Joint pain or swelling
Sherif Gonem, Ian Pavord in Diagnosis in Acute Medicine, 2017
Joint pain or swelling may be caused by any of the following broad mechanisms: systemic inflammation; local or systemic infection; degenerative or mechanical factors; and miscellaneous causes. Septic arthritis is the most important diagnosis to make in a timely manner. Acute monoarthritis should be assumed to be due to septic arthritis until proved otherwise. If the patient is septic, circulatory support may be required with fluid resuscitation and possibly inotropes in a high-dependency setting. Early liaison with the orthopaedic team is essential for consideration of joint wash-out in theatre. Following blood cultures and joint aspiration for Gram stain and culture, broad-spectrum antibiotics should be commenced.
Brain Death and Organ Donation
T.M. Craft, P.M. Upton in Key Topics In Anaesthesia, 2021
Brain stem death is defined as the irreversible cessation of brain stem function, but not necessarily the physical destruction of the brain. Head injury and intracranial haemorrhage account for approximately 80% of cases. The head is moved rapidly from side to side. If the brain stem is dead the eyes remain in a fixed position within the orbit. If the cortex is dead but the brain stem is intact the eyes appear to move to the opposite side and then realign with the head. It does not form part of the legally required brain stem death tests. Some countries require other tests for the diagnosis of brain death. Organ retrieval takes place in the operating theatre. Organ perfusion is maintained, with fluids and inotropes if necessary. High-dose inotropes are, however, detrimental to subsequent organ function. Spinal reflexes and autonomic haemodynamic responses require the use of neuromuscular blockers and opioids for control.
Critical care and emergency surgery
Stephen Brennan in FRCS General Surgery Viva Topics and Revision Notes, 2017
Diagnostic laparoscopy is safe and effective when used in pregnancy. Several studies have shown that pregnant patients may undergo laparoscopic surgery safely during any trimester without any appreciated increased risk to the mother or foetus. Systemic inflammatory response syndrome differs from sepsis in that sepsis is SIRS with a documented infection. Septic shock is sepsis with refractory arterial hypotension and/or need for inotropes despite adequate fluid resuscitation. The physiological changes occurring in patients with severe sepsis and septic shock are myriad and include changes that are clearly detrimental such as decreased contractility of the left and right ventricle, increased venous capacitance, increased pulmonary vascular resistance, and capillary leak. A damage control laparotomy (DCL) is a laparotomy performed usually for trauma where the primary aim is to control haemorrhage and limit sepsis in the first instance. The central nervous system degeneration, trauma, or neoplasms may affect the hypothalamic regulatory centre.
New arylsparteine derivatives as positive inotropic drugs
Published in Journal of Enzyme Inhibition and Medicinal Chemistry, 2017
Vito Boido, Marcella Ercoli, Michele Tonelli, Federica Novelli, Bruno Tasso, Fabio Sparatore, Elena Cichero, Paola Fossa, Paola Dorigo, Guglielmina Froldi
Positive inotropic agents are fundamental in the treatment of heart failure; however, their arrhythmogenic liability and the increased myocardial oxygen demand strongly limit their therapeutic utility. Pursuing our study on cardiovascular activities of lupin alkaloid derivatives, several 2-(4-substituted-phenyl)-2-dehydrosparteines and 2-(4-substituted-phenyl)sparteines were prepared and tested for inotropic and chronotropic activities on isolated guinea pig atria. Four compounds (6b, 6e, 7b, and 7f) exhibited significant inotropism that, at the higher concentrations, was followed by negative inotropism or toxicity. Compound 7e (2-(4-tolyl)sparteine) exhibited a steep dose-depending inotropic activity up to the highest concentration tested (300 µM) with an Emax of 116.5 ± 3.4% of basal force, proving less potent but much more active in comparison to the highest concentrations tested of digoxin and milrinone having Emax of 87.5 ± 3.1% and 52.2 ± 1.1%, respectively. Finally, docking studies suggested that the relevant sparteine derivatives could target the sigma-1 receptor, whose involvement in cardiac activity is well documented.
Risk factors for spontaneous localized intestinal perforation in the preterm infant
Published in The Journal of Maternal-Fetal & Neonatal Medicine, 2018
Maissa Rayyan, Ivan Myatchin, Gunnar Naulaers, Yasmin Ali Said, Karel Allegaert, Marc Miserez
Purpose: The aim of this study was to investigate prenatal and postnatal risk factors for spontaneous intestinal perforation (SIP) in preterm infants. Material and methods: Matched case-control study of 62 preterm infants (matching based on gender, gestational age and birth weight) who developed a SIP over a period of 20 years in a single NICU. Univariate and multivariate logistic regression analysis were performed. Results: Prenatal risk factors were not significantly different between cases and controls. Patients exposed to surfactant and inotropic agents have an increased risk for SIP. No initiation of feeding before development of SIP and IVH ≥ grade 3 were also associated with an increased risk for SIP. In multivariate analysis inotropic agents, lack of initiation of feeding and IVH ≥ grade 3 remained significant risk factors (OR 5.58 (95% CI 1.14–27.22), 0.29 (95% CI 0.09–0.88), 15.2 (95% CI 1.09–211.55) respectively). Conclusions: The study found that patients with SIP are more likely to have been exposed to inotropic agents and to have developed IVH ≥ grade 3. They were also less likely to have been fed. These risk factors most likely reflect the severity of illness of preterm infants and an increased vulnerability for developing SIP.
Early inotropes use is associated with higher risk of death and/or severe brain injury in extremely premature infants
Published in The Journal of Maternal-Fetal & Neonatal Medicine, 2020
Ahmad Nizar Abdul Aziz, Sumesh Thomas, Prashanth Murthy, Yacov Rabi, Amuchou Soraisham, Amelie Stritzke, Majeeda Kamaluddeen, Essa Al-Awad, Khorshid Mohammad
Introduction: Extremely premature infants are susceptible to fluctuations in cerebral blood flow due to immaturity of cerebral autoregulation. Inotropes may cause rapid changes to systemic blood pressure and consequently cerebral blood flow, especially within the first 72 hours of life. This period is recognized to carry the greatest risk for cerebral hemorrhage. This study evaluates the incidence of death and/or severe brain injury in extremely preterm infants treated with inotropes in the first 72 hours of life. Methods: Prospective cohort study of infants born ≤29+0 weeks gestational age (GA) between January 2013 and December 2016. Severe brain injury was defined based on head ultrasound as presence of: grade III or IV intraventricular hemorrhage (IVH), moderate to severe post-hemorrhagic ventricular dilatation (PHVD), or cystic periventricular leukomalacia (cPVL). The association between inotrope use and death and/or brain injury was explored via logistic regression controlling for predefined confounding risk factors. Results: Of 497 eligible infants, 97 (19.5%) received inotropes during the first 72 hours. GA at birth, birth weight (BW), and 5-minute Apgar scores were lower among infants who received early inotropes compared to those not treated with inotropes. A stepwise logistic regression of the predefined confounding factors showed GA, exposure for antenatal steroids, and admission hypothermia to be significant confounding factors. Adjusting for those factors, early use of inotropes was associated with increased risk of death and/or severe brain injury (AOR 4.5; 95%CI: 2.4–8.5), severe brain injury (AOR 4.2; 95% CI: 1.9–8.9), and IVH of any grade (AOR 2.9; 95%CI: 1.7–4.9). Conclusion: Early inotropes use was associated with higher risk of death and/or severe brain injury. Strict indications and strategies for minimizing inotrope use while preventing hypotension should be implemented in the early postnatal care of infants at risk for severe brain injury.