Ina Ismiarti Shariffuddin

A randomised comparison of two intranasal dexmedetomidine doses for premedication in children

We compared sedation levels in children following administration of intranasal dexmedetomidine. One hundred and sixteen children aged between 1 and 8 years were enrolled in this prospective, randomised trial. Children were assigned to receive either intranasal dexmedetomidine 1 μg.kg−1 (Group 1) or 2 μg.kg−1 (Group 2). Thirty‐one (53%) patients from Group 1 and 38 (66%) patients from Group 2 were satisfactorily sedated at the time of anaesthetic induction. Logistic regression showed a significant interaction effect (p = 0.049), with the odds ratio between Group 2 over Group 1 estimated as 1.1 (95% CI 0.5–2.7) for the 1–4 year age group, and 10.5 (95% CI 1.4–80.2) for the 5–8 year age group. Both doses produced a similar level of satisfactory sedation in children aged 1–4 years, whereas 2 μg.kg−1 resulted in a higher proportion of satisfactory sedation in children aged 5–8 years. There were no adverse haemodynamic effects. We conclude that intranasal dexmedetomidine in a premedication dose of 2 μg.kg−1 resulted in excellent sedation in children.

CAFFEIC ACID PHENETHYL ESTER (CAPE): SCAVENGER OF PEROXYNITRITE IN VITRO AND IN SEPSIS MODELS

ABSTRACT Excessive free radical production by immune cells has been linked to cell death and tissue injury during sepsis. Peroxynitrite is a short-lived oxidant and a potent inducer of cell death that has been identified in several pathological conditions. Caffeic acid phenethyl ester (CAPE) is an active component of honeybee products and exhibits antioxidant, anti-inflammatory, and immunomodulatory activities. The present study examined the ability of CAPE to scavenge peroxynitrite in RAW 264.7 murine macrophages stimulated with lipopolysaccharide/interferon-&ggr; that was used as an in vitro model. Conversion of 123-dihydrorhodamine to its oxidation product 123-rhodamine was used to measure peroxynitrite production. Two mouse models of sepsis (endotoxemia and cecal ligation and puncture) were used as in vivo models. The level of serum 3-nitrotyrosine was used as an in vivo marker of peroxynitrite. The results demonstrated that CAPE significantly improved the viability of lipopolysaccharide/interferon-&ggr;–treated RAW 264.7 cells and significantly inhibited nitric oxide production, with effects similar to those observed with an inhibitor of inducible nitric oxide synthase (1400W). In addition, CAPE exclusively inhibited the synthesis of peroxynitrite from the artificial substrate SIN-1 and directly prevented the peroxynitrite-mediated conversion of dihydrorhodamine-123 to its fluorescent oxidation product rhodamine-123. In both sepsis models, CAPE inhibited cellular peroxynitrite synthesis, as evidenced by the absence of serum 3-nitrotyrosine, an in vivo marker of peroxynitrite. Thus, CAPE attenuates the inflammatory responses that lead to cell damage and, potentially, cell death through suppression of the production of cytotoxic molecules such as nitric oxide and peroxynitrite. These observations provide evidence of the therapeutic potential of CAPE treatment for a wide range of inflammatory disorders.

Kidney Function Alters the Relationship between Postoperative Troponin T Level and Death

Cardiac troponin T (cTnT), even at low concentrations, is a risk factor for 30-day mortality in patients undergoing noncardiac surgery, but it is uncertain whether that risk is generalizable to patients with poor kidney function. We, therefore, evaluated the relationship between cTnT concentration and kidney function on the outcome of 30-day mortality in a post hoc analysis of a prospective cohort study of patients undergoing noncardiac surgery. cTnT was measured for 3 days after surgery and considered abnormal if the peak was ≥0.02 ng/ml. Of the included 14,037 patients, 267 (1.9%) patients died within 30 days of surgery. The adjusted hazard ratios for death with an abnormal cTnT concentration were 4.37 (95% confidence intervals [95% CI], 3.21 to 6.22), 6.15 (95% CI, 2.95 to 140.9), 6.30 (95% CI, 3.12 to 21.23), 1.33 (95% CI, 0.56 to 4.85), and 1.46 (95% CI, 0.46 to 9.21) for eGFR≥60, 45 to <60, 30 to <45, 15 to <30, and <15 ml/min per 1.73 m(2) or on dialysis, respectively. Compared with patients with eGFR≥60 ml/min per 1.73 m(2), the adjusted hazard ratio was significantly lower for patients with eGFR=15 to <30 ml/min per 1.73 m(2) (interaction P value=0.02). Redefining abnormal cTnT concentration as ≥0.03 ng/ml or a change of ≥0.02 ng/ml did not alter results. Because the risk associated with postoperative cTnT levels may be different for patients with eGFR<30 ml/min per 1.73 m(2), additional research is required to determine how to interpret perioperative cTnT values for patients with low kidney function.

Randomized comparison of the Baska FESS mask and the LMA Supreme in different head and neck positions

ABSTRACT Background: The Baska functional endoscopic sinus surgery (FESS) mask is a new supraglottic airway designed for head and neck procedures. This prospective, randomized controlled trial compared the oropharyngeal leak pressure (OLP) of the Baska FESS mask with the laryngeal mask airway (LMA) Supreme in different head and neck positions. Methods: One hundred patients undergoing elective surgery were recruited. OLP was compared in supine position, 45° lateral rotation, 45° neck extension, and 30° neck flexion. Glottic view, insertion time, ease of insertion, number of attempts, ease and time of insertion of gastric tube, and complications were also compared. Results: The OLP of the Baska FESS was higher than the LMA Supreme in all head and neck positions studied (p < 0.001). Glottic views were better in the Baska FESS in supine and lateral rotation. LMA Supreme was easier (p = 0.046) and faster (p < 0.001) to insert. First attempt insertion success rates were 91.8% for Baska FESS and 98% for LMA Supreme. Gastric drain was easier and faster to insert (p < 0.001) in the LMA Supreme. Conclusions: The Baska FESS provides a superior airway seal with higher mean OLP than the LMA Supreme in all head and neck positions studied. However, LMA Supreme was superior in terms of ease and speed of insertion.

The Bleeding Patient

In the bleeding patient, the first line of management is to replace the blood loss with fluids or blood/blood products in a timely manner to ensure that perfusion to the vital organs is maintained. Securing hemostasis through surgical or other interventions at the earliest opportunity is important to enable successful volume replacement. Coagulopathy associated with inadequate replacement will worsen the bleeding. Unless torrential bleeding is arrested, efforts to replace blood volume and oxygen carrying capacity of blood will fail. The type of coagulopathy can be determined by the use of thromboelastography or plasma based coagulation tests in the laboratory. This will allow appropriate selective component replacement therapy. In those with bleeding as a result of trauma, balanced blood transfusion is advocated. Drugs that improve coagulation work at either the coagulation pathway or at the fibrinolytic pathway. Tranexamic acid prevents the activation of plasminogen to plasmin. Aprotinin inhibits the proteolytic enzymes and prevents fibrinolysis. Activated Factor Vlla increases clot formation at sites of exposed tissue factor.

The Paediatric Airway: Normal and Abnormal

Management of paediatric airway is a great challenge especially for the non-paediatric anaesthesiologist. The children’s airway is different from adults and any mishandling of it can lead to airway obstruction and hypoxia. The first part of the chapter aims at providing a basic understanding of anatomy and physiology in paediatric airway, followed by a basic airway evaluation. The second half of this chapter provides simple principles for management of the abnormal paediatric airway.

Safe delivery of two parturient women in severe metabolic acidosis.

Care of an acutely ill parturient is particularly difficult when we have to balance the needs of both mother and the fetus to survive. The literature suggests there should be emphasis on stabilising the mothers condition. In dealing with metabolic acidosis, however, we believe delivering the baby early might not only relieve the threat of the acidosis on the mother, it may be the only way to deliver a live baby. We report two parturient women with severe metabolic acidosis which was considerably reduced very soon after the delivery and how our timely delivery resulted in the birth of two neurologically intact babies.

Peri-operative management of hysterostomy in a parturient with complete heart block, placenta accreta and intrauterine death

BackgroundComplete heart block in pregnancy has serious implications particularly during the period of delivery. This is more so if the delivery is an operative one as the presence of heart block may produce haemodynamic instability in the intra operative period. We report a unique case of a pregnant mother with complete heart block undergoing hysterostomy, complicated by placenta accreta and intrauterine death.Case presentationA 37 year old Malaysian Chinese parturient was admitted at 25 weeks gestation following a scan which suggested intrauterine death and placenta accreta. She was diagnosed to have congenital complete heart block after her first delivery eight years previously but a pacemaker was never inserted. These medical conditions make her extremely likely to experience massive bleeding and haemodynamic instability. Among the measures taken to optimise her pre-operatively were the insertion of a temporary intravenous pacemaker and embolization of the uterine arteries to minimize peri-operative blood loss. She successfully underwent surgery under general anesthesia, which was relatively uneventful and was discharged well on the fourth post-operative day.ConclusionCongenital heart block in pregnancies in the presence of potential massive bleeding is best managed by a team, with meticulous pre-operative optimization. Suggested strategies would include insertion of a temporary pacemaker and embolization of the uterine arteries to reduce the risk of the patient getting into life threatening situations.