Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients

Objective: Epidural anesthesia is a central neuraxial block technique with many applications. It is a versatile anesthetic technique, with applications in surgery, obstetrics and pain control. Its versatility means it can be used as an anesthetic, as an analgesic adjuvant to general anesthesia, and for postoperative analgesia. Off pump coronary artery bypass (OPCAB) surgery triggers a systemic stress response as seen in coronary artery bypass grafting (CABG). Thoracic epidural anesthesia (TEA), combined with general anesthesia (GA) attenuates the stress response to CABG. There is Reduction in levels of Plasma epinephrine, Cortisol and catecholamine surge, tumor necrosis factor-Alpha( TNF ά), interleukin-6 and leucocyte count. Design: A prospective randomised non blind study. Setting: A clinical study in a multi specialty hospital. Participants: Eighty six patients. Material and Methods/intervention: The study was approved by hospital research ethics committee and written informed consent was obtained from all patients. Patients were randomised to receive either GA plus epidural (study group) or GA only (control group). Inclusion Criteria (for participants) were -Age ≥ 70 years, Patient posted for OPCAB surgery, and patient with comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, renal dysfunction). Serum concentration of Interlukin: - 6, TNF ά, cortisol, Troponin - I, CK-MB, and HsCRP (highly sensitive C reactive protein), was compared for both the group and venous blood samples were collected and compared just after induction, at day 2, and day 5 postoperatively. Time to mobilization, extubation, total intensive care unit stay and hospital stay were noted and compared. Independent t test was used for statistical analysis. Primary Outcomes: Postoperative complications, total intensive care unit stay and hospital stay. Secondary Outcome: Stress response. Result: Study group showed decreased Interlukin - 6 at day 2, TNF ά at day 2 and 5,troponin I at day 5, and decreased total hospital stay ( p < 0.05). Conclusion: Thoracic epidural anesthesia decreases stress and inflammatory response to surgery and decreases hospital stay. However a large multicentre study may be needed to confirm it

Cannulation practices at haemodialysis initiation via an arteriovenous fistula or arteriovenous graft

Introduction: A functioning long-term vascular access is required for haemodialysis therapy; however, establishing this can be challenging in the setting of advanced age and vessels damaged by diabetes. Complications include the inability to insert two needles for the treatment resulting in miscannulation trauma and in some cases insertion of a temporary central venous access device. The broad objective of this review is to define the evidence base regarding cannulation practices in the initiation of haemodialysis via an arteriovenous fistula or an arteriovenous graft. Methods: This review uses the framework recommended by the Joanna Briggs Institute and the process by which papers were included or excluded followed the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses group approach. A total of 20 primary research studies met the inclusion criteria. Results: Cannulation in the 10- to 15-week period rather than delaying past this time frame is associated with the best outcomes. New vascular access given time to mature through single-needle haemodialysis treatments may improve long-term patency. Duplex ultrasound mapping prior to initiation of cannulation supports the clinical decision-making process on timing of and selection of cannulation sites. Conclusion: Cannulation trauma at the initiation of haemodialysis could potentially be reduced with a strategy of incremental haemodialysis using single-needle treatment supported with duplex ultrasonography assessment to ‘map’ the vascular access as a guide for clinicians prior to cannulation initiation

Atypical Haemolytic Uraemic Syndrome Associated with Clostridium difficile Infection Successfully Treated with Eculizumab

Clostridium difficile infection is a rare precipitant of atypical haemolytic uraemic syndrome (aHUS). A 46-year-old man presented with watery diarrhoea following an ileocaecal resection. He developed an acute kidney injury with anaemia, thrombocytopaenia, raised lactate dehydrogenase, low haptoglobin, and red cell fragments. Stool sample was positive for C. difficile toxin B. He became dialysis-dependent as his renal function continued to worsen despite treatment with empiric antibiotics and plasma exchange. The ADAMTS13 level was normal consistent with a diagnosis of aHUS. The commencement of eculizumab led to the resolution of haemolysis and stabilisation of haemoglobin and platelets with an improvement in renal function