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BACKGROUND Severe COVID-19 patients may become critically ill and require treatment in the intensive care unit (ICU). As intensive care resources are limited, mortality predictors should be used to guide resource allocation. This study aimed to validate the Charlson comorbidity index (CCI) as the mortality predictor of critical COVID-19 patients in the ICU. METHODS A retrospective cohort study was done in adult patients admitted to the ICU with severe COVID-19 at Cipto Mangunkusumo Hospital and Universitas Indonesia Hospital from March to August 2020. We extracted the subject’s CCI score from the medical records and the 28-day mortality after ICU admission. The CCI score was validated by the Hosmer–Lemeshow calibration test, determination of area under the curve (AUC), and optimal cut-off point for the critical patients in the ICU. We used the chi-square test to examine the association of comorbidities with mortality. RESULTS Mortality was higher in CCI scores >4 (odds ratio [OR]: 8.83; 95% confidence interval [CI] = 1.81–43.01). The CCI score had moderate discrimination ability (AUC 76.1%; 95% CI = 0.661–0.881). Chronic kidney disease (CKD) (OR: 18.00, 95% CI = 2.19–147.51), congestive heart failure (CHF) (OR: 4.25, 95% CI = 1.23–14.75), and uncontrolled diabetes mellitus (DM) (OR: 18.429, 95% CI = 2.19–155.21) increased the risk of 28-day mortality. CONCLUSIONS The CCI score could predict the 28-day mortality of critical COVID-19 patients. The coexistence of CKD, CHF, DM, peripheral vascular disease, and peptic ulcer in COVID-19 patients should be considered for patient management.

Lumbar intrathecal administration provides an ideal route for drug delivery into the central nervous system, especially when dorsal root ganglions are the main target for the therapy in rat model of chronic pain. Two main methods of lumbar intrathecal administrations are chronic catheter implantation and the acute needle puncture. Chronic catheter implantation involves surgical manipulation to insert micro indwelling catheter into the intrathecal space. However, this method is invasive, produces inflammatory reactions, and generates more surgical stress. Acute needle puncture is less invasive and cheaper however is technically challenging to perform. We performed an ultrasound-guided lumbar intrathecal injection in six male Sprague Dawley rat cadavers, on average weighing 250–300 grams. Fresh rat cadavers were positioned in a sternal recumbent position, vertebrae were palpated and scanned using a linear probe ultrasound. A 25G needle insertion was advanced with real-time ultrasound guidance, and placement was confirmed prior to dye injection (Methylene blue, Sigma Aldrich). Cadavers were then dissected, and the vertebrae were visually inspected for dye staining. All three cadavers that underwent intrathecal injection with sagittal and axial plane ultrasound guidance showed positive dye staining within the intrathecal space, confirming successful acute intrathecal administration. There was one successful intrathecal injection under sagittal plane-only ultrasound guidance. Ultrasound is a useful, operator-dependent tool to guide acute needle puncture intrathecal administration.

Background and AimsCesarean section is commonly performed under spinal anesthesia, as it is simple, rapid, safe, effective, and maintains maternal awareness. Total spinal anesthesia is a known complication manifested by loss of consciousness, severe bradycardia, hypotension, and respiratory arrest. We describe a case of an unconscious event following spinal anesthesia in the presence of stable hemodynamic and respiratory function.Methods21-year-old parturient, 150 cm, 60 kg, 40–41 weeks of gestation, primigravida, and premature rupture of membrane, scheduled for cesarean section. The patient was assessed with physical status ASA 2 (pregnancy), without any other medical illness. Spinal anesthesia was performed uneventfully, using a 27G spinal needle, at L3/L4 interspinous space, paramedian approach, with the patient in the left lateral decubitus position. Bupivacaine 0.5% heavy 12.5 mg was administered after cerebrospinal fluid flow was confirmed.ResultsWhen obstetrician would make an incision, approximately 5 minutes following spinal anesthesia, the patient was unresponsive, and her pupil dilated. Hemodynamic status was stable, and no respiratory depression was observed. There were no complaints before the loss of consciousness. Supportive management was done, and the patient regained consciousness one and a half-hour after spinal anesthesia. The rostral spread of inadvertent injection of local anesthetics into subdural space is speculated.ConclusionsLoss of consciousness following spinal anesthesia in non-sedated patients with stable hemodynamic and respiratory function is uncommon, but it should be considered, and resuscitation equipment must always be available. When recognized, supportive treatment, especially airway management, is needed until patient regains consciousness, in accordance with the local anesthetic duration of action.

Background Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy. Methods Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB ( n  = 31) or continuous epidural ( n  = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed. Result The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group ( p  = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter ( p  < 0.001) in the QLB group. Conclusion The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia , and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy. Trial registration ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.

Pain management in post transperitoneal laparoscopic nephrectomy is a key to early recovery. Different types of regional anesthesia techniques have been applied for managing post-operative pain. However, the results are still not satisfactory. This study aims to compare effectiveness of ultrasound-guided bilateral Quadratus Lumborum (QL) block with continuous epidural analgesia in improving post transperitoneal laparoscopic nephrectomy analgesia and motoric mobility. This is a randomized controlled trial that included 26 healthy living kidney donor patients. All subjects were randomized to receive preoperatively bilateral QL block (n=13) or continuous epidural analgesia (n=13). Subjects in QL group received 20 mL of bupivacaine 0.25% bilaterally and subjects in epidural group received continuous bupivacaine 0.125% infusion 6 mL/hour. Numerical rating scale (NRS), Bromage score, and duration of urinary catheterization were recorded. The results presented no significant differences in NRS scores at rest and movement, and Bromage score between QL block group and epidural block group in at 2,6,12,24 hours after surgery. The QL block group received significantly lower total dose of bupivacaine (p<0.001) and duration of urinary catheterization was significantly shorter (p=0.001) compared to epidural group. This study found that QL block produced similar postoperative NRS and Bromage score with fewer dose of bupivacaine and shorter duration of urinary catheterization compared with continuous epidural analgesia within 24 hours.

BACKGROUND Shivering is a frequent event during neuraxial anesthesia due to impaired central and peripheral thermoregulation control. Meperidine and MgSO4 are effective in lowering the shivering threshold. Hence, this study aimed to compare the efficacy of MgSO4 and meperidine to prevent shivering in patients undergoing spinal anesthesia. METHODS This was a double-blind randomized clinical trial of 100 patients divided into 2 groups. One group had MgSO4 30 mg/kg, and the other group had meperidine 0.5 mg/kg intravenously in 100 ml of 0.9% NaCl before undergoing spinal anesthesia. Participants were non-pregnant patients aged 18–65 years and had physical status I or II (based on the American Society of Anesthesiologist). Shivering was considered significant if it occurred in grade 3 or 4. Patient characteristics, shivering degree, tympanic membrane temperature, and side effects were recorded. RESULTS Shivering occurred 10% in the MgSO4 group and 19% in the meperidine group, with p = 0.23. Both groups had similar side effects of nausea, vomiting, and hypotension. CONCLUSIONS MgSO4 30 mg/kg was not superior to meperidine 0.5 mg/kg intravenously in preventing shivering in patients undergoing spinal anesthesia.

Post-operative pain is a major clinical problem and must be managed properly. Various types of pharmacotherapy regimens have been used for managing post-operative pain. However, the results are still not satisfactory. This study aimed to determine the effects of electroacupuncture (EA) on post-caesarean section pain. This randomised control trial included 38 women who underwent caesarean section. The participants were divided into two groups: the EA group that received 2 Hz electroacupuncture at the ST36 Zusanli, SP6 Sanyinjiao, LI4 Hegu and LR3 Taichong points for 30 min and the control group that did not receive EA. Morphine was provided to both groups according to their individual needs through patient-controlled analgesia. The assessment was performed by measuring the total dose of morphine used within the first 24 h and during the time when a patient first requested for morphine after surgery. The results showed that the median amount of morphine consumption of the EA and control groups for 24 h were 4.5 and 15 mg, respectively (p < 0.05), and the median time to the first use of morphine in the EA and control groups were 205 and 60 min, respectively (p < 0.05). Thus, EA had an analgesic effect on post-caesarean section pain, as indicated by a delay in the time when a patient first requested for morphine and the decrease in the total dose of morphine that was used within the first 24 h after surgery.

Central venous catheter (CVC) insertion is a routine procedure in either intensive care or in perioperative circumstances. A simple and accurate method or rule is needed to predict the optimum depth of the CVC. The aim of this study is to evaluate the position and depth of CVCs using Peres' formula ([height/10]-2) and landmark measurements, as well as assessing the incidence of malpositions of CVC installation. This research was an analytic observational study. Fifty patients undergoing central venous catheter (CVC) installation with the right subclavian vein approach were divided into two groups: a Peres' formula ([height/10]-2) and an anatomy topography measurement group. The results of the calculations were used to determine the boundary prediction of skin fixation. CVC depth was evaluated by measuring the distance between the distal end of the CVC and the carina, from chest radiographs. The measurement results were analyzed by a Bland and Altman plot. The patient's characteristics were equal for both groups. In the Peres' formula group we found that the mean of the distal CVC was 1.5 (0.82) cm under the carina (CI 95%: 1.2 to 1.9 cm), with the limit of agreement as 0.0 cm to 3.0 cm. The mean of the landmark group was 0.85 (0.73) cm (CI 95%: 0.5 to 1.1 cm) with the limit of agreement as -0.5 cm to 2.2 cm. The incidence of malposition was found to be similar in both groups. The results showed that both prediction methods are not accurate enough to predict the depth of CVC insertion in Indonesian people.

Lumbar intrathecal administration provides an ideal route for drug delivery into the central nervous system, especially when dorsal root ganglions are the main target for the therapy in rat model of chronic pain. Two main methods of lumbar intrathecal administrations are chronic catheter implantation and the acute needle puncture. Chronic catheter implantation involves surgical manipulation to insert micro indwelling catheter into the intrathecal space. However, this method is invasive, produces inflammatory reactions, and generates more surgical stress. Acute needle puncture is less invasive and cheaper but is technically challenging to perform. We performed an ultrasound-guided lumbar intrathecal injection in six male Sprague Dawley rat cadavers, on average weighing 250–300 grams. Fresh rat cadavers were positioned in a sternal recumbent position, vertebrae were palpated and scanned using a linear probe ultrasound. A 25G needle insertion was advanced with real-timeultrasound guidance, and placement was confirmed prior to dye injection (Methylene blue, Sigma Aldrich). Cadavers were then dissected, and the vertebrae were visually inspected for dye staining. All three cadavers that underwent intrathecal injection with sagittal and axial plane ultrasound guidance showed positive dye staining within the intrathecal space, confirming successful acute intrathecal administration. There was one successful intrathecal injection under sagittal plane-only ultrasound guidance. Ultrasound is a useful, operator-dependent tool to guide acute needle puncture intrathecal administration.