Background Thiamine, an essential vitamin for aerobic metabolism and glutathione cycling, may decrease the effects of critical illnesses. The objective of this study was to determine whether intravenous thiamine administration can reduce vasopressor requirements in patients with septic shock. Methods This study was a prospective randomized double-blind placebo-controlled trial. We included adult patients with septic shock who required a vasopressor within 1–24 h after admission between March 2018 and January 2019 at a tertiary hospital in Thailand. Patients were divided into two groups: those who received 200 mg thiamine or those receiving a placebo every 12 h for 7 days or until hospital discharge. The primary outcome was the number of vasopressor-free days over 7 days. The pre-defined sample size was 31 patients per group, and the study was terminated early due to difficult recruitment. Results Sixty-two patients were screened and 50 patients were finally enrolled in the study, 25 in each group. There was no difference in the primary outcome of vasopressor-free days within the 7-day period between the thiamine and placebo groups (mean: 4.9 days (1.9) vs. 4.0 days (2.7), p = 0.197, mean difference − 0.9, 95% CI (− 2.9 to 0.5)). However, the reductions in lactate (p = 0.024) and in the vasopressor dependency index (p = 0.02) at 24 h were greater among subjects who received thiamine repletion vs. the placebo. No statistically significant difference was observed in SOFA scores within 7 days, vasopressor dependency index within 4 days and 7 days, or 28-day mortality. Conclusions Thiamine was not associated to a significant reduction in vasopressor-free days over 7-days in comparison to placebo in patients with septic shock. Administration of thiamine could be associated with a reduction in vasopressor dependency index and lactate level within 24 h. The study is limited by early stopping and low sample size. Trial registration TCTR, TCTR20180310001. Registered 8 March 2018, http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=3330.
Background Thoracic epidural placement (TEP) using the conventional anatomic landmark-based technique is technically challenging, may require multiple attempts, and is associated with a high failure rate (12–40%). We hypothesized that real-time ultrasound guidance would be superior in the “first-pass” success rate of TEP, when compared with the conventional technique. Methods This prospective, randomized, superiority trial was conducted in a University hospital, and recruited 96 patients undergoing elective major abdominal or thoracic surgery and scheduled to receive a TEP for postoperative analgesia. Patients were randomly allocated to receive TEP using either the conventional technique (Gp-Conv, n = 48) or real-time ultrasound guidance (Gp-Usg, n = 48). The success of TEP was defined as eliciting loss of resistance technique and being able to insert the epidural catheter. The primary outcome variable was the “first-pass success rate” meaning the successful TEP at the first needle insertion without redirection or readvancement of the Tuohy needle. The secondary outcomes included the number of skin punctures, number of attempts, the overall success rate, TEP time, and total procedure time. Results The first-pass success rate of TEP was significantly higher (p = 0.002) in Gp-Usg (33/48 (68.8%); 95%CI 55.6 to 81.9) than in Gp-Conv (17/48 (35.4%); 95%CI 21.9 to 49.0). There was no statistically significant difference (p = 0.12) in the overall success rate of TEP between the 2 study groups (Gp-Usg; 48/48 (100%) vs. Gp-Conv; 44/48 (91.7%); 95%CI 83.9 to 99.5). Ultrasound guidance reduced the median number of skin punctures (Gp-Usg; 1 [1, 1] vs Gp-Conv; 2 [1, 2.2], p < 0.001) and attempts at TEP (Gp-Usg; 1 [1, 2] vs Gp-Conv; 3 [1, 7.2], p < 0.001) but the procedure took longer to perform (Gp-Usg; 15.5 [14, 20] min vs Gp-Conv; 10 [7, 14] min, p < 0.001). Conclusions This study indicates that real-time ultrasound guidance is superior to a conventional anatomic landmark-based technique for first-pass success during TEP although it is achieved at the expense of a marginally longer total procedure time. Future research is warranted to evaluate the role of real-time ultrasound guidance for TEP in other groups of patients. Trial registration Thai Clinical Trials Registry; http://www.thaiclinicaltrials.org/; Trial ID: TCTR20200522002, Registration date: 22/05/2020.
Truncus arteriosus (TA) is defined as a congenital cardiovascular malformation in which one great artery arises from the base of the heart and gives origin to the pulmonary and systemic arteries. TA patients who become pregnant have high morbidity and mortality rates because physiologic changes during pregnancy can worsen the cardiopulmonary balance causing cardiopulmonary decompensation. In this case report we report a successful general anesthesia in a truncus arteriosus patient with severe pulmonary hypertension (Eisenmenger syndrome) who underwent a full-term pregnancy delivery monitored by intraoperative transesophageal echocardiography, a new technique to assist physicians in dealing with patients with hemodynamic instability during both cardiac and noncardiac surgery.
Objective Nasogastric tube (NGT) insertion in anesthetized and intubated patients can be challenging, even for experienced anesthesiologists. Various techniques have been proposed to facilitate NGT insertion in these patients. This study aimed to compare the success rate and time required for NGT insertion between GlideScope™ visualization and neck flexion, with lateral neck pressure techniques. Material and methods This randomized clinical trial was performed at a teaching hospital on 86 adult patients undergoing abdominal surgery, under relaxant general anesthesia, who required intraoperative NGT insertion. The patients were randomized into two groups, the GlideScope™ group (group G) and the neck flexion with lateral neck pressure group (group F). The success rate of the first and second attempts, duration of insertion, and complications were recorded. Results The total success rate was 79.1% in group G, compared with 76.7% in group F (P = 1). The median time required for NGT insertion was significantly longer in group G, for both first and second attempts (97 vs 42 s P < 0.001) and (70 vs 48.5 s P = 0.015), respectively. Complications were reported in 23 patients (53.5%) in group G and 13 patients (30.2%) in group F. Bleeding and kinking were the most common complications for both techniques. Conclusion Using GlideScope™ visualization to facilitate NGT insertion was comparable to neck flexion with lateral neck pressure technique, in the degree of success rates of insertion. Although complications were not statistically significant between groups, neck flexion with lateral neck pressure technique was significantly less time-consuming for both first and second attempts. Trial registration Retrospectively registered: Thai Clinical Trial Registry (TCTR)20171229003. Registered on 19 December 2017
The rates of perioperative morbidity and mortality during major surgery have shown a declining trend due to improvements in hemodynamic monitoring and fluid assessment. However, several million surgical procedures involving aged patients and those with multiple comorbidities are performed every year worldwide. Thus, the establishment and constant re-evaluation of appropriate threshold values of perioperative hemodynamic parameters for the management of immediate- to high-risk patients with a narrow safety margin are especially important. Perioperative fluid balance is an important independent risk factor of postoperative morbidity and mortality. In this article, we provide an overview of intraoperative hemodynamic fluid resuscitation and fluid-response monitoring during non-cardiac surgery. We also focus on targets at the macrocirculatory, microcirculatory, and cellular levels.
การตรวจคลื่นเสียงความถี่สูงบริเวณทรวงอกในผู้ป่วยเวชบำบัดวิกฤตได้รับความนิยมเนื่องจาก มีความไวและความแม่นยำในการวินิจฉัยโรคสูง เช่น ปอดอักเสบ ปอดแฟบ หรือ ภาวะโพรงเยื่อหุ้มปอดมีอากาศ มากกว่าการตรวจวินิจฉัยด้วยภาพถ่ายรังสีทรวงอกหรือการตรวจร่างกาย นอกจากนี้ยังมีความปลอดภัยสูง ไม่เสี่ยงต่อการสัมผัสรังสี ทำได้อย่างรวดเร็ว และไม่ต้องเคลื่อนย้ายผู้ป่วย อย่างไรก็ตาม การตรวจด้วยคลื่นเสียงความถี่สูงจำเป็นต้องอาศัยความรู้ ทักษะ และประสบการณ์ของผู้ตรวจ เพื่อให้การตรวจเป็นไปอย่างถูกต้อง และน่าเชื่อถือ บทความนี้จึงได้รวบรวมความรู้เรื่อง การตรวจด้วยคลื่นความถี่สูงบริเวณทรวงอกขั้นพื้นฐาน เพื่อให้ง่ายต่อการนำไปประยุกต์ใช้ และฝึกปฏิบัติในหอผู้ป่วยวิกฤต
Objective: This study aims to evaluate the ability of stroke volume variation (SVV), pulse pressure variation (PPV), and change in PVV and SVV after tidal volume challenge testing (ΔPPV and ΔSVV) aiming to predict fluid responsiveness in patients undergoing laparoscopic urologic surgery. Material and Methods: A prospective interventional study was performed with 23 patients undergoing urologic surgery while they were placed in Trendelenburg positions. A Vigileo/FloTrac system was used for the analysis. Hemodynamic data such as: arterial pressure (MAP), heart rate (HR), peak airway pressure (PIP), stroke volume (SV), cardiac output (CO), SVV, and PPV were recorded at the tidal volume settings of 8 mL/kg and 12 mL/kg before, and after a fluid challenge (FC). Fluid responsiveness was defined as an increase in SV(ΔSV) ≥15.0%. Results: After tidal volume challenge tests, there were significant increases in PIP in both groups. PPV increased only in the responders, as opposed to SVV, which increased significantly only in non-responders after tidal volume challenge test. After fluid challenge, PVV and SVV decreased gradually and significantly in both groups. The area under the ROC curves of patients undergoing laparoscopic urologic surgery was 0.872 (95% CI: 0.57-0.96) for ΔPPV, this change was the highest compared to other parameters. The threshold of the ΔPPV of patients undergoing laparoscopic urologic surgery was 4% with a sensitivity at 0.75 and specificity at 0.93. Conclusion: Change in PPV after the tidal volume challenge test from 8 mL/kg to 12 mL/kg can be used as an effective indicator to monitor fluid responsiveness in regards to patients undergoing urologic surgery.
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