Glycemia management in critical care patients

Over the last decade, the approach to clinical management of blood glucose concentration (BGC) in critical care patients has dramatically changed. In this editorial, the risks related to hypo, hyperglycemia and high BGC variability, optimal BGC target range and BGC monitoring devices for patients in the intensive care unit (ICU) will be discussed. Hypoglycemia has an increased risk of death, even after the occurrence of a single episode of mild hypoglycemia (BGC < 80 mg/dL), and it is also associated with an increase in the ICU length of stay, the major determinant of ICU costs. Hyperglycemia (with a threshold value of 180 mg/dL) is associated with an increased risk of death, longer length of stay and higher infective morbidity in ICU patients. In ICU patients, insulin infusion aimed at maintaining BGC within a 140-180 mg/dL target range (NICE-SUGAR protocol) is considered to be the state-of-the-art. Recent evidence suggests that a lower BGC target range (129-145 mg/dL) is safe and associated with lower mortality. In trauma patients without traumatic brain injury, tight BGC (target < 110 mg/dL) might be associated with lower mortality. Safe BGC targeting and estimation of optimal insulin dose titration should include an adequate nutrition protocol, the length of insulin infusion and the change in insulin sensitivity over time. Continuous glucose monitoring devices that provide accurate measurement can contribute to minimizing the risk of hypoglycemia and improve insulin titration. In conclusion, in ICU patients, safe and effective glycemia management is based on accurate glycemia monitoring and achievement of the optimal BGC target range by using insulin titration, along with an adequate nutritional protocol.

Complicated course of biliary inflammatory myofibroblastic tumor mimicking hilar cholangiocarcinoma:A case report and literature review

BACKGROUND The inflammatory myofibroblastic tumor(IMT)is a rare,idiopathic,usually benign,mass-forming disease with myofibroblastic proliferation and a varying amount of inflammatory cells.Although it can affect various organs,the biliary tract is a rare localization of primary IMT,clinically,endoscopically and radiologically imitating cholangiocarcinoma.The treatment options are based only on clinical practice experience.CASE SUMMARY A 70-year-old woman was referred to our center due to progressive fatigue,weight loss,abdominal pain,night sweats,and elevated liver enzymes.Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography(ERCP)revealed proximal common hepatic duct and hilar biliary strictures extending bilaterally to lobular bile ducts.Although initial clinical,endoscopic and radiological signs were typical for hilar cholangiocarcinoma,histological examination showed no signs of malignancy.In total,8 biopsies using different approaches were performed(several biopsies from dominant stricture during ERCP and direct cholangioscopy;ultrasound-guided liver biopsy;diagnostic laparoscopy with liver and lymph node biopsies).Histological examination revealed signs of IMT,and the final diagnosis of biliary IMT was stated.Although IMT is usually a benign disease,in our case,it was complicated.All pharmacological treatment measures were ineffective.The patient still needs permanent stenting,suffers from recurrent infections and mechanical jaundice.Despite that,the patient already survived 24 mo.CONCLUSION IMT presenting with hilar biliary strictures is a unique diagnostic and clinical challenge as it is indistinguishable from cholangiocarcinoma,and there are no evidence-based treatment options.Our goal is to increase the understanding of this rare disease and its possible course.

Effect of clonidine on the cutaneous silent period during spinal anesthesia

AIM To investigate the effect of clonidine on the cutaneous silent period(CSP) during spinal anesthesia. METHODS A total of 67 adult patients were included in this randomized, prospective, single-center, double-blind trial. They did not have neurological disorders and were scheduled for inguinal hernia repair surgery. This trial was registered on ClinicalTrials.gov(NTC03121261). The patients were randomized into two groups with regards to the intrathecally administered solution:(1) 15 mg of 0.5% levobupivacaine with 50 μg of 0.015% clonidine, or(2) 15 mg of 0.5% levobupivacaine alone. There were 34 patients in the levobupivacaine-clonidine(LC) group and 33 patients in the levobupivacaine(L) group. CSP and its latency were measured four times: prior to the subarachnoid block(SAB), after motor block regression to the 0 level of the Bromage scale, with ongoing sensory blockade, and both 6 and 24 h after SAB.RESULTS Only data from 30 patients in each group were analyzed. There were no significant differences between the groups investigated preoperatively and after 24 h. The CSP of the L group at the time point when the Bromage scale was 0 was 44.8 ± 8.1 ms, while in the LC group it measured 40.2 ± 3.8 ms(P = 0.007). The latency in the L group at the time point when the Bromage scale was 0 was 130.3 ± 10.2 ms, and in the LC group it was 144.7 ± 8.3 ms(P < 0.001). The CSP of the L group after 6 h was 59.6 ± 9.8 ms, while in the LC group it was 44.5 ± 5.0 ms(P < 0.001). The latency in the L group after 6 h was 110.4 ± 10.6 ms, while in LC group it was 132.3 ± 9.7 ms(P < 0.001).CONCLUSION Intrathecal addition of clonidine to levobupivacaine for SAB in comparison with levobupivacaine alone resultsin a diminished inhibitory tonus and shortened CSP.

Ultrasound Guided Erector Spinae Block with Costotransverse Ligament Puncture Is More Effective than Erector Spinae Block Alone;Eight Cases for Oncologic Breast Surgery;A Brief Technical Report

Objectives: Due to the complex breast innervation, postoperative analgesia after breast surgery is a challenge for the anesthesiologists. The erector spinae plane block (ESP) is a newly defined promising technique for this purpose. Since the description by Forero, ultrasound-guided erector spinae block (ESP) has performed for several surgeries for postoperative analgesia. Many regional methods pectoral nerve block (PECs), serratus plane block (SPB), were described in the literature for maintaining postoperative analgesia. Among all these regional anesthesia techniques, paravertebral block (PVB) is the most studied and found to be a valid regional technique for this purpose. Due to its anatomic proximity to the pleura and central neuraxial system, it’s also one of the most challenging techniques. Materials and Methods: Patients aged between 37 and 47 years, American Society of Anesthesiologists physical status I-II and scheduled for elective unilateral modified radical mastectomy (MRM) surgery without axillary lymph node dissection were enrolled to this case series. In this report, we describe a novel combination of ESP and simplified PVB block and its successful application in 8 cases of oncologic breast surgery. In our clinic, ESP block is performed for all oncological breast cases. Eight cases of MRM without axillary dissection were randomly selected by the same anesthesiologist (AS). 15 mL 0.25% bupivacaine was administered between the erector spinae muscles and the transverse process at the level of the 4th thoracal vertebra with the caudo-cranial approach. Additionally, the needle tip was directed to T4 superior costotransverse ligament, and the ligament was perforated at the top point where it attaches to the T4 transverse process. Results: The ESP block is used for a local anesthetic depot, as a safe and straightforward technique and costotransverse ligament puncture facilitates diffusion and ensures local anesthetic passage to the paravertebral area for thoracic postsurgical analgesia. Using lower doses, comparing this combination with all studies with ESP, it appears that there are a better Numeric Pain Rating Scale (NPRS) scores in the first postoperative hours. NPRS scores at the 12th and 24th hours appear to be similar to those performed in ESP without costotransverse ligament puncture. Conclusion: We submit the first description of a novel combination of ESP block and simplified paravertebral block (PVB) and its successful application in 8 cases of oncologic breast surgery.

Management of Flood syndrome:What can we do better?

Approximately 20%of cirrhotic patients with ascites develop umbilical herniation.These patients usually suffer from multisystemic complications of cirrhosis,have a significantly higher risk of infection,and require accurate surveillance–especially in the context of the coronavirus disease 2019 pandemic.The rupture of an umbilical hernia,is an uncommon,life-threatening complication of largevolume ascites and end-stage liver disease resulting in spontaneous paracentesis,also known as Flood syndrome.Flood syndrome remains a challenging condition for clinicians,as recommendations for its management are lacking,and the available evidence for the best treatment approach remains controversial.In this paper,four key questions are addressed regarding the management and prevention of Flood syndrome:(1)Which is the best treatment approach–conservative treatment or urgent surgery?(2)How can we establish the individual risk for herniation and possible hernia rupture in cirrhotic patients?(3)How can we prevent umbilical hernia ruptures?And(4)How can we manage these patients in the conditions created by the coronavirus disease 2019 pandemic?

Effects of Exposure to GSM Mobile Phone Base Station Signals on Salivary Cortisol,Alpha-Amylase,and Immunoglobulin A

Objective The present study aimed to test whether exposure to radiofrequency electromagnetic fields （RF-EMF） emitted by mobile phone base stations may have effects on salivary alpha-amylase, immunoglobulin A （IgA）, and cortisol levels. Methods Fifty seven participants were randomly allocated to one of three different experimental scenarios （22 participants to scenario 1, 26 to scenario 2, and 9 to scenario 3）. Each participant went through five 50-minute exposure sessions. The main RF-EMF source was a GSM-900-MHz antenna located at the outer wall of the building. In scenarios 1 and 2, the first, third, and fifth sessions were ＂low＂ （median power flux density 5.2 μW/m^2） exposure. The second session was ＂high＂ （2126.8 μW/m^2）, and the fourth session was ＂medium＂ （153.6 μW/m^2） in scenario 1, and vice versa in scenario 2. Scenario 3 had four ＂low＂ exposure conditions, followed by a ＂high＂ exposure condition. Biomedical parameters were collected by saliva samples three times a session. Exposure levels were created by shielding curtains. Results In scenario 3 from session 4 to session 5 （from ＂low＂ to ＂high＂ exposure）, an increase of cortisol was detected, while in scenarios 1 and 2, a higher concentration of alpha-amylase related to the baseline was identified as compared to that in scenario 3. IgA concentration was not significantly related to the exposure. Conclusions RF-EMF in considerably lower field densities than ICNIRP-gnidelines may influence certain psychobiological stress markers.

肺泡复张策略复合高水平呼气末正压通气不影响血容量充足的病态肥胖患者的血流动力学

我们观察了20例血容量充足，准备行腹腔镜手术的病态肥胖（体重指数为50±9kg/m^2）患者，评估肺泡复张策略复合高水平呼气末正压通气（posidveend-expiratorypressure，PEEP）对其血流动力学的影响。肺泡复张策略是在有气腹和无气腹的情况下序贯进行，将PEEP水平逐渐升高，使平台压达到50—60cmH2O，呼吸10次／分，然后将PEEP水平逐渐降低。通过体循环和肺动脉导管的监测，没有发现肺泡复张及高水平PEEP对血流动力学产生显著的影响。经食管超声心动图显示左室舒张末期面积未发生变化，也无局部室壁运动异常的迹象。

压力支持通气和双相气道正压通气通过肺血流重新分布从而提高氧合

背景机械通气时保留自主呼吸（spontaneousbreathing，SB）可改善气体交换，主要是因为这种通气方式可使萎陷的肺复张。在保留SB的机械通气中，常选择压力支持通气（pressuresupportventilation，PSV）和双相气道正压通气（biphasicpositiveairwaypressure，BIPAP）。但医师对这些辅助性机械通气方式改善肺功能的机制却不甚了解。我们评价了采用PSV和BIPAP改善氧合的机制。方法5头猪（25-29．3kg）于仰卧位行机械通气，并通过清除肺表面活性物质诱发其发生急性肺损伤（acutelung砸jury，Au）。状态稳定后，给予BIPAP通气，初期较低持续气道正压设置为5cmH2O，随后逐渐增加持续气道正压至维持潮气量在6-8ml／kg。减浅麻醉深度，当SB≥每分通气量的20％时，随机进行1小时的PSV或BIPAP＋SB通气。于呼气末行全胸螺旋式计算机体层扫描，并记录肺功能参数。静脉给予荧光微球体来记录肺血流（pulmonarybloodflow，PBF），并利用空间聚类分析来评估每种通气方式对PBF重新分布的影响。结果Au损伤肺功能并加大了下肺萎陷或不张组织的面积（P〈0．05）。和对照组比较，PSV和BIPAP＋SB的通气模式提高了氧合并减少了静脉血掺杂（P〈0．05）。尽管如此，我们观察到自主呼吸时下肺的不张肺组织或通气不良组织明显增加，而可正常通气的肺组织减少。观察到6例中有5例行PSV或sB＋BIPAP通气时PBF由下至上重新分布，肺通气也较好。结论在ALI模型中采用PSV或BIPAP＋SB行机械通气可改善氧合，减少静脉血掺杂的原因为PBF由下至上的重新分布，而不是因为下肺复张。