Upper-limb RIPC performed while patients were under propofol-induced anesthesia did not show a relevant benefit among patients undergoing elective cardiac surgery. (Funded by the German Research Foundation; RIPHeart ClinicalTrials.gov number, NCT01067703.).

Administration of omega-3 fatty acid may reduce mortality, antibiotic use, and length of hospital stay in different diseases. Effects and effect sizes related to fish oil doses are diagnosis dependent. In view of the lack of substantial study literature concerning diagnosis-related nutritional single-substrate intervention in the critically ill, the present data can be used in formulating hypotheses and may serve as reference doses for randomized, controlled studies, which may, for instance, confirm the value of omega-3 fatty acid in the adjunctive therapy of peritonitis and abdominal sepsis.

SummaryRopivacaine 1% 40 ml was mistakenly injected as part of an axillary plexus block in an 84-year-old woman. After 15 min the patient complained of dizziness and drowsiness and developed a generalised tonic-clonic seizure followed by an asystolic cardiac arrest. After 10 min of unsuccessful cardiopulmonary resuscitation, a bolus of 100 ml of Intralipid 20% (2 ml.kg )1 ) was administered followed by a continuous infusion of 10 ml.min )1 . After a total dose of 200 ml of Intralipid 20%had been given spontaneous electrical activity and cardiac output was restored. The patient recovered completely. We believe the cardiovascular collapse was secondary to ropivacaine absorption following the accidental overdose. This case shows that lipid infusion may have a beneficial role in cases of local anaesthetic toxicity when conventional resuscitation has been unsuccessful. Lipid infusion has been evaluated in several animal models as a treatment for local anaesthetic-induced cardiovascular collapse [1,2]. Although this method might offer a possible therapeutic alternative for treatment of local anaesthetic intoxication [3][4][5] there are no reports of successful human use to date. We report an 84-year-old patient who was successfully resuscitated from cardiovascular collapse after axillary plexus blockade with ropivacaine by use of a lipid infusion. Case reportAn 84-year-old, ASA III, 50-kg woman presented for surgery on a Dupuytren contracture under brachial plexus block. Her medical history included a mild form of Morgagni-Adams-Stokes syndrome, left bundle branch block, and grade II mitral and tricuspid valve regurgitation. The patient was premedicated with midazolam 7.5 mg orally 30 min prior to start of anaesthesia. After placement of routine monitoring and peripheral venous access, an axillary brachial plexus block was performed using a 22-G insulated needle and peripheral nerve stimulation. Nerves were located at three sites corresponding with the ulnar, median and radial nerves. Due to a misunderstanding between the anaesthesiologist and the nurse anaesthetist a total of 40 ml of 1% (instead of 0.5%) ropivacaine was injected after repeated negative aspiration tests. After 15 min the patient complained of dizziness and drowsiness, lost consciousness and had a generalised tonic-clonic seizure. Her heart rate increased to 120 beats.min )1 but blood pressure remained unchanged.The patient was immediately ventilated by mask with oxygen 100% and thiopental 150 mg was given intravenously to stop seizure activity. About 2 min later, the patient developed ventricular extrasystoles followed by severe bradycardia and asystole. Cardiopulmonary resuscitation was started. The patient was given 1-mg increments of epinephrine (total 3 mg), which did not restore cardiovascular activity. An arterial line and central venous line were placed. The patient remained asystolic.

Medical emergencies are not rare in dental practice, although most of them are not life-threatening. Improvement of competence in emergency management should include repeated participation in life support courses, standardisation of courses and offering courses designed to meet the needs of dentists.

Fructose is a major component of dietary sugar and its overconsumption exacerbates key pathological features of metabolic syndrome. The central fructose-metabolising enzyme is ketohexokinase (KHK), which exists in two isoforms: KHK-A and KHK-C, generated through mutually exclusive alternative splicing of KHK pre-mRNAs. KHK-C displays superior affinity for fructose compared with KHK-A and is produced primarily in the liver, thus restricting fructose metabolism almost exclusively to this organ. Here we show that myocardial hypoxia actuates fructose metabolism in human and mouse models of pathological cardiac hypertrophy through hypoxia-inducible factor 1α (HIF1α) activation of SF3B1 and SF3B1-mediated splice switching of KHK-A to KHK-C. Heart-specific depletion of SF3B1 orgenetic ablation of Khk, but not Khk-A alone, in mice, suppresses pathological stress-induced fructose metabolism, growth and Reprints and permissions information is available at www.nature.com/reprints.

A 91-yr-old man (57 kg, 156 cm, ASA III) received an infraclavicular brachial plexus block for surgery of bursitis of the olecranon. Twenty minutes after infraclavicular injection of 30 mL of mepivacaine 1% (Scandicain) and 5 min after supplementation of 10 mL of prilocaine 1% (Xylonest) using an axillary approach, the patient complained of agitation and dizziness and became unresponsive to verbal commands. In addition, supraventricular extrasystole with bigeminy occurred. Local anesthetic toxicity was suspected and a dose of 200 mL of a 20% lipid emulsion was infused. Symptoms of central nervous system and cardiac toxicity disappeared within 5 and 15 min after the first lipid injection, respectively. Plasma concentrations of local anesthetics were determined before, 20, and 40 min after lipid infusion and were 4.08, 2.30, and 1.73 microg/mL for mepivacaine and 0.92, 0.35, and 0.24 microg/mL for prilocaine. These concentrations are below previously reported thresholds of toxicity above 5 microg/mL for both local anesthetics. Signs of toxicity resolved and the patient underwent the scheduled surgical procedure uneventfully under brachial plexus blockade.

Background Myocardial involvement induced by SARS-CoV-2 infection might be important for long-term prognosis. The aim of this observational study was to characterize the myocardial effects during SARS-CoV-2 infections by echocardiography. Results and methods An extended echocardiographic image acquisition protocol was performed in 18 patients with SARS-CoV-2 infection assessing LV longitudinal, radial, and circumferential deformation including rotation, twist, and untwisting. Furthermore, LV deformation was analyzed in an age-matched control group of healthy individuals ( n = 20). The most prevalent finding was a reduced longitudinal strain observed predominantly in more than one basal LV segment ( n = 10/14 patients, 71%). This pattern reminded of a “reverse tako-tsubo” morphology that is not typical for other viral myocarditis. Additional findings included a biphasic pattern with maximum post-systolic or negative regional radial strain predominantly basal ( n = 5/14 patients, 36%); the absence or dispersion of basal LV rotation ( n = 6/14 patients, 43%); a reduced or positive regional circumferential strain in more than one segment ( n = 7/14 patients, 50%); a net rotation showing late post-systolic twist or biphasic pattern ( n = 8/14 patients, 57%); a net rotation showing polyphasic pattern and/or higher maximum net values during diastole ( n = 8/14 patients, 57%). Conclusion Myocardial involvement due to SARS-CoV-2-infection was highly prevalent in the present cohort—even in patients with mild symptoms. It appears to be characterized by specific speckle tracking deformation abnormalities in the basal LV segments. These data set the stage to prospectively test whether these parameters are helpful for risk stratification and for the long-term follow-up of these patients.

Lipid application in l-bupivacaine-induced cardiac depression had a significant positive inotropic effect, which we would attribute to a direct inotropic effect. However, in an isolated heart model, indirect, local anesthetic plasma-binding effect of lipids cannot be excluded.