Prevalence and Prognostic Impact of Hypernatremia in Sepsis and Septic Shock Patients in the Intensive Care Unit: A Single Centre Experience.

INTRODUCTION: Hypernatremia is a commonly associated electrolyte disturbance in sepsis and septic shock patients in the ICU. The objective of this study was to identify the prognostic value of hypernatremia in sepsis and septic shock. MATERIAL AND METHODS: A prospective study conducted on sepsis and septic shock patients diagnosed prior to admission in the ICU in King Hamad University Hospital, Bahrain from January 1st 2017 to February 28th 2019. Data including age, sex, comorbidities, source of sepsis, sodium levels on days one, three, and seven. Data was correlated with the outcome (survival/death and the length of ICU stay). RESULTS: Patients included were 168, 110 survived, and 58 died. Hypernatraemia at day seven was associated with significantly higher mortality (P= 0.03). Hypernatraemia at Day1was associated with a significantly prolonged stay in the ICU (p= 0.039).Multivariate analysis to identify the independent predictors of mortality revealed that immunosuppression and hypernatraemia at Day7 proved to be independent predictors of mortality (P= 0.026 and 0.039 respectively). CONCLUSION: Hypernatremia can be an independent predictor of poor outcome in septic and septic shock patients in the ICU.

A Case of Oropharyngeal Angioedema Following Intravenous Recombinant Tissue Plasminogen Activator (rt-PA) and Mechanical Thrombectomy.

A 72-year-old housewife presented with ischemic cerebrovascular stroke. Intravenous thrombolysis using recombinant tissue plasminogen activator (rt-PA) followed by mechanical thrombectomy under general anesthesia were attempted. The patient developed stridor and tongue swelling, in addition to hypotension and bradycardia, 60 min after completion of the rt-PA infusion. The airway was intubated, and intramuscular adrenaline, together with intravenous hydrocortisone and diphenhydramine, were administered. On the second day, the tongue edema subsided, and the cuff leak test was negative. However, extubation was not attempted due to the development of brain edema. A tracheostomy was later performed, and the patient was weaned off mechanical ventilation.

Opioid-Free Total Intravenous Anesthesia Improves Postoperative Quality of Recovery after Ambulatory Gynecologic Laparoscopy.

BACKGROUND: Gynecological laparoscopic surgery is commonly performed on an ambulatory basis under general anesthesia. The postoperative quality of recovery (QOR) should be considered one of the principal endpoints after ambulatory surgery. Total intravenous anesthesia (TIVA) with opioids is known to improve postoperative QOR after ambulatory surgery. However, opioids can be associated with an increased incidence of postoperative complications, which can affect postoperative QOR. The primary aim of this study was to compare the patient recovery using the QOR-40 at 24 h postoperative in ambulatory gynecological laparoscopy between opioid-free (OF) TIVA and opioid-based TIVA. SETTINGS AND DESIGN: A prospective, randomized, controlled, comparative study was conducted at the day surgery center. PATIENTS AND METHODS: Eighty females were included in the study. They were randomized into two equal groups: OF TIVA group with dexmedetomidine and propofol or opioid-based TIVA (O) group with fentanyl and propofol. The primary outcome was QOR-40 at 24 h postoperative, and the secondary outcomes were postoperative numerical rating scale (NRS), time to first rescue analgesia, number of rescue tramadol analgesia, and the incidence of postoperative nausea and vomiting. RESULTS: A statistically significant difference in total QOR-40 score at 24 h postoperative was observed between the groups (median [range] QOR-40 of 182.0 [164.0-192.0] in the OF TIVA group and 170.0 [156.0-185.0] in the O group; P = 0.03). OF group had significantly lower time to first rescue analgesia, maximum NRS pain scores, number of rescue tramadol analgesia, and ondansetron use. CONCLUSIONS: OF TIVA significantly improves postoperative QOR in patients undergoing ambulatory gynecological laparoscopic surgery.

Comparative Study between the Efficacy of Fentanyl, Antihistamines, and Dexmedetomidine in Suppressing Photic Sneeze Reflex during Peribulbar Block.

BACKGROUND: The photic sneeze reflex (autosomal dominant) is a condition that causes sneezing in response to numerous stimuli, such as looking at bright lights or periocular (surrounding the eyeball) injection. Unexpected or sudden sneezing during injection can be a dangerous side effect in periocular injection, in which abrupt head movement may cause globe injury. AIMS: We intended to evaluate the efficacy of adding fentanyl, dexmedetomidine, and antihistamines on the incidence of the sneeze reflex associated with propofol sedation during periocular local anesthesia injections. SETTINGS AND DESIGN: Our study was a randomized, prospective, double-blinded and controlled clinical study. PATIENTS AND METHODS: This study was conducted in Ain Shams and Fayoum university hospitals at the ophthalmic surgery department. After obtaining approval from our universities ethical committee and written informed valid consents from the patients, 90 patients were included in this study. The study population included patients of both sex, ASA grade 1 and 2, in the age ranging from 18-65 years. Patients were scheduled for cataract extraction surgeries and received peribulbar block. Then patients were randomly divided into three groups (30 patients each) using a computer- generated table of random numbers. Patients were preoxygenated with supplemental oxygen by nasal cannula, all 90 patients received intravenous propofol 1mg.kg- 1 bolus for sedation and were randomized to receive adjunctive drug 2 to 4 minutes prior to propofol injection: 30 patients received intravenous fentanyl 1 µmg.kg-1 (Group F), 30 patients received dexmedetomidine 1µmg.kg-1 (Group D), and 30 patients received antihistamine (pheniramine 22.75 mg) (Group H). The same local anesthetic admixture, consisting of 5 mL 2% lidocaine with 90 IU hyaluronidase, combined with 5 mL 0.5% plain bupivacaine in a 10-mL syringe at room temperature was administered to all patients using peribulbar block technique. A masked observer (surgeon or anesthesia assistant) recorded whether the patient had a sneezing event. Continuous cardiorespiratory monitoring was performed intraoperatively. Intraoperative and postoperative medication side effects were recorded including bradycardia (HR <55 beats/min), hypotension (MAP <50 mmHg sustained for >10 min), oxygen desaturation (SpO2<90%), nausea, vomiting and prolonged sedation using Ramsay Sedation Score (RSS). STATISTICAL ANALYSIS USED: Student's t-test and Chi-square test were used for analysis. RESULTS: The demographic data of the three study groups revealed non-significant differences between the three study groups as regards age, sex distribution, and the duration of surgery. No patient was excluded after inclusion to the study. All patients were able to complete the entire study and their data were included in the final analysis. Five events of sneezing had occurred in 90 patients. Two in (D) group and three in (H) group with is no statistically significant difference between the three groups as regard sneezing. Bradycardia, hypotension and sedation had occurred significantly in group (D) compared to group (F) and group (D). No patient suffered from nausea, vomiting or oxygen desaturation in all studied groups. No statistically significant difference as regards patient satisfaction between the three studied groups. CONCLUSION: Fentanyl, dexmedetomidine and antihistamines with propofol sedation suppress photic sneeze reflex during peribulbar block.

Factors associated with increased pancreatic enzymes in septic patients: a prospective study.

BACKGROUND: The perfusion of splanchnic organs is deeply altered in patients with septic shock. The aim of the study is to identify the predictive factors of septic shock-induced increase of serum lipase and amylase and to assess and evaluate its prognostic impact. METHODS: We conducted a prospective observational study. All adult patients admitted with septic shock were eligible for our study. Serum lipase and amylase were measured on admission. Patients with and those without increased pancreatic enzymes were compared. Predictive factors of pancreatic insult identified by the univariate analysis were integrated in a stepwise multivariate analysis. Odds ratios (OR) with the 95% confidence interval (CI) were calculated accordingly. Second, the sensitivity and the specificity of amylase and lipase to predict intensive care unit (ICU) mortality were identified through the Receiver Operator Curve. RESULTS: Fifty patients were included. Median [quartiles] age was 68.5 [58-81] years. The APACHE II score was 26 [20-31]. Twenty-three patients (46%) had increased serum amylase and/or serum lipase. Diabetes mellitus (OR = 16; 95% CI [1.7-153.5]; p = 0.016), increased blood urea nitrogen (OR = 1.12; 95% CI [1.02-1.20], p = 0.016), and decreased C-reactive protein (OR = 0.97; 95% CI [0.96-0.99]; p = 0.027) were identified as independent factors predicting increased pancreatic enzymes. Twenty patients (40%) died in the ICU. Neither serum amylase level nor serum lipase level was significantly different between survivors and non-survivors (respectively 49 [27.7-106] versus 85.1 [20.1-165] UI/L; p = 0.7 and 165 [88-316] versus 120 [65.5-592] UI/L; p = 0.952). CONCLUSION: Increase of pancreatic enzymes is common in patients with septic shock. Diabetes and impaired renal function are predictive of increased pancreatic enzymes. Such finding does not carry any negative prognostic value.

Effectiveness of Systemic Fluconazole in Adult Patients With Asymptomatic Candiduria: A Systematic Review and Meta-Analysis.

Asymptomatic candiduria is a common finding in hospitalized patients. Its management modalities are still a matter of debate. Urinary catheter should be removed or replaced in all cases. In the current meta-analysis, we aimed to compare 2 different strategies in term of candida clearance from the urinary tract: Systemic fluconazole versus conservative management. A systematic search was performed in Pubmed, Web of science, and Cochrane Library database by 2 investigators. Three studies were included (421 patients). Data were extracted and the quality of each study was assessed. Systemic fluconazole was associated with a significantly higher short-term clearance of the funguria after 14 days of treatment [odds ratio = 0.43; confidence interval (CI) 95% (0.26-0.65)]. No significant heterogeneity was found among the included studies (Q statistic test = 0.38; I = 0). In conclusion, fluconazole significantly hasten short-term candida clearance from the urinary tract.

Pancreatic injury in patients with septic shock: A literature review.

Sepsis and septic shock are life threatening condition associated with high mortality rate in critically-ill patients. This high mortality is mainly related to the inadequacy between oxygen delivery and cellular demand leading to the onset of multiorgan dysfunction. Whether this multiorgan failure affect the pancreas is not fully investigated. In fact, pancreatic injury may occur because of ischemia, overwhelming inflammatory response, oxidative stress, cellular apoptosis and/or metabolic derangement. Increased serum amylase and/or lipase levels are common in patients with septic shock. However, imaging test rarely reveal significant pancreatic damage. Whether pancreatic dysfunction does affect the prognosis of patients with septic shock or not is still a matter of debate. In fact, only few studies with limited sample size assessed the clinical relevance of the pancreatic injury in this group of patients. In this review, we aimed to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. Our main finding is that pancreatic injury does not significantly affect the outcome in septic shock patients. Hence, increased serum pancreatic enzymes without clinical features of acute pancreatitis do not require further imaging investigations and specific therapeutic intervention.

Successful management of H1N1 related severe acute respiratory distress syndrome with noninvasive positive pressure ventilation.

Acute respiratory distress syndrome (ARDS) is a life threatening complication of H1N1 pneumonia. According to the Berlin conference guidelines, severe ARDS requires management with early invasive mechanical ventilation. Whether noninvasive positive pressure ventilation (NIPPV) should be attempted in patients with H1N1 pneumonia is still a matter of debate. We report the case of one patient with severe ARDS without other organ failure. The patient was managed successfully using NIPPV. Endotracheal intubation was avoided and the patient was discharged from the intensive care unit (ICU) after 10 days with a successful outcome. NIPPV can be useful in patients with isolated severe H1N1 ARDS provided early improvement of the oxygenation parameters is achieved. Patients with multiple organ failure or with persistent severe hypoxemia under noninvasive ventilation should be electively intubated and started on invasive mechanical ventilation.

Usefulness of full outline of unresponsiveness score to predict extubation failure in intubated critically-ill patients: A pilot study.

OBJECTIVE: To assess the usefulness of the full outline of unresponsiveness (FOUR) score in predicting extubation failure in critically ill intubated patients admitted with disturbed level of conscious in comparison with the Glasgow coma scale (GCS). PATIENTS AND METHODS: All intubated critically ill patients with a disturbed level of consciousness were assessed using both the FOUR score and the GCS. The FOUR score and the GCS were compared regarding their predictive value for successful extubation at 14 days after intubation as a primary outcome measure. The 28-day mortality and the neurological outcome at 3 months were used as secondary outcome measures. RESULTS: Eighty-six patients were included in the study. Median age was 63 (50-77) years. Sex-ratio (M/F) was 1.46. On admission, median GCS was 7 (3-10) while median FOUR score was 8.5 (2.3-11). A GCS ≤ 7 predicted the extubation failure at 14 days after intubation with a sensitivity of 88.5% and specificity of 68.3%, whereas a FOUR score <10 predicted the same outcome with a sensitivity of 80.8% and a specificity of 81.7%. The areas under the curves was significantly higher with the FOUR score than with GCS (respectively 0.867 confidence interval [CI]: 95% [0790-0.944] and 0.832 CI: 95% [0.741-0.923]; P = 0.014). When calculated before extubation, FOUR score <12 predicted extubation failure with a sensitivity of 92.3% and a specificity of 85%, whereas a GCS <12 predicted the same outcome with a sensitivity of 73% and a specificity of 61.7%. Both scores had similar accuracy for predicting 28-day mortality and neurological outcome at 3 months. CONCLUSION: The FOUR score is superior to the GCS for the prediction of successful extubation of intubated critically ill patients.