgical exploration in cases of hemodynamic instability, avoiding the delay of a timely treatment.

Anesthetic management of carcinoid syndrome: is octreotide enough? A case report / Manejo anestésico del síndrome carcinoide: es el octreótido suficiente? Presentación de un caso

Abstract: Carcinoid tumors are rare slow-growing neuroendocrine tissue neoplasms. Their ability to secrete bioactive substances to the systemic circulation is accountable for a clinical presentation known as carcinoid syndrome. Main symptoms include bronchoconstriction, flushing, diarrhea and hemodynamic instability. Octreotide, a somatostatin analogue, is the current mainstay for carcinoid syndrome treatment and perioperative management. However, no regimen has proven to be completely effective in preventing systemic manifestations and recent literature suggests that it might be an insufficient measure. We report a case of a 51-year-old male with a functioning small bowel neuroendocrine tumor and carcinoid syndrome presenting for a primary tumor resection, discussing possible pitfalls and key points in the care of these patients.

Resumen: Los tumores carcinoides son neoplasias de tejido neuroendocrino poco comunes y de crecimiento lento. Su capacidad para secretar sustancias bioactivas a la circulación sistémica es responsable por una presentación clínica conocida como síndrome carcinoide. Los principales síntomas incluyen broncoconstricción, enrojecimiento, diarrea e inestabilidad hemodinámica. Octreótido, un análogo de la somatostatina, es el pilar actual para el tratamiento del síndrome carcinoide y su manejo perioperatorio. Sin embargo, ningún tratamiento ha demostrado ser completamente eficaz para prevenir las manifestaciones sistémicas y estudios recientes indican que puede ser una medida insuficiente. Presentamos un caso de un varón de 51 años con un tumor neuroendocrino funcionante en el intestino delgado y un síndrome carcinoide, sometido a una resección del tumor primario, discutiendo posibles dificultades y puntos clave en la atención de estos pacientes.

Clinical Outcome of Blunt Abdominal Trauma in Tertiary Care Teaching Hospital

Introduction: Blunt abdominal trauma occurs when injuryto organs inside abdominal cavity is present due to externalforces exerted over abdomen as result of trauma. Widespectrum of clinical presentation is seen ranging from milderforms of injury to fatal solid organ injuries with irreversibleshock and ongoing bleeding. Management ranges fromwatchful observation to emergency laparotomy. Aim ofthis study was to evaluate different clinical presentation,organ specific injury and management of blunt abdominaltrauma.Material and Methods: A retrospective study with 25patients sustaining Blunt abdominal trauma who came toTrauma centre in Guru Gobindsingh Government Hospital,Jamnagar attached to medical college from 2016 to 2018 wereincluded. The patients were selected randomly.Results: Blunt abdominal injury was seen in all age from 1 to60 years. Highest incidence noted in age group 11 to 20 years.Male predominance was noted with Male: Female ratio21:4 of5.25:1.Most common mode of injury was road traffic accident(44%). Most common injured organ was Liver (32%).Liver and spleen injuries were associated with rib fractures.Abdominal pain and tenderness was most common clinicalpresentation (90%). Patients with hemodynamic instabilityhad more mortality.Conclusion: Blunt abdominal injury is one of the commonestinjuries encountered in polytrauma patients. Morbidity andmortality can be prevented by timely initial resuscitation andcorrect diagnosis as well as management (operative or nonoperative) which depend on patient’s hemodynamic stabilityand findings of imaging studies.

Norepinefrina/vasopresina versus norepinefrina en pacientes politraumatizados con traumatismo craneoencefálico severo / Norepinephrine/vasopressin versus norepinephrine, in polytraumatized patients with severe traumatic brain injury / Norepinefrina/vasopressina vs norepinefrina em pacientes com traumatismo cranioencefálico grave

Resumen: Introducción: Los pacientes politraumatizados desarrollan una respuesta inflamatoria sistémica y sucesos quimiotácticos similares a los observados en procesos infecciosos; de éstos los que además presentan TCE severo requieren mantenimiento de presión arterial media (TAM) ≥ 90 mmHg, lo que conlleva la necesidad de dosis altas de vasopresores. Objetivo: Evaluar los efectos hemodinámicos de la administración de norepinefrina/vasopresina (grupo experimental) versus norepinefrina (grupo control) en pacientes politraumatizados con traumatismo craneoencefálico severo hemodinámicamente inestables. Material y métodos: Ensayo clínico controlado, no aleatorizado, abierto y de grupos paralelos. Resultados: Se obtuvo una muestra homogénea de 20 pacientes; ambos grupos mantuvieron las medianas de TAM similares [experimental 90 versus control 93 mmHg, p = 0.516]. Los efectos hemodinámicos a favor del grupo experimental fueron: presión arterial sistólica (PAS) [primera hora, p = .041], frecuencia cardiaca (FC) [primera hora p = .029] así como lactato [hora 5, p = .015]. En cuanto al balance hídrico, la mediana del grupo control fue de +1,516 mL versus +553 mL del grupo experimental [p = 0.579]. Conclusión: No existe diferencia significativa en la TAM en la reanimación y neuroprotección de ambos grupos. Hubo mejoría estadísticamente significativa en la TAS y FC en la primera hora a favor del grupo experimental.

Abstract: Introduction: The politraumatized patients develop a systemic inflammatory response and quimiotaxis cascade like the infectious diseases; from this kind of patients, those with severe traumatic brain injury, need to hold medium arterial pressure ≥ 90 mmHg, that triggers high doses of vasopressor. Objective: Evaluate hemodynamic repercussion, of infusion Vasopressin/Norepinephrine (experimental group) vs Norepinephrine (control group) in politraumatized patients with severe traumatic brain injury whom present hemodynamic instability. Material and methods: Controlled, non randomized and open trial, with parallel groups. Results: We got a standardized sample of 20 patients; both groups had the same median of mean arterial pressure (MAP) [experimental group 90 versus control group 93 mmHg, p = 0.516]. There were better hemodynamic effect in experimental group, in systolic arterial pressure (SAP) [first hour, p = .041], heart rate (HR) [first hour p = .029], and lactate [hour 5, p = .015]. The fluid balance's median in control group was +1,516 mL versus +553 mL in experimental group [p = 0.579]. Conclusion: There was no significant difference in MAP of both groups, in reanimation period either neurological protection therapy. There was statistically significant improvement in SAP and HR, in experimental group.

Resumo: Introdução: Os pacientes politraumatizados desenvolvem uma resposta inflamatória sistêmica e eventos quimiotáticos semelhantes aos observados em processos infecciosos; destes, os que además apresentam TCE grave requerem manter a pressão arterial média (PAM) ≥ 90 mmHg, o que leva à necessidade de altas doses de vasopressores. Objetivo: Avaliar os efeitos hemodinâmicos da administração de norepinefrina/vasopressina (grupo experimental) contra norepinefrina (grupo controle), em pacientes politraumatizado com traumatismo cranioencefálico grave, que apresentam instabilidade hemodinâmica. Material e métodos: Ensaio clínico controlado, não randomizado, aberto e com grupos paralelos. Resultados: Obteve-se uma amostra homogênea de 20 pacientes; ambos os grupos mantiveram médias PAM similares [experimental 90 versus controle 93 mmHg, p = 0.516]; Os efeitos hemodinâmicos a favor do grupo experimental foram: pressão arterial sistólica (PAS) [1o hora, p = .041], freqüência cardíaca (FC) [1o hora p = 0.029], bem como lactato [5o, p = 0.015]; Em relação ao balanço hídrico, a mediana do grupo controle foi +1,516 ml vs + 553 ml do grupo experimental [p = 0.579]. Conclusão: Não há diferença significativa na PAM, na ressuscitação e neuroproteção de ambos os grupos. Houve melhora estatisticamente significativa na PAS e FC na primeira hora a favor do grupo experimental.

Risk Factors of On-Pump Conversion during Off-Pump Coronary Artery Bypass Graft

BACKGROUND: Off-pump coronary artery bypass grafting (OPCABG) procedures can avoid the complications of an on-pump bypass. However, some cases unexpectedly require conversion to cardiopulmonary bypass during OPCABG. The risk factors associated with a sudden need for cardiopulmonary bypass were analyzed. METHODS: This retrospective study included 283 subjects scheduled for OPCABG from 2001 to 2010. These were divided into an OPCABG group and an on-pump conversion group. Preoperative, operative, and postoperative variables were compared between the 2 groups. RESULTS: Of the 283 patients scheduled for OPCABG, 47 (16%) were switched to on-pump coronary artery bypass grafting (CABG). The mortality of the both the OPCABG and on-pump conversion groups was not significantly different. The major risk factors for conversion to on-pump CABG were congestive heart failure (CHF) (odds ratio [OR], 3.5; p=0.029), ejection fraction (EF) <35% (OR, 4.4; p=0.012), and preoperative beta-blocker (BB) administration (OR, 0.3; p=0.007). The use of intraoperative (p=0.007) and postoperative (p=0.021) inotropics was significantly higher in the conversion group. The amount of postoperative drainage (p<0.001) and transfusion (p<0.001) also was significantly higher in the conversion group. There were no significant differences in stroke or cardiovascular complications between the groups over the course of short-term and long-term follow-up. CONCLUSION: Patients who undergo OPCABG and have CHF or a lower EF (<35%) are more likely to undergo on-pump conversion, while preoperative BB administration could help prevent conversions from OPCABG to on-pump CABG.

Prediction of Prolonged Hemodynamic Instability During Carotid Angioplasty and Stenting / 신경중재치료의학

PURPOSE: The aim of this study was to assess the risk factors of prolonged hemodynamic instability (HDI) after carotid angioplasty and stenting (CAS). Herein, a simplified predictive scoring system for prolonged HDI is proposed. MATERIALS AND METHODS: Sixty-six patients who had CAS from 2011 to 2016 at a single institution were evaluated. Prolonged HDI was defined as systolic blood pressure >160 mm Hg or <90 mm Hg or heart rate <50 beats/min, lasting over 30 minutes despite medical treatments. For the study, clinical data and radiologic data, including plaque morphology and stenosis were analyzed. RESULTS: Prolonged HDI was observed in 21 patients (31.8%). Multivariable analysis revealed that calcification (OR, 6.726; p=0.006), eccentric stenosis (OR, 3.645; p=0.047) and extensive plaque distribution (OR, 7.169; p=0.006) were related to prolonged HDI. According to these results, a simplified scoring scale was proposed based on the summation of points: 2 points for calcified plaque, 2 points for extensive plaque distribution, and 1 point for eccentric stenosis. The percentages of prolonged HDI according to the total score were as follows: score 0, 8.7%; score 1, 20.0%; score 2, 38.5%; score 3, 72.7%; score 4, 66.7%; score 5, 100%. From the analysis, the total score in patients with prolonged HDI was significantly higher than those without prolonged HDI (p<0.001). CONCLUSION: Prolonged HDI can be associated with calcification of plaque, eccentric stenosis and extensive plaque distribution, and a simplified scoring system enables prediction of prolonged HDI according to our cohort.

Tolerability and safety of enteral nutritionin in critical ill patients with hemodynamic instability / 中华急诊医学杂志

In patients with a functional gut,enteral nutrition is the preferred route of nutrition support.The favorable effects of enteral nutrition include prevention of mucosal atrophy,maintaining of the integrity of gut flora,and improvement of immunocompetence.The guidlines recommend EN be withheld in patients requiring significant hemodynamic support,because of highdose catecholamine agents which could reduce EN tolerance.Splanchnic perfusion is reduced in sepsis shock,yet vasoactive agents have demonstrated both improved and diminished perfusion.Inadequate perfusion increases the risk of experiencing rare but serious adverse events.This study summarizes the tolerability and safety of enteral nutritionin in critically iH patients with hemodynamic instability and provides theoretical basis for the early administration of EN.

Pharmacologic agents for acute hemodynamic instability: Recent advances in the management of perioperative shock- A systematic review.

Despite the growing body of evidence evaluating the efficacy of vasoactive agents in the management of hemodynamic instability and circulatory shock, it appears no agent is superior. This is becoming increasingly accepted as current guidelines are moving away from detailed algorithms for the management of shock, and instead succinctly state that vasoactive agents should be individualized and guided by invasive hemodynamic monitoring. This extends to the perioperative period, where vasoactive agent selection and use may still be left to the discretion of the treating physician with a goal-directed approach, consisting of close hemodynamic monitoring and administration of the lowest effective dose to achieve the hemodynamic goals. Successful therapy depends on the ability to rapidly diagnose the etiology of circulatory shock and thoroughly understand its pathophysiology as well as the pharmacology of vasoactive agents. This review focuses on the physiology and resuscitation goals in perioperative shock, as well as the pharmacology and recent advances in vasoactive agent use in its management.

Hemodynamic Instability during Carotid Angioplasty and Stenting-Relationship of Calcified Plaque and Its Characteristics

PURPOSE: During carotid angioplasty and stenting (CAS), hemodynamic instability (HDI) can occur, possibly causing post-procedural ischemic complications. The goal of this study was to investigate the risk factors of HDI focusing on characteristics of plaque. MATERIALS AND METHODS: Thirty nine CAS patients were retrospectively evaluated for HDI. Prolonged HDI that lasted over 30 minutes was analyzed in relation to characteristics of calcified plaque. RESULTS: Nineteen (48.7%) patients had HDI. Ten of the 19 had both bradycardia and hypotension, and nine had only bradycardia. All bradycardia was treated well with a transcutaneous temporary cardiac pacemaker. But eight patients presented with prolonged hypotension in spite of recovery of bradycardia. Calcified plaque was a related factor associated with HDI (odds ratio, 8.571; 95% confidence interval, 1.321-55.62; p=0.024). Extensive and eccentric type calcified plaques were associated with prolonged hypotension (p=0.04, and p=0.028, respectively). CONCLUSION: The calcification of plaque is a predictable factor of HDI during CAS, and its extensive and eccentric calcified plaques may be related to prolonged HDI.

Minimally Invasive Surgery for Fracture-dislocation of the Lumbar Spine with Neurologic Deficit and Hemodynamic Instability: A Case Report

STUDY DESIGN: A case report. OBJECTIVES: In patients with fracture-dislocation of the lumbar spine with neurologic deficit and hemodynamic instability, minimally invasive surgery made/produced good clinical results. So the authors have reported the results with literature review. SUMMARY OF LITERATURE REVIEW: In patients with unstable lumbar spine fracture-dislocation, early surgical treatment has been preferred due to its many advantages of anatomical reduction, nerve decompression, recovery of nerve function, and early rehabilitation, etc. But for patients with unstable lumbar spine fracture-dislocation and who are hemodynamically unstable, the surgical treatment is generally delayed, so there are many cases that cannot fulfill the expectation of neurologic recovery. MATERIALS AND METHODS: In patients with unstable lumbar 2-3 spine fracture-dislocation and who are hemodynamically unstable, applying the concept of stage operation, postural reduction and minimal invasive percutaneous pedicle screw fixation were conducted as soon as possible. Then after recover of general condition, decompression and posterior fusion were conducted as a second stage operation. RESULTS: After the first stage operation, motor grade was improved from 3 to 4 below the L3 spine level in postoperative physical examination. The second stage operation was conducted two weeks later and neurologic symptom was more improved after the second stage operation. CONCLUSIONS: In patients with lumbar spine fracture-dislocation having hemodynamic instability and neurologic deficit, early minimally invasive fixation for reducing complications of open reduction and internal fixation may contribute to improving general conditions and recovery of neurologic deficits.

Hemodinamia inestable en fracturas de pelvis estables / Results in the surgical treatment of the unstable shoulder

We report two cases of hemodynamic instability secondary to stable pelvic fractures. Both patients had isolated arterial lesions with large pelvic hematomas. In the two cases embolization of the injured vessel was performed. Knowing the existence of this kind of traumatic lesion is crucial for early diagnosis improving the results in the treatment of this life-threatening condition. Patients with pelvic fractures should be under observation for long periods of time, because delayed hemorrhage can occur.

Presentamos dos casos de inestabilidad hemodinámica en pacientes con fracturas de pelvis que fueron consideradas estables. Los pacientes presentaban lesión arterial traumática aislada y hematoma para-vesical de gran tamaño. Ambos fueron tratados de manera exitosa mediante embolización de su lesión arterial. Conocer este tipo de lesiones y diagnosticarlas de manera oportuna son claves en el buen resultado clínico de una lesión potencialmente mortal pero frecuentemente subvalorada. Es aconsejable observar por períodos prolongados de tiempo a pacientes con fracturas de pelvis ya que pueden producirse sangrados tardíos.

Factors Affecting Hemodynamic Instability in Patients with Pelvic Bone Fracture

PURPOSE: Treatment and prognosis in patients with pelvic bone fracture depend on the characteristics of the fracture and the stability of the pelvic ring. The purpose of this study is to analyze the characteristics of and the relationships between fracture patterns, injury mechanisms, clinical courses, and prognoses according to the hemodynamic pattern. METHODS: Between January 2004 and September 2006, 89 patients under diagnosis of pelvic bone fracture were retrospectively analyzed on the basis of medical records and radiologic examinations. Patients with confirmed hemorragic shock with a systolic pressure of less than 90 mmHg were defined as the shock group. Young's classification was used to characterize fracture patterns. Factors relating to the clinical manifestation and to treatments such as transfusion and surgery were analytically compared. RESULTS: The mean age of the patients was 48.8+/-18.7, among which 49 (55.1%) were male. The numbers of shock and non-shock patients were 35 (39.3%) and 54 (60.7%) respectively. Eighteen (51.4%) of the shock patient had injuries resulting from pedestrian accidents (p=0.008). According to Young's classification, lateral impact fractures amounted to 20 and 33, front-rear impact fractures to 9 and 20, and multiple fractures to 6 and 1 among the shock and non-shock patients, respectively (p=0.027). Thirty-nine (39) cases in non-shock injuries were conservatively managed while 18 cases in shock injuries were surgically treated. In the shock group, the liver and the kidney were often damaged, as well. Among the shock patients, the average admission period was 7.5+/-8.7 days in intensive care and 55.1+/-47.9 days in total, which were longer than the corresponding numbers of days for the non-shock patients (p<0.05). No deaths occurred in the non-shock group while 5 deaths (14.2%) occurred in the shock group (p=0.007). CONCLUSION: The factors affecting hemodynamic instability in patients with pelvic bone fracture are injury mechanism, classification of fracture, and associated injuries.