Acute kidney injury in Coronavirus disease-19 related pneumonia in the intensive care unit: a retrospective multicenter study, Saudi Arabia.

Background: Acute kidney injury (AKI) poses a significant morbidity and mortality risk to critically ill COVID-19 patients. The aim of this study was to investigate the incidence, predictors, and outcomes of AKI in patients admitted to the intensive care unit (ICU) with critically ill COVID-19 pneumonia. Methods: A multicenter retrospective study in Saudi Arabia of adult patients aged at least 18 years diagnosed with COVID-19 pneumonia and admitted to the intensive care unit between May 2020 and May 2021 was conducted. The occurrence of AKI and associated risk factors, the need for continous renal replacement therapy (CRRT), and the outcome were reported. Results: The study included 340 patients admitted to the ICU with COVID-19. Their mean age was 66.7±13.4 years, ranging from 49 to 84 years, and most of them were men (63.8%). The most common concomitant diseases were hypertension (71.5%), diabetes (62.4%), IHD (37.6%), CKD (20%), heart failure (19.4%), and 81.2% suffered from ARDS. AKI occurred in 60.3% of patients, 38% were stage 1, 16.6% were stage 2, and 45.4% were stage 3. Approximately, 39% of patients required CRRT, out of which 76.2% were stage 3, which was significantly higher than the other stages (p<0.001). AKI patients suffered significantly from asthma and had lower levels of C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and blood urea nitrogen (BUN) and higher creatinine levels than patients without AKI (p<0.05 all). The overall mortality rate was 39.4%, and the mortality rate was significantly higher in patients with AKI than in patients without AKI (48.3% versus 25.9%; p<0.001). Conclusion: AKI is common in adults admitted to the ICU with COVID-19 and is associated with an increased risk of death. Early detection of AKI and appropriate treatment can positively impact COVID-19 outcome. CRRT is the preferred dialysis method in critically ill ICU patients with AKI.

Mepolizumab and dupilumab as a replacement to systemic glucocorticoids for the treatment of Chronic Eosinophilic Pneumonia and Allergic Bronchopulmonary Aspergillosis - Case series, Almoosa specialist hospital.

In this case series, we present four patients who had asthma and blood eosinophilia. Two patients were diagnosed with Chronic Eosinophilic Pneumonia (CEP) and the other two with Allergic Bronchopulmonary Aspergillosis (ABPA). Laboratory findings revealed profound peripheral eosinophilia with abnormal chest radiography (alveolar shadows, segmental atelectasis, and cystic changes). Initial improvement (clinical, laboratory, and radiological) occurred with traditional asthma therapy, including systemic corticosteroids. The patients did not tolerate corticosteroid therapy because of weight gain, uncontrolled diabetes, bone fractures, and psychological adverse effects. Mepolizumab (administered to two CEP cases and one ABPA case) and Dupilumab (administered to one ABPA case) were initiated as steroid-sparing agents, resulting in successful therapy without relapse or adverse effects. Mepolizumab, and Interleukin-5 (IL-5) antagonist, targets diseases mediated by eosinophil activity and proliferation. Dupilumab blocks the Interleukin-4/Interleukin-13 pathway and suppresses Type 2 inflammation, including Immunoglobulin E (IgE). Dupilumab resulted in up to 70% drop in total IgE levels from baseline and reduced eosinophil-mediated lung inflammation, despite the presence of normal or increased blood eosinophil counts.

Puntuación de Mallampati modificada, como predictor de la presencia y la gravedad de la apnea obstructiva del sueño en pacientes que roncan / Modified Mallampati Score as a Predictor for the Presence and the Severity of Obstructive Sleep Apnea in Snoring Patients

Objetivo del estudio: evaluar si la puntuación de Mallampati modificada (MMS) puede predecir la presencia y la gravedad del síndrome de apnea obstructiva del sueño (AOS) en un grupo de pacientes que roncaban y presentaban apnea en los hospitales universitarios de Al-Azhar, El Cairo, Egipto y el Hospital Almoosa, Alhasa, Arabia Saudita. Métodos: Se realizó un estudio retrospectivo de pacientes que roncaban y presentaron apnea remitidos a un laboratorio del sueño para el diagnóstico de AOS mediante polisomnograma completo durante la noche desde enero de 2017 a noviembre de 2020. Se utilizó el índice de apnea-hipopnea (IAH) para categorizar la gravedad apnea del sueño. Se registraron edad, sexo, SMM, índice de masa corporal (IMC), comorbilidades, sueño y parámetros de laboratorio. Además, se registraron exámenes completos de Otorrinolaringología, Neurología y Medicina Interna. Resultados: El estudio se realizó en 350 pacientes que cumplían los criterios de inclusión con una edad media de 51,3 ± 14,3 años con un rango de 14 a 81 años. Más de la mitad de ellos (58,6%) eran hombres, el IMC medio fue de 35,1 ± 8,8 kg / m2 y el MMS medio fue de 4,7 ± 1,6 con aproximadamente el 65% de los pacientes agrupados en clases III y IV. Se diagnosticó AOS (IAH> 5) en 278 (79,4%) pacientes. Significativamente, la AOS se detectó más entre los hombres, aquellos con mayor edad, IMC, MMS y aquellos con diabetes mellitus tipo 2 (DM2). Una evaluación adicional mostró una correlación positiva significativa entre el IMC y el MMS con la gravedad de la AOS (ρ = 0,23, P <0,001 y ρ = 0,36, P <0,001) respectivamente. Conclusión: MMS es una herramienta útil para predecir la presencia y la gravedad de la AOS en pacientes que roncan. El IMC y el sexo masculino son predictores independientes

Aim of the study: To assess if the modified Mallampati score (MMS) can predict the presence and the severity of obstructive sleep apnea syndrome (OSA) in a group of patients who had snoring and witnessed apnea from Al -Azhar university hospitals, Cairo, Egypt, and Almoosa Hospital, Alhasa, Saudi Arabia. Methods: A retrospective study was done for patients who had snoring and witnessed apnea referred to a sleep lab for the diagnosis of OSA by overnight full polysomnogram from January 2017 to November 2020. Apnea-hypopnea index (AHI) was used to categorize the severity of sleep apnea. Age, sex, MMS, body mass index (BMI), comorbidities, sleep and laboratory parameters were recorded. Also, full Otorhinolaryngological, Neurological and Internal medicine examinations were recorded. Results: The study was carried out on 350 patients fulfilling the inclusion criteria with a mean age 51.3 ± 14.3 years ranging from 14 to 81 years. More than half of them (58.6%) were males, the mean BMI was 35.1 ± 8.8 kg/m2 and the mean MMS was 4.7 ± 1.6 with about 65% of patients grouped in classes III and IV. OSA (AHI>5) was diagnosed in 278 (79.4%) patients. Significantly, OSA was more detected among males, those with increased age, BMI, MMS, and those with type 2 diabetes mellitus (T2DM). Further evaluation showed a significant positive correlation between both BMI and MMS with the severity of OSA (ρ =0.23, P<0.001 and ρ =0.36, P<0.001) respectively. Conclusion: MMS is a useful tool to predict the presence as well as the severity of OSA in snoring patients. BMI and male gender are independent predictors

Estimating Apparent Nutrient Digestibility of Diets Containing Leucaena leucocephala or Moringa oleifera Leaf Meals for Growing Rabbits by Two Methods.

This study aimed to evaluate the nutrient digestibility of growing rabbits fed diets with different levels of either Leucaena leucocephala (LLM) or Moringa oleifera (MOLM) leaf meals and also to compare total collection and TiO2 marker methods for estimating digestibility. A total of 30 California growing rabbits (1.81±0.19 kg live weight on average) were randomly distributed into five experimental groups of six rabbits each and were housed in individual cages. The groups were control, 30% LLM, 40% LLM, 30% MOLM, and 40% MOLM. All groups received pelleted diets for two weeks; diets also contained 4 g/kg titanium dioxide as dietary marker. Daily feed intake was recorded during the whole experimental period and total feces were collected daily and weighed individually during four days. The results showed that there were no difference (p>0.05) in feed, dry matter (DM), organic matter (OM), crude protein (CP), digestible energy, and crude fiber (CF) intake between the control group and the other experimental groups. The apparent digestibility values of DM, OM, CP, CF, acid detergent fiber, and gross energy were the highest for control group (p = 0.001), meanwhile MOLM diets had generally higher nutrient digestibility coefficients than LLM diets. Increasing the inclusion level of leaf meal in the diet from 30% to 40% improved the digestibility of CF from 45.02% to 51.69% for LLM and from 48.11% to 55.89% for MOLM. Similar results for apparent nutrient digestibility coefficients were obtained when either total collection or indigestible marker method was used. In conclusion, the digestibility of MOLM containing diets were better than LLM diets, furthermore TiO2 as an external marker could be used as a simple, practical and reliable method to estimate nutrients digestibility in rabbit diets.

Determination of tropical forage preferences using two offering methods in rabbits.

Two methods of feed preference trials were compared to evaluate the acceptability of 5 fresh foliages: Leucaena leucocephala, Moringa oleifera, Portulaca oleracea, Guazuma ulmifolia, and Brosimum alicastrum that was included as control. The evaluation included chemical analyses and forage intake by rabbits. The first method was a cafeteria trial; 12 California growing rabbits aged 8 wk, allocated in individual cages, were offered the five forage plants at the same time inside the cage, while in the second trial 60 California growing rabbits aged 8 wk, allocated individually, were randomly distributed into 5 experimental groups (n = 12/group); for each group just one forage species was offered at a time. The testing period for each method lasted for 7 d, preceded by one week of adaptation. The results showed that B. alicastrum and L. lecocephala were the most preferred forages while on the contrary G. ulmifolia was the least preferred one by rabbits. The results also revealed that the CV% value for the 2nd method (16.32%), which the tested forages were presented separately to rabbits, was lower and methodologically more acceptable than such value for the 1(st) method (34.28%), which all forages were presented together at the same time. It can be concluded that a range of tropical forages were consumed in acceptable quantities by rabbits, suggesting that diets based on such forages with a concentrate supplement could be used successfully for rabbit production. However, growth performance studies are still needed before recommendations could be made on appropriate ration formulations for commercial use.

Management of Jehovah's Witness patients for scoliosis surgery: the use of platelet and plasmapheresis.

Four patients whose religious beliefs prohibited accepting blood during surgery for scoliosis were anesthetized and managed successfully using plateletpheresis and plasmapheresis. Blood losses were replaced with crystalloid and hetastarch solutions. In addition, a moderate hypotensive technique was used to minimize surgical blood loss. Postoperatively, the patients received iron therapy and/or erythropoietin. Three of these patients had an uncomplicated postoperative course, however, the fourth patient had some postoperative bleeding with initial hemodynamic instability. We believe that patients who refuse to receive blood transfusion during surgery because of religious beliefs or health issues can be managed safely using other alternatives and techniques such as plateletpheresis and plasmapheresis, which conserve and minimize blood loss. Each case should be assessed on an individual basis.

Role of systemic arterial pressure, heart rate, and derived variables in prediction of severity of myocardial ischemia during acute coronary occlusion in anesthetized dogs.

The present study examined the postulate that the quotient of mean systemic arterial pressure and heart rate predicts the severity of myocardial ischemia during occlusion of the left anterior descending coronary artery. Studies were performed in open-chest fentanyl-anesthetized dogs before and during halothane (n = 8) or isoflurane (n = 8) anesthesia. The pressure-rate quotient (PRQ) decreased significantly in both groups during incremental increases in halothane or isoflurane to 68% and 57% of control values at 0.5 MAC and to 41% and 38% at 1.5 MAC for halothane and isoflurane, respectively. Myocardial lactate production was unchanged from the ischemic region, and no correlation between the PRQ and myocardial lactate production was observed. In contrast, heart rate correlated significantly (r = 0.376; P less than 0.05) with lactate production. The product of systolic systemic arterial pressure and heart rate (rate-pressure product) correlated with blood flow (r = 0.493; P less than 0.001) and with oxygen consumption (r = 0.571; P less than 0.001) in the normal myocardium. A weak correlation (r = 0.330; P less than 0.05) of rate-pressure product with myocardial lactate production from the ischemic region was observed. There were no correlations between the PRQ and myocardial lactate production from the ischemic region or indices of blood flow distribution (i.e., inner/outer ratio in the ischemic region or ischemic/normal ratio). The relationship of hemodynamic variables to measurements of regional myocardial metabolism was independent of background anesthetic agent of depth of anesthesia. The current data suggest that heart rate changes are weakly predictive of severity of myocardial ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

No evidence for blood flow redistribution with isoflurane or halothane during acute coronary artery occlusion in fentanyl-anesthetized dogs.

The present study examines the postulate that isoflurane, in contrast to halothane, causes redistribution of blood flow away from an ischemic myocardial region through vasodilation of adjacent normally perfused myocardium. The study was performed in open-chest dogs anesthetized with fentanyl; ischemia was induced by occlusion of the left anterior descending coronary artery. At 0.6% alveolar concentration, isoflurane increased transmural blood flow to 125% of control values (P less than 0.05) in the normal region without concomitant changes in blood flow to the ischemic region or in the endocardial/epicardial flow ratio in the ischemic region. The evidence excludes either transmural steal or regional redistribution phenomena. Myocardial blood flow variables returned to control values at 1.8% isoflurane, and no blood flow redistribution effects were evident. In contrast, whereas halothane 0.4% caused no significant effect on myocardial blood flows, an alveolar concentration of 1.2% decreased transmural blood flow to normally perfused left ventricle to 70% of control (P less than 0.05). Regional myocardial oxygen consumption in the normal and ischemic areas decreased at higher alveolar concentrations and was unchanged at the lower concentrations for both agents. Myocardial lactate production from the ischemic region was unchanged with either agent, suggesting that, in terms of metabolic changes, neither agent worsened ischemia during sustained occlusion of the left anterior descending coronary artery. The present data show no evidence for worsening of myocardial ischemia with either isoflurane or halothane. Isoflurane causes a relatively greater increase in perfusion compared to myocardial oxygen consumption of normally perfused myocardium; nevertheless, sufficient coronary vascular reserve remains in the native collateral circulation so that myocardial metabolic supply-and-demand relationships during ischemia are not further compromised.

Monitoring of ionized calcium during human hepatic transplantation. Critical values and their relevance to cardiac and hemodynamic management.

During human hepatic transplantation, ionized calcium (ICa) measured in whole blood with an ion-selective electrode varied greatly from ICa predicted from total calcium (TCa), protein, albumin, and pH, by means of recently published nomograms. Measurement of ICa was necessary because the interaction of citrate in transfused blood and calcium chloride (administered to offset citrate binding) caused large variations in TCa. During hepatic transplantation, ICa and electrolyte measurements were obtained at approximately 15-minute intervals or more frequently if indicated by changing cardiac status. In one patient, hemodynamic instability was accompanied by a large decrease in ICa, which then was followed by cardiac arrest aggravated by myocardial depression from inadequate ICa. Cardiovascular phenomena associated with ionized hypocalcemia suggest that the critical value for ICa should be no more than 0.4 mmol/L (1.6 mg/dL) below the reference range mean. The authors propose critical limits for ICa and discuss their significance in clinical management of tetany, hypotension, arrythmias, and cardiac arrest.

Successful management of an elderly patient with multiple trauma.

An elderly female patient with multiple trauma and flail chest received thoracic and lumbar epidural analgesia and anesthesia, respectively, in the surgical ICU and the operating room. This technique provided segmental analgesia with minimal amounts of narcotics. This allowed for the very important early ambulation and absence of respiratory complications, the main cause of increased morbidity in this age group.

The use of propranolol in rapid sequence anaesthetic induction: optimal time interval for pretreatment.

Forty patients ASA physical status I-III were selected and divided into four groups. Group I, Control, received saline pretreatment five minutes prior to rapid sequence induction and intubation, while Groups II, III and IV received propranolol 0.01 mg X kg-1 IV two, five or eight minutes prior to induction and intubation. Measurements of heart rate (HR), arterial blood pressure (ABP) were recorded as baseline values and at one, two, five, eight and 20 minutes, and simultaneous venous samples were withdrawn for propranolol levels. Calculated rate pressure product (RPP) showed best haemodynamic control in Group III. Serum propranolol levels were under 5 ng X ml-1 in Group III and undetectable in Group IV. Our data show that the optimal time interval between IV propranolol administration and intubation was five minutes.

Pulmonary capillary leak associated with methylmethacrylate during general anesthesia. A case report.

Noncardiogenic pulmonary edema (capillary leak syndrome) developed in a 61-year-old woman after methylmethacrylate was inserted for total hip replacement. The diagnosis was based on the low pulmonary artery and pulmonary artery wedge pressures, low systemic vascular resistance, relative hypovolemia, and clear pulmonary edema. The diagnosis of capillary leak syndrome can be confirmed by the finding of a protein composition of the pulmonary edema approximating that of plasma. The mechanism causing the capillary leak syndrome is unclear, but may be related to hypersensitivity, i.e., a previous hip arthroplasty, or to the release of vasoactive substances. Management consisted of fluid replacement to maintain cardiac output, and mechanical ventilation with positive end expiratory pressure to provide adequate oxygenation.

Use of propranolol to control rate-pressure product during cardiac anesthesia.

The use of propranolol to control heart rate (HR), systolic pressure, and rate-pressure product (RPP) during laryngoscopy and sternotomy was studied in 21 patients, New York Heart Association functional Classes 1 and 2, scheduled for coronary artery bypass graft surgery. All patients were anesthetized in an identical fashion, but the treatment group (N = 13) received propranolol, 0.5 to 1 mg IV, 4 minutes before laryngoscopy and again, in most cases, before skin incision. Patients not given propranolol (N = 8) showed a clinically and statistically significant increase in HR and RPP, whereas HR and RPP remained essentially unchanged from the preanesthetic period in patients given propranolol.