Safety of a 90-min duration of intravenous infusion of obinutuzumab in patients with B-cell non-Hodgkin's lymphoma in a tertiary hospital in China: a prospective, open-label, exploratory clinical trial

This study aimed to analyze the safety and applicability of a 90-min duration of infusion (SDI) of obinutuzumab in patients with B-cell non-Hodgkin's lymphoma (NHL) in a tertiary hospital in China. This exploratory clinical trial was performed at Jiangsu Province Hospital. All patients were treated with the standard infusion regimen for the first infusion. If no grade ≥3 infusion-related reactions (IRRs) occurred, the subsequent infusions were given as SDI. The primary endpoint was the incidence of IRR during the standard infusion (3-4 h) and 90-min SDI regimens. This study enrolled 208 patients and all completed cycle 1. Forty-one patients (19.71%) had IRRs: five (2.40%) with grade 1, twenty-eight (13.46%) with grade 2, and eight (3.85%) with grade 3. The 41 patients had 71 IRRs, mainly fever (40.85%), chest pain/tightness (12.68%), and dyspnea (9.86%). The occurrence of IRRs in the first infusion was significantly lower in patients who received oral acetaminophen prophylaxis than those who did not (10.72% vs 30.21%, P<0.001). For the subsequent cycles with 90-min SDI, only two (0.25%) IRRs occurred among 814 infusions (one grade 1 hand numbness and one grade 2 chill/fever). The 90-min obinutuzumab SDI might be safe and feasible in patients with B-cell NHL in China.

Uso clínico de lidocaína intravenosa para manejo de dolor neuropático no oncológico en adultos / Clinical Use of Intravenous Lidocaine for Management of non-Oncologic Neuropathic Pain in Adults

El dolor neuropático es común en la práctica clínica. Se estima que afecta entre el 2 y 3 % de la población a nivel global. Una cantidad considerable de pacientes presentan dolor refractario a tratamientos existentes, volviéndolo un reto diagnóstico y terapéutico. El objetivo de este estudio es describir el uso clínico de lidocaína intravenosa para manejo de dolor neuropático no oncológico en adultos. La búsqueda de información se realizó consultando las bases de datos HINARI, SciELO y PubMed. Se seleccionaron artículos en inglés y español de 2017 a 2021. Se utilizaron artículos originales, ensayos clínicos, revisiones bibliográficas y metaanálisis. Las causas de dolor neuropático en las que ha sido utilizada la lidocaína son la neuralgia posherpética, neuropatía diabética y neuralgia del trigémino. El uso de lidocaína intravenosa demostró que disminuye la intensidad del dolor; sin embargo, al compararlo con otros fármacos de primera línea no hay diferencias a largo plazo. La mayoría de efectos secundarios se presentan en el sistema nervioso, gastrointestinal y cardiovascular. La lidocaína intravenosa como monoterapia para manejo de dolor neuropático no oncológico, si bien fue eficaz a corto plazo con dosis de 3-5 mg/Kg, no tuvo un efecto persistente y duradero

Neuropathic pain is common in clinical practice; it is estimated that 2 to 3 % of the global population is affected; a considerable number of patients present pain refractory to existing treatments, making it a diagnostic and therapeutic challenge. The objective of this study is to describe the clinical use of intravenous lidocaine for the management of non-cancer neuropathic pain in adults. The information search was performed by consulting the HINARI, SciELO and PubMed databases. Articles with an obsolescence of no more than five years, both in English and Spanish, were selected. Original articles, clinical trials, bibliographic reviews and meta-analyses were used. The causes of neuropathic pain in which lidocaine has been used were postherpetic neuralgia, diabetic neuropathy, and trigeminal neuralgia. The use of intravenous lidocaine has been shown to decrease pain intensity; however, when compared with other first line drugs, there are no long-term differences. Most side effects occur in the nervous, gastrointestinal, and cardiovascular systems. Intravenous lidocaine as monotherapy for the management of non-cancer neuropathic pain, although effective in the short term with doses of 3-5 mg/Kg, does not have a persistent and long-lasting effect

Application of FMEA model and 6S management method in reducing dispensing errors in PIVAS of children’s hospitals / 中国药房

OBJECTIVE To reduce dispensing errors in pharmacy intravenous admixture service （PIVAS） of children’s hospitals. METHODS The risk of dispensing procedures in our PIVAS was identified by applying failure mode and effect analysis （FMEA） model. Potential failure modes that might lead to dispensing errors in each link were determined， and failure causes were analyzed. The severity， incidence and detection degree of potential failure modes were quantitatively scored， and their risk priority number （RPN） was calculated to screen failure modes that needed to be improved in priority； the corresponding improvement measures were developed by 6S management method from six aspects， namely， finishing （seiri）， rectifying （seiton）， sweeping （seiso）， sanitation （seiketsu）， literacy （shitsuke） and safety. The effect of intervention before and after rectification was evaluated. RESULTS Based on the RPN， 32 potential failure modes were selected， of which a total of 18 critical failure modes that needed to be improved in priority. After implementing corresponding measures according to 6S management method， the RPN of 18 critical failure modes decreased. The total RPN decreased from 497 to 142 with a decrease rate of 71.43%. The error rates of 15 critical failure modes were significantly lower than before implementation （P＜0.05）. CONCLUSIONS Applying FMEA model and 6S management method to the risk control of all aspects of PIVAS workflow can effectively reduce the risk of PIVAS dispensing errors and ensure the safety of children’s intravenous medication.

Strategies for ABO-incompatible liver transplantation / 器官移植

With rapid development of organ transplantation, the issue of global organ shortage has become increasingly prominent. At present, liver transplantation is the most effective treatment for end-stage liver disease. Nevertheless, the shortage of donors has been a key problem restricting the development of liver transplantation. China is a country with a larger number of hepatitis B, and the shortage of donor liver is particularly significant. Many critically ill patients often lose the best opportunity or even die because they cannot obtain a matched donor liver in time. As a strategy to expand the donor pool, ABO-incompatible (ABOi) liver transplantation offers new options for patients who are waiting for matched donors. However, ABOi liver transplantation is highly controversial due to higher risk of complications, such as severe infection, antibody-mediated rejection (AMR), biliary complications, thrombotic microangiopathy, and acute kidney injury, etc. In this article, research progress in preoperative, intraoperative and postoperative strategies of ABOi liver transplantation was reviewed, aiming to provide reference for clinical application and research of ABOi liver transplantation.

Hemodynamic impact of increasing time between fentanyl and propofol administration during anesthesia induction: a randomised, clinical trial

Abstract Background and objective: Anesthesia induction can produce severe propofol dose-dependent hypotension. Fentanyl coadministration reduces the catecholaminergic response to orotracheal intubation allowing propofol dose reduction. The aim of this study is to determine whether the hemodynamic response is improved by increasing the time between fentanyl and propofol administration and reducing the dose of the latter without increasing the time to achieve optimal hypnosis. Methods: After approval by the Research Ethics Committee, patients undergoing non-cardiac surgery with endotracheal intubation were randomized by a computer-generated table into six time-dose groups (1 or 2 minutes/1, 1.5, or 2mg.kg-1 of propofol). Patients with high bronchoaspiration risk, a difficult airway, hemodynamic instability, or anesthetic allergies were excluded. After giving intravenous fentanyl (2 μg.kg-1 ), each group received different doses of propofol after 1 or 2 minutes. Non-invasive blood pressure (BP) and heart rate (HR) were measured at pre-induction, pre-intubation, and post-intubation. Time to hypnosis (bispectral index < 60) was also recorded. Results: Of the 192 recruited patients, 186 completed the study (1 min group n = 94; 2 min group n = 92). It was observed that HR and BP decreased after propofol administration and increased after intubation in all groups (p<0.0001). In patients over 55 years, the 2 min - 2 mg.kg-1 group showed the greatest systolic BP reduction (36 ± 12%) at pre-intubation, while the 1 min - 1.5 mg.kg-1 group showed the least hemodynamic alteration between pre- and post-intubation (-4 ± 13%). No significant differences were found in younger patients or in the time to reach hypnosis between the six groups. While no cases of severe bradycardia were recorded, 5,4% of the sample required vasopressors. Conclusion: Increasing the time between the administration of fentanyl and propofol by up to two minutes results in greater hypotension in patients over 55 years.

Accuracy of closed-loop and open-loop propofol delivery systems by bispectral index monitoring in breast surgery patients: a prospective randomized trial

Abstract Background: This randomized and controlled prospective study tested the hypothesis that closed-loop Target-Controlled Infusion (TCI) of propofol would be associated with better system performance when compared with open-loop controlled delivery of propofol. Methods: Patients scheduled for elective breast surgery were randomly assigned to two groups: a closed-loop group, in which propofol infusion was performed by a closed-loop TCI system that used the Bispectral Index (BIS) as a feedback parameter to titrate the rate of propofol infusion, and an open-loop group, in which propofol infusion was performed manually and guided by the bispectral index. Results: A total of 156 patients were recruited for this study (closed-loop group n = 79; open-loop group n = 77). The Global Score (GS) of the closed-loop group was lower than that of the open-loop group (34.3 and 42.2) (p = 0.044). The proportions of time with a BIS value between 40 and 60 were almost identical in the closed-loop group and the open-loop group (68.7 ± 10.6% and 66.7 ± 13.3%) (p = 0.318). The individuals in the closed-loop group consumed more propofol compared with those in the open-loop group (7.20 ± 1.65 mg.kg−1.h−1 vs. 6.03 ± 1.31 mg.kg−1.h−1, p < 0.001). No intraoperative recall, somatic events or adverse events occurred. No significant difference in heart rate was observed between the two groups (p = 0.169). Conclusion: The closed-loop protocol was associated with lower BIS variability and lower out-of-range BIS values, at the cost of a greater consumption of propofol when compared to the open loop group. Register number:ChiCTR-INR-17010399.

Michigan appropriateness guide for intravenous catheters in pediatrics — miniMAGIC-Brasil: translation into Brazilian portuguese / Michigan appropriateness guide for intravenous catheters in pediatrics — miniMAGIC-Brasil: tradução para o português do Brasil

ABSTRACT Objective: To perform the translation and adaptation of the Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (miniMAGIC) into Brazilian Portuguese. Methods: Methodological study performed in five recommended stages: initial translations; synthesis of the translations; back translations; assessment of the back translations; expert committee assessment. The expert committee was composed of three registered nurses and two doctors who had a Master's and/or PhD degree, and an expertise in intravenous therapy and pediatric and neonatal care. To assess the semantic, idiomatic, experiential and conceptual adequacy, a Likert scale was applied, in which 1, "not equivalent"; 2, "inequivalent"; 3, "cannot assess"; 4, "quite equivalent"; 5, "totally equivalent". The terms mostly analyzed as negative in equivalence and with a lower than 20 score were reviewed and submitted to a new assessment, with the Delphi Technique until consensus was obtained. The results were stored in electronic spreadsheets and treated with concordance index, with a minimum acceptable result of 0.80. Results: The content of all recommendations, named as miniMAGIC-Brasil, was validated by the expert committee after two stages of evaluation. All recommendations had an overall agreement index of 0.91. Conclusions: The miniMAGIC-Brazil guide was validated in respect to the adequacy of the translation after two steps.

RESUMO Objetivo: Realizar a tradução e adaptação do miniMAGIC para a língua portuguesa do Brasil. Métodos: Estudo metodológico realizado em cinco etapas: traduções iniciais; síntese das traduções; retrotraduções; avaliação das retrotraduções; avaliação por comitê de especialistas. O comitê foi composto de três enfermeiros e dois médicos que possuíssem pós-graduação stricto sensu e experiência em acesso vascular e pediatria. Para a análise de adequação semântica, idiomática, experiencial e conceitual de cada item do instrumento, foi empregada escala tipo Likert graduada em 1, como "não equivalente"; 2, "pouco equivalente"; 3, "não sei avaliar"; 4, "bastante equivalente"; e 5, "totalmente equivalente". Os termos majoritariamente analisados como negativos quanto à equivalência e com pontuação inferior a 20 foram revisados e submetidos a nova análise segundo a técnica Delphi até que o consenso fosse alcançado. Os resultados obtidos foram armazenados em planilhas eletrônicas e tratados com análise do índice de concordância mínimo de 0,80. Resultados: O conteúdo de todas as recomendações, que receberam nomeação de miniMAGIC-Brasil, alcançou índice de concordância mínimo, segundo julgamento por comitê de especialistas, após duas etapas de avaliação. Todas as recomendações obtiveram índice de concordância ao final de 0,91. Conclusões: O guia miniMAGIC-Brasil obteve índice de concordância dos termos segundo análise da adequação da tradução após duas etapas.

A meta-analysis of ferric carboxymaltose versus other intravenous iron preparations for the management of iron deficiency anemia during pregnancy

Abstract Objective: We conducted a meta-analysis of randomized clinical trials evaluating the clinical effects of ferric carboxymaltose therapy compared to other intravenous iron in improving hemoglobin and serum ferritin in pregnant women. We also assessed the safety of ferric carboxymaltose vs. other intravenous iron. Data source: EMBASE, PubMed, and Web of Science were searched for trials related to ferric carboxymaltose in pregnant women, published between 2005 and 2021. We also reviewed articles from google scholar. The keywords "ferric carboxymaltose," "FCM," "intravenous," "randomized," "pregnancy," "quality of life," and "neonatal outcomes" were used to search the literature. The search was limited to pregnant women. Selection of studies: Studies related to ferric carboxymaltose in pregnancy were scanned. Observational studies, review articles, and case reports were excluded. Randomized studies in pregnant women involving ferric carboxymaltose and other intravenous iron formulations were shortlisted. Of 256 studies, nine randomized control trials were selected. Data collection: Two reviewers independently extracted data from nine selected trials Data synthesis: The final effect size for increase in hemoglobin after treatment was significant for ferric carboxymaltose vs. iron sucrose/iron polymaltose (standard mean difference 0.89g/dl [95% confidence interval 0.27,1.51]). The final effect size for the increase in ferritin after treatment was more for ferric carboxymaltose vs. iron sucrose/iron polymaltose (standard mean difference 22.53µg/L [-7.26, 52.33]). No serious adverse events were reported with ferric carboxymaltose or other intravenous iron. Conclusion: Ferric carboxymaltose demonstrated better efficacy than other intravenous iron in increasing hemoglobin and ferritin levels in treating iron deficiency anemia in pregnant women.

Safety and efficacy of target-controlled infusion versus intermittent bolus administration of propofol for sedation in colonoscopy: a randomized controlled trial

Abstract Background: Our objective was to compare the safety and efficacy of Target-Controlled Infusion (TCI) versus intermittent bolus of propofol for colonoscopy sedation. Methods: We conducted a randomized (1:1), single-blind, parallel-group superiority trial with fifty ASA I or II patients, both sexes, aged 18 to 65 years, Body Mass Index ≤ 30 kg.mr-2, undergoing colonoscopy, allocated to receive propofol by TCI (effect-site, 2 μg.mL-1 plus 0.5 μg.mL-1 until unconsciousness and as necessary for agitation) or intermittent bolus (1 mg.kg-1 plus 0.5 mg.kg-1 every 5 minutes or as above). The primary safety outcome was the need for airway maneuvers and the primary efficacy outcome was the need for interventions to adjust the level of sedation. Secondary outcomes included incidence of agitation, propofol dose, and time to recovery. Results: The median (IQR) number of airway maneuvers and interventions needed to adjust sedation was 0 (0-0) vs. 0 (0-0) (p = 0.239) and 1 (0-1) vs. 3 (1-4) (p < 0.001) in the TCI and control groups, respectively. Agitation was more common in the intermittent bolus group - 2 (0-2) vs. 1 (0-1), p < 0.001. The mean ± SD time to recovery was 4.9 ± 1.4 minutes in the TCI group vs. 2.3 ± 1.6 minutes in the control group (p < 0.001). The total propofol dose was higher in the TCI group (234 ± 46 μg.kg-1.min-1 vs. 195 ± 44 μg.kg-1.min-1 (p = 0.040)). Conclusions: During colonoscopy, TCI is as safe as intermittent bolus of propofol while reducing the incidence of agitation and the need for dose adjustments. However, intermittent bolus administration was associated with lower total propofol dose and earlier recovery.

Cardiac output and the pharmacology of general anesthetics: a narrative review

The relationship between cardiac output and anesthetic drugs is important to anesthesiologists, since cardiac output determines the speed with which a drug infused into the bloodstream reaches its target and the intensity of the drug's effect. But rather than focus on how anesthetic drugs affect cardiac output, this narrative review focuses on how changes in cardiac output affect the pharmacokinetics and pharmacodynamics of general anesthetics during the three phases of anesthesia. At induction, an increase in cardiac output shortens both the onset time of propofol for hypnosis and the neuromuscular blocking effect of rapid-acting neuromuscular blockers, favoring the conditions for rapid sequence intubation. During maintenance, changes in cardiac output are followed by opposite changes in the drug plasma concentration of anesthetic drugs. Thus, an increase in cardiac output followed by a decrease in the plasma concentration of the anesthetic could expose the patient to a real risk of intraoperative awakening, which can be avoided by increasing the dose of hypnotic drugs. At emergence, an increase in cardiac output secondary to an increase in pC02 allows for a more rapid recovery from anesthesia. The pC02 can be increased by adding CO2 to the respiratory circuit, lowering the ventilatory rate, or placing the patient on partial rebreathing. Finally, the reversal action of sugammadex for rocuronium-induced neuromuscular block can be shortened by increasing the cardiac output.

La relación entre el gasto cardíaco y los fármacos anestésicos es importante para los anestesiólogos puesto que el gasto cardíaco determina la velocidad con la cual un medicamento que se infunde al torrente sanguíneo llega a su diana y la intensidad del efecto del agente. Pero en lugar de concentrarnos en cómo los fármacos anestésicos afectan el gasto cardíaco, esta revisión narrativa se enfoca en cómo los cambios en el gasto cardíaco afectan la farmacocinética y la farmacodinámica de los agentes anestésicos generales durante las tres fases de la anestesia. En el momento de la inducción, un incremento en el gasto cardíaco acorta tanto el tiempo de inicio del efecto del propofol para la hipnosis como el efecto del bloqueo neuromuscular causado por los bloqueadores neuromusculares de acción rápida, favoreciendo las condiciones para la intubación de secuencia rápida. Durante la fase de mantenimiento, los cambios en el gasto cardíaco vienen seguidos de cambios opuestos en la concentración plasmática del medicamento de los agentes anestésicos. Por lo tanto, un aumento del gasto cardíaco, seguido de una reducción en la concentración plasmática del anestésico, podría exponer al paciente a un riesgo real de despertar intraoperatorio, lo cual puede evitarse aumentando la dosis de los fármacos hipnóticos. En la educción, un aumento en el gasto cardíaco secundario al incremento en el pCO2 permite una recuperación más rápida de la anestesia. El pCO2 puede aumentar agregando CO2 al circuito de la respiración, reduciendo la tasa ventilatoria, o colocando al paciente en re-inhalación parcial. Finalmente, la acción de reversión de sugammadex en caso de bloqueo neuromuscular inducido por rocuronio, puede acortarse aumentando el gasto cardíaco.

Presentación de un caso y revisión de literatura: anestesia total intravenosa en cirugía de estesioneuroblastoma / Presentation of a case and literature review: total intravenous anesthesia in estesioneuroblastoma surgery

Resumen: El estesioneuroblastoma es una neoplasia de las células del neuroepitelio olfatorio. Tiene una baja incidencia de 0.4 por cada millón de habitantes. Se caracteriza por síntomas como sinusitis, epistaxis, cefalea, discapacidad visual, obstrucción nasal, hiposmia y rinorrea. En este reporte se presenta el caso de un paciente masculino de 29 años con estesioneuroblastoma estadio Kadish C, quien fue programado para resección quirúrgica bajo anestesia total intravenosa con resultados satisfactorios durante el procedimiento quirúrgico.

Abstract: Esthesioneuroblastoma is a neoplasm of the olfactory neuroepithelium cells, it has a low incidence of 0.4 per million inhabitants. It is characterized by symptoms such as sinusitis, epistaxis, headache, visual impairment, nasal obstruction, hyposmia, and rhinorrhea. We present the case of a 29-year-old male patient with Kadish C stage esthesioneuroblastoma, who was scheduled for surgical resection under total intravenous anesthesia with satisfactory results during the surgical procedure.

Síndrome Stevens Jonhson: reporte de caso clínico / Stevens Johnson syndrome: clinical case report

Resumen Introducción: El síndrome Stevens Johnson (SSJ) es una dermatosis potencialmente fatal caracterizada por una extensa necrosis epidérmica y de mucosas que se acompaña de ataque al estado general, y junto con la necrólisis epidérmica tóxica (NET) se consideran reacciones de hipersensibilidad tipo IV, relacionadas con ciertos fármacos en 60% de los casos, siendo uno de los diagnósticos pocos frecuentes, pero con una alta mortalidad hasta del 40%. Caso clínico: El siguiente caso clínico es un masculino de 34 años de edad que inició un cuadro de eritema generalizado inmediatamente tras la administración del medicamento trimetoprima/sulfametoxazol. Se le solicitó un hemograma mostrando leucocitosis, neutrofilia, VSG elevada, PCR elevada, IgE elevada, y tras el interrogatorio clínico se realiza el algoritmo ALDEN dando positivo con 10 puntos asociado al medicamento previamente dicho. Por lo tanto se le inicia tratamiento con metilprednisolona, difenhidramina, inmunoglobulina humana intravenosa y un plan terapéutico cutáneo, dando como resultado una mejoría clínica, evitando complicaciones y secuelas, hasta el día de su egreso. A manera de conclusión, se requiere un manejo multidisciplinario para atender las manifestaciones clínicas del inmunoglobulina humana intravenosa.

Abstract Introduction: Stevens Johnson Syndrome (SJS) is a potentially fatal dermatosis characterized by extensive epidermal and mucosal necrosis accompanied by an attack on the general condition, which together with Toxic Epidermal Necrolysis (TEN) are considered type IV hypersensitivity reactions, related to certain drugs in 60% of cases, being one of the rare diagnoses, but with a high mortality of up to 40%. Case report: The following clinical case is a 34 year old male who started a generalized erythema picture immediately after administration of the medication trimethoprim/sulfamethoxazole, for which a complete blood count was requested showing leukocytosis, neutrophilia, elevated ESR, elevated PCR, elevated IgE, and after the clinical questioning, the ALDEN algorithm was performed, giving positive with 10 points associated with the previously mentioned medication, for which treatment was started with methylprednisolone, diphenhydramine, intravenous human immunoglobulin and a skin therapeutic plan, resulting in clinical improvement, avoiding complications and sequelae, until the day of discharge. In conclusion, a multidisciplinary management is required to attend to the clinical manifestations of the patient, helping him to a quick and effective recovery.

Experiencia de uso de hierro intravenoso para el tratamiento de la anemia en niños y adolescentes. Respuesta terapéutica y evolución / Experience in using intravenous iron for the treatment of anemia in children and adolescents. Therapeutic response and evolution

Introducción: El hierro de administración intravenosa (iv) está indicado en los casos en que el tratamiento oral no es posible. El objetivo de este trabajo fue describir el perfil de uso, respuesta terapéutica y seguridad de la administración de hierro iv en el tratamiento de la anemia ferropénica en niños, niñas y adolescentes (NNA) asistidos en un centro de referencia de Uruguay entre 2018 y 2023. Método: Estudio retrospectivo mediante revisión de historias. Incluyó todos los NNA que recibieron hierro iv. Se registraron variables sociodemográficas, comorbilidades, clínica y severidad de la anemia. Se evaluó: motivos de la indicación y tipo de hierro iv, dosis, tiempo de infusión, respuesta terapéutica y efectos adversos. Resultados: Se incluyeron 35 pacientes, mediana de edad 4 años; 51,4% de sexo masculino, con comorbilidades 37,1%. Todos los menores de 3 años presentaban factores de riesgo para anemia ferropénica, la falta de adherencia al hierro oral se asoció con mayor severidad de la anemia (p<0,05). El motivo principal de indicación de hierro iv fue la severidad de la anemia e inadecuada respuesta al hierro oral concomitante en 37,1%. Todos recibieron hierro sacarato; mediana de dosis: 2 mg/kg y de tiempo de infusión: 1 hora. Se registró un caso de edema y exantema de cara vinculado a la rápida infusión. La evolución fue satisfactoria. Conclusiones: La administración de hierro iv fue segura. Es necesario establecer consensos respecto a la posología y monitorización. Se requieren nuevos estudios para continuar evaluando la eficacia y seguridad del hierro iv en sus diversas formulaciones.

Introduction: Intravenous (IV) iron administration it is indicated in cases where oral treatment is impossible. The objective of this work was to describe the profile of use, therapeutic response, and safety of the iron IV administration in treating anemia in children and adolescents (NNA) assisted in a reference center in Uruguay between 2018 and 2023. Method: Retrospective study through review of histories. It included all children and adolescents who received IV iron. Sociodemographic variables, comorbidities, clinical symptoms, and severity of anemia they were recorded. They were evaluated: reasons for the indication and type of IV iron, dose, infusion time, therapeutic response, and adverse effects. Results: we included 35 patients, with a median age of four years; 51.4% were male, and 37.1% had comorbidities. All children under three years of age had risk factors for iron deficiency anemia; greater severity of anemia was associated with lack of adherence to oral iron (p<0.05). The main reason for the indication of IV iron was the severity of anemia and inadequate response to concomitant oral iron at 37.1%. All received iron saccharate; median dose: 2 mg/kg and infusion time: 1 hour. A case of facial edema and rash linked to rapid infusion was recorded. The evolution was satisfactory. Conclusions: The administration of IV iron was safe. It is necessary to establish a consensus regarding dosage and monitoring. New studies are required to continue evaluating the efficacy and safety of IV iron in its various formulations.

Lidocaína para el alivio del dolor en pacientes de cuidados paliativos, una serie de casos / Lidocaine for pain relief in palliative care patients, a case series

Introducción. El dolor neuropático afecta al 2 % de la población y 15 de cada 100 pacientes que acuden a consulta médica, sufren de dolor neuropático. Este tipo de dolor es muy común en pacientes con cáncer. Objetivo. Determinar si el uso de lidocaína en infusión endovenosa disminuye el dolor neuropático en los cuidados paliativos con tratamiento opioide. Metodología. Serie de casos de tres pacientes en cuidados paliativos que presentaron dolor neuropático y se les administraron múltiples infusiones de lidocaína intravenosa como coadyuvante para el manejo del dolor, se describieron las dosis utilizadas, el número de infusiones, se evaluó la mejoría del dolor a través de la escala visual análoga y se monitorizaron los posibles efectos secundarios. Resultados. Caso 1: escala visual análoga al ingreso 9/10; 24 horas posinfusión de lidocaína: 4/10. Caso 2: escala visual análoga al ingreso 6/10; 24 horas posinfusión de lidocaína 2/10. Caso 3: escala visual análoga al ingreso 8/10; 24 horas posinfusión 2/10. Conclusión. La infusión intravenosa de lidocaína al 2 % disminuyó el dolor neuropático en los tres pacientes del estudio, sin embargo, el alivio fue transitorio y el efecto positivo se perdió con el paso del tiempo

Introduction. Neuropathic pain affects 2 % of the population and 15 out of 100 patients who go to a physician suffer from neuropathic pain. This type of pain is common in cancer patients. Objective. To determine if the use of lidocaine in intravenous infusion reduces neuropathic pain in palliative care with opioid treatment. Methodology. Case series of three patients in palliative care who presented neuropathic pain and underwent multiple infusions of intravenous lidocaine as an adjuvant for pain management; the doses used and the number of infusions were described, pain improvement was evaluated through the visual analog scale and possible side effects were monitored. Results. Case 1: visual analogue scale on admission 9/10; 24 hours post lidocaine infusion: 4/10. Case 2: visual analogue scale on admission 6/10; 24 hours post lidocaine infusion 2/10. Case 3: visual analogue scale on admission 8/10; 24 hours post-infusion 2/10. Conclusion.Intravenous infusion of 2 % lidocaine reduced neuropathic pain in the three patients of the study, however, the relief is transitory, and the positive effect is lost over time.

Perspectiva neurológica en la elección del anticoagulante oral directo para la prevención del accidente cerebrovascular en fibrilación auricular / Neurological perspective in the choice of direct oral an ticoagulants for prevention of stroke in atrial fibrillation

Resumen La fibrilación auricular no valvular (FA) es la arritmia con potencial embolígeno más prevalente y una de las principales y crecientes causas de accidente cerebrovas cular isquémico (ACVi). El principal objetivo del uso de la anticoagulación en pacientes con FA es la prevención del ACVi. Hasta hace poco tiempo, la anticoagulación con antagonistas de la vitamina K (AVKs) era la única opción disponible. Los anticoagulantes orales directos (DOACs) como el inhibidor directo de la trombina, dabigatrán, o los inhibidores directos del factor Xa, rivaroxabán, apixa bán y edoxabán, tienen un perfil de efectividad/seguridad más favorable en comparación con los AVKs. No existen estudios que comparen la efectividad de los DOACs entre sí. La elección del DOAC depende de múltiples factores específicos del paciente, preferencias del médico, costos y accesibilidad. Entre 1-2% de los pacientes correctamente tratados con un DOAC intercurre con un ACVi cada año. La posibilidad de contar con un agente reversor debería ser tenida en cuenta al momento de la elección del DOAC, especialmente por el riesgo residual de ocurrencia de ACVi. En la actualidad, en nuestro país solo el dabigatrán cuenta con un agente reversor disponible y lo convierte en el único DOAC que no contraindica el uso de trombolisis intraveno sa con rtPA. Esta situación debería ser considerada en el momento de la elección del DOAC para la prevención de eventos tromboembólicos en pacientes con FA.

Abstract Non-valvular atrial fibrillation (AF) is the most preva lent arrhythmia with high embolic potential, and one of the main and growing causes of stroke. The main objec tive of anticoagulation in patients with AF is prevention of stroke. Until recently, anticoagulation with vitamin K antagonists (VKAs) was the only available option. Direct oral anticoagulants (DOACs), such as the direct thrombin inhibitor dabigatran, or the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, have a more favor able effectiveness/safety profile compared to VKAs. There are no studies comparing the efficacy of DOACs with each other. The choice of a DOAC arose from patient car achterictis, physician preferences, cost, and accessibility. Between 1-2% of patients correctly treated with a DOAC experience a stroke each year. The possibility of having a reversal agent should be taken into account when choos ing a DOAC, especially due to the residual risk of stroke occurrences even under DOACs. Currently, in our country only dabigatran has a reversing agent available, making it the only DOAC that does not contraindicate the use of intravenous thrombolysis. This should be taken into account when choosing the DOAC for the prevention of thromboembolic events in patients with AF.

Menor aerolización con bloqueo del nervio laríngeo superior comparado con lidocaína intravenosa a la extubación / Less aerolization with superior laryngeal nerve block compared to intravenous lidocaine at extubation

Resumen: Introducción: La tos es una respuesta fisiológica de protección de la vía aérea, produce aerosoles que se identifican por imagen y alcanza una velocidad de hasta ocho metros por segundo. La extubación produce tos, hipertensión, taquicardia, apnea y laringoespasmo, existen métodos para minimizar su aparición. Debido a la pandemia de COVID-19 se han utilizado como profilaxis del reflejo tusígeno, la lidocaína intravenosa y el bloqueo del nervio laríngeo superior. El objetivo fue compararlos en la inhibición de la tos. Material y métodos: Se seleccionaron pacientes entre 18-60 años, cirugía electiva con anestesia general balanceada, ASA 1-3, con intubación menor a tres horas. Se aleatorizó un total de 90 pacientes, 45 en cada grupo, se eliminó un total de 10 pacientes por presentar inestabilidad hemodinámica al final de la cirugía o por no administrar dosis intravenosa de lidocaína en el tiempo establecido. Resultados: No hubo diferencia estadísticamente significativa en el número de pacientes que presentaron tos en ambos grupos (13 vs 10, p = 0.4684), de éstos se obtuvo una diferencia estadísticamente significativa en el número de decibeles a favor del grupo de bloqueo (75.6 vs 67, p < 0.001). Conclusiones: El bloqueo (selectivo) presenta menos aerolización que la lidocaína intravenosa en la extubación.

Abstract: Introduction: Coughing is a physiological response to protect the airway, it produces aerosols that are identified by imaging reaching a speed of up to 8 meters per second. Extubation produces cough, hypertension, tachycardia, apnea and laryngospasm, there are methods to minimize its occurrence. Due to the COVID-19 pandemic, intravenous lidocaine and superior laryngeal nerve block have been used as cough reflex prophylaxis. The aim was to compare them in cough inhibition. Material and methods: Patients aged 18-60 years, elective surgery with balanced general anesthesia, ASA 1-3, with intubation less than 3 hours, were selected. A total of 90 patients were randomized, 45 in each group. A total of 10 patients were eliminated because they presented hemodynamic instability at the end of surgery, and because the intravenous dose of lidocaine was not administered within the established time. Results: There was no statistically significant difference in the number of patients who presented cough in both groups (13 vs 10, p = 0.4684), of these there was a statistically significant difference in the number of decibels in favor of the block group (75.6 vs 67, p < 0.001). Conclusions: Block presents less aerolization than intravenous lidocaine in extubation.

Clinical Profile, Intensive Care Needs, and Short-Term Outcome of Toxic Shock Syndrome Among Children: A 10-Year Single-Centre Experience from North India

Objective To describe the clinical and laboratory profle, management, intensive care needs, and outcome of children with toxic shock syndrome (TSS) admitted to the pediatric intensive care unit (PICU) of a tertiary care center in North India. Methods This retrospective study was conducted in the PICU of a tertiary care hospital in North India over a period of 10 y (January 2011–December 2020) including children<12 y with TSS (n=63). Results The median (interquartile range, IQR) age was 5 (2–9) y, 58.7% were boys, and Pediatric Risk of Mortality III (PRISM-III) score was 15 (12–17). The primary focus of infection was identifed in 60.3% children, 44.5% had skin and soft tissue infections, and 17.5% (n=11) had growth of Staphylococcus aureus. Common manifestations were shock (100%), rash (95.2%), thrombocytopenia (79.4%), transaminitis (66.7%), coagulopathy (58.7%), and acute kidney injury (AKI) (52.4%); and involvement of gastrointestinal (61.9%), mucus membrane (55.5%), respiratory (47.6%), musculoskeletal (41.3%), and central nervous system (CNS) (31.7%). The treatment included fuid resuscitation (100%), vasoactive drugs (92.1%), clindamycin (96.8%), intravenous immunoglobulin (IVIG) (92.1%), blood products (74.6%), mechanical ventilation (58.7%), and renal replacement therapy (31.7%). The mortality was 27% (n=17). The duration of PICU and hopsital stay was 5 (4–10) and 7 (4–11) d, respectively. Higher proportion of nonsurvivors had CNS involvement, transaminitis, thrombocytopenia, coagulopathy, and AKI; required mechanical ventilation and blood products; and had higher vasoactive–inotropic score. Conclusion TSS is not uncommon in children in Indian setup. The management includes early recognition, intensive care, antibiotics, source control, and adjunctive therapy (IVIG and clindamycin). Multiorgan dysfunction and need for organ supportive therapies predicted mortality.

A pilot study on effect of intravenous iron sucrose on oxidative stress and antioxidant status of pregnant women with iron deficiency anemia

Objectives: Iron deficiency anemia (IDA) is the most common nutritional deficiency among pregnant women in India. Iron can be supplemented orally or intravenously to treat IDA. Intravenous supplementation of iron can be risky as there is more possibility for the production of free iron in circulation. The role of free iron in the generation of free radicals and thereby oxidative stress is well known. The present study tends to evaluate oxidative stress and antioxidant status of intravenous iron sucrose treated pregnant women. Materials and Methods: This prospective study was conducted in ACS Medical College and Hospital, Chennai. Twenty pregnant women with moderate IDA (Hb: 7–9.9 g/dl) were included in the present study. Blood samples were collected before and after the treatment with intravenous iron sucrose to measure antioxidants such as reduced glutathione, catalase and superoxide dismutase, and lipid peroxidation marker such as malondialdehyde. Results: In the present study, plasma malondialdehyde levels were increased significantly after the treatment with intravenous iron sucrose. No significant alterations were observed in the levels of reduced glutathione and activities of catalase and superoxide dismutase. Conclusion: In the present study, intravenous iron sucrose infusion was associated with oxidative stress as evidenced by increased lipid peroxidation in antenatal women with IDA. Hence, treatment with antioxidants during iron infusions can be considered

Deficiencia de hierro en enfermedad renal crónica

Contexto: la deficiencia de hierro es un trastorno frecuentemente observado en pacientes con enfermedad renal crónica (ERC), sobre todo en estadios avanzados. Su presencia se asocia a una mayor morbilidad y mortalidad. La deficiencia de hierro puede ser absoluta o funcional. La deficiencia absoluta se refiere a una ausencia o una reducción de las reservas de hierro, mientras que la deficiencia funcional se define por la presencia de depósitos de hierro adecuados pero con una disponibilidad insuficiente de hierro para su incorporación en los precursores eritroides. Varios factores de riesgo contribuyen a la deficiencia absoluta y funcional de hierro en ERC, incluyendo pérdidas hemáticas, absorción alterada de hierro e inflamación crónica. Objetivo: con esta revisión narrativa se pretende presentar las definiciones, los aspectos fisiopatológicos, los criterios diagnósticos y las medidas terapéuticas en el paciente con diagnóstico de ERC con deficiencia de hierro. Metodología: se realizó una revisión no sistemática de la literatura en la base de datos PubMed, incluyendo además las guías internacionales más utilizadas que abordan el tema de deficiencia de hierro en ERC. Resultados: se incluyeron un total de 30 referencias bibliográficas. La deficiencia de hierro puede ser absoluta o relativa y el déficit absoluto de hierro se produce con valores de ferritina 100 mcg/l, pero con una TSAT < 20 %. El tratamiento del déficit absoluto consta de reposición de hierro oral o endovenoso y en pacientes que aún no reciben diálisis, se puede hacer una prueba terapéutica con hierro oral, de no haber respuesta se optará por hierro endovenoso, mientras que en pacientes que sí reciben diálisis, la medida ideal es el hierro endovenoso, preferiblemente en preparaciones que permitan esquemas de altas dosis y bajas frecuencias de administración. Las metas propuestas por las distintas guías presentan variaciones entre 500 y 700 mcg/l de ferritina. Conclusiones: el déficit de hierro debe buscarse activamente en pacientes con ERC, ya que su presencia y la falta de intervención conlleva a un incremento en los desenlaces adversos. La terapia con hierro es el pilar del tratamiento y la elección del agente a utilizar dependerá de las características individuales del paciente y de la disponibilidad de las preparaciones de hierro oral o endovenoso.

Background: Iron deficiency is a disorder frequently observed in patients with chronic kidney disease (CKD), especially in advanced stages. Its presence is associated with increased morbidity and mortality. Iron deficiency can be absolute or functional. Absolute deficiency refers to absent or reduced iron stores, while functional deficiency is defined by the presence of adequate iron stores but insufficient iron availability for incorporation into erythroid precursors. Several risk factors contribute to absolute and functional iron deficiency in CKD, including blood fi, impaired iron absorption, and chronic inflammation. Purpose: With this narrative review, it is intended to present the details, pathophysiological aspects, diagnostic criteria and therapeutic options in patients diagnosed with chronic kidney disease with iron deficiency. Methodology: A non-systematic review of the fi ron ra was carried out, in the PubMed database, also including the most used international guidelines that address the issue fi ron deficiency in chronic kidney disease. Results: A total of 30 bibliographical references were included. Iron deficiency can be absolute or relative. The absolute iron deficiency occurs with ferritin values 100 mcg/l but with a TSAT <20 % Treatment of absolute deficiency consists of oral or intravenous iron replacement. In a patient who is not yet receiving dialysis, a therapeutic trial with oral iron can be done, if there is no response, intravenous iron will be chosen. In patients receiving dialysis, the ideal measure is intravenous iron, preferably in preparations that allow high-dose schemes and low frequencies of administration. The goals proposed by the different guidelines present variations between 500 and 700 mcg/l d ferritin. Conclusions: iron deficiency should be actively sought in patients with CKD, since its presence and lack of intervention leads to an increase in adverse outcomes. Iron therapy is the mainstay of treatment; the choice of the agent to be used depends on the individual characteristics of the patient and the availability of oral or intravenous iron preparations.

Therapeutic Window of Intravenous Immunoglobulin (IVIG) and its correlation with IVIG-resistant in Kawasaki Disease: a retrospective study

Abstract Objective: To investigate the optimal timing of initial intravenous immunoglobulin (IVIG) treatment in Kawasaki disease (KD) patients. Methods: KD patients were classified as the early group (day 1-4), conventional group (day 5-7), conventional group (day 8-10), and late group (after day 10). Differences among the groups were analyzed by ANOVA and Chi-square analysis. Predictors of IVIG resistance and the optimal cut-off value were determined by multiple logistic regression analyses and receiver operating characteristic (ROC) curve analysis. Results: There were no significant differences in IVIG resistance among the 4 groups (p = 0.335). The sensitivity analysis also confirmed no difference in the IVIG resistance between those who started the initial IVIG ≤ day 7 of illness and those who received IVIG >day 7 of illness (p = 0.761). In addition, patients who received IVIG administration more than 7 days from the onset had a higher proportion of coronary artery abnormalities (p = 0.034) and longer length of hospitalization (p = 0.033) than those who started IVIG administration less than 7 days. The optimal cut-off value of initial IVIG administration time for predicting IVIG resistance was >7 days, with a sensitivity of 75.25% and specificity of 82.41%. Conclusions: IVIG therapy within 7 days of illness is found to be more effective for reducing the risk of coronary artery abnormalities than those who received IVIG >day 7 of illness. IVIG treatment within the 7 days of illness seems to be the optimal therapeutic window of IVIG. However, further prospective studies with long-term follow-up are required.