Inverse ratio ventilation versus conventional ratio ventilation during one lung ventilation in neonatal open repair of esophageal atresia/tracheoesophageal fistula: A randomized clinical trial.

BACKGROUND: Maintaining oxygenation during neonatal open repair of esophageal atresia/tracheoesophageal fistula is difficult. Inverse ratio ventilation can be used during one lung ventilation to improve the oxygenation and lung mechanics. OBJECTIVE: The aim of this study was to describe the impact of two different ventilatory strategies (inverse ratio ventilation vs. conventional ratio ventilation) during one lung ventilation in neonatal open repair of esophageal atresia/tracheoesophageal fistula on the incidence of oxygen desaturation episodes. METHODS: We enrolled 40 term neonates undergoing open right thoracotomy for esophageal atresia/tracheoesophageal fistula repair and randomly assigned into two groups based on inspiratory to expiratory ratio of mechanical ventilation parameters (2:1 in inverse ratio ventilation "IRV" and 1:2 in conventional ratio ventilation "CRV"). The incidence of desaturation episodes that required stopping the procedure and reinflation of the lung were recorded as the primary outcome while hemodynamic parameters, incidence of complications, and length of surgical procedure were recorded as the secondary outcomes. RESULTS: There was a trend toward a reduction in the incidence of severe desaturations (requiring stopping of surgery) with the use of inverse ratio ventilation (15% in IRV vs. 35% in CRV, RR [95% CI] 0.429 [0.129-1.426]). Incidence of all desaturations (including those requiring only an increase in ventilatory support or inspired oxygen saturation) was also reduced (40% in IRV vs. 75% in CRV, RR [95% CI] 0.533 [0.295-0.965]). This in turn affected the length of surgical procedure being significantly shorter in inverse ratio ventilation group (mean difference -16.3, 95% CI -31.64 to -0.958). The intraoperative fraction of inspired oxygen required to maintain adequate oxygen saturation was significantly lower in the inverse ratio ventilation group than in the conventional ratio ventilation group (mean difference -0.22, 95% CI -0.33 to -0.098), with no significant difference in hemodynamic stability or complications apart from higher blood loss in inverse ratio group. CONCLUSION: There may be a role for inverse ratio ventilation with appropriate positive end-expiratory pressure to reduce the incidence of hypoxemia during open repair of esophageal atresia/tracheoesophageal fistula in neonates, further studies are required to establish the safety and efficacy of this technique.

Effect of convalescent plasma transfusion on outcomes of coronavirus disease 2019: a meta-analysis with trial sequential analysis.

The aim of this review was to update evidence for benefit of convalescent plasma transfusion (CPT) in patients with coronavirus disease 2019 (COVID-19). Databases were searched for randomized controlled trials (RCT) comparing CPT plus standard treatment versus standard treatment only in adults with COVID-19. Primary outcome measures were mortality and need for invasive mechanical ventilation (IMV). Twenty-Six RCT involving 19,816 patients were included in meta-analysis for mortality. Quantitative synthesis showed no statistically significant benefit of adding CPT to standard treatment (RR = 0.97, 95% CI = 0.92 to 1.02) with unimportant heterogeneity (Q(25) = 26.48, p = .38, I2 = 0.00%). Trim-and-fill-adjusted effect size was unimportantly changed and level of evidence was graded as high. Trial sequential analysis (TSA) indicated information size was adequate and CPT was futile. Seventeen trials involving 16,083 patients were included in meta-analysis for need of IMV. There was no statistically significant effect of CPT (RR = 1.02, 95% CI = 0.95 to 1.10) with unimportant heterogeneity (Q(16) = 9.43, p = .89, I2 = 3.30%). Trim-and-fill-adjusted effect size was trivially changed and level of evidence was graded as high. TSA showed information size was adequate and indicated futility of CPT. It is concluded with high level of certainty that CPT added to standard treatment of COVID-19 is not associated with reduced mortality or need of IMV compared with standard treatment alone. In view of these findings, further trials on efficacy of CPT in COVID-19 patients are probably not needed.

[Propofol-ketamine versus dexmedetomidine-ketamine for sedation during upper gastrointestinal endoscopy in pediatric patients: a randomized clinical trial]. / Propofol­cetamina versus dexmedetomidina­cetamina para sedação durante endoscopia digestiva alta em pacientes pediátricos: estudo clínico randomizado.

BACKGROUND AND OBJECTIVES: Day-case pediatric sedation is challenging. Dexmedetomidine is a sedative analgesic that does not induce respiratory depression. We compared dexmedetomidine to propofol when it was added to ketamine for sedation during pediatric endoscopy, regarding recovery time and hemodynamic changes. METHODS: We enrolled 120 patients (2-7 years in age) and randomly assigned them into two groups. Each patient received intravenous (IV) ketamine at a dose of 1 mg.kg-1 in addition to either propofol (1 mg.kg-1) or dexmedetomidine (0.5 µg.kg-1). The recovery time was compared. Hemodynamics, oxygen saturation, need for additional doses, postoperative complications and endoscopist satisfaction were monitored. RESULTS: There was no significant difference in hemodynamics between the groups. The Propofol-Ketamine (P-K) group showed significantly shorter recovery times than the Dexmedetomidine-Ketamine (D-K) group (21.25 and 29.75 minutes respectively, p <0.001). The P-K group showed more oxygen desaturation. Eleven and six patients experienced SpO2 <92% in groups P-K and D-K, respectively. A significant difference was noted regarding the need for additional doses; 10% of patients in the D-K group needed one extra dose, and 5% needed two extra doses, compared to 25% and 20% in the P-K group, respectively (p=0.001). The P-K group showed less post-procedure nausea and vomiting. No statistically significant difference between both groups regarding endoscopist satisfaction. CONCLUSIONS: The P-K combination was associated with a shorter recovery time in pediatric upper gastrointestinal endoscopy, while the D-K combination showed less need for additional doses. REGISTRATION NUMBER: Clinical trials.gov (NCT02863861).

Propofol-ketamine versus dexmedetomidine-ketamine for sedation during upper gastrointestinal endoscopy in pediatric patients: a randomized clinical trial / Propofol­cetamina versus dexmedetomidina­cetamina para sedação durante endoscopia digestiva alta em pacientes pediátricos: estudo clínico randomizado

Abstract Background and objectives Day-case pediatric sedation is challenging. Dexmedetomidine is a sedative analgesic that does not induce respiratory depression. We compared dexmedetomidine to propofol when it was added to ketamine for sedation during pediatric endoscopy, regarding recovery time and hemodynamic changes. Methods We enrolled 120 patients (2−7 years in age) and randomly assigned them into two groups. Each patient received intravenous (IV) ketamine at a dose of 1 mg.kg-1 in addition to either propofol (1 mg.kg-1) or dexmedetomidine (0.5 µg.kg-1). The recovery time was compared. Hemodynamics, oxygen saturation, need for additional doses, postoperative complications and endoscopist satisfaction were monitored. Results There was no significant difference in hemodynamics between the groups. The Propofol-Ketamine (P-K) group showed significantly shorter recovery times than the Dexmedetomidine-Ketamine (D-K) group (21.25 and 29.75 minutes, respectively, p < 0.001). The P-K group showed more oxygen desaturation. Eleven and 6 patients experienced SpO2 < 92% in groups P-K and D-K, respectively. A significant difference was noted regarding the need for additional doses; 10% of patients in the D-K group needed one extra dose, and 5% needed two extra doses, compared to 25% and 20% in the P-K group, respectively (p = 0.001). The P-K group showed less post-procedure nausea and vomiting. No statistically significant difference between both groups regarding endoscopist satisfaction. Conclusions The P-K combination was associated with a shorter recovery time in pediatric upper gastrointestinal endoscopy, while the D-K combination showed less need for additional doses. Registration number Clinical trials.gov (NCT02863861).

Resumo Justificativa e objetivos A sedação ambulatorial pediátrica é um desafio. A dexmedetomidina é um analgésico sedativo que não induz à depressão respiratória. Comparamos a dexmedetomidina ao propofol quando associados à cetamina para sedação durante endoscopia pediátrica, quanto ao tempo de recuperação e às alterações hemodinâmicas. Métodos Foram recrutados 120 pacientes (2−7 anos de idade) que foram aleatoriamente alocados em dois grupos. Cada paciente recebeu cetamina IV na dose de 1 mg.kg‐1, além de propofol (1 mg.kg‐1) ou dexmedetomidina (0,5 µg.kg‐1). Comparamos o tempo de recuperação. A hemodinâmica, saturação de oxigênio, necessidade de doses adicionais, complicações pós‐operatórias e satisfação do endoscopista foram monitoradas. Resultados Não houve diferença significante entre os grupos no que diz respeito à hemodinâmica. O grupo Propofol‐Cetamina (P‐C) apresentou tempos de recuperação significantemente mais curtos do que o grupo Dexmedetomidina‐Cetamina (D‐C) (21,25 e 29,75 minutos respectivamente, p < 0,001). Observou‐se frequência maior de dessaturação de oxigênio no grupo P‐C. Onze e 6 pacientes apresentaram SpO2 < 92% nos grupos P‐C e D‐C, respectivamente. Uma diferença significante foi observada em relação à necessidade de doses adicionais; 10% dos pacientes no grupo D‐C precisaram de uma dose extra e 5% precisaram de duas doses extras, em comparação com 25% e 20% no grupo P‐C, respectivamente (p = 0,001). O grupo P‐C apresentou menos náuseas e vômitos após o procedimento. Não houve diferença estatisticamente significante entre os dois grupos em relação à satisfação do endoscopista. Conclusões A combinação P‐C foi associada a tempo mais curto de recuperação na endoscopia digestiva alta pediátrica, enquanto a combinação D‐C mostrou menor necessidade de doses adicionais. Número de registro Clinical trials.gov (NCT02863861).

Magnesium sulphate protect against propofol-induced neurotoxicity in developing rats’ cerebral cortex

Propofol-induced neurotoxicity in developing brain is an evolving problem. Magnesium is proved to be neuro-protective when administered antenatally in case of pre-eclampsia and eclampsia. The aim of this work is to investigate the protective role of magnesium sulphate (MgSO4) against propofol-induced neurotoxicity in developing rats’ cerebral cortex (CC). Forty albino rats of the Sprague-Dawley strain aged 5 to 7 days were divided into four groups; Control group (Group A); MgSO4 group (Group B) receiving MgSO4 at a dose of 270 mgkg; Propofol group (Group C) receiving propofol at a dose of 20 mgkg; and Propofol+ MgSO4 group (Group D) receiving both drugs simultaneously. All drugs were given by intra-peritoneal (IP) injection. 48 hours following exposure, blood samples were collected from rats for cytochrome-c plasma assay. Also, Specimens from rats’ CC were processed for light microscopic examination. An immune-histo-chemical study was conducted using Glial Fibrillary Acidic Protein (GFAP) and Bcl-2-associated X protein (BAX).Propofol administration led to disruption of the cortical laminar architecture, with a significant decrease in the number of pyramidal cells. Also, GFAP and BAX immune-stained sections revealed a significant increase in the area percentage of their immune-reaction as compared to the control group, together with a significant increase in the serum level of cytochrome-c. Administration of MgSO4 with propofol could improve the histological picture of the cortex, including its laminar appearance and neuronal density. Also MgSO4 could decrease GFAP and BAX immune-reaction, with no change that could be noticed in the serum level of cytochrome-c. MgSO4 could be used as neuro-protective agent against propofol-induced cortical injury in infant rats

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