Filgrastim as a Rescue Therapy for Persistent Neutropenia in a Case of Dengue Hemorrhagic Fever with Acute Respiratory Distress Syndrome and Myocarditis

Pathogenesis of dengue involves suppression of immune system leading to development of characteristic presentation of haematological picture of thrombocytopenia and leucopenia. Sometimes, this suppression in immune response is responsible for deterioration in clinical status of the patient in spite of all specific and supportive therapy. Certain drugs like steroids are used for rescue therapy in conditions like sepsis. We present a novel use of filgrastim as a rescue therapy in a patient with dengue hemorrhagic fever (DHF) with acute respiratory distress syndrome (ARDS), myocarditis, and febrile neutropenia and not responding to standard management

Erector spinae plane block for cancer pain – A scoping review of current evidence

Cancer patients experience pain secondary to the disease process or due to treatment. Refractory cancer pain can present a clinical challenge for pain physicians, which significantly affects patients' quality of life and increases disability. Erector spinae plane (ESP) blocks have rapidly been used in both acute and chronic pain practice. However, the use of ESP block for cancer pain management remains unclear. Thus, we conducted this scoping review to perform a comprehensive overview of current evidence on ESP block for cancer pain management. We searched the PubMed and Google Scholar databases for relevant articles published between January 2016 and March 2023 using the keywords “erector spinae plane block,” “ESP block,” and “cancer pain”. After excluding duplicate and irrelevant articles, we included a total of 26 studies, which were case reports, case series, cohort studies, and randomized control trials. Both neurolytic and non-neurolytic ESP blocks were used for cancer pain. The ESP blocks were performed in all patients with severe pain (Visual Analog Score or Numerical Rating Scale >7) and the majority of cases had some degree of pain relief. None of the studies has reported any serious complications related to procedure or drug used. There was heterogeneity in the type of drug, volume, and concentration used for ESP block. A definitive conclusion regarding the efficacy and safety of ESP block in cancer pain management was not possible. The current literature suggests that the ESP block can be helpful in cancer pain management. However, caution must be exercised not to overestimate the safety of either neurolytic or non-neurolytic ESP block as 88% (n = 23) of included studies were either case reports or case series. Randomized controlled clinical trials are warranted to establish the efficacy and safety of ESP block in cancer pain management.

Impact of fluid and haemodynamic management in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy on postoperative outcomes – A systematic review

Background and Aims: Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive surgery associated with significant fluid shift and blood loss. The haemodynamic management and fluid therapy protocol may impact postoperative outcomes. This systematic review was conducted to find the effect of haemodynamic monitoring and perioperative fluid therapy in CRS-HIPEC on postoperative outcomes. Methods: We searched PubMed, Scopus and Google Scholar. All studies published between 2010 and 2022 involving CRS-HIPEC surgeries that compared the effect of fluid therapy and haemodynamic monitoring on postoperative outcomes were included. Keywords for database searches included a combination of Medical Subject Headings terms and plain text related to the CRS-HIPEC procedure. The risk of bias and the certainty assessment were done by Risk of Bias-2 and the methodological index for non-randomised studies. Results: The review included 16 published studies out of 388 articles. The studies were heterogeneous concerning the design type and parameter measures. The studies with goal-directed fluid therapy protocol had a duration of intensive care unit (ICU) stay that varied from 1 to 20 days, while mortality varied from 0% to 9.5%. The choice of fluid, crystalloid versus colloid, remains inconclusive. The studies that compared crystalloids and colloids for perioperative fluid management did not show a difference in clinical outcomes. Conclusion: The interpretation of the available literature is challenging because the definitions of various fluid regimens and haemodynamic goals are not uniform among studies. An individualised approach to perioperative fluid therapy and a justified dynamic index cut-off for haemodynamic monitoring seem reasonable for CRS-HIPEC procedures

Comparison of respiratory quotient and resting energy expenditure in two regimens of enteral feeding – continuous vs. intermittent in head-injured critically ill patients

Introduction: Measurement of respiratory quotient (RQ) and resting energy expenditure (REE) has been shown to be helpful in designing nutritional regimens. There is a paucity of the literature describing the impact of a feeding regimen on the energy expenditure patterns. Therefore, we studied the effect of continuous vs. intermittent feeding regimen in head-injured patients on mechanical ventilation on RQ and REE . Methods: After institutional ethical approval, this randomized study was conducted in 40 adult male patients with head injury requiring controlled mode of ventilation. Patients were randomly allocated into two groups. Group C: Feeds (30 kcal/kg/day) were given for 18 h/day, with night rest for 6 h. Group I: Six bolus feeds (30 kcal/kg/day) were given three hourly for 18 h with night rest for 6 h. RQ and REE were recorded every 30 min for 24 h. Blood sugar was measured 4 hourly. Other adverse effects such as feed intolerance, aspiration were noted. Results: Demographic profile and SOFA score were comparable in the two groups. Base line RQ (0.8 vs. 0.86) and REE (1527 vs. 1599 kcal/day) were comparable in both the groups (P>0.05). RQ was comparable in both groups during the study period at any time of the day (P>0.05). Base line RQ was compared with all other RQ values measured every half hour and fluctuation from the base line value was insignificant in both groups (P>0.05). REE was comparable in both the groups throughout the study period (P>0.5). Adequacy of feeding as assessed by EI/MREE was 105.7% and 105.3% in group C and group I, respectively. There was no significant difference in the blood sugar levels between the two groups (P>0.05). Conclusion: We found from our study that RQ, REE, and blood sugar remain comparable with two regimens of enteral feeding - continuous vs. intermittent in neurosurgical patients on ventilator support in a ICU setup

Airway management in neurotrauma care: Basic considerations

The predictability of the airway compromise affects the decision for tracheal intubation. Associated specific injuries, clinical presentation, and expected deterioration are the deciding factors regarding the need for securing the airway. Emergent or semi-urgent intubations are straightforward in the majority of patients. Airway management in trauma patients aims to improve tissue oxygenation, ensure ventilatory exchange, stabilize other injuries and prevent aspiration. Airway management in the trauma and emergency room is challenging as the emergency team has limited time for full airway assessment unlike pre-anaesthesia check-up clinic/operative room. The airway cart must be checked routinely in the emergency room for the working condition of the equipment and its availability. All trauma patients must be considered to have cervical spine injuries unless ruled out. The airway management for trauma patients is best done using a team approach including emergency medicine physicians, anesthesiologists, surgeons, and trained paramedical staff. Regardless of the emergency room setting, airway management of a trauma patient requires effective communication and efficient teamwork

Efficacy of flupirtine for postoperative pain: A systematic review and meta-analysis

Background and Aims: Flupirtine has been used for various chronic pain conditions, but its utility in the perioperative period as an analgesic is still inconclusive. This systematic review and meta-analysis aimed to assess the efficacy of flupirtine for postoperative pain. Methods: PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) were explored for the randomised controlled trials (RCTs) which compared flupirtine with other analgesic/placebo for perioperative pain in adult patients undergoing surgery. The standardised mean difference (SMD) of pain scores, the need for rescue analgesia and all adverse effects were assessed. Heterogeneity was assessed using Cochrane's Q statistic test and I2 statistic. Cochrane Collaboration's tool was used to evaluate the risk of bias and the quality of the RCTs. Results: A total of 13 RCTs (including 1,014 patients) that evaluated the use of flupirtine for postoperative pain were included in the study. The pooled SMD of postoperative pain scores revealed that flupirtine and other analgesics were comparable at 0, 6, 12 and 24 hours (P > 0.05), while at 48 hours, flupirtine showed poor pain control (P = 0.04) as compared to other analgesics. There were no significant differences at other time points and on comparison of flupirtine with placebo. The side effect profile was comparable between flupirtine and other analgesics. Conclusion: The current evidence suggests that perioperative flupirtine was not superior to other most commonly used analgesics and placebo for the treatment of postoperative pain