Iatrogenic operative hysteroscopic intravascular absorption syndrome: a recurring possibility!

Background Operative hysteroscopic intravascular absorption syndrome (OHIA) is the constellation of signs and symptoms due to fluid overload during hysteroscopic procedures. It can present with hyponatremia, deranged coagulation, pulmonary, and cerebral edema which are life-threatening issues. To our knowledge, this is the first reported case of recurrent OHIA syndrome which was managed uneventfully. Case presentation A 26-year-old American Society of Anesthesiologist (ASA) patient presented with primary infertility and prolonged, heavy menstruation. The abdominal and transvaginal ultrasound (USG) revealed a large posterior intramural fibroid of size 6.1 cm × 4.2 cm with submucosal intracavitary extension. She was planned for two-step laparoscopic and hysteroscopic evaluation and resection of the myoma under general anesthesia. Severe OHIA syndrome occurred with 1.5% glycine in phase 1 resection and recurred with 0.9% sodium chloride in phase 2 resection of intrauterine myoma at two different surgical settings. The uniqueness of this case is recurrence of OHIA syndrome in the same patient despite the use of normal saline (NS) due to lack of precautionary measures for fluid management. Conclusions Normal saline as an irrigating medium may not eliminate the risk of OHIA. Lack of adequate fluid management strategies can be detrimental especially in cases of hysteroscopic myoma resections. Following a standard protocol for vigilant monitoring under general anesthesia is the key in successful management.

The accuracy of Pleth Variability Index for directed fluid optimization in donors in living donor liver transplantation

Background Fluid management strongly affects hepatic resection and aims to reduce intraoperative bleeding during living donation. The Pleth Variability Index (PVI) is a tool to assess the fluid responsiveness from the pulse oximeter waveform; we evaluated the efficacy and accuracy of finger PVI compared to pulse pressure variation (PPV) from arterial waveform in predicting the fluid response in donor hepatectomy patients with the guide of non-invasive cardiac output (CO) measurements. We recruited forty patients who were candidates for right lobe hepatectomy for liver transplantation under conventional general anesthesia methods. During periods of intraoperative hypovolemia not affected by surgical manipulation, PVI, PPV, and CO were recorded then compared with definitive values after fluid bolus administration of 3–5 ml/kg aiming to give a 10% increase in CO which classified the patients into responders and non-responders. Results Both PPV and PVI showed a significant drop after fluid bolus dose (P < 0.001) leading to an increase of the CO (P < 0.0001), and the area under the curve was 0.934, 0.842 (95% confidence interval, 0.809 to 0.988, 0.692 to 0.938) and the standard error was 0.0336, 0.124, respectively. Pairwise comparison of PPV and PVI showed non-significant predictive value between the two variables (P = 0.4605); the difference between the two areas was 0.0921 (SE 0125 and 95% CI − 0.152 to 0.337). Conclusions PVI is an unreliable indicator for fluid response in low-risk donors undergoing right lobe hepatectomy compared to PPV. We need further studies with unbiased PVI monitors in order to implement a non-invasive and safe method for fluid responsiveness.

Cord-blood derived chemistry reference values in preterm infants for sodium, chloride, potassium, glucose, and creatinine

Objectives: Guidelines recommend preterm infants be supported to maintain their serum electrolytes within “normal” ranges. In term babies, cord blood values differed in pathological pregnancies from healthy ones. Study design: We examined cord blood sodium, chloride, potassium, glucose, and creatinine to derive maturity-related reference intervals. We examined associations with gestational age, delivery mode, singleton versus multiple, and prenatal maternal adverse conditions. We compared preterm cord values to term, and to adult reference ranges. Results: There were 591 infants, 537 preterm and 54 term. Preterm cord glucose levels were steady (3.7+/-1.1mmol/l), while sodium, chloride and creatinine increased over GA by 0.17, 0.14 and 1.07 micromol/week respectively (p<0.003). Average preterm cord potassium and chloride were higher than term (p<0.05). Compared to adult reference intervals, cord preterm reference intervals were higher for chloride (100-111 vs 98-106 mmol/l), lower for creatinine (29-84 vs 62-115 micromol/l), more variable for potassium (2.7-7.9 vs. 3.5-5.0 mmol/l) and sodium (130-141 vs. 136-145 mmol/l). Cesarean section was associated with higher potassium and lower glucose; multiple births with higher chloride and creatinine and lower glucose; SGA with lower glucose. Conclusions: Cord blood values vary across the GA range with increases in sodium, chloride and creatinine while glucose remained steady. Average preterm reference values were higher than term values for potassium and chloride. Preterm reference values differed from published adults’ reference values. The varies across GA and by delivery mode, SGA, and being a multiple, which may have direct implications for neonatal care and fluid management.

Acute Mesenteric Ischemia in COVID-19 Patients

Acute mesenteric ischemia is a rare but extremely severe complication of SARS-CoV-2 infection. The present review aims to document the clinical, laboratory, and imaging findings, management, and outcomes of acute intestinal ischemia in COVID-19 patients. A comprehensive search was performed on PubMed and Web of Science with the terms “COVID-19” and “bowel ischemia” OR “intestinal ischemia” OR “mesenteric ischemia” OR “mesenteric thrombosis”. After duplication removal, a total of 36 articles were included, reporting data on a total of 89 patients, 63 being hospitalized at the moment of onset. Elevated D-dimers, leukocytosis, and C reactive protein (CRP) were present in most reported cases, and a contrast-enhanced CT exam confirms the vascular thromboembolism and offers important information about the bowel viability. There are distinct features of bowel ischemia in non-hospitalized vs. hospitalized COVID-19 patients, suggesting different pathological pathways. In ICU patients, the most frequently affected was the large bowel alone (56%) or in association with the small bowel (24%), with microvascular thrombosis. Surgery was necessary in 95.4% of cases. In the non-hospitalized group, the small bowel was involved in 80%, with splanchnic veins or arteries thromboembolism, and a favorable response to conservative anticoagulant therapy was reported in 38.4%. Mortality was 54.4% in the hospitalized group and 21.7% in the non-hospitalized group (p < 0.0001). Age over 60 years (p = 0.043) and the need for surgery (p = 0.019) were associated with the worst outcome. Understanding the mechanisms involved and risk factors may help adjust the thromboprophylaxis and fluid management in COVID-19 patients.

Trauma and COVID-Induced Severe Rhabdomyolysis

The novel coronavirus COVID-19 has been implicated in a number of extra-pulmonary manifestations including rhabdomyolysis. It is hypothesized to be secondary to direct muscle damage from the virus. The usual treatment of rhabdomyolysis is resuscitation with aggressive fluid management to prevent acute renal failure. However, the combination of blunt thoracic trauma and COVID pneumonia has posed additional challenges for critical care management. A 68-year-old male presented to our institution after being found down for an unknown duration of time. He was diagnosed symptomatic COVID pneumonia. His traumatic injuries included 4 rib fractures, a rectus sheath hematoma, and rhabdomyolysis with a creatinine kinase (CK) level of 16,716 U/L. He was initially treated with steroids, prone positioning, and aggressive fluid administration. Despite treatment his CK level peaked at 146,328 U/L. Here we present the case of trauma and COVID-induced rhabdomyolysis with an extremely elevated CK level.

Perioperative approach to precapillary pulmonary hypertension in non-cardiac non-obstetric surgery

Pulmonary hypertension (PH) confers a significant challenge in perioperative care. It is associated with substantial morbidity and mortality. A considerable amount of information about management of patients with PH has emerged over the past decade. However, there is still a paucity of information to guide perioperative evaluation and management of these patients. Yet, a satisfactory outcome is feasible by focusing on elaborate disease-adapted anaesthetic management of this complex disease with a multidisciplinary approach. The cornerstone of the peri-anaesthetic management of patients with PH is preservation of right ventricular (RV) function with attention on maintaining RV preload, contractility and limiting increase in RV afterload at each stage of the patient's perioperative care. Pre-anaesthetic evaluation, choice of anaesthetic agents, proper fluid management, appropriate ventilation, correction of hypoxia, hypercarbia, acid–base balance and pain control are paramount in this regard. Essentially, the perioperative management of PH patients is intricate and multifaceted. Unfortunately, a comprehensive evidence-based guideline is lacking to navigate us through this complex process. We conducted a literature review on patients with PH with a focus on the perioperative evaluation and suggest management algorithms for these patients during non-cardiac, non-obstetric surgery.